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README.md

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-license: apache-2.0
----
-
-SOAP dataset Initial Version

biomegix--soap_inital/csv-test.parquet

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test.csv

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-text,label
- h  o nephrolithiasis s  p lithotripsy and h   o left ureteropelvic junction stone 03 spontaneously passing by U  S    no evidence of right stone on most recent u  s 5 months ago  h  o pyelo   last episode in 03   MRSA in blood and urine   SLE w   h   o pericarditis    last flare couple years ago didn t flare  w   urosepsis  Devic s disease  Recurrent transverse myelitis with sequelae of paraplegia-exacerbation in 93 Recurrent bilateral optic neuritis with legal  neurologist  Dr. Heaton   UMass Memorial Medical Center    steroids increased to 40 qd in Renee for concern for recurrent optic neuritis which turned out to be capsular ossification   blindness in right CMED CSRU .   Bilateral knee arthritis  Suspected glaucoma in left CMED CSRU   turned out to be capsular ossification or a secondary cataract   corrected w   laser surgery 2014-11-03  Urostomy s  p ileal loop conduit in 2007 for neurogenic bladder w   persistent leak  Steroid-induced hyperglycemia  Hypothyroid  Osteoporosis  Hx of DVT in RLE 93  on coumadin for a couple years and then ASA until a couple months ago Social History  Retired ICU nurse  Thomas Haas  x 15 yrs but maintains her certification .  Lives at Lowell Home NH x 11 yrs due to chronic CMED issues  Her doctor there is Dr. Gerald Jones .  No h  o tobacco   alcohol   or IVDA  Wheelchair dependent  requires Hoyer lift .  UE strength intact but poor motor movements due to loss of sensation .,0
- Colace 100 mg p.o. b.i.d.   Folate 1 mg q.d.   Artificial Tears 2 drops each eye b.i.d. and p.r.n.   Serax 15 mg p.o. q6h  hold if patient excessively sleepy   Thiamine 100 mg p.o. q.d.   MS  Contin 30 mg p.o.b.i.d multivitamin q.d.   MSIR 15 mg p.o. q3-4h p.r.n. pain   and Axid 150 mg p.o. b.i.d. The patient is to undergo dry dressing changes and splint to his right arm q.d. DIET  Regular . FOLLOWUP  The patient is to be seen in the burn clinic two days after discharge . The patient was discharged in stable condition . Dictated By  TELSHEY K. PAP   M.D. IK06 Attending  TELSHEY K. PAP   M.D. BH2 MC084  4189 Batch  9441 Index No. YROINI4 PGM D  01  07  97 T  01  07  97 CC  1.,2
- Atrial fibrillation secondary to hyperthyroidism   initially diagnosed in 2005  Status post  current cardioversion times four  Hyperthyroidism   status post radioactive iodine ablation .  Status post carpal tunnel release  Status post umbilical hernia repair .  Hypertension  MEDICATIONS AT HOME  1.  Accupril 40 mg q.d.  Aspirin 325 mg q.d Clonidine 0.1 mg b.i.d.,0
- On admission   in general   the patient was in no acute distress   comfortable . Vital signs showed temperature 96.3   pulse 64   blood pressure 170  70   respiratory rate 20   oxygen saturation 98 in room air . Head   eyes   ears   nose and throat examination is normocephalic and atraumatic . Extraocular movements are intact . The pupils are equal   round   and reactive to light and accommodation . Anicteric . Throat is clear . The chest is clear to auscultation bilaterally . Neck was supple with no lymphadenopathy . Cardiovascular shows grade II  VI systolic ejection murmur   regular rate and rhythm . The abdomen is soft   nontender   nondistended   with a small umbilical hernia . Extremities are warm   noncyanotic and nonedematous times four . There is no peripheral edema .,1
- Metastatic gallbladder cancer . Status post cholecystectomy . Status post transverse colectomy with anastomosis . G tube placement . Feeding jejunostomy . Hypothyroidism . Blood loss requiring transfusion .,2
- As above . PAST SURGICAL HISTORY   As above  MEDICATIONS ON ADMISSION  Percocet and Naprosyn .  ALLERGIES  Demerol,0
- VITAL SIGNS  Temp 98.5   heart rate 74   BP 140  90   respiratory rate 18   O2 sat 98 . GENERAL  The patient was alert but in mild discomfort . HEENT  PERRL   EOMI   oropharynx clear   moist buccal mucosa . NECK  No lymphadenopathy   no JVD . LUNGS  Bibasilar crackles . Breath sounds were of good intensity . HEART  Regular rate and rhythm   normal S1   S2   no murmurs   rubs   or gallops . ABDOMEN  Soft   non-distended . Tender to palpation at the left lower quadrant and especially at the epigastrium . There was no splenomegaly or hepatosplenomegaly . Bowel sounds were present . BACK  Point tenderness at the left costovertebral angle . EXTREMITIES  Warm to touch   no clubbing   cyanosis   or edema . NEURO  The patient was alert and oriented x3 . Deep tendon reflexes were equal and adequate in upper and lower extremities . Cerebellar function was intact . Sensation was intact to pain and light touch .,1
- In Clinic his cervical spine examination was benign . Shoulder elevation is 170 degrees with 70 degrees of external rotation and internal rotation of the right shoulder to T9 vertebra versus T7 on the left . Rotator cuff measures 4-5 on the right and 5 out of 5 on the left . Mild pain with resistive test and his Pigott sign is mildly positive on the right   negative on the left . There is 1 cm. sulcus sign bilaterally . Laxity is noted as well as markedly positive apprehension sign on the right . Biceps are normal . HOSPITAL COURSE AND TREATMENT  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 . FOLLOW UP  He is to follow up with Dr. Rach Breutznedeaisscarvwierst in Clinic .,1
- 1  Cardiovascular  The patient was admitted for rule out myocardial infarction . She remained on telemetry for greater than 48 hours which demonstrated no dysrhythmia during this time . The patient underwent an echocardiogram which demonstrated a preserved ejection fraction with left ventricular hypertrophy and no significant valvular abnormalities . The patient was maintained on her aspirin and Lasix . The patient &aposs Diltiazem was stopped due to her increased blood pressure and was started on Labetalol which was gradually titrated up to a target blood pressure of 160-170 systolic in her right arm . The patient also underwent an Adenosine MIBI stress test which showed only mild lateral ischemia . At this time   the patient &aposs presyncopal symptoms were not felt to be secondary to a cardiovascular etiology . 2  Neurological    vascular  The discrepancy in the patient &aposs pulses and blood pressure was felt to be consistent with a subclavian artery stenosis . The patient underwent MRI    MRA of the head   neck and upper chest which demonstrated a proximal left subclavian artery stenosis   proximal to the take off of the left vertebral artery . The left vertebral artery had a decreased flow consistent with either native vessel disease or some degree of retrograde flow with subclavian steal phenomenon . The patient had patent carotids bilaterally on her neck MRA . MRI of the head demonstrated a small vessel disease and was likely an old right cerebellar infarct . The patient underwent non-invasive carotid ultrasounds which demonstrated no significant carotid disease . The patient was also noted to have antegrade flow in both of her vertebral arteries bilaterally . The results of these studies suggested that the patient &aposs symptoms were not due to subclavian steal phenomenon   and therefore   it was decided that the patient would not go further to angio and    or surgical or percutaneous intervention . A Neurology consult was obtained and it was felt that the most valuable intervention that could be done for the patient &aposs intervascular disease would be adequate control of her blood pressure . 3  Orthopedic The patient suffered a fall at home with her initial event . Outside hip films were obtained   but were not available for view . Repeat hip films demonstrated a right sided pubic rami fracture   likely new . An Orthopedics consult was obtained and the patient was encouraged to weight bear as tolerated with Physical Therapy assistance . A bone scan was also obtained to rule out an occult hip fracture which was negative . At the time of this dictation   the patient was able to bear weight with the assistance of Physical Therapy and a walker .Plan,0
- Notable for sodium 141   potassium 4.2   chloride 109   bicarb 19.8   BUN 38   creatinine 1.2 and glucose 388 . She had a pneumonia of 31   calcium was 7.5   phosphorous 3.0   magnesium 1.3 . Her bilirubin was 1.4 total   0.2 direct . alkaline phosphatase 101 . SGPT 22   SGOT 41   amylase 31   lipase less than 1 . LDH was 38.9   CK was 66   her hematocrit was 27.4   white count was 8.0 and her platelets were 55 . PT was 14.5   PTT 25.5 . ,1
- Percocet one to two tablets p.o. q.4-6h. p.r.n.   Iron Sulfate 325 mg p.o. b.i.d Colace 100 mg b.i.d.   and one Aspirin q.d. She is to follow-up with Dr. Para for follow-up . Dictated By  RIMARVNAA D. KUSHDREPS   M.D. AV94 Attending  EARLLAMARG S. PARA   M.D. FT99 OH475  4059 Batch  2446 Index No. LXAIB23C4 L D  06  07  93 T,2
- Allergies include AMOXICILLIN and CODEINE . MEDICATIONS ON ADMISSION Insulin by sliding-scale   NPH insulin 16 units in the morning and 6 units in the evening . Lipitor 20 mg p.o. q.d. Zoloft 50 mg p.o. t.i.d. 4. Reglan 10 mg p.o. t.i.d. Lopressor 50 mg p.o. b.i.d. Aspirin 81 mg p.o. q.d. Multivitamin 1 p.o. q.d. Remeron p.o. q.d. ,2
-"1. GI  Patient was transfused 2 units of packed red blood cells overnight   the first night after admission and his hematocrit bumped up appropriately .', 'He remained hemodynamically stable throughout his admission . He was continued on a proton pump inhibitor and on iron sulfate and vitamin C .', 'His Coumadin was held at the time given the bleeding   even though it was important to keep his INR 2.5-3.5   given his artificial valve it was felt that the risk of continued bleeding was to', 'great to continue the Coumadin . He was subsequently seen by the GI team who performed an upper endoscopy which demonstrated the following', 'In the esophagus   there was a small hiatal hernia and in the stomach there is evidence of erosive gastritis of the body of the stomach and the antrum   the mucous appeared edematous .', 'A small polyp was found in the fundus which stigmata of old bleeding  an Endoclip was applied to this . Another polyp was found in the antrum and cold biopsies were obtained there .', 'In the duodenum   a small AVM was noted in the second portion of the duodenum and was cauterized . The biopsy subsequently demonstrated a hyperplastic polyp with acute and chronic inflammation', 'and erosion and reactive epithelial changes but no dysplasia . Also of note   prior to the upper endoscopy   the patient received fresh frozen plasma to reverse his anticoagulation .', 'Patient remained hemodynamically stable during and after the upper endoscopy and his hematocrit remained above 30 following this until the point of discharge .', 'His last recorded hematocrit on discharge was 31.3 . His last BUN and creatinine were 42 and 1.5 with an INR of 2.5 . Consideration was given to performing a repeat colonoscopy .', 'This was discussed with the GI Service who felt that this was not necessary given the recent colonoscopy that he had had in 05  2003 . 2.', 'Cardiovascular  A  Ischemia  Patient &aposs troponin bump was found to be likely to demand ischemia in the setting of his GI bleed   it was not felt that he was having acute coronary syndrome .', 'On discharge   he was continued on his aspirin   simvastatin and his Lopressor which was initially held   and subsequently restarted . B  Rhythm  Patient continued to be in A-fib.', 'throughout the admission and was restarted on his Coumadin concurrently with heparin . Heparin was subsequently DCd once his INR reached a therapeutic level between 2.5-3.5 .', 'His last reported INR on discharge was 2.5 . C  Valves  Patient had   as noted above   his anticoagulation was initially reversed despite his having artificial valves .', 'However   his Coumadin was subsequently restarted and he achieved therapeutic INR levels before discharge . D Pump  Patient   during this hospital course', 'became hypervolemic likely due to his diuretics being held and due to his receiving blood products . He was diuresed initially with one dose of Lasix and subsequently with one dose of torsemide', 'after it was discovered that he developed thrombocytopenia on a prior admission in reaction to Lasix . He subsequently was diuresed to a euvolemic state . Of note   he did not become', 'thrombocytopenic on this admission .",0
-"Auditory hearing screening was performed with automated auditory brain stem responses   and the infant passed both ears on his previous admission .', 'Hearing screens were repeated on 2018-05-13 and he passed both ears . PSYCHOSOCIAL  Family is invested and involved .",1
- As above   and once transferred to the floor   patient had fingersticks monitored every four hours with a sliding scale . Patient reached goal of fingersticks between 50 and 300   which is what she maintains at home . Sliding scale was adjusted as necessary . Patient was continued on intravenous fluids until taking good po . Infectious Disease  The patient had an elevated white count upon admission   however   white count came down to 7.1 and prior to discharge   patient was afebrile and no clear etiology for elevated white blood cell on admission   questionably secondary to short gastrointestinal infection   however   patient is completely symptom free upon discharge . Fluid   electrolytes and nutrition The patient s electrolytes were repleted as necessary . Potassium was given with her intravenous fluids and phosphate will be repleted as patient increases her po intake .,0
- Atenolol 50 mg p.o. q.d.   Lipitor 10 mg p.o. q.d.   baby aspirin 81 mg p.o. q.d.   iron sulfate 81 mg p.o. q.d Lasix 40 mg p.o. q.d.   Accupril 40 mg p.o. q.d.   hydrochlorothiazide 12.5 mg p.o. q.d.   NPH insulin 18 units q.a.m. and 10 units q.p.m.   Humalog sliding-scale q.a.m. and q.p.m.,3
- 1  Bronchiolitis obliterans organizing pneumonia  The video assisted thoracoscopic study at the outside hospital was consistent with bronchiolitis obliterans organizing pneumonia . The patient was continued on steroids throughout the course of her stay . This was changed to Solu-Medrol part way through the course due to her hematologic problems   see below . By discharge   she was returned to 40 mg of Prednisone q. day times one month to be followed by a slow taper . The patient &aposs bronchiolitis obliterans organizing pneumonia appeared to improve slowly throughout her hospital course   however on July 12   1998   after starting dialysis  see below    the patient desaturated and required supplemental oxygen . Repeat chest x-rays and chest CT scans appeared consistent with pulmonary edema from volume overload given her renal failure and eventually   the patient &aposs pulmonary status did improve after significant volume removal with dialysis for several weeks . At the time of her discharge   the patient was still requiring two liters of supplemental oxygen to maintain her oxygen saturations in the mid 90 . 2  Thrombotic thrombocytopenic purpura  The patient was initially admitted with platelet count of 28   hematocrit of 32   LDH of 496 with 2 schistocytes and 2 spherocytes on her smear . This was felt to be consistent with thrombotic thrombocytopenic purpura and on June 20   1998   she was started on daily plasma exchange which continued through July 27   1999 . She was also changed to intravenous Solu-Medrol 50 mg q. day which was changed back to 40 mg of Prednisone prior to discharge . Her platelet count initially rose to a maximum of 159 on July 3   1998   then they steadily fell to a low of 60 on July 20   1999 . Her LDH which peaked at 1255 decreased to the mid 200s   but remained elevated . She continued to have a few schistocytes on her smear   but it was much decreased . The patient also required red blood cell transfusions   approximately two units every seven to ten days to maintain her hematocrit . Eventually   her plasma exchange was tapered to a smaller and smaller dose each day and then discontinued altogether after July 27   1999 . After this   the patient &aposs platelet count rose to a maximum of 177 on discharge . It is felt that the patient &aposs thrombotic thrombocytopenic purpura has resolved . She will continue on her Prednisone for one month as above for the bronchiolitis obliterans organizing pneumonia with a very slow taper . 3  Renal  The patient presented in acute renal failure with a BUN of 101 and a creatinine of 3.7 . Throughout the month of June   she had a rising Potassium phosphate and increasing volume overload with decreasing response to diuretics and she was finally initiated on dialysis with ultrafiltration on July 12   1998 . The opinion of the Renal consult was that this was permanent and non-reversible renal failure since it did not improve with dialysis and the patient will continue on dialysis three times per week . She required approximately five liters of ultrafiltration fluid removal at each dialysis session due to her significant volume overload . During the course of her dialysis   she had a great improvement in her lower extremity edema and her oxygen saturation . 4  Infectious disease The patient had multiple line infections during her admission including a confirmed coag. negative Staphylococcus line infection with positive blood cultures on June 23   1998   July 4   1998   July 8   1998 and July 9   1998 . The patient eventually had a left subclavian Tesio catheter placed and a right brachial PICC line placed on July 10   1998 which remained patent and uninfected . She received a full three week course of Vancomycin and also received a three week course of Ceftazidime . In addition   she had a fungal urinary tract infection treated with Amphojel bladder irrigation   which was followed by a Klebsiella urinary tract infection for which she received Levofloxacin times fourteen days . She also received a fourteen day course of Acyclovir which was begun on June 21   1998 for perianal lesions consistent with herpes simplex virus . She was also on Fluconazole for some oral thrush which was inadvertently continued for a total of thirty days . The patient was also started on Bactrim one double strength tablet q.o.d. as prophylaxis for Pneumocystis carinii pneumonia while on her high dose steroids . 5  Rheumatology  The patient was admitted with a question of lupus given her ANA of 1640 although her rheumatoid factor and ANCA were negative . Unfortunately throughout her admission   we were unable to test any more titers since she was receiving daily plasma exchange . A repeat ANA   rheumatoid factor and ANCA may be repeated as an outpatient . FOLLOW-UP  1  The patient will follow-up with her primary care physician   Dr. Tamarg Study   in Arvus after she is discharged from rehabilitation . 2  The patient is being discharged to A Hospital where she will receive onsite hemodialysis three times per week on Monday   Wednesday and Friday . The nephrologist who will follow her there is Dr. Study . 3  The patient will continue to have her CBC   LDH   bilirubin   chem-7 and magnesium and calcium checked with each dialysis and the results will be faxed to Dr. Ian Zineisfreierm   the hematology attending at fax number 751-329-8840 . 4  The patient will eventually need a permanent dialysis fistula . The left subclavian Tesio which she has in place will last for several months in the mean time . She would like to arrange to have her fistula placed at Pre Health and the vascular surgeons there should be contacted regarding this . 5  The patient will need packed red blood cell transfusions with dialysis when her hematocrit falls below 26 . 6  The patient will continue her Prednisone at 40 mg p.o. q. day times one month  this was started on July 27   1999  and then she will begin a slow taper as guided by Pulmonary . 7  The patient has a follow-up appointment in the Pulmonary Clinic with Dr. Cedwi Stone at 336-2931 on August 30   1999 at 140 PM . 8  The patient has a follow-up appointment with Dr. Ian Zineisfreierm at the We Erthunt Hospital at 180-0455 on August 15   1999 at 1230 PM . MEDICATIONS ON DISCHARGE  1  Calcitriol 0.25 mcg p.o. q. day . 2  TUMS 1250 mg p.o. t.i.d. 3  Premarin 0.625 mg p.o. q. day . 4  Colace 100 mg p.o. b.i.d. 5  Humulin sliding scale q.a.c. and q.h.s. 6  Labetalol 400 mg p.o. t.i.d. 7  Omeprazole 20 mg p.o. q. day . 8  Serax 15 mg p.o. q.h.s. p.r.n. insomnia . 9  Prednisone 40 mg p.o. q. day times thirty days beginning on July 27   1999 to be followed by a slow taper as directed by the pulmonologist . 10  Metamucil one packet p.o. q. day . 11  Amlodipine 10 mg p.o. q. day . 12  Bactrim Double Strength one tablet p.o. q.o.d. 13  Nephrocaps one tablet p.o. q. day . 14  Epogen 1 000 units subcutaneously three times per week . 15  Iron sulfate 300 mg p.o. t.i.d. Dictated By  CHELA FYFENEIGH   M.D. NY5 Attending  LENNI E. NECESSARY   M.D. BE1 IZ845  6789 Batch  7665 Index No. YQGKGG4LST D  08  01  98 T  08  01  98 CC  CEDWI STONE   MD   BMH PULMONARY CLINIC TAMARG STUDY   MD   Port O,0
- Toprol XL 100 mg daily   Hydralazine 25 mg daily   Lasix 40 mg twice a day   digoxin 0.75 mg daily   Lovenox 40 mg twice daily subcutaneously and albuterol p.r.n. Peter Richard   MD Dictated By  Michael O. Tucker   M.D. MEDQUIST36 D  2016-01-29 090727 T  2016-01-29 094948 Job  72842 Signed electronically by  DR.,2
- In general   confused white man   in mild distress . Vital signs  Temperature was 102   heart rate was 110   respiratory rate was 22   blood pressure was 113  63 . His head   eyes   ears   nose   throat was benign . His neck was supple . Lungs  Rales at the right base   bilateral decreased breath sounds at the bases . Cor  Regular rate and rhythm   S1 and S2   no extra heart sounds   abdomen distended with an epigastric mass noted   mildly tender to palpation   no guarding . Bowel sounds were present . The neurological examination was nonfocal .,1
- Stable . DISCHARGE DIAGNOSIS  1. Depression . Insulin-dependent diabetes mellitus . Asthma . Alcohol abuse . DISCHARGE MEDICATIONS  1. Insulin NPH 10 units q.a.m.   5 units q.p.m. Humalog sliding scale insulin for fingerstick blood glucose 151-200 2 units  201-250 4 units  251-300 6 units  301-350 8 units  351-400 10 units  greater than 400 12 units . Multivitamin . Fluticasone . Albuterol p.r.n. Pepcid 20 mg p.o. q.d. FOLLOW-UP PLANS  The patient will be transferred to the Inpatient Psychiatry Unit on Springfield Municipal Hospital IV for further evaluation and treatment of his depression and possible suicidal ideation . He will follow-up with his primary care doctor   Dr. Gillis   after discharge   Johannes for Diabetes management   and Psychiatry for further management of his impulsive behaviors . Patty K. Wagner   M.D. 01 -820 Dictated By  Cora C. Haskett   M.D. MEDQUIST36 D  2010-08-31 0908 T  2010-09-10 0823 JOB  34336 Signed electronically by  DR. Elizabeth Gabriele on  FRI 2010-09-10,2
- Na 134   K 4.2   Cl 98   bicarb 26   BUN 11   creatinine 0.5   glucose 119 . CBC  White count 7.5   hematocrit 28.5   platelets 452 . PT 16.2   PTT 34.7   INR 1.8 . LDH 254   amylase 727   lipase 8600 .,1
- On admission   weight 1515 grams   10th to 25th percentile   head circumference 30 cm   25th to 50th percentile   length 41 cm   10th to 25th percentile . Warm   dry   premature infant   active with exam   mild respiratory distress at rest . Overall appearance consistent with estimated gestational age . Thin   warm   dry   pink   no rashes . Fontanelle soft and flat . Ears normal . Palate intact . Nondysmorphic . Positive red reflex bilaterally . Neck supple   no lesions . Chest moderately aerated . Mild grunting . Cardiovascular  Regular rate and rhythm   no murmur femoral pulses 2 . Abdomen soft   no hepatosplenomegaly   quiet bowel sounds   3 vessel cord . CMED CSRU  Normal female   anus patent . Hips stable . Back normal . No lesions . Appropriate tone and activity for gestational age .,1
- Insulin 44 units NPH qam  8 units qpm  Vasotec 2.5 qd  Lasix 40 qd  Mevacor 40 qd  Cardizem CD 180 qd  Ciprofloxacin for urinary tract infection  aspirin .,3
-"She remains very weak and will most likely benefit from some physical therapy andshe still has the bilateral edema . She is to go to the Necsoncardel Medical Center for more chronic care .', 'Follow-up is with Dr. Wedleung in the Hem    Onc in two weeks . The appointment has already been made . The patient is very limited in how much she can do right now because of her pain primarily', 'and her difficulty breathing . Dictated By  JEABRIHARL FIGEFREIERMFOTHGRENDCAJAQUE   M.D. Attending  LA INEMACISTIN PRONTMANDES   M.D. HD45 SY882  1177 Batch  020 Index No. YJQI3J9VU6 D  01  25  94",2
- Cardiology was consulted to evaluate this and felt that the changes seen on the EKG were not significant . The patient was also seen by Dr. Nusc from General Surgery for evaluation of micro calcifications in the right breast . The patient refused a biopsy for this admission and desires follow-up mammograms . She is to be followed up by General Surgery . The patient underwent a total vaginal hysterectomy on June 4   1993 which she tolerated without complications . Her post-operative course has been uncomplicated . She remained afebrile throughout her admission tolerating a regular diet by post-operative day two and was discharged on June 6   1993 with Percocet for pain . The Foley was discontinued and the patient was urinating on her own . DISPOSITION,0
- Coronary artery disease Myocardial infarction x3  Coronary artery bypass graft Systemic lupus erythematosus in remission HOME MEDICATIONS  1.  Coreg 6.25 mg po bid 2 Lasix 25 mg  po qd 3 Imdur 30 mg  po qd K-Dur 10 milliequivalents po qd  Zestril 2.5 mg po bid Multivitamin  Folate ALLERGIES  He has no known drug allergies . ,0
- Mother died at 51 metastatic BCA Father died at 36 aplastic anemia only child Physical Exam  T 100.0 bp 109  56 CVP 11 hr 113 rr 16 O2 95 on 3L NC mixed Quinn 82 genrl  in nad   resting comfortably heent  perrla  4->3 mm  bilaterally   blind in right visual field   eomi   dry mm   ? thrush neck  no bruits cv  rrr   no m  r  g   faint s1  s2 pulm  cta bilaterally abd  midline scar  from urostomy    nabs   soft   appears distended but patient denies   ostomy RLQ c  d   i   NT to palpation back  right flank urostomy tube   c  d   i   nt to palpation extr  no Gardner neuro  a   ox3   wiggles toes bilaterally   unable to lift LE   06-12 grip bilaterally w   UE   decrease sensation to soft touch in left UE and LE Pertinent Results  2014-11-29 0511PM WBC  23.5  RBC  3.81  HGB  9.4  HCT  29.2  MCV  77  MCH  24.6  MCHC  32.1 RDW  18.1 2014-11-29 0511PM NEUTS  93  BANDS  1 LYMPHS  0 MONOS  6 EOS  0 BASOS  0 ATYPS  0 METAS  0 MYELOS  0 2014-11-29 0511PM GLUCOSE  229 UREA N  25  CREAT  0.8 SODIUM  136 POTASSIUM  5.3  CHLORIDE  101 TOTAL CO2  17  ANION GAP  23  2014-11-29 0511PM LD  LDH   214 2014-11-29 0641PM LACTATE  1.4 2014-11-29 0511PM URINE COLOR  Straw APPEAR  Hazy SP Thibodeaux  1.008 2014-11-29 0511PM URINE BLOOD  LG NITRITE  NEG PROTEIN  TR GLUCOSE  NEG KETONE  NEG BILIRUBIN  NEG UROBILNGN  NEG PH  9.0 LEUK  SM 2014-11-29 0511PM URINE RBC  21-50 WBC  04-12 BACTERIA  MANY YEAST  NONE EPI  0-2 2014-11-29 0511PM URINE 3PHOSPHAT  OCC 2014-11-29 CT CAP  1. An 8 x 7 x 7 mm stone in the proximal right ureter with associated right hydronephrosis and inflammatory perinephric stranding . Additional smaller non-obstructing right renal stones . 2. Left renal stones without evidence of hydronephrosis . Ileal conduit is not well evaluated . 3. Right breast calcification . Correlation with mammography is suggested . . 2014-11-29 CXR  No evidence of pneumonia . . 2014-11-29 CT AP 2  with contrast   1. Eight mm right proximal ureteral stone with right-sided hydronephrosis and inflammatory stranding . Pyelonephritis of the left kidney without left sided hydronephrosis . No evidence of intraabdominal abscess or of diverticulitis . Bilateral round   hypodense renal lesions   too small to accurately characterize but likely representing cysts . 4. 1.4 cm hypodense lesion in right lobe of the liver is incompletely characterized . . 2014-11-30 CT CAP  Nephrostomy tube in the right kidney with an 8 mm right ureteric stone . 6 mm nonobstructing calculus in the left kidney . Calcified focus and a small hypodense lesion in the right lobe of the liver   incompletely characterized . Bibasilar and dependent atelectasis . . 2014-11-29 510 pm BLOOD CULTURE 2 .   FINAL REPORT 2014-12-04   AEROBIC BOTTLE  Final 2014-12-04   KLEBSIELLA PNEUMONIAE . IDENTIFICATION AND SENSITIVITIES PERFORMED FROM ANAEROBIC BOTTLE . OF TWO COLONIAL MORPHOLOGIES . ANAEROBIC BOTTLE  Final 2014-12-04   REPORTED BY PHONE TO Robert BURGER 2014-11-30 1035A . KLEBSIELLA PNEUMONIAE . FINAL SENSITIVITIES . Trimethoprim  Sulfa sensitivity testing available on request . KLEBSIELLA PNEUMONIAE . FINAL SENSITIVITIES . Trimethoprim  Sulfa sensitivity testing available on request . 2ND STRAIN . SENSITIVITIES  MIC expressed in MCG  ML KLEBSIELLA PNEUMONIAE | KLEBSIELLA PNEUMONIAE | | AMPICILLIN  SULBACTAM- = >32 R = >32 R CEFAZOLIN  =4 S  =4 S CEFEPIME  =1 S  =1 S CEFTAZIDIME  =1 S  =1 S CEFTRIAXONE  =1 S  = 1 S CEFUROXIME 4 S 4 S CIPROFLOXACIN = >4 R = >4 R GENTAMICIN 8 I 8 I IMIPENEM  = 1 S  =1 S LEVOFLOXACIN = >8 R = >8 R MEROPENEM  =0.25 S  = 0.25 S PIPERACILLIN  TAZO  = 4 S  =4 S TOBRAMYCIN 4 S 8 I . 2014-11-30 150 pm URINE KIDNEY PERC. NEPH. .   FINAL REPORT 2014-12-03  FLUID CULTURE  Final 2014-12-03   Due to mixed bacterial types  >= 3 colony types  an abbreviated workup is performed appropriate to the isolates recovered from the site  including a screen for Pseudomonas aeruginosa   Staphylococcus aureus and beta streptococcus  . STAPH AUREUS COAG  . > 100 000 ORGANISMS  ML. . OF TWO COLONIAL MORPHOLOGIES . Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins   cephalosporins   carbacephems   carbapenems   and beta-lactamase inhibitor combinations . Rifampin should not be used alone for therapy . GRAM NEGATIVE ROD S  . > 100 000 ORGANISMS  ML. . OF TWO COLONIAL MORPHOLOGIES . SENSITIVITIES  MIC expressed in MCG  ML STAPH AUREUS COAG  | GENTAMICIN = >16 R LEVOFLOXACIN = >8 R NITROFURANTOIN  = 16 S OXACILLIN = >4 R PENICILLIN = >0.5 R TETRACYCLINE = >16 R VANCOMYCIN  =1 S . 2014-12-03 BLOOD CULTURE AEROBIC BOTTLE  PENDING  ANAEROBIC BOTTLE  PENDING 2014-12-03 BLOOD CULTURE AEROBIC BOTTLE  PENDING  ANAEROBIC BOTTLE  PENDING 2014-12-02 URINE URINE CULTURE  FINAL No Growth 2014-12-02 CATHETER TIP  IV WOUND CULTURE  FINAL No Growth 2014-12-02 BLOOD CULTURE AEROBIC BOTTLE  PENDING  ANAEROBIC BOTTLE  PENDING Brief Hospital Course  47 yo F w   h  o steroid-induced hyperglycemia   SLE w   h   o pericarditis   transverse myelitis w   paraplegia and neurogenic bladder s  p urostomy w   ileal conduit   h  o ureteropelvic stone and urosepsis   and h   o RLE DVT admitted 11-29 w   left pyelo and right 8 mm proximal ureteral stone w   right hydro s  p perc urostomy tube to relieve right hydro . .  GNR sepsis Upon admission   pt was febrile to 101.2 with U  A consistent with UTI . A CT abd showed 8mm obstructing stone   hydro with stranding consistent with pylonephritis . Her presentation was thought likely due to urosepsis given h  o foul smelling urine and in setting of stone w   hydro  pyelo by CT. The patient went to IR on 2014-11-30 given evidence of right hydronephrosis on imaging for decompression and drainage. Upon admission   she was treated with Vancomycin and Gentamycin and Flagyl . She was started on the MUST protocol with high dose steroids as well and a goal SVO2 >70 . She was hypoxic requiring 3L nasal cannula O2 . She subsequently developed hypotension with SBP in the 70s . She was transferred to the CMED where the patient was continued on the MUST protocol with goais of CVP 10-12   SVO2 greater than 70 . The patient was bolused with NS and did not required pressors . On the day after admission to the CMED   the patient was noted to have small oxygen requirement with 2L NC . Repeat imaging revealed evidence of mild pulmonary congestion which was thought to account for the patient s mild hypoxia . Given that the patient had been maintaining a MAP of 60 without fluids or pressors   her goal CVP was decreased to >8 to avoid fluid overload . The patient was continued on Vancomycin and Gentamycin while speciation and sensitivities were pending . Ciprofloxacin was added on 2014-12-01 for synergy when surveillance cultures were found to be growing again GNR . Gent and Cipro were then discontinued and changed to meropenem when blood culture sensitivities became available revealing GNR sensitive to Jacoby but resistant to both Gent and Cipro . Additionaly surveillance cultures were drawn daily and the patient was transferred back to the floor with no subsequent pressor requirement . Blood cltures from 11-30 grew KLEBSIELLA PNEUMONIAE and 12-01 grew KLEBSIELLA PNEUMONIAE and PROTEUS MIRABILIS both sensitive to the Meropenam which she had already been receiving . Urine cultures from 11-30 grew STAPH AUREUS COAG    and GRAM NEGATIVE RODS of two morphologies  not further speciated  . She defervesed by 12-02 and remained clinically stable with normal blood pressures until the day of discharge . At the time of discharge   blood cultures from 12-02 and 12-03 have no growth to date . She received a midline on 12-04 with a goal of 16 days of further antibiotic treatment with Meropenam  for a total of 3 weeks  upon discharge back to the nursing home where she lives . .  Right hydronephrosis  Given right sided hydronephrosis and GNR bactermeia   a percutaneous nephrostomy tube was placed by IR 2014-11-30 . The patient put out 1385 cc urine the day after placement   950 cc of which came from nephrostomy tube . The tube appeared to be functioning well   draining urine with occasional clot passage . Urology was notified about the clots and occasional blood tinged urine but they did not make any further recommendations . Cultures from urine drawn from the nephrostomy tube are currently growing > 100K GNR   possibly of two colony morphologies   speciation and sensitivity pending . .  Hct drop  On admission to hospital patient had Hct of 29.2 . In the setting of Right sublavian line placement as well as nephrostomy tube placement the patient was noted to have a drifting Hct   concerning for bleed   with nadir of 22.8 on 2014-12-01 . A CT abdomen was performed which did not demonstrate any retroperitoneal bleed . Hct stabilized to 24 for three days prior to discharge . This can be followed as an outpatient . Anemia workup revealed a picture of anemia of chronic disease  TIBC 225   B12 and Folate normal   Hapto 397   Ferritin 51   TRF 173   Iron 35  . .  Hypoxia The patient on admission was requiring 3 L NC in the setting of receiving 2L NS and chest film which demonstrated pulmonary congestion . The patient was not diuresed but allowed to auto-diurese any additional fluids and is currently with O2 sats 97-98 on room air . As her BP remained stable she did not receiving any standing fluids but was be bolused as appropriate for a MAP   60 or CVP   8 with careful monitoring of pulmonary status . Patient had an echocardiogram in 2012 which demonstrated an EF of 60-65 . her O2 requirement by discharge was 96 on room air with no SOB . .  Steroid-induced hyperglycemia  At home   the patient received metformin and SSI . The patient s metformin was held and she has been maintained on SSI qid while in the CMED . As the patient appeared to be clinically stable   her stress dose steroids were discontinued and the patient was changed back to her home dose of Prednisone 40mg PO qd for maintenance with anticipated decrease in her blood sugars . Her Metformin was re-added 2 days prior to discharge as well and fingerstick glucoses on the day of discharge were 93 and 156   respectively . .  Hypothyroidism  Repeat TSH and Free T4 were appropriate on current outpatient regimen. Patient was continued on Levothyroxine 75mcg po qd . .  H  o transverse myelitis  optic neuritis  On stress dose steroids originally given MUST protocol and sepsis   as patient clinically stabilized   she was changed back to home dose of Prednisone 40mg pO qd . .  SLE  Currently no sx of active disease . No manifestations of SLE during this admission . .  Osteoporosis  We continued actonel  vit D   Tums .  Capsular ossification We continued CMED CSRU gtt . .  FEN She had a low bicarb likely due to renal wasting but there is an anion gap present . Serum acetone was normal . We followed lactate while she was in the CMED which was normal . She was NPO periodically but maintained a normal diet prior to discharge . .  PPX  SQ Heparin during this admission   PPI .  Communication  patient .  Dispo  To nursing home for follow up with Dr. Hipp  urology  this coming Monday   12-08 at 130pm and with her PCP at the nursing home Medications on Admission  Home Meds  Ascorbic Acid 500 TID Cranberry Extract 425 BID Bisacodyl 10mg Senna Dephenhydramine 50mg prn loperamide prn famotidine 20mg KCL 20mg QD Metformin 1000 qd tums 1500 bid MVI Timolol 1 Drop BID 0.5 L CMED CSRU Synthroid 75 QD Compro 25mg pr Citrucel Vitamin D 50k Qmondays Oxazepam 15mg qhs tizamidine 8mg qhs actonel 35 qwed Diovan 80 qd prednisone 40 qd bactrim ds qmwf baclofen pump 2-3yrs Insulin SS . Meds on transfer Actonel 35 mg Oral qwednesdays Ascorbic Acid 500 mg PO TID Sodium Polystyrene Sulfonate 15 gm PO ONCE 11-29 @ 2201 Famotidine 20 mg PO DAILY Sulfameth  Trimethoprim DS 1 TAB PO QMOWEFR Gentamicin 80 mg IV Q8H Timolol Maleate 0.5 1 DROP OS BID Heparin 5000 UNIT SC TID Tizanidine HCl 8 mg PO QHS Hydrocortisone Na Succ. 100 mg IV Q8H 11-30 @ 0906 Valsartan 80 mg PO DAILY Insulin SC  per Insulin Flowsheet  Vancomycin HCl 1000 mg IV Q 12H Levothyroxine Sodium 75 mcg PO DAILY Vitamin D 50 000 UNIT PO QWEDNESDAYS Discharge Disposition  Extended Care Discharge Diagnosis  GNR Sepsis  Steroid induced hyperglycemia  Hydronephrosis  SLE Discharge Condition  Stable Discharge Instructions  Pls take all meds as prescribed . Call your doctor immediately if any new symptoms develop including fevers   rash   increase in bloody urine in nephrostomy or urostomy bags   etc . Follow up appointments listed below . Followup Instructions  With Dr. Vivian Hansen   UMass Memorial Medical Center   3rd floor Morris on Monday 12-08 at @ 130pm  you also have an appointment scheduled with Dr. Hipp for 01-14  . . Provider  Sheena Phone  361-438-6334 Date  Time  2015-01-07 830 Colleen Thomas MD 80-548 Completed by  Edward James MD 50-497 2014-12-05 @ 1042 Signed electronically by  DR. Ronald Z. Thome on,0
- Lorazepam 1 mg. PO q6 hours PRN   and Timoptic 0.5 1 drop b.i.d.,3
- Her admission physical revealed a birth weight of 901 gm   20th percentile  length 34 cm   25th percentile  head circumference 25 cm   25th percentile . Anterior fontanelle open   soft and flat . Red reflex was difficult to appreciate bilaterally . Pupils were large but equal and reactive . Palate deferred due to oral intubation . No defect noted during procedure . Increased work of breathing prior to intubation   but presently comfortable . Breath sounds slightly crackly   symmetric equal air entry . Cardiovascular regular rate and rhythm without murmur . Peripheral pulses plus 2 and symmetric . Abdomen soft without hepatosplenomegaly . Three-vessel cord   clamped . Normal female external genitalia . Normal back and hips . Skin was pink and well-perfused . Appropriate tone and activity .,1
- On admission   showed a gentleman in no acute distress  afebrile . Chest was clear to auscultation bilaterally . Heart has a regular rate and rhythm . Abdomen is benign   no mass . Extremities were well perfused and warm .,1
- Methylprednisolone 4 mg q. a.m. and 2 mg p.o. q.h.s.   spironolactone 50 mg p.o. q.d.   metformin 1500 mg p.o. q.h.s.   Pravastatin 10 mg p.o. q.h.s.   lisinopril 20 mg p.o. q. a.m.   Lasix 80 mg p.o. q. a.m.   Tylenol as needed   insulin regular 22 units in the morning and 12 units at night  lispro regular .,3
- Briefly   this 68 year old male with a history of coronary artery disease   diabetes mellitus   peripheral vascular disease   was admitted originally to the Podiatry Service for a left patellar mid-foot ulcer . He underwent angiogram on 2013-08-28   to evaluate his circulation and found at that time that the patient had a poor circulation to the left leg . The patient was transferred to the Vascular Surgery Service for bilateral iliac stenting at that time . The patient also at that time was followed by Cardiology and for preoperative evaluation had a stress test which was positive and he became diaphoretic but denied any chest pain . Atropine was given and heart rate returned to the 70s and his blood pressure returned to the 120s over 80s . The patient denied any orthopnea   shortness of breath   chest pain   paroxysmal nocturnal dyspnea or cough . He had occasional leg swelling . PAST MEDICAL HISTORY 1 . Coronary artery disease status post myocardial infarction in 2006 and 1997 and status post percutaneous transluminal coronary angioplasty times two . Diabetes mellitus type 2 since age 25  now currently on insulin   which is complicated by peripheral neuropathy   nephropathy and Charcot s foot . Chronic renal insufficiency . Peripheral vascular disease status post left iliac stent and right femoral stent . Hypertension . High cholesterol . Question of tendonitis . MEDICATIONS ON ADMISSION  1. Insulin 70  30   40 units q. a.m. and 40 units q. p.m. 2. Diovan 160 mg p.o. q. day . Nortriptyline 25 mg p.o. q. h.s. Norvasc 10 mg p.o. q. day . 5. Metoprolol 50 mg p.o. twice a day . 6. Hydrochlorothiazide   15 mg p.o. q. day .,0
- Atrial fibrillation   on coumadin Coronary artery disease status post NQWMI 02-25  s  p LAD angioplasty and stent 05-26  Known non-dominant 90 RCA lesion not intervened upon .  Dementia Mild-moderate aortic stenosis  Hyperlipidemia Colon cancer  Obstructive sleep apnea Anxiety  Diabetes mellitus   on oral medications Social History  Married  Lives with wife .  One son   in area  Social alcohol .  No tobacco   drug use,0
- n  a Discharge Condition  n   a Discharge Instructions  n   a Followup Instructions  n  a Ruby Eric MD 73-490 Completed by  Verna Richard MD 01-822 2016-04-04  2005 Signed electronically by  DR.,2
- The patient was taken to the operating room on March 11   2002   and underwent an uncomplicated right total hip replacement . The patient tolerated the procedure well and was transferred to the Post Anesthesia Care Unit and then to the floor in stable condition . On postoperative check   he was doing well . He was afebrile and his vital signs were stable . He was neurovascularly intact . His hematocrit was 34.7 . He was started on Coumadin for DVT prophylaxis and Ancef for routine antimicrobial coverage . He was made partial weight-bearing for his right lower extremity . He was placed on posterior hip dislocation precautions and was out of bed with physical therapy and occupational therapy . On postoperative day one   there were no active issues . He was afebrile . His vital signs were stable . He was neurovascularly intact . On postoperative day two   he was afebrile   vital signs were stable . His incision was clean   dry and intact with no erythema . He remained neurovascularly intact . His hematocrit was 34.8 . On postoperative day three   lower extremity noninvasive ultrasounds were performed   which showed no evidence of deep venous thrombosis in the lower extremities . The remainder of his hospitalization was uncomplicated . CONDITION ON DISCHARGE  Stable .,0
- Breast cancer in multiple female relatives .,0
- Brother and sister both have asthma . Brother has diabetes mellitus . There is no family history of coronary artery disease .,0
- The patient has no known drug allergies . MEDICATIONS ON ADMISSION  Tylenol   Ciprofloxacin and Insulin   about 16 units of NPH qa.m.,0
- Dr. Lloyd van de Clark in approximately one month postoperative . Please call the office at  854  787-3243 for an appointment . The patient is also to follow up with his primary care physician for diabetes management . He is to follow up with Dr. East here at the Heart Failure Clinic to continue follow up with cardiac rehabilitation and heart failure management . Brown des Stone   M.D. 07 -760 Dictated By  Anthony O Carreno   M.D. MEDQUIST36 D  2011-10-31 1025 T  2011-10-31 1045 JOB  02527 Signed electronically by  DR.,3
- On admission   temperature was 96.2   blood pressure 150  80   heart rate 92   respiratory rate 16 . In general   he was unarousible   intubated   not on any sedation . Head   eyes   ears   nose and throat  His pupils were equal and three millimeters . They were minimally reactive . His sclerae were anicteric . The cardiac examination was unremarkable without murmurs . The lungs were clear to auscultation bilaterally . His abdomen had normal bowel sounds   soft and nontender . Extremities had multiple bilateral lower extremity excoriations . Neurologic examination  he was unarousible and without sedation . He had no spontaneous movements . Flaccid . Extremities  Babinski reflex was equivocal bilaterally .,1
-Feeds at discharge  Enfamil 20 p.o. ad lib . Medications  none . Car seat positioning  not yet done . State newborn screening sent . Immunizations  received hepatitis B on 09-16 .,2
- As above  Myocardial infarction also in l983 and l988   congestive heart failure in l989   diverticulitis in l978   and spontaneous pneumothorax in l956 .  He had a coronary artery bypass graft times three as mentioned above  CURRENT MEDICATIONS   He came in on Carafate   Enteric Coated Aspirin   Albuterol Inhaler   Atrovent Inhaler   Procan SR   Mevacor   and Digoxin,0
- Lasix 40 mg po bid . Potassium Chloride 20 milliequivalents po bid . Colace 100 mg po bid . Zantac 150 mg po bid . Aspirin 325 mg po qd . Captopril 25 mg po tid . Digoxin 0.25 mg po q day . Atorvastatin 10 mg po q day . Toprol XL 100 mg po q day . 10. Bollin insulin 18 units subcutaneous q A.M.   Richard insulin 14 units subcutaneous q P.M. 11. Sliding scale Humalog regular insulin for breakfast is blood glucose of 151 to 200 equal 4 units   201 to 250 equal 6 units   251 to 350 equal 12 units   greater than 350 equals 15 units . For lunch blood glucose of 101 to 150 equals 4 units   151 to 200 equals 7 units   201 to 250 equals 8 units   251 to 350 equals 12 units   greater than 350 equals 15 units . Dinner blood glucose 101 to 150 equals 2 units   151 to 200 equals 3 units   201 to 250 equals 6 units   251 to 350 equals 12 units   greater than 350 equals 15 units .,2
-'1. Prolonged Respiratory Transition . Hyaline Membrane Disease . Rule out sepsis without antibiotics . Kevin F Juliusson   M.D. 04 -834 Dictated ByAnita X. Duffy   M.D. MEDQUIST36 D  2015-09-17 1345 T  2015-09-17 1415 JOB  24313 Signed electronically by  DR.,2
- Lisinopril 5 mg p.o. q. day . Metoprolol 37.5 mg p.o. twice a day . 3. Lipitor 10 mg p.o. q. day . Pantoprazole 40 mg p.o. q. day . Levothyroxine 100 micrograms p.o. q. day . DISCHARGE INSTRUCTIONS The patient was to arrange his follow-up with his primary care physician   Bryan Smith . To follow-up with his Cardiologist   Dr. Delores Padilla within one to two weeks of discharge . Tammy Thompson   M.D. 40-318 Dictated By  Randolph Q Barber   M.D. MEDQUIST36 D  2015-11-26 1515 T  2015-11-26 1610 JOB  90402 Signed electronically by  DR.,2
- By problems  1. Infectious Disease . The patient was started on Amphotericine at .6 mg    kg for a total of 250 mg for positive blood cultures for candida . The passport in his left arm was pulled and will be replaced if needed after the Amphotericine is completed . The patient will continue on his antibiotics for pseudomonas pneumonia to complete the fourteen day course which was completed on 09  06  92 . The patient was continued on his admission medications . 2. Hematology . The patient was continued on his G-CSF with an increase in his white count to 8 from 1.8 . The patient required multiple blood transfusions for a low hematocrit . ,0
- Aspirin 325 mgs PO q.d.   Prilosec 20 mgs PO q.d.   Azmacort 2 puffs q.i.d. PRN   Atrovent 2 puffs q.i.d. PRN   heparin 5 000 units subcu. b.i.d.   Digoxin 0.125 mgs PO q.d.   Wellbutrin 37.5 mgs PO b.i.d.   Kaopectate PRN   Betoptic 0.25 OU q.d.   Ritalin 10 mgs PO q.a.m. and at noon time   Norvasc 2.5 mgs PO q.d. The patient reported disorientation with Ambien and Halcyon .,3
-Home with parents,3
- BACTRIM  SEVERE RASH    GANCICLOVIR  RASH   HAS BEEN DESENSITIZED  .,0
-CONDITION OF DISCHARGE Good . DISCHARGE STATUS To home .  DISCHARGE DIAGNOSES Diabetic ketoacidosis . Viral gastroenteritis .,2
-"1. Metoprolol 100 mg b.i.d. Plavix 75 mg q.d. Advair 550 mcg two puffs b.i.d. 4. Neurontin 300 mg t.i.d. Protonix 40 mg q.d. Montelukast 10 mg q.d.', 'Bethanechol 25 mg b.i.d. Docusate sodium 100 mg b.i.d. Zetia 10 mg q.d. Estrogen 0.3 mg q.d. Fluoxetine 40 mg q.d. Vicodin 5 -500 mg tablets q.4-6h. as needed for pain . 13.', 'Cyclobenzaprine 10 mg tablet one tablet orally t.i.d. Atorvastatin 80 mg q.d. Valsartan 320 mg q.d. Aspirin one q.d. Benadryl as needed .The patient will follow up with her primary care physician   Dr. Benson    845  253 6629 in two weeks by calling to schedule an appointment . DR. Luedeman Melissa 69-853 Dictated By', 'Andrew C Hoffman   M.D. MEDQUIST36 D  2017-07-02 1135 T  2017-07-04 0514 JOB  19444 Signed electronically by  DR. Andrew X .. Dale on  FRI 2017-09-22'",3