Plus|Pulse|114|He has intact sensation in deep peroneal superficial peroneal and tibial nerve distribution. The patient also has +2 dorsalis pedis and posterior tibial pulses. The patient has 5/5 knee flexion, extension and 3-4/5 hip flexion on that left side.
Plus|Reflexes|179|EXTREMITIES: No cyanosis, clubbing or edema. NEURO: Cranial nerves II through XII were grossly intact. Strength was 5/5 in upper and lower extremities bilaterally. Reflexes were 2+ and symmetric. LABS: CT of the head showed no evidence of acute hemorrhage, mass or fluids.
Plus|Pregnancy dating|175|2. Oligohydramnios. 3. Previous cesarean section, desires repeat. 4. Multiple births, desires permanent sterilization. DIAGNOSIS ON DISCHARGE: 1. Intrauterine pregnancy at 37 + 5 weeks, delivered. 2. Oligohydramnios. 3. Previous cesarean section, desires repeat. 4. Multibirths, desires permanent sterilization.
Plus|Edema(swelling)|127|ABDOMEN: Soft, no organomegaly. LOWER EXTREMITIES: Full motion of the hips and knees. Regarding the right lower leg, there is 1+ swelling; there is a gap in the posterior heel approximately three fingerbreadths from the insertion of the Achilles.
Plus|Pulse|201|The patient's postoperative course was entirely unremarkable without complication. He was discharged from the hospital on _%#MMDD2007#%_. At the time of discharge his wound was healing nicely, he had 4+ pedal pulses bilaterally, he was ambulating well, tolerating a soft diet and bowel habits were returning to normal.
Plus|Edema(swelling)|175|CHEST: Quiet breath sounds with prolonged expiratory time but without significant wheezes. HEART: Irregular rate and rhythm. ABDOMEN: Soft. EXTREMITIES: Edema at the ankles, 2+. Posterior tibial pulses are good, as are the radial pulses.
Plus|And|83|To his regime of medications was added Actonel 30 mg q. weekly, as well as calcium + vitamin D q. day. The patient is followed by Dr. _%#NAME#%_ for his myasthenia gravis.
Plus|Edema(swelling)|211|CARDIOVASCULAR: Bradycardic with irregular rate with a 2/6 systolic ejection murmur best heard at the aortic area. ABDOMEN: Positive bowel sounds, soft and nontender. EXTREMITIES: 1+ edema in the right leg and 2+ edema in the left to the upper shin. LABORATORY DATA: Pending. Electrocardiogram from clinic shows bradycardia with AV dissociation.
Plus|Pulse|126|HEENT: Unremarkable. LUNGS: Faint bilateral crackles. HEART: Jugular venous distention (JVD) to 18-cm of water. Carotids are 2+ bilaterally without any bruits. Heart has regular rate and rhythm, S1 and S2, with a 2/6 holosystolic murmur at the apex.
Plus|Excess|148|He had been prescribed Lisinopril 2.5 mg but is not taking it currently. ALLERGIES: Include penicillin. HABITS: He is currently a nonsmoker times 30+ years, had a seventeen pack year history in the past.
Plus|Pregnancy dating|249|However, she has been on no medications since 1988. There is a family history of no significant medical problems. PAST SURGICAL HISTORY: Myomectomy, D&C, and cesarean section. Radiologic studies: Initial ultrasound done on _%#MM#%_ _%#DD#%_, 6 days + 1 viable intrauterine pregnancy. Many small fibroids indicated by exam. Repeat ultrasound done on _%#MM#%_ _%#DD#%_ compatible with 20 weeks, 5 days, with echogenic focus myoma behind the placenta.
Plus|Pregnancy dating|161|Viral load was undetectable. A 3-hour GTT was abnormal. IMAGING: Ultrasound at 20 weeks by LMP was measured 19 + 5 weeks, with estimated fetal weight 28%. At 23 + 4 weeks showed an estimated fetal weight at the 9th percentile.
Plus|Pulse|145|I cannot palpate left popliteal nor pedal pulses. Bedside Doppler reveals a biphasic signal within the right popliteal with a monophasic left. A +2 monophasic right dorsalis pedis pulse is noted with only trace signal in the left foot.
Plus|Edema(swelling)|142|He does report some mild discomfort with palpation, but has no peritoneal signs. EXTREMITIES: Warm and well perfused. There is approximately 1+ lower extremity edema in both of the pretibial areas.
Plus|Excess|286|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is in today for follow-up of her infiltrating ductal carcinoma and DCIS that was initially diagnosed _%#MMDD2005#%_ with subsequent lumpectomy on _%#MMDD2005#%_. Nottingham grade 1 of 3 with one of five lymph nodes, ER/PR positive at 90+% and 51%, respectively and HER-2/neu negative. REVIEW OF SYSTEMS: GENERAL: Energy is low. She is off of her high blood pressure medicine, as her blood pressure has been running quite low with her therapy.
Plus|Pregnancy dating|150|In reviewing the patient's new OB labs, they were 149,000 at her first new OB visit back in _%#MM#%_ 2005. IMPRESSION: 1. Intrauterine pregnancy at 35+ 6 weeks gestation. 2. Intractable diarrhea. 3. Thrombocytopenia, most likely idiopathic thrombocytopenia of pregnancy.
Plus|Reflexes|109|GENITAL exam and BREAST exam were deferred. Bilateral KNEES are good and stable without crepitance. She has 2+ patellar reflexes. No clonus. SKIN exam is unremarkable. Her gait is normal. LAB: Preop hemoglobin was normal at 13.1. Preop stress test is pending.
Plus|Edema(swelling)|177|Thyroid is normal size LUNGS: Clear CARDIOVASCULAR: S-1 and S-2 normal, no S-3, S-4 or murmurs ABDOMEN: No masses, tenderness, liver and spleen not palpable. EXTREMITIES: Show 4+ brawny edema which has been present for years, likely related to the dependency of her legs.
Plus|Edema(swelling)|140|ABDOMEN: Abdomen is obese, soft, nontender. Groin has mild tenderness with no hematoma and no audible bruit. EXTREMITIES: Extremities have 1+ edema bilaterally. LABORATORY AND DIAGNOSTIC DATA: Total cholesterol 122.
Plus|Pulse|74|She has a large nevus over the left upper quadrant. Popliteal pulses are 2+ bilaterally and femoral pulses are 2+ bilaterally.
Plus|Edema(swelling)|131|ABDOMEN: Soft and nontender. No liver or spleen noted. PELVIC/RECTAL: Not done. EXTREMITIES: Pedal pulses hard to feel. There was 1+ pedal edema I thought at each ankle. All uses of legs and arms normal. NEUROLOGICAL EXAM: Gross function normal, speech normal.
Plus|Pregnancy dating|33|ADMISSION DIAGNOSES: 1. IUP at 40+ 4 weeks. 2. Latent labor. DISCHARGE DIAGNOSES: 1. IUP at 40+ 5 weeks delivered.
Plus|Pulse|86|S1 and S2 without murmur, gallop, or rub. JVP is nondistended. Carotid upstrokes are 2+ symmetric without bruit. ABDOMEN: Soft, nontender without hepatosplenomegaly. EXTREMITIES: Without cyanosis, clubbing, or edema.
Plus|Positive(laboratory test)|58|AST 24, currently at 39. ALT 16, current up to 24. Urine 1+ protein currently, previously trace or negative. ASSESSMENT: The patient would appear to have worsening toxemia based on her rise in blood pressures, the increase in urine protein and mild increases in AST, ALT and the significant elevation in alkaline phosphatase.
Plus|Plus|156|ALLERGIES: No known drug allergies. CODE STATUS: DNR/DNI. DISCHARGE INSTRUCTIONS: 1. Diet: 2 gm sodium restriction, no added salt. 2. Weigh q.o.d.; call if +/- 3 pounds. 3. For skin care, please follow the ET Nurse recommendations for skin cleansing, alternate gradient compression bandages and graduated Tubigrip per patient tolerance on bilateral lower extremities.
Plus|Edema(swelling)|221|HEART: Regular rate and rhythm. ABDOMEN: Tender on the left lower rib flank area but positive bowel sounds and moderately obese. GU: Deferred. MUSCULOSKELETAL: Very mild arthritic changes. Lower extremity - He has about 3+ pitting edema in his feet, 2+ to his mid shin and 2-4 DP pulses.
Plus|Edema(swelling)|120|Eschar is present in left upper quadrant without any drainage from his G-tube removal. EXTREMITIES: Extremities reveal 1+ edema. Distal pulses are 2+. LEFT SHOULDER: Left shoulder is in a sling. LABORATORY DATA: Laboratory studies are remarkable for an elevated white count 14.0, hemoglobin 11.4, basic metabolic profile that is unremarkable.
Plus|Reflexes|214|His left leg is weaker proximally than distally, 4-/5 proximally; 4/5 in leg extension and flexion, plantar flexion and dorsiflexion. Deep tendon reflexes are 2+ in the biceps brachial radialis on the right side, 3+ in the biceps brachial radialis on the left side, 2+ in the patellar tendon and Achilles bilaterally, and toes are downgoing bilaterally.
Plus|Uncommon rating|188|BACK: No costovertebral angle (CVA) tenderness. ABDOMEN: Benign. No scars, masses or tenderness. PELVIC: Vagina with a cystocele, rectocele and loose perineum. Cystocele is approximately 3+. Rectocele is 2+. There is, of course, prolapse of the uterus.
Plus|Reflexes|115|Lower extremities are likewise 5/5 strength throughout. Sensation intact to light touch. Deep tendon reflexes are 2+ throughout. Proprioception is intact. Toes are downgoing. There is no clonus. He does have midline tenderness at the C4 level.
Plus|Excess|214|The patient has had intermittent episodes of chest discomfort. She is not a very good historian; she may have had palpitations in the past. She has a very distant history of cigarette smoking, has not smoked for 20+ years. She also has a positive family history of coronary disease and a history of hypertension which has been intermittently treated.
Plus|Pulse|187|No jugular venous distention (JVD) or hepatojugular reflux (HJR). There is a diffuse apical impulse. ABDOMEN: Soft and nontender without organomegaly, mass, or bruit. Femoral pulses are 2+ and symmetrical without bruit. EXTREMITIES: Pedal pulses are 1-to-2+ . No pedal edema, cyanosis or erythema.
Plus|Pulse|198|I hear a S4, no S3. No murmurs. Because of her back pain will not let me sit her up but she has no JVD when she sits upright but I cannot do anything in between. She has no edema. Pulses are about 2+ in the lower extremities. ABDOMEN: Has normal bowel sounds, soft, nontender. No hepatosplenomegaly. I do not appreciate any masses but she complains of a little tenderness on the left side.
Plus|Pulse|121|ABDOMEN: Is soft without organomegaly, masses, or bruits EXTREMITIES: Are warm, dry, pink and perfused. Pedal pulses are +1. SKIN: Is normal with small petechial rash on both lower extremities.
Plus|Edema(swelling)|146|CARDIOVASCULAR: Regular rate and rhythm, S1, S2. ABDOMEN: Bowel sounds were positive; nontender, nondistended. She is obese. EXTREMITIES: Showed 2+ bilateral pitting edema. NEUROLOGIC: Cranial nerves II-XII are grossly intact. LABORATORY DATA: White blood cell count 11.1, hemoglobin 11.6, platelets 201.
Plus|Pulse|130|No click, no JVD. Abdomen: nondistended, soft, nontender, without organomegaly or mass, positive bowel sounds. Peripheral pulses 2+ dorsalis pedis. There is no clubbing, cyanosis, or edema.
Plus|Pregnancy dating|387|DOB: _%#MMDD1970#%_ PREOPERATIVE DIAGNOSIS: Recent history of vacuum curettage for partial molar pregnancy with retained products. PLANNED PROCEDURE: Suction curettage. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 31-year-old now para 0-0-1-0 who was diagnosed with a missed abortion at 8+4 weeks based on an ultrasound revealing an abnormal fetus with no cardiac activity measuring 7+5 days. She underwent a suction curettage on _%#MMDD2002#%_, and final pathology revealed a triploidy fetus and tissue consistent with a partial mole.
Plus|Pregnancy dating|151|She underwent triple screen chorionic villous sampling both of which were normal as well as a normal level 2 ultrasound. Ultrasound was performed at 20+3 weeks gestational age on _%#MM#%_ _%#DD#%_, 2001. Patient's obstetrical history is significant for four prior elective terminations of pregnancy.
Plus|Pulse|179|Pulse is 62, respiratory rate 16 per minute. Skin is intact without lesions, rashes or ulcerations on any of his four extremities or trunk. Cardiovascular: Peripheral pulses are 2+ and symmetric in all four extremities. There is no extremity edema. On examination of his left knee he has well-healed arthroscopic incisions anteriorly and a posteromedial scar that is fairly well-indented and heavily scarred.
Plus|Pulse|123|Extraocular movements and convergence intact. Fundi benign. Oral exam normal. NECK: Thyroid normal to palpation. Carotids 2+ bilaterally without bruits. LUNGS: Lung fields are clear. HEART: Normal sinus rhythm without any murmurs or gallops.
Plus|Pulse|159|BREASTS: Are without any obvious lumps or masses. ABDOMEN: Is soft, without any organomegaly, masses or tenderness. There is 2+ pulses in both radial pulses, 1+ pulses both femoral pulses. There is a right femoral bruit and 1+ pulses in both pedal pulses.
Plus|Plus|405|The patient was followed closely and in 1998 PSA remained was unchanged at 5.0, and in 1999 PSA only rose slightly to 5.6. Over the year, PSA rose to 8.6. Initial digital rectal exams were reported to be negative. The patient was seen at Fairview _%#CITY#%_ _%#CITY#%_ Clinic, _%#MMDD2000#%_ at which time he underwent transrectal needle biopsy of the prostate with ultrasound guidance revealing Gleason 2+2=4 adenocarcinoma, left side, involving 10% to 20% of tissue.
Plus|Edema(swelling)|192|There were no obvious masses. EXTREMITIES: Examination of the lower extremities revealed femoral arterial pulses were normal and were symmetric. There was pedal edema which was approximately 2+, although the patient's legs were obese as well and the amount of fluid versus "woody edema" was difficult to assess.
Plus|Pulse|121|Normal sphincter tone. Normal rectal masses. Stool Hemoccult negative. Extremities: Without swelling. Peripheral pulses 2+. Joints: Full range of motion. Neurologic: Without deficits. Skin: No rashes/jaundice. LABORATORY DATA: WBC 4.1, hemoglobin 14.3, platelet count 208.
Plus|Strength|233|These symptoms occurred suddenly in _%#MM2002#%_, and are compatible with neurogenic claudication. Preoperative exam revealed motor strength of 4+ out of 5, bilateral hip flexion 4 out of 5, 5 out of 5 bilateral knee extension, and 4+ out of 5 bilateral knee flexion, dorsiflexion, and 5 out of 5 strength bilateral plantar flexion.
Plus|Strength|175|Fundus is technically difficult to assess. Gait: Mildly unsteady but walks independently with a right footdrop. Minimal left upper extremity drift. Strength: Digit extensors 4+/4. Interossei: 4/3. Finger flexors (median): 5/3. Finger flexors (ulnar): 5/4.
Plus|Heart murmur|355|5. Hypercholesterolemia. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 70-year-old woman from _%#CITY#%_, Nebraska, who came to the emergency room with fevers, dyspnea and chills. She underwent rule out protocol, and had three negative troponins, a normal myoglobin, and an echocardiogram revealing an ejection fraction of 50-55%, 1+ mitral regurgitation, 1+ aortic insufficiency, 2+ tricuspid regurgitation, and normal right atrium.
Plus|Excess|209|SURGEON: _%#NAME#%_ _%#NAME#%_, MD ANESTHESIA: Spinal anesthesia is anticipated. PATIENT IDENTIFICATION: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is a 26-year-old, married woman with a due date of _%#MMDD2002#%_ at 39+ weeks gestation who is to undergo a repeat elective cesarean section.
Plus|And|40|DISCHARGE DIAGNOSES: 1. Status post day +9 autologous bone marrow transplant for Hodgkin's disease. 2. Neutropenia. 3. Serratia sepsis. 4. Coag-negative staph sepsis. 5. Diarrhea. 6. History of familial platelet dysfunction. 7. Hypothyroidism.
Plus|Pulse|225|Abdomen was soft, mildly tender to palpation in the lower quadrants; positive bowel sounds; nondistended; no guarding or rebound tenderness. No CVA tenderness. Extremities showed no clubbing, cyanosis, or edema; pulses were 2+ throughout. Neuro exam was nonfocal. ADMISSION LABORATORY DATA: Hemoglobin 11.3, hematocrit 34.0, white blood cell count 6.8. Electrolytes of note: potassium was low at 3.2, glucose was high at 185; INR is elevated at 1.11; PTT was normal at 27.
Plus|Blood type|240|4. GI: _%#NAME#%_ received phototherapy on DOL 2 for a bilirubin of 9.4. After approximately 30 hours of treatment, his bilirubin had come down to 7.6. His hyperbilirubinemia was thought to be physiologic. 5. Heme: Maternal blood type was A+ and _%#NAME#%_'s blood type was also A+. Direct coombs was negative. 6. ID: _%#NAME#%_ had a sepsis workup initiated at birth because of the theoretical risk of infection as underlying cause for PPROM.
Plus|Pregnancy dating|142|Pap was normal. Urine culture was without growth. Hemoglobin electrophoresis was normal. Platelets were 404. Ultrasound in _%#MM#%_ 2002 at 11+2 weeks gave an EDC. In _%#MM#%_ 2002, at 18 weeks at the Perinatal Center showed normal anatomy.
Plus|Fetal position during labor|139|No gallops, lifts, or heaves. ABDOMEN: Soft. Breech presentation. Estimated fetal weight 8 pounds. PELVIC: The cervix is complete and 5-6, +1 station. NEUROLOGIC: Muscle stretch reflexes 1-2+. There are no focal neurological findings.
Plus|Reflexes|100|Cranial nerves II through XII are intact. Cerebellum and gait are normal. Deep tendon reflexes are 1+ and symmetrical. Plantars are downgoing. Sensation and motor function are intact. LABORATORY DATA: White count is 0.45, neutrophil count 0, hemoglobin 8.8, hematocrit 25, platelet count 4,000, AST 14, ALT 15, total bilirubin 0.6, alkaline phosphatase 67, ____ bilirubin is 0.1, total protein 6, albumin 4.2.
Plus|Reflexes|233|No masses. MUSCULOSKELETAL: Patient with normal gait and station. Inspection and palpation of lower extremities show 2 to 3+ pitting edema to knees bilaterally. NEUROLOGIC: Cranial nerves II-XII are intact. Deep tendon reflexes are 2+ and symmetric. Toes are downgoing bilaterally. Cerebellar exam is intact. PSYCHIATRIC: Awake, alert, oriented x 3.
Plus|Uncommon rating|154|There is a very small 2 cm x 2 cm soft hematoma at the right groin and there is no bruit associated with this hematoma. Capillary refill in the toes are 2+ bilaterally. There is no peripheral edema. IMPRESSIONS AND RECOMMENDATIONS: The patient had typical AV nodal reentry tachycardia and has underwent successful radiofrequency ablation for this.
Plus|Reflexes|105|He does not respond to voice command. He does not follow commands. He will withdraw from pain. DTRs are 2+ and symmetric. ADMISSION LABS: ABG - pH is 7.40, pCO2 37, pO2 is 76, bicarb is 22 - this is on 21% FiO2.
Plus|Pregnancy dating|220|PROCEDURE: Repeat low segment transverse C-section via Pfannenstiel skin incision. COMPLICATIONS: None. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is a 26- year-old Latino gravida 2, para 1-0-0-1 at 36 + two weeks' gestation who presents for elective repeat C-section.
Plus|Pregnancy dating|188|2. Prolonged rupture of membranes. 3. Light meconium. 4. Chorioamnionitis. 5. Likely herpes infection on lip. HISTORY OF PRESENT ILLNESS: The patient is a G2, P0-0-1-0, who presented at 41+1 weeks' gestation age on _%#MMDD2003#%_. She presented after complaining of spontaneous rupture of membranes of clear fluid on _%#MMDD2003#%_ at 0430.
Plus|Pregnancy dating|108|PRENATAL CARE: The patient had prenatal care at CUHCC Clinic with Dr. _%#NAME#%_. Her first visit was at 30 + 3 weeks' gestational age, and she had a total of nine visits.
Plus|Reflexes|142|LYMPHATICS: There is no lymphadenopathy present in the cervical region. NEURO: Cranial nerves II-XII grossly intact. Deep tendon reflexes are +2/4 bilaterally at the patella. LABORATORY RESULTS: White count 7.4, hemoglobin 13.0, platelet 282, troponin is less than 0.07. BNP 171.
Plus|Reflexes|141|BREASTS: Free of masses or discharge. ABDOMEN: Soft. Uterus at umbilicus. EXTREMITIES: Homans sign is negative. Muscle stretch reflexes are 1+. There are no focal or neurological signs. IMPRESSION: Multiparity, desires surgical contraception, first postoperative day, status post normal spontaneous vaginal delivery of a living female.
Plus|Pulse|123|No murmurs, rubs, or gallops. ABDOMEN: Soft, nontender, nondistended. EXTREMITIES: No clubbing, cyanosis or edema. He has 2+ pulses in all of his extremities. NEURO EXAM: Completely nonfocal. His reflexes are symmetric. His strength is symmetric throughout.
Plus|Pregnancy dating|269|3. History of prior cesarean section, desires repeat. PROCEDURES: Repeat low transverse cesarean section. COMPLICATIONS: None apparent. STAFF PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 28-year-old, G2, para 0-1-0-1 at 33+4 weeks who presents with preterm contractions. She is well known to Dr. _%#NAME#%_ and has had multiple triage visits with preterm contractions.
Plus|Reflexes|81|Sensory is intact to light touch throughout. Tone is normal throughout. She has 2+ reflexes in all her extremities. She has downgoing Babinski, negative Hoffman. She is able to transfer without any assistance.
Plus|Pregnancy dating|62|FINAL DIAGNOSES ON ADMISSION: 1. Intrauterine pregnancy at 40 + 5 weeks. 2. Elective induction for postdates. 3. Microhematuria during pregnancy, evaluated by Renal who recommended followup postpartum.
Plus|Edema(swelling)|256|HEART: Tones are distant but significant murmurs are not appreciated on auscultation of the heart, possibly a short grade 2/6 systolic flow-type murmur. ABDOMEN: Soft. There is no organomegaly. EXTREMITIES: Do show pretibial edema which is about trace to 1+. Dorsal pedis, posterior tibial pulses are decreased, although capillary refill and color of the extremities is good.
Plus|Excess|138|GCT 86, GBS negative. PAST OB HISTORY: Termination of pregnancy at 6 weeks. ASSESSMENT and PLAN: This is a 25-year-old G2, P0-0-1-0 at 40 + weeks. She had artificial rupture of membranes with blood-tinged fluid. Her cervix was 3 cm dilated.
Plus|Pulse|157|No wheezing, no crackles. ABDOMEN: Soft, bowel sounds present. No tenderness. No organomegaly. EXTREMITIES: No edema, no calf tenderness. Peripheral pulses 2+. CNS: Grossly intact. SKIN: Acne-like lesions on his chin and also on the cheek.
Plus|Edema(swelling)|166|There is a Grade 2/6 holosystolic murmur. LUNGS: Diminished breath sounds at the bases bilaterally. No wheezing. ABDOMEN: Distended but not tympanitic. EXTREMITIES: 1+ bilateral pedal edema. No skin breakdown is noted. NEURO: The patient is alert and oriented.
Plus|Pulse|145|_%#NAME#%_. Extraocular muscles are intact. NECK: Is supple without, mass, thyromegaly or adenopathy. No jugular venous distention. Carotids are +2 without bruits. HEART: Tachycardic, but regular rate at 114 beats per minute.
Plus|Excess|140|On admission her blood pressure in the office had been 158/104 with a repeat of 140/99. Reflexes were brisk as well. The patient did have 30+ proteinuria in the clinic as well. The patient's pregnancy was complicated only by pyelonephritis. Otherwise the patient's prenatal labs were all within normal limits.
Plus|Edema(swelling)|98|Cardiac and pulmonary exam was normal. Abdomen was remarkable for moderate ascites. She did have 2+ pitting edema at the left ankle and none on the right.
Plus|Pregnancy dating|163|PROCEDURES: 1. Tocolysis. 2. Preterm delivery at 31+4 weeks. HISTORY OF PRESENT ILLNESS: This is a 29-year-old G-III, P-0-0- 2-0, transferred from _%#CITY#%_ at 31+3 weeks for preterm labor. The patient is dated by LMP consistent with a first trimester ultrasound.
Plus|Pulse|155|Abdomen is largely soft, non- tender, no masses or hepatosplenomegaly and it is not distended. EXTREMITIES: Are without edema and clubbing and pulses are 4+. LYMPHATIC EXAMINATION: Cervical, axillary and inguinal area negative. Her cranial nerves II-VII and IX-XII are intact.
Plus|Reflexes|112|Negative for any cyanosis or clubbing. NEUROLOGIC: Cranial nerves II-XII are intact. Deep tendon reflexes were 2+ throughout. Muscle strength was 4+ throughout. LABORATORY DATA: INR 2.77, PTT 40. Hemoglobin 11.1, hematocrit 33.5, white count 24.3, platelet count 237,000.
Plus|Reflexes|92|NEUROLOGIC: Cranial nerves II-XII are intact. Sensory and motor exams are normal. DTRs are 2+ bilateral and symmetric. The patient does have a positive Tinel's sign in his right wrist with tingling in his second and third finger and some discomfort in his elbow.
Plus|Heart murmur|203|CHIEF COMPLAINT: One year history of angina, in retrospect, and a previous history of mitral valve prolapse _%#NAME#%_ _%#NAME#%_ is 63. She is very active. She has had a history of MVP in the past with +1 to +2 mitral regurgitation. Over the past year, she has noted tightness in the chest.
Plus|Edema(swelling)|133|ABDOMEN: Soft, very obese, and nontender without mass or organomegaly. GENITALIA/RECTAL: Deferred. EXTREMITIES: Obese with trace to 1+ edema. No calf tenderness. Pulses are 1+ in both feet. Left arm graft site incision is healing nicely with minimal erythema.
Plus|Reflexes|199|His strength is narrowly full bilaterally and slightly asymmetric, with his right side being slightly weak and 4+/5 both in the arm and the leg. There is no pronator drift. Deep tendon reflexes are 1+ bilaterally. His sensation is grossly intact, but slightly decreased on the right to light touch and pinprick and from the neck down through the arm, trunk, and leg.
Plus|Blood type|78|Patient has never undergone a mammogram as well as a colonoscopy. Patient is O+, antibody negative. Last chest x-ray _%#MM#%_ _%#DD#%_, 2003, that was within normal limits.
Plus|Edema(swelling)|94|LUNGS: Clear to auscultation anteriorly. ABDOMEN: Is soft and nontender. EXTREMITIES: Reveal 2+ pitting edema bilaterally. LABORATORY DATA: Urinalysis is fairly unremarkable with WBCs 0-2, digoxin level is normal.
Plus|Pregnancy dating|244|2. Wound cellulitis, stable. PROCEDURE DURING HOSPITALIZATION: Primary low transverse cesarean section for breech presentation. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ was admitted on _%#MMDD2006#%_ in active labor, in breech presentation, at 36+5 weeks gestation. The patient's prenatal course had been complicated by preterm cervical change, diagnosed at 31 weeks gestation, for which she was hospitalized for three nights and received betamethasone x2.
Plus|Pulse|179|ABDOMEN: Soft with active bowel sounds with mild upper abdominal tenderness without rebound and no palpable hepatosplenomegaly. EXTREMITIES: Without clubbing, cyanosis or edema. 2+ radial and 1+ pedal pulses. SKIN: Clear. NEUROLOGIC: With cranial nerves intact, sensation intact to touch and strength intact in her upper and lower extremities.
Plus|Fetal position during labor|197|The patient labored overnight with her Cervidil, and Cervidil was removed approximately 12 hours later. AROM was then performed and returned clear fluid. The patient progressed to 6-7 complete and +1, at which time, the patient pushed through her cervix resulting of cervical tear, delivery of a viable infant.
Plus|Excess|155|She progressed to term with a normal antepartum testing. The baby was confirmed to be breech from 35 weeks on. There was a normal biophysical profile at 37+ weeks gestation for decreased fetal movement and this was normal.
Plus|Blood type|125|Problem #2: Hyperbilirubinemia. _%#NAME#%_ received phototherapy for a peak bilirubin level of 13.4 mg%. His blood type was A+; maternal blood type was AB+. Antibody screening tests were negative. The last bilirubin level prior to discharge was 13 mg% on _%#MMDD2007#%_.
Plus|Pregnancy dating|103|At the time of discharge, the infant's postmenstrual age was 38 weeks and 5 days. She is a 3066 gm, 37 + 5 week gestational age female infant born at Immanuel-St. Joseph's in _%#CITY#%_, Minnesota, to a 29-year-old, gravida 5, para 3-1-0-4, blood type A-, Caucasian female whose LMP was _%#MMDD2006#%_ and whose EDC was _%#MMDD2007#%_.
Plus|Reflexes|170|NEUROLOGIC: Difficult to assess due to patient's cognitive impairment; however, there appears to be no focal deficits. Deep tendon reflexes in the brachial radialis are 2+/4+ and 1+/4+ in the patellar reflexes. She seems to have good sensation in all 4 extremities.
Plus|Pregnancy dating|195|Her pregnancy was complicated by gestational hypertension for which she was on modified bedrest. Prenatal care was obtained with Dr. _%#NAME#%_ _%#NAME#%_ at University Specialists beginning at 9+3 weeks on _%#MM#%_ _%#DD#%_, 2003. Her first trimester blood pressure was 127 to 140 over 66 to 70.
Plus|Pulse|84|Eyes - Pupils equal, round, and react to light. Oral exam negative. NECK: Carotids 2+ bilaterally without bruits. Thyroid normal to palpation.
Plus|Strength|174|On discharge, his wound is clean, dry, and intact. His nerve function is stable from preop which is at his baseline. EHL is 3/5, tibialis anterior is 4/5, gastroc soleus is 4+/5, and peroneal tendons are 4+/5 on the left. His right lower extremity has 5/5 nerve function and all motor of those muscle groups.
Plus|Edema(swelling)|164|No murmurs, rubs or gallops. ABDOMEN: Soft. Bowel sounds are normal active; nontender, nondistended. No hepatosplenomegaly. EXTREMITIES: Right lower extremity has 1+ edema, mild erythema and positive warmth. The left lower extremity shows no edema or clubbing. NEUROLOGICAL: Alert and oriented times three.
Plus|Strength|120|EXTREMITIES: There was no evidence for clubbing, cyanosis or edema. He moves all four extremities. His muscle strength 5+ throughout. Peripheral pulses were 2+ throughout. NEUROLOGICAL EXAM: He was intact.
Plus|Pulse|121|ABDOMEN: No rebound or guarding. EXTREMITIES: Lower extremities, hips, knees and ankles are normal. Gait normal. Pulses 4+ in the lower extremities. Pertinent upper extremity exam: The left wrist is very tender and swollen, mild carpal tunnel symptoms.
Plus|Edema(swelling)|110|He has diffuse edema in his upper and lower extremities. Lower extremities are remarkably reasonable. Edema, 1+, noted but he just got off his compression hose at this point and time.
Plus|Pregnancy dating|54|HISTORY OF PRESENT ILLNESS: A 24-year-old G1, P0 at 36+1 weeks by 9+1-week ultrasound admitted for induction secondary to known IUGR less than the respiratory distress percentile. The patient was admitted and received 1 dose of misoprostol and had good effect with contractions.
Plus|Pregnancy dating|63|ADMITTING AND DISCHARGE DIAGNOSIS: Intrauterine pregnancy at 39+ 0 weeks, breech. Declining external cephalic version, desiring permanent sterilization. PROCEDURE: Primary long-standing transverse cesarean section.
Plus|Reflexes|156|EXTREMITIES: Show 3+ pitting edema from the knees down. NEUROLOGIC: Cranial nerves II-XII are grossly intact. Sensory and motor exams are normal. DTRs are 2+ bilateral and symmetric. Gait was not tested. Asterixis is present. LABORATORY DATA: Hemoglobin of 11.4 with an MCV of 104, white count 6700 with a normal differential, platelet count is 94,000, metabolic panel shows a sodium 141, potassium 4.1, chloride of 117 and bicarbonate of 15.
Plus|Pulse|137|Cardiovascular examination demonstrated a regular rate and rhythm without the presence of murmurs, rubs, or gallops. Distal pulses were 2+ throughout, including dorsal pedal and posterior tibial.
Plus|Blood type|154|Birth weight was 2155 g. He was admitted to the special care nursery because of prematurity and respiratory distress. Mother is a 20-year-old gravida 1, A+ whose LMP was _%#MMDD2004#%_ and EDD _%#MMDD2004#%_ with GBS status unknown and hepatitis beta surface antigen negative.
Plus|Pulse|189|Height 5 feet 10 inches. Weight 170. EXTREMITIES: On examination of his upper extremities the skin is intact without lesions, rashes, or ulcerations. CARDIOVASCULAR: Peripheral pulses are 2+ symmetric in the upper extremity. NEURO: Examination reveals intact sensation, motion, and reflexes in the upper extremity.
Plus|Reflexes|151|Non-tender and non-distended. EXTREMITIES: No edema. NEUROLOGIC: Cranial nerves II through XII are intact. Motor exam is 4/5 throughout. Reflexes are 2+ at the ankles, 3+ at the knees and 2+ in the upper extremities.
Plus|Strength|78|Finger abduction on the right is 4, left is 5. Wrist flexion on the right is 4+, left is 5. Wrist extension on the right is 4+, left is 5.
Plus|Pulse|158|CARDIAC: PMI fifth ICS laterally displaced about 1 cm. Normal S1 and S2, S4, no S3, no murmurs, no bruits over carotids or abdominal vessels. Pulses about 2-3+ in the lower extremities, no edema. ABDOMEN: Soft, nontender, no masses or hepatosplenomegaly. NEUROLOGIC: She is alert, cooperative.
Plus|Pregnancy dating|355|A 24 hour urine revealed protein at 209 mg. The patient was placed on bed rest for several days during which time her blood pressure improves, however, she was unwilling to continue on bed rest and requested induction of labor with the risks and benefits of doing so discussed. Prenatal course had been complicated only by gestational hypertension from 37+1 weeks. Labs include blood type A positive, rubella immune, hepatitis B negative, RPR negative.
Plus|Heart murmur|240|Echocardiogram was performed on _%#MMDD#%_ and showed concentric left ventricular hypertrophy with retained left ventricular function and diastolic dysfunction present. There was severe pulmonary hypertension, 1-2 tricuspid regurgitation, 1+ pulmonary regurgitation. The patient has a history of urinary tract infection in the recent past from Vancomycin resistant enterococcus.
Plus|Excess|241|FINAL _%#NAME#%_ is a 35-year-old gravida 3, para 2 with intrauterine pregnancy at 6 weeks gestation with significant hyperemesis gravidarum. She is currently on oral Zofran without any relief. She is not able to eat or drink anything for 24+ hours. PAST MEDICAL HISTORY: Significant for asthma. MEDICATIONS: Zofran 4 mg 3 times a day.
Plus|Pulse|181|PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 125/78, pulse 80, respiratory rate 16. GENERAL: Well-developed, well-nourished, in no acute distress. NECK: Carotid upstrokes are 1+ bilaterally. There are no bruits. Jugular venous distention is 5 cm of water.
Plus|Present|73|There is external rotation and foreshortening of the right leg. She has 2+ varicose veins in both feet, but no edema. Pulses are 2+ in both feet, a little stronger on the left than on the right.
Plus|Pulse|103|EXTREMITIES without cyanosis, clubbing, or edema in the upper or lower extremities bilaterally. Pulses +2 radial and femoral pulses bilaterally. NEUROLOGICAL EXAM: Deep tendon reflexes 2+ bilaterally. Upper and lower extremity strength grossly 5 out of 5 in the upper and lower extremities bilaterally.
Plus|Strength|188|Decreased active, but full passive range of left upper and lower extremity. Strengths are 5/5 in the right upper and lower extremity and approximately 4/5 in the left upper extremity and 2+/5 at the left hip flexor and extensor. 1+ at the left knee flexor extensor and ankle dorsi and plantar flexors.
Plus|Excess|133|Apgar scores were 1 at one minute, 3 at five minutes, and 6 at ten minutes. Baby _%#NAME#%_ was a term AGA male infant, 2821 gm at 38+ weeks gestation, with a length of 48.9 cm and head circumference of 34.3 cm.
Plus|Fetal position during labor|258|The placenta was noted to be posterior. There was no previa component, and no evident retroplacental sound lucency consistent with abruption. Fetal motion and fetal cardiac activity were noted. Vaginal exam by the admitting triage nurse showed the cervix at +1 to +2 station and closed. Cerclage was in place. Clotted blood was present in the vagina.
Plus|Pregnancy dating|219|Delivery was a normal, spontaneous, vaginal delivery. This was complicated by postpartum hemorrhage. HPI: The patient is a 24-year-old, Somalian, G2, P1-0-0-1, at 41+2 weeks by last menstrual period consistent with an 8+4 week ultrasound who presented for induction of labor secondary to post dates.
Plus|Pulse|220|Tympanic membranes gray and pearly bilaterally, normal light reflex. Oral and posterior pharynx without erythema, swelling or discharge. NECK: Supple, without adenopathy. No jugular venous distention. Carotid upstrokes 1+ without bruits or thrills. LUNGS: Clear with good air movement, no wheezes, rales or rhonchi.
Plus|Reflexes|142|On further evaluation the patient was found to have no focal deficits and all cranial nerves were intact. All deep tendon reflexes were also 2+. ADMISSION LABS: WBC 11.4, hemoglobin 15.7, platelets 278, neutrophils 86% which was noted to be elevated, lymphocytes 6, monocytes 6, eosinophils 2.
Plus|Strength|100|Skin: No rashes. Neuro: The patient is alert and oriented x3. Strength of the upper extremities is 5+. Reflexes: Right upper extremity 2+, left upper extremity 4+, right and left lower extremities 0.
Plus|Reflexes|164|PELVIC, RECTAL - not indicated. EXTREMITIES - moves all four extremities. Reflexes unable to get below patella. JOINTS -no inflammation. NEURO - patellar reflexes 2+, warm, pink, dry, no edema extremities. SKIN - normal. ASSESSMENT: 1. Suicide attempt with atenolol, hydrochlorothiazide, stable.
Plus|Excess|203|DOB: _%#MMDD2004#%_ FINAL DISCHARGE DIAGNOSES: 1. Perinatal distress. 2. Transient leukopenia. 3. Aspiration pneumonia. 4. Borderline abnormal neonatal screening test. HOSPITAL COURSE: _%#NAME#%_ is a 40+ week EGA female, delivered to a 29-year-old, G1, P0-1, Caucasian female, who was A positive, rubella immune, HBSAG negative, HIV negative, Group B strep negative, and RPR unknown.
Plus|Edema(swelling)|166|HEART: Regular rate and rhythm with a 2/6 systolic murmur. ABDOMEN: Soft, nondistended, nontender without organomegaly. Multiple surgical scars. EXTREMITIES: Reveal 1+ edema and are doughy in texture. Distal pulses are 1+. There are a few scattered petechial lesions.
Plus|Pregnancy dating|53|ADMISSION DIAGNOSIS: 1. Intrauterine pregnancy at 36 +1 weeks. 2. Twin gestation, vertex, transverse. 3. Spontaneous rupture of membranes, early labor.
Plus|Plus|323|4. Transthoracic echocardiogram (_%#MM#%_ _%#DD#%_, 2005): Mildly decreased LV function with visually estimated ejection fraction of 45%. Increase in LV wall thickness, mild-to-moderate mitral regurgitation, mild-to- moderate right atrial dilation, mild right ventricular dilation, RV systolic pressure mildly increased (29+ RAP). Tissue Doppler suggested restrictive cardiomyopathy. 5. Pulmonary function tests (_%#MM#%_ _%#DD#%_, 2005): FEV1 was 1.39. FVC was 1.91. These values are approximately 50% predicted.
Plus|Pulse|182|Left upper quadrant fullness suggestive of splenomegaly. There is tenderness in the right upper quadrant as well. EXTREMITIES: Left leg with 2+ pulses and no ulcers. Right leg with 2+ dorsalis pedis and posterior tibialis pulses. There is a 2.0 x 2.0-cm fluctuant density over the dorsum of his right great toe over the interphalangeal joint.
Plus|Pulse|84|EYES, EARS, MOUTH, NOSE AND THROAT: Are grossly within normal limits. Carotids are 2+ bilaterally without bruits. LUNG: Fields are clear.
Plus|Pulse|234|This was following IV Lasix in the emergency department. VITAL SIGNS: Blood pressure 130/72, heart rate 70s with a regular rhythm, respirations nonlabored, O2 sat 94% on 4 L and temperature 101 degrees. HEENT: Unremarkable. Carotids 1+ without bruits. CHEST: Fairly good inspiratory effort with rales at the right base (chronic).
Plus|Pulse|209|ABDOMEN: Well-healed midline incision. The catheters are located in the left graft in the thigh region with one being directed cephaladly and the other caudally. A +3 right thigh and posterior tibial pulse. A +2 left above knee PTFE pulse. The foot is somewhat cooler than the right foot. However, motor and sensory intact.
Plus|Pulse|83|His right groin is healing well with minimal ecchymosis, no bruit. There are 2 to 3+ palpable pulses in the right femoral right dorsalis pedis and right posterior tibial locations.
Plus|Plus|43|FINAL DIAGNOSIS: Stage B II (T2b) Gleason 3+4=7 adenocarcinoma of prostate. NARRATIVE: The patient is a 64-year-old male referred for evaluation and consideration of treatment following diagnosis of adenocarcinoma of prostate.
Plus|Present|221|She has had no blood in the stool, no bile, no hematemesis, no cough or runny nose, not lethargic, no rash. PAST MEDICAL HISTORY: No surgeries or hospitalizations. She was a term child with blood type of A positive, DAP 1+ positive, neonatal screen within normal limits. Peak bilirubin was 8.6 in hospital on _%#MMDD2007#%_, up 0.6 from the previous day.
Plus|Pulse|156|LUNGS: Clear to auscultation with decreased breath sounds all over. ABDOMEN: Soft, no hepatosplenomegaly, normal bowel sounds. EXTREMITIES: No pedal edema, +2 pulses bilateral and equal. SKIN: There is a follicular rash over the upper chest.
Plus|Edema(swelling)|149|Most recently, he underwent a dialysis shunt placement to his left forearm. The patient immediately did have swelling following his surgery. He has 3+ pitting edema from the elbow down to his fingers.
Plus|Reflexes|127|Normal bowel sounds. She is not particularly tender and there are no masses. EXTREMITIES: Reveal thin legs, no edema. She has 2+ bilateral patellar reflexes. SKIN: Is intact. EKG shows the expected AV node dissociation.
Plus|Pregnancy dating|86|FINAL HISTORY AND HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 24-year-old G1, P0 at 40+6 estimated gestational age who presented on _%#MMDD#%_ for induction for post-dates. Prenatal course was uncomplicated. Patient was admitted and Pitocin augmentation begun.
Plus|Pregnancy dating|83|FINAL HISTORY/HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 36-year-old, G1 P0, at 38+5 weeks estimated gestational age. She was admitted in early labor with elevated blood pressures.
Plus|Present|127|He is really not receiving intravenous fluids. Heart rate is 90-100. His mucous membranes are dry. Conjunctiva are red. He has +4 neck vein distention supine. HEART: Tones are a bit muffled. No gallop or murmur heard.
Plus|Excess|141|ABDOMEN: Gravid with fetus in the vertex presentation. Heart tones present. PELVIC: Cervix exam not performed. IMPRESSION: 1) Pregnancy at 39+ weeks gestation. 2) History of previous cesarean section x2. 3) Desires permanent tubal sterilization.
Plus|Excess|158|PAST MEDICAL HISTORY: 1. Hyperlipidemia. Last lipid possibly in the 250 range. No medication treatment. 2. Tobacco abuse, quit _%#MM2001#%_. Weight gain of 30+ pounds since stopping. 3. Uterine cancer in the 1970's, status post total abdominal hysterectomy and bilateral salpingo-oophorectomy.
Plus|Pulse|122|There are no other organomegaly or masses, bowel sounds are normal and no bruits. Distal lower extremity pulses are 1 to 2+, no clubbing, cyanosis, or edema. Musculoskeletal is without synovitis. Right knee wound is presently covered with a dressing.
Plus|Reflexes|131|No edema. SKIN: Intact. LYMPHADENOPATHY: Negative. NEUROLOGICAL EXAM: Intact cranial nerves II-XII. Deep tendon reflexes reactive, +2 and symmetric in upper and lower extremities and no peripheral neuro findings.
Plus|Edema(swelling)|138|ABDOMEN: Is soft and non-tender without any masses. GENITALIA, RECTAL AND PROSTATE EXAMINATIONS: Are deferred. EXTREMITIES: Show edema 2-3+ with some weeping bleb area in the left lower shin area and with some slight erythema.
Plus|Pulse|78|CARDIAC: Tachycardic. Normal S1, S2. No murmurs or extra sounds. Carotids are +2 bilaterally. Peripheral pulses in all four extremities are brisk and symmetric without lower extremity edema.
Plus|Blood type|110|PRENATAL CARE: This was at CUHCC Clinic as well as in _%#CITY#%_ _%#CITY#%_. Prenatal labs were a blood type A+, antibody screen negative, hemoglobin ranged from 13.2 to 10.6. Rubella immune.
Plus|Pregnancy dating|151|_%#NAME#%_ was delivered via C-section with Apgar scores of 7 at one minute and 9 at five minutes. _%#NAME#%_ was a term AGA male infant, 2930 gm at 37+0 weeks gestation, with a length of 50 cm and head circumference of 34.75 cm.
Plus|Excess|199|Urine negative for sugar and protein. Hemoglobin 13.2. The LUNGS are clear and the HEART feels normal sinus rhythm. The fundal height measures 40 cm and the clinical estimated fetal weight today is 9+ pounds. IMPRESSION: 1. Macrosomia both on clinical examination and by ultrasound.
Plus|Heart murmur|88|A. Left ventricle mildly dilated with an EF of 40%. B. Normal RV function. C. There was +1 mitral regurgitation. D. Calcified posterior leaflet. E. Mild aortic insufficiency. F. Mild aortic stenosis and calcified valve.
Plus|Pregnancy dating|214|She had an ultrasound on __ + 5 weeks giving an EDD of _%#MMDD2004#%_, the date of that ultrasound was 3/5, she had a repeat ultrasound at 10+3 weeks which showed resolution of a previously noted cyst. She had a 22+1 week ultrasound on _%#MMDD2004#%_, her LMP was _%#MMDD2004#%_, dating was based on 6+5 week ultrasound.
Plus|Excess|63|DOB: _%#MMDD1973#%_ PREOP DIAGNOSIS: Intrauterine pregnancy, 39+ weeks' gestation; previous low segment transverse cesarean section; patient declines trial of labor after cesarean section; patient requests repeat cesarean section, patient requests permanent sterilization. PROPOSED PROCEDURE: Repeat low segment transverse cesarean section, bilateral postpartum tubal sterilization.
Plus|Pregnancy dating|129|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ presented to labor and delivery as a 39-year-old gravida 1, para 1-0-0-1 at 38 + 3 weeks' gestation by last menstrual period of _%#MMDD2004#%_ for a scheduled cesarean section secondary to transverse lie. She denied any contractions, loss of fluid, or vaginal bleeding.
Plus|Pregnancy dating|113|Cervical exam is deferred. EXTREMITIES are nontender with minimal edema. IMPRESSION: Intrauterine pregnancy at 38+5 weeks gestation. History of prior cesarean section. Declines trial of labor. PLAN: Proceed with repeat cesarean section on _%#MMDD2004#%_.
Plus|Pregnancy dating|206|The patient is Group strep negative at 36 weeks. Her cervix is closed and 50% effaced at -2 station. IMPRESSION: Intrauterine pregnancy at 39+0 weeks scheduled for repeat cesarean delivery in two days at 39+2 weeks on _%#MMDD2005#%_. The patient has a history of a prior cesarean delivery and desires delivery by repeat cesarean section.
Plus|Reflexes|101|Femoral, dorsalis pedis and posterior tibial pulses normal. ORTHO: Normal. NEURO: Patellar reflexes 2+. SKIN: Normal. LABORATORY: Lipase 8400, troponin-I normal.
Plus|Pregnancy dating|59|PRELIMINARY ADMITTING DIAGNOSES: 1. A twin pregnancy at 37 +3 weeks 2. Twin A in breech presentation. 3. Mild preeclampsia. DISCHARGE DIAGNOSES: Status post primary low-transverse cesarean section with delivery of a twin male and twin female on _%#MMDD2005#%_.
Plus|Pulse|191|NECK: Supple. No lymphadenopathy, thyromegaly. LUNGS: Clear bilaterally. CARDIOVASCULAR: Irregularly irregular with about a 2/6 systolic murmur. ABDOMEN: Soft. EXTREMITIES: Pulses are about 1+ bilaterally and warm. LABORATORY: White count 24.4, hemoglobin 4.5, platelets 23, creatinine 2.5.
Plus|Edema(swelling)|119|Bowel sounds are normally active. GENITORECTAL: Genital and rectal exams are deferred. EXTREMITIES: Demonstrate about 1+ edema. NEUROLOGIC: Demonstrates no sign of focal deficit, and in particular there is no weakness of either arms or either leg.
Plus|Excess|269|2. Chronic hypertension. DISCHARGE DIAGNOSIS: Status post primary low segment transverse cesarean section for cephalopelvic disproportion and persistent occiput posterior position. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 39-year-old female, gravida 3, para 1, at 39+ weeks gestation with chronic hypertension, admitted to Labor and Delivery on _%#MMDD2006#%_ for labor induction.
Plus|Pregnancy dating|235|PRELIMINARY ADMITTING DIAGNOSIS: Intrauterine pregnancy with previous cervical surgery with cervical stenosis. PROCEDURES: Primary low segment transverse cesarean section. HISTORY: _%#NAME#%_ _%#NAME#%_ is a 35-year-old gravida 1 at 40+1 weeks gestation who was admitted for primary cesarean section.
Plus|Pulse|199|MOUTH/THROAT: Intubated. Mucous membranes moist. LUNGS: Clear to auscultation bilaterally with no wheezes or crackles. CARDIOVASCULAR: S1, S2, no murmurs; regular rate and rhythm. Peripheral pulses 2+ bilaterally, symmetrical. ABDOMEN: Positive bowel sounds, soft, nondistended, no hepatosplenomegaly. LYMPHATICS: No lymphadenopathy.
Plus|Pregnancy dating|215|DISCHARGE DIAGNOSES: 1. Delivery of viable male infant weighing 3410 g. 2. Previous cesarean section x 2. 3. Blood loss anemia. HISTORY OF PRESENT ILLNESS: The patient is a 34-year-old gravida 7, para 2-0-4-2 at 38 + 6 weeks intrauterine pregnancy by sure last menstrual period of _%#MMDD2002#%_, consistent with a 7 + 6 week ultrasound on _%#MMDD2003#%_ with an EDC of _%#MMDD2003#%_.
Plus|Plus|190|The infant was delivered via C-section with Apgar scores of 8 at one minute and 9 at five minutes. _%#NAME#%_ was a term AGA male infant, 3350 gm at 40+6 weeks gestation, with a length of 49+5 cm and head circumference of 36 cm. He was transferred to the NICU for Respiratory distress. The admission physical examination was significant for pallor, tachypnea, heart exam showed a I/VI systolic murmur best heard in LSB and split S2.
Plus|Reflexes|162|PELVIC/RECTAL: Deferred. EXTREMITIES: No cervical, axillary or femoral nodes. Femoral and dorsalis pedis pulses normal. ORTHO: Normal, normal patellar reflexes, 2+. SKIN: Normal. ASSESSMENT: 1) Urinary incontinence. 2) Migraine headaches. 3) Retinopathy. PLAN: Approved for surgery.
Plus|Plus|224|10. EKG showing normal sinus rhythm, no ST-T wave abnormalities or conduction abnormalities. 11. Cardiac echo showing normal LV function, EF 65-70%, no wall motion abnormality, normal chamber sizes, moderate TR, pressures 36+ RA. HISTORY OF PRESENT ILLNESS: Please see admission H&P. PAST MEDICAL HISTORY: Please see admission H&P.
Plus|Pulse|105|LUNGS: Clear to auscultation bilaterally. CARDIAC: Regular rate and rhythm without murmurs. Pulses were 2+. ABDOMEN: Nondistended. Bowel sounds were present.
Plus|Edema(swelling)|215|HEART: S1 and S2 are physiologic. ABDOMEN: Obese, not distended. Bowel sounds are normal. No abdominal tenderness. GENITAL/RECTAL: Deferred. EXTREMITIES: Nontender with chronic venous stasis changes and a trace to 1+ pretibial edema. His pulses were 2/4+ bilaterally symmetrical throughout. No calf tenderness.
Plus|Strength|114|Moderate left upper extremity drift. Gait not tested due to unstable status. Deltoids 5/3, biceps 5/3, triceps 5/4+, digit extensors 5/4+, finger flexors 5/5, wrist extensors 5/4, wrist flexors 5/4.
Plus|Pregnancy dating|278|DISCHARGE DIAGNOSES: 1. Status post primary low transverse cesarean section. 2. Acute blood-loss anemia. OPERATIONS/PROCEDURES PERFORMED: Primary low transverse cesarean section. COMPLICATIONS: None. HISTORY OF PRESENT ILLNESS: This patient is a 37-year-old G5, P2-0-2-2, at 36 + 5 weeks' gestation by last menstrual period, consistent with a 19 + 1 week ultrasound, who presents to labor and delivery with spontaneous rupture of membranes.
Plus|Reflexes|201|Bowel sounds were present. EXTREMITIES: Symmetrical for tone. There is some weakness in the lower extremities bilaterally. She has good symmetric upper extremity grip strength. DTRs are diminished at 1+/4+ bilaterally in the upper and lower extremities. There is no lower extremity edema. She has no tremor noted.
Plus|Reflexes|244|Ears were without any abnormalities. Neck: Supple. No lymphadenopathy. Cardiovascular: Regular rate without any murmur. Lungs: Clear bilaterally. Abdomen: Soft and nontender. No hepatosplenomegaly. Lower extremities reveal deep tendon reflexes +1 bilaterally. Decrease in sensitivity bilaterally. Normal strength. Cranial nerve 2 through 12 were intact.
Plus|Edema(swelling)|133|HEART: Demonstrates an S4, but otherwise is negative. ABDOMEN: Negative. EXTREMITIES: Demonstrate distal dependent edema of about 1-2+. ASSESSMENT: The patient's cardiac decompensation with subsequent pulmonary edema is presumably on the basis of her hypertensive heart disease, inadequate control of volume status may also be leading to the current problems.
Plus|Excess|287|Bilateral postpartum tubal ligation. SURGEON: Dr. _%#NAME#%_ _%#NAME#%_. PATIENT IDENTIFICATION: _%#NAME#%_ _%#NAME#%_ is a 25-year-old, single woman, gravida XI, para III-0-VII-III, with an LMP of _%#MMDD2004#%_, and a due date of _%#MMDD2005#%_ confirmed by a 21-week ultrasound. At 36+ weeks gestation, who is evaluated at Fairview Ridges Labor and Delivery for evaluation of vaginal mucous passage and lower abdominal swelling.
Plus|Plus|85|PROBLEMS: 1. Scoliosis. 2. MRSA in the past. 3. Port-A-Cath. DIET: G-tube feeds Neo-K+1, 428 mL plus 120 mL of free water via G- tube q.i.d., and the patient to have no food after 1 a.m. on _%#MM#%_ _%#DD#%_, 2005, and may have clear liquids until 5 a.m. on _%#MM#%_ _%#DD#%_, 2005.
Plus|Pulse|233|Heart tones are distant. ABDOMEN: Nontender, nondistended without hepatosplenomegaly. No masses or bruits. Bowel sounds are normal. EXTERNAL GENITALIA, RECTAL: Deferred EXTREMITIES: Without calf tenderness, edema, peripheral pulses 2+ symmetric without bruits. IMPRESSION: 1. Atrial fibrillation with fast ventricular response and associated congestive heart failure .
Plus|Pulse|151|Bowel sounds are normal. EXTERNAL GENITALIA, PELVIC, RECTAL: Deferred. EXTREMITIES: Without calf tenderness, Homan's, or edema. Peripheral pulses are 2+ symmetrical without bruits. NEUROLOGIC: Able to move all extremities. Normal fine touch in all extremities.
Plus|Excess|206|With regard to her cancer status, she has most recently been on oral VP16. Unfortunately in addition to the bilateral pleural effusions which are new, she has also had a dramatic rise in her CA-125 (119,000+). Of note is that in the fall of 2005, the patient was noted to have some ataxia and CT scan of her brain revealed multiple brain metastases.
Plus|Pulse|142|ABDOMEN: Mildly obese but nontender without organomegaly, mass or bruit. Femoral pulses are 2+ without bruits. EXTREMITIES: Pedal pulses are 2+ and symmetrical. There is 1+ to 2+ chronic pitting edema two-thirds of the way to the knee on the left with chronic stasis changes and some pigmentation as well as dependent rubor.
Plus|Edema(swelling)|103|CARDIOVASCULAR: Regular rate and rhythm, no murmur. ABDOMEN: Soft, nontender. EXTREMITIES: Revealed 3-4+ pretibial and 2+ pedal edema bilaterally. She has erythematous skin changes on the left lower leg.
Plus|Plus|232|HISTORY OF PRESENT ILLNESS: The patient underwent the above mentioned procedures under a general endotracheal anesthetic with a 250 cc blood loss. Postoperative course was uneventful. Final pathology revealed a Gleason score of 7 (4+3) carcinoma of the prostate with the clinical stage of T2A, NOMX.
Plus|Strength|169|Normal dexterity and speed. Strength is 5/5 in the upper extremities bilaterally including SA, EE, EF, WE, WF, FE, DI. Strength in the left lower extremity HF4, KE5, KF4+, PF5, DF4+. Strength of the lower extremity 4+HF, 5KE, 4+KF, 5PF, 5DF.
Plus|Heart murmur|378|The left lung is otherwise clear. There is two focal ill-defined small nodular densities in the right mid and right lower lung that could represent pulmonary nodules or mild nodular infiltrates that are new since _%#MMDD2006#%_. Recommendation for follow with CT in the future. 3. Echocardiogram which showed an ejection fraction of 65-70% with normal LV systolic function with +1 aortic regurgitation. No evidence of aortic stenosis. Doppler flow pattern suggestive of impaired LV relaxation.
Plus|Edema(swelling)|130|ABDOMEN: Nontender, no masses. RECTAL EXAM and PELVIC: Deferred. NEUROLOGIC: Grossly normal. Babinski's plantar flexion. She has 2+ posterior tibials and 1+ pedals. No edema. LABORATORY DATA: Normal EKG. Hemoglobin 13.5, potassium 4.0. UA is negative.
Plus|Edema(swelling)|121|There are normal bowel sounds and it is somewhat distended, but soft and nontender. EXTREMITIES: Lower extremities show 1+ edema and diminished pulses. Hands show muscle atrophy in the interosseous position. She does have some contractures and trigger finger is obvious.
Plus|Edema(swelling)|113|There is no drainage. There were Steri-Strips across the incision. Distal CMS is intact. There is approximately 1+ left lower extremity edema postsurgically. Right lower extremities unremarkable. His grip strength is symmetrical. Reflexes are diminished at 1+/4+ in the upper and lower extremities bilaterally.
Plus|Edema(swelling)|193|There are distant, quiet heart tones without a gallop. There is a III/VI systolic murmur at the apex compatible with his mitral insufficiency. ABDOMEN: Protuberant and firm. EXTREMITIES: 2 to 3+ pretibial edema, remarkably has pretty good dorsalis pedal pulses and good capillary refill.
Plus|Edema(swelling)|134|She will discharged home on postoperative day #3. Her examination was normal with incision being clean, dry and intact. She did have 2+ pitting edema but this was relatively nontender. At this time she is ambulating, voiding, and tolerating a regular diet.
Plus|Pulse|137|CARDIOVASCULAR: Cardiac rhythm is regular. Normal S1 and S2. Heart rate is 59. No murmurs or gallops. No bruits. No edema. PULSES: 3 to 4+ in the lower extremities. ABDOMEN: Soft, nontender without masses or hepatosplenomegaly. Bowel sounds are normal.
Plus|Pregnancy dating|220|Ultrasound #2 on _%#MMDD2004#%_ at 22 plus one week, at this time showed the infant was measuring 23 plus 4 weeks, fundal placenta, and normal anatomy. Ultrasound #3 on _%#MMDD2004#%_ at 27 plus 5 weeks was measuring 30 + three, showed normal ventricles, and posterior fundal placenta.
Plus|Pulse|57|No calf pain and no signs of infection at present time. 2+ pulses, normal __________ bilateral lower extremities.
Plus|Pregnancy dating|53|ADMISSION DIAGNOSES: 1. Intrauterine pregnancy at 27 +0 weeks. 2. Preterm contractions with history of previous preterm delivery. 3. Bicornate uterus.
Plus|Plus|169|It is also restricted in its excursion. The degree of mitral regurgitation was judged to be grade 3+. There is trace aortic regurgitation. The RV systolic pressure is 42+ mean right atrial pressure. She underwent adenosine thallium test to assess for any worsening coronary artery disease that may explain her presentation in heart failure.
Plus|Pulse|92|Bowel sounds are present. EXTREMITIES: Extremities without cyanosis or edema. Pulses are 1-2+ below the femorals, 2+ above. NEURO: Neurologic exam was not done in detail. The patient was able to move all extremities and respond to sensory stimuli.
Plus|Pulse|125|LUNGS: Clear to auscultation bilaterally. ABDOMEN: Soft and nontender with good bowel sounds. EXTREMITIES: Trace edema with 2+ dorsalis pedis pulses. NEUROLOGIC: There is 0 to 1 out of 5 strength in his right upper and right lower extremities, unchanged subjectively.
Plus|Pulse|179|No evidence for hepatojugular reflux. It is difficult to assess for organomegaly given the patient's body habitus. EXTREMITIES: No peripheral edema. VASCULATURE: The patient has 2+ radial pulses and 1+ dorsalis pedis and posterior tibialis pulses bilaterally.
Plus|And|72|9. Betoptic eyedrops 0.25% one drop in each eye b.i.d. 10. Caltrate 600 + vitamin D1 p.o. b.i.d. 11. Fosamax 70 mg weekly. 12. Glucotrol 5 mg daily.
Plus|Pulse|109|CARDIOVASCULAR: Regular rate without murmur. ABDOMEN: Mildly obese, soft, nontender with no hernias. PULSES: +3 right and +2 left radial pulse. A +3 right dorsalis pedis pulse is noted with no palpable left pedal pulses.
Plus|Pulse|109|No perineal signs are present. Bowel sounds are present but slightly hypoactive. PULSES: Femoral pulses are 4+ in the ankle bilaterally. EXTREMITIES: No evidence of cyanosis, clubbing or edema. NEURO: Cranial nerves II-XII are intact.
Plus|Strength|169|He does have tremors of bilateral upper extremities. ..........drift is negative. All muscle groups on the right side, upper extremity and lower extremity are rated at 4+/5. Note on the on the left I wrote it 5/5.
Plus|Edema(swelling)|117|CARDIOVASCULAR: S1, S2, tachycardic. ABDOMEN: Soft, nontender, nondistended. BACK: Mild CVA tenderness. EXTREMITIES: +2 edema of her right lower extremity. There is old skin breakdown and ecchymosis around the upper part of her left lower extremity, ankle.
Plus|Edema(swelling)|123|ABDOMEN: Gravid with breech presentation and the fetal vertex in the right upper quadrant. CERVIX: Deferred. EXTREMITIES: 1+ edema. LABORATORY DATA: The patient's prenatal labs include a blood type of O positive with a negative antibody screen, pap smear normal, rubella immune, VDRL non-reactive, urine culture negative, hepatitis B surface antigen negative, HIV negative, GC and chlamydia negative, cystic fibrosis negative, Group B strep negative at 36 weeks gestation, and her last hemoglobin was 12.3 on _%#MMDD2007#%_.
Plus|Positive(laboratory test)|400|She was a 2180 gm, 32+6 week gestational age female infant born at the University of Minnesota Children's Hospital, Fairview to a 24-year-old, gravida 1, para 0-0-0-0, blood type O positive, Caucasian female whose LMP was _%#MMDD2006#%_ and whose EDC was _%#MMDD2007#%_. The mother's pregnancy was complicated by a maternal history of lupus, rheumatoid arthritis, asthma, multiple drug allergies, GBS+ status, and a prenatal diagnosis of gastroschisis.
Plus|Pregnancy dating|158|They were checked the day of surgery and were again unremarkable. Preoperative hemoglobin was 11.0. ASSESSMENT: This is a 32-year-old gravida 3, para 2, at 31+3 weeks gestation with chronic hypertension, admitted with accelerating blood pressures with recent antenatal testing that was nonreassuring, with oligohydramnios and elevated S/D ratio on Doppler studies.
Plus|Reflexes|102|Fetal heart tracing baseline 140s and reactive. Toco contraction of every 6-10 minutes. EXTREMITIES: 3+ DTRs and no clonus. ANTENATAL COURSE: Magnesium was initiated.
Plus|Pulse|212|NECK: No lymphadenopathy. LUNGS: Clear to auscultation bilaterally. CARDIOVASCULAR: Regular rate and rhythm, S1, S2. ABDOMEN: Bowel sounds are positive, nontender, nondistended. EXTREMITIES: Showed trace edema, 2+ pulses. LABORATORY DATA: From clinic white blood cell count 7.4, hemoglobin 6.3, hematocrit 21.4, platelet count 399.
Plus|Heart murmur|124|The patient had an improved chest x-ray which showed mild pleural effusions. The patient had an echocardiogram which showed +1 mitral regurgitation and bilateral pleural effusion, evidence of pulmonary hypertension.
Plus|Strength|188|She has tenderness to palpation about the knee. There is valgus deformity of the right knee and she has intact dorsalis pedal pulse. Extensor hallucis longus and flexor hallux longus are 4+/5 on the right. She can plantar flex and dorsiflex the foot without pain.
Plus|Pregnancy dating|175|Since rupture of membranes, the patient had contractions every three minutes that lasted approximately 40 seconds, which were mild by palpation. PRENATAL CARE: Care began at 9+ 6 weeks on _%#MMDD2004#%_. The patient had 10 visits with the nurse midwives at Fairview Riverside Women's Clinic.
Plus|Positive(laboratory test)|131|LAB DATA: White blood cell count is normal. Influenza is negative. Troponin negative times three. BNP is 2200. Urinalysis shows 300+ protein, 500 glucose, trace blood. EKG shows slight T wave inversions in AVL that are slightly more pronounced than prior EKG, but only in this lead and as noted his troponins are negative .
Plus|Plus|150|HOSPITAL COURSE: PROBLEM #1: Graft. Ms. _%#NAME#%_ has stable counts and is fully donor engrafted as of _%#MMDD2005#%_. He is scheduled to have a day +100 bone marrow biopsy on _%#MMDD2005#%_. This is a routine day 100 post transplant evaluation. PROBLEM #2: Hemorrhagic cystitis.
Plus|Uncommon rating|208|Extremities: Edema 2+. LABOR COURSE: The patient was admitted to labor and delivery for induction of labor secondary to preeclampsia. She had been noted to have elevated blood pressures as well as edema and 3+ protein in clinic on the day prior to admission. On bedrest in the hospital, the patient's blood pressures initially were improved.
Plus|Strength|167|He is not able to fully adduct his thumb to his fifth digit but can reach his fourth digit. Hip flexor strength bilaterally is grade 2. Knee extensor on the right is 3+ and on the left 2+. Ankle dorsiflexion on the right is approximately 4 and 3- on the left.
Plus|Pulse|93|Decreased bowel sounds. EXTREMITIES: Femoral pulses are 2+ without bruits. Pedal pulses are 2+ and symmetrical. There is no pedal edema, cyanosis or erythema.
Plus|Strength|344|Briefly, the patient was admitted for elective cytoxan infusion, further treatment of both his chronic inflammatory demyelinating polyneuropathy and idiopathic thrombocytic purpura, and subsequent readmission for increased weakness in his lower extremities. HOSPITAL COURSE: The patient was admitted to the neurology service and initially had 3+ out of 5 strength in both lower extremities to manual motor testing.
Plus|Edema(swelling)|111|LUNGS: Clear. ABDOMEN: Negative. There is no tenderness to palpation and no masses are palpable. EXTREMITIES: 1+ edema at the right lower extremity, trace on the left.
Plus|Reflexes|127|Cranial nerves II through XII are within normal limits. Strength is 5/5 in all extremities. Sensory is symmetric. Reflexes are +2 DTRs. HOSPITAL COURSE: As mentioned previously, _%#NAME#%_ was admitted in order to wean milrinone to off and to observe him after discontinuing milrinone as previously he did not tolerate being off milrinone.
Plus|Plus|244|PRELIMINARY UNTIL SIGNED DISCHARGE DIAGNOSES: 1. Status post auto, as part of auto-auto tandem transplant for kappa light chain multiple myeloma. 2. Mucositis. HISTORY OF PRESENT ILLNESS: This is a 65-year-old female with multiple myeloma, day +8 after an autologous transplant on _%#MMDD2006#%_ as part of an auto-auto tandem protocol.
Plus|Plus|305|This showed a large right-sided pulmonary embolism involving upper and lower lobe pulmonary segments. He then went on to have a transthoracic echocardiogram. This indeed revealed that he did have a large pulmonary embolism causing some right heart strain, in that he had elevated pulmonary pressures of 48+ RA , he had hypokinetic right ventricle with moderately elevated pulmonary hypertension.
Plus|Edema(swelling)|98|CARDIOVASCULAR: Regular rate and rhythm. ABDOMEN: Soft, nontender, bowel sounds x4. EXTREMITIES: 1+ edema with right posterior tibial sore. This was noted for the past couple of days. It is shooting sharp pains.
Plus|Edema(swelling)|225|She is mildly tender in the left lower quadrant. She has most likely an umbilical area hernia but it is difficult to fully assess. No masses are appreciated. EXTREMITIES: She has trace edema in the right lower extremity and 1+ edema left lower extremity. SKIN: No rashes. NEUROLOGIC: No focal deficits. LABORATORY DATA: CT scan which I personally reviewed shows an anterior abdominal wall hernia containing: No signs of colonic inflammation or abscess.
Plus|Pulse|120|There is also some bluish discoloration on the left lower leg status post knee surgery, patient says. No edema. He has 3+ bilateral femoral pulses and 3+ bilateral DP pulses.
Plus|Pulse|105|No hepatosplenomegaly or other masses are noted. Extremities: 1+ pitting edema at the bilateral ankles. 2+ dorsalis pedis pulses bilaterally. No clubbing or cyanosis.
Plus|Edema(swelling)|164|CORONARY: Irregularly irregular. No murmur appreciated. ABDOMEN: Normal active bowel sounds, nontender to deep palpation. Wearing Depends. EXTREMITIES: There is 2-3+ pitting edema of his normally thin ankles bilaterally.
Plus|Reflexes|186|Shoulder shrug within normal limits. Motor examination showed normal tone, bulk, and strength in the upper and lower extremities. Strength was 5/5 bilaterally throughout. Reflexes were 2+ throughout symmetrically. Toes were downgoing bilaterally. Sensory examination was normal for all modalities.
Plus|Pulse|226|HEART: Normal S1, S2 with 2/6 systolic ejection murmur. LUNGS: Bilateral rales on lung auscultation with decreased breath sounds basilar. ABDOMEN: Soft, no hepatosplenomegaly, normal bowel sounds. EXTREMITIES: No pedal edema, +1 pulses bilateral and equal. SKIN: No rash, wound or ulcer NEUROLOGIC: Nonfocal with normal cranial nerve and motor power.
Plus|Strength|199|Facial sensation intact to pinprick bilaterally. Smile is symmetrical, nasolabial folds symmetrical. Shoulder shrug strong. Strength exam limited by effort. Upper extremities: Right elbow extension 4+, left elbow extension 4+, right elbow flexion 5, left elbow flexion 5, right wrist flexion 4+, left wrist flexion 4+, right wrist extension 4+, left wrist extension 4+, left hip flexion 4, right hip flexion 4, left dorsiflexion 5, right dorsiflexion 5.
Plus|Edema(swelling)|139|No murmurs, gallops or rubs are present. ABDOMEN: Soft, nontender, bowel sounds present, there is no hepatosplenomegaly. EXTREMITIES: Have +3 pitting edema bilaterally though there is no skin breakdown.
Plus|Pulse|183|CARDIAC: Regular S1, S2, without murmurs, rubs, or gallops. ABDOMEN: Scaphoid, without distention, without tenderness, without organomegaly. EXTREMITIES: Without edema. Distal pulses +2. DERMATOLOGIC: Without rash. NEUROLOGIC: Cranial nerves II through XII without deficit. Remainder of the exam is without focal deficit.
Plus|Pulse|134|ABDOMEN: Soft, nontender, normal bowel sounds, no masses or organomegaly. EXTREMITIES: Shows no clubbing, cyanosis or edema. She had 2+ pulses. NEUROLOGIC: Intact. DIAGNOSTIC DATA: White count is 20 and chest x-rays and CT shows developing pneumonia.
Plus|Edema(swelling)|142|Hyperresonant to percussion with dullness starting around the mid-axillary line bilaterally, unable to appreciate organomegaly. EXTREMITIES: 3+ lower extremity pitting edema bilaterally. No cyanosis or clubbing. SKIN: Rash located on the upper arms, erythematous confluent areas, nonraised.
Plus|Reflexes|290|She does have neck stiffness. However, there is a negative Brudzinski's and a negative Kernig's as passive flexion of her neck did not cause any hip or knee flexion and passive flexion of her hip and knee with extension of her knee did not cause any passive flexion of her neck. Reflexes: 2+ patellar, 1+ Achilles, downgoing toes and no clonus bilaterally.
Plus|Edema(swelling)|87|There is no rebound or guarding. There are positive bowel sounds. EXTREMITIES: Reveal 1+ pitting edema bilateral lower extremities. LABORATORY STUDIES: WBC of 14.8, hematocrit of 36.2, platelets of 332,000.
Plus|Edema(swelling)|155|She has large incision site with staples in place. She has a right lower quadrant ostomy bag placed over the previous JP drain site. EXTREMITIES: She has 3+ edema. NEUROLOGIC: Cranial nerves II-XII grossly intact.
Plus|Blood type|112|Blood cultures obtained on admission were negative. Problem #3: Hyperbilirubinemia. _%#NAME#%_'s blood type is A+; maternal blood type is A+. Antibody screening tests were negative. _%#NAME#%_ received phototherapy for a total of 2 days for a peak bilirubin level of 7.6 mg%.
Plus|Reflexes|77|Sensory exam is normal. Motor exam - he is moving all extremities. DTRs are 2+, bilateral and symmetric. Babinski's are downgoing.
Plus|Edema(swelling)|151|Left lower base with crackles. CARDIAC: Regular rate and rhythm. ABDOMEN: Positive bowel sounds, soft, nontender, nondistended. EXTREMITIES: Trace to 1+ edema. NEURO: Cranial nerves II-XII are grossly intact. SKIN: Without suspicious lesions.
Plus|Uncommon rating|148|Uterus was anterior, slightly enlarged consistent with a 5-6 week pregnancy which is by dates what she was supposed to be. Adnexa on the right was 2+ tender but no definite mass could be felt. Slightly tender on the left adnexa. IMPRESSION: Pregnancy with right pelvic pain, rule out right ectopic pregnancy.
Plus|Pregnancy dating|58|FINAL ADMISSION DIAGNOSES: 1. Intrauterine pregnancy at 39+2 weeks' gestation. 2. History of prior cesarean section, declines trial of labor.
Plus|Reflexes|178|There is no hepatosplenomegaly or masses. EXTREMITIES: No clubbing, cyanosis or edema NEUROLOGIC: Cranial nerves II-XII are intact. Sensory and motor exams are normal. DTRs are 2+ bilateral and symmetric. Gait is unremarkable. LABORATORY DATA: Shows atrial fibrillation with a rate in the 70s-80s.
Plus|Pregnancy dating|174|PROCEDURES: 1. Primary low segment transverse cesarean section. 2. Spinal. 3. Foley catheterization. HISTORY OF PRESENT ILLNESS: This is a 31-year-old gravida 1, para 0 at 39+4 weeks' gestational age who arrived to Labor and Delivery on _%#MMDD#%_ with spontaneous rupture of membranes.
Plus|Pulse|146|HEART: Regular rate and rhythm. ABDOMEN: Soft, nontender, nondistended with positive bowel sounds. EXTREMITIES: Trace edema in bilateral ankles, 2+ dorsalis pedis pulses bilaterally. LABORATORY STUDIES: Chest x-ray is negative. TSH 1.83, troponin is less than 0.04. Sodium 141, potassium 3.9, chloride 105, bicarb 28, glucose 103, BUN 13, creatinine 1, calcium 8.8, total bilirubin 0.3, albumin 4.5, total protein 7.8, alkaline phosphatase 108, ALT 23, AST 30.
Plus|Excess|190|He was admitted for an elective TIPS placement. The patient has recurrent ascites and abdominal pain. The patient has a long history of alcohol abuse, drinking 24 ounces of beer per day x 40+ years. He quit drinking 14 months prior to this admission. The patient was found to be hepatitis C positive, most likely secondary to IV drug abuse.
Plus|Excess|144|CHIEF COMPLAINT: Jaundice. HISTORY: _%#NAME#%_ _%#NAME#%_ is a four day old infant born of an uncomplicated pregnancy and vaginal delivery at 38+ weeks gestation. His birth weight was 7 pounds 14 ounces. Discharge weight was 7 pounds 5 ounces on _%#MMDD#%_.
Plus|Reflexes|177|LUNGS: Clear. ABDOMEN: Mildly to moderately distended. Bowel sounds sluggish and slightly tympanic. EXTREMITIES: Warm and dry. No obvious edema. Good pulses. Reflexes: Patella 1+, Achilles 2+, biceps 1-2+ and equal. RECTAL: 3+ prostatic enlargement without any obvious nodularity. Marked tenderness to digital rectal exam.
Plus|Positive(laboratory test)|178|She has a prior history of smoking, having stopped in the 70s. PAST MEDICAL HISTORY: 1. Hypertension. 2. 1.5 cm breast cancer with negative lymph nodes, ER positive, HER- 2/neu 1+, treated by mastectomy followed by tamoxifen. 3. Small cancer of the head and neck area. REVIEW OF SYSTEMS: She is not any more short of breath than she usually has been.
Plus|Blood type|178|PRENATAL CARE: Prenatal care began at 9 weeks' gestation. She was seen for a total of nine visits. Total weight gain was 26 pounds. Blood pressure 94/48. PRENATAL LABS: Include O+, antibody negative, RPR nonreactive, hepatitis B negative, hemoglobin 12.1, GC and Chlamydia negative, Pap normal, HIV negative, varicella immune, AST normal, GCT 108.
Plus|Plus|40|DISCHARGE DIAGNOSES: 1. Status post day +8 after an allo-sib peripheral blood stem cell infusion for AML, non-myeloablative prep. 2. Neutropenia. 3. History of Aspergillus pneumonia. 4. Heartburn.
Plus|Edema(swelling)|126|NEUROLOGIC -as above, he does have a resting tremor which worsens with activity. Rest of neurologic exam is normal. He has 1-2+ pitting edema of his ankles. SKIN - has no rashes, warm and dry.
Plus|Uncommon rating|134|HEART: Regular rate and rhythm without audible murmur. ABDOMEN: Soft, nontender, no hepatosplenomegaly. EXTREMITIES: Left knee has a 2+ effusion. There is diffuse tenderness. No ecchymosis, however. The knee is held in 10 degrees of flexion and she has pain with any active or passive motion.
Plus|Edema(swelling)|143|CARDIOVASCULAR: Regular rate and rhythm with normal S1, S2. ABDOMEN: Distended, positive bowel sounds, soft and nontender. EXTREMITIES: About 2+ edema to the shin. DP pulses are palpable. LABORATORY AND DIAGNOSTIC DATA: EKG shows sinus rhythm and is very similar to prior EKGs.
Plus|Excess|101|FINAL _%#NAME#%_ _%#NAME#%_ developed failure to progress in the occiput posterior presentation at 38+ weeks gestation. She desired permanent sterilization and underwent a primary low transverse cesarean section with a Parkland BPS.
Plus|Excess|184|PHYSICAL EXAMINATION: A brief physical examination is normal. The patient is prepared for cesarean section. Pelvic examination is described above. IMPRESSION: Intrauterine pregnancy 37+ weeks gestation, lack of satisfactory progress in labor, floating ballottable presenting vertex.
Plus|Pregnancy dating|160|Abdomen is nontender. EXTREMITIES: Nontender with 1+ edema bilaterally. CERVIX: Closed, long and high. ASSESSMENT: A 36-year-old, gravida 2, para 0-1-0-1 at 36 +6 weeks gestation with a di/di twin gestation who presents for repeat cesarean section.
Plus|Pulse|145|LUNGS: Clear to auscultation bilaterally. ABDOMEN: Soft, nontender, nondistended, with positive bowel sounds. EXTREMITIES: No peripheral edema. 2+ dorsalis pedis pulses bilaterally. There is no clubbing or cyanosis. NEUROLOGIC: Strength is 5/5 for bilateral upper and lower extremities.
Plus|Edema(swelling)|140|ABDOMEN: Soft, nontender, nondistended, positive bowel sounds, no organomegaly, no ascites. EXTREMITIES: No cyanosis or clubbing. There was +1 to +2 edema. LABORATORY: Investigations done today included a chest x-ray that showed bilateral pulmonary venous congestion.
Plus|Edema(swelling)|224|LUNGS: The patient had right-sided rhonchi throughout the right side, crackles at the left base otherwise clear on the left. ABDOMEN: Soft, nontender, nondistended, positive bowel sounds. EXTREMITIES: Patient with trace to 1+ pedal edema. NEUROVASCULAR: The patient has had 4-5 strength in his lower extremities with symmetric exam.
Plus|Edema(swelling)|180|HEENT: Sclerae are icteric. SKIN: Remarkably jaundiced throughout. RESPIRATORY: Chest is clear. CARDIOVASCULAR: Normal S1/S2, normal regular rate and rhythm. EXTREMITIES: She has 2+ edema. LABORATORY AND DIAGNOSTIC STUDIES: Creatinine is notably elevated at 2.1, baseline 0.6, sodium 23 which has been downtrending since _%#MMDD2006#%_.
Plus|Reflexes|162|The left lower extremity was also free of any clear numbness by the patient's report. Coordination was consistent with his strength. Reflexes were actually 0 to 1+ in the right lower extremity, perhaps 1+ in the left lower extremity and 2+ or slightly better in the upper extremities.
Plus|Excess|228|LABORATORY DATA: AB positive, antibody negative, serology nonreactive, rubella immune, GCT one hour 149, three hour within normal limits. PAST MEDICAL HISTORY: None. SURGICAL: Cesarean section. OB: Primary Cesarean section at 41+ weeks for failed induction, 7 pounds 14 ounces. Today the patient complains of some difficulty sleeping, otherwise the baby is active and she is having only occasional contractions.
Plus|Excess|64|PRELIMINARY ADMITTING DIAGNOSES: 1. Intrauterine pregnancy at 37+ weeks. 2. History of gestational diabetes. 3. Non reassuring fetal testing.
Plus|Reflexes|167|GENITOURINARY: Not performed. EXTREMITIES: No clubbing, cyanosis or edema. NEUROLOGIC: Cranial nerves II-XII are intact. Sensory and motor exams are normal. DTRs are 2+ bilateral and symmetric. LABORATORY DATA: Laboratory currently available includes a hemoglobin of 15.3 with a MCV of 84, which is on the low side for a 26-year-old male.
Plus|Heart murmur|142|There is mild biatrial enlargement. No dilation of the inferior vena cava is appreciable. The mitral valve and tricuspid valve are rated for 1+ for regurgitation. The same was noted for the aortic valve. The pulmonic valve was not visualized.
Plus|Excess|297|With the patient continuing to do well, on hospital day #3 she was discharged to home though a CBC obtained prior to discharge was unavailable at the time of this dictation DISCHARGE MEDICATIONS: 1. The only new medication to her regimen is a discharge order for doxycycline 100 mg p.o. b.i.d. x12+ plus days (25 with no refill). 2. She was also told to hold her Cozaar 25 mg p.o. every day due to low-normal systolic blood pressure values noted during her hospitalization causing us to hold her Cozaar during her entire hospital stay.
Plus|Pregnancy dating|53|ADMISSION DIAGNOSIS: 1. Intrauterine pregnancy at 33 +3 weeks gestation. REPORT ENDS HERE.
Plus|Heart murmur|278|_%#NAME#%_ _%#NAME#%_, age 72, was admitted because of decompensated congestive heart failure, underlying cardiomyopathy and unloading of his left ventricle using intravenous Dobutamine and other unloading agents. He ultimately had an ischemic cardiomyopathy with an EF of 25%, +3 mitral insufficiency, +3 tricuspid insufficiency, history of chronic atrial fibrillation, although, he has been in and out of a sinus rhythm.
Plus|And|116|7. Metoprolol 25 mg p.o. b.i.d. Hold if heart rate less than 60 or systolic blood pressure less than 90. 8. Calcium + Vitamin D 500 mg p.o. b.i.d. Start after the patient starts stooling.
Plus|Reflexes|157|BREASTS not examined. ABDOMEN soft, vertex, estimated fetal weight 8 pounds. The cervix is 25 percent and about 1, posterior. Muscle stretch reflex is 1 to 2+ with no focal neurological findings. IMPRESSION: Intrauterine pregnancy at term. Increasing pregnancy- induced hypertension. We will plan admission with Cytotec cervical ripening.
Plus|Pregnancy dating|132|Ultrasound #2 on _%#MMDD2002#%_ at 21 + 6 weeks' gestational age showed a posterior placenta. Ultrasound #3 on _%#MMDD2003#%_ at 38 + 6 weeks' gestational age showed an estimated fetal weight of 3548 gm, in the 75th percentile for growth.
Plus|Positive(laboratory test)|330|ADMITTING DIAGNOSES: 1. Intrauterine pregnancy at 36 6/7th weeks. 2. Twin gestation with vertex breech presentation. 3. Preeclampsia. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 28-year-old gravida 1-para 0 at 36 6/7th weeks who presented to the clinic for a routine obstetrical visit with blood pressures of 150/102, 3+ proteinuria, headache which she has had for approximately two-and-a-half-days.
Plus|Reflexes|123|No rashes. He has decreased sensation in a stocking glove distribution up to elbow in upper extremities. His reflexes are 1+ in both of his patellar deep tendon reflexes and were not elicited in his upper extremities.
Plus|Blood type|106|PRENATAL CARE: The patient's prenatal care was with Dr. _%#NAME#%_ and was uncomplicated. The patient is O+, rubella immune, VDRL negative, hepatitis B negative, and GBS negative.
Plus|Pulse|123|Musculoskeletal: Decreased range of motion of the cervical spine, otherwise 5/5 strength throughout. Peripheral vascular: 2+ pulses throughout. Skin: No edema or rash. Neurologic: Globally normal. PREOPERATIVE LABORATORY DATA: BUN and creatinine 20 and 0.9, respectively.
Plus|Reflexes|109|Good fetal heart tones of 156. Cervix closed. EXTREMITIES: Two plus edema bilaterally. NEUROLOGIC: Two plus/4+ patellar reflexes bilaterally. IMPRESSION: 1) Term pregnancy.
Plus|Reflexes|143|His left shoulder has crepitation with adduction and decreased external rotation. Motor was completely intact. His deep tendon reflexes are 3/4+ bilateral symmetrical throughout. His Babinski's were downgoing. LABORATORY STUDIES: His EKG shows normal change.
Plus|Edema(swelling)|95|No clubbing of digits. NEUROLOGIC: Cranial nerves II-XII are intact. No tremor. SKIN: There is +1 pitting edema in the lower extremities bilaterally.
Plus|Edema(swelling)|97|ABDOMEN: Soft, nondistended, bowel sounds are present. Foley catheter is in place. EXTREMITIES: 1+ lower extremity edema, there is no JVD. There is no evidence of any gross neurological deficit .
Plus|Pregnancy dating|71|PRELIMINARY ADMISSION DIAGNOSES: 1. This 36-year-old G2 P 0-0-1-0 at 29+ 1 weeks. 2. History of di-di IUP with donor eggs and IVF.
Plus|Pulse|104|His radial pulses are 3+ bilaterally. His dorsalis pedis are 3+ bilaterally. His posttibial pulses are 3+ bilaterally. DISPOSITION: The patient was discharged home with family after bed rest was complete.
Plus|Pulse|168|ABDOMEN: Soft. There is no rebound or guarding. There is diffuse tenderness to palpation predominantly, however, in the epigastrium. EXTREMITIES: No peripheral edema, 2+ dorsalis pedis pulses bilaterally. INTEGUMENT: There are no skin rashes. There is a burn on the right side of his chest from where he fell into space heater.
Plus|Reflexes|198|Sternocleidal muscle strength was 5/5 bilaterally. Tongue was midline. Motor exam revealed good power throughout. Normal tone. Normal bulk. Reflexes were 2+ and symmetric in the upper extremities, 1+ on the right patella and left patellar reflex 3+.
Plus|Edema(swelling)|92|GENITOURINARY: Not done. RECTAL: Guaiac negative in the Emergency Department. EXTREMITIES: 1+ edema in the toes on the left foot. The dorsal foot incision was not unwrapped.
Plus|Pregnancy dating|69|FINAL ADMISSION DIAGNOSIS: This is a 36-year-old G2, P1-0-0-1, at 27 + 4 weeks' gestational age with a chronic subchorionic placenta bleed. DISCHARGE DIAGNOSIS: This is a 36-year-old G2, P1-0-0-1 at 27 + 6 weeks' with chronic subchorionic placental bleed versus chronic abruption which appears stable.
Plus|Pregnancy dating|175|FINAL DATE OF ADMISSION: _%#MMDD2006#%_ DATE OF DISCHARGE: _%#MMDD2006#%_ PATIENT IDENTIFICATION: _%#NAME#%_ _%#NAME#%_ is a 32-year-old, gravida 2, para 2-0-0-1, female at 39+4 weeks gestational age with a history of a prior cesarean section who desires to undergo delivery by repeat cesarean section. The risks, benefits, alternatives were reviewed and she was taken to the operating room on _%#MMDD2006#%_, for a repeat low segment transverse cesarean section with findings of a vigorous female infant from a vertex presentation to clear fluid at 1054 hours with Apgars at 8 and 9 at 1 and 5 minutes respectively with a birth weight of 8 pounds 12 ounces.
Plus|Edema(swelling)|102|There is a 3/6 systolic murmur. ABDOMEN: Soft, without organomegaly or tenderness. EXTREMITIES: Show 2+ edema, they are cool and some acrocyanosis. NEUROLOGIC: The patient does look at me, but won't respond.
Plus|Pregnancy dating|238|FINAL CHIEF COMPLAINT: Desires repeat Cesarean section HISTORY OF THE PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 32-year-old gravida 2, para 1-0-0-1 who will be at 39+ 3 days by a last menstrual period of _%#MMDD2006#%_ confirmed by a 19+5 week ultrasound on _%#MMDD2006#%_ for estimated date of delivery of _%#MMDD2007#%_. She presents for repeat Cesarean section and tubal ligation. PAST OB HISTORY: Is significant for a term delivery in 2004, a Cesarean section after labor x 1 1/2 days, she was induced for oligohydramnios.
Plus|Reflexes|91|Strength is 5/5 in all extremities. Sensation is grossly intact. Deep tendon reflexes are 2+ throughout. EXTREMITIES: No clubbing, cyanosis or edema.
Plus|Edema(swelling)|143|GENITALIA/PELVIC/RECTAL: Exams deferred. EXTREMITIES: Right leg is externally rotated and slightly shorter than the left. He has chronic 2 to 3+ lower extremity edema in the feet and shins. He does have faintly palpable dorsalis pedis pulses. NEUROLOGICAL: Grossly nonfocal.
Plus|Pregnancy dating|209|PROCEDURES PERFORMED DURING THIS ADMISSION: Cesarean section and repair of incarcerated umbilical hernia. HISTORY OF PRESENT ILLNESS: The patient is a 34-year-old, G1, P0, who presented on _%#MMDD2002#%_ at 35+4 weeks by LMP consistent with 15- week ultrasound.
Plus|Pulse|118|GENITOURINARY: Deferred. RECTAL: Hemoccult negative per ED. EXTREMITIES: No cyanosis, erythema, or edema. Pulses are 2+ and symmetric throughout. No bruits. NEUROLOGIC: Nonfocal. DATA: Lipase 508 on admission. Electrolytes notable for potassium of 3.3. Glucose was elevated at 122, but I believe there is a glucose IV running.
Plus|Pregnancy dating|301|HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 33-year-old G3, P1-0-1-1, at 40 +6 weeks gestation who presents for elective repeat cesarean section. She had initially desired for a trial labor after cesarean section, but after no spontaneous labor, subsequently consented to a cesarean section at 40 +6 weeks. Her prenatal course has been otherwise uncomplicated. PAST MEDICAL HISTORY: Negative for hypertension, diabetes, or asthma.
Plus|Strength|188|No costovertebral angle tenderness. SKIN: No rashes. NEURO: The patient was alert and oriented X 3. Cranial nerves II-XII intact. Motor strength was generally symmetrical except for some 4+ out of 5 motor strength detected in left upper and lower extremity, compared to 5/5 in the right.
Plus|Reflexes|151|Mental status: Alert and oriented. Cranial nerves II through XII are grossly intact. Motor is grossly intact. Sensory is grossly intact. Reflexes are 2+ bilaterally. ADMISSION LABS: CBC on the day prior to admission showed a white blood cell count of 1.9, hemoglobin 8.9, platelets 74, with an absolute neutrophil count of 900.
Plus|Reflexes|174|No guarding and no rebounding. EXTREMITIES: Negative for any clubbing, edema or cyanosis. Sensation was intact. Muscle strength was 5+ throughout. Deep tendon reflexes were 2+ throughout. Pulses were 2+ throughout as well. EKG with nonspecific ST changes with no changes since _%#MM#%_ 2003.
Plus|Pregnancy dating|138|Prenatal care was obtained initially at CUHCC clinic and she transferred her care to University Specialists. Her prenatal care began at 17+ 4 weeks at CUHCC on _%#MMDD2003#%_. Her blood pressure was 114/62 and her total weight gain was from 162 on initiation of prenatal care to 188 at 37+ 4 weeks.
Plus|Edema(swelling)|101|She has a 2/6 systolic ejection murmur. ABDOMEN: Soft, nontender, good bowel sounds. EXTREMITIES: 2-3+ edema in the bilateral lower extremities with some chronic stasis dermatitis changes.
Plus|Tonsil size|220|He had no nasal discharge or crusting. Oropharynx was significant for a whitish ulcer on his right anterior upper gum over the area of the canine tooth, which was missing. Otherwise, there was no erythema. Tonsils were 1+ without exudate. NECK: Supple without lymphadenopathy. CHEST: Clear to auscultation bilaterally. CARDIOVASCULAR: Unremarkable.
Plus|Edema(swelling)|109|GU: Testes unremarkable. No hernia. Rectal exam declined by the patient at this time. EXTREMITIES: Trace to 1+ pitting edema of the lower extremities. NEUROLOGIC: He has normal mental status, function and cranial nerves.
Plus|Pulse|101|EXTREMITIES: There is a 1-cm diameter moveable lymph node in the right groin area. Pedal pulses are 2+ bilaterally. RECTAL EXAM: Some mild hemorrhoids in the anal area.
Plus|Reflexes|112|NEUROLOGIC: Intact. C2 through XII and sensory, motor is intact peripherally. Deep tendon reflexes are reactive +2 in upper and lower extremities. SKIN: Intact. LYMPHATIC: normal with no lymphadenopathy. LABORATORY DATA: Troponin I less than 0.04 times three, myoglobin normal at 84.
Plus|Reflexes|158|Strength is 5/5 in all muscles groups other than the right hand, which has decreased grip strength and decreased intrinsic muscles. Deep tendon reflexes are 2+ bilaterally. Sensation is intact to light touch. Finger-nose-finger is normal. LABORATORY DATA: White count 15.7 with 87% neutrophils, hemoglobin 14.7, platelets 200, sodium 140, potassium 4.6, chloride 98, bicarb 34, BUN 12, creatinine 0.41, glucose 114, calcium 9.9, ALT 17, AST 42, alkaline phosphatase 119, T-bili 0.5, albumin 4.6. Troponin was less than 0.04. INR 1.27. Blood culture pending.
Plus|Pulse|143|ABDOMEN: Soft, nontender, nondistended; bowel sounds are positive. PULSES: Femoral pulses are 2+ and symmetric bilaterally. Radial pulses are 2+ and palpable bilaterally. HIPS: Ortolani and Barlow are negative. SPINE: Spine appears straight without tuft or dimple.
Plus|Blood type|120|Cultures obtained on admission were negative for >48 hours. Problem #4: Hyperbilirubinemia. _%#NAME#%_'s blood type is O+; maternal blood type is O+. Antibody screening tests were negative. _%#NAME#%_ received phototherapy for a total of one day for a peak bilirubin level of 12.8 mg%.
Plus|Blood type|251|She was discharged on _%#MMDD2007#%_. At the time of discharge, the infant's postmenstrual age was 36 weeks and 6 days. She is a 2640 gm, 35 week gestational age female infant born at Fairview Riverside to a 25-year-old, gravida 2 para 1-0-0-1 blood O+, Caucasian female whose LMP was _%#MMDD2007#%_. The mother's pregnancy was complicated by premature labor. The mother received an epidural prior to delivery.
Plus|Edema(swelling)|166|ABDOMEN: Nontender without organomegaly or mass. PULSES: Normal carotid pulses without bruits. Normal femoral, posterior tibial, dorsalis pedis pulses. EXTREMITIES: 1+ pretibial/ankle edema. NEUROLOGIC: Oriented to person. He knows he is in the hospital, but does not know the city or name of the hospital.
Plus|Blood type|246|At the time of transfer, the infant's postmenstrual age was 33 weeks and 1 days. She is a 1550gm, 31 week gestational age female infant born at the University of Minnesota Medical Center, Fairview to a 17-year-old, gravida 1, para 0, blood type A+, Caucasian female whose EDC was _%#MMDD2007#%_. The mother's pregnancy was complicated by spontaneous preterm labor. The mother received betamethasone on _%#MMDD2007#%_, prior to delivery.
Plus|Excess|313|She had no further syncopal episode. The patient on admission had a mild left facial droop that was persistent throughout her stay here. Occupational therapy reveals the short-term memory loss. The patient was in theory using Lipitor 20 mg daily on admission, however, fasting lipid profile did show an LDL of 170+. DISCHARGE PLANS: The patient will be discharged to home.
Plus|Pulse|163|There are at least four open ulcerated areas, the largest measuring approximately 6 by 7 cm. with some areas of necrotic tissue overlying. Pulses in this leg are 1+ at the groin, absent at the ankle, foot and knee.
Plus|Reflexes|228|Temperature afebrile. She was having labored breathing with contractions. Her abdomen was gravid with an appropriate fundal height of 39 cm. Nontender. Estimated fetal weight was 3600 g by Leopold's. Her patellar reflexes were 3+ bilaterally. Her cervix was dilated 5-6 cm, 100% effaced, and in a -1 to 0 station.
Plus|Pulse|97|Oropharynx is clear. Upper dentures are in place. Mucosal membranes are moist. Carotid upstroke 1+ without bruits, no thyromegaly or lymphadenopathy.
Plus|Pulse|119|ABDOMEN: Moderately to severely obese but nontender without organomegaly, mass, or bruit. Femoral pulses are deep and 1+ without bruits. EXTREMITIES: Pedal pulses are trace to 1+. No pedal edema, cyanosis., or erythema.
Plus|Blood type|141|CHIEF COMPLAINT: Baby _%#NAME#%_ is a newborn female, 34 weeks estimated gestational age, delivered vaginally to a G-2, P-0 mother, who was O+, Rubella immune, VDRL negative, hepatitis negative, HIV negative. HISTORY OF PRESENT ILLNESS: The patient is a 34 week estimated gestational age female, delivered to a G-2, P-0 mother.
Plus|Pulse|139|HEENT exam was within normal limits. Cardiovascular Exam: Regular rate, no murmurs, rubs, or gallops. Normal S1 and S2. Pedal pulses were 2+ bilaterally. Lungs were clear to auscultation bilaterally. Abdominal Exam: Nondistended, nontender, no hepatosplenomegaly, positive bowel sounds, no abdominal or renal bruits.
Plus|Fetal position during labor|214|Cervical examination was 5 cm, 100% effaced, 0 station. Two minutes later the fetal heart rate rebounded to 140 beats with accelerations. At 1920, the patient had another decel to 60s. The cervical exam was 10 cm, +2 station, and fetal heart rate returned back to 150s with good long-term and short-term variability.
Plus|Pregnancy dating|103|At the time of discharge, the infant's postmenstrual age was 36 weeks and 4 days. She is a 2955 gm, 35 + 5/7 week gestational age female infant born at Fairview Lakes in _%#CITY#%_, MN to a 34-year-old, gravida 3, para 1-0-1-1, blood type A- female whose EDC was _%#MM#%_ _%#DD#%_, 2008.
Plus|Pregnancy dating|97|PRENATAL CARE: The patient is followed at _____ Clinic and MFM Clinic. Prenatal care started at 7+1 weeks'. PRENATAL LABS: A negative, hemoglobin of 12.8. Antibody negative.
Plus|Edema(swelling)|101|CARDIAC: Systolic murmur heard at the left sternal border, carotids are normal. His extremities show +1 edema. ABDOMEN: Obese, soft, nontender. NEUROLOGIC: Deep tendon reflexes are present at brachial radialis, as well as biceps and patella.
Plus|Edema(swelling)|386|His creatinine also improved and it was 2.14 on the day of admission, but increased to 2.3 before again falling to 2.17 on the day prior to discharge and with dobutamine discontinuation and additional diuresis, rose to 2.27 on the day of discharge which is very near or within the range of his baseline. Mr. _%#NAME#%_ feels well. He has chronic leg edema and his leg edema which is 1-2+ at discharge is the very least edema he has had in the last 2 months.
Plus|Blood type|145|At the time of transfer, _%#NAME#%_ has completed her antibiotic course. Problem #4: Physiologic Hyperbilirubinemia. _%#NAME#%_'s blood type is O+; maternal blood type is O+. Antibody screening tests were negative. _%#NAME#%_ did not require phototherapy.
Plus|Pregnancy dating|53|ADMISSION DIAGNOSES: 1. Intrauterine pregnancy at 40 + 4 weeks. 2. Latent labor. DISCHARGE DIAGNOSES: 1. Intrauterine pregnancy at 40 + 4 weeks.
Plus|Pulse|291|Pharynx without erythema. NECK: Supple. CHEST: Clear to auscultation. HEART: Regular rate and rhythm with normal S1, S2 with a 1/6 systolic ejection murmur, best heard at the right upper sternal border. ABDOMEN: Positive bowel sounds, soft and nontender. EXTREMITIES: Dorsalis pedis pulses 2+ bilaterally, radial pulses 3+ bilaterally. NEUROLOGIC: Cranial nerves II-XII are grossly intact. Strength is 5/5 throughout.
Plus|Reflexes|98|A cervical exam was done which revealed a closed and posterior cervix. Her lower extremities had 1+ reflexes and bilateral clonus. She was admitted at this time for observation and given the elevated blood pressures, a workup for pre-eclampsia.
Plus|Excess|148|By his primary doctor approximately 1 1/2 months ago. He reports he has not felt the same since. He reports doing some heavy lifting over the last 2+ weeks prior to this chest pain. In further talking with the patient he denies any fevers, chills.
Plus|Edema(swelling)|144|HEART: Regular with distant heart tones. No murmur heard. LUNGS: Lungs are clear. ABDOMEN: Soft without organomegaly. He is obese. EXTREMITIES: +1 lower leg edema. +1 pedal pulses. This 76-year-old man has had two months of recurrent dizzy and near- syncopal spells, highlighted by documented wide QRS tachycardia.
Plus|Pulse|173|Dentition is largely absent. Tongue is midline. Soft palate elevation is symmetrical. NECK: Is supple without adenopathy. No jugular venous distention, carotid upstroke is 1+ bilaterally without bruits or thrills. Thyroid is decreased to palpation. LUNGS: Breath sounds are slightly decreased with very slight rales at the base on the right and mild wheezing noted at the base of the left lung posteriorly and with expiration anteriorly they are quite clear.
Plus|Edema(swelling)|173|NECK: Supple without lymphadenopathy. LUNGS: Breath sounds are distant with expiratory wheezes and crackles at the bases. HEART: Tachycardic. EXTREMITIES: She has trace to 1+ pitting edema in feet bilaterally. LABORATORY DATA: White blood cell count is 14,300, hemoglobin 13.9.
Plus|Tonsil size|171|She has some difficulty swallowing secondary to obstruction from her tonsils, but no weight loss. PHYSICAL EXAMINATION: On examination, mouth and oropharynx demonstrated 3+, large, cryptic tonsils, hypertrophied and obstructive in nature.
Plus|Pulse|67|EXTREMITIES: No obvious gross injuries. No swelling at the joints. +3 pedal pulses bilaterally. GU: A Foley catheter has clear urine.
Plus|Pregnancy dating|144|He was born on _%#MMDD2005#%_ at 0335 hours, transferred to the NICU on _%#MMDD2005#%_ and discharged on _%#MMDD2005#%_. He was the 1670 gm, 33 +6 week gestational age male infant born at Fairview Riverside Hospital to a 22-year-old, O positive, gravida 3 para 0-0-2-0 single Ethiopian female whose LMP was _%#MMDD2004#%_ and whose EDC was _%#MMDD2005#%_.
Plus|Positive(laboratory test)|152|She also has a history of asthma and migraine headaches. The patient was stabilized on bed rest. On _%#MMDD2004#%_, she became considerably worse with 4+ proteinuria, a 24-hour urine collection showed 12 g protein, platelets 144,000, and the patient complained of severe headache.
Plus|Reflexes|80|Sensation was intact. There was no pronator drift. No dysmetria. Reflexes were 1+ throughout the upper and lower extremities bilaterally, with downgoing toes.
Plus|Pregnancy dating|269|2. Anemia, on iron. DISCHARGE DIAGNOSES: 1. Status post primary low transverse cesarean section of a viable male infant secondary to fetal intolerance of labor. 2. Anemia, on iron. HISTORY OF PRESENT ILLNESS: The patient is a 20-year-old G2 P0-0-1-0 who presented at 41+3 weeks on _%#MMDD2003#%_ per last menstrual period of _%#MMDD2002#%_ and an estimated date of confinement of _%#MMDD2003#%_.
Plus|Reflexes|111|Romberg is positive. Position sense appears to be intact. Sensory to feet is intact. Deep tendon reflexes are 1+ and intact. Cerebellar testing is normal with some mild proximal leg weakness but he is able to stand up with his arms crossed and his cranial nerves are intact.
Plus|Pregnancy dating|127|Fetal heart tones were auscultated in the 140's. Cervical examination was deferred. IMPRESSION: 1. Intrauterine pregnancy at 22+1 weeks. 2. Symptomatic cholelithiasis scheduled to undergo laparoscopic cholecystectomy tomorrow with Dr. _%#NAME#%_ on _%#MMDD2003#%_.
Plus|Edema(swelling)|165|No Rhonchi and minimal old dry bibasilar rales. HEART: Sounds are distant but I hear regular rate and rhythm without murmur. Pulses in the feet are present despite 1+ pitting edema which quits at the knees. ABDOMEN: Soft and nontender without hepatosplenomegaly, mass, guarding, rebound or tenderness.
Plus|Pulse|122|GENITALIA: Deferred. RECTAL: Deferred. EXTREMITIES: Without calf tenderness, Homans sign or edema. Peripheral pulses are 2+ symmetrical without bruits. NEUROLOGIC: Intact with respect to mental status, cranial nerves, motor, sensory, coordination.
Plus|Blood type|82|She is taking a multivitamin. She quit smoking with the pregnancy. Blood type is A+. She is rubella immune. VDRL, hepatitis, and HIV were negative. Pap smear was normal.
Plus|Reflexes|168|BREAST: Not performed. EXTREMITIES: No clubbing, cyanosis or edema. NEUROLOGIC: Cranial nerves II-XII are grossly intact. Sensory and motor exams are normal. DTRs are 2+ bilateral and symmetric. LABORATORY DATA: Laboratory data obtained tonight in the emergency room includes the following studies: Influenza A, B antigen that is negative.
Plus|Edema(swelling)|144|The patient presented to the hospital in rapid atrial fibrillation with a rate of 145, blood pressure 171/62. She had crackles bilaterally and 1+ bipedal edema noted. The patient had a chest x-ray which showed bilateral interstitial infiltrates consistent with congestive heart failure (CHF).
Plus|Pulse|139|He is markedly obese. EXTREMITIES: Reveal no edema. There is a clean ulcer on the medial aspect of his left fourth toe. Distal pulses are 2+. LABORATORY DATA: Most remarkable for a lipase of 14,700 with otherwise-normal liver function tests.
Plus|Excess|197|ADMISSION DIAGNOSES: 1) Intrauterine pregnancy at term. 2) Prior cesarean section times three. HISTORY OF PRESENT ILLNESS: The patient is a 33-year-old, gravida 4, para 3-0-0-3, who presented at 39+ weeks for repeat cesarean section. OB history was significant for uncomplicated cesarean section times three.
Plus|Pregnancy dating|55|PREOPERATIVE DIAGNOSES: 1. Intrauterine pregnancy at 40+ 5 weeks. 2. Fetal intolerance of labor, remote from vaginal delivery 3. Abnormal labor pattern.
Plus|Reflexes|158|The patient has normal swallow and gag. Trapezius and sternocleidomastoid are both intact and symmetrical. The tongue protrudes in the midline. Reflexes are 2+ throughout and symmetrical. Plantar reflexes are flexor bilaterally. On motor the patient has normal bulk and tone and full 5 out of 5 strength throughout.
Plus|Pulse|75|EXTREMITIES: Reveal 1+ edema all the way to both knees. Distal pulses are 2+, no ulcerations. LABORATORY DATA: Reveal a white count of 10,000 with a left shift, normal electrolytes, glucose 190, BUN 20, creatinine 0.9. EKG reveals sinus rhythm and is otherwise unremarkable.
Plus|Pulse|104|ABDOMEN: Soft, obese, and non-tender. No organomegaly. EXTREMITIES: Reveal no edema. Distal pulses are 2+. Right knee has tremendous anterior swelling, a patella that seems to ride higher than the contralateral side.
Plus|Edema(swelling)|121|_%#NAME#%_, few irregular contractions. Fetal heart tones 140s to 150s, reassuring, reactive. EXTREMITIES: Positive for 1+ edema and no calf tenderness. PELVIC : Not done. LABORATORY: The patient is B positive, rubella immune, HBsAG negative, RPR negative, HIV negative.
Plus|Pulse|133|LUNGS: Are clear to auscultation bilaterally. ABDOMEN: Is soft, non-tender, non-distended EXTREMITIES: No edema. FEMORAL PULSES: Are +4 bilaterally SKIN: Exam is grossly normal
Plus|Edema(swelling)|81|ABDOMEN: Obese but she is not guarding or showing tenderness. EXTREMITIES: Show 2+ edema, it is up since I saw her last. LABORATORY VALUES: Her BNP is 219. She has some fibrotic changes on the base of her x-ray.
Plus|Pulse|99|No accessory muscle use. No wheezing. HEART: Regular rate and rhythm. ABDOMEN: Soft. EXTREMITIES: 2+ pulses. LABORATORY DATA: See CBC. EKG: Noted. ASSESSMENT AND PLAN: 1. Preprocedure evaluation prior to otolaryngology surgery as described.
Plus|Pregnancy dating|161|Arterial pH 7.31, base excess 0.3, venous pH 7.36 with base excess 0.1. Clear amniotic fluid. Indications for the procedure included intrauterine pregnancy at 40+5 weeks undelivered with prolonged premature rupture of membranes for 60 hours, no active labor, mild preeclampsia, fetal tachycardia.
Plus|Strength|128|MUSCULOSKELETAL: Tender to the right ischial crest area with palpation and reproducibility. The patient had muscle strength of 5+ throughout. The deep tendon reflexes were 2+ throughout. Sensation was intact throughout and peripheral pulses were 2+ throughout.
Plus|Reflexes|158|SKIN: No rash. Mental status is alert. Cranial nerves II through XII are grossly intact. Motor: 5/5 bilaterally. Sensory is equal and symmetric. Reflexes are +2 brachial. Patellar reflexes could not be evaluated. Gait, also, could not be evaluated at the time of admission due to pain.
Plus|Pregnancy dating|103|She was planning a trial of labor after cesarean section. PRENATAL CARE: She had her first visit at 32 + 2/7 weeks, by last menstrual period, which was uncertain.
Plus|Excess|159|CHIEF COMPLAINT: Shortness of breath on the airplane. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 72-year-old white male, retired farmer, with a 100+ pack year tobacco use history who quit three months ago. He has a history of COPD and is normally O2 dependent on two-and-a-half liters.
Plus|Reflexes|107|NEUROLOGICAL: Cranial nerves II-XII were intact. Sensory and motor exams are normal. Deep tendon reflexes 2+ bilaterally and symmetric. Gait was not tested. LABORATORY DATA: Sodium 137, potassium 5.2, chloride 106, bicarbonate 24, BUN 25, creatinine 1.24. GFR is 59.
Plus|Excess|130|He was transported to the hospital where he was found to have some multiple fractures. The patient otherwise has been a healthy 63+ year old male with a history of abnormal lipids, high cholesterol, low HDL, and presently takes Zocor 10 mg a day and Niaspan 500 mg q.h.s. He is not on any aspirin.
Plus|Reflexes|148|No rash, no edema. NEUROLOGIC EXAM: Nonfocal. The patient is alert and oriented x 3. No abnormal movements, normal tone. Normal reflexes. They are 2+ symmetric throughout. Toes downgoing bilaterally. Normal finger-nose-finger. No pronator drift. Normal tone.
Plus|Reflexes|176|Cranial nerves II through XII intact. Sensory intact to light touch. I was unable to elicit deep tendon reflexes at the biceps and triceps, but patella and Achilles were both 1+ bilaterally equal. CHEST X-RAY: There are cystic fibrosis changes present bilaterally, as well as a new opacity at the left heart border, consistent with a left lower lobe pneumonia, new from prior x-ray.
Plus|Pulse|143|ABDOMEN: Soft, protuberant and nontender. No rebound or guarding. EXTREMITIES: Warm with no cyanosis, clubbing or edema. Dorsalis pedis pulse 2+ bilaterally. NEUROLOGIC: Again, the patient is not oriented to person, place or time.
Plus|Excess|151|She lives independently in an apartment on _%#STREET#%_ _%#STREET#%_. G4, P4. Family is not involved in her care currently. She used to be a smoker, 20+ pack year. No alcohol or drugs. REVIEW OF SYSTEMS: Head, eyes, ears, nose and throat - is otherwise negative.
Plus|Pulse|98|There is no organomegaly. There is an ileostomy in the right lower quadrant. EXTREMITIES: Reveal 4+ pedal pulses without any significant deformity. EYES: Reveal bilateral cataracts. LABORATORY STUDIES: Hemoglobin 12.6, white count 7.9, platelet count 228,000, glucose 244, sodium 143, potassium 4.8, chloride 106, CO2 26, BUN 43, creatinine 1.5 and calcium 9.9. EKG shows a normal sinus rhythm and is entirely normal.
Plus|Pulse|200|CARDIOVASCULAR: S-1 and S-2 without gallop, rub or murmur. ABDOMEN: Is soft, bowel sounds are decreased, there is no tenderness, mass or bruit. Femoral pulses are 1+ without bruits. Pedal pulses are 1+ and symmetrical. There is no pedal edema, cyanosis or erythema. She does follow commands appropriately most of the time although these are delayed response at times.
Plus|And|108|4. Fosamax 70 mg p.o. weekly. 5. Cymbalta 60 mg p.o. daily. 6. Vitamin C 1000 mg p.o. at dinner. 7. Calcium + D 500 mg 1 tab p.o. b.i.d. 8. Triamterene hydrochlorothiazide 37.5/25 - 1 tab p.o. as needed for dizziness with her Meniere's.
Plus|Edema(swelling)|122|ABDOMEN: Soft. He does have some epigastric tenderness and seems to have a mass or fullness there. EXTREMITIES: Reveal 2-3+ pitting edema in the lower extremities bilaterally.
Plus|Pregnancy dating|241|3. General endotracheal anesthesia. 4. Primary low transverse cesarean section via Pfannenstiel skin incision. 5. Laboratory evaluation. COMPLICATIONS: None apparent. HISTORY OF PRESENT ILLNESS: This is a 34-year-old, G3, P0, 0, 1, 0, at 33 +1 weeks gestational age by last menstrual period of _%#MM#%_ _%#DD#%_, 2005.
Plus|Pregnancy dating|242|5. Laboratory evaluation. COMPLICATIONS: None apparent. HISTORY OF PRESENT ILLNESS: This is a 34-year-old, G3, P0, 0, 1, 0, at 33 +1 weeks gestational age by last menstrual period of _%#MM#%_ _%#DD#%_, 2005. This is also consistent with a 19 +3 week ultrasound done on _%#MM#%_ _%#DD#%_, 2005. Patient presented as a transfer of care from Woodwinds Hospital, Dr. _%#NAME#%_, with preeclampsia and possible HELP syndrome.
Plus|Pregnancy dating|52|ADMISSION DIAGNOSIS: 1. Intrauterine pregnancy at 40+0 weeks. 2. Early labor. 3. Positive GBS status.
Plus|Reflexes|160|Dorsalis pedis pulses 2+ bilaterally. NEUROLOGIC: Intact cranial nerves II-XII grossly. Strength is +5/5 in bilateral upper and lower extremities. Reflexes are +2/4 bilateral upper and lower extremities. Sensation grossly intact. LABORATORY & DIAGNOSTIC DATA: Initial laboratory from the emergency department included a CBC which showed a white count of 9.2, hemoglobin 16, hematocrit 46.3, platelets 279,000.
Plus|Pulse|134|ABDOMEN: Moderately obese without organomegaly, mass or bruit. Femoral pulses are 2+ without bruits. EXTREMITIES: Pedal pulses are 1-2+ and symmetrical. There is no pedal edema, cyanosis or erythema. SKIN: Clear.
Plus|Pulse|160|CHEST: Clear to auscultation. CARDIAC: Regular rate and rhythm, I hear no murmur, rub or gallop. ABDOMEN: Soft, nontender. EXTREMITIES: Without edema. She has 2+ pulses. SKIN: Warm and dry. No clubbing, cyanosis or rash. NEUROLOGIC: Nonfocal.
Plus|Reflexes|154|There was no spine or CVA tenderness. Neurologically, the patient was alert, pleasant, and cooperative. He had a normal gait, and patellar reflexes were 2+. LABORATORY: Labs obtained from _%#CITY#%_ _%#CITY#%_ on _%#MM#%_ _%#DD#%_, 2006, urinalysis was remarkable for 3+ protein, negative glucose, trace ketones, large blood, and 50 to 100 wbc's.
Plus|Edema(swelling)|85|No murmur of MR. No S3. No jugular venous distention. The abdomen benign. Pretibial 2+ edema bilaterally, not extending above the knee. Left leg demonstrates circumferential erythema and almost a petechial-like appearance consistent primarily with stasis dermatitis.
Plus|Reflexes|175|Left shoulder and left elbow joints exhibit full range of motion without any evidence of synovitis. NEURO: Strength is +5/5 bilaterally in the upper extremities. Reflexes are +2/4 bilateral upper extremities. Strength slightly diminished in his right lower extremity with normal reflexes bilateral lower extremities.
Plus|Excess|128|PELVIC: Cervix is fingertip, 50%, vertex, -3. EXTREMITIES: Normal other than varicosities. IMPRESSION: Intrauterine pregnancy 39+ weeks' gestation, previous low segment transverse cesarean section x 2.
Plus|Pulse|168|Peripheral pulses reveal right foot dorsalis pedis 2+ with posterior tibial 1+. Left foot posterior tibial and dorsalis pedis are barely palpable and the popliteal is 1+ bilateral and radial 2+. NEUROLOGIC - reveals cranial nerves grossly intact. Strength intact in the lower extremities and sensation intact to touch.
Plus|Edema(swelling)|142|ABDOMEN: Is moderately obese, non-tender, non-distended. Decreased bowel sounds, no hepatosplenomegaly no masses, palpable. EXTREMITIES: Had 1+ edema in bilaterally ankles. There are lipomas in bilateral elbows. There are scattered bruises in the upper extremities.
Plus|Strength|179|NEURO: 5+ strength in her hand grip, elbow flexors and extensors and shoulders. She does have some mild probably 3 to 4+ muscle strength in her hip flexors bilaterally and about 4+ strength in her knee extensors bilaterally. Her ankle flexor extensors appear to be 5+ and equal bilaterally.
Plus|Edema(swelling)|135|He does have some crackles in the bases of his lungs. ABDOMEN: Positive bowel sounds, soft, nontender, and nondistended. He does have 2+ pitting edema in his lower extremities. He has scrotal edema and some erythema as well. DISCHARGE PLAN: Patient will be sent to Providence Place Nursing Home this afternoon with plan to maintain his comfort cares.
Plus|And|170|3. Hypokalemia will start potassium protocol. Will also start some potassium in her IV fluids. 4. Mild dehydration. Will plan gentle hydration with D5 half normal saline +20 of K at 75 cc an hour. Will also get daily weights 5. Probable GERD. Will substitute Protonix for her Prevacid.
Plus|Edema(swelling)|165|Bowel sounds are normal. No epigastric or iliac bruits. Distal lower extremities pulses are 1+. Feet warm symmetrically. There is no clubbing or cyanosis. There is 1+ left and trace to 1+ right pretibial edema. There is 1 to 2+ pitting edema over the dorsum of the left foot with diffuse erythema (as above).
Plus|Plus|137|PRELIMINARY UNTIL SIGNED ADMITTING DIAGNOSIS: Adenocarcinoma of the prostate, clinical stage T2, prostate-specific antigen 2.7, Gleason 3+4. OPERATIONS/PROCEDURES PERFORMED: Procedure performed on _%#MM#%_ _%#DD#%_, 2006: Robotic assisted laparoscopic radical prostatectomy with bilateral nerve sparing.
Plus|Plus|156|HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ _%#NAME#%_ is a pleasant 66-year-old gentleman with a history of prostate cancer. He has clinical TIIa, Gleason 3+3=6 disease in 3 of 5 cores, 5% surface volume on the left.
Plus|Strength|177|Neurologically, the patient is awake and alert. Has appropriate speech. Motor strength is 5/5 in upper and lower extremities throughout except for triceps bilaterally which is 4+ on the left and 5- on the right. The patient has intact sensation to light touch. The patient has a brisk deep tendon reflexes throughout.
Plus|Pregnancy dating|291|ADMITTING DIAGNOSIS: 1. Intrauterine pregnancy at 30+2 weeks gestation 2. Complete previa, bleeding HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 36-year-old gravida 1, para 0, who presented to Fairview Southdale Hospital in the middle of the night on _%#MM#%_ _%#DD#%_, 2005, at 30+2 weeks gestation, based on LMP _%#MMDD2004#%_ with EDC _%#MMDD2005#%_, with complaints of a gush of blood.
Plus|Pulse|72|NECK: Jugular venous pressure (JVP) is at 18-cm of water. Carotids are 2+ bilateral without any bruits. HEART: Regular rate and rhythm, S1 and S2, with a 3/6 holosystolic murmur at the apex.
Plus|Pulse|85|No Murphy's sign. GENITALIA: Deferred. EXTREMITIES: No cyanosis or edema. There are 2+ pulses throughout and equal. Moves all extremities. NEUROLOGIC: No focal deficits. Cranial nerves II-XII are grossly intact.
Plus|Pulse|173|No hepatomegaly. No skin rashes or lesions. Neurologic exam: Cranial nerves II through XII are grossly intact. Extremities are warm and well perfused. Dorsalis pedis pulses +2/4 bilaterally. There is no edema. ASSESSMENT AND PLAN: The patient is status post pacemaker placement with heart rate in 70s.
Plus|Pulse|86|CARDIOVASCULAR: Tachycardiac. Regular rhythm. Normal S1 and S2. No murmur. DP pulses 2+ bilaterally. LUNGS: Diffuse wheezes, prolonged expiratory phase, no crackles, positive upper airway noise.
Plus|Reflexes|92|Absent Babinski. No drift. Cranial nerves 2 through 12 are intact without tremor. Reflex is +1. diffusely. Cerebellar, rapid alternating movements and balance are not tested on admission.
Plus|Excess|350|He states his appetite is okay. He was having trouble urinating, prompted the paramedics to come and bring him to the Emergency Room early this morning at which time he was noted to have a progressively increased left sided effusion with question of infiltrate. He had a minimal elevation of white count of 14,000, but an elevation of his BNP to 3000+, compared to 2000 during his last admission. In the Emergency Room he was given Rocephin IV, Zithromax orally, was given Duonebs, and 40 mg of Lasix.
Plus|Strength|192|NEUROLOGIC: Cranial nerves II-XII are grossly intact. Sensory and motor exams appear to be grossly normal to my exam. The patient appears to have normal strength in his upper extremities and 4+/5+ strength in his lower extremities. Babinskis are downgoing bilaterally. Reflexes are diminished at the ankle, 1+ at the knees.
Plus|Pulse|159|There was some bruising around the incision; otherwise, the incision was clean, dry, and intact. Extremities are without cyanosis, clubbing, or edema and had 2+ pulses in the radial and dorsalis pedis bilaterally.
Plus|Pulse|162|The patient tolerated the procedures well. The catheter was removed from the brachial axillary artery with no difficulty. He continued to have excellent palpable +3 dorsalis pedis pulse bilaterally and a +3 left posterior tibial pulse with a warm, pink foot.
Plus|Edema(swelling)|186|Mucous membranes are moist. CARDIOVASCULAR: Regular rate and rhythm. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Protuberant, soft; bowel sounds present; nontender. EXTREMITIES: 1+ edema in bilateral lower extremities with Ted hose in place.
Plus|Excess|101|8. Aspirin 81 mg p.o. daily. SOCIAL HISTORY: He quit smoking back in the 80s. He had greater than 100+ pack-years. FAMILY HISTORY: Unremarkable. PAST MEDICAL HISTORY: Includes emphysema, coronary artery disease with stenting done in _%#CITY#%_ _%#CITY#%_ in _%#MM2006#%_, chronic renal insufficiency with his baseline creatinine last month around 3.5. This is presumed secondary to contrast nephrotoxicity after his angiogram in _%#MM2006#%_.
Plus|Edema(swelling)|154|EXTREMITIES: No cervical, axillary or femoral nodes. Femoral pulses present. No DP or PT pulses palpable. She has 4+ edema of the dorsum of the feet and 1+ lower leg. Calves not tender. Left hip and dressing. Unable to get patellar reflexes due to restraints.
Plus|Pulse|171|No masses, bruits or hernia. Bowel sounds are normal. PELVIC/EXTERNAL GENITALIA/RECTAL: Deferred. EXTREMITIES: Without calf tenderness, Homans', edema. Peripheral pulses 2+ symmetric without bruits. IMPRESSION: 1. Epigastric tenderness, nausea, unknown etiology. 2. Hyponatremia, unknown etiology.
Plus|Plus|99|5. Lasix 60 mg p.o. q. day. 6. Seroquel 25 mg q.h.s. 7. Reglan 5 mg b.i.d. 8. Xanax 0.5 mg q.i.d., +1 tablet at bedtime. 9. Protonix 40 mg p.o. q.day. 10. Cozaar 100 mg p.o. q. day.
Plus|Pulse|132|NECK: Supple with shotty lymphadenopathy, left greater than right. CARDIOVASCULAR: Regular rate and rhythm with no murmur. She has 2+ radial pulses. LUNGS: Clear bilaterally with normal effort.
Plus|Edema(swelling)|157|SKIN: She has ecchymosis over the right hand and arm as well as the right leg and left upper extremity from recent attempts at blood draws and IVs. She has 3+ edema in the right hand and lower arm and 2+ in the left hand, lower arm.
Plus|Reflexes|187|Her gait was stable by report. Her muscular strength is full bilaterally in the upper and lower extremities at all muscle groups tested. Her tone is normal. Her deep tendon reflexes are 2+ at the patella with no clonus. Her sensation is grossly intact. Her cerebellar findings are normal.
Plus|Excess|159|5. Glucophage 500 mg b.i.d. 6. 10 mg of prednisone b.i.d. for polymyalgia rheumatica 7. 50 mg of sertraline q. daily SOCIAL HISTORY: The patient married for 60+ years, lives with his wife who also has memory problems in _%#CITY#%_ _%#CITY#%_.
Plus|Pulse|181|Regular rate and rhythm. ABDOMEN: Soft, bowel sounds are normal, only slight tenderness he says in the muscles from when he was vomiting yesterday but no masses. EXTREMITIES: Show 1+ pedal pulses, no significant edema. His ankle show severe DJD with his medial malleolus nearly weightbearing now.
Plus|Edema(swelling)|149|HOSPITAL COURSE: Upon admission the patient was transferred with IV magnesium therapy running. Her blood pressure on admit was 140/86. She did have 2+ pitting edema of her lower extremities and 2+ reflexes with one beat of clonus.
Plus|Blood type|153|Problem #2: Hyperbilirubinemia. _%#NAME#%_ received phototherapy for a peak bilirubin level of 18.2 mg%. His blood type was A-; maternal blood type was A+. Antibody screening tests were negative. The last bilirubin level prior to discharge was 13.5 mg% on _%#MMDD2007#%_.
Plus|Heart murmur|149|She did have evidence of normal left atrial size at that time. She had as well evidence of modest calcification of the mitral valve leaflets with 2-3+ mitral regurgitation. There was no sign of significant right heart issues. The patient also underwent a non-diagnostic adenosine stress test demonstrating no sign of ischemia.
Plus|Pregnancy dating|231|PROCEDURE: Repeat Cesarean section by Pfannenstiel incision and bilateral tubal ligation by modified Parkland. CONSULTANTS: None. BRIEF HISTORY: _%#NAME#%_ _%#NAME#%_ is a 21-year-old, G4 P2-0-1-2, with intrauterine pregnancy at 39+5 weeks gestation dated by a 24+3 week ultrasound on _%#MMDD2007#%_ with estimated date of confinement of _%#MMDD2007#%_ who presents for repeat cesarean section with bilateral tubal ligation procedure.
Plus|Pregnancy dating|65|PRELIMINARY ADMISSION DIAGNOSIS: 1. Intrauterine pregnancy at 37 +5. 2. Preterm premature rupture of membranes. 3. Prior cesarean section.
Plus|Edema(swelling)|141|HEART: Regular rate and rhythm with a systolic ejection murmur at the left sternal border. LUNGS: Clear. EXTREMITIES: Lower extremities have +4 pitting edema, right greater than the left. LABORATORY: EKG findings are normal sinus rhythm in the 70s with poor R-wave progression.
Plus|Excess|83|Upon evaluation she was found to be contracting every 3-4 minutes. Her cervix was 1+ cm dilated, 60% effaced, at a -2 station. Her first pregnancy had been delivered by cesarean section in _%#MM2002#%_ because of a failure to progress.
Plus|Reflexes|211|Nipples are without bleeding, excoriation or discharge. ABDOMEN: Soft, slightly distended, but non-tender. EXTREMITIES: Without cyanosis, clubbing or edema. NEUROLOGIC EXAMINATION: The deep tendon reflexes are 2+ bilaterally in the upper and lower extremities and are symmetrical.
Plus|Edema(swelling)|185|ABDOMEN: The abdomen is soft but distended. He has diffuse discomfort particularly in his lower quadrants and he has a CVA tenderness. EXTREMITIES: No clubbing, cyanosis. He does have 1+ edema in his lower extremities. I suspect he probably has a component of cor pulmonale.
Plus|Pregnancy dating|179|COMPLICATIONS: None apparent. DISCHARGING STAFF: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, MD HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ _%#NAME#%_ is a 31-year-old G3, para 2-0-0-2 at 38+0 weeks by first trimester (7+2 weeks ultrasound) who presents with uncomfortable contractions every 3-5 minutes.
Plus|Edema(swelling)|112|LUNGS: Clear bilaterally. ABDOMEN: Soft, nontender, nondistended, positive bowel sounds. EXTREMITIES: Trace to 1+ edema and palpable dorsalis pedis pulses bilaterally.
Plus|Positive(laboratory test)|214|Her blood pressures starting to be increased at approximately 20 weeks and she was started on labetalol 100 mg b.i.d. at 26 weeks. Over the last 2 weeks she has had progressively increasing blood pressures with 1-2+ protein. She presented to clinic today with a blood pressure of 170/110 and 4+ protein.
Plus|Pregnancy dating|149|PROCEDURES THIS ADMISSION: 1. Cesarean section. 2. Pitocin augmentation. HISTORY OF PRESENT ILLNESS: The patient is a 28-year-old, para 2-0-3-2 at 40+5 weeks estimated gestational age who presented early morning of _%#MM#%_ _%#DD#%_, 2002 with possible rupture of membranes which was not confirmed.
Plus|Edema(swelling)|175|CARDIOVASCULAR: S1 and S2 were physiologic. ABDOMEN: Obese. There was no palpable organomegaly, masses or tenderness. GENITOURINARY: Deferred. RECTAL: Deferred. EXTREMITIES: 3+ pretibial edema without tenderness. She does have multiple linear excoriations. Her feet were otherwise unremarkable.
Plus|Pulse|68|EXTREMITIES: He has bilateral 2+ pretibial edema. Pedal pulses are 2+, posterior tibials 2+. NEUROLOGIC: Grossly normal. Babinski is negative. DIAGNOSTIC IMPRESSION: 1. Coronary syndrome with unstable angina.
Plus|Present|91|MUSCULOSKELETAL: Significant for thin extremities with full range of motion. He does have 1+ clubbing bilateral fingernails. NEUROLOGIC: Grossly intact. LABORATORY DATA: Sputum results from _%#MMDD#%_ are available at this admission with heavy growth staph aureus and light growth Pseudomonas aeruginosa.
Plus|Pulse|168|Clavicles were intact bilaterally and lungs were clear to auscultation. Cardiac exam showed a regular rate and rhythm without murmurs, gallops or rubs and pulses were 1+ throughout. Abdominal exam showed bowel sounds present with a soft abdomen, no hepatosplenomegaly and no other masses.
Plus|Pregnancy dating|120|AFI 11.1. Anatomy survey within normal limits. HISTORY OF PRESENT ILLNESS: Mrs. _%#NAME#%_ is a 25-year-old G1, P0 at 35+ 3 weeks by last menstrual period of _%#MM#%_ _%#DD#%_, 2001 consistent with a 7 week ultrasound.
Plus|Blood type|161|The patient's postpartum course was unremarkable. At discharge, she was ambulating, tolerating a regular diet, and having good pain control. Her blood type was A+, hemoglobin is 10.0. I did discuss with her whether she wanted a tubal ligation.
Plus|Pulse|147|GU: Deferred. BREASTS: Deferred. EXTREMITIES: The patient has full range of motion without any clubbing, cyanosis or edema. Peripheral pulses are 2+. NEUROLOGIC: Cranial nerves II-XII are intact. DTRs are 2+. LABORATORY DATA: Shows an ECG done in _%#MM2006#%_ is normal, as is a chest x-ray done in _%#MM2006#%_.
Plus|Pulse|141|No organomegaly. RECTAL: Examination done in the Emergency Department showed bright red blood. EXTREMITIES: No clubbing, cyanosis or edema. 1+ pulses. NEURO: Intact with normal strength and sensation. Absent deep tendon reflexes, which is chronic.
Plus|Edema(swelling)|191|Normoactive bowel sounds were present. Rectal exam: There was bright red blood on the glove per the emergency department exam, but no masses or hemorrhoids were noted. Musculoskeletal exam: 3+ pitting edema in the right lower extremity, 2+ in the left lower extremity.
Plus|Pregnancy dating|254|3. Failed induction. 4. Arrest of dilatation. PROCEDURES: 1. Primary low transverse cesarean section via Pfannenstiel skin incision. 2. Induction of labor with Cytotec and Pitocin. HISTORY OF PRESENT ILLNESS: This is a 22-year-old gravida 1, para 0 at 41+2 weeks gestation presented for induction of labor on _%#MMDD2002#%_ for postdates status.
Plus|Reflexes|175|Palpable pulses. GENITORECTAL: Deferred. EXTREMITIES: Lower extremities are without edema. Palpable pulses. Good capillary refill. NEUROLOGIC: Deep tendon reflexes (DTR) are 1+ and symmetrical at the patella. SKIN: Clear. MUSCULOSKELETAL: Grossly normal. LABORATORY DATA: Sodium 143, potassium 4.3, chloride 110, CO2 22, BUN 26, creatinine 1.9. Blood sugar 123 on arrival.
Plus|Edema(swelling)|112|Cardiovascular: Tachycardic. No murmurs. Abdomen: Rare bowel sounds. Firm and distended. Extremities: There is 1+ pedal edema. Neurologic: The patient is unresponsive to deep pain or voice.
Plus|Pregnancy dating|75|_%#NAME#%_ _%#NAME#%_ is a 36-year-old female gravida 3, para 1-0-1-1 at 31+ 2/7ths weeks gestation. She was seen at the _%#NAME#%_ _%#NAME#%_, OB-GYN Clinic for routine antenatal care because of a history of preterm labor as well as pregnancy induced hypertension.
Plus|Pregnancy dating|132|She was intubated 7 minutes after birth and transferred to the NICU. Baby _%#NAME#%_ was a pre-term AGA female infant, 1670 gm at 31+6 weeks gestation, with a length of 43.5 cm and head circumference of 28 cm.
Plus|Reflexes|201|BREASTS: Mild fibrocystic changes in the periareolar area which have not significantly changed from prior exam. NEUROLOGIC: Exam of the legs reveals 5/5 strength bilaterally. Deep tendon reflexes are 2+ at both the knees and ankles. She walks using a cane, and appears to have quite a bit of discomfort.
Plus|Pregnancy dating|257|3. Repeat echocardiogram with ejection fraction of 50%. PROCEDURES PERFORMED: 1. Low segment transverse cesarean section. 2. Bilateral tubal ligation. HISTORY OF PRESENT ILLNESS: This patient is a 35-year-old African-American, gravida 2, para 1-0-0-2, at 38+6 weeks' gestation by 7+0 week ultrasound, who presents for elective repeat cesarean section and tubal ligation.
Plus|Heart murmur|204|She had very extensive osteoporosis and ______ old compression fractures at multiple levels of thoracic and lumbar spine. Her echocardiogram showed an ejection fraction at the 45-50% range and there was 2+ tricuspid regurgitation, left atrial enlargement.
Plus|Heart murmur|216|5. Helicobacter pylori serology was negative. She was transfused 2 units of packed red blood cells and 2 units of FFT. 6. Chronic atrial fibrillation since 1996. Her most recent echocardiogram _%#MM2001#%_ showed 1-2+ mitral regurgitation with normal left ventricular size and function, and an ejection fraction of about 60%.
Plus|Reflexes|121|BREASTS: No masses or discharge. ABDOMEN: Soft. Breech presentation, 7-8 pounds. EXTREMITIES: Muscle stretch reflexes 1-2+. IMPRESSION: Intrauterine pregnancy at term, breech presentation.
Plus|Edema(swelling)|116|There was no hepatomegaly and I could not palpate the spleen. There was no fluid wave present. Extremities-she had 2+ edema of the lower extremities bilaterally to the knee.
Plus|Edema(swelling)|121|Liver seems like it is down a little bit, although, a little bit of difficult with exam. EXTREMITIES: He does have some 1+ ankle edema, right greater than left. NEURO: He is alert and oriented, moves all extremities well.
Plus|And|164|PROBLEM #1: Orthopedics. OT and PT as above. Lovenox was initially administered for DVT prophylaxis and this was changed over to aspirin 325 mg p.o. q. day. Os-Cal +D was started while an inpatient and was continued given the patient's high risk for osteoporosis given that she is thin, is a heavy smoker, and has had this femur fracture.
Plus|Blood type|170|This infant was the 2745-gram product to a 36-year-old, white, married primiparous female whose EDC was _%#MMDD2003#%_. Prenatal laboratory studies noted blood type was O+, antibody screen negative, rubella immune, VDRL - nonreactive, hepatitis B surface antigen - nonreactive, and HIV - nonreactive.
Plus|Pulse|155|Upper lung fields are clear. Cardiac exam reveals a regular rate and rhythm, questionable S4. No murmur or rub. Carotid pulses are 2+. Femoral pulses are 2+. Dorsal pedal pulses are 1+. Neck veins are flat. Abdominal exam is benign.
Plus|Pregnancy dating|192|DISCHARGE DIAGNOSES: 1. ......................pregnancy at term, delivered. 2. Gestational diabetes. 3. Asthma. HISTORY OF PRESENT ILLNESS: This patient is a 22-year-old G1, P0 admitted at 38 + 4 weeks gestation by EDC of _%#MMDD2003#%_. The patient was admitted for induction of labor secondary to history of gestational diabetes at term.
Plus|Pregnancy dating|199|However, no bloody vaginal discharge was noted. The infant was delivered vaginally with Apgar scores of 5 at one minute and 8 at five minutes. _%#NAME#%_ was a Pre-term AGA Male infant, 2860 gm at 33+5 weeks gestation, with a length of 49.5 cm and head circumference of 33 cm.
Plus|Pulse|108|No laceration or obvious lump. Oral mucosa is moist without lesions. NECK: No bruit, carotid upstrokes are 1+ bilaterally. CHEST: Clear to auscultation bilaterally. BACK: No significant kyphoscoliosis or tenderness CARDIAC: Regular S-1 and S-2 with a soft I-II/VI systolic murmur at the base.
Plus|Pregnancy dating|201|4. C-difficile negative. 5. WBC 24.2 on admission to 14.8 deemed secondary to steroid usage. IDENTIFICATION: Ms. _%#NAME#%_ is a 28-year-old gravida 1, para 0, who was admitted on _%#MMDD2003#%_ at 30 + four weeks' gestation by an 8 week ultrasound giving her estimated date of confinement of _%#MMDD2003#%_.
Plus|Plus|40|DISCHARGE DIAGNOSES: 1. Status post day + 28 double cord bone marrow transplant for myelodysplastic syndrome/acute myelogenous leukemia. 2. Graft-versus-host disease of the skin, biopsy proven. 3. Status post gram-negative rod sepsis treated with tobramycin and imipenem.
Plus|Positive(laboratory test)|166|3. Neuro: A urine tox screen was sent which was negative. 4. Heme: The mother's blood type is O positive and the baby's blood type is B positive with a Coombs test 1 + positive. Hemoglobin was 13.3 on admission. 5. GI: _%#NAME#%_ had been on phototherapy prior to admission for a bilirubin of 14.1. This was continued during her admission.
Plus|Pulse|133|ABDOMEN - soft, bowel sounds present. No tenderness, no organomegaly. EXTREMITIES - no edema, no calf tenderness. Peripheral pulses 2+. SKIN - no rash, no ulcers. CNS - patient is intubated, opens eyes to verbal commands.
Plus|Heart murmur|218|The patient felt much better and was able to ambulate. His echocardiography was consistent with abnormalities in the distal septal apical anterior walls with left anterior enlargement and mitral insufficiency that was +2 to +3. (Again, please review the report for full results.) His blood pressure was well-controlled.
Plus|Pulse|123|No JVD. Carotid pulses are 2+ and equal bilaterally, without bruit. She has no abdominal bruit. Her peripheral pulses are 2+ and symmetric throughout. Her abdomen is eumorphic, soft, with normoactive bowel sounds, non-distended, non-tender, with no hepatosplenomegaly or masses.
Plus|Pregnancy dating|52|ADMITTING DIAGNOSES: 1. Intrauterine pregnancy at 38+2 weeks estimated gestational age. 2. Pregnancy-induced hypertension with edema. 3. Suspected large-for-gestational-age infant.
Plus|Edema(swelling)|154|HEART: Heart tones are clear. The patient does have irregular pulse. LUNGS: Clear. BREASTS: Not examined. ABDOMEN: Soft and nontender. EXTREMITIES: 1 to 2+ edema of the lower legs, extending to the mid calf, especially on the left the swelling is marked.
Plus|Edema(swelling)|134|He does have a III/VI systolic ejection murmur of the aortic stenosis radiating to the carotids. He has bibasilar crackles. There is 3+ lower extremity pitting edema. He does have swollen and slightly erythematous scrotum and penis, which is much improved from admission; this is secondary to his hernia surgery.
Plus|Pregnancy dating|209|2. Preterm contractions without preterm labor and without premature rupture of membranes. HISTORY OF PRESENT ILLNESS: The patient is a 22-year-old gravida 3, para 1-1-0-2, with an intrauterine pregnancy at 23 + 2 weeks by a 15 + 2 week ultrasound on _%#MMDD2003#%_. The patient presented to Fairview-University Medical Center, Riverside campus, after noticing a gush of fluid from her vagina at around 5 p.m. on _%#MMDD2003#%_.
Plus|Excess|242|7. Reminyl 8 mg po bid, adjusted for renal dosing. 8. Insulin glargine 7 units daily. 9. Sliding scale of regular insulin, blood sugars 0-139 no insulin, 140- 160 get 4 units, 161-200 get 6 units, 201-250 get 7 units, 251-300 get 8 units, 301+ get 10 units. 10. Tylenol 325 2 po every four hours as needed for pain.
Plus|Pulse|86|Microfilament testing for sensation to touch in all toes is normal. Pedal pulses are 2+ bilaterally and color is good. SKIN: No abnormalities. ASSESSMENT: 1. Degenerative disk disease of the cervical spine.
Plus|Heart murmur|166|The patient was subsequently ambulating well and had no further chest pain after _%#MMDD2003#%_. The patient underwent echocardiogram which showed significant 3-to- 4+ mitral regurgitation with preserved left ventricular function, left ventricular hypertrophy, and 2-3+ aortic insufficiency.
Plus|Excess|72|DOB: _%#MMDD1984#%_ ADMISSION DIAGNOSIS: 1. Intrauterine pregnancy at 36+ weeks. 2. History of previous cesarean section. 3. Spontaneous rupture of membranes in early labor.
Plus|Pregnancy dating|72|DOB: _%#MMDD1978#%_ ADMISSION DIAGNOSIS: 1. Intrauterine pregnancy at 38+3 weeks gestation. 2. Breech presentation. 3. Premature rupture of membranes.
Plus|Edema(swelling)|182|GENITAL/RECTAL: Deferred. EXTREMITIES: Orthopedic normal. LYMPH: No cervical, axillary or femoral nodes. NEUROLOGICAL: Patellar reflexes 2+. SKIN: Venous stasis dermatitis changes. 1+ edema two-thirds up both tibias. ASSESSMENT: 1. Abdominal aortic aneurysm. 2. Left common iliac artery aneurysm.
Plus|Strength|140|ABDOMEN: Positive for bowel sounds, soft, nontender, nondistended with no hepatosplenomegaly. NEUROLOGIC: She was intact. MUSCULOSKELETAL: 5+ throughout, sensation intact, deep tendon reflexes were 2+ throughout.
Plus|Fetal position during labor|121|The patient requested a c-section at that time. The cervix was reexamined. There was no change in the fetal station from +1 over the previous hour and 20 minutes. Fetal heart rate tracing remained reassuring. The risks, benefits, and alternatives of a primary c-section were discussed with the patient, including the fairly significant risk of postoperative wound infection and breakdown with prolonged need to heal by secondary intention given her morbid obesity.
Plus|Fetal position during labor|216|The patient progressed to complete and pushing at 11:30 a.m. on _%#MMDD2003#%_. The patient had effective pushing for greater than two hours and was complete for greater than 3- 1/2 hours and made no progress beyond +1 to +2 station. Discussion was had with the patient at that point. She proceeded to cesarean section and the patient agreed and consent was obtained.
Plus|Pulse|100|ABDOMEN: Soft, nontender. There are normal active bowel sounds. EXTREMITIES: Without edema. He has 2+ throughout. SKIN: Warm and dry. There is no clubbing, cyanosis, or rash. NEURO: Grossly intact.
Plus|Excess|210|She has never been insulin dependent. She does not test her own sugars noted above. She feels, however, that she has watched her diet carefully, but notes that her A1Cs have gradually increased from 6.5 up to 8+. Additional medical history: 1. Appendectomy at age 21. 2. D&C in 1974.
Plus|Excess|214|Prior to discharge from the hospital on day 7, transvaginal ultrasound was re-obtained and revealed a fetal pole with cardiac activity. The subchorionic bleed imaged on the previous study in the emergency room at 5+ weeks appeared to be stable. Blood sugars at the time of discharge were within 20 points or so of the goal.
Plus|Pulse|124|NECK: Supple without adenopathy. Thyroid decreased to palpation. No jugular venous distention (JVD). Carotid upstrokes are 1+ bilaterally without thrills. LUNGS: Clear with good air movement; no wheezing, rales, or rhonchi.
Plus|Pregnancy dating|219|4. Arrest of descent. 5. Occiput posterior position. 6. Cervical laceration. OPERATIONS/PROCEDURES PERFORMED: 1. Cesarean section. 2. Pitocin induction. HISTORY OF PRESENT ILLNESS: The patient is a 38-year-old G1 P0 39 + 6 weeks estimated gestational age who presented with possible rupture of membranes.
Plus|Pregnancy dating|62|HISTORY OF PRESENT ILLNESS: This is a 31-year-old G1, P0 at 39+0 weeks' gestation at the time of presentation based on a true last menstrual period of _%#MM#%_ _%#DD#%_, 2003, with an estimated date of delivery of _%#MM#%_ _%#DD#%_, 2004. The patient was found to have a breech presentation and had a failed external cephalic version 2 weeks prior.
Plus|Pregnancy dating|80|HISTORY OF PRESENT ILLNESS: This is a 27-year-old gravida 3, para 0-1-1-1, at 24+1 weeks by last menstrual period of _%#MM#%_ _%#DD#%_, 2004, consistent with an 8+3 week ultrasound on _%#MM#%_ _%#DD#%_, 2004. The patient has known severe non-immune hydrops and mild preeclampsia at the time of admission.
Plus|Pulse|120|Murmurs are hard to hear because there is a lot of background noise in the emergency room. She has no edema. Pulse are 2+, no jugular venous distention at 20 degrees. ABDOMEN: Is soft. Non-tender, no masses or hepatosplenomegaly. Bowel sounds are normal.
Plus|Positive(laboratory test)|226|Her family has a remarkable history for having had two siblings which had prolonged hyperbilirubinemia, one requiring lights for one month, as stated per mom. Her evaluation ended up with her blood type being B positive with 2+ Coombs. Her peak bilirubin was 14.0, which occurred at 2003 on _%#MMDD#%_.
Plus|Edema(swelling)|97|Fetal heart tones reassuring. Cervix is 1 cm, 50% effaced and -2 station. EXTREMITIES: Trace to 1+ lower extremity edema. LABORATORY DATA: Hemoglobin 11.6, urinalysis negative. Blood type B positive, antibody screen negative, rubella immune, hepatitis B surface antigen nonreactive, RPR nonreactive, Pap smear, gonorrhea, Chlamydia all negative.
Plus|Excess|49|PREOPERATIVE DIAGNOSIS: Intrauterine pregnancy 38+ weeks gestation, advanced maternal age, large lower uterine segment fibroid, previous operative hysteroscopy x 2, breech fetal position. PROPOSED PROCEDURE: Classical cesarean section. SURGEON: Dr. _%#NAME#%_ _%#NAME#%_. ASSISTANT: _%#NAME#%_ _%#NAME#%_.
Plus|Edema(swelling)|150|ABDOMEN: Distended, positive for ascites. He has multiple masses, more on the right, hard, immobile, slightly tender in the pelvis area. EXTREMITIES: +1 edema in the ankles. LYMPHATIC: There is a hard lymph node in the left supraclavicular region consistent with malignancy.
Plus|Pregnancy dating|179|HIV nonreactive. Varicella immune. ASP within normal limits. Group B Strep negative on _%#MMDD2004#%_. White count negative on _%#MMDD2004#%_. The patient had an ultrasound at 26 + 0 weeks on _%#MMDD2004#%_ which confirmed dating established by her LMP.
Plus|Reflexes|131|ABDOMEN: Gravid, fundus high at 26 cm, mild epigastric and right upper quadrant tenderness on deep palpation. NEUROLOGIC: Reflexes +2-3. One beat of clonus on the right side. CERVIX EXAMINATION: Closed, long, and high. EFM: Baseline fetal heart rate 140-150.
Plus|Strength|70|Cranial nerves 2 through 12 intact with corrective vision wear. Motor +5 upper and lower extremities, and sensory intact to soft touch with normal gait.
Plus|Strength|121|On postoperatively day #1, he had weakness in the right deltoid, about a 3- / 5. His other right muscle groups were all 4+/5. The left was 5/5. A CT scan was obtained and revealed good position of all screws.
Plus|Excess|110|_%#NAME#%_ _%#NAME#%_ is a 35-year-old white female, gravida 1 para 0 with an EDC of _%#MMDD2004#%_, now at 39+ weeks, presented for induction of labor for pregnancy induced hypertension. The patient has been followed in the office for her blood pressures and also seen in triage for her blood pressure.
Plus|Strength|178|Abdomen is soft, non-tender. Extremities: No peripheral edema. Neuro examination: Cranial nerves II through XII are intact. Motor examination: Normal tone and bulk. Strength is 4+/5 in the upper extremities proximally and distally, 4+/5 in the distal lower extremities, and 4/5 in the hip flexors bilaterally.
Plus|Reflexes|101|NEUROLOGIC - nonfocal, toes downgoing bilaterally. Strength 5/5 in extremities times four. Reflexes 2+, symmetric in the upper extremities, not elicited in the lower extremities.
Plus|Pregnancy dating|180|She was born on _%#MMDD2005#%_ at 1124 hours, transferred here to the Riverside NICU on _%#MMDD#%_ and transferred back to _%#CITY#%_ _%#CITY#%_ on _%#MMDD#%_. She was a 770 gm, 25+4/7 week gestational age female infant born at _%#CITY#%_ _%#CITY#%_ Hospital to a 30-year-old, B positive, gravida 7, para 1-2-5-3, married Caucasian female whose EDC was _%#MMDD2005#%_.
Plus|Pulse|106|LUNGS: Clear. ABDOMEN: Flat, soft and nontender. EXTREMITIES: No edema and +1 pedal pulses. Femorals were +2. NEURO: Grossly intact. I believe the results of this nuclear study require that we rule out severe multiple vessel coronary artery disease.
Plus|Pulse|197|Her lungs are clear to all. CARDIAC: Her rhythm is regular with S1 and S2. No S3 or S4, murmurs, rubs, or gallops. PERIPHERAL PULSES: She has 2+ carotid and femoral pulses bilaterally, as well as 2+ radial and pedal pulses bilaterally. EXTREMITIES: There is no lower extremity noted. NEURO: There is no gross motor deficits.
Plus|Pregnancy dating|34|ADMISSION DIAGNOSES: 1. IUP at 31 + 5 weeks. 2. Vaginal bleeding. 3. Placental mass, possible chorioangioma versus molar pregnancy.
Plus|Pregnancy dating|169|2. Artificial rupture of membranes. 3. Normal spontaneous vaginal delivery. COMPLICATIONS: Infant in NICU. HISTORY OF PRESENT ILLNESS: This is a 24-year-old G1, P0 at 41+2 weeks by an last menstrual period of _%#MMDD2004#%_ consistent with 20+2 ultrasound on _%#MMDD2004#%_ who presented with complaints of contractions beginning in the morning, increasing in strength and frequency over the day, becoming every 15 minutes.
Plus|Pregnancy dating|133|2. IV antibiotics. 3. Urinalysis that showed trace leukocyte esterase. HISTORY OF PRESENT ILLNESS: This is 24-year-old G1, P0, at 39 +3 weeks by last menstrual period that was consistent with a first trimester ultrasound.
Plus|Edema(swelling)|149|RESPIRATORY: Clear to auscultation. No wheezing, no crackles. ABDOMEN: Soft. Bowel sounds are present. No tenderness. No organomegaly. EXTREMITIES: 3+ pitting edema noted in bilateral lower extremities.
Plus|Edema(swelling)|194|HEART: Regular rhythm, bradycardic. Normal S1 and S2. No S3, S4, murmur, gallop or rub. ABDOMEN: Normoactive bowel sounds, soft, nondistended, nontender. EXTREMITIES: Extremities have trace to 1+ pretibial edema bilaterally. There is a saphenous vein harvest scar on the right lower extremity.
Plus|Heart murmur|94|PAST MEDICAL HISTORY: 1. Congestive heart failure and LVEF 25% from a non-ischemic cause. 2. 4+ aortic regurgitation. 3. Laryngectomy remote past for cancer.
Plus|Pregnancy dating|296|4. Desires permanent sterilization. DISCHARGE DIAGNOSES: 1. Status post repeat low transverse cesarean section with delivery of a viable male infant on _%#MMDD2006#%_. 2. Status post tubal ligation. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 37-year-old gravida 8, para 2-0-5-2 at 39 + 2 weeks whose pregnancy has been uncomplicated. The patient has had a cesarean section performed in the past and elects to have a repeat cesarean section with this delivery.
Plus|Plus|437|However, when he was evaluated here, he appeared to have a fairly small troponin leak with a peak troponin at 0.99. The patient went on to have a transthoracic echocardiogram showing moderate aortic stenosis, estimated valve area of 1.14 cm, left ventricular size normal, left systolic function mildly reduced at 45%. Hypokinesis in the inferior and high lateral walls and some mild pulmonary hypertension with pulmonary pressures of 30 +RA. Cardiology was consulted and felt that given his overall health, with his mild dementia and recurrent aspiration pneumonia, that the patient should be treated medically.
Plus|Excess|187|ADMISSION DIAGNOSES: 1. Intrauterine pregnancy at term. 2. Repeat Cesarean section. HISTORY: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is a 31-year-old white female, Gravida 3, Para 2-0-0-3, at 37+ weeks gestation in early labor for a repeat Cesarean section.
Plus|Plus|163|A day 14 bone marrow biopsy revealed persistent disease again with normal cytogenics. She received second induction chemotherapy course of doxorubicin and Ara-C (5+2). A day 14 bone marrow biopsy on _%#MMDD2005#%_ revealed hypocellular marrow without evidence of leukemia.
Plus|Reflexes|168|Exam remarkable for cranial nerves II through X and XII intact. He is unable to shrug his right shoulder. Deep tendon reflexes 1+ in the upper extremity on the right, 2+ on the left, 3+ in the right knee, and 2+ in the left.
Plus|Uncommon rating|136|He does have diastasis recti, cholecystectomy scar, but no palpable aneurysmal dilatation. GU: No testicular masses or hernia. Prostate +2/4, soft, no nodules, no rectal masses. Not due for colonoscopy until 2013. He has had previous negative colonoscopy.
Plus|Excess|344|PRELIMINARY ADMITTING DIAGNOSIS: Intrauterine pregnancy, 7+ weeks gestation, fetal intolerance of labor, deep variable decelerations with contractions. DISCHARGE DIAGNOSIS: Status post primary low segment transverse cesarean section next PATIENT IDENTIFICATION: _%#NAME#%_ _%#NAME#%_ is a 34-year-old married woman, gravida 5, para 2-0-2-2 at 7+ weeks gestation admitted to Labor and Delivery at Ridges Hospital for evaluation of spontaneous rupture of membranes and to rule out labor.
Plus|Edema(swelling)|180|Carotids are equal, no bruits were heard. HEART: Tones were distant and apical S4 is noted. No S3 or murmur heard LUNGS: Clear ABDOMEN: Soft without organomegaly EXTREMITIES: Show +2 to +3 lower leg edema wrapped with Ace bandages. Pedal pulses were not felt. Femoral pulses were +1 to +2.
Plus|Reflexes|161|Motor strength in the lower extremities 5/5. Hoffmann's test is positive on the right side. Deep tendon reflexes are +3 in the biceps, triceps, brachioradialis, +2 in the right patella, 0 in the left patella and diminished in the Achilles tendon.
Plus|Edema(swelling)|136|No identifiable surgical or incisional hernias. PELVIS: External BUS within normal limits. Cervix, long, closed and high. EXTREMITIES: 2+ edema. Reflexes symmetric and bilateral. DERM: Clear. ASSESSMENT: Healthy adult female, term pregnancy, previous cesarean section, now for repeat cesarean section at term.
Plus|Edema(swelling)|91|No appreciable wheezes at this time. ABDOMEN: Soft, mildly distended. EXTREMITIES: With 2-3+ edema. There is a petechial rash on the lower extremities.
Plus|Pulse|123|There are bilateral basilar rales. ABDOMEN: Soft, no hepatosplenomegaly, normal bowel sounds. EXTREMITIES: No pedal edema, +1 pulses in bilateral lower extremity. SKIN: No rash, wound or ulcer. NEUROLOGIC: Nonfocal except for left facial weakness.
Plus|Pregnancy dating|252|2. Preterm labor. 1. Transverse-transverse twin gestation. The patient has chronic hypertension without superimposed preeclampsia. HISTORY OF PRESENT ILLNESS: The patient is a 28-year-old G2, para 0-0-1-0 at 26 weeks and 1 day by LMP consistent with 7 + 5 week ultrasound, on _%#MM#%_ _%#DD#%_, 2005, with twin gestation.
Plus|Pregnancy dating|204|PRELIMINARY ADMISSION DIAGNOSES: 1. A 30-year-old, gravida 2, para 0-0-1-0, at 39+5 weeks gestation, undelivered. 2. Labor. DISCHARGE DIAGNOSIS: A 30-year-old, now gravida 2, para 1-0-1-1, delivered at 39+6 weeks gestation. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ was admitted on _%#MMDD2006#%_ at 39+5 weeks gestation with a spontaneous rupture of membranes and in active labor.
Plus|Heart murmur|209|TEE was performed which showed mild decreased left ventricular systolic function with mild left ventricular enlargement. Very small vegetations were seen on the aortic valve with moderately severe to severe (3+ to 4+) aortic valve regurgitation. A mycotic aneurysm of the anterior and mitral valve leaflet was seen with only a trace of mitral valve regurgitation.
Plus|Reflexes|222|CONTRACTIONS: _%#NAME#%_ has been indicating contractions from every 1-2 minutes, to every 5-6 minutes, and they are irregular. EXTREMITIES: The patient has no edema. Nontender lower extremities. NEUROLOGIC: Reflexes 0 to +1. PRENATAL LABS: She is O positive, and antibody screening negative.
Plus|Pulse|201|LUNGS: Are clear anteriorly and posteriorly. CHEST WALL: Is non-tender ABDOMEN: Is soft, obese, non-tender without organomegaly, masses or bruits or pain. Bowel sounds were normal. EXTREMITIES: Showed +1 pedal pulses and no edema. Radial pulses were +2. NEUROLOGIC AND CUTANEOUS EXAMINATION: Are normal This 68-year-old woman is now asymptomatic.
Plus|Edema(swelling)|150|HEENT: Unremarkable. NECK: No JVD. LUNGS: Clear. HEART: Normal sinus rhythm, no rub, no murmur. ABDOMEN: Nontender, no enlarged organs. EXTREMITIES: 1+ edema of lower extremities has some stasis. There is no bruit over the right forearm fistula. NEUROLOGIC: Is intact, no focal motor signs.
Plus|Strength|385|Reassessed lower extremity strength at final visit: Flexion 3+ to 4-/5 bilaterally, knee extension 3+ to 4-/5 bilaterally, knee flexion 4+/5 bilaterally, dorsiflexion 4+/5 bilaterally, big toe extension symmetrical and strong bilaterally. Also reassessed upper extremity strength at today's visit: Shoulder flexion 3+/5 bilaterally, shoulder abduction 4-/5 bilaterally, elbow flexion 3+/5 bilaterally and shoulder extension 4/5 bilaterally.
Plus|Excess|125|PAST MEDICAL HISTORY: 1. Prostate cancer recently diagnosed on leupride. 2. Hypertension. 3. GERD. 4. Remote appendectomy, 30+ years ago. 5. History of nares bleed through the left naris. ALLERGIES: He has no known drug allergies.
Plus|Plus|253|8. Ativan 0.5 mg q.6 h. p.r.n. nausea, vomiting. DISCHARGE STATUS: _%#NAME#%_ will be discharged to local housing accompanied by her family and will be seen on a daily basis in the Bone Marrow Transplant Outpatient Clinic. She should begin G-CSF on day +5, which is _%#MMDD2007#%_ and should have daily laboratory evaluation until she is engrafted.
Plus|Present|127|BACK: No CVA tenderness. ABDOMEN: Benign. No scars, masses or tenderness. Slightly obese. PELVIC: Vagina with slight atrophy. 3+ bladder prolapse to the introitus, 2+ uterine prolapse but good vesicle neck elevation and small rectocele.
Plus|Edema(swelling)|192|She was afebrile with vital signs stable. The abdomen had a firm fundus, umbilicus -2, and was nontender. The incision was clean, dry, intact, and bandaged. The extremities were nontender and +1 edema. She was doing well and had no problems. Her Foley catheter was discontinued, IV fluids were discontinued, and her diet was advanced as tolerated.
Plus|Reflexes|140|EXTREMITIES: Without edema, clubbing or cyanosis. Peripheral pulses are intact. NEURO: Speech is intact. Motor and sensory is intact. DTRs 1+. Gait is not tested. EKG showed sinus rhythm at 64 per minute.
Plus|Edema(swelling)|156|No diastolic murmur, rub or S3. ABDOMEN: Obese, soft, nontender, without palpable liver, spleen or masses. Bowel sounds are present. EXTREMITIES: Showed 1-2+ edema. Pulses were 1+ below the femorals, 2+ above. NEUROLOGIC: Exam was not done in detail but the patient was able to move all extremities and respond to sensory stimuli.
Plus|Pregnancy dating|63|_%#NAME#%_ _%#NAME#%_ is a 29-year-old gravida 1, para 0 at 29 + 2 weeks who has a recent history of right-sided abdominal pain that started approximately 3 p.m. this afternoon. The patient states that pain is constant in nature somewhere between cramping and a sharp severe pain.
Plus|Excess|90|_%#NAME#%_ _%#NAME#%_ is a 38-year-old, para 1031, with EDC of _%#MMDD2002#%_ who is at 38+ weeks gestation. She has as history of cesarean section in 2000 for fetal distress.
Plus|Edema(swelling)|111|The patient's abdomen was quite large; I could feel the edge of the rectus muscle bilaterally. The patient has +1 edema of the right lower extremity, and has an upper left leg prosthesis.
Plus|Pregnancy dating|53|ADMISSION DIAGNOSES: 1. Intrauterine pregnancy at 39 + 3 weeks. 2. History of prior cesarean section, declines trial of labor.
Plus|Pulse|150|J tube is present. EXTERNAL GENITALIA: Deferred. RECTAL: Deferred. EXTREMITIES: Without calf tenderness, Homans sign or edema. Peripheral pulses are 2+ symmetrical without bruits. NEUROLOGIC: Deep tendon reflexes (DTR): 1+ right and left biceps; absent quadriceps and Achilles.
Plus|Pulse|157|ABDOMEN: Soft, nontender, without masses or organomegaly. GENITALIA: Bilateral inguinal herniation, not severe. RECTAL: Deferred. LOWER EXTREMITIES: Pulses 1+ in both feet, no edema. NEUROLOGICAL: Nonfocal. EKG, sinus rhythm with slight left ward axis deviation, no acute changes.
Plus|Pulse|153|ABDOMEN: Abdomen is soft and nontender. Positive bowel sounds. EXTREMITIES: No edema. His DP pulses were palpable but very weak. His radial pulses were 3+ bilaterally. NEUROLOGICAL: Downgoing reflexes, 1+ symmetrical. Strength is 5/5 throughout. Sensation intact.
Plus|Edema(swelling)|222|Lungs were clear to auscultation bilaterally. His abdomen was soft and nontender, nondistended. There was no CVA tenderness. He did have some trace edema in the left extremity and much enlarged right lower extremity with 1+ pitting. No rash or other abnormalities were noted. Neurological exam showed no focal deficits.
Plus|Strength|133|Soft, nontender and nondistended. Extremities: Negative for any clubbing, cyanosis or edema. Neurologically intact. Muscle strength 5+. The tendon reflexes were 2+ throughout. LABORATORY: Hemoglobin 15.6, white blood count of 5.2, platelets 231,000, hematocrit 45.
Plus|Pulse|179|EXTREMITIES: Reveal hands with long fingers and osteoarthritic changes. No tenderness of the wrists, elbows or shoulders. Legs with some venous stasis changes, distal pulses are 2+. No edema. Ankles and knees are negative. Left hip has full range of motion.
Plus|Edema(swelling)|109|No gallop or murmur. ABDOMEN: Obese, soft without tenderness. Benign exam. EXTREMITIES: Lower extremities - 2+ pitting edema. The patient has chronic erythematous changes over the front of the legs.
Plus|Edema(swelling)|185|Abdomen: Soft, nontender, nondistended. Genitourinary: Significant penile edema. The patient had a Foley catheter with continuous bladder irrigation with light red urine. Extremities: 3+ pitting edema. ADMISSION LABORATORY DATA: Hemoglobin approximately 10.0, creatinine approximately 1.6. HOSPITAL COURSE: The patient was admitted on _%#MMDD2002#%_ and initially started on continuous bladder irrigation.
Plus|Pregnancy dating|206|6. Fetal renal pyelectasis. 7. Abdominal adhesions. PROCEDURES THIS ADMISSION: 1. Repeat cesarean section. 2. Lysis of adhesions. HISTORY OF PRESENT ILLNESS: The patient is a 33-year-old, P 1- 0-1-1, at 36 + 3 weeks estimated gestational age, who presents with spontaneous rupture of membranes and uncomfortable contractions q.2 minutes.
Plus|Pulse|197|CHEST: Clear to percussion and auscultation. ABDOMINAL: Unremarkable. No hepatosplenomegaly. No masses, tenderness, bruits, enlargement of the aorta. PULSES: Femoral pulses are 3+, popliteals are 2+, dorsalis pedis and posterior tibials are 2+. I do not see any peripheral edema, though there does appear to be increased adiposity in the lower limbs.
Plus|Heart murmur|247|The left ventricle was severely enlarged. Gating demonstrated global hypokinesia, inferior and inferolateral wall akinesis, and apex with severe hypokinesis and akinesis. Ejection fraction was 26%. On ultrasound, mitral insufficiency was of 2 to 3+ in severity. Adenosine thallium stress test showed no EKG changes. EKG demonstrated a dual-chamber pacemaker, and initially showed wide complex tachycardia felt secondary to ventricular tachycardia.
Plus|Pulse|107|CARDIOVASCULAR: Regular rate and rhythm, without rubs, murmurs, or gallops. No elevation of JVD or edema. 2+ pulses distally. PULMONARY: Clear to auscultation bilaterally at the bases. ABDOMEN: Soft, non-tender, non-distended; normoactive bowel sounds.
Plus|Pregnancy dating|53|ADMISSION DIAGNOSIS: A 35-year-old G8, P1-0-5-1 at 40+6 weeks gestation by 19+1 week ultrasound. DISCHARGE DIAGNOSIS: Status post primary low segment transverse cesarean section.
Plus|Pulse|154|The cardiovascular exam was irregularly irregular, with a 1/6 holosystolic murmur radiating to the base. The liver was not enlarged. Femoral pulses were 2+ and symmetrical without bruit, and there was no peripheral edema.
Plus|Heart murmur|293|Mild mitral insufficiency was seen, possibly catheter induced. The ejection fraction was 45-50%. The patient tolerated the procedure well. Echocardiography on _%#MMDD2003#%_ showed apical and anterior akinesis with 50-55% ejection fraction, mild thickening of the aortic valve was seen, 1 to 2+ mitral, and 1+ tricuspid insufficiency. Right ventricular systolic pressures were moderately increased with a right ventricular systolic pressure of 50-55 mmHg.
Plus|Pulse|130|Vital signs were stable. The wound was clean, dry and intact. There was no erythema or drainage. CMS was intact distally, with a 2+ dorsalis pedis pulse. The patient is ready for discharge to home. Discharge hemoglobin was stable at 10.2. DISCHARGE DISPOSITION: The patient is discharged to home.
Plus|Pulse|110|Murphy's sign was negative. EXTREMITIES: No cyanosis, clubbing or edema. His popliteal and pedal pulses were 2+ on both sides which per my examination were normal.
Plus|Reflexes|108|Femoral pulses are strong and equal. NEUROLOGIC: Cranial nerves II-XII grossly intact. Deep tendon reflexes +2/4 in all extremities. He is alert and oriented x 3. His speech is very clear.
Plus|Pregnancy dating|336|2. Postpartum hemorrhage requiring D and C. 3. Cholestasis of pregnancy. 4. Postpartum/postoperative anemia. HISTORY OF PRESENT ILLNESS: The patient is a 20-year-old Persian-speaking Iranian, gravida 1, para 0 who presented to Fairview- University Medical Center, Riverside campus at 38+5 weeks gestational age by LMP, consistent with 9+3 and 22+4 week ultrasounds on _%#MMDD2003#%_. She presented for induction of labor secondary to cholestasis of pregnancy.
Plus|Pregnancy dating|135|3. HIV positive, not on antiretroviral medication secondary to hyperemesis gravida. DISCHARGE DIAGNOSES: 1. Intrauterine pregnancy at 9+3 weeks estimated gestational age. 2. HIV positive, on Combivir and Viracept and able to tolerate medications.
Plus|Pregnancy dating|228|Pap within normal limits. HIV non- reactive. HCV negative. Hepatitis B negative. GCT of 116, hemoglobin 13.1 and 12.0. OB HISTORY: The patient has a history of cesarean in _%#MM1999#%_ for what appears to be prolapsed cord at 41+3 weeks. This initial C-section was in _%#CITY#%_ _%#CITY#%_ _%#CITY#%_, and this was a viable boy.
Plus|Pregnancy dating|166|ADMISSION DIAGNOSES: 1. The patient is a 27-year-old gravida 3, para 2-0-0-2 at 28+6/7 weeks. 2. Febrile illness. DISCHARGE DIAGNOSES: 1. Intrauterine pregnancy at 29+0 weeks. 2. Febrile illness, unclear etiology, resolved.
Plus|Pregnancy dating|50|ADMISSION DIAGNOSIS: Intrauterine pregnancy at 39 + 2 weeks gestation, frank breech presentation. DISCHARGE DIAGNOSIS: Intrauterine pregnancy at 39 + 2 weeks gestation, frank breech presentation, status post delivery of viable male infant.
Plus|Reflexes|124|NEURO: His sensation was intact over his lower extremities, as well as his perineum. His motor exam was 5/5. Reflexes were 1+ and symmetric at his knee jerk and ankle jerks. He had negative Babinski signs. Plane films of his thoracic spine demonstrates chronic degenerative changes particularly at T12-L1.
Plus|Pulse|170|EARS: Negative. EYES: Pupils equal, round, and reactive to light and accommodation. Extraocular muscles and convergence intact. ORAL: Oral exam negative. NECK: Carotids 2+ bilaterally without bruits. Neck is supple. Forward flexion does increase the pain, however.
Plus|Pregnancy dating|162|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 32-year-old gravida 1, para 0 with last menstrual period of _%#MM#%_ _%#DD#%_, 2003. She is currently at 6 + 3 weeks gestation based on last menstrual period.
Plus|Reflexes|150|She has varicosities in the left lower extremity with trace edema. NEUROLOGIC: Cranial nerves II-XII grossly intact. No abnormal movements. Reflexes 2+, symmetric throughout. She has normal sensation throughout. Normal finger-nose-finger. LABORATORY STUDIES: Sodium 134, potassium 3.8, bicarb 24, chloride 99, BUN 25, creatinine 0.9. Anion gap is 12.
Plus|Plus|495|He is an 83-year-old with a history of congestive heart failure and had a normal echocardiogram with a normal ejection fraction in _%#MM#%_ 2003. Progressively, he has been having this deterioration of ejection fraction with the current ejection fraction noticed on _%#MM#%_ _%#DD#%_, 2004, on an echocardiogram of 15%, with also mild moderate increased of LV wall thickness, moderate right ventricular dilatation, moderate severely decreased right ventricular function, RV systolic pressure 31 + RA, moderate LA enlargement, severe aortic stenosis with a mean gradient of 17.3 mmHg.
Plus|Reflexes|113|Her strength on the right is at 5- to 4+/5. There is no sensory neglect. Reflexes are increased on the right at 2+ compared to 1 to 2+ on the left. The right Babinski is equivocal, left negative. CARDIOPULMONARY: On auscultation, shows no localizing findings.
Plus|Reflexes|182|No palpable masses. No inguinal nodes. No inguinal hernia. She has palpable posterior tibial and dorsalis pedis pulses. No peripheral edema. Biceps and patellar tendon reflexes are 2+/4 and symmetrical. I do not detect Phalen's or Tinel's sign on either hand.
Plus|Pregnancy dating|320|PROCEDURES: 1. Pitocin augmentation. 2. External fetal monitoring. 3. Primary low segment transverse cesarean section. COMPLICATIONS: None. CONSULTS: OB-GYN Service. HISTORY OF PRESENT ILLNESS: The patient is a 24-year-old African-American gravida V, para 1-0-3-4, admitted to Labor and Delivery on _%#MMDD2004#%_ at 40 + 2 weeks, by 23 week ultrasound, who is in latent labor.
Plus|Edema(swelling)|138|LUNGS: Lungs were clear to auscultation bilaterally. ABDOMEN: Soft, nontender, nondistended. Positive bowel sounds. EXTREMITIES: She had 3+ pedal/lower extremity edema. NEUROLOGIC: Grossly nonfocal. LABORATORY STUDIES ON ADMISSION: White count 12.7, hemoglobin 7.5 (down from 9.3 on _%#MM#%_ _%#DD#%_, 2004), platelets 129.
Plus|Pulse|140|There is no guarding or rebound. EXTREMITIES: Lower extremities show no clubbing, cyanosis or edema. There is no calf asymmetry. Pulses are +2, strong, in both upper and lower extremities. NEUROLOGIC: Grossly nonfocal. Cranial nerves II-XII are grossly intact. Gait was not assessed.
Plus|Excess|106|DOB: _%#MMDD1967#%_ This 36-year-old Gravida V, Para 2-0-2-2 was delivered of a term sized pregnancy at 41+ week gestation. Delivery was spontaneous, however, during labor and pushing the patient developed a hematoma of her left labia.
Plus|Reflexes|142|NEURO - cranial nerves are intact. Motor exam of the upper and lower extremities 5/5. Deep tendon reflexes of the upper and lower extremities +2. There is otherwise no focal deficit. GENITOURINARY - there is a Foley in place with grossly bloody urine.
Plus|Pregnancy dating|258|PROCEDURE: 1. Pitocin induction. 2. Epidural. 3. Normal spontaneous vaginal delivery. COMPLICATIONS: None. HISTORY: This patient is a 32-year-old G2, P1-0-0-1, at 35+4 weeks' gestation by last menstrual period of _%#MM#%_ _%#DD#%_, 2003, consistent with a 21+1 week ultrasound on _%#MM#%_ _%#DD#%_, 2004, who presents to Labor and Delivery on the day of admission for induction of labor secondary to severe oligohydramnios.
Plus|Edema(swelling)|144|Her abdominal exam revealed positive bowel sounds, soft, and obese. Her skin revealed a few small telangiectasia. Her extremities showed woody 2+ edema bilaterally. Her neuro exam cranial nerves II-XII intact grossly nonfocal. LABORATORY: Her admission white count was 3.4, her hemoglobin was 8.3, her platelets were 189, her INR was 1.22, her PTT was 34, her electrolytes were all within normal limits.
Plus|Excess|203|5. History of gout. 6. History of chronic renal failure, baseline creatinine 1.6 to 2.0. SOCIAL HISTORY: Patient lives with her daughter-in-law and son along with her husband. She has been married for 60+ years. HABITS: She does not smoke or drink. ADMISSION PHYSICAL EXAMINATION: Vitals: Temperature 98.2, respirations 18, pulse 95, blood pressure 151/83.
Plus|Reflexes|103|CNS: A/O cannot be evaluated because of aphasia but she followed verbal commands. Deep tendon reflexes +2, cranial nerves III, IV, VI, XI, XII grossly intact.
Plus|Edema(swelling)|116|ABDOMEN: Soft, nontender, nondistended with normoactive bowel sounds, no hepatosplenomegaly. EXTREMITIES: There is 1+ pitting edema in the extremities bilaterally. There is no cyanosis or clubbing. SKIN: No ulcers, rashes or lesions.
Plus|Excess|234|24. Dilaudid 2-4 mg p.o. q. 4-6 h. p.r.n. pain. 25. Keflex 500 mg p.o. q.i.d. x 10 doses. 26. Insulin sliding scale Lispro 100-150 no units, 151-200 2 units; 201-250 4 units; 251-300 6 units; 301-350 8 units; 351-400 10 units, and 401+ 12 units. 27. Albuterol two puffs p.o. q.i.d.
Plus|Excess|156|PHYSICAL EXAMINATION: General physical examination is normal. The patient is prepared for primary cesarean section. IMPRESSION: Intrauterine pregnancy at 35+ weeks gestation, breech presentation, severe oligohydramnios.
Plus|Excess|169|SOCIAL HISTORY: She works at SAMS Club. She is normally very active and ambulates without any assistance or shortness of breath. She denies any alcohol use. She has a 50+ pack year history of smoking tobacco. She recently quit smoking tobacco. She lives with her son.
Plus|And|72|3. Atenolol 50 mg p.o. q.day 4. Aspirin 81 mg p.o. q.day 5. Caltrate 600+D b.i.d. 6. Lisinopril 20 mg p.o. q.day 7. Multi-vitamin one p.o. q.day PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 160/71, heart rate 56 and regular, respirations 16 and unlabored, temperature 97.4, O2 saturation 99% on room air.
Plus|Pulse|100|The patient does show full range of motion and strength of the left hand and wrist joint. There is 2+ radial pulse noted bilaterally. IMAGING: AP and lateral views of the left shoulder show a comminuted fracture of the left humeral surgical neck.
Plus|Edema(swelling)|131|There is some faint erythema of the anterior ankles bilaterally which has the appearance of venous stasis skin change. There is 2-3+ edema in the legs bilaterally. For further details of patient's history please refer to the chart.
Plus|Pregnancy dating|220|FINAL REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ at 4 NICU. REASON FOR CONSULTATION: MRI abnormalities with cerebellar hemorrhage and prognosis. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a gestational age 38 +1 male former 26 +2 week preemie, twin A born at 1049 grams to a G2, P1 21-year-old female.
Plus|Pulse|108|No hepatosplenomegaly, no masses, tenderness, bruits, enlargement of the aorta. PULSES: Femoral pulses are 3+, popliteals are 2+, dorsalis pedis and posterior tibials are 2+.
Plus|Reflexes|103|Sensation intact to light touch. Strength 5 out of 5 bilaterally. Gait within normal limits. Reflexes 1+ bilaterally. LABORATORY DATA: His hemoglobin this morning was 12.2. His INR was 0.97 and his electrolytes were normal.
Plus|Pulse|93|Bowel sounds are present. EXTREMITIES: Without significant cyanosis or edema. Pulses are 1- 2+ below the femorals and 2+ above. NEUROLOGICAL EXAM: Not done in detail because it was difficulty for the patient to totally cooperate.
Plus|Plus|240|PSA at that time was 3.3. In _%#MM2003#%_, the patient had a biopsy which demonstrated PIN. In _%#MM2004#%_, the patient's PSA was 4.2. On _%#MMDD2004#%_, the patient had a transrectal ultrasound-guided biopsy, which demonstrated Gleason 3 + 4 involving 10% of the specimen on the right. There was no perineural invasion. On _%#MMDD2004#%_, the patient had a CT scan of his chest, abdomen, and pelvis, and a bone scan, neither of which demonstrated any evidence of metastatic disease.
Plus|Plus|532|The patient has a long complicated past medical history and is currently in the hospital for shortness of breath and on evaluation of his electrolytes was found to have a creatinine of 2.5, which was increased from baseline at 0.8. Again a renal ultrasound was obtained to evaluate for post-renal causes and he was found to have bilateral hydronephrosis with a large amount of urine retained in the bladder. The patient also has a history of prostate cancer first diagnosed with a PSA of 55 in 2001 was found to have Gleason score 4+4. Patient underwent external beam radiation therapy and it was completed in _%#MM#%_ 2001.
Plus|Pulse|65|EXTREMITIES: No distal edema. He has had bilateral knee surgery. +3 posterior tibial pulses bilaterally. LABORATORY: Today white blood count 6300, hemoglobin 13.7, potassium 3.6, glucose 80, serum creatinine 0.78. Admission lipase 24 with normal liver function tests.
Plus|Pulse|79|Femoral pulses are 2+ bilaterally with a left femoral bruit. Pedal pulses are 2+ and symmetric. There is no pedal edema, cyanosis or erythema.
Plus|Pulse|99|Examination of the lower extremities shows no cyanosis, clubbing or edema. His femoral pulses are 2+ bilaterally, his radial pulses are 3+ bilaterally.
Plus|Edema(swelling)|216|CARDIAC: Tachycardic without appreciable murmurs, rubs, or gallops. I cannot appreciate any significant jugular venous distention; however, her neck is quite thick. ABDOMEN is soft and nontender. Extremities reveal 2+ edema bilaterally. SKIN is free of rashes. There is some bruising present.
Plus|Edema(swelling)|109|He has some edema of the legs 2+ sitting when seen initially and then upon re-exam. Later in the day it was 1+. Gastrointestinal: He has a low appetite. Musculoskeletal: He has right thigh pain, probably related to a fall, and he is using a walker right now.
Plus|Pulse|126|There is no tenderness over the SC joint, clavicle, AC joint, or scapula. Her sensation to light touch is intact. Pulses are 1+, and her hand is well perfused. SPL, EPL, finger abduction are 5/5. Axillary sensation is intact.
Plus|Reflexes|117|Face was symmetric. Tongue protruded in the midline. She had no pronator drift. She had no dysmetria. Reflexes were 2+ and symmetric. She had no Hoffmann reflex. Toes were downgoing bilaterally. EMERGENCY ROOM COURSE: The patient was immediately brought to CT after initial assessment in the emergency room and underwent repeat head CT scan without contrast.
Plus|Pulse|100|No hepatosplenomegaly. No masses, tenderness, bruits, enlargement of the aorta. Femoral pulses are 2+, popliteals are 2+, dorsalis pedis and posterior tibials are 2+.
Plus|Pulse|102|ABDOMEN: Mild to moderately obese, nontender without organomegaly, mass or bruit. Femoral pulses are 2+ without bruits. EXTREMITIES: Pedal pulses are 2+ and symmetrical.
Plus|Reflexes|99|Hearing: Auditory canal to finger rubbing was intact in both ears. Deep tendon reflexes: Trace to 1+ in the upper extremities and trace in the knees and ankles.
Plus|Pulse|186|ABDOMEN: Soft and nontender, bowel sounds positive. Groin is clean, dry and intact without bruit or hematoma. EXTREMITIES: Free of edema. Dorsalis pedis and posterior tibial pulses are 3+. LABORATORY DATA: Troponin 0.04, hemoglobin 13.7, potassium 3.7, BUN 16, creatinine 1.05. EKG shows normal sinus rhythm without any significant ST changes noted.
Plus|Edema(swelling)|135|COR: Normal S1, S2. CHEST: Clear to auscultation. ABDOMEN: 3+ distended was shifting dullness. Bowel sounds are present. EXTREMITIES: 1+ edema. There is no asterixis and she is oriented x3. LABORATORY DATA: Alkaline phosphatase 166.
Plus|Reflexes|149|Distal strength is also 1/5 on the right and he is slightly strongly distally in the left leg. Reflexes are very brisk, +4 in the lower extremities, +3 in the upper extremities. SENSORY: Exam is grossly intact although vibratory sensation is absent in the lower extremities.
Plus|Edema(swelling)|140|No gallop or murmur heard. Lungs showed trace rales at the right base. Abdomen was doughy, somewhat firm. No pain noted. He has swelling of +1 at the umbilicus and +2 down by the symphysis pubis.
Plus|Strength|119|He has scissoring posture with increased tone in the abductors. He cannot abduct. His hips he has 4/5 knee extension, 3+/5 knee flexion, 0 movement at the ankle and feet. There are no ankle reflexes. No plantar response. Minimal knee jerks.
Plus|Edema(swelling)|137|HEART - normal. LUNGS - clear. ABDOMEN - reveals midline abdominal scar. No tenderness in his abdomen. Normal size liver. EXTREMITIES - 1+ edema. NEUROLOGIC - he has a peripheral neuropathy. RECTAL - decreased tone.
Plus|Edema(swelling)|159|OROPHARYNX: Exam was unremarkable. NECK: No adenopathy. LUNGS: Rhonchi. HEART: Normal sinus rhythm. ABDOMEN: No obvious organomegaly, no masses. EXTREMITIES: 1+ edema. CURRENT LABORATORY STUDIES: Hemoglobin 8.4, platelet count 52,000, white count 8400 with 77% neutrophils and some immature myeloid elements, questionable blasts.
Plus|Edema(swelling)|146|LUNGS: Clear to auscultation. HEART: Irregular, no murmurs. ABDOMEN: Obese, soft, nontender, no masses. No organomegaly appreciated. EXTREMITIES: +1 edema in the legs and chronic skin changes with hyperpigmentation in the lower legs.
Plus|Positive(laboratory test)|262|LABORATORY DATA: Her initial hemoglobin and presentation to the hospital was 5.4, WBC 9.8, platelet count 295,000, INR 1.14, PTT 32, digoxin level 1.4. EKG showed evidence of an old inferior MI and no acute changes. Stool guaiac was positive. Urinalysis showed 2+ leukocyte esterase, 2+ protein, 4+ blood, and packed white cells.
Plus|Pulse|118|Otherwise no tenderness, guarding, organomegaly, or mass. Bowel sounds are normal. Distal lower extremity pulses are 2+, there is no cyanosis or clubbing. There is no edema. Musculoskeletal without synovitis. Genitalia/rectal exam deferred.
Plus|Pulse|196|JVP is flat. PMI is within normal limits. ABDOMEN: Soft and nontender without hepatosplenomegaly. EXTREMITIES: Without clubbing, cyanosis or edema. Dorsalis pedis and posterior tibial pulses are 2+ and symmetric. NEUROLOGIC: Decreased strength in the left side. 12 lead EKG is described.
Plus|And|172|Showing an ejection fraction of 30%. 3. Transfuse at interval to keep hemoglobin greater than 9. 4. Urology and renal follow up 5. Continue Cardizem for heart rate control + or - nitrates. 6. Flagyl therapy for the C-Difficile colitis.
Plus|Pulse|122|PULSES: Femoral pulses are 2+ bilaterally. Popliteals are 1+ bilaterally. Dorsalis pedis and posterior tibial pulses are 1+. There is no peripheral edema. NEURO: Locomotor examination is unremarkable.
Plus|Strength|475|Pronator drift testing reveals no loss of extensor tone or pronation of the hands; however, she does report aching of the shoulders and proximal arm muscles and a mild downdrift. Individual muscle group testing on a scale of 1 to 5 (right/left) is as follows: neck flexion 4+, neck extension 4, shoulder abduction 4/4, rhomboids 4-/4-, elbow flexion 5-/5-, elbow extension 4+/4+, wrist extension 5/5, wrist flexion 5/5, finger extension at the MCP joint 5/5-, grip strength 4+/4+, finger abduction 5-/4+, and APB 4+/4. Lower extremities are hip flexion 4/4, hip abduction 4+/4+, hip adduction 4+/4+, knee extension 4+/4+, knee flexion 5-/5-, ankle dorsiflexion 5/5, and ankle plantar flexion 5/5.
Plus|Strength|185|Motor tone and bulk appear normal in all four extremities. She does have weakness of the distal left upper extremity as follows: Wrist extensors 5/3+, digit extensors 5/3+, interossei 4+/4, ? positional, thenar 4+/4, flexor pollicis longus 5/5, finger flexors fourth and fifth digits 5/4, second and third digits 5/5, wrist flexors 5/5; biceps, triceps, deltoid strength are all within normal limits.
Plus|Pulse|123|HEENT: Unremarkable. LUNGS: Clear to auscultation bilaterally. CARDIOVASCULAR: No jugular venous distention. Carotids are 2+ bilaterally without any bruits. HEART: Regular rate and rhythm. S1, S2 with a 2/6 holosystolic murmur at the apex.
Plus|Strength|136|She does open eyes to voice and follows one-step commands with lots of reinforcement. She gives a motor strength of approximately 4 to 4+ throughout except in the left upper extremity which she is unable to give any grasp and unable to give any proximal abduction either.
Plus|Reflexes|159|During my portion of the evaluation I could not convince myself of any resting tremor however. Sensory examination was consistent with his age. Reflexes were 1+ throughout. Babinski's were absent. IMPRESSION: History of dementia with coincident history of development of Parkinsonian-like features with rigidity, some facial masking, shuffling of gait.
Plus|Pulse|104|CARDIAC: Reveals a rapid, irregular rhythm. I do not appreciate a gallop or murmur. Carotid pulses are 2+ and femoral pulses are 2+ and no bruits. Neck veins are slightly distended and there is a slight V wave.
Plus|Edema(swelling)|146|EXTREMITIES: Lower extremities have no cyanosis, clubbing, or edema. There is a patent AV fistula in the right upper arm. Lower extremities have 2+ pitting ankle and pretibial edema. Urinalysis shows 100 mg/dl albumin, otherwise negative. Head CT shows atrophy and is otherwise negative.
Plus|Reflexes|210|Neck free of neck-vein distention, mass, bruit or goiter. HEART: Regular with an apical S4, no murmur heard. LUNGS: Clear. ABDOMEN: Soft, obese, nontender, no bruit heard. EXTREMITIES: Normal without edema and +1 to +2 to pedal pulses. This very nice gentleman presents with worsening left heart failure.
Plus|Reflexes|141|The rectovaginal examination confirms this finding. EXTREMITIES: Without clubbing, cyanosis or edema. NEUROLOGIC: Deep tendon reflexes were 2+ bilaterally. Motor and sensory examinations are 5/5 in the upper and lower extremities bilaterally.
Plus|Edema(swelling)|111|HEART: S1, S2 regular rate and rhythm. ABDOMEN: Soft, obese, non-tender, non-distended. EXTREMITIES: There is 1+ edema in both lower extremities. MUSCULOSKELETAL: Reveals functional active and passive range of motion in all joints.
Plus|Reflexes|134|Negative clonus and negative Romberg test. Deep tendon reflexes are 2+ and equal bilaterally. Deep tendon reflexes of the right is 0-1+ and left is 0. LABORATORY DATA: None at this time.
Plus|Reflexes|242|There is no definite carotid bruit. Motor power slightly reduced on the left at 5-/5 and she does have a modest amount of gait ataxia which seems reasonably well-managed with use of walker. The reflexes are slightly increased on the left at 2+ compared to 1+ on the right. The left Babinski, however, does remain negative as does the right.
Plus|Pulse|105|CHEST: Exam is clear CARDIAC: Regular rate and rhythm, I do not appreciate a murmur. Carotid pulses are 2+, femoral pulses 2+, dorsal pedal pulses 2+ and no bruits.
Plus|Pulse|133|Lungs showed diminished breath sounds at the bases without rales. Abdomen soft without organomegaly. Extremities showed no edema and +1 pedal pulses. Mrs. _%#NAME#%_, age 84, presents with six months and probably more of shortness of breath on exertion.
Plus|Edema(swelling)|120|CARDIOVASCULAR: Irregular and tachycardic. LUNGS: Decreased breath sounds. ABDOMEN: Bowel sounds present. EXTREMITIES: 1+ lower extremity edema. SKIN: Intact. REVIEW OF SYSTEMS: MUSCULOSKELETAL: She moves all extremities. NEUROLOGIC: The patient is confused.
Plus|Edema(swelling)|158|No thyromegaly. Oropharyngeal mucosa is clear. LUNGS: Clear bilaterally to auscultation. CARDIOVASCULAR: Normal S-1 and S-2 with no murmurs. The patient has 2+ pitting edema in her lower calves and ankles. ABDOMEN: Is soft and non-tender to palpation with no palpable masses.
Plus|Pulse|179|No diastolic murmur, rub or S3. ABDOMEN: Soft, nontender, without palpable liver, spleen or masses. Bowel sounds are present. EXTREMITIES: Without cyanosis or edema. Pulses were 1+ below the femorals, 1-2+ above. NEUROLOGIC: Grossly intact. The patient was able to move extremities and respond to sensory stimuli.
Plus|Edema(swelling)|130|Lungs are clear. Cardiac: regular rhythm, 2/6 systolic murmur heard at the left sternal border. Abdomen benign. Extremities show 1+ to 2+ pitting edema with shiny discoloration of the left lower extremity.
Plus|Pulse|126|Abdomen: Nondistended, soft, without tenderness, guarding, organomegaly or mass. Bowel sounds are normal. Peripheral pulses: 2+ dorsalis pedis. There is no cyanosis or clubbing.
Plus|Pulse|216|ABDOMEN: Non-distended, soft, and non-tender without palpable organomegaly or mass. Bowel sounds are normal. No epigastric or ileac bruits. Distal lower extremities are well perfused with right dorsalis pedis pulse 1+, left 2+. There is no cyanosis or clubbing. There is trace pretibial/ankle edema.
Plus|Edema(swelling)|103|CARDIAC: Soft precordium, normal S1, S2, there is a positive S4, there are no murmurs. EXTREMITIES: 1-2+ edema bilaterally. LABORATORY & DIAGNOSTIC DATA: Echocardiogram demonstrates a 30% ejection fraction with lateral wall hypokinesis with normal LV size, normal RV function, normal valve function.
Plus|Pulse|196|Abdomen: Soft and nondistended. Mild epigastric tenderness. No guarding, rebound, organomegaly or mass. Bowel sounds normal. Scar from prior gastric surgery noted. Extremities: Peripheral pulses 2+ posterior tibials. No cyanosis, clubbing, or edema. Musculoskeletal: Without synovitis. Pelvic/Rectal: Exam deferred.
Plus|Blood type|139|No fetal cardiac activity was noted. It was apparently a fetal demise. The patient's quantitative hCG level was 41,636. Her blood type is O+. Her hemoglobin was 13.2. White blood count 11.6. After evaluation by the emergency room physician, the patient requested to proceed with a D&C for completion of the miscarriage.
Plus|Uncommon rating|230|HEAD/NECK: Negative. CHEST: Clear to auscultation and percussion. HEART/LUNGS: Normal. ABDOMEN: Reveals hypoactive taps and bowel sounds and she is exquisitely tender in her right lower quadrant with rebound and guarding of 3 to 4+ level. PLAN: Will be to proceed with appendectomy as soon as can be arranged.
Plus|Pulse|104|ABDOMINAL: Unremarkable. No masses, tenderness, bruits or enlargement of the aorta. Femoral pulses are 3+. Popliteal pulses are 3+, dorsalis pedis pulses are 3+.
Plus|Edema(swelling)|117|There were bibasilar rales noted. He had a regular heart rate, with no murmurs. Abdomen was soft, nontender. He had 1+ lower extremity pitting. He underwent ultrafiltration yesterday, resulting in improved cardiopulmonary functioning. There was some question, however, about the appearance of the ultrafiltration fluid.
Plus|Pulse|125|Defibrillator is well healed. ABDOMEN: Soft and nontender with normoactive bowel sounds. EXTREMITIES: Without edema. He has 2+ peripheral pulses. SKIN: Warm and dry without clubbing, cyanosis or rash. NEUROLOGICAL EXAM: Nonfocal.
Plus|Pulse|180|No click; no jugular venous distention. ABDOMEN: non-distended; soft; non-tender. No organomegaly or mass. Bowel sounds are normal. EXTREMITIES: distal lower extremity pulses are 2+. No cyanosis or clubbing, no edema. MUSCULOSKELETAL: no synovitis. PELVIC/RECTAL: deferred.
Plus|Edema(swelling)|146|Cardiac exam shows regular rhythm without murmurs or gallops. Abdomen: Benign without organomegaly or masses. Lymphatics: Negative. Extremities: 1+ to trace edema in the lower extremities. Peripheral pulses are normal. Right leg is foreshortened and externally rotated.
Plus|Pulse|152|CARDIOVASCULAR: S1, S2 without murmur, rub, gallop, heave or JVD. ABDOMEN: Quiet. Recent incision. Nondistended. No bruits. PULSES: Femoral pulses are 2+ without bruits. Pedal pulses are trace bilaterally. EXTREMITIES: No pedal edema. SKIN: Currently without cyanosis, pallor or erythema.
Plus|Excess|105|Her vital signs include temperature 99; it went as high as 102 degrees. Blood pressure is pressure at 100+ systolic on pressors. Respiratory rate is 22 and unlabored. Oxygen saturation acceptable on nasal cannula oxygen.
Plus|Strength|93|Strength 5/5 in right upper and lower extremities. 5- in left deltoid, triceps, and biceps. 4+ in left wrist flexor and extensor. She is seen opening and closing her left hand; however, to testing she is reluctant to do so.
Plus|Reflexes|108|He had poor fine finger movements. He had intact sensation to pin, light touch and vibration. Reflexes are 2+ in his arms, 3+ knee jerks, trace ankle jerks. Toes are downgoing. Finger-to-nose and heel-to-shin are intact. He was not ambulated.
Plus|Pulse|98|I don't appreciate a murmur at this time, although one is noted on admission. Carotid pulses are 2+, femoral pulses are 2+, there are bilateral femoral bruits noted.
Plus|Pulse|133|ABDOMEN: Unremarkable. No hepatosplenomegaly. No masses, tenderness, bruits or enlargement of the aorta. PULSES: Femoral pulses are 2+, popliteal pulses 2+, dorsalis pedis pulses and posterior tibial pulses are 2+.
Plus|Pulse|201|ABDOMEN: Flat and soft, she has marked point tenderness with guarding and rebound present in the right lower quadrant of the abdomen over McBurney's point. Bowel sounds are diminished. Femoral pulses 4+ and equal bilaterally. EXTREMITIES: No evidence of cyanosis, clubbing or edema. NEUROLOGIC: Motor and sensory function grossly intact.
Plus|Pulse|126|Bowel sounds are present. EXTREMITIES: Without significant cyanosis, clubbing or edema . Pulses 1+ at the femorals or below, 2+ above. NEURO: Grossly intact. EKG showed normal sinus rhythm with T wave inversion present both in the inferior leads and anterolateral leads as well as mild ST segment depression.
Plus|Uncommon rating|162|Pupils are round and reactive to light. PHARYNX: Benign NECK: Is unremarkable CORONARY: Normal S-1 and S-2. CHEST: Clear to percussion and auscultation ABDOMEN: 1+ diffuse tenderness, intermittent guarding. Slight increased tenderness in the right flank and left lower quadrant.
Plus|Reflexes|104|Sensation was intact to light touch. Strength 5/5 bilaterally. Gait within normal limits. Reflexes are 1+ bilaterally. LAB DATA: Comprehensive Metabolic Panel and CBC drawn in the emergency room were shown to be normal.
Plus|Pulse|151|CARDIOVASCULAR: Regular rate and rhythm, normal S1 and S2. ABDOMEN: Positive bowel sounds, soft, nontender. EXTREMITIES: No edema. Her D-P pulses are 3+ bilaterally. NEURO: Her reflexes on the left patella are 2+ and on the right patella might be slightly less.
Plus|Pulse|131|No heave or jugular venous distention. ABDOMEN: Abdomen is soft and nontender. No organomegaly, mass or bruit. Femoral pulses are 2+ without bruits. Pedal pulses are 2+ and symmetrical. EXTREMITIES: There is no pedal edema, cyanosis or erythema.
Plus|Pulse|101|I hear no murmurs, rubs or gallops. ABDOMEN: Soft and nontender EXTREMITIES: Without edema. She has 2+ pulses. SKIN: Warm and dry without clubbing, cyanosis or rash.
Plus|Edema(swelling)|85|ABDOMEN: Positive bowel sounds, soft. She has diffuse mild tenderness. EXTREMITIES: 3+ edema bilaterally. MUSCULOSKELETAL: She moves all extremities equally.
Plus|Edema(swelling)|149|COR: S1, S2 normal. No S3, S4 or murmur. ABDOMEN: Soft and nontender. No mass or hepatosplenomegaly. Bowel sounds are normal. EXTREMITIES: There is 2+ edema in the lower extremities with chronic venous stasis dermatitis changes.
Plus|Excess|174|ABDOMEN: Soft and nontender. Vertex per Leopold. NST is reactive. Tocometry shows occasional contractions. Cervical exam is deferred. ASSESSMENT: Intrauterine pregnancy at 37+ weeks with decreased fetal movement, reactive tracing now.
Plus|Reflexes|121|She is not ataxic on finger-nose-finger. Heel-knee-shin is also not ataxic. Gait was not tested today. Her reflexes are 2+/4+ at the biceps, 1-2+/4+ at the brachial radialis, 2+/4+ at the knees bilaterally, and plantar responses are flexor.
Plus|Excess|131|Patient was hospitalized at Fairview Ridges Hospital because of GI bleed in mid _%#MM#%_ 2004. He also describes PND for the last 6+ months. Mr. _%#NAME#%_ lives alone in _%#CITY#%_ _%#CITY#%_, Iowa and has been receiving cardiology care in _%#CITY#%_ from a Mayo Clinic cardiologist.
Plus|Pulse|136|ABDOMEN: Unremarkable. No hepatosplenomegaly, masses, tenderness, bruits, or enlargement of the aorta. EXTREMITIES: Femoral pulses are 3+, popliteal pulses are 3+, and dorsalis pedis and posterior tibial pulses are 2+.
Plus|Strength|157|Hip flexors are less than antigravity on the right, grade 4 on the left, knee extensor grade 2+ on the right, 4 on the left. Extensor hallucis longus grade 4+ on the right, and 4 on the left. Pulses are strong in both feet. He does not have any swelling in either feet.
Plus|Pulse|126|The left foot is pink and hyperemic. The toes are somewhat pale, however. She has good motor function of the foot. She has a 2+ pulse in the bypass graft medial to the left knee.
Plus|Reflexes|163|MUSCULOSKELETAL: The patient has full range of motion of the extremities with passive movement. NEURO: Cranial nerves II-XII grossly intact. Deep tendon reflexes 2+ and symmetric. Toes are upgoing bilaterally. Sensation is difficulty to assess given the patient's varying mental status.
Plus|Pulse|110|ABDOMEN: Flat, soft, nontender, no masses are noted. Bowel sounds are present and active. Femoral pulses are 4+ and equal bilaterally. EXTREMITIES: No evidence of cyanosis, clubbing or edema. She will not lift her leg off of the bed.
Plus|Pulse|175|He has a long scar in his left groin area, consistent with his gunshot wound. Femoral pulses are 2+. EXTREMITIES: Popliteals are 2+. Dorsalis pedis and posterior tibials are 2+. There is no peripheral edema. SKIN: No skin lesions noted, apart from surgical scars.
Plus|Edema(swelling)|229|Cardiovascular: regular rate and rhythm, no murmurs. Abdomen: positive bowel sounds, soft, nontender, no organomegaly, and no masses. Extremities: right fourth finger with erythema, and mild nonpitting edema noted approximately 1+. There is also trace edema noted on the patient's hands bilaterally.
Plus|Edema(swelling)|180|HEENT: Unremarkable. LUNGS: Significant upper airway stridor, otherwise relatively clear. CARDIAC: Regular rhythm. ABDOMEN: Distended, bowel sounds are present. EXTREMITIES: Show 1+ edema. RECENT MEDS STOPPED: 1) IV Zosyn. 2) Metoprolol. 3) Insulin.
Plus|Uncommon rating|114|No bleeding. On the right side there is only 1 deep split in the right earlobe. NOSE: Septum midline. Turbinates 2+ bilaterally. Mucosal linings appear normal. No polyps. OROPHARYNX: Normal mucosa. No masses or lesions. NECK: Supple.
Plus|Pulse|234|Symmetrical expansion of the chest is present. ABDOMEN: Unremarkable, no hepatosplenomegaly, no masses, tenderness, bruits, enlargement of the aorta. Femoral pulses are 2+, popliteals are 2+, dorsalis pedis and posterior tibials are 2+. He has an indwelling urinary catheter with the urine bag tied to his right leg.
Plus|Excess|218|PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 99.2, max current 98.6, blood pressure 110-120s/60s to 70s, heart rate 60s-80s, respiratory rate 20, sats 94% on 2 liters, weight 133.5 kilograms. Overnight 400 in and 300+ out, and so far today was 2400 in and 500 out. GENERAL: He is pleasant in no acute distress. He is alert and oriented x3.
Plus|Edema(swelling)|94|ABDOMEN: Positive bowel sounds; soft and nontender; no organomegaly; no masses. EXTREMITIES: 2+ pitting edema on the right foot and 1 to 2+ edema with mild pitting on the left.
Plus|Edema(swelling)|157|HEART: Regular with a 1/6 systolic murmur in the aortic area, no S3 is heard. LUNGS: Clear. ABDOMEN: Soft, obese, pendulous and nontender. EXTREMITIES: Show +2 lower leg edema. Pedal pulses could not be felt. Radial pulses were +2.
Plus|Pulse|116|Musculoskeletal exam revealed no acute inflammatory change or trauma. There was no edema. Dorsal pedal pulses were 3+. The patient did not have any bruising. Skin exam was normal. LABORATORY TESTS: Included the initial glucose that was 22 on _%#MMDD2002#%_.
Plus|Excess|169|She does not have any other urologic symptoms of note. She tells me that she felt hot last night but did not describe chills, and generally her temperature was about 102+ degrees. She has significant past history of multiple sclerosis, progressive, and is followed by Dr. _%#NAME#%_ for this condition.
Plus|Reflexes|82|NEUROLOGIC: The patient has abnormal mental status, as noted above. Reflexes are 1+ and symmetrical. A detailed neurologic exam is limited by the patient's mental status.
Plus|Edema(swelling)|136|COR: S1, S2 normal. No S3, S4, or murmur. ABDOMEN; Soft, nontender. No mass or hepatosplenomegaly. Bowel sounds normal. EXTREMITIES: 1-2+ edema in the left foot. There is hemorrhagic discoloration of the left foot and into the left lower leg.
Plus|Pulse|121|HEART: Regular with a loud S4. No S3 or murmur heard. LUNGS: Clear. ABDOMEN: Soft, obese, nontender. EXTREMITIES: Showed +1 pedal pulses and no edema. This elderly frail slow-moving female developed unstable angina last night without EKG changes or acute enzyme elevations.
Plus|Edema(swelling)|127|No hepatosplenomegaly is detected. She has both lower legs wrapped. I did not remove the dressings. She does appear to have 1-2+ edema and chronic venostasis changes. She has a well-healed scar from her right total knee.
Plus|Pulse|176|NECK supple, chest is clear to auscultation and percussion. CARDIOVASCULAR EXAM: S4, S1, S2 with Grade I/VI apical systolic murmur. JVP is not elevated. Carotid upstrokes are 2+ symmetric without bruit. ABDOMEN is soft, nontender without hepatosplenomegaly. No masses palpated. Femoral pulses are 2+ and symmetric.
Plus|Pulse|175|There is obesity present. No masses, tenderness, bruits, enlargement of the aorta present. Femoral pulses are 3+, popliteals are 2+, dorsalis pedis and posterior tibials are 2+. SKIN: Examination of the skin and lymph nodes were unremarkable.
Plus|Pulse|195|ABDOMEN: Unremarkable. No hepatosplenomegaly. No masses, tenderness, bruits, enlargement of the aorta. PULSES: Femoral pulses are 3+. Popliteals are 2+. Dorsalis pedis and posterior tibials are 2+. There is 1+ ankle edema. LABORATORY DATA: Sodium 136, potassium 3.5, glucose level which was random was 126, ALT raised at 123, AST 65, magnesium 1.5 which is low.
Plus|Reflexes|109|Sensation is intact to light touch. Strength is 5/5 bilaterally. Gait is within normal limits. Reflexes are 2+ in the upper extremities, 1+ in the lower extremities.
Plus|Pulse|172|CHEST: Clear to percussion and auscultation. ABDOMEN: Unremarkable with no hepatosplenomegaly. No masses, tenderness, bruits, enlargement of the aorta. Femoral pulses are 3+. EXTREMITIES: Popliteal pulses are 2+. Dorsalis pedis and posterior tibial pulses are 2+.
Plus|Pulse|104|He has a bag over his right lower quadrant. EXTREMITIES: Have only trace edema bilaterally. Pulses are 1+ throughout. SKIN: Is warm and dry. There is no cyanosis, clubbing or rash. NEUROLOGIC: Examination is non-focal.
Plus|Edema(swelling)|139|CHEST: Has a few crackles in the right base, clear on the left. ABDOMEN: Soft, nontender with normoactive bowel sounds. EXTREMITIES: Have 1+ edema bilaterally. Pulses are 1+. SKIN: Warm and dry without clubbing, cyanosis or rash.
Plus|Pulse|152|She says her left hand feels cool but just the same as her right hand. Sensory and motor functions are normal. She has a 4+ left brachial pulse with a 2+ left radial pulse, but I cannot palpate a left ulnar pulse.
Plus|Pulse|223|ABDOMEN: Unremarkable. No hepatosplenomegaly. No masses, tenderness, bruits or enlargement of the aorta. PULSES: Femoral pulses are 3+, popliteal arteries are 3+. Dorsalis pedis pulses and posterior tibial pulses are both 3+. EXTREMITIES: He has an ulcer on the base of the right great toe which is bandaged.
Plus|Pulse|90|She has a positive grinding test. Sensation intact in all dermatomes. Grip strength 4/5. 2+ and symmetric radial pulses. No pain with elbow motion. She does have a silver dollar sized area of ecchymosis from where she has scratched.
Plus|And|174|MRI is not available. Radiographs as described, not available for my review at this time. IMPRESSION: Back and right thigh pain suggesting possible discogenic pain etiology, +/- symptoms of L4 radicular pain. At this point, a MRI is pending to evaluate for a post fall disk extrusion or other pathology to explain her back and leg symptoms.
Plus|Pulse|168|CHEST: Clear to percussion and auscultation. ABDOMEN: Unremarkable. No hepatosplenomegaly. No masses, tenderness, bruits, enlargement of the aorta. Femoral pulses are 3+, popliteals are 3+, dorsalis pedis and posterior tibials are 3+.
Plus|Strength|180|She has TED hose. Hip flexion on the right is 4 minus over 5; knee flexion to 50 degrees. Left hip flexion 5/5; knee flexion to 50 degrees. Ankle plantar flexion and dorsiflexion 4+ to 5 over 5. Sensation to light touch grossly intact. Reflexes +1 to +2 bilateral.
Plus|Strength|155|Left hip flexion 5/5; knee flexion to 50 degrees. Ankle plantar flexion and dorsiflexion 4+ to 5 over 5. Sensation to light touch grossly intact. Reflexes +1 to +2 bilateral. ASSESSMENT: 1. Status post bilateral total knee arthroplasties, stable. Pain well controlled with Vicodin.
Plus|Reflexes|150|Coordination: finger-to-nose is intact in bilateral upper extremities. Rapid alternating movements are intact in the upper extremities. Reflexes are 2+ at bilateral biceps, 1+ at the triceps and brachial radialis, 0 at the right knee, 1+ at the left knee, ankles are 0 on the right and 1+ on the left.
Plus|Reflexes|119|EXTREMITIES: Her upper extremities have 5/5 strength in all muscle groups and are symmetric. Deep tendon reflexes are 2+ and symmetric. In the lower extremities on the right hip flexion, extension, leg extension, leg flexion, dorsiflexion, and plantar flexion are all 5/5.
Plus|Pulse|85|Bowel sounds are present. EXTREMITIES: No cyanosis, clubbing or edema. Pulses 1+ to 2+ below the femorals, 2+ above. NEUROLOGICAL: Appears to be grossly intact. EKG shows a normal sinus rhythm with no acute ST abnormalities present.
Plus|Pulse|138|ABDOMEN: Mild-to-moderately obese, nontender, with normal bowel sounds. No bruits, organomegaly or mass. EXTREMITIES: Femoral pulses are 2+ without bruits. Pedal pulses are 3+ and symmetrical. There is no pedal edema, erythema or cyanosis.
Plus|Reflexes|123|There is no sensory neglect. There is really not the opportunity to assess coordination more fully. Reflexes however were 1+ and Babinskis are absent bilaterally. She has now undergone MRI of the brain. This does not show acute infarction or other acute change.
Plus|Strength|102|Strength at bilateral shoulders is 5/5. Elbow flexion and extension 5/5. Wrist extension and flexion 4+/5. Finger flexion 4+/5. Hip flexion bilaterally 4/5. Hip extension bilaterally 4/5. Knee flexion bilaterally 5/5.
Plus|Pulse|110|There is guarding, rebound, organomegaly or mass, bowel sounds are normal. Distal lower extremity pulses are 2+. There is no cyanosis or clubbing. There is no edema. There is no posterior calf or thigh tenderness or induration to suggest DVT.
Plus|Reflexes|141|Tenderness is noted in the lumbar midline at L5 and off to the left. There is significant paralumbar muscle spasm bilaterally. Reflexes are 2+ bilaterally in knee and ankle jerk. Babinskis sign is negative on both sides. There is a negative bilateral straight leg raise.
Plus|Pulse|98|Lungs clear to auscultation. Heart regular rate and rhythm without murmur, rub or gallop. Pulses 2+ and symmetrical. Abdomen soft, nontender without palpable organomegaly.
Plus|Edema(swelling)|201|LUNGS: A few basilar crackles at the bases. HEART: Grade II/VI holosystolic murmur at the base and left lower sternal border. No obvious diastolic murmurs. ABDOMEN: Nontender, no masses. EXTREMITIES: 1+ pedal and pretibial edema. LABORATORY DATA: The admission creatinine 2.8 with BUN 78, potassium 6.8. Subsequent creatinines have been in the same range over the last several days with a peak of 3.2 on _%#MMDD2006#%_ and today's reading 2.8 with BUN of 91, potassium 4.3 mEq/L.
Plus|Pulse|131|Abdomen is soft, not distended, and non-tender, no organomegaly or masses. Bowel sounds are normal. Distal lower extremity pulses 2+. No cyanosis, clubbing, or edema. Musculoskeletal is without synovitis. Genitalis and rectal exam deferred.
Plus|Pulse|139|ABDOMEN: Unremarkable. No hepatosplenomegaly. No masses, tenderness, bruits, or enlargement of the aorta. EXTREMITIES: Femoral pulses are 3+, popliteals are 3+, dorsalis pedis and posterior tibials re 2+.
Plus|Pulse|166|HEART: Currently reveals a regular rate and rhythm without rub and there is a minimal early systolic murmur. Carotid pulses are 2+ without bruit. Femoral pulses are 2+. Neck veins are relatively flat. ABDOMEN: He has well healed surgical scars.
Plus|Edema(swelling)|161|Pharynx is benign. There is no lymphadenopathy. Lungs clear. Heart: regular rate and rhythm without murmurs. Abdomen: soft, non-tender, no masses. Extremities: 1+ lower extremity edema bilaterally. Neurologic: alert and fully oriented. She does have a resting tremor of both hands which I would add has been new for the past several weeks.
Plus|Reflexes|172|Neurologic: Cranial nerves II through XII are grossly intact. Sensation is intact to light touch. Strength is 5/5 bilaterally. Gait was within normal limits. Reflexes are 1+ in the upper extremities, lower extremities deferred.
Plus|Pulse|111|He has mild kyphosis. CARDIAC: Reveals an irregular rhythm, no S3 or S4, no murmur or rub. Carotid pulses are 2+, femoral pulses are 2+, no bruits. Neck veins are relatively flat. ABDOMEN: Has a midline surgical scar and probably from his small bowel obstruction; there is no organomegaly.
Plus|Excess|203|Mother alive and well. SOCIAL HISTORY: Single, divorced, no children, unemployed, former realtor. REVIEW OF SYSTEMS: CARDIOVASCULAR: Hypertension, otherwise negative. PULMONARY: Smoker 1 pack per day x20+ years. GASTROINTESTINAL: No hepatitis, gallbladder disease, ulcers or GERD. No history of IV drug use.
Plus|Pulse|186|CARDIOVASCULAR: S1, S2 without murmur, gallop, JVD. ABDOMEN: Nontender without organomegaly, mass or bruit. Femoral pulses are 2+ without bruits. EXTREMITIES: Pedal pulses are trace to 1+ and symmetrical. There is no pedal edema, cyanosis or erythema. SKIN: Clear.
Plus|Pulse|159|ABDOMEN: Apart from mild obesity was unremarkable, no hepatosplenomegaly, no masses, tenderness, bruits, enlargement of the aorta. PULSES: Femoral pulses are 2+, popliteals are 2+, dorsalis pedis and posterior tibials were 2+.
Plus|Pulse|175|CHEST: Clear to percussion and auscultation. ABDOMEN: Unremarkable with no hepatosplenomegaly. No masses, tenderness, or enlargement of the aorta. PULSES: Femoral pulses are 3+ and popliteals are 3+. Dorsalis pedis and posterior tibials are 3+. LOCOMOTOR: Unremarkable. NEURO: Unremarkable.
Plus|Edema(swelling)|155|There is a palpable liver edge 1-2 cm. below the right costal margin. No palpable spleen or masses. Bowel sounds are present EXTREMITIES: Showed trace to 1+ edema. Pulses were 1+ below the femorals, 1-2+ above. NEUROLOGIC: Exam was not done in detail.
Plus|Reflexes|103|She had decreased sensation to pin, light touch, vibration, proprioception in her feet. Reflexes were 2+ in her arms, 3+ knee jerks, trace ankle jerks. She had upgoing toes. Finger-to-nose was intact. Heel-to-shin was difficult for her to do.
Plus|Pulse|168|No click. No jugular venous distention. Abdomen: Nondistended, soft and nontender. No organomegaly or masses. Bowel sounds normal. Distal lower extremity pulses are 1-2+. There is no cyanosis, clubbing or edema. Musculoskeletal: Without synovitis.
Plus|Heart murmur|168|The patient had an echocardiogram when he came into the hospital on _%#MMDD#%_ and this shows an EF of 30% with inferior septal and posterior akinesis. There was 1 to 2+ MR and 1+ tricuspid insufficiency. There was decreased right ventricular function. The patient's risk factors of coronary artery disease were positive for hyperlipidemia and adult onset diabetes.
Plus|Edema(swelling)|130|ABDOMEN is without guarding or rebound. Bowel sounds are hypoactive. EXTREMITIES show no cyanosis or clubbing, but she does have 2+ peripheral edema. LABORATORY VALUES OF INTEREST: A blood gas in the emergency room showed pH 7.26, PCO2 80, PO2 95 on five liters of oxygen, bicarbonate 37.
Plus|Pulse|200|CHEST: Clear to percussion and auscultation. ABDOMEN: Abdominal examination is unremarkable with no hepatosplenomegaly. No masses, tenderness, bruits, or enlargement of the aorta. Femoral pulses are 3+, popliteals are 2+, dorsalis pedis and posterior tibials are 2+.
Plus|Edema(swelling)|180|ABDOMEN is relatively soft, nontender. There is mild liver edge palpable to 2 cm below the right costal margin. Bowel sounds are present, slightly decreased. EXTREMITIES showed 2-3+ edema extending up towards the knee bilaterally. Pulses were somewhat difficult to palpate below the popliteals. There appeared to be trace present below the popliteals, 1-2+ at the femorals and 2+ above in the upper extremities.
Plus|Pulse|137|No murmurs. ABDOMEN: Unremarkable. No hepatosplenomegaly. No masses, tenderness, bruits or enlargement of the aorta. Femoral pulses are 3+, popliteals are 3+, dorsalis pedis and posterior tibials are 3+.
Plus|Edema(swelling)|138|LUNGS: Clear to auscultation bilaterally. ABDOMEN: Obese. Bowel sounds positive, soft, nontender, and nondistended. EXTREMITIES: She has 1+ edema in her legs. She has strong peripheral pulses. Right wrist shows a cock-up wrist splint.
Plus|Plus|227|He has interstitial lung disease as a diagnosis as well. An echocardiogram apparently did show inferior, posterior scarring and a mid and basal septum abnormality as well on echo with pulmonary hypertension moderately severe 42+ right atrial pressure. This gentleman has been a drinker in the past. He is a retired welder who did fairly scientific welding as far as I can understand his history.
Plus|Strength|76|No joint deformity noted. NEUROLOGIC: Shows tone to be normal. Strength is 4+ throughout. Sensation grossly intact to touch. FUNCTIONAL STATUS: She has poor balance in standing and she had impaired transfer for sit to stand.
Plus|Pulse|174|Chest is clear to auscultation and percussion. Cardiovascular: Regular rate and rhythm, S1 and S2 without murmur, gallop, or rub. JVD is nondistended. Carotid upstrokes are 2+ and symmetric without bruits. Abdomen is soft and nontender without hepatosplenomegaly. Femoral pulses are 2+ and symmetric without bruits.
Plus|Pulse|234|CHEST: Is clear to percussion and auscultation ABDOMEN: Examination reveals that there is no guarding or rigidity, but she clearly has tenderness, marked tenderness in the epigastrium. There are no bruits present. Femoral pulses are 3+, popliteals are 2+, dorsalis pedis and posterior tibials are 2+, there is no peripheral edema.
Plus|Reflexes|197|Strength is 4- in both elbow extensors, 4- in the right elbow extension, 5/5 in both upper extremities, and 3+ in the right ankle dorsiflexion, otherwise, 5/5 throughout. Deep tendon reflexes are 2+ except for well-sustained right ankle clonus on the left side.
Plus|Reflexes|78|I could not detect any definite asymmetry at the bedside exam. Reflexes 1 to 2+ as mentioned. Babinskis were nonresponsive at the time of my visit with him.
Plus|Strength|111|He has distal greater than proximal right upper extremity weakness. Digit extensors 3/5, deltoid 5/5, triceps 4+/5. Lower extremity - mild right lower extremity weakness graded 4/5.
Plus|Pregnancy dating|123|FINAL TRIAGE VISIT CHIEF COMPLAINT: Contractions. HISTORY OF PRESENT ILLNESS: The patient is a 30-year-old G1 P0 who is 39 + 5/7 weeks' gestation and presents with complaints of contractions. Contractions started earlier today and were every 10 minutes and became more like every 5 minutes at approximately 3 p.m. She had talked to our triage line before it closed at 5 p.m. and then called again at 8:30 p.m. with continued contractions.
Plus|Pulse|107|Allen's test is negative. No digital ischemia. Temporal artery pulses full and equal. Right femoral pulse 2+. Popliteal 2+. Posterior tib and dorsal pedis in the right foot are 2+.
Plus|Plus|155|_____ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Prostate cancer HPI: Gleason 3 + 4, PSA 5, T2a by exam Exam: Nodule along right side of gland from base to apex Assessment and Plan: Ultrasound suggested a T3 lesion.
Plus|Pulse|121|LUNGS: Are clear to auscultation bilaterally. CARDIOVASCULAR: Exam shows no jugular venous distention. His carotids are 2+ bilaterally without any bruits. HEART: Is regular rate and rhythm, S-1 and S-2 without gallops or murmurs.
Plus|Edema(swelling)|125|COR: S1, S2 normal, with no S3, S4 or murmur. ABDOMEN: Soft and nontender, with no mass or hepatosplenomegaly. EXTREMITIES: 2+ ankle edema bilaterally. For further details of the patient's history, please refer to the chart.
Plus|Edema(swelling)|236|There is abdominal distention with no clear fluid wave, but her liver appears to be significantly enlarged. Bowel sounds were intact. Distal extremities showed lower extremity edema from approximately the mid tibia down to the feet as 2+ pitting edema noted. No calf tenderness. The patient did have a Doppler ultrasound study done on admission and they were negative for DVT without thrombus.
Plus|Pulse|109|The right shoulder is bandaged with an ice pack on it, removal of this is not done. The right wrist has got 2+ radial pulse. 2+ femoral pulses noted bilaterally. Both feet are warm, well perfused.
Plus|Pulse|173|JVP is not distended. ABDOMEN: Soft, nontender without hepatosplenomegaly. EXTREMITIES: Without clubbing, cyanosis or edema. Dorsalis pedis and posterior tibial pulses are 2+, symmetric. NEUROLOGIC: Grossly intact. A 12 lead EKG is as described.
Plus|Pulse|170|Abdomen has positive bowel sounds; it is soft, nontender, and nondistended; no organomegaly or masses are palpated. Extremities: No cyanosis, clubbing, or edema. Pulses 2+ in radial and dorsalis pedis. Skin: No rashes noted. Neurologic: The patient is fairly alert and oriented.
Plus|Reflexes|69|He has decreased sensation to pin and vibration in his legs. He has 1+ reflexes in his arms, absent reflexes in his legs.
Plus|Heart murmur|495|He was seen by Dr. _%#NAME#%_ in consultation. The patient subsequently underwent cardiac catheterization and coronary angiography by Dr. _%#NAME#%_. Please refer to those reports. Basically, the patient was found to have total occlusion of the right coronary artery, mild disease of the left anterior descending, 70% stenosis of the diagonal branch and total occlusion of the third diagonal branch with ejection fraction severely depressed at 20-25%, moderate severe pulmonary hypertension, 2-3+ aortic insufficiency and 1-2+ mitral regurgitation.
Plus|And|104|RECOMMENDATIONS: 1. Telemetry 2. Pacer interrogation and possible reprogramming 3. Intravenous diuresis + - potassium supplement 4. Beta blocker and nitrate therapy 5. Diabetic therapy 6. Social Services follow up
Plus|Pulse|109|Extremities: Ecchymotic bruising of the upper extremities. Distal lower extremity pulses are full. There is 2+ pedal edema bilaterally with trace pretibial edema bilaterally.
Plus|Pulse|181|ABDOMEN: Soft. Bowel sounds are present. No organomegaly appreciated. No abdominal pulsations noted. EXTREMITIES: Free of cyanosis, clubbing or edema. Bilateral femoral pulses are 3+ and equal and distal lower extremity pulses are 2+ and equal.
Plus|Pulse|120|He has no chest wall tenderness. Abdomen is soft and nontender without organomegaly, mass or bruit. Femoral pulses are 2+. Pedal pulses are 2+, dorsalis pedis 1+ posterior tibial bilaterally.
Plus|Reflexes|229|His muscles were nontender. Sensory exam was unremarkable to touch and temperature bilaterally with vibration diminished appropriately in the lower legs and feet for age. He was not ataxic in the arms or legs. His reflexes were 1+/4+ at the biceps, brachial radialis and 2+/4+ at the knees with reduced ankle jerks.
Plus|Reflexes|75|She had intact sensation to pin, light touch and vibration. Reflexes were 2+ at the knee, 1+ at the ankle, toes were downgoing.
Plus|Pulse|154|No pulsatile mass noted. SKIN: No rashes noted. No other ecchymosis or lacerations noted. EXTREMITIES: No cyanosis, clubbing, or edema noted. Pulses are 2+ bilaterally at the dorsalis pedis. Capillary refill at the great toe is 2 seconds. NEUROLOGIC: The patient is somnolent.
Plus|Edema(swelling)|247|GENERAL: Obese white male, no obvious distress. HEAD, EYES, EARS, NOSE AND THROAT: Positive hepatojugular reflex CARDIOVASCULAR EXAMINATION: Regular rate and rhythm LUNGS: Bibasilar crackles ABDOMEN: Soft, non-tender, and tympanitic. EXTREMITIES: +1 edema. Peripheral exam, +4 femoral pulses bilaterally SKIN: Exam is chronic venous stasis changes on his lower extremities
Plus|Pulse|144|S1 and S2 are present. No murmurs. LUNGS: Clear bilaterally. ABDOMEN: Soft and nontender. Positive bowel sounds. EXTREMITIES: Extremities show 2+ pulses bilaterally. No clubbing, cyanosis or edema. LABORATORY DATA: Hemoglobin 15.1, white count 7.7, platelets 196.
Plus|Edema(swelling)|126|ABDOMEN: Exam in the chair shows no hepatomegaly. EXTREMITIES: Right leg, which is covered with bandage was not removed. Had 2+ edema and trace to 1+ edema was present in the left leg.
Plus|Edema(swelling)|183|No diastolic murmur, rub or S-3. ABDOMEN: Soft, non-tender without palpable liver, spleen or masses. Bowel sounds were present. EXTREMITIES: Without significant cyanosis. There is 1-2+ edema. Pulses were 1+ below the femorals and 1-2+ above. NEUROLOGIC EXAMINATION: Showed decreased sensation of the lower extremities but the patient was able to move all extremities and respond to sensory stimuli.
Plus|Edema(swelling)|105|ABDOMEN: Soft and nontender with normal bowel sounds. No palpable masses. EXTREMITIES: Adequate pulses. 1+ edema bilaterally. No cyanosis or clubbing. EKG - the EKG shows atrial fibrillation with intermittent ventricular pacing and effusion complexes.
Plus|Edema(swelling)|134|CARDIOVASCULAR: S1, S2. Borderline bradycardic. ABDOMEN: Soft. Bowel sounds present. No distention, no focal tenderness. EXTREMITIES: +1 edema of the left lower extremity with _%#NAME#%_'s on. Right lower extremity is in a dressing but the patient is neurovascularly intact.
Plus|Pulse|102|It is a green exudate, and I estimate is 4 mm deep. Dorsalis pedis and posterior tibialis pulses are 2+. Surrounding area reveals diffuse erythema and edema consistent with venous stasis, but not clearly cellulitis.
Plus|Pulse|120|There is either no murmur or a very minimal early systolic murmur. There is no S3, there is no rub. Carotid pulses are 2+, femoral pulses are 1-2+, dorsal pedal pulses are 1+.
Plus|Reflexes|91|Sensory exam as mentioned was negative. There were no active fasciculations. Reflexes are 1+ throughout. Babinski's absent. Coordination consistent with his strength.
Plus|Edema(swelling)|112|ABDOMEN: Abdomen is soft and nontender. No mass or hepatosplenomegaly. Bowel sounds are normal. EXTREMITIES: 1-2+ ankle edema bilaterally. For further details of the patient's history, please refer to the chart.
Plus|Reflexes|150|He has very mild bilateral dysmetria with hand movements. He has normal fine motor skills with his hands. He has hypoactive reflexes in his arms and 2+ patellar and Achilles reflexes. He has no clonus. He has no Hoffmann's sign. He has no Babinski's sign.
Plus|Pulse|134|ABDOMEN: Unremarkable, no hepatosplenomegaly, no masses, tenderness, bruits, or enlargement of the aorta. PULSES: Femoral pulses are 3+, popliteals are 3+, dorsalis pedis and posterior tibials are 3+.
Plus|Reflexes|101|She has decreased sensation in a stocking glove distribution to pin and vibration. Her reflexes are 2+ in her arms, 1+ knee jerks, absent ankle jerks, toes are downgoing.
Plus|Pulse|165|Pedal pulses are 1+ and symmetric. Reflux examination triceps, biceps, brachioradialis, knee and ankle jerk is 1+. This is symmetric bilaterally. Radial pulses are 2+. Babinski shows downgoing toes bilaterally. RADIOGRAPHIC REVIEWS: Multiple views of her cervical spine were reviewed.
Plus|Pulse|178|CHEST; Clear to percussion and auscultation. ABDOMEN: Unremarkable with no hepatosplenomegaly, no masses, tenderness, bruits or enlargement of the aorta. PULSES: Femoral pulses 3+, popliteals 3+, dorsalis pedis 2+, posterior tibial trace.
Plus|Plus|272|Arterial blood gases - 7.45/47/132/33/96. HCO3 is 32. PHYSICAL EXAMINATION: Vital signs - Temperature is 100.2, respiratory rate 11-14, blood pressure is 150/60, sPO2 is 93%. Mechanical ventilator settings - assist control, tidal volume 850, FIO2 60%, rate is 10, PEEP is +5. He is intubated, sedated. NECK: Supple, nontender LUNGS: Clear to auscultation HEART: Normal S1, S2, regular rate and rhythm.
Plus|Edema(swelling)|148|EXTREMITIES: There is 2+ edema in the right lower leg with a 1 cm eschar on the lateral right ankle and some faint accompanying erythema. There is 4+ edema in the left foot and to a lesser degree in the left ankle and lower leg.
Plus|Reflexes|210|Sensation is intact to light touch except for a decreased area of sensation on the patient's abdomen secondary the surgeon severing nerves during surgery for her pseudocyst drainage. Gait: Deferred. Reflexes: 1+ bilaterally. LABORATORY DATA: ALT 81, AST 171, total bilirubin 0.3, GGT 533.
Plus|Pulse|142|Nontender. Nondistended. No evidence for organomegaly. No hepatojugular reflux. EXTREMITIES: Extremities reveal no peripheral edema. She has 1+ distal pulses bilaterally. LABORATORY AND DIAGNOSTIC DATA: Labs drawn yesterday show a white count of 7.3. Hemoglobin 15.9. Hematocrit 47.7. Platelets 226,000.
Plus|Pulse|217|Jugular venous pressure (JVP) is not elevated. ABDOMEN: Soft and nontender without hepatosplenomegaly. EXTREMITIES: Extremities are without cyanosis, clubbing or edema. Dorsalis pedis and posterior tibial pulses are 2+ symmetric. NEUROLOGIC: Grossly intact. SKIN: No lesions. LABORATORY DATA: Laboratory results are pending.
Plus|Reflexes|180|Neurologic: Cranial nerves II through XII were grossly intact. Muscle strength testing was grossly 5/5 and equal bilaterally. Gait was slightly wide-based. Patellar reflexes were 2+ bilaterally. Distal sensation to light touch, pinprick and temperature was intact.
Plus|Reflexes|131|Sensory exam shows decreased sensation in the lower extremities consistent with her peripheral neuropathy from diabetes. DTRs are 2+ bilateral and symmetric. Gait was not tested. LABORATORY DATA: That is currently available on this patient includes the following studies.
Plus|Excess|89|Vital signs show a blood pressure of 115/46, pulse of 87, respirations 20. O2 sats are 90+. She does have +3 lower extremity edema. IMPRESSION: Elderly _%#1914#%_ female patient with rapidly deteriorating cardiac status, currently attempting to optimize her cardiac function.
Plus|Edema(swelling)|145|There are no audible murmurs, rubs, or gallops. ABDOMEN: Distended with ascites. Both liver and spleen are palpable. EXTREMITIES: Show trace to 1+ bilateral ankle edema. ASSESSMENT: This 76-year-old female with a significant myelofibrosis issue is anemic with hemoglobins of 7.5. Approximately four months ago she was diagnosed with a pulmonary embolism and has been on full dose Coumadin therapy since then.
Plus|Pulse|157|There is fibrotic sounding crackles throughout CARDIAC: Exam reveals a very rapid irregular rhythm. No obvious murmur or rub is heard. Carotid pulses are 1-2+, femoral pulses are 1-2+, as are dorsal pedal pulses.
Plus|Plus|241|The chart was reviewed. Radiological reports and films were reviewed. HISTORY OF PRESENT ILLNESS: The patient is a 62-year-old gentleman who in 1999 had a radical retropubic prostatectomy for a PSA of 9.5. Pathology demonstrated a Gleason 3 + 3. The margins were negative, the closest margin was less than 1 mm.
Plus|Excess|215|She also is a long-term methadone user and is on 100 mg a day. She also uses oxycodone for breakthrough bleeding. SOCIAL HISTORY: The patient's has a long-term history of smoking and has accumulated approximately 30+ pack years. She does not use alcohol. FAMILY HISTORY: She has a family history positive for hypertension.
Plus|Pulse|94|He has scarring in left groin consistent with hernia repair. EXTREMITIES: Femoral pulses are 3+ bilaterally. Popliteals are 3+. Dorsalis pedis and posterior tibials are 3+. LABORATORY INVESTIGATIONS: As yet not available to us.
Plus|Reflexes|280|No fevers, chills, numbness, tingling or other constitutional symptoms. She has a history of hypertension, colitis and reflux. She is on multiple medications. ORTHOPEDIC EXAMINATION: Reflexes are decreased about the right patella that is trace in comparison to the left which is 2+ and brisk. She has symmetric Achilles reflexes, negative straight leg raising bilaterally.
Plus|Pulse|147|The respirations are 20 and unlabored. The HEENT exam is without corneal arcus or xanthelasma. The neck veins are not distended. The carotids are 2+ without audible bruits. Her lungs reveal minimal basilar rales. There are no wheezes or rhonchi heard.
Plus|Strength|107|No facial weakness. His tongue is midline. Motor examination: There is no pronator drift. His strength is 4+/5 bilaterally in both upper extremities proximally and 5/5 distally.
Plus|Reflexes|112|No evidence for organomegaly or hepatojugular reflux. EXTREMITIES revealed no significant pedal edema. She had 2+ distal pulses throughout. EKG shows sinus bradycardia at 53 beats/min.
Plus|Reflexes|104|The dorsalis pedal and posterior tibial pulses are palpable. There is a 2+ patellar reflex. There is a 2+ plantar reflex. Left lower extremity quadriceps and hamstring strength is 4+/5 with diminution secondary to back discomfort.
Plus|Pulse|224|CARDIOVASCULAR: S1-S2 without murmur, rub, gallop, heave, or JVD. ABDOMEN: Mild-to-moderately obese, nondistended and soft, with normal bowel sounds. There is no mass, organomegaly or bruit. EXTREMITIES: Femoral pulses are 2+ without bruits. Pedal pulses are 2+ and symmetrical. There is no pedal edema, cyanosis or erythema.
Plus|Pulse|127|ABDOMEN: Non-distended, soft, non-tender, no organomegaly or mass; bowel sounds are normal. Distal lower extremity pulses are 2+, no cyanosis or clubbing, no edema. MUSCULOSKELETAL: Without synovitis. GENITALIA AND RECTAL: Deferred. NEUROLOGIC: No facial asymmetry, no lateralizing extremity weakness.
Plus|Pulse|143|Sclerae are anicteric. Funduscopic exam is deferred. Oropharynx is not well visualized. Dentition is in good repair. Carotid upstroke is 1 to 2+ without bruits. What appears to be a right internal jugular line is in place.
Plus|Pulse|172|CHEST: Clear to percussion and auscultation. ABDOMINAL: Unremarkable with no hepatosplenomegaly. No mass, tenderness, bruits, enlargement of the aorta. Femoral pulses are 3+. Popliteals are 3+. Dorsalis pedis and posterior tibials are 3+.
Plus|Pulse|77|GROINS: Swan-Ganz catheter and arterial line is present in the right groin. 2+ left femoral pulse. PELVIC: Not performed. RECTAL: Not performed. EXTREMITIES: No clubbing or cyanosis. No edema.
Plus|Pulse|192|His tracheostomy is attached to a ventilator. ABDOMEN: Reveals some tenderness in the abdomen, PEG tube placement is present. No hepatosplenomegaly noted. No bruits noted. Femoral pulses are 2+, popliteals are 2+, dorsalis pedis and posterior tibials are 2+.
Plus|Pulse|130|Some fullness is noted across the upper abdomen. No masses appreciated. Tenderness is in the same location. Femoral arteries are 2+. EXTREMITIES: Without edema. CMS intact. LABORATORY DATA: White blood count 9.1, hemoglobin 13.4, MCV 95, platelets 318.
Plus|Edema(swelling)|161|HEENT: Unremarkable. NECK: Neck veins mildly distended. LUNGS: Expiratory wheezing bilaterally. CARDIAC: Regular rate and rhythm. ABDOMEN: Benign. EXTREMITIES: 1+ lower extremity edema. LABORATORY & DIAGNOSTIC DATA: Chest imaging reveals extensive bilateral pulmonary emboli, right greater than left.
Plus|Edema(swelling)|194|NECK: Supple without masses, no palpable lymphadenopathy. NEUROLOGIC: Grossly intact, nonfocal exam, strength normal. CARDIOVASCULAR: S1/S2 and irregularly irregular, no obvious JVD. She has 2-3+ edema to the shins bilaterally. LUNGS: Diminished sounds at both bases with left greater than right base crackles, but minimal.
Plus|Excess|207|ALLERGIES: He has multiple allergies; refer to the chart. PHYSICAL EXAMINATION: GENERAL: This patient is rather confused and disoriented. VITAL SIGNS: Vital signs per the RN note: He had a temperature of 100+. HEENT: Sclerae nonicteric, injected. Oral membranes are dry and sticky.
Plus|Pulse|92|Right femoral artery shows an incision with some fresh blood in it. His femoral pulses are 3+ bilaterally. LABORATORY STUDIES: EKG shows sinus rhythm with concave upper ST changes which are non-significantly different from his previous EKG.
Plus|Uncommon rating|125|Examination of the anus and perineum is normal. Rectal exam reveals good sphincter tone and no masses. His prostate is 1 to 2+ enlarged, feels soft and benign, and non-tender. Seminal vesicles normal. LABORATORY DATA: Urinalysis and culture are pending.
Plus|Edema(swelling)|178|ABDOMEN: Soft, bowel sounds present, nondistended, nontender. Both sternal and abdominal wounds are healed well with no evidence of infection or instability. LOWER EXTREMITIES: 2+ pitting edema. NEUROLOGICAL: Moves all extremities.
Plus|Edema(swelling)|129|CARDIAC: Exam reveals irregular rhythm without murmurs or gallops. ABDOMEN: Obese, otherwise benign. EXTREMITIES: There is 2 to 3+ pitting edema. NEUROLOGIC: Cranial nerves are intact. Motor exam shows symmetric strength.
Plus|Strength|152|He is not ambulatory. Both legs are antigravity. The left leg is weaker than the right. His dorsiflexion and plantar flexion strength is approximately 3+/5. His grasp is quite weak on the left. This is less than 3/5.
Plus|Reflexes|154|He is able to walk independently, arise from squatting posture and walk on heels, and toes. Romberg is negative. Grip is symmetric. FDN normal. Reflexes 1+, toes downgoing. Sensation to position touch, temperature, and pinprick normal. He is able to walk independently some distance without being fatigued.
Plus|Pulse|83|EXTREMITIES: 1+ nonpitting edema noted on the patient's bilateral leg. Pulses are 2+ bilaterally. There are bilateral erythematous areas on the patient's legs that are warm to palpation.
Plus|Edema(swelling)|181|No gallops identified today. ABDOMEN: Generous in size but soft and stoma site not inflamed. No peritoneal signs. EXTREMITIES: Lower extremities showed poor muscle tones, trace to 1+ edema. No signs of phlebitis. NEUROLOGIC: She is oriented to her surroundings and has no focal signs on the screening examination conducted at the bedside.
Plus|Pulse|162|HEENT: Benign. Neck is supple without thyromegaly or adenopathy. CHEST: Clear. CARDIOVASCULAR: Regular rate and rhythm without murmur or rub. Carotid pulses are 2+. Dorsal pedal pulses are 2+. There are no bruits. Neck veins are flat. ABDOMEN: Obese.
Plus|Pulse|154|Pupils are equal, reacting symmetrically. Sclerae nonicteric; fundi deferred. Oropharynx is clear. Dentition is in good repair. Carotid upstroke is 1 to 2+ without bruits; there is no thyromegaly or lymphadenopathy.
Plus|Reflexes|157|On the left side he does move particularly when stimulated and has some spontaneous movements of the left leg. Reflexes are difficult to elicit, but may be 1+ in the knees. Toe signs are equivocal. IMPRESSION: This boy has abnormal involuntary movements primarily proximally in the shoulder girdle along with what appears to be a right hemiparesis with recent onset.
Plus|Reflexes|128|Sensation was intact to light touch in all distributions of both lower extremities and both upper extremities. The patient had 1+ reflexes of ankle jerks and knees bilaterally. Pulses demonstrated a +3 of the dorsalis pedis and posterior tibialis bilaterally.
Plus|Pulse|143|CARDIOVASCULAR: Regular rate and rhythm with normal S1 and S2. ABDOMEN: Positive bowel sounds, soft and nontender. EXTREMITIES: DP pulses are 2+ bilaterally. EKG shows normal sinus rhythm without ST or T-wave changes.
Plus|Pregnancy dating|142|FINAL This is a GYN consultation for the emergency room. HISTORY OF PRESENT ILLNESS: The patient is a 33-year-old gravida 3, para 0-0-2-0 at 8+3 weeks' gestation by her last menstrual period of _%#MMDD2006#%_.
Plus|Pulse|96|Bowel sounds are present in the extremities without cyanosis. There is trace edema. Pulses are 1+ throughout the femorals, 1-2+ below. NEURO: Appeared to be grossly intact. LABORATORY AND DIAGNOSTIC DATA: Troponin was 0.96. Sodium 136.
Plus|Strength|227|Sternocleidomastoid and trapezia are strong symmetrically. Range of motion - full active range of bilateral upper and right lower extremity. Left lower extremity is not aggressively tested. Strengths are antigravity, at least 4+/5 examined in the supine position. Sensation is decreased to light touch in a stocking distrubution over the lower extremities to the Semmes-Weinstein monofilament over the right plantar surface of the foot.
Plus|Reflexes|126|Right lower extremity strength is 5-. Left side strength is normal. Deep tendon reflexes are bilaterally symmetrical, brisk, 3+. Sensation is intact to touch. Gait is cautious, slow, and she walks with a walker.
Plus|Heart murmur|174|No recent history of angina. 2. Ischemic cardiomyopathy with an ejection fraction of 20-25%. 3. Severe mitral regurgitation in the past. Echocardiogram at this time shows 2-3+ mitral regurgitation. 4. History of pneumonia. 5. History of non-insulin dependent diabetes mellitus.
Plus|Positive(laboratory test)|241|The twin infants were delivered by C-section in the midday of _%#MMDD2007#%_ without major incident. She is stable postoperatively. Review of the prenatal records shows evidence of qualitative proteinuria as early as _%#MM#%_ of this year (1+ qualitative protein). In _%#MM#%_, the reading was 2+ and subsequently 1+ at each visit.
Plus|Pulse|154|HEAD, EYES, EARS, NOSE AND THROAT: Reveals pupils are equal, reactive to light. Pharynx is not inflamed. Dentition is somewhat poor repair. Carotids are 3+ here no bruits. LYMPH: I feel no supraclavicular, cervical or axillary adenopathy. There is no inguinal adenopathy and no splenomegaly.
Plus|Strength|114|Biceps is 2+/5, not able to show full active range of motion. Triceps is 3/5. Wrist extension is 2/5, flexion is 2+/5, finger extensors are 2+/5, finger flexors are 2/5.
Plus|Plus|175|______ Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Recurrent prostate cancer. HPI: pT3b, Gleason 7 (4+3) with slowly rising PSA now to 0.15. Exam: No palpable nodule in the rectum/prostate bed.
Plus|Edema(swelling)|61|There is no audible S3 or S4. There are no bruits. There is 2+ pitting edema to the knees bilaterally. ABDOMEN: Active bowels sounds. No palpable liver or spleen tip.
Plus|Positive(laboratory test)|123|Fetal heart tones in the 130s, which react to nonstress test. No contractions noted on the tachometer. Patient did have a 3+ protein on initial urine dip, 1+ on urine dip 2 hours later.
Plus|Excess|103|There is no weight. Overnight he had 900 in, 250+ out. In the first half of today, he has 1650 in, 1500+ out. GENERAL: He is pleasant, no acute distress. He is alert and oriented x3.
Plus|Pulse|102|ABDOMEN: Obese, making exam difficult but no surgical scars are appreciated and no tenderness. He has +3 radial/femoral pulses bilaterally. EXTREMITIES: He has +3 left dorsalis pedis pulse.
Plus|Edema(swelling)|78|Positive bowel sounds. No masses. EXTREMITIES: Without clubbing or cyanosis. 1+ bilateral lower extremity pitting edema. NEUROLOGIC: Grossly intact.
Plus|Excess|170|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD _%#NAME#%_ _%#NAME#%_ is a _%#1914#%_ man who was admitted with a fall and hip pain. He was found to have an aneurysm at 7+ cm. Dr. _%#NAME#%_ has evaluated him for that. Originally I became in contact with him when he was initially admitted about a year or two ago with a septic left total knee arthroplasty with complex revision but he is doing fine.
Plus|Edema(swelling)|147|HEART: Rate is irregularly irregular. ABDOMEN: Moderately obese. There is no guarding. EXTREMITIES: Ace wraps to the knees bilaterally and he has 2+ to 3+ edema of the feet and 2+ of the calves. SKIN: Pale and dry. STUDIES OF INTEREST: He has a CT scan of the chest done on _%#MMDD2006#%_.
Plus|Present|153|Pulses: +3 radial-femoral bilaterally, +2 left dorsalis pedis pulse. I could not palpate the right popliteal nor pedal pulses. Bedside Doppler reveals a +2 biphasic seen within the left dorsalis pedis artery.
Plus|Present|128|She shows a generous amount of clear yellow urine from a Foley catheter. SKIN: Shows somewhat reduced turgor but no lesions and +/- jaundice. HEENT: Negative. Pupils are equal, round and reactive. Extraocular movements are full and conjugate.
Plus|Present|137|This has no surrounding drainage, nor necrosis. Sensation is intact to her feet. LABORATORY & DIAGNOSTIC DATA: Bedside Doppler reveals a +3 strong biphasic signal within the left calf bypass graft.
Plus|Excess|151|It did show some slight increase in activity in the upper chest. There was a CT scan available from today. It shows a probable left upper lobe lesion 2+ cm in size adjacent to the mediastinal pleura next to the aorta.
Plus|Edema(swelling)|90|I do not hear a murmur. Bowel sounds are present. There is no guarding. Extremities show 3+ peripheral edema with brawny induration, particularly the right lower extremity, and gauze wrapping around both ankles.
Plus|Pulse|139|Abdominal examination is unremarkable. No hepatosplenomegaly. No masses, tenderness, bruits, enlargement of the aorta. Femoral pulses are 3+, popliteals are 3+, dorsalis pedis and posterior tibials are 3+.
Plus|Positive(laboratory test)|350|_%#NAME#%_ _%#NAME#%_, MD _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_, MN _%#55400#%_ Dear _%#NAME#%_: _%#NAME#%_, our mutual patient with Stage I left breast cancer, has been seeing me since her diagnosis in _%#MM#%_ 2001. As you recall, this was a Stage I tumor. It was ER-positive and TR-negative; however, it was also HER-2 3+. Because she was still menstruating at the time, we placed her on Zoladex along with tamoxifen.
Plus|Reflexes|127|EXTREMITIES: Bilateral lower extremity 1+ edema. There is no cyanosis. There is no clubbing. NEUROLOGIC: Deep tendon reflexes 2+ bilaterally. Motor and sensory examination are 5/5 and are symmetrical. The cerebellar examination is nonfocal and is intact.
Plus|Edema(swelling)|101|Does have a caput medusae, nontender. No hepatosplenomegaly. Bowel sounds are present. EXTREMITIES: 2+ edema. MENTAL STATUS: Oriented x 3. Negative for asterixis. IMPRESSION: 1. Alcoholic cirrhosis. 2. Child's C.
Plus|Strength|178|Upper extremity strength and coordination are intact. She has thin, frail body habitus. Anterior tibialis strength 4/1, peroneus longus 4/1, posterior tibialis 4/4, hip flexors 4+/P3. Abductors/adductors 4/4. The patient is unable to give consistent effort for muscle strength testing making full assessment difficult.
Plus|Edema(swelling)|118|Mild to moderate distention. Nontender to palpation. No rebound or guarding. EXTREMITIES: Warm. He has approximately 2+ edema bilaterally. He has onychomycosis of the feet. He has palpable dorsalis pedis and posterior tibial pulses bilaterally.
Plus|Pulse|109|Abdomen: nondistended, soft, nontender, no organomegaly or mass; bowel sounds are normal. Peripheral pulses 1+ dorsalis pedis, there is no cyanosis or clubbing, there is no edema.
Plus|Reflexes|168|He does have some sensation abnormalities in his lower legs which he states is normal for him. Strength is 5/5 bilaterally. Gait is within normal limits. Reflexes are 1+ bilaterally. LABORATORY DATA: Sodium is 141, potassium is 3.9, BUN 9, creatinine of 0.9. WBC 7.3 with a hemoglobin of 16.2. GGT elevated at 85.
Plus|Reflexes|149|Fine motor movements were normal. Sensory testing revealed intact pin and light touch. Vibration was slightly diminished in the feet. Reflexes were 2+ including ankle jerks, which were 1+. Toes were downgoing. Finger-to-nose and heel- to-shin were in tact.
Plus|Edema(swelling)|218|ENT: No complaints of sore mouth or throat or excessive secretions. Her mouth is a little bit dry. CARDIOVASCULAR: The patient has atrial fibrillation with variable ventricular conduction, and she also has probably 1-2+ edema in her legs and her feet. RESPIRATIONS: No complaints of cough or dyspnea. GASTROINTESTINAL: No complaints of nausea, vomiting, or diarrhea.
Plus|Pulse|128|CARDIOVASCULAR: Reveals bradycardiac rhythm, regular rate, and rhythm otherwise. There is no murmur or rub. Carotid pulses are 2+, femoral pulse 2+, and no bruits. Neck veins are flat. ABDOMEN: Benign. There is no organomegaly.
Plus|Pulse|178|No diastolic murmur, rub or S3. ABDOMEN: Soft, nontender, without palpable liver, spleen or masses. Bowel sounds are present. EXTREMITIES: Without cyanosis or edema. Pulses are 1+ below the femorals, 1-2+ above. NEUROLOGIC: Grossly intact. LABORATORY AND DIAGNOSTIC DATA: Electrocardiogram showed sinus rhythm with left bundle branch block pattern.
Plus|Present|75|Her left shoulder is significantly elevated compared to the right. She has +/+ trigger points in the left upper extremity. VITALS SIGNS: Blood pressure is 139/66, temperature is normal. IMPRESSION: A 56-year-old woman with symptoms of numbness in the face and arm and headache after a course of vigorous exercise.
Plus|Excess|336|CHIEF COMPLAINT: Hematuria. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a pleasant 56-year- old male who is status post a right hemispheric stroke in _%#MM2004#%_, with a resulting left hemiparesis. The patient resides in a local nursing facility presently. The patient says he has had an indwelling Foley catheter for approximately 1+ months. This catheter was changed yesterday evening, and this was a traumatic placement, and the patient complained of pain with the Foley placement.
Plus|Pregnancy dating|332|She came to clinic with her husband, _%#NAME#%_, for genetic consultation and first trimester screening due to advanced maternal age in pregnancy. Pregnancy History: G 5 P 2022 LMP: _%#MMDD2007#%_ (irregular) Age: 39 EDC (LMP): _%#MMDD2008#%_ Age at Delivery: 40 EDC (U/S): _%#MMDD2008#%_ (7+5 on _%#MMDD2007#%_) Gestational Age: 11+5 weeks * No significant complications or exposures were reported in the current pregnancy.
Plus|Pulse|199|It is relatively clear. CARDIAC: Exam reveals distant heart tones, relatively regular rate and rhythm, no additional exam can be done because of the noise in the room. Femoral pulses are probably 1-2+ without bruits. Dorsal pedal pulses are probably trace to 1+. Neck veins cannot be assessed.
Plus|Pregnancy dating|296|She came to clinic with her husband, _%#NAME#%_, for genetic consultation and first trimester screening due to advanced maternal age in a twin pregnancy. Pregnancy History: G 2 P 1001 LMP: _%#MMDD2006#%_ Age: 39 EDC (LMP): _%#MMDD2007#%_ Age at Delivery: 39 EDC (U/S): C/W edc Gestational Age: 12+2 weeks * No significant complications or exposures were reported in the current pregnancy.
Plus|Pulse|207|He has the chest pain as described above. PHYSICAL EXAMINATION: Blood pressure is 130/78, pulse rate is 92, respiratory rate 16. GENERAL: He is moderately obese, in no acute distress. Carotid upstrokes are 1+ bilaterally without bruits. Jugular venous distention is 6 cm of water. Chest excursion is somewhat reduced.
Plus|Pulse|103|No evidence of hematoma from groin puncture site. Right foot is warm and fairly pink. There is a 2 to 3+ right popliteal pulse and no palpable right dorsalis pedis or posterior pulses.
Plus|Pregnancy dating|111|FINAL OBSERVATION TRIAGE NOTE HISTORY OF PRESENT ILLNESS: The patient is a 26y G4, P2-0-1-2, who presents at 24+5 weeks' gestation with complaints of pelvic pressure for the last 3 days. She denies contractions or cramping. She is having some low back pain, but is more constant and no recent changes.
Plus|Pregnancy dating|242|She came to clinic for genetic consultation and first trimester screening due to advanced maternal age in pregnancy. Pregnancy History: G 1 P 0000 LMP: _%#MMDD2007#%_ Age: 35 EDC (LMP): _%#MMDD2007#%_ Age at Delivery: 35 EDC (U/S): c/w EDC (9+0 on _%#MMDD2007#%_) Gestational Age: 11+6 weeks * No significant exposures were reported in the current pregnancy.
Plus|Edema(swelling)|159|LUNGS: Clear bilaterally on auscultation. ABDOMEN: Slightly distended, diffusely tender, positive bowel sounds, no organomegaly. EXTREMITIES: Pitting edema 1-2+ bilaterally in the lower extremities. SKIN: Generalized jaundice. NEUROLOGIC: Cranial nerves II through XII grossly intact.
Plus|Pregnancy dating|265|Rule out seizure. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 4 day old infant with surgical repair of transposition of the great artery yesterday who developed abnormal movements of the diaphragm and abdomen today leading to concern for seizures. She was a term 38+6 week female delivered via repeat cesarean section to a 35-year-old female with complications of gestational diabetes controlled with insulin and Apgar scores of 8 and 9.
Plus|Edema(swelling)|120|CARDIAC exam reveals an irregularly irregular rhythm. No murmurs, rubs, or gallops appreciated. EXTREMITIES - there is 1+ bilateral edema of her ankles and calves and possibly 2+ bilateral pedal edema.
Plus|Pulse|230|No diastolic murmur, rub or S3. ABDOMEN: Soft, nontender, without palpable liver, spleen or masses. Bowel sounds are present. EXTREMITIES: Showed 2-3+ edema extending up to the knees (patient states this is chronic), pulses were 1+ below the femorals, 1-2+ above. NEUROLOGIC: Not done in detail but appeared to be grossly intact.
Plus|Pulse|132|He keeps his right eye closed. HEENT: Head normocephalic. Fundi benign. Discs are sharp without hemorrhage. NECK: Supple. Carotids 2+. I could not auscultate a bruit. VITAL SIGNS: Blood pressure 163/85, pulse rate 90 and regular.
Plus|Excess|117|SOCIAL HISTORY: The patient lives with his wife. He is retired. He does not use tobacco products. Alcohol intake is 4+ cocktails a day, usually starting in the morning.
Plus|Pregnancy dating|305|She came to clinic with her husband, _%#NAME#%_, for genetic consultation and first trimester screening due to advanced maternal age in pregnancy. Pregnancy History: G 2 P 1001 LMP: _%#MMDD2007#%_ (IUI pregnancy) Age: 40 EDC (LMP): _%#MMDD2007#%_ Age at Delivery: 41 EDC (U/S): c/w EDC Gestational Age: 13+4 weeks * No significant complications or exposures were reported in the current pregnancy.
Plus|Edema(swelling)|188|CARDIAC: Reveals a controlled rate, irregular rhythm. He has a very high pitched late peaking systolic ejection murmur. ABDOMEN: Soft, nontender. No hepatosplenomegaly. EXTREMITIES: Have 1+ bilateral edema. He has decreased pulses. SKIN: Warm and dry without clubbing, cyanosis or rash.
Plus|Pulse|119|HEENT: Head is normocephalic. Fundi are benign. Disks are sharp without hemorrhage or exudate. NECK: Supple. Carotids 2+. HEART: Difficult to auscultate his heart due to excessive motion.
Plus|Pulse|208|ABDOMEN: Nondistended and soft, with mild epigastric tenderness. There is no guarding, rebound, or palpable organomegaly or mass. Bowel sounds are normal. EXTREMITIES: Distal lower extremity pulses are 1 to 2+ right leg, with a left below-the- knee amputation.
Plus|Reflexes|97|Sensation intact to light touch. Strength 5/5 bilaterally. Gait: Within normal limits. Reflexes 2+ bilaterally. LABORATORY DATA: Pending.
Plus|Strength|155|Range of motion: Full active range of bilateral upper and lower extremities. Strengths are 5-/5 in the upper extremities, 5- at the quads and hamstrings, 4+ at the hip flexors, and ankle, plantar, and dorsiflexors in the right.
Plus|Pulse|148|2. Verapamil. 3. Prevacid. 4. Plavix. 5. Trazodone. PHYSICAL EXAMINATION: Exam reveals a very pleasant alert woman. Afebrile. Vital signs stable. A +3 left and +2 right superficial temporal pulse. No obvious carotid bruits. CHEST: Clear to auscultation. CARDIOVASCULAR: Regular rate with Grade 3/6 systolic murmur.
Plus|Edema(swelling)|105|RESPIRATORY: Lungs are clear, without wheezes, rhonchi or rales. ABDOMEN: Soft, nontender. EXTREMITIES: 2+ edema bilateral lower extremities. LABORATORY DATA: Sodium is 131, potassium 4.8, chloride 102, bicarbonate 23, BUN is 85, creatinine 2.86, glucose 100.
Plus|Pulse|102|Abdomen is soft and nontender. There is no hepatosplenomegaly. Extremities are without edema. He has 2+ pulses. Skin is warm and dry without cyanosis, clubbing or rash.
Plus|Reflexes|144|Sensory testing reveals only some patchy diminished appreciation of temperature and sharp sensation of the right lateral leg. Her reflexes are 2+/4+ in the biceps and brachioradialis, 2+/4+ at the left knee, 1+/4+ at the right knee with 1+/4+ ankle jerks.
Plus|Edema(swelling)|142|ABDOMEN: Soft, bowel sounds present. Incisional scars healing well. G-tube site healing well. EXTREMITIES: Lower extremities showed trace to 1+ edema. No evidence of phlebitis. NEUROLOGIC: Mentation clear. Speech articulate. Somewhat flat affect.
Plus|Pulse|146|ABDOMEN: Soft, nontender. There is no hepatosplenomegaly and palpable abdominal masses. EXTREMITIES: Without cyanosis or edema. Pedal pulses are 2+. ASSESSMENT: This 55-year-old gentleman presents with a three to four week history of rather classic exertional chest pain.
Plus|Pulse|123|ABDOMEN: Unremarkable. No hepatosplenomegaly. No masses, tenderness, bruits, enlargement of the aorta. Femoral pulses are 3+. EXTREMITIES: Popliteal pulses are 2+. Dorsalis pedis and posterior tibial pulses are 2+. No significant peripheral edema present.
Plus|Reflexes|116|SENSATION: Intact to light touch and pinprick without a sensory level. He has a negative Romberg. REFLEXES: He has 2+ biceps reflex bilaterally 1+ brachioradialis on the right 2+ brachioradialis on the left.
Plus|Pulse|168|CARDIAC: Reveals an irregularly irregular rhythm without murmur, rub or gallop. ABDOMEN: Soft and nontender, no hepatosplenomegaly. EXTREMITIES; Without edema; he has 2+ pulses throughout. No clubbing, cyanosis or rash. SKIN: Warm and dry. TSH is mildly elevated at 7.83; EKG demonstrates atrial fibrillation with a controlled ventricular response; this is supported by telemetry.
Plus|Pulse|92|Bowel sounds are present and active. Femoral pulses are 4+ and equal. EXTREMITIES: She has 4+ dorsalis pedis pulses bilaterally. No evidence of clubbing, cyanosis or edema. SKIN: Negative Reviewing her CT scan, she has a large 9 cm mass encasing the aorta just below the level of the left renal vein.
Plus|Reflexes|172|She awakens and answers questions but is somewhat confused. Cranial nerves II-XII are grossly intact. Sensory and motor exams are grossly normal. Deep tendon reflexes are 2+ bilateral and symmetric. Gait was not tested. LABORATORY DATA: Shows a chest x-ray which is similar to the one that was done on _%#MMDD#%_.
Plus|Strength|129|Is unable to move these joints secondary to severe pain. Able to move other joints without difficulty. Strengths: approximately 4+/5 bilateral upper and lower extremities except for right extensor halluces longus which is 3/5.
Plus|Pulse|132|CHEST: Chest is clear. HEART: Regular rate and rhythm. Distant heart tones. No obvious murmurs or rubs. PULSES: Carotid pulses are 2+, femoral pulses are 2+ with	 no bruits, dorsalis pedis pulses are 1+.
Plus|Pulse|135|There is no heave, gallop, JVD. ABDOMEN: Moderately obese, soft and nontender without organomegaly, mass or bruit. Femoral pulses are 2+ without bruits. EXTREMITIES: Without edema. Pedal pulses are 1+ and symmetrical. There is a right total knee arthroplasty scar.
Plus|Pulse|170|Sclerae anicteric. Fundi deferred. Tympanic membranes not inflamed. No significant ceruminosis. Oropharynx is clear. Dentition in adequate repair. Carotid upstroke 1 to 2+ without bruits. There is no thyromegaly or lymphadenopathy. Skin exam remarkable for xerosis.
Plus|Strength|251|Strength is about 3 proximally in both upper extremities and 4- in the right upper extremity at biceps and triceps, otherwise 4 throughout in both upper extremities. In both lower extremities her strength was 4+ except proximally where it was around 3+ on the left hip and less than 3 on the right hip with patient in sitting position.
Plus|Strength|104|Tone was normal in all four LIMBS except for a mild paratonia. Strength in all four LIMBS was at least 4+/5 and equal. No adventitious movements were observed. CEREBELLAR: No dysmetria on finger-to-nose examination with mild incoordination on heel-to-shin examination in BOTH LOWER EXTREMITIES, right more than left.
Plus|Reflexes|128|Sensation is grossly normal to light touch throughout. Reflexes show clonus in both ankles of five beats approximately. Uppers 2+ and bilateral; lowers 4+ and bilateral. Cranial nerves II through XII are intact. Gait was not tested.
Plus|Reflexes|103|Sensation intact to light touch. Strength 5 out of 5 bilaterally. Gait within normal limits. Reflexes 3+ in the lower extremities, 2+ in the upper extremities.
Plus|Pulse|119|HEENT examination is without corneal arcus or xanthelasma. The neck veins are not visibly distended. The carotids are 2+ without bruits. There is no thyromegaly. Lungs are notable for scant basilar crackles; there are no wheezes or rhonchi heard.
Plus|Pulse|216|The rest of her neurologic examination was normal, 5/5 strength in her EIP, FPL, dorsal interosseous I, as well as her biceps, triceps and her sensation was intact to light tough in all distributions. She did have a +3 radial pulse. LABORATORY STUDIES: Initially her white blood cell count yesterday was 16,000, today repeat demonstrated a white blood cell count of 8.5, hemoglobin 12.2. Urinalysis was performed which was essentially unremarkable.
Plus|Pulse|93|The patient was unable to do a straight leg test due to intense pain. Pulse was demonstrated +3 dorsalis pedis and +3 posterior tibialis bilaterally.
Plus|Edema(swelling)|88|Her foot pulses are significantly diminished. Femoral pulse also diminished. She has 1-2+ bilateral ankle edema which appears tense. CENTRAL NERVOUS SYSTEM: She is alert, oriented to time, place, and person.
Plus|Reflexes|179|EXTREMITIES: No clubbing, cyanosis or edema. NEURO: Cranial nerves II through XII are grossly intact. Motor and sensory examinations are grossly normal. Deep tendon reflexes are 2+ bilaterally and symmetric. Babinskis are downgoing. The patient does have signs consistent with dementia, with frequent forgetfulness and inability to remember three objects at five minutes.
Plus|Pulse|129|Comprehension is intact. His recall is flawed for recent events. Funduscopic exam is deferred. The neck is supple, carotids are 2+. His heart reveals regular rhythm with occasional premature beats. His cranial nerve exam II-XII reveals no abnormalities.
Plus|Edema(swelling)|95|She did have adequate bowel sounds. No hepato or splenomegaly could be palpated. EXTREMITIES: 2+ edema was also noted in bilateral upper and lower extremities.
Plus|Pulse|196|ABDOMEN: H has distended abdomen with decreased bowel sounds. He is tender throughout, especially near the surgical incision. His staples are still in place. EXTREMITIES: No edema. DP pulses are 3+ bilaterally. NEUROLOGIC: Strength of upper extremities is 5/5 bilaterally. Reflexes are symmetrical.
Plus|Pulse|130|No guarding or rebound. No psoas or obturator sign. BACK: No costovertebral angle (CVA) tenderness. EXTREMITIES: No distal edema. +3 pedal pulses bilaterally. NEUROLOGIC: Normal. CT SCAN: I reviewed the CT scan including the delayed films.
Plus|Pulse|134|ABDOMEN: Soft and nontender without organomegaly, mass or bruit. Femoral pulses are 2+ without bruits. EXTREMITIES: Pedal pulses are 2+ and symmetrical. There is no pedal edema, cyanosis or erythema. SKIN: Clear.
Plus|Edema(swelling)|247|No mass or hepatosplenomegaly. Bowel sounds are normal. EXTREMITIES: Some mild erythema extending from above the ankle to below the knee with more of a hemorrhagic skin change from the midportion of the lower leg to below the knee. There is 2-to-3+ swelling of the lower leg and No calf tenderness or pedal edema.
Plus|Pulse|236|Chest is clear to percussion and auscultation. ABDOMEN: Unremarkable. No hepatosplenomegaly, no masses, tenderness, bruits or enlargement of the aorta. Femoral pulses are 1+, popliteals are 1+, dorsalis pedis and posterior tibials are 1+. There is no peripheral edema, no skin lesions noted. NEUROLOGIC: Unremarkable with normal power, tone and sensation grossly bilaterally.
Plus|Pulse|187|There is question of upper abdominal tenderness but no guarding, rebound, palpable organomegaly or mass. Bowel sounds are normal. Genitalia and rectal exam: Deferred. Peripheral pulses: 1+ dorsalis pedis. There is no cyanosis, clubbing or edema. Musculoskeletal demonstrates no synovitis.
Plus|Reflexes|143|Sensation was not tested. Muscle tone is increased in the lower extremities. He has several beats of clonus in bilateral ankles. Reflexes are 3+ at the knees and 3+ at the ankles. Toes are upgoing bilaterally. Coordination: The patient followed directions poorly.
Plus|Excess|219|The patient developed acute fevers in the 102 degree range with chills and sweats in the last couple of days and was seen in the emergency room and admitted. Since admission, the patient has had ongoing fevers up to 101+ degrees plus has positive blood cultures coming back at less than 24 hours for gram positive cocci.
Plus|Pulse|253|SKIN: Exam is benign. HEAD, EYES, EARS, NOSE AND THROAT: Benign NECK: Is supple without thyromegaly or adenopathy CHEST: Examination is clear CARDIAC: Exam reveals a regular rate and rhythm. There is a minimal early systolic murmur. Carotid pulses are 2+, femoral pulses are 1+, but this is hard to feel because of obesity.
Plus|Reflexes|204|Cranial nerves II, ophthalmologic - he has a field cut on his right side and right visual field deficit and cranial nerves VII, right facial weakness. Motor strength is intact throughout and reflexes are +2 and sensory intact with decrease on the right side of his face.
Plus|Edema(swelling)|174|CARDIAC: Reveals a regular rate and rhythm. She has a 2/6 systolic ejection murmur that does radiate up into both carotids. ABDOMEN: Soft and nontender. EXTREMITIES: Have 1-2+ bilateral edema. Right leg is in an immobilizer. LABORATORY: Electrocardiogram here demonstrates an aortic valve area of 1.1. She does have a dilated hypocontractile right ventricle.
Plus|Pulse|129|VITAL SIGNS: Blood pressure is 144/76, he weighs 173 pounds. Pulse 70 and sinus. NECK veins are not distended. The carotids are 2+ without bruits. There is no thyromegaly. LUNGS: Clear. CARDIAC: Normal first and second heart sounds.
Plus|Edema(swelling)|91|He was hospitalized in _%#MM#%_ of this year for the same. He had redness of the legs and 4+ edema. The erythema was most likely secondary to edema rather than cellulitis though he did receive vancomycin at that time.
Plus|Pregnancy dating|187|_%#NAME#%_ _%#NAME#%_, MD CUHCC Clinic _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#CITY#%_, MN _%#55400#%_ Dear Dr. _%#NAME#%_: The patient is a 20-year-old, G2, P0-1-0-1 at 30+1 weeks' gestation, who presented overnight to Labor and Delivery for evaluation of pelvic pain.
Plus|Uncommon rating|142|SKIN: No rashes or nodules. HEENT: Eyes: No subconjunctival hemorrhages or scleral icterus. Oropharynx without erythema or exudate. NECK: 1-2 + nuchal rigidity. No thyromegaly. LYMPH: No cervical or axillary lymphadenopathy. LUNGS: Clear to auscultation, no use of accessory muscles of respiration.
Plus|Pulse|86|EXTREMITIES: Without cyanosis, clubbing or edema. No rash can be appreciated. Pulses 2+ on the right, 1+ on the left posterior tibialis. LABORATORY DATA: INR is 3.4, hemoglobin 9, white count 5, platelets 226,000.
Plus|Pulse|185|No click. No jugular venous distension. Breast exam deferred. Abdomen: Nondistended, soft, nontender, without palpable organomegaly or mass. Bowel sounds are normal. Peripheral pulses 2+ dorsalis pedis. There is no cyanosis or clubbing. There is no pitting edema.
Plus|Strength|134|Neurologic exam: Revealed alert and oriented patient. Cranial nerves II through XII grossly intact. Sensation intact to light touch, 5+ bilateral strength with 1+ deep tendon reflexes. LABORATORY: CMP, hemogram with a differential count, GGT, and TSH all came back within normal limits.
Plus|Uncommon rating|262|It is slightly comminuted, intra-articular. EMERGENCY DEPARTMENT COURSE: A 26-year-old presents with a fracture of her proximal phalanx of her little finger. Fortunately it is the nondominant hand; however, this f is intra-articular and is associated with some 2+ discrimination loss. I suspect this is related to contusion but will be need to be closely followed.
Plus|Blood type|180|The patient is known to be U-tox positive for cocaine on _%#MMDD2003#%_, here at Fairview-University Medical Center. The prenatal chart is reviewed, which demonstrates blood type A+, antibody negative, rubella immune, hepatitis B surface antigen nonreactive.
Plus|Pulse|149|CARDIOVASCULAR: Regular rate and rhythm, S1 and S2 without murmurs, rubs or gallops; jugular venous pressure is nondistended. Carotid upstrokes are 2+ and symmetric without bruit. ABDOMEN: Soft and nontender without hepatosplenomegaly. EXTREMITIES: Without clubbing, cyanosis or edema.
Plus|Pregnancy dating|283|She came to clinic with her husband, _%#NAME#%_, for genetic consultation and first trimester screening. Pregnancy History: G 2 P 0010 LMP: _%#MMDD2007#%_ (uncertain) Age: 27 EDC (LMP): _%#MMDD2007#%_ Age at Delivery: 27 EDC (U/S): c/w EDC (8+2 on _%#MMDD2007#%_) Gestational Age: 11+6 weeks * No significant complications or exposures were reported in the current pregnancy.
Plus|Reflexes|108|His sensation is intact. There is no pronator drift. There is no ataxia of trunk or gait. His reflexes are 1+ bilaterally in the upper and lower extremities. ASSESSMENT: Persistent otorrhea. Status post repair of tegmental defect in _%#MM2003#%_.
Plus|Strength|263|Her tone is decreased in the left lower extremity. Strength is 4+ -5- distally bilaterally. Proximally there was weakness especially in the left upper extremity and a range of less than 3 with patient lying in the bed at hip flexors and knee extensors, probably 1+ -2-. In the right lower extremity her knee extensor is 4 plus.
Plus|Edema(swelling)|106|CARDIAC: Regular rate and rhythm. ABDOMEN: Obese, soft, nontender. Bowel sounds positive. EXTREMITIES: A 2+ edema. IMPRESSION: 1. Severe chronic obstructive pulmonary disease, with exacerbation.
Plus|Edema(swelling)|174|NEUROLOGICAL: Alert and oriented. Cranial nerves II through XII grossly intact. Sensation intact to light touch. Strength 5/5 bilaterally. MUSCULOSKELETAL: Right ankle with 2+ edema over medial and lateral malleoli with tenderness to palpation over the medial malleoli.
Plus|Edema(swelling)|134|Lungs, rales in both bases. Heart: Regular, slow, and irregular. No murmurs heard. Abdomen: Soft, non-tender. Extremities: There was 1+ edema. Skin revealed a sacral decubitus ulcer. Neurologic exam: The patient could move extremities and was minimally responsive.
Plus|Edema(swelling)|143|There is a scar from what I presume to be recent ulcer surgery. Her abdomen is nontender. Extremities: 2+ pretibial and pedal on the left and 1+ on the right. Pedal pulses are faintly palpable. Neurologic: Deferred to Dr. _%#NAME#%_.
Plus|Edema(swelling)|204|There were no murmurs. ABDOMEN: There were no bruits, masses, tenderness or organomegaly. The abdomen did appear to be distended. EXTREMITIES: On examination of the lower extremities, there was at least 2+ bilateral and symmetric leg edema which was pitting to above the knees.
Plus|Pulse|100|HEENT: Normal. NECK: Supple, no significant cervical or supraclavicular adenopathy. Carotid pulses 4+. No bruits noted. PULMONARY: Lung fields are clear bilaterally to auscultation.
Plus|Edema(swelling)|244|Sinuses nontender. CHEST: Diminished breath sounds bilaterally. No definite crackles, wheezes, or rhonchial breath sounds. CARDIOVASCULAR: Distal heart tones. ABDOMEN: Very obese, soft. EXTREMITIES: Chronic venous stasis changes with trace to 1+ edema. LABORATORY DATA: Blood gases as described above. Today's metabolic panel reveals: Sodium 141.
Plus|Pulse|166|EXTREMITIES: Without clubbing, cyanosis or edema but do appears atrophic with minimal peripheral pulses. The right femoral pulse is undetectable; left femoral pulse 1+. ASSESSMENT/PLAN: The patient is a complex 71-year-old female with many comorbid diagnoses including diabetes, hypertension, renal artery stenosis, chronic obstructive pulmonary disease, emphysema, O2 dependent, history of abdominal aortic aneurysm, evidence of peripheral vascular disease.
Plus|Pulse|147|No guarding, rebound, palpable organomegaly or mass. Bowel sounds are normal. GENITALIA/ RECTAL EXAM: Deferred. Distal lower extremity pulses are 2+. No cyanosis, clubbing or edema. MUSCULOSKELETAL: No synovitis. NEUROLOGIC: The patient moves all extremities well.
Plus|Pulse|96|CARDIAC EXAMINATION: Reveals distant heart tones. No obvious murmur or rub. Carotid pulses are 2+, femoral pulses 2+ and no bruits. Neck veins flat. ABDOMEN: Benign, there is no organomegaly, abdominal aorta is not palpably enlarged.
Plus|Reflexes|164|Certainly no worse at 5-/5. There was a very modest amount of coincident ataxia however. Sensory examination was consistent with age, reflexes nearly symmetric at 1+ with Babinski's absent. IMPRESSION: Transient right upper extremity weakness in the context of intermittent confusion.
Plus|Reflexes|139|Fine motor movements were normal. Sensory testing revealed intact pin, light touch, vibration, proprioception, temperature. Reflexes were 2+. Ankle jerks 1+. Toes were downgoing. Cerebellar exam revealed intact finger-to-nose, heel-to-shin. Gait and station were normal.
Plus|Strength|106|Wrist extension and flexion, grip is approximately 4+ to 5- over 5. In her left upper extremity, she has 4+ shoulder abduction. Upper extension and flexion is 4+ over 5 with flexion, extension, and grip is 5- over 5.
Plus|Reflexes|110|Skin: No rash or ulceration. Neurologic: Cranial nerves are within normal limits. Motor is 5/5 general. DTRs 2+. Cerebellar within normal limits. Psychiatric: The patient is alert, awake and oriented x3. No sign of depression or suicidal ideation.
Plus|Pulse|117|There is no peritonitis. EXTREMITIES: There are no changes of chronic arterial or venous insufficiency. He has 3 to 4+ dorsalis pedis and posterior tibial pulses bilaterally.
Plus|Edema(swelling)|170|LUNGS: Clear to auscultation bilaterally. ABDOMEN: Positive bowel sounds, soft, nontender, nondistended, no organomegaly or masses. EXTREMITIES: There was approximately 3+ edema noted in his legs bilaterally. He reported that this was normal for him and that his shoes seemed to fit appropriately.
Plus|Pulse|87|S1 and S2 without murmur, gallop, or rub. JVP is not distended. Carotid upstrokes are 2+ symmetric without bruit. ABDOMEN: Soft, nontender without hepatosplenomegaly. Femoral pulses are 2+ symmetric without bruit.
Plus|Positive(laboratory test)|202|Her hemoglobin has fluctuated since that time. In view of the persistent anemia, she had laboratory studies performed for possible hemolytic anemia. Specifically, a direct Coombs' test was positive at 1+, and reticulocyte count was elevated at 5.3%. LDH was normal at 449 and a haptoglobin was also normal at 113.
Plus|Pulse|96|ABDOMEN: Nontender. Well-healed right paramedian incision. No aneurysms. No tenderness. GROIN: 2+ femoral pulses. RECTAL: Not performed. EXTREMITIES: No significant varicosities. No clubbing or cyanosis. NEURO: Oriented x 3.
Plus|Reflexes|166|The patient is unaware of any definite weakness to examination, may be a minimal amount of weakness on the left as this is difficult to fully assess. Reflexes are 1-2+ symmetrically. Babinskis are absent. There is no clear sensory loss today and perhaps some minor complaint of left hand numbness.
Plus|Pregnancy dating|275|She came to clinic for genetic consultation and first trimester screening due to advanced maternal age in pregnancy. Pregnancy History: G 1 P 0000 LMP: _%#MMDD2007#%_ Age: 42 EDC (LMP): Age at Delivery: 43 EDC (U/S): _%#MMDD2008#%_ (IUI on _%#MMDD2007#%_) Gestational Age: 12+6 weeks * No significant complications or exposures were reported in the current pregnancy.
Plus|Uncommon rating|192|There is a prominent V wave. CARDIOVASCULAR: Regular rate and rhythm with gallop and 3/6 systolic murmur heard along the left sternal border. She also has a prominent RV lift of approximately +2. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Soft and nontender. EXTREMITIES: She has anasarca and is grossly edematous all the way up to her sacrum and abdomen.
Plus|Edema(swelling)|219|Soft systolic murmur apically, consistent with mitral insufficiency. There is a soft, systolic ejection murmur. ABDOMEN: Bowel sounds are positive, obese. No hepatosplenomegaly. EXTREMITIES: Lower extremities reveal 1-2+ pretibial edema throughout. Pulses are significantly reduced consistent with peripheral vascular disease. LABORATORY DATA: Electrolytes - Sodium 133, potassium 4.9, creatinine 1.5, hemoglobin reduced at 11.9, albumin is reduced at 3.1. Troponin is 12.9, peak.
Plus|Reflexes|93|Within the limits of her cooperation, her strength seems quite good and symmetric. DTRs are 1+. FTN normal. No drift. She is able to stand, and I believe the Romberg is negative.
Plus|Pulse|179|ABDOMEN: Nondistended, soft without tenderness, guarding, organomegaly, or masses. Bowel sounds are normal. Distal lower extremities are well perfused with dorsalis pedis pulses 2+, no clubbing, cyanosis, or edema. Musculoskeletal reveals no synovitis. GENITALIA/RECTAL: Deferred. NEUROLOGIC: No facial asymmetry, no lateralizing extremity weakness.
Plus|Reflexes|150|Visual acuity was normal in both eyes. Funduscopic examination showed normal appearing discs. No nystagmus. Cranial nerves V - XII were normal. MSRs: +2 throughout. Motor: Bulk, tone, strength, coordination normal. Sensory: Temperature, light touch, vibration and position normal.
Plus|Pulse|106|There is a palpable defect over the anterior PATELLA. Sensation is intact in all dermatomes bilaterally. 2+ pedal pulses. No pedal edema. Extensor hallicus longus and tib ant gastroc strength is 5 out of 5.
Plus|Pulse|145|She has full flexion of her FDS, FDP, ADM, ADP, APB as well as EHL bilaterally. The remainder of her extremity is within normal limits. She has 2+ radial and ulnar pulses of the hand. No crepitus, catching or locking. Remainder of her right upper extremity was within normal limits.
Plus|Pulse|116|Gait was not assessed. The patient has alert mental status. EXTREMITIES: Bilateral wrists are bandaged. Pulses are 2+. Calves are not edematous, non-tender and non-erythematous. LABORATORY DATA: ANA, vitamin B12, folic acid and TSH levels were all pending.
Plus|Uncommon rating|153|She does have relatively good motion of her neck without radicular symptoms. There is some stiffness. She has good motion of her right upper extremity, 4+ when 60 degrees rotated, cuff appears to be intact on the right.
Plus|Pulse|180|He is retired. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 164/104, respiratory rate is 16, 93% on room air, unlabored. Heart rate 60 and regular. JVP is flat. Carotids are 2+ without bruits. CARDIOVASCULAR: Regular rate and rhythm. There are no murmurs, rubs or gallops.
Plus|Edema(swelling)|144|There is a sternotomy incision which feels well-healed and stable. ABDOMEN: Massively obese. There are no masses palpated. EXTREMITIES: Show 2-3+ pitting edema around the feet bilaterally extending up to the thigh.
Plus|Pulse|100|ABDOMEN: Flat, nontender, no masses are noted, bowel sounds present and active. Femoral pulses are 4+ and equal bilaterally. She is tender over her internal ring on the left side.
Plus|Reflexes|466|Respiratory: Bibasilar crackles noted. Abdomen: Obese, nontender, positive bowel sounds. Skin: Abrasion present on right forehead. Neuro: Loss of forehead crease noted on left forehead; cranial nerves 2 through 12 reported to be intact by examiner, 5/5 upper extremity strength bilaterally noted by examiner; 4/5 lower extremity strength noted bilaterally by examiner; does not track with eyes, follows most commands with some prompting noted by examiner; reflexes 1+ or 2+ bilaterally. Toes upgoing noted by examiner. LABORATORY: At the time of admission, total white blood cell count 22.4, hemoglobin 11.2, platelets 44; differential not available.
Plus|Uncommon rating|242|He had several brief episodes of dropped heartbeats consistent with second-degree heart block, type I. A twelve-lead EKG on _%#MMDD#%_ showed first-degree block. Prior to LADD, in anticipation of discharge, Cardiology initially recommended Na+ and K+ supplementation. But as _%#NAME#%_ was stable in spite of TID Lasix, and Lasix was decreased to BID prior to discharge, we felt that supplementation was not warranted.
Plus|Pulse|171|There were no wheezes or crackles. ABDOMEN: Was soft, distended, decreased bowel sounds. There is no hepatomegaly. There is no peritoneal signs. PULSES: Pedal pulses are 2+ bilaterally. Femoral pulses are 2+ bilaterally. EXTREMITIES: The patient has no lower extremity edema.
Plus|Reflexes|231|Palate raised symmetrically, and uvula was midline. Sternocleidomastoid and trapezius muscle were strong bilaterally. Tongue protruded midline and had full range of motion. Muscle stretch reflexes (scale of 0 to 4+, R/L): Triceps 2+/2+, biceps not tested/2+, brachial radialis 3+/3+, knee jerks 3+/3+, ankle jerks 2+/2+.
Plus|Plus|224|She will be seen on a daily basis in the Bone Marrow Transplant Outpatient Clinic and will receive G-CSF until her absolute neutrophil count is above 2500 for two days. She should have peripheral blood RFLPs obtained on day +21.
Plus|Blood type|177|Probable occiput posterior presentation. LABORATORY DATA: Ultrasound obtained _%#MMDD2001#%_ compatible with 19 6/7ths weeks gestation, or EDC of _%#MMDD2002#%_. Blood type is O+. Antibody screen negative. Pap smear normal, Rubella immunity present, serology nonreactive, urine screen negative, hepatitis B and HIV screening negative.
Plus|Excess|120|10. Tylenol. 11. Albuterol nebs. 12. Vanceril 42 mcg, 4 puffs b.i.d. 13. Senokot. SOCIAL HISTORY: The patient reports 40+ pack years of tobacco use, having quit some years prior to admission.
Plus|Edema(swelling)|193|P2 was audible. LUNG: Chest clear to auscultation bilaterally. ABDOMEN: Soft, nontender, and distended with ascites. Positive bowel sounds. NEUROLOGIC: Grossly intact. LYMPHATIC: Pedal edema, 2+. RELEVANT LABS ON ADMISSION: CBC revealed a hemoglobin of 11.8, WBC of 8.3, and platelets of 94.
Plus|Edema(swelling)|97|There is sense of hepatomegaly, although unable to accurately estimate liver span. EXTREMITIES: 2+ nonpitting edema is seen in both lower extremities.
Plus|Pregnancy dating|150|Occasional blood sugars in the past several weeks were all within normal limits. 7. Mild preeclampsia. Hypertension on _%#MM#%_ _%#DD#%_, 2004, at 27 +2 weeks' with a blood pressure of 150/90. Modified bedrest at 28 weeks. Strict bedrest at home beginning 29 +6 weeks with blood pressure of 140/90.
Plus|Plus|280|HOSPITAL COURSE: PROBLEM #1. Bone marrow transplant. On date of discharge, the patient is 17 days status post auto peripheral blood stem cell transplant on _%#MMDD2006#%_. PROBLEM #2. Hematology. Patient was admitted and was neutropenic. He had increasing counts starting on days +10 and 11. He is no longer neutropenic but does have some leukocytosis of unknown etiology.
Plus|Present|216|An echocardiogram done just prior to discharge revealed a PFO with left to right shunt, RV wall <2mm, however, pulmonary pressures could not be evaluated. 3. ID. Empiric antibiotics were started given her mothers GBS+ status and inadequate antibiotics prior to delivery.
Plus|Pulse|142|Abdomen: Nondistended, soft, without tenderness, guarding, organomegaly, or mass. Bowel sounds are normal. Distal lower extremity pulses are 2+. There is no cyanosis or clubbing, no edema. Musculoskeletal: No synovitis. C-spine is nontender, full range of motion without compromise.
Plus|Strength|134|EXTREMITIES: 1+ pitting edema bilaterally. Dorsalis pedis pulse 2+ bilaterally. NEUROLOGIC: Cranial nerves II-XII intact. Strength is +4/5 bilaterally in the upper and lower extremities. Reflexes are symmetric. LABORATORY DATA: CBC shows a white count 8.5, hemoglobin 12.6, platelets 165.
Plus|Reflexes|125|NEUROLOGIC grossly intact. Normal sensation throughout. Strength 5 out of 5 in extremities throughout. Deep tendon reflexes 2+ and symmetric throughout. No abnormal movements. LABORATORY STUDIES: Sodium 142. Potassium 3.9. Bicarbonate 28.
Plus|Positive(laboratory test)|279|SGOT was 105. SGPT was 56. Alkaline phosphatase was 169. His total bilirubin was 1.9. Albumin was 3.6. His ionized calcium was 3.7. Urinalysis was positive for protein at 1+, 3+ blood, 1+ white blood cells, 3+ red blood cells, trace leukocytes, occasional epithelial cells, and 1+ bacteria. He had iron studies done which showed an iron of 13 which is low.
Plus|Reflexes|143|Motor: 5/5 strength in biceps, triceps, deltoid, quadriceps. Sensory: no sensory deficits; some tenderness over the right shoulder. Reflexes: 2+ throughout. Babinski flexor bilaterally. No cerebellar dysfunction.
Plus|Reflexes|154|SKIN: He has laceration over his left eyebrow, otherwise no other gross abnormalities. Pedal pulses present, no edema. NEUROLOGIC: Normal tone. Reflexes 2+ symmetric throughout. Toes downgoing bilaterally. He is obtunded as stated, unable to cooperate.
Plus|Reflexes|106|EXTREMITIES: No edema. Distal pulses are intact. Full range of motion x4. NEUROLOGIC: Nonfocal. DTRs are 1+ bilaterally in the patellas. As I was leaving, she began to talk about how bad her boyfriend is.
Plus|Present|1192|16. Senna 1-4 tablets b.i.d. p.r.n. Outpatient prescriptions as of _%#MMDD2006#%_: TRENTAL 400 MG TAB take 1 tablet (400mg) by oral route 2 times per day with meals DAPSONE 100 MG TAB take 1 tablet (100mg) by oral route once daily FENTANYL 75 MCG/HR 72 HR TRANSDERM PATCH take one patch every 72 hours KEFLEX 500 MG CAP take 1 capsule (500mg) by oral route every 6 hours PERCOCET 5 MG-325 MG TAB take 1 tablet by oral route every 12 hours as needed NICOTINE 21MG/24HR-14MG/24HR-7MG/24HR DAILY TRANSDERM PATCH,SEQUENTIAL use daily PREDNISONE 10 MG TAB 3 tabs bid VICODIN 5 MG-500 MG TAB take 1 tablet by oral route every 4-6 hours as needed for pain PROTONIX 40 MG TAB take 1 tablet (40mg) by oral route once daily LIDOCAINE 5 % (700 MG/PATCH) ADHESIVE PATCH 1 Patch Transdermal EVERY MORNING off at night for neck CYCLOBENZAPRINE 10 MG TAB 10 mg Oral 3 TIMES A DAY AS NEEDED neck head pain LACTULOSE 10 G/15 ML ORAL SOLN 30 ML 20 g Oral 3 TIMES A DAY LISINOPRIL-HYDROCHLOROTHIAZIDE 20 MG-12.5 MG TAB take one tablet by mouth every day. LEVOTHYROXINE 200 MCG TAB take 1 tablet (200mcg) by oral route once daily WELLBUTRIN SR 150 MG TAB one po bid REVIEW OF SYSTEMS: CONSTITUTIONAL: no fevers, + weight gain over past 2 months EYES: no vision changes HEENT: no sores in mouth, wears dentures, no sore throat PULM: no cough, SOB CV: no chest pain, palpitations, orthopnea, PND GI: no N/V/D, may have had some blood in BMs once or twice in the past couple months GU: no dysuria/hematuria RHEUM: no joint pains or swelling ENDO: no heat/cold intolerance, no polyuria/polydipsia LYMPH: lower leg swelling over past 2 months MSK: ingrown toenail removed a few weeks ago NEURO: no weakness, numbness or paresthesias of the extremities PHYSICAL EXAM GENERAL: Alert, obese man in NAD EYES: PERRLA, EOMI, no scleral icterus HEENT: upper dentures, OC/OP clear without ulcers, erythema, exudates or petechiae NECK: obese habitus, supple, no JVD PULM: good air entry bilaterally, no crackles, few expiratory wheezes CV: RRR, S1/S2, no m/r/g ABD: obese, mildly distended, + normal BS, no HSM GU: no genital or anal lesions SKIN: extensive ulcerated lesions over both legs up to the thighs, some being at least 10 cm in diameter.
Plus|Reflexes|166|Strength is 5-/5 on the left upper extremity and left lower extremity and 5/5 on the right side. Gait and Romberg were not assessed. Deep reflexes are symmetrically 1+. LABORATORY STUDIES: WBC 18.6, hemoglobin 10.9, platelets 205,000. Sodium 136, potassium 4.2, chloride 104, CO2 20, BUN 23, creatinine 1.28, glucose 264, calcium 8.7. Troponin-I less than 0.07. Initial ABG attempt was unfortunately venous.
Plus|Pulse|122|GU: Deferred. EXTREMITIES: No clubbing, cyanosis or edema noted on her lower or upper extremities bilaterally. Pulses are +2 at the radial and femoral arteries bilaterally. NEURO: She is alert and oriented times three, moves all four extremities without difficulty.
Plus|Pregnancy dating|309|Expectant management was continued until the gestational age of 38 + 3 weeks, at which time the patient elected to proceed with induction as recommended by the perinatal service. Induction was performed at this gestational age rather than 37 weeks secondary to patient's rather poor dating consisting of a 22 + 4 week ultrasound not consistent with an LMP of _%#MM#%_ _%#DD#%_, 2003, which would have given her an EDC of _%#MM#%_ _%#DD#%_, 2003.
Plus|Positive(laboratory test)|306|She also had noted 1 day of puffy eyelids about a week prior to her visit for which she took Benadryl for a questionable allergy and the swelling resolved by the end of the day. The patient's primary physician worked _%#NAME#%_ up extensively. Laboratory studies included a UA which showed trace ketones, 3+ protein, 3+ blood, too many red blood cells to count.
Plus|Reflexes|141|Her cervix was checked; she was 1 cm, long, and very posterior. Medium consistency. Extremities showed 3+ edema to mid tibia. Reflexes were 1+. No clonus. No tenderness on examination. On admission, BUN 9, creatinine 0.9, fibrinogen 445, D-dimer 1.1. Hemoglobin 12, WBC 9900, platelets 217, uric acid 6.1, PTT 26, INR 0.94. Bilirubin less than 0.1, ALT 8, AST 20.
Plus|Reflexes|190|Strength is 5/5 bilaterally in the upper extremities and lower extremities. NEUROLOGIC: Cranial nerves II-XII are grossly intact. DTRs are 2+ and brisk bilaterally in the patellar area and 2+ bilaterally in the ankles. No ankle clonus elicited. There is no pronated drift and she does have good balance with the Romberg test.
Plus|Heart murmur|223|Mild right-sided subclavian stenosis. 5. On _%#MMDD2007#%_, transesophageal echocardiogram shows no pericardial effusion, normal left ventricular size and function, no regional wall motion abnormalities. There is moderate 2+ mitral regurgitation and trace aortic regurgitation.
Plus|Edema(swelling)|201|No epigastric or iliac bruits. PELVIC AND RECTAL: Deferred. EXTREMITIES: Distal lower extremities were well perfused with dorsalis pedis pulses 1 to 2+. There was cyanosis or clubbing. There was 1 to 2+ pre-tibial edema, left greater than right. MUSCULOSKELETAL: Without active synovitis. NEUROLOGIC: No facial asymmetry. No gross lateralizing weakness.
Plus|Edema(swelling)|114|LUNGS: Demonstrate some slight bibasilar crackles, clear at the apices. ABDOMEN: Soft. EXTREMITIES: Demonstrates 2+ edema with chronic venous stasis dermatitis changes.
Plus|Reflexes|86|The knees are not warm to the touch and there is no erythema. DTRs are diminished at 1+/4+ in the upper and lower extremities bilaterally. PSYCHIATRIC: The patient has a pleasant affect, is oriented towards future goals of getting home, as well as returning to her previous lifestyle.
Plus|Excess|201|Echo on _%#MMDD2002#%_ showed good LV function, RV function is low normal to mildly decreased, mild TR, and continuing pulmonary hypertension noted above. A follow-up echo ordered on 5/6 showed RVSP 90+, bidirectional flow across a PFO, right AE, and no comment was made on the sinous venosus.
Plus|Positive(laboratory test)|417|Hemoglobin 13.5 with MCV 96. Platelet counts 108. Basic chemistry essentially within normal limits except for low sodium at 131, and low potassium at 3.1. Normal creatinine at 0.87. Based on records from Mayo Medical Center, the patient had a blood culture drawn on _%#MMDD2006#%_, which grew out Gram negative bacilli after one day, one out of three bottles. The patient also had a bio-fluid culture which grew out 2+ Gram negative bacillus and 4+ Gram positive cocci resembling streptococcus.
Plus|Pulse|134|EARS: Normal pinna, canal, and TMs. Normal throat and nose. NECK: Supple. No nodes, abnormal masses. No palpable thyroid. Pulses are 2+. Carotids, radials, femoral, dorsalis pedis, and posterior tibial arteries. CHEST is clear with good breath sounds throughout.
Plus|Blood type|243|At the time of discharge, the infant's postmenstrual age was 39 weeks and 3 days. She is a 3033 gm, 39 week gestational age female infant born at Fairview University Hospital-Riverside to a 40-year-old, gravida 11, para 11-0-0-10, blood type A+, Hmong female whose EDC was _%#MMDD2007#%_. The mother's pregnancy was uncomplicated. Prenatal level II ultrasound was significant for multiple fetal anomalies.
Plus|Pulse|106|He actually has no significant presacral edema or dependent edema in his trunk, to my exam. He does have 2+ dorsalis pedis pulses bilaterally. LABORATORY STUDIES: An EKG done today shows what appears to be an underlying sinus rhythm with frequent PACs and PVCs.
Plus|Edema(swelling)|155|No rebound or guarding. I cannot palpate liver or spleen size accurately due to the ascites. By auscultation, liver seems somewhat enlarged. EXTREMITIES: 2+ pitting edema in the distal calves. Peripheral pulses are intact. SKIN: Remarkable for some spider angiomata.
Plus|Plus|87|14. Head CT without contrast. _%#MMDD2007#%_. No acute intracranial pathology. 15. Day +27 bone marrow biopsy, _%#MMDD2007#%_. Findings include trilineage hematopoiesis with slight dyserythropoiesis and 3.6% blasts.
Plus|Pulse|110|There is mechanical S2 with a 3/6 systolic ejection murmur at the left upper sternal border. The patient has 2+ dorsalis pedis pulses palpable bilaterally. ABDOMEN: The abdomen is soft, nontender and nondistended with bowel sounds present.
Plus|Edema(swelling)|219|CARDIOVASCULAR: Regular rate and rhythm. ABDOMEN: Obese, soft, slightly tympanitic, some slight tenderness diffusely, nonspecific, no guarding, essentially a benign abdomen by my exam. LOWER EXTREMITIES: Show at least 2+ if not 3+ pitting near woody edema with hyperemic changes.
Plus|Reflexes|114|Neurologic: Mental status was alert and oriented x 3. Cranial nerves II through XII were grossly intact. She had 2+ deep tendon reflexes. ADMISSION LABORATORY DATA: _%#NAME#%_'s ALT was 37, bilirubin 0.5, sodium 138, potassium 3.9, chloride 104, bicarb 30, glucose 78, BUN 4, creatinine 0.46, calcium 8.4. Her white blood cell count was 2.1 with differential of 23% neutrophils and 77% lymphocytes.
Plus|Edema(swelling)|270|CARDIOVASCULAR exam: Regular rate and rhythm. LUNG exam: Very distant breath sounds, no crackles, no wheezes appreciated. ABDOMINAL exam: Nontender, nondistended, soft, no masses. EXTREMITY exam: Patient's left lower extremity is erythematous and has palpable edema to 2+. Right lower extremity has palpable edema to 1+. She does have a previous scar, which I assume is from a venous graft for her previous bypass procedure.
Plus|Tonsil size|179|There was noted to be aversive/defensive with new foods and textures. 3. Ear, nose, throat evaluation by Dr. _%#NAME#%_, _%#MMDD2005#%_. Results revealed adenoid hypertrophy and 3+ tonsils, no laryngeal obstruction. 4. Intravenous steroid therapy. 5. Nebulizer treatment. HISTORY OF PRESENT ILLNESS: Please refer to admission history and physical dated _%#MMDD2005#%_ for full details.
Plus|Pregnancy dating|110|(_______________) was read by Dr. _%#NAME#%_ _%#NAME#%_ at Fairview Radiology. 3. _%#MM#%_ _%#DD#%_, 2005, 21 +2 weeks' at Fairview Riverside MFM per Dr. _%#NAME#%_' report. AFI was 8. Echogenic bowel was noted. Bilateral renal arteries were seen.
Plus|Strength|279|Non-tender to palpation throughout the cervical spine. Posture-wise he does have bilateral rounded shoulders as well as a forward head position as well as a forward trunk lean minimally. NEUROLOGIC: Cranial nerves II through XII are intact. Manual muscle testing gross measures 4+/5 to 5-/5 throughout. Strength functionally is within normal limits. Intact sensation of bilateral upper extremities and lower extremities to light touch and symmetrical.
Plus|Edema(swelling)|196|Questionable distention versus ascites versus obesity. Unable to appreciate organomegaly or fluid wave. EXTREMITIES: No cyanosis or clubbing. Extreme lower extremity bilateral edema greater than 4+ pitting edema. Lower extremities are cool to the touch, difficulty palpating pulses bilaterally were present but faint.
Plus|Pulse|212|ABDOMEN: Soft, nontender, nondistended without tenderness, guarding, organomegaly, or mass. Bowel sounds are normal. No epigastric or iliac bruits. EXTREMITIES: Distal lower extremities are well-perfused with 1-2+ dorsalis pedis, 1+ posterior tibial pulses. There is no cyanosis, clubbing, or edema. There is no posterior calf or thigh tenderness/induration to suggest DVT.
Plus|Plus|185|PROBLEM #3: Graft Versus Host Disease. Mrs. _%#NAME#%_ received graft versus host disease prophylaxis with cyclosporin and methotrexate. She received all 4 doses of methotrexate on day +1, +3, +6, and +11. However, she received a leucovorin rescue with her day #11 methotrexate due to the presence of pleural effusions.
Plus|Edema(swelling)|189|There is tachypnea present with no accessory muscle use. There is no dullness to percussion. ABDOMEN: Soft, nontender, nondistended with no organomegaly or masses. EXTREMITIES: There is 1-2+ pitting edema of both lower extremities bilaterally.
Plus|Positive(laboratory test)|159|Also a white count was obtained that was 10,100, a hemoglobin of 15.9, a platelet count of 187,000. Urinalysis showed a specific gravity of 1.025, a pH of 5, 1+ protein, and a negative dip for nitrates, blood, and leukocytes.
Plus|Heart murmur|169|Ejection fraction 50-55%, no wall motion abnormalities. Right ventricle mildly dilated, right ventricular systolic function normal, mild right ventricular hypertrophy. 3+ or moderately severe mitral regurgitation. Severe tricuspid repair dictation.
Plus|Pulse|291|LEGS: Reveal multiple varicosities, superficial. She has the small coin size lesion over the lateral malleolus on the left as we mentioned. No signs of erythema, no pretib pitting. She has kind of poor, but present dorsalis pedis, posterior tibial, popliteal and femoral pulses, maybe 2- 3/4+ max. She is no acute distress, alert and oriented times three.
Plus|Edema(swelling)|103|He was seen recently in our clinic on _%#MMDD2006#%_ for followup. At that time, he was noted to have 2+ edema in the right lower extremity with open wounds and cellulitis.
Plus|Pulse|117|Fundi deferred. OROPHARYNX: Clear. Dentition is in adequate repair. Mucosal membranes are moist. Carotid upstroke 1-2+ without bruits. There is no thyromegaly or lymphadenopathy.
Plus|Pulse|92|CARDIAC: Minimal early systolic murmur, no S3 and somewhat bradycardic. Carotid pulses are 2+, and again I do not hear any bruits. Femoral pulses are 1-2+, no bruits. Neck veins are flat.
Plus|Pulse|217|Apex was difficult to palpate. ABDOMEN: Abdomen reveals soft bowel sounds to be present, but no organomegaly. EXTREMITIES: Extremities reveal trace to 1+ pedal pitting edema. Peripheral distal extremity pulses are 1-2+ and equal. Bilateral femoral pulse 2-3+ and equal. There is no clubbing, cyanosis or lymphadenopathy.
Plus|Pulse|141|No jugular venous distention or hepatojugular reflux. Pulses are all intact with left greater than right carotid bruit. Distal pulses are 3-4+/4+ with no bruits. No tenderness to palpation across the precordium. ABDOMEN: Soft, nontender, without organomegaly.
Plus|Reflexes|99|Sensory was intact to light touch throughout and proprioception was intact. Reflexes were brisk at +3 throughout. Her Babinski was downgoing bilaterally.
Plus|Pulse|96|There is trace pedal edema. Distal lower extremity pulses are not felt. Bilateral femorals are 2+ with bilateral soft femoral bruits. Surgical scars are well-healed. CHEST: Auscultation is clear with no rales or rhonchi.
Plus|Strength|229|Hoffman's is negative. Romberg deferred. Coordination grossly appears intact. General movements were overall slow. Strength in bilateral upper extremities was quite good, in the right side 4+ to 5-/5, left arm is 5/5, right leg 4+ to 5-/5 left leg 5/5. Functionally the patient was moderately independent to standby assist going supine to sitting at the edge of the bed.
Plus|Edema(swelling)|141|There are no bruits. Distal lower extremities are well perfused with dorsalis pedis pulses 1-2+. There is no cyanosis or clubbing. There is 2+ pretibial edema bilaterally extending 2/3rds up to the knees.
Plus|Edema(swelling)|114|She had ecchymosis and bruising at the arms (right greater than left) and mild ecchymosis on the legs. There was 2+ pitting edema at both ankles. The lungs were clear to auscultation without crackles or wheezes posterolaterally.
Plus|Pulse|176|I do not think it is a fixed split. The rhythm is irregular and there is a blowing murmur of either MR or TR. I do not appreciate an S3. Carotid pulses are only approximately 1+. Femoral pulses are approximately 1+. He has a fistula in the left arm.
Plus|Reflexes|129|This has been present since her surgery. Cranial nerves VIII, IX, XI and XII are within normal limits. Deep tendon reflexes are 1+ and strength is 4+. Lymphatic: Negative for supraclavicular, cervical or axillary lymphadenopathy. RADIOGRAPHIC STUDIES: MRI scan of brain with and without contrast (_%#MMDD2002#%_) reveals multiple foci of enhancement in left cerebellar hemisphere which has markedly increased since the examination of _%#MMDD2002#%_.
Plus|Pulse|180|No diastolic murmur, rub or S3. ABDOMEN is soft, nontender without palpable liver, spleen or masses; bowel sounds are present. EXTREMITIES without cyanosis or edema; pulses are 1-2+ below, 2+ above. NEUROLOGIC exam was not done, appeared to be grossly intact.
Plus|Pulse|96|There is trace pedal edema. Distal lower extremity pulses are not felt. Bilateral femorals are 2+ with bilateral soft femoral bruits. Surgical scars are well-healed. CHEST: Auscultation is clear with no rales or rhonchi.
Plus|Strength|127|Knee flexion and extension 4/5 bilaterally with the right slightly stronger than the left. Ankle dorsi and plantar flexion is 4+ to 5-/5 bilaterally. Her reflexes were +1 throughout. Her toes were downgoing on the right side, equivocal on the left.
Plus|Reflexes|117|Only can lift hand to about shoulder level. No clubbing, no cyanosis. NEURO: Hyperreflexic at patellar and Achilles 3+. Cranial nerves II-XII grossly intact. No new focal defects noted.
Plus|Pulse|167|ABDOMEN: Soft with normoactive bowel sounds. CHEST: Clear to auscultation, no rales or rhonchi. EXTREMITIES: No peripheral edema. Distal lower extremity pulses are 2-3+ and equal. There is no cyanosis, clubbing or lymphadenopathy. NEUROLOGIC: Grossly nonfocal.
Plus|Pulse|141|Sclerae are nonicteric. Fundi deferred. Oropharynx is clear. Dentition in adequate repair. Mucosal membranes are dry. Carotid upstroke 1 to 2+ without bruits. There is no thyromegaly or lymphadenopathy. SKIN: Unremarkable. CHEST: Clear lung fields without rales, rhonchi, or bronchospasm.
Plus|Edema(swelling)|139|Abdomen was obese but soft and nontender. No appreciable masses. Bowel sounds were present. Extremities: Bilateral lower extremity edema, 2+ pitting, with legs bandaged and braced. LABS: White count 6.4, hemoglobin 11.9, and platelets 266, with a differential of 91% neutrophils, 7% lymphocytes, and 1% monocytes.
Plus|Edema(swelling)|121|ABDOMEN: Soft and nontender with normoactive bowel sounds. There is no hepatosplenomegaly. EXTREMITIES: He has trace to 1+ bilateral edema. He has 2+ pulses. SKIN: Warm and dry with no clubbing, cyanosis or rash.
Plus|Heart murmur|617|A 12-lead electrocardiogram was interpreted by me here today and shows poor R wave progression in the anteroseptal leads, however, this could be consistent with a prior anterior myocardial infarct, although we know that his left anterior descending artery is not occluded, and there is no past history of anterior MI No acute ischemic changes were seen on his EKG. IMPRESSION: 1. Increasing shortness of breath, which appears to be related to pulmonary, vascular congestion and pleural effusions in the setting of end-stage renal disease and moderately reduced left ventricular function with an EF of 30-35% and a 2-3+ mitral regurgitation. 2. Hypertension. 3. Not on an ACE inhibitor (this is not contraindicated in this patient as he is on dialysis).
Plus|Plus|117|On the echocardiogram, his right ventricular function appeared moderately decreased. His pressure was estimated at 25+ right atrial pressure. There was no pericardial effusion, shunt or clot. The formal report is pending.
Plus|Pulse|97|Bowel sounds are normal. Distal lower extremities are well perfused. Left dorsalis pedis pulses 2+. Right leg cast in place. There is no left leg cyanosis or clubbing. There is no edema.
Plus|Plus|129|RECOMMENDATIONS: 1. Telemetry 2. Follow hemoglobin and stool hemoccults. 3. Gastrointestinal consult about endoscopy 4. Atenolol + - nitrates and Lisinopril 5. Antiplatelet therapy depending on #3 6. Carotid ultrasound 7. Diabetic therapy
Plus|Excess|510|Excellent prenatal care at _%#COUNTY#%_ _%#COUNTY#%_ Medical Center via the High Risk Obstetrical Clinic given the chaos of the patient's social milieu, and her use of drugs, the amount, and depth of care she has received via the High Risk Obstetrical Clinic at _%#COUNTY#%_ _%#COUNTY#%_ as commendable-she has undergone genetic counseling for a history of cocaine abuse, as well as family history of polycystic kidney disease among other issues. She had quad-screen early in pregnancy, and anatomy scan at 19 + weeks, and appeared to be compliant with care up until the _%#MMDD2006#%_.
Plus|Edema(swelling)|103|I could not appreciate carotid bruits. ABDOMEN: Soft, some discomfort but no tenderness. EXTREMITIES: 2+ edema in both ankles. NEUROLOGICAL: The patient is awake, alert and oriented x 3.
Plus|Pulse|137|There may have been a soft secondary systolic murmur heard towards the base of the heart and less blowing character. Carotid pulses are 2+ and no bruits, femoral pulses are 1-2+. Neck veins are only mildly distended. ABDOMEN - reveals no abdominal bruits, no masses, there is no organomegaly.
Plus|Pulse|179|No click. No jugular venous distention. Abdomen: Soft, nondistended, and nontender, without organomegaly or mass. Bowel sounds are normal. Distal lower extremity pulses are 1 to 2+. No cyanosis or clubbing. No edema. Musculoskeletal: No synovitis. Absence of the ulnar two digits of the right hand.
Plus|Reflexes|106|Whenever pain was elicited, she would immediately break and give up the attempt. Reflexes appeared to be 2+ and symmetrical throughout. Toes were a bit difficult to test because of heavy callous on the soles of the feet.
Plus|Pulse|162|Gait was not assessed. The patient has an alert mental status. EXTREMITIES: Calves are nonedematous, nontender, and nonerythematous. Radial and pedal pulses are 2+. LABORATORY DATA: Capillary glucose was 102. Urinalysis showed large leukocyte esterase.
Plus|Plus|199|The right atrium was severely dilated, the left atrium was severely dilated. There was moderate MR and mitral valve leaflets were thick and there was moderate TR, with pulmonary hypertension, RVSP 60+ RA pressure. There was no significant aortic valve disease. More recently, the patient was just at University Hospital for what was thought to be acalculous cholecystitis and he was treated for such.
Plus|Edema(swelling)|104|EXTREMITIES: Distal lower extremity pulses are 1+. There is no cyanosis or clubbing. There is trace to 1+ pretibial edema bilaterally. No suggestion of acute DVT. PELVIC/RECTAL: deferred. NEUROLOGIC: No facial asymmetry.
Hyphen|Compound pre-modifiers|265|FINAL DISCHARGE DIAGNOSES: 1. Acute anterior myocardial infarct. 2. Coronary artery disease with 100% occlusion of the mid-left anterior descending artery, successful angioplasty and stenting of the mid-left anterior descending artery with a 2.5 x 13 mm Cypher drug-eluting stent and a 2.5 x 8 mm drug-eluting stent with a 0% residual lesion. Also, PTCA and stenting of a large distal diagonal artery with a 2.5 x 13 mm Cypher drug-eluting stent with a 0% residual lesion, 75% first obtuse marginal artery, 50-60% second obtuse marginal artery, 70% posterolateral artery, 25% mid-right coronary artery.
Hyphen|Compound pre-modifiers|164|She denies chest pain. PAST MEDICAL HISTORY: 1. COPD. 2. Idiopathic peripheral neuropathy. 3. Hypertension. 4. Hyponatremia. She apparently has had kind of some low-level hyponatremia. It had gotten down to 129 in the past, looks like a few years ago, but was up to 133 in _%#MM#%_, questionable cause.
Hyphen|Lexical hyphen|346|He was admitted on _%#MMDD2006#%_ and had an esophagogastroscopy, laparoscopic mobilization of the stomach and laparoscopic feeding jejunostomy, laparoscopic pyloroplasty, left chest tube thoracostomy, right VATS mobilization of esophagus and gastric pull-up. A right muscle-sparing thoracotomy and a flexible bronchoscopy and a percutaneous mini-tracheostomy. By Dr. _%#NAME#%_ _%#NAME#%_ on _%#MMDD2006#%_. He had a distal squamous cell carcinoma and a dense scar of the distal esophagus to the mediastinum.
Hyphen|Lexical hyphen|193|GENITOURINARY: See present illness. NEUROMUSCULAR: Negative. HEME: Negative. ENDOCRINE: Negative. FAMILY HISTORY: The patient is adopted and history unknown. HEALTH HABITS: The patient is an ex-smoker, light social use of alcohol PHYSICAL EXAMINATION: GENERAL: Healthy appearing 63-year-old.
Hyphen|Junction|197|_%#NAME#%_ with apparently retroperitoneal masses and mets in 2003, history of allergic rhinitis, history of hypertension, history of hypercholesterolemia. PAST SURGICAL HISTORY: Wrist fracture, L4-5 fusion in 1995, bladder neck suspension and suture removal in 2003, right nephrectomy in _%#MM2003#%_, appendectomy at 14 years of age, total abdominal hysterectomy and bilateral salpingo-oophorectomy in 1985.
Hyphen|Compound|80|DISCHARGE DIAGNOSIS: Oligodendroglioma. OPERATIONS/PROCEDURES PERFORMED: 1. Port-A-Cath placement. 2. IV/IA chemotherapy. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ _%#NAME#%_ is a 45-year-old gentleman with a history of temporal oligodendroglioma that was originally resected in 1997 by Dr. _%#NAME#%_ and has had radiation therapy in 2003.
Hyphen|Quotative or expressing a quantity or rate|87|She would like an IUD for postpartum birth control and will see Dr. _%#NAME#%_ at her 6-week postpartum visit for this. She was discharged home on FESO4, Colace, ibuprofen, and Percocet.
Hyphen|Typographic convention|206|day. ALLERGIES: Niacin, thiazides, Yohimbine, labetalol, aspirin, nifedipine. FAMILY HISTORY: Mother died at age 50 of a stroke, father had six strokes and died at the age of 74. REVIEW OF SYSTEMS: General - positive fatigue. Pulmonary - dyspnea on exertion. Cardiac - no chest pressure.
Hyphen|Quotative or expressing a quantity or rate|178|ADMISSION DIAGNOSIS: The patient is a 35-year-old gravida 1-para 0 at 39 weeks gestation in early labor. PROCEDURES: Primary transverse cesarean section DISCHARGE DIAGNOSIS: A 35-year-old gravida 1-para 0, postoperative day #5, status post primary cesarean section for fetal intolerance to labor.
Hyphen|Junction|189|MRI scanning showed a herniated disk at L3-L4 which was impinging the exiting nerve root on the right. After explanation of the risks and benefits, the patient elected to undergo a right L3-L4 hemilaminectomy and microdiskectomy. PHYSICAL EXAMINATION: The patient is awake, alert, and oriented. His wound is clean, dry, and intact.
Hyphen|Compound|242|PRELIMINARY ADDENDUM LABORATORY DATA: Sodium 132, potassium 4.1, chloride 99, bicarbonate 25, BUN 15, creatinine 0.6, calcium 8.6, total bilirubin 0.3, AST 27, ALT 39, alkaline phosphatase 86, total protein 6.1, albumin 3.3, CRP 52.4. Chest x-ray reviewed by me did not reveal an infiltrate. Chest CT also reviewed by me today also did not reveal an infiltrate in the right lung.
Hyphen|Compound|112|EKG is reported as being unchanged. The only EKG that is on the chart is one from _%#MM#%_ _%#DD#%_. Her chest x-ray shows bilateral pleural effusions without pulmonary congestion and this appears unchanged from previous cardiograms from the last hospitalization.
Hyphen|Compound pre-modifiers|231|Iron panel was performed, which showed a iron level of 44, a transferrin of 332, transferrin-binding capacity of 495 and iron saturation of 9, and reticular white count of 1.9. Ferritin level was 20. This is consistent with an iron- deficiency anemia. He should be further evaluated and managed as an outpatient for iron-deficiency anemia.
Hyphen|Negative|157|Twin A was initially intubated but soon after, it was clear that she would not live. Her weight was 623 g and her arterial pH was 7.34 with a base excess of -4.1. Twin B was in an intact water with clear fluid and was delivered from breech presentation with standard maneuvers and weighed 635 g.
Hyphen|Quotative or expressing a quantity or rate|180|Coronary artery disease, status post TAXUS drug-eluting stent of the right coronary artery (RCA). 2. Atrial fibrillation. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is an 82-year-old female who was seen recently by her primary physician, Dr. _%#NAME#%_ _%#NAME#%_ (Fairview Northland Clinic (_%#CITY#%_), in regards to difficulty with chest discomfort and shortness of breath for several months.
Hyphen|Quotative or expressing a quantity or rate|106|DATE OF PROCEDURE: _%#MMDD2005#%_ DATE OF DISCHARGE: _%#MMDD2005#%_ HISTORY: _%#NAME#%_ _%#NAME#%_ is a 34-year-old, gravida 3, para 1-0-1-1, female, at 39+2 weeks gestational age by an estimated due date of _%#MMDD2005#%_, who presented for a scheduled repeat cesarean section due to her history of a previous cesarean section. She declined a trial of labor after cesarean section. The risks, benefits and alternatives were reviewed.
Hyphen|Compound pre-modifiers|151|It was recommended the patient be on lactulose daily. PROBLEM #7. Code status: Dr. _%#NAME#%_ and the TLC team spoke with the patient regarding the end-stage aspect of her disease, and favored perhaps not doing any chemotherapy.
Hyphen|Quotative or expressing a quantity or rate|99|Sensation: Light touch and pinprick are intact, symmetric in the hands and feet. Cerebellar: Finger-nose-finger is executed somewhat slowly, but accurately and without dysmetria.
Hyphen|Lexical hyphen|153|Blood pressure 110/75, pulse 72 and regular, respirations 12 per minute at rest. SKIN: Normal, although there is considerable sun damage. LYMPH NODE: Non-tender, not enlarged. HEENT: ENT was normal. NECK: Normal without bruit. LUNGS: Clear.
Hyphen|To|166|The patient will be going to the _%#CITY#%_ Nursing Home. DISCHARGE MEDICATIONS: The patient's updated discharge medications include: 1. Compazine 5 to 10 mg p.o. q.6-8 h. p.r.n. 2. Nexium 20 mg p.o. daily. 3. Reglan 15 mg p.o. q.a.c. 4. TPN on a 14-hour cycle for the next week. 5. Maalox 30 cc p.o. q.6 h. p.r.n. reflux.
Hyphen|To|305|HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 72-year-old female with end-stage lung cancer adenocarcinoma who last had a chemotherapy treatment 1 1/2 weeks prior to admission. She came in to the emergency department complaining of increased weakness over the last week and decreased p.o. intake times 3-4 days. She was becoming more difficult for her caretakers to help the patient at home.
Hyphen|Quotative or expressing a quantity or rate|66|DOB: _%#MMDD1975#%_ HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 30-year-old occupational therapist at term. She had cesarean section for cephalopelvic disproportion with her first baby and wishes to have repeat cesarean section.
Hyphen|To|343|He was then transferred to the ICU in good condition where his post-operative course was uncomplicated except for a sternum upper pole incision area of erythema. The patient was placed on Keflex and discharged to home on _%#MMDD2006#%_ with instructions for incisional care, not to drive for four weeks, no lifting greater than 10 pounds for 8-12 weeks. Observe his incision for increased redness or drainage. Call for increased pain, swelling, elevated temperature of greater than 101 or increased redness in his incision or increased shortness of breath.
Hyphen|To|283|Ibuprofen. 12. Tylenol. SOCIAL HISTORY: The patient lives in an apartment alone but he has staff care from 7 a.m. to midnight. He does not drink and does use tobacco. PHYSICAL EXAMINATION: Vital signs: Blood pressure 149/72, pulse 101, respiratory rate 24, weight is estimated at 350-400 pounds, temperature is 101.3. Saturations are 96% on room air.
Hyphen|Compound pre-modifiers|162|Chest pain, ruled out for myocardial infarction. a. The patient had serial troponin which were negative. His electrocardiogram showed sinus bradycardia with first-degree A-V block with left anterior fascicular block and incomplete right bundle-branch block.
Hyphen|Compound pre-modifiers|144|It appears to be slightly vasculitic, will check sed rate. 4. Post-nasal drip: Offered nasal steroid or a............for what appears to be post-nasal drip causing chronic cough, and patient declined.
Hyphen|Typographic convention|72|EYES -pupils equal, round, reactive to light. ORAL MUCOSA - moist. NECK - supple. CARDIOVASCULAR - S1, S2, regular. RESPIRATORY - clear to auscultation, no wheezing, no crackles. ABDOMEN - soft, bowel sounds present, no tenderness, no hepatosplenomegaly.
Hyphen|To|125|DISCHARGE PLAN: The plan is for her to be discharged to home with followup in the orthopedic clinic with Dr. _%#NAME#%_ in 10-14 days for wound check. She is also to have followup with pediatric as well as endocrine, and this will be scheduled.
Hyphen|To|101|We will start him on Coumadin tomorrow. His biggest risk factor is his malignancy. Goal INR will be 2-3. Monitor in the unite. We will also check Doppler for a source of his embolus.
Hyphen|Quotative or expressing a quantity or rate|55|PRELIMINARY _%#NAME#%_ _%#NAME#%_ is a very pleasant 84-year-old male whom I am dictating a preoperative on. The patient apparently is having cataract surgery on _%#MM#%_ _%#DD#%_.
Hyphen|And(fraction)|324|DISCHARGE DIAGNOSES: 1. Nausea and vomiting. 2. Abdominal pain. 3. End-stage renal disease. HISTORY OF PRESENT ILLNESS: Briefly, this is a very pleasant, 32- year-old female with a past medical history significant for focal segmental glomerulonephritis status post cadaveric transplant x2 who presents with approximately a 1-1/2-day history of nausea, vomiting, and abdominal pain. The patient's abdominal pain is located in the epigastrium radiating slightly to the right upper quadrant.
Hyphen|To|167|Physical Therapy and Occupational Therapy should evaluate and treat this patient. The patient should have his wound vacs on his lateral and medial left thigh changed 2-3 times per week. The staples in his distal thigh should be removed in 7-10 days.
Hyphen|To|82|Vital signs stable. Follow-up with Dr. _%#NAME#%_ in 1 week. Steroids are on for 7-10 days. Do not drive for 1 week. DISCHARGE MEDICATIONS: Home medications upon discharge are: 1. Norvasc 10 mg daily.
Hyphen|Compound pre-modifiers|149|The patient reports being in his normal state of health until approximately Tuesday of this week, _%#MM#%_ _%#DD#%_. He reports he came down with flu-type symptoms. He felt nauseous, queasy and over the next 4-5 days his symptoms progressed.
Hyphen|Hyphenated name|137|Follow-up appointments were to be scheduled with the peds gastroenterology service and the colorectal surgery service with Dr. _%#NAME#%_-_%#NAME#%_ approximately one month following discharge. DISCHARGE MEDICATIONS: 1. Prednisone taper 10 mg p.o. q.d. for a total of 5 days, followed by 5 mg p.o. q.d. for five days, and then 5 mg p.o. q.o.d. for two days and then discontinuing.
Hyphen|Quotative or expressing a quantity or rate|145|He was able to walk without an untimely gait. The patient was alert and oriented x 3. Cranial nerves II through VII were intact. A Romberg finger-to-nose test was negative. ADMISSION LABS: White count 8.0. An AST was mildly elevated per clinic, but the exact number was not known.
Hyphen|Compound|208|ADMISSION DIAGNOSES: 1. Secondary infertility. 2. Greater than 4 cm anterior fundal myoma, diagnosed by MRI. DISCHARGE DIAGNOSIS: 1. Postoperative day number three status post adenomectomy with right salpingo-oophorectomy. PROCEDURES: 1. Exam under anesthesia. 2. Exploratory laparotomy. 3. Lysis of adhesions.
Hyphen|Compound pre-modifiers|70|DIAGNOSIS: Autologous peripheral blood stem cell transplant for mucosa-associated lymphoid tissue lymphoma in second remission. BRIEF HISTORY AND PHYSICAL EXAMINATION: Mr. _%#NAME#%_ _%#NAME#%_ is a 53-year-old Caucasian gentleman who was diagnosed with a MALT lymphoma on _%#MM#%_ _%#DD#%_, 2000, on routine colonoscopy.
Hyphen|Quotative or expressing a quantity or rate|137|2. Acute renal insufficiency, resolved during this hospitalization (etiology unclear). HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 50-year-old gentleman admitted as a transfer from the _%#CITY#%_ emergency room, with increasing lower extremity edema and scrotal edema for the past 3 weeks.
Hyphen|To|279|DISCHARGE MEDIATIONS: Those medications on admission, and also iron gluconate 325 mg p.o. t.i.d., and Dilaudid 2 mg p.o. q.4-6h. p.r.n. DIET: Regular. AMBULATORY STATUS: Nonweightbearing on the right leg. DISCHARGE FOLLOW UP: I will see this patient back in my office in about 10-14 days.
Hyphen|Compound pre-modifiers|202|The patient has developed severe knee pain that resulted in her developing nausea and vomiting due to various oral narcotics she used in an attempt to relieve the knee pain. Labs were obtained by the on-call physician last night, and revealed a hemoglobin of 6.8 with an elevated INR.
Hyphen|Quotative or expressing a quantity or rate|77|REFERRING PHYSICIAN: Dr. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is an 87-year-old man well known to me whom I have seen in the clinic for many years for end stage chronic obstructive pulmonary disease. The patient, in the clinic and here, per his family and the patient's wishes has WANTED TO BE DNR, DNI.
Hyphen|Compound|89|Potassium 10 mEq p.o. q.d. 4. Lasix 20 mg p.o. q.d. 5. Protonix 40 mg p.o. b.i.d. 6. Depo-Provera q. month. 7. Trazodone 75 mg p.o. p.r.n. 8. Propranolol 40 mg p.o. b.i.d.
Hyphen|Quotative or expressing a quantity or rate|107|HOSPITAL COURSE: PROBLEM #1: CHF exacerbation/pulmonary edema and non-Q-wave MI. As noted above, this an 85-year-old with severe heart disease, including CHF, class III, labile hypertension, coronary artery disease, hypercholesterolemia, and dual chamber pacemaker, who has had multiple admissions for CHF as well as MIs in the past.
Hyphen|Quotative or expressing a quantity or rate|124|PRELIMINARY REASON FOR HOSPITALIZATION: Abdominal pain, vomiting. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is an 84-year-old female examined in the emergency room whose niece is at the bedside. The patient states that yesterday the whole day she was vomiting.
Hyphen|Compound pre-modifiers|116|2. Chronic pain secondary to myositis. 3. Chronic renal insufficiency with a baseline creatinine of 1.8 to 2. 4. HIV-positive status. 5. Asthma. 6. Seasonal allergies. 7. Peptic ulcer disease. 8. Chronic lymphedema. 9. Hypertension. ADMISSION LABS AND IMAGING: Amylase 183, sodium 130, potassium 6.7, chloride 88, bicarbonate 20, anion gap 22, glucose 114, BUN 179, creatinine 8.83. Total bilirubin 1.2, albumin 4.9, protein 9.2, alkaline phosphatase 166, ALT 23, AST 34.
Hyphen|Phone number|203|_%#NAME#%_ during her hospitalization. We hope that she is able to manage her severe renal failure as she sees appropriate. If you have any questions regarding this dictation, please page me at _%#TEL#%_-_%#TEL#%_.
Hyphen|Lexical hyphen|181|FAMILY HISTORY: Is fairly noncontributory. REVIEW OF SYSTEMS: Is difficult to obtain given the patient's sedated, agitated and confused state. He often wanders in discussions to non-medically relevant topics of discussion at inappropriate times.
Hyphen|Quotative or expressing a quantity or rate|267|ALLERGIES: To penicillin, erythromycin, Quinidine and tissue plasminogen activator. SOCIAL HISTORY: Widowed, lives semi independently, has a son in town. Will be moving to an assisted living environment soon. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is an 81-year-old man who fell attempting to move from his bed to bathroom.
Hyphen|Lexical hyphen|197|ASSESSMENT/PLAN: This is a 79-year-old female patient with a history of hypertension, asthma and diabetes, in addition hyperlipidemia, who now presents with multiple medical issues. 1. Cardiac. Non-ST elevation myocardial infarction. Also with ST changes on EKG.
Hyphen|Quotative or expressing a quantity or rate|84|FINAL CHIEF COMPLAINT: Progressive dyspnea. HISTORY OF PRESENT ILLNESS: This is a 72-year-old female well known to our service with a history of end-stage COPD, trache dependent with a history of severe obstructive sleep apnea who presents her with progressive dyspnea that was notably worse today en route today to her doctor's appointment. She was noted to be tachypneic and had increasing thick phlegm according to the family.
Hyphen|Quotative or expressing a quantity or rate|176|The patient tolerated the procedure well and was transferred to PACU and Recovery in stable condition. HOSPITAL COURSE/HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 77-year-old gentleman who was admitted to Fairview Southdale Hospital for fever, dehydration, possible sepsis, ?cholecystitis.
Hyphen|Quotative or expressing a quantity or rate|201|She was then transferred to Meritcare Hospital in _%#CITY#%_ North Dakota for further evaluation when she underwent cardiac catheterization at approximately 2100 on _%#MMDD2007#%_. This showed severe 3-vessel disease and it was determined at that time the patient's disease was not amenable to PCI or coronary artery bypass grafting.
Hyphen|Typographic convention|220|Avelox 400 mg on day three so far. PHYSICAL EXAM: Reveals blood pressure 119/96, pulse 122, respirations 20-24, temperature 97.9, oxygen saturation 98% on room air. She is alert and oriented, in no acute distress. HEENT - unremarkable except for dry oral mucosa. NECK - supple with no adenopathy, no carotid bruits. No JVD.
Hyphen|Compound pre-modifiers|123|His extraocular movements are slightly restricted in upgaze OS and in right gaze OD. His incisions are clean with mild post-op edema, and some mild chemosis inferiorly in the right eye.
Hyphen|Lexical hyphen|460|Follow-up, therefore, will include a check of fasting lipid panel, AST, ALT, total bilirubin, alkaline phosphatase and CK one month (approximately _%#MM#%_ _%#DD#%_, 2003) after starting this statin drug, firstly, to assure that she is benefiting in the treatment of her hyperlipidemia, but secondly to assure that no adverse effects such as abnormal liver functions or statis-induced myopathy have occurred as a result of starting this drug. Additional follow-up will include evaluation and treatment of her blood pressure one month after the stroke to maintain a systolic blood pressure less than 140.
Hyphen|Hyphenated name|99|COUNSELOR DISCHARGE SUMMARY PHYSICIAN: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, M.D. REFERRED BY: Fairview-University Medical Center/Stop Unit. The client was discharged early with staff advice. PROBLEMS PRESENTED AT ADMISSION: _%#NAME#%_ is a 17-year-old female referred to _%#CITY#%_ Adolescent Chemical Dependency Outpatient Program and Lodging Plus at Nord House following an inpatient evaluation at Fairview-University Medical Center/Stop Unit.
Hyphen|Quotative or expressing a quantity or rate|213|DISCHARGE DIAGNOSES: 1. Right displaced femoral neck fracture. Right hemiarthroplasty on _%#MMDD2003#%_ under spinal anesthetic. 2. Early left lower lobe pneumonia diagnosed _%#MMDD2003#%_. The patient received 24-hours of Zosyn. 3. Coronary artery disease. a. History of bypass surgery in 1989.
Hyphen|Quotative or expressing a quantity or rate|107|She was admitted for ongoing treatment of her fluid overload. PAST MEDICAL HISTORY: Surgeries include below-the-knee amputation on the right. Prior to that she had a ray amputation of the right fifth toe which did not heal back in _%#MM#%_.
Hyphen|Compound pre-modifiers|176|10. Trazodone 50 mg qhs prn. PHYSICAL EXAMINATION: On arrival to the emergency room his temperature was 98.8, blood pressure was 107/75. Heart rate 129. Respirations 20. Follow-up blood pressure dropped to 85/63, heart rate 122. GENERAL: Very frail elderly man in no respiratory distress. He is awake and alert.
Hyphen|Typographic convention|180|The patient has had a past history of having a pelvic ultrasound with a 7 mm intrametrial structure suggesting a polyp. The patient will undergo D&C. PAST MEDICAL HISTORY: Surgery - cesarean section and cholecystectomy. Medical illnesses - unremarkable. ALLERGIES: None MEDICATIONS: Lipitor, hormone replacement therapy, Dyazide HABITS: Unremarkable REVIEW OF SYSTEMS: Noncontributory PHYSICAL EXAMINATION: Blood pressure 120/80.
Hyphen|Phone number|120|Thank you again for allowing us to share in the care of your patient. If questions arise, please contact us as _%#TEL#%_-_%#TEL#%_ (NICU) or _%#TEL#%_ (office). We hope to be of continuing service to you.
Hyphen|And(fraction)|257|She has had three prior uncomplicated term vaginal deliveries. However, in _%#MM#%_, 2002, she experienced preterm premature rupture of membranes at 25 weeks and had a classical cesarean section emergently for cord prolapse. That infant eventually died at 6-1/2 months of age of complications of prematurity. PAST MEDICAL HISTORY: ILLNESSES: History of depression. SURGERIES: History of heart surgery at age 12.
Hyphen|Quotative or expressing a quantity or rate|29|_%#NAME#%_ _%#NAME#%_ is a 34-year-old woman who underwent exploratory laparotomy and myomectomy on _%#MMDD2003#%_ at Fairview Southdale Hospital. The surgery was uncomplicated. Postoperatively she did very well. She was discharged on postoperative day two.
Hyphen|To|222|Sickle-cell pain crisis. The patient has known adverse reactions to morphine, meperidine, and fentanyl which induce significant vomiting in this patient. The patient is normally treated with Demerol taking 50 to 100 mg q.2-4 h. when he is in active sickle-cell pain crisis. The patient improved markedly up to the day of discharge, requiring less pain medications as the hospitalization progressed.
Hyphen|Quotative or expressing a quantity or rate|139|8. Tylenol 325 to 650 mg every 6 hours p.r.n. for pain or fever. 9. Aspirin 81 mg daily. HOSPITAL COURSE: Mr. _%#NAME#%_ _%#NAME#%_ is a 78-year-old man who has been living alone who was found down in his apartment.
Hyphen|Quotative or expressing a quantity or rate|85|FINAL DISCHARGE SUMMARY HISTORY OF PRESENT ILLNESS: The patient is a very pleasant 78-year-old woman who lives with her husband and sees Dr. _%#NAME#%_, _%#CITY#%_ _%#CITY#%_ Medical Center. She has a history of coronary artery disease, hypothyroidism, aortic valve replacement.
Hyphen|Junction|93|He is currently on a cardiac diet. PAST MEDICAL HISTORY: 1. Cervical stenosis, status post C3-C4 laminectomy. 2. Status post kidney transplant in 2006 for hypertensive nephropathy. 3. History of nephrectomy because of concern of possible neoplasia in recent past.
Hyphen|Quotative or expressing a quantity or rate|132|She is a current tobacco abuser. She smokes 3 cigarettes a day. She does have an extensive past history of tobacco abuse, roughly 24-pack-years. She quit smoking significantly at the age of 50 and started again 3 years ago because she enjoyed it.
Hyphen|Quotative or expressing a quantity or rate|156|FINAL PROPOSED PROCEDURE: Placement of right thigh PTFE graft for dialysis access. SURGEON: _%#NAME#%_ _%#NAME#%_, MD HISTORY: _%#NAME#%_ _%#NAME#%_ is a 47-year-old female who has end-stage renal disease. She has had a very difficult history of various vascular access procedures and failures.
Hyphen|Quotative or expressing a quantity or rate|81|FINAL HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a very unfortunate, 35-year-oldm morbidly obese, white female who presented into our emergency room for the second time in three days with very complex symptomatology resulting in her being admitted into the CICU for chest pain, coronary disease rule out. She has just been seen by Dr. _%#NAME#%_ _%#NAME#%_ who has very nicely elucidated all of her Cardiology issues which for purposes of this dictation amount to that this patient has had recently two cardiac heart surgeries.
Hyphen|Compound pre-modifiers|136|REVIEW OF SYSTEMS: Noncontributory. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 132/90, weight 145 pounds. GENERAL: This is a well-developed, well-nourished adult female in no acute distress.
Hyphen|Compound|286|In terms of her oxygen requirement, however, the patient continued to require 4 to 5 L of oxygen. She had been saturating at 95% and 96%. Other issues during the hospital stay were her history of migraines with were controlled with Imitrex subcutaneously, IV morphine, and eventually MS-Contin. The patient had serial x-rays done which did not reveal any improvement in the infiltrates.
Hyphen|Compound pre-modifiers|218|CHIEF COMPLAINT: Increasing unresponsiveness at home. Bruising. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is an 86-year-old female who has a history of advancing dementia, also history of previous CVA with left-sided weakness. The patient lives at home with her husband. She has a caregiver who helps with some home health aid and sometimes with feeding.
Hyphen|Compound|142|_%#NAME#%_ _%#NAME#%_ _%#NAME#%_ as the attending physician and Dr. _%#NAME#%_ _%#NAME#%_ for the anterior exposure. _%#NAME#%_ _%#NAME#%_, PA-C, was the assistant on the case. There was 500 cc estimated blood loss and no complications.
Hyphen|Compound|158|Bowel sounds were present. Chest x-ray in the emergency room showed left-sided infiltrate consistent with pneumonia. HOSPITAL COURSE: The patient remained DNR-DNI status but was treated with intravenous fluids for blood pressure maintenance, IV ceftazidime, and vancomycin, and transfusion of red cells and platelets.
Hyphen|Compound|244|His fevers continued to become worse, and bilious fluid began to drain from his JP. On _%#MMDD2003#%_ he was taken to the operating room for an exploratory laparotomy, lysis of adhesions, partial cholecystectomy, bile duct exploration, and Roux-en-Y choledochojejunostomy over a 14- French T-tube. Upon admission, the patient continues to have fevers in the low 100s.
Hyphen|Compound pre-modifiers|474|_%#NAME#%_ is a 62-year-old, retired metal worker who presented to Fairview Southdale Hospital with severe chest pressure on the day of admission; this was brought on by exertion but recurred without provocation. HOSPITAL COURSE: The patient underwent urgent cardiac catheterization and was found to have a dominant left coronary artery with left main coronary stenosis and occlusion of the left anterior descending (LAD), subtotal occlusion of the obtuse marginal, and high- grade obstruction of the A-V groove circumflex. The left anterior descending was reopened with balloon dilatation and in two locations.
Hyphen|Compound|180|ASSESSMENT: Term infant admitted to Special Care Nursery for an episode of desaturation and duskiness. Differential likely polycythemia and some gagging. Cultures negative. Chest x-ray negative. Being discharged home with parents. Instructions to follow-up in our office in one week.
Hyphen|Compound|183|Most of her history comes from her old chart as she was just seen here in the Emergency Room in _%#MM#%_ 2003. PAST MEDICAL HISTORY: Medications just albuterol inhaler. She takes Depo-Provera for birth control. She has history of asthma and depression. She had been on Lithium and Remeron in the past.
Hyphen|Compound pre-modifiers|85|DISCHARGE DIAGNOSES: 1. Metastatic renal cell carcinoma status post course #2 of high-dose interleukin-2. 2. Drug eruption and hypertension secondary to IL-2 infusion. OPERATIONS/PROCEDURES PERFORMED: PICC line insertion on _%#MM#%_ _%#DD#%_, 2003.
Hyphen|To|171|No new neurologic, psychiatric, or endocrine symptoms. SOCIAL HISTORY: The patient is a former smoker. She is a retired teacher. She drinks gin the patient reports up to 2-3x per week. I suspect this is more. She does not measure her alcohol.
Hyphen|Compound pre-modifiers|164|REVIEW OF SYSTEMS: Negative with the exception of the HPI symptoms as well as some symptoms of back pain persisting for several months. PHYSICAL EXAMINATION: An ill-appearing, heavily sedated female lying quietly in bed. Blood pressure 101/65, pulse 93, temp 100.2. HEENT: Normocephalic, atraumatic.
Hyphen|Compound|164|The lowest it has ever been is 39. Her CEA is 5.1 and that has been up to 5.7. Bone scan shows some areas that are consistent with arthritis and are stable. Chest x-ray and mammogram are normal. FAMILY HISTORY/SOCIAL HISTORY: No change in family or social history since _%#MM#%_ of 1999.
Hyphen|Quotative or expressing a quantity or rate|153|PREOPERATIVE DIAGNOSIS: Intact hymen PROCEDURE: Hymenotomy/hymenectomy/examination under anesthesia HISTORY OF PRESENT ILLNESS: _%#MM#%_ _%#DD#%_ is a 19-year-old nulligravid virginal female who was first seen in our office in _%#MM#%_ 2004 with complaints of inability to use a tampon. The patient notes that she has normal regular periods that are quite light, but when she has tried to place a tampon into the vaginal area, she meets significant resistance.
Hyphen|Compound|159|Discharged to home without issue. Instructed to contact our office with any problems of questions. He was instructed on brace use, incision management and self-cares.
Hyphen|Quotative or expressing a quantity or rate|184|The patient then underwent a myeloablative matched sibling donor peripheral blood stem cell transplant. He had a very complicated peri transplant course including mucositis acute graft-versus-host disease, CMV reactivation, C-diff colitis, hemorrhagic cystitis, viruria, parainfluenza pneumonitis and pulmonary aspergillosis.
Hyphen|Compound pre-modifiers|159|HOSPITAL COURSE: A 65-year-old guy with history of squamous cell lung cancer, admitted for another episode of pneumonia. 1. Respiratory/pneumonia: He had a low-grade fever at the time of admission of 100.3. We sent a blood culture for him, which was negative.
Hyphen|Quotative or expressing a quantity or rate|215|On postoperative day #1, she was transitioned from IV pain medications to oral pain medication including OxyContin, Percocet, and Vistaril. She was discharged home on these medications. She will follow up at 2 and 6-week intervals. She will be toe-touch weightbearing with crutches for the next 6 weeks.
Hyphen|Compound|130|9. Sinus bradycardia secondary to atenolol. PROCEDURES PERFORMED: 1. CT scan of the head without contrast which was negative. 2. X-ray of the right hand which showed dislocation of right fifth digit.
Hyphen|Compound|81|Will check some gases on room air to see if he qualifies for home oxygen. Chest x-ray as stated showed the right lung infiltrate was interstitial and actually improved significantly during his hospital stay.
Hyphen|To|129|Itraconazole 100 bid. Magnesium oxide 400 qid. Metoprolol 50 bid. Multivitamin one tablet q d. Cellcept 1,500 mg bid. Restoril 15-30 q hs prn. Ativan 1 mg po q 8 hours prn. Tylenol 325-650 mg q 4 hours prn.
Hyphen|Compound|122|CURRENT MEDICATIONS: 1. Coumadin. 2. Norvasc. 3. Hydrochlorothiazide. 4. Atenolol. 5. Calcium. 6. Vitamin E. 7. Centrum. X-rays showed significant degenerative arthritis of the left hip with an erosive change to the acetabulum.
Hyphen|Compound pre-modifiers|165|She had excellent urine output, and on post-operative day #1, her Foley catheter was removed and she was up and ambulating. The patient was somewhat nauseous on post- operative day #2 and received Zofran oral dissolving tablets that helped.
Hyphen|Typographic convention|195|Bone and joint - has chronic right and left hip symptoms and chronic back pain. Neuromuscular - denies seizures, syncope, paresthesias, dysesthesias or vertigo. PHYSICAL EXAMINATION: Vital signs - blood pressure 100/46, heart rate is 141, respirations are 20 and unlabored.
Hyphen|Quotative or expressing a quantity or rate|236|Her hospital course was uncomplicated. She tolerated antibiotics without incident. She was followed by both orthopedics and infectious disease. She will be discharged on IV vancomycin, oral Cipro, and IV ceftazidime for expected total 6-week course. She will follow up with infectious disease and with orthopedics.
Hyphen|Compound|71|REASONS FOR HOSPITALIZATION: 1. Chest discomfort. 2. Weakness. 3. Light-headedness. 4. Presyncope. PAST MEDICAL HISTORY: 1. Paroxysmal atrial fibrillation, on monitoring in the hospital.
Hyphen|Compound|140|_%#NAME#%_ _%#NAME#%_. In brief, Ms. _%#NAME#%_ is a _%#1914#%_ female who is admitted complaining of chest discomfort. On admission chest x-ray noted right upper lobe pneumonia. A VQ scan was indeterminate on admission to evaluate for PE and the patient also had an elevated D- Dimer.
Hyphen|Compound pre-modifiers|156|She went home and felt well until she finished her prednisone taper two day ago. Yesterday she said she felt fairly well in the morning but described an ill-defined shortness of breath and sense of illness the rest of the day.
Hyphen|Compound pre-modifiers|211|The patient was placed on metformin 500 mg p.o. b.i.d. but the patient has been taking as much as 1500 mg b.i.d. because his blood sugars have been too high to read. The patient reports that he has had a several-month history of polyuria, polydipsia, weakness and fatigue and has had about a 30-pound weight loss.
Hyphen|Compound|156|D-dimer obtained on admission was 0.04 and within normal limits. The patient does have a 20-pack year history of smoking and did appear as though on chest x- ray that he may have some hyperinflation of his lungs, and again, pulmonary function tests are recommended as an outpatient.
Hyphen|Quotative or expressing a quantity or rate|96|DISCHARGE DIAGNOSIS: Sickle cell pain crisis. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 29-year-old man with sickle cell anemia who is well known to our facility.
Hyphen|Typographic convention|69|Bowel sounds are active. EXTREMITIES - there is no edema. NEUROLOGIC - strength is 5/5 and symmetric in all four extremities.
Hyphen|Compound pre-modifiers|203|This is a longstanding problem. 2. Acute renal failure secondary to dehydration. 3. Urinary tract infection. The patient has a history of having a urinary tract infection that was positive for vancomycin-resistant enterococcus, which is susceptible to linezolid in the past.
Hyphen|Typographic convention|319|Comprehensive metabolic battery on admission. Sodium -- 137, potassium -- 3.1, chloride -- 92, bicarbonate -- 26, glucose -- 88, BUN -- 23, creatinine -- 6.8, calcium -- 9.4, bilirubin total -- 0.9, albumin -- 3.9, protein -- 6.9, alkaline phosphatase -- 127, ALT -- 13 and AST -- 15. Amylase level -- 35, lipase level -- 22 and troponin-1 -- 0.69 (troponin level continuously trending up and peaked at a value of 8).
Hyphen|Compound|223|9. Prednisone 40 mg daily for 4 days, then 30 mg daily for 4 days, then 20 mg daily for 4 days, then 10 mg daily (eventually I will try to taper her down to her baseline dose of 5 mg daily). 10. Spiriva 18 mcg daily. 11. Os-Cal 500 mg twice daily. 12. Klor-Con 20 mEq twice daily. 13. DuoNeb 3 mL neb every 2 hours p.r.n. dyspnea.
Hyphen|Compound pre-modifiers|107|He reports that the weakness came on suddenly and he fell. His workup revealed progression of his known non-small cell lung cancer with spinal and epidural involvement at the level of T1-T4.
Hyphen|And(fraction)|201|ALLERGIES: No known drug allergies. MEDICATIONS: Prenatal vitamins. SOCIAL HISTORY: The patient is married. She is a nonsmoker. Her husband is supportive. PHYSICAL EXAMINATION: VITALS SIGNS: Weight 229-3/4 pounds. Blood pressure 124/76. Urine dip is negative for protein and glucose.
Hyphen|Negative|233|HSV negative. She is noted to be GBS positive. PHYSICAL EXAMINATION ON ADMISSION: She was afebrile with a blood pressure of 100/59. Otherwise her physical examination was unremarkable. She had a cervix examination which was 7, 100%, -2, with a bulging bag of water and vertex. Fetal heart rate was in the 120's to 150's with positive accelerations, no decelerations, and reactive.
Hyphen|Compound|83|PPD was placed and will be read by a home nurse 48 hours after placement. A chest x-ray was also obtained and did not reveal any lesions following the tap.
Hyphen|Compound|248|For COPD, prednisone 60 mg p.o. daily for three days, followed by 50 mg p.o. daily for three days, 40 mg daily for three days, 30 mg daily for three days, 20 mg daily for seven days, and then 10 mg daily. For COPD, Lasix 20 mg one p.o. daily, Chlor-Con 10 meq one p.o. daily. For bronchitis, Biaxin 500 mg p.o. b.i.d. through _%#MMDD2003#%_, Ceftin 500 mg p.o. b.i.d. through _%#MMDD2003#%_.
Hyphen|Compound pre-modifiers|153|She was given IV steroids around the time of her surgery, and then put on 4 mg b.i.d. on postoperative day #1. She was given steroids because of her long-term steroid use because of her multiple sclerosis. On postoperative day #5, Ms. _%#NAME#%_ was doing well and ready for discharge.
Hyphen|And(fraction)|300|Tubal with reanastomosis in _%#MM2001#%_. PAST GYNECOLOGIC HISTORY: Abnormal Pap smear in _%#MM1995#%_ consistent with CIN. Questionable if colposcopy was ever done. PAST OBSTETRICAL HISTORY: The patient had four normal spontaneous vaginal deliveries at term, weighing 7 pounds 3 ounces to 9 pounds 1-1/2 ounces. Her labors lasted from four hours to 20 hours. She also had a miscarriage at eight weeks.
Hyphen|To|396|Patient felt his pain was much improved with a change in his medications and he was able to ambulate with a walker without difficulty. Requested discharge to home. Patient is discharged to home. He will continue on his usual admit medications other than the discontinuation of MS Contin and Methocarbamol with the initiation of Fentanyl patch 50 micrograms changing q 3 days as well as Zanaflex 4-8 mg po q 6 hours prn. One month prescription for both of these medications were given.
Hyphen|Typographic convention|177|REVIEW OF SYSTEMS: HEENT: Negative except for complaint of dry mouth due to the patient's reluctance to eat or drink for fear of exacerbating her symptoms. Ears -negative. Eyes - negative. Neck - negative. Cardiac - The patient underwent a nuclear stress test and stress echocardiogram in 2003.
Hyphen|Compound pre-modifiers|105|The patient arrived to the emergency room. She was conscious, awake, alert. No disorientation. No seizure-like activity. Denied any trauma to the head and no complaint of chest pain.
Hyphen|Compound pre-modifiers|145|Given her quality of pain and multiple risk factors, there is great concern for acute coronary syndrome. We will start her on IV heparin with low-dose protocol. The patient took aspirin at home. We will treat her heart rate and blood pressure with IV metoprolol 500 mg X3 as tolerated.
Hyphen|Lexical hyphen|457|HEAD, EYES, EARS, NOSE AND THROAT: Normocephalic, atraumatic, EOMI clear, conjunctiva are clear NECK: Supple, no lymphadenopathy, no thyromegaly HEART: S-1 and S-2 regular rate and rhythm LUNGS: Clear to auscultation bilaterally. No wheezes, no rales, no rhonchi BACK: No costovertebral angle tenderness ABDOMEN: Exam is soft, non-tender, non-distended, no organomegaly PELVIC EXAMINATION: Deferred to the OR EXTREMITIES: No cyanosis, clubbing or edema, non-tender. ASSESSMENT: 1. A 25-year-old gravida 1, para 0 with a missed abortion.
Hyphen|Junction|19|FINAL DIAGNOSIS: L4-L5 stenosis. OPERATIONS AND PROCEDURES PERFORMED DURING ADMISSION: L4-L5 decompression. SUMMARY: _%#NAME#%_ _%#NAME#%_ was admitted to the Orthopedic Service under the attending doctor, Dr. _%#NAME#%_ _%#NAME#%_ on _%#MMDD2007#%_ and was discharged home on _%#MMDD2007#%_.
Hyphen|Compound|110|He is also advised to not immerse incisions in fluids for 3 weeks. MEDICATIONS: 1. Protonix suspension 40 mg J-tube daily. 2. Desitin ointment topical J-tube site b.i.d. 3. Metoprolol suspension 50 mg J-tube b.i.d., hold for heart rate less than 65.
Hyphen|Compound|72|White blood cell count is 67.8, hemoglobin 6.9. LFTs are normal. Chest x-ray pending at this time, though by report has been normal at the clinic.
Hyphen|Quotative or expressing a quantity or rate|208|Troponin-I less than 0.04, myoglobin 34. Lipase 135. Hemoglobin 14.6, platelet count 280,000, white blood cell count 8.5 with 73 neutrophiles, 19 lymphocytes, 7 monocytes, 1 eosinophil. INR 0.89, PTT 21. A 12-lead ECG shows first degree AV block, but no ischemic changes.
Hyphen|Quotative or expressing a quantity or rate|59|PATIENT INFORMATION: _%#NAME#%_ _%#NAME#%_ is an _%#1914#%_-year old white female followed by Dr. _%#NAME#%_ _%#NAME#%_. Please see his dictated history and physical for full details of admission.
Hyphen|Lexical hyphen|345|An appointment was made for her on _%#MMDD#%_ at 9:45 a.m., and at this visit, she should discuss her long-term headaches as well as neck problems. 3. The patient should also follow up with Dr. _%#NAME#%_ in his GI Clinic in approximately three weeks, an appointment was subsequently made for her on _%#MMDD#%_ at 2:00 p.m., and at this time, re-evaluation of her ulcers and progress should be done.
Hyphen|Compound pre-modifiers|91|A goal will be just rate- control anticoagulation as according to the Affirm study. 3. MRSA-related bronchitis/pneumonia: The patient will finish a one- week course of vancomycin at Bethesda.
Hyphen|Compound pre-modifiers|237|PROCEDURES DURING THIS HOSPITALIZATION: 1. Coronary angiogram, performed on _%#MMDD2003#%_, revealed a left main 30% ostial lesion and the LAD which was occluded after first and second diagonals. The first diagonal was noted to have high-grade disease in its proximal and mid portion. D2z was moderately diseased, but small. Left circumflex: With mild luminal disease only.
Hyphen|Compound|134|However, it just slowed it down for a few beats and it was very difficult to tell at this point. He is being labeled as sinus. Chest x-ray reveals possible biopsy pleural effusion and some possible mild cardiomegaly and pulmonary edema.
Hyphen|Lexical hyphen|273|11. History of congestive heart failure, stable. 12. Chronic obstructive pulmonary disease, stable. 13. Mild dementia, stable. DISCHARGE DISPOSITION: _%#NAME#%_ _%#NAME#%_ will be discharged to a transitional care unit and/or nursing home for rehabilitation and care follow-up. A chest x-ray has been recommended after completion of his antibiotics with follow-up of his hemoglobin and routine electrolytes in one week.
Hyphen|Lexical hyphen|193|No adjustments were made in the hospital. She is mildly bradycardic but asymptomatic, so will continue her current dose of beta blocker. Discharge creatinine was 1.2 and the patient will follow-up with Dr. _%#NAME#%_ and Dr. _%#NAME#%_ as needed.
Hyphen|Compound|234|Recurrent cervical dysplasia, status post LEEP. 2. Significant left lower quadrant pain, likely related to her left ovary. 3. Symptomatic myomas, menorrhagia. PLAN: Proceed with laparoscopic vaginal hysterectomy and bilateral salpingo-oophorectomy. Risks, benefits and alternatives of the procedure have been discussed with the patient.
Hyphen|To|158|It is recommended the patient follow up with her dentist and recheck to be sure this is not a dental based problem. Also, with her primary care physician in 1-2 weeks.
Hyphen|Lexical hyphen|197|A nearby passerby called 911 and she was transferred to the hospital. PAST MEDICAL HISTORY: 1. Hypothyroidism, well-treated. 2. Peripheral neuropathy with some dysesthesias and burning that is well-controlled with Neurontin. 3. Multiple cancers in the past with a full evaluation during the past three months with all cancers in remission.
Hyphen|Quotative or expressing a quantity or rate|199|There was also a 1.5-cm nodule anterior to the SVC, and 3.3 x 1.5-cm right lower lobe mass that appeared to have arisen from the pleura. An outside MRI _%#MM#%_ _%#DD#%_, 2005, showed a 3.8 x 1.9 x 4-cm right paraspinal lesion at the level of approximately T10, but no bony or spinal cord involvement.
Hyphen|Compound pre-modifiers|278|Her labs were normal, platelet count was normal. The urine was negative for protein, uric acid was 4, blood pressure 120s-80s/90s. The patient remained at bedrest. Since her previous evaluations, the decision was made to proceed with induction of labor due to her mild pregnancy- induced hypertension and her post-date, 40+ weeks.
Hyphen|Compound pre-modifiers|199|He had used alcohol on a daily basis in the past, but has not been drinking since 2001. He is an electrical engineer. PHYSICAL EXAMINATION: GENERAL: Physical exam demonstrates a pale, chronically ill-appearing 59-year-old gentleman lying comfortably in bed. VITAL SIGNS: Temperature 97, pulse 88, respirations 16, blood pressure 129/79.
Hyphen|Compound|80|DISCHARGE DIAGNOSIS: Atypical chest pain. MAJOR PROCEDURES PERFORMED: 1. Chest x-ray dated _%#MM#%_ _%#DD#%_, 2006, shows the heart is enlarged. The right lung and costophrenic angles are clear. There is slight increased opacity in the left base with some cardiomegaly and questionable left pleural atelectasis.
Hyphen|Typographic convention|101|Also Benicar 20 mg p.o. daily and Lipitor 20 mg p.o. per evening. DISCHARGE DIAGNOSES: 1. Cellulitis - partial gangrene of the left second toe. 2. Peripheral vascular disease causing nonhealing wound of the left second toe - this was treated with atherectomy and PTCA of distal vessels of the left leg, see operative report for details.
Hyphen|And(fraction)|207|She has been trying to use additional medications for the treatment of this. I have suggested she treat it with narcotics. PHYSICAL EXAMINATION: VITALS: Shows _%#NAME#%_ to weigh 225 pounds, her height is 64-1/2 inches. Blood pressure 120/60, pulse is regular at about 67 beats/minute.
Hyphen|Compound pre-modifiers|130|An MRI scan apparently showed no significant defects and it was thought that he had a possible transient ischemic attack. His post-operative course was also complicated by atrial flutter and atrial fibrillation which was treated with amiodarone, Lovenox, Coumadin and cardioversion on _%#MM#%_ _%#DD#%_.
Hyphen|To|72|10. Tamsulosin 400 mcg p.o. each day at bedtime. 11. Percocet 5/325 mg 1-2 tablets p.o. q.6h. p.r.n. pain. 12. Multivitamin 1 tablet orally daily. 13. Senna 2 tablets oral daily.
Hyphen|Compound pre-modifiers|140|PROBLEM #3: Chronic low back pain. The patient has a known L2 conversion fracture and did have some low back pain. We did continue on his at-home pain medications and he seemed to do well with these.
Hyphen|Compound pre-modifiers|91|She was treated conservatively with antibiotics. Her condition continued to worsen. A small-bowel follow-through revealed multiple strictures throughout the adhesions, but could have intrinsic inflammation causing stricturing or even a malignancy.
Hyphen|To|85|2. Multivitamin. FOLLOW UP INSTRUCTIONS: 1. Should follow up with Dr. _%#NAME#%_ in 2-3 weeks. 2. Should follow up with me on an as needed basis.
Hyphen|Compound pre-modifiers|99|He was able to have his chest tubes postoperatively, successfully removed on _%#MMDD2007#%_. Follow-up chest x-rays were obtained and patient was without any symptoms at the time of discharge on _%#MMDD2007#%_.
Hyphen|To|115|Zocor 80 mg p.o. daily 13. Coumadin 7.5 mg p.o. tonight with further dosing per covering physician. 14. Oxycodone 5-10 mg p.o. q.3h. p.r.n. 15. Vicodin 1-2 tabs p.o. q. 3 hours p.r.n. 16. Bactrim double strength 1 p.o. b.i.d. for 5 more days
Hyphen|Lexical hyphen|142|An Internal Medicine doctor was consulted to help manage her medical issues that included hypertension and hypokalemia. In terms of orthopedic-wise, she had an uneventful hospital course. The patient continued to make great improvement throughout her hospital course.
Hyphen|Quotative or expressing a quantity or rate|72|3. Abdominal abscess. 4. Blood loss anemia. DISCHARGE DIAGNOSES: 1. A 62-year-old with adenocarcinoma of the cervix. 2. Postoperative day number 33. 3. Abdominal abscess, status post drainage.
Hyphen|Quotative or expressing a quantity or rate|199|PATIENT IDENTIFICATION: _%#NAME#%_ _%#NAME#%_ is seen at the Oxboro Clinic by Dr. _%#NAME#%_ _%#NAME#%_. CHIEF COMPLAINT: Shortness of breath. HISTORY OF PRESENT ILLNESS: The patient is a pleasant 80-year- old female who called 911 this evening due to acute worsening shortness of breath.
Hyphen|Lexical hyphen|170|ASSESSMENT: Pneumonia, left-sided. PLAN: 1. We will put her on the Rocephin and Zithromax pathway. 2. I expect her to be here several days and this is explained to her in- depth and she understands. 3. We will admit her to a regular medical bed.
Hyphen|Quotative or expressing a quantity or rate|164|ADMISSION DIAGNOSIS: Adenocarcinoma of the rectosigmoid. DISCHARGE DIAGNOSIS: Adenocarcinoma of the rectosigmoid. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 79-year-old woman who underwent screening colonoscopy by Dr. _%#NAME#%_ and was found to have 2 sigmoid/rectosigmoid lesions; one a benign polyp, one a cancer.
Hyphen|Quotative or expressing a quantity or rate|92|DISCHARGE DIAGNOSIS: Deep venous thrombosis. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is an 80-year-old male with a past medical history for idiopathic P-E in 1998 and a right superficial clot and previous right lower extremity deep venous thrombosis with chronic congenital right lower extremity deformity with a two week history of increased girth of right lower extremity. He was seen for physical exam by his primary care physician.
Hyphen|Compound pre-modifiers|82|The patient states that she forgoes breakfast on a frequent basis. Often the light-headed episodes are in the morning when she is walking before she has had breakfast.
Hyphen|Quotative or expressing a quantity or rate|88|CHIEF COMPLAINT: Leg redness and warmth. HISTORY OF PRESENT ILLNESS: The patient is a 74-year-old female with a known history of atrial fibrillation on Coumadin, now with a 2- to 3-day history of left lower leg redness, warmth, tenderness, and mild swelling, who was seen in the emergency room. The patient had a D-dimer and Doppler that were negative for blood clots.
Hyphen|Quotative or expressing a quantity or rate|164|PHYSICAL EXAMINATION ON ADMISSION: VITAL SIGNS: Temperature 98.6, pulse 80, respiration 16, blood pressure 114/74, O2 SATs 95% on room air. GENERAL: Patient is a 44-year-old female who is acutely intoxicated and somewhat delusional on admission.
Hyphen|Quotative or expressing a quantity or rate|150|BONE MARROW TRANSPLANT NOTE Briefly, the patient was seen, examined, and I agree with physician's assistant's note. SUBJECTIVE: Ms. _%#NAME#%_ is a 59-year-old female who received a non- myeloablative sibling transplant for non-Hodgkin's lymphoma in _%#MM#%_ of 2005.
Hyphen|Compound|208|She presents with a 2-3 week history of progressively worsening shortness of breath, orthopnea, dry cough, and dizziness with decreased exercise tolerance. She came to the emergency department where a chest x-ray showed pulmonary edema and a possible left lower lobe infiltrate.
Hyphen|Quotative or expressing a quantity or rate|321|In general, the patient was awake, alert, in no acute distress, and appropriate. Complete physical exam is documented on the H and P, pertinent positives were her lung exam where she had decreased breath sounds at the right base with rare inspiratory crackles and clear on the left, her mouth exam which showed multiple 5- to 10-mm erythematous and ulcerated lesions in the mucosa of the lips and also on the buccal mucosa.
Hyphen|Compound|198|MEDICATIONS: The patient's medications should be adjusted as follows: 1. Prednisone taper 30 mg twice a day x2 days, then prednisone 20 mg G-tube x2 days, then 20 mg G-tube x4 days, then 20 mg via G-tube x4 days, then 10 mg via G-tube x4 days, then off if able to wean off.
Hyphen|Lexical hyphen|86|He was found to have bilateral pleural effusions, left greater than right. He was over-anticoagulated with an INR of 5.4. He also noted an erythematous area just to the left of his sternal incision which he states has been there for he thinks the last several days, although there is some discrepancy as to how long it has been there.
Hyphen|Compound|170|She was discharged to home on postoperative day #6 tolerating regular diet. Her pain was adequately controlled. Follow up with Dr. _%#NAME#%_ in four weeks with a chest x-ray, PA and lateral before seen in clinic as well as PFTs, supine and upright before being seen in clinic.
Hyphen|Compound pre-modifiers|196|Status post living-unrelated liver transplant. PROCEDURES: Living unrelated liver transplant on _%#MMDD2007#%_. Briefly, this is a 47-year-old female with a history of autoimmune hepatitis and end-stage liver disease who presents for living unrelated liver transplant.
Hyphen|To|136|EXAMINATION: GENERAL: The patient is extremely pale. She is alert and is able to verbalize discussion. VITAL SIGNS: Blood pressure is 90-100/50s, heart rate is 60-75, the patient is afebrile, O2 sats were 99% on room air.
Hyphen|Quotative or expressing a quantity or rate|112|FINAL REASON FOR ADMISSION: Term pregnancy, active labor. BRIEF ADMISSION HISTORY: _%#NAME#%_ _%#NAME#%_ is a 31-year-old gravida 2 para 1-0-0-1 female, admitted at 37 weeks plus 5 days, EDC _%#MMDD2007#%_, after spontaneous rupture of membranes for clear fluid at 2 a.m. on _%#MMDD2007#%_. The patient is known group B strep positive. She began contracting shortly thereafter and presented to labor and delivery around 4 a.m. She has a history of a prior cesarean section for cephalopelvic disproportion and desired a repeat cesarean section.
Hyphen|To|117|She will follow-up with both Dr. _%#NAME#%_, in the gynecology clinic, and Dr. _%#NAME#%_ in the medicine clinic in 4-6 weeks. All of her questions were answered prior to discharge.
Hyphen|Compound pre-modifiers|223|His diagnostic white count is 11.9, hemoglobin 15.2, platelet count is 281, urinalysis is negative. specific gravity is greater than 1.030, comprehensive metabolic profile: Sodium 138, potassium is 2.9, chloride is 101, non-fasting glucose is 104, BUN is 19, creatinine is 1.0, calcium is 9.0, alkaline phosphatase is 78, AST 16, ALT 37, total bilirubin 0.29, total protein is 7.2, albumin is 4.1, globulin 3.1, TSH 2.11.
Hyphen|Lexical hyphen|286|The patient's history is not considered reliable. Patient himself thinks that he was weak and felt light-headed and fell to the ground. However, the paramedics, upon interviewing the patient's girlfriend, state in their run report that the girlfriend describes episodes that are seizure-like. She states his eyes get a blank stare and then his entire body starts to shake.
Hyphen|Compound pre-modifiers|195|For complete past medical history, family history, and social history, refer to the admission history and physical. HOSPITAL COURSE: This patient is a 72-year-old woman status post a right single-lung transplant in _%#MM#%_ 1997 for COPD. Her course has had numerous complications including pulmonary emboli, acute lung rejection, reperfusion injury, and multiple pneumonias.
Hyphen|Lexical hyphen|108|He is not short of breath on exertion. SOCIAL HISTORY: He is married. He does not drink or smoke. He is semi-retired. He still lives a relatively active lifestyle. He drives a car.
Hyphen|Compound pre-modifiers|176|Because of the risk for hypothyroidism with Down Syndrome, thyroid function tests were obtained at one week of age and were normal. * Hearing: _%#NAME#%_ passed the ABR hearing-screening test. * Immunizations: Hepatitis B vaccine was given on _%#MMDD2005#%_. Ongoing problems and suggested management: * FEN: _%#NAME#%_ was discharged on breast milk on an ad lib on demand schedule.
Hyphen|Compound pre-modifiers|129|It is possible that has already been done but will discuss this with Minnesota Heart. She just recently had angioplasty with drug-eluting stent placement and it is very unlikely that drug-eluting stent would restenose at this point but this would be a time period for restenosis.
Hyphen|Compound pre-modifiers|198|4. History of rheumatoid arthritis with no recent increase in his arthritis pain. PLAN: Mr. _%#NAME#%_ will be admitted to Oncology Unit. We will be starting him on fluids and chemotherapy with high-dose methotrexate based on his CNS involvement. I will also add Rituxan at some point and I offered him a Port-A-Cath, which may facilitate intravenous administration and blood draws based on his expected frequent treatments.
Hyphen|Quotative or expressing a quantity or rate|223|_%#NAME#%_, within one week for her migraine headaches. The patient was strictly advised to stop smoking and use nicotine patch or gum to help stop smoking. The patient is to avoid caffeine and try to decrease Soma and over-the-counter analgesics. The patient is to also have follow-up with MAPS Clinic as an outpatient.
Hyphen|Quotative or expressing a quantity or rate|104|However, she did have a little bit of an air fluid level in her sinus. ASSESSMENT AND PLAN: This is a 66-year-old woman with syncope. I suspect it was some orthostatic hypotension secondary to dehydration and illness.
Hyphen|Quotative or expressing a quantity or rate|246|3. CT scan of the abdomen which showed no hematoma, unchanged hepatic hypodensities, stable pancreatic head with new duodenal stent and pneumobilia in the liver. CONSULTATIONS: Interventional radiology, Dr. _%#NAME#%_. BRIEF SUMMARY: This is a 58-year-old male with renal cell carcinoma with metastasis to the liver, head of pancreas, brain and adrenal glands who is status post unilateral left nephrectomy and bilateral adrenalectomies.
Hyphen|Quotative or expressing a quantity or rate|99|CHIEF COMPLAINT: Shortness of breath. HISTORY OF THE PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 54- year-old Caucasian male with a history of diabetes mellitus and coronary artery disease who woke up at 2 a.m. today with abrupt onset of shortness of breath. He is visiting friends here in _%#CITY#%_ and lives in _%#CITY#%_, Wisconsin.
Hyphen|Compound|141|Hemoglobin 14.6, white blood count 11,900. EKG shows a left bundle branch block with minor biphasic T-waves in the lateral leads. His chest x-ray shows cardiomegaly. ASSESSMENT: 1. Chest pain, most likely related to his gastroesophageal reflux disease and dietary indiscretion.
Hyphen|Compound|176|3. Diabetes mellitus. Check A1C. Blood glucose monitoring q.i.d. with sliding scale coverage. Continue Actos and add low dose Glucotrol. 4. Hypertestosteronism. Outpatient Depo-Testosterone. 5. Health care maintenance. The patient does not believe he has had a PSA done in recent years.
Hyphen|Quotative or expressing a quantity or rate|92|8. Anemia microcytic with hemoglobin E trait. ALLERGIES: NONE KNOWN. SOCIAL HISTORY: This 62-year-old patient speaks Vietnamese only and lives with her daughter in _%#CITY#%_ _%#CITY#%_.
Hyphen|Compound|124|Dulcolax 10 mg per rectum p.r.n. constipation. 13. Colchicine 0.6 mg p.o. daily. 14. Neurontin 300 mg p.o. daily. 15. Detrol-LA 4 mg p.o. daily. 16. Oxycodone 5-10 mg p.o. q. 4h. p.r.n. 17. Miconazole topical cream to be applied to effected area p.r.n. FAMILY HISTORY: Positive for stroke and diabetes.
Hyphen|Quotative or expressing a quantity or rate|154|HOSPITAL PROCEDURES: 1. _%#MMDD2007#%_ _%#NAME#%_ _%#NAME#%_ underwent left heart catheterization performed by Dr. _%#NAME#%_ _%#NAME#%_ with finding of 3-vessel disease. There was a stenting of the saphenous vein graft to the LAD improving 90% stenosis to 0% stenosis.
Hyphen|Quotative or expressing a quantity or rate|74|FINAL CHIEF COMPLAINT: Shortness of breath. HISTORY OF PRESENT ILLNESS: 49-year-old morbidly obese African-American female with history of obstructive sleep apnea, hypertension, asthma, and narcotic-seeking behavior. She is a frequent flyer and this is her fifth admission over the last 2 months.
Hyphen|Compound pre-modifiers|123|He will be given a nebulizer machine and DuoNeb to use at home. Probably the patient has ongoing hypoxia and will need long-term oxygen. Patient continues to smoke one pack per day. At this point he does not appear to be in the contemplative stage for quitting.
Hyphen|Phone number|79|It has been a pleasure taking care of this patient. Please page me at _%#TEL#%_-_%#TEL#%_ with any further questions.
Hyphen|Compound pre-modifiers|297|She is a full code. We did discuss this with her granddaughter, and she would like her to remain a full code at this time as she says that is what the patient desires. The patient is discharged to _%#CITY#%_ Care Center. I think likely given the overall picture the patient will probably need long-term care. This is a complex discharge, requiring 45 minutes time.
Hyphen|Quotative or expressing a quantity or rate|89|CURRENT MEDICATIONS: None. PHYSICAL EXAMINATION: VITAL SIGNS: Weight 155 pounds. Height 5-feet-6-inches. Blood pressure 108/68. Pulse 80. HEENT: Clear with no thyromegaly. CHEST: Clear to auscultation and percussion.
Hyphen|Compound|144|Also, need to work up the weakness with carotid ultrasound, echocardiogram and possibly CT scan pending further evaluation. We will also get a D-Dimer to rule out pulmonary embolism.
Hyphen|Quotative or expressing a quantity or rate|151|EXTREMITIES: Showed 1+ edema. NEUROLOGIC: Cranial nerves II through XII are grossly intact. LABORATORY DATA: Pending. ASSESSMENT AND PLAN: This is a 59-year-old woman status post complex abdominal surgery for colovesical fistula and colovaginal cysto with phlegmon.
Hyphen|Compound pre-modifiers|122|PAST MEDICAL HISTORY: 1. End-stage renal disease secondary to lupus nephropathy. 2. Lupus. PAST TRANSPLANT HISTORY: Living-related kidney transplant in _%#MM2004#%_. REVIEW OF SYSTEMS: See history of present illness. PHYSICAL EXAMINATION: VITAL SIGNS: The patient is afebrile and hemodynamically stable.
Hyphen|Quotative or expressing a quantity or rate|212|FINAL PRESENTING COMPLAINT: Admission for wound infection. HISTORY OF PRESENT ILLNESS: Please see my detailed history and physical from _%#MMDD2007#%_, clinic note, for details. In summary, Mr. _%#NAME#%_ is a 49-year-old gentleman well known to my service. He underwent a reexcision of a recurrent verrucous carcinoma of his perineal area on _%#MMDD2007#%_.
Hyphen|Quotative or expressing a quantity or rate|141|On the day of discharge PFT revealed an FEV1 of 4 (85%) and FVC of 4.78 (84%). He will remain on oral ciprofloxacin and dicloxacillin for a 3-week course to try to bring his PFTs to baseline period.
Hyphen|Quotative or expressing a quantity or rate|132|FINAL IDENTIFICATION: _%#NAME#%_ _%#NAME#%_ is a 76-year-old patient of Dr. _%#NAME#%_. HISTORY OF PRESENT ILLNESS: The patient a 76-year-old woman. She has a history of COPD. She was a smoker until five years ago and then quit.
Hyphen|To|342|She is sent home simply on full liquids. PROBLEM #4: Diabetes: The patient does not have a history of diabetes but while she was on the TPN she did require subcutaneous Lantus, and this was discontinued after the TPN was stopped and the patient was tolerating a full liquid diet. It is thought, however, that at the time of her discharge in 2-3 days when she gets her INR checked she should also have fingerstick blood glucose to make sure that her glucoses are still in control.
Hyphen|Compound|112|Basic metabolic panel and CBC are both normal. EKG shows normal sinus rhythm with heart rate of 67. There is a Q-wave in III and a Q-wave in AVF. I do not have an old EKG to compare to at this time.
Hyphen|Compound pre-modifiers|71|Her pulse is 93. The respiratory rate is 16. She is afebrile. A healthy- appearing white female lying comfortably in bed at this time.
Hyphen|Quotative or expressing a quantity or rate|190|Echocardiogram shows a left ventricular ejection fraction of 60%, normal chamber size, normal left ventricular function, trace MR, trace pericardial effusion. IMPRESSION: The patient is a 30-year-old female presenting with right-sided chest pain with shortness of breath for about 1 month with abnormal CT scan of the chest, small pericardial effusions, trace pericardial effusion, and abnormal EKG.
Hyphen|Compound|366|ADMITTING DIAGNOSIS: Left upper extremity deep venous thrombosis. DISCHARGE DIAGNOSIS: Left upper extremity deep venous thrombosis status post thrombolysis and angioplasty of left upper extremity veins. HISTORY OF PRESENT ILLNESS: The patient is a 65-year-old male with a history of multiple myeloma diagnosed in _%#MM#%_ of 2002 with subsequent left subclavian Port-A-Cath placement in _%#MM#%_ of 2002 for chemotherapy. During the time the patient had the subclavian port there were times that the port was difficult to use, and this was finally evaluated demonstrating the tip of the port was in a poor location against the vena cava wall.
Hyphen|To|102|DISCHARGE MEDICATIONS: 1. Keflex 500 mg, 1 p.o. q.6h x 7 days, for a total of 28 tablets. 2. Vicodin 1-2 tablets p.o. q.4-6h p.r.n. break through pain. 3. OxyContin 40 mg, 1 p.o. b.i.d. 4. Colace 100 mg, 1 p.o. b.i.d. 5. Boost 1 can p.o. t.i.d., 1 case.
Hyphen|To|172|She has been having an acute episode of vomiting, diarrhea and nausea that actually came after lower abdominal pain the night before her admission. She went to the toilet 5-6 times, having watery diarrhea, and she vomited the same amount of times.
Hyphen|Quotative or expressing a quantity or rate|32|DOB: _%#MMDD1977#%_ This is a 25-year-old Gravida IV, Para 3-0-0-3 with last menstrual period _%#MMDD2002#%_ and EDC _%#MMDD2002#%_ was induced today for post dates. There was artificial rupture of membranes at 1935 hours. She progressed to complete with Pitocin augmentation at 2140 hours.
Hyphen|Compound pre-modifiers|165|3. The patient is to follow up with primary-care physician for inspection of incision in one week for signs of infection. 4. The patient is to follow up with primary-care physician for check of LFTs in four to six weeks after having been started on Lipitor.
Hyphen|To|194|She was brought to the ED by paramedics. She was found to have markedly elevated blood glucose of over 600. Incidentally, Mrs. _%#NAME#%_ had not been taking her usual Lantus and insulin doses 1-2 days prior to the fall because she had not been feeling well.
Hyphen|To|109|Mother and infant did well in the post-operative recovery time. Blood pressures improved and were mostly 120s-130s/70s-80s post-operatively. She was discharged home on post-operative day four. She was given precautions regarding her increased risk of wound infection, given her morbid obesity.
Hyphen|Compound pre-modifiers|70|FINAL DISCHARGE DIAGNOSES: 1. Sinus node dysfunction, status post dual-chamber permanent pacemaker. 2. Dizziness. 3. Hypoxemia. 4. Elevated erythrocyte sedimentation rate and C-reactive protein.
Hyphen|Compound pre-modifiers|124|PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98, pulse 80, respirations 20, blood pressure 130/80. GENERAL: This is a well-developed, well-nourished 37-year-old male in no apparent distress.
Hyphen|To|230|At home, over the past several days she has continued become weaker to the point where she has been unable to transfer from her scooter to her bed. Normally she is able to do this. She also has had some constipation for the past 3-4 days. She did have a small bowel movement yesterday, but prior to this the last bowel movement was about 4 days.
Hyphen|Compound pre-modifiers|171|HOSPITAL COURSE: The patient underwent the above procedure without complication. Postoperatively, she was having a little bit of trouble with oxygen saturation in the post-anesthesia care unit. The patient was admitted for observation. Overnight, she had an uneventful postoperative course.
Hyphen|Compound pre-modifiers|117|1. INR check in 1-2 days' time with dosage adjustment of warfarin as needed. 2. EP Clinic visit in 1 month. 3. Follow-up appointment with Dr. _%#NAME#%_ _%#NAME#%_, the primary care physician, in 2-3 weeks. As stated above, please see Dr. _%#NAME#%_'s Interim Summary for further details regarding this patient's hospitalization.
Hyphen|Compound pre-modifiers|195|PHYSICAL EXAMINATION: VITAL SIGNS: The patient's blood pressure is 132/75, her pulse is 132, respiratory rate 24, temperature is 102.9, O2 sat is 98% on 3 liters. The patient is a chronically ill-appearing female who has a barrel chest, who is tan and resting comfortably, coughing frequently with a wet moist cough.
Hyphen|Compound pre-modifiers|177|EXTREMITIES: Trace edema. LABORATORY DATA: Chest x-ray is normal. EKG is normal; a copy was given to the patient. IMPRESSION: 1. Morbid obesity. 2. Stiffman syndrome. 3. Insulin-dependent diabetes mellitus. 4. Hypothyroidism. 5. Depression. The patient is okay for the contemplated procedure.
Hyphen|Compound|287|The biopsy was consistent with minimal change glomerulonephropathy or focal segmental glomerulosclerosis. Also had some element of acute tubular necrosis, questioned if that was secondary to some recent IV contrast on top of the other and at that point corticosteroid treatment with Solu-Medrol was started and the patient was switched to a renal diet.
Hyphen|To|120|NEUROLOGIC: He is slow to respond and understand who I am but then he is cooperative and appropriate. Cranial nerves III-VII and IX-XII are intact with diminished eyesight and diminished hearing.
Hyphen|Compound pre-modifiers|138|His FEF 25/75 is 2.57, 67% of predicted. His PEF is 3.75, 43% of predicted. ASSESSMENT: 1. Metatarsal fracture x4. 2. Asthma. 3. Attention-deficit/hyperactivity disorder. PLAN: I see no contraindication of proposed surgical procedure. The patient is an ASA 2.
Hyphen|Compound pre-modifiers|185|She does not have any evidence for any ongoing contractions at this time. She is 34 weeks. We would recommend that OB, Pulmonary and the Medicine services come up with a plan for a high-risk pregnancy and delivery, given her multiple medical issues.
Hyphen|To|127|Senokot 3 tablets p.o. daily p.r.n. 5. Tylenol 650 mg p.o. q.6 hours p.r.n. 6. OxyContin 10 mg p.o. b.i.d. p.r.n. 7. Percocet 1-2 tablets p.o. q.4 hours p.r.n. DISCHARGE INSTRUCTIONS: The patient was to eat a low-residue diet consistent with a new colostomy.
Hyphen|Typographic convention|133|Height 70 inches. Weight 195 lb. Blood pressure 144/70. Temperature 97 degrees. Pulse 60 and irregular. Respirations 24. HEENT: EYES - pupils equal and reactive to light. Extraocular muscles intact. Conjunctivae normal. EARS - tympanic membranes negative.
Hyphen|Compound|104|3. Left adnexal torsion within this pelvic mass on the left. 4. Exploratory laparotomy. 5. Left salpingo-oophorectomy. 6. Evacuation of large hemoperitoneum. SURGICAL FINDINGS: The peritoneum was entered.
Hyphen|Quotative or expressing a quantity or rate|127|PROCEDURES: 1. Primary, low-segment, transverse, cesarean section. 2. Cervical ripening and induction. HPI: The patient is a 30-year-old G7, P0-0-6-0 at 40-6/7 weeks by an estimated due date of _%#MM#%_ _%#DD#%_, 2002.
Hyphen|Compound pre-modifiers|163|5. She has no history of diabetes. BRIEF HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 77-year- old female with a past medical history of hypertension and single-vessel coronary artery disease who presents with two weeks of intermittent left- sided chest pain.
Hyphen|Lexical hyphen|327|Other medical issues have been pretty stable. At the time of discharge she is going to Ebenezer Ridges where she is going to have physical therapy and occupational therapy and continue with her dialysis. She has a Vancomycin dose scheduled for _%#MMDD2003#%_, _%#MMDD2003#%_, and _%#MMDD2003#%_, and I am asking that she follow-up with Dr. _%#NAME#%_ in a couple of weeks as well as Dr. _%#NAME#%_ in a couple of weeks and Dr. _%#NAME#%_ on dialysis per his scheduling.
Hyphen|Compound pre-modifiers|240|Pupils are unequal in diameter. The right pupil is pin point, the left with irregular pupils secondary to post-cataract surgery, but both pupils are reactive. Extraocular muscles are intact. Neck: Supple. There is no thyromegaly, no jugular-venous distention, no bruit. Lungs show decreased breath sounds in both bases, also a few crackles on the left base.
Hyphen|Quotative or expressing a quantity or rate|101|HISTORY OF PRESENT ILLNESS: This is a 65-year-old female patient of Dr. _%#NAME#%_'s, who has a three-year history of dilated cardiomyopathy with progressive heart failure that was initially diagnosed in 2000.
Hyphen|To|110|Lantus insulin 18 units at bedtime. 13. NPH Novolin insulin 5 units every morning. 14. Sliding scale insulin 0-10 units before meals, self-directed by patient. She is extremely labile with blood sugars, will fluctuate from 400 to less than 100 on short notice.
Hyphen|Lexical hyphen|158|Temperature is 97.7, heart rate of 108, blood pressure of 110/74, his respiratory rate is 28 and he is satting 100% on room air. GENERAL: _%#NAME#%_ is a well-developed, well-nourished Caucasian male who is crying at the time of exam but is consolable.
Hyphen|To|87|She does need a CBC done in 1 week. She does need to follow up with Dr. _%#NAME#%_ in 1-2 weeks and with Dr. _%#NAME#%_ _%#NAME#%_ in 2 weeks. If the patient's INR drops below 2.0, the patient does need to be restarted on Lovenox.
Hyphen|To|316|CHIEF COMPLAINT: Right flank pain. HISTORY OF PRESENT ILLNESS: This is a 25-year-old white male who was otherwise healthy who presented to the emergency room with complaint of right flank pain. The patient's right flank pain started at 7:00 p.m. on _%#MMDD2007#%_, described as severe pain, worse pain he ever had, 8-10 intensity and sometimes 10/10 intensity. Describes it as a colicky pain on and off. Severe pain lasted about 2 minutes, but recurs frequently.
Hyphen|Lexical hyphen|234|Cranial nerves II-XII grossly intact. Affect is normal. ASSESSMENT: 1. _%#NAME#%_ _%#NAME#%_ is a delightful, 74-year-old male, with a recent abnormal stress echocardiogram showing inferior wall myocardial infarction and possible peri-infarction ischemia. Coronary angiography is going to be performed on _%#MMDD#%_ at 1:00 or 1:30 p.m. All risks and benefits for coronary angiography, angioplasty, stenting and bypass surgery have been defined, including the risk of death, heart attack, stroke or blood clots, bleeding, infection, arrhythmia and allergy to the dye.
Hyphen|Compound|123|CT scan confirmed this showing a small bowel obstruction in the ileum with an enhancing mass at the transition point. An NG-tube was placed, which helped with her symptomatology.
Hyphen|Quotative or expressing a quantity or rate|193|FINAL CHIEF COMPLAINT: Nausea and vomiting. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 20-year-old male with past history of diffuse abdominal pain. The patient said he has had a 20-pound weight loss over the last six months. He was last seen in the ER on _%#MMDD2007#%_ and diagnosed with GERD or peptic ulcer disease.
Hyphen|Lexical hyphen|141|Since admission, he has been feeling fine. He has no further nausea and vomiting. He feels stronger and he is afebrile. His symptoms were non-specific. His urinalysis was normal. The patient denied headache, cough, shortness of breath, chest pain, urinary symptoms.
Hyphen|To|152|LABORATORY: Hemoglobin 13.3. White count 9,800 with 68% PMN's. Platelets 189,000. Sodium 133. Potassium 4.4. Creatinine 0.5. BUN 21. Urinalysis showed 2-5 white cells and positive leukocyte esterase. EKG: Old septal infarct with no acute changes. CHEST X-RAY: Within normal limits.
Hyphen|Quotative or expressing a quantity or rate|192|He denies any shortness of breath, chest pain, abdominal pain, pain with urination, burning with urination. He does report a little bit of constipation. OBJECTIVE: GENERAL: The patient is a 65-year-old male, well-developed, well- nourished, in no apparent distress.
Hyphen|Compound|184|HEENT: Nothing new acute noted. CHEST: Clear to auscultation. HEART: No murmurs are noted. ABDOMEN: Soft; non-tender. EXTREMITEIS: No peripheral edema. LABS: Potassium was 3.8. Chest x-ray shows patchy infiltrate in the middle lower lungs consistent with pneumonia, improvement noted, some scarring noted.
Hyphen|Typographic convention|155|CHEST - clear to auscultation with good effort. HEART - regular rate and rhythm without murmur. There is no jugular venous distention, normal PMI. ABDOMEN - bowel sounds present, nontender, nondistended. EXTREMITIES - bilateral calcaneal pain, left greater than right. NEUROLOGIC - nonfocal.
Hyphen|Junction|148|Status post appendectomy 9. Status post tonsillectomy 10. Status post hemorrhoidectomy (Dr. _%#NAME#%_) 11. Status post vasectomy 12. Status post C5-6 and C6-7 diskectomy and fusion (2000, Dr. _%#NAME#%_ at Abbott-Northwestern Hospital) 13. Status post C4-5 diskectomy (_%#MM#%_ 2003, Dr. _%#MM#%_, Abbott- Northwestern Hospital)
Hyphen|Lexical hyphen|74|She is married. He has one grandchild, five years old, through her. His ex-wife lives in _%#CITY#%_. The daughter is thinking he is going to need to go to a nursing home from here.
Hyphen|Compound|178|He was monitored in the Intensive Care Unit and was given Natrecor and slowly improved. His wedge pressures initially were quite high, in the 35 to 40 range, although his chest x-ray showed no evidence of edema; and clinically he was not significantly fluid overloaded.
Hyphen|Quotative or expressing a quantity or rate|225|Troponin less than 0.07, less than 0.07. ECG: Normal sinus rhythm at 84 with left ventricular hypertrophy, without acute changes. ASSESSMENT: The patient is a complicated 71-year-old woman with a history of severe COPD, three-vessel coronary disease, diabetes mellitus, and poorly controlled hypertension who presents with complaints of recurrent chest pain and shortness of breath.
Hyphen|To|77|Gatifloxacin 400 mg p.o. q.d.; stop on _%#MM#%_ _%#DD#%_, 2003. 2. Percocet 1-2 tablets p.o. q.4-6h. p.r.n. pain. 3. Azmacort 3 puffs t.i.d. 4. Cyclobenzaprine 10 mg p.o. t.i.d. 5. Cytotec 200 mg p.o. q.i.d.
Hyphen|Compound|272|MUSCULOSKELETAL: No obvious joint effusions or erythema. PSYCH: Affect is blunted. LYMPH: No palpable lymphadenopathy. LABORATORY DATA: Electrocardiogram from the clinic reveals normal sinus rhythm and normal axis, rate of about 80 beats per minute, and no obvious ST or T-wave anomalies save for leads III and AVF which are nearly isoelectric.
Hyphen|Typographic convention|71|Cardiac - Negative. GI - Vomiting this morning, otherwise negative. GU - Negative. Musculoskeletal - She does have some arthritis.
Hyphen|To|210|She called her daughter back and had her come pick her up and bring her over to Riverside even though she usually goes to United Hospital because she had gastric bypass surgery here on _%#MMDD#%_. She has had 3-4 episodes of dark liquid stools/blood. She had another episode this morning at about 3 in the morning and got very dizzy with that.
Hyphen|Compound|151|Apparently, he still lives in a senior apartment. The patient past history is negative for allergies. MEDICATIONS: 1. Lisinopril 10 mg daily. 2. Toprol-XL 50 mg b.i.d. 3. Lasix 20 mg daily. 4. Pravastatin 20 mg at bedtime.
Hyphen|Compound pre-modifiers|219|The results of the EGD are still pending and ultimately she will have a colonoscopy under the direction of Dr. _%#NAME#%_. 3. Addison's disease. She did not have any hemodynamic problems here and was continued on her at-home hydrocortisone dose. 4. Hypokalemia. Her potassium was quite low when she arrived and thus she was given potassium.
Hyphen|Quotative or expressing a quantity or rate|211|DISCHARGE DIAGNOSIS: Borderline acute rejection. PROCEDURES AND TREATMENTS: Solu-Medrol 500 mg IV x3 doses. CONSULTS: Transplant nephrology. HISTORY OF PRESENT ILLNESS: The patient, _%#NAME#%_ _%#NAME#%_ is a 19-year-old male status post living donor kidney transplant in either 1997 or 1998 from his father for congenital kidney problem.
Hyphen|Compound pre-modifiers|125|The patient denied any chest pain, shortness of breath, nausea, vomiting or dizziness. She was, however, complaining of right-sided ear pain. For the details of the presenting illness, please see the note titled admission H and P in the patient's chart.
Hyphen|Compound pre-modifiers|216|FINAL PLANNED DISCHARGE DATE: _%#MMDD2007#%_ DISCHARGE DIAGNOSES: 1. Urinary tract infection with sepsis syndrome secondary to enterococcus faecium. 2. Probable pyelonephritis versus prostatitis related to #1. 3. End-stage renal disease, long-standing. 4. Diabetes mellitus. DISCHARGE MEDICATIONS: 1. Lipitor 10 mg p.o. each day at bedtime.
Hyphen|Quotative or expressing a quantity or rate|86|She denies any alcohol and tobacco use and any other drug use. REVIEW OF SYSTEMS: A 10-point review of systems was obtained while she was on the ward, which is essentially negative except that she was having some kind of chills.
Hyphen|Compound pre-modifiers|129|FINAL ADMISSION DIAGNOSIS: Living kidney donor. DISCHARGE DIAGNOSIS: Living kidney donor. PROCEDURES DURING HOSPITALIZATION: Hand-assisted laparoscopic left donor nephrectomy. HISTORY: _%#NAME#%_ _%#NAME#%_ is a 50-year-old otherwise healthy male who volunteered for kidney donation.
Hyphen|To|94|There is no evidence of hematomas. PLAN: The patient should follow up with Dr. _%#NAME#%_ in 1-2 weeks or when drain output is less than 30 cc per 24 hours.
Hyphen|To|163|2) Hypertension under good control. 3) Depression being treated. 4) Degenerative joint disease, moderately severe. PLAN: She will continue to be transfused up to 8-9 gm of hemoglobin. We will obtain a CT scan of her abdomen as part of her work-up for the anemia.
Hyphen|Compound|334|LABORATORY DATA: TSH 0.41. White count 7.2, hemoglobin 12.5, platelets 352,000, sodium 141, potassium 4.8, chloride 104, bicarbonate 28, BUN 13, creatinine 0.74, glucose 94, D-dimer less than 0.2, myoglobin 16, troponin less than 0.07. Chest x-ray negative for infiltrate. EKG: The patient is currently in sinus rhythm with no ST or T-wave changes. Initial EKG showed atrial fibrillation with RVR with a rate in the one tens.
Hyphen|Compound|229|HOSPITAL COURSE: (Please see admission H&P for details). Mr. _%#NAME#%_ _%#NAME#%_ is a 79-year-old male who is admitted for shortness of breath and productive cough. He did have low grade temperatures upon admission. His chest x-ray revealed a right lower lung field infiltrate and white cell count of 1900 with 93% neutrophils.
Hyphen|Compound pre-modifiers|218|She also had a culture that came back positive from an intraoperative disc sample that was sent in because the patient had had symptoms of low-grade insolent discitis preoperatively. This came back as positive for gram-positive cocci and two strains of staph. She was started on vancomycin. One strain came back as being pansensitive, while the other came back as resistant to oxacillin.
Hyphen|Lexical hyphen|80|Hopefully, she will not need any more therapy after that. She is going to follow-up with me in six days to recheck her electrolytes.
Hyphen|Quotative or expressing a quantity or rate|194|She will also take Tricor 160 mg at supper and atenolol 25 mg b.i.d. We will add Sorbitol 1 tbsp after breakfast. She can use the Colace as needed. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 73-year-old female who presented to the Fairview Southdale Hospital emergency room with symptoms of pain that actually had started in the back and somewhat in the low back.
Hyphen|Lexical hyphen|161|In 1992, he had an inferolateral myocardial infarction, followed by angioplasty of the circumflex artery. In _%#MM#%_ of this year, he presented again with a non-Q-wave myocardial infarction and angioplasty was performed to a complex 75% proximal circumflex lesion which also involved the ostium of the first OM.
Hyphen|Compound pre-modifiers|209|PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 181/127, heart rate 74 and regular, respirations 16 and unlabored, temperature 97.8, O2 saturation 95% with room air. GENERAL APPEARANCE: The patient is a well-developed, well- nourished, older, white male, in no acute distress.
Hyphen|Compound|167|LUNGS: The patient's lungs, she has rales in the left base with bronchial breath sounds. CARDIOVASCULAR: Examination reveals a regular rate and rhythm, with a normal S-1 and S-2. There is no S-3, S-4 or murmur, rub, or click.
Hyphen|To|153|She wears glasses. Regarding her right shoulder she has a 12 cm healed incision anteriorly. She has forward flexion at 140 degrees. She appears to have 4-5 strength and external rotation. She has some impingement signs. Regarding the left shoulder she has tenderness and swelling.
Hyphen|Lexical hyphen|199|After five hours, she decided to come into the emergency room where an EKG done with ongoing mild chest discomfort showed only mild ST segment elevation in the inferior leads. This was felt to be non-diagnostic and she was treated with medications to try to reduce her angina.
Hyphen|To|165|The patient was in to clinic for a regularly scheduled, 1- year postoperative visit and was having severe abdominal pain. He states that this has been going on for 7-8 weeks, and the pain is crampy and sharp in nature.
Hyphen|To|226|He did eventually have upper endoscopy that was benign. He was initiated in physical therapy but this went extremely slow and he was quite weak, needed assistance just to stand and transfer. His sodium also remained in the 127-129 range throughout his hospital stay. His white count did come down nicely, on discharge it was 15,000 down from his admission 33,000.
Hyphen|Lexical hyphen|226|I would not consider her a Coumadin failure at this point, as her INR had been subtherapeutic recently. We will increase her Coumadin dose. We will also initiate the start of a hypercoagulable workup and likely have her follow-up with Hematology as an outpatient. This patient is currently feeling well and on room air.
Hyphen|Compound pre-modifiers|263|He actually has been returning to work and golfing on a daily basis over the past few weeks. We received a phone call from _%#NAME#%_ and his daughter at the Fairview Southdale Clinic today and _%#NAME#%_ had complaints of left facial droop with drooling and left-sided arm weakness. He was brought in for evaluation to the Neurosurgical Clinic today.
Hyphen|Compound|95|He was then transferred back to _%#CITY#%_ Care Center on _%#MM#%_ _%#DD#%_, 2002. A portable x-ray was scheduled to obtain x-rays 1 month postoperatively and sent to our office for review.
Hyphen|Quotative or expressing a quantity or rate|89|CHIEF COMPLAINT: Abdominal pain HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 50-year-old married white female with a history 10 years ago of Crohn's disease requiring a resection of small bowel. The patient has not been on any medications until her recent problems began.
Hyphen|Compound|174|6. Omeprazole 5 mg every day per G-tube. 7. Reglan 0.5 mg per G-tube three times a day. 8. Poly-Vi-Sol 1 cc per G-tube every day. 9. Vitamin D 0.5 cc equals 4,000 units per G-tube every day. 10. Vitamin E 2 cc (100 mg) per G-tube every day.
Hyphen|To|282|DISCHARGE MEDICATIONS: All the patient's preadmission medications, and in addition we are giving her Colace 100 mg p.o. b.i.d. p.r.n. and Percocet 1-2 p.o. q.4-6 p.r.n. DISCHARGE INSTRUCTIONS: 1. Follow up with Dr. _%#NAME#%_ in 2-3 weeks. 2. Follow up with primary care doctor in 2-3 weeks or as needed. 3. No heavy lifting for six weeks. 4. Resume a regular diet.
Hyphen|Compound|183|She needs to take for pain control Tylenol, and for constipation Colace. Her primary doctor, Dr. (_____________) in (_______________) Clinic was notified the patient needs to get an x-ray after 2 weeks of treatment. Her last x- ray, _%#MM#%_ _%#DD#%_, 2002, showed dense infiltration and atelectasis in the left lower lobe with left-side effusion, and small right side effusion.
Hyphen|Quotative or expressing a quantity or rate|93|His last use prior to admission was at 8 p.m. the night before admission. He had a previous 9-month period of sobriety on 3 different occasions. PHYSICAL EXAMINATION: On admission, his physical examination was essentially normal.
Hyphen|Typographic convention|118|REVIEW OF SYSTEMS: Eyes, ears, mouth, nose and throat - wears glasses. Respiratory review is negative. Cardiovascular - positive for frequent palpitations. History of MVP. Gastrointestinal - negative except for difficulty with defecation and in fact has been seen by Dr. _%#NAME#%_ _%#NAME#%_ and has had biofeed back in regards to this problem.
Hyphen|Typographic convention|125|HEENT: Normal. LUNGS: Clear. HEART: Normal sinus rhythm, S1, S2. BREASTS: No masses. ABDOMEN: Normal. PELVIC: Uterus and BUS - normal. Vagina - no lesions. Cervix - normal. Uterus - enlarged, irregular.
Hyphen|Compound pre-modifiers|126|Weight is 120 pounds. Blood pressure is 110/58 in left arm seated. Pulse is 64 beats/minute and regular. The patient is a well-developed, thin female who appears her stated age, is in no acute distress, is alert and cooperative throughout the examination.
Hyphen|And(fraction)|198|Discussed the options of medication. The patient feels that while Phenergan had faster onset than Zofran, she had some CNS effects which were not positive. ASSESSMENT: 1. Intrauterine pregnancy at 6-1/2 weeks. 2. Hyperemesis gravidarum. 3. Gastritis, probably secondary to recurrent vomiting.
Hyphen|Lexical hyphen|58|2. Physical therapy to see her as an outpatient. 3. Follow-up with Dr. _%#NAME#%_ on _%#MMDD2004#%_ for admission and chemotherapy.
Hyphen|Quotative or expressing a quantity or rate|136|2. Restless leg syndrome. 3. Hypertension. 4. Positive FANA of unclear significance. HOSPITAL COURSE: 1. Stroke. Mrs. _%#NAME#%_ is a 63-year-old female with a long history of hypertension who was admitted with left facial and upper extremity weakness.
Hyphen|Quotative or expressing a quantity or rate|170|DISCHARGE DIAGNOSES: 1. Unstable angina. 2. Atrial fibrillation. STUDIES DONE: Echocardiogram and cardiac catheterization. BRIEF HISTORY AND HOSPITAL COURSE: This is a 79-year-old male status post coronary artery bypass graft surgery in 1981 and 1994, status post stent placement in _%#MM#%_ of 2002, who presents with a 2- day history of chest pain.
Hyphen|Compound pre-modifiers|244|There were no associated visual, facial or speech difficulties. The patient was refractory to the medical therapy and was considered high risk for surgery based on the prior history of cardiovascular disease. Noninvasive study demonstrated high-grade, 70% to 85% stenosis of the right internal carotid artery.
Hyphen|Compound pre-modifiers|221|She declined a trial of labor after cesarean section. Also requested a tubal ligation for permanent sterilization. Her examination at the time of admission was normal. On _%#MMDD2002#%_, the patient underwent a repeat low-segment transverse cesarean section and bilateral Pomeroy postpartum tubal ligation.
Hyphen|Lexical hyphen|184|Discharge diet: TPN plus regular diet as tolerated. 3. Discharge activities as tolerated. 4. _%#NAME#%_'s family was asked to please call the Pediatric Bone Marrow Transplant fellow on-call for any temperatures greater than 100.5, or any other questions or concerns.
Hyphen|Typographic convention|97|CHEST is clear. HEART is regular to auscultation; there is no rub or murmur. ABDOMEN is soft. GU - he is in a diaper, genitalia not examined; he has a Foley catheter indwelling.
Hyphen|Compound|95|Prednisone-dependent. Not on home O2. Was seen by Dr. _%#NAME#%_ in the emergency room. Chest x-ray was noted to be negative. Peak flows went from 130 to 170. EKG was noted to be negative.
Hyphen|Compound pre-modifiers|134|He last dialyzed on _%#MM#%_ _%#DD#%_, 2004, the day prior to this admission. He was admitted on _%#MM#%_ _%#DD#%_, 2004, for a living-related renal transplant from his mother. Prior to the time of this admission, he has had incisional pain from his midline incision after his bilateral nephrectomy.
Hyphen|To|71|9. Tylenol 650 mg p.o. prn q 4-6 hours. 10. Vicodin one to two p.o. q 6-8 hours prn pain. 11. Nitroglycerin 1 to 150 sublingual q five minutes times three prn chest pain.
Hyphen|Junction|82|DISCHARGE DIAGNOSIS: Herniated disk, C6 to C7. OPERATIONS/PROCEDURES PERFORMED: C6-C7 anterior cervical diskectomy with fusion, plating. HISTORY OF PRESENT ILLNESS: Miss _%#NAME#%_ is a 56-year-old woman with a history of right arm pain, radiation in the C7 distribution on the right, no significant weakness.
Hyphen|Lexical hyphen|173|Her exercise capacity was 14 minutes. She had a normal ejection fraction. The patient therefore felt relieved that she did not have cardiac condition and she plans to follow-up with her primary care physician. She denies any heartburn symptoms or symptoms consistent with cholecystitis or gallbladder disease.
Hyphen|Compound pre-modifiers|172|Coronary angiogram: Revealed right dominant circulation with mild diffuse RCA disease; left circumflex showed mild diffuse disease. LAD had mild diffuse disease with 40% in-stent re-stenosis of the LAD stent. The OM stent was patent. No focal lesions were noted.
Hyphen|Junction|62|DIAGNOSIS: Herniated disk at C7-T1 on the left. PROCEDURES: C7-T1 decompression (decompressed left C8 nerve root). HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a patient well- known to Dr. _%#NAME#%_.
Hyphen|Quotative or expressing a quantity or rate|150|ALLERGIES: No known drug allergies. FAMILY HISTORY: His mother had multiple sclerosis. No known heart disease. SOCIAL HISTORY: He is married. Has a 24-year-old daughter. He is healthy. He lives with his spouse. He recently retired from the air force and working doing stock work for Home Depot at night.
Hyphen|To|194|REVIEW OF SYSTEMS: Currently significant for ongoing malaise, body weak. She has also noted drenching night sweats as above. Her appetite has been very poor over the last month or so with only 1-2 pound weight loss. However, she has not been monitoring her weight. She has also been getting progressively weak.
Hyphen|Phone number|119|It was a pleasure to be involved in her care. If you have any questions regarding her care, please page me at _%#TEL#%_-_%#TEL#%_ with any questions.
Hyphen|Junction|113|6) Stroke in 2000 with residual gait imbalance. 7) Degenerative arthritis. 8) Postpolio syndrome. SURGICAL: 1) C4-4 and C5-6 discectomy in 1995. 2) Cholecystectomy in 1989. 3) Appendectomy. 4) Vitrectomy related to retinal hemorrhage.
Hyphen|Lexical hyphen|88|CARDIAC: Regular rate and rhythm. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Non-tender and non- distended. SKIN: No rash. NEUROLOGIC: Cranial nerves II through XII were intact. LABORATORY DATA: White count 5.7, hemoglobin 12.9, platelets 287.
Hyphen|Compound pre-modifiers|228|This angiogram showed that the two stents in the LAD and the diagonal stent were okay with minimal restenosis. The distal left circumflex stent was fine but there had been progression of proximal left circumflex and another drug-eluting stent was placed in the proximal left circumflex Cypher 3.0 x 28.
Hyphen|Compound pre-modifiers|79|3. Vicodin up to 2 each day for neck pain. 4. Multivitamin each day. 5. Enteric-coated aspirin 325 mg each day. ALLERGIES: Codeine. SOCIAL HISTORY: The patient lives alone in her apartment.
Hyphen|Quotative or expressing a quantity or rate|142|OPERATIVE PROCEDURE PERFORMED DURING THIS ADMISSION: Wedge biopsy of left pulmonary nodule. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 75-year-old gentleman who presented to Thoracic Surgery Clinic _%#MMDD2004#%_ with consultation for a new left lung pulmonary nodule.
Hyphen|Compound pre-modifiers|112|Lisinopril 10 mg daily. DISCHARGE DIAGNOSES: 1. Congestive heart failure with right pleural effusion. 2. Insulin-dependent diabetes mellitus. 3. Essential hypertension. 4. Hypothyroidism. 5. Iron deficiency anemia. 6. Dementia. 7. Atrial fibrillation.
Hyphen|Quotative or expressing a quantity or rate|146|2) Hypertension. 3) Nodular density, 2.1 cm, right upper lung on PA view, indeterminate in nature. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is an 82-year-old female who presented to Fairview Southdale Hospital with weakness and dizziness.
Hyphen|Quotative or expressing a quantity or rate|111|Chest x-ray done in clinic show bilateral pleural effusions and cardiomegaly. ASSESSMENT AND PLAN: This is a 77-year-old man with a history of coronary artery disease and a history of congestive cardiac failure who presents with progressive shortness of breath.
Hyphen|Lexical hyphen|91|DISCHARGE INSTRUCTIONS: The patient was discharged to home in good condition. He has follow-up in the Bone Marrow Transplant Clinic on _%#MMDD2005#%_ with Dr. _%#NAME#%_.
Hyphen|Quotative or expressing a quantity or rate|140|CHIEF COMPLAINT: _%#NAME#%_ _%#NAME#%_ presents with nausea over the last week. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a very pleasant 54- year-old white female with a fairly extensive past medical history of gastrointestinal problems who presents today with increasing nausea and abdominal pain over the last week.
Hyphen|Quotative or expressing a quantity or rate|90|DOB: CHIEF COMPLAINT: Nausea, vomiting and cough. HISTORY OF PRESENT ILLNESS: This is a 77-year-old male with history of hypertension and in his usual state of health until a week and a half ago when he developed a cough somewhat productive of greenish phlegm and has been getting progressively better up until _%#MM#%_ _%#DD#%_, when he developed flu-like symptoms with nausea, vomiting and loose stools. He had about five to seven bowel movements that day described as loose, watery but non mucousy or bloody.
Hyphen|Compound pre-modifiers|101|DIAGNOSES: 1. Coronary artery disease. 2. Percutaneous coronary intervention with placement of a drug-eluting stent. 3. Hypertension. 4. Hyperlipidemia. PROCEDURES: 1. Coronary angiography. 2. Placement of a drug-eluting stent.
Hyphen|Lexical hyphen|290|She underwent a cervical biopsy which confirmed invasive squamous cell carcinoma, and she was seen by Dr. _%#NAME#%_, who performed retroperitoneal staging laparotomy in early _%#MM#%_. She was found to have a poorly differentiated squamous cell carcinoma involving multiple pelvic and para-aortic lymph nodes. Her primary tumor was felt to be unresectable, and treatment with chemoradiation therapy was recommended.
Hyphen|Compound|132|He is becoming more independent in mobility. His endurance is also improved. Between he and his spouse, they are independent in self-cares of his L- VAD and its associated support equipment.
Hyphen|Compound|119|She was hypoxic. The paramedics were called and brought her in for evaluation. She had bilateral infiltrates on chest x-ray, right greater than left, suspicious for possible volume overload.
Hyphen|Compound|191|She is being followed by Thoracic Surgery and is to see them in clinic every Tuesday for further management of the chest tube. At this time they have been pulling the chest tube by out a half-inch per week. She should have weekly chest x- rays on Mondays, prior to her Tuesday Thoracic Surgery appointments.
Hyphen|Quotative or expressing a quantity or rate|148|PROGRAM PARTICIPATION: While attending the outpatient program, _%#NAME#%_ participated in daily therapeutic and community groups. _%#NAME#%_ had one-to-ones with staff members, received on site schooling, and participated in weekly developmental asset building, and spirituality workshops.
Hyphen|Compound|83|Subsequently, blood pressure improved and she was transferred to the ICU. A chest x-ray revealed bilateral pulmonary infiltrates consistent with pulmonary edema.
Hyphen|Quotative or expressing a quantity or rate|191|PRINCIPAL DIAGNOSIS: Non-ischemic cardiomyopathy, status post heart transplant. PRINCIPAL PHYSICIAN: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, MD IDENTIFICATION AND REASON FOR ADMISSION: This is a 40- year-old gentleman with non-ischemic cardiomyopathy who is admitted to Fairview-University Medical Center to undergo heart transplant.
Hyphen|ZIP+4 code|113|_%#NAME#%_ _%#NAME#%_ _%#NAME#%_, MD _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#CITY#%_ _%#CITY#%_, MN _%#55000#%_-_%#ADDRESS#%_ _%#TEL#%_ _%#MM#%_ _%#DD#%_, 2004 Dear Dr. _%#NAME#%_, Thank you for accepting care of _%#NAME#%_ _%#NAME#%_ from the Neonatal Intensive Care Unit of Fairview-University Children's Hospital.
Hyphen|Lexical hyphen|196|We will give her pain medication with IV Morphine and Zofran for nausea. 2. History of P-E. Her INR is currently 2.20 and we will hold her Coumadin obviously and give her some Vitamin K and follow-up with her INR tomorrow morning. 3. Hypercholesterolemia. We will continue the patient on her Lopid.
Hyphen|Lexical hyphen|123|The patient was admitted to the hospitalist service for further evaluation and presumed cellulitis. HOSPITAL COURSE: 1. Pre-septal left knee bursitis infection. Patient initially had a wound culture on admission which grew MRSA.
Hyphen|Compound|91|6. Furosemide 20 mg by mouth twice daily. 7. Haldol 0.5 mg by mouth twice daily. 8. Senokot-S 2 tablets by mouth twice daily. 9. Decadron 5 mg by mouth 3 times a day.
Hyphen|Compound|213|As a result of her elevated pressures and elevated liver enzymes, a decision was made to proceed with delivery. DELIVERY COURSE: With a history of C-section, no risks, benefits, or alteratives were seen with her C-section. We discussed with the patient and consent was given. The patient was on magnesium prior to the C-section, although this was discontinued shortly after with concerns for bleeding.
Hyphen|To|121|Levaquin 250 mg daily x5 more days. 10. OxyContin 10 mg b.i.d. 11. Oxycodone 5 mg p.o. q.6h. p.r.n. pain. 12. Compazine 5-10 mg p.o. q.6h. p.r.n. nausea. 13. Senna 1 tab p.o. b.i.d. 14. Spiriva 18 mcg inhaled daily.
Hyphen|Quotative or expressing a quantity or rate|226|PRELIMINARY PREOPERATIVE DIAGNOSIS: Acute appendicitis. POSTOPERATIVE DIAGNOSES: Severe acute appendicitis with necrosis and severe surrounding peritonitis. SURGICAL INDICATIONS: This is a 63-year-old diabetic gentleman with 5-day history of right-sided abdominal pain. He underwent CT scan on _%#MMDD2006#%_, which showed findings consistent with acute appendicitis.
Hyphen|Quotative or expressing a quantity or rate|125|I expressed the importance of taking antibiotics for this infection. A prescription for Flagyl 500 mg, 3 times daily for a 10-day course has been called in to his local pharmacy (phone number _%#TEL#%_).
Hyphen|Quotative or expressing a quantity or rate|114|She had one drink per day approximately. She drinks about 10 to 12 cans of soda per day. She is married and has 32-year-old twins and one teenage daughter. FAMILY HISTORY: Paternal grandfather had pancreatic cancer and died in his 50's.
Hyphen|Lexical hyphen|235|His admission sodium was 134 and it dropped on _%#MMDD2005#%_ to 128. His diuretic dosing was altered and his sodium level appeared stable at the 129 on _%#MMDD2005#%_ so it was felt that the was okay to be discharged with close follow-up in approximately one week's time. His potassium on _%#MMDD2005#%_ was 4.5. His blood sugars were running in the low to mid 100s.
Hyphen|Compound pre-modifiers|201|OPERATIONS/PROCEDURES PERFORMED: Procedures performed while the patient was in the hospital: 1. Coronary angiogram. 1. Cardiac catheterization performed on _%#MM#%_ _%#DD#%_, 2006, that showed a single-vessel left circumflex lesion with successful stent placement of the left circumflex.
Hyphen|Compound|165|He was hypotensive and developed a rash as manifestation of this hypersensitivity/anaphylactic reactions from contrast dye. Because of this, we treated him with Solu-Medrol, Benadryl as well as epinephrine. His blood pressure did come up a little bit, but it remained unstable at about 70s to 80s cyclic range, and this prompted us to transfer him to ICU for monitoring.
Hyphen|Lexical hyphen|291|If the patient opts for Hospice involvement one may make the reasonable argument to stop his cardiovascular medications. Despite the fact that that would increase his risk of a second subsequent vascular event, this may not necessarily be such a bad thing in somebody who has extensive intra-abdominal metastatic disease. Consultation was undertaken with Dr. _%#NAME#%_ _%#NAME#%_ of Hematology/Oncology who will set up outpatient follow-up on this patient.
Hyphen|To|148|Soft, nontender without organomegaly. GU: Deferred. EXTREMITIES: No edema. Deep tendon reflexes equal and symmetrical bilaterally. Cranial nerves II-XII are grossly intact. She does have varicosities on the lower extremities bilaterally.
Hyphen|Quotative or expressing a quantity or rate|109|ADMISSION DIAGNOSIS: Chest pain. DISCHARGE DIAGNOSIS: Chest pain. HISTORY OF PRESENT ILLNESS: Patient is a 67-year-old, white female with a 4-day history of left-sided chest wall pain and shortness of breath. She denies substernal or crushing-like symptoms. She had a similar episode approximately 1 year ago that lasted 3 days and resolved spontaneously.
Hyphen|Compound|162|Left ovarian fibroma. 2. Hypertension. 3. Osteopenia. OPERATIONS/PROCEDURES PERFORMED: 1. Exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy with washings. 2. IV antibiotics. 3. IV fluids. 4. Epidural anesthesia. COMPLICATIONS: None apparent.
Hyphen|Quotative or expressing a quantity or rate|209|IMAGING: 1. Head CT: The preliminary read of the head CT is that there are no acute changes and there is evidence of the old resection of the GBM. 2. Neck CT: No fractures are noted. ASSESSMENT AND PLAN: An 81-year-old female status post fall with a head laceration and with significant bleeding from the laceration.
Hyphen|Obstetrical data|126|SOCIAL HISTORY: The patient is married. She works as a director of human resources. OBSTETRICAL HISTORY: The patient is para 0-0-1-0, and has 1 voluntary interruption of pregnancy. GYN HISTORY: The patient had abnormal Pap smear in 1994, but most recently in our office has a normal Pap smear from _%#MMDD2006#%_.
Hyphen|Lexical hyphen|194|Per the available records, there is a history of abuse and misuse of opiates. She has in the past been followed by the Pain Service at Fairview but was discharged from that clinic because of non-compliance with the program. She apparently has been obtaining Percocet from other sources. She vaguely tells me that she has been getting from a doctor at _%#COUNTY#%_ though I cannot verify this.
Hyphen|Compound|163|Aortic sclerosis without stenosis. Diastolic dysfunction. Mild increase in left ventricular thickness. Estimated left ventricular ejection fraction 60%. 2. Chest x-ray _%#MMDD2006#%_. Clear lungs were the impression. 3. Ultrasound of transplanted kidney.
Hyphen|Compound|107|Infectious disease adjusted antibiotics and the patient was then switched to Rocephin and vancomycin. The E-Coli was found to be sensitive to ceftriaxone. Vancomycin was discontinued on _%#MM#%_ _%#DD#%_, 2007. Neurology was also consulted to assist with management of the patient's neurologic deficits.
Hyphen|Compound|145|The patient did progress well to complete and after approximately 2 hours of pushing, failure to descend was diagnosed. At this point a primary C-section was performed without difficulties or complications.
Hyphen|Compound|103|INR 0.91, white blood cell count 13, hemoglobin is 14.8, electrolytes all within normal limits. Chest x-ray does not show infiltrates or effusions I suspect there is a fractured rib T8 await radiology confirmation of this.
Hyphen|Quotative or expressing a quantity or rate|186|Intrauterine pregnancy at 39 plus 1 week, delivered. 2. Unicorn uterus. OPERATIONS/PROCEDURES PERFORMED: Primary low transverse cesarean section. HISTORY OF PRESENT ILLNESS: This is a 28-year-old gravida 1, para 0, 39 plus 1 week female. LMP consistent with a 19-week ultrasound who presented to labor and delivery for a primary elective C- section for a breech presentation.
Hyphen|Quotative or expressing a quantity or rate|127|Seizure and syncopal event. 2. Acute myelogenous leukemia recurrence, status post bone marrow transplant 4 months ago. 3. Graft-versus-host disease. 4. Diarrhea, improved. 5. Malnutrition. 6. Lung infiltrates with positive Enterobacteriaceae, negative for CMV.
Hyphen|Compound pre-modifiers|224|9. Amiodarone 200 mg daily. DISCHARGE FOLLOW-UP: She will follow up with a tilt-table test a week following dismissal from the hospital and she will follow up with Dr. _%#NAME#%_ for ongoing evaluation. We discussed the tilt-table procedure. She expressed understanding.
Hyphen|Compound|77|p.r.n. 13. Nexium 20 mg p.o. daily. 14. Norvasc 10 mg p.o. daily. 15. Naphcon-A 0.025 to 0.035 ophthalmic solution 2 drip HI t.i.d. 16. Doxazosin 6 mg p.o. daily.
Hyphen|Quotative or expressing a quantity or rate|229|Ocuvite daily 6. Lipitor 10 mg a day REVIEW OF SYSTEMS: Head, ears, eyes, nose and throat, GI, GU, cardiovascular, neuromuscular otherwise negative except as in history of present illness. PHYSICAL EXAMINATION: Shows she is an 81-year-old female, well-developed, well-nourished, oriented x3 and in no acute distress at this time.
Hyphen|Compound|248|He is to scheduled for appointment on _%#MMDD#%_ with Dr. _%#NAME#%_ in neurology clinic. The patient is to follow at home with Fairview Homecare _%#CITY#%_ and the nurse is to visit his home to asses the G-tube site, provide followup teaching of G-tube cares on tube feeding administration. Fairview home infusions is to follow the patient for tube feeding and supplies.
Hyphen|Compound|81|Fish oil 9. Glucosamine 500 mg tablets 3 a day 10. Norvasc 5 mg p.o. daily 11. Os-Cal 500/200 1 tab 12. Fosamax 70 mg a day 13. Aspirin 325 mg a day 14. Milk of Magnesia p.r.n.
Hyphen|To|96|His blood culture was negative for 48 hours during his admission here. Urine culture grew 10,000-50,000 of E. coli which was sensitive to penicillin. Throat culture grew staph aureus. With his positive urine culture, we discharged _%#NAME#%_ home with amoxicillin 500 mg p.o. twice daily.
Hyphen|Compound pre-modifiers|192|Chest x-ray shows possible mild bibasilar atelectasis with no focal infiltrates. Also degenerative changes in the left shoulder. Otherwise negative. A 12-lead EKG shows sinus rhythm with first-degree AV block and a right bundle branch block. No obvious acute ischemic changes. ASSESSMENT: Acute constitutional weakness which is likely multifactorial.
Hyphen|Quotative or expressing a quantity or rate|72|CHIEF COMPLAINT: Failed T6-7 fusion. HISTORY OF PRESENT ILLNESS: This 39-year-old married gentleman had T6-7 fusion in 1999 and has had two revisions since then both of which have failed and he is to have a third revision. PAST MEDICAL HISTORY: Allergy: Penicillin gives him a rash. Surgery: Strabismus age 6, ORIF of right second metacarpal, vasectomy and T6-7 fusions times three.
Hyphen|Typographic convention|134|13. Calcium with vitamin D, 1,250 mg tablets one daily. 14. K-Dur 20 mEq p.o. daily. DISCHARGE DIAGNOSES: 1. Congestive heart failure - improved. 2. Severe aortic stenosis causing congestive heart failure. 3. Left pleural effusion related to congestive heart failure.
Hyphen|Lexical hyphen|185|REASON FOR HOSPITAL ADMISSION: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is admitted for further evaluation of severe back pain and with a known diagnosis of metastatic gastric cancer with intra-abdominal carcinomatosis. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 41-year-old woman who has a diagnosis of gastric carcinoma diagnosed in _%#MM#%_ of 2000.
Hyphen|Lexical hyphen|83|4. She takes 600 mg calcium daily. 5. Vitamin E daily. 6. Colace recently. 7. Multi-vitamin. ALLERGIES: No known drug allergies. HABITS: She is a nonsmoker, drinks approximately 2 alcoholic beverages a day.
Hyphen|Typographic convention|553|_%#NAME#%_ _%#NAME#%_, and nurse practitioner _%#NAME#%_ _%#NAME#%_. Follow-up will include chest x-ray in one week and serum creatinine in one week, hemoglobin in one week. DISCHARGE MEDICATIONS: Tequin 200 mg p.o. through _%#MMDD2002#%_, clindamycin 300 mg p.o. q.i.d through _%#MMDD2002#%_, Lanoxin 0.125 mg p.o. q.d., lisinopril which is a new medicine 5 mg p.o. daily for CHF, fursemide 20 mg tablets one tablet daily for one week and then every other day, for GERD - Aciphex 20 mg p.o. daily, for dementia - Aricept 10 mg p.o. daily, for dementia - Risperdal has been at 1 mg p.o. b.i.d. but that will be reduced as she seems too somnolent to 0.5 mg p.o. b.i.d. with some attempt at weaning thought to be prudent at this point in time.
Hyphen|Compound pre-modifiers|219|Initial troponin-I is not detectable. Other labs include, on chest x-ray, evidence of pulmonary vascular congestion. Blood counts are noteworthy for a hemoglobin of 14.4, white blood count elevated to 15,100 with a left-shifted differential. Platelets are normal. INR is normal. Blood chemistry panel reveals no pertinent findings.
Hyphen|To|136|The patient was brought to catheter lab for further evaluation. He had chest pain which was exertional and he could walk approximately 4-5 blocks before the onset of chest pain. He did not have any dyspnea on exertion or any syncope.
Hyphen|Quotative or expressing a quantity or rate|199|She has a well-healed scar in midline abdomen. Her abdomen is soft, nontender, nondistended, otherwise unremarkable physical exam. LABORATORY DATA: Within normal limits. HOSPITAL COURSE: This is a 10-year-old female with history of kidney transplant and membranoproliferative glomerulonephritis type II admitted for IVIG.
Hyphen|Lexical hyphen|116|Biopsy site needle site is healed well. No signs of pus or oozing. She has some tenderness to palpation over the mid-epigastric area, otherwise she is nontender. She has no referred pain, no peritoneal signs, and no guarding.
Hyphen|Compound pre-modifiers|115|5. Transfuse for hemoglobins less than 8. 6. Check INR although this has only been mild in the past. 7. Review long-term options with GI service once again.
Hyphen|Junction|206|Mrs. _%#NAME#%_ _%#NAME#%_ is a 74-year-old woman who I am evaluating today for medical clearance prior to revision decompression from L2 or L3 down to L4 and posterolateral fusion with pedical screws at L3-4. The patient underwent previous lumbosacral spine laminectomy with fusion in 2000 and that hospitalization and surgery was complicated by a large hematoma resulting in anemia and consequent myocardial infarction.
Hyphen|Compound pre-modifiers|129|She has 3 grown children. the patient enters Fairview Recovery Services at this time of her own volition. She admits to a several-year history of alcohol dependence. She says she was a social drinker for most of the time but her use increased recently to the point where she has been unable to control it.
Hyphen|Typographic convention|191|MEDICATIONS: His medications have been Lisinopril, hydrochlorothiazide 20/25 1 orally daily, hydrochlorothiazide 25 mg 1 orally daily, Effexor XR 75 mg 1 orally daily. SOCIAL HISTORY: Habits - he does not use alcohol to excess or smoke. He's married, living with his wife and family. FAMILY HISTORY: Significant for a brother with insulin dependent diabetes, who apparently was diagnosed very similarly coming in in DKA.
Hyphen|Compound|161|CT scan of the head was negative. Ultrasound of the neck revealed no carotid or vertebral stenosis. Echocardiogram was preliminarily read as normal. CBC and chem-7 were normal. The patient did not have any recurrence of his symptoms.
Hyphen|Junction|171|Removal of bilateral L4-L5-S1 pedicle screws. 2. L2-L3-L4 posterolateral fusion with allograft and autograft. 3. Bilateral L2-L3-L4 pedicle screw fusion. 4. TLIF L2-L3, L3-L4. 5. Right L2-L3 and L3-L4 posterolateral arthrodesis with BMP.
Hyphen|To|220|Pulmonary: Negative. He is a nonsmoker. GI: Negative. No significant alcohol use. Hematologic: Negative. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 96.2, pulse 101, respirations 20, blood pressure 142/76, pulse ox 92-93%. GENERAL: Well developed, thin white, wasted male breathes with accessory muscles.
Hyphen|Quotative or expressing a quantity or rate|27|DOB: _%#MMDD1981#%_ This 21-year-old black Nigerian male is admitted for acute right upper back pain from sickle cell crisis. He has a history of frequent hospitalizations for sickle cell crisis.
Hyphen|Lexical hyphen|86|Mr. _%#NAME#%_ _%#NAME#%_ is a 73-year-old gentleman who was admitted with a small non-Q wave myocardial infarction and also had heart failure. He has obesity, severe peripheral vascular disease, status post recent peripheral vascular procedure at the University.
Hyphen|Quotative or expressing a quantity or rate|188|REASON FOR HOSPITAL ADMISSION: Continuation of chemotherapy as part of ongoing treatment of osteosarcoma involving the pelvis. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ _%#NAME#%_ is a 39-year-old woman who has a history of grade IV osteosarcoma involving the pelvis, diagnosed in approximately _%#MM#%_ 2002.
Hyphen|Quotative or expressing a quantity or rate|497|The patient did have several episodes in the hospital where her blood pressure would dip into the 80-90s systolic and she would be asymptomatic; however, given the catastrophic nature of what these hypotensive episodes might represent she was carefully evaluated several times with intact peripheral pulses, no belly pain, and eventually it was felt that this was not clinically significant. In addition, the patient did have a hemoglobin drop while in the hospital from 13.4 down to 10.7 in a two-day period; however, the patient showed no signs of active bleeding.
Hyphen|Compound pre-modifiers|326|PROGRAM PARTICIPATION: While on the STOP unit, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. _%#NAME#%_ attended step groups, gender group, NA and AA meetings on site, individual therapy, multifamily group, therapeutic recreation, developmental asset-building activities, and chemical dependency and related lectures.
Hyphen|Quotative or expressing a quantity or rate|37|_%#NAME#%_ _%#NAME#%_ is a retired 83-year-old economics professor with pancreatic cancer. Recently he has had increasing pain, control issues and had a Duragesic patch started one week ago along with some MS Contin.
Hyphen|Lexical hyphen|141|3. He has also been given activity restrictions and parameters for calling Dr. _%#NAME#%_' office should he have problems prior to his follow-up. 4. Home health care has been arranged for PICC cares and IV antibiotics, as above.
Hyphen|Lexical hyphen|143|CARDIOVASCULAR: Regular rate and rhythm; no murmurs, gallops, or rubs. LUNGS: Crackles bilaterally, right greater than left. ABDOMEN: Soft, non-tender, non-distended; positive bowel sounds; no organomegaly.
Hyphen|Junction|105|There was also multi-level degenerative disease, extensive degenerative arthritis of the lumbar spine. L5-S1 moderate to severe left foraminal stenosis. 22) Incidental 3 to 4 cm in transverse diameter abdominal aortic aneurysm.
Hyphen|Lexical hyphen|166|4. She was encouraged to contact the transplant coordinator with any questions or concerns regarding care after the time of discharge. 5. She was instructed to follow-up with a CT of the abdomen as an outpatient. 6. She was also instructed to follow-up with Cardiology on Tuesday, _%#MMDD2003#%_, at 2:00 p.m., in clinic.
Hyphen|Lexical hyphen|153|HISTORY: Mr. _%#NAME#%_ was referred in consultation by Dr. _%#NAME#%_ _%#NAME#%_ for evaluation and management of airway constriction secondary to a non-small cell carcinoma. Mr. _%#NAME#%_ is a 65-year-old male who is known to have advanced lung cancer.
Hyphen|Lexical hyphen|114|Over the next couple of days, he remained stable without much deterioration and perhaps slight improvement. Follow-up CT scan on hospital day #3 revealed significant edema in the area of the right middle cerebral artery stroke with midline shift.
Hyphen|Compound pre-modifiers|278|The patient then had a fairly-significant recovery, initially coming back with strength in the right arm and right leg and speech, then more slowly resolution of the weakness in the left leg and arm. The patient's mental status improved and she was conversant but did have short-term memory loss. At the time of my evaluation she is resting comfortably; she denies complaints; she cannot recall the events of the evening and has amnesia for most of the events of this afternoon.
Hyphen|Compound pre-modifiers|184|HEENT; Shows a profoundly-dry oropharynx. Ocular structures are unremarkable. There is no icterus. NECK; Supple. LUNGS; Clear bilaterally without crackles or wheezes. There is somewhat-decreased air flow but no crackles or wheezes. CARDIAC; Regular rhythm; neck veins are flat, no appreciable S3, S4 or murmur.
Hyphen|Compound|149|Concentric LVH, left atrial enlargement, Mild P-R, RV systolic pressure of 36 mmHg plus the right atrial pressure. Left atrial enlargement and mild P-R. The patient does have a pronounced murmur best heard in the aortic area.
Hyphen|Lexical hyphen|274|HOSPITAL COURSE: Patient is an 18-year-old male who came into the emergency room on _%#MMDD2004#%_ after he had a spontaneous left pneumothorax probably that occurred the day prior. A chest tube was apparently placed and Heimlich valve was attached and then he was to follow-up with Dr. _%#NAME#%_ in clinic. On follow-up he had an increase in size of his 25% pneumothorax and was subsequently admitted to the hospital where she placed a larger, 24 French chest tube.
Hyphen|Lexical hyphen|332|Acton. There were no complications during the procedure. 2. CV: An echocardiogram was obtained on _%#MMDD#%_ to assess for vascular rings or slings pre-operatively and to rule out the VACTERL association. The echocardiogram showed a left aortic arch with normal branching, a normal PA bifurcation, no vascular rings or slings, a non-obstructive bicuspid aortic valve, and a small muscular VSD with left to right shunting.
Hyphen|Compound|273|PAST SURGICAL HISTORY: Lung transplant, appendectomy, tubal ligation, one cesarean section, and right mastectomy. ALLERGIES: The patient has allergies to amoxicillin. HOSPITAL COURSE: The patient was admitted to the Bariatric Service on _%#MMDD2004#%_ for laparoscopic Roux-en-Y gastrointestinal bypass. This procedure was performed on this date with no noted complications.
Hyphen|Quotative or expressing a quantity or rate|110|Speech and OT with minimal residual neurological deficit. HOSPITAL COURSE: Mrs. _%#NAME#%_ _%#NAME#%_ is an 84-year-old woman who presents through the emergency room with dysarthria and inability to use the left side of her body.
Hyphen|Compound|267|2. Atorvastatin 10 mg p.o. q day. 3. Rythmol 300 mg p.o. t.i.d. 4. Coumadin as directed. FOLLOW-UP: He will follow up in one week with one of our physician's assistants or nurse practitioners to determine whether he is tolerating his medications well and if any break-through has occurred. _%#NAME#%_ _%#NAME#%_ is a 75-year-old patient with known history of paroxysmal atrial fibrillation.
Hyphen|Quotative or expressing a quantity or rate|39|DOB: _%#MMDD1978#%_ The patient is a 25-year-old gravida 1 para 0 patient who is currently at 38 weeks and brought to the hospital by her primary physician for cervical ripening and induction of labor. The patient's pregnancy has been of note for insulin-dependent gestational diabetic, which has been under good control.
Hyphen|Compound pre-modifiers|107|She was felt to be at her baseline at the time of discharge. 2. Urinary tract infection. Culture grew a pan-sensitive E.coli. She was begun on Macrobid at admission. She remained afebrile and will complete her seven day course after discharge.
Hyphen|Quotative or expressing a quantity or rate|204|ADMISSION DIAGNOSIS: Right frontal glioblastoma multiforme. DISCHARGE DIAGNOSIS: Same. PROCEDURE PERFORMED: Blood-brain barrier disruption and chemotherapy. HISTORY OF PRESENT ILLNESS: The patient is a 35-year-old white woman with a history of right frontal glioblastoma multiforme, initially resected in _%#MM2002#%_.
Hyphen|Lexical hyphen|85|She declined the need for any antibiotics and she will take one aspirin daily. Follow-up in the office will be done in the next 7 to 10 days.
Hyphen|Quotative or expressing a quantity or rate|162|DOB: _%#MMDD1919#%_ FINAL DISCHARGE DIAGNOSES: 1. Aspiration pneumonia. 2. Parkinson's disease. 3. Shy-Drager syndrome. 4. Dementia. HISTORY: The patient is an 85-year-old male who initially presented to the emergency room with difficulty breathing, low saturation.
Hyphen|Lexical hyphen|264|ADMITTING DIAGNOSIS: Right testicular cancer, non-seminomatous germ cell tumor. PROCEDURE PERFORMED: Laparoscopic retroperitoneal lymph node dissection. HISTORY OF PRESENT ILLNESS: This is a 34-year-old male who is status post a right radical orchiectomy for a non-seminomatous germ cell tumor of the testis. Postoperative CT scan of the chest, abdomen, and pelvis performed on _%#MMDD2005#%_ had a few post surgical changes in the inguinal region and enlarged deep right inguinal node as well as a questionable hypodensity in the liver and a pulmonary nodule.
Hyphen|Compound pre-modifiers|165|Reconstructed repeat CT scan of the head showed air in the ethmoid sinuses, though no distinct fracture could be located by the bony reconstructive views. Some right-sided injury was noted as well, likely consistent with the mechanism of injury.
Hyphen|Quotative or expressing a quantity or rate|87|4. He will continue to use nutritional supplementation at home. 5. Type and screen of 6-units of blood has been initiated in anticipation of the _%#MM#%_ _%#DD#%_, 2005 surgery.
Hyphen|To|161|Trazodone 100 mg p.o. q.h.s. 24. Valcyte 900 mg p.o. each day. 25. Prednisone taper as follows: _%#MMDD#%_ - _%#MMDD#%_: 17.5 mg q.a.m., 15 mg q.p.m. _%#MMDD#%_ - _%#MMDD#%_: 15 mg p.o. b.i.d. _%#MMDD#%_ - _%#MMDD#%_: 15 mg p.o. q.a.m., 12.5 mg p.o. q.p.m. (for remainder of taper, refer to discharge orders).
Hyphen|Quotative or expressing a quantity or rate|134|PRELIMINARY PRIMARY MD: Dr. _%#NAME#%_ _%#NAME#%_, Oxboro Clinic, _%#NAME#%_ HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 63-year-old white male who awoke this morning from sleep with diarrhea that was described as dark red, very foul smelling and also black in appearance. He proceeded to have three or four further stools of similar description over the next few hours.
Hyphen|Compound|56|5. Lasix 40 mg twice daily. 6. Vytorin 10/40 daily. 7. K-Dur 20 mEq daily. 8. Aldactone 12.5 mg daily. 9. Insulin 70/30, 45 units in the morning and 32 units in the evening.
Hyphen|Compound pre-modifiers|192|DISCHARGE PLAN: 1. She is to continue her chemical dependency treatment in the Lodging Plus program. 2. She is to continue her prescribed medications. 3. She is to refrain from the use of mood-altering chemicals. 4. She is to meet with the diabetic educator on Thursday, _%#MM#%_ _%#DD#%_, 2004.
Hyphen|And(fraction)|203|PRELIMINARY HISTORY OF PRESENT ILLNESS: The patient is a 21-year-old gravida 1, para 0 with an EDC of _%#MMDD2005#%_ admitted with fever, chills, abdominal pain and urinary tract infection symptoms at 37-1/2 weeks gestation. Her examination at the time of admission revealed a temperature of 100.9. No CVA tenderness.
Hyphen|To|87|Pedal pulses present. No rash. No edema. NEUROLOGIC exam is nonfocal. Cranial nerves II-XII grossly intact. Normal finger-nose-finger. Strength 5/5 in the extremities times four. Normal tone and no abnormal movements.
Hyphen|Compound|115|The patient was treated with Levaquin and is being discharged on Levaquin as noted below. Blood culture also grew E-coli which was sensitive to Ciprofloxacin. The patient improved clinically to her baseline. 2. Acute renal failure: This was secondary to sepsis and in part to dehydration.
Hyphen|To|177|Mother died from colon cancer at age 66. Niece, age 53, has breast cancer. Daughter has epilepsy. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post stent placement 5-6 years ago. 2. Hyperlipidemia, on Lipitor. 3. Bilateral knee arthroplasty for meniscal repair.
Hyphen|Quotative or expressing a quantity or rate|172|OPERATIONS/PROCEDURES PERFORMED: Repeat low transverse cesarean section after failed trial of labor. COMPLICATIONS: None. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 24-year-old Asian gravida 2, para 1-0-0-1 female who was admitted on _%#MM#%_ _%#DD#%_, 2006, at 41 plus 6 weeks' estimated gestational age with spontaneous rupture of membranes.
Hyphen|Compound pre-modifiers|142|In addition, he was advised to wear Miami J collar while driving and also for comfort as needed. He is being discharged home on his regular at-home medications as well as pain medications as detailed below.
Hyphen|Lexical hyphen|101|BREAST: Normal male bilaterally with out mass, tenderness or discharge. ABDOMEN: Abdomen is soft, non-tender, no masses. No significant hepatosplenomegaly. Normal bowel sounds present. LYMPH NODES: No significant peripheral lymph nodes palpable in the cervical, supraclavicular, axillary or inguinal areas.
Hyphen|Lexical hyphen|189|ASSESSMENT: Ms. _%#NAME#%_ has a symptomatic tumor with headache and a visual field cut. This is possibly a metastatic lesion of lung primary, which is undiagnosed, versus a high grade glio-malignancy. Otherwise the patient is stable. PLAN: The patient to be admitted and preoperative evaluation for the operating room tomorrow for resection.
Hyphen|Quotative or expressing a quantity or rate|133|5. Diabetes mellitus type 2. 6. Osteopenia diagnosed on DEXA scan in _%#MM2004#%_. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 49-year-old gentleman with end-stage liver disease secondary to hepatitis cirrhosis who is status post TIPS, reported hypertension, and refractory ascites who follows with Dr. _%#NAME#%_ as an outpatient.
Hyphen|Quotative or expressing a quantity or rate|83|EKG shows a right bundle branch block and inferior Q waves. ASSESSMENT/PLAN: Eighty-five year old man with history of coronary artery disease and recently blepharoplasty who presents after presumed fall.
Hyphen|Compound pre-modifiers|197|PSYCHIATRIC: Mood is stable, affect is flat there LABORATORY: BNP is 2590, troponin-I 0.04, white blood count is 12.3, hemoglobin 11.3, platelet count 237. EKG does not show any ST elevations or ST-segment depression. Chest x-ray shows pulmonary edema, cardiomegaly and a questionable lower lobe infiltrate on the lateral view, INR 6.06, sodium is 137, potassium 3.8, chloride 104, CO2 is 27, glucose is 185, chloride is 1.10, BUN is 12.
Hyphen|To|161|Peripheral pulses are intact in the upper and lower extremities bilaterally. NEUROLOGIC: The patient appears intact and nonfocal. Specifically, cranial nerves II-XII appear intact. Pupils are equal and reactive to light. Extraocular movements are all intact.
Hyphen|Compound pre-modifiers|203|Alternatively I suppose one could say that she may have vitamin K deficiency, however, it appears that simply with time that the PTT is correcting of its own perhaps as the heparin is wearing off. 2. End-stage kidney disease. 3. Chronic atrial fibrillation 4. Hypertension.
Hyphen|To|122|He should also establish care with a primary care physician in about two weeks. DISCHARGE MEDICATIONS: 1. Percocet 5/325 1-2 tabs q 4-6 hours p.r.n. for pain. 2. To use no more than 4 grams of Tylenol per day.
Hyphen|Quotative or expressing a quantity or rate|201|She does have borderline renal insufficiency so will have to watch the use of metformin closely, but hopefully we can keep things simple and keep this woman out of trouble in the future. Anticipate one- to two-day stay in the hospital.
Hyphen|To|377|FINAL HISTORY OF PRESENT ILLNESS: The patient is a 35-year-old white female, gravida 2, para 0-1-0-1 with a previous delivery at 37 weeks gestation, blood group O Rh positive, rubella status immune, 1-hour blood sugar screen of 88, GBS on _%#MMDD2006#%_ had been pending, who had been admitted on _%#MMDD#%_ in early labor. Her membranes had ruptured. She progressed to about 3-4 cm in labor. She had an epidural block placed when all of a sudden she developed a very profuse heavy vaginal bleeding.
Hyphen|Quotative or expressing a quantity or rate|178|9. History of gout. 10. Hypothyroidism. 11. History of pancreatic cyst remote past. I do not have full details. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is an _%#1914#%_-year-old man now admitted with left lower lobe pneumonia. He was seen in the clinic several days ago with a one time episode of scant amount of hemoptysis, although feeling clinically well.
Hyphen|Compound|323|NEUROLOGIC: Normal. IMAGING: Chest x-ray results are still pending. LABORATORY DATA: I did not see blood cultures ordered on the computer system, but it may have been done in emergency room, but we will redo these. ASSESSMENT AND PLAN: 1. Pneumonitis with possible pneumonia, although it has not shown up yet on the chest x-ray. Due to her elevated white blood count and her negative influenza swab I believe she may actual have community-acquired pneumonia and we will start her on pneumonia protocol.
Hyphen|Lexical hyphen|149|5. Iron sulfate 325 mg daily. 6. Percocet p.r.n. pain. FINAL DIAGNOSES: 1. Peripheral artery disease a. Right common femoral below knee popliteal non-reversed vein bypass graft. b. Repair of left femoral pseudoaneurysm. 2. Acute blood loss anemia not requiring transfusion.
Hyphen|Quotative or expressing a quantity or rate|207|Open cholecystectomy and appendectomy. 9. History of carpal metacarpal joint resection. 10. Cataract surgery. 11. Hysterectomy. 12. Rectocele repair. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 71-year- old woman who was in her usual state of health and underwent endoscopic sinus surgery today by Dr. _%#NAME#%_ _%#NAME#%_ of ENT Department.
Hyphen|Compound pre-modifiers|168|FINAL PROCEDURES PERFORMED: 1. Left thoracoscopic left upper lobectomy. 2. Thoracic lymphadenectomy. 3. Placement of an epidural catheter. ADMITTING DIAGNOSIS: Nonsmall-cell lung cancer of the left upper lobe. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 61-year-old female who has biopsy proven and nonsmall-cell lung cancer of her left upper lobe.
Hyphen|Typographic convention|105|No fundoscopic exam was done. NOSE - nasal mucosa normal. OROPHARYNX - without erythema or exudate. NECK - supple. THYROID - not enlarged and nontender. No lymphadenopathy. LUNGS - clear to auscultation, no wheezes or rhonchi.
Hyphen|To|239|I have advised her that everything that can be done laparoscopically, depending on findings, will be undertaken at the time of surgery, and that this might require more than 1 puncture site in the lower abdomen. Prescription for Vicodin, 1-2 to be used every 4-6 hours for postoperative pain, #10 with 1 refill, is faxed to her pharmacy.
Hyphen|And|52|DISCHARGE DIAGNOSES: 1. Pseudoarthrosis of a Type II-III odontoid fracture with C-1 and C-2. 2. Atherosclerotic vascular disease. 3. Hyponatremia secondary to diuretic effect.
Hyphen|To|85|Niacin tablets 500 mg p.o. b.i.d. 6. Enteric aspirin 325 mg p.o. q.d. 7. Temazepam 15-30 mg q.h.s. p.r.n. for insomnia. 8. Beconase nasal spray 2 sprays to each nostril q.d. 9. Gentamicin nasal solution to irrigate both nasal passages twice daily.
Hyphen|Compound pre-modifiers|180|The patient is also on iron. The patient was also on Macrobid. At her last admission, she had had a fever on postop day number 2 to 100.7 and the UA had shown 10,000 to 50,000 gram-negative rods, hence the treatment. She had finished her last dose on the day of presentation.
Hyphen|Typographic convention|88|I did not hear any carotid bruits, no abdominal bruits that I could appreciate. BREASTS - normal. She had no cervical, supraclavicular, or inguinal adenopathy.
Hyphen|To|207|Upon returning, she started to develop episodes of abdominal pain, this being in the epigastric area, through to the back, associated with retching. These episodes would come on quickly and resolve within 15-30 minutes. These progressed until she came to the Emergency Room last night with persistent retching and epigastric to back pain.
Hyphen|Compound pre-modifiers|137|IMPRESSION: 1. Deconditioning. 2. Acute urinary tract infection secondary to group D enterococcus, treated. 3. Cerebral atrophy and small-vessel brain disease. 4. Degenerative joint disease of the spine, with cervical spinal canal stenosis.
Hyphen|To|262|The patient also needs a PT, INR, and PTT on _%#MMDD2002#%_, as well as a follow- up visit in the Coumadin Clinic to insure he is therapeutic on his current regimen. Regular diet. Activity is no lifting greater than 10 pounds or strenuous exercise for the next 3-4 weeks. Okay to shower, no baths for four weeks. The patient will be sent home with a Foley night bag, as well as a Foley leg bag prior to discharge.
Hyphen|Lexical hyphen|171|Enteric-coated aspirin 325 mg p.o. q.d. 9. Tylenol 650 mg p.o. q.i.d. p.r.n. pain ALLERGIES: Morphine. FAMILY HISTORY: Not obtainable. SOCIAL HISTORY: The patient is a non-smoker and non-drinker. She lives independently in a senior apartment with much family support.
Hyphen|Compound pre-modifiers|174|His surgery was uneventful. His postoperative course was uneventful. The patient started a diet on the second postoperative day . His incision was healing nicely. The Jackson-Pratt drains were removed. His Foley catheter was draining clear urine. DISCHARGE PLAN: On _%#MMDD2002#%_ the patient was discharged home with an indwelling Foley catheter.
Hyphen|Quotative or expressing a quantity or rate|113|He has been afebrile, with his vital signs stable. The Foley catheter was removed on postoperative day #1. The 22-French Councill-tip left nephrostomy tube has been draining well postoperatively.
Hyphen|Compound|171|It is noteworthy that she has recently discontinued both Catapres patch and also Avapro because of lower blood pressures than usual. Other pertinent labs include a chest x-ray which shows diffuse fine interstitial infiltrate in both lung fields.
Hyphen|Quotative or expressing a quantity or rate|148|ALLERGIES: INTOLERANCE TO TEGRETOL AND AMIODARONE. MEDICATIONS: 1. Neurontin 300 mg five a day with meals and two at HS. 2. Coumadin 5 mg a day, one-and-a-half on Wednesday. 3. Lasix 40 mg bid. 4. Clarinex 1 qd. 5. Potassium 20 mEq bid. 6. Zaroxolyn 2.5 qd.
Hyphen|Typographic convention|109|Weight 166 pounds, up roughly 11 pounds since the aforementioned _%#MM#%_ _%#DD#%_, 2003 weight. Vital signs - blood pressure 153/79, heart rate 82, respirations 26 with some "sniffing" type respiratory effort at times, temperature 96.4. HEAD - normal.
Hyphen|Typographic convention|84|8 h. - _%#MMDD2003#%_, to complete a 21-day course. 8. Ceftazidine 1 gm IV q. 12 h. - _%#MMDD2003#%_, to complete a 14-day course. 9. Gengraf 175 mg p.o. b.i.d. It has been a pleasure to be involved in _%#NAME#%_'s care.
Hyphen|Typographic convention|124|Eyes - pupils equal, round, and reactive to light and accomodation. Extraocular movements and convergence intact. Oral exam - normal. NECK: Carotids 2+ bilaterally without bruits. Thyroid normal to palpation.
Hyphen|Compound pre-modifiers|130|PHYSICAL EXAMINATION: VITAL SIGNS: Her blood pressure preoperatively was 142/80. Pulse of 92. Weight 137.3. GENERAL: She is a well-developed, well-nourished female in no acute distress. HENT: Within normal limits. LYMPHATICS: There is no supraclavicular or cervical lymphadenopathy.
Hyphen|Lexical hyphen|168|ASSESSMENT: Perianal skin tag and screening colonoscopy. PLAN: Okay for procedures as noted above. The patient seems at low risk for proposed procedures. We will follow-up as needed.
Hyphen|Compound|72|It did seem to help relieve the patient's discomfort somewhat. A chest x-ray was obtained, the report of which is not available.
Hyphen|Lexical hyphen|133|She does have one adopted sister who is deceased. No other siblings. SOCIAL HISTORY: She is married and has no children. She is a non- smoker. Alcohol use is rare. Most recent laboratory studies on _%#MMDD2003#%_: Hemoglobin 12.7, white count 8300, 80% PMNs, 6% lymphocytes, platelets 318,000.
Hyphen|Compound pre-modifiers|183|Protonix 40 mg p.o. b.i.d. 9. Paxil 40 mg p.o. q.d. 10. Seroquel 300 mg p.o. q.i.d. HISTORY OF PRESENT ILLNESS: This is a 46-year-old male with a history of traumatic brain and spinal-cord injury who presented secondary to two episodes of coffee-ground emesis on the evening prior to admission.
Hyphen|Compound pre-modifiers|201|Chronic obstructive pulmonary disease (COPD). 5. Hepatitis C with positive antibody study. 6. Congestive heart failure (CHF) with an ejection fraction of 30% with an implantable defibrillator with dual-chamber pacing, I believe. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is a 78-year- old man presenting with worsening shortness of breath.
Hyphen|Typographic convention|188|97% on room air. Physical exam, general patient is alert, oriented, pleasant, up ambulating, no acute distress, appears comfortable. LUNGS - clear to auscultation bilaterally. EXTREMITIES - left upper extremity with significant decrease in swelling from admission, nontender, no erythema.
Hyphen|Lexical hyphen|250|Further cardiovascular workup and intervention was delayed pending stabilization of his pulmonary status. The patient did have a chest tube placed and, ultimately, a second chest tube placed that failed to adequately drain his hydropneumothorax or re-expand his lungs. Attempts were made to dissolve loculations with lytics and his tubes were repositioned and replaced with larger tubes in Interventional Radiology, however, his right lung never adequately re-expanded.
Hyphen|Compound pre-modifiers|122|8. Tamiflu 75 mg p.o. b.i.d. for the next two days. DISCHARGE FOLLOW-UP: 1. Follow-up with primary care physician on an as-needed basis. 2. Continue follow-ups with neurologist for multiple sclerosis.
Hyphen|Quotative or expressing a quantity or rate|103|5. CT and MRI of the head. 6. Cardiology evaluation. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 51-year-old white male with a history of type I diabetes mellitus, which was complicated by end-stage renal disease, who received a living donor kidney transplant in _%#MM2001#%_, followed by a bladder drained pancreas in _%#MM2002#%_.
Hyphen|To|169|The patient also should follow up with her primary clinic in approximately 7 to 10 days postoperatively to have her staples removed. DISCHARGE MEDICATIONS: 1. Percocet 1-2 tablets p.o. q.4-6h. p.r.n. 2. Motrin 600 mg p.o. q.6h. p.r.n. 3. Colace 100 mg p.o. b.i.d.
Hyphen|Compound|114|STABLE MEDICAL CONDITIONS: Include hypertension, migraines, detrusor overactivity. PROCEDURES, STUDIES: 1. Chest x-ray on admission showing mild thoracic scoliosis, otherwise negative.
Hyphen|Typographic convention|69|Cardiorespiratory - no cough, chest pain, or shortness of breath. GI - no nausea or vomiting, diarrhea or constipation. GU - no history of urinary tract infection and no current irritative or obstructive symptoms.
Hyphen|Compound pre-modifiers|153|3. Chronic anemia and pancytopenia with bone marrow diagnosis of myelodysplasia. 4. Recent MRSA bacteremia with infection of prosthetic right hip on long-term vancomycin therapy. 5. Status-post resection of hepatoma with chronic distal common bile duct obstruction, managed with long-term external biliary drainage.
Hyphen|Compound pre-modifiers|195|Otherwise, there has been no new pain. Her respiratory, bowel and urinary status have been stable, and she denies headaches or neurologic symptoms. PAST MEDICAL HISTORY: Significant for: 1. Above-mentioned metastatic breast cancer. 2. Supraventricular tachycardia. 3. Left upper extremity deep venous thrombosis.
Hyphen|Compound|254|She had CA-125 testing performed which was 134. REVIEW OF SYSTEMS: The patient has been feeling well overnight with weight loss of approximately 12 pounds on Weight Watchers. She has noticed some decreased appetite since finding out about the elevated CA-125. She has also experienced some depression and anxiety with this news.
Hyphen|Quotative or expressing a quantity or rate|99|CHIEF COMPLAINT: Fall with left leg pain. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 46-year-old woman with multiple orthopedic problems including a possible metabolic bone disease. She has seen two orthopedists as well as a rheumatologist.
Hyphen|Compound pre-modifiers|75|She has required Neupogen and Aranesp support during her treatments. Follow-up CT scans after two cycles demonstrated a significant reduction in the large left groin complex mass and a decrease in size of the mildly enlarged left inguinal lymph node.
Hyphen|Compound pre-modifiers|120|Extremities: No edema, pain, or erythema, 2+ deep tendon reflexes with no clonus. Fetal heart tones: 130s with good long-term variability with accelerations. TOCO: Irregular. The latest run was 5 contractions that were approximately 6 minutes apart.
Hyphen|To|176|DISCHARGE MEDICATIONS: 1. Avandia 4 mg p.o. b.i.d. 2. Elavil 25 mg p.o. q.h.s. x 3 days then 50 mg p.o. q.h.s. 3. Mirapex 0.125 mg p.o. q.h.s. 4. Tylenol 325 mg 1 to 2 p.o. q.4-6 hours p.r.n. pain. 5. Iron gluconate 1 p.o. b.i.d. 6. Finasteride 5 mg p.o. daily.
Hyphen|Typographic convention|93|Vital signs - blood pressure 126/80, pulse 80, respiratory rate 14 and he is afebrile. HEENT - head is atraumatic, normocephalic. Pupils are equal, round, reactive to light and accommodation.
Hyphen|Lexical hyphen|235|The patient tolerated the procedure without complications. His postoperative course was complicated by abdominal pain and fevers. Serial blood and urine cultures were negative. Initial CT scan of the abdomen showed no evidence of intra-abdominal abscess. He was covered with broad-spectrum antibiotics but continued with fever.
Hyphen|Lexical hyphen|126|She has been treated as an outpatient for mental health problems. HISTORY OF PRESENT ILLNESS: She was discharged from Fairview-University Medical Center Lodging Plus chemical dependency treatment program on _%#MMDD2005#%_.
Hyphen|Quotative or expressing a quantity or rate|19|The patient is a 61-year-old female and has known multiple sclerosis of a progressive nature. She is a resident of Ebenezer Luther Hall. She was taken to the emergency room at the University Campus yesterday because of abdominal problem with the feeding tube, some fever, and general weakness.
Hyphen|And(fraction)|104|HEAD: Normal. EYES: Normal. ENT: Negative. NECK: Normal. LUNGS: Clear. HEART: Regular rate and rhythm; 1-2/6 systolic murmur. ABDOMEN: Soft; There are varicosities ventrally. There is a ventral hernia present.
Hyphen|Compound|186|The patient had dietary consult for pancreas insufficiency. It was recommended that patient take 1000 units of lipase per kilogram per meal. The patient was instructed to take Ultrase MT-12, take 4-5 capsules with meals. The patient was also recommended to take fat-soluble vitamins ADEK1 tablet p.o. b.i.d. The patient was seen by rheumatology for consult regarding whether biopsy of the native pancreas would be helpful in diagnosing autoimmune pancreatitis.
Hyphen|Compound|93|2. We will follow up with culture data. 3. We will achieve pain control. 4. We will get an OB-GYN consultation for further management. 5. We will give her attentive wound care with frequent dressing changes with the possibility of I and D procedure if she progresses.
Hyphen|Typographic convention|177|SOCIAL HISTORY: She grew up in _%#NAME#%_, Louisiana. She describes her family life as "strict and religious." She was #4 of 7 children. She is currently working on the Fairview-University Medical Center - University Campus, as a medical-legal correspondent.
Hyphen|Quotative or expressing a quantity or rate|159|2. Intravenous Thymoglobulin and steroids. CONSULTATIONS: 1. Interventional Radiology. 2. Psychiatry. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 46-year-old female Caucasian with a history of type 1 diabetes.
Hyphen|Lexical hyphen|142|His heart rate is regular rate and rhythm. His skin is warm and moist. His affect appears to be within normal limits. His abdomen is soft, non-tender, non-distended. No CVA tenderness. GU exam reveals normal secondary sexual characteristics, uncircumcised penis with normal meatus.
Hyphen|Quotative or expressing a quantity or rate|201|GTT elevated at 91. Borderline elevated white count of 1600, not likely felt to be clinically significant. Hemoglobin was 14.2, MCV 91, platelet count 239,000, TSH 1.86. ASSESSMENT: The patient is a 36-year-old male admitted with the following: 1. Depression/alleged suicidal ideation with prior psychiatric diagnoses, as above; defer to Dr. _%#NAME#%_.
Hyphen|Date|194|She came to clinic for genetic consultation and first trimester screening due to advanced maternal age in pregnancy. Pregnancy History: G 5 P 3013 LMP: _%#MMDD2006#%_ Age: 37 EDC (LMP): _%#MM#%_-_%#DD2007#%_ Age at Delivery: 37 EDC (U/S): _%#MMDD2006#%_ Gestational Age: 13+4 weeks * _%#NAME#%_'s prenatal records indicated that her EDC based upon ultrasound is _%#MMDD2006#%_.
Hyphen|Compound|150|Normoactive bowel sounds. EXTREMITIES: Unremarkable. NEUROLOGIC: Grossly intact. LABS: On admission, x-rays showed fracture of right clavicle. Chest x- ray was negative for infiltrate. On admission, TSH was normal. Also on admission, electrolytes with sodium of 120, potassium 2.7, chloride 77, bicarbonate 35, BUN 7, creatinine 0.89, glucose 100.
Hyphen|Quotative or expressing a quantity or rate|98|CHIEF COMPLAINT: Iron deficiency anemia. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 63-year-old retired teacher who has a finding of recent severe aortic stenosis, requiring surgery. This will probably arranged for next week. The cardiologist feels that in the setting of new finding of iron deficiency anemia, that a GI evaluation will be in order prior to surgery.
Hyphen|Quotative or expressing a quantity or rate|132|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD _%#NAME#%_ _%#NAME#%_ is an 82-year-old male seen with his wife present and daughter-in-law who happens to be a pharmacist. This patient apparently called our clinic last night concerned that he was having some weakness episodes, was directed to the emergency room and of course was admitted for a rule out MI and monitoring.
Hyphen|Quotative or expressing a quantity or rate|71|DOB: _%#MMDD1922#%_ HISTORY OF PRESENT ILLNESS: Mrs. _%#NAME#%_ is a 79-year-old female with a history of coronary artery disease. In 1997, she underwent bypass surgery. Reportedly, this was three vessel bypass.
Hyphen|Compound pre-modifiers|220|Ventilator support through her preexisting tracheostomy until able to wean--anticipate rapid weaning within the next several hours. 2. She received Tequin in the emergency room and will continue until cultures and follow-up chest x-ray is available. 3. Urine culture and blood cultures. 4. Seizure medication sedation per Neurology service.
Hyphen|Compound|122|His potassium is 4.4, creatinine 1.3, BUN 36, magnesium 2.1, INR 3.8, WBC 20.4, hemoglobin 10.3, platelets 96,000. Chest x-ray shows a moderate-sized right pleural effusion. CT scan of the chest was performed, although I do not have a copy of those results available at this time.
Hyphen|Phone number|193|The patient will be called with the results of her first trimester screening, as soon as they become available. If I can be of additional assistance, please feel free to contact me at _%#TEL#%_- _%#TEL#%_. Thank you again for the kind referral of this pleasant patient.
Hyphen|Compound pre-modifiers|155|6. Ethambutol induced eye toxicity, has slow improvement in her vision. 7. Gastroesophageal reflux disease. 8. Prior astrocytoma and seizure disorder, well-controlled. PLAN: 1. Timentin and tobramycin for the pseudomonas. 2. Acyclovir IV in full doses for the zoster.
Hyphen|Phone number|118|Thank you for allowing us to participate in the care of this very pleasant patient. Please feel free to call _%#TEL#%_-_%#TEL#%_ should you have any questions or concerns. I was personally present with the resident during the history and exam.
Hyphen|Compound pre-modifiers|92|They did obtain an MRI at that time which was normal. The patient was set up to have a sleep-deprived EEG on an outpatient basis through the Neurology Service.
Hyphen|Quotative or expressing a quantity or rate|127|HISTORY OF PRESENT ILLNESS: I saw _%#NAME#%_ _%#NAME#%_ in neuromuscular consultation on _%#MMDD2003#%_. Mr. _%#NAME#%_ is a 76-year-old man who reports the following history: Over the past 1-1/2 years he has been treated intermittently with steroids for asthma, and has noted a "steroid allergy." Specifically, he reports that his throat "swells up" and "I get crazy." When pressed further, it is not clear whether this is a sensation of swelling in the throat or, in fact, true edema.
Hyphen|Compound pre-modifiers|346|_%#NAME#%_ _%#NAME#%_, MD Fairview Riverside Women's Clinic _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#CITY#%_, MN _%#55400#%_ Dear Dr. _%#NAME#%_: Thank you for the kind referral of your patient, _%#NAME#%_ _%#NAME#%_, who is seen along with her husband, _%#NAME#%_, for genetic counseling at the Maternal-Fetal Medicine Center at Fairview-University Medical Center on _%#MM#%_ _%#DD#%_, 2005.
Hyphen|Quotative or expressing a quantity or rate|47|HISTORY OF PRESENT ILLNESS: The patient is a 37-year-old male, admitted to Station 10 for evaluation and treatment of depression in the setting of alcohol abuse. I have been asked to see him for a general medical evaluation.
Hyphen|Compound|92|She is in a sling and swath with ecchymosis about a swollen right shoulder. I reviewed her x-rays with Dr. _%#NAME#%_. She appears to have a surgical neck fracture of the right humerus that is completely displaced.
Hyphen|Typographic convention|125|Blood pressure is 90/50, pulse is 66. Pupils are round, reactive to light. Conjunctiva are pale. Pharynx is benign. Coronary - normal S-1 and S-2. I-II/VI systolic ejection murmur at the apex. CHEST: Is clear to percussion and auscultation ABDOMEN: Benign.
Hyphen|Quotative or expressing a quantity or rate|259|EXTREMITIES: No peripheral edema, 2+ dorsalis pedis pulses bilaterally. LABORATORY DATA: Hemoglobin 13.3, glucose 107. Sodium 144, potassium 3.8, chloride 106, bicarbonate 28, glucose 97, BUN 11, creatinine 0.6, calcium 9.6. ASSESSMENT/PLAN: Highly complex 50-year-old female with: 1. Hypertension, would recommend continuing home medications which include amlodipine, lisinopril and metoprolol XL.
Hyphen|Quotative or expressing a quantity or rate|47|HISTORY OF PRESENT ILLNESS: The patient is a 23-year-old female admitted to the hospital with fever and abdominal wall pain for a week. She has a significant history of spina bifida, status post colostomy formation and ileal diversion of ureters secondary to her spina bifida.
Hyphen|Quotative or expressing a quantity or rate|134|I will be able to see _%#NAME#%_ during his hospitalization for concurrent medical concerns. DISCUSSION: _%#NAME#%_ _%#NAME#%_ is a 15-year-old tenth grader, currently is hospitalized on STOP Unit, I have been asked to see him by Dr _%#NAME#%_ to assess medical concerns, including cough and head congestion..
Hyphen|Compound pre-modifiers|285|GASTROINTESTINAL: As we have noted above. URINARY TRACT: Foley catheter in place prior to admission. No complaint. SKIN: Without complaint. NEUROLOGIC: Without complaint. IMMUNOLOGIC: The patient stated that last fall, he had adult mononucleosis, and then he stated that it was Epstein-Barr virus- associated, but it seems to have cleared. ENDOCRINE: No history of diabetic or thyroid disorder. PHYSICAL EXAMINATION: GENERAL: This is an obese male who is actually resting reasonably comfortably, although he is mildly tachypneic.
Hyphen|Compound pre-modifiers|153|PAST SURGICAL HISTORY: Right hip replacement earlier this year. ALLERGIES: Amoxicillin has caused respiratory distress in the past. MEDICATIONS: Her long-term regimen has included the following: 1. Protonix 40 mg p.o. q.d. 2. Furosemide 10 mg p.o. q.d. 3. Phenytoin 100 mg p.o. q.d.
Hyphen|Compound pre-modifiers|180|She has been hypotensive into the 50s. The patient had a decreased level of consciousness noted since yesterday. EMS was activated and she was brought here. She had a lot of maroon-red stool liquid stools from her colostomy bag. Her INR was 8.0 and she was given FFP. She is also getting blood and IV fluids through peripheral IVs.
Hyphen|To|207|Demedex 30 mg b.i.d. THERE IS A HISTORY OF ALLERGIES OR INTOLERANCES TO PREDNISONE AND CELEBREX, ALTHOUGH The DETAILS OF THIS ARE UNCERTAIN PHYSICAL EXAMINATION: Blood pressure is running 110/60. Pulse is 55-60 and irregular. Respirations are 16 and unlabored.
Hyphen|Compound|164|HEENT: Orally intubated. Neck veins not distended. LUNGS: Clear to auscultation. CARDIAC: Regular rate and rhythm. ABDOMEN: Benign. RADIOLOGICAL EVALUATION: Chest x-ray was obtained showing no focal infiltrates. LABORATORY DATA: Arterial blood gases as per history of present illness.
Hyphen|Lexical hyphen|207|_%#NAME#%_ reported that she was recently diagnosed with spina bifida occulta, which was found after workup for her distended bladder. A laminectomy was performed, and subsequent requires her to perform self-catheterization. She stated she is adjusting okay, however, this is all new to her, as she had no other problems, and did not know that she has spina bifida occulta previously.
Hyphen|Lexical hyphen|89|3. Paxil 60 mg daily. 4. Zetia 10 mg p.o. daily PAST MEDICAL HISTORY: 1. Status post post-cholecystectomy in 1972. 2. Tubal ligation in 1984. 3. Hypothyroidism on replacement. 4. Fibromyalgia. 5. Previous motor vehicle accident in 2001 with injury requiring evaluation by neurologist.
Hyphen|And|86|LUNGS: Clear to auscultation. No use of accessory muscles of respiration. CORONARY: S1-S2 normal. No S3, S4 or murmur. ABDOMEN: Soft, nontender, no mass or hepatosplenomegaly. Bowel sounds are normal.
Hyphen|Compound pre-modifiers|105|Exam of the extremities reveals normal muscular bulk, peripheral pulses are intact. There is a large well-developed, approximately 3.0 cm in diameter bruise noted to the lateral aspect of the left upper arm, which appeared much older than those bruises noted on his back.
Hyphen|Quotative or expressing a quantity or rate|83|REASON FOR CONSULTATION: Evaluation of febrile illness. IMPRESSION: 1. This is a 20-year-old gentleman here with an acute febrile illness associated with headaches, myalgias, and a very sore throat, plus cervical adenopathy. His workup is negative for bacteremia and CSF pleocytosis.
Hyphen|Typographic convention|161|3) He reports hiccoughs. PAST MEDICAL HISTORY (It should be noted that there is no old chart available): 1) Bipolar disorder. This is his first visit to Fairview-University Medical Center Mental Health Unit. He was seen previously on the Fairview- University Medical Center Chemical Dependency Unit for amphetamine and alcohol abuse.
Hyphen|Compound|182|Mulmed identified hyperaldosteronism with good control of his blood pressure since. His admission labs show a negative troponin but a mildly-elevated serum creatinine of 1.71 and a D-dimer of 0.2. Liver function tests were normal. INR was normal. The remainder of his labs were relatively normal.
Hyphen|Junction|210|INTERNAL MEDICINE CONSULTATION ATTENDING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD. HISTORY OF PRESENT ILLNESS: This is a 53-year-old man with a past medical history of spinal lumbar surgery, recently postop from L3- L4 fusion revision, who presents with 24 hours of severe 8/10, throbbing, constant headache which begins occipitally and radiates throughout. The patient states the headaches have been associated with low grade temps, up to 100 degrees, at home, with chills, nausea and vomiting.
Hyphen|Quotative or expressing a quantity or rate|57|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 79-year-old female who was seen with her husband present. Her husband is a volunteer at this hospital. They say the patient has never had any prior medical illnesses whatsoever, and yesterday told her husband that she was not feeling well and he directed her to come to the Emergency Room.
Hyphen|Quotative or expressing a quantity or rate|47|HISTORY OF PRESENT ILLNESS: The patient is a 23-year-old white man with a history of schizophrenia admitted with increased suicidality with a history of recent alcohol abuse. The patient denies any acute medical problems. PAST MEDICAL HISTORY: HABITS: The patient is a half pack per day smoker.
Hyphen|To|228|The rest of his review of systems is normal. PHYSICAL EXAMINATION: General - the patient is well nourished, alert, oriented, obviously in distress, spitting up sputum. Vital signs - afebrile, blood pressure 125/72, heart rate 75-80, respirations 18. HEENT - he has no oral lesions, no scleral icterus.
Hyphen|Compound|297|HISTORY OF THE PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a otherwise healthy 26-year-old female who was in her usual state of health until last night when she was running. She tripped and fell and injured her left knee. She continued to having pain and was seen in the emergency room today where x-rays were taken. She was found to have a tibial plateau fracture and was splinted and admitted for further evaluation and treatment.
Hyphen|Compound pre-modifiers|396|FINAL OB-GYN Group Fairview-Riverside Women's Clinic _%#STREET#%_ - _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#CITY#%_, MN _%#55400#%_ Dr. _%#NAME#%_ _%#NAME#%_ FV Haiwatha Clinic Dear OB-GYN group, Thank you for the referral of your patient, _%#NAME#%_ _%#NAME#%_, who was seen along with her husband, _%#NAME#%_ _%#NAME#%_, on _%#MM#%_ _%#DD#%_, 2007, at the Maternal-Fetal Medicine Center at the University of Minnesota Medical Center, Fairview.
Hyphen|Compound|143|2. I would limit the Mucomyst use to just a few days to try to help raise secretions but not aggravate her bronchospasm and bronchorrhea. 3. Bi- PAP as needed for respiratory support and would certainly use this when sleeping.
Hyphen|Compound pre-modifiers|433|She has not noticed anything unusual with the hip. She was recently discharged from the Jones-Harrison Home for rehab, to her own dwelling, but went steadily downhill, and within three to four days was admitted by the emergency room physician at Fairview Southdale Hospital with problems including hyponatremia, and a urinary tract infection with sepsis. She is currently on IV vancomycin. PHYSICAL EXAMINATION: The patient is a well-developed, well- nourished, elderly female, in no acute distress.
Hyphen|Compound pre-modifiers|149|PAST MEDICAL HISTORY: Documented in prenatal records. SOCIAL/FAMILY HISTORY: Documented in prenatal records. REVIEW OF SYSTEMS: Please refer to above-mentioned genitourinary, gastrointestinal, musculoskeletal issues.
Hyphen|Lexical hyphen|182|Tetracycline was not tested. PHYSICAL EXAMINATION: The patient is examined in her quad- wheelchair. She does have a Port-A-Cath device in place and the site looks to be clean and non-inflamed. LUNGS: The lungs were clear. CARDIOVASCULAR: The cardiac rhythm was regular.
Hyphen|Compound|159|LABORATORY STUDIES: White blood cell count 4.5, hemoglobin 15.3, platelets 164,000, creatinine 1.02, total bilirubin 0.8, LD 494, TSH 1.17. PATHOLOGY: 1. UHH05-270 (_%#MMDD2005#%_) no evidence of lymphoma. 2. UHR04-582 (_%#MMDD2004#%_) mantle cell lymphoma involving bone marrow. 3. USR04-1146 (_%#MMDD2004#%_) right femoral lymph node biopsy, mantle cell lymphoma.
Hyphen|Date|235|She came to clinic with her husband, _%#NAME#%_ _%#NAME#%_, for genetic consultation and first trimester screening due to advanced maternal age in pregnancy. Pregnancy History: G 3 P 0020 LMP: _%#MMDD2006#%_ Age: 36 EDC (LMP): _%#MM#%_-_%#DD2007#%_ Age at Delivery: 37 EDC (U/S): c/w EDC Gestational Age: 12+5 weeks * No significant complications or exposures were reported in the current pregnancy.
Hyphen|Quotative or expressing a quantity or rate|110|FINAL REASON FOR CONSULTATION: Evaluation of generalized constitutional symptoms. IMPRESSION: 1. This is an 82-year-old woman here for the past several days because of a variety of constitutional symptoms including malaise, weakness, fatigue, general decline in her health over the past several months, reason unclear.
Hyphen|Compound pre-modifiers|200|3) Status post total ankle arthroplasty limiting his exercise. SUGGESTIONS: 1) Metoprolol 50 mg b.i.d. 2) IV amiodarone. 3) IV heparin. 4) Echocardiogram. 5) Thyroid function tests. 6) Possible direct-current cardioversion if necessary. 7) Antiarrhythmic therapy to depend on left ventricular size and function.
Hyphen|Lexical hyphen|396|A TEE done this morning demonstrated moderate to severe mitral valve insufficiency with what sounds like prolapse of both anterior and posterior leaflets to some extent with a myxomatous valve. In addition, the patient had coronary angiography demonstrating 3 vessel coronary artery disease including lesions of the LAD, diagonal and circumflex arteries with a left posterior descending and a non-dominant right coronary artery being demonstrated. PAST HISTORY: Negative for any previous surgeries. The patient has hypercholesterolemia.
Hyphen|Compound pre-modifiers|135|Post-operatively, he is likewise quite stable on low- dose IV nitroglycerin, as well as insulin infusion. PAST MEDICAL HISTORY: 1. Long-standing diabetes mellitus, complicated by diabetic nephropathy and end-stage renal disease.
Hyphen|Compound pre-modifiers|151|Probation allegedly is for 10 years. He has a prior assault charge. He has been previously incarcerated. He has no history of suicidal ideation or self-injurious behavior. He is treated with Lexapro and Seroquel. According to record prior mental health diagnoses of impulse control disorder, cleptomania, and mental retardation.
Hyphen|To|140|Strengths are decreased dramatically on the right between 1-2/5 throughout. Difficult to test due to aphasia. Left side is approximately 3/4-5. Sensation is decreased on the right side. Tone: The patient has sustained clonus in the right upper extremity.
Hyphen|Compound pre-modifiers|200|She has a longstanding history of asthma. She has been bothered by gestational diabetes this admission. She also has problems with gastroesophageal reflux disease. PHYSICAL EXAMINATION: Reveals a well-developed, well-nourished female in no apparent distress. She seems quite happy and is doing well postpartum. HEAD AND NECK: Unremarkable.
Hyphen|Quotative or expressing a quantity or rate|160|DISCHARGE DIAGNOSES: 1. Celiac sprue. 2. Diarrhea secondary to celiac sprue. 3. Dehydration secondary to celiac sprue. HISTORY OF PRESENT ILLNESS: This is an 82-year-old female with past medical history significant for metastatic melanoma, status post multiple treatment regimens, who presented from hematology oncology clinic with worsening diarrhea.
Hyphen|Compound pre-modifiers|168|The pain then extended into the subxiphoid region associated with shortness of breath and nausea. She came to the emergency room where ECG showed diffuse nonspecific ST-T changes without Q waves. The patient was started on IV nitroglycerin, IV heparin, Aggrastat, and aspirin.
Hyphen|Compound pre-modifiers|207|LYMPHATIC: Negative for known lymphadenopathy or lymphedema. PSYCHOLOGICAL/SOCIAL: Negative for depression. Positive for treated seizure disorder. PHYSICAL EXAMINATION: GENEAL: Shows an alert, oriented, well-nourished, well-developed gentleman. Cranial nerves II-XII are intact. VITAL SIGNS: Blood pressure is being monitored at 135/70, pulse is 72.
Hyphen|Compound|92|She has an angular deformity to her small finger and it is ulnarly deviated. Review of her x-rays show a comminuted fracture of the proximal phalanx and she has a small ulnar corner piece as well as a sagittal splitting piece and then the phalanx is deviated, apex ulnar.
Hyphen|Compound pre-modifiers|242|Previous radiation therapy denied. PAST SURGICAL HISTORY: Angioplasty _%#MM1999#%_ with stent placement; transrectal needle biopsy of the prostate; pyloric stenosis treatment; tonsillectomy. PHYSICAL EXAMINATION: General: well-developed, well- nourished male in no acute distress. Appears stated age. Lungs clear to auscultation and percussion. Cardiac: regular sinus rhythm.
Hyphen|Compound pre-modifiers|200|However, cognitive difficulties persist. A question about the value of a lumbar puncture has now arisen, and my opinion regarding this has been requested. On examination, the patient was alert, bright-eyed, and quite appropriate. She admitted to poor memory, which has been a problem, she states, since her gastric bypass surgery.
Hyphen|Quotative or expressing a quantity or rate|57|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 65-year-old woman who was transferred from Queen of Peace Hospital to Fairview Southdale Hospital for analgesic control. I was asked to see her in consultation by Dr. _%#NAME#%_ _%#NAME#%_.
Hyphen|Quotative or expressing a quantity or rate|118|PRELIMINARY REFERRING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is an 83-year-old right-handed white female who is admitted to Fairview Ridges Hospital because of severe intractable left leg pain. I was asked to see the patient for neurologic assessment by Dr. _%#NAME#%_.
Hyphen|Quotative or expressing a quantity or rate|153|He has no history of asthma, seizures or any surgeries. MEDICATIONS: None. ALLERGIES: Cleaning solutions. SOCIAL HISTORY: The patient reports smoking one-half pack of cigarettes per day. He will drink on the weekends approximately eight beers. He denies the use of any street drugs.
Hyphen|Quotative or expressing a quantity or rate|157|Continue Zosyn. 2. Would give oral vancomycin as C. difficile prophylaxis. 3. Surgical considerations being weighed. HISTORY OF PRESENT ILLNESS: This is a 58-year-old female who carried a diagnosis of chronic ulcerative colitis for about 18 years.
Hyphen|Compound pre-modifiers|286|He appears to be in overall good physical condition. SKIN: Evaluation reveals a significant road rash injury involving the back and right posterior arm and left posterior shoulder. Total surface area is approximately 10% of total body surface and the burns consist of fairly deep second-degree burns. At this point, we will need to initiate twice-a-day dressing changes, applying Silvadene cream to the burn, and washing this between dressing changes with saline.
Hyphen|Quotative or expressing a quantity or rate|235|This consultation will also serve as the History and Physical for hospital admission on _%#MMDD2003#%_. EMERGENCY ROOM CONSULTATION REASON FOR CONSULTATION: Left hand infection. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 34-year- old, right-hand dominant electrician who is currently unemployed who is originally from Russia and speaks very little English.
Hyphen|Compound|181|The patient states he does get reflux from time to time. The patient denies hematemesis. He states he has very painful headaches with history of many years, and they have a migraine-component to them. He states he has photophobia and phonophobia, and the headaches are quite debilitating.
Hyphen|Quotative or expressing a quantity or rate|210|Funduscopic examination is benign bilaterally. Facial motility and sensation, tongue and palate motility, hearing, shoulder shrug, muscle bulk, tone and strength. Deep tendon reflexes, plantar responses, finger-nose-finger, heel-knee-shin, light touch and vibration sense are all within normal limits.
Hyphen|Quotative or expressing a quantity or rate|71|Her TSH was normal at 0.81. Her serum pregnancy test was negative. A 12-lead EKG showed sinus tachycardia with a rate of 101 beats per minute.
Hyphen|Quotative or expressing a quantity or rate|166|_%#NAME#%_, at the Fairview-University Medical Center today in follow up of her ICD implantation and left ventricular thrombus. As you will recall, _%#NAME#%_ is a 43-year-old female who has no history of coronary disease who presented to the hospital 1 month ago with complaints of profound dyspnea, palpitations, chest pain, hypotension and tachycardia.
Hyphen|Compound pre-modifiers|161|3. Avandia. 4. Insulin. 5. Hydrochlorothiazide. 6. Toprol. 7. Lipitor. 8. Aspirin. 9. Multivitamins. FAMILY HISTORY: Family history of mental health and chemical- dependency problems show none known. SOCIAL HISTORY: _%#NAME#%_ is married. He has three adult children.
Hyphen|Junction|215|He does have a history of significant back problems with exacerbation such that it is difficult for him to do anything. He has significant right-sided radiculopathy and apparently is scheduled for back surgery of L4-5 next month. Apparently a fusion is being anticipated. He has had significant problems.
Hyphen|Compound pre-modifiers|133|No voiding complaints. Regular menses, menstruating presently. No rash. No focal neurologic complaint. OBJECTIVE: A generally healthy-appearing adult female in no acute distress. Blood pressure earlier today was 120/82 sitting, 100/74 standing. Heart rate in the 60s and regular.
Hyphen|Lexical hyphen|153|2. Chronic lower extremity lymphedema. 3. History of deep venous thrombosis in 1999. 4. Hypertension. 5. Morbid obesity. PAST SURGICAL HISTORY: ORIF post-right hip fracture in 2001. FAMILY HISTORY: Father has coronary disease, diabetes, hypertension, leukemia. Mother has asthma.
Hyphen|Lexical hyphen|95|PHYSICAL EXAMINATION: GENERAL: This is a normal-appearing male in no acute distress. He is well-visualized. HEENT: There is no thyroid enlargement or gynecomastia.
Hyphen|Quotative or expressing a quantity or rate|176|FINAL We have been asked by Dr. _%#NAME#%_ _%#NAME#%_ to evaluate this patient for urinary incontinence. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a very pleasant 62-year-old female with a past medical history significant for chronic paranoid schizophrenia, admitted on _%#MMDD2006#%_ after an episode of increased paranoia, decreased insight and possibly medical noncompliance.
Hyphen|Protocol number|435|2. UHH06-3059 (_%#MMDD2006#%_) Variable cellular marrow, overall 40% persistent dyspoiesis and elevated blast percentage (7%) consistent with persistent disease. IMPRESSION: Myelodysplastic syndrome. RECOMMENDATIONS: _%#NAME#%_ was seen with Dr. _%#NAME#%_ _%#NAME#%_, who agrees the patient appears to be a suitable candidate for 200 cGy total body irradiation prior to her umbilical cord blood transplant per our local protocol #2005-02. Conditioning for this protocol includes chemotherapy, as well as the total body irradiation.
Hyphen|Quotative or expressing a quantity or rate|21|HISTORY: This is a 70-year-old male from _%#CITY#%_, Minnesota, who underwent a left total ankle arthroplasty and mid foot fusion earlier today. We were asked by the patient's orthopedic surgeon, Dr. _%#NAME#%_ to see the patient for postoperative general medical care.
Hyphen|Quotative or expressing a quantity or rate|149|INDICATION FOR CARDIAC CONSULTATION: Abnormal stress echocardiogram with inferior akinesis. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 34-year- old man who was sent for stress echocardiography because of chest discomfort and hypertension.
Hyphen|Compound|144|He has three siblings, all of whom have passed away with what he says was of old age. He tells me he has four children. LABORATORY DATA: Chest x-ray dated _%#MMDD2003#%_ shows a dense right lower lobe infiltrate that was new from _%#MMDD2003#%_.
Hyphen|Lexical hyphen|291|I will also give him Plavix. We will plan on left heart catheterization tomorrow unless he becomes unstable. Currently as mentioned he has no chest pain. ADDENDUM: If the patient's angiogram is negative for coronary disease, I would next look for pulmonary embolism and gastrointestinal work-up and effusion.
Hyphen|Typographic convention|156|HEART, LUNGS - normal. ABDOMEN - only minimally distended, bowel sounds are present. There is tenderness throughout the abdomen but no rebound. EXTREMITIES - negative. NEURO - nonfocal. SKIN - no spiders. CT - I have had a chance to review this with the radiologist, Dr. _%#NAME#%_.
Hyphen|Compound|120|Extraocular movements conjugate. Speech is fluent and articulate. No dysarthria. No hoarseness of voice. Chest has Steri-Strips over the left upper quadrant over a pacemaker incision.
Hyphen|Quotative or expressing a quantity or rate|219|ASSESSMENT/PLAN: 1. Depression with suicidal ideation, PTSD, and borderline personality per Dr. _%#NAME#%_. 2. Urinary retention. We will increase the patient's bethanechol to 50 mg p.o. b.i.d. and give the patient a 10-day supply when she is discharged. The patient will also make an appointment with the urologist at the University of Minnesota upon discharge.
Hyphen|To|222|Will look into these issues for her. We will be very glad to assist in her care. Thank you for allowing us to help. Anticipate discharge to her own home with visiting health care aides and nurses probably within the next 3-4 days. Thank you for allowing us to help.
Hyphen|Lexical hyphen|116|Lungs reveal scattered rhonchi. Cardiac exam reveals a regular rate and rhythm without murmurs. Abdomen is soft, non-tender, non- distended. Extremities reveal no edema. Neurologically she is alert and not tremulous. Motor, sensory and coordination are intact.
Hyphen|Quotative or expressing a quantity or rate|145|She also takes eye drops. She is also on Prozac for depression. She also has a history of osteoporosis. PHYSICAL EXAMINATION: Pleasant _%#1914#%_-year-old alert female. She is very slim. She has tenderness over her left hip and pain with any motion but alignment.
Hyphen|Compound|86|No leg tenderness, swelling, pain, PND or orthopnea. PAST MEDICAL HISTORY: 1. Guillain-Barre 30 years ago. 2. GERD. 3. GI bleeding. 4. Barrett's esophagus. 5. Recent UTI. 6. No recent echo.
Hyphen|Compound pre-modifiers|202|In addition, the patient would likely benefit from an increase in dose of his beta blocker to 50 mg p.o. daily. Lipids will be evaluated and if elevated as the patient has previous noted, eventual lipid-lowering therapy will be of benefit. At this time, there is no evidence that the patient is experiencing any pulmonary process such as pulmonary embolus.
Hyphen|Compound pre-modifiers|354|EKG on _%#MM#%_ _%#DD#%_, 2006 showed A-pacing and a normal QRS complex with one occasional PVC and mild ST-T segment change. LABORATORY: Magnesium 2.2, sodium 137, potassium 3.9, chloride 106, bicarbonate 27, BUN 24, creatinine 1.09, hemoglobin 11.6, white blood cell count 6.9. ASSESSMENT AND PLAN: It sounds like the patient has typical vasovagal near-syncope episode. He did have a pacemaker implantation for a long, long time and still seemed to be functioning well from the EKG and telemetry.
Hyphen|Quotative or expressing a quantity or rate|141|_%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_ at the request of the patient himself. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 62-year-old Caucasian gentleman with adenocarcinoma of the prostate.
Hyphen|Compound|237|There is no family history of sleep disorders except a grandmother apparently had sleep apnea, although unsure how this diagnosis would have been made. LABORATORY DATA: HCO3 is 31. Arterial blood gases on room air: 7.40/45/51/84. Chest x-ray dated _%#MMDD2005#%_ shows no infiltrates or effusions and is clear.
Hyphen|Compound|166|We will await formal interpretation by Radiology. IMPRESSION: 1. Respiratory failure. Will check sputum culture and Gram stain. Will put him on Combivent MDI and Solu-Medrol. I agree with the antibiotics. We will manage his ventilator and adjust it for good oxygenation and ventilation.
Hyphen|Lexical hyphen|229|There was some radiation to the back. Therefore, a CT scan of the chest with contrast was performed, and it did not show any dissection or aneurysm or any pulmonary embolism. Hiatal hernia was noticed. She has remained chest pain-free since 11:40 last night. Her pain really improved with some Mylanta, and belching that was precipitated by drinking Pepsi.
Hyphen|Compound pre-modifiers|214|4. Apparent elevated creatinine, raising the question of whether this represents acute renal insufficiency related to above, or is in fact a chronic renal insufficiency. BUN is 26, which may suggest a more prerenal-type etiology, given his clinical presentation. There is no documentation of urinary sediment and no history of renal insufficiency.
Hyphen|Compound|149|She was taken to the emergency room, x-rays were taken which demonstrated a pneumothorax in her chest and a chest tube was placed on the left side. X-rays also demonstrated a displaced intertrochanteric femur fracture of her left hip, and an old bipolar hemiarthroplasty on the right.
Hyphen|Quotative or expressing a quantity or rate|100|REASON FOR CONSULTATION: Left renal colic. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 55-year-old gentleman, from _%#CITY#%_, and was planning on leaving today, who developed left renal colic. Yesterday he presented to an Urgent Care Center and was diagnosed with a urinary tract infection.
Hyphen|Quotative or expressing a quantity or rate|173|Risperdal. 3. Trazodone. 4. Albuterol. The patient uses albuterol approximately twice a week, per patient report. ALLERGIES: Penicillin. SOCIAL HISTORY: The patient is a one-pack-per-day smoker x 13 years. The patient denies drug use. FAMILY HISTORY: Negative for diabetes, coronary artery disease, hypertension, and cancer.
Hyphen|Lexical hyphen|107|HEENT EXAM: Extraocular movements are full. No nystagmus. Pupils equal, reacting symmetrically. Sclerae non-icteric. Funduscopic exam deferred. Oropharynx is clear. Dentition: Adequate repair. Carotids: 1-2+ with right-sided bruit. Right carotid endarterectomy scar is noted.
Hyphen|Phone number|171|_%#NAME#%_ to the University of Minnesota Medical Center, Fairview. If you have any questions or concerns feel free to contact me or Dr. _%#NAME#%_ _%#NAME#%_ at _%#TEL#%_-_%#TEL#%_. Prior transplant Mrs. _%#NAME#%_ will be followed by Dr. _%#NAME#%_ _%#NAME#%_, and after transplant by the BMT Clinic.
Hyphen|Obstetrical data|182|I spent approximately 50 minutes with this patient reviewing the following information. _%#NAME#%_ is a 35-year-old who will be 36 at the time of delivery, and is a gravida 2, para 1-0-0-1 who is currently 13 weeks and 3 days gestation based on an estimated date of delivery of _%#MM#%_ _%#DD#%_, 2005.
Hyphen|Quotative or expressing a quantity or rate|136|He also sells church furniture. He occasionally drinks wine. He does not smoke. He is married with two children. REVIEW OF SYSTEMS: A 10-point review of systems is significant for corrective lenses and hypertension.
Hyphen|Compound pre-modifiers|193|4. Hyponatremia. This is new. He has clinical evidence of right heart failure. 5. Cor pulmonale with clinical findings suggestive of significant pulmonary hypertension, all secondary to his end-stage emphysema. RECOMMENDATIONS: Diuretics may add to the current excellent choice of medication.
Hyphen|Typographic convention|188|HEENT - negative Neurologic - negative. Respiratory - no cough dyspnea, chest pain, orthopnea, PND. Cardiac - no syncope, presyncope, palpitations, claudication or edema. Gastrointestinal - no nausea, vomiting, diarrhea or constipation. Urinary - negative. Musculoskeletal - negative. Psychiatric - some stress as discussed above.
Hyphen|Quotative or expressing a quantity or rate|201|The patient has a history of abuse, but has gone through numerous years of therapy and feels that she is in an emotionally stable status at the present time. PHYSICAL EXAMINATION: GENERAL: This is a 31-year-old Hispanic female who is morbidly obese, in moderate state of health, no acute distress, full affect.
Hyphen|Compound|156|NECK: She has bilateral carotid bruits, but normal carotids by palpation. LUNGS: Clear lung fields. HEART: Normal first and second heart sounds, with a gull-type of systolic ejection murmur that appears to peak in mid-systole, suggestive of the possibility of aortic stenosis versus aortic sclerosis.
Hyphen|Quotative or expressing a quantity or rate|171|FINAL We have been by Dr. _%#NAME#%_ _%#NAME#%_ to evaluate this patient for urinary retention. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ _%#NAME#%_ is a very pleasant 51-year-old Caucasian male with a history of degenerative spine disease and status post previous L2/L3, L3/L4 fusion.
Hyphen|Compound pre-modifiers|254|We will reschedule to visit with her daughter around treatment options for her mother, and delineation of further advance direct, as the patient is currently DNR/DNI. 2. TLC will follow to support the daughter in caring for mother, and help with decision-making process. Thank you for involving us in this patient's care.
Hyphen|Quotative or expressing a quantity or rate|163|_%#NAME#%_ to do a consult for low back pain. She states that Thursday night she did come to the Emergency Room because the pain was so intense. _%#NAME#%_ is a 40-year-old female who is approximately 5 feet 6 inches weighing 145 pounds.
Hyphen|Compound|113|PHYSICAL EXAM: Reveals an adult male who at times was coughing. He is not bringing up any sputum. Yesterday his T-max was 101.5, currently he is afebrile and his vital signs are stable.
Hyphen|Compound|174|There is compressive atelectasis. There is a question as to whether there is a pneumothorax on the right. Left upper extremity duplex shows no deep venous thrombosis. Chest x-ray shows bilateral pleural effusions, right greater than left with moderate cardiomegaly.
Hyphen|Quotative or expressing a quantity or rate|61|_%#NAME#%_ _%#NAME#%_ is seen in his patient room. He is a 78-year-old gentleman who is just one week post laparoscopic cholecystectomy. Mr. _%#NAME#%_ postoperatively developed symptoms of odynophagia. He describes when he eats or drinks anything, including water, that it seems that everything gets tightened up and plugged up in the proximal to mid- substernal area.
Hyphen|Quotative or expressing a quantity or rate|246|Her right lower extremity is neurovascularly intact distally. X-ray examination of the right hip and femur shows a relatively transverse subtrochanteric femur fracture with displacement. ASSESSMENT: Right subtrochanteric femur fracture in this 65-year-old female with morbid obesity. It appears that she had a stress fracture, which completed today.
Hyphen|To|437|We will step in as a TLC team to be supportive at this time to his wife and will work with our team of physicians to manage his care and direct the conversation of medical value for continued treatments for this patient. PAST MEDICAL HISTORY: Diabetes mellitus, end-stage renal disease with dialysis 3 times a day, hypertension, hyperlipidemia, diabetic neuropathy, cardiomyopathy, coronary artery disease with an ejection fraction of 20-25%, atrial fib, atrial flutter, peripheral vascular disease, hypotensive events which have led to frequent falls, IBS, CVI in 2006 with relatively few deficits, depression.
Hyphen|Compound pre-modifiers|181|PAST MEDICAL HISTORY: She is an otherwise healthy, active, young lady. PHYSICAL EXAMINATION: A healthy-appearing young lady. She is alert and oriented, quite comfortable in the long-arm sugar-tong splint. The splint is fitting well. She does have tenderness along the distal radial shaft and distal forearm.
Hyphen|Typographic convention|157|One brother with a history of leukemia. SOCIAL HISTORY: Single, no children. Works in the hospital as a nursing assistant. REVIEW OF SYSTEMS: Cardiovascular - negative. History of hypertension when she has severe pain. Pulmonary - occasional smoker, would not quantitate the amount for me.
Hyphen|Quotative or expressing a quantity or rate|214|At your request, Ms. _%#NAME#%_ was referred here to discuss the influence of maternal age on pregnancy outcomes and the first trimester biochemical and nuchal translucency screen. This letter will summarize our 45-minute discussion. As you know, Ms. _%#NAME#%_ is a 35-year-old, gravida 1, para 0, whose pregnancy was 12 weeks 6 days based on an estimated date of delivery of _%#MMDD2008#%_.
Hyphen|Typographic convention|146|Aspirin 9. Nitroglycerin 10. Acetaminophen 11. Ibuprofen REVIEW OF SYSTEMS: Constitutional - she has not had any fever or weight loss. Neurologic - no dizziness or light-headedness except for her vertigo.
Hyphen|Typographic convention|100|NEUROLOGIC: Sedated, he has had no focal signs when allowed to awaken. LABORATORY DATA: ABGs on 60% - FIO2 7.46/37/176/25/98 percent. Hemoglobin 9.1, white count 28,100, platelets 354. Sodium 135, K 4.3, chloride 106, CO2 29, creatinine 1.5 (slightly above baseline), BUN 30, albumin less than 1, and calcium 6.5 (reflecting the low albumin).
Hyphen|Compound pre-modifiers|212|ASSESSMENT/PLAN: 1. Depression, per Dr. _%#NAME#%_. 2. Uncontrolled hypertension: Will start patient at 5 mg of Norvasc p.o., dosed daily in the morning. 3. Low hemoglobin and hematocrit, likely secondary to iron-deficiency anemia: Will continue patient on ferrous sulfate and add Colace 100 mg b.i.d. for constipation prevention.
Hyphen|Compound|244|The client started drinking alcohol at the age of 17, which progressed to daily use of 6 beers or more per day and his last use was _%#MMDD2007#%_. SUMMARY OF CD SYMPTOMS ACKNOWLEDGED BY THE PATIENT: The client is identified with 7 out of 7 DSM-IV criteria for diagnosis of substance dependency with physiological dependence.
Hyphen|Lexical hyphen|157|REVIEW OF SYSTEMS: She admits to having recent headache, which appears to be stress related. She does not take any sort of medication and it seems to be self-resolving. She also admits to having decreased iron in the past during menstrual periods.
Hyphen|Quotative or expressing a quantity or rate|166|PRELIMINARY GASTROINTESTINAL CONSULTATION CHIEF COMPLAINT: Bloody diarrhea. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 39-year-old male who has had a four- to five-day history of abdominal pain, now associated with bloody diarrhea. He had had some fevers at home. He also had some episodes of vomiting.
Hyphen|Compound pre-modifiers|308|He did have positive bleeding and discomfort with debridement. The excisional debridement was done with a #15 blade and a forceps. Site was then dressed with Silvadene and dry sterile gauze dressing and order was written for a consult with Orthotics and Prosthetics to place patient in a CAM boot with an off-loading forefoot accommodation to protect the ulceration site.
Hyphen|Compound pre-modifiers|158|He was not found to have any focal findings. He was spitting and biting throughout this time. He also had paranoid ideations. One time he had another "seizure-like activity" which his eyes rolled to the back of his head, but he was able to respond to questions.
Hyphen|Quotative or expressing a quantity or rate|166|The patient has one sister who is alive and well. The patient's father has diabetes, depression and alcohol abuse. REVIEW OF SYSTEMS: The patient has experienced a 60-pound weight loss in the last two years. The patient has expressed that she has some chest pain with the most recent being within about the last week.
Hyphen|Compound pre-modifiers|178|Cod liver oil. LABORATORY DATA: ESR is 17, sodium 139, potassium 3.8, glucose 1.27, white cell count 7.4. Hemoglobin 12.9, platelet count 380. RADIOLOGIC FINDINGS: T2 level right-sided neuroforaminal 1 cm lesion which is contrast enhancing.
Hyphen|Typographic convention|256|2) Hyperlipidemia -- We will be getting a fasting lipid profile in the morning and we will probably need to resume his lipid medications, but we will wait for those results to restart his medications. 3) Hypertension, which is controlled on his medication -- We would recommend that his systolic blood pressure remain less than 110 due to his decreased ejection fraction.
Hyphen|Lexical hyphen|89|The left breast also has no masses or lumps palpable. ABDOMEN: Positive bowel sounds, non-tender, non- distended, no hepatosplenomegaly. EXTREMITIES: No clubbing, cyanosis, or edema. NEUROLOGIC: Cranial nerves II through XII intact., strength is 5/5 in all 4 extremities, light touch is symmetric and intact, gait is smooth and symmetric.
Hyphen|Lexical hyphen|153|She denies fevers or chills. PAST MEDICAL HISTORY: 1. Chronic psychiatric illness. She has undergone ECT in the distant past. 2. History of seizures well-controlled. She cannot recall when she last had a seizure.
Hyphen|Quotative or expressing a quantity or rate|152|HISTORY OF PRESENT ILLNESS: Dr. _%#NAME#%_ _%#NAME#%_ is requesting an orthopedic consultation for _%#NAME#%_'s left upper extremity. _%#NAME#%_ is a 49-year-old Caucasian male who unfortunately has poorly controlled insulin-dependent diabetes who presented to the Emergency Room on _%#MMDD2007#%_ with abrupt onset of left forearm swelling, induration and erythema.
Hyphen|Lexical hyphen|99|The patient was seen and examined by Dr. _%#NAME#%_ _%#NAME#%_. CHIEF COMPLAINT: Stage T1 N2 M0 non-small-cell lung cancer. HISTORY OF PRESENT ILLNESS: The patient is a 54-year-old female with a history of limited-stage small-cell carcinoma treated with chemotherapy and radiation _%#MM2002#%_.
Hyphen|Compound|150|3. Right lower lobe pneumonia, probably related to splinting from her right upper quadrant pain. This process was not present on her admission chest x-ray. 4. History of cervical cancer, status post hysterectomy.
Hyphen|Quotative or expressing a quantity or rate|49|DOB: _%#MMDD1976#%_ _%#NAME#%_ _%#NAME#%_ is a 26-year-old female patient seen in consultation on _%#MMDD2002#%_ for a neurological evaluation following a seizure episode. The patient was being transferred from the cart when she felt tightness in her jaw she could not talk or breath.
Hyphen|Compound pre-modifiers|113|3. Pneumonia, possible aspiration. RECOMMENDATIONS: 1. I would recommend intubation. 2. Sputum culture. 3. Follow-up chest x-ray. 4. Blood cultures. 5. Mechanical ventilation is required. 6. Sedation as needed.
Hyphen|Phone number|92|ADDRESS: _%#STREET#%_ _%#STREET#%_ _%#STREET#%_, _%#CITY#%_, MN _%#55300#%_ PHONE: _%#TEL#%_-_%#TEL#%_ CHIEF COMPLAINT: _%#NAME#%_ _%#NAME#%_ is a 60-year-old woman with rheumatoid arthritis kindly referred by Dr. _%#NAME#%_ _%#NAME#%_ because of hematochezia. The patient was well until Sunday night, _%#MM#%_ _%#DD#%_, in the middle of the night when she woke up with severe urge to defecate.
Hyphen|Quotative or expressing a quantity or rate|109|Remaining liver function normal. White count 4400, hemoglobin 14.7, MCV 96, platelets 263,000. ASSESSMENT: 39-year-old male admitted with the following: 1. Chemical dependency to alcohol, with relapse. a. Mild alcohol withdrawal.
Hyphen|Lexical hyphen|121|IMPRESSION: This lady presents with unclear episode of loss of consciousness and now she is encephalopathic. Current work-up shows that she has problems with electrolytes and sugar.
Hyphen|Lexical hyphen|110|Chest x-ray done at the home yesterday, showed no acute infiltrates. PAST MEDICAL HISTORY: HABITS: He is a non-smoker, non-drinker. MEDICATIONS: Are listed in the nursing home sheets.
Hyphen|To|205|He came to the hospital noting the onset at approximately 9:30 p.m. on the evening of _%#MMDD2003#%_ of substernal chest aching and discomfort. This had no radiation, and it was rated as 4, on a scale of 1-10. He has never had this symptom before, but it was bad enough to make him come to the emergency room, and this is a man who does not pay a lot of attention to his health.
Hyphen|Compound|135|PAST MEDICAL HISTORY: 1. Hypertension. 2. Hyperlipidemia. 3. Degenerative joint disease. 4. Hypothyroidism. MEDICATIONS: Atenolol and L-thyroxine. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 128/61, respiratory rate 24 on BiPAP.
Hyphen|Typographic convention|72|EYES - negative. MOUTH - reveals no oral lesions. HEART - normal. LUNGS - clear. ABDOMEN - nontender. EXTREMITIES - negative.
Hyphen|Line-breaking hyphen|181|The patient has a history of systemic lupus erythematosus and underwent a primary hip arthroplasty by Dr. _%#NAME#%_ _%#NAME#%_. Her course was complicated by an infection postopera-tively, which required treatment with debridement, placement of antibiotic beads, and long-term antibiotic intravenous treatment.
Hyphen|To|132|* Chorionic villus sampling (CVS) is an invasive procedure that can diagnose chromosome conditions with 99% accuracy. There is a 0.5-1% risk of miscarriage associated with this procedure.
Hyphen|Quotative or expressing a quantity or rate|173|He also has a positive Babinski sign bilaterally. Vibration is decreased in the lower extremities distally bilaterally. Light touch, however, is relatively preserved. Finger-nose-finger and heel-knee-shin are intact. Rapid alternating motion rate is acceptable. I did not examine gait, posture and stance because the patient just had a coronary angiogram and he has an arterial puncture in the femoral artery.
Hyphen|Lexical hyphen|101|Lungs are clear. Cardiac exam reveals a regular rate and rhythm without murmurs. Abdomen is soft, non-tender, and non-distended. Extremity exam reveals no calf tenderness.
Hyphen|Compound|117|She was noted to have a hemoglobin of 12.6, white count of 18,900 with 85% PMNs, platelet count of 370,000. A chest x- ray on 3/19/2005 revealed a pattern consistent with congestive heart failure with mild cardiomegaly and diffuse hazy moderate pulmonary congestion.
Hyphen|Lexical hyphen|270|PAST MEDICAL HISTORY: For Past Medical History and further review, please see inpatient consultation from _%#MMDD2004#%_. In the interim, there has been no significant change. We continue our recommendation that the patient should have intermittent catheterization as in-house she has had residuals of 400 to 500. Whether or not the patient can self-cath is an issue.
Hyphen|Compound pre-modifiers|181|She is morbidly obese. Her incision is healed satisfactorily. There is no evidence of drainage, erythema, or rash. NEUROLOGIC: Examination does not reveal any focal deficits. Two AP-pelvis x-rays are reviewed with Dr. _%#NAME#%_. A dislocated hip prosthesis is in place. There has been disarticulation and fracture of the constrained liner, which was previously cemented into the ingrowth cup.
Hyphen|Minus|286|Her vitamin B12 level was 143. We did do a nuclear medicine red blood cell mass study which showed her red cell mass to be 55.5 ml/kg (normal 24 + or - 3 ml/kg). Her total blood volume was 53 ml/kg (normal 59 + or - 5 ml/kg), and a calculated plasma volume was 28 ml/kg (normal 35 + or - 5). Putting all of this together, this patient, in my estimation, has a contracted plasma volume which results in an elevation in her hematocrit.
Hyphen|Compound pre-modifiers|226|LABORATORY VALUES: Most notable for a white count of 11,800, hemoglobin 9.9, BUN and creatinine are normal at 41 and 1.86. Blood cultures and urine cultures are negative so far. IMPRESSION: Hematuria, chronic with a suprapubic-indwelling catheter. It is most likely due to trauma. There may be an element of infection.
Hyphen|Typographic convention|79|LUNGS - clear to auscultation. No use of accessory muscles of respiration. COR - S1, S2 normal. No S3, S4, or murmur. ABDOMEN - soft, nontender. No mass or hepatosplenomegaly. Bowel sounds normal.
Hyphen|Lexical hyphen|204|LUNGS: Clear to auscultation bilaterally. CARDIAC EXAMINATION: Regular rate and rhythm with a normal S- 1 and S-2, no S-3 on S-4. No murmurs, no rubs, no gallops. ABDOMEN: Positive bowel sounds, soft, non-tender, non-distended without hepatosplenomegaly. EXTREMITIES: No cyanosis, no clubbing and no edema. NEUROLOGICAL EXAMINATION: Cranial nerves II-XII are intact.
Hyphen|Compound pre-modifiers|158|He has two sisters in good health. REVIEW OF SYSTEMS: At this time unobtainable since the patient is intubated and sedated. PHYSICAL EXAMINATION: He is a well-nourished gentleman, sedated and intubated. His blood pressure ranges from 135/80 on Dopamine, his pulse drops to the 40s, his temperature is 96.6. SKIN: Quite pale.
Hyphen|Compound|133|PAST MEDICAL HISTORY: 1. Multiple previous psychiatric hospitalizations, most recent discharge was _%#MMDD2002#%_. 2. Status post TAH-BSO in 1997 for treatment of endometriosis. 3. Asthma. MEDICATIONS 1. Neurontin 900 mg p.o. t.i.d. 2. Estradiol 1 tab q.d.
Hyphen|Junction|177|The contribution of L3-4 is difficult to ascertain, although its central protrusion causes some effacement of the thecal sac and may cause problems with the traversing roots. L4-5 is quite degenerative with bony end plate and reactive marrow changes present in addition to the advanced degenerative disc changes.
Hyphen|Lexical hyphen|107|5. Very slightly elevated bilirubin. Will plan to check a fractionated bilirubin. I will be happy to follow-up should further issues arise. Thanks.
Hyphen|Junction|415|He plays football for the University of Minnesota and was noted to have a significant injury several days ago/week ago with a right brachial plexus injury from trauma. The patient was evaluated carefully at that time with MRI demonstrating edema and presumed stretch injury in the right brachial plexus and clinical examination demonstrated weakness from the C-5 level in the brachial plexus through at least the C7-8 level. The patient was placed in a splint and has been in physical therapy, I believe, and has had some improvement such that now his strength is perhaps 1-2/5 in these regions, at least indicating improvement.
Hyphen|Compound|111|MEDICATIONS: 1. Tikosyn 375 mg p.o. b.i.d. 2. Lisinopril 20 mg b.i.d. 3. Norvasc 5 mg b.i.d. on hold. 4. Toprol-XL 25 mg p.o. b.i.d. 5. Aspirin is on hold. CODE STATUS: Full code. SOCIAL HISTORY: The patient lives alone.
Hyphen|And|193|coli, susceptibilities are pending. CSF culture-no growth so far, gram stain- no organisms, rare PMNs. Fungal CSF culture-no growth so far, CSF- white count 13, RBC 4583, differential 69.6, 16 -14 monocytes, 1 eosinophil. Glucose and protein within normal limits. _%#MMDD2005#%_ Chest x-ray. Borderline heart size, distinct pulmonary vascularity, right IJ catheter in the right atrium.
Hyphen|Lexical hyphen|200|He still has had problems with severe insomnia. He was prescribed Trazodone 50 mg last night to get four hours' sleep. The patient denies any other acute medical problems. HABITS: The patient is a non-smoker. He drinks one beer every three days. ALLERGIES: Penicillin. CURRENT MEDICATIONS: None.
Hyphen|Compound|215|PSYCHOLOGY TESTING REPORT MMPI-II REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, M.D. PATIENT INFORMATION: The patient is a 37-year-old male. He was admitted to the mental health unit. He was asked to complete an MMPI- II as part of his initial diagnostic work up. FACTORS AND CONFIDENCE OF FINDINGS: It should be noted that this test was interpreted in a blind fashion, that is without direct patient contact such as clinical interview or behavioral observations.
Hyphen|Lexical hyphen|149|NECK: Supple, no lymphadenopathy or thyromegaly. HEART: Regular rate and rhythm, no murmurs or rubs. LUNGS: Clear to auscultation. ABDOMEN: Soft, non-tender, non-distended, no organomegaly or mass. EXTREMITIES: Normal muscular bulk. Gait appears normal. LABORATORY EVALUATION: CBC and CMP without abnormality.
Hyphen|Compound pre-modifiers|210|2. Hemoccult-positive stool with a 2-gram drop in hemoglobin. This does not, in my mind, appear to be a significant GI bleed. This is not true melena. The hemoccult-positive stool is probably coming from stress-induced gastritis or stress-induced ulcerations, as well as and in addition to her excoriated bottom.
Hyphen|Compound pre-modifiers|262|He did note that he has had lower extremity edema which has gotten worse particularly over the last few days prior to admission and he had a cough productive of some green phlegm which bothered him starting about a week before admission. He had also had some low-grade fevers which resolved prior to admission. He has a history of sleep apnea and has a CPAP at home which apparently he has been using at night.
Hyphen|Quotative or expressing a quantity or rate|186|Hemoglobin is 13, creatinine 0.56, white count on 1/17 was 11.1 and yesterday was 7.2. PAST MEDICAL HISTORY: Remarkable for gestational diabetes, and that has been recently. She has a 10-month-old. It did normalize after birth. She has a non-alcoholic fatty liver disease and positive H.
Hyphen|Quotative or expressing a quantity or rate|372|In the midst of all of this, in spite of there being no symptoms to suggest coronary ischemia of an anginal variety, although he is more short of breath and weak and identifies some postural dizziness, he has two sets of enzymes which show a non-Q wave myocardial infarction that are 6 and 12, well within the range of diagnostic numbers. Mr. _%#NAME#%_ is a remarkable 78-year-old man, who is a World War II veteran, having fought in the last great battle in the South Pacific at _%#CITY#%_.
Hyphen|Lexical hyphen|222|CT scan of the abdomen and pelvis was also reviewed, and this showed proximally-dilated small bowel with distally-decompressed small bowel, no obvious acute etiology for this. The pancreas appeared normal, no obvious intra-abdominal masses. Abdominal ultrasound was obtained, and at this time the results of that are still pending.
Hyphen|Lexical hyphen|113|I will review urinalysis to rule out abnormality. Thank you for this consultation. We will be available to follow-up should any other medical concerns arise during this hospitalization.
Hyphen|Obstetrical data|164|The patient only speaks Korean and our discussion today is facilitated by the patient's daughter who speaks both English and Korean. PAST MEDICAL HISTORY: G4, P4, 0-0-4 menopausal female with no previous history of hospitalizations.
Hyphen|Compound pre-modifiers|163|HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ was found to have an abscess associated with diverticulitis. She was transferred from Fairview Northland Hospital for CT-guided drainage of the diverticular abscess. Although she has had a number of CT scans, the final CT scan was suggestive that this was an abscess that could not be drained percutaneously because of the location of the abscess deep within the abdomen.
Hyphen|Quotative or expressing a quantity or rate|218|Balance; the patient walks without loss of balance. She is able to stand on one leg; both the right side and left side without loss of balance. Reflex is 1+ at the biceps, ankles, and knees. ASSESSMENT: Patient is a 22-year-old woman with new onset seizure disorder and sagittal sinus thrombosis which has resulted in very mild left sided weakness and decreased coordination.
Hyphen|Compound pre-modifiers|292|FAMILY HISTORY: Not obtained. REVIEW OF SYSTEMS: He does deny headaches, fevers, chills, dyspnea, chest pain, abdominal pain, nausea, vomiting, constipation, diarrhea, or urinary complaints. PHYSICAL EXAMINATION (HLI): GENERAL: The patient appears to be somewhat overweight, generally healthy-appearing African American male in no acute distress. HEENT: Head normocephalic, atraumatic. Eyes show extraocular motions intact; PERRLA.
Hyphen|Compound pre-modifiers|146|REVIEW OF SYSTEMS: Remarkable for fatigue and for diarrhea over the last few days. Denies abdominal pain, nausea or vomiting. She does note a long-standing problem with itching on the soles of her feet. PHYSICAL EXAMINATION: She is a well-appearing female who is in no acute distress.
Hyphen|Compound pre-modifiers|145|TMs were pearly gray without effusion. Oropharynx revealed 3+-4+ tonsillar hypertrophy without erythema or exudate. He did have a nasal congested-sounding voice. Neck was supple. There was shotty anterior and posterior chain cervical lymphadenopathy without thyromegaly.
Hyphen|And(fraction)|161|I discussed all these options with the patient and his family as well as with the heart failure team. I spent a total of 2-1/2 hours with the patient, of which 2-1/2 hours for the exam of the patient and reviewing investigations and 1 hour spent on discussion of therapeutic options.
Hyphen|Quotative or expressing a quantity or rate|47|HISTORY OF PRESENT ILLNESS: The patient is a 16-year-old female admitted to station 6A for evaluation and treatment of polysubstance abuse. The patient had a suicide attempt in which she ingested approximately 25 mg of Ativan.
Hyphen|Quotative or expressing a quantity or rate|134|I will be able to see her during her hospitalization for these and any other medical issues. DISCUSSION: _%#NAME#%_ _%#NAME#%_ is a 15-year-old female with a history of depression and chemical abuse who is currently hospitalized on station 4B under the care of Dr. _%#NAME#%_ for the treatment of Trazodone ingestion.
Hyphen|Quotative or expressing a quantity or rate|173|The patient also states that she has been using crack for the last 3 days. She binged on 2 gm this weekend. She has had this problem for the past 5 years; however, had an 18-month-old sobriety prior to _%#MMDD2006#%_. She also has a history of IV heroin use. The patient works at Baker's Square in _%#CITY#%_ _%#CITY#%_.
Hyphen|To|91|5. History of perennial allergies. ADMISSION MEDICATIONS: 1. Prozac. 2. Albuterol inhaler 1-2 puffs q.4-6 h. p.r.n. 3. Allegra 30 mg p.o. daily. ALLERGIES: No known drug allergies.
Hyphen|Quotative or expressing a quantity or rate|261|In the course of her evaluation, she was found to have significant regurgitation of her prosthetic mitral valve, as well as aortic stenosis and coronary artery disease. She ultimately underwent aortic valve replacement, redo mitral valve replacement and a three-vessel coronary artery bypass grafting with a LIMA to the LAD, a saphenous vein graft to the obtuse marginal and a saphenous vein graft to the right coronary artery.
Hyphen|To|143|Therefore, we were asked to see him today. He has been afebrile for several days. His respiratory rate has been between 16 and 32, his heart 88-114, and oxygen saturation of 93 percent with 3.5 liters/min O2 by oximizer.
Hyphen|Compound pre-modifiers|154|Dr. _%#NAME#%_ asked me to see her for medical assessment. Please see Dr. _%#NAME#%_'s notes and the charting for details regarding the patient's chemical-use history and circumstance leading up to admission.
Hyphen|Compound pre-modifiers|152|The lower extremities have no cyanosis, clubbing, or edema. The laboratories show an INR of 1.6. IMPRESSION 1. Fall with right scapular fracture. 2. End-stage renal disease; due for dialysis tomorrow. 3. Chronic atrial fibrillation; maintained on Coumadin. 4. Failed right wrist and left upper arm AV fistulas.
Hyphen|Compound pre-modifiers|124|Pulses are intact. LABORATORY DATA/STUDIES: White count is 12,700, hemoglobin 12.1. INR is 1.79. Occult blood is positive. B-type natriuretic peptide 342. Chest x-ray demonstrates moderate volume with a right pleural effusion.
Hyphen|Lexical hyphen|117|No cough, dysuria, or diarrhea. PHYSICAL EXAMINATION: Vital signs: Please see nursing notes from today. GENERAL: Well-developed, well-nourished, obese, alert and oriented. Does not look acutely ill. SKIN: No rashes or nodules.
Hyphen|Typographic convention|154|There is no evidence of any inflammatory change in the pelvis or right lower quadrant. The appendix is not clearly visualized. IMPRESSION: Abdominal pain -etiology ?. This could be due to her ovarian cyst, but, as she is improving I do not think this is from appendicitis.
Hyphen|Quotative or expressing a quantity or rate|157|PRELIMINARY HISTORY OF PRESENT ILLNESS: The patient is a 24-year-old white female who initially presented to an Urgent Care facility earlier today with a one-week history of sore throat. This seems to have been increasing in severity over the past few days, and she is having some difficulty swallowing because of the degree of her severity.
Hyphen|Compound pre-modifiers|88|This is despite IV vancomycin and ceftazidime. Blood cultures have been negative. Follow-up CT scan yesterday reportedly showed "developing" abscess in the prevertebral space.
Hyphen|Quotative or expressing a quantity or rate|138|4. If possible, we should try to cut down or eliminate her immunosuppressive therapy while she is actively infected. SUMMARY: This is a 52-year-old woman with longstanding rheumatoid arthritis. Her rheumatologist is Dr. _%#NAME#%_ _%#NAME#%_. Her primary care physician is Fairview Hiawatha Clinic.
Hyphen|To|181|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 23-year-old female who has a history of multiple urinary tract infections since the age of 14. She reports anywhere between 35-40 infections since that time, and this has resulted in approximately five hospitalizations for pyelonephritis over the years, two of which being this last calendar year.
Hyphen|Lexical hyphen|184|He also has a history of hypertension and hyperlipidemia on medications. There is also a long history of obesity. HOSPITAL COURSE: The patient underwent an aortogram with right leg run-offs by Dr. _%#NAME#%_ of Interventional Radiology. This revealed no significant aortoiliac occlusive disease.
Hyphen|To|99|Both procedures allow for direct fetal chromosomal analysis with 99% accuracy. CVS is offered at 10-12 weeks gestation, and amniocentesis is offered after 15 weeks gestation.
Hyphen|Quotative or expressing a quantity or rate|408|_%#NAME#%_ _%#NAME#%_ _%#NAME#%_, MD Fairview _%#CITY#%_ _%#CITY#%_ Medical Center _%#STREET#%_ _%#STREET#%_ _%#STREET#%_, _%#ADDRESS#%_ _%#ADDRESS#%_ _%#CITY#%_ _%#CITY#%_, MN _%#55000#%_ Dear _%#NAME#%_, This letter is in followup to my phone call and to document the _%#MMDD2005#%_ visit to the Maternal Fetal Medicine Center, University of Minnesota Medical Center, Fairview, of Kachine Camp. She is a 32- year-old individual, para 4-0-2-4, with an estimated date of delivery of _%#MMDD2006#%_.
Hyphen|Quotative or expressing a quantity or rate|173|Denies chest pain or shortness of breath. GASTROINTESTINAL: Denies problems with constipation, diarrhea, or abdominal pain. MUSCULOSKELETAL: Denies bony aches or pains. A 10-point review of systems was done and was otherwise negative.
Hyphen|Lexical hyphen|161|NECK: Supple, no lymphadenopathy or thyromegaly. HEART: Regular rate and rhythm; no murmurs or rubs. LUNGS: Clear to auscultation. ABDOMEN: Soft, non-tender, non-distended; no organomegaly or mass. EXTREMITIES: Reveals normal muscular bulk. Gait appears normal. LABORATORY EVALUATION: Reveals a complete metabolic panel, CBC without abnormality.
Hyphen|To|141|Liver function tests are normal. Beta HCG was negative. TSH elevated at 6.63. ASSESSMENT AND PLAN: 1. Depression. Status post overdose. Her 4-5 hour Tylenol was in the nontoxic range at 19. Hepatic studies were normal. I think she should have no ongoing sequelae of this incident.
Hyphen|Compound pre-modifiers|385|Items of interest include a moderate level of fearing the worst happening, feeling nervous and feeling shaky. SUMMARY OF CURRENT FINDINGS: This is a 15-year-old Caucasian female who was admitted to the adolescent inpatient mental health unit at University of Minnesota Medical Center, Fairview, due to concerns related to increased intensity of depressive and anxiety symptoms and self-injurious behavior, as well as suicidal ideation. This clinician assessed her on the subacute diagnostic unit at University of Minnesota Medical Center, Fairview, last month.
Hyphen|Compound pre-modifiers|260|However, with one finger in the vagina, the physician was able to feel the ureteral meatus in a somewhat retropubic location on the anterior vaginal wall. A 16-French coude catheter was guided blindly after prepping the vagina as best as possible with Betadine- soaked swab. There was a fairly significant leakage of urine with manipulation of the anterior vaginal wall suggesting the possibility of some mechanical obstruction to bladder emptying with the bladder too full, which was relieved with intravaginal palpation of the anterior wall.
Hyphen|Compound|179|Dulcolax 10 mg suppository rectally daily p.r.n. constipation. 2. Marinol 2.5 mg by mouth twice a day for nausea and vomiting. Please give before lunch and dinner. 3. Robitussin A-C 10 mL syrup by mouth q.4h. p.r.n. cough. 4. Synthroid 100 mcg tablet p.o. daily. 5. Reglan 10 mg p.o. q.i.d. with meals and each day at bedtime.
Hyphen|Typographic convention|255|An echocardiogram showed an ejection fraction of 15%. Subsequently, the patient had a few episodes of cardiac arrest with ventricular fibrillation, with over 60 minutes of cardiac compression and resuscitation. The patient was then transferred to Fairview-University Medical Center on _%#MMDD2004#%_ for consideration of left ventricular assist device.
Hyphen|Quotative or expressing a quantity or rate|174|Mild eczema. 2. Reactive airway disease. 3. Chronic allergic rhinitis. FAMILY HISTORY: Non-contributory. SOCIAL HISTORY: The patient lives in _%#CITY#%_, Minnesota with her 9- year-old sister and her brother. She also has a teenage half-sister, biological father who lives in Wisconsin, and currently, according to her mother, custody is in dispute in the courts.
Hyphen|Quotative or expressing a quantity or rate|103|CHIEF COMPLAINT: Revision right total hip arthroplasty. HISTORY OF PRESENT ILLNESS: The patient is a 70-year-old female with complex orthopaedic surgical history involving the right hip with 5 prior surgical procedures, to undergo revision right total hip arthroplasty by Dr. _%#NAME#%_ _%#NAME#%_ on _%#MMDD2004#%_. She has history significant for a fall on the ice on _%#MMDD2003#%_, resulting in a comminuted fracture of the right trochanter.
Hyphen|Lexical hyphen|254|Left heart catheterization showed normal coronaries. The patient might have non-ST elevation MI as on echocardiogram, dull areas of akinesis were in the distribution of left anterior descending artery. The patient was kept on heparin because she was post-cath, as well as because of her low ejection fraction. More over, she had episodes of supraventricular tachycardia before going into cath lab, which required discontinuation of cardioversion because of low blood pressure.
Hyphen|Typographic convention|176|The patient has T wave inversion over the chest leads, symmetrical T wave inversion, and no acute ST elevation. I will get a nother 12-lead ECG now. The patient's blood workup - I obtained blood gas while on oxygen. This showed pH 7.50, pC02 22, p02 93, bicarbonate 18, and oxygen sat is 96%.
Hyphen|Lexical hyphen|250|She spent about two months in the hospital for treatment and was transferred to the University of Washington. She was discharged home and was doing fine until about a few weeks prior to this admission when she had recurrence of her ascites and was re-admitted. During that hospitalization in _%#CITY#%_, Montana, the patient was noted to have worsening renal failure.
Hyphen|Quotative or expressing a quantity or rate|182|She received several units of fresh frozen plasma and platelets as well as 2 more units of red blood cells. She has an open wound in the area of her left iliac for which she gets wet-to-dry dressings which seems to be improving. She had a blister which occurred postoperatively on the posterior part of her left thigh.
Hyphen|Lexical hyphen|244|No active bleeding was found. We maintained the patient on an IV PPI while in house, gave her IV fluids, transfused her with 2 units of packed red blood cells, and her hemoglobin remained stable. We will discharge her on a PPI with close follow-up. It is possible that her gastritis could have been slowly bleeding, but there was no active bleeding found.
Hyphen|Compound|127|14. Colace 100 mg p.o. daily p.r.n. constipation. 15. Bioflavonoids tabs p.o. daily. 16. Vitamin C 1000 mg p.o. daily. 17. Beta-carotene 9000 units p.o. daily. 18. Vitamin E 200 units p.o. daily. 19. Folic acid 800 mg p.o. daily.
Hyphen|Compound pre-modifiers|197|3. Pericardial effusion that is chronic. 4. Normal coronary angiogram. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 56-year-old male with COPD and no prior cardiac disease who presented to the F-UMC Emergency Department on _%#MMDD2003#%_ from his _%#CITY#%_ nursing home, where he is being admitted for severe end-stage COPD, with a one-week history of general malaise, shortness of breath, cold sweats, nausea, decreased appetite, and dull right upper quadrant pain.
Hyphen|Quotative or expressing a quantity or rate|141|DISCHARGE DIAGNOSIS: Parkinson disease. MAJOR PROCEDURES: Right selector generator placement. HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old gentleman with a history of Parkinson disease. His symptoms have progressively worsened over the past 1 to 2 years and as a result he underwent placement of right deep-brain stimulator in the subthalamic nucleus recently.
Hyphen|Typographic convention|89|He has no lower extremity edema or syncope. He has no history of hypertension. Pulmonary - Productive cough with blood-streaked, slightly purulent sputum for approximately 1-2 weeks.
Hyphen|Hyphenated name|295|HOSPITAL COURSE: Much of the following, in particular _%#NAME#%_'s PICU course is derived from Dr. _%#NAME#%_ _%#NAME#%_'s detailed consultation note dated _%#MMDD2007#%_. Again, _%#NAME#%_ is by this point a 22-month-old male toddler from _%#CITY#%_, South Dakota who was transferred from Avera-McKennan Hospital to the University of Minnesota Children's Hospital with unexplained spells of apnea and cyanosis.
Hyphen|Compound|136|For the neutropenia itself, she received a granulocyte-macrophage colony-stimulating factor (GM- CSF). White count did improve on the GM-CSF, however, with administration of GM-CSF, the patient's white count subsequently over corrected to a peak of over 20,000.
Hyphen|Quotative or expressing a quantity or rate|337|FINAL CHIEF COMPLAINT: Probable urinary tract infection with generalized weakness with no new acute focal weakness, in a patient who has had a right-sided head bleed after a traumatic fall about four weeks ago requiring monitoring in hospital for infection and high seizure risk. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 73-year-old gentleman who was admitted on _%#MMDD#%_ after falling at home.
Hyphen|Compound|68|4. Toprol XL 50 mg p.o. daily. 5. Paroxetine 40 mg p.o. daily. 6. Os-Cal. SOCIAL HISTORY: The patient is married to her husband, _%#NAME#%_.
Hyphen|Lexical hyphen|148|A bone marrow biopsy and aspirate were taken as well as lumbar puncture. Cytology was done. Bone marrow biopsy and aspirate were consistent with pre-B-cell acute lymphocytic leukemia with no CNS involvement.
Hyphen|Compound pre-modifiers|176|CBC 9.2, hemoglobin 13.9, platelets 300. No other tests are reported. IMPRESSION: This is a 70-year-old woman who presents with change in behavior, unsteady gait, increased low-back pain. She was noted to be ataxic in _%#CITY#%_ Medical Center.
Hyphen|Lexical hyphen|123|They have elected not to use Coumadin in this patient in the past. Would agree with that assessment, given the patient's co- morbidities and recent fall episode, given the risk factors of Coumadin and bleeding.
Hyphen|Compound pre-modifiers|201|Winter at North Memorial. 4. Direct laryngoscopy and removal of left vocal cord lesion done on _%#MMDD1995#%_ by Dr. _%#NAME#%_ at West Health. 5. Coronary angiography and then PTCA and stenting of mid-LAD stenosis done on _%#MMDD1998#%_ by Dr. _%#NAME#%_ at North Memorial. 6. Coronary angiography and PTCA of the mid-LAD stenosis within the area of stenting done on _%#MMDD1999#%_ at North Memorial.
Hyphen|Compound|105|2. Respiratory. _%#NAME#%_ presented with a cough and no signs of increased short of breathing. A chest x-ray was repeated on hospital day 2 and showed no evidence of new consolidation and was read as unchanged from her previous chest x-ray on _%#MM#%_ _%#DD#%_, 2005.
Hyphen|To|189|Discharge instructions include no lifting greater than 10 pounds times 1 month. She was instructed to follow up at the General Surgery Clinic in 1 week and with the Perinatology Clinic in 1-2 weeks. Also the patient was instructed to all the Perinatology Clinic on Monday morning to arrange for a platelet check that day.
Hyphen|To|102|(vitamin D2). 13. Risedronate 35 mg p.o. q. Monday. 14. OxyContin 40 mg b.i.d. daily. 15. Oxycodone 10-20 mg q.3h. p.r.n. pain. ALLERGIES: To penicillin, amoxicillin and latex. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 97.8, blood pressure 128/82, respirations 14, heart rate 75.
Hyphen|Compound|225|At that time, she presented to her primary care physician with overwhelming, fatigue, weakness, achiness and a 20-pound weight loss. She was also found to have anemia and elevated creatinine, increased serum viscosity, a beta-2-microglobulin of 6.4 and elevated calcium of 10.3 mg/dL and an LDH of 134.
Hyphen|To|136|9. Allopurinol 300 mg p.o. daily. 10. Lantus insulin 35 units subcu q. evening. 11. Regular insulin sliding scale. 12. Nystatin powder 2-3 times daily behind the knees. 13. Aspirin 81 mg p.o. daily. 14. Digitek 0.125 mg p.o. daily.
Hyphen|Compound pre-modifiers|137|The images revealed no mass lesion, midline shift or abnormal fluid collection. Dedicated views of the posterior fossa including contrast-enhanced fat-suppressed views demonstrate no focal abnormality.
Hyphen|Quotative or expressing a quantity or rate|190|Electrocardiogram shows normal sinus rhythm, rate 103, borderline left axis deviation, normal intervals, no ST or T-wave changes. No evidence of LVH. ASSESSMENT AND PLAN: The patient is a 77-year-old male with chronic obstructive pulmonary disease exacerbation, unclear what his trigger this time might have been.
Hyphen|Compound|109|Millon Adolescent Clinical Inventory (MACI). 5. Rorschach Ink Blot Test. 6. Beck Depression Inventory-II (BDI-II). 7. Beck Anxiety Inventory (BAI). TEST RESULTS: The MMPI-A was responded to in a highly cautions manner to the point where the profile has some questionable validity.
Hyphen|Compound pre-modifiers|182|The patient also showed evidence of bearing weight on that right leg. She tended to evert the foot and vault over the right leg with extension at the hip and the knee, but some swing-through pattern with hip flexion was present. LABORATORY DATA: All labs were normal. ASSESSMENT/RECOMMENDATIONS: This is a 49-year-old right-handed woman with right hemiplegia secondary to a conversion disorder, per Neurology Service.
Hyphen|Quotative or expressing a quantity or rate|83|She admits to developing hives with Lasix 3 years ago. SOCIAL HISTORY: She is a one-half-pack-per-day smoker for the previous 40 years. She currently does not use alcohol, but there is a history of alcoholism.
Hyphen|Typographic convention|307|In addition to ADHD, _%#NAME#%_ also has a history of nocturnal enuresis and oppositional defiant disorder (ODD) that was diagnosed at Washburn Child Guidance Center in _%#MM2007#%_. TESTS ADMINISTERED: Wechsler Intelligence Scale for Children-Fourth Edition (WISC-IV), Wechsler Individual Achievement Test - Second Edition (WIAT-II), Selected subtests, the Trail-Making Test, Verbal Fluency Test, Conners Continuous Performance Test - Second Edition (CPT (CPT-II), Child Depression Inventory (CDI), Revised Children's Manifest Anxiety Scale (RCMAS), Roberts Apperception Test for Children (RATC) and clinical interview.
Hyphen|Quotative or expressing a quantity or rate|164|This test was non-timed. _%#NAME#%_ obtained an overall score within the average range for his age (SS=101) at the 53rd percentile. His score is consistent with a 9-year-old child's level of ability. MEMORY AND LEARNING SKILLS _%#NAME#%_'s visual memory and learning skills were assessed using the WRAML-2.
Hyphen|To|315|He found it difficult because he and his brother had to "accommodate his stepsisters, especially where they were going to be living in the house." Depressive symptoms have included hypersomnia, sadness, decreased motivation, sitting in the dark alone and felling hopeless. He also cut his forearm "out of boredom" 3-4 years ago but has not done so since then. He also has a history of worry about homework and tests.
Hyphen|Compound|117|No evidence of malignancy was seen on four lymph nodes taken from the left supraclavicular region. Note, that chest x-ray performed on _%#MMDD2003#%_ was negative. A CT scan of the neck performed on _%#MMDD2003#%_ demonstrated a 3 cm left retromandibular mass with evidence of central necrosis.
Hyphen|Compound|172|Sodium 141, potassium 4.7, bicarbonate 26, INR 2.55, white count 14.1, hemoglobin 13.0, platelet count 187,000, MCV 91. He has 84% neutrophils. EKG is 100% V-paced. Chest x-ray is pending. Per Dr. _%#NAME#%_'s note, there is no clear heart failure.
Hyphen|Compound pre-modifiers|406|She was oriented to person, place, and time. TESTS ADMINISTERED AND TASKS COMPLETED: Diagnostic interview, review of medical records, Bender-Gestalt test, Wechsler Adult Intelligence Scale-Third Edition, WAIS-III, Minnesota Multiphasic Personality Inventory-Adolescent (MMPI-A), Rorschach Inkblot test, Sentence Completion test, TEST RESULTS: Cognitive functioning. This patient was administered the Bender-Gestalt test, which is a screening measure for overall neuropsychological dysfunction.
Hyphen|Compound pre-modifiers|291|A CT scan of the lumbar spine was done on _%#MMDD2005#%_ which revealed an L2 vertebral compression fracture, lumbar spondylosis, and multiple level degenerative disk disease. He is a very poor historian and much of the history is actually obtained from the chart records sent by his primary- care physician. He cannot recall start dates or triggers for his pain.
Hyphen|Compound pre-modifiers|106|At this time, we will gradually wean off the pressors gradually as tolerated by the blood pressure. 3. End-stage renal disease on hemodialysis. He is to follow with the renal service and hemodialysis is planned for tomorrow.
Hyphen|Compound pre-modifiers|122|DIAGNOSTIC IMPRESSION: Axis I Depressive disorder, not otherwise specified. Alcohol abuse. Cannabis abuse. Axis II Passive-aggressive personality features. Axis III Review medical record. Axis IV Stress and adjustment associated with family and academic functioning.
Hyphen|Compound pre-modifiers|331|Specifically she denies diarrhea, constipation, weight loss, weight gain, skin rashes, or neurologic deficits. She does take iron for mild anemia. PAST MEDICAL HISTORY: Notable for celiac sprue with gluten sensitivity; however this was diagnosed 5 years ago and manifested as abdominal discomfort and since she has been on a gluten-free diet she has been essentially free of symptoms, although she does take iron supplements, presumably related partially to her malabsorption of iron.
Hyphen|Compound pre-modifiers|222|Dr. _%#NAME#%_ was present and lead the discussion about risks, benefits, and alternatives to radiation therapy. In particular, we discussed the acute side effects of possible redness of skin and sore throat, possible long-term effects of risk or damage to the spinal cord, to bone, and to the lung.
Hyphen|To|76|15. Lipitor 40 mg daily. 16. Ranitidine 150 b.i.d. 17. Albuterol 2 puff q. 4-6 hours p.r.n. REVIEW OF SYSTEMS: It is difficult to obtain the review of systems at the time of HPI as the patient was having severe chest pain.
Hyphen|Compound pre-modifiers|129|She experiences anxiety symptoms such as worrying about her mother, sister, and friends. She denied any panic symptoms, obsessive- compulsive symptoms, hallucinations, or conduct disorder symptoms.
Hyphen|Quotative or expressing a quantity or rate|272|Good pulses bilaterally in the wrists and arms. No extremity swelling. SKIN: Clear. LABORATORY DATA: Sodium 136, potassium 4.4, chloride 95, bicarb 28, BUN 21, creatinine 0.75, glucose 127, magnesium 2.7, phosphorus 3.0. ASSESSMENT AND RECOMMENDATIONS: The patient is a 65-year-old man with poorly differentiated adenocarcinoma of the right middle lobe with hilar, mediastinal lymphadenopathy and metastatic lesions in the thoracic and lumbar spine, as well as a right adjacent lateral rib.
Hyphen|Quotative or expressing a quantity or rate|159|She occasionally does experience some significant nausea triggered by certain foods. This has also been associated with a decrease in general appetite and a 20-pound weight loss since her surgery. She continues to use a lot of Climara patches and relates that she does have hot flashes when she goes for a week off the patch.
Hyphen|Compound|240|Dr. _%#NAME#%_ mentions in his note that he suspected that the pain may have been noncardiac and could have corresponded to esophageal spasm, given this gentleman's known esophageal disease. This is supported by the findings of esophageal x-ray evaluation with contrast and EGD performed in _%#MM#%_ of this year which revealed _______________esophagus with poor peristalsis _____________ esophagus on endoscopy.
Hyphen|Lexical hyphen|86|She has some left knee pain with degenerative joint disease. She denies syncope or pre-syncope. She has had constipation since being started on Verapamil.
Hyphen|Quotative or expressing a quantity or rate|312|Socially, _%#NAME#%_ demonstrated a number of nice skills, such as typical eye contact, a desire to please others and an ability to pick up on nonverbal cues (e.g., holding the door for others when their hands were full, etc.). _%#NAME#%_ also said, "Hello," without prompting, and was able to converse in a back-and-forth manner regarding a range of topics. Regarding mood, _%#NAME#%_'s mood appeared typical for the testing session.
Hyphen|To|314|The patient's echocardiogram on _%#MMDD2007#%_ shows a normal bubble study. Left ventricle was normal, otherwise essentially normal. ASSESSMENT: The patient is a 42-year-old gentleman with history Behcet disease based on recurrent ulcerations of mouth, genitals and pustular lesions over the course of more than 12-15 years. The patient presented with acute stroke in the setting of stopping his prednisone.
Hyphen|Phone number|120|Thank you again for allowing us to share in the care of your patient. If questions arise, please contact us as _%#TEL#%_-_%#TEL#%_ (NICU) or _%#TEL#%_ (office). We hope to be of continuing service to you.
Hyphen|Phone number|120|Thank you again for allowing us to share in the care of your patient. If questions arise, please contact us as _%#TEL#%_-_%#TEL#%_ (NICU) or _%#TEL#%_ (office). We hope to be of continuing service to you.
Hyphen|Phone number|120|Thank you again for allowing us to share in the care of your patient. If questions arise, please contact us as _%#TEL#%_-_%#TEL#%_ (NICU) or _%#TEL#%_ (office). We hope to be of continuing service to you.
Hyphen|Phone number|120|Thank you again for allowing us to share in the care of your patient. If questions arise, please contact us as _%#TEL#%_-_%#TEL#%_ (NICU) or _%#TEL#%_ (office). We hope to be of continuing service to you.
Hyphen|Phone number|120|Thank you again for allowing us to share in the care of your patient. If questions arise, please contact us as _%#TEL#%_-_%#TEL#%_ (NICU) or _%#TEL#%_ (office). We hope to be of continuing service to you.
Hyphen|Lexical hyphen|174|She was transfused with 1 unit packed red blood cells. The patient's blood pressures did improve. Her blood pressure medications will continue to be held until further follow-up. The patient's hemoglobin was 9.4 at time of discharge. She overall was feeling better.
Hyphen|Lexical hyphen|93|5. Zyprexa 5 mg p.o. q.h.s. 6. Celexa 80 mg p.o. daily. FOLLOW-UP: He is instructed to follow-up with his primary care physician, Dr. _%#NAME#%_, in 5-10 days. He is instructed to come back to the emergency room if his shortness of breath worsens.
Hyphen|Lexical hyphen|83|10. K-Dur 20 mEq three times a week only with Lasix. DISCHARGE FOLLOW-UP: 1. Follow-up at my clinic in one month. 2. The patient may consult with the house medical doctor in the transitional care unit as needed.
Hyphen|Compound pre-modifiers|174|HEALTH MAINTENANCE: Mammogram in _%#MM2007#%_, self reported normal. She has not had colorectal or chest x-ray screening. PHYSICAL EXAMINATION UPON ADMISSION: GENERAL: A well-developed and well-nourished female. HEENT: Normal. No palpable neck masses or lymphadenopathy. She had no lymphadenopathy in the cervical, supra or infraclavicular or groin areas.
Hyphen|Lexical hyphen|168|4. He is to follow up in the device clinic for wound check in 7 to 10 days, and he will then have a three month appointment for device check. 5. The patient will follow-up with Dr. _%#NAME#%_ in two months. I have asked _%#NAME#%_ to contact our clinic if he has any questions, concerns or problems related to his activity restrictions or any symptoms that arise.
Hyphen|Hyphenated name|292|The patient did well at home until _%#MMDD2004#%_, when similar symptoms of increasing nasal congestion recurred. There were no further cyanotic or apneic episodes, however. The patient was readmitted to _%#CITY#%_ Memorial Hospital on _%#MMDD2004#%_, but was then transferred to the Fairview-University Medical Center on _%#MMDD2004#%_ for definitive cares and management.
Hyphen|Hyphenated name|289|_%#CITY#%_ _%#CITY#%_, Minnesota. HISTORY OF THE PRESENT PROBLEM: Mr. _%#NAME#%_ was discharged from Southdale Hospital on _%#MMDD2005#%_ having received nine electroconvulsive therapy treatments for refractory major depression. He was referred to the Senior Outpatient Program of Fairview-University Medical Center for ongoing psychiatric and other mental health care.
Hyphen|Quotative or expressing a quantity or rate|208|UA was negative. Urine culture is pending. Blood culture is pending. Sodium 133, potassium 3.9, chloride 102, CO2 24, BUN 18, creatinine 0.8, glucose 135, calcium 8.4. ASSESSMENT AND PLAN: The patient is a 79-year-old male with a history of coronary artery disease, adenocarcinoma of the lung admitted with weakness, radiation burns, esophagitis.
Hyphen|Lexical hyphen|253|Therefore, discharge was cancelled until postoperative day #4, at which time she was discharged home on ibuprofen, Percocet and told to follow-up at six weeks. DISCHARGE MEDICATIONS: 1. Ibuprofen. 2. Percocet. FOLLOW-UP INSTRUCTIONS: Patient will follow-up in six weeks for postoperative check-up.
Hyphen|Lexical hyphen|203|_%#NAME#%_ _%#NAME#%_ of Intermed Consultants/Infectious Disease. 3. The patient should have Fairview Partners follow the patient while the patient is at Martin Luther Manor. 4. The patient should follow-up with his new primary care physician, Dr. _%#NAME#%_ _%#NAME#%_ at the Oxboro Clinic in _%#CITY#%_, in approximately 1-2 weeks after discharge from Martin Luther Manor.
Hyphen|Compound|130|Extraocular movements are intact. Cranial nerves II-XII are intact. Corneal and gag reflexes were not tested. CHEST X-RAY: Chest x-ray and lateral view reveals a retrocardiac infiltrate; there is a suggestion of an infiltrate at the left lateral base but there is also a decrease in volume versus a symmetrical posture.
Hyphen|Quotative or expressing a quantity or rate|128|3. MRI-gadolinium scan of abdomen. 4. Intravenous ganciclovir. 5. Urology consultation. HISTORY OF PRESENT ILLNESS: This is a 57-year-old male with a history of diabetes mellitus type 1, complicated by end-stage renal disease.
Hyphen|Quotative or expressing a quantity or rate|222|_%#NAME#%_ _%#NAME#%_, attending. CONSULTS: None. PROCEDURES: On _%#MMDD2007#%_, exploratory laparotomy, which was aborted secondary to discovery of widely invasive cancer. INDICATION HISTORY: _%#NAME#%_ _%#NAME#%_ is a 78-year-old woman who had a transurethral resection of a bladder tumor, which showed an invasive bladder cancer after considering risks, benefits and alternatives.
Hyphen|Junction|228|LABORATORY DATA: Hemoglobin 10.5, white count 5900, basic metabolic panel was within normal limits. MRI of the lumbar spine showed minimal broad-based right lateral disc protrusion at L5-S1 and moderate facet joint disease at L3-4. Pelvis x-ray was within normal limits. Hip x-ray also was negative.
Hyphen|Quotative or expressing a quantity or rate|55|HISTORY OF PRESENT ILLNESS: The patient is a _%#1914#%_-year-old woman admitted to Fairview University Transitional Services for rehab following an episode of acute low back pain, most likely secondary to spondylolisthesis. No nerve root impingement was seen. The patient received physical and occupational therapy and pain control with Lidoderm patch and oxycodone/acetaminophen 5/325 every 4 hours as needed for pain, and this worked quite well.
Hyphen|Compound pre-modifiers|162|PROBLEM #2: Bladder mass. The patient did have a previous diagnosis of bladder mass. This has not been previously evaluated because the patient's wife and primary-care physician have agreed that they would not do anything about the mass regardless of what was found, if it was cancer or not.
Hyphen|Quotative or expressing a quantity or rate|121|DISCHARGE DIAGNOSIS: Atrial fibrillation with rapid ventricular response. HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old female with a known history of paroxysmal atrial fibrillation who is currently on anticoagulation and diltiazem for treatment. She continued to have episodes of symptomatic atrial fibrillation and so was told that if one of these were to recur, she should present to the emergency department or clinic for an EKG as she is trying to become enrolled in a study.
Hyphen|Junction|233|He received 1080 cc of CellSaver plus 4 units of FFP. He was further stabilized in the ICU. He was taken back to the OR for second- step procedure on _%#MMDD2006#%_, including L1-2 osteotomy, transforaminal lumbar interbody fusion L1-L2, and L1-L3 posterior fusion. After second procedure, the patient is having a new left quadriceps pain that is brought on with activity of the muscle.
Hyphen|Quotative or expressing a quantity or rate|89|The patient sounds like he is obviously depressed and suicidal. We will get patient a one-to-one sitter and re- evaluate his depression when he is sober, and consider possible Psychiatric Consultation.
Hyphen|Quotative or expressing a quantity or rate|109|PROCEDURES PERFORMED DURING THIS HOSPITAL STAY: None. BRIEF SUMMARY OF HOSPITAL STAY: Ms. _%#NAME#%_ is an 85-year-old Ukrainian female with a history of CVA, atrial fibrillation, coronary artery disease and severe osteoporosis who was discharged from the hospital on _%#MMDD#%_ and returned to the hospital on _%#MMDD#%_ requesting a rehab placement.
Hyphen|Quotative or expressing a quantity or rate|169|FINAL DISCHARGE DIAGNOSES: 1. Abdominal pain following ERCP. 2. Recent history of pancreatitis. 3. Spina bifida HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 37-year-old white female with a recent history of abdominal pain felt to be due to pancreatitis of unclear etiology.
Hyphen|Quotative or expressing a quantity or rate|70|HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is an unfortunate 71-year- old female who had an episode of being quite deconditioned. She fell into her bathtub and was lying in her bathtub from Wednesday through the weekend over four days.
Hyphen|Quotative or expressing a quantity or rate|102|Normal axis. There is no evidence of hyperacute ischemic changes. ASSESSMENT/PLAN: The patient is a 72-year-old gentleman who presented to his primary care physician with increasing dysuria, fevers and chills.
Hyphen|Compound|29|DISCHARGE DIAGNOSES: 1. Osler-Weber-Rendu syndrome. 2. Pulmonary arteriovenous malformation, status post pulmonary angiogram. 3. Pulmonary hypertension.
Hyphen|Compound|140|_%#NAME#%_ is a 56-year-old female who was diagnosed with stage I A1 grade 3 adenocarcinoma of the cervix in 2002. The patient underwent TAH-BSO for treatment of this disease. Margins were negative. There was no lymph-vascular space involvement and she did not receive adjuvant therapy postoperatively.
Hyphen|Quotative or expressing a quantity or rate|29|_%#NAME#%_ _%#NAME#%_ is a 70-year-old man diagnosed recently with a stage IV non small cell lung cancer. He presented in early 2004 with a 5 cm right upper lobe primary tumor with additional intrapulmonary metastases measuring up to 1.7 cm in size.
Hyphen|Compound|189|During her hospital course stay her the INR remained therapeutic at 2.55 presently and we will continue this and she will have a follow up in the Warfarin Clinic as an outpatient. A chest x-ray was also obtained during this hospitalization and was significant for cardiomegaly, mild vascular cephalization, probable small left pleural effusion.
Hyphen|Compound|131|The remainder of his physical examination was unremarkable. He has no upper extremity complaints. LEFT HIP X-RAY, PA AND LATERAL: X-rays were reviewed and revealed a minimally displaced fracture of the femoral neck with slight extension of the fracture on the lateral view.
Hyphen|Compound|213|Tobacco use PROCEDURE: 1. Admission chemistries remarkable for normal electrolytes and glucose, white count of 20,000 with a left shift, and a hemoglobin of 13.6. No blood cultures. 2. Imaging studies with chest x-ray showed a possible left lower lobe infiltrate. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 33-year-old smoker with a history of asthma.
Hyphen|Compound pre-modifiers|205|He quit smoking for about 4 years, beginning in 2000, but he resumed smoking last year at about 1/2 pack per day. He currently lives in _%#CITY#%_. PHYSICAL EXAMINATION: GENERAL: Patient is an older middle-aged male who appeared comfortable, on oxygen. He was alert and fully oriented. VITAL SIGNS: Normal as recorded in his chart.
Hyphen|Quotative or expressing a quantity or rate|93|There is no rigidity or rebound. EXTREMITIES: No edema, no lesions. IMPRESSION AND PLAN: A 50-year-old female with type 1 diabetes admitted for elective right diaphragm plication.
Hyphen|Quotative or expressing a quantity or rate|152|PRELIMINARY CHIEF COMPLAINT: The patient is an 88-year-old gentleman with a left femoral neck fracture. HISTORY OF PRESENT ILLNESS: The patient is an 88-year-old gentleman who lives in Senior Housing. He was in his usual state of health until last night when he fell injuring his left hip.
Hyphen|Lexical hyphen|393|She has had ongoing problems with acid reflux manifested by substernal burning discomfort relieved temporarily with antacid. She is not aware of hemorrhoids or diverticulum. She apparently last underwent objective colon evaluation with colonoscopy in excess of 30 years ago for what patient indicates was "colitis." She is presently having one to two bowel movements daily which are loose/semi-formed. She has been on chronic Bextra and prednisone. No anticoagulation.
Hyphen|Compound pre-modifiers|156|LABORATORY DATA: A CT scan from _%#MMDD2005#%_ from MeritCare shows an enlarged lymph node in the groin areas bilaterally, more severe on the left. The left-sided lymph node measures 3.5 cm. There are multiple smaller lymph nodes in the groin on the right side, with the largest measuring 1.8 cm.
Hyphen|Compound|187|Stool is guaiac positive. EXTREMITIES: No edema. NEUROLOGIC: Nonfocal. Electrocardiogram performed demonstrates a normal sinus rhythm. There is a ventricular rate of 90. There is normal R-wave progression through the precordium with T wave inversion across leads V2, V3, V4, V5, and V6, and isoelectric flattening of T waves in leads I and AVL.
Hyphen|To|260|Problems during _%#NAME#%_'s hospitalization included the following: Problem #1: Fluids/Electrolytes/Nutrition. _%#NAME#%_ had the following lines placed: umbilical arterial catheter (_%#MMDD2006#%_ - _%#MMDD2006#%_); umbilical venous catheter (_%#MMDD2006#%_ - _%#MMDD2006#%_); percutaneously inserted arterial catheter (right radial, _%#MMDD2006#%_ - _%#MMDD2006#%_).
Hyphen|Compound pre-modifiers|157|Following the steroid pulse, his creatinine continued rise, and he also became more edematous with massive ascites. He was given a second 3-day pulse of high-dose IV Solu-Medrol starting on _%#MM#%_ _%#DD#%_, 2004. During his hospital stay at _%#CITY#%_ _%#CITY#%_ Childrens Hospital, he was also on high-dose diuretics and antihypertensive medications.
Hyphen|Compound|161|PPD read with primary care physician 1 day after discharge. 2. Cardiology with Dr. _%#NAME#%_ _%#MM#%_ _%#DD#%_ at Fairview-University Medical Center with a chem-10 prior to the visit. 3. Dr. _%#NAME#%_, care of the Urology Clinic, appointment was called for _%#MM#%_ _%#DD#%_, 2002, via the Urology Clinic.
Hyphen|Date|133|In the hospital the patient had a fluid restriction of 2000 cc and had her Digoxin held for several days. She was feeling better by 6-10-02. The nausea had resolved. Her legs were weak and she was only able to use the commode with assistance.
Hyphen|Quotative or expressing a quantity or rate|134|FINAL ORTHOPEDIC CONSULTATION REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD HISTORY: I am consulted by Dr. _%#NAME#%_ to see this 79-year-old woman with a right hip injury. _%#NAME#%_ _%#NAME#%_ was injured at home approximately ten p.m. last night.
Hyphen|Quotative or expressing a quantity or rate|281|CARDIOVASCULAR: S1, S2, regular rate and rhythm. Hemogram: Unremarkable. Sodium 138, potassium 3.3, BUN 26, creatinine 0.9. CT head done earlier shows a dilated ventricles with evidence of transependymal CSF flow concerning for obstructive hydrocephalus. ASSESSMENT AND PLAN: An 87-year-old postop day 0 status post ventricular peritoneal shunt placed for hydrocephalus.
Hyphen|Quotative or expressing a quantity or rate|75|PRELIMINARY REFERRING PHYSICIAN: Dr. _%#NAME#%_. INDICATIONS: This is an 87-year-old who gives absolutely no history at all. History according to his wife was that he had 3 black stools of fairly large quantity starting at 1 in the morning.
Hyphen|Quotative or expressing a quantity or rate|222|PERTINENT LABORATORY DATA: White cell count 18.3, hemoglobin 9.5, platelets 210. Electrolytes are normal. Creatinine 0.64. As mentioned above, A1c was 5.4%. A random C-peptide 1.2 stimulated to 3.3. IMPRESSION AND PLAN: 45-year-old female with chronic pancreatitis, status post total pancreatectomy followed by auto islet cell transplantation.
Hyphen|Compound pre-modifiers|295|Apparently he has been having trouble with it off and on for three years, but more recently after an acute febrile illness while he was visiting _%#CITY#%_, Florida, the leg ballooned up on him and became extremely painful. He has findings on x-ray that are indeterminate, and does have a high C-reactive protein. He is an apparent alcohol user for quite a long time.
Hyphen|Compound pre-modifiers|179|No dyspepsia or abdominal pain. No diarrhea or constipation. No signs of GI blood loss. No voiding complaints. No rash. No focal neurologic complaint. OBJECTIVE: Generally healthy-appearing adult female in no acute distress. Does have a raspy quality to her voice. Blood pressure in 90s/50s to 60s, heart rate 70s and regular, temperature max 100.6, subsequently down to 99.9 degrees, oxygen saturation 100% on 3 liters, respirations unlabored.
Hyphen|Compound pre-modifiers|135|Estimated blood loss of 500 mL. No history of abnormal bleeding tendency. No history of recent steroids. Denies preoperative URI or flu-like symptoms. Postoperatively, maintained on morphine sulfate PCA for pain control. Onset of dyspnea, which seemed to be aggravated with "every bump." Prompted the patient to avoid using PCA, with worsening left knee pain.
Hyphen|Compound|259|These studies included a CRP level or C- reactive protein, which was elevated at 3.57 and an elevated sed rate of 36. She had a negative ANA, a negative rheumatoid factor, a negative SPEP, a negative ANCA, a mildly elevated C-3 complement level but a normal C-4 complement level, and a normal angiotensin-converting enzyme.
Hyphen|Compound pre-modifiers|71|There were no other findings. No pleural effusion was present. No right-sided infiltrate or nodules was present. She has never smoked but was exposed to secondhand smoke in her youth.
Hyphen|Typographic convention|100|REVIEW OF SYSTEMS: General - denies fever or chills, weight loss. Head, ears, eyes, nose and throat - denies odynophagia, dysphagia, visual problems. Respiratory - denies asthma, bronchitis, cough or productive sputum. Cardiac - denies palpitations or syncope.
Hyphen|To|114|Also, right eye drifts to medial side. Funduscopic exam is normal. Intraocular pressure performed in the ER was 12-13 on the right, not measured on the left. EARS: Unremarkable. OROPHARYNX was clear. NECK: Supple. No lymphadenopathy. CV: Regular rate and rhythm.
Hyphen|Quotative or expressing a quantity or rate|54|CODE BLUE NOTE: HISTORY: _%#NAME#%_ _%#NAME#%_ is a 60-year-old male who presented this evening with inferior wall MI, third degree heart block and asystole. Emergency angioplasty was performed. After the procedure was done and the patient was being transported to his room, he had a VF cardiac arrest.
Hyphen|Compound pre-modifiers|178|PHYSICAL EXAMINATION: VITAL SIGNS: Current vital signs show a temperature of 36.6. A pulse of 92. Blood pressure of 203/97. Respiratory rate of 18. GENERAL: The patient is a well-developed, well-nourished, Asian male who is somewhat lethargic at this point in time and keeps falling back to sleep.
Hyphen|Quotative or expressing a quantity or rate|220|Right cord structures are otherwise normal. Left side, he has an atrophic left testicle with otherwise normal cord structures. Scrotal skin is normal. Perianal skin is normal. Rectal exam reveals normal rectal tone, a 25- to 30-mL prostate that is benign, symmetric with no nodularity.
Hyphen|Quotative or expressing a quantity or rate|182|PRELIMINARY TIME: 2030 CHIEF COMPLAINT: Right groin pain REQUESTING PHYSICIAN: Dr. _%#NAME#%_ _%#NAME#%_, Fairview Southdale Hospital EPPA HISTORY: Ms. _%#NAME#%_ _%#NAME#%_ is an 80-year-old female. She suffers from dementia. She lives in an assisted living complex.
Hyphen|Compound pre-modifiers|160|She has not been able to produce sputum for stain or culture. The only specimen so far was notable for oral contamination with over 10 epithelial cells per high-powered field. She has been afebrile since her first doses of antibiotics, and reports today that her sore throat is much better, and she is able to eat.
Hyphen|Compound pre-modifiers|179|Strength 5/5 bilaterally in the upper and lower extremities. LABORATORY DATA: Pending. On previous admission she had hematuria. ASSESSMENT/PLAN: 1. Bipolar disorder, anxiety, self-injurious behavior; treatment is going to be continued as per Dr. _%#NAME#%_.
Hyphen|Quotative or expressing a quantity or rate|58|DOB: _%#MMDD1939#%_ HISTORY: _%#NAME#%_ _%#NAME#%_ is a 64-year-old right handed white male who was admitted to Fairview Ridges Hospital because of left sided numbness and a transient episode of left upper extremity shaking. I was asked to see him for neurologic assessment by Dr. _%#NAME#%_.
Hyphen|Compound|120|IMMUNE: Negative. PSYCH: Negative. SLEEP: Okay. PAIN: Takes Tylenol or ibuprofen for pain. LABORATORY DATA: Lab, chest x-ray, mammogram and bone scan were all negative for any evidence of disease.
Hyphen|Quotative or expressing a quantity or rate|141|No diarrhea and no urinary complaints. She has not yet started menstruating. PHYSICAL EXAMINATION: The patient is moderately overnourished 11-year-old female in no acute distress. HEAD: Normocephalic and atraumatic. EYES: Extraocular muscles intact. PERRLA. OROPHARYNX: Unremarkable.
Hyphen|Lexical hyphen|141|_%#NAME#%_. 2. Asthma, mild, intermittent which appears quiescent presently. I will have albuterol available on a p.r.n. basis. 3. I would re-attempt general screening for metabolic derangement including CBC, CMP, and TSH.
Hyphen|Quotative or expressing a quantity or rate|99|Light touch is equal in the four extremities. There are no tremors or involuntary movements. Finger-nose-finger, heel-knee-shin, and rapid alternating motion rate is unremarkable.
Hyphen|Compound pre-modifiers|174|Gait: Patient can stand up on both feet. She moves the left leg cautiously and then complains of not able to walk and sits down. ASSESSMENT/PLAN: This is a 22-year-old, right-handed, pleasant white female who was admitted for subjective left leg weakness and chronic pressure type headaches.
Hyphen|Compound pre-modifiers|239|The night prior to admission he had an episode of nausea and coffee-grounds emesis followed by melena and an episode of hematochezia which was bright red. By the next morning he proceed to the emergency room with further episodes of coffee-grounds emesis. The patient denies any indigestion or heartburn. He has previously not had any upper GI problems.
Hyphen|Compound|213|He subsequently has been rubber-banded initially frequently and now on an every three month period. His last rubber-banding was in _%#MM#%_ 2000. At that time, he did not have varices and it did not require rubber-banding. He presented in _%#MM#%_ of 2003 with confusion and wandering.
Hyphen|Quotative or expressing a quantity or rate|196|FINAL CONSULTING AREA: Emergency department REASON FOR CONSULTATION: Abnormal CT scan with a small traumatic subarachnoid hemorrhage. We were called to consult on _%#NAME#%_ _%#NAME#%_ who is a 48-year-old gentleman who was heard to have fallen down the stairs and was brought to the emergency room.
Hyphen|Compound pre-modifiers|112|He indicates a prior history of alcohol withdrawal. No overt symptoms presently. No history of DTs or withdrawal-related seizures. Unaware of alcohol-related liver disease, pancreatitis, or upper GI bleeding.
Hyphen|Compound pre-modifiers|111|At admission, the patient was febrile in the 101 degree range. White count was elevated. The patient had a boil-like area on his left hip and in the neck type area. The patient was started on Clindamycin and Ancef and admitted.
Hyphen|Junction|296|Examination of the thoracic area indicates no pain between spinous process, no pain in the paraspinal muscles. Examination of the lumbar area indicates pain between spinous processes, and she does have a Lidoderm patch on right now, which she has had most of the day and is between L1-2, L2-3, L3-4, L4-5, L5-S1, and then pain in the paraspinal muscles more on the right than on the left, pain over the right SI joint, no pain over the piriformis.
Hyphen|Compound|188|Ferrous sulfate ALLERGIES: Nonsteroidals give a rash. HABITS: Nonsmoker, no regular alcohol. PAST SURGICAL HISTORY: Status post right knee arthroscopy, hysterectomy with bilateral salpingo-oophorectomy, bladder suspension, laparoscopic cholecystectomy.
Hyphen|Compound pre-modifiers|153|Follow-up brain MRI performed on _%#MMDD2005#%_ showed a recurrent mass, measuring 3 x 7 mm, in the right internal auditory canal. It now had a more mass-like appearance as opposed to the linear enhancement in the past.
Hyphen|To|119|EXTREMITIES: No clubbing, cyanosis, or edema. SKIN: No rash is noted. NEUROLOGIC: Alert and oriented. Cranial nerves II-XII are grossly intact. Sensation is intact to light touch. Strength 5/5 bilaterally. LABORATORY: GGT of 36, glucose is 111, AST 105, urine tox screen is positive for cannabinoids and opiates.
Hyphen|Quotative or expressing a quantity or rate|235|INTAKE/OUTPUT: 2320/1705 mL. GENITOURINARY SYSTEM: Urine output 1850 mL. LABORATORIES: White count 12.2, hemoglobin 8.5, platelet count 116, INR 1.55, electrolytes within normal limits, creatinine 0.9, BUN 11. ASSESSMENT AND PLAN: A 54-year-old female status post Ventracor LVAD placed as a bridge to transplantation for dilated nonischemic cardiomyopathy, is currently doing well, will continue with her current Coumadin dosing to maintain INR between 2-2.5. I agree with the plan to obtain a duplex ultrasound of her upper extremities to rule out any thrombosis.
Hyphen|Quotative or expressing a quantity or rate|64|She has been using Prozac for a long time for depression. Her 12-lead EKG that was repeated today shows no evidence of prolonged QT interval.
Hyphen|Compound pre-modifiers|323|FAMILY HISTORY: Noncontributory. REVIEW OF SYSTEMS: Otherwise noncontributory. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 190/90, pulse 60s and regular, respiratory rate 18, afebrile. GENERAL: He is of normal stature. NEUROLOGIC: He has expressive aphasia with phonemic and word substitution errors, significant word-finding difficulty. Comprehension is intact. Impaired repetition. Right facial droop. Facial strength on the left side is intact.
Hyphen|Lexical hyphen|145|I would be happy to follow up if further issues arise during the hospitalization. Thank you for this consultation. We will be available to follow-up should any other medical concerns arise during this hospitalization.
Hyphen|Compound pre-modifiers|158|She states that she has been taking increasing amounts of overt-the-counter medications, including Tylenol and ibuprofen. The patient presented to her primary-care physician, who obtained an MRI at _%#CITY#%_ _%#CITY#%_ Radiology on _%#MMDD2005#%_, which showed what appeared to be a small subcentimeter cavernous angioma in the right anterior temporal lobe.
Hyphen|Compound pre-modifiers|121|ORTHOPAEDIC CONSULTATION CHIEF COMPLAINT: Left hip pain. HISTORY OF PRESENT ILLNESS: The patient is a 50-year-old nursing-home resident who has bilateral lower extremity weakness and particularly left-sided hemiplegia related to a pontine stroke. He also has some aphasia. He was seen in the emergency room, x-rays were obtained and demonstrated a femoral neck hip fracture.
Hyphen|Compound pre-modifiers|112|We did discuss possible inheritance patterns including autosomal recessive as well as X-linked inheritance. If X-linked inheritance then this patient may be at increased risk to be a carrier and could be at an increased risk to have an affected child, but again without further review of records or more information we would need to assess to help clarify the inheritance risk as well as diagnosis in this half-brother.
Hyphen|Typographic convention|95|NECK - supple without adenopathy or thyromegaly. CHEST - clear to auscultation. CARDIOVASCULAR - regular rhythm. ABDOMEN - bowel sounds present, no peritonitis but he is distended and tympanitic.
Hyphen|To|64|DISPOSITION: 1. Splint, sling and ice to the area. 2. Motrin 300-400 mg every 6 hours take with food, Tylenol plus Codeine 2 teaspoons every 4-6 hours, take this also with food.
Hyphen|To|283|REQUESTING PHYSICIAN: Dr. _%#NAME#%_ _%#NAME#%_. NEPHROLOGY CONSULTATION: Azotemia - BUN 100, creatinine 1.7. ASSESSMENT: Mr. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is an 82-year-old man whose azotemia would appear to be almost certainly prerenal, with a steady rise in BUN over the last 3-4 days with a relatively stable creatinine. I would not think that this represents a primary renal parenchymal disease or a destruction of the remaining kidney.
Hyphen|Compound pre-modifiers|129|A grandfather had lung cancer, and her father has basal cell cancer. SOCIAL HISTORY: She lives with her husband and has 2 college-aged daughters. She does not smoke and drinks alcohol occasionally. She teachers religion at Augsburg College.
Hyphen|To|114|Extremities: No edema noted. Skin: No rashes noted. Neurological: He was alert and oriented x 3. Cranial nerves II-XII are intact. Sensation intact. Gait within normal limits. There was no reproducible tenderness on palpation of the forehead or temporal or parietal regions.
Hyphen|Quotative or expressing a quantity or rate|46|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 50-year-old Caucasian male who presents for evaluation of major depression. He also had chronic pain related to headaches. A pain consultation is ordered.
Hyphen|Compound|211|HISTORY OF PRESENT ILLNESS: This is a 46-year-old woman whom years ago underwent a gastric bypass and has had chronic problems with constipation since that time. She routine takes enemas as well as Fleet Phospho-Soda but two days ago developed more severe pain that usual and this has not resolved.
Hyphen|To|271|She has not been aware of any problems with previous pulmonary embolization, but again she has had issues with deep asymmetrical right leg swelling that makes this more problematic. She has not had any problems with sleep apnea. Pulmonary functions done within the last 1-2 years have not shown any major obstructive or restrictive lung disease.
Hyphen|Lexical hyphen|167|Chest: Clear lung fields without bronchospasm. Cardiac exam regular without gallop or murmur. No click, no jugular venous distention. Breast exam deferred. Abdomen non-distended, soft, non-tender, no organomegaly or mass. Bowel sounds are normal. Distal lower extremity pulses are 2+, no cyanosis or clubbing.
Hyphen|Junction|144|When she sits, she has difficulty feeling the chair. Her rectal tone is reduced. MRI SCAN OF LUMBAR SPINE, _%#MMDD2004#%_: Lumbar stenosis at L1-2 which is moderate. There is no obvious impingement of the conus medullaris and there is no acute pathological process.
Hyphen|Junction|135|Recent history of idiopathic thrombocytopenic purpura (ITP). 2. Osteoporosis/osteopenia with pathologic fracture. 3. Lumbar stenosis L1-2. 4. Ho alcoholism, status post treatment, sobriety for 15 years.
Hyphen|Compound pre-modifiers|173|SOCIAL HISTORY: The patient smokes a pack of cigarettes per day. She is widowed. She had been living in _%#CITY#%_, Minnesota, but there are plans to move her to an assisted-living facility in _%#CITY#%_, Minnesota. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 97.1. Blood pressure 196/94. Heart rate 74.
Hyphen|Quotative or expressing a quantity or rate|191|FINAL REASON FOR CONSULTATION: Esophageal cancer. HISTORY OF PRESENT ILLNESS: Please refer to my consultation note from _%#MMDD2007#%_ for details. In brief, Ms. _%#NAME#%_ _%#NAME#%_ is a 79-year-old lady with multiple medical problems who was being followed by Dr. _%#NAME#%_ for resected lung cancer that she had in 2004 when surveillance scan showed thickening of the midesophagus.
Hyphen|Typographic convention|87|REVIEW OF SYSTEMS: Modest shortness of breath. No chest pain, orthopnea is present. GI - lots of gas and eructation. No GI bleeding. GU - no lower urinary symptoms. She thinks her urine output had declined.
Hyphen|Compound|417|On transfer here the patient was found to be coagulopathic with an INR of 2.6. Initial hemoglobin was 9.0 which is around her baseline with a recheck in the morning of 7.9. Since then the patient has received 2 units of blood with hemoglobin going up to 9.3. The patient's white cells are normal at 6.7 and platelets are low at 27. The patient was also thought to have a picture consistent with DIC with an elevated D-dimer, low fibrinogen, again elevated INR and PTT. The patient had also received blood at the outside hospital.
Hyphen|To|169|No calf asymmetry. LABORATORY DATA: Laboratory review is remarkable for a recent testing including a blood gas with a pH 7.38, pO2 753, pCO2 58. Blood sugars between 100-200. Prealbumin low at 19.0. CBC with a white count of 15.0, hemoglobin 11.0. Liver function tests are normal except for an alkaline phosphatase of 193 (could be bone).
Hyphen|To|132|Respiratory effort was good. Heart rate was regular without murmur. Abdomen was gravid with a vertex fetus, estimated fetal weight 8-9 pounds. No hernia or hepatosplenomegaly was noted. No abnormal axillary lymphadenopathy was noted.
Hyphen|Lexical hyphen|167|Electrolytes normal. INR 1.68. CHEST X-RAY: Clear. CT SCAN: As mentioned above. IMPRESSION: Colonic distention of the transverse and ascending colon with an abrupt cut-off. It is likely this is just colonic ileus. By clinical exam right now he does not have an ileus.
Hyphen|Compound|284|In addition, _%#NAME#%_ reports some problems during this pregnancy with recurrent urinary tract infection, constipation and abdominal pain. She reports having visits to the Emergency Room because of this and being given prophylactic antibiotics as well as Vicodin and Colace and Peri-Colace to help treat the constipation. She also reports having a PICC line placed for treatment of urinary tract infection earlier in this pregnancy.
Hyphen|Compound|138|The patient underwent general medical evaluation with his primary care physician yesterday. He was felt to be doing well and had a chest x-ray. He was told to come in for more information. He was advised that from a medical standpoint he was felt to be a good candidate and could proceed without limitation or difficulty.
Hyphen|Compound pre-modifiers|232|We will tap it and have it analyzed and subsequently get a CT scan to try to further evaluate the situation. Given her low ejection fraction, a cardiac cause could be an explanation although it is unusual to get a predominantly left-sided pleural effusion with heart failure alone. Thank you very much for this consultation.
Hyphen|Quotative or expressing a quantity or rate|99|He does drink as well, though he does not quantify just exactly how much. REVIEW OF SYSTEMS: Twelve-point review of systems was performed and was negative.
Hyphen|Compound pre-modifiers|333|RECOMMENDATIONS: Relative to her recent stroke picture the right external carotid artery stenosis is of no clinical significance. This is not an embolic source to explain her recent left hemispheric stroke and with a widely patent common carotid and internal carotid on that side there is no indication presently for any type of left-sided external carotid artery endarterectomy. I do recommend that she remain on antiplatelet therapy and she has been started on enteric-coated aspirin.
Hyphen|Compound|59|In the emergency room, she was noted to have a sore knee. X-rays were done. Labs were also checked and it was discovered that her hemoglobin was 5.6. Felt she needed to be admitted for the above mentioned problems.
Hyphen|To|241|In addition to major birth defects, the level II ultrasound also screens for markers or variations that may be indicative of a chromosome abnormality. Markers are seen in approximately 50-60% of babies with Down syndrome and approximately 80-90% of babies with the more severe trisomies 13 and 18.
Hyphen|Compound|225|He also has a history of hiatal hernia repair. Other medications include Lavoxyl, Zantac, and hydrochlorothiazide. Admission laboratory studies reveal an unremarkable CBC, platelet count, amylase, lipase level, and a troponin-I. Liver function tests were normal. BUN, calcium, glucose, and electrolytes were likewise unremarkable.
Hyphen|Compound pre-modifiers|137|PLACE OF CONSULTATION: Riverside IV Oncology Clinic. Dear _%#NAME#%_: Mrs. _%#NAME#%_, our mutual patient with follicular cleave cell non-Hodgkin's lymphoma returned to see me today. As you know, her diagnosis was made approximately three years ago.
Hyphen|Quotative or expressing a quantity or rate|44|FINAL HISTORY: _%#NAME#%_ _%#NAME#%_ is a 27-year-old 25 weeks gestation dialysis nurse who was admitted through the emergency room with severe right flank pain and some bladder spasms. The patient has had this pain in the past few weeks.
Hyphen|Quotative or expressing a quantity or rate|63|HISTORY: I was asked to see _%#NAME#%_ _%#NAME#%_, who is an 87-year- old woman who was admitted to the hospital yesterday after falling on her right side. She injured her right shoulder and I am asked to see her about injuries to the right side of the face.
Hyphen|Compound pre-modifiers|120|She stated it has been more difficult for her to recall information that she has read. She feels that she has less "long-term memory." She denies getting lost in familiar places.
Hyphen|Compound|109|The apices wee clear and had a slightly hyperresonant sound. CARDIAC: On cardiac auscultation, there was an S-1 and S-2 without extra sounds or murmur. The carotid arterial upstrokes were normal bilaterally. There were no carotid bruits.
Hyphen|Compound pre-modifiers|149|REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD REASON FOR CONSULTATION: Evaluation and management of electrolyte abnormalities in the setting of end-stage renal disease. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 78-year-old male admitted with new onset shortness of breath through the emergency room.
Hyphen|Compound|186|This patient is not having any angina. He is a very anxious person by nature and is worried about swelling on his left hand and some numbness in his fingers. He is not aware of any tachy-arrhythmias. Toprol has been restarted at 100 mg per day and he is back on his antipsychotic medications, Risperdal and Effexor.
Hyphen|Quotative or expressing a quantity or rate|251|_%#NAME#%_'s admission history and physical on _%#MMDD2006#%_. This includes information on medications, allergies, review of systems, past history, family history and social profile. PHYSICAL EXAMINATION: GENERAL: The patient is an alert, oriented 85-year-old female in no apparent acute distress. She has had some pain medication, she is lying in bed with a knee immobilizer splint in place.
Hyphen|Compound pre-modifiers|170|He then became briefly apneic and was intubated and was admitted to the MICU Service. Head CT was obtained this morning and shows a large 15 mm (at largest diameter) left-sided subdural hematoma with midline shift, which appears to be chronic with some acute elements/hyperintensity.
Hyphen|Compound pre-modifiers|205|I reviewed that a level two ultrasound, which can be performed today, can detect most cases of spina bifida, however, would be unlikely to detect spina bifida occulta. I reviewed _%#NAME#%_'s normal triple-screen blood test, which reduces her chance of having a baby with neural-tube defect, Down syndrome, and trisomy 18.
Hyphen|Quotative or expressing a quantity or rate|100|ASSESSMENT: Thirty-seven-year-old male admitted with the following: 1. Alcohol dependency: 2. A mild-to-moderate alcohol withdrawal. 3. Abnormal liver function with massive hepatomegaly on exam, doubt this relates alcoholic hepatitis or fatty change.
Hyphen|Compound pre-modifiers|225|She is not sexually active. She has no history of STDs and she had her last menstrual period one year ago and is going through menopausal symptoms/changes. PHYSICAL EXAMINATION: GENERAL: The patient is a well- nourished, well-hydrated female in no acute distress. She appears to be responding to internal stimuli with a flat affect and very paranoid during the examination.
Hyphen|Quotative or expressing a quantity or rate|182|I was asked by Dr. _%#NAME#%_'s Service to see this patient in consultation regarding epigastric abdominal pain. HISTORY OF PRESENT ILLNESS: The patient is a 38-year-old man with a 4-day history of progressive epigastric abdominal pain.
Hyphen|Quotative or expressing a quantity or rate|272|LABORATORY DATA: Laboratory work-up reveals a negative urine culture; however, his UA shows 25 to 50 RBCs, moderate leukocyte esterase. His creatinine also seems to be elevated today at 1.9 from a baseline of 1.7. His hemoglobin is 14.6. ASSESSMENT AND PLAN: This is an 82-year-old gentleman with dysuria and urinary retention. The patient has several factors that may be responsible for his urinary retention including history of BPH, recent CVA, and a history of spinal stenosis.
Hyphen|Compound|127|He presented here to Ridges Hospital with progressive weakness and inability to eat. He was started on tube feeding after an NG-tube was placed. He has continued to deteriorate since. His LFTs, alkaline phosphatase is high, which it has been high in the past, but his transaminases are now increasing.
Hyphen|Compound pre-modifiers|113|The patient was then transferred back to the ICU after the exploratory laparotomy. The patient was extubated post-op day one. Pulmonary artery catheter was discontinued post-op day one. The patient was started on full liquid diet.
Hyphen|To|61|For 201-250, give 3 units. For 251-300, give 5 units. For 301-350, give 6 units. For greater than 350, give 8 units and call physician.
Hyphen|To|111|PHYSICAL EXAMINATION: Lower extremity right foot and leg vascular vital signs are stable. Pedal pulses right +1-2/4. The right foot was edematous, erythematous at the lateral aspect including the fourth ray with chronic open wound with macerated tissue.
Hyphen|Quotative or expressing a quantity or rate|129|IDENTIFICATION: 74-year-old gentleman. CHIEF COMPLAINT: Abdominal pain. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 74-year- old gentleman who woke up this morning about 2:30 with severe epigastric pain with no radiation. He had some mild nausea associated. It was very persistent.
Hyphen|Quotative or expressing a quantity or rate|62|Date of Transfer: _%#MMDD2004#%_ _%#NAME#%_ _%#NAME#%_ is a 37-year-old female admitted with abdominal pain for several days. This was associated with nausea. She has a history of pancreatitis in the past with several admissions for this.
Hyphen|Lexical hyphen|124|PAST SURGICAL HISTORY: None. ALLERGIES: No known drug allergies. MEDICATIONS: Prenatal vitamins. HEALTH HABITS: She is a non-smoker. PHYSICAL EXAMINATION: VITALS: Vitals signs were reviewed from the nurse's flow sheet.
Hyphen|To|144|7. Betagan ophthalmic drops, 0.25 percent, 1 drop in each eye q.a.m. 8. Synthroid, 0.075 mg, 1 daily. 9. Multivitamin daily. 10. Ultram, 50 mg 1-2 every 6 hours as needed for pain. 11. She will continue with the knee high TEDs, on in the morning, off in the evening.
Hyphen|Compound pre-modifiers|183|She will also have her weight gain monitored. DISCHARGE INSTRUCTIONS: 1. Diet: Regular, age appropriate. As above, these should be limited to a maximum of 6 ounces per feed and a wide-based, low-flow nipple should be used for feeds. 2. Activity: Ad lib. 3. Return to emergency room or call Dr. _%#NAME#%_'s office for temperature in excess of 101 degrees, bleeding, or any sign of recurrent respiratory distress.
Hyphen|To|157|Chronic hyponatremia. Her sodium is mildly decreased to discharge sodium of 129 on _%#MMDD2003#%_. This has not been worsening. It has remained stable at 129-130 throughout her stay. This is likely related to increased diuretic therapy along with her underlying SIADH.
Hyphen|Quotative or expressing a quantity or rate|35|FINAL _%#NAME#%_ _%#NAME#%_ is a 45-year-old massively obese white female with severe bilateral lower extremity edema and chronic stasis ulceration, much worse on the left than the right lower leg. The patient is admitted because of severe cellulitis, ulceration and edema particularly of left lower leg and further treatment with elevation and pneuma boots to try to decrease the edema.
Hyphen|To|200|5. Most recently abdominoplasty. 6. Has had multiple urinary and cystoscopic procedures related to the multiple kidney stones. CURRENT MEDICATIONS: 1. Atenolol 25-50 mg at bedtime. 2. Amitriptyline 50-100 mg at bedtime. 3. Neurontin 300 mg t.i.d. 4. Aciphex q.d. up to b.i.d. 5. Flagyl t.i.d.
Hyphen|Quotative or expressing a quantity or rate|177|DOB: _%#MMDD1933#%_ ADMITTING DIAGNOSIS: Right neck mass. DISCHARGE DIAGNOSIS: Right tonsil squamous cell carcinoma with metastatic carcinoma in the right neck. HISTORY: This 69-year-old male noticed a rapidly enlarging right upper neck mass that was suspicious for carcinoma.
Hyphen|Lexical hyphen|265|On the tenth postoperative day, the day of discharge, he was tolerating a general diet, had experienced a bowel movement, and had active flatus. His urine output was excellent, his cystoma was healthy and pink at the time of discharge, and he will be seen in follow-up for removal of the gastrostomy tube in approximately 2 weeks, along with the indwelling ureteral stents.
Hyphen|Quotative or expressing a quantity or rate|144|_%#NAME#%_ underwent repeat low-segment transverse cesarean section with modified Parkland bilateral tubal ligation. Findings were of a viable 5-pound-15-ounce female infant delivered from frank breech presentation through clear fluid.
Hyphen|Compound pre-modifiers|141|DOB: _%#MMDD1974#%_ ADMISSION DIAGNOSES: 1. Diabetic ketoacidosis (DKA). 2. Pneumonia. This is a 28-year-old female with a history of insulin-dependent diabetes since the age of 13 admitted with nausea and vomiting.
Hyphen|Compound pre-modifiers|103|The patient is currently unable to provide any further details of history. PAST MEDICAL HISTORY: 1) End-stage renal disease, on hemodialysis. 2) Status post right upper fistula with revascularization of the fistula on _%#MM#%_ _%#DD#%_, 2002.
Hyphen|Quotative or expressing a quantity or rate|215|The patient has known metastatic breast cancer to the mediastinum, left chest wall and axilla. Her exam otherwise was normal except for the skin lesion noted, mild tenderness in the left sternal border and difficult-to-appreciate left axillary mass that is involved in her axillary surgical scar.
Hyphen|Lexical hyphen|150|LUNGS: Clear to auscultation. HEART: S1, S2. No gallops or murmurs. ABDOMEN: Benign. Thin. No masses noted. Surgical scar from cholecystectomy is well-healed. EXTREMITIES: Negative edema or calf tenderness. LABORATORY DATA: Head CT shows no acute findings.
Hyphen|Junction|150|3. History of documented peptic ulcer disease on EGD two years ago. She avoids nonsteroidals and aspirin (resultant GI upset). 4. Herniated disk of L4-5 with chronic lumbar pain. 5. History of Raynaud phenomenon. 6. History of heart murmur and right ventricular valve "damage." The details are not available.
Hyphen|Lexical hyphen|125|Cardiovascular is S1/S2, no S3, faint S4. Lungs clear to auscultation bilaterally. No rales or rhonchi. Abdomen was soft, non-tender, positive bowel sounds, obese, no guarding or rebound.
Hyphen|Compound pre-modifiers|220|The study was negative. The patient was also covered with a broad- spectrum antibiotics for both community and hospital-acquired pneumonia. The patient failed to show a significant improvement despite being on this broad-spectrum antibiotics. Short burst of high- dose steroid was tried without response.
Hyphen|Compound pre-modifiers|183|CARDIOVASCULAR: Negative. RESPIRATORY: Cough and seasonal allergies. GASTROINTESTINAL: Some abdominal pain and diarrhea. GENITOURINARY: Incontinence with both activity as well as urge-type incontinence. The patient also noted that she had a history of pelvic pain for approximately 5 years.
Hyphen|Compound|108|Abdomen soft. Extremities, without edema. Skin was warm and dry. LABORATORY DATA: Her hemoglobin was 11.5, d-dimer 0.3. Electrolytes were normal, glucose 151, creatinine 2.66. BNP was modestly elevated at 310.
Hyphen|Lexical hyphen|236|He feels that the reason for his admission is that the morphine makes him very sleepy and with low energy, and he would like to be able to do more and be more involved in his life around the house. PAST MEDICAL HISTORY: Metastasized non-small lung cancer. This was diagnosed in the year 2000.
Hyphen|Quotative or expressing a quantity or rate|158|PRELIMINARY PROCEDURE: Takedown ileostomy. SURGEON: _%#NAME#%_ _%#NAME#%_, M.D. ASSISTANT: _%#NAME#%_ _%#NAME#%_, PAC. HISTORY: _%#NAME#%_ _%#NAME#%_ is an 80-year-old, extremely healthy female who was admitted for takedown of an ileostomy.
Hyphen|Hyphenated name|15|Mrs. _%#NAME#%_-_%#NAME#%_ was discharged on _%#MM#%_ _%#DD#%_, 2005. On the evening of the second following discontinuation of her antibiotic, she had a fever spike to 39.1. Subsequently, the diagnosis of untreated pyelonephritis was entertained.
Hyphen|Lexical hyphen|380|HOSPITAL COURSE: Mr. _%#NAME#%_ _%#NAME#%_ is a 50-year-old gentleman with a strong family history of coronary artery disease, with sister dying of an MI at the age of 37 and his father having his first myocardial infarction at the age of 40. He has diabetes mellitus for 8-10 years. He was admitted to Fairview Southdale Hospital _%#MMDD2004#%_ with unstable angina, versus a non-Q wave myocardial infarction. He underwent angioplasty and stenting of an LAD lesion. This was felt to be the culprit lesion.
Hyphen|Compound|67|ADMISSION AND DISCHARGE DIAGNOSIS: Morbid obesity. PROCEDURES: Roux-en-Y gastric bypass and laparoscopic cholecystectomy. SURGEON: Dr. _%#NAME#%_ _%#NAME#%_. REFERRAL SURGEON: Dr. _%#NAME#%_. HOSPITAL COURSE: On _%#MM#%_ _%#DD#%_, 2004, _%#NAME#%_ _%#NAME#%_, a 41- year-old woman, was admitted to Fairview Southdale Hospital where she underwent surgery for Roux-en-Y gastric bypass and laparoscopic cholecystectomy.
Hyphen|Lexical hyphen|243|There is some modification in his discharge medications. His Cozaar has been increased to 100 mg daily and his furosemide to 40 mg b.i.d. His magnesium oxide is discontinued as he was replaced intravenously over the last couple of days. Follow-up will be as previously dictated.
Hyphen|Compound pre-modifiers|153|He was present for 1 week, arriving Monday and discharging on _%#MM#%_ _%#DD#%_, 2004, a week later. There were no spells captured. There were no seizure-like events while he was present. He had no episodes where he would press his event button, and, in fact, his visit was entirely without incident.
Hyphen|Compound pre-modifiers|162|He does not have any peripheral blood RFLPs pending. PROBLEM #3: Infectious disease. Mr. _%#NAME#%_ received routine prophylaxis with Tequin, fluconazole, and low-dose acyclovir. He was afebrile throughout his hospitalization. He will need to begin Bactrim after he is fully engrafted.
Hyphen|Quotative or expressing a quantity or rate|40|HISTORY OF PRESENT ILLNESS: This is a 34-year-old male who presents as a kidney donor for his father. Currently, he is well with no constitutional symptoms and no specific complaints.
Hyphen|Quotative or expressing a quantity or rate|113|Exam is limited. Normal vulva, vaginal, cervical mucosa. No cervical motion tenderness. ASSESSMENT AND PLAN: A 48-year-old with menometrorrhagia. Ultrasound demonstrating a submucosal fibroid and endometrial thickening. Endometrial biopsy demonstrating benign endometrial polyp and ultrasound demonstrating questionable bicornuate uterus with thickening in the right horn of 2.5 cm.
Hyphen|Lexical hyphen|150|The patient's scrotal incision was clean, dry, and intact. There was no erythema. FOLLOW-UP: The patient will be discharged home with scheduled follow-up with Dr. _%#NAME#%_ in approximately one week for a wound check and a review if voiding symptoms.
Hyphen|To|164|FOLLOW-UP: The patient is to follow up with Dr. _%#NAME#%_ as well as Dr. _%#NAME#%_ for radiation as scheduled by Rad/Onc and a nurse visit for staple removal in 7-10 days with her primary care doctor.
Hyphen|Quotative or expressing a quantity or rate|144|The patient underwent 6 additional cycles of carbo-Taxol, which was completed in _%#MM2006#%_. CA125 at that time was 25. Followup CT showed a 4-mm mediastinal lymph nodes. The patient presented to the ED on _%#MMDD2007#%_ complaining of 4 days of not feeling well and crampy periumbilical abdominal pain.
Hyphen|To|133|Bicarbonate was normal and he had no symptoms of diabetes. Hemoglobin A1c later came back at 9.9%. His blood sugars ranged in the 190-250 range. He was started on Amaryl and this will require further adjustment.
Hyphen|To|211|No wheezes or rales. HEART: Regular rate and rhythm without murmurs, gallops or rubs. ABDOMEN: Soft, nontender, nondistended. EXTREMITIES: Show no edema. NEUROLOGIC: The patient appears to have cranial nerves II-XII intact and equal bilaterally with the exception of the left eyelid drooping and left pupil abnormalities.
Hyphen|To|103|6. Aspirin 325 mg p.o. daily 7. Senokot/docusate 2 tablets p.o. q.h.s. p.r.n. constipation 8. Cepacol 1-2 lozenges p.o. q1h p.r.n. sore throat 9. Guaifenesin 5 ml p.o. q.6h. p.r.n. cough Unchanged: 1. Tiotroprium 18 mcg 1 puff daily 2. Tylenol 1000 mg p.o. q.6h. p.r.n. pain
Hyphen|Quotative or expressing a quantity or rate|197|FINAL DIAGNOSIS: Infected lymphangioma. SERVICE: Pediatric Oncology. RESIDENT: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, MD CONSULTS: None. PROCEDURES: None. HISTORY AND HOSPITAL COURSE: _%#NAME#%_ is an 8-month-old boy who has a known lymphangioma. He was evaluated by ENT on _%#MMDD2007#%_ in the emergency room for increased swelling and discomfort in the area.
Hyphen|Compound pre-modifiers|276|On _%#MMDD2006#%_, he had a revision of the prosthesis with an exchange of his polyethylene liner. On _%#MMDD2006#%_, the patient presented to an outside hospital with intractable pain and subsequently transferred here where he had his left hip aspirated revealing methicillin-sensitive Staphylococcus. Infectious Diseases was consulted and the patient returned to the operating room for irrigation and debridement.
Hyphen|Compound|340|FINAL PREOPERATIVE DIAGNOSIS: Failed hardware mandible, status post bilateral sagittal split ramus osteotomies. PLANNED PROCEDURE: Replacement of fixation mandible. PLANNED ANESTHESIA: General. SURGEONS: _%#NAME#%_ _%#NAME#%_, assistant _%#NAME#%_ _%#NAME#%_ INDICATION FOR OPERATION: _%#NAME#%_ _%#NAME#%_ is a patient who underwent LeFort-I osteotomy and bilateral sagittal split ramus osteotomy procedure earlier today.
Hyphen|Compound pre-modifiers|164|She then became bradycardiac and hypertensive at which time a code was called. Anesthesia arrived on the scene and was able to intubate her with difficulty with a 3-0 uncuffed ET tube. Her intubation was confirmed by change of her end-tidal CO2 as well as auscultation and initial improvement in her oxygen saturations.
Hyphen|Compound|127|Pain is improved with lying completely still but is exacerbated with all movements at this time. She was scheduled to have an L-spine MRI as an outpatient here today because she has a history of a VP shunt and require readjustment, but was transferred to our hospital for completion of that MRI, as well as further workup.
Hyphen|Quotative or expressing a quantity or rate|81|She is retired and her husband is present at her bedside. REVIEW OF SYSTEMS: A 10-point review of systems was done and found to be positive for the items noted in the HPI.
Hyphen|Compound|179|Patient was eventually able to undergo an orthotopic liver transplant on _%#MM#%_ _%#DD#%_, 2007. During the hospitalization he was having difficulty with p.o. intake and thus a G-tube was placed for nocturnal tube feeds. He has also had problems with elevated potassium for which he was started on Florinef and appears to have resolved his issues with hyperkalemia.
Hyphen|Compound pre-modifiers|122|ALLERGIES: Sulfa. REVIEW OF SYSTEMS: Negative with the exception of the HPI. PHYSICAL EXAMINATION: GENERAL: Pleasant, well-developed, well-nourished female in no apparent distress. VITAL SIGNS: Stable. Her temperature was up to 102.5, now 99.2. HEENT: Normocephalic, atraumatic.
Hyphen|Junction|173|HOSPITAL COURSE: The patient was admitted, taken to surgery on _%#MM#%_ _%#DD#%_, 2006, where he underwent a posterior spinal fusion from C4 to C7. He had nonunion at the C6-7 level. On postoperative day #1, he was awake, alert, taking medications well.
Hyphen|Compound pre-modifiers|208|No dominant masses were noted. Extremities were well developed. She had some sensory deficits of the extremities that were stable. Gynecologic exam was deferred. LABORATORY: Abdominal x-ray revealed a few air-fluid levels with dilated loops of large bowel and a large amount of stool and a large colon.
Hyphen|To|160|The patient was told that he is allowed to shower 48 hours postoperatively. However, he is not allowed to soak his wounds in a tub or go swimming for at least 3-4 weeks after surgery. The patient is told to make a followup appointment in clinic at UMMC with Dr. _%#NAME#%_ in 2-4 weeks for a postoperative check or earlier if needed and to contact _%#NAME#%_ to schedule that appointment at _%#TEL#%_.
Hyphen|And(fraction)|115|NECK: Supple. CARDIOVASCULAR: Heart sounds 1 and 2 were present and normal. She had sharp S2 valve click. She had 1-2/6 murmur that was loudest and the left upper sternal border and was a late systolic murmur.
Hyphen|Compound|299|Her admission labs were as follows: Sodium 139, potassium 4.1, chloride 104, bicarbonate 27, glucose 100, BUN 27, creatinine 0.9, white count 7.3, hemoglobin 11.7. She had blood cultures drawn which showed no growth after 48 hours. Over the course of her hospitalization, we had to decrease her Solu-Medrol and steroids because of worsening anxiety. She was started on vigorous q.4.h. nebulizers, also her home inhalers were continued.
Hyphen|Compound|161|She was stable until yesterday afternoon when the pain recurred and was much more severe throughout her abdomen and severe in the epigastric region. She took Gas-X again without relief. She had associated nausea although no vomiting. Her stools in her ileostomy were slightly looser than normal.
Hyphen|To|106|In the past the patient has been seen by Dr. _%#NAME#%_ _%#NAME#%_ (Minnesota Heart Clinic) for the past 2-3 years. He has had a coronary artery bypass graft (CABG) with known coronary artery disease.
Hyphen|Compound|127|She underwent nebulization treatments times two, Lasix 80 mg and nitroglycerin and her respiratory status was stabilized. Her D-dimer was 2.5 and BNP was 471. She had ultrasound which was negative for deep venous thrombosis bilaterally.
Hyphen|Typographic convention|144|Cardiac - As dictated above. Respiratory - as dictated above. Genitourinary - no nausea, vomiting, and no diarrhea, constipation. Genitourinary - negative. Musculoskeletal - some chronic back pain. Miscellaneous- the patient has been in stable health.
Hyphen|Quotative or expressing a quantity or rate|136|OPERATIONS/PROCEDURES PERFORMED: 1. EP study with ablation of SVT. 2. Right eye surgery. HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old man who presented to an outside hospital and was was transferred here for further care after an injury to his right eye.
Hyphen|Compound pre-modifiers|114|_%#NAME#%_ _%#NAME#%_ on Wednesday, _%#MM#%_ _%#DD#%_, 2005, at 1320 p.m. appointment. The patient is to be on low-salt, low-fat diet, and she is to keep activity as tolerated.
Hyphen|Lexical hyphen|129|We had increased her pramipexole to 1 mg nightly on _%#MM#%_ _%#DD#%_, 2005. 3. Card. A. Coronary artery disease, status post non-Q-wave MI, 2003; CHF with 20% ejection fraction, status post exacerbation, _%#MM#%_ 2005; and biventricular failure, status post biventricular pacing.
Hyphen|Lexical hyphen|201|HOSPITAL COURSE: The patient is a 72-year-old gentleman who was admitted on _%#MM#%_ _%#DD#%_ and underwent a right total knee arthroplasty. Postoperatively, he did well, and was discharged to Fairview-University Transitional Services on _%#MM#%_ _%#DD#%_.
Hyphen|Quotative or expressing a quantity or rate|74|Plavix 75 mg p.o. daily. 6. Colace 100 mg p.o. b.i.d. 7. Fentanyl patch 25-mcg topically every 3 days. 8. Lasix 40 mg p.o. daily (which the patient has not been taking).
Hyphen|Junction|163|3. Hypertension. 4. Coronary artery disease. 5. Hypogonadism. 6. Compression fractures with severe osteoporosis. 7. Compression fracture has previously been at T11-12 and T-8. 8. He has benign prostatic hypertrophy with an irritable bladder.
Hyphen|Quotative or expressing a quantity or rate|29|_%#NAME#%_ _%#NAME#%_ is a 40-year-old white female admitted to the hospital because of swelling in her right leg. She was seen in the emergency room where, even though a Doppler ultrasound of the leg was normal, she went on to have a CT scan of the lung, which revealed a pulmonary embolism.
Hyphen|Lexical hyphen|193|HISTORY: _%#NAME#%_ _%#NAME#%_ is an 84-year-old gentleman admitted on _%#MMDD2003#%_ for evaluation and treatment of dizziness with generalized weakness and recent multiple falls. Initial work-up showed high white counts up to 22.2 with 84% neutrophils and 5% lymphocytes.
Hyphen|Quotative or expressing a quantity or rate|119|CHIEF COMPLAINT: Multiparty, desires permanent sterilization. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 32-year-old gravida 7, now para 2, status post normal vaginal delivery who desires permanent sterilization. The benefits and risks have been discussed including risks of bleeding, infection, injury to bowel or bladder, anesthetic complications and perioperative risks as well as the permanence, irreversibility, failure rate and increased ectopic rate were discussed with the patient and her husband.
Hyphen|Lexical hyphen|117|He was instructed with regard to wound care, diet and activity. He will be seen in our office in postoperative follow-up.
Hyphen|Quotative or expressing a quantity or rate|191|HOSPITAL COURSE: Community-acquired pneumonia with respiratory failure, non-Q-wave MI, malnourished state and leukopenia and acute renal failure all present on admission. The patient is an 87-year-old with history of moderate dementia, hypertension, history of lung cancer, status post right upper lobe resection and dual chamber pacemaker for his complete heart block along with COPD who presented with shortness of breath.
Hyphen|Compound pre-modifiers|300|PRELIMINARY CHIEF COMPLAINT: Infection on abdomen. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 12-month-old boy who approximately 2-3 weeks ago developed a rash on his abdomen. This remained stable for several days and then began increasing and was seen in our office and was diagnosed with varicella-like reaction after a varicella vaccine. At that time, no treatment was deemed necessary and he continued to do well until the evening prior to admission while during a diaper change, the father noticed a red nodule with surrounding erythema on his abdomen.
Hyphen|Quotative or expressing a quantity or rate|29|_%#NAME#%_ _%#NAME#%_ is a 43-year-old acute and chronic alcoholic, admitted for probable withdrawal. He became agitated and was in the ICU. He required heavy dose of tranquilizers for sedation.
Hyphen|Compound pre-modifiers|262|HOSPITAL COURSE: As noted in the history of present illness, Ms. _%#NAME#%_ was initially admitted to the cardiology service. Her coronary artery angiogram revealed severe 3-vessel disease with a proximal stent in the right coronary artery with some degree of in-stent stenosis. She also had proximal posterior descending artery narrowing. There was noted to be significant stenosis in the proximal left anterior descending artery.
Hyphen|Obstetrical data|212|The carboplatin was dropped as she was developing a sensitivity to it with shortness of breath and anxiety in the last 1-1/2 hours of her infusion of course #3 in _%#MM#%_ of 2004. PAST MEDICAL HISTORY: 1. Para 3-0-0-3. 2. Hypertension. 3. Asthma. 4. Alcoholic liver cirrhosis, stable.
Hyphen|Typographic convention|91|Lungs - he denies any shortness of breath, but he has a little bit of a scant cough. Chest - he does report occasional chest pain he says is not associated with exertion and has occurred throughout the day for several years.
Hyphen|Compound|126|White cell count elevated slightly at 11.8, only a slight neutrophil shift, otherwise normal exam. Negative cardiac enzymes. X-ray of the chest was normal. A CT scan of the abdomen revealed no biliary dilatation, no retained gallstone, etc.
Hyphen|Compound|236|On _%#MMDD2004#%_ the patient was deemed stable for discharge to the nursing facility. Her vital signs are stable. She is afebrile. Of note, the patient had a mild hyperglycemia with sugars up to 170, I have asked that she have bid Accu-Chek for monitoring and to follow-up with Dr. _%#NAME#%_. Greater than 30 minutes were spent in time of discharge.
Hyphen|Typographic convention|340|Neurologic: Patient was alert and oriented x3. LAB VALUES ON DISCHARGE: WBC 6.1, hemoglobin 12.5, platelet count 209, sodium 141, potassium 3.9, chloride 109, bicarb 25, BUN 18, creatinine 1.0, calcium, magnesium and phosphorus levels are 8.4, 2.4 and 2.8 respectively. Glucose was 93. Troponin was decreasing on the day prior to admission - it was 8, down from 11 on the date of admission. HOSPITAL COURSE: Patient was taken to the catheterization lab on _%#MM#%_ _%#DD#%_ and stents were placed as described above.
Hyphen|Quotative or expressing a quantity or rate|195|_%#NAME#%_ _%#NAME#%_ (University of Minnesota Physicians, Department of Endocrinology and Metabolism). She had a vaginal delivery in _%#MM#%_ 2001 at 40 weeks at which time she gave birth to a 9-pound-13-ounce infant and she describes a tough vaginal delivery with significant tearing in the vaginal area.
Hyphen|Compound|93|No evidence of hemorrhage was noted. Mrs. _%#NAME#%_ was seen in consultation by neurology. T-PA was discontinued on _%#MMDD2004#%_ and the patient's IV Heparin was also discontinued.
Hyphen|To|248|The patient refused the Neurology consult at that time. The patient received his fifth dose of Thymoglobulin. His ALC then decreased to 0.0. The patient's creatinine increased to a level of 2.5 and throughout his hospital course remained around 1.8-2.2 with an average of 2.0. The patient's appetite was poor.
Hyphen|Obstetrical data|189|CHIEF COMPLAINT: Intrauterine pregnancy 38 3/7ths weeks gestation, intrauterine growth restriction, oligohydramnios. HISTORY: _%#NAME#%_ _%#NAME#%_ is a 32-year-old female gravida 2, para 1- 0-0-1, last menstrual period _%#MMDD2002#%_, estimated date of confinement _%#MMDD2003#%_ confirmed by multiple ultrasounds.
Hyphen|Quotative or expressing a quantity or rate|119|Extra strength Tylenol p.r.n. 4. Inspra 25 mg p.o. q. day. 5. Metoprolol 100 mg 1/2 tablet b.i.d., 6. Lipitor 20 mg one-half tablet q.h.s. 7. Cipro 500 mg b.i.d. since _%#MMDD2007#%_ for urinary tract infection (given this in urgent care)
Hyphen|Quotative or expressing a quantity or rate|152|FINAL DIAGNOSIS: Degenerative joint disease, right knee. PROCEDURE: Right total knee arthroplasty _%#MMDD2007#%_. SUMMARY: _%#NAME#%_ _%#NAME#%_ is a 77-year-old man who was admitted to the hospital after having failed nonoperative treatment program for degenerative arthritis of the knee.
Hyphen|Quotative or expressing a quantity or rate|35|FINAL CHIEF COMPLAINT: This is a 49-year-old Anesthesiologist with a history of recurrent nasal polyps. HISTORY: We discussed the risks, benefits and alternatives to bilateral endoscopic ethmoidectomy and antrostomies as well as possible sphenoidotomy.
Hyphen|Quotative or expressing a quantity or rate|127|She has no history of neuropathy or seizures noted. Psychiatric history is unremarkable. The patient is employed. She has one 6-year-old child. PHYSICAL EXAMINATION: GENERAL: She is an alert adult woman who is resting in bed.
Hyphen|Compound pre-modifiers|266|By report, the seizures resolved soon after the medication administration, though the patient was still significantly agitated. The patient then underwent non-contrast head CT that revealed a large right posterior frontal hypointensity with a moderate amount of mass-effect. No significant midline shifts and no sign of hemorrhage. After the CT was obtained, the patient was loaded with fosphenytoin, and started on Decadron and arrangements were made for transfer to Fairview-University Medical Center.
Hyphen|To|201|On postoperative day #3 she had no complaints and was discharged home on postoperative day #4. Discharge hemoglobin on her second postoperative day was 10.2. DISCHARGE MEDICATIONS: Percocet 1-2 every 4-6 hours as needed for pain.
Hyphen|Typographic convention|182|JVD elevated, hepatojugular reflux positive. ABDOMEN: Soft, nontender without mass or organomegaly, moderately overweight. GENITALIA/RECTAL: Deferred. EXTREMITIES: Lower extremities - pulses 2+ in both feet with trace edema. NEUROLOGICAL EXAM: Nonfocal. EKG currently paced on telemetry monitor. ER EKG showed an accelerated junctional rhythm with rate of 101 and nonspecific ST-T wave changes.
Hyphen|Quotative or expressing a quantity or rate|77|REQUESTING PHYSICIAN: Dr. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is a 62-year-old white male who enters the hospital via the emergency room with a history of having had an episode of right upper abdominal pain two weeks ago while in _%#CITY#%_ _%#CITY#%_, Missouri. He was seen in the emergency room. A CT scan was done and was negative.
Hyphen|Quotative or expressing a quantity or rate|294|COUNSELOR'S DISCHARGE SUMMARY PROGRAM NAME: STOP MEDICAL DOCTOR: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, MD TYPE OF DISCHARGE: The patient completed the program. PROBLEMS PRESENTED AT ADMISSION: The patient is a 17-year- old female who was admitted through the emergency department and placed on a 72-hour hold. The patient reports her drug of choice as methamphetamine. She was recently tested at school.
Hyphen|Lexical hyphen|94|At the time of discharge, the patient was alert and oriented x 3 and full cognition. He was re-instructed on the proper use and frequency of lactulose and was instructed to contact his primary care physician if he becomes constipated again.
Hyphen|Compound pre-modifiers|97|Urinary tract infection. TESTS DONE DURING THIS HOSPITAL STAY: 1. Urine culture shows 50,000 gram-negative rods. 2. Ultrasound of the right upper quadrant shows fatty liver, normal common duct of 4 mm, previous cholecystectomy, large bloody habitus which made the image poor image or difficult.
Hyphen|Quotative or expressing a quantity or rate|151|She stated that she had throbbing low back pain and sharp lower abdominal pain. Her cervix was checked at that time and she was found to be 1.5- to 2.0-cm dilated, 50% effaced, and -2 station. At this point the patient was sent to Labor and Delivery for monitoring.
Hyphen|Compound|97|2. Lasix 20 mg p.o. daily, hold for systolic blood pressure less than 100 and call the MD. 3. Lac-Hydrin 12% applied to lower legs and dry skin areas twice daily p.r.n. dryness.
Hyphen|To|139|TPN was stopped yesterday, and his calorie count from yesterday was 2000 calories. DISCHARGE MEDICATIONS: 1. Ativan 0.5 mg by mouth every 4-6 hours as needed for nausea. 2. G-CSF 480 mcg subcutaneous/IV q.24h. until his ANC is greater than 2.5 x 2 days.
Hyphen|To|190|MEDICATIONS: Bactrim and Albuterol. SOCIAL HISTORY: Significant for two to three packs per day for 33 years. Has less than one drink per week. He has been smoking Cannabis, but he stopped 6 - 8 months ago. He lives with his stepfather in _%#CITY#%_. He has a cleaning business.
Hyphen|Compound pre-modifiers|203|9. Repair of trochanteric osteotomy using internal fixation. ALLERGIES: Penicillin and erythromycin. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ was taken to the operating room on _%#MMDD2007#%_ for the above-listed procedure. She tolerated the procedure well. There were no complications. Intraoperatively, she did have a drain postoperatively which was removed when the output was minimal.
Hyphen|Quotative or expressing a quantity or rate|94|PRELIMINARY ORTHOPEDIC CONSULTATION: HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 72-year-old male with a history of Parkinson's who fell at home yesterday sustaining an intratrochanteric fracture on the left. He denied any previous pain with this. He does have a history of Parkinson's with bilateral subthalamic brain stimulator.
Hyphen|Compound pre-modifiers|94|LABORATORY DATA: Hemoglobin 10.3, MCV 108, MCHC 34, WBC 4200, platelets 288 K. ASSESSMENT: Pre-anesthesia consult, suitable candidate for surgery and anesthesia.
Hyphen|To|223|6. Lisinopril 20 mg p.o. daily. 7. Metoprolol 25 mg p.o. b.i.d. 8. Dilantin 300 mg p.o. daily. DISCHARGE INSTRUCTIONS: 1. The patient is instructed to followup in the Fairview University Medical Center Neurology Clinic in 6-8 weeks with an MRI of her brain prior to this appointment.
Hyphen|Compound|168|The right ventricle is normal in size and function with mild pulmonary hypertension. There was a round echodensity noted in the pericardial cavity at the level of the A-V groove junction of the LA and LV and has a broad based attachment to the LA wall and measures approximately 1.14 x 1.16 cm.
Hyphen|Compound pre-modifiers|72|She does not have any pain or symptoms of her head. Apparently had tonic-clonic movements. She did not bite her tongue, or loose her bowel or bladder.
Hyphen|Compound pre-modifiers|149|A) No recurrence of CHF symptoms and heart has looked good on recent Adenosine thallium study done _%#MMDD2002#%_. 3. Ischemic heart disease with non-Q myocardial infarction _%#MMDD2001#%_; a predischarge Adenosine thallium study showed 38% ejection fraction and no areas of significant ischemia; most recent Adenosine thallium done _%#MMDD2002#%_ again does not show any major areas of ischemia and an ejection fraction of upper 30's to low 40% range.
Hyphen|Quotative or expressing a quantity or rate|166|6. Depression and anxiety. 7. Diarrhea. 8. Anemia. 9. Moderately severe dehydration. 11. Nausea and vomiting, resolved. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 52-year-old female who presented to the emergency department at Fairview Ridges Hospital with a 4 week history of cough and a 3 week history of nausea, vomiting, and decreased p.o. intake and increasing lethargy.
Hyphen|Quotative or expressing a quantity or rate|39|DOB: Mr. _%#NAME#%_ _%#NAME#%_ is an 82-year-old male with pancreatic carcinoma, who was admitted with a right lower extremity cellulitis. Please refer to Dr. _%#NAME#%_'s initial history and physical for details of his recent medical course.
Hyphen|To|159|A course of outpatient cardiac rehabilitation was recommended. The patient will be seeing his physician, Dr. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ in follow up in 1-2 weeks. The patient was also scheduled to see Ms. _%#NAME#%_ _%#NAME#%_, physician's assistant in follow-up at the Park Nicollet Clinic in one week.
Hyphen|To|111|The patient did very well overnight and started feeling better the next morning. Her pain was down from 10 to 1-2 the next morning and she did not have any episodes of nausea, vomiting or headaches.
Hyphen|Quotative or expressing a quantity or rate|95|NEUROLOGICALLY: Alert and oriented, no focal deficit. SKIN is warm and dry. LABORATORY DATA: 12-lead EKG by my review is normal sinus rhythm without ischemic changes.
Hyphen|Quotative or expressing a quantity or rate|206|No tobacco, occasional alcohol, no IV drug use. He is a very active person and reportedly exercises daily. FAMILY HISTORY: Reviewed and noncontributory to patient's current admission. REVIEW OF SYSTEMS: Ten-point review of systems is all negative except for right arm weakness.
Hyphen|To|74|3-4 hours p.r.n. for pain. 2. OxyContin, 20 mg p.o. b.i.d. 3. Baclofen, 10-20 mg p.o. b.i.d. 4. Valium, 10 mg p.o. t.i.d. p.r.n. 5. Wellbutrin, 150 mg p.o. daily.
Hyphen|Quotative or expressing a quantity or rate|42|HISTORY: Mr. _%#NAME#%_ is a delightful 79-year-old gentleman with severe ischemic cardiomyopathy with an estimated ejection fraction of 15 to 20%. He had a dual chamber ICD for which he underwent upgrade on _%#MM#%_ _%#DD#%_, 2003 to biventricular pacing by Dr. _%#NAME#%_.
Hyphen|Quotative or expressing a quantity or rate|41|FINAL HISTORY: _%#NAME#%_ _%#NAME#%_ a 45-year-old patient developed a severe sigmoid diverticulitis with microperforation treated with intravenous and oral antibiotics. Shortly following his initial discharge he developed acute gout which required readmission.
Hyphen|Hyphenated name|331|PRELIMINARY HISTORY OF PRESENT ILLNESS: The patient is 32-year-old Caucasian male with past medical history significant for renal transplant, who presented to the emergency room at Fairview Ridges Hospital in the late afternoon with complaint of febrile illness and worsening flank discomfort. Ironically, the patient was at Abbott-Northwestern Hospital earlier that day for outpatient iron supplementation therapy as performed by Hematology over there.
Hyphen|Compound pre-modifiers|127|DISCHARGE DIAGNOSES: 1. Hypertensive urgency. 2. Hypertension. HISTORY OF PRESENT ILLNESS: The patient is a 67-year-old African-American male with a history of stage IV chronic kidney disease and hypertension, went to the doctor this afternoon at the Hematology/Oncology clinic, and his blood pressure was found to be 161/94. Afterwards, at home his blood pressure was 161/115. The patient was experiencing headache at this time, so he called 911.
Hyphen|Lexical hyphen|48|COUNSELOR'S DISCHARGE SUMMARY: PROGRAM: Fairview-University Medical Center STOP unit. REFERRED BY: The patient was referred to the STOP unit in care of his biological mother per concern of chemical use.
Hyphen|Quotative or expressing a quantity or rate|291|The patient's initial postoperative course was relatively unremarkable. He did have a fair amount of abdominal distension and his stoma mucosa was rather dusky in appearance. I attributed this to significant bowel wall edema. His wound had been loosely closed and we were packing it with wet-to-dry dressings. He was maintained on intravenous antibiotics. Additionally, he was started on hyperalimentation.
Hyphen|To|213|25. Patient is to follow up with Dr. _%#NAME#%_ in 1 week after CT. 26. Patient is to follow up with Fairview Lakes Coumadin Clinic on Monday, _%#MM#%_ _%#DD#%_, 2002, and patient is to have a follow up chest CT 2-3 months after discharge. It was a pleasure being involved in Ms. _%#NAME#%_'s care.
Hyphen|Quotative or expressing a quantity or rate|29|_%#NAME#%_ _%#NAME#%_ is a 69-year-old gentleman who is followed by Dr. _%#NAME#%_ _%#NAME#%_, as well as Minnesota Hematology/Oncology for metastatic adenocarcinoma.
Hyphen|Junction|176|There was no intracranial mass. There was mild cerebral atrophy. MR angiogram at the Circle of Willis was negative. MR of the cervical spine showed severe spinal stenosis at C3-4 secondary to congenital changes and disk herniation.
Hyphen|Quotative or expressing a quantity or rate|145|AXIS II: Cluster B. AXIS III: None. AXIS IV: Severe. AXIS V: Global assessment of functioning 45. HISTORY OF PRESENT ILLNESS: The patient is a 34-year-old Caucasian male who was admitted here for abusing Vicodin.
Hyphen|Quotative or expressing a quantity or rate|158|Following a bilateral EUA and cryotherapy to the left eye, the patient was admitted for chemotherapy with vincristine, carboplatin and etoposide. This was a 2-day course that she received. She tolerated the chemotherapy well with only 1 episode of emesis and she was discharged after her last etoposide dose on _%#MMDD2007#%_.
Hyphen|Lexical hyphen|244|At that time, the patient was discharged. It was recommended that he take a daily aspirin and to establish with a primary care physician. On the day of admission, the patient did see a new primary care physician and at that time, was chest pain-free. Later that day, the patient was working where he was delivering food, which required heavy lifting and walking significant distances, and developed the same type of chest pain that he presented with initially.
Hyphen|Typographic convention|190|The patient is sedated, comatose and on a ventilator. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 126/101, pulse 82, respiratory rate 12, temperature 99.5. SKIN: Negative. HEENT: Head - no trauma. The pupils are dilated and fixed. Funduscopic exam reveals hyperemia and I can not see clear details.
Hyphen|Compound pre-modifiers|279|MEDICATIONS: She is normally on no medications. She did take the Ketek today 800 mg p.o. SOCIAL HISTORY: The patient has a desk job. She does not smoke, nor drink. She has been under stress lately with the purchase of a new home, and the illness of her father, he is one day post-op coronary artery bypass grafting surgery here at Fairview Southdale Hospital.
Hyphen|Quotative or expressing a quantity or rate|222|INR 0.94, PTT of 26. TSH 1.96. ESR of 4, brain MRI does reveal an acute ischemic injury in the left frontal lobe, following a single gyrus. Tox screen is negative. Urinalysis is negative. ASSESSMENT/PLAN: Highly complex 32-year-old gentleman hospital day #1 with: 1. Ischemic cerebrovascular accident. Agree with TPA as given as well as the hypercoagulable panel is ordered.
Hyphen|Typographic convention|121|Admitted to inpatient psychiatry, where patient has continued to do well clinically. PAST MEDICAL HISTORY: 1. Depression - presumed anxiety disorder (as above). 2. Bladder cancer diagnosed two months ago. This was after patient presented to the emergency department on _%#MMDD2005#%_ for dysuria, urinary frequency, and urgency with voiding of small amounts.
Hyphen|Compound pre-modifiers|257|Her symptoms really began one week ago when she had a very rare steak and then had one episode of diarrhea the following day. The following day after that, Tuesday, she began to feel sore in her legs and felt a low-grade fever and then began to develop high-grade fever after that. An outpatient workup did reveal evidence of low white blood cell count and thrombocytopenia and a chest x-ray was negative.
Hyphen|Obstetrical data|137|_%#NAME#%_: Thank you very much for the consultation on your patient, Ms. _%#NAME#%_ _%#NAME#%_. As you know, she is a 26-year-old para 1-4-0-4 who is currently 23 weeks' gestation. She has a rather complicated prenatal history. She had a term vaginal delivery followed by a preterm vaginal delivery with an abruption due to being kicked in the abdomen.
Hyphen|Compound|78|An incidental finding on CT scan was right lower lobe consolidation. A chest x-ray confirmed patchy left lower lobe and moderate right lower lobe infiltrates.
Hyphen|Compound pre-modifiers|151|2. History of chronic and acute renal failure. 3. Restrictive lung disease. 4. History of COPD, but no smoking history. 5. History of diabetes, insulin-dependent. 6. Hyperlipidemia. 7. Hypertension 8. History of idiopathic pancreatitis. 9. History of gout.
Hyphen|Compound pre-modifiers|183|The patient was also seen by Dr. _%#NAME#%_ in medical oncology who has ordered a bone scan and a PET scan for continued workup of the patient's lytic bone lesion. Other than the left-sided hip pain, the patient has no other current symptoms of metastatic disease.
Hyphen|Quotative or expressing a quantity or rate|90|DOB: _%#MMDD1987#%_ DIAGNOSES: 1. Tonsillitis. 2. Dehydration. HISTORY: _%#NAME#%_ is a 17-year-old male with severe sore throat and tonsillar swelling who was initially seen on _%#MM#%_ _%#DD#%_ with two days of a sore throat without fever, cough or runny nose. No rash or abdominal pain. Strep was negative. He was diagnosed with viral pharyngitis and given Percocet and ibuprofen and advised to return if worsened.
Hyphen|Compound pre-modifiers|177|Hosfield for a general medical evaluation. At this time, the patient denies any acute or chronic medical condition. PAST MEDICAL HISTORY: 1. Substance abuse. 2. History of major-depressive disorder. 3. History of insomnia. 4. History of rape at age 3 by cousin and was reported.
Hyphen|Compound pre-modifiers|202|There is no thyromegaly or lymphadenopathy. Skin exam is unremarkable. Chest: Clear lung fields, without rales, rhonchi, or bronchospasm. Cardiac: Regular, without gallop or murmur, no click, no jugular-venous distention. Abdomen: Nondistended, soft, nontender, without organomegaly or mass. Bowel sounds are normal.
Hyphen|To|91|No edema on the left hand. Skin: no rashes noted. Neurologic examination: cranial nerves II-XII grossly intact. Sensation intact to light touch. Strength 5/5 bilaterally. Reflexes 2+ in the lower extremities, upper extremities deferred.
Hyphen|Line-breaking hyphen|141|At today's visit we plan to have a computed tomography scan repeated in _%#MM#%_. She will have further labs next month to include also a BCL- II by PCR. The patient will see me in follow up in three months.
Hyphen|Lexical hyphen|210|This is complicated by his underlying chronic obstructive pulmonary disease. This was likely precipitated by atrial fibrillation. He may have some element of volume overloaded and may need more aggressive ultra-filtration on dialysis. His symptoms have resolved. 2. End stage renal disease. We do not need to dialyze him today.
Hyphen|Compound pre-modifiers|107|DOB: _%#MMDD1949#%_ HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ _%#NAME#%_ is a pleasant 55-year-old African-American female, who has had off and on crampy abdominal pain since _%#MMDD2004#%_. She actually went to the emergency room on _%#MMDD2004#%_ with the same symptoms - abdominal pain associated with generalized weakness, nausea, some decreased appetite, and abdominal pain.
Hyphen|Compound|219|History of D and C. 4. Status post tonsillectomy and adenoidectomy. 5. History of hypothyroidism which was treated with thyroid replacement for some years, however, this is discontinued and the patient continued to be u-thyroid. 6. History of urinary incontinence. PRESENT MEDICATIONS: 1. Sonata. 2. Risperdal. 3. Effexor.
Hyphen|Compound|89|There is no swelling, however, range of motion of the fingers, wrist and hand are fine. X-ray shows a fracture of the left pubic ramus and my assessment is pelvic fracture, unable to manage, and will admit for pain relief, management, nursing care and PT to get her active again.
Hyphen|Obstetrical data|339|PREOPERATIVE DIAGNOSIS: Dysfunctional uterine bleeding, perimenopausal, thickened endometrium on ultrasound. PROPOSED SURGERY: Examination under anesthesia, diagnostic hysteroscopy, endometrial curettage. SURGEON: _%#NAME#%_ _%#NAME#%_, M.D. IDENTIFYING DATA/HISTORY: _%#NAME#%_ _%#NAME#%_ is a 58-year-old, single woman, gravida 1, para 0-0-1-0, perimenopausal, who is to undergo the above-named procedure for persistent prolonged vaginal spotting and bleeding and a thickened endometrium on pelvic ultrasound.
Hyphen|Compound|226|A chest x-ray was done which showed an infiltrate. Thus, the patient was started on an antibiotic and she responded well. A UA/UC was negative. A chest CT was done which was consistent with the findings of the lungs on chest x-ray. No evidence of PE was noted. Some changes in thyroid were noted, and then an ultrasound of the thyroid was done.
Hyphen|Quotative or expressing a quantity or rate|140|DOB: _%#MMDD1981#%_ ADMITTING DIAGNOSIS: Acute appendicitis. HISTORY OF PRESENT ILLNESS: This is a 22-year-old woman who presents with a one-day history of progressive right lower quadrant pain. She was seen in the emergency room, found to have an elevated white blood cell count, and CT scan was ordered which showed findings consistent with acute appendicitis.
Hyphen|Compound pre-modifiers|144|He presented to FirstCare and was seen by _%#NAME#%_ _%#NAME#%_ on _%#MM#%_ _%#DD#%_. He was given an injection of cefotaxime and placed on high-dose Augmentin. He presented again on the _%#DD#%_ with no improvement. Ms. _%#NAME#%_ thought that the finger looked about the same but the patient was complaining of increased pain.
Hyphen|Compound pre-modifiers|100|There is no organomegaly. There is no masses or tenderness. Bowel sounds are normal. There is a well-healed right lower quadrant surgical scar. CHEST: Displayed a sternal splitting surgical scar. PULSES: She has excellent femoral and dorsal pedis pulsations.
Hyphen|Lexical hyphen|54|_%#NAME#%_ _%#NAME#%_ is a 68-year-old female being re-admitted to Fairview Southdale Hospital by Dr. _%#NAME#%_ for elective eye surgery, namely a left cataract extraction and glaucoma repair.
Hyphen|Quotative or expressing a quantity or rate|161|HISTORY: Mr. _%#NAME#%_ _%#NAME#%_ is an 81-year-old male admitted with anorexia, weight loss, and an enterococcal urinary tract infection. The patient had a one-and-one-half month history of decreasing appetite and drop in weight of approximately 11 pounds.
Hyphen|Typographic convention|39|FINAL ADMITTING DIAGNOSIS: Bone defect - anterior maxilla. HISTORY OF PRESENT ILLNESS: This 59-year-old male has had an extensive problem along the anterior maxilla ever since incurring trauma to the anterior maxilla in his youth, playing hockey.
Hyphen|Typographic convention|121|PROBLEM #4: Cardiovascular system: She has aortic valve repair and history of dissection. I will continue Coumadin. Diet - cardiac diet. PROBLEM #5: Prophylaxis: TEDS stockings. CODE: She is full code.
Hyphen|Compound|116|Ongoing problems and suggested management: 1. Working on breastfeeding. 2. Vitamin and iron supplementation with Tri-vi-sol 0.5 mL per day. 3. ABR hearing screening. Discharge medications, treatments and special equipment: Tri-vi-sol with Fe 0.5 ml po q day Discharge measurements: Weight 3405 gms; length 54 cm; OFC 37 cm.
Hyphen|Compound pre-modifiers|220|He is improving but not appreciably so. Copies of x-rays were brought in from Dr. _%#NAME#%_'s office. I could not clearly see them well so I took AP, lateral, oblique x-rays of the left elbow in my office, showing radio-opaque density right in line with the open laceration. Presumably this is a foreign body. It is extremely tender and this goes along with the exam.
Hyphen|To|175|For complete list, please see admission and clinic note. In addition to his home medications, the patient was given the following medications. 1. Percocet 1-2 tablets p.o. q.4-6h. p.r.n. pain, 60 total tablets. 2. Levaquin 500 mg p.o. daily for 5 days.
Hyphen|Compound pre-modifiers|356|The SI fusion was done, and went uneventfully. He had excellent quality of bone. Bone morphogenic protein was used. The patient's postoperative course was, in every respect, targeted towards very difficult pain complaints, including the use of an epidural catheter, (with placement in the intensive care unit for 2 or 3 days), extraordinary amounts of long-term analgesics (up to 60 mg of MS Contin 4 times a day), use of Vicodin, and other augmenting medications, such as Flexeril and Tylenol.
Hyphen|Lexical hyphen|252|LABS AT THIS POINT: Are pending. ASSESSMENT: 1. Right lower lobe pleural effusion, likely hyponatremia, elevated cortisol. 2. General weakness and shortness of breath. PLAN: We will admit the patient to the hospital and try to coordinate a careful work-up of this process. I initially thought that the Fludrocortisone might help with the salt wasting nephropathy.
Hyphen|Lexical hyphen|138|He is to follow up with nephrology for his renal disease. Problem #3. Glucose intolerance: The patient's blood sugars were reasonably well-controlled during his hospital course. His hemoglobin A1c was less than 6. This will be continued to be monitored as an outpatient.
Hyphen|Compound|190|Fetal heart rate was elevated at 150-160 and the patient had a fever consistent with chorioamnionitis. As she had made no cervical change, she was diagnosed with arrest of dilatation and a C- section recommended. She was brought to the operating room where she underwent a primary low segment transverse cesarean section, delivered a healthy female infant, 7 lb 12 oz.
Hyphen|Quotative or expressing a quantity or rate|191|DISCHARGE DIAGNOSIS: Left ureteral stone at ureterovesical junction with intractable pain, status post cystoscopy. HOSPITAL COURSE: As previously noted. The patient is an otherwise healthy 39-year-old Caucasian male admitted with the acute onset of left- sided flank pain.
Hyphen|Typographic convention|156|Bedside Doppler reveals a strong biphasic signal within the digital artery of the second finger all the way out to the tip. LABORATORY DATA: _%#MMDD2002#%_ - serum creatinine 1.0, potassium 3.9, sodium 143, albumin 4.2, total bilirubin 0.6. AST, ALT, alkaline phosphatase all normal.
Hyphen|Quotative or expressing a quantity or rate|38|IDENTIFICATION: Ms. _%#NAME#%_ is a 44-year-old female admitted for polysubstance dependence and abuse. She has been using alcohol, Vicodin, marijuana, and Klonopin. She has had previous chemical dependency treatment.
Hyphen|Quotative or expressing a quantity or rate|174|He will follow up in the senior outpatient program at the University of Minnesota Medical Center, Fairview with Dr. _%#NAME#%_. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 63-year-old male admitted from the senior outpatient program for further assessment of major depressive disorder, recurrent, refractory, and progressive accompanied by suicidal ideation with intent to jump off the Lake Street bridge.
Hyphen|Compound|186|She remained afebrile with stable vital signs. There was a firm fundus at the umbilicus -2, was nontender. The incision remained clean, dry and intact. The staples were removed and Steri-Strips were placed. The patient was able to be discharged to home. DISCHARGE PLANS: The patient was given pain medications, and was recommended to follow up in approximately two weeks for an incision check, and in six weeks for a postpartum exam.
Hyphen|Lexical hyphen|301|Temperature curve was reasonably flat. Hemoglobin postoperatively was 11 grams, and the patient was discharged home on the fourth day following surgery, afebrile, doing well. The patient was given postoperative instructions and a prescription for Percocet and an appointment for an office visit follow-up. Final pathology report revealed uterus with the cervix with no pathologic diagnosis; the endometrium was inactive compressed endometrium, and the myometrium showed multiple large and small leiomyomata, submucosa and intramural and subserosal.
Hyphen|Quotative or expressing a quantity or rate|223|_%#NAME#%_ _%#NAME#%_, who was admitted to Fairview Southdale Hospital from _%#CITY#%_ Healthcare for rapidly declining status. On admission to the emergency room she was noted to have pleural effusion and at least at three-inch mass in the left lung, presumed to be a malignant lesion.
Hyphen|Lexical hyphen|298|At the time of discharge her wound was healing well, however, she reappeared in the office with a history of increased abdominal pain and some distention and the wound was draining pus-like fluid. The wound was opened and drained in the office, however, the concern was that she could have an intra-abdominal abscess and a CT scan was done en route to Admissions and did show evidence of a pelvic abscess which was drained by Radiology and over a period of the next two days her ileus resolved and she was allowed to go home on _%#MMDD2002#%_, two days following admission, to be followed in the office.
Hyphen|Compound pre-modifiers|177|There is certainly is a chance that his oral intake may not be sufficient, particularly in that, there may be some residual renal contributing deficits. If so, he may need short-term IVs at the nursing home. At the time of discharge, however, the patient's oral intake did seem adequate to maintain his hydration status.
Hyphen|To|148|She was recently diagnosed with lymphocytic colitis per colonoscopy on _%#MM#%_ _%#DD#%_. She was started on Asacol with improved diarrhea to only 3-4 times per day, down from 6- 10 times per day. The patient denies any recent travel, denies any suspicious meals recently.
Hyphen|To|143|The sutures and drains were removed today DISCHARGE MEDICATIONS: 1. Resume preoperative medications. 2. Percocet 5/325, 1 to 2 tablets p.o. q.4-6 h. 3. Aquaphor ointment applied to incisions b.i.d. FOLLOW UP: Followup appointment with Dr. _%#NAME#%_ in 1 week.
Hyphen|Compound|202|She is encouraged to consider assisted living in the near future. 2. Medications are as follows: Aspirin 81 mg daily; isosorbide mononitrate 30 mg every morning; Ambien 5 mg at bedtime as needed; Toprol-XL 75 mg q. day; Lidoderm patch 5% 1 patch over the skin site where the pain is, change daily; Lasix 60 mg daily; Mirapex 1 mg at bedtime; ferrous gluconate 324 mg twice daily; oxycodone/acetaminophen 5/325 1 to 2 tablets every 4 to 6 hours as needed for pain; Dulcolax suppositories per rectum q. day p.r.n. no stool; docusate 100 mg b.i.d. p.r.n. hard stools; and senna 1 tab p.o. q. day p.r.n. constipation.
Hyphen|Compound pre-modifiers|178|DISCHARGE DIAGNOSIS: Left frontal anaplastic oligodendroglioma. OPERATIONS/PROCEDURES PERFORMED: Cycle #9 of left internal carotid artery intraarterial chemotherapy without blood-brain barrier disruption. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 36-year-old gentleman with a history of left frontal anaplastic oligodendroglioma, had a resection in 1997, and underwent another resection in _%#MM#%_ 2003.
Hyphen|Lexical hyphen|90|Lipitor 20 mg PO QHS 4. Aspirin 81 mg PO daily DISCHARGE DIAGNOSES: 1. Hypertension 2. Non-cardiac chest pain 3. Hyperlipidemia Follow up with PMD in one week for blood pressure check.
Hyphen|Compound pre-modifiers|132|She underwent an uncemented bipolar right hip arthroplasty on _%#MMDD2005#%_. There were no complications of the operation. Her post-operative course was smooth and is documented in the medical records.
Hyphen|Compound|226|Her Solu-Medrol, as she continued to improve, was decreased to 80 mg IV q.8.h. As she stabilized, she was transferred up to the Third Floor. She was noted to have initially a fairly high sugar that slowly came down as the Accu-Cheks were performed with her final Accu-Chek being 105.
Hyphen|To|163|19. Nystatin 100,000 units p.o. Swish and Swallow. 20. MiraLax 17 g p.o. once a day, hold for loose stools. 21. _____ 20 mg p.o. in the evening. 22. Hydroxyzine 50-100 mg p.o. 3 times a day as needed for itching. 23. Hurricaine spray topical to throat every 4 hours as needed for pain.
Hyphen|Lexical hyphen|164|_%#NAME#%_ was discharged in good condition, with instructions to follow up with Dr. _%#NAME#%_ on _%#MMDD2004#%_ in the Transplant Clinic at 10:30 a.m. at Fairview-University Medical Center. DISCHARGE MEDICATION: 1. Aspirin 10 mg p.o. q. day. 2. Prevacid 15 mg p.o. b.i.d. 3. CellCept 250 mg p.o. b.i.d.
Slash|Divided by|259|After about a week some of the other residual symptoms of the upper respiratory tract infection faded; however, they continued to leave him with significant dyspnea on exertion and increased cough production above baseline. One week ago he had an episode of 1/4 cup of streaks of hemoptysis. Normally he is able to job about a half mile before he gets significant dyspnea.
Slash|Over(blood pressure)|215|Skin has been okay. Essentially the rest of complete review of systems either negative or in the HPI. PHYSICAL EXAMINATION: VITAL SIGNS: Height 5 foot 8, 221 pounds with a body mass index of 37.3. Blood pressure 122/75, respirations are 16, pulse is 68. He feels afebrile. HEENT: Atraumatic. Mouth is moist. NECK: Supple.
Slash|Date|176|8. Hepatitis C, diagnosed 1 year ago, started on ribavirin and Pegasys, treatment was complicated by thrombocytopenia. DIAGNOSTIC PROCEDURES: A flexible sigmoidoscopy, _%#MM#%_/_%#DD2007#%_. Impression: Internal, nonbleeding, mild hemorrhoids were found.
Slash|Of|130|FINAL CHIEF COMPLAINT: Chest pain HISTORY OF THE PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is an 82-year-old female with substernal 3/10 chest discomfort that was intermittent in quality with both exertion and rest. The patient has been having increased cough and said she has been having a slightly increased secretions.
Slash|Date|193|4. Poorly controlled diabetes mellitus, retinopathy and neuropathy. 5. Hyperlipidemia. 6. CHF. PAST SURGICAL HISTORY: 1. Lithotripsy. 2. Cystoscopy and placement of left ureteral stent _%#MM#%_/2006. 3. Total abdominal hysterectomy. 4. Left shoulder arthroscopy, rotator cuff repair.
Slash|Date|233|DISCHARGE DIAGNOSES: Status post primary low transverse cesarean section for delivery of a viable male infant. HISTORY OF PRESENT ILLNESS: The patient is a 22-year-old gravida 1, para 0 who presented to Labor and Delivery on _%#MM#%_/_%#DD#%_/2006 at 39 plus 4 weeks gestational age by a last menstrual period of _%#MMDD2005#%_ consistent with a 21 week ultrasound.
Slash|Per|298|PROBLEM #4: Diabetes mellitus. The patient continued on evening dose of glargine 9 units as well as NovoLog for meals and sliding scale. Her sliding scale insulin regimen is as follows: 1 unit of insulin for every 50 mg/dL above 150 to 200, 2 units of insulin for blood sugars between 201 to 250 mg/dL, 3 units of insulin for blood glucoses between 251 to 300 mg/dL, 4 units of insulin for blood sugars ranging between 301 to 350 mg/dL.
Slash|Date|13|DOB: _%#MM#%_/_%#DD1924#%_ PRINCIPAL FINAL DIAGNOSES: 1. Chronic headache, likely migraine. 2. Mitral valve replacement with mechanical valve. 3. Hyponatremia, consistent with syndrome of inappropriate antidiuretic hormone secretion.
Slash|Date|288|She was taken to the OR on _%#MMDD2002#%_ by Dr. _%#NAME#%_ who performed a left ORIF. Postoperative, the patient's course is complicated by a drop in hemoglobin from 9.8 down to 7.5 for which she received 2 units of packed red cells which increased her hemoglobin up to 10.1. On _%#MM#%_/_%#DD2002#%_ she developed markedly swollen warm left knee. Dr. _%#NAME#%_ came back and evaluated and felt that it was osteoarthritis.
Slash|Either meaning|142|Hemoglobin 13.4. Ultrasound shows fetal demise. IMPRESSION AT THE TIME OF ADMISSION: Missed abortion. PLAN: Evacuation by vacuum curretage and/or sharp curettage.
Slash|Date|187|He developed kidney failure that required dialysis, and also had elevated liver function panels, and had hepatomegaly. Many family conferences were advised about his progress. On _%#MM#%_/_%#DD2002#%_, the patient had a spiral CT done of the lungs to rule out pulmonary embolism.
Slash|Over(blood pressure)|253|4. Hypertension. The patient says that he has had borderline hypertension for many years. His cardiac echo shows mild concentric left ventricular hypertrophy. I started the patient on Toprol XL, and his blood pressure on the day of discharge was 127-138/56-78, with a pulse from 58-73. 5. Fever. The patient did have a fever to 100.9 degrees at 4:00 p.m. on _%#MMDD2002#%_.
Slash|Date|13|DOB: _%#MM#%_/_%#DD1958#%_ CHIEF COMPLAINT: Multiple symptomatic lipomas. HISTORY: The patient has multiple subcutaneous nodules on his arms, trunk, and right SI joint region.
Slash|Date|278|IN addition, Mr. _%#NAME#%_ received allopurinol through day 0. He tolerated his preparative regimen very well with minimal toxicity. 2. Allogeneic sibling peripheral blood stem cell transplant: Mr. _%#NAME#%_ received two peripheral blood stem cell infusions, first on _%#MM#%_/_%#DD#%_ then on _%#MMDD#%_. He started GCSF on the day of transplant and he had initial evidence of engraftment by day plus 13 with a white count of 800.
Slash|Date|127|1. Diagnosis of ALL _%#MMDD2001#%_. 2. History of Staph hominis infection in _%#MM2002#%_. 3. History of RSV infection _%#MM#%_/_%#DD2002#%_. 4. History of hepatomegaly. 5. Last hospital admission discharge _%#MMDD2002#%_ on home vancomycin for staphylococcus bacteremia.
Slash|Date|337|This diagnosis had been made previously by Dr. _%#NAME#%_ and he had started her on an appropriate heart failure program, but she was transferred for assessment from a cardiac standpoint, specifically to rule out significant coronary disease and to discuss the issue of possible AICD. Cardiac catheterization was done, dated for _%#MM#%_/_%#DD2005#%_, showing a visually approximated EF of 15%, no significant MR, near normal coronary arteries, trivial irregularities in a left circumflex dominant system.
Slash|Date|168|2. History of bulimia. 3. History of anorexia nervosa. 4. History of depression. 5. History of intraductal breast carcinoma. 6. History of pubic rami fractures _%#MM#%_/_%#DD2004#%_. MAJOR PROCEDURES: Status post right hip bipolar hemi-arthroplasty performed on _%#MMDD2004#%_.
Slash|Date|13|DOB: _%#MM#%_/_%#DD1970#%_ HOSPITAL COURSE: The patient is a 35-year-old who presents for repeat cesarean section at 39-weeks. Taken to the operating suite where a repeat low transverse uterine incision is carried out of a living female, 6 lb 13 oz, Apgars of 9 and 9.
Slash|Date|142|MEDICATIONS: None. ALLERGIES: Sudafed. There are no bleeding tendencies. REVIEW OF SYSTEMS: GI: Negative. GU: Negative. Her LMP began _%#MM#%_/_%#DD#%_. MUSCULOSKELETAL: Negative. RESPIRATORY: Negative. CARDIOVASCULAR: Negative. SOCIAL HISTORY: The patient is a supervisor for UPS.
Slash|Over(blood pressure)|172|The rest of her review of systems is negative on questioning the patient and husband. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98.4. Heart rate 85. Blood pressure 125/62. Respirations 16. 92% oxygen saturation. Weight is 211.5 pounds. GENERAL APPEARANCE: The patient is sitting on the edge of the bed after eating breakfast in no acute distress, though she does lean her head to the left side.
Slash|Date|142|Contractions were mild. We waited for the C-section room and staff to become available, and then she was taken down for C-section. On _%#MM#%_/_%#DD2005#%_, primary low segment transverse C-section was performed under spinal anesthetic.
Slash|Date|240|COUNSELOR'S DISCHARGE SUMMARY: ADMISSION DATE: _%#MMDD2005#%_. DISCHARGE DATE: _%#MMDD2005#%_. PROBLEMS PRESENTED UPON ADMISSION: _%#NAME#%_ _%#NAME#%_, a 16- year-old male, was admitted to the F-UMC _%#CITY#%_ _%#CITY#%_ ACDP on a _%#MM#%_/_%#DD2005#%_. He was referred by _%#CITY#%_ _%#CITY#%_ staff after completing a chemical dependency assessment at the request of his high school.
Slash|Date|280|At the time of discharge, the infant's corrected gestational age was 36 weeks and 3 days . He was the 1584 gm, 33 2/7 week gestational age male infant born at Fairview Riverside to a 33-year-old, B positive, gravida 1, para 0-0-0-0, married Caucasian female whose EDC was _%#MM#%_/_%#DD2006#%_. He was the first born of twin boys. The mother's pregnancy was complicated by polycystic ovarian syndrome with diabetes mellitus, preeclampsia, and chlamydia.
Slash|Date|25|PRELIMINARY DOB: _%#MM#%_/_%#DD1973#%_. The patient is at 32-year-old female who presents for repeat cesarean section, undergoes repeat cesarean section of a living female, weighing 8 pounds, 8 ounces, Apgars of 8 and 9. Postoperatively, she has done well with release on the fourth postoperative day with normal bowel and bladder function, fully ambulatory, tolerating a regular diet.
Slash|Date|170|There was a 1 cm loose body seen anterior to the ACL. She saw Dr. _%#NAME#%_ today in clinic, and has been scheduled for elective arthroscopy this coming Friday, _%#MM#%_/_%#DD2002#%_. PAST MEDICAL HISTORY: 1. Hereditary neuropathy in her lower extremities, for which she follows with Dr. _%#NAME#%_ _%#NAME#%_.
Slash|Date|249|The patient was completely alert and oriented. She came back to her normal usual baseline state of health. Patient also on admission had significant hypokalemia with a potassium level of 2.6. We used potassium protocol and on the morning of _%#MM#%_/_%#DD2002#%_ her potassium level was 5.0. The patient was a little bit anxious to go home.
Slash|Date|88|Both were susceptible to the antibiotics that he was on. Initial chest x-ray on _%#MM#%_/_%#DD#%_ showed interstitial infiltrates. Repeat on _%#MMDD#%_ showed improvement. ASSESSMENT: 1. Pneumonia. 2. Chronic obstructive pulmonary disease.
Slash|Phone number|120|Thank you again for allowing us to share in the care of your patient. If questions arise, please contact us as _%#TEL#%_/_%#TEL#%_ (NICU) or _%#TEL#%_ (office). We hope to be of continuing service to you.
Slash|Date|200|She was admitted for elective resection of this tumor. PAST MEDICAL HISTORY: 1. Bilateral thoracotomy with metastatic tumor removal, _%#MM2000#%_. 2. Aspergillus infection in her right stump, _%#MM#%_/_%#2000#%_. 3. History of sinusitis with chemotherapy. 4. Above-the-knee amputation, _%#MM2000#%_, with reconstruction.
Slash|Date|308|The patient will need a follow-up CBC. He also will need follow-up for his guaiac positive stools during this hospitalization and his anemia. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 54-year-old white male who was admitted directly from the infectious disease clinic to the hospitalist service on _%#MM#%_/_%#DD2006#%_. You are referred to the admission H&P dictated by Dr. _%#NAME#%_ on _%#MMDD2006#%_.
Slash|Date|169|She does not drink alcohol and does not smoke and never has. REVIEW OF SYSTEMS: Please refer to the nursing admission database that was reviewed by me and dated _%#MM#%_/_%#DD2006#%_. PHYSICAL EXAMINATION: VITAL SIGNS: Her blood pressure was 183/94, pulse is 95, respiratory rate 18, temperature afebrile.
Slash|Date|160|He had a complicated evaluation in which he was found to have a bile duct dilatation with stones. He was transferred to Abbott Northwestern Hospital on _%#MM#%_/_%#DD2006#%_.
Slash|Date|208|PAST MEDICAL HISTORY: 1. History of right rotator cuff tear as above. 2. History of major depression. 3. Hyperlipidemia. The patient's cholesterol on _%#MMDD2000#%_ was 281, lipid profile obtained on _%#MM#%_/_%#DD2000#%_ showed cholesterol 276, LDL cholesterol of 195, triglyceride level 77 and HDL of 66.
Slash|Date|97|FINAL PREVIOUS HOSPITALIZATION: University of Minnesota Medical Center Riverside Campus, _%#MM#%_/_%#DD2006#%_ to _%#MMDD2006#%_. PROBLEMS ADDRESSED DURING TRANSITIONAL CARE: Deconditioning and balance disturbance. The patient has underlying cerebral palsy and had been using Lofstrand crutches at home.
Slash|Date|249|DISCHARGE INSTRUCTIONS: 1. Discharge status stable. 2. Discharge diet, no added salt, low cholesterol diet. 3. Oxygen 2 liters by nasal cannula on discharge. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 79-year-old female who was admitted on _%#MM#%_/_%#DD2006#%_ by Dr. _%#NAME#%_. You are referred to his admission H&P. LABORATORY DATA: When she presented to the emergency room she had the following laboratory studies done: She had a hemoglobin of 5.9 with a MCV of 60, white count of 9000 with 87% neutrophils, 7% lymphocytes, 5% monocytes, 1% basophil, 2% nucleated red blood cells, an INR 0.99, a PTT of 28, D-dimer of 0.8, sodium 140, potassium 4.9, chloride 103, bicarbonate 29, glucose 104, BUN of 38, creatinine 1.14. The patient had LFTs that were normal.
Slash|Over(blood pressure)|192|She does not smoke or drink alcohol. FAMILY HISTORY: Mother died of rheumatic heart disease at age 76 and father died an accidental death. PHYSICAL EXAMINATION: Today her blood pressure is 132/60, pulse and respirations are normal. CHEST: Lungs - there are crackles in the left lung base.
Slash|Date|13|DOB: _%#MM#%_/_%#DD1975#%_ ADMISSION HISTORY: The patient is an otherwise healthy 28-year- old gravida 2 para 1-0-0-1 female who underwent an elective repeat cesarean section at term on _%#MMDD2003#%_. The procedure was uncomplicated, and a healthy 9 pound 10 ounce male infant was delivered.
Slash|Date|103|Pain control was initiated and full gastroenterology workup was initiated. This was started on _%#MM#%_/_%#DD2003#%_. PAST MEDICAL HISTORY: 1. Pseudotumor cerebri and migraine headaches. 2. Irritable bowel. 3. GERD.
Slash|Date|304|HOSPITAL COURSE: PROBLEM #1: Chemotherapy prep. The patient received Cytoxan on _%#MMDD2003#%_ and fludarabine on _%#MMDD2003#%_ through _%#MMDD2003#%_, followed by total body irradiation for one dose on _%#MMDD2003#%_. She received her allogenic sibling peripheral blood stem-cell transplant on _%#MM#%_/_%#DD2003#%_, and started GCSF after the transplant. She received a nadir for her white count on _%#MMDD2003#%_ of 300 and begin to graft approximately day nine after transplant.
Slash|Date|43|FINAL DEATH SUMMARY DATE OF DEATH: _%#MM#%_/_%#DD2006#%_. TIME OF DEATH: 5:23 p.m. CAUSE OF DEATH: Diffuse ischemic bowel factors contributing to death, sepsis syndrome secondary to ischemic bowel and ischemic cardiomyopathy.
Slash|Date|110|He did not require any transfusions and progressed well in physical therapy. On postoperative day #3, _%#MM#%_/_%#DD2006#%_, he did not have any complaints. During his stay he did feel that he had a "knot" in his left calf; however, this improved and during his stay he had a negative Homans' the entire time.
Slash|Date|245|Her incision is intact with staples and she has otherwise remained stable throughout her hospital stay. ASSESSMENT: Endometrial cancer status post total abdominal hysterectomy/bilateral salpingo-oophorectomy and lymph node dissection on _%#MM#%_/_%#DD2007#%_. FOLLOW UP: The patient is to be discharged today to her home.
Slash|Either meaning|134|3. Not suspicious for meningitis at this time. 4. Diabetes mellitus type 2, controlled with insulin. 5. Post-traumatic stress disorder/psychomotor retardation. 6. Gastroesophageal reflux disease. 7. Hypertension. PLAN: Will hold Lantus, will use Novolog as needed, will check blood glucoses every 2 hours for 8 hours and then per routine.
Slash|Date|86|She did receive Nubain for pain control at this time. By the early morning of _%#MM#%_/_%#DD2007#%_ at 01:35 a.m. the patient's cervix was dilated to 4-5 cm, 80% and -2 station.
Slash|Date|346|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 25-year-old White male who was previously followed by Dr. _%#NAME#%_ at HealthPartners but currently has no primary physician and no insurance and is admitted as an unassigned to Dr. _%#NAME#%_ _%#NAME#%_. The patient is status post DUI in _%#MM2000#%_ and has been unemployed since _%#MM#%_/2000. He was reportedly out drinking last p.m. He states that he consumed a 12-pack, denies any more than that.
Slash|Date|169|She had an ultrasound which was normal except for two small fibroids 2.5 cm and 1.7 cm, she had an 18 mm endometrial lining, the ovaries were not visualized. On _%#MM#%_/_%#DD2004#%_, she had an endometrial biopsy and ECC. The ECC was benign, the endometrial biopsy was insufficient tissue for diagnosis.
Slash|Date|236|She had been hospitalized in _%#MM#%_ with hypercalcemia and a few days in early _%#MM#%_ with generalized weakness, poor p.o. intake, and weight loss, then again with an aspiration pneumonia. She had been discharged to home on _%#MM#%_/_%#DD2004#%_ and had been managing fairly well, walking with her walker, and was oriented until about two weeks ago.
Slash|Date|425|This was done on _%#MMDD2004#%_, and showed normal left ventricular size and function with an ejection fraction of 60%, normal right ventricular size and function, normal left atrium and left atrial appendage in pulmonary veins, normal atrial septum with no atrial septal defect or patent foramen ovale by color or bubble study, and aorta was normal. The patient had another CT scan of her head, without contrast, on _%#MM#%_/_%#DD2004#%_, which did not show any bleed. She also had some lab tests done to evaluate for hypercoagulable workup.
Slash|Either meaning|97|Hepatitis B nonreactive. HIV nonreactive. Pap within normal limits in _%#MM#%_ of 2004. Gonorrhea/chlamydia negative. Urinalysis within normal limits. Ultrasound done prior to transfer revealed an AFI of 3.9 and measurements of fetus approximately 20 plus 4 weeks.
Slash|Date|189|DISCHARGE MEDICATIONS: 1. Metoprolol 50 mg p.o. b.i.d. 2. Coumadin 5 mg p.o. every day. Of note, the patient is clearly advised to check the INR level 3 days later, which is on the _%#MM#%_/_%#DD2007#%_ or _%#MMDD2007#%_. The future Coumadin dose is determined by the INR levels.
Slash|Over(blood pressure)|161|PAST MEDICAL HISTORY: Left hemicolectomy one week prior to current admission. DRUG ALLERGIES: NKDA. OBJECTIVE: The patient presented with a blood pressure of 108/88. Pulse of 70. Respiratory rate was 18. Temperature: 99.3. Alert and oriented x3.
Slash|Date|113|IMPRESSION: 1. Carcinoma of the bladder, admitted for surgery _%#MMDD2004#%_. Electrocardiogram obtained _%#MM#%_/_%#DD2004#%_ normal. Hemoglobin _%#MMDD2004#%_ - 13.2. creatinine has been obtained and is pending at the time of this dictation.
Slash|Of|170|There is no acute distress and no respiratory distress. Pupils are equal, round, and reactive to light. Extraocular movements are intact bilaterally. Muscle strength is 5/5 in the upper and lower extremities bilaterally. No sensory deficits to light touch in either upper extremity.
Slash|Date|167|PAST MEDICAL HISTORY: Primary care physician is Dr. _%#NAME#%_ at HealthPartners in _%#CITY#%_. ALLERGIES: None known. PAST MEDICAL HISTORY: 1. C-spine fusion _%#MM#%_/2005 at North Memorial Hospital. 2. Status post appendectomy. 3. Status post wrist surgery.
Slash|Over(blood pressure)|257|ENDOCRINE: History of diabetes mellitus type 2. NEUROLOGIC: Reports some bilaterally hand and foot tingling in a glove and stocking distribution. COGNITIVE: Negative. PHYSICAL EXAMINATION: She is afebrile. She is moderately hypertensive with bilaterally 184/113/ She is alert, in no distress. HEENT: Normocephalic, atraumatic. Extraocular muscles are intact. NECK is supple.
Slash|Date|8|_%#MM#%_/_%#DD2005#%_ _%#NAME#%_ _%#NAME#%_, M.D. Fairview Northeast _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#CITY#%_, MN _%#55400#%_ Dear Dr. _%#NAME#%_; Thank you for accepting the care of _%#NAME#%_ _%#NAME#%_ from the Neonatal Intensive Care Unit of University of Minnesota Children's Hospital, Fairview.
Slash|Separates two doses|79|10. Tylenol 650 mg p.o. q.4h. p.r.n. 11. Ventolin 2 puffs q.i.d. 12. Advair 250/50 one puff b.i.d. DISCHARGE FOLLOW-UP: Dr. _%#NAME#%_ and Dr. _%#NAME#%_. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 35-year-old woman who presented to Fairview Southdale Emergency Room on _%#MMDD2007#%_ with hypertension, chest pain and dyspnea.
Slash|Over(blood pressure)|206|Brother AAA rupture. Brother prostate cancer. Brother diabetes. SOCIAL HISTORY: Currently lives at home with her husband. Has a very supportive family. PHYSICAL EXAMINATION: VITALS SIGNS: Blood pressure 210/110, pulse 93, respirations 24, O2 on 98% on 2 liters oxygen, temperature 97.9. GENERAL: Sleeping during exam and not arousable.
Slash|Of|130|PULMONARY: Lungs are clear bilaterally, no dullness. ABDOMEN: Soft, mildly tender, bowel sounds are hypoactive. MUSCULOSKELETAL: 5/5 upper/lower muscular strength bilaterally, no clubbing.
Slash|Date|160|5. History of hyperlipidemia. 6. History of depression. 7. History of celiac sprue disease. 8. Peripheral vascular disease. He had aortoiliac bypass in _%#MM#%_/2006 that reportedly failed. He also had a left fem-pop he believes about 2 years ago versus possibly angioplasty alone of that leg.
Slash|Over(blood pressure)|186|Serum TNF and IL-1 beta levels were checked before his discharge to rule out any central etiology for his fevers. DISCHARGE EXAMINATION: VITAL SIGNS: Temperature 99.1, blood pressure 140/82, heart rate 71. NEURO: He is alert and oriented x3. Cranial nerve examination, pupils equal, round and reactive to light bilaterally.
Slash|Date|172|FINAL HISTORY: Ms. _%#NAME#%_ is a 54-year-old female being admitted at this time for a right total knee arthroplasty. HOSPITAL COURSE: The patient was admitted on _%#MM#%_/_%#DD2007#%_. She underwent an uncomplicated right total knee arthroplasty. She also had a Cortisone injection into the left knee at the same time.
Slash|Over(blood pressure)|262|Here, she was treated with first sublingual nitroglycerin and then a nitroglycerin patch and her chest heaviness has resolved and has not recurred. She does have home health and her visiting nurse found her blood pressure to be quite elevated today at around 199/101. Additionally, she has had some changes in her medications recently.
Slash|Date|13|DOB: _%#MM#%_/_%#DD1930#%_ ADMITTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, M.D. ATTENDING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, M.D. CHIEF COMPLAINT: Arm pain. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 72 yo white male, who was at home this evening at rest and developed bilateral arm pain at approximately 2130 hours.
Slash|Over(blood pressure)|135|REVIEW OF SYSTEMS: As above; otherwise negative. PHYSICAL EXAMINATION: She is in mild distress. Her blood pressure is borderline at 100/70. Her pulse is approximately in the 80s, rate controlled, atrial fibrillation.
Slash|Either meaning|165|I am asked to see her for preoperative evaluation and clearance. The patient sustained a complex bimalleolar fracture in _%#MM#%_ of this year and had open reduction/internal fixation by Dr. _%#NAME#%_. She has had increasing pain in that ankle. 2. Caesarian section. 3. Hysterectomy.
Slash|Date|137|Urine drug screen done on _%#MMDD2006#%_ shows evidence of amphetamines, otherwise normal. Comprehensive metabolic panel done on _%#MM#%_/_%#DD2006#%_ shows an increased chloride level 111, a decreased alkaline phosphatase 62, but normal ALT 42, normal AST 24.
Slash|Over(blood pressure)|325|It was Wednesday night, 2 days ago, when she developed a cough. This progressed to a productive cough with yellow sputum on Thursday, 1 day prior to admission Last night was a rough night as she experienced worsening cough, an increase in shortness of breath associated with chest pain and a rise in her blood pressure to 200/70. The fever just started today. There has been a weight gain of 3 pounds over the last 4 days, and there was a wee bit of dizziness yesterday.
Slash|Either meaning|155|3. Postoperative anemia. 4. Ramsay Hunt syndrome with left-sided facial droop. 5. Morbid obesity. 6. Dyslipidemia. 7. Chronic obstructive pulmonary disease/bronchitis. 8. Recent aspiration pneumonia. 9. Recent postoperative delirium.
Slash|Separates two doses|91|7. Ambien 10 mg J-tube each day at bedtime. 8. Amiodarone 200 mg J-tube b.i.d. 9. Roxicet 5/325 5-10 mL J-tube q.6 hours p.r.n. breakthrough pain.
Slash|Either meaning|85|Routine Foley catheter cares will be done. 3. Advanced directives. The patient is DNR/DNI. This was discussed with the patient's son. At this time he is still thinking that she would want (and he would want for her) Intensive Care Unit level care if need be.
Slash|Divided by|199|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 32-year-old, G3, P2, with an estimated due date of _%#MMDD2003#%_. Her history is complicated by two previous cesarean sections. She is now 38 3/7 weeks gestational age. Her first cesarean section was in 1989 for failure to progress.
Slash|Date|181|7. Type 2 diabetes mellitus. 8. History of an abnormal kidney function study. HOSPITAL COURSE: Ms. _%#NAME#%_ underwent an open gastric bypass and liver biopsy procedure on _%#MM#%_/_%#DD2003#%_. She tolerated the procedure well and had an uncomplicated and unremarkable postoperative course.
Slash|Date|173|3. RESP: NC 02 at 25-30%. Caffeine level will need to be checked today or tomorrow. 4. HEME: Follow hemoglobin. Transfuse for <11. 5. NEURO: Follow up HUS needed at _%#MM#%_/_%#DD#%_. Discharge medications, treatments and special equipment: 1. Caffeine 5mg IV QD 2. Vitamin A 3x/wk. Next dose due on _%#MMDD#%_.
Slash|Date|225|She was placed on Zithromax and discharged to home. However, she was called back to the hospital after two days when her blood cultures grew out Hemophilus influenzae. Please see admission note from Dr. _%#NAME#%_ of _%#MM#%_/_%#DD2004#%_. The patient did not feel terribly ill, but had noticed fairly frequent coughing and some left posterior pleuritic chest pain.
Slash|Date|190|2. Severe chronic obstructive pulmonary disease with pulmonary hypertension. 3. Critical aortic stenosis aortic valve area 0.6 cmm and a left ventricular ejection fraction of 70% in _%#MM#%_/2004. 4. Morbid obesity. 5. Coronary artery disease. 6. Peripheral neuropathy with chronic pain.
Slash|Date|30|FINAL PROCEDURE DATE: _%#MM#%_/_%#DD#%_ SURGEON: _%#NAME#%_ _%#NAME#%_, MD PROCEDURE TO BE PERFORMED: Excision of necrotic tissue in the left inguinal region. REASON FOR ADMISSION: _%#NAME#%_ _%#NAME#%_ is a 63-year-old female who has suffered from squamous-cell carcinoma in several sites including disease spread to the left inguinal lymph node.
Slash|Date|123|1. Video swallow done _%#MMDD2007#%_ with intermittent/laryngeal penetration with thin barium. 2. MRI and MRA done _%#MM#%_/_%#DD2007#%_, no evidence of acute injury, extensive nonspecific white matter changes which could represent chronic small vessel ischemic disease, moderate parenchymal loss without hilar predominance, no evidence of hemodynamic significant stenosis, aneurysm or dissection.
Slash|Date|257|No bloody stools, no abdominal pain. PAST MEDICAL HISTORY: History of pyelonephritis two episodes, last treated in the OR _%#MM2005#%_, hospitalization earlier. She did have an episode of urosepsis in _%#MM2004#%_. History of iron deficiency anemia _%#MM#%_/04, osteoporosis. She is also on methotrexate for unclear reasons. PAST SURGICAL HISTORY: Tubal ligation.
Slash|Date|171|A repeat KUB on _%#MMDD2007#%_ did show that the stool had moved out of the colon and that air was starting to move a little bit more. She was started on feeds on _%#MM#%_/_%#DD2007#%_. For the patient's urinary tract infection she was started on Levaquin.
Slash|Over(blood pressure)|242|He is a nonsmoker, social drinker. FAMILY HISTORY: Noncontributory. REVIEW OF SYSTEMS: Negative for chest pain, dyspnea, abdominal pain or urinary complaints. PHYSICAL EXAMINATION: GENERAL: Pleasant, thin male. VITAL SIGNS: Blood pressure 124/76, resting pulses in the 50s. HEENT: Normal ears, eyes, pharynx. NECK: Without bruits, thyromegaly or adenopathy.
Slash|Date|158|READMISSION TO TRANSITIONAL CARE UNIT: _%#MMDD2006#%_ ADMITTED: Fairview-University Transitional Services PREVIOUSLY HOSPITALIZED: 1. Hospitalized on _%#MM#%_/_%#DD2006#%_. 2. Transitional-services unit stay: _%#MMDD2006#%_ to _%#MMDD2006#%_.
Slash|Date|220|On the morning of the _%#MMDD2007#%_, she was successfully cardioverted into normal sinus rhythm. Upon admission and daily thereafter she received Lovenox 75 mg subq daily and received 1 dose of Coumadin 5 mg on _%#MM#%_/_%#DD2007#%_. On the morning of _%#MMDD2007#%_, her INR was 1.08 and plans were for her to be discharged to home on Lovenox and Coumadin.
Slash|Date|150|9. Bilateral pleural effusions. KEY IMAGING STUDIES AND PROCEDURE PERFORMED DURING THIS HOSPITALIZATION: 1. Abdomen flat plate and upright on _%#MM#%_/_%#DD2007#%_ reveals findings of dilatation of small bowel loops in the left central abdomen with air fluid levels on the upright view.
Slash|Over(blood pressure)|135|Reports a similar episode 3-4 years ago to what happened this morning. When the paramedics got to her house, her blood pressure was 250/140. Denies any visual change, denies any focal weakness. The patient was brought to the emergency room where she had further evaluation and admitted to the hospital.
Slash|Date|121|The plan was to follow this closely. Blood pressure remained normal. However, she called early on the morning of _%#MM#%_/_%#DD2007#%_ complaining of epigastric pain. She was advised to present to L&D. HOSPITAL COURSE: On admission to L&D, the patient's blood pressure was noted to be elevated with a blood pressure in the 160 over 110 range initially.
Slash|Date|122|Positive fevers and chills. No nausea or vomiting. PRENATAL CARE: Family practice, Dr. _%#NAME#%_, with an EDC of _%#MM#%_/_%#DD2008#%_. Prenatal labs, A positive, antibody negative. HIV negative, RPR negative, wet prep negative. Pap NILM. Hepatitis B surface antigen negative, rubella immune.
Slash|Over(blood pressure)|212|She denies abuse of other drugs. She took some Klonopin on _%#MMDD#%_ when she increased her use prior to coming into treatment. PHYSICAL EXAMINATION: Temperature 98, pulse 80, respirations 20, blood pressure 124/80. In general, this is a well-developed, well- nourished 40-year-old female in no acute distress.
Slash|Date|229|The patient seen in consultation by Dr. _%#NAME#%_ from Psychiatry. As he was tolerating a diet with normal vital signs and unremarkable exam, it was elected to pursue this on Psychiatry, where patient was transferred on _%#MM#%_/_%#DD#%_ or _%#MMDD2004#%_, condition at time of transfer stable.
Slash|Separates two doses|145|16. Lisinopril 40 mg p.o. each day at bedtime. 17. Metoclopramide 5 mg, 1/2-1 tablet p.o. b.i.d. 18. Protonix 40 mg p.o. q. day. 19. Dyazide 37.5/25, 1 p.o. q. day. 20. Amitriptyline 25 mg, 1-2 tablets p.o. each day at bedtime.
Slash|Date|138|She is instructed to have the wet-to-dry dressing changes in the intraabdominal wound 2 times a day. She is to followup on Monday _%#MM#%_/_%#DD2006#%_ with Dr. _%#NAME#%_. She was given _%#NAME#%_'s phone number to make that appointment, _%#TEL#%_.
Slash|Over(blood pressure)|171|FAMILY HISTORY: Significant for father with elevated cholesterol. MEDICATIONS: 1. Prenatal vitamins. 2. Baby aspirin. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 136/89, temperature 97.9, pulse 98, respirations 16. GENERAL: She is alert and oriented in no acute distress.
Slash|Date|154|This was attempted laparoscopically. However, this was not able to be well exposed via laparoscopy. Therefore, an open drainage was undertaken on _%#MM#%_/_%#DD2002#%_. The patient's post-operative course was entirely unremarkable and without complication.
Slash|Divided by|135|ALLERGIES: SENSITIVITIES THE FOLLOWING MANNITOL (HIVES), REGLAN, (HIVES) TRIAMTERENE (HYPERKALEMIA.) MEDICATIONS: 1. Lipitor to 80 mg 1/2 p.o. q. daily 2. Monopril 4 mg p.o. q. day. 3. Levothyroxine 88 mcg.
Slash|Date|187|2. Atrial fibrillation with tachybrady syndrome. 3. Elevated liver function test. 4. Left hospital against medical advice. MAJOR TESTS/PROCEDURES: 1. CT scan of the abdomen dated _%#MM#%_/_%#DD2007#%_: No significant change in inflammatory changes of diverticulitis in the sigmoid colon, new right pleural effusion with bilateral patchy ground glass opacities.
Slash|Over(blood pressure)|148|In the event the patient continues to remain non-hypertensive without his lisinopril, it may be discontinued. Tonight his blood pressure fell to 70s/30s and so if he is asymptomatic will be given gentle hydration.
Slash|Date|261|After a careful discussion of the risks and benefits of resection, the patient elected to proceed with surgery for this. PAST MEDICAL HISTORY: 1. Diabetes mellitus. 2. Parkinson's disease. HOSPITAL COURSE: The patient was taken to the operating room on _%#MM#%_/_%#DD2006#%_ for the above-named procedure. She tolerated it well and was taken to the floor postoperatively.
Slash|Date|177|PROCEDURES PERFORMED: Laparoscopic unroofing of lymphocele. BRIEF MEDICAL HISTORY: Mrs. _%#NAME#%_ is a 54-year-old female patient status post kidney transplant done in _%#MM#%_/_%#DD2006#%_. Her postoperative course was complicated by the formation of a lymphocele.
Slash|Divided by|264|Overall, the procedure time was 6 hours. T-tube drain was left in place. Minnesota Gastroenterology was also consulted for ERCP. The biliary team was consulted and recommended that they allow the T-tube to mature and that she will undergo an ERCP approximately 1 1/2 weeks following discharge. The patient was placed empirically on Zosyn on admission and she was afebrile through her hospital stay.
Slash|Date|150|FINAL HISTORY OF PRESENT ILLNESS: The patient is a 15-year-old female with a history of osteosarcoma of the left proximal fibula diagnosed in _%#MM#%_/2007 status post resection in _%#MM2006#%_ on COG protocol AOST0331 who presents for scheduled chemotherapy. She is on week 39 and is scheduled for methotrexate with leucovorin rescue.
Slash|Date|126|9. Sildenafil 50 mg p.o. daily. 10. Ferrous sulfate 325 mg p.o. b.i.d. DISCHARGE INSTRUCTIONS: 1. INR check on Monday _%#MM#%_/_%#DD2007#%_ at the University Lab with results monitored by the university anticoagulation monitoring service and adjustment of her Coumadin should be addressed at that time.
Slash|Date|298|A Duplex carotid ultrasound study showed significant carotid stenosis bilaterally, 60-79% in the right ICA, 80-99% in the left ICA and significant external carotid artery disease also with retrograde flow in the left vertebral artery presumably due to subclavian steel. Echocardiogram done _%#MM#%_/_%#DD2002#%_ showed normal right ventricular dimensions and function, mild left ventricular dysfunction with an ejection fraction of 40-45%, aortic sclerosis, mitral annular thickening and mild mitral insufficiency, mild tricuspid insufficiency, and mild pulmonary hypertension.
Slash|Either meaning|106|Today she is hungry and wanting to eat which is an improvement for her. PAST MEDICAL HISTORY: 1. Emphysema/COPD. 2. Osteoporosis. 3. G-3, Patient-2 with two female children. 4. Status post cholecystectomy.
Slash|Either meaning|279|HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 52-year-old with Stage III-C endometrioid adenocarcinoma of the ovary diagnosed in 2001 after the patient has right lower quadrant pain and microscopic hematuria. On _%#MMDD2001#%_ the patient underwent examination under anesthesia/exploratory laparoscopy/total abdominal hysterectomy/bilateral salpingo-oophorectomy/tumor debulking omentectomy/rectal sigmoid resection/colostomy/ Hartman's pouch/appendectomy/cystotomy with repair/bilateral ureterolysis.
Slash|Date|277|There were no serial EKG changes, although there was an elevation in troponins, with peak troponin level of 2.26, suggesting small myocardial injury. (Troponin-I 0.64, 0.69, 2.26, 0.72). She was treated with nitrates and beta blocker when oral medications were resumed _%#MM#%_/_%#DD#%_. Her volume was replaced and she did receive 3 units of packed RBC's.
Slash|Either meaning|168|2. Track her diabetic status and blood sugars carefully. 3. Review her medication usage. 4. Check a Lyme disease titer and VDRL. 5. Plan for empiric steroid therapy and/or acyclovir, depending upon results of lab studies and radiographic findings.
Slash|Date|231|ULTRASOUNDS: 1. On _%#MMDD2007#%_ twin A with severe polyhydramnios. Single pocket 17 cm and twin B with oligohydramnios ad periods of absent end-diastolic flow at 26 plus 1 week, amniocentesis with 1450 mL of fluid. 2. On _%#MM#%_/_%#DD2007#%_ at 27 plus 1 week's twin A with severe polyhydramnios 13 cm fluid pocket and thickened heart wall, normal umbilical artery Dopplers; twin B with mild oligohydramnios with normal anatomy visualized.
Slash|Date|125|3. Headaches. 4. Possible chronic graft versus host disease. PROCEDURES PERFORMED: 1. An echocardiogram performed on _%#MM#%_/_%#DD2007#%_ revealing normal left ventricular function. There was moderate right ventricular dysfunction with dilatation, mild tricuspid regurgitation.
Slash|Date|456|As such we will get a renal artery ultrasound to look for renal artery stenosis and will obtain a transthoracic echocardiogram to evaluate obviously systolic function but most notably diastolic function, pulmonary pressures and whether or not there is an LV outflow tract obstruction. In addition, to further evaluate the role of ischemia in this situation, even though the troponins were negative, I still feel that coronary angiography on Monday _%#MM#%_/_%#DD#%_ would be appropriate and I have tentatively scheduled her for this.
Slash|Either meaning|149|Prior to this she had a left-sided DVT in 2002 with a negative hypercoagulable workup at that time. She has been seen by Dr. _%#NAME#%_ of hematology/oncology and the recommendation is that she be maintained on lifelong Coumadin which she is on at this point.
Slash|Date|189|He is retired. He has spent many years in the video game business and was an entrepreneur with his own company. The patient enters with addiction to opiates. He had knee surgery in _%#MM#%_/2004, and had 3 subsequent knee surgeries in a matter of several months.
Slash|Date|119|She states that usually menses are regular, and she had normal menses approximately two weeks ago. However, on _%#MM#%_/_%#DD2002#%_ at approximately three o'clock she started bleeding heavily and required changing a pad every 30 minutes.
Slash|Date|132|He is to have his INRs followed through _%#CITY#%_ Lake Clinic on _%#STREET#%_ _%#STREET#%_. His first appointment there is _%#MM#%_/_%#DD2007#%_. DISCHARGE MEDICATIONS: 1. Zyloprim 100 mg p.o. daily. 2. Amiodarone 200 mg p.o. b.i.d.
Slash|Of|118|NECK: Reveals no bruits. Given his habitus, his JVD is difficult to estimate. HEART: Regular rate and rhythm with a +1/6 systolic murmur, without gallops or rubs. LUNGS: Surprisingly have fairly good air movement, but some diminished sounds at bases, more so on the left.
Slash|Either meaning|409|He does not withdraw to painful stimuli. The head CT was reviewed and demonstrates a large acute on chronic subdural hematoma with approximately 8 mm of midline shift. LABORATORY DATA: Sodium 146, potassium 4.2, BUN 31, creatinine 1.03, white count 12.9, hemoglobin 12.6, INR 3.13. PRELIMINARY ASSESSMENT AND DIAGNOSIS: This is a _%#1914#%_ man with an acute on chronic subdural hematoma that is currently DNR/DNI. RECOMMENDATIONS: After a long discussion with his son, Power-of-Attorney about the risks and benefits of drainage of an acute on chronic subdural hematoma, as well as the various lifestyle decisions associated with having a profound dementia and living in a nursing home the sone elected to forego surgery in favor of comfort care.
Slash|Date|270|DISCHARGE DIAGNOSES: 1. Migraine headache. 2. Status post lung transplant. OPERATIONS AND PROCEDURES: None. HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old Caucasian female with past medical history of bilateral single lung transplant which occurred in _%#MM#%_/2004 in the setting of alpha-1 antitrypsin disease. She was initially admitted on _%#MMDD2006#%_ in the setting of a post-bronchoscopy migraine headache.
Slash|Date|280|The patient's creatinine did improve daily and through his hospital stay and was thought to be prerenal acute renal failure on top of chronic renal failure. He was transferred out of the Intensive Care Unit on postoperative day #2 and was able to be discharged to home on _%#MM#%_/_%#DD2006#%_. Laboratory work upon discharge showed hematocrit 32, hemoglobin 11, creatinine 1.89, white blood cell count 12,800.
Slash|Date|179|She symptomatically was much improved. Her medications were changed around a little bit while she was in the hospital. She also had an echocardiogram of her heart done on _%#MM#%_/_%#DD2006#%_. Results of that are pending at the time of discharge.
Slash|Either meaning|188|SOCIAL HISTORY: The patient was recently divorced. In fact that is the primary reason for her return now to Minnesota. She is a nonsmoker. Drinks about an average of one alcoholic beverage/wine per night. At times it can be more according to her daughter.
Slash|Over(blood pressure)|124|PHYSICAL EXAM: VITAL SIGNS: Temperature 99.1. His blood pressure lying is 110/48 and pulse 60. Sitting blood pressure is 108/48 and pulse of 60. GENERAL: Alert, oriented x 3, not in acute distress. The patient is hard of hearing.
Slash|Per|263|As such, I find it appropriate to make sure that we are not dealing with a pulmonary embolism, and the patient will have a CT scan with PE protocol, the result of which is pending at the time of this dictation. Nevertheless we went ahead and gave the patient 1 mg/kg of Lovenox which will be given every 12 hours, the first dose being given in the Emergency Department.
Slash|Date|238|She slept well that evening on _%#MMDD2004#%_. She began to have a severe headache in the bilateral temporal region associated with some nausea. This again had gradually improved and she slept well that night until she woke up on _%#MM#%_/_%#DD2004#%_ with a severe headache which progressively worsened throughout the day.
Slash|Date|182|He does not know whether the leg gave out on him or not. He was admitted to the University where he was found to have a left intertrochanteric fracture which was repaired on _%#MM#%_/_%#DD#%_ by Dr. _%#NAME#%_'s team. He was evaluated for possible causes of his syncope.
Slash|Over(blood pressure)|121|He has no respiratory cardiopulmonary distress. The patient is not having any chest pain. VITAL SIGNS: Blood pressure 148/93. Heart rate is 69, respirations 20, temperature 98.1, oxygen saturation 100% on room air.
Slash|Date|119|FINAL FINAL DISCHARGE DIAGNOSIS: Right hip degenerative joint disease. OPERATIONS AND PROCEDURES: Performed on _%#MM#%_/_%#DD2007#%_, right minimally invasive total hip arthroplasty performed by Dr. _%#NAME#%_ _%#NAME#%_. HOSPITAL COURSE: This is a 53-year-old female who has a long history of right hip degenerative joint disease, failing conservative treatment She was found to be a good candidate for right minimally invasive total hip arthroplasty for which she wished to proceed.
Slash|Date|135|At this point the decision was made to proceed with Cesarean section. Primary low transverse Cesarean section was performed on _%#MM#%_/_%#DD2007#%_ without complications or difficulties. On postoperative day #1 the patient was noted to be doing well.
Slash|Date|30|FINAL ADMISSION DATE: _%#MM#%_/_%#DD2006#%_ DISCHARGE DATE: _%#MMDD2006#%_ DISCHARGE DIAGNOSES: 1. Posterior spinal fusion. 2. Ankylosing spondylitis. DISCHARGE MEDICATIONS: See discharge medication form.
Slash|Of|151|ABDOMEN: Soft and non-tender. He no longer has epigastric tenderness. EXTREMITIES: No edema, warm. SKIN: No rashes or ulcerations. NEURO: Strength is 5/5 throughout. Cranial nerves are normal. MUSCULOSKELETAL: No synovitis or joint effusions.
Slash|Either meaning|122|3. Colace two tabs by mouth at h.s. 4. Gabapentin 300 mg q.a.m. and at noon and then 600 mg at h.s. 5. Hydrochlorothiazide/triamterene 50/75 one tablet by mouth q. day. 6. Phenobarbital 100 mg rather b.i.d. 7. Metoprolol 100 mg p.o. b.i.d.
Slash|Per|129|He is being discharge today on hospice. He will continue his radiation therapy. His discharge medicines include morphine at 31 mg/hr, morphine sulfate bolus 5 mg q. 1 hour p.r.n., Senna S 1 p.o. b.i.d. for constipation, Prevacid 15 mg for reflux, Vioxx 50 mg/day, Neurontin 300 mg/day, Lasix 40 a day, and potassium 20 mg p.o. q. day.
Slash|Date|109|Her mother and sister have a history of thyroid cancer. PHYSICAL EXAMINATION: Hemoglobin was 12.1 on _%#MM#%_/_%#DD2003#%_. PELVIC EXAMINATION: External genitalia normal. Vagina smooth and with no lesions.
Slash|Date|186|Remove dressing on Wednesday. 4. Return for any increased drainage, significant pain, swelling, or temperature greater than 101.5. 5. Follow up with Dr. _%#NAME#%_ on Wednesday, _%#MM#%_/_%#DD2004#%_. 6. Follow up with primary-care physician, Dr. _%#NAME#%_, as needed.
Slash|Date|195|By postoperative day number four the output had significantly decreased and the drain was removed. Her staples were removed and she was discharged home. _%#NAME#%_ was discharged home on _%#MM#%_/_%#DD2004#%_ with instructions to follow up in approximately six weeks' time.
Slash|Date|219|Mrs. _%#NAME#%_ _%#NAME#%_ is a 54-year-old woman with a past medical history of mitral regurg with normal coronary arteries. No other significant past medical history. She underwent mitral valve replacement on _%#MM#%_/_%#DD2007#%_ by Dr. _%#NAME#%_ _%#NAME#%_. They attempted mitral valve repair which was unsuccessful and then went on to replace her with a 27 mm Onyx mechanical valve.
Slash|Date|262|She experienced some nausea and vomiting with her chemotherapy and radiation which was well controlled with a Zofran drip and scheduled Phenergan. 2. Bone marrow transplant: Ms. _%#NAME#%_ received her autologous peripheral blood stem cell transplant on _%#MM#%_/_%#DD2002#%_ followed by daily GCSF. She engrafted and has been off growth factor with stable counts.
Slash|Date|192|Dear Dr. _%#NAME#%_, Thank you for accepting care of _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ from the Neonatal Intensive Care Unit of Fairview-University Children's Hospital. She was born on _%#MM#%_/_%#DD2002#%_ at _%#CITY#%_ Memorial Hospital and transferred to the NICU on _%#MMDD2002#%_ and discharged on _%#MMDD2002#%_.
Slash|Date|133|5. Coumadin 1 mg p.o. q.d. (may adjust this dose based on results of INR today). DISCHARGE PLAN: 1. She will check an INR on _%#MM#%_/_%#DD2002#%_ with results to Dr. _%#NAME#%_ and will follow up with Dr. _%#NAME#%_ in one week.
Slash|Date|189|DISCHARGE DIAGNOSIS: Non-Q wave myocardial infarction. HISTORY: Mr. _%#NAME#%_ _%#NAME#%_ is a delightful 79-year-old gentleman who essentially has been healthy all of his life. On _%#MM#%_/_%#DD2003#%_, he experienced dizziness with mild shoulder discomfort.
Slash|Date|69|SUBJECTIVE: The patient is a 50-year-old who was admitted on _%#MM#%_/_%#DD2003#%_ and was discharged on _%#MMDD2003#%_. Diagnoses at the time of discharge includes implantation of the baclofen pump for intractable spasticity, multiple sclerosis, urinary tract infection, yeast infection.
Slash|Date|158|Hematology/Oncology was consulted and felt it would be safe for her to go to the operating room after her absolute neutrophil count was over 1000. On _%#MM#%_/_%#DD2004#%_, her counts were sufficient and she underwent right hip hemiarthroplasty following an uneventful postoperative course.
Slash|Date|13|DOB: _%#MM#%_/_%#DD2003#%_ HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 20-month-old boy, who was in his usual state of health until approximately 24 hours prior to admission, when he developed the onset of wheezing following an episode of otitis diagnosed two days prior to admission. The patient was seen in the emergency room on the day prior to admission, where he was started on nebulization treatments and prednisone with no improvement in symptoms, and he was seen in the emergency room on the day of admission and admitted for further care.
Slash|Date|13|DOB: _%#MM#%_/_%#DD1965#%_ Patient is a 39-year-old Caucasian male who is admitted with alcohol abuse. The patient had been drinking half a gallon of vodka daily for four days prior to admission.
Slash|Over(blood pressure)|251|4. OxyContin 100 mg b.i.d. 5. Morphine Elixir. HEALTH MAINTENANCE: The patient did have a mammogram last year, which was reportedly within normal limits. She has never had a colonoscopy. PHYSICAL EXAMINATION ON ADMISSION VITAL SIGNS: Blood pressure 97/50, temperature 98.8, pulse 77, and respirations 16. GENERAL: The patient is alert and oriented x3. HEENT: Normal with no masses or thyromegaly.
Slash|Date|13|DOB: _%#MM#%_/_%#DD1916#%_ The patient is an 87-year-old female who comes in with abdominal pain and cramps. She reports that this started late last night. She reports being in her normal state of health yesterday, although she reports her only having a very loose stool.
Slash|Over(blood pressure)|186|Neurologic: No falls, syncope, cerebrovascular accident or focal findings, such as focal weakness or paresthesias, headaches or visual changes. VITAL SIGNS: Blood pressure 140's to 160's/60, pulse 60 to 70, respiratory rate 20, temperature 97.2, afebrile since admission, O2 sats 88 to 89% on room air, 92% on 2 liters.
Slash|Date|150|FOLLOW-UP: She is to get a complete blood count with differential and platelets on _%#MMDD2005#%_. She is to follow up with Dr. _%#NAME#%_ on _%#MM#%_/_%#DD2005#%_ for an already scheduled appointment. DISCHARGE DIET: Regular pediatric diet for her age. ACTIVITY: As tolerated.
Slash|Date|172|2. Status post Norwood _%#MMDD2003#%_. Required ECMO for one day postoperatively. 3. Repair of aortic stenosis _%#MM2004#%_. 4. Status post Nissen G-tube procedure _%#MM#%_/04. 5. The patient has received no immunizations. 6. The patient is not eligible for cavopulmonary (Glen) surgery at this time due to increased pulmonary pressures.
Slash|Divided by|54|DOB: ADMISSION DIAGNOSIS: Intrauterine pregnancy, 37-6/7 weeks gestation, previous cesarean section, breach, rupture of membranes, multiparity, desires sterilization. DISCHARGE DIAGNOSIS: Same. Status post repeat low segment transverse cesarean section, bilateral partial salpingectomy.
Slash|Over(blood pressure)|155|REVIEW OF SYSTEMS: Difficult and mainly per HPI secondary to his dementia. PHYSICAL EXAMINATION: VITAL SIGNS: He presents here afebrile. Blood pressure 118/66, heart rate 80, respirations 24 with 88%-90% room air sats.
Slash|Either meaning|165|The results were periodic breathing of >50% of the time. A repeat CR scan was performed on _%#MMDD2006#%_, there was an approximate 30 minute episode of mixed apneic/periodic breathing without significant desats or bradycardia.
Slash|Date|266|Review of systems otherwise is non-contributory. She has cataracts. She occasionally has some discomfort in her teeth/jaw. She does have a history of previous ischemic heart disease, but has had an ejection fraction of 61% and normal stress Cardiolyte as of _%#MM#%_/_%#DD2003#%_. She did have previous inferolateral myocardial infarction. She did undergo stenting in _%#MM#%_ 2000 of the RCA from 99% to 0% residual.
Slash|Date|13|DOB: _%#MM#%_/_%#DD1972#%_ Patient is a 32-year-old gravida 5, para 1 patient who presents to the emergency room after being referred from clinic with positive pregnancy test. Patient was previously unaware that she was pregnant, although last menstrual period was _%#MM#%_ _%#DD#%_.
Slash|Date|152|FOLLOW UP: 1. He will follow up with Dr. _%#NAME#%_ next week. 2. Dr. _%#NAME#%_, electrophysiologist at Minnesota Heart Clinic, this Thursday, _%#MM#%_/_%#DD#%_ at 8:15. I think at that time they are going to reconsider placing a biventricular pacer because the patient has probably entered class III heart failure.
Slash|Either meaning|280|MEDICATIONS: Coumadin 5 mg every day but Tuesday and Thursday when she takes 2.5 mg, atenolol 50 mg b.i.d., Lasix 20 mg every day, temazepam 50 mg at bedtime, Ativan 0.5 mg q.i.d. p.r.n. MAJOR DIAGNOSES: Atrial fibrillation. Congestive heart failure. Anxiety. History of a gastric/pancreatic tumor. HOSPITALIZATIONS: She was hospitalized in _%#MM#%_ secondary to her congestive heart failure/atrial fibrillation.
Slash|Date|122|His Insignia device was checked and staples removed for thresholds, which were good. On the date of my dictation, _%#MM#%_/_%#DD2005#%_, the patient was up ambulating. He still had mild bilateral effusions and was wished to keep him for one more day minimally to have the patient gain strength, improve breathing and further diuresis starting with ACE inhibitors.
Slash|Date|218|Her chest x-ray shows probable hyperinflation consistent with COPD and possibly some fibrosis. ASSESSMENT/PLAN: 1. Chest pain in a 47-year-old smoker. She does have some EKG changes which are new compared with _%#MM#%_/04 and she will be admitted for chest pain workup. The patient is is not very pleased to be admitted to the hospital.
Slash|Date|182|Baby Girl _%#NAME#%_ had the following lines placed: peripheral IV. She was initially maintained on a parenteral glucose infusion. We were able to start enteral nutrition on _%#MM#%_/_%#DD2005#%_. At the time of discharge, she was breastfeeding some of her feedings of breast milk or Enfamil formula.
Slash|Date|213|He has recurrent right facial pain, presumably secondary to trigeminal neuralgia since _%#MM2006#%_. The patient underwent rhizolysis 18 years ago with resolution of pain for approximately 18 years, until _%#MM#%_/2006. Pain is present with rubbing his cheek, blowing his nose or other trauma to the region.
Slash|Date|103|DISPOSITION: The patient will be discharged home. He has an appointment with Dr. _%#NAME#%_ on _%#MM#%_/_%#DD2006#%_ at 2:00 p.m.
Slash|Date|176|Today it is 132. INR 1.43 with a target of 1.8 to 2.2. The patient should be on a standard total knee postoperative protocol. He should return to see Dr. _%#NAME#%_ on _%#MM#%_/_%#DD2006#%_ at 1:45 p.m. DISCHARGE MEDICATIONS: 1. Glyburide 0.625 mg b.i.d. 2. Prinzide 20/25 mg daily.
Slash|Date|214|She never had any additional chest pain during her hospital stay and it was felt safe to discharge her to home to follow-up with electrophysiology in clinic. The patient also had a normal echocardiogram in _%#MM#%_/2006. Her potassium was replaced and on the day of discharge her serum potassium level was 4.1.
Slash|Date|333|We have increased his NPH to 45 units twice a day, would consider Lantus in the future as well. Chest x-ray on the morning on _%#MMDD2005#%_, showed decrease in the amount of left lower lobe opacity consistent with improved infiltrated atelectasis, some mild compressive atelectasis to the right base minimally improved from _%#MM#%_/_%#DD2005#%_. CBC on _%#MMDD2005#%_ showed a white count of 10.2, hemoglobin 12.3, platelets 163,000 and negative blood cultures from _%#MMDD2005#%_.
Slash|Over(blood pressure)|226|As part of the ENT surgery, Dr. _%#NAME#%_ is also going to look at his eyes when he is under anesthesia, and he will have a PICC line. Other review of systems are negative. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 96/58, weight 47 pounds, 43 1/2 was his height. HEENT: Ears are normal. Eyes: Eyelashes are kind of, for the most part, turning out.
Slash|Date|276|Because of this he was started on Levaquin 500 mg IV q. day on the _%#DD#%_. The patient improved on this. He was maintained on Lovenox or as follows: The patient received a dose of 7.5 mg of Coumadin on _%#MMDD#%_ for an INR of 1.10. He received 10 mg of Coumadin on _%#MM#%_/_%#DD#%_ for an INR of 1.16. He received 10 mg of Coumadin on _%#MMDD#%_ for an INR of 1.43. His INR today is 2.15 and he is receiving 8 mg of Coumadin.
Slash|Date|306|His white count actually decreased overnight to 6500. His bilirubin was the only abnormal in the hepatic profile and it was only slightly elevated at 1.5. The rest of the enzymes were normal. Urinalysis was normal. As patient continued to improve, he was given some clear liquids on the morning of _%#MM#%_/_%#DD2006#%_. Follow-up abdominal flat plate looked okay with some nonspecific bowel gas then.
Slash|Date|226|Ultrasound of the abdomen on _%#MMDD2007#%_: Impression: 1. Cholelithiasis and gallbladder sludge without evidence for cholecystitis. 2. No focal liver lesion identified. 3. Splenomegaly. CT of pelvis with contrast on _%#MM#%_/_%#DD2007#%_: 1. Significant interval increase in fluid infiltration of the soft tissue around both lower extremities, this is asymmetric and the right lower extremity is now significantly greater in diameter than the left.
Slash|Either meaning|572|A care conference was done with the patient, his wife and his daughter who does work at a nursing home locally with a long discussion at this point If we are going to do more they would have to discuss starting dialysis, getting the fluid off knowing that he may be on dialysis if we do a cardiac catheterization or other interventions were all discussed in detail. Treatment options from the Renal, the Cardiovascular and the Pulmonary standpoint etc., and after significant discussion with time over an hour, the patient and the patient's wife and daughter felt that DNR/DNI would be the best option and also that they do not want dialysis and they would like to discuss the TLC Hospice and a consult for them was obtained by _%#NAME#%_ _%#NAME#%_.
Slash|Date|111|3. Lisinopril 10 mg daily. 4. Lipitor 20 mg daily. 5. Aspirin 81 mg daily. He had an angiogram done in _%#MM#%_/2004 which showed normal coronary arteries, mild cardiomyopathy and at that time his ejection fraction was 40%.
Slash|Over(blood pressure)|163|Denies anemia. Neurologic: Negative. Infectious disease: Negative. Musculoskeletal: Negative. Skin: Negative. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 130/73, pulse 70, respirations 24, temperature 97.6, sats 95% on room air.
Slash|Date|272|2. Diastolic dysfunction with mild lower extremity edema. a. Echocardiogram on _%#MMDD2007#%_ showed mild concentric left ventricular hypertrophy (LVH) as well as diastolic dysfunction. No significant valvular disease noted. b. MRI of the patient's brain obtained _%#MM#%_/_%#DD2007#%_ showed some mild atrophy with nonspecific white matter hyperdensities.
Slash|Separates two doses|103|3. Zoloft 100 mg 2 daily. 4. Lomotil 1 q.i.d. p.r.n. 5. Orphenadrine 100 mg b.i.d. p.r.n. 6. Advair 500/50 one puff b.i.d. 7. Omeprazole 40 mg daily. 8. Percocet 1 q.6h. p.r.n. (has used infrequently).
Slash|Separates two doses|73|8. Furosemide 80 mg p.o. daily. 9. Altace 5 mg p.o. daily. 10. Advair 250/50 one puff 2 times daily. 11. Salsalate 1500 mg p.o. b.i.d. 12. Tylenol Extra Strength 1000 mg p.o. t.i.d.
Slash|Either meaning|157|We continued to monitor and optimize her medical management. PROBLEM #3: Hypothyroidism. The patient is currently euthyroid. DISCHARGE MEDICATIONS: 1. Diovan/hydrochlorothiazide 160/12.5 mg q.d. 2. Nifedipine long-acting 60 mg q.d. 3. Toprol XL 25 mg q.d.
Slash|Date|187|DISPOSITION: As stated above, the patient was discharged to his home on _%#MMDD2003#%_. He will follow with primary-care physician in his hometown. He has a scheduled appointment _%#MM#%_/_%#DD2003#%_. In addition, the patient will be maintained on his medications, including his 20 mg of prednisone q.d. for graft-versus-host disease (graft-versus- host disease stable throughout this hospitalization).
Slash|Date|223|COUNSELOR'S DISCHARGE SUMMARY PROGRAM: _%#CITY#%_ Adolescent Chemical Outpatient Program PHYSICIAN: Self-referred REFERRED BY: Fairview-University Medical Center/STOP unit ADMIT DATE: _%#MMDD2003#%_ DISCHARGE DATE: _%#MM#%_/_%#DD2003#%_. Client graduated from the program. PROBLEMS PRESENTED ON ADMISSION: _%#NAME#%_ is a 17-year-old female who was referred to _%#CITY#%_ Adolescent Chemical Dependency Outpatient Program and Lodging Plus at Nord House following an inpatient assessment at Fairview-University Medical Center/STOP Unit.
Slash|Abbreviation|256|DISCHARGE MEDICATIONS: 1. Aspirin 325 mg p.o. q.day. 2. Zofran 8 mg p.o. q.i.d. 3. Multivitamin one tablet p.o. q.day. 4. Folic acid 1 mg p.o. q.day. FOLLOW-UP: The patient will be followed by the Stroke Clinic at Fairview-University Medical Center, the Ob/Gyn Service, and by her midwife.
Slash|Date|201|She was counseled in VBAC versus repeat cesarean section. Risks and benefits of each procedure were explained to her. She had uneventful prenatal care. She refused VBAC and she was admitted on _%#MM#%_/_%#DD2004#%_ and underwent repeat cesarean section delivery with no low-transverse incision of the uterus under spinal anesthesia.
Slash|Over(blood pressure)|187|Neurologic: No evidence of deficit. DIAGNOSTIC IMPRESSION: Acute nausea and vomiting. Possible pancreatitis. Low platelet count. Hypertension; blood pressures measured included one at 162/104. Among the possibilities are acute gastroenteritis or pancreatitis, and gallbladder disease is suspect due to thickening of the wall of the gallbladder.
Slash|Respectively|168|EXTREMITIES: She has mild finger DJD and some subpatellar crepitation, but range of motion is really quite full at the hips and knees. Calves are soft. DP and PT are 1+/4+. NEUROLOGIC: Save for the gyrating movements of both upper and lower extremities, and her trunk.
Slash|Over(blood pressure)|242|No neurologic symptoms of dysarthria, dysphasia, or focal weakness. No acute cognitive changes although he has some obvious memory impairment and is somewhat tangential. No edema or lymphadenopathy. No fevers or chills. PHYSICAL EXAM: BP: 132/75. HR: 84. RR: 20. T: 96 degrees. GENERAL: In no distress.
Slash|Over(blood pressure)|127|She is married and lives over an hour away from the city. PHYSICAL EXAMINATION: Vitals: Weight 134.9 pounds, blood pressure 102/59 with pulse of 82. Neurologic Exam: The patient is awake, alert, oriented x 3.
Slash|Date|125|With these findings, it was felt that she would benefit from a distal bypass. She was taken to the operating room on _%#MM#%_/_%#DD2004#%_ where under spinal anesthetic she underwent a left common femoral to below knee popliteal in situ bypass graft.
Slash|Date|221|2. Posterior spinal fusion, L5-S1 with TSRH instrumentation. 3. Complete Gill type decompression posteriorly. 4. Laminotomy. 5. Right iliac crest bone graft. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ was admitted on _%#MM#%_/_%#DD2004#%_ and underwent the above-noted procedure. She tolerated the procedure well and there were no intraoperative complications.
Slash|Date|13|DOB: _%#MM#%_/_%#DD1971#%_ This is a 33-year-old insulin dependent diabetic since age 9 with chronic renal failure beginning at age 20. She has had a sore in her scalp just inside her hairline on the right side for some time.
Slash|Either meaning|208|DOB: ADMISSION DIAGNOSIS: Complex cystic pelvic mass with subacute abdominal and pelvic pain. DISCHARGE DIAGNOSIS: Hemorrhagic right ovarian cyst with dense pelvic adhesions status post diagnostic laparoscopy/laparotomy, right salpingo-oophorectomy, lysis of pelvic adhesions.
Slash|Over(blood pressure)|123|In the second trimester her blood pressures did decrease. She has never been on antihypertensives. At 29 weeks, she was 110/78, 31 weeks 112/72. Blood pressures began to increase around 35 weeks, she had a blood pressure at 35 weeks of 132/100.
Slash|Date|166|_%#NAME#%_ does not have a sober support network and made it very clear that he will continue to hang out with his using friends. He will return to school on _%#MM#%_/_%#DD2005#%_ with no support in place. 4. Dimension 6: Recreation/leisure. _%#NAME#%_ will not be involved in phase 2 programming due to unwillingness to maintain abstinence and follow program expectations.
Slash|Date|181|She was tolerating clear liquids on the a.m. of _%#MMDD#%_, was very much encouraged to increase her activity level as well as this also was progressing somewhat slowly. On _%#MM#%_/_%#DD#%_ and _%#MMDD#%_, did have return of some symptoms of nausea as well as abdominal discomfort and had an abdominal CT which was positive for a small bowel obstruction, peritoneal fluid, small amount of extra luminal gas as well as bilateral pleural effusions and nonspecific enhancing lesion on the liver.
Slash|Date|57|PRELIMINARY CHIEF COMPLAINT: Bloody stools since _%#MM#%_/_%#DD2005#%_. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 75-year-old white female with memory loss, diverticulosis, and irritable bowel syndrome, atrial fibrillation on aspirin, hypothyroidism and anxiety and depression who is followed by Dr. _%#NAME#%_ _%#NAME#%_ at Dr. _%#NAME#%_ _%#NAME#%_ of Gastroenterology for irritable bowel syndrome.
Slash|Date|191|The patient was seen by CD and recommended transfer over to Lodging Plus as soon as she was medically stable. The patient was also placed on a 72-hour upon admit, which expired as of _%#MM#%_/_%#DD2005#%_. PROBLEM #2: Depression. Remained stable throughout the entire hospital stay.
Slash|Date|115|The patient lives with a friend. He works for a company called Intereum. The patient was here for detox on _%#MM#%_/_%#DD2006#%_ for 1 day. He had an episode of an alcohol binge the night before.
Slash|Date|207|She does continue to have a mild cough. She also has occasional fevers at home, which are reportedly brief and intermittent, according to the parents. PAST MEDICAL HISTORY: 1. I-cell disease HSCT in _%#MM#%_/05. 2. Tracheostomy/ventilator dependence secondary to restrictive lung disease. 3. Autoimmune hemolytic anemia.
Slash|Date|186|FINAL REASON FOR ADMISSION: Splenic cyst with left upper quadrant chronic pain. DISCHARGE DIAGNOSIS: Status post laparoscopic splenectomy. PROCEDURE: Laparoscopic splenectomy on _%#MM#%_/_%#DD2006#%_. HISTORY OF PRESENT ILLNESS: Mrs. _%#NAME#%_ _%#NAME#%_ is a 43-year-old female who I met in the clinic and came in with a complaint of a long history of left upper quadrant pain which has been worsening and a known splenic cyst that had been growing over the years.
Slash|Date|146|She had artificial rupture of membranes at 7 a.m. on _%#MMDD2006#%_ with clear fluid. She delivered a viable male infant at 2105 hours on _%#MM#%_/_%#DD2006#%_. Neonatal Intensive Care Unit was present. She was noted to have less than 30 seconds shoulder dystocia relieved with McRoberts and suprapubic pressure.
Slash|Date|269|She presented to the office on _%#MMDD2006#%_ for IUD removal, and the strings had not been seen since a month after they were placed 10 years ago. IUD was unable to be removed in the office, and the patient is now scheduled for hysteroscopy and IUD removal on _%#MM#%_/_%#DD2006#%_ at 2:45 p.m. with Dr. _%#NAME#%_ at Fairview Southdale Same Day Surgery. PAST MEDICAL HISTORY: History of urinary tract infections and patient sees Infectious Disease, Dr. _%#NAME#%_ _%#NAME#%_, at Abbott Northwestern.
Slash|Date|157|HISTORY OF PRESENT ILLNESS: Brief hospital course. Please also refer to the history and physical dictated by Dr. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ on _%#MM#%_/_%#DD2006#%_. _%#NAME#%_ _%#NAME#%_ is an 84-year-old lady with past medical history significant for gouty arthritis and osteoarthritis who had a recent flare up about a week ago.
Slash|Date|228|The previously placed stent was removed and a temporary self-ejecting pancreatic duct stent was placed, which should pass spontaneously into the bowel within 1-2 weeks. The stent was removed without any complications on _%#MM#%_/_%#DD2006#%_. The patient will be following up with an abdominal x-ray in 2-3 weeks to assess passage of the stent.
Slash|Date|149|Risks, benefits and complications of the surgery were explained to the patient. HOSPITAL COURSE: The patient was admitted to the hospital on _%#MM#%_/_%#DD2006#%_. The above mentioned surgery was done under general anesthesia. The patient withstood the surgery and anesthesia very well.
Slash|Over(blood pressure)|114|He was extremely tremulous and anxious appearing, alert but shaking profusely. VITAL SIGNS: Blood pressure was 150/90. Heart rate was in the mid 90s-100, sinus rhythm. Saturations were 98% on room air. HEENT: Head atraumatic, normocephalic.
Slash|Date|190|CURRENT PLAN: 1. The patient is scheduled for repeat biophysical with amniotic fluid index on _%#MMDD2006#%_. 2. The patient will be scheduled for primary cesarean section on either _%#MM#%_/_%#DD2006#%_ or _%#MMDD2006#%_. 3. The patient understands to call immediately with onset of spontaneous rupture of membranes or labor.
Slash|Date|139|REASON FOR ADMISSION: 1. Pleuritic pain. 2. Shortness of breath. EXAMINATION FINDINGS: Please see the history and physical done on _%#MM#%_/_%#DD2007#%_. CONSULTATIONS: 1. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, MD, for wrist pain. 2. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, MD, Orthopedic Surgery, for wrist fracture.
Slash|Date|215|Urinalysis was not suspicious for a urinary tract infection. A urine culture obtained just prior to admission grew 10,000 to 50,000 colonies of group D enterococcus. Blood cultures obtained while febrile on _%#MM#%_/_%#DD#%_ x2, _%#MMDD#%_ x2 and _%#MMDD#%_ x2 were all without growth after several days.
Slash|Date|222|HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 54-year-old male with a history of meningiomas and with a history of subtotal resection and radiation done in 1977. The patient had been on prophylactic Dilantin. On _%#MM#%_/_%#DD#%_ the patient's mother noted that he was becoming groggy and unbalanced with poor limb movement.
Slash|Date|186|The patient's postoperative and postpartum courses were unremarkable. Lactation was satisfactorily established. The postpartum hemoglobin was reported at an acceptable level. On _%#MM#%_/_%#DD2007#%_, the patient was discharged from the hospital in satisfactory condition.
Slash|Date|214|There was some pulmonary edema. ___________ was called and after Lasix, he was stabilized, but by then he pretty said he wanted to be hospice care. He did not want any more treatments. At the hospice care, _%#MM#%_/_%#DD2007#%_, the patient passed away.
Slash|Over(blood pressure)|248|REVIEW OF SYSTEMS: SKIN: Negative. HEENT: Negative. RESPIRATORY: Negative. CARDIOVASCULAR: No chest pain or shortness of breath. GASTROINTESTINAL: As above. GENITOURINARY: No dysuria, hematuria. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 102/56, pulse 60, temperature 97.8 with a respiratory rate of 16.
Slash|Date|75|FINAL HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 9-year-old, born _%#MM#%_/_%#DD1998#%_, who was admitted on _%#MMDD2007#%_ with an acute exacerbation of asthma. He was in his usual state of good health until 2 days ago when he started coughing.
Slash|Date|262|Primary diagnoses during hospitalization included: 1. Prematurity 2. Possible sepsis. Problems during her hospitalization included the following: Problem #1: Fluids/Electrolytes/Nutrition: _%#NAME#%_ was initially maintained on parenteral nutrition from _%#MM#%_/_%#DD2007#%_ until _%#MMDD2007#%_. Feedings were started on _%#MMDD2007#%_ of Enfacare 22kcal. At the time of discharge, she was bottling all of her feedings of Enfacare 22kcal.
Slash|Over(blood pressure)|157|2. Postoperative ileus. HOSPITAL COURSE: On presentation to the Emergency Department, the patient was in stable condition. Vital signs were stable, 97.9, 104/47 and 76. On exam, abdomen was with tenderness in right upper quadrant, positive Murphy sign, positive rebound to the upper quadrant.
Slash|Either meaning|261|We should note, we discussed the possibility of keeping him in the hospital, placing a feeding tube to prevent aspiration, but the son felt that would be inconsistent with his previous stated wishes regarding tube feedings. We should note, we also discussed DNR/DNI. He does not want cardiopulmonary resuscitation, and his son still reserves the possibility of wanting intubation if it would be for a short period of time with a potential for recovery, but not if there is no potential for recovery.
Slash|Date|201|1. Anemia presumed secondary to blood loss. No distinct etiology identified. See description below. s/p EGD and colonoscopy. 2. Prostatic carcinoma status post radioactive seed implantation in _%#MM#%_/07. 3. Coronary artery disease, clinically stable, status post coronary bypass grafting in 2004.
Slash|Date|163|5. _%#MMDD2007#%_, tacrolimus level 8.4 and today's tacrolimus level from _%#MMDD2007#%_ is pending. 6. Glucometer checks mostly run in the 100-120 range. _%#MM#%_/_%#DD2007#%_: HGB IS 10.8. Pt is stable for dc home.
Slash|Of|218|Sensation was intact in L3 through S1 distribution and with slight burning dysesthesias in the left L5 area. Dorsalis pedis pulses +2. He has 5/5 tibialis anterior, gastrocnemius and eversion strength bilaterally and 4/5 EHL on his right and 5/5 EHL on his left. The patient was therefore cleared for discharge. DISCHARGE: The patient will be discharged to home.
Slash|Over(blood pressure)|200|He is a retired engineer. He does not smoke and he drinks alcohol only occasionally. REVIEW OF SYSTEMS: Was completely negative. ADMISSION PHYSICAL EXAMINATION: Temperature is 97.7. Blood pressure 123/70. Respirations 16. Pulse 72. Oxygen saturation 90% on room air.
Slash|Either meaning|131|Extraocular movements were full. Fundi were not examined. The pupils were round and reactive. Neck: supple. Chest: clear. Heart: S1/S2 without murmur. The patient has some tenderness when palpating the anterior chest but not pushing over the sternum or side-to-side.
Slash|Date|13|DOB: _%#MM#%_/_%#DD1971#%_ NARRATIVE SUMMARY: Patient is a 31-year-old gravida 1, para 0 patient, presents at 41 weeks for induction of labor. Was found to have a favorable cervix with artificial rupture of membranes carried out.
Slash|Separates two doses|65|3. Lasix 20 mg per day. 4. Lisinopril 20 mg per day. 5. Advair 50/100 one puff b.i.d. 6. Coumadin 5 mg Monday and Friday, 2.5 on the other days.
Slash|Of|101|HEENT: Head was normal. Neck showed a soft right carotid bruit. LUNGS: Clear. HEART: Regular with a 1/6 systolic murmur in the aortic area. ABDOMEN: Soft without organomegaly. EXTREMITIES: Pedal pulses are diminished, no edema noted.
Slash|Per|147|The adnexa are normal. EXTREMITY EXAM is within normal limits. NEUROLOGIC EXAM is grossly intact. LABORATORY EVALUATION: Hemoglobin measured 8.6 gm/dl on _%#MMDD2003#%_. A urine pregnancy test was negative. A urine culture showed no growth.
Slash|Over(blood pressure)|301|REVIEW OF SYSTEMS: Complete review of systems was obtained and remarkable for rhinorrhea with mild non-productive cough, and flu- like symptoms of vomiting and diarrhea two weeks prior with mild fever, otherwise non-contributory. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 101.8, blood pressure 92/48, heart rate 124, respiratory rate 28, weight 13.4 kg.
Slash|Date|13|DOB: _%#MM#%_/_%#DD1927#%_ The patient is a 76-year-old white female with a history of stage IV non- small cell lung cancer who was admitted on _%#MMDD2003#%_ with dehydration, anemia, and neutropenia. She had had three cycles of carboplatin and Taxol chemotherapy for her lung cancer and appeared to be having cumulative effects of the chemotherapy.
Slash|Per|258|The admission physical examination was significant for acrocyanosis, decreased breath sounds, grunting and nasal flaring. Problems during the hospitalization included the following: 1. FEN- She was initially was placed on IVF and TPN for total fluids of 60cc/kg/day. On day one of life, she was started on feeds.
Slash|Date|235|CONDITION AT DISCHARGE: Stable/improving. CODE STATUS: She is a full code. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 68-year-old female who was admitted to Fairview Southdale Hospital through the emergency room on _%#MM#%_/_%#DD2003#%_ with a one-month history of progressive shortness of breath in the setting of known chronic obstructive lung disease.
Slash|Date|100|FOLLOW-UP PLAN: The patient will follow up in the ENT Clinic with Dr. _%#NAME#%_ on Monday, _%#MM#%_/_%#DD2003#%_. DISCHARGE MEDICATIONS: 1. The patient may resume his pre-hospital medications. 2. Percocet one to two tablets p.o. q4-6h p.r.n. pain.
Slash|Either meaning|455|DISCHARGE MEDICATIONS: ____________ 8 70 mg one p.o. q week, aspirin 325 mg p.o. q day, cefuroxime 250 mg p.o. b.i.d., diltiazem SR 240 p.o. q day, __________ 220 mcg two puffs with spacer p.o. b.i.d., Lasix 40 mg p.o. q day, __________ PM one neb p.o. t.i.d., Xopenex one neb p.o. t.i.d., _________ 50 mg p.o. q day, ____________ 10 mg p.o. q.P.M., nicotine gum 4 mg p.r.n., Tylenol 500 mg one to two q 4-6 hours p.r.n. for arthritis. The patient had DNR/DNI reaffirmed prior to discharge. ALLERGIES: Cipro causes hives. Vioxx causes hypertension.
Slash|Over(blood pressure)|165|NEUROLOGIC: Paraplegia. PSYCHIATRIC: No complaint. PHYSICAL EXAMINATION: GENERAL: The patient is a 26-year- old in no acute distress. VITAL SIGNS: Blood pressure 121/76, pulse 91, respirations 18, temperature 97.6 Fahrenheit, pulse oximetry 96% on room air.
Slash|Date|140|DOB: DISCHARGE DIAGNOSIS: Osteomyelitis, left first metatarsal. PROCEDURE PERFORMED: 1. Irrigation and debridement, left great toe (_%#MM#%_/_%#DD2005#%_). 2. Irrigation and debridement with delayed primary closure, left foot (_%#MMDD2005#%_).
Slash|Of|145|CARDIOVASCULAR: Apical impulse was in the fifth intercostal space and ______ line. First and second heart sounds were normal. There was Grade 1-2/6 mid and late systolic murmur, anterior, fixed. No click was heard. S4 gallop was present. All peripheral vessels were equal and bilaterally pulsating in the upper extremities and the lower extremities.
Slash|Date|311|Cyclosporin was discontinued on postoperative day #1. She received a total of 3 doses of Campath during this hospital stay as well as one dose Thymoglobulin. She was scheduled to receive an additional 2 doses of Campath as an outpatient in the transplant center at Fairview-University Medical Center on _%#MM#%_/_%#DD2004#%_ and on _%#MMDD2005#%_. The patient had good function of both transplant grafts during this hospital stay.
Slash|Date|162|The patient was educated on daily cares, and recording of daily output, and bring record to followup visit with Dr. _%#NAME#%_, Appointment scheduled for _%#MM#%_/_%#DD2005#%_ at 2:15 p.m. DISCHARGE MEDICATIONS: 1. Lipitor 10 mg p.o. each day. 2. Lasix 20 mg p.o. each day.
Slash|Date|163|14. Anemia with hypocellular marrow of multifactorial etiologies. 15. Failure of pancreas transplant #2 secondary to rejection. 16. Acute cholecystitis in _%#MM#%_/2005. 17. Allograft pancreatitis in _%#MM2005#%_. PAST SURGICAL HISTORY: 1. Living donor kidney transplant in _%#MM2004#%_.
Slash|Date|173|9. Protonix 40 mg p.o. daily. 10. Colace 100 mg p.o. b.i.d. p.r.n. constipation. 11. Fibercon tablets 2 p.o. daily p.r.n. 12. Thymoglobulin 60 mg IV, to be given on _%#MM#%_/_%#DD2004#%_, with 30 mg Solu- Medrol, 650 mg Tylenol, 50 mg Benadryl, and 8 mg Zofran as premedications.
Slash|Divided by|90|Her husband is concerned. She wants to go through treatment again. The patient has had 2 1/2 years of sobriety in the past after treatment at River Place.
Slash|Of|87|He had problems with his remote memory. Recent memory was adequate. He was able to do 3/3 on registration and 3/3 on recall. His abstract thinking was moderate. H BIOPSYCHOSOCIAL FORMULATION: Mr. _%#NAME#%_ has a biological predisposition as evidenced by history of mood problems and substance abuse problems and childhood history of sexual abuse.
Slash|Per|279|FAMILY HISTORY: Relatively noncontributory for mother and father. ALLERGIES: None. MEDICATIONS PRIOR TO ADMISSION: Recorded as Imdur 60 mg q.d., lisinopril 40 mg/day, Lasix 40 mg b.i.d., Zantac 150 mg h.s., Lipitor 20 mg/day, KCl 40 mEq/day, Coreg 3.25 mg b.i.d., prednisone 5 mg/day. PHYSICAL EXAMINATION: Reveals a bright, alert, oriented female. Blood pressure has been a bit high at 140/80, heart rate 100 beats/min and regular.
Slash|Either meaning|119|He has had isolated diarrhea, without melena or hematochezia. He has had no voiding complaints. Generalized arthralgias/myalgias. No rash. Generally weak. Otherwise, no focal neurologic complaints.
Slash|Date|221|I was asked to see her by Dr. _%#NAME#%_ to follow the patient medically secondary to a left knee hematoma. The patient is one week status post left total knee arthroplasty and was discharged from the hospital on _%#MM#%_/_%#DD2003#%_. She was discharged to the nursing home and had been experiencing increasing pain and increasing swelling in the left knee.
Slash|Abbreviation|155|_____Patient examined by resident/fellow in my presence. Discussed with resident and agree with note. My key findings: CC: Stage IV NSC lung cancer. HPI: S/P 3750 cGy to hilum _%#MMDD#%_, and now with left-sided obstruction.
Slash|Over(blood pressure)|158|The patient is DNR/DNI. ALLERGIES: There are no known medication allergies recorded on her intake sheet. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 133/87, weight 66 kg, pulse 105, respirations 18, temperature 98.2 degrees Fahrenheit.
Slash|Over(blood pressure)|131|12 category review of systems, etc. is covered and reviewed. PHYSICAL EXAMINATION: Vital signs are stable. His blood pressure is 98/66. In general, he is resting comfortably. Alert and oriented and somewhat hard of hearing.
Slash|Divided by|95|He also has been a moderate drinker in the past. He smoked until his admission, 50 years of 1 1/2 packs per day. He has never been told that he has COPD or emphysema.
Slash|Date|168|He was found at the time to have coag-negative staph and a urinary tract infection and was treated with antibiotics. Prior to this admission he was admitted on _%#MM#%_/_%#DD2006#%_ for pancreas re-transplant and discharged on _%#MMDD2006#%_.
Slash|Per|185|2. Since he is on the Lexapro, 10 mg/day, it would be preferable to not be using Ultram in conjunction with that. 3. Decrease the Neurontin to 600 mg t.i.d. Currently, he is on 3,000 mg/day. The wife has not noticed any difference. With the addition of the Lamictal, he may not need as high a dose of Neurontin.
Slash|Date|238|She was then finally discharged to her home, but was home for only a couple of days, when she was readmitted to Fairview-Southdale Hospital. Her medications were adjusted and she was treated with IV fluids, and was discharged, on _%#MM#%_/_%#DD2002#%_. At the time of her discharge, on the _%#DD#%_ of _%#MM#%_, she was apparently doing better.
Slash|Over(blood pressure)|182|REVIEW OF SYSTEMS: Unobtainable. SOCIAL HISTORY: Unobtainable. PHYSICAL EXAMINATION: GENERAL: She is resting comfortably in bed. She is not jaundiced. VITAL SIGNS: Blood pressure 126/64, pulse 62, afebrile. HEART: Normal. LUNGS: Clear. EYES; No scleral icterus. ABDOMEN: Completely normal with no abdominal tenderness or pain.
Slash|Date|199|EXTREMITIES: There is no edema. No calf tenderness appreciated. The patient was reporting some mild pain over the right groin. LABORATORY AND RADIOLOGY STUDIES: Basic metabolic panel done on _%#MM#%_/_%#DD2006#%_ showed a sodium 129, potassium 3.7, chloride 91, bicarbonate 28, glucose 106, BUN 12, and a creatinine of 0.6. The complete blood count on _%#MMDD2006#%_ showed hemoglobin 10.2, hematocrit 30.0, white blood cell count 4.8, and a platelet count of 205,000.
Slash|Over(blood pressure)|349|8. Tylenol 9. Aspirin 10. Norvasc 11. Lipitor 12. Metoprolol ALLERGIES: Penicillin LABORATORY DATA: White blood cell count 19.5, hemoglobin 13.2, sodium 137, potassium 3.9, creatinine 1.16, urinalysis was negative. CT scan - please see history of present illness. PHYSICAL EXAMINATION: Temperature 98.8, pulse 58, respirations 18, blood pressure 113/60. General - he is alert and oriented and very pleasant.
Slash|Abbreviation|234|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is in today for follow-up of her left infiltrating ductal carcinoma with DCIS diagnosed _%#MMDD2005#%_, grade 2/3. She was ER positive at greater than 90%, PR positive at 10% and HER-2/neu negative. REVIEW OF SYSTEMS: GENERAL: She has hot flashes. Appetite is pretty good.
Slash|Over(blood pressure)|198|There is a history of diet controlled diabetes. She has some trouble with her right shoulder. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98, pulse 80, respiratory rate 20, and blood pressure 120/80. GENERAL: This is a well-developed, well-nourished 44-year-old female in no apparent distress.
Slash|Over(blood pressure)|199|No other focal neurologic complaint. OBJECTIVE: GENERAL: Relatively healthy-appearing adult male in no acute distress except for indication of suboptimal pain control. VITAL SIGNS: Blood pressure 120/73, heart rate low 100s, with a sinus rhythm, respirations nonlabored, O2 sat 95% HEENT: Extraocular movements full.
Slash|Of|125|Oxygen saturation is 96%. She is currently is on O2 and it is unclear if that is necessary. HEART: Regular rate and rhythm, 2/6 systolic murmur, and rate of 75. ABDOMEN: Moderate tenderness, no significant drainage from incision. LABORATORY DATA: Reviewed in assessment above.
Slash|Separates two doses|302|She has no recent problems in terms of headaches. PAST MEDICAL HISTORY: Notable for chronic multiple sclerosis, for which she has been on Copaxone. She also has hypertension, hyperlipidemia and restless leg syndrome. MEDICATIONS: At home include: Zocor, lisinopril, Baclofen 10 mg t.i.d., Sinemet CR 50/200 t.i.d., Neurontin 600 mg every four to six hours, 30 mg of codeine at night for restless legs, calcium, glucosamine chondroitin, vitamin E and Copaxone.
Slash|Date|210|At present, the patient denies any active physical issues. He states he has been feeling well. PAST MEDICAL HISTORY: Behavioral concerns and previous psychiatric hospitalizations here, most recently in _%#MM#%_/04. He has had diagnoses of attention deficit hyperactivity disorder and oppositional defiant disorder.
Slash|Date|333|TRANSITIONS AND LIFE CHOICES CONSULTATION REQUESTING PROVIDER: _%#NAME#%_ _%#NAME#%_, CNP REASON FOR CONSULTATATION: Metastatic ovarian cancer with mets, weakness and poor prognosis. HISTORY OF PRESENT ILLNESS: The patient is a 74-year-old female who was transferred from University of Minnesota Medical Center, Fairview, on _%#MM#%_/_%#DD2005#%_ for rehabilitation. The patient has presented with massive ascites, abdominal carcinomatosis, and elevated CA-125 to a hospital in _%#CITY#%_, North Dakota, on _%#MMDD2005#%_.
Slash|Separates two doses|136|2. Hypertension. 3. Osteoarthritis status post right TKA in 2006. 4. BHP. 5. Open cholecystectomy. MEDICATIONS: 1. Carbidopa-levodopa 50/200 mg 1-1/2 tablets p.o. t.i.d. 2. Mirapex 1 mg p.o. t.i.d. 3. Trihexyphenidyl 2 mg p.o. b.i.d.
Slash|Either meaning|138|Strength 5/5 bilaterally in the upper and lower extremities. LABORATORY DATA: Comprehensive metabolic panel within normal limits. Hemogram/differential/platelet count: Hemoglobin 15.9, hematocrit 47.1, otherwise within normal limits.
Slash|Date|134|Note at the time of his ESWL on _%#MMDD2007#%_, the creatinine was not normal. It was 2.3 mg/dL (previously normal at 1.17 in _%#MM#%_/2007). PAST MEDICAL HISTORY: Surgery: 1. Bilateral total hip arthroplasties. 2. Lumbosacral spine lumbar laminectomies.
Slash|Date|134|PAST MEDICAL HISTORY: 1. Asthma - late onset diagnosis. a. Originally diagnosed at the University of Minnesota. b. PFTs dated _%#MM#%_/_%#DD2004#%_ showed an FEV-1 of 29%, an FVC of 46% and a FEV-1/FVC% of 49.
Slash|Over(blood pressure)|145|REVIEW OF SYSTEMS: He has no other significant problems and his review of systems is otherwise negative. PHYSICAL EXAM: His blood pressure is 153/88, temperature is 97.3. He is resting comfortably in bed.
Slash|Date|214|7. In the past she has been on Sular 20 mg p.o. q. day, which is a calcium channel blocker. Past medical history, family history and social history have been outlined in Dr. _%#NAME#%_ _%#NAME#%_'s note of _%#MM#%_/_%#DD2002#%_, and I have included that history in the chart here.
Slash|Date|147|He was also noted to have thrush and Nystatin was prescribed. The patient did not take any other antibiotics until he was admitted here on _%#MM#%_/_%#DD2006#%_ for his TURP. Intraoperatively, he was given 1 g of Rocephin IV and again did not have any subsequent problems until early evening after he received one dose of p.o. Bactrim approximately 4 p.m. His granddaughter noted that he started having a rash shortly after that time with some itching.
Slash|Date|12|TBA _%#MM#%_/_%#DD2003#%_ _%#NAME#%_ _%#NAME#%_ is a 70-year-old woman who had colonoscopy earlier today by Dr. _%#NAME#%_, and a large probable malignant mass was noted in the left transverse colon.
Slash|Over(blood pressure)|168|REVIEW OF SYSTEMS: As per HPI. All other systems were reviewed and were negative. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 35.9, heart rate 59, blood pressure 106/68, respirations 16. GENERAL: A well-appearing female in no acute distress. HEENT: Within normal limits.
Slash|Date|13|TBA: _%#MM#%_/_%#DD2005#%_ UROLOGY CONSULTATION REQUESTING PHYSICIAN: _%#NAME#%_ _%#NAME#%_, MD DIAGNOSIS: Rule out bilateral ureteropelvic junction (UPJ) obstruction. She has some hydronephrosis. PLAN: To do cystoscopy, bilateral retrograde ureterograms.
Slash|Date|215|ASSESSMENT AND PLAN: Mr. _%#NAME#%_ is a very pleasant 77-year-old man who has had previous coronary artery bypass grafting. He now has severe aortic stenosis. We plan to perform aortic valve replacement on _%#MM#%_/_%#DD2003#%_. We will plan to place a tissue valve in the event that he may come out of atrial fibrillation and not require long-term anticoagulation.
Slash|Over(blood pressure)|110|PHYSICAL EXAMINATION: Adult female in no distress. She is alert and oriented. Blood pressure earlier today 118/60 sitting, 124/77 standing, heart rate 110 earlier, presently in the 80s and regular.
Slash|Either meaning|209|REASON FOR CONSULTATION: Rule out sarcoidosis. ASSESSMENT: 1) Extensive bilateral hilar and mediastinal adenopathy with a few scattered nodules. a. Differential diagnosis includes sarcoid, malignancy (lymphoma/testicular), infectious, inflammatory. b. Recommend mediastinoscopy given the bulkiness of his adenopathy to rule out a malignancy; based on his CT scan there is about a 50% chance of obtaining a diagnosis with transbronchial biopsies.
Slash|Over(blood pressure)|195|PHYSICAL EXAMINATION: A pleasant, thin female in no acute distress. She does appear uncomfortable, but does not look ill. Her vital signs are a temperature maximum of 100.8, blood pressure 90-105/60, pulse 110, and respirations 18. HEENT: Normocephalic and atraumatic. The neck is supple. Respirations labored.
Slash|Date|130|His heaviest use has been the last 5 years. He drinks at least 6 drinks 4 nights-plus per week. His last reported use was _%#MM#%_/_%#DD2007#%_. He smoked marijuana in college. He uses Tylenol PM occasionally at night. SUMMARY OF CHEMICAL DEPENDENCY SYMPTOMS ACKNOWLEDGED BY CLIENT: This client believes he has a problem with chemicals and that it has been a problem for around 5 years.
Slash|Date|214|Sister has coronary artery disease. He has a daughter with ovarian carcinoma. DATA: Chest x-ray dated _%#MMDD2002#%_ - There is a density in the medial region of the right lower lung that is unchanged from _%#MM#%_/_%#DD2002#%_. Spirometry is consistent with low normal spirometry with a low normal DLCO.
Slash|Date|107|SUBJECTIVE: Ms. _%#NAME#%_ is here today for a routine follow-up visit. She was last seen by us on _%#MM#%_/_%#DD2006#%_. Since that time she has been feeling very well. She denies pain or headaches.
Slash|Divided by|130|This ultrasound revealed no evidence of neural tube defects. Today's ultrasound was more consistent with a gestational age of 21 6/7 weeks gestation (as opposed to 18+5 by reported dates).
Slash|Date|13|TBA: _%#MM#%_/_%#DD2004#%_ INTERNAL MEDICINE CONSULTATION REQUESTED BY: _%#NAME#%_ _%#NAME#%_, MD HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old white female scheduled for elective right total knee arthroplasty with Dr. _%#NAME#%_ for degenerative joint disease on _%#MMDD2004#%_. The patient denies any other acute medical problems.
Slash|Date|193|She has had rather prominent fatigue, no definite exacerbation of her MS and is followed on a regular basis by Dr. _%#NAME#%_ who saw her last in _%#MM2005#%_ and was due to see her in _%#MM#%_/06. Unfortunately, for the past few weeks she has had increasing generalized fatigue from head to toe, unable barely to navigate and operate independently.
Slash|Either meaning|320|PAST MEDICAL HISTORY: The patient has significant previous medical history, including peripheral vascular disease, hypertension, significant ischemia in the lower extremities and skin changes consistent with this. He has had previous CVA with residual weakness. He has had previous cardiac bypass surgery, as well as fem/pop bypass surgery. MEDICATIONS: Patient is on multiple medications, previously listed by Dr. _%#NAME#%_.
Slash|Date|13|DOB: _%#MM#%_/_%#DD1912#%_ The patient is an 89-year-old gentleman well known to us from many previous hospitalizations for ischemic cardiomyopathy. He was noted to be increasingly tachypneic and was having peripheral edema, which his wife states he never had before.
Slash|Of|139|There is a mild degree of facial flushing. Chest demonstrates upper airway rhonchi. No rales. No bronchospasm. Cardiac exam: Regular with 1/6 systolic ejection murmur best heard at the best extending down the left sternal border.
Slash|Date|119|He was on chemotherapy. He was evaluated for a partial small bowel obstruction. A Foley catheter was placed on _%#MM#%_/_%#DD#%_ because of voiding in small amounts. A bladder scan at that time demonstrated about 400 cc in the bladder.
Slash|Over(blood pressure)|198|This level of consciousness appears to be improved from a quite anxious and combative woman yesterday. VITAL SIGNS: Her temperature is normal, pulse is regular in the 80s, blood pressure earlier 100/60, currently 140/70. Respirations are calm at 20. Room air oxygen saturation is satisfactory at 94-95%.
Slash|Date|211|In addition, as noted the patient has end-stage renal disease, he has a suprapubic catheter in place secondary to neurogenic bladder and he is on three times a day dialysis. He underwent dialysis today, _%#MM#%_/_%#DD#%_ without difficulty. SURGICAL: The patient is status post remote appendectomy and status post remote cholecystectomy.
Slash|Over(blood pressure)|133|PHYSICAL EXAMINATION: Reveals a pleasant, elderly female sitting comfortably in bed with no acute distress. Her blood pressure is 190/90, her pulse is 46 and regular. The respiratory rate is 18. HEENT: Without corneal arcus or xanthelasma.
Slash|Date|204|She has had 3 recent operations and has done well from a cardiovascular standpoint without any signs of perioperative cardiovascular event. PAST MEDICAL HISTORY: 1. She had a bowel obstruction in _%#MM#%_/2007 with resection and multiple wound breakdown and infection with enterococcus and MRSA.
Slash|Date|316|REASON FOR CONSULTATION: Evaluate for rehabilitation needs. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 64-year-old gentleman who was admitted to Fairview Southdale through the emergency room with a chief complaint of shortness of breath and anxiety for the past couple days. His admission was on _%#MM#%_/_%#DD2006#%_. Hospital course was pertinent for acute respiratory failure, which required intubation, nebulizers, IV steroids, and empiric antibiotics.
Slash|Of|144|SKIN: No rashes noted. NEUROLOGIC: Alert and oriented. Cranial nerves 2 through 12 grossly intact. Sensation is intact to lighttouch. Strength 5/5 bilaterally in hands, strength 4/5 in left leg, and strength 2/5 in right leg.
Slash|Date|244|LABORATORY DATA: White blood cell count 7.8, hemoglobin 14.6, platelet count 229,000, creatinine 0.9, total bilirubin 0.5. PATHOLOGY: 1. UHR 02-116 (_%#MMDD1999#%_): Bilateral involvement by low-grade non- Hodgkin lymphoma (5 to 10%); (_%#MM#%_/_%#DD1999#%_) rare lymphoid aggregates; (_%#MMDD2002#%_) tiny aggregate of slightly irregular lymphocytes; (_%#MMDD2002#%_) No evidence of lymphoma.
Slash|Over(blood pressure)|149|FAMILY HISTORY: Not obtained. PHYSICAL EXAMINATION: In general the patient is sleeping, and appears in no acute distress. Pulse 89, blood pressure 84/55, respiratory rate 15, O2 saturations at 96% on room air.
Slash|Date|191|Over the last 3-4 days she has developed some redness and swelling distally. She was initially evaluated. There was concern about infection. She was placed on Keflex 500 mg t.i.d. On _%#MM#%_/_%#DD2005#%_ she was evaluated in my office and was somewhat improved but still had some swelling.
Slash|Over(blood pressure)|205|Denies any postural dizziness, syncope, or palpitations. FAMILY AND SOCIAL HISTORY: She lives alone. She is currently on disability. She is unemployed. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 106/72, pulse 80 and regular. She is alert and oriented in no acute distress. HEENT: Negative.
Slash|Date|163|RECOMMENDATIONS: Try intravenous vancomycin and follow the appearance of the hip. This is an 86-year-old male, father of Dr. _%#NAME#%_ _%#NAME#%_, who on _%#MM#%_/_%#DD#%_ underwent left total hip arthroplasty for osteoarthritis.
Slash|Date|133|HABITS: She smokes 1 pack-per-day since age 16 daily. Consumption of alcohol about 1 liter or more of vodka. Last use was on _%#MM#%_/_%#DD2006#%_. SOCIAL HISTORY: She is married, has 1 child. FAMILY HISTORY: Her mother had a brain tumor, diabetes and alcohol abuse.
Slash|Over(blood pressure)|142|PHYSICAL EXAMINATION: GENERAL: The patient is a mild to moderately overweight white male in no acute distress. VITAL SIGNS: Blood pressure 120/80 with a heart rate of 60 and regular. HEENT: Pupils equal, round, react to light and accommodate. NECK: Without jugular venous distention, carotid bruit or palpable thyroid.
Slash|Over(blood pressure)|236|She actually immediately came to again. Blood pressure appeared to be somewhat thready and possibly bradycardic. She has had no problems since that time. She was taken to the emergency room and initial blood pressure was found to be 145/67 without any tilt. She is feeling fine at this time. She had no chest, arm, neck, jaw, or shoulder discomfort at any time.
Slash|Either meaning|159|No dyspepsia. Mild upper abdominal pain. His last bowel movement was on _%#MMDD2005#%_, no melena. He has had wipe hematochezia, possibly related to hard stool/straining. No voiding complaints. No rash. No other focal neurologic complaint.
Slash|Date|102|7. History of back injury secondary to work construction. 8. History of thrombocytopenia last _%#MM#%_/_%#DD#%_ and also now. PAST SURGICAL HISTORY: 1. Leg surgery in 2003 for right tib/fib fracture.
Slash|Per|185|b) Carnitine: She had a low carnitine level through the followup newborn screening labs. She was treated with IV carnitine drip. It has now been changed to p.o. at a high dose of 100 mg/kg/day. c) Cobalamin: Some of these children have mutations in genes that encode enzymes in the cobalamin pathway.
Slash|Date|279|The pathology of mandibular mass was a myxofibroma; chronic inflammation and reactive changes of the overlying squamous epithelium. IMPRESSION AND PLAN: 1. Status post composite resection of left mandibular mass with left fibular free flap and insertion of tracheostomy (_%#MM#%_/_%#DD2007#%_). Clinically, patient is doing well. The plan is to transition her to a TCU on Monday, _%#MMDD2007#%_ for patient and family need to be taught how to care for a tracheostomy as well as how to administer tube feeds.
Slash|Date|229|He has undergone a prior right femoral below knee popliteal graft several years ago and recently had a below knee popliteal bypass graft peroneal run off by Dr. _%#NAME#%_ on _%#MMDD2005#%_. The patient was discharged on _%#MM#%_/_%#DD2005#%_ and was readmitted within 48 hours with apparent postoperative infection along the bypass graft site.
Slash|Over(blood pressure)|186|FAMILY HISTORY: Noncontributory at this time. PHYSICAL EXAMINATION: She is seen lying in bed in the intensive care unit. She is cooperative and appears comfortable. Blood pressure is 125/98, pulse 115, temperature 36.3, her pulse oximeter shows respiratory rate 20 and O2 saturation of 95%.
Slash|Date|493|The patient was seen at the bedside on floor 7D for initial consultation by Dr. _%#NAME#%_ _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_ on _%#MMDD2004#%_ at the request of Dr. _%#NAME#%_ _%#NAME#%_ from the Department of Medical Oncology and Dr. _%#NAME#%_ _%#NAME#%_ from the Department of Medical Oncology at Fairview-University Medical Center. HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 59-year-old white female with a history of metastatic non-small cell lung cancer diagnosed in _%#MM#%_/04. The patient had presented with headaches and loss of right peripheral vision with a head CT showing a left occipital mass.
Slash|Either meaning|199|She has had a recent UTI. She has had this rather persistent vague numbness and tingling in the head and somewhat in the hands that has been very difficult to assess. PAST MEDICAL HISTORY: 1. Anxiety/depression. 2. Paroxysmal atrial fibrillation. PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished, bright, alert female. HEAD AND NECK: Normal.
Slash|Of|171|EXTREMITIES: No changes of chronic arterial or venous insufficiency. There is no significant edema. PULSES (right/left, 4 = normal pulse, 0 = no palpable pulse): Carotid 4/4, subclavian 4/4, radial 4/4, femoral 4/4, popliteal 4/4, dorsalis pedis 4/4, posterior tibial 4/4.
Slash|Over(blood pressure)|139|NEURO PSYCH: The patient does acknowledge that she has had panic attacks in the past. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 100/62, pulse if 100. The patient is afebrile. There is definite fairly deep scleral icterus.
Slash|Separates two doses|134|4. clindamycin 600 mg IV q.8h. started last night. 5. Colace 100 mg p.o. b.i.d. 6. Flonase one spray both nares q daily. 7. Advair 250/50 1 puff b.i.d. 8. Ativan 0.5 mg p.o. q.h.s. 9. Protonix 40 mg p.o. daily.
Slash|Date|326|FINAL CARDIOLOGY CONSULTATION INDICATION FOR CONSULTATION: Cardiology consultation was requested by Dr. _%#NAME#%_ _%#NAME#%_ because of atrial fibrillation and cardiomyopathy. HISTORY: _%#NAME#%_ _%#NAME#%_ is a 64-year-old gentleman who developed what he describes to me today as right-sided arm and leg weakness on _%#MM#%_/_%#DD2007#%_. The patient had difficulty getting up from a chair while at work.
Slash|Date|169|Strength was 5/5 bilaterally in the upper and lower extremities. LABORATORY DATA: From Children's Hospital her AST was 88, ALT of 75, Tylenol level at 8 a.m. on _%#MM#%_/_%#DD2006#%_ was 173 and at 11 a.m. on _%#MMDD2006#%_ it was 115.4. Comprehensive metabolic panel, CBC with differential, and reflux TSH are pending from this hospital admission.
Slash|Divided by|72|He is unclear as to the name of the chemotherapy. Chemotherapy ended 2-1/2 weeks ago. According to Mr. _%#NAME#%_, no scans were performed in order to determine response.
Slash|Date|143|FAMILY MEDICAL HISTORY: The patient is very drowsy at this time and unable to give me any history. Again, see Dr. _%#NAME#%_'s note of _%#MM#%_/_%#DD2007#%_ to retrieve information most recently gathered on her family medical history, social history, habits and review of systems, as these are unable to be attained at this time.
Slash|Over(blood pressure)|150|ALLERGIES: Zocor. FAMILY HISTORY: Noncontributory. REVIEW OF SYSTEMS: Otherwise noncontributory. PHYSICAL EXAMINATION: VITAL SIGNS: blood pressure 109/63, pulse 72, temperature 36.7, respiratory rate 20. NEUROLOGIC: The patient is alert and oriented x3. He admits that he has markedly improved over night.
Slash|Date|155|He was kept on antibiotics at that time and every other staple was removed from his incisions. The drainage had slowed. He saw me in the office on _%#MM#%_/_%#DD2007#%_ and had the remainder of his staples removed. He drove 80 miles home, and when he arrived home he noted that the right thigh wound had opened.
Slash|Date|180|LABORATORY DATA: Pending. Rectal swab obtained at outside hospital, received _%#MMDD2004#%_, revealed Enterococcus faecalis sensitive to vancomycin. Blood culture received _%#MM#%_/_%#DD2004#%_ revealed methicillin-sensitive staph aureus (MSSA) bacteremia and urine culture collected _%#MMDD2004#%_ showed klebsiella.
Slash|Date|153|HPI: This is a 64-year-old morbidly obese woman who has been on systemic steroids in the past for rheumatologic conditions. She was hospitalized _%#MM#%_/_%#DD#%_-_%#MMDD2004#%_, at Ridges Hospital with bilateral lower extremity cellulitis.
Slash|Either meaning|98|2. Clonidine 0.1 mg p.o. b.i.d. 3. Tricor 145 mg daily. 4. Felodipine 10 mg p.o. q day. 5. Benicar/hydrochlorothiazide 40/25 one p.o. q day. 6. Aspirin 81 mg p.o. q day. 7. K-Dur 20 mEq p.o. q day.
Slash|Over(blood pressure)|170|HABITS: She denies alcohol or drugs. She is a nonsmoker. REVIEW OF SYSTEMS: Review of systems is otherwise negative. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 113/75. Temperature 100.3. Pulse 100. She is alert. Her speech is not slurred, but she has very poor short-term memory.
Slash|Either meaning|189|5. Telemetry 6. Follow laboratories and Digoxin level. 7. EKG if not previously performed. HISTORY: The patient was admitted and discharged approximately two weeks ago for upper respiratory/chronic obstructive pulmonary disease related problems. Her discharge medications included, as I noted, lisinopril, spironolactone, Lasix, in addition to a number of upper respiratory tract medications.
Slash|Of|106|NEUROLOGIC: Alert and oriented. Cranial nerves grossly intact. Sensation intact to light touch. Strength 5/5 bilaterally. No involuntary movements noted. LABORATORY DATA: CBC revealed a low red blood cell count 3.57, a low hemoglobin of 10.8, a low hematocrit of 31.3, a low percentage of neutrophils of 30, a high percentage of lymphocytes 60, low absolute neutrophils of 1.3, otherwise within normal limits.
Slash|Of|110|Neurologic exam: Cranial nerves II through XII are grossly intact. Sensation intact to light touch. Strength 5/5 bilaterally. Gait within normal limits. Reflexes 1+ bilaterally. LABS: TSH 12.87, electrocardiogram normal sinus rhythm, rate 87, no signs of ST changes.
Slash|Over(blood pressure)|147|VITAL SIGNS: Temperature 101.4, respirations 24, oxygen saturations 100% on four liters per minute nasal cannula. Blood pressure running 100 to 120/60 to 70, heart rate in the 90's. HEENT: Normocephalic, atraumatic, pupils are not equal; the right pupil is somewhat larger than the left; the right pupil appears to be postsurgical.
Slash|Over(blood pressure)|151|PHYSICAL EXAMINATION: GENERAL: The patient is an 84-year- old white female in no acute distress. VITALS: Temperature 97.2, pulse 66, blood pressure 129/63 and respiratory rate 16. HEAD: Normocephalic atraumatic. EYES: Pupils equal ,round and reactive to light.
Slash|Over(blood pressure)|112|The patient has positive stool. PHYSICAL EXAMINATION: The patient is in no apparent distress. Blood pressure 110/58, heart rate 60, regular. HEENT: Unremarkable. NECK: Supple. No jugular venous distention or carotid bruits.
Slash|Of|198|Pupils are equal, and react to light. Extraocular muscles are intact. NECK: Is supple and non-tender. No thyromegaly or lymphadenopathy. HEART: Regular rhythm, no significant murmur, maybe a Grade 1/6 systolic murmur in the background. ABDOMEN: Is soft and nontender. EXTREMITIES: 2+ edema of both legs.
Slash|Per|237|LABORATORY DATA: White count 4.0, hemoglobin 11.3 compared 12.3 in 3/04, platelets 316, MCV 79, RDW 17.1. Electrolytes and renal function are normal. AST is elevated at 49, ALT normal, TSH 3.39 Urinalysis revealed 5 to 10 RBCs and 100 mg/dL glucose. Glucose was 117. ASSESSMENT AND PLAN: 1. Depression in the setting of chemical abuse, followed by Dr. _%#NAME#%_.
Slash|Date|125|He had a normal BUN and creatinine of 16 and 0.9, with normal electrolytes. When he was readmitted on the evening of _%#MM#%_/_%#DD#%_, he had the following laboratory tests: He had a hemoglobin of 13.4, INR of 1.04, he had a BNP of 21, PTT of 28, and electrolytes that showed sodium of 137, potassium 3.6, chloride 98, CO2 of 28.
Slash|Date|105|Total time: 45 minutes of which of 30 minutes was counseling coordination of care. REVISED DATE: _%#MM#%_/_%#DD2007#%_/_%#NAME#%_
Slash|Either meaning|357|2. UA to check for glucose and urine protein. DISCUSSION: Seroquel certainly is a risk in an obese male for developing glucose intolerance and frank diabetes. I do appreciate that Seroquel has worked well in helping this patient's underlying psychiatric disorder, thus I feel more data is required before making a final determination in regards to the risks/benefits of continuing on Seroquel. I will follow up over the next 48 hours as more data becomes available with further recommendations.
Slash|Divided by|176|He has had chronic bronchitis, recurrent. No tuberculosis. He had a remote positive PP; repeat was negative. SOCIAL HISTORY: The patient quit smoking in 1998; he had smoked 1 1/2 packs per day. He worked as an engineer and was exposed to chemicals, polyurethanes.
Slash|Date|320|FINAL HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is an 11-year-old young lady with cystic fibrosis who underwent a liver transplant on _%#MMDD2007#%_. In reviewing her chart she had a relatively easy course post transplantation though she did have a right upper lobe infiltrate on a CT scan that was done _%#MM#%_/_%#DD2007#%_. She was discharged from the hospital on _%#MMDD2007#%_ to home and according to mom did really well for the 1st week.
Slash|Over(blood pressure)|236|He denies any GI complaints or GU complaints. PHYSICAL EXAMINATION: GENERAL: This is a well-nourished, well-developed male in no acute distress, alert and oriented x 3. He is pleasant appearing. VITAL SIGNS: Pulse 88, blood pressure 104/60, respirations 24. HEENT: Head was normocephalic and atraumatic. Eyes: PERRLA. Lids and sclerae were normal.
Slash|Either meaning|387|The possibility of sick sinus syndrome with contribution from even low- dose beta blockers is the best first guess as to the etiology of syncope in this gentleman, and I would be in agreement with simply discontinuing atenolol and observing making sure not to give any additional drug that might slow the heart rate. These do include Tegretol, any beta blocker, Verapamil, diltiazem, and/or digitalis. In addition, I wonder if he might be relatively dry, although the creatinine and BUN do not suggest prerenal status, being 1.2 and 17 respectively.
Slash|Date|119|She was hospitalized here in 2005 for a two-day period and was quickly discharged. She subsequently came in on _%#MM#%_/_%#DD2004#%_ with what appears to be a perforation of her colon from ulcerative colitis, and she was emergently taken to have a subtotal colectomy and an ileostomy.
Slash|Date|178|Her first fever spike occurred on _%#MMDD#%_ 05. At that time she was started on vancomycin, ceftazidime, and Flagyl because of her bad mucositis. Acyclovir was added on _%#MM#%_/_%#DD2005#%_ and voriconazole on _%#MMDD2005#%_ for persistent fevers.
Slash|Per|155|We will obtain blood cultures for both fungal and bacteria from both the port and also from the peripheral. She will continue on maintenance fluid at 80 mL/hour of D5-1/2 normal saline. In addition, we will draw for a CRP and also for a sed rate.
Slash|Either meaning|182|Surgery was consulted, Dr. _%#NAME#%_ has been consulted. He would like to get the platelets up and the patient will be transfused platelets overnight. Dr. _%#NAME#%_ from hematology/oncology was also called and recommends transfusing platelets.
Slash|Per|95|MEDICATIONS AT DISCHARGE: 1. Prevacid 15 mg daily. 2. Ursodiol 100 mg t.i.d. 3. Bactrim 200, 40/5, 2 teaspoons daily. 4. ADEKs vitamins. 5. Vitamin K 2.5 mg daily. 6. Cefotaxime 500 mg IV q.8 h.
Slash|Date|216|3. Hypertension, likely secondary to cyclosporine. 4. hyperglycemia. 5. Gastrointestinal bleed secondary to gastric ulcers, _%#MM2005#%_. 6. Right ureteral obstruction status post ureteral stent placement in _%#MM#%_/05. 7. Chronic kidney disease with acute renal failure secondary to obstruction with baseline creatinine 1.4 to 1.5. ADMISSION PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure was 148/99, respirations 20, pulse 103, temperature 102.7. GENERAL: The patient was shaking, has a moon faces.
Slash|Over(blood pressure)|213|MUSCULOSKELETAL: No known joint pain. NEUROLOGIC: No known seizure disorder or focal weakness or paresthesias. Again review of systems per mother at this time. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 125/85, pulse 87, respiratory rate 20, temperature 96.0 and O2 sat 97% on room air.
Slash|Date|142|SOCIAL HISTORY: The patient is a chronic smoker. He used to smoke about 1.5 pack of cigarettes per day for about 50 years. He quit in _%#MM#%_/04. No significant history of alcohol abuse. The patient is married and lives with his wife. He teaches music and he plays guitar.
Slash|Date|115|4. History of sleep apnea central with desaturations currently off O2. 5. Tonsillectomy and adenoidectomy, _%#MM#%_/_%#DD2002#%_, with PE tube placement. After this surgery, she was intubated for six days. 6. History of feeding problems and developmental delay.
Slash|Date|175|PAST MEDICAL HISTORY: 1. History of right hip congenital disorder which progressed to advanced degenerative joint disease. Status post right total hip arthroplasty on _%#MM#%_/_%#DD2004#%_ by Dr. _%#NAME#%_ _%#NAME#%_. 2. Hypertension. 3. Degenerative joint disease. 4. Factor V Leyden heterozygote.
Slash|Either meaning|150|3. E-coli urinary tract infection, on cephalexin. 4. IV phlebitis/cellulitis left antecubital fossa, gradually improving on cephalexin. 5. Hypokalemia/hypomagnesemia, replaced. 6. Closed head injury, left occipital temporal region with scalp contusion.
Slash|Over(blood pressure)|236|We will continue to follow her daily labs, as well as she will receive any form of cultures if she spikes a fever. Continue oxygen support as needed. She will have a portable chest x-ray in the morning, and will continue the BiPAP at 10/5 to maintain saturations greater than 90%. PROBLEM #2: Acute lateral sclerosis. This since 2004. She is on current medication and will be continued to be followed by the Neurology Service.
Slash|Date|123|Because of apneic and bradycardic episodes, _%#NAME#%_ was treated with caffeine. The caffeine was discontinued on _%#MM#%_/_%#DD2007#%_. The last episode occurred on _%#MMDD2007#%_. A CR scan was done on _%#MMDD#%_ and revealed no evidence of apnea or bradycardia of prematurity but frequent desaturation events particularly during feeding, suggesting an immature feeding pattern.
Slash|Of|139|Ears: TMs normal. Nose normal without paranasal sinus tenderness. Mouth no rmal. Neck: JVP normal, thyroid not palpable. Carotid arteries 4/4 without bruits. Chest: Normal excursions and resonance, lungs clear. Heart: S1 and S2 normal without murmurs, rubs or gallops or clicks.
Slash|Date|287|PRENATAL LABORATORY STUDIES: The patient is O-positive, antibody screen negative, rubella immune, hepatitis B-negative, HIV- negative, RPR-negative, gonorrhea and chlamydia negative, GVS negative. One-hour GCT 123. Hemoglobin 13.4. Urine toxicology screening positive for THC on _%#MM#%_/_%#DD2003#%_. Verbal report by Dr. _%#NAME#%_ the day prior to admission, stating that the patient's liver function, as well as platelets, were within normal limits on _%#MMDD2003#%_.
Slash|Per|125|This can be clarified by review of the chest x-ray when available. Based on previous cultures I will begin tobramycin at 3 mg/kg and imipenem IV. Vest therapy will be increased to 4 times a day with albuterol and Intal with each therapy and Pulmozyme twice daily.
Slash|Date|203|History of appendectomy. There was a tiny fibrotic-appearing nodule in the periphery of the right mid lung. 2. Chest x-ray on _%#MMDD2007#%_ showed no infiltrate. 3. MRI of the cervical spine on _%#MM#%_/_%#DD2007#%_ showed some posterior disc bulging at C4-5 with no neural impingement.
Slash|Date|227|Also of note, the patient showed signs of agitation and increasing confusion, consistent clinically with an alcohol withdrawal process. She was treated with the Ativan protocol, and she was initially quite somnolent on _%#MM#%_/_%#DD#%_ secondary to the treatment, but as the patient awoke with time, her alcohol withdrawal symptoms abated and her mental status continued to improve.
Slash|Over(blood pressure)|209|Gravida 0, para 0. She smokes half a pack per day for the past 2 years, cigarettes. Occasional alcohol use and marijuana. PHYSICAL EXAMINATION: On discharge temperature 98.5, heart rate 110, blood pressure 113/61, respiratory rate 18, oxygen saturation 99% to 100% on room air.
Slash|Either meaning|175|FINAL DISCHARGE DIAGNOSES: 1. Palpitations. 2. Status post electrophysiology study showing inducible ventricular tachycardia. 3. Status post automatic implantable cardioverter/defibrillator. 4. Dyslipidemia. 5. Peptic ulcer disease/gastroesophageal reflux disease. 6. Chronic kidney disease, stage IV.
Slash|Date|438|FINAL ACCEPTANCE OF TRANSFER OF CARE It is still unclear if we are going to manage this patient with Trauma Surgery or take over the care of this patient. Mrs. _%#NAME#%_ _%#NAME#%_ is a 62-year-old WF with past medical history significant for type 2 DM, hypertension, morbid obesity resulting in gastric bypass surgery on _%#MMDD2007#%_ who was initially admitted to University of Minnesota Medical Center, Fairview Riverside on _%#MM#%_/_%#DD2007#%_ with weakness and orthostatic hypotension felt to be secondary to volume depletion (in turn secondary to diarrhea).
Slash|Date|186|Problem #5: Screening for Intraventricular Hemorrhage. Anna was not treated with prophylactic indomethacin for the first three days after birth. A portable cranial ultrasound on _%#MM#%_/_%#DD#%_ revealed no abnormalities. Follow- up 1 month cranial ultrasound done on _%#MMDD2006#%_. Results are pending at the time of transfer.
Slash|Date|133|The patient had a remote history of about 30 years of open gastrointestinal bypass. She presented to the Riverside Campus on _%#MM#%_/_%#DD2006#%_ with a 1-week history of nausea, emesis and expanding abdominal mass.
Slash|Date|233|20. Hypertriglyceridemia. PROCEDURES AND OPERATIONS: 1. Pancreatic drainage/clot removal on _%#MMDD2007#%_. 2. Debridement with splenectomy and cholecystectomy _%#MMDD2007#%_. 3. Debridement of abdomen and fascial closure on _%#MM#%_/_%#DD2007#%_. 4. J-tube placement in OR on _%#MMDD2007#%_. 5. Lines changed out on _%#MMDD2007#%_ with left Broviac and right femoral atrial.
Slash|Date|151|_%#NAME#%_ had the following lines placed: umbilical arterial catheter, umbilical venous catheter, and a peripheral IV. His UAC was removed on _%#MM#%_/_%#DD2005#%_, and the UVC on _%#MMDD2005#%_. _%#NAME#%_ was initially maintained on a parenteral glucose infusion. We were able to start parenteral nutrition on _%#MMDD2005#%_.
Slash|Date|235|This medication was given on day #2 1/2 hour after a dose of Decadron and was repeated twice, as noted, for a total cycle dose of 9.2 gm. He also received intrathecal Ara-C as a liposomal formulation with 50 mg administered on _%#MM#%_/_%#DD2002#%_ and again 50 mg administered intrathecally on _%#MMDD2002#%_.
Slash|Either meaning|175|MENTAL HEALTH: Positive for anxiety. ENDOCRINE: Negative. PAST MEDICAL HISTORY: 1. Stage IIIa endometrioid adenocarcinoma of the ovary. 2. Infiltration IP port during first IV/IP chemotherapy on _%#MMDD2007#%_. 3. History of neutropenic fevers. 4. Anxiety. 5. Para 2-0-0-2.
Slash|Of|174|No nasal discharge. Pink oral mucosa. NECK: Supple without tracheal deviation. LUNGS: Showed decreased breath sounds in the left. CARDIOVASCULAR: She was tachycardic with a 2/6 systolic murmur. ABDOMEN: Soft and nontender with positive bowel sounds and hepatosplenomegaly present.
Slash|Either meaning|71|ADMISSION DIAGNOSES: 1. Persistent mucinous adenocarcinoma of the ovary/appendix. 2. Acute renal failure. 3. Gastroesophageal reflux disease. 4. Status post abdominal aortic aneurysm repair.
Slash|Date|188|PROBLEM #4. Renal: Mrs. _%#NAME#%_ developed acute renal failure and oliguria during the MICU stay. She required dialysis during her stay and her last dialysis run was noted to be _%#MM#%_/_%#DD2005#%_. She subsequently demonstrated adequate urine output and there is evidence now that her renal function has stabilized and returned to normal.
Slash|Date|123|This request is more than happy to be granted by Dr. _%#NAME#%_ for which he will follow up and see the patient on _%#MM#%_/_%#DD2006#%_. The patient will transfer all his further care to Dr. _%#NAME#%_ at Cleveland Clinic in _%#CITY#%_.
Slash|Date|109|She is now 77 days status post transplant at the time of discharge. Her 60-day bone marrow biopsy on _%#MM#%_/_%#DD2006#%_ revealed 30% cellularity with trilineage hematopoiesis and no evidence of leukemia.
Slash|Date|215|For additional information, please refer to the discharge summary dated _%#MMDD2007#%_ by Dr. _%#NAME#%_ _%#NAME#%_. The patient was initially admitted to University of Minnesota Medical Center, Fairview on _%#MM#%_/_%#DD2007#%_ for dehydration and fever. The patient presented with persistent hypotension and difficulty responding with IV fluids.
Slash|Date|141|He has not been eating for 1-2 weeks. This is his third recurrence of C. difficile colitis. The prior 2 required hospitalizations in _%#MM#%_/2007 and in _%#MM2007#%_. He is also status post 2 courses of Flagyl. ALLERGIES: IV dye.
Slash|Date|212|This was complete at the end of _%#MM2006#%_ and since then she has complained of severe left hip, buttock and thigh pain that has not been well controlled even on narcotics regimen. She was then seen in _%#MM#%_/2007 for routine surveillance visit at which time she was noted to have a pelvic mass.
Slash|Either meaning|153|No difficulty with vision or hearing. Cardiovascular/Respiratory: No cough, shortness of breath or chest pain. No lower extremity edema. Gastrointestinal/Genitourinary: No nausea or vomiting. No abdominal pain, no blood in the urine or stool.
Slash|Date|264|I have been asked by Dr. _%#NAME#%_ _%#NAME#%_ to see _%#NAME#%_ _%#NAME#%_ for evaluation of a new onset atrial fibrillation with rapid ventricular response. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a delightful 60-year-old female admitted on _%#MM#%_/_%#DD2007#%_ for evaluation of cough and shortness of breath. I am currently asked to see this patient for onset of atrial fibrillation with rapid ventricular response at approximately 3 a.m. this morning.
Slash|Date|252|He worked in several different positions, and ultimately settled into tool and die making, explaining that he became a Class A tool and die maker at the age of 21. He worked in his most recent position for 13 years, and has been disabled since _%#MM#%_/_%#DD#%_. He has a history of incarceration, including 4-1/2 months in jail for DWIs, and more time related to probation violations, most recently in 2000.
Slash|Either meaning|153|Bowel sounds are normal. EXTREMITIES: Distal lower extremities are well perfused; no cyanosis or clubbing. There is no posterior calf or thigh tenderness/induration to suggest DVT. PELVIC/RECTAL: Exams deferred. NEUROLOGIC: Grossly nonfocal. LAB DATA: Available laboratory data from this morning includes sodium 135, potassium 4.4, chloride 100, CO2 27, anion gap 8, glucose 126, BUN 26, creatinine 1.25 with reduced GFR of 46.
Slash|Over(blood pressure)|223|PHYSICAL EXAMINATION: GENERAL: This is a well-developed, overweight, elderly woman, appearing in no acute distress at this time, alert and oriented x3. VITAL SIGNS: Temperature 94.7, pulse 71 and regular, blood pressure 123/59, respirations 24 and regular, O2 sats 95% on ten liters of nasal O2.
Slash|Over(blood pressure)|147|He denies smoking. REVIEW OF SYSTEMS: Unobtainable due to the patient's confusion. PHYSICAL EXAMINATION: VITAL SIGNS: Current blood pressure is 108/85, pulse is 80 and regular with moderately frequent premature ventricular contractions and rare couplets, respiratory rate is 21 with grunting respirations, temperature is 97.8, the patient is oxygenating 91% on room air and weight is 132.3 kg.
Slash|Date|112|In fact, she noted that this made her increasingly depressed and somewhat hopeless about the future. In _%#MM#%_/04, her father passed away, and according to this patient, it was originally thought to be suicide, but it has now come to the family's attention that this may not have been the case and could have been an accident.
Slash|Either meaning|91|He had lysis of adhesions. Subsequently, he has apparently had poor p.o. intake. He has DNR/DNI status. He was transferred to Southdale yesterday for central line placement in the left internal jugular for TPN administration, and on his return from Southdale, he developed worsening shortness of breath.
Slash|Date|217|Cardiology was consulted on _%#MMDD2002#%_ to assist in managing her heart failure and made numerous recommendations. She continued to eat very poorly, if at all. Comfort care was discussed with the family on _%#MM#%_/_%#DD2002#%_, but no decision was made. The family was waiting for another daughter to arrive from _%#CITY#%_ _%#CITY#%_ when her condition deteriorated further, and she was intubated last night.
Slash|Date|173|This case has been reviewed at the Mayo Clinic. CT scan of the sinuses on _%#MMDD2005#%_ showed some left maxillary sinus mucosal thickening. Whole-body PET scan on _%#MM#%_/_%#DD2005#%_ showed increased activity in the right nasal cavity, bilateral upper mid posterior neck, and bilateral tonsils.
Slash|Either meaning|304|His renal and bone marrow aspirates were re-evaluated here in our Pathology Department and interpreted as showing a bone marrow picture consistent with evolving myelodysplastic syndrome. The renal biopsy interpretation was confirmed and was felt to be consistent with a variety of disorders causing a TTP/HUS-like syndrome, including lupus, scleroderma, chemotherapy drugs malignant hypertension, etc.
Slash|Date|119|3. Flagyl IV. 4. Tigacillin IV 5. Vancomycin IV. 6.. Voriconazole IV. PHYSICAL EXAMINATION: VITAL SIGNS: As of _%#MM#%_/_%#DD2007#%_ at 8 a.m., vital signs 37.2 degrees, heart rate 126, blood pressure 117/66, respirations 18 with 98%, 30% oxygen on BiPAP and trach dome.
Slash|Date|136|I actually had talked to her husband and she simply no longer allowed her husband to see her without clothes. When I saw her on _%#MM#%_/_%#DD2006#%_ I took her urgently to the catheterization lab. Her right coronary artery was totally occluded. I did atherectomy and balloon angioplasty of the right coronary artery.
Slash|Date|187|There was metastatic tumor in 2 of 16 lymph nodes. Since the surgery the patient has received 7 cycles of leucovorin, 5-FU and oxaliplatin as well as Avastin between the dates of _%#MM#%_/_%#DD2004#%_ and _%#MMDD2005#%_. She is receiving this chemotherapy every 3 weeks, and is scheduled to receive a total of 12 cycles.
Slash|Either meaning|174|4. Combivent 2 puffs inhaler q.i.d. 5. Compazine p.r.n. 6. Zofran p.r.n. 7. First dose of her infusion of ABRAXANE. PALLIATIVE MEDICINE REVIEW CODE STATUS: The patient is DNR/DNI. PROXY IDENTIFICATION: The patient identifies her daughter _%#NAME#%_ as proxy.
Slash|Divided by|101|She works full-time. HABITS: She does not drink any alcohol. She does smoke, for the last 20 years, 1/2 - 1 pack a day; has tried quitting multiple times.
Slash|Date|258|IMAGING: The patient's CT scans of the head and neck from _%#MMDD2003#%_, as well as the CT scans of the chest from _%#MMDD2003#%_, are examined and described above in history of present illness. PATHOLOGY: The reports from the patient's biopsy done _%#MM#%_/_%#DD2003#%_ are reviewed and described above as well. ASSESSMENT: Mr. _%#NAME#%_ is a 69-year-old male with a T4 squamous cell carcinoma of the left tonsil who has been referred to our clinic for consideration of definitive chemoradiation.
Slash|Date|161|A minimal amount of spot drainage was noted on dressings over the right groin incision. No appreciable drainage was noted. The patient was discharged on _%#MM#%_/_%#DD2006#%_. He was converted to oral antibiotic therapy, including Cipro and Keflex.
Slash|Date|114|Please also see handwritten notes of the same date for additional information. Mr. _%#NAME#%_ awakened on _%#MM#%_/_%#DD#%_ with a sense of pressure in his head and heaviness in his right leg.
Slash|Date|169|For the last 3 weeks, most measures have been palliative in nature to keep _%#NAME#%_ comfortable using hydromorphone and Ativan for anxiety. _%#NAME#%_ died on _%#MM#%_/_%#DD2007#%_ at 7:22 p.m. CAUSE OF DEATH: Metastatic osteosarcoma.
Slash|Separates two doses|107|Hepatitis C and HIV tests were negative. Liver functions were normal. In addition, he is to take Advair 500/50 mcg 1 puff b.i.d., Lexapro 10 mg daily and albuterol MDI 2 puffs q.i.d. DISCHARGE: He was discharged on 14 Suboxone, 8 mg one-half tablet b.i.d. DISCHARGE DIAGNOSIS: Heroin dependence and asthma.
Slash|Per|105|He will be allowed to eat a regular diet and his fever will be controlled. He will receive Rocephin 50 mg/kg I.V. q.12h.
Slash|Either meaning|377|Dr. _%#NAME#%_ actually suggested going ahead and putting in a biventricular pacing device, which was done uneventfully on _%#MMDD2004#%_ and this is a lower power device with just pacing capabilities and not a defibrillator as Dr. _%#NAME#%_ felt that her prognosis, unless she had significant cardiac improvement from medication, would be very poor. In fact, she was made DNR/DNI after her extensive ICU hospitalization. Dr. _%#NAME#%_ found that she had separate ostia for the great cardiac vein and the coronary sinus and this led to some significant technical difficulties where she received 120 minutes of fluoroscopy time with concerns that later she may have some radiation burn over the chest.
Slash|Of|162|EXTREMITIES: Distal pulses +2 without edema. SKIN: Without rashes. NEURO: Cranial nerves II - XII without deficit. Motor exam of the upper and lower extremities 5/5 (there is no demonstrable weakness). Deep tendon reflexes in the upper and lower extremities, +2.
Slash|Date|107|The patient had only minimal abdominal pain, which was well covered with oral pain medications. On _%#MM#%_/_%#DD2004#%_ the patient was deemed ready for discharge. He was tolerating a normal diet. DISCHARGE INSTRUCTIONS: 1. No lifting greater or equal to 10 pounds for 4 weeks.
Slash|Either meaning|70|DISCHARGE MEDICATIONS: 1. Nexium 40 mg p.o. daily. 2. Lisinopril 20 mg/hydrochlorothiazide 25 mg q. tablet p.o. daily. 3. Digoxin 0.125 mg p.o. daily. 4. Cardia 120 mg p.o. daily.
Slash|Date|321|She moves all extremities equally. LABORATORY DATA: Laboratory studies on _%#MMDD2004#%_: sodium 135, potassium 3.9, BUN 30, creatinine 0.96. Hemoglobin 12.7. EKG: 12-lead EKG shows atrial fibrillation pattern with mild left axis deviation. No ST segment changes. STRESS TEST: Adenosine stress thallium test from _%#MM#%_/_%#DD2004#%_ showed no inducible ischemia. IMPRESSION: Normal preoperative exam. The patient has no obvious medical contraindications for proceeding with a hemicolectomy.
Slash|Date|120|On postoperative day #3, the patient had a T. max of 100.8. Otherwise, he had stable vital signs. Hemoglobin on _%#MM#%_/_%#DD2005#%_ was 11.8. He had a stable physical examination. He passed physical therapy on postoperative day #3. He was tolerating p.o. and had adequate pain control.
Slash|Over(blood pressure)|162|NEUROMUSCULAR: Fatigue over the past two years. Denies seizures, syncope, paresis, paresthesias, or vertigo. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 144/76, heart rate 84 and regular, respirations 14 and unlabored, temperature 97.8. 02 saturation 93%.
Slash|Date|156|A social worker was involved and they set-up some home health care for him as an outpatient. The patient was discharged to home in stable condition _%#MM#%_/_%#DD2002#%_ with the following instructions. He is to resume his physical and occupational therapy guidelines.
Slash|Either meaning|128|Careful I's and O's, daily weights. 3. Plastic surgery consult for treatment of right biceps mass fungating and bleeding. 4. DNR/DNI status is discussed with the patient and daughter, _%#NAME#%_, and confirmed.
Slash|Either meaning|312|In the interim, the patient has been provided instructions if he becomes short of breath, he is to immediately present to a local ER, and they are to place his tube to suction. The patient was informed if he continues to have problems or questions should arise, he can contact the thoracic surgery department and/or clinics. Patient states he understands this, has no questions of concerns at this time, and is eager to be discharged home today, on _%#MMDD#%_.
Slash|Divided by|132|His vital signs are stable at this time. He has no concerns or questions this morning. DISCHARGE MEDICATIONS: 1. Metoprolol 50 mg, 1/2 p.o. b.i.d. 2. Plavix 75 mg, 1 p.o. daily. This will be for 12 months.
Slash|Date|401|DISCHARGE MEDICATIONS: Protonix 40 mg p.o. daily, metronidazole 500 mg p.o. q. 6 hours times seven days, Levofloxacin 500 mg p.o. daily times seven days, prednisone 30 mg daily times one day, then decrease to 20 mg daily times two days, then decrease to 10 mg daily times two days, then decrease to 5 mg daily times two days, then discontinue. The patient will follow-up at Ridges Hospital on _%#MM#%_/_%#DD#%_ for elective laparoscopic cholecystectomy with Dr. _%#NAME#%_.
Slash|Date|87|She was not a good version candidate, and cesarean section was recommended. On _%#MM#%_/_%#DD2005#%_ the patient underwent primary cesarean section with delivery of viable female infant in breech presentation weighing 6 pounds 13 ounces with Apgars of 9 and 9.
Slash|Date|208|She also has a history of adult onset diabetes, hypertension, chronic renal insufficiency secondary to the hypertension and diabetes. She was morbidly obese. She underwent an uncomplicated surgery on _%#MM#%_/_%#DD2005#%_. Her postoperative course was slowed somewhat by her renal insufficiency and her diabetes.
Slash|Date|223|His other medicines, unchanged, include Hydrea, folic acid, Flexeril p.r.n., Fentanyl patch 200 mcg, and aspirin. DISCHARGE/FOLLOW-UP: 1. The patient will be followed up with Hematology-Oncology Clinic on Thursday, _%#MM#%_/_%#DD2005#%_, at 2 p.m. 2. Follow up with Infectious Disease Clinic with Dr. _%#NAME#%_ _%#NAME#%_ in 2 weeks.
Slash|Either meaning|118|OTHER PROVIDER: Dr. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ in hematology bone marrow transplant. Death was on the hematology/oncology hospital service. PATIENT CARE UNIT: 7-D. HPI: The patient is a 67-year-old gentleman who was admitted on _%#MM#%_ _%#DD#%_, 2005, after a prolonged hospitalization and rehabilitation in _%#MM#%_ 2005 and _%#MM#%_ 2005.
Slash|Date|125|DOB: _%#MMDD1964#%_ DIAGNOSIS: Degenerative arthritis right knee. OPERATIVE PROCEDURE: Right total knee arthroplasty _%#MM#%_/_%#DD2005#%_. SUMMARY: _%#NAME#%_ _%#NAME#%_ is a 41-year-old woman, was admitted to the hospital having failed a nonoperative treatment program for degenerative arthritis of the knee.
Slash|Either meaning|74|Social work is to see the patient and arrange for this. The patient is DNR/DNI . He has also expressed on multiple occasions that he wishes he would go peacefully.
Slash|Date|128|She lives with her husband who aids in her care. She will follow-up with her primary-care physician, Dr. _%#NAME#%_, on _%#MM#%_/_%#DD2005#%_ at 1:40 in the afternoon. It was a pleasure to be involved in the care of Ms. _%#NAME#%_.
Slash|Of|147|GENERAL: He is alert and playing. HEENT: Reveals no facial edema. LUNGS: Clear to auscultation bilaterally. HEART: Regular rate and rhythm with a 2/6 systolic murmur. ABDOMEN: Protuberant, but soft and nontender. EXTREMITIES: Reveal no edema.
Slash|Date|150|6. MiraLax 17 grams p.o. q. day, the same dose as before admission 7. Ferrous sulfate 320 mg p.o. q. day 8. Levaquin 500 mg p.o. q. day until _%#MM#%_/_%#DD2005#%_ FOLLOW-UP LABS: Daily INR. Hemoglobin and hematocrit check in four weeks. Also follow with Ortho as scheduled by them.
Slash|Of|162|No field cut. Neck supple. No adenopathy or thyromegaly. Jugular venous distention is noted bolt upright to behind the ear. LUNGS: Rales throughout. HEART: Loud 3/6 systolic and diastolic murmurs heard best at the base of the heart.
Slash|Date|275|With continued observation as well as physical therapy and occupational therapy evaluation, the patient was recommended to have a brief rehab and strengthening, which was accepted by the patient and her family. As a result, she was discharged to her care facility on _%#MM#%_/_%#DD2006#%_. DISCHARGE MEDICATIONS: 1. Norvasc 5 mg p.o. q.a.m. 2. Protonix 40 mg p.o. q.p.m.
Slash|Date|144|Low normal EF with an EF of 50%. This is an improvement in her pericardial effusions compared to her last admission. 2. Chest CT, dated _%#MM#%_/_%#DD2006#%_: Findings: No CT evidence of pulmonary embolus. Small left lower lobe infiltrate and small left pleural effusion, which are both decreased in size compared to _%#MMDD2006#%_.
Slash|Of|132|Cranial nerves II-XII are intact. Deep tendon reflexes are 2+ bilaterally in both upper and lower extremities. Strength is grossly 5/5 in the upper and lower extremities bilaterally. IMPRESSION: 1. Severe aortic stenosis 2. Atherosclerotic cardiovascular disease
Slash|Either meaning|141|Histochemical testing for CMV was performed, and no evidence of CMV was identified. We initiated treatment with IV foscarnet for possible CMV/HSV esophagitis, which was discontinued upon results of the biopsy which were negative.
Slash|Divided by|168|Cultures taken in early _%#MM#%_ by an outside otolaryngologist showed bacteria susceptible to Bactrim. This was treated and did not resolve. Cultures taken on _%#MM#%_/_%#DD#%_ by Dr. _%#NAME#%_ in ENT Clinic grew out an MRSA strain. Patient presented for vancomycin and PICC line placement.
Slash|Date|280|An erythrocyte sedimentation rate (ESR) was 2.0 and a uric acid was 5.6. On the morning of _%#MMDD2002#%_ UA was negative for blood, completely clean. While in-house, the patient remained asymptomatic without any complaints. The patient was discharged on the afternoon of _%#MM#%_/_%#DD2002#%_ and will be returning to Virginia shortly. In discussion with the Pediatric Nephrology team, several diagnoses were entertained.
Slash|Over(blood pressure)|180|4. Hysterectomy. 5. Back surgery. LABORATORY: Laboratory results today revealed white count 13.6, hemoglobin 16, glucose 206. PHYSICAL EXAMINATION: On admission, blood pressure 152/92, temperature 96.9, pulse 120, respirations 18. She is alert and oriented, no acute distress. She feels much better after treatment from the ER with fluid and Zofran.
Slash|Either meaning|94|The above plans were discussed with the patient and his son. The patient will be continued DNR/DNI from multiple previous conversations.
Slash|Respectively|116|She smokes 16-18 cigarettes per day. She is divorced and has two children. CURRENT MEDICATIONS: 1. Accupril /HCTZ 20/12.5 mg PO Q day 2. Provera 3. Estratest 4. Xalatan 5. Timoptic Doses unknown on above.
Slash|Respectively|107|2. Prevacid 30 mg b.i.d. 3. Atenolol 25 mg q. day 4. Norvasc 5 mg q. day 5. Diovan/hydrochlorothiazide (160/12.5) one p.o. q. day 6. Lasix 20 mg q. day 7. K-Dur 10 mEq q. day
Slash|Date|198|This has recurred on her right wrist. She is scheduled for sentinel node biopsy and the wrist tumor bed excision on the same day. HOSPITAL COURSE: Patient was taken to the operating room on _%#MM#%_/_%#DD2003#%_. There Dr. _%#NAME#%_ performed a sentinel node biopsy from the right axilla.
Slash|Date|238|She had presented to Dr. _%#NAME#%_ in _%#MM#%_ 2005, at which time she was having an episode of heart failure, and her Lasix had to be increased, and atenolol decreased from 50 mg to 25 mg per day. A stress test was completed on _%#MM#%_/_%#DD2005#%_, with moderately severe reversible anterior and anterolateral ischemia defect.
Slash|Per|145|2. Primary Care Physician at Boynton to be established within one week. DISCHARGE MEDICATIONS: 1. Lantus 25 units subcu q.p.m. 2. Novolog 2 units/carb (15 grams) and preprandial correction as follows: 120-149 1 unit, 150-199 2 unit, 200-249 3 units, 250-299 5 units, 300-349 7 units, greater than 350 8 units.
Slash|Over(blood pressure)|177|Caffeine, approximately 2 per day. He is divorced with significant other, 2 kids. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature is 96.4, pulse is 85, his blood pressure was 144/86, he is 92% on room air, weight of 221. HEENT: His TMs are negative except for otosclerosis. Pupils equal, round, reactive to light and accommodation.
Slash|Date|124|He was tolerating a regular diet. His pain was controlled with oral pain medications, and he was still afebrile. On _%#MM#%_/_%#DD2006#%_ the patient was discharged home on a regular diet, with activity as tolerated.
Slash|Over(blood pressure)|118|SOCIAL HISTORY: She has never smoked and she remains quite active. PHYSICAL EXAMINATION: VITALS: Blood pressure is 126/78, respiratory rate 16, pulse 80. The patient is alert in no distress. SKIN: Warm and dry.
Slash|Over(blood pressure)|310|Endocrine: Negative. Neurologic: Negative except as above. Musculoskeletal: Negative. PHYSICAL EXAMINATION: GENERAL: Alert and oriented. Walks with some slight incoordination. VITAL SIGNS: Initial blood pressure was 223/128, heart rate 71, respirations 20, temperature 97.7. Later blood pressure dropped to 187/119. HEENT: Unremarkable. NECK: Carotids 2+ bilaterally without bruits. LUNGS: Clear.
Slash|Separates two doses|323|Noted are her LFTs are within normal limits. 5. I will follow up with the patient in 4-6 weeks and Dr. _%#NAME#%_ will see her sooner. DISCHARGE MEDICATIONS: Lipitor, hydrochlorothiazide 25 mg q.d., Lovenox 110 mg b.i.d. until last dose Sunday evening, Coumadin 7.5 mg tonight, 5 mg tomorrow night, and then alternating 2.5/5 mg, and she is to hold aspirin during her use of Coumadin.
Slash|Per|188|Prevacid will be used 30 mg per capsule down the G tube for a month and then switched to ___________ 300 mg at h.s. after the Prevacid is done. Peridex mouth wash twice daily. Jevity 55 cc/hr, 880 cc. Patient will be hydrated with 350 cc of water four times daily.
Slash|Either meaning|123|If unable to control the infection, we will have the Infectious Disease consultant see the patient. 2. Severe hyperglycemia/poorly-controlled diabetes. The patient has had poorly controlled diabetes for far too long.
Slash|Over(blood pressure)|180|He has had a laceration of his neck. He has had an appendectomy. MEDICATIONS: None. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98, pulse 80, respirations 20, blood pressure 120/80. GENERAL: This is a well-developed, well-nourished 47-year-old male in no apparent distress.
Slash|Over(blood pressure)|161|She is a homemaker. She denies any alcohol, IV drug use, or tobacco use. She uses caffeine minimally. ADMISSION PHYSICAL EXAMINATION: Afebrile. Blood pressure 98/61. Heart was regular rate and rhythm. Lungs were clear to auscultation bilaterally.
Slash|Date|217|DISCHARGE FOLLOW-UP: The patient will follow up with Dr. _%#NAME#%_ later this week. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a _%#1914#%_ man who was admitted through the emergency room by Dr. _%#NAME#%_ on _%#MM#%_/_%#DD2006#%_ with a unusual symptoms of confusion and whole body tingling.
Slash|Over(blood pressure)|220|MUSCULOSKELETAL: Negative. NEUROLOGICAL: As per HPI. Also notes some chronic lower extremity paresthesias. PSYCHIATRIC: Unremarkable. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 97.9, heart rate 74, blood pressure 116/68, respiratory rate 16, 96% on room air. GENERAL: Alert and oriented x3, no acute distress. HEAD AND CMT: Ears unremarkable.
Slash|Over(blood pressure)|206|HEENT: Please see history of present illness. NEUROLOGIC: Please see history of present illness. She denies any cognitive or constitutional symptoms. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure is 137/64, pulse 85, respirations 18, temperature 96.7. Oxygen saturation 97% on room air.
Slash|Either meaning|248|3. Palliative care for oral ulcerations. 4. Pain medication. I did discuss with her beginning long-acting narcotics and she is in agreement. 5. Dietary consultation. 6. I did also discuss with her advance directive forms, including the issue of DNR/DNI status. She would like additional time to consider this issue and is willing to have further information provided through social services.
Slash|Date|173|LABORATORY DATA: Urinalysis shows trace leukocyte esterase, large blood, 50-100 red cells, few bacteria. White blood cell count 8.6, hemoglobin 10.8, up from 9.4 in _%#MM#%_/2006. Platelets 225, sodium 139, potassium 4.9, chloride 109, bicarbonate 14, anion gap was 16.
Slash|Date|131|He was extubated on _%#MMDD2007#%_ and has done well since that time. The patient was transferred to the medicine floor on _%#MM#%_/_%#DD2007#%_. He has continued to do well from the infection standpoint.
Slash|Date|94|BRIEF HISTORY OF PRESENT ILLNESS: Please refer to the completed H&P by Dr. _%#NAME#%_ _%#MM#%_/_%#DD2007#%_ for complete details. Briefly, she is a 58-year-old female with history of diabetes with triopathy presents with 2-3 day history of feeling very rundown.
Slash|Date|199|IMPRESSION: Mr. _%#NAME#%_ is an 81-year-old white male who presents today for preoperative evaluation for his upcoming right carpal tunnel surgery to be done by Dr. _%#NAME#%_ _%#NAME#%_ on _%#MM#%_/_%#DD2007#%_. At this point in time, I would place him at a relatively low risk for any cardiopulmonary complications even though he does have a history of underlying coronary artery disease.
Slash|Separates two doses|167|He will follow up with his primary care physician, Dr. _%#NAME#%_ in 7-10 days at Fairview Lakes Hospital. DISCHARGE MEDICATIONS: 1. Aspirin 81 mg daily. 2. Vytorin 10/20 mg daily. 3. Multivitamins 1 daily. 4. Glucosamine/chondroitin 1 tablet daily. If you have any questions, you may page at _%#TEL#%_.
Slash|Date|166|Hemoglobin 13.1, potassium 4.5, urinalysis is negative, INR 1.31. PSA 8.1. Recent CMP on _%#MMDD2003#%_ was normal. BUN of 18, creatinine 1.5. Chest x-ray on _%#MM#%_/_%#DD2001#%_ was essentially negative. DIAGNOSTIC IMPRESSION: 1. Chronic urinary retention with 400 plus residual urine which is symptomatic.
Slash|Date|263|We will attempt to get his INR down in the 2 range at least but we will also need to get his old records to evaluate his heart and his history of mitral valve replacement. According to his wife, he had a cardiac echo done at the Minnesota Heart clinic in _%#MM#%_/_%#DD#%_, and we will also attempt to get these records. We will get records of the stool tests that were done in the clinic with Dr. _%#NAME#%_ and also try to get his last hemoglobins from the clinic.
Slash|Date|180|14. Emla cream p.r.n. to port sites. FOLLOW-UP: 1. The patient will have a CBC with differential checked two to three times a week with results faxed to Hem/Onc Clinic. 2. _%#MM#%_/_%#DD2004#%_, the patient will follow up in the Masonic Day Hospital for packed red blood cells and platelets.
Slash|Date|367|As the cultures were pending at the time of discharge from the emergency room on the _%#DD#%_, she was treated empirically with ceftriaxone and sent home with an outpatient regimen of doxycycline and metronidazole to cover bacterial vaginosis and chlamydia. Since this visit to the emergency room her pelvic pain has completely resolved, but she presented on _%#MM#%_/_%#DD2004#%_ with a new complaint of fatigue, vomiting, and nausea.
Slash|Of|165|CARDIOVASCULAR: Regular, no murmurs, rubs or gallops. ABDOMEN: Soft and nontender. EXTREMITIES: No edema; they are warm. NEURO: Cranial nerves are normal, power is 5/5 throughout, gait was not observed. SKIN: He has a couple stage II decubiti, one on the right hip and one in the mid back area.
Slash|Date|147|FINAL FINAL DIAGNOSIS: Treated non-small-cell carcinoma left upper lobe lung. Final pathological stage T0, N0, M0. OPERATIVE PROCEDURE: On _%#MM#%_/_%#DD2007#%_, left limited thoracotomy and wedge resection of left upper lobe lung cancer and mediastinal lymph node dissection was performed.
Slash|Date|67|FINAL DATE OF ADMISSION: _%#MMDD2007#%_ DATE OF DISCHARGE: _%#MM#%_/_%#DD2007#%_ _%#NAME#%_ _%#NAME#%_ is 87. She was admitted because of complaints of low sternal chest discomfort.
Slash|Date|13|DOB: _%#MM#%_/_%#DD1956#%_ SUMMARY: Mr. _%#NAME#%_ is a 47-year-old man who is admitted with acute abdominal pain and found to have an appendicitis. He was taken to surgery where a gangrenous appendicitis with rupture was found and resected.
Slash|Of|165|I hear bilateral carotid bruits which may, in fact, be conducted aortic murmur. LUNGS: Clear but slightly diminished in size. HEART: Regular rate and rhythm with a 2/6 midsystolic murmur with radiation to the carotids consistent with aortic stenosis without stenosis.
Slash|Date|13|DOB: _%#MM#%_/_%#DD1995#%_ FINAL DISCHARGE DIAGNOSES: 1. Asthma exacerbation. 2. Right otitis media. HOSPITAL COURSE: _%#NAME#%_ has a history of asthma for four years and prior to admission she had been having cough for a day with some respiratory distress, shortness of breath, wheezing, and coughing.
Slash|Date|271|DISCHARGE FOLLOW-UP: 1. She should call my secretary, _%#NAME#%_, at _%#TEL#%_ _%#TEL#%_ to set up outpatient Coumadin therapy if she is discharged home; otherwise she will participate in Coumadin therapy at the nursing home. 2. Discharge follow-up is with me on _%#MM#%_/_%#DD2004#%_ for staple removal.
Slash|Over(blood pressure)|218|The patient has a history of transfusions with his colon cancer surgery, otherwise no bleeding tendencies or clotting. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 97.5, pulse 127, respirations 24, blood pressure 158/105, O2 sats 97%. HEENT: Atraumatic. The patient's throat without obstruction. NECK: Supple. No lymphadenopathy.
Slash|Over(blood pressure)|189|His mom is currently expecting her next baby. PHYSICAL EXAMINATION: Weight is 10.3 kg. In general, _%#NAME#%_ is a sleeping comfortably. Vital signs are heart rate of 119, blood pressure 97/50, pulse ox 95% on room air with respiratory rate of 30.
Slash|Date|177|This was biopsied and sphincterotomy was performed. Following that, she did well, as described above. 3. Superficial thrombophlebitis, right upper extremity: On Friday, _%#MM#%_/_%#DD2005#%_, she developed redness, swelling and induration in her right antecubital fossa where an IV site had been.
Slash|Either meaning|212|HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 39-year-old woman with a history of phase III, hormone receptor positive breast cancer, status post bilateral mastectomy, currently undergoing treatment with Adriamycin/Cytoxan ,which will be followed by Taxol ______________. The patient has had significant side effect with chemotherapy. She was admitted yesterday after her third dose of chemotherapy with protracted nausea, vomiting and dehydration.
Slash|Date|93|PRELIMINARY DISCHARGE SUMMARY: DATE OF ADMISSION: _%#MMDD2005#%_ DATE OF DISCHARGE: _%#MM#%_ / _%#DD2005#%_ Please see Dr. _%#NAME#%_'s Admission H&P for details. HOSPITAL COURSE: 1. Metastatic rectal cancer.
Slash|Date|172|15. Lidocaine 2% jelly apply prior to Accu-Cheks q.i.d. p.r.n. DISCHARGE INFORMATION: 1. _%#NAME#%_ will be seen in the pediatric bone marrow transplant clinic on _%#MM#%_ /_%#DD2007#%_ at 11:30 a.m. by _%#NAME#%_ _%#NAME#%_, nurse practitioner.
Slash|Separates two doses|106|1. Aspirin 325 mg p.o. daily. 2. Norvasc 10 mg p.o. daily. 3. Allopurinol 150 mg p.o. daily. 4. Advair 250/50, one puff b.i.d. 5. Levaquin 250 mg p.o. every other day x5 doses.
Slash|Date|162|There were no breath sounds present. There was no cardiac action, and the pupils were dilated and fixed. The patient was pronounced dead at 11:50 A.M. on _%#MM#%_/_%#DD2002#%_ by Dr. _%#NAME#%_ _%#NAME#%_.
Slash|Either meaning|215|PROGRAM PARTICIPATION: While on the STOP Unit _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. She attended daily groups, gender group, and AA/NA meetings on-site. _%#NAME#%_ also did attend therapeutic recreation, developmental asset building activities, and music therapy.
Slash|Date|139|Soon after one of these episodes, his pulse dropped down to 30 and then soon thereafter his heart stopped. He was declared dead on _%#MM#%_/_%#DD2002#%_. The cause of death was thought to be congestive heart failure secondary to aortic stenosis.
Slash|Over(blood pressure)|162|Therefore he had his father bring him to the emergency department here for a second opinion. ADMISSION EXAMINATION: Temperature 99.7, pulse 99, blood pressure 134/66, respiratory rate 24, O2 saturations at 100% on room air.
Slash|Over(blood pressure)|184|He is currently still living. Apparently there is also some family history of diabetes, ulcers, and panic attacks. PHYSICAL EXAMINATION: VITAL SIGNS ON ADMISSION: blood pressure is 126/74, pulse is 66, respirations 14, temperature was 98.9. GENERAL: The patient is an alert, well-nourished, well- developed male who is in no acute distress.
Slash|Date|13|DOB: _%#MM#%_/_%#DD1936#%_ PRESENTING COMPLAINT: Mr. _%#NAME#%_ is a 66-year-old man that had bilateral inguinal hernias repaired in the past. One of these was done in 1968 and one in 1969.
Slash|Either meaning|429|Slight hyperinflation in the bases. No definite CHF. LABS: Troponin 0.56 and later 0.49, myoglobin 51, sodium 143, potassium 4.3, chloride 111, bicarb 22, BUN 25, creatinine 1.3, glucose 89, white count 7.1, hemoglobin 15.5, platelets 190. ASSESSMENT: 1. 72-year-old male with several risk factors. Presents to the Emergency Department with unstable angina with symptoms seem to be present for the past week and several PVC's and/or bigeminy on monitoring. He also appears to have some COPD versus mild congestive heart failure and by clinical picture including lab results, also has ruled in for a subendocardial myocardial infarction.
Slash|Over(blood pressure)|207|No pleuritic chest pain. GI: Some nausea associated with the symptoms described above. GU: Negative. Musculoskeletal: Negative. Psych: Negative. ID: Negative. PHYSICAL EXAMINATION: VITALS: Blood pressure 138/64, pulse 58, respiratory rate 26, temperature 97.6, sats 100% on room air.
Slash|Separates two doses|419|He was seen in consultation by Cardiology, who felt that he has high risk of having significant coronary disease and the plan is for him to be transferred to Fairview Southdale Hospital today and undergo angiogram tomorrow. He is discharged in stable condition. His medications on discharge are Protonix 40 mg daily, Lipitor 10 mg daily, Allopurinol 150 mg Monday, Wednesday and Friday, amiloride/ hydrochlorothiazide 5/50 1 daily, aspirin 81 mg daily, atenolol 25 mg daily, Tylenol 650 q. 4 to 6 hours p.r.n..
Slash|Date|163|DOB: HOSPITAL COURSE: _%#NAME#%_ is a 50-year-old who underwent a vaginal hysterectomy, bilateral salpingo-oophorectomy, anterior and posterior repairs on _%#MM#%_/_%#DD2004#%_ at Fairview Ridges Hospital. Surgery was uncomplicated. Estimated blood loss was 250 cc. A vaginal packing was placed along with a Foley catheter.
Slash|Date|157|DOB: _%#MMDD1971#%_ _%#NAME#%_ _%#NAME#%_ is a 33-year-old female gravida 2, brought in for repeat cesarean section. This procedure was performed on _%#MM#%_/_%#DD2004#%_ and went without difficulty, with delivery of a living infant in good condition.
Slash|Separates two doses|118|There is no other known family history of breast, ovarian, or endometrial cancer. DISCHARGE MEDICATIONS: 1. Percocet 5/325 q. 4 hours p.r.n. 2. Synthroid 50 mcg p.o. q. day.
Slash|Over(blood pressure)|209|GU: Negative. MUSCULOSKELETAL: Negative. NEUROLOGIC: Negative. ENDOCRINE: Negative PSYCHIATRIC: Negative. PHYSICAL EXAMINATION: GENERAL: Pleasant female in no apparent distress. VITAL SIGNS: Blood pressure 137/83, pulse of 86, respiratory rate 18, temperature 98.7. She is 99% on room air.
Slash|Over(blood pressure)|319|5. Insomnia. 6. Hypercholesterolemia. SOCIAL HISTORY: The patient quit smoking cigarettes approximately 5 years ago, she is a nondrinker, and denies using any street drugs. PHYSICAL EXAMINATION VITAL SIGNS: On admission, vital signs were as follows: Temperature 97.8 degrees Fahrenheit, pulse of 105, blood pressure 105/65, respiratory rate of 24, and O2 saturation of 97% on room air.
Slash|Date|169|Her hemoglobin was 9.5. Her iron was 42. B12 and folic acid were normal. She was stabilized medically and transferred to the Residential Lodging Plus Program on _%#MM#%_/_%#DD2007#%_. She was to take her admission medication of Prozac 10 mg daily and also take ferrous sulfate 325 mg daily.
Slash|Either meaning|119|6. A left frontal shunt catheter. 7. A right parietal occipital subdural hematoma. HOSPITAL COURSE: The patient was DNR/DNI at the time of admission. The patient was admitted to unit 4D for observation and blood pressure control.
Slash|Date|278|1. Viral meningitis. 2. Severe headache secondary to problem #1. Key imaging and procedures performed during this hospital stay: CT of the head without contrast on _%#MM#%_ _%#DD#%_. Impression - no acute intracranial pathology. ADMISSION HISTORY: Please see the H&P on _%#MM#%_/_%#DD2007#%_ for complete details. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ was seen in the ER for a severe headache.
Slash|Divided by|146|The ABDOMEN is gravid with a fundal height of 39 cm. The fetus is vertex by Leopold's position with an estimated fetal weight of approximately 8-1/2 pounds. The EXTREMITIES are nontender with 2+ pitting lower extremity edema, 2+ deep tendon reflexes bilaterally with no clonus.
Slash|Date|156|There was no evidence of an abscess. DISPOSITION: The patient is to be discharged to home. She will follow up at the Parker Hughes Cancer Center on _%#MM#%_/_%#DD2003#%_ as previously scheduled. DISCHARGE MEDICATIONS: 1. Ceftin 250 mg p.o. b.i.d. 2. Levaquin 750 mg p.o. q.d.
Slash|Date|13|DOB: _%#MM#%_/_%#DD1941#%_ REASON FOR ADMISSION: Bimalleolar fracture. This is a pleasant 62-year-old gentleman, overall had been very healthy, was out working in his yard today when he was moving some leaves stepped wrong and came down on his left ankle and felt a severe snap in his ankle.
Slash|Date|225|He had a PTCA showing a flow of bile to the small bowel, a choledochojejunostomy and had a percutaneous stent and drain placed. He had a follow-up HIDA scan, which showed no extravasation of bile, and subsequently on _%#MM#%_/_%#DD2003#%_, he was discharged to home in stable condition. He is to restart his pre-hospitalization medications. He is to take Percocet one to two tablets p.o. q. 4 h. p.r.n pain, cortisone 100 mg p.o. b.i.d.
Slash|Over(blood pressure)|142|PHYSICAL EXAMINATION: My examination reveals that he is alert in no apparent distress. V VITALS: He is afebrile. His blood pressure is now 128/60. HEENT: There is no scleral icterus or conjunctival changes. Ears and nose are grossly normal.
Slash|Separates two doses|100|DISCHARGE MEDICATIONS: 1. Macrodantin 50 mg feeding tube q. hours x7 days. 2. Carbidopa, levodopa 25/100 1 p.o. feeding tube t.i.d. 3. Lisinopril 20 mg feeding tube daily. 4. Ranitidine 150 mg feeding tube q.h.s. 5. Sertraline 25 mg feeding tube daily.
Slash|Per|332|2. Mild decrease in mental status. 3. Anorexia 4. Dehydration. SECONDARY DIAGNOSES: 1. Advanced dementia 2. Failure to thrive HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a _%#1914#%_ female who was brought in by her primary caretakers, her son and daughter in law, who have been taking care of her at home for the past 3 to 4 years 24/7 along with help from a neighbor. They stated that over the past 24 hours prior to admission she did not seem to be herself, was not awake as much and seemed to be drooling and leaning to the right side.
Slash|Over(blood pressure)|121|At the time of discharge her weight was 48.5 kilograms from an admission weight of 50.3 kilograms. Blood pressure was 120/64. DISCHARGE MEDICATIONS: 1. Fosamax 70 mg q.Monday. 2. Amiodarone 200 mg daily.
Slash|Separates two doses|76|3. Lipitor 20 daily. 4. Lopressor 50 q day. 5. Lasix 40 q day. 6. Novilog 70/30 15 units in the morning and the evening. 7. Prevacid 30 a day. 8. Aspirin 325 a day.
Slash|Over(blood pressure)|165|He has six brothers and sisters, none of whom have heart disease. His mother is alive and well in her eighties. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 159/99. Pulse 69. Respirations 16. He is afebrile. Oxygen saturations in the high-90s on room air.
Slash|Date|140|Postoperatively, the wound healed satisfactorily. She was treated with Lovenox prophylaxis. She was seen by physical therapy and on _%#MM#%_/_%#DD2005#%_ she was transferred to a transitional care unit. She will be seen in the office 2 weeks from the date of her surgery.
Slash|Date|233|4. Harvest right iliac crest bone graft. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is 77-year-old man who was admitted on the day of the above procedure. Postoperatively he did well without complications. Hemoglobin was 10.6 on _%#MM#%_/_%#DD2006#%_. At the time of discharge the patient's preop pain was gone.
Slash|Either meaning|90|5. Miconazole powder 2% topically on the left breast b.i.d. 6. Lactulose 15 mL p.o. b.i.d./p.r.n. 7. Senna-S 2 tablets p.o. daily. 8. Protonix 40 mg p.o. b.i.d.
Slash|Date|156|Taper of her prednisone with some recurrence of her symptoms. The video-assisted thoracoscopy was indicated for further diagnosis. This was done on _%#MM#%_/_%#DD2006#%_. Postoperative course was uneventful. The final pathology showed a chronic bronchiolitis with fibrosis and mild patchy cellular interstitial pneumonia.
Slash|Over(blood pressure)|148|She is alert and oriented in time, place and person. VITAL SIGNS: Temperature 96.8 degrees Fahrenheit, pulse 62, respirations 16, blood pressure 143/53, oxygen saturation is 97% on room air. HEENT: Unremarkable. NECK: Supple. LUNGS: Clear to auscultation bilaterally. CARDIAC: Regular rate and rhythm with a normal S1 and S2, no S3, no S4, no murmurs, rubs or gallops.
Slash|Separates two doses|83|13. Maxzide 75/50 mg 1 tablet daily. 14. Stelazine 1 mg twice daily. 15. Percocet 5/325 mg 1 tablet every 3 hours as needed. The patient is to be discharged to a nursing home for further rehabilitation.
Slash|Over(blood pressure)|184|No tobacco, no alcohol, no IV drug use. REVIEW OF SYSTEMS: Ten organ systems were checked and were all negative. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 97.1, blood pressure 126/67, heart rate of 79, respiratory rate 16, 96% saturation on two liter nasal cannula.
Slash|Over(blood pressure)|153|The rest of the complete review of systems is either negative or in the History of Present Illness. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 145/90. Respirations 16. Pulse about 75 and when he is quiet it drops down to the high-60s.
Slash|Date|139|Gavage feedings were started on _%#MMDD2007#%_, consisting of expressed breastmilk and Enfamil Lipil, which she tolerated well. On _%#MM#%_/_%#DD2007#%_, her ability to suck and swallow was evaluated by speech.
Slash|Date|187|She will receive 500 mg of Levaquin p.o. daily and we will follow her blood cultures and urine cultures, which are pending at this time. She will follow up with Dr. _%#NAME#%_ on _%#MM#%_/_%#DD2007#%_ at her previously scheduled appointment.
Slash|Over(blood pressure)|191|FAMILY HISTORY: Multiple siblings with CF. REVIEW OF SYSTEMS: A 12-point review was negative except as mentioned in HPI. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 97.7, blood pressure 97/56, pulse 80, respiratory rate 22, oxygen saturation 92% on 2 liters per minute by nasal cannula, weight 41 kg.
Slash|Date|240|1. Depression. 2. Gastroesophageal reflux disease. HOSPITAL COURSE: Please see consults on FCIS for events leading up to the patient's hospitalization. The patient was diagnosed with acute cholecystitis and had a cholecystectomy on _%#MM#%_/_%#DD2006#%_ by Dr. _%#NAME#%_. The patient tolerated the procedure without complications. The patient remained medically stable after his procedure in regards to seizure history.
Slash|Date|77|2. Discharge hemoglobin is 9.2. 3. Surgery done by Dr. _%#NAME#%_ on _%#MM#%_/_%#DD2007#%_. Patient had nailing for a left intratrochanteric fracture.
Slash|Over(blood pressure)|240|GENITOURINARY: Negative. The rest of the 10-point review of systems was completely negative. PHYSICAL EXAMINATION: VITAL SIGNS: On initial presentation to the ER, the patient had an oxygen saturation in the 70s, with a blood pressure of 217/99, pulse 95, respirations 30, temperature 98, 02 saturation was in the 79% on room air.
Slash|Either meaning|79|I will hold off on IV fluids. I will hold her Lasix. 7. Code status: She is DNR/DNI and this was discussed with her.
Slash|Either meaning|127|5. Code status. I discussed this in depth with the patient. She states she does have an advanced directive and she requests DNR/DNI. We will write an order to this effect.
Slash|Date|318|5. Ultram. HOSPITAL COURSE: Mr. _%#NAME#%_ _%#NAME#%_ is a 35-year-old gentleman who presented on _%#MMDD2007#%_ with bright red blood per rectum and two syncopal episodes associated with the passing of bright red blood per rectum. Please see admission history and physical examination dictated by myself from _%#MM#%_/_%#DD2007#%_ for details of his presenting complaint. He had initially begun on Coumadin approximately 1 week prior to hospital admission for a progressive greater saphenous vein superficial thrombophlebitis so on presentation, he was noted to have an elevated INR of 2.6. This was followed up with a chromogenic factor X which did confirm that this was accurate.
Slash|Separates two doses|176|DISCHARGE MEDICATIONS: 1. Augmentin 875 mg p.o. b.i.d. Blood cultures were obtained prior to discharge and will be obtained in follow-up once off his antibiotics. 2. Insulin 70/30, 30 units b.i.d. 3. Norvasc 5 mg a day. 4. Prednisone 5 mg a day.
Slash|Over(blood pressure)|195|She had no pain with full range of motion in all major joints. Abdomen was benign. At the time of discharge, vital signs: Temperature 98.5, pulse 70, respiratory rate 16, blood pressure 93 to 108/50, O2 sat 98% on room air. PHYSICAL EXAMINATION: General, patient alert, oriented, pleasant, appropriate, increased range of motion at the neck though still limited, full range of motion at the shoulders, knees and ankles without pain.
Slash|Over(blood pressure)|127|She was on tamoxifen, and now is on Femara. ALLERGIES: Penicillin, Cipro. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 115/70, pulse 62, respirations 18, temperature 97.7, weight 144.
Slash|Over(blood pressure)|82|T current is 95.0. Heart rate 75. Respiratory rate 16. Blood pressure 114/83 to 82/51. She is saturating 90% on room air. In general, she is in mild distress secondary to her pain.
Slash|Separates two doses|136|She should call for a temperature greater than 100.4. She should call for heavy vaginal bleeding. DISCHARGE MEDICATIONS: 1. Percocet 325/5 mg 1 to 2 tablets p.o. q.4-6 h. p.r.n. pain. 2. Ibuprofen 800 mg 1 tablet p.o. q.8 h.
Slash|Divided by|114|DOB: FINAL DIAGNOSES 1. Transitional apnea, resolved. 2. Term male. 3. Sepsis ruled out. The baby was born at 38-6/7 weeks' gestation and had Nubain 20 minutes prior to delivery and had apnea noted in the Delivery Room.
Slash|Date|181|PROCEDURES: Blood transfusion 2 units. IMAGING STUDIES: Chest x-ray on admission shows COPD, no acute findings. No interval change from _%#MMDD2003#%_. Followup chest x-ray _%#MM#%_/_%#DD2007#%_ shows hyperinflation, no focal infiltrates. Calcified aorta. HOSPITAL COURSE: 1. COPD exacerbation. The patient is a 73-year-old woman with a history of COPD without requirements for oxygen who presented with 3 weeks of shortness of breath.
Slash|Of|325|During her hospital course, the patient participated in group sessions which provided an increased sense of coping skills as well as an outlet to express depressive thoughts and suicidal tendencies. During the hospital stay, the patient's symptoms progressively subsided and mood increased to discharge today of a rating of 9/10 being the highest. The patient was on a trial dose of Celexa 20 mg which caused GI discomfort which was discontinued.
Slash|Date|185|CAT scan showed no significant change in his dissection. However, he was found to have a nonfunctioning right kidney. Patient underwent a right nephrectomy by Dr. _%#NAME#%_ on _%#MM#%_/_%#DD2002#%_. His postoperative course was uneventful and he made a good recovery.
Slash|Of|286|Dear Dr. _%#NAME#%_: It is with deep regret that I am writing to inform you that your patient, _%#NAME#%_ _%#NAME#%_, died tonight at Fairview University Medical Center in _%#CITY#%_. As you know, _%#NAME#%_ was an 8-year-old girl with Fanconi anemia who underwent T cell depleted HLA 6/6 matched unrelated donor marrow transplant back in _%#MM#%_ of 2001.
Slash|Date|149|Problem #6: Hypertension. Antihypertensive regimen was adjusted with an increased dose of beta-blocker. Problem #7: 10-beat run of V-tach on _%#MM#%_/_%#DD2002#%_ in the early morning. Mr. _%#NAME#%_ had an asymptomatic 10-beat run of V-tach. I informed the patient's cardiologist.
Slash|Divided by|129|PELVIC: 4 cm dilated. NEUROLOGICAL: Reflexes 1-2+. No focal neurological findings. IMPRESSION: Intrauterine pregnancy at 38 and 6/7ths weeks in labor. Previous Cesarean section times two. Desire for tubal ligation. Risks, benefits and side effects discussed.
Slash|Date|208|She now presents for elective surgery. HOSPITAL COURSE: The patient had a laparoscopic assisted sigmoid resection on the date of admission. She was advanced up to a low residue diet and discharged on _%#MM#%_/_%#DD2007#%_ in good condition. The wounds looked excellent. The pathology report revealed pneumatosis coli but no sign of malignancy.
Slash|Date|148|Followup with physician was arranged at the Veterans Administration Hospital Primary Care Clinic. The appointment is scheduled for Tuesday, _%#MM#%_/_%#DD2007#%_ at 10:30 am. It was our pleasure to be involved in Mr. _%#NAME#%_'s care.
Slash|Date|323|SPECIFIC DISCHARGE MEDICATIONS: 1. Neurontin 3 pills p.o. b.i.d. which is his outpatient medication. 2. Tegretol-XR taper recommended as follows: 200 mg p.o. b.i.d. between _%#MMDD2007#%_ and _%#MMDD2007#%_ then 100 mg p.o. b.i.d. from _%#MMDD2007#%_ to _%#MMDD2007#%_ then 100 mg p.o. daily from _%#MMDD2007#%_ to _%#MM#%_/_%#DD2007#%_, then discontinue. 3. Valium 5 mg p.o. q.6h. p.r.n. for pain, of which 30 pills are dispensed with 1 refill.
Slash|Separates two doses|81|5. Multivitamin. 6. Restoril p.r.n. h.s. 7. Tylenol p.r.n. 8. Calcium with D 2000/200 b.i.d. 9. Aspirin 81 mg daily.
Slash|Date|123|FINAL This is a 31-year-old who underwent a repeat low-transverse cesarean section and bilateral tubal ligation on _%#MM#%_/_%#DD2006#%_, at Fairview Ridges Hospital. There were no complications with the surgery. Estimated blood loss was 500 cc.
Slash|Date|292|He has had a complicated post-injury postop course with esophageal perforation, development of esophageal abscess and now status post definitive repair of the esophageal perforation by microvascular surgery. With regards to his spinal cord injury, the hardware has been removed as of _%#MM#%_/_%#DD2007#%_ by Neurosurgery. This patient was previously listed as a C4-5 spinal cord injury patient.
Slash|Date|13|DOB: _%#MM#%_/_%#DD1957#%_ ADMISSION DIAGNOSIS: Abdominal pain. Partial bowel obstruction. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 45-year-old male, who awoke from sleep with diffuse abdominal pain radiating through to his back.
Slash|Over(blood pressure)|226|Her daughter had to help her. VITAL SIGNS: Her blood pressures have been relatively low the whole time she has been here. We did not check orthostatics. Currently she is 112/60, on presentation in the emergency room she was 82/63. I do not have a paramedic report, so I do not know what it was at the scene.
Slash|Date|181|2. History of hypertension, possibly represent hypertensive nephrosclerosis. 3. Peripheral vascular disease. SUGGESTIONS: 1. Rehydrate. 2. Permanent dual chamber pacemaker, _%#MM#%_/_%#DD2007#%_, for sick sinus syndrome and pauses. 3. Okay to resume beta blocker after the pacemaker has been placed.
Slash|Date|457|She states that it really has not worked despite going up doubling the dose and things like that, there has been no relief, so it seems as though that is probably not going to be an her future, I would not recommend it be in her future. She currently states she is taking 60 mg a day at the increments of 3 B.i.d. and the _%#CITY#%_ _%#CITY#%_, South Dakota pharmacy, _%#CITY#%_ _%#CITY#%_ pharmacy which is the last one that she had worked with in _%#MM#%_/2007, states that she is taking methadone 10 mg 2 tablets b.i.d. So it seems reasonable to go back down to that dose of _%#MM#%_ and see how she does.
Slash|Either meaning|91|2. Decision on surgery per orthopedics. 3. Antibiotics per Dr. _%#NAME#%_. 4. Follow up lab/cultures. 5. DuoNebs p.r.n. 6. Pain Management Service consultation. 7. Resume therapeutic anticoagulation with subcu Lovenox until INR is therapeutic on Coumadin.
Slash|Date|256|In the right arm, he has 5/5 strength at the shoulders, biceps, and wrist flexion. Triceps and wrist extension are 2/5. ASSESSMENT/RECOMMENDATIONS: This is a 28-year-old male who has had a complicated medical course since his spinal cord injury in _%#MM#%_/2006. he was previously classified as C7 ASIA B, but my exam today is moer consistent with a C6 ASIA B SCI.
Slash|Date|179|Neurologic: No facial asymmetry. No lateralizing extremity weakness. Romberg negative. Cerebellar function intact. There is no tremor or rigidity. LABORATORY DATA: Lab data from 4/26 includes a white count of 4400, hemoglobin 12.5, MCV 80, platelet count 284,000.
Slash|Date|115|She has had at least 3 prior psychiatric hospitalizations, beginning in 1989 and most recently in 1995. On _%#MM#%_/_%#DD2004#%_ she was admitted on a 72-hour hold after being brought to the emergency room with paranoid symptoms.
Slash|Per|190|He should continue on his regular oral methadone does of 115 mg per day, single dose. 2. He should be started on intravenous morphine as an analgesic for his acute postoperative pain at 4 mg/hr basal rate with PCA bumps of 2 mg every 10 minutes.
Slash|Separates two doses|122|4. Synthroid 137 mcg PO daily. 5. Celexa 20 mg PO daily. 6. Atenolol 50 mg PO daily. 7. Triamterene hydrochlorothiazide 25/37.5 1 tablet PO daily. 8. K-Dur 20 mEq PO daily.
Slash|Date|217|DISCHARGE INSTRUCTIONS: 1. Diet general. Activity as tolerated. 2. The patient should report back with increased pain or temperature greater than 100.4. 3. The patient was given a work excuse for the dates of _%#MM#%_/_%#DD2003#%_ through _%#MMDD2003#%_.
Slash|Over(blood pressure)|111|No neurologic deficits. The rest of the review of systems is negative. PHYSICAL EXAMINATION: Blood pressure 148/97, pulse 85, respirations 12, saturation 98 percent.
Slash|Date|116|8. GCSF 170 mcg subcutaneously daily to be taken until counts recover. FOLLOWUP: The patient is followup on _%#MM#%_/_%#DD2008#%_ for admission for cycle 2 of chemotherapy including ifosfamide and etoposide.
Slash|Either meaning|332|DISPOSITION: The patient had requested that the patient did not want any further treatment for her large-cell lymphoma and wanted to be treated only symptomatically without any further chemotherapy. She was discharged to home on home hospice. This was discussed with the attending on call as well as the patient's primary hematology/oncology attending, Dr. _%#NAME#%_ _%#NAME#%_. DISCHARGE MEDICATIONS: 1. Synthroid 0.112 mg p.o. q.d. 2. Premarin 1.25 mg p.o. q.d.
Slash|Of|187|DEXA scan in _%#MM#%_ 2005, was within normal limits. PHYSICAL EXAMINATION VITAL SIGNS: Stable and the patient is afebrile. NEUROLOGIC: The patient is alert and oriented x3. Strength is 5/5 throughout. Reflexes are 2+ bilaterally. The patient does have decreased proprioception in the right lower extremity.
Slash|Date|165|Therefore, he was transferred to the University of Minnesota Medical Center for further evaluation. For detailed H&P, please see the note in the chart dated _%#MM#%_/_%#DD2007#%_ HOSPITAL COURSE: PROBLEM #1: Atrial flutter. As mentioned above, the patient has previous history of proximal atrial flutter, which resolved on its own.
Slash|Over(blood pressure)|206|Had persistence of the dysuria and frequent urination. The patient was brought to the emergency room by his wife early evening and was found to have a temperature of 100.1 degrees orally. Blood pressure 130/87. Pulse 87. Respirations 18. O2 saturation at 99%. The patient felt quite lethargic in the emergency room.
Slash|Of|114|Grossly, no focal deficit. ASSESSMENT AND PLAN: 1. Abdominal pain, etiology unclear. Decreasing now from 8/10 to 3/10. The patient had a small bowel movement today with no blood.
Slash|Over(blood pressure)|149|She denies headache. She denies any other specific symptoms currently. PHYSICAL EXAMINATION: On exam now she is resting and her blood pressure is 146/58 with a pulse of 86. She is afebrile. She is alert. She is oriented to Fairview Hospital in _%#CITY#%_.
Slash|Over(blood pressure)|115|PHYSICAL EXAMINATION: GENERAL: At this point this is a very comfortable Asian male. VITAL SIGNS: Blood pressure 160/80, pulse 60 and regular, O2 sats are now 99% on 2 liters nasal cannula.
Slash|Date|177|HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a pleasant, _%#1914#%_ female who lives in a Memory Center with a history of significant Alzheimer's dementia. She fell on _%#MM#%_/_%#DD2007#%_ and was taken to the Emergency Department at Fairview Ridges Hospital for evaluation and treatment.
Slash|Date|221|She did undergo successful pericardiocentesis on _%#MMDD2005#%_ after being turned down for a pericardial window due to increased perceived risk. She had a few doses of Coumadin several days ago on _%#MMDD#%_ and _%#MM#%_/_%#DD2005#%_. She probably is still seeing the effects of that with an INR of 5.6 which prevents us from doing anything urgently.
Slash|Divided by|103|10. Senna 8.6 mg q.8 p.m. 11. Seroquel 12.5 mg q.8 p.m. 12. Aspirin 81 mg q.a.m. 13. Senna met 25/100 1/2-tab q.8 a.m., q. noon. and q.4 p.m. 14. Jevity 100 mL/hour for 13 hours as Jevity 1.2-calorie solution.
Slash|Of|136|These are not infected. NEUROLOGY: Alert and oriented. Cranial nerves II-XII grossly intact. Sensation intact to light touch. Strength 5/5 bilaterally. LABORATORY DATA: The patient had an elevated GGT of 706.
Slash|Date|220|Has had alcohol withdrawal. No symptoms presently. Denies knowledge of DTs, withdrawal-related seizures, alcohol-related liver disease, pancreatitis or upper GI blood loss. 4. History of upper extremity cat bite _%#MM#%_/2006 for which patient hospitalized Fairview Southdale Hospital for intravenous antibiotics.
Slash|Over(blood pressure)|267|GASTROINTESTINAL: No nausea, vomiting, diarrhea, constipation. GENITOURINARY: No dysuria, hematuria or increased frequency of urination. MUSCULOSKELETAL: No joint pain SKIN: No bleeding or bruising HEMATOLYMPHATIC: Negative PHYSICAL EXAMINATION: Blood pressure is 156/95, pulse is 77, respiration is 20, oxygen saturation is 97% on room air.
Slash|Date|183|Her creatinine now has risen to 1.48 with a BUN of 32 and potassium 4.7, mildly elevated, therefore her ACE inhibitor will be on hold. She should have follow-up creatinine on _%#MM#%_/_%#DD#%_ and if normalized, may restart the ACE inhibitor.
Slash|Over(blood pressure)|233|FAMILY HISTORY: Noncontributory. REVIEW OF SYSTEMS: Negative for cough, fever, purulent sputum or respiratory complaints before he fell today. PHYSICAL EXAMINATION: VITAL SIGNS: Afebrile, temperature 37.7, pulse 95, blood pressure 91/49, respiratory rate 12 on pressure regulated volume control of 12, with 550 cc tidal volumes and 60% FiO2 with PEEP of 5.
Slash|Either meaning|82|HIS DISCHARGE MEDICATIONS WERE AS FOLLOWS: 1. Glucovance 1.25/2.5 t.i.d. 2. Diovan/HCT 160/12.5 two tablets daily. 3. KCl 10 mEq b.i.d. 4. Lipitor 20 mg daily. 5. Toprol XL 100 mg daily. 6. Catapres 0.1 mg b.i.d.
Slash|Date|182|She has had problems with middle lobe atelectasis back in 1999, but more recently has a history of right upper lobe bronchiectasis. She has had a bronchoscopy in the past on _%#MM#%_/_%#DD1999#%_, as well as in 2003 by Dr. _%#NAME#%_ _%#NAME#%_ and was found to have persistent MAI infection.
Slash|Date|183|FINAL HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 61-year-old female who had undergone a vaginal hysterectomy, rectocele, cystocele and urethral sling procedure on _%#MM#%_/_%#DD2007#%_ with Dr. _%#NAME#%_ and Dr. _%#NAME#%_ _%#NAME#%_. Postoperatively, the patient did well.
Slash|Respectively|96|3. Inderal caused bradycardia. MEDICATIONS: 1. Glipizide 10 mg twice a day. 2. Micardis/HCTZ, 80/12.5 once daily. 3. Simvastatin 40 mg a day. 4. Actos 15 mg each day at bedtime.
Slash|Date|264|She subsequently developed renal failure in 1998, and received a transplant from a living-related donor kidney. She has been on CellCept, and is currently on Prograf 30 mg b.i.d., prednisone 7.5 mg q.d. She had one episodes of graft versus host disease in _%#MM#%_/00, and none since. Her creatinine is currently in the range of 1.2. She also has history of hypertension, for which she is currently being treated with Norvasc 5 mg q.d., metoprolol 50 mg b.i.d. Her other medications include prenatal vitamins and Bactrim, as PCP prophylaxis.
Slash|Over(blood pressure)|238|She does not remember how she sustained them. PHYSICAL EXAMINATION: GENERAL: The patient is a well- nourished, well-hydrated female in no acute distress. VITAL SIGNS: Temperature afebrile, pulse 91, respiratory rate 16, blood pressure 112/91. HEAD: Normocephalic and atraumatic. EYES: Pupils are equal and round.
Slash|Date|13|DOB: _%#MM#%_/_%#DD1917#%_ REASON FOR CONSULTATION: I was asked by Dr. _%#NAME#%_ to provide antibiotic recommendations. IMPRESSION: 1) An 85-year-old male admitted with acute swelling and pain in the right knee.
Slash|Either meaning|427|Hepatitis B surface antibody and antigen negative. HCV RNA quantitative: 8,270,000 from _%#MMDD#%_. LFTs: Albumin is 4.6, protein 8.9, AST 49, ALT 67, alkaline phosphatase 71, total bilirubin 0.8. ASSESSMENT AND PLAN: The patient is a 29-year-old Egyptian male admitted for Seroquel overdose and depression, found to be hepatitis C positive on this admission with a significant past history for HIV, methamphetamine IV drug use/dependence. Hepatitis C Viral Infection: The patient with a quantitative RNA of 8,270,000 HCV and genotype is currently pending.
Slash|Divided by|278|_%#NAME#%_ _%#NAME#%_, MD Trinity Medical Center _%#STREET#%_ _%#STREET#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#ADDRESS#%_ _%#CITY#%_, North Dakota _%#58000#%_ Dear Dr. _%#NAME#%_: It was a pleasure meeting with your patient, _%#NAME#%_ _%#NAME#%_, on _%#MMDD2004#%_ at 18 weeks and 4/7 days gestation for pregnancy complicated by maternal Kell antibody sensitization.
Slash|Separates two doses|164|Smoking cessation was an excellent idea. The cat is no longer in the house. Other triggers should be removed where identified. Her Advair should be increased to 500/50 strength one p.o. b.i.d. at discharge. I recommend adding Spiriva one inhalation daily. This will require discontinuing Atrovent.
Slash|Date|237|She is guaiac-positive this morning on her stools. I suspect that she may have either a slow upper GI or lower GI source for her anemia. She does have a history of chronic anemia, but this is a change in her last hemoglobin from _%#MM#%_/_%#DD2004#%_. PLAN: 1. Left pulmonary artery PE: At this time we will continue her on her heparin drip and hold her Coumadin until after further workup for her anemia, weight loss, and chronic lung infection.
Slash|Over(blood pressure)|149|PHYSICAL EXAMINATION: GENERAL: Female in no acute distress. VITAL SIGNS: Standing blood pressure 97/68, pulse 131, per FCIS. Lying blood pressure 107/73 with a pulse of 113. Currently, the pulse is approximately 100. HEENT: Negative. NECK: No adenopathy, no thyromegaly.
Slash|Date|368|No motor ability, no deep tendon reflexes in the lower extremities. IMAGING STUDIES: MRI of brain and spine is cheduled. LABORATORY DATA: White blood cell count 2.4, hemoglobin 9.7, platelet count 20,000, creatinine 0.35, total bilirubin 0.9. PATHOLOGY: USR07-912(_%#MMDD2005#%_) CSF - flow cytometry positive for involvement by pre-B lymphoblastic leukemia; (_%#MM#%_/_%#DD2007#%_) CSF - numerous leukemic blasts. UHH07-2459 (_%#MMDD2007#%_) No morphologic evidence of leukemia. IMPRESSION: ALL in presumed third remission.
Slash|Per|225|He now has what appears to be myoclonic jerking. Possibility of underlying seizure activity cannot be ruled out. Consequently, would recommend proceeding with an EEG. In addition, I will empirically start him on Cerebyx 18 mg/kg IV load and starting tomorrow 100 mg q.8h. Further management depends on outcome of the above measures.
Slash|Of|147|Soft palate movements were symmetrical on phonation. Positive gag. Motor examination: The tone was within normal limits. No drifting. Strength is 5/5 all over except that there is decreased dexterity on the left hand.
Slash|Date|142|He has use opium, narcotics and inhalents in the past. He also describes using alcohol approximately every three weeks, most recently _%#MM#%_/_%#DD2002#%_. He does smoke one-half pack of cigarettes per day. PAST MEDICAL HISTORY: Unremarkable for chronic medical concerns.
Slash|Over(blood pressure)|174|FAMILY HISTORY: Her father had strokes. PHYSICAL EXAMINATION: GENERAL: General appearance is normal. Mental status and language are normal. VITAL SIGNS: Blood pressure of 111/58, heart rate is 66, temperature 96.7, respiratory rate 16, her balance appears steady.
Slash|Over(blood pressure)|123|His blood pressure since admission has been running in the 150 to 100/60 to 40 range. It presently is on the low side at 98/46. His pulse rate is 60 and regular. His mental status and cranial nerve exams are otherwise normal aside from the ptosis noted above.
Slash|Date|178|REASON FOR CONSULTATION: Management of plasmapheresis in a patient with Guillan-Barre syndrome. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 30-year-old who on _%#MM#%_/_%#DD2004#%_ developed facial numbness, fever and fatigue. She was hospitalized at Fairview Southdale Hospital and underwent extensive evaluation and was considered to have Lyme disease.
Slash|Over(blood pressure)|160|PHYSICAL EXAMINATION: GENERAL: The patient is an alert white male, appearing his stated age and in no acute distress. VITAL SIGNS: Current blood pressure is 136/74, pulse 83 and regular, respiratory rate 18 and unlabored.
Slash|Date|356|REASON FOR CONSULTATION: Choking and aspiration. HISTORY OF PRESENT ILLNESS: The patient is a 55-year-old male resident of a group home with a past medical history significant for LEOPARD syndrome admitted to Fairview-University Medical Center with progressive spastic paraparesis and confined to a wheelchair secondary to weakness. The patient on _%#MM#%_/_%#DD2002#%_ underwent an anterior C4-5 diskectomy and fusion secondary to the finding of a large C4-5 central disk herniation with spinal cord compression.
Slash|Date|340|PRELIMINARY To _%#NAME#%_ _%#NAME#%_, MD. Fairview _%#CITY#%_ Clinic, _%#STREET#%_ _%#STREET#%_ _%#STREET#%_, _%#CITY#%_, MN _%#55000#%_. Dear Dr. _%#NAME#%_: This letter will summarize the discussion that took place with your patient _%#NAME#%_ _%#NAME#%_ and her family in the Maternal Fetal Medicine Center at Fairview Ridges on _%#MM#%_/_%#DD2006#%_. As you know, she was here for genetic counseling because of the finding on your office's ultrasound of left renal pyelectasis/hydronephrosis.
Slash|Over(blood pressure)|162|PHYSICAL EXAMINATION: GENERAL: Patient is a pleasant alert and oriented woman in no distress. She is sitting up in a chair eating. VITAL SIGNS: Blood pressure 101/66, heart rate 70 and regular, respiratory rate is 12 and unlabored.
Slash|Over(blood pressure)|224|PHYSICAL EXAMINATION: She is an alert, oriented times three _%#1914#%_ female lying on the cart in pain and afraid to move her left leg. VITAL SIGNS: Her pulse is 98 per minute, respirations 18 per minute, blood pressure 140/80. LOWER EXTREMITIES: In general, she is holding her left lower extremity, slightly shortened and externally rotated.
Slash|Date|75|He has been on Dilantin. His last visit with Dr. _%#NAME#%_ was in _%#MM#%_/2006 at which point he was clinically stable. He was on Dilantin 360 mg daily, as well as folic acid and calcium.
Slash|Over(blood pressure)|181|He describes quitting alcohol in _%#MM#%_ 2000. REVIEW OF SYSTEMS: See HPI. ALLERGIES: 1. Pentasa. 2. Asacol. PHYSICAL EXAMINATION: VITAL SIGNS: The patient's blood pressure was 106/62, pulse 77, respiratory rate 16, pulse oximetry 98% on room air, temperature 36.5. GENERAL: He is a middle-aged white male in no apparent distress who is alert and cooperative.
Slash|Date|166|Current creatinine is 0.96. Electrolytes are essentially within normal limits, except for elevated blood glucose. White count is slightly elevated at 14.3 on _%#MM#%_/_%#DD2005#%_. Hemoglobin is between 9 and 10. There is no other concerning laboratory data.
Slash|Over(blood pressure)|211|MEDICATIONS: 1. Evista. 2. Omeprazole. 3. Micardis. PHYSICAL EXAMINATION: GENERAL: At the time of exam the patient is in no distress. She is complaining of diffuse abdominal pain. VITAL SIGNS: Blood pressure 150/70, pulse 80. LUNGS: Clear. CARDIOVASCULAR: Regular rhythm without murmur. ABDOMEN: Distended with a right lower quadrant incision as well as a right periumbilical incision, both well-healed.
Slash|Date|214|Bronchoscopy with transbronchial biopsy were positive for nonsmall cell carcinoma of the left lower lobe lung. Video-assisted thoracoscopy was indicated for further staging and palliation. This was done on _%#MM#%_/_%#DD2004#%_, and 3.3 liters of fluid was drained. The biopsies were positive for nonsmall cell carcinoma. His postoperative course was complicated with some atrial fibrillation that was treated medically.
Slash|Over(blood pressure)|115|She keeps forgetting why she is in the emergency room. PHYSICAL EXAMINATION: VITAL SIGNS: Her blood pressure is 140/76, her pulse is 104, respiratory rate is 18, temperature is 96.9. GENERAL: The patient is a frail elderly female who complains of chronic neck pain as well as her hip discomfort.
Slash|Of|105|Coordination: the patient has slight dysmetria bilaterally. Tone is within normal limits. Reflexes are 2+/4 in the upper extremities, and I/IV at the ankles and knees.
Slash|Over(blood pressure)|199|PSYCHIATRIC: No history of psychiatric disorder. HEMATOLOGIC/LYMPHATIC: No history of anemia or lymphadenopathy. PHYSICAL EXAM: VITAL SIGNS: Temperature is 37.2 here. Blood pressure has been 137- 178/80-96 overnight. He had some elevated blood pressures in the emergency room.
Slash|Date|200|4. Support with mechanical ventilation, steroids and antibiotics. Note pulmonary will be seeing him tomorrow. 5. His chemistries are bad enough that we may have to consider dialysis tomorrow, _%#MM#%_/_%#DD#%_. If it is in keeping with the patient's wishes, I note that his overall prognosis is very poor and that a comfort care hospice approach would be quite appropriate
Slash|Either meaning|191|Mood and affect appropriate. OUTCOME OF ASSESSMENT: Client was seen in the hospital and is a categorical vulnerable adult according to Minnesota statute. DSM-IV classification Axis I is 303.9/depression. Axis II: See medical records. Axis III: See medical records.
Slash|Date|331|LABORATORY DATA: Include a Creatinine initially of 1.9 which improved with hydration to 1.4, BUN 28-24, potassium 4.2, hemoglobin 12.6. Chest x-ray showed clear lungs and some atherosclerotic calcification within the thoracic aorta and a little bit of atelectasis or scarring at the left lung base. Electrocardiogram dated _%#MM#%_/_%#DD2007#%_ demonstrated normal sinus rhythm without abnormality except perhaps some minimal voltage criteria for left ventricular hypertrophy.
Slash|Date|201|MEDICATIONS: prenatal vitamins FAMILY HISTORY: Paternal grandmother with breast cancer, paternal grandfather with heart disease. Mom with hypertension. The patient delivered a female infant on _%#MM#%_/_%#DD2006#%_. PHYSICAL EXAMINATION: The patient's weight was 240, blood pressure was 138/80, hemoglobin was 12.3. HEART: Regular rate and rhythm.
Slash|Over(blood pressure)|168|She is a pleasant _%#1914#%_ woman. She is well- developed, well-nourished and in no acute distress. She is awake, alert, cogent. VITAL SIGNS: Blood pressure in the 160/100 range, pulse 100 and irregularly irregular. She is afebrile. HEART: Reveals an irregularly irregular rhythm with an early systolic murmur heard best at the base without radiation to the carotids.
Slash|Over(blood pressure)|269|The patient denies fevers, chills, cough, headache, chest pain, shortness of breath and abdominal pain. PHYSICAL EXAMINATION: GENERAL: Well-developed male in no apparent distress. VITAL SIGNS: Temperature 98.9, blood pressure sitting 104/52, blood pressure standing 118/64, pulse sitting 48, pulse standing 88, respiratory rate 14.
Slash|Date|354|He was very active and continued to participate in sports, but eventually he became aware of the mass in the anterior right neck which brought him to the _%#CITY#%_ _%#CITY#%_ Clinic where a chest x-ray and CT scan were obtained revealing a large anterior mediastinal and neck mass. He was referred to the Mayo Clinic and was first seen there on _%#MM#%_/_%#DD2004#%_. A biopsy was obtained revealing nodular sclerosing Hodgkin disease. At the time of presentation, he had no B symptoms and the rest of his staging included a CAT scan of the chest, abdomen and pelvis, but no PET scan.
Slash|Over(blood pressure)|183|She denies any hot or cold intolerance. She denies any peripheral or focal neurological complaints or headache or vision changes. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 132/60, pulse 72, respirations 16, temperature 95.4, sats normal on room air.
Slash|Either meaning|129|Abdomen soft. Assessment and Plan: Recurrent sarcoma. I recommend PET/CT to better assess the extent of metastatic cancer. If PET/CT is negative of lung nodules, I would consider abdominal XRT.
Slash|Over(blood pressure)|166|He denies significant alcoholic or other caffeinated intake. PHYSICAL EXAMINATION: The patient is awake, alert, cooperative. He is oriented x 3. Blood pressure is 145/86, pulse is 78, respirations 16. He is afebrile. Temperature is 97.9. His abdomen is soft without any hepatosplenomegaly, masses, tenderness, costovertebral angle tenderness, hernias, abnormal respiratory movements or sounds, abnormal kidneys or bladder, abnormal skin lesions, adenopathy or gynecomastia.
Slash|Date|107|HISTORY: This is a 73-year-old male who was recently found to have colon cancer on colonoscopy. On _%#MM#%_/_%#DD2003#%_ he underwent laparoscopic partial colon resection by Dr. _%#NAME#%_ with reanastomosis.
Slash|Date|207|He underwent percutaneous transluminal coronary angioplasty of his left anterior descending with a plan for review of his case for a decision how best to manage either with surgery or staged PCI. On _%#MM#%_/_%#DD2007#%_, he underwent coronary artery bypass grafting x 4 with a LIMA to the left anterior descending and saphenous vein graft to the first diagonal and first OM and a second saphenous vein graft to the posterior descending artery.
Slash|Over(blood pressure)|139|He does report occasional burning when urinating for the about the last one month. PHYSICAL EXAMINATION: Blood pressure at this time is 148/98, pulse 80, remainder of vital signs are stable and he is afebrile.
Slash|Divided by|203|No signs of compartment syndrome. Right lower extremity shortened rotated. SKIN: Skin without bruises or lesions. LYMPHATIC: Negative. PULSES: Pulses were intact and equal, although I would rate them 2-3/4. Very painful movement. Knees mild crepitus and effusions in both.
Slash|Per|108|His urine output is only now slightly higher than near-frank anuria. Most recent urine output is about 20-cc/hour. The patient's hypokalemia has been corrected. His hypoglycemia has been corrected.
Slash|Over(blood pressure)|211|The patient has no knowledge of prior colonic polyps or colonic neoplasm. Past surgical history: Cholecystectomy. FAMILY HISTORY: Will be reviewed. PHYSICAL EXAMINATION: VITAL SIGNS: Admission blood pressure 135/90, heart rate 90. The patient is afebrile. HEENT: The patient is somewhat pale.
Slash|Date|201|4. Lithium. 5. Risperdal. 6. Trazodone. 7. Synthroid. The patient should be taking 50 mcg p.o. q. day, but apparently was taken 100 mcg p.o. daily. Appears that her last dose was approximately _%#MM#%_/_%#DD2007#%_. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Is per documentation in FCIS.
Slash|Date|13|DOB: _%#MM#%_/_%#DD1960#%_ INDICATION: This is a 41-year-old who was well until Saturday. At that time, she was doing her taxes and then developed nausea and began throwing up.
Slash|Over(blood pressure)|161|On general examination her neck is supple. The carotid pulses are symmetric without bruits. The vital signs reveal that she is afebrile. The blood pressure is 86/52. The pulse is 48 beats per minute and regular. These vitals were taken at 4 o'clock in the morning.
Slash|Either meaning|122|PHYSICAL EXAMINATION: GENERAL: She is not in any acute distress. VITAL SIGNS: Stable. She is afebrile. HEAD: Normocephalic/atraumatic. EYES: EOMI. PERRL. Mouth is without thrush or exudate. No erythema or tonsillar enlargement.
Slash|Of|116|She has had no more nausea since being in the hospital. She has ranked her pain a 10/10 yesterday and today was an 8/10. REVIEW OF SYSTEMS: Otherwise is negative. PAST MEDICAL HISTORY: Significant for multiple myeloma, heart arrhythmias, appendectomy, knee surgery.
Slash|Date|160|An appointment was made at Minnesota Heart Clinic on Monday at the Coumadin Clinic at 3:00. The patient will see Dr. _%#NAME#%_ at 3:15 p.m. on Monday, _%#MM#%_/_%#DD2007#%_. He also has an appointment with _%#NAME#%_ _%#NAME#%_ on _%#MMDD2007#%_ for Coumadin education that will be at 1500.
Slash|Date|415|The headache as a big problem. He did receive some narcotic here in the Emergency Room and there is reluctance to send him out with narcotic at this point so he has in his mind a good treatment plan of going to the University get a second opinion, and coming back here to work with me on just starting to get the pain control. PAST MEDICAL HISTORY: Remarkable for mastoiditis, mastoidectomy on the right on _%#MM#%_/2006 and then pleurisy in the past, and he does not have any history of headaches.
Slash|Separates two doses|78|5. History of hyponatremia. MEDICATIONS: 1. Zanaflex 2 mg t.i.d. 2. Maxzide 75/50 one daily. 3. Trazodone 150 mg q.h.s. 4. ____________ 10 mg daily p.r.n. 5. Serzone 200 mg q.a.m. and 400 mg q.h.s. 6. Risperdal 1 mg b.i.d.
Slash|Of|265|His speech is significantly slowed, however when given time his responses are quite pertinent. HEART: Regular. LUNGS: Clear. ABDOMEN: Soft. EXTREMITIES: Without edema. MOTOR EXAM: Finds him to be somewhat apractic in his right upper extremity but he is at least a 4/5. His left upper extremity strength is within normal limits. Left lower extremity strength is within normal limits.
Slash|Over(blood pressure)|142|He has not noticed jaundice. He has had no arthritis. His review of systems is otherwise negative. PHYSICAL EXAMINATION: Blood pressure is 158/74, pulse 81. He is an ill-appearing gentleman, animated, pale. EYES show no scleral icterus.
Slash|Of|139|EXTREMITIES: No cyanosis, clubbing, or edema. NEUROLOGIC: Cranial nerves II-XII grossly intact. Sensation intact to light touch. Strength 5/5 bilaterally. Gait within normal limits. SKIN: Bruising on his right arm where the IV site was located.
Slash|Date|157|In addition, I have asked home health to follow up in this regard tomorrow. She has a regularly-scheduled appointment with Dr. _%#NAME#%_ on Friday, _%#MM#%_/_%#DD2003#%_ I have asked her to keep this appointment. They will address resolution of her symptoms at that time.
Slash|Date|13|DOB: _%#MM#%_/_%#DD1956#%_ CHIEF COMPLAINT: Left foot pain and swelling. HISTORY: Dr. _%#NAME#%_ has requested an orthopedic evaluation on Mr. _%#NAME#%_ _%#NAME#%_.
Slash|Over(blood pressure)|165|He had two vodkas last night. He resides in _%#NAME#%_ _%#NAME#%_. ALLERGIES: To penicillin. MEDICATIONS: None. PHYSICAL EXAMINATION: Temperature is afebrile, BP 136/86, heart rate 79, respirations 18, 100% sats on room air.
Slash|Date|226|3. Echocardiogram as part of her workup. 4. She will need telemetry to monitor the atrial flutter and any other pertinent cardiac evaluation per Dr. _%#NAME#%_/Quello Clinic, Ltd. 5. Dr. _%#NAME#%_ will assume care on _%#MM#%_/_%#DD2005#%_ for our service. 6. Glucose was elevated which will need to be monitored during the course of her stay to rule out new-onset diabetes.
Slash|Date|185|X-rays show a minimally displaced left distal radius fracture. There is pain in the left hip and left wrist, otherwise no pain has been noted. She fell at approximately 5:30 on _%#MM#%_/_%#DD2003#%_. The patient is on Coumadin. PAST MEDICAL HISTORY: Significant for hypertension, depression, history of osteopenia, history of ____, and a history of questionable GI bleed.
Slash|Date|258|She does have known peripheral vascular disease affecting her left internal carotid artery but this is a less than 70% stenosis and is asymptomatic so no further workup is indicated at this time. Hopefully, she was scheduled for surgery on Thursday, _%#MM#%_/_%#DD2007#%_. The patient understands the risks and benefits of surgery and agrees to proceed.
Slash|Date|181|The patient is currently on lisinopril and metoprolol which have controlled his blood pressure well. He is not on any cholesterol-lowering agents. His last cholesterol from _%#MM#%_/_%#DD2006#%_ showed a total cholesterol of 202, triglycerides 144, HDL 47 and LDL 127.
Slash|Over(blood pressure)|160|No icterus. Remainder of system review is unremarkable. PHYSICAL EXAMINATION: Pleasant elderly female in no acute distress. Temperature 96.8, blood pressure 144/78. HEENT: Normocephalic, atraumatic. Sclera anicteric. NECK: Supple, no JVD, lymphadenopathy, bruits or thyromegaly.
Slash|Date|122|Gallbladder was normal in size without any evidence of cholelithiasis. Bile duct is not dilated. HYDAscan done on _%#MM#%_/_%#DD2007#%_, showed a decreased gallbladder ejection fraction of 10% and otherwise was normal.
Slash|Either meaning|274|He previously had no other medical issues. He was admitted through the emergency room with left-sided weakness, and was diagnosed with a right putaminal hemorrhage secondary to his hypertension. No other bleeding symptoms. His left-sided weakness is improving. He had an MRA/MRI today which showed the hematoma, but was otherwise negative.
Slash|Over(blood pressure)|121|PHYSICAL EXAMINATION: GENERAL: Female, in no acute distress. VITAL SIGNS: Temperature 99.6. Pulse 137. Blood pressure 132/72. HEENT: Negative. No thyromegaly. LUNGS: Clear to auscultation bilaterally. CARDIOVASCULAR: Tachycardic, but regular rate.
Slash|Date|117|The patient is paralyzed from the waist down secondary to a spinal cord lesion. She has been paralyzed since _%#MM#%_/03. PAST MEDICAL HISTORY: Neurofibromatosis type 2. SURGICAL HISTORY: 1. Floor of mouth tumor removal _%#MM2004#%_.
Slash|Date|305|She did have a 24 hour EEG and after her evaluation Dr. _%#NAME#%_ felt that she most likely had nonepileptic events. However, she did have one EEG in which there was some question of seizure activity, and consequently, decision was made to maintain her on Dilantin. Her last visit with me was in _%#MM#%_/2007. Plan at that time was that if she remained symptom-free for 3-6 months, she could be tapered off Dilantin.
Slash|Over(blood pressure)|192|PHYSICAL EXAMINATION: GENERAL: The patient is a well- nourished, well-hydrated female in no acute distress. VITAL SIGNS: Temperature afebrile. Pulse 72. Respiratory rate 16. Blood pressure 100/80. HEENT: Head is normocephalic, atraumatic. Eyes pupils are equally round.
Slash|Date|102|There is no obvious lumbosacral plexus lesion on the left. MRI of the lumbosacral spine dated _%#MM#%_/_%#DD2006#%_ was also personally reviewed. There was good disk height preservation. There is some inhomogeneity of the marrow of the vertebral segments.
Slash|Date|154|Mother feels the baby does startle to noises and does fix and follow some visually. Some smiling is reported. The baby did have a CT head scan on _%#MM#%_/_%#DD2007#%_, and that was normal. Currently, the baby had surgery on _%#MMDD2007#%_ for increase in the esophageal pouch, and he was intubated but taken off muscle relaxants on _%#MMDD2007#%_ and began to be weaned from the ventilator.
Slash|Divided by|115|He has had no surgeries. MEDICATIONS: None. ALLERGIES: No known drug allergies. HABITS: The patient smokes 1 to 1-1/2 packs of cigarettes per day. He rarely drinks per his report, however, the chart notes that he uses alcohol 1 time per week to the point of intoxication.
Slash|Of|173|She is extremely hard of hearing. She is alert and oriented x3 with normal attention, concentration, language, long-term memory and fund of knowledge. Short-term memory is 1/3 words at 5 minutes but again this is difficult to assess because of the hearing loss.
Slash|Date|135|His consolidation was per the COG protocol. This ended in _%#MM2005#%_. Unfortunately, _%#NAME#%_ had a bone marrow relapse in _%#MM#%_/2006. He was re-induced with VP16 and mitoxantrone. He was able to achieve a remission.
Slash|Over(blood pressure)|125|She is alert and oriented. Temperature was 96.4 degrees F. The pulse rate was 83 beats per minute. The blood pressure was 113/62. EENT: No abnormalities. The thyroid was not enlarged. She did not have a skin rash.
Slash|Of|153|The packing was removed. Upon review of the packing, it was negative for gross purulence or signs or symptoms of infection. Lower extremity strength is 0/5 bilateral. Sensation none in bilateral lower extremities. Dorsalis pedis pulse 1+.
Slash|Of|141|NEUROLOGIC: The patient was alert and oriented. Cranial nerves II through VII are grossly intact. Sensation intact to light touch. Strength 5/5 bilaterally. LABORATORY DATA: Comprehensive metabolic panel, hemogram, platelet count, urine drug screen, TSH, and GGT, which were all within normal limits.
Slash|Divided by|138|This is based on clinical features of her presentation as well as MRI findings of atrophy particularly in her right hemisphere. An EEG 2-1/2 years ago revealed focal slowing in the right anterior temporal region.
Slash|Per|117|His father died during World War I. PHYSICAL EXAMINATION: GENERAL: The patient appears ill. VITAL SIGNS: Pulse is 120/minute, blood pressure 120/70. He is afebrile. O2 saturation is 95% on O2 by nasal cannula.
Slash|Date|426|CHIEF COMPLAINT: Weakness and palpitations. HISTORY OF PRESENT ILLNESS: This is a 69-year-old white woman who underwent a left inguinal femoral lymph node dissection with left radical hemivulvectomy for mass found to be angiomyofibroblastoma. This surgery was performed on _%#MMDD2005#%_. Postoperatively she had went into atrial fibrillation with rapid ventricular rate and was seen by cardiology and cardioverted on _%#MM#%_/_%#DD2005#%_. The patient had been undergoing rehab care at the transitional service, but returned for a left gracilis flap and right rectus and myocutaneous flap.
Slash|Over(blood pressure)|135|Duplex ultrasound was negative at that time, these were done at North Memorial Medical Center. Arterial blood gas at that time was 7.40/61/105. Current studies include arterial blood gas 7.34/56/40/30. Echocardiogram shows ejection fraction of 55% with normal RV size and mildly decreased RV function.
Slash|Either meaning|168|7. Mitral regurgitation, status post mitral valve replacement. 8. Recent ventricular tachycardia. Also, the patient is status post ICD placement. 9. Atrial fibrillation/atrial flutter. 10. Lower extremity edema. 11. Chronic renal insufficiency. 12. Status post hypotension.
Slash|Either meaning|101|RECOMMENDATIONS: 1. Continue amiodarone infusion at this time. 2. IV digoxin load. 3. IV diltiazem if/when blood pressure permits. 4. I will get an echocardiogram now. 5. Volume support given her blood pressure.
Slash|Of|72|There is a normal S1 and 2. No S3 or S4. The PMI is normal. There is a 2/6 holosystolic apical murmur as well as a component of a harsh murmur along the left sternal border which is a systolic ejection murmur.
Slash|Either meaning|173|Because of her leg pain and anxiety and heart failure, it would seem reasonable to cover her at this time with morphine, either 5 mg p.o. q.3 h. p.r.n. for pain, dyspnea and/or anxiety or to have available morphine 1-2 mg IV q.1 h. p.r.n.
Slash|Date|160|She has had other lab studies done prior to transfer here which included I and R of 2.1 on _%#MMDD2002#%_. The patient hemoglobin is 12.6, WBC 8.8 from _%#MM#%_/_%#DD2002#%_. Her BUN and creatinine are both in the normal range.
Slash|Over(blood pressure)|203|16. Restoril 7.5 mg p.o. q.h.s. p.r.n. REVIEW OF SYSTEMS: Unable to obtain, the patient is unresponsive and sedated. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 97.9, heart rate 90, blood pressure 113/54, respiratory rate 12, oxygen 100% on 6 liters. GENERAL: The patient is an ill-appearing, elderly gentleman lying in bed.
Slash|Either meaning|121|She underwent the surgical procedure under general anesthesia on _%#MMDD#%_ and at that for the surgery by Dr. _%#NAME#%_/_%#NAME#%_ and had an uneventful right hemicolectomy with reanastomosis, handsewn.
Slash|Date|184|At present, he is off of active treatment. He has had a chronic thrombocytopenia as well as chronic mild neutropenia. The patient had a routine follow-up bone marrow biopsy on _%#MM#%_/_%#DD#%_. He had the typical post-procedure discomfort, which persisted for a few days and then resolved.
Slash|Over(blood pressure)|160|NEUROPSYCHIATRIC: Unremarkable, although the patient is concerned about a son who tends to exhibit antisocial behavior. PHYSICAL EXAMINATION: Blood pressure 128/68, pulse is 81, the patient is afebrile. HEENT: There is no icterus or cervical adenopathy. CARDIOPULMONARY: Reveals a soft systolic murmur at the left sternal border.
Slash|Date|157|Seed placement and position identified. IMPRESSION: 1. Adenocarcinoma of the prostate B1, 19 months post brachytherapy. 2. PSA history reviewed. PSA _%#MM#%_/_%#DD2001#%_ ( 3.6), _%#MMDD2001#%_ (1.22), _%#MMDD2002#%_ (1.0), _%#MMDD2002#%_ (1.4). No more recent PSA available at the present time.
Slash|Over(blood pressure)|152|Genitourinary: Renal failure. Gastrointestinal: Denies. Integument: Denies. Neurological: Diabetic nephropathy. PHYSICAL EXAMINATION: Blood pressure 140/80. Heart rate 76. The patient appears comfortable at rest. He is alert and oriented x 3.
Slash|Over(blood pressure)|67|Height is 5 feet 2 inches; weight is 149 pounds. Blood pressure 100/64, pulse 72, temperature 97, and respiratory rate 18.
Slash|Either meaning|128|Will continue to monitor. 2. Dyspnea. The patient does not appear dyspneic at this time. We will continue to monitor. 3. Patient/family support. Will continue to follow patient and support wife. The patient's wife does not seem comfortable with deciding on comfort care at this time.
Slash|Over(blood pressure)|110|He did note he was told of anemia in the spring of 2006. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 164/83, pulse 102. HEENT: Pupils round, reactive to light. Status post cataract extractions bilaterally.
Slash|Over(blood pressure)|139|PHYSICAL EXAMINATION: GENERAL: This is a young, morbidly obese patient, appearing her stated age. CURRENT VITAL SIGNS: Blood pressure is 96/50 with at least 20 mm of pulsus paradoxus. Respiratory rate is 28. O2 sats are 90% on 100% rebreather.
Slash|Date|230|The patient was returned to his nursing home and was readmitted because of rectal bleeding, which was accompanied by hypotension. He was found to be considerably anemic with a drop in his hemoglobin from last admission on _%#MM#%_/_%#DD2006#%_ of 12.1 to a hemoglobin of 7.6 on admission yesterday.
Slash|Separates two doses|93|7. Prostate cancer as noted above. MEDICATIONS: 1. Diltiazem 540 mg p.o. daily. 2. Advair 700/50 mcg 1 puff inhaled b.i.d. 3. Protonix 4 mg p.o. daily. 4. Bisacodyl 5 mg p.o. daily.
Slash|Date|126|Some psychomotor retardation, not sleeping, decreased food intake. I again refer you to Dr. _%#NAME#%_'s admission of _%#MM#%_/_%#DD2006#%_ for the details. FAMILY HISTORY: Great grandfather committed suicide. Both parents abused alcohol and went to AA.
Slash|Date|164|8. Hypoglycemic, unawareness. 9. Seizures. 10. PVD. 11. Erectile dysfunction. 12. Hyperlipidemia. 13. Living-donor kidney transplants on _%#MMDD1985#%_ and _%#MM#%_/_%#DD2003#%_. 14. Pancreas transplant with enteric drainage, _%#MMDD2004#%_. 15. Bilateral retinal photocoagulation.
Slash|Date|93|He enters with a relapse with regard to his alcoholism. He was here for treatment in _%#MM#%_/03 and completed day outpatient treatment. He did not follow through with the after care program.
Slash|Date|111|The patient is to continue with n.p.o. and TPN for 1 week. Patient to follow up with Dr. _%#NAME#%_ on _%#MM#%_/_%#DD#%_ at 11:10 a.m. The patient to have of orthostatic blood pressures checked to assess for dehydration.
Slash|Per|169|He had stable kidney graft function with a creatinine of 1.15 mg/dL. He was euglycemic independent of exogenous insulin with amylase and lipase levels of 52 u/L and 39 u/L respectively. DISCHARGE MEDICATIONS: 1. Prednisone 5 mg p.o. daily. 2. Imuran 150 mg p.o. daily.
Slash|Date|124|DISCHARGE MEDICATIONS: 1. Neoral 175 mg p.o. b.i.d. 2. CellCept 1 g p.o. b.i.d. 3. Prednisone 25 mg p.o. 1x time on _%#MM#%_/_%#DD2004#%_, then discontinue. 4. Bactrim SS 1 p.o. each day. 5. Valcyte 450 mg p.o. each day.
Slash|Over(blood pressure)|236|The patient develops aches, pains, coryza, and insomnia. At the time of admission, he was in very severe withdrawal. ALLERGIES: Penicillin. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98, pulse 72, respirations 18, blood pressure 106/60. GENERAL: This is a well- developed, well-nourished 36-year-old male in no apparent distress, alert, cooperative, oriented to time, person, and place.
Slash|Date|22|Date of Note: _%#MM#%_/_%#DD2004#%_ IDENTIFICATION: _%#NAME#%_ is a 50-year-old Caucasian male, never married and has never had children. He currently lives in _%#CITY#%_. He states no mental health admissions.
Slash|Per|135|9. Nystatin 4 mL 4 times daily. 10. Bactrim single strength 36 mg once daily. 11. Valganciclovir 200 mg once daily. 12. Tylenol #3 5 mL/h as needed for pain. 13. Dilaudid 0.1 mg p.o. q.4 h. p.r.n. for pain.
Slash|Date|298|Postoperatively, the patient did quite well. Routine postoperative cares were provided. A Foley catheter was discontinued. Her diet was advanced, her pain was well controlled, and her postoperative hemoglobin was 9.3. She continued to do well postoperatively and was ready for discharge on _%#MM#%_/_%#DD2004#%_. On that day she was afebrile with stable vital signs.
Slash|Date|204|DOB: _%#MMDD1933#%_ ADDENDUM TO PREVIOUSLY DICTATED H&P Additional information has been received from the patient's rheumatologist. This includes an MRI examination of the right knee performed on _%#MM#%_/_%#DD2004#%_ in _%#CITY#%_ _%#CITY#%_. This demonstrates severe degenerative arthritis of the lateral compartment. She has a completely displaced lateral meniscus.
Slash|Separates two doses|117|8. Prednisone, 10 mg p.o. q.d. 9. Colace, 100 mg p.o. b.i.d. 10. Multivitamin with iron, one p.o. q.d. 11. Vicodin (5/500) one q.i.d. p.r.n. for pain. 12. Os-Cal D, 600 mg p.o. b.i.d. 13. Zofran, 8 mg q.i.d. at 8:00 a.m., 12 noon, 4:00 p.m., 8:00 p.m.
Slash|Over(blood pressure)|230|She is also asking to eat breakfast. She is also asking to lie down and seems quite confused. PHYSICAL EXAMINATION: VITAL SIGNS: Most recent vital signs show a temperature of 97.0, pulse 72, respiratory rate 24, blood pressure 122/70, room air O2 saturation 94%. Weight 39.0-kg. GENERAL: The patient is an elderly, frail female who has marked kyphosis who has multiple complaints to this provider, not localizing her complaints to any particular area.
Slash|Date|13|DOB: _%#MM#%_/_%#DD1962#%_ HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ woke up this morning initially with midepigastric pain which radiated through to the back. He notes that there was also some lower abdominal pain but it seemed to settle into the midepigastric or lower chest region.
Slash|Date|13|DOB: _%#MM#%_/_%#DD1922#%_ REASON FOR HOSPITALIZATION: Mrs. _%#NAME#%_ is an 81-year-old woman with multiple medical problems including diabetes mellitus, arteriosclerotic cardiovascular disease, porcine aortic valve, chronic renal insufficiency, and hypertension.
Slash|Date|180|She then had the hemoglobin that was 10.8 and she was started on iron therapy. Quantitative HCGs were negative. The ultrasound was scheduled and the ultrasound was done on _%#MM#%_/_%#DD#%_ that shows debris and retained products of conception in the uterus with heterogeneous, irregular, thickened endometrium of 21 mm.
Slash|Divided by|175|Status post endoscopy in _%#MM#%_ 2003. He is currently on Prevacid q.d. to b.i.d. He is allergic to Augmentin. The physical examination on admission revealed a weight of 51-1/2 pounds down from 54 pounds the prior week, decreased skin turgor, and decreased moisture of his mucous membranes.
Slash|Date|197|A subsequent workup revealed that this is a locally advanced T3 lesion and that he had metastatic disease to the liver. _%#NAME#%_ had undergone preoperative chemo radiation therapy and on _%#MM#%_/_%#DD2003#%_ he underwent a low anterior resection with diverting loop ileostomy.
Slash|Over(blood pressure)|166|Her family lives in _%#CITY#%_. PHYSICAL EXAMINATION: On the day of admission, she was a well-appearing Somali woman lying comfortably. Weight 129, blood pressure 141/84, pulse 86. Abdomen soft. No hepatosplenomegaly. No masses. She was point tender just to the left of the midline in lower pelvis.
Slash|Divided by|122|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ is a 22- year-old male. He has a fiance and twin sons age 1-1/2-years-old. He is employed. He enters Fairview Recovery Services at this time on transfer from the Fairview-University Medical Center Intensive Care Unit where he was admitted _%#MMDD2003#%_ with an overdose of cocaine.
Slash|Of|110|EXTREMITIES: Lower extremities - without edema. Palpable pulses. Good capillary refill. Deep tendon reflexes 1/2+ and symmetric at the patella. NEURO: Cranial nerves II-XII are grossly intact and symmetric. SKIN: Without concerning lesions.
Slash|Date|209|She now presents on a semi-elective basis for reconstruction of her lumbar spine due to the collapsed disc and instability. HOSPITAL COURSE: The patient was admitted and taken to the operating room on _%#MM#%_/_%#DD2003#%_. Under general anesthetic with 1600 cc of blood loss. The procedure itself was complicated such that during the posterior instrumentation portion on the exam, the previously placed anterior strep graft was dislodged.
Slash|Over(blood pressure)|174|PHYSICAL EXAMINATION: GENERAL: The patient is awake, alert and oriented to time, place and person. He is very pleasant during the examination. VITAL SIGNS: Blood pressure 132/76, pulse 60, respiratory rate 18, afebrile, oxygen saturation 94% on 2 liters per nasal cannula.
Slash|Either meaning|175|DISCHARGE MEDICATIONS: Cited earlier. FOLLOW UP: The patient is due next week to follow up with his primary care doctor, Dr. _%#NAME#%_. He is to follow up with his hematology/oncology doctor, Dr. _%#NAME#%_, and to have the home health care nurse draw CBC, platelets, and a CMP on Monday morning.
Slash|Date|212|CARDIAC EXAMINATION: Is irregular without a murmur. ABDOMEN: Is soft without any masses or tenderness noted. EXTREMITIES: Have 1+ edema with reduced pulses bilaterally. The patient's laboratory result on _%#MM#%_/_%#DD2003#%_ reveals a hemoglobin of 10.0, a BUN and creatinine of 57 and 2.2. Potassium level of 5.8, albumin of 3.0, AST and ALT of 16 and 17, sodium of 145, HDL of 29, LDL 49.
Slash|Date|136|DOB: _%#MMDD1968#%_ _%#NAME#%_ _%#NAME#%_ is a 34-year-old Gravida II, Para 1-0-0-1 with an LMP of _%#MMDD2002#%_ and an EDC of _%#MM#%_/_%#DD2003#%_ and a history of previous low segment transverse cesarean section for breech presentation who desires repeat cesarean section with this pregnancy. Risks, benefits and alternatives to repeat cesarean section including TOLAC was discussed with the patient at length and she elected to proceed with a repeat cesarean section.
Slash|Over(blood pressure)|95|He has no wheezing. He has a history of borderline increased lipids. Blood pressure at home 120/88. PAST MEDICAL HISTORY: SURGICAL: 1) Several lipomas removed.
Slash|Over(blood pressure)|279|FAMILY HISTORY: Noncontributory REVIEW OF SYSTEMS: As per history of present illness, other organ systems were reviewed and are noncontributory. PHYSICAL EXAMINATION: VITAL SIGNS: Pulse 100, respirations 32, blood pressure 139/81, 02 saturations 93% on 35% on 02 with BiPAP at 14/5 at a rate of 14. GENERAL: Moderate respiratory distress. HEENT: Sinuses nontender. Oral pharynx is clear.
Slash|Over(blood pressure)|167|PHYSICAL EXAMINATION: GENERAL/VITAL SIGNS: The patient is an 80-year-old gentleman who is tachypneic at 28 with a pulse oximetry of 98% on room air. Blood pressure 160/66, respiratory rate 28, pulse 66, temperature 98.4. HEENT: Head - normocephalic and atraumatic.
Slash|Over(blood pressure)|174|No diarrhea. ? Decubitus ulcers. Increased right hip pain and drainage. PHYSICAL EXAMINATION: Temperature 100.2. Blood pressure 119/90 initially, and then dropping to the 90s/50s where it has been stable. Pulse 120-140. Pulse oximetry 98% on room air. GENERAL: Elderly chronically ill appearing female.
Slash|Divided by|216|HIV negative. FAMILY HISTORY: Negative. REVIEW OF SYSTEMS: The patient is anxious for delivery, but no specific problems. PHYSICAL EXAMINATION: Well developed, well nourished female, gravid, height 5'8", weight 199-1/2 lb. Prepregnancy weight 175 lb for a total weight gain of 24-1/2 lb.
Slash|Date|221|CSF, urine, and blood cultures were all negative and she was observed overnight, then discharged the _%#DD#%_ with follow-up with her normal pediatrician, Dr. _%#NAME#%_ _%#NAME#%_, at _%#CITY#%_ Park Nicollet on _%#MM#%_/_%#DD2002#%_.
Slash|Date|127|4. Porta-Cath x 3 most recently in _%#MM#%_ 2000. 5. Glucose intolerance, mild. 6. Sinus surgery x 6, most recently in _%#MM#%_/1989. 7. Cholecystectomy in 1993. 8. Left knee cyst removal at age of 5.
Slash|Date|211|She had some reservations at first about undergoing an epidural steroid injection for this but after thorough discussion regarding the potential risks and benefits she did wish to proceed. Therefore, on _%#MM#%_/_%#DD2002#%_ Dr. _%#NAME#%_ did perform a right L5-S1 cortisone epidural injection.
Slash|Date|130|DISPOSITION: The patient was discharged home in good condition. She is to follow up with Dr. _%#NAME#%_ from Pulmonary on _%#MM#%_/_%#DD2002#%_; this appointment has already been scheduled. She will also be contacted concerning outpatient PT and OT.
Slash|Either meaning|538|We will give her a 10-day course. In addition other medications will be maintained as previously taken, including Lipitor 40 mg daily, Clonidine 200 mg q.a.m., Catapres 300 mcg nightly, furosemide 20 mg every other day p.o. We will start hydrocortisone valerate 0.2% to right foot b.i.d. Labetalol 300 mg b.i.d, clobetasol ointment topical for feet p.r.n. or as recommended by Dr. _%#NAME#%_. Zoloft 100 mg daily, aspirin 81 mg daily, Vicodin 1 tablet q.6h. p.r.n. as previously taken for pain, Byetta 10 mcg injection b.i.d., Glimepiride/Amaryl 2 mg b.i.d., Januvia 25 mg p.o. daily. As mentioned, doxycycline. She will follow up with Dr. _%#NAME#%_ in 7-10 days in his office.
Slash|Separates two doses|60|13. Tylenol 650 mg p.o. q.6 hours p.r.n. pain. 14. Vicodin 5/500 mg 1-2 tablets p.o. q.6 hours p.r.n. pain. 15. Not greater than 4 grams acetaminophen in 24 hours.
Slash|Date|106|He was transferred to Fairview Southdale Hospital for surgical treatment. He underwent surgery on _%#MM#%_/_%#DD2002#%_ by Dr. _%#NAME#%_. Post-operatively, he had a diagnosis of a 9 cm abdominal aortic aneurysm, right common iliac artery aneurysm and diverticulosis.
Slash|Of|208|Extraocular movements are intact. CARDIAC: Normal S1 plus S2, regular rate and rhythm, no murmurs, gallops, rubs or clicks. PULMONARY: Lungs are clear bilaterally, no dullness to percussion. MUSCULOSKELETAL 5/5 upper/lower muscular strength bilaterally. No clubbing of digits. NEUROLOGIC: Cranial nerves II-XII are intact.
Slash|Date|164|DISCHARGE FOLLOW-UP: 1. Dr. _%#NAME#%_. 2. Follow up with Minnesota Heart. 3. Follow-up labs: patient should have an INR and basic metabolic panel tomorrow _%#MM#%_/_%#DD#%_. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is an 86-year-old woman who presented to Fairview Southdale Emergency Room on _%#MMDD2007#%_.
Slash|Date|129|HOSPITAL COURSE: Mr. _%#NAME#%_ _%#NAME#%_ was cleared for surgery prior to admission to Fairview Riverside Hospital. On _%#MM#%_/_%#DD2006#%_, the patient was brought to the operating room where he underwent a general anesthetic without complication.
Slash|Of|220|NEUROLOGIC: Cranial nerves II through XII intact except for visual acuity. There is also disconjugate gaze with left exotropia. His strength is 5/5 in both upper extremities and less than 3 for hip flexors bilaterally, 4/5 at knee extensors bilaterally, ankle dorsiflexor and EHL is 1/5.
Slash|Either meaning|318|Neurosurgery did not maintain that this left subdural hematoma needed to be emergently evacuated. Neurosurgery will follow her in the outpatient clinic. Physical therapy and occupational therapy saw the patient and the patient did actually well without any propensity to fall However, physical therapy recommended home/assisted living, continued physical therapy evaluation and treatment.
Slash|Of|243|She is a 68-year-old Somali Woman with past medical history is significant for gastritis, osteoarthritis, cyclic vomiting syndrome and also polycythemia vera. The patient is having vomiting for the last 2 days and epigastric abdominal pain, 10/10 in severity, nonradiating, feels very nauseated at that time.
Slash|Date|202|8. Evista 60 mg p.o. daily. 9. Senokot S 2 tablets p.o. b.i.d. 10. Desyrel 50 mg p.o. each day at bedtime. 11. Triamcinolone topical ointment 0.1% cream apply to chest and groin t.i.d., stop on _%#MM#%_/_%#DD2007#%_. 12. Protonix 40 mg p.o. q.a.m. and each day at bedtime.
Slash|Date|166|DIET AND ACTIVITY: As tolerated by the patient. PHYSICIAN FOLLOW-UP: The patient will follow up with Dr. _%#NAME#%_ at his Hematology Oncology appointment on _%#MM#%_/_%#DD2006#%_ at 1300. The patient will need to have an LDH of fetoprotein, beta HCG, and labs drawn prior to this appointment.
Slash|Date|462|2. Right pathologic fracture of clavicle treated nonsurgically. 3. Recent history of right hip pathologic fracture status post right hemiarthroplasty. 4. Acute and chronic deconditioning. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 68-year-old woman with a history of multiple myeloma who was admitted to the hospital on _%#MMDD2006#%_ with left hip pain, diagnosis was that of pathologic fracture and she underwent a left hemiarthroplasty on _%#MM#%_/_%#DD2006#%_, per Dr. _%#NAME#%_. Her postoperative course was noted for postop anemia requiring 2 units of packed RBCs.
Slash|Date|111|She was treated with Thymoglobulin, as well as plasmapheresis and IVIG. She was admitted once again on _%#MM#%_/_%#DD2006#%_ with fevers and pancytopenia. Her workup revealed a fungemia, and her dialysis catheter, which was a lumbar catheter, was removed, and the tip also grew candida glabrata, as well as the blood.
Slash|Either meaning|115|In the emergency department the patient had a CT scan of the chest which ruled out dissection. EKG showed no new ST/T changes. Her first troponin was negative. REVIEW OF SYSTEMS: No dizziness, no headache, no shortness of breath, no abdominal pain, positive for nausea and vomiting, no hematochezia, no diarrhea, no hemoptysis, no dysuria, no leg swelling.
Slash|Divided by|103|4. Prinzide 12.5 mg 1 tablet daily. 5. Vicodin 1 or 2 tablets once a day for headache. 6. Zocor 40 mg 1/2 tablet once a day. 7. Aspirin 325 mg 1 tablet daily. FOLLOWUP: The patient will follow with her primary care physician in 2 weeks.
Slash|Date|306|DISCHARGE ACTIVITY: The patient is to follow up with physical medicine rehabilitation and has a walker for ambulation. DISCHARGE FOLLOWUP: With the otolaryngology is approximately 1 week. HOSPITALIZATION COURSE: This is a 35-year-old female who underwent resection of her right frontal mucocele on _%#MM#%_/_%#DD2006#%_. She tolerated the procedure well, going home postoperatively on medications.
Slash|Over(blood pressure)|252|2. Received double unrelated cord blood transplant on _%#MM#%_ _%#DD#%_, 2006, course complicated by CMV reactivation. 3. Physical exam: At the time of admission, _%#NAME#%_'s temperature was 99.5, heart rate 88, respiratory rate 20, blood pressure 108/61, and weight 58.4 kg. His physical exam was remarkable for bilateral scleral icterus and a Port-A-Cath in the left upper chest.
Slash|Date|638|K-Phos 2 tabs (500 mg tablets) p.o. t.i.d., senna 8.6 mg p.o. each day at bed-time p.r.n., Skelaxin 800 mg p.o. t.i.d., vitamin B12 1000 mcg p.o. daily, Ambien 10 mg p.o. daily, multivitamin 1 p.o. daily, Crestor 10 mg p.o. daily, Detrol 2 mg p.o. b.i.d., docusate 100 mg p.o. b.i.d. p.r.n. constipation, gemfibrozil 600 mg p.o. b.i.d., glyburide 2.5 mg p.o. daily., Lexapro 30 mg p.o. daily, lisinopril 5 mg p.o. daily, methadone 5 mg 2 tablets p.o. b.i.d. 2 tablets p.o. each day at bed-time, Kaopectate 30 cc p.r.n. diarrhea., Lidoderm patches to fit every 12 hours daily. FOLLOW-UP LABORATORY STUDIES: She is to have a BMP on _%#MM#%_/_%#DD2006#%_ and hemoglobin on _%#MMDD2006#%_. PLAN: 1. She is to see Dr. _%#NAME#%_, renal doctor as scheduled.
Slash|Date|246|We did evaluate the right leg greater saphenous vein in preparation for eventual right leg bypass graft and this was noted to be of excellent caliber. The drains were removed from her left thigh and she was ready for discharge to home on _%#MM#%_/_%#DD2005#%_. DISCHARGE MEDICATIONS: 1. Aspirin 81 mg daily. 2. Dipyridamole 75 mg p.o. b.i.d.
Slash|Either meaning|276|On the floor, he reported shortness of breath that was mild and was transferred to the bed. PAST MEDICAL HISTORY: 1. Coronary artery disease. Angiogram on _%#MM#%_ _%#DD#%_, 2005, showed one- vessel coronary artery disease in the RCA without left main lesion; status post PTCA/stent of the proximal RCA. Echocardiogram on _%#MM#%_ _%#DD#%_, 2005, showed normal global LV function without regional wall motion abnormalities.
Slash|Over(blood pressure)|266|She is not on any medications for this. Psychiatric: Significant psychiatric history including schizoaffective disorder, PTSD and borderline personality disorder. All of these are stable according to the patient. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 151/94, pulse 112, respirations 15, temperature 97.8, oxygen saturation 99% on room air.
Slash|Separates two doses|73|9. Furosemide 40 mg p.o. p.r.n. as previously directed. 10. Augmentin 500/125 one tablet p.o. q. 12 hours for 14 days, unless changed by primary care provider.
Slash|Over(blood pressure)|194|3. Asthma, controlled with Flovent without recent flares. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: On admission temperature 101.4, pulse 101, respirations 18, blood pressure 156/86, oxygen saturations 98% on room air. In general, Ms. _%#NAME#%_ was an alert, appropriate, young woman who appeared tired but in no acute distress.
Slash|Date|135|7. Milk of Magnesia 30 cc p.o., up to 2 times a day as needed. FOLLOW-UP: 1. The patient will follow up with Dr. _%#NAME#%_ on _%#MM#%_/_%#DD2004#%_ at 10 a.m. 2. Because of his continued negative blood cultures, the patient will have a port placed on Thursday, _%#MMDD2004#%_, at 10 a.m. The patient was told that his check-in was at 8 a.m. on 3C on the morning of _%#MMDD2004#%_.
Slash|Date|105|For the last year she has had unpredictable periods. She is 46 years old. Her last period was on _%#MM#%_/_%#DD#%_ and she has been constantly bleeding. Her hemoglobin in _%#MM#%_ was 10.9. When checked on _%#MMDD#%_ it was 7.3. On repeat today it was 8.8. An ultrasound reveals some fibroids.
Slash|Date|207|Patient was delivered without complications with Apgars of 8 and 8 and breast fed well throughout his stay. Baby was noted to be jaundiced on _%#MMDD2004#%_ with a peak bilirubin climbing to 16.0 on _%#MM#%_/_%#DD2004#%_. He was started on bili lights and had bili blanket.
Slash|Date|173|Patient was admitted then for treatment including IV antibiotics, hot compresses and elevation in that leg. She did not show much improvement so we added Lovenox on _%#MM#%_/_%#DD#%_ and Ted stockings. She slowly improved then over the next few days and it was felt reasonable for discharge.
Slash|Over(blood pressure)|317|9. K-Dur. ALLERGIES: Sulfa. REVIEW OF SYSTEMS: She denies any recent chills or fevers, coughing, chest pains, abdominal symptoms. She denies any urinary problems, any open skin sores. PHYSICAL EXAMINATION: VITAL SIGNS: At this moment she is afebrile, her heart rate is 90 per minute and regular, blood pressure is 119/70, her respiratory rate is 16- 20, she is no acute distress, she is on supplemental oxygen.
Slash|Date|243|She will be transferred to the Residential Lodging Plus Program and use trazodone with an as needed dose. That is Trazodone 50-100 mg q.h.s. p.r.n. She was evaluated, assigned to a group, and transferred to the Lodging Plus Program on _%#MM#%_/_%#DD2004#%_. She was to take Effexor XR 37.5 mg daily for one day and then 75 mg daily.
Slash|Date|233|4. Desires permanent sterilization. PROCEDURES: 1. Repeat low segment transverse cesarean section. 2. Bilateral partial salpingectomy. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 25-year-old, now para 2-0-0- 2 with an LMP of _%#MM#%_/_%#DD2003#%_ and a history of a previous low segment transverse cesarean section who was admitted for repeat low segment transverse cesarean section as well as bilateral salpingectomy for sterilization on _%#MMDD2004#%_.
Slash|Date|310|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 42-year-old male with ostium secundum ASD with a history of multiple TIA's and no known hypercoagulable state who presented for patent foramen ovale closure (PFO) closure. HOSPITAL COURSE: The patient's PFO closure was uncomplicated. Echo done on _%#MM#%_/_%#DD2003#%_ showed no major shunting across the interatrial septum, normal right atrial size, no evidence of pericardial effusion, however the patient did have a fever with unclear source.
Slash|Date|139|2. Rifampin 300 mg p.o. b.i.d. through _%#MMDD2003#%_. 3. Coumadin per INR (2.5 mg x 1 on _%#MMDD2003#%_). a. INR to be checked in _%#MM#%_/_%#DD2003#%_ with primary physician called to be given INR results and nursing home to get further Coumadin instructions.
Slash|Date|13|DOB: _%#MM#%_/_%#DD2010#%_ PRIMARY DIAGNOSIS: Urinary tract infection, fall, and knee contusion. SECONDARY DIAGNOSIS: Gastroesophageal reflux disease, osteoarthritis, anemia, depression, hyperlipidemia, glaucoma.
Slash|Per|177|9. History of atypical Pap smears. 10. Hypercholesterolemia. 11. Hypertension. HOSPITAL COURSE: Admission labs revealed hemoglobin to be 6.4 gm/dl, serum creatinine to be 8.0 mg/dl. She was promptly transfused with 2 units of PRBCs. Hemoglobin remained stable for duration of possible stay thereafter and at the time of discharge was 10.0 gm/dl.
Slash|Date|198|His incision was clean, dry, and intact. His drain has minimal output of less than 10 cc per shift, and this was discontinued prior to discharge. The patient is allowed to shower on Sunday, _%#MM#%_/_%#DD2003#%_; however, he should not bathe for two weeks. He should avoid any strenuous activity. He should give us a call with increased temperature greater than 101.5, drainage, and pain.
Slash|Per|171|PLAN: The patient was admitted to the Intensive Care Unit for close monitoring. The patient will start with D5 half-normal saline with 20 mEq of potassium chloride, 125 cc/hour, and the patient was placed on the MSSA protocol for withdrawal.
Slash|Of|157|She has good posterior tibial and dorsalis pedis pulses. Her cranial nerves II through XII are grossly intact. Her biceps and patellar tendon reflexes are 2+/4 and symmetrical. Skin is normal. Her hemoglobin is 14.2. Her urinalysis is unremarkable and her cardiogram is normal.
Slash|Date|403|He had available a bottle with #90 tablets, it was filled over a week ago, he is supposed to be taking one in the morning and two at bedtime. He had a bottle with #15-40 mg Celexa tablets and that was filled on _%#MMDD2003#%_-he is supposed to be taking 1 of those per day and a bottle of Wellbutrin 100 mg tablets, #120 tablets, he is supposed to be taking 2 twice a day and that was filled on _%#MM#%_/_%#DD2003#%_. His mother reports that some of the Wellbutrin tablets were still in the bottle.
Slash|Date|13|DOB: _%#MM#%_/_%#DD1972#%_ The patient is a 30-year-old who underwent a primary low transverse cesarean for a breech presentation. Postoperatively the patient did well with release on the fourth postoperative day, tolerating a regular diet, fully ambulatory, and with normal bowel and bladder function.
Slash|Abbreviation|127|Initially it was felt that she may have appendicitis, however, the CT scan did not document an appendicitis. She was seen by OB/GYN for possible PID or ruptured ovarian cyst and their conclusion was that this may well have been a ruptured cyst or white count which was slightly elevated returned to normal.
Slash|Date|138|She had a tubal ligation in 1997 or 1998 (she does not recall which). Because of this ongoing history of bleeding, I did a D&C on _%#MM#%_/_%#DD2002#%_ at Southdale, which revealed proliferative endometrium and a relatively normal uterine cavity.
Slash|Date|186|2. Spina bifida, status post intrauterine repair. 3. Viral upper respiratory infection. 4. Ex-33 week infant. DISCHARGE MEDICATIONS: 1. Ceftriaxone 800 mg IV q day until Monday, _%#MM#%_/_%#DD#%_ or until without fevers for seven days, whichever is longer.
Slash|Either meaning|167|The patient remained in a sinus rhythm. The patient was treated with amiodarone drip. The patient returned to the Cardiac Catheterization Laboratory and underwent PTCA/stent with brachytherapy of the proximal LAD lesion with 0% residual.
Slash|Either meaning|120|On _%#MM#%_ _%#DD#%_, 2000, she was admitted with a partial small bowel obstruction. In _%#MM#%_ 2000, she started Taxol/carboplatin chemotherapy treatments, which were completed in _%#MM#%_ 2001.
Slash|Divided by|248|HISTORY OF PRESENT ILLNESS ON ADMISSION: A 42-year-old African-American female with history of type 1 diabetes came to the emergency room not feeling well for the past 3 days. Decreased appetite, nausea, vomiting, abdominal pain, not eating for 1-1/2 days. Denying chest pain or shortness of breath, decrease in vision.
Slash|Either meaning|141|7. Singulair 10 mg q day. 8. Trazodone 50 mg each day at bed-time. 9. Chantix 0.5 mg b.i.d. x4 days, then 1 mg b.i.d. 10.Roxanol 5-10 mg p.o./sublingual q.2 hours p.r.n. pain or air hunger. 11.Ativan 1-2 mg p.o. or sublingual q.2-4 hours p.r.n. anxiety.
Slash|Either meaning|150|FINAL Date of discharge: _%#MMDD2007#%_ ADMISSION/DISCHARGE DIAGNOSES: 1. Oligoastrocytoma. 2. Epilepsy. OPERATIONS/PROCEDURES DURING ADMISSION: 1. IV/IA chemotherapy. 2. EEG monitoring. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 52-year-old man with a history of oligoastrocytoma, status post resection in _%#MM#%_ 2006.
Slash|Date|239|The patient has received multiple intravesicular treatments with BCG. He is also recently admitted for hemorrhagic stroke about 3 weeks ago. The patient is followed by Metro Urology and had BCG treatment on the day of admission on _%#MM#%_/_%#DD2007#%_. Later that evening he spiked high fever and complained of weakness and inability to walkup the stairs.
Slash|Of|175|There were no complications. There was an estimated blood loss of 1000 mL. At the time of discharge, the pathology revealed metastatic malignant solitary fibrous tumor grade 3/3. The pelvic mass tumor showed avid infiltration of the fiber adipose tissue.
Slash|Either meaning|168|Physical examination was normal. Primary reason for admission was to rule out sepsis. Problems during his/her hospitalization included the following: Problem #1: Fluids/Electrolytes/Nutrition. _%#NAME#%_ had the following lines placed: peripheral IV. _%#NAME#%_ was allowed to breastfeed ad lib and supplemented with intravenous fluids because she had poor oral intake initially.
Slash|Over(blood pressure)|116|PHYSICAL EXAMINATION: GENERAL: The patient appears healthy, in no acute distress. VITAL SIGNS: Blood pressure is 130/70 with a heart rate of 60, afebrile. HEENT: Normocephalic, atraumatic. Oropharynx moist. NECK: Supple. LUNGS: Clear. CARDIOVASCULAR: Normal S1 and S2.
Slash|Separates two doses|118|3. Bactrim 16 mg NG daily. 4. Bactrim 3 mL NG 3 times daily. 5. Calcium carbonate 750 mg NG 4 times daily. DIET: PM 60/40, mixed in 900 mL with 3.5 teaspoons Kayexalate. Allow to sit for 4 hours and decant off. Run at 52 mL/hour x17 hours.
Slash|Separates two doses|133|5. Potassium chloride 20 mEq orally once daily. 6. DuoNeb 3 ml inhaled every 6 hours as needed for shortness of breath. 7. Advair 100/150 one puff inhaled twice daily - rinse mouth after inhalation.
Slash|Over(blood pressure)|107|He is in no apparent respiratory distress now and is sleeping very soundly. VITAL SIGNS: Blood pressure 118/72, pulse is 84, respirations 24. He has 92% O2 saturation on 3 liters nasal cannula.
Slash|Date|184|3. Ambien 10 mg po qhs. PAST MEDICAL HISTORY: 1. History of fibrosarcoma; first lung resection done in 1976. Has had several rounds of chemotherapy since then, the last one in _%#MM#%_/00. 2. Status post partial hysterectomy and rectal resection. 3. Hypothyroidism.
Slash|Over(blood pressure)|135|Negative for any definite exertional chest tightness or prior cardiac history. PHYSICAL EXAMINATION: On exam, his blood pressure is 134/63. His pulse is 100 and regular. His weight is 68.1 kg.
Slash|Either meaning|119|10. Zocor 40 mg p.o. q. day. 11. Hytrin 10 mg p.o. q. day. 12. Ativan 0.5 mg p.o. q.6h. agitation. 13. Haldol 1 mg p.o./IV q.6h. agitation. I would note her p.o. medications are given per feeding tube.
Slash|Separates two doses|114|4. MiraLax 17 g p.o. daily p.r.n. constipation. 5. Benadryl 25 mg IV/p.o. q. 4 hours p.r.n. pruritus. 6. Vicodin 5/500 mg p.o. q. 4-6 hours p.r.n. pain. 7. Protonix 40 mg p.o. daily for GI prophylaxis.
Slash|Date|208|FINAL PRIMARY CARE: _%#NAME#%_ _%#NAME#%_, MD (_%#CITY#%_ Family Physicians) DISCHARGE DIAGNOSIS: 1. Left proximal humerus fracture. He is actually scheduled to have open reduction of his fracture on _%#MM#%_/_%#DD2006#%_. He will be going to a transitional care unit (TCU) while waiting for surgery because he is on anticoagulation and his Coumadin needs to be on hold.
Slash|Divided by|140|The plan for the patient for tonight is as follows: 1. Fluids, electrolytes and nutrition: We will continue him on maintenance fluid of D5-1/2 normal saline at a rate of 45. Given the patient is very somnolent, we will make the patient n.p.o. and will check electrolytes.
Slash|Date|313|PRELIMINARY ADMISSION DIAGNOSIS: Degenerative arthrosis right knee. DISCHARGE DIAGNOSIS: Degenerative arthrosis right knee. PROCEDURE THIS ADMISSION: Right total knee arthroplasty. COMPLICATIONS: None. HISTORY AND HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ was taken to the OR on the same day as admission on _%#MM#%_/_%#DD2006#%_ and underwent an uneventful right total knee arthroplasty.
Slash|Either meaning|220|He received gamma knife radiation on _%#MM#%_ _%#DD#%_, 2006. In _%#MM#%_ 2006, he started his IV/IA chemotherapy consisting of Cytoxan, etoposide, and intraarterial carboplatin. He was admitted for his third cycle of IV/IA chemotherapy. HOSPITAL COURSE: Mr. _%#NAME#%_ did receive his intravenous/intraarterial chemotherapy. He tolerated this quite well and was without neurologic deficit at the time of discharge.
Slash|Of|92|CARDIOVASCULAR: Reveals tachycardia with a normal S1, S2. There is no S3 or S4. There is a 2/6 holosystolic murmur at the left lower sternal border going to the axilla.
Slash|Separates two doses|119|No signs of infection in the thigh region and improving cellulitis in the left calf. DISCHARGE MEDICATIONS: 1. Lotrel 5/21 p.o. q.a.m. 2. Aspirin 81 mg daily. 3. Dipyridamole 75 mg p.o. b.i.d.
Slash|Date|263|The patient denies any pelvic pain, dyspareunia, but desires proceeding with laparoscopy and tubal dye studies to know if that tube is damaged or not. She has had the same partner for one year and is now scheduled for laparoscopy and tubal dye studies on _%#MM#%_/_%#DD2006#%_ at 10:15 a.m. with Dr. _%#NAME#%_ _%#NAME#%_ at Fairview Southdale Hospital same day surgery. ALLERGIES: No known drug allergies.
Slash|Of|218|2. History of cerebrovascular disease. The patient has some left lower extremity weakness which, according to her and also according to her daughters, is not new. Neurologic exam today is fairly unimpressive. She has 4/5 strength in the left upper extremity. The patient has had a CT scan which shows no hemorrhage and no masses.
Slash|Either meaning|157|Respiratory therapy was consulted to measure negative inspiratory flow (NIF) which was minus 60. Hospital course was uncomplicated, daily checkups for inputs/outputs. Respiratory rate and NIF were measured b.i.d. On _%#MM#%_ _%#DD#%_, 2006, chest tube was discontinued, and the patient was started on oral pain medications.
Slash|Date|192|The patient was noted to be quite hypertensive throughout the case. The patient did not have an echocardiogram during his hospitalization, but her last echocardiogram was performed in _%#MM#%_/05 demonstrating normal left ventricular chamber dimension, ejection fraction estimated to be 40% with severe hypokinesia with a lateral and posterolateral wall contracting best.
Slash|Separates two doses|145|DISCHARGE MEDICATIONS: Prednisone 40 mg tapering to 5 mg daily over the course of one week. Nicotine patch 21 mg daily #30 no refills, Percocet 5/325 one to two tablets q 6 hours prn #40 no refills. Azithromycin 250 mg daily times 4 days. FOLLOW UP: The patient will follow up with Dr. _%#NAME#%_ at Fairview _%#CITY#%_ Clinic in one to two weeks.
Slash|Date|157|The day of discharge, his bilirubin was 9.8. Circumcision was done on day 3 of life without any complications. DISCHARGE INFORMATION: Discharge date _%#MM#%_/_%#DD2004#%_. Discharge diagnosis: 1. Respiratory distress in a term infant. 2. Hyperbilirubinemia. Patient is instructed to follow-up in about two to five days to recheck jaundice and follow-up with the heart murmur, sooner if they have any questions or concerns.
Slash|Over(blood pressure)|167|SOCIAL HISTORY: He drinks alcohol minimally. He does smoke cigarettes. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98, pulse 80, respirations 20, blood pressure 110/70. GENERAL: This is a well- developed, well-nourished 32-year-old male in no apparent distress with opiate withdrawal symptoms.
Slash|Either meaning|76|2. Pioglitazone 15 mg p.o. q. day. 3. Cipro 500 mg p.o. b.i.d. 4. Lisinopril/hydrochlorothiazide combination 10 mg/12.5 mg p.o. q. day. PROCEDURES PERFORMED: 1. Echocardiogram. She had an initial echocardiogram done on admission on _%#MM#%_ _%#DD#%_, 2005, that showed normal LV function with a pacer wire that perforated the RV.
Slash|Date|96|7. History of aortic grafting. 8. History of hyperlipidemia. 9. History of colectomy in _%#MM#%_/2004 for ischemia. 10. History of left total knee replacement. 11. History of peptic ulcer disease.
Slash|Date|145|Diastolic dysfunction noted. Ultrasound guided thoracentesis of 800 cc transudative pleural effusion. No complications. This was done on _%#MM#%_/_%#DD2004#%_ after normalizing INR. HOSPITAL COURSE: The patient is an 84-year-old male who lives independently with his wife.
Slash|Date|180|OTHER DIAGNOSES: Exacerbation of chronic obstructive pulmonary disease, torticollis, hypertension, anxiety state, history of smoking. PROCEDURE: Placement of chest tube on _%#MM#%_/_%#DD2004#%_ for injection of a slurry ___ through the indwelling chest tube.
Slash|Date|251|The flat and upright of the abdomen showed a mild right lower quadrant ileus and a chest x-ray showed heart size that was enlarged but probably within normal limits. There was no active infiltrate or effusion. The chest appears unchanged from _%#MM#%_/_%#DD2003#%_. Hypothyroidism. She is to continue on her Synthroid. For her hypertension, she is to continue on he atenolol.
Slash|Date|144|She will follow up in clinic in two weeks. Her job requires her to work 14 hour days as dialysis tech. She is next scheduled to work on _%#MM#%_/_%#DD2005#%_. At the present time it is felt that she should be ready to return to work at that time without restriction.
Slash|Date|13|DOB: _%#MM#%_/_%#DD2005#%_ DISCHARGE DIAGNOSES: 1. A 35-week preterm newborn female. 2. Mild respiratory distress syndrome. 3. Newborn jaundice. 4. Sepsis ruled out.
Slash|Divided by|138|He subsequently had an L5-S1 laminectomy in _%#CITY#%_ _%#CITY#%_, California. He had a prolonged interval of pain free activity until 1-1/2 weeks prior to hospital admission when he was golfing and felt a "clunk" in his lower back soon associated with stiffness, increasing pain, and decreasing mobility.
Slash|Either meaning|176|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is in today for follow-up of her DCIS of the right breast diagnosed on _%#MMDD1998#%_. The patient was a grade 3/3. She was ER/PR positive. REVIEW OF SYSTEMS: GENERAL: She has some hot flashes. Appetite is okay.
Slash|Date|55|ADMISSION DATE: _%#MMDD2005#%_ DISCHARGE DATE: _%#MM#%_/_%#DD2005#%_ ADMISSION & DISCHARGE DIAGNOSIS: Morbid obesity. PROCEDURE: Laparoscopic Roux-en-Y gastric bypass. SURGEON: Dr. _%#NAME#%_ _%#NAME#%_. REFERRING PHYSICIAN: Not noted.
Slash|Over(blood pressure)|150|Her mental health is good. No infectious symptoms other than her cough and elevated white blood cell count. OBJECTIVE: VITAL SIGNS: Blood pressure 142/77, heart rate 78, temperature 98.2. O2 sat 99 percent.
Slash|Date|186|She denies any dizziness or any other symptoms. PAST MEDICAL HISTORY: 1. DVT. The patient was first diagnosed in 1981 during pregnancy with a deep venous thrombosis and again in _%#MM#%_/98 the patient did receive Coumadin therapy. However, this was stopped after a 6-month therapy. 2. Depressive disorder.
Slash|Over(blood pressure)|144|4. Flexeril 10 mg t.i.d. 5. Vioxx. 6. Humalog insulin. PHYSICAL EXAMINATION: VITAL SIGNS: On admission, his temperature 99.8, blood pressure 162/92, heart rate 89, and saturation 95% on room air. LUNGS: His lungs were clear to auscultation. HEART: His heart was regular rate and rhythm.
Slash|Date|321|DOB: _%#MMDD1925#%_ REASON FOR ADMISSION: Exacerbation of COPD. _%#NAME#%_ _%#NAME#%_ is a pleasant 78-year-old white female, has been hospitalized recently at Fairview Ridges times two for pneumonia, where she grew an unusual bacteria. She had been seen by Dr. _%#NAME#%_ and Dr. _%#NAME#%_, had been discharged _%#MM#%_/_%#DD2003#%_. Had actually been doing fairly well when I saw her last week, but over the last 48 hours she had a significant exacerbation in her symptoms where she has become significantly weaker.
Slash|Separates two doses|188|PAST SURGICAL HISTORY: Includes laparoscopic cholecystectomy, appendectomy and history of some prostate ablation procedure with microwaves in _%#CITY#%_ _%#CITY#%_. MEDICATIONS: Include 70/30 insulin 12 units in the morning and 6 units in the evening, Rhinocort one puff in each nostril each night, Pulmicort two puffs b.i.d., Serevent two puffs b.i.d., Combivent b.i.d. p.r.n., Actonel he takes 5 mg daily and calcium 800 mg daily.
Slash|Date|206|In view of these symptoms she went on to have additional studies including a repeat CBC which again showed evidence of pancytopenia. She ultimately went on to have a bone marrow biopsy performed on _%#MM#%_/_%#DD2003#%_ with findings of acute myeloid leukemia with maturation.
Slash|Either meaning|170|She needs the physical therapy. Occupational therapy might be nice, but it is probably not something she will agree to so therefore I am not going to order it. She is DNR/DNI. She will be on Advair 500-50 one inhalation b.i.d., Singulair 10 mg q.d., albuterol and Atrovent nebs q.4h. p.r.n. She is on 20 mg of furosemide for edema, ranitidine 300 mg q.d. for reflux, and she is on Avapro 150 mg q.d. for her blood pressure.
Slash|Either meaning|31|MAJOR DIAGNOSIS: Splenic injury/laceration. MAJOR PROCEDURES: Interventional radiological embolysis of splenic artery branch and blood transfusion. HISTORY OF PRESENT ILLNESS: This is an 18-year-old Asian male in excellent physical condition otherwise who presented to the Fairview- University Emergency Room after sustaining a injury to his right flank in the dorms.
Slash|Date|105|Dr _%#NAME#%_ saw Mr _%#NAME#%_ on _%#MMDD2005#%_ and began to order the buprenorphine doses. By _%#MM#%_/_%#DD2005#%_ a tapering dose of buprenorphine was order, see chart.
Slash|Either meaning|123|HOSPITAL COURSE: 1. Acute respiratory failure. _%#NAME#%_ _%#NAME#%_ was admitted with acute respiratory failure. He is DNR/DNI and he was placed on BiPAP. The patient apparently had fairly agonal breaths when he was evaluated by EMS.
Slash|Of|167|Occasional end-expiratory wheezes on the left side, a little bit greater than the right side, with adequate air exchange. HEART: Regular rate and rhythm with about a 2/6 systolic murmur best heard in the right upper sternal border.
Slash|Over(blood pressure)|316|She has had three vaginal deliveries. REVIEW OF SYSTEMS: Otherwise negative for other major problems other than some paresthesia in her right hand when she uses her canes and pain intermittently in the right great toenail. She has occasional paresthesias of her toes. PHYSICAL EXAMINATION: VITALS: Blood pressure 138/70, pulse 70 and afebrile, weight 204 pounds, 5'3". GENERAL: Obese female in no acute distress. She uses a cane.
Slash|Date|322|She had an unremarkable postoperative course. Upper GI on postoperative day #1 revealed intact gastrojejunostomy which was patent and intact. Her diet was advanced to clears. She ambulated without difficulty, voided without difficulty, and when she was taking adequate p.o. she was discharged in good condition on _%#MM#%_/_%#DD2004#%_. DISCHARGE INSTRUCTIONS: 1. Follow up with Dr. _%#NAME#%_ in one to two weeks.
Slash|Date|260|The patient failed to show any real improvement and was made comfort measures only, and evaluated by the TLC team on approximately hospital day 10 or 11. The patient's pulmonary status failed to improve and the patient was made comfort care only as of _%#MM#%_/_%#DD2004#%_. The patient died _%#MMDD2004#%_ with family present. 2. ATN, acute renal failure.
Slash|Date|296|This was removed. There was a question that he could have a small pneumonia, based on CT scan of the chest on _%#MMDD2004#%_ which showed a possible small right upper lobe pneumonia. Nonetheless, the patient was started on IV vancomycin. He had blood cultures that were positive up until _%#MM#%_/_%#DD2004#%_ when they cleared. They were also clear on _%#MMDD2004#%_. The patient then developed some recurrent positive blood cultures growing MRSA on _%#MMDD2004#%_, _%#MMDD2004#%_ and _%#MMDD2004#%_.
Slash|Divided by|121|He had pulmonary function tests that were done while here on the admission. His FVC was 1.81, FEV1 was 0.01, and his FEV1/FVC was 56. Post bronchodilators, his FVC was 2.01, his FEV1 was 1.15, and his FEV1/FVC was 57.
Slash|Date|262|HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 31-year-old male who was admitted to Fairview Southdale Hospital following lensectomy, vitrectomy, and attempted retinal attachment in his right eye. He suffered a severe penetrating injury in the right eye on _%#MM#%_/_%#DD2002#%_. At the time of surgery, he was found to have an inoperable retinal detachment with a 360-degree giant retinal tear.
Slash|Over(blood pressure)|168|REVIEW OF SYSTEMS: 12-point review of systems is negative except for that noted in the history of present illness. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 140/74, temperature 99.2, pulse 72, respirations 28, weight 130 pounds.
Slash|Separates two doses|270|2. Acute renal insufficiency secondary to diuresis. Baseline creatinine 0.9 which did increase to 2.6 with diuresis and continued to improve; at the time of discharge it was 1.6 with continued improvement anticipated. MEDICATIONS AT THE TIME OF DISCHARGE: Avandamet 1000/4 mg p.o. b.i.d, Neurontin 600 mg p.o. q.A.M., Neurontin 900 mg p.o. q noon, and Neurontin 600 mg p.o. q.P.M., Buspar 15 mg p.o. t.i.d., Lexapro 10 mg p.o. q day, Dulcolax 10 mg p.o. t.i.d., Lopid 600 mg p.o. b.i.d., Plavix 75 mg p.o. q day, Prevacid 30 mg p.o. q day, trazodone 200 mg p.o. q.h.s., Zanaflex 4 mg p.o. q.i.d., Sonata 10 mg p.o. q.h.s., Zocor 80 mg p.o. q.h.s., Imdur 90 mg p.o. q day, morphine immediate release 15 mg p.o. q.i.d. p.r.n., Glucotrol XL 5 mg p.o. q day, enteric coated aspirin 81 mg p.o. q day, Tenormin 100 mg p.o. q day.
Slash|Date|198|PAST SURGICAL HISTORY: 1. Total colectomy with Parks pouch in 1980. 2. Hysterectomy. 3. Bilateral mastectomy. ALLERGIES: Compazine and morphine. HOSPITAL COURSE: The patient was admitted on _%#MM#%_/_%#DD2003#%_ and observed. An abdominal and pelvic CT scan showed no evidence of small bowel obstruction.
Slash|Date|238|2. Hemodialysis since _%#MM2002#%_. 3. Dialysis catheter placement. MEDICATIONS ON ADMISSION: Prevacid, multivitamin, and PhosLo. HOSPITAL COURSE: Status post living-related kidney transplantation. The transplant was performed on _%#MM#%_/_%#DD2003#%_. There were no complications. He was transported to the PACU in stable condition.
Slash|Of|234|He left the hospital with medications that included stoma supplies, Keflex liquid 500 mg t.i.d. and no pain medication except for plain Tylenol. FINAL DIAGNOSIS: Carcinoma of the rectum with regional lymph node metastatic disease to 2/9 pericolonic lymph nodes and of a worse prognosis vascular invasion of his poorly differentiated adenocarcinoma with signet ring features.
Slash|Either meaning|77|4. Begin Neupogen. 5. Hold further radiation therapy for now. 6. Continue DNR/DNI status from previous hospitalizations.
Slash|Date|185|FINAL HISTORY: The patient is a 23-year-old gravida 2 para 1 at 39 weeks gestation with previous Cesarean section. She desired repeat Cesarean section and presented for that on _%#MM#%_/_%#DD2007#%_. She underwent this without complication on that date and delivered a viable 8 pound 4 ounce female at 12:55.
Slash|Date|215|The medication intravenously has been stopped and the patient was started on levofloxacin 750 mg p.o. The repeat blood culture 1 day after start treatments no growth until now. The patient was discharged on _%#MM#%_/_%#DD2007#%_. The patient will be prescribed levofloxacin 750 mg a day to complete a course of treatment for community-acquired pneumonia for 14 days.
Slash|Date|243|PROGRAM PARTICIPATION: While at _%#CITY#%_, _%#NAME#%_ was involved in various tasks and assignments designed to address chemical dependency, sobriety, and recovery. _%#NAME#%_ attended 2 days of CD treatment at _%#CITY#%_. On Monday, _%#MM#%_/_%#DD2004#%_, _%#NAME#%_ admitted that he had been drinking all weekend.
Slash|Divided by|122|ASSESSMENT: Elderly female with constipation. Also lower gastrointestinal bleed, possible hem stool. PLAN: IV fluids, D5 1/2 normal 20 of K at 90 cc an hour. We will start conservative treatment to relieve her of her stool, enema times one, may repeat, as well as Colace 100 mg PO qd.
Slash|Date|13|DOB: _%#MM#%_/_%#DD1928#%_ DISCHARGE DIAGNOSES: 1) Congestive heart failure. 2) Cardiac dysrhythmias with atrial fibrillation/flutter and ventricular tachycardia. 3) Chronic obstructive pulmonary disease.
Slash|Date|182|She had had a previous cesarean section times two and declined vaginal birth after cesarean, she also desired permanent sterilization. She was taken to the operating room on _%#MM#%_/_%#DD2003#%_ where she underwent a repeat cesarean section and bilateral tubal ligation.
Slash|Over(blood pressure)|134|General negative. Endocrine: Sugars are checked usually once a day, around 1:30. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 132/64, pulse and respirations normal. GENERAL: The patient appears well. HEENT: Mouth normal. Eyes normal.
Slash|Date|218|5. Elevated prostatic specific antigen. 6. Family history of colon cancer, mother diagnosed in her 40s. HOSPITAL COURSE: Mr. _%#NAME#%_ was admitted in stable condition. He was brought to the operating room on _%#MM#%_/_%#DD2003#%_ for a Whipple procedure with Dr. _%#NAME#%_. After the patient's abdomen was opened, it was determined that the Whipple procedure would not be done, and instead an excisional liver biopsy, cholecystectomy, and exploratory laparotomy was done.
Slash|Over(blood pressure)|126|He complains of pain in the upper abdomen, underneath the ribcage. VITAL SIGNS: Temperature normal at 99.0, blood pressure 120/80, pulse and respirations normal. HEENT: Head is normal. Eyes reveal normal pupils. There is no evidence of jaundice, and the conjunctivae are normal.
Slash|Divided by|195|On her last cholesterol check, her triglycerides and cholesterol were elevated, but she had not been taking medications for this. PHYSICAL EXAMINATION: VITAL SIGNS: Weight 178 pounds, height 65 1/2 inches, blood pressure 120/70, temperature 98.3. HEENT: Within normal limits.
Slash|Date|13|DOB: _%#MM#%_/_%#DD1922#%_ CHIEF COMPLAINT: Shortness of breath. Back pain. HISTORY OF PRESENT ILLNESS: Patient is an 80-year-old white female who lives at Ebenezer Ridges Assisted Living.
Slash|Date|13|DOB: _%#MM#%_/_%#DD1922#%_ FINAL DISCHARGE DIAGNOSES: 1. Congestive heart failure probably secondary to diastolic dysfunction. 2. Hypertension.
Slash|Either meaning|94|PRIMARY DISCHARGE DIAGNOSES: 1. Syncope, with negative work up, and without recurrence. 2. UTI/hematuria. 3. Right hip pain. 4. Hypertension. SECONDARY DISCHARGE DIAGNOSES: 1. Dementia/depression. 2. Hypothyroidism.
Slash|Date|408|He had an angiogram at Abbott Northwestern Hospital in _%#MM2005#%_ which showed a 20% ostial and mid vessel lesion in the left anterior descending, a 20% lesion in the OM1 of the left circumflex system, and right coronary 30-50% mid vessel stenosis. Ejection fraction was 60%. The right coronary was nondominant. He has also undergone nuclear stress testing in _%#MM2006#%_ as well as a week ago on _%#MM#%_/_%#DD2007#%_. He was admitted on both occasions to North Memorial Medical Center for chest pain.
Slash|Of|221|Strength normal in all fields. Normal sensation and normal 2-point discrimination in all fields. Reflexes, biceps, brachioradialis, and patella are 2 /4 with exception of right patellar reflex which is hyperreflexive at 3/6. Plantar reflexes normal. Remainder of exam is unremarkable. Right SLR 65 degrees.
Slash|Either meaning|97|If ascites recurs, he may need therapeutic paracentesis for symptomatic relief. 2. Chronic anemia/thrombocytopenia. Her hemoglobin has been stable at 8.5. There is no evidence of acute active GI bleed.
Slash|Date|109|3. May shower. 4. The patient is to follow up with Dr. _%#NAME#%_ _%#NAME#%_ (Nephrology) on Monday, _%#MM#%_/_%#DD2006#%_ to receive her first dose of IV iron (of 2). Dr. _%#NAME#%_'s address is _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_, _%#CITY#%_, North Dakota _%#58000#%_.
Slash|Separates two doses|212|She was discharged with oral Dilaudid to use on a p.r.n. basis only, with 30 tablets with no refills, to be used only as she was recovering from this most recent exacerbation. DISCHARGE MEDICATIONS: 1. Advair 500/50 one puff b.i.d. 2. Ativan 1 mg p.o. nightly p.r.n. insomnia. 3. Prednisone 3 mg p.o. daily.
Slash|Over(blood pressure)|101|She has a visiting nurse who comes once a week. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 132/66, pulse is 50, irregularly irregular, temperature 97.1, 36.1 Celsius.
Slash|Date|305|PROGRAM: Fairview _%#CITY#%_ _%#CITY#%_ Outpatient REFERRED: _%#NAME#%_ _%#NAME#%_ DISCHARGE DATE: _%#MMDD2005#%_ DISCHARGE TYPE: Completed program. PROBLEMS PRESENT UPON ADMISSION: _%#NAME#%_ _%#NAME#%_ a 17- year-old male was admitted to our Fairview _%#CITY#%_ _%#CITY#%_ Outpatient Program on _%#MM#%_/_%#DD2005#%_. He was accompanied his social worker, _%#NAME#%_ _%#NAME#%_, and _%#NAME#%_ _%#NAME#%_, care manger at Hearthstone Group Home for the admission.
Slash|Either meaning|115|The patient was started on IV vancomycin. He underwent a 7-day course of IV vancomycin for this. 3. Wound infection/suspected fistula. On postoperative day 8, the patient's wound was noted to be leaking serous fluid and was slightly erythematous.
Slash|Either meaning|81|RECOMMENDATIONS: 1. Admit to surgical ICU. 2. Blood pressure control. 3. Stat MRI/MRA/MRV to rule out cavernous sinus thrombosis. 4. Repeat head CT without contrast at 4:00 p.m., 10:00 p.m. and 10:00 a.m. 5. Blood pressure control.
Slash|Date|76|FINAL HISTORY OF PRESENT ILLNESS: This 25-year-old para 2-0-0-3 EDD _%#MM#%_/_%#DD2008#%_ was admitted at 23 weeks' 3 days' complaining of lower abdominal pain. She reported that this pain had been present for about a week and had gradually increased.
Slash|Either meaning|268|Diet is regular, activity is as tolerated. The patient was seen by physical therapy and occupational therapy and secondary to her deconditioning, it was recommended that she go to a Transitional Care Unit. She refused this and therefore referrals were made for home PT/OT.
Slash|Date|209|FINAL DIAGNOSIS: Adenocarcinoma of the distal esophagus, status post induction chemotherapy and radiation therapy, with no evidence of residual carcinoma. SECONDARY DIAGNOSIS: Hypertension. PROCEDURE: _%#MM#%_/_%#DD2005#%_, right thoracotomy with mobilization of the thoracic esophagus and ligation of the thoracic duct.
Slash|Divided by|113|ALLERGIES: None known. Has an ACE inhibitor intolerance due to cough or tickle in his throat. HABITS: He smokes 1/2 pack a cigarettes a day, gets no regular exercise.
Slash|Date|131|2. Chronic venous insufficiency. The patient is known to have chronic renal insufficiency. His last creatinine was 1.76 on _%#MM#%_/_%#DD2005#%_. His other labs on _%#MMDD#%_ show a white blood count of 12.4, hemoglobin 12.2 and a platelet count of 267.
Slash|Date|168|She subsequently dialyzed well with her central venous catheter giving her TPA after each run and did well. She had several febrile episodes. Blood cultures on _%#MM#%_/_%#DD2005#%_, were negative. On _%#MMDD2005#%_, blood cultures were negative times one but positive times one for gram-positive cocci in clusters, perhaps a contaminant.
Slash|Either meaning|104|Of note, she was still having some mild increased urinary frequency symptoms. At this point, a repeat UA/UC is pending and she is on day 3 of 5 of her ciprofloxacin course.
Slash|Date|362|CARDIAC: Normal. Patient is B positive. ASSESSMENT: Probable retained products of conception noted on recent ultrasound status post termination of a 16-week pregnancy with lethal anomalies on _%#MMDD2007#%_. PLAN: Proceed with a suction dilatation and curettage. This will be performed by Dr _%#NAME#%_ _%#NAME#%_ at Fairview Ridges Hospital on Saturday _%#MM#%_/_%#DD#%_.
Slash|Date|198|FINAL REFERRING PHYSICIAN: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, MD. Dear Dr. _%#NAME#%_: Your patient, _%#NAME#%_ _%#NAME#%_, was admitted to the University of Minnesota Children's Hospital on _%#MM#%_/_%#DD2006#%_ in preparation for surgery. As you know, she was born with esophageal atresia and had her first 3 operations at the University of North Carolina Hospitals.
Slash|Over(blood pressure)|158|It is unclear what chronic symptoms she might have with a significant amount of renal failure. PHYSICAL EXAMINATION: In the office, her blood pressure was 166/98. HEART: Regular sinus rhythm without murmurs, gallops or rubs. LUNGS: Were clear.
Slash|Date|254|The only other new medication is amoxicillin which will be prescribed as 500 mg once a day x7 days to complete a 2 week course of antibiotic therapy. The patient will return to our office for another set of blood chemistries 48 hours from now on _%#MM#%_/_%#DD#%_. We will see the patient in the office during the week of _%#MM#%_ _%#DD#%_.
Slash|Either meaning|122|In the meantime, continue Levaquin 250 mg daily for at least a full weeks course of antibiotics. The patient remains a DNR/DNI DISCHARGE DIAGNOSIS: 1. Urinary tract infection and a neurogenic bladder. 2. Dehydration related to diuretics and treatment of her congestive heart failure.
Slash|Per|189|After she received O2 nebs and 80 mg of Lasix IV, she was reporting feeling quite comfortable and breathing easily in the ICU. PAST MEDICAL HISTORY: 1. Medications. She is on atenolol 20 mg/day, Miacalcin nasal spray once daily, Ativan 0.5 mg at h.s., Paxil 10 mg at h.s., Advair Diskus one puff twice daily, Atrovent one puff four times a day, albuterol one puff four times a day.
Slash|Date|13|DOB: _%#MM#%_/_%#DD2000#%_ HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 22-month- old with a history of a couple of URIs this year so far that have made a clinic visit. He presents now for a two-day history of worsening URI symptoms to the point he has increased shortness of breath, worsening cough, a little bit of low-grade temperature.
Slash|Of|383|He stated that the pain waxed and waned in intensity during the 3 minutes prior to him taking the nitroglycerin tablets, but it did not entirely go away on each occasion. The patient awoke this morning, ate breakfast, and shortly thereafter began to "feel rotten." Simultaneously with feeling rotten the patient developed a vague chest aching which was less intense than the _%#MM#%_/_%#DD#%_ chest discomfort that he had the previous evening.
Slash|Date|161|I JUST FINISHED A DICTATION ON _%#NAME#%_ _%#NAME#%_. I'M NOT SURE OF THE ADMISSION AND DISCHARGE DATES THAT I LISTED. The correct date of admission was _%#MM#%_/_%#DD2003#%_ and date of discharge is _%#MMDD2003#%_. If those dates were not given, please change the dictation to reflect that these were the dates of admission and discharge.
Slash|Over(blood pressure)|244|Denies any actual vomiting, abdominal pain, diarrhea or constipation. GENITOURINARY: The patient denies dysuria, hematuria or frequency. REMAINDER OF 16-POINT REVIEW OF SYSTEMS: Negative. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure is 145/96, pulse 75, respiratory rate 18. Oxygen saturation is 99% on room air. GENERAL: The patient is an alert, well-appearing male, lying comfortably in his hospital bed, in no apparent distress.
Slash|Date|160|The patient presents to Labor and Delivery on _%#MMDD2006#%_ with spontaneous rupture of membranes prior to onset of labor. The patient was admitted on _%#MM#%_/_%#DD2006#%_ at 2150 hours and at that point only irregular contractions were noted.
Slash|Date|183|The patient initially underwent a right total hip arthroplasty on _%#MMDD2006#%_ and went to rehabilitation four days later on _%#MMDD#%_. The patient eventually went home on _%#MM#%_/_%#DD2006#%_. Four days after her discharge to home, the patient had experienced right leg pain and was diagnosed with a deep venous thrombosis of the right lower extremity.
Slash|Over(blood pressure)|259|She denies tobacco or alcohol. FAMILY HISTORY: Noncontributory REVIEW OF SYSTEMS: Pertinent positives are mentioned in history of present illness. Review of systems is otherwise negative. PHYSICAL EXAMINATION : VITAL SIGNS: Temperature 98.2, blood pressure 73/48, pulse 87, respiratory rate 20, O2 sats 98% on room air.
Slash|Phone number|120|Thank you again for allowing us to share in the care of your patient. If questions arise, please contact us as _%#TEL#%_/_%#TEL#%_ (NICU) or _%#TEL#%_ (office). We hope to be of continuing service to you.
Slash|Of|135|He has never had similar chest pain. Initially, the pain was 3/10. On his arrival in the emergency department it was 7/10, reduced to 6/10 with three nitroglycerin, and then subsequently has gone down to 0 after 10 mg of IV morphine and some Dilaudid.
Slash|Date|72|BRIEF HISTORY: _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ was admitted to _%#MM#%_/_%#DD2003#%_ with metastatic breast cancer and history of spinal compromise with increased pain. (For details of her history please refer to the dictated History and Physical.) HOSPITAL COURSE: She was basically admitted because of uncontrolled pain secondary to her cancer.
Slash|Over(blood pressure)|94|PHYSICAL EXAMINATION ON ADMISSION: Weight 66 kg. Pulse 70. Respirations 16. Blood pressure 126/64. The patient is afebrile. GENERAL: He is alert and in no acute distress. HEENT: Benign.
Slash|Divided by|102|FINAL PROCEDURE: Laparoscopic appendectomy. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 5-1/2-year-old male child with a past medical history of Noonan's syndrome. The patient was referred to the peds surgery clinic for the complaint of nausea, vomiting and right lower quadrant pain.
Slash|Date|261|By postoperative day #2, the patient's creatinine had decreased to 0.5 from an initial reading of 4.45 immediately postoperatively. On _%#MMDD2007#%_ because of the patient's failure with Thymoglobulin, Simulect 10 mg IV was begun with a repeat dose on _%#MM#%_/_%#DD2007#%_. The steroid taper was given and weaned and the patient was discharged on 2.5 mg of prednisone p.o. daily.
Slash|Separates two doses|81|DISCHARGE MEDICATIONS: 1. Nasacort AQ one spray each nostril b.i.d. 2. Advair 250/50 mg 1 puff b.i.d. 3. Lescol 40 mg each day at bedtime. 4. Zetia 10 mg daily.
Slash|Date|112|FINAL HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 62-year-old white male who was admitted on _%#MM#%_/_%#DD#%_ after he presented with right arm numbness. The patient underwent a MRI, MRA which showed watershed infarct on the left.
Slash|Date|179|GENERAL: Alert, cooperative, no acute distress. HEAD, EARS, EYES, NOSE, THROAT: Clear. Nasal O2. GENITOURINARY: Continent of urine. GASTROINTESTINAL: Bowel, less function _%#MM#%_/_%#DD2006#%_. REHABILIATION EXAMINATION: Strength is increasing with therapy. She is oriented to time and place.
Slash|Divided by|114|5. Chronic gastroesophageal reflux. PLAN: The patient was discharged to home. She is on Metoprolol 50 mg tablets 1/2 PO b.i.d., Clonidine 100 mcg at bed time daily, Prilosec 20 mg daily and iron sulfate liquid 300 mg per 5 cc, 5 cc b.i.d. Follow- up with Dr. _%#NAME#%_ for blood pressure and check of anemia in 2-3 weeks.
Slash|Over(blood pressure)|348|On the day following the procedure, Mr. _%#NAME#%_'s wound was dry and intact with no drainage. PA and Lateral chest x-ray showed absence of pneumothorax and maintained favorable position of the new coronary sinus lead as well as the chronic right atrial and right ventricular leads. He experienced no fever overnight and his blood pressure was 109/74 with a heart rate of 61. His jugular venous pressure was less than 10 cm of water.
Slash|Date|240|She remained afebrile with vital signs stable. She is breast-feeding without problems. Discharged hemoglobin is 9.5. DISCHARGE INSTRUCTIONS: She will be discharged home with routine discharge instructions and routine medications on _%#MM#%_/_%#DD2003#%_.
Slash|Over(blood pressure)|129|For constitutional, please see History of Present Illness. He denies any HEENT symptoms. PHYSICAL EXAMINATION: Blood pressure 130/102, pulse 113, respirations 22, temperature 99.2, oxygen saturation 97%.
Slash|Date|85|She had a slow return of ability to take liquids. She was able to go home by _%#MM#%_/_%#DD#%_. Follow-up will be next week for drain removal.
Slash|Over(blood pressure)|161|REVIEW OF SYSTEMS : Nine-point review of systems is normal except for that which is stated on the HPI. PHYSICAL EXAMINATION: Temperature 98.2, blood pressure 117/67, pulse 83, weight 239 pounds. HEENT: Oropharynx is clear. PERRL. Respiratory: Lungs clear to auscultation.
Slash|Over(blood pressure)|110|There has been a history of hypertension. The patient's exam reveals normal vital signs. Blood pressure is 138/70, pulse is 81. The patient is afebrile. The patient of course is unable to communicate.
Slash|Over(blood pressure)|196|She has also had anxiety since her diagnosis, understandably. The rest of her complete review of systems is negative. PHYSICAL EXAMINATION: Weight is 139 pounds, height is 5'6". Blood pressure 129/73, pulse 70. GENERAL: The patient is in no apparent distress. She is alert and oriented.
Slash|Over(blood pressure)|77|Her temperature is normal. Her pulse is in the 50s. Her blood pressure is 109/65. She is making normal urine output. She has not passed gas or had a stool. She has not really had anything to eat since Thursday.
Slash|Date|198|HISTORY OF PRESENT ILLNESS: The patient is a 35 gentleman admitted to station 32 for evaluation and treatment of increasing symptoms of depression. He has been readmitted after discharge on _%#MM#%_/_%#DD#%_. I have been asked to see him for a general medical evaluation.
Slash|Over(blood pressure)|152|PHYSICAL EXAMINATION: GENERAL: This is an obese African-American female with good development, good hygiene, and full affect. VITALS: Blood pressure 132/80, pulse 72, age 55, height 5 feet 2 inches, weight 238, BMI 42.
Slash|Date|260|Additionally, there was no perineural or angiolymphatic invasion. The patient also had a bone scan on _%#MMDD2004#%_ which showed abnormal uptake in T12 and a questionable increased uptake in T7. He was further evaluated by a CT scan of the T-spine on _%#MM#%_/_%#DD2004#%_ which showed a 12 mm lesion on the right inferolateral aspect of the T12 vertebral body near a fractured osteophyte.
Slash|Over(blood pressure)|194|Respiratory rate 16 per minute, blood pressure 152/72. He is afebrile. Pulse ox is 95% on room air. Orthostatic blood pressures were checked and are as follows: The supine blood pressure was 163/73 with a pulse of 64, sitting blood pressure 159/75 with a pulse of 61, and a standing blood pressure of 104/55 with a pulse of 70.
Slash|Date|203|The patient has been counseled regarding the indication, risks, and benefits of the procedure. Because of her O negative status, the patient has already received the RhoGAM shot in our office on _%#MM#%_/_%#DD2002#%_.
Slash|Over(blood pressure)|187|NEUROLOGIC: None. PSYCHIATRIC: None. INTEGUMENT: None. EYES: None. ENT: None. CARDIOVASCULAR: Status post LVAD. PHYSICAL EXAMINATION: VITAL SIGNS: Afebrile, T-max 98.1, blood pressure 115/86, heart rate 142. GENERAL: He is awake, alert, oriented x3, appears comfortable at rest.
Slash|Date|175|REQUESTING PHYSICIAN: Dr. _%#NAME#%_ _%#NAME#%_. CHIEF COMPLAINT: Fell out of bed. Pelvic and hip pain. Rule out fracture. HISTORY: _%#NAME#%_ _%#NAME#%_ was admitted _%#MM#%_/_%#DD2005#%_ with a non- syncopal fall. Has good recollection of the injury. Was seen at Fairview Southdale Hospital also for UTI.
Slash|Over(blood pressure)|106|Does not smoke or drink. REVIEW OF SYSTEMS: See HPI. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 139/66, pulse 112, respiratory rate 36, temperature 102.8, saturations were in the 90s on oxygen.
Slash|Over(blood pressure)|205|We will need to obtain additional information from previous records. PHYSICAL EXAMINATION: GENERAL: 70-year-old male in moderate respiratory distress but breathing comfortably with BiPAP at a setting of 15/5, sinus tachycardia. VITAL SIGNS: Blood pressure is hypotensive but stable with fluids and low-dose of dopamine.
Slash|Over(blood pressure)|158|CHEMOTHERAPY/RADIATION TREATMENT: No chemo, hormone or radiation therapy. ALLERGIES: No known allergies. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 132/80, pulse 88, respirations 18, temperature 97.1 and weight 196.
Slash|Either meaning|83|PHYSICIAN FOLLOWUP: 1. The patient is scheduled to see Dr. _%#NAME#%_ in hematology/oncology clinic on _%#MM#%_ _%#DD#%_, 2006, at 8 a.m. 2. The patient is also scheduled to have outpatient labs as well as IV fluids as needed at Masonic Day Hospital on _%#MM#%_ _%#DD#%_, 2006 and _%#MM#%_ _%#DD#%_, 2006, at 8:30 a.m. Please page me at _%#TEL#%_ with any further questions.
Slash|Either meaning|149|HEAD is atraumatic and normocephalic. Eyes - Pupils are equal, round and reactive to light. Oral mucosa is moist. NECK is supple. CARDIOVASCULAR - S1/S2 and regular. RESPIRATORY - Clear to auscultation. ABDOMEN is soft, bowel sounds present, no tenderness, mild hepatomegaly present.
Slash|Over(blood pressure)|148|No change in bowel or bladder habits. Review of systems is completed and is otherwise negative. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 96/70. Pulse 80 and regular. Afebrile. GENERAL: She does appear well.
Slash|Over(blood pressure)|139|At the time of her evaluation by a surgical team, her pain had resolved. On admission, the patient was afebrile. Her blood pressure was 117/79, pulse 78, respiratory rate of 20, and oxygen saturations were 100% on room air.
Slash|Date|133|Her hemoglobin is 15.1. Her potassium is pending. IMPRESSION/PLAN: 1. Left foot pain secondary to fracture which occurred in _%#MM#%_/2006.
Slash|Separates two doses|100|5. Zoloft 100 mg q.h.s. 6. Lasix 20 mg daily. 7. Lantus insulin 10 units q.h.s. 8. Advair Diskus 100/50, 1 puff b.i.d. 9. Ultram 100 mg q.i.d. p.r.n. 10. Midrin 1-2 tablets q.4h. p.r.n. headache.
Slash|Of|144|She answered questions appropriately, although sometimes slightly delayed in her response. Her cranial nerves were intact bilaterally. She had 5/5 strength in all major muscle groups in the upper and lower extremities bilaterally.
Slash|Of|97|NEUROLOGIC: Cranial nerves II-XII are grossly intact without any facial droop. Grip strength is 5/5 throughout. Sensation is intact. Her reflexes are 2+ in the upper extremities bilaterally. Trace patellar reflexes on the lower extremities bilaterally.
Slash|Divided by|126|Premature rupture of membranes was confirmed at _%#MM#%_ _%#DD#%_, 2003. She is status post betamethasone x2 approximately 2-1/2 weeks prior to admission after a bleeding episode with her primary physician.
Slash|Date|119|The appointment with Dr. _%#NAME#%_ is at 12:30 p.m. and the appointment with Dr. _%#NAME#%_ this at 1 p.m. on _%#MM#%_/_%#DD2007#%_. The patient will need a postoperative scan in 4 weeks' time and should schedule before that clinic visit.
Slash|Date|95|FINAL _%#NAME#%_ _%#NAME#%_ is coming in for surgery at Fairview Southdale Hospital on _%#MM#%_/_%#DD2006#%_. She is a 38-year-old female who I saw in consultation in mid _%#MM#%_.
Slash|Separates two doses|78|4. Coumadin 2 mg daily or as directed. 5. Metoprolol 25 mg b.i.d. 6. Cozaar 50/12.5 one pill daily. 7. Multivitamin daily. 8. She uses 2.5% hydrocortisone cream on her left lower leg twice daily.
Slash|Either meaning|141|FOLLOW-UP: 1. _%#CITY#%_ _%#CITY#%_ Coumadin Clinic for INR draw at 9 a.m. on _%#MMDD2005#%_ and daily thereafter for 3 days. 2. Oral Surgery/dentist at F-UMC on Thursday, _%#MMDD2005#%_. The patient is to call _%#TEL#%_ for directions if needed.
Slash|Over(blood pressure)|202|REVIEW OF SYSTEMS: Recent fevers, vomiting and diarrhea without abdominal pain. No dysuria, cough, dyspnea, headache, sore throat. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 97.2, blood pressure 113/64, heart rate 63 and regular, respirations 20. GENERAL: Well-developed, well-nourished, alert and oriented. Looks mildly to moderately ill and dehydrated.
Slash|Over(blood pressure)|152|2. There is a left renal simple cyst. 3. An 8 mm right hepatic lobe lesion. EXAMINATION: Temperature 99.0, pulse 77, respirations 18, blood pressure 131/67. GENERAL: She is alert and oriented and became very tearful when she had left flank pain.
Slash|Date|169|HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 63-year-old man with type 2 diabetes mellitus who was admitted to the General Clinical Research Center on _%#MM#%_/_%#DD2005#%_. He has participated in protocol 1008. Research tests were accomplished without difficulty, and he was discharged in _%#MMDD2005#%_.
Slash|Either meaning|196|On _%#MM#%_ _%#DD#%_, 2005, the patient was taken to the OR; as stated above, the patient underwent a left lower lobectomy. At the time of surgery, it was noted that the patient had a mat of nodes/mass at the distal portion of her mainstem bronchus that came back positive for metastatic disease.
Slash|Respectively|154|4. Nephrolithiasis. 5. Parathyroidectomy. 6. "Tumor" removed from brain. I do not have details regarding this. MEDICATIONS: Diovan/hydrochlorothiazide 160/12.5 mg p.o. q. day. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Nonsmoker. Occasional alcohol.
Slash|Date|208|This was felt to be viral etiology and did clear with supportive measures and has left no residual problems. Her last menstrual period was _%#MMDD#%_, her estimated date of confinement was originally _%#MM#%_/_%#DD#%_. However, based on an early ultrasound, we have changed that to _%#MMDD#%_.
Slash|Date|13|DOB: _%#MM#%_/_%#DD1921#%_ HISTORY OF PRESENT ILLNESS: This 81-year-old gentleman with Alzheimer's disease was seen in Urgent Care with a swollen, painful left foot. He was felt to have cellulitis and was given IM Rocephin in the clinic three days in a row with no improvement.
Slash|Over(blood pressure)|215|No hot or cold intolerance, no lymphadenopathy or edema. SOCIAL HISTORY: She is married, does not use alcohol, smokes half a pack of cigarettes per day. FAMILY HISTORY: Noncontributory. OBJECTIVE: Blood pressure 216/116, heart rate 74, temperature 98.1, respiratory rate 18.
Slash|Date|267|PRELIMINARY REASON FOR ADMISSION: Symptomatic rectocele. FINAL DIAGNOSIS: Status post vaginal hysterectomy, bilateral salpingo-oophorectomy, anterior and posterior repairs. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ was admitted to Fairview Southdale Hospital on _%#MM#%_/_%#DD2006#%_ for scheduled surgery secondary to a symptomatic cystocele.
Slash|Either meaning|418|In particular, we have discussed the risks of hospitalization, anesthesia, swelling, discomfort, jaw wiring, Lefort I risks, including but not limited to nasal air flow changes, septal deviation, bleeding, hardware placement and/or removal, sinus problems, endodontics therapy or damage to teeth. In the mandible, we discussed the following to include, but not limited to the sagittal split cut, hardware placement and/or removal, nonunion, malunion, reoperation, TMJ problems, numbness along the third division of the trigeminal nerve which can be temporary or permanent, and other issues.
Slash|Date|239|4. Oxycodone 5-10 mg p.o. q.6h. p.r.n. HOSPITAL COURSE: The patient is a 55-year-old man who was admitted on _%#MMDD2006#%_ by Dr. _%#NAME#%_. Please refer to her dictated H&P for details. The patient had actually been admitted on _%#MM#%_/_%#DD#%_ with right lower extremity cellulitis. He left AMA and he came back in intoxicated with a blood alcohol level of 0.15. He was placed back on IV Unasyn and because of his behavior related to his alcoholism, psychiatry was called back and commitment proceedings were begun.
Slash|Either meaning|156|Will start Clonidine when medication list arrives or it is apparent that her blood pressures are not adequately controlled on Zestril. 6. Code status is DNR/DNI. Discussed with the patient and she does emphatically confirm this.
Slash|Date|128|For the first several days of admission, the patient did not have any spells subjectively or objectively on the EEG. On _%#MM#%_/_%#DD2003#%_, the patient's EEG was noted to be abnormal, showing focal abnormalities in the left posterior temporal area and some runs of rhythmic high voltage sharp waves with the left temporal and parasagittal region compatible with electrographic seizure.
Slash|Separates two doses|81|1. Lipitor 40. 2. Lopid 600 b.i.d. 3. Norvasc 10. 4. Atenolol 25. 5. Lisinopril 5/500 mg. 6. Aspirin 81 mg.
Slash|Date|176|Cervical os was closed. External genitalia within normal limits. Right adnexal and right uterine tenderness were present, although no cervical motion tenderness. d. On _%#MM#%_/_%#DD2003#%_, the patient was seen for similar symptoms at North Memorial, and at that visit also had an ultrasound that showed an intrauterine pregnancy, as well as small ovarian cysts.
Slash|Either meaning|54|HISTORY OF PRESENT ILLNESS: 34-year-old woman with HIV/AIDS is admitted with recurrent vaginal ulcers. She has been followed by Dr. _%#NAME#%_ at Regions for this problem as well as here for a number of months.
Slash|Of|242|HEENT: Normocephalic. However, there is some evidence of trauma on the left occiput with some bruising. NECK: Supple. CHEST: Clear to auscultation and percussion. CARDIOVASCULAR: Regular rate and rhythm, S1, S2 are somewhat decreased with a 1/6 systolic murmur. JVP is normal. Carotid upstrokes are normal. ABDOMEN: Soft, nontender without hepatosplenomegaly.
Slash|Over(blood pressure)|176|She also had high blood pressure, may have been exacerbated by her steroid use. At any rate, I did start her on nifedipine because her blood pressures were very high in the 180/100 range, and then even if her blood pressure comes down after the steroids, she may have benefit from prophylactic treatment for migraines with the nifedipine.
Slash|Over(blood pressure)|251|Negative for other constitutional, endocrine, HEENT, GI, respiratory, cardiovascular, genitourinary, musculoskeletal, or neurologic symptoms outside of her usual knee pain. PHYSICAL EXAMINATION: VITAL SIGNS: In the ER, initially blood pressure was 115/67, pulse 107, respiratory rate 12, temperature 98.6, O2 saturation 94% on room air.
Slash|Date|347|DOB: DISCHARGE DIAGNOSIS Gastroenteritis, likely viral in etiology. CONSULTATIONS: None. PROCEDURES: None. PERTINENT LABORATORY STUDIES: On presentation, the urinalysis showed some ketones, 2 to 5 white blood cells, no nitrites or leukocyte esterase; urine culture negative; fecal leukocytes negative; magnesium 1.8; and phosphorus 1.8 on _%#MM#%_/_%#DD2004#%_. At the time of discharge, white blood cell count 3100, hemoglobin 10.9, MCV 90, platelet count 236,000, and RDW 10.8, normal.
Slash|Either meaning|240|1. End-stage renal disease on hemodialysis Tuesday, Thursday and Saturday at the _%#CITY#%_ Dialysis Unit. 2. Atherosclerotic cardiovascular disease (ASCVD) and is apparently status post percutaneous transluminal coronary angioplasty (PTCA)/stent. 3. Chronic obstructive pulmonary disease (COPD). 4. Recent upper GI bleed due to gastritis.
Slash|Of|166|ABDOMEN: Benign and diffusely nontender, without focal findings. EXTREMITIES: Symmetric for tone and strength. She is right-hand dominant. Deep tendon reflexes are 2+/4+ in the upper and lower extremities bilaterally. She has no edema. There is no tremor. Cranial nerves II through XII appear to be grossly intact, though visual acuity, hearing, taste, and smell were not specifically evaluated.
Slash|Date|217|PREOPERATIVE MEDICATIONS: Ritalin, Prempro, Prevacid, Synthroid, Lithobid, Trazodone, Alprazolam, Temazepam. ALLERGIES: No known drug allergies. HOSPITAL COURSE: The patient was taken to the operating room on _%#MM#%_/_%#DD2002#%_ and underwent ACDF at C5-6 level with fixation. Her hospital course was complicated in the postoperative recovery room by acute onset of difficulty breathing as well as chest pain.
Slash|Date|13|DOB: _%#MM#%_/_%#DD1988#%_ _%#NAME#%_ _%#NAME#%_ is a 14-year-old referred by Dr. _%#NAME#%_ _%#NAME#%_ with a history of chronic sinusitis symptoms. He also has had recurrent bouts of pharyngitis and tonsillitis associated with sinus symptoms.
Slash|Over(blood pressure)|223|REVIEW OF SYSTEMS: Constitutional: Weight loss, anorexia, general weakness. Eye, ENT, respiratory, cardiovascular, GI, GU, and neurologic: Stable and negative. PHYSICAL EXAMINATION: VITAL SIGNS: Afebrile; blood pressure 150/93, heart rate 90, respiratory rate 20, oxygen saturation 96% on room air.
Slash|Per|141|She is accompanied by her daughter _%#NAME#%_. She says that she wears glasses mainly for reading. Vision without glasses for distance was 20/50 +2 right eye, 20/40 left eye. The external eyes showed 1-2+ conjunctival injection bilaterally. Pupils were round and reactive.
Slash|Date|120|For further details about admission note, please review the note dictated by Dr. _%#NAME#%_'s admission note on _%#MM#%_/_%#DD2007#%_. I have spent more than 30 minutes doing this discharge summary.
Slash|Over(blood pressure)|259|The patient has no arthralgias or myalgias. The patient's history is certainly questionable due to her dementia and her illness at the present time. PHYSICAL EXAMINATION: VITAL SIGNS: The patient's vital signs show her to have a blood pressure initially of 96/53, pulse 79, respiratory rate 20 and O2 saturation was 99% on room air, I believe.
Slash|Divided by|125|PRELIMINARY HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 36-year-old female, gravida 2, para 1-0-0-1, who was admitted at 33 5/7 weeks estimated gestational age with preterm labor. At the time of admission, she was having regular contractions and her cervix was noted to be 1 and 75% effaced.
Slash|Date|112|No thigh edema. Muscles are atrophic. NEUROLOGIC: He appears nonfocal. LABORATORY DATA: Laboratory from _%#MM#%_/_%#DD2007#%_ reveals an INR of 5.72, BUN 94, creatinine 4.1, potassium is 3.8. IMPRESSION: 1. Kidney failure. Recent decline from his baseline level of kidney function of uncertain cause, it may only all be prerenal in the setting of high diuretic use.
Slash|Date|188|This showed mild superficial perivascular lymphocytic infiltrate with mild papillary dermal edema. No microorganisms were noted with staining. 5. Abdominal ultrasound performed on _%#MM#%_/_%#DD2004#%_ performed for jaundice. This showed a cystic structure in the pancreas, which may represent a pancreatic pseudocyst.
Slash|Date|249|3. Portable abdominal x-ray on _%#MMDD2007#%_ showing obstruction is not seen, moderate gasses, distention of the colon with air extending to the rectum. The pattern is similar to _%#MMDD2007#%_ study. 4. Abdominal flat and upright x-ray on _%#MM#%_/_%#DD2007#%_ showing nonobstructive bowel gas pattern, bibasilar subsegmental atelectasis.
Slash|Respectively|73|1. Lisinopril 20 mg daily. 2. Clonidine 0.1 gm q.h.s. 3. Atenolol/HCTZ 50/25 mg daily. 4. Levothroid 100 mcg daily. ALLERGIES: No known drug allergies. SOCIAL HISTORY: She lives alone.
Slash|Either meaning|77|He was started on promotility agents and his fentanyl patch was stopped. Heme/Onc was consulted who recommended a trial of oral Narcan.
Slash|Date|239|MRSA bacteremia and bronchopneumonia. The patient was seen by infectious disease during his hospitalization. They elected to have 28 day total vanco treatment and at that time the patient should finish his 28 days of vancomycin on _%#MM#%_/_%#DD2007#%_. He has tolerated this well. Depression. The patient's Wellbutrin will be restarted on _%#MMDD2006#%_.
Slash|Date|187|DISCHARGE DIAGNOSIS: Degenerative arthritis, right knee. PROCEDURES: Hardware removal, right knee, and right high tibial osteotomy, both performed by Dr. _%#NAME#%_ _%#NAME#%_ on _%#MM#%_/_%#DD2002#%_. Please see the patient's admission history and physical for details.
Slash|Date|175|DISCHARGE MEDICATIONS: 1. Decadron 40 mg taken daily with a start of his second full schedule being started on _%#MMDD2002#%_. 2. He was to take high dose Decadron on _%#MM#%_/_%#DD2002#%_ and _%#MMDD2002#%_ followed by four day rest and then restart on _%#MMDD2002#%_.
Slash|Either meaning|65|8. Tylenol 650 mg p.o. or p.r.n every 4 hours p.r.n. 9. Albuterol/Atrovent neb every 4 hours p.r.n. 10. Artificial tears, one drop to each eye 5 times a day p.r.n. 11. Oxycodone 5 to 10 mg oral solution every 4 hours p.r.n.
Slash|Date|111|The patient was in bed all day, is weak and tired, with generalized weakness. The day after, Thursday, _%#MM#%_/_%#DD2007#%_, the patient felt increase in above symptoms. The patient was seen in urgent care at Fairview Hiawatha Clinic on _%#MMDD2007#%_.
Slash|Date|115|She continued to have coarse rhonchi and some rales in the lower lung fields. She had concomitant COPD. By _%#MM#%_/_%#DD2006#%_ she was feeling quite well. Her diabetes medications were followed and adjusted. She was discharged to home.
Slash|Separates two doses|245|6. Aortic valve replacement with tissue valve. ALLERGIES: No known drug allergies. MEDICATIONS: Toprol XL 50 mg p.o. q.d., Hytrin 10 mg p.o. q.d., Cozaar 50 mg p.o. b.i.d., Zocor 40 mg p.o. q.h.s., potassium chloride 20 mEq p.o. q.d., Advair 250/50 one inhalation b.i.d., Zantac 150 mg p.o. b.i.d. p.r.n., allopurinol (renal dose) 200 mg p.o. q.d., Augmentin (renal dose) 500 mg p.o. b.i.d. five days complete full course of therapy.
Slash|Of|184|GU: She is a gravida 3 AB 1, LC 2. She is not sexually active. Neurologic: See above. Musculoskeletal: Low back is "killing her," with bilateral leg pain up to 10/10 with walking but 0/10 at rest. Endocrine: No history of diabetes or thyroid disease. PHYSICAL EXAMINATION: Delores is pleasant, cooperative, well- nourished and well-developed.
Slash|Per|481|Reflexes were symmetric and 2+ throughout. LABORATORY: Chest x-ray demonstrated poor inspiratory film with small bilateral pleural effusions and a bibasilar atelectasis greater on the right than on the left with heart size being within normal limits. Albumin was 1.6. Ionized calcium was 4.7. Basic metabolic panel demonstrated sodium 135, potassium 4.0, chloride 107, total CO2 25, anion gap 2, glucose 119, BUN 18, creatinine 0.5, and total calcium 7.8. Urinalysis showed >300 mg/dL protein and 50-100 RBC. PROBLEMS: 1. Relapsing nephrotic syndrome. The patient was started on Solu- Medrol 2/mg/kg/d divided t.i.d. On day 6 he was switched over to oral prednisone at the same dose.
Slash|Date|149|PAST MEDICAL HISTORY: 1. Diabetes mellitus type 1. 2. End-stage kidney disease secondary to diabetic nephropathy. 3. History of hemodialysis _%#MM#%_/2007-_%#MM2007#%_. 4. Hypertension, controlled. 5. Hyperlipidemia, controlled. 6. History of severe depression.
Slash|Date|13|DOB: _%#MM#%_/_%#DD1941#%_ ADMITTING DIAGNOSIS: Diabetes, out of control with dehydration and hyperosmolar state. DISCHARGE DIAGNOSIS: Diabetes, out of control with dehydration and hyperosmolar state.
Slash|Over(blood pressure)|149|REVIEW OF SYSTEMS: Non-contributory. The patient denies any medical problems at this time or other symptoms. PHYSICAL EXAMINATION: Blood pressure 150/90, pulse is 80 and regular, afebrile. He alert and oriented x 1. HEENT: negative. NECK: normal.
Slash|Separates two doses|80|4. Digitek 0.125 mg daily. 5. Rythmol 225 mg, 1 tablet q. 8 hours. 6. Advair 250/50, 1 puff twice a day. 7. Albuterol inhaler 1-2 puffs every 4 hours as needed.
Slash|Over(blood pressure)|281|We admitted him and gave him IV furosemide. We continued him on his Avapro, changed the bisacodyl to Coreg and by _%#MM#%_ _%#DD#%_, he had no orthopnea, no paroxysmal nocturnal dyspnea, no dyspnea on exertion. His blood pressure sitting was 100/48; blood pressure standing was 105/50, his pulse was running in the 50's, percent saturation on room air was 96 and he was able to walk 100 feet without difficulty.
Slash|Per|474|LABORATORY: White blood count 4.2, hemoglobin 10.7, platelets 369,000, with an absolute neutrophil count of 2.7. Her basic metabolic panel was all within normal limits with a potassium of 4.1 and a creatinine of 0.9. Liver function profile was also within normal limits. Her albumin was 3.8. Her magnesium was 2.0. HOSPITAL COURSE: She underwent her chemotherapy course which included an initial dose of etoposide 12.5 mg/m2 on day 1 followed by course of cisplatin at 15 mg/m2 for a total dose of 83 mg and then completed her course of chemotherapy with a second dose of etoposide at 112.5 mg/m2 just prior to discharge.
Slash|Date|138|He has been seen two or three times in the clinic with what was felt to be a viral syndrome. He was seen in the emergency room on _%#MM#%_/_%#DD2003#%_, at which time a spinal tap was done, and it was negative.
Slash|Of|138|2. On _%#MM#%_ _%#DD#%_, 2003, a BPP of 8/8 for NST. Fetal presentation at transfer, head on left. 3. On _%#MM#%_ _%#DD#%_, 2003, BPP of 8/8, AFI of 7.01 cm, cephalic presentation. Doppler study SD ratio of 2.69. 4. On _%#MM#%_ _%#DD#%_, 2003, BPP 6/8, Doppler study SD ratio of 2.13, amniotic fluid 2.64, placenta anterior with vertex presentation.
Slash|Date|200|After the angiography she was reanticoagulated. We adjusted her medications for rate control, and idiopathic cardiomyopathy regimen. The patient slowly improved and is stable for discharge on _%#MM#%_/_%#DD2004#%_. The patient is requiring 2.5 units of oxygen. Her weight on discharge is 84.8. Her blood pressure is 113/76.
Slash|Over(blood pressure)|328|No melena. Patient's risk factors for cardiac disease includes hyperlipidemia in the past, a strong family history with her older brother, 41 years old, having 3 MI in the past year, patient also smokes pot 2-3 times a week. Patient was admitted to the cardiology unit on telemetry. Her vital signs included blood pressure of 94/57, heart rate 72, afebrile, saturation 99% on room air.
Slash|Separates two doses|133|DISCHARGE MEDICATIONS: Same as on the admission including: 1. Toprol-XL 25 mg PO q. day. 2. Lisinopril 10 mg PO q. day. 3. Vytorin 10/5 one pill PO q. day. 4. Baby aspirin PO q. day. 5. Multivitamin PO q. day.
Slash|Date|448|The patient was admitted to the ICU, MI was ruled out, but because he had a slight bump in cardiac enzyme up to 0.43, Cardiology was consulted and recommended stress testing following hospitalization. Cardiology followed him through the course of the hospitalization. He was treated with anti-inflammatories, initially Indocin, then switched to Toradol, which offered better symptom improvement, and then he was switched back to Indocin on _%#MM#%_/_%#DD2005#%_. His pain has continued to improve with decreased discomfort with respirations and with position.
Slash|Either meaning|122|7. Colace 100 mg b.i.d. 8. Celebrex 100 mg daily. REHABILITATION COURSE: The patient was admitted to rehabilitation for PO/OT. She did well. There were no complications. Her narcotics were managed by the physician because of the patient's concern about dependent issues.
Slash|Date|140|She states she felt slightly less short of breath within 24 hours but the symptoms have been slow to resolve this time. However, by _%#MM#%_/_%#DD2004#%_, she states she felt like her breathing had improved dramatically.
Slash|Divided by|124|13. Warfarin dose on _%#MMDD#%_ and _%#MMDD#%_ should be 1.5 mg for INR of 1.85. 14. The patient has been receiving 1 to 1 1/2 mg of Coumadin daily. The patient should have a follow-up with Dr. _%#NAME#%_ in the _%#CITY#%_ Office in four weeks.
Slash|Date|114|She had group B Strep negative culture late in pregnancy. One-hour glucose was 83. She received RhoGAM on _%#MM#%_/_%#DD2006#%_. FAMILY HISTORY: Is negative essentially. No pertinent diseases. ALLERGIES: No known allergies to medications.
Slash|Date|240|Pericardiocentesis had been performed during that stay, 420 mL of fluid was drained off during that visit and a followup echocardiogram showed limited reaccumulation of fluid. However, when he was seen again in Cardiology Clinic on _%#MM#%_/_%#DD2006#%_, the size of the effusion had increased. He was therefore admitted for observation. Additionally, _%#NAME#%_ was having some abdominal pain.
Slash|Date|160|4. Pravachol 20 mg p.o. daily. 5. Flomax 400 mcg p.o. daily. HOSPITAL COURSE: Ms. _%#NAME#%_ _%#NAME#%_ is an 84-year-old gentleman who was admitted on _%#MM#%_/_%#DD2007#%_ with delirium and blood loss anemia. Upon admission, the patient was started on IV proton pump inhibitor.
Slash|Of|205|HEENT: Normocephalic, atraumatic examination. Mucous membranes slightly dry. Multiple actinic keratoses on the skin. Neck is supple with no lymphadenopathy. Cardiovascular: Regular rate and rhythm with a 2/6 systolic murmur located along the left and right sternal border.
Slash|Date|164|5. Folic acid 5 mg p.o. daily. 6. Hydroxyurea 2000 mg p.o. daily. 7. Senokot S 2 tablets p.o. daily. 8. Vancomycin 1 gm IV b.i.d., to be discontinued after _%#MM#%_/_%#DD2007#%_. DISCHARGE FOLLOWUPS: She shoul follow up with Dr. _%#NAME#%_ in clinic in 1 week.
Slash|Date|130|3. Infectious disease. Blood culture, urine culture, influenzae A&B and RSV were all negative. He spiked a temperature on _%#MM#%_/_%#DD2002#%_ to 101.2 and was afebrile after that. 4. Ophthalmologic. He had purulent drainage from both eyes and was started on Polytrim drops on the day of discharge.
Slash|Over(blood pressure)|215|There are no other major medical problems. REVIEW OF SYSTEMS: Essentially negative, except for the symptoms of withdrawal. PHYSICAL EXAMINATION: Temperature is98, pulse is 80, respirations are 20, blood pressure 124/90. In general, this is a well- developed, well-nourished 54-year-old male in no apparent distress.
Slash|Date|258|Postoperatively, she was monitored on the ward. Her externalized shunt was clamped for several days, and repeat head CT demonstrated no change. Also, she had no change in her mental status. It was felt that she was not dependent on her shunt, and on _%#MM#%_/_%#DD2002#%_ she was taken to the operating room where the distal portion of the shunt was removed and the proximal portion was tied in the neck.
Slash|Date|13|DOB: _%#MM#%_/_%#DD1927#%_ ADMISSION DIAGNOSES: 1. Exacerbation of chronic obstructive pulmonary disease with acute onset of shortness of breath and a cough. Also felt to have pneumonia. 2. He also had known coronary artery disease with previous myocardial infarction and had some mild signs of congestive heart failure as well.
Slash|Over(blood pressure)|105|She does have a gag. She does not have any obvious focal neurologic motor deficits. Blood pressure is 110/50. Heart rate is 90 and regular. She is afebrile. Respiratory rate is 24. Oxygen saturations 98% on 15 liters of O2 per mask.
Slash|Date|241|The social worker is also ensuring that her Lovenox will be covered by her insurance company as an outpatient. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ is a 46-year-old white female who was admitted to Fairview Southdale Hospital on _%#NAME#%_/_%#DD2004#%_ after she presented to Fairview Southdale Hospital emergency room with a history of swelling and pain in her left calf for approximately one month.
Slash|Date|112|On _%#MMDD2004#%_ Seroquel at 25 to 50 mg, up to 4 times daily if needed for anxiety, was reordered. On _%#MM#%_/_%#DD2004#%_ Antabuse 250 mg every day was added, and a decreasing scale of Depakote was started.
Slash|Date|232|DISCHARGE INSTRUCTIONS: Therapy instructions are for sling full-time with elbow, wrist and hand exercises and no shoulder movement. She is to sponge bathe. DISCHARGE FOLLOW-UP: I will see her back in the office on Thursday, _%#MM#%_/_%#DD2006#%_, at Minnesota Sports Medicine - Riverside Clinic, at which time she will need AP and lateral radiographs of the entire left humerus.
Slash|Date|204|According to her she had just seen Dr. _%#NAME#%_ several weeks ago where her Glargine insulin was increased to 51 units in the morning and 50 in the evening. Her discharge insulin, however, from _%#MM#%_/_%#DD#%_ was 15 units in the morning and 4 units in the evening.
Slash|Over(blood pressure)|141|ADMIT EXAMINATION: VITAL SIGNS: On admit, _%#NAME#%_ weighed 86.9 kg. Temperature was 96.8, pulse 106, respirations 20 and blood pressure 132/93. GENERAL: He is a well nourished, well developed male in no apparent distress.
Slash|Date|153|Her hemoglobin was 10.2 on the first postoperative day. The babies also did very well in the newborn nursery. The patient was discharged home on _%#MM#%_/_%#DD2006#%_ in stable condition. She received prescriptions for Lexapro 1 tablet daily and Vicodin 1-2 tablets q. 6h p.r.n.
Slash|Divided by|201|In addition, after admission, she did have one episode of recurrent chest pain that was relieved by nitro. Therefore I decided to keep her over the weekend. She walked in cardiac rehab for the last 2 1/2 days and she has not had any recurrent symptoms. She then went on for further evaluation to have a stress nuclear thallium test.
Slash|Abbreviation|64|She was treated with antibiotics as well as pain medications. OB/GYN consultation also was obtained. It was felt that she likely had an inflammatory reaction following the hysterosalpingogram.
Slash|Date|308|There were no other significant abnormal abdominal findings. Given his anatomy it is my opinion that he indeed would be best approached with coronary bypass grafting and mitral annular repair but the patient would like to trial a course of medical therapy initially. To that end he was discharged on _%#MM#%_/_%#DD2002#%_ on the following medications. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg p.o. q.d. 2. Plavix 75 mg p.o. q.d.
Slash|Over(blood pressure)|203|The patient was receiving Lasix 40 mg b.i.d. and was cut down to 40 mg daily on admission date. The patient was feeling dry. His blood pressure was low, running at 114/52 on admission and went down to 92/50 on _%#MM#%_ _%#DD#%_, 2002. Also, the patient's mucous membranes were dry. The patient's Lasix was held, and the patient was started on hydration with normal saline 100 c per hour.
Slash|Either meaning|112|7. Vitamin C 500 mg p.o. q.d. 8. Vitamin E 400 units p.o. q.d. 9. Vitamin K 5 mg p.o. q.d. 10. Calcium carbonate/vitamin B 500 mg p.o. q.d. 11. Magnesium oxide 400 mg p.o. b.i.d. 12. Ambien 10 mg p.o. q.h.s.
Slash|Date|207|HISTORY: _%#NAME#%_ _%#NAME#%_ is a 34-year-old para 3-0-0-3 female who has been followed by Dr. _%#NAME#%_ _%#NAME#%_ in the Fairview Riverside Women's Clinic for cervical dysplasia. She underwent LEEP in 8/03 which demonstrated adenocarcinoma in situ after Pap revealed CINIII and carcinoma in situ.
Slash|Either meaning|143|No nausea, vomiting or fevers. ALLERGIES: Imuran. PAST MEDICAL HISTORY: Ulcerative colitis. SOCIAL HISTORY: He is a college student. Non-smoker/non-drinker. HOSPITAL COURSE: The patient was admitted to the Colorectal Surgery for conservative management of his partial small bowel obstruction.
Slash|Over(blood pressure)|168|She denies any dysuria or odor to the urine. NEURO: Negative. ENDOCRINE: Negative. PSYCH: Negative. PHYSICAL EXAMINATION: On examination today her blood pressure is 170/82 with a pulse of 78. GENERAL: The patient is seated in her wheelchair. She is hard of hearing but answers questions fairly appropriately with just some mild memory loss.
Slash|Date|225|PROCEDURES PERFORMED: 1) Left distal biceps tendon repair. 2) Primary repair of arterial laceration. SECONDARY DIAGNOSIS: 1) Postoperative nausea. HOSPITAL COURSE: The patient underwent the above listed procedures on _%#MM#%_/_%#DD2004#%_. Due to the arterial laceration, he was kept overnight for observation.
Slash|Date|152|3. Status post coronary angiogram on _%#MMDD2004#%_ with stenting of left anterior descending and circumflex arteries. 4. Carotid ultrasound on _%#MM#%_/_%#DD2004#%_ that showed greater than 70% stenosis of the right internal carotid artery and 50-69% stenosis of left internal carotid artery.
Slash|Date|280|She was not a good candidate for that procedure and it was noted on her most recent CT scan that she had multiple pulmonary nodules, the largest of which was approximately 1 cm in size and located at the base of the right lung. It was this that she was having biopsied on _%#MM#%_/_%#DD2004#%_. During the biopsy, the patient developed a pneumothorax and a percutaneous catheter was placed and re-expanded the lung.
Slash|Date|159|3. History of arteriosclerotic cardiovascular disease status post coronary artery bypass surgery in 1991, three vessel. 4. Status post AICD implant in _%#MM#%_/2005. 5. History of hypertension. 6. History of non-insulin dependent diabetes mellitus.
Slash|Either meaning|111|Endocrine: No heat or cold intolerance. Respiratory: No cough, no sputum production, no hemoptysis. Hematologic/Lymph: The patient has history of anemia and had transfusion on arrival to the hospital.
Slash|Over(blood pressure)|165|PHYSICAL EXAMINATION: The patient is alert, pleasant, oriented x3 with normal attention, concentration, language, memory and fund of knowledge. Blood pressure is 141/84, heart rate is 76 and regular without any murmurs or gallop.
Slash|Over(blood pressure)|127|PHYSICAL EXAMINATION: GENERAL: The patient is an elderly male who appears his stated age. VITALS: Stable. Blood pressure is 125/80, heart rate of 91 and irregular, afebrile. HEENT: Unremarkable. Oropharynx is clear. Neck is supple. CHEST: Clear to auscultation and percussion.
Slash|Date|266|2. Drug toxicity from a combination of docetaxel and gemcitabine may explain all of the above. This is a diagnosis of exclusion. 3. Stage IV leiomyosarcoma of the uterus with bladder and peritoneal involvement, receiving docetaxel and gemcitabine, last dose _%#MM#%_/_%#DD2007#%_. 4. Hyperglycemia on TPN. She is transitioning to enteral feeding today.
Slash|Date|13|DOB: _%#MM#%_/_%#DD1952#%_ IMPRESSIONS: 1. A 51-year-old male with acute apparent epiglottitis, exact anatomy unclear, question abscess in the area, most likely anaerobe/strep in the cultures. 2. Question healthy male otherwise. PLANS: 1. Continue Unasyn, adjust as cultures direct.
Slash|Date|190|Abdomen is soft, nontender, nondistended. Peripad is inspected. It had been in place for 15 minutes and there was a scant amount of blood on the maxi size pad. LABORATORY VALUES: On _%#MM#%_/_%#DD2004#%_, she had an HCG of 3320, hemoglobin of 14.4, and she is A positive.
Slash|Either meaning|198|3. Unknown coronary artery status. Ms. _%#NAME#%_ has never had a coronary artery assessment. MEDICATIONS: Medications normally are verapamil 180 mg SR two a day; potassium 8 mEq b.i.d.; triamterene/HCTZ, 37.5/25 mg daily; Altace 10 mg daily; Ambien 10 mg q.h.s. p.r.n.; Vicodin on a p.r.n. basis.
Slash|Either meaning|266|ALLERGIES: On admission she had no known drug allergies. MEDICATIONS: Clonidine, Centrum, hydrochlorothiazide, Lexapro, Travatan, atenolol, bisacodyl, amoxicillin, Ativan, Tylenol #2, Seroquel, potassium chloride, Aricept, Ensure and Tylenol. CODE STATUS: She is DNR/DNI. SOCIAL HISTORY: She lives in Ebenezer Ridges long-term care.
Slash|Date|185|SUMMARY OF CASE: This is a 51-year-old woman admitted here for evaluation of left hip infection. She has a history of invasive squamous cell carcinoma of the vulva diagnosed in _%#MM#%_/04 after which time she was treated with chemotherapy.
Slash|Either meaning|395|Due to their invasive nature, CVS is associated with a 1:200 (0.5%) to 1:100 (1.0%) risk of miscarriage and amniocentesis is nationally associated with a 1:200 (0.5%) risk of miscarriage. After our discussion together, _%#NAME#%_ indicated that she has been very anxious about this pregnancy due to the history of fetal demise in her last pregnancy and would like the screen for more information/reassurance; however, she would not consider CVS or amniocentesis if her screen came back at increased risk.
Slash|Date|13|DOB: _%#MM#%_/_%#DD1962#%_ REASON FOR CONSULTATION: Chest pain. It is my pleasure to see this 41-year-old gentleman with a brief history of chest pain.
Slash|Over(blood pressure)|244|Hematologic system negative for known bleeding disorders. Psychological and social systems are negative for seizure disorder or depression. PHYSICAL EXAMINATION: GENERAL: Well-nourished, well-developed gentleman. VITAL SIGNS: Blood pressure 120/70. Pulse 80. Respirations 18 and unlabored. The patient is afebrile.
Slash|Over(blood pressure)|177|Otherwise, 10 system review is unremarkable. PHYSICAL EXAMINATION: GENERAL: The patient appears alert in no acute distress with appropriate affect. VITALS: Blood pressure is 148/91 with a heart rate of 94. Telemetry showed atrial fibrillation with a rate of 90 to 120 beats per minute.
Slash|Either meaning|224|Does note he has some right hip pain. He tells me, "it's from playing football." PHYSICAL EXAMINATION: A very large 17-year-old male, obese, in no acute distress, obvious diminished cognitive functioning. Head: Normocephalic/atraumatic. Eyes: Extraocular motion is intact. PERRLA. Oropharynx is unremarkable. Tongue protrudes in the midline. There is mild acne vulgaris noted over the face.
Slash|Date|264|In approximately _%#MM2004#%_, he underwent a ventral hernia repair at an outside hospital, which was complicated by an enterocutaneous fistula and recurrent hernia. The patient underwent a reoperation by Dr. _%#NAME#%_ _%#NAME#%_ at Fairview Southdale on _%#MM#%_/_%#DD2005#%_. Massive reconstruction of the large ventral hernia was performed with an AlloDerm, along with extensive enterolysis, and excision of the enterocutaneous small bowel fistula.
Slash|Over(blood pressure)|243|PHYSICAL EXAMINATION: GENERAL: The patient appears comfortable at rest. She is alert and oriented to time, place and person. The patient just returned from her surgery. Temperature 101( Fahrenheit, pulse 91, respirations 24, blood pressure 135/75. HEENT: Unremarkable. NECK: Supple. LUNGS: Currently clear to auscultation bilaterally.
Slash|Over(blood pressure)|164|PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished Caucasian female in no acute distress. VITAL SIGNS: Temperature afebrile, pulse 67, blood pressure 102/62, respiratory rate 16. HEENT: Negative. NECK: Supple; no adenopathy. LUNGS: Clear. CARDIOVASCULAR: Regular rate and rhythm, no murmurs.
Slash|Over(blood pressure)|158|At today's visit her physical examination showed the lungs to be clear bilaterally. Her abdomen was soft. Her weight was 192 pounds and blood pressure was 132/80. At this juncture we are not seriously considering any further chemotherapy in this patient unless she starts to once again show progression of her lung cancer.
Slash|Either meaning|141|She does have a macular rash extending under the left axilla and onto the back of her torso. She speaks nonsensically with spontaneous speech/idioms that are understandable but other words are non-sensical.
Slash|Divided by|141|PAST SURGICAL HISTORY: None. ADMISSION MEDICATIONS: None. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient uses tobacco of 1-1/2 packs to 2 packs per day. He uses alcohol 6 to 12 beers a week, crack daily, and marijuana daily.
Slash|Over(blood pressure)|135|PHYSICAL EXAMINATION: GENERAL: This is a pleasant older patient appearing his stated age and in good spirits. His blood pressure is 155/80, his pulse is 64, respirations are normal and he is afebrile.
Slash|Date|207|This pain did not relent and he eventually presented to the Emergency Department at approximately 10:00 on _%#MMDD2003#%_. He had some nausea, but no vomiting. He has not had a bowel movements since _%#MM#%_/_%#DD2003#%_ at approximately 8:00 pm. Since having an NG tube placed on admission he says that the abdominal pain has been much improved, but he continues to remain obstipated.
Slash|Either meaning|98|Denies alcohol or other ongoing drug use. REVIEW OF SYSTEMS: Remarkable for "hot flashes". Frontal/retroorbital headache earlier today which has since resolved. Dizziness with upright posture. No visual change. Denies chest discomfort or dyspnea.
Slash|Per|232|LABORATORY DATA: Laboratory studies form admission show a white count of 11,100, hemoglobin 14.0, platelet count 154,000; differential shows 45% neutrophils and 47% lymphocytes. INR 0.96. Myoglobin is quite elevated at over 2000 mcg/L. PTT is normal at 23 seconds. Urinalysis is largely unremarkable apart from the presence of a large amount of blood in the urine and a trace amount of protein.
Slash|Date|111|Creatinine is 1.54. At the time of admission he did have evidence of gram-negatives in his urine. From _%#MM#%_/_%#DD2007#%_ he did have Klebsiella in the urine. I note that when he was hospitalized earlier in the month his stool studies did not show a C.
Slash|Date|13|TBA: _%#MM#%_/_%#DD2003#%_. REQUESTING PHYSICIAN: Dr. _%#NAME#%_ _%#NAME#%_. I have been asked by Dr. _%#NAME#%_ to evaluate _%#NAME#%_ _%#NAME#%_ who is a very pleasant 85-year-old female, scheduled for hernia repair.
Slash|Over(blood pressure)|219|No focal neurologic complaints. OBJECTIVE: He is a generally healthy appearing adult male in no acute distress. He is alert and oriented. Blood pressure since admission has been significantly elevated in the 140 to 160s/low 100s to 113 range. Heart rate is 90s and regular. Respirations normal. Temperature normal.
Slash|Date|264|At the present time, the patient is doing well with just moderate pain, but appears to be quite comfortable without any shortness of breath or chest pain. PAST MEDICAL HISTORY: 1. Left total knee arthroplasty, _%#MM2002#%_ with I and D in _%#MM2002#%_ and _%#MM#%_/03. He was noted to have MRSA infections requiring IV antibiotics.
Slash|Of|170|No obvious abnormalities. NECK: Supple, nontender, no lymphadenopathy, no thyromegaly. HEART: Regular rhythm with somewhat irregular moments and has a fairly loud grade 3/6 murmur in the left lower sternal border. ABDOMEN: Soft and nontender. EXTREMITIES: No rashes or skin lesions.
Slash|Date|188|Indicates use of alcohol for "medication" and socialization. Record indicates drinking up to a liter of vodka daily. The patient indicates average of 1 pint per day. Last drink on _%#MM#%_/_%#DD#%_. Admitted to HCMC detox at that time. Alcohol withdrawal with shakes and sweats which patient indicates has since resolved.
Slash|Per|109|MEDICATIONS: The current medications include the following: 1. Insulin drip 20 units/hour. 2. Propofol 25 mcg/kg/minute. 3. Amiodarone. 4. Metoprolol. 5. Zocor. 6. Timentin. 7. Vancomycin. ALLERGIES: THE PATIENT IS ALLERGIC TO AMOXICILLIN.
Slash|Over(blood pressure)|154|PHYSICAL EXAMINATION: VITAL SIGNS: The patient is afebrile, pulse rate running in the 110s. Respirations running about 20. Blood pressure is running 85-90/44. He is running about 96% on 2 liters. GENERAL: He is lethargic, answers questions, is oriented x1-2.
Slash|Date|108|On _%#MMDD2005#%_, the patient received a double-cord transplant for CLL. He was discharged home on _%#MM#%_/_%#DD2005#%_. At the time of discharge the patient had signs of rhinorrhea and had been experiencing nose congestion.
Slash|Either meaning|213|He does not want to give up, and he would like to proceed to see if there is anything that could explain his symptoms on a bone marrow biopsy. I did discuss code status with the patient, and he desires to be a DNR/DNI. However, he would want all cares up to that point and still diagnostic testing.
Slash|Date|133|PROBLEM #5: Infectious disease. The patient was HSV and CMV positive prior to transplant. The patient had her first fever on _%#MM#%_/_%#DD2002#%_, and was started on Vancomycin and ceftazidime. All her cultures remained negative, including urine and blood. The patient did have headaches between _%#MMDD#%_ and _%#MMDD#%_.
Slash|Of|551|The patient's mother declined because the patient was due to come to the University of Minnesota Medical Center, Fairview, the next day on _%#MM#%_ _%#DD#%_, 2006, to be admitted for a routine tonsillectomy and adenoidectomy, and the mother was wishing that they could delay. _%#NAME#%_ was admitted to that day. The patient was discharged from the _%#CITY#%_ Emergency Department, went home for a few hours, gathered her things, and then the next day, was admitted to the University of Minnesota Children's Hospital on _%#MM#%_ _%#DD#%_, 2006, with 8/10 bilateral upper extremity pain. PHYSICAL EXAMINATION: On admission, temperature 36.4, pulse 94, blood pressure 142/95, oxygen saturation 93%, weight 21.9 kg, and height 117 cm.
Slash|Over(blood pressure)|147|PHYSICAL EXAMINATION: GENERAL: The patient is an orally intubated gentleman, alert and responding appropriately. VITAL SIGNS: Blood pressure is 100/60, pulse is 90 and regular, respirations 10 on the ventilator, temperature 100.2, saturations 100% on 40% FiO2.
Slash|Either meaning|163|PAST MEDICAL HISTORY: Significant for a gun shot wound to the right upper extremity in Somalia, status post right upper extremity amputation. History of depression/PTSD. History of malaria in 1994, 1996, 1998. ALLERGIES: No known drug allergies. FAMILY HISTORY: Father died during the war in Somalia.
Slash|Over(blood pressure)|169|His initial examination by me in the emergency room showed an alert but very uncomfortable-appearing obese man. His blood pressure initially in the emergency room was 77/50 and was 104/36 at the time of the examination. Temperature was 96.4, respiratory rate 20, saturations 97% on room air, pulse in the 90s.
Slash|Over(blood pressure)|132|PHYSICAL EXAMINATION: Reveals an alert, pleasant woman in no distress. She has some mild bruising on her face. Blood pressure is 124/78, pulse is 82, respirations are 16, temperature is 96.3, oxygen saturation is 95% on room air.
Slash|Date|118|Biopsies were also taken. The patient tolerated the procedure well without any complications. DISCHARGE DATE: _%#MM#%_/_%#DD2007#%_. DISCHARGE DIAGNOSIS: Transverse colon polyp status post resection.
Slash|Date|341|FINAL HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 5-year-old male with a history of maroon, current jelly-like stools and abdominal pain, possible intussusception in _%#MM2007#%_ who presents today for a bowel prep for endoscopy and colonoscopy tomorrow morning. Per his parents, the patient has not had any more bloody stools since _%#MM#%_/2007. They have been followed by Dr. _%#NAME#%_ _%#NAME#%_ of the Pediatrics GI Department in _%#CITY#%_ _%#CITY#%_, Minnesota.
Slash|Abbreviation|122|If she rules out, I would get a stress test as an outpatient. 9. I will get a D-dimer. If it is abnormal, I will check a V/Q scan to rule out any pulmonary embolus. 10. I will treat her with I.V. steroids, frequent nebulizer and doxycycline.
Slash|Date|145|She never smoked, never drank alcohol, and does not use any drug. REVIEW OF SYSTEMS: Please refer to the KBC adult patient profile dated _%#MM#%_/_%#DD2007#%_ at 1713 that was reviewed and verified by me and included a complete review of system.
Pound|Number|231|HOSPITAL COURSE: The patient underwent surgery on _%#MMDD2006#%_. For complete operative report see dictation dictated on that day. The patient tolerated the procedure well. Hemoglobin prior to operation was 12.7 and on postop day #1 it was 9.8. EBL was approximately 600 mL. Fluids, electrolytes, nutrition: The patient did have hypokalemia as well as hypocalcemia during her postoperative course.
Pound|Number|133|Old records, her baseline creatinine is unknown. I did stop her Celebrex, however, during this hospitalization stay. On hospital day #2 a Physical Therapy and Occupational Therapy consult was obtained, felt that patient was sufficient to go home.
Pound|Number|266|He was started on a morphine PCA with a basal rate of 1 mg/hour and bumps of 1 mg every 10 minutes maximum. On this regimen, his pain was well controlled, and he was weaned to oral pain medication consisting of ibuprofen 800 mg t.i.d. plus oxycodone on hospital day #3. At discharge, his pain is well controlled on ibuprofen 800 mg p.o. t.i.d. without need for additional narcotics.
Pound|Number|211|She tolerated the procedure without difficulty and returned to the regular hospital ward postoperatively. Her postoperative course was remarkable for an episode of chest pain on the evening of postoperative day #1. She was evaluated by the hospitalist at that time, EKG was normal.
Pound|Number|125|Pain management was achieved with Dilaudid 2 mg IV q.4 h. scheduled, and Dilaudid 2 to 4 mg IV q.4 h. p.r.n. On hospital day #2, the patient still had some abdominal pain, but was partially relieved with IV Dilaudid.
Pound|Number|198|A Dilaudid PCA was used for pain control postoperatively. The patient's subcutaneous Hemovac drain was left in place until postoperative day #2 and then removed. In the evening of postoperative day #2, the patient had her first bowel movement and her NG tube was removed.
Pound|Number|264|Blood gases: Venous was a pH of 7.33, with a base excess of 2.8; arterial was a pH of 7.25, with a base excess of 3.6. On postoperative day #1, the patient did have complaints of gas pain, which was alleviated with simethicone and ambulation. On postoperative day #2, gentamicin and clindamycin were discontinued, and the patient remained afebrile throughout the remainder of her hospital stay.
Pound|Quantity|131|DISCHARGE MEDICATIONS: 1. Vancomycin 250 mg p.o. q.i.d. for 12 more days to complete a 14-day course. 2. Vicodin 1-2 q.4h. p.r.n. (#20 dispensed). She was on no home medications.
Pound|Number|117|Please see operative note for full details of this procedure. She tolerated the procedure well. On postoperative day #1, she had a esophagram, which was normal and did not show any evidence of leak or perforation.
Pound|Number|205|See family practice notes for more information regarding their following of the patient during the hospital stay. The patient was given discharge instructions as to discharge medications including Tylenol #3, Colace, Protonix and Lipitor. He was recommended to follow up with Dr. _%#NAME#%_ in 7-14 days for regular postoperative check and to call Dr. _%#NAME#%_ prior to that point if he had other questions or concerns.
Pound|Number|214|2. Extraction of tooth #31. 3. Placement of Penrose drains x2 on _%#MM#%_ _%#DD#%_, 2006, was the date of procedure. INDICATIONS FOR ADMISSION: The patient is a 25-year-old female who underwent extraction of teeth #1, #16, #17, and #32 at _%#COUNTY#%_ _%#COUNTY#%_ Medical Center by Dr. _%#NAME#%_ _%#NAME#%_.
Pound|Number|79|By postoperative day # 2, the patient was passing flatus. By postoperative day #3, the patient had a formed bowel movement. Her NG tube was removed. The patient began tolerating a clear liquid diet on the afternoon and evening of postoperative day # 3, and a pureed diet on the morning and afternoon of postoperative day # 4.
Pound|Number|103|FOLLOW-UP: The patient will follow up with Dr. _%#NAME#%_ as needed. DISCHARGE MEDICATIONS: 1. Tylenol #3 1-2 tabs p.o. q.4h. p.r.n. 2. Enteric-coated aspirin 81 mg p.o. q.d. 3. Zantac 150 mg p.o. q.d. 4. Neurontin 300 mg p.o. t.i.d. p.r.n.
Pound|Quantity|127|2. Lovenox 120 mg subcu b.i.d. x 3 days, one week supply given (with three refills). 3. Coumadin 5 mg p.o. q.h. night, q. day (#20 given). HOSPITAL COURSE: The patient is a 54-year-old woman who has recurrent clear-cell carcinoma of her ovary, who is status post TAH and BSO, status post Cytoxan and carboplatin x 6 in 1993, status post exploratory laparotomy in 1996, and with a recurrence to her pelvis in _%#MM2002#%_.
Pound|Number|121|The patient was placed on Heparin and Coumadin for her atrial fibrillation. Her INR was therapeutic on postoperative day #8 and on postoperative day #9, heparin was discontinued.
Pound|Number|152|Pre-B cell acute lymphocytic leukemia refractory to multiple chemotherapy trials and to stem cell treatments. During this stay _%#NAME#%_ received shot #11 of 24 of trial drug 852A. His platelets were transfused on 3 separate days. PROBLEM #4: Neurologic.
Pound|Number|141|The patient continued to have melanotic stools throughout her hospitalization. Despite this, her hemoglobin increased to 0.4 on hospital day #2 and then 10.5 on hospital day #3. She had an EGD performed (results above) on hospital day #5.
Pound|Quantity|139|7. MiraLax p.r.n. constipation. 8. In addition the patient was given a prescription for Percocet one to two tabs q. four hours p.r.n. pain #40. PATIENT INSTRUCTIONS: The patient was instructed to keep her incision clean.
Pound|Number|79|She was given TEDs, pneumoboots and Lovenox for DVT prophylaxis. On postop day #1, the patient underwent an upper GI study, which showed no leak, and she was started on a clear-liquid diet.
Pound|Number|156|She was being weaned from the ventilator after dialysis as tolerated, intraaortic balloon pump per cardiologist. The patient did fail weaning on postop day #1; this was attempted again on postoperative day #2, where she also failed.
Pound|Number|147|DOB: _%#MMDD1978#%_ PROCEDURE PERFORMED: Primary low cervical transverse cesarean section on _%#MMDD2003#%_. HOSPITAL COURSE: On postoperative day #1, she was afebrile, tolerating clear liquids. On postoperative day #2, she was doing well without problems.
Pound|Number|122|Dr. _%#NAME#%_ _%#NAME#%_ _%#CITY#%_ Children's, Pediatric and Adolescent Services _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ # _%#ADDRESS#%_ _%#CITY#%_, MN _%#55400#%_ _%#MM#%_ _%#DD#%_, 2003 Dear Dr. _%#NAME#%_, Thank you for accepting care of _%#NAME#%_ _%#NAME#%_ from the Neonatal Intensive Care Unit of Fairview-University Children's Hospital.
Pound|Quantity|100|9. Multivitamin 1 daily. 10. Potassium chloride 25 mEq p.o. t.i.d. 11. Prednisone 60 mg p.o. daily, #20 are dispensed and she will follow up with GI for determination of what to do with this dose.
Pound|Number|117|Postoperatively, the patient had no neurologic deficits, and recovered well from the procedure. By postoperative day #3, the patient was tolerating food, had her pain controlled on oral pain medication, was ambulating, and the decision was made that she was safe to be discharged home.
Pound|Number|82|BUN 17, creatinine 1.3. Glucose 137. Myoglobin 103, troponin 0.13. BNP is 38. ABG #1, 7.30, 31, 149; #2, 7.37, 29, 141. Chest x-ray portable no acute infiltrate or CHF. EKG showed sinus tachycardia, very poor baseline, rate of 106, possibly some PVCs.
Pound|Number|272|He remained stable and had the main issue of incisional pain, which was treated with low-dose IV narcotics and muscle relaxants. On postoperative day #1, the patient was transferred to the general pediatric floor, where he remained on flat bedrest until postoperative day #3. By postoperative day #3, the patient was tolerating a regular diet.
Pound|Number|92|After blood cultures were negative x 48 hours, the Unasyn was discontinued. On hospital day #2, CMV antigenemia was sent, and also CT scan of his neck, chest, and abdomen were performed.
Pound|Number|280|It was an extensive surgery given the large size of the myomatous uterus and the patient's obesity; however, there were no complications. _%#NAME#%_ did well in the postoperative recovery time. Hemoglobin was 9.6 (preoperative hemoglobin 12.9). She went home on postoperative day #3. Final pathology from the uterus was benign, weight 1651 gm.
Pound|Number|245|The patient was unable to tolerate dressing changes on hospital day #2 and she was taken back to the OR for a dressing change under light sedation. She had been started on vancomycin, gentamicin and Flagyl and was continued through hospital day #3 on IV antibiotics, but converted to oral clindamycin for 10 days with instructions of daily dressing changes.
Pound|Number|265|Her vital signs were stable during this hospitalization. On hospital day #1, she received 2 units of packed red blood cells for anemia of chronic disease. She tolerated the transfusion well and was stable. Following that, she was discharged to home on hospital day #2. She received a regular diet during this hospitalization. She received IV fluids.
Pound|Number|140|Ms. _%#NAME#%_ was treated with routine physical therapy rehabilitation for total hip arthroplasty. She was discharged on postoperative day #4 to her home for self-care. Ms. _%#NAME#%_ is scheduled for follow-up in our office at two weeks postoperative for suture removal and radiographic evaluation.
Pound|Quantity|141|DISCHARGE MEDICATIONS: 1. Atenolol 50 mg daily. 2. Imdur 30, 1/2 a tablet daily. 3. Zocor 40 mg in the evening. 4. Restoril 15 mg at hs prn, #10 tablets. 5. Lasix 20 mg daily. 6. Kay Ciel 20 mEq daily.
Pound|Number|174|He continued to have good urine output also throughout his hospital stay. On postoperative day #8, the patient's creatinine went down to 9.53 and today, on postoperative day #9, his creatinine was 9.36, potassium was 3.9, phosphorus 5.4, and BUN 72 and stable.
Pound|Quantity|193|At the time of discharge she was in excellent condition, tolerating a regular diet with no activity restrictions. DISCHARGE MEDICATIONS: 1. Tylenol No. 3 one to two p.o. q.4 hours p.r.n. pain, #20. 2. Valium 5 mg p.o. q.6 hours p.r.n. muscle spasm.
Pound|Quantity|64|DISCHARGE MEDICATIONS: 1. Percocet 1 to 2 p.o. q.4-6 h. p.r.n., #80 were given. 2. Vistaril 25 to 50 mg p.o. q.4-6 h. p.r.n. pain, #80 were given.
Pound|Number|107|She is breast feeding the infant. Pain well controlled on Q-pump and p.o. pain medications. Her postop day #1 hemoglobin was 11.8. She is rH positive, rubella immune.
Pound|Number|220|POSTPARTUM COURSE: The patient did follow routine postpartum course. Her diet was advanced as tolerated and she was tolerating a regular diet at the time of discharge. The Foley catheter was removed on postoperative day #1 and the patient was voiding with no problems at the time of discharge.
Pound|Number|222|The patient did well throughout her postoperative course. Her vital signs were stable, and she remained afebrile throughout her postoperative stay. She tolerated a regular diet and was ambulating well by postoperative day #2. She was breast-feeding without any problems. She had minimal lochia and had passed flatus without problems.
Pound|Number|153|NEUROLOGIC: The patient is alert and oriented x3. Motor strength and sensation are intact. Deep tendon reflexes are symmetric. LABORATORY DATA: Troponin #1 less than 0.04. Chest x-ray pending at this time.
Pound|Number|440|RECOMMENDATIONS: 1. The patient will have a port placed by Interventional Radiology at Fairview Southdale Hospital on _%#MMDD2007#%_. 2. He will start chemotherapy on _%#MMDD2007#%_. His chemo includes Bortezomib at 1.0 mg per meter squared on day #1 and day #4, rituximab 375 mg per meter squared IV day #1, cyclophosphamide 300 mg per meter squared IV q12h days #1 to #3, doxorubicin 25 mg per meter squared continuous infusion over days #1 and #2, vincristine 1 mg IV push day #3, dexamethasone 40 mg p.o. for days #1 to #4 and then Neulasta to follow after that.
Pound|Number|180|Urine output was satisfactory. The patient's incisions were healing appropriately with no signs of infection, erythema or drainage. The patient was discharged on postoperative day #6 and was instructed with regard to wound care, recovery, follow-up and signs and symptoms of infection.
Pound|Number|181|She received two units of packed red blood cells, and her hemoglobin from that point through the remainder of the hospitalization was stable in the 9-10 range. On postoperative day #3, she began having some shortness of breath. She was assessed by the house physician who felt her symptoms were suggestive of mild pulmonary edema.
Pound|Number|190|The patient's primary care doctor is Dr. _%#NAME#%_. PAST MEDICAL HISTORY: Healthy. CURRENT MEDICATIONS: None, although the patient is currently on cefotetan, vancomycin, and gentamicin day #2. ALLERGIES: NO KNOWN DRUG ALLERGIES. SURGERIES: No surgeries. PAST SURGICAL HISTORY: A normal spontaneous vaginal delivery in 2004.
Pound|Number|99|3. Chronic pain. 4. Bilateral knee replacement. 5. Hypothyroidism. CURRENT MEDICATIONS: 1. Tylenol #3 every 6 hours as needed. 2. Levoxyl 0.05 mg p.o. daily. 3. Celexa 40 mg 1/2 tablet daily.
Pound|Number|223|11. Degenerative joint disease. 12. Hypercholesterolemia. HOSPITAL COURSE: Ms. _%#NAME#%_, a 61-year-old female with significant comorbidities, tolerated this procedure well. The patient was discharged on postoperative day #5 doing well. The patient was performing ADLs independently, ambulating and participating in her own hygiene.
Pound|Number|98|3. Pain: The patient was on a Dilaudid PCA postoperatively for pain control. On postoperative day #1, she was transitioned to oral pain medications, and her pain was well controlled on oral medications at the time of discharge.
Pound|Quantity|191|I will be contacting her with appointment date and time, sometime next week. DISCHARGE MEDICATIONS: 1. Protonix 40 mg p.o. b.i.d. 2. Ativan 1 to 2 mg p.o. q.i.d. p.r.n. anxiety (she is given #80 one-mg tablets with one refill). 3. Voriconazole 200 mg p.o. b.i.d. x 18 days. 4. Maalox p.r.n. 5. Prednisone 20 mg p.o. q. day.
Pound|Number|215|Brisk capillary refill. DISCHARGE INSTRUCTIONS : The patient will be toe-touch weightbearing of his right lower extremity. He should wear his CAM boot at all times. He can take his dressing off on postoperative day #3. If he is able to shower, then should not bathe.
Pound|Number|85|She was initially placed on IV ceftriaxone with clinical monitoring. On hospital day #2, the patient seemed to have slight improvement in erythema, however, the neck CT was ordered to rule out any abscess formation.
Pound|Number|158|She underwent a normal spontaneous vaginal delivery. On postpartum day #2 she underwent postpartum tubal ligation. She was kept in house until postpartum day #3 due to stressors at home and pain from her surgery that had been performed on postpartum day #2.
Pound|Number|203|She tolerated this well. DISCHARGE INFORMATION: 1. DISCHARGE DATE: _%#MMDD2007#%_. 2. DISCHARGE DIAGNOSIS: A 10-year-old female with Ewing sarcoma, being treated per protocol AEW20031, status post cycle #10 of chemotherapy with etoposide and ifosfamide and mesna.
Pound|Number|148|She was ambulating and she was tolerating bariatric clear liquid diet. Her IV fluids were discontinued. She saw the dietician. On postoperative day #1, she was ready for discharge to home. DISCHARGE CONDITION: On the day of discharge, the patient was afebrile.
Pound|Number|67|Please feel free to contact me if you have any questions. My pager #_%#TEL#%_.
Pound|Number|132|The indication for surgery was a placental abruption and very remote from delivery. The patient was doing well on postoperative day #1. She was afebrile, and her vital signs were stable. On postoperative day #2, her incision was clean, dry and intact, and she was tolerating a regular diet.
Pound|Quantity|144|DISCHARGE MEDICATIONS: 1. Oxycodone 5 mg tablets 1 to 2 p.o. q.4-6 h. p.r.n. 2. Prednisone 20 mg p.o. b.i.d., #8. 3. Flexeril 5 mg p.o. t.i.d., #15. 4. She will also resume her regular baseline prednisone when her burst is over at 5 mg a day
Pound|Number|178|2. She has a total of 4 Rituxan treatments with the second one tomorrow. 3. Follow-up Dr. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_ here or her primary care physician in 1-2 weeks, phone #_%#TEL#%_. Fax _%#FAX#%_. 4. We will check with orthopedics, Dr. _%#NAME#%_ as to whether he would like to see the patient postoperatively for her fibular fracture or this has healed significantly enough that follow up is not needed by orthopedics.
Pound|Number|79|4. Alcohol abuse. 5. Chest pain, noncardiac. DISCHARGE MEDICATIONS: 1. Tylenol #3, 1-2 tabs po q4-6h prn, #20 tablets. 2. Zantac 150 mg po bid prn. 3. Nicoderm patch 21 mg qd, change patch qd. 4. Clonidine 0.1 mg po bid.
Pound|Quantity|112|13. Warfarin 5 mg p.o. q. day. 14. Zofran 4 mg p.o. q. day. 15. Percocet 1-2 tablets p.o. q. 4-6h. p.r.n. pain, #60. 16. Vistaril 25 mg p.o. q. 4h. p.r.n. for itching.
Pound|Number|143|On postoperative #12, the patient was doing well. She continued on her p.o. antibiotics and discharge planning was begun. On postoperative day #13, the patient was doing well. She was ambulating without difficulty and voiding without difficulty. All her ostomy was working.
Pound|Quantity|231|ASSESSMENT/PLAN: Mid back pain and lower abdominal pain resolved with Percocet, patient has long history of pelvic/abdominal pain, felt to be secondary to her interstitial cystitis managed by Dr. _%#NAME#%_. She was given Percocet #20 to take p.r.n. She will return to the office p.r.n.
Pound|Quantity|159|DISCHARGE DISPOSITION: The patient is likely to be discharged home with home hospice. DISCHARGE MEDICATIONS: 1. Oxycodone 5 mg tabs 1-2 p.o. q 4 hours p.r.n., #40. 2. Ativan 0.5 mg p.o. q 4 hours p.r.n., #20.
Pound|Number|265|However, it was not related to any muscular symptoms and she was able to ambulate without difficulty, starting as soon as postoperative day #1. Her pain was initially managed postoperatively with a PCA. This was weaned to oral pain medications on postoperative day #1. At the time of discharge, she was tolerating oral pain medications.
Pound|Quantity|134|7. Diovan 160 a day 8. Aspirin 9. Spiriva. 10. Diltiazem 360 a day 11. Lipitor 40 a day, 12. Niaspan 2000 a day 13 Catapres patch TTS #3, change weekly. ALLERGIES: ACE inhibitor causes cough. HABITS: Tobacco: None since 1988, but over 100-pack-year history.
Pound|Number|287|Fundal massage, IV Pitocin and Methergine were given. Hemoglobin stat was performed and this was 8.2. Hemoglobin on postpartum day #1 was 7.7. The patient otherwise did well postpartum. She was breastfeeding and pumping for her triplet infants. She was discharged home on postpartum day #3. At the time of discharge, she was voiding, ambulating and tolerating a regular diet and had decreasing lochia.
Pound|Number|173|On postop day #1, he underwent physical therapy evaluation and treatment on postop day #1 and did well with his mobility. He was deemed able to go home on postoperative day #2. He had a very uncomplicated postoperative course and received good pain control with Vicodin and Vistaril combination.
Pound|Number|436|Her final pathology returned as poorly differentiated carcinoma consistent with metastasis from a fallopian tube primary, and the patient is to meet with Dr. _%#NAME#%_ in 2 to 3 weeks to discuss this pathology, and a plan for future treatments. 2. Pain. Initially, postoperatively the patient was started on Dilaudid PCA, and she was continued on this while she was n.p.o. She was started on p.o. pain medications on postoperative day #3 when her diet was advanced, she was tolerating oral pain medications at the time of discharge, and her pain was mostly controlled with Extra Strength Tylenol or ibuprofen.
Pound|Number|142|His postoperative course was notable for a stay in the surgical intensive care unit immediately following the procedure. On postoperative day #1, he was noted to have dropped his hemoglobin acutely, and a chest x-ray was reviewed, and the patient was taken urgently back to the operating room for evacuation of presumptive hemothorax.
Pound|Number|284|On discharge, the patient was tolerating a regular diet, having normal bowel function, and ambulating several times a day. The patient will be discharged to home on his home medications, and the patient will get Bactrim Single-Strength for an antibiotic, bacitracin ointment, Tylenol #3 for pain medications, and B and O suppositories p.r.n. The patient will be scheduled to follow up in one week in Dr. _%#NAME#%_'s clinic for pathology report.
Pound|Number|88|He was somewhat irritable and unwilling to take in p.o. fluids. Throughout hospital day #2, he continued to be fussy, have respiratory distress, and diffuse wheezing with a poor appetite.
Pound|Number|162|On postoperative day #2 she was passing gas and tolerating a regular diet. She remained afebrile and her preoperative hemoglobin was 9.7 and on postoperative day #1 it was 9.7, and on postoperative day #3 it was 9.1. The patient was ready for discharge on postoperative day #3 and was discharged home as below.
Pound|Number|150|Pain was adequately controlled with Fentanyl PCA and the patient gradually regained her bowel function. The PCA was discontinued on postoperative day #3. She was sent home with oral Percocet, and her pain was adequately controlled on this particular medication.
Pound|Quantity|130|DISCHARGE MEDICATIONS: 1. PTU 150 mg p.o. t.i.d. 2. Augmentin 875 mg p.o. b.i.d. x 14 days. 3. Percocet 1-2 tablets q.4h. p.r.n. (#30 dispensed). 4. Atenolol 100 mg p.o. q.d. Cipro has been discontinued.
Pound|Number|121|1. Acute renal failure likely due to dehydration and medications. 2. Dehydration. 3. Dementia. 4. Delirium, acute due to #1 and #2 above, now resolved. 5. Weakness and deconditioning, improving. HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE: The patient is an 88-year-old female who presented to _%#CITY#%_ _%#CITY#%_ Urgent Care with dizziness, fatigue and nausea.
Pound|Number|140|By postoperative day #1 she was ambulating, voiding, tolerating full diet and pain was well controlled. On the morning of postoperative day #1 the baby A did pass away due to difficulty with ventilation including continued air leak due to pneumothorax.
Pound|Number|379|On postoperative day #2, the patient's Thymoglobulin was held for a low platelet count. On postoperative day #3, the patient was given Thymoglobulin in a half dose for decreased platelets and on postoperative day #4, he was given Thymoglobulin in a Corder standard dose for decreased white count and platelets as well as an absolute lymphocyte count of 0.0. By postoperative day #4, the patient's creatinine had fallen to 1.76 and the patient was ambulating without assistance, tolerating a regular diet.
Pound|Number|164|The patient experienced mild edema in the right leg and persisting leg and foot numbness which had not changed from preop. The patient was ambulating on postop day #2 and had no difficulty tolerating the diet. She was discharged on _%#MMDD#%_ in stable condition and afebrile.
Pound|Number|116|IMPRESSION: 1. Acute gastroenteritis with diarrheal illness and dehydration. 2. Hyponatremia, probably secondary to #1. 3. Confusion, probably secondary to hyponatremia and toxic metabolic encephalopathy. 4. Consider underlying Alzheimer's or other memory disturbance.
Pound|Number|135|Given her lengthy duration of fevers, we also sent EBV titers and a monospot, given a known exposure to mononucleosis. On hospital day #2 she grew Staph from her line, which was sensitive to vancomycin.
Pound|Number|226|The patient was on milrinone at 0.5 mcg/kg/minute after discontinuation of the dopamine and epinephrine drips, and this was discontinued on postoperative day #2. The patient was started on oral lisinopril on postoperative day #2, and this was continued throughout her hospitalization.
Pound|Number|255|FINAL DISCHARGE DIAGNOSES: 1. Intractable pleuritic left-sided chest pain. Present on admission secondary to prior pulmonary emboli with suspected associated small hemorrhage and a small degree of lung infarct causing pain. 2. Fever, suspect secondary to #1. No evidence for infection. PAST MEDICAL HISTORY: 1. Notable for pulmonary emboli diagnosed _%#MMDD2007#%_ with associated left-sided chest pain and recurrent hospitalization x2 for pain control.
Pound|Number|425|Just in brief, she will be receiving a 5-week course of external beam radiation scheduled by the Radiation Oncology Department here at the University, and following completion of this treatment, she will require a followup appointment with Dr. _%#NAME#%_ as well as a followup appointment with Radiation Oncology Dr. _%#NAME#%_ to assess response to treatment and further planning. Then, as previously noted, on hospital day #5, the day prior to her discharge, she was started on Procrit 40,000 units subcu weekly.
Pound|Number|121|There were no complications and the patient was extubated and transferred to the PACU in stable condition. On postop day #1 the patient was started on Lovenox for DVT prophylaxis in addition, he was also given Ted hose and pneumoboots for DVT prophylaxis.
Pound|Number|186|Her IV was hep-locked on postoperative day #2. At the time of discharge, the patient was tolerating a regular diet. PROBLEM #5. GI: The patient had some mild nausea on postoperative day #1, which resolved fairly good that day. By the evening of postoperative day #1, the patient was eating a regular diet.
Pound|Number|88|FINAL DISCHARGE DIAGNOSES: 1. Cholelithiasis. 2. Epigastric pain, possibly secondary to #1 3. Contrast allergy. 4. Abnormal ECG PROCEDURES PERFORMED: 1. Coronary angiogram: Normal coronaries.
Pound|Number|268|DISCHARGE DIET: Regular. DISCHARGE ACTIVITY: Ad lib as tolerated, except for no heavy lifting or straining greater than 10 pounds x 6 weeks postoperatively. Additionally, she is to refrain from operating motor vehicles or operating heavy machinery while using Tylenol #3. DISCHARGE INSTRUCTIONS: She is to return to the emergency room or to call either Dr. _%#NAME#%_ or her primary physician, Dr. _%#NAME#%_'s office, if she experiences any of the following at home: Increased wound redness or purulent drainage, increased nausea or vomiting, increased abdominal distention, or fevers greater than 101 degrees.
Pound|Number|90|She was followed by the medical service and was stabilized. Finally, by postoperative day #5, she was stable and ready for discharge to the nursing home.
Pound|Number|163|ASSESSMENT: 1. Colon cancer with large liver metastases, perhaps mild ascites but I do believe this is really more progression of disease. 2. Dyspnea secondary to #1 and #2. 3. History of tobacco abuse. 4. Distant history of kidney stones.
Pound|Number|98|The patient was brought to the hospital for the previously described procedure. Postoperative day #1 she was doing well on the floor. Her hospital course was unremarkable. She had a slow taper of her Decadron.
Pound|Number|170|Of note, she was treated with amiodarone. She went slowly through rehab with intermittent bouts of atrial fibrillation. She did have some complaints of postoperative day #7 of cramping and lower abdominal pain and constipation.
Pound|Number|139|FINAL DISCHARGE DIAGNOSES: 1. Bilateral posterior cerebral artery strokes of unclear etiology. 2. Left homonomous hemianopsia secondary to #1. 3. Hypertriglyceridemia. 4. Hypertension. 5. Cardiomyopathy.
Pound|Number|164|Torsemide and Bumex were attempted on postoperative days #1 and #2, without apparent improvement in her urine output. Nesiritide was initiated on postoperative day #2, and the patient responded well to this. She remained on this medication for three days, with a significant increase in her urine output.
Pound|Number|315|Electrolytes were normal. HOSPITAL COURSE: PROBLEM #1: Neutropenic fevers. The patient had fevers for only 24 hours of hospitalization. She was treated with IV vancomycin and ceftazidime. After her fevers decreased and she increased her white count with an ANC of 1,100 her antibiotics were stopped by hospital day #3. The patient remained afebrile without any signs of positive cultures.
Pound|Number|181|Both infant and mother did well. Postoperatively, there was no evidence of infection, fever or excessive bleeding. Patient expressed desire for release to home on postoperative day #2 because she was doing well. That was executed. Plan was for outpatient follow-up.
Pound|Number|160|Please see operative dictation for details. Following the Whipple, the patient had a fairly uncomplicated hospital course. On the evenings of postoperative day #2 and postoperative #3, he suffered 2 separate episodes of confusion and agitation.
Pound|Number|271|In 9th or 10th grade, Dr. _%#NAME#%_ re-referred the patient to Dr. _%#NAME#%_ _%#NAME#%_ for orthognathic surgery and removal of teeth #1, 16, 17, and 32. On _%#MM#%_ _%#DD#%_, 2004, teeth #17 and 32 were surgically removed under IV sedation with a plan to remove teeth #1 and 16 during the Le Fort I osteotomy (secondary to their extreme apical position).
Pound|Number|152|The patient was seen and evaluated by Dr. _%#NAME#%_ who recommended irrigation and debridement of her right hip in the operating room. On hospital day #1 the patient was brought to the operating room and had a right hip incision irrigation and debridement.
Pound|Number|210|Birth control has been discussed. The husband is planning to undergo vasectomy. The patient has been counseled regarding interim birth control. The patient will be discharged to home today on postoperative day #4. She is tolerating a regular diet, voiding spontaneously, and ambulating.
Pound|Number|298|2. Wound exploration and drainage. COMPLICATIONS: None. HISTORY OF PRESENT ILLNESS: The patient is a 34-year-old P 5-2- 2-6, postop day #14 from a C-section on _%#MM#%_ _%#DD#%_, 2006. In the hospital, her postoperative course was uncomplicated, and she was discharged to home on postoperative day #4. She was seen in clinic on _%#MM#%_ _%#DD#%_, 2006, where she was thought to have a wound cellulitis.
Pound|Number|294|Uterus, tubes, and ovaries were within normal limits. EBL was 750 mL. POSTOPERATIVE COURSE: The patient underwent routine postoperative care. She was tolerating a regular diet, ambulating, and voiding spontaneously prior to discharge after the discontinuation of the Foley on postoperative day #1. She is A-positive. At this time, it is unclear as to what her rubella status was.
Pound|Number|218|Otherwise, there were no complications. Preop hemoglobin was 13.0. Three hours after cesarean section, hemoglobin was 10.6. POSTPARTUM COURSE: The patient's postoperative course was uncomplicated. On postoperative day #1, hemoglobin was 11.0, stable. The patient remained afebrile. On postoperative day #3, she was passing gas, having a small amount of lochia, ambulating without difficulty, and breastfeeding without problems.
Pound|Number|140|2) Gynecology as previously scheduled. 3) Follow-up with primary M.D. at Park Nicollet _%#CITY#%_ Clinic. ADDENDUM: Lastly, on hospital day #2, Anesthesiology was reconsulted as to whether this could also be persistent spinal headache despite the fact that she did not improve with a blood patch.
Pound|Number|26|PRELIMINARY _%#ADDRESS#%_ #_%#ADDRESS#%_. Bed #2. CHIEF COMPLAINT: This 67-year-old female is admitted because of constipation and nausea/vomiting. HISTORY OF PRESENT ILLNESS: This has been present for about a week.
Pound|Quantity|102|DISCHARGE MEDICATIONS: OxyContin 20 mg p.o. b.i.d. x 1 week, oxycodone 5-10 mg p.o. q. 4 hours p.r.n. #80, Vistaril 25-50 mg p.o. q. 4 hours p.r.n. #80, Colace 100 mg p.o. b.i.d. x 3 weeks.
Pound|Number|105|Estimated blood loss was 1000 cc. Postoperatively, _%#NAME#%_ did well. She was discharged on postop day #2. By that day she was ambulating, tolerating diet, urinating, passing gas, her vital signs remained stable.
Pound|Number|48|PRELIMINARY ADMITTING DIAGNOSIS: Postpartum day #5 with late onset HELLP syndrome. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 31-year-old gravida 3, para 2-0-1-2 presented in active labor on _%#MMDD2006#%_.
Pound|Number|328|Mr. _%#NAME#%_'s hemoglobin and chemistries were closely monitored throughout the postoperative period, he remained afebrile and vital signs stable with excellent urine output from the Indiana pouch and the SP tube throughout this period. An NG tube was maintained throughout postoperative day #6. However, by postoperative day #8, the patient was beginning to pass flatus, and on postoperative day #9, the TPN was completely discontinued, and the patient was advanced as tolerated in terms of his diet without difficulty.
Pound|Number|169|The patient is unsure about birth control and would like to discuss this at her 6-week postpartum examination. DISPOSITION: A 34-year-old para 7-0-0-7 postoperative day #4 status post primary low transverse C-section secondary to failed induction.
Pound|Number|125|Single IUP at 24 plus 0 by given EDC and vertex presentation. The patient given second dose of betamethasone on hospital day #2, _%#MM#%_ _%#DD#%_, 2005. Cervical check by Dr. (_______________)later on _%#MM#%_ _%#DD#%_, 2005, revealed cervix 7 cm, 100% effaced, minus 1 with head partially through the cervix.
Pound|Number|154|Tube feeds were started postoperatively with the assistance of the nutrition team. She was transferred to the general surgical floor on postoperative day #1 after uneventful course in the Intensive Care Unit.
Pound|Number|134|Her hemoglobin dropped to 10, but remained stable. She did not require a transfusion. She was discharged to home on postoperative day #3 with instructions on passive range of motion of the shoulder and active range of motion of the elbow and wrist.
Pound|Number|168|The incision was clean, dry and intact. Extremities were nontender and there was trace edema. She continued with routine cares. Later that evening on postoperative day #2, patient complained of some heaviness in her chest and she was very tearful.
Pound|Number|70|9. Tylenol 500 mg one tablet 3x daily as needed for pain. 10. Tylenol #3 one tablet twice daily as needed for severe breakthrough pain.
Pound|Quantity|211|She may shower with her incision and drains exposed. She should wear the abdominal binder at all times and may wear a mastectomy bra p.r.n. comfort. She has been given a prescription for Percocet 5/225 dispense #40.
Pound|Number|229|Based on the CT scan there was also concern for possible pyelonephritis and infectious disease recommended starting ceftriaxone. Unfortunately, the patient remained persistently febrile with the T-max of 104 on postoperative day #4. On postoperative day #5, the ceftriaxone was discontinued and vancomycin started.
Pound|Number|152|Once this was satisfactory, he was transferred to the regular floor for further monitoring and pain control. He was kept n.p.o. until postoperative day #1. An NG tube had been placed intraoperatively and was put to low intermittent suction until postoperative day #1 when it was continued.
Pound|Number|253|Her postoperative course was uncomplicated. Her hemoglobin after delivery was 11.3. By postoperative day # 4, the patient was ambulating, voiding, and tolerating a regular diet without difficulty. The patient was discharged to home on postoperative day #4. Her staples were removed from her incision and Steri-Strips were placed prior to discharge.
Pound|Number|222|He was transferred from the operating room to the postanesthesia care unit and then the orthopedic floor where he underwent pain management and physical therapy. He tolerated oral pain medications and on postoperative day #1 his IV PCA pain medication was discontinued. At that point he underwent physical therapy visits and did well with these.
Pound|Number|210|Please see a copy of the patient's medical consult for further medical details. The patient was treated with routine physical therapy rehabilitation for right knee arthroplasty and was discharged on postop day #4 to home. The patient is scheduled for follow-up in our office at 2 weeks postop for suture removal and radiographic evaluation.
Pound|Number|154|He received routine antibiotic prophylaxis with Ancef, DVT prophylaxis with foot pumps as well as pneumoboots. Developed some nausea on postoperative day #1 secondary to his PCA. This was treated with Zofran and Compazine and then he raised issues with possible exposure to scabies.
Pound|Quantity|107|DISCHARGE MEDICATIONS: 1. Atenolol 25 mg p.o. daily. 2. Percocet 1 to 2 tablets p.o. q.4-6 h. p.r.n. pain; #60, refills PRN by her family doctor.. 3. Plavix 75 mg p.o. daily; #90 with optional refills.
Pound|Number|203|Preliminary for the ultrasound done by Maternal Fetal Medicine. Estimated fetal weight was appropriate for gestational age, AFI was 11 cm, BPP was 8/8 and there were normal Doppler flow. On hospital day #2 the patient was stable, was not meeting criteria for preeclampsia and headache was reasonably well-controlled with narcotics.
Pound|Number|120|Her first IV and IP cycle was on _%#MMDD2007#%_, which was tolerated well. Unfortunately, she was unable to get her day #8 infusion of IV chemotherapy secondary to neutropenia with an ANC of 0.9 despite Neupogen administration.
Pound|Number|139|Intraorally, the patient has poor dentition. It is difficult to get a good exam at this time. Panoramic film reveals gross caries on teeth #15, 18 and 31. Tooth #18 is the obvious source for this patient's infection.
Pound|Number|189|Physical activity restrictions include no lifting more than 10 pounds, no sit-ups for six weeks, and no driving for two weeks. DIETARY RESTRICTIONS: None. DISCHARGE MEDICATIONS: 1. Tylenol #3 1 to 2 tablets p.o. q.4-6h. p.r.n. pain. 2. Colace 100 mg p.o. b.i.d. 3. Bactrim SS 1 tablet p.o. b.i.d. x 5 doses, then discontinue.
Pound|Number|259|This was gangrenous and required resection and reanastomosis x2. For full details of the operation, please see dictated operative note. Postoperatively, we primarily waited for the patient's return of bowel function and he was discharged on postoperative day #6. The patient was given p.o. antibiotics for staphylococcal pneumonia.
Pound|Number|163|Please see operative report for further details. Postoperative course was, overall, uncomplicated. Postoperative hemoglobin returned at 11.5. By postoperative day #3, patient was tolerating a regular diet. Her pain was controlled with oral pain medications, and she was ambulating without difficulty.
Pound|Number|218|Lungs were clear to auscultation bilaterally. Abdomen showed no masses, positive bowel sounds, soft, non-tender, no pulsatile mass, no hepatosplenomegaly. No costovertebral angle tenderness. Spine showed tenderness at #6 with deep palpation. He showed mild edema in the lower extremities. Neurologic showed he was alert and oriented X3.
Pound|Number|219|The patient's postoperative course was fairly unremarkable. Her hemoglobin was 9.8. The patient's diet was advanced. Her pain was well-controlled with oral pain medications. She was discharged home on postoperative day # #3. She remained afebrile throughout her entire hospital stay. Vital signs were stable.
Pound|Number|118|The gallbladder was seen, and no stones were noted in the gallbladder. This was an unremarkable MRCP. On hospital day #4, an ultrasound of the abdomen was completed. There was no evidence of gallstones or acute cholecystitis, but it was noted that there may be borderline hepatosplenomegaly, with a prominent portal vein.
Pound|Number|134|He thought that the patient had an episode of gallstone pancreatitis, resulting in her abdominal pain. It was decided on hospital day #10 that the patient would undergo an open cholecystectomy, performed by Dr. _%#NAME#%_.
Pound|Number|131|She also complained of a yeast vaginitis with discharge and Diflucan was started. She complains of some chronic headaches, Tylenol-#3 will be used for that. She is steady, ambulating on her own without any difficulty and will be discharged to home.
Pound|Number|189|The infant was in the breech presentation and was a 9 pound 4 ounce female with Apgars of 8 at 1 minute and 9 at 5 minutes. Her postoperative course was uncomplicated. On postoperative day #1, her pain was well controlled. Ambulation was begun, her Foley catheter was discontinued, and her diet was advanced.
Pound|Number|116|His first biopsy was performed on _%#MMDD2004#%_, which demonstrated no evidence of rejection. On postoperative day #14, he did experience an episode of severe joint pain, focused primarily in the right elbow, but including lower extremity joints as well.
Pound|Number|126|Once her ileus resolved, on postoperative day #2, her diet was fully advanced. At the time of discharge, on postoperative day #4, the patient was tolerating a regular diet, was having normal bowel movements, was ambulating without difficulty, and was having adequate pain control with oral medications.
Pound|Number|251|He was then taken to the operating room on _%#MMDD2005#%_ at which time he underwent cadaveric pancreas transplantation with bladder drainage of the graft. His postoperative course was smooth. He did require a 2-unit blood transfusion on hospital day #1 when he dropped his hemoglobin to 7.9. His lipase and amylase were high ly, and then fell consistently throughout his hospital stay to a final value of 59 by the day of discharge.
Pound|Number|205|Cross sections of both fallopian tubes were confirmed histologically prior to her discharge. Her postoperative course was unremarkable. Her hemoglobin on postoperative day #1 was 9.0, on postoperative day #3 was 8.9. She remained afebrile throughout her postoperative course, was ambulating without difficulty, nursing with out difficulty, and tolerating a general diet on the day of discharge, which was postoperative day 4.
Pound|Number|192|The patient is to follow up with his primary care physician, Dr. _%#NAME#%_ _%#NAME#%_, at approximately 1 week. At this time, he will need to have the Dilantin level drawn. Please page me at #_%#TEL#%_ if you have any questions.
Pound|Number|295|DISCHARGE FOLLOW-UP: 1. Follow-up with Dr. _%#NAME#%_ at the Oxboro Clinic in _%#NAME#%_ in approximately 10-14 days, or as soon as can be arranged or whenever Dr. _%#NAME#%_'s schedule permits to follow-up this hospital stay and to coordinate further workup. The patient was instructed to call #_%#TEL#%_ _%#TEL#%_ and to schedule a specific 30 minute follow-up appointment for this.
Pound|Number|202|HOSPITAL COURSE: 1. Respiratory: She did not require oxygen. Her tachypnea resolved by day of life #4, at which point she began breathing in the 40-50 range. Her chest x-ray was repeated at day of life #6 and was clear with normal heart size. 2. Cardiovascular: Initial faint slow murmur resolved by day of life #3.
Pound|Number|165|Postoperatively, the patient did well and had a Dilaudid PCA for pain that was stopped on post-op day #1 and she was converted to oral pain medications. Post-op day #1 hemoglobin was 11.7. She remained afebrile with stable vital signs throughout her hospital stay.
Pound|Quantity|146|2. Flagyl 500 mg p.o. t.i.d. x3 days. 3. Prilosec 20 mg p.o. q.p.m. 4. Zoloft 100 mg p.o. q. day. 5. Percocet 1-2 tabs every 4-6 hours as needed, #45, no refill. 6. Potassium supplement in the form of K-Dur 20 mEq tabs, 1 tab p.o. b.i.d. x7 days.
Pound|Quantity|111|MEDICATIONS: 1. Percocet 1 tabs p.o. q. 4-6h. p.r.n. pain, #60. 2. Flexeril 10 mg p.o. q.8 hours p.r.n. spasm, #40. 3. Colace 100 mg p.o. b.i.d., #60.
Pound|Quantity|133|2. Percocet 1-2 tablets p.o. q.4h. p.r.n. for pain, dispensed #60. 3. Colace 100 mg p.o. b.i.d. for constipation x14 days, dispensed #28. INSTRUCTIONS FOR CONTINUING CARE: 1. The patient is to remain nonweightbearing in his right lower extremity.
Pound|Number|152|She also may have syndrome of inappropriate antidiuretic hormone secretion (SIADH) on the basis of her recent pain. 2. Left ankle fracture secondary to #1 above. PLAN: 1. The patient is admitted to the hospital.
Pound|Number|129|She reported that her leg pain had gotten much better and the symptoms of spinal claudication had subsided. On postoperative day #2, she was evaluated on the ward. She was tolerating a regular diet, had excellent pain control.
Pound|Quantity|107|10. Albuterol 2.5 mg inhaled as needed q.4 h. 11. Colace 100 mg p.o. b.i.d. p.r.n. constipation, dispensed #30. 12. Vicodin one to two tablets p.o. q.4-6 h. p.r.n. pain, dispensed #60.
Pound|Number|163|Perioperatively she had a hemoglobin of 8.4, but really was asymptomatic. She was oriented x 2 in the early postoperative period, but today on postoperatively day #2 she is oriented x 3. She has been followed by Dr. _%#NAME#%_ for medical issues and will be discharged to extended care facility to be followed there by medical management.
Pound|Number|297|The patient did, however, have a fever the night prior to the morning of postoperative day #1, with 2 fevers, one at 101.8 followed by another fever of 100.8. The patient was started on gentamicin and clindamycin until she was afebrile for 24 hours. The patient's examination on postoperative day #1 was within normal limits. By postoperative day #2, the gentamicin and clindamycin were discontinued, as the patient remained afebrile for 24 hours.
Pound|Number|87|She was started on iron, and was continued on her IV antibiotics. On postoperative day #4, her white blood cell count was down to 12,500, and her hemoglobin was stable at 8.2. She remained afebrile.
Pound|Quantity|156|She is eating and voiding on her own. She will be discharged today, _%#MMDD#%_(?), with: 1. Vicodin #40, Sig. 1 p.o. q.4-6h. p.r.n. pain. 2. Vistaril 25 mg #40, Sig. 1 p.o. q.6h. p.r.n. muscle spasms. 3. Bactroban cream 30-gram tube, apply to grade II pin site infections.
Pound|Number|252|She had some leakage of the On-Q catheter, and the reservoir was nearly empty; therefore, it was discontinued on postoperative day #3. On postoperative day #4, she continued to do well. She was discharged to home in good condition on postoperative day #4. DISCHARGE MEDICATIONS: Percocet and ibuprofen for pain. She will follow up in approximately one to two weeks for a postoperative check and in four to six weeks for a postpartum check.
Pound|Number|136|ALLERGIES: No known drug allergies. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ was medically cleared for surgery on admission. On house day #2 she underwent a right hip open reduction and internal fixation without complication by Dr. _%#NAME#%_.
Pound|Number|300|2. Heme. Preop hemoglobin 12.8, postoperative hemoglobin 10.3. Lower extremity Dopplers were negative for DVT; these were checked secondary to some cellulitis on the patient's thigh. 3. Pain. The patient was given morphine PCA postoperatively and was tolerating p.o. medications by postoperative day #1. The patient was discharged home on Percocet p.o. and her pain was well controlled at the time of discharge.
Pound|Number|288|NEUROLOGICAL: Grossly negative. Toe signs are plantar flexion. Side effects from medications include a number of medications that she has been taking at the present time but she had a lot of trouble with cardiac medications causing nausea and vomiting. Side effects from codeine, Tylenol #3, Oxycodone, Darvon. Question of allergy to sulfa medications. Neurontin gave her most of the side effects listed on the literature that comes with the medication, but currently she is taking it without any problem.
Pound|Number|172|There were no intraoperative complications. Postoperatively the patient was transferred to the floor. She had immediate graft function. Her creatinine on postoperative day #1 was 2.5. Her current creatinine is 1.01. During her hospital course the patient received a total of four doses of Thymoglobulin.
Pound|Number|150|She has tried altering her diet principally increasing her fiber intact and trying Citrucel without significant relief. She reports today, postop day #1 (underwent the operation last night), the pain is persistent.
Pound|Number|193|2. Hypertension. a. Agree with resumption of ACE-inhibitor and beta-blocker. b. Stop ACE-inhibitor should acute renal failure develop. 3. Pain control. a. Note that the patient prefers Tylenol #3. b. Laxatives prophylactically have already been ordered. 4. History of ventricular tachycardia.
Pound|Number|165|REVIEW OF SYSTEMS: The patient was initially seen postoperative day #1 and on review of systems she was extremely nauseated and unable to do much. Postoperative day #2 she was complaining of pain and nausea, initially refusing examination.
Pound|Level|119|RECOMMENDATIONS: The patient is receiving transfusion of packed red blood cells. I would try to keep her hemoglobin at #10 in view of her history of syncope. She will be maintained on low dose beta blockers which apparently has been beneficial in the past in managing her syncope.
Pound|Number|134|FINAL _%#NAME#%_ _%#NAME#%_, CNM Fairview Riverside Women's Clinic _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_, _%#ADDRESS#%_ #_%#ADDRESS#%_ _%#CITY#%_, MN _%#55400#%_ Dear Ms. _%#NAME#%_: Thank you for the referral of your patient, _%#NAME#%_ _%#NAME#%_, who was seen on _%#MMDD2007#%_ at the Maternal-Fetal Medicine Center at the University of Minnesota Medical Center, Fairview.
Pound|Number|176|Tooth #11 appears to be impacted. Tooth #10 is distally positioned. The mandible is intact. There are no fractures noted. ASSESSMENT: Dental alveolar trauma, luxation of teeth #'s 9 and 10. RECOMMENDATIONS: Orthodontic bonding and stabilization. The father states that mother of child has already contacted the orthodontist, and they have plans to meet in the orthodontic office tomorrow, Saturday, _%#MMDD2005#%_, and initiate the stabilization process.
Pound|Number|163|Blood glucose highest since admission was 156. WBC 12.0, platelets 363. ASSESSMENT AND PLAN: 1. Status post decompression with hardware removal, postoperative day #3. 2. Mild postoperative anemia. Will observe for symptoms. Surgical drains discontinued last evening.
Pound|Number|128|2. Tubal ligation in 1991. MEDICATIONS: 1. Effexor XR 75 mg b.i.d. for perimenopausal symptoms. 2. Nexium 40 mg q.d. 3. Tylenol #3 p.r.n. knee pain. 4. Centrum Silver multivitamin tablet q.d. ALLERGIES: The patient reports no known drug allergies.
Pound|Number|82|5. Seroquel 200 mg q.h.s. 6. Anafrinil 150 mg q.h.s. 7. Tylenol p.r.n. 8. Tylenol #3 p.r.n. 9. Mylanta p.r.n. FAMILY HISTORY: Mother died from CVA. Brother is status post CVA.
Pound|Number|198|RECOMMENDATIONS: We agree that radiation therapy is indicated for Ms. _%#NAME#%_'s recurrence of papillary serous adenocarcinoma. She is currently being treated under Women's Cancer Center protocol #38 and has already received her 3 cycles of neoadjuvant carbo/Taxol.
Pound|Number|128|FINAL _%#NAME#%_ _%#NAME#%_, MD Southdale Ob-Gyn Consultants _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_, _%#ADDRESS#%_ #_%#ADDRESS#%_ _%#CITY#%_, MN _%#55400#%_ Dear Dr. _%#NAME#%_: Thank you for the referral of your patient _%#NAME#%_ _%#NAME#%_ who was seen along with her husband, _%#NAME#%_ on _%#MMDD2007#%_ at the Maternal-Fetal Medicine Center at University of Minnesota Medical Center, Fairview.
Pound|Number|171|2. Worsening status in the hospital currently including some progressive pneumonia, worsening respiratory status and new major fever. May still all be just progression of #1, new aspiration, new nosocomial infection or #3 below.
Pound|Number|244|RECTAL: Deferred. NEUROLOGIC: The patient is grossly nonfocal. ASSESSMENT: 27-year-old, postop day #1 with fevers, low blood pressure, dehydration, abdominal bloating and discomfort being admitted for further stabilization. PLAN: 1. Postop day #1 with hemorrhoidectomy and fissure repair. Will follow her hemoglobins. She is on morphine PCA and still is not completely having adequate pain relief.
Pound|Number|171|IMPRESSION: 1. _%#NAME#%_ _%#NAME#%_ is a 54-year-old female with acute meningitis. No significant encephalitis. Likely viral type syndrome, but even more likely, part of #2 below. 2. Prior recurrent meningitis syndrome with at least three episodes, eventually concluded to be a "Mollaret's" type syndrome, likely herpes simplex by belief, although HSV was negative on prior events.
Pound|Number|239|Cytotoxic rash on _%#MMDD#%_ was treated with hydrocortisone cream and hydrocortisone IV that was resolved by the time of discharge. The IV hydrocortisone was able to be discontinued on day #14 and hydrocortisone cream discontinued on day #19. MMF was discontinued on the day of discharge, day #27, after seven days of ANC greater than 0.5. A preliminary RSLP was 100% donor.
Pound|Number|218|PROBLEM #2: Fluids, electrolytes and nutrition: The patient was n.p.o. prior to the procedure, so IV fluids were started at the time of her procedure and these continued. The fluids were decreased on postoperative day #1 when she was able to tolerate some clears and then her fluids were discontinued at the time that she was tolerating an adequate amount of oral liquids and regular food.
Pound|Number|136|He was initially run at 1.5 X maintenance for his hemorrhagic cystitis. This was eventually tapered to maintenance rate on hospital day #12. Initially, _%#NAME#%_ took no p.o. but later in his hospital course he started taking sips of fluid.
Pound|Number|129|She required high frequency ventilation and nitric oxide on the day of birth. She was changed to conventional ventilation on DOL #3. She was maintained on mechanical ventilation for a total of 30 days before being extubated to nasal CPAP on _%#MMDD2007#%_.
Pound|Number|240|9. Prophylaxis. The patient was given TEDs and pneumos and Lovenox for prophylaxis in the postoperative period. 10. Psych. The patient has a history of bipolar disorder and she resumed her home medication valproic acid on postoperative day #1 DISCHARGE INSTRUCTIONS: The patient was discharged to home on postop day #3 with instructions to call with increased pain, bleeding or temperature greater than 100.4 or any increase in drainage or swelling.
Pound|Number|90|DIAGNOSES: 1. End-stage ischemic cardiomyopathy. 2. Congestive heart failure secondary to #1. 3. Insulin-dependent diabetes mellitus. 4. Status post renal transplant.
Pound|Number|189|b. Congestive heart failure, presently compensated. 3. Dementia dating back several years. Exact etiology unclear (question Alzheimer's, question vascular). _%#NAME#%_, _%#NAME#%_ Hospital #: _%#MRN#%_ PAST SURGICAL HISTORY: 1. Varicose vein stripping, right or left leg (late 1950s).
Pound|Quantity|313|Then on _%#MMDD2005#%_ she received chlorohydrate syrup 500 mg/5 mL, 300 mL total, 1 to 2 teaspoons at bedtime and that was just a one time fill and that was Dr. _%#NAME#%_ _%#NAME#%_. His telephone number is _%#TEL#%_. Then she received on _%#MMDD2005#%_ chlorohydrate capsules 500 mg 1 to 2 capsules at bedtime #17 by Dr. _%#NAME#%_ _%#NAME#%_ same clinic. On _%#MMDD2005#%_, she received lorazepam 2 mg 4 tablets that she received total before an x-ray ordered by Dr. _%#NAME#%_ _%#NAME#%_.
Pound|Number|130|PRELIMINARY _%#MM#%_ _%#DD#%_, 2006 _%#NAME#%_ _%#NAME#%_, MD Ob-Gyn West, PA _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ #_%#ADDRESS#%_ _%#CITY#%_ _%#CITY#%_, MN _%#55300#%_ RE: _%#NAME#%_ _%#NAME#%_ DOB: _%#MMDD1974#%_ Dear Dr. _%#NAME#%_: This letter will summarize the discussion that took place with your patient _%#NAME#%_ _%#NAME#%_ and her husband at the Maternal Fetal Medicine Center at Fairview Ridges on _%#MM#%_ _%#DD#%_, 2006.
Pound|Number|235|Your risk to have a live born child with an unbalanced amount of genetic information is approximately 3% to 6%. I reviewed that it would be difficult to predict exactly what a baby with an imbalance of information involving chromosome #1 or #6 would be like; however, in general one could expect varying degrees of mental retardation as well as possible other birth defects.
Pound|Number|206|At that time, recommendation was to increase the patient's beta-blocker and continue observation. The patient's chest tube output progressively decreased and his chest tube was removed on postoperative day #4. Followup chest x-ray showed stable small right apical pneumothorax. The patient did well otherwise.
Pound|Quantity|165|8. Vitamin C 100 mg p.o. daily. 9. Vitamin E 400 IU p.o. daily. 10. Omega fish oil 2 g p.o. b.i.d. 11. Percocet 1 tablet every 4 hours as needed for pain, dispensed #20. No refills.
Pound|Quantity|84|1. Protonix 40 mg p.o. daily. 2. Vicodin 1 to 2 p.o. q. 6 hours p.r.n. severe pain, #15, with no additional refills. DISCHARGE INSTRUCTIONS AND FOLLOW-UP: The patient is urged to follow up with a new primary care physician in this coming week.
Pound|Number|352|BRIEF ADMISSION HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a very pleasant 46-year-old male who presents on day of admission to begin part 2 of his CALGB 50202 remission induction therapy regimen on cycle one. This involves high dose methotrexate to be administered on protocol day 15 followed by leucovorin initiation beginning protocol day #16 and Rituxan administration on protocol day #17. The leucovorin is then given until methotrexate serum level is less than 0.05 micromoles.
Pound|Number|224|She tolerated pain well once she received pain medications. She was ambulating, voiding spontaneously and passing flatus by postoperative day #1. The patient was therefore discharged in stable condition on postoperative day #3. Her staples were removed prior to discharge and restrictions were reviewed.
Pound|Number|170|She was up and ambulating, tolerating a regular diet. Her incision remained clean, dry, and intact. No evidence of hematoma, swelling, or infection. On postoperative day #2, the drain output had decreased significantly and the JP drain was removed.
Pound|Number|204|IMPRESSION: 1. Mandibular fracture secondary to _%#MMDD2002#%_ fall. 2. Facial laceration secondary to _%#MMDD2002#%_ fall - sutured, with large amount of bleeding before suturing. 3. Anemia secondary to #2 hemorrhage and also may have been chronic. 4. Acute HTN crisis secondary to pain, secondary to the above, with a history of poor control and poor patient cooperation in the past.
Pound|Number|98|He was extubated on postoperative day #1 and started on a clear liquid diet. On postoperative day #2, he was transferred to the telemetry unit for further recovery, he was started on a steroid taper, and his insulin continuous infusion was exchanged for a sliding scale.
Pound|Number|135|The patient was consulted with Dr. _%#NAME#%_ and decided to undergo blood-brain disruption chemotherapy. The patient now presents for #12 of blood brain disruption chemotherapy with methotrexate.
Pound|Number|158|The patient progressed nicely with physical therapy. He was toe-touch weightbearing in right lower extremity with a walker at all times. By postoperative day #6, the patient was without complaints. His pain was well controlled. He was tolerating normal diet.
Pound|Number|302|Postoperatively, the patient had an uneventful course. He was put into a continuous passive motor machine on postoperative day # 1. His activity is to be weight bearing as tolerated. The patient initially had some trouble with adequate pain control, but this resolved subsequently on postoperative day # 2. He was ambulating quite well, tolerating a regular diet, and his pain was well-controlled with oral pain medicine.
Pound|Number|277|Nephew has noticed that she is not quite herself over the last several days. ALLERGIES: None. MEDICATIONS: Include Fosamax 10 mg a day, Synthroid 0.1 mg a day, Zestril 10 mg a day, Calcium Carbonate 500 mg tid, Tylenol Extra Strength prn, Ultram 50 mg prn q 4-6 hours, Tylenol #3 1-2 q 4 prn. PAST MEDICAL HISTORY: Significant for Alzheimer's x 2 years, fractured hip x 2 in the last 10 years, hypertension and bladder spasm.
Pound|Number|158|2. History of psoriatic dermatitis, clear after treatment with triamcinolone cream. 3. Last admission _%#MMDD2002#%_ to _%#MMDD2002#%_ for chemotherapy, week #29, with vincristine, actinomycin, mesna, and Cytoxan.
Pound|Number|219|_%#NAME#%_ used 5 liters of oxygen throughout his hospital stay, primarily used for comfort, but he was having increased oxygen needs as well. PROBLEM #5: Cardiac. _%#NAME#%_ was complaining of retrosternal pain on day #2 of admission. There was the question of a pericardial friction rub noted on exam.
Pound|Number|85|6. Vitamin E 400 International units Q day 7. Lorazepam 0.5 mg as needed. 8. Tylenol #3 4-6 hours prn. for pain which she is not taking. SOCIAL HISTORY: Retired, no alcohol, no tobacco use.
Pound|Number|125|The patient did well postoperatively and had no postoperative complications. She was discharged to home on postoperative day #4. She was instructed to follow-up with Dr. _%#NAME#%_ in six weeks.
Pound|Number|247|The patient's pain was well controlled. She was ambulating and voiding without difficulty, and tolerating a regular diet. She did have positive flatus. Postoperative hemoglobin was 9.0. DISPOSITION: The patient was discharged on postoperative day #3 in stable condition. She was given routine discharge instructions including lifting and driving restrictions.
Pound|Number|190|She advances her mobility with physical therapy without complication. She transitioned to oral pain medications over the course of her first several postoperative days. On postoperative day #3, the decision was made she was ready for discharge home.
Pound|Number|300|The patient did have some hypertension during his postoperative course; however, this was completely asymptomatic, and was thought by the medical doctor who saw him in consultation to be related to pain. He was ready for discharge after he was comfortable on oral pain medicines on postoperative day #1. Condition on discharge is stable. Discharge medications include Percocet one to two p.o. q.4-6h p.r.n. pain.
Pound|Number|113|PAST MEDICAL HISTORY: 1. Graves disease with a history of radioactive iodine. 2. Secondary hypothyroidism due to #1. 3. Hypertension. 4. Degenerative joint disease. 5. Gastroesophageal reflux disease.
Pound|Number|98|The patient was restarted on a clear liquid diet, and she tolerated it well. On postoperative day #3, the patient underwent another abdominal exam, which showed no gastric remnant distention.
Pound|Number|175|This is well above the normal range, and she is being sent home on an initial dose of Synthroid of 12.5 mcg per day. Another issue starting on approximately postoperative day #3 was hypertension. She was requiring multiple doses per day of p.r.n. 0.1 mg Clonidine for blood pressures in the low 200s systolic.
Pound|Quantity|110|DISCHARGE MEDICATIONS: 1. Zantac 150 mg p.o. b.i.d. 2. Percocet 5/325 one to two tabs p.o. q.6 h. p.r.n. pain #40. 3. Baza Cleanse transdermally apply after every bowel movement, 1 month's supply.
Pound|Number|225|HOSPITAL COURSE: The patient was then admitted to the Intensive Care Unit where he remained stable but required mask to optimize oxygenation. He was able to be transferred to the step-down unit of floor care on posterior day #1. The rest of his hospital course was uneventful except for his inability to remain on room air.
Pound|Number|102|5. Glipizide 5 mg q.a.m. 6. Colchicine 0.6 mg taking 1-2 daily. 7. Lisinopril 10 mg daily. 8. Tylenol #3 p.r.n. He has not been taking his medications with any regular form of compliance apparently.
Pound|Quantity|218|Medications that he was taking prior to hospitalization that he is to avoid include aspirin and Naproxen or Aleve. He will also be discharged on Percocet 5/325 mg one to two tablets every 3-4 hours as needed for pain, #60 dispensed, and Robaxin 750 mg one p.o. q.6h. p.r.n. muscle spasm and tightness.
Pound|Number|130|PROBLEM #2: Diffuse large B-cell lymphoma. The patient had received his chemotherapy on _%#MMDD2006#%_. He will present for cycle #2 on _%#MMDD2006#%_ at 8:30 in the morning in the Cancer Center.
Pound|Number|172|Estimated blood loss: 250 cc. She had laceration that was repaired with a 3-0 chromic. She has been doing well post-partum. She is discharged home today on post-partum day #2. She is breast feeding. We discussed continuing with her prenatal vitamins and calcium intake.
Pound|Number|180|d. She will also be sent home with a Home Health aide and a registered nurse (RN) to help with her tube feeds which will be on a chronic basis. 2. Chronic aspiration. (See Problem #1 above.) 3. Osteoporosis. a. The patient has a recent T-12 compression fracture, therefore, she was placed on Actonel empirically and will continue this on an outpatient basis along with calcium.
Pound|Number|99|Pulse width was 350 msec at a rate of 60 Hertz and an amplitude of 0.4 volts. On postoperative day #1, the patient had good pain control, vital signs were stable, and maximum temperature overnight was 98 degrees.
Pound|Quantity|136|He was to return to Health Recovery Associates, and get back on their vitamin therapy. He was given a prescription for Antabuse 250 mg, #30, one daily. The Antabuse-alcohol reaction was explained to him. He was also treated with atenolol 50 mg daily for hypertension.
Pound|Number|164|The patient was treated with routine physical therapy rehabilitation for a total hip arthroplasty. DISCHARGE PLANS: The patient was discharged on postoperative day #3 to her home for self care. She is scheduled for follow up in our office two weeks postop for suture removal and radiographic evaluation.
Pound|Number|204|DISCHARGE DIAGNOSIS: Recurrent osteosarcoma status post cycle #8 high-dose methotrexate. HISTORY OF PRESENT ILLNESS: This 35-year-old man with recurrent osteosarcoma of the right femur presents for cycle #8 of high- dose methotrexate. He has been feeling well and denies complaints. His past doses of methotrexate have been complicated by nausea.
Pound|Number|232|However, she developed increasing confusion and lethargy. She returned to the Emergency Department on _%#MMDD2004#%_ and was subsequently admitted. She was receiving Timentin to treat her cellulitis, and vancomycin was added on day #4, as she was at an increased risk for MRSA secondary to living in a long-term care facility.
Pound|Number|248|Her nausea was gone and the patient was reporting mild urinary frequency and dysuria and a urinalysis was negative. Her incisions were healing well on _%#MMDD2004#%_ and the patient was passing gas and had had a bowel movement by postoperative day #3 on _%#MMDD2004#%_. She remained afebrile and final pathology showed adenomyosis and benign ovaries.
Pound|Number|221|Please see dictated operative report for full details. POSTOPERATIVE COURSE: The patient's postoperative course was uncomplicated. She remained afebrile with stable vital signs throughout. Hemoglobin on postoperative day #1 was 14.0. She is Rh positive and rubella immune. She was continued on her Synthroid. Throughout her hospitalization her pain was controlled with oral medications.
Pound|Number|92|The patient will be discharged to rehab for ongoing PT and OT cares. 2. Ataxia secondary to #1, currently resolving. 3. Metabolic encephalopathy, likely multifactorial secondary to acute CVI, mild delirium, and UTI.
Pound|Number|219|The patient was afebrile and her vital signs were stable and within normal limits (with the exception of intermittent hypertension) throughout her entire hospital course. The patient was discharged on postoperative day #4 in stable condition. DISCHARGE MEDICATIONS: 1. Trazodone 50 mg p.o. q.h.s. 2. Fosamax 70 mg p.o. q. weekly (Sundays).
Pound|Number|198|PROCEDURES PERFORMED: 1. On _%#MMDD2007#%_, mitral valve replacement with 27 mm mosaic porcine valves by Dr. _%#NAME#%_ _%#NAME#%_. 2. On _%#MMDD2007#%_, a placement of a Medtronic Adapter DR model #ADDR 01 was implanted by Dr. _%#NAME#%_ _%#NAME#%_. CONSULTATIONS OBTAINED: Electrophysiology Cardiology was consulted on _%#MMDD2007#%_ for evaluation of pacemaker for slow heart rate in the postoperative period.
Pound|Number|149|She had a 9 pound 2 ounce female infant weighing, Apgars of 8 and 9. Her blood loss was 600 cc. She did well and was going home on postoperative day #3 with a hemoglobin of 11.0. She is to return to the clinic in six weeks for follow-up.
Pound|Number|237|She remained afebrile throughout the hospital course and was afebrile, as well, on the morning of discharge. Her pain was well controlled throughout the hospital course, as well, with a combination of morphine, sulfate, and p.o. Tylenol #3. Her pain was well controlled prior to discharge. She was received 24 hours of clindamycin for postoperative antibiotics.
Pound|Quantity|235|However, the patient did state that he would follow-up at Fairview _%#CITY#%_ Clinic in the next 1-2 weeks. DISCHARGE PLANS: The patient was discharged to home. DISCHARGE MEDICATIONS: Vicodin 5/500 one to two tablets q.6.h. as needed, #20, no refills. Dilantin 200 mg q.h.s. The patient will follow-up with Dr. _%#NAME#%_ in Neurology Clinic in the next 7-10 days.
Pound|Number|118|7. Humulin insulin 70/30, 21 units subcu q.p.m. 8. Imdur 60 mg p.o. daily. 9. Toprol XL 75 mg p.o. daily. 10. Tylenol #3 one to two tablets p.o. p.r.n. pain. 11. Lasix 80 mg p.o. b.i.d. Of note, these medications may be adjusted as deemed necessary by Fairview Home Hospice Care in regards to focusing on the patient's comfort.
Pound|Number|108|5) Plavix 75 mg per day - hold for one week or as directed by Urology. 6) Lipitor 10 mg per day. 7) Tylenol #3 one to two tablets q.4.h. p.r.n. pain. FOLLOW-UP APPOINTMENTS: 1) With Dr. _%#NAME#%_ on _%#MMDD2005#%_ for ESWL procedure.
Pound|Number|140|The patient did not have any respiratory compromise with the development of this rash. The patient was discharged home on postoperative day #2. At the time of discharge, the patient's incision/trocar sites were clean without any erythema or discharge.
Pound|Number|148|Her postoperative hemoglobin was 8.7, and she was discharged home with iron to improve her hemoglobin. She was discharged home on postoperative day #4, and she will follow up in six weeks.
Pound|Quantity|222|Her blood work - the urine drug screen was positive for cocaine. Her hemoglobin last taken on _%#MM#%_ _%#DD#%_, is low at 11.7. During hospital course, because of mom's hepatitis status, she was given hepatitis B vaccine #1 and hepatitis and H bag immunoglobulin to cover her.
Pound|Number|108|Her creatinine on the date of discharge is 1.13 with a BUN of 7. She is now discharged on postoperative day #4.
Pound|Number|134|DISCHARGE DIAGNOSES: 1. Bacterial infection of undetermined site. 2. Lumbar spinal pain of uncertain etiology. 3. Extraction of tooth #15. PROCEDURES: 1. Bone scan. This was entirely normal. 2. Oral maxillofacial surgery consult.
Pound|Number|139|Postoperatively, she did well. She had normal return of bowel and bladder function. She was stable for discharge home on postoperative day #3. Her staples were removed prior to discharge. DISCHARGE MEDICATIONS: Percocet, ibuprofen and prenatal vitamins.
Pound|Number|215|FINAL CHIEF COMPLAINT: Dog attack with facial injuries. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a previously-healthy, mixed Hispanic and Caucasian, 22-month-old young lady who was admitted to the floor postop day #0 status post repair of multiple complex facial, gingival, and left eyelid lacerations by Oculoplastics and Oral Maxillofacial Surgery as a result of a dog bite. Her family is here visiting relatives, from Northern California, and are staying in _%#CITY#%_ _%#CITY#%_, for the _%#DD#%_ of _%#MM#%_ holiday.
Pound|Number|117|These were continued for 24 hours postop and she was then transitioned back to oral prednisone, 40 mg. By postop day #4, the patient was tolerating regular diet. Her pain was well controlled. She was voiding and having bowel movements.
Pound|Number|161|His abdominal x-rays at the time of admission show partial small bowel obstruction with dilated small bowel as well as gas throughout the colon. On hospital day #2, his repeat abdominal films show worsening of obstruction with increasingly dilated small bowel.
Pound|Number|120|She gradually resumed an ambulatory status, and she has remained afebrile. She is being discharged on postoperative day #4 in satisfactory condition. All incisions are nicely approximated. There is no evidence of infection.
Pound|Number|100|DISCHARGE INSTRUCTIONS: 1. Dilantin level on _%#MMDD2002#%_, please call Dr. _%#NAME#%_'s Office at #_%#TEL#%_ if this level is abnormal. 2. Follow-up appointment with Dr. _%#NAME#%_ in four weeks, please call to set up this appointment.
Pound|Number|256|I have asked the pharmacist to review the patient's at-home medications, which include multiple herbal medicines and vitamins, and to recommend whether he should take any of these while on Coumadin therapy. The patient was given a prescription for Tylenol #3, 1-2 tablets p.o. q.4- 6h. p.r.n. left back pain. DISCHARGE DIET: As previously. DISCHARGE ACTIVITY LEVEL: No activity restrictions at this time.
Pound|Number|171|The patient's postoperative course was unremarkable. She remained afebrile throughout. Her postoperative hemoglobin was 10.0. She was discharged home on postoperative day #4 ambulating without difficulty and tolerating a general diet.
Pound|Number|83|2. Fluconazole 40 mg p.o. daily. 3. Cis-retinoic acid 50 mg p.o. daily. 4. Tylenol #3, 5 mg p.o. q. 6 h. p.r.n. for pain. 5. Heparin 3 ml to each line daily.
Pound|Number|146|Apgars 9 and 9. Postoperative course was uncomplicated with normal return of bowel and bladder function. She was discharged to home on postop day # 4. Restrictions were discussed with the patient. She was given instructions to follow-up in two weeks for postop examination.
Pound|Quantity|126|She is to receive a follow up Pap smear in the postpartum time. ADMISSION MEDICATIONS: 1. Prenatal vitamins. 2. Betamethasone #1 on _%#MM#%_ _%#DD#%_, 2004. ALLERGIES: NO KNOWN DRUG ALLERGIES. FAMILY HISTORY: A history of maternal grandfather with hemophilia B.
Pound|Quantity|170|Patient should also be evaluated by her orthopedic surgeon for need for further physical therapy. DISCHARGE MEDICATIONS: Vistaril 25 mg 1 to 2 tablets p.o. q.4h. p.r.n., #75, Colace 100 mg p.o. b.i.d., #60, oxycodone 5 mg 1 to 4 tablets p.o. q.4h. p.r.n. pain, #100.
Pound|Number|108|The patient was voiding, tolerating p.o., taking p.o. pain medications and oral foods. On postoperative day #4, the patient was discharged to home. Staples were removed from incision. Steri-Strips were placed. She was discharged home on Percocet and given instructions to call with any fever, drainage from incision, or increasing bleeding.
Pound|Gauge|197|Upon evaluation, in the emergency room, a chest x-ray showed that the lung was expanded, that there was no pneumothorax present, but a small pleural effusion at the base. Since he has been here, a #14 chest catheter was inserted under CT guidance by Dr. _%#NAME#%_ in radiology.
Pound|Number|106|This again showed no leaks. Her diet was gradually resumed. On postoperative day #5 and postoperative day #6, the patient was complaining of a cough. Potentially, it did appear though her chest x-ray did show an area of infiltrate, and Levaquin 500 mg p.o. q. day was started.
Pound|Number|60|The patient was considered stable to be discharged to home. #2: Nutrition. The patient was evaluated twice for suspected poor weight gain during this pregnancy.
Pound|Quantity|132|As noted above, she will be seeking new primary care elsewhere. DISCHARGE MEDICATIONS: 1. She was given a prescription for Vicodin, #60, so she will be taking that twice a day now. 2. Continue on fentanyl patches 25 mcg every three days.
Pound|Number|200|Please see a copy of Ms. _%#NAME#%_'s medical consult for further medical details. Ms. _%#NAME#%_ was treated with routine physical therapy rehabilitation and was discharged to her home on postop day #5 with in-home skilled nursing. Ms. _%#NAME#%_ is scheduled for followup in our office at two weeks postop for suture removal and radiographic evaluation.
Pound|Number|144|She again remained afebrile and was ambulating without difficulty, tolerating a regular diet. She was then discharged home on postoperative day #4. She was afebrile. Incision was clean, dry and intact. She was given instructions to follow up in the office in two and six weeks.
Pound|Number|103|LUNGS: Clear. HEART: Normal sinus rhythm. ABDOMEN: Soft, nontender, nondistended. On postoperative day #1, her hemoglobin is at 10.1 grams per deciliter, representing a decrease from her preoperative hemoglobin measured _%#MMDD2006#%_ at 13.2 grams per deciliter.
Pound|Number|206|However, she was stable postoperatively with no evidence of cardiac arrhythmia, chest pain, shortness of breath or other complications. She was transferred from the intensive care unit on postoperative day #1 to the postsurgical ward. Her vital signs remained stable. She did receive 2 units of packed red cells intraoperatively into PACU due to intraoperative blood loss, but required no further transfusions.
Pound|Number|133|On postoperative day #1, he was afebrile and his vital signs were stable and he was fitted for a lumbar corset. On postoperative day #2, he was able to walk without problems with the lumbar corset on.
Pound|Number|166|She was switched to a regular diet. She tolerated all these well. She did have some urinary frequency and urinalysis and urine culture were sent on postoperative day #2. This urinalysis showed only trace leukocyte esterase, therefore we awaited the culture results before initiating any treatments.
Pound|Number|228|On postoperative day 1, he reported feeling markedly better with his pain controlled. He was started on a clear liquid diet and advanced to regular and transitioned to oral pain medications on the afternoon of postoperative day #1, he was ambulating. His pain was controlled with oral pain medications and he was tolerating a diet.
Pound|Number|346|It was decided at this time by Dr. _%#NAME#%_ that the patient would benefit from a blood transfusion and she received 2 units of packed red blood cells the evening of postoperative day 2 well until the night and so stayed an additional day. Aside from this issue, the patient progressed well in the postoperative period and by postoperative day #2, was ambulating, voiding, passing bowel movements and tolerating clear liquids without nausea or vomiting, and had adequate pain control with p.o. analgesia.
Pound|Number|343|LABORATORY & DIAGNOSTIC DATA: EKG shows sinus rhythm at a rate of 62 with some PVCs, no ischemic-looking changes. Her CBC shows platelet count of 303,000, hemoglobin 13.6 and white count of 6.3. Other blood work was drawn including potassium, creatinine and INR, those are pending at the time of this dictation and can be available by calling #_%#TEL#%_ if they have not been faxed prior to surgery. ASSESSMENT/PLAN: 1. Preoperative physical. The patient is acceptable for the proposed procedure.
Pound|Number|140|However, I could not document this in the chart, and I will obtain further records. The patient was discharged to home on postoperative day #4 afebrile tolerating a regular diet, ambulating, and urinating without difficulty.
Pound|Number|261|She harks back to when she had Vicodin and some kind of patch when she was back at Abbott- Northwestern Hospital; she said vaguely it was for some kind of ulcers on her buttock and for her surgery, and wants to have this. We finally ended up giving her Tylenol #3 and Vioxx, and Tylenol as the first coverup. At any rate, she is a cheerful person. She wears a refraction.
Pound|Number|193|Postoperatively, her vital signs remained stable and she was moving her lower extremities and her strength remained intact as did her sensation. She was discharged to home on postoperative day #1 with the following medications: OxyContin and Vicodin for pain relief as well as her at home medications including atenolol, Zocor, isosorbide, Premarin, Norvasc, aspirin, Prozac, Protonix and Senokot.
Pound|Number|412|ADMISSION DIAGNOSIS: Recurrent suprasellar choriocarcinoma. DISCHARGE DIAGNOSIS: Same. OPERATIONS AND PROCEDURES PERFORMED: Head CT and blood-brain barrier disruption, with chemotherapy, under general anesthesia in the operating room. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ is a 12-year-old female with recurrent suprasellar choriocarcinoma, admitted for blood-brain barrier disruption, with chemotherapy, cycle #9. She was admitted on _%#MMDD2003#%_ for preparation for the operating room.
Pound|Number|229|It is unclear as to the method of the patient's previous tubal ligation, but this may be consistent with possibly a surgical clip or Falope ring. DISCHARGE INSTRUCTIONS: 1. The patient was discharged to home on postoperative day #3, with instructions to do no lifting of greater than 20 pounds for six weeks, no driving for two weeks, or while on narcotics, and nothing in the vagina for six weeks.
Pound|Quantity|178|The pager number is _%#TEL#%_. She is also given contact numbers for setting up her appointments. DISCHARGE MEDICATIONS: 1. Sustiva. 2. Dilaudid 3 mg p.o. q.3h p.r.n.; dispensed #100 total. 3. Ibuprofen 600-mg p.o. q.8h x 10 days. 4. Klonopin 1 mg p.o. b.i.d.
Pound|Number|195|2. Respiratory. Albuterol nebulizers and steroids were started at the time of admission but proved not to be helpful in improving his respiratory symptoms. They were discontinued on hospital day #2. Racemic epinephrine nebs were somewhat helpful, and he received these p.r.n. during his hospitalization.
Pound|Number|159|HOSPITAL COURSE: Hospital course has been unremarkable. Postoperatively she was managed with p.o. and IV pain medications. On the morning of postoperative day #1, she was comfortable on p.o. pain medication only and was asking to go home.
Pound|Number|100|DOB: _%#MMDD1965#%_ DISCHARGE DIAGNOSES: 1. Sinusitis. 2. Suspect vertigo, peripheral, secondary to #1. Other diagnoses include: Irritable bowel syndrome, anxiety and hypothyroidism. CONSULTS: Neurology.
Pound|Number|90|10. EMLA cream topical as needed for pain at port site. 11. Tylenol with Codeine (Tylenol #3) 1 to 2 tablets p.o. every 6 hours as needed for pain not relieved by other medications.
Pound|Number|171|The patient remained afebrile during the postpartum course and her remaining vital signs were stable. Her hemoglobin was stable at 12.4 postoperatively. On postpartum day #2, the patient was feeling well and was requesting discharge home.
Pound|Number|333|LABORATORY: Her labs on admission are normal range. INR 1, hemoglobin 14, and creatinine 0.7. HOSPITAL COURSE: She underwent laparoscopic, hand-assisted left nephroureterectomy on _%#MM#%_ _%#DD#%_, 2006, without complications. The patient's hospital course is unremarkable. She is advanced to clear liquid diet on postoperative day #2 and to a regular diet on postoperative day #3. Her wound is clean and dry. She has good pain control with the On- Q pump as well as p.o. medications with Darvocet.
Pound|Number|236|He will be followed by Fairview Homecare and Hospice at the time of discharge. Complicating his social situation is the fact that the patient's mother recently underwent emergency heart bypass surgery and currently is postoperative day #1 and Fairview Southdale Hospital. DISCHARGE STATUS: Guarded. CODE STATUS: DNR/DNI. ALLERGIES: intolerance to Dilantin.
Pound|Number|157|Liver function tests were normal. Urinalysis shows glucose greater than 3 to 1000. IMPRESSION: 1. Uncontrolled diabetes. 2. Dehydration secondary to problem #1. 3. Abdominal pain probably related to problem #1. 4. Overall, I feel that the patient has uncontrolled diabetes, probably more related to dietary indiscretions.
Pound|Number|206|She was in normal sinus rhythm. The patient's troponins were negative following her elevated heart rate. Mild electrolyte disturbances were corrected. She was transferred back to floor on postoperative day #1. She had good allograft function throughout her hospital course. The patient was initially on a PCA for pain control.
Pound|Number|215|The patient's hand was normal in caliber and color and there was no evidence that she had any further occlusion of her venous outflow tract. The patient did develop a very small stable hematoma on postoperative day #2, presumably secondary to anticoagulation. This was however, self-limiting and within 24 hours had already begun to soften and there was no progression of the hematoma.
Pound|Number|262|See Dr. _%#NAME#%_ _%#NAME#%_'s detailed H&P from _%#MMDD2007#%_. At the time of admission he was found to be hyperglycemic with a blood sugar of 657. Ketones were negative. He was admitted to the hospital with uncontrolled diabetes and dehydration secondary to #1. HOSPITAL COURSE: 1. After admission to the hospital he was started on IV fluids.
Pound|Quantity|90|2. Migraine headaches. DISCHARGE MEDICATIONS: Vicodin 5/500 1 tab p.o. q. 6 hours p.r.n., #10 tablets given. DISCHARGE FOLLOW-UP: The patient is to follow up with new PMD in one to two weeks.
Pound|Quantity|193|2. Clostridium difficile colitis. 3. Chronic constipation. 4. T10 paraplegia. 5. Neurogenic bladder. 6. Neuropathic pain. DISCHARGING MEDICATIONS: 1. Colace 100 mg p.o. b.i.d. for constipation #60, 1 refill. 2. Fish oil 1 mg capsules p.o. b.i.d. quantity 60, refills 2.
Pound|Number|216|The patient's Foley was discontinued. She was advanced to regular diet, ambulating, voiding spontaneously, and the patient remained afebrile. The patient diagnosed with a urinary tract infection on postoperative day #2 and started on amoxicillin for this pending culture results.
Pound|Number|162|Please see operative dictation for further details. The patient's postoperative course was unremarkable. He had return of his bowel function on postoperative day #2. His diet was advanced to clears which he tolerated well.
Pound|Number|132|4. Dysphagia. She is working with speech therapy. She will continue to work with speech therapy. She is on the dysphagia diet level #1. 5. Steroid induced hyperglycemia. Her blood sugars, she actually only needed to be treated once yesterday with a few units of insulin.
Pound|Number|172|The patient was transferring with two assist and a walker at the time of discharge. The patient was discharged to a short-term rehabilitation facility on postoperative day #4 with the following medications. DISCHARGE MEDICATIONS: Percocet one to two tabs p.o. q.4-6 hours p.r.n. for pain.
Pound|Number|215|Estimated blood loss was 800 cc. For complete operative details, please see the operative date of the same date. She progressed through a normal postoperative course and was ready for discharge on postoperative day #4 with a postoperative hemoglobin noted to be 11.6. At the time of discharge, she was ambulating, voiding, and tolerating a regular diet with normal return of bowel function.
Pound|Quantity|113|DISCHARGE MEDICATIONS: 1. Levaquin 500 mg p.o. q. day. x3 days. 2. Percocet 1-2 tablets p.o. q.4-6h. p.r.n. pain #40, no refills. 3. Colace 100 mg p.o. b.i.d. #16. 4. Ditropan 5 mg p.o. t.i.d. p.r.n. #20, no refills.
Pound|Number|46|FINAL NOTE TO SIGNER: Dr. _%#NAME#%_, Dict ID #_%#MRN#%_ and this one appear to be almost identical...do you want one of them deleted? _%#NAME#%_ _%#MMDD2007#%_ CHIEF COMPLAINT: Bilateral ankle pain and swelling. HISTORY OF PRESENT ILLNESS: This is a 32-year-old Somali woman who has been having fevers and headaches for the past 7 days.
Pound|Number|105|The patient had a postoperative ileus, which resolved by postop day #3. The patient on postoperative day #3 was noted to have several fevers. Her white blood cell count was noted to be elevated.
Pound|Quantity|182|DISCHARGE MEDICATIONS: His home medications are unchanged of atenolol, Glucotrol-XL, Toprol-XL, Zoloft and Zocor. He was given a script for Vicodin 1-2 tabs p.o. q.4-6h. p.r.n. pain #40 and senna S 2 tabs p.o. each day at bedtime, hold for loose stool #60.
Pound|Number|211|31. Excision, left pulmonary nodule, benign. ALLERGIES AND SENSITIVITIES TO THE FOLLOWING MEDICATIONS: Penicillin (GI), Elavil (increased heart rate), theophylline, Cipro (rash). CURRENT MEDICATIONS: 1. Tylenol #3, 1-2 p.o. q. 4-6 hours pain relief. 2. Lopid 600 mg b.i.d.
Pound|Gauge|130|FINAL PRINCIPAL DIAGNOSIS. 1. Aortic stenosis. 2. Coronary artery disease. PROCEDURES PERFORMED: 1. Aortic valve replacement with #23 Medtronic Mosaic valve. 2. CABG x2 with saphenous vein graft. HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old male with a past medical history significant for malaise, chest pain and an angiographically diagnosed coronary artery disease as well as an echocardiogram which demonstrates aortic stenosis.
Pound|Number|143|HISTORY OF PRESENT ILLNESS: Ms. _%#NAME#%_ is a 52-year-old woman who is being admitted with the above complaints. This is patient's admission #3 in the last 4 weeks. PAST MEDICAL HISTORY: 1. Nephrolithiasis. 2. Hypothyroid state. 3. Allergic rhinitis.
Pound|Number|101|The JP was removed, but had slow bowel function, was continued to have a migraine. Postoperative day #3, she was afebrile, sore, slow bowel function. Postoperative day #4, she was afebrile with slow return to function.
Pound|Number|134|AST 27, ALT 36, magnesium 5.3, electrolytes were normal, her creatinine was 0.66. ASSESSMENT/PLAN: 1. _%#NAME#%_ is on postpartum day #5 with increased blood pressures and preeclampsia exacerbation postpartum.
Pound|Number|208|The patient's postoperative course was fairly uneventful. She defervesced immediately following surgery and remained afebrile throughout her postoperative course. She was discharged home on postoperative day #3, ambulating without difficulty and tolerating a general diet.
Pound|Quantity|199|She was hemodynamically stable through the night and as mentioned before her pain was well controlled. She will be discharged to home. DISCHARGE MEDICATIONS: 1. Percocet 1-2 p.o. q.4-6h. p.r.n. pain #80 given. 2. Vistaril 25-50 mg p.o. q.4-6h p.r.n. pain, #80 given.
Pound|Number|72|She very slowly improved over the next several days. After hospital day #3, GI consultation was obtained because of the patient's rather slow recovery.
Pound|Number|242|2. Multiple previous surgical resections of above-described tumor. 3. Postoperative day #1, patient experienced acute left hemiparesis, thought related to right frontal and right anterior cerebral artery infarct. 4. Dysphagia associated with #2 above. Patient currently requires tube feeding support. MEDICATIONS ON TRANSFER: 1. Lovenox 30 mcg subcutaneous each day.
Pound|Number|191|Postoperatively, the patient had significant amount of incisional pain. During her first night postoperatively, the patient required some IV Dilaudid to manage her pain. On postoperative day #1, the patient's pain was improving. She was ambulating without assistance, was tolerating a regular diet, and had good bladder function.
Pound|Gauge|204|3. The patient has a history of diabetes. 4. The patient also has a history of chronic pain secondary to his esophageal problems. HOSPITAL COURSE: The patient underwent another dilation up to Savary size #16 on _%#MM#%_ _%#DD#%_, 2005. Following this operative procedure, the patient had right-sided chest pain and the patient underwent EKG, troponins and other labs drawn, and had a CT to rule out perforation.
Pound|Number|132|She was tolerating clear liquids the following day, and having bowel movements. She was feeling much improved. On postoperative day #3 her pain was controlled with oral pain medications, she was feeling well and tolerating a liquid diet, and it was decided she would go home on that day.
Pound|Number|164|Pupils equal, round, and reactive to light. He had a conjugate gaze. He was continued on Keppra for seizure prophylaxis and Decadron and was placed on hospital day #2 at Shalom Home East Hospice. DISCHARGE INSTRUCTIONS: No future appointments have been scheduled.
Pound|Number|212|Postoperative hemoglobin was 9.6. Because of her A positive blood type, she did not need RhoGAM. She wanted an IUD at her postpartum check for contraception, and her pain was well controlled on postoperative day #2 with ibuprofen and Percocet, and her Foley catheter was discontinued on postoperative day #1.
Pound|Quantity|101|2. Allopurinol for gout, 100 mg, one p.o. daily. 3. Augmentin XR 1000/62.5 mg, two tabs p.o. b.i.d., #40, and then discontinue. 4. Flexeril 5 mg, one p.o. b.i.d. 5. For constipation, Colace 100 mg, one p.o. b.i.d.
Pound|Number|165|The estimated blood loss was 500 cc and the fallopian tubes and ovaries were normal bilaterally. The patient's preoperative hemoglobin was 9.1. On postoperative day #1 her hemoglobin was 8.9. She was started on iron supplementation three times a day and remained afebrile.
Pound|Number|198|Her fundus was firm and nontender. Her incision was clean, dry and intact. Routine postoperative cesarean section discharge instructions were given. The patient was given a prescription for Tylenol #3 and ibuprofen.
Pound|Number|168|EXTREMITIES: No edema. NEUROLOGICAL: Grossly intact. Pulses are down at the right wrist, but there is a bandage there for the IV. LABORATORY DATA: Arterial blood gases #1 on 4 liters: 7.38, O2 64, cO2 28, bicarbonate 17, 91% saturation.
Pound|Quantity|158|We will continue with metoprolol and clonidine patch as well as p.r.n. hydralazine. 4. Anemia. Currently his hemoglobin is stable. I will continue his Epogen #5. 5. DVT prophylaxis. We will continue Lovenox.
Pound|Quantity|228|The reason for choosing mirtazapine is that it has been associated with increased appetite and also should help with any anxiety. 6. I have also given him a prescription of lorazepam 0.5 mg 1 every 6 hours as needed for anxiety #30 with 2 refills because he looks anxious at this time.
Pound|Number|40|FINAL _%#MMDD2007#%_: ADDENDUM ADDED DIC#_%#MRN#%_/_%#NAME#%_ ADMISSION DIAGNOSIS: Atherosclerotic coronary artery disease. DISCHARGE DIAGNOSIS: Atherosclerotic coronary artery disease. PROCEDURE PERFORMED: Coronary artery bypass grafting x 4.
Pound|Number|207|HOSPITAL COURSE: PROBLEM #1: Disease. The patient received her second course of IVIP chemotherapy without any difficulty. Plan was made for her to return to Dr. _%#NAME#%_'' clinic in 3 weeks prior to cycle #3 of her IVIP chemotherapy. PROBLEM #2: FEN: Her IV fluids were begun at the time of admission.
Pound|Number|40|FINAL _%#MMDD2007#%_: ADDENDUM ADDED DIC# _%#MRN#%_ / _%#NAME#%_ DISCHARGE DIAGNOSES: 1. Hyponatremia likely secondary to diuretics. 2. Status post liver transplant on immunosuppression.
Pound|Number|201|He was gradually weaned from his ventilator and transferred to the general Neurosurgery floor. He underwent physical and occupational therapy. Jackson-Pratt drain was discontinued on postoperative day #3. He regained 4/5 strength in his upper extremities and 3/5 strength in his triceps.
Pound|Number|136|She had had the pneumoboots on and was ambulatory. Percocet was used for pain control. The patient ready for discharge. On hospital day #3, she was afebrile and vital signs were stable. Abdominal exam, abdomen soft, nontender, and nondistended with bowel sounds.
Pound|Number|130|His discharge weight was 2.66 kg and he was taking 160 cc/kg/day. The second problem was jaundice and he initially on day of life #2 had a bilirubin level of 9.1 which was greater than the 75th percentile.
Pound|Number|148|There was some question about pyelonephritis, and she did receive antibiotics empirically, although her cultures remained negative. On hospital day #5, her symptoms of pain had resolved. She was adequately taking in a regular diet and subsequently discharged home with a possibility of having had a viral gastroenteritis.
Pound|Number|154|Fetal heart tone showed 150s. _%#NAME#%_ was without evidence of uterine contractions. The patient was then ready for discharge home on postoperative day #1. Notably during the patient's admission to the hospital, yeast vaginitis was diagnosed.
Pound|Number|190|The patient was transferred to floor on postoperative day #2 after a fairly uneventful course in the SICU. The patient was started on anticoagulation with p.o. Coumadin on postoperative day #2. She was seen and evaluated by cardiac rehab which continued through her hospital stay and planned as an outpatient.
Pound|Number|165|4. CBC with differential, comprehensive metabolic panel, magnesium, phosphate, and type and screen. 5. Home care support services at the children's home care, phone #_%#TEL#%_. Service as needed, _%#NAME#%_, RN to check every Thursday for PICC dressing change and assessment of the patient's condition.
Pound|Number|130|Estimated blood loss is 400 cc. Postoperatively, the patient did well. Her postoperative hemoglobin was 8.9. On postoperative day #3, she was ambulating and tolerating a regular diet, voiding without difficulty.
Pound|Number|206|At the time of surgery she was converted from a cruciate-retaining to cruciate-stabilizing total knee. She did well postoperatively. Arrangements were made for her to be discharged to home on postoperative #3 with plans to follow up in my clinic.
Pound|Number|131|_%#NAME#%_'s home care agency is to arrange for counts to be monitored in her hometown. Her home care agency is Option Care, phone # _%#TEL#%_, fax # _%#FAX#%_. Her next F-UMC admission date is to be announced. It has been a pleasure to be involved in _%#NAME#%_'s care.
Pound|Number|40|FINAL _%#MMDD2007#%_: ADDENDUM ADDED DIC#_%#MRN#%_/_%#NAME#%_ DISCHARGE DIAGNOSIES: 1. Acute obstructive cholangitis. 2. Urinary tract infection secondary to E.
Pound|Number|141|The patient was continued on nifedipine 20 mg q. 8h. with no contractions and no complaints. The patient was discharged home on hospital day #3 to continue on nifedipine and discharged home to bed rest.
Pound|Number|119|She was given a dose of IV clindamycin in the emergency room and started on IV Ancef. Later on the day of hospital day #1, her wound did look stable. She was afebrile and had stable vital signs during her entire hospital course.
Pound|Number|101|Does not appear to be having any severe active bleeding at this time. 2. Anemia secondary to problem #1. PLAN: 1. Start the patient on a PPI. 2. Check serial hemoglobins.
Pound|Number|176|Ms. _%#NAME#%_ _%#NAME#%_ hospital course was uncomplicated. A Foley catheter was placed at the time of surgery and IV fluids were started. On the evening of postoperative day #0 she began tolerating clears without nausea or vomiting.
Pound|Quantity|177|DISCHARGE MEDICATIONS: 1. Lovenox 100 mg injections subcutaneously twice a day, quantity sufficient for 30 days. 2. Naprosyn 500 mg tablets p.o. b.i.d., take with food or milk, #30, no refills. 3. Alcohol swab, box #100, use prior to Lovenox injections.
Pound|Quantity|133|7. Lidocaine patch 3 patches transdermally 12 hours on, 12 hours off daily, 120 given. 8. Compazine 10 mg p.o. q.6 h. p.r.n. nausea, #15. 9. Percocet 5/325 one to two tablets p.o. q.4-6 h. p.r.n. pain, #50.
Pound|Number|71|4. Premarin 0.625 mg p.o. q.d. 5. Enalapril 20 mg p.o. q.d. 6. Tylenol #3 one tablet twice a day. PHYSICAL EXAMINATION: Blood pressure 142/70, pulse 85, temperature 97.2. The patient appears comfortable and in no acute respiratory distress.
Pound|Number|112|The patient did well with the surgery but had pain so was kept for an additional hospital day. On postoperative #2 it was elected that she should be discharged to home as her pain was better controlled and her eye appeared stable.
Pound|Number|146|2. Tonsillectomy at age 27. 3. Wisdom teeth impacted in which she was hospitalized to have them removed. ALLERGIES: None. MEDICATIONS: 1. Tylenol #3 prn. 2. Lonox one to two tablets a day prn diarrhea which the patient says does not help.
Pound|Number|224|The patient remained stable throughout her hospital stay. She did develop some colored tracheal secretions for which she was started on Cipro 100 mg p.o. b.i.d. Her trach was downsized to a Shiley No. 3 on postoperative day #4. The patient was decannulated prior to discharge to home.
Pound|Number|156|She was able to take clear liquids p.o. She did have some nausea during her hospital stay, which had resolved at the time of her discharge. By hospital day #3, the patient was feeling much better and ready for discharge to home.
Pound|Number|271|EBL was 900 mL. There were no complications. Postoperative course was complicated by blood loss anemia with hemoglobin dropping to 8 from 9.8. Postoperative course was otherwise uncomplicated. The patient was afebrile throughout the hospitalization. By postoperative day #3, she was voiding, ambulating and tolerating a regular diet without difficulty.
Pound|Number|410|HOSPITAL COURSE: After risks and benefits of the procedure and alternatives to the procedure were explained, Ms. _%#NAME#%_ consented to laparoscopic Roux-en-Y gastric bypass surgery and underwent laparoscopic Roux-en-Y gastric bypass surgery without complication and estimated blood loss of 50 cc and her intraabdominal habitus had few adhesions. Her current hospital course was unremarkable. On hospital day #2, the patient underwent an upper GI study, which showed no leak and was started on a clear liquid diet and on the day of discharge, the patient is ambulating.
Pound|Number|183|Her hemoglobin went from 12.0 preoperatively to 8.1 and then 7.7 finally postoperatively. She was tolerating a regular diet. She was ambulating without complaint by postoperative day #2. The patient's hemoglobin was ultimately nadired at 7.7. She was transfused with 2 units of packed red blood cells which raised it to 11.3. She was fit for discharge by postoperative day #3, tolerating a regular diet and restrictions were discussed.
Pound|Number|226|She underwent prostaglandin cervical ripening followed by Pitocin induction. Subsequently went on to having normal spontaneous vaginal delivery. Please refer to delivery record. HOSPITAL COURSE: I was consulted postpartum day #1 for tubal ligation. We discussed the risks of the procedure including the risk of injury to bowel or bladder as well as risk of bleeding, infection, and tubal failure with subsequent ectopic pregnancy as well as the permanency of the nature.
Pound|Number|120|He received a total of four doses of IV Thymoglobulin as an inpatient. He was initiated on Prograf on postoperative day #1. Levels were within therapeutic range at 5.8 at the time of discharge.
Pound|Number|70|DIAGNOSES: 1. Severe dehydration. 2. Acute renal failure secondary to #1. 3. End-stage liver disease secondary to hepatitis C.
Pound|Number|276|As her baby was blood type 0-positive, her incision was inspected daily, was clean, dry and intact. her fundus palpated firm daily as well. She had good return of bowel function; however, she did experience some urinary retention, so a Foley was replaced on postoperative day #1. This was successfully discontinued with good return of urinary function on postoperative day #2.
Pound|Number|164|We did encourage her to quit alcohol all together. She understands this and agreed to this. 2. Chronic nausea and vomiting. This may be likely secondary to problem #1 especially in relation to her antidepressants which were started and with possibly her alcohol use may have caused some intolerance.
Pound|Number|212|He received evaluation and treatment by physical and occupational therapy at the rehabilitation center and he is okay for all nursing home standing orders. His Foley is to remain in place until postoperative day #7 per Urology recommendations and he should remain on the Keflex as ordered until his Foley is removed.
Pound|Number|270|The patient tolerated the operation well and was than transferred to the floor for postoperative care. Overall, the hospital course was uneventful. The patient remained hemodynamically stable and was noted to have a postoperative hemoglobin of 13.3 on postoperative day #2. The patient was also given appropriate antibiotic therapy for 24 hours after surgery.
Pound|Gauge|96|She will have home health and home PT, home OT and home speech therapy. Her diet is a dysphagia #2 with nectar liquids with renal restrictions. She will continued to have Tuesday, Thursday, Saturday dialysis and thus her next run should be tomorrow at _%#CITY#%_.
Pound|Number|192|He had some mild right eye periorbital edema which resolved few days postoperatively. He was closely monitored for vasospasm. He tolerated clamping of his ventriculostomy by postoperative day #2 and the ventriculostomy was removed by postoperative day #4.
Pound|Number|170|As for her neck, x-rays were taken on the day of discharge to make sure that there are no inadvertent fracture or significant injury to her cervical spine. On postop day #5 she is ready for transfer to acute rehabilitation where she will continue with her physical therapy.
Pound|Number|257|The procedure overall was uncomplicated. The pathology revealed a benign uterus with severe endometriosis, as well as adenomyosis. The patient's recovery course was uncomplicated. Postoperative hemoglobin was 12.6. Staples were removed on postoperative day #2. She was stable for discharge home on postoperative day 3, tolerating a general diet and ambulating and urinating without difficulty.
Pound|Number|171|PLAN: The plan was to have him discharged from the hospital and continue with a once daily dose of vancomycin in the Infusion Therapy Center. DISPOSITION: On hospital day #4, he was discharged to home, with continued postoperative IV antibiotics.
Pound|Number|194|Also she had clinical evidence of an anastomotic leak, and this was treated with drainage, antibiotics, and enteral nutrition. Finally the drain was pulled back and removal on postoperative day #21. The patient was dismissed on postoperative day #23 on a regular diet.
Pound|Number|145|He then was able to take in small amounts of clear liquids without nausea or vomiting. He was ambulating without difficulty on postoperative day #2. His pain was well controlled. His incision was clean, dry, and intact at the time of discharge.
Pound|Quantity|89|DISCHARGE MEDICATIONS: 1. Percocet one to two tablets q. 4-6 h. as needed for pain 5/325 #40 dispensed with no refills. 2. Colace 100 mg p.o. b.i.d. to keep bowel movements soft.
Pound|Number|122|He returned to the floor where he continued to do well. He was transitioned to oral pain medications on postoperative day #1. He was tolerating a regular diet and was ambulating freely.
Pound|Number|216|Please see a copy of Mr. _%#NAME#%_'s medical consult for further medical details. Mr. _%#NAME#%_ is treated with routine physical therapy rehabilitation for a total hip arthroplasty and was discharged on postop day #3 to his home for self care. Mr. _%#NAME#%_ is scheduled for follow- up in our office at two weeks postop for suture removal and radiographic evaluation.
Pound|Number|177|The patient has some trace edema in the lower extremities. There is no erythema or pain. ASSESSMENT AND PLAN: The patient will be admitted on _%#MM#%_ _%#DD#%_, 2004, for cycle #5 of 6 of VP-16/cisplatin. She will be given Ativan for her anxiety and will return in 4 weeks for her next chemotherapy visit.
Pound|Number|304|Ampicillin and azithromycin have been continued for GBS in latency antibiotics. It was noted that she was monitored for signs and symptoms of suspected endometritis secondary to suspicion of chorioamnionitis secondary to the onset of labor, the fetal tachycardia, and a T-max of 100.4. On postpartum day #1 the patient was doing well. She was afebrile and her vital signs were stable. Her infant was in the NICU doing well.
Pound|Quantity|152|5. Zocor 10 mg p.o. at bedtime. 6. Coumadin 5 mg p.o. daily. 7. Amiodarone 200 mg p.o. b.i.d. 8. Percocet 1-2 tabs p.o. q.6h. p.r.n. for pain, dispense #40.
Pound|Number|182|He did not finally get up out of bed and move march until about #5 or #6 postoperative day. Due to his slow ambulation we elected to transfer him to Riverside Rehabilitation Unit on #7 postoperative day for a few more days or weeks in rehabilitation.
Pound|Number|152|She was afebrile, had a normal postoperative abdominal pain and no problems with her wound. Her bowel function returned completely on postoperative day #3 with flatus. She was gradually advanced onto a diet and was discharged on postoperative day 4.
Pound|Number|176|She had a rapid return of GI function, remained afebrile throughout her hospitalization. Postoperative hemoglobin was 10.6. The patient was discharged on the postoperative day #3. DISCHARGE DISPOSITION: 1. Return to clinic in 6 weeks. 2. Nothing per vagina, no heavy listing x 4-6 weeks. 3. Percocet p.r.n. pain.
Pound|Number|222|This appeared abnormal. The lung was biopsied which showed some post- inflammatory changes but was noted to have some malignancy. The patient's postoperative course was unremarkable. She was dismissed on postoperative day #3 in good condition. Instructions were given. The patient will follow-up in my office in 10 days.
Pound|Quantity|193|5. He will get his laboratory studies checked on _%#MMDD2003#%_, _%#MMDD2003#%_, and _%#MMDD2004#%_ as previously stated. 6. He is discharged home in stable condition. 7. He has been dispensed #50 of the Oxycodone immediate release tablets to use for severe pain.
Pound|Number|111|Otherwise a grossly normal appearing adnexa. Her postoperative course was uncomplicated. Her postoperative day #1 hemoglobin was 9.5. She was gradually advanced as tolerated and tolerated a regular diet well prior to her discharge on postoperative day #3.
Pound|Number|203|The patient did better with hot packs. She also noted ringing in her ears which decreased after she stopped taking the Naprosyn postoperatively. The patient was discharged to home on postoperative day # #4 with a discharge hemoglobin of 11.0. She is planning to follow up with her chiropractor on the day of discharge for evaluation and treatment of her neck pain.
Pound|Number|106|3. Wound care, right buttock. Change dressing daily p.r.n. if not sealed. Clean with Clinical Care spray, #146238. Apply thin layer of Silvadene cream. Apply Allevyn 3 x 3 foam dressing (MTKON #128075).
Pound|Number|136|The patient was able to advance to a regular diet without difficulty. The patient had his chest tubes discontinued on postoperative day #3. The patient did not have any further symptoms of chest pain following his CABG.
Pound|Quantity|131|DISPOSITION: This patient returns home eating a regular diet. DISCHARGE MEDICATIONS: 1. Vicodin 1-2 tablets q.6h. p.r.n. (dispense #20). 2. Vivelle patch two times per day. 3. Multivitamin with iron one per day.
Pound|Quantity|296|The discharge examination was negative. She was advised regarding routine postoperative precautions, including lifting restrictions. Given prescription for Motrin 600 mg to be used every six hours as needed for pain relief, as well as Percocet one to two every 4 to 6 hours for more severe pain, #30. Also, a prescription for Premarin 0.625 mg to be taken daily.
Pound|Number|126|Her oxygen saturations fell to 85 percent. She was transported to the Emergency Room. Her past medical history includes items #3 and beyond in the discharge diagnoses above. She had a pulmonary embolism in the past and has had a Greenfield filter placed.
Pound|Number|211|She was transfused. On _%#MM#%_ _%#DD#%_, 2005, she was noted to have hemoglobin 7.6 and she was transfused 2 units of blood. She responded nicely, and on the following day, _%#MM#%_ _%#DD#%_, postoperative day #4, she was transferred to the nursing home with instructions to weight bear as tolerated, follow up with Dr. _%#NAME#%_ in approximately 4 weeks.
Pound|Number|103|Her infant was also doing very well and she was breast-feeding her son. A hemoglobin on postpartum day #1 was 9.8 (had been 12.3 at the time of admission).
Pound|Number|187|HOSPITAL COURSE: The patient was taken to the operating room for the above procedure. Please see the operative report for details. Postoperatively, a drain was discontinued on postop day #1, and she was tolerating an oral diet. DISCHARGE AND PREOPERATIVE MEDICATIONS: Percocet one to two p.o. q. 4h. p.r.n. pain.
Pound|Number|431|PROBLEM #6: Genitourinary. Voiding spontaneously. PROBLEM #7: Hematology. The patient underwent a blood transfusion on postoperative day #2 for blood loss anemia with a hemoglobin of 8.7. She had family members donate blood for her prior to the procedure and she received 2 units of packed red blood cells. She had a post- transfusion hemoglobin of 9.5. DISCHARGE INSTRUCTIONS: The patient was discharged home on postoperative day #3 in stable condition. She was instructed to return to clinic in 5-7 days for staple removal.
Pound|Number|194|The back donor site wound became an issue with regard to attempts to maintain suction. The VAC was applied with some success and the patient was finally ready for discharge on postoperative day #15. At that time a portable VAC machine was provided by KCI and home nursing care had been arranged by the Social Work Services.
Pound|Number|314|The patient was then admitted to the oral and maxillofacial surgery service for conversion of his heparin back to Coumadin. The patient was then restarted on loading dose of 5 mg of Coumadin one day postoperatively and then his normal dose of 2 mg and 2.5 mg daily of Coumadin was reinitiated on postoperative day #2. On postoperative day #3, an INR was finally obtained which was 2.17 which is therapeutic for his St. Jude aortic valve.
Pound|Number|118|DISCHARGE DIAGNOSES: 1. Stage II-B adenocarcinoma of the cervix. 2. INR reversal. 3. Status post cesium brachytherapy #1. 4. Hypertension. 5. History of deep venous thrombosis in _%#MM#%_ 2005.
Pound|Number|165|She was normotensive throughout this hospitalization. 5. Pulmonary: The patient has no history of lung disease. Her perioperative O2 was weaned on postoperative day #1. She was saturating in the high 90s on room air.
Pound|Number|92|He was weaned off of the heparin and maintained on aspirin and Plavix. On postoperative day #5, we noticed some new onset petechiae which appeared on the medial aspect of his left leg.
Pound|Number|111|The patient was noted to have elevated blood pressures during his stay and this was worked up. On hospital day #2, the following pressures were recorded. Systolic and diastolic in the right and left arm 117/74 and 120/70.
Pound|Number|213|The patient was rehydrated and imaged with an abdominopelvic CT scan. This scan was negative for pancreatic anastomotic leak. His nausea, vomiting, and dehydration were rapidly corrected; however, on hospital day #2, the patient passed large amounts of bright red blood per rectum.
Pound|Number|135|Please see operative dictation for the details. Postoperatively, the patient had a relatively uneventful course. He was treated with a #6 TLSO postoperative convalescence. His pain was well controlled, eventually switching over from IV narcotics to oral pain meds.
Pound|Number|146|We will also begin Constanzi's solution for her stomatitis and Roxanol Elixir for her pain related to the stomatitis. 2. Dehydration secondary to #1. We will begin IV fluids using normal saline at 125.
Pound|Quantity|113|He should return for follow-up in approximately two weeks time. He will be discharged with Percocet and received #100 of those.
Pound|Quantity|151|1. Effexor XR 75 mg a day 2. Triazolam on a p.r.n. basis 3. Vitamin B12 shots monthly. 4. New medication: Vicodin one to two p.o. q 4-6 h p.r.n. pain, #30 She will see Dr. _%#NAME#%_ or Dr. _%#NAME#%_ in two weeks for follow-up of the left ureteral stone.
Pound|Number|93|Date of Discharge: _%#MMDD2005#%_ FINAL DIAGNOSIS: 1. Acute respiratory failure secondary to #2. 2. Acute exacerbation of chronic obstructive pulmonary disease. 3. Chronic obstructive pulmonary disease.
Pound|Number|180|The phrenic nerve was resected as it was next to tumor and it could not be dissected free. The patient's postoperative course was uneventful. He was dismissed on postoperative day #5 in good condition. ________ dismissal - the wound is healing well, the lungs are clear, but a chest x- ray shows some slight elevation of the right hemidiaphragm but no infiltrate.
Pound|Number|139|Postoperative, the patient did well. Her hemoglobin stabilized at 10.5. She had no febrile morbidity. She was discharged on postpartum day #3 after having staples removed and will follow up in six weeks.
Pound|Quantity|234|The patient had been seen by oncology while in the hospital and they will follow up with him as an outpatient for adjuvant therapy. DISCHARGE MEDICATIONS: Augmentin 875 b.i.d. for seven days, and Percocet one to two q.4-6 p.r.n. pain #30. DISCHARGE DIAGNOSIS: Perforated splenic flexure carcinoma status post left colectomy and partial gastrectomy.
Pound|Number|100|However, gradually her IV narcotic pain was converted to oral pain medication. On postoperative day #2, her Foley was removed and her diet was advanced to regular diet.
Pound|Number|224|She was not a candidate for VBAC. During her antenatal course, she requested permanent sterilization. Her pregnancy was also complicated by familial hypercholesterolemia. She was then discharged to home on postoperative day #3 and will follow up to clinic _%#NAME#%_ for routine postoperative care.
Pound|Number|247|The patient was enrolled in the (BELATACEPT) benefit study. Therefore, her immunosuppression followed the study protocol, which included 250 mg prednisone. On the first postoperative day, she was started on CellCept and given on postoperative day #5 BETALACEPT as well as basiliximab per the study protocol.
Pound|Number|383|She has undergone a D&C as far as that evaluation. ALLERGIES: Protonix and Nexium and Pepcid. MEDICATIONS: Medications on admission include Benzaclin twice a day p.r.n., Relpax 20 mg p.r.n. headache, Drysol p.r.n., Astelin nasal spray 2 puffs each nostril b.i.d. p.r.n., Imitrex 50 mg p.o. p.r.n., Inderal, of which the dose is not entirely clear, Estradiol with menses, and Tylenol #3 p.r.n. SOCIAL HISTORY: The patient is married and has two children.
Pound|Number|196|She was delivered of a viable male infant weighing 9 pounds 1 ounce with Apgars of 8 and 9 with one loose nuchal cord. Her postoperative course was essentially uncomplicated. By postoperative day #4, the patient was ambulating, tolerating a house diet, and voiding without difficulty.
Pound|Quantity|227|MRI of the right shoulder showed mild supraspinatus tendonosis. CONDITION AT DISCHARGE: Improving. DISCHARGE MEDICATIONS: Medrol Dosepak, Robaxin 750 mg one p.o. b.i.d., Klonopin 1 mg one p.o. b.i.d., prescription for Ultracet #40 and Percocet #40 given. She is to continue her Prozac 60 mg daily, Zocor 20 mg at h.s., and trazodone 1-2 p.o. q.h.s. p.r.n. I did also give her a prescription for Detrol LA 4 mg per her request one p.o. q.h.s. and a written prescription for hot water hydrotherapy to see if she can get insurance coverage for this.
Pound|Number|407|Outpatient upper GI and small bowel follow-through x- rays, resume previous home medicines, Pentasa 250 mg four tablets q.i.d., ranitidine 300 mg q.h.s., Relpax 40 mg as needed for migraines, Claritin 10 mg p.o. q.day. multi-vitamin one p.o. q.d, Caltrate 500 mg with vitamin D t.i.d., Fosamax 70 mg q. week, Tylenol p.r.n. , propranolol 20 mg b.i.d., Reglan 5 mg t.i.d., Soma 350 mg q.i.d. p.r.n., Tylenol #3 p.r.n. Over 30 minutes was spent with this patient in discharge planning.
Pound|Number|232|She was admitted to Special Care Nursery because of low birth weight. Admission exam was normal. She was transferred to the regular nursery on day of life #2, where she continued to do well with stable vital signs until day of life #5, when she was getting ready to go home. It was noted that she had borderline temperature instability and poor feeding, in addition to lethargy.
Pound|Number|231|Blood cultures were negative. Urine culture was negative. There were 366 white cells noted in the cerebrospinal fluid of which 84% were lymphocytes, 7% neutrophils, 7% monocytes, 2% eosinophils. Fluid was colorless and clear. Tube #4 was studied. The patient's symptoms improved and she was subsequently discharged. She was seen by Dr. _%#NAME#%_ from the infectious disease department.
Pound|Number|117|The patient had continued to improve clinically. Vital signs remained stable, she remained afebrile. On hospital day #2, _%#MM#%_ _%#DD#%_, 2005, after seeing patient and reviewing all labs, it was decided the patient could be continued to be treated an a outpatient.
Pound|Quantity|66|DISCHARGE MEDICATIONS: Zofran 4 to 8 mg p.o. q.6 h. p.r.n. nausea #15. FOLLOW UP: The patient is to follow up with Dr. _%#NAME#%_ in approximately 3 weeks or p.r.n. recurrent abdominal pain.
Pound|Number|197|On postoperative day #1 her hemoglobin was 10.7. Her Foley catheter was removed and she was able to void without difficulty. Her diet was advanced and she tolerated this well. On postoperative day #3 she was discharged to home in stable condition. She was afebrile, tolerating regular diet and ambulating and voiding without difficulty at the time of discharge.
Pound|Number|227|By postoperative day #3 she was ambulating well, tolerating a regular diet and pain was controlled well with oral medications. Her postoperative hemoglobin had gone down to 8.3 from 9.9 preoperatively, but by postoperative day #3 was back up to 9.0. The patient was started on iron.
Pound|Number|205|DISCHARGE DIAGNOSES: 1. Abdominal pain, presumed secondary to constipation, resolved. 2. Chronic hepatitis C, with hyperammonemia, resolved. 3. Elevated liver function tests, stable, presumed secondary to #2, status post GI consultation, abdominal ultrasound.
Pound|Number|85|She underwent the above noted procedure. She tolerated it well. By postoperative day #3 she was stable and ready for discharge to a nursing home setting.
Pound|Number|250|Final pathology revealed benign leiomyomata and cysts. Postoperatively the patient had some issues initially with nausea, but by postoperative day #3 she was tolerating a regular diet and voiding. Her hemoglobin was stable at 10.9. Postoperative day #3 the patient was discharged to home with a Foley catheter in place due to her periostotomy.
Pound|Number|242|Initially postoperatively the patient was unable to tolerate liquids or solids secondary to dizziness and subsequent nausea. By postoperative day #3 the patient was tolerating liquids and his diet was able to be advanced by postoperative day #4. However, the patient remained significantly unstable. Physical Therapy and Occupational Therapy were consulted and worked with the patient and recommended a PMR consultation for possible placement.
Pound|Number|291|The patient's blood pressures continued to be in the 150s to 160s range over 90s to 100s, therefore she was started on labetalol 100 p.o. b.i.d. on _%#MM#%_ _%#DD#%_, 2006. The patient diuresed well. Serial labs demonstrated improvement. The patient was discharged home on postoperative day #4 with stable blood pressures in the 150s over 90s to 100s range.
Pound|Number|266|HOSPITAL COURSE: 1. DISEASE: The patient has recurring, persistent ovarian cancer despite multiple chemotherapy regimens. Options were presented to the patient during this hospital stay including weekly Taxol versus daily taxotere per Woman's Cancer Center protocol #35. The patient is undecided at the time of this dictation and she will follow up in Dr _%#NAME#%_ clinic for further discussion.
Pound|Number|335|ENT on _%#MMDD2007#%_ confirmed the diagnosis of peritonsillar abscess and she underwent drainage of this abscess on _%#MMDD2007#%_. She had continued improvement and oral intake with decreased pain over the next hospital day and was discharged in stable condition on oral clindamycin for a total of a 14-day course along with Tylenol #3 to be used for pain control. Mother was asked to follow up as soon as possible if she has significant increase in throat pain or difficulty swallowing recurs.
Pound|Number|91|On postoperative day #2 the patient was started on clear liquid diet. On postoperative day #3 the patient was started on p.o. pain medications.
Pound|Number|104|It was decided that he would be best suited with transitional care type situation. On postoperative day #3, he was transferred from Fairview Riverside Hospital to the Golden Care Center _____ Minnesota for short rehab stay in preparedness to return to his home.
Pound|Quantity|103|24. Dilaudid 8 mg tablets, 1 p.o. every 2-3 hours p.r.n. pain, maximum 10 tablets in a 24-hour period. #70 given. HOSPITAL COURSE: 1. Patient came in with right upper quadrant pain and fever, was placed on antibiotics and found to have acute on chronic cholecystitis which required open cholecystectomy.
Pound|Quantity|223|There is no blood in his stools. He has had no known exposures and has not had any cough or runny nose, vomiting or diarrhea. He has had no conjunctivitis but has been treated for a diaper rash the past week with Poop Goop #2. _%#NAME#%_ lives at home with his physical therapist mother, dad and 3-year-old sister who are all healthy.
Pound|Number|287|Neurology signed out at this point and recommended no further workup or followup with neurology at this point. They recommended no antiplatelet therapy at this point. Regarding the patient's robotic prostatectomy course, the patient had a slightly distended abdomen on postoperative day #1. He was given a Dulcolax suppository which gave him good results with flatus.
Pound|Quantity|139|Will set him up for an oncology consult in _%#CITY#%_ when he comes to get his staples out. DISCHARGE MEDICATIONS: Vicodin p.r.n. for pain #40 and Keflex 500 mg b.i.d. times two weeks.
Pound|Quantity|113|3. Valium 5 mg one tablet p.o. q.6 hours p.r.n., #40, no refills. 4. Senna-S one to two tabs p.o. b.i.d. p.r.n., #50, no refills. 5. Neurontin 300 mg p.o. at bed time, to be increased gradually over the next approximately 10-12 days to 900 mg p.o. t.i.d.
Pound|Number|217|She had a normal anatomy noted. For complete details, please see the operative notes. POSTOPERATIVE COURSE: Overall, the patient's postoperative course was uncomplicated. Fluids were discontinued on postoperative day #1 and she was able to void spontaneously. Her diet was advanced as tolerated and she was tolerating a regular diet without nausea, vomiting prior to discharge.
Pound|Number|238|The patient was started on p.o. Keflex 500 mg q.i.d. for a total of 10 days for treatment of her wound cellulitis. She remained afebrile for the following 24 hours and symptomatically and clinically appeared improved on postoperative day #5. The patient desired discharge home and met all discharge criteria.
Pound|Number|211|Next, a thoracoscopic approach was undertaken, and the extrapulmonary sequestration was localized within the left diaphragm. This was removed without complications. Postoperatively she did well. On hospital day #1, she was tolerating a regular diet, her pain was well controlled with oral pain medication, and the chest tube was removed without evidence of pneumothorax.
Pound|Quantity|113|5. Robitussin AC expectorant one teaspoon Q 4 hours prn. six ounces. 6. Compazine 10 mg Q 6 hours prn for nausea #34. 7. Zofran 4 mg q.i.d. prn #30 if Compazine is unavailable.
Pound|Number|186|The patient tolerated the procedure well. Please refer to operative report for further details. The patient did well on her postoperative course. She was discharged on postoperative day #1. Upon discharge, the patient was tolerating a clear liquid diet, achieving adequate analgesia on oral medications, and voiding without difficulty.
Pound|Number|110|She is now here for maintenance biotherapy. She received her first cycle on _%#MMDD#%_. She is here for cycle #2. ALLERGIES: No known drug allergies. ADMISSION MEDICATIONS: 1. Zoloft 100 mg per day.
Pound|Number|110|Abdominal x-ray showed moderate amount of stool. She had lumbar spine which was unremarkable. On hospital day #2, she had essentially minimal pain with transfers. She was seen by physical therapy on the day of discharge and did quite well but does need ongoing home PT.
Pound|Number|54|PRELIMINARY ADDENDUM Discharge Summary previously was #_%#MRN#%_. The patient's medication list has been adjusted to correct that she is currently on Catapres patch 200 mcg daily, Lopressor 175 mg p.o. b.i.d. and lisinopril 40 mg p.o. daily.
Pound|Number|227|Her C. diff was negative, her Isospora and cryptosporidium studies were negative, fecal leukocytes were negative, no growth in bacteria or parasites were seen, rotavirus negative. The patient became better from diarrhea on day #3. She was placed on Imodium p.r.n. She was able to drink and eat without having nausea or vomiting.
Pound|Number|239|FINAL HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ was admitted to the hospital after undergoing total knee arthroplasty. Did well initially postoperatively using her CPM, up with physical therapy, range of motion was 0-70 degrees by postop day # 3, taking in good p.o. She was neurovascularly intact distally and incision was healing nicely.
Pound|Number|284|HOSPITAL COURSE: The patient was admitted upper GI endoscopy was performed, which showed multiple small marginal ulcers located at the site of the gastrojejunal anastomosis from the Roux-en-Y gastric bypass. She was started on a Protonix drip following this procedure on hospital day #2, the patient desired to be discharged. We recommended that she remained in the hospital on Protonix drip.
Pound|Number|99|Her creatinine increased as expected by approximately 40% to 50%. It was 1.24 on postoperative day #2. She gradually began feeling better and regaining mobility. She advanced to a regular diet and tolerating p.o. medicines and was able to be discharged on postoperative day #4.
Pound|Quantity|201|_%#NAME#%_ _%#NAME#%_ is being discharged to home with followup with Dr. _%#NAME#%_ _%#NAME#%_ at HealthPartners. The patient is discharged on Dilaudid 2 mg 1 tablet p.o. q. 3-4 hours, discharged with #20. The patient presented to the emergency department with the chief complaint of abdominal pain.
Pound|Number|261|Fetal heart tones were reactive in the 120s. The patient received second dose of betamethasone and ultrasound was performed on admission, which showed an AFI of 8.5 and normal umbilical artery Doppler. The patient then received gross ultrasound on hospital day #2, which showed EFW 1022 g, which was Hadlock percentile of 17th percentile.
Pound|Number|440|The intraoperative findings included a moderate amount of central obesity with dense upper intraabdominal adhesions involving the transverse colon to the anterior abdominal wall within the right upper quadrant secondary to the patient's previous cholecystectomy. This required approximately 30 minutes of adhesiolysis. Overall, Ms. _%#NAME#%_ tolerated the procedure well and was extubated and transferred to the floor on postoperative day #1. Ms. _%#NAME#%_ was given TEDs, pneumo boots and Lovenox subcutaneously for DVT prophylaxis.
Pound|Number|194|2. Respiratory: The patient experienced some mild respiratory distress after extubation status post line removal and PICC placement. Her respiratory status improved and stabilized by postop day #2. Chest x- rays on postop day #2 and the day of discharge showed stable small left pleural effusion and some retrocardiac fullness; small or early pneumonia could not be ruled out, although the patient was asymptomatic at this time.
Pound|Number|226|For induction immunosuppression, the patient received 5 doses of intravenous Thymoglobulin and 5 doses of Solu-Medrol. She received one dose of Zenapax in the Operating Room and will receive a second dose on postoperative day #14 in the Transplant Center. She was started on p.o. Prednisone at discharge and will be rapidly tapered over a 5-day period to 5 mg once daily.
Pound|Number|218|10. Hydrochlorothiazide 12.5 mg PO Q day 11. Evista 60 mg PO Q day ALLERGIES: Lisinopril is noted to have caused mouth paresthesias with generic Lisinopril in the past. She has unspecified allergies to FDAC. dye, blue #2 and yellow dye #10. SOCIAL HISTORY: She has a 50 pack year tobacco use history.
Pound|Number|96|Postoperative day #2, she had a hemoglobin of 10.5 and was on Darvocet-N 100. Postoperative day #3, she was doing well and wished to be discharged home.
Pound|Number|215|There was .....entry into the uterus. For details, please my dictated operative notes. Postoperative course was uncomplicated. Hemoglobin after delivery was 11.5. Patient was discharged to home on postoperative day #4. Activity levels and restrictions were discussed, staples removed, and Steri-Strips placed prior to discharge.
Pound|Number|196|The Endocrine team did recommend trying to mitigate the normal renin angiotensin/ADA response by trying an Ace inhibitor or angiotensin receptor blocker in addition to spironolactone. Also on day #2 a low-dose Natrecor drip was initiated overnight and subsequently discontinued the following evening as the patient responded appropriately with approximately four-liter diuresis in addition to the five liters the previous day.
Pound|Number|245|A lumbar drain was placed preoperatively. The lumbar drain was opened immediately postoperatively secondary to drainage seen from the right ear immediately postoperatively during closure. The lumbar drain remained open, and on postoperative day #1 the dressings were changed and there was no further drainage from the wound.
Pound|Number|129|He was on doxorubicin, cyclophosphamide, vincristine and intrathecal cytarabine. The patient was also given methotrexate. On day #10 of the patient's course of chemotherapy, high-dose methotrexate, he developed acute renal failure and increase in his liver enzymes.
Pound|Number|101|Dr. _%#NAME#%_ _%#NAME#%_ Southdale Pediatrics. _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_, #_%#ADDRESS#%_ _%#CITY#%_, MN _%#55300#%_` Phone: _%#TEL#%_ _%#TEL#%_ _%#TEL#%_ Fax: _%#TEL#%_ _%#TEL#%_ _%#TEL#%_ _%#MMDD2003#%_ Dear Dr. _%#NAME#%_, Thank you for accepting care of _%#NAME#%_ from the Neonatal Intensive Care Unit of Fairview-University Children's Hospital.
Pound|Number|157|Her blood pressure was measured relatively soon after the event and found to be in the 115 range and her heart rate was in the low 80s. On postoperative day #2, the patient was doing well and able to ambulate and get out of bed on her own.
Pound|Number|192|She tolerated the advancement of her diet to pureed foods without difficulty. Her NG tube was discontinued when she started eating. The patient had bowel movements on postoperative day #3 and #4. She had some difficulty with sleep apnea-like symptoms, and was seen by the pulmonologist prior to her discharge.
Pound|Number|126|She required no further oxygen support and continued w/o tachypnea. 3. FEN - She was started on D10W but was decreased on DOL #1 to off. Breast-feeding was started immediately with significant lactation beginning on DOL#2.
Pound|Number|182|The patient tolerated minimal-to-moderate p.o. intake during her stay. She regularly took supplements. Her colostomy functioned well. PROBLEM #6: Infectious disease. On hospital day #3 the patient was found to be febrile. She had blood cultures taken, however, these returned negative, and it was thought that these fevers were likely secondary to her cancer.
Pound|Number|175|The patient went to the PICU overnight where she recovered well and then was transferred to the floor. She had minimal issues with pain and began feeding on postoperative day #2. By the day of discharge she was tolerating pretty well.
Pound|Number|163|Her INR was 1.29 at the time of discharge. Her Coumadin had been resumed two days prior to discharge. She was transferred to the nursing home on postoperative day #5 with the following medications. DISCHARGE MEDICATIONS: 1. Potassium Chloride 20 mEq po bid. 2. Zoloft 100 mg po q d.
Pound|Number|139|3. Timoptic 0.5% one drop OS q.a.m. HOSPITAL COURSE: _%#NAME#%_ did well overnight with no problems with respiration. On postoperative day #1 his cornea was clear. His anterior tabor was formed, and there was a clear red reflex in the right eye.
Pound|Number|132|Please refer to the operative report for further information regarding the procedure. The patient was kept NPO on postoperative day #1. Antibiotics were started. IV antibiotics included ciprofloxacin and Flagyl. She remained on IV fluids awaiting return of normal bowel function.
Pound|Number|179|DOB: _%#MMDD1935#%_ FINAL DISCHARGE DIAGNOSES: 1. Large right middle cerebral artery stroke. 2. New right occipital lobe stroke. 3. Brain edema with midline shift associated with #1 above. 4. Comfort care after several discussions with family. PAST MEDICAL HISTORY: Includes obstructive sleep apnea, type 2 diabetes, hypothyroidism, hypercholesterolemia, hypertension, history of ventricular fibrillation with ICD placement, and history of hypertension.
Pound|Number|182|She delivered a vigorous male infant with Apgars of 9 and 9. Weight was 8 pounds 3 ounces. Postoperatively, the patient did well, and she was discharged to home on postoperative day #4. Her discharge hemoglobin was 13.3. She was instructed to call for fever, heavy vaginal bleeding, or drainage from her incision.
Pound|Number|167|A Pap smear was within normal limits. GC/Chlamydia negative. TSH 1.3. Hemoglobin 13.5. Urine culture negative. GCT 94. On _%#MMDD2004#%_ hemoglobin was 12.8. Sonogram #1 was at 8 + 2 weeks on _%#MMDD2003#%_, revealing a twin gestation with an EDC of _%#MMDD2004#%_ for twin A, and _%#MMDD2004#%_ for twin B.
Pound|Number|165|The patient continued to have a good appetite and was eating without nausea or vomiting, and the PCA was discontinued and oral analgesia begun. By postoperative day #3, the patient was comfortable on oral analgesia, eating a regular diet, had been taught to empty the JP drains, which were putting out 50-100 mL a day of serosanguineous fluid, and she was discharged home on oral analgesia with instructions to empty and record the JP drainage and follow up with Dr. _%#NAME#%_ _%#NAME#%_, the plastic surgeon, in 1 week.
Pound|Number|171|She was afebrile with stable vital signs. She was having some trouble with sore, cracked nipples secondary to breast feeding. She was discharged home on postoperative day #3 in stable condition. FOLLOW UP: She was instructed to follow up in 6 weeks for a postpartum visit, contraception to be discussed at that time.
Pound|Quantity|132|2. Relpax 40 mg p.o. p.r.n. onset of headache, and may repeat after 2 hours. Max dose of 3 per day. 3. Percocet 1-2 q.4-6h. p.r.n. (#40 dispensed). 4. Flexeril 10 mg p.o. t.i.d. p.r.n. 5. Continue on same psychiatric medications as before, including Strattera, Lamictal, Xanax, trazodone.
Pound|Number|147|At the time of his discharge, the cultures sent from this biopsy specimen are still negative. His chest tube was discontinued on postoperative day #1, and he continued to progress rapidly. At the time of his discharge, he is tolerating a regular diet with excellent pain control, and is ambulating in the hallways without assistance.
Pound|Number|118|She will continue to check her blood sugars at home and follow up with Dr. _%#NAME#%_ next week. On postoperative day #4, patient was discharged home with routine instructions.
Pound|Number|120|Pelvic lymph nodes were negative, and the appendix was normal. The patient's gastrostomy tube was clamped on postop day #5, and he began to tolerate his diet. The patient had one JP drain discontinued on _%#MM#%_ _%#DD#%_, 2005, and the other JP drain was discontinued on _%#MM#%_ _%#DD#%_, 2005.
Pound|Number|312|No bowel sounds, no flank pain or tenderness. EXTREMITIES: Show a forearm fistula for dialysis. NEUROLOGICAL: Appears to move all extremities equally. LABORATORY STUDIES: Sodium is 134, potassium is 4.6, BUN Is 51, creatinine is 5.01, glucose is 198, white blood cell count is 13.0, hemoglobin is 13.5, Troponin #1 is less than 0.33, troponin #2, 1.30. The EKG does show some new sign of T-wave inversions, some minimal ST segment changes that were different from an EKG of 2004.
Pound|Quantity|89|5. Pantoprazole 40 mg p.o. b.i.d. 6. Oxycodone 2.5 mg p.o. q.4 h. p.r.n. pain, dispensed #30. 7. Propranolol 10 mg p.o. t.i.d.
Pound|Number|181|She will be discharged to home on purees. Her pain was well controlled, and her incision was healing well with no sign of infection. She was discharged to home on postoperative day #5 in good condition with plans to follow up with Dr. _%#NAME#%_ in approximately 2 weeks.
Pound|Number|219|ASSESSMENT AND PLAN: No evidence of recurrent breast cancer. She is tolerating chemotherapy well but with some increasing pain. I have put her on Restoril for sleep. We will switch her from Celexa to Paxil, try Tylenol #3 and Xanax. I will see her again in two weeks with labs.
Pound|Number|177|Final pathology is pending at the time of discharge. The patient did have difficulty with pain postoperatively and was admitted overnight for pain control. By postoperative day #1, she tolerated regular diet. She was ambulating with minimal assistance. Her pain was under control with oral pain medication, and she had a return of bladder and bowel functions.
Pound|Number|144|On 5D in the progressive care unit, she was found to be stable with heart monitoring and pulse oximetry. Early in the morning of her postop day #1, she was taking good p.o. with actually out of bed and walking to the bathroom without difficulty, and expressed desire to go home.
Pound|Number|245|DISCHARGE DIAGNOSES: 1. Bleeding gastric ulcer. 2. Alcoholic cirrhosis with portal hypertension, coagulopathy, esophageal varices, elevated ammonia level thrombocytopenia. 3. Hypertension. 4. Depression. 5. Alcohol abuse. 6. Anemia secondary to #1. OPERATIONS/PROCEDURES PERFORMED: Esophagogastroduodenoscopy x3, first showing no gastric varices or ulcer identified, fresh blood in the stomach, with mild to moderate portal gastropathy.
Pound|Number|243|Final pathology pending. 2. Fluids, electrolytes, and nutrition. The patient's IV fluids were discontinued on postoperative day #1, and she was tolerating PO. 3. Pulmonary. She required O2 postoperatively which was weaned on postoperative day #1. She was oxygenating adequately on room air at the time of discharge.
Pound|Number|197|This procedure was performed by Dr. _%#NAME#%_ _%#NAME#%_. The patient tolerated this procedure without difficulty and was taken back to the regular floor in stable condition. On postoperative day #1, we began to advance the patient's diet from half strength to full strength feeds that he tolerated very well.
Pound|Number|175|One year ago, she tried birth control pills for 6 months, but all that it did was increase the frequency of her menses. She has a back ache all the time and she takes Tylenol #3 during her menses for the cramping. The patient states that she is feeling fatigued from the bleeding, drained emotionally, and is just tired of it all and wants to get something done for this.
Pound|Number|252|The patient had a temperature to 101.1 in the immediate postpartum period, but there was no evidence of infection, so she was not started on any antibiotics. DISPOSITION: Ms. _%#NAME#%_ is being discharged home in stable condition on postoperative day #3, with advice to follow up at the clinic in 6 weeks' time.
Pound|Number|120|POSTPARTUM COURSE: The patient had an uncomplicated postpartum course overall. Her Foley was discontinued on postop day #1 and the patient was voiding without difficulty. Her diet was advanced as tolerated. She was tolerating a regular diet prior to discharge without nausea or vomiting.
Pound|Number|108|PRELIMINARY FINAL DIAGNOSES: 1. Diverticular abscess. 2. Status post partial sigmoid resection secondary to #1. 3. Hypertension. 4. Diabetes. 5. Malnutrition. 6. Postoperative wound infection.
Pound|Number|118|Intraoperatively, there were no complications. The patient had a prolonged postoperative course. By postoperative day #3, the patient had spontaneous return of bowel function.
Pound|Number|180|HOSPITAL COURSE: PROBLEM #1. Hypercalcemia: The patient was admitted and was immediately initiated on intravenous fluids and Lasix which improved calcium somewhat. On hospital day # 2 the patient began therapy with calcitonin and renally-dosed bisphosphonate.
Pound|Quantity|128|She underwent exam under anesthesia, cystoscopy, proctoscopy, and bladder biopsies on _%#MM#%_ _%#DD#%_, 2005. She began on WCC #34 with cisplatin potentiation and topotecan chemotherapy along with external beam radiotherapy.
Pound|Number|136|2. Attention deficit disorder treated with Adderall 3. Hives treated with Zyrtec 4. Pain most recent treated with ibuprofen and Tylenol #3 5. Hypertension just diagnosed recently treated with propranolol transiently at home.
Pound|Number|158|She was afebrile. Her hemoglobin and electrolytes were checked serially. These were normal throughout her stay. Her JP drain was removed on postoperative day #2 as they had no drainage. Her Foley catheter was removed on postoperative day #2 as it was clear.
Pound|Number|150|TRANSFER DIAGNOSES: 1. Acute renal failure and dehydration secondary to recurrent acute episodes of nausea and vomiting. 2. Hyperkalemia secondary to #1. The patient did not receive any kayexalate because of the urgency of transfer.
Pound|Number|210|Please see a copy of the patient's medical consult for further medical details. The patient was treated with routine physical therapy rehabilitation for hip arthroplasty and was discharged on postoperative day #3 to a TCU for assisted care. The patient is scheduled for follow-up in our office at two weeks post-op for suture removal and radiographic evaluation.
Pound|Number|194|Pain was controlled with pain medications and shortness of breath was improving with pain control. Her vital signs were stable during her hospital stay. Her chest tube was removed on postop day #1 in addition to her Foley. On _%#MMDD2006#%_, she was doing fine. Her vital signs were stable.
Pound|Number|141|Rather, she was started on iron therapy. The infant did well. Both patient and infant were stable for discharge to home on postoperative day #3.
Pound|Number|196|FINAL PROCEDURE: Total knee arthroplasty. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ was admitted to the hospital, did well. Initially, postoperatively had a fair amount of pain. On postoperative day #1, hemoglobin was 9.1. She was up with physical therapy.
Pound|Number|148|Moves all extremities equally. SKIN: Shows no rashes or lesions. LABORATORY STUDIES: Hemoglobin 12.8, platelet count 293,000. INR is 0.89. Troponin #1 less than 0.04, myoglobin 43. Creatinine is 1.01, BUN 19, glucose 88, sodium 136, potassium 4.1, calcium 9.7. Twelve-lead EKG shows sinus rhythm, with no significant ST segment changes.
Pound|Quantity|65|He will be discharged with vicodin 1-2 tablets p.o. q. 4-6 hours #40, Colace 100 mg p.o. b.i.d. and Levaquin to be taken for a 3-day course initially at discharge and another 3-day course to start one day before catheter removal.
Pound|Number|117|On_%#MMDD2006#%_ she underwent thoracoscopic resection without incident. She did well postoperatively. On postop day #1, her chest tube was removed. She was ambulatory. The patient was well controlled with p.o. pain medications and she will be discharged home.
Pound|Quantity|222|Her path report revealed a T1N1M0 lesion. By the 6th postop day, she was ready for discharge on a full liquid to advance slowly to a low residue diet. To do no heavy lifting or straining at home. To stay on Darvocet N 100 # 40 for pain. Return to the office in approximately one weeks time. No heavy lifting or straining for the next three months.
Pound|Number|131|She was taken to surgery at which time total knee arthroplasty was performed. Surgery was without complications. Postoperative day #1 she had primary wound healing. She had no medical complications. She was advanced to physical therapy per usual protocol.
Pound|Number|157|2. NICU stay x3 months. 3. Diagnosed with meconium plug prenatally. 4. Perforation of the distal ileum, likely secondary to the meconium plug on day of life #1. 5. Status post resection of 6-cm small bowel including ileocecal valve.
Pound|Number|175|Immediate postop EKG and troponins were negative; however, by the third set of troponins that it began to increase. The patient herself remained asymptomatic until postop day #3 when she developed atrial fibrillation with rapid ventricular response.
Pound|Number|94|The patient was treated with MiraLax and had a bowel movement later that night. On postop day #5, the patient's chest tube was removed and the chest x-ray was negative for pneumothorax, as well as negative cultures.
Pound|Number|244|Her postoperative anemia was corrected and mild coagulopathy was corrected, however, this required 6 units of blood, six pack of platelets, 6 units of fresh frozen plasma. She was transferred out of the Intensive Care Unit on postoperative day #2 and taken to the regular hospital ward where she continued making good recovery.
Pound|Number|140|The results of that biopsy showed recurrence of hepatitis B virus. The patient was then continued on his Epivir medication. On hospital day #3, it was decided that the patient's pain was controlled, and he could be discharged home with follow-up in the Transplant Center in 1-2 weeks.
Pound|Number|223|Her postoperative course was remarkably unremarkable. Despite having perforation, her temperatures resolved nicely within 24 hours of surgery. Her ileus was relatively short lived with a diet initiated on postoperative day #3. She was discharged on postoperative day #4 after a delayed closure of the wound at the bedside and tolerating a regular diet.
Pound|Number|135|1. Acute renal failure/the patient has end-stage renal disease and she will be on chronic hemodialysis. 2. Anemia secondary to problem #1. 3. Thrombocytopenia resolved. 4. The patient has right tunneled catheter for hemodialysis.
Pound|Number|176|CT scan of the abdomen and pelvic performed showed a small amount of fluid collection behind the cecum, but was otherwise non-diagnostic. The patient was discharged on Tylenol #3, but this has not significantly improved symptoms so she represented to the emergency department this morning.
Pound|Number|115|She was breast feeding and infant was noted to be doing well. The patient was discharged home on postoperative day #4 in stable condition. Her vital signs were noted to be stable. She remained afebrile through her hospital course with the vital signs stable.
Pound|Quantity|189|We will use Ativan at this time for her. We will obtain both a chemical dependency as well as a psychiatric consult. We will re- initiate her Paxil. We will hydrate her with D5 electrolyte #75 at 150 cc per hour. We will reevaluate the patient in the morning.
Pound|Number|126|DISCHARGE MEDICATIONS: 1. Percocet 5/325, 1-2 tablets q.6h. p.r.n. pain. (new medication). While taking Percocet, her Tylenol #3, which she chronically takes, will be on hold. 2. Coumadin 2 mg p.o. q.d. 3. Zestril 40 mg p.o. q.d., 4. Lasix 160 mg p.o. a.m., 80 mg p.o. q. 2 p.m.
Pound|Number|160|Furthermore, the patient was also changed to oral pain medications on postoperative day #2. The patient's anticoagulation was also started on postoperative day #2 with Coumadin. On _%#MMDD2003#%_, the patient's INR was 1.56 and he received another dose of Coumadin 5 mg orally.
Pound|Number|99|She recuperated well overnight, remained afebrile, and vital signs remained stable. On post-op day #1, she was significantly improved, was taking oral diet, was up to bathroom on her own, and was ready for discharge.
Pound|Number|101|7. Colace 100 mg p.o. b.i.d. 8. Augmentin 875 mg p.o. b.i.d. to complete a 10 day course. 9. Tylenol #3 one to two p.o. q6h p.r.n. pain. DISCHARGE INSTRUCTIONS: 1. Follow up with primary physician, Dr. _%#NAME#%_, at Fairview Hiawatha later this week.
Pound|Quantity|118|He was given new prescriptions for Antabuse 250 mg PO Q day, and Ativan 1 mg 1-2 Q 6 hours prn. agitation. (dispensed #15). I explained that alcohol consumption while taking Antabuse would cause him to become violently ill.
Pound|Number|94|2. Zofran p.r.n. nausea. 3. Torecan p.r.n. nausea. 4. Spironolactone 150 mg b.i.d. 5. Tylenol #3 p.r.n. 6. Dexamethasone prior to chemo. ALLERGIES: None. SOCIAL HISTORY: No alcohol, no tobacco. He works as a parking attendant and parking lot supervisor.
Pound|Number|137|She was tolerating a soft diet already. She remained afebrile with normal vital signs throughout her hospital stay. By postoperative day #2 she was ambulating. She had her Foley catheter out the day before. By postoperative day #3 she was tolerating a regular diet and doing quite well.
Pound|Number|2|SS#: _%#SSN#%_. The patient is to be admitted _%#MMDD2003#%_ for surgery the same date by ENT specialist, Dr. _%#NAME#%_. HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 74-year-old Caucasian male admitted to the hospital for a left ear surgery by Dr. _%#NAME#%_.
Pound|Number|116|She was able to ambulate. The Foley was discontinued. Her hemoglobin was 13.1 postoperatively. On postoperative day #2 she was tolerating a regular diet, able to ambulate and void.
Pound|Quantity|131|Discharge instructions were reviewed. The staples were removed and Steri-Strips were placed. A prescription was given for Percocet #20 and the patient was encouraged to continue using ibuprofen.
Pound|Number|110|Estimated blood loss was 250 cc. Postoperatively _%#NAME#%_ did well. She was discharged on postoperative day #2. Her vital signs remained stable. She remained afebrile. She was ambulating and tolerating a regular diet and urinating and passing gas.
Pound|Number|125|She also left the operating room with a Hemovac which was discontinued on postoperative day #3 as well. By postoperative day #4, she was off all narcotic pain medications at her request.
Pound|Number|174|Her white count is slightly elevated at 11,700 with some left shift. An LP shows some increase in rbc's probably due to a traumatic tap because the wbc's are normal and tube #4 is colorless and clear with a normal sugar. There is a slight increase in the protein in the CSF probably related to the blood that is present.
Pound|Number|92|5. Zetia 10 mg p.o. at bedtime daily. 6. Ibuprofen 600 mg p.o. t.i.d. x 10 days. 7. Tylenol #3, 1 tablet q.4h. p.r.n. for pain. He was instructed to follow up with his primary care physician in _%#CITY#%_ _%#CITY#%_ in one week, and he is to contact our office as needed by phone.
Pound|Number|200|Her diet was advanced as tolerated. She passed flatus. She had not had a bowel movement at the time of discharge from the hospital. She remained afebrile with stable vital signs. On postoperative day #3, staples were removed from her skin incision. She was discharged home on postoperative day #3 in good condition.
Pound|Number|122|The patient tolerated immunosuppressive agents well during this hospital stay. Prograf was initiated on postoperative day #1, levels were greater than therapeutic range at 15.2 mcg/L on the day of discharge.
Pound|Quantity|172|3. OxyContin 20 mg p.o. b.i.d. 4. Bactrim single strength 1 p.o. q. Monday and Thursday. 5. Multivitamins 1 p.o. daily. 6. Dilaudid 2-4 mg p.o. q.6h. p.r.n. pain, dispense #20. 7. Zofran ODT 4 mg p.o. q.8h. p.r.n. nausea. 8. Epivir 100 mg p.o. daily.
Pound|Quantity|139|7. Aspirin 81 mg p.o. daily. 8. Senna-S 2 p.o. daily to be held for loose stools. 9. Oxycodone 5-10 mg p.o. q.4-6h. p.r.n. pain, dispensed #40. 10. Prograf 2.5 mg p.o. b.i.d., to be adjusted to keep level between 8 and 10.
Pound|Number|125|AXIS V: Current Global Assessment of Functioning: 40. PLAN: _%#NAME#%_ has had one outpatient treatment today. This would be #6 in a series. He will be readmitted to the Senior Treatment Program to complete a series of eight ECT.
Pound|Number|226|The patient is status post pancreas-after-kidney re-transplantation, with bladder drainage of exocrine secretions on _%#MMDD2004#%_. Postoperatively, the patient had excellent pancreas allograft function. By postoperative day #3, his serum amylase and lipase were within normal limits.
Pound|Number|293|5. AV fistula 2006. ALLERGIES: No known drug allergies. HOSPITAL COURSE: During the patient's postoperative course, he was initially managed on insulin drip and then converted to Lantus 5 units with a sliding scale NovoLog insulin. The patient's amylase and lipase peaked on postoperative day #1 and then decreased over the hospital course. Conversely urine amylase levels increased over the hospital course. On the day prior to discharge the patient's Lantus was discontinued.
Pound|Number|388|His postoperative course was largely unremarkable. His creatinine quickly declined after surgery, dropping from a high of 10.45 prior to surgery to 1.34 at the time of discharge. As far as immunosuppression, the patient was started on the pediatric steroid avoidance protocol wherein he was maintained on a rapidly tapering dose of steroids and on no steroids at all by postoperative day #6. He was maintained on Thymoglobulin while in the hospital. At the time of discharge, his Neoral level was not yet therapeutic; therefore the patient was scheduled for outpatient Thymoglobulin until his Neoral and cyclosporine levels were at therapeutic levels.
Pound|Number|236|HISTORY OF PRESENT ILLNESS: This is a 33-year-old female status post pancreas kidney transplantation in 1998 in _%#CITY#%_ _%#CITY#%_ with immediate pancreas graft failure intra-operatively secondary to thrombosis. On postoperative day #1 at that time she had a left leg vein thrombosis. She has a significant history of diabetes mellitus with associated diabetic complications, as well as a factor V Leiden mutation.
Pound|Number|86|Over the next several days the patient continued to improve steadily. By hospital day #3 he was back to a regular diet and he had had several bowel movements.
Pound|Number|185|There were no complications. Mr. _%#NAME#%_ was returned to the general care floor the same day of his surgery. He had an unremarkable convalescence. His ileus resolved by hospital day #4, at which time the NG tube was removed and his diet was advanced and tolerated.
Pound|Number|129|4. Hypertension. 5. End-stage renal disease secondary to diabetic nephropathy. 6. Hyperlipidemia. 7. Failure of kidney allograft #1 secondary to chronic allograft nephropathy and recurrent diabetic nephropathy, 2004.
Pound|Number|142|Her creatinine quickly trended downward reaching a new post-transplantation nadir of 0.9 mg/dL at the time of discharge. On postoperative day #7, 1 week following percutaneous nephrostomy tube placement, a repeat nephrostogram was performed revealing a patent and intact anastomosis.
Pound|Number|129|He has not had recurrent chest pain as no history of myocardial infarction based on his report. I discussed the option of either # 1 Continue metoprolol for his coronary artery disease and implant a permanent pacemaker versus # 2 Discontinue Metoprolol and dismiss him from the hospital with an event recorder.
Pound|Number|54|7. Digoxin 0.125 mg p.o. q.d. 8. Os-Cal D. 9. Tylenol #3 p.r.n. 10. Zaroxolyn 5 mg p.o. q.d. SOCIAL HISTORY: The patient has a 69 year pack history of smoking, and was smoking up until the last admission.
Pound|Number|350|DOB: _%#MMDD1959#%_ INFECTIOUS DISEASE CONSULTATION IMPRESSIONS: 1. A 45-year-old male, very well known to me, now readmitted with acute lethargy, fever, nausea, vomiting, and concern level high this is some type of new infection, either opportunistic infection or community acquired. None are evident on exam or initial labs. Another possibility is #2 below. 2. Cryptococcal meningitis, now on a long course of treatment approaching the 4-month mark.
Pound|Number|115|LABORATORY DATA: Sodium 141, potassium 4.4, calcium 8.2, magnesium 2.1, hemoglobin 10.7. IMPRESSION: 1. Postop day #1 status post aneurysm clipping, doing well. 2. History of hypertension with blood pressure well controlled.
Pound|Number|129|IMPRESSION: 1. End-stage multiple sclerosis secondary progressive. 2. Seizure disorder secondary to #1. 3. Dementia secondary to #1. 4. Increased difficulty with CNS function in the setting of generalized sepsis with superimposed metabolic encephalopathy.
Pound|Number|280|IMPRESSION: 1. _%#NAME#%_ _%#NAME#%_ is an 82-year-old female with chronic pyelonephritis, left staghorn calculus and nonfunctioning left kidney. She is status post left nephrectomy yesterday. 2. History of recurrent urinary tract infections in the past year, likely secondary to #1. Most often this has been with enterococcus, but the most recent urine culture grew Klebsiella.
Pound|Number|149|IMPRESSION: 1. Chronic renal failure secondary to diabetic nephropathy. 2. Nephrotic syndrome secondary to #1 3. Hypertension may be contributing to #1. 4. Episode of pulmonary edema with normal LV function, probably diastolic dysfunction.
Pound|Number|133|ALLERGIES: NO KNOWN DRUG ALLERGIES. CURRENT MEDICATIONS: 1) Decadron 4 mg IV q6h. 2) Peri-Colace b.i.d. 3) Senokot p.r.n. 4) Tylenol #3 p.r.n. 5) Labetalol 10 mg IV p.r.n. systolic blood pressure greater than 180.
Pound|Number|105|Her hands show trace edema at best. LABORATORY STUDIES: None. IMPRESSION: A 52-year-old woman postop day #0 vein surgery now with probable allergic reaction.
Pound|Number|118|EMERGENCY ROOM CONSULTATION DIAGNOSES: 1. Left lower extremity recurrent deep venous thrombosis. 2. Postoperative day #3 from glaucoma eye surgery. HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old gentleman with a past medical history of hypercoagulable state and glaucoma who had been holding his Coumadin doses for the past week because of urgent eye surgery.
Pound|Number|286|Creatinine 1.5, total bilirubin 0.5. PATHOLOGY: Review is pending. IMPRESSION: Metastatic renal cell carcinoma refractory to IL-2. RECOMMENDATION: The patient is a suitable candidate for BMT and total body irradiation prior to umbilical cord blood transplantation per local MT protocol #2000-15. This conditioning regimen includes TBI of 200 cGy in one treatment with a non-myeloablative regimen.
Pound|Number|280|FINAL INFECTIOUS DISEASE CONSULTATION IMPRESSION: 1. A 47-year-old female with new acute left facial cellulitis, question abscess underlying this, although not obvious MRI scan and not fluctuant currently, quite likely this is another community-acquired MRSA related process, see #2 below. 2. Prior numerous community-acquired MRSA skin abscesses over the last nearly 2 years, no decolonization attempts previously.
Pound|Number|132|The patient is receiving rotation every 2 hours. The patient's Jackson-Pratt tubes have serosanguineous fluid. 3. Pain secondary to #2. The patient currently has a patient-controlled analgesia pump and reports that her pain is better controlled now compared to yesterday.
Pound|Number|319|EXTREMITIES: No signs of edema. LABORATORY STUDIES: In the chart and reviewed, with hemoglobin noted at 9.5 and white count to 14.4. Right upper quadrant ultrasound also reviewed is consistent with cholelithiasis/acute cholecystitis. IMPRESSION: The patient is a 23-year-old otherwise healthy female now postpartum day #2 with cholecystitis. Given her present hospitalization and discomfort, she has been made n.p.o. She is on IV antibiotics.
Pound|Number|162|We will see how the patient does with the measures above. 2. Non-Hodgkin's lymphoma. Management is per hematology/oncology. 3. Pancytopenia. This is secondary to #2 above. The patient is on Neupogen for his low white blood count.
Pound|Number|102|_%#NAME#%_ _%#NAME#%_, MD University Specialists _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_, #_%#ADDRESS#%_ _%#CITY#%_, MN _%#55400#%_ Dear Dr. _%#NAME#%_: Thank you for the kind referral of your patient, _%#NAME#%_ _%#NAME#%_, who was seen for genetic counseling at the Maternal-Fetal Medicine Center at Fairview-University Medical Center on _%#MM#%_ _%#DD#%_, 2005.
Pound|Number|200|RESPIRATORY: See history of present illness, above. GASTROINTESTINAL: The patient admits to some generalized abdominal pain, but no nausea or vomiting. She is status post C-section, postoperative day #1. SKIN: She denies any skin rashes or lesions. EXTREMITIES: She denies any lower extremity pain or swelling.
Pound|Number|104|_%#NAME#%_ _%#NAME#%_, MD Fairview Women's Clinic _%#STREET#%_ _%#STREET#%_ "_%#STREET#%_ _%#STREET#%_, #_%#ADDRESS#%_ _%#CITY#%_, MN _%#55400#%_ Dear Dr. _%#NAME#%_: Thank you for the kind referral of your patient _%#NAME#%_ _%#NAME#%_, who was seen with her husband _%#NAME#%_ for genetic counseling at Maternal Fetal Medicine Center at Fairview-University Medical Center on _%#MMDD2005#%_.
Pound|Number|164|Follow-up with Dr. _%#NAME#%_ on Wednesday in 4 days to have the packing removed. Continue Augmentin twice a day until packing is removed. Prescription for Tylenol #3 to take q 4 hours p.r.n. 55 tablets are given for discomfort.
Pound|Number|193|IMPRESSION: 1. Diabetes mellitus type 1 with variable control of hypoglycemia. 2. Hypoglycemia secondary to insulin. 3. Postoperative day #1. PLAN: Patient is diabetic in a postpartum state PPD#1 . Patient's insulin requirement is markedly decreased. Patient was discussed in current care, and she prefers to have a more simple insulin treatment to continue as an outpatient.
Pound|Number|151|LABORATORY DATA: Creatinine is notably elevated at 7.6. Potassium is okay at 4.7. Creatinine from last week is 5.4. ASSESSMENT AND PLAN: 1. Postop day #0 right intramedullary nailing for his right surgical neck fracture.
Pound|Number|106|_%#NAME#%_ _%#NAME#%_, MD, University Specialists _%#STREET#%_ - _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ - #_%#ADDRESS#%_ _%#CITY#%_, Minnesota _%#55400#%_ Dear Dr. _%#NAME#%_, Thank you for the kind referral of your patient _%#NAME#%_ _%#NAME#%_, who was seen along with her husband _%#NAME#%_ for genetic counseling at the Maternal- Fetal Medicine Center at University of Minnesota Medical Center, Fairview, on _%#MM#%_ _%#DD#%_, 2005.
Pound|Gauge|285|He is currently on Zosyn IV. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: He is married and lives with his wife who saved his life last night by calling 911. PHYSICAL EXAMINATION: The physical examination reveals a sleeping and possibly sedated elderly man orally intubated with a #8 endotracheal tube on assist control mode ventilation with saturations in the 90s on 60 percent inspired oxygen.
Pound|Number|240|DOB: _%#MMDD1985#%_ IMPRESSION: 1. _%#NAME#%_ _%#NAME#%_ is a 17-year-old female with what appears to be a typical left periorbital cellulitis, is such likely streptococcal origin, staph less likely, other organisms much less likely. Given #2 below, however, there is some concern this might be some alternative process given the lack of systemic symptoms, the slow response to appropriate antibiotics.
Pound|Number|84|3. Tobramycin 1.5 mg/kg per dose q. 8h day #2. 4. Azithromycin 5 mg/kg per dose day #2. 5. Fluconazole 3 mg/kg per day. 6. Foscarnet 62 mg/kg per dose q. 8h.
Pound|Number|127|_%#NAME#%_ _%#NAME#%_ _%#NAME#%_, MD University Specialists _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_, _%#ADDRESS#%_ #_%#ADDRESS#%_ _%#CITY#%_, Minnesota _%#55400#%_ Dear Dr. _%#NAME#%_: Thank you for referring your patient, _%#NAME#%_ _%#NAME#%_, for genetic counseling.
Pound|Number|308|_%#MRN#%_? Scheduled for _%#MMDD2004#%_. IMPRESSION: AML in presumed first remission. RECOMMENDATIONS: Ms. _%#NAME#%_ was seen and examined by Dr. _%#NAME#%_ and appears to be a suitable candidate for total body irradiation prior to an allogeneic peripheral blood stem cell transplant per our local protocol #2001-02 conditioning for this protocol includes chemotherapy and total body irradiation given in 8 treatments over 4 days for a total dose of 1320 cGy.
Pound|Number|148|FINAL LOCATION: IV Infusion Center University of Minnesota Medical Center, Fairview, Riverside Campus. Medical Professional Building, _%#ADDRESS#%_ #_%#ADDRESS#%_ Ms. _%#NAME#%_ _%#NAME#%_ came in for followup of her hip infection.
Pound|Number|127|_%#NAME#%_ _%#NAME#%_, MD Fairview Riverside Women's Clinic _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_, _%#ADDRESS#%_ #_%#ADDRESS#%_ _%#CITY#%_, MN _%#55400#%_ Dear Dr. _%#NAME#%_: Thank you for the kind referral of your patient, _%#NAME#%_ _%#NAME#%_, who was seen along with her partner, _%#NAME#%_, for genetic counseling at the Maternal-Fetal Medicine Center at University of Minnesota Medical Center, Fairview on _%#MM#%_ _%#DD#%_, 2006.
Pound|Gauge|91|I initially cleansed the penis and then put down 10 ccs. of 2% Xylocaine jelly and tried a #26 sound and it stopped in the posterior urethra so I realized this was not a bladder neck contracture but a urethral stricture.
Pound|Number|164|5) Status post hysterectomy. 6) Osteoarthritis. 7) Status post liver biopsy. CURRENT MEDICATIONS: 1) Amaryl 4 mg q a.m. 2) Glucophage XR 1,000 mg q h.s. 3) Tylenol #3 one or two q.i.d. p.r.n. pain. ALLERGIES: PENICILLIN AND SULFA. HABITS: The patient is not a cigarette smoker and does not drink alcohol.
Pound|Number|255|From _%#MM#%_ _%#DD#%_, hemoglobin 11.6, INR 1.18. IMPRESSION/PLAN: Mr. _%#NAME#%_ is a 56-year-old male with a history of diet controlled diabetes mellitus, hypertension and coronary disease who was admitted for right total hip arthroplasty. Post-op day #1. 1. Diabetes mellitus. Patient's fasting blood sugars have been elevated during his admission from 200 to 300.
Pound|Number|180|IMPRESSION: 1. Methicillin sensitive staphylococcus aureus infection of the left hand with persistent bacteremia. 2. Acute renal failure, nonoliguric. I suspect this is related to #1 (prerenal renal failure due to sepsis ). Acute tubular necrosis is not excluded. Obstruction has essentially been ruled out.
Pound|Number|260|IMPRESSION: AML in presumed first remission. RECOMMENDATIONS: Mrs. _%#NAME#%_ was seen with Dr. _%#NAME#%_ _%#NAME#%_ who agrees the patient appears to be a suitable candidate for total body irradiation prior to an umbilical cord blood transplant per protocol #2005-02. Condition for this protocol is non-myeloablative. It includes chemotherapy and total body irradiation given in a single treatment of 200 cGy.
Pound|Number|118|2. Dysphagia. 3. Status post PEG tube placement. ALLERGIES: Contrast. MEDICATIONS: 1. Timentin. 2. Zantac. 3. Tylenol #3. 4. Zofran. 5. Tylenol. SOCIAL HISTORY: Mr. _%#NAME#%_ is married.
Pound|Number|184|Labetalol, torsemide and hydrochlorothiazide. His pressures are well controlled on this regimen and range in the 130 systolically. a. Continue all current medications. 5. Postop daily #1 status post left pneumonectomy secondary to nonsmall cell carcinoma of the lung.
Pound|Number|116|1. Flonase. 2. Lisinopril/hydrochlorothiazide 20/25 one per day. 3. Advair 500/50 one puff b.i.d. p.r.n. 4. Tylenol #3 p.r.n. 5. Ibuprofen p.r.n. ALLERGIES: Sulfa (rash), Compazine (trismus).
Pound|Number|173|a. Chest x-ray without pneumonia but she has pulmonary vascular congestion. b. Severe underlying chronic obstructive pulmonary disease. c. Severe cor pulmonale secondary to #1. d. She is unrealistic about her expectations given the severity of her heart and lung disease.
Pound|Number|147|4. Bacteremia with gram negative rods. 5. Bacteremia with gram positive cocci, alpha hemolytic strep. 6. Hypotension, presumed sepsis given #4 and #5 above along with accompanying leukocytosis and tachycardia.
Pound|Number|135|Her electrolytes on _%#MMDD2004#%_ were normal. Her alkaline phosphatase was 232. IMPRESSION: This 58-year-old woman postoperative day #1 right hip total hip arthroplasty and open reduction and internal fixation of the right femur.
Pound|Number|128|The ABDOMEN is nontender with active bowel sounds. NEUROLOGICAL: Cranial nerves II-XII intact. ASSESSMENT: 1. Postoperative day #1 triple arthrodesis. 2. Acute onset of lightheadedness and some mild vertigo. Visual focus difficulties.
Pound|Gauge|232|The cervix was dilated to a 39 Hegar dilator. A Hern forceps was then introduced into the uterus and with serial removal of complete placental tissue. After it was felt that all placental tissue was out, two passes were made with a #10 curved firm French curet with vacuum for removal of any remainder of placental tissue.
Pound|Number|109|She is status post renal transplant. Kidney function is reasonably good. She does have pain and uses Tylenol #3. Will occasionally use Dilaudid and Zofran for nausea. She has had a number of endoscopies in the past few years.
Pound|Number|420|IMPRESSION: 1. _%#NAME#%_ _%#NAME#%_ is a 55-year-old female with acute fever, increased liver function tests, elevated white count, has underlying sickle cell disease and prior splenectomy, at very high risk for infection although has went many years with no major infection problems, streptococcus pneumoniae, meningococcus and Salmonella all particularly notable possible pathogens here. 2. Diarrhea probably part of #1, although unclear. 3. Sickle cell disease which has been fairly unremarkable but has had chronic anemia.
Pound|Number|141|IMPRESSION: 1. Lupus nephritis-diffuse proliferative glomerulonephritis class IV (biopsy _%#MMDD2007#%_). 2. Nephrotic syndrome secondary to #1-amlodipine may also be contributing to edema. 3. Leukopenia secondary to IV Cytoxan given for SLE on _%#MMDD2007#%_.
Pound|Number|166|REQUESTING PHYSICIAN: Dr. _%#NAME#%_ _%#NAME#%_. REASON FOR CONSULTATION: Dyspnea. ASSESSMENT: 1. Status-post coronary artery bypass grafting times three, postop day # 1. 2. Dyspnea postoperatively secondary to atelectasis and volume overload. A. Better with C-PAP.
Pound|Number|156|My key findings: CC: MMT Stage IB HPI: Doing well status post TAH/BSO. Exam: Scan well-healed. No mass or tenderness. Assessment and Plan: Eligible for GOG #150. Risks and benefits explained. She has signed consent.
Pound|Number|89|Arterial blood gas this morning: pH of 7.46, pCO2 31, pO2 277. IMPRESSION: 1. Postop day #3 aortic valve replacement and coronary artery bypass.
Pound|Quantity|151|We will discuss this later when she returns to our office. 3. A trial of Entocort 9 mg every morning to try to improve the Crohn's disease, script for #100 good for a year was given. My concerns about this are that it may not work due to a rapid transit through the gut and in any event would need to be taken in the morning when there is a least amount of fluid secretion in the gut.
Pound|Quantity|70|10. Percocet one to two tabs q4-6h as needed. 11. Remeron 15 mg q day #12. 12. Trazodone 25 mg prn sleep. 13. Triamcinolone 0.25 to face qhs.
Pound|Number|196|No other obvious source. 2. Aortic valve replacement, without evidence of problems. 3. Coronary artery disease. 4. Hypertension. 5. Pacemaker. 6. Acute renal insufficiency, undoubtedly related to #1. PLANS: 1. Needs needle aspirate for diagnosis/cultures and treatment, assuming it is an abscess.
Pound|Number|71|5. Imodium. 6. Lorazepam. 7. Tylenol. 8. Albuterol inhaler. 9. Tylenol #3. 10. Prevacid. 11. Multivitamin. 12. Allegra. CURRENT IN HOUSE MEDICATIONS: 1. Lisinopril. 2. Metoprolol.
Pound|Number|150|1. Cerebrovascular accident x2 in 2002 with residual cognitive deficits. 2. Hypertension. 3. Gastroesophageal reflux disease. 4. Dysphagia related to #1. 5. Sensory neural hearing loss. 6. Common iliac artery aneurysm, status post aortoiliac bypass _%#MM2003#%_.
Pound|Quantity|405|Since Ms. _%#NAME#%_ has a chronic illness related to alcohol abuse and since she is a chronic smoker of greater than 1 pack per day and also since she is a small person who weighs 57 kilograms, I am recommending starting with low dose of thyroid hormone replacement at 25 mcg each day. I gave Ms. _%#NAME#%_ a prescription for levothyroxine 25 microgram tablets to take one each morning before breakfast #31 with one refill. If Mrs. _%#NAME#%_'s labs return and it is not consistent with secondary hypothyroidism, we will contact her and have her discontinue thyroid hormone replacement.
Pound|Number|259|IMPRESSION: AML with persistent disease. RECOMMENDATIONS: Mr. _%#NAME#%_ was seen and examined by Dr. _%#NAME#%_ _%#NAME#%_, and appears to be a potential candidate for total body irradiation prior to an umbilical cord blood transplant per our local protocol #1999-09. Conditioning for this protocol includes chemotherapy and total body irradiation given in 8 fractions over 4 days, for a total dose of 1320 cGy.
Pound|Number|340|2. _%#MRN#%_ (_%#MMDD2002#%_): No evidence of leukemia. IMPRESSION: Acute myeloid leukemia in first remission. RECOMMENDATIONS: Mr. _%#NAME#%_ was seen and examined by Dr. _%#NAME#%_ and appears to be a potential candidate for total body irradiation (TBI) prior to an allogeneic peripheral blood stem-cell transplant per our local protocol #2001-02. Conditioning for this protocol includes conditioning of chemotherapy and total body irradiation.
Pound|Number|158|PRESENT ILLNESS: The patient had the diagnosis of rectal cancer made this year, and has undergone radiation and chemotherapy. She is now in postoperative day #16 from a rectal perineal resection for this problem, and apparently the margins were free of tumor.
Pound|Quantity|250|We also wrote a note for him today to case worker or attorney named _%#NAME#%_ _%#NAME#%_, indicting that the patient is unable to resume working, that he has a permanent disability. In addition, I gave him a prescription for Dilaudid 2 mg, quantity #40, to use for pain control. No refills authorized. We will see him again in follow-up in about 6 weeks or p.r.n.
Pound|Number|188|Therefore, postoperatively the patient was transferred to the Surgical Intensive Care Unit for intensive monitoring. The patient was found to be troponin negative x 3, and on hospital day #3 the patient transferred to the transplant floor. At this time the patient remained afebrile, stable vital signs, and was begun on regimen of immunosuppression for his transplantation.
Pound|Number|91|She does not have diabetes mellitus, but she has smoked as described. MEDICATIONS: Tylenol #3 obtained over-the-counter in the Canada. PAST MEDICAL HISTORY: 1. Status post two cesarean sections with the last occurring 14 years ago.
Pound|Number|223|6. This clinician will continue to consult with this patient, this patient's family, and Dr. _%#NAME#%_ if necessary. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, PhD _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_, _%#ADDRESS#%_ #_%#ADDRESS#%_ _%#CITY#%_ _%#CITY#%_, Minnesota _%#55100#%_ Phone: _%#TEL#%_ FAX: _%#TEL#%_
Pound|Number|217|The patient had a Foley catheter placed during the surgery, which was discontinued on postoperative day #1. The patient was able to void spontaneously after that. The patient had low urine output on postoperative day #1, which resolved with increasing her IV fluids. The patient was voiding spontaneously on the day of discharge.
Pound|Number|228|8. Cardiovascular: The patient was placed on a beta blocker protocol due to her hypertension and obesity risk factors. She was transitioned to her lisinopril and atenolol which she takes as home medications on postoperative day #1. Her blood pressure was well controlled throughout the hospitalization.
Pound|Number|120|PAST MEDICAL HISTORY: 1. Dilated cardiomyopathy secondary to valvular disease. 2. Congestive heart failure secondary to #1. 3. Rheumatic heart disease with mitral and aortic valve replacement in 1986.
Pound|Number|154|This was advanced to a regular diet while she was here without difficulties with nausea or vomiting. She did have one episode of diarrhea on hospital day #2; however, this since subsided. Cause of her pancreatitis is uncertain. There was question of the Avastin causing this side effect.
Pound|Quantity|122|14. Fentanyl 25 mcg patch q.72h., #5 tablets, no refills. 15. Flexeril 5 mg liquid via G tube t.i.d. p.r.n. muscle spasm, #30, no refills. 16. Caltrate 950 mg liquid G tube b.i.d., #30, no refills.
Pound|Number|240|4. Pulmonary: No issues. She was using use her incentive spirometer immediately postoperatively and throughout her hospital course. 5. Pain: The patient's pain was controlled with the PCA in the postoperative period until postoperative day #1 when she was transitioned to p.o. medications and her pain was controlled well at time of discharge.
Pound|Number|194|Her obstruction did not necessitate an NG tube treatment as she did not continue to have nausea or vomiting. Her abdominal pain was successfully treated with a Dilaudid PCA, and by hospital day #3, she was free of pain. At this point during her admission, her diet was slowly advanced, and she was tolerating a soft transitional diet at the time of her discharge.
Pound|Number|179|He was on Coumadin q.Monday, Wednesday, and Friday following dialysis to maintain his fistula. On admission, his INR was elevated to 9.1. Consequently, vitamin K was given on day #1, and his INR was followed closely with titration of Coumadin.
Pound|Number|231|6. History of mitral valve prolapse. 7. Deconditioning: She will commence with physical therapy and occupational therapy today. 8. Attention deficit disorder: She does take Straterra. 9. Deep vein thrombosis prophylaxis related to #1 as well as her history of pedal edema and deep vein thrombosis: She will have Coumadin for approximately 4 weeks and at this point we are utilizing Lovenox until we can have a consistent INR about 2 with a goal of 2 to 3.
Pound|Number|221|5 This clinician will continue to consult with this patient, this patient's family and Dr. _%#NAME#%_ if necessary. _%#NAME#%_ _%#NAME#%_ _%#NAME#%_, PhD _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_, _%#ADDRESS#%_ #_%#ADDRESS#%_ _%#CITY#%_ _%#CITY#%_, Minnesota _%#55100#%_ Phone: _%#TEL#%_ FAX: _%#TEL#%_
Pound|Number|155|2. History of hypertension. 3. History of asthma. 4. History of anxiety. 5. Status post excision of left cholesteatoma. 6. History of vertigo secondary to #1. 7. Status post tubal ligation. 8. History of arthritis.
Pound|Number|101|3. Candida colonized including urine and therefore quite probably bowel. 4. Diarrhea, likely part of # 1. C-difficile negative, although conceivably still involved. 5. Abdominal aortic aneurysm of significant size.
Pound|Quantity|89|3. Add sedimentation rate and CPK to laboratories. 4. Check O2 sat. 5. Z-pack 500 mg day #1 and 250 mg q. day x 4. 6. Humibid LA 1 q.12h. to help loosen/promote secretion clearance.
Pound|Number|137|RECOMMENDATIONS: 1. A cranial MRI should be considered. 2. Performance of an EEG should be considered. 3. Most probably; however, #1 and #2 will yield either normal or mild, nondiagnostic findings.
Pound|Number|91|MEDICATIONS: 1. Recent oxycodone 5 to 10 mg, I believe q.4h. p.r.n. 2. Had been on Tylenol #3 previously. 3. Prevacid 30 mg q.d. 4. Senokot. 5. Citrucel.
Pound|Number|132|The patient was initially treated with doxycycline, piperacillin/tazobactam and tobramycin. She was able to wean to room air on day #4 of her hospital stay. Her pulmonary function test showed gradual improvement with the best FEV1 seen on _%#MMDD2007#%_ at 63% predicted.
Pound|Number|94|Postoperatively, the patient was taken to the floor in stable condition. On postoperative day #1, the patient was stable, afebrile and her vital signs were stable.
Pound|Number|162|The patient tolerated the procedure well and was transferred to the Neurosurgery Intermediate Care unit in stable condition postoperatively. On postoperative day #2, the patient developed increased confusion. An extensive work-up was carried out including electrolytes, infection work- up, head CT, and medication check, revealing no abnormalities.
Pound|Number|138|She was given betamethasone prior to being transferred, and then she received her second dose on _%#MM#%_ _%#DD#%_, 2006. On hospital day #2, a sterile speculum exam was performed. It did reveal moderate amount thick white vaginal discharge; however, there was no pooling, and there was no fluid from coughing.
Pound|Number|185|She started to tolerate a PO diet. On postoperative day #4 was started with rehabilitation; physical therapy, occupational therapy. She was resumed on Coumadin and on postoperative day #6 she was improved and acute rehab referral was made.
Pound|Number|210|Though reports are unavailable except for verbal reports by patient. While the patient was primarily closed after the initial procedure from _%#MMDD2002#%_, she and her husband report that on postoperative day #1, the staples providing approximation of her skin were removed to allow open wound and frequent daily dressing changes for intraabdominal drainage.
Pound|Number|73|10. Calcium with vitamin D. 600 mg QD. 11. Ultram 50 mg prn. 12. Tylenol #3 30 mg QD. 13. Tylenol 500 mg PO prn. 14. Atrovent 15. Albuterol nebs q.i.d.
Pound|Number|370|Microscopic evaluation of the surgical specimens showed benign proliferative endometrium, adenomyosis, multiple intramural leiomyomas with subserosal leiomyoma, benign follicular cyst of the right ovary and unremarkable Fallopian tubes and no evidence of malignancy. Her postoperative course was without complications and she was discharged to home on postoperative day #3. Risks and restrictions were discussed prior to her discharge and she was given a follow-up appointment in two weeks' time.
Pound|Quantity|180|Follow-up with her primary care physician, Dr. _%#NAME#%_, was arranged within two weeks time. DISCHARGE MEDICATIONS: Atenolol 25 mg p.o. q.d., prednisone 5 mg p.o. q.d., Catapres #2 patch weekly, Lipitor 10 mg p.o. q.h.s, Protonix 40 mg p.o. q.d., Alphagan one drop both eyes daily, Zestril 50 mg p.o. b.i.d., clonidine 0.1 mg b.i.d. p.r.n. systolic blood pressure greater than 185, Cosopt one drop both eyes daily.
Pound|Number|90|The patient did well after her left total hip arthroplasty revision. On postoperative day #2, the patient's drain was removed. Her incision was clean, dry and intact. The patient was placed on Coumadin for DVT prophylaxis.
Pound|Number|147|This will be continued upon discharge. PROBLEM #2: Diet. The patient initially was NPO. He was started on a clear liquid diet on postoperative day #1, which was increased to a full liquid diet which he tolerates well at this point.
Pound|Number|374|PROBLEM #2: Infectious disease. Fevers were initially believed to be infectious in etiology, and blood cultures were drawn Ceftazidine, vancomycin, and tobramycin were started intravenously, and cultures were continued with fever spikes. Tobramycin was discontinued on postoperative day #5, and an antibiotic regimen was changed to Ancef and cefotaxime on postoperative day #6, because of continued low-grade temperature spikes.
Pound|Number|169|DISCHARGE DIAGNOSIS: 1. Carcinoma of the prostate/hormone refractory. 2. Urinary outlet obstruction. 3. Acute renal failure, on chronic renal insufficiency secondary to #2. 4. Urinary tract infection. 5. Depression. 6. Anemia.
Pound|Number|257|The patient, however, continued to tolerate fluids fairly well and wanted to be discharged with a trial of oral Zofran and oral fluid intake, without having an additional procedure for placement of a PICC line. Therefore, she was discharged on hospital day # 3, stable on Zofran therapy. It should be noted also that the patient's home situation was that of abuse by her husband and social services was also contacted during this hospitalization regarding the home situation in hopes of rectifying that problem.
Pound|Number|248|Her hemoglobin was 7.9. She was observed for anemia, however, remained asymptomatic throughout her postoperative course. On postoperative day #3 the patient was doing well, ambulating without difficulty and was discharged home on postoperative day #4 with instructions to follow-up in the office in two weeks.
Pound|Number|107|PROBLEM #2: Cardiovascular, the patient did recover from a cardiovascular standpoint. On postoperative day #2 he had gained considerable pulsatility on his arterial line waveform.
Pound|Number|158|4. Pancytopenia. 5. History of liver abscess. 6. Hyperlipidemia. 7. History of GI bleed. 8. History of pyelonephritis. PLANNED PROCEDURE: Extraction of teeth #2, 15, 26, 27 and 32. PLANNED ANESTHESIA: General. INDICATIONS FOR OPERATION: _%#NAME#%_ _%#NAME#%_ is a 52-year-old gentleman referred by his general dentist, Dr. _%#NAME#%_ _%#NAME#%_ for removal of indicated teeth secondary to dental caries.
Pound|Number|161|2. Recent right sided chest effusion for which it was strained, this is resolved. 3. Multi-organ and system failure; liver, kidney, and respiratory secondary to #1, resolved. 4. Decrease in nutrition. He had TPN at one point and feeding tubes.
Pound|Number|104|Currently, she was undergoing treatment with the study drug amrubicin. The patient was undergoing cycle #5 of amburicin treatment and had received it on _%#MMDD#%_ and _%#MMDD#%_.
Pound|Number|112|Her diet was advanced slowly, and she was transitioned off of IV fluids and pain medicine. On postoperative day #3, she was tolerating a regular diet, and her pain was controlled with p.o. pain medicines.
Pound|Number|227|INDICATIONS FOR PROCEDURE AND HOSPITAL COURSE: The patient is a 58-year-old female who was taken to the operating room for the above-mentioned procedure for her ameloblastic carcinoma of the left mandible. On postoperative day #0, the patient was in the surgical intensive care unit.
Pound|Number|117|Her vital signs remained stable. She remained afebrile. There were no problems with her wounds. By postoperative day #2 she was feeling quite well and felt like going home.
Pound|Number|86|She tolerated the procedure quite well and had no complications. On postoperative day #1, she was doing quite well. On postoperative day #2 she continued to do well. Her pain was controlled with a PCA.
Pound|Number|180|PROBLEM #5: GI: Postoperatively, the patient was made n.p.o. As she became more awake and her bowel function returned, she was transitioned to a regular diet. By postoperative day #2, she was eating a regular diet without difficulty.
Pound|Number|293|The patient underwent the procedure, tolerated the procedure well, was transferred to the general surgery floor postoperatively, had no apparent postoperative complications. The pain was well controlled. The patient underwent an upper GI, small bowel follow through study on postoperative day #1 which showed no leak, showed an intact anastomosis.
Pound|Quantity|111|DISCHARGE MEDICATIONS: 1. Keflex 250 mg p.o. q. day x 10 days. 2. Vicodin 1-2 tabs p.o. q.6 hours p.r.n. pain, #20. 3. Wellbutrin 200 mg p.o. q. day. 4. Effexor 37.5 mg 3 tabs p.o. q. day.
Pound|Number|102|They thought it was transient and due to pregnancy and recommended just following it. By hospital day #4, _%#MM#%_ _%#DD#%_, 2005 she was feeling very well. She had been tolerating p.o. including McDonald's, with no IV hydration for more than 12 hours.
Pound|Number|165|3. Status post AICD placement. 4. CVA of the left MCA artery at the time of the _%#MM#%_ 2003 ablation. 5. Affluent aphasia and right-sided hemiparesis secondary to # above. 6. Hypothyroidism. 7. History of leukocytoclastic vasculitis. 8. Polyserositis.
Pound|Number|150|4. Colace 100 mg p.o. b.i.d. while on narcotics. DISCHARGE INSTRUCTIONS: 1. She is instructed that she could take her dressings off postoperative day #3 and shower. 2. No baths x2 weeks. 3. Resume regular diet.
Pound|Number|134|PROBLEM #6: Pain. The patient was on morphine PCA postoperatively, with scheduled Toradol. She did not tolerate the Percocet. Tylenol #3 was used, and she was discharged home with those.
Pound|Number|170|2. Prerenal azotemia secondary to dehydration, decreased p.o. intake, and underlying infection. Patient was treated with gentle hydration with resolution by hospital day #3 of her renal failure. Her ACE inhibitors were held on admission. 3. Cardiomyopathy, likely ischemic cardiomyopathy.
Pound|Number|131|Her pain was controlled with oral Percocet and ibuprofen. Her diet was advanced as tolerated. On _%#MMDD2004#%_, postoperative day #3, the patient was doing well. She had some vaginal bleeding. She did report a bowel movement, was tolerating a regular diet, and was ambulating.
Pound|Number|296|At the time of discharge, she was voiding spontaneously and without difficulty, and will follow up with Dr. _%#NAME#%_ postoperatively to reevaluate her urologic symptoms. The patient was passing some flatus starting on postoperative day #2, and was regaining bowel function by postoperative day #3. Ms. _%#NAME#%_'s pathology has not returned at the time of discharge.
Pound|Number|180|There was some initial necrosis around the stoma that by postoperative day #11 appeared much more viable and pink throughout. She was tolerating a normal diet by postoperative day #12. She had a CT scan on _%#MMDD2006#%_ that showed a loculated fluid collection beneath the anterior abdominal wall.
Pound|Number|163|However, in the evening she was able to tolerate a clear liquid diet, which was advanced to a full, normal breakfast in the morning. DISCHARGE MEDICATION: Tylenol #3, a supply of 10 pills in case of abdominal pain. DISPOSITION: Home. DISCHARGE DIET: Regular. DISCHARGE ACTIVITY: As tolerated. FOLLOW-UP: Follow-up with primary-care physician in one week, to be determined, since the patient has not had any primary-care physician yet.
Pound|Number|152|3. Hypertension 4. Pneumonia in the past 5. 45 pack year tobacco use history, quit 2001. 6. Possible chronic obstructive pulmonary disease secondary to #5. PREVIOUS SURGICAL HISTORY: 1. Appendectomy MEDICATIONS: 1. Meridia 15 mg PO Q day
Pound|Number|152|PROBLEM #2: Oncology. _%#NAME#%_ has metastatic osteosarcoma and is currently being treated under protocol AOST0121, not unsteady. He is currently week #24. _%#NAME#%_ received 20 gm (or 12 gm/m2) of methotrexate on hospital day #1.
Pound|Gauge|372|X-ray showed significant arthritis of the hip joint with bone on bone. HOSPITAL COURSE: The patient was taken to the operating room on _%#MMDD2003#%_ where he underwent a right total hip arthroplasty using Osteonics hydroxyapatite-coated components including the trident PSL acetabular shell, a single-bone screw, a 10 degree polyethylene insert, 32 mm femoral head and a #10 secure fit HA-coated femoral stem. Following surgery he made steady progress. His hemoglobin did fall to 8.3 which was well tolerated.
Pound|Number|324|His urine output remained good during his hospital course. By postoperative day #5 his creatinine had decreased to 2.7. On the day of discharge his creatinine was 2.3. Amylase and lipase levels peaked on postoperative day #1, then decreased over the hospital course. He was weaned from his insulin drip on postoperative day #4. On the day prior to discharge, the patient developed a fever of 100.8. On the day of discharge his temperature was 98.1 with a WBC of 6100 and absolute lymphocyte count of 0.1. He will be followed as an outpatient in the Transplant Center.
Pound|Number|130|Deep tendon reflexes are hypoactive in bilateral patellar and Achilles reflexes. ASSESSMENT: 56-year-old female postoperative day #12 status post posterior approach for a C5-6 foraminotomy for neural foraminal stenosis, with a wound dehiscence and yellow drainage.
Pound|Number|148|Given his stable hemoglobins he was transitioned to clear liquids and then his diet was advanced. He was transferred out of the CCU on hospital day #2 given his stable hemoglobins. The patient was changed over to Protonix 40 mg p.o. b.i.d. The patient was instructed that he is to never take NSAIDs of any type, including aspirin.
Pound|Number|172|A male infant, weighing 8 pounds 6 ounces, with Apgars of 9 and 9, was delivered. She did well postoperatively. DISCHARGE PLANS: The patient went home on postoperative day #3 on Percocet. The patient is to follow up in the office in six weeks.
Pound|Number|139|He did have a history of heart issues, so a transfusion was performed. He had no other complications postoperatively. On postoperative day #2, he was moved to the general patient ward, where he was seen by Physical Therapy.
Pound|Number|41|FINAL _%#MMDD2007#%_: ADDENDUMS ADDED DIC#_%#MRN#%_, _%#MRN#%_ / _%#NAME#%_ ADMISSION DIAGNOSES: 1. Status post kidney transplant in 2002 with current acute renal failure.
Pound|Number|170|POSTOPERATIVELY: On postoperative day #1 she was afebrile, tolerating general diet. Postoperative day #2 she was doing well. She was discharged home on postoperative day #3. Discharge hemoglobin was 10.5. DISCHARGE MEDICATIONS: Percocet 1 every 3-4 hours as needed for pain.
Pound|Number|277|She is being discharged home today, on hospital day #4, and will follow- up with Dr. _%#NAME#%_ in two to three weeks, on _%#MMDD2004#%_. PROBLEM #2: Hematologic. The patient's hemoglobin was 9.7 on admission. She did receive one unit of packed red blood cells on hospital day #2, following which her hemoglobin was 10.3 and remained stable for the remainder of her hospitalization.
Pound|Quantity|76|DISCHARGE MEDICATIONS: 1. Narco 5/125 mg 1-2 p.o. q. 4h. for pain, dispense #40. 2. Celexa 10 mg p.o. daily. 3. Lasix 20 mg p.o. daily. 4. Synthroid 200 mcg p.o. daily.
Pound|Number|174|Postoperatively the patient did well without complications. She remained afebrile. She had a postoperative hemoglobin of 10.6 and was discharged to home on postoperative day #4. Discharge medications included Percocet and Ibuprofen. She is instructed to call for fever, heavy vaginal bleeding, or drainage from her incision.
Pound|Number|192|1. Extreme anxiety with nausea and retching during her examination that appears to be simply due to her severe anxiety. 2. Abscess, tooth #31. 3. Rampant decay with some tenderness into tooth #2 and #3 area. 4. Multiple medical issues. PLAN: I discussed with _%#NAME#%_ and her mother the options for treatment.
Pound|Number|134|On postoperative day #3, her Thymoglobulin was held for an absolute lymphocyte count of 0. Her Foley was removed on postoperative day #4, and she was able to void without any problems. It was determined that she would be in stable condition to be discharged to home.
Pound|Number|155|The patient had a blood loss of approximately 800 cc. Postop day #1 the patient's hemoglobin was 11.9. She had good return of bowel function by postop day #2. The baby was Rh negative and the patient did not need RhoGAM.
Pound|Number|165|PROBLEM #2: Nutrition. The patient was kept n.p.o. after the surgery with a nasogastric tube to gravity. He regained his bowel function slowly. On postoperative day #8 he was able to take a liquid and was advanced to a regular diet the next day on discharge.
Pound|Number|167|PROBLEM #1: Gastrointestinal. The patient had an NG placed with vigorous output for the first two to three days postoperatively. This was clamped on postoperative day #3, and the patient denied nausea. She was sipping around this without difficulty. Residual was minimal, and the NG was pulled.
Pound|Number|128|The patient was then advanced to a clear liquid diet on postoperative day #1, tolerated the clear liquids. By postoperative day #2, she was taking 60 cc p.o., had good oral intake, was passing gas.
Pound|Number|165|She had secondary difficulties with bilateral shoulders. She was seen by physical therapy and fitted for a roll-about. Her pain was controlled. On postoperative day #1, her cast remained clean, dry, and intact. She was discharged to home with followup in 2 weeks.
Pound|Number|118|She did well on the floor with good pain control. Her hemoglobin on the day of surgery was 11.6, on postoperative day #1 it was 10.8 and felt to be stable. Her pain was controlled and she was therefore discharged home.
Pound|Number|208|After surgery, she was transferred to the general orthopedic floor and started on a postoperative orthopedic protocol. She tolerated this well. There was no complications. Her hemoglobin on postoperative day #2 was 8.7. She was transfused 2 units. The hemoglobin responded to 11.1. The rest of her hospital course was without incidence or complication.
Pound|Number|230|ADMISSION DIAGNOSIS: Wound infection. DISCHARGE DIAGNOSIS: Wound infection. PROCEDURE: IV antibiotics. HISTORY OF PRESENT ILLNESS: The patient is a 56-year-old male, status post right modified neck dissection, admitted postop day #10 with a wound infection. The patient presented with purulent discharge and was admitted for IV Unasyn treatment, wound packing and wound cares.
Pound|Number|216|GI medicine evaluated the patient and obtained MRCP which showed no stones on the duct. His lipase had decreased and then he was brought to the operating room for a laparoscopic cholecystectomy on hospital day #3 or #4. He underwent the procedure well. He had no complications. He was transfused with fresh frozen plasma to correct his INR prior to the procedure.
Pound|Quantity|186|Cardiology was consulted over the phone and recommended event monitor and followup with Cardiology in 2-3 weeks. She was kept on her regular medicines and recommended to take an aspirin #1 daily.
Pound|Number|198|By hospital day #10, it was apparent that the patient was in generalized decline with the onset of multisystem organ failure. Both the patient's wife and son were thoroughly briefed on hospital day #10 and #11 on the declining situation and poor prognosis which they clearly understood.
Pound|Number|226|HOSPITAL COURSE: Hospital course was uneventful for neurologic, hematologic or infectious complications. After surgery, the patient was kept in the intensive care unit overnight in the operative room, and on postoperative day #1 the patient expereinced diabetes insiexperienced was significant and was replaced with volume replacement and treated with DDAVP in both IV and PO forms.
Pound|Number|105|The patient was started on both Megace and Arimidex during her hospital course. Of note, on hospital day #5, the patient did develop a rash over her back and abdomen.
Pound|Quantity|96|DISCHARGE MEDICATIONS: 1. Keflex 250 mg p.o. t.i.d. for 5 days. 2. Percocet as needed for pain, #40 dispensed. 3. Bacitracin to wound b.i.d. FOLLOW-UP PLAN: The patient is to follow up with Dr. _%#NAME#%_ in 2 to 3 weeks at his _%#CITY#%_ _%#CITY#%_ office.
Pound|Quantity|292|She presents for chemotherapy for her recurrence. Miss _%#NAME#%_'s history goes back to _%#MM#%_ of 2003 at which time she had her initial optimal debulking surgery. She subsequently received carboplatin x 6 courses. In the summer of 2003 she had an initial recurrence and was placed on WCC #31, receiving topotecan and thalidomide x 6 courses. In _%#MM#%_ of 2004, a chest x-ray was performed which showed a large pleural effusion.
Pound|Number|176|She was given Colace for stool softener due to the fact that she is on narcotics. 6. GU. Foley catheter was placed at the time of surgery and discontinued on postoperative day #1. She was voiding spontaneously at the time of discharge. 7. ID.
Pound|Quantity|126|6. Dilaudid 2 mg p.o. q.4h p.r.n.; dispense #30. 7. Reglan 10 mg p.o. q.6h p.r.n. 8. Ativan 0.5 mg p.o. q.4h p.r.n., dispense #15. 9. Senokot 2 p.o. b.i.d.
Pound|Number|117|He worked with PT for gait training (_______________) touch-down weight bearing. By the end of the postoperative day #1, he had advanced to the point where he was ready for discharge home.
Pound|Number|136|2. 20-year history diabetes type 2. 3. 120 year pack history nicotine addiction, quit in _%#MM#%_ 2002. 4. Relative anemia secondary to #2. PLAN: Complete bowel rest until he recovers.
Pound|Number|283|She had rapid return of bowel function, was ambulating and voiding without difficulty. Her examination showed that she remained afebrile and her incision remained clean and dry without signs of infection and a JP drain was placed, and operative case was removed on postoperative day #3. Patient is discharged to home with lifting restrictions for a total of 6 weeks.
Pound|Number|255|However, it was recommended that she have a stay at short-term rehab for further strengthening. PROBLEM #7: Congestive heart failure. The patient remained without evidence of congestive heart failure throughout the hospital stay; however, on hospital day #5, she developed a few crackles at her bases and had a slight increase in her O2 needs.
Pound|Number|98|She was started on a higher dose of beta blocker. She was discharged to home on postoperative day #4 in stable condition, feeling well, in minimal pain, and doing well.
Pound|Number|168|She had minimal vaginal bleeding, she was tolerating a regular diet, her pain was well controlled, and she was doing well. She was discharged home on postoperative day #2. She was to follow up with OB-GYN and Urology as scheduled.
Pound|Number|96|Ultrasound #1 was performed at 9 + 4 weeks giving an EDC of _%#MM#%_ _%#DD#%_, 2004. Ultrasound #2 was at 20 + 2 weeks with normal anatomy scan. Issues with prenatal care included blood type Rh negative, A1 gestational diabetes, and history of C-section desires repeat.
Pound|Number|126|5. Afrin nasal spray bilateral nares p.r.n. congestion. 6. Claritin D 12 hour 1 tab p.o. b.i.d. p.r.n. congestion. 7. Tylenol #3 elixir 5-10 cc p.o. q.6h. p.r.n. pain. SPECIAL DISCHARGE INSTRUCTIONS: The patient is to follow a clear liquid diet and advance as tolerated to a soft non-chew diet.
Pound|Number|214|b. Keep him NPO. c. Repeat his enzymes. d. Further plans for Gastroenterology for an endoscopic retrograde cholangiopancreatography (ERCP). e. We will hold his Lipitor for now. 9. Leukocytosis, likely secondary to #1. Doubt any infection. a. We will repeat laboratory tests. 10. Chronic left hip pain, etiology unclear.
Pound|Number|103|He has been in treatment more than 12 times. 2. History of cirrhosis with gastric varices secondary to #1. 3. History of gastrointestinal bleed with variceal banding in 2001, possible Mallory-Weiss tear in _%#MM2004#%_.
Pound|Number|99|Her drain was removed on postoperative day #2, along with her Foley catheter. On postoperative day #3, the patient was doing well with physical therapy.
Pound|Number|183|PAST MEDICAL HISTORY: 1. Left frontal lobe mass consistent with oligodendroglioma diagnosed _%#MM#%_ _%#DD#%_, 2004, secondary to tonoclonic seizure. 2. Seizure disorder secondary to #1. ADMISSION MEDICATIONS: The patient had been on OCPs and Dilantin until the onset of this rash, at which time her OCPs and Dilantin were both discontinued.
Pound|Number|125|An epidural PCA with fentanyl in the basal rate was continued and patient was finally made comfortable. On postoperative day #6, he started to have return of bowel function through the ostomy.
Pound|Number|223|HISTORY OF PRESENT ILLNESS: Mr. _%#NAME#%_ is a 49-year-old male who is status post allogeneic sibling mini peripheral blood stem cell transplant for T cell non-Hodgkin's lymphoma. He was discharged after transplant on day #19. At that time he was found to have three small skin lesions, biopsy on _%#MMDD2001#%_ confirmed these to be relapsed T cell NHL.
Pound|Number|127|5. EMLA cream p.r.n. 6. Zofran 4 mg p.o. q.8h p.r.n. nausea. DISCHARGE FOLLOW-UP: 1. Oncology Clinic on _%#MMDD2003#%_ for day #8 of vincristine, and then report back every Thursday and Monday for CBC, diff, and platelets.
Pound|Number|80|He was also placed into a Dyna splint when not in the CPM. On postoperative day #2, his epidural was weaned and eventually shut off, and he was changed over to Percocet and OxyContin and continued to have excellent pain control with this.
Pound|Number|162|CT scan subsequently showed no evidence of progression of disease and PET scan showed increased uptake in lymph nodes. She was subsequently begun on WCC protocol #31 for topotecan x 3 cycles and was subsequently admitted in _%#MM#%_ 2004 for fever of unknown origin.
Pound|Number|154|He underwent the above-named procedures with no initial complications. He recovered on floor 7A. He was doing well until the evening of postoperative day #3, when the patient was noted to be in respiratory duress.
Pound|Number|247|Drinks ETOH. HOSPITAL COURSE: The patient was admitted and taken to the operating room where the above-noted procedure was performed without complication. The patient tolerated the procedure very well and was very comfortable on postoperative day #1. He passed physical therapy, was able to tolerate oral intake, and his pain was controlled on oral medications.
Pound|Number|138|On hospital day #3, the patient had a large bowel movement with the aid of the bowel regimen. A ureteral stent was placed on hospital day #3 by Interventional Radiology. Following this, it was determined that she was in stable condition to be discharged to home.
Pound|Number|202|4. The next scheduled admission at Fairview-University Medical Center is possibly on _%#MMDD2003#%_, depending on the laboratories done during clinic visit that day. At that time, he will receive round #2 of chemotherapy with topotecan. 5. He was instructed to call his doctor or return to the hospital with a fever of over 100.5 degrees F.
Pound|Number|354|DIET: Renal. ACTIVITY: Normal, without restrictions. DISCHARGE INSTRUCTIONS: The patient was instructed to report any increased pain, swelling, fevers, nausea, vomiting, diarrhea, or any other concerns immediately to the Transplant Office. Medications and discharge instructions were reviewed with the patient, and he was discharged home on hospital day #11, with plans for close follow-up.
Pound|Number|144|Her vital signs were stable and she was afebrile. Her incision healed well. Her staples were removed on her day of discharge, postoperative day #4. At that time she was tolerating a regular diet. She has had 2 bowel movements and ambulating without difficulty and also breast feeding.
Pound|Number|335|Otherwise no acute lesions. LABORATORY DATA: Sodium 142, creatinine 0.98, BUN 23, potassium 3.6, bicarbonate 27, glucose 193, hemoglobin A1-C checked in the clinic three days ago was 6.2. White blood cell count is 14.5 with a very minimal left shift. Hemoglobin is 13.5, MCV decreased at 70. INR 1.0, lipase 89, myoglobin 52, troponin #1 less than 0.07. Platelets 307,000. Abdominal CT scan pending at the time of this dictation.
Pound|Number|165|She was initially placed on a PCA for pain control, and she was changed to oral medications on postoperative day #1. She was discharged to home on postoperative day #3. Her postoperative hemoglobin was 10.7. At that time, she was doing well; her vital signs were stable and she was afebrile.
Pound|Number|254|The patient's pain was under control. The patient was afebrile, vital signs were stable, and the patient had bowel sounds on postoperative day #1 and started on p.o. diet. The patient tolerated diet very well and had bowel movements on postoperative day #2. On the day of discharge the patient was taking p.o. and tolerating it very well, and had bowel movements and bowel sounds.
Pound|Number|157|_%#NAME#%_ is a 31-year-old female status post HeartMate II left ventricular assist device placed as a bridge to transplantation. Today is postoperative day #1. She has been found to be hemodynamically stable _____________ REVIEW OF SYSTEMS: The patient is intubated and sedated.
Pound|Number|288|TEST RESULTS AND PROCEDURES: A series of fine-tuning adjustments were tried, but the most successful was changing from the extended filter sets to the standard filter sets. This was applied to the _%#CITY#%_ speech processor and a program for quiet was created and downloaded to position #1. A noise program was created by reducing the IDR to 50 and downloaded to position 2 and 3.
Pound|Number|189|She has relatively pronounced lower extremity peripheral edema, which is being treated with diuretics with only modest response. On her recent CT examination, she had the lesion in segment #5 discovered which was proven to be hepatocellular carcinoma by percutaneous biopsy.
Pound|Number|395|Also, IV morphine at 2-4 mg q. 10 minutes being delivered by pCa. Likely by postoperative day #3, the pain will have receded enough that the IV opioids may be switched to oral analgesics for an additional week or so before being discontinued giving only NSAID or acetaminophen (the latter should be used cautiously in this liver transplanted patient). Please consult us on the day of surgery at #_%#TEL#%_ for further recommendations. Finally I would like to thank Dr. _%#NAME#%_ for allowing us to participate in the management of her patient.
Pound|Number|134|_%#NAME#%_ is currently utilizing the HiResolution speech processor with a Platinum Series speech processor. He is utilizing position #1 (program 4) at a volume of 11 o'clock. His parents report that volume increases above that do seem to be uncomfortable for him.
Pound|Number|112|There was a true knot in the umbilical cord at birth. _%#NAME#%_ was discharged from the newborn nursery on day #2. He was then breast feeding, voiding, and stooling well. He underwent circumcision prior to his discharge.
Pound|Gauge|197|She received a 14-day course of gatifloxacin and ceftriaxone for presumed pneumonia. She failed multiple pressor support tr ials. Thus a tracheostomy was placed on _%#MMDD2003#%_, initially with a #6 Shiley. The patient experienced a few episodes of air leak. ENT evaluated the patient and, finally a #8 Shiley was placed on _%#MMDD2004#%_.
Pound|Number|216|PROBLEM #5. GI: The patient had normal bowel functioning throughout her course in the hospital. She was having a bit of trouble with nausea secondary to the pain meds on postoperative day #1 and on postoperative day #2, she was stable at discharge. PROBLEM #6. GU: A Foley catheter was placed at the time of surgery and was discontinued on postoperative day #1.
Pound|Number|91|The patient and her husband opted for the nonoperative treatment. She was placed in a TLSO #6 brace and was instructed to wear this at all times when sitting and standing.
Pound|Number|138|PAST MEDICAL HISTORY: 1. Non-metastatic osteosarcoma of the left distal femur, diagnosed in _%#MM2003#%_. A. Status post induction course #1 with cisplatin and Adriamycin (doxorubicin) from _%#MMDD2003#%_ to _%#MMDD2003#%_.
Pound|Number|179|However, it was asymptomatic. The patient continued to be observed very closely for any bleeding. Repeat hemoglobin on the third day dropped to 8.3. However, on postoperative day #4 her hemoglobin dropped from 8.3 to 7.4. It was decided by the Orthopedic Service to transfuse at this point, with which we agreed.
Pound|Number|169|The patient tolerated the procedure well, however, no abdominal wall defect was identified. Postoperatively she had no postoperative complications. By postoperative day #1, she was tolerating p.o., was taken off her IV fluids, and discharged home under the care of her grandmother.
Pound|Number|88|9. Avalide 150/12.5 p.o. daily. 10. Tylenol Extra Strength p.r.n. for pain. 11. Tylenol #3 with codeine p.r.n. for pain. 12. Sulindac 200 mg p.o. b.i.d. for osteoarthritis. 13. Ferrous Sulfate 325 mg p.o. b.i.d.
Pound|Number|331|CURRENT ADMISSION PROBLEMS: 1. Underlying pulmonary fibrosis for several years, status post left-sided single lung transplant on _%#MMDD2005#%_. Postoperative complications included hematoma formation in left chest with evacuation on _%#MMDD2005#%_ and subsequent chest tube placement, which were discontinued on postoperative day #13. She had a positive sputum culture for fungal pneumonia and is currently on voriconazole and amphotericin B nebulizer.
Pound|Quantity|112|Regular diet. DISCHARGE MEDICATIONS: 1. Zantac 150 mg p.o. b.i.d. 2. Percocet 1-2 p.o. q. 4-6 hours p.r.n. pain #40. 3. Ibuprofen 600 mg p.o. q. 6 hours p.r.n. pain.
Pound|Number|146|CONSULTS: The patient was followed along with the radiology/oncology team during entire hospital stay. The patient was discharged on hospital day #2 and the tandem and ovoids were removed and she is to have cesium brachytherapy at the time of removal.
Pound|Number|113|She began to tolerate increased p.o. intake. Her IV rate was decreased. Her IV was Hep-Lock on postoperative day #2. At the time of discharge the patient was tolerating a regular diet.
Pound|Number|237|By postoperative day #1, she was ready to be transferred to the regular floor of the hospital where she was ambulating well on her own, tolerating a regular diet and had her pain controlled on oral pain medications. By postoperative day #2 the patient was ready to go home. DISCHARGE INSTRUCTIONS: 1. Follow up with Dr. _%#NAME#%_ in 4-6 weeks.
Pound|Number|205|HEART: Heart is regular without murmurs. ABDOMEN: Flat and soft. There is a palpable aortic aneurysm that is nontender. EXTREMITIES: There are blue toes bilaterally, particularly the right #4 and the left #5. LABORATORY DATA: Sodium, potassium, chloride, urea nitrogen, creatinine, calcium, hemoglobin all normal.
Pound|Number|215|The patient remained in the hospital for observation as he developed a significant hematoma in his right upper extremity and he required intravenous pain medications. The patient was discharged home on hospital day #4. on p.o. Vicodin and p.o. Dilaudid for breakthrough pain. His heparin drip was stopped at that time despite a normal INR of 1.1. He had received Coumadin starting on a hospital day #2 each evening and will continue Coumadin at home until for light therapeutic.
Pound|Quantity|171|3. OxyContin 30 mg p.o. b.i.d. x7 days, then 20 mg p.o. b.i.d. x7 days, then 10 mg p.o. daily x5 days, then discontinue. 4. Percocet 1 to 2 tabs p.o. q. 4-6h. p.r.n. pain #80. The patient understands the plan. She has no further questions.
Pound|Number|169|The patient received a PCA for pain management for postoperative day #1 and then was transitioned to oral medications without incident. The patient on postoperative day #2 was begun on hand therapy and was placed on bilateral hinged elbow splints.
Pound|Number|136|The patient did have blood loss anemia with hemoglobin of 7.9. She was asymptomatic and refused blood transfusion. On postoperative day #3, the patient was doing well. Her hemoglobin was 6.9, again asymptomatic and declining transfusion. She was cleared to be discharged home and she was given the following instructions: 1. No lifting anything greater than 15 pounds for the next 6 weeks.
Pound|Number|162|The patient will be following closely with the IDC after discharge to help her adjust her insulin as needed. The patient was doing very well on postoperative day #4 and was ready for discharge. The baby remained in the special care nursery, so the patient was actually discharged to a room and board.
Pound|Number|143|Her pain was well controlled and she was up ambulating without difficulty. She was discharged to home in stable condition on postoperative day #4. DISCHARGE MEDICATIONS: 1. Roxicet 5 to 10 mL p.o. q.4-6h. p.r.n. for pain.
Pound|Number|203|V- resection was performed by Dr. _%#NAME#%_ and recurrence was noted in _%#MM#%_ 2004. The patient underwent seven treatments of blood-brain disruption chemotherapy. The patient now presents for course #8 of blood-brain barrier disruption chemotherapy. PAST MEDICAL HISTORY: Per HPI. PAST SURGICAL HISTORY: Multiple craniotomies and resection of the oligodendroglioma.
Pound|Number|229|The patient underwent a primary cesarean section delivery on _%#MMDD2005#%_ for viable female infant, weighing 7 pounds 1 ounce. Please see the operative note for complete details. She was discharged to home on postoperative day # 3 in stable condition. DISCHARGE MEDICATIONS: Tylenol with codeine as well as Advil as needed for pain.
Pound|Number|214|4. Hypothyroidism. 5. Parkinson's disease. ALLERGIES: Benadryl. CONSULTS: None. IMAGING STUDIES: Chest x-ray on admission shows possible right base infiltrate. Follow-up chest x-ray on _%#MMDD2005#%_, hospital day #2, shows no active process and right infiltrate, thought to be possibly a superimposed soft tissue density.
Pound|Quantity|106|At the time of her discharge, final pathology was still pending. She was given a prescription for Vicodin #20. Subsequently pathology returned showing a small microscopic focus of immature teratoma amongst the neural tissue.
Pound|Number|239|He tolerated the procedure without difficulty and was returned to the regular hospital ward postoperatively. His postoperative course was remarkable for some numbness and tingling in his right hand, which was resolved by postoperative day #2. He had a normal neurologic examination at the time of discharge.
Pound|Number|168|The patient underwent a primary low transverse cesarean section. She delivered a male infant, 8 lbs/15 oz, Apgars 9/10. She did well and went home on postoperative day #3 to return to clinic in six weeks.
Pound|Number|185|Postoperatively, he was continued on an insulin drip. He was continued on Neoral, CellCept , and Solu-Medrol postoperatively. He received one dose of Thymoglobulin on postoperative day #1. He was advanced on his diet without problems. On postoperative #4, his Foley catheter was removed without problems.
Pound|Quantity|117|3. Seroquel 50 mg p.o. b.i.d. 4. Nicotine patch 21 mg per 24 hours. 5. Oxycodone 10 mg p.o. q. 4 hours p.r.n., given #40. 6. Routine home medications. HOSPITAL COURSE: Ms. _%#NAME#%_ is a 46-year-old white female with history of chronic autoimmune sclerosing cholangiopathy and chronic pancreatitis who was admitted once again for abdominal pain.
Pound|Number|183|As far as his immunosuppression regimen, the patient was started on CellCept early postoperatively but his Neoral was held secondary to the ATN. This was started on postoperative day #7 because of the delayed graft function. The patient was also noted to have bladder spasms on one hospital day and required a B and O suppository for relief.
Pound|Number|205|Her postoperative hemoglobin was 9.0, placental pathology was negative. A social work consult was obtained secondary to the patient's poor social situation. She was discharged to home on postoperative day #3. She is able to ambulate, void, tolerate p.o. and her pain is well controlled with p.o. medications.
Pound|Number|187|FAMILY HISTORY: Mother with breast cancer, sister with breast cancer, father with myocardial, grandfather with an myocardial brother with diabetes and obesity. She is allergic to Tylenol #3. REVIEW OF SYSTEMS: Allegra, aspirin, Xanax and Lasix 40 mg daily.
Pound|Number|139|Functional inquiry shows the patient to be allergic to penicillin and sulfa. Currently she is taking Advil for the pain as well as Tylenol #3. PHYSICAL EXAMINATION: VITAL SIGNS: Weight 148, blood pressure 122/82, hemoglobin 13.1, urine clear.
Pound|Quantity|69|ADDENDUM to DISCHARGE SUMMARY DISCHARGE MEDICATIONS: Antabuse 250 mg #30 one day. Patient is to follow up with her own doctor for refills.
Pound|Quantity|127|1. Percocet 1-2 p.o. q.4h. as needed for pain (#60). 2. Oxy-Contin 20 mg p.o. q.d. for 2 days then 10 mg p.o. q.d. for 2 days (#12). 3. Senokot S 1-2 b.i.d. while on pain medications for constipation.
Pound|Quantity|292|She has Health Partners insurance and I talked with the patient representative and she is best off is she follows up with urology at the _%#CITY#%_ Park Nicollet Clinic which I am recommending at the time of discharge. I am sending her out with 12 days of Cipro 500 mg p.o. b.i.d. as well as #20 Percocet that she can take one to two q.6.h. as needed.
Pound|Number|172|HOSPITAL COURSE: Mr. _%#NAME#%_ _%#NAME#%_ was admitted. He underwent a left total hip without complication. Postoperatively, he mobilized in therapy. By postoperative day #3, he was stable and ready for. DISCHARGE INSTRUCTIONS: Discharge activity is toe touch weight bear left lower extremity.
Pound|Number|152|Her diet was advanced as tolerated. She was tolerating a regular diet on the day of discharge. Her Foley catheter was discontinued on postoperative day #1, and she was voiding spontaneously. She was started on Macrobid 100 mg b.i.d. from her Foley catheter for the UTI prophylaxis.
Pound|Number|142|PLAN: 1. Right lower extremity ulcers: The patient was previously cultured and treated with Zosyn 3.75 mg for 14 days. He is currently on day #12 - plan to continue that. The patient will be recultured, blood culture will be recultured.
Pound|Number|145|The patient remained normotensive throughout her hospital stay, and so her outpatient hypertensive medications were not changed. On hospital day #3 she did have increased pain in the leg that was operated on, and there was some concern for a clot.
Pound|Number|180|Her pain was adequately controlled with a PCA and On-Q pump, and eventually she was transitioned over to Percocet and Advil. She was tolerating a regular diet by postoperative day #1, was voiding, passing flatus, and ambulating without difficulty.
Pound|Number|197|The patient did have 3 small loose stools as a result of the magnesium citrate, so on hospital day #2, we switched the patient to GoLYTELY in order to aid with her bowel clean out. By hospital day #3, the patient was having a significant amount of both liquid and solid stool as a result of the GoLYTELY.
Pound|Number|138|She was counseled on birth control options. She was breast feeding so opted to try Micronor. She was discharged to home on postpartum day #2 in stable condition with prescriptions for the following medications: 1. Motrin 600 mg p.o. q.6h p.r.n.
Pound|Number|135|The patient's postoperative course was unremarkable. She remained afebrile throughout. She was discharged to home on postoperative day #4. She was ambulating without difficulty and tolerating a general diet.
Pound|Number|225|Of note, this was preintubation. ASSESSMENT AND PLAN: 1. Shortness of breath, acute onset with respiratory arrest requiring mechanical intubation and sedation. 2. Chronic obstructive pulmonary disease, presumed precipitating #1. 3. Hyperlipidemia. 4. Reflux disease. At the present time, the patient is a 76-year-old white female with a history of severe COPD, hyperlipidemia and reflux disease admitted to Southdale with sudden onset of shortness of breath and respiratory arrest.
Pound|Number|108|The patient was transfused 4 units of packed red blood cells. Her lowest hemoglobin was 5.1 on hospital day #1. Posttransfusion her hemoglobin rose to 7.9. The patient tolerated a clear liquid diet.
Pound|Number|288|Surgeon was _%#NAME#%_, anesthesia was epidural. Findings at time of procedure were a viable, 8-pound 13-ounce female in the vertex presentation, Apgars were 8 and 9 with a tight nuchal cord. Her postoperative course was without complication. She was discharged home on postoperative day #3. Risks and restrictions were discussed prior to her discharge. Discharge hemoglobin was 12.5.
Pound|Number|112|FINAL DISCHARGE DIAGNOSES: 1. Squamous cell carcinoma of the base of the tongue, T2 N2 M0. 2. Status post cycle #3 of induction chemotherapy with cisplatin. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 67-year-old male who was recently diagnosed with squamous cell carcinoma of the tongue.
Pound|Number|163|She also had removal of a labial cyst. This went without complications. Her postoperative course was unremarkable and she was discharged home on postoperative day #3 in stable condition. Activity limitations were discussed prior to discharge. She will follow up in two weeks.
Pound|Number|362|The patient tolerated this procedure very well and was transferred to the post-anesthesia care unit and then subsequently to the orthopedic floor where she underwent initiation of physical therapy as well as pain control measures. She was discharged to home with Home Health arranged by Fairview Southdale Hospital social service department on postoperative day #3. She did receive follow-up instructions from Dr. _%#NAME#%_ postoperatively.
Pound|Number|100|The cultures were negative on this, and gram stain was negative. On the next day, postoperative day #7, the patient had her pleural effusions tapped. These also were sterile transudate pleural effusions of unknown etiology.
Pound|Number|269|Estimated blood loss was 800 cc. A healthy female infant was delivered weighing 6 pounds 4 ounces. Postoperatively _%#NAME#%_ did very well. She did have elevated blood pressures and was placed on Aldomet 250 mg t.i.d. DISCHARGE PLAN: She was discharged on post-op day #4 with instructions, precautions, pain pills, home nurse was ordered to visit her and check her blood pressures.
Pound|Number|130|2. Mono-di discordant twin pregnancy, advanced cervical dilatation. 3. Rubella indeterminate. DISCHARGE DIAGNOSIS: Postpartum day #2, status post normal spontaneous vaginal delivery of twin gestation.
Pound|Number|163|Patient's hospitalization was without complication. On postoperative day #3, the patient had 1 or 2 chest tubes pulled without complications. On postoperative day #4, the patient had the remainder of chest tubes pulled, also without complication.
Pound|Number|147|FINAL DISCHARGE DIAGNOSES: 1. E. coli urinary tract infection with suspected urosepsis. 2. Dehydration. 3. Acute renal failure secondary to #1 and #2 and lisinopril, resolved. 4. Non-Q-wave myocardial infarction. Suspect demand ischemia and not primary acute coronary syndrome.
Pound|Number|265|After explanation of the risks, benefits and alternatives to the surgical treatment were explained, an informed consent was obtained and Ms. _%#NAME#%_ underwent the above-mentioned procedures without complication. The specimens sent were #4 right lymph node and a #7 subcarinal lymph node. The findings of frozen section were suggestive of Hodgkin's disease.
Pound|Number|283|Her diet was advanced slowly. She had Jackson-Pratt drains which were stripped, and the outputs diminished appropriately. She was gradually started on a diet and advanced. DISCHARGE PLANS: The patient's pain control improved such that she was discharged to home on postoperative day #5. Instructions were to follow up with me on Thursday. Pain medications included Darvocet p.r.n., and she was to resume her previous home medications.
Pound|Number|231|She delivered a male fetus at 01:28 a.m. on _%#MMDD2004#%_ with Apgar scores of 9 and 9 and a weight of 6 pounds 14 ounces. POSTPARTUM COURSE: The patient developed a postpartum hematoma and a postpartum fever on postoperative day #3. The patient had a urinary culture at that time, which was negative, as well as it was noted that the left edge of her abdominal incision was red and swollen consistent with a large subcutaneous hematoma.
Pound|Number|257|Two days prior to admission, the patient underwent an uncomplicated laparoscopic cholecystectomy for symptomatic cholelithiasis. Other than urinary retention, her postoperative convalescence was unremarkable. She was discharged to home on postoperative day #1 with a Foley catheter in place, and was scheduled to follow-up in clinic on _%#MMDD2004#%_.
Pound|Number|255|EXTREMITIES - with normal pulses, no edema. IMPRESSION: 1. Abdominal pain, probably gastroenteritis, rule out inflammatory bowel disease based on CT findings, although clinical picture certainly does not appear to be that nature. 2. Vomiting secondary to #1. PLAN: Place n.p.o. with allowing ice chips. I.V. fluids, will give analgesics and antiemetics as needed. Will check stool culture.
Pound|Number|222|The patient mobilized her fluids postoperative day #3. The patient was seen by PT and OT, and worked with Physical Therapy. She was ambulating on postoperative day #2. The patient had a bowel movement on postoperative day #7 and was passing gas without difficulty. She had mild distention. She had a J-tube placed in the operating room that was not clamped until postoperative day #10.
Pound|Number|148|He had been on Norvasc 5 mg p.o. b.i.d. at home; however, his high blood pressure had not been controlled. On _%#MM#%_ _%#DD#%_, 2004, hospital day #2, again during his dialysis run he exhibited high blood pressure for which he received nifedipine.
Pound|Number|206|Once the imaging studies were obtained, it confirmed the clinical diagnosis of partial small bowel obstruction. The patient recovered from her pleurodesis well. Chest tubes were pulled on postoperative day #4 without complication. The patient had no negative respiratory sequelae from this. Of note, the patient had biopsy of pleura taken during the time of her pleurodesis.
Pound|Number|91|SURGICAL: Status post excision of an ingrown toenail right great toe. MEDICATIONS: Tylenol #3 p.r.n. ALLERGIES: NO KNOWN DRUG ALLERGIES. FAMILY HISTORY: Unremarkable. SOCIAL HISTORY: The patient lives in _%#CITY#%_ with her husband, who was in hospital recently with Pseudomonas pneumonia.
Pound|Number|123|Her first degree vaginal laceration was repaired in the usual manner. The patient was discharged to home on postpartum day #2. At that time she was complaining of hemorrhoidal pain and multiple remedies were dispensed for this at the time of discharge.
Pound|Number|308|PROBLEM #5: GI: The patient's diet advanced as tolerated. She was treated with antiemetics as needed and prior to discharge she was doing well with her diet. PROBLEM #6: GU: The patient was initially treated with a postoperative Foley catheter, which was discontinued prior to discharge on postoperative day #1 and prior to discharge she was voiding without issues.
Pound|Number|189|There was no evidence of fever or infection. Her pain was well managed with oral medications. The infant did well in addition. Both were stable and ready for discharge on postoperative Day #3.
Pound|Number|237|She was brought to the operating room where a viable female infant with Apgars of 8 and 8 at 1 and 5 minutes respectively was delivered with a weight of 5 pounds and 7 ounces. Her postpartum course was unremarkable. By postoperative day #1, she was feeling better, ambulating, passing flatus, spontaneously voiding and tolerating a regular diet.
Pound|Gauge|206|ALT 102. AST 144. Lipase 66. On the day of admission, Dr. _%#NAME#%_ attempted retrograde catheterization of the left ductal system, this was not possible but the distal left hepatic duct was dilated and a #10 French stent was placed across the duct into the common bile duct with the tip advanced into the duodenum.
Pound|Number|130|She will follow-up in my clinic ten days from the time of discharge for removal of her staples. She was instructed to wear a TLSO #6 at all times when out of bed until her follow-up appointment.
Pound|Gauge|340|Dr. _%#NAME#%_'s evaluation that the patient was a good candidate for mitral valve repair or replacement with left-sided May's procedure with obliteration at the left atrial appendage. She was subsequently taken to the operating room on _%#MMDD2003#%_ and at that time she had an attempted mitral valve repair and then a replacement with a #25 mm St. Jude valve and a modified left-sided May's. Postoperatively _%#NAME#%_ has done extremely well.
Pound|Number|128|The patient was treated with analgesic and respiratory care. An epidural was placed. Patient was dismissed on postoperative day #10. At the time of dismissal, lungs are clear. Chest x-ray showed some atelectasis.
Pound|Number|179|There are no additional rashes. NEURO reveals an active, alert infant with a vigorous cry and normal tone. She has a good suck. ASSESSMENT: A full term female infant, day of life #3, with hyperbilirubinemia, unconjugated. This probably represents normal physiologic jaundice which may be exaggerated by the breast feeding.
Pound|Number|123|He was taken to the operating room and underwent cholecystectomy with acute gangrenous cholecystitis. On postoperative day #1, he had had some fever and was continued on IV antibiotics.
Pound|Number|123|PAST MEDICAL HISTORY: 1. Myasthenia gravis. 2. Left hemidiaphragm paralysis. 3. Respiratory compromise secondary to #1 and #2. 4. Hypothyroidism. 5. ASCVD. 6. Labyrinthitis. 7. Osteopenia/osteoporosis. 8. Agranulocytosis.
Pound|Number|524|REVISED REPORT: CHIEF COMPLAINT: Severe upper respiratory symptoms for eight days with increasing shortness of breath. HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ is a 79-year-old, white male with a history of coronary artery disease, status post AVR for critical aortic stenosis in _%#MM2003#%_, congestive heart failure, atrial fibrillation/flutter in _%#MM2003#%_ prior to his valvular surgery and his bypass surgery, prostate cancer diagnosed in _%#MM2004#%_ and treated with radiation therapy, he is on treatment #35 of RT, elevated cholesterol, macular degeneration, who is being admitted as an unassigned to Fairview Southdale Hospital after presenting with upper respiratory symptoms for eight days and shortness of breath.
Pound|Number|125|He was extubated and has had no further difficulty in terms of respiratory status. 4. Underlying mucopolysaccharide disorder #6. 5. Neurogenic bladder related to mucopolysaccharide disease. The patient was self-cathing at home approximately every 4 hours.
Pound|Number|166|HOSPITAL COURSE: The patient tolerated the procedure well. He was transferred in a stable condition to 6A on the Neurosurgery Service overnight. On postoperative day #1, he was awake and alert. His House-Brackman score was I/VI which it remained for his entire hospital stay and he was deemed ready for transfer to the ENT Service.
Pound|Number|189|She underwent standard physical therapy for full active assisted and passive range of motion, right shoulder, in all planes. She was discharged home in good condition on post-operative day #1. MEDICATIONS: Dilaudid, Vistaril, Senokot and Colace. She will begin outpatient physical therapy today and will continue daily for the first three weeks.
Pound|Number|189|The patient was voiding without difficulty. Hemoglobin stabilized at 11.3 and the patient was tolerating a p.o. diet by post-op day #1. The patient was discharged home on postoperative day #3. She was given Percocet for pain. Hemoglobin was down to 9.2 for a preoperative of 11.3 and this was stable.
Pound|Number|176|HOSPITAL COURSE: On admission, the patient had a creatinine of 4.56, he underwent a decreased donor kidney transplant by Dr. _%#NAME#%_ on _%#MMDD2007#%_. On postoperative day #1, the patient had a transplant kidney ultrasound, which demonstrated pelviectasis of the renal transplant without evidence for hydronephrosis.
Pound|Number|86|She is to follow-up with her primary at Park Nicollet. DISCHARGE MEDICATIONS: Tylenol #3 one to two tablets p.o. q.4.h. p.r.n. Vicodin 5/500 1-2 tablets q.6.h. p.r.n. Hydroxyzine 25 mg p.o. t.i.d. p.r.n. Bactrim DS one b.i.d. to be stopped after the second dose on _%#MMDD2003#%_.
Pound|Number|403|Since she did receive her rituximab at _%#MMDD2005#%_ at midnight the patient's ICE part of the chemotherapy was started in the afternoon of _%#MMDD2005#%_ and continued through _%#MMDD2005#%_. The patient receive etoposide 190 mg q. day on days 2, 3, and 4, as well as carboplatin with an AUC of 5, so she received 700 mg on day 3, as well as ifosfamide 5000 mg/MSQ mixed with MESNA 5000 mg/MSQ on day #3 for 24 hour infusion. The patient received the appropriate related antiemetic drugs, as well as allopurinol for 10 days, Compazine, Zofran, and Ativan.
Pound|Number|202|It is not painful. IMPRESSION: Mononucleosis with vomiting and dehydration. PLAN: Admit her for IV fluid rehydration. Will control nausea with Zofran if needed and pain with either ibuprofen or Tylenol #2. I will check her electrolytes upon admission and again tomorrow morning.
Pound|Number|200|Mr. _%#NAME#%_ underwent a distal pancreatectomy for pancreatic cancer 1 year ago and now presents with a growing nodule in his pulmonary ligament. His hospital course was unremarkable. On postop day #1, the patient was ambulating without assistance. His chest tube was removed and a chest x-ray was reviewed.
Pound|Number|390|2. Echocardiogram performed on _%#MMDD2006#%_ demonstrated normal global LV systolic function, mild LV dilation, mild aortic dilation with a size of 4 cm and no significant valvular disease. 3. Coronary angiography performed on _%#MMDD2006#%_ demonstrated two-vessel coronary artery disease with percutaneous interventions performed in proximal RCA with bare-metal stent and acute marginal #1 with drug-eluting stent. Please refer to the catheterization report for further details. CONSULTATIONS: None.
Pound|Number|154|DISCHARGE INSTRUCTIONS: 1. _%#NAME#%_ has to follow up with her primary care physician, Dr. _%#NAME#%_ _%#NAME#%_ at Amery Regional Medical Center, phone #_%#TEL#%_, in one week for weight check and complete blood count with differential and platelets.
Pound|Number|130|Over the next 2 days he was somewhat labile and slow to wean from his pressors. He was however able to be extubated on postop day #1. He did complain of a shortness of breath and nonproductive cough.
Pound|Number|206|Please see operative report for details. Postoperatively, she was placed into a CPM within her brace, which was unlocked for motion. She received 24-hours of perioperative antibiotics. On postoperative day #1, she was converted to oral pain medications and she tolerated well.
Pound|Number|92|In addition, he met with occupational therapy to avoid deconditioning. On postoperative day #1, Mr. _%#NAME#%_ underwent an upper GI study, which showed no leak and was started on a clear liquid diet.
Pound|Quantity|279|The patient will be instructed to call the University of Minnesota Medical Center at _%#TEL#%_ if there is any signs of increased drainage, pain or swelling or an elevated temperature of 101.5 or higher. The patient will be discharged on Percocet 1-2 tabs p.o. q.4h. p.r.n. pain #60.
Pound|Number|111|2. History of coronary artery disease, deemed to be a candidate for medical management. 3. Anemia exacerbating #1, suspect postoperative secondary to total knee arthroplasty.
Pound|Quantity|123|2. Percocet one to two p.o. q.4-6h (#80). 3. Vistaril 25 to 50 p.o. q.4-6h p.r.n. (#60). 4. Senna two tablets p.o. b.i.d. (#60). 5. Colace 100 mg p.o. b.i.d. (#60).
Pound|Number|82|He was on Lovenox for DVT prophylaxis while in the hospital. By postoperative day #4, the patient was afebrile. Vital signs were stable. He was tolerating a regular diet.
Pound|Number|281|Transfusion was offered at that time, but declined. The following morning at 7 a.m., on _%#MMDD2006#%_, she was a bit more symptomatic and her hemoglobin was 5 after equilibration. She received 2 units of packed red blood cells and her hemoglobin came up to 8.3. On postpartum day #3, on _%#MMDD2006#%_, her hemoglobin was 6.9. She was clinically stable and was discharged home ambulating without difficulty and tolerating a general diet.
Pound|Number|127|He was initially placed on FFP infusion at 50 mL an hour, and his hepatic function seemed to correct. So, on postoperative day #2, he was off the FFP drip, and his synthetic function was able to maintain an INR of a normal range.
Pound|Number|109|He had volume overload and poor inspiratory effort, probably secondary to being sleepy. By postoperative day #4, the patient was making good progress, the chest tube loss was minimal, there was no air leak, and the chest tubes were removed without problem.
Pound|Number|85|Prednisone was also continued, and he received half dose Thymo. On postoperative day #3, the patient was continuing to do well. His On-Q pain pump was removed. Immunosuppression was given including FK.
Pound|Quantity|135|DISCHARGE MEDICATIONS: 1. Percocet 5/325 tabs 1-2 tabs p.o. q. 4 hours p.r.n. for pain #80. 2. OxyContin 20 mg p.o. b.i.d. for 10 days #20. 3. Cleocin 300 mg p.o. t.i.d. 4. Aspirin 325 mg p.o. q. day for 6 weeks.
Pound|Number|96|Chest x-ray was negative as well. The patient's LFTs were within normal limits. On hospital day #1, she was doing well. Her tube feeds were restarted. Her methadone was increased to 30 mg p.o. q. 8h. for her increased right upper quadrant pain.
Pound|Number|200|11. Zoloft 25 mg p.o. q.p.m. PAST MEDICAL HISTORY: 1. The patient has history of chronic renal disease and is status post living-related kidney transplant in _%#MM2006#%_. 2. colostomy on day of life #2. 3. Agenesis of bladder and urethra. 4. History of nephrogenic diabetes insipidus.
Pound|Number|158|2. Renal: The patient's creatinine at clinic on admission was 1.1. She was given IV fluids and her creatinine did decrease, but slowly. Her creatinine on day #2 of hospital stay was 1.02 and on _%#MMDD2007#%_, it was 1.01. On the day of discharge, creatinine was 0.96. Since her creatinine had only fallen slowly, it was recommended that she pursue a renal biopsy.
Pound|Number|169|10. General anesthesia. COMPLICATIONS: 1. Intraoperative bradycardia prompting cardiology consult and workup. 2. Postoperative ileus which resolved on postoperative day #4. HISTORY AND PHYSICAL: Please see the office H&P dictated on _%#MMDD2007#%_ by Dr. _%#NAME#%_ _%#NAME#%_ under Dr. _%#NAME#%_ _%#NAME#%_.
Pound|Number|130|FINAL DATE OF ADMISSION: _%#MMDD2007#%_ DATE OF DISCHARGE: _%#MMDD2007#%_ HISTORY OF PRESENT ILLNESS: _%#NAME#%_ _%#NAME#%_ (Baby #2) is the product of a pregnancy complicated by twin gestation and premature delivery at 34-2/7 weeks. He was born to a 21-year-old mother whose status was gravida 1, O positive, hepatitis B surface antigen negative and Group B Strep unknown.
Pound|Quantity|154|Motor strength is intact to all nerve distributions. Dressing is clean, dry and intact. DISCHARGE MEDICATIONS: 1. Percocet 1-2 tabs p.o. q. 4-6h. p.r.n., #80 with no refills. 2. Colace 100 mg p.o. b.i.d. 3. Vistaril 25-50 mg p.o. q.4-6h. p.r.n. DISCHARGE INSTRUCTIONS AND FOLLOWUP APPOINTMENTS: The patient is discharged to home, nonweightbearing left upper extremity, sling on at all times except for excercises 4 times daily.
Pound|Number|138|Plan at the present time is I.V. fluids with following of his electrolytes and his BUN and creatinine. 2. Dehydration related to probably #1. Again, plan is for I.V. fluids. 3. Adult-onset diabetes which appears to be under decent control.
Pound|Number|146|He received physical therapy crutch training prior to his discharge. He is to keep the incision clean and dry. He may shower on postoperative day #3. He is instructed not to be in a bath or pool until the wound is healed or a minimum of 2 weeks postoperatively.
Pound|Number|217|Please see operative note for further details. Postoperatively, the patient did fairly well. He was able to be extubated on postoperative day #1 and the intra-aortic balloon pump was also removed on postoperative day #1. He continued to have issues with right heart failure requiring continuation of Nesiritide, Milrinone and __________ drips.
Pound|Number|194|PLANNED ANESTHESIA: General anesthesia. INDICATIONS FOR OPERATION: _%#NAME#%_ _%#NAME#%_ is a 61-year-old woman, referred by her general dentist, Dr. _%#NAME#%_ _%#NAME#%_, for removal of tooth #17 and 18. PAST MEDICAL HISTORY: The patient's past medical history is significant for: 1. Hypertension.
Pound|Number|164|The patient tolerated this procedure without complications. She was transferred to the surgical intensive care unit for overnight observation. On postoperative day #1, the patient continued to do well, was transferred from the surgical intensive care unit to the general neurosurgical floor.
Pound|Quantity|116|She will continue taking her multiple vitamins while breast- feeding. She will be given a prescription for Percocet #30 tablets for incisional discomfort.
Pound|Number|187|The patient had an intraoperative drain placed which was stable with small amounts of serosanguineous drainage. The patient is discharged to home in stable condition on postoperative day #2. Her incision site is clean, dry, and intact without any drainage or erythema.
Pound|Number|210|Postoperatively, she had a drop in hemoglobin to 6.6 and was transfused 2 units and her hemoglobin came up to 8.8. On _%#MMDD2006#%_, her hemoglobin was up to 10.9. She is here today primarily for two reasons. #1. She stated that she developed vaginal bleeding. On closer questioning, she also had a small amount of blood on the toiler paper when she got up to urinate.
Pound|Number|178|She had an EKG which was negative and serial troponins which were negative x2. This chest pain and shortness of breath had completely resolved spontaneously by postoperative day #3. The patient's Foley was discontinued on postoperative day #1, and she was voiding without difficulty prior to discharge.
Pound|Gauge|154|She was sent home on suction devices for home use. The Penrose drains were discontinued on postoperative day #4. _%#NAME#%_ was changed over to a Jackson #5 on postoperative day 3. Her tube feeds were at goal and bolus. She was ambulating without difficulty and postoperative day #7, she was deemed an appropriate candidate for discharge.
Pound|Number|251|The patient remained on the floor for the next four days and was afebrile throughout her entire stay. The patient had large quantities of urine the first two days while in hospital up to 12 liters and began tolerating a p.o. diet on postoperative day #2. The patient's Foley was removed on postoperative day #3 and she was having normal voiding patterns at that time.
Pound|Number|132|Her postoperative course was uncomplicated. The infant did well upon birth. The patient was discharged to home on postoperative day #4 with her infant. She will follow-up to the _%#NAME#%_ _%#NAME#%_ OB-GYN Clinic for routine postoperative care.
Pound|Number|141|The patient initially presented with a 3- month history of vaginal spotting. 2. History of frequent UTI's and kidney infections secondary to #1. 3. History of hypertension. 4. History of chronic diarrhea secondary to radiation.
Pound|Quantity|130|Social work assisted with arranging home physical therapy. DISCHARGE MEDICATIONS: 1. Vicodin 1-2 tablets p.o. q.3-4h. p.r.n. pain #25 2. Norvasc 10 mg tablets p.o. daily. 3. Tenoretic 50/25 mg 1 tablet p.o. daily.
Pound|Number|224|Postpartum course was unremarkable by postoperative day #2. The patient was feeling well, ambulating, tolerating a regular diet, voiding spontaneously, passing flatus. The patient was discharged to home on postoperative day #3 with medications that included Percocet, ibuprofen and stool softener.
Pound|Quantity|83|8. Ambien 10 mg p.o. each day at bedtime. 9. Oxycodone 10 mg p.o. q.a.m., dispense #30, no refills. 10. Synthroid 100 mcg p.o. q. day. 11. Lidoderm patch 5%, 1 patch q. 12h. on and 12 hours off.
Pound|Number|269|The patient's postoperative care was uneventful. Hematology/Oncology was consulted and the patient was set up for an outpatient consultation with Dr. _%#NAME#%_ two weeks after discharge. He did not have an air leak in his chest tubes were removed on postoperative day #4. He had no evidence of pneumothorax on chest x-ray and he was having good O2 saturations in the 96 percentile on room air.
Pound|Number|143|He was started on a clear liquid diet. His JP drains were sent for amylase. These were normal and his drains were removed on postoperative day #5. The patient did have a small amount of blistering along his incision site and there was no sign of fluctuance or erythema nor any purulent drainage.
Pound|Number|219|Please see a copy of the patient's medical consultations for further medical details. The patient was treated with routine physical therapy rehabilitation for a knee arthroplasty and was discharged on postoperative day #3 to a skilled nursing facility for further assisted care.
Pound|Number|77|DISCHARGE MEDICATIONS: 1. Tylenol 325 mg p.o. q.4 h. p.r.n. pain. 2. Tylenol #3 one tablet p.o. q.4 h. p.r.n. pain. The parents were instructed not to give more than 6 doses of Tylenol in the course of 24 hours.
Pound|Quantity|436|DISCHARGE INFORMATION: 1. Discharge date: _%#MM#%_ _%#DD#%_, 2005. 2. Discharge diagnosis: Sickle cell disease. 3. Discharge medications: Folic acid 1 mg p.o. q. day; penicillin VK 250 mg p.o. q.12 h.; vitamin C 250 mg p.o. daily; Dulcolax 10 mg p.o. b.i.d. to be used until stool is soft and/or presence of stool, do not crush or chew tabs; and Desferal 1500 mg subcutaneous over 10 hours with 10 mg of hydrocortisone in each syringe, #30 syringes. 9. Followup: _%#NAME#%_ is supposed to follow up with the heme clinic per scheduled visit.
Pound|Number|164|His hospital stay was very unremarkable. On postoperative day #1, the patient was able to ambulate. Therefore, his Foley catheter was removed. On postoperative day #2, a bowel regimen was given to the patient. He subsequently had a bowel movement. Therefore, his diet was advanced from a clear liquid diet gradually to a regular diet on the day of his discharge.
Pound|Quantity|113|4. Senna S 2 tablets p.o. each day at bedtime while on narcotics #60. 5. Flexeril 10 mg p.o. t.i.d. p.r.n. spasm #60. 6. Vicodin 5/500, 1-2 tablets p.o. q. 6h. p.r.n. pain #40.
Pound|Number|245|The patient clinically continued to improve and the patient even though remaining NPO was consistently walking and her abdominal pain slowly decreased. On postoperative day #9 the patient was begun on clear liquid diet and on post operative day #10 started a full liquid diet, all of which the patient tolerated.
Pound|Number|165|2. Pre-eclampsia. 3. GDMA-1. 4. Obesity. DISCHARGE DIAGNOSIS: 1. 35 year-old G-1 P-0 at 37 + 6 weeks. 2. Pre-eclampsia. 3. GDMA-1. 4. Obesity. 5. Post-operative day #4 from primary cesarean section. PROCEDURE: Primary low transverse cesarean section. HISTORY: _%#NAME#%_ _%#NAME#%_ is a 35-year-old G-1 P-0 with an EDC of _%#MMDD2007#%_, who was admitted at 37 + 6 weeks for induction of labor.
Pound|Number|219|Pain was well controlled. The patient was feeling well and feeling ready to go home. The patient remained afebrile with stable vital signs throughout her stay and was felt to be ready for discharge on postoperative day #2. DISCHARGE INSTRUCTIONS: The patient is to not lift anything greater than 10 pounds for 6 weeks.
Pound|Number|224|PROCEDURE: Intramedullary rodding of the right femur. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ was admitted through the emergency room and taken to the operating room the next day. Postoperatively, she did well. On postop day #2 arrangements were made for her to be discharged to home on postop day #3.
Pound|Number|208|HOSPITAL COURSE: The patient's hospital course was uncomplicated. She was advanced to a regular diet without difficulty. She remained afebrile throughout her stay and was discharged home on postoperative day #3 with instructions to follow up in 2 weeks for postoperative check, and in 6 weeks for a postpartum check.
Pound|Number|178|The hemoglobin on postoperative day #2 was 12.4. The patient was slow to rehabilitate plus with home issues was deemed a candidate for discharge to rehabilitation. On postop day #3 the patient had no other issues and was cleared for discontinued rehabilitation.
Pound|Number|191|Following delivery the patient was continued on magnesium sulfate for 12 hours. Her blood pressures improved. Both infant and mother did well and both were released home on postoperative day #3.
Pound|Quantity|165|Discharge examination was negative. DISCHARGE MEDICATIONS: 1. Motrin 600 mg every 6 hours for pain. 2. Percocet 1-2 to be used every 4-6 hours for more severe pain, #30. She was advised to return to the obstetric clinic 6 weeks following discharge, sooner should any problems develop prior to that time.
Pound|Number|192|Presurgical orthodontics has been done by _%#NAME#%_ _%#NAME#%_, DDS orthodontist, to align the teeth in maxillary and mandibular skeletal structures. In addition, we will remove third molars #1, 16 and 17. Risks, benefits, options of treatment including no treatment have been discussed.
Pound|Quantity|130|DISCHARGE FOLLOW-UP: He should return for follow-up in approximately two weeks time. DISCHARGE MEDICATIONS: Percocet and received #50 of those.
Pound|Quantity|188|DISCHARGE INSTRUCTIONS: She was instructed to return to the office in six weeks for follow-up examination. Routine discharge instructions were given as well as a prescription for Percocet #25 as needed for pain.
Pound|Number|116|Ms. _%#NAME#%_ was admitted to the floor and on _%#MMDD2003#%_ underwent ORIF of the left hip. On postoperative day #3, she dropped her hemoglobin to 8.4 due to a bleed into her left thigh.
Pound|Quantity|163|Then after that time frame, the Steri-Strips can get wet, and they will fall off independently. DISCHARGE MEDICATIONS: 1. Vicodin 1-2 tablets q.4-6h. p.r.n. pain (#61). 2. Decadron 1 mg b.i.d. x 3 days, then discontinue.
Pound|Number|430|After exhausting conservative treatment including intra-articular joint injections and nonsteroidal anti-inflammatories the patient agreed and consented to a routine left total hip arthroplasty. Mr. _%#NAME#%_ was prophylactically anticoagulated with 7.5 mg of Coumadin the night prior to surgery and his perioperative course was uneventful with the implantation of a cementless Biomet acetabulum and a cemented Richards Spectron #1 femoral component. Please see copy of Mr. _%#NAME#%_'s medical consult for further details.
Pound|Number|86|She had difficulty with nausea and was switched to Dilaudid pCa. On postoperative day #2, her pCa was discontinued, and she was switched to p.o. pain medications without difficulty.
Pound|Quantity|105|7. Ativan 0.5 mg b.i.d. 8. Norvasc 5 mg daily. 9. Percocet 1-2 tablets every 4 hours as needed for pain, #30 dispensed with no refills. 10. Zanaflex 4 mg t.i.d. as needed for headaches, #90 dispensed with no refills.
Pound|Number|22|FINAL REVISED ACCOUNT #/_%#NAME#%_/_%#NAME#%_ This is a discharge summary from the cath lab. DISCHARGE DIAGNOSES: 1. Atrial fib/flutter status post heart biopsy.
Pound|Number|177|Her hemoglobin was 9.5 and she was asymptomatic. On postoperative day #2, she reported some nausea with p.o. Percocet for pain and was switched to Vicodin. On postoperative day #3, she was doing well, ambulating, eating and voiding without difficulty.
Pound|Number|143|The patient will be discharged home with a PICC line and IV vancomycin. 1. Follow up with Orthopedic Surgery at Dr. _%#NAME#%_'s office, phone # _%#TEL#%_ in 1 weeks& time. 2. Follow up with Infectious Disease, Dr. _%#NAME#%_, in 1 week's time for the IV antibiotics.
Pound|Number|184|This will need further titration as an outpatient. She was having significant pleuritic pain, and this has fortunately completely resolved. She will be treated with Tylenol or Tylenol #3 as needed. 2. Mallory-Weiss tear. The patient developed some nausea during her hospital stay and subsequent vomiting.
Pound|Number|200|Her postoperative course was smooth. She underwent sterile dressing changes and nonweightbearing therapy protocol. She was transferred to _%#CITY#%_ Care Center in good condition on postoperative day #3/5. Instructions are for clinical follow-up in 2 weeks for repeat AP and lateral radiographs of the left tibia/fibula at that time.
Pound|Number|197|The patient's baby boy remained with her during the hospital stay and had no problems. He was circumcised prior to being discharged. Both were discharged home in stable condition on postpartum day #2. DISCHARGE INSTRUCTIONS: Follow up in six weeks for postpartum check or sooner if needed.
Pound|Number|170|This was thought secondary to some postop ATN. This resolved without any aggressive intervention. The patient was transferred to a regular floor bed on postoperative day #5. The patient during his hospitalization had his mediastinum and LVAD pump pocket wound irrigated with vancomycin and normal saline.
Pound|Quantity|108|DISCHARGE MEDICATIONS: 1. Dilaudid 2 mg po 1-2 4-6 hours prn pain, #40. 2. Robaxin 750 mg po tid prn spasm, #60. 3. Decadron 2 mg po bid, #6 with no refills.
Pound|Number|131|4. Depression. 5. History of reflux. 6. Degenerative joint disease. DISCHARGE DIAGNOSES: 1. Upper GI bleed. 2. Anemia secondary to #1. 3. Dementia. 4. Reflux. 5. Old ulcer. 6. Osteoarthritis.
Pound|Number|259|She had failure to progress and underwent a primary low-segment transverse cesarean section delivering a viable female infant weighing 6 pounds 15 ounces with Apgars of 8 at 1 minute and 9 at 5 minutes. The patient did well and went home on postoperative day #4. She will follow-up to the _%#NAME#%_ _%#NAME#%_ OB/GYN Clinic for routine postoperative cares.
Pound|Number|191|Bilirubin 0.8. Troponin negative. Electrocardiogram is unremarkable. HOSPITAL COURSE: PROBLEM #1: Food poisoning. The patient was treated with hydration and symptomatic support. Hospital day #2 the patient felt better and was tolerating p.o. intake.
Pound|Number|100|She tolerated the procedure well and had an unremarkable postoperative course. On postoperative day #4 she underwent an upper GI study to evaluate the integrity of the anastomosis.
Pound|Number|238|On postoperative day #2 her pain was well controlled. She was having some gas pain, but was otherwise ambulating and eating well. The pain was well controlled on oral pain medications. Her hemoglobin returned at 9.5. On postoperative day #3 she was doing well and desired discharge. She was discharged to home in good condition on postoperative day #3.
Pound|Quantity|123|He told me that Naprosyn causes some constipation, so he can try a stool softener also. He was given Percocet 5 mg tablets #30 that he can take 1-2 tablets every 4-6 hours as needed.
Pound|Number|170|Please see the operative report for details of the procedure. _%#NAME#%_'s pain control was obtained with a morphine PCA, he was easily transitioned on postoperative day #2 to oral Percocet and Flexeril. He was also maintained on IV fluids until his p.o. intake was adequate.
Pound|Quantity|110|MEDICATIONS ON DISCHARGE: Include his home medications along with: 1. Percocet 1-2 p.o. q.4-6 h. p.r.n. pain, #80. 2. Lovenox 40 mg subcutaneous daily x2 weeks. He will see Dr. _%#NAME#%_ in consultation this Friday, which will be set up by our office.
Pound|Number|189|On postoperative day #1, she was weaned off the PCA and started on Darvocet and ibuprofen. She continued to have very minimal pain. Her Foley catheter was discontinued on postoperative day #1 and she started voiding spontaneously that day and continued to void spontaneously at the time of discharge.
Pound|Number|189|She made rapid progress eating, voiding, ambulating and was able to accomplish these activities without difficulty at the time of discharge. She was discharged to home on postoperative day #2 with the following medications: Percocet 1-2 tablets p.o. q 4-6 hours p.r.n. for pain.
Pound|Number|156|A TLC consult was performed, who recommended increasing the patient's Celexa dose and adding p.r.n. Zyprexa. She did try Zyprexa during the day time on day #3 of hospitalization, which caused somnolence. At that point it was determined that she should only take the Zyprexa at nighttime, which she agreed to.
Pound|Number|260|The patient is a 49-year-old who was admitted on _%#MMDD2002#%_ and discharged _%#MMDD2002#%_. Diagnosis at the time of discharge is that of rehabilitation for multiple sclerosis, convulsive disorder secondary to #1, severe cognitive difficulties secondary to #1, ongoing problems with amenorrhea, and a terrible social situation.
Pound|Quantity|130|The patient is being discharged to be seen in the office in 10-14 days. DISCHARGE MEDICATIONS: Percocet 1-2 q.4-6.h. p.r.n. pain, #30, and Augmentin 875 mg b.i.d. for 10 days. He will of course call sooner should he have any problem with his wound or any fever.
Pound|Number|155|Estimated blood loss at the time of surgery was 750 cc. The patient's postoperative course was uncomplicated. She was discharged home on postoperative day #4. On that day, she was afebrile, and vital signs were stable.
Pound|Number|125|He was given Amiodarone and Metoprolol with resolution of his atrial fibrillation. Also, on the evening of postoperative day #1, the patient was noted to have a decreased level of consciousness.
Pound|Number|211|The patient does have decreased appetite. See chart record for remaining history, review of systems, past medical history, social history, and family history. ALLERGIES: Penicillin. HOME MEDICATIONS: 1. Tylenol #3 one tablet p.o. q.h.s. 2. Spironolactone 25 mg p.o. q.d. 3. Lovenox 0.73 cc of the 150 gm solution b.i.d.
Pound|Number|100|DISCHARGE MEDICATIONS: 1. Enoxaparin 110 mg subcu b.i.d. 2. Estradial 250 mg p.o. b.i.d. 3. Tylenol #3 one tablet p.o. q.h.s. p.r.n. 4. Lactulose 30 mL p.o. q.d. 5. Spironolactone 25 mg p.o. q.d.
Pound|Number|145|MEDICATIONS: 1. Ferrous sulfate 325 mg p.o. t.i.d. 2. Prinzide 10/12.5 one tablet p.o. q. day 3. Multi-vitamin 4. Norethindrone daily 5. Tylenol #3 p.r.n. PHYSICAL EXAMINATION: VITAL SIGNS: The patient is afebrile.
Pound|Number|112|HOSPITAL COURSE: Problem #1. GI. The patient was initially managed conservatively and kept NPO. By hospital day #2, she had started to feel better and started passing stools and flatus.
Pound|Number|144|The patient, on postoperative day #1, was afebrile with stable vital signs, tolerating a regular diet, and advancing well. On postoperative day #2, the patient continued to advance. Postoperative hemoglobin was 10.8. She was tolerating a regular diet, had positive flatus, was breast feeding her infant, and pain was well controlled with p.o. pain medicine.
Pound|Number|802|DISCHARGE MEDICATIONS: Include the medications which were being taken prior to admission which are hydrochlorothiazide 25 mg p.o. q.d., aspirin 325 mg p.o. q.d., glipizide XL 5 mg p.o. q.d., Glucophage 500 mg p.o. q.d., Vasotec 5 mg p.o. q.d., atorvastatin or Lipitor 20 mg p.o. q.d., calcium 500 mg p.o. b.i.d., and Fibercon 6 tablets p.o. q.d. New medications will include Augmentin 875 mg p.o. b.i.d. x 7 days, Colace 100 mg p.o. b.i.d., lansoprazole 30 mg p.o. q.d., Miralax 1 teaspoon in 8 ounces of water p.o. every third day to start on the _%#DD#%_ of _%#MM#%_, and finally Percocet 5/325 1-2 p.o. q.4h. p.r.n. for pain. HOSPITAL COURSE: CAT scan on admission showed diverticulosis without evidence of perforation, and after antibiotic initiation, the patient was without fever by hospital day #2. The remainder of her hospital course was uneventful, as she remained n.p.o. for several days, and then was able to pass stool, and then was able to be advanced to a clear liquid diet which was well tolerated, and continued to pass stool.
Pound|Quantity|142|She may resume her regular home diet. She was given the following medications. DISCHARGE MEDICATIONS: Vicodin 1 to 2 tabs p.o. q.4-6h. p.r.n. #40, 1 refill. FOLLOW UP: She is to follow up with Dr. _%#NAME#%_ in 4 weeks& time or before then if she has any further questions or concerns.
Pound|Number|145|Pain control became an issue for the patient as she had been on a long-term course of Vicodin and narcotics preoperatively. On postoperative day #3, the patient stated her anterior thigh numbness resolved.
Pound|Gauge|179|She spent the first night in the intensive care unit and following day was transferred to the floor. By the second postoperative day, her cuff tracheostomy tube was replaced with #6 cuffless tube without difficulty. She was started on a liquid diet and was slowly advanced to a soft diet.
Pound|Quantity|281|Should she have any problems with increased drainage, increased swelling, increased pain, or elevated temperature greater than 102, she should call our office immediately. DISCHARGE MEDICATIONS: The patient will be sent home with Percocet 1 to 2 tabs p.o. q.4-6h. p.r.n. for pain, #30, no refills.
Pound|Number|211|She also was noted to have some difficulty eating and, combining this with the pruritus and the burning sensation in the incision, the decision was made to keep her for an additional postop night. On postop day #4, she was doing better. She still had the pruritus, but she was having flatus and bowel movements.
Pound|Number|164|During his hospital stay, he had a CT scan of the abdomen and pelvis, and he had no evidence of metastatic disease. The patient was discharged on postoperative day #6, tolerated a regular diet, and was having formed bowel movements.
Pound|Quantity|227|His wound is healing satisfactorily. He has been instructed in care of his wound, physical activity, diet, and follow-up. The discharge medications are Augmentin 875 mg b.i.d. for seven days and Vicodin 1-2 q.6.h. p.r.n. pain, #40.
Pound|Number|116|2) FEN: Initially n.p.o. on IV fluids. Hyperalimentation from day of life #2 through #5. NG feeds until day of life #14 when she tolerated p.o. well. She roomed in with her mother and breast fed on demand for 24 hours before discharge with good weight gain during that period.
Pound|Number|295|_%#NAME#%_'s blood cultures obtained here at Fairview- University Medical Center were all negative at the time of hospital discharge. _%#NAME#%_ was initially continued on ceftriaxone on hospital day #1, however, was changed to intravenous penicillin and intravenous clindamycin on hospital day #2. The IV penicillin was continued until the day prior to hospital discharge.
Pound|Number|177|This could be weaned after only one day as his pulmonary hypertension resolved. His RDS gradually improved with respiratory ventilatory support. He remained intubated until DOL #7, when he could be weaned off the ventilator and extubated without problem (_%#MMDD2003#%_).
Pound|Number|153|Psych was consulted because of concern for possible conversion disorder in patient. Psych assessment by Dr. _%#NAME#%_ _%#NAME#%_ on _%#MMDD2003#%_ was, #1, conversion disorder likely; #2, rule out complicated bereavement; #3, rule out somatization disorder.
Pound|Number|128|2. Pancytopenia presumed secondary to Imuran therapy. We will discontinue Imuran. 3. Anemia, status post transfusion related to #2. 4. Urinary tract infection, resolved with 3 days of IV antibiotic therapy.
Pound|Number|258|The patient does report symptoms with this. She states that she has noted increase in shortness of breath throughout the pregnancy, some dyspnea on exertion including shortness of breath with walking to the bathroom or up a flight of stairs. On hospital day #2, the patient's magnesium was discontinued following her second dose of betamethasone.
Pound|Number|193|HOSPITAL COURSE: Mr. _%#NAME#%_ _%#NAME#%_ is a 32-year-old who was admitted to the inpatient ward on 55 following uneventful surgery. His postoperative course was smooth. On postoperative day #1, he was tolerating oral pain medication and a general diet.
Pound|Number|97|Her hemoglobin postpartum was 8.9. Patient is asymptomatic, and pain is controlled. Hospital day #4, patient has no complaints. She is ambulating. Reports positive bowel movements. She is pumping her breasts.
Pound|Quantity|84|2. Hydrochlorothiazide 12.5 mg p.o. q. day. 3. Oxycodone 5 mg p.o. q. 4 to 6 p.r.n. #25, to be given with the patient. 4. She may take Tylenol 1 to 2 tablets Extra Strength p.o. q. 6 p.r.n. pain.
Pound|Number|147|The patient's operative course was uncomplicated. His postoperative course remained uncomplicated, as well. He was discharged on postoperative day #2 with a Foley catheter in place and draining well.
Pound|Number|103|She continued to do remarkably well, and her diet was advanced to a regular diet. On postoperative day #3, she continued to do well, with no signs of CSF leak.
Pound|Number|160|The patient was continuing to breast feed. On the day of discharge, contraception was discussed with the patient and the patient declined. By postoperative day #4, the patient's vital signs were stable and her incision was clean, dry and intact.
Pound|Number|189|The patient's postoperative course was unremarkable. After his continent neoappendicostomy procedure, the patient had adequate pain control, and had increased activity by postoperative day #3. He was tolerating a regular diet, and did not have issues with nausea or vomiting.
Pound|Number|153|After the procedure the patient was taken to the surgical intensive care unit for observation overnight. He did well. On the morning postoperatively day #1 he was transferred to the general surgical floor.
Pound|Number|215|After appropriate preoperative medical and surgical evaluation, she was taken to the operating room where the hip was fixed with cannulated screws. She did very well postoperatively. Hemoglobin on postoperative day #1 was 10.5, on postoperative day #2 it was 10.9, and she tolerated this very well.
Pound|Number|137|IMPRESSION: 1. Probable acute gastroenteritis with nausea, vomiting, diarrhea, and some dehydration. 2. Significant malaise secondary to #1. 3. Cough paroxysms, probably secondary to asthmatic bronchitis. 4. Fatigue secondary to her illness and cough paroxysms.
Pound|Number|86|He was found to have diverticulitis. He was started on IV Flagyl and IV Cipro. By day #2 he had already markedly decreased pain. We did obtain a dietary consult. We did advance his diet to clear liquids and then to a regular diet by _%#MM#%_ _%#DD#%_, 2005.
Pound|Number|208|Thereafter, she had no air leak and improved consistency of ventilation. Postoperatively, she did have some discomfort, which was treated with a fentanyl drip overnight as well as p.r.n. On postoperative day #1 she was changed to p.r.n. morphine. On postoperative day #1, her OG feedings were restarted, along with her oral electrolyte replacements.
Pound|Number|231|She has had some slight vomiting as well. She has been having 3-4 bouts daily of loose stool. She notes anorexia, fatigue, and weakness. A month ago she was placed on a 10-day course of clindamycin for an infected tooth and on day #7 the diarrhea started. She notes that currently the toe is not painful and she does not require any medications for pain.
Pound|Number|141|The patient was monitored on the floor following this procedure and continued to advance along an uncomplicated course. By postoperative day #1, the patient was passing flatus and was advanced to clear liquid diet.
Pound|Number|250|Blood sugars ranged from 40 to 80 during the first 11 days of life at _%#CITY#%_ Memorial Hospital. She remained asymptomatic throughout these hypoglycemic episodes. IVF were gradually decreased as feeds were introduced, and were discontinued on DOL #8. Because of persistent hypoglycemia, _%#NAME#%_ was transferred for further evaluation.
Pound|Number|198|The patient was able to be weaned and extubated without difficulty. The patient had frequent neurological checks, which were unchanged, the patient was transferred to the floor on postoperative day #3 after clinical improvement in the SICU. While on the floor the patient continued to improve. PROBLEM #3: Pulmonary edema: The patient showed signs of pulmonary edema for which he was diuresed with good response.
Pound|Quantity|108|DISCHARGE PLANS: Instructions were given. The patient is to follow up in six weeks. She was given Percocet (#60).
Pound|Number|151|The patient was consulted to undergo blood-brain barrier disruption chemotherapy. The patient presents for blood-brain barrier disruption chemotherapy #6. PAST MEDICAL HISTORY: Includes only a tonsillectomy as a child and seizure disorder related to his brain tumor.
Pound|Number|103|PAST MEDICAL HISTORY: 1. Obesity. 2. Gastric bypass surgery in 2001. 3. Incisional hernia secondary to #2. 4. Periumbilical hernia. BMT WORK-UP: 1. Virology. CMV, EBV, HSV positive.
Pound|Number|614|He was mildly coagulopathic with an INR of 1.9 and fibrinogen of 302, for which he received FFP. His diagnoses on admission were: 1) 4 day old premature IUGR infant with corrected gestational age of 345/7 weeks 2) NEC with perforation, surgical consult obtained 3) Metabolic acidosis secondary to #2, corrected with respiratory and fluid support 4) Respiratory failure secondary to #2, requiring ventilatory support 5) Hypotension secondary to #2, requiring fluid support 6) Potential for sepsis secondary to #2, with clindamycin added to the antibiotic therapy for anaerobic coverage 7) Coagulopathy secondary to #2 and #5, requiring blood product support Dr. _%#NAME#%_ _%#NAME#%_ of pediatric surgery was consulted and determined surgical intervention was indicated.
Pound|Number|183|Heavy growth of Pseudomonas species mucoid strain susceptible to amikacin, ceftazidime, piperacillin, and intermediate to ciprofloxacin. Heavy growth of Pseudomonas aeruginosa strain #2 susceptible to amikacin, aztreonam, ceftazidime, ciprofloxacin, and piperacillin; resistant to tobramycin.
Pound|Number|194|PROCEDURE THIS ADMISSION: Right total hip arthroplasty. HOSPITAL COURSE: _%#NAME#%_ _%#NAME#%_ was admitted. She underwent the above-noted procedure. She tolerated it well. By postoperative day #3 she was stable and ready for discharge to the nursing home setting.
Pound|Number|175|His postoperative course was smooth. On postoperative day #1 he was tolerating oral diet and pain medication. He was discharged to home in good condition on postoperative day #1. Instructions are to keep the splint clean and dry. I will see him back in the office on Tuesday _%#MMDD2005#%_ for application of a long arm cast.
Pound|Quantity|119|8. V8. 9. itamins for Women 1 tab daily. 10. Vitamin B complex daily. 11. She was also give a prescription for Vicodin #30 1-2 q.4-6h. p.r.n. for pain. She has no known drug allergies. She will be seen in the Surgery Clinic by Dr. _%#NAME#%_ in 2 weeks.
Pound|Number|97|Wonder if this is from decreased renal perfusion from bradycardia. 3. Hyperkalemia, secondary to #2. 4. Hypertension. 5. Hypothyroidism. 6. Osteoarthritis. 7. Depression. 8. Gastroesophageal reflux.
Pound|Number|90|She passed flatus by postoperative day #2 and had good bowel sounds. By postoperative day #3, was ambulating well and tolerating regular diet and had two bowel movements.
Pound|Number|132|He has been out of bed and ambulating without assistance. His pain was well controlled on oral pain medicines. On postoperative day #4, his dressing was taken down, showing nicely approximated left postauricular incision with no erythema, swelling, or exudate, no leak of cerebrospinal fluid was apparent.
Pound|Number|52|7. Keflex 500 mg p.o. b.i.d. for 7 days. 8. Tylenol #3 one tablet p.o. b.i.d. for 7 days p.r.n. 9. Metformin 1000 mg p.o. b.i.d. Follow-up EP and Dr. _%#NAME#%_ _%#NAME#%_ on _%#MMDD2006#%_.
Pound|Number|177|PAST MEDICAL HISTORY: 1. Cerebral vascular disease, as above. 2. Subclinical hyperthyroidism. 3. Idiopathic peripheral neuropathy. 4. Osteoarthrosis. 5. Immobility secondary to #s 3 and 4. 6. Unspecified COPD. 7. Iron deficiency anemia. 8. Gastroesophageal reflux disease.
Pound|Number|134|5. Pulmonary. Known history of asthma. No issues on this hospitalization. 6. GI: The patient's diet was advanced on postoperative day #1, and she was able to tolerate a regular diet upon discharge.
Pound|Number|181|There were no intraoperative complications. Please see the operative report for further details. Postoperatively, the patient was admitted to the general ward. On postoperative day #1, he was started on a clear liquid diet. After removing his Foley catheter, he experienced urinary retention, requiring intermittent straight catheterization and ultimately replacement of his Foley catheter.
Pound|Number|184|In the immediate postoperative period, a Dilaudid PCA was utilized and provided adequate analgesia. Low molecular weight Heparin was utilized for DVT prophylaxis. On postoperative day #2, tube feedings were initiated and were gradually increased to a goal rate over the ensuing 24-48 hours.
Pound|Number|294|CHIEF COMPLAINT: Postoperative knee pain, left. HISTORY: Ms. _%#NAME#%_ is a 49-year-old female who underwent total knee replacement on _%#MMDD2006#%_ at Regions Hospital. Her immediate postoperative course was uneventful and she was discharged to a transitional care unit on postoperative day #4. The patient was strongly dissatisfied with this particular transitional care unit (Good Shepherd).
Pound|Number|210|FINAL CHIEF COMPLAINT: This patient presented to the emergency room complaining of nausea, vomiting, headache and dizziness since her discharge 2 days ago on _%#MMDD2006#%_. This is currently postoperative day #6 for a resection of her left-sided acoustic neuroma using a middle fossa approach.
Pound|Number|144|He did very well initially, he diuresed very well, he continued on ultrafiltration for 3-1/2 days. However, his creatinine starting to rise day #3. It continued to rise and it reached 7.5 day #5 despite being off ultrafiltration.
Pound|Number|203|Please see a copy of the patient's medical consult for further medical details. The patient was treated with routine physical therapy rehabilitation for hip arthroplasty and was discharged on postop day #3 to home. The patient is scheduled for follow-up in our office at 2 weeks postop for suture removal and radiographic evaluation.
Pound|Number|181|HOSPITAL COURSE: Mr. _%#NAME#%_ _%#NAME#%_ underwent uncomplicated decompression on _%#MMDD2006#%_. Estimated blood loss was 150 cc. Medicine consult obtained. On postoperative day #1, no lower extremity complaints. Overall, doing well. Regular diet initiated. Discontinuation of PCA. On postoperative day #2, continued to do well although had difficulty with voiding.
Pound|Number|165|The patient was then monitored and did return to a rapid atrial fib/flutter off amiodarone. With these findings, a permanent pacemaker was then placed on postop day #4 without complications. Anticoagulation was then started. Since then he has been 100% atrial paced at a rate of 60.
Pound|Number|259|She was started on clears on the afternoon following surgery, and her diet was advanced to a regular diet by the time of discharge. She had some minor nausea and vomiting on postop day #1, which had resolved completely prior to discharge on postoperative day #2. Her JP output was a small amount of serosanguinous material only.
Pound|Number|231|ASSESSMENT: A _%#1914#%_ year old admitted with mental status changes, acute renal failure, dehydration, improved with intravenous fluids, being admitted under observation status. PLAN: 1. Mental status changes likely secondary to #2. 2. Acute renal failure with dehydration. The patient will receive normal saline overnight.
Pound|Number|158|He was also given specific discharge instructions regarding access site care, as well as the importance of taking his medications (especially Plavix). PAGER: #_%#TEL#%_
Pound|Quantity|393|She should report increased drainage, pain or swelling or temperature greater than 101.5 to the neurosurgery office immediately and the numbers have been provided. DISCHARGE MEDICATIONS: Her discharge medications include her home medications, Ventolin, Allegra, Neurontin, Singulair, Protonix, Senna-S and Zocor at the already prescribed doses and Vicodin 1-2 tablets p.o. q.4-6h. p.r.n. pain #40.
Pound|Number|119|He was ambulating, tolerating a regular diet. He was also voiding. The patient will be discharged on postoperative day #2 to home with follow-up in Dr. _%#NAME#%_'s clinic in 2-4 weeks. The JP drain was discontinued prior to discharge.
Pound|Number|163|On postoperative day #1, he discontinued use of IV pain medication and was transitioned to oral medication. He was able to be discharged home on postoperative day #1 after completing an eval with physical therapy. He is toe-touch weightbearing and will follow up with us in 2 and 6 week intervals.
Pound|Quantity|119|PLAN: 1. The patient was discharged home with Keflex t.i.d. until the drainage stopped. 2. He was also given Oxycodone # 50 for pain. 3. He is to wear his lumbar support when up.
Pound|Quantity|195|She did however continue to smoke. DISCHARGE MEDICATIONS: Basically her discharge medications are the same as when she was admitted. I gave her a script for diltiazem X-R 180 mg to take 1 po qd, #30, no refills. I as well gave her a note for her work per her request which basically said there are no medical contraindications to her resuming work without restrictions.
Pound|Quantity|183|The patient is being discharged to be followed up by Dr. _%#NAME#%_ in four days and will see me in about 3-4 weeks. DISCHARGE MEDICATIONS: 1. Vicodin 1-2 tablets q.4-6h. p.r.n. pain #30 2. Keflex 250 mg q.i.d. for seven days.
Pound|Quantity|265|The swelling, pain and redness cleared over the subsequent two days, and she was discharged home to be followed up as outpatient and have to have home evaluation. Discharge medications same as admission, except she was given Percocet one every 4 hours p.r.n. pain, #15. Augmentin 875 mg p.o. b.i.d. for 10 days. She is to be seen by her primary care provider about 3-4 days following discharge.
Pound|Quantity|66|3. Zantac 150 mg po qd. 4. Tiazac 360 mg po qd. 5. Catapres T-T-S #2 patch weekly. 6. Coumadin 5 mg po qd on _%#MMDD2002#%_ and _%#MMDD2002#%_.
Pound|Quantity|211|She was given routine postpartum postoperative instructions and will be seen in the office in six weeks. She will continue taking her multivitamins while breast-feeding. She was given a prescription for Vicodin #20 for incisional discomfort.
Pound|Number|157|She did however continue to spike temperature. She had a fever of unknown origin and by hospital day #4 she continued to spike temperatures. On hospital day #5, the decision was made to empirically start Heparin for possible septic pelvic thrombophlebitis.
Pound|Number|83|CURRENT MEDICATIONS: 1. Coumadin 5 mg p.o. qd. 2. Atarax 25 mg p.o. qd. 3. Tylenol #3 prn. 4. Lanoxin 0.25 mg p.o. qd. 5. Flexeril 10 mg t.i.d. prn. 6. Tylenol prn.
Pound|Number|95|5. Combivent inhaler q.i.d. 6. Quinine 60 mg q.h.s. p.r.n. 7. Lisinopril 40 mg q.d. 8. Tylenol #3 p.r.n. for pain. MEDICATION ALLERGIES: To penicillin. HOSPITAL COURSE: PROBLEM #1: COPD. The patient was admitted for treatment of COPD exacerbation.
Pound|Number|134|HIPS: No clicks are noted. GU: Normal, healed circumcision and patent anus are noted. SUMMARY OF HOSPITAL COURSE: This is day of life #20 for this X 34 week AGA male who is now feeding and growing and ready for discharge.
Pound|Number|144|The NG tube was clamped, and the patient tolerated the clamping of the NG tube without difficulty. The NG tube was removed on postoperative day #2. The patient was given clears initially, and diet was advanced to a regular diet without difficulty prior to discharge.
Pound|Number|201|She was treated on a CPM machine until independent with her activities of daily living. Social Services assessed her living situation and it was felt she was able to be discharged on postoperative day #4, _%#MMDD2002#%_, to her home. She was given routine prophylactic antibiotic coverage, as well as anticoagulation.
Pound|Number|71|A Fox shield was kept in place over the left eye. On postoperative day #1, dilating drops and the antibiotic corticosteroid topical combination was started in the left eye.
Pound|Number|138|On postoperative day #1, the patient's IV fluids were hep-locked. He was tolerating a regular diet and having flatus on postoperative day #2. The patient was on a regular diet. His pain was well controlled on oral medications.
Pound|Number|165|Postoperatively she did well. She tolerated clear liquids on postoperative day #1. Solid foods on postoperative day #2. She was discharged home on postoperative day #3. The patient's physical examination was all within normal limits. No problems whatsoever.
Pound|Number|183|Her post operative hemoglobin was 9.5. Her pain was well controlled with Percocet, and ibuprofen, and she was tolerating a general diet. She was discharged home on post operative day #3. Her activity restrictions were no heavy lifting for 4-6 weeks, and pelvic rest for 2-4 weeks.
Pound|Number|181|The results of her operative findings were discussed with the patient and her family, by Dr. _%#NAME#%_. The remainder of her hospital course was unremarkable. By postoperative day #2, she was tolerating a regular diet. Her IV fluids were discontinued, and her pain was well controlled on oral pain medications.
Pound|Number|113|We continued to titrate up the ACE inhibitor, started her on low dose beta-blocker at that time. By hospital day #3, she had been feeling, much, much better, walking around, no shortness of breath, not requiring any oxygen, and had lost probably about 6 or 7 liters with diuresis.
Pound|Number|317|Given the fact that the patient had an IV line in the arm which could have precipitated thrombus as well as recent significant GI bleed, he was not anticoagulated due to high risk, as well as non-life threatening nature of the DVT. PROBLEM #4: Right knee erythema and warmth. During the ICU admission on hospital day #3 the patient was noted to have right leg redness over the area of a joint replacement.
Pound|Number|174|The admission physical examination was positive for prematurity. Problems during the hospitalization included the following: 1. FEN: _%#NAME#%_ was on TPN from DOL #2 to DOL #13, after that he gradually started taking enteral feeds.
Pound|Number|145|_%#NAME#%_ _%#NAME#%_, M.D. Fairview University Medical Center U Special Kids _%#STREET#%_ _%#STREET#%_ _%#STREET#%_ _%#STREET#%_, _%#ADDRESS#%_ #_%#ADDRESS#%_ _%#CITY#%_, MN _%#55400#%_ _%#MMDD2003#%_ Dear Dr. _%#NAME#%_, Thank you for accepting care of _%#NAME#%_ _%#NAME#%_ from the Neonatal Intensive Care Unit of Fairview-University Children's Hospital.
Pound|Number|297|10. Zoloft 50 mg p.o. q. daily. 11. Ativan 1 mg p.o. q6-8h p.r.n. nausea. 12. Benadryl 25 mg p.o. q6-8h p.r.n. nausea. FOLLOW-UP: Follow-up includes on _%#MMDD2003#%_ Oncology Clinic for CBC, differential, platelets, CMP, magnesium, and phosphorus, then admission to F-UMC for chemotherapy course #4 with methotrexate.
Pound|Number|177|HOSPITAL COURSE: The patient underwent the above procedure. Postoperatively, he did well, and his renal function remained stable. He diuresed spontaneously on postoperative day #2. His diet was advanced, and he was transitioned to oral pain medicine.
Pound|Number|171|She eventually defervesced, recovered her white counts, and was discharge. She followed up with me in clinic this week, four weeks after her first cycle to initiate cycle #2 of TAC chemotherapy at reduced doses. However, 48 hours later, she presented again to clinic with complaints of intractable nausea and vomiting and the inability to keep down either solids or liquids.
Pound|Number|164|Twin B had a nuchal cord times two. Microscopic evaluation of the twin placenta showed a diamniotic dichorionic placenta. It was chorioamnionitis noted in placenta #1, as well as a focal area of infarction. Placenta 2 showed some intravillous thrombus. Her postoperative course was without complication.
Pound|Number|194|DISCHARGE DIAGNOSES: 1. Pleuritic chest pain, fever, possibly related to atypical pneumonia, possibly viral. 2. Prominent hilar lymphadenopathy of unclear etiology. 3. Anemia secondary to #1 or #2. 4. History of hypertension. 5. History of mild dementia.
Pound|Number|248|Contraception was discussed with the patient, and she elected to use Micronor, and this was given to her while she was in the hospital. DISPOSITION: She was discharged to home in stable condition on _%#MM#%_ _%#DD#%_, 2004, which is postpartum day #2. DISCHARGE INSTRUCTIONS: 1. She was instructed to follow up at the _%#CITY#%_ Clinic in 6 weeks for a postpartum check.
Pound|Number|142|Hepatitis A antibody is pending at the time of discharge. Her liver function tests were monitored and came down significantly on hospital day #2. An abdominal ultrasound was negative for any acute liver abnormalities.
Pound|Number|216|Please see a copy of Ms. _%#NAME#%_'s medical consult for further medical details. Ms. _%#NAME#%_ was treated with routine physical therapy rehabilitation for total knee arthroplasty and was discharged on postop day #3 to a skilled nursing facility for assisted care. Ms. _%#NAME#%_ is scheduled for follow-up in our office at two weeks postop for suture removal and radiographic evaluation.
Pound|Number|260|She has had chronic low back pain and some shoulder pain since this car accident. MEDICATIONS: Include Zyrtec 10 mg daily, Robaxin, dose uncertain twice a day, amitriptyline 75 mg at night, Lexapro 20 mg daily, Maxalt as needed for migraine headaches, Tylenol #3 as needed, recently prescribed; Lactaid as needed, and Depo-Provera shots every three months.
Pound|Number|103|On postoperative day #2, she was afebrile, doing well, tolerating a general diet. On postoperative day #3, she was doing well, ambulating without difficulty.
Pound|Number|223|He had two troponin levels and negative results. On postoperative day #2, the patient had serosanguineous drainage. The patient's abdomen was distended. Beta-blockers and antihypertensives were started on postoperative day #2. Also on postoperative day #2 the patient's stents were pulled without any problems.
Pound|Number|133|On postoperative day #1, the patient had an esophagram, which revealed no leak. His chest tube was also removed on postoperative day #1 with minimal drainage. Chest x-ray showed a well-expanded lung with no effusion. Mr. _%#NAME#%_ was started on a diet, which he tolerated well, and was converted to oral pain medications.
Pound|Quantity|88|3. Prednisone 20 mg one p.o. q. day. 4. Lortab 10/500 one tablet q.4 h. p.r.n. for pain #40 given. 5. Imodium. 6. Canasa. 7. Triamcinolone as before. ALLERGIES: No known drug allergies.
Pound|Number|222|She tolerated the procedure well. She did remain in the SICU overnight for monitoring and close observation with pulse checks in the immediate postoperative period. She was transferred out of the SICU on postoperative day #1. She did very well in the postoperative period. She was started on clear liquid diet which was advanced to regular as soon as she had return of bowel function.
Pound|Number|79|Hemoglobin up to 12.4 at the time of discharge. 2. Acute weakness secondary to #1. SECONDARY DIAGNOSES: 1. Dementia (mild). 2. Hypertension. 3. Hypothyroidism. The patient is discharged to rehab.
Pound|Number|86|IMPRESSION: 1. New diagnosis of a 7 cm periaortic mass 2. Abdominal pain secondary to #1. 3. Hypothyroidism 4. Bipolar disorder. 5. Sleep apnea PLAN: 1. Will consult with surgery in the morning about the options for diagnosing and treating this periaortic mass.
Pound|Number|99|The patient was on Lovenox for DVT prophylaxis while in the hospital as well. On postoperative day #2, which was _%#MM#%_ _%#DD#%_, 2004, the patient was doing well and decision was made to discharge to home.
Pound|Number|153|The patient tolerated the procedure well and left tolerating room in good condition. Her postoperative course was uncomplicated and on postoperative day #4 she was felt to be a candidate for discharge. DISCHARGE MEDICATIONS: 1. Maxzide 37.5/25 mg one po daily.
Pound|Number|174|Her postoperative course was unremarkable. She had normal vital signs and remained afebrile throughout her hospital stay. Her urine output was excellent on postoperative day #1 and so her Foley catheter was removed. Her postoperative hemoglobin was 9.9. She was ambulating, tolerating clear liquids and then by postoperative day #2 she was passing flatus.
Pound|Number|344|The patient was then admitted postoperatively for observational purposes. On postoperative #1, call was that the patient was experiencing severe gasping and had not yet taken much p.o. We elected to keep the patient for an additional day until he could tolerate more p.o. as well as tolerate his pain with oral analgesics. By postoperative day #2, the patient was tolerating a diet had had a BM, and was taking minimal amounts of analgesia.
Pound|Number|104|DOB: _%#MMDD1947#%_ DISCHARGE DIAGNOSES 1. Pneumonia (right middle lobe). 2. Bronchospasm, secondary to #1. 3. Atherosclerotic heart disease. 4. Hyperlipidemia. 5. Anxiety disorder. This 57-year-old male presented with dyspnea and cough.
Pound|Number|170|The remainder of the patient's hospital stay was unremarkable. The patient steadily improved over the next week. However, the patient's nausea persisted. On hospital day #9, the patient's IV Flagyl was switched to p.o. and vancomycin was also added to his antibiotic regimen.
Pound|Number|188|She underwent an uneventful left hemicolectomy and appendectomy. Her postoperative course was unremarkable. She had the expected ileus which had essentially resolved. By postoperative day #4, she was started on a diet and discharged home the following day tolerating regular diet, afebrile and with the incision healing nicely.
Pound|Quantity|198|Furthermore, the patient was able to spontaneously void this morning and was subsequently deemed appropriate for discharge. DISCHARGE MEDICATIONS: 1. Vicodin 1-2 tablets PO q.4-6h. p.r.n., dispense #30. 2. Levaquin 400 mg PO daily x 5 days.
Pound|Quantity|114|11. Sodium bicarbonate 2600 mg p.o. 8 times daily. 12. Oxycodone 5 mg 1-2 tablets p.o. q. 4-6 hours p.r.n. pain.; #100 given, no refills. 13. Levaquin 500 mg p.o. daily for 10 days.
Pound|Number|135|His bowel function also returned after several days of both suppository and enemas. Therefore, he was able to discharged on postop day #6. At the time of discharge, he was tolerating p.o. and passing flatus.
Pound|Quantity|98|3. Compazine 10 mg p.o. q. 6-8 h. p.r.n. nausea, #30. 4. Prednisone reduced to 10 mg p.o. b.i.d., #60. 5. Marinol 5 mg p.o. t.i.d. 6. Methadone 5 mg p.o. q. 8 h. 7. Prilosec OTC daily.
Pound|Number|269|PRELIMINARY ADMITTING DIAGNOSIS: 27-year-old, gravida 2, para 0-0-1-0, at 40-6/7 weeks gestation, admitted for induction of labor secondary to post dates. PROCEDURE: Primary cesarean section. DISCHARGE DIAGNOSIS: 27-year-old, gravida 2, para 0-0-1-0, postoperative day #3, status post primary cesarean section for arrest of dilation and descent with failed induction.
Pound|Number|225|ADMISSION DIAGNOSIS: A 43-year-old gravida 2, para 0-0-1-0 at 38 weeks for elective primary cesarean section for pruritic urticarial papules and plaques, cholestasis, and unripe cervix. DISCHARGE DIAGNOSIS: Postoperative day #4, stable. HISTORY OF PRESENT ILLNESS: The patient is a 43-year-old G2, para 0-0-1-0 at 38 weeks gestation by LMP of _%#MM#%_ _%#DD#%_, 2005, who presents for elective primary cesarean section because of PUPPS, cholestasis, and unripe cervix.
Pound|Number|300|However, with continued reassurance and better pain control, she accepted the fact that we would likely wait until at least 34 weeks to consider delivery and obviously further than that if her ulcerative colitis did not continue to flare and worsen. _%#NAME#%_ was discharged to home on hospital day #7 with postprandial blood sugars in the 140s to 180s and fasting sugars in the 90s to 100s.
Pound|Number|247|Basic metabolic panel was insignificant. The patient additionally reported that he had some difficulty urinating initially after surgery; however, by the time the patient was seen at Riverside, he was found to be urinating normal. On hospital day # 1, the patient continued to be afebrile with stable vital signs.
Pound|Number|227|Her urinalysis reveals trace blood but otherwise was unremarkable. Her EKG shows atrial fibrillation with a paced rhythm. ASSESSMENT: 1. Light-headedness, uncertain etiology. 2. Elevated INR. 3. Anemia, presumably secondary to #2. PLAN: Will admit the patient to the hospital. Will have a Cardiology consult obtained in the morning.
Pound|Number|321|Her preoperative hemoglobin was 12.2, her postoperative hemoglobin was stable at 10.7. The patient did develop PUPPPs during her pregnancy late in the third trimester which was worsening postpartum; however, it was responsive to p.o. and topical Benadryl as well as topical hydrocortisone cream. Today, postoperative day #4, the patient is voiding spontaneously, and she is eating a regular diet.
Pound|Number|264|4. Zantac 150 mg per G-tube q.12 h. 5. Novolog insulin sliding scale with fingerstick q.i.d. Blood Sugar Dose 120-149 Give 1 unit 150-198 Give 2 units 200-249 Give 3 units 250-299 Give 5 units 300-349 Give 7 units ( 350 Give 8 units, call house office. 6. Tylenol #3 one to two tablets p.o. q.4-6 h. 7. Senna-S 2 tablets p.o. per G-tube q.h.s. for constipation.
Pound|Number|190|The patient was able to up and ambulate and void independently without difficulty. The patient had adequate pain control with p.o. Elixir. The patient was discharged to home on hospital day #3 in stable condition. DISCHARGE INSTRUCTIONS: 1. The patient will be discharged to home.
Pound|Number|86|She is on Zantac 8 mg by mouth twice daily. 3. Prematurity. 32+5 week AGA twin female #1. 4. Respiratory: _%#NAME#%_ required brief oxygen on admission but weaned quickly to room air.
Pound|Quantity|253|At the time of her discharge, her incision was clean and dry, she was tolerating a normal diet, ambulating without assistance and her pain was well controlled with oral pain medications. DISCHARGE PLAN: The patient was discharged to home with oxycodone #40. She is to wear a lumbar support when up. She was given our discharge instruction sheet and told to contact our office with any questions or complications.
Pound|Number|146|_%#NAME#%_ is also to follow up with Dr. _%#NAME#%_ his primary care physician in one to two weeks. Additionally Children's _%#NAME#%_ program Fax# _%#FAX#%_ has received a referral to assess _%#NAME#%_ for admission to the program.
Pound|Number|203|Please see a copy of the patient's medical consult for further medical details. The patient was treated with routine physical therapy rehabilitation for hip arthroplasty and was discharged on postop day #4 to home. The patient is scheduled for follow-up in our office at 2 weeks postoperatively for suture removal and radiographic evaluation.
Pound|Number|93|Estimated blood loss was 800 cc. Postoperatively, the patient did well. On postoperative day #2 she had a T-max of 100 but otherwise she remained afebrile throughout her hospital course and by the time of discharge, she was tolerating a regular diet, ambulating and urinating without difficulty.
Pound|Quantity|243|He did not have any difficulty voiding and at the time of his discharge he was able to ambulate without assistance, getting out of bed independently and tolerating normal diet. DISCHARGE PLAN: The patient was discharged to home with oxycodone #30. He was given a discharge instruction sheet from our office and told to contact us with any questions or complications.
Pound|Number|91|Spiral CT was performed following this which showed no pulmonary embolism. On hospital day #2, cardiac echocardiogram was performed, which was normal per the report of the Cardiology Team.
Pound|Number|116|The patient had tube feeds initiated at this point. MAJOR ISSUES: PROBLEM #1: Wound infection. On postoperative day #3, the patient began to develop pain and erythema at his feeding tube site.
Pound|Number|117|26) Hypertension. MEDICATIONS: Will be called later; she did not bring her list with her today. ADDENDUM: 1) Tylenol #3 one to two tablets p.o. q.i.d. prn pain. 2) Metoprolol 100 mg p.o. q day. 3) Dyazide 25/37.5 mg p.o. q day.
Pound|Number|220|Please see dictation for details. Neurology decided the patient did have some abnormal signals on his EEG and that he should continue on his phenobarbital. Otherwise, the patient was doing well, and on postoperative day #6, the patient was discharged out of the hospital. The patient did have low CSA levels. On the day of discharge, his CSA level was 118.
Pound|Quantity|170|She was also instructed to call for any increasing drainage, pain, swelling, or fever to 100.4 F or greater. DISCHARGE MEDICATIONS: 1. Colace 100 mg p.o. b.i.d. Dispense #100. 2. Vicodin one to two tablets p.o. q4-6h p.r.n. Dispense #40.
Pound|Number|181|She was subsequently transferred to the floor for continuation of care. The patient remained stable throughout her hospital stay. She was started on tube feeds on postoperative day # 2. The patient is able to tolerate bolus feeds without any complications.
Pound|Number|169|Alkaline phosphatase and bilirubin are normal. ASSESSMENT: 1. Suicide attempt. a. We will admit this patient to the Intensive Care Unit (ICU) and treat as delineated in #2 below. b. Psychiatric consultation will be obtained on this patient.
Pound|Number|164|She was not immediately able to ambulate, but did eventually get to the point where she could get up and walk without difficulty. DISCHARGE MEDICATIONS: 1. Tylenol #3, 1 - 2 tablets p.o. q4h p.r.n. pain. 2. Tigan suppository, 200 mg per rectum, q6h p.r.n. nausea.
Pound|Number|92|PLAN: 1. Discharge to home. 2. Continue the antibiotic (Augmentin). 3. Celebrex and Tylenol #3 for breakthrough pain. 4. RTC 2-3 weeks.
Pound|Number|82|FINAL DIAGNOSES: 1. AMLM 4 subtype, status post chemotherapy; consolidation cycle #2 during this admission with high dose Ara-C x 12 doses. This was given on _%#MMDD2002#%_. 2. Neutropenic fever, resolved. Treated with multiple antibiotics including Amphotericin B.
Pound|Number|157|Subsequent postpartum course was fairly uncomplicated. Postpartum/postoperative hemoglobin returned at 9.9 and was subsequently stable. On postoperative day #1 patient had the Penrose drain removed. This area was slightly swollen but was not noted to reaccumulate any blood.
Pound|Number|113|OR course was uncomplicated. The patient was then admitted to 7B for further observation and care. On postop day #1 the patient began having bowel function demonstrated by flatus.
Pound|Number|139|She has been requiring significant amounts of narcotics, which has been managed by the pain management team. However, on postoperative day #4 after a number of changes were made overnight, the patient states that she is actually quite comfortable on her new regimen and wishes to be discharged to home.
Pound|Quantity|114|He was to go to AA meetings and contact his sponsor. DISCHARGE MEDICATIONS: He was discharged on Antabuse 250 mg, #30, one daily. DISCHARGE DIAGNOSIS: Alcohol dependence.
Pound|Number|201|She appears to have been tolerating a regular diet and voiding spontaneously. Her pain is well controlled with oral pain medications. At this time, she is being discharged to home on postoperative day #4. She is instructed to avoid any bending, twisting, jumping or running.
Pound|Number|340|Please refer to the complete operative dictation for further details of this procedure. POSTOPERATIVE COURSE: The patient had an unremarkable postoperative course with a postoperative hemoglobin of 9.4. She initially had blood tinged urine which was present prior to initiation of her C-section which resolved nicely postoperatively on day #1 in the morning. She went on to have normal return of bowel and bladder function by the end of postoperative day #2.
Pound|Number|163|She subsequently was afebrile and had no complaints. The pain was well controlled. She was eating, ambulating, and voiding without difficulty on postoperative day #1. The incision was clean, dry, and intact, with minimal ooze at the inferior portion.
Pound|Number|170|Pulmonary Medicine followed his immunosuppression dosing during his hospital stay. PROBLEM #2: New postoperative atrial fibrillation/atrial flutter. On postoperative day #10 this common arrhythmia was noted. We ruled out myocardial infarction and pulmonary embolus through serial troponins and ultrasound studies.
Pound|Number|188|The operative course was uneventful. After a short stay in the post- anesthesia care unit, the patient was transferred to 6A for the remainder of her hospitalization. On postoperative day #1, the patient underwent an upper GI study, which did not demonstrate any leaks.
Pound|Quantity|127|DISCHARGE MEDICATIONS: 1. Cipro 500 mg p.o. b.i.d., #4. 2. Flagyl 250 mg p.o. t.i.d., #6. 3. Darvocet-N 100 p.o. q.6h. p.r.n., #15. 4. Reglan 5 mg q.i.d. a.c. and h.s. per GI.
Pound|Number|218|The patient received a total of five days of steroid therapy (taper). The patient was not enrolled in any known studies. Overall, the patient did very well postoperatively, and was discharged home on postoperative day #5. The patient was able to tolerate a regular diet without any complaints of nausea or vomiting.