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To Newborn Nursery ,3
 Toprol . Lasix . Digoxin . Coumadin . Flovent . Albuterol . Lisinopril .,3
 Of note  Na 133   K 4   WBC 8.82   hematocrit 35.1   platelets 229 . PT 13.8 with an INR of 1.3   PTT 25.5 total protein was 6.2   albumin 3.4   globulin of 2.8   calcium of 9.1   phos 2.7   mag 2.1   urea 3.7 . ALT was elevated at 240   AST 85   LDH 305   alk phos 85   total bilirubin was 1.3   direct bili was .8 . Cholesterol 188   triglyceride was 127 . UA  trace protein   trace ketones   positive for bilirubin and nitrogen and also 4 to 6 wbcs with 1 bacteria . Chest x-ray  Showed a left paratracheal adenopathy and small left pleural effusion with no evidence of pneumonia . In summary   the patient is a 49 year old woman with metastatic breast cell CA   status post chemotherapy with CMSAP and PVSC and XRT who presented with fever   four days of diarrhea   nausea and vomiting and had been on Keflex for an erythema on her left chest wall . The Keflex was stopped when she developed the diarrhea . When she arrived the plan was to go ahead and treat here rythematous induration and possible cellulitis with IV antibiotics . So she was put on dicloxicillin and we did local wound care with an agent called Santyl   which is a collagenace ondebrided which worked very well for her . Also at the time of admission we were also considering palliative Taxol chemotherapy   which the patient declined . She refused the Taxol therapy so that was not done . Another major issue with this patient was pain control . She had been in a whole lot of pain from her left arm lesion . So pain control was a big issue so she was on MS Contin and MSIR at home she thought that clouded her thinking   so we tried different things for pain management . One of them was to do a subarachnoid neurologic block at C6-C7 interface on 1-6-94 . After that the patient had minimal relief of pain . However   she declined further blocks   which were offered to her . So accepted to be on dilaudid p.o. which was started at a dosage of 2-4 meg but since then we have tapered it up . She is now getting dilaudid 8 mg q2h and in addition she has been on fentanyl patch . She is now getting 75 micrograms per hour of the fentanyl patch which is changed every 72 hours . We can go up by 25 mg on the fentanyl patch as needed to control her pain and we can always go up on the dilaudid because she is still in considerable amount of pain . Other things that happened during this admission  we obtained ahead CT for her on the 8th of January because of her clouded thinking and altered mental status   which was probably due to the morphine that she was taking . We went ahead and got a head CT scanand it showed no enhancing lesions . In addition her liver transaminases were elevated   we thought about doing further work-up   but that was deferred because the patient wanted to wait on that . That has been stable . The patient on January 13 became hyponatremic . Her sodium went down to 121 and before that on admission she was 133 . A renal consult was obtained and their assessment was that this was probably a mixture of hypovolemia as well as SIADH . We proceeded to do for her hyponatremia  we gave her some fluid and her urine sodium became higher than her serum sodium  we stopped it . We had given her some normal saline and then we proceeded to just do fluid restriction . In addition we gave her a sodium chloride one gram per day and that also helped   so that now at the time of discharge   the patient &aposs sodium is between 126 and 129  prior to that it had gone down to as low 116. So that has really improved . We suggest continuing increased salt intake in her diet and also continuing with the fluid restriction of free water intake to one liter per day . On the 14th of January   the patient developed increased shortness of breath and chest x-ray was taken showed a wedge shaped infiltrate in the right upper lobe which was consistent with Hampton &aposs hump . Also a VQ scan obtained the next day showed high probability for PE . So we proceeded to put her on heparin for anticoagulation and then when she was therapeutic on heparin   we went ahead and started her on coumadin and she is currently on coumadin at 2.5 mg q.h.s. Her INR is 2.3 . We want her INR to remain between 2 and 3 . So if it goes much lower than 2   then we would consider increasing it to perhaps coumadin 2.5 and 5 alternating every other night . However   we would leave it at 2.5 for now . Other major issues  As a result of all the things happened and with her hyponatremia and also the other problems   her blood pressure was elevated also . We put her on nifedipine IR   SL and that was not enough to control her blood pressure which was in the 200s in the systolic   so we had started her on atenolol . So on discharge she is on atenolol 100 . If needed to you can give her some nifedipine SL to decrease her blood pressure . The patient also has significant edema in both arms now and also some mild edema in the lower extremities   so I think that fluid restriction should help with that . She is also a little dry . The patient is on oxygen . Ever since the pulmonary embolus she has been on oxygen . She was on 4 liters  now she is on 5 liters   sating 94 to 96 on 5 liters . We would like for her to remain on the oxygen as well . The complications that I have listed include the hyponatremia   pulmonary embolus and also the elevatd blood pressure . ,1
"Feedings at discharge  Similac 22 calories per ounce by mouth ad lib with a goal of decreasing to 20 calories per ounce for dextrose sticks of greater than 60 . Medications  None .', 'A state newborn screen was sent on day of life three  the results are pending . Received hepatitis B vaccine on 2012-09-30 .",2
 Pentamidine 300 mg IV q. 36 hours   Pentamidine nasal wash 60 mg per 6 ml of sterile water q.d.   voriconazole 200 mg p.o. b.i.d.   acyclovir 400 mg p.o. b.i.d.   cyclosporine 50 mg p.o. b.i.d.   prednisone 60 mg p.o. q.d.   GCSF 480 mcg IV q.d.   Epogen 40 000 units subcu q. week   Protonix 40 mg q.d.   Simethicone 80 mg p.o. q. 8   nitroglycerin paste 1 &quot q. 4 h. p.r.n.   flunisolide nasal inhaler   2 puffs q. 8   OxyCodone 10 -15 mg p.o. q. 6 p.r.n.   Sudafed 30 mg q. 6 p.o. p.r.n.   Fluconazole 2 cream b.i.d. to erythematous skin lesions   Ditropan 5 mg p.o. b.i.d.   Tylenol 650 mg p.o. q. 4 h. p.r.n.   Ambien 5 -10 mg p.o. q. h.s. p.r.n.   Neurontin 100 mg q. a.m.   200 mg q. p.m.   Aquaphor cream b.i.d. p.r.n.   Lotrimin 1 cream b.i.d. to feet   Dulcolax 5 -10 mg p.o. q.d. p.r.n.   Phoslo 667 mg p.o. t.i.d.   Peridex 0.12   15 ml p.o. b.i.d. mouthwash   Benadryl 25-50 mg q. 4 -6 h. p.r.n. pruritus   Sarna cream q.d. p.r.n. pruritus   Nystatin 5 ml p.o. q.i.d. swish and ! spit   folate 1 mg p.o. q.d.   vitamin E 400 units p.o. q.d.   Haldol 2 mg IV q. 6 p.r.n. agitation   Colace 100 mg b.i.d.   Senna 2 tablets p.o. b.i.d.,3
 Atazanavir 300 mg q.d. Ritonavir 100 mg q.d. Tenofovir 300 mg q.d. Didanosine 250 mg q.d.,3
"Continue ad lib feeding . Follow up with pediatrician at SCCHC on Tuesday 2018-05-15 . Medications  Not applicable . Car seat positioning screen  Not applicable .', 'State newborn screens were sent on 2018-05-09  and results are pending . On his previous admission', 'Terrance received hepatitis B vaccine on 2018-05-09 . 6. Immunization recommended  Influenza immunization is recommended annually in the Fall for all infants once they reach 6 months of age .', 'Before this age  and for the first 24 months of the child s life  immunization against influenza is recommended for household contacts and out of home caregivers .",2
HISTORY OF PRESENT ILLNESS  Date of birth  10  4  88 . This patient is a 5 year old white female with a history of type I renal tubular acidosis on nephrocalcinosis who was admitted to Noughwell Entanbon Health of Washington on 9  5  93 at 2116 hours with a 2-3 day history of chills   fevers   cough   vomiting and weakness  unable to walk  . At Noughwell Entanbon Health   her temperature was 101   pulse 135   blood pressure 94  74   respiratory rate 20 . Positive findings of physical examination include chicken pox lesions on thorax   sunken eyes   thick nasal discharge   dry lips   tongue and mucous membranes   red tonsils . The remainder of the physical examination was considered within normal limits . Admission diagnosis at Ni Hospital &aposs  vomiting and dehydration   hypokalemia   hyponatremia   tonsillitis . A peripheral intravenous line was started on Labor Day in the a.m. No respiratory distress was noted . Oral cyanosis and shallow respirations were noted on 9  7  93 at 245 a.m. Therefore the patient was intubated at 345 a.m. on 9  7  93 . Chest x-ray was unremarkable . Cardiovascular stable   significant hypertension was noted on 9  7  93 at 510 a.m. and therefore 10 cc&aposs per kilo albumin was given . The patient was admitted was started on clear fluids   tolerated   with D5 normal saline plus 40 mEq per liter of KCL at a rate of 50 cc &aposs per hour for 9 hours .  100 cc&aposs per kilo  . Sodium and potassium at this time were 128  1.5 . At Labor Day   930 a.m.   the fluids were increased to 100 cc&aposs per hour  200 cc&aposs per kilo for 5 hours  . Electrolytes at this point were sodium 132   potassium 1.8 . At 9  6  93   230 p.m.   fluids were decreased to 75 cc&aposs per hour   150 cc&aposs per kilo   40 mEq of K phosphate added to the intravenous fluids . Electrolytes at this point were a sodium of 143 and potassium 1.7 . On 9  6  93   2200   fluids were changed to D5 normal saline plus 40 KCL and 40 K phosphate at 75 cc &aposs per hour . This rate was maintained for 11 hours . Electrolytes at this time were a sodium of 148   potassium 1.7 . At 9  7  93   100 a.m.   intravenous fluids rate was decreased to 50 cc&aposs per hour   total fluids given during the first 24 hours were 140 to 150 cc&aposs per kilo per day . At this time   sodium was 147   potassium 2.6   total sodium given during the first 24 hours 20 mEq per kilo per day . On 9  7  93 at 400 a.m.   albumin bolus 5 10 cc&aposs per kilo was given   a total of 120 cc&aposs   electrolytes were sodium 155   potassium 3.1 . At 9  7  93 at 500 a.m.   sodium bicarbonate given 60 mEq   calcium bolus 10 cc&aposs given . On 9  7   530 a.m.   D5 quarter normal saline   and 40 of K phosphate at 100 cc&aposs per hour was given . The patient was taking PO initially until 9  6  93 at 1745 . There were no abnormal findings in abdominal exam . On 9  5  93   hematocrit 48   white blood count 11.2   neutrophiles 67   bands 14   lymphs 11   monos 6   meta 2   platelets 220 000 . Copious urine output   BUN 1.0   creatinine .8 . Normal neurologic exam on admission   then lethargic on 9  6  93 at 1745   then patient became unresponsive   areflexic and limp at 9  6  93   at 1745 to 2200 . Patient was having seizures   twitching of face and rapid movements of eyes . Pupils dilated and sluggish . Valium was given at 9  7  93   0002 . IV ampicillin   chloramphenicol   ceftriaxone   and culture were sent . Finally   Fairm of Ijordcompmac Hospital transport team was called and transport team arrived on 9  7  93   630 a.m.   and on arrival patient was seizing with rhythmic eye movement to left . The patient was unresponsive   poor perfusion . Temperature was 101.8 . A second intravenous was started and given normal saline bolus   change in intravenous fluids to D5 water with 80 mEq of bicarbonate   plus 40 mEq of KCL at 45 cc&aposs per hour   bicarbonate given 2 mEq per kilo   attempted to start dopa for poor perfusion but worsening perfusion . Therefore   dopa was stopped . Total volume given as bolus 50 cc&aposs per kilo   sodium bicarbonate at 2 mEq per kilo was given . Last ABG there was 6.98   31   171   bicarbonate of 7 . Phenobarbital and Dilantin given for seizure control . Electrolytes before departure for Fairm of Ijordcompmac Hospital was a sodium of 176   potassium 2.5   chloride 140   bicarbonate 14   calcium 7.2   magnesium 2.7 . Admission to the Pediatric Intensive Care Unit at Fairm of Ijordcompmac Hospital was 9  7  93   1115 a.m. Lines placed were a right femoral triple lumen   endotracheal tube 4.0   arterial line   right radial line   Foley placed   peripheral intravenous line   nasogastric tube . On admission to Fairm of Ijordcompmac Hospital   temperature 100.2   pulse 149   respiratory rate 50   blood pressure 98  66   mean arterial pressure of 73   weight 12 kilos .,0
 Prednisone 60 mg daily for 4 days . Continue inhalers as prescribed . Disposition   Follow up and Instructions to Patient  Call Dr. Linketerf tomorrow and make an appointment for follow-up on the lung nodule . THIS IS VERY IMPORTANT .,2
 Cardiac arrest  His arrest was of unknown etiology at the time of admission . No further history was ever gained about his cardiac arrest throughout his hospitalization . CT angiogram had been negative for pulmonary embolism . The patient had an echocardiogram on 2013-04-26   which showed a normal ejection fraction and trivial mitral regurgitation  otherwise no obvious abnormalities were seen . Given the patient had an out of hospital arrest   remained unresponsive despite hemodynamic stability   he was treated with induced hypothermia and with cold packs and a cooling blanket were placed with goals of reducing his core body temperature to 32 degrees Celsius for a period of twelve hours at which point he would be rewarmed over the subsequent six hours . This was done   however   as in problem number two below   we were not successful in any neurologic recovery . Neurology  The patient remained unresponsive after the induced hypothermia   the patient was noticed to develop myoclonic jerks and occasional fluttering of his eyelids . Electroencephalogram revealed the patient was experiencing persistent seizure activity . Neurology was consulted and the patient was treated very aggressively   loaded with multiple drugs   including Ativan and Propofol drips . The patient continued to demonstrate seizure activity despite this . He was loaded with Dilantin and ultimately was treated with a Pentobarb coma . After multiple attempts of weaning the Pentobarb   the patient was continually reverting to status epilepticus which was never able to be suppressed . Infectious disease  Over the course of his hospital stay   the patient s white blood cell count rose to a peak of 17 . Multiple cultures were done and the patient was ultimately found to have methicillin resistant Staphylococcus aureus bacteremia   pneumonia   and urinary tract infection . For all these infections   the patient was treated with Vancomycin and he was also on Levofloxacin and Flagyl for presumed aspiration pneumonia at the time of his admission . Blood cultures cleared by 2013-05-03 . Sputum culture as late as 2013-05-10   however was still positive for coagulase positive Staphylococcus which was methicillin resistant Staphylococcus aureus . The patient remained gravely ill throughout his hospital stay and had multiple meetings were held with his family with his son being his next of kin . Ultimately it was decided that the patient s wishes would be to not be maintained in a vegetative state and given his poor prognosis ultimately the decision was made to pursue comfort measures only . With these goals of care   the patient expired on 2013-05-11 . The family did consent to a postmortem examination . DISCHARGE DIAGNOSES  Cardiac arrest . Anoxic brain injury Status epilepticus Methicillin resistant Staphylococcus aureus pneumonia . MRSA urinary tract infection . MRSA Bacteremia . Steven Welch   Montana 61528 Dictated By  Julie DD George   M.D. MEDQUIST36 D  2013-12-24 135505 T  2013-12-24 204707 Job  52892 Signed electronically by  DR. Patricia Henley on  Maxine 2014-01-02 1045 AM,0
 Severe blunt abdominal trauma with rupture of liver   left renal vein   pancreas   and transverse mesocolon . SPECIAL PROCEDURES AND OPERATIONS  1. 7-2-93   emergency room exploratory laparotomy   repair of liver laceration   repair of torn transverse mesocolon   repair of serosal tear of transverse colon   ligation and division of ruptured left renal vein   exploration of pancreas   2. 7-4-93   exploratory laparotomy   irrigation and debridement   pancreatic drainage placement   gastrostomy tube   jejunostomy   cholecystostomy   placement of right subclavian Quinton catheter   3. 7-10-93   abdominal irrigation and debridement and packing of pancreas   4. 7-12-93   7-14   7-20   7-22   and 7-24   were the same as 7-10-93   and 7-17 was the same with the addition of tracheostomy were same as 7-10   COMPLICATIONS  Severe necrotizing pancreatitis and diffuse peritonitis . MEDICATIONS ON DISCHARGE  N    A. DOCTORS DISCHARGE ORDERS N    A. ESTIMATED DISABILITY AND PROBABLE DURATION  N    A. DISPOSITION  Mason Street . RISSPA BREATH   M.D. TR  un    bmot DD 08-07-93 TD,2
"The patient is to be transferred to the Cambridge Hospital Hospital Special Care Nursery .', ",3
 He is healthy looking . The general physical examination did not reveal any abnormality . Heart   chest   and abdominal examinations were normal . The right knee examination showed some effusion . The range of motion was 15 to 120 degree on the right side  and on the left side   it was zero to 135 . There was normal muscle power . The peripheral pulses were palpable .,1
"Continue breast feeding with post-feed supplemental EBM . Follow-up bilirubin in 1 day  f  u with PMD in 1-3 days . Medications  Not applicable . Car seat position and screening', 'Not applicable . State newborn screens were sent on 2018-12-31   and the results are pending . Immunizations received  Hepatitis B vaccine on 12-31   2006 .', 'Immunization recommended  Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age . Before this age  and for the first 24 months of the child s life', 'immunization against influenza is recommended for all household contacts and out of home caregivers .",2
 All systems were reviewed and were negative except as given above . MEDICATIONS  Metformin   Zocor   and analgesics . ALLERGIES  None .,0
 Notable for a white blood cell of 9.5   ANC 7.7   hematocrit 26   platelets of 248   BUN and creatinine 12. and 1.2 respectively   magnesium 1.1   calcium 8.7 .,1
 Prilosec 20 mg p.o. q.d.  Percocet 1-2 tabs p.o. q.6-8h. x5 days  MVI 1 tab p.o. q.d. DISCHARGE FOLLOW-UP  The patient was advised to follow-up with Dr. Edwards in clinic in one week . CONDITION ON DISCHARGE  Stable condition . DISCHARGE DISPOSITION  The patient was discharged to home . Dictated By  SON RHALT   SUBINTERN . Attending  MOPAIGEIT S. SOLID   M.D. KP91 KX681  6848 Batch  52108 Index No. GAEHS07465 D  03  01  00 T  03  01  00 CC  1.,2
 Dyazide one p.o. q.d. Propanolol 5 mg. p.o. t.i.d. Isordil 5 mg. p.o. t.i.d. Glaucoma drops .,3
 Atrial fibrillation 2 s  p MVR  mechanical  3 CHF EF 15 4 HTN 5  multiple CVA s  last 1998  6 Hypercholesterolemia 7  Type II DM 8 Multiple prior UTI Social History  Lives in Danvers with wife   denies Timothy or alcohol,0
 1  Lasix 20 mg. PO q.d. 2  Sinemet 25  100 1 t.i.d. 3  Cogentin 0.5 mg. 1 tabs PO q.a.m. and 1 q.noon as well as 1 q.h.s. 4  Eldepryl 5 mg. PO b.i.d. 5  Enteric coated aspirin 325 mg. PO q.d. 6  Potassium chloride 10 mEq. PO q.d.,3
"Term  37 and 1  7 weeks  appropriate for gestational age male neonate . Exaggerated physiologic hyperbilirubinemia responsive to phototherapy .', 'Nicole Monica   MD 48-041 Dictated By  Michelle A Sweeney   M.D. MEDQUIST36 D  2019-01-02 121610 T  2019-01-02 130035 Job   38170 Signed electronically by  DR. Victoria Cox on  FRI 2019-01-04 1125 AM'",2
 ON ADMISSION  On presentation   temperature 99.3 degrees F   other vital signs were within normal limits . He was in no acute distress   non-toxic . Cardiovascular  Regular rate and rhythm . Pulmonary  Clear to auscultation bilaterally . Abdomen soft and there was wound erythema with three areas of dehiscence draining foul-smelling   purulent fluid . The fascia appeared intact by probing . The stoma was pink and functional . The wound was a midline incision for his radical cystoprostatectomy .,1
 Notable for a BUN and creatinine of 78   1.7  for a sodium   potassium 139 and 3.6  chloride and bicarb 108   21 . White count 7   hematocrit 24.2 platelet count was 183 . His INR was also 3.4 . PTT was 55 . His EKG was notable for right bundle branch block   left axis deviation   but was in sinus rhythm . His UA had 10-17 white blood cells  trace leukocyte esterase hyaline casts numbering 60-70 . His chest x-ray was notable for clear lungs with no edema or infiltrates and small bilateral effusions . OTHER NOTALBE LABS  Patient was found to have a troponin of 0.71 on admission with a CK of 46 and CKMB of 3.4 . ,1
 Stable . DISCHARGE STATUS  Leona Wheeler is to be transferred on 2015-07-17 to a rehabilitation facility . DISCHARGE DIAGNOSIS  1. Status post CABG times four . Meghan G. Bardin   M.D. 43 -132 Dictated By  Louise B. Robertson   M.D. MEDQUIST36 D  2015-07-17 0839 T  2015-07-22 1029 JOB   72575 Signed electronically by  DR. Derek Vildosola on  WED 2015-07-29 115 PM,2
 Alcohol abuse in the past  Chronic obstructive pulmonary disease .  Chronic pleural effusions  Chronic renal insufficiency with baseline creatinine 1.8-2 . 5  Ischemic bowel status post SMA Percutaneous Transluminal Coronary Angioplasty . 6 Serratiaurosepsis .  Positive PPD . 8 Status post total hip replacement . 9  Right bundle branch block with left anterior hemiblock on electrocardiogram  Allergies to penicillin   sulfa   codeine   morphine sulfate .Medications on transfer included thiamine  multivitamin  Pepcid  ceftizoxime 1 gm intravenously q. eight hours  Flagyl 500 mg intravenously q. eight hours  gentamicin 80 mg IV q. 24 hours  Ventolin inhaler  Lotrimin cream  sliding scale nitro paste  pyridium  Vancomycin 125 mg p.o. q.i.d.  and calcium carbonate .  Habits  Positive for cigarettes of 40 pack    years quit in 1990.  Positive alcohol abuse in the distant past  Family history is positive for tuberculosis   hypertension   and alcoholism .  Social history  Former Vermont blacksmith  He has one son and lives in a nursing home .,0
 ON ADMISSION  Birth weight 1455 grams  50th percentile   head circumference 29.25 cm  50th percentile   length 41.5 cm  50th percentile . Nondysmorphic with overall appearance consistent with gestational age . Anterior fontanel soft   open   flat   red reflex present bilaterally   palate intact . Intermittent grunting   moderate intercostal retractions   diminished air entry   regular rate and rhythm without murmur   2 femoral pulses . Abdomen benign with no hepatosplenomegaly or masses . No external female genitalia . Normal back and extremities with stable hips   appropriate tone   skin pink with fair perfusion . ,1
 PHYSICAL EXAM  VITAL SIGNS   He was afebrile with stable vital signs HEART  Regular rate and rhythm with a 2 out of 6 systolic ejection murmur heard loudest at the apex .  LUNGS  Clear to auscultation .  ABDOMEN  Soft   nontender   nondistended .  EXTREMITIES  No cyanosis   clubbing or edema .  Palpable DP s bilaterally  PERTINENT LABS   His hematocrit was 44  White count was 8 .  Potassium was 3.9  BUN and creatinine was 18 and 0.9 .  His troponin was 29.7,1
 Significant for sodium 140   potassium 3   BUN 35   creatinine 3.6   liver function tests within normal limits   calcium 6.6   albumin 2   magnesium1.4   PT 14   white count 30.1 with 77 polys   13 bands   5 lymphs   and 5 monos . Urine sodium is 75   urine creatinine 143 urine osmose 392 . Pleural fluid pH is 7.29   glucose 91   total protein3.1   LDH 296   70 white blood cells   50 red blood cells . HOSPITAL COURSE  1. Colitis . The patient has a history of ischemic bowel status post SMA Percutaneous Transluminal Coronary Angioplasty with recent admission for gram negative rod urosepsis complicated by C. difficile colitis . The patient received a full course of Flagyl and was C. difficile toxin negative times three prior to transfer . He now returns with fever   rising white count   diarrhea   and dehydration . Initially treated with intravenous ceftizoxime   gentamicin   and Flagyl for presumed sepsis   either with urine or bowel source . He was also started on p.o. Vancomycin . Blood cultures and urine cultures came back negative . Stool for C. difficile returned positive . The diagnosis   therefore   was relapsed C. difficile colitis . Intravenous antibiotics were discontinued and the patient was continued on p.o. Vancomycin . He improved clinically with defervescence   decreased white blood cell count to 10 000 with resolution of left shift   and some decrease in abdominal distention on exam . An abdominal CAT scan revealed thickened bowel wall and thumb printing   primarily involving the cecum and right colon greater than the left   consistent with C. difficile colitis . The diagnosis of recurrent bowel ischemia   however   was not ruled out and this will continue to be a concern in the future . The patient was initially n.p.o. and was then advanced to clear liquids which he tolerated . He will be advanced to soft solids prior to discharge . 2. Azotemia . The patient has chronic renal insufficiency with baseline creatinine 1.8-2 . Creatinine had risen to 4.3 on admission presumed secondary to sepsis and dehydration . With intravenous hydration the BUN and creatinine fell to 12  1.9 which is within normal limits for this patient . The abdominal CAT scan showed no evidence of hydronephrosis orrenal abscess . 3. Mental status . The patient was alert and oriented throughout the admission  however   by personality   he is somewhat cantankerous and demanding of the nurses . He was written for Haldol 1 mg p.o.b.i.d. p.r.n. to help with this problem . DISCHARGE DISPOSITION  Medications on transfer include multivitamin 1 tablet p.o. q.d.  Pepcid 20 mg p.o. b.i.d.  Ventolin inhaler two puffs q.i.d.  Vancomycin 125 mg p.o. q.i.d. times seven days  calcium carbonate 1250 mg p.o. b.i.d.  Lotrimin cream to groin b.i.d. p.r.n.  O2 at four liters per minute  and Haldol 1 mg p.o. b.i.d. p.r.n. Dictated By  CA NA SHUFF   M.D. SO92 VX072  9578 TRANGCA CHIRDSTEN   M.D. ZO84 D  07  17  91 T  07  17  91 Batch,1
 Notable on admission were BUN and creatinine of 8.0 and 0.7 . Sodium 134   ALT 18   AST 27   LDH 221   white count 2.05   hematocrit 23   platelet count 137 000 . The differential showed 45 polys   6 bands   8 lymphs   32 monos . Urinalysis was negative . Sputum gram stain showed no polys and no bacteria . AFB stain was negative . Chest X-ray was consistent with an old chest X-ray on 08  08  92 showing a resolving left lower lobe and lingular infiltrate and resolution of the right mid lung infiltrate .,1
 Tylenol 650 mg p.o. q. 4 -6h p.r.n. headache or pain  acyclovir 400 mg p.o. t.i.d. acyclovir topical t.i.d. to be applied to lesion on corner of mouth  Peridex 15 ml p.o. b.i.d. Mycelex 1 troche p.o. t.i.d. g-csf 404 mcg subcu q.d. folic acid 1 mg p.o. q.d. lorazepam 1-2 mg p.o. q. 4 -6h p.r.n. nausea and vomiting  Miracle Cream topical q.d. p.r.n. perianal irritation  Eucerin Cream topical b.i.d. Zantac 150 mg p.o. b.i.d. Restoril 15 -30 mg p.o. q. h.s. p.r.n. insomnia  multivitamin 1 tablet p.o. q.d. viscous lidocaine 15 ml p.o. q. 3h can be applied to corner of mouth or lips p.r.n. pain control . CONDITION UPON DISCHARGE  Stable . FOLLOWUP Follow up appointment with Die Anoort and Tomedankell Care on 11  18  00 at 930 a.m.  one day after discharge  . The patient knows to go to Sper Medical Center every day for line care   blood draws   and monitoring . Dictated By  CONRELLIE KOTERUDES   M.D. VJ31 Attending  SUOT CARE   M.D. OB89 RL958  5760 Batch  24769 Index No. GFNC2Z5N8Q D  11  22  00 T  11  22  00 CC  1.,2
 ON admission physical examination reveals a non dysmorphic infant   well saturated and perfused with multiple bruises noted over the upper legs   left arm and chest . No bony abnormalities or petechiae noted . She was moving all joints and extremities well . HEENT  Within normal limits . CV  Normal S1 and S2 without a murmur . Lungs were clear . Abdomen was benign . Genitalia normal . Premature female . Neuro  Non focal and age appropriate . Hips normal   held in the breech position . Anus patent . Spine intact .,1
"The patient was admitted to the Hospital and was taken to the operating room for an open Bankart procedure with biceps tenodesis', 'Please see the operative note for full details  . Postoperatively   the patient did very well and was neurovascularly intact.', 'His wound was intact   clean and dry and it was covered with perioperative antibiotics . He was discharged to home on Percocet.', 'He was given strict instructions to limit his external rotation no more than 30 degrees . He was seen by physical therapy prior to discharge",2
 Hydrochlorothiazide 50 mg p.o. q day   atenolol 50 mg p.o. q day   dicloxacillin started on December 29   2002   Naproxen 500 mg p.o. t.i.d.   aspirin 81 mg p.o. q day   Tylenol p.r.n. SOCIAL HISTORY  Widowed since 1972   no tobacco   no alcohol   lives alone . Smoked 3 packs per day x 17 years .,3
 On admission . GENERAL  He was well-appearing and in no apparent distress . Performance status was 0 . VITAL SIGNS  Weight 70.4 kilograms   temperature 96.5   respiratory rate 20   blood pressure 105  60   pulse 76 . SKIN  Unremarkable without rashes or lesions . HEENT  Sclerae anicteric . Pupils equal   round and reactive to light . Oropharynx   lips   teeth and gums were without lesions and without evidence of mucositis . NECK  Supple with a normal thyroid gland . No cervical   supraclavicular or axillary adenopathy . CHEST  Clear . HEART  Heart sounds normal . ABDOMEN  Soft   nontender   without any masses and without any hepatosplenomegaly . GU  Normal testes and penis . EXTREMITIES  Without clubbing   cyanosis or edema . NEURO  Normal with intact cranial nerves   deep tendon reflexes and normal motor    sensory exam .,1
 As above . PAST SURGICAL HISTORY   02  90   total abdominal hysterectomy complicated by ureteral transection with right ureteral tube placed for six weeks   stent tube placed in left ureter six weeks prior to admission for a hydronephrosis post   in 03  91   bilateral salpingo-oophorectomy and appendectomy  CURRENT MEDICATIONS   Prednisone 20 mg p.o. q.a.m with 10 mg p.o. q.p.m.   Uniphyl 400 mg p.o. q.d.   Augmentin 250 p.o.  t.i.d.   Estrase 2 mg p.o. q.d.   MS Contin 30 mg  q.12h.   and Morphine p.r.n.,0
 Notable for a sodium of 145   potassium 3.6   BUN 23   creatinine 1.3   glucose 104   hematocrit 42   white count 8.7   platelet count 235 and a PT of 12.9 seconds . The urinalysis was negative . The Troponin I was less than .4 and the creatine kinase was 114 . Chest x-ray revealed moderate cardiomegaly with no clear interstitial or alveolar pulmonary edema and chronic atelectasis and    or scarring at both lung bases . The electrocardiogram revealed normal sinus rhythm with premature atrial complexes and right bundle branch block with left anterior hemiblock and old anterior myocardial infarction .,1
 Initial white count 19.4 thousand   64 polys   3 bands   hematocrit 35.8   platelets 281 000 . Chest x-ray revealed streaky lung fields of normal situs   no consolidation   consistent with retained fetal lung fluid . ,1
 Acetaminophen 325 mg Tablet Sig  Two  2  Tablet PO Q4-6H  every 4 to 6 hours  as needed for fever or pain . Albuterol-Ipratropium 103-18 mcg  Actuation Aerosol Sig  06 -17 Puffs Inhalation Q2-4H  every 2 to 4 hours  as needed . Calcium Acetate 667 mg Capsule Sig  Two  2  Capsule PO TID W  MEALS  3 TIMES A DAY WITH MEALS  . Fentanyl Citrate  PF  0.05 mg  mL Solution Sig  25-100 mcg Injection Q2H  every 2 hours  as needed for comfort . Insulin Regular Human 100 unit  mL Solution Sig  2-10 units Injection ASDIR  AS DIRECTED   per sliding scale for blood sugars > 150mg  dl . 6. Midazolam 1 mg  mL Solution Sig  1-2 mg Injection Q2H  every 2 hours  as needed for comfort . 7. Phenytoin Sodium 50 mg  mL Solution Sig  One 95y  150  mg Intravenous Q8H  every 8 hours  . 8. Ranitidine HCl 15 mg  mL Syrup Sig  One 95y  150  mg PO DAILY  Daily  . 9. Polyvinyl Alcohol-Povidone 1.4-0.6  Dropperette Sig  01-12 Drops Ophthalmic QID  4 times a day  . Discharge Disposition  Extended Care Discharge Diagnosis  Hypoxic brain injury Cranial hemorrages  sub arachnoid and parenchemal  Pseudomonal sepsis   completed antibiotic course Metastatic Squamous cell carcinoma of unknown primary . Thrombocytopenia Blood loss anemia Discharge Condition  Intubated   stable Discharge Instructions  You are being transferred to another hospital   intubated   with the plan to extubate upon arrival to Women s and Infants hosptial and initiation of palliative care . . Your antibiotics were stopped 2016-05-15  Vancomycin 1000mg q24 and Aztreonam 1000mg q8  as your micorbiology data has been negative and your course for pseudomonal sepsis has been completed . If you continue to have fevers   blood cultures should be repeated . Followup Instructions  As directed . Jacque John MD 40-836 Completed by  Marcy Caroline Latham MD 51-251 2016-05-31  1628 Signed electronically by  DR. Richard Ronald Lockett on  MON 2016-08-01,2
 ON ADMISSION  General The patient was in no acute distress   well developed . Vital signs  Stable   afebrile . HEENT  Normocephalic   atraumatic . PERRL   anicteric   EOMI . The throat was clear . Neck  Supple   midline   without masses or lymphadenopathy . No bruit or JVD . Cardiovascular  Irregularly    irregular without murmurs   rubs   or gallops . Chest  Clear to auscultation bilaterally . Abdomen  Soft   nontender   nondistended   without masses or organomegaly . Extremities  Warm   noncyanotic   nonedematous times four . Neurological  Grossly intact . ADMISSION LABORATORY DATA  CBC 11.3    15.7    44.6    183 . PT 14   INR 1.3   PTT 115 . Chemistries  137    4.3    104    22    14    0.7    155 . ALT 27   AST 21   alkaline phosphatase 72   total bilirubin 1.2   amylase 47 . The U  A was negative .,1
 On admission   includes an electrocardiogram that shows DDD pacing . Hematocrit 39 percent   white blood cell count 4500   PT and PTT normal . Sodium 140   potassium 4.2   chloride 105   carbon dioxide 30   BUN 24   creatinine 1.0 . HOSPITAL COURSE AND TREATMENT  The patient was admitted to the Cardiac Catheterization Laboratory . There   her pulmonary wedge pressure was 12 and her right atrial pressure was 4 and pulmonary artery pressure 44  17 . Her left ventricular contraction showed akinesis of the anterior wall with dyskinesis of the apex . She had preserved inferior contraction and basal contraction . Her native right and left anterior descending vessels were occluded as was an obtuse marginal branch . The saphenous vein to the high diagonal or high obtuse marginal was occluded . The left internal mammary artery to the left anterior descending was also occluded . The saphenous vein graft to the second obtuse marginal was open with no significant stenosis   but there was an outflow lesion in the obtuse marginal 2 as well as severe distal lesion as the obtuse marginal 2 fed the posterior descending artery . This was considered her culprit lesion . This was considered too high risk for angioplasty because of the severe disease in the graft . In addition   it was noted that she had saphenous vein harvested from both thighs . Her left internal mammary artery was also unused . It was also noted that she had failure to sense with the atrial lead . She would not sense the atrial contraction and the fire and this occasionally led to competition of firing . This was intermittent . The P wave amplitude was .6 and this could not be totally sensed . The patient was admitted for management of her coronary artery disease and evaluation of her pacemaker . It was noted that she became very symptomatic when she was not on a beta blocker but that on a beta blocker she had significant pacemaker failure . Her pacemaker was set to a VVI mode which sensed appropriately . She was in sinus rhythm with most of the time . When her pacemaker was in a sinus rhythm without a beta blocker   she had significant angina . Carotid non-invasive testing was unremarkable . The situation was reviewed with Dr. Niste Graft . He felt the patient was not a coronary artery bypass graft candidate because of the lack of conduit and because of the presence of a large anterior myocardial infarction . For this reason   it was decided to maximize her beta blockers and nitrates . The situation was reviewed with Dr. No of the Pacemaker Service . On August 20   under local anesthesia the right pectoral region was explored and the leads disconnected and the pulse generator changed to a CPI unit in which the sensitivity could be adjusted to .15 mm.   which permitted appropriate atrial sensing . There was nothing wrong with the prior generator and nothing wrong with the leads . It just needed a unit that could have more sensitivity in the atrial mode . She tolerated this well . Her medications were resumed . She ambulated without difficulty and was discharged to home to be followed medically for her coronary artery disease following two failed bypass graft procedure by Dr. Brendniungand Asilbekote in Bi Masase   KS . ACHASTHA N. GRAFT   M.D. TR  hfr DD  08  22  1998 TD  08  27  1998 356 P cc  ACHASTHA NICEMAEN GRAFT   M.D. GITTETUMN DARNNAMAN,1
DISPOSITION  MEDICATIONS at the time of discharge are G-CSF 300 micrograms subcu q. day   Acyclovir 200 mg p.o. b.i.d.   Erythromycin 500 mg p.o. b.i.d.   Dapsone 50 mg p.o. Monday   Wednesday and Friday   Imodium 1-2 tablets p.o. q. 6 hours p.r.n.   Nystatin 5 cc swish and swallow q.i.d Serax 50 mg p.o. q. 6 hours p.r.n. and Kay-Ceil 40 mEq p.o. b.i.d. The patient needs to have his blood drawn the day after discharge to check a potassium and magnesium which he has been wasting secondary to Amphotericine . He will probably need potassium and magnesium replacement . He will need follow up lytes drawn throughout the week . CR887  2594 TRANGCA FERCI CHIRDSTEN   M.D. UO2 D  09  07  92 Batch  5346 Report  P4722W3 T  09  09  92 Dicatated,3
"Discharge medications  Baclofen 10 p.o. t.i.d.   MVI one tablet p.o. q.d.   Mycostatin powder TP q.d. to be applied to the rash in her left groin area   also dilaudid 8 mg p.o. q2h   Colace 100 mg p.o. b.i.d.', 'coumadin 2.5 mg p.o. q.h.s. fentanyl patch 75 micrograms per hour topical q72 hours   atenolol 100 mg p.o. q.d.",3
 Good . DISCHARGE DIAGNOSES  Community-acquired pneumonia . Acute respiratory distress syndrome . Iron-deficiency anemia . Hypothyroidism .,2
 PHYSICAL EXAMINATION ON PRESENTATION The patient had a temperature of 100.9 . He had a blood pressure of 148 to 162  45 to 54 . He had a heart rate of 85 to 87   breathing at 17 to 23   satting 100 on room air . In general   he was alert and in no acute distress . His neck was supple without any jugular venous distention . HEENT examination revealed his pupils were equal   round   and reactive to light . His extraocular movements were intact . His sclerae were anicteric . His mucous membranes were moist . His oropharynx was benign . Cardiovascular revealed a regular rate and rhythm   heart sounds muffled   no murmurs . Respiratory revealed bibasilar rales . Abdomen was soft   nontender   and nondistended   positive bowel sounds . Extremities revealed trace lower extremity edema   right greater than left   2 dorsalis pedis and posterior tibialis pulses . He had 2 femoral pulses bilaterally . No hematomas were noted   but a soft right femoral bruit was heard . LABORATORY DATA ON PRESENTATION  The patient had a white blood cell count of 9.5   a hematocrit of 34.5   a platelet count of 194 . His Chem-7 revealed sodium of 132   potassium of 43   chloride of 97   bicarbonate of 28   BUN of 25   creatinine of 1.3   glucose of 220 . He had an INR of 1.1 . A calcium of 8.4   phosphate of 2.5   magnesium of 1.9 . Pericardial fluid analysis was consistent with an exudative etiology . RADIOLOGY    IMAGING  The patient had an electrocardiogram with normal sinus rhythm at 70   normal axis   normal intervals   low voltage in the limb leads . Chest x-ray on admission revealed a large left pleural effusion . The patient had an echocardiogram on 11-10 which revealed the following  Global left ventricular systolic function appeared grossly preserved . Due to technical quality a focal wall motion abnormality could not be fully excluded . The aortic valve leaflets were mildly thickened . The mitral valve leaflets were mildly thickened . There was a large pericardial effusion  up to greater than 6 cm wide anterior to the right ventricle . The right ventricle was compressed .,1
 Coumadin 5 mg po q d   Tagamet 400 mg po q d   Amoxicillin which was started on Labor Day   for a sore throat and Ativan 1 mg po prn nausea    anxiety .,3
 On admission   the Baby Lucas is well appearing   no jaundice . He has bilateral breath sounds that are clear and equal . The heart rate is regular without murmur . Pulses are 2 and symmetrical . The abdomen is soft and nontender with no hepatosplenomegaly . His weight is 3.160 kilograms  7 pounds 3 ounces  at birth . He is circumcised with testes descended bilaterally . His hips are stable . His tone is normal . Normal neonatal reflexes . He is tolerating his feedings well . ,1
 Neurontin   Keppra   Lamictal   decadron   multivitamin   Murray   Calcium Discharge Medications  1. Heparin Sodium  Porcine  5 000 unit    mL Solution Sig  One  1  Injection TID  3 times a day  . 2. Diphenhydramine HCl 25 mg Capsule Sig  One  1  Capsule PO Q6H  every 6 hours  as needed . 3. Albuterol  Ipratropium 103-18 mcg    Actuation Aerosol Sig  03-04 Puffs Inhalation Q4H  every 4 hours  as needed . Acetaminophen 325 mg Tablet Sig  1-2 Tablets PO Q4-6H  every 4 to 6 hours  as needed . Fluticasone  Salmeterol 250-50 mcg    Dose Disk with Device Sig  One  1  Disk with Device Inhalation BID  2 times a day  . Lamotrigine 100 mg Tablet Sig  1.5 Tablets PO BID  2 times a day  . Levetiracetam 500 mg Tablet Sig  Three  3  Tablet PO BID  2 times a day  . Ibuprofen 400 mg Tablet Sig  Two  2  Tablet PO Q8H  every 8 hours  as needed . 9. Docusate Sodium 100 mg Capsule Sig  One  1  Capsule PO BID  2 times a day  . 10. Pantoprazole Sodium 40 mg Tablet   Delayed Release  E.C.  Sig  One  1  Tablet   Delayed Release  E.C.  PO Q24H  every 24 hours  . 11. Ciprofloxacin 500 mg Tablet Sig  One  1  Tablet PO Q12H  every 12 hours  for 2 weeks. Tablet  s  Metoprolol Tartrate 25 mg Tablet Sig  0.5 Tablet PO BID  2 times a day  . Lorazepam 1 mg Tablet Sig  One  1  Tablet PO HS  at bedtime  as needed . 14. Dexamethasone 2 mg Tablet Sig  One  1  Tablet PO Q12H  every 12 hours  . 15. Insulin Regular Human 100 unit    mL Solution Sig  One  1  Injection ASDIR  AS DIRECTED   51-150 0 Units 151-200 2 Units 201-250 4 Units 251-300 6 Units 301-350 8 Units 351-400 10 Units > 400 Bessie MD 16. Hydralazine HCl 20 mg    mL Solution Sig  0.5 syringe Injection Q4HR   as needed for sbp > 150 . Disp  qs syringe  Refills  0  Discharge Disposition  Extended Care Discharge Diagnosis  Cerebrospinal fluid leak Chronic steroid use wound infection Perforated sigmoid diverticulum status post exploratory laparotomy Status post sigmoid colectomy   hartmans pouch and washout Post operative fever fever status post Reveision Right craniotomy and revsion of bone flap change in mental status Seizure Conant palsy with Left sided weakness Respiratory failure requiring intubation Methicillin resistant staph aureus infection of central nervous system Pelvic abscess oligodendroglioma Asthma S  p craniotomy x 3 Hernia Surgery x 3 Discharge Condition  Good Discharge Instructions  Call with any spiking fevers   leakage from your head wound   increase in headaches   confusion   blurry vision severe neck stiffness   redness   swelling   or discharge around your wound site Call your general surgeon if you experience increased abdominal pain   vomiting   decreased or increased ostomy output . Followup Instructions  1. Dr. Martha Lopez or Dr. Henson in infectious disese in 2 weeks . Call for an appointment  724  875 5043 2. Dr Fisher in General surgery   1 week   call his office for an appointment . 515-3442 3. Follow up in 1 week at brain tumor clinic . Call for an appointment 908-6508 Cherrie Celeste MD 44-924 Completed by  Angie Irene MD 36-512 2012-06-19  0950 Signed electronically by  DR. Charles Mcwilliams on,3
 Included a white blood count of 140 000   7 polys   1 bands   3 lymphs   1 monos   2 basos   4 blasts   76 pearl monocytes   6 meta &aposs   3 nucleated red blood cells . There were some oval tear drop cells and target cells with a few schistocytes . The platelet count was 9 000   hematocrit was 26.5   with an mean corpuscular volume of about 73 . His prothrombin time and partial thromboplastin time were normal . His uric acid was up at 97   his total bilirubin was up at 1.8   his LDH was 428   his phosphorus was 1.2   calcium 8.6   Digoxin level was 1.0   potassium on admission was 2.9   sodium 135   BUN and creatinine 13  1.6   and sugar of 267 . A computerized tomography scan of his head showed no signs of an acute bleed   a chest X-ray showed no new infiltrates or masses . There was cardiomegaly with prominent vascularity   but no effusions . An electrocardiogram was consistent with atrial fibrillation .,1
 ON ADMISSION  On admission   Thomas was well-appearing though slightly sleepy with jaundice . He had bilateral breath sounds that were clear and equal . The heart rate was regular without murmur   and pulses were 2 and symmetrical . The abdomen was soft and nontender with no hepatosplenomegaly . His weight was 3.505  7 pounds    12 ounces  on readmission . He had normal male genitalia with bilaterally descended testes . His hips were stable . His tone was normal with normal neonatal reflexes . He is tolerating his feedings well . SUMMARY OF HOSPITAL COURSE  RESPIRATORY  Without issues on this admission . Breath sounds are clear and equal . CARDIOVASCULAR  Without issues on this admission . He had a regular heart rate and rhythm   no murmur   and pulses were 2 and symmetric . FLUIDS   ELECTROLYTES AND NUTRITION  Alleyne birth weight was 3.710 kg  8 pounds    3 ounces . His weight on this admission was 3.505 kg  7 pounds    12 ounces . Linda is breast feeding every 3 hours and supplementing with expressed breast milk . He is feeding well . His discharge weight is 3585 grams  7 pounds 13 ounces  . GASTROINTESTINAL  Alleyne bilirubin on 2018-05-09 was 10.4  at which time he was discharged to home . At the primary pediatrician s office on 2018-05-12 his bilirubin had been 23   at which time he was readmitted to the HealthSouth Rehab Hospital of Western Mass. and double phototherapy was started . His bilirubin on 05-13 was 18.4  and on 05-14 it was 14.7 . Phototherapy was discontinued on 2018-05-14   and a rebound bilirubin will be checked in the pediatrician s office . HEMATOLOGY  The hematocrit on 05-12 was 48.7 with a reticulocyte count of 1.9   and his blood type is O    Coombs negative . INFECTIOUS DISEASE  No issues on this admission . NEUROLOGICAL  The infant has been appropriate for gestational age . ,1
 He had mild elevation of the WBC intermittently grossly bloody urine . No cultures were positive but the chest x-ray showed bilateral densities more on the left than the right compatible with aspiration pneumonia . There were no radiographic indications of congestive heart failure . HOSPITAL COURSE AND TREATMENT  The patient was started on Clindamycin intravenous and Cefuroxime intravenous with clearing of his fever but persistence of cough   choking   and intermittently many coarse rales in his base with no clearing by x-ray . His ambulation was minimal and always with assistance but he had a transurethral resection of the prostate on 09  14  96 . He is transferred to Louline Mauikings Medical Center for future rehabilitation and hopeful return home with considerable support and assistance .,1
 He was a chronically ill appearing elderly man   with a respiratory rate of 30   temperature 99.6   pulse 100   and irregularly irregular   blood pressure 148  71 . He had some petechiae on his extremities   as well as in his mucosal membranes with some hemorrhagic bullae . There were bibasilar rales with some wheezing . He had no cardiac murmur . His abdomen was distended with massive hepatosplenomegaly   which was somewhat tender . The neurological examination aside from the blind right eye was unremarkable .,1
 PHYSICAL EXAMINATION  Emaciated white female in mild respiratory distress .  Temperature was 98.1   heart rate 116   blood pressure 120  68   and room air O2 saturation was 93  HEENT   Dry mucous membranes and myotic pupils  NECK   No lymphadenopathy  CHEST   Few inspiratory wheezes and no rhonchi  HEART   Regular rate and rhythm with tachycardia and no rubs or murmur  ABDOMEN   Well healed Pfannenstiel scars and no masses  PELVIC   No masses  RECTAL   No masses and guaiac negative  EXTREMITIES   No edema or cyanosis  LABORATORY EXAMINATION   Hematocrit was 40   white count was 21   and platelet count of 723 000  PT and PTT were 12 and 26 .  Electrolytes were within normal limits   liver function tests within normal limits   and EKG showed a heart rate of 128   axis 73   and possible ectopic P,1
 Lopressor 25 mg p.o. b.i.d. Lasix 20 mg p.o. q. 12 hours times seven days . 3. Potassium chloride 20 mEq p.o. q. 12 hours times seven days . Colace 100 mg p.o. b.i.d. Metformin 500 mg p.o. b.i.d. Percocet 5  325 one to two tablets p.o. q. four to six hours p.r.n. Celexa 20 mg p.o. q.d. Lipitor 20 mg p.o. q.d. Warfarin 5 mg p.o. q.d. times four days   after which point the patient s dosage schedule is to be coordinated by his PCP   Dr. Jerold Esqueda . DISCHARGE INSTRUCTIONS  The patient is to maintain his incisions clean and dry at all times . The patient may shower but should pat dry incisions afterwards  no bathing or swimming until further notice . The patient may resume a Heart Healthy Diet . The patient had been advised to limit his physical exercise  no heavy exertion . No driving while taking prescription pain medications . The patient is to have his Coumadin managed by his primary care provider   Dr. Jerold Esqueda   for a target INR of 2.5 . The patient is to report to Dr. Jones office on 2010-06-14 for an initial blood draw and subsequent Coumadin titration  Coumadin levels are to be monitored per his PCP David . The patient is to follow-up with Dr. Leanne Larimore in Cardiology within two to three weeks following discharge . The patient is to follow-up with Dr. Brenda Hummer four weeks following discharge . The patient is to call to schedule all appointments . Tracy X. Carmen   M.D. 76-050 Dictated By  Gerald R. Quiroz   M.D. MEDQUIST36 D  2010-06-12 0200 T  2010 -06-12 1421 JOB  47222 Signed electronically by  DR. Tiffany D. Picklesimer on  WED 2010-07-28,2
 Coronary artery disease . DISCHARGE DIAGNOSES  Coronary artery disease . Status post off pump coronary artery bypass graft times three .,2
 Metoprolol 50 mg PO b.i.d.   Isordil 20 mg PO t.i.d.   Ecotrin aspirin q.day .,3
"1.Respiratory . Without issues on this admission . Breath sounds are clear and equal . 2. Cardiovascular . Without issues on this admission . He had a regular heart rate and rhythm   no murmur', 'pulses were 2 and symmetric . 3. Fluids   electrolytes and nutrition . The baby s weight was 3.160 kilograms  7 pounds 3 ounces . He is breast and bottle feeding every 3 hours with expressed breast milk', 'and    or Enfamil . He is feeding well . His discharge weight is 3025 gm   and has been stable for past 2 days . 4. Gastrointestinal . The baby s bilirubin on 2018-12-31   was 15.5', '0.5 at which time double phototherapy was started . On 01-01   his bilirubin was 17.3    0.4 at which time triple phototherapy was started and then his subsequent bilirubins are 16.5', '0.4 on 2019-01-01   and 16.2    0.5 on 2019-01-02 . Phototherapy was discontinued on 2019-01-04 for a bilirubin of 12.1   and a rebound bilirubin will be checked on 01-05 . 5. Hematology .', 'The hematocrit on 01-02   was 61 with a reticulocyte of 2.6 . His blood type is A   Coombs negative . 6. Infectious disease . No issues on this admission . 7. Neurological .', 'The baby has been appropriate for gestational age with normal newborn reflexes . 8.', 'Sensory Auditory hearing screening was performed with automated brainstem responses . The infant passed both ears on 2018-12-30 . 9. Psychosocial . The family is invested and involved .'",0
 1. cerebrovascular accident . The patient suffered some mild weakness which was attributed to stenosis of the distal right internal carotid artery . This was determined by head CT   head MRI   head MRA   carotid noninvasive studies   transcranial Dopplers . The possibility of a cardiac origin was evaluated by echocardiogram and Holter monitor . Her echocardiogram curiously showed a normal left ventricular size and systolic function   a patent foramen ovale   with a trace right to left shunt   as determined by bubble study   trace MR was present . Previous echoes have shown MVP at the Ona Hospital . Her Holter showed up to 12 beats of SVT   but was otherwise unremarkable . The patient had a normal B12   negative syphilis serologies and normal thyroid function during this hospitalization . She was anticoagulated with heparin and after several days Coumadin was started . Her exact Coumadin dose is undetermined at this point   however it looks like it will be something around 5 mg a day . Her pro time and PTT have normalized at the time of discharge . She needs to be given 5 mg of Coumadin tonight   5  22  92 . In addition heparin should be started to drip on arrival at 400 units an hour . It is discontinued at the time of transport . The patient has received physical therapy and occupational therapy and her recovery is near complete . During evaluation of her neurologic status   it was determined that for several months prior to admission   the patient has been too unsteady to ambulate . On our exam she is found to have a significant amount of ataxia   especially in the midline and the exact cause of this is unknown . There are multiple possible contributions and this is where her need for careful internal medical evaluation has arisen . At the time we were to embark on this evaluation   the patient &aposs family strongly requested that she be transferred to the Sas General Hospital . What follows is a summary of her medical problems and their possible relationship to her ataxia . Her ataxia is likely due to some cerebellar function   though this is not certain . Moreover her MRI did not show any discrete cerebellar lesions . Our leading theory at this point is that her cerebellar dysfunction relates to perineoplastic syndrome   relating to her history of breast Ca . As I mentioned above   her evaluation was limited by her cardiologic status at the time . While mammogram and CA-15.3 and breast exam are all normal   the idea of a perineoplastic syndrome with or without concomitant breast Ca has reared its head . Two possible markers are anti-Hu syndrome and anti-Yo antibody . These tests were sent on the 18th and are pending at the time of discharge . The results can be obtained by paging me   Do A. Joasscchird   M.D. at 834-364-2251 . I will be happy to furnish the results . The patient has a history of MI in 1989 . Echocardiogram no longer shows wall motion abnormalities . EKG   when the patient goes out of left bundle branch block transiently shows an anterolateral Q  wave inversion . We would like to discontinue her Isordil to improve upon some orthostatic hypotension   but we are not certain whether her heart will tolerate this . Persantine thallium is scheduled at this time   but is yet to be performed . The patient has a history of orthostatic hypotension x many years . It has been evaluated in the past without success . During her hospitalization   we confirmed the presence of this   even when she was hydrated with saline   to a fractional excretion of sodium of 2 . Studies of her autonomic system did not document any dysautonomia . Studies of skin galvanic conduction were normal and her RR interval evaluation was not abnormal . This is a chronic problem but may be contributing to her current weakness and inability to walk . Florinef is to be considered   however stopping the Isordil is one goal . The patient has a history of bronchiectasis from a childhood pneumonia . In addition there is a distant history of M. kansasaii infection . This has been evaluated by Dr. Screen at Sas General Hospital and probably relates to her lung xray . CT at the Ona Hospital in 1989 showed similar findings . A chest CT was to be performed and may be yielding . A PPD was placed and is to be read on Saturday   4 26th . The left volar forearm has the PPD just proximal to the wrist crease and a candida albicans placed just distal to the antecubital fossa . The patient has a history of deep venous thrombosis in 1990   for which she received 6 months of Coumadin . Dopplers of her lower extremities were negative on this admission . It is doubtful that she has chronic PE   but this is one consideration . It is likely that she has pulmonary hypertension from her lung disease   and so this is a consideration . The patient had mild hyponatremia during this hospitalization with a sodium as low as 131 . We think this is likely due to an SIADH as she is euvolemic . This can be evaluated further and is not a problem at this time . The patient has glaucoma . Her medications are as listed below . Her ophthalmologist is aware of transfer . His name is Ettrent Can and he can be reached at 678-233-5033   b 549 . DOCTORS DISCHARGE ORDERS  Propanolol 5 mg. p.o. t.i.d.  hold for SBP less than 110    Isosorbide 5 mg. p.o. t.i.d.   hold for SBP less than 110   Colace 100 mg. p.o. b.i.d. Pilocarpine 4 one drop q.i.d. O.D. Pilocarpine 2 one drop b.i.d. O.S. Betasan 0.5 one drop b.i.d. O.D. . Bacitracin ointment one drop O.D. q.h.s. Ciprofloxacin 500 mg. one p.o. b.i.d. x four more days  until 5  25  92    for recently discovered siderobacter UTI . Coumadin 5 mg. p.o. q.h.s. She needs her dose on 5  22  92 . Heparin i.v. drip at 400 units per hour   on her arrival . In addition the patient requires occupational therapy and physical therapy .,0
"Pulmonary  On admission the infant required CPAP 6 cm of water   30 oxygen . Initial capillary blood gas was pH 7.29   CO2 47 . Infant was intubated on day of life two for increased respiratory distress', 'and received one dose of surfactant . Infant was extubated on day of life four to CPAP and transitioned to room air on day of life six . The infant has remained in room air throughout the hospitalization .', 'Caffeine citrate was started on day of life six and was discontinued on 05-23  day of life 18 . The last apnea and bradycardia was on 06-10 . 2. Cardiovascular  The infant has remained hemodynamically', 'stable throughout this hospitalization   no murmur . Heart rate 150 to 160   mean blood pressure 40 to 54 . 3.', 'Fluid   electrolytes and nutrition Infant was initially nothing by mouth receiving 80 cc per kilogram per day of D10W intravenously .', 'Infant was started on enteral feedings on day of life four and advanced to full volume feedings of 150 cc per kilogram per day by day of life seven .', 'During feeding advancement infant was given parenteral nutrition and intralipids . The infant tolerated feeding advancement without difficulty .', 'Infant was advanced to maximum caloric density of breast milk or premature Enfamil 26 calories per ounce with ProMod by day of life 11 .', 'Infant is currently on breast milk or Enfamil 24 calories per ounce po minimum 140 cc per kilogram per day . The most recent weight is 2525 g.', 'Head circumference 24.5 cm   length 45.5 cm . The most recent electrolytes on day of life five were sodium 145   chloride 115   potassium 4   TCO2 of 21 .', 'On day of life 25   calcium 10.1   phosphorus 6.9   alkaline phosphatase 341 . 4. Gastrointestinal  Infant was started on double phototherapy on day of life two for a maximum bilirubin level of 8.1 with', 'a direct of 0.3 . Infant decreased to single phototherapy and phototherapy was discontinued on day of life six . Rebound bilirubin level on day of life seven was 5.3 with a direct of 0.3 . 5.', 'Hematology  The infant did not receive any blood transfusions this hospitalization . The most recent hematocrit on day of life two was 47 . CBC on admission white blood cell count 8.9   hematocrit 47', 'platelets 243 000   6 neutrophils   0 bands . Repeat CBC on day of life two showed a white blood cell count of 8.4   platelets 95   41 neutrophils   0 bands . Repeat platelet count on day of life three', 'was 229 . 6. Infectious disease The infant received 48 hours of ampicillin and gentamicin for rule out sepsis . Blood cultures remained negative to date . Infant has not had any issues with sepsis this', 'hospitalization . 7. Neurology  Head ultrasound on day of life seven showed no intraventricular hemorrhage . A repeat head ultrasound on day of life 33 06-07 showed a slight increase of echogenicity', 'in the caudothalamic groove   which may represent tiny bilateral germinal matrix hemorrhages   no periventricular leukomalacia . A repeat head ultrasound is recommended in one month .', 'Normal neurological examination . Sensory   hearing screening was performed with automated auditory brain stem responses . Infant passed both ears . Ophthalmology', 'eyes examined most recently on 05-30 revealing immaturity of the retinal vessels   but no ROP as of yet . A follow up examination should be scheduled for the week of 06-20 .', 'Ophthalmologist is Dr. Cruea Franklin . 8. Psycho    social Parents involved . Triplet number one is still in the Neonatal Intensive Care Unit and triplet number three is home with family', 'and there is also a 2 year-old sibling .', 'CONDITION ON DISCHARGE', 'Stable on room air .",0
 BY SYSTEM  Respiratory  The baby was intubated in the Delivery Room   received two doses of surfactant . Radiograph revealed bilateral diffuse granular pattern consistent with surfactant deficiency . Maximum mechanical ventilation PIP 26   PEEP 6   rate of 25   maximum FIO2 35 percent . Mychelia was extubated to a CPAP of 6 cm on day of life two where she remained until day of life 20 . On day of life two   she was also loaded with caffeine and continues on caffeine at time of transfer . She was transitioned to a nasal cannula on day of life 20 and remains on nasal cannula O2 100 percent at 13 cc flow . She averaged 2-3 apnea episodes a day with bradycardia and desaturations . She has a comfortable respiratory rate and good air exchange . Cardiovascular  She received a normal saline bolus times one initially for poor perfusion and was started on dopamine with a maximum infusion rate of 6 mcg per kg per hour . This was discontinued on day of life two to maintain a mean arterial pressure of greater than 33 . She has remained hemodynamically stable during the remainder of her hospitalization here . Fluids   electrolytes   nutrition  Initially maintained NPO . UAC and UVC lines were placed upon admission to the CMED . The UAC was left in place until day of life two and was removed after wean from dopamine . UVC remained in place through day of life six and was utilized to administer parenteral nutrition . Electrolytes and glucose remained in the normal range throughout the first week . She was started on enteral feeds on day of life six with a slow advance secondary to increased abdominal girth which was felt to be due to CPAP . She passed meconium . She achieved full feeds on day of life 13 . Calories were gradually increased to breast milk 30 calories with ProMod consisting of four of human milk fortifier   four of MCT and two of Polycose with a 12-28 teaspoon of ProMod per 50 ml of breast milk or 60 ml of formula . On day of life six due to concerns for hyperglycemia and abdominal distention   sepsis evaluation was obtained . She was noted at this time to have hyperglycemia requiring two subcutaneous doses of insulin and a decreased glucose infusion rate to achieve euglycemia . This resolved that same day . Urine output was always noted to be of sufficient quantity . Gastrointestinal  Mychelia demonstrated slow gastrointestinal motility and abdominal distention felt to be due to CPAP . She was slow to advance on enteral feeds and gradually attained full enteral volume on day of life 13 . On day of life 15   she was made NPO for a distended abdomen and a bilious spit . Serial KUBs revealed nonspecific changes with dilated loops . No pneumatosis or free air was seen . She was noted to have bluish discoloration thought to perhaps be a bruise on her left lower quadrant . There was no radiographic correlation with this . Feeds were restarted . Again   she was advanced to full volume but was made NPO on day of life 20 for abdominal distention . This NPO was temporary for that day and she then resumed feedings and has been tolerating full enteral feeds well   improved since off of CPAP   passing normal stools   guaiac negative . Mychelia was also treated for physiologic jaundice . She was started under phototherapy on day of life one through day of life three with a peak serum bilirubin of 4.7  0.3 . This issue resolved . Hematologic and Infectious Disease  Initial CBC was notable for a white count of 5.5 with 49 polys   1 band and 47 lymphs . Initial hematocrit was 46.3 percent and platelets 320 000 . Her initial blood culture remained negative and she received 48 hours of ampicillin and gentamicin . As previously noted on day of life six with hyperglycemia   abdominal distention   a CBC and blood culture were again obtained revealing a white count of 9.1 with 30 polys   0 bands and 58 lymphs . Hematocrit at that time was noted to be 31 and platelets 370 000 . Blood culture grew staph coagulase negative and the baby received seven days of vancomycin and gentamicin . A lumbar puncture was also performed to rule out meningitis . This culture remained negative with normal cell counts and chemistries . Antibiotic levels were monitored and doses adjusted accordingly . Mychelia required two transfusions during her hospital stay . On day of life 15 for a hematocrit of 29   she received 20 cc of packed red blood cells . She started on iron and vitamin E supplements on day of life 25 and continues on that at this time of transfer . However   on day of life 34   12-04   she was noted to be pale and less stress tolerant   mottling easily with care . A hematocrit and reticulocyte count showed a hematocrit of 23 percent and a reticulocyte count of 1.9 percent . Therefore   with blood available from the first aliquot   a second 20 cc per kg of packed red blood cells were infused without incident . Neurological  Initial head ultrasound on day of life seven was normal . At one month of age   on 12-03   she was noted to have an absent septum pellucidum . An MRI obtained and reviewed by the Hallmark Health System Radiology Department revealed focal gyral morphology consistent with prematurity   normal midline structures   normal myelination   no lesions   no signal abnormalities or extracerebral collections . The cortical ribbon is intact . The major vascular structures at the skull base are normal . The septal leaflets may be partially absent   but there are no coronal images provided for confirmation and the pituitary stalk is present . An Ophthalmology consult was obtained to determine the presence of optic nerves . These were both determined to be present and intact . Endocrine was also consulted . Several labs were ordered . Electrolytes and thyroid studies were noted to be in the normal range with serum sodium of 136   potassium 4.7   chloride 98 and CO2 34 . She had a calcium of 10.3   a phosphorus of 4.8 and alkaline phosphatase of 440 . Thyroid function studies revealed a TSH of 2.2   T4 of 5.7   T3 of 101 and a cortisol level of 43   all within the normal range . A growth hormone was sent and the results were pending at time of transfer . In addition   an FSH and LH were obtained on 12-10 and results are pending at time of transfer . Please contact lab control at Mattapan Community Health Center for results   409  238-8236 . The baby s neurologic examination is appropriate for corrected gestational age which is 33 and 6  7 weeks on day of transfer . By mother s report   a maternal cousin also has an absent septum pellucidum . Given normal pituitary tests thus far and normal optic nerve   no evidence of septic optic dysplasia . Pediatrician should have low threshold for endocrinology reconsult if any signs of pituitary problems . Sensory  Audiology hearing has not yet been obtained . This is recommended prior to discharge from hospital to home . Ophthalmology  Initial ROP screen was done on 12-02 and revealed immature retinas to zone 2 bilaterally . They recommended follow-up examination due on the week of 12  20 . Psychosocial  Gardner State Hospital social worker has assisted in working with this family . The contact may be reached at  754  791 7976 . Parents have been very involved and appropriate with infant and have eagerly learned to care for their baby . Condition at time of transfer is good . Discharge disposition is to level 2 nursery at Jordan Hospital Hospital . Name of primary pediatrician is Ashley Daley of Village Pediatrics in Stockbridge . Feedings at the time of transfer include breast milk 30 with ProMod at 150 cc per kg per day   all gavage given over one hour . Medications include Fer-In-Norman   vitamin E 5 international units each day and caffeine citrate once a day . Car seat positioning screening has not been obtained . Newborn state screens have been sent per protocol . Results have been in the normal range . IMMUNIZATIONS RECEIVED  Mychelia received hepatitis B vaccine on 11-02 due to unknown maternal hepatitis B surface antigen status . She also received hepatitis B immune globulin on 11-02 . On 12-06   she received her second hepatitis B vaccine . Her two month immunizations have not yet been given . IMMUNIZATIONS RECOMMENDED  Synagis RSV prophylaxis should be considered from November through March for infants who meet any of the following three criteria  1 born at less than 32 weeks   2 born at between 32 and 35 weeks with two of the following  Daycare during RSV season   a smoker in the household   neuromuscular disease   airway abnormalities or school age siblings or 3 infants with chronic lung disease . Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age . Before this age and for the first 24 months of the infant s life   immunization against influenza is recommended for household contacts and out of home caregivers . Follow-up appointments recommended with the primary pediatrician   Dr. Marilyn Daley of Stockbridge   Village Pediatrics   Dr. Lynn Warren of Neurology from Emerson Hospital and Ophthalmology to follow her ophthalmology status . DISCHARGE DIAGNOSES  Prematurity at 28-2  7 weeks . Surfactant deficiency . Hypotension . Sepsis suspect . Physiologic jaundice . Coagulase negative bacteremia . Anemia of prematurity . Apnea of prematurity . Absent septum pellucidum . Rosalie Gloria   North Dakota 67177 Dictated By  George D Gregory   M.D. MEDQUIST36 D  2013-12-10 124122 T  2013-12-10 140332 Job,0
 On admission   the patient s birth weight was 1.705 kilograms   which is 50th percentile . Length was 40 cm   50th percentile . Head circumference was 30 cm   50th percentile . The patient was born at 32 and 4  7 weeks gestation and brought directly to the CMED CSRU .,0
She is a half to one pack per day smoker for 10 years who quit approximately one week prior to her admission . She denies alcohol use .,0
 Her temperature is 97.9   blood pressure 160  80   heart rate 92   her HEENT examination reveals anicteric sclerae and her left eye has slightly relaxed inferoorbital wall . Her chest is clear to auscultation . Her heart has regular rate and rhythm with I    VI systolic ejection murmur at the base . Abdomen is obese   soft   non-tender   and without palpable masses . Extremities two plus pulses bilaterally and nonpitting edema up to the knees in both legs . Neurologic examination  is unremarkable . LABORATORY DATA  sodium 142   potassium 3.3   chloride 98   bicarbonate 34   BUN and creatinine 14  0.9 . Her alkaline phosphatase is 77   white blood count 12.5   hematocrit 42.6   platelet count 268 . IN SUMMARY  This is a patient with recurrence of a mixed mesodermal cancer at the vaginal apex who presents for local excision .,1
discharge disposition    'Home .,3
 Coumadin 2.5 mg. five times a week   Ativan and Lomotil prn . ADVERSE DRUG REACTIONS  no known drug allergies   but has shellfish allergy   and question of an Iodine allergy .,3
 On admission   chest x-ray with no acute cardiopulmonary process . Electrocardiogram notable for sinus tachycardia with a rate of 104 beats per minute   normal axis   normal intervals   new T wave inversion in III and old T wave inversions in aVL and V1 . This was not significantly changed from comparison with 2016-03-17 . On admission   white blood cell count 7.3   73 percent neutrophils   15 percent bands   6 percent lymphocytes   hematocrit 30.4   platelet count 228 000 . Sodium 136   potassium 3.5   chloride 98   bicarbonate 23   blood urea nitrogen 16   creatinine 0.8   glucose 142 .,1
 celexa premarin trazodone 6-MP Prednisone Discharge Medications  1. Phenytoin Sodium Extended 100 mg Capsule Sig  One  1  Capsule PO TID  3 times a day  for 1 months . Disp  90 Capsule s  Refills  0  2. Acetaminophen  Caff  Butalbital 504-61-78 mg Capsule Sig  01-28 Tablets PO Q4-6H  every 4 to 6 hours  as needed for 1 months . Disp  60 Tablet s  Refills  0  3. Citalopram 20 mg Tablet Sig  One  1  Tablet PO DAILY  Daily . 4. Metoprolol Tartrate 25 mg Tablet Sig  One  1  Tablet PO BID  2 times a day . 5. Hydromorphone 2 mg Tablet Sig  1-2 Tablets PO Q4H  every 4 hours  as needed for pain . Disp  40 Tablet s  Refills  0  6. Docusate Sodium 100 mg Capsule Sig  One  1  Capsule PO BID  2 times a day Use while taking narcotics . 7. Phenytoin Sodium Extended 100 mg Capsule Sig  One  1  Capsule PO TID  3 times a day . Disp  90 Capsule s  Refills  0  Discharge Disposition  Extended Care Facility  St. Annes Hospital  Burlington Discharge Diagnosis  Head trauma with subarachnoid hemorrhage C7 fracture Discharge Condition neurologically stable Discharge Instructions Call for severe headache or any other problems . Please take Fioricet as directed for headaches . Please do not drive while on this medication . Please continue to wear your C-collar at all times . Please continue Dilantin as directed for seizure prophylaxis . Followup Instructions  Follow up with Dr. Kelley in 4 weeks with head CT  call 716 3268 Please also follow-up with Dr. Obrecht of CMED CCU spine in 2 weeks for flexion    extension X-rays  228  411-7660  Please follow-up with your PCP N 6-12 months reguading the right thyroid nodule and the bilateral small lung nodules seen on your chest CT . Vernia Diana MD 76-016 Completed by  Sonya Ramona NP 80-AKY 2013-04-01  1453 Signed electronically by  DR.,3
 Morphine prn . Ativan prn . Tylenol prn . Albuterol and Atrovent nebs prn . Rice S.F. Thrash M.D. 15-419 Dictated By  Brett E.X. Im   M.D. MEDQUIST36 D  2012-06-29 0115 T  2012-06-29 0547 JOB  44693 Signed electronically by  DR. Vicki Baker on  TUE 2012-07-03 823 AM,2
"As described above the patient was transfused an additional 2 units in the Intensive Care Unit and the patient also received an upper endoscopy study and her varices were banded .', 'On transfer to the Lemgarson Hospital service   her hematocrit was 31.2   white count 11.1 and a platelet count 80 . Her PT was 13.1   PTT 26.7 . The rest of her labs were unremarkable .', 'She was watched very closely while on the floor . She was on GI bleed precautions at all times   was too large for IV . She had a clot at the blood bank and she had BID hematocrits checked .', 'She was kept NPO until January 26 when she began to feel hungry . At that time clear liquids were started . All of her stools were guaiaced . She also began Nadolol 40 mg QD to reduce her portal', 'hypertension . The GI consult team continued to follow her . We also tried to contact her physician at Va Sit Namar Healthcare and was unsuccessful . Therefore we decided to work up her cirrhosis .', 'She was described as having cirrhosis and we decided that we wanted to try to figure out the etiology .', 'Her ferritin and iron studies did not reveal any evidence of hemochromatosis and her hep serologies were all negative . She also had negative antimitochondrial antibody and she also had no evidence', 'of ceruloplasmin . Over the course of her admission were also sent an alpha-1-antitrypsin   which was negative .', 'She did very well over the course of her admission with no evidence of further bleeding .', 'Her hematocrit stayed stable at approximately 32 . We also did an ultrasound guided paracentesis .', 'The peritoneal fluid showed a glucose of 244   total protein 0.8 and a albumin of 0.5   globulin 0.3   amylase 16   LDH of 51 . The serum albumin gradient was 1.8 consistent with portal hypertension .', 'The cell count showed a white blood cell count of 160 with 16 polys . She therefore criteria for a spontaneous bacterial peritonitis .', 'Her platelet count stayed persistently low and we decided that it might be due to Cimetidine . Therefore we switched her Cimetidine to Prilosec .', 'By the 2th the patient was feeling very well and desired to transfer or discharge to home . She wanted to be closer to North Dakota .', 'After discussion with her private physician   Dr. Joasscchird   tel. 090-249-6079   at Va Sit Namar Healthcare and Dr. Acrookesjo at Do Of Hospital', 'the patient was judged to be fit for discharge and she was sent home with AH and physical therapy . She was quite able to climb stairs on her own in the hospital .', 'She is to follow up with Dr. Acrookesjo in one week and Dr. Work the gastrointestinal fellow here at PUOMC in 2 weeks . She may require a repeat upper endoscopy study to see if she needs any rebanding .', 'The patient however complained of a persistent wheeze with beta blocker   therefore it was agreed that we would stop the beta blocker until the patient was followed up as an outpatient .",2
Assessment was continued with laboratory studies which showed the patient to have a white blood cell count of 9   hematocrit 39   and platelets 470 . The patient had a normal amylase and lipase   and a normal basic metabolic panel . The patient had KUB that showed multiple dilated loops of small bowel and was admitted for a partial small bowel obstruction . An nasogastric tube was placed and had an H2 blocker started   and was admitted for bowel rest and decompression . The patient tolerated the nasogastric tube well . The nasogastric tube was removed on hsp day  3 . The pain improved quickly and the patient was started on a clear liquid diet which was advanced as tolerated . On 7  9  99   the patient was tolerating a house diet . The patient had some minimal back pain that occurred after food but with negative urinalysis and negative fever spikes over the entire course of this stay . The patient will be discharged home on Zantac   Simethicone   and preoperative medications with follow-up with Dr. Ur in two weeks . Dictated By  NISTE BLOCKER   M.D. AQ36 Attending  STIE FYFE   M.D. BW3 BL436  5666 Batch  85114 Index No. FNQXCX58 EM D  07  09  99 T,0
 Spironolactone 50 mg p.o. b.i.d. 2 Advil p.r.n. 3 Topical steroids for eczema p.r.n. ALLERGIES  The patient had no known drug allergies .,3
 Levoxine 0.125 mg PO q.day   Vasotec 10 mg PO b.i.d.   Maxzide 75  50   30 mg PO q.day .,3
 Thromboembolus to the right profunda femoris   and right superficial femoral artery . MA JAMTLANDBRANTESSLIGH   M.D. DICTATING FOR  COR TLAND   M.D. TR  qa    bmot DD  07  02  92 TD,2
 On admission   the patient s birth weight was 1.705 kilograms   which is 50th percentile . Length was 40 cm   50th percentile . Head circumference was 30 cm   50th percentile . The patient was born at 32 and 4  7 weeks gestation and brought directly to the CMED CSRU .,1
 Cigarette smoking  Insulin dependent diabetes mellitus .  Proteinuria  Aortic stenosis .  Cellulitis  Gangrene of his left second toe in 2010-06-06 followed by an amputation .  Left common femoral dorsalis pedis bypass graft  Right leg bypass graft in 1999 .  Right below the knee amputation in 2008,0
 Coronary artery disease   status post coronary artery bypass graft   four vessels . Congestive heart failure . Klebsiella pneumonia . Failed swallow study status post percutaneous endoscopic gastrostomy tube placement . Central line culture positive for coagulase  negative Staphylococcus aureus   status post a 14 day treatment with vancomycin and removal of the line .,2
 ON ADMISSION This is a gentleman who is intubated   comfortable   with minimal sedation . He was afebrile with a temperature of 99.1 . His pulse was in the 70s   blood pressure 119  58 . He was breathing 12 per minute and saturating 98 . His CVP is ranging from 07-27 . He was intubated and has a nasogastric tube . His neck has a well-healed right carotid endarterectomy scar . There is also a well-healing tracheostomy scar . The lungs were clear to auscultation bilaterally . The heart was regular with an S1 and S2 . The abdomen was soft   nontender   nondistended with normoactive bowel sounds . The extremities were without edema . The left arm was in a cast .,1
 On admission   the sodium was 136   potassium 3.0   chloride 98   CO2 20   BUN 8   creatinine 0.8 and glucose 94   ALT 5   AST 10   LDH 166   alkaline phosphatase 81   total bili 0.6   direct bili .3   albumin 3.3   calcium 8.8 and uric acid 3.1 . She had CA-125 which was pending at the time of discharge . Her hematocrit was 31.1   WBC 11.6 and 151 000 platelets .,1
 Brothers with William cancer and a MI . Father with emphysema . Mother with lung cancer .,0
 ON ADMISSION  Physical examination at the time of admission revealed she was in no acute distress . Blood pressure was 150  79   a pulse of 81 . She is legally blind . She was without any adenopathy . Her chest was clear to auscultation . Heart had a normal S1 and S2   with no murmurs   gallops or rubs . Her abdomen was soft with well-healed incisions . There was no organomegaly . Extremities were without edema . She had a functioning arteriovenous fistula with a thrill and a bruit in her left arm .,1
 Stable DISCHARGE DIAGNOSES  Coronary artery disease Mitral valve regurgitation   status post coronary artery bypass graft x2 and mitral valve annuloplasty SECONDARY DIAGNOSES  1. Coronary artery disease Myocardial infarction x3 Coronary artery bypass graft DISCHARGE MEDICATIONS  1. Lopressor 25 mg po bid 2. Amiodarone taper 400 mg po tid x4 days   then bid x7 days   qd x7 days   then 200 mg po qd 3. Lasix 20 mg po qd K-Dur 20 milliequivalents po qd Aspirin 81 mg po qd 6. Percocet 1 to 2 po q 4 to 6 hours prn 7. Colace 100 mg po bid Percocet Protonix 20 mg po qd DIGrimmE INSTRUCTIONS  The patient should follow up with Dr. von Diamond in approximately three weeks . The patient should also follow up with his primary care doctor   Dr. Beals   in approximately three weeks . Briley von der Ross   M.D. 67 -576 Dictated By  Julie H. Bullock   M.D. MEDQUIST36 D  2013-08-15 0755 T  2013-08-15 0901 JOB  15357 Signed electronically by  DR. Santos von der Ross on  WED 2013-08-21,2
 Oxycontin Percocet Paxil Gabapentin Atenolol Discharge Disposition  Extended Care Discharge Diagnosis  benzodiazipine overdose Discharge Condition  stable Discharge Instructions please take your medications and call your doctor if you experience chest pain   abdominal pain or shortness of breath or any thoughts of hurting yourself or anyone else . Followup Instructions  please call your primary doctor Edmund Starke once your are discharge from the hospital Clemmie Shawn MD 65-948 Completed by  Michael Melvin Kinzer MD 51-991 2012-03-26  1709 Signed electronically by  DR.,3
 Satisfactory TO DO    PLAN  1  Follow-up esophageal biopsy results 2  Schedule GI follow-up if biopsy results abnormal or if continued bleeding . 3  Consider oncology follow-up if biopsies suggestive of malignancy 4  Omeprazole 40 mg po bid x6 wks . No dictated summary ENTERED BY  ZISKFUSCJALK   ACRI   M.D.,2
"82   119  60   22   and 99 on room air . Well appearing in no apparent distress . Pupils are equal   round   and reactive to light . Moist mucous membranes . No JVD . Regular rate and rhythm .', 'Positive tenderness to sternum . Chest was clear to auscultation bilaterally . Abdomen  Obese   soft . Extremities show no edema   2 dorsalis pedis   1 femoral pulses .'Troponin-T less than 0.01. EKG  Sinus   84   normal axis   QTc 430   Q s in III and aVF   no ST changes as compared to 2017-05-01 EKG .",1
DISCHARGE DISPOSITION To home .,3
Physical examination revealed that the vital signs were stable . Lungs were clear to auscultation bilaterally . Heart was irregular with no murmurs palpated . Abdomen was benign . Pulses were 2 throughout .,1
 Coumadin Lipitor Toprol XL ASA Zoloft Glucophage Aricept Namenda Artificial Tears Discharge Medications  Not applicable . Discharge Disposition  Extended Care Facility  Patient deceased . Discharge Diagnosis  Not applicable patient deceased . Discharge Condition  Not applicable . Discharge Instructions  Not applicable . Followup Instructions  Not applicable . William William MD   PHD 13-279 Completed by Barbara Josephine MD 21-547 2013-11-15  1413 Signed electronically by  DR. Exie Culbreath on  MON 2013-11-18 1006 AM,3
 1  Enteric coated aspirin 325 mg p.o. q. day . 2  Capoten 25 mg p.o. t.i.d. 3  Lanoxin 0.25 mg p.o. q. day . 4  Cardizem 125 mg p.o. q. day . 5  Glucotrol XL 10 mg p.o. b.i.d. 6  Glucophage 500 mg p.o. q. day . 7  Amaryl 2 mg p.o. q.h.s. ,3
 Augmentin 500 mg t.i.d. Senokot one q.h.s. Sertraline 75 mg q.day . Aspirin 81 mg q.day . Vitamin B12 100 mcg IM q.month . Urecholine 25 mg t.i.d. Colace .,3
 Cefuroxime 1.5 grams intravenously q8h   Solu-Medrol 62.5 mg intravenously q8h   Ventolin metered dose inhaler   2 puffs PO q.i.d.   Pepcid 20 mg intravenously b.i.d.,3
 Timolol .5 Discharge Disposition  Extended Care Discharge Diagnosis  Right lower extremity necrosing fascitis history of prostate cancer s  p TURP glaucoma Discharge Condition  Fair Discharge Instructions  If you have any fevers  chills   nausea  vomiting   chest pain   foot pain   please seek medical attention . Followup Instructions  Please follow up with Dr. Mallard in one week   call 421-3721 for an appointment . Follow up with Dr. Adner in 2 weeks   call 763-9180 for an appointment . Mark William MD 19-081 Completed by  Shane Gabrielle MD 73-971 2016-04-01  0836 Signed electronically by  DR. Robert Howell on WED 2016-05-18,3
 His meds on transfer to FIH were Levophed   Dopamine   and Ceftriaxone .,3
 BY SYSTEM  1. NEUROLOGY  Mr. Roach was transported to Intensive Care Unit from the trauma bay . Upon arrival   Neurosurgery promptly placed V. Holtzen bolt . This allowed continuous monitoring of intracranial pressure . Notably   intracranial pressure was 17 when the bolt was placed . During his hospitalization   his intracranial pressure was monitored very closely and maintained to a level of less than 20 . To do this   mannitol 25 mg q. 6h. was used . While using mannitol   his serum osmolalities were followed closely . In addition   to monitoring his intracranial pressure   his systemic blood pressures were maintained in such a manner that his cerebral perfusion pressure was maintained at 70 mmHg . A parameter monitor for his neurologic status PaCO2 which was maintained between 35 and 40 during his hospitalization . Mr. Roach was kept sedated with propofol and was given Fentanyl and    or morphine boluses for pain . Neurologic checks were followed initially every one hour and then every two hours to monitor for change in neurologic examination . During his hospitalization   two subsequent CAT scans were obtained  one on hospital day two . This CAT scan revealed possible worsening and was read as epidural versus subdural bleed . After a discussion with both Radiology and Neurosurgery   the decision was made that the worsening did not appear significant   and this was not accompanied by a change in his clinical condition . His intracranial pressure remained stable   and his clinical examination was unchanged . An additional CT scan was obtained on hospital day three . This examination was unchanged from the previous examination . Again   his intracranial pressure and neurologic examination remained the same   and conservative treatment was opted for . CARDIOVASCULAR  As described in previous section   Neo-Synephrine and eventually Levophed were used to maintain a coronary perfusion pressure of greater than 70 . A pulmonary artery catheter was placed on hospital day four . This catheter was placed when the patient started to demonstrate septic physiology and for increasing pressor support . Please see Infectious Disease section for more details . 3. GASTROINTESTINAL  Mr. Roach was n.p.o. from the time of his admission . A orogastric tube was passed . Initially during admission   carafate was given down the orogastric tube . However   on a routine chest x-ray shot on hospital day three   a mediastinum was noted . This raised the question of potential esophageal rupture . Gastroenterology was consulted for this . Gastroenterology was consulted to assist in creating the most appropriate diagnostic rhythm given his intubated and sedated status . At this point   his carafate was switched to intravenous Protonix and he was strictly n.p.o. 4. HEMATOLOGY  Throughout Mr. Richard admission   his hematocrit remained stable in the low 30s . As will be discussed in the Infectious Disease section   he developed an episode of what appeared to be sepsis   and his white blood cell count peaked at 23 . Mr. Roach was on Pneumo boots spontaneous compression devices for deep venous thrombosis prophylaxis . He was not a candidate for subcutaneous heparin as we were concerned of an intracranial hemorrhage . An inferior vena cava filter was considered but was deferred   as it was felt that Mr. Roach was too unstable to undergo the procedure . 5. ENDOCRINE  Mr. Marian blood sugar was maintained under tight control from 100 to 130 using a regular insulin sliding-scale . 6. INFECTIOUS DISEASE  Mr. Roach had a spike in white blood cell count and developed fevers . His blood urine and sputum were all cultured . Blood cultures were pertinent for one bottle of gram  positive coagulase  negative Staphylococcus which grew from 08-25 . His preliminary cultures including sputum from 08-25 grew Escherichia coli . Sputum from 08-27 grew gram-negative rods   not yet speciated   and from 08-27 a bronchoalveolar lavage grew 1 gram-negative rods and 4 polymorphonuclear lymphocytes . Throughout this time   Mr. Richard temperature continued to increase and was such that on hospital day four   his temperature maximum was 42.2 degrees centigrade . During his hospitalization   his was treated with vancomycin for his gram-negative rods   imipenem   and Flagyl . Initially   he had been placed on clindamycin to cover his drain   but his cultures became positive   and his white blood cell count increased . He was switched from clindamycin to the imipenem and Flagyl . Vancomycin was added when we had the positive blood culture . With a fever of 102   up to 42 degrees centigrade   aggressive measures including cooling blankets   alcohol swabs   and fans were used in an attempt to bring his body temperature down . Hypercarbia would result and increase in cerebral perfusion   paralysis was initiated to decrease genesis of carbon dioxide secreted during shivering . 7. PULMONARY  As discussed in the Infectious Disease section   Mr. Roach developed a pneumonia likely from gram-negative organisms   but most likely from Escherichia coli . For this pneumonia   he was placed empirically on imipenem   vancomycin   and Flagyl . On hospital day three   Mr. Roach had developed an episode of tachycardia and tachypnea . For this   a CT angiogram was obtained which demonstrated no pulmonary embolism . On hospital day four   a routine chest x-ray revealed a left-sided pneumothorax . For this   a left 34 Caucasian chest tube was placed . On the evening of hospital day four   Mr. Roach had an acute episode whereby his central venous pressure rose sharply and immediately followed by a period of asystole . Urgent resuscitation measures were initiated . The measures included attempts at pacing . Epinephrine and atropine were administered as were bicarbonate and calcium . He had a differential diagnosis of asystole preceded by an acute rise in central venous pressure included attention pneumothorax   cardiac tamponade   and pulmonary embolism . During the resuscitation afterwards   it was noted that a patent left chest tube was present in the left chest   so initially neo-decompression was attempted in the right chest . There was no sign of attention pneumothorax with decompression   and a right chest tube was placed . During this time   a needle aspiration of what was felt to be the pericardium was performed revealing bloody fluid coming back . A left anterior thoracotomy was made by the Cardiac Surgery fellow who was present . After 30 minutes of active resuscitation including internal cardiac massage   there was no evidence of return of vital signs or electric activity to the heart as noted on electrocardiogram monitors . Resuscitation was terminated at 1914 on 08-27 . After the termination of resuscitation   both the anesthesia Intensive Care Unit attending and the surgical attending were present to discuss the proceedings events with the patient s family members including his next of kin   his mother . Permission for a postmortem examination was granted . Matthew M. Barnett   M.D. 78 -102 Dictated By  Mark D. Eng   M.D. MEDQUIST36 D  2013 08-28 0021 T  2013-09-03 1111 JOB   24887 Signed electronically by  DR. Katherin Toth on  MON 2013,0
 Toprol 75 mg po bid   Furosemide 20 mg po bid times one week   potassium chloride 20 mEq po bid while on Lasix   Colace 100 mg po bid while on Percocet   enteric coated Aspirin 325 mg po q day   Indocin 25 mg po bid Sarna cream applied to affected area prn   Percocet 1-2 tabs po q 4-6 hours prn   Ibuprofen 400 mg po q 6 hours prn   Tylenol 650 mg po q 4-6 hours prn   Ativan 0.5 mg po q 8 hours prn . FOAnterP  The patient will follow-up in the wound care clinic in two weeks . The patient will also follow-up with Dr. Fairchild   her primary care physician in three weeks . The patient will follow-up with Dr. vel Diaz in 3-4 weeks . Briley von der Ross  M.D. 67 -576 Dictated By  Emily O Ennis   M.D. MEDQUIST36 D  2013-01-08 1646 T  2013-01 -08 1708 JOB  67252 Signed electronically by  DR.,2
 Atenolol 25 mg p.o. q. day . Lasix 20 mg p.o. q. day times seven days . 3. Potassium chloride 20 mEq p.o. q. day times seven days . 4. Niferex 150 mg p.o. q. day times one month . 5. Vitamin C 500 mg p.o. twice a day times one month . 6. Multivitamin one p.o. q. day times one month . Ambien 5 mg p.o. q. h.s. p.r.n. Colace 100 mg p.o. twice a day . Avandia 4 mg p.o. q. day . Glucophage 500 mg p.o. twice a day . Lipitor 20 mg p.o. q. day . Zantac 150 mg p.o. twice a day . 13. Niaspan 500 mg p.o. q. day . 14. Percocet 5  325 one to two p.o. q. four to six hours p.r.n. DISPOSITION  The patient is to be discharged to home . CONDITION ON DISCHARGE  Stable condition . DISCHARGE INSTRUCTIONS  The patient is to follow-up with Dr. Neri in one to two weeks . The patient is to follow-up with Dr. Rota in three to four weeks . The patient is to return to Smith on or about 05-17 to have his staples removed . Gabriela E. D. Castillo   M.D. 05-025 Dictated By  Julia Q Mcafee   M.D. MEDQUIST36 D  2017-05-01 1506 T  2017-05-01 1537 JOB   59432 Signed electronically by  DR. Kathy Brendel on  TUE 2017-05-02 808 AM,2
 Intravenous chemotherapy for lung cancer . DOCTORS DISCHARGE ORDERS  Slo-Mag one tab p.o. b.i.d. Stelazine 2 mg. p.o. q.d. Ativan 1 mg p.o. or s.l. q. 4 -6 hr. p.r.n. nausea . WORK DISABILITY AND PROBABLE DURATION   COMPLETE . Followup will be with Dr. Guabenfranda Day in his office . CA SHUFF   M.D. TR  ds    bmot DD  6-2 93 TD,2
At that time   it was felt that the patient was likely having a repeat GI bleed and while he was hemodynamically stable   he had evidently lost a substantial amount of blood .,2
 Lopressor 100 mg po three times a day . Captopril 75 mg po three times a day . Prilosec 20 mg po per day . Hydralazine 12.5 mg four times per day . Reglan 10 mg po three times a day .,3
 Cerebrovascular accident  Atrial fibrillation on Coumadin .  Diabetes mellitus type 2  Hypothyroidism .  Mild dementia  Proteinuria .  Nephropathy  Anemia .  Hearing impaired  PAST SURGICAL HISTORY   Laparoscopic cholecystectomy as above  Total hip replacement in 2002 .  Appendectomy  Diskectomy .  MEDICATIONS ON ADMISSION  1 Digoxin .125  mg qod   .25 mg qod .  Colace 100 mg po tid  Levoxyl 100  ugm po qd  Prinivil 20 mg po qd .  Zantac 150 mg po bid  Aspirin 325  mg qd  Aricept 5 mg po qd .  Glyburide 1.25 mg po qam  Oxybutynin 5 mg po bid .  Coumadin 7.5 mg on Sun   Tues   Wed   Fri and Sat  5 mg on Mon and Thurs .  ALLERGIES  Fluoroquinolones,0
 Include Librax 1 PO before meals   Pancrease 2 tabs before meals   Synthroid 0.125 mg PO qd . Tenormin 50 mg bid   Valium 5 mg bid to tid   Premarin 0.625 mg qd   Provera 2.5 mg qod   Desyrel 50 mg qhs .,3
 Sandostatin 100 mcg subcu. b.i.d.  Percocet 1-2 tabs q.3 -4h. p.r.n. pain  Axid 150 mg p.o. b.i.d.  Colace 100 mg p.o. b.i.d. DISCHARGE FOLLOW-UP The patient has been instructed to follow-up with Dr. Red in one week and in the Urology Clinic in three weeks . DISCHARGE DISPOSITION  The patient is discharged to home on 7  10  98 . CONDITION ON DISCHARGE  Stable condition . Dictated By  MALICHARLEAR KROENER   M.D. EB85 Attending  LEAND L. KROENER   M.D. QW18 FO508  6558 Batch  54270 Index No. YCCYST5DG2 D  07  10  98 T  07  12  98 CC  1.,2
 His hematocrit was 44.4   with white blood count of 11.9   and platelet count of 410 . His MCV was 92   MCH 32.1   and MCHE 34.8 . His chest X-ray did not reveal any abnormality . A electrocardiogram showed nonspecific T-wave abnormalities   otherwise   it was normal .,1
"erm   appropriate for gestational age   male neonate . Exaggerated physiologic hyperbilirubinemia responsive to phototherapy . Jennifer Martin   North Dakota 07287 Dictated By', 'Jean TE Fletcher   M.D. MEDQUIST36 D  2018-05-13 130731 T  2018-05-13 142441 Job  75582 Signed electronically by  DR. Deloris O. Williams on  MON 2018-05-14'",2
 Neurological  Alert and oriented times 3 . Moves all extremities and follows commands . Respiratory  Clear to auscultation bilaterally . Cardiovascular  Regular rate and rhythm   S1 and S2 . No murmurs . Sternum is stable   incision with staples   opened to air   clean and dry . Abdomen  Soft and nontender   nondistended with positive bowel sounds . Extremities  Warm and well profuse with 1 to 2 plus edema . Right saphenous vein graft site with Steri-strips   open to air   clean and dry . The patient s condition at discharge is good .,1
 Breast cancer diagnosed in 2010   Stage I   status post left lumpectomy   on 2012-05-08   and repeat surgery with sentinel node dissection on 2012-06-05  Invasive mucinous carcinoma with estrogen receptor positivity and HER2  NEU negative .  Left chest radiation   on Tamoxifen therapy  She is followed by Dr. Alonso Naugle .  Question of vertebral basilar cerebrovascular accident in 2016-08-17   with associated limb ataxia  Magnetic resonance imaging was negative except for some microvascular cerebral white matter changes .  Question peripheral vertigo   takes Meclizine p.r.n. Hypothyroidism  Hypertension .  Hypercholesterolemia  Glaucoma .  Cataract  Osteopenia .  Left hip arthritis  History of urinary tract infections .  Anemia   with a baseline hematocrit of 31.0   with a TIBC that was low and a high ferritin  Echocardiogram in 2016-09-16   with preserved ejection fraction of 60 percent with trivial mitral regurgitation and mild left atrial enlargement .  Cardiac stress test in 2016-03-17   that was negative for inducible ischemia,0
 A quantitative V    Q scan was also done preoperatively and Pulmonary consult was obtained preoperatively . Pulmonary recommended that he just be started on Albuterol and Atrovent metered dose inhalers   2 puffs q6h   prior to surgery . The patient underwent his procedure on 12-4-93   without complications . Findings included thickened pleura with multiple adhesions and an abscess near the margin major fissure . He had a firm nodule in the left lower lobe . The patient was transferred to the Respiratory Intensive Care Unit in stable condition and had an uneventful stay there . He had oxygen saturations of 99 with an Fi02 of 40 and had no complaints . He was transferred to the floor on postoperative day number one and tolerated his PO&aposs well . His left lower lobe micro results revealed alpha hemolytic Streptococcus on culture and he was then switched to penicillin and Gentamicin after being started on triples of Flagyl   Ampicillin   and Gentamicin . He had low grade temperatures   though did not spike a high temperature during his hospital course . His hospital course was otherwise uneventful and the patient was discharged in stable condition on postoperative day   afebrile . The chest X-ray on the morning of discharge was unchanged from the previous day   with slight increase in left pleural fluid . He had completed six days of penicillin and Gentamicin and was discharged on Ciprofloxacin and Flagyl for the next seven days . He stayed at the local Comfort Inn before his return back to Aujer Cin .,0
 Coronary artery disease status post myocardial infarction in 1990   peptic ulcer disease and hypertension,0
 1  Aspirin 81 mg p.o. q. day . 2  Os-Cal 1250 mg p.o. three times a day . 3  Lasix 40 mg p.o. q.o.d. 4  Plaquenil 200 mg p.o. q. day . 5  Ibuprofen 400 mg p.o. t.i.d. 6  Levoxyl 100 mg p.o. q. day . 7  Arava 20 mg p.o. q. day . 8  Zantac 150 mg p.o. b.i.d. 9  Isosorbide dinitrate unclear dose . 10  Diltiazem 240 mg p.o. q. day . 11  Epogen q. two weeks .,3
 Brother with MI at age 35 Father with MI  CABG died at age 60 . Physical Exam Vitals  BP 144  90   HR 64   RR 14 General  well developed male in no acute distress HEENT  oropharynx benign   poor dental health Neck  supple   no JVD Heart  regular rate   normal s1s2   no murmur Lungs  clear bilaterally Abdomen  soft   nontender   normoactive bowel sounds Ext  warm   no edema   no varicosities Pulses  2 distally Neuro  nonfocal Pertinent Results 2014 -04-24 0730AM BLOOD Hct  25.9 2014-04-23 0705AM BLOOD WBC  5.9 RBC  2.72  Hgb  8.6  Hct  25.2  MCV  93 MCH  31.5 MCHC  34.0 RDW  13.0 Plt Ct  150 2014-04-23 0705AM BLOOD Plt Ct  150 2014-04-24 0730AM BLOOD UreaN  11 Creat  0.8 K  4.4 2014-04-21 ECHO No spontaneous echo contrast is seen in the body of the left atrium . No mass  thrombus is seen in the left atrium or left atrial appendage . No spontaneous echo contrast is seen in the body of the right atrium . A patent foramen ovale  secundum ASD is present . A left-to-right shunt across the interatrial septum is seen at rest . A right-to-left shunt across the interatrial septum is seen at rest with injection of agitated saline contrast . The inferior vena cava is dilated  >2.5 cm  . Left ventricular wall thickness   cavity size   and systolic function are normal  LVEF >55  . Left ventricular wall thicknesses are normal . Regional left ventricular wall motion is normal . Overall left ventricular systolic function is normal  LVEF>55  . Right ventricular chamber size and free wall motion are normal . The ascending   transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque . The aortic valve leaflets  3  appear structurally normal with good leaflet excursion and no aortic regurgitation . No aortic regurgitation is seen . The mitral valve appears structurally normal with trivial mitral regurgitation . The mitral valve leaflets are structurally normal . There is no pericardial effusion . POST BYPASS Flow across the interatrial septum is no longer visualized with color flow doppler or with injection of agitatated saline at rest or with valsalva . The study is otherwise unchanged from pre-bypass . 2014-04-22 CXR Previous right pneumothorax has resolved except for what is either a small fissural component or a bulla adjacent to the minor fissure . May be a small right pleural effusion . Right apical pleural tube in place . Left lung clear from basal atelectasis . Paratracheal mediastinal hematoma is resolving . Heart size is normal . Tip of the left internal jugular line projects over the SVC . Brief Hospital Course  Mr. Freeman was admitted to the Nantucket Cottage Hospital on 2014-04-21 for surgical management of his PFO . He was taken to the operating room where he underwent a mini-thoracotomy with closure of his patent foramen ovale  PFO  . Postoperatively he was taken to the cardiac surgical intensive care unit for monitoring . Within a few hours   he woke neurologically intact and was extubated . Aspirin was resumed. On postoperative day one   he was transferred to the cardiac surgical step down unit . He was gently diuresed towards his preoperative weight . The physical therapy service was consulted for assistance with his postoperative strength and mobility . Iron and vitamin C were started for postoperative anemia . Mr. Freeman maintained stable hemodynamics with a normal sinus rhythm throughout his postoperative course . He continued to make steady progress and was discharged home on postoperative day three . He will follow-up with Dr. de la Cisneros   Dr. Belt   his cardiologist and his primary care physician as an outpatient . Medications on Admission  Plavix 75mg daily aspirin 81mg daily Discharge Medications  1. Potassium Chloride 10 mEq Capsule   Sustained Release Sig  Two  2  Capsule   Sustained Release PO Q12H  every 12 hours  for 5 days . Disp  10 Capsule   Sustained Release s   Refills  0  2. Docusate Sodium 100 mg Capsule Sig  One  1  Capsule PO BID  2 times a day  . Disp  60 Capsule s   Refills  0  3. Aspirin 81 mg Tablet   Delayed Release  E.C.  Sig  One  1  Tablet   Delayed Release  E.C.  PO DAILY  Daily  . Disp  30 Tablet   Delayed Release  E.C.   s   Refills  2  4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig  1-2 Tablets PO every 4-6 hours as needed for pain . Disp  50 Tablet s  Refills  0  5. Ferrous Sulfate 325  65  mg Tablet Sig  One  1  Tablet PO DAILY  Daily   Take for one month then stop . Disp  30 Tablet s  Refills  0  6. Camphor-Menthol 0.5-0.5  Lotion Sig  One  1  Appl Topical TID  3 times a day  as needed . Disp  qs qs  Refills  0  7. Ascorbic Acid 500 mg Tablet Sig  One  1  Tablet PO BID  2 times a day   Take for one month then stop . Disp  60 Tablet s  Refills  0  8. Furosemide 20 mg Tablet Sig  One  1  Tablet PO BID  2 times a day  for 5 days . Disp  10 Tablet s   Refills  0  Discharge Disposition  Home with Service Discharge Diagnosis  PFO TIA lung nodule  followed by Dr. Belt  s  p fissurectomy  skull Fx Discharge Condition  Good Discharge Instructions  1 Shower   wash incisions with mild soap and water and pat dry . No lotions   creams or powders to incisions . Call with fever >101   redness or drainage from incision   or weight gain more than 2 pounds in one day or five pounds in one week . 3 No driving while on narcotics . Take lasix twice daily with potassium for five days then stop . Take Vitamin C with iron for one month then stop . Call with any questions or concerns . Followup Instructions Follow up with Dr. Heird in four weeks   671 745 2553 Follow up with Dr. Knowlton in 1-2 weeks   246 828-4417 Follow up with Dr. Eckman in 2-3 weeks   506 946-4576 Call all providers for appointments . CAT SCAN Phone  476 713 6117 Date  Time  2014-10-16 915 Edna Arnold   MD Phone  300 922-6590 Date  Time  2014-10-16 230 Melonson de la Donnelly MD 08-301 Completed by  Jeremy N. P. Moschella PA 80-BYE 2014-04-24  1103 Signed electronically by  DR. Dorothy au Pratt on  FRI 2014-06-06 1027 AM,0
" Aspirin under which she develops worsening of her shortness of breath and asthma flare   tetracycline   sulfa   Demerol . MEDICATIONS Diovan 106 mg q.d. Advair 500  50 two puffs b.i.d. Plavix 75 mg q.d. Crestor 20 mg q.d. Neurontin 300 mg t.i.d. Prilosec 20 mg b.i.d. Vicodin as needed . Trazodone 50 mg q.d. Singulair 10 mg q.d. Flexeril 10 mg t.i.d. 11. Lopressor 75 mg b.i.d. Humibid 3600 b.i.d. Colace 100 mg b.i.d. Zetia 10 mg q.d. Benadryl as needed . Tricor 106 mg q.d. Premarin 0.3 mg q.d. Prozac 40 mg q.d. 19. Omega-3 fatty acids t.i.d. 1. Chest pain  The patient ruled out for myocardial infarction . However   with her history of disease   patient underwent a cardiac catheterization .', 'The patient was found at cardiac catheterization to have mild diffuse instent restenosis in the mid stent   otherwise hemodynamically normal and the coronary arteries', 'otherwise were without flow-limiting stenoses . The patient was then continued on her cardiac medications . It was felt that if we attempted aspirin desensitize her while an inpatient', 'then she would benefit from the use of aspirin and Plavix . The patient was sent to the CCU and underwent aspirin desensitization protocol   which she tolerated well .', 'She had mild worsening of her asthma attacks   which was relieved by Benadryl and occasionally albuterol . The patient found that if she took the aspirin in the evening with her Benadryl', 'that she takes for sleep   that the asthma exacerbation did not occur . Aspirin no longer should be considered an allergy for this patient   and she is going to take this as an outpatient .', '2. Hyperlipidemia  The patient s Lipitor was increased to 80 mg q.d. 3. Back pain  This is a chronic issue and was controlled with Flexeril and Vicodin . DISPOSITION  To home .",0
"Respiratory  On admission   the patient had what appeared to be acute respiratory distress syndrome secondary to community  acquired pneumonia .', 'She was maintained on a ventilator and ventilated according to ARDSNet protocol . For antibiotic coverage of her pneumonia   she was started on Levaquin   ceftriaxone   and vancomycin .', 'Over the next two days after admission   the patient s vent settings were gradually weaned   and she was extubated two days after being transferred to this hospital .', 'After extubation   the patient was oxygenating well on face mask . She did continue to have a persistent fairly severe cough  however   her cough was weak due to abdominal muscle pain from repeated coughing .', 'The cough was mostly nonproductive . The patient was breathing comfortably . As there was no identified bacterial pathogen on any cultures', 'the patient was continued on the triple antibiotics for first several days of the hospitalization . She was also on round-the-clock Atrovent and albuterol nebulizers .', 'Once the patient was transferred out of the ICU and after extubation   the antibiotics were gradually narrowed . The vancomycin and Levaquin were discontinued after approximately four days in the hospital .', 'The ceftriaxone was discontinued after four days in the hospital   and the patient was to continue on Levaquin . The patient had gradual improvement in her oxygenation .', 'Pain control  The patient had fairly significant abdominal pain secondary to persistent cough . She was started on a regimen of MS Contin with oxycodone for breakthrough pain .', 'This helped her somewhat though she has continued to have difficulty coughing due to the pain . Tylenol and ibuprofen were also added for better control .', 'Transaminitis  The patient was noted to have mild transaminitis on admission . However   this was felt to be due to her significant infection .', 'This should continue to be followed as an outpatient to assure that it returns back to normal . Anemia  The patient s reticulocyte count showed inadequate production .', 'Iron studies showed a mixed picture with decreased iron and decreased iron to TIBC ratio suggestive of iron-deficiency anemia   but also normal to high MCV .', 'B12 was noted to be low and the patient was given an injection of IM B12 while in the hospital .', 'She was also started on iron supplementation . Hypothyroidism  The patient was continued on Synthroid for her chronic hypothyroidism .",0
 On admission   vital signs Temperature 101.4   blood pressure 101  62   pulse 80   respiratory rate 19 on a ventilator with settings of assist control at 500  12 and a PEEP of 5 . General  The patient is intubated and sedated   but easily arousable . HEENT  Pupils equally round and reactive to light . Sclerae are anicteric . ET tube is in place . Neck  Soft and supple . Cardiovascular  Normal . Chest  Faint scattered wheezes bilaterally . Abdomen  Benign . Extremities  Warm with good distal pulses . There is no edema . Neurologic  Able to follow simple commands .,1
 Albuterol inhaler . Amphotericin B 40 mg. qday . Ceftazidime 1 gram intravenous q 8 . Ciprofloxacin 500 mg. po. q12 . Cisapride 10 mg. po. qid . Dakin &aposs solution 1  4 strength to ulcer of penis . Benadryl 50 mg. intravenous tid prn . capsule 1 po. tid . Lasix prn . Nystatin swish and swallow tid . Percocet po. q4 to 6 prn . Trazodone 50 mg. qhs. multivitamins 1 po. qd .,3
 He is 5 feet   9 inches   225 pounds . He walks with a limp related to his right hip . His right hip is irritable with a 10-degree fixed flexion contracture . He is able to flex his right hip to 100 degrees . He has 10 degrees of internal and external rotation . He has intact distal pulses and 5  5 muscle strength in all major muscle groups . His X-rays show advanced osteoarthritis of his right hip . IMPRESSION AND PLAN  This is a 62-year-old male with severe osteoarthritis of the right hip who after discussion   including the nature   risks   benefits and alternative treatment plans   signed informed consent for a right total hip replacement .,1
 Coronary artery disease   status post MI x2   CABG x2 in 02  89 and 2  21   history of arthritis   history of bilateral rotator cuff degeneration and tears   history of hypertension   history of hyperlipidemia .,0
"1. Respiratory . The Athol Memorial Hospital hospital course was initially consistent with transient tachypnea of the newborn .', 'Chest x-ray revealed mild streakiness of the lung fields . He was initially placed on nasal cannula with subsequent resolution of respiratory distress .', 'Nasal cannula was weaned off on day of life 3 and he initially was maintaining O2 sat above 94 and breathing comfortably .', 'He was subsequently placed back on nasal cannula for mild oxygen desaturation and was requiring 25 c  min flow at the time of discharge .', 'No apneic or brady episodes . 2. Cardiovascular . The patient s cardiovascular status has been stable throughout his CMED CSRU stay .', 'No murmur on exam . 3. FEN . The patient had been tolerating oral feeding as of day of life 2 and is currently taking Enfamil 20 p.o. ad lib .', 'He has been weaned off IV fluids and has been maintaining good blood glucose . His birth weight was 3285 gm . His weight is 3015 gm on day of life 5 . 4. GI .', 'The patient s bilirubin level at 24 hours of life was 4.6. No phototherapy was started . 5. ID . The patient was not started on antibiotics   given lack of sepsis risk factors .', 'His initial CBC showed no left shift . Blood culture had remained no growth to date . 6. Heme . The patient s initial hematocrit was 35.8 . No transfusion during this admission .",0
 Percocet 5  325 mg one to two q. four hours p.r.n. Aspirin 325 mg q.d. Colace 100 mg b.i.d. Coumadin 5 mg q.d. Sotalol 180 mg b.i.d. Digoxin 0.125 mg q.d. Diltiazem 60 mg q.i.d. 8. Ambien 5-10 mg q.h.s. p.r.n. DISCHARGE INSTRUCTIONS  The patient should follow-up with his cardiologist in one to two weeks . He will also go home with VNA for INRs twice weekly with the results reported to his PCP or cardiologist for Coumadin adjustment . The patient should follow-up with Dr. Halcomb in six weeks time . Octavia W. Levitre   M.D. 05 -383 Dictated By  James Q. Mitchell   M.D. MEDQUIST36 D  2010-03-28 1015 T  2010-03-28 1046 JOB   41466 Signed electronically by  DR. Janice Carpenter on,2
 Menthol  Cetylpyridinium lozenges 1 as needed . Tenofovir 300 mg p.o. q.d. Didanosine 250 mg p.o. q.d. Atazanavir 300 mg p.o. q.d. Ritonavir 100 mg p.o. q.d. Calcium carbonate 500 mg p.o. q.d. Methylprednisolone 4 mg tablets per taper regimen . The patient was to take one 4 mg tablet dinner and at bedtime the day of discharge   then the next day take one 4 mg tablet in the morning   lunch time   and with dinner and then at bedtime   then the third day to take 4 mg tablet in the morning   lunch   and bedtime   the fourth day to take one tablet in the morning and dinner   and in the last day take one 4 mg tablet in the morning . He was also discharged on Augmentin XR 1000 mg    62.5 mg sustained release 1 tablet q. 12h . for 2 weeks . FOLLOW-UP The patient was to follow up with his PCP A. L. . Taylor in 7 to 10 days   and the patient was to call Dr. Thibodeau   CMED CSRU doctor to follow up in 2 weeks  time . Teddy Stephen   Louisiana 32870 Dictated By  Judy J Johnston   M.D. MEDQUIST36 D  2011-07-12 155531 T  2011-07-13 111452 Job  79962 Signed electronically by  DR. Ruth Gibson on MON 2011-07-18 748 AM,2
He is to follow up with Dr. Rach Breutznedeaisscarvwierst in Clinic.,3
DISCHARGE DISPOSITION Home .follow up VNA and pediatric primary care physician appointments to be scheduled prior to discharge .,3
 Lopressor 100 mg p.o.b.i.d. Lisinopril 10 mg p.o.q.d. Lipitor 10 mg p.o.q.d. Aspirin 81 mg p.o.q.d. Percocet one to two tablets p.o.q. 3-4 h. p.r.n. pain . Colace 100 mg p.o.b.i.d. DISCHARGE PHYSICAL EXAMINATION  The patient had a temperature of 98.4   heart rate 72   blood pressure 154  89   respiratory rate 18 and oxygen saturation 90 in room air . He was alert and oriented . His neck was supple without lymphadenopathy . He had faint bibasilar crackles on lung examination . His heart had a regular rate and rhythm with no murmur   rub or gallop . His abdomen was soft   nontender and nondistended with a nonerythematous peritoneal dialysis insertion site . Extremities were warm and well perfused . DR . Kemp   Julie R. 02 -358 Dictated By  Judy Y Carnevale   M.D. MEDQUIST36 D  2010-09-18 1942 T  2010-09-22 1110 JOB   34822 Signed electronically by  DR. Dalila Talbot on  Robert 2010-09-23,2
 As noted . PAST SURGICAL HISTORY   Significant for having had a cholecystectomy and hysterectomy   tonsillectomy and adenoidectomy   and mastoidectomy,0
 Topical Bactroban to be applied three times a day to affected naris   prednisone 5 mg p.o. q.a.m.   K-Dur 10 mEq x2 p.o. q.d.   OxyContin 10 mg p.o. q.12h clindamycin 300 mg p.o. q.i.d.   lisinopril 10 mg p.o. q.d.   atenolol 25 mg p.o. q.d.   trazodone 100 mg p.o. q.h.s.   Prilosec 40 mg p.o. q.d   clotrimazole 1 cream topical to be applied b.i.d. DISCHARGE FOLLOW-UP The patient was arranged for follow-up appointment with Dr. Scarvzine of rheumatology on 10  11  01 . Also   with Dr. Fyfe of ENT scheduled for Halloween . Dr. Twada   his primary care physician at the SBH clinic for 10  11  01 and Dr. Fyfechird   gastroenterologist   on 10  13  01 . COMPLICATIONS  There were no complications during the patient &aposs hospitalization and he was discharged in stable condition . Dictated By  THRYNE ANA   M.D. GN628 Attending  DRIS UPHKOTE   M.D. IF67 TB150  196806 Batch  48373 Index No. RYZKWV6XG4 D,2
 By systems  Respiratory . After receiving brief blow by oxygen in the delivery room   the patient had no further episodes of ventilatory assistance required with good respiratory rate consistently . The patient was never placed on caffeine . He is stable in room air at this time . Cardiovascular . No active issues . No history of hypotension . On no medications at this time . Notably with respect to apnea and bradycardia of prematurity   the patient has reached 5 days without significant apneic or bradycardic spells as of the time of discharge . Fluids   electrolytes and nutrition . The patient reached full volume feeds by day of life 6 and had calories increased to maximum of 26 kilocalories per ounce of Similac special care until 2014-12-03   at which point this was weaned to 24 kilocalories per ounce of straight Similac . This is the baby s discharge feedings and he is p.o. ad lib with a minimum of 130 ml  kg  day   the patient has taken on an average greater than 150 ml  kg  day ad lib over each of the past 5 days . GI . The patient with peak bilirubin of 6.5 on day of life 3 . No phototherapy was required . Hematology    Infectious Disease . The patient s hematocrit at delivery was 48   with a white count of 11.2 and platelets of 301 000 . Initial differential was 35 polys and zero bands   not suspicious for infectious condition . The patient was initially treated with 48 hours of ampicillin and gentamicin until blood cultures were negative . The infant has had no antibiotics since that time . Neurology . No issues . Sensory . Hearing screen was performed with automated auditory brainstem responses and was normal on 2014-11-24 . Ophthalmology . The patient did not qualify for routine ophthalmology exams due to his gestational age at birth . ,0
 Patient was stable with complete clearance of her mental status   advancement of her diet   blood pressure   and heart rate remained stable   and her oxygen saturations were well above 90 during the daytime on 2 liters nasal cannula and at night on the BiPAP settings described above . Physical Therapy consult is pending today . DISCHARGE MEDICATIONS  1. NPH 70 units q.a.m.   50 units q.p.m. Humalog sliding scale . SubQ Heparin 5 000 units t.i.d. Ranitidine 150 mg p.o. b.i.d. Multivitamin x1 . Losartan 25 mg p.o. q.d. Iron supplementation 150 mg p.o. q.d. Levofloxacin day four of 10 to be completed for a full 10-day course   500 mg p.o. q.d. Metoprolol 25 mg p.o. b.i.d. Colace 100 mg p.o. b.i.d. Mark Nibbe   M.D. 87 -896 Dictated By  Jeffrey N. Elvington   M.D. MEDQUIST36 D  2015-10-02 0819 T  2015-10-02 0820 JOB   15790 Signed electronically by  DR.,2
 Patient is being sent home on Ecotrin one q.d.   Digoxin 0. l25 mg every three days   Quinidine 648 mg q.a.m. and 324 mg q.p.m. and q.h.s.   Mevacor 20 mg p.o. q.d.   Carafate one gram p.o. q.i.d.   Colace l00 mg p.o. t.i.d.   Lasix 80 mg p.o. q.d.   Potassium 20 mEq p.o. q.d.   and iron supplements . Patient has follow-up with Dr. Merkel and with his private medical doctor . EV956  4659 RISHAN M. MERKEL   M.D. BS9 D  01  02  92 Batch  3669 Report  F6644X53 T  01  02  92 Dicatated By  RAMA R. KOTEOBE   M.D. cc  1.,2
 Aricept 10 mg qd   Aspirin 81 mg qd   Folic acid   Gabapentin 200 mg tid   Lopressor 12.5 mg bid   Lisinopril 5 mg qd   Daptomycin 420 mg IV qd   Protonix 40 mg qd   Seroquel 50 mg tid   Heparin 5000 units SQ tid   Colace 100 mg bid   Lactulose 15 mg bid   Comtan 200 mg qd   Mirapex 1.5 mg tid   Sinemet 50    200 mg tid Discharge Medications  1. Furosemide 20 mg Tablet Sig  One  1  Tablet PO once a day for 2 weeks . Potassium Chloride 20 mEq Packet Sig  One  1  Packet PO once a day for 2 weeks . Docusate Sodium 100 mg Capsule Sig  One  1  Capsule PO BID  2 times a day  . 4. Pantoprazole 40 mg Tablet   Delayed Release  E.C.  Sig  One  1  Tablet   Delayed Release  E.C.  PO Q24H  every 24 hours  . 5. Aspirin 81 mg Tablet   Delayed Release  E.C.  Sig  One  1  Tablet   Delayed Release  E.C.  PO DAILY  Daily  . 6. Magnesium Hydroxide 400 mg    5 mL Suspension Sig  Thirty  30  ML PO HS  at bedtime  as needed for constipation . 7. Entacapone 200 mg Tablet Sig  One  1  Tablet PO TID  3 times a day  . 8. Pramipexole 0.25 mg Tablet Sig  Six  6  Tablet PO TID  3 times a day  . 9. Carbidopa  Levodopa 50  200 mg Tablet Sustained Release Sig  One  1  Tablet PO TID  3 times a day  . Quetiapine 25 mg Tablet Sig  Two  2  Tablet PO DAILY  Daily  . Procainamide 250 mg Capsule Sig  Three  3  Capsule PO Q6H  every 6 hours   x 6 weeks . 12. Acetaminophen  Codeine 300-30 mg Tablet Sig  One  1  Tablet PO Q4H  every 4 hours  as needed . Warfarin 1 mg Tablet Sig  as directed Tablet PO DAILY  Daily  . Daptomycin 500 mg Recon Soln Sig  Four 90y  480  mg Intravenous Q24H  every 24 hours  thru 05-02 . Discharge Disposition  Extended Care Discharge Diagnosis  mitral valve endocarditis s  p MV replacement HTN s   p CVA Spinal stenosis s  p Lumbar Laminectomy Parkingson s h  o paranoid delusions MGUS vs MM Discharge Condition  good Discharge Instructions  May take shower . Wash incisions with warm water and gentle soap . Do no take bath or swim . Do not apply lotions   creams   ointments or powders to incision . Do not drive for 1 month . Do not lift more than 10 pounds for 2 months . Please contact office if you develop a fever more than 101.5 or notice drainage from chest incision . Followup Instructions  Dr. Portsche in 4 weeks Dr. Bravo  PCP  in 1-2 weeks Infectious disease Provider  Marsha Harriet   MD Phone  574-5036 Date    Time  2019-04-29 1000 Jeffrey Everett MD 23-815 Completed by  MARK Carolyn NP 80-AUO 2019-03 -26  1033 Signed electronically by  DR.,3
 A Neurosurgery consultation was obtained   and it was their impression that the patient &aposs paraplegia might possibly represent a cord concussion   and recommended treatment with intravenous steroids for 24 hours . The patient &aposs paraplegia resolved by the morning of her second hospital day   and she maintained 5  5 motor strength in all groups . A Urology consultation was obtained   and it was recommended that an IVP be obtained . This was obtained on the day of discharge   however   due to residual contrast in the colon from the patient &aposs prior abdominal CT scan the exam was postponed after a scout film was obtained . The patient fell well on the day of discharge . She remained afebrile throughout her hospital course . Additionally on the night before discharge   flexion and extension views of the lumbosacral spine were obtained   and showed no fracture or instability . DISPOSITION  CONDITION ON DISCHARGE  Good .,0
discharge disposition   'To home .',3
 BY SYSTEM 1. PULMONARY  She was treated with albuterol and Atrovent continuous nebulizers and was weaned then to intermittent nebulizer treatments and then to her meter-dosed inhalers taking them q.4h. at the time of discharge . She was continued on salmeterol and Flovent . She was continued on Solu-Medrol 80 mg q.8h. then converted to prednisone at 60 mg p.o. q.d. She was started on Singulair 10 mg p.o. q.d. Serial arterial blood gases were followed after an arterial line was placed . Her PCO2 gradually declined to the 48 range . Despite episodes of somnolence the first night which were presumably due to having spent the entire night in the Emergency Department   she never became more hypercarbic   and her PCO2 trended to 48 by the time the arterial line was discontinued . On the night of admission and thereafter   she was noted to have a very stridorous sounding breathing when the patient was asleep . This would disappear whenever she was awake . Her case was discussed with Ear  Nose  Throat and the Medical Intensive Care Unit attending . She was given a trial of 80  20 mixed helium  oxygen to decrease the stridor but had minimal effect . Ear  Nose  Throat recommended not considering this an airway problem unless she was stridorous while awake . The patient was to arrange for Pulmonary and Medicine followup through her primary care physician upon discharge as she has not been seen in the Pulmonary Clinic in two years . 2. CARDIOVASCULAR  The patient ruled out for myocardial infarction with serial creatine kinases   although these did rise to 816 . MB was negative . She was treated with captopril for hypertension   and this was switched to Norvasc 7.5 mg p.o. q.d. on discharge . She had an echocardiogram which showed a hyperdynamic left ventricular of normal thickness and size   and no significant valvular disease . She apparently did not have a cardiovascular component to her wheezing or shortness of breath  however   she was to go home on Lasix 20 mg p.o. q.d. to help with lower extremity edema   as she experiences discomfort with this   and the team felt this may be a limiting factor with her prednisone compliance . 3. ENDOCRINE  She was treated with a sliding-scale of regular insulin while she was in house . She was given 500 mg p.o. q.d. of metformin to treat her steroid-induced diabetes on discharge . This should be followed up by her primary care physician . 4. INFECTIOUS DISEASE  She was treated briefly with levofloxacin because of the gram-positive cocci in her sputum culture  however   her symptoms were felt to be consistent with a viral upper respiratory infection   and levofloxacin was continued at the time of discharge . MEDICATIONS ON DISCHARGE Lasix 20 mg p.o. q.d. Combivent meter-dosed inhaler 2 puffs q.4h. weaning to albuterol meter-dosed inhaler 2 puffs q.4h. Salmeterol 2 puffs q.12h. Flovent 220 mcg 2 puffs q.12h. Prednisone 40 mg p.o. q.d. with taper . Fentress 60 mg p.o. b.i.d. Singulair 10 mg p.o. q.d. Univasc 7.5 mg p.o. q.d. Metformin 500 mg p.o. q.d. Dyazide was discontinued . DISCHARGE STATUS  Discharge services included visiting nursing which was to assess in her inhaler technique   monitor her fasting blood sugars   as well as her blood pressure   monitor her peak flows   and assess her mobility and activities of daily living at home . DISCHARGE FOLLOWUP She was also to seek the next available appointment with Dr. Jeanette Barr or to see another resident in the Saint Vincent Hospital Clinic if she cannot get an appointment within one week . CONDITION AT DISCHARGE  Condition on discharge was good .. CODE STATUS  Full code . DISCHARGE DIAGNOSES Asthma flare . Hypertension . Steroid-induced diabetes . James Z Berg   M.D. 19-421 Dictated By  Melanie L.W. Palevic   M.D. MEDQUIST36 D  2011-06-18 1633 T  2011-06-21 1534 JOB  92012 Signed electronically by  DR. Andrea Trotter on,0
 Prozac . Tetracycline for acne .,3
Large for gestational age . Infant of a diabetic mother . Hypoglycemia . Reviewed By  Mary Karina   Oregon 30621 Dictated By  James H. Acosta   M.D. MEDQUIST36 D  2012-10-02 154605 T  2012-10-02 171444 Job  07783 Signed electronically by  DR. Richard Stripling on  Maxine 2012-10-25,2
"eedings breast milk or Enfamil 24 calories per ounce breast milk mixed with 4 calories per ounce of Enfamil powder', 'minimum of 140 cc per kilogram per day po ",2
 Labs on admission from outside hospital   CBC notable for a white count of 21.9 with hematocrit of 36.3 and normal platelets . Chem-7 notable for potassium of 3.2 and bicarbonate of 30 . LFTs show an elevated ALT of 52 and AST of 101 with normal alkaline phosphatase and total bilirubin . Latest arterial blood gas with pH of 7.45   pCO2 43 and pO2 155 on 100 percent oxygen via ventilator . RADIOGRAPHIC STUDIES  Chest x-ray shows right middle lobe   right lower lobe   and left lower lobe infiltrates . EKG shows normal sinus rhythm at 70 beats per minute with normal axis and intervals   borderline LVH . ,1
 Negative for any history of sudden death or coronary artery disease .,0
 Nonischemic dilated cardiomyopathy . MEDICATIONS ON DISCHARGE  1. Digoxin 375 mcg and 250 mcg alternating doses each day . Lisinopril 40 mg p.o. q.d. Toprol XL 75 mg p.o. q.d. Flovent 110 mcg two puffs b.i.d. 5. Albuterol 1-2 puffs q.6h. prn . 6. Coumadin 10 mg p.o. q.h.s. Lasix 40 mg p.o. q.d. Keflex 500 mg x6 doses . FOLLOW-UP INSTRUCTIONS  The patient will follow up in EP Clinic on 2012-03-19 . She will also be seen in the Heart Failure Clinic on 2012-03-28 . Patient will also followup with her primary care provider   Dr. Sandra Lamar for check of her INR in one week s time . Felix Weiss   M.D. 95 -771 Dictated By  Randy EB Brooks   M.D. MEDQUIST36 D  2012-03-13 1225 T  2012-03-13 1400 JOB  15824 Signed electronically by  DR.,2
 After consultation with Cardiology as well as Anesthesia on call that evening   it was decided to transfer the patient to the ICU for intensive monitoring . Central IV access was obtained . The patient was carefully diuresed over the next 48 hours . Symptoms of congestive heart failure gradually abated over the next 48 to 72 hours . The patient was given antenatal corticosteroids for fetal lung maturity . A Neonatology consultation was obtained during the course of the hospitalization . After discussion   it was decided to attempt to obtain 28 weeks gestation and then deliver electively by cesarean section given the decompensation in the third trimester . The patient underwent primary low transverse cesarean section on 2014-05-19 at approximately 28 weeks gestation . The cesarean section was performed on the West Campus in the Cardiothoracic Surgical Suite . This was performed in this location in case any acute cardiac decompensation occurred during the time of cesarean section . Cardiothoracic Surgery was on standby during the surgery . The patient went to the cardiac Intensive Care Unit on the West Campus postoperatively . She did well during the postoperative period . She required several episodes of diuresis due to increasing shortness of breath on postoperative day 1 and postoperative day 2 due to worsening symptoms of shortness of breath from fluid shifts that normally occur during the postpartum period . The patient was transferred to the West Campus on postoperative day 2 in stable condition . She did well during the remainder of her postoperative course and was continued on her medication regimen that she had been on during the antepartum period . She was discharged to home on postoperative day 4 . She was to followup with Maternal Fetal Medicine in 5 to 7 days . She had followup with her primary cardiologist in Shaugnessy-Kaplan Rehab Hospital scheduled for 1 week postoperatively . Of note   the patient also underwent tubal ligation at the time of cesarean section .,0
 Aspirin 325 mg. PO q.d. Lipitor 80 mg. PO q.d. Toprol XL 50 mg. PO q.d. Lasix 80 mg. q.a.m. and 40 mg. q.p.m. Potassium chloride 20 mEq. PO b.i.d. Citracal 1 packet q.d. Imdur 60 mg. PO q.d. Vitamin E 400 international units q.d. Prilosec 20 mg. PO q.d. HISTORY OF PRESENT ILLNESS Breunlinke is a 70-year-old patient of Dr. Brendniungand Asilbekote in California . She is referred for progressive angina . She had rheumatoid fever as a child and a heart murmur noted but no further testing . She has used antibiotic prophylaxis since 1980 . In 1980 she had quadruple coronary artery bypass graft surgery by Dr. Elks at Feargunwake Otacaa Community Hospital and did well until 1988 when she had exertional angina and a positive stress test and found that three or four grafts were occluded . In October   1989   Dr. No re-did her bypass operation . She had a left internal mammary artery graft to the left anterior descending   saphenous vein graft to the obtuse marginal 1 and a saphenous vein graft to the obtuse marginal 2 . In 1993 she had a DDD pacemaker for complete heart block . She had exertional angina at that time . In November   1997 she had a small myocardial infarction as was transferred to Ona Hospital where a cardiac catheterization showed a tight left internal mammary artery to left anterior descending stenosis   high grade saphenous vein graft to obtuse marginal 1 stenosis and patent obtuse marginal 2 graft . She had normal left ventricular function with apical tip akinesis . Since that time she has continued to have exertional left chest burning   radiating to the left neck and arm   relieved by nitroglycerin . She was turned down for re-do surgery at that time and did not have a percutaneous transluminal coronary angioplasty . Because these symptoms have been increasing   particularly at cardiac rehabilitation   she was referred here . In May   1998 she had an exercise tolerance test in which her heart rate went to 112 and her blood pressure fell to 95 systolic . She had diffuse ischemic ST segment changes and increased lung uptake and a reversible anterior and lateral defect . She has had no syncope . Her cardiac risk factors are hypertension and elevated cholesterol . She has a very strong family history of coronary artery disease with a mother   sister and brother dying of myocardial infarction . She is a remote cigarette smoker . She also has a history of lactose intolerance   peptic ulcer disease   with a remote gastrointestinal bleed and multiple ectopic pregnancies and mid term miscarriages . She has had a total abdominal hysterectomy .,0
 Coronary artery disease   status post coronary artery bypass grafting times 4 with LIMA to the LAD   saphenous vein graft to OM1   saphenous vein graft to OM2 and saphenous vein graft to the diagonal . Hypertension . Hypercholesterolemia . Status post partial thyroidectomy . Status post hernia repair . Status post left knee surgery . Status post tonsil and adenoid surgery . DISCHARGE MEDICATIONS  1. Atorvastatin 10 mg q.d. 2. Plavix 75 mg q.d. times 3 months . Aspirin 325 mg q.d. Lasix 20 mg q.d. times two weeks . Potassium chloride 20 mEq q.d. times two weeks . Metoprolol 12.5 mg b.i.d. Percocet 1 to 2 tabs q. 4 hours p.r.n . The patient is to be discharged home with visiting nurses . He is to have follow up in the wound clinic in two weeks and follow up with Dr. Brewster in two to three weeks and follow up with Dr. Rota in 4 weeks . Herbert Jesus   Georgia 01835 Dictated By  Scott OK Astarita   M.D. MEDQUIST36 D  2016-09-14 125227 T  2016-09-14 132805 Job  15604 Signed electronically by  DR. Richard Gomez on  FRI 2016-09-16,2
 Dexedrine 5 mg per day and Motrin 600 mg tid .,3
 ON ADMISSION  Birth weight was 5235 grams   length was 56 cm   and head circumference was 37.5 cm . Anterior fontanel open and flat . The palate was intact . Nares were patent . Bilateral breath sounds were clear and equal . No grunting   flaring   or retracting . No murmurs . A regular rate and rhythm . Pink and well perfused . The abdomen was soft and nondistended . There was no hepatosplenomegaly . There was a 3-vessel cord . The spine was intact . The anus was patent . Normal male genitalia . Tone was appropriate for gestational age . SUMMARY OF HOSPITAL COURSE BY ISSUES-SYSTEM  RESPIRATORY  The infant has remained on room air throughout his hospitalization with oxygen saturations of greater than 95 percent . Respiratory rates have been 40 s to 60 s. The infant has had two spontaneous desaturations which quickly self-resolved on day of life one . No other issues . No apnea or bradycardia . CARDIOVASCULAR  The infant has remained hemodynamically stable with heart rates in the 120 s to 140 s and mean blood pressures of 57 to 60 . FLUIDS   ELECTROLYTES AND NUTRITION  The infant was admitted to the Neonatal Intensive Care Unit for treatment of hypoglycemia . The infant was started on enteral feedings of Enfamil 20 calories per ounce by mouth ad lib and maintained glucoses in the middle to high 40 s taking by mouth feedings every two to three hours by mouth ad lib . On day of life one   the infant had a dextrose stick of 34 . At that time   an intravenous of D-10-W was started at 80 cc    kilogram per day . On day of life two   the infant began to wean off intravenous fluids   and this was completed by day of life four . Calories were increased to Similac 24 calories per ounce . Before discharge to the Newborn Nursery   the infant was taking Similac 22 calories per ounce by mouth ad lib and maintaining dextrose sticks in the 60 s. Weight on discharge was 5200 grams . GASTROINTESTINAL  No issues . HEMATOLOGY  No issues . NEUROLOGY  Normal neurologic examination . SCREENS  A hearing screen was performed with automated auditory brain stem responses and the infant passed on both ears . PSYCHOSOCIAL  The parents are involved . ,1
 Admission medications . YERTREY TANELI SUMCHIRDKAYSMAVVEINDREPS   M.D. DICTATING FOR  Electronically Signed ALEN LAA CREDKOTE   M.D. 09  30  2003 1334 ALEN LAA CREDKOTE   M.D. TR  ruw DD  09  11  2003 TD  09  12  2003 223 P 366967 cc,0
Was discharged on 11  16  2003 in stable condition with the last recorded hematocrit of 31.3 . He was asked to continue on his Nexium   iron and vitamin C and was continued on his other home medications .,3
 By systems  Respiratory  Pocasset was admitted to the newborn intensive care unit with mild respiratory distress . Chest x-ray revealed a left pneumothorax which resolved on its own without intervention . The infant has remained in room air throughout her hospital course with occasional apnea and bradycardia episodes   the last being documented on 2020-01-14 . Cardiovascular  Attleboro has been stable throughout her newborn intensive care course without issue . Fluids and electrolytes  Birth weight was 1515 grams . She was initially started on 80 cc per kilo per day of D10W . Enteral feedings were initiated on day of life 1 . Full enteral feedings were achieved by day of life 7 . The infant had a course of heme positive stools with grossly bloody streaks and mucus felt to be protein allergy . The infant is now receiving breast milk with Nutramigen powder concentrate to 24 calorie . Stools have been negative to trace positive and abdominal exam is reassuring . Discharge weight is 2040 gm   the head circumference is 32 cm and the length is 46 cm. . GI  Peak bilirubin was on day of life 2 of 4.8  0.3 . Hematology  Hematocrit on admission was 41 . The infant did not require any blood transfusions during this hospital course . Infectious disease  CBC and blood culture were obtained on admission . White count was 4.8   7 polys   zero bands   platelet count of 316 000 . ANC at that time was 336 . A 24 hour CBC was obtained . White blood cell count was 5.1   22 polys   zero bands with a hematocrit of 39.3 and platelets of 313 000 . The infant received 48 hours of ampicillin and gentamicin which were discontinued with a negative blood culture . Neurology  The infant has been appropriate for gestational age . Sensory  Audiology hearing screen was performed with automated auditory brainstem responses and the infant passed on both ears . ,0
 Aspirin 325 mg po q day . Vasotec 7.5 mg po q day . Humalog insulin sliding scale with meals and at bedtime . Humulin Walters insulin 24 units subcutaneous q A.M. and 8 to 16 in the evening depending upon where his blood sugar has been . Preoperative laboratory values were unremarkable . The patient underwent cardiac catheterization on 2011-10-17 which revealed a 20 left vein osteal lesion as well as 70 LAD lesion and an 80 right coronary . The patient was taken to the operating room on 2011-10-18 where he underwent an aortic valve replacement with 23 mm pericardial valve as well as coronary artery bypass graft times two with a LIMA to the LAD and saphenous vein to the acute marginal . Postoperatively the patient was transported to the cardiac surgery recovery unit on Milrinone   Neo-Synephrine and Levophed drip . The patient was weaned from mechanical ventilation and subsequently extubated on the night of surgery . He remained on Levophed   Milrinone and Neo-Synephrine drips and was hemodynamically stable . N. Saez clinic consult was obtained due to hyperglycemia and the need for insulin drip in the Intensive Care Unit . On postoperative day the Milrinone was weaned down . The Levophed had been discontinued as the Neo-Synephrine and the patient was beginning to progress hemodynamically . Upon discontinuation of the Milrinone the patient s SV02 had dropped significantly in the low 50 s. The patient had decreased exercise tolerance and therefore was placed back on his milrinone to keep his cardiac index greater than 2.0 . Over the next couple of days it was very slowly decreased as his Ace inhibitors were increased orally . The patient ultimately was weaned off the Milrinone   transitioned to Captopril on postoperative day five and remained hemodynamically stable . Once the patient had remained off of inotropics for approximately 24 hours   he had been given diuretics and Ace inhibitors and remained hemodynamically stable he was transferred from the Intensive Care Unit to the Telemetry floor on postoperative day six . A physical therapy evaluation was obtained for assistance and mobility . Cardiac rehabilitation was initiated at that time . On 2011-10-24 postoperative day six consultation heart failure cardiology service was obtained . It was their recommendation to continue Ace inhibitors   to continue daily weights   to switch the patient to a long acting beta-blocker and to enroll the patient in postoperative cardiac rehabilitation as well as to make sure the patient was on statin drugs . These measures were all instituted . The patient continued to progress from cardiac rehabilitation and physical therapy standpoint while on the floor . The patient remained hemodynamically stable over the next few days   continued to increase with physical therapy and ambulation . His blood sugars were followed by the Cape Cod Hospital Clinic service and insulin has been adjusted accordingly . Today   2011-10-31   postoperative day 13 the patient remains stable and ready for discharge to home . The patient s condition today is as follows  Temperature 96.9 F   pulse 84   respiratory rate 18   blood pressure 106  59 . Most recent laboratory values are from 2011-10-25 which revealed a white blood cell count 8.4000   hematocrit 35   platelet count 202 000. Sodium 133   potassium 4.4   chloride 93   CO2 30   BUN 24   creatinine 0.7   glucose 198 . The patient s finger stick blood glucose levels range from 151 to 390 over the past 24 hours and his insulin scale has been adjusted upward to compensate for that . Neurologically the patient is grossly intact . Pulmonary exam he is clear upper lobes   diminished bilateral bases left greater than right . Coronary exam is regular rate and rhythm . His abdomen is benign . His sternum is stable. His incision is clean and dry Steri Strips intact . His extremities are warm and well perfused with minimal edema of his left foot as well as his right stump . He is able to apply his prosthesis and ambulate as well .,0
 Procardia sustained release 60 mg. po q.day   Digoxin .25 mg. po q.day   Lasix 30 mg.  interval unspecified    Prozac 40 mg. po q.day   Lovestatin 20 mg. po bid   aspirin q. day and supplemental potassium .,3
HISTORY OF THE PRESENT ILLNESS  The patient is a 63  year-old man with a history of hypertension and prior history of atrial fibrillation secondary to hyperthyroidism who presented to an outside hospital with a history of left-sided chest pain at rest . The patient awoke with chest pressure radiating to the right chest associated with diaphoresis . The patient was found to have a blood pressure of 170  108 with atrial fibrillation and rapid ventricular response to a heart rate of 140s . The patient was rate controlled and transferred to the Stillman Infirmary for emergent cardiac catheterization .,0
 The patient is thus stage IV endometrial and stage III-C ovarian vs metastatic endometrial for line II   cycle I chemotherapy IFEX   MESNA and VP-16 . The plan was for urinalysis q d . With the history of DVT   we plan Coumadin and check her coags . The patient was tachycardiac on admission and it was felt she was dehydrated and    or anxious at the time of her initial evaluation . EKG showed sinus tachycardia and incomplete right bundle branch block . When compared with ECG of 11-06-90   there was borderline criteria for anterior MI although the patient denied any chest pain at any point .,3
 Hematocrit was 42   PT was 10   potassium was 3.6   BUN was 29   creatinine was 1.4   blood sugar was 111 . EKG showed atrial fibrillation   moderate ventricular response   right ventricular hypertrophy   right axis deviation .,1
 ON ADMISSION  Temperature 98.8   heart rate 68   blood pressure 107  82   and oxygen saturation 99 on room air . CHEST  Clear to auscultation . HEART  Regular rate and rhythm with no murmurs . ABDOMEN  Soft   mildly distended   and tympanic with midepigastric tenderness to palpation and no rebound . The ostomy was pink with minimal fluid in the ostomy bag . It was guaiac negative . EXTREMITIES  No signs of edema and the patient had warm and palpable pulses distally .,1
 Docusate sodium 100 mg p.o. b.i.d. Ursodiol 300 mg p.o. b.i.d. Ascorbic acid 500 mg p.o. q.d. Zinc sulfate 220 mg p.o. q.d. Lansoprazole oral solution 30 mg per gastric tube q.d. Caspofungin acetate 50 mg IV q.d.   day 23 of treatment and patient should remain on it indefinitely . Nephrocaps one cap p.o. q.d. If on dialysis  please take after dialysis treatment . Metoclopramide 5 mg p.o. b.i.d.   take 30 minutes before meals . Fluconazole 200 mg p.o. q.h.d. Patient should remain on this medication . Magnesium sulfate 2 gm in 100 ml of D5W IV as needed for repletion p.r.n. Miconazole powder 2 one application t.p. t.i.d. p.r.n. 12. Acetaminophen 325 mg to 650 mg p.o. q.four to six hours p.r.n. 13. Albuterol one to two puffs inhaled q. six hours p.r.n. 14. Bisacodyl 10 mg per rectum h.s. as needed p.r.n. 15. Hydralazine hydrochloride 10 mg IV q. six hours p.r.n. systolic blood pressure greater than 140 . 16. Vancomycin 1 gm IV as needed for vancomycin level less than 15 . This is day 23 of treatment for an approximate six week course . 17. Ceftazidime 1 gm IV q.h.d. after dialysis . 18. Alteplase for catheter clearance 2 mg IV once times one dose for indwelling PermCath . DISCHARGE DIAGNOSES  Status post aortic valve replacement and coronary artery bypass grafting times four . Status post sternal debridement . Status post skin graft to chest incision . Status post open jejunostomy tube placement   open left subclavian PermCath placement . Status post DDD pacer placement with external generator . Status post abdominal repair of wound dehiscence of jejunostomy site . Status post percutaneous tracheostomy . Status post acute renal failure . Status post myocardial infarction . Hypertension . Hypercholesterolemia . Asthma . Peptic ulcer disease status post gastrectomy 30 years ago . Colon cancer status post colectomy with XRT four years ago . Peripheral vascular disease with history of bilateral lower extremity claudication . COPD with asbestosis on chest CT scan . The patient is discharged on Thursday   12-31   to a rehabilitation facility   on postoperative day 93   in stable condition   from the cardiac surgery recovery unit . Perry G. Ozuna   M.D. 83 -390 Dictated By  Keith E. Shafer   M.D. MEDQUIST36 D  2015-12-31 1112 T  2015-12-31 1119 JOB  04648 Signed electronically by  DR. Kelsey MOORMAN on  FRI 2016-01-08,2
 Synthroid   Prilosec 20 mg p.o.   Fioricet   Celebrex .,3
 He was a well-developed   well-nourished man who was breathing comfortably . Temperature was 101.3 . HEENT were normal . Neck was supple . Lungs were clear to percussion and auscultation with a few scattered rales   left greater than right . Abdominal examination was normal . Extremities were normal . Neurological examination was nonfocal .,1
 Breast cancer   status post lumpectomy  Mitral commissurectomy .  Atrial fibrillation  Peripheral vascular disease .  Arterial emboli   left femoral artery  Congestive heart failure .  MEDICATIONS ON TRANSFER  Lopressor intravenous q 6 hours .  Morphine Sulfate 1 mg intravenous p.r.n. ALLERGIES  Penicillin   Sulfa and Quinidine .,0