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Daniel Fried NLP Lab 10

2162-06-22 20:01:00

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[[21789721, Timestamp('2162-06-22 20:02:43'), '', 'CMED'], [21789721, Timestamp('2162-06-28 18:12:19'), 'CMED', 'MED']]

[[{'Medications on Admission': ':\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. aspart 1 Units Breakfast\naspart 1 Units Lunch\naspart 1 Units Dinner\naspart 1 Units Bedtime\n2. Omeprazole 20 mg PO DAILY \n3. Furosemide 20 mg PO DAILY \n4. LevETIRAcetam 500 mg PO DAILY \n5. Chlorthalidone 25 mg PO DAILY \n6. Fludrocortisone Acetate 0.1 mg PO QID \n7. Metoprolol Tartrate 25 mg PO BID \n8. PARoxetine 40 mg PO DAILY \n\n13. Prochlorperazine 10 mg PO BID:PRN nausea \n14. Psyllium Wafer 2 WAF PO BID \n15. sevelamer CARBONATE 800 mg PO TID W/MEALS \n16. Simethicone 40 mg PO QID:PRN gas pain \n17. Sodium Bicarbonate 1300 mg PO TID \n18. Insulin SC \n Sliding Scale\nInsulin SC Sliding Scale using Novolog Insulin \n19. Chlorthalidone 50 mg PO DAILY \n20. LevETIRAcetam 500 mg PO DAILY \n21. PARoxetine 20 mg PO DAILY \n\nFacility:\n___\n\nSecondary Diagnosis:\n=================\n-Metastatic pancreatic Cancer\n-Malignant effusion \n-Diabetic nephropathy\n-Hyptertension\n-DM2', 'Brief Hospital Course': ':\nPRINICPLE REASON FOR ADMISSION:\n===============================\nMr. ___ is a ___ male with history of metastatic \npancreatic cancer (s/p = hepaticojejunostomy, gastrojejunostomy, \nCCY) who was initially transferred from ___ due to \nconcern for pericardial tamponade (only small effusion seen on \nmost recent echo), and found to be ___ hypoxemic respiratory \nfailure requiring intubation ___ secondary to pneumonia \nand volume overload. Early hospital course complicated by renal \nfailure and ATN. Subsequently received C1D1 FOLFOX ___ house on \n___ with further renal failure and hyperkalemia. Course \notherwise notable for persistent diarrhea, recurrent right \npleural effusion, and hypertension.\n\nACTIVE ISSUES:\n==============\n# Hypoxic Respiratory Failure:\n# Malignant Pleural Effusions: Initially with hypoxic \nrespiratory failure requiring intubation ___ due to PNA \nand anasarca. He is s/p cefepime ___ for pneumonia). \nBrief hypoxia to 90% on ___ required IV lasix. No CMV on BAL. \nCXR ___ with some right pleural effusion increase, IP drained 1L \non ___, but did not place pleurex as CT chest suggested \npersistent pulmonary parenchymal issues as large contributor. On \n___ patient reported worsening SOB and hypoxic to 88% with \nminimal exertion. Repeat CXR showed reaccumulation of right \npleural effusion. Thoracentesis by IP with drainage of 1L. \nPatient has refused Pleurex catheter at that time. Again, \ndeveloped O2 requirement on ___ with recurrent pleural \neffusion. Restarted IV Lasix 120mg bid and will need repeat \nthoracentesis vs. pleurX. \n\n# Acute on chronic renal failure\n# ATN: Initial etiology ATN thougth from from overdiuresis ___ \nsetting of respiratory failure, and improved prior to initiation \nof chemotherapy. More recently, oxaliplatin likely caused \nsignificant kidney damage. Cr has now stabilized around 3.8. \nNephrology has been following, and he has not yet needed \ndialysis. However, K has risen again starting ___, neprhology \naware and Lasix 120mg IV bid, chorthalidone, and po bicarb was \nstarted. Patient refused foley for closer UOP monitoring, but is \nfrequently incontinent of large volume urine. Will need very \nclose monitoring of volume status and potassium. \n\n# Hyperkalemia: See above; was quite severe over a number of \ndays\nearly ___ hospitalization following initial renal insult. \nImproved\nmarkedly at that time after initiation of chlorthalidone.\nChlorthalidone was then held given recurrent renal failure.\nHowever, now that Cr has stabilized a bit, feel OK to continue\nchlorthalidone and IV Lasix. He has been treated with IV Lasix \n120mg bid, chlorthalidone 50mg daily, and sodium bicarbonate. \nReceived IV insulin and dextrose on ___. Kayexelate not given \ndue to severe diarrhea. Also maintained on low K diet.\n\n# Proteinuria: 24 hour urine w/ >3g protein. Per renal likely \ndue to diabetic glomerulopathy as had proteinuria to similar \ndegree at least for past 8 months(300 prot on dipstick ___. Unlikely membranous GN iso active malignancy. C4 wnl, C3 \nslightly low. Hep B/C negative. ___, ANCA negative. Cryo \nnegative. Likely contributing to anasarca.\n\n# Metastatic Pancreatic Cancer: \nBiopsy confirmed metastatic pancreatic ca to the lungs. FOLFOX \ngiven ___ finished ___. Given worsening kidney disease and \nfunctional status C1D15 due ___ on hold, and there are no \nactive plans to resume chemotherapy. Dr. ___ will \ncontinue to re-evaluate patient for possibility of resuming \nchemotherapy if renal function and function status improve. \nPlease maintain contact with Dr. ___ at ___ and \narrange follow up when appropriate.\n\n# N/V/Diarrhea: Patient with significant persistent diarrhea and \nincontinence during entire hospital stay. Initially with \nFlexiseal, removed ___. GI was consulted early ___ course, and \netiology thought to be post-abx diarrhea vs. recent\nliquid diet vs. pancreatic enzyme deficiency vs. post FOLFOX. C. \ndiff was neg x2, O&P and stool cultures were also negative. CT \nabdomen/pelvis w/ PO contrast did not show any cause for \ndiarrhea. He has been managed with loperamide, Lomotil, opium \ntincture along with creon and psyllium wafers. ___ need to \nconsider reconsulting GI, resending stool cultures, and imaging \nstudies of diarrhea persists.\n\n# Anasarca\n# Bilateral Lower Extremity Edema\n# Upper Extremity Edema: Fluid status fluctuates, appears volume \noverloaded. Likely secondary to hypoalbuminemia ___ setting of \npossible nephrotic syndrome and poor nutrition with active \nmalignancy. ___ ___ negative. LUE ultrasound negative for DVT. \n120mg IV Lasix bid as above.\n\n# Transaminitis: Stable/resolving. RUQ US without hepatic mets. \nHBV/HCV serologies negative and HBV VL not detected. Likely from \nportal congestion from anasarca. \n\n# Guaiac-Positive Stools:\n# Anemia: Anemia is stable near baseline Hgb ___. Hemolysis labs \nwere negative. Reported frank bloody BM overnight on ___ with \npreviously guaiac positive stools. No prior colonoscopy on \nrecord. Colonoscopy was deferred.\n\n# HTN: Treated with labetolol 600mg tid and amlodipine. \nChlorthalidone was held much of hospitalization but restarted on \n___ ___ setting of hyperkalemia and stable kidney function. \n\n# Type II Diabetes: Continued Humalog ISS \n\n# Epilepsy: History of grand mal seizures. Continue keppra 500mg \nBID. Was thought to have partial seizure on complex partial \nseizure witnessed by RN on ___. However, EEG did not reveal any \nepileptiform activity x 48 hrs. MRI brain completed w/o contrast \nand w/ significant motion activity but did not reveal any \nobvious acute process. \n\n# Pericardial Effusion: Very small with no evidence of \ntamponade. Likely from severe hypoalbuminemia vs. physiologic as \nopposed to malignant ___ origin. \n\n# Psych: Continued paroxetine 40mg daily\n\n# FEN: replete electrolytes prn, renal diet\n# Prophylaxis: Subcutaneous heparin \n# Access: POC \n# Restraints: Shackles\n# Communication: HCP: ___ (sister) ___ \n# Full Code (confirmed by ICU Team) \n# DISPO: ___\n\nTRANSITIONAL ISSUES:\n====================\n- Please monitor K upon arrival to unit and maintain cardiac \nmonitoring\n- Please evaluate for thoracentesis vs tunneled pleural catheter\n- Consider GI consult for persistent diarrhea refractory to \naggressive antidiarrheals\n- Please continue to re-evaluate fromo oncologic perspective for \npossibility of palliative chemotherapy\n\nBILLING: >30 min coordinating care or discharge\nDISPO: ___\n\n', 'Pertinent Results:': '\nADMISSION LABS:\n===============\n___ 08:14PM BLOOD WBC-9.3# RBC-3.06* Hgb-8.7* Hct-28.2* \nMCV-92 MCH-28.4 MCHC-30.9* RDW-12.2 RDWSD-41.0 Plt ___\n___ 08:14PM BLOOD Neuts-88* Bands-2 Lymphs-6* Monos-4* \nEos-0 Baso-0 ___ Myelos-0 AbsNeut-8.37* \nAbsLymp-0.56* AbsMono-0.37 AbsEos-0.00* AbsBaso-0.00*\n___ 08:14PM BLOOD ___ PTT-46.4* ___\n___ 08:14PM BLOOD Glucose-97 UreaN-29* Creat-1.9* Na-137 \nK-3.9 Cl-106 HCO3-21* AnGap-14\n___ 08:14PM BLOOD ALT-25 AST-43* AlkPhos-250* TotBili-<0.2\n___ 08:14PM BLOOD Albumin-1.1* Calcium-6.8* Phos-4.2 Mg-1.7\n\nIMAGING:\n========\n___ Imaging CHEST (PORTABLE AP) \nLarge layering right pleural effusion and suspected pulmonary \nedema.\n\n___ Imaging RENAL U.S \n1. Limited renal Doppler evaluation, secondary to suboptimal \npatient \ncomplaints during exam. Within this limitation, no evidence of \nmain renal \nartery stenosis or renal vein thrombosis. \n2. Moderate ascites. \n\n___ Imaging MR HEAD W/O CONTRAST \n1. Severely limited study due to motion artifact. No \nabnormalities detected.\n\n___ Imaging CHEST (PORTABLE AP) \n___ comparison with the study of ___, there again are low \nlung volumes that accentuate the enlargement of the cardiac \nsilhouette. Diffuse areas of pulmonary opacification are less \nprominent, consistent with decreasing vascular congestion, \nresolving aspiration, or both. No evidence of increase ___ the \nright pleural effusion. The Port-A-Cath tip is also unchanged. \n\n___BD & PELVIS W/O CON \n1. Multiple metastatic pulmonary nodules are seen the lung \nbases, which appear enlarged compared to the prior study ___ \n___, concerning for worsening metastatic disease. \n2. The known pancreatic mass is not well seen on this \nnoncontrast exam, however, pancreatic ductal dilatation appears \nsimilar to the prior study ___ ___. \n3. There is new mild perihepatic ascites which was not seen ___ \n___ and extends along the right paracolic gutters and \ninto the deep pelvis. \n4. Bilateral pleural effusions are new since ___, \nmoderate on the right and small on the left, with associated \nright lower lobe volume loss. \n\n___ Imaging UNILAT UP EXT VEINS US \nNo evidence of deep vein thrombosis ___ the left upper extremity.\n\n___HEST W/O CONTRAST \n1. Enlargement of multiple pleural based and parenchymal soft \ntissue lesions ___ the thorax with interseptal thickening ___ the \nleft lower lobe, concerning for worsening metastatic disease \nwith lymphangitic spread. \n2. A new 2.4 cm soft tissue lesion seen along the subcutaneous \ntissues of the right chest may represent a site of prior port \ninsertion vs new metastatic lesion. \n3. Increased diffuse anasarca with inflammatory changes seen ___ \nthe right chest wall. \n4. New moderate, nonhemorrhagic, layering right pleural \neffusion. \n5. Interval increase ___ perihepatic ascites compared to the \nprior study ___ ___. \n6. Mild central pneumobilia and pancreatic ductal dilatation \nappear stable. \n\n___ Imaging CHEST (PORTABLE AP) \n___ comparison with study of ___, there has been a \nthoracentesis \nperformed on the right with removal of some pleural fluid. No \nevidence of \npost procedure pneumothorax. \nLittle change ___ the diffuse bilateral pulmonary opacifications. \n\n___ Imaging RENAL U.S. \nNo evidence of hydronephrosis. Thickened bladder wall may be \nsecondary to \nunderdistention of the bladder. \n\n___ Imaging CHEST (PORTABLE AP) \nNo evidence of hydronephrosis. Thickened bladder wall may be \nsecondary to underdistention of the bladder. \n\n___ Imaging RENAL U.S. \nNo evidence of hydronephrosis. Thickened bladder wall may be \nsecondary to \nunderdistention of the bladder. \n\n___ Imaging LIVER OR GALLBLADDER US \n1. Limited exam for evaluation of hepatic lesion and pancreatic \nhead mass due to overlying bowel gas after hepaticojejunostomy. \nHowever, no definite hepatic metastatic disease. \n2. Persistent dilation of main pancreatic duct with abrupt \nocclusion ___ the head. \n3. Moderate right pleural effusion. \n4. Borderline splenomegaly. \n\n___ Imaging BILAT LOWER EXT VEINS \nNo evidence of deep venous thrombosis ___ the right or left lower \nextremity \nveins. Right calf vessels were not definitely visualized. \n\n___ THORACENTESIS NEEDLE\nIMPRESSION: \nSuccessful ultrasound-guided right thoracentesis with removal of \n0.8 L of\nclear, straw-colored fluid, which was sent for cytology.\n\n___ REPLACEMENT\nIMPRESSION: \nSuccessful placement of a single lumen chest power Port-a-cath \nvia the right internal jugular venous approach. The tip of the \ncatheter terminates ___ the right atrium. The catheter is ready \nfor use.\n\nSuccessful removal of the malpositioned right Port-A-cath.\n\n___ U.S.\n\nIMPRESSION: \n\n1. No hydronephrosis.\n2. Echogenic kidneys may reflect medical renal disease.\n3. Trace ascites.\n\n___ ABDOMEN\n\nIMPRESSION: \n\nNo of evidence of bowel obstruction or pneumoperitoneum.\n\n___ LAVAGE\nNEGATIVE FOR MALIGNANT CELLS.\n\n___ TTE\nThe left atrium is normal ___ size. The estimated right atrial \npressure is ___ mmHg. Left ventricular wall thickness, cavity \nsize and regional/global systolic function are normal (LVEF \n>55%). Right ventricular chamber size and free wall motion are \nnormal. There is abnormal septal motion/position. The ascending \naorta is mildly dilated. The aortic valve leaflets (3) are \nmildly thickened but aortic stenosis is not present. No aortic \nregurgitation is seen. The mitral valve appears structurally \nnormal with trivial mitral regurgitation. The pulmonary artery \nsystolic pressure could not be determined. There is a very small \nto small pericardial effusion measuring up to 0.8 centimeters ___ \ngreatest dimension, but generally 0.2-0.4 cm ___ size. The \neffusion appears circumferential. There are no echocardiographic \nsigns of tamponade. \n\n IMPRESSION: Very small to small pericardial effusion without \nechocardiographic evidence of tamponade. Mildly dilated \nascending aorta. Preserved biventricular systolic function. \nIndeterminate pulmonary artery systolic pressure. \n\n___ CXR\nExtensive consolidations ___ particular involving right upper \nlobe as well as bibasal areas is unchanged. Central venous line \ntip terminates at the level of mid right subclavian vein. \nCardiomediastinal silhouette is difficult to assess since it is \nobscured by widespread parenchymal consolidations. Bilateral \npleural effusions are present. No pneumothorax. \n\nMICROBIOLOGY:\n=============\n\n___\nNO CRYPTOSPORIDIUM OR GIARDIA SEEN.\n\n___\n NO OVA AND PARASITES SEEN. \n\n___\n\nFECAL CULTURE (Final ___: \n NO ENTERIC GRAM NEGATIVE RODS FOUND. \n NO SALMONELLA OR SHIGELLA FOUND. \n\n CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER \nFOUND. \n\n OVA + PARASITES (Final ___: \n NO OVA AND PARASITES SEEN. \n This test does not reliably detect Cryptosporidium, \nCyclospora or\n Microsporidium. While most cases of Giardia are detected \nby routine\n O+P, the Giardia antigen test may enhance detection when \norganisms\n are rare. \n\n FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO \nFOUND. \n\n FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA \nFOUND. \n\n___\n\n C. difficile DNA amplification assay (Final ___: \n Negative for toxigenic C. difficile by the Cepheid nucleic \nacid\n amplification assay.. \n\n___ Respiratory Viral Screen & Culture\n\nRespiratory Viral Culture (Final ___: \n No respiratory viruses isolated. \n Culture screened for Adenovirus, Influenza A & B, \nParainfluenza type\n 1,2 & 3, and Respiratory Syncytial Virus.. \n\n___ LAVAGE\n\nGRAM STAIN (Final ___: \n 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR \nLEUKOCYTES. \n NO MICROORGANISMS SEEN. \n\n RESPIRATORY CULTURE (Final ___: NO GROWTH, <1000 \nCFU/ml. \n\n LEGIONELLA CULTURE (Final ___: NO LEGIONELLA \nISOLATED. \n\n POTASSIUM HYDROXIDE PREPARATION (Final ___: \n Test cancelled by laboratory. \n PATIENT CREDITED. \n This is a low yield procedure based on our ___ \nstudies. \n if pulmonary Histoplasmosis, Coccidioidomycosis, \nBlastomycosis,\n Aspergillosis or Mucormycosis is strongly suspected, \ncontact the\n Microbiology Laboratory (___). \n\n Immunoflourescent test for Pneumocystis jirovecii (carinii) \n(Final\n ___: NEGATIVE for Pneumocystis jirovecii \n(carinii). \n\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. \n\n NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED. \n\n ACID FAST SMEAR (Final ___: \n NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. \n\n ACID FAST CULTURE (Final ___: NO MYCOBACTERIA \nISOLATED. \n\n___\n\n ACID FAST CULTURE (Final ___: NO MYCOBACTERIA \nISOLATED. \n\n ACID FAST SMEAR (Final ___: \n NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. \n\n___ BLOOD CX: NO GROWTH x2\n___ SPUTUM GRAM STAIN & CULTURE: \n\nGRAM STAIN (Final ___: \n >25 PMNs and <10 epithelial cells/100X field. \n 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. \n ___ PAIRS SINGLY. \n\n RESPIRATORY CULTURE (Final ___: \n RARE GROWTH Commensal Respiratory Flora. \n\n___ URINE CX: NO GROWTH\n\nPATHOLOGY:\n==========\n___ Tissue: LUNG, CORE BIOPSY FOR TUMOR \nMetastatic adenocarcinoma\n- Positive: CK7, ___.\n- Negative: CK20, TTF-1, B72.3.\n\nOTHER LABS OF NOTE:\n==================\n___ 06:00AM BLOOD %HbA1c-6.1* eAG-128*\n___ 05:21AM BLOOD Triglyc-110 HDL-20 CHOL/HD-3.9 LDLcalc-36\n___ 06:00AM BLOOD HBsAg-Negative HBsAb-Negative \nHBcAb-Negative\n___ 06:00AM BLOOD ANCA-NEGATIVE B\n___ 06:00AM BLOOD ___\n___ 06:00AM BLOOD C3-78* C4-38\n___ 11:17PM BLOOD HIV Ab-Negative\n\n', 'Physical Exam:|Physical': "\nADMISSION PHYSICAL EXAM: \n========================\nVITALS: 99 81 157/89 31 99% non rebreather at 10 \nGENERAL: Alert, oriented, tachypnic \nHEENT: Sclera anicteric, MMM, oropharynx clear \nNECK: supple, JVP not elevated, no LAD \nLUNGS: diffusely rhonchirus, wheezy upper airways bilaterally \nCV: tachycardic, normal S1 S2, no murmurs, rubs, gallops \nABD: soft, non-tender, non-distended, bowel sounds present, no \nrebound tenderness or guarding, no organomegaly \nEXT: 3+ pitting edema upper and lower extremities bilaterally \nSKIN: no rash \nNEURO: grossly intact \n\nDISCHARGE PHYSICAL EXAM:\n=======================\nVITAL SIGNS: T 98.4 BP 161/89 HR 75 RR 18 O2 95%3L\nGeneral: Fatigued and ill appearing man, withdrawn, keeps sheet \nover head and\ndoesn't maintain eye contact with examiner. Actively vomiting.\nHEENT: MMM. OP clear.\nCV: RRR, prominent S1S2, no S3S4, no MRG.\nPULM: Nonlabored appearing. Decreased BS at right base. Coarse \nthroughout\nABD: BS+, soft, NTND.\nLIMBS: TEDS ___ place, bilateral ___ ___ edema throughout thighs \nto\nsacrum above level of TEDS, Bilateral UE nonpitting edema.\nSKIN: Bilateral skin breakdown at elbows and shins from the \nmetal\nshacks, now ___ padded boots and improving \nNEURO: Awake. Very short answers sporadically to questions,\nalthough appropriate. Symmetric generalized weakness, but moves\nall extremities.\n\n", 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\n Mr. ___ is a ___ yo man with a presumed diagnosis metastatic \npancreatic cancer, likely metastatic who is being transferred \nfrom ___ out of concern for tamponande and need for \ncardiac window ___ setting of new hypoxemia. \n\n___ course: Mr. ___ presented to ___ on ___ from \ncorrection facility with SOB and productive cough and low grade \ntemperature. CXR ___ the ED was concerning for an infiltrate vs. \natelectasis vs. edema. He was initiated on levofloxacin and \nthen transitioned to azithromycin and ceftriaxone. Troponin was \n0.07 and BNP 499. Due to troponin bump and history of cancer \ndecision was made to treat empirically with treatment dose of \nenoxaparin. He was also given "low dose" Lasix. D-dimer was \nsent and positive. V/Q scan was performed and indeterminate. On \nevening of ___ he was noted to have increased oxygen \nrequirement and started on ___ mask with 100% oxygen \nsaturation. Later ___ the evening, however, he was noted to be \n"unresponsive and hypoxemic with oxygen mask off." ABG at that \ntime was blood gas showed pH 7.29. PCO2 52 and PO2 ___ the 64 26 \non 100% nonrebreather." He was then transferred to the MICU \nwhere antibiotics were broadened to meropenem and vancomycin. He \nwas reportedly very hypertensive at time of transfer (no vitals \nnoted) and given 5 mg IV metoprolol. An echo was performed that \nshowed, "Cardiologist reports small but pre-tamponade physiology \nseen on TTE." He was transferred to ___ out of concern for \nneed for cardiac window. \n\nAt time of transfer he was on high flow 60% satting 92-95%. ___ \naddition to hypoxemia and cough, he is having diarrhea requiring \nrectal tube. \n\nPancreatic cancer course (per OMR and oncology notes): ___ \n___ he developed new onset abdominal pain and was noted \nto have a pancreatic mass. Biopsies were performed and \nindeterminate. ___ ___ he was admitted to ___ with \nperforated cholecystitis s/p percutaneous cholecystostomy tube. \nMRCP at that time raised\nsuspicion for head of pancreas mass. Later that month she ERCP \nwith Spyglass done showed a malignant-appearing stricture and \nEUS showing an ill-defined mass ___ the pancreatic neck with an \nabrupt transition ___ caliber of the PD, brushings and biopsies \nagain atypical. Repeat ERCP for rising LFTs was performed. A \nfully covered metal stent placed (prior stent dislodged). \nAbscess cavity had collapsed and drain removed. Given all this, \nhad large-volume weight loss with inability to maintain feeds \nwith subsequent malnutrition and hypoalbuminemia requiring NJT \nfeeds. ___ ___ he was planned for Whipple procedure for \ndefinitive diagnosis of pancreatic mass. However, \nintra-operatively he became hypotensive and hypoglycemic. \nSurgery was converted to CCY and double bypass was performed \nwith fiducial placement. Biopsies of the pancreatic head \nreturned positive for ductaladenocarcinoma with invasion of \nperipancreatic adipose tissue. There was a delay ___ follow-up \nbetween ___ and ___ when he followed up with Dr. \n___ ___ oncology. At that visit he was scheduled for \nbiopsy of known lung nodules to make formal diagnosis of \nmetastatic lung cancer. At this time plan is to initiate \npalliative systemic therapy for his pancreatic cancer (once \nbiopsy is done). At that visit it was also noted that he was \ngrossly anasarcic and hypertensive. \n\nOn arrival to the MICU, he states that he is feeling very short \nof breath and weak. He also endorses some diarrhea. \n\nPast Medical History:\n- Metastatic pancreatic cancer, presumed\n- HTN\n- Grand mal seizures\n- Depression\n- HLD\n- DM, insulin dependent\n- History of Biliary obstruction/stricture\n\nSocial History:\n___\nFamily History:\nDenies family history of colon, pancreas, liver,\nbreast or other malignancies. Denies history of other family\ngastrointestinal disease or pancreatitis.\n\n', 'Chief Complaint:|Complaint:': '\nShortness of breath \n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nNo Known Allergies / Adverse Drug Reactions\n\n'}, '16013806-DS-23', 23, 'medicine']]

[['EXAMINATION: CHEST (PORTABLE AP)\n\nINDICATION: ___ year old man with hypoxemia and metastatic pancreatic cancer. \n// pna ? edema ? pna ? edema ?\n\nIMPRESSION: \n\nExtensive consolidations in particular involving right upper lobe as well as\nbibasal areas is unchanged. Central venous line tip terminates at the level\nof mid right subclavian vein. Cardiomediastinal silhouette is difficult to\nassess since it is obscured by widespread parenchymal consolidations. \nBilateral pleural effusions are present. No pneumothorax.\n', '16013806-RR-38', 38, ''], ['INDICATION: ___ year old man with ETT // Eval ETT placement\n\nTECHNIQUE: AP portable chest radiograph\n\nCOMPARISON: ___ from earlier in the day\n\nFINDINGS: \n\nThe tip of the endotracheal tube projects at the level of the clavicular\nheads. The tip of the right central venous catheter is unchanged.\n\nThere are increased bilateral lung volumes. Grossly unchanged consolidations\ninvolving both lungs but more so involving the right upper lobe. Layering\nbilateral pleural effusions are present. No pneumothorax. The size of the\ncardiac silhouette is enlarged but likely unchanged.\n\nIMPRESSION: \n\nThe tip of the endotracheal tube projects at the level of the clavicular\nheads. Increased bilateral lung volumes with persisting bilateral\nconsolidative opacities.\n', '16013806-RR-39', 39, 'ap portable chest radiograph'], ['INDICATION: ___ year old man with ETT + RIJ CVL with severe pneumonia // Eval\nfor RIJ CVL placement\n\nTECHNIQUE: AP portable chest radiograph\n\nCOMPARISON: ___\n\nFINDINGS: \n\nThe tip of the new right internal jugular central venous catheter projects\nover the distal SVC. A right central venous catheter tip is unchanged\nprojecting over the right clavicle. The tip of the endotracheal tube projects\nover the mid thoracic trachea. A nasogastric tube extends into the stomach.\n\nPersisting diffuse bilateral airspace opacities. Layering bilateral pleural\neffusions are suspected. No pneumothorax. The size of the cardiac silhouette\nis unchanged.\n\nIMPRESSION: \n\nInterval placement of a right internal jugular central venous catheter whose\ntip projects over the distal SVC. The tip of the endotracheal tube projects\nover the mid thoracic trachea.\n', '16013806-RR-40', 40, 'ap portable chest radiograph'], ['EXAMINATION: Chest one view\n\nINDICATION: ___ year old man with intubated. // assess infiltrates\n\nTECHNIQUE: Chest portable AP with the patient supine.\n\nCOMPARISON: ___.\n\nFINDINGS: \n\nAs with the previous exam there are bilateral diffuse pulmonary opacities with\nno interval change. Right IJ tube in distal SVC. ET tube above the carina.\n\nIMPRESSION: \n\nNo interval change.\n', '16013806-RR-41', 41, 'chest portable ap with the patient supine.'], ['EXAMINATION: BILAT UP EXT VEINS US\n\nINDICATION: ___ year old man with ___ upper extremity edema and pancreatic\ncancer.\n\nTECHNIQUE: Grey scale and Doppler evaluation was performed on the bilateral\nupper extremity veins.\n\nCOMPARISON: None.\n\nFINDINGS: \n\nThere is normal flow with respiratory variation in the bilateral subclavian\nveins.\n\nThe bilateral internal jugular and axillary veins are patent, show normal\ncolor flow and compressibility.\nThe bilateral brachial, basilic, and cephalic veins are patent, compressible\nand show normal color flow and augmentation.\n\nThere is significant subcutaneous edema involving both upper extremities.\n\nIMPRESSION:\n\n\n1. No evidence of deep vein thrombosis in the bilateral upper extremity veins.\n2. Subcutaneous edema involves both upper extremities.\n', '16013806-RR-43', 43, 'grey scale and doppler evaluation was performed on the bilateral\nupper extremity veins.'], ['EXAMINATION: CHEST (PORTABLE AP)\n\nINDICATION: ___ year old man with pneumonia // Eval for interval change \nEval for interval change\n\nIMPRESSION: \n\nComparison to ___. No relevant change is noted. Monitoring and\nsupport devices are stable. Moderate cardiomegaly. Bilateral pleural\neffusions and subsequent areas of atelectasis. Moderate parenchymal opacities\nare stable. No new opacities. No overt pulmonary edema.\n', '16013806-RR-44', 44, ''], ['EXAMINATION: CHEST (PORTABLE AP)\n\nINDICATION: ___ year old man with hypoxemic resp failure and metastatic\npancreatic cancer. // interval change interval change\n\nIMPRESSION: \n\nIn comparison with study of ___, the monitoring and support devices are\nessentially unchanged. Continued enlargement of the cardiac silhouette with\nengorged pulmonary vessels and bilateral pleural effusions with compressive\natelectasis, more prominent on the right.\n', '16013806-RR-45', 45, ''], ['EXAMINATION: CHEST (PORTABLE AP)\n\nINDICATION: ___ year old man with vol overload PNA // Eval for interval\nchange Eval for interval change\n\nIMPRESSION: \n\nCompared to chest radiographs ___ through ___.\n\nLeft lower lobe consolidation was severe early on ___ and had\nsubstantially cleared during the day. Therefore this was not pneumonia. Lung\nbases however remain densely consolidated, the left since ___, the\nright since ___. This could be pneumonia, but is always difficult to\ndistinguish from basal atelectasis and concurrent pleural effusion which is\nsmall to moderate on the right.\n\nHeart is mildly enlarged.\n\nET tube, right internal jugular line, and nasogastric drainage tube are in\nstandard placements.\n\nAn intended right subclavian line has been present since prior to this\nadmission and still ends at the level of the right clavicle. It could be in a\nsmall vein or even extravascular. Clinical assessment is essential.\n', '16013806-RR-46', 46, ''], ['INDICATION: ___ year old man with pancreatic cancer now with n/v concerning\nfor obstruction. // Please assess for possible obstruction, ileus.\n\nTECHNIQUE: Portable supine abdominal radiograph was obtained.\n\nCOMPARISON: None.\n\nFINDINGS: \n\nThere are no abnormally dilated loops of large or small bowel.\nThere is no free intraperitoneal air.\nOsseous structures are unremarkable.\nSurgical clips are present in the right upper abdomen. There are no\nunexplained soft tissue calcifications or radiopaque foreign bodies.\n\nIMPRESSION: \n\nNo radiographic evidence of bowel obstruction.\n', '16013806-RR-47', 47, 'portable supine abdominal radiograph was obtained.'], ['INDICATION: ___ year old man with metastatic pancreatic cancer now with n/v\nconcerning for obstruction // Please perform upright abdominal xray to assess\nfor bowel obstruction\n\nTECHNIQUE: Portable supine and upright abdominal radiographs were obtained.\n\nCOMPARISON: Abdominal radiographs from ___ at 0016.\n\nFINDINGS: \n\nThere are no abnormally dilated loops of large or small bowel.\nThere is no free intraperitoneal air.\nOsseous structures are unremarkable.\nA right-sided Port-A-Cath terminates at the cavoatrial junction. Surgical\nclips are present in the right side of the abdomen. There are no unexplained\nsoft tissue calcifications or radiopaque foreign bodies.\n\nIMPRESSION: \n\nNo of evidence of bowel obstruction or pneumoperitoneum.\n', '16013806-RR-48', 48, 'portable supine and upright abdominal radiographs were obtained.'], ['EXAMINATION: RENAL U.S.\n\nINDICATION: ___ year old man with a PMH of (suspected metastatic) pancreatic\ncancer and HTN here with hypoxemic respiratory failure from pneumonia and\nvolume overload. Continues to have worsening kidney function w/ proteinuria \n// eval for hydronephrosis;\n\nTECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were\nobtained.\n\nCOMPARISON: None.\n\nFINDINGS: \n\nThe right kidney measures 11.8 cm. The left kidney measures 13.2 cm. There is\nno hydronephrosis, stones, or masses bilaterally. Bilateral renal cortices\nappear echogenic.\n\nBladder is decompressed about a Foley catheter.\nTrace ascites is noted.\n\nIMPRESSION: \n\n1. No hydronephrosis.\n2. Echogenic kidneys may reflect medical renal disease.\n3. Trace ascites.\n', '16013806-RR-49', 49, 'grey scale and color doppler ultrasound images of the kidneys were\nobtained.'], ["INDICATION: Mr. ___ is a ___ year old man with a PMH of pancreatic cancer and\nHTN here with hypoxemic respiratory failure from pneumonia and volume\noverload. Port in wrong place, plan for chemo in the future. // Please\nreplace outside hospital placed chest port for chemotherapy; ___ aware and\ndiscussed w/ ___ last week.\n\nCOMPARISON: Chest radiograph on ___.\n\nTECHNIQUE: OPERATORS: Dr. ___ and Dr.\n___ radiologist performed the procedure. Dr. ___\nsupervised the trainee during the key components of the procedure and has\nreviewed and agrees with the trainee's findings.\nANESTHESIA: Moderate sedation was provided by administrating divided doses of\n25 mcg of fentanyl and 0.5 mg of midazolam throughout the total intra-service\ntime of 55 minutes during which the patient's hemodynamic parameters were\ncontinuously monitored by an independent trained radiology nurse. 1% lidocaine\nwas injected in the skin and subcutaneous tissues overlying the access site.\nMEDICATIONS: Fentanyl and versed.\nCONTRAST: None.\nFLUOROSCOPY TIME AND DOSE: 2.3 min, 57 mGy\n\nPROCEDURE\n1. Right internal jugular approach chest single lumen Port-a-cath placement.\n2. Right Port-A-Cath removal.\n\nPROCEDURE DETAILS: Following the explanation of the risks, benefits and\nalternatives to the procedure, written informed consent was obtained from the\npatient. The patient was then brought to the angiography suite and placed\nsupine on the exam table. A pre-procedure time-out was performed per ___\nprotocol. The upper chest was prepped and draped in the usual sterile fashion.\nUnder continuous ultrasound guidance, the patent right internal jugular vein\nwas compressible and accessed using a micropuncture needle. Permanent\nultrasound images were obtained before and after intravenous access, which\nconfirmed vein patency. Subsequently a Nitinol wire was passed into the right\natrium using fluoroscopic guidance. The needle was exchanged for a\nmicropuncture sheath. The Nitinol wire was removed and a short ___ wire was\nadvanced to make appropriate measurements for catheter length. The ___ wire\nwas then passed distally into the IVC.\nNext, attention was turned towards creation of a subcutaneous pocket over the\nupper anterior chest wall. After instilling superficial and deeper local\nanesthesia using lidocaine mixed with epinephrine, a 2.5 cm transverse\nincision was made and a subcutaneous pocket was created by using blunt\ndissection. The single lumen port was then connected to the catheter. The\ncatheter was tunneled from the subcutaneous pocket towards the venotomy site\nfrom where it was brought out using a tunneling device. The port was then\nconnected to the catheter and checks were made for any leakage by accessing\nthe diaphragm using a non-coring ___ needle. No leaks were found.\nThe port was then placed in the subcutaneous pocket and secured with ___\nprolene sutures on either side. The venotomy tract was dilated using the\nintroducer of the peel-away sheath supplied. Following this, the peel-away\nsheath was placed over the ___ wire through which the port was threaded into\nthe right side of the heart with the tip in the right atrium. The sheath was\nthen peeled away.\nThe subcutaneous pocket was closed in layers with ___ interrupted and ___\nsubcuticular continuous Vicryl sutures. Steri-Strips were used to close the\nvenotomy incision site. Steri-Strips were applied over the sutures. Final spot\nfluoroscopic image demonstrating good alignment of the catheter and no\nkinking. The tip is in the right atrium.\nThe port was accessed using a non coring ___ needle and could be aspirated\nand flushed easily. Sterile dressings were applied. The patient tolerated the\nprocedure well without immediate complication. The port was left accessed as\nrequested.\n\nNext, the final position of right-sided or was identified. After instillation\nof 1% lidocaine and lidocaine with epinephrine into the skin and subcutaneous\ntissues, a 2.5 cm transverse incision was made. Blunt dissection was\nperformed to the port. The port was removed completely. The subcutaneous\npocket was closed in layers with ___ interrupted and ___ subcuticular\ncontinuous Vicryl sutures. Steri-Strips and sterile dressings were applied.\n\nFINDINGS: \n\nPatent right internal jugular vein. Final fluoroscopic image showing port with\ncatheter tip terminating in the right atrium.\n\nExisting malposition port with its tip pulled back into the right subclavian\nvein. The port was removed entirely.\n\nIMPRESSION: \n\nSuccessful placement of a single lumen chest power Port-a-cath via the right\ninternal jugular venous approach. The tip of the catheter terminates in the\nright atrium. The catheter is ready for use.\n\nSuccessful removal of the malpositioned right Port-A-cath.\n", '16013806-RR-50', 50, "operators: dr. ___ and dr.\n___ radiologist performed the procedure. dr. ___\nsupervised the trainee during the key components of the procedure and has\nreviewed and agrees with the trainee's findings.\nanesthesia: moderate sedation was provided by administrating divided doses of\n25 mcg of fentanyl and 0.5 mg of midazolam throughout the total intra-service\ntime of 55 minutes during which the patient's hemodynamic parameters were\ncontinuously monitored by an independent trained radiology nurse. 1% lidocaine\nwas injected in the skin and subcutaneous tissues overlying the access site.\nmedications: fentanyl and versed.\ncontrast: none.\nfluoroscopy time and dose: 2.3 min, 57 mgy"], ['EXAMINATION: CHEST (PORTABLE AP)\n\nINDICATION: Mr. ___ is a ___ year old man with a PMH of (suspected metastatic)\npancreatic cancer and HTN here with hypoxemic respiratory failure from\npneumonia and volume overload. Now w/ desatting // Fluid? Pna? Fluid? Pna?\n\nIMPRESSION: \n\nCompared to chest radiographs ___ through ___.\n\nLarge right pleural effusion continues to grow. Right upper and lower lobe\nconsolidation have improved, but the middle lobe is probably now collapsed. \nLeft lower lobe atelectasis may also have improved.\n\nRight heart border is obscured so extent of cardiac enlargement is\nindeterminate, but probably unchanged.\n\nPatient has been extubated. Right supraclavicular central venous catheter\nends in the region of the superior cavoatrial junction.\n', '16013806-RR-51', 51, ''], ['INDICATION: ___ year old man with a PMH of (suspected metastatic) pancreatic\ncancer and HTN here with hypoxemic respiratory failure from pneumonia and\nvolume overload. Continues to have pulmonary edema, no s/p diuresis. //\ninterval changes Surg: ___ (Lung biopsy. Please OBTAIN IN AM)\n\nTECHNIQUE: Chest PA and lateral\n\nCOMPARISON: ___\n\nFINDINGS: \n\nRight-sided prepectoral Port-A-Cath in situ with the tip in the distal SVC. \nLarge sized right-sided pleural effusion is again noted and appears relatively\nsimilar in size compared to prior. Associated right lower lobe atelectasis is\nstable. Minor left lower lobe atelectasis.\nNo overt pulmonary edema.\nMultiple pulmonary nodules appear similar compared to prior. Bilateral\ndegenerative changes of the shoulder joints with associated calcifications.\n\nIMPRESSION: \n\nModerate sized right-sided pleural effusion with associated right lower lobe\natelectasis.\nMultiple pulmonary nodules appear similar compared to prior in keeping with\nmetastatic disease.\nNo overt pulmonary edema.\n', '16013806-RR-52', 52, 'chest pa and lateral'], ["EXAMINATION: CT Limited Study\n\nINDICATION: ___ with h/o inoperable pancreatic cancer, for percutaneous\nbiopsy of lung nodules..\n\nTECHNIQUE: Limited preprocedure CT scan of the chest was performed.\n\nDOSE: DLP: ___ MGy-cm\n\nCOMPARISON: CT of the chest from ___\n\nFINDINGS: \n\nThere is a large right pleural effusion with associated atelectasis. The right\nlung shows little aeration and the known lung nodules targeted for biopsy\ncannot be visualized. Multiple nodules are seen in the aerated left lung.\nHowever, due to the patient's renal insufficiency, there is a an increased\nrisk of bleeding which could have negative impact on the patient given that O2\nsaturation on room air is < 90%. The patient may be re-scheduled for biopsy\nonce the pleural effusion is managed and his respiratory status improves.\n\nIMPRESSION: \n\nLimited pre-procedure CT scan of the chest. A lung biopsy was not performed.\n", '16013806-RR-53', 53, 'limited preprocedure ct scan of the chest was performed.'], ["EXAMINATION: Ultrasound-guided thoracentesis\n\nINDICATION: ___ year old man with R pleural effusion // thoracentesis\n\nTECHNIQUE: Ultrasound guided diagnostic and therapeutic thoracentesis.\n\nCOMPARISON: Limited CT of the chest and chest radiograph from ___.\n\nFINDINGS: \n\nLimited grayscale ultrasound imaging of the right hemithorax demonstrated\nmoderate pleural fluid. A suitable target in the deepest pocket in the right\nposterior mid scapular line was selected for thoracentesis.\n\nPROCEDURE: The procedure, risks, benefits and alternatives were discussed\nwith the patient and written informed consent was obtained.\n\nA preprocedure time-out was performed discussing the planned procedure,\nconfirming the patient's identity with 3 identifiers, and reviewing a\nchecklist per ___ protocol.\n\nUnder ultrasound guidance, an entrance site was selected and the skin was\nprepped and draped in the usual sterile fashion. 1% lidocaine buffered with\nsodium bicarbonate was instilled for local anesthesia.\n\nA 5 ___ catheter was advanced into the largest fluid pocket in the right\nposterior mid scapular line and 0.8 L of clear, straw-colored fluid was\nremoved. Fluid samples were submitted to the laboratory for cytology.\n\nThe patient tolerated the procedure well without immediate complication.\nEstimated blood loss was minimal.\n\nDr. ___ personally supervised the trainee during the key components of\nthe procedure and reviewed and agrees with the trainee's findings.\n\nIMPRESSION: \n\nSuccessful ultrasound-guided right thoracentesis with removal of 0.8 L of\nclear, straw-colored fluid, which was sent for cytology.\n", '16013806-RR-54', 54, 'ultrasound guided diagnostic and therapeutic thoracentesis.'], ['INDICATION: ___ year old man with R pleural effusion s/p thoracentesis //\nPost R thoracentesis. Evaluate for pneumothorax. Please perform upright.\n\nCOMPARISON: ___.\n\nIMPRESSION: \n\nThere has been interval resolution of the right-sided pleural effusion since\nthoracentesis. There are no pneumothoraces. There is a right-sided\nPort-A-Cath with the distal lead tip in the proximal right atrium. There is\nagain seen several rounded opacities throughout both lung fields consistent\nwith known pulmonary nodules.\n', '16013806-RR-55', 55, ''], ['EXAMINATION: Chest radiograph\n\nINDICATION: ___ year old man with suspected metastatic pancreatic cancer with\nrecent ___ for right pleural effusion. // Eval for interval changes\n\nTECHNIQUE: Portable semi upright view of the chest\n\nCOMPARISON: Chest radiograph from ___\n\nFINDINGS: \n\nA right Port-A-Cath tip terminates slightly below the caval atrial junction. \nAgain seen are several rounded opacities in the bilateral lung fields,\nconsistent with known pulmonary nodules. There are small bilateral pleural\neffusions, right greater than left. No pneumothorax. The cardiomediastinal\nsilhouette is mildly obscured due to adjacent opacities but likely unchanged.\n\nIMPRESSION: \n\n1. Persistence of small bilateral pleural effusions, right greater than left,\nsince prior study in ___.\n2. Pulmonary metastatic nodules are better seen on the CT chest from ___\n', '16013806-RR-56', 56, 'portable semi upright view of the chest'], ['ADDENDUM The pathology showed: Metastatic pancreatic adenocarcinoma.\nThis result is concordant with imaging findings.\nRecommendations: no further evaluation of this lesion is indicated.\nThe meeting was attended by: , ___.\n', '16013806-AR-57', 57, ''], ["EXAMINATION: CT-guided procedure\n\nINDICATION: ___ year old man with panc cancer, concern for metastatic disease \n// ? metastatic panc cancer\n\nCOMPARISON: CT of the chest from ___\n\nPROCEDURE: CT-guided right lower lobe lung nodule biopsy.\n\nOPERATORS: Dr. ___ fellow and Dr. ___\nradiologist. Dr. ___ supervised the trainee during the key\ncomponents of the procedure and reviewed and agrees with the trainee's\nfindings.\n\nTECHNIQUE: The risks, benefits, and alternatives of the procedure were\nexplained to the patient. After a detailed discussion, informed written\nconsent was obtained. A pre-procedure timeout using three patient identifiers\nwas performed per ___ protocol.\n\nThe patient was placed in a right lateral decubitus position on the CT scan\ntable. Limited preprocedure CTscan of the intended biopsy area was performed.\nBased on the CT findings an appropriate position for the biopsy was chosen. \nThe site was marked. The preprocedural CT demonstrates numerous bilateral\npulmonary nodules as well as bibasilar areas of subsegmental atelectasis and a\nlayering small to moderately sized right pleural effusion. 2 cm right lower\nlobe nodule was chosen for biopsy.\n\nThe site was prepped and draped in the usual sterile fashion. 1% lidocaine\nwere administered to the subcutaneous and deep tissues for local anesthetic\neffect. Under CT guidance, a 17 gauge coaxial needle was introduced into the\npleural space. Positioning of the needle was technically difficult due to the\npresence of the pleural effusion and atelectasis which allowed the lung to be\ndisplaced with the advancement of the needle as well as difficulty in\nreproducing breath holds with the patient. With some difficulty the needle\nwas placed to the edge of the target right lower lobe lung nodule. A 18 gauge\ncore biopsy device with a 20 mm throw was used to obtain a core biopsy\nspecimen. Verification of biopsy needle location after it was deployed was not\npossible as gravity and breathing motion caused the biopsy needle to withdraw.\nPost biopsy CT after the first biopsy demonstrated that the introducer needle\nwas positioned at the chosen nodule for biopsy and it appeared to be an\nappropriate position. A second biopsy was then attempted however\nvisualization of the 2 cm nodule was difficult due to intraparenchymal\nhemorrhage after the first biopsy, but a second 18 gauge core biopsy was\nobtained. Once again verification of the biopsy needle location after it was\ndeployed was not possible. These two specimens were provided to on-site\ncytologist who indicated pulmonary macrophages without evidence of malignancy.\n\nA third 18 gauge biopsy was then attempted noting as above that visualization\nof the nodule was even more difficult as it was obscured by intraparenchymal\nhemorrhage. As the nodule could not be adequately visualized, no additional\nbiopsy attempts were made.\n\nPost procedure limited CT demonstrated that there was no pneumothorax. The\npreviously seen small to moderate right pleural effusion had increased in size\nand was now a moderate right pleural effusion. In addition there was intra\nparenchymal pulmonary hemorrhage at the site of biopsy.\n\nThe procedure was tolerated well and there were no immediate post-procedural\ncomplications.\n\nDOSE: Total DLP (Body) = 839 mGy-cm.\n\nSEDATION: Moderate sedation was provided by administering divided doses of\n0.5 mg Versed and 25 mcg fentanyl throughout the total intra-service time of\n53 minutes during which patient's hemodynamic parameters were continuously\nmonitored by an independent trained radiology nurse.\n\nFINDINGS:\n\n\n1. Preprocedural CT showed multiple bilateral pulmonary nodules, a small to\nmoderately sized right pleural effusion, and bibasilar subsegmental\natelectasis.\n2. Procedure was technically challenging due to the presence of the right\npleural effusion and atelectasis allowing displacement of the lung with\nadvancement of the needle, as well as patient difficulty with reproducing\nbreath holds. 3 x 18 gauge core biopsy of a 2 cm right lower lobe nodule was\nperformed.\n3. Postprocedural CT showed no pneumothorax. The small to moderate right\npleural effusion had increased in size and was now moderate. In addition\nthere was ensure parenchymal pulmonary hemorrhage at the site of biopsy.\n\nIMPRESSION: \n\nTechnically difficult CT-guided lung nodule biopsy targeting a 2 cm right\nlower lobe nodule as noted above, with three 18 gauge core biopsies obtained.\n\nPostprocedural CT showed that there was no pneumothorax but that the\nright-sided pleural effusion head increased in size and was now moderate. \nThere was also intraparenchymal pulmonary hemorrhage at the site of biopsy.\n\nPatient tolerated the procedure well without coughing or oxygen desaturation.\n", '16013806-RR-57', 57, 'the risks, benefits, and alternatives of the procedure were\nexplained to the patient. after a detailed discussion, informed written\nconsent was obtained. a pre-procedure timeout using three patient identifiers\nwas performed per ___ protocol.'], ['EXAMINATION: BILAT LOWER EXT VEINS\n\nINDICATION: ___ year old man with pancreatic ca, metastatic, now w/ b/l lower\next edema // r/o dvt\n\nTECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed\non the bilateral lower extremity veins.\n\nCOMPARISON: None.\n\nFINDINGS: \n\nThere is normal compressibility, flow, and augmentation of the bilateral\ncommon femoral, femoral, and popliteal veins.\nThe posterior tibial and peroneal veins are difficult to visualize\nbilaterally. Compressibility in the left posterior tibial vein is\ndemonstrated as is color within the left posterior tibial and peroneal veins. \nThe right calf vessels are not well seen.\n\nThere is normal respiratory variation in the common femoral veins bilaterally.\n\nNo evidence of medial popliteal fossa (___) cyst.\n\nIMPRESSION: \n\nNo evidence of deep venous thrombosis in the right or left lower extremity\nveins. Right calf vessels were not definitely visualized.\n', '16013806-RR-58', 58, 'grey scale, color, and spectral doppler evaluation was performed\non the bilateral lower extremity veins.'], ['EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)\n\nINDICATION: ___ year old man with pancreatic cancer and about to get chemo\nwith new jump in LFTs // evaluate for biliary obstruction or hepatic mets.\n\nTECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were\nobtained.\n\nCOMPARISON: CTA from ___\n\nFINDINGS: \n\nThere is moderate amount of pleural effusion.\n\nLIVER: The hepatic parenchyma appears within normal limits. The contour of the\nliver is smooth. No focal liver mass, though evaluation is limited due to\nbowel gas from prior hepaticojejunostomy. The main portal vein is patent with\nhepatopetal flow. No ascites.\n\nBILE DUCTS: There is mild intrahepatic biliary dilation with pneumobilia,\nunchanged from prior exam on ___. The CHD was not visualized,\nlikely related to hepaticojejunostomy.\n\nGALLBLADDER: The patient is status post cholecystectomy and status post\nhepaticojejunostomy.\n\nPANCREAS: The pancreas is not well visualized, largely obscured by overlying\nbowel gas. The main pancreatic duct is dilated, measuring up to 8 mm. The\nknown pancreatic head mass is not well seen due to overlying bowel gas.\n\nSPLEEN: Normal echogenicity, measuring 12.9 cm.\n\nKIDNEYS: The kidneys were not well seen due to overlying bowel gas.\n\nRETROPERITONEUM: The visualized portions of aorta and IVC are within normal\nlimits.\n\n\nIMPRESSION:\n\n\n1. Limited exam for evaluation of hepatic lesion and pancreatic head mass due\nto overlying bowel gas after hepaticojejunostomy. However, no definite\nhepatic metastatic disease.\n2. Persistent dilation of main pancreatic duct with abrupt occlusion in the\nhead.\n3. Moderate right pleural effusion.\n4. Borderline splenomegaly.\n', '16013806-RR-59', 59, 'grey scale and color doppler ultrasound images of the abdomen were\nobtained.'], ['EXAMINATION: Chest radio\n\nINDICATION: ___ year old man with pancreatic cancer and pleural effusion now\nwith dyspnea // eval for progression of pleural effusion\n\nTECHNIQUE: Chest PA and lateral\n\nCOMPARISON: Chest radiograph from ___.\nCT chest from ___\n\nFINDINGS: \n\nAgain seen are several rounded opacities seen projecting over the bilateral\nlung fields, compatible with known pulmonary nodules. There is again\nelevation of the right hemidiaphragm with mild interval increase in the size\nof the right pleural effusion, now appearing moderate in size. A small left\npleural effusion is unchanged. There is no pneumothorax. The\ncardiomediastinal silhouette is mildly obscured due to adjacent opacities, but\nlikely unchanged.\n\nIMPRESSION: \n\n1. Mild interval increase in the size of the now moderate right pleural\neffusion with stable appearance of a small left pleural effusion.\n2. Again seen are several rounded opacities projecting over the bilateral\nlung fields, compatible with known pulmonary nodules, better seen on the CT\nchest exam from ___.\n', '16013806-RR-60', 60, 'chest pa and lateral'], ["EXAMINATION: RENAL U.S.\n\nINDICATION: ___ year old man with metastatic pancreatic cancer and renal\nfailure, worsening // please evaluate for obstruction/hydronephrosis, if you\ncan also comment on whether bladder distended that would be useful to eval for\npost-obstr process also thank you!Pt is a prisoner and can't leave the floor\nplease come to floor sorry thanks\n\nTECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were\nobtained.\n\nCOMPARISON: ___\n\nFINDINGS: \n\nThe right kidney measures 10.9 cm. The left kidney measures 12.6 cm. There is\nno hydronephrosis, stones, or masses bilaterally. There is normal\ncorticomedullary differentiation bilaterally. There is no evidence of\nhydronephrosis or stones. Bladder wall appears thickened, but the bladder is\npoorly distended.\n\nIMPRESSION: \n\nNo evidence of hydronephrosis. Thickened bladder wall may be secondary to\nunderdistention of the bladder.\n", '16013806-RR-61', 61, 'grey scale and color doppler ultrasound images of the kidneys were\nobtained.'], ['EXAMINATION: CT chest without contrast\n\nINDICATION: ___ year old man with pancreatic cancer // please do on ___.\nplease establish baseline for staging as initiating chemotherapy. noncontrast\nchest CT\n\nTECHNIQUE: Contiguous axial images were obtained through the chest without\nintravenous contrast. Coronal and sagittal reformats were obtained.\n\nCOMPARISON: CT chest with contrast from ___\n\nFINDINGS: \n\nHEART AND VASCULATURE: The thoracic aorta is normal in caliber. Mild\natherosclerotic calcifications are seen in the aortic arch. The heart and\ngreat vessels are within normal limits based on an unenhanced scan. \nAtherosclerotic calcifications are again seen in the coronary arteries. A\nright Port-A-Cath tip is seen at the cavoatrial junction. There is a small\npericardial effusion, likely physiologic.\n\nAXILLA, HILA, AND MEDIASTINUM: No axillary or mediastinal lymphadenopathy is\npresent. A new soft tissue lesion is seen along the subcutaneous tissues of\nthe right chest, measuring approximately 1.6 x 2.4 cm, which may represent a\nsite of prior port insertion vs new metastatic nodule (series 3: Image 14). \nThere is diffuse anasarca throughout the visualized thorax. In addition to\nthe diffuse anasarca, there is increased soft tissue thickening and\ninflammatory changes in the right chest wall, which is new since the prior\nstudy. No mediastinal mass or hematoma.\n\nPLEURAL SPACES: There is a new moderate, dependent, nonhemorrhagic, layering\nright pleural effusion. There is associated near complete volume loss of the\nright lower lobe.\n\n\nLUNGS/AIRWAYS: Of note, the study is slightly limited due to motion,\nparticularly in the lung bases. Again seen are innumerable pleural and\nparenchymal soft tissue nodules, many of which appear enlarged compared to the\nprior study in ___ under concerning for worsening metastatic\ndisease. There is increased interseptal thickening in combination with\nincreased nodularity in the left lower lobe, which may represent lymphangitic\nspread. The airways are patent to the level of the segmental bronchi\nbilaterally.\n\nBASE OF NECK: Visualized portions of the base of the neck show no abnormality.\n\nABDOMEN: Included portion of the unenhanced upper abdomen demonstrates\nperihepatic ascites. There is mild central pneumobilia, compatible with\nbiliary stenting. Fiducials are noted at the uncinate process. There is\nagain pancreatic ductal dilatation, measuring up to 9 mm.\n\nBONES: No suspicious osseous abnormality is seen.? There is no acute fracture.\n\n\nIMPRESSION: \n\n1. Enlargement of multiple pleural based and parenchymal soft tissue lesions\nin the thorax with interseptal thickening in the left lower lobe, concerning\nfor worsening metastatic disease with lymphangitic spread.\n2. A new 2.4 cm soft tissue lesion seen along the subcutaneous tissues of the\nright chest may represent a site of prior port insertion vs new metastatic\nlesion.\n3. Increased diffuse anasarca with inflammatory changes seen in the right\nchest wall.\n4. New moderate, nonhemorrhagic, layering right pleural effusion.\n5. Interval increase in perihepatic ascites compared to the prior study in\n___.\n6. Mild central pneumobilia and pancreatic ductal dilatation appear stable.\n\nRECOMMENDATION(S): Recommend correlation with clinical exam and history for\nthe 2.4 cm soft tissue lesion seen along the right chest wall.\n', '16013806-RR-62', 62, 'contiguous axial images were obtained through the chest without\nintravenous contrast. coronal and sagittal reformats were obtained.'], ['EXAMINATION: CHEST (PORTABLE AP)\n\nINDICATION: ___ year old man with right pleural effusion // s/p thoracentesis\ns/p thoracentesis\n\nIMPRESSION: \n\nIn comparison with study of ___, there has been a thoracentesis\nperformed on the right with removal of some pleural fluid. No evidence of\npost procedure pneumothorax.\nLittle change in the diffuse bilateral pulmonary opacifications.\n', '16013806-RR-63', 63, ''], ['EXAMINATION: UNILAT UP EXT VEINS US\n\nINDICATION: ___ year old man with pancreatic cancer and left upper extremity\nedema.// Please evaluate for left upper extremity DVT.\n\nTECHNIQUE: Grey scale and Doppler evaluation was performed on the left upper\nextremity veins.\n\nCOMPARISON: None.\n\nFINDINGS: \n\nThere is normal flow with respiratory variation in the left subclavian vein.\nThe left internal jugular and axillary veins are patent, show normal color\nflow and compressibility. The left brachial, basilic, and cephalic veins are\npatent, compressible and show normal color flow and augmentation. There is\nsubcutaneous edema in the Left upper extremity.\n\nIMPRESSION: \n\nNo evidence of deep vein thrombosis in the left upper extremity.\n', '16013806-RR-64', 64, 'grey scale and doppler evaluation was performed on the left upper\nextremity veins.'], ['EXAMINATION: CT Abdomen and Pelvis without contrast\n\nINDICATION: ___ year old man with metastatic pancreatic cancer with resolved\nrespiratory distress complicated by acute on chronic kidney with persistent\nculture negative as well as nausea/vomiting.// Please evaluate for colitis,\netiology of diarrhea and nausea. OK for PO contrast. No IV contrast.\n\nTECHNIQUE: THIS EXAMINATION WAS PERFORMED WITHOUT INTRAVENOUS CONTRAST oral\ncontrast was administered.\nCoronal and sagittal reformations were performed and reviewed on PACS.\n\nDOSE: Acquisition sequence:\n 1) Spiral Acquisition 9.1 s, 58.9 cm; CTDIvol = 25.6 mGy (Body) DLP =\n1,493.6 mGy-cm.\n Total DLP (Body) = 1,494 mGy-cm.\n\nCOMPARISON: CT Chest without contrast from ___.\n\nFINDINGS: \n\nLOWER CHEST:\nThere is a moderate nonhemorrhagic, dependent, layering right pleural\neffusion. A small left pleural effusion is also noted. There is associated\ndependent atelectasis. Multiple metastatic nodules are again seen in the lung\nbases, which appear enlarged compared to the prior study in ___ but\nsimilar to the prior CT Chest exam in ___, compatible with worsening\nmetastatic disease. There is associated volume loss of the right lower lobe. \nSuperimposed pneumonia would be difficult to exclude in the right lower lobe\nin the appropriate clinical setting. Atherosclerotic calcifications are noted\nin the coronary arteries.\n\nABDOMEN:\n\nHEPATOBILIARY:\nThe liver demonstrates homogeneous attenuation throughout. Intrahepatic\nbiliary air is unchanged compared to the prior study, and is expected in the\npost-sphincterotomy setting. There is no evidence of focal lesions within the\nlimitations of an unenhanced scan. The gallbladder is surgically absent. \nThere is mild perihepatic ascites which is new since the prior study in\n___ and is seen tracking along the right paracolic gutters and into\nthe pelvis.\n\nPANCREAS:\nThe known pancreatic mass is not well seen on this noncontrast exam. There is\nredemonstration pancreatic ductal dilatation, measuring 7-8 mm, which is\nsimilar to the prior study in ___. A fiducial is noted at the\npancreatic head. There is no peripancreatic stranding.\n\nSPLEEN: The spleen shows normal size and attenuation throughout.\n\nADRENALS: The right and left adrenal glands are normal in size and shape.\n\nURINARY: The kidneys are of normal and symmetric size there is no evidence of\nfocal renal lesions within the limitations of a non-contrast enhanced exam. \nThere is no nephrolithiasis or hydronephrosis. There is no perinephric fluid\ncollection.\n\nGASTROINTESTINAL: The stomach is distended with food products and contrast. \nSmall bowel loops demonstrate normal caliber, wall thickness, and enhancement\nthroughout. The colon and rectum are within normal limits. There is no\ndefinite bowel wall thickening to suggest colitis. The appendix is not\nvisualized.\n\nPELVIS: The urinary bladder and distal ureters are unremarkable. A small\namount of simple appearing free fluid is noted in the deep pelvis.\n\nREPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.\n\nLYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There\nis no pelvic or inguinal lymphadenopathy.\n\nVASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic\ndisease is noted.\n\nBONES: There is no evidence of worrisome osseous lesions or acute fracture.\n\nSOFT TISSUES: There is diffuse anasarca, unchanged.\n\nIMPRESSION:\n\n\n1. Multiple metastatic pulmonary nodules are seen the lung bases, which appear\nenlarged compared to the prior study in ___ but similar to ___, compatible with worsening metastatic disease.\n2. The known pancreatic mass is not well seen on this noncontrast exam,\nhowever, pancreatic ductal dilatation appears similar to the prior study in\n___.\n3. there is new mild perihepatic ascites which was not seen in ___\nand extends along the right paracolic gutters and into the deep pelvis.\n4. Bilateral pleural effusions are new since ___, moderate on the\nright and small on the left, with associated right lower lobe volume loss. \nSuperimposed pneumonia is difficult to exclude in the appropriate clinical\nsetting.\n', '16013806-RR-65', 65, 'this examination was performed without intravenous contrast oral\ncontrast was administered.\ncoronal and sagittal reformations were performed and reviewed on pacs.'], ['EXAMINATION: CHEST (PORTABLE AP)\n\nINDICATION: ___ year old man with pancreatic cancer and pleural effusion.//\nPlease evaluate for effusion. Please evaluate for effusion.\n\nIMPRESSION: \n\nIn Comparison with study of ___, there has been a substantial increase\nin the right pleural effusion. The degree of pleural effusion is similar to\nthe pre thoracentesis study of ___.\nOtherwise, little change.\n', '16013806-RR-66', 66, ''], ['EXAMINATION: CHEST (PORTABLE AP)\n\nINDICATION: ___ year old man with pleural effusion// s/p thoracentesis \ns/p thoracentesis\n\nIMPRESSION: \n\nIn comparison with the earlier study of this date, there has been a right\nthoracentesis with removal of a substantial amount of pleural fluid. No\nevidence of pneumothorax. Little overall change in the appearance of the\nheart and lungs.\n', '16013806-RR-67', 67, ''], ['EXAMINATION: MR HEAD W/O CONTRAST T9113 MR HEAD\n\nINDICATION: ___ year old man with pancreatic ca now w/ altered mental status,\nh/o seizures// eval for acute cva\n\nTECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was\nperformed with gradient echo, FLAIR, diffusion, and T2 technique were then\nobtained.\n\nCOMPARISON Head CT ___.\n\nFINDINGS: \n\nThe study is severely limited by motion artifact. Although a variety of fast\nimaging methods were attempted, the image quality is for the most part\nnondiagnostic. T2 weighted images demonstrate partial opacification of the\nmastoid air cells bilaterally. No masses are identified. Limited diffusion\nimaging reveals no definite abnormalities. There is no evidence of mass\neffect.\n\nIMPRESSION:\n\n\n1. Severely limited study due to motion artifact. No abnormalities detected..\n', '16013806-RR-68', 68, 'sagittal t1 weighted imaging was performed. axial imaging was\nperformed with gradient echo, flair, diffusion, and t2 technique were then\nobtained.'], ['EXAMINATION: CHEST (PORTABLE AP)\n\nINDICATION: ___ year old man with inc hypoxia// eval for aspiration or\nworsening pleural effusions eval for aspiration or worsening pleural\neffusions\n\nIMPRESSION: \n\nIn comparison with the study of ___, there again are low lung volumes\nthat accentuate the enlargement of the cardiac silhouette. Diffuse areas of\npulmonary opacification are less prominent, consistent with decreasing\nvascular congestion, resolving aspiration, or both.\nNo evidence of increase in the right pleural effusion. The Port-A-Cath tip is\nalso unchanged.\n', '16013806-RR-69', 69, ''], ['EXAMINATION: RENAL U.S.\n\nINDICATION: ___ year old man with metastatic pancreatic ca w/ worsening renal\nfunction//- eval for hydronephrosis- eval renal veins for thrombosis\n\nTECHNIQUE: Grey scale, color and spectral Doppler ultrasound images of the\nkidneys were obtained.\n\nCOMPARISON: CT abdomen and pelvis without contrast dated ___.\n\nFINDINGS: \n\nThe right kidney measures 11.8 cm. The left kidney measures 10.7 cm. There is\nno hydronephrosis, stones, or masses bilaterally. Normal cortical\nechogenicity and corticomedullary differentiation are seen bilaterally.\n\nLimited renal Doppler examination, due to lack of patient compliance. Given\nthis limitation:\n\nRenal Doppler: Intrarenal arteries show normal waveforms with sharp systolic\npeaks and continuous antegrade diastolic flow. The resistive indices of the\nright main renal artery is 0.86. The resistive index on the left is 0.8. \nBilaterally, the main renal arteries are patent with normal waveforms. The\npeak systolic velocity on the right is 65.8 centimeters/second. The peak\nsystolic velocity on the left is 67.5 centimeters/second. Main renal veins are\npatent bilaterally with normal waveforms.\n\nA Foley catheter is present within a decompressed urinary bladder.\n\nThere is a moderate amount of ascites.\n\nIMPRESSION: \n\n1. Limited renal Doppler evaluation, secondary to suboptimal patient\ncomplaints during exam. Within this limitation, no evidence of main renal\nartery stenosis or renal vein thrombosis.\n2. Moderate ascites.\n', '16013806-RR-70', 70, 'grey scale, color and spectral doppler ultrasound images of the\nkidneys were obtained.'], ['INDICATION: ___ year old man with pancreatic cancer and history of right\npleural effusion with worsening hypoxia.// Evaluate for recurrent pleural\neffusion.\n\nTECHNIQUE: AP portable chest radiograph\n\nCOMPARISON: ___\n\nFINDINGS: \n\nA right chest wall Port-A-Cath is present the tip, projecting over the right\natrium.\n\nSuboptimal evaluation secondary to patient positioning. A large right\nlayering pleural effusion is present. Superimposed pulmonary edema is also\nnoted. No pneumothorax. Evaluation of the cardiac silhouette is limited.\n\nIMPRESSION: \n\nLarge layering right pleural effusion and suspected pulmonary edema.\n', '16013806-RR-71', 71, 'ap portable chest radiograph']]

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['medicine']

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20:14:00'), Timestamp('2162-06-22 21:13:00'), 'Estimated GFR (MDRD equation)'], [50931, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:13:00'), 'Glucose'], [50934, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:13:00'), 'H'], [50947, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:13:00'), 'I'], [50960, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:13:00'), 'Magnesium'], [50970, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:13:00'), 'Phosphate'], [50971, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:13:00'), 'Potassium'], [50983, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:13:00'), 'Sodium'], [51006, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:13:00'), 'Urea Nitrogen'], [51678, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:13:00'), 'L'], [51237, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 20:48:00'), 'INR(PT)'], [51274, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 20:48:00'), 'PT'], [51275, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 20:48:00'), 'PTT'], [51133, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:23:00'), 'Absolute Lymphocyte Count'], [51137, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:23:00'), 'Anisocytosis'], [51143, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:23:00'), 'Atypical Lymphocytes'], [51144, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:23:00'), 'Bands'], [51146, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:23:00'), 'Basophils'], [51200, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:23:00'), 'Eosinophils'], [51221, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 20:37:00'), 'Hematocrit'], [51222, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 20:37:00'), 'Hemoglobin'], [51233, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:23:00'), 'Hypochromia'], [51244, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:23:00'), 'Lymphocytes'], [51246, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:23:00'), 'Macrocytes'], [51248, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 20:37:00'), 'MCH'], [51249, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 20:37:00'), 'MCHC'], [51250, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 20:37:00'), 'MCV'], [51251, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:23:00'), 'Metamyelocytes'], [51252, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:23:00'), 'Microcytes'], [51254, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:23:00'), 'Monocytes'], [51255, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:23:00'), 'Myelocytes'], [51256, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:23:00'), 'Neutrophils'], [51265, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 20:37:00'), 'Platelet Count'], [51266, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:23:00'), 'Platelet Smear'], [51267, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:23:00'), 'Poikilocytosis'], [51268, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:23:00'), 'Polychromasia'], [51277, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 20:37:00'), 'RDW'], [51279, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 20:37:00'), 'Red Blood Cells'], [51301, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 20:37:00'), 'White Blood Cells'], [52069, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:23:00'), 'Absolute Basophil Count'], [52073, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:23:00'), 'Absolute Eosinophil Count'], [52074, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:23:00'), 'Absolute Monocyte Count'], [52075, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 21:23:00'), 'Absolute Neutrophil Count'], [52172, Timestamp('2162-06-22 20:14:00'), Timestamp('2162-06-22 20:37:00'), 'RDW-SD'], [50861, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:41:00'), 'Alanine Aminotransferase (ALT)'], [50863, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:41:00'), 'Alkaline Phosphatase'], [50868, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:41:00'), 'Anion Gap'], [50878, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:41:00'), 'Asparate Aminotransferase (AST)'], [50882, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:41:00'), 'Bicarbonate'], [50885, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:41:00'), 'Bilirubin, Total'], [50893, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:41:00'), 'Calcium, Total'], [50902, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:41:00'), 'Chloride'], [50912, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:41:00'), 'Creatinine'], [50931, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:41:00'), 'Glucose'], [50934, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:41:00'), 'H'], [50947, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:41:00'), 'I'], [50954, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:41:00'), 'Lactate Dehydrogenase (LD)'], [50960, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:41:00'), 'Magnesium'], [50970, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:41:00'), 'Phosphate'], [50971, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:41:00'), 'Potassium'], [50983, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:41:00'), 'Sodium'], [51006, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:41:00'), 'Urea Nitrogen'], [51009, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 07:02:00'), 'Vancomycin'], [51678, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:41:00'), 'L'], [51221, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:17:00'), 'Hematocrit'], [51222, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:17:00'), 'Hemoglobin'], [51248, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:17:00'), 'MCH'], [51249, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:17:00'), 'MCHC'], [51250, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:17:00'), 'MCV'], [51265, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:17:00'), 'Platelet Count'], [51277, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:17:00'), 'RDW'], [51279, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:17:00'), 'Red Blood Cells'], [51301, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:17:00'), 'White Blood Cells'], [52172, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:17:00'), 'RDW-SD'], [51237, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:30:00'), 'INR(PT)'], [51274, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:30:00'), 'PT'], [51275, Timestamp('2162-06-23 05:43:00'), Timestamp('2162-06-23 06:30:00'), 'PTT'], [50802, Timestamp('2162-06-23 06:07:00'), Timestamp('2162-06-23 06:10:00'), 'Base Excess'], [50804, Timestamp('2162-06-23 06:07:00'), Timestamp('2162-06-23 06:10:00'), 'Calculated Total CO2'], [50818, Timestamp('2162-06-23 06:07:00'), Timestamp('2162-06-23 06:10:00'), 'pCO2'], [50820, Timestamp('2162-06-23 06:07:00'), Timestamp('2162-06-23 06:10:00'), 'pH'], [50821, Timestamp('2162-06-23 06:07:00'), Timestamp('2162-06-23 06:10:00'), 'pO2'], [52033, Timestamp('2162-06-23 06:07:00'), Timestamp('2162-06-23 06:08:00'), 'Specimen Type'], [51463, Timestamp('2162-06-23 10:17:00'), Timestamp('2162-06-23 11:12:00'), 'Bacteria'], [51464, Timestamp('2162-06-23 10:17:00'), Timestamp('2162-06-23 11:12:00'), 'Bilirubin'], [51466, Timestamp('2162-06-23 10:17:00'), Timestamp('2162-06-23 11:12:00'), 'Blood'], [51476, Timestamp('2162-06-23 10:17:00'), Timestamp('2162-06-23 11:12:00'), 'Epithelial Cells'], [51478, Timestamp('2162-06-23 10:17:00'), Timestamp('2162-06-23 11:12:00'), 'Glucose'], [51482, Timestamp('2162-06-23 10:17:00'), Timestamp('2162-06-23 11:12:00'), 'Hyaline Casts'], [51484, Timestamp('2162-06-23 10:17:00'), Timestamp('2162-06-23 11:12:00'), 'Ketone'], [51486, Timestamp('2162-06-23 10:17:00'), Timestamp('2162-06-23 11:12:00'), 'Leukocytes'], [51487, Timestamp('2162-06-23 10:17:00'), Timestamp('2162-06-23 11:12:00'), 'Nitrite'], [51491, Timestamp('2162-06-23 10:17:00'), Timestamp('2162-06-23 11:12:00'), 'pH'], [51492, Timestamp('2162-06-23 10:17:00'), Timestamp('2162-06-23 11:12:00'), 'Protein'], [51493, Timestamp('2162-06-23 10:17:00'), Timestamp('2162-06-23 11:12:00'), 'RBC'], [51498, Timestamp('2162-06-23 10:17:00'), Timestamp('2162-06-23 11:12:00'), 'Specific Gravity'], [51506, Timestamp('2162-06-23 10:17:00'), Timestamp('2162-06-23 11:12:00'), 'Urine Appearance'], [51508, Timestamp('2162-06-23 10:17:00'), Timestamp('2162-06-23 11:12:00'), 'Urine Color'], [51512, Timestamp('2162-06-23 10:17:00'), Timestamp('2162-06-23 11:12:00'), 'Urine Mucous'], [51514, Timestamp('2162-06-23 10:17:00'), Timestamp('2162-06-23 11:12:00'), 'Urobilinogen'], [51516, Timestamp('2162-06-23 10:17:00'), Timestamp('2162-06-23 11:12:00'), 'WBC'], [51519, Timestamp('2162-06-23 10:17:00'), Timestamp('2162-06-23 11:12:00'), 'Yeast'], [51082, Timestamp('2162-06-23 10:17:00'), Timestamp('2162-06-23 11:17:00'), 'Creatinine, Urine'], [51087, Timestamp('2162-06-23 10:17:00'), NaT, 'Length of Urine Collection'], [51099, Timestamp('2162-06-23 10:17:00'), Timestamp('2162-06-23 11:27:00'), 'Protein/Creatinine Ratio'], [51102, Timestamp('2162-06-23 10:17:00'), Timestamp('2162-06-23 11:27:00'), 'Total Protein, Urine'], [50868, Timestamp('2162-06-23 14:31:00'), Timestamp('2162-06-23 15:12:00'), 'Anion Gap'], [50882, Timestamp('2162-06-23 14:31:00'), Timestamp('2162-06-23 15:12:00'), 'Bicarbonate'], [50893, Timestamp('2162-06-23 14:31:00'), Timestamp('2162-06-23 15:12:00'), 'Calcium, Total'], [50902, Timestamp('2162-06-23 14:31:00'), Timestamp('2162-06-23 15:12:00'), 'Chloride'], [50912, Timestamp('2162-06-23 14:31:00'), Timestamp('2162-06-23 15:12:00'), 'Creatinine'], [50931, Timestamp('2162-06-23 14:31:00'), Timestamp('2162-06-23 15:12:00'), 'Glucose'], [50934, Timestamp('2162-06-23 14:31:00'), Timestamp('2162-06-23 15:12:00'), 'H'], [50947, Timestamp('2162-06-23 14:31:00'), Timestamp('2162-06-23 15:12:00'), 'I'], [50960, Timestamp('2162-06-23 14:31:00'), Timestamp('2162-06-23 15:12:00'), 'Magnesium'], [50970, Timestamp('2162-06-23 14:31:00'), Timestamp('2162-06-23 15:12:00'), 'Phosphate'], [50971, Timestamp('2162-06-23 14:31:00'), Timestamp('2162-06-23 15:12:00'), 'Potassium'], [50983, Timestamp('2162-06-23 14:31:00'), Timestamp('2162-06-23 15:12:00'), 'Sodium'], [51006, Timestamp('2162-06-23 14:31:00'), Timestamp('2162-06-23 15:12:00'), 'Urea Nitrogen'], [51678, Timestamp('2162-06-23 14:31:00'), Timestamp('2162-06-23 15:12:00'), 'L']]

Question: A 50 M is admitted. He/she says he/she has Shortness of breath . History of illness: Mr. ___ is a ___ yo man with a presumed diagnosis metastatic pancreatic cancer, likely metastatic who is being transferred from ___ out of concern for tamponande and need for cardiac window ___ setting of new hypoxemia. ___ course: Mr. ___ presented to ___ on ___ from correction facility with SOB and productive cough and low grade temperature. CXR ___ the ED was concerning for an infiltrate vs. atelectasis vs. edema. He was initiated on levofloxacin and then transitioned to azithromycin and ceftriaxone. Troponin was 0.07 and BNP 499. Due to troponin bump and history of cancer decision was made to treat empirically with treatment dose of enoxaparin. He was also given "low dose" Lasix. D-dimer was sent and positive. V/Q scan was performed and indeterminate. On evening of ___ he was noted to have increased oxygen requirement and started on ___ mask with 100% oxygen saturation. Later ___ the evening, however, he was noted to be "unresponsive and hypoxemic with oxygen mask off." ABG at that time was blood gas showed pH 7.29. PCO2 52 and PO2 ___ the 64 26 on 100% nonrebreather." He was then transferred to the MICU where antibiotics were broadened to meropenem and vancomycin. He was reportedly very hypertensive at time of transfer (no vitals noted) and given 5 mg IV metoprolol. An echo was performed that showed, "Cardiologist reports small but pre-tamponade physiology seen on TTE." He was transferred to ___ out of concern for need for cardiac window. At time of transfer he was on high flow 60% satting 92-95%. ___ addition to hypoxemia and cough, he is having diarrhea requiring rectal tube. Pancreatic cancer course (per OMR and oncology notes): ___ ___ he developed new onset abdominal pain and was noted to have a pancreatic mass. Biopsies were performed and indeterminate. ___ ___ he was admitted to ___ with perforated cholecystitis s/p percutaneous cholecystostomy tube. MRCP at that time raised suspicion for head of pancreas mass. Later that month she ERCP with Spyglass done showed a malignant-appearing stricture and EUS showing an ill-defined mass ___ the pancreatic neck with an abrupt transition ___ caliber of the PD, brushings and biopsies again atypical. Repeat ERCP for rising LFTs was performed. A fully covered metal stent placed (prior stent dislodged). Abscess cavity had collapsed and drain removed. Given all this, had large-volume weight loss with inability to maintain feeds with subsequent malnutrition and hypoalbuminemia requiring NJT feeds. ___ ___ he was planned for Whipple procedure for definitive diagnosis of pancreatic mass. However, intra-operatively he became hypotensive and hypoglycemic. Surgery was converted to CCY and double bypass was performed with fiducial placement. Biopsies of the pancreatic head returned positive for ductaladenocarcinoma with invasion of peripancreatic adipose tissue. There was a delay ___ follow-up between ___ and ___ when he followed up with Dr. ___ ___ oncology. At that visit he was scheduled for biopsy of known lung nodules to make formal diagnosis of metastatic lung cancer. At this time plan is to initiate palliative systemic therapy for his pancreatic cancer (once biopsy is done). At that visit it was also noted that he was grossly anasarcic and hypertensive. On arrival to the MICU, he states that he is feeling very short of breath and weak. He also endorses some diarrhea. Past Medical History: - Metastatic pancreatic cancer, presumed - HTN - Grand mal seizures - Depression - HLD - DM, insulin dependent - History of Biliary obstruction/stricture Social History: ___ Family History: Denies family history of colon, pancreas, liver, breast or other malignancies. Denies history of other family gastrointestinal disease or pancreatitis. Allergies: No Known Allergies / Adverse Drug Reactions What is the best procedure plan for this patient?

TARGETS Target Prescriptions: 0.9% Sodium Chloride Calcium Gluconate Iso-Osmotic Dextrose Vancomycin Insulin Furosemide Ipratropium Bromide MDI Syringe (0.9% Sodium Chloride) Alteplase (Catheter Clearance) 0.9% Sodium Chloride (Mini Bag Plus) CefePIME PARoxetine Fludrocortisone Acetate Insulin Lidocaine 1% (For PICC/Midline Insertions) Glucose Gel Furosemide Albuterol Inhaler Azithromycin Iso-Osmotic Dextrose Vancomycin Omeprazole Glucagon Bisacodyl Dextrose 5% Levofloxacin 0.9% Sodium Chloride (Mini Bag Plus) CefePIME LevETIRAcetam HydrALAZINE Heparin Flush (10 units/ml) Insulin Fludrocortisone Acetate Bisacodyl Albumin 25% 0.9% Sodium Chloride Calcium Gluconate Dextrose 50% 0.9% Sodium Chloride Calcium Gluconate HydrALAZINE Albuterol 0.083% Neb Soln 0.9% Sodium Chloride Calcium Gluconate 5% Dextrose Ciprofloxacin IV 0.9% Sodium Chloride (Mini Bag Plus) CefePIME Sodium Chloride 0.9% Flush Ipratropium-Albuterol Neb Senna Heparin Labetalol Target Lab Orders: Alanine Aminotransferase (ALT) Albumin Alkaline Phosphatase Anion Gap Asparate Aminotransferase (AST) Bicarbonate Bilirubin, Total Calcium, Total Chloride Creatinine Estimated GFR (MDRD equation) Glucose H I Magnesium Phosphate Potassium Sodium Urea Nitrogen L INR(PT) PT PTT Absolute Lymphocyte Count Anisocytosis Atypical Lymphocytes Bands Basophils Eosinophils Hematocrit Hemoglobin Hypochromia Lymphocytes Macrocytes MCH MCHC MCV Metamyelocytes Microcytes Monocytes Myelocytes Neutrophils Platelet Count Platelet Smear Poikilocytosis Polychromasia RDW Red Blood Cells White Blood Cells Absolute Basophil Count Absolute Eosinophil Count Absolute Monocyte Count Absolute Neutrophil Count RDW-SD Alanine Aminotransferase (ALT) Alkaline Phosphatase Anion Gap Asparate Aminotransferase (AST) Bicarbonate Bilirubin, Total Calcium, Total Chloride Creatinine Glucose H I Lactate Dehydrogenase (LD) Magnesium Phosphate Potassium Sodium Urea Nitrogen Vancomycin L Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells RDW-SD INR(PT) PT PTT Base Excess Calculated Total CO2 pCO2 pH pO2 Specimen Type Bacteria Bilirubin Blood Epithelial Cells Glucose Hyaline Casts Ketone Leukocytes Nitrite pH Protein RBC Specific Gravity Urine Appearance Urine Color Urine Mucous Urobilinogen WBC Yeast Creatinine, Urine Length of Urine Collection Protein/Creatinine Ratio Total Protein, Urine Anion Gap Bicarbonate Calcium, Total Chloride Creatinine Glucose H I Magnesium Phosphate Potassium Sodium Urea Nitrogen L Target Procedures: Respiratory Ventilation, 24-96 Consecutive Hours Insertion of Endotracheal Airway into Trachea, Via Natural or Artificial Opening Insertion of Infusion Device into Superior Vena Cava, Percutaneous Approach DOCTOR'S NOTE Hospital Notes: : PRINICPLE REASON FOR ADMISSION: =============================== Mr. ___ is a ___ male with history of metastatic pancreatic cancer (s/p = hepaticojejunostomy, gastrojejunostomy, CCY) who was initially transferred from ___ due to concern for pericardial tamponade (only small effusion seen on most recent echo), and found to be ___ hypoxemic respiratory failure requiring intubation ___ secondary to pneumonia and volume overload. Early hospital course complicated by renal failure and ATN. Subsequently received C1D1 FOLFOX ___ house on ___ with further renal failure and hyperkalemia. Course otherwise notable for persistent diarrhea, recurrent right pleural effusion, and hypertension. ACTIVE ISSUES: ============== # Hypoxic Respiratory Failure: # Malignant Pleural Effusions: Initially with hypoxic respiratory failure requiring intubation ___ due to PNA and anasarca. He is s/p cefepime ___ for pneumonia). Brief hypoxia to 90% on ___ required IV lasix. No CMV on BAL. CXR ___ with some right pleural effusion increase, IP drained 1L on ___, but did not place pleurex as CT chest suggested persistent pulmonary parenchymal issues as large contributor. On ___ patient reported worsening SOB and hypoxic to 88% with minimal exertion. Repeat CXR showed reaccumulation of right pleural effusion. Thoracentesis by IP with drainage of 1L. Patient has refused Pleurex catheter at that time. Again, developed O2 requirement on ___ with recurrent pleural effusion. Restarted IV Lasix 120mg bid and will need repeat thoracentesis vs. pleurX. # Acute on chronic renal failure # ATN: Initial etiology ATN thougth from from overdiuresis ___ setting of respiratory failure, and improved prior to initiation of chemotherapy. More recently, oxaliplatin likely caused significant kidney damage. Cr has now stabilized around 3.8. Nephrology has been following, and he has not yet needed dialysis. However, K has risen again starting ___, neprhology aware and Lasix 120mg IV bid, chorthalidone, and po bicarb was started. Patient refused foley for closer UOP monitoring, but is frequently incontinent of large volume urine. Will need very close monitoring of volume status and potassium. # Hyperkalemia: See above; was quite severe over a number of days early ___ hospitalization following initial renal insult. Improved markedly at that time after initiation of chlorthalidone. Chlorthalidone was then held given recurrent renal failure. However, now that Cr has stabilized a bit, feel OK to continue chlorthalidone and IV Lasix. He has been treated with IV Lasix 120mg bid, chlorthalidone 50mg daily, and sodium bicarbonate. Received IV insulin and dextrose on ___. Kayexelate not given due to severe diarrhea. Also maintained on low K diet. # Proteinuria: 24 hour urine w/ >3g protein. Per renal likely due to diabetic glomerulopathy as had proteinuria to similar degree at least for past 8 months(300 prot on dipstick ___. Unlikely membranous GN iso active malignancy. C4 wnl, C3 slightly low. Hep B/C negative. ___, ANCA negative. Cryo negative. Likely contributing to anasarca. # Metastatic Pancreatic Cancer: Biopsy confirmed metastatic pancreatic ca to the lungs. FOLFOX given ___ finished ___. Given worsening kidney disease and functional status C1D15 due ___ on hold, and there are no active plans to resume chemotherapy. Dr. ___ will continue to re-evaluate patient for possibility of resuming chemotherapy if renal function and function status improve. Please maintain contact with Dr. ___ at ___ and arrange follow up when appropriate. # N/V/Diarrhea: Patient with significant persistent diarrhea and incontinence during entire hospital stay. Initially with Flexiseal, removed ___. GI was consulted early ___ course, and etiology thought to be post-abx diarrhea vs. recent liquid diet vs. pancreatic enzyme deficiency vs. post FOLFOX. C. diff was neg x2, O&P and stool cultures were also negative. CT abdomen/pelvis w/ PO contrast did not show any cause for diarrhea. He has been managed with loperamide, Lomotil, opium tincture along with creon and psyllium wafers. ___ need to consider reconsulting GI, resending stool cultures, and imaging studies of diarrhea persists. # Anasarca # Bilateral Lower Extremity Edema # Upper Extremity Edema: Fluid status fluctuates, appears volume overloaded. Likely secondary to hypoalbuminemia ___ setting of possible nephrotic syndrome and poor nutrition with active malignancy. ___ ___ negative. LUE ultrasound negative for DVT. 120mg IV Lasix bid as above. # Transaminitis: Stable/resolving. RUQ US without hepatic mets. HBV/HCV serologies negative and HBV VL not detected. Likely from portal congestion from anasarca. # Guaiac-Positive Stools: # Anemia: Anemia is stable near baseline Hgb ___. Hemolysis labs were negative. Reported frank bloody BM overnight on ___ with previously guaiac positive stools. No prior colonoscopy on record. Colonoscopy was deferred. # HTN: Treated with labetolol 600mg tid and amlodipine. Chlorthalidone was held much of hospitalization but restarted on ___ ___ setting of hyperkalemia and stable kidney function. # Type II Diabetes: Continued Humalog ISS # Epilepsy: History of grand mal seizures. Continue keppra 500mg BID. Was thought to have partial seizure on complex partial seizure witnessed by RN on ___. However, EEG did not reveal any epileptiform activity x 48 hrs. MRI brain completed w/o contrast and w/ significant motion activity but did not reveal any obvious acute process. # Pericardial Effusion: Very small with no evidence of tamponade. Likely from severe hypoalbuminemia vs. physiologic as opposed to malignant ___ origin. # Psych: Continued paroxetine 40mg daily # FEN: replete electrolytes prn, renal diet # Prophylaxis: Subcutaneous heparin # Access: POC # Restraints: Shackles # Communication: HCP: ___ (sister) ___ # Full Code (confirmed by ICU Team) # DISPO: ___ TRANSITIONAL ISSUES: ==================== - Please monitor K upon arrival to unit and maintain cardiac monitoring - Please evaluate for thoracentesis vs tunneled pleural catheter - Consider GI consult for persistent diarrhea refractory to aggressive antidiarrheals - Please continue to re-evaluate fromo oncologic perspective for possibility of palliative chemotherapy BILLING: >30 min coordinating care or discharge DISPO: ___ Other Results: ADMISSION LABS: =============== ___ 08:14PM BLOOD WBC-9.3# RBC-3.06* Hgb-8.7* Hct-28.2* MCV-92 MCH-28.4 MCHC-30.9* RDW-12.2 RDWSD-41.0 Plt ___ ___ 08:14PM BLOOD Neuts-88* Bands-2 Lymphs-6* Monos-4* Eos-0 Baso-0 ___ Myelos-0 AbsNeut-8.37* AbsLymp-0.56* AbsMono-0.37 AbsEos-0.00* AbsBaso-0.00* ___ 08:14PM BLOOD ___ PTT-46.4* ___ ___ 08:14PM BLOOD Glucose-97 UreaN-29* Creat-1.9* Na-137 K-3.9 Cl-106 HCO3-21* AnGap-14 ___ 08:14PM BLOOD ALT-25 AST-43* AlkPhos-250* TotBili-<0.2 ___ 08:14PM BLOOD Albumin-1.1* Calcium-6.8* Phos-4.2 Mg-1.7 IMAGING: ======== ___ Imaging CHEST (PORTABLE AP) Large layering right pleural effusion and suspected pulmonary edema. ___ Imaging RENAL U.S 1. Limited renal Doppler evaluation, secondary to suboptimal patient complaints during exam. Within this limitation, no evidence of main renal artery stenosis or renal vein thrombosis. 2. Moderate ascites. ___ Imaging MR HEAD W/O CONTRAST 1. Severely limited study due to motion artifact. No abnormalities detected. ___ Imaging CHEST (PORTABLE AP) ___ comparison with the study of ___, there again are low lung volumes that accentuate the enlargement of the cardiac silhouette. Diffuse areas of pulmonary opacification are less prominent, consistent with decreasing vascular congestion, resolving aspiration, or both. No evidence of increase ___ the right pleural effusion. The Port-A-Cath tip is also unchanged. ___BD & PELVIS W/O CON 1. Multiple metastatic pulmonary nodules are seen the lung bases, which appear enlarged compared to the prior study ___ ___, concerning for worsening metastatic disease. 2. The known pancreatic mass is not well seen on this noncontrast exam, however, pancreatic ductal dilatation appears similar to the prior study ___ ___. 3. There is new mild perihepatic ascites which was not seen ___ ___ and extends along the right paracolic gutters and into the deep pelvis. 4. Bilateral pleural effusions are new since ___, moderate on the right and small on the left, with associated right lower lobe volume loss. ___ Imaging UNILAT UP EXT VEINS US No evidence of deep vein thrombosis ___ the left upper extremity. ___HEST W/O CONTRAST 1. Enlargement of multiple pleural based and parenchymal soft tissue lesions ___ the thorax with interseptal thickening ___ the left lower lobe, concerning for worsening metastatic disease with lymphangitic spread. 2. A new 2.4 cm soft tissue lesion seen along the subcutaneous tissues of the right chest may represent a site of prior port insertion vs new metastatic lesion. 3. Increased diffuse anasarca with inflammatory changes seen ___ the right chest wall. 4. New moderate, nonhemorrhagic, layering right pleural effusion. 5. Interval increase ___ perihepatic ascites compared to the prior study ___ ___. 6. Mild central pneumobilia and pancreatic ductal dilatation appear stable. ___ Imaging CHEST (PORTABLE AP) ___ comparison with study of ___, there has been a thoracentesis performed on the right with removal of some pleural fluid. No evidence of post procedure pneumothorax. Little change ___ the diffuse bilateral pulmonary opacifications. ___ Imaging RENAL U.S. No evidence of hydronephrosis. Thickened bladder wall may be secondary to underdistention of the bladder. ___ Imaging CHEST (PORTABLE AP) No evidence of hydronephrosis. Thickened bladder wall may be secondary to underdistention of the bladder. ___ Imaging RENAL U.S. No evidence of hydronephrosis. Thickened bladder wall may be secondary to underdistention of the bladder. ___ Imaging LIVER OR GALLBLADDER US 1. Limited exam for evaluation of hepatic lesion and pancreatic head mass due to overlying bowel gas after hepaticojejunostomy. However, no definite hepatic metastatic disease. 2. Persistent dilation of main pancreatic duct with abrupt occlusion ___ the head. 3. Moderate right pleural effusion. 4. Borderline splenomegaly. ___ Imaging BILAT LOWER EXT VEINS No evidence of deep venous thrombosis ___ the right or left lower extremity veins. Right calf vessels were not definitely visualized. ___ THORACENTESIS NEEDLE IMPRESSION: Successful ultrasound-guided right thoracentesis with removal of 0.8 L of clear, straw-colored fluid, which was sent for cytology. ___ REPLACEMENT IMPRESSION: Successful placement of a single lumen chest power Port-a-cath via the right internal jugular venous approach. The tip of the catheter terminates ___ the right atrium. The catheter is ready for use. Successful removal of the malpositioned right Port-A-cath. ___ U.S. IMPRESSION: 1. No hydronephrosis. 2. Echogenic kidneys may reflect medical renal disease. 3. Trace ascites. ___ ABDOMEN IMPRESSION: No of evidence of bowel obstruction or pneumoperitoneum. ___ LAVAGE NEGATIVE FOR MALIGNANT CELLS. ___ TTE The left atrium is normal ___ size. The estimated right atrial pressure is ___ mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. There is abnormal septal motion/position. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is a very small to small pericardial effusion measuring up to 0.8 centimeters ___ greatest dimension, but generally 0.2-0.4 cm ___ size. The effusion appears circumferential. There are no echocardiographic signs of tamponade. IMPRESSION: Very small to small pericardial effusion without echocardiographic evidence of tamponade. Mildly dilated ascending aorta. Preserved biventricular systolic function. Indeterminate pulmonary artery systolic pressure. ___ CXR Extensive consolidations ___ particular involving right upper lobe as well as bibasal areas is unchanged. Central venous line tip terminates at the level of mid right subclavian vein. Cardiomediastinal silhouette is difficult to assess since it is obscured by widespread parenchymal consolidations. Bilateral pleural effusions are present. No pneumothorax. MICROBIOLOGY: ============= ___ NO CRYPTOSPORIDIUM OR GIARDIA SEEN. ___ NO OVA AND PARASITES SEEN. ___ FECAL CULTURE (Final ___: NO ENTERIC GRAM NEGATIVE RODS FOUND. NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final ___: NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO FOUND. FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA FOUND. ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Cepheid nucleic acid amplification assay.. ___ Respiratory Viral Screen & Culture Respiratory Viral Culture (Final ___: No respiratory viruses isolated. Culture screened for Adenovirus, Influenza A & B, Parainfluenza type 1,2 & 3, and Respiratory Syncytial Virus.. ___ LAVAGE GRAM STAIN (Final ___: 2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final ___: NO GROWTH, <1000 CFU/ml. LEGIONELLA CULTURE (Final ___: NO LEGIONELLA ISOLATED. POTASSIUM HYDROXIDE PREPARATION (Final ___: Test cancelled by laboratory. PATIENT CREDITED. This is a low yield procedure based on our ___ studies. if pulmonary Histoplasmosis, Coccidioidomycosis, Blastomycosis, Aspergillosis or Mucormycosis is strongly suspected, contact the Microbiology Laboratory (___). Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final ___: NEGATIVE for Pneumocystis jirovecii (carinii). FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Final ___: NO MYCOBACTERIA ISOLATED. ___ ACID FAST CULTURE (Final ___: NO MYCOBACTERIA ISOLATED. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ___ BLOOD CX: NO GROWTH x2 ___ SPUTUM GRAM STAIN & CULTURE: GRAM STAIN (Final ___: >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS SINGLY. RESPIRATORY CULTURE (Final ___: RARE GROWTH Commensal Respiratory Flora. ___ URINE CX: NO GROWTH PATHOLOGY: ========== ___ Tissue: LUNG, CORE BIOPSY FOR TUMOR Metastatic adenocarcinoma - Positive: CK7, ___. - Negative: CK20, TTF-1, B72.3. OTHER LABS OF NOTE: ================== ___ 06:00AM BLOOD %HbA1c-6.1* eAG-128* ___ 05:21AM BLOOD Triglyc-110 HDL-20 CHOL/HD-3.9 LDLcalc-36 ___ 06:00AM BLOOD HBsAg-Negative HBsAb-Negative HBcAb-Negative ___ 06:00AM BLOOD ANCA-NEGATIVE B ___ 06:00AM BLOOD ___ ___ 06:00AM BLOOD C3-78* C4-38 ___ 11:17PM BLOOD HIV Ab-Negative

2143-11-17 21:09:00

ENGLISH

MARRIED

WHITE

F

[[23153038, Timestamp('2143-11-17 21:10:24'), '', 'CMED']]

[[{'Medications on Admission': ':\nThe Preadmission Medication list is accurate and complete.\n1. Lisinopril 10 mg PO DAILY \n2. Lorazepam 1 mg PO QAM:PRN anxiety \n3. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze, sob \n\nSECONDARY DIAGOSES:\n- Hypertension\n- Anxiety\n- H/O Undifferentiated right neck tumor in ___, s/p resection \nand chemotherapy and radiation at ___. \n- H/O Malignant spindle cell tumor of right posterior shoulder, \ns/p \n excisional biopsy ___, \n- H/O Left breast cancer', 'Brief Hospital Course': 'NIL', 'Pertinent Results:': '\nADMISSION LABS:\n___ 06:05PM BLOOD WBC-6.0 RBC-3.63* Hgb-11.9 Hct-35.3 \nMCV-97 MCH-32.8* MCHC-33.7 RDW-12.4 RDWSD-43.8 Plt ___\n___ 06:05PM BLOOD Neuts-59.1 ___ Monos-9.4 Eos-3.0 \nBaso-1.3* Im ___ AbsNeut-3.57 AbsLymp-1.58 AbsMono-0.57 \nAbsEos-0.18 AbsBaso-0.08\n___ 06:05PM BLOOD ___ PTT-28.2 ___\n___ 06:05PM BLOOD Glucose-81 UreaN-9 Creat-0.4 Na-138 K-3.9 \nCl-102 HCO3-24 AnGap-16\n___ 06:05PM BLOOD proBNP-2292*\n___ 06:05PM BLOOD cTropnT-<0.01\n___ 06:05PM BLOOD Calcium-9.6 Phos-3.1 Mg-1.7\n___ 06:05PM BLOOD TSH-3.4\n\nCXR ___\nFINDINGS: \nPreviously seen left parenchymal opacity has resolved. Lungs \nare now clear without effusion, edema or consolidation. Right \napical pleural based opacity with superior retraction of the \nright hilum is most compatible with scarring as identified on \nprevious exams. The cardiomediastinal silhouette is stable. \nPortions of the right clavicle are not visualized. No acute \nosseous abnormalities. \nIMPRESSION: \nNo acute cardiopulmonary process. \n\nCTA ___\nIMPRESSION: \n1. No evidence of pulmonary embolism. \n2. Resolution of previously seen airspace opacities since ___. \n3. Unchanged borderline right hilar lymphadenopathy. \n4. Small right pleural effusion. \n5. Patulous thoracic esophagus, unchanged. \n6. Enlarged heterogeneous left thyroid with a discrete 10 mm \nposterior thyroid nodule, a nonemergent thyroid ultrasound can \nbe obtained for further evaluation if not already performed. \n\n#DYSPNEA ON EXERTION: Patient presented with dyspnea on exertion \nwithout chest pain. EKGs with ST depressions in inferior limb \nleads and lateral precordial leads have been seen previously, \nare unchanged, and likely due to LVH rather than ischemia. Her \ntroponins were negative x2 and BNP elevated. CT findings showed \nemphysema and mild right pleural effusion without evidence of \npulmonary embolus. Echo in ___ was unremarkable, with normal \nLVEF, normal RV function, and only mildly elevated TR gradient, \nalthough interval worsening is possible. COPD felt to be most \nlikely, given her heavy smoking history, wheezing, emphysematous \nchanges on CT. Monitored on telemetry overnight without acute \nevent. Treated with ipratropium nebulizers and furosemide 10mg \nIV. Discharged on Spiriva Respimat 2 puffs daily and aspirin \n81mg daily. Consider repeat ECHO as outpatient if concern for \ncardiac health arises. \n\n# Thyroid nodule: Enlarged heterogeneous left thyroid with a \ndiscrete 10 mm posterior thyroid nodule found on CTA from \n___. TSH normal. Given history of malignancy recommend \nthyroid ultrasound for further evaluation if not already \nperformed.\n\n#Hypertension: BP well controlled, continued lisinopril. \n\n#Anxiety: Continued AM lorazepam PRN \n\nTRANSITIONAL ISSUES:\n- Like previous providers, recommend ___ as outpatient, please \nfollow up scheduling.\n- Discharged on ASA 81 daily and Spiriva 2 puffs daily. \n- Consider repeat ECHO if any changes in cardiac status. \n- Patient given instructions to call for follow up with PCP and \npulmonology \n- NEW!!!! ****Enlarged heterogeneous left thyroid with a \ndiscrete 10 mm posterior thyroid nodule, a nonemergent thyroid \nultrasound recommended for further evaluation if not already \nperformed. ****\n\n# CODE STATUS: FULL CODE\n\n', 'Physical Exam:|Physical': '\nADMISSION PHYSICAL EXAM:\nVitals: 97.6-98.8, 105/65-118/67, 90-92, 20, 96-99% RA\n General: Alert, oriented, no acute distress \n HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL \n Neck: Supple, JVP 8-9cm above RA with patient at 45 degrees \n CV: Regular rate and rhythm, normal S1 + S2, pre-systolic click \nwith ___ last systolic murmur. \n Lungs: Decreased breath sounds. Prolonged expiratory phase. Low \npitch wheezing and faint rhonchi. Unlabored breathing at rest on \nRA. \n Abdomen: Soft, non-tender, non-distended, bowel sounds present, \nno organomegaly, no rebound or guarding \n GU: No foley \n Ext: Warm, well perfused, 2+ pulses. 1+ pitting edema to lower \nshins. \n Neuro: CNII-XII intact, ___ strength upper/lower extremities, \ngrossly normal sensation, gait deferred. \n\nDISCHARGE PHYSICAL EXAM:\nVitals: 97.6-98.8, 105/65-118/67, 90-92, 20, 96-99% RA\nGeneral: Alert, oriented, no acute distress \n HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL \n Neck: Supple, JVP 8 cm above RA with patient at 45 degrees \n CV: Regular rate and rhythm, normal S1 + S2, pre-systolic click \nwith ___ last systolic murmur. \n Lungs: CTAB. Unlabored breathing at rest on RA. \n Abdomen: Soft, non-tender, non-distended, bowel sounds present, \nno organomegaly, no rebound or guarding.\n GU: No foley \n Ext: Warm, well perfused, 2+ pulses. trace pitting edema at the \nankles.\n Neuro: CNII-XII intact, ___ strength upper/lower extremities, \ngrossly normal sensation, gait deferred. \n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\n ___ year old woman with history of undifferentiated carcinoma of \nthe right neck, malignant ___ cell tumors, and left breast \ncancer, HTN, and likely emphysema (no ___, not on medications), \npresenting with dyspnea on exertion. \n She was admitted from ___ to ___ for shortness of \nbreath, cough, left sided chest pain, hypoxemia. SHe was \nadmitted to the MICU with hypoxemic respiratory failure and \nsepsis due to pneumonia; she was quickly transitioned of ___ \nmask to nasal canula and transferred to the floor. Blood \ncultures grew strep pneumo; she was treated with ceftriaxone and \nazithro; vancomycin added given severe initial hypoxemia; \ntransitioned to levofloxacin to complete treatment. She followed \nup with ___ in pulmonology in ___, who receommended \n___, which the patient has not done yet. \n She returned several days ago from a 2 week vacation in ___. \nOne week ago, she developed dyspnea on exertion and severe \nfatigue. She becomes short of breath with walking short \ndistances on a flat surface, and must walk more slowly and stop \nfor several minutes to catch her breath. Has had several \nepisodes of feeling short of breath at rest, but her symptoms \nare mainly with exertion. Her symptoms have not progressed over \nthe past week. She has had adequate improvement in her symptoms \nif she uses her albuterol inhaler (has been using BID in order \nto conserve limited supply). She states she is able to breath \nmore comfortably if propped up in bed, concerning for orthopnea. \nShe has mild cough. No pleuritic pain or discomfort; able to \ntake deep breaths. She denies fevers, chills, sputum production, \nchest pain, lightheadedness, diaphoresis, nausea, vomiting, \ndiarrhea, urinary symptoms, myalgia/arthralgia, or lower \nextremity edema. No sick contacts. \n In ___, she had a CXR and a CTA for PE, which reportedly \nshowed a "7cm mass" in lungs (not seen on ___ radiology \nreview). \n In the ED, initial vitals were: T 97.3 HR 102 BP 141/74 RR 18 \nSPO2 100% RA \n - Labs were significant for : \n -- WBC 6.0, Hgb 11.9, Plt 296 \n --INR 1.0 \n --proBNP 2292 \n --Chem 7 normal (creat 0.4) \n --troponin T <0.01 \n EKG: sinus tachy, ST depressions lat/inf, STE V2 ~1mm. NEW \n Repeat EKG: NSR 95, NA, NI, 1mm STE v2, STD laterally, improved \nfrom prior, but new from ___. \n - Imaging: \n -- CTA chest: no PE, small right pleural effusion. Enlarged \nheterogeneous left thyroid with a discrete 10mm posterior \nthyroid nodule. \n -- CXR: no acute process . \n\n -The patient was given lorazepam 0.5mg PO and aspirin 325mg PO. \n\n Vitals prior to transfer were: t 97.8 HR 97 BP 115/71 RR 25 \nSPO2 98% RA \n Upon arrival to the floor, she denies complaints. \n REVIEW OF SYSTEMS: \n (+) Per HPI \n (-) Denies fever, chills, night sweats, recent weight loss or \ngain. Denies headache, sinus tenderness, rhinorrhea or \ncongestion. Denies chest pain or tightness, palpitations. Denies \nnausea, vomiting, diarrhea, constipation or abdominal pain. No \nrecent change in bowel or bladder habits. No dysuria. Denies \narthralgias or myalgias. \n\nPast Medical History:\n1. Undifferentiated right neck tumor in ___, s/p \nresection and chemotherapy and radiation at ___ \n___. \n2. Malignant spindle cell tumor of right posterior shoulder, s/p \nexcisional biopsy ___, 7 x 4 x 1 cm overlying the right \nsupraspinatus muscle. The original pathology from the tumor in \n___ has been unavailable so it has been difficult to know \nwhether this is a new tumor, or a recurrence. A follow-up MRI \nand CT-guided biopsy of the right supraspinatus prominence in \n___ did not reveal evidence of tumor. In ___ had 2 \nmore spindle cell tumors \nremoved from her right shoulder. \n3. Left breast cancer, ___, likely ___ previous radiation. s/p \nlumpectomy without radiation or chemotherapy. Then tubular \ncarcinoma ___ s/p mastectomy ___. \n4. R clavicular fracture s/p repair ___\n5. Hypertension\n6. Anxiety \n\nSocial History:\n___\nFamily History:\nMother had MI in her ___ and congestive heart disease. Unknown \nwhat father died of. No other family members with heart disease \nor malignancies. \n\n', 'Chief Complaint:|Complaint:': '\nDyspnea on Exertion\n\n', 'Attending:': ' ___\n\n', 'Allergies:': ' \nNo Known Allergies / Adverse Drug Reactions\n\n'}, '12823948-DS-18', 18, 'medicine']]

[['INDICATION: ___ with sob // eval for sob\n\nTECHNIQUE: Frontal lateral views the chest.\n\nCOMPARISON: Chest x-ray from ___.\n\nFINDINGS: \n\nPreviously seen left parenchymal opacity has resolved. Lungs are now clear\nwithout effusion, edema or consolidation. Right apical pleural based opacity\nwith superior retraction of the right hilum is most compatible with scarring\nas identified on previous exams. The cardiomediastinal silhouette is stable. \nPortions of the right clavicle are not visualized. No acute osseous\nabnormalities.\n\nIMPRESSION: \n\nNo acute cardiopulmonary process.\n', '12823948-RR-75', 75, 'frontal lateral views the chest.'], ['EXAMINATION: CTA CHEST.\n\nINDICATION: ___ woman with shortness of breath, evaluate for\npulmonary embolism. The patient has a history of sarcoma, spindle cell\nneoplasm, and left breast cancer.\n\nTECHNIQUE: Images were acquired at an outside hospital and submitted for\nreview. No sagittal images and only coronal MIPS images were available for\nreview.\n\nDOSE: Dose report not provided.\n\nCOMPARISON: Comparison is made to CTA chest ___ and PET-CT from ___.\n\nFINDINGS: \n\nCTA:\n\nThe pulmonary arteries are well opacified to the subsegmental level. There is\nno filling defect to suggest pulmonary embolism. The main pulmonary trunk is\nnormal in size measuring 2.7 cm. The thoracic aorta is not well opacified\nhowever, there is no evidence of aneurysmal dilation. There is mild\natherosclerotic calcification at the level of the aortic arch.\n\nCT CHEST: The left thyroid lobe is heterogeneous with a 10 mm posterior\nhypodense thyroid nodule, better seen on the current study (series 5, image\n4).\n\nThere is no axillary or supraclavicular adenopathy. There is no significant\nmediastinal adenopathy. There are prominent hilar lymph nodes measuring up to\n10 mm on the right (series 5, image 46), not significantly changed from ___.\n\nHeart size is normal. Coronary artery and aortic valvular calcifications are\nmoderate.\n\nThe thoracic esophagus is mildly patulous. Views of the upper abdomen are\nunremarkable.\n\nThe airway is patent to the subsegmental level bilaterally. There is moderate\ncentrilobular emphysema, most pronounced at the lung bases. Previously seen\nconsolidative opacities in the right upper lobe, right lower lobe, right\nmiddle lobe and lingula have resolved. Pleural thickening with adjacent\nparenchymal scarring at the right lung apex is unchanged since ___ and likely\npost radiation. There is also pleural thickening of the left lung apex, to a\nlesser degree, also unchanged. There is a small amount of pleural fluid on\nthe right (series 6, image 141). There is no left-sided pleural effusion. \nThere are multiple scattered calcified granulomas.\n\nOSSEOUS STRUCTURES: A left breast prosthesis is present. An old right\nclavicular fracture is present. Irregular sclerosis of the superior right\nribs is also likely post treatment related. Mixed lucency and sclerosis in\nthe upper thoracic vertebral bodies is also noted as on prior. There is no\nacute fracture identified. There are no new suspicious bony lesions.\n\nIMPRESSION:\n\n\n1. No evidence of pulmonary embolism.\n2. Resolution of previously seen airspace opacities since ___.\n3. Unchanged borderline right hilar lymphadenopathy.\n4. Small right pleural effusion.\n5. Patulous thoracic esophagus, unchanged.\n6. Enlarged heterogeneous left thyroid with a discrete 10 mm posterior thyroid\nnodule, a nonemergent thyroid ultrasound can be obtained for further\nevaluation if not already performed.\n', '12823948-RR-76', 76, 'images were acquired at an outside hospital and submitted for\nreview. no sagittal images and only coronal mips images were available for\nreview.']]

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[]

['medicine']

[[51221, Timestamp('2143-11-18 07:00:00'), Timestamp('2143-11-18 08:37:00'), 'Hematocrit'], [51222, Timestamp('2143-11-18 07:00:00'), Timestamp('2143-11-18 08:37:00'), 'Hemoglobin'], [51248, Timestamp('2143-11-18 07:00:00'), Timestamp('2143-11-18 08:37:00'), 'MCH'], [51249, Timestamp('2143-11-18 07:00:00'), Timestamp('2143-11-18 08:37:00'), 'MCHC'], [51250, Timestamp('2143-11-18 07:00:00'), Timestamp('2143-11-18 08:37:00'), 'MCV'], [51265, Timestamp('2143-11-18 07:00:00'), Timestamp('2143-11-18 08:37:00'), 'Platelet Count'], [51277, Timestamp('2143-11-18 07:00:00'), Timestamp('2143-11-18 08:37:00'), 'RDW'], [51279, Timestamp('2143-11-18 07:00:00'), Timestamp('2143-11-18 08:37:00'), 'Red Blood Cells'], [51301, Timestamp('2143-11-18 07:00:00'), Timestamp('2143-11-18 08:37:00'), 'White Blood Cells'], [52172, Timestamp('2143-11-18 07:00:00'), Timestamp('2143-11-18 08:37:00'), 'RDW-SD'], [50868, Timestamp('2143-11-18 07:00:00'), Timestamp('2143-11-18 09:11:00'), 'Anion Gap'], [50882, Timestamp('2143-11-18 07:00:00'), Timestamp('2143-11-18 09:11:00'), 'Bicarbonate'], [50902, Timestamp('2143-11-18 07:00:00'), Timestamp('2143-11-18 09:11:00'), 'Chloride'], [50912, Timestamp('2143-11-18 07:00:00'), Timestamp('2143-11-18 09:11:00'), 'Creatinine'], [50931, Timestamp('2143-11-18 07:00:00'), Timestamp('2143-11-18 09:11:00'), 'Glucose'], [50971, Timestamp('2143-11-18 07:00:00'), Timestamp('2143-11-18 09:11:00'), 'Potassium'], [50983, Timestamp('2143-11-18 07:00:00'), Timestamp('2143-11-18 09:11:00'), 'Sodium'], [51003, Timestamp('2143-11-18 07:00:00'), Timestamp('2143-11-18 09:11:00'), 'Troponin T'], [51006, Timestamp('2143-11-18 07:00:00'), Timestamp('2143-11-18 09:11:00'), 'Urea Nitrogen']]

Question: A 50 F is admitted. He/she says he/she has Dyspnea on Exertion . History of illness: ___ year old woman with history of undifferentiated carcinoma of the right neck, malignant ___ cell tumors, and left breast cancer, HTN, and likely emphysema (no ___, not on medications), presenting with dyspnea on exertion. She was admitted from ___ to ___ for shortness of breath, cough, left sided chest pain, hypoxemia. SHe was admitted to the MICU with hypoxemic respiratory failure and sepsis due to pneumonia; she was quickly transitioned of ___ mask to nasal canula and transferred to the floor. Blood cultures grew strep pneumo; she was treated with ceftriaxone and azithro; vancomycin added given severe initial hypoxemia; transitioned to levofloxacin to complete treatment. She followed up with ___ in pulmonology in ___, who receommended ___, which the patient has not done yet. She returned several days ago from a 2 week vacation in ___. One week ago, she developed dyspnea on exertion and severe fatigue. She becomes short of breath with walking short distances on a flat surface, and must walk more slowly and stop for several minutes to catch her breath. Has had several episodes of feeling short of breath at rest, but her symptoms are mainly with exertion. Her symptoms have not progressed over the past week. She has had adequate improvement in her symptoms if she uses her albuterol inhaler (has been using BID in order to conserve limited supply). She states she is able to breath more comfortably if propped up in bed, concerning for orthopnea. She has mild cough. No pleuritic pain or discomfort; able to take deep breaths. She denies fevers, chills, sputum production, chest pain, lightheadedness, diaphoresis, nausea, vomiting, diarrhea, urinary symptoms, myalgia/arthralgia, or lower extremity edema. No sick contacts. In ___, she had a CXR and a CTA for PE, which reportedly showed a "7cm mass" in lungs (not seen on ___ radiology review). In the ED, initial vitals were: T 97.3 HR 102 BP 141/74 RR 18 SPO2 100% RA - Labs were significant for : -- WBC 6.0, Hgb 11.9, Plt 296 --INR 1.0 --proBNP 2292 --Chem 7 normal (creat 0.4) --troponin T <0.01 EKG: sinus tachy, ST depressions lat/inf, STE V2 ~1mm. NEW Repeat EKG: NSR 95, NA, NI, 1mm STE v2, STD laterally, improved from prior, but new from ___. - Imaging: -- CTA chest: no PE, small right pleural effusion. Enlarged heterogeneous left thyroid with a discrete 10mm posterior thyroid nodule. -- CXR: no acute process . -The patient was given lorazepam 0.5mg PO and aspirin 325mg PO. Vitals prior to transfer were: t 97.8 HR 97 BP 115/71 RR 25 SPO2 98% RA Upon arrival to the floor, she denies complaints. REVIEW OF SYSTEMS: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Past Medical History: 1. Undifferentiated right neck tumor in ___, s/p resection and chemotherapy and radiation at ___ ___. 2. Malignant spindle cell tumor of right posterior shoulder, s/p excisional biopsy ___, 7 x 4 x 1 cm overlying the right supraspinatus muscle. The original pathology from the tumor in ___ has been unavailable so it has been difficult to know whether this is a new tumor, or a recurrence. A follow-up MRI and CT-guided biopsy of the right supraspinatus prominence in ___ did not reveal evidence of tumor. In ___ had 2 more spindle cell tumors removed from her right shoulder. 3. Left breast cancer, ___, likely ___ previous radiation. s/p lumpectomy without radiation or chemotherapy. Then tubular carcinoma ___ s/p mastectomy ___. 4. R clavicular fracture s/p repair ___ 5. Hypertension 6. Anxiety Social History: ___ Family History: Mother had MI in her ___ and congestive heart disease. Unknown what father died of. No other family members with heart disease or malignancies. Allergies: No Known Allergies / Adverse Drug Reactions What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Lorazepam Heparin Furosemide Lorazepam Lisinopril Ipratropium Bromide Neb Sodium Chloride 0.9% Flush Target Lab Orders: Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells RDW-SD Anion Gap Bicarbonate Chloride Creatinine Glucose Potassium Sodium Troponin T Urea Nitrogen Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: NIL Other Results: ADMISSION LABS: ___ 06:05PM BLOOD WBC-6.0 RBC-3.63* Hgb-11.9 Hct-35.3 MCV-97 MCH-32.8* MCHC-33.7 RDW-12.4 RDWSD-43.8 Plt ___ ___ 06:05PM BLOOD Neuts-59.1 ___ Monos-9.4 Eos-3.0 Baso-1.3* Im ___ AbsNeut-3.57 AbsLymp-1.58 AbsMono-0.57 AbsEos-0.18 AbsBaso-0.08 ___ 06:05PM BLOOD ___ PTT-28.2 ___ ___ 06:05PM BLOOD Glucose-81 UreaN-9 Creat-0.4 Na-138 K-3.9 Cl-102 HCO3-24 AnGap-16 ___ 06:05PM BLOOD proBNP-2292* ___ 06:05PM BLOOD cTropnT-<0.01 ___ 06:05PM BLOOD Calcium-9.6 Phos-3.1 Mg-1.7 ___ 06:05PM BLOOD TSH-3.4 CXR ___ FINDINGS: Previously seen left parenchymal opacity has resolved. Lungs are now clear without effusion, edema or consolidation. Right apical pleural based opacity with superior retraction of the right hilum is most compatible with scarring as identified on previous exams. The cardiomediastinal silhouette is stable. Portions of the right clavicle are not visualized. No acute osseous abnormalities. IMPRESSION: No acute cardiopulmonary process. CTA ___ IMPRESSION: 1. No evidence of pulmonary embolism. 2. Resolution of previously seen airspace opacities since ___. 3. Unchanged borderline right hilar lymphadenopathy. 4. Small right pleural effusion. 5. Patulous thoracic esophagus, unchanged. 6. Enlarged heterogeneous left thyroid with a discrete 10 mm posterior thyroid nodule, a nonemergent thyroid ultrasound can be obtained for further evaluation if not already performed. #DYSPNEA ON EXERTION: Patient presented with dyspnea on exertion without chest pain. EKGs with ST depressions in inferior limb leads and lateral precordial leads have been seen previously, are unchanged, and likely due to LVH rather than ischemia. Her troponins were negative x2 and BNP elevated. CT findings showed emphysema and mild right pleural effusion without evidence of pulmonary embolus. Echo in ___ was unremarkable, with normal LVEF, normal RV function, and only mildly elevated TR gradient, although interval worsening is possible. COPD felt to be most likely, given her heavy smoking history, wheezing, emphysematous changes on CT. Monitored on telemetry overnight without acute event. Treated with ipratropium nebulizers and furosemide 10mg IV. Discharged on Spiriva Respimat 2 puffs daily and aspirin 81mg daily. Consider repeat ECHO as outpatient if concern for cardiac health arises. # Thyroid nodule: Enlarged heterogeneous left thyroid with a discrete 10 mm posterior thyroid nodule found on CTA from ___. TSH normal. Given history of malignancy recommend thyroid ultrasound for further evaluation if not already performed. #Hypertension: BP well controlled, continued lisinopril. #Anxiety: Continued AM lorazepam PRN TRANSITIONAL ISSUES: - Like previous providers, recommend ___ as outpatient, please follow up scheduling. - Discharged on ASA 81 daily and Spiriva 2 puffs daily. - Consider repeat ECHO if any changes in cardiac status. - Patient given instructions to call for follow up with PCP and pulmonology - NEW!!!! ****Enlarged heterogeneous left thyroid with a discrete 10 mm posterior thyroid nodule, a nonemergent thyroid ultrasound recommended for further evaluation if not already performed. **** # CODE STATUS: FULL CODE

2116-01-18 10:00:00

ENGLISH

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[[21835428, Timestamp('2116-01-18 02:25:50'), '', 'VSURG']]

[[{'Medications on Admission': ':\npercocet ___ tabs q8h, ultram, ibuprofen 800mg TID\n\nFacility:\n___ \n- ___', 'Brief Hospital Course': ":\nThe patient was admitted to the surgery service for evaluation \nand treatment.\n\nNeuro: The patient received a lumbar epidural with good effect \nand adequate pain control. This was used for the first 2 days \npost operatively and then removed.When tolerating oral intake, \nthe patient was transitioned to oral pain medications. He also \nrecieved toradol for better pain control. \n\nCV: The patient was stable from a cardiovascular standpoint; \nvital signs were routinely monitored.\n\nPulmonary: The patient was stable from a pulmonary standpoint; \nvital signs were routinely monitored. Good pulmonary toilet, \nearly ambulation and incentive spirometry were encouraged \nthroughout this hospitalization. \n\nGI/GU/FEN: \nPost operatively, the patient was made NPO with IVF. \nThe patient's diet was advanced when appropriate, which was \ntolerated well. \nThe patient's intake and output were closely monitored, and IVF \nwere adjusted when necessary. The patient's electrolytes were \nroutinely followed during this hospitalization, and repleted \nwhen necessary. \n\nID: The patient's white blood count and fever curves were \nclosely watched for signs of infection. \n\nEndocrine: The patient's blood sugar was monitored throughout \nthis stay; insulin dosing was adjusted accordingly. \n\nHematology: The patient's complete blood count was examined \nroutinely; no transfusions were required during this stay.\n\nProphylaxis: The patient received subcutaneous heparin during \nthis stay, and was encouraged to get up and ambulate as early as \npossible. \n\nAt the time of discharge, the patient was doing well, afebrile \nwith stable vital signs. The patient was tolerating a regular \ndiet, ambulating, voiding without assistance, and pain was well \ncontrolled. \n\n", 'Pertinent Results:': '\n___ 01:54PM BLOOD WBC-7.2 RBC-4.19* Hgb-12.7* Hct-35.9* \nMCV-86 MCH-30.3 MCHC-35.3* RDW-13.4 Plt ___\n___ 01:54PM BLOOD Glucose-99 UreaN-10 Creat-0.7 Na-136 \nK-4.6 Cl-99 HCO3-32 AnGap-10\n___ 01:54PM BLOOD Calcium-8.5 Phos-3.5 Mg-1.9\n___ 06:35AM BLOOD WBC-8.7 RBC-3.85* Hgb-11.8* Hct-33.8* \nMCV-88 MCH-30.5 MCHC-34.8 RDW-13.7 Plt ___\n\n', 'Physical Exam:|Physical': '\n98.3 HR: 54 BP: 112/70 RR: 16 Spo2: 97%\nNAD, alert and oriented x 3\nRRR, n mrg,, + S1 S2\nlungs CTA bilaterally\nsoft, NT, ND\nLeft BKA site clean dry anf intact. Right ___ warm without edema. \nPalpable femoral and right pedal pulses\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\n___ is a ___, nondiabetic man on Tramadol and \nMotrin, who, ___ years ago, was involved in a motorcycle accident, \nresulting in multiple\nfractures of his left ankle. Since then, his foot causes \nextreme pain and swelling, preventing him from walking. It \nmakes it uncomfortable for him to stand for any length of time. \n\nPast Medical History:\ndenies\n\nSocial History:\n___\nFamily History:\nn/a\n\n', 'Chief Complaint:|Complaint:': '\nLeft foot chronic pain\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nNo Known Allergies / Adverse Drug Reactions\n\n'}, '11287511-DS-11', 11, 'surgery']]

[]

[[21835428, Timestamp('2116-01-19 01:00:00'), Timestamp('2116-01-19 14:00:00'), 'ADDITIVE', 'Bupivacaine 0.1%', '', '0', '250 mL CADD Med Cassette'], [21835428, Timestamp('2116-01-19 01:00:00'), Timestamp('2116-01-19 14:00:00'), 'BASE', 'Yellow CADD Cassette', '', '0', '250 mL CADD Med Cassette'], [21835428, Timestamp('2116-01-19 01:00:00'), Timestamp('2116-01-19 14:00:00'), 'MAIN', 'HYDROmorphone', '004100', '59011044225', '250 mL CADD Med Cassette'], [21835428, Timestamp('2116-01-19 00:00:00'), Timestamp('2116-01-21 18:00:00'), 'MAIN', 'Acetaminophen', '004490', '00904198861', '500mg Tablet'], [21835428, Timestamp('2116-01-19 08:00:00'), Timestamp('2116-01-21 18:00:00'), 'MAIN', 'Gabapentin', '021414', '00172438210', '300mg Capsule'], [21835428, Timestamp('2116-01-19 08:00:00'), Timestamp('2116-01-19 16:00:00'), 'MAIN', 'Heparin', '006549', '63323026201', '5000 Units / mL- 1mL Vial'], [21835428, Timestamp('2116-01-19 00:00:00'), Timestamp('2116-01-19 23:00:00'), 'BASE', 'Bag', '', '0', '50 mL Bag'], [21835428, Timestamp('2116-01-19 00:00:00'), Timestamp('2116-01-19 23:00:00'), 'MAIN', 'Magnesium Sulfate', '016546', '00409672924', '2 g / 50 mL Premix Bag'], [21835428, Timestamp('2116-01-19 01:00:00'), Timestamp('2116-01-21 18:00:00'), 'BASE', '0.45% Sodium Chloride', '001209', '00338004304', '1000mL Bag']]

[]

['surgery']

[[51221, Timestamp('2116-01-18 13:54:00'), Timestamp('2116-01-18 14:35:00'), 'Hematocrit'], [51222, Timestamp('2116-01-18 13:54:00'), Timestamp('2116-01-18 14:35:00'), 'Hemoglobin'], [51248, Timestamp('2116-01-18 13:54:00'), Timestamp('2116-01-18 14:35:00'), 'MCH'], [51249, Timestamp('2116-01-18 13:54:00'), Timestamp('2116-01-18 14:35:00'), 'MCHC'], [51250, Timestamp('2116-01-18 13:54:00'), Timestamp('2116-01-18 14:35:00'), 'MCV'], [51265, Timestamp('2116-01-18 13:54:00'), Timestamp('2116-01-18 14:35:00'), 'Platelet Count'], [51277, Timestamp('2116-01-18 13:54:00'), Timestamp('2116-01-18 14:35:00'), 'RDW'], [51279, Timestamp('2116-01-18 13:54:00'), Timestamp('2116-01-18 14:35:00'), 'Red Blood Cells'], [51301, Timestamp('2116-01-18 13:54:00'), Timestamp('2116-01-18 14:35:00'), 'White Blood Cells'], [50868, Timestamp('2116-01-18 13:54:00'), Timestamp('2116-01-18 15:04:00'), 'Anion Gap'], [50882, Timestamp('2116-01-18 13:54:00'), Timestamp('2116-01-18 15:04:00'), 'Bicarbonate'], [50893, Timestamp('2116-01-18 13:54:00'), Timestamp('2116-01-18 15:04:00'), 'Calcium, Total'], [50902, Timestamp('2116-01-18 13:54:00'), Timestamp('2116-01-18 15:04:00'), 'Chloride'], [50910, Timestamp('2116-01-18 13:54:00'), Timestamp('2116-01-18 15:04:00'), 'Creatine Kinase (CK)'], [50912, Timestamp('2116-01-18 13:54:00'), Timestamp('2116-01-18 15:04:00'), 'Creatinine'], [50931, Timestamp('2116-01-18 13:54:00'), Timestamp('2116-01-18 15:04:00'), 'Glucose'], [50960, Timestamp('2116-01-18 13:54:00'), Timestamp('2116-01-18 15:04:00'), 'Magnesium'], [50970, Timestamp('2116-01-18 13:54:00'), Timestamp('2116-01-18 15:04:00'), 'Phosphate'], [50971, Timestamp('2116-01-18 13:54:00'), Timestamp('2116-01-18 15:04:00'), 'Potassium'], [50983, Timestamp('2116-01-18 13:54:00'), Timestamp('2116-01-18 15:04:00'), 'Sodium'], [51003, Timestamp('2116-01-18 13:54:00'), Timestamp('2116-01-18 15:04:00'), 'Troponin T'], [51006, Timestamp('2116-01-18 13:54:00'), Timestamp('2116-01-18 15:04:00'), 'Urea Nitrogen'], [51221, Timestamp('2116-01-19 03:34:00'), Timestamp('2116-01-19 04:13:00'), 'Hematocrit'], [51222, Timestamp('2116-01-19 03:34:00'), Timestamp('2116-01-19 04:13:00'), 'Hemoglobin'], [51248, Timestamp('2116-01-19 03:34:00'), Timestamp('2116-01-19 04:13:00'), 'MCH'], [51249, Timestamp('2116-01-19 03:34:00'), Timestamp('2116-01-19 04:13:00'), 'MCHC'], [51250, Timestamp('2116-01-19 03:34:00'), Timestamp('2116-01-19 04:13:00'), 'MCV'], [51265, Timestamp('2116-01-19 03:34:00'), Timestamp('2116-01-19 04:13:00'), 'Platelet Count'], [51277, Timestamp('2116-01-19 03:34:00'), Timestamp('2116-01-19 04:13:00'), 'RDW'], [51279, Timestamp('2116-01-19 03:34:00'), Timestamp('2116-01-19 04:13:00'), 'Red Blood Cells'], [51301, Timestamp('2116-01-19 03:34:00'), Timestamp('2116-01-19 04:13:00'), 'White Blood Cells'], [50861, Timestamp('2116-01-19 03:34:00'), Timestamp('2116-01-19 04:57:00'), 'Alanine Aminotransferase (ALT)'], [50863, Timestamp('2116-01-19 03:34:00'), Timestamp('2116-01-19 04:57:00'), 'Alkaline Phosphatase'], [50868, Timestamp('2116-01-19 03:34:00'), Timestamp('2116-01-19 04:57:00'), 'Anion Gap'], [50878, Timestamp('2116-01-19 03:34:00'), Timestamp('2116-01-19 04:57:00'), 'Asparate Aminotransferase (AST)'], [50882, Timestamp('2116-01-19 03:34:00'), Timestamp('2116-01-19 04:57:00'), 'Bicarbonate'], [50885, Timestamp('2116-01-19 03:34:00'), Timestamp('2116-01-19 04:57:00'), 'Bilirubin, Total'], [50893, Timestamp('2116-01-19 03:34:00'), Timestamp('2116-01-19 04:57:00'), 'Calcium, Total'], [50902, Timestamp('2116-01-19 03:34:00'), Timestamp('2116-01-19 04:57:00'), 'Chloride'], [50912, Timestamp('2116-01-19 03:34:00'), Timestamp('2116-01-19 04:57:00'), 'Creatinine'], [50931, Timestamp('2116-01-19 03:34:00'), Timestamp('2116-01-19 04:57:00'), 'Glucose'], [50960, Timestamp('2116-01-19 03:34:00'), Timestamp('2116-01-19 04:57:00'), 'Magnesium'], [50970, Timestamp('2116-01-19 03:34:00'), Timestamp('2116-01-19 04:57:00'), 'Phosphate'], [50971, Timestamp('2116-01-19 03:34:00'), Timestamp('2116-01-19 04:57:00'), 'Potassium'], [50983, Timestamp('2116-01-19 03:34:00'), Timestamp('2116-01-19 04:57:00'), 'Sodium'], [51003, Timestamp('2116-01-19 03:34:00'), Timestamp('2116-01-19 04:57:00'), 'Troponin T'], [51006, Timestamp('2116-01-19 03:34:00'), Timestamp('2116-01-19 04:57:00'), 'Urea Nitrogen']]

Question: A 38 M is admitted. He/she says he/she has Left foot chronic pain . History of illness: ___ is a ___, nondiabetic man on Tramadol and Motrin, who, ___ years ago, was involved in a motorcycle accident, resulting in multiple fractures of his left ankle. Since then, his foot causes extreme pain and swelling, preventing him from walking. It makes it uncomfortable for him to stand for any length of time. Past Medical History: denies Social History: ___ Family History: n/a Allergies: No Known Allergies / Adverse Drug Reactions What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Bupivacaine 0.1% Yellow CADD Cassette HYDROmorphone Acetaminophen Gabapentin Heparin Bag Magnesium Sulfate 0.45% Sodium Chloride Target Lab Orders: Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells Anion Gap Bicarbonate Calcium, Total Chloride Creatine Kinase (CK) Creatinine Glucose Magnesium Phosphate Potassium Sodium Troponin T Urea Nitrogen Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells Alanine Aminotransferase (ALT) Alkaline Phosphatase Anion Gap Asparate Aminotransferase (AST) Bicarbonate Bilirubin, Total Calcium, Total Chloride Creatinine Glucose Magnesium Phosphate Potassium Sodium Troponin T Urea Nitrogen Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : The patient was admitted to the surgery service for evaluation and treatment. Neuro: The patient received a lumbar epidural with good effect and adequate pain control. This was used for the first 2 days post operatively and then removed.When tolerating oral intake, the patient was transitioned to oral pain medications. He also recieved toradol for better pain control. CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout this hospitalization. GI/GU/FEN: Post operatively, the patient was made NPO with IVF. The patient's diet was advanced when appropriate, which was tolerated well. The patient's intake and output were closely monitored, and IVF were adjusted when necessary. The patient's electrolytes were routinely followed during this hospitalization, and repleted when necessary. ID: The patient's white blood count and fever curves were closely watched for signs of infection. Endocrine: The patient's blood sugar was monitored throughout this stay; insulin dosing was adjusted accordingly. Hematology: The patient's complete blood count was examined routinely; no transfusions were required during this stay. Prophylaxis: The patient received subcutaneous heparin during this stay, and was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. Other Results: ___ 01:54PM BLOOD WBC-7.2 RBC-4.19* Hgb-12.7* Hct-35.9* MCV-86 MCH-30.3 MCHC-35.3* RDW-13.4 Plt ___ ___ 01:54PM BLOOD Glucose-99 UreaN-10 Creat-0.7 Na-136 K-4.6 Cl-99 HCO3-32 AnGap-10 ___ 01:54PM BLOOD Calcium-8.5 Phos-3.5 Mg-1.9 ___ 06:35AM BLOOD WBC-8.7 RBC-3.85* Hgb-11.8* Hct-33.8* MCV-88 MCH-30.5 MCHC-34.8 RDW-13.7 Plt ___

2181-11-17 01:08:00

ENGLISH

MARRIED

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[[29830193, Timestamp('2181-11-17 01:09:55'), '', 'CMED'], [29830193, Timestamp('2181-11-19 11:41:40'), 'CMED', 'CSURG']]

[[{'Medications on Admission': ':\nAggrenox 1cap BID, Trazadone 50mg qhs, lorazepam 1mg Q6H, \npantoprazole 40 mg Q12H, metoprolol 50 mg BID, simvastatin 80 mg \nQD, Lantus 45u-breakfast & bedtime, RISS \n\nFacility:\n___', 'Brief Hospital Course': ':\n___ Year old male with DMII, Hypertension, Hyperlipidemia, \nPeripheral vascular disease, question history of Myocardial \nInfarction without intervention, initially treated for Diabetic \nketo acidosis but found to have worsening signs of Congestive \nheart failure, EKG changes, + Cardiac enzymes, ejection fraction \nof 10%, intubated, IABP in place and on pressors for treatment \nof cardiogenic shock transferred via med flight from outside \nhospital. His hospital course was complicated by multiple \nepisodes of VF arrest.\n\nOn ___ he was taken to the operating room and underwent \nemergent coronary artery bypass grafting x3 on an intra-aortic \nballoon pump with left internal mammary\nartery to left anterior descending coronary; reverse saphenous \nvein single graft from aorta to ramus intermedius coronary \nartery; reverse saphenous vein single graft from aorta to first \nobtuse marginal coronary artery with ___. Cardiopulmonary \nBYPASS TIME: 92 minutes. CROSS-CLAMP TIME: 64 minutes. Please \nsee operative report for further surgical details. He was \ntransferred to the CVICU intubated, sedated on pressors. He \nremained intubated on pressors until ___ when he was weaned \n off and was successfully extubated.\n\nEvents: ___ he was hypotensive requiring pressors and \ndecreasing renal function. An echocargiogram was done and \nrevealed a large pericardial effusion with right ventricular \ndiastolic collapse. He was taken to the operating room for \nSubxiphoid pericardial window.\n\nRespiratory: aggressive pulmonary toilet, chest ___, nebs, his \noxygen requirement improved to ___ via nasal cannula.\n\nChest-tubes: were all removed per protocol\n\nCardiac: Intermittent atrial fibrillation 90-135, amiodarone \nbolus and drip with low-dose beta-blocker he converted to sinus \nrhythm. \n\nGI: aggressive bowel regimen and PPI were continued\n\nNutrition: he was seen by Speech and Swallow on ___ who \nrecommended regular diet thin liquid, medications whole with \nwater. His PO intake was poor. On ___ he was seen again by \nSpeech who recommended a regular diet, thin liquid and \nmedications whole pills. Nutrition recommended Cardiac, \nDiabetic, Sugar-Free Carnation Instant Breakfast. His PO intake \ncontinued to be poor therefore a Doboff feeding tube was placed \nand tube feeds were started. Nutrition recommended Boost Glucose \nControl @ 90 mL x 15 hrs to supplement his PO intake.\n\nID: On ___ he was seen by infectious disease for low-grade \nfevers, positive BC for strept viridans, catheter tip with \n___. He completed a 2 week course of Vancomycin \nand fluconazole per ID recommendations.\n\nRenal: Renal function baseline Creatnine 0.9 On ___ his \nCreatnine increased to 1.3 peak 2.1 secondary to large \npericardial effusion which once treated his renal function \nreturned to his baseline. He was gently diuresed. His \nelectrolytes were repleted as needed. Required foley \nre-insertion for urinary retention. Flomax was started and he \nwas discharged to rehab with his Foley. He will have a void \ntrial on ___, following a week of Flomax therapy.\n\nEndocrine: Insulin drip was titrated to maintain blood sugars < \n150 converted to Lantus with sliding scale regular once transfer \nto floor\n\nNeuro: Flat-affect. follows commands. Pain well controlled with \nPO pain medications.\n\nDisposition: He was seen by physical therapy. Requires max \nassist for ambulation and lift device. On POD 24 he was \ndischarged to ___ in ___. All follow \nup appointments were advised.\n\n', 'Pertinent Results:': '\n___ 05:00AM BLOOD WBC-5.1 RBC-3.23* Hgb-10.3* Hct-31.2* \nMCV-97 MCH-32.0 MCHC-33.1 RDW-18.1* Plt ___\n___ 03:17AM BLOOD WBC-4.9 RBC-3.30* Hgb-10.6* Hct-31.4* \nMCV-95 MCH-32.1* MCHC-33.7 RDW-18.1* Plt ___\n___ 04:38AM BLOOD WBC-5.1 RBC-3.22* Hgb-10.3* Hct-31.1* \nMCV-97 MCH-32.0 MCHC-33.2 RDW-18.5* Plt ___\n___ 05:00AM BLOOD Glucose-116* UreaN-33* Creat-1.2 Na-138 \nK-4.3 Cl-99 HCO3-30 AnGap-13\n___ 05:59AM BLOOD Glucose-69* UreaN-31* Creat-1.0 Na-138 \nK-3.5 Cl-96 HCO3-34* AnGap-12\n___ 03:17AM BLOOD Glucose-243* UreaN-31* Creat-0.9 Na-134 \nK-4.4 Cl-94* HCO3-34* AnGap-10\n___ 05:15AM BLOOD UreaN-26* Creat-0.7 Na-137 K-4.3 Cl-96\n\n.\nBiomarker Trend:\n___ 01:25AM BLOOD CK-MB-215* MB Indx-14.0* cTropnT-2.54*\n___ 06:59AM BLOOD CK-MB-251* MB Indx-12.5* cTropnT-4.64*\n___ 01:28PM BLOOD CK-MB-167* MB Indx-7.9* cTropnT-5.01*\n___ 10:12PM BLOOD CK-MB-63* MB Indx-4.1 cTropnT-3.30*\n___ 05:01AM BLOOD CK-MB-35* MB Indx-2.8 cTropnT-3.12*\n___ 05:25PM BLOOD CK-MB-15* MB Indx-1.4 cTropnT-3.09*\n___ 11:07PM BLOOD CK-MB-11* MB Indx-1.2 cTropnT-2.39*\n___ 06:59AM BLOOD %\n\nHbA1c-11.4* eAG-280*\n\nImaging:\n.\nOSH CARDIAC CATH: ___\nLM 90%\nLAD: 90%\nLcx: luminal irregularities\nRCA: 100% \nRight heart cath:\nRA: 15\nRV: ___\nPA: 50/35\nPCWP: 35\nCardiac Output: 3.8L/min\nCardiac Index: 2L/min/m2.\nEF: 15%, no significant MR\n.\nCXR:\nPORTABLE CHEST, ___ \nFINDINGS: Radiodense tip of an intraaortic balloon pump is at \nthe expected \njunction of the superior aspect of the aortic knob and left \nsubclavian artery, as communicated by telephone to Dr. ___ on \n___ at 8:20 a.m. Endotracheal tube and nasogastric tube \nare in standard position. Heart size is normal. Bilateral \ninterstitial pulmonary edema is present as well as an \nasymmetrical left perihilar alveolar process, likely reflecting \nasymmetrical edema. \n.\nTTE: ___\nThe left atrium is normal in size. No atrial septal defect is \nseen by 2D or color Doppler. Left ventricular wall thicknesses \nare normal. The left ventricular cavity size is normal. There is \nsevere global left ventricular hypokinesis (LVEF = ___ %). No \nmasses or thrombi are seen in the left ventricle. There is no \nventricular septal defect. There is no aortic valve stenosis. No \naortic regurgitation is seen. Trivial mitral regurgitation is \nseen. The pulmonary artery systolic pressure could not be \ndetermined. There is no pericardial effusion. \n\n___ ECHOCARDIOGRAPHY REPORT\n\n___ ___ MRN: ___ TEE (Complete) \nDone ___ at 1:36:29 ___ FINAL \nReferring Physician ___ \n___.\n___ Status: Inpatient DOB: ___ \nAge (years): ___ M Hgt (in): 70 \nBP (mm Hg): 103/67 Wgt (lb): 150 \nHR (bpm): 78 BSA (m2): 1.85 m2 \nIndication: Intraoperative TEE for CABG procedure. Chest pain. \nCoronary artery disease. Left ventricular function. Preoperative \nassessment. Right ventricular function. \nICD-9 Codes: 786.___, 786.51, 424.0, 424.2 \n___ Information \nDate/Time: ___ at 13:36 ___ MD: ___, \nMD \n___ Type: TEE (Complete) Sonographer: ___, MD \nDoppler: Limited Doppler and color Doppler ___ Location: \nAnesthesia West OR cardiac \nContrast: None Tech Quality: Adequate \nTape #: ___-: Machine: u/s 3 \nEchocardiographic Measurements \nResults Measurements Normal Range \nLeft Ventricle - Ejection Fraction: 20% >= 55% \nAorta - Ascending: 2.9 cm <= 3.4 cm \n\nFindings \nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is \nseen in the RA and extending into the RV. No ASD by 2D or color \nDoppler. \n\nLEFT VENTRICLE: Severe regional LV systolic dysfunction. \n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion. \n\nAORTA: Normal aortic diameter at the sinus level. Normal \nascending aorta diameter. Normal descending aorta diameter. \n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. \n\nMITRAL VALVE: Mild (1+) MR. \n\n___ VALVE: Mild [1+] TR. \n\nGENERAL COMMENTS: A TEE was performed in the location listed \nabove. I certify I was present in compliance with ___ \nregulations. The ___ was under general anesthesia throughout \nthe procedure. No TEE related complications. The ___ appears \nto be in sinus rhythm. Results were personally reviewed with the \nMD caring for the ___. Left pleural effusion. \n\nREGIONAL LEFT VENTRICULAR WALL MOTION: \n\n N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic \nConclusions \nPrebypass\n\nNo atrial septal defect is seen by 2D or color Doppler. There is \nsevere regional left ventricular systolic dysfunction with \nakinesia of the apex and apical portion of the inferior wall. \nThere is also hypokinesia of the apical and mid portions of the \nanterior, anteroseptal and inferospetal walls . Right \nventricular chamber size and free wall motion are normal. The \naortic valve leaflets (3) appear structurally normal with good \nleaflet excursion. There is no aortic valve stenosis. No aortic \nregurgitation is seen. Mild (1+) mitral regurgitation is seen. \nTip of IABP in good position. Dr. ___ was notified in person \nof the results on ___ at 1230pm.\n\nPost bypass\n\n___ is AV paced and receiving an infusion of phenylephrine, \nmilrinone and epinephrine. LVEF= 35%. Aorta is intact post \ndecannulation. Mild mitral regurgitation present. \n I certify that I was present for this procedure in compliance \nwith ___ regulations.\n\nElectronically signed by ___, MD, Interpreting \nphysician ___ ___ 17:03 \n\n© ___ ___. All rights reserved.\n\n', 'Physical Exam:|Physical': '\nOn Admission:\nGENERAL: Intubated, Sedated, Paralyzed NAD. \nHEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were \npink, OT tube in place with yellow secretions. No xanthalesma. \nNECK: Supple. \nCARDIAC: PMI located in ___ intercostal space, midclavicular \nline. RR, normal S1, S2. SEM heard throughout precordium. No \nthrills, lifts. No S3 or S4, no peripheral edema. \nLUNGS: No chest wall deformities, scoliosis or kyphosis. \nAnterior fields with anterior rhonchi. No audible crackles. \nABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not \nenlarged by palpation. No abdominial bruits. \nEXTREMITIES: Cool, missing right toes. Right femoral line in \nplace \n- No groin hematomas\nSKIN: No stasis dermatitis, ulcers, scars, or xanthomas. \nPULSES: \nRight: Carotid 2+ Femoral 2+ DP 0 ___ 0 \nLeft: Carotid 2+ Femoral 2+ dopplerable DP dopplerable ___ 2+ \nT/L/D:\n- ET in place\n- foley \n- IABP in right femoral artery and vein\n- right and left radial artery line\n.\nOn Discharge:\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\n___ YO M with DMII, HTN, HLD, PVD s/p fem-pop bypass on the left \nand iliac stent on the right, ? h/o MI without intervention, \npresented to the ED at ___ found to be in DKA with glucose \nin the 490\'s. Per report ___ with gradual onset weakness, \nnausea, loose stool, excessive thirst. Due to decreased PO \nintake ___ omitted "several days" of insulin therapy. \nProgressive symptoms prompted presentation to OSH ED found to \nhave a ph 7.0 and admitted to ICU for treatment of DKA. In the \nICU ___ placed on an Insulin gtt overnight and covered \nempirically with broad spectrum antibiotics: vancomycin and \nflagyl. In the AM, gap had resolved and pH normalized and \ntransitioned to SQ Lantus. Antibiotics were stopped as clinical \nsuspicion for infection low. \nLater in morning, he was noted to develop increased agitation, \nEKG showed ST depression V4-V6. ___ started on Arixtra for \nanticoagulation as unable to start Heparin secondary to allergy \n(though pt received hep SQ during OSH stay without problem) and \n___ refused Plavix. CXR obtained which was consistent with \nvolume overload. He was urgently taken to Cath lab. Per report \nhe was intubated for respiratory stabilization pre-procedure but \nhad never been hypoxic. In cath lab, he was noted to have severe \ndistal left main disease with diffused LAD disease, RCA noted to \nbe chronically occluded, there are collateral artery L-R and \nR-R, PCWP of 35, EF of ___. IABP was placed through right \nfemoral artery and vein. In the cath lab he was given 40mg of \nIV Lasix, 5 of dobutamine and 20 of levophed and agumented BP to \n140s of note his prior unaugmented SBP was 85-90 systolic. Per \nmed flight ___ with uneventful transport. He is sedated \n(versed) and paralyzed (vecuronium). On arrival to the CCU \n___ SBP is augmented with levophed. Cardiac surgery \nconsulted for coronary revascularization. \n\nPast Medical History:\nDiabetes mellitus Type II\nPeripheral Vascular Disease\nHypertension\nHypercholesterolemia\n?prior Myocardial infarctions without intervention\nPrior Transient Ischemic Attacks\nHistory of Alcohol abuse\ns/p Right lower extremity SFA to AT bypass eith saphenous vein \n___\nAppendectomy\nLaparoscopic cholecystectomy\n\nSocial History:\n___\nFamily History:\n No family history of early MI, arrhythmia, cardiomyopathies, or \nsudden cardiac death; otherwise non-contributory.\n\n', 'Chief Complaint:|Complaint:': '\nchest pain\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nKeflex\n\n'}, '13174926-DS-13', 13, 'cardiothoracic']]

[['PORTABLE CHEST, ___\n\nCOMPARISON: Chest x-ray ___.\n\nFINDINGS: Radiodense tip of an intraaortic balloon pump is at the expected\njunction of the superior aspect of the aortic knob and left subclavian artery,\nas communicated by telephone to Dr. ___ on ___ at 8:20 a.m. \nEndotracheal tube and nasogastric tube are in standard position. Heart size\nis normal. Bilateral interstitial pulmonary edema is present as well as an\nasymmetrical left perihilar alveolar process, likely reflecting asymmetrical\nedema.\n', '13174926-RR-19', 19, ''], ['PORTABLE CHEST ___\n\nCOMPARISON: Radiograph of earlier the same date.\n\nFINDINGS: Tip of intra-aortic balloon pump has been slightly retracted but\nstill remains in close proximity to the superior aspect of the aortic knob,\nnear the expected junction with the left subclavian artery. Dr. ___ has been\ntelephoned with the location of the intra-aortic balloon pump on ___\n12:00 p.m. Other indwelling devices are in standard position. Heart size\nremains normal. Bilateral hazy opacities in the mid and lower lungs have\nslightly shifted in distribution but are only minimally worse in the interval,\nand likely reflect asymmetrical pulmonary edema. There is a questionable\nlayering left pleural effusion. \n', '13174926-RR-20', 20, ''], ['PORTABLE CHEST X-RAY ___ WITH COMPARISON RADIOGRAPH OF EARLIER THE\nSAME DATE\n\nFINDINGS: Intra-aortic balloon pump has been repositioned, with tip now\nterminating approximately 3 cm below the superior aspect of the aortic knob. \nOther indwelling devices remain in standard position, and cardiomediastinal\ncontours are similar in appearance. Slightly asymmetric pattern of pulmonary\nedema is improving. Otherwise, no relevant short interval changes.\n', '13174926-RR-21', 21, ''], ['VENOUS DUPLEX, LOWER EXTREMITY\n\nREASON: Patient in need of CABG.\n\nDuplex evaluation was performed of both lower extremities. The right lesser\nsaphenous vein shows diameters of 0.19-0.23. The left lesser saphenous is\n0.17-0.22. No greater saphenous veins were visualized.\n\nIMPRESSION: Diminutive bilateral lesser saphenous veins as described above.\n', '13174926-RR-22', 22, ''], ['\nStandard Report Carotid US\n\nStudy: Carotid Series Complete\n\nReason: Preop CABG patient on balloon pump.\n\nFindings: Duplex evaluation was performed of bilateral carotid arteries. On\nthe right there is severe homogenous no plaque in the ICA. On the left there\nis mild homogenous plaque seen in the ICA.\n\nOn the right the ICA is occluded throughout. CCA peak systolic velocity is\n114 cm/sec. ECA peak systolic velocity is 177 cm/sec. These findings are\nconsistent with a total occlusion of the right ICA.\n\nOn the left systolic/end diastolic velocities of the ICA proximal, mid and\ndistal respectively are 102/22, 65/12, and 70/14 cm/sec. CCA peak systolic\nvelocity is 104 cm/sec. ECA peak systolic velocity is 143 cm/sec. The ICA/CCA\nratio is .98. These findings are consistent with a less than 40% stenosis.\n\n Right antegrade vertebral artery flow.\n Left antegrade vertebral artery flow.\n\nImpression: Right ICA occlusion- although this cannot be detected with 100%\naccuracy by US. Appears chronic- clinical correlation and potential CTA\nevaluation is warranted\n Left ICA less than 40% stenosis.\n', '13174926-RR-23', 23, ''], ['INDICATION: Cardiogenic shock, now intubated with rising fever curve. \nEvaluate for consolidation.\n\nCOMPARISON: Chest radiograph from ___.\n\nFINDINGS: The ET tube ends 4.1 cm above the carina. The intra-aortic balloon\npump catheter tip ends 2.4 cm above the superior wall of the left main stem\nbronchus, a slightly lower position than before. The NG tube passes below the\nlevel of the diaphragm, ending within the mid to low stomach. Thickening of\nthe minor fissure and peribronchial cuffing could be minimal pulmonary edema. \nThe vascular pedicle is slightly increased in width. There are no definite\npleural effusions. No pneumothorax is seen.\nHeart size is normal. \n\nIMPRESSION:\n\n1. Possible minimal pulmonary edema.\n\n2. No evidence of pneumonia.\n', '13174926-RR-24', 24, ''], ['INDICATION: Intubated, evaluate ET tube placement.\n\nCOMPARISON: Chest radiograph from ___.\n\nFINDINGS: The ET tube ends 4.4 cm above the carina. The NG tube passes below\nthe level of the diaphragm and out of the field of view inferiorly. The\nintra-aortic balloon pump device ends 1.8 cm above the superior wall of the\nleft main stem bronchus. Minimal interstitial pulmonary edema is slightly\nincreased. There are no pleural effusions. No pneumothorax is seen. The\ncardiac and mediastinal contours are unchanged.\n\nIMPRESSION:\n\n1. ET tube ends 4.4 cm above the carina.\n\n2. Slightly increased minimal interstitial pulmonary edema.\n', '13174926-RR-25', 25, ''], ['SINGLE AP PORTABLE VIEW OF THE CHEST\n\nREASON FOR EXAM: Status post CABG.\n\nComparison is made with prior study performed the same day earlier in the\nmorning.\n\nET tube tip is 4.5 cm above the carina. NG tube tip is in the stomach. \nSwan-Ganz catheter tip is in the main pulmonary artery. Mediastinal and chest\ntubes are in place. Intraaortic balloon pump tip is 5.1 cm from the aortic\narch, at the level of the left mainstem bronchus. There is no evident\npneumothorax or large pleural effusions. Bibasilar opacities are consistent\nwith atelectasis. There is post-operative mediastinal widening. Sternal\nwires are aligned. Pulmonary edema has improved.\n', '13174926-RR-26', 26, ''], ['INDICATION: Hemoptysis following attempted left central venous line\nplacement.\n\nCOMPARISON: ___.\n\nBEDSIDE SEMI-ERECT FRONTAL CHEST RADIOGRAPH: An endotracheal tube ends 5.1 cm\nabove the carina. A nasogastric tube ends in the stomach. There are\nbilateral pleural drains as well as mediastinal drains. A right internal\njugular approach Swan-Ganz catheter is visualized. Notably the tip of this\ncatheter has advanced considerably and is now directed towards the right lower\nor middle lobe. This catheter should be retracted by several centimeters. \nCardiac, mediastinal and hilar contours are normal. Median sternotomy wires\nare intact. There is no pleural effusion or pneumothorax. Increased opacity\nis noted in the left lung, with more focal opacity in the upper lobe\nspecifically. This may represent increasing left lung atelectasis with areas\nof coexisting infection, hemorrhage or aspiration.\n\nThese results and recommendations were discussed over the telephone by Dr.\n___ with ___ at 13:41 p.m. on ___\n\n', '13174926-RR-27', 27, ''], ['HISTORY: ___ man, with emergent CABG. Presents with right upper arm\nswelling. Assess for right upper extremity DVT.\n\nCOMPARISON: None.\n\nFINDINGS: Color and grayscale sonogram was performed on the right upper\nextremity. The right internal jugular, subclavian, axillary, brachial,\ncephalic and basilic veins are normal in compressibility, augmentation, and\nDoppler waveforms. An IV catheter is noted in the right subclavian vein, with\nnormal venous flow around it. There is no deep vein thrombosis.\n\nIMPRESSION: No DVT in the right upper extremity.\n', '13174926-RR-28', 28, ''], ['ADDENDUM: Findings were communicated to nurse ___,\nover the phone by Dr. ___ at 3:10 p.m. on ___.\n\n', '13174926-AR-29', 29, ''], ['REASON FOR EXAMINATION: Right PICC line placement.\n\nPortable AP chest radiograph was reviewed in comparison to ___.\n\nThe NG tube tip is in the stomach. The ET tube tip is extremely high, 11.5 cm\nabove the carina, at the level of vocal cord and should be advanced at least\n6-7 cm. The Swan-Ganz catheter tip is at the level of the right ventricle\noutflow tract. The intra-aortic balloon pump tip is approximately 4 cm below\nthe roof of the aortic arch. Bilateral chest tubes are in unchanged position.\nMediastinal drains are in unchanged position. Left upper lobe opacity has\ndecreased in the interim. No interval development of pneumothorax.\n\nThe PICC line is malpositioned, looping back in the axilla and continuing most\nlikely towards the basilic vein.\n', '13174926-RR-29', 29, ''], ['HISTORY: _____ CABG.\n\nCHEST, SINGLE AP PORTABLE VIEW.\n\nET tube and NG tube, left and right-sided chest tubes, and mediastinal drain\nwithin normal limits in position. Right IJ Swan-Ganz catheter tip over\npulmonary outflow tract. \n\nPossible mild pulmonary vascular plethora. Doubt overt CHF. Patchy increased\nretrocardiac density. No effusion. \n\nCompared with ___, the right-sided PICC line is no longer visualized. The\naortic balloon pump appears to have been removed. The ET tube has been\nrepositioned (now in satisfactory position approximately 3.4 cm above the\ncarina.\n', '13174926-RR-30', 30, ''], ['HISTORY: Status post CABG, pneumothorax.\n\nCHEST, SINGLE AP VIEW.\n\nSlightly oblique positioning.\n\nAn ET tube is present, tip in satisfactory position approximately 3.0 cm above\nthe carina. An NG tube is present, tip beneath diaphragm overlying stomach. \nA right IJ Swan-Ganz catheter is present, tip over right ventricular outflow\ntract. There are bilateral chest tubes and two mediastinal drains. A\nleft-sided IJ central line tip overlies the distal SVC. No pneumothorax is\ndetected.\n\nThe patient is status post sternotomy, with expected prominence of\ncardiomediastinal silhouette.Mild diffuse pulmonary vascular plethora and mild\ndiffuse vascular blurring is noted, suggesting mild CHF. No frank\nconsolidation or effusion is identified. Probable minimal bibasilar\natelectasis. Mild elevation of the left hemidiaphragm persists.\n\nIMPRESSION:\n\n1. Status post sternotomy. \n2. Lines and tubes in satisfactory position. No pneumothorax detected.\n3. Suspect mild CHF. \n', '13174926-RR-31', 31, ''], ['HISTORY: Mediastinal chest tube removal, to assess for pneumothorax.\n\nFINDINGS: In comparison with study of ___, there is no evidence of\npneumothorax. Bilateral chest tubes are in place. Mild elevation of the left\nhemidiaphragm is seen with mild atelectatic changes at the bases. Swan-Ganz\ncatheter has been removed.\n', '13174926-RR-32', 32, ''], ['CHEST RADIOGRAPH:\n\nINDICATION: Status post CABG, rule out pneumothorax.\n\nCOMPARISON: ___, 7:38.\n\nFINDINGS: As compared to the previous radiograph, the monitoring and support\ndevices have all been removed, except for the left central venous access line\nand the left pleural drain. In the interval, a large right pneumothorax has\nnewly appeared, at the level of the apex, the pneumothorax has a diameter of\napproximately 3 cm. There are no signs of tension. The referring physician,\n___ was paged notification at the time of dictation, 3:35 p.m.,\non ___. The findings were then discussed over the telephone.\n\nModerate cardiomegaly with mild retrocardiac atelectasis. Signs of mild\noverhydration.\n', '13174926-RR-33', 33, ''], ['INDICATION: Status post CABG.\n\nCOMPARISON: ___.\n\nCHEST RADIOGRAPH, PORTABLE AP VIEW: A left central line tip terminates in the\nmid SVC, unchanged. Interval decrease of large right pneumothorax, now\nminimal. Pulmonary edema is again noted. Bibasilar atelectasis is unchanged.\n\n\nModerate cardiomegaly is unchanged. The mediastinal and hilar contours are\nstable. There is no pneumothorax on the left. There is no pleural effusion.\n\nIMPRESSION:\n\n1. Interval decrease of right pneumothorax, now minimal.\n\n2. Unchanged pulmonary edema and stable moderate cardiomegaly.\n', '13174926-RR-34', 34, ''], ['EXAMINATION: Focussed ultrasound of the right internal jugular vein.\n\nINDICATION: ___ male status post emergent CABG procedure. Evaluate\nright internal jugular vein for clot.\n\nCOMPARISONS: Right upper extremity duplex ultrasound dated ___.\n\nFINDINGS:\n\nNonocclusive thrombus is seen within the right internal jugular vein. No\ncentral venous catheter is seen within the vein. There is normal\ncompressibility of the right internal jugular vein, just proximal to the clot.\nDistally, there is some flow preservation of the visualized collapsed internal\njugular vein. The right subclavian vein is patent with preserved wall-to-wall\nflow and cardiorespiratory variation.\n\nIMPRESSION: Nonocclusive clot involving the right internal jugular vein. \nPatent subclavian vein.\n\nFindings were discussed with Dr. ___ at 4:58 p.m. by telephone.\n', '13174926-RR-35', 35, ''], ['INDICATION: Status post CABG.\n\nCOMPARISON: ___.\n\nPORTABLE CHEST RADIOGRAPH: A left central line tip terminates in the mid SVC,\nunchanged in position. Multiple anterior mediastinal wires appear intact. \nThere is no pneumothorax. The cardiomediastinal and hilar contours are\nstable. Again noted is mild pulmonary edema, without significant change from\nprior study two days earlier. The left costophrenic angle is clear.\n\nIMPRESSION:\n\n1. Interval resolution of right pneumothorax.\n\n2. Mild pulmonary edema unchanged. \n', '13174926-RR-36', 36, ''], ['PORTABLE CHEST, ___\n\nCOMPARISON: ___.\n\nFINDINGS: Heart is upper limits of normal in size and distention of the\nazygous vein is present as well as pulmonary vascular congestion. \nInterstitial edema has slightly worsened in the interval and is accompanied by\nincreasing confluent basilar opacities. The latter could potentially\nrepresent dependent pulmonary edema, but aspiration pneumonia is an additional\nconsideration in the appropriate clinical setting. Small pleural effusions\nare present bilaterally. Paucity of visible bowel gas in the imaged portion\nof the abdomen raises the possibility of ascites but is not specific for this\ncondition.\n', '13174926-RR-37', 37, ''], ['REASON FOR EXAMINATION: Evaluation of the patient status post re-exploration\nfor bleeding.\n\nPortable AP chest radiograph was reviewed in comparison to ___.\n\nThe ET tube tip is just above the clavicular head, 7.5 cm above the carina. \nSwan-Ganz catheter tip is at the right main pulmonary artery. NG tube tip is\nin the stomach.\n\nCardiomediastinal silhouette is unchanged. Bilateral pleural effusions appear\nto be increased since the prior study, still associated with at least moderate\ninterstitial pulmonary edema. No appreciable pneumothorax is noted.\n', '13174926-RR-38', 38, ''], ['INDICATION: New line placement.\n\nCOMPARISON: ___.\n\nCHEST RADIOGRAPH, PORTABLE VIEW: A right-sided PICC line tip terminates in\nthe cavoatrial junction. Anterior mediastinal wires are intact. A left-sided\nSwan-Ganz is in unchanged position. Interval removal of nasogastric tube and\nETT.\n\nThe cardiac silhouette is enlarged, unchanged from prior studies. The\nmediastinal and hilar contours are stable. No pneumothorax is noted.\n\nBilateral diffuse lung opacities are again noted, and likely represent a\ncombination of moderate interstitial edema and bilateral pleural effusion. \n\n', '13174926-RR-39', 39, ''], ['REASON FOR EXAMINATION: Followup of the patient after CABG.\n\nPortable AP radiograph of the chest was reviewed in comparison to ___.\n\nThe patient continues to be in interstitial edema, moderate accompanied by\nbilateral pleural effusions and bibasal atelectasis. The Swan-Ganz catheter\nhas been removed in the interim. The right PICC line tip is at the level of\nlow SVC.\n', '13174926-RR-40', 40, ''], ['INDICATION: ___ male, status post CABG. Evaluate Dobbhoff tube\nplacement.\n\nCOMPARISON: ___.\n\nFINDINGS:\n\nA portable supine radiograph of the lower chest/upper abdomen is submitted for\nreview. There has been interval placement of a Dobbhoff tube, which extends\ninto the proximal stomach. Intact median sternotomy wires and the tip of an\nincompletely visualized right PICC are noted. There are bilateral effusions\nand persistent pulmonary edema. The lung apices are not visualized. Surgical\nclips in the right upper quadrant reflect the prior cholecystectomy.\n\nIMPRESSION:\n\n1. Dobbhoff tube extends to the proximal stomach.\n2. Persistent bilateral pleural effusions and pulmonary edema.\n', '13174926-RR-41', 41, ''], ['INDICATION: Dobbhoff tube placement.\n\nCOMPARISON: Chest radiograph ___.\n\nTWO VIEWS, ABDOMEN\n\nA Dobbhoff tube is seen projecting over the mid esophagus. On subsequent\nimages, this has been advanced into the stomach. Right-sided PICC line is\nagain noted. There is moderate pulmonary edema and bilateral pleural\neffusions.\n', '13174926-RR-42', 42, ''], ['INDICATION: Nasogastric tube placement.\n\nCOMPARISON: ___.\n\nA Dobbhoff tube has been placed and the tip lies in the lower abdomen, likely\nwithin a distended stomach. The bowel gas pattern is unremarkable with mild\nfecal loading. There is no definite intraperitoneal free air. Bilateral\npleural effusions and atelectasis are noted. Clips are noted overlying the\nright upper quadrant. Two rounded radiodensities overlying the left upper\nquadrant are of uncertain significance.\n', '13174926-RR-44', 44, ''], ['INDICATION: Placement of Dobbhoff tube.\n\nCOMPARISON: ___ and ___.\n\nTWO VIEWS CHEST: Again seen is a Dobbhoff tube in unchanged position coursing\ninto the lower abdomen where it likely resides in a distended stomach. \nRight-sided PICC line is noted in unchanged position. The heart is enlarged\nand there is moderate-to-severe pulmonary edema and small-to-moderate sized\nbilateral pleural effusions.\n', '13174926-RR-45', 45, ''], ['AP CHEST, 9:47 A.M., ___\n\nHISTORY: Productive cough.\n\nIMPRESSION: Small-to-moderate bilateral pleural effusion, left greater than\nright, has continued to decrease, smaller today than that of ___. Upper\nlungs are clear. Left lung base is partially airless, most likely\natelectasis. The cardiomediastinal silhouette is unremarkable. Right PIC\ncatheter can be traced as far as in mid SVC. No pneumothorax.\n', '13174926-RR-46', 46, ''], ['SINGLE AP PORTABLE VIEW OF THE CHEST\n\nREASON FOR EXAM: Status post CABG.\n\nComparison is made to prior study ___.\n\nCardiomediastinal contours are unchanged. Small right and small-to-moderate\nleft pleural effusion associated with adjacent bibasilar opacities, left\ngreater than right, consistent with atelectases are unchanged. Sternal wires\nare aligned. Right PICC remains in place in standard position.\n', '13174926-RR-47', 47, ''], ['INDICATION: A ___ man with right upper extremity swelling.\n\nCOMPARISON: Right arm ultrasound, ___.\n\nFINDINGS: Grayscale, color and Doppler images were obtained of the right IJ,\nsubclavian, axillary, brachial, basilic, and cephalic veins.\n\nA PICC line is seen within one of the two brachial veins. Appropriate flow is\nseen coursing past this PICC line and there is no thrombus material identified\nsurrounding it. Normal flow, compression, and augmentation is seen in all the\nvessels. Particular attention is paid to the right IJ, which demonstrates\nnormal flow and compression.\n\nIMPRESSION: No evidence of deep vein thrombosis in the right arm.\n', '13174926-RR-48', 48, ''], ['REASON FOR EXAMINATION: Evaluation of the patient after chest tube removal.\n\nPortable AP radiograph of the chest was reviewed in comparison to prior study\nfrom ___.\n\nRight PICC line tip is at the level of mid SVC. Cardiomediastinal silhouette\nis unchanged. Bibasilar atelectasis, bilateral pleural effusions and mild\npulmonary edema are unchanged. No evidence of pneumothorax is present.\n', '13174926-RR-49', 49, '']]

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10 mL Vial'], [29830193, Timestamp('2181-11-17 02:00:00'), Timestamp('2181-11-17 03:00:00'), 'MAIN', 'Fentanyl Citrate', '041384', '10019003867', '100mcg/2mL Amp'], [29830193, Timestamp('2181-11-17 10:00:00'), Timestamp('2181-11-19 15:00:00'), 'MAIN', 'Aspirin', '004376', '63739002401', '325mg Tablet'], [29830193, Timestamp('2181-11-17 04:00:00'), Timestamp('2181-11-19 15:00:00'), 'BASE', '0.9% Sodium Chloride', '001210', '00338004904', '1000mL Bag'], [29830193, Timestamp('2181-11-17 04:00:00'), Timestamp('2181-11-19 15:00:00'), 'MAIN', 'Potassium Chloride', '001255', '00409665305', '2mEq/mL-20mL'], [29830193, Timestamp('2181-11-17 22:00:00'), Timestamp('2181-11-19 15:00:00'), 'MAIN', 'Insulin', '047780', '00088222033', '100 Units / mL - 10 mL Vial'], [29830193, Timestamp('2181-11-18 01:00:00'), Timestamp('2181-11-18 00:00:00'), 'MAIN', 'Potassium Chloride', '001275', '00245004101', '10mEq ER Tablet'], [29830193, Timestamp('2181-11-17 04:00:00'), Timestamp('2181-11-18 09:00:00'), 'BASE', '5% Dextrose', '', '0', 'HEPARIN BASE'], [29830193, Timestamp('2181-11-17 04:00:00'), Timestamp('2181-11-18 09:00:00'), 'MAIN', 'Heparin Sodium', '060301', '00409779362', '25,000 unit Premix Bag'], [29830193, Timestamp('2181-11-17 08:00:00'), Timestamp('2181-11-19 15:00:00'), 'MAIN', 'Chlorhexidine Gluconate 0.12% Oral Rinse', '057959', '54569523500', '15ml Cup'], [29830193, Timestamp('2181-11-17 04:00:00'), Timestamp('2181-11-19 15:00:00'), 'BASE', '0.9% Sodium Chloride', '001210', '00338004903', '500mL Bag'], [29830193, Timestamp('2181-11-17 04:00:00'), Timestamp('2181-11-19 15:00:00'), 'MAIN', 'Potassium Chloride', '001255', '00409665305', '2mEq/mL-20mL'], [29830193, Timestamp('2181-11-17 10:00:00'), Timestamp('2181-11-19 15:00:00'), 'MAIN', 'Atorvastatin', '045772', '00071015823', '80mg Tablet'], [29830193, Timestamp('2181-11-17 03:00:00'), Timestamp('2181-11-18 23:00:00'), 'BASE', 'NS', '060300', '00338043103', '500 mL Bag'], [29830193, Timestamp('2181-11-17 03:00:00'), Timestamp('2181-11-18 23:00:00'), 'MAIN', 'Heparin (IABP)', '060300', '00338043103', '1000 Units / 500 mL Premix Bag'], [29830193, Timestamp('2181-11-17 08:00:00'), Timestamp('2181-11-19 15:00:00'), 'MAIN', 'Insulin', '047780', '00088222033', '100 Units / mL - 10 mL Vial'], [29830193, Timestamp('2181-11-17 04:00:00'), Timestamp('2181-11-19 15:00:00'), 'BASE', 'Sterile Water', '', '0', '50 mL Bag'], [29830193, Timestamp('2181-11-17 04:00:00'), Timestamp('2181-11-19 15:00:00'), 'MAIN', 'Potassium Chloride', '045309', '00338070341', '20mEq/50mL Premix'], [29830193, Timestamp('2181-11-17 05:00:00'), Timestamp('2181-11-18 04:00:00'), 'MAIN', 'Insulin', '001723', '00002821501', '100 Units / mL - 10 mL Vial'], [29830193, Timestamp('2181-11-17 04:00:00'), Timestamp('2181-11-19 15:00:00'), 'BASE', 'Bag', '', '0', '50 mL Bag'], [29830193, Timestamp('2181-11-17 04:00:00'), Timestamp('2181-11-19 15:00:00'), 'MAIN', 'Magnesium Sulfate', '016546', '00409672924', '2 g / 50 mL Premix Bag'], [29830193, Timestamp('2181-11-17 05:00:00'), Timestamp('2181-11-19 15:00:00'), 'MAIN', 'Sodium Chloride 0.9% Flush', '', '0', 'Syringe']]

[]

['cardiothoracic']

[[50861, Timestamp('2181-11-17 01:25:00'), Timestamp('2181-11-17 04:00:00'), 'Alanine Aminotransferase (ALT)'], [50863, Timestamp('2181-11-17 01:25:00'), Timestamp('2181-11-17 04:00:00'), 'Alkaline Phosphatase'], [50868, Timestamp('2181-11-17 01:25:00'), Timestamp('2181-11-17 02:59:00'), 'Anion Gap'], [50878, Timestamp('2181-11-17 01:25:00'), Timestamp('2181-11-17 04:00:00'), 'Asparate Aminotransferase (AST)'], [50882, Timestamp('2181-11-17 01:25:00'), Timestamp('2181-11-17 02:59:00'), 'Bicarbonate'], [50885, Timestamp('2181-11-17 01:25:00'), Timestamp('2181-11-17 04:00:00'), 'Bilirubin, Total'], [50893, Timestamp('2181-11-17 01:25:00'), Timestamp('2181-11-17 02:59:00'), 'Calcium, Total'], [50902, Timestamp('2181-11-17 01:25:00'), Timestamp('2181-11-17 02:59:00'), 'Chloride'], [50908, Timestamp('2181-11-17 01:25:00'), Timestamp('2181-11-17 10:55:00'), 'CK-MB Index'], [50910, Timestamp('2181-11-17 01:25:00'), Timestamp('2181-11-17 10:55:00'), 'Creatine Kinase (CK)'], [50911, Timestamp('2181-11-17 01:25:00'), Timestamp('2181-11-17 03:05:00'), 'Creatine Kinase, MB Isoenzyme'], [50912, Timestamp('2181-11-17 01:25:00'), Timestamp('2181-11-17 02:59:00'), 'Creatinine'], [50931, Timestamp('2181-11-17 01:25:00'), Timestamp('2181-11-17 02:59:00'), 'Glucose'], [50960, Timestamp('2181-11-17 01:25:00'), Timestamp('2181-11-17 02:59:00'), 'Magnesium'], [50970, Timestamp('2181-11-17 01:25:00'), Timestamp('2181-11-17 02:59:00'), 'Phosphate'], [50971, Timestamp('2181-11-17 01:25:00'), Timestamp('2181-11-17 02:59:00'), 'Potassium'], [50983, Timestamp('2181-11-17 01:25:00'), Timestamp('2181-11-17 02:59:00'), 'Sodium'], [51003, Timestamp('2181-11-17 01:25:00'), Timestamp('2181-11-17 03:05:00'), 'Troponin T'], [51006, Timestamp('2181-11-17 01:25:00'), Timestamp('2181-11-17 02:59:00'), 'Urea Nitrogen'], [51221, Timestamp('2181-11-17 01:25:00'), Timestamp('2181-11-17 01:47:00'), 'Hematocrit'], [51222, Timestamp('2181-11-17 01:25:00'), Timestamp('2181-11-17 01:47:00'), 'Hemoglobin'], [51248, Timestamp('2181-11-17 01:25:00'), Timestamp('2181-11-17 01:47:00'), 'MCH'], [51249, Timestamp('2181-11-17 01:25:00'), Timestamp('2181-11-17 01:47:00'), 'MCHC'], [51250, Timestamp('2181-11-17 01:25:00'), Timestamp('2181-11-17 01:47:00'), 'MCV'], [51265, Timestamp('2181-11-17 01:25:00'), Timestamp('2181-11-17 01:47:00'), 'Platelet Count'], [51277, Timestamp('2181-11-17 01:25:00'), Timestamp('2181-11-17 01:47:00'), 'RDW'], [51279, Timestamp('2181-11-17 01:25:00'), Timestamp('2181-11-17 01:47:00'), 'Red Blood Cells'], [51301, Timestamp('2181-11-17 01:25:00'), Timestamp('2181-11-17 01:47:00'), 'White Blood Cells'], [51237, Timestamp('2181-11-17 01:25:00'), Timestamp('2181-11-17 02:06:00'), 'INR(PT)'], [51274, Timestamp('2181-11-17 01:25:00'), Timestamp('2181-11-17 02:06:00'), 'PT'], [51275, Timestamp('2181-11-17 01:25:00'), Timestamp('2181-11-17 02:06:00'), 'PTT'], [50802, Timestamp('2181-11-17 03:35:00'), Timestamp('2181-11-17 03:56:00'), 'Base Excess'], [50804, Timestamp('2181-11-17 03:35:00'), Timestamp('2181-11-17 03:56:00'), 'Calculated Total CO2'], [50813, Timestamp('2181-11-17 03:35:00'), Timestamp('2181-11-17 03:36:00'), 'Lactate'], [50818, Timestamp('2181-11-17 03:35:00'), Timestamp('2181-11-17 03:56:00'), 'pCO2'], [50820, Timestamp('2181-11-17 03:35:00'), Timestamp('2181-11-17 03:56:00'), 'pH'], [50821, Timestamp('2181-11-17 03:35:00'), Timestamp('2181-11-17 03:56:00'), 'pO2'], [52033, Timestamp('2181-11-17 03:35:00'), Timestamp('2181-11-17 03:36:00'), 'Specimen Type'], [51463, Timestamp('2181-11-17 03:53:00'), Timestamp('2181-11-17 04:48:00'), 'Bacteria'], [51464, Timestamp('2181-11-17 03:53:00'), Timestamp('2181-11-17 04:48:00'), 'Bilirubin'], [51466, Timestamp('2181-11-17 03:53:00'), Timestamp('2181-11-17 04:48:00'), 'Blood'], [51476, Timestamp('2181-11-17 03:53:00'), Timestamp('2181-11-17 04:48:00'), 'Epithelial Cells'], [51478, Timestamp('2181-11-17 03:53:00'), Timestamp('2181-11-17 04:48:00'), 'Glucose'], [51479, Timestamp('2181-11-17 03:53:00'), Timestamp('2181-11-17 04:48:00'), 'Granular Casts'], [51482, Timestamp('2181-11-17 03:53:00'), Timestamp('2181-11-17 04:48:00'), 'Hyaline Casts'], [51484, Timestamp('2181-11-17 03:53:00'), Timestamp('2181-11-17 04:48:00'), 'Ketone'], [51486, Timestamp('2181-11-17 03:53:00'), Timestamp('2181-11-17 04:48:00'), 'Leukocytes'], [51487, Timestamp('2181-11-17 03:53:00'), Timestamp('2181-11-17 04:48:00'), 'Nitrite'], [51491, Timestamp('2181-11-17 03:53:00'), Timestamp('2181-11-17 04:48:00'), 'pH'], [51492, Timestamp('2181-11-17 03:53:00'), Timestamp('2181-11-17 04:48:00'), 'Protein'], [51493, Timestamp('2181-11-17 03:53:00'), Timestamp('2181-11-17 04:48:00'), 'RBC'], [51498, Timestamp('2181-11-17 03:53:00'), Timestamp('2181-11-17 04:48:00'), 'Specific Gravity'], [51506, Timestamp('2181-11-17 03:53:00'), Timestamp('2181-11-17 04:48:00'), 'Urine Appearance'], [51508, Timestamp('2181-11-17 03:53:00'), Timestamp('2181-11-17 04:48:00'), 'Urine Color'], [51512, Timestamp('2181-11-17 03:53:00'), Timestamp('2181-11-17 04:48:00'), 'Urine Mucous'], [51514, Timestamp('2181-11-17 03:53:00'), Timestamp('2181-11-17 04:48:00'), 'Urobilinogen'], [51516, Timestamp('2181-11-17 03:53:00'), Timestamp('2181-11-17 04:48:00'), 'WBC'], [51519, Timestamp('2181-11-17 03:53:00'), Timestamp('2181-11-17 04:48:00'), 'Yeast'], [50802, Timestamp('2181-11-17 04:02:00'), Timestamp('2181-11-17 04:05:00'), 'Base Excess'], [50804, Timestamp('2181-11-17 04:02:00'), Timestamp('2181-11-17 04:05:00'), 'Calculated Total CO2'], [50817, Timestamp('2181-11-17 04:02:00'), Timestamp('2181-11-17 04:05:00'), 'Oxygen Saturation'], [50818, Timestamp('2181-11-17 04:02:00'), Timestamp('2181-11-17 04:05:00'), 'pCO2'], [50820, Timestamp('2181-11-17 04:02:00'), Timestamp('2181-11-17 04:05:00'), 'pH'], [50821, Timestamp('2181-11-17 04:02:00'), Timestamp('2181-11-17 04:05:00'), 'pO2'], [52033, Timestamp('2181-11-17 04:02:00'), Timestamp('2181-11-17 04:04:00'), 'Specimen Type'], [50868, Timestamp('2181-11-17 06:59:00'), Timestamp('2181-11-17 08:14:00'), 'Anion Gap'], [50882, Timestamp('2181-11-17 06:59:00'), Timestamp('2181-11-17 08:14:00'), 'Bicarbonate'], [50893, Timestamp('2181-11-17 06:59:00'), Timestamp('2181-11-17 08:14:00'), 'Calcium, Total'], [50902, Timestamp('2181-11-17 06:59:00'), Timestamp('2181-11-17 08:14:00'), 'Chloride'], [50903, Timestamp('2181-11-17 06:59:00'), Timestamp('2181-11-17 14:03:00'), 'Cholesterol Ratio (Total/HDL)'], [50904, Timestamp('2181-11-17 06:59:00'), Timestamp('2181-11-17 14:03:00'), 'Cholesterol, HDL'], [50905, Timestamp('2181-11-17 06:59:00'), Timestamp('2181-11-17 14:03:00'), 'Cholesterol, LDL, Calculated'], [50907, Timestamp('2181-11-17 06:59:00'), Timestamp('2181-11-17 14:03:00'), 'Cholesterol, Total'], [50908, Timestamp('2181-11-17 06:59:00'), Timestamp('2181-11-17 10:48:00'), 'CK-MB Index'], [50910, Timestamp('2181-11-17 06:59:00'), Timestamp('2181-11-17 10:48:00'), 'Creatine Kinase (CK)'], [50911, Timestamp('2181-11-17 06:59:00'), Timestamp('2181-11-17 09:05:00'), 'Creatine Kinase, MB Isoenzyme'], [50912, Timestamp('2181-11-17 06:59:00'), Timestamp('2181-11-17 08:14:00'), 'Creatinine'], [50920, Timestamp('2181-11-17 06:59:00'), Timestamp('2181-11-17 08:14:00'), 'Estimated GFR (MDRD equation)'], [50931, Timestamp('2181-11-17 06:59:00'), Timestamp('2181-11-17 08:14:00'), 'Glucose'], [50960, Timestamp('2181-11-17 06:59:00'), Timestamp('2181-11-17 08:14:00'), 'Magnesium'], [50970, Timestamp('2181-11-17 06:59:00'), Timestamp('2181-11-17 08:14:00'), 'Phosphate'], [50971, Timestamp('2181-11-17 06:59:00'), Timestamp('2181-11-17 08:14:00'), 'Potassium'], [50983, Timestamp('2181-11-17 06:59:00'), Timestamp('2181-11-17 08:14:00'), 'Sodium'], [51000, Timestamp('2181-11-17 06:59:00'), Timestamp('2181-11-17 14:03:00'), 'Triglycerides'], [51003, Timestamp('2181-11-17 06:59:00'), Timestamp('2181-11-17 09:05:00'), 'Troponin T'], [51006, Timestamp('2181-11-17 06:59:00'), Timestamp('2181-11-17 08:14:00'), 'Urea Nitrogen'], [51221, Timestamp('2181-11-17 06:59:00'), Timestamp('2181-11-17 07:58:00'), 'Hematocrit'], [51222, Timestamp('2181-11-17 06:59:00'), Timestamp('2181-11-17 07:58:00'), 'Hemoglobin'], [51248, Timestamp('2181-11-17 06:59:00'), Timestamp('2181-11-17 07:58:00'), 'MCH'], [51249, Timestamp('2181-11-17 06:59:00'), Timestamp('2181-11-17 07:58:00'), 'MCHC'], [51250, Timestamp('2181-11-17 06:59:00'), Timestamp('2181-11-17 07:58:00'), 'MCV'], [51265, Timestamp('2181-11-17 06:59:00'), Timestamp('2181-11-17 07:58:00'), 'Platelet Count'], [51277, Timestamp('2181-11-17 06:59:00'), Timestamp('2181-11-17 07:58:00'), 'RDW'], [51279, Timestamp('2181-11-17 06:59:00'), Timestamp('2181-11-17 07:58:00'), 'Red Blood Cells'], [51301, Timestamp('2181-11-17 06:59:00'), Timestamp('2181-11-17 07:58:00'), 'White Blood Cells'], [50852, Timestamp('2181-11-17 06:59:00'), Timestamp('2181-11-18 13:22:00'), '% Hemoglobin A1c'], [51613, Timestamp('2181-11-17 06:59:00'), Timestamp('2181-11-18 13:22:00'), 'eAG'], [50802, Timestamp('2181-11-17 07:09:00'), Timestamp('2181-11-17 07:10:00'), 'Base Excess'], [50804, Timestamp('2181-11-17 07:09:00'), Timestamp('2181-11-17 07:10:00'), 'Calculated Total CO2'], [50808, Timestamp('2181-11-17 07:09:00'), Timestamp('2181-11-17 07:11:00'), 'Free Calcium'], [50813, Timestamp('2181-11-17 07:09:00'), Timestamp('2181-11-17 07:11:00'), 'Lactate'], [50818, Timestamp('2181-11-17 07:09:00'), Timestamp('2181-11-17 07:10:00'), 'pCO2'], [50820, Timestamp('2181-11-17 07:09:00'), Timestamp('2181-11-17 07:10:00'), 'pH'], [50821, Timestamp('2181-11-17 07:09:00'), Timestamp('2181-11-17 07:10:00'), 'pO2'], [52033, Timestamp('2181-11-17 07:09:00'), Timestamp('2181-11-17 07:10:00'), 'Specimen Type'], [51275, Timestamp('2181-11-17 09:40:00'), Timestamp('2181-11-17 10:15:00'), 'PTT'], [50802, Timestamp('2181-11-17 11:33:00'), Timestamp('2181-11-17 11:35:00'), 'Base Excess'], [50804, Timestamp('2181-11-17 11:33:00'), Timestamp('2181-11-17 11:35:00'), 'Calculated Total CO2'], [50805, Timestamp('2181-11-17 11:33:00'), Timestamp('2181-11-17 11:36:00'), 'Carboxyhemoglobin'], [50812, Timestamp('2181-11-17 11:33:00'), Timestamp('2181-11-17 11:34:00'), 'Intubated'], [50817, Timestamp('2181-11-17 11:33:00'), Timestamp('2181-11-17 11:36:00'), 'Oxygen Saturation'], [50818, Timestamp('2181-11-17 11:33:00'), Timestamp('2181-11-17 11:35:00'), 'pCO2'], [50820, Timestamp('2181-11-17 11:33:00'), Timestamp('2181-11-17 11:35:00'), 'pH'], [50821, Timestamp('2181-11-17 11:33:00'), Timestamp('2181-11-17 11:35:00'), 'pO2'], [50825, Timestamp('2181-11-17 11:33:00'), Timestamp('2181-11-17 11:34:00'), 'Temperature'], [52033, Timestamp('2181-11-17 11:33:00'), Timestamp('2181-11-17 11:34:00'), 'Specimen Type'], [50908, Timestamp('2181-11-17 13:28:00'), Timestamp('2181-11-17 14:39:00'), 'CK-MB Index'], [50910, Timestamp('2181-11-17 13:28:00'), Timestamp('2181-11-17 14:39:00'), 'Creatine Kinase (CK)'], [50911, Timestamp('2181-11-17 13:28:00'), Timestamp('2181-11-17 14:39:00'), 'Creatine Kinase, MB Isoenzyme'], [51003, Timestamp('2181-11-17 13:28:00'), Timestamp('2181-11-17 14:39:00'), 'Troponin T'], [50802, Timestamp('2181-11-17 13:35:00'), Timestamp('2181-11-17 13:37:00'), 'Base Excess'], [50804, Timestamp('2181-11-17 13:35:00'), Timestamp('2181-11-17 13:37:00'), 'Calculated Total CO2'], [50805, Timestamp('2181-11-17 13:35:00'), Timestamp('2181-11-17 13:37:00'), 'Carboxyhemoglobin'], [50812, Timestamp('2181-11-17 13:35:00'), Timestamp('2181-11-17 13:36:00'), 'Intubated'], [50817, Timestamp('2181-11-17 13:35:00'), Timestamp('2181-11-17 13:37:00'), 'Oxygen Saturation'], [50818, Timestamp('2181-11-17 13:35:00'), Timestamp('2181-11-17 13:37:00'), 'pCO2'], [50820, Timestamp('2181-11-17 13:35:00'), Timestamp('2181-11-17 13:37:00'), 'pH'], [50821, Timestamp('2181-11-17 13:35:00'), Timestamp('2181-11-17 13:37:00'), 'pO2'], [50825, Timestamp('2181-11-17 13:35:00'), Timestamp('2181-11-17 13:36:00'), 'Temperature'], [52033, Timestamp('2181-11-17 13:35:00'), Timestamp('2181-11-17 13:36:00'), 'Specimen Type'], [50868, Timestamp('2181-11-17 16:09:00'), Timestamp('2181-11-17 17:35:00'), 'Anion Gap'], [50882, Timestamp('2181-11-17 16:09:00'), Timestamp('2181-11-17 17:35:00'), 'Bicarbonate'], [50885, Timestamp('2181-11-17 16:09:00'), Timestamp('2181-11-18 00:13:00'), 'Bilirubin, Total'], [50893, Timestamp('2181-11-17 16:09:00'), Timestamp('2181-11-17 17:35:00'), 'Calcium, Total'], [50902, Timestamp('2181-11-17 16:09:00'), Timestamp('2181-11-17 17:35:00'), 'Chloride'], [50912, Timestamp('2181-11-17 16:09:00'), Timestamp('2181-11-17 17:35:00'), 'Creatinine'], [50931, Timestamp('2181-11-17 16:09:00'), Timestamp('2181-11-17 17:35:00'), 'Glucose'], [50935, Timestamp('2181-11-17 16:09:00'), Timestamp('2181-11-18 00:13:00'), 'Haptoglobin'], [50954, Timestamp('2181-11-17 16:09:00'), Timestamp('2181-11-18 00:13:00'), 'Lactate Dehydrogenase (LD)'], [50960, Timestamp('2181-11-17 16:09:00'), Timestamp('2181-11-17 17:35:00'), 'Magnesium'], [50970, Timestamp('2181-11-17 16:09:00'), Timestamp('2181-11-17 17:35:00'), 'Phosphate'], [50971, Timestamp('2181-11-17 16:09:00'), Timestamp('2181-11-17 17:35:00'), 'Potassium'], [50983, Timestamp('2181-11-17 16:09:00'), Timestamp('2181-11-17 17:35:00'), 'Sodium'], [51006, Timestamp('2181-11-17 16:09:00'), Timestamp('2181-11-17 17:35:00'), 'Urea Nitrogen'], [51221, Timestamp('2181-11-17 16:10:00'), Timestamp('2181-11-17 17:02:00'), 'Hematocrit'], [51222, Timestamp('2181-11-17 16:10:00'), Timestamp('2181-11-17 17:02:00'), 'Hemoglobin'], [51248, Timestamp('2181-11-17 16:10:00'), Timestamp('2181-11-17 17:02:00'), 'MCH'], [51249, Timestamp('2181-11-17 16:10:00'), Timestamp('2181-11-17 17:02:00'), 'MCHC'], [51250, Timestamp('2181-11-17 16:10:00'), Timestamp('2181-11-17 17:02:00'), 'MCV'], [51265, Timestamp('2181-11-17 16:10:00'), Timestamp('2181-11-17 17:02:00'), 'Platelet Count'], [51277, Timestamp('2181-11-17 16:10:00'), Timestamp('2181-11-17 17:02:00'), 'RDW'], [51279, Timestamp('2181-11-17 16:10:00'), Timestamp('2181-11-17 17:02:00'), 'Red Blood Cells'], [51301, Timestamp('2181-11-17 16:10:00'), Timestamp('2181-11-17 17:02:00'), 'White Blood Cells'], [51275, Timestamp('2181-11-17 16:10:00'), Timestamp('2181-11-17 16:56:00'), 'PTT'], [51275, Timestamp('2181-11-17 22:10:00'), Timestamp('2181-11-17 22:52:00'), 'PTT'], [50868, Timestamp('2181-11-17 22:12:00'), Timestamp('2181-11-18 00:08:00'), 'Anion Gap'], [50882, Timestamp('2181-11-17 22:12:00'), Timestamp('2181-11-18 00:08:00'), 'Bicarbonate'], [50893, Timestamp('2181-11-17 22:12:00'), Timestamp('2181-11-18 00:08:00'), 'Calcium, Total'], [50902, Timestamp('2181-11-17 22:12:00'), Timestamp('2181-11-18 00:08:00'), 'Chloride'], [50908, Timestamp('2181-11-17 22:12:00'), Timestamp('2181-11-18 00:08:00'), 'CK-MB Index'], [50910, Timestamp('2181-11-17 22:12:00'), Timestamp('2181-11-18 00:08:00'), 'Creatine Kinase (CK)'], [50911, Timestamp('2181-11-17 22:12:00'), Timestamp('2181-11-18 00:08:00'), 'Creatine Kinase, MB Isoenzyme'], [50912, Timestamp('2181-11-17 22:12:00'), Timestamp('2181-11-18 00:08:00'), 'Creatinine'], [50931, Timestamp('2181-11-17 22:12:00'), Timestamp('2181-11-18 00:08:00'), 'Glucose'], [50960, Timestamp('2181-11-17 22:12:00'), Timestamp('2181-11-18 00:08:00'), 'Magnesium'], [50970, Timestamp('2181-11-17 22:12:00'), Timestamp('2181-11-18 00:08:00'), 'Phosphate'], [50971, Timestamp('2181-11-17 22:12:00'), Timestamp('2181-11-18 00:08:00'), 'Potassium'], [50983, Timestamp('2181-11-17 22:12:00'), Timestamp('2181-11-18 00:08:00'), 'Sodium'], [51003, Timestamp('2181-11-17 22:12:00'), Timestamp('2181-11-18 00:08:00'), 'Troponin T'], [51006, Timestamp('2181-11-17 22:12:00'), Timestamp('2181-11-18 00:08:00'), 'Urea Nitrogen'], [51221, Timestamp('2181-11-17 22:12:00'), Timestamp('2181-11-17 22:35:00'), 'Hematocrit'], [51222, Timestamp('2181-11-17 22:12:00'), Timestamp('2181-11-17 22:35:00'), 'Hemoglobin'], [51248, Timestamp('2181-11-17 22:12:00'), Timestamp('2181-11-17 22:35:00'), 'MCH'], [51249, Timestamp('2181-11-17 22:12:00'), Timestamp('2181-11-17 22:35:00'), 'MCHC'], [51250, Timestamp('2181-11-17 22:12:00'), Timestamp('2181-11-17 22:35:00'), 'MCV'], [51265, Timestamp('2181-11-17 22:12:00'), Timestamp('2181-11-17 22:35:00'), 'Platelet Count'], [51277, Timestamp('2181-11-17 22:12:00'), Timestamp('2181-11-17 22:35:00'), 'RDW'], [51279, Timestamp('2181-11-17 22:12:00'), Timestamp('2181-11-17 22:35:00'), 'Red Blood Cells'], [51301, Timestamp('2181-11-17 22:12:00'), Timestamp('2181-11-17 22:35:00'), 'White Blood Cells'], [50802, Timestamp('2181-11-17 22:25:00'), Timestamp('2181-11-17 22:28:00'), 'Base Excess'], [50804, Timestamp('2181-11-17 22:25:00'), Timestamp('2181-11-17 22:28:00'), 'Calculated Total CO2'], [50808, Timestamp('2181-11-17 22:25:00'), Timestamp('2181-11-17 22:28:00'), 'Free Calcium'], [50812, Timestamp('2181-11-17 22:25:00'), Timestamp('2181-11-17 22:27:00'), 'Intubated'], [50813, Timestamp('2181-11-17 22:25:00'), Timestamp('2181-11-17 22:28:00'), 'Lactate'], [50816, Timestamp('2181-11-17 22:25:00'), Timestamp('2181-11-17 22:27:00'), 'Oxygen'], [50818, Timestamp('2181-11-17 22:25:00'), Timestamp('2181-11-17 22:28:00'), 'pCO2'], [50819, Timestamp('2181-11-17 22:25:00'), Timestamp('2181-11-17 22:27:00'), 'PEEP'], [50820, Timestamp('2181-11-17 22:25:00'), Timestamp('2181-11-17 22:28:00'), 'pH'], [50821, Timestamp('2181-11-17 22:25:00'), Timestamp('2181-11-17 22:28:00'), 'pO2'], [50825, Timestamp('2181-11-17 22:25:00'), Timestamp('2181-11-17 22:27:00'), 'Temperature'], [50826, Timestamp('2181-11-17 22:25:00'), Timestamp('2181-11-17 22:27:00'), 'Tidal Volume'], [50827, Timestamp('2181-11-17 22:25:00'), Timestamp('2181-11-17 22:27:00'), 'Ventilation Rate'], [52033, Timestamp('2181-11-17 22:25:00'), Timestamp('2181-11-17 22:27:00'), 'Specimen Type']]

Question: A 54 M is admitted. He/she says he/she has chest pain . History of illness: ___ YO M with DMII, HTN, HLD, PVD s/p fem-pop bypass on the left and iliac stent on the right, ? h/o MI without intervention, presented to the ED at ___ found to be in DKA with glucose in the 490's. Per report ___ with gradual onset weakness, nausea, loose stool, excessive thirst. Due to decreased PO intake ___ omitted "several days" of insulin therapy. Progressive symptoms prompted presentation to OSH ED found to have a ph 7.0 and admitted to ICU for treatment of DKA. In the ICU ___ placed on an Insulin gtt overnight and covered empirically with broad spectrum antibiotics: vancomycin and flagyl. In the AM, gap had resolved and pH normalized and transitioned to SQ Lantus. Antibiotics were stopped as clinical suspicion for infection low. Later in morning, he was noted to develop increased agitation, EKG showed ST depression V4-V6. ___ started on Arixtra for anticoagulation as unable to start Heparin secondary to allergy (though pt received hep SQ during OSH stay without problem) and ___ refused Plavix. CXR obtained which was consistent with volume overload. He was urgently taken to Cath lab. Per report he was intubated for respiratory stabilization pre-procedure but had never been hypoxic. In cath lab, he was noted to have severe distal left main disease with diffused LAD disease, RCA noted to be chronically occluded, there are collateral artery L-R and R-R, PCWP of 35, EF of ___. IABP was placed through right femoral artery and vein. In the cath lab he was given 40mg of IV Lasix, 5 of dobutamine and 20 of levophed and agumented BP to 140s of note his prior unaugmented SBP was 85-90 systolic. Per med flight ___ with uneventful transport. He is sedated (versed) and paralyzed (vecuronium). On arrival to the CCU ___ SBP is augmented with levophed. Cardiac surgery consulted for coronary revascularization. Past Medical History: Diabetes mellitus Type II Peripheral Vascular Disease Hypertension Hypercholesterolemia ?prior Myocardial infarctions without intervention Prior Transient Ischemic Attacks History of Alcohol abuse s/p Right lower extremity SFA to AT bypass eith saphenous vein ___ Appendectomy Laparoscopic cholecystectomy Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Allergies: Keflex What is the best procedure plan for this patient?

TARGETS Target Prescriptions: 0.9% Sodium Chloride Potassium Chloride Lorazepam Famotidine Bag Magnesium Sulfate Sodium Chloride 0.9% Flush Lorazepam Senna Heparin Soln Fentanyl Citrate Docusate Sodium (Liquid) Bisacodyl 5% Dextrose NORepinephrine 0.9% Sodium Chloride Insulin Human Regular Bisacodyl Acetaminophen (Liquid) Soln Fentanyl Citrate Potassium Chloride 0.9% Sodium Chloride Sodium Phosphate Heparin Insulin Dextrose 50% Sterile Water Potassium Chloride Glucagon 0.9% Sodium Chloride Midazolam Bag Magnesium Sulfate Insulin Fentanyl Citrate Aspirin 0.9% Sodium Chloride Potassium Chloride Insulin Potassium Chloride 5% Dextrose Heparin Sodium Chlorhexidine Gluconate 0.12% Oral Rinse 0.9% Sodium Chloride Potassium Chloride Atorvastatin NS Heparin (IABP) Insulin Sterile Water Potassium Chloride Insulin Bag Magnesium Sulfate Sodium Chloride 0.9% Flush Target Lab Orders: Alanine Aminotransferase (ALT) Alkaline Phosphatase Anion Gap Asparate Aminotransferase (AST) Bicarbonate Bilirubin, Total Calcium, Total Chloride CK-MB Index Creatine Kinase (CK) Creatine Kinase, MB Isoenzyme Creatinine Glucose Magnesium Phosphate Potassium Sodium Troponin T Urea Nitrogen Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells INR(PT) PT PTT Base Excess Calculated Total CO2 Lactate pCO2 pH pO2 Specimen Type Bacteria Bilirubin Blood Epithelial Cells Glucose Granular Casts Hyaline Casts Ketone Leukocytes Nitrite pH Protein RBC Specific Gravity Urine Appearance Urine Color Urine Mucous Urobilinogen WBC Yeast Base Excess Calculated Total CO2 Oxygen Saturation pCO2 pH pO2 Specimen Type Anion Gap Bicarbonate Calcium, Total Chloride Cholesterol Ratio (Total/HDL) Cholesterol, HDL Cholesterol, LDL, Calculated Cholesterol, Total CK-MB Index Creatine Kinase (CK) Creatine Kinase, MB Isoenzyme Creatinine Estimated GFR (MDRD equation) Glucose Magnesium Phosphate Potassium Sodium Triglycerides Troponin T Urea Nitrogen Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells % Hemoglobin A1c eAG Base Excess Calculated Total CO2 Free Calcium Lactate pCO2 pH pO2 Specimen Type PTT Base Excess Calculated Total CO2 Carboxyhemoglobin Intubated Oxygen Saturation pCO2 pH pO2 Temperature Specimen Type CK-MB Index Creatine Kinase (CK) Creatine Kinase, MB Isoenzyme Troponin T Base Excess Calculated Total CO2 Carboxyhemoglobin Intubated Oxygen Saturation pCO2 pH pO2 Temperature Specimen Type Anion Gap Bicarbonate Bilirubin, Total Calcium, Total Chloride Creatinine Glucose Haptoglobin Lactate Dehydrogenase (LD) Magnesium Phosphate Potassium Sodium Urea Nitrogen Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells PTT PTT Anion Gap Bicarbonate Calcium, Total Chloride CK-MB Index Creatine Kinase (CK) Creatine Kinase, MB Isoenzyme Creatinine Glucose Magnesium Phosphate Potassium Sodium Troponin T Urea Nitrogen Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells Base Excess Calculated Total CO2 Free Calcium Intubated Lactate Oxygen pCO2 PEEP pH pO2 Temperature Tidal Volume Ventilation Rate Specimen Type Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : ___ Year old male with DMII, Hypertension, Hyperlipidemia, Peripheral vascular disease, question history of Myocardial Infarction without intervention, initially treated for Diabetic keto acidosis but found to have worsening signs of Congestive heart failure, EKG changes, + Cardiac enzymes, ejection fraction of 10%, intubated, IABP in place and on pressors for treatment of cardiogenic shock transferred via med flight from outside hospital. His hospital course was complicated by multiple episodes of VF arrest. On ___ he was taken to the operating room and underwent emergent coronary artery bypass grafting x3 on an intra-aortic balloon pump with left internal mammary artery to left anterior descending coronary; reverse saphenous vein single graft from aorta to ramus intermedius coronary artery; reverse saphenous vein single graft from aorta to first obtuse marginal coronary artery with ___. Cardiopulmonary BYPASS TIME: 92 minutes. CROSS-CLAMP TIME: 64 minutes. Please see operative report for further surgical details. He was transferred to the CVICU intubated, sedated on pressors. He remained intubated on pressors until ___ when he was weaned off and was successfully extubated. Events: ___ he was hypotensive requiring pressors and decreasing renal function. An echocargiogram was done and revealed a large pericardial effusion with right ventricular diastolic collapse. He was taken to the operating room for Subxiphoid pericardial window. Respiratory: aggressive pulmonary toilet, chest ___, nebs, his oxygen requirement improved to ___ via nasal cannula. Chest-tubes: were all removed per protocol Cardiac: Intermittent atrial fibrillation 90-135, amiodarone bolus and drip with low-dose beta-blocker he converted to sinus rhythm. GI: aggressive bowel regimen and PPI were continued Nutrition: he was seen by Speech and Swallow on ___ who recommended regular diet thin liquid, medications whole with water. His PO intake was poor. On ___ he was seen again by Speech who recommended a regular diet, thin liquid and medications whole pills. Nutrition recommended Cardiac, Diabetic, Sugar-Free Carnation Instant Breakfast. His PO intake continued to be poor therefore a Doboff feeding tube was placed and tube feeds were started. Nutrition recommended Boost Glucose Control @ 90 mL x 15 hrs to supplement his PO intake. ID: On ___ he was seen by infectious disease for low-grade fevers, positive BC for strept viridans, catheter tip with ___. He completed a 2 week course of Vancomycin and fluconazole per ID recommendations. Renal: Renal function baseline Creatnine 0.9 On ___ his Creatnine increased to 1.3 peak 2.1 secondary to large pericardial effusion which once treated his renal function returned to his baseline. He was gently diuresed. His electrolytes were repleted as needed. Required foley re-insertion for urinary retention. Flomax was started and he was discharged to rehab with his Foley. He will have a void trial on ___, following a week of Flomax therapy. Endocrine: Insulin drip was titrated to maintain blood sugars < 150 converted to Lantus with sliding scale regular once transfer to floor Neuro: Flat-affect. follows commands. Pain well controlled with PO pain medications. Disposition: He was seen by physical therapy. Requires max assist for ambulation and lift device. On POD 24 he was discharged to ___ in ___. All follow up appointments were advised. Other Results: ___ 05:00AM BLOOD WBC-5.1 RBC-3.23* Hgb-10.3* Hct-31.2* MCV-97 MCH-32.0 MCHC-33.1 RDW-18.1* Plt ___ ___ 03:17AM BLOOD WBC-4.9 RBC-3.30* Hgb-10.6* Hct-31.4* MCV-95 MCH-32.1* MCHC-33.7 RDW-18.1* Plt ___ ___ 04:38AM BLOOD WBC-5.1 RBC-3.22* Hgb-10.3* Hct-31.1* MCV-97 MCH-32.0 MCHC-33.2 RDW-18.5* Plt ___ ___ 05:00AM BLOOD Glucose-116* UreaN-33* Creat-1.2 Na-138 K-4.3 Cl-99 HCO3-30 AnGap-13 ___ 05:59AM BLOOD Glucose-69* UreaN-31* Creat-1.0 Na-138 K-3.5 Cl-96 HCO3-34* AnGap-12 ___ 03:17AM BLOOD Glucose-243* UreaN-31* Creat-0.9 Na-134 K-4.4 Cl-94* HCO3-34* AnGap-10 ___ 05:15AM BLOOD UreaN-26* Creat-0.7 Na-137 K-4.3 Cl-96 . Biomarker Trend: ___ 01:25AM BLOOD CK-MB-215* MB Indx-14.0* cTropnT-2.54* ___ 06:59AM BLOOD CK-MB-251* MB Indx-12.5* cTropnT-4.64* ___ 01:28PM BLOOD CK-MB-167* MB Indx-7.9* cTropnT-5.01* ___ 10:12PM BLOOD CK-MB-63* MB Indx-4.1 cTropnT-3.30* ___ 05:01AM BLOOD CK-MB-35* MB Indx-2.8 cTropnT-3.12* ___ 05:25PM BLOOD CK-MB-15* MB Indx-1.4 cTropnT-3.09* ___ 11:07PM BLOOD CK-MB-11* MB Indx-1.2 cTropnT-2.39* ___ 06:59AM BLOOD % HbA1c-11.4* eAG-280* Imaging: . OSH CARDIAC CATH: ___ LM 90% LAD: 90% Lcx: luminal irregularities RCA: 100% Right heart cath: RA: 15 RV: ___ PA: 50/35 PCWP: 35 Cardiac Output: 3.8L/min Cardiac Index: 2L/min/m2. EF: 15%, no significant MR . CXR: PORTABLE CHEST, ___ FINDINGS: Radiodense tip of an intraaortic balloon pump is at the expected junction of the superior aspect of the aortic knob and left subclavian artery, as communicated by telephone to Dr. ___ on ___ at 8:20 a.m. Endotracheal tube and nasogastric tube are in standard position. Heart size is normal. Bilateral interstitial pulmonary edema is present as well as an asymmetrical left perihilar alveolar process, likely reflecting asymmetrical edema. . TTE: ___ The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is severe global left ventricular hypokinesis (LVEF = ___ %). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. There is no aortic valve stenosis. No aortic regurgitation is seen. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. ___ ECHOCARDIOGRAPHY REPORT ___ ___ MRN: ___ TEE (Complete) Done ___ at 1:36:29 ___ FINAL Referring Physician ___ ___. ___ Status: Inpatient DOB: ___ Age (years): ___ M Hgt (in): 70 BP (mm Hg): 103/67 Wgt (lb): 150 HR (bpm): 78 BSA (m2): 1.85 m2 Indication: Intraoperative TEE for CABG procedure. Chest pain. Coronary artery disease. Left ventricular function. Preoperative assessment. Right ventricular function. ICD-9 Codes: 786.___, 786.51, 424.0, 424.2 ___ Information Date/Time: ___ at 13:36 ___ MD: ___, MD ___ Type: TEE (Complete) Sonographer: ___, MD Doppler: Limited Doppler and color Doppler ___ Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: ___-: Machine: u/s 3 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 20% >= 55% Aorta - Ascending: 2.9 cm <= 3.4 cm Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. LEFT VENTRICLE: Severe regional LV systolic dysfunction. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal descending aorta diameter. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mild (1+) MR. ___ VALVE: Mild [1+] TR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with ___ regulations. The ___ was under general anesthesia throughout the procedure. No TEE related complications. The ___ appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the ___. Left pleural effusion. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions Prebypass No atrial septal defect is seen by 2D or color Doppler. There is severe regional left ventricular systolic dysfunction with akinesia of the apex and apical portion of the inferior wall. There is also hypokinesia of the apical and mid portions of the anterior, anteroseptal and inferospetal walls . Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. Mild (1+) mitral regurgitation is seen. Tip of IABP in good position. Dr. ___ was notified in person of the results on ___ at 1230pm. Post bypass ___ is AV paced and receiving an infusion of phenylephrine, milrinone and epinephrine. LVEF= 35%. Aorta is intact post decannulation. Mild mitral regurgitation present. I certify that I was present for this procedure in compliance with ___ regulations. Electronically signed by ___, MD, Interpreting physician ___ ___ 17:03 © ___ ___. All rights reserved.

2185-12-21 00:00:00

ENGLISH

SINGLE

WHITE

M

[[26762034, Timestamp('2185-12-21 02:17:04'), '', 'CSURG']]

[[{'Medications on Admission': ':\n1. Lisinopril 10 mg PO DAILY \n2. Atorvastatin 80 mg PO QPM \n3. Furosemide 10 mg PO DAILY ', 'Brief Hospital Course': ':\nMr. ___ was scheduled for an aortic valve replacement this \nmorning, however he arrived for surgery 4 hours late, having \neaten breakfast. Dr. ___ him until he could ensure \nthat he was able to return for surgery on ___ morning, having \nfollowed his pre-operative instructions.\n\n', 'Pertinent Results:': '\nnone\n\n', 'Physical Exam:|Physical': '\nPulse:89 Resp:18 O2 sat:97%RA\nB/P ___\nHeight:67" Weight:100.7kg\n\nGeneral: overweight white older male\nSkin: Dry [x] intact [x]\nHEENT: PERRLA [x] EOMI [x]\nNeck: Supple [x] Full ROM [x]\nChest: Lungs clear bilaterally x[]\nHeart: RRR [x] Irregular [] Murmur [x] grade SEM ___\nAbdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds\n+\n[]\nExtremities: Warm [x], well-perfused [] Edema [] dry ___: None [x]\nNeuro: Grossly intact [x]\nPulses:\nFemoral Right: 2+ palp Left:2+ palp \nDP Right: 2+ palp Left:2+ palp \n___ Right: 2+ palp Left:2+ palp \nRadial Right: 2+ palp Left:2+ palp \n\nCarotid Bruit Right: none Left: none\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\n___ year old male who originally\npresented to ___ with chest pain, shortness of\nbreath, and respiratory distress. He has had increasing chest\npain and shortness of breath over the last week. \n While at ___, he was found to have an elevated DDIMER at\n1.16. Echocardiogram was obtained and revealed severe aortic\nstenosis. He was admitted for diuresis over the weekend. He was\ntransferred to ___ for further evaluation and cardiac\ncatheterization. \n He was found to have non-obstructive CAD upon cardiac\ncatheterization and is now being referred to cardiac surgery for\nan aortic valve replacement. \n\nPast Medical History:\nNewly diagnosed systolic heart failure\nHypertension (pt denies)\nRight eye blindness \nRight Achilles repair\n\nSocial History:\n___\nFamily History:\nFamily History:Premature coronary artery disease- Father died of\nan MI at ___, mother had a MI at ___\n\n', 'Chief Complaint:|Complaint:': '\nnone\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nNo Known Allergies / Adverse Drug Reactions\n\n'}, '10400376-DS-2', 2, 'cardiothoracic']]

[]

[[26762034, Timestamp('2185-12-21 16:00:00'), Timestamp('2185-12-21 23:00:00'), 'MAIN', 'PNEUMOcoccal 23-valent polysaccharide vaccine', '048548', '00006494300', '25mcg/0.5mL Vial'], [26762034, Timestamp('2185-12-21 16:00:00'), Timestamp('2185-12-21 23:00:00'), 'MAIN', 'Multivitamins', '002532', '00904053061', '1 Tablet'], [26762034, Timestamp('2185-12-21 16:00:00'), Timestamp('2185-12-21 23:00:00'), 'MAIN', 'Senna', '019964', '00904516561', '8.6 mg Tablet'], [26762034, Timestamp('2185-12-21 16:00:00'), Timestamp('2185-12-21 23:00:00'), 'MAIN', 'Docusate Sodium', '003009', '00904224461', '100mg Capsule'], [26762034, Timestamp('2185-12-21 16:00:00'), Timestamp('2185-12-21 23:00:00'), 'MAIN', 'Senna', '002922', '57896045208', '8.6 mg / 4.9 mL Syringe'], [26762034, Timestamp('2185-12-21 16:00:00'), Timestamp('2185-12-21 23:00:00'), 'MAIN', 'FoLIC Acid', '002366', '51079010520', '1 mg Tab'], [26762034, Timestamp('2185-12-21 16:00:00'), Timestamp('2185-12-21 23:00:00'), 'MAIN', 'Sodium Chloride 0.9% Flush', '', '0', '10 mL Syringe'], [26762034, Timestamp('2185-12-21 16:00:00'), Timestamp('2185-12-21 23:00:00'), 'MAIN', 'Influenza Vaccine Quadrivalent', '075715', '49281041688', '0.5 mL Syringe'], [26762034, Timestamp('2185-12-21 16:00:00'), Timestamp('2185-12-21 23:00:00'), 'MAIN', 'Docusate Sodium', '003020', '57896042101', '100 mg Tablet']]

[]

['cardiothoracic']

[]

Question: A 78 M is admitted. He/she says he/she has none . History of illness: ___ year old male who originally presented to ___ with chest pain, shortness of breath, and respiratory distress. He has had increasing chest pain and shortness of breath over the last week. While at ___, he was found to have an elevated DDIMER at 1.16. Echocardiogram was obtained and revealed severe aortic stenosis. He was admitted for diuresis over the weekend. He was transferred to ___ for further evaluation and cardiac catheterization. He was found to have non-obstructive CAD upon cardiac catheterization and is now being referred to cardiac surgery for an aortic valve replacement. Past Medical History: Newly diagnosed systolic heart failure Hypertension (pt denies) Right eye blindness Right Achilles repair Social History: ___ Family History: Family History:Premature coronary artery disease- Father died of an MI at ___, mother had a MI at ___ Allergies: No Known Allergies / Adverse Drug Reactions What is the best procedure plan for this patient?

TARGETS Target Prescriptions: PNEUMOcoccal 23-valent polysaccharide vaccine Multivitamins Senna Docusate Sodium Senna FoLIC Acid Sodium Chloride 0.9% Flush Influenza Vaccine Quadrivalent Docusate Sodium Target Lab Orders: NONE Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : Mr. ___ was scheduled for an aortic valve replacement this morning, however he arrived for surgery 4 hours late, having eaten breakfast. Dr. ___ him until he could ensure that he was able to return for surgery on ___ morning, having followed his pre-operative instructions. Other Results: none

2130-08-13 18:14:00

ENGLISH

SINGLE

BLACK/AFRICAN AMERICAN

F

[[26810295, Timestamp('2130-08-13 18:15:53'), '', 'OBS']]

[[{'Medications on Admission': ':\nPNV', 'Brief Hospital Course': 'NIL', 'Pertinent Results:': '\n___ 12:00AM HCT-36.___ yo ___ s/p SVD at ___ Hospital on ___ at 35 weeks \ntransferred to ___ for NICU proximity. She remained stable \nwithout issues. She was discharged in stable condition on \n___ with plan for repeat glucose screening at 6 week \npostpartum visit for GDMA1.\n\n', 'Physical Exam:|Physical': '\nGen: NAD, well-appearing\nBreasts: non-tender, no erythema\nCV: RRR\nResp: no respiratory distress \nAbd: soft, non-tender, fundus firm 3 cm below umbilicus \nGU: scant spotting \nExt: non-tender, no edema \n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\nMs. ___ is a ___ yo G5 now ___ s/p SVD at ___\non ___ at 35 weeks transferred to ___ for NICU proximity.\nPatient went into preterm labor ___ with subsequent\nuncomplicated SVD on ___. This pregnancy was complicated by\nGDMA1, diet controlled. She reports her pain is well controlled\nwith Ibuprofen, bleeding is minimal, breast feeding is going\nwell, and denies CP, SOB. \n\nPNC: \n- ___: ___\n- Rh+/cold auto-AB (cold agglutinin screen +)/HBsAg neg/RI/RPR\nNR/HIV neg\n- Screening: NIPT wnl \n- FFS: bilateral fetal pyelectasis, pt counseled and requested\nNIPT which was wnl, f/u U/S on ___ kidneys wnl \n- GLT: elevated, failed GTT -> GDMA1, diet controlled, seen by\nendocrine \n- Issues: GDMA1, diet controlled, bilateral fetal pyelectasis\nresolved on repeat U/S \n\nPast Medical History:\nOBHx: G5P3\n- SVD x3, FT x 2, ___ x 1\n- SAB x 2, D&C x 1\n- GDMA1 in most recent pregnancy, diet controlled\n\nPGYNHx:\n- Denies hx of ectopic pregnancy, fibroids, endometriosis. \nRemote\nhistory of chlamydia s/p treatment. \n- Denies hx of abnormal pap smears. \n\nPMHx: Denies\n\nPSHx: \n- D&C for SAB\n\nSocial History:\n___\nFamily History:\nNC\n\n', 'Chief Complaint:|Complaint:': '\ntransfer of care for NICU proximity\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nFlagyl / Tylenol-Codeine\n\n'}, '15426262-DS-19', 19, 'obstetrics/gynecology']]

[]

[[26810295, Timestamp('2130-08-13 19:00:00'), Timestamp('2130-08-13 18:00:00'), 'MAIN', 'Docusate Sodium', '003009', '00904224461', '100mg Capsule'], [26810295, Timestamp('2130-08-13 19:00:00'), Timestamp('2130-08-13 18:00:00'), 'MAIN', 'Milk of Magnesia', '003026', '00121043130', '30mL UD Cup'], [26810295, Timestamp('2130-08-13 19:00:00'), Timestamp('2130-08-13 18:00:00'), 'MAIN', 'Acetaminophen', '004490', '00904198861', '500mg Tablet'], [26810295, Timestamp('2130-08-13 19:00:00'), Timestamp('2130-08-15 17:00:00'), 'MAIN', 'Simethicone', '002821', '37205011278', '80mg Tablet'], [26810295, Timestamp('2130-08-13 19:00:00'), Timestamp('2130-08-13 18:00:00'), 'MAIN', 'Calcium Carbonate', '002689', '66553000401', '500mg Tablet'], [26810295, Timestamp('2130-08-13 19:00:00'), Timestamp('2130-08-15 17:00:00'), 'MAIN', 'Docusate Sodium', '003009', '00904224461', '100mg Capsule'], [26810295, Timestamp('2130-08-13 19:00:00'), Timestamp('2130-08-15 17:00:00'), 'MAIN', 'Influenza Vaccine Quadrivalent', '074020', '49281041550', '0.5 mL Syringe'], [26810295, Timestamp('2130-08-13 19:00:00'), Timestamp('2130-08-13 18:00:00'), 'MAIN', 'Tetanus-DiphTox-Acellular Pertuss (Adacel)', '063901', '49281040015', '0.5 mL Injection'], [26810295, Timestamp('2130-08-13 19:00:00'), Timestamp('2130-08-15 17:00:00'), 'MAIN', 'Bisacodyl', '002944', '00574705050', '10mg Suppository'], [26810295, Timestamp('2130-08-13 19:00:00'), Timestamp('2130-08-13 18:00:00'), 'MAIN', 'Ibuprofen', '008349', '00904585461', '600mg Tablet'], [26810295, Timestamp('2130-08-13 19:00:00'), Timestamp('2130-08-15 17:00:00'), 'MAIN', 'Tetanus-DiphTox-Acellular Pertuss (Adacel)', '063901', '49281040015', '0.5 mL Injection'], [26810295, Timestamp('2130-08-13 19:00:00'), Timestamp('2130-08-15 17:00:00'), 'MAIN', 'Milk of Magnesia', '003026', '00121043130', '30mL UD Cup'], [26810295, Timestamp('2130-08-13 19:00:00'), Timestamp('2130-08-15 17:00:00'), 'MAIN', 'Ibuprofen', '008349', '00904585461', '600mg Tablet'], [26810295, Timestamp('2130-08-13 19:00:00'), Timestamp('2130-08-13 18:00:00'), 'MAIN', 'Simethicone', '002821', '37205011278', '80mg Tablet'], [26810295, Timestamp('2130-08-13 19:00:00'), Timestamp('2130-08-13 18:00:00'), 'MAIN', 'Bisacodyl', '002944', '00574705050', '10mg Suppository'], [26810295, Timestamp('2130-08-13 19:00:00'), Timestamp('2130-08-15 17:00:00'), 'MAIN', 'Acetaminophen', '004490', '00904198861', '500mg Tablet'], [26810295, Timestamp('2130-08-13 19:00:00'), Timestamp('2130-08-13 18:00:00'), 'MAIN', 'Influenza Vaccine Quadrivalent', '074020', '49281041550', '0.5 mL Syringe'], [26810295, Timestamp('2130-08-13 19:00:00'), Timestamp('2130-08-15 17:00:00'), 'MAIN', 'Calcium Carbonate', '002689', '66553000401', '500mg Tablet']]

[]

['obstetrics/gynecology']

[[51221, Timestamp('2130-08-14 00:00:00'), Timestamp('2130-08-14 00:45:00'), 'Hematocrit']]

Question: A 25 F is admitted. He/she says he/she has transfer of care for NICU proximity . History of illness: Ms. ___ is a ___ yo G5 now ___ s/p SVD at ___ on ___ at 35 weeks transferred to ___ for NICU proximity. Patient went into preterm labor ___ with subsequent uncomplicated SVD on ___. This pregnancy was complicated by GDMA1, diet controlled. She reports her pain is well controlled with Ibuprofen, bleeding is minimal, breast feeding is going well, and denies CP, SOB. PNC: - ___: ___ - Rh+/cold auto-AB (cold agglutinin screen +)/HBsAg neg/RI/RPR NR/HIV neg - Screening: NIPT wnl - FFS: bilateral fetal pyelectasis, pt counseled and requested NIPT which was wnl, f/u U/S on ___ kidneys wnl - GLT: elevated, failed GTT -> GDMA1, diet controlled, seen by endocrine - Issues: GDMA1, diet controlled, bilateral fetal pyelectasis resolved on repeat U/S Past Medical History: OBHx: G5P3 - SVD x3, FT x 2, ___ x 1 - SAB x 2, D&C x 1 - GDMA1 in most recent pregnancy, diet controlled PGYNHx: - Denies hx of ectopic pregnancy, fibroids, endometriosis. Remote history of chlamydia s/p treatment. - Denies hx of abnormal pap smears. PMHx: Denies PSHx: - D&C for SAB Social History: ___ Family History: NC Allergies: Flagyl / Tylenol-Codeine What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Docusate Sodium Milk of Magnesia Acetaminophen Simethicone Calcium Carbonate Docusate Sodium Influenza Vaccine Quadrivalent Tetanus-DiphTox-Acellular Pertuss (Adacel) Bisacodyl Ibuprofen Tetanus-DiphTox-Acellular Pertuss (Adacel) Milk of Magnesia Ibuprofen Simethicone Bisacodyl Acetaminophen Influenza Vaccine Quadrivalent Calcium Carbonate Target Lab Orders: Hematocrit Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: NIL Other Results: ___ 12:00AM HCT-36.___ yo ___ s/p SVD at ___ Hospital on ___ at 35 weeks transferred to ___ for NICU proximity. She remained stable without issues. She was discharged in stable condition on ___ with plan for repeat glucose screening at 6 week postpartum visit for GDMA1.

2124-12-30 10:15:00

?

MARRIED

WHITE - BRAZILIAN

F

[[25448487, Timestamp('2124-12-30 01:00:19'), '', 'ORTHO']]

[[{'Medications on Admission': ":\nnorvasc,colace,fosamax,ayclovir,senna,zocor,T3,Ca\n\n1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 \ntimes a day). \n2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). \n\n3. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QTUES (every \n___. \n4. Acyclovir 200 mg Capsule Sig: One (1) Capsule PO Q12H (every \n12 hours). \n5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY \n(Daily). \n6. Hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q4H (every 4 \nhours) as needed for Pain: Do not drive, operate machinery, or \ndrink alcohol while taking this medication. As your pain \ndecreases, take fewer tablets and increase the time between \ndoses. Take a stool softener to prevent constipation.\nDisp:*90 Tablet(s)* Refills:*0*\n7. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day for 6 \nmonths: Please continue lovenox and coumadin until INR>2.0. \nStop lovenox when INR>2.0. Continue coumadin for 6 months with \nINR goal of ___. \n8. Lovenox 80 mg/0.8 mL Syringe Sig: 0.7 ML's Subcutaneous every \ntwelve (12) hours: 70 MG dose. Continue as bridge until INR >2.0 \nthen discontinue. \n9. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML's \nPO twice a day as needed for constipation. \n10. Dulcolax 10 mg Suppository Sig: One (1) supp Rectal once a \nday as needed for constipation. \n\nFacility:\n___\n\nMental Status: Clear and coherent\nLevel of Consciousness: Alert and interactive\nActivity Status: Ambulatory - requires assistance or aid (walker \nor cane)", 'Brief Hospital Course': ":\nThe patient was admitted and was taken to the operating room for \na total hip arthroplasty. Please see operative report for \ndetails. The surgery was uncomplicated and the patient tolerated \nthe procedure well. Pain was initially controlled with a PCA \nfollowed by a transition to oral pain medications on POD#1. The \npatient received IV antibiotics for 24 hours postoperatively, as \nwell as Lovenox for DVT prophylaxis starting on the morning of \nPOD#1. The Foley was removed on POD#2 and the patient was \nvoiding independently thereafter. The surgical dressing was \nchanged on POD#2 and the surgical incision was found to be clean \nand intact without erythema or abnormal drainage. \n\nHospital course was remarkable for the following:\n\nOn POD#2 patient developed fever to 102 and was pan-cultured; \nhowever, she defervesced and remained afebrile with stable vital \nsigns. Urine culture was negative; blood cultures still pending \nat time of this dictation.\n\nShe was noted with persistent tachycardia on POD#3; a CTA of the \nchest was done which showed acute lobar/segmental right lower \nlobe pulmonary emboli. She was started on therapeutic Lovenox \n70mg BID as a bridge for Coumadin therapy. The Lovenox can be \nstopped once her INR>2.0 and continue with Coumadin for 6 \nmonths. Hematology was consulted and have agreed with the \nanticoagulation plan. She can be followed by ___ Hematology \nand ___ clinic ___ or through Dr. ___ \n(___) office.\n\nWhile in the hospital she was followed by physical therapy. Labs \nwere checked throughout the hospital course and repleted \naccordingly. At the time of discharge the patient was tolerating \na regular diet and feeling well. The operative extremity was \nneurovascularly intact and the wound was benign. The patient \nprogressed well with physical therapy. Post-operative Xrays \ndemonstrated hardware in good position. The patient was \ndischarged in stable condition. The patient's weight-bearing \nstatus is weight bearing as tolerated on the operative extremity \nwith posterior hip precautions. \n\nShe is being discharged to rehab with specific instructions for \nsurgical and hematologic follow up.\n\n", 'Pertinent Results:': '\n___ 04:15PM BLOOD WBC-6.2 RBC-3.70* Hgb-9.7* Hct-30.5* \nMCV-82 MCH-26.2* MCHC-31.8 RDW-14.1 Plt ___\n___ 04:15PM BLOOD Neuts-44.7* Lymphs-49.1* Monos-5.4 \nEos-0.6 Baso-0.2\n___ 04:15PM BLOOD Plt ___\n___ 04:15PM BLOOD Glucose-138* UreaN-9 Creat-0.8 Na-144 \nK-4.0 Cl-108 HCO3-26 AnGap-14\n___ 04:15PM BLOOD Calcium-8.8 Phos-4.7* Mg-2.0\n\n___\nTWO VIEWS OF THE LEFT HIP WITH A SINGLE VIEW OF THE AP PELVIS: \nThe left total hip arthroplasty, superior femoral osteotomy, and \nlateral \nsutures are unchanged and in good position. No hardware \ncomplications are \nnoted. \nIMPRESSION: Unchanged uncomplicated left total hip arthroplasty. \n\n', 'Physical Exam:|Physical': '\nWell appearing in no acute distress\nAfebrile with stable vital signs\nPain well-controlled\n\nRespiratory: CTAB\nCardiovascular: RRR\nGastrointestinal: NT/ND\nGenitourinary: Voiding independently\n\nNeurologic: Intact with no focal deficits\nPsychiatric: Pleasant, A&O x3\n\nMusculoskeletal Lower Extremity:\n\n * Incision healing well with staples\n * Scant serosanguinous drainage\n * Thigh full but soft\n * No calf tenderness\n * ___ strength ___\n * SILT DP/SP/T/S/S\n * Toes warm\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\nMs. ___ has a history ofCNS lymphoma. This was treated \nwith high-dose methotrexate aswell as dexamethasone. She has \nhad a two-month history of\nincreasing left thigh and hip pain. She is now nonambulatory \ndue\nto the pain. She is able to walk only short distances with a\nwalker, however, presents today in a wheelchair. She does not\nhave any pain distal to the knee. She does not have \nparesthesias\nor weakness. She does not complain of any other musculoskeletal\npain. An MRI was performed at ___ MRI on ___. I\nhave both the films as well as the dictated report, which\nrevealed evidence of avascular necrosis of the left hip with\nfemoral head collapse. Ms. ___ does not have a history\nof bone metastasis or involvement of the musculoskeletal system\nwith lymphoma. The MRI was not suspicious of metastatic \ndisease.\n\nPast Medical History:\n-CNS lymphoma (see below) \n-Depression \n-HSV infection during MTX treatment in the past \n-GERD \n-HTN \n. \nOncological History (from the ___ medical record): \nShe initially presented with headaches, dizziness, and diplopia \nand then had a head MRI of the brain showed a tectal mass and \nthree areas of nodular enhancement on the ventricular surfaces, \nconcerning for brain metastases with ventricular seeding. She \nunderwent a stereotactic biopsy on ___ which was consistent \n with high-grade B-cell lymphoma. CT of the torso on ___ \ndid not show a distinct primary site, only some subcentimeter \nleft axillary lymph nodes. She then got 5 cycles of induction \nhigh-dose methotrexate starting on ___. Her last cycle of \nmaintenance high-dose methotrexate was on ___. \n\nSocial History:\n___\nFamily History:\nReports that she has 6 healthy children and a nephew with a \nbrain tumor. \n\n', 'Chief Complaint:|Complaint:': '\nleft hip pain\n\n', 'Attending:': ' ___\n\n', 'Allergies:': ' \nPatient recorded as having No Known Allergies to Drugs\n\n'}, '10378079-DS-27', 27, 'orthopaedics']]

[['HISTORY: Total hip replacement.\n\nSingle AP supine radiograph of the pelvis apparently obtained in recovery\nroom. Since exam ___, the patient has undergone a total left hip\nprosthesis with satisfactorily positioned non-cemented components. The\nsuboptimally visualized right hip and remainder of the pelvis are WNL. Skin\nstaples are seen laterally.\n', '10378079-RR-48', 48, ''], ['INDICATION: ___ woman with new hip, postop day 2 film.\n\nCOMPARISON: Pelvic radiographs from ___.\n\nTWO VIEWS OF THE LEFT HIP WITH A SINGLE VIEW OF THE AP PELVIS:\n\nThe left total hip arthroplasty, superior femoral osteotomy, and lateral\nsutures are unchanged and in good position. No hardware complications are\nnoted.\n\nIMPRESSION:\n\nUnchanged uncomplicated left total hip arthroplasty.\n', '10378079-RR-49', 49, ''], ['INDICATION: ___ female with postoperative fever.\n\n___.\n\nCHEST, PA AND LATERAL: The lungs are clear. The cardiomediastinal and hilar\ncontours are normal. There are no pleural effusions.\n\nIMPRESSION: No acute cardiopulmonary process.\n', '10378079-RR-50', 50, ''], ['HISTORY: ___ woman, with persistent tachycardia, status post THA.\nAssess for acute pulmonary embolism.\n\nCOMPARISON: CT torso on ___.\n\nTECHNIQUE: MDCT images were acquired from the thoracic inlet to the lung\nbases before and after administration of IV contrast. Multiplanar reformatted\nimages were obtained for evaluation.\n\nCTA CHEST: Filling defects are noted in the basal trunk of the right lower\nlobe pulmonary artery distal to the takeoff of the superior segment branch,\nwith extension into anterior, lateral and posterioa segmental branches,\ncompatible with acute lobar/segmental pulmonary embolism. There is no\nassociated parenchymal abnormality to suggest acute pulmonary infarct. No\nother definite filling defects are noted. There is no pneumothorax or pleural\neffusion. The tracheobronchial tree is patent to the subsegmental level.\n\nIncidental small solid pulmonary nodules measure 3 mm in the left upper lobe\n(2:23), 2-mm in the subpleural right upper lobe (2:25), 2-mm in the right\nmiddle lobe (2:34) and 4 mm in the right lower lobe (2:34). A 5-mm calcified\ngranuloma is noted in the left lung base (2:42).\n\nHeart size is top normal. There is no pericardial effusion. No mediastinal,\nhilar or axillary lymphadenopathy is identified. The aorta is normal in\ncourse and caliber without acute aortic pathology. The remaining great\nmediastinal vessels are normal.\n\nThe study is not designed for subdiaphragmatic diagnosis, but no gross\nabnormality is identified.\n\nBONE WINDOWS: There is no suspicious osteolytic or blastic lesion. Multilevel\ndegenerative changes are minimal.\n\nIMPRESSION:\n1. Acute lobar/segmental right lower lobe pulmonary emboli.\n2. Multiple sub-5-mm solid pulmonary nodules. If the patient has no known\nrisk for lung cancer, no followup is required. Otherwise, follow up in 12\nmonths to establish stability.\n\nDr. ___ has communicated the urgent findings to the primary care team,\nDr. ___, at 9:30 a.m. on the day of the study.\n', '10378079-RR-51', 51, 'mdct images were acquired from the thoracic inlet to the lung\nbases before and after administration of iv contrast. multiplanar reformatted\nimages were obtained for evaluation.']]

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[]

['orthopaedics']

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Question: A 57 F is admitted. He/she says he/she has left hip pain . History of illness: Ms. ___ has a history ofCNS lymphoma. This was treated with high-dose methotrexate aswell as dexamethasone. She has had a two-month history of increasing left thigh and hip pain. She is now nonambulatory due to the pain. She is able to walk only short distances with a walker, however, presents today in a wheelchair. She does not have any pain distal to the knee. She does not have paresthesias or weakness. She does not complain of any other musculoskeletal pain. An MRI was performed at ___ MRI on ___. I have both the films as well as the dictated report, which revealed evidence of avascular necrosis of the left hip with femoral head collapse. Ms. ___ does not have a history of bone metastasis or involvement of the musculoskeletal system with lymphoma. The MRI was not suspicious of metastatic disease. Past Medical History: -CNS lymphoma (see below) -Depression -HSV infection during MTX treatment in the past -GERD -HTN . Oncological History (from the ___ medical record): She initially presented with headaches, dizziness, and diplopia and then had a head MRI of the brain showed a tectal mass and three areas of nodular enhancement on the ventricular surfaces, concerning for brain metastases with ventricular seeding. She underwent a stereotactic biopsy on ___ which was consistent with high-grade B-cell lymphoma. CT of the torso on ___ did not show a distinct primary site, only some subcentimeter left axillary lymph nodes. She then got 5 cycles of induction high-dose methotrexate starting on ___. Her last cycle of maintenance high-dose methotrexate was on ___. Social History: ___ Family History: Reports that she has 6 healthy children and a nephew with a brain tumor. Allergies: Patient recorded as having No Known Allergies to Drugs What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Morphine Sulfate Senna DiphenhydrAMINE Bisacodyl DiphenhydrAMINE Alendronate Sodium HYDROmorphone (Dilaudid) HYDROmorphone (Dilaudid) HYDROmorphone (Dilaudid) Acetaminophen Morphine Sulfate 0.9% Sodium Chloride CefazoLIN Multivitamins DiphenhydrAMINE Amlodipine Bisacodyl Acyclovir Ondansetron Docusate Sodium Milk of Magnesia LR Enoxaparin Sodium Simvastatin Pantoprazole Target Lab Orders: Anion Gap Bicarbonate Calcium, Total Chloride Creatinine Glucose Magnesium Phosphate Potassium Sodium Urea Nitrogen Basophils Eosinophils Hematocrit Hemoglobin Lymphocytes MCH MCHC MCV Monocytes Neutrophils Platelet Count RDW Red Blood Cells White Blood Cells Anion Gap Bicarbonate Calcium, Total Chloride Creatinine Glucose Magnesium Phosphate Potassium Sodium Urea Nitrogen Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : The patient was admitted and was taken to the operating room for a total hip arthroplasty. Please see operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Pain was initially controlled with a PCA followed by a transition to oral pain medications on POD#1. The patient received IV antibiotics for 24 hours postoperatively, as well as Lovenox for DVT prophylaxis starting on the morning of POD#1. The Foley was removed on POD#2 and the patient was voiding independently thereafter. The surgical dressing was changed on POD#2 and the surgical incision was found to be clean and intact without erythema or abnormal drainage. Hospital course was remarkable for the following: On POD#2 patient developed fever to 102 and was pan-cultured; however, she defervesced and remained afebrile with stable vital signs. Urine culture was negative; blood cultures still pending at time of this dictation. She was noted with persistent tachycardia on POD#3; a CTA of the chest was done which showed acute lobar/segmental right lower lobe pulmonary emboli. She was started on therapeutic Lovenox 70mg BID as a bridge for Coumadin therapy. The Lovenox can be stopped once her INR>2.0 and continue with Coumadin for 6 months. Hematology was consulted and have agreed with the anticoagulation plan. She can be followed by ___ Hematology and ___ clinic ___ or through Dr. ___ (___) office. While in the hospital she was followed by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The operative extremity was neurovascularly intact and the wound was benign. The patient progressed well with physical therapy. Post-operative Xrays demonstrated hardware in good position. The patient was discharged in stable condition. The patient's weight-bearing status is weight bearing as tolerated on the operative extremity with posterior hip precautions. She is being discharged to rehab with specific instructions for surgical and hematologic follow up. Other Results: ___ 04:15PM BLOOD WBC-6.2 RBC-3.70* Hgb-9.7* Hct-30.5* MCV-82 MCH-26.2* MCHC-31.8 RDW-14.1 Plt ___ ___ 04:15PM BLOOD Neuts-44.7* Lymphs-49.1* Monos-5.4 Eos-0.6 Baso-0.2 ___ 04:15PM BLOOD Plt ___ ___ 04:15PM BLOOD Glucose-138* UreaN-9 Creat-0.8 Na-144 K-4.0 Cl-108 HCO3-26 AnGap-14 ___ 04:15PM BLOOD Calcium-8.8 Phos-4.7* Mg-2.0 ___ TWO VIEWS OF THE LEFT HIP WITH A SINGLE VIEW OF THE AP PELVIS: The left total hip arthroplasty, superior femoral osteotomy, and lateral sutures are unchanged and in good position. No hardware complications are noted. IMPRESSION: Unchanged uncomplicated left total hip arthroplasty.

2142-04-08 19:58:00

ENGLISH

MARRIED

WHITE

M

[[27574184, Timestamp('2142-04-08 19:59:25'), '', 'CMED']]

[[{'Medications on Admission': ':\n- Pravastatin 80 mg Oral Tablet Take 1 tablet every evening for \ncholesterol \n- Terazosin 5 mg Oral Capsule TAKE 1 CAPSULE DAILY at bedtime \n- Warfarin 3 mg Oral Tablet M, W, Th, ___, ___ 1mg PO on ___, ___ \n\n- Glipizide 5 mg Oral Tablet TAKE 2 TABLET in the morning and 2 \ntablets with evening meal \n- Amiodarone 200 mg Oral Tablet take ___ of a tablet (100mg \ndose) once daily (100mg tablets not avail) \n- Donepezil 5 mg Oral Tablet TAKE 1 TABLET DAILY AT BEDTIME \n- Nifedipine (NIFEDIAC CC) 60 mg Oral Tablet Extended Release \nTAKE ONE TABLET DAILY \n- Furosemide 40 mg Oral Tablet TAKE ONE TABLET DAILY \n- Ranitidine HCl 150 mg Oral Tablet TAKE 1 TABLET TWICE DAILY \n- Lisinopril 40 mg Oral Tablet TAKE ONE TABLET DAILY \n- Atenolol 25 mg Oral Tablet Take 1 tablet daily \n- Triamcinolone Acetonide 0.1 % Topical Cream apply to affected \narea TWICE DAILY \n- WARFARIN 1 MG TAB TAKE 1 TO 2 TABLETS DAILY AS DIRECTED \n- ASPIRIN 81 MG TAB 1 tablet daily. Available over the counter. \n\nFacility:\n___\n\nSecondary diagnosis:\nType 2 diabetes mellitus \nHyperlipidemia\nAtrial fibrillation', 'Brief Hospital Course': ":\nHOSPITAL COURSE:\n___ year old male with a PMH notable for CAD s/p MI ___ years \nprior (unknown anatomy), atrial fibrillation on coumadin, DMII, \nHL, HTN, CKD, presents with exertional chest pain. He was \ntreated with aspirin and heparin drip x 48hrs. ___ labs were \nNEGATIVE x3. No recurrent chest pain during this admission at \nrest or with ambulation. \n.\nACTIVE ISSUES:\n#Chest Pain: His symptoms at admission were very concerning for \nunstable angina given that it is brought on with exertion and \nalleviated with rest, similar in nature to prior MI. EKG changes \nwere difficult to interpret but did show more pronounced TWI in \nI and aVL than prior, which also corresponds to the LCX \nterritory (adenosine nuclear stress in ___ demonstrated large \narea of moderate stress-induced myocardial ischemia in the LCX). \n___ labs are negative x3 (troponin is equivocal in the setting \nof CKD, and stable). EKG remained stable. ___ medical therapy \nwas initiated in the ED with ASA, heparin drip, and beta \nblocker, which were continued for 48-hours. Given the patient's \nage and chronic kidney disease, as well as his preferences,left \nheart catheterization was not done and optimized medical \nmanagement was persued. He was chest pain free through the \nadmission, and did not have pain with exertion. Patient was \ndetermined to have a TIMI risk score of ___ which conveys a 26% \nrisk for major adverse cardiac events. The patient was started \non Imdur XL 60mg daily for control of anginal symptoms. Patient \nwas discharged home on aspirin 81 mg, Toprol 100mg, Imdur XL \n60mg, and Pravastatin 80mg daily. \n OUTPATIENT ISSUES: Follow-up with cardiology regarding \nmedical management of unstable angina. \n.\n#Atrial fibrillation: Patient on coumadin as an outpatient as \nwell as beta blocker, atenolol on admission, and amiodarone. \nCoumadin was discontinued on admission as the patient was placed \non a heparin drip. Home Amiodarone was continued; atenolol was \ndiscontinued given the patient's underlying elevated creatinine \nand metoprolol was started instead. Patient was discharged home \non coumadin with instructions to follow-up at ___ \nclinic on ___. The patient's INR on day of discharge \nwas 1.4. He will go home on Toprol XL 25mg daily, Amiodarone \n100mg daily, and Coumadin 3mg daily until his next INR check. \n OUTPATIENT ISSUES: Follow-up in ___ clinic on ___ for INR check. \n.\n# Acute on chronic renal failure: Creatinine mildly elevated \nfrom recent measurement of 1.57 on ___ at 1.8 during \nadmission. We held his home lasix and linsinopril. His \ncreatinine was stable at 1.6 throughout this hospitalization; \nlisinopril was resumed at 5mg daily.\n.\n#Hypertension: Patient was normal to mildly hypertensive during \nadmission. Lasix and lisinopril were discontinued initially in \nthe setting of acute on chronic renal failure. Patient's \nanti-hypertensive regimen was adjusted in the setting of \noptimizing medical therapy for unstable angina: DECREASED \nnefidipine to 30mg daily; STARTED Imdur at 30mg daily initially \nand increased to 60mg daily; DECREASED lisinopril to 5mg daily; \nand STOPPED his lasix; STOPPED atenolol and STARTED Metoprolol \ngiven patient's underlying chronic kidney disease. \n OUTPATIENT ISSUES: Titration of anti-hypertension medication \nregimen to achieve goal SBP < 130 without symptoms of \northostasis. \n.\n#Hyperlipidemia: Last profile from ___: Chol-172, HDL-40, \nLDL-103, ___. Upon presentation, patient was dosed with \natorvastatin. Patient was discharged home on original \npravastatin dose daily. \n OUTPATIENT ISSUES: Follow-up of fasting lipid panel in the \nnext 1 month.\n.\nINACTIVE ISSUES:\n#Type 2 Diabetes Mellitus: Last A1c was 6.3 on ___. He was on \na ISS while in house. Patient discharged on home glipizide 5mg \ntwice daily. \n.\n#Gastritis/Duodenitis: Hematocrit was stable through the \nadmission. Patient was transitioned into PPI during the \nadmission, but patient was discharged with Ranitidine HCl 150 \nmg, patient's original medication.\n.\n#Anemia: Hematocrit trended and stable during this admission.\n.\n#Obstructive Sleep Apnea: Continued CPAP at night. \n.\n#Benign Prostatic Hypertrophy: Continued on home terazosin. \n.\n\n", 'Pertinent Results:': '\nPERTINENT LABS:\nCHEM:\nADMISSION:\n___ 04:50PM BLOOD Glucose-113* UreaN-44* Creat-1.9* Na-139 \nK-4.6 Cl-103 HCO3-27 AnGap-14 \n___ 07:50AM BLOOD Calcium-9.1 Phos-3.5 Mg-2.2\nDISCHARGE:\n___ 06:40AM BLOOD Glucose-141* UreaN-35* Creat-1.6* Na-141 \nK-4.3 Cl-105 HCO3-27 AnGap-13 Calcium-9.0 Phos-3.4 Mg-2.2\n.\n___ 07:50AM BLOOD Calcium-9.1 Phos-3.5 Mg-2.2\n___ 06:40AM BLOOD Calcium-9.0 Phos-3.4 Mg-2.2\n.\nCBC:\nADMISSION: ___ WBC-7.9 RBC-3.90* Hgb-12.2* Hct-35.4* MCV-91 \nMCH-31.3 MCHC-34.5 RDW-13.5 Plt ___ Neuts-50.1 Lymphs-39.5 \nMonos-5.8 Eos-3.3 Baso-1.3\nDISCHARGE: ___ WBC-7.7 RBC-3.38* Hgb-10.6* Hct-30.5* \nMCV-90 MCH-31.3 MCHC-34.7 RDW-13.3 Plt ___\n.\nCOAG:\n___ ___ PTT-35.7 ___\n___ ___ PTT-150* ___\n___ ___ PTT-90.6* ___\n___ ___ PTT-93.6* ___\n___ PTT-48.4*\n___ PTT-53.5*\n___ ___ PTT-53.3* ___\n.\nCARDIAC ENZYMES:\n___ CK(CPK)-182\n___ CK(CPK)-52\n___ cTropnT-0.03*\n___ CK-MB-5\n___ CK-MB-4 cTropnT-0.02*\n.\nOTHER:\n___ Lactate-2.1*\n___ Lactate-1.9\n.\nURINE: ___ 04:50PM URINE Color-Straw Appear-Clear Sp \n___ Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG \nKetone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG Hours-RANDOM \nUreaN-534 Creat-49 Na-58 K-51 Cl-73\n___ Gr Hold-HOLD\n.\nEKG:\nADMISSION:EKG: Normal sinus rhythm with rate of 62. Normal axis. \nIVCD. TWI in I and AVL. Sub 1mm ST depressions in V4-V6. \nCompared to prior: more prominent TWI \nDISCHARGE: unchanged\n.\nCULTURES:\n___ (BLOOD): Pending\n.\nIMGING:\nCXR:FINDINGS: The heart is normal in size. The mediastinal and \nhilar contours are unremarkable. There is no pleural effusion or \npneumothorax. Patchy lingular opacity is probably due to minor \nscarring. Otherwise, the lungs appear clear. Moderate \ndegenerative changes are noted along the thoracic spine. \nIMPRESSION: No evidence of acute disease. \n\n', 'Physical Exam:|Physical': '\nAdmission Physical Exam:\nVS: T: 98, BP: 154/66, P: 60, R: 18, O2sat: 96%2L. \nGENERAL: Elderly gentleman, NAD. Oriented x3. Mood, affect \nappropriate. \nHEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were \npink, no pallor or cyanosis of the oral mucosa. No xanthalesma. \n\nNECK: Supple with JVP of 6cm. \nCARDIAC: PMI located in ___ intercostal space, midclavicular \nline. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or \nS4. \nLUNGS: No chest wall deformities, scoliosis or kyphosis. Resp \nwere unlabored, no accessory muscle use. Bibasilar crackles. \nABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not \nenlarged by palpation. No abdominial bruits. \nEXTREMITIES: No c/c/e. No femoral bruits. \nSKIN: 2+ pitting edema in bilateral lower extremities; stockings \npresent. \n.\nDischarge Exam:\nVitals: T 98.2, 106-162/51-71, 52-56, ___, 94-96% RA and \n99-100% on CPAP \nI-1150 \nO-2525 \nNet-negative 1.1L \nWeight: 80.9kg ___ yesterday and at time of admission) \n___: 127(-), 278 (6H), 146 (-), 189 (-) \nGeneral: Comfrotable. Lying in bed in NAD \nHEENT: EOMI. MMM \nCV: RRR. No M/R/G. \nLungs: Slight crackles/improve with deep inspiration. Nml work \nof breathing. No wheezes. \nAbd: NABS+. Soft. NT/ND. \nExt: WWP. No pitting edema bilaterally. No clubbing or cyanosis. \n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\nThis is a ___ with a PMH notable for CAD s/p MI ___ years prior \n(unknown anatomy), Afib on coumadin, DMII, HL, HTN, CKD \n(baseline Creatinine 1.5-2), who presents with exertional chest \npain. He is accompanied by his home nurse, who is also his \nhealth care proxy. \n. \nPatient reports that he developed 2 episodes of substernal chest \n"prickly" and "tingling" without radiation that lasted for \napproximately 1 hour that were very similar in sensation to one \nexperienced during a heart attack ___ years prior (s/p cath in \n___, denies stent placement, unclear anatomy). He reports \nthat it occurred while working with physical therapy and \nambulation with a walker earlier this morning and was relieved \nwith aspirin 162mg PO X 1 and rest, with several short episodes \nlasting a few minutes over the course of the day. He denies any \nassociated dyspnea, nausea, vomiting, diaphoresis, palpitations. \nNo fevers, chills, dysuria, abdominal pain, PND. Uses 2 pillows \nto sleep and OSA at night. Denies peripheral edema (wears \ncompression stockings at gine). He reports good PO intake. \nDenies any history of GI bleed. No recent illness. At baseline, \nhe can walk ___ mile without symptoms. \n. \nIn the ED, initial vitals were T: 98.1, P: 60, BP: 162/72, RR: \n20, O2sat: 96% RA. Labs notable for hct of 35.4, BUN of ___ \ncreatinine of 1.9, troponin of 0.03, lactate of 2.1. ECG \ndemonstrated TWI in I and AVL (stable/slightly more pronounced \nfrom prior from ___. Chest radiograph notable for no acute \nprocess. Patient given aspirin 324mg PO X 1, heparin gtt with \n4000 units bolus. Received 1L NS in ED. Vitals on transfer were \n98.2, 151/86, 86, 19, 97% 2L. Was guiac negative in ED. \n. \nOn arrival to the floor, patient reports that he is feeling well \nand chest pain free. \n\nPast Medical History:\n1. CARDIAC RISK FACTORS: (+)Diabetes, (+)Dyslipidemia, \n(+)Hypertension \n2. CARDIAC HISTORY: \n- CAD s/p MI ___ years ago, unknown anatomy, denies stents) \n- Atrial fibrillation on coumadin \n- PERCUTANEOUS CORONARY INTERVENTIONS: None per patient. \n- PACING/ICD: None. \n3. OTHER PAST MEDICAL HISTORY: \n- Chronic kidney disease \n- Hemmorrhoids \n- Anemia \n- Gastritis/duodenitis \n- Spinal stenosis \n- Obesity \n- OSA \n- BPH \n- Erectile dysfunction \n- Left hip degeneration; uses walker. \n\nSocial History:\n___\nFamily History:\nNoncontributory. \nNo family history of early MI, arrhythmia, cardiomyopathies, or \nsudden cardiac death; otherwise non-contributory. \n\n', 'Chief Complaint:|Complaint:': '\nChest pressure \n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nNo Known Allergies / Adverse Drug Reactions\n\n'}, '16825821-DS-14', 14, 'medicine']]

[['CHEST RADIOGRAPHS \n\nHISTORY: Intermittent chest pain.\n\nCOMPARISONS: None.\n\nTECHNIQUE: Chest, PA and lateral.\n\nFINDINGS: The heart is normal in size. The mediastinal and hilar contours\nare unremarkable. There is no pleural effusion or pneumothorax. Patchy\nlingular opacity is probably due to minor scarring. Otherwise, the lungs\nappear clear. Moderate degenerative changes are noted along the thoracic\nspine.\n\nIMPRESSION: No evidence of acute disease.\n', '16825821-RR-17', 17, 'chest, pa and lateral.']]

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[]

['medicine']

[[51078, Timestamp('2142-04-08 22:56:00'), Timestamp('2142-04-08 23:11:00'), 'Chloride, Urine'], [51082, Timestamp('2142-04-08 22:56:00'), Timestamp('2142-04-08 23:11:00'), 'Creatinine, Urine'], [51087, Timestamp('2142-04-08 22:56:00'), NaT, 'Length of Urine Collection'], [51093, Timestamp('2142-04-08 22:56:00'), Timestamp('2142-04-08 23:07:00'), 'Osmolality, Urine'], [51097, Timestamp('2142-04-08 22:56:00'), Timestamp('2142-04-08 23:11:00'), 'Potassium, Urine'], [51100, Timestamp('2142-04-08 22:56:00'), Timestamp('2142-04-08 23:11:00'), 'Sodium, Urine'], [51104, Timestamp('2142-04-08 22:56:00'), Timestamp('2142-04-08 23:11:00'), 'Urea Nitrogen, Urine'], [50910, Timestamp('2142-04-09 02:51:00'), Timestamp('2142-04-09 03:41:00'), 'Creatine Kinase (CK)'], [50911, Timestamp('2142-04-09 02:51:00'), Timestamp('2142-04-09 03:41:00'), 'Creatine Kinase, MB Isoenzyme'], [51003, Timestamp('2142-04-09 02:51:00'), Timestamp('2142-04-09 03:41:00'), 'Troponin T'], [50868, Timestamp('2142-04-09 07:50:00'), Timestamp('2142-04-09 09:07:00'), 'Anion Gap'], [50882, Timestamp('2142-04-09 07:50:00'), Timestamp('2142-04-09 09:07:00'), 'Bicarbonate'], [50893, Timestamp('2142-04-09 07:50:00'), Timestamp('2142-04-09 09:07:00'), 'Calcium, Total'], [50902, Timestamp('2142-04-09 07:50:00'), Timestamp('2142-04-09 09:07:00'), 'Chloride'], [50912, Timestamp('2142-04-09 07:50:00'), Timestamp('2142-04-09 09:07:00'), 'Creatinine'], [50931, Timestamp('2142-04-09 07:50:00'), Timestamp('2142-04-09 09:07:00'), 'Glucose'], [50960, Timestamp('2142-04-09 07:50:00'), Timestamp('2142-04-09 09:07:00'), 'Magnesium'], [50970, Timestamp('2142-04-09 07:50:00'), Timestamp('2142-04-09 09:07:00'), 'Phosphate'], [50971, Timestamp('2142-04-09 07:50:00'), Timestamp('2142-04-09 09:07:00'), 'Potassium'], [50983, Timestamp('2142-04-09 07:50:00'), Timestamp('2142-04-09 09:07:00'), 'Sodium'], [51006, Timestamp('2142-04-09 07:50:00'), Timestamp('2142-04-09 09:07:00'), 'Urea Nitrogen'], [51221, Timestamp('2142-04-09 07:50:00'), Timestamp('2142-04-09 08:40:00'), 'Hematocrit'], [51222, Timestamp('2142-04-09 07:50:00'), Timestamp('2142-04-09 08:40:00'), 'Hemoglobin'], [51248, Timestamp('2142-04-09 07:50:00'), Timestamp('2142-04-09 08:40:00'), 'MCH'], [51249, Timestamp('2142-04-09 07:50:00'), Timestamp('2142-04-09 08:40:00'), 'MCHC'], [51250, Timestamp('2142-04-09 07:50:00'), Timestamp('2142-04-09 08:40:00'), 'MCV'], [51265, Timestamp('2142-04-09 07:50:00'), Timestamp('2142-04-09 08:40:00'), 'Platelet Count'], [51277, Timestamp('2142-04-09 07:50:00'), Timestamp('2142-04-09 08:40:00'), 'RDW'], [51279, Timestamp('2142-04-09 07:50:00'), Timestamp('2142-04-09 08:40:00'), 'Red Blood Cells'], [51301, Timestamp('2142-04-09 07:50:00'), Timestamp('2142-04-09 08:40:00'), 'White Blood Cells'], [51237, Timestamp('2142-04-09 07:50:00'), Timestamp('2142-04-09 09:56:00'), 'INR(PT)'], [51274, Timestamp('2142-04-09 07:50:00'), Timestamp('2142-04-09 09:56:00'), 'PT'], [51275, Timestamp('2142-04-09 07:50:00'), Timestamp('2142-04-09 09:59:00'), 'PTT'], [50813, Timestamp('2142-04-09 08:29:00'), Timestamp('2142-04-09 08:30:00'), 'Lactate'], [50813, Timestamp('2142-04-09 15:43:00'), Timestamp('2142-04-09 15:45:00'), 'Lactate'], [51275, Timestamp('2142-04-09 16:45:00'), Timestamp('2142-04-09 17:59:00'), 'PTT']]

Question: A 91 M is admitted. He/she says he/she has Chest pressure . History of illness: This is a ___ with a PMH notable for CAD s/p MI ___ years prior (unknown anatomy), Afib on coumadin, DMII, HL, HTN, CKD (baseline Creatinine 1.5-2), who presents with exertional chest pain. He is accompanied by his home nurse, who is also his health care proxy. . Patient reports that he developed 2 episodes of substernal chest "prickly" and "tingling" without radiation that lasted for approximately 1 hour that were very similar in sensation to one experienced during a heart attack ___ years prior (s/p cath in ___, denies stent placement, unclear anatomy). He reports that it occurred while working with physical therapy and ambulation with a walker earlier this morning and was relieved with aspirin 162mg PO X 1 and rest, with several short episodes lasting a few minutes over the course of the day. He denies any associated dyspnea, nausea, vomiting, diaphoresis, palpitations. No fevers, chills, dysuria, abdominal pain, PND. Uses 2 pillows to sleep and OSA at night. Denies peripheral edema (wears compression stockings at gine). He reports good PO intake. Denies any history of GI bleed. No recent illness. At baseline, he can walk ___ mile without symptoms. . In the ED, initial vitals were T: 98.1, P: 60, BP: 162/72, RR: 20, O2sat: 96% RA. Labs notable for hct of 35.4, BUN of ___ creatinine of 1.9, troponin of 0.03, lactate of 2.1. ECG demonstrated TWI in I and AVL (stable/slightly more pronounced from prior from ___. Chest radiograph notable for no acute process. Patient given aspirin 324mg PO X 1, heparin gtt with 4000 units bolus. Received 1L NS in ED. Vitals on transfer were 98.2, 151/86, 86, 19, 97% 2L. Was guiac negative in ED. . On arrival to the floor, patient reports that he is feeling well and chest pain free. Past Medical History: 1. CARDIAC RISK FACTORS: (+)Diabetes, (+)Dyslipidemia, (+)Hypertension 2. CARDIAC HISTORY: - CAD s/p MI ___ years ago, unknown anatomy, denies stents) - Atrial fibrillation on coumadin - PERCUTANEOUS CORONARY INTERVENTIONS: None per patient. - PACING/ICD: None. 3. OTHER PAST MEDICAL HISTORY: - Chronic kidney disease - Hemmorrhoids - Anemia - Gastritis/duodenitis - Spinal stenosis - Obesity - OSA - BPH - Erectile dysfunction - Left hip degeneration; uses walker. Social History: ___ Family History: Noncontributory. No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Allergies: No Known Allergies / Adverse Drug Reactions What is the best procedure plan for this patient?

TARGETS Target Prescriptions: NIFEdipine CR Dextrose 50% Influenza Virus Vaccine Omeprazole 0.9% Sodium Chloride Atenolol Glucagon Dextrose 50% Heparin Docusate Sodium Docusate Sodium Amiodarone Aspirin 5% Dextrose Heparin Sodium Aspirin Atorvastatin Senna Insulin Senna NIFEdipine CR Insulin Acetaminophen Isosorbide Mononitrate (Extended Release) Glucagon Sodium Chloride 0.9% Flush Sodium Chloride 0.9% Flush Acetaminophen Pneumococcal Vac Polyvalent Target Lab Orders: Chloride, Urine Creatinine, Urine Length of Urine Collection Osmolality, Urine Potassium, Urine Sodium, Urine Urea Nitrogen, Urine Creatine Kinase (CK) Creatine Kinase, MB Isoenzyme Troponin T Anion Gap Bicarbonate Calcium, Total Chloride Creatinine Glucose Magnesium Phosphate Potassium Sodium Urea Nitrogen Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells INR(PT) PT PTT Lactate Lactate PTT Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : HOSPITAL COURSE: ___ year old male with a PMH notable for CAD s/p MI ___ years prior (unknown anatomy), atrial fibrillation on coumadin, DMII, HL, HTN, CKD, presents with exertional chest pain. He was treated with aspirin and heparin drip x 48hrs. ___ labs were NEGATIVE x3. No recurrent chest pain during this admission at rest or with ambulation. . ACTIVE ISSUES: #Chest Pain: His symptoms at admission were very concerning for unstable angina given that it is brought on with exertion and alleviated with rest, similar in nature to prior MI. EKG changes were difficult to interpret but did show more pronounced TWI in I and aVL than prior, which also corresponds to the LCX territory (adenosine nuclear stress in ___ demonstrated large area of moderate stress-induced myocardial ischemia in the LCX). ___ labs are negative x3 (troponin is equivocal in the setting of CKD, and stable). EKG remained stable. ___ medical therapy was initiated in the ED with ASA, heparin drip, and beta blocker, which were continued for 48-hours. Given the patient's age and chronic kidney disease, as well as his preferences,left heart catheterization was not done and optimized medical management was persued. He was chest pain free through the admission, and did not have pain with exertion. Patient was determined to have a TIMI risk score of ___ which conveys a 26% risk for major adverse cardiac events. The patient was started on Imdur XL 60mg daily for control of anginal symptoms. Patient was discharged home on aspirin 81 mg, Toprol 100mg, Imdur XL 60mg, and Pravastatin 80mg daily. OUTPATIENT ISSUES: Follow-up with cardiology regarding medical management of unstable angina. . #Atrial fibrillation: Patient on coumadin as an outpatient as well as beta blocker, atenolol on admission, and amiodarone. Coumadin was discontinued on admission as the patient was placed on a heparin drip. Home Amiodarone was continued; atenolol was discontinued given the patient's underlying elevated creatinine and metoprolol was started instead. Patient was discharged home on coumadin with instructions to follow-up at ___ clinic on ___. The patient's INR on day of discharge was 1.4. He will go home on Toprol XL 25mg daily, Amiodarone 100mg daily, and Coumadin 3mg daily until his next INR check. OUTPATIENT ISSUES: Follow-up in ___ clinic on ___ for INR check. . # Acute on chronic renal failure: Creatinine mildly elevated from recent measurement of 1.57 on ___ at 1.8 during admission. We held his home lasix and linsinopril. His creatinine was stable at 1.6 throughout this hospitalization; lisinopril was resumed at 5mg daily. . #Hypertension: Patient was normal to mildly hypertensive during admission. Lasix and lisinopril were discontinued initially in the setting of acute on chronic renal failure. Patient's anti-hypertensive regimen was adjusted in the setting of optimizing medical therapy for unstable angina: DECREASED nefidipine to 30mg daily; STARTED Imdur at 30mg daily initially and increased to 60mg daily; DECREASED lisinopril to 5mg daily; and STOPPED his lasix; STOPPED atenolol and STARTED Metoprolol given patient's underlying chronic kidney disease. OUTPATIENT ISSUES: Titration of anti-hypertension medication regimen to achieve goal SBP < 130 without symptoms of orthostasis. . #Hyperlipidemia: Last profile from ___: Chol-172, HDL-40, LDL-103, ___. Upon presentation, patient was dosed with atorvastatin. Patient was discharged home on original pravastatin dose daily. OUTPATIENT ISSUES: Follow-up of fasting lipid panel in the next 1 month. . INACTIVE ISSUES: #Type 2 Diabetes Mellitus: Last A1c was 6.3 on ___. He was on a ISS while in house. Patient discharged on home glipizide 5mg twice daily. . #Gastritis/Duodenitis: Hematocrit was stable through the admission. Patient was transitioned into PPI during the admission, but patient was discharged with Ranitidine HCl 150 mg, patient's original medication. . #Anemia: Hematocrit trended and stable during this admission. . #Obstructive Sleep Apnea: Continued CPAP at night. . #Benign Prostatic Hypertrophy: Continued on home terazosin. . Other Results: PERTINENT LABS: CHEM: ADMISSION: ___ 04:50PM BLOOD Glucose-113* UreaN-44* Creat-1.9* Na-139 K-4.6 Cl-103 HCO3-27 AnGap-14 ___ 07:50AM BLOOD Calcium-9.1 Phos-3.5 Mg-2.2 DISCHARGE: ___ 06:40AM BLOOD Glucose-141* UreaN-35* Creat-1.6* Na-141 K-4.3 Cl-105 HCO3-27 AnGap-13 Calcium-9.0 Phos-3.4 Mg-2.2 . ___ 07:50AM BLOOD Calcium-9.1 Phos-3.5 Mg-2.2 ___ 06:40AM BLOOD Calcium-9.0 Phos-3.4 Mg-2.2 . CBC: ADMISSION: ___ WBC-7.9 RBC-3.90* Hgb-12.2* Hct-35.4* MCV-91 MCH-31.3 MCHC-34.5 RDW-13.5 Plt ___ Neuts-50.1 Lymphs-39.5 Monos-5.8 Eos-3.3 Baso-1.3 DISCHARGE: ___ WBC-7.7 RBC-3.38* Hgb-10.6* Hct-30.5* MCV-90 MCH-31.3 MCHC-34.7 RDW-13.3 Plt ___ . COAG: ___ ___ PTT-35.7 ___ ___ ___ PTT-150* ___ ___ ___ PTT-90.6* ___ ___ ___ PTT-93.6* ___ ___ PTT-48.4* ___ PTT-53.5* ___ ___ PTT-53.3* ___ . CARDIAC ENZYMES: ___ CK(CPK)-182 ___ CK(CPK)-52 ___ cTropnT-0.03* ___ CK-MB-5 ___ CK-MB-4 cTropnT-0.02* . OTHER: ___ Lactate-2.1* ___ Lactate-1.9 . URINE: ___ 04:50PM URINE Color-Straw Appear-Clear Sp ___ Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG Hours-RANDOM UreaN-534 Creat-49 Na-58 K-51 Cl-73 ___ Gr Hold-HOLD . EKG: ADMISSION:EKG: Normal sinus rhythm with rate of 62. Normal axis. IVCD. TWI in I and AVL. Sub 1mm ST depressions in V4-V6. Compared to prior: more prominent TWI DISCHARGE: unchanged . CULTURES: ___ (BLOOD): Pending . IMGING: CXR:FINDINGS: The heart is normal in size. The mediastinal and hilar contours are unremarkable. There is no pleural effusion or pneumothorax. Patchy lingular opacity is probably due to minor scarring. Otherwise, the lungs appear clear. Moderate degenerative changes are noted along the thoracic spine. IMPRESSION: No evidence of acute disease.

2160-04-23 01:18:00

ENGLISH

SINGLE

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[[20682033, Timestamp('2160-04-23 01:18:58'), '', 'MED']]

[[{'Medications on Admission': ':\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 20 mg PO QPM \n4. ClonazePAM 0.5 mg PO TID \n5. Metoprolol Succinate XL 100 mg PO QAM \n6. Metoprolol Succinate XL 50 mg PO QHS \n7. Mirtazapine 15 mg PO QHS \n8. Senna 8.6 mg PO BID:PRN Constipation - First Line \n9. Nitrofurantoin Monohyd (MacroBID) 100 mg PO BID \n10. TraMADol 50 mg PO Q6H:PRN Pain - Moderate \n\nFacility:\n___', 'Brief Hospital Course': ":\n___ w/ ___ spinal stenosis (s/p ___ L4-L5 laminectomy with \nconversion to T10-S1 posterior fusion a day later due to post-op \nvertebral collapse), pAF (not on AC), recently admitted for \nleft-sided low back pain, urinary retention, and an episode of\nfecal incontinence, treated for ?UTI, who now returns with \nrecurrence of low back pain on the contralateral side and \nrecurrence of urinary retention. \n\n# Right-sided low back pain \nRight sided lower back/flank pain developed acutely in the \nsetting of patient pulling herself up from seated position. The \npain was sharp initially, though later described as a twisting \nsensation. She had paraspinal tenderness to palpation on the \nright (L3/4 distribution and over the quadratus lumborum) which \noverall suggested an MSK pathology. She was treated \nsupportively with Tylenol q8, lidocaine patch, gabapentin BID, \nflexeril PRN, oxycodone PRN. She was seen by Physical therapy \nwho recommended discharge to rehab. The patient will follow-up \nwith her PCP and with her Orthopedic Surgeon after discharge \nfrom rehab. \n\nOf note, the patient had no focal weakness, numbness/sensory \nchanges, or changes in bowel movements to suggest cord \ninvolvement or cauda equina. She did have transient urinary \nretention, which was present transiently at her prior admission \nand subsequently resolved, which also resolved this admission, \nand was ultimately not thought to be related to spinal pathology \n(further discussed below). She had a recent MRI (___) at BID-N \nafter she presented with similar symptoms on the left-side, \nwhich was overall not convincing for cord involvement. \nUnfortunately, her extensive spinal hardware makes it hard to \nreally clear her spinal roots. At her prior admission, she was \nevaluated by Spine Surgery team who did not recommend any acute \nsurgical intervention. CT A/P this admission without any acute \nfracture or change. \n\n# Urinary retention\nThe patient's urinary retention is of unclear chronicity. The \nurinary retention was discovered when she was undergoing work-up \nfor the back pain, but she could have had high residuals for \nsome period prior to this. The urinary retention could be \nsecondary to pain, pain medications, constipation or limited \nmobility. She could also have an underlying urologic \nabnormality, though overall suspect this is less likely as the \nurinary retention did resolve this hospitalization. She did not \nshow signs of pyelonephritis or UTI (urinalysis negative). This \nis less likely cauda equina as above (does not examine with \nstrength or sensory deficits, had recent MRI spine without cauda \nequina, and was seen by Spine Surgery with low suspicion for \nthis at last admission). In the hospital, she was monitored \nwith bladder scans. While she did require straight \ncatheterization x 2, her urinary retention ultimately resolved. \nAn aggressive bowel regimen was started and she was mobilizing \nwell with ___. Follow-up with Atrius Urology for further testing \nand urodynamic evaluation is recommended after rehab.\n\n# Constipation\nLikely secondary to limited mobility and medication-induced. \nStarted aggressive bowel regimen. Would add a suppository or \nenema PRN if she does not have a bowel movement at rehab within \n___ days.\n\n# Paroxysmal atrial fibrillation \nCHA2DS2-VASc is 3 (age, sex, HTN). She has been documented to \nhave a-fib post-op after her spinal surgery and in the setting \nof urosepsis. Patient states that she has discussed \nanticoagulation with her outpatient Cardiologist and decided \nagainst starting a blood thinner. We discussed how her risk of \nstroke is elevated given her risk factors. We discussed how \nother patients at her similar risk level would be recommended to \nstart anticoagulation. Patient preferred to discuss further \nwith her outpatient providers. She continued home metoprolol \n100 mg qAM, 50 mg qPM.\n\n# Anxiety/depression\nContinued home Klonopin 0.5 mg TID and mirtazapine. Would \nconsider future SSRI trial to replace klonopin.\n\n#CARDIAC RISK\nContinued Atorvastatin 20 mg PO QPM and aspirin. \n\nTRANSITIONAL ISSUES:\n[] Follow-up with Urology for urodynamic testing for urinary \nretention\n[] Consider starting anticoagulation for history of atrial \nfibrillation\n[] Monitor constipation and up titrate bowel regimen as needed\n\n> 30 minutes spent in discharge planning and counseling\n\n", 'Pertinent Results:': "\nADMISSION LABS:\n___ 09:51PM GLUCOSE-101* UREA N-27* CREAT-1.4* SODIUM-138 \nPOTASSIUM-4.7 CHLORIDE-100 TOTAL CO2-25 ANION GAP-13\n___ 09:51PM WBC-9.8 RBC-3.96 HGB-11.5 HCT-36.6 MCV-92 \nMCH-29.0 MCHC-31.4* RDW-14.3 RDWSD-48.0*\n___ 09:51PM NEUTS-67.3 LYMPHS-14.9* MONOS-7.6 EOS-8.6* \nBASOS-0.7 IM ___ AbsNeut-6.57* AbsLymp-1.46 AbsMono-0.74 \nAbsEos-0.84* AbsBaso-0.07\n___ 09:51PM PLT COUNT-216\n___ 06:15AM BLOOD Glucose-98 UreaN-28* Creat-1.4* Na-138 \nK-5.0 Cl-101 HCO3-23 AnGap-14\n\nNOTABLE IMAGING:\n\nMRI L-SPINE ___ from prior hospitalization at ___\nFINDINGS: There has been posterior fusion with pedicle screws\nand rods from T10-S1. There have been laminectomies at\nevery level at least from T10 through L5. Further evaluation of\nthe posterior elements is prevented by artifact from\nthe hardware. Artifact from the hardware severely obscures\nimages of the spinal canal. On the sagittal T2 weighted\nimages there is no evidence of spinal canal encroachment. The\naxial images are heavily degraded by artifact and\nprevent reliable evaluation of the neural foramina.\nThere is a compression fracture of the L4 vertebral body with\nnormal signal on all images. This suggests that it is\nchronic. There is marked hyperintensity of the intervertebral\ndisc on the T2 weighted images at L3-4. This may be\nseen in the setting of severe disc degeneration with a fluid\nfilled cleft within the disc. Although a hyperintense\ndisc on T2 weighted images may also be seen as result of\ndiscitis, the normal signal intensity of the adjacent\nvertebral bodies on the STIR images argues against an infectious\nor inflammatory etiology. There are similar findings\nat L5-S1, again most likely due to degenerative disease. There\nis no abnormal enhancement after contrast\nadministration. No abnormal fluid collections are identified. \nThere is no evidence of compression of the spinal cord\nor cauda equina.\n\nIMPRESSION:\n1. Limited study due to artifact from fusion hardware.\n2. Status post posterior fusion from T10 through S1 with rods \nand\npedicle screws.\n3. Chronic-appearing L4 compression fracture.\n4. Laminectomies at least from T10 through L5.\n5. No evidence of spinal cord or cauda equina compression.\n\nCT ABD/PELVIS ___\nNo acute intra-abdominal process, no findings to explain\npatient's symptoms. Specifically:\n- There is no perinephric abnormality. \n- No renal or ureteral calculus.\n- There is no evidence of worrisome osseous lesions or acute\nfracture. Laminectomies with posterior fixation hardware seen\nspanning T10 through S1. No evidence of hardware related\ncomplication. \n- The abdominal and pelvic wall is within normal limits. \n\n", 'Physical Exam:|Physical': '\nADMISSION EXAM:\nCONSTITUTIONAL: obese woman in NAD\nEYE: sclerae anicteric, EOMI\nENT: audition grossly intact, MMM, OP clear \nLYMPHATIC: No LAD\nCARDIAC: RRR, no M/R/G, JVP not elevated, no edema\nPULM: normal effort of breathing, LCAB\nGI: soft, NT, ND, NABS\nGU: no CVA tenderness, suprapubic region soft and nontender\nMSK: no visible joint effusions or acute deformities. She is TTP\nover the R flank and the lateral aspect of the body wall. Pain \nis\nvisibly worsened by movements in the bed. Point tenderness over\nthe spine at L3/L4 level (but that is a lower spinal level than\nwhere her pain corresponds to). \nDERM: no visible rash. No jaundice.\nNEURO: AAOx3. No facial droop, moving all extremities.\nPSYCH: Full range of affect\n\nDISCHARGE EXAM:\nCONSTITUTIONAL: obese woman in NAD\nCARDIAC: RRR, no M/R/G\nPULM: normal effort of breathing, CTAB\nGI: soft, NT, ND, NABS\nGU: no CVA tenderness, suprapubic region soft and non-tender\nMSK: no visible joint effusions or acute deformities. She is TTP\nat the top of the R hip and pelvis, tender along the R \nparaspinal\nmuscles. Point tenderness over the spine at L3/L4 level\nNEURO: AAOx3. No facial droop, moving all extremities. ___\nstrength in bilateral lower extremities, somewhat limited by \npain\non R. Normal sensation to light touch in lower extremities and\nperineum. Normal rectal tone. \nPSYCH: Full range of affect\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\n___ w/ PMH spinal stenosis (s/p ___ L4-L5 laminectomy with\nconversion to T10-S1 posterior fusion a day later due to post-op\nvertebral collapse), pAF (not on AC), recently admitted for\nleft-sided low back pain, urinary retention, and an episode of\nfecal incontinence and treated for ?UTI, who now returns with\nrecurrence of low back pain on the contralateral side. \n\nShe recently presented with fairly abrupt onset of non-traumatic\nleft-sided low back pain, a single episode of fecal \nincontinence,\nand was additionally found to be in acute urinary retention.\nBecause she lives alone in the community, these deficits made it\nimpossible to function and she presented to the ED, where \nconcern\nwas initially for ?cauda equina. MRI L spine ___) and CT\nabdomen/pelvis (___) were both fairly unremarkable -- although\nnotably her extensive spinal hardware limits radiographic\nassessment of the spinal nerve roots. There was an old\ncompression fracture, which I note is causing displacement of a\npedicle screw into the adjacent disc space, where an increased \nT2\nsignal suggests significant inflammation from the chronic\ntrauma... but per review of ___ records, this anatomy is\nyears old. She was seen by spine surgery in our ED, who felt the\nneurologic exam was reassuring and they did not feel the back\npain symptoms were caused by impingement of the cord or of nerve\nroots. \n\nShe was found to have a very modest pyuria and so was admitted \nto\nmedicine for ?UTI. Although the UA was unimpressive, she had a\nmild systemic leukocytosis and the urinary retention, so was\ntreated for a presumed UTI with CTX->Macrobid. However her urine\nculture has since resulted as mixed flora consistent with fecal\ncontamination, making this whole UTI theory questionable.\nNonetheless, her urinary retention seemed to be resolving and \nher\npain got better, so this was felt to be the diagnosis.\n\nHowever, she had abrupt recurrence of low back pain the day\nafter discharge. This time it was centered on the RIGHT flank \nand\nradiating anteroinferiorly (roughly in an L1 distribution). The\npain is quite manageable when she lies still, but becomes severe\nwith movement. The pain started abruptly after she pulled \nherself\nup from a seated position using her arms. She did this in a\nrowing sort of motion, which would heavily utilize the latissimi\ndorsi (and apply a transverse force on the spine where this\nmuscle inserts). \n\nShe returned to the ED with the pain, and was again admitted due\nto her inability to function independently in the community with\nthis symptom. She was straight cathed for 1000 mL of urine in \nthe\nED, suggesting urinary retention has also recurred. \n\n REVIEW OF SYSTEMS\n GEN: denies fevers/chills\n CARDIAC: denies chest pain or palpitations\n PULM: denies new dyspnea or cough\n GI: denies n/v, denies change in bowel habits\n GU: denies dysuria or change in appearance of urine\n Full 14-system review of systems otherwise negative and\nnon-contributory. \n\nPast Medical History:\nspinal stenosis \n- s/p ___ L4-L5 laminectomy \n- conversion to T10-S1 posterior fusion a day later due to\npost-op vertebral collapse\nParoxysmal a-fib (not on AC, as this has only occurred in the\nsetting of urosepsis and post-op)\nBilateral paraparesis following spinal surgery\nNeurologic gait disorder \nObesity s/p gastric bypass \nGERD\nHistory of pulmonary embolism \nAbd hernia\nCKD\nAnxiety/depression\n\nSocial History:\n___\nFamily History:\nBrother ___ at age ___ Cancer \nFather ___ at age ___ CAD/PVD \nMother ___ at age ___ of CHF\n\n', 'Chief Complaint:|Complaint:': '\nRight low back/flank pain\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nPenicillins / codeine\n\n'}, '16341189-DS-20', 20, 'medicine']]

[]

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[]

['medicine']

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Question: A 71 F is admitted. He/she says he/she has Right low back/flank pain . History of illness: ___ w/ PMH spinal stenosis (s/p ___ L4-L5 laminectomy with conversion to T10-S1 posterior fusion a day later due to post-op vertebral collapse), pAF (not on AC), recently admitted for left-sided low back pain, urinary retention, and an episode of fecal incontinence and treated for ?UTI, who now returns with recurrence of low back pain on the contralateral side. She recently presented with fairly abrupt onset of non-traumatic left-sided low back pain, a single episode of fecal incontinence, and was additionally found to be in acute urinary retention. Because she lives alone in the community, these deficits made it impossible to function and she presented to the ED, where concern was initially for ?cauda equina. MRI L spine ___) and CT abdomen/pelvis (___) were both fairly unremarkable -- although notably her extensive spinal hardware limits radiographic assessment of the spinal nerve roots. There was an old compression fracture, which I note is causing displacement of a pedicle screw into the adjacent disc space, where an increased T2 signal suggests significant inflammation from the chronic trauma... but per review of ___ records, this anatomy is years old. She was seen by spine surgery in our ED, who felt the neurologic exam was reassuring and they did not feel the back pain symptoms were caused by impingement of the cord or of nerve roots. She was found to have a very modest pyuria and so was admitted to medicine for ?UTI. Although the UA was unimpressive, she had a mild systemic leukocytosis and the urinary retention, so was treated for a presumed UTI with CTX->Macrobid. However her urine culture has since resulted as mixed flora consistent with fecal contamination, making this whole UTI theory questionable. Nonetheless, her urinary retention seemed to be resolving and her pain got better, so this was felt to be the diagnosis. However, she had abrupt recurrence of low back pain the day after discharge. This time it was centered on the RIGHT flank and radiating anteroinferiorly (roughly in an L1 distribution). The pain is quite manageable when she lies still, but becomes severe with movement. The pain started abruptly after she pulled herself up from a seated position using her arms. She did this in a rowing sort of motion, which would heavily utilize the latissimi dorsi (and apply a transverse force on the spine where this muscle inserts). She returned to the ED with the pain, and was again admitted due to her inability to function independently in the community with this symptom. She was straight cathed for 1000 mL of urine in the ED, suggesting urinary retention has also recurred. REVIEW OF SYSTEMS GEN: denies fevers/chills CARDIAC: denies chest pain or palpitations PULM: denies new dyspnea or cough GI: denies n/v, denies change in bowel habits GU: denies dysuria or change in appearance of urine Full 14-system review of systems otherwise negative and non-contributory. Past Medical History: spinal stenosis - s/p ___ L4-L5 laminectomy - conversion to T10-S1 posterior fusion a day later due to post-op vertebral collapse Paroxysmal a-fib (not on AC, as this has only occurred in the setting of urosepsis and post-op) Bilateral paraparesis following spinal surgery Neurologic gait disorder Obesity s/p gastric bypass GERD History of pulmonary embolism Abd hernia CKD Anxiety/depression Social History: ___ Family History: Brother ___ at age ___ Cancer Father ___ at age ___ CAD/PVD Mother ___ at age ___ of CHF Allergies: Penicillins / codeine What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Mirtazapine Nitrofurantoin Monohyd (MacroBID) ClonazePAM Atorvastatin Docusate Sodium Heparin OxyCODONE (Immediate Release) OxyCODONE (Immediate Release) Metoprolol Succinate XL Metoprolol Succinate XL Ramelteon Lidocaine 5% Patch Ondansetron Polyethylene Glycol Sodium Chloride 0.9% Flush Aspirin Senna Acetaminophen Target Lab Orders: Bilirubin Blood Glucose Ketone Leukocytes Nitrite pH Protein Specific Gravity Urine Appearance Urine Color Urobilinogen Length of Urine Collection Uhold Absolute Lymphocyte Count Basophils Eosinophils Hematocrit Hemoglobin Lymphocytes MCH MCHC MCV Monocytes Neutrophils Platelet Count RDW Red Blood Cells White Blood Cells Absolute Basophil Count Absolute Eosinophil Count Absolute Monocyte Count Absolute Neutrophil Count Immature Granulocytes RDW-SD Blue Top Hold Green Top Hold (plasma) Anion Gap Bicarbonate Chloride Creatinine Glucose H I Potassium Sodium Urea Nitrogen L Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : ___ w/ ___ spinal stenosis (s/p ___ L4-L5 laminectomy with conversion to T10-S1 posterior fusion a day later due to post-op vertebral collapse), pAF (not on AC), recently admitted for left-sided low back pain, urinary retention, and an episode of fecal incontinence, treated for ?UTI, who now returns with recurrence of low back pain on the contralateral side and recurrence of urinary retention. # Right-sided low back pain Right sided lower back/flank pain developed acutely in the setting of patient pulling herself up from seated position. The pain was sharp initially, though later described as a twisting sensation. She had paraspinal tenderness to palpation on the right (L3/4 distribution and over the quadratus lumborum) which overall suggested an MSK pathology. She was treated supportively with Tylenol q8, lidocaine patch, gabapentin BID, flexeril PRN, oxycodone PRN. She was seen by Physical therapy who recommended discharge to rehab. The patient will follow-up with her PCP and with her Orthopedic Surgeon after discharge from rehab. Of note, the patient had no focal weakness, numbness/sensory changes, or changes in bowel movements to suggest cord involvement or cauda equina. She did have transient urinary retention, which was present transiently at her prior admission and subsequently resolved, which also resolved this admission, and was ultimately not thought to be related to spinal pathology (further discussed below). She had a recent MRI (___) at BID-N after she presented with similar symptoms on the left-side, which was overall not convincing for cord involvement. Unfortunately, her extensive spinal hardware makes it hard to really clear her spinal roots. At her prior admission, she was evaluated by Spine Surgery team who did not recommend any acute surgical intervention. CT A/P this admission without any acute fracture or change. # Urinary retention The patient's urinary retention is of unclear chronicity. The urinary retention was discovered when she was undergoing work-up for the back pain, but she could have had high residuals for some period prior to this. The urinary retention could be secondary to pain, pain medications, constipation or limited mobility. She could also have an underlying urologic abnormality, though overall suspect this is less likely as the urinary retention did resolve this hospitalization. She did not show signs of pyelonephritis or UTI (urinalysis negative). This is less likely cauda equina as above (does not examine with strength or sensory deficits, had recent MRI spine without cauda equina, and was seen by Spine Surgery with low suspicion for this at last admission). In the hospital, she was monitored with bladder scans. While she did require straight catheterization x 2, her urinary retention ultimately resolved. An aggressive bowel regimen was started and she was mobilizing well with ___. Follow-up with Atrius Urology for further testing and urodynamic evaluation is recommended after rehab. # Constipation Likely secondary to limited mobility and medication-induced. Started aggressive bowel regimen. Would add a suppository or enema PRN if she does not have a bowel movement at rehab within ___ days. # Paroxysmal atrial fibrillation CHA2DS2-VASc is 3 (age, sex, HTN). She has been documented to have a-fib post-op after her spinal surgery and in the setting of urosepsis. Patient states that she has discussed anticoagulation with her outpatient Cardiologist and decided against starting a blood thinner. We discussed how her risk of stroke is elevated given her risk factors. We discussed how other patients at her similar risk level would be recommended to start anticoagulation. Patient preferred to discuss further with her outpatient providers. She continued home metoprolol 100 mg qAM, 50 mg qPM. # Anxiety/depression Continued home Klonopin 0.5 mg TID and mirtazapine. Would consider future SSRI trial to replace klonopin. #CARDIAC RISK Continued Atorvastatin 20 mg PO QPM and aspirin. TRANSITIONAL ISSUES: [] Follow-up with Urology for urodynamic testing for urinary retention [] Consider starting anticoagulation for history of atrial fibrillation [] Monitor constipation and up titrate bowel regimen as needed > 30 minutes spent in discharge planning and counseling Other Results: ADMISSION LABS: ___ 09:51PM GLUCOSE-101* UREA N-27* CREAT-1.4* SODIUM-138 POTASSIUM-4.7 CHLORIDE-100 TOTAL CO2-25 ANION GAP-13 ___ 09:51PM WBC-9.8 RBC-3.96 HGB-11.5 HCT-36.6 MCV-92 MCH-29.0 MCHC-31.4* RDW-14.3 RDWSD-48.0* ___ 09:51PM NEUTS-67.3 LYMPHS-14.9* MONOS-7.6 EOS-8.6* BASOS-0.7 IM ___ AbsNeut-6.57* AbsLymp-1.46 AbsMono-0.74 AbsEos-0.84* AbsBaso-0.07 ___ 09:51PM PLT COUNT-216 ___ 06:15AM BLOOD Glucose-98 UreaN-28* Creat-1.4* Na-138 K-5.0 Cl-101 HCO3-23 AnGap-14 NOTABLE IMAGING: MRI L-SPINE ___ from prior hospitalization at ___ FINDINGS: There has been posterior fusion with pedicle screws and rods from T10-S1. There have been laminectomies at every level at least from T10 through L5. Further evaluation of the posterior elements is prevented by artifact from the hardware. Artifact from the hardware severely obscures images of the spinal canal. On the sagittal T2 weighted images there is no evidence of spinal canal encroachment. The axial images are heavily degraded by artifact and prevent reliable evaluation of the neural foramina. There is a compression fracture of the L4 vertebral body with normal signal on all images. This suggests that it is chronic. There is marked hyperintensity of the intervertebral disc on the T2 weighted images at L3-4. This may be seen in the setting of severe disc degeneration with a fluid filled cleft within the disc. Although a hyperintense disc on T2 weighted images may also be seen as result of discitis, the normal signal intensity of the adjacent vertebral bodies on the STIR images argues against an infectious or inflammatory etiology. There are similar findings at L5-S1, again most likely due to degenerative disease. There is no abnormal enhancement after contrast administration. No abnormal fluid collections are identified. There is no evidence of compression of the spinal cord or cauda equina. IMPRESSION: 1. Limited study due to artifact from fusion hardware. 2. Status post posterior fusion from T10 through S1 with rods and pedicle screws. 3. Chronic-appearing L4 compression fracture. 4. Laminectomies at least from T10 through L5. 5. No evidence of spinal cord or cauda equina compression. CT ABD/PELVIS ___ No acute intra-abdominal process, no findings to explain patient's symptoms. Specifically: - There is no perinephric abnormality. - No renal or ureteral calculus. - There is no evidence of worrisome osseous lesions or acute fracture. Laminectomies with posterior fixation hardware seen spanning T10 through S1. No evidence of hardware related complication. - The abdominal and pelvic wall is within normal limits.

2206-01-06 03:22:00

ENGLISH

SINGLE

BLACK/AFRICAN AMERICAN

F

[[27264929, Timestamp('2206-01-06 03:22:58'), '', 'MED']]

[[{'Medications on Admission': ':\nThe Preadmission Medication list is accurate and complete.\n1. Genvoya (elviteg-cobi-emtric-tenofo ala) ___ mg \noral QPM \n2. Omeprazole 20 mg PO DAILY \n3. Aspirin 81 mg PO DAILY \n4. Fish Oil (Omega 3) 2400 mg PO DAILY \n5. Fluticasone Propionate NASAL 1 SPRY NU DAILY \n6. Loratadine 10 mg PO DAILY \n7. MetFORMIN (Glucophage) 1000 mg PO BID \n8. Vitamin D ___ UNIT PO DAILY \n9. amLODIPine 5 mg PO DAILY \n10. Losartan Potassium 100 mg PO DAILY \n11. Albuterol Inhaler 1 PUFF IH Q4H:PRN SOB \n12. Ibuprofen 220 mg PO BID:PRN Pain - Moderate \n13. norethindrone acetate 10 mg oral DAILY \n\nSecondary: \nHIV\nType 2 Diabetes', 'Brief Hospital Course': ":\n___ with history of HIV (on HAART, ___ CD4 926, HIV VL \nundetectable), Thyroid nodule s/p FNA ___, benign), \niron-deficiency anemia treated presents with diarrhea and abd \npain x 2 days with fevers and rigors, with positive UA on \nadmission.\n\n #Pyelonephritis: grossly positive UA (leukocyte esterase and \nnitrites) in the setting of abd pain and fever. Has history of \nnephrolithiasis, moderate RBCs in UA on ___. Allergy to \nPenicillins. Grew pan-sensitive e-coli in ___. Diarrhea has \nstopped. Cipro started on ___. Urine culture growing e coli \nwith sensitivity to ceftriaxone; blood cx from ___ (after \ninitiation of antibiotics) with GNRs, sensitive to ceftriaxone \n(resistant to cipro). Cipro d/c'ed and ceftriaxone started on \n___, will complete 14 day course. Lactate 1.8 on ___ \n(from 2.9 on admission), s/p 2L NS in ED. \n\n # Diabetes mellitus, type II: Last HbA1c=6.5% in ___. On \nmetformin 1000mg BID at home. Received ISS during \nhospitalization; discharged back home on metformin.\n\n # HIV: Well-controlled on HAART. VL undetectable as of ___, \nlast CD4=946 on ___. Pt ran out of home genvoya, continued \nHAART on Stribild while in house, per pharmacy protocol. Will \nrestart genvoya when home.\n\n #HTN: continued home Amlodipine 5mg daily and Losartan 100mg \ndaily.\n\n # MICROCYTIC ANEMIA: Patient with very significant iron \ndeficiency anemia since ___ with ferritin of 7.2 and TIBC of \n655, thought secondary to gastropathy as well as menorrhagia in \nthe setting of uterine fibroids. SPEP and UPEP were negative in \n___. EGD in ___ with gastritis, colonoscopy in ___ with polyp. She is unable to tolerate PO Iron. Currently on \n___ IV iron infusions in ___ clinic. She received four \nweekly doses of SC Vitamin B12 ___ through ___ for a \nreported low B12. With her history of anemia, and B12 deficiency \nthat responded best to SQ, she could have pernicious anemia. And \nwhile this classically presents as a macrocytic anemia, her \nsevere Fe-deficiency could mask an elevated MCV (indeed in ___, \nshe had a macrocytosis to 111). Denies melena or BRPBR. \nPost-menopausal. Could consider Anti-IF Ab or send as outpt.\n\nTransitional Issues: \n[ ] On cefpodoxime for total 14 day course (last day ___\n[ ] f/u blood cultures\n# CODE: DNR/DNI\n# CONTACT: ___, brother. ___\n\n", 'Pertinent Results:': '\nADMISSION LABS\n==============\n___ 06:05AM GLUCOSE-188* UREA N-10 CREAT-0.8 SODIUM-135 \nPOTASSIUM-4.5 CHLORIDE-101 TOTAL CO2-22 ANION GAP-17\n___ 06:05AM MAGNESIUM-1.4*\n___ 06:05AM WBC-12.1* RBC-4.00 HGB-9.5* HCT-30.5* MCV-76* \nMCH-23.8* MCHC-31.1* RDW-23.2* RDWSD-61.7*\n___ 06:05AM PLT COUNT-335\n___ 03:42AM LACTATE-1.9\n___ 01:55AM URINE COLOR-Yellow APPEAR-Clear SP ___\n___ 01:55AM URINE BLOOD-MOD NITRITE-POS PROTEIN-30 \nGLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-6.5 \nLEUK-LG\n___ 01:55AM URINE RBC-7* WBC->182* BACTERIA-FEW YEAST-NONE \nEPI-2\n___ 12:38AM LACTATE-2.9*\n___ 12:30AM GLUCOSE-202* UREA N-14 CREAT-1.2* SODIUM-139 \nPOTASSIUM-4.7 CHLORIDE-100 TOTAL CO2-22 ANION GAP-22*\n___ 12:30AM ALT(SGPT)-26 AST(SGOT)-18 ALK PHOS-74 TOT \nBILI-0.4\n___ 12:30AM LIPASE-27\n___ 12:30AM ALBUMIN-4.5\n___ 12:30AM WBC-14.6*# RBC-4.56 HGB-10.7* HCT-35.0 \nMCV-77* MCH-23.5* MCHC-30.6* RDW-23.3* RDWSD-63.3*\n___ 12:30AM NEUTS-85.3* LYMPHS-6.7* MONOS-7.0 EOS-0.1* \nBASOS-0.3 IM ___ AbsNeut-12.46*# AbsLymp-0.98* \nAbsMono-1.02* AbsEos-0.02* AbsBaso-0.05\n___ 12:30AM PLT COUNT-400\n\nMICRO\n=====\n___ 12:47 am BLOOD CULTURE ESCHERICHIA COLI. FINAL \nSENSITIVITIES. \n___ 1:25 am URINE \n URINE CULTURE (Final ___: \n ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE \nIDENTIFICATION. \n Cefazolin interpretative criteria are based on a dosage \nregimen of\n 2g every 8h. \n GRAM POSITIVE BACTERIA. 10,000-100,000 CFU/mL. \n Alpha hemolytic colonies consistent with alpha \nstreptococcus or\n Lactobacillus sp. \n ESCHERICHIA COLI. 10,000-100,000 CFU/mL. \n PRESUMPTIVE IDENTIFICATION. SECOND MORPHOLOGY. \n Cefazolin interpretative criteria are based on a dosage \nregimen of\n 2g every 8h. \n\nIMAGING\n=======\n___ CT ABD & PELVIS W/O CON \n1. New right renal perinephric fat stranding, centered along the \nright lower pole is worrisome for acute pyelonephritis in the \nappropriate clinical setting. \n2. No interval change in several subcentimeter nonobstructing \nleft lower pole renal stones measuring up to 0.5 cm. No \nhydronephrosis. \n3. 3.9 cm asymmetric skin thickening along left breast is \nsimilar to ___ mammographic findings and reportedly \ncorresponds to raised skin lesion at this level. \n4. 0.3 cm right lower pole pulmonary nodule is stable since \n___. No \nadditional followup is warranted. \n5. No evidence of acute diverticulitis or colitis. \n\n', 'Physical Exam:|Physical': '\nADMISSION PHYSICAL EXAM\n=======================\n Vital Signs: \n 98.4 \n PO 141 / 75 85 18 100 RA \n General: Alert, oriented, no acute distress \n HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, \nneck supple, JVP not elevated, no LAD \n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, \ngallops \n Lungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \n Abdomen: Soft, non-distended, bowel sounds present, no \norganomegaly, no rebound or guarding, CVA tenderness on the \nright. \n GU: No foley \n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \n Neuro: CNII-XII intact, ___ strength upper/lower extremities, \ngrossly normal sensation, 2+ reflexes bilaterally, gait \ndeferred. \n\nDISCHARGE PHYSICAL EXAM\n=======================\nVitals: T 98.8, Tmax 98.8, BP 132-144/67-79, HR 76-82, RR 16, \nSpO2 100/RA \nGeneral: Alert, oriented, no acute distress \nHEENT: Sclera anicteric, MMM, oropharynx clear \nNeck: supple\nLungs: Clear to auscultation bilaterally, no wheezes, rales, \nrhonchi \nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, \ngallops \nAbdomen: soft, non-distended, bowel sounds present, mild TTP in \nRLQ, no rebound tenderness or guarding\nBack: no CVA tenderness\nExt: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \nNeuro: grossly intact, moving all extremities\nSkin: no rashes or lesions\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\n___ female history of of HIV (on HAART, ___ CD4 926, \n HIV VL undetectable), Thyroid nodule s/p FNA ___, benign), \n iron-deficiency anemia treated presents with diarrhea and abd \npain x 2 days with fevers and rigors. She reports poor PO intake \nand appetite w/ nausea, no vomiting. No sick contacts or recent \ntravel. Has been following up with PCP for infusions for her \nanemia. \n In the ED, initial vitals were: 100.8 108 198/74 16 100% RA \n Labs notable for: \n Cr to 1.2, grossly positive UA, normal LFTs, H&H of 10.7/35 \nwith a neutrophilic predominance leukocytosis to 14.6, lactate \n2.9 \n Imaging notable for: CT ABB Pelvis W/o Contrast: Stranding \naround right kidney no hydro. \n Patient was given: 2L NS, IV Cipro, Zofran, and Morphine.\n\nPast Medical History:\nHIV on HAART, ___ absolute CD4 ct ___, VL undetectable, dx \nin ___ \nHTN \nCongenital hearing loss \nIron deficiency anemia\nAsthma\nBenign R-sided thyroid nodule, FNA bx in ___, followed by \nendocrine \nuterine fibroids s/p myomectomy \nStatus post removal of subcutaneous cyst \n\nSocial History:\n___\nFamily History:\nCAD, CVA, HTN and DM. No known bowel/digestive disorders. \n\n', 'Chief Complaint:|Complaint:': '\nabdominal pain, fevers/chills\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nPenicillins / pollen / Iodinated Contrast Media - IV Dye\n\n'}, '18683574-DS-24', 24, 'medicine']]

[['EXAMINATION: CT abdomen/pelvis without contrast.\n\nINDICATION: ___ with HIV w/ abd pain, diarrhea w/ fevers+PO contrast. Assess\nfor diverticulitis, colitis, any abnl\n\nTECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired\nwithout intravenous contrast. Non-contrast scan has several limitations in\ndetecting vascular and parenchymal organ abnormalities, including tumor\ndetection.\nOral contrast was administered.\nCoronal and sagittal reformations were performed and reviewed on PACS.\n\nDOSE: Acquisition sequence:\n 1) Spiral Acquisition 4.7 s, 51.0 cm; CTDIvol = 15.3 mGy (Body) DLP = 779.4\nmGy-cm.\n Total DLP (Body) = 779 mGy-cm.\n\nCOMPARISON: CT abdomen/ pelvis without contrast ___\nAbdominal ultrasound ___\nCT abdomen/pelvis ___.\n\nFINDINGS: \n\nLOWER CHEST: Stable 0.3 cm right lower lobe pulmonary nodule (2:9) is\nunchanged from ___. Visualized lung fields are otherwise within\nnormal limits. There is no evidence of pleural or pericardial effusion. The\nvisualized heart is normal in size. No pericardial effusion.\n\nABDOMEN:\n\nHEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout. \nThere is no evidence of focal lesions within the limitations of an unenhanced\nscan. There is no evidence of intrahepatic or extrahepatic biliary\ndilatation. The gallbladder is decompressed without gallstones.\n\nPANCREAS: The pancreas has normal attenuation throughout, without evidence of\nfocal lesions within the limitations of an unenhanced scan. There is no\npancreatic ductal dilatation. There is no peripancreatic stranding.\n\nSPLEEN: The spleen shows normal size and attenuation throughout, without\nevidence of focal lesions. 0.7 cm accessory spleen is noted.\n\nADRENALS: The right and left adrenal glands are normal in size and shape.\n\nURINARY: New subtle right perinephric fat stranding primarily involving the\nright lower pole. No perinephric collection. The kidneys are of symmetric\nsize. There is no evidence of focal renal lesions within the limitations of\nan unenhanced scan. There is no hydronephrosis or hydroureter. Again seen\nare several nonobstructing left lower pole renal stones, largest measuring up\nto 0.5 x 0.4 cm (723 ___ units) which is unchanged since prior\nexamination.\n\nGASTROINTESTINAL: No hiatal hernia. The stomach is unremarkable. Small bowel\nloops demonstrate normal caliber and wall thickness throughout. The colon and\nrectum are within normal limits. The appendix is normal.\n\nPELVIS: The urinary bladder and distal ureters are unremarkable. There is no\nfree fluid in the pelvis.\n\nREPRODUCTIVE ORGANS: Bulky enlarged uterus is again noted with multiple\nexophytic fibroids, largest measuring 3.1 x 3 cm along the right fundus with\ncentral punctate calcifications, unchanged in appearance since prior\nexamination.\n\nLYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There\nis no pelvic or inguinal lymphadenopathy.\n\nVASCULAR: There is no abdominal aortic aneurysm. Minimal atherosclerotic\ndisease is noted.\n\nBONES: There is no evidence of worrisome osseous lesions or acute fracture.\n\nSOFT TISSUES: 3.9 x 1.5 cm asymmetric skin thickening along the left breast is\nsimilar to ___ mammographic findings, which reportedly correspond\nto a raised skin lesion at this level (2: 1). 0.9 cm sebaceous cyst is seen\nalong the anterior subcutaneous tissue at midline (2:5). The abdominal and\npelvic wall is otherwise within normal limits.\n\nIMPRESSION:\n\n\n1. New right renal perinephric fat stranding, centered along the right lower\npole is worrisome for acute pyelonephritis in the appropriate clinical\nsetting.\n2. No interval change in several subcentimeter nonobstructing left lower pole\nrenal stones measuring up to 0.5 cm. No hydronephrosis.\n3. 3.9 cm asymmetric skin thickening along left breast is similar to ___ mammographic findings and reportedly corresponds to raised skin lesion at\nthis level.\n4. 0.3 cm right lower pole pulmonary nodule is stable since ___. No\nadditional followup is warranted.\n5. No evidence of acute diverticulitis or colitis.\n', '18683574-RR-105', 105, 'multidetector ct images of the abdomen and pelvis were acquired\nwithout intravenous contrast. non-contrast scan has several limitations in\ndetecting vascular and parenchymal organ abnormalities, including tumor\ndetection.\noral contrast was administered.\ncoronal and sagittal reformations were performed and reviewed on pacs.']]

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[]

['medicine']

[[50868, Timestamp('2206-01-06 06:05:00'), Timestamp('2206-01-06 09:11:00'), 'Anion Gap'], [50882, Timestamp('2206-01-06 06:05:00'), Timestamp('2206-01-06 09:11:00'), 'Bicarbonate'], [50902, Timestamp('2206-01-06 06:05:00'), Timestamp('2206-01-06 09:11:00'), 'Chloride'], [50912, Timestamp('2206-01-06 06:05:00'), Timestamp('2206-01-06 09:11:00'), 'Creatinine'], [50931, Timestamp('2206-01-06 06:05:00'), Timestamp('2206-01-06 09:11:00'), 'Glucose'], [50934, Timestamp('2206-01-06 06:05:00'), Timestamp('2206-01-06 09:11:00'), 'H'], [50947, Timestamp('2206-01-06 06:05:00'), Timestamp('2206-01-06 09:11:00'), 'I'], [50960, Timestamp('2206-01-06 06:05:00'), Timestamp('2206-01-06 09:11:00'), 'Magnesium'], [50971, Timestamp('2206-01-06 06:05:00'), Timestamp('2206-01-06 09:11:00'), 'Potassium'], [50983, Timestamp('2206-01-06 06:05:00'), Timestamp('2206-01-06 09:11:00'), 'Sodium'], [51006, Timestamp('2206-01-06 06:05:00'), Timestamp('2206-01-06 09:11:00'), 'Urea Nitrogen'], [51678, Timestamp('2206-01-06 06:05:00'), Timestamp('2206-01-06 09:11:00'), 'L'], [51221, Timestamp('2206-01-06 06:05:00'), Timestamp('2206-01-06 08:03:00'), 'Hematocrit'], [51222, Timestamp('2206-01-06 06:05:00'), Timestamp('2206-01-06 08:03:00'), 'Hemoglobin'], [51248, Timestamp('2206-01-06 06:05:00'), Timestamp('2206-01-06 08:03:00'), 'MCH'], [51249, Timestamp('2206-01-06 06:05:00'), Timestamp('2206-01-06 08:03:00'), 'MCHC'], [51250, Timestamp('2206-01-06 06:05:00'), Timestamp('2206-01-06 08:03:00'), 'MCV'], [51265, Timestamp('2206-01-06 06:05:00'), Timestamp('2206-01-06 08:03:00'), 'Platelet Count'], [51277, Timestamp('2206-01-06 06:05:00'), Timestamp('2206-01-06 08:03:00'), 'RDW'], [51279, Timestamp('2206-01-06 06:05:00'), Timestamp('2206-01-06 08:03:00'), 'Red Blood Cells'], [51301, Timestamp('2206-01-06 06:05:00'), Timestamp('2206-01-06 08:03:00'), 'White Blood Cells'], [52172, Timestamp('2206-01-06 06:05:00'), Timestamp('2206-01-06 08:03:00'), 'RDW-SD'], [51463, Timestamp('2206-01-07 01:35:00'), Timestamp('2206-01-07 02:09:00'), 'Bacteria'], [51464, Timestamp('2206-01-07 01:35:00'), Timestamp('2206-01-07 02:10:00'), 'Bilirubin'], [51466, Timestamp('2206-01-07 01:35:00'), Timestamp('2206-01-07 02:10:00'), 'Blood'], [51476, Timestamp('2206-01-07 01:35:00'), Timestamp('2206-01-07 02:09:00'), 'Epithelial Cells'], [51478, Timestamp('2206-01-07 01:35:00'), Timestamp('2206-01-07 02:10:00'), 'Glucose'], [51482, Timestamp('2206-01-07 01:35:00'), Timestamp('2206-01-07 02:09:00'), 'Hyaline Casts'], [51484, Timestamp('2206-01-07 01:35:00'), Timestamp('2206-01-07 02:10:00'), 'Ketone'], [51486, Timestamp('2206-01-07 01:35:00'), Timestamp('2206-01-07 02:10:00'), 'Leukocytes'], [51487, Timestamp('2206-01-07 01:35:00'), Timestamp('2206-01-07 02:10:00'), 'Nitrite'], [51491, Timestamp('2206-01-07 01:35:00'), Timestamp('2206-01-07 02:10:00'), 'pH'], [51492, Timestamp('2206-01-07 01:35:00'), Timestamp('2206-01-07 02:10:00'), 'Protein'], [51493, Timestamp('2206-01-07 01:35:00'), Timestamp('2206-01-07 02:09:00'), 'RBC'], [51498, Timestamp('2206-01-07 01:35:00'), Timestamp('2206-01-07 02:10:00'), 'Specific Gravity'], [51506, Timestamp('2206-01-07 01:35:00'), Timestamp('2206-01-07 02:10:00'), 'Urine Appearance'], [51508, Timestamp('2206-01-07 01:35:00'), Timestamp('2206-01-07 02:10:00'), 'Urine Color'], [51512, Timestamp('2206-01-07 01:35:00'), Timestamp('2206-01-07 02:09:00'), 'Urine Mucous'], [51514, Timestamp('2206-01-07 01:35:00'), Timestamp('2206-01-07 02:10:00'), 'Urobilinogen'], [51516, Timestamp('2206-01-07 01:35:00'), Timestamp('2206-01-07 02:09:00'), 'WBC'], [51519, Timestamp('2206-01-07 01:35:00'), Timestamp('2206-01-07 02:09:00'), 'Yeast']]

Question: A 43 F is admitted. He/she says he/she has abdominal pain, fevers/chills . History of illness: ___ female history of of HIV (on HAART, ___ CD4 926, HIV VL undetectable), Thyroid nodule s/p FNA ___, benign), iron-deficiency anemia treated presents with diarrhea and abd pain x 2 days with fevers and rigors. She reports poor PO intake and appetite w/ nausea, no vomiting. No sick contacts or recent travel. Has been following up with PCP for infusions for her anemia. In the ED, initial vitals were: 100.8 108 198/74 16 100% RA Labs notable for: Cr to 1.2, grossly positive UA, normal LFTs, H&H of 10.7/35 with a neutrophilic predominance leukocytosis to 14.6, lactate 2.9 Imaging notable for: CT ABB Pelvis W/o Contrast: Stranding around right kidney no hydro. Patient was given: 2L NS, IV Cipro, Zofran, and Morphine. Past Medical History: HIV on HAART, ___ absolute CD4 ct ___, VL undetectable, dx in ___ HTN Congenital hearing loss Iron deficiency anemia Asthma Benign R-sided thyroid nodule, FNA bx in ___, followed by endocrine uterine fibroids s/p myomectomy Status post removal of subcutaneous cyst Social History: ___ Family History: CAD, CVA, HTN and DM. No known bowel/digestive disorders. Allergies: Penicillins / pollen / Iodinated Contrast Media - IV Dye What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Insulin HYDROmorphone (Dilaudid) Omeprazole Glucagon Fluticasone Propionate NASAL Fish Oil (Omega 3) Acetaminophen Genvoya Sodium Chloride 0.9% Flush Loratadine Glucose Gel 5% Dextrose Ciprofloxacin IV Dextrose 50% Heparin Ondansetron norethindrone acetate Bag Magnesium Sulfate amLODIPine Losartan Potassium Acetaminophen Target Lab Orders: Anion Gap Bicarbonate Chloride Creatinine Glucose H I Magnesium Potassium Sodium Urea Nitrogen L Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells RDW-SD Bacteria Bilirubin Blood Epithelial Cells Glucose Hyaline Casts Ketone Leukocytes Nitrite pH Protein RBC Specific Gravity Urine Appearance Urine Color Urine Mucous Urobilinogen WBC Yeast Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : ___ with history of HIV (on HAART, ___ CD4 926, HIV VL undetectable), Thyroid nodule s/p FNA ___, benign), iron-deficiency anemia treated presents with diarrhea and abd pain x 2 days with fevers and rigors, with positive UA on admission. #Pyelonephritis: grossly positive UA (leukocyte esterase and nitrites) in the setting of abd pain and fever. Has history of nephrolithiasis, moderate RBCs in UA on ___. Allergy to Penicillins. Grew pan-sensitive e-coli in ___. Diarrhea has stopped. Cipro started on ___. Urine culture growing e coli with sensitivity to ceftriaxone; blood cx from ___ (after initiation of antibiotics) with GNRs, sensitive to ceftriaxone (resistant to cipro). Cipro d/c'ed and ceftriaxone started on ___, will complete 14 day course. Lactate 1.8 on ___ (from 2.9 on admission), s/p 2L NS in ED. # Diabetes mellitus, type II: Last HbA1c=6.5% in ___. On metformin 1000mg BID at home. Received ISS during hospitalization; discharged back home on metformin. # HIV: Well-controlled on HAART. VL undetectable as of ___, last CD4=946 on ___. Pt ran out of home genvoya, continued HAART on Stribild while in house, per pharmacy protocol. Will restart genvoya when home. #HTN: continued home Amlodipine 5mg daily and Losartan 100mg daily. # MICROCYTIC ANEMIA: Patient with very significant iron deficiency anemia since ___ with ferritin of 7.2 and TIBC of 655, thought secondary to gastropathy as well as menorrhagia in the setting of uterine fibroids. SPEP and UPEP were negative in ___. EGD in ___ with gastritis, colonoscopy in ___ with polyp. She is unable to tolerate PO Iron. Currently on ___ IV iron infusions in ___ clinic. She received four weekly doses of SC Vitamin B12 ___ through ___ for a reported low B12. With her history of anemia, and B12 deficiency that responded best to SQ, she could have pernicious anemia. And while this classically presents as a macrocytic anemia, her severe Fe-deficiency could mask an elevated MCV (indeed in ___, she had a macrocytosis to 111). Denies melena or BRPBR. Post-menopausal. Could consider Anti-IF Ab or send as outpt. Transitional Issues: [ ] On cefpodoxime for total 14 day course (last day ___ [ ] f/u blood cultures # CODE: DNR/DNI # CONTACT: ___, brother. ___ Other Results: ADMISSION LABS ============== ___ 06:05AM GLUCOSE-188* UREA N-10 CREAT-0.8 SODIUM-135 POTASSIUM-4.5 CHLORIDE-101 TOTAL CO2-22 ANION GAP-17 ___ 06:05AM MAGNESIUM-1.4* ___ 06:05AM WBC-12.1* RBC-4.00 HGB-9.5* HCT-30.5* MCV-76* MCH-23.8* MCHC-31.1* RDW-23.2* RDWSD-61.7* ___ 06:05AM PLT COUNT-335 ___ 03:42AM LACTATE-1.9 ___ 01:55AM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 01:55AM URINE BLOOD-MOD NITRITE-POS PROTEIN-30 GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-6.5 LEUK-LG ___ 01:55AM URINE RBC-7* WBC->182* BACTERIA-FEW YEAST-NONE EPI-2 ___ 12:38AM LACTATE-2.9* ___ 12:30AM GLUCOSE-202* UREA N-14 CREAT-1.2* SODIUM-139 POTASSIUM-4.7 CHLORIDE-100 TOTAL CO2-22 ANION GAP-22* ___ 12:30AM ALT(SGPT)-26 AST(SGOT)-18 ALK PHOS-74 TOT BILI-0.4 ___ 12:30AM LIPASE-27 ___ 12:30AM ALBUMIN-4.5 ___ 12:30AM WBC-14.6*# RBC-4.56 HGB-10.7* HCT-35.0 MCV-77* MCH-23.5* MCHC-30.6* RDW-23.3* RDWSD-63.3* ___ 12:30AM NEUTS-85.3* LYMPHS-6.7* MONOS-7.0 EOS-0.1* BASOS-0.3 IM ___ AbsNeut-12.46*# AbsLymp-0.98* AbsMono-1.02* AbsEos-0.02* AbsBaso-0.05 ___ 12:30AM PLT COUNT-400 MICRO ===== ___ 12:47 am BLOOD CULTURE ESCHERICHIA COLI. FINAL SENSITIVITIES. ___ 1:25 am URINE URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE IDENTIFICATION. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. GRAM POSITIVE BACTERIA. 10,000-100,000 CFU/mL. Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. ESCHERICHIA COLI. 10,000-100,000 CFU/mL. PRESUMPTIVE IDENTIFICATION. SECOND MORPHOLOGY. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. IMAGING ======= ___ CT ABD & PELVIS W/O CON 1. New right renal perinephric fat stranding, centered along the right lower pole is worrisome for acute pyelonephritis in the appropriate clinical setting. 2. No interval change in several subcentimeter nonobstructing left lower pole renal stones measuring up to 0.5 cm. No hydronephrosis. 3. 3.9 cm asymmetric skin thickening along left breast is similar to ___ mammographic findings and reportedly corresponds to raised skin lesion at this level. 4. 0.3 cm right lower pole pulmonary nodule is stable since ___. No additional followup is warranted. 5. No evidence of acute diverticulitis or colitis.

2119-01-16 00:33:00

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[[25347307, Timestamp('2119-01-16 00:34:05'), '', 'CSURG']]

[[{'Medications on Admission': ':\n1. Clopidogrel 75 mg PO DAILY \nRX *clopidogrel 75 mg 1 Tablet(s) by mouth daily Disp #*60 \nTablet Refills:*0\n2. Docusate Sodium 100 mg PO DAILY \nRX *docusate sodium 100 mg 1 Capsule(s) by mouth twice a day \nDisp #*60 Tablet Refills:*0\n3. Finasteride 5 mg PO DAILY \nRX *finasteride 5 mg 1 Tablet(s) by mouth daily Disp #*60 Tablet \n\nRefills:*0\n4. Multivitamins 1 TAB PO DAILY \nRX *Daily Multi-Vitamin 1 Tablet(s) by mouth daily Disp #*60 \nTablet Refills:*0\n5. OLANZapine 5 mg PO HS \nRX *olanzapine 5 mg 1 Tablet(s) by mouth HS Disp #*60 Tablet \nRefills:*0\n6. Paroxetine 30 mg PO DAILY \nRX *paroxetine HCl 30 mg 1 Tablet(s) by mouth daily Disp #*60 \nTablet Refills:*0\n7. Simvastatin 40 mg PO DAILY \nRX *simvastatin 40 mg 1 Tablet(s) by mouth daily Disp #*60 \nTablet Refills:*0\n8. Lorazepam 0.5 mg PO HS \nHold for oversedation or RR<10 \nRX *Ativan 0.5 mg 0.5 (One half) mg by mouth HS Disp #*45 Tablet \n\nRefills:*0\n9. Acetaminophen 650 mg PO Q4H:PRN pain, fever \nRX *8 HOUR PAIN RELIEVER 650 mg 1 Tablet(s) by mouth q4 hours \nprn Disp #*60 Tablet Refills:*0\n10. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob \nRX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 2.5 mg inhaled via \nnebulizaiton q 6 h Disp #*1 Inhaler Refills:*0\n11. Amiodarone 400 mg PO BID \nx 7 days, then decrease to 400 mg daily x 7 days, then decrease \nto 200mg daily \nRX *amiodarone 200 mg 2 Tablet(s) by mouth bid x 7 days, then \ndecrease to 1 tab bid x 7 days then decrease to 1 tab daily Disp \n\n#*60 Tablet Refills:*0\n12. Bisacodyl ___AILY:PRN constipation \nRX *bisacodyl 10 mg 1 Suppository(s) rectally daily Disp #*30 \nTablet Refills:*0\n13. Furosemide 20 mg IV BID \nRX *furosemide 20 mg 1 Tablet(s) by mouth twice a day Disp #*30 \nTablet Refills:*0\n14. Ipratropium Bromide Neb 1 NEB IH Q6H \nRX *ipratropium bromide 0.2 mg/mL (0.02 %) 0.02% inhalation \nevery six (6) hours Disp #*1 Inhaler Refills:*0\n15. Metoprolol Tartrate 37.5 mg PO TID \nHold for HR < 55 or SBP < 90 and call medical provider. \nRX *metoprolol tartrate 25 mg 1.5 Tablet(s) by mouth three times \n\na day Disp #*90 Tablet Refills:*0\n16. Potassium Chloride 20 mEq PO Q12H \nHold for K+ > 4.5 \nRX *potassium chloride 20 mEq 20 mEQ by mouth twice a day Disp \n#*60 Tablet Refills:*0\n17. Ranitidine 150 mg PO DAILY \nRX *ranitidine HCl 150 mg 1 Tablet(s) by mouth daily Disp #*60 \nTablet Refills:*0\n18. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain \nRX *tramadol 50 mg ___ Tablet(s) by mouth q4h prn Disp #*45 \nTablet Refills:*0\n19. Aspirin EC 81 mg PO DAILY \n\nFacility:\n___\n\n___ Diagnosis:\nshortness of breath\nPMH:\nCoronary artery disease s/p Coronary artery bypass graft x 3, \n___\nlacunar CVA ___ \nlumbar spinal stenosis \nbipolar disorder \northostatic hypotension \nambulates without walker with supervision r/t orthostatic\nhypotension \nhyperlipidemia\nPAD\nPVD\nlives at nursing home for 6+ years r/t bipolar/anxiety\nAnxiety\nBPH \nCOPD\nDepression\nSyncope\nbilateral carotid endarterectomies ___arotid stent ___ \nleft renal artery stent \nleft external iliac stenting \nleft popliteal stenting \ncataract surgery', 'Brief Hospital Course': ':\nMr. ___ was admitted with shortness of breath. He was given \nlasix and diuresed well. He felt better after diuresis and \nmoving his bowels. A chest radiograph completed on the day of \nre-admission already showed resolved pulmonary edema and \ndecreased alalectasis. By hospital day 2 he was ready for \ntransfer back to the nursing home where he resides, Kindred \n___ Care and Rehabilitation in ___. \n\n', 'Pertinent Results:': 'NIL', 'Physical Exam:|Physical': '\nAdmission\nSkin: Dry [x] intact [x]\nHEENT: PERRLA [x] EOMI []\nNeck: Supple [x] Full ROM [x]\nChest: Bilaterally basilar rales, Decreased breath sound at the\nbases\nHeart: RRR [x] Irregular [] Murmur [] grade ______\nAbdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds\n+ [x]\nExtremities: Warm [x], well-perfused [x] Edema [x] left leg\n+1\nNeuro: Grossly intact [x]\n\nDischarge:\nGen: NAD\nNeuro: A&O x3, MAE, follows commands\nPulm: CTA-bilat\nCV: RRR, sternum stable incision CDI\nAbdm: soft, NT/ND/+BS\nExt; 1+ pedal edema bilat\n\nRadiology Report CHEST (PA & LAT) Study Date of ___ 10:43 \nAM \nREASON FOR THIS EXAMINATION: eval for pleural effusions \nFinal Report: PA AND LATERAL CHEST OF ___ \nCOMPARISON: ___ radiograph. \nFINDINGS: The patient is status post median sternotomy and \ncoronary artery \nbypass surgery. Cardiac silhouette has slightly decreased in \nsize since the previous study, pulmonary edema has resolved. \nImproving aeration at both lung bases. Residual patchy \nretrocardiac atelectasis and bibasilar linear atelectasis \nremaining. Small pleural effusions are also noted. \nIMPRESSION: Resolution of pulmonary edema. Bibasilar \natelectasis and small pleural effusions. \n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\nMr. ___ underwent an ___ coronary artery bypass grafting \non ___ and was discharged to the nursing facility where he \nlives on ___. Once there, he was noted to be short of \nbreath with oxygen saturations of 88% on room air. He was \ntransferred back to ___ for \nfurther diuresis.\n\nPast Medical History:\nshortness of breath\nPMH:\nCoronary artery disease s/p Coronary artery bypass graft x 3, \n___\nlacunar CVA ___ \nlumbar spinal stenosis \nbipolar disorder \northostatic hypotension \nambulates without walker with supervision r/t orthostatic\nhypotension \nhyperlipidemia\nPAD\nPVD\nlives at nursing home for 6+ years r/t bipolar/anxiety\nAnxiety\nBPH \nCOPD\nDepression\nSyncope\nbilateral carotid endarterectomies ___arotid stent ___ \nleft renal artery stent \nleft external iliac stenting \nleft popliteal stenting \ncataract surgery\n\nSocial History:\n___\nFamily History:\nFam Hx: Mother died of chronic heart disease, father had kidney \ntrouble, 2 sisters have DM. No hx sudden death or seizures.\n\n', 'Chief Complaint:|Complaint:': '\nshortness of breath\n\n', 'Attending:': ' ___\n\n', 'Allergies:': ' \nCodeine / Sudafed\n\n'}, '12009312-DS-16', 16, 'cardiothoracic']]

[['PA AND LATERAL CHEST OF ___\n\nCOMPARISON: ___ radiograph.\n\nFINDINGS: The patient is status post median sternotomy and coronary artery\nbypass surgery. Cardiac silhouette has slightly decreased in size since the\nprevious study, pulmonary edema has resolved. Improving aeration at both lung\nbases. Residual patchy retrocardiac atelectasis and bibasilar linear\natelectasis remaining. Small pleural effusions are also noted.\n\nIMPRESSION: Resolution of pulmonary edema. Bibasilar atelectasis and small\npleural effusions.\n', '12009312-RR-56', 56, '']]

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[]

['cardiothoracic']

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Question: A 79 M is admitted. He/she says he/she has shortness of breath . History of illness: Mr. ___ underwent an ___ coronary artery bypass grafting on ___ and was discharged to the nursing facility where he lives on ___. Once there, he was noted to be short of breath with oxygen saturations of 88% on room air. He was transferred back to ___ for further diuresis. Past Medical History: shortness of breath PMH: Coronary artery disease s/p Coronary artery bypass graft x 3, ___ lacunar CVA ___ lumbar spinal stenosis bipolar disorder orthostatic hypotension ambulates without walker with supervision r/t orthostatic hypotension hyperlipidemia PAD PVD lives at nursing home for 6+ years r/t bipolar/anxiety Anxiety BPH COPD Depression Syncope bilateral carotid endarterectomies ___arotid stent ___ left renal artery stent left external iliac stenting left popliteal stenting cataract surgery Social History: ___ Family History: Fam Hx: Mother died of chronic heart disease, father had kidney trouble, 2 sisters have DM. No hx sudden death or seizures. Allergies: Codeine / Sudafed What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Clopidogrel 0.9% Sodium Chloride Acetaminophen Simvastatin Aspirin Lorazepam Bisacodyl Sodium Chloride 0.9% Flush Lorazepam Ipratropium Bromide Neb Simvastatin Furosemide Paroxetine TraMADOL (Ultram) Finasteride Furosemide Amiodarone Ranitidine Docusate Sodium Amiodarone Furosemide Potassium Chloride Multivitamins Aspirin OLANZapine Ipratropium Bromide Neb Metoprolol Tartrate Albuterol 0.083% Neb Soln Target Lab Orders: Anion Gap Bicarbonate Chloride Creatinine Glucose Potassium Sodium Urea Nitrogen Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : Mr. ___ was admitted with shortness of breath. He was given lasix and diuresed well. He felt better after diuresis and moving his bowels. A chest radiograph completed on the day of re-admission already showed resolved pulmonary edema and decreased alalectasis. By hospital day 2 he was ready for transfer back to the nursing home where he resides, Kindred ___ Care and Rehabilitation in ___. Other Results: NIL

2175-03-16 06:48:00

ENGLISH

SINGLE

WHITE

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[[25421605, Timestamp('2175-03-16 06:49:29'), '', 'ORTHO']]

[[{'Medications on Admission': 'NIL', 'Brief Hospital Course': ":\nThe patient presented to the emergency department and was \nevaluated by the orthopedic surgery team. The patient was found \nto have left open tibial fracture and was admitted to the \northopedic surgery service. The patient was taken to the \noperating room on ___ for I&D and ORIF open left distal \ntibia fracture, which the patient tolerated well. For full \ndetails of the procedure please see the separately dictated \noperative report. The patient was taken from the OR to the PACU \nin stable condition and after satisfactory recovery from \nanesthesia was transferred to the floor. The patient was \ninitially given IV fluids and IV pain medications, and \nprogressed to a regular diet and oral medications by POD#2. The \npatient was given ___ antibiotics and anticoagulation \nper routine. The patient's home medications were continued \nthroughout this hospitalization. The patient worked with ___ who \ndetermined that discharge to rehab was appropriate. The \n___ hospital course was otherwise unremarkable. She was \nplaced in a short leg cast on the day before discharge. \n\nAt the time of discharge the patient's pain was well controlled \nwith oral medications, incisions were clean/dry/intact, and the \npatient was voiding/moving bowels spontaneously. The patient is \nNWB in the left lower extremity in a short leg cast, and will be \ndischarged on Lovenox for DVT prophylaxis. The patient will \nfollow up with Dr. ___ routine. \n\nFacility:\n___", 'Pertinent Results:': 'NIL', 'Physical Exam:|Physical': '\nGen: Alert, conversant, occasionally confused (baseline \ncognitive delay). \n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\n___ with hx cognitive delay, non verbal, presents in transfer \nafter being found down at her nursing home. She was brought to \nOSH where she was found to have an open left distal third tibia \nfracture. She received ancef and tetanus at OSH. Transferred to \n___ for orthopaedic care. History based on OSH records and \ndiscussion with HCP. \n\nPast Medical History:\nLevnothyroxine50mcg QD \nLisinipril 5mg QD \nLovastatin 100mg QD \nProlia \nVit D \n\nSocial History:\n___\nFamily History:\nNC \n\n', 'Chief Complaint:|Complaint:': '\nLeft open tibia fracture \n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nNo Known Allergies / Adverse Drug Reactions\n\n'}, '19175544-DS-7', 7, 'orthopaedics']]

[['EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD\n\nINDICATION: History: ___ with found down, nonverbal from MR, points to both\nlegs as site of pain; known L tibfib fx s/p reduction without post reduction\nfilms, // eval for fx\n\nTECHNIQUE: Contiguous axial images of the brain were obtained without\ncontrast. Coronal and sagittal reformations as well as bone algorithm\nreconstructions were provided and reviewed.\n\nDOSE: Acquisition sequence:\n 1) Sequenced Acquisition 16.0 s, 16.1 cm; CTDIvol = 49.7 mGy (Head) DLP =\n802.7 mGy-cm.\n 2) Sequenced Acquisition 16.0 s, 16.1 cm; CTDIvol = 49.7 mGy (Head) DLP =\n802.7 mGy-cm.\n Total DLP (Head) = 1,605 mGy-cm.\n\nCOMPARISON: None.\n\nFINDINGS: \n\nThe exam is somewhat motion limited.\n\nWithin these limitations, there is no evidence of acute large vascular\nterritorial infarction, hemorrhage, edema, or mass/mass effect. There is\nprominence of the ventricles and sulci suggestive of involutional changes.\n\nThere is no evidence of fracture. The imaged paranasal sinuses are clear. \nChanges related to prior bilateral mastoidectomies are noted. The right\nmiddle ear is opacified.\n\nIMPRESSION:\n\n\n1. Motion limited exam.\n2. No acute intracranial pathology on noncontrast head CT. Specifically no\nintracranial hemorrhage.\n3. Bilateral mastoidectomies with opacified right middle ear. No calvarial\nfracture.\n', '19175544-RR-5', 5, 'contiguous axial images of the brain were obtained without\ncontrast. coronal and sagittal reformations as well as bone algorithm\nreconstructions were provided and reviewed.'], ['EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE\n\nINDICATION: History: ___ with found down, nonverbal from MR, points to both\nlegs as site of pain; known L tibfib fx s/p reduction without post reduction\nfilms, // eval for fx eval for fx\n\nTECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue\nand bone algorithm images were generated. Coronal and sagittal reformations\nwere then constructed.\n\nDOSE: Acquisition sequence:\n 1) Spiral Acquisition 5.1 s, 19.8 cm; CTDIvol = 36.8 mGy (Body) DLP = 730.7\nmGy-cm.\n Total DLP (Body) = 731 mGy-cm.\n\nCOMPARISON: None.\n\nFINDINGS: \n\nAlignment is anatomic. No fractures are identified. There is no evidence of\nspinal canal or neural foraminal stenosis. There is no prevertebral soft\ntissue swelling. Multilevel mild degenerative changes are noted throughout\nthe cervical spine including anterior posterior osteophytosis, disc space\nnarrowing, and sclerotic endplate changes, most prominent at the C5-6 and C6-7\nlevels. At these levels, there is mild spinal canal narrowing and mild\nbilateral neural foraminal narrowing. Mild pleural-parenchymal scarring is\nnoted at the bilateral lung apices. A bone island is present in the posterior\nT2 to vertebral body (602b:37). There is no cervical lymphadenopathy by size\ncriteria. The visualized thyroid glands are atrophic but otherwise\nunremarkable.\n\nIMPRESSION: \n\nNo acute cervical spine fracture or malalignment.\n', '19175544-RR-6', 6, 'non-contrast helical multidetector ct was performed. soft tissue\nand bone algorithm images were generated. coronal and sagittal reformations\nwere then constructed.'], ['EXAMINATION: DX BILATERAL HIPS\n\nINDICATION: History: ___ with found down, nonverbal from MR, points to both\nlegs as site of pain; known L tibfib fx s/p reduction without post reduction\nfilms, // eval for fx\n\nTECHNIQUE: Frontal view radiograph of the pelvis with additional frontal and\nfrog-leg lateral views of bilateral hips.\n\nCOMPARISON: Bilateral knee radiographs: ___, obtained concurrently.\n\nFINDINGS: \n\nThere is no fracture or dislocation. There are no gross degenerative changes.\nThere is no suspicious lytic or sclerotic lesion. There is no soft tissue\ncalcification or radio-opaque foreign body. There is overall\ndemineralization.\n\nIMPRESSION: \n\nNo fracture in the bilateral hips.\n', '19175544-RR-7', 7, 'frontal view radiograph of the pelvis with additional frontal and\nfrog-leg lateral views of bilateral hips.'], ['EXAMINATION: Chest radiographs.\n\nINDICATION: History: ___ with found down, nonverbal from MR. ___ for fx\n\nTECHNIQUE: Single supine radiograph of the chest was obtained.\n\nCOMPARISON: None.\n\nFINDINGS: \n\nThe lungs are well inflated and grossly clear. There is no pleural effusion,\npneumothorax, pulmonary edema, or focal consolidation. The cardiomediastinal\nsilhouette is unremarkable. No acute osseous abnormalities are detected.\n\nIMPRESSION: \n\nNo displaced rib fracture or acute cardiopulmonary process.\n', '19175544-RR-8', 8, 'single supine radiograph of the chest was obtained.'], ['EXAMINATION: KNEE (AP, LAT AND OBLIQUE) BILATERAL\n\nINDICATION: History: ___ with found down, nonverbal from MR, points to both\nlegs as site of pain; known L tibfib fx s/p reduction without post reduction\nfilms, // eval for fx eval for fx \neval for fx\n\nTECHNIQUE: Frontal, lateral, and sunrise view radiographs of bilateral knees.\n\nCOMPARISON: Left tib-fib radiographs: ___, obtained concurrently.\nBilateral hip radiographs: ___, obtained concurrently.\n\nFINDINGS: \n\nThere is a nondisplaced obliquely oriented fracture through the midshaft of\nthe left fibula, with perhaps minimal fragmentation. There is no evidence of\nfracture on the right. No joint effusion is identified bilaterally. No\nradiopaque foreign body is detected.\n\nIMPRESSION: \n\nNondisplaced midshaft left fibular fracture, with minimal fragmentation.\n', '19175544-RR-9', 9, 'frontal, lateral, and sunrise view radiographs of bilateral knees.'], ['EXAMINATION: TIB/FIB (AP AND LAT) LEFT\n\nINDICATION: History: ___ with found down, nonverbal from MR, points to both\nlegs as site of pain; known L tibfib fx s/p reduction without post reduction\nfilms, // eval for fx eval for fx \neval for fx\n\nTECHNIQUE: Frontal and lateral view radiographs of the left tibia and fibula.\n\nCOMPARISON: Bilateral knee radiographs: ___.\n\nFINDINGS: \n\nThere is an obliquely oriented nondisplaced mid diaphyseal fracture through\nthe left fibula. Obliquely oriented fractures are also present at the distal\ndiaphyses of the left tibia and fibula, both with angulation and\nfragmentation. There is lateral angulation of the distal fracture fragments\nof both the tibia and fibula, with mild posterior distraction. No discrete\nextension to the intra-articular surfaces is noted. Overlying soft tissue\nswelling is present, as well as a posterior splint device.\n\nIMPRESSION:\n\n\n\n1. Fragmented and angulated distal diaphyseal fractures of the left tibia and\nfibula.\n2. Nondisplaced mid diaphyseal left fibular fracture.\n', '19175544-RR-10', 10, 'frontal and lateral view radiographs of the left tibia and fibula.'], ['INDICATION: History: ___ with found down // eval for fx eval for fx\n\nTECHNIQUE: Frontal, oblique, and lateral view radiographs of the right ankle.\n\nCOMPARISON: None.\n\nFINDINGS: \n\nNo fracture, dislocation, or significant degenerative change is detected. The\nmortise is congruent on this non stress view. The tibial talar joint space is\npreserved and no talar dome osteochondral lesion is identified. No suspicious\nlytic or sclerotic lesion is identified. No soft tissue calcification or\nradiopaque foreign body is identified. Soft tissue swelling is noted about\nthe dorsum of the right foot.\n\nIMPRESSION: \n\nNo right ankle fracture.\n', '19175544-RR-11', 11, 'frontal, oblique, and lateral view radiographs of the right ankle.'], ["INDICATION: ___ year old woman with L distal tib/fib fracture. Evaluate for\nfracture extension into the mortise.\n\nTECHNIQUE: Multidetector CT scan of the ankle was performed without\nintravenous contrast. Reformatted images in bone and soft tissue algorithm\nwere provided.\n\nDOSE: Total DLP (Body) = 461 mGy-cm.\n\nCOMPARISON: Ankle radiographs ___.\n\nFINDINGS: \n\nAn oblique comminuted fracture of the distal diaphysis of the tibia is\ndisplaced laterally by ___ of the shaft width. The fracture does not extend\ninto the mortise. An oblique comminuted fracture of the distal diaphysis of\nthe fibula is displaced laterally by a shaft's width. There are nondisplaced\nfractures of the bases of the second and third metatarsals. (Series 2, image\n135 and series 400b, image 85). Both metatarsal fractures extend into the\ntarsometatarsal joints. The Lisfranc interval is not widened, however, the\npatient is not weight-bearing. A fracture of the navicular is nondisplaced\n(series 2, image 111 and series 401b, image 53). In addition, there is an\nnondisplaced fracture of the medial cuneiform (series 403b, image 124).\n\nDegenerative changes are present in the tarsometatarsal and\nmetatarsophalangeal joints. There are subchondral cystic changes in the talar\ndome. There is talocalcaneal coalition and related eversion of the talus\nrelative to the tibia. There is soft tissue irregularity and subcutaneous air\nalong the anteromedial portion of the tibia. Presumed related to a laceration\nat the time of the initial trauma.\n\nIMPRESSION:\n\n\n1. Comminuted obliquely oriented fractures the distal diaphyses of the tibia\nand fibula with no evidence of extension to the mortise.\n2. Nondisplaced fractures of the base of the second and third metatarsals, the\nnavicular and medial cuneiform.\n3. Soft tissue injury overlying min anterior medial lower leg with multiple\nareas of subcutaneous air.\n4. Talocalcaneal coalition and tilting of the talar dome. The ligaments at the\nankle joint are not well assessed on CT.\n\nNOTIFICATION: The findings were discussed with ___, M.D. by\n___, M.D. on the telephone on ___ at 11:35 AM, 20 minutes\nafter discovery of the findings.\n", '19175544-RR-12', 12, 'multidetector ct scan of the ankle was performed without\nintravenous contrast. reformatted images in bone and soft tissue algorithm\nwere provided.'], ['EXAMINATION: Intraoperative fluoroscopic images\n\nINDICATION: Comminuted distal left tibia and fibula fractures\n\nTECHNIQUE: Intraoperative fluoroscopy\n\nCOMPARISON: Same day tibia and fibula radiographs\n\nFINDINGS: \n\n17 intraoperative images were acquired without a radiologist present.\n\nImages show open reduction and internal fixation of a comminuted distal left\ntibia fracture. An intra medullary rod with 2 proximal interlocking screws\nand 2 distal interlocking screws is seen.\n\nIMPRESSION: \n\nIntraoperative images were obtained during open reduction and internal\nfixation of a comminuted distal left tibia fracture.. Please refer to the\noperative note for details of the procedure.\n', '19175544-RR-13', 13, 'intraoperative fluoroscopy']]

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[['0QSH06Z', 10, 1, Timestamp('2175-03-16 00:00:00'), 'Reposition Left Tibia with Intramedullary Internal Fixation Device, Open Approach']]

['orthopaedics']

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18:13:00'), NaT, 'Length of Urine Collection'], [51103, Timestamp('2175-03-16 18:13:00'), NaT, 'Uhold'], [51463, Timestamp('2175-03-16 18:13:00'), Timestamp('2175-03-16 18:30:00'), 'Bacteria'], [51464, Timestamp('2175-03-16 18:13:00'), Timestamp('2175-03-16 18:30:00'), 'Bilirubin'], [51466, Timestamp('2175-03-16 18:13:00'), Timestamp('2175-03-16 18:30:00'), 'Blood'], [51476, Timestamp('2175-03-16 18:13:00'), Timestamp('2175-03-16 18:30:00'), 'Epithelial Cells'], [51478, Timestamp('2175-03-16 18:13:00'), Timestamp('2175-03-16 18:30:00'), 'Glucose'], [51479, Timestamp('2175-03-16 18:13:00'), Timestamp('2175-03-16 18:30:00'), 'Granular Casts'], [51484, Timestamp('2175-03-16 18:13:00'), Timestamp('2175-03-16 18:30:00'), 'Ketone'], [51486, Timestamp('2175-03-16 18:13:00'), Timestamp('2175-03-16 18:30:00'), 'Leukocytes'], [51487, Timestamp('2175-03-16 18:13:00'), Timestamp('2175-03-16 18:30:00'), 'Nitrite'], [51491, Timestamp('2175-03-16 18:13:00'), Timestamp('2175-03-16 18:30:00'), 'pH'], 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Question: A 72 F is admitted. He/she says he/she has Left open tibia fracture . History of illness: ___ with hx cognitive delay, non verbal, presents in transfer after being found down at her nursing home. She was brought to OSH where she was found to have an open left distal third tibia fracture. She received ancef and tetanus at OSH. Transferred to ___ for orthopaedic care. History based on OSH records and discussion with HCP. Past Medical History: Levnothyroxine50mcg QD Lisinipril 5mg QD Lovastatin 100mg QD Prolia Vit D Social History: ___ Family History: NC Allergies: No Known Allergies / Adverse Drug Reactions What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Iso-Osmotic Dextrose CeFAZolin Potassium Chl 20 mEq / 1000 mL D5 1/2 NS Multivitamins Docusate Sodium Sodium Chloride 0.9% Lovastatin OxyCODONE (Immediate Release) Enoxaparin Sodium Morphine Sulfate Morphine Sulfate Sodium Chloride 0.9% Flush Soln Acetaminophen IV DiphenhydrAMINE Bisacodyl DiphenhydrAMINE DiphenhydrAMINE Ondansetron Senna Bisacodyl Acetaminophen Target Lab Orders: Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells RDW-SD Anion Gap Bicarbonate Chloride Creatinine Estimated GFR (MDRD equation) Glucose Magnesium Potassium Sodium Urea Nitrogen Length of Urine Collection Urine tube, held Length of Urine Collection Uhold Bacteria Bilirubin Blood Epithelial Cells Glucose Granular Casts Ketone Leukocytes Nitrite pH Protein RBC Specific Gravity Urine Appearance Urine Color Urine Mucous Urobilinogen WBC Yeast Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells RDW-SD Anion Gap Bicarbonate Calcium, Total Chloride Creatinine Glucose Magnesium Phosphate Potassium Sodium Urea Nitrogen Target Procedures: Reposition Left Tibia with Intramedullary Internal Fixation Device, Open Approach DOCTOR'S NOTE Hospital Notes: : The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have left open tibial fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for I&D and ORIF open left distal tibia fracture, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#2. The patient was given ___ antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to rehab was appropriate. The ___ hospital course was otherwise unremarkable. She was placed in a short leg cast on the day before discharge. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is NWB in the left lower extremity in a short leg cast, and will be discharged on Lovenox for DVT prophylaxis. The patient will follow up with Dr. ___ routine. Facility: ___ Other Results: NIL

2164-10-08 07:15:00

ENGLISH

MARRIED

WHITE

M

[[21199168, Timestamp('2164-10-08 01:15:26'), '', 'GU']]

[[{'Medications on Admission': ':\nHCTZ, Norvasc, UroXatral \n\n3. Amlodipine 10 mg Tablet Sig: 2.5 Tablets PO HS (at bedtime). \n\n4. Uroxatral 10 mg Tablet Sustained Release 24 hr Sig: One (1) \nTablet Sustained Release 24 hr PO DAILY (Daily). \n5. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY \n(Daily). \n6. Tylenol-Codeine #3 300-30 mg Tablet Sig: ___ Tablets PO every \nsix (6) hours as needed for pain.\nDisp:*60 Tablet(s)* Refills:*0*', 'Brief Hospital Course': ":\nPatient was admitted to Dr. ___ service on \n___ after undergoing robotic assisted laparoscopic right \nradical nephrectomy. No concerning intraoperative events \noccurred; please see dictated operative note for details. The \npatient received perioperative antibiotic prophylaxis. The \npatient was transferred to the floor from the PACU in stable \ncondition. On POD0, pain was well controlled on PCA, hydrated \nfor urine output >30cc/hour, provided with pneumoboots and \nincentive spirometry for prophylaxis, and ambulated once. On \nPOD1, the patient was restarted on home medications, basic \nmetabolic panel and complete blood count were checked, pain \ncontrol was transitioned from PCA to oral analgesics, diet was \nadvanced to a clears/toast and crackers diet. On POD2, urethral \ncatheter (foley) was removed without difficulty. JP was removed \non POD3. The patient's diet was advanced as tolerated on POD4. \nThe remainder of the hospital course was relatively \nunremarkable. The patient was discharged in stable condition on \nPOD4, eating well, ambulating independently, voiding without \ndifficulty, and with pain control on oral analgesics. On exam, \nincision was clean, dry, and intact, with no evidence of \nhematoma collection or infection. The patient was given explicit \ninstructions to follow-up in clinic with Dr. ___ in 3 weeks.\n\n", 'Pertinent Results:': '\n___ 06:30AM BLOOD WBC-9.4 RBC-3.78* Hgb-12.3* Hct-35.9* \nMCV-95 MCH-32.4* MCHC-34.2 RDW-12.0 Plt ___\n___ 06:30AM BLOOD Glucose-91 UreaN-17 Creat-1.4* Na-135 \nK-3.5 Cl-99 HCO3-29 AnGap-11\n\n', 'Physical Exam:|Physical': '\nOn exam, he is a well-appearing Caucasian gentleman in no \napparent distress. Temperature is 97.4, pulse 75, blood \npressure 110/74. Abdomen is soft, nontender. He is alert and \noriented x3. HEENT normal. No thyromegaly, cervical or \nsupraclavicular adenopathy. Chest expands equally with normal \neffort. His abdomen is soft, nontender. He has a left inguinal \nhernia scar,\nwhich is healing. His penis is normal without discharge, \nuncircumcised. Scrotum is without rashes. Testicles are both \ndescended without masses. Epididymi, cord structures normal \nbilaterally. No inguinal hernias. Normal rectal tone, 50-60 g \nprostate, smooth, no nodules. No extremity rashes or edema.\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\n___ nurse who presented initially with gross hematuria \nin early ___ x1 day, painless, no fevers or chills. Subsequent \ncystoscopy was negative, but CT\nscan revealed a 1.5 cm right renal mass which is solid and \nsuspicious for small renal cell carcinoma. There is also small \nhemorrhagic cyst in the upper pole of the right kidney.\nHe denies any current gross hematuria, incontinence, dysuria, \nSTDs or history of UTIs. \nHe does complain of some lower urinary tract symptoms including \nurinary frequency and urgency during the day, nocturia x3. He \nis on UroXatral for these symptoms.\n\nPast Medical History:\nPMH-BPH, HTN \nPSH-L inguinal hernia repair \n\nSocial History:\n___\nFamily History:\nFamily history is negative for kidney cancer. Positive for \nprostate cancer in father and uncle. His uncle is ___ alive and \ndrives in ___.\n\n', 'Chief Complaint:|Complaint:': '\nRight renal mass\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nZestril / Vicodin\n\n'}, '17918100-DS-20', 20, 'urology']]

[['INDICATION: 1.5-cm right renal mass. Please provide intraoperative\nultrasound.\n\nINTRAOPERATIVE ULTRASOUND: Sonographic guidance was provided for Dr. ___\n___ the performance of a laparoscopic robotic-assisted partial nephrectomy\nof a right anterior interpolar region tumor. A largely exophytic nodule is\nidentified measuring 1.5 cm, corresponding to the abnormality on previous CT.\nThere is no evidence of extension into the renal sinus fat. The lesion is\nmoderately vascular. In the upper pole of the kidney, a 0.6-cm cortical cyst\nis seen which could possibly correlate with a cyst seen previously on CT.\nDetailed evaluation of the upper pole was limited due to constraints of\nimaging in the presence of the robotic guidance equipment.\n\nIMPRESSION: 1.5-cm partially exophytic right renal mass corresponding to\nfindings on previous CT.\n', '17918100-RR-21', 21, '']]

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[]

['urology']

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Question: A 67 M is admitted. He/she says he/she has Right renal mass . History of illness: ___ nurse who presented initially with gross hematuria in early ___ x1 day, painless, no fevers or chills. Subsequent cystoscopy was negative, but CT scan revealed a 1.5 cm right renal mass which is solid and suspicious for small renal cell carcinoma. There is also small hemorrhagic cyst in the upper pole of the right kidney. He denies any current gross hematuria, incontinence, dysuria, STDs or history of UTIs. He does complain of some lower urinary tract symptoms including urinary frequency and urgency during the day, nocturia x3. He is on UroXatral for these symptoms. Past Medical History: PMH-BPH, HTN PSH-L inguinal hernia repair Social History: ___ Family History: Family history is negative for kidney cancer. Positive for prostate cancer in father and uncle. His uncle is ___ alive and drives in ___. Allergies: Zestril / Vicodin What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Sodium Chloride 0.9% Flush Aluminum-Magnesium Hydrox.-Simethicone HYDROmorphone (Dilaudid) Valsartan Ondansetron Pneumococcal Vac Polyvalent Hydrochlorothiazide D5LR Acetaminophen Morphine Sulfate Docusate Sodium HYDROmorphone (Dilaudid) Oxycodone-Acetaminophen DiphenhydrAMINE Target Lab Orders: Anion Gap Bicarbonate Chloride Creatinine Glucose Potassium Sodium Urea Nitrogen Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : Patient was admitted to Dr. ___ service on ___ after undergoing robotic assisted laparoscopic right radical nephrectomy. No concerning intraoperative events occurred; please see dictated operative note for details. The patient received perioperative antibiotic prophylaxis. The patient was transferred to the floor from the PACU in stable condition. On POD0, pain was well controlled on PCA, hydrated for urine output >30cc/hour, provided with pneumoboots and incentive spirometry for prophylaxis, and ambulated once. On POD1, the patient was restarted on home medications, basic metabolic panel and complete blood count were checked, pain control was transitioned from PCA to oral analgesics, diet was advanced to a clears/toast and crackers diet. On POD2, urethral catheter (foley) was removed without difficulty. JP was removed on POD3. The patient's diet was advanced as tolerated on POD4. The remainder of the hospital course was relatively unremarkable. The patient was discharged in stable condition on POD4, eating well, ambulating independently, voiding without difficulty, and with pain control on oral analgesics. On exam, incision was clean, dry, and intact, with no evidence of hematoma collection or infection. The patient was given explicit instructions to follow-up in clinic with Dr. ___ in 3 weeks. Other Results: ___ 06:30AM BLOOD WBC-9.4 RBC-3.78* Hgb-12.3* Hct-35.9* MCV-95 MCH-32.4* MCHC-34.2 RDW-12.0 Plt ___ ___ 06:30AM BLOOD Glucose-91 UreaN-17 Creat-1.4* Na-135 K-3.5 Cl-99 HCO3-29 AnGap-11

2115-09-09 21:14:00

ENGLISH

WIDOWED

WHITE

F

[[26350844, Timestamp('2115-09-09 21:15:19'), '', 'EYE'], [26350844, Timestamp('2115-09-10 09:50:46'), 'EYE', 'MED']]

[[{'Medications on Admission': ':\nThe Preadmission Medication list is accurate and complete.\n1. Amiodarone 200 mg PO EVERY OTHER DAY \n2. Aspirin 81 mg PO DAILY \n3. Lisinopril 5 mg PO DAILY \n4. Multivitamins 1 TAB PO DAILY \n5. PredniSONE 5 mg PO DAILY \n6. Simvastatin 10 mg PO DAILY \n7. Cyanocobalamin 1000 mcg PO DAILY \n8. Omeprazole 40 mg PO BID \n9. Levothyroxine Sodium 125 mcg PO DAILY \n10. Ferrous Sulfate 325 mg PO TID \n11. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 \nmg(1,500mg) -400 unit oral tid \n12. Mirtazapine 15 mg PO HS \n13. TraZODone 50 mg PO HS:PRN sleep \n14. Venlafaxine XR 37.5 mg PO DAILY \n15. TraMADOL (Ultram) 50 mg PO Q8H:PRN pain \n16. Acetaminophen 650 mg PO Q6H:PRN pain \n17. Bisacodyl ___AILY:PRN constipation \n18. Simethicone 40 mg PO BID:PRN gas \n19. Ondansetron 4 mg PO Q8H:PRN nausea \n20. Milk of Magnesia 30 mL PO DAILY:PRN constipatio \n21. Fleet Enema ___AILY:PRN constipation \n\nFacility:\n___', 'Brief Hospital Course': ":\n___ yo F with MMP, including hx of CAD s/p CABG, VT, DM2, s/p \nleft cataract surgery with transient hypotension post-op in the \nPACU, likely due to hypovolemia from NPO status.\n.\n# Hypotension, likely hypovolemia: Most likely volume depletion \nin the setting of NPO status for surgery, which would also be \nconsistent with her elevated Cr / ___. However, ddx does \ninclude many other etiologies, including many cardiac etiologies \ngiven her cardiac history, including ACS, arrythmia, heart \nfailure, although her EKG, initial troponin and proBNP are \nreassuring. Other etiologies include SIRS / sepsis given her \nleukocytosis, although less likely since she is afebrile and has \nno localizing symptoms. Her leukocytosis improved overnight and \nshe did not receive any antibiotics. Adrenal insufficiency is \npossible given her long-standing steroid use, but her dose of \nPrednisone is quite low, making adrenal crisis unlikely. \nHypovolemic shock from blood loss is unlikely given only minor \nsurgery and stable H/H. Overnight, her troponins remained \nnegative, total x 3 sets. Her home anti-HTN agent (lisinopril) \nwas held, but her blood pressure otherwise returned to baseline \nand she did not develop any new symptoms. She was monitored on \ntelemetry overnight without any events noted. \n.\n# ___: Cr 1.3, baseline 1. Likely pre-renal. Her ACEi was held \non admission. With IVF, her Cr improved to baseline, was 0.9 on \nday of discharge.\n.\n# Cataract: s/p removal and lens implanation. Keep dressing \nintact. F/U in ___ the following morning. She will \nsee them again on ___. She was prescribed steroid eye \ndrops and antibiotic ointment. \n.\n# Hx of VT: Currently in NSR. She continued on home amiodarone. \n She did not have any events noted on telemetry.\n.\n# DM2, not on any insulin or oral agents. Unknown A1C. She was \non gentle HISS as inpatient but her blood sugars were in good \nrange and did not require significant insulin. She was kept on \na diabetic diet. She is on ASA, statin. She is on ACEi as \noutpatient, which was held during hospitalization, but can be \nresumed on discharge.\n.\n# chronic ___: No evidence of active bleed. Her initial Hct was \nstable and c/w her baseline. Her repeat Hct was slightly lower, \nbut most likely due to hemodilution from IV fluids. \n.\n# CAD, # PVD, # HLD, # HTN: s/p CABG and CEA in distant past. \nGiven hypotension, ACS is a consideration. However, EKG was \nstable, and cardiac biomarkers x 3 sets were unremarkable. No \nevents on tele were noted. Her anti-HTN's were initially held, \nbut can be restated on discharge as her BP has improved to \nbaseline and she is slightly hypertensive. \n.\n# Hypothyroidism: \n- continued levothyroxine.\n.\n# Rheumatoid Arthritis: Well controlled / asymptomatic. \n- continued chronic prednisone dose. \n- contined Tylenol PRN pain.\n.\n# Depresion: stable mood.\n- continued Effexor and Remeron.\n. \n# CODE: Full Code (confirmed with patient and HCP on admission)\n# CONTACT: PCP, HCP (Son ___ ___, \npatient \n.\nTRANSITIONAL ISSUES:\n1. f/u with ___ ___, continue ointment and eye \ndrops per Ophtho instructions\n2. Please note, patient has confirmed that she is FULL CODE and \nwishes to cancel previous DNR / DNI order. This was confirmed \nwith her HCP, ___ as well via telephone on \n___. \n3. PENDING STUDIES:\n### ___ Blood Culture x 1 set - NGTD, final PENDING\n### ___ Blood Culture x 1 set - NGTD, final PENDING\n.\n\n", 'Pertinent Results:': '\nADMISSION LABS:\n================\nLABS: \nWBC 13.5\nHct 30.1\nPlt 387\n\n135 / 97 / 31\n--------------< 144\n4.1 / 25 / 1.3\n.\nProBNP 333\nTroponin 0.01\n.\nMICRO: none sent\n.\nSTUDIES: \n___ EKG NSR at 81 BPM, no ST segment elevation or \ndepression, overall comparable to prior\n.\nADDIONAL LABS:\n===============\n___ 07:15AM BLOOD WBC-6.0# RBC-2.78* Hgb-8.1* Hct-25.2* \nMCV-91 MCH-29.1 MCHC-32.1 RDW-16.2* Plt ___\n___ 07:15AM BLOOD Glucose-81 UreaN-21* Creat-0.9 Na-136 \nK-4.3 Cl-100 HCO3-26 AnGap-14\n___ 07:15AM BLOOD ___ PTT-30.3 ___\n___ 10:11PM BLOOD cTropnT-<0.01\n___ 07:15AM BLOOD cTropnT-<0.01\n___ 07:15AM BLOOD Calcium-8.5 Phos-4.5 Mg-1.9\n.\nMICROBIOLOGY:\n==============\n___ Blood culture x 1 set - NGTD, final PENDING\n___ Blood culture x 1 set - NGTD, final PENDING\n\n', 'Physical Exam:|Physical': "\nADMISSION PHYSICAL EXAM: \nVitals: T: 98 BP: 100/37 P: 67 R: 16 O2: 100% on 2L\nPain: ___ \nGeneral: Alert, oriented, NAD \nHEENT: dry MM, left eye patch in place\nNeck: no JVD\nLungs: CTAB/L, no crackles \nCV: RRR, no murmur\nAbdomen: soft, NT, ND, NABS, + ostomy with soft yellow stool\nExt: Warm, well perfused, no edema \nSkin: no rash, no lesions \nNeuro: AAOx3, fluent speech\n.\nDISCHARGE DAY PHYSICAL EXAM:\nSimilar to above\nNotable for SBP's 130's - 140's\nOtherwise unchanged from above\n\n", 'History of Present Illness:|Past Medical History:|Social History:|Family History:': "\n___ yo ___, ___ resdient, with MMP, including hx of CAD, \ns/p CABG, ILD, polymorphic VT, DM2, ischemic colitis s/p \nhemicolectomy / ostomy, most recently admitted ___ for \ngastroenteritis and ___, s/p elective left cataract surgery \ntoday, noted to have transient hypotension in the PACU to SBP \n70's, responded to 200 mcg neosynephrine and small fluid bolus. \nFor her procedure, she received a small dose of fentanyl only. \nNo other anesthesia or sedation was administered. Given her \ncardiac risk, she is being admitted for further evaluation and \nwork-up.\n.\nPt was seen and examined in the PACU. She reports that prior to \ncoming for cataract surgery, she was in USOH and denied any \ncomplaints, including any recent illness, fever, chills, \ndiarrhea, nausea, vomiting, chest pain, SOB, upper respiratory \nsyptoms. She denies any sick contacts. She currently denies \nany specific complaints besides for generalized lethargy. \n.\nSince receiving the small fluid bolus (approximately 250 ml) and \nneosynephrine, her SBP's have remained stable 90's - 100's, \nDBP's ___ (c/w her baseline). All other VS stable. Labs \nsent showed WBC of 13K, stable anemia (Hct 30), Cr 1.3 (baseline \n1), proBNP only 333, troponin NEGATIVE. Her EKG is c/w her \nprior, and does not show any ST segment changes concerning for \nACS. \n. \nReview of sytems: \n(+) Per HPI \n(-) Denies fever, chills, night sweats, recent weight loss or \ngain. Denies headache, sinus tenderness, rhinorrhea or \ncongestion. Denies cough, shortness of breath. Denies chest pain \nor tightness, palpitations. Denies nausea, vomiting, diarrhea, \nconstipation or abdominal pain. No recent change in bowel or \nbladder habits. No dysuria. Denies arthralgias or myalgias. Ten \npoint review of systems is otherwise negative. \n\nPast Medical History:\nCAD s/p CABG\nCarotid stenosis s/p left CEA\nCataract surgery\n? h/o Clostridium difficle colitis, suspected\nDepression\nDiabetes mellitus type II\nFactor V Leiden\nHemicolectomy in ___ ischemic colitis with end colostomy\nHypertension\nHypothyroidism\nInterstitial lung disease\nIron deficiency anemia\nPapillary thyroid carcinoma with lymph node metastases\nPeripheral vascular disease\nRestless leg syndrome \nRheumatoid arthritis\nS/p cholecystectomy \nSyncope due to recurrent polymorphic ventricular tachycardia\n\nSocial History:\n___\nFamily History:\nper OMR review, 1 son with hx of papillary thyroid cancer. \nSister has rare throat cancer.\n\n", 'Chief Complaint:|Complaint:': '\n======================================================= \n___ ADMISSION NOTE \nDate of admission: ___\n======================================================= \nPCP: Dr. ___\nCC: hypotension \n\nMajor ___ or Invasive Procedure:\n___ left cataract surgery\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nProchlorperazine / Celexa / Dilaudid / Ambien / Methotrexate / \ncitalopram / Zolpidem\n\n'}, '10872930-DS-36', 36, 'medicine']]

[]

[[26350844, Timestamp('2115-09-09 22:00:00'), Timestamp('2115-09-10 21:00:00'), 'MAIN', 'Simethicone', '002821', '00182864389', '80mg Tablet'], [26350844, Timestamp('2115-09-09 22:00:00'), Timestamp('2115-09-10 21:00:00'), 'MAIN', 'Sodium Chloride 0.9% Flush', '', '0', '10 mL Syringe'], [26350844, Timestamp('2115-09-09 22:00:00'), Timestamp('2115-09-10 21:00:00'), 'MAIN', 'Dextrose 50%', '001989', '00409490234', '25 g / 50 mL Syringe'], [26350844, Timestamp('2115-09-09 22:00:00'), Timestamp('2115-09-10 21:00:00'), 'MAIN', 'Levothyroxine Sodium', '006653', '00074706811', '125mcg Tab'], [26350844, Timestamp('2115-09-09 22:00:00'), Timestamp('2115-09-10 21:00:00'), 'MAIN', 'Amiodarone', '000266', '51079090620', '200 mg Tab'], [26350844, Timestamp('2115-09-09 22:00:00'), Timestamp('2115-09-10 21:00:00'), 'MAIN', 'Simvastatin', '016577', '51079045420', '10mg Tablet'], [26350844, Timestamp('2115-09-09 22:00:00'), Timestamp('2115-09-10 21:00:00'), 'MAIN', 'Heparin', '006549', '63323026201', '5000 Units / mL- 1mL Vial'], [26350844, Timestamp('2115-09-09 22:00:00'), Timestamp('2115-09-10 21:00:00'), 'MAIN', 'TraZODone', '046241', '00904399061', '50mg Tablet'], [26350844, Timestamp('2115-09-09 22:00:00'), Timestamp('2115-09-10 14:00:00'), 'BASE', 'Sodium Chloride 0.9%', '001210', '00338004904', 'Floor Stock Bag'], [26350844, Timestamp('2115-09-09 22:00:00'), Timestamp('2115-09-10 21:00:00'), 'MAIN', 'Glucagon', '041660', '55390000401', '1mg Vial'], [26350844, Timestamp('2115-09-09 22:00:00'), Timestamp('2115-09-10 21:00:00'), 'MAIN', 'Aspirin', '004380', '00904404073', '81mg Tab'], [26350844, Timestamp('2115-09-09 22:00:00'), Timestamp('2115-09-10 21:00:00'), 'MAIN', 'Mirtazapine', '046450', '51079008620', '15 mg Tablet'], [26350844, Timestamp('2115-09-09 23:00:00'), Timestamp('2115-09-10 21:00:00'), 'MAIN', 'Insulin', '027413', '00002751001', '100 Units / mL - 10 mL Vial'], [26350844, Timestamp('2115-09-09 22:00:00'), Timestamp('2115-09-10 21:00:00'), 'MAIN', 'PredniSONE', '006753', '00054872425', '5 mg Tablet'], [26350844, Timestamp('2115-09-09 23:00:00'), Timestamp('2115-09-10 21:00:00'), 'MAIN', 'TraMADOL (Ultram)', '023139', '00406717162', '50mg Tablet'], [26350844, Timestamp('2115-09-09 22:00:00'), Timestamp('2115-09-10 21:00:00'), 'MAIN', 'Venlafaxine XR', '046403', '00008083703', '37.5mg XR Capsule'], [26350844, Timestamp('2115-09-09 22:00:00'), Timestamp('2115-09-10 21:00:00'), 'MAIN', 'Omeprazole', '033530', '00904568461', '20mg DR Capsule'], [26350844, Timestamp('2115-09-09 22:00:00'), Timestamp('2115-09-10 21:00:00'), 'MAIN', 'Ondansetron', '016392', '51079052420', '4 mg Tablet'], [26350844, Timestamp('2115-09-09 22:00:00'), Timestamp('2115-09-10 21:00:00'), 'MAIN', 'Acetaminophen', '004489', '51079000220', '325mg Tablet'], [26350844, Timestamp('2115-09-09 23:00:00'), Timestamp('2115-09-10 21:00:00'), 'MAIN', 'Glucose Gel', '001781', '38396055018', '15 g Tube'], [26350844, Timestamp('2115-09-09 22:00:00'), Timestamp('2115-09-10 21:00:00'), 'MAIN', 'Milk of Magnesia', '003026', '00121043130', '30mL UD Cup']]

[]

['medicine']

[[51003, Timestamp('2115-09-09 22:11:00'), Timestamp('2115-09-09 23:30:00'), 'Troponin T'], [50868, Timestamp('2115-09-10 07:15:00'), Timestamp('2115-09-10 09:47:00'), 'Anion Gap'], [50882, Timestamp('2115-09-10 07:15:00'), Timestamp('2115-09-10 09:47:00'), 'Bicarbonate'], [50893, Timestamp('2115-09-10 07:15:00'), Timestamp('2115-09-10 09:47:00'), 'Calcium, Total'], [50902, Timestamp('2115-09-10 07:15:00'), Timestamp('2115-09-10 09:47:00'), 'Chloride'], [50912, Timestamp('2115-09-10 07:15:00'), Timestamp('2115-09-10 09:47:00'), 'Creatinine'], [50931, Timestamp('2115-09-10 07:15:00'), Timestamp('2115-09-10 09:47:00'), 'Glucose'], [50960, Timestamp('2115-09-10 07:15:00'), Timestamp('2115-09-10 09:47:00'), 'Magnesium'], [50970, Timestamp('2115-09-10 07:15:00'), Timestamp('2115-09-10 09:47:00'), 'Phosphate'], [50971, Timestamp('2115-09-10 07:15:00'), Timestamp('2115-09-10 09:47:00'), 'Potassium'], [50983, Timestamp('2115-09-10 07:15:00'), Timestamp('2115-09-10 09:47:00'), 'Sodium'], [51003, Timestamp('2115-09-10 07:15:00'), Timestamp('2115-09-10 10:34:00'), 'Troponin T'], [51006, Timestamp('2115-09-10 07:15:00'), Timestamp('2115-09-10 09:47:00'), 'Urea Nitrogen'], [51237, Timestamp('2115-09-10 07:15:00'), Timestamp('2115-09-10 09:39:00'), 'INR(PT)'], [51274, Timestamp('2115-09-10 07:15:00'), Timestamp('2115-09-10 09:39:00'), 'PT'], [51275, Timestamp('2115-09-10 07:15:00'), Timestamp('2115-09-10 09:39:00'), 'PTT'], [51221, Timestamp('2115-09-10 07:15:00'), Timestamp('2115-09-10 09:25:00'), 'Hematocrit'], [51222, Timestamp('2115-09-10 07:15:00'), Timestamp('2115-09-10 09:25:00'), 'Hemoglobin'], [51248, Timestamp('2115-09-10 07:15:00'), Timestamp('2115-09-10 09:25:00'), 'MCH'], [51249, Timestamp('2115-09-10 07:15:00'), Timestamp('2115-09-10 09:25:00'), 'MCHC'], [51250, Timestamp('2115-09-10 07:15:00'), Timestamp('2115-09-10 09:25:00'), 'MCV'], [51265, Timestamp('2115-09-10 07:15:00'), Timestamp('2115-09-10 09:25:00'), 'Platelet Count'], [51277, Timestamp('2115-09-10 07:15:00'), Timestamp('2115-09-10 09:25:00'), 'RDW'], [51279, Timestamp('2115-09-10 07:15:00'), Timestamp('2115-09-10 09:25:00'), 'Red Blood Cells'], [51301, Timestamp('2115-09-10 07:15:00'), Timestamp('2115-09-10 09:25:00'), 'White Blood Cells']]

Question: A 79 F is admitted. He/she says he/she has ======================================================= ___ ADMISSION NOTE Date of admission: ___ ======================================================= PCP: Dr. ___ CC: hypotension Major ___ or Invasive Procedure: ___ left cataract surgery . History of illness: ___ yo ___, ___ resdient, with MMP, including hx of CAD, s/p CABG, ILD, polymorphic VT, DM2, ischemic colitis s/p hemicolectomy / ostomy, most recently admitted ___ for gastroenteritis and ___, s/p elective left cataract surgery today, noted to have transient hypotension in the PACU to SBP 70's, responded to 200 mcg neosynephrine and small fluid bolus. For her procedure, she received a small dose of fentanyl only. No other anesthesia or sedation was administered. Given her cardiac risk, she is being admitted for further evaluation and work-up. . Pt was seen and examined in the PACU. She reports that prior to coming for cataract surgery, she was in USOH and denied any complaints, including any recent illness, fever, chills, diarrhea, nausea, vomiting, chest pain, SOB, upper respiratory syptoms. She denies any sick contacts. She currently denies any specific complaints besides for generalized lethargy. . Since receiving the small fluid bolus (approximately 250 ml) and neosynephrine, her SBP's have remained stable 90's - 100's, DBP's ___ (c/w her baseline). All other VS stable. Labs sent showed WBC of 13K, stable anemia (Hct 30), Cr 1.3 (baseline 1), proBNP only 333, troponin NEGATIVE. Her EKG is c/w her prior, and does not show any ST segment changes concerning for ACS. . Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Ten point review of systems is otherwise negative. Past Medical History: CAD s/p CABG Carotid stenosis s/p left CEA Cataract surgery ? h/o Clostridium difficle colitis, suspected Depression Diabetes mellitus type II Factor V Leiden Hemicolectomy in ___ ischemic colitis with end colostomy Hypertension Hypothyroidism Interstitial lung disease Iron deficiency anemia Papillary thyroid carcinoma with lymph node metastases Peripheral vascular disease Restless leg syndrome Rheumatoid arthritis S/p cholecystectomy Syncope due to recurrent polymorphic ventricular tachycardia Social History: ___ Family History: per OMR review, 1 son with hx of papillary thyroid cancer. Sister has rare throat cancer. Allergies: Prochlorperazine / Celexa / Dilaudid / Ambien / Methotrexate / citalopram / Zolpidem What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Simethicone Sodium Chloride 0.9% Flush Dextrose 50% Levothyroxine Sodium Amiodarone Simvastatin Heparin TraZODone Sodium Chloride 0.9% Glucagon Aspirin Mirtazapine Insulin PredniSONE TraMADOL (Ultram) Venlafaxine XR Omeprazole Ondansetron Acetaminophen Glucose Gel Milk of Magnesia Target Lab Orders: Troponin T Anion Gap Bicarbonate Calcium, Total Chloride Creatinine Glucose Magnesium Phosphate Potassium Sodium Troponin T Urea Nitrogen INR(PT) PT PTT Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : ___ yo F with MMP, including hx of CAD s/p CABG, VT, DM2, s/p left cataract surgery with transient hypotension post-op in the PACU, likely due to hypovolemia from NPO status. . # Hypotension, likely hypovolemia: Most likely volume depletion in the setting of NPO status for surgery, which would also be consistent with her elevated Cr / ___. However, ddx does include many other etiologies, including many cardiac etiologies given her cardiac history, including ACS, arrythmia, heart failure, although her EKG, initial troponin and proBNP are reassuring. Other etiologies include SIRS / sepsis given her leukocytosis, although less likely since she is afebrile and has no localizing symptoms. Her leukocytosis improved overnight and she did not receive any antibiotics. Adrenal insufficiency is possible given her long-standing steroid use, but her dose of Prednisone is quite low, making adrenal crisis unlikely. Hypovolemic shock from blood loss is unlikely given only minor surgery and stable H/H. Overnight, her troponins remained negative, total x 3 sets. Her home anti-HTN agent (lisinopril) was held, but her blood pressure otherwise returned to baseline and she did not develop any new symptoms. She was monitored on telemetry overnight without any events noted. . # ___: Cr 1.3, baseline 1. Likely pre-renal. Her ACEi was held on admission. With IVF, her Cr improved to baseline, was 0.9 on day of discharge. . # Cataract: s/p removal and lens implanation. Keep dressing intact. F/U in ___ the following morning. She will see them again on ___. She was prescribed steroid eye drops and antibiotic ointment. . # Hx of VT: Currently in NSR. She continued on home amiodarone. She did not have any events noted on telemetry. . # DM2, not on any insulin or oral agents. Unknown A1C. She was on gentle HISS as inpatient but her blood sugars were in good range and did not require significant insulin. She was kept on a diabetic diet. She is on ASA, statin. She is on ACEi as outpatient, which was held during hospitalization, but can be resumed on discharge. . # chronic ___: No evidence of active bleed. Her initial Hct was stable and c/w her baseline. Her repeat Hct was slightly lower, but most likely due to hemodilution from IV fluids. . # CAD, # PVD, # HLD, # HTN: s/p CABG and CEA in distant past. Given hypotension, ACS is a consideration. However, EKG was stable, and cardiac biomarkers x 3 sets were unremarkable. No events on tele were noted. Her anti-HTN's were initially held, but can be restated on discharge as her BP has improved to baseline and she is slightly hypertensive. . # Hypothyroidism: - continued levothyroxine. . # Rheumatoid Arthritis: Well controlled / asymptomatic. - continued chronic prednisone dose. - contined Tylenol PRN pain. . # Depresion: stable mood. - continued Effexor and Remeron. . # CODE: Full Code (confirmed with patient and HCP on admission) # CONTACT: PCP, HCP (Son ___ ___, patient . TRANSITIONAL ISSUES: 1. f/u with ___ ___, continue ointment and eye drops per Ophtho instructions 2. Please note, patient has confirmed that she is FULL CODE and wishes to cancel previous DNR / DNI order. This was confirmed with her HCP, ___ as well via telephone on ___. 3. PENDING STUDIES: ### ___ Blood Culture x 1 set - NGTD, final PENDING ### ___ Blood Culture x 1 set - NGTD, final PENDING . Other Results: ADMISSION LABS: ================ LABS: WBC 13.5 Hct 30.1 Plt 387 135 / 97 / 31 --------------< 144 4.1 / 25 / 1.3 . ProBNP 333 Troponin 0.01 . MICRO: none sent . STUDIES: ___ EKG NSR at 81 BPM, no ST segment elevation or depression, overall comparable to prior . ADDIONAL LABS: =============== ___ 07:15AM BLOOD WBC-6.0# RBC-2.78* Hgb-8.1* Hct-25.2* MCV-91 MCH-29.1 MCHC-32.1 RDW-16.2* Plt ___ ___ 07:15AM BLOOD Glucose-81 UreaN-21* Creat-0.9 Na-136 K-4.3 Cl-100 HCO3-26 AnGap-14 ___ 07:15AM BLOOD ___ PTT-30.3 ___ ___ 10:11PM BLOOD cTropnT-<0.01 ___ 07:15AM BLOOD cTropnT-<0.01 ___ 07:15AM BLOOD Calcium-8.5 Phos-4.5 Mg-1.9 . MICROBIOLOGY: ============== ___ Blood culture x 1 set - NGTD, final PENDING ___ Blood culture x 1 set - NGTD, final PENDING

2183-09-18 01:46:00

ENGLISH

MARRIED

WHITE

F

[[28894951, Timestamp('2183-09-18 01:46:57'), '', 'EYE'], [28894951, Timestamp('2183-09-18 17:40:40'), 'EYE', 'MED']]

[[{'Medications on Admission': ':\nThe Preadmission Medication list is accurate and complete.\n1. Allopurinol ___ mg PO BID \n2. Amlodipine 2.5 mg PO DAILY \n3. Lovastatin 40 mg oral daily \n4. Multivitamins W/minerals 1 TAB PO DAILY \n5. Nitroglycerin SL 0.4 mg SL PRN chest pain \n6. Omeprazole 20 mg PO DAILY \n7. Aspirin 325 mg PO DAILY \n\nSecondary Diagnoses\n- Hypertension', 'Brief Hospital Course': ':\n___ with CAD, PVD admitted post-operatively for glaucome surgery \non right eye. \n. \nACTIVE ISSUES\n# Glaucoma: s/p right trabeculectomy by Dr. ___. No \ncomplications. The patient was discharged the following day.\n.\nINACTIVE ISSUES \n# PVD: Right SFA s/p stenting: Cont ASA. No currently on other \nplatelet agents. \n. \n# CAD: Prior LAD and RCA stenting. Cont ASA, lovastatin. Not \ncurrently on B-Blocker. \n.\n# GERD: Continue omeprazole. \n# Gout: cont allopurinol. \n.\nTRANSITIONAL ISSUES:\n- PCP and ___ emailed while patient in house\n\n', 'Pertinent Results:': '\nNo labs or imaging performed\n\n', 'Physical Exam:|Physical': '\nAdmission Exam:\nAfebrile SBP 160s/90s, HR ___, 16 98RA \nGen: NAD, HEENT: Right eye patch, Left surgical eye, MMM \nNeck: Supple \nCard: S1S2 No MRG \nResp: CTAB \nAbd: Abdomen Soft NT ND BS+ \nExtr: No Edema \n.\nDischarge Exam:\nAVSS, SBP 180\nRight eye patch removed\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\n___ with a history of PVD with claudication, CAD status post MI \nand stenting of RCA and LAD/Diag in ___ and ___ that presented \ntoday for emergent glaucoma surgery. She is being admitted to \nthe hospital post-operatively. \n. \nFollowing the procedure she has no complaints. Denies eye pain. \nNo headache, neckstiffness. Denies chest pain, shortness of \nbreath, fevers, chills. No nausea or vomiting. Last ___ was this \nmorning. She did not take her morning medications. \n. \n\nPast Medical History:\n# CAD s/p cath in ___ showed stenosis of the RCA and LAD; cath \nin ___ showed an LAD restenosis, s/p Rotablator; ETT in \n___ showed a small partial reversible apical \ndefect. \n# PVD s/p left SFA stenting ___ \n# Hypercholesterolemia \n# Total abdominal hysterectomy/bilateral salpingo-oophorectomy \n# Peptic ulcer disease \n# GERD w/ an esophagogastroduodenoscopy ___ years ago \n# Glaucoma \n# Macular degeneration \n# HOH- bilateral hearing aides \n\nSocial History:\n___\nFamily History:\nson had MI at age ___, s/p CABG, and is currently doing well.\n\n', 'Chief Complaint:|Complaint:': '\ns/p Right Trabeculectomy\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nLipitor / lisinopril / Plavix / Iodinated Contrast Media - IV \nDye\n\n'}, '14146558-DS-17', 17, 'medicine']]

[]

[[28894951, Timestamp('2183-09-18 17:00:00'), Timestamp('2183-09-19 16:00:00'), 'MAIN', 'Amlodipine', '016925', '51079045020', '2.5mg Tablet'], [28894951, Timestamp('2183-09-18 22:00:00'), Timestamp('2183-09-19 16:00:00'), 'MAIN', 'Amlodipine', '016925', '51079045020', '2.5mg Tablet'], [28894951, Timestamp('2183-09-18 21:00:00'), Timestamp('2183-09-19 16:00:00'), 'MAIN', 'Sodium Chloride 0.9% Flush', '', '0', '10 mL Syringe'], [28894951, Timestamp('2183-09-18 21:00:00'), Timestamp('2183-09-19 16:00:00'), 'MAIN', 'Acetaminophen', '004489', '51079000220', '325mg Tablet']]

[]

['medicine']

[]

Question: A 91 F is admitted. He/she says he/she has s/p Right Trabeculectomy . History of illness: ___ with a history of PVD with claudication, CAD status post MI and stenting of RCA and LAD/Diag in ___ and ___ that presented today for emergent glaucoma surgery. She is being admitted to the hospital post-operatively. . Following the procedure she has no complaints. Denies eye pain. No headache, neckstiffness. Denies chest pain, shortness of breath, fevers, chills. No nausea or vomiting. Last ___ was this morning. She did not take her morning medications. . Past Medical History: # CAD s/p cath in ___ showed stenosis of the RCA and LAD; cath in ___ showed an LAD restenosis, s/p Rotablator; ETT in ___ showed a small partial reversible apical defect. # PVD s/p left SFA stenting ___ # Hypercholesterolemia # Total abdominal hysterectomy/bilateral salpingo-oophorectomy # Peptic ulcer disease # GERD w/ an esophagogastroduodenoscopy ___ years ago # Glaucoma # Macular degeneration # HOH- bilateral hearing aides Social History: ___ Family History: son had MI at age ___, s/p CABG, and is currently doing well. Allergies: Lipitor / lisinopril / Plavix / Iodinated Contrast Media - IV Dye What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Amlodipine Amlodipine Sodium Chloride 0.9% Flush Acetaminophen Target Lab Orders: NONE Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : ___ with CAD, PVD admitted post-operatively for glaucome surgery on right eye. . ACTIVE ISSUES # Glaucoma: s/p right trabeculectomy by Dr. ___. No complications. The patient was discharged the following day. . INACTIVE ISSUES # PVD: Right SFA s/p stenting: Cont ASA. No currently on other platelet agents. . # CAD: Prior LAD and RCA stenting. Cont ASA, lovastatin. Not currently on B-Blocker. . # GERD: Continue omeprazole. # Gout: cont allopurinol. . TRANSITIONAL ISSUES: - PCP and ___ emailed while patient in house Other Results: No labs or imaging performed

2170-06-08 00:00:00

ENGLISH

DIVORCED

BLACK/AFRICAN AMERICAN

F

[[24154882, Timestamp('2170-06-08 01:44:51'), '', 'VSURG']]

[[{'Medications on Admission': ':\nThe Preadmission Medication list may be inaccurate and requires \nfurther investigation.\n1. Lisinopril 5 mg PO DAILY \n2. Acetaminophen 1000 mg PO BID:PRN Pain - Mild/Fever \n3. Cilostazol 100 mg PO BID \n4. Clopidogrel 75 mg PO DAILY \n5. Metoprolol Succinate XL 25 mg PO DAILY \n6. Pantoprazole 40 mg PO Q24H \n7. Rivaroxaban 2.5 mg PO DAILY \n8. Rosuvastatin Calcium 10 mg PO QPM \n9. TraMADol 50 mg PO BID:PRN Pain - Moderate \n10. Vitamin D 1000 UNIT PO DAILY \n11. ubidecarenone-omega 3-vit E ___ mg-mg-unit oral DAILY \n\n12. Niacin SR 500 mg PO BID \n13. Multivitamins 1 TAB PO DAILY \n\nFacility:\n___', 'Brief Hospital Course': ':\nMs. ___ is an ___ nonsmoker,nondiabetic with right \nchronic limb threatening ischemia, presenting with worsening \nrest pain She was admitted for Right lower extremity chronic \nlimb threatening ischemia with rest pain. She underwent angio of \nRLE. \nAngio findings:Patent right common femoral artery,\nprofunda femoris and proximal superficial femoral artery. The\nright superficial femoral artery occludes in the mid thigh\nwithin the previously placed SFA stent, the SFA reconstitutes\ndistally and the mid popliteal artery where it feeds into a\nsingle vessel peroneal runoff. The peroneal vessel was patent\nall the way to the ankle, at which point it collateralizes to\ntarsal vessels. The right anterior and posterior tibial\narteries are chronically occluded and do not appear to\nreconstitute distally.\nSurgery with Dr. ___ is scheduled on ___ for a Right \nlower extremity bypass with vein possible PFTE after discussing \nrisks and benefits with patient. \n\nRecommndations: We have scheduled an appointment with \ncardiologist Dr. ___ on ___ at ___ for preop \nclearance. \n\nLocation: ___, ___. \nAddress: ___ OF CARDIOLOGY, ___ \nPhone: ___ \nFax: ___ \n\n', 'Pertinent Results:': '\n___ 05:02AM BLOOD WBC-4.3 RBC-4.64 Hgb-12.4 Hct-40.4 MCV-87 \nMCH-26.7 MCHC-30.7* RDW-14.2 RDWSD-45.5 Plt ___\n\n', 'Physical Exam:|Physical': ' ___:\nA&O x3, non-focal exam, no neurological deficits. \neyes: pallor and icterus are absent \nCV: RRR, heart is regular\nChest: clear \nGi Abdomen is soft, non-tender, BS present \nGu:voiding\npulses: \n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\nMs. ___ is an ___ nonsmoker,nondiabetic with right \nchronic limb threatening ischemia,presenting with worsening rest \npain. She has had several\nright lower extremity SFA and popliteal artery \ninterventions,which have been complicated by recurrent SFA \nin-stentrestenosis. Her initial procedure was performed on \n___, where she underwent a right SFA angioplasty and \nstenting with a 5 x ___ mm Innova stent. Over the following \nyears, she has had reinterventions on this SFA stent with \ndrug-coated balloons 2 and repeat stenting of the right SFA on \n___. She underwent an outpatient\nduplex given worsening right lower extremity rest pain symptoms, \nwhich revealed occlusion of the SFA stents. Given these \nfindings, a right lower extremity angiogram was considered. \n\nPast Medical History:\nCAD/MI s/p coronary stenting ___, HTN, HLD, PVD, \nOsteoarthritis, GERD \n\nSocial History:\n___\nFamily History:\nDiabetes mellitus: mother\n\n', 'Chief Complaint:|Complaint:': '\nBILATERAL LOWER EXTREMITY CLAUDICATION/ resting pain\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \npeanuts / shellfish derived / Oxycodone\n\n'}, '12861596-DS-7', 7, 'surgery']]

[['EXAMINATION: ___ DUP UPPER EXT BILAT (MAP)\n\nINDICATION: ___ year old woman with right leg rest pain// vein conduit\n\nTECHNIQUE: Real-time grayscale, color, and spectral Doppler ultrasound\nimaging was obtained.\n\nCOMPARISON: None\n\nFINDINGS: \n\nRIGHT UPPER EXTREMITY:\nRight Cephalic Vein\n\nLocation: Diameter / Patency\nProximal upper arm 0.25 cm/Thickened walls\nMid upper arm 0.25 cm/Thickened walls\nDistal upper arm 0.22 cm/Thickened walls\nAntecubital fossa 0.27 cm/Thickened walls\nProximal forearm 0.17 cm/Thickened walls\nMid forearm 0.12 cm/Thickened walls\nDistal forearm 0.15 cm/Thickened walls\n\n\nRight Basilic Vein\n\nLocation: Diameter / Patency\nProximal upper arm 0.23 cm/Thickened walls\nMid upper arm 0.25 cm/Thickened walls\nDistal upper arm 0.07 cm/Thickened walls\nAntecubital fossa 0.06 cm/Thickened walls\nProximal forearm 0.06 cm/Thickened walls\nMid forearm 0.07 cm/Thickened walls\n\n\n----------------------------------------------------------------\nLEFT UPPER EXTREMITY:\nLeft Cephalic Vein\n\nLocation: Diameter / Patency\n\nProximal upper arm 0.06 cm /Thickened walls\nMid upper arm 0.08 cm/Thickened walls\nDistal upper arm 0.07 cm/Thickened walls\nAntecubital fossa 0.24 cm/Thickened walls\nProximal forearm 0.07 cm/Thickened walls\nMid forearm 0.11 cm/Thickened walls\nDistal forearm 0.13 cm/Thickened walls\n\n\nLeft Basilic Vein\n\nLocation: Diameter / Patency\n\nProximal upper arm 0.10 cm/Thickened walls\nMid upper arm 0.07 cm/Thickened walls\nDistal upper arm 0.10 cm/Thickened walls\nAntecubital fossa 0.07 cm/Thickened walls\nProximal forearm 0.05 cm/Thickened walls\nMid forearm 0.04 cm/Thickened walls\n\nIMPRESSION: \n\nUpper extremity venous mapping as detailed\n', '12861596-RR-18', 18, 'real-time grayscale, color, and spectral doppler ultrasound\nimaging was obtained.'], ['EXAMINATION: ___\n\nINDICATION: ___ year old woman with right leg rest pain// vein bypass conduit\n\nTECHNIQUE: Real-time grayscale, color, and spectral Doppler ultrasound\nimaging was obtained.\n\nCOMPARISON: None\n\nFINDINGS: \n\nRIGHT LOWER EXTREMITY:\nRight Greater Saphenous Vein\n\nLocation: Diameter / Patency\n___ upper thigh 0.56 cm/Patent\nMid thigh 0.42 cm/Patent\nDistal thigh 0.33 cm/Patent\nMid knee 0.31 cm/Patent\nProximal calf 0.19 cm/Patent\nMid calf 0.14 cm/Patent\nDistal calf 0.14 cm/Patent\n\nRight Small Saphenous Vein\n\nLocation: Diameter / Patency\nProximal calf 0.13 cm/Thickened walls\nMid calf 0.10 cm/Thickened walls\nDistal calf 0.16 cm/Thickened walls\n\nLEFT LOWER EXTREMITY:\nLeft Greater Saphenous Vein\n\nLocation: Diameter / Patency\n___ upper thigh 0.37 cm/Patent\nMid thigh 0.22 cm/Patent\nDistal thigh 0.22 cm/Patent\nMid knee 0.17 cm/Patent\nProximal calf 0.18 cm/Patent\nMid calf 0.18 cm/Patent\nDistal calf 0.09 cm/Patent\n\nLeft Small Saphenous Vein:\n\nLocation: Diameter / Patency\nProximal calf 0.05 cm/Thickened walls\nMid calf 0.09 cm/Thickened walls\nDistal calf 0.11 cm/Thickened walls\n\nIMPRESSION: \n\nLower extremity venous mapping as detailed.\n', '12861596-RR-19', 19, 'real-time grayscale, color, and spectral doppler ultrasound\nimaging was obtained.']]

[[24154882, Timestamp('2170-06-08 20:00:00'), Timestamp('2170-06-09 21:00:00'), 'MAIN', 'Dorzolamide 2%/Timolol 0.5% Ophth.', '039531', '61314003002', '10mL Dropper Bottle'], [24154882, Timestamp('2170-06-08 20:00:00'), Timestamp('2170-06-09 09:00:00'), 'MAIN', 'Heparin', '006549', '00641040012', '5000 Units / mL- 1mL Vial'], [24154882, Timestamp('2170-06-08 18:00:00'), Timestamp('2170-06-09 21:00:00'), 'MAIN', 'Pantoprazole', '027462', '00904647461', '40 mg Tablet'], [24154882, Timestamp('2170-06-08 18:00:00'), Timestamp('2170-06-09 21:00:00'), 'BASE', 'Sodium Chloride 0.9%', '001210', '00338004904', 'Floor Stock Bag'], [24154882, Timestamp('2170-06-08 22:00:00'), Timestamp('2170-06-09 21:00:00'), 'MAIN', 'Mirtazapine', '046450', '51079008620', '15 mg Tablet'], [24154882, Timestamp('2170-06-08 20:00:00'), Timestamp('2170-06-09 21:00:00'), 'MAIN', 'Rosuvastatin Calcium', '052944', '60687023401', '5mg Tablet'], [24154882, Timestamp('2170-06-08 18:00:00'), Timestamp('2170-06-09 21:00:00'), 'MAIN', 'TraMADol', '023139', '57664037708', '50mg Tablet']]

[['B41FYZZ', 10, 1, Timestamp('2170-06-08 00:00:00'), 'Fluoroscopy of Right Lower Extremity Arteries using Other Contrast']]

['surgery']

[[51237, Timestamp('2170-06-09 05:02:00'), Timestamp('2170-06-09 05:58:00'), 'INR(PT)'], [51274, Timestamp('2170-06-09 05:02:00'), Timestamp('2170-06-09 05:58:00'), 'PT'], [51275, Timestamp('2170-06-09 05:02:00'), Timestamp('2170-06-09 05:58:00'), 'PTT'], [51221, Timestamp('2170-06-09 05:02:00'), Timestamp('2170-06-09 05:31:00'), 'Hematocrit'], [51222, Timestamp('2170-06-09 05:02:00'), Timestamp('2170-06-09 05:31:00'), 'Hemoglobin'], [51248, Timestamp('2170-06-09 05:02:00'), Timestamp('2170-06-09 05:31:00'), 'MCH'], [51249, Timestamp('2170-06-09 05:02:00'), Timestamp('2170-06-09 05:31:00'), 'MCHC'], [51250, Timestamp('2170-06-09 05:02:00'), Timestamp('2170-06-09 05:31:00'), 'MCV'], [51265, Timestamp('2170-06-09 05:02:00'), Timestamp('2170-06-09 05:31:00'), 'Platelet Count'], [51277, Timestamp('2170-06-09 05:02:00'), Timestamp('2170-06-09 05:31:00'), 'RDW'], [51279, Timestamp('2170-06-09 05:02:00'), Timestamp('2170-06-09 05:31:00'), 'Red Blood Cells'], [51301, Timestamp('2170-06-09 05:02:00'), Timestamp('2170-06-09 05:31:00'), 'White Blood Cells'], [52172, Timestamp('2170-06-09 05:02:00'), Timestamp('2170-06-09 05:31:00'), 'RDW-SD'], [50868, Timestamp('2170-06-09 05:02:00'), Timestamp('2170-06-09 05:58:00'), 'Anion Gap'], [50882, Timestamp('2170-06-09 05:02:00'), Timestamp('2170-06-09 05:58:00'), 'Bicarbonate'], [50893, Timestamp('2170-06-09 05:02:00'), Timestamp('2170-06-09 05:58:00'), 'Calcium, Total'], [50902, Timestamp('2170-06-09 05:02:00'), Timestamp('2170-06-09 05:58:00'), 'Chloride'], [50912, Timestamp('2170-06-09 05:02:00'), Timestamp('2170-06-09 05:58:00'), 'Creatinine'], [50920, Timestamp('2170-06-09 05:02:00'), Timestamp('2170-06-09 05:58:00'), 'Estimated GFR (MDRD equation)'], [50931, Timestamp('2170-06-09 05:02:00'), Timestamp('2170-06-09 05:58:00'), 'Glucose'], [50934, Timestamp('2170-06-09 05:02:00'), Timestamp('2170-06-09 05:58:00'), 'H'], [50947, Timestamp('2170-06-09 05:02:00'), Timestamp('2170-06-09 05:58:00'), 'I'], [50960, Timestamp('2170-06-09 05:02:00'), Timestamp('2170-06-09 05:58:00'), 'Magnesium'], [50970, Timestamp('2170-06-09 05:02:00'), Timestamp('2170-06-09 05:58:00'), 'Phosphate'], [50971, Timestamp('2170-06-09 05:02:00'), Timestamp('2170-06-09 05:58:00'), 'Potassium'], [50983, Timestamp('2170-06-09 05:02:00'), Timestamp('2170-06-09 05:58:00'), 'Sodium'], [51006, Timestamp('2170-06-09 05:02:00'), Timestamp('2170-06-09 05:58:00'), 'Urea Nitrogen'], [51678, Timestamp('2170-06-09 05:02:00'), Timestamp('2170-06-09 05:58:00'), 'L']]

Question: A 77 F is admitted. He/she says he/she has BILATERAL LOWER EXTREMITY CLAUDICATION/ resting pain . History of illness: Ms. ___ is an ___ nonsmoker,nondiabetic with right chronic limb threatening ischemia,presenting with worsening rest pain. She has had several right lower extremity SFA and popliteal artery interventions,which have been complicated by recurrent SFA in-stentrestenosis. Her initial procedure was performed on ___, where she underwent a right SFA angioplasty and stenting with a 5 x ___ mm Innova stent. Over the following years, she has had reinterventions on this SFA stent with drug-coated balloons 2 and repeat stenting of the right SFA on ___. She underwent an outpatient duplex given worsening right lower extremity rest pain symptoms, which revealed occlusion of the SFA stents. Given these findings, a right lower extremity angiogram was considered. Past Medical History: CAD/MI s/p coronary stenting ___, HTN, HLD, PVD, Osteoarthritis, GERD Social History: ___ Family History: Diabetes mellitus: mother Allergies: peanuts / shellfish derived / Oxycodone What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Dorzolamide 2%/Timolol 0.5% Ophth. Heparin Pantoprazole Sodium Chloride 0.9% Mirtazapine Rosuvastatin Calcium TraMADol Target Lab Orders: INR(PT) PT PTT Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells RDW-SD Anion Gap Bicarbonate Calcium, Total Chloride Creatinine Estimated GFR (MDRD equation) Glucose H I Magnesium Phosphate Potassium Sodium Urea Nitrogen L Target Procedures: Fluoroscopy of Right Lower Extremity Arteries using Other Contrast DOCTOR'S NOTE Hospital Notes: : Ms. ___ is an ___ nonsmoker,nondiabetic with right chronic limb threatening ischemia, presenting with worsening rest pain She was admitted for Right lower extremity chronic limb threatening ischemia with rest pain. She underwent angio of RLE. Angio findings:Patent right common femoral artery, profunda femoris and proximal superficial femoral artery. The right superficial femoral artery occludes in the mid thigh within the previously placed SFA stent, the SFA reconstitutes distally and the mid popliteal artery where it feeds into a single vessel peroneal runoff. The peroneal vessel was patent all the way to the ankle, at which point it collateralizes to tarsal vessels. The right anterior and posterior tibial arteries are chronically occluded and do not appear to reconstitute distally. Surgery with Dr. ___ is scheduled on ___ for a Right lower extremity bypass with vein possible PFTE after discussing risks and benefits with patient. Recommndations: We have scheduled an appointment with cardiologist Dr. ___ on ___ at ___ for preop clearance. Location: ___, ___. Address: ___ OF CARDIOLOGY, ___ Phone: ___ Fax: ___ Other Results: ___ 05:02AM BLOOD WBC-4.3 RBC-4.64 Hgb-12.4 Hct-40.4 MCV-87 MCH-26.7 MCHC-30.7* RDW-14.2 RDWSD-45.5 Plt ___

2196-03-29 16:09:00

ENGLISH

MARRIED

BLACK/AFRICAN AMERICAN

M

[[21118413, Timestamp('2196-03-29 16:09:52'), '', 'VSURG']]

[[{'Medications on Admission': ":\namlodipine 10', calcitriol 0.25 qod, citalopram 20', vit D2 \n50,000unit weekly, fluticasone 50mcg nasal spray daily, \nlatanoprost both eyes qhs, metop tartrate 25'', omeprazole 20', \nsimvastatin 10' ", 'Brief Hospital Course': ":\nMr. ___ was admitted for prehydration for a scheduled \nhypogastric aneurysm embolization. However, the morning of the \nprocedure the patient became hypotensive to the 20's, SBP 120s. \nHe was given two doses of atropine which brought his heart rate \nto the 50's. EKG was done showing sinus bradycardia. Cardiology \nwas consulted and thought this was secondary to his mediactions, \nin specific metoprolol. The case was cancelled and the patient \nwas monitored closely in the VICU. An ECHO and CT chest were \nobtained showing mild dilation of the descending thoracic aorta. \nThe patient's heart rate remained 50-70s with stable blood \npressure. The patient never had any subjective symptoms of chest \npain or dizziness. No further interventions were implemented. \nThe patient was monitored and was discharged home with follow up \nwith Cardiology in a few days, and was instructed to discontinue \nthe metoprolol.\n\n", 'Pertinent Results:': '\nCT Chest\nIMPRESSION: \n1. Minimal fusiform dilatation descending thoracic aorta. No \nevidence of \ndissection or periaortic hemorrhage. \n2. Mild-to-moderate emphysema, moderate-to-severe pulmonary \nfibrosis, explain \nprobable pulmonary arterial hypertension, contributing to \nmoderate \ncardiomegaly. \n\nECHO\nIMPRESSION: Normal left ventricular cavity size with mild \nsymmetric left ventricular hypertrophy and preserved global and \nregional biventricular systolic function. Mildly dilated \nascending aorta. Markedly dilated descending thoracic aorta. \nMild aortic regurgitation. Indeterminate pulmonary artery \nsystolic pressure. \n\nCompared with the prior study (images unavailable for review) of \n___, a markedly dilated descending thoracic aorta \nmeasuring up to 5.2 centimeters in greatest dimension is now \nappreciated (previously mildly dilated at 3.3 centimeters, but \nnot consistently well-visualized or commented upon). The \nascending aorta is now mildly dilated. The severity of aortic \nregurgitation has increased minimally and is now mild. \n\n', 'Physical Exam:|Physical': '\nT 97.7 HR 74 BP 137/81 RR 24 94%2L\nGen: NAD, A/Ox3\nCardiac: RRR\nLungs: CTA bilat, no resp distress\nAbd: soft, NT, ND\nExtrem: no edema, bilat ___ palpable\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\nMr. ___ is a ___ y/o male with h/o bilateral iliac artery \naneurysms and s/p aortobi-iliac bypass in ___ and ischemic left \nleg due to thrombosed popliteal artery aneurysm s/p left ___ \nbypass and left leg fasciotomy in ___.\nHe now has a hypogastric aneurysm measuring 6.3 x 4.5 cm on the \nright. He is admitted for prehydration for his right hypogastric \naneurysm embolization scheduled for ___. \n\nPast Medical History:\nPVD, IPF (on home O2), CRI (baseline 3.5), HTN, Osteoarthritis\n\nPSH: ___: Thrombectomy of femoral artery/Fasciotomy of the \nposterior compartment deep and superficial/L SFA to ___ bypass \ngraft using NRSVG, ___ distal SFA to BK pop BPG with \nRGSV ligation above and below aneurysm, ___ debridement L \ncalf, RUE AVF ___, AAA repair ___, s/p head injury ___ from \nassault, cataract surg R eye\n\nSocial History:\n___\nFamily History:\nmother had DM, no hx of heart problems\n\n', 'Chief Complaint:|Complaint:': '\nhypogastric aneurysm\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nDilaudid\n\n'}, '17856695-DS-25', 25, 'surgery']]

[['PA AND LATERAL VIEWS OF THE CHEST\n\nREASON FOR EXAM: Preop, hypogastric aneurysm.\n\nThere is mild cardiomegaly, unchanged from ___. The aorta is\ntortuous and elongated. There is no pneumothorax or pleural effusion. \nMild-to-moderate peripheral subpleural reticular opacities are chronic, larger\non the lower lobes bilaterally, probably unchanged since ___. The main\npulmonary arteries appear enlarged, suggestive of pulmonary hypertension. \nThere is no evidence of pneumonia or CHF. Mild degenerative changes are in\nthe thoracic spine. Surgical clips project in the upper abdomen, midline.\n\nIMPRESSION: No evidence of acute cardiopulmonary abnormalities.\n\nChronic interstitial lung disease.\n\nProbable pulmonary hypertension.\n', '17856695-RR-66', 66, ''], ['CHEST CT, ___\n\nHISTORY: Ascending thoracic aortic aneurysm.\n\nTECHNIQUE: Multidetector helical scanning of the chest was performed without\nintravenous contrast agent reconstructed as contiguous 5- and 1.25-mm thick\naxial and 5-mm thick coronal and parasagittal images compared to CT scanning\nof the chest in ___, most recently partially imaged ___\nduring a CTA of the abdominal aorta.\n\nFINDINGS: Ascending thoracic aorta caliber is top normal and descending aorta\nmildly, but generally enlarged, with diameters as follows, supra-annular 39\nmm, right pulmonary artery 41 mm, proximal aortic arch 39 mm, descending\nthoracic aorta, level of the carina, 40 mm. Just above the diaphragm the\naorta becomes very tortuous, with diameter of 39 mm as it crosses the\ndiaphragm. There is no abnormality of the periaortic tissue to suggest\nhemorrhage and no hyperattenuation of the aortic wall or intimal elevation to\nsuggest dissection. Heart is moderately enlarged. There is no pleural or\npericardial effusion. The pulmonary artery is dilated, main between 36 and 44\nmm, right pulmonary artery 41 mm.\n\nEmphysema is mild-to-moderate and pulmonary fibrosis, moderate-to-severe most\npronounced at the lung bases but also quite marked in the anterior periphery\nof the left upper lobe anterior and lingular segments.\n\nThis study is not designed for subdiaphragmatic diagnosis, but shows small\ncalcified stones in a small gallbladder.\n\nIMPRESSION:\n1. Minimal fusiform dilatation descending thoracic aorta. No evidence of\ndissection or periaortic hemorrhage.\n2. Mild-to-moderate emphysema, moderate-to-severe pulmonary fibrosis, explain\nprobable pulmonary arterial hypertension, contributing to moderate\ncardiomegaly.\n', '17856695-RR-67', 67, 'multidetector helical scanning of the chest was performed without\nintravenous contrast agent reconstructed as contiguous 5- and 1.25-mm thick\naxial and 5-mm thick coronal and parasagittal images compared to ct scanning\nof the chest in ___, most recently partially imaged ___\nduring a cta of the abdominal aorta.']]

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[]

['surgery']

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Timestamp('2196-03-29 19:03:00'), Timestamp('2196-03-29 19:32:00'), 'Specific Gravity'], [51506, Timestamp('2196-03-29 19:03:00'), Timestamp('2196-03-29 19:32:00'), 'Urine Appearance'], [51508, Timestamp('2196-03-29 19:03:00'), Timestamp('2196-03-29 19:32:00'), 'Urine Color'], [51512, Timestamp('2196-03-29 19:03:00'), Timestamp('2196-03-29 19:32:00'), 'Urine Mucous'], [51514, Timestamp('2196-03-29 19:03:00'), Timestamp('2196-03-29 19:32:00'), 'Urobilinogen'], [51516, Timestamp('2196-03-29 19:03:00'), Timestamp('2196-03-29 19:32:00'), 'WBC'], [51519, Timestamp('2196-03-29 19:03:00'), Timestamp('2196-03-29 19:32:00'), 'Yeast'], [51237, Timestamp('2196-03-30 06:30:00'), Timestamp('2196-03-30 07:02:00'), 'INR(PT)'], [51274, Timestamp('2196-03-30 06:30:00'), Timestamp('2196-03-30 07:02:00'), 'PT'], [51275, Timestamp('2196-03-30 06:30:00'), Timestamp('2196-03-30 07:02:00'), 'PTT'], [51221, Timestamp('2196-03-30 06:30:00'), Timestamp('2196-03-30 07:09:00'), 'Hematocrit'], [51222, Timestamp('2196-03-30 06:30:00'), Timestamp('2196-03-30 07:09:00'), 'Hemoglobin'], [51248, Timestamp('2196-03-30 06:30:00'), Timestamp('2196-03-30 07:09:00'), 'MCH'], [51249, Timestamp('2196-03-30 06:30:00'), Timestamp('2196-03-30 07:09:00'), 'MCHC'], [51250, Timestamp('2196-03-30 06:30:00'), Timestamp('2196-03-30 07:09:00'), 'MCV'], [51265, Timestamp('2196-03-30 06:30:00'), Timestamp('2196-03-30 07:09:00'), 'Platelet Count'], [51277, Timestamp('2196-03-30 06:30:00'), Timestamp('2196-03-30 07:09:00'), 'RDW'], [51279, Timestamp('2196-03-30 06:30:00'), Timestamp('2196-03-30 07:09:00'), 'Red Blood Cells'], [51301, Timestamp('2196-03-30 06:30:00'), Timestamp('2196-03-30 07:09:00'), 'White Blood Cells'], [50852, Timestamp('2196-03-30 06:30:00'), Timestamp('2196-03-30 10:49:00'), '% Hemoglobin A1c'], [51613, Timestamp('2196-03-30 06:30:00'), Timestamp('2196-03-30 11:01:00'), 'eAG'], [50868, Timestamp('2196-03-30 06:30:00'), Timestamp('2196-03-30 07:39:00'), 'Anion Gap'], [50882, 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16:59:00'), 'Lipase'], [51003, Timestamp('2196-03-30 11:24:00'), Timestamp('2196-03-30 13:15:00'), 'Troponin T'], [50979, Timestamp('2196-03-30 12:10:00'), NaT, 'Red Top Hold'], [50802, Timestamp('2196-03-30 13:03:00'), Timestamp('2196-03-30 13:08:00'), 'Base Excess'], [50804, Timestamp('2196-03-30 13:03:00'), Timestamp('2196-03-30 13:08:00'), 'Calculated Total CO2'], [50806, Timestamp('2196-03-30 13:03:00'), Timestamp('2196-03-30 13:08:00'), 'Chloride, Whole Blood'], [50808, Timestamp('2196-03-30 13:03:00'), Timestamp('2196-03-30 13:08:00'), 'Free Calcium'], [50809, Timestamp('2196-03-30 13:03:00'), Timestamp('2196-03-30 13:08:00'), 'Glucose'], [50813, Timestamp('2196-03-30 13:03:00'), Timestamp('2196-03-30 13:08:00'), 'Lactate'], [50818, Timestamp('2196-03-30 13:03:00'), Timestamp('2196-03-30 13:08:00'), 'pCO2'], [50820, Timestamp('2196-03-30 13:03:00'), Timestamp('2196-03-30 13:08:00'), 'pH'], [50821, Timestamp('2196-03-30 13:03:00'), Timestamp('2196-03-30 13:08:00'), 'pO2'], 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Question: A 81 M is admitted. He/she says he/she has hypogastric aneurysm . History of illness: Mr. ___ is a ___ y/o male with h/o bilateral iliac artery aneurysms and s/p aortobi-iliac bypass in ___ and ischemic left leg due to thrombosed popliteal artery aneurysm s/p left ___ bypass and left leg fasciotomy in ___. He now has a hypogastric aneurysm measuring 6.3 x 4.5 cm on the right. He is admitted for prehydration for his right hypogastric aneurysm embolization scheduled for ___. Past Medical History: PVD, IPF (on home O2), CRI (baseline 3.5), HTN, Osteoarthritis PSH: ___: Thrombectomy of femoral artery/Fasciotomy of the posterior compartment deep and superficial/L SFA to ___ bypass graft using NRSVG, ___ distal SFA to BK pop BPG with RGSV ligation above and below aneurysm, ___ debridement L calf, RUE AVF ___, AAA repair ___, s/p head injury ___ from assault, cataract surg R eye Social History: ___ Family History: mother had DM, no hx of heart problems Allergies: Dilaudid What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Metoprolol Tartrate 5% Dextrose Sodium Bicarbonate Atropine Sulfate Latanoprost 0.005% Ophth. Soln. Sodium Chloride 0.9% Flush Heparin Simvastatin D5 1/2NS Target Lab Orders: Bacteria Bilirubin Blood Epithelial Cells Glucose Ketone Leukocytes Nitrite pH Protein RBC Specific Gravity Urine Appearance Urine Color Urine Mucous Urobilinogen WBC Yeast INR(PT) PT PTT Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells % Hemoglobin A1c eAG Anion Gap Bicarbonate Calcium, Total Chloride Creatinine Estimated GFR (MDRD equation) Glucose Magnesium Phosphate Potassium Sodium Urea Nitrogen Alanine Aminotransferase (ALT) Albumin Alkaline Phosphatase Amylase Asparate Aminotransferase (AST) Bilirubin, Total Creatine Kinase (CK) Creatine Kinase, MB Isoenzyme Lactate Dehydrogenase (LD) Lipase Troponin T Red Top Hold Base Excess Calculated Total CO2 Chloride, Whole Blood Free Calcium Glucose Lactate pCO2 pH pO2 Potassium, Whole Blood Sodium, Whole Blood Specimen Type Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : Mr. ___ was admitted for prehydration for a scheduled hypogastric aneurysm embolization. However, the morning of the procedure the patient became hypotensive to the 20's, SBP 120s. He was given two doses of atropine which brought his heart rate to the 50's. EKG was done showing sinus bradycardia. Cardiology was consulted and thought this was secondary to his mediactions, in specific metoprolol. The case was cancelled and the patient was monitored closely in the VICU. An ECHO and CT chest were obtained showing mild dilation of the descending thoracic aorta. The patient's heart rate remained 50-70s with stable blood pressure. The patient never had any subjective symptoms of chest pain or dizziness. No further interventions were implemented. The patient was monitored and was discharged home with follow up with Cardiology in a few days, and was instructed to discontinue the metoprolol. Other Results: CT Chest IMPRESSION: 1. Minimal fusiform dilatation descending thoracic aorta. No evidence of dissection or periaortic hemorrhage. 2. Mild-to-moderate emphysema, moderate-to-severe pulmonary fibrosis, explain probable pulmonary arterial hypertension, contributing to moderate cardiomegaly. ECHO IMPRESSION: Normal left ventricular cavity size with mild symmetric left ventricular hypertrophy and preserved global and regional biventricular systolic function. Mildly dilated ascending aorta. Markedly dilated descending thoracic aorta. Mild aortic regurgitation. Indeterminate pulmonary artery systolic pressure. Compared with the prior study (images unavailable for review) of ___, a markedly dilated descending thoracic aorta measuring up to 5.2 centimeters in greatest dimension is now appreciated (previously mildly dilated at 3.3 centimeters, but not consistently well-visualized or commented upon). The ascending aorta is now mildly dilated. The severity of aortic regurgitation has increased minimally and is now mild.

2152-03-24 15:03:00

ENGLISH

MARRIED

WHITE

F

[[26203283, Timestamp('2152-03-24 15:03:34'), '', 'ENT']]

[[{'Medications on Admission': ":\nsee ___'ed meds", 'Brief Hospital Course': ":\nPatient was admitted to the hospital for obs overnight following \nher ___ procedure. Please see operative report dicatated by \nDr. ___ details of the procedure. Patient's neck \ndrain was kept in place until it met criteria.\n\nOn POD1, day of discharge, pt was ambulating independently, her \nvoice was normal,no evidence of bleeding, pain well controlled \nwith PO pan medication.\n\n", 'Pertinent Results:': '\nNA\n\n', 'Physical Exam:|Physical': '\nOn discharge, patient was in NAD, neck flat, incision clean, \ndry, and steri strips intact. Tongue midline. No evidence of \nbleeding. OP/OC clear.\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\nI had the pleasure of seeing Ms. ___ in consultation on\n___. She was previously seen by my colleague, Dr.\n___, for what was found to be a thyroglossal duct\ncyst. An ultrasound on ___, identified a 1.1 x 0.7 \nx\n1.1 cm midline hypoechoic structure. She had presented with \nwhat\nwas described as an infection and was placed on Augmentin. The\nexternal part went away, but on an MRI, she was found to have \nthe\nupper portion of it still present measuring approximately 6.2 mm\nin size consistent with a cystic lesion in the region of the\nforamen cecum. She was also noted to have very enlarged tonsils\nand some level IIa lymph node enlargement. More recently, she\nhas been having problems with swelling in the same area with \nsome\nerythema of the overlying skin. She denies any dysphagia or\nodynophagia. She is a nonsmoker and does not drink alcohol.\n\nPast Medical History:\nThalassemia intermdedia\nGERD\nOSteopenia\nPalpitations\nProteinuria with ___ edema on lisinopril\nAllergic rhinitis\nLPR\nrecurrent UTIs\ns/p choleystectomy\ns/p splenectomy\n\nSocial History:\n___\nFamily History:\n___\n\n', 'Chief Complaint:|Complaint:': '\nThyroglossal duct cyst\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nNo Known Allergies / Adverse Drug Reactions\n\n'}, '10948183-DS-12', 12, 'otolaryngology']]

[]

[[26203283, Timestamp('2152-03-24 16:00:00'), Timestamp('2152-03-25 16:00:00'), 'MAIN', 'OxycoDONE-Acetaminophen Elixir', '004221', '00054864816', '5mL Cup'], [26203283, Timestamp('2152-03-24 16:00:00'), Timestamp('2152-03-25 16:00:00'), 'MAIN', 'HYDROmorphone (Dilaudid)', '062823', '00409128331', '1mg/1mL Syringe'], [26203283, Timestamp('2152-03-24 16:00:00'), Timestamp('2152-03-25 07:00:00'), 'MAIN', 'Influenza Virus Vaccine', '071215', '49281001350', '0.5 mL Syringe'], [26203283, Timestamp('2152-03-24 16:00:00'), Timestamp('2152-03-25 16:00:00'), 'BASE', 'Lactated Ringers', '001187', '00338011704', '1000ml Bag'], [26203283, Timestamp('2152-03-24 16:00:00'), Timestamp('2152-03-25 16:00:00'), 'MAIN', 'Lorazepam', '003757', '00904598061', '0.5mg Tablet'], [26203283, Timestamp('2152-03-24 16:00:00'), Timestamp('2152-03-25 16:00:00'), 'MAIN', 'Albuterol Inhaler', '028090', '00173068254', '8 g Inhaler'], [26203283, Timestamp('2152-03-24 16:00:00'), Timestamp('2152-03-25 16:00:00'), 'BASE', '0.9% Sodium Chloride (Mini Bag Plus)', '001210', '00338055318', '100mL Bag'], [26203283, Timestamp('2152-03-24 16:00:00'), Timestamp('2152-03-25 16:00:00'), 'MAIN', 'Ampicillin-Sulbactam', '008921', '63323036920', '3g Vial'], [26203283, Timestamp('2152-03-25 08:00:00'), Timestamp('2152-03-25 16:00:00'), 'MAIN', 'Lisinopril', '000393', '68084006001', '5mg Tablet'], [26203283, Timestamp('2152-03-24 16:00:00'), Timestamp('2152-03-25 16:00:00'), 'MAIN', 'Sodium Chloride 0.9% Flush', '', '0', '10 mL Syringe'], [26203283, Timestamp('2152-03-24 16:00:00'), Timestamp('2152-03-24 15:00:00'), 'BASE', 'Iso-Osmotic Dextrose', '', '0', '50ml Bag'], [26203283, Timestamp('2152-03-24 16:00:00'), Timestamp('2152-03-24 15:00:00'), 'MAIN', 'CefazoLIN', '051880', '00264310311', '1g Froz.Bag'], [26203283, Timestamp('2152-03-24 16:00:00'), Timestamp('2152-03-25 16:00:00'), 'MAIN', 'Ondansetron', '061716', '00641608025', '2mg/mL-2mL'], [26203283, Timestamp('2152-03-25 08:00:00'), Timestamp('2152-03-25 16:00:00'), 'MAIN', 'Levothyroxine Sodium', '006649', '00074455211', '50mcg Tablet']]

[]

['otolaryngology']

[]

Question: A 40 F is admitted. He/she says he/she has Thyroglossal duct cyst . History of illness: I had the pleasure of seeing Ms. ___ in consultation on ___. She was previously seen by my colleague, Dr. ___, for what was found to be a thyroglossal duct cyst. An ultrasound on ___, identified a 1.1 x 0.7 x 1.1 cm midline hypoechoic structure. She had presented with what was described as an infection and was placed on Augmentin. The external part went away, but on an MRI, she was found to have the upper portion of it still present measuring approximately 6.2 mm in size consistent with a cystic lesion in the region of the foramen cecum. She was also noted to have very enlarged tonsils and some level IIa lymph node enlargement. More recently, she has been having problems with swelling in the same area with some erythema of the overlying skin. She denies any dysphagia or odynophagia. She is a nonsmoker and does not drink alcohol. Past Medical History: Thalassemia intermdedia GERD OSteopenia Palpitations Proteinuria with ___ edema on lisinopril Allergic rhinitis LPR recurrent UTIs s/p choleystectomy s/p splenectomy Social History: ___ Family History: ___ Allergies: No Known Allergies / Adverse Drug Reactions What is the best procedure plan for this patient?

TARGETS Target Prescriptions: OxycoDONE-Acetaminophen Elixir HYDROmorphone (Dilaudid) Influenza Virus Vaccine Lactated Ringers Lorazepam Albuterol Inhaler 0.9% Sodium Chloride (Mini Bag Plus) Ampicillin-Sulbactam Lisinopril Sodium Chloride 0.9% Flush Iso-Osmotic Dextrose CefazoLIN Ondansetron Levothyroxine Sodium Target Lab Orders: NONE Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : Patient was admitted to the hospital for obs overnight following her ___ procedure. Please see operative report dicatated by Dr. ___ details of the procedure. Patient's neck drain was kept in place until it met criteria. On POD1, day of discharge, pt was ambulating independently, her voice was normal,no evidence of bleeding, pain well controlled with PO pan medication. Other Results: NA

2157-02-02 09:00:00

ENGLISH

MARRIED

WHITE

F

[[22794615, Timestamp('2157-02-02 03:24:23'), '', 'GYN']]

[[{'Medications on Admission': ':\n1. Lotrel ___ mg Capsule Sig: One (1) Capsule PO once a day. \n2. MVI PO daily', 'Brief Hospital Course': ':\nMs. ___ underwent radical hysterectomy, bilateral \nsalpingo-oophorectomy, pelvic and ___ lymph node \ndissection, omentectomy for clear cell endometrial cancer on \n___. Please see operative report for full details. She was \nadmitted to the gynecologic oncology service post-operatively. \nHer post-operative course was unremarkable. She was discharged \nhome on postoperative day #6 and was tolerating a regular diet, \nhad her pain was controlled on oral pain medications. Due to the \nureteral dissection, her foley catheter was still in place at \ndischarge and will remain until her follow-up appointment with \nDr. ___ on ___. \n\n', 'Pertinent Results:': '\n___ 06:11PM GLUCOSE-172* UREA N-11 CREAT-0.7 SODIUM-141 \nPOTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-23 ANION GAP-17\n___ 06:11PM CALCIUM-8.3* PHOSPHATE-3.6 MAGNESIUM-1.7\n___ 06:11PM ___ PTT-23.1 ___\n___ 06:11PM ___ 04:35PM HGB-11.1* calcHCT-33\n___ 04:35PM TYPE-ART PO2-158* PCO2-44 PH-7.36 TOTAL \nCO2-26 BASE XS-0 INTUBATED-INTUBATED VENT-CONTROLLED\nPATHOLOGY: \nHistologic Grade: G3: Clear Cell\nWashings/cytology: Negative.\nPrimary Tumor: pT2 (II): Tumor invades stromal connective \ntissue of the cervix.\nMyometrial Invasion: Invasion present: <10%, see note.\nCervix: Stromal invasion.\nOvaries\n Right: Negative.\n Left: Negative.\nFallopian tube\n Right: Negative.\n Left: Negative.\nSerosa: Negative.\nOmentum: Negative.\nRegional Lymph Nodes: pN0: No regional lymph node metastasis.\nPelvic lymph Nodes\n Number examined: 35.\n Number involved: 0.\nPara-aortic lymph Nodes\n Number examined: 7.\n Number involved: 0.\nLymph-Vascular invasion: Absent.\n\nNote: The tumor is exophytic and the depth of myometrial \ninvasion is difficult to evaluate. Most sections show minimal \n(<10%) invasion, but one area (slide R) shows tumor closer to \nthe serosa. This likely represents an artifact of sectioning \n(ie. sections are taken from the lateral wall, next to the \nparametrium). \n\n', 'Physical Exam:|Physical': '\nGEN: NAD\nSkin: Warm and dry, no jaundice, no petechiae, no pallor\nHEENT: Normocephalic, atraumatic, pupils equal round reactive to\nlight, extraocular movements intact. Oropharynx clear. \nNeck: Soft, supple, midline trachea, no lymphadenopathy\nappreciated. \nCardiovascular: Regular rate and rhythm. Normal S1 and S2. No \nmurmurs, rubs, gallops appreciated. \nRespiratory: Lungs clear to auscultation bilaterally with good \nair flow and normal effort. \nAbdomen: Positive bowel sounds, nontender.\nExtremities: 2+ lower extremity pitting edema. Non-tender \nextremities with negative ___ sign. No clubbing or \ncyanosis. \nPelvic/SSE: A large, approximately 5-6 cm, vascular friable mass \nwas noted protruding from the cervix. The vagina appeared to be \ngrossly uninvolved with disease. The uterus was enlarged as \nwell. The rectum appeared to be uninvolved. General: Alert and \noriented x 3, no acute distress, sitting comfortably.\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\n___ gravida 4 para 4 with postmenopausal bleeding and \nrecent cervical biopsy which showing clear cell carcinoma. \nImaging showed the bulk of the tumor mass in the corpus with \napparent extension into the cervix. \n\nPast Medical History:\n1) Hypertension \n2)Melanoma, in the distant past. \n\nPast Surgical History: Melanoma excision of her neck and \nDilation and curettage. \n\nPast OB/GYN history: G4, P4. Menopausal for ___ years. Normal\nPaps and no pelvic infections.\n\nSocial History:\n___\nFamily History:\nBreast cancer in a cousin and ovarian cancer in an aunt.\n\n', 'Chief Complaint:|Complaint:': '\nclear cell endometrial cancer\n\n', 'Attending:': ' ___\n\n', 'Allergies:': ' \nPatient recorded as having No Known Allergies to Drugs\n\n'}, '14372862-DS-17', 17, 'obstetrics/gynecology']]

[["CHEST ON ___\n\nHISTORY: Hysterectomy, difficult weaning oxygen.\n\nFINDINGS: A small amount of free air is seen under the hemidiaphragm,\nconsistent with patient's postoperative state. There is plate-like\natelectasis in both lower lungs and probable small effusion seen best on the\nlateral films. There is no infiltrate. There is no pneumothorax.\n", '14372862-RR-6', 6, '']]

[[22794615, Timestamp('2157-02-02 22:00:00'), Timestamp('2157-02-05 18:00:00'), 'MAIN', 'HYDROmorphone (Dilaudid)', '004101', '00074233411', '12.5mg/50mL Syringe'], [22794615, Timestamp('2157-02-02 10:00:00'), Timestamp('2157-02-04 09:00:00'), 'MAIN', 'benazepril', '016040', '00078044805', '10mg Tablet'], [22794615, Timestamp('2157-02-02 10:00:00'), Timestamp('2157-02-04 09:00:00'), 'MAIN', 'Amlodipine', '016926', '51079045120', '5mg Tablet'], [22794615, Timestamp('2157-02-02 21:00:00'), Timestamp('2157-02-08 17:00:00'), 'MAIN', 'Sodium Chloride 0.9% Flush', '', '0', 'Syringe'], [22794615, Timestamp('2157-02-02 21:00:00'), Timestamp('2157-02-06 07:00:00'), 'MAIN', 'Pneumococcal Vac Polyvalent', '048548', '00006473900', '25mcg/0.5mL Vial'], [22794615, Timestamp('2157-02-02 21:00:00'), Timestamp('2157-02-08 17:00:00'), 'MAIN', 'Ondansetron', '061716', '00781305714', '2mg/mL-2mL'], [22794615, Timestamp('2157-02-02 21:00:00'), Timestamp('2157-02-02 21:00:00'), 'MAIN', 'HYDROmorphone (Dilaudid)', '004101', '00074233411', '12.5mg/50mL Syringe'], [22794615, Timestamp('2157-02-02 21:00:00'), Timestamp('2157-02-08 17:00:00'), 'MAIN', 'Oxycodone-Acetaminophen', '004222', '00406051262', '5mg/325mg Tablet'], [22794615, Timestamp('2157-02-02 21:00:00'), Timestamp('2157-02-06 07:00:00'), 'MAIN', 'Influenza Virus Vaccine', '066525', '33332001001', '0.5 mL Syringe'], [22794615, Timestamp('2157-02-02 10:00:00'), Timestamp('2157-02-02 21:00:00'), 'MAIN', 'benazepril', '016040', '00078044805', '10mg Tablet'], [22794615, Timestamp('2157-02-02 21:00:00'), Timestamp('2157-02-08 17:00:00'), 'MAIN', 'Ibuprofen', '008349', '00904585461', '600mg Tablet'], [22794615, Timestamp('2157-02-02 20:00:00'), Timestamp('2157-02-08 17:00:00'), 'MAIN', 'Heparin', '006549', '63323026201', '5000 Units / mL- 1mL Vial'], [22794615, Timestamp('2157-02-02 21:00:00'), Timestamp('2157-02-06 09:00:00'), 'BASE', 'LR', '001187', '00338011704', '1000ml Bag'], [22794615, Timestamp('2157-02-02 10:00:00'), Timestamp('2157-02-02 21:00:00'), 'MAIN', 'Amlodipine', '016926', '51079045120', '5mg Tablet'], [22794615, Timestamp('2157-02-02 23:00:00'), Timestamp('2157-02-08 17:00:00'), 'MAIN', 'Artificial Tears Preserv. Free', '030016', '00023050601', '0.3mL UD']]

[]

['obstetrics/gynecology']

[[50802, Timestamp('2157-02-02 16:35:00'), Timestamp('2157-02-02 16:38:00'), 'Base Excess'], [50804, Timestamp('2157-02-02 16:35:00'), Timestamp('2157-02-02 16:38:00'), 'Calculated Total CO2'], [50806, Timestamp('2157-02-02 16:35:00'), Timestamp('2157-02-02 16:39:00'), 'Chloride, Whole Blood'], [50808, Timestamp('2157-02-02 16:35:00'), Timestamp('2157-02-02 16:39:00'), 'Free Calcium'], [50809, Timestamp('2157-02-02 16:35:00'), Timestamp('2157-02-02 16:39:00'), 'Glucose'], [50810, Timestamp('2157-02-02 16:35:00'), Timestamp('2157-02-02 16:39:00'), 'Hematocrit, Calculated'], [50811, Timestamp('2157-02-02 16:35:00'), Timestamp('2157-02-02 16:39:00'), 'Hemoglobin'], [50812, Timestamp('2157-02-02 16:35:00'), Timestamp('2157-02-02 16:38:00'), 'Intubated'], [50813, Timestamp('2157-02-02 16:35:00'), Timestamp('2157-02-02 16:39:00'), 'Lactate'], [50818, Timestamp('2157-02-02 16:35:00'), Timestamp('2157-02-02 16:38:00'), 'pCO2'], [50820, Timestamp('2157-02-02 16:35:00'), Timestamp('2157-02-02 16:38:00'), 'pH'], [50821, Timestamp('2157-02-02 16:35:00'), Timestamp('2157-02-02 16:38:00'), 'pO2'], [50822, Timestamp('2157-02-02 16:35:00'), Timestamp('2157-02-02 16:39:00'), 'Potassium, Whole Blood'], [50824, Timestamp('2157-02-02 16:35:00'), Timestamp('2157-02-02 16:39:00'), 'Sodium, Whole Blood'], [50828, Timestamp('2157-02-02 16:35:00'), Timestamp('2157-02-02 16:38:00'), 'Ventilator'], [52033, Timestamp('2157-02-02 16:35:00'), Timestamp('2157-02-02 16:38:00'), 'Specimen Type'], [51214, Timestamp('2157-02-02 18:11:00'), Timestamp('2157-02-02 19:47:00'), 'Fibrinogen, Functional'], [51237, Timestamp('2157-02-02 18:11:00'), Timestamp('2157-02-02 19:47:00'), 'INR(PT)'], [51274, Timestamp('2157-02-02 18:11:00'), Timestamp('2157-02-02 19:47:00'), 'PT'], [51275, Timestamp('2157-02-02 18:11:00'), Timestamp('2157-02-02 19:47:00'), 'PTT'], [50868, Timestamp('2157-02-02 18:11:00'), Timestamp('2157-02-02 19:26:00'), 'Anion Gap'], [50882, Timestamp('2157-02-02 18:11:00'), Timestamp('2157-02-02 19:26:00'), 'Bicarbonate'], [50893, Timestamp('2157-02-02 18:11:00'), Timestamp('2157-02-02 19:26:00'), 'Calcium, Total'], [50902, Timestamp('2157-02-02 18:11:00'), Timestamp('2157-02-02 19:26:00'), 'Chloride'], [50912, Timestamp('2157-02-02 18:11:00'), Timestamp('2157-02-02 19:26:00'), 'Creatinine'], [50920, Timestamp('2157-02-02 18:11:00'), Timestamp('2157-02-02 19:26:00'), 'Estimated GFR (MDRD equation)'], [50931, Timestamp('2157-02-02 18:11:00'), Timestamp('2157-02-02 19:26:00'), 'Glucose'], [50960, Timestamp('2157-02-02 18:11:00'), Timestamp('2157-02-02 19:26:00'), 'Magnesium'], [50970, Timestamp('2157-02-02 18:11:00'), Timestamp('2157-02-02 19:26:00'), 'Phosphate'], [50971, Timestamp('2157-02-02 18:11:00'), Timestamp('2157-02-02 19:26:00'), 'Potassium'], [50983, Timestamp('2157-02-02 18:11:00'), Timestamp('2157-02-02 19:26:00'), 'Sodium'], [51006, Timestamp('2157-02-02 18:11:00'), Timestamp('2157-02-02 19:26:00'), 'Urea Nitrogen'], [51221, Timestamp('2157-02-02 18:11:00'), Timestamp('2157-02-02 18:36:00'), 'Hematocrit'], [51222, Timestamp('2157-02-02 18:11:00'), Timestamp('2157-02-02 18:36:00'), 'Hemoglobin'], [51248, Timestamp('2157-02-02 18:11:00'), Timestamp('2157-02-02 18:36:00'), 'MCH'], [51249, Timestamp('2157-02-02 18:11:00'), Timestamp('2157-02-02 18:36:00'), 'MCHC'], [51250, Timestamp('2157-02-02 18:11:00'), Timestamp('2157-02-02 18:36:00'), 'MCV'], [51265, Timestamp('2157-02-02 18:11:00'), Timestamp('2157-02-02 18:36:00'), 'Platelet Count'], [51277, Timestamp('2157-02-02 18:11:00'), Timestamp('2157-02-02 18:36:00'), 'RDW'], [51279, Timestamp('2157-02-02 18:11:00'), Timestamp('2157-02-02 18:36:00'), 'Red Blood Cells'], [51301, Timestamp('2157-02-02 18:11:00'), Timestamp('2157-02-02 18:36:00'), 'White Blood Cells'], [50868, Timestamp('2157-02-03 06:30:00'), Timestamp('2157-02-03 08:15:00'), 'Anion Gap'], [50882, Timestamp('2157-02-03 06:30:00'), Timestamp('2157-02-03 08:15:00'), 'Bicarbonate'], [50893, Timestamp('2157-02-03 06:30:00'), Timestamp('2157-02-03 08:15:00'), 'Calcium, Total'], [50902, Timestamp('2157-02-03 06:30:00'), Timestamp('2157-02-03 08:15:00'), 'Chloride'], [50912, Timestamp('2157-02-03 06:30:00'), Timestamp('2157-02-03 08:15:00'), 'Creatinine'], [50931, Timestamp('2157-02-03 06:30:00'), Timestamp('2157-02-03 08:15:00'), 'Glucose'], [50960, Timestamp('2157-02-03 06:30:00'), Timestamp('2157-02-03 08:15:00'), 'Magnesium'], [50970, Timestamp('2157-02-03 06:30:00'), Timestamp('2157-02-03 08:15:00'), 'Phosphate'], [50971, Timestamp('2157-02-03 06:30:00'), Timestamp('2157-02-03 08:15:00'), 'Potassium'], [50983, Timestamp('2157-02-03 06:30:00'), Timestamp('2157-02-03 08:15:00'), 'Sodium'], [51006, Timestamp('2157-02-03 06:30:00'), Timestamp('2157-02-03 08:15:00'), 'Urea Nitrogen'], [51221, Timestamp('2157-02-03 06:30:00'), Timestamp('2157-02-03 07:41:00'), 'Hematocrit'], [51222, Timestamp('2157-02-03 06:30:00'), Timestamp('2157-02-03 07:41:00'), 'Hemoglobin'], [51248, Timestamp('2157-02-03 06:30:00'), Timestamp('2157-02-03 07:41:00'), 'MCH'], [51249, Timestamp('2157-02-03 06:30:00'), Timestamp('2157-02-03 07:41:00'), 'MCHC'], [51250, Timestamp('2157-02-03 06:30:00'), Timestamp('2157-02-03 07:41:00'), 'MCV'], [51265, Timestamp('2157-02-03 06:30:00'), Timestamp('2157-02-03 07:41:00'), 'Platelet Count'], [51277, Timestamp('2157-02-03 06:30:00'), Timestamp('2157-02-03 07:41:00'), 'RDW'], [51279, Timestamp('2157-02-03 06:30:00'), Timestamp('2157-02-03 07:41:00'), 'Red Blood Cells'], [51301, Timestamp('2157-02-03 06:30:00'), Timestamp('2157-02-03 07:41:00'), 'White Blood Cells']]

Question: A 73 F is admitted. He/she says he/she has clear cell endometrial cancer . History of illness: ___ gravida 4 para 4 with postmenopausal bleeding and recent cervical biopsy which showing clear cell carcinoma. Imaging showed the bulk of the tumor mass in the corpus with apparent extension into the cervix. Past Medical History: 1) Hypertension 2)Melanoma, in the distant past. Past Surgical History: Melanoma excision of her neck and Dilation and curettage. Past OB/GYN history: G4, P4. Menopausal for ___ years. Normal Paps and no pelvic infections. Social History: ___ Family History: Breast cancer in a cousin and ovarian cancer in an aunt. Allergies: Patient recorded as having No Known Allergies to Drugs What is the best procedure plan for this patient?

TARGETS Target Prescriptions: HYDROmorphone (Dilaudid) benazepril Amlodipine Sodium Chloride 0.9% Flush Pneumococcal Vac Polyvalent Ondansetron HYDROmorphone (Dilaudid) Oxycodone-Acetaminophen Influenza Virus Vaccine benazepril Ibuprofen Heparin LR Amlodipine Artificial Tears Preserv. Free Target Lab Orders: Base Excess Calculated Total CO2 Chloride, Whole Blood Free Calcium Glucose Hematocrit, Calculated Hemoglobin Intubated Lactate pCO2 pH pO2 Potassium, Whole Blood Sodium, Whole Blood Ventilator Specimen Type Fibrinogen, Functional INR(PT) PT PTT Anion Gap Bicarbonate Calcium, Total Chloride Creatinine Estimated GFR (MDRD equation) Glucose Magnesium Phosphate Potassium Sodium Urea Nitrogen Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells Anion Gap Bicarbonate Calcium, Total Chloride Creatinine Glucose Magnesium Phosphate Potassium Sodium Urea Nitrogen Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : Ms. ___ underwent radical hysterectomy, bilateral salpingo-oophorectomy, pelvic and ___ lymph node dissection, omentectomy for clear cell endometrial cancer on ___. Please see operative report for full details. She was admitted to the gynecologic oncology service post-operatively. Her post-operative course was unremarkable. She was discharged home on postoperative day #6 and was tolerating a regular diet, had her pain was controlled on oral pain medications. Due to the ureteral dissection, her foley catheter was still in place at discharge and will remain until her follow-up appointment with Dr. ___ on ___. Other Results: ___ 06:11PM GLUCOSE-172* UREA N-11 CREAT-0.7 SODIUM-141 POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-23 ANION GAP-17 ___ 06:11PM CALCIUM-8.3* PHOSPHATE-3.6 MAGNESIUM-1.7 ___ 06:11PM ___ PTT-23.1 ___ ___ 06:11PM ___ 04:35PM HGB-11.1* calcHCT-33 ___ 04:35PM TYPE-ART PO2-158* PCO2-44 PH-7.36 TOTAL CO2-26 BASE XS-0 INTUBATED-INTUBATED VENT-CONTROLLED PATHOLOGY: Histologic Grade: G3: Clear Cell Washings/cytology: Negative. Primary Tumor: pT2 (II): Tumor invades stromal connective tissue of the cervix. Myometrial Invasion: Invasion present: <10%, see note. Cervix: Stromal invasion. Ovaries Right: Negative. Left: Negative. Fallopian tube Right: Negative. Left: Negative. Serosa: Negative. Omentum: Negative. Regional Lymph Nodes: pN0: No regional lymph node metastasis. Pelvic lymph Nodes Number examined: 35. Number involved: 0. Para-aortic lymph Nodes Number examined: 7. Number involved: 0. Lymph-Vascular invasion: Absent. Note: The tumor is exophytic and the depth of myometrial invasion is difficult to evaluate. Most sections show minimal (<10%) invasion, but one area (slide R) shows tumor closer to the serosa. This likely represents an artifact of sectioning (ie. sections are taken from the lateral wall, next to the parametrium).

2170-08-08 19:12:00

ENGLISH

SINGLE

WHITE

M

[[21141052, Timestamp('2170-08-08 19:12:57'), '', 'NMED']]

[[{'Medications on Admission': ':\nCYCLOBENZAPRINE - 5 mg Tablet - 1 Tablet(s) by mouth up to 3\ntimes a day as needed for back spasm ** may cause drowsiness **\nLAMOTRIGINE [LAMICTAL XR] - 300 mg Tablet Extended Rel 24 hr - 1\nTablet(s) by mouth twice daily. NO SUBSTITUTION. - No\nSubstitution\nLAMOTRIGINE [LAMICTAL XR] - 100 mg Tablet Extended Rel 24 hr - 1\nTablet(s) by mouth daily at 9PM. (with 300mg for total daily \ndose\n300mg in AM, 400mg in ___ - No Substitution\nOMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)\nby mouth once daily\nSIMVASTATIN - 20 mg Tablet - 1 Tablet(s) by mouth daily\nZONISAMIDE [ZONEGRAN] - (Dose adjustment - no new Rx) - 100 mg\nCapsule - 3 Capsule(s) by mouth twice daily.\n\n2. lamotrigine 100 mg Tablet Extended Rel 24 hr Sig: Four (4) \nTablet Extended Rel 24 hr PO HS (at bedtime). \n3. zonisamide 100 mg Capsule Sig: Three (3) Capsule PO BID (2 \ntimes a day). \n4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) \nCapsule, Delayed Release(E.C.) PO DAILY (Daily). \n5. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY \n(Daily). \n6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). \n\n7. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: One (1) \nTablet PO DAILY (Daily). \n8. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) \nTablet PO BID (2 times a day). \n9. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) \nTablet PO BID (2 times a day). \n10. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable \nSig: One (1) Tablet, Chewable PO BID (2 times a day). \n11. Trileptal 150 mg Tablet Sig: One (1) Tablet PO twice a day: \nweek 1: 150mg BID\nweek 2: 150mg in am and 300mg in pm\nweek 3 and on: 300mg BID.\nDisp:*180 Tablet(s)* Refills:*4*', 'Brief Hospital Course': ':\nMr. ___ did not have any further seizures during his \nadmission.\nWe kept his home medications at the same dose, and we added \noxcarbazepine at 300mg BID. The next day however, his gait was \nslightly imbalanced, most likely as a medication side effect. \nTherefore we gave him instructions to decreased the \noxcarbazepine to 150mg BID and he can reiniate this at home. His \ngait improved throughout the day and we were able to discharge \nhim back to his assisted living facility, with instructions on \nthe oxcarbazepine dosing schedule.\n\nHis infectious and metabolic work ups returned negative, and we \nwere unable to determine the specific reason for his increased \nseizure frequency. Sleep deprivation is a possible culprit. The \nmedication levels are still pending at the time of discharge.\n\nHe will follow this schedule:\ntrileptal 150mg BID for the first week, 150/300mg for the second \nweek, then 300mg until he sees Dr. ___.\n\nDr. ___ the possibility of doing a pre-surgical \nevaluation during this admission. He requires more time to think \nabout this and therefore elected to do that at a later time.\n\n', 'Pertinent Results:': '\n___ 06:55PM URINE HOURS-RANDOM\n___ 06:55PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG \ncocaine-NEG amphetmn-NEG mthdone-NEG\n___ 03:40PM URINE COLOR-Yellow APPEAR-Hazy SP ___\n___ 03:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 \nLEUK-NEG\n___ 01:40PM GLUCOSE-99 UREA N-12 CREAT-1.1 SODIUM-139 \nPOTASSIUM-4.4 CHLORIDE-105 TOTAL CO2-25 ANION GAP-13\n___ 01:40PM estGFR-Using this\n___ 01:40PM ALT(SGPT)-32 AST(SGOT)-24 ALK PHOS-84 TOT \nBILI-0.3\n___ 01:40PM ALBUMIN-4.8 CALCIUM-9.0 PHOSPHATE-3.9 \nMAGNESIUM-2.0\n___ 01:40PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG \nbarbitrt-NEG tricyclic-NEG\n___ 01:40PM WBC-4.3 RBC-4.28* HGB-12.8* HCT-38.6* MCV-90 \nMCH-29.9 MCHC-33.1 RDW-12.4\n___ 01:40PM NEUTS-69.9 ___ MONOS-3.9 EOS-2.0 \nBASOS-0.5\n___ 01:40PM PLT COUNT-179\n\n', 'Physical Exam:|Physical': '\nGeneral: Drowsy, difficulty keeping eyes open. Mild asterixis. \nHEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in\noropharynx \nNeck: Supple, no carotid bruits appreciated. No nuchal rigidity.\nFull range of motion \nPulmonary: Lungs CTA bilaterally without R/R/W \nCardiac: RRR, nl. S1S2, no M/R/G noted \nAbdomen: soft, NT/ND, normoactive bowel sounds. \nExtremities: No C/C/E bilaterally, 2+ radial, DP pulses\nbilaterally. Calves SNT bilaterally. \nSkin: no rashes or lesions noted.\n\nNeurological examination: \n\n- Mental Status: \nPatient was drowsy and inattentive. It was difficult keeping his\neyes open to follow tasks but he was able to correctly follow\ncommands.\nORIENTATION - Alert, oriented x person, place (___) and\npartially time (not exact date and said ___ then corrected\nhimself to ___ \nSPEECH\nAble to relate history but unreliable. \nLanguage was fluent with intact repetition and comprehension but\nwas at times perseverative and would sometimes reverse dates and\nsome paraphasic errors (phonemically related). \nNormal prosody. Speech was not dysarthric. \nNAMING Pt. was able to name both high and low frequency objects.\nREADING - Able to read without difficulty\nATTENTION - Poorly attentive but still able to name ___ backward\nwithout difficulty. \nREGISTRATION and RECALL\nPt. was able to register 3 objects but recalled ___ even with\ncategory prompts at 5 minutes.\nCOMPREHENSION\nAble to follow both midline and appendicular commands \nThere was no evidence of apraxia or neglect. \n\n- Cranial Nerves: \nI: Olfaction not tested. \nII: PERRL 3 to 1.5mm and brisk. VFF to confrontation but\ncomplicated by drowsiness. Blinks to threat bilaterally.\nFunduscopic exam was not possible due to poor cooperation but \nhad\npresent red reflexes bilaterally.\nIII, IV, VI: EOMI without clear nystagmus but difficult due to\ndrowsiness. \nV: Facial sensation intact to light touch. Good power in muscles\nof mastication. \nVII: No facial weakness, facial musculature symmetric. \nVIII: Hearing intact to finger-rub bilaterally. \nIX, X: Palate elevates symmetrically. \nXI: ___ strength in trapezii and SCM bilaterally. \nXII: Tongue protrudes in midline with normal velocity movements.\n\n- Motor: Normal bulk with slight increased tone in LUE and\nincreased tone in LLE. No pronator drift bilaterally. \nMild bilateral postural tremor. Mild asterixis noted.\nFull power throughout.\n\n- Sensory: No deficits to light touch, cold sensation, vibratory\nsense, proprioception throughout in UE and ___. No extinction to\nDSS.\n\n- DTRs: \n BJ SJ TJ KJ AJ \nL ___ 3 3 \nR ___ 2 2\nReflexes brisker on LUE and pathologically brisk in LLE.\nThere was no evidence of sustained clonus.\n___ negative. \nPlantar response was flexor bilaterally.\n\n- Coordination: Bilateral intention tremor without ataxia. No\nclear dysmetria on FNF or HKS bilaterally.\n\n- Gait: Deferred.\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\nHPC: \n___ with a history of intractable seizures (under Dr ___\n___ Grade I olfactory groove meningioma s/p Cyberknife SRS\n___ to 1300 cGy and resection of meningioma (necrosis)\n___ who presents with increased seizure frequency.\n\nPatient was assessed post IV lorazepam and was very drowsy on\ninitial assessment although improved during the course of the\ninterview. He was generally appropriate although had a few\nparaphasic errors (phonemically related and when asked a \nspecific\ndate at times would reverse it) and reasonably inattentive.\n\nThe patient presented with 2 generalised tonic clonic seizures\nper EMS report to ED triage this morning (perhaps at around \nnoon)\nat his assisted living which were witnessed. These lasted ___\nminutes and had a space of a couple of minutes in between before\nself-terminating. No incontinence. He was seated when they\noccurred and per report, there was no head injury. He was\npost-ictal on arrival to the ED but knew that he had 2 seizures.\nOn prior speaking with the patient he had endorsed poor sleep \nand\nfatigue which the ED physicians felt was the likely precipitant\nand when he was able to do so, the patient had denied symptoms \nof\ninfection. Neurological examination exam was nonfocal on\nassessment by ED and he was due to be discharged after \ninfectious\nworkup (UA and CXR and labs) proved negative until he had an\nevent which likely represents a complex partial seizure at\nroughly 17:05 after which neurology were consulted for further\nmanagement.\n\nPrior to the episode he was walking and talking and was going to\narrange a ride then nurses noted ___ change in his mental status.\nThe details are all per nursing report and he was initially \nnoted\nto be staring off and "out of it" (not like a blank staring \nspell\nbut perhaps more inattentive) then started counting but in\nincorrect sequence. He was seemingly following commands but slow\nto react per nursing staff. He then started to pick at his\nclothing and objects and staring off ? automatism then became\nmore agitated. This all lasted perhaps ___ minutes although\ntiming is uncertain after which he was more agitated. He was \nseen\nby ED staff and given 1mg IV lorazepam at 17:11 after which he\nwas sedated.\n\nHe currently feels well, knows he had 2 seizures today (he\npreviously described these as "petit mal") but was very vague\nregarding responses. Hew as hiccuping (started after lorazepam)\nand this eventually stopped.\n\nOf note, he had a recent change back from lacosamide to\nzonisamide in ___ significant side effects from \nlacosamide\nand increased seizure frequency. Also, per previous\ndocumentation, he has had recurrence of seizures after going \nback\nto his original AED regimen although at that time, he felt that\nthe side effects were better and in ___ on review by Dr\n___ had wanted to see how he did over the next several\nmonths before considering another change in AEDs. At that \nmeeting\nhowever, she had discussed the possibility of admitting him for\nvideo-EEG monitoring, with a plan for epilepsy surgery but there\nwas no plan made at that time.\n\nPer previous documentation in ___ his typical seizure frequency\nused to be a seizure every ___ days although his more recent\nseizure frequency seems to be less than this and in ___ was at least 1 seizure per month. More recent frequency is\nsomewhat unclear but sounds like he has not had a seizure in\nseveral weeks. In regard to semiologies this is unclear (? GTC)\nbut has also had reports of episodes of "confusion" while \ntalking\non the phone to friends which were attributed to seizures. On \nhis\nlast admission in ___, he had complex partial seizure with\nhead turning to the right, his eyes were glazed, had rhythmic\nmovements of his right forearm, followed by a drumming motion on\nhis lap.\n\nOn neuro ROS, although sedated (he was reasonably attentive at\ntimes but the following responses are somewhat unreliable) the \npt\ndenied headache, loss of vision, blurred vision, diplopia,\ndysarthria, dysphagia, lightheadedness, vertigo, tinnitus or\nhearing difficulty. Denies difficulties producing or\ncomprehending speech although had some paraphasic errors and was\nsomewhat disorganised on assessment. Denied focal weakness,\nnumbness, parasthesiae. No bowel or bladder incontinence or\nretention. Denies difficulty with gait.\n\nAs above, to be taken somewhat unreliably, on general review of\nsystems, the pt denies recent fever or chills. No night sweats\nor recent weight loss or gain. Denies cough, shortness of \nbreath.\nDenies chest pain or tightness, palpitations. Denies nausea,\nvomiting, diarrhea, constipation or abdominal pain. No recent\nchange in bowel or bladder habits. No dysuria. Denies\narthralgias or myalgias.\n\nPast Medical History:\n- first probably GTCS about ___ years ago, noted to have \nmeningioma\nand had one convulsive seizure every several months (possible\nwith a lateralized onset to the left at times)\n- He was also tried on Keppra for one week but it was\ndiscontinued due to side effects on mood. He tolerated dilantin\nwell and is on since then.\n- admissions to ___ in ___, and was evaluated in detail,\nfollowed by Dr. ___ Dr. ___.\n- Cyberknife radiosurgery to the meningioma on ___ to 1300\ncGy at 75% isodose line,\n- admission to the Epilepsy Service for generalized\ntonic-clonic seizure from ___ to ___,\n- resection of a grade I meningioma from the inferior right\nfrontal brain by ___, M.D, in ___.\n- Has had about 4 episodes of passing out after the surgery \nafter\nabout 1 month of "seizure free post op"\n- The patient is now off steroids , off since end ___\n- he is on ativan taper and planned to taper off dilantin and to\ncontinue on zonegran monotherapy per notes.\n-Epilepsy Neurologists = (Dr ___ & Dr ___ frontal meningioma, diagnosed ___ years ago\n-Alcohol abuse, stopped ___ years ago, but recent binge on ___\n-Hyperlipidemia\n-Macular degeneration\n\nSocial History:\n___\nFamily History:\nHis parents are alive. His father has ___ disease. He \nhas 2 sisters and 2 brothers, and they are all healthy. His 2 \ndaugthers are healthy.\n\n', 'Chief Complaint:|Complaint:': '\nIncreased seizure frequency \n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nNo Known Allergies / Adverse Drug Reactions\n\n'}, '10180407-DS-21', 21, 'neurology']]

[['INDICATION: ___ male with seizure. Evaluate for evidence of\ninfection.\n\nCOMPARISON: ___.\n\nTECHNIQUE: PA and lateral chest radiograph.\n\nFINDINGS: The lungs are well expanded and clear. Cardiomediastinal and hilar\ncontours are unremarkable. There is no pleural effusion or pneumothorax.\n\nIMPRESSION: Unremarkable chest.\n', '10180407-RR-50', 50, 'pa and lateral chest radiograph.']]

[[21141052, Timestamp('2170-08-08 10:00:00'), Timestamp('2170-08-10 19:00:00'), 'MAIN', 'Omeprazole', '033530', '00093521193', '20mg Cap'], [21141052, Timestamp('2170-08-08 22:00:00'), Timestamp('2170-08-10 19:00:00'), 'MAIN', 'LaMICtal XR', '065252', '00173075600', '100 mg XR Tab'], [21141052, Timestamp('2170-08-08 21:00:00'), Timestamp('2170-08-10 19:00:00'), 'MAIN', 'Docusate Sodium', '003009', '00904224461', '100mg Capsule'], [21141052, Timestamp('2170-08-09 08:00:00'), Timestamp('2170-08-10 19:00:00'), 'MAIN', 'LaMICtal XR', '065252', '00173075600', '100 mg XR Tab'], [21141052, Timestamp('2170-08-08 21:00:00'), Timestamp('2170-08-10 19:00:00'), 'MAIN', 'Lorazepam', '003753', '00409198530', '2mg/mL Syringe'], [21141052, Timestamp('2170-08-08 20:00:00'), Timestamp('2170-08-10 19:00:00'), 'MAIN', 'Vitamin D', '019166', '10432017002', '400 Unit Tablet'], [21141052, Timestamp('2170-08-08 10:00:00'), Timestamp('2170-08-10 19:00:00'), 'MAIN', 'Simvastatin', '016577', '51079045420', '10mg Tablet'], [21141052, Timestamp('2170-08-08 20:00:00'), Timestamp('2170-08-10 19:00:00'), 'MAIN', 'Ferrous Sulfate', '011832', '00245005301', '325 mg Tablet'], [21141052, Timestamp('2170-08-08 10:00:00'), Timestamp('2170-08-10 19:00:00'), 'MAIN', 'Cyanocobalamin', '002341', '87701071218', '500 mcg Tab'], [21141052, Timestamp('2170-08-08 20:00:00'), Timestamp('2170-08-10 19:00:00'), 'MAIN', 'Calcium Carbonate', '002689', '66553000401', '500mg Tablet'], [21141052, Timestamp('2170-08-08 21:00:00'), Timestamp('2170-08-10 19:00:00'), 'MAIN', 'Sodium Chloride 0.9% Flush', '', '0', 'Syringe'], [21141052, Timestamp('2170-08-08 21:00:00'), Timestamp('2170-08-10 19:00:00'), 'MAIN', 'Senna', '019964', '00904516561', '1 Tablet'], [21141052, Timestamp('2170-08-08 20:00:00'), Timestamp('2170-08-10 19:00:00'), 'MAIN', 'Heparin', '006549', '63323026201', '5000 Units / mL- 1mL Vial'], [21141052, Timestamp('2170-08-08 20:00:00'), Timestamp('2170-08-10 19:00:00'), 'MAIN', 'Zonisamide', '045100', '68084018301', '100mg Capsule'], [21141052, Timestamp('2170-08-08 22:00:00'), Timestamp('2170-08-09 16:00:00'), 'MAIN', 'Lorazepam', '003757', '51079041720', '0.5mg Tablet'], [21141052, Timestamp('2170-08-08 10:00:00'), Timestamp('2170-08-10 19:00:00'), 'MAIN', 'Multivitamins', '002532', '00904053061', '1 Tablet']]

[]

['neurology']

[[50861, Timestamp('2170-08-09 05:45:00'), Timestamp('2170-08-09 06:30:00'), 'Alanine Aminotransferase (ALT)'], [50862, Timestamp('2170-08-09 05:45:00'), Timestamp('2170-08-09 06:30:00'), 'Albumin'], [50863, Timestamp('2170-08-09 05:45:00'), Timestamp('2170-08-09 06:30:00'), 'Alkaline Phosphatase'], [50868, Timestamp('2170-08-09 05:45:00'), Timestamp('2170-08-09 06:30:00'), 'Anion Gap'], [50878, Timestamp('2170-08-09 05:45:00'), Timestamp('2170-08-09 06:30:00'), 'Asparate Aminotransferase (AST)'], [50882, Timestamp('2170-08-09 05:45:00'), Timestamp('2170-08-09 06:30:00'), 'Bicarbonate'], [50885, Timestamp('2170-08-09 05:45:00'), Timestamp('2170-08-09 06:30:00'), 'Bilirubin, Total'], [50893, Timestamp('2170-08-09 05:45:00'), Timestamp('2170-08-09 06:30:00'), 'Calcium, Total'], [50902, Timestamp('2170-08-09 05:45:00'), Timestamp('2170-08-09 06:30:00'), 'Chloride'], [50912, Timestamp('2170-08-09 05:45:00'), Timestamp('2170-08-09 06:30:00'), 'Creatinine'], [50931, Timestamp('2170-08-09 05:45:00'), Timestamp('2170-08-09 06:30:00'), 'Glucose'], [50960, Timestamp('2170-08-09 05:45:00'), Timestamp('2170-08-09 06:30:00'), 'Magnesium'], [50970, Timestamp('2170-08-09 05:45:00'), Timestamp('2170-08-09 06:30:00'), 'Phosphate'], [50971, Timestamp('2170-08-09 05:45:00'), Timestamp('2170-08-09 06:30:00'), 'Potassium'], [50983, Timestamp('2170-08-09 05:45:00'), Timestamp('2170-08-09 06:30:00'), 'Sodium'], [50993, Timestamp('2170-08-09 05:45:00'), Timestamp('2170-08-09 14:39:00'), 'Thyroid Stimulating Hormone'], [51006, Timestamp('2170-08-09 05:45:00'), Timestamp('2170-08-09 06:30:00'), 'Urea Nitrogen'], [51237, Timestamp('2170-08-09 05:45:00'), Timestamp('2170-08-09 06:23:00'), 'INR(PT)'], [51274, Timestamp('2170-08-09 05:45:00'), Timestamp('2170-08-09 06:23:00'), 'PT'], [51275, Timestamp('2170-08-09 05:45:00'), Timestamp('2170-08-09 06:23:00'), 'PTT'], [51221, Timestamp('2170-08-09 05:45:00'), Timestamp('2170-08-09 06:03:00'), 'Hematocrit'], [51222, Timestamp('2170-08-09 05:45:00'), Timestamp('2170-08-09 06:03:00'), 'Hemoglobin'], [51248, Timestamp('2170-08-09 05:45:00'), Timestamp('2170-08-09 06:03:00'), 'MCH'], [51249, Timestamp('2170-08-09 05:45:00'), Timestamp('2170-08-09 06:03:00'), 'MCHC'], [51250, Timestamp('2170-08-09 05:45:00'), Timestamp('2170-08-09 06:03:00'), 'MCV'], [51265, Timestamp('2170-08-09 05:45:00'), Timestamp('2170-08-09 06:03:00'), 'Platelet Count'], [51277, Timestamp('2170-08-09 05:45:00'), Timestamp('2170-08-09 06:03:00'), 'RDW'], [51279, Timestamp('2170-08-09 05:45:00'), Timestamp('2170-08-09 06:03:00'), 'Red Blood Cells'], [51301, Timestamp('2170-08-09 05:45:00'), Timestamp('2170-08-09 06:03:00'), 'White Blood Cells']]

Question: A 56 M is admitted. He/she says he/she has Increased seizure frequency . History of illness: HPC: ___ with a history of intractable seizures (under Dr ___ ___ Grade I olfactory groove meningioma s/p Cyberknife SRS ___ to 1300 cGy and resection of meningioma (necrosis) ___ who presents with increased seizure frequency. Patient was assessed post IV lorazepam and was very drowsy on initial assessment although improved during the course of the interview. He was generally appropriate although had a few paraphasic errors (phonemically related and when asked a specific date at times would reverse it) and reasonably inattentive. The patient presented with 2 generalised tonic clonic seizures per EMS report to ED triage this morning (perhaps at around noon) at his assisted living which were witnessed. These lasted ___ minutes and had a space of a couple of minutes in between before self-terminating. No incontinence. He was seated when they occurred and per report, there was no head injury. He was post-ictal on arrival to the ED but knew that he had 2 seizures. On prior speaking with the patient he had endorsed poor sleep and fatigue which the ED physicians felt was the likely precipitant and when he was able to do so, the patient had denied symptoms of infection. Neurological examination exam was nonfocal on assessment by ED and he was due to be discharged after infectious workup (UA and CXR and labs) proved negative until he had an event which likely represents a complex partial seizure at roughly 17:05 after which neurology were consulted for further management. Prior to the episode he was walking and talking and was going to arrange a ride then nurses noted ___ change in his mental status. The details are all per nursing report and he was initially noted to be staring off and "out of it" (not like a blank staring spell but perhaps more inattentive) then started counting but in incorrect sequence. He was seemingly following commands but slow to react per nursing staff. He then started to pick at his clothing and objects and staring off ? automatism then became more agitated. This all lasted perhaps ___ minutes although timing is uncertain after which he was more agitated. He was seen by ED staff and given 1mg IV lorazepam at 17:11 after which he was sedated. He currently feels well, knows he had 2 seizures today (he previously described these as "petit mal") but was very vague regarding responses. Hew as hiccuping (started after lorazepam) and this eventually stopped. Of note, he had a recent change back from lacosamide to zonisamide in ___ significant side effects from lacosamide and increased seizure frequency. Also, per previous documentation, he has had recurrence of seizures after going back to his original AED regimen although at that time, he felt that the side effects were better and in ___ on review by Dr ___ had wanted to see how he did over the next several months before considering another change in AEDs. At that meeting however, she had discussed the possibility of admitting him for video-EEG monitoring, with a plan for epilepsy surgery but there was no plan made at that time. Per previous documentation in ___ his typical seizure frequency used to be a seizure every ___ days although his more recent seizure frequency seems to be less than this and in ___ was at least 1 seizure per month. More recent frequency is somewhat unclear but sounds like he has not had a seizure in several weeks. In regard to semiologies this is unclear (? GTC) but has also had reports of episodes of "confusion" while talking on the phone to friends which were attributed to seizures. On his last admission in ___, he had complex partial seizure with head turning to the right, his eyes were glazed, had rhythmic movements of his right forearm, followed by a drumming motion on his lap. On neuro ROS, although sedated (he was reasonably attentive at times but the following responses are somewhat unreliable) the pt denied headache, loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech although had some paraphasic errors and was somewhat disorganised on assessment. Denied focal weakness, numbness, parasthesiae. No bowel or bladder incontinence or retention. Denies difficulty with gait. As above, to be taken somewhat unreliably, on general review of systems, the pt denies recent fever or chills. No night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Past Medical History: - first probably GTCS about ___ years ago, noted to have meningioma and had one convulsive seizure every several months (possible with a lateralized onset to the left at times) - He was also tried on Keppra for one week but it was discontinued due to side effects on mood. He tolerated dilantin well and is on since then. - admissions to ___ in ___, and was evaluated in detail, followed by Dr. ___ Dr. ___. - Cyberknife radiosurgery to the meningioma on ___ to 1300 cGy at 75% isodose line, - admission to the Epilepsy Service for generalized tonic-clonic seizure from ___ to ___, - resection of a grade I meningioma from the inferior right frontal brain by ___, M.D, in ___. - Has had about 4 episodes of passing out after the surgery after about 1 month of "seizure free post op" - The patient is now off steroids , off since end ___ - he is on ativan taper and planned to taper off dilantin and to continue on zonegran monotherapy per notes. -Epilepsy Neurologists = (Dr ___ & Dr ___ frontal meningioma, diagnosed ___ years ago -Alcohol abuse, stopped ___ years ago, but recent binge on ___ -Hyperlipidemia -Macular degeneration Social History: ___ Family History: His parents are alive. His father has ___ disease. He has 2 sisters and 2 brothers, and they are all healthy. His 2 daugthers are healthy. Allergies: No Known Allergies / Adverse Drug Reactions What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Omeprazole LaMICtal XR Docusate Sodium LaMICtal XR Lorazepam Vitamin D Simvastatin Ferrous Sulfate Cyanocobalamin Calcium Carbonate Sodium Chloride 0.9% Flush Senna Heparin Zonisamide Lorazepam Multivitamins Target Lab Orders: Alanine Aminotransferase (ALT) Albumin Alkaline Phosphatase Anion Gap Asparate Aminotransferase (AST) Bicarbonate Bilirubin, Total Calcium, Total Chloride Creatinine Glucose Magnesium Phosphate Potassium Sodium Thyroid Stimulating Hormone Urea Nitrogen INR(PT) PT PTT Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : Mr. ___ did not have any further seizures during his admission. We kept his home medications at the same dose, and we added oxcarbazepine at 300mg BID. The next day however, his gait was slightly imbalanced, most likely as a medication side effect. Therefore we gave him instructions to decreased the oxcarbazepine to 150mg BID and he can reiniate this at home. His gait improved throughout the day and we were able to discharge him back to his assisted living facility, with instructions on the oxcarbazepine dosing schedule. His infectious and metabolic work ups returned negative, and we were unable to determine the specific reason for his increased seizure frequency. Sleep deprivation is a possible culprit. The medication levels are still pending at the time of discharge. He will follow this schedule: trileptal 150mg BID for the first week, 150/300mg for the second week, then 300mg until he sees Dr. ___. Dr. ___ the possibility of doing a pre-surgical evaluation during this admission. He requires more time to think about this and therefore elected to do that at a later time. Other Results: ___ 06:55PM URINE HOURS-RANDOM ___ 06:55PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG ___ 03:40PM URINE COLOR-Yellow APPEAR-Hazy SP ___ ___ 03:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 01:40PM GLUCOSE-99 UREA N-12 CREAT-1.1 SODIUM-139 POTASSIUM-4.4 CHLORIDE-105 TOTAL CO2-25 ANION GAP-13 ___ 01:40PM estGFR-Using this ___ 01:40PM ALT(SGPT)-32 AST(SGOT)-24 ALK PHOS-84 TOT BILI-0.3 ___ 01:40PM ALBUMIN-4.8 CALCIUM-9.0 PHOSPHATE-3.9 MAGNESIUM-2.0 ___ 01:40PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 01:40PM WBC-4.3 RBC-4.28* HGB-12.8* HCT-38.6* MCV-90 MCH-29.9 MCHC-33.1 RDW-12.4 ___ 01:40PM NEUTS-69.9 ___ MONOS-3.9 EOS-2.0 BASOS-0.5 ___ 01:40PM PLT COUNT-179

2168-11-07 20:39:00

ENGLISH

MARRIED

WHITE

F

[[22558993, Timestamp('2168-11-07 20:40:11'), '', 'NSURG']]

[[{'Medications on Admission': 'NIL', 'Brief Hospital Course': 'NIL', 'Pertinent Results:': '\nOSH CTS with 6 mm A1/AComm aneurysm ', 'Physical Exam:|Physical': '\nEXAM ON DISCHARGE: \nA&Ox3, L pupil 5mm irregular shaped (dart to eye injury), R \npupil 3->2. +right beating nystagmus while focusing at rest and \nlooking R. MAE ___. \n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\n___ year old female with PMH significant for HTN,\nhypothyroidism presented to ___ with visual\ndisturbances. Per medical records from ___, patient presented\nto ___ on ___ and was admitted for workup, CT/MRI\nBrain reportably negative and discharged the following day on\nAspirin 81mg with diagnosis of TIA. \n\nOn ___, patient was sitting on the couch watching TV and \nnoticed\nthat that the TV and objects on wall were moving, she was unable\nto focus. Per the patient, she had nausea at this time but not\nvomiting; this lasted approximately ___ minutes. Patient also\nnoted she was diaphoretic/clammy, unable to recall if any\nspecific cardiac complaints. During admission at ___,\nNeurology was consulted. EEG was completed that was normal per\nrecords as well as TEE. Per patient, she had carotid ultrasound\nthat was negative for stenosis however did not see report in\nrecords. CTA of Head was completed showing 6mm aneurysm arising\nfrom A1/ACOMM. Patient transferred to ___ Neurosurgery for\nfurther evaluation and treatment of aneurysm. \n\nPast Medical History:\nHTN\nHypothyrodism \nGlaucoma\nHLD\n\nSocial History:\n___\nFamily History:\ndenies immediate family history of vascular \nmalformation/aneurysm, states mother\'s aunt "had something" but \nunable to recall.\n\n', 'Chief Complaint:|Complaint:': '\nA1 aneurysm \n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nNo Known Allergies / Adverse Drug Reactions\n\n'}, '16182920-DS-11', 11, 'neurosurgery']]

[]

[[22558993, Timestamp('2168-11-07 21:00:00'), Timestamp('2168-11-09 15:00:00'), 'MAIN', 'Docusate Sodium', '003020', '57896042101', '100 mg Tablet'], [22558993, Timestamp('2168-11-07 23:00:00'), Timestamp('2168-11-09 15:00:00'), 'MAIN', 'Ondansetron', '061716', '00641607825', '2mg/mL-2mL'], [22558993, Timestamp('2168-11-07 21:00:00'), Timestamp('2168-11-09 15:00:00'), 'MAIN', 'OxyCODONE (Immediate Release)', '004224', '66689040150', '5mg/5mL Cup'], [22558993, Timestamp('2168-11-08 08:00:00'), Timestamp('2168-11-09 15:00:00'), 'MAIN', 'Lisinopril', '000390', '51079098220', '10mg Tablet'], [22558993, Timestamp('2168-11-07 21:00:00'), Timestamp('2168-11-09 15:00:00'), 'MAIN', 'Senna', '019964', '00904516561', '8.6 mg Tablet'], [22558993, Timestamp('2168-11-07 21:00:00'), Timestamp('2168-11-09 15:00:00'), 'MAIN', 'Docusate Sodium', '003009', '00904224461', '100mg Capsule'], [22558993, Timestamp('2168-11-08 06:00:00'), Timestamp('2168-11-09 15:00:00'), 'MAIN', 'Metoclopramide', '005229', '00703450204', '5mg/mL-2mL Vial'], [22558993, Timestamp('2168-11-08 08:00:00'), Timestamp('2168-11-09 15:00:00'), 'MAIN', 'Levothyroxine Sodium', '006651', '00074662411', '100mcg Tablet'], [22558993, Timestamp('2168-11-07 21:00:00'), Timestamp('2168-11-09 15:00:00'), 'MAIN', 'Heparin', '006549', '63323026201', '5000 Units / mL- 1mL Vial'], [22558993, Timestamp('2168-11-07 21:00:00'), Timestamp('2168-11-09 15:00:00'), 'MAIN', 'Sodium Chloride 0.9% Flush', '', '0', '10 mL Syringe'], [22558993, Timestamp('2168-11-07 21:00:00'), Timestamp('2168-11-09 15:00:00'), 'MAIN', 'Acetaminophen', '004489', '00904198261', '325mg Tablet'], [22558993, Timestamp('2168-11-08 20:00:00'), Timestamp('2168-11-09 15:00:00'), 'MAIN', 'Atorvastatin', '029969', '51079021020', '40mg Tablet'], [22558993, Timestamp('2168-11-07 21:00:00'), Timestamp('2168-11-09 15:00:00'), 'MAIN', 'Senna', '002922', '57896045208', '8.6 mg / 4.9 mL Syringe'], [22558993, Timestamp('2168-11-07 21:00:00'), Timestamp('2168-11-09 15:00:00'), 'MAIN', 'Bisacodyl', '002947', '00536338101', '5 mg Tab'], [22558993, Timestamp('2168-11-07 21:00:00'), Timestamp('2168-11-09 15:00:00'), 'MAIN', 'OxyCODONE (Immediate Release)', '004225', '00406055262', '5mg Tablet'], [22558993, Timestamp('2168-11-08 17:00:00'), Timestamp('2168-11-09 15:00:00'), 'MAIN', 'Meclizine', '004731', '51079008920', '12.5 mg Tab'], [22558993, Timestamp('2168-11-07 21:00:00'), Timestamp('2168-11-09 15:00:00'), 'MAIN', 'Acetaminophen', '065758', '00121065721', '650mg UD Cup']]

[]

['neurosurgery']

[[51221, Timestamp('2168-11-08 04:50:00'), Timestamp('2168-11-08 06:24:00'), 'Hematocrit'], [51222, Timestamp('2168-11-08 04:50:00'), Timestamp('2168-11-08 06:24:00'), 'Hemoglobin'], [51248, Timestamp('2168-11-08 04:50:00'), Timestamp('2168-11-08 06:24:00'), 'MCH'], [51249, Timestamp('2168-11-08 04:50:00'), Timestamp('2168-11-08 06:24:00'), 'MCHC'], [51250, Timestamp('2168-11-08 04:50:00'), Timestamp('2168-11-08 06:24:00'), 'MCV'], [51265, Timestamp('2168-11-08 04:50:00'), Timestamp('2168-11-08 06:24:00'), 'Platelet Count'], [51277, Timestamp('2168-11-08 04:50:00'), Timestamp('2168-11-08 06:24:00'), 'RDW'], [51279, Timestamp('2168-11-08 04:50:00'), Timestamp('2168-11-08 06:24:00'), 'Red Blood Cells'], [51301, Timestamp('2168-11-08 04:50:00'), Timestamp('2168-11-08 06:24:00'), 'White Blood Cells'], [52172, Timestamp('2168-11-08 04:50:00'), Timestamp('2168-11-08 06:24:00'), 'RDW-SD'], [51237, Timestamp('2168-11-08 04:50:00'), Timestamp('2168-11-08 06:25:00'), 'INR(PT)'], [51274, Timestamp('2168-11-08 04:50:00'), Timestamp('2168-11-08 06:25:00'), 'PT'], [51275, Timestamp('2168-11-08 04:50:00'), Timestamp('2168-11-08 06:25:00'), 'PTT'], [50868, Timestamp('2168-11-08 04:50:00'), Timestamp('2168-11-08 06:46:00'), 'Anion Gap'], [50882, Timestamp('2168-11-08 04:50:00'), Timestamp('2168-11-08 06:46:00'), 'Bicarbonate'], [50893, Timestamp('2168-11-08 04:50:00'), Timestamp('2168-11-08 06:46:00'), 'Calcium, Total'], [50902, Timestamp('2168-11-08 04:50:00'), Timestamp('2168-11-08 06:46:00'), 'Chloride'], [50912, Timestamp('2168-11-08 04:50:00'), Timestamp('2168-11-08 06:46:00'), 'Creatinine'], [50920, Timestamp('2168-11-08 04:50:00'), Timestamp('2168-11-08 06:46:00'), 'Estimated GFR (MDRD equation)'], [50931, Timestamp('2168-11-08 04:50:00'), Timestamp('2168-11-08 06:46:00'), 'Glucose'], [50934, Timestamp('2168-11-08 04:50:00'), Timestamp('2168-11-08 06:46:00'), 'H'], [50947, Timestamp('2168-11-08 04:50:00'), Timestamp('2168-11-08 06:46:00'), 'I'], [50960, Timestamp('2168-11-08 04:50:00'), Timestamp('2168-11-08 06:46:00'), 'Magnesium'], [50970, Timestamp('2168-11-08 04:50:00'), Timestamp('2168-11-08 06:46:00'), 'Phosphate'], [50971, Timestamp('2168-11-08 04:50:00'), Timestamp('2168-11-08 06:46:00'), 'Potassium'], [50983, Timestamp('2168-11-08 04:50:00'), Timestamp('2168-11-08 06:46:00'), 'Sodium'], [51006, Timestamp('2168-11-08 04:50:00'), Timestamp('2168-11-08 06:46:00'), 'Urea Nitrogen'], [51678, Timestamp('2168-11-08 04:50:00'), Timestamp('2168-11-08 06:46:00'), 'L']]

Question: A 53 F is admitted. He/she says he/she has A1 aneurysm . History of illness: ___ year old female with PMH significant for HTN, hypothyroidism presented to ___ with visual disturbances. Per medical records from ___, patient presented to ___ on ___ and was admitted for workup, CT/MRI Brain reportably negative and discharged the following day on Aspirin 81mg with diagnosis of TIA. On ___, patient was sitting on the couch watching TV and noticed that that the TV and objects on wall were moving, she was unable to focus. Per the patient, she had nausea at this time but not vomiting; this lasted approximately ___ minutes. Patient also noted she was diaphoretic/clammy, unable to recall if any specific cardiac complaints. During admission at ___, Neurology was consulted. EEG was completed that was normal per records as well as TEE. Per patient, she had carotid ultrasound that was negative for stenosis however did not see report in records. CTA of Head was completed showing 6mm aneurysm arising from A1/ACOMM. Patient transferred to ___ Neurosurgery for further evaluation and treatment of aneurysm. Past Medical History: HTN Hypothyrodism Glaucoma HLD Social History: ___ Family History: denies immediate family history of vascular malformation/aneurysm, states mother's aunt "had something" but unable to recall. Allergies: No Known Allergies / Adverse Drug Reactions What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Docusate Sodium Ondansetron OxyCODONE (Immediate Release) Lisinopril Senna Docusate Sodium Metoclopramide Levothyroxine Sodium Heparin Sodium Chloride 0.9% Flush Acetaminophen Atorvastatin Senna Bisacodyl OxyCODONE (Immediate Release) Meclizine Acetaminophen Target Lab Orders: Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells RDW-SD INR(PT) PT PTT Anion Gap Bicarbonate Calcium, Total Chloride Creatinine Estimated GFR (MDRD equation) Glucose H I Magnesium Phosphate Potassium Sodium Urea Nitrogen L Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: NIL Other Results: OSH CTS with 6 mm A1/AComm aneurysm

2146-12-19 00:00:00

ENGLISH

MARRIED

WHITE

F

[[20453089, Timestamp('2146-12-19 05:19:54'), '', 'PSURG']]

[[{'Medications on Admission': ':\nThe Preadmission Medication list is accurate and complete.\n1. Anastrozole 1 mg PO DAILY \n2. Escitalopram Oxalate 5 mg PO BID \n3. MetFORMIN (Glucophage) 1000 mg PO BID \n\nFacility:\n___', 'Brief Hospital Course': ':\nThe patient underwent bilateral breast reconstruction with ___ \nflaps on ___. She tolerated the procedure well and there \nwere no adverse intraoperative events. She was monitored on the \nsurgical floor postoperatively. She remained hemodynamically \nstable. Her flaps remained well perfused. She was advanced per \n___ protocol. She is now tolerating a regular diet, ambulating \nindependently and her pain is adequately controlled with oral \npain medications. She is stable for discharge home today. \n\nOpioid analgesic to be initiated today for indication of acute \npost-surgical pain. Non-opioid alternatives were considered and \ndeemed not to be appropriate options.\n\nImmediate-release opioid prescribed.\n\nRisks of opioid dependence, addition and misuse were reviewed \nwith the patient. Patient advised that she can fill a lesser \namount than prescribed if desired.\n\nOnline Prescription Drug Monitoring Program was queried and no \naberrant behavior was noted.\n\nEducation was provided regarding the risks associated with \nopiates as well as the option to fill the prescription in a \nlesser dose. \n\n', 'Pertinent Results:': '\n___ 03:58AM BLOOD WBC-10.5* RBC-3.74* Hgb-12.4 Hct-36.9 \nMCV-99* MCH-33.2* MCHC-33.6 RDW-13.8 RDWSD-50.0* Plt ___\n\n', 'Physical Exam:|Physical': '\nGen: Well-appearing F in no acute distress\nHEENT: Sclerae anicteric\nCV: RRR\nPulm: No increased work of breathing\nBreasts: Bilateral reconstructed breasts soft, flaps with good \ncolor and cap refill, dopplerable signals bilaterally, incisions \nwithout erythema or drainage, ___ drains x 2 to bulb suction \ndraining serosanguinous fluid\nAbdomen: Soft, non-distended; lower abdominal incision without \nerythema or drainage; umbilicus viable; ___ drains x 2 to bulb \nsuction draining serosanguinous fluid\nExtremities: Warm, well-perfused\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\n___ yo F with history of right breast cancer s/p bilateral \nmastectomies and radiation presented ___ for elective \ndelayed reconstruction with bilateral ___ flaps. \n\nPast Medical History:\nPCOS\n\nSocial History:\n___\nFamily History:\n+breast ca. (ATM/VUS BRCA2) \n\n', 'Chief Complaint:|Complaint:': '\nHistory of right breast cancer s/p bilateral mastectomies\n\n', 'Attending:': ' ___\n\n', 'Allergies:': ' \nNo Known Allergies / Adverse Drug Reactions\n\n'}, '17835350-DS-12', 12, 'plastic']]

[]

[[20453089, Timestamp('2146-12-20 08:00:00'), Timestamp('2146-12-23 19:00:00'), 'MAIN', 'Aspirin', '004380', '66553000201', '81mg Tab']]

[['0HRV077', 10, 1, Timestamp('2146-12-19 00:00:00'), 'Replacement of Bilateral Breast using Deep Inferior Epigastric Artery Perforator Flap, Open Approach']]

['plastic']

[[51221, Timestamp('2146-12-20 03:58:00'), Timestamp('2146-12-20 04:19:00'), 'Hematocrit'], [51222, Timestamp('2146-12-20 03:58:00'), Timestamp('2146-12-20 04:19:00'), 'Hemoglobin'], [51248, Timestamp('2146-12-20 03:58:00'), Timestamp('2146-12-20 04:19:00'), 'MCH'], [51249, Timestamp('2146-12-20 03:58:00'), Timestamp('2146-12-20 04:19:00'), 'MCHC'], [51250, Timestamp('2146-12-20 03:58:00'), Timestamp('2146-12-20 04:19:00'), 'MCV'], [51265, Timestamp('2146-12-20 03:58:00'), Timestamp('2146-12-20 04:19:00'), 'Platelet Count'], [51277, Timestamp('2146-12-20 03:58:00'), Timestamp('2146-12-20 04:19:00'), 'RDW'], [51279, Timestamp('2146-12-20 03:58:00'), Timestamp('2146-12-20 04:19:00'), 'Red Blood Cells'], [51301, Timestamp('2146-12-20 03:58:00'), Timestamp('2146-12-20 04:19:00'), 'White Blood Cells'], [52172, Timestamp('2146-12-20 03:58:00'), Timestamp('2146-12-20 04:19:00'), 'RDW-SD']]

Question: A 46 F is admitted. He/she says he/she has History of right breast cancer s/p bilateral mastectomies . History of illness: ___ yo F with history of right breast cancer s/p bilateral mastectomies and radiation presented ___ for elective delayed reconstruction with bilateral ___ flaps. Past Medical History: PCOS Social History: ___ Family History: +breast ca. (ATM/VUS BRCA2) Allergies: No Known Allergies / Adverse Drug Reactions What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Aspirin Target Lab Orders: Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells RDW-SD Target Procedures: Replacement of Bilateral Breast using Deep Inferior Epigastric Artery Perforator Flap, Open Approach DOCTOR'S NOTE Hospital Notes: : The patient underwent bilateral breast reconstruction with ___ flaps on ___. She tolerated the procedure well and there were no adverse intraoperative events. She was monitored on the surgical floor postoperatively. She remained hemodynamically stable. Her flaps remained well perfused. She was advanced per ___ protocol. She is now tolerating a regular diet, ambulating independently and her pain is adequately controlled with oral pain medications. She is stable for discharge home today. Opioid analgesic to be initiated today for indication of acute post-surgical pain. Non-opioid alternatives were considered and deemed not to be appropriate options. Immediate-release opioid prescribed. Risks of opioid dependence, addition and misuse were reviewed with the patient. Patient advised that she can fill a lesser amount than prescribed if desired. Online Prescription Drug Monitoring Program was queried and no aberrant behavior was noted. Education was provided regarding the risks associated with opiates as well as the option to fill the prescription in a lesser dose. Other Results: ___ 03:58AM BLOOD WBC-10.5* RBC-3.74* Hgb-12.4 Hct-36.9 MCV-99* MCH-33.2* MCHC-33.6 RDW-13.8 RDWSD-50.0* Plt ___

2135-07-08 04:44:00

ENGLISH

WIDOWED

WHITE

F

[[26875190, Timestamp('2135-07-08 04:46:48'), '', 'SURG']]

[[{'Medications on Admission': ':\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Metolazone 5 mg PO DAILY \n2. Furosemide 120 mg PO DAILY \n3. Levothyroxine Sodium 150 mcg PO DAILY \n4. TraZODone 25 mg PO QHS \n5. OLANZapine 2.5 mg PO DAILY \n6. Sertraline 75 mg PO DAILY \n7. Metoprolol Succinate XL 50 mg PO DAILY \n8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY \n9. Gabapentin 300 mg PO BID \n10. Albuterol 0.083% Neb Soln 1 NEB IH TID \n\nFacility:\n___', 'Brief Hospital Course': ':\nMs. ___ is an ___ yo F with past medical history significant for \nAlzheimers dementia presented to the emergency department on \n___ via EMS after being found down on the ground in her \nnursing home. She was conscious and moving all extremities. Exam \nwas limited due to her dementia history but endorsed a head ache \nand left sided chest pain. Trauma evaluation was negative for \nacute injury. Her labs were notable for a white blood cell count \nof 14.2 and serum creatinine of 2.3 (.97 on ___. CT scan \nwas concerning for diverticulosis, a 6.3 cm enterouterine \nfistula with endometrial cavity distended with air and fluid and \nassociated left hydroureter and calictasis. She was admitted to \nthe Acute Care Surgery Service, started on IV antibiotics and \nadmitted to the surgical floor for further management.\n\nOn HD1 after discussion of risk and benefit with the family and \nconsultation with the OB/GYN team, non-operative management was \ndetermined the appropriate option for the patient. On HD2 she \nwas taken to interventional radiology for placement of an \n___ pigtail catheter into the collection. Samples were sent \nfor microbiology evaluation. She tolerated the procedure well. \nShe remained afebrile and her white blood cell count trended \ndown to 9.6. On HD3 her diet was advanced to regular which she \ntolerated well. Her white blood cell count continued to trend \ndown to 8.4. Her foley catheter was removed and she voided \nspontaneously without difficulty. Her creatinine trended down to \n0.7. \n\nShe was seen and evaluated by physical therapy who recommended \nshe return to her facility with ___ supervision and skilled \nnursing care. \n\nAt the time of discharge, the patient was doing well, afebrile \nwith stable vital signs. The patient was tolerating a regular \ndiet, out of bed with assist, voiding (incontinent) without \nassistance, and pain was well controlled. The patient was \ndischarged back to her nursing home. The patient and family \nreceived discharge teaching and follow-up instructions with \nunderstanding verbalized and agreement with the discharge plan.\n\n', 'Pertinent Results:': '\n___ 05:40AM BLOOD WBC-8.4 RBC-3.79* Hgb-10.9* Hct-35.2 \nMCV-93 MCH-28.8 MCHC-31.0* RDW-13.2 RDWSD-44.9 Plt ___\n___ 06:00AM BLOOD WBC-9.6 RBC-3.69* Hgb-11.0* Hct-35.9 \nMCV-97 MCH-29.8 MCHC-30.6* RDW-13.5 RDWSD-47.9* Plt ___\n___ 01:00PM BLOOD WBC-13.8* RBC-3.58* Hgb-10.7* Hct-32.8* \nMCV-92 MCH-29.9 MCHC-32.6 RDW-13.2 RDWSD-45.3 Plt ___\n___ 08:40PM BLOOD WBC-14.2* RBC-3.47* Hgb-10.2* Hct-32.0* \nMCV-92 MCH-29.4 MCHC-31.9* RDW-13.4 RDWSD-45.6 Plt ___\n___ 08:40PM BLOOD Neuts-83.8* Lymphs-8.0* Monos-6.3 \nEos-0.8* Baso-0.2 NRBC-0.1* Im ___ AbsNeut-11.90* \nAbsLymp-1.13* AbsMono-0.90* AbsEos-0.12 AbsBaso-0.03\n___ 08:40PM BLOOD ___ PTT-26.8 ___\n___ 05:40AM BLOOD Glucose-97 UreaN-16 Creat-0.7 Na-138 \nK-3.2* Cl-96 HCO3-30 AnGap-15\n___ 09:20PM BLOOD Glucose-110* UreaN-19 Creat-0.9 Na-135 \nK-2.8* Cl-94* HCO3-31 AnGap-13\n___ 06:00AM BLOOD Glucose-115* UreaN-25* Creat-0.9 Na-134 \nK-3.0* Cl-90* HCO3-30 AnGap-17\n___ 01:00PM BLOOD Glucose-117* UreaN-32* Creat-1.3* Na-131* \nK-3.2* Cl-86* HCO3-33* AnGap-15\n___ 08:40PM BLOOD Glucose-120* UreaN-45* Creat-2.3* Na-125* \nK-3.3 Cl-80* HCO3-35* AnGap-13\n___ 05:40AM BLOOD Calcium-9.0 Phos-1.9* Mg-1.6\n___ 09:20PM BLOOD Calcium-9.0 Phos-2.2* Mg-1.8\n___ 06:00AM BLOOD Calcium-9.3 Phos-2.6* Mg-2.8*\n___ 01:00PM BLOOD Calcium-9.2 Phos-3.0 Mg-1.6\n___ 08:49PM BLOOD Lactate-1.1\n\n___ CT C-spine:\n1. No fracture is identified. \n2. Moderate to severe degenerative changes of the cervical spine \nwith fusion of CT wall and C3. Multilevel mild subluxations are \nlikely degenerative in etiology. \n\n___ CT Head:\nNo acute intracranial process.\n\n___ CT Chest:\n1. 6.3-cm abscess in the mid pelvis with apparent fistulous \ncommunication with the small bowel and uterus likely due to \nperforated sigmoid diverticulitis, in the setting of extensive \nsigmoid diverticulosis. If further delineation of the fistulous \ncommunication is needed, consider repeat CT with oral and rectal \ncontrast for improved evaluation or non-contrast pelvic MRI. \n2. Endometrial cavity is distended with air and fluid as a \nresult of the \nfistulous communication with the pelvic abscess. \n3. Mild left hydroureter and caliectasis as a result of the \ndistal left ureter appearing involved by the pelvic inflammation \nand perhaps compressed by the enlarged uterus. \n4. No acute injury or acute fracture is identified. \n\n', 'Physical Exam:|Physical': '\nAdmission Physical Exam:\nVitals: 97.7 70 137/77 18 94%RA \nGEN: confused, A&Ox0, calm, occasionally responds to questions\nappropriately \nHEENT: No scleral icterus, mucus membranes somewhat dry\nCV: RRR\nPULM: Clear, no respiratory distress, comfortable on RA\nABD: Soft, nondistended, nontender, no rebound or guarding,\nreducible umbilical hernia, paramedian scar noted\nExt: No CCE\n\nDischarge Physical Exam:\nVS: 97.6 PO 165/61 65 18 98 RA \nGen: A&O, confused, baseline dementia\nCV: HRR\nPulm: LS ctab\nAbd: Soft, NT/ND. ___ drain with purulent material\nExt: No edema\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': "\nMs. ___ is an ___ year old female with a history Alzheimer's \ndementia status post unwitnessed fall at nursing home, found \ndown on ground. Patient's dementia is advanced and she is unable \nto provide a history of review of systems though she denies pain \nat this time. History derived from records which are sparse. \nThere is no care giver available at this time. Per report to ED \nby nursing home, patient has been 'having malaise for the last 3 \ndays and not taking her medications. No reports of vomiting or \nchange in BMs or fevers.' On presentation, pan-scan revealed no \nacute traumatic injury, but did note diverticulosis, a 6.3cm \nabscess in the mid pelvis, and what appears to be an\nenterouterine fistula with endometrial cavity distended with air \nand fluid and associated left hydroureter and caliectasis. She \nis afebrile but her WBC is 14.2. Her serum Cre is 2.3. Last Cre \non ___ was 0.97 at ___. Pelvic exam by ED did \nnot reveal stool in the vagina and she has no gross stool per \nvagina at time of exam. A foley catheter was placed in the ED \nand her UA\nwas negative. She received cipro and flagyl in the ED.\n\nPast Medical History:\nPast medical history:\nALZHEIMER'S DEMENTIA\nCHF\nAFIB\nSPINAL STENOSIS\nHYPERTENSION\nMACULAR DEGENERATION\nGENERALIZED ANXIETY DISORDER\nDEPRESSION\nNEUROPATHY\nHYPOTHYROIDISM\n\nSocial History:\n___\nFamily History:\nDementia in her siblings\n\n", 'Chief Complaint:|Complaint:': '\nMalaise for the previous 3 days\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \naspirin\n\n'}, '13474585-DS-2', 2, 'surgery']]

[["EXAMINATION:\nCT-guided pelvic fluid collection aspiration and drainage\n\nINDICATION: ___ w/ dementia s/p fall, incidentally found to have\nenterouterine fistula on CT // needs drainage of pelvic abscess\n\nCOMPARISON: ___ chest, abdomen, and pelvis\n\nPROCEDURE: CT-guided drainage of pelvic fluid collection.\n\nOPERATORS: Dr. ___, radiology trainee and Dr. ___ ,\nattending radiologist. Dr. ___ personally supervised the trainee\nduring the key components of the procedure and reviewed and agrees with the\ntrainee's findings.\n\nTECHNIQUE: The risks, benefits, and alternatives of the procedure were\nexplained to the patient. After a detailed discussion, informed written\nconsent was obtained. A pre-procedure timeout using three patient identifiers\nwas performed per ___ protocol.\n\nThe patient was placed in a supine position on the CT scan table. Limited\npreprocedure CT scan was performed to localize the collection. Based on the\nCT findings an appropriate skin entry site for the drain placement was chosen.\nThe site was marked. Local anesthesia was administered with 1% Lidocaine\nsolution.\n\nUsing intermittent CT fluoroscopic guidance, an 18-G ___ needle was\ninserted into the collection. A sample of fluid was aspirated, confirming\nneedle position within the collection. 0.038 ___ wire was placed through\nthe needle and needle was removed. This was followed by placement of ___\nExodus pigtail catheter into the collection. The metal stiffener and the wire\nwere removed. The pigtail was deployed. The position of the pigtail was\nconfirmed within the collection via CT fluoroscopy.\n\nApproximately 50 cc of purulent fluid was aspirated with a sample sent for\nmicrobiology evaluation. The catheter was secured by a StatLock. The catheter\nwas attached to suction bulb. Sterile dressing was applied.\n\nThe procedure was tolerated well, and there were no immediate post-procedural\ncomplications.\n\nDOSE: Acquisition sequence:\n 1) Spiral Acquisition 8.3 s, 25.4 cm; CTDIvol = 17.3 mGy (Body) DLP = 418.1\nmGy-cm.\n 2) Stationary Acquisition 10.5 s, 1.4 cm; CTDIvol = 109.1 mGy (Body) DLP =\n157.1 mGy-cm.\n Total DLP (Body) = 587 mGy-cm.\n\nSEDATION: Moderate sedation was provided by administering divided doses of 0\nmg Versed and 70 prior mcg fentanyl throughout the total intra-service time of\n30 minutes during which patient's hemodynamic parameters were continuously\nmonitored by an independent trained radiology nurse.\n\nFINDINGS: \n\nThe pelvic fluid collection is similar in size compared to ___\nmeasuring up to 5.1 cm and containing an air-fluid level. There is extensive\nsigmoid diverticulosis. The suspected enterouterine fistula is poorly\nevaluated on this study and was better seen on the contrast enhanced CT of the\nabdomen and pelvis.\n\nIMPRESSION: \n\nSuccessful CT-guided placement of an ___ pigtail catheter into the\ncollection. Samples were sent for microbiology evaluation.\n", '13474585-RR-5', 5, 'the risks, benefits, and alternatives of the procedure were\nexplained to the patient. after a detailed discussion, informed written\nconsent was obtained. a pre-procedure timeout using three patient identifiers\nwas performed per ___ protocol.']]

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[['0W9J30Z', 10, 1, Timestamp('2135-07-09 00:00:00'), 'Drainage of Pelvic Cavity with Drainage Device, Percutaneous Approach']]

['surgery']

[[51237, Timestamp('2135-07-07 20:40:00'), Timestamp('2135-07-07 21:14:00'), 'INR(PT)'], [51274, Timestamp('2135-07-07 20:40:00'), Timestamp('2135-07-07 21:14:00'), 'PT'], [51275, Timestamp('2135-07-07 20:40:00'), Timestamp('2135-07-07 21:14:00'), 'PTT'], [50868, Timestamp('2135-07-07 20:40:00'), Timestamp('2135-07-07 21:19:00'), 'Anion Gap'], [50882, Timestamp('2135-07-07 20:40:00'), Timestamp('2135-07-07 21:19:00'), 'Bicarbonate'], [50902, Timestamp('2135-07-07 20:40:00'), Timestamp('2135-07-07 21:19:00'), 'Chloride'], [50912, Timestamp('2135-07-07 20:40:00'), Timestamp('2135-07-07 21:19:00'), 'Creatinine'], [50920, Timestamp('2135-07-07 20:40:00'), Timestamp('2135-07-07 21:19:00'), 'Estimated GFR (MDRD equation)'], [50931, Timestamp('2135-07-07 20:40:00'), Timestamp('2135-07-07 21:19:00'), 'Glucose'], [50934, Timestamp('2135-07-07 20:40:00'), Timestamp('2135-07-07 21:19:00'), 'H'], [50947, Timestamp('2135-07-07 20:40:00'), Timestamp('2135-07-07 21:19:00'), 'I'], [50971, Timestamp('2135-07-07 20:40:00'), Timestamp('2135-07-07 21:19:00'), 'Potassium'], [50983, Timestamp('2135-07-07 20:40:00'), Timestamp('2135-07-07 21:19:00'), 'Sodium'], [51006, Timestamp('2135-07-07 20:40:00'), Timestamp('2135-07-07 21:19:00'), 'Urea Nitrogen'], [51678, Timestamp('2135-07-07 20:40:00'), Timestamp('2135-07-07 21:19:00'), 'L'], [50955, Timestamp('2135-07-07 20:40:00'), NaT, 'Light Green Top Hold'], [51133, Timestamp('2135-07-07 20:40:00'), Timestamp('2135-07-07 21:03:00'), 'Absolute Lymphocyte Count'], [51146, Timestamp('2135-07-07 20:40:00'), Timestamp('2135-07-07 21:03:00'), 'Basophils'], [51200, Timestamp('2135-07-07 20:40:00'), Timestamp('2135-07-07 21:03:00'), 'Eosinophils'], [51221, Timestamp('2135-07-07 20:40:00'), Timestamp('2135-07-07 21:03:00'), 'Hematocrit'], [51222, Timestamp('2135-07-07 20:40:00'), Timestamp('2135-07-07 21:03:00'), 'Hemoglobin'], [51244, Timestamp('2135-07-07 20:40:00'), Timestamp('2135-07-07 21:03:00'), 'Lymphocytes'], [51248, Timestamp('2135-07-07 20:40:00'), Timestamp('2135-07-07 21:03:00'), 'MCH'], [51249, Timestamp('2135-07-07 20:40:00'), Timestamp('2135-07-07 21:03:00'), 'MCHC'], [51250, Timestamp('2135-07-07 20:40:00'), Timestamp('2135-07-07 21:03:00'), 'MCV'], [51254, Timestamp('2135-07-07 20:40:00'), Timestamp('2135-07-07 21:03:00'), 'Monocytes'], [51256, Timestamp('2135-07-07 20:40:00'), Timestamp('2135-07-07 21:03:00'), 'Neutrophils'], [51257, Timestamp('2135-07-07 20:40:00'), Timestamp('2135-07-07 21:03:00'), 'Nucleated Red Cells'], [51265, Timestamp('2135-07-07 20:40:00'), Timestamp('2135-07-07 21:03:00'), 'Platelet Count'], [51277, Timestamp('2135-07-07 20:40:00'), Timestamp('2135-07-07 21:03:00'), 'RDW'], [51279, Timestamp('2135-07-07 20:40:00'), Timestamp('2135-07-07 21:03:00'), 'Red Blood Cells'], [51301, Timestamp('2135-07-07 20:40:00'), Timestamp('2135-07-07 21:03:00'), 'White Blood Cells'], [52069, Timestamp('2135-07-07 20:40:00'), Timestamp('2135-07-07 21:03:00'), 'Absolute Basophil Count'], [52073, Timestamp('2135-07-07 20:40:00'), Timestamp('2135-07-07 21:03:00'), 'Absolute Eosinophil Count'], [52074, Timestamp('2135-07-07 20:40:00'), Timestamp('2135-07-07 21:03:00'), 'Absolute Monocyte Count'], [52075, Timestamp('2135-07-07 20:40:00'), Timestamp('2135-07-07 21:03:00'), 'Absolute Neutrophil Count'], [52135, Timestamp('2135-07-07 20:40:00'), Timestamp('2135-07-07 21:03:00'), 'Immature Granulocytes'], [52172, Timestamp('2135-07-07 20:40:00'), Timestamp('2135-07-07 21:03:00'), 'RDW-SD'], [50813, Timestamp('2135-07-07 20:49:00'), Timestamp('2135-07-07 20:51:00'), 'Lactate'], [51463, Timestamp('2135-07-07 21:05:00'), Timestamp('2135-07-07 22:00:00'), 'Bacteria'], [51464, Timestamp('2135-07-07 21:05:00'), Timestamp('2135-07-07 22:00:00'), 'Bilirubin'], [51466, Timestamp('2135-07-07 21:05:00'), Timestamp('2135-07-07 22:00:00'), 'Blood'], [51476, Timestamp('2135-07-07 21:05:00'), Timestamp('2135-07-07 22:00:00'), 'Epithelial Cells'], [51478, Timestamp('2135-07-07 21:05:00'), Timestamp('2135-07-07 22:00:00'), 'Glucose'], [51482, Timestamp('2135-07-07 21:05:00'), Timestamp('2135-07-07 22:00:00'), 'Hyaline Casts'], [51484, Timestamp('2135-07-07 21:05:00'), Timestamp('2135-07-07 22:00:00'), 'Ketone'], [51486, Timestamp('2135-07-07 21:05:00'), Timestamp('2135-07-07 22:00:00'), 'Leukocytes'], [51487, Timestamp('2135-07-07 21:05:00'), Timestamp('2135-07-07 22:00:00'), 'Nitrite'], [51491, Timestamp('2135-07-07 21:05:00'), Timestamp('2135-07-07 22:00:00'), 'pH'], [51492, Timestamp('2135-07-07 21:05:00'), Timestamp('2135-07-07 22:00:00'), 'Protein'], [51493, Timestamp('2135-07-07 21:05:00'), Timestamp('2135-07-07 22:00:00'), 'RBC'], [51498, Timestamp('2135-07-07 21:05:00'), Timestamp('2135-07-07 22:00:00'), 'Specific Gravity'], [51506, Timestamp('2135-07-07 21:05:00'), Timestamp('2135-07-07 22:00:00'), 'Urine Appearance'], [51508, Timestamp('2135-07-07 21:05:00'), Timestamp('2135-07-07 22:00:00'), 'Urine Color'], [51514, Timestamp('2135-07-07 21:05:00'), Timestamp('2135-07-07 22:00:00'), 'Urobilinogen'], [51516, Timestamp('2135-07-07 21:05:00'), Timestamp('2135-07-07 22:00:00'), 'WBC'], [51519, Timestamp('2135-07-07 21:05:00'), Timestamp('2135-07-07 22:00:00'), 'Yeast'], [51082, Timestamp('2135-07-07 21:05:00'), Timestamp('2135-07-07 23:06:00'), 'Creatinine, Urine'], [51087, Timestamp('2135-07-07 21:05:00'), NaT, 'Length of Urine Collection'], [51093, Timestamp('2135-07-07 21:05:00'), Timestamp('2135-07-07 22:59:00'), 'Osmolality, Urine'], [51100, Timestamp('2135-07-07 21:05:00'), Timestamp('2135-07-07 23:06:00'), 'Sodium, Urine'], [51103, Timestamp('2135-07-07 21:05:00'), NaT, 'Uhold'], [51104, Timestamp('2135-07-07 21:05:00'), Timestamp('2135-07-07 23:06:00'), 'Urea Nitrogen, Urine'], [50868, Timestamp('2135-07-08 13:00:00'), Timestamp('2135-07-08 13:42:00'), 'Anion Gap'], [50882, Timestamp('2135-07-08 13:00:00'), Timestamp('2135-07-08 13:42:00'), 'Bicarbonate'], [50893, Timestamp('2135-07-08 13:00:00'), Timestamp('2135-07-08 13:42:00'), 'Calcium, Total'], [50902, Timestamp('2135-07-08 13:00:00'), Timestamp('2135-07-08 13:42:00'), 'Chloride'], [50912, Timestamp('2135-07-08 13:00:00'), Timestamp('2135-07-08 13:42:00'), 'Creatinine'], [50931, Timestamp('2135-07-08 13:00:00'), Timestamp('2135-07-08 13:42:00'), 'Glucose'], [50934, Timestamp('2135-07-08 13:00:00'), Timestamp('2135-07-08 13:42:00'), 'H'], [50947, Timestamp('2135-07-08 13:00:00'), Timestamp('2135-07-08 13:42:00'), 'I'], [50960, Timestamp('2135-07-08 13:00:00'), Timestamp('2135-07-08 13:42:00'), 'Magnesium'], [50970, Timestamp('2135-07-08 13:00:00'), Timestamp('2135-07-08 13:42:00'), 'Phosphate'], [50971, Timestamp('2135-07-08 13:00:00'), Timestamp('2135-07-08 13:42:00'), 'Potassium'], [50983, Timestamp('2135-07-08 13:00:00'), Timestamp('2135-07-08 13:42:00'), 'Sodium'], [51006, Timestamp('2135-07-08 13:00:00'), Timestamp('2135-07-08 13:42:00'), 'Urea Nitrogen'], [51678, Timestamp('2135-07-08 13:00:00'), Timestamp('2135-07-08 13:42:00'), 'L'], [51221, Timestamp('2135-07-08 13:00:00'), Timestamp('2135-07-08 13:27:00'), 'Hematocrit'], [51222, Timestamp('2135-07-08 13:00:00'), Timestamp('2135-07-08 13:27:00'), 'Hemoglobin'], [51248, Timestamp('2135-07-08 13:00:00'), Timestamp('2135-07-08 13:27:00'), 'MCH'], [51249, Timestamp('2135-07-08 13:00:00'), Timestamp('2135-07-08 13:27:00'), 'MCHC'], [51250, Timestamp('2135-07-08 13:00:00'), Timestamp('2135-07-08 13:27:00'), 'MCV'], [51265, Timestamp('2135-07-08 13:00:00'), Timestamp('2135-07-08 13:27:00'), 'Platelet Count'], [51277, Timestamp('2135-07-08 13:00:00'), Timestamp('2135-07-08 13:27:00'), 'RDW'], [51279, Timestamp('2135-07-08 13:00:00'), Timestamp('2135-07-08 13:27:00'), 'Red Blood Cells'], [51301, Timestamp('2135-07-08 13:00:00'), Timestamp('2135-07-08 13:27:00'), 'White Blood Cells'], [52172, Timestamp('2135-07-08 13:00:00'), Timestamp('2135-07-08 13:27:00'), 'RDW-SD']]

Question: A 87 F is admitted. He/she says he/she has Malaise for the previous 3 days . History of illness: Ms. ___ is an ___ year old female with a history Alzheimer's dementia status post unwitnessed fall at nursing home, found down on ground. Patient's dementia is advanced and she is unable to provide a history of review of systems though she denies pain at this time. History derived from records which are sparse. There is no care giver available at this time. Per report to ED by nursing home, patient has been 'having malaise for the last 3 days and not taking her medications. No reports of vomiting or change in BMs or fevers.' On presentation, pan-scan revealed no acute traumatic injury, but did note diverticulosis, a 6.3cm abscess in the mid pelvis, and what appears to be an enterouterine fistula with endometrial cavity distended with air and fluid and associated left hydroureter and caliectasis. She is afebrile but her WBC is 14.2. Her serum Cre is 2.3. Last Cre on ___ was 0.97 at ___. Pelvic exam by ED did not reveal stool in the vagina and she has no gross stool per vagina at time of exam. A foley catheter was placed in the ED and her UA was negative. She received cipro and flagyl in the ED. Past Medical History: Past medical history: ALZHEIMER'S DEMENTIA CHF AFIB SPINAL STENOSIS HYPERTENSION MACULAR DEGENERATION GENERALIZED ANXIETY DISORDER DEPRESSION NEUROPATHY HYPOTHYROIDISM Social History: ___ Family History: Dementia in her siblings Allergies: aspirin What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Ipratropium-Albuterol Neb OLANZapine (Disintegrating Tablet) Heparin PNEUMOcoccal 23-valent polysaccharide vaccine Metoprolol Tartrate Sodium Chloride 0.9% Flush Sertraline 5% Dextrose Ciprofloxacin IV NS MetroNIDAZOLE Levothyroxine Sodium Sodium Chloride 0.9% Bag Magnesium Sulfate 0.9% Sodium Chloride Potassium Chloride TraZODone Acetaminophen TraMADol Target Lab Orders: INR(PT) PT PTT Anion Gap Bicarbonate Chloride Creatinine Estimated GFR (MDRD equation) Glucose H I Potassium Sodium Urea Nitrogen L Light Green Top Hold Absolute Lymphocyte Count Basophils Eosinophils Hematocrit Hemoglobin Lymphocytes MCH MCHC MCV Monocytes Neutrophils Nucleated Red Cells Platelet Count RDW Red Blood Cells White Blood Cells Absolute Basophil Count Absolute Eosinophil Count Absolute Monocyte Count Absolute Neutrophil Count Immature Granulocytes RDW-SD Lactate Bacteria Bilirubin Blood Epithelial Cells Glucose Hyaline Casts Ketone Leukocytes Nitrite pH Protein RBC Specific Gravity Urine Appearance Urine Color Urobilinogen WBC Yeast Creatinine, Urine Length of Urine Collection Osmolality, Urine Sodium, Urine Uhold Urea Nitrogen, Urine Anion Gap Bicarbonate Calcium, Total Chloride Creatinine Glucose H I Magnesium Phosphate Potassium Sodium Urea Nitrogen L Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells RDW-SD Target Procedures: Drainage of Pelvic Cavity with Drainage Device, Percutaneous Approach DOCTOR'S NOTE Hospital Notes: : Ms. ___ is an ___ yo F with past medical history significant for Alzheimers dementia presented to the emergency department on ___ via EMS after being found down on the ground in her nursing home. She was conscious and moving all extremities. Exam was limited due to her dementia history but endorsed a head ache and left sided chest pain. Trauma evaluation was negative for acute injury. Her labs were notable for a white blood cell count of 14.2 and serum creatinine of 2.3 (.97 on ___. CT scan was concerning for diverticulosis, a 6.3 cm enterouterine fistula with endometrial cavity distended with air and fluid and associated left hydroureter and calictasis. She was admitted to the Acute Care Surgery Service, started on IV antibiotics and admitted to the surgical floor for further management. On HD1 after discussion of risk and benefit with the family and consultation with the OB/GYN team, non-operative management was determined the appropriate option for the patient. On HD2 she was taken to interventional radiology for placement of an ___ pigtail catheter into the collection. Samples were sent for microbiology evaluation. She tolerated the procedure well. She remained afebrile and her white blood cell count trended down to 9.6. On HD3 her diet was advanced to regular which she tolerated well. Her white blood cell count continued to trend down to 8.4. Her foley catheter was removed and she voided spontaneously without difficulty. Her creatinine trended down to 0.7. She was seen and evaluated by physical therapy who recommended she return to her facility with ___ supervision and skilled nursing care. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, out of bed with assist, voiding (incontinent) without assistance, and pain was well controlled. The patient was discharged back to her nursing home. The patient and family received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Other Results: ___ 05:40AM BLOOD WBC-8.4 RBC-3.79* Hgb-10.9* Hct-35.2 MCV-93 MCH-28.8 MCHC-31.0* RDW-13.2 RDWSD-44.9 Plt ___ ___ 06:00AM BLOOD WBC-9.6 RBC-3.69* Hgb-11.0* Hct-35.9 MCV-97 MCH-29.8 MCHC-30.6* RDW-13.5 RDWSD-47.9* Plt ___ ___ 01:00PM BLOOD WBC-13.8* RBC-3.58* Hgb-10.7* Hct-32.8* MCV-92 MCH-29.9 MCHC-32.6 RDW-13.2 RDWSD-45.3 Plt ___ ___ 08:40PM BLOOD WBC-14.2* RBC-3.47* Hgb-10.2* Hct-32.0* MCV-92 MCH-29.4 MCHC-31.9* RDW-13.4 RDWSD-45.6 Plt ___ ___ 08:40PM BLOOD Neuts-83.8* Lymphs-8.0* Monos-6.3 Eos-0.8* Baso-0.2 NRBC-0.1* Im ___ AbsNeut-11.90* AbsLymp-1.13* AbsMono-0.90* AbsEos-0.12 AbsBaso-0.03 ___ 08:40PM BLOOD ___ PTT-26.8 ___ ___ 05:40AM BLOOD Glucose-97 UreaN-16 Creat-0.7 Na-138 K-3.2* Cl-96 HCO3-30 AnGap-15 ___ 09:20PM BLOOD Glucose-110* UreaN-19 Creat-0.9 Na-135 K-2.8* Cl-94* HCO3-31 AnGap-13 ___ 06:00AM BLOOD Glucose-115* UreaN-25* Creat-0.9 Na-134 K-3.0* Cl-90* HCO3-30 AnGap-17 ___ 01:00PM BLOOD Glucose-117* UreaN-32* Creat-1.3* Na-131* K-3.2* Cl-86* HCO3-33* AnGap-15 ___ 08:40PM BLOOD Glucose-120* UreaN-45* Creat-2.3* Na-125* K-3.3 Cl-80* HCO3-35* AnGap-13 ___ 05:40AM BLOOD Calcium-9.0 Phos-1.9* Mg-1.6 ___ 09:20PM BLOOD Calcium-9.0 Phos-2.2* Mg-1.8 ___ 06:00AM BLOOD Calcium-9.3 Phos-2.6* Mg-2.8* ___ 01:00PM BLOOD Calcium-9.2 Phos-3.0 Mg-1.6 ___ 08:49PM BLOOD Lactate-1.1 ___ CT C-spine: 1. No fracture is identified. 2. Moderate to severe degenerative changes of the cervical spine with fusion of CT wall and C3. Multilevel mild subluxations are likely degenerative in etiology. ___ CT Head: No acute intracranial process. ___ CT Chest: 1. 6.3-cm abscess in the mid pelvis with apparent fistulous communication with the small bowel and uterus likely due to perforated sigmoid diverticulitis, in the setting of extensive sigmoid diverticulosis. If further delineation of the fistulous communication is needed, consider repeat CT with oral and rectal contrast for improved evaluation or non-contrast pelvic MRI. 2. Endometrial cavity is distended with air and fluid as a result of the fistulous communication with the pelvic abscess. 3. Mild left hydroureter and caliectasis as a result of the distal left ureter appearing involved by the pelvic inflammation and perhaps compressed by the enlarged uterus. 4. No acute injury or acute fracture is identified.

2180-02-14 00:00:00

?

MARRIED

ASIAN

M

[[28995359, Timestamp('2180-02-14 07:09:52'), '', 'DENT'], [28995359, Timestamp('2180-02-15 07:53:13'), 'DENT', 'MED']]

[[{'Medications on Admission': ':\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Lisinopril 5 mg PO DAILY \n2. Fish Oil (Omega 3) 1000 mg PO BID \n3. Metoprolol Succinate XL 75 mg PO DAILY \n4. Warfarin 2.5-3.75 mg PO DAILY16 \n5. Tacrolimus 0.5 mg PO AM \n6. Tacrolimus 1 mg PO ___ \n7. Levemir 15 Units Bedtime\n8. Entecavir 1 mg PO DAILY \n9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n10. Calcium Carbonate 600 mg PO BID \n11. Aspirin 81 mg PO DAILY \n12. GlipiZIDE 10 mg PO DAILY \n\nFacility:\n___\n\nSecondary:\nHypertension\nHistory of deep vein thrombosis now on chronic anticoagulation', 'Brief Hospital Course': ':\nMr. ___ is a ___ man who is currently about ___ years \npost liver transplant for hepatitis B-induced liver cirrhosis \nfound to have SCC of floor of mouth s/p wide local excision of \nthe floor ofthe mouth and mandibulectomy resection who has \nbilateral neck dissection and bilateral JP drain placement by \n___ on ___.\n\nACUTE ISSUES:\n=============\n#Squamous cell cancer of the mouth\n#Post-Operative Management \ns/p He had bilateral neck dissection and bilateral JP drains \nplacement by ___ ___ due to unclear margins on initial \nexcision. He was placed on ancef while inpatient and \ntransitioned to keflex on discharge to complete a 7 day course \nof antibiotics from ___. Warfarin was held pre-operatively \nand restarted ___. Bilateral JP drains were placed and closely \nmonitored. The output continued during his stay with over 100cc \nin the 24 hours prior to discharge and the drains remained in \nplace at discharge. They will be removed at ___ outpatient \nfollow up. Sutures to be removed POD 14. Diet clears \npost-operatively and advanced to regular diet at the time of \ndischarge. His pain was managed with Tylenol.\n\n#ESLD s/p Liver transplant.\n#Hepatitis B\nPatient is ___ years post liver transplant. At this point her \nliver function test are at baseline. The patient is unsure if \npatient took AM tacro or entecavir on the day of surgery. \nRestarted home doses on ___ ___. Continued tacrolimus 0.5mg QAM, \n1mg QPM with goal between 2 and 3. Tacrolimus trough level on \n___ was 6.8. No changed in tacrolimus were made. He will have \nlabs checked one week after discharge. He continued entecavir \nfor Hep B.\n\n#History of DVT\nPatient has history of thrombophilia and recurrent \npost-transplant DVT maintained on Coumadin. Coumadin was held \nprior to procedure and warfarin was restarted on ___. He was \nplaced on subcutaneous heparin while INR was subtherapeutic \nwhile inpatient. INR at discharge was 1.1.\n\n#Hypertension: \nPatient is maintained on Metoprolol and lisinopril.\n\n#Diabetes Holding Glipizide and Levemir while inpatient. ISS\n\n#Primary prevention: Aspirin was restarted on ___.\n\nTRANSITIONAL ISSUES\n===================\n# NEW MEDICATIONS\n- Cephalexin 500 mg PO Q6H Duration: 5 Days to complete ___\n\n[] f/u pathology from neck dissection\n[] ensure follow up with OMFS on ___\n[] Check INR on ___\n[] Continue prophylactic post-op antibiotics for 7 days with \nkeflex (to complete ___\n[] Sutures to be removed POD 14\n[] Monitor INR\n[] Labs including tacrolimus level in one week after discharge \n(___), goal tacrolimus level ___.\n\n#Code status: Full\n#Health care proxy/emergency contact: ___ contact Daughter ___ \n___ speaking) ___\n___ Wife ___\n\n', 'Pertinent Results:': '\nADMISSION LABS\n=============\n___ 10:31AM BLOOD WBC-7.1 RBC-4.99 Hgb-15.7 Hct-46.2 MCV-93 \nMCH-31.5 MCHC-34.0 RDW-13.2 RDWSD-44.2 Plt ___\n___ 10:31AM BLOOD ___\n___ 10:31AM BLOOD UreaN-15 Creat-1.0 Na-140 K-4.3 Cl-99 \nHCO3-24 AnGap-17\n___ 10:31AM BLOOD ALT-24 AST-22 AlkPhos-75 TotBili-1.0\n___ 10:31AM BLOOD Albumin-4.5 Calcium-8.5 Phos-2.2* Mg-1.9\n___ 10:31AM BLOOD HBsAg-NEG\n___ 10:31AM BLOOD HBV VL-NOT DETECT\n___ 10:31AM BLOOD HBsAg-NEG\n\n', 'Physical Exam:|Physical': '\nADMISSION PHYSICAL EXAM\n=====================\nVITALS: T 97.5PO BP140 / 69 L Lying HR 72 RR16 O2 96 \nGENERAL: AOx3, NAD, \nHEENT: bilateral JP drain in place. ___ CC of serosanguinous\ndraining. Staple lines intact. No oozing, puss, or other\ndrainage. \nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No\nmurmurs/rubs/gallops. \nLUNGS: Anterior lung fields clear bilaterally. \nABDOMEN: Normal bowels sounds, non distended, non-tender to deep\npalpation in all four quadrants. No organomegaly. \nSKIN: No evidence of ulcers, rash or lesions suspicious for\nmalignancy \nNEUROLOGIC: no gross motor or sensory deficits \n\nDISCHARGE PHYSICAL EXAM\n=====================\nVITALS:24 HR Data (last updated ___ @ 1133)\n Temp: 98.2 (Tm 98.4), BP: 133/83 (127-143/78-83), HR: 65\n(62-73), RR: 16 (___), O2 sat: 95% (94-95), O2 delivery: Ra,\nWt: 231.92 lb/105.2 kg \nFluid Balance (last updated ___ @ 533) \n Last 8 hours Total cumulative -300ml\n IN: Total 0ml\n OUT: Total 300ml, Urine Amt 300ml, R neck JP 0ml, L neck JP\n0ml\n Last 24 hours Total cumulative -1691ml\n IN: Total 564ml, PO Amt 380ml, IV Amt Infused 184ml\n OUT: Total 2255ml, Urine Amt 2100ml, R neck JP 75ml, L neck\nJP 80ml \nGENERAL: AOx3, NAD, \nHEENT: bilateral JP drain in place draining serosanguinous\ndraining. Staple lines intact. No oozing, puss, or other\ndrainage. \nCARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No\nmurmurs/rubs/gallops. \nLUNGS: Anterior lung fields clear bilaterally. \nABDOMEN: Normal bowels sounds, non distended, non-tender to deep\npalpation in all four quadrants. No organomegaly. \nSKIN: No evidence of ulcers, rash or lesions suspicious for\nmalignancy \nNEUROLOGIC: no gross motor or sensory deficits \n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\nMr. ___ is a ___ man who is currently about ___ years\npost liver transplant for hepatitis B-induced liver cirrhosis\ncomplicated with mixed hepatocellular cholangiocarcinoma.Who was\nfound to have erythroleukoplakia on mouth about 2 months ago. \n\nHe underwent wide local excision of the floor of\nthe mouth and mandibulectomy resection of Squamous Cell\ncarcinoma floor of tongue recently. He had bilateral neck\ndissection and bilateral JP drains placement by OMFS today due \nto\nunclear margins on initial excision.\n\nIt was planed that the patient will be admitted to the \ntransplant\nservice to be managed by a liver attending. \n\nIn regards to his liver disease, this point, the patient in not\nacutely decompensated. He was last seen by his hepatologist Dr.\n___ on ___ has been on Coumadin for recurrent\npost-transplant DVT and thrombophilia.\n\nhis warfarn has been held for the procedure and per the\nhepataolgy fellow and surgery teams should resume tomorrow\n___.\n\nPrior to presentation for the surgery the patient was in good\nhealth and had no acute complaints.\n\nOn the floor, \n\nThe patient was in no acute distress. The above history was\nconfirmed wit help from ___ interpreter.\n\nThe patient had neck pain. He denied any other symptoms.\n\nThe patient and wife were unsure about his medication list. I\ntook his medication list from the mot recent Hepatology note \nfrom\n___ which stated they were up to date/\n\nThe patient reports he took three medications but are unsure \nwhat\nthey were. He was unsure if they related to his liver or blood\npressure.\nI am assuming that the patient took his AM metoprolol,\nTacrolimus, and entecavir but was unable to get collateral. \n\nREVIEW OF SYSTEMS: \nComplete ROS obtained and is otherwise negative. \n\nPast Medical History:\n- ESLD secondary to HBV and HCC, s/p liver transplant ___ \n\n- HBV (HBV DNA not detected ___ \n- s/p left femoral/popliteal DVT and PE, s/p IVC filter ___ \n\n- RLE DVT ___ on Coumadin \n- DM type 2 \n- PTSD \n- Depression \n- SCC in situ excised ___ \n\nSocial History:\n___\nFamily History:\n6 daughters, all alive and well. \n\n', 'Chief Complaint:|Complaint:': '\nSQUAMOUS CELL CARCINOMA OF THE MOUTH\n\n', 'Attending:': ' ___\n\n', 'Allergies:': ' \nIbuprofen / atorvastatin / Motrin / fenofibrate\n\n'}, '14092612-DS-14', 14, 'medicine']]

[]

[[28995359, Timestamp('2180-02-14 21:00:00'), Timestamp('2180-02-16 22:00:00'), 'MAIN', 'Acetaminophen', '004489', '00904198261', '325mg Tablet'], [28995359, Timestamp('2180-02-14 21:00:00'), Timestamp('2180-02-15 06:00:00'), 'BASE', 'Lactated Ringers', '001187', '00338011704', 'Floor Stock Bag'], [28995359, Timestamp('2180-02-14 21:00:00'), Timestamp('2180-02-16 22:00:00'), 'MAIN', 'Sodium Chloride 0.9% Flush', '', '0', '10 mL Syringe'], [28995359, Timestamp('2180-02-14 21:00:00'), Timestamp('2180-02-16 22:00:00'), 'MAIN', 'Sodium Chloride 0.9% Flush', '', '0', '10 mL Syringe'], [28995359, Timestamp('2180-02-14 21:00:00'), Timestamp('2180-02-16 22:00:00'), 'MAIN', 'Dextrose 50%', '001989', '00409490234', '25 g / 50 mL Syringe'], [28995359, Timestamp('2180-02-14 21:00:00'), Timestamp('2180-02-16 22:00:00'), 'MAIN', 'Acetaminophen', '065758', '00121197100', '650mg UD Cup'], [28995359, Timestamp('2180-02-14 21:00:00'), Timestamp('2180-02-16 22:00:00'), 'MAIN', 'OxyCODONE (Immediate Release)', '004225', '00904644461', '5mg Tablet'], [28995359, Timestamp('2180-02-14 21:00:00'), Timestamp('2180-02-16 22:00:00'), 'MAIN', 'Tacrolimus', '021796', '00781210301', '1 mg Capsule'], [28995359, Timestamp('2180-02-14 21:00:00'), Timestamp('2180-02-16 22:00:00'), 'MAIN', 'Glucagon', '066517', '00597026010', '1mg Vial'], [28995359, Timestamp('2180-02-14 21:00:00'), Timestamp('2180-02-16 22:00:00'), 'MAIN', 'HYDROmorphone (Dilaudid)', '062823', '00409128331', '1mg/1mL Syringe'], [28995359, Timestamp('2180-02-14 21:00:00'), Timestamp('2180-02-16 22:00:00'), 'MAIN', 'Fish Oil (Omega 3)', '006422', '10939033733', '1000 mg Cap'], [28995359, Timestamp('2180-02-14 21:00:00'), Timestamp('2180-02-16 22:00:00'), 'BASE', 'Iso-Osmotic Dextrose', '', '0', '50ml Bag'], [28995359, Timestamp('2180-02-14 21:00:00'), Timestamp('2180-02-16 22:00:00'), 'MAIN', 'CeFAZolin', '009059', '00338350341', '1g Froz.Bag'], [28995359, Timestamp('2180-02-14 22:00:00'), Timestamp('2180-02-16 22:00:00'), 'MAIN', 'Latanoprost 0.005% Ophth. Soln.', '027370', '61314054701', '2.5mL Dropper Bottle'], [28995359, Timestamp('2180-02-14 21:00:00'), Timestamp('2180-02-16 22:00:00'), 'MAIN', 'Calcium Carbonate', '002684', '00121476605', '1250mg/5mL UDCup'], [28995359, Timestamp('2180-02-14 20:00:00'), Timestamp('2180-02-16 22:00:00'), 'MAIN', 'Influenza Vaccine Quadrivalent', '075715', '49281041688', '0.5 mL Syringe'], [28995359, Timestamp('2180-02-14 21:00:00'), Timestamp('2180-02-16 22:00:00'), 'MAIN', 'Insulin', '027413', '00002751001', '100 Units / mL - 10 mL Vial'], [28995359, Timestamp('2180-02-14 21:00:00'), Timestamp('2180-02-16 22:00:00'), 'MAIN', 'Glucose Gel', '001781', '38396055018', '15 g Tube']]

[['07T20ZZ', 10, 1, Timestamp('2180-02-14 00:00:00'), 'Resection of Left Neck Lymphatic, Open Approach'], ['07T10ZZ', 10, 2, Timestamp('2180-02-14 00:00:00'), 'Resection of Right Neck Lymphatic, Open Approach'], ['0CTH0ZZ', 10, 3, Timestamp('2180-02-14 00:00:00'), 'Resection of Left Submaxillary Gland, Open Approach'], ['0CTG0ZZ', 10, 4, Timestamp('2180-02-14 00:00:00'), 'Resection of Right Submaxillary Gland, Open Approach']]

['medicine']

[[51221, Timestamp('2180-02-14 10:31:00'), Timestamp('2180-02-14 13:15:00'), 'Hematocrit'], [51222, Timestamp('2180-02-14 10:31:00'), Timestamp('2180-02-14 13:15:00'), 'Hemoglobin'], [51248, Timestamp('2180-02-14 10:31:00'), Timestamp('2180-02-14 13:15:00'), 'MCH'], [51249, Timestamp('2180-02-14 10:31:00'), Timestamp('2180-02-14 13:15:00'), 'MCHC'], [51250, Timestamp('2180-02-14 10:31:00'), Timestamp('2180-02-14 13:15:00'), 'MCV'], [51265, Timestamp('2180-02-14 10:31:00'), Timestamp('2180-02-14 13:15:00'), 'Platelet Count'], [51277, Timestamp('2180-02-14 10:31:00'), Timestamp('2180-02-14 13:15:00'), 'RDW'], [51279, Timestamp('2180-02-14 10:31:00'), Timestamp('2180-02-14 13:15:00'), 'Red Blood Cells'], [51301, Timestamp('2180-02-14 10:31:00'), Timestamp('2180-02-14 13:15:00'), 'White Blood Cells'], [52172, Timestamp('2180-02-14 10:31:00'), Timestamp('2180-02-14 13:15:00'), 'RDW-SD'], [51648, Timestamp('2180-02-14 10:31:00'), Timestamp('2180-02-15 16:30:00'), 'Hepatitis B Viral Load'], [51237, Timestamp('2180-02-14 10:31:00'), Timestamp('2180-02-14 13:40:00'), 'INR(PT)'], [51274, Timestamp('2180-02-14 10:31:00'), Timestamp('2180-02-14 13:40:00'), 'PT'], [50861, Timestamp('2180-02-14 10:31:00'), Timestamp('2180-02-14 14:06:00'), 'Alanine Aminotransferase (ALT)'], [50862, Timestamp('2180-02-14 10:31:00'), Timestamp('2180-02-14 14:06:00'), 'Albumin'], [50863, Timestamp('2180-02-14 10:31:00'), Timestamp('2180-02-14 14:06:00'), 'Alkaline Phosphatase'], [50868, Timestamp('2180-02-14 10:31:00'), Timestamp('2180-02-14 14:06:00'), 'Anion Gap'], [50878, Timestamp('2180-02-14 10:31:00'), Timestamp('2180-02-14 14:06:00'), 'Asparate Aminotransferase (AST)'], [50882, Timestamp('2180-02-14 10:31:00'), Timestamp('2180-02-14 14:06:00'), 'Bicarbonate'], [50885, Timestamp('2180-02-14 10:31:00'), Timestamp('2180-02-14 14:06:00'), 'Bilirubin, Total'], [50893, Timestamp('2180-02-14 10:31:00'), Timestamp('2180-02-14 14:06:00'), 'Calcium, Total'], [50902, Timestamp('2180-02-14 10:31:00'), Timestamp('2180-02-14 14:06:00'), 'Chloride'], [50912, Timestamp('2180-02-14 10:31:00'), Timestamp('2180-02-14 14:06:00'), 'Creatinine'], [50920, Timestamp('2180-02-14 10:31:00'), Timestamp('2180-02-14 14:06:00'), 'Estimated GFR (MDRD equation)'], [50934, Timestamp('2180-02-14 10:31:00'), Timestamp('2180-02-14 14:06:00'), 'H'], [50941, Timestamp('2180-02-14 10:31:00'), Timestamp('2180-02-14 13:57:00'), 'Hepatitis B Surface Antigen'], [50947, Timestamp('2180-02-14 10:31:00'), Timestamp('2180-02-14 14:06:00'), 'I'], [50960, Timestamp('2180-02-14 10:31:00'), Timestamp('2180-02-14 14:06:00'), 'Magnesium'], [50970, Timestamp('2180-02-14 10:31:00'), Timestamp('2180-02-14 14:06:00'), 'Phosphate'], [50971, Timestamp('2180-02-14 10:31:00'), Timestamp('2180-02-14 14:06:00'), 'Potassium'], [50983, Timestamp('2180-02-14 10:31:00'), Timestamp('2180-02-14 14:06:00'), 'Sodium'], [51006, Timestamp('2180-02-14 10:31:00'), Timestamp('2180-02-14 14:06:00'), 'Urea Nitrogen'], [51657, Timestamp('2180-02-14 10:31:00'), Timestamp('2180-02-14 13:57:00'), 'HPE1'], [51678, Timestamp('2180-02-14 10:31:00'), Timestamp('2180-02-14 14:06:00'), 'L'], [50986, Timestamp('2180-02-14 10:31:00'), Timestamp('2180-02-14 15:01:00'), 'tacroFK'], [50931, Timestamp('2180-02-14 10:31:00'), Timestamp('2180-02-14 13:47:00'), 'Glucose'], [50934, Timestamp('2180-02-14 10:31:00'), Timestamp('2180-02-14 13:47:00'), 'H'], [50947, Timestamp('2180-02-14 10:31:00'), Timestamp('2180-02-14 13:47:00'), 'I'], [51678, Timestamp('2180-02-14 10:31:00'), Timestamp('2180-02-14 13:47:00'), 'L']]

Question: A 58 M is admitted. He/she says he/she has SQUAMOUS CELL CARCINOMA OF THE MOUTH . History of illness: Mr. ___ is a ___ man who is currently about ___ years post liver transplant for hepatitis B-induced liver cirrhosis complicated with mixed hepatocellular cholangiocarcinoma.Who was found to have erythroleukoplakia on mouth about 2 months ago. He underwent wide local excision of the floor of the mouth and mandibulectomy resection of Squamous Cell carcinoma floor of tongue recently. He had bilateral neck dissection and bilateral JP drains placement by OMFS today due to unclear margins on initial excision. It was planed that the patient will be admitted to the transplant service to be managed by a liver attending. In regards to his liver disease, this point, the patient in not acutely decompensated. He was last seen by his hepatologist Dr. ___ on ___ has been on Coumadin for recurrent post-transplant DVT and thrombophilia. his warfarn has been held for the procedure and per the hepataolgy fellow and surgery teams should resume tomorrow ___. Prior to presentation for the surgery the patient was in good health and had no acute complaints. On the floor, The patient was in no acute distress. The above history was confirmed wit help from ___ interpreter. The patient had neck pain. He denied any other symptoms. The patient and wife were unsure about his medication list. I took his medication list from the mot recent Hepatology note from ___ which stated they were up to date/ The patient reports he took three medications but are unsure what they were. He was unsure if they related to his liver or blood pressure. I am assuming that the patient took his AM metoprolol, Tacrolimus, and entecavir but was unable to get collateral. REVIEW OF SYSTEMS: Complete ROS obtained and is otherwise negative. Past Medical History: - ESLD secondary to HBV and HCC, s/p liver transplant ___ - HBV (HBV DNA not detected ___ - s/p left femoral/popliteal DVT and PE, s/p IVC filter ___ - RLE DVT ___ on Coumadin - DM type 2 - PTSD - Depression - SCC in situ excised ___ Social History: ___ Family History: 6 daughters, all alive and well. Allergies: Ibuprofen / atorvastatin / Motrin / fenofibrate What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Acetaminophen Lactated Ringers Sodium Chloride 0.9% Flush Sodium Chloride 0.9% Flush Dextrose 50% Acetaminophen OxyCODONE (Immediate Release) Tacrolimus Glucagon HYDROmorphone (Dilaudid) Fish Oil (Omega 3) Iso-Osmotic Dextrose CeFAZolin Latanoprost 0.005% Ophth. Soln. Calcium Carbonate Influenza Vaccine Quadrivalent Insulin Glucose Gel Target Lab Orders: Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells RDW-SD Hepatitis B Viral Load INR(PT) PT Alanine Aminotransferase (ALT) Albumin Alkaline Phosphatase Anion Gap Asparate Aminotransferase (AST) Bicarbonate Bilirubin, Total Calcium, Total Chloride Creatinine Estimated GFR (MDRD equation) H Hepatitis B Surface Antigen I Magnesium Phosphate Potassium Sodium Urea Nitrogen HPE1 L tacroFK Glucose H I L Target Procedures: Resection of Left Neck Lymphatic, Open Approach Resection of Right Neck Lymphatic, Open Approach Resection of Left Submaxillary Gland, Open Approach Resection of Right Submaxillary Gland, Open Approach DOCTOR'S NOTE Hospital Notes: : Mr. ___ is a ___ man who is currently about ___ years post liver transplant for hepatitis B-induced liver cirrhosis found to have SCC of floor of mouth s/p wide local excision of the floor ofthe mouth and mandibulectomy resection who has bilateral neck dissection and bilateral JP drain placement by ___ on ___. ACUTE ISSUES: ============= #Squamous cell cancer of the mouth #Post-Operative Management s/p He had bilateral neck dissection and bilateral JP drains placement by ___ ___ due to unclear margins on initial excision. He was placed on ancef while inpatient and transitioned to keflex on discharge to complete a 7 day course of antibiotics from ___. Warfarin was held pre-operatively and restarted ___. Bilateral JP drains were placed and closely monitored. The output continued during his stay with over 100cc in the 24 hours prior to discharge and the drains remained in place at discharge. They will be removed at ___ outpatient follow up. Sutures to be removed POD 14. Diet clears post-operatively and advanced to regular diet at the time of discharge. His pain was managed with Tylenol. #ESLD s/p Liver transplant. #Hepatitis B Patient is ___ years post liver transplant. At this point her liver function test are at baseline. The patient is unsure if patient took AM tacro or entecavir on the day of surgery. Restarted home doses on ___ ___. Continued tacrolimus 0.5mg QAM, 1mg QPM with goal between 2 and 3. Tacrolimus trough level on ___ was 6.8. No changed in tacrolimus were made. He will have labs checked one week after discharge. He continued entecavir for Hep B. #History of DVT Patient has history of thrombophilia and recurrent post-transplant DVT maintained on Coumadin. Coumadin was held prior to procedure and warfarin was restarted on ___. He was placed on subcutaneous heparin while INR was subtherapeutic while inpatient. INR at discharge was 1.1. #Hypertension: Patient is maintained on Metoprolol and lisinopril. #Diabetes Holding Glipizide and Levemir while inpatient. ISS #Primary prevention: Aspirin was restarted on ___. TRANSITIONAL ISSUES =================== # NEW MEDICATIONS - Cephalexin 500 mg PO Q6H Duration: 5 Days to complete ___ [] f/u pathology from neck dissection [] ensure follow up with OMFS on ___ [] Check INR on ___ [] Continue prophylactic post-op antibiotics for 7 days with keflex (to complete ___ [] Sutures to be removed POD 14 [] Monitor INR [] Labs including tacrolimus level in one week after discharge (___), goal tacrolimus level ___. #Code status: Full #Health care proxy/emergency contact: ___ contact Daughter ___ ___ speaking) ___ ___ Wife ___ Other Results: ADMISSION LABS ============= ___ 10:31AM BLOOD WBC-7.1 RBC-4.99 Hgb-15.7 Hct-46.2 MCV-93 MCH-31.5 MCHC-34.0 RDW-13.2 RDWSD-44.2 Plt ___ ___ 10:31AM BLOOD ___ ___ 10:31AM BLOOD UreaN-15 Creat-1.0 Na-140 K-4.3 Cl-99 HCO3-24 AnGap-17 ___ 10:31AM BLOOD ALT-24 AST-22 AlkPhos-75 TotBili-1.0 ___ 10:31AM BLOOD Albumin-4.5 Calcium-8.5 Phos-2.2* Mg-1.9 ___ 10:31AM BLOOD HBsAg-NEG ___ 10:31AM BLOOD HBV VL-NOT DETECT ___ 10:31AM BLOOD HBsAg-NEG

2172-02-05 22:23:00

ENGLISH

MARRIED

PATIENT DECLINED TO ANSWER

F

[[20602846, Timestamp('2172-02-05 22:25:08'), '', 'OBS']]

[[{'Medications on Admission': 'NIL', 'Brief Hospital Course': ':\nOn ___, Ms. ___ was admitted to the antepartum service \nat 20w6d for asthma exacerbation in the setting of community \nacquire pneumonia. CXR performed in the ED showed patchy right \nupper lobe opacity concerning for pneumonia with streaky \nbibasilar atelectasis. Her WBC count was noted to be elevated at \n17.4 without any bandemia, which trended down to 14.5 on HD#2. \nShe was given a nebulizer treatment and IV hydration. She was \ngiven a dose of IM Ceftriaxone 1g and was continued on PO \nazithromycin for a ___y ___, she was afebrile with stable vital signs, saturating \n95-96% on RA without any evidence of respiratory distress. She \nwas discharged home with outpatient follow up scheduled. ', 'Pertinent Results:': '\n___ 07:30AM BLOOD WBC-14.5* RBC-3.22* Hgb-10.3* Hct-31.3* \nMCV-97 MCH-32.0 MCHC-32.9 RDW-12.5 RDWSD-44.1 Plt ___\n___ 05:45PM BLOOD WBC-17.4* RBC-3.47* Hgb-11.4 Hct-33.4* \nMCV-96 MCH-32.9* MCHC-34.1 RDW-12.6 RDWSD-44.3 Plt ___\n___ 07:30AM BLOOD Neuts-67.9 Lymphs-18.7* Monos-7.2 Eos-5.4 \nBaso-0.3 Im ___ AbsNeut-9.84* AbsLymp-2.71 AbsMono-1.05* \nAbsEos-0.79* AbsBaso-0.05\n___ 05:45PM BLOOD Neuts-77.3* Lymphs-12.5* Monos-6.0 \nEos-3.4 Baso-0.2 Im ___ AbsNeut-13.47*# AbsLymp-2.18 \nAbsMono-1.05* AbsEos-0.60* AbsBaso-0.04\n___ 07:30AM BLOOD Plt ___\n___ 05:45PM BLOOD Plt ___\n___ 05:45PM BLOOD Glucose-97 UreaN-4* Creat-0.5 Na-136 \nK-4.2 Cl-100 HCO3-24 AnGap-16\n___ 05:45PM BLOOD cTropnT-<0.01\n___ 05:45PM BLOOD D-Dimer-893*\n\nSputum Culture x 2 contaminated\n\n', 'Physical Exam:|Physical': '\nCONSTITUTIONAL: normal \n HEENT: normal, MMM \n NEURO: alert, appropriate, oriented x 4 \n RESP: no increased WOB \n HEART: extremities warm and well perfused \n ABDOMEN: gravid, non-tender \n EXTREMITIES: non-tender, no edema \n FHR: present at a normal rate \n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': "\n___ yo G10 ___ at 20w6d with 'a few weeks' of cough and\nSOB. SOB acutely worsened today with wheezing. No fevers, \nchills,\nrigors, nausea, vomiting, diarrhea. No malaise, aches, myalgias. \n\nNo ctx, VB, LOF. +FM.\n\nPNC: \n- ___ ___ by first trimester US\nB NEG/ ABS RH IG/ RI/ RPR NR/ HBsAg - / HIV -/ GC CT -\n- FFS - normal\n- Issues: obesity\n\nPast Medical History:\nOBHx:\n- SVD x 7 - sab x 2 D&C\n\nGynHx: denies STI \n\nPMH: asthma - no meds, no hospitlaizations or intubations\n\nPSH: tonsils, D&C\n\nMeds: PNV\n\nAll: NKDA\n\nSHx: ___\nFamily History:\nnon-contributory\n\n", 'Chief Complaint:|Complaint:': '\nshortness of breath\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nNo Known Allergies / Adverse Drug Reactions\n\n'}, '11139232-DS-11', 11, 'obstetrics/gynecology']]

[['EXAMINATION: CHEST (PA AND LAT)\n\nINDICATION: History: ___ with childhood asthma, 20 weeks pregnant here for 1\nmonth worsening, shortness of breath. diffuse wheezing on exam. Concern for\nasthma exacerbation versus pneumonia versus pulmonary embolism.\n\nTECHNIQUE: Chest PA and lateral\n\nCOMPARISON: None.\n\nFINDINGS: \n\nHeart size is borderline enlarged. Mediastinal and hilar contours are\nunremarkable. Pulmonary vasculature is not engorged. A patchy opacity within\nthe right upper lobe is concerning for an area of infection. Streaky\natelectasis noted in the lung bases. No pleural effusion or pneumothorax is\npresent. No acute osseous abnormality is visualized.\n\nIMPRESSION: \n\nPatchy right upper lobe opacity is concerning for pneumonia. Streaky\nbibasilar atelectasis.\n', '11139232-RR-29', 29, 'chest pa and lateral']]

[[20602846, Timestamp('2172-02-06 01:00:00'), Timestamp('2172-02-06 02:00:00'), 'MAIN', 'Albuterol 0.083% Neb Soln', '005039', '00487950101', '0.083%;3mL Vial'], [20602846, Timestamp('2172-02-06 03:00:00'), Timestamp('2172-02-07 02:00:00'), 'BASE', '0.9% Sodium Chloride (Mini Bag Plus)', '001210', '00338055318', '100mL Bag'], [20602846, Timestamp('2172-02-06 03:00:00'), Timestamp('2172-02-07 02:00:00'), 'MAIN', 'CefTRIAXone', '009162', '60505075204', '1g Vial (For Mini Bag plus)'], [20602846, Timestamp('2172-02-06 01:00:00'), Timestamp('2172-02-07 02:00:00'), 'MAIN', 'Albuterol Inhaler', '028090', '00173068224', 'Inhaler'], [20602846, Timestamp('2172-02-06 01:00:00'), Timestamp('2172-02-06 02:00:00'), 'MAIN', 'Influenza Vaccine Quadrivalent', '075715', '49281041688', '0.5 mL Syringe'], [20602846, Timestamp('2172-02-06 01:00:00'), Timestamp('2172-02-06 02:00:00'), 'MAIN', 'Ipratropium-Albuterol Neb', '048018', '00487020101', '(0.5mg - 3 mg) - 3 mL Neb'], [20602846, Timestamp('2172-02-06 01:00:00'), Timestamp('2172-02-07 02:00:00'), 'MAIN', 'Milk of Magnesia', '003026', '00121043130', '30mL UD Cup'], [20602846, Timestamp('2172-02-06 01:00:00'), Timestamp('2172-02-07 02:00:00'), 'MAIN', 'Prenatal Vitamins', '068215', '00904531360', 'Tablet'], [20602846, Timestamp('2172-02-06 01:00:00'), Timestamp('2172-02-07 02:00:00'), 'MAIN', 'Albuterol 0.083% Neb Soln', '005039', '00487950101', '0.083%;3mL Vial'], [20602846, Timestamp('2172-02-06 01:00:00'), Timestamp('2172-02-07 02:00:00'), 'MAIN', 'Azithromycin', '026721', '54569452202', '250 mg Tablet '], [20602846, Timestamp('2172-02-06 01:00:00'), Timestamp('2172-02-07 02:00:00'), 'MAIN', 'Bisacodyl', '002944', '00574705050', '10mg Suppository'], [20602846, Timestamp('2172-02-06 01:00:00'), Timestamp('2172-02-07 02:00:00'), 'MAIN', 'Calcium Carbonate', '002689', '66553000401', '500mg Tablet'], [20602846, Timestamp('2172-02-06 01:00:00'), Timestamp('2172-02-07 02:00:00'), 'MAIN', 'Docusate Sodium', '003009', '00904224461', '100mg Capsule'], [20602846, Timestamp('2172-02-06 01:00:00'), Timestamp('2172-02-07 02:00:00'), 'MAIN', 'Acetaminophen', '004489', '00904198261', '325mg Tablet']]

[]

['obstetrics/gynecology']

[[51133, Timestamp('2172-02-06 07:30:00'), Timestamp('2172-02-06 08:21:00'), 'Absolute Lymphocyte Count'], [51146, Timestamp('2172-02-06 07:30:00'), Timestamp('2172-02-06 08:21:00'), 'Basophils'], [51200, Timestamp('2172-02-06 07:30:00'), Timestamp('2172-02-06 08:21:00'), 'Eosinophils'], [51221, Timestamp('2172-02-06 07:30:00'), Timestamp('2172-02-06 08:21:00'), 'Hematocrit'], [51222, Timestamp('2172-02-06 07:30:00'), Timestamp('2172-02-06 08:21:00'), 'Hemoglobin'], [51244, Timestamp('2172-02-06 07:30:00'), Timestamp('2172-02-06 08:21:00'), 'Lymphocytes'], [51248, Timestamp('2172-02-06 07:30:00'), Timestamp('2172-02-06 08:21:00'), 'MCH'], [51249, Timestamp('2172-02-06 07:30:00'), Timestamp('2172-02-06 08:21:00'), 'MCHC'], [51250, Timestamp('2172-02-06 07:30:00'), Timestamp('2172-02-06 08:21:00'), 'MCV'], [51254, Timestamp('2172-02-06 07:30:00'), Timestamp('2172-02-06 08:21:00'), 'Monocytes'], [51256, Timestamp('2172-02-06 07:30:00'), Timestamp('2172-02-06 08:21:00'), 'Neutrophils'], [51265, Timestamp('2172-02-06 07:30:00'), Timestamp('2172-02-06 08:21:00'), 'Platelet Count'], [51277, Timestamp('2172-02-06 07:30:00'), Timestamp('2172-02-06 08:21:00'), 'RDW'], [51279, Timestamp('2172-02-06 07:30:00'), Timestamp('2172-02-06 08:21:00'), 'Red Blood Cells'], [51301, Timestamp('2172-02-06 07:30:00'), Timestamp('2172-02-06 08:21:00'), 'White Blood Cells'], [52069, Timestamp('2172-02-06 07:30:00'), Timestamp('2172-02-06 08:21:00'), 'Absolute Basophil Count'], [52073, Timestamp('2172-02-06 07:30:00'), Timestamp('2172-02-06 08:21:00'), 'Absolute Eosinophil Count'], [52074, Timestamp('2172-02-06 07:30:00'), Timestamp('2172-02-06 08:21:00'), 'Absolute Monocyte Count'], [52075, Timestamp('2172-02-06 07:30:00'), Timestamp('2172-02-06 08:21:00'), 'Absolute Neutrophil Count'], [52135, Timestamp('2172-02-06 07:30:00'), Timestamp('2172-02-06 08:21:00'), 'Immature Granulocytes'], [52172, Timestamp('2172-02-06 07:30:00'), Timestamp('2172-02-06 08:21:00'), 'RDW-SD']]

Question: A 28 F is admitted. He/she says he/she has shortness of breath . History of illness: ___ yo G10 ___ at 20w6d with 'a few weeks' of cough and SOB. SOB acutely worsened today with wheezing. No fevers, chills, rigors, nausea, vomiting, diarrhea. No malaise, aches, myalgias. No ctx, VB, LOF. +FM. PNC: - ___ ___ by first trimester US B NEG/ ABS RH IG/ RI/ RPR NR/ HBsAg - / HIV -/ GC CT - - FFS - normal - Issues: obesity Past Medical History: OBHx: - SVD x 7 - sab x 2 D&C GynHx: denies STI PMH: asthma - no meds, no hospitlaizations or intubations PSH: tonsils, D&C Meds: PNV All: NKDA SHx: ___ Family History: non-contributory Allergies: No Known Allergies / Adverse Drug Reactions What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Albuterol 0.083% Neb Soln 0.9% Sodium Chloride (Mini Bag Plus) CefTRIAXone Albuterol Inhaler Influenza Vaccine Quadrivalent Ipratropium-Albuterol Neb Milk of Magnesia Prenatal Vitamins Albuterol 0.083% Neb Soln Azithromycin Bisacodyl Calcium Carbonate Docusate Sodium Acetaminophen Target Lab Orders: Absolute Lymphocyte Count Basophils Eosinophils Hematocrit Hemoglobin Lymphocytes MCH MCHC MCV Monocytes Neutrophils Platelet Count RDW Red Blood Cells White Blood Cells Absolute Basophil Count Absolute Eosinophil Count Absolute Monocyte Count Absolute Neutrophil Count Immature Granulocytes RDW-SD Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : On ___, Ms. ___ was admitted to the antepartum service at 20w6d for asthma exacerbation in the setting of community acquire pneumonia. CXR performed in the ED showed patchy right upper lobe opacity concerning for pneumonia with streaky bibasilar atelectasis. Her WBC count was noted to be elevated at 17.4 without any bandemia, which trended down to 14.5 on HD#2. She was given a nebulizer treatment and IV hydration. She was given a dose of IM Ceftriaxone 1g and was continued on PO azithromycin for a ___y ___, she was afebrile with stable vital signs, saturating 95-96% on RA without any evidence of respiratory distress. She was discharged home with outpatient follow up scheduled. Other Results: ___ 07:30AM BLOOD WBC-14.5* RBC-3.22* Hgb-10.3* Hct-31.3* MCV-97 MCH-32.0 MCHC-32.9 RDW-12.5 RDWSD-44.1 Plt ___ ___ 05:45PM BLOOD WBC-17.4* RBC-3.47* Hgb-11.4 Hct-33.4* MCV-96 MCH-32.9* MCHC-34.1 RDW-12.6 RDWSD-44.3 Plt ___ ___ 07:30AM BLOOD Neuts-67.9 Lymphs-18.7* Monos-7.2 Eos-5.4 Baso-0.3 Im ___ AbsNeut-9.84* AbsLymp-2.71 AbsMono-1.05* AbsEos-0.79* AbsBaso-0.05 ___ 05:45PM BLOOD Neuts-77.3* Lymphs-12.5* Monos-6.0 Eos-3.4 Baso-0.2 Im ___ AbsNeut-13.47*# AbsLymp-2.18 AbsMono-1.05* AbsEos-0.60* AbsBaso-0.04 ___ 07:30AM BLOOD Plt ___ ___ 05:45PM BLOOD Plt ___ ___ 05:45PM BLOOD Glucose-97 UreaN-4* Creat-0.5 Na-136 K-4.2 Cl-100 HCO3-24 AnGap-16 ___ 05:45PM BLOOD cTropnT-<0.01 ___ 05:45PM BLOOD D-Dimer-893* Sputum Culture x 2 contaminated

2195-10-02 22:42:00

ENGLISH

MARRIED

WHITE

M

[[24447853, Timestamp('2195-10-02 22:43:32'), '', 'ORTHO']]

[[{'Medications on Admission': ':\nasa \nlopressor\ncoumadin\nsynthroid\nlisinopril\ndiltazem\n\n4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One \n(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). \n5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY \n(Daily). \n6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 \ntimes a day). \n7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a \nday). \n8. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1) \nCapsule, Sustained Release PO BID (2 times a day). \n9. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). \n10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) \nTablet, Chewable PO TID (3 times a day). \n11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) \nTablet PO DAILY (Daily). \n12. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical BID \n(2 times a day) as needed. \n13. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H \n(every 4 hours). \n14. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every \n6 hours) as needed for Breakthrough pain. \n15. Warfarin 2 mg Tablet Sig: dose to keep inr 2.5 -3.0 Tablets \nPO once a day: goal inr is 2.5 -3.0 dc lovenox when \ntherapeutic\nfollow up for dosing with ___ ___. \n16. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous \nDAILY (Daily): DC WHEN INR THERAPEUTIC. \n\nFacility:\n___', 'Brief Hospital Course': ':\nHe was taken to the or on ___ and undewerwent a orif of left \nhip fracture with out complications transfered to pacu stable . \nhe was then tx to the ___ floor and was started back on coumadin \n with a lovenox bridge, \n\n', 'Pertinent Results:': '\n___ 06:10AM BLOOD Hct-26.9*\n___ 06:15AM BLOOD Hct-23.6*\n___ 06:35AM BLOOD WBC-8.8 RBC-2.90* Hgb-9.3* Hct-26.0* \nMCV-90 MCH-32.2* MCHC-36.0* RDW-13.0 Plt ___\n___ 04:37PM BLOOD Hct-27.4*\n___ 06:28AM BLOOD Hct-32.2*\n___ 06:32AM BLOOD WBC-8.8 RBC-3.64* Hgb-11.6* Hct-33.3* \nMCV-92 MCH-32.0 MCHC-34.9 RDW-13.0 Plt ___\n___ 07:25PM BLOOD WBC-6.9 RBC-4.24* Hgb-13.4* Hct-38.3* \nMCV-90 MCH-31.6 MCHC-35.0 RDW-13.4 Plt ___\n___ 07:25PM BLOOD Neuts-69.2 ___ Monos-6.1 Eos-3.6 \nBaso-0.5\n___ 06:10AM BLOOD ___\n___ 06:15AM BLOOD ___\n___ 06:40AM BLOOD ___\n___ 06:35AM BLOOD Plt ___\n___ 12:40PM BLOOD ___\n___ 06:28AM BLOOD ___ PTT-34.9 ___\n___ 03:30PM BLOOD ___ PTT-35.7* ___\n___ 06:32AM BLOOD ___ PTT-34.3 ___\n___ 07:25PM BLOOD ___ PTT-35.2* ___\n___ 06:28AM BLOOD Glucose-126* UreaN-11 Creat-0.7 Na-135 \nK-4.8 Cl-102 HCO3-26 AnGap-12\n___ 06:32AM BLOOD Glucose-151* UreaN-13 Creat-0.7 Na-140 \nK-4.9 Cl-104 HCO3-28 AnGap-13\n___ 07:25PM BLOOD Glucose-146* UreaN-13 Creat-0.8 Na-138 \nK-4.3 Cl-103 HCO3-25 AnGap-14\n___ 07:25PM BLOOD cTropnT-<0.01\n___ 06:35AM BLOOD Calcium-7.9* Phos-2.1* Mg-1.9\n___ 06:32AM BLOOD Calcium-8.4 Phos-2.9 Mg-2.2\n\n', 'Physical Exam:|Physical': '\nheeent wnl no jvd or bruits\nchest clear\n___ no mrg\nabd sft nt nd\northo wound intact ___ fhl sensation intact\nneuro non focal\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': "\n___ yo male s/p fall now with left hip fxhx of a fib on coumadin \ninr is 3.7\n\nPast Medical History:\n1. CAD- Pt with one vessel CAD.\n2. Atrial fibrillation- Pt had been on amiodarone but this was \ndiscontinued due to atrial tachycardia vs aberrated complexes \nand a wide QRS at 132 milliseconds. His metoprolol was increased \nto 100 mg BID and he has been moniter on ___ of Hearts since \nthat time.\n3. HTN\n4. Hypothyroidism\n5. Obesity \n6. Hydrocele\n7. Pelvic fracture s/p ORIF- Occurred when pt fell down a \nflight of stairs ___ years ago.\n8. BPH\n\nSocial History:\n___\nFamily History:\nPt's father died from a MI in his ___. His mother died from \nrenal disease.\n\n", 'Chief Complaint:|Complaint:': '\npain left hip\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nPatient recorded as having No Known Allergies to Drugs\n\n'}, '13058288-DS-5', 5, 'orthopaedics']]

[['LEFT HIP AND PELVIS RADIOGRAPH PERFORMED ON ___\n\nCOMPARISON: None.\n\nCLINICAL HISTORY: ___ man with left hip fracture. Evaluate fracture.\n\nFINDINGS: Four views of the left hip and pelvis are obtained. An acute\nfracture is seen involving the left proximal femur. Fractures comminuted with\nfracture lines noted in an intertrochanteric and subtrochanteric level. There\nis hardware noted along the left acetabulum compatible with prior surgical\nfixation. Both femoral heads are well located. No additional fractures are\nseen.\n\nIMPRESSION: Acute fracture of the left proximal femur.\n', '13058288-RR-7', 7, ''], ['PRE-OP CHEST RADIOGRAPH PERFORMED ON ___\n\nComparison is made with a prior study from ___.\n\nCLINICAL HISTORY: Pre-op chest radiograph, hip fracture.\n\nFINDINGS: Single frontal view of the chest is obtained. Dual-lead pacer\ndevice is again noted with lead tips in the expected location of the right\natrium and right ventricle. Right CP angle is excluded thus limiting\nevaluation. Lungs are clear bilaterally. There is no pleural effusion or\npneumothorax. Thickening of the right paratracheal stripe is again noted and\nmay be related to vascular ectasia.\n\nIMPRESSION: No acute intrathoracic process.\n', '13058288-RR-8', 8, ''], ['\nSTUDY: Left femur intraoperative study, ___.\n\nHISTORY: Patient with ORIF of left femur.\n\nFINDINGS: 21 fluoroscopic images from the operating room demonstrate interval\nplacement of a short intramedullary rod and proximal gamma nail fixating an\nintertrochanteric fracture of the left femur. There are no signs of hardware-\nrelated complications. There is improved anatomic alignment. A fracture\nplate is again seen within the left acetabulum, which is unchanged without\ncomplications. The total intraservice time was 151 seconds. Please refer to\nthe operative note for additional details.\n\n\n\n', '13058288-RR-9', 9, '']]

[[24447853, Timestamp('2195-10-02 23:00:00'), Timestamp('2195-10-08 16:00:00'), 'MAIN', 'Pantoprazole', '027462', '00008084199', '40mg Tablet'], [24447853, Timestamp('2195-10-02 20:00:00'), Timestamp('2195-10-08 16:00:00'), 'MAIN', 'Senna', '019964', '00904516561', '1 Tablet'], [24447853, Timestamp('2195-10-02 23:00:00'), Timestamp('2195-10-05 15:00:00'), 'MAIN', 'Pneumococcal Vac Polyvalent', '048548', '00006494300', '25mcg/0.5mL Vial'], [24447853, Timestamp('2195-10-03 09:00:00'), Timestamp('2195-10-03 22:00:00'), 'MAIN', 'Phytonadione', '002301', '00409915801', '10mg/mL Amp'], [24447853, Timestamp('2195-10-02 23:00:00'), Timestamp('2195-10-06 09:00:00'), 'MAIN', 'Morphine Sulfate', '004072', '00409125830', '4mg Syringe'], [24447853, Timestamp('2195-10-02 23:00:00'), Timestamp('2195-10-03 15:00:00'), 'BASE', 'Potassium Chl 20 mEq / 1000 mL D5NS', '011988', '00338080304', '1000 mL Bag'], [24447853, Timestamp('2195-10-02 20:00:00'), Timestamp('2195-10-08 16:00:00'), 'MAIN', 'Diltiazem Extended-Release', '024537', '00258368890', '180 mg ER Cap'], [24447853, Timestamp('2195-10-02 23:00:00'), Timestamp('2195-10-05 15:00:00'), 'MAIN', 'Influenza Virus Vaccine', '064182', '58160087546', '0.5mL Syringe'], [24447853, Timestamp('2195-10-02 10:00:00'), Timestamp('2195-10-08 16:00:00'), 'MAIN', 'Atorvastatin', '029967', '00071015540', '10mg Tablet'], [24447853, Timestamp('2195-10-02 23:00:00'), Timestamp('2195-10-06 09:00:00'), 'MAIN', 'Acetaminophen', '004489', '00182844789', '325mg Tablet'], [24447853, Timestamp('2195-10-02 10:00:00'), Timestamp('2195-10-08 16:00:00'), 'MAIN', 'Lisinopril', '000391', '00172376010', '20mg Tablet'], [24447853, Timestamp('2195-10-03 16:00:00'), Timestamp('2195-10-04 15:00:00'), 'BASE', 'Potassium Chl 20 mEq / 1000 mL D5NS', '011988', '00338080304', '1000 mL Bag'], [24447853, Timestamp('2195-10-02 10:00:00'), Timestamp('2195-10-08 16:00:00'), 'MAIN', 'Levothyroxine Sodium', '006649', '00074455211', '50mcg Tablet'], [24447853, Timestamp('2195-10-03 05:00:00'), Timestamp('2195-10-03 22:00:00'), 'MAIN', 'Cyclobenzaprine', '004681', '51079064420', '10 mg Tab'], [24447853, Timestamp('2195-10-02 23:00:00'), Timestamp('2195-10-08 16:00:00'), 'MAIN', 'Sodium Chloride 0.9% Flush', '', '0', 'Syringe'], [24447853, Timestamp('2195-10-02 20:00:00'), Timestamp('2195-10-08 16:00:00'), 'MAIN', 'Docusate Sodium', '003009', '00904224461', '100mg Capsule'], [24447853, Timestamp('2195-10-02 20:00:00'), Timestamp('2195-10-08 16:00:00'), 'MAIN', 'Metoprolol Tartrate', '005132', '51079080120', '50mg Tablet'], [24447853, Timestamp('2195-10-02 23:00:00'), Timestamp('2195-10-06 09:00:00'), 'MAIN', 'Morphine Sulfate', '004070', '00409176230', '2mg Syringe'], [24447853, Timestamp('2195-10-03 04:00:00'), Timestamp('2195-10-03 04:00:00'), 'MAIN', 'Diazepam', '003767', '51079028420', '2 mg Tab']]

[]

['orthopaedics']

[[51237, Timestamp('2195-10-03 06:32:00'), Timestamp('2195-10-03 08:01:00'), 'INR(PT)'], [51274, Timestamp('2195-10-03 06:32:00'), Timestamp('2195-10-03 08:01:00'), 'PT'], [51275, Timestamp('2195-10-03 06:32:00'), Timestamp('2195-10-03 08:01:00'), 'PTT'], [50868, Timestamp('2195-10-03 06:32:00'), Timestamp('2195-10-03 08:11:00'), 'Anion Gap'], [50882, Timestamp('2195-10-03 06:32:00'), Timestamp('2195-10-03 08:11:00'), 'Bicarbonate'], [50893, Timestamp('2195-10-03 06:32:00'), Timestamp('2195-10-03 08:11:00'), 'Calcium, Total'], [50902, Timestamp('2195-10-03 06:32:00'), Timestamp('2195-10-03 08:11:00'), 'Chloride'], [50912, Timestamp('2195-10-03 06:32:00'), Timestamp('2195-10-03 08:11:00'), 'Creatinine'], [50931, Timestamp('2195-10-03 06:32:00'), Timestamp('2195-10-03 08:11:00'), 'Glucose'], [50960, Timestamp('2195-10-03 06:32:00'), Timestamp('2195-10-03 08:11:00'), 'Magnesium'], [50970, Timestamp('2195-10-03 06:32:00'), Timestamp('2195-10-03 08:11:00'), 'Phosphate'], [50971, Timestamp('2195-10-03 06:32:00'), Timestamp('2195-10-03 08:11:00'), 'Potassium'], [50983, Timestamp('2195-10-03 06:32:00'), Timestamp('2195-10-03 08:11:00'), 'Sodium'], [51006, Timestamp('2195-10-03 06:32:00'), Timestamp('2195-10-03 08:11:00'), 'Urea Nitrogen'], [51221, Timestamp('2195-10-03 06:32:00'), Timestamp('2195-10-03 07:41:00'), 'Hematocrit'], [51222, Timestamp('2195-10-03 06:32:00'), Timestamp('2195-10-03 07:41:00'), 'Hemoglobin'], [51248, Timestamp('2195-10-03 06:32:00'), Timestamp('2195-10-03 07:41:00'), 'MCH'], [51249, Timestamp('2195-10-03 06:32:00'), Timestamp('2195-10-03 07:41:00'), 'MCHC'], [51250, Timestamp('2195-10-03 06:32:00'), Timestamp('2195-10-03 07:41:00'), 'MCV'], [51265, Timestamp('2195-10-03 06:32:00'), Timestamp('2195-10-03 07:41:00'), 'Platelet Count'], [51277, Timestamp('2195-10-03 06:32:00'), Timestamp('2195-10-03 07:41:00'), 'RDW'], [51279, Timestamp('2195-10-03 06:32:00'), Timestamp('2195-10-03 07:41:00'), 'Red Blood Cells'], [51301, Timestamp('2195-10-03 06:32:00'), Timestamp('2195-10-03 07:41:00'), 'White Blood Cells'], [51237, Timestamp('2195-10-03 15:30:00'), Timestamp('2195-10-03 16:25:00'), 'INR(PT)'], [51274, Timestamp('2195-10-03 15:30:00'), Timestamp('2195-10-03 16:25:00'), 'PT'], [51275, Timestamp('2195-10-03 15:30:00'), Timestamp('2195-10-03 16:25:00'), 'PTT']]

Question: A 82 M is admitted. He/she says he/she has pain left hip . History of illness: ___ yo male s/p fall now with left hip fxhx of a fib on coumadin inr is 3.7 Past Medical History: 1. CAD- Pt with one vessel CAD. 2. Atrial fibrillation- Pt had been on amiodarone but this was discontinued due to atrial tachycardia vs aberrated complexes and a wide QRS at 132 milliseconds. His metoprolol was increased to 100 mg BID and he has been moniter on ___ of Hearts since that time. 3. HTN 4. Hypothyroidism 5. Obesity 6. Hydrocele 7. Pelvic fracture s/p ORIF- Occurred when pt fell down a flight of stairs ___ years ago. 8. BPH Social History: ___ Family History: Pt's father died from a MI in his ___. His mother died from renal disease. Allergies: Patient recorded as having No Known Allergies to Drugs What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Pantoprazole Senna Pneumococcal Vac Polyvalent Phytonadione Morphine Sulfate Potassium Chl 20 mEq / 1000 mL D5NS Diltiazem Extended-Release Influenza Virus Vaccine Atorvastatin Acetaminophen Lisinopril Potassium Chl 20 mEq / 1000 mL D5NS Levothyroxine Sodium Cyclobenzaprine Sodium Chloride 0.9% Flush Docusate Sodium Metoprolol Tartrate Morphine Sulfate Diazepam Target Lab Orders: INR(PT) PT PTT Anion Gap Bicarbonate Calcium, Total Chloride Creatinine Glucose Magnesium Phosphate Potassium Sodium Urea Nitrogen Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells INR(PT) PT PTT Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : He was taken to the or on ___ and undewerwent a orif of left hip fracture with out complications transfered to pacu stable . he was then tx to the ___ floor and was started back on coumadin with a lovenox bridge, Other Results: ___ 06:10AM BLOOD Hct-26.9* ___ 06:15AM BLOOD Hct-23.6* ___ 06:35AM BLOOD WBC-8.8 RBC-2.90* Hgb-9.3* Hct-26.0* MCV-90 MCH-32.2* MCHC-36.0* RDW-13.0 Plt ___ ___ 04:37PM BLOOD Hct-27.4* ___ 06:28AM BLOOD Hct-32.2* ___ 06:32AM BLOOD WBC-8.8 RBC-3.64* Hgb-11.6* Hct-33.3* MCV-92 MCH-32.0 MCHC-34.9 RDW-13.0 Plt ___ ___ 07:25PM BLOOD WBC-6.9 RBC-4.24* Hgb-13.4* Hct-38.3* MCV-90 MCH-31.6 MCHC-35.0 RDW-13.4 Plt ___ ___ 07:25PM BLOOD Neuts-69.2 ___ Monos-6.1 Eos-3.6 Baso-0.5 ___ 06:10AM BLOOD ___ ___ 06:15AM BLOOD ___ ___ 06:40AM BLOOD ___ ___ 06:35AM BLOOD Plt ___ ___ 12:40PM BLOOD ___ ___ 06:28AM BLOOD ___ PTT-34.9 ___ ___ 03:30PM BLOOD ___ PTT-35.7* ___ ___ 06:32AM BLOOD ___ PTT-34.3 ___ ___ 07:25PM BLOOD ___ PTT-35.2* ___ ___ 06:28AM BLOOD Glucose-126* UreaN-11 Creat-0.7 Na-135 K-4.8 Cl-102 HCO3-26 AnGap-12 ___ 06:32AM BLOOD Glucose-151* UreaN-13 Creat-0.7 Na-140 K-4.9 Cl-104 HCO3-28 AnGap-13 ___ 07:25PM BLOOD Glucose-146* UreaN-13 Creat-0.8 Na-138 K-4.3 Cl-103 HCO3-25 AnGap-14 ___ 07:25PM BLOOD cTropnT-<0.01 ___ 06:35AM BLOOD Calcium-7.9* Phos-2.1* Mg-1.9 ___ 06:32AM BLOOD Calcium-8.4 Phos-2.9 Mg-2.2

2121-06-06 18:31:00

ENGLISH

WHITE

M

[[23158031, Timestamp('2121-06-06 18:32:42'), '', 'CSURG']]

[[{'Medications on Admission': ':\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Levothyroxine Sodium 25 mcg PO DAILY \n2. Atenolol 25 mg PO DAILY \n3. Simvastatin 10 mg PO QPM \n4. GlipiZIDE XL 5 mg PO DAILY \n5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS \n\nFacility:\n___\n\nPast medical history:\nHypertension\nHyperlipidemia\nHypothyroidism\nDiabetes\nRemote afib history never on anticoagulation', 'Brief Hospital Course': ':\nMr. ___ was admitted to ___ on ___. He underwent \nroutine preoperative testing and evaluation. He was medically \nmanaged while undergoing surgical work-up and Brillinta \nwash-out. He was taken to the operating room on ___ and \nunderwent coronary artery bypass graft x 2 (left internal \nmammary artery graft to the left anterior descending and reverse \nsaphenous vein graft to the second marginal branch). He \ntolerated the procedure well and was transferred to the CVICU in \nstable condition for recovery and invasive monitoring. Over the \nnext several hours he awoke neurologically intact, was \nextubated, and weaned off vasopressors. \nBeta blocker was initiated and he was diuresed toward his \npreoperative weight. He was transferred to the telemetry floor \nfor further recovery. He was evaluated by the physical therapy \nservice for assistance with strength and mobility. He had \npost-operative atrial fibrillation which was treated with \nLopressor and oral amiodarone. He was started on Coumadin for \nanticoagulation. By the time of discharge on POD 4 he was \nambulating with assistance, the wound was healing, and pain was \ncontrolled with oral analgesics. He was discharged to ___ \n___ in ___ in good condition with appropriate follow up \ninstructions.\n\n', 'Pertinent Results:': '\nTransthoracic Echocardiogram ___\nThe left atrial volume index is normal. The right atrium is \nmildly enlarged. There is mild symmetric left ventricular \nhypertrophy with a normal cavity size. There is mild regional \nleft ventricular systolic dysfunction with severe hypokinesis to \nakinesis of the inferior and inferolateral walls (see schematic) \nand preserved/normal contractility of the remaining segments. \nThe visually estimated left ventricular ejection fraction is \n40-45%. There is no resting left ventricular outflow tract \ngradient. Tissue Doppler suggests an increased left ventricular \nfilling pressure (PCWP greater than 18 mmHg). There is \nechocardiographic evidence for diastolic dysfunction (grade \nindeterminate). Normal right ventricular cavity size with mild \nglobal free wall hypokinesis. The aortic sinus is mildly dilated \nwith normal ascending aorta diameter for gender. The aortic\narch diameter is normal with a normal descending aorta diameter. \nThe aortic valve leaflets (3) are mildly thickened. There is no \naortic valve stenosis. There is no aortic regurgitation. The \nmitral valve leaflets are\nmildly thickened with no mitral valve prolapse. There is mild to \nmoderate [___] mitral regurgitation. The pulmonic valve \nleaflets are not well seen. The tricuspid valve is not well \nseen. There is physiologic tricuspid\nregurgitation. There is moderate pulmonary artery systolic \nhypertension. There is no pericardial effusion.\n\nIMPRESSION: Suboptimal image quality. Mild regional left \nventricular systolic dysfunction c/w CAD. Echocardiographic \nevidence for diastolic dysfunction with elevated PCWP. Normal \nright ventricular cavity size with mild global hypokinesis. \nModerate pulmonary artery systolic hypertension. Mild to \nmoderate mitral regurgitation.\n\nTransesophageal Echocardiogram ___\nPRE-OPERATIVE STATE: Pre-bypass assessment.\nLeft Atrium ___ Veins: Dilated ___. No spontaneous \necho contrast is seen in the ___.\nLeft Ventricle (LV): Normal cavity size. Mild-moderate regional \nsystolic dysfunction (see schematic).\nRight Ventricle (RV): Normal cavity size. Normal free wall \nmotion.\nAorta: Normal sinus diameter. Normal descending aorta diameter. \nNo dissection. Complex (>4mm) descending atheroma.\nAortic Valve: Thin/mobile (3) leaflets. No stenosis. Mild [1+] \nregurgitation.\nMitral Valve: Mildly thickened leaflets. Mild annular \ncalcification. Mild-moderate [___] regurgitation.\nTricuspid Valve: Mild [1+] regurgitation.\nPericardium: No effusion.\n\nPOST-OP STATE: The post-bypass TEE was performed at 14:52:00. \nSinus rhythm.\nSupport: Vasopressor(s): none.\nLeft Ventricle: Similar to preoperative findings.\nAorta: Intact. No dissection.\nAortic Valve: No change in aortic valve morphology from \npreoperative state.\nMitral Valve: No change in mitral valve morphology from \npreoperative state.\n\nCXR: ___\nStable, borderline enlarged cardiomediastinal silhouette. \nMildly low lung \nvolumes bilaterally. Prominent vascular congestion. Stable \nleft apical \npneumothorax. No area of focal consolidation. Trace left \npleural effusion. In comparison to the study completed on ___, patient has been extubated and enteric tube removed. \nThe mediastinal and left sided chest tube have also been \nremoved. The right internal jugular hemodialysis catheter is \nstable, terminates at the distal SVC. \n IMPRESSION: \nStable left apical pneumothorax. \n\n', 'Physical Exam:|Physical': '\nPulse: 78 Resp: 16 O2 sat:95%RA \nB/P ___\n___ Weight:80 kg\n\nGeneral:\nSkin: Dry [x] intact [x]\nHEENT: PERRLA [x] EOMI [x]\nNeck: Supple [x] Full ROM [x]\nChest: Lungs clear bilaterally [x]\nHeart: RRR [x] Irregular [] Murmur [] grade ______ \nAbdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds \n+[x]\nExtremities: cool feet [x], well-perfused [x] Edema [] _____\nVaricosities: None [x]\nNeuro: Grossly intact [x]\nPulses:\nFemoral Right:p Left:p\nDP Right:p Left:p\n___ Right:p Left:p\nRadial Right:p Left:p\n\nCarotid Bruit Right: - Left:-\n\nDischarge Physical Exam:\nBP: 108/66 HR:71 T:97.7 RR:16 o2sat:98% RA\n\nPhysical Examination:\nGeneral: NAD [x] \nNeurological: A/O x3 [x] non-focal [x] \nHEENT: PEERL [x] \nCardiovascular: RRR [x] SR\nRespiratory: CTA [x] No resp distress [x]\nGI/Abdomen: Bowel sounds present [x] Soft [x] ND [x] NT [x]\nExtremities: \nRight Upper extremity Warm [x] Edema \nLeft Upper extremity Warm [x] Edema \nRight Lower extremity Warm [x] Edema tr\nLeft Lower extremity Warm [x] Edema tr\nPulses:\nDP Right: + Left:+\n___ Right: Left:\nRadial Right: + Left:+\nSkin/Wounds: Dry [x] intact [x]\nSternal: CDI [x] no erythema or drainage [x]\n Sternum stable [x] Prevena []\nLower extremity: Right [x] Left [] CDI [x]\nUpper extremity: Right [] Left [] CDI []\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\nMr. ___ is n ___ year old man with a past medical history \nsignificant for diabetes mellitus, hyperlipidemia, hypertension, \nand hypothyroid. He presented to ___ with a one day \nhistory of chest pain. He was in his usual state of health until \nthe day prior to presentation. He developed midsternal chest \nshortly after climbing a hill which was persistent until he fell \nasleep. When he awakened in the morning, he continued to have \nchest discomfort which caused his wife to bring him to the \nemergency department. He ruled in for an inferior wall ST \nelevation myocardial infarction. A cardiac catheterization a ___ \n___ demonstrated multivessel coronary artery disease. He \nwas transferred to ___ for surgical consultation. \n\nPast Medical History:\nAtrial Fibrillation, remote, never anticoagulated\nDiabetes Mellitus Type II\nHyperlipidemia\nHypertension \nHyperlipidemia \nHypothyroidism \n\nSocial History:\n___\nFamily History:\nMother with PPM at age ___\nBrother with PPM\nBrother with HTN\n\n', 'Chief Complaint:|Complaint:': '\nChest pain/tightness\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nNo Known Allergies / Adverse Drug Reactions\n\n'}, '13025572-DS-19', 19, 'cardiothoracic']]

[['EXAMINATION: CHEST (PRE-OP PA AND LAT) ___\n\nINDICATION: ___ year old man with CAD// pre-op baseline study Surg: ___\n(CABG) ACUTE MYOCARDIAL INFARCTION\n\nIMPRESSION: \n\nNo prior chest radiographs available.\n\nLateral view shows a region of peribronchial infiltration at one of the lung\nbases, projecting over the lower thoracic spine. This could be residual of\nprevious infection, but should be evaluated clinically for the possibility of\nactive pneumonia. Lateral view also shows very small pleural effusions.\n\nNo pulmonary edema. Heart size normal.\n\nRECOMMENDATION(S): Clinical evaluation for any evidence of active pneumonia.\n', '13025572-RR-12', 12, ''], ['EXAMINATION: CHEST PORT. LINE PLACEMENT\n\nINDICATION: ___ year old man with CAD s/p CABG. Please ___ at\n___ with abnormalities.// Fast track extubation cardiac surgery, ?line\nplacement, r/o PTX/Effusion Contact name: ___: ___\n\nTECHNIQUE: Chest AP\n\nCOMPARISON: AP and lateral dated ___\n\nFINDINGS: \n\nStatus post CABG with stable postsurgical changes of the cardiac and\nmediastinal silhouettes. The lungs are well expanded. No pneumothorax. \nSmall left-sided pleural effusion. The endotracheal tube is in appropriate\nposition. The right internal jugular central venous catheter terminates at\nthe distal SVC. An enteric tube is seen passing well below the level of the\ndiaphragm. The mediastinal and left-sided chest tube tube are well\npositioned.\n\nIMPRESSION: \n\n1. No pneumothorax. Small left-sided pleural effusion.\n2. Appropriate positioning of the enteric tube, right internal jugular\ncentral venous catheter, mediastinal and chest tube\n', '13025572-RR-13', 13, 'chest ap'], ['EXAMINATION: CHEST (PORTABLE AP)\n\nINDICATION: ___ year old man with s/p CABG, CTs to WS now// eval for ptx\n\nTECHNIQUE: Chest AP film\n\nCOMPARISON: AP film from ___\n\nFINDINGS: \n\nIn comparison to the previous study completed on ___, patient has\nbeen extubated with removal of NG tube. There still remain 2 chest tubes in\nthe left base with right IJ hemodialysis catheter terminating at the\ncavoatrial junction.\n\nMildly low lung volumes bilaterally. Pulmonary vascular congestion has\nimproved compared to prior image. No area of focal consolidation. Small left\napical pneumothorax. Trace left pleural effusion, stable. Borderline\nenlarged cardiomediastinal silhouette is stable.\n\nIMPRESSION: \n\nSmall left apical pneumothorax.\n', '13025572-RR-14', 14, 'chest ap film'], ["EXAMINATION: CHEST (PORTABLE AP)\n\nINDICATION: ___ year old man with s/p CABG, CTs d/c'd// eval for ptx\n\nTECHNIQUE: Chest AP film\n\nCOMPARISON: AP film from ___\n\nFINDINGS: \n\nStable, borderline enlarged cardiomediastinal silhouette. Mildly low lung\nvolumes bilaterally. Prominent vascular congestion. Stable left apical\npneumothorax. No area of focal consolidation. Trace left pleural effusion.\n\nIn comparison to the study completed on ___, patient has been\nextubated and enteric tube removed. The mediastinal and left sided chest tube\nhave also been removed. The right internal jugular hemodialysis catheter is\nstable, terminates at the distal SVC.\n\nIMPRESSION: \n\nStable left apical pneumothorax.\n", '13025572-RR-15', 15, 'chest ap film'], ['EXAMINATION: CHEST (PORTABLE AP)\n\nINDICATION: ___ year old man s/p CABG// eval for pleural effusions\n\nTECHNIQUE: Chest AP\n\nCOMPARISON: ___\n\nIMPRESSION: \n\nLungs are low volume with slight increase in volume of the left pleural\neffusion.. Trace left apical pneumothorax is unchanged. Cardiomediastinal\nsilhouette is stable. The right lung remains clear. Consolidative opacity in\nthe left lower lobe is slightly more prominent and most likely represents\natelectasis.\n', '13025572-RR-17', 17, 'chest ap']]

[[23158031, Timestamp('2121-06-06 22:00:00'), Timestamp('2121-06-09 14:00:00'), 'MAIN', 'Latanoprost 0.005% Ophth. Soln.', '027370', '61314054701', '2.5mL Dropper Bottle'], [23158031, Timestamp('2121-06-07 08:00:00'), Timestamp('2121-06-09 14:00:00'), 'MAIN', 'Atenolol', '015864', '51079075920', '25 mg Tab'], [23158031, Timestamp('2121-06-06 19:00:00'), Timestamp('2121-06-09 14:00:00'), 'MAIN', 'Aspirin', '004380', '66553000201', '81mg Tab'], [23158031, Timestamp('2121-06-06 22:00:00'), Timestamp('2121-06-07 10:00:00'), 'BASE', '5% Dextrose', '', '0', 'HEPARIN BASE'], [23158031, Timestamp('2121-06-06 22:00:00'), Timestamp('2121-06-07 10:00:00'), 'MAIN', 'Heparin Sodium', '060301', '00409779362', '25,000 unit Premix Bag'], [23158031, Timestamp('2121-06-06 08:00:00'), Timestamp('2121-06-09 14:00:00'), 'MAIN', 'Levothyroxine Sodium', '006648', '00378180077', '25mcg Tablet'], [23158031, Timestamp('2121-06-06 19:00:00'), Timestamp('2121-06-09 14:00:00'), 'MAIN', 'Insulin', '001723', '00002821501', '100 Units / mL - 10 mL Vial'], [23158031, Timestamp('2121-06-06 19:00:00'), Timestamp('2121-06-09 14:00:00'), 'MAIN', 'Glucagon', '066517', '00597026010', '1mg Vial'], [23158031, Timestamp('2121-06-06 20:00:00'), Timestamp('2121-06-09 14:00:00'), 'MAIN', 'Simvastatin', '016577', '68084051101', '10mg Tablet'], [23158031, Timestamp('2121-06-07 11:00:00'), Timestamp('2121-06-08 01:00:00'), 'BASE', '5% Dextrose', '', '0', 'HEPARIN BASE'], [23158031, Timestamp('2121-06-07 11:00:00'), Timestamp('2121-06-08 01:00:00'), 'MAIN', 'Heparin Sodium', '060301', '00409779362', '25,000 unit Premix Bag'], [23158031, Timestamp('2121-06-06 19:00:00'), Timestamp('2121-06-09 14:00:00'), 'MAIN', 'Senna', '002922', '54162000708', '8.8 mg / 5 mL Syrup'], [23158031, Timestamp('2121-06-06 19:00:00'), Timestamp('2121-06-09 14:00:00'), 'MAIN', 'Senna', '019964', '00904652261', '8.6 mg Tablet'], [23158031, Timestamp('2121-06-06 19:00:00'), Timestamp('2121-06-09 14:00:00'), 'MAIN', 'Glucose Gel', '001781', '38396055018', '15 g Tube'], [23158031, Timestamp('2121-06-06 19:00:00'), Timestamp('2121-06-06 19:00:00'), 'MAIN', 'Metoprolol Tartrate', '050631', '62584026501', '25mg Tablet'], [23158031, Timestamp('2121-06-06 20:00:00'), Timestamp('2121-06-09 14:00:00'), 'MAIN', 'GlipiZIDE', '001777', '51079081020', '5 mg Tab'], [23158031, Timestamp('2121-06-06 19:00:00'), Timestamp('2121-06-09 14:00:00'), 'MAIN', 'Docusate Sodium', '003009', '00904645561', '100mg Capsule'], [23158031, Timestamp('2121-06-06 19:00:00'), Timestamp('2121-06-09 14:00:00'), 'MAIN', 'Sodium Chloride 0.9% Flush', '', '0', '10 mL Syringe'], [23158031, Timestamp('2121-06-06 19:00:00'), Timestamp('2121-06-09 14:00:00'), 'MAIN', 'Docusate Sodium', '003017', '50383077111', '100mg / 10 mL Cup'], [23158031, Timestamp('2121-06-06 19:00:00'), Timestamp('2121-06-09 14:00:00'), 'MAIN', 'Dextrose 50%', '001989', '00409751716', '25 g / 50 mL Syringe']]

[['021009W', 10, 1, Timestamp('2121-06-09 00:00:00'), 'Bypass Coronary Artery, One Artery from Aorta with Autologous Venous Tissue, Open Approach'], ['02100Z9', 10, 2, Timestamp('2121-06-09 00:00:00'), 'Bypass Coronary Artery, One Artery from Left Internal Mammary, Open Approach'], ['06BP4ZZ', 10, 3, Timestamp('2121-06-09 00:00:00'), 'Excision of Right Saphenous Vein, Percutaneous Endoscopic Approach'], ['5A1221Z', 10, 4, Timestamp('2121-06-09 00:00:00'), 'Performance of Cardiac Output, Continuous']]

['cardiothoracic']

[[50861, Timestamp('2121-06-06 19:54:00'), Timestamp('2121-06-06 20:53:00'), 'Alanine Aminotransferase (ALT)'], [50862, Timestamp('2121-06-06 19:54:00'), Timestamp('2121-06-06 20:53:00'), 'Albumin'], [50863, Timestamp('2121-06-06 19:54:00'), Timestamp('2121-06-06 20:53:00'), 'Alkaline Phosphatase'], [50867, Timestamp('2121-06-06 19:54:00'), Timestamp('2121-06-06 20:53:00'), 'Amylase'], [50868, Timestamp('2121-06-06 19:54:00'), Timestamp('2121-06-06 20:53:00'), 'Anion Gap'], [50878, Timestamp('2121-06-06 19:54:00'), Timestamp('2121-06-06 20:53:00'), 'Asparate Aminotransferase (AST)'], [50882, Timestamp('2121-06-06 19:54:00'), Timestamp('2121-06-06 20:53:00'), 'Bicarbonate'], [50883, Timestamp('2121-06-06 19:54:00'), Timestamp('2121-06-07 02:17:00'), 'Bilirubin, Direct'], [50884, Timestamp('2121-06-06 19:54:00'), Timestamp('2121-06-07 02:17:00'), 'Bilirubin, Indirect'], [50885, Timestamp('2121-06-06 19:54:00'), Timestamp('2121-06-06 20:53:00'), 'Bilirubin, Total'], [50893, Timestamp('2121-06-06 19:54:00'), Timestamp('2121-06-06 20:53:00'), 'Calcium, Total'], [50902, Timestamp('2121-06-06 19:54:00'), Timestamp('2121-06-06 20:53:00'), 'Chloride'], [50912, Timestamp('2121-06-06 19:54:00'), Timestamp('2121-06-06 20:53:00'), 'Creatinine'], [50920, Timestamp('2121-06-06 19:54:00'), Timestamp('2121-06-06 20:53:00'), 'Estimated GFR (MDRD equation)'], [50931, Timestamp('2121-06-06 19:54:00'), Timestamp('2121-06-06 20:53:00'), 'Glucose'], [50934, Timestamp('2121-06-06 19:54:00'), Timestamp('2121-06-06 20:53:00'), 'H'], [50947, Timestamp('2121-06-06 19:54:00'), Timestamp('2121-06-06 20:53:00'), 'I'], [50954, Timestamp('2121-06-06 19:54:00'), Timestamp('2121-06-06 20:53:00'), 'Lactate Dehydrogenase (LD)'], [50960, Timestamp('2121-06-06 19:54:00'), Timestamp('2121-06-06 20:53:00'), 'Magnesium'], [50970, Timestamp('2121-06-06 19:54:00'), Timestamp('2121-06-06 20:53:00'), 'Phosphate'], [50971, Timestamp('2121-06-06 19:54:00'), Timestamp('2121-06-06 20:53:00'), 'Potassium'], [50983, Timestamp('2121-06-06 19:54:00'), Timestamp('2121-06-06 20:53:00'), 'Sodium'], [51006, Timestamp('2121-06-06 19:54:00'), Timestamp('2121-06-06 20:53:00'), 'Urea Nitrogen'], [51678, Timestamp('2121-06-06 19:54:00'), Timestamp('2121-06-06 20:53:00'), 'L'], [51237, Timestamp('2121-06-06 19:54:00'), Timestamp('2121-06-06 20:55:00'), 'INR(PT)'], [51274, Timestamp('2121-06-06 19:54:00'), Timestamp('2121-06-06 20:55:00'), 'PT'], [51275, Timestamp('2121-06-06 19:54:00'), Timestamp('2121-06-06 20:55:00'), 'PTT'], [50852, Timestamp('2121-06-06 19:54:00'), Timestamp('2121-06-06 21:51:00'), '% Hemoglobin A1c'], [51613, Timestamp('2121-06-06 19:54:00'), Timestamp('2121-06-06 21:51:00'), 'eAG'], [51221, Timestamp('2121-06-06 19:54:00'), Timestamp('2121-06-06 20:23:00'), 'Hematocrit'], [51222, Timestamp('2121-06-06 19:54:00'), Timestamp('2121-06-06 20:23:00'), 'Hemoglobin'], [51248, Timestamp('2121-06-06 19:54:00'), Timestamp('2121-06-06 20:23:00'), 'MCH'], [51249, Timestamp('2121-06-06 19:54:00'), Timestamp('2121-06-06 20:23:00'), 'MCHC'], [51250, Timestamp('2121-06-06 19:54:00'), Timestamp('2121-06-06 20:23:00'), 'MCV'], [51265, Timestamp('2121-06-06 19:54:00'), Timestamp('2121-06-06 20:23:00'), 'Platelet Count'], [51277, Timestamp('2121-06-06 19:54:00'), Timestamp('2121-06-06 20:23:00'), 'RDW'], [51279, Timestamp('2121-06-06 19:54:00'), Timestamp('2121-06-06 20:23:00'), 'Red Blood Cells'], [51301, Timestamp('2121-06-06 19:54:00'), Timestamp('2121-06-06 20:23:00'), 'White Blood Cells'], [52172, Timestamp('2121-06-06 19:54:00'), Timestamp('2121-06-06 20:23:00'), 'RDW-SD'], [51463, Timestamp('2121-06-06 21:14:00'), Timestamp('2121-06-06 22:23:00'), 'Bacteria'], [51464, Timestamp('2121-06-06 21:14:00'), Timestamp('2121-06-06 22:23:00'), 'Bilirubin'], [51466, Timestamp('2121-06-06 21:14:00'), Timestamp('2121-06-06 22:23:00'), 'Blood'], [51476, Timestamp('2121-06-06 21:14:00'), Timestamp('2121-06-06 22:23:00'), 'Epithelial Cells'], [51478, 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[51512, Timestamp('2121-06-06 21:14:00'), Timestamp('2121-06-06 22:23:00'), 'Urine Mucous'], [51514, Timestamp('2121-06-06 21:14:00'), Timestamp('2121-06-06 22:23:00'), 'Urobilinogen'], [51516, Timestamp('2121-06-06 21:14:00'), Timestamp('2121-06-06 22:23:00'), 'WBC'], [51519, Timestamp('2121-06-06 21:14:00'), Timestamp('2121-06-06 22:23:00'), 'Yeast'], [51877, Timestamp('2121-06-06 22:20:00'), Timestamp('2121-06-07 14:02:00'), 'MRSA PCR'], [51893, Timestamp('2121-06-06 22:20:00'), Timestamp('2121-06-07 14:02:00'), 'Staph aureus PCR'], [51275, Timestamp('2121-06-07 04:50:00'), Timestamp('2121-06-07 06:15:00'), 'PTT'], [51275, Timestamp('2121-06-07 17:35:00'), Timestamp('2121-06-07 18:04:00'), 'PTT']]

Question: A 81 M is admitted. He/she says he/she has Chest pain/tightness . History of illness: Mr. ___ is n ___ year old man with a past medical history significant for diabetes mellitus, hyperlipidemia, hypertension, and hypothyroid. He presented to ___ with a one day history of chest pain. He was in his usual state of health until the day prior to presentation. He developed midsternal chest shortly after climbing a hill which was persistent until he fell asleep. When he awakened in the morning, he continued to have chest discomfort which caused his wife to bring him to the emergency department. He ruled in for an inferior wall ST elevation myocardial infarction. A cardiac catheterization a ___ ___ demonstrated multivessel coronary artery disease. He was transferred to ___ for surgical consultation. Past Medical History: Atrial Fibrillation, remote, never anticoagulated Diabetes Mellitus Type II Hyperlipidemia Hypertension Hyperlipidemia Hypothyroidism Social History: ___ Family History: Mother with PPM at age ___ Brother with PPM Brother with HTN Allergies: No Known Allergies / Adverse Drug Reactions What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Latanoprost 0.005% Ophth. Soln. Atenolol Aspirin 5% Dextrose Heparin Sodium Levothyroxine Sodium Insulin Glucagon Simvastatin 5% Dextrose Heparin Sodium Senna Senna Glucose Gel Metoprolol Tartrate GlipiZIDE Docusate Sodium Sodium Chloride 0.9% Flush Docusate Sodium Dextrose 50% Target Lab Orders: Alanine Aminotransferase (ALT) Albumin Alkaline Phosphatase Amylase Anion Gap Asparate Aminotransferase (AST) Bicarbonate Bilirubin, Direct Bilirubin, Indirect Bilirubin, Total Calcium, Total Chloride Creatinine Estimated GFR (MDRD equation) Glucose H I Lactate Dehydrogenase (LD) Magnesium Phosphate Potassium Sodium Urea Nitrogen L INR(PT) PT PTT % Hemoglobin A1c eAG Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells RDW-SD Bacteria Bilirubin Blood Epithelial Cells Glucose Ketone Leukocytes Nitrite pH Protein RBC Specific Gravity Transitional Epithelial Cells Urine Appearance Urine Color Urine Mucous Urobilinogen WBC Yeast MRSA PCR Staph aureus PCR PTT PTT Target Procedures: Bypass Coronary Artery, One Artery from Aorta with Autologous Venous Tissue, Open Approach Bypass Coronary Artery, One Artery from Left Internal Mammary, Open Approach Excision of Right Saphenous Vein, Percutaneous Endoscopic Approach Performance of Cardiac Output, Continuous DOCTOR'S NOTE Hospital Notes: : Mr. ___ was admitted to ___ on ___. He underwent routine preoperative testing and evaluation. He was medically managed while undergoing surgical work-up and Brillinta wash-out. He was taken to the operating room on ___ and underwent coronary artery bypass graft x 2 (left internal mammary artery graft to the left anterior descending and reverse saphenous vein graft to the second marginal branch). He tolerated the procedure well and was transferred to the CVICU in stable condition for recovery and invasive monitoring. Over the next several hours he awoke neurologically intact, was extubated, and weaned off vasopressors. Beta blocker was initiated and he was diuresed toward his preoperative weight. He was transferred to the telemetry floor for further recovery. He was evaluated by the physical therapy service for assistance with strength and mobility. He had post-operative atrial fibrillation which was treated with Lopressor and oral amiodarone. He was started on Coumadin for anticoagulation. By the time of discharge on POD 4 he was ambulating with assistance, the wound was healing, and pain was controlled with oral analgesics. He was discharged to ___ ___ in ___ in good condition with appropriate follow up instructions. Other Results: Transthoracic Echocardiogram ___ The left atrial volume index is normal. The right atrium is mildly enlarged. There is mild symmetric left ventricular hypertrophy with a normal cavity size. There is mild regional left ventricular systolic dysfunction with severe hypokinesis to akinesis of the inferior and inferolateral walls (see schematic) and preserved/normal contractility of the remaining segments. The visually estimated left ventricular ejection fraction is 40-45%. There is no resting left ventricular outflow tract gradient. Tissue Doppler suggests an increased left ventricular filling pressure (PCWP greater than 18 mmHg). There is echocardiographic evidence for diastolic dysfunction (grade indeterminate). Normal right ventricular cavity size with mild global free wall hypokinesis. The aortic sinus is mildly dilated with normal ascending aorta diameter for gender. The aortic arch diameter is normal with a normal descending aorta diameter. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. There is mild to moderate [___] mitral regurgitation. The pulmonic valve leaflets are not well seen. The tricuspid valve is not well seen. There is physiologic tricuspid regurgitation. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Mild regional left ventricular systolic dysfunction c/w CAD. Echocardiographic evidence for diastolic dysfunction with elevated PCWP. Normal right ventricular cavity size with mild global hypokinesis. Moderate pulmonary artery systolic hypertension. Mild to moderate mitral regurgitation. Transesophageal Echocardiogram ___ PRE-OPERATIVE STATE: Pre-bypass assessment. Left Atrium ___ Veins: Dilated ___. No spontaneous echo contrast is seen in the ___. Left Ventricle (LV): Normal cavity size. Mild-moderate regional systolic dysfunction (see schematic). Right Ventricle (RV): Normal cavity size. Normal free wall motion. Aorta: Normal sinus diameter. Normal descending aorta diameter. No dissection. Complex (>4mm) descending atheroma. Aortic Valve: Thin/mobile (3) leaflets. No stenosis. Mild [1+] regurgitation. Mitral Valve: Mildly thickened leaflets. Mild annular calcification. Mild-moderate [___] regurgitation. Tricuspid Valve: Mild [1+] regurgitation. Pericardium: No effusion. POST-OP STATE: The post-bypass TEE was performed at 14:52:00. Sinus rhythm. Support: Vasopressor(s): none. Left Ventricle: Similar to preoperative findings. Aorta: Intact. No dissection. Aortic Valve: No change in aortic valve morphology from preoperative state. Mitral Valve: No change in mitral valve morphology from preoperative state. CXR: ___ Stable, borderline enlarged cardiomediastinal silhouette. Mildly low lung volumes bilaterally. Prominent vascular congestion. Stable left apical pneumothorax. No area of focal consolidation. Trace left pleural effusion. In comparison to the study completed on ___, patient has been extubated and enteric tube removed. The mediastinal and left sided chest tube have also been removed. The right internal jugular hemodialysis catheter is stable, terminates at the distal SVC. IMPRESSION: Stable left apical pneumothorax.

2148-02-26 17:18:00

ENGLISH

SINGLE

WHITE

M

[[24674789, Timestamp('2148-02-26 17:19:49'), '', 'TRAUM']]

[[{'Medications on Admission': ':\nMVI', 'Brief Hospital Course': ':\nMr. ___ was evaluated by the Trauma team in the Emergency Room \nand his scans were reviewed. He had a grade 4 left renal \nlaceration with associated hematuria. His hematocrit was 39 and \nhe had stable hemodynamics. He was admitted to the hospital for \nserial hematocrits and abdominal exams.\n\nFollowing transfer to the Trauma floor he had some flank pain \nwhich was controlled with Oxycodone. His urine changed from \nbloody to dark brown without any dysuria or passage of clots. \nHis hematocrit ranged from 37-39 and his vital signs remained \nstable.\n\nAfter no evidence of active bleeding was established, he started \na regular diet which was well tolerated. He was walking \nindependently and passing urine without difficulty. He was \ncautioned about not participating in any contact sports , skiing \nor snow boarding.\n\nAfter an uncomplicated stay he was discharged to home on ___ \nand will follow up in the ___ in ___ weeks.\n\n', 'Pertinent Results:': '\n___ 02:14PM WBC-10.1 RBC-4.51* HGB-14.1 HCT-39.9* MCV-88 \nMCH-31.2 MCHC-35.3* RDW-12.6\n___ 02:14PM NEUTS-76.6* LYMPHS-16.4* MONOS-6.0 EOS-0.4 \nBASOS-0.6\n___ 02:14PM PLT COUNT-292\n___ 02:14PM ___ PTT-24.7 ___\n___ 02:14PM GLUCOSE-96 UREA N-14 CREAT-1.0 SODIUM-138 \nPOTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-25 ANION GAP-14\n___ 10:10PM HCT-36.0*\n\n___ CTA Abdomen :\n1. Left anterior renal cortical laceration, extending to the \ncollecting \nsystem, resulting in a small focal collection of urine and \nexcreted contrast in the interpolar region. The left ureter \nremains patent with excreted IV contrast. The constellation of \nfindings constitutes a grade IV renal injury. \n2. No sign of arterial hemorrhage. Essentially stable \nsmall-to-moderate left perirenal hemorrhage with a small \ncomponent of subcapsular hematoma. \n3. No acute osseous injury. \n\n___ Head CT :\nNo acute intracranial traumatic injury.\n\n', 'Physical Exam:|Physical': '\nTemp 99.5 HR 80 BP 137/72 RR 16 O2 sat 98% RA \nGen: NAD, AAOx3\nHEENT: head atraumatic, normocephalic, R pupil 4->2, L pupil\n3->2, reactive; EOMIB; neck NTTP, full ROM\nChest: NTTP, no crepitus, CTAB, RRR, no lesions\nAbd: soft, ND, TTP LUQ and L flank, no guarding or rebound, no\nlesions or ecchymoses\nExt: wwp, no edema or gross deformities\nSpine: NTTP, no step-offs\nDRE: no gross blood, good tone\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\nThis is a ___ s/p a snowboarding accident who presents with\nhematuria and a left grade 2 renal laceration. He reports that\nhe fell while snowboarding yesterday and rolled down the\nmountain, hitting all parts of his body. +head strike, no\nhelmet, possible LOC. Remembers the entire incident. Reports\npink tinged blood yesterday, rust colored today. Went to \n___, where CT showed a L perinephric hematoma (by report, a\ngrade 2 renal lac). Was transferred to ___ for further\nmanagement. Is HDS. + current mild HA and nausea. \n\nPast Medical History:\nPMH\nnone\n\nPSH\nnone\n\nSocial History:\n___\nFamily History:\nnon contributory\n\n', 'Chief Complaint:|Complaint:': '\nhematuria\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nNo Known Allergies / Adverse Drug Reactions\n\n'}, '15308551-DS-4', 4, 'surgery']]

[["HISTORY: ___ man, with left renal laceration from snowboard injury. \nAssess for interval changes.\n\nCOMPARISON: Outside hospital's CT abdomen and pelvis performed on ___ at 10:30 hours at ___.\n\nTECHNIQUE: MDCT images were acquired from the lung bases to the lower abdomen\nbefore and after administration of IV contrast at different phases. \nMultiplanar reformatted images were obtained for evaluation.\n\nCT ABDOMEN WITH AND WITHOUT CONTRAST: In the non-contrast images, there is a\nsmall focal collection of hyperdensity in the left anterior interpolar region,\nwith trace amount of hyperdensity in the posterior perirenal region, (image\n2:27 and image 2:30), compatible with a peripheral renal laceration extending\nto the collecting system and focal contrast leak from prior study. \nSurrounding fluid density is noted, ikely comprised of part perirenal\nhemorrhage, perirenal urinoma, and subcapsular hematoma. There is no evidence\nof transection of the left ureter. Normal intraluminal excreted IV contrast\nis seen in the mid-to-distal left ureter. \n\nIn the arterial and venous phase, there is no evidence of active arterial\nextravasation. The small-to-moderate left perirenal hematoma is\nunchanged-to-minimally-increased in size with maximum thickness measuring at\n18 mm (3A:49), compared to 16 mm in the outside hospital study. The right\nkidney is normal.\n\nThe visualized lung bases are clear without pleural effusion. The liver\nenhances normally. The spleen, gallbladder, pancreas, adrenal glands are\nnormal. The visualized loops of small bowel and colon are unremarkable.\n\nBONE WINDOW: There is no acute fracture or dislocation. No suspicious\nosteolytic or sclerotic lesions are noted.\n\nIMPRESSION:\n1. Left anterior renal cortical laceration, extending to the collecting\nsystem, resulting in a small focal collection of urine and excreted contrast\nin the interpolar region. The left ureter remains patent with excreted IV\ncontrast. The constellation of findings constitutes a grade IV renal injury.\n2. No sign of arterial hemorrhage. Essentially stable small-to-moderate left\nperirenal hemorrhage with a small component of subcapsular hematoma.\n3. No acute osseous injury.\n", '15308551-RR-10', 10, 'mdct images were acquired from the lung bases to the lower abdomen\nbefore and after administration of iv contrast at different phases. \nmultiplanar reformatted images were obtained for evaluation.'], ['HISTORY: ___ man, status post snowboard accident, hitting head. \nAssess for intracranial hemorrhage.\n\nCOMPARISON: None.\n\nTECHNIQUE: Non-contrast MDCT images were acquired through the head. \nMultiplanar reformatted images were obtained for evaluation.\n\nFINDINGS: The study is slightly limited from prior IV contrast\nadministration, which decreases sensitivity of detecting small subarachnoid\nhemorrhage. Allowing for the limitation, there is no acute intracranial\ntraumatic injury. No acute intracranial hemorrhage, edema, mass effect or\nmajor vascular territorial infarct is noted. The ventricles and sulci are\nnormal in size and symmetric in configuration. There is no shift of normally\nmidline structures. The gray-white matter differentiation is well preserved. \nThere is no acute fracture. The visualized paranasal sinuses and mastoid air\ncells are clear.\n\nIMPRESSION: No acute intracranial traumatic injury.\n', '15308551-RR-11', 11, 'non-contrast mdct images were acquired through the head. \nmultiplanar reformatted images were obtained for evaluation.']]

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[]

['surgery']

[[51221, Timestamp('2148-02-26 22:10:00'), Timestamp('2148-02-26 23:10:00'), 'Hematocrit'], [51221, Timestamp('2148-02-27 06:00:00'), Timestamp('2148-02-27 07:01:00'), 'Hematocrit'], [50868, Timestamp('2148-02-27 06:00:00'), Timestamp('2148-02-27 08:03:00'), 'Anion Gap'], [50882, Timestamp('2148-02-27 06:00:00'), Timestamp('2148-02-27 08:03:00'), 'Bicarbonate'], [50893, Timestamp('2148-02-27 06:00:00'), Timestamp('2148-02-27 08:03:00'), 'Calcium, Total'], [50902, Timestamp('2148-02-27 06:00:00'), Timestamp('2148-02-27 08:03:00'), 'Chloride'], [50912, Timestamp('2148-02-27 06:00:00'), Timestamp('2148-02-27 08:03:00'), 'Creatinine'], [50931, Timestamp('2148-02-27 06:00:00'), Timestamp('2148-02-27 08:03:00'), 'Glucose'], [50960, Timestamp('2148-02-27 06:00:00'), Timestamp('2148-02-27 08:03:00'), 'Magnesium'], [50970, Timestamp('2148-02-27 06:00:00'), Timestamp('2148-02-27 08:03:00'), 'Phosphate'], [50971, Timestamp('2148-02-27 06:00:00'), Timestamp('2148-02-27 08:03:00'), 'Potassium'], [50983, Timestamp('2148-02-27 06:00:00'), Timestamp('2148-02-27 08:03:00'), 'Sodium'], [51006, Timestamp('2148-02-27 06:00:00'), Timestamp('2148-02-27 08:03:00'), 'Urea Nitrogen'], [51221, Timestamp('2148-02-27 12:45:00'), Timestamp('2148-02-27 14:31:00'), 'Hematocrit']]

Question: A 24 M is admitted. He/she says he/she has hematuria . History of illness: This is a ___ s/p a snowboarding accident who presents with hematuria and a left grade 2 renal laceration. He reports that he fell while snowboarding yesterday and rolled down the mountain, hitting all parts of his body. +head strike, no helmet, possible LOC. Remembers the entire incident. Reports pink tinged blood yesterday, rust colored today. Went to ___, where CT showed a L perinephric hematoma (by report, a grade 2 renal lac). Was transferred to ___ for further management. Is HDS. + current mild HA and nausea. Past Medical History: PMH none PSH none Social History: ___ Family History: non contributory Allergies: No Known Allergies / Adverse Drug Reactions What is the best procedure plan for this patient?

TARGETS Target Prescriptions: HYDROmorphone (Dilaudid) HYDROmorphone (Dilaudid) OxycoDONE (Immediate Release) LR Acetaminophen Sodium Chloride 0.9% Flush LR Influenza Virus Vaccine Target Lab Orders: Hematocrit Hematocrit Anion Gap Bicarbonate Calcium, Total Chloride Creatinine Glucose Magnesium Phosphate Potassium Sodium Urea Nitrogen Hematocrit Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : Mr. ___ was evaluated by the Trauma team in the Emergency Room and his scans were reviewed. He had a grade 4 left renal laceration with associated hematuria. His hematocrit was 39 and he had stable hemodynamics. He was admitted to the hospital for serial hematocrits and abdominal exams. Following transfer to the Trauma floor he had some flank pain which was controlled with Oxycodone. His urine changed from bloody to dark brown without any dysuria or passage of clots. His hematocrit ranged from 37-39 and his vital signs remained stable. After no evidence of active bleeding was established, he started a regular diet which was well tolerated. He was walking independently and passing urine without difficulty. He was cautioned about not participating in any contact sports , skiing or snow boarding. After an uncomplicated stay he was discharged to home on ___ and will follow up in the ___ in ___ weeks. Other Results: ___ 02:14PM WBC-10.1 RBC-4.51* HGB-14.1 HCT-39.9* MCV-88 MCH-31.2 MCHC-35.3* RDW-12.6 ___ 02:14PM NEUTS-76.6* LYMPHS-16.4* MONOS-6.0 EOS-0.4 BASOS-0.6 ___ 02:14PM PLT COUNT-292 ___ 02:14PM ___ PTT-24.7 ___ ___ 02:14PM GLUCOSE-96 UREA N-14 CREAT-1.0 SODIUM-138 POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-25 ANION GAP-14 ___ 10:10PM HCT-36.0* ___ CTA Abdomen : 1. Left anterior renal cortical laceration, extending to the collecting system, resulting in a small focal collection of urine and excreted contrast in the interpolar region. The left ureter remains patent with excreted IV contrast. The constellation of findings constitutes a grade IV renal injury. 2. No sign of arterial hemorrhage. Essentially stable small-to-moderate left perirenal hemorrhage with a small component of subcapsular hematoma. 3. No acute osseous injury. ___ Head CT : No acute intracranial traumatic injury.

2121-03-27 09:00:00

ENGLISH

MARRIED

WHITE

M

[[23868878, Timestamp('2121-03-27 03:06:33'), '', 'TSURG']]

[[{'Medications on Admission': ':\n-COLCHICINE 0.6 mg Tablet PO qAM\n-OMEPRAZOLE 40 mg Capsule, Delayed Release(E.C.) PO BID\n-TADALAFIL \n-LIPITOR 40mg PO daily\n-ATENOLOL 12.5mg PO daily (dosage uncertain) \n-ASPIRIN 325 mg Tablet, Delayed Release (E.C.) PO daily\n-CHOLECALCIFEROL (VITAMIN D3) 1,000 unit Capsule PO daily\n-TYLENOL ___ QID PRN\n\n6. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable \nSig: ___ Tablet, Chewables PO QID (4 times a day) as needed for \nheartburn. \n7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) \nCapsule, Delayed Release(E.C.) PO BID (2 times a day). \n8. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO \nQ4H (every 4 hours) as needed for pain: Do not exceed 4gm of \nacetaminophen intake daily. .\nDisp:*30 Tablet(s)* Refills:*0*\n9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice \na day as needed for constipation.\nDisp:*30 Capsule(s)* Refills:*0*\n10. senna 8.6 mg Capsule Sig: One (1) Capsule PO at bedtime as \nneeded for constipation.\nDisp:*30 Capsule(s)* Refills:*0*', 'Brief Hospital Course': ":\nMr. ___ was admitted to the Thoracic Surgery clinic \nfollowing a Right VATS wedge resection that was advanced to RUL \nlobectomy after positive frozen section for a RUL lung nodule, \nwhich went well without complication (reader referred to \noperative note for complete detail). The patient received a \nnerve block by anethesia in the pre-operative period and his \npain was well controlled postoperatively. Patient's diet was \nadvanced on POD 1 and patient was begun on PO pain medications \nwith good effect and adequate pain control. Diet was well \ntolerated and advanced as appropriate. Fluids and elecytrolytes \nwere routinely monitored and adjusted as necessary. Patient had \nundergone CABG and Maze early this year to control his A-fib \nbut he was switched from his normal home dose of atenolol to \nlopressor 50mg TID immediately postoperatively to mitigate the \nrisk of recurrence of A-fib in the post-operative period. \nPatient remained hemodynamically stable with rate well \ncontrolled. One right sided apical chest tube was left \npost-operatively and was kept to water seal after leaving the \nOR. The patient had a persistent 1 chamber air leak that had \nresolved by POD 2. Chest tube was removed and no significant \npneumothorax was seen on CXR. Patient was ambulating without \nthe need of oxygen and was in no respiratory distress. Foley was \ndiscontinued POD1 and patient voided without assistance. Fever \ncurves were closely monitored and patient remained afebrile and \nsurgical incisions were well healing without erythema. \n\nAt the time of discharge, the patient was doing well, afebrile \nwith stable vital signs. The patient was tolerating a regular \ndiet, ambulating, voiding without assistance, and pain was well \ncontrolled. The patient received discharge teaching and \nfollow-up instructions with understanding verbalized and \nagreement with the discharge plan.\n\n", 'Pertinent Results:': '\n___ 08:10AM BLOOD WBC-14.4* RBC-4.43* Hgb-13.1* Hct-39.6* \nMCV-89 MCH-29.5 MCHC-33.0 RDW-13.1 Plt ___\n___ 07:15PM BLOOD WBC-15.1* RBC-4.93# Hgb-14.7 Hct-44.4# \nMCV-90 MCH-29.7 MCHC-33.0 RDW-13.0 Plt ___\n___ 08:10AM BLOOD Glucose-125* UreaN-15 Creat-0.9 Na-134 \nK-4.3 Cl-101 HCO3-25 AnGap-12\n___ 07:15PM BLOOD Glucose-120* UreaN-17 Creat-0.9 Na-138 \nK-4.6 Cl-104 HCO3-24 AnGap-15\n___ 08:10AM BLOOD Calcium-9.0 Phos-3.1 Mg-1.7\n___ 07:15PM BLOOD Calcium-9.2 Phos-3.3 Mg-1.8\n\n___ CXR: FINDINGS: Patient is status post right upper \nlobectomy. Minimal right apical pneumothorax is present, which \nis likely related to postop. A single right chest drain tube is \ntube is seen with distal end coursing along the mediastinal \naspect and extending up to the right lung base. No lung \nopacities concerning for pneumonia. Lower lung atelectasis has \nsignificantly improved since ___. Heart size is top \nnormal. Mediastinal and hilar\ncontours are unchanged. Status post median sternotomy with \nintact sternal\nsutures for CABG.\n\n___ CXR: IMPRESSION: PA and lateral chest compared to \n___:\nRight apical pneumothorax is infinitesimal seen only along the \nlateral costal surface on the frontal view. Subcutaneous \nemphysema in the right chest wall has increased slightly but \nthere is no appreciable right pleural effusion. Mediastinum has \na normal post-operative appearance. Left lung is clear.\n\n', 'Physical Exam:|Physical': '\nOn Discharge: \nVS: 98.2 82 109/68 18 97% on RA\nGEN: NAD, AOX3\nCV: RRR, nl S1 and S2\nPULM: CTA b/l. No subcutaneous emphysema, no respiratory \ndistress, non-labored breathing. Incisions c/d/i. Chest tube \nsite dressing clean and dry. Sternotomy scar well healing. \nABD: Soft, non-tender, non-distended\nEXT: No c/c/e, MAE\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\nMr. ___ is a ___ year old man that has been followed by his \nPCP ___ ___ for lung nodules. The patient reports that he \nrequested the CT at that time as a\nscreening mechanism for lung cancer given his smoking history. \nSeveral small nodule were found which have been monitored since \n___. Routine scan from this ___ showed an interval \nincrease in size of the right upper lobe nodule which now \nmeasures up to 7.5 mm, has transformed from ground glass to \nsolid, and has irregular, spiculated margins. These findings \nprompted his PCP to order ___ PET scan which revealed mildly avid \nnodule in the RUL. He was referred to the Thoracic Surgery \nclinic for further evaluation. \n\nHe currently states he feels well and has recovered well from \nhis bypass surgery in ___. He denies shortness of breath, \ndyspnea on exertion, chest pain, heart palpitations, headache, \ndizziness, changes in vision, or new or bony pain. \n\nPast Medical History:\nDeveloped Atrial Fibrillation this past\n___ due to his Coronary Artery Disease manifested as an MI in\n___ - underwent cardiac catheterization. Subsequently underwent\n4 vessel CABG and modified left-sided maze procedure (pulmonary\nvein isolation)procedure with radiofrequency bipolar clamp and\nleft atrial appendage amputation. \nGERD, Pseudogout, Lipoma - excised at age ___. \n\nSocial History:\n___\nFamily History:\nMother - CAD with bypass/CABS in her ___ \nFather - ___ and ___ Cancer\nSiblings\nOffspring\nOther\n\n', 'Chief Complaint:|Complaint:': '\nRight upper lobe lung nodule \n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nCelebrex / Aleve / Advil\n\n'}, '16465238-DS-7', 7, 'cardiothoracic']]

[['CHEST RADIOGRAPH\n\nTECHNIQUE: Portable semi-erect chest view was read in comparison with prior\nchest radiographs from ___.\n\nFINDINGS: Patient is status post right upper lobectomy. Minimal right apical\npneumothorax is present, which is likely related to postop. A single right\nchest drain tube is tube is seen with distal end coursing along the\nmediastinal aspect and extending up to the right lung base. No lung opacities\nconcerning for pneumonia. Lower lung atelectasis has significantly improved\nsince ___. Heart size is top normal. Mediastinal and hilar\ncontours are unchanged. Status post median sternotomy with intact sternal\nsutures for CABG.\n', '16465238-RR-23', 23, 'portable semi-erect chest view was read in comparison with prior\nchest radiographs from ___.'], ['PA AND LATERAL CHEST ___ \n\nHISTORY: VATS right upper lobectomy. Chest tube removed.\n\nIMPRESSION: PA and lateral chest compared to ___:\n\nRight apical pneumothorax is infinitesimal seen only along the lateral costal\nsurface on the frontal view. Subcutaneous emphysema in the right chest wall\nhas increased slightly but there is no appreciable right pleural effusion. \nMediastinum has a normal post-operative appearance. Left lung is clear.\n', '16465238-RR-24', 24, '']]

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[]

['cardiothoracic']

[[51221, Timestamp('2121-03-27 19:15:00'), Timestamp('2121-03-27 20:36:00'), 'Hematocrit'], [51222, Timestamp('2121-03-27 19:15:00'), Timestamp('2121-03-27 20:36:00'), 'Hemoglobin'], [51248, Timestamp('2121-03-27 19:15:00'), Timestamp('2121-03-27 20:36:00'), 'MCH'], [51249, Timestamp('2121-03-27 19:15:00'), Timestamp('2121-03-27 20:36:00'), 'MCHC'], [51250, Timestamp('2121-03-27 19:15:00'), Timestamp('2121-03-27 20:36:00'), 'MCV'], [51265, Timestamp('2121-03-27 19:15:00'), Timestamp('2121-03-27 20:36:00'), 'Platelet Count'], [51277, Timestamp('2121-03-27 19:15:00'), Timestamp('2121-03-27 20:36:00'), 'RDW'], [51279, Timestamp('2121-03-27 19:15:00'), Timestamp('2121-03-27 20:36:00'), 'Red Blood Cells'], [51301, Timestamp('2121-03-27 19:15:00'), Timestamp('2121-03-27 20:36:00'), 'White Blood Cells'], [50868, Timestamp('2121-03-27 19:15:00'), Timestamp('2121-03-27 20:49:00'), 'Anion Gap'], [50882, Timestamp('2121-03-27 19:15:00'), Timestamp('2121-03-27 20:49:00'), 'Bicarbonate'], [50893, Timestamp('2121-03-27 19:15:00'), Timestamp('2121-03-27 20:49:00'), 'Calcium, Total'], [50902, Timestamp('2121-03-27 19:15:00'), Timestamp('2121-03-27 20:49:00'), 'Chloride'], [50912, Timestamp('2121-03-27 19:15:00'), Timestamp('2121-03-27 20:49:00'), 'Creatinine'], [50920, Timestamp('2121-03-27 19:15:00'), Timestamp('2121-03-27 20:49:00'), 'Estimated GFR (MDRD equation)'], [50931, Timestamp('2121-03-27 19:15:00'), Timestamp('2121-03-27 20:49:00'), 'Glucose'], [50960, Timestamp('2121-03-27 19:15:00'), Timestamp('2121-03-27 20:49:00'), 'Magnesium'], [50970, Timestamp('2121-03-27 19:15:00'), Timestamp('2121-03-27 20:49:00'), 'Phosphate'], [50971, Timestamp('2121-03-27 19:15:00'), Timestamp('2121-03-27 20:49:00'), 'Potassium'], [50983, Timestamp('2121-03-27 19:15:00'), Timestamp('2121-03-27 20:49:00'), 'Sodium'], [51006, Timestamp('2121-03-27 19:15:00'), Timestamp('2121-03-27 20:49:00'), 'Urea Nitrogen'], [50868, Timestamp('2121-03-28 08:10:00'), Timestamp('2121-03-28 09:30:00'), 'Anion Gap'], [50882, Timestamp('2121-03-28 08:10:00'), Timestamp('2121-03-28 09:30:00'), 'Bicarbonate'], [50893, Timestamp('2121-03-28 08:10:00'), Timestamp('2121-03-28 09:30:00'), 'Calcium, Total'], [50902, Timestamp('2121-03-28 08:10:00'), Timestamp('2121-03-28 09:30:00'), 'Chloride'], [50912, Timestamp('2121-03-28 08:10:00'), Timestamp('2121-03-28 09:30:00'), 'Creatinine'], [50931, Timestamp('2121-03-28 08:10:00'), Timestamp('2121-03-28 09:30:00'), 'Glucose'], [50960, Timestamp('2121-03-28 08:10:00'), Timestamp('2121-03-28 09:30:00'), 'Magnesium'], [50970, Timestamp('2121-03-28 08:10:00'), Timestamp('2121-03-28 09:30:00'), 'Phosphate'], [50971, Timestamp('2121-03-28 08:10:00'), Timestamp('2121-03-28 09:30:00'), 'Potassium'], [50983, Timestamp('2121-03-28 08:10:00'), Timestamp('2121-03-28 09:30:00'), 'Sodium'], [51006, Timestamp('2121-03-28 08:10:00'), Timestamp('2121-03-28 09:30:00'), 'Urea Nitrogen'], [51221, Timestamp('2121-03-28 08:10:00'), Timestamp('2121-03-28 08:57:00'), 'Hematocrit'], [51222, Timestamp('2121-03-28 08:10:00'), Timestamp('2121-03-28 08:57:00'), 'Hemoglobin'], [51248, Timestamp('2121-03-28 08:10:00'), Timestamp('2121-03-28 08:57:00'), 'MCH'], [51249, Timestamp('2121-03-28 08:10:00'), Timestamp('2121-03-28 08:57:00'), 'MCHC'], [51250, Timestamp('2121-03-28 08:10:00'), Timestamp('2121-03-28 08:57:00'), 'MCV'], [51265, Timestamp('2121-03-28 08:10:00'), Timestamp('2121-03-28 08:57:00'), 'Platelet Count'], [51277, Timestamp('2121-03-28 08:10:00'), Timestamp('2121-03-28 08:57:00'), 'RDW'], [51279, Timestamp('2121-03-28 08:10:00'), Timestamp('2121-03-28 08:57:00'), 'Red Blood Cells'], [51301, Timestamp('2121-03-28 08:10:00'), Timestamp('2121-03-28 08:57:00'), 'White Blood Cells']]

Question: A 75 M is admitted. He/she says he/she has Right upper lobe lung nodule . History of illness: Mr. ___ is a ___ year old man that has been followed by his PCP ___ ___ for lung nodules. The patient reports that he requested the CT at that time as a screening mechanism for lung cancer given his smoking history. Several small nodule were found which have been monitored since ___. Routine scan from this ___ showed an interval increase in size of the right upper lobe nodule which now measures up to 7.5 mm, has transformed from ground glass to solid, and has irregular, spiculated margins. These findings prompted his PCP to order ___ PET scan which revealed mildly avid nodule in the RUL. He was referred to the Thoracic Surgery clinic for further evaluation. He currently states he feels well and has recovered well from his bypass surgery in ___. He denies shortness of breath, dyspnea on exertion, chest pain, heart palpitations, headache, dizziness, changes in vision, or new or bony pain. Past Medical History: Developed Atrial Fibrillation this past ___ due to his Coronary Artery Disease manifested as an MI in ___ - underwent cardiac catheterization. Subsequently underwent 4 vessel CABG and modified left-sided maze procedure (pulmonary vein isolation)procedure with radiofrequency bipolar clamp and left atrial appendage amputation. GERD, Pseudogout, Lipoma - excised at age ___. Social History: ___ Family History: Mother - CAD with bypass/CABS in her ___ Father - ___ and ___ Cancer Siblings Offspring Other Allergies: Celebrex / Aleve / Advil What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Colchicine Aspirin Zolpidem Tartrate Sodium Chloride 0.9% Flush Omeprazole Oxycodone-Acetaminophen Lactated Ringers Pneumococcal Vac Polyvalent Morphine Sulfate Chloraseptic Throat Spray Heparin Simvastatin Metoprolol Tartrate Influenza Virus Vaccine Calcium Carbonate Target Lab Orders: Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells Anion Gap Bicarbonate Calcium, Total Chloride Creatinine Estimated GFR (MDRD equation) Glucose Magnesium Phosphate Potassium Sodium Urea Nitrogen Anion Gap Bicarbonate Calcium, Total Chloride Creatinine Glucose Magnesium Phosphate Potassium Sodium Urea Nitrogen Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : Mr. ___ was admitted to the Thoracic Surgery clinic following a Right VATS wedge resection that was advanced to RUL lobectomy after positive frozen section for a RUL lung nodule, which went well without complication (reader referred to operative note for complete detail). The patient received a nerve block by anethesia in the pre-operative period and his pain was well controlled postoperatively. Patient's diet was advanced on POD 1 and patient was begun on PO pain medications with good effect and adequate pain control. Diet was well tolerated and advanced as appropriate. Fluids and elecytrolytes were routinely monitored and adjusted as necessary. Patient had undergone CABG and Maze early this year to control his A-fib but he was switched from his normal home dose of atenolol to lopressor 50mg TID immediately postoperatively to mitigate the risk of recurrence of A-fib in the post-operative period. Patient remained hemodynamically stable with rate well controlled. One right sided apical chest tube was left post-operatively and was kept to water seal after leaving the OR. The patient had a persistent 1 chamber air leak that had resolved by POD 2. Chest tube was removed and no significant pneumothorax was seen on CXR. Patient was ambulating without the need of oxygen and was in no respiratory distress. Foley was discontinued POD1 and patient voided without assistance. Fever curves were closely monitored and patient remained afebrile and surgical incisions were well healing without erythema. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Other Results: ___ 08:10AM BLOOD WBC-14.4* RBC-4.43* Hgb-13.1* Hct-39.6* MCV-89 MCH-29.5 MCHC-33.0 RDW-13.1 Plt ___ ___ 07:15PM BLOOD WBC-15.1* RBC-4.93# Hgb-14.7 Hct-44.4# MCV-90 MCH-29.7 MCHC-33.0 RDW-13.0 Plt ___ ___ 08:10AM BLOOD Glucose-125* UreaN-15 Creat-0.9 Na-134 K-4.3 Cl-101 HCO3-25 AnGap-12 ___ 07:15PM BLOOD Glucose-120* UreaN-17 Creat-0.9 Na-138 K-4.6 Cl-104 HCO3-24 AnGap-15 ___ 08:10AM BLOOD Calcium-9.0 Phos-3.1 Mg-1.7 ___ 07:15PM BLOOD Calcium-9.2 Phos-3.3 Mg-1.8 ___ CXR: FINDINGS: Patient is status post right upper lobectomy. Minimal right apical pneumothorax is present, which is likely related to postop. A single right chest drain tube is tube is seen with distal end coursing along the mediastinal aspect and extending up to the right lung base. No lung opacities concerning for pneumonia. Lower lung atelectasis has significantly improved since ___. Heart size is top normal. Mediastinal and hilar contours are unchanged. Status post median sternotomy with intact sternal sutures for CABG. ___ CXR: IMPRESSION: PA and lateral chest compared to ___: Right apical pneumothorax is infinitesimal seen only along the lateral costal surface on the frontal view. Subcutaneous emphysema in the right chest wall has increased slightly but there is no appreciable right pleural effusion. Mediastinum has a normal post-operative appearance. Left lung is clear.

2171-01-28 14:57:00

ENGLISH

MARRIED

WHITE

F

[[29761842, Timestamp('2171-01-28 14:58:26'), '', 'ORTHO']]

[[{'Medications on Admission': ':\nThe Preadmission Medication list may be inaccurate and requires \nfuther investigation.\n1. Gabapentin 300 mg PO TID \n2. Norethindrone-Estradiol 1 TAB PO DAILY \n3. TraMADol 50 mg PO Q4H:PRN Pain - Moderate ', 'Brief Hospital Course': ':\nPatient was admitted to the ___ Spine Surgery Service and \ntaken to the Operating Room for an ACDF C6/7. Refer to the \ndictated operative note for further details. The surgery was \nwithout complication and the patient was transferred to the PACU \nin a stable condition. TEDs/pnemoboots were used for \npostoperative DVT prophylaxis. Intravenous antibiotics were \ncontinued for 24hrs postop per standard protocol. Initial postop \npain was controlled with a IV and PO pain medications. Diet was \nadvanced as tolerated. The patient was transitioned to oral \npain medication when tolerating PO diet. Foley was removed \npostoperatively without issue. Hospital course was otherwise \nunremarkable. On the day of discharge the patient was afebrile \nwith stable vital signs, comfortable on oral pain control and \ntolerating a regular diet.\n\n', 'Pertinent Results:': 'NIL', 'Physical Exam:|Physical': '\n99.3\nPO 110 / 71 78 18 97 ra \n\nNAD, A&Ox4\nnl resp effort\nRRR\n\nSensory:\nUE \n C5 C6 C7 C8 T1\n (lat arm) (thumb) (mid fing) (sm finger) (med arm)\nR SILT SILT SILT SILT SILT\nL SILT SILT SILT SILT SILT\n\nMotor:\nUE Dlt(C5) Bic(C6) WE(C6) Tri(C7) WF(C7) FF(C8)FinAbd(T1)\nR 5 5 5 5 5 5 5\nL 5 5 5 5 5 5 5\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\nMs. ___ is a pleasant ___ lady\nwho is seen today with complaints of bilateral upper extremity\nradicular pain, numbness and weakness right more than left. \nThis\nhas been going on since last 5 days. This probably-when she was\nin an exercise class. She describes the pain along bilateral C7\nand C8 dermatomes right more than left. Her examination showed\nC7 and C8 dermatomal numbness. Her hand grip weakness. To be\ndue to the pain limitation. Her radiographs showed C5-6 and \nC6-7\ndegenerative disease C5-7 focal kyphosis. Her MRI shows \npresence\nof large right-sided paracentral and foraminal disc herniation \nat\nC6-7 causing spinal cord and nerve root impingement. There is\nabsence of is positive for signal intensity changes. \nConsidering\nseverity of her symptoms presence of numbness and the size of\ndisc she can either consider epidural steroid injection or\nsurgical treatment. It was explained to her that the injection\nmay not help her symptoms fully. She was in understanding. The\nsurgical procedure details were also explained to her. Risks of\nsurgery were also explained to her. We will try and get her to\nsee 1 of our pain management physicians for possible urgent\nepidural steroid injection. I would like to see him back in a\nweek for reassessment. She should give us a call if symptoms\nworsen. She was in understanding. I spent approximately 45\nminutes with this patient and more than 50% time was spent in\ncounseling and coordination of care.\n\nPast Medical History:\ncancer in the form of\nmelanoma in situ\n\nSocial History:\n___\nFamily History:\nnc\n\n', 'Chief Complaint:|Complaint:': '\nright arm pain/weakness\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nPenicillins / Ceclor\n\n'}, '18553883-DS-4', 4, 'orthopaedics']]

[['EXAMINATION: CHEST (PA AND LAT)\n\nINDICATION: History: ___ with neck pain. pre-op labs// ? pneumonia\n\nTECHNIQUE: Chest PA and lateral\n\nCOMPARISON: None.\n\nFINDINGS: \n\nHeart size is normal. The mediastinal and hilar contours are normal. The\npulmonary vasculature is normal. Lungs are hyperinflated but clear. No\npleural effusion or pneumothorax is seen. There are no acute osseous\nabnormalities.\n\nIMPRESSION: \n\nNo acute cardiopulmonary abnormality.\n', '18553883-RR-27', 27, 'chest pa and lateral'], ['EXAMINATION: CERVICAL SINGLE VIEW IN OR\n\nIMPRESSION: \n\nFluoroscopic images show placement of a C6-C7 anterior fusion with interbody\nspacer in place. Further information can be gathered from the operative\nreport.\n', '18553883-RR-28', 28, ''], ['EXAMINATION: C-SPINE NON-TRAUMA ___ VIEWS\n\nINDICATION: ___ year old woman with cervical stenosis// evaluation of hardware\nevaluation of hardware\n\nTECHNIQUE: C spine AP and lateral views\n\n___\n\nFINDINGS: \n\nC1 through T1 are demonstrated on the lateral view. There is evidence of\ninternal fixation of the C6 and C7 vertebral bodies anterior fusion hardware. \nThe soft tissues of the neck are within normal limits. The airways are\npatent.\n\nIMPRESSION: \n\nStatus post anterior fusion of C6 and C7 vertebral body. No abnormal\ndisplacement seen.\n', '18553883-RR-29', 29, 'c spine ap and lateral views']]

[[29761842, Timestamp('2171-01-28 17:00:00'), Timestamp('2171-01-29 18:00:00'), 'MAIN', 'Sodium Chloride 0.9% Flush', '', '0', '10 mL Syringe'], [29761842, Timestamp('2171-01-28 17:00:00'), Timestamp('2171-01-29 18:00:00'), 'MAIN', 'DiphenhydrAMINE', '011590', '63323066401', '50mg/mL Vial'], [29761842, Timestamp('2171-01-28 17:00:00'), Timestamp('2171-01-29 18:00:00'), 'MAIN', 'Milk of Magnesia', '003026', '00121043130', '30mL UD Cup'], [29761842, Timestamp('2171-01-28 17:00:00'), Timestamp('2171-01-29 18:00:00'), 'MAIN', 'Ketorolac', '039500', '63323016201', '30mg/mL Vial'], [29761842, Timestamp('2171-01-28 17:00:00'), Timestamp('2171-01-29 18:00:00'), 'MAIN', 'Morphine Sulfate', '074851', '00641612525', '4 mg / 1 mL Vial'], [29761842, Timestamp('2171-01-28 17:00:00'), Timestamp('2171-01-29 18:00:00'), 'MAIN', 'Docusate Sodium', '003009', '63739047810', '100mg Capsule'], [29761842, Timestamp('2171-01-28 17:00:00'), Timestamp('2171-01-29 18:00:00'), 'MAIN', 'DiphenhydrAMINE', '011592', '00121048910', '25mg/10mL Cup'], [29761842, Timestamp('2171-01-28 17:00:00'), Timestamp('2171-01-29 18:00:00'), 'MAIN', 'DiphenhydrAMINE', '011582', '00904530661', '25mg Cap'], [29761842, Timestamp('2171-01-28 17:00:00'), Timestamp('2171-01-29 18:00:00'), 'MAIN', 'Senna', '019964', '00904652261', '8.6 mg Tablet'], [29761842, Timestamp('2171-01-28 17:00:00'), Timestamp('2171-01-29 18:00:00'), 'MAIN', 'Bisacodyl', '002944', '00574705050', '10mg Suppository'], [29761842, Timestamp('2171-01-28 17:00:00'), Timestamp('2171-01-29 18:00:00'), 'MAIN', 'Acetaminophen', '004490', '00904198861', '500mg Tablet'], [29761842, Timestamp('2171-01-28 17:00:00'), Timestamp('2171-01-29 18:00:00'), 'MAIN', 'Influenza Vaccine Quadrivalent', '075715', '49281041688', '0.5 mL Syringe'], [29761842, Timestamp('2171-01-29 08:00:00'), Timestamp('2171-01-30 21:00:00'), 'MAIN', 'Bisacodyl', '002947', '00536338101', '5 mg Tab'], [29761842, Timestamp('2171-01-28 20:00:00'), Timestamp('2171-01-29 18:00:00'), 'MAIN', 'Gabapentin', '021414', '00904563261', '300mg Capsule'], [29761842, Timestamp('2171-01-28 17:00:00'), Timestamp('2171-01-29 18:00:00'), 'MAIN', 'Bisacodyl', '002947', '00536338101', '5 mg Tab'], [29761842, Timestamp('2171-01-28 17:00:00'), Timestamp('2171-01-29 18:00:00'), 'MAIN', 'Calcium Carbonate', '002689', '66553000401', '500mg Tablet'], [29761842, Timestamp('2171-01-28 17:00:00'), Timestamp('2171-01-29 18:00:00'), 'BASE', 'Lactated Ringers', '001187', '00338011704', 'Floor Stock Bag'], [29761842, Timestamp('2171-01-29 08:00:00'), Timestamp('2171-01-30 21:00:00'), 'MAIN', 'Bisacodyl', '002944', '00574705050', '10mg Suppository'], [29761842, Timestamp('2171-01-28 17:00:00'), Timestamp('2171-01-29 18:00:00'), 'MAIN', 'OxyCODONE (Immediate Release)', '004225', '00904644461', '5mg Tablet'], [29761842, Timestamp('2171-01-28 17:00:00'), Timestamp('2171-01-29 18:00:00'), 'MAIN', 'Ondansetron', '061716', '00641607825', '2mg/mL-2mL'], [29761842, Timestamp('2171-01-28 17:00:00'), Timestamp('2171-01-29 18:00:00'), 'MAIN', 'Pantoprazole', '027462', '00904647461', '40mg Tablet'], [29761842, Timestamp('2171-01-28 17:00:00'), Timestamp('2171-01-29 18:00:00'), 'MAIN', 'Multivitamins', '002532', '00904053061', '1 Tablet'], [29761842, Timestamp('2171-01-28 17:00:00'), Timestamp('2171-01-29 18:00:00'), 'MAIN', 'Vitamin D', '019166', '10432017002', '400 Unit Tablet']]

[['0RG10K1', 10, 1, Timestamp('2171-01-29 00:00:00'), 'Fusion of Cervical Vertebral Joint with Nonautologous Tissue Substitute, Posterior Approach, Posterior Column, Open Approach'], ['0RB30ZZ', 10, 2, Timestamp('2171-01-29 00:00:00'), 'Excision of Cervical Vertebral Disc, Open Approach']]

['orthopaedics']

[]

Question: A 44 F is admitted. He/she says he/she has right arm pain/weakness . History of illness: Ms. ___ is a pleasant ___ lady who is seen today with complaints of bilateral upper extremity radicular pain, numbness and weakness right more than left. This has been going on since last 5 days. This probably-when she was in an exercise class. She describes the pain along bilateral C7 and C8 dermatomes right more than left. Her examination showed C7 and C8 dermatomal numbness. Her hand grip weakness. To be due to the pain limitation. Her radiographs showed C5-6 and C6-7 degenerative disease C5-7 focal kyphosis. Her MRI shows presence of large right-sided paracentral and foraminal disc herniation at C6-7 causing spinal cord and nerve root impingement. There is absence of is positive for signal intensity changes. Considering severity of her symptoms presence of numbness and the size of disc she can either consider epidural steroid injection or surgical treatment. It was explained to her that the injection may not help her symptoms fully. She was in understanding. The surgical procedure details were also explained to her. Risks of surgery were also explained to her. We will try and get her to see 1 of our pain management physicians for possible urgent epidural steroid injection. I would like to see him back in a week for reassessment. She should give us a call if symptoms worsen. She was in understanding. I spent approximately 45 minutes with this patient and more than 50% time was spent in counseling and coordination of care. Past Medical History: cancer in the form of melanoma in situ Social History: ___ Family History: nc Allergies: Penicillins / Ceclor What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Sodium Chloride 0.9% Flush DiphenhydrAMINE Milk of Magnesia Ketorolac Morphine Sulfate Docusate Sodium DiphenhydrAMINE DiphenhydrAMINE Senna Bisacodyl Acetaminophen Influenza Vaccine Quadrivalent Bisacodyl Gabapentin Bisacodyl Calcium Carbonate Lactated Ringers Bisacodyl OxyCODONE (Immediate Release) Ondansetron Pantoprazole Multivitamins Vitamin D Target Lab Orders: NONE Target Procedures: Fusion of Cervical Vertebral Joint with Nonautologous Tissue Substitute, Posterior Approach, Posterior Column, Open Approach Excision of Cervical Vertebral Disc, Open Approach DOCTOR'S NOTE Hospital Notes: : Patient was admitted to the ___ Spine Surgery Service and taken to the Operating Room for an ACDF C6/7. Refer to the dictated operative note for further details. The surgery was without complication and the patient was transferred to the PACU in a stable condition. TEDs/pnemoboots were used for postoperative DVT prophylaxis. Intravenous antibiotics were continued for 24hrs postop per standard protocol. Initial postop pain was controlled with a IV and PO pain medications. Diet was advanced as tolerated. The patient was transitioned to oral pain medication when tolerating PO diet. Foley was removed postoperatively without issue. Hospital course was otherwise unremarkable. On the day of discharge the patient was afebrile with stable vital signs, comfortable on oral pain control and tolerating a regular diet. Other Results: NIL

2150-04-04 18:36:00

ENGLISH

SINGLE

WHITE

M

[[24242993, Timestamp('2150-04-04 18:36:46'), '', 'MED']]

[[{'Medications on Admission': ':\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild \n2. Metoprolol Succinate XL 25 mg PO DAILY \n3. FoLIC Acid 1 mg PO DAILY \n4. Furosemide 20 mg PO DAILY \n5. Multivitamins 1 TAB PO DAILY \n6. Spironolactone 25 mg PO DAILY \n7. Thiamine 100 mg PO DAILY \n8. Warfarin 4.5 mg PO Frequency is Unknown \n9. Diltiazem Extended-Release 120 mg PO DAILY \n10. DULoxetine ___ 60 mg PO DAILY \n11. DULoxetine ___ 30 mg PO QHS \n12. GuaiFENesin-Dextromethorphan 10 mL PO Q4H:PRN cough \n13. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - \nModerate \n14. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line \n15. Milk of Magnesia 30 mL PO DAILY:PRN Constipation - Third \nLine \n16. Fleet Enema (Saline) 1 Enema PR Q72HR PRN constipation \n\nFacility:\n___', 'Brief Hospital Course': ':\n___ year old man with afib (on warfarin), aortic stenosis, HTN, \nspinal stenosis and liver cirrhosis decompensated by portal \nhypertension in the form of ascites/pleural effusion and \nmultifocal HCC now s/p recent thermal ablation who presents with \nvisual/tactile hallucinations c/f possible HE vs. medication \nside effects.\n\nTRANSITIONAL ISSUES:\n====================\n[] Duloxetine -- may accumulate in patients with hepatic \ndysfunction. Consider tapering.\n[] Continue to monitor for hallucinations and consider \nneurologic evaluation if they persist despite treatment of his \nhepatic encephalopathy.\n[] Spironolactone was held for ___ on presentation. Furosemide \nwas continued. This diuretic regimen should continue to be \nreassessed based on labs and volume status.\n\nACUTE ISSUES: \n============= \n# Visual/Tactile Hallucinations\nPt presented w/ increasing confusion and hallucinations s/p \nrecent thermal ablation. Head imaging and neuro exam \nunremarkable. Concerning for hepatic encephalopathy given\nconstipation in the last week and improvement with starting \nlactulose. Also considered medication side effect (Robitussin, \nduloxetine. Duloxetine may have accumulated given hepatic \ndysfunction. His symptoms improved with increased stooling and a \nmild decrease in the dose of his duloxetine (from 60mg qAM and \n30mg qPM to 30mg BID). Continuing to taper this medication can \nbe considered by his outpatient providers.\n\n# EtoH Cirrhosis - MELD 22 \nPatient had 2 prior para in ___, 5L and 2 L, 1x thoracentesis \non low dose diuretics, no history of varices, no SBP or previous \nHE. Per CT scan on ___ there was expected post ablation \nchanges within the liver with increased moderate volume \nnonhemorrhagic perihepatic ascites. No gastric or esophageal \nvarices on ___. Worsening LFTs likely secondary to \nablation, now improving. Infectious workup negative. Continuing \nrifaximin 550mg PO BID, lactulose TID titrate to ___ BMs/day.\n\n#Localized HCC\nHe was diagnosed with 2.6cm HCC in ___ S/P ablation to seg 4 \non ___ and s/p microwave ablation of 3 hepatic lesions in \nsegment VII and IV A + paracentesis of\napproximately 50 cc of serosanguineous perihepatic ascites on \n___. Most recent MRI from ___ showing 4 lesions, 2 \nof which HCC size 1cm and 1.1cm and 2 suspicious lesions less \nthan cm. In addition there is intrahepatic ductal dilation \nlikely ___ prior intervention. CT chest without concerning lung \nlesions.\n\n# Hyponatremia - resolved. Thought to be secondary to \nhypovolemia, improved with IV albumin.\n\n# ___ on CKD - resolved. Most likely in setting of poor PO \nintake, improved after 75g albumin on admission.\n\nCHRONIC ISSUES: \n=============== \n# Lt pleural effusion, diagnostic thoracentesis done in ___: \ntransudate, negative cytology. Cardiac vs hepatic origin. Per \nCXR on ___, small left and trace right bilateral pleural \neffusions. No respiratory distress during this admission.\n\n# Atrial fibrillation \n - Rate control: Continued home dilt 120mg ER, metoprolol \nsuccinate 25mg PO daily\n - AC: warfarin (4.5mg daily)\n\n# Aortic stenosis \nLast TTE ___ with moderate calcific aortic stenosis with \nvalve area 1.0-1.5 cm2. \n- Per last cards note, patient will be seen in ___ for \nre-evaluation and will likely proceed with AVR at that time\n\n# Depression \n - Duloxetine taper per above\n\n', 'Pertinent Results:': '\nADMISSION LABS\n===============\n___ 12:00PM BLOOD WBC-8.9 RBC-3.20* Hgb-10.0* Hct-30.5* \nMCV-95 MCH-31.3 MCHC-32.8 RDW-14.4 RDWSD-49.0* Plt ___\n___ 12:00PM BLOOD Neuts-77.8* Lymphs-10.4* Monos-9.9 \nEos-0.7* Baso-0.2 Im ___ AbsNeut-6.89* AbsLymp-0.92* \nAbsMono-0.88* AbsEos-0.06 AbsBaso-0.02\n___ 03:44PM BLOOD ___ PTT-30.2 ___\n___ 12:00PM BLOOD Glucose-203* UreaN-24* Creat-1.3* Na-128* \nK-5.5* Cl-96 HCO3-22 AnGap-10\n___ 12:00PM BLOOD ALT-111* AST-116* AlkPhos-142* \nTotBili-0.9\n___ 12:00PM BLOOD Albumin-2.9* Calcium-8.8 Phos-3.6 Mg-1.9\n\nIMAGING STUDIES\n================\nCXR ___\nSmall left and trace right bilateral pleural effusions. Patchy \nopacities in lung bases may reflect atelectasis though infection \nis difficult to exclude in the correct clinical setting. \n\nLEFT SHOULDER XRAY ___. No acute fracture or dislocation. \n2. Moderate acromioclavicular and mild glenohumeral joint \ndegenerative changes. \n3. Minimal periarticular calcifications suggestive of calcific \ntendinopathy. \n\nNCHCT ___\nNo acute intracranial process\n\nCT A/P w/ contrast ___. Expected post ablation changes within the liver with \nincreased moderate volume nonhemorrhagic perihepatic ascites.\n2. No acute intra-abdominal process.\n3. Stable moderate left and new small right pleural effusion \nwith associated bibasilar atelectasis.\n\nMICROBIOLOGY\n==============\nURINE CULTURE NEGATIVE\nBLOOD CULTURES NGTD\n\n', 'Physical Exam:|Physical': 'NIL', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': 'NIL', 'Chief Complaint:|Complaint:': 'NIL', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nNo Known Allergies / Adverse Drug Reactions\n\n'}, '19745809-DS-3', 3, 'medicine']]

[['EXAMINATION: CHEST (AP AND LAT)\n\nINDICATION: History: ___ with hallucinations, ams, cough, recent hepatic\nablation // PNA?\n\nTECHNIQUE: Upright AP and lateral views of the chest\n\nCOMPARISON: CT chest ___\n\nFINDINGS: \n\nCardiac silhouette size is normal.Mediastinal and hilar contours are\nnormal.Pulmonary vasculature is normal.Patchy opacities are seen in the lung\nbases.A small left and trace right bilateral pleural effusions are\ndemonstrated. No pneumothorax.Mild degenerative changes are seen in the\nthoracic spine.\n\nIMPRESSION: \n\nSmall left and trace right bilateral pleural effusions. Patchy opacities in\nlung bases may reflect atelectasis though infection is difficult to exclude in\nthe correct clinical setting.\n', '19745809-RR-27', 27, 'upright ap and lateral views of the chest'], ['INDICATION: History: ___ with L shoulder pain, arthritis x months, worse\nrecently // Eval fx\n\nTECHNIQUE: Left shoulder, three views\n\nCOMPARISON: None.\n\nFINDINGS: \n\nNo acute fracture or dislocation. Mild degenerative changes of the\nglenohumeral joint and moderate degenerative changes of the acromioclavicular\njoint are seen with degenerative spurring and joint space narrowing. Minimal\nperiarticular calcifications along the superolateral aspect of the humeral\nhead may reflect calcific tendinopathy. No concerning lytic or sclerotic\nosseous abnormalities. Imaged left lung demonstrates patchy opacities in the\nleft lung base.\n\nIMPRESSION:\n\n\n1. No acute fracture or dislocation.\n2. Moderate acromioclavicular and mild glenohumeral joint degenerative\nchanges.\n3. Minimal periarticular calcifications suggestive of calcific tendinopathy.\n', '19745809-RR-28', 28, 'left shoulder, three views'], ['EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD\n\nINDICATION: History: ___ with fall 2 weeks ago, on AC, now c/o\nhallucinations, AMS. // Eval ICH\n\nTECHNIQUE: Contiguous axial images of the brain were obtained without\ncontrast. Coronal and sagittal reformations as well as bone algorithm\nreconstructions were provided and reviewed.\n\nDOSE: Acquisition sequence:\n 1) Sequenced Acquisition 16.0 s, 16.4 cm; CTDIvol = 49.1 mGy (Head) DLP =\n802.7 mGy-cm.\n Total DLP (Head) = 803 mGy-cm.\n\nCOMPARISON: Outside hospital head CT ___\n\nFINDINGS: \n\nThere is no evidence of fracture, acute territorial\ninfarction,hemorrhage,edema,or mass. There is prominence of the ventricles\nand sulci suggestive of involutional changes. Calcifications of the cavernous\nportions of bilateral carotid arteries are noted.\n\nThe visualized portion of the paranasal sinuses, mastoid air cells, and middle\near cavities are clear. The visualized portion of the orbits are normal. \nBilateral lens replacements are noted.\n\nIMPRESSION: \n\nNo acute intracranial process.\n', '19745809-RR-29', 29, 'contiguous axial images of the brain were obtained without\ncontrast. coronal and sagittal reformations as well as bone algorithm\nreconstructions were provided and reviewed.'], ['EXAMINATION: CT ABD AND PELVIS WITH CONTRAST\n\nINDICATION: NO_PO contrast; History: ___ with abdominal distention, diffuse\nTTP, most in epigastrium, recent liver biopsy NO_PO contrast // Eval acute\nintra-abdominal process\n\nTECHNIQUE: Single phase contrast: MDCT axial images were acquired through the\nabdomen and pelvis following intravenous contrast administration.\nOral contrast was not administered.\nCoronal and sagittal reformations were performed and reviewed on PACS.\n\nDOSE: Acquisition sequence:\n 1) Stationary Acquisition 6.0 s, 0.5 cm; CTDIvol = 28.9 mGy (Body) DLP =\n14.4 mGy-cm.\n 2) Spiral Acquisition 6.6 s, 52.1 cm; CTDIvol = 22.9 mGy (Body) DLP =\n1,193.7 mGy-cm.\n Total DLP (Body) = 1,208 mGy-cm.\n\nCOMPARISON: CT abdomen/pelvis images from ablation procedure ___\nLiver MRI ___\n\nFINDINGS: \n\nLOWER CHEST: Stable moderate left and new small right pleural effusions are\nnoted. There is associated compressive atelectasis at the bases bilaterally. \nLungs otherwise clear. Extensive coronary artery calcifications, mitral\nannular, and aortic valvular calcifications are noted. No pericardial\neffusion.\n\nABDOMEN:\n\nHEPATOBILIARY: Nodular contour of the liver is consistent with cirrhosis. \nPost ablation changes in segment 7 and segments ___ are noted. No evidence of\nnew focal lesions on this non tailored exam. There is increased moderate\nvolume nonhemorrhagic perihepatic ascites. There is no evidence of\nintrahepatic or extrahepatic biliary dilatation. The gallbladder contains\ngallstones but is otherwise unremarkable.\n\nPANCREAS: The pancreas has normal attenuation throughout, without evidence of\nfocal lesions or pancreatic ductal dilatation. Known cystic lesions within\nthe pancreatic tail are better seen on prior MRI. There is no peripancreatic\nstranding.\n\nSPLEEN: The spleen shows normal size and attenuation throughout. Scattered\nsubcentimeter hypodensities are too small to characterize.\n\nADRENALS: The right and left adrenal glands are normal in size and shape.\n\nURINARY: The kidneys are of normal and symmetric size with normal nephrogram. \nArea of chronic scarring at the upper pole of the right kidney is noted,\nunchanged. Subcentimeter hypodensity in the lower pole the right kidney may\nreflect a cyst. There is no evidence of solid renal lesions or\nhydronephrosis. There is no perinephric abnormality.\n\nGASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate\nnormal caliber, wall thickness, and enhancement throughout. Extensive\ndiverticulosis of the sigmoid and descending colon without evidence of\ndiverticulitis. Appendix is normal.\n\nPELVIS: The urinary bladder and distal ureters are unremarkable. There is\nsmall to moderate free fluid in the pelvis.\n\nREPRODUCTIVE ORGANS: Coarse calcifications within the prostate likely reflect\nsequela of prior inflammation or infection.\n\nLYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There\nis no pelvic or inguinal lymphadenopathy.\n\nVASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic\ndisease is noted.\n\nSoft a G ovarian sees are redemonstrated. Extensive calcifications of the\nsplenic artery are noted.\n\nBONES: There is no evidence of worrisome osseous lesions or acute fracture.\n\nSOFT TISSUES: The abdominal and pelvic wall is within normal limits. Severe\nbilateral symmetric gynecomastia is noted.\n\nIMPRESSION:\n\n\n1. Expected post ablation changes within the liver with increased moderate\nvolume nonhemorrhagic perihepatic ascites.\n2. No acute intra-abdominal process.\n3. Stable moderate left and new small right pleural effusion with associated\nbibasilar atelectasis.\n', '19745809-RR-30', 30, 'single phase contrast: mdct axial images were acquired through the\nabdomen and pelvis following intravenous contrast administration.\noral contrast was not administered.\ncoronal and sagittal reformations were performed and reviewed on pacs.']]

[[24242993, Timestamp('2150-04-05 01:00:00'), Timestamp('2150-04-06 22:00:00'), 'MAIN', 'Thiamine', '016981', '51645090599', '100mg Tablet'], [24242993, Timestamp('2150-04-05 01:00:00'), Timestamp('2150-04-06 22:00:00'), 'MAIN', 'FoLIC Acid', '002366', '62584089701', '1 mg Tab'], [24242993, Timestamp('2150-04-05 08:00:00'), Timestamp('2150-04-05 08:00:00'), 'MAIN', 'Spironolactone', '006817', '00904692761', '25mg Tablet'], [24242993, Timestamp('2150-04-04 23:00:00'), Timestamp('2150-04-05 16:00:00'), 'MAIN', 'Lactulose', '068217', '50383077933', '20g/30mL Cup'], [24242993, Timestamp('2150-04-05 08:00:00'), Timestamp('2150-04-06 22:00:00'), 'MAIN', 'Diltiazem Extended-Release', '021282', '60687019501', '120 mg ER Cap'], [24242993, Timestamp('2150-04-05 01:00:00'), Timestamp('2150-04-06 22:00:00'), 'MAIN', 'Fluticasone Propionate NASAL', '018368', '60505082901', '16g NASAL SPRAY'], [24242993, Timestamp('2150-04-04 23:00:00'), Timestamp('2150-04-06 22:00:00'), 'MAIN', 'Sodium Chloride 0.9% Flush', '', '0', '10 mL Syringe'], [24242993, Timestamp('2150-04-04 23:00:00'), Timestamp('2150-04-05 16:00:00'), 'MAIN', 'Influenza Vaccine Quadrivalent', '079654', '19515090641', '0.5 mL Syringe'], [24242993, Timestamp('2150-04-05 17:00:00'), Timestamp('2150-04-06 22:00:00'), 'MAIN', 'Lactulose', '068217', '50383077933', '20g/30mL Cup'], [24242993, Timestamp('2150-04-05 08:00:00'), Timestamp('2150-04-06 22:00:00'), 'MAIN', 'Metoprolol Succinate XL', '047586', '00904632261', '25mg XL Tab'], [24242993, Timestamp('2150-04-05 01:00:00'), Timestamp('2150-04-05 16:00:00'), 'MAIN', 'Albumin 25% (12.5g / 50mL)', '006329', '00944049302', '100 mL Bag'], [24242993, Timestamp('2150-04-05 08:00:00'), Timestamp('2150-04-06 00:00:00'), 'MAIN', 'Heparin', '006549', '25021040201', '5000 Units / mL- 1mL Vial'], [24242993, Timestamp('2150-04-05 08:00:00'), Timestamp('2150-04-06 22:00:00'), 'MAIN', 'Multivitamins', '002532', '00904053061', '1 Tablet'], [24242993, Timestamp('2150-04-05 16:00:00'), Timestamp('2150-04-06 22:00:00'), 'MAIN', 'Warfarin', '014198', '00056016975', 'Check with MD for Dose'], [24242993, Timestamp('2150-04-04 22:00:00'), Timestamp('2150-04-04 22:00:00'), 'MAIN', 'Influenza Vaccine Quadrivalent', '079654', '19515090641', '0.5 mL Syringe']]

[]

['medicine']

[[50824, Timestamp('2150-04-05 01:21:00'), Timestamp('2150-04-05 01:23:00'), 'Sodium, Whole Blood'], [50861, Timestamp('2150-04-05 07:17:00'), Timestamp('2150-04-05 09:17:00'), 'Alanine Aminotransferase (ALT)'], [50863, Timestamp('2150-04-05 07:17:00'), Timestamp('2150-04-05 09:17:00'), 'Alkaline Phosphatase'], [50868, Timestamp('2150-04-05 07:17:00'), Timestamp('2150-04-05 09:17:00'), 'Anion Gap'], [50878, Timestamp('2150-04-05 07:17:00'), Timestamp('2150-04-05 09:17:00'), 'Asparate Aminotransferase (AST)'], [50882, Timestamp('2150-04-05 07:17:00'), Timestamp('2150-04-05 09:17:00'), 'Bicarbonate'], [50885, Timestamp('2150-04-05 07:17:00'), Timestamp('2150-04-05 09:17:00'), 'Bilirubin, Total'], [50893, Timestamp('2150-04-05 07:17:00'), Timestamp('2150-04-05 09:17:00'), 'Calcium, Total'], [50902, Timestamp('2150-04-05 07:17:00'), Timestamp('2150-04-05 09:17:00'), 'Chloride'], [50912, Timestamp('2150-04-05 07:17:00'), Timestamp('2150-04-05 09:17:00'), 'Creatinine'], [50931, Timestamp('2150-04-05 07:17:00'), Timestamp('2150-04-05 09:17:00'), 'Glucose'], [50934, Timestamp('2150-04-05 07:17:00'), Timestamp('2150-04-05 09:17:00'), 'H'], [50947, Timestamp('2150-04-05 07:17:00'), Timestamp('2150-04-05 09:17:00'), 'I'], [50954, Timestamp('2150-04-05 07:17:00'), Timestamp('2150-04-05 09:17:00'), 'Lactate Dehydrogenase (LD)'], [50960, Timestamp('2150-04-05 07:17:00'), Timestamp('2150-04-05 09:17:00'), 'Magnesium'], [50970, Timestamp('2150-04-05 07:17:00'), Timestamp('2150-04-05 09:17:00'), 'Phosphate'], [50971, Timestamp('2150-04-05 07:17:00'), Timestamp('2150-04-05 09:17:00'), 'Potassium'], [50983, Timestamp('2150-04-05 07:17:00'), Timestamp('2150-04-05 09:17:00'), 'Sodium'], [51006, Timestamp('2150-04-05 07:17:00'), Timestamp('2150-04-05 09:17:00'), 'Urea Nitrogen'], [51678, Timestamp('2150-04-05 07:17:00'), Timestamp('2150-04-05 09:17:00'), 'L'], [51133, Timestamp('2150-04-05 07:17:00'), Timestamp('2150-04-05 08:31:00'), 'Absolute Lymphocyte Count'], [51146, Timestamp('2150-04-05 07:17:00'), Timestamp('2150-04-05 08:31:00'), 'Basophils'], [51200, Timestamp('2150-04-05 07:17:00'), Timestamp('2150-04-05 08:31:00'), 'Eosinophils'], [51221, Timestamp('2150-04-05 07:17:00'), Timestamp('2150-04-05 08:31:00'), 'Hematocrit'], [51222, Timestamp('2150-04-05 07:17:00'), Timestamp('2150-04-05 08:31:00'), 'Hemoglobin'], [51244, Timestamp('2150-04-05 07:17:00'), Timestamp('2150-04-05 08:31:00'), 'Lymphocytes'], [51248, Timestamp('2150-04-05 07:17:00'), Timestamp('2150-04-05 08:31:00'), 'MCH'], [51249, Timestamp('2150-04-05 07:17:00'), Timestamp('2150-04-05 08:31:00'), 'MCHC'], [51250, Timestamp('2150-04-05 07:17:00'), Timestamp('2150-04-05 08:31:00'), 'MCV'], [51254, Timestamp('2150-04-05 07:17:00'), Timestamp('2150-04-05 08:31:00'), 'Monocytes'], [51256, Timestamp('2150-04-05 07:17:00'), Timestamp('2150-04-05 08:31:00'), 'Neutrophils'], [51265, Timestamp('2150-04-05 07:17:00'), Timestamp('2150-04-05 08:31:00'), 'Platelet Count'], [51277, Timestamp('2150-04-05 07:17:00'), Timestamp('2150-04-05 08:31:00'), 'RDW'], [51279, Timestamp('2150-04-05 07:17:00'), Timestamp('2150-04-05 08:31:00'), 'Red Blood Cells'], [51301, Timestamp('2150-04-05 07:17:00'), Timestamp('2150-04-05 08:31:00'), 'White Blood Cells'], [52069, Timestamp('2150-04-05 07:17:00'), Timestamp('2150-04-05 08:31:00'), 'Absolute Basophil Count'], [52073, Timestamp('2150-04-05 07:17:00'), Timestamp('2150-04-05 08:31:00'), 'Absolute Eosinophil Count'], [52074, Timestamp('2150-04-05 07:17:00'), Timestamp('2150-04-05 08:31:00'), 'Absolute Monocyte Count'], [52075, Timestamp('2150-04-05 07:17:00'), Timestamp('2150-04-05 08:31:00'), 'Absolute Neutrophil Count'], [52135, Timestamp('2150-04-05 07:17:00'), Timestamp('2150-04-05 08:31:00'), 'Immature Granulocytes'], [52172, Timestamp('2150-04-05 07:17:00'), Timestamp('2150-04-05 08:31:00'), 'RDW-SD'], [51214, Timestamp('2150-04-05 07:17:00'), Timestamp('2150-04-05 08:42:00'), 'Fibrinogen, Functional'], [51237, Timestamp('2150-04-05 07:17:00'), Timestamp('2150-04-05 08:42:00'), 'INR(PT)'], [51274, Timestamp('2150-04-05 07:17:00'), Timestamp('2150-04-05 08:42:00'), 'PT'], [51275, Timestamp('2150-04-05 07:17:00'), Timestamp('2150-04-05 08:42:00'), 'PTT']]

Question: A 73 M is admitted. He/she says he/she has NIL. History of illness: NIL Allergies: No Known Allergies / Adverse Drug Reactions What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Thiamine FoLIC Acid Spironolactone Lactulose Diltiazem Extended-Release Fluticasone Propionate NASAL Sodium Chloride 0.9% Flush Influenza Vaccine Quadrivalent Lactulose Metoprolol Succinate XL Albumin 25% (12.5g / 50mL) Heparin Multivitamins Warfarin Influenza Vaccine Quadrivalent Target Lab Orders: Sodium, Whole Blood Alanine Aminotransferase (ALT) Alkaline Phosphatase Anion Gap Asparate Aminotransferase (AST) Bicarbonate Bilirubin, Total Calcium, Total Chloride Creatinine Glucose H I Lactate Dehydrogenase (LD) Magnesium Phosphate Potassium Sodium Urea Nitrogen L Absolute Lymphocyte Count Basophils Eosinophils Hematocrit Hemoglobin Lymphocytes MCH MCHC MCV Monocytes Neutrophils Platelet Count RDW Red Blood Cells White Blood Cells Absolute Basophil Count Absolute Eosinophil Count Absolute Monocyte Count Absolute Neutrophil Count Immature Granulocytes RDW-SD Fibrinogen, Functional INR(PT) PT PTT Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : ___ year old man with afib (on warfarin), aortic stenosis, HTN, spinal stenosis and liver cirrhosis decompensated by portal hypertension in the form of ascites/pleural effusion and multifocal HCC now s/p recent thermal ablation who presents with visual/tactile hallucinations c/f possible HE vs. medication side effects. TRANSITIONAL ISSUES: ==================== [] Duloxetine -- may accumulate in patients with hepatic dysfunction. Consider tapering. [] Continue to monitor for hallucinations and consider neurologic evaluation if they persist despite treatment of his hepatic encephalopathy. [] Spironolactone was held for ___ on presentation. Furosemide was continued. This diuretic regimen should continue to be reassessed based on labs and volume status. ACUTE ISSUES: ============= # Visual/Tactile Hallucinations Pt presented w/ increasing confusion and hallucinations s/p recent thermal ablation. Head imaging and neuro exam unremarkable. Concerning for hepatic encephalopathy given constipation in the last week and improvement with starting lactulose. Also considered medication side effect (Robitussin, duloxetine. Duloxetine may have accumulated given hepatic dysfunction. His symptoms improved with increased stooling and a mild decrease in the dose of his duloxetine (from 60mg qAM and 30mg qPM to 30mg BID). Continuing to taper this medication can be considered by his outpatient providers. # EtoH Cirrhosis - MELD 22 Patient had 2 prior para in ___, 5L and 2 L, 1x thoracentesis on low dose diuretics, no history of varices, no SBP or previous HE. Per CT scan on ___ there was expected post ablation changes within the liver with increased moderate volume nonhemorrhagic perihepatic ascites. No gastric or esophageal varices on ___. Worsening LFTs likely secondary to ablation, now improving. Infectious workup negative. Continuing rifaximin 550mg PO BID, lactulose TID titrate to ___ BMs/day. #Localized HCC He was diagnosed with 2.6cm HCC in ___ S/P ablation to seg 4 on ___ and s/p microwave ablation of 3 hepatic lesions in segment VII and IV A + paracentesis of approximately 50 cc of serosanguineous perihepatic ascites on ___. Most recent MRI from ___ showing 4 lesions, 2 of which HCC size 1cm and 1.1cm and 2 suspicious lesions less than cm. In addition there is intrahepatic ductal dilation likely ___ prior intervention. CT chest without concerning lung lesions. # Hyponatremia - resolved. Thought to be secondary to hypovolemia, improved with IV albumin. # ___ on CKD - resolved. Most likely in setting of poor PO intake, improved after 75g albumin on admission. CHRONIC ISSUES: =============== # Lt pleural effusion, diagnostic thoracentesis done in ___: transudate, negative cytology. Cardiac vs hepatic origin. Per CXR on ___, small left and trace right bilateral pleural effusions. No respiratory distress during this admission. # Atrial fibrillation - Rate control: Continued home dilt 120mg ER, metoprolol succinate 25mg PO daily - AC: warfarin (4.5mg daily) # Aortic stenosis Last TTE ___ with moderate calcific aortic stenosis with valve area 1.0-1.5 cm2. - Per last cards note, patient will be seen in ___ for re-evaluation and will likely proceed with AVR at that time # Depression - Duloxetine taper per above Other Results: ADMISSION LABS =============== ___ 12:00PM BLOOD WBC-8.9 RBC-3.20* Hgb-10.0* Hct-30.5* MCV-95 MCH-31.3 MCHC-32.8 RDW-14.4 RDWSD-49.0* Plt ___ ___ 12:00PM BLOOD Neuts-77.8* Lymphs-10.4* Monos-9.9 Eos-0.7* Baso-0.2 Im ___ AbsNeut-6.89* AbsLymp-0.92* AbsMono-0.88* AbsEos-0.06 AbsBaso-0.02 ___ 03:44PM BLOOD ___ PTT-30.2 ___ ___ 12:00PM BLOOD Glucose-203* UreaN-24* Creat-1.3* Na-128* K-5.5* Cl-96 HCO3-22 AnGap-10 ___ 12:00PM BLOOD ALT-111* AST-116* AlkPhos-142* TotBili-0.9 ___ 12:00PM BLOOD Albumin-2.9* Calcium-8.8 Phos-3.6 Mg-1.9 IMAGING STUDIES ================ CXR ___ Small left and trace right bilateral pleural effusions. Patchy opacities in lung bases may reflect atelectasis though infection is difficult to exclude in the correct clinical setting. LEFT SHOULDER XRAY ___. No acute fracture or dislocation. 2. Moderate acromioclavicular and mild glenohumeral joint degenerative changes. 3. Minimal periarticular calcifications suggestive of calcific tendinopathy. NCHCT ___ No acute intracranial process CT A/P w/ contrast ___. Expected post ablation changes within the liver with increased moderate volume nonhemorrhagic perihepatic ascites. 2. No acute intra-abdominal process. 3. Stable moderate left and new small right pleural effusion with associated bibasilar atelectasis. MICROBIOLOGY ============== URINE CULTURE NEGATIVE BLOOD CULTURES NGTD

2138-12-08 12:53:00

?

MARRIED

OTHER

M

[[28550583, Timestamp('2138-12-08 12:54:22'), '', 'CMED']]

[[{'Medications on Admission': ':\nThe Preadmission Medication list is accurate and complete.\n1. Gabapentin 100 mg PO BID \n2. Atenolol 50 mg PO DAILY \n3. amLODIPine 10 mg PO DAILY \n4. Atorvastatin 80 mg PO QPM \n5. Multivitamins 1 TAB PO DAILY \n6. Aspirin 325 mg PO DAILY \n7. Vitamin D ___ UNIT PO DAILY ', 'Brief Hospital Course': ':\nThis is a ___ year old male s/p PCI to LAD ___ and PCI to OM \n___rteries and right ulnar artery. \n\n # Coronary Artery Disease: Declined CABG. s/p DES to LAD \n(emergently)\n___ and DES to OM ___. PCI were done separately due to \nhigh contrast load for procedures. \n- Decrease Aspirin 81mg daily \n- Start clopidogrel 75mg daily x ___ year\n- Continue Atorvastatin 80mg @ HS\n- Stop atenolol and start Carvedilol 6.25mg BID \n- Check labs as outpatient ___ at PCP ___\n\n# Hematoma: s/p PCI ___ via right ulnar artery. Required \nprolonged manual pressure and 2 TR bands, has since stabilized. \nRight forearm measures 34cm at its widest portion. Denies \ntingling, numbness, pain to right arm/wrist/fingers. Right \nradial/ulnar pulse palpable. \n- Patient instructed to report any S/S pain, numbess/tingling, \nincreased swelling\n- Dr. ___ Dr. ___ with picture and arm \nmeasurements, close follow up scheduled with cardiology and PCP \n\n # ___ Disease: Cr stable at 1.3 today. ___ yesterday\nand 1.3 the day prior. \n-**Received a total of 290mL IV contrast dye combined over 3 \ncath procedures \n-Did receive IV hydration pre and post PCI\n-Check labs as outpatient ___ prior to PCP ___\n\n # Hypertension: Stable after switching atenolol to carvedilol \nthis admission. \n- Continue carvedilol \n- Continue Amlodipine \n\n # Hyperlipidemia: \n- Continue high dose Atorvastatin\n\n', 'Pertinent Results:': '\nCoronary Angiogram ___:\nCoronary Description\nThe coronary circulation is right dominant.\nLM: The Left Main, arising from the left cusp, is a large \ncaliber vessel. This vessel bifurcates into the Left Anterior \nDescending and Left Circumflex systems.\nLAD: The Left Anterior Descending artery, which arises from the \nLM, is a large caliber vessel. There is a 99% stenosis in the \nproximal and mid segments with TIMI I/II flow. Collaterals from \nthe distal segment of the AM connect to the distal segment.\nThe ___ Diagonal, arising from the proximal segment, is a medium \ncaliber vessel. There is a stent in the proximal and mid \nsegments.\nThe Septal Perforator, arising from the proximal segment, is a \nsmall caliber vessel.\nThe ___ Diagonal, arising from the proximal segment, is a small \ncaliber vessel. There is an 85% stenosis in the proximal \nsegment.\nCx: The Circumflex artery, which arises from the LM, is a large \ncaliber vessel.\nThe ___ Obtuse Marginal, arising from the proximal segment, is a \nmedium caliber vessel. There is a stent in the ostium extending \nto the mid segment. There is a 95% in-stent restenosis in the \nproximal segment.\nThe ___ Obtuse Marginal, arising from the mid segment, is a \nmedium caliber vessel.\nRCA: The Right Coronary Artery, arising from the right cusp, is \na large caliber vessel. The Acute Marginal, arising from the \nproximal segment, is a small caliber vessel.\nThe Right Posterior Descending Artery, arising from the distal \nsegment, is a medium caliber vessel.\nThere is a 60% stenosis in the proximal and mid segments.\nThe Right Posterolateral Artery, arising from the distal \nsegment, is a medium caliber vessel. There is a 60% stenosis in \nthe mid segment.\n\nFindings\n\x95 Two vessel coronary artery disease, including proximal LAD. \nLIMA patent.\n\nRecommendations\n\x95 ___ consult\n\x95 If not a good surgical candidate or elects to undergo PCI, \nwill plan for PCI of the LAD and the OM1.\n\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n================================================================\n\nCardiac Catheterization ___:\nCoronary Description\nThe left main has no angiographically significant coronary \nabnormalities. The LAD had subtotal occlusion after D2 with slow \nflow. D2 is a small vessel with prior stent with 80% stenosis. \nThe LCX has a moderately large OM1 with long 70-80- instent \nrestenosis with normal flow.\nInterventional Details\nPercutaneous Coronary Intervention: Percutaneous coronary \nintervention (PCI) was performed on a planned basis based on \ncoronary angiographic findings documented on a prior angiogram. \nA 6 ___ EB4 guide provided adequate support. Crossed with a \nSion Blue wire into the distal LAD. Predilated with a 2.0 mm \nballoon and then deployed a 3.5mm x 18mm DES. Postdilated with a \n3.5mm balloon.\nFinal angiography revealed normal flow, no dissection and 0% \nresidual stenosis.\n\nRecommendations\n\x95 ASA 81mg per day.\n\x95 Plavix 75mg/day\n\x95 Return for PCI of LCX because of renal dysfunction\n\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n================================================================\n\n--------------------\nTransthoracic Echo ___ \n--------------------\nCONCLUSION:\nThe left atrial volume index is normal. There is mild symmetric \nleft ventricular hypertrophy with a normal cavity size. There is \nnormal regional and global left ventricular systolic function. \nThe visually estimated left ventricular ejection fraction is \n>=65%. There is no resting left ventricular outflow tract \ngradient. No ventricular septal defect is seen. Tissue Doppler \nsuggests a normal left ventricular filling pressure (PCWP less \nthan 12mmHg). Normal right ventricular cavity size with normal \nfree wall motion. The aortic sinus diameter is normal for gender \nwith mildly dilated ascending aorta. The aortic arch diameter is \nnormal. The aortic valve leaflets (3) are mildly thickened. \nThere is no aortic valve stenosis. There is no aortic \nregurgitation. The mitral valve leaflets appear structurally \nnormal with no mitral valve prolapse. There is trivial mitral \nregurgitation. The tricuspid valve leaflets appear structurally \nnormal. There is physiologic tricuspid regurgitation. The \nestimated\npulmonary artery systolic pressure is high normal. There is no \npericardial effusion. \nIMPRESSION: Mild symmetric left ventricular hypertrophy with \nnormal cavity size and regional/ global biventricular systolic \nfunction. No valvular pathology or pathologic flow identified. \nHigh normal pulmonary artery systolic pressure. Mildly dilated \nascending aorta. Compared with the prior TTE (images reviewed) \nof ___ , the ascending aorta\n\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n================================================================\nCardiac Catheterization ___ \nInterventional Details\nPercutaneous Coronary Intervention: Percutaneous coronary \nintervention (PCI) was performed on a planned basis based on \ncoronary angiographic findings documented on a prior angiogram. \nA 6 ___ EBU3.5 guide provided adequate support. Crossed with \na Prowater wire into the distal OM after a Sion Blue was placed \nin the lower pole of the OM. Predilated with a 3.0 mm balloon \nand then deployed a 3.0 mm x 30 mm DES and a more distal \noverlapping 3.0 x 12 mm DES. Postdilated with a 3.0 mm balloon. \nFinal angiography revealed normal flow, no dissection and 0% \nresidual stenosis.\nComplications: There were no clinically significant \ncomplications.\nFindings\n\x95 Successful PCI with drug-eluting stent of the OM coronary \nartery.\nRecommendations\n\x95 ASA 81mg per day.\n\x95 Plavix 75mg/day\n\x95 Secondary prevention of CAD\n\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n=\n================================================================\n\n-----\nLABS\n-----\n___ 08:00AM POTASSIUM-4.8\n___ 08:00AM UREA N-18 CREAT-1.2\n___ 08:00AM estGFR-Using this\n___ 08:00AM cTropnT-<0.01\n___ 08:00AM HCT-44.9\n___ 08:00AM PLT COUNT-195\n___ 08:00AM ___\n___ 06:40AM BLOOD WBC-7.1 RBC-4.61 Hgb-13.5* Hct-42.4 \nMCV-92 MCH-29.3 MCHC-31.8* RDW-13.5 RDWSD-45.3 Plt ___\n___ 01:10PM BLOOD ___ PTT-150* ___\n___ 06:40AM BLOOD ___ PTT-85.5* ___\n___ 08:57PM BLOOD cTropnT-<0.01\n___ 06:40AM BLOOD Calcium-9.4 Phos-3.2 Mg-2.1\n___ 06:55AM BLOOD WBC-6.5 RBC-4.55* Hgb-13.5* Hct-40.8 \nMCV-90 MCH-29.7 MCHC-33.1 RDW-13.3 RDWSD-43.8 Plt ___\n___ 06:55AM BLOOD Plt ___\n___ 06:55AM BLOOD UreaN-19 Creat-1.3* Na-141 K-4.4 Cl-102 \nHCO3-25 AnGap-14\n___ 06:55AM BLOOD cTropnT-0.01\n___ 07:10AM BLOOD Glucose-105* UreaN-19 Creat-1.2 Na-140 \nK-4.6 Cl-102 HCO3-24 AnGap-14\n___ 07:10AM BLOOD Plt ___\n___ 07:10AM BLOOD WBC-4.5 RBC-5.08 Hgb-14.8 Hct-46.3 MCV-91 \nMCH-29.1 MCHC-32.0 RDW-13.4 RDWSD-45.2 Plt ___\n___ 07:06AM BLOOD WBC-5.1 RBC-4.50* Hgb-13.1* Hct-40.8 \nMCV-91 MCH-29.1 MCHC-32.1 RDW-13.3 RDWSD-43.8 Plt ___\n___ 07:06AM BLOOD Calcium-9.1 Mg-2.1\n\n==================================================\n\n', 'Physical Exam:|Physical': '\nAdmission Physical Exam: \nHR: 46, RR: 16, BP: 132/63, O2 sat: 97 % RA\nGeneral: lying on stretcher, calm/cooperative, in NAD\nHEENT: moist, no lesions; atraumatic/normocephalic\nNeck: no LAD, no JVD\nCV: RRR, no M/R/G or clicks\nChest: LS CTA, no wheezes/rubs/rhonchi or accessory use\nABD: soft, NT/ND with normactive BS throughout, no\nhepatosplenomegly, no rebound tenderness/guarding\nExt: no edema, DP and ___ pulses palp\nSkin: warm/dry and well perfused\nAccess: Bilateral TR bands in place, soft/NT with no hematoma \nand\nsmall amount of oozing. +CSM, +radial pulses\n\nDischarge Physical Exam: Patient examined on ___ 5 inpatient \nunit prior to d/c\nVS:T:98.5PO BP:136/68 HR:67 RR: 20 SpO2:94RA\nWt: 104.92 kg \nGeneral: Patient sitting at side of bed eating breakfast, in no \nacute distress.\nNeuro: Alert, oriented X3. Speech is clear and coherent. Facial \nstructures are symmetrical. Moving all 4 extremities without \ndifficulty. \nPulmonary: LS clear throughout all lung fields. \nCardiac: RRR, no murmurs ausculated. \nGI: Abdomen soft, nontender. Tolerating POs. \nGU: Voiding spontaneously in urinal. \nExtremities/Access site: Right forearm hematoma, stable from day \nprior. Measuring 34cm at widest portion. Denies numbness, \ntingling in arm/wrist/fingers. Palpable radial/ulnar pulse. \nCapillary refill <3 seconds. No ooze at right radial or ulnar \nsite. Left radial site, CDI. No oozing, no hematoma. +CMS. \nBilateral lower extremities warm, no edema. \n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\n___ year old gentleman with history of CAD and PVD s/p AAA\nopen repair with renal artery bypass in ___ ___s left\npopliteal thrombectomy and fasciotomy in ___. His coronary\nartery disease history is notable for a PTCA of the LAD and \nstent\nto the diagonal in ___ and overlapping BX velocity stents\nto a totally occluded OM1 in ___. He had been doing well until\nrecently when he started to have increased chest pain. He \nreports\nchest pain for the last ___ days occuring continuously unrelated\nto activity. Hurts when he presses on it. He was seen by Dr.\n___ on ___ for a routine check up where he had a\nstress echo. This was notable for 2mm ST segment depression with\nexercise and a large apical wall motion abnormality at peak\nexercise. There was no chest pain during exercise.\n\nHe was referred for further evaluation and treatment with \ncardiac catheterization. \n\nPast Medical History:\nPMH: \nAAA which embolized to LLE, CAD s/p PTCA of LAD and stent to \ndiagonal in ___ & overlapping stents to occluded OM1 in \n___, HLD ,CKD\n\nPSH: \nL pop thrombectomy with vein patch angioplasty ___ \nTakeback for 4-compartment fasciotomy ___ \nSplit-thickness skin graft to the left lower leg, 20 x 6 cm in \ndimension ___.\n\nSocial History:\n___\nFamily History:\nNo family history of sudden cardiac death\n\n', 'Chief Complaint:|Complaint:': '\nChest Pain \n\n', 'Attending:': ' ___\n\n', 'Allergies:': ' \nNo Known Allergies / Adverse Drug Reactions\n\n'}, '17327254-DS-19', 19, 'medicine']]

[]

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[['027034Z', 10, 1, Timestamp('2138-12-09 00:00:00'), 'Dilation of Coronary Artery, One Artery with Drug-eluting Intraluminal Device, Percutaneous Approach'], ['B211YZZ', 10, 3, Timestamp('2138-12-08 00:00:00'), 'Fluoroscopy of Multiple Coronary Arteries using Other Contrast']]

['medicine']

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Question: A 69 M is admitted. He/she says he/she has Chest Pain . History of illness: ___ year old gentleman with history of CAD and PVD s/p AAA open repair with renal artery bypass in ___ ___s left popliteal thrombectomy and fasciotomy in ___. His coronary artery disease history is notable for a PTCA of the LAD and stent to the diagonal in ___ and overlapping BX velocity stents to a totally occluded OM1 in ___. He had been doing well until recently when he started to have increased chest pain. He reports chest pain for the last ___ days occuring continuously unrelated to activity. Hurts when he presses on it. He was seen by Dr. ___ on ___ for a routine check up where he had a stress echo. This was notable for 2mm ST segment depression with exercise and a large apical wall motion abnormality at peak exercise. There was no chest pain during exercise. He was referred for further evaluation and treatment with cardiac catheterization. Past Medical History: PMH: AAA which embolized to LLE, CAD s/p PTCA of LAD and stent to diagonal in ___ & overlapping stents to occluded OM1 in ___, HLD ,CKD PSH: L pop thrombectomy with vein patch angioplasty ___ Takeback for 4-compartment fasciotomy ___ Split-thickness skin graft to the left lower leg, 20 x 6 cm in dimension ___. Social History: ___ Family History: No family history of sudden cardiac death Allergies: No Known Allergies / Adverse Drug Reactions What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Acetaminophen Multivitamins Atenolol Potassium Chloride Influenza Vaccine Quadrivalent Potassium Chloride Aspirin Simethicone Gabapentin Potassium Chloride Potassium Chloride Ramelteon Potassium Chloride Potassium Chloride Sodium Chloride 0.9% Flush Atorvastatin Heparin Heparin D5W Nitroglycerin amLODIPine Vitamin D 5% Dextrose Heparin Sodium Nitroglycerin SL Target Lab Orders: Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells RDW-SD Anion Gap Bicarbonate Calcium, Total Chloride Creatinine Glucose H I Magnesium Phosphate Potassium Sodium Urea Nitrogen L INR(PT) PT PTT Target Procedures: Dilation of Coronary Artery, One Artery with Drug-eluting Intraluminal Device, Percutaneous Approach Fluoroscopy of Multiple Coronary Arteries using Other Contrast DOCTOR'S NOTE Hospital Notes: : This is a ___ year old male s/p PCI to LAD ___ and PCI to OM ___rteries and right ulnar artery. # Coronary Artery Disease: Declined CABG. s/p DES to LAD (emergently) ___ and DES to OM ___. PCI were done separately due to high contrast load for procedures. - Decrease Aspirin 81mg daily - Start clopidogrel 75mg daily x ___ year - Continue Atorvastatin 80mg @ HS - Stop atenolol and start Carvedilol 6.25mg BID - Check labs as outpatient ___ at PCP ___ # Hematoma: s/p PCI ___ via right ulnar artery. Required prolonged manual pressure and 2 TR bands, has since stabilized. Right forearm measures 34cm at its widest portion. Denies tingling, numbness, pain to right arm/wrist/fingers. Right radial/ulnar pulse palpable. - Patient instructed to report any S/S pain, numbess/tingling, increased swelling - Dr. ___ Dr. ___ with picture and arm measurements, close follow up scheduled with cardiology and PCP # ___ Disease: Cr stable at 1.3 today. ___ yesterday and 1.3 the day prior. -**Received a total of 290mL IV contrast dye combined over 3 cath procedures -Did receive IV hydration pre and post PCI -Check labs as outpatient ___ prior to PCP ___ # Hypertension: Stable after switching atenolol to carvedilol this admission. - Continue carvedilol - Continue Amlodipine # Hyperlipidemia: - Continue high dose Atorvastatin Other Results: Coronary Angiogram ___: Coronary Description The coronary circulation is right dominant. LM: The Left Main, arising from the left cusp, is a large caliber vessel. This vessel bifurcates into the Left Anterior Descending and Left Circumflex systems. LAD: The Left Anterior Descending artery, which arises from the LM, is a large caliber vessel. There is a 99% stenosis in the proximal and mid segments with TIMI I/II flow. Collaterals from the distal segment of the AM connect to the distal segment. The ___ Diagonal, arising from the proximal segment, is a medium caliber vessel. There is a stent in the proximal and mid segments. The Septal Perforator, arising from the proximal segment, is a small caliber vessel. The ___ Diagonal, arising from the proximal segment, is a small caliber vessel. There is an 85% stenosis in the proximal segment. Cx: The Circumflex artery, which arises from the LM, is a large caliber vessel. The ___ Obtuse Marginal, arising from the proximal segment, is a medium caliber vessel. There is a stent in the ostium extending to the mid segment. There is a 95% in-stent restenosis in the proximal segment. The ___ Obtuse Marginal, arising from the mid segment, is a medium caliber vessel. RCA: The Right Coronary Artery, arising from the right cusp, is a large caliber vessel. The Acute Marginal, arising from the proximal segment, is a small caliber vessel. The Right Posterior Descending Artery, arising from the distal segment, is a medium caliber vessel. There is a 60% stenosis in the proximal and mid segments. The Right Posterolateral Artery, arising from the distal segment, is a medium caliber vessel. There is a 60% stenosis in the mid segment. Findings • Two vessel coronary artery disease, including proximal LAD. LIMA patent. Recommendations • ___ consult • If not a good surgical candidate or elects to undergo PCI, will plan for PCI of the LAD and the OM1. = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = ================================================================ Cardiac Catheterization ___: Coronary Description The left main has no angiographically significant coronary abnormalities. The LAD had subtotal occlusion after D2 with slow flow. D2 is a small vessel with prior stent with 80% stenosis. The LCX has a moderately large OM1 with long 70-80- instent restenosis with normal flow. Interventional Details Percutaneous Coronary Intervention: Percutaneous coronary intervention (PCI) was performed on a planned basis based on coronary angiographic findings documented on a prior angiogram. A 6 ___ EB4 guide provided adequate support. Crossed with a Sion Blue wire into the distal LAD. Predilated with a 2.0 mm balloon and then deployed a 3.5mm x 18mm DES. Postdilated with a 3.5mm balloon. Final angiography revealed normal flow, no dissection and 0% residual stenosis. Recommendations • ASA 81mg per day. • Plavix 75mg/day • Return for PCI of LCX because of renal dysfunction = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = ================================================================ -------------------- Transthoracic Echo ___ -------------------- CONCLUSION: The left atrial volume index is normal. There is mild symmetric left ventricular hypertrophy with a normal cavity size. There is normal regional and global left ventricular systolic function. The visually estimated left ventricular ejection fraction is >=65%. There is no resting left ventricular outflow tract gradient. No ventricular septal defect is seen. Tissue Doppler suggests a normal left ventricular filling pressure (PCWP less than 12mmHg). Normal right ventricular cavity size with normal free wall motion. The aortic sinus diameter is normal for gender with mildly dilated ascending aorta. The aortic arch diameter is normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral valve leaflets appear structurally normal with no mitral valve prolapse. There is trivial mitral regurgitation. The tricuspid valve leaflets appear structurally normal. There is physiologic tricuspid regurgitation. The estimated pulmonary artery systolic pressure is high normal. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with normal cavity size and regional/ global biventricular systolic function. No valvular pathology or pathologic flow identified. High normal pulmonary artery systolic pressure. Mildly dilated ascending aorta. Compared with the prior TTE (images reviewed) of ___ , the ascending aorta = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = ================================================================ Cardiac Catheterization ___ Interventional Details Percutaneous Coronary Intervention: Percutaneous coronary intervention (PCI) was performed on a planned basis based on coronary angiographic findings documented on a prior angiogram. A 6 ___ EBU3.5 guide provided adequate support. Crossed with a Prowater wire into the distal OM after a Sion Blue was placed in the lower pole of the OM. Predilated with a 3.0 mm balloon and then deployed a 3.0 mm x 30 mm DES and a more distal overlapping 3.0 x 12 mm DES. Postdilated with a 3.0 mm balloon. Final angiography revealed normal flow, no dissection and 0% residual stenosis. Complications: There were no clinically significant complications. Findings • Successful PCI with drug-eluting stent of the OM coronary artery. Recommendations • ASA 81mg per day. • Plavix 75mg/day • Secondary prevention of CAD = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = ================================================================ ----- LABS ----- ___ 08:00AM POTASSIUM-4.8 ___ 08:00AM UREA N-18 CREAT-1.2 ___ 08:00AM estGFR-Using this ___ 08:00AM cTropnT-<0.01 ___ 08:00AM HCT-44.9 ___ 08:00AM PLT COUNT-195 ___ 08:00AM ___ ___ 06:40AM BLOOD WBC-7.1 RBC-4.61 Hgb-13.5* Hct-42.4 MCV-92 MCH-29.3 MCHC-31.8* RDW-13.5 RDWSD-45.3 Plt ___ ___ 01:10PM BLOOD ___ PTT-150* ___ ___ 06:40AM BLOOD ___ PTT-85.5* ___ ___ 08:57PM BLOOD cTropnT-<0.01 ___ 06:40AM BLOOD Calcium-9.4 Phos-3.2 Mg-2.1 ___ 06:55AM BLOOD WBC-6.5 RBC-4.55* Hgb-13.5* Hct-40.8 MCV-90 MCH-29.7 MCHC-33.1 RDW-13.3 RDWSD-43.8 Plt ___ ___ 06:55AM BLOOD Plt ___ ___ 06:55AM BLOOD UreaN-19 Creat-1.3* Na-141 K-4.4 Cl-102 HCO3-25 AnGap-14 ___ 06:55AM BLOOD cTropnT-0.01 ___ 07:10AM BLOOD Glucose-105* UreaN-19 Creat-1.2 Na-140 K-4.6 Cl-102 HCO3-24 AnGap-14 ___ 07:10AM BLOOD Plt ___ ___ 07:10AM BLOOD WBC-4.5 RBC-5.08 Hgb-14.8 Hct-46.3 MCV-91 MCH-29.1 MCHC-32.0 RDW-13.4 RDWSD-45.2 Plt ___ ___ 07:06AM BLOOD WBC-5.1 RBC-4.50* Hgb-13.1* Hct-40.8 MCV-91 MCH-29.1 MCHC-32.1 RDW-13.3 RDWSD-43.8 Plt ___ ___ 07:06AM BLOOD Calcium-9.1 Mg-2.1 ==================================================

2158-04-29 17:05:00

ENGLISH

MARRIED

WHITE

M

[[29313300, Timestamp('2158-04-29 17:06:05'), '', 'EYE'], [29313300, Timestamp('2158-04-29 18:58:51'), 'EYE', 'MED']]

[[{'Medications on Admission': 'NIL', 'Brief Hospital Course': ':\nPatient is a ___ man with chronic lymphocytic leukemia \nin ___ (s/p chlorambucil/rituximab ___, history of \ncomplete heart block s/p dual-chamber ___ Adapta L \npacemaker, hypertension, recently diagnosed SCC of skin, DJD, \nDM, HLD, who presents after developing flash pulmonary edema in \nthe setting of significant hypertension and anxiety, during \nscheduled vitrectomy procedure.\n\n# Flash pulmonary edema\n# Hypertension\nCurrent presentation of cough/hypoxia with pulmonary congestion \non CXR all consistent with flash pulmonary edema driven by \nsevere hypertensive episode causing increased afterload. Suspect \nsome component of anxiety driving hypertension. Patient also did \nnot take morning BP med and morning dose of Lasix which likely \ncontributed. Pt was given 1x 20mg IV Lasix for diuresis and \nimproved significantly with this and titrated off O2. Plan to \nresume home Lasix post-discharge.\n\n# Leukocytosis: ___ presented with WBC: 17.8, likely a \nstress-related reaction. He does not have any signs of infection \n(no infiltrates on CXR, no urinary sxs). Improved without \nintervention.', 'Pertinent Results:': '\n___ 09:40PM CK(CPK)-72\n___ 02:19PM CK-MB-4 cTropnT-<0.01\n___ 12:00PM GLUCOSE-246* UREA N-15 CREAT-1.0 SODIUM-141 \nPOTASSIUM-4.8 CHLORIDE-104 TOTAL CO2-24 ANION GAP-18\n___ 12:00PM CALCIUM-9.3 PHOSPHATE-5.1* MAGNESIUM-1.7\n___ 12:00PM WBC-17.8*# RBC-4.80 HGB-16.1 HCT-46.5 MCV-97 \nMCH-33.5* MCHC-34.6 RDW-14.1 RDWSD-50.2*\n___ 12:00PM PLT COUNT-145*\n\nCXR:\nModerate pulmonary edema is new, pleural effusions are small if \nany. Heart size is top-normal, unchanged. \n\nTransvenous right atrial and right ventricular pacer leads \nfollow their \nexpected courses intact from the left pectoral generator. \n\n', 'Physical Exam:|Physical': '\nGen: NAD, lying in bed, obese\n Eyes: EOMI, sclerae anicteric \n ENT: MMM, OP clear\n Neck: JVP 10cm\n Cardiovasc: RRR, no MRG, full pulses, no edema \n Resp: normal effort, no accessory muscle use, faint crackles at \nbases\n GI: soft, NT, ND, BS+\n MSK: No significant kyphosis. No palpable synovitis.\n Skin: No visible rash. No jaundice.\n Neuro: AAOx3. No facial droop.\n Psych: Full range of affect\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': "\nPatient is a ___ man with chronic lymphocytic leukemia \nin ___ (s/p chlorambucil/rituximab ___, history of \ncomplete heart block s/p dual-chamber ___ Adapta L \npacemaker, hypertension, recently diagnosed SCC of skin, DJD, \nDM, HLD, who presents with acute onset cough and hypoxia \nfollowing a scheduled vitrectomy procedure.\n\nHe is POD#0 vitrectomy. During procedure, he reports feeling \nvery anxious and uncomfortable being under drape. He reports \nfeeling suffocated. Anesthesia records note that his SBP rose at \none point to 170s (normally he is ___ and during this time, \nhe also developed a cough and hypoxia with sats down to ___. He \nwas put on NRB and CXR showed pulmonary edema. He was given \nlasix 30 mg IV x1 given. Following this, he reports his \nbreathing improved significantly, and while in PACU he was \nquickly weaned down to ___ NC. Labs notable for WBC 17, \notherwise normal chemistry, ABG.\n\nOn arrival to floor, he reports feeling significantly improved. \nHe is hungry and wants to eat. Otherwise ROS negative.\n\nPast Medical History:\n1. Hypertensive cardiomyopathy (LVEF ___ when BP poorly \ncontrolled. S/o ___ medical therapy, LVEF 50-55%).\n2. Hypertension\n3. Diabetes\n4. Hyperlipidemia\n5. CLL\n6. Frequent ventricular ectopy\n7. Remote possible h/o sarcoid based on skin biopsy, no \npulmonary\nissues\n\nSocial History:\n___\nFamily History:\nPatient's father was a heavy tobacco smoker. Had emphysema and \n?MI in his ___. Patient denies any family history of arrhythmias \nor episodes that resemble sudden cardiac death. \n\n", 'Chief Complaint:|Complaint:': '\ncough, hypoxia\n\n', 'Attending:': ' ___\n\n', 'Allergies:': ' \nNo Known Allergies / Adverse Drug Reactions\n\n'}, '19368054-DS-3', 3, 'medicine']]

[['EXAMINATION: CHEST (PORTABLE AP)\n\nINDICATION: ___ year old man with acute pulmonary edema // evaluate hypoxia \nevaluate hypoxia\n\nIMPRESSION: \n\nCompared to chest radiographs since ___, most recently ___.\n\nModerate pulmonary edema is new, pleural effusions are small if any. Heart\nsize is top-normal, unchanged.\n\nTransvenous right atrial and right ventricular pacer leads follow their\nexpected courses intact from the left pectoral generator.\n', '19368054-RR-12', 12, '']]

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[['08N43ZZ', 10, 1, Timestamp('2158-04-29 00:00:00'), 'Release Right Vitreous, Percutaneous Approach'], ['08933ZZ', 10, 2, Timestamp('2158-04-29 00:00:00'), 'Drainage of Left Anterior Chamber, Percutaneous Approach'], ['3E0C33Z', 10, 3, Timestamp('2158-04-29 00:00:00'), 'Introduction of Anti-inflammatory into Eye, Percutaneous Approach']]

['medicine']

[[50910, Timestamp('2158-04-29 21:40:00'), Timestamp('2158-04-29 23:41:00'), 'Creatine Kinase (CK)'], [50911, Timestamp('2158-04-29 21:40:00'), Timestamp('2158-04-29 23:41:00'), 'Creatine Kinase, MB Isoenzyme'], [50934, Timestamp('2158-04-29 21:40:00'), Timestamp('2158-04-29 23:41:00'), 'H'], [50947, Timestamp('2158-04-29 21:40:00'), Timestamp('2158-04-29 23:41:00'), 'I'], [51678, Timestamp('2158-04-29 21:40:00'), Timestamp('2158-04-29 23:41:00'), 'L'], [51221, Timestamp('2158-04-30 13:10:00'), Timestamp('2158-04-30 13:36:00'), 'Hematocrit'], [51222, Timestamp('2158-04-30 13:10:00'), Timestamp('2158-04-30 13:36:00'), 'Hemoglobin'], [51248, Timestamp('2158-04-30 13:10:00'), Timestamp('2158-04-30 13:36:00'), 'MCH'], [51249, Timestamp('2158-04-30 13:10:00'), Timestamp('2158-04-30 13:36:00'), 'MCHC'], [51250, Timestamp('2158-04-30 13:10:00'), Timestamp('2158-04-30 13:36:00'), 'MCV'], [51265, Timestamp('2158-04-30 13:10:00'), Timestamp('2158-04-30 13:36:00'), 'Platelet Count'], [51277, Timestamp('2158-04-30 13:10:00'), Timestamp('2158-04-30 13:36:00'), 'RDW'], [51279, Timestamp('2158-04-30 13:10:00'), Timestamp('2158-04-30 13:36:00'), 'Red Blood Cells'], [51301, Timestamp('2158-04-30 13:10:00'), Timestamp('2158-04-30 13:36:00'), 'White Blood Cells'], [52172, Timestamp('2158-04-30 13:10:00'), Timestamp('2158-04-30 13:36:00'), 'RDW-SD'], [50868, Timestamp('2158-04-30 13:10:00'), Timestamp('2158-04-30 13:53:00'), 'Anion Gap'], [50882, Timestamp('2158-04-30 13:10:00'), Timestamp('2158-04-30 13:53:00'), 'Bicarbonate'], [50893, Timestamp('2158-04-30 13:10:00'), Timestamp('2158-04-30 13:53:00'), 'Calcium, Total'], [50902, Timestamp('2158-04-30 13:10:00'), Timestamp('2158-04-30 13:53:00'), 'Chloride'], [50912, Timestamp('2158-04-30 13:10:00'), Timestamp('2158-04-30 13:53:00'), 'Creatinine'], [50931, Timestamp('2158-04-30 13:10:00'), Timestamp('2158-04-30 13:53:00'), 'Glucose'], [50934, Timestamp('2158-04-30 13:10:00'), Timestamp('2158-04-30 13:53:00'), 'H'], [50947, Timestamp('2158-04-30 13:10:00'), Timestamp('2158-04-30 13:53:00'), 'I'], [50960, Timestamp('2158-04-30 13:10:00'), Timestamp('2158-04-30 13:53:00'), 'Magnesium'], [50971, Timestamp('2158-04-30 13:10:00'), Timestamp('2158-04-30 13:53:00'), 'Potassium'], [50983, Timestamp('2158-04-30 13:10:00'), Timestamp('2158-04-30 13:53:00'), 'Sodium'], [51006, Timestamp('2158-04-30 13:10:00'), Timestamp('2158-04-30 13:53:00'), 'Urea Nitrogen'], [51678, Timestamp('2158-04-30 13:10:00'), Timestamp('2158-04-30 13:53:00'), 'L']]

Question: A 77 M is admitted. He/she says he/she has cough, hypoxia . History of illness: Patient is a ___ man with chronic lymphocytic leukemia in ___ (s/p chlorambucil/rituximab ___, history of complete heart block s/p dual-chamber ___ Adapta L pacemaker, hypertension, recently diagnosed SCC of skin, DJD, DM, HLD, who presents with acute onset cough and hypoxia following a scheduled vitrectomy procedure. He is POD#0 vitrectomy. During procedure, he reports feeling very anxious and uncomfortable being under drape. He reports feeling suffocated. Anesthesia records note that his SBP rose at one point to 170s (normally he is ___ and during this time, he also developed a cough and hypoxia with sats down to ___. He was put on NRB and CXR showed pulmonary edema. He was given lasix 30 mg IV x1 given. Following this, he reports his breathing improved significantly, and while in PACU he was quickly weaned down to ___ NC. Labs notable for WBC 17, otherwise normal chemistry, ABG. On arrival to floor, he reports feeling significantly improved. He is hungry and wants to eat. Otherwise ROS negative. Past Medical History: 1. Hypertensive cardiomyopathy (LVEF ___ when BP poorly controlled. S/o ___ medical therapy, LVEF 50-55%). 2. Hypertension 3. Diabetes 4. Hyperlipidemia 5. CLL 6. Frequent ventricular ectopy 7. Remote possible h/o sarcoid based on skin biopsy, no pulmonary issues Social History: ___ Family History: Patient's father was a heavy tobacco smoker. Had emphysema and ?MI in his ___. Patient denies any family history of arrhythmias or episodes that resemble sudden cardiac death. Allergies: No Known Allergies / Adverse Drug Reactions What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Glucagon Albuterol 0.083% Neb Soln Sodium Chloride 0.9% Flush Simvastatin Insulin Vitamin D Furosemide Dextrose 50% Metoprolol Succinate XL Aspirin Glucose Gel Target Lab Orders: Creatine Kinase (CK) Creatine Kinase, MB Isoenzyme H I L Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells RDW-SD Anion Gap Bicarbonate Calcium, Total Chloride Creatinine Glucose H I Magnesium Potassium Sodium Urea Nitrogen L Target Procedures: Release Right Vitreous, Percutaneous Approach Drainage of Left Anterior Chamber, Percutaneous Approach Introduction of Anti-inflammatory into Eye, Percutaneous Approach DOCTOR'S NOTE Hospital Notes: : Patient is a ___ man with chronic lymphocytic leukemia in ___ (s/p chlorambucil/rituximab ___, history of complete heart block s/p dual-chamber ___ Adapta L pacemaker, hypertension, recently diagnosed SCC of skin, DJD, DM, HLD, who presents after developing flash pulmonary edema in the setting of significant hypertension and anxiety, during scheduled vitrectomy procedure. # Flash pulmonary edema # Hypertension Current presentation of cough/hypoxia with pulmonary congestion on CXR all consistent with flash pulmonary edema driven by severe hypertensive episode causing increased afterload. Suspect some component of anxiety driving hypertension. Patient also did not take morning BP med and morning dose of Lasix which likely contributed. Pt was given 1x 20mg IV Lasix for diuresis and improved significantly with this and titrated off O2. Plan to resume home Lasix post-discharge. # Leukocytosis: ___ presented with WBC: 17.8, likely a stress-related reaction. He does not have any signs of infection (no infiltrates on CXR, no urinary sxs). Improved without intervention. Other Results: ___ 09:40PM CK(CPK)-72 ___ 02:19PM CK-MB-4 cTropnT-<0.01 ___ 12:00PM GLUCOSE-246* UREA N-15 CREAT-1.0 SODIUM-141 POTASSIUM-4.8 CHLORIDE-104 TOTAL CO2-24 ANION GAP-18 ___ 12:00PM CALCIUM-9.3 PHOSPHATE-5.1* MAGNESIUM-1.7 ___ 12:00PM WBC-17.8*# RBC-4.80 HGB-16.1 HCT-46.5 MCV-97 MCH-33.5* MCHC-34.6 RDW-14.1 RDWSD-50.2* ___ 12:00PM PLT COUNT-145* CXR: Moderate pulmonary edema is new, pleural effusions are small if any. Heart size is top-normal, unchanged. Transvenous right atrial and right ventricular pacer leads follow their expected courses intact from the left pectoral generator.

2177-04-01 14:50:00

ENGLISH

SINGLE

BLACK/AFRICAN AMERICAN

M

[[23682462, Timestamp('2177-04-01 14:50:56'), '', 'CMED']]

[[{'Medications on Admission': ':\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 500 mg PO Q6H:PRN pain \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 80 mg PO DAILY \n4. Calcitriol 0.25 mcg PO DAILY \n5. Carbamazepine 100 mg PO HS \n6. Clopidogrel 75 mg PO DAILY \n7. Docusate Sodium 100 mg PO BID:PRN constipation \n8. FoLIC Acid 1 mg PO DAILY \n9. Morphine SR (MS ___ 15 mg PO Q12H:PRN pain \n10. Multivitamins 1 TAB PO DAILY \n11. Omeprazole 20 mg PO DAILY \n12. Pancrelipase 5000 1 CAP PO TID W/MEALS \n13. Senna 1 TAB PO BID:PRN constipation \n14. Vesicare (solifenacin) 10 mg oral daily \n15. Warfarin 5 mg PO DAILY16 \n16. Glargine 26 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin\n17. Polyethylene Glycol 17 g PO DAILY \n18. Carvedilol 25 mg PO BID \n19. Lisinopril 5 mg PO DAILY \n\nFacility:\n___', 'Brief Hospital Course': ":\n___ with poorly controlled DM2, HTN, HLD, CAD, s/p anterior ST \nelevation MI, s/p DES to the LAD ___, Ischemic \ncardiomyopathy, LVEF 30%, hx of CVAs most recent ___, \nhistory of DVT s/p IVF filter and currently on Coumadin who \npresented with chest pain. \n\n# Acute Coronary Syndrome: Likely unstable angina. Patient \npresented with chest pain which was attributed to poor \ncollateral from occluded RCA therefore his RCA was opened with \ntwo ___. He intermittently complained of chest pain post \nhis stent placement. His EKG remained unchanged. His TTE was \nunchanged from prior. He is currently on triple anticoagulation \ntherapy. He will follow up with Dr. ___ will make \nfurther management decisions. \n- Continue plavix 75 mg daily\n- Carvedilol 12.5mg BID\n- Atorvastatin 80mg daily\n- Continue aspirin 81mg daily\n- Continue coumadin with goal INR >2\n- Continue lisinopril 2.5mg daily\n\n# Ischemic Cardiomyopathy: EF of 30%. Currently euvolemic with \nno evidence of heart failure. Not on any diuretics as \noutpatient. \n- Monitor Daily weight as outpatient. \n- Outpatient eval for an ICD\n\n# DM: Poorly controlled. Finger sticks in the low 200s. \nPatient should follow up with PCP for further management. \n- Diabetic diet\n- Home lantus and SSI\n\n# HLD: atorvastatin\n\n# Chronic Pain: Patient appeared somnolent on the morning of \ndischarge raising concern for narcotic sedation. Patient's \nbecame more awake and interactive after few hours. If patient \nbecomes somnolent in the rehab, his narcotic dose should be \nheld. Patient will follow up with PCP who will determine if he \nstill has indication for opioid treatment given repeated \nepisodes of cocaine abuse. \n\nTransitional Issues:\n- Outpatient follow up with Dr. ___ will further decide \non his triple anticoagulation. He will also be evaluated for \nICD placement in the future given his low EF.\n- PCP follow up to determine continued need for narcotics\n- INR check on ___\n\n", 'Pertinent Results:': '\nPertinent Labs:\n\n___ 10:25AM BLOOD WBC-9.7 RBC-4.69 Hgb-13.8* Hct-43.4 \nMCV-93 MCH-29.5 MCHC-31.8 RDW-13.2 Plt ___\n___ 07:00AM BLOOD WBC-9.0 RBC-4.17* Hgb-12.4* Hct-38.7* \nMCV-93 MCH-29.7 MCHC-32.1 RDW-13.1 Plt ___\n___ 10:25AM BLOOD ___ PTT-37.8* ___\n___ 07:00AM BLOOD ___ PTT-36.4 ___\n___ 10:25AM BLOOD Glucose-243* UreaN-19 Creat-1.5* Na-133 \nK-4.2 Cl-96 HCO3-29 AnGap-12\n___ 07:00AM BLOOD Glucose-253* UreaN-18 Creat-1.4* Na-136 \nK-4.6 Cl-98 HCO3-30 AnGap-13\n___ 07:00AM BLOOD ALT-17 AST-19 CK(CPK)-39* AlkPhos-106 \nTotBili-0.3\n___ 10:25AM BLOOD cTropnT-<0.01\n___ 05:17PM BLOOD CK-MB-2 cTropnT-<0.01\n___ 07:00AM BLOOD CK-MB-2 cTropnT-<0.01\n___ 10:25AM BLOOD Calcium-9.4 Phos-3.3 Mg-2.3\n.\nTTE: ___\nThe left atrial volume is mildly increased. Left ventricular \nwall thicknesses are normal. The left ventricular cavity is \nmoderately dilated. There is severe regional left ventricular \nsystolic dysfunction with mid anterolateral, anterior, and \ninferoseptal hypokinesis. Diastolic function could not be \nassessed. Right ventricular chamber size and free wall motion \nare normal. The ascending aorta is mildly dilated. The aortic \narch is mildly dilated. The aortic valve leaflets are mildly \nthickened (?#). There is no aortic valve stenosis. No aortic \nregurgitation is seen. The mitral valve leaflets are mildly \nthickened. There is no mitral valve prolapse. Trivial mitral \nregurgitation is seen. The pulmonary artery systolic pressure \ncould not be determined. There is an anterior space which most \nlikely represents a prominent fat pad. \n\nIMPRESSION: Severely depressed left ventricular function with \nregional wall motion abnormalities in the distribution of the \nLAD. Moderately dilated left ventricle. Normal RV function.\n.\nAssessment & Recommendations\n 1. Stable two vessel coronary artery disease ___ diagonal and\nchronic diffuse collateralized subtotal occlusion of the RCA)\nwith patent prior proximal LAD stent and no angiographic \nevidence\nof anatomy consistent with acute STEMI.\n 2. Low normal systemic arterial pressures.\n 3. Failed attempt to engage the LMCA via the right radial\nartery.\n 4. Successful deployment of 2 drug-eluting stent in the\nproximal-distal RCA for unstable angina and possible acute \nNSTEMI\n(with chronic ST elevations).\n 5. Successful right femoral artery AngioSeal closure\n 6. Routine post-TR Band care of the right radial artery.\n 7. Cycle CK-MB and platelets.\n 8. ASA indefinitely for life.\n 9. Clopidogrel 75 mg daily for at least another year to prevent\nRCA stent thrombosis.\n10. Continue warfarin as clinically indicated.\n11. Consider reassessment of LVEF with TTE.\n12. Reinforce secondary preventative measures against CAD, LVSD,\nand recurrent acute coronary syndrome.\n\nAttending Electronic Signature attests that the attending was\npresent for the key components of this procedure.\n\nAddendum by ___, MD, MSC on ___ at 11:48 am:\nCorrections:\n-Coronary angiography using 6 ___ XB-LAD 4 guide via\nright femoral artery, 6 ___ JR4 guide\n\nCoronary angiography: right dominant\n LMCA: The LMCA was short and patent.\n\n', 'Physical Exam:|Physical': '\nPHYSICAL EXAMINATION: \nVitals- 97.4 115/70 84 99%2L \nGeneral- Alert, oriented, some discomfort\nHEENT- Sclera anicteric, MMM, \nNeck- supple, JVP not elevated, no cervical LAD \nLungs- CTAB \nCV- S1 S2 RRR \nAbdomen- soft, non-distended, hyperactive BS, no rebound \ntenderness or guarding, no organomegaly \nExt- cool, extremities with poor pulses \nNeuro- CN ___ intact \n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\nMr. ___ is a ___ with poorly controlled DM2, HTN, HLD, CAD, \ns/p anterior ST elevation MI, s/p DES to the LAD ___, \nIschemic cardiomyopathy, LVEF 30%, hx of CVAs most recent \n___, history of DVT s/p IVC filter and currently on coumadin \nwho presents with crushing chest pain. Patient reports waking \nup in the morning with right chest chest pressure which lasted \nfew minutes and resolved. However few hours later chest \npressure returned. Denies any shortness of breath or \npalpitations during these episodes. Mentioned feeling \nlightheaded while waking up in the morning. \n\nOf note patient was found to have STEMI in ___ s/p DES to \nLAD. He had moderate disease in other territories. Acute echo \nshowed an ejection fraction of ___ down from >65% few years \nago. He was ultimately discharged to Radius Rehab on triple \nanticoagulation therapy given poor EF following myocardial \ninfarction as well as a drug-eluting stent implantation. Most \nrecently he was admitted to neurology service in ___ in the \nsetting of new stroke throught be from cardioembolic in the \nsetting of supratheraputic INR. He has history of frequent \ncocacine use however per has not been using in the rehab. \n\nToday he complained of severe chest pain and found to have ST \nelevation on EKG. He was trasnfered to ___ ED where code \nSTEMI was called. He was plavix loaded and started on IV \nheparin. He was taken to cath lab but no new lesions were \nidentified. He was thought to have insufficient collateral from \nhis RCA therefore his RCA was opened with two ___. Radial \napproach failed therefore right groin approach for access. \nCurrently chest pain free. \n\nPast Medical History:\nPAST MEDICAL HISTORY: \n1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension \n\n2. CARDIAC HISTORY: \n- CAD, s/p anterior ST elevation MI, s/p DES to the LAD ___. \n\n- PVD, s/p PTA of the R peroneal artery.\n- Ischemic cardiomyopathy, LVEF 30%. \n- PERCUTANEOUS CORONARY INTERVENTIONS: DES to LAD\n- PACING/ICD: None\n3. OTHER PAST MEDICAL HISTORY: \n- Peripheral vascular disease, s/p R peroneal artery angioplasty\n- Recurrent DVTs (on Coumadin and s/p IVC filter)\n- CVA in ___ (treated at ___ in ___), with residual \nright-sided deficits per his report; stroke in ___ in the \nsetting of subtherapuetic INR\n- H/O cocaine use\n- Pancreatic disease (chronic pancreatitis versus IPMN) - \nhistory of alcohol use. He recently saw gastroenterology. They \nscheduled him for an endoscopic ultrasound to evaluate the \nampulla given the concern for IPMN.\n- Bilateral shoulder pain from degenerative joint disease \n- Phlebitis\n- BPH\n- Gout\n\nSocial History:\n___\nFamily History:\nNo family history of early MI, arrhythmia, cardiomyopathies, or \nsudden cardiac death; otherwise non-contributory. \n\n', 'Chief Complaint:|Complaint:': '\nchest pain\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nNo Known Allergies / Adverse Drug Reactions\n\n'}, '17967161-DS-22', 22, 'medicine']]

[]

[[23682462, Timestamp('2177-04-01 17:00:00'), Timestamp('2177-04-02 22:00:00'), 'MAIN', 'Docusate Sodium', '003009', '00904224461', '100mg Capsule'], [23682462, Timestamp('2177-04-01 17:00:00'), Timestamp('2177-04-02 22:00:00'), 'MAIN', 'Carbamazepine', '004559', '51079087020', '100mg Tablet'], [23682462, Timestamp('2177-04-02 08:00:00'), Timestamp('2177-04-02 22:00:00'), 'MAIN', 'Aspirin', '004376', '68016001129', '325mg Tablet'], [23682462, Timestamp('2177-04-01 17:00:00'), Timestamp('2177-04-02 22:00:00'), 'MAIN', 'Omeprazole', '033530', '00904568461', '20mg Cap'], [23682462, Timestamp('2177-04-01 17:00:00'), Timestamp('2177-04-02 22:00:00'), 'MAIN', 'FoLIC Acid', '002366', '62584089701', '1 mg Tab'], [23682462, Timestamp('2177-04-01 17:00:00'), Timestamp('2177-04-02 22:00:00'), 'MAIN', 'Senna', '019964', '00904516561', '1 Tablet'], [23682462, Timestamp('2177-04-02 08:00:00'), Timestamp('2177-04-02 22:00:00'), 'MAIN', 'Atorvastatin', '045772', '00071015892', '80mg Tablet'], [23682462, Timestamp('2177-04-01 17:00:00'), Timestamp('2177-04-02 22:00:00'), 'MAIN', 'Insulin', '047780', '00088222033', '100 Units / mL - 10 mL Vial'], [23682462, Timestamp('2177-04-01 17:00:00'), Timestamp('2177-04-02 22:00:00'), 'MAIN', 'Clopidogrel', '038164', '63653117103', '75 mg Tablet'], [23682462, Timestamp('2177-04-02 14:00:00'), Timestamp('2177-04-02 22:00:00'), 'MAIN', 'Aluminum-Magnesium Hydrox.-Simethicone', '002701', '00121176130', '30 mL UDCup'], [23682462, Timestamp('2177-04-01 17:00:00'), Timestamp('2177-04-01 18:00:00'), 'MAIN', 'Warfarin', '006560', '00056017675', '2.5mg Tablet'], [23682462, Timestamp('2177-04-01 17:00:00'), Timestamp('2177-04-02 22:00:00'), 'MAIN', 'Acetaminophen', '004490', '00904198861', '500mg Tablet'], [23682462, Timestamp('2177-04-01 17:00:00'), Timestamp('2177-04-02 22:00:00'), 'MAIN', 'Multivitamins', '002532', '00904053061', '1 Tablet'], [23682462, Timestamp('2177-04-01 17:00:00'), Timestamp('2177-04-02 22:00:00'), 'MAIN', 'Dextrose 50%', '001989', '00409490234', '25 g / 50 mL Syringe'], [23682462, Timestamp('2177-04-01 17:00:00'), Timestamp('2177-04-02 22:00:00'), 'MAIN', 'Morphine SR (MS Contin)', '011887', '00406831562', '15mg Tab'], [23682462, Timestamp('2177-04-02 08:00:00'), Timestamp('2177-04-02 13:00:00'), 'MAIN', 'Lisinopril', '000393', '68084006001', '5mg Tablet'], [23682462, Timestamp('2177-04-01 17:00:00'), Timestamp('2177-04-02 22:00:00'), 'MAIN', 'Polyethylene Glycol', '034313', '11523726808', '17g Packet'], [23682462, Timestamp('2177-04-01 17:00:00'), Timestamp('2177-04-02 22:00:00'), 'MAIN', 'Glucagon', '041660', '55390000401', '1mg Vial'], [23682462, Timestamp('2177-04-01 17:00:00'), Timestamp('2177-04-02 22:00:00'), 'MAIN', 'Pancrelipase 5000', '065700', '39822020501', '5,000-17,000-27,000 DR Capsule'], [23682462, Timestamp('2177-04-01 16:00:00'), Timestamp('2177-04-02 22:00:00'), 'MAIN', 'Sodium Chloride 0.9% Flush', '', '0', '10 mL Syringe'], [23682462, Timestamp('2177-04-01 20:00:00'), Timestamp('2177-04-02 13:00:00'), 'MAIN', 'Carvedilol', '022233', '51079093120', '12.5mg Tablet'], [23682462, Timestamp('2177-04-01 17:00:00'), Timestamp('2177-04-02 22:00:00'), 'MAIN', 'Insulin', '027413', '00002751001', '100 Units / mL - 10 mL Vial'], [23682462, Timestamp('2177-04-01 17:00:00'), Timestamp('2177-04-02 22:00:00'), 'MAIN', 'Glucose Gel', '001781', '38396055018', '15 g Tube']]

[]

['medicine']

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18:57:00'), 'Potassium'], [50983, Timestamp('2177-04-01 17:17:00'), Timestamp('2177-04-01 18:57:00'), 'Sodium'], [51003, Timestamp('2177-04-01 17:17:00'), Timestamp('2177-04-01 18:57:00'), 'Troponin T'], [51006, Timestamp('2177-04-01 17:17:00'), Timestamp('2177-04-01 18:57:00'), 'Urea Nitrogen'], [51237, Timestamp('2177-04-01 17:17:00'), Timestamp('2177-04-01 18:11:00'), 'INR(PT)'], [51274, Timestamp('2177-04-01 17:17:00'), Timestamp('2177-04-01 18:11:00'), 'PT'], [51275, Timestamp('2177-04-01 17:17:00'), Timestamp('2177-04-01 18:11:00'), 'PTT'], [51221, Timestamp('2177-04-01 17:17:00'), Timestamp('2177-04-01 18:07:00'), 'Hematocrit'], [51222, Timestamp('2177-04-01 17:17:00'), Timestamp('2177-04-01 18:07:00'), 'Hemoglobin'], [51248, Timestamp('2177-04-01 17:17:00'), Timestamp('2177-04-01 18:07:00'), 'MCH'], [51249, Timestamp('2177-04-01 17:17:00'), Timestamp('2177-04-01 18:07:00'), 'MCHC'], [51250, Timestamp('2177-04-01 17:17:00'), Timestamp('2177-04-01 18:07:00'), 'MCV'], [51265, 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Timestamp('2177-04-02 08:07:00'), 'Red Blood Cells'], [51301, Timestamp('2177-04-02 07:00:00'), Timestamp('2177-04-02 08:07:00'), 'White Blood Cells']]

Question: A 67 M is admitted. He/she says he/she has chest pain . History of illness: Mr. ___ is a ___ with poorly controlled DM2, HTN, HLD, CAD, s/p anterior ST elevation MI, s/p DES to the LAD ___, Ischemic cardiomyopathy, LVEF 30%, hx of CVAs most recent ___, history of DVT s/p IVC filter and currently on coumadin who presents with crushing chest pain. Patient reports waking up in the morning with right chest chest pressure which lasted few minutes and resolved. However few hours later chest pressure returned. Denies any shortness of breath or palpitations during these episodes. Mentioned feeling lightheaded while waking up in the morning. Of note patient was found to have STEMI in ___ s/p DES to LAD. He had moderate disease in other territories. Acute echo showed an ejection fraction of ___ down from >65% few years ago. He was ultimately discharged to Radius Rehab on triple anticoagulation therapy given poor EF following myocardial infarction as well as a drug-eluting stent implantation. Most recently he was admitted to neurology service in ___ in the setting of new stroke throught be from cardioembolic in the setting of supratheraputic INR. He has history of frequent cocacine use however per has not been using in the rehab. Today he complained of severe chest pain and found to have ST elevation on EKG. He was trasnfered to ___ ED where code STEMI was called. He was plavix loaded and started on IV heparin. He was taken to cath lab but no new lesions were identified. He was thought to have insufficient collateral from his RCA therefore his RCA was opened with two ___. Radial approach failed therefore right groin approach for access. Currently chest pain free. Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: - CAD, s/p anterior ST elevation MI, s/p DES to the LAD ___. - PVD, s/p PTA of the R peroneal artery. - Ischemic cardiomyopathy, LVEF 30%. - PERCUTANEOUS CORONARY INTERVENTIONS: DES to LAD - PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: - Peripheral vascular disease, s/p R peroneal artery angioplasty - Recurrent DVTs (on Coumadin and s/p IVC filter) - CVA in ___ (treated at ___ in ___), with residual right-sided deficits per his report; stroke in ___ in the setting of subtherapuetic INR - H/O cocaine use - Pancreatic disease (chronic pancreatitis versus IPMN) - history of alcohol use. He recently saw gastroenterology. They scheduled him for an endoscopic ultrasound to evaluate the ampulla given the concern for IPMN. - Bilateral shoulder pain from degenerative joint disease - Phlebitis - BPH - Gout Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Allergies: No Known Allergies / Adverse Drug Reactions What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Docusate Sodium Carbamazepine Aspirin Omeprazole FoLIC Acid Senna Atorvastatin Insulin Clopidogrel Aluminum-Magnesium Hydrox.-Simethicone Warfarin Acetaminophen Multivitamins Dextrose 50% Morphine SR (MS Contin) Lisinopril Polyethylene Glycol Glucagon Pancrelipase 5000 Sodium Chloride 0.9% Flush Carvedilol Insulin Glucose Gel Target Lab Orders: Anion Gap Bicarbonate Calcium, Total Chloride Creatine Kinase (CK) Creatine Kinase, MB Isoenzyme Creatinine Glucose Magnesium Phosphate Potassium Sodium Troponin T Urea Nitrogen INR(PT) PT PTT Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells Alanine Aminotransferase (ALT) Alkaline Phosphatase Anion Gap Asparate Aminotransferase (AST) Bicarbonate Bilirubin, Total Calcium, Total Chloride Creatine Kinase (CK) Creatine Kinase, MB Isoenzyme Creatinine Glucose Magnesium Phosphate Potassium Sodium Troponin T Urea Nitrogen INR(PT) PT PTT Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : ___ with poorly controlled DM2, HTN, HLD, CAD, s/p anterior ST elevation MI, s/p DES to the LAD ___, Ischemic cardiomyopathy, LVEF 30%, hx of CVAs most recent ___, history of DVT s/p IVF filter and currently on Coumadin who presented with chest pain. # Acute Coronary Syndrome: Likely unstable angina. Patient presented with chest pain which was attributed to poor collateral from occluded RCA therefore his RCA was opened with two ___. He intermittently complained of chest pain post his stent placement. His EKG remained unchanged. His TTE was unchanged from prior. He is currently on triple anticoagulation therapy. He will follow up with Dr. ___ will make further management decisions. - Continue plavix 75 mg daily - Carvedilol 12.5mg BID - Atorvastatin 80mg daily - Continue aspirin 81mg daily - Continue coumadin with goal INR >2 - Continue lisinopril 2.5mg daily # Ischemic Cardiomyopathy: EF of 30%. Currently euvolemic with no evidence of heart failure. Not on any diuretics as outpatient. - Monitor Daily weight as outpatient. - Outpatient eval for an ICD # DM: Poorly controlled. Finger sticks in the low 200s. Patient should follow up with PCP for further management. - Diabetic diet - Home lantus and SSI # HLD: atorvastatin # Chronic Pain: Patient appeared somnolent on the morning of discharge raising concern for narcotic sedation. Patient's became more awake and interactive after few hours. If patient becomes somnolent in the rehab, his narcotic dose should be held. Patient will follow up with PCP who will determine if he still has indication for opioid treatment given repeated episodes of cocaine abuse. Transitional Issues: - Outpatient follow up with Dr. ___ will further decide on his triple anticoagulation. He will also be evaluated for ICD placement in the future given his low EF. - PCP follow up to determine continued need for narcotics - INR check on ___ Other Results: Pertinent Labs: ___ 10:25AM BLOOD WBC-9.7 RBC-4.69 Hgb-13.8* Hct-43.4 MCV-93 MCH-29.5 MCHC-31.8 RDW-13.2 Plt ___ ___ 07:00AM BLOOD WBC-9.0 RBC-4.17* Hgb-12.4* Hct-38.7* MCV-93 MCH-29.7 MCHC-32.1 RDW-13.1 Plt ___ ___ 10:25AM BLOOD ___ PTT-37.8* ___ ___ 07:00AM BLOOD ___ PTT-36.4 ___ ___ 10:25AM BLOOD Glucose-243* UreaN-19 Creat-1.5* Na-133 K-4.2 Cl-96 HCO3-29 AnGap-12 ___ 07:00AM BLOOD Glucose-253* UreaN-18 Creat-1.4* Na-136 K-4.6 Cl-98 HCO3-30 AnGap-13 ___ 07:00AM BLOOD ALT-17 AST-19 CK(CPK)-39* AlkPhos-106 TotBili-0.3 ___ 10:25AM BLOOD cTropnT-<0.01 ___ 05:17PM BLOOD CK-MB-2 cTropnT-<0.01 ___ 07:00AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 10:25AM BLOOD Calcium-9.4 Phos-3.3 Mg-2.3 . TTE: ___ The left atrial volume is mildly increased. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is severe regional left ventricular systolic dysfunction with mid anterolateral, anterior, and inferoseptal hypokinesis. Diastolic function could not be assessed. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Severely depressed left ventricular function with regional wall motion abnormalities in the distribution of the LAD. Moderately dilated left ventricle. Normal RV function. . Assessment & Recommendations 1. Stable two vessel coronary artery disease ___ diagonal and chronic diffuse collateralized subtotal occlusion of the RCA) with patent prior proximal LAD stent and no angiographic evidence of anatomy consistent with acute STEMI. 2. Low normal systemic arterial pressures. 3. Failed attempt to engage the LMCA via the right radial artery. 4. Successful deployment of 2 drug-eluting stent in the proximal-distal RCA for unstable angina and possible acute NSTEMI (with chronic ST elevations). 5. Successful right femoral artery AngioSeal closure 6. Routine post-TR Band care of the right radial artery. 7. Cycle CK-MB and platelets. 8. ASA indefinitely for life. 9. Clopidogrel 75 mg daily for at least another year to prevent RCA stent thrombosis. 10. Continue warfarin as clinically indicated. 11. Consider reassessment of LVEF with TTE. 12. Reinforce secondary preventative measures against CAD, LVSD, and recurrent acute coronary syndrome. Attending Electronic Signature attests that the attending was present for the key components of this procedure. Addendum by ___, MD, MSC on ___ at 11:48 am: Corrections: -Coronary angiography using 6 ___ XB-LAD 4 guide via right femoral artery, 6 ___ JR4 guide Coronary angiography: right dominant LMCA: The LMCA was short and patent.

2156-10-31 09:35:00

ENGLISH

SINGLE

OTHER

M

[[25974943, Timestamp('2156-10-31 09:37:02'), '', 'OMED']]

[[{'Medications on Admission': ':\nThe Preadmission Medication list is accurate and complete.\n1. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO DAILY:PRN \nindigestion \n2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation \n3. Cepacol (Sore Throat Lozenge) ___ LOZ PO Q2H:PRN sore throat \n4. ChlorproMAZINE 10 mg PO BID:PRN hiccups \n5. Docusate Sodium 100 mg PO BID \n6. Enoxaparin Sodium 40 mg SC Q24H \n7. Nystatin Oral Suspension 5 mL PO QID:PRN mouth pain \n8. Ondansetron 4 mg PO Q8H:PRN nausea \n9. Pantoprazole 40 mg PO Q24H \n10. Psyllium Powder 1 PKT PO DAILY \n11. Senna 17.2 mg PO QHS \n12. TraZODone 25 mg PO QHS:PRN insomnia \n\n5. ChlorproMAZINE 10 mg PO BID:PRN hiccups \n6. Docusate Sodium 100 mg PO BID \n7. Ondansetron 4 mg PO Q8H:PRN nausea \n8. Pantoprazole 40 mg PO Q24H \n9. Psyllium Powder 1 PKT PO DAILY \n10. Senna 17.2 mg PO QHS \n11. TraZODone 25 mg PO QHS:PRN insomnia \n\nFacility:\n___', 'Brief Hospital Course': ':\nMr. ___ is a gentleman with HCV and HCC metastatic to the \nspine who after receiving 4 cycles of FOLFOX developed \nperipheral neuropathy. He presents today for his first cycle of \n___ Acid. \n\n#Stage IV Hepatocellular Carcinoma: Metastatic to bone and \nspine. Has received 4 cycles of FOLFOX with stable disease on \nlast re-staging scans ___. Given neuropathy plan is to continue \nwith ___ acid with palliative intent given that it \ninterferes with playing guitar which is one of the activities he \nenjoys most. AFP is lowest ___ from highest 164.5 on ___. \nReceived ___ acid per protocol without any abnormality. \n\n#Spinal Metastatic Disease\n#Lower extremity weakness\nStatus-post surgical decompression and radiation. Still some \ncomponent of spinal disease amenable to SRS but non-urgent. Per \nrecent neurosurgery notes patient may have reached functional \nplateau for rehab although patient feels he may achieve more\nmobility now that he has axes to a gym with parallel bard. \n\n#Chronic Hepatitis C: Viral load 6.3 on ___. AST>ALT but \nnot AST>ALT, likely some fibrosis without over cirrhosis. \nTreatment with DAAV indicated but ideal during chemotherapy \nbreak. \n\n#Pancytopenia: Mild. Likely secondary to myelosuppression from \nchemotherapy. \n\n#FEN: IVF/Encourage PO, Replete Electrolytes PRN, Regular \n\nTRANSIONAL ISSUES: Due for readmission in ~15 days. \n\nMore than 30 minutes were spent planning the discharge of this \npatient. \n\n', 'Pertinent Results:': '\nON ADMISSION\n==============\n\n___ 08:00AM BLOOD WBC-2.6* RBC-3.56* Hgb-10.1* Hct-31.2* \nMCV-88 MCH-28.4 MCHC-32.4 RDW-15.9* RDWSD-50.5* Plt Ct-96*\n___ 08:00AM BLOOD Neuts-63.3 Lymphs-14.1* Monos-19.5* \nEos-1.9 Baso-0.8 Im ___ AbsNeut-1.66 AbsLymp-0.37* \nAbsMono-0.51 AbsEos-0.05 AbsBaso-0.02\n___ 08:00AM BLOOD UreaN-11 Creat-0.5 Na-133 K-3.3 Cl-102 \nHCO3-21* AnGap-13\n___ 08:00AM BLOOD ALT-49* AST-69* AlkPhos-123 TotBili-1.0\n___ 08:00AM BLOOD Calcium-8.7 Phos-2.6* Mg-1.9\n___ 08:00AM BLOOD AFP-24.6*\n\nON DISCHARGE\n=============\n\n___ 05:17AM BLOOD WBC-2.9* RBC-3.65* Hgb-10.4* Hct-31.7* \nMCV-87 MCH-28.5 MCHC-32.8 RDW-15.7* RDWSD-49.2* Plt ___\n___ 05:17AM BLOOD Neuts-73.5* Lymphs-11.2* Monos-13.3* \nEos-1.0 Baso-0.7 Im ___ AbsNeut-2.10 AbsLymp-0.32* \nAbsMono-0.38 AbsEos-0.03* AbsBaso-0.02\n___ 05:17AM BLOOD Plt ___\n___ 05:17AM BLOOD Glucose-90 UreaN-14 Creat-0.5 Na-137 \nK-4.0 Cl-105 HCO3-20* AnGap-16\n___ 05:17AM BLOOD ALT-66* AST-82* LD(LDH)-246 AlkPhos-140* \nTotBili-0.9\n___ 05:17AM BLOOD Albumin-3.0* Calcium-8.2* Phos-3.1 Mg-2.2\n\n', 'Physical Exam:|Physical': '\nON ADMISSION\n============\nVS: 97.9 PO 110 / 67 90 18 98 RA \nGeneral: Well-appearing man in no acute distress\nHEENT: MMM, OP clear\nHeart: RRR, no murmurs / rubs / gallops.\nLungs: CTAB. No crackles or wheezes.\nAbdomen: Globulous, normal bowel sounds, soft, non-tender, no\nmasses\nExtremities: No edema, lower extremities weaker, no change since\nyesterday.\nNeuro: A&Ox3. ___ strength in both lower extremities.\nHypoesthesia with preserved thermoalgesia in both lower\nextremities up to umbilicus. Preserved strength in bilateral\nupper extremities. \n\nON DISCHARGE\n=============\nVS: 97.9 106/71 85 18 100% RA \nGeneral: Well-appearing man in no acute distress\nHEENT: MMM, OP clear\nHeart: RRR, no murmurs / rubs / gallops.\nLungs: CTAB. No crackles or wheezes.\nAbdomen: Globulous, normal bowel sounds, soft, non-tender, no\nmasses\nExtremities: No edema, lower extremities weaker, no change since\nyesterday.\nNeuro: A&Ox3. ___ strength in both lower extremities.\nHypoesthesia with preserved thermoalgesia in both lower\nextremities up to umbilicus. Preserved strength in bilateral\nupper extremities.\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\nMr. ___ is a gentleman with HCV and HCC metastatic to the\nspine who after receiving 4 cycles of FOLFOX developed \nperipheral\nneuropathy. He presents today for his first cycle of \n___\nAcid. \n\nOn arrival to the floor, patient reports feeling well and having\nno complaints. \n\nPatient denies fevers/chills, night sweats, headache, vision\nchanges, dizziness/lightheadedness, shortness of breath, cough,\nhemoptysis, chest pain, palpitations, abdominal pain,\nnausea/vomiting, diarrhea, hematemesis, hematochezia/melena,\ndysuria, hematuria, and new rashes. \n\nPast Medical History:\nPAST ONCOLOGIC HISTORY (per OMR):\n___ man without previous known medical\nhistory who presented with progressive diffuse chest pain and\nbilateral lower extremity weakness. ED evaluation ___ with\nunremarkable CXR and EKG; discharged home with plans to set up\nwith a PCP. Over the interim he developed progressive bilateral\nleg weakness, numbness and tingling with fall for which he\npresented on ___. CTA c/a/p and MR spine revealed 5.3cm lesion\nin T4 with severe cord compression, T10 lesion, multiple hepatic\nlesions (largest 11.5cm in right lobe) and multiple splenic\nlesions (largest 3.6cm). He was transferred to neurosurgery\nservice started on dexamethasone and on ___ underwent\nfusion/instrumentation T1 to T8, and decompression of tumor T3 \nto\nT5 through laminectomies. Pathology revealed moderately\ndifferentiated hepatocellular carcinoma. Hepatitic C serology\npositive with viral load 6.3 IU/ml. Elevated AFP 165 on \n___.\nC1D1 FOLFOX ___\nC2D1 FOLFOX ___\nC2D15 FOLFOX ___\nC3D1 FOLFOX ___\nC3D15 FOLFOX ___\nC4D1 FOLFOX ___, stopped after half cycle due to peripheral\nneuropathy\nC1D1 ___ acid ___\n\nPAST MEDICAL HISTORY:\n___ diagnosis of metastatic HCC with HCV infection.\n___:\n1. Fusion, T1 to T8.\n2. Instrumentation, T1 to T8.\n3. Decompression of tumor T3 to T5 through laminectomies.\n4. Multiple thoracic laminotomies.\n5. Autograft and allograft.\n\nSocial History:\n___\nFamily History:\nMother with renal cell carcinoma at ___\nMaternal grandmother with ovarian cancer in ___\nMaternal aunt with leukemia? at ___.\nNo other know h/o malignancy.\n\n', 'Chief Complaint:|Complaint:': '\nscheduled chemotherapy\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nlactose\n\n'}, '17048990-DS-19', 19, 'medicine']]

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[['3E04305', 10, 1, Timestamp('2156-10-31 00:00:00'), 'Introduction of Other Antineoplastic into Central Vein, Percutaneous Approach']]

['medicine']

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Question: A 58 M is admitted. He/she says he/she has scheduled chemotherapy . History of illness: Mr. ___ is a gentleman with HCV and HCC metastatic to the spine who after receiving 4 cycles of FOLFOX developed peripheral neuropathy. He presents today for his first cycle of ___ Acid. On arrival to the floor, patient reports feeling well and having no complaints. Patient denies fevers/chills, night sweats, headache, vision changes, dizziness/lightheadedness, shortness of breath, cough, hemoptysis, chest pain, palpitations, abdominal pain, nausea/vomiting, diarrhea, hematemesis, hematochezia/melena, dysuria, hematuria, and new rashes. Past Medical History: PAST ONCOLOGIC HISTORY (per OMR): ___ man without previous known medical history who presented with progressive diffuse chest pain and bilateral lower extremity weakness. ED evaluation ___ with unremarkable CXR and EKG; discharged home with plans to set up with a PCP. Over the interim he developed progressive bilateral leg weakness, numbness and tingling with fall for which he presented on ___. CTA c/a/p and MR spine revealed 5.3cm lesion in T4 with severe cord compression, T10 lesion, multiple hepatic lesions (largest 11.5cm in right lobe) and multiple splenic lesions (largest 3.6cm). He was transferred to neurosurgery service started on dexamethasone and on ___ underwent fusion/instrumentation T1 to T8, and decompression of tumor T3 to T5 through laminectomies. Pathology revealed moderately differentiated hepatocellular carcinoma. Hepatitic C serology positive with viral load 6.3 IU/ml. Elevated AFP 165 on ___. C1D1 FOLFOX ___ C2D1 FOLFOX ___ C2D15 FOLFOX ___ C3D1 FOLFOX ___ C3D15 FOLFOX ___ C4D1 FOLFOX ___, stopped after half cycle due to peripheral neuropathy C1D1 ___ acid ___ PAST MEDICAL HISTORY: ___ diagnosis of metastatic HCC with HCV infection. ___: 1. Fusion, T1 to T8. 2. Instrumentation, T1 to T8. 3. Decompression of tumor T3 to T5 through laminectomies. 4. Multiple thoracic laminotomies. 5. Autograft and allograft. Social History: ___ Family History: Mother with renal cell carcinoma at ___ Maternal grandmother with ovarian cancer in ___ Maternal aunt with leukemia? at ___. No other know h/o malignancy. Allergies: lactose What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Potassium Chloride Replacement (Critical Care and Oncology) Potassium Chloride Replacement (Critical Care and Oncology) Psyllium Powder Docusate Sodium Bisacodyl Potassium Chloride Replacement (Critical Care and Oncology) Potassium Chloride Replacement (Critical Care and Oncology) Aluminum-Magnesium Hydrox.-Simethicone Potassium Chloride Replacement (Critical Care and Oncology) Pantoprazole Ondansetron Bag Magnesium Sulfate Sterile Water Potassium Chloride Sterile Water Potassium Chloride Potassium Chloride Replacement (Critical Care and Oncology) Potassium Chloride Replacement (Critical Care and Oncology) ChlorproMAZINE TraZODone Sterile Water Potassium Chloride Potassium Chloride Replacement (Critical Care and Oncology) 5% Dextrose Leucovorin Calcium Bag Magnesium Sulfate Syringe (Chemo) Fluorouracil Polyethylene Glycol 0.9% Sodium Chloride Fluorouracil Enoxaparin Sodium Bisacodyl Cepacol (Sore Throat Lozenge) Sodium Chloride 0.9% Bag Magnesium Sulfate Ondansetron Sterile Water Potassium Chloride Dexamethasone Target Lab Orders: Bacteria Bilirubin Blood Epithelial Cells Glucose Ketone Leukocytes Nitrite pH Protein RBC Specific Gravity Urine Appearance Urine Color Urine Mucous Urobilinogen WBC Yeast Anion Gap Bicarbonate Calcium, Total Chloride Creatinine Estimated GFR (MDRD equation) Glucose H I Magnesium Phosphate Potassium Sodium Urea Nitrogen L Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells RDW-SD INR(PT) PT Target Procedures: Introduction of Other Antineoplastic into Central Vein, Percutaneous Approach DOCTOR'S NOTE Hospital Notes: : Mr. ___ is a gentleman with HCV and HCC metastatic to the spine who after receiving 4 cycles of FOLFOX developed peripheral neuropathy. He presents today for his first cycle of ___ Acid. #Stage IV Hepatocellular Carcinoma: Metastatic to bone and spine. Has received 4 cycles of FOLFOX with stable disease on last re-staging scans ___. Given neuropathy plan is to continue with ___ acid with palliative intent given that it interferes with playing guitar which is one of the activities he enjoys most. AFP is lowest ___ from highest 164.5 on ___. Received ___ acid per protocol without any abnormality. #Spinal Metastatic Disease #Lower extremity weakness Status-post surgical decompression and radiation. Still some component of spinal disease amenable to SRS but non-urgent. Per recent neurosurgery notes patient may have reached functional plateau for rehab although patient feels he may achieve more mobility now that he has axes to a gym with parallel bard. #Chronic Hepatitis C: Viral load 6.3 on ___. AST>ALT but not AST>ALT, likely some fibrosis without over cirrhosis. Treatment with DAAV indicated but ideal during chemotherapy break. #Pancytopenia: Mild. Likely secondary to myelosuppression from chemotherapy. #FEN: IVF/Encourage PO, Replete Electrolytes PRN, Regular TRANSIONAL ISSUES: Due for readmission in ~15 days. More than 30 minutes were spent planning the discharge of this patient. Other Results: ON ADMISSION ============== ___ 08:00AM BLOOD WBC-2.6* RBC-3.56* Hgb-10.1* Hct-31.2* MCV-88 MCH-28.4 MCHC-32.4 RDW-15.9* RDWSD-50.5* Plt Ct-96* ___ 08:00AM BLOOD Neuts-63.3 Lymphs-14.1* Monos-19.5* Eos-1.9 Baso-0.8 Im ___ AbsNeut-1.66 AbsLymp-0.37* AbsMono-0.51 AbsEos-0.05 AbsBaso-0.02 ___ 08:00AM BLOOD UreaN-11 Creat-0.5 Na-133 K-3.3 Cl-102 HCO3-21* AnGap-13 ___ 08:00AM BLOOD ALT-49* AST-69* AlkPhos-123 TotBili-1.0 ___ 08:00AM BLOOD Calcium-8.7 Phos-2.6* Mg-1.9 ___ 08:00AM BLOOD AFP-24.6* ON DISCHARGE ============= ___ 05:17AM BLOOD WBC-2.9* RBC-3.65* Hgb-10.4* Hct-31.7* MCV-87 MCH-28.5 MCHC-32.8 RDW-15.7* RDWSD-49.2* Plt ___ ___ 05:17AM BLOOD Neuts-73.5* Lymphs-11.2* Monos-13.3* Eos-1.0 Baso-0.7 Im ___ AbsNeut-2.10 AbsLymp-0.32* AbsMono-0.38 AbsEos-0.03* AbsBaso-0.02 ___ 05:17AM BLOOD Plt ___ ___ 05:17AM BLOOD Glucose-90 UreaN-14 Creat-0.5 Na-137 K-4.0 Cl-105 HCO3-20* AnGap-16 ___ 05:17AM BLOOD ALT-66* AST-82* LD(LDH)-246 AlkPhos-140* TotBili-0.9 ___ 05:17AM BLOOD Albumin-3.0* Calcium-8.2* Phos-3.1 Mg-2.2

2129-05-03 07:15:00

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[[28318852, Timestamp('2129-05-03 00:19:17'), '', 'ENT']]

[[{'Medications on Admission': ':\nNone', 'Brief Hospital Course': ':\nMr. ___ was admitted to the ___ on ___ after \nundergoing excision of a right postauricular mass, likely a \nlipoma. Please see the separately dictated operative report for \ndetails of the procedure. He tolerated the procedure well, and \npost-operatively was transferred to the floor in stable \ncondition. A single ___ drain was in place.\n\nHis diet was advanced as tolerated and he was transitioned to \noral pain medication. He did not have a Foley placed and he was \nable to ambulate independently.\n\nHis drain output was monitored, and by the afternoon of POD#2 it \nmet criteria for removal.\n\nThe patient was discharged home in good condition to follow up \nwith Dr. ___ week for suture removal and review \nof the pathology.\n\n', 'Pertinent Results:': '\nNone\n\n', 'Physical Exam:|Physical': '\nAVSS\nNAD, breathing quietly and comfortably\nNeck soft and flat\nIncision clean, dry and intact\nCranial nerves II-XII intact and symmetric\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\nHe is a ___ reporter/journalist, who five to ___ years \nago noticed a lump behind his right ear. When he first found \nit, it measured not much more than raisin, but more recently \nover the past year it has grown significantly. He has had no \ndiscomfort or pain associated with it. He does not recall an \ninjury to that area. He has no history of other subcutaneous \nmasses. There is no family history of lipomas. Despite the \nfact that he has smoked one pack per day for over ___ years, he \ndenies any dysphagia or odynophagia. He has had no change in \nhis voice.\n\nHe was previously seen and evaluated by Dr. ___, who \nobtained an MRI of the soft tissues of the neck. This \ndemonstrated a 3.2 x 2.1 cm subcutaneous lesion with the same \nsignal intensity as neighboring fat. There was no nodule or \nmass-like enhancement. Several thin non-enhancing septations\nwere present. No adenopathy was found. \n\nPast Medical History:\nPast Medical History:\n1. Hypercholesterolemia.\n2. Depression.\n\nPast Surgical History: Appendectomy in ___.\n\nSocial History:\n___\nFamily History:\nHis mother apparently had a history of blood clots of unknown \netiology. She also had lung cancer. There is no other family \nhistory of thrombosis or cancer.\n\n', 'Chief Complaint:|Complaint:': '\nright postauricular mass\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nNo Known Allergies / Adverse Drug Reactions\n\n'}, '18808404-DS-13', 13, 'otolaryngology']]

[]

[[28318852, Timestamp('2129-05-03 15:00:00'), Timestamp('2129-05-04 19:00:00'), 'MAIN', 'Acetaminophen', '004489', '51079000220', '325mg Tablet'], [28318852, Timestamp('2129-05-03 15:00:00'), Timestamp('2129-05-04 19:00:00'), 'MAIN', 'Morphine Sulfate', '004070', '00409176230', '2mg Syringe'], [28318852, Timestamp('2129-05-03 11:00:00'), Timestamp('2129-05-04 19:00:00'), 'MAIN', 'Oxycodone-Acetaminophen (5mg-325mg)', '004222', '00406051262', '5mg/325mg Tablet'], [28318852, Timestamp('2129-05-03 15:00:00'), Timestamp('2129-05-04 19:00:00'), 'MAIN', 'Ondansetron', '061716', '00781305714', '2mg/mL-2mL'], [28318852, Timestamp('2129-05-03 15:00:00'), Timestamp('2129-05-04 19:00:00'), 'MAIN', 'Morphine Sulfate', '004080', '00641607325', '5 mg Vial'], [28318852, Timestamp('2129-05-03 11:00:00'), Timestamp('2129-05-04 19:00:00'), 'MAIN', 'Sodium Chloride 0.9% Flush', '', '0', 'Syringe'], [28318852, Timestamp('2129-05-03 13:00:00'), Timestamp('2129-05-04 19:00:00'), 'BASE', 'Iso-Osmotic Dextrose', '', '0', '50ml Bag'], [28318852, Timestamp('2129-05-03 13:00:00'), Timestamp('2129-05-04 19:00:00'), 'MAIN', 'CefazoLIN', '051880', '00264310311', '1g Froz.Bag'], [28318852, Timestamp('2129-05-03 11:00:00'), Timestamp('2129-05-04 19:00:00'), 'MAIN', 'Aluminum-Magnesium Hydrox.-Simethicone', '002701', '00121176130', '30 mL UDCup'], [28318852, Timestamp('2129-05-03 11:00:00'), Timestamp('2129-05-04 19:00:00'), 'MAIN', 'Milk of Magnesia', '003026', '00121043130', '30mL UD Cup'], [28318852, Timestamp('2129-05-03 11:00:00'), Timestamp('2129-05-04 19:00:00'), 'BASE', 'Lactated Ringers', '001187', '00338011704', '1000ml Bag'], [28318852, Timestamp('2129-05-03 22:00:00'), Timestamp('2129-05-04 19:00:00'), 'MAIN', 'traZODONE', '046241', '00904399061', '50mg Tablet']]

[]

['otolaryngology']

[]

Question: A 55 M is admitted. He/she says he/she has right postauricular mass . History of illness: He is a ___ reporter/journalist, who five to ___ years ago noticed a lump behind his right ear. When he first found it, it measured not much more than raisin, but more recently over the past year it has grown significantly. He has had no discomfort or pain associated with it. He does not recall an injury to that area. He has no history of other subcutaneous masses. There is no family history of lipomas. Despite the fact that he has smoked one pack per day for over ___ years, he denies any dysphagia or odynophagia. He has had no change in his voice. He was previously seen and evaluated by Dr. ___, who obtained an MRI of the soft tissues of the neck. This demonstrated a 3.2 x 2.1 cm subcutaneous lesion with the same signal intensity as neighboring fat. There was no nodule or mass-like enhancement. Several thin non-enhancing septations were present. No adenopathy was found. Past Medical History: Past Medical History: 1. Hypercholesterolemia. 2. Depression. Past Surgical History: Appendectomy in ___. Social History: ___ Family History: His mother apparently had a history of blood clots of unknown etiology. She also had lung cancer. There is no other family history of thrombosis or cancer. Allergies: No Known Allergies / Adverse Drug Reactions What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Acetaminophen Morphine Sulfate Oxycodone-Acetaminophen (5mg-325mg) Ondansetron Morphine Sulfate Sodium Chloride 0.9% Flush Iso-Osmotic Dextrose CefazoLIN Aluminum-Magnesium Hydrox.-Simethicone Milk of Magnesia Lactated Ringers traZODONE Target Lab Orders: NONE Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : Mr. ___ was admitted to the ___ on ___ after undergoing excision of a right postauricular mass, likely a lipoma. Please see the separately dictated operative report for details of the procedure. He tolerated the procedure well, and post-operatively was transferred to the floor in stable condition. A single ___ drain was in place. His diet was advanced as tolerated and he was transitioned to oral pain medication. He did not have a Foley placed and he was able to ambulate independently. His drain output was monitored, and by the afternoon of POD#2 it met criteria for removal. The patient was discharged home in good condition to follow up with Dr. ___ week for suture removal and review of the pathology. Other Results: None

2131-03-03 20:57:00

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[[27572858, Timestamp('2131-03-03 20:57:45'), '', 'TSURG']]

[[{'Medications on Admission': ':\n1. Coreg 12.5 mg Tablet Sig: One (1) Tablet ___ twice a day\n2. Digoxin 250 mcg Tablet Sig: One (1) Tablet ___ DAILY (Daily)\n3. Esomeprazole Magnesium [Nexium Packet], 40 mg Susp,Delayed \nRelease for Recon \n40 mg by mouth four times a day \n4. Lisinopril 5 mg Tablet Sig: One (1) Tablet ___ DAILY (Daily)\n5. Ipratropium Bromide 0.02 % Solution Sig: Three (3) mL \nInhalation Q6H\n6. Simvastatin 10 mg Tablet Sig: One (1) Tablet ___ DAILY (Daily)\n7. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic BID\n8. Guaifenesin 100 mg/5 mL Syrup Sig: ___ MLs ___ Q6H prn\n9. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL ___ BID\n10.Acetominophen 650 mg ___ q4h\n11.Diphenhydramine 12.5 mg/5 mL Liquid, 15mL ___ qHS prn: \ninsomnia \n\n2. Simvastatin 10 mg Tablet Sig: One (1) Tablet ___ DAILY \n(Daily). \n3. Lisinopril 5 mg Tablet Sig: One (1) Tablet ___ DAILY (Daily). \n\n4. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL ___ BID (2 \ntimes a day). \n5. Acetaminophen 650 mg/20.3 mL Solution Sig: Twenty (20) mL ___ \nQ6H (every 6 hours) as needed for pain/HA/fever. \n6. Trazodone 50 mg Tablet Sig: 0.5 Tablet ___ HS (at bedtime). \n7. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic BID \n(2 times a day). \n8. Coreg 12.5 mg Tablet Sig: One (1) Tablet ___ twice a day: hold \nHR < 60 SBP < 100. \n9. Guaifenesin 100 mg/5 mL Syrup Sig: ___ MLs ___ Q6H (every 6 \nhours) as needed for cough. \n10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for \nNebulization Sig: Three (3) mL Inhalation Q6H (every 6 hours) as \nneeded for SOB/wheezes. \n11. Ipratropium Bromide 0.02 % Solution Sig: Three (3) mL \nInhalation Q6H (every 6 hours). \n12. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID \n(3 times a day) as needed for rash: apply to rash coccyx. \n13. Prevacid SoluTab 30 mg Tablet,Rapid Dissolve, ___ Sig: One \n(1) Tablet,Rapid Dissolve, ___ ___ a day. \n14. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) \nInjection twice a day. \n15. Atrovent HFA 17 mcg/Actuation HFA Aerosol Inhaler Sig: One \n(1) Inhalation every ___ hours as needed for shortness of \nbreath or wheezing. \n\nFacility:\n___\n\nwith gastric conduit and jejunal-tube placement ___ \nChronic Obstructive Pulmonary Disease \nCongestive Heart Failure\nHypertension \nHyperlipidemia \nPeripheral vascular disease status post stents \nHorseshoe kidney ', 'Brief Hospital Course': ':\n___ - Admitted to thoracic surgery. Rigid bronchoscopy, \nstent removal, flexible\nbronchial surveillance performed. Findings were showed a healed \nTE fistula and a metallic stent removal with down sizing of \ntracheostomy tube to #6 cuffed Protex was performed.\n\n___ - On tube feeds, speech and swallow evaluation \nperformed. \nTolerated PMV without changes in vital signs, increased tracheal \npressures, or interference of secretions. Pt endorsed breathing \ncomfortably with valve in place and achieved mildly breathy and \nhoarse vocal quality. \n\nVideo swallow study performed showed Gross aspiration of \nnectar-thick barium. \n\nOn ___ he was taken for flexible bronchscopy: Visualization \nof the\nlarynx revealed a cord poorly moving on vocalization. The area \nat the distal trachea which was the site of the previous TE \nfistula was thoroughly examined and there was no evidence of TE \nfistula. There was a layer of well healed healthy granulation \ntissue covering the distal end of the trachea. The #6 x 25 long \nterm cannula ___ T tube was then measured for length and \nwidth and then placed into the tracheostomy site. This was \nvisualized with the bronchoscope\nthroughout the procedure. There were several areas of \ngranulation tissue around the tracheostomy site that were \nremoved via forceps through the flexible bronchoscope. \n\nVideo swallow study performed with aforementioned results\n\nNutrition: Strict NPO; Tube feeds were resumed \n\nWound: Stage I Right buttocks/coccyx barrier applied. Self \nreposition\n\n', 'Pertinent Results:': '\n___ - video oropharyngeal swallow: Barium passes freely \nthrough the oropharynx without evidence of obstruction. There \nwas aspiration of the nectar-thick barium. A small amount of \nbarium did pass into the esophagus. \n\n', 'Physical Exam:|Physical': '\nVS: T 97.2 HR: 82 SR BP 102/62 Sats: 96% 4L NC\nGeneral: frail appearing ___ year-old male\nHEENT: normocephalic, mucus membranes moist\nNeck: ___ cannula in place no erythema\nCard: RRR\nResp: decreased but clear breath sounds\nGI: J-tube in place\nExtr: warm no edema\nNeuro: depressed mood\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\n___ year old male with a complicated history status post \ntranshiatal esophagectomy ___ for esophageal cancer. \nPostoperatively he developed a severe stricture involving the \nproximal 3 cm of his conduit. He was dilated subsequently, \ndeveloped tracheoesophageal fistula which ultimately healed with\nthe placement of the endoscopic stent. He continued to suffer \nfrom severe dysphagia and was unable to tolerate saliva. As a \nlost resort treatment, patient chose to proceed with substernal \ncolon interposition, which was done on ___. Following the \noperation, patient developed tracheo-conduit fistula status post \nmetal stent placement. On ___ tracheostomy was performed. \nHe was being followed by Speech and Swallow for aspiration, L VC \nimmobility. He was admitted following tracheo-conduit stent \nremoval and Trach down sized to #6 Portex-cuffed.\n\nPast Medical History:\nEsophageal cancer with esophagectomy 7.09\nCOPD\nhx of CHF but normal EF and echo in ___\nHTN\nHyperlipidemia\nPVD with history of stents\nHorseshoe kidney\ncataract surgery\ntonsillectomy as a child\n\nPSH\ntracheostomy\nrigid bronchoscopy with stent placement \ndrainage of pleural effusions with pigtail catheter\ncataract surgery\ntonsillectomy during childhood\n\nSocial History:\n___\nFamily History:\nNon-contribitory\n\n', 'Chief Complaint:|Complaint:': '\nTracheoesophageal fistula requiring metallic stent placement and \ntracheostomy.\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nAmpicillin / Golytely / Fortaz / Levaquin / Fluconazole / \nClindamycin / Trimethoprim / Sulfamethoxazole\n\n'}, '13835573-DS-23', 23, 'cardiothoracic']]

[['INDICATION: ___ male with history of tracheoesophageal fistula,\nstatus post stent removal, and history of aspiration. Evaluate for\naspiration.\n\nCOMPARISON: Video oropharyngeal swallow from ___.\n\nTECHNIQUE: Oropharyngeal swallowing video fluoroscopy was performed in\nconjunction with the speech and swallow division. Nectar-thick barium was\nadministered.\n\nFINDINGS: Barium passes freely through the oropharynx without evidence of\nobstruction. There was aspiration of the nectar-thick barium. A small amount\nof barium did pass into the esophagus. For details, please refer to speech\nand swallow division note in OMR.\n\nIMPRESSION: Gross aspiration of nectar-thick barium.\n', '13835573-RR-104', 104, 'oropharyngeal swallowing video fluoroscopy was performed in\nconjunction with the speech and swallow division. nectar-thick barium was\nadministered.']]

[[27572858, Timestamp('2131-03-03 22:00:00'), Timestamp('2131-03-04 21:00:00'), 'MAIN', 'Codeine Phosphate', '004174', '00409109732', '30mg Syringe'], [27572858, Timestamp('2131-03-03 22:00:00'), Timestamp('2131-03-06 19:00:00'), 'MAIN', 'Albuterol 0.083% Neb Soln', '005039', '49502069724', '0.083%;3mL Vial'], [27572858, Timestamp('2131-03-03 20:00:00'), Timestamp('2131-03-06 19:00:00'), 'MAIN', 'Docusate Sodium (Liquid)', '003017', '00121054410', '100mg UD Cup'], [27572858, Timestamp('2131-03-03 21:00:00'), Timestamp('2131-03-06 19:00:00'), 'MAIN', 'Guaifenesin', '000759', '00121174410', '10mL Cup'], [27572858, Timestamp('2131-03-03 20:00:00'), Timestamp('2131-03-06 19:00:00'), 'MAIN', 'Timolol Maleate 0.5%', '007856', '61314022705', '5 mL Bottle'], [27572858, Timestamp('2131-03-03 21:00:00'), Timestamp('2131-03-06 19:00:00'), 'MAIN', 'Sodium Chloride 0.9% Flush', '', '0', 'Syringe'], [27572858, Timestamp('2131-03-03 10:00:00'), Timestamp('2131-03-06 19:00:00'), 'MAIN', 'Lisinopril', '000393', '00172375810', '5mg Tablet'], [27572858, Timestamp('2131-03-03 22:00:00'), Timestamp('2131-03-06 19:00:00'), 'MAIN', 'Miconazole Powder 2%', '007367', '00064065001', '30g Bottle'], [27572858, Timestamp('2131-03-03 10:00:00'), Timestamp('2131-03-06 19:00:00'), 'MAIN', 'Lansoprazole Oral Disintegrating Tab', '051654', '64764054411', '30mg SoluTab'], [27572858, Timestamp('2131-03-03 21:00:00'), Timestamp('2131-03-04 20:00:00'), 'MAIN', 'Lidocaine 1%', '060671', '00409471332', '2mL Amp'], [27572858, Timestamp('2131-03-03 21:00:00'), Timestamp('2131-03-06 19:00:00'), 'BASE', '0.9% Sodium Chloride', '001210', '00338004902', '250mL Bag'], [27572858, Timestamp('2131-03-03 21:00:00'), Timestamp('2131-03-06 19:00:00'), 'MAIN', 'Acetaminophen (Liquid)', '065758', '00121065721', '650mg UD Cup'], [27572858, Timestamp('2131-03-03 10:00:00'), Timestamp('2131-03-06 19:00:00'), 'MAIN', 'Digoxin', '000019', '00173024956', '0.25mg Tablet'], [27572858, Timestamp('2131-03-03 22:00:00'), Timestamp('2131-03-06 19:00:00'), 'MAIN', 'Ipratropium Bromide Neb', '021700', '00487980125', '2.5mL Vial'], [27572858, Timestamp('2131-03-03 10:00:00'), Timestamp('2131-03-06 19:00:00'), 'MAIN', 'Simvastatin', '016577', '51079045420', '10mg Tablet'], [27572858, Timestamp('2131-03-03 22:00:00'), Timestamp('2131-03-06 19:00:00'), 'MAIN', 'traZODONE', '046241', '00904399061', '50mg Tablet']]

[]

['cardiothoracic']

[]

Question: A 73 M is admitted. He/she says he/she has Tracheoesophageal fistula requiring metallic stent placement and tracheostomy. . History of illness: ___ year old male with a complicated history status post transhiatal esophagectomy ___ for esophageal cancer. Postoperatively he developed a severe stricture involving the proximal 3 cm of his conduit. He was dilated subsequently, developed tracheoesophageal fistula which ultimately healed with the placement of the endoscopic stent. He continued to suffer from severe dysphagia and was unable to tolerate saliva. As a lost resort treatment, patient chose to proceed with substernal colon interposition, which was done on ___. Following the operation, patient developed tracheo-conduit fistula status post metal stent placement. On ___ tracheostomy was performed. He was being followed by Speech and Swallow for aspiration, L VC immobility. He was admitted following tracheo-conduit stent removal and Trach down sized to #6 Portex-cuffed. Past Medical History: Esophageal cancer with esophagectomy 7.09 COPD hx of CHF but normal EF and echo in ___ HTN Hyperlipidemia PVD with history of stents Horseshoe kidney cataract surgery tonsillectomy as a child PSH tracheostomy rigid bronchoscopy with stent placement drainage of pleural effusions with pigtail catheter cataract surgery tonsillectomy during childhood Social History: ___ Family History: Non-contribitory Allergies: Ampicillin / Golytely / Fortaz / Levaquin / Fluconazole / Clindamycin / Trimethoprim / Sulfamethoxazole What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Codeine Phosphate Albuterol 0.083% Neb Soln Docusate Sodium (Liquid) Guaifenesin Timolol Maleate 0.5% Sodium Chloride 0.9% Flush Lisinopril Miconazole Powder 2% Lansoprazole Oral Disintegrating Tab Lidocaine 1% 0.9% Sodium Chloride Acetaminophen (Liquid) Digoxin Ipratropium Bromide Neb Simvastatin traZODONE Target Lab Orders: NONE Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : ___ - Admitted to thoracic surgery. Rigid bronchoscopy, stent removal, flexible bronchial surveillance performed. Findings were showed a healed TE fistula and a metallic stent removal with down sizing of tracheostomy tube to #6 cuffed Protex was performed. ___ - On tube feeds, speech and swallow evaluation performed. Tolerated PMV without changes in vital signs, increased tracheal pressures, or interference of secretions. Pt endorsed breathing comfortably with valve in place and achieved mildly breathy and hoarse vocal quality. Video swallow study performed showed Gross aspiration of nectar-thick barium. On ___ he was taken for flexible bronchscopy: Visualization of the larynx revealed a cord poorly moving on vocalization. The area at the distal trachea which was the site of the previous TE fistula was thoroughly examined and there was no evidence of TE fistula. There was a layer of well healed healthy granulation tissue covering the distal end of the trachea. The #6 x 25 long term cannula ___ T tube was then measured for length and width and then placed into the tracheostomy site. This was visualized with the bronchoscope throughout the procedure. There were several areas of granulation tissue around the tracheostomy site that were removed via forceps through the flexible bronchoscope. Video swallow study performed with aforementioned results Nutrition: Strict NPO; Tube feeds were resumed Wound: Stage I Right buttocks/coccyx barrier applied. Self reposition Other Results: ___ - video oropharyngeal swallow: Barium passes freely through the oropharynx without evidence of obstruction. There was aspiration of the nectar-thick barium. A small amount of barium did pass into the esophagus.

2178-01-28 15:22:00

ENGLISH

MARRIED

WHITE

M

[[25298310, Timestamp('2178-01-28 15:23:10'), '', 'GU']]

[[{'Medications on Admission': ':\nNSAIDS for arthritis\n\nFacility:\n___', 'Brief Hospital Course': ':\nThe pt was admitted after attempted looposcopy and \ninternalization of nephroureteral stent during which an injury \nto the loop occurred while attempting to navigate the scope into \nthe stoma. The pt was taken to CT where an atempt to pass a \nfoley catheter into the loop revealed the folye was adjacent to \nthe loop in the peritoneum. There was no evidence of conduit \nperforation below the fascia. The pt did very well clinically \nand was advanced to clears POD 1 and a house diet POD 2. The pt \nnever had abdominal pain, n/v/f/c. His urine ouput was \nexcellent. His urine was distributed between the perc \nnephrostomy (which had been unclamped) and the loop. He was \ngiven amp/cipro/flagyl intitially. The flagyl was disontinued \nPOD 1 and the pt was discharged only on cipro, as his urine \nculture showed no growth. He is discharged POD 2 after \ntolerating a diet, having BMs, making good, urine without signs \nof intraperitoneal process. He will have ___ to flush his PCN \nonce daily to optimize drainage and to check in on his progress.\n\n', 'Pertinent Results:': "\n___ 10:50AM BLOOD WBC-6.8 RBC-4.15* Hgb-11.5* Hct-35.4* \nMCV-86 MCH-27.7 MCHC-32.4 RDW-14.4 Plt ___\n___ 07:05AM BLOOD Glucose-104 UreaN-25* Creat-2.4* Na-139 \nK-4.3 Cl-108 HCO3-23 AnGap-12\n___ 07:05AM BLOOD Calcium-8.0* Mg-2.0\n\nCT abd\nIMPRESSION: \n\n1. Initial placement of catheter through the stoma tracks \ndirectly adjacent to the patient's right lower quadrant ileal \nconduit, and terminates freely in the peritoneum, with small \namount of free contrast seen which had been injected through the \ncatheter directly into the peritoneum. No evidence of perforated \nileal conduit. \n\n2. Successful manouvering and subsequent placement of catheter \nwithin the \nileal conduit, with tip adjacent to the pigtail of the \npercutaneous \nnephroureteral stent following discussion by Dr. ___ with Dr. \n___. \n\n3. Small amount of contrast reflux seen into the left renal \ncollecting \nsystem. \n\n4. Air centrally within the prostate, presumably related to air \nwithin the \nprostatic urethra due to recent instrumentation. \n\n", 'Physical Exam:|Physical': '\nNAD\nRRR\nCTAB\nAbdomen soft, NT, ND, RLQ urostomy in place draining clear \nyellow urine with some mucus, Rt PCN draining yellow urine\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\nPt is a ___ with bladder cancer s/p ileal conduit with right \nUPJ obstruction on nephrostogram, which was previously \nsuccessfully dilated with a ballooncatheter. A ___ Fr x 22 cm \nnephroureteral stent was deployed withthe tip of the catheter \nresting in the ileal loop on ___. He presented this \nvisit for internalization of the stent. \n\nPast Medical History:\nPMH:\npartial cystectomy/tumor resection ___\nradical prostatectomy in ___ in ___ \ngunshot wound to abdomen ___ years ago - compicated by \npancreatic fistula and abdominal abscesses\nHTN\n.\nOnc hx:\nThe patient is a former ___ from ___. He had some \nfrequency, urgency, and hematuria that led to his daignsosis of \ninvasive, high grade bladder cancer. On the ___ was offered \nneoadjuvant chemotherapy prior to cystectomy. He decidied to \nhave a radical cystectomy here at the BID. Of note, he has also \nhad a radical prostatectomy prior to the diagnosis of his \nbladder cancer. In any case during his operation either because \nof the radical prostatectomy or because of extensive tumor, he \nhad a locally unresectable disease and it was impossible to \nremove his bladder. He had an ileoconduit placed \nintra-operatively. \n\nSocial History:\n___\nFamily History:\nFather with CAD and cancer. Mother was healthy.\n\n', 'Chief Complaint:|Complaint:': '\nRight ureteral stricture\n\n', 'Attending:': ' ___\n\n___ ', 'Allergies:': ' \nPatient recorded as having No Known Allergies to Drugs\n\n'}, '15229282-DS-16', 16, 'urology']]

[["INDICATION: ___ male with urostomy, right percutaneous nephroureteral\nstent. Please evaluate for possible perforation of ileal conduit.\n\nCOMPARISON: CT from ___, and images from nephroureteral stent placement\nfrom ___.\n\nTECHNIQUE: MDCT-acquired axial imaging of the abdomen and pelvis was\nperformed without oral or intravenous contrast. Multiplanar reformatted\nimages were obtained and reviewed.\n\nFINDINGS: Initial images of the abdomen and pelvis demonstrate extensive\npostoperative change in the lower abdomen and pelvis, related to prior\ncystectomy, with creation of ileal conduit which exits through the right lower\nabdominal wall.\n\nThere is a right percutaneous nephroureterostomy stent in place. There is a\nsmall amount of contrast seen in the right renal collecting system, consistent\nwith recent intraoperative contrast administration.\n\nA second catheter is seen entering the abdomen, but rather than entering\nthrough the ileal conduit, it traverses directly adjacent to the conduit,\nentering the peritoneum through the same fascial defect, but terminating\nfreely within the peritoneal cavity adjacent to loops of large bowel in the\nright lower quadrant. Contrast which was injected intraoperatively is seen\ntracking along the catheter in the subcutaneous tissues, and there is a small\namount of free contrast seen within the peritoneum in the right lower\nquadrant.\n\nGiven the urgent concern for possible perforation, while the patient was still\non the table, Dr. ___ these findings with Dr. ___\nthe likely situation of catheter misplacement, rather than perforation.\nSubsequently, Dr. ___ the catheter, and repeat scanning of\nthe pelvis was performed without oral or intravenous contrast.\n\nRepeat scan confirmed proper positioning of the catheter entering the ileal\nconduit directly, terminating with its tip adjacent to the pigtail of the\npercutaneous nephroureteral stent in the patient's ileal conduit in the right\nlower quadrant.\n\nIncidental note made of mild contrast reflux into the left ureter, and left\nrenal pelvis. Mild cortical thinning in the left kidney is also unchanged.\nPelvic loops of large and small bowel are unremarkable. Incidental note is\nmade of air centrally within the prostate, likely within the prostatic\nurethra, and related to recent instrumentation.\n\nThere is no osseous lesion suspicious for malignancy. Healed left eighth rib\nfracture is unchanged.\n\nIMPRESSION:\n\n1. Initial placement of catheter through the stoma tracks directly adjacent\nto the patient's right lower quadrant ileal conduit, and terminates freely in\nthe peritoneum, with small amount of free contrast seen which had been\ninjected through the catheter directly into the peritoneum. No evidence of\nperforated ileal conduit.\n\n2. Successful manouvering and subsequent placement of catheter within the\nileal conduit, with tip adjacent to the pigtail of the percutaneous\nnephroureteral stent following discussion by Dr. ___ with Dr. ___.\n\n3. Small amount of contrast reflux seen into the left renal collecting\nsystem.\n\n4. Air centrally within the prostate, presumably related to air within the\nprostatic urethra due to recent instrumentation.\n\n", '15229282-RR-29', 29, 'mdct-acquired axial imaging of the abdomen and pelvis was\nperformed without oral or intravenous contrast. multiplanar reformatted\nimages were obtained and reviewed.']]

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[]

['urology']

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Question: A 76 M is admitted. He/she says he/she has Right ureteral stricture . History of illness: Pt is a ___ with bladder cancer s/p ileal conduit with right UPJ obstruction on nephrostogram, which was previously successfully dilated with a ballooncatheter. A ___ Fr x 22 cm nephroureteral stent was deployed withthe tip of the catheter resting in the ileal loop on ___. He presented this visit for internalization of the stent. Past Medical History: PMH: partial cystectomy/tumor resection ___ radical prostatectomy in ___ in ___ gunshot wound to abdomen ___ years ago - compicated by pancreatic fistula and abdominal abscesses HTN . Onc hx: The patient is a former ___ from ___. He had some frequency, urgency, and hematuria that led to his daignsosis of invasive, high grade bladder cancer. On the ___ was offered neoadjuvant chemotherapy prior to cystectomy. He decidied to have a radical cystectomy here at the BID. Of note, he has also had a radical prostatectomy prior to the diagnosis of his bladder cancer. In any case during his operation either because of the radical prostatectomy or because of extensive tumor, he had a locally unresectable disease and it was impossible to remove his bladder. He had an ileoconduit placed intra-operatively. Social History: ___ Family History: Father with CAD and cancer. Mother was healthy. Allergies: Patient recorded as having No Known Allergies to Drugs What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Acetaminophen Sarna Lotion D5W Ciprofloxacin IV NS (Mini Bag Plus) Ampicillin Sodium Loperamide NS MetRONIDAZOLE (FLagyl) Sodium Chloride 0.9% Flush DiphenhydrAMINE D5 1/2NS Target Lab Orders: Anion Gap Bicarbonate Calcium, Total Chloride Creatinine Estimated GFR (MDRD equation) Glucose Magnesium Potassium Sodium Urea Nitrogen Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells Anion Gap Bicarbonate Calcium, Total Chloride Creatinine Glucose Magnesium Potassium Sodium Urea Nitrogen Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : The pt was admitted after attempted looposcopy and internalization of nephroureteral stent during which an injury to the loop occurred while attempting to navigate the scope into the stoma. The pt was taken to CT where an atempt to pass a foley catheter into the loop revealed the folye was adjacent to the loop in the peritoneum. There was no evidence of conduit perforation below the fascia. The pt did very well clinically and was advanced to clears POD 1 and a house diet POD 2. The pt never had abdominal pain, n/v/f/c. His urine ouput was excellent. His urine was distributed between the perc nephrostomy (which had been unclamped) and the loop. He was given amp/cipro/flagyl intitially. The flagyl was disontinued POD 1 and the pt was discharged only on cipro, as his urine culture showed no growth. He is discharged POD 2 after tolerating a diet, having BMs, making good, urine without signs of intraperitoneal process. He will have ___ to flush his PCN once daily to optimize drainage and to check in on his progress. Other Results: ___ 10:50AM BLOOD WBC-6.8 RBC-4.15* Hgb-11.5* Hct-35.4* MCV-86 MCH-27.7 MCHC-32.4 RDW-14.4 Plt ___ ___ 07:05AM BLOOD Glucose-104 UreaN-25* Creat-2.4* Na-139 K-4.3 Cl-108 HCO3-23 AnGap-12 ___ 07:05AM BLOOD Calcium-8.0* Mg-2.0 CT abd IMPRESSION: 1. Initial placement of catheter through the stoma tracks directly adjacent to the patient's right lower quadrant ileal conduit, and terminates freely in the peritoneum, with small amount of free contrast seen which had been injected through the catheter directly into the peritoneum. No evidence of perforated ileal conduit. 2. Successful manouvering and subsequent placement of catheter within the ileal conduit, with tip adjacent to the pigtail of the percutaneous nephroureteral stent following discussion by Dr. ___ with Dr. ___. 3. Small amount of contrast reflux seen into the left renal collecting system. 4. Air centrally within the prostate, presumably related to air within the prostatic urethra due to recent instrumentation.

2143-10-26 22:24:00

ENGLISH

SINGLE

WHITE

M

[[28492782, Timestamp('2143-10-26 22:25:28'), '', 'PSYCH']]

[[{'Medications on Admission': ":\nMedications: \nCitalopram 40mg QD\nKlonopin 1mg TID\nProAir HFA 1 PUFF BID\nOmeprazole 40mg QAM\nLevothyroxine 75mcg QD\nFerrous sulfate QD\nNicotine Patch QD (at ED)\nNicotine Gum PRN (at ED)\nMeclizine 25mg x 1 (at ED)\n\nAppearance: Dressed in own clothes, newly shaven, well groomed\nBehavior: Fine postural tremor, no additional abnormal movements\nSpeech: Regular rate and rhythm\nMood: 'I feel my depression is better today'\nAffect; Flat\nThought Process; Linear. Patient is future oriented, reports \nwanting to stay off alcohol and attend the ___ program. He is \nalso able to express that if he has recurrent suicidal ideation \nthat he will reach out to help at a local emergency room. \nThought Content: Denies SI/HI\nPerceptions: Denies a/v hallucinations\nInsight: Fair\nJudgement: Fair", 'Brief Hospital Course': ':\nPsychiatric Hospital Course:\nPatient was admitted ___ for depression with SI in the setting \nof abruptly stopping alcohol use. He was admitted on a ___ \nprotocol and treated for 3 days for alcohol withdrawal symptoms \nand continued on home psychotropics including celexa 40mg PO QD \nand maintained on Thiamine, MTV and folic acid. Patient had \nresolution of alcohol withdrawal symptoms by day ___ in the \nhospital and also expressed improvement in mood. Patient \ncontinued to intermittently express dysphoric mood throughout \nadmission, however was future oriented with plans to attend AA \nand begin treatment at a partial hospitalization. Patient also \nwas able to express motivation to abstain from alcohol use and \nin the event that he developed suicidal ideation verbalized a \nwillingness to represent for treatment. Main diagnosis suspected \nto be alcohol dependence with a component of substance induced \nmood disorder. Longitudinal evaluations will further evaluate if \npatient has a recurrent major depressive illness. \n\n___ Course:\nPatient has known hypothyroidism with TSH at 8.7 but with \nreported synthroid non-compliance and thus continued on home \nsynthroid dose of 75mcg QD.\n\nLegal:\n___\nPsychosocial:\nMedication non-compliance and poor ability to maintain sobriety. \nPoor longstanding relationship with mental health providers. \n\nSafety: \nPatient was maintained on Q15 minute checks throughout admission \nwithout issue. \n\n', 'Pertinent Results:': '\n___ 06:23PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG \ncocaine-NEG amphetmn-NEG mthdone-NEG\n___ 08:30AM GLUCOSE-152* UREA N-9 CREAT-0.8 SODIUM-140 \nPOTASSIUM-4.1 CHLORIDE-95* TOTAL CO2-25 ANION GAP-24*\n___ 08:30AM ALT(SGPT)-78* AST(SGOT)-112* LD(LDH)-308* ALK \nPHOS-80 TOT BILI-0.4\n___ 08:30AM LIPASE-26\n___ 08:30AM ASA-NEG ___ ACETMNPHN-NEG \nbnzodzpn-NEG barbitrt-NEG tricyclic-NEG\n___ 08:30AM WBC-6.8 RBC-3.96* HGB-12.6* HCT-39.6* \nMCV-100* MCH-31.9 MCHC-31.9 RDW-16.3*\n___ 08:30AM PLT COUNT-412\n___ 08:30AM ___ PTT-24.4 ___\n\n', 'Physical Exam:|Physical': '\nNeuropsychiatric Examination:\n*VS: BP:137/100 HR:105 temp:98 resp:18 O2 sat: 93% on \nRA\nHeight: 5\'3 Weight:148.6\nGen: NAD\nHEENT: MMM, EOMI, ___\nNeck: Supple\n___: Tachycardic, RR, S1 S2 no m/r/g\nChest: BCTA\nAbdomen: SNTND, +BS\nExt: No pedal edema\n Neurological: Brisk reflexes \n *station and gait: Normal-based gait, normal arm swing, no\ntruncal ataxia\n *tone and strength: Normal tone, ___ strength in UE and ___\nbilaterally\n cranial nerves: CN II-XII intact\n abnormal movements: Tremulous, mild asterixis\n frontal release: None\n\n Cognition: \n *Attention, *orientation, and executive function: Alert and\noriented to person, place, and time.\n *Memory: ___ at 0 minutes and ___ in 5 minutes\n *Fund of knowledge: Intact\n Calculations: intact, $1.75\n Abstraction: Apples/Oranges: "They\'re Fruits", Book Cover:\n"Ignorance before knowledge"\n *Speech: Normal rate, rhythm, tone, with decreased volume\n *Language: Fluent, appropriate\n\nAppearance: Dressed in own clothes, newly shaven, well groomed\nBehavior: Fine postural tremor, no additional abnormal movements\nSpeech: Regular rate and rhythm\nMood: "I feel my depression is better today"\nAffect; Flat\nThought Process; Linear\nThought Content: Denies SI/HI\nPerceptions: Denies a/v hallucinations\nInsight: Fair\nJudgement: Fair\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\n___ yr old male known ot our service, history of depression, \nanxiety and\nsevere alcoholism. He has been unable to maintain sobriety and\nover the last few weeks to days has begun to feel more suicidal.\n\nWe discussed what has been contributing to his drinking. He\nreports that he has been depressed and anxious. He has had\nfrequent thougths of his sister\'s death. She died ___ years ago\nof cirrhosis. He reports that he keeps imagining her end, with\nblood coming from her mouth, her discoloration due to liver\nfailure.\n\nOver the last few days he has been more suicidal, today he found\nhimself walking towards a bridge with a train track,thinking of\njumping in front of the train. He stopped himself, walked over \nto\na local ___ and asked them to call the ambulance. What\nmade him hold back was the history of being Catholic and the\nthought that this is wrong.\n\nHis drinking has been very heavy, liter of vodka a day, for the\nfirst few days it lessens the anxiety and then the depression\nescalates. also drinking a 40 oz beer and a few nips. Recently\nduring a blackout he fell and broke his ribs he has no recall of\nthis. \n\nHe reports difficulty with sleep, poor appetite, with nausea and\nvomiting recently, over the last 24 hours feeling more \ndepressed,\nhopeless and overwhelmed\n\nPast Medical History:\nPast Medical History:\n- COPD\n- Meniere\'s disease - diagnosed in ___, has not followed up \nwith\noutpatient care\n- Hypothyroidism\n- Hx of Borderline HTN\n- History of frostbite to bilateral toes ("my toes turned \nblack")\n\nPast psychiatric history:\n-Diagnoses: Depression, anxiety, panic disorder\n-Hospitalizations: ___, ___ , ___. Numerous\ndetoxes ___ and ___. Thinks last\ninpatient psych was Deac ___.\n-SA/SIB: Denies\n-Violence: ___\n-Therapist: ___ at ___ until ___\nmonths ago, when she fired him for coming to an appointment\nintoxicated. She now no longer works there.\n-Psychiatrist: Has been seeing someone at ___\n\nSocial History:\n___\nFamily History:\nFather - alcoholism \nMother - depression, anxiety, hospitalizations \nTwo sisters - depression, anxiety, psych hospitalizations, EtOH. \nOne sister died of cirrhosis, other is sober.\n\n', 'Chief Complaint:|Complaint:': '\n" I just can\'t make it"\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nNo Known Allergies / Adverse Drug Reactions\n\n'}, '13070242-DS-15', 15, 'psychiatry']]

[['PA AND LATERAL CHEST, ___ AT 0859 HOURS\n\nHISTORY: Productive cough and subjective fever.\n\nCOMPARISON: Multiple priors, the most recent dated ___.\n\nFINDINGS: Chronic changes are again evident at the right lung base including\nsubpleural fat deposition, calcified pleural plaque, and lung scarring, and\nchronic atelectasis. No superimposed focal consolidation or edema noted. The\nmediastinum is unremarkable. The cardiac silhouette is within normal limits\nfor size. No left effusion is noted. There is no pneumothorax. The osseous\nstructures are unremarkable.\n\nIMPRESSION: Chronic changes in the right lung base, similar to multiple prior\nexams. No superimposed acute process noted.\n', '13070242-RR-38', 38, '']]

[[28492782, Timestamp('2143-10-27 08:00:00'), Timestamp('2143-11-02 18:00:00'), 'MAIN', 'Clonazepam', '004561', '57664027408', '1mg Tablet'], [28492782, Timestamp('2143-10-27 04:00:00'), Timestamp('2143-10-27 04:00:00'), 'MAIN', 'Acetaminophen', '004489', '51079000220', '325mg Tablet'], [28492782, Timestamp('2143-10-27 08:00:00'), Timestamp('2143-11-02 18:00:00'), 'MAIN', 'FoLIC Acid', '002366', '00182050789', '1 mg Tab'], [28492782, Timestamp('2143-10-27 04:00:00'), Timestamp('2143-10-27 04:00:00'), 'MAIN', 'Aluminum-Magnesium Hydrox.-Simethicone', '002701', '00121176130', '30 mL UDCup'], [28492782, Timestamp('2143-10-27 05:00:00'), Timestamp('2143-10-30 13:00:00'), 'MAIN', 'Acetaminophen', '004489', '51079000220', '325mg Tablet'], [28492782, Timestamp('2143-10-27 04:00:00'), Timestamp('2143-11-02 18:00:00'), 'MAIN', 'Albuterol Inhaler', '028090', '00173068254', '8 g Inhaler'], [28492782, Timestamp('2143-10-27 08:00:00'), Timestamp('2143-11-02 18:00:00'), 'MAIN', 'Nicotine Patch', '016426', '00135019502', '14mg/24Hr Patch'], [28492782, Timestamp('2143-10-27 08:00:00'), Timestamp('2143-11-02 18:00:00'), 'MAIN', 'Omeprazole', '033530', '00093521193', '20mg Cap'], [28492782, Timestamp('2143-10-27 08:00:00'), Timestamp('2143-11-02 18:00:00'), 'MAIN', 'Thiamine', '002451', '00904054460', '100mg Tablet'], [28492782, Timestamp('2143-10-27 04:00:00'), Timestamp('2143-10-27 04:00:00'), 'MAIN', 'Milk of Magnesia', '003026', '00121043130', '30mL UD Cup'], [28492782, Timestamp('2143-10-27 07:00:00'), Timestamp('2143-10-27 11:00:00'), 'MAIN', 'Diazepam', '003768', '51079028520', '5 mg Tab'], [28492782, Timestamp('2143-10-27 12:00:00'), Timestamp('2143-10-29 17:00:00'), 'MAIN', 'Diazepam', '003766', '51079028620', '10 mg Tab'], [28492782, Timestamp('2143-10-27 04:00:00'), Timestamp('2143-10-27 06:00:00'), 'MAIN', 'Diazepam', '003768', '51079028520', '5 mg Tab'], [28492782, Timestamp('2143-10-27 05:00:00'), Timestamp('2143-11-02 18:00:00'), 'MAIN', 'Milk of Magnesia', '003026', '00121043130', '30mL UD Cup'], [28492782, Timestamp('2143-10-27 05:00:00'), Timestamp('2143-11-02 18:00:00'), 'MAIN', 'Aluminum-Magnesium Hydrox.-Simethicone', '002701', '00121176130', '30 mL UDCup'], [28492782, Timestamp('2143-10-27 05:00:00'), Timestamp('2143-11-02 18:00:00'), 'MAIN', 'Meclizine', '004731', '51079008920', '12.5 mg Tab'], [28492782, Timestamp('2143-10-27 08:00:00'), Timestamp('2143-11-02 18:00:00'), 'MAIN', 'Citalopram', '046203', '60505251903', '20mg Tablet'], [28492782, Timestamp('2143-10-27 08:00:00'), Timestamp('2143-11-02 18:00:00'), 'MAIN', 'Levothyroxine Sodium', '006650', '00074518211', '75mcg Tab'], [28492782, Timestamp('2143-10-26 23:00:00'), Timestamp('2143-10-27 03:00:00'), 'MAIN', 'Magnesium Oxide', '001408', '63739035410', '400 mg Tab'], [28492782, Timestamp('2143-10-27 08:00:00'), Timestamp('2143-11-02 18:00:00'), 'MAIN', 'Ferrous Sulfate', '011832', '00245005301', '325 mg Tablet'], [28492782, Timestamp('2143-10-27 05:00:00'), Timestamp('2143-11-02 18:00:00'), 'MAIN', 'Ondansetron ODT', '041562', '00093730165', '4mg ODT Tab'], [28492782, Timestamp('2143-10-26 23:00:00'), Timestamp('2143-10-27 03:00:00'), 'MAIN', 'Sodium Chloride 0.9% Flush', '', '0', 'Syringe']]

[]

['psychiatry']

[[51221, Timestamp('2143-10-27 10:10:00'), Timestamp('2143-10-27 11:32:00'), 'Hematocrit'], [51222, Timestamp('2143-10-27 10:10:00'), Timestamp('2143-10-27 11:32:00'), 'Hemoglobin'], [51248, Timestamp('2143-10-27 10:10:00'), Timestamp('2143-10-27 11:32:00'), 'MCH'], [51249, Timestamp('2143-10-27 10:10:00'), Timestamp('2143-10-27 11:32:00'), 'MCHC'], [51250, Timestamp('2143-10-27 10:10:00'), Timestamp('2143-10-27 11:32:00'), 'MCV'], [51265, Timestamp('2143-10-27 10:10:00'), Timestamp('2143-10-27 11:32:00'), 'Platelet Count'], [51277, Timestamp('2143-10-27 10:10:00'), Timestamp('2143-10-27 11:32:00'), 'RDW'], [51279, Timestamp('2143-10-27 10:10:00'), Timestamp('2143-10-27 11:32:00'), 'Red Blood Cells'], [51301, Timestamp('2143-10-27 10:10:00'), Timestamp('2143-10-27 11:32:00'), 'White Blood Cells'], [50861, Timestamp('2143-10-27 10:10:00'), Timestamp('2143-10-27 12:19:00'), 'Alanine Aminotransferase (ALT)'], [50863, Timestamp('2143-10-27 10:10:00'), Timestamp('2143-10-27 12:19:00'), 'Alkaline Phosphatase'], [50868, Timestamp('2143-10-27 10:10:00'), Timestamp('2143-10-27 12:19:00'), 'Anion Gap'], [50878, Timestamp('2143-10-27 10:10:00'), Timestamp('2143-10-27 12:19:00'), 'Asparate Aminotransferase (AST)'], [50882, Timestamp('2143-10-27 10:10:00'), Timestamp('2143-10-27 12:19:00'), 'Bicarbonate'], [50885, Timestamp('2143-10-27 10:10:00'), Timestamp('2143-10-27 12:19:00'), 'Bilirubin, Total'], [50893, Timestamp('2143-10-27 10:10:00'), Timestamp('2143-10-27 12:19:00'), 'Calcium, Total'], [50902, Timestamp('2143-10-27 10:10:00'), Timestamp('2143-10-27 12:19:00'), 'Chloride'], [50912, Timestamp('2143-10-27 10:10:00'), Timestamp('2143-10-27 12:19:00'), 'Creatinine'], [50931, Timestamp('2143-10-27 10:10:00'), Timestamp('2143-10-27 12:19:00'), 'Glucose'], [50946, Timestamp('2143-10-27 10:10:00'), Timestamp('2143-10-27 12:19:00'), 'Human Chorionic Gonadotropin'], [50960, Timestamp('2143-10-27 10:10:00'), Timestamp('2143-10-27 12:19:00'), 'Magnesium'], [50970, Timestamp('2143-10-27 10:10:00'), Timestamp('2143-10-27 12:19:00'), 'Phosphate'], [50971, Timestamp('2143-10-27 10:10:00'), Timestamp('2143-10-27 12:19:00'), 'Potassium'], [50983, Timestamp('2143-10-27 10:10:00'), Timestamp('2143-10-27 12:19:00'), 'Sodium'], [50993, Timestamp('2143-10-27 10:10:00'), Timestamp('2143-10-27 20:53:00'), 'Thyroid Stimulating Hormone'], [50995, Timestamp('2143-10-27 10:10:00'), Timestamp('2143-10-27 20:53:00'), 'Thyroxine (T4), Free'], [51006, Timestamp('2143-10-27 10:10:00'), Timestamp('2143-10-27 12:19:00'), 'Urea Nitrogen']]

Question: A 47 M is admitted. He/she says he/she has " I just can't make it" . History of illness: ___ yr old male known ot our service, history of depression, anxiety and severe alcoholism. He has been unable to maintain sobriety and over the last few weeks to days has begun to feel more suicidal. We discussed what has been contributing to his drinking. He reports that he has been depressed and anxious. He has had frequent thougths of his sister's death. She died ___ years ago of cirrhosis. He reports that he keeps imagining her end, with blood coming from her mouth, her discoloration due to liver failure. Over the last few days he has been more suicidal, today he found himself walking towards a bridge with a train track,thinking of jumping in front of the train. He stopped himself, walked over to a local ___ and asked them to call the ambulance. What made him hold back was the history of being Catholic and the thought that this is wrong. His drinking has been very heavy, liter of vodka a day, for the first few days it lessens the anxiety and then the depression escalates. also drinking a 40 oz beer and a few nips. Recently during a blackout he fell and broke his ribs he has no recall of this. He reports difficulty with sleep, poor appetite, with nausea and vomiting recently, over the last 24 hours feeling more depressed, hopeless and overwhelmed Past Medical History: Past Medical History: - COPD - Meniere's disease - diagnosed in ___, has not followed up with outpatient care - Hypothyroidism - Hx of Borderline HTN - History of frostbite to bilateral toes ("my toes turned black") Past psychiatric history: -Diagnoses: Depression, anxiety, panic disorder -Hospitalizations: ___, ___ , ___. Numerous detoxes ___ and ___. Thinks last inpatient psych was Deac ___. -SA/SIB: Denies -Violence: ___ -Therapist: ___ at ___ until ___ months ago, when she fired him for coming to an appointment intoxicated. She now no longer works there. -Psychiatrist: Has been seeing someone at ___ Social History: ___ Family History: Father - alcoholism Mother - depression, anxiety, hospitalizations Two sisters - depression, anxiety, psych hospitalizations, EtOH. One sister died of cirrhosis, other is sober. Allergies: No Known Allergies / Adverse Drug Reactions What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Clonazepam Acetaminophen FoLIC Acid Aluminum-Magnesium Hydrox.-Simethicone Acetaminophen Albuterol Inhaler Nicotine Patch Omeprazole Thiamine Milk of Magnesia Diazepam Diazepam Diazepam Milk of Magnesia Aluminum-Magnesium Hydrox.-Simethicone Meclizine Citalopram Levothyroxine Sodium Magnesium Oxide Ferrous Sulfate Ondansetron ODT Sodium Chloride 0.9% Flush Target Lab Orders: Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells Alanine Aminotransferase (ALT) Alkaline Phosphatase Anion Gap Asparate Aminotransferase (AST) Bicarbonate Bilirubin, Total Calcium, Total Chloride Creatinine Glucose Human Chorionic Gonadotropin Magnesium Phosphate Potassium Sodium Thyroid Stimulating Hormone Thyroxine (T4), Free Urea Nitrogen Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : Psychiatric Hospital Course: Patient was admitted ___ for depression with SI in the setting of abruptly stopping alcohol use. He was admitted on a ___ protocol and treated for 3 days for alcohol withdrawal symptoms and continued on home psychotropics including celexa 40mg PO QD and maintained on Thiamine, MTV and folic acid. Patient had resolution of alcohol withdrawal symptoms by day ___ in the hospital and also expressed improvement in mood. Patient continued to intermittently express dysphoric mood throughout admission, however was future oriented with plans to attend AA and begin treatment at a partial hospitalization. Patient also was able to express motivation to abstain from alcohol use and in the event that he developed suicidal ideation verbalized a willingness to represent for treatment. Main diagnosis suspected to be alcohol dependence with a component of substance induced mood disorder. Longitudinal evaluations will further evaluate if patient has a recurrent major depressive illness. ___ Course: Patient has known hypothyroidism with TSH at 8.7 but with reported synthroid non-compliance and thus continued on home synthroid dose of 75mcg QD. Legal: ___ Psychosocial: Medication non-compliance and poor ability to maintain sobriety. Poor longstanding relationship with mental health providers. Safety: Patient was maintained on Q15 minute checks throughout admission without issue. Other Results: ___ 06:23PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG ___ 08:30AM GLUCOSE-152* UREA N-9 CREAT-0.8 SODIUM-140 POTASSIUM-4.1 CHLORIDE-95* TOTAL CO2-25 ANION GAP-24* ___ 08:30AM ALT(SGPT)-78* AST(SGOT)-112* LD(LDH)-308* ALK PHOS-80 TOT BILI-0.4 ___ 08:30AM LIPASE-26 ___ 08:30AM ASA-NEG ___ ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 08:30AM WBC-6.8 RBC-3.96* HGB-12.6* HCT-39.6* MCV-100* MCH-31.9 MCHC-31.9 RDW-16.3* ___ 08:30AM PLT COUNT-412 ___ 08:30AM ___ PTT-24.4 ___

2181-01-21 07:15:00

ENGLISH

MARRIED

WHITE

F

[[28309922, Timestamp('2181-01-21 00:31:02'), '', 'VSURG']]

[[{'Medications on Admission': ':\nThe Preadmission Medication list is accurate and complete.\n1. Albuterol Inhaler Dose is Unknown IH Frequency is Unknown \n2. Lisinopril 40 mg PO DAILY \n3. Ranitidine (Liquid) 150 mg PO BID \n4. Simvastatin Dose is Unknown PO DAILY \n5. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation \ninhalation prn COPD \n6. PleTAL (cilostazol) 100 mg oral BID \n7. Alendronate Sodium 70 mg PO DAILY \n8. Amlodipine 5 mg PO DAILY \n\nFacility:\n___\n\n___ Diagnosis:\nDisabling claudication, bilateral aortoiliac occlusion', 'Brief Hospital Course': ":\nMs. ___ presented to ___ on ___. She was \nevaluated by anaesthesia and taken to the operating room for \nRight axillary bilateral femoral bypass and Bilateral femoral \nendarterectomy including profunda. There were no adverse events \nin the operating room; please see the operative note for \ndetails. \nPt was extubated, taken to the PACU until stable, and then \ntransferred to the ward for observation. \n\nNeuro: The patient was alert and oriented throughout \nhospitalization; pain was well controlled.\nCV: The patient remained stable from a cardiovascular \nstandpoint; vital signs were routinely monitored.\nPulmonary: During early ambulation, her oxygen saturation \ndropped to the 80's, but improved and remained stable for the \nrest of the hospitalization; vital signs were routinely \nmonitored. Good pulmonary toilet, and incentive spirometry were \nencouraged throughout hospitalization. \nGI/GU/FEN: The patient was initially kept NPO for the procedure, \nbut then was resumed on a regular diet, which was tolerated \nwell. \nID: The patient's fever curves were closely watched for signs of \ninfection, of which there were none.\nHEME: The patient's blood counts were closely watched for signs \nof bleeding, of which there were none.\n\nAt the time of discharge, the patient was doing well, afebrile \nwith stable vital signs. The patient was tolerating a regular \ndiet, ambulating with a walker and physical therapy, voiding \nwithout assistance, and pain was well controlled. The patient \nreceived discharge teaching and follow-up instructions with \nunderstanding verbalized and agreement with the discharge plan.\n\n", 'Pertinent Results:': '\n___ 04:00PM WBC-15.6* RBC-3.29* HGB-8.9* HCT-29.5* MCV-90 \nMCH-27.0 MCHC-30.1* RDW-15.3\n___ 04:00PM PLT COUNT-254\n___ 04:00PM PTT-24.6*\n___ 12:00PM GLUCOSE-135* UREA N-11 CREAT-0.8 SODIUM-139 \nPOTASSIUM-4.1 CHLORIDE-109* TOTAL CO2-24 ANION GAP-10\n___ 12:00PM CALCIUM-8.1* PHOSPHATE-3.8 MAGNESIUM-1.9\n___ 12:00PM WBC-15.8*# RBC-3.59* HGB-9.5* HCT-32.9* \nMCV-92 MCH-26.4* MCHC-28.8* RDW-14.8\n___ 12:00PM PLT COUNT-387\n___ 12:00PM ___ PTT-123.5* ___\n___ 09:18AM TYPE-ART PO2-293* PCO2-49* PH-7.27* TOTAL \nCO2-23 BASE XS--4\n___ 09:18AM GLUCOSE-114* LACTATE-0.8 NA+-140 K+-3.6 \nCL--109*\n___ 09:18AM HGB-7.6* calcHCT-23 O2 SAT-98 CARBOXYHB-2\n___ 09:18AM freeCa-1.13\n___ 08:51AM TYPE-ART PO2-306* PCO2-60* PH-7.23* TOTAL \nCO2-26 BASE XS--3 INTUBATED-INTUBATED\n___ 08:51AM HGB-8.0* calcHCT-24 O2 SAT-98\n___ 08:51AM GLUCOSE-101 LACTATE-1.0 NA+-140 K+-3.4 \nCL--106\n___ 08:51AM freeCa-1.17\n\n', 'Physical Exam:|Physical': '\nPhysical Exam:\nAlert and oriented x 3 \nCarotids: 2+, no bruits or JVD\nResp: Lungs clear, no acute distress, no labored breathing\nAbd: Soft, non tender, non distended\nExt: Pulses: Left Femoral Dopplerable, DP Dopplerable \n,___ Dopplerable \n Right Femoral Dopplerabl, DP Dopplerable \n,___ Dopplerable \nFeet warm, well perfused. No open areas\nIncisions - clean, staples in tact, no erythema Dressing clean \ndry and intact. Soft, no hematoma or ecchymosis\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\n A ___ female with a past medical\nhistory of severe disabling claudication. For the past ___\nyears she has been unable to walk aside from a few feet only.\nShe does have bilateral calf pain. She has been treated \nconservatively with medication which she continued to fail to \nprogress. She had a recent CT angiogram showing an aortic \naneurysm with a seemingly bilateral iliac occlusion. She does \nhave some reconstitution bilaterally via collateral\nvessels. Given the severity of her symptoms, in addition to the \nCT imaging, the patient was offered a bypass option. However, \ngiven her severe COPD and aortic aneurysm noted on imaging it \nwas discussed that an axillary bifemoral bypass would be the \nprocedure of choice.\n\nPast Medical History:\nPVD, COPD, CHF, HTN, AAA, kypho-scoliosis, osteoporosis, PUD, \nanemia\n\nSocial History:\n___\nFamily History:\nnon contributory \n\n', 'Chief Complaint:|Complaint:': '\nDisabling claudication, bilateral aortoiliac occlusion\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \ncodeine / antihistamines\n\n'}, '15787730-DS-17', 17, 'surgery']]

[]

[[28309922, Timestamp('2181-01-21 18:00:00'), Timestamp('2181-01-25 20:00:00'), 'MAIN', 'Albuterol Inhaler', '028090', '00173068224', '8 g Inhaler'], [28309922, Timestamp('2181-01-21 19:00:00'), Timestamp('2181-01-25 20:00:00'), 'MAIN', 'HYDROmorphone (Dilaudid)', '062823', '00409128331', '1mg/1mL Syringe'], [28309922, Timestamp('2181-01-21 20:00:00'), Timestamp('2181-01-25 20:00:00'), 'MAIN', 'Heparin', '006549', '63323026201', '5000 Units / mL- 1mL Vial'], [28309922, Timestamp('2181-01-21 18:00:00'), Timestamp('2181-01-25 20:00:00'), 'MAIN', 'Metoprolol Tartrate', '019808', '00409177805', '5mg/5mL Vial'], [28309922, Timestamp('2181-01-21 18:00:00'), Timestamp('2181-01-22 09:00:00'), 'BASE', 'Lactated Ringers', '001187', '00338011704', 'Floor Stock Bag'], [28309922, Timestamp('2181-01-21 18:00:00'), Timestamp('2181-01-21 18:00:00'), 'MAIN', 'HYDROmorphone (Dilaudid)', '062823', '00409128331', '1mg/1mL Syringe'], [28309922, Timestamp('2181-01-21 18:00:00'), Timestamp('2181-01-25 20:00:00'), 'BASE', 'D5W', '', '0', '250mL Bottle'], [28309922, Timestamp('2181-01-21 18:00:00'), Timestamp('2181-01-25 20:00:00'), 'MAIN', 'Nitroglycerin', '064586', '00338105102', '100 mg / 250 mL Premix Bottle'], [28309922, Timestamp('2181-01-21 20:00:00'), Timestamp('2181-01-25 20:00:00'), 'MAIN', 'Fluticasone-Salmeterol Diskus (250/50) ', '043367', '00173069604', '250/50mcg Diskus'], [28309922, Timestamp('2181-01-21 18:00:00'), Timestamp('2181-01-23 20:00:00'), 'BASE', 'Iso-Osmotic Sodium Chloride', '', '0', '50ml Bag'], [28309922, Timestamp('2181-01-21 18:00:00'), Timestamp('2181-01-23 20:00:00'), 'MAIN', 'Famotidine', '021732', '00338519741', '20mg Premix Bag'], [28309922, Timestamp('2181-01-21 18:00:00'), Timestamp('2181-01-21 18:00:00'), 'MAIN', 'PNEUMOcoccal 23-valent polysaccharide vaccine', '048548', '00006473900', '25mcg/0.5mL Vial'], [28309922, Timestamp('2181-01-21 21:00:00'), Timestamp('2181-01-25 20:00:00'), 'MAIN', 'Acetaminophen', '004489', '51079000220', '325mg Tablet'], [28309922, Timestamp('2181-01-22 05:00:00'), Timestamp('2181-01-25 20:00:00'), 'MAIN', 'Sodium Chloride 0.9% Flush', '', '0', '10 mL Syringe']]

[]

['surgery']

[[50802, Timestamp('2181-01-21 08:51:00'), Timestamp('2181-01-21 08:56:00'), 'Base Excess'], [50804, Timestamp('2181-01-21 08:51:00'), Timestamp('2181-01-21 08:56:00'), 'Calculated Total CO2'], [50806, Timestamp('2181-01-21 08:51:00'), Timestamp('2181-01-21 08:56:00'), 'Chloride, Whole Blood'], [50808, Timestamp('2181-01-21 08:51:00'), Timestamp('2181-01-21 08:56:00'), 'Free Calcium'], [50809, Timestamp('2181-01-21 08:51:00'), Timestamp('2181-01-21 08:56:00'), 'Glucose'], [50810, Timestamp('2181-01-21 08:51:00'), Timestamp('2181-01-21 08:56:00'), 'Hematocrit, Calculated'], [50811, Timestamp('2181-01-21 08:51:00'), Timestamp('2181-01-21 08:56:00'), 'Hemoglobin'], [50812, Timestamp('2181-01-21 08:51:00'), Timestamp('2181-01-21 08:53:00'), 'Intubated'], [50813, Timestamp('2181-01-21 08:51:00'), Timestamp('2181-01-21 08:56:00'), 'Lactate'], [50817, Timestamp('2181-01-21 08:51:00'), Timestamp('2181-01-21 08:56:00'), 'Oxygen Saturation'], [50818, Timestamp('2181-01-21 08:51:00'), Timestamp('2181-01-21 08:56:00'), 'pCO2'], [50820, Timestamp('2181-01-21 08:51:00'), Timestamp('2181-01-21 08:56:00'), 'pH'], [50821, Timestamp('2181-01-21 08:51:00'), Timestamp('2181-01-21 08:56:00'), 'pO2'], [50822, Timestamp('2181-01-21 08:51:00'), Timestamp('2181-01-21 08:56:00'), 'Potassium, Whole Blood'], [50824, Timestamp('2181-01-21 08:51:00'), Timestamp('2181-01-21 08:56:00'), 'Sodium, Whole Blood'], [52033, Timestamp('2181-01-21 08:51:00'), Timestamp('2181-01-21 08:53:00'), 'Specimen Type'], [50802, Timestamp('2181-01-21 09:18:00'), Timestamp('2181-01-21 09:20:00'), 'Base Excess'], [50804, Timestamp('2181-01-21 09:18:00'), Timestamp('2181-01-21 09:20:00'), 'Calculated Total CO2'], [50805, Timestamp('2181-01-21 09:18:00'), Timestamp('2181-01-21 09:20:00'), 'Carboxyhemoglobin'], [50806, Timestamp('2181-01-21 09:18:00'), Timestamp('2181-01-21 09:20:00'), 'Chloride, Whole Blood'], [50808, Timestamp('2181-01-21 09:18:00'), Timestamp('2181-01-21 09:20:00'), 'Free Calcium'], [50809, Timestamp('2181-01-21 09:18:00'), Timestamp('2181-01-21 09:20:00'), 'Glucose'], [50810, Timestamp('2181-01-21 09:18:00'), Timestamp('2181-01-21 09:20:00'), 'Hematocrit, Calculated'], [50811, Timestamp('2181-01-21 09:18:00'), Timestamp('2181-01-21 09:20:00'), 'Hemoglobin'], [50813, Timestamp('2181-01-21 09:18:00'), Timestamp('2181-01-21 09:20:00'), 'Lactate'], [50817, Timestamp('2181-01-21 09:18:00'), Timestamp('2181-01-21 09:20:00'), 'Oxygen Saturation'], [50818, Timestamp('2181-01-21 09:18:00'), Timestamp('2181-01-21 09:20:00'), 'pCO2'], [50820, Timestamp('2181-01-21 09:18:00'), Timestamp('2181-01-21 09:20:00'), 'pH'], [50821, Timestamp('2181-01-21 09:18:00'), Timestamp('2181-01-21 09:20:00'), 'pO2'], [50822, Timestamp('2181-01-21 09:18:00'), Timestamp('2181-01-21 09:20:00'), 'Potassium, Whole Blood'], [50824, Timestamp('2181-01-21 09:18:00'), Timestamp('2181-01-21 09:20:00'), 'Sodium, Whole Blood'], [52033, Timestamp('2181-01-21 09:18:00'), Timestamp('2181-01-21 09:19:00'), 'Specimen Type'], [51221, Timestamp('2181-01-21 12:00:00'), Timestamp('2181-01-21 12:41:00'), 'Hematocrit'], [51222, Timestamp('2181-01-21 12:00:00'), Timestamp('2181-01-21 12:41:00'), 'Hemoglobin'], [51248, Timestamp('2181-01-21 12:00:00'), Timestamp('2181-01-21 12:41:00'), 'MCH'], [51249, Timestamp('2181-01-21 12:00:00'), Timestamp('2181-01-21 12:41:00'), 'MCHC'], [51250, Timestamp('2181-01-21 12:00:00'), Timestamp('2181-01-21 12:41:00'), 'MCV'], [51265, Timestamp('2181-01-21 12:00:00'), Timestamp('2181-01-21 12:41:00'), 'Platelet Count'], [51277, Timestamp('2181-01-21 12:00:00'), Timestamp('2181-01-21 12:41:00'), 'RDW'], [51279, Timestamp('2181-01-21 12:00:00'), Timestamp('2181-01-21 12:41:00'), 'Red Blood Cells'], [51301, Timestamp('2181-01-21 12:00:00'), Timestamp('2181-01-21 12:41:00'), 'White Blood Cells'], [51237, Timestamp('2181-01-21 12:00:00'), Timestamp('2181-01-21 13:47:00'), 'INR(PT)'], [51274, Timestamp('2181-01-21 12:00:00'), Timestamp('2181-01-21 13:47:00'), 'PT'], [51275, Timestamp('2181-01-21 12:00:00'), Timestamp('2181-01-21 13:47:00'), 'PTT'], [50868, Timestamp('2181-01-21 12:00:00'), Timestamp('2181-01-21 13:24:00'), 'Anion Gap'], [50882, Timestamp('2181-01-21 12:00:00'), Timestamp('2181-01-21 13:24:00'), 'Bicarbonate'], [50893, Timestamp('2181-01-21 12:00:00'), Timestamp('2181-01-21 13:24:00'), 'Calcium, Total'], [50902, Timestamp('2181-01-21 12:00:00'), Timestamp('2181-01-21 13:24:00'), 'Chloride'], [50912, Timestamp('2181-01-21 12:00:00'), Timestamp('2181-01-21 13:24:00'), 'Creatinine'], [50931, Timestamp('2181-01-21 12:00:00'), Timestamp('2181-01-21 13:24:00'), 'Glucose'], [50960, Timestamp('2181-01-21 12:00:00'), Timestamp('2181-01-21 13:24:00'), 'Magnesium'], [50970, Timestamp('2181-01-21 12:00:00'), Timestamp('2181-01-21 13:24:00'), 'Phosphate'], [50971, Timestamp('2181-01-21 12:00:00'), Timestamp('2181-01-21 13:24:00'), 'Potassium'], [50983, Timestamp('2181-01-21 12:00:00'), Timestamp('2181-01-21 13:24:00'), 'Sodium'], [51006, Timestamp('2181-01-21 12:00:00'), Timestamp('2181-01-21 13:24:00'), 'Urea Nitrogen'], [51221, Timestamp('2181-01-21 16:00:00'), Timestamp('2181-01-21 18:11:00'), 'Hematocrit'], [51222, Timestamp('2181-01-21 16:00:00'), Timestamp('2181-01-21 18:11:00'), 'Hemoglobin'], [51248, Timestamp('2181-01-21 16:00:00'), Timestamp('2181-01-21 18:11:00'), 'MCH'], [51249, Timestamp('2181-01-21 16:00:00'), Timestamp('2181-01-21 18:11:00'), 'MCHC'], [51250, Timestamp('2181-01-21 16:00:00'), Timestamp('2181-01-21 18:11:00'), 'MCV'], [51265, Timestamp('2181-01-21 16:00:00'), Timestamp('2181-01-21 18:11:00'), 'Platelet Count'], [51277, Timestamp('2181-01-21 16:00:00'), Timestamp('2181-01-21 18:11:00'), 'RDW'], [51279, Timestamp('2181-01-21 16:00:00'), Timestamp('2181-01-21 18:11:00'), 'Red Blood Cells'], [51301, Timestamp('2181-01-21 16:00:00'), Timestamp('2181-01-21 18:11:00'), 'White Blood Cells'], [51275, Timestamp('2181-01-21 16:00:00'), Timestamp('2181-01-21 18:26:00'), 'PTT'], [51237, Timestamp('2181-01-22 04:41:00'), Timestamp('2181-01-22 06:19:00'), 'INR(PT)'], [51274, Timestamp('2181-01-22 04:41:00'), Timestamp('2181-01-22 06:19:00'), 'PT'], [51275, Timestamp('2181-01-22 04:41:00'), Timestamp('2181-01-22 06:20:00'), 'PTT'], [50868, Timestamp('2181-01-22 04:41:00'), Timestamp('2181-01-22 06:40:00'), 'Anion Gap'], [50882, Timestamp('2181-01-22 04:41:00'), Timestamp('2181-01-22 06:40:00'), 'Bicarbonate'], [50893, Timestamp('2181-01-22 04:41:00'), Timestamp('2181-01-22 06:40:00'), 'Calcium, Total'], [50902, Timestamp('2181-01-22 04:41:00'), Timestamp('2181-01-22 06:40:00'), 'Chloride'], [50912, Timestamp('2181-01-22 04:41:00'), Timestamp('2181-01-22 06:40:00'), 'Creatinine'], [50931, Timestamp('2181-01-22 04:41:00'), Timestamp('2181-01-22 06:40:00'), 'Glucose'], [50960, Timestamp('2181-01-22 04:41:00'), Timestamp('2181-01-22 06:40:00'), 'Magnesium'], [50970, Timestamp('2181-01-22 04:41:00'), Timestamp('2181-01-22 06:40:00'), 'Phosphate'], [50971, Timestamp('2181-01-22 04:41:00'), Timestamp('2181-01-22 06:40:00'), 'Potassium'], [50983, Timestamp('2181-01-22 04:41:00'), Timestamp('2181-01-22 06:40:00'), 'Sodium'], [51006, Timestamp('2181-01-22 04:41:00'), Timestamp('2181-01-22 06:40:00'), 'Urea Nitrogen'], [51221, Timestamp('2181-01-22 04:41:00'), Timestamp('2181-01-22 06:09:00'), 'Hematocrit'], [51222, Timestamp('2181-01-22 04:41:00'), Timestamp('2181-01-22 06:09:00'), 'Hemoglobin'], [51248, Timestamp('2181-01-22 04:41:00'), Timestamp('2181-01-22 06:09:00'), 'MCH'], [51249, Timestamp('2181-01-22 04:41:00'), Timestamp('2181-01-22 06:09:00'), 'MCHC'], [51250, Timestamp('2181-01-22 04:41:00'), Timestamp('2181-01-22 06:09:00'), 'MCV'], [51265, Timestamp('2181-01-22 04:41:00'), Timestamp('2181-01-22 06:09:00'), 'Platelet Count'], [51277, Timestamp('2181-01-22 04:41:00'), Timestamp('2181-01-22 06:09:00'), 'RDW'], [51279, Timestamp('2181-01-22 04:41:00'), Timestamp('2181-01-22 06:09:00'), 'Red Blood Cells'], [51301, Timestamp('2181-01-22 04:41:00'), Timestamp('2181-01-22 06:09:00'), 'White Blood Cells']]

Question: A 78 F is admitted. He/she says he/she has Disabling claudication, bilateral aortoiliac occlusion . History of illness: A ___ female with a past medical history of severe disabling claudication. For the past ___ years she has been unable to walk aside from a few feet only. She does have bilateral calf pain. She has been treated conservatively with medication which she continued to fail to progress. She had a recent CT angiogram showing an aortic aneurysm with a seemingly bilateral iliac occlusion. She does have some reconstitution bilaterally via collateral vessels. Given the severity of her symptoms, in addition to the CT imaging, the patient was offered a bypass option. However, given her severe COPD and aortic aneurysm noted on imaging it was discussed that an axillary bifemoral bypass would be the procedure of choice. Past Medical History: PVD, COPD, CHF, HTN, AAA, kypho-scoliosis, osteoporosis, PUD, anemia Social History: ___ Family History: non contributory Allergies: codeine / antihistamines What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Albuterol Inhaler HYDROmorphone (Dilaudid) Heparin Metoprolol Tartrate Lactated Ringers HYDROmorphone (Dilaudid) D5W Nitroglycerin Fluticasone-Salmeterol Diskus (250/50) Iso-Osmotic Sodium Chloride Famotidine PNEUMOcoccal 23-valent polysaccharide vaccine Acetaminophen Sodium Chloride 0.9% Flush Target Lab Orders: Base Excess Calculated Total CO2 Chloride, Whole Blood Free Calcium Glucose Hematocrit, Calculated Hemoglobin Intubated Lactate Oxygen Saturation pCO2 pH pO2 Potassium, Whole Blood Sodium, Whole Blood Specimen Type Base Excess Calculated Total CO2 Carboxyhemoglobin Chloride, Whole Blood Free Calcium Glucose Hematocrit, Calculated Hemoglobin Lactate Oxygen Saturation pCO2 pH pO2 Potassium, Whole Blood Sodium, Whole Blood Specimen Type Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells INR(PT) PT PTT Anion Gap Bicarbonate Calcium, Total Chloride Creatinine Glucose Magnesium Phosphate Potassium Sodium Urea Nitrogen Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells PTT INR(PT) PT PTT Anion Gap Bicarbonate Calcium, Total Chloride Creatinine Glucose Magnesium Phosphate Potassium Sodium Urea Nitrogen Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : Ms. ___ presented to ___ on ___. She was evaluated by anaesthesia and taken to the operating room for Right axillary bilateral femoral bypass and Bilateral femoral endarterectomy including profunda. There were no adverse events in the operating room; please see the operative note for details. Pt was extubated, taken to the PACU until stable, and then transferred to the ward for observation. Neuro: The patient was alert and oriented throughout hospitalization; pain was well controlled. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: During early ambulation, her oxygen saturation dropped to the 80's, but improved and remained stable for the rest of the hospitalization; vital signs were routinely monitored. Good pulmonary toilet, and incentive spirometry were encouraged throughout hospitalization. GI/GU/FEN: The patient was initially kept NPO for the procedure, but then was resumed on a regular diet, which was tolerated well. ID: The patient's fever curves were closely watched for signs of infection, of which there were none. HEME: The patient's blood counts were closely watched for signs of bleeding, of which there were none. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating with a walker and physical therapy, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Other Results: ___ 04:00PM WBC-15.6* RBC-3.29* HGB-8.9* HCT-29.5* MCV-90 MCH-27.0 MCHC-30.1* RDW-15.3 ___ 04:00PM PLT COUNT-254 ___ 04:00PM PTT-24.6* ___ 12:00PM GLUCOSE-135* UREA N-11 CREAT-0.8 SODIUM-139 POTASSIUM-4.1 CHLORIDE-109* TOTAL CO2-24 ANION GAP-10 ___ 12:00PM CALCIUM-8.1* PHOSPHATE-3.8 MAGNESIUM-1.9 ___ 12:00PM WBC-15.8*# RBC-3.59* HGB-9.5* HCT-32.9* MCV-92 MCH-26.4* MCHC-28.8* RDW-14.8 ___ 12:00PM PLT COUNT-387 ___ 12:00PM ___ PTT-123.5* ___ ___ 09:18AM TYPE-ART PO2-293* PCO2-49* PH-7.27* TOTAL CO2-23 BASE XS--4 ___ 09:18AM GLUCOSE-114* LACTATE-0.8 NA+-140 K+-3.6 CL--109* ___ 09:18AM HGB-7.6* calcHCT-23 O2 SAT-98 CARBOXYHB-2 ___ 09:18AM freeCa-1.13 ___ 08:51AM TYPE-ART PO2-306* PCO2-60* PH-7.23* TOTAL CO2-26 BASE XS--3 INTUBATED-INTUBATED ___ 08:51AM HGB-8.0* calcHCT-24 O2 SAT-98 ___ 08:51AM GLUCOSE-101 LACTATE-1.0 NA+-140 K+-3.4 CL--106 ___ 08:51AM freeCa-1.17

2134-07-30 04:05:00

ENGLISH

DIVORCED

WHITE

M

[[22632160, Timestamp('2134-07-30 04:06:02'), '', 'OMED']]

[[{'Medications on Admission': ':\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 650 mg PO Q6H:PRN pain or fever \n2. Aspirin 81 mg PO DAILY \n3. FoLIC Acid 1 mg PO DAILY \n4. Mirtazapine 15 mg PO QHS \n5. Morphine SR (MS ___ 30 mg PO Q12H \n6. Morphine Sulfate ___ 15 mg PO Q4H:PRN pain \n7. Enoxaparin Sodium 80 mg SC Q12H \nStart: ___, First Dose: Next Routine Administration Time \n8. Polyethylene Glycol 17 g PO DAILY:PRN constipation \n9. Levofloxacin 500 mg PO Q24H ', 'Brief Hospital Course': ':\n___ yo male with a history of lung cancer and recent\nhospitalization for new pulmonary embolus and pneumonia who is\nadmitted with shortness of breath. A specific etiology to his \nshortness of breath was not found and it was thought that this \nmay have been related to perhaps a mucous plug. Imaging did not \nshow any worsening pulmonary problem. Echo showed only a very \nsmall pericardial effusion. He did not have a desaturations or \nepisodes of shortness of breath while here and he was discharged \nhome in good condition. \n\n', 'Pertinent Results:': '\n___ 06:07AM BLOOD WBC-10.9* RBC-3.41* Hgb-10.9* Hct-33.4* \nMCV-98 MCH-32.0 MCHC-32.6 RDW-15.7* RDWSD-55.8* Plt ___\n___ 07:10AM BLOOD WBC-12.1* RBC-3.31* Hgb-10.6* Hct-32.5* \nMCV-98 MCH-32.0 MCHC-32.6 RDW-15.9* RDWSD-57.0* Plt ___\n___ 06:07AM BLOOD Glucose-86 UreaN-13 Creat-0.9 Na-137 \nK-4.3 Cl-102 HCO3-23 AnGap-16\n___ 07:10AM BLOOD Glucose-86 UreaN-13 Creat-1.0 Na-136 \nK-4.9 Cl-104 HCO3-26 AnGap-11\n___ 07:10AM BLOOD ALT-18 AST-23 AlkPhos-122 TotBili-0.2\n___ 06:07AM BLOOD Calcium-9.0 Phos-4.1 Mg-2.1\n___ 01:31AM BLOOD proBNP-769*\n___ 01:31AM BLOOD cTropnT-<0.01\n___ 07:10AM BLOOD TSH-27*\n___ 07:10AM BLOOD Free T4-0.66*\n\nIMAGING:\nCXR: Short interval stability of mid and lower left lung\nopacification related to lymphangitic carcinomatosis and a small\npleural effusion. Superimposed infectious process is possible in\nthe proper clinical setting. \nChest CTA: \n1. Interval increase in moderate pericardial effusion with\nassociated pericardial enhancement most consistent with a\nmalignant effusion. \n2. Unchanged or slightly decreased extent of bilateral\nsubsegmental pulmonary emboli. \n3. Short interval stability of left apical lung cancer with\nextensive lymphangitic carcinomatosis involving the left lung,\nparticularly the left lower lobe. Infectious process at the left\nlung base may also be present. \n4. Unchanged sclerotic lesion within the posterior right seventh\nrib. \n\n', 'Physical Exam:|Physical': '\nPHYSICAL EXAM:\nGeneral: NAD\nVITAL SIGNS: 98.3 110/72 97 18 99%RA\nHEENT: MMM, no OP lesions\nCV: RR, NL S1S2\nPULM: Decreased breath sounds greater on the left\nABD: Soft, NTND, no masses or hepatosplenomegaly\nLIMBS: No edema, clubbing, tremors, or asterixis\nSKIN: No rashes or skin breakdown\nNEURO: Alert and oriented, no focal deficits.\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\nHISTORY OF PRESENT ILLNESS:\n___ yo male with a history of lung cancer and recent\nhospitalization for new pulmonary embolus and pneumonia who is\nadmitted with shortness of breath. The patient was discharged\nhome yesterday and states he felt a little short of breath doing\nthings about his house but not bad and it would resolve when he\ntook a break. However around 1am he got progressively short of\nbreath and had his son call ___. He states he started coughing\nsome and then the shortness of breath just kept getting worse. \nHe\nstates the shortness of breath is worse when he tries to lay\ndown. He states then the paramedics got there they said his\noxygen saturation was in the 50% on room air. He improved \nquickly\nwhen placed on a nonrebreather and was transitioned back to room\nair in the ED without further intervention. \nOf note he was recently hospitalized and discharged yesterday\nafter having an episode of severe chest pain in the ___\nclinic prior to any treatment. He was found to have pulmonary\nembolisms and was started on lovenox. He was also found to have \na\npneumonia and has been taking levaquin. He was found to have a\nsmall pericardial effusion that was thought to be possibly\nmalignant but did not seem to cause any hemodynamic changes and\nno intervention was done.\nOn arrival to the floor he feels much better but still very \nshort\nof breath with any movement and does have a cough.\n\nREVIEW OF SYSTEMS:\n- All reviewed and negative except as noted in the HPI.\n\nPast Medical History:\nPAST ONCOLOGIC HISTORY (per OMR):\nHis course began toward the end of this past ___ when he \nbegan\nto develop left lower back discomfort initially felt to be due \nto\na muscle spasm. His discomfort persisted for several weeks\nprompting PCP ___. CXR was obtained and concerning for a\nparenchymal lesion, so CT scan was pursued (at ___) which\nrevealed a 2.7cm mass and large left pleural effusion with\nblastic lesions in L1 and right ilium concerning for metastatic\nmalignancy. PET/CT showed SUVmax of 9.8 compatible with\nmalignancy. Outpatient thoracentesis was scheduled however he\ndeveloped respiratory symptoms with dyspnea prompting ED\npresentation and hospitalization ___. Work-up was \nnotable\nfor CTA chest with large left pleural effusion, no PE. Chest \ntube\nwas placed on ___ by IP with subsequent pleural biopsy and \ntalc\npleurodesis on ___. Biopsy and pleural cytology results\nrevealed adenocarcinoma confirmed with TTF-1 and napsin-a\npositivity.\n- ___ - establish care in Thoracic Oncology, discussed\nenrollment into trial DF/HCC14-160; started palliative\ndexamethasone, mirtazapine, and B12/folate in anticipation of\nchemotherapy\n- Was to start trial drug but required hospitalization before\nthis could occur.\n\nPAST MEDICAL HISTORY:\n- Hodgkin in ___ with radiation and\nsplenectomy, no recurrence\n- HLD\n- microvascular angina\n- dizziness with autonomic dysregulation\n- cluster headache \n\nSocial History:\n___\nFamily History:\n- mother with breast cancer twice and lung cancer twice\n- maternal aunt and uncle with lung cancer, all extensive \nsmoking\nhistory\n\n', 'Chief Complaint:|Complaint:': '\nshortness of breath\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nwine\n\n'}, '13603593-DS-16', 16, 'medicine']]

[['INDICATION: ___ with dyspnea, evaluate for pneumonia.\n\nTECHNIQUE: Single portable AP view radiograph of the chest.\n\nCOMPARISON: Multiple prior chest radiographs dating back to ___.\n\nFINDINGS: \n\nOpacification of the mid and lower left lung is grossly unchanged from the\nprior study and better characterized by same day chest CT. Opacity likely\nrepresents a combination of lymphangitic carcinomatosis and a small pleural\neffusion. Superimposed infectious process in the left lung base is possible\nin the proper clinical setting. The right lung is clear. There is no\npneumothorax. The osseous structures are notable for cervical spinal fusion\nhardware. The upper abdomen is unremarkable.\n\nIMPRESSION: \n\nShort interval stability of mid and lower left lung opacification related to\nlymphangitic carcinomatosis and a small pleural effusion. Superimposed\ninfectious process is possible in the proper clinical setting.\n', '13603593-RR-86', 86, 'single portable ap view radiograph of the chest.'], ['INDICATION: ___ with shortness of breath, evaluate for pulmonary embolism.\n\nTECHNIQUE: Axial multidetector CT images were obtained through the thorax\nafter the uneventful administration of intravenous contrast.\nReformatted coronal, sagittal, thin slice axial images, and oblique maximal\nintensity projection images were submitted to PACS and reviewed.\n\nDOSE: Acquisition sequence:\n 1) CT Localizer Radiograph\n 2) CT Localizer Radiograph\n 3) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 9.1 mGy (Body) DLP = 4.6\nmGy-cm.\n 4) Spiral Acquisition 3.5 s, 27.1 cm; CTDIvol = 13.9 mGy (Body) DLP = 377.3\nmGy-cm.\n Total DLP (Body) = 382 mGy-cm.\n\nCOMPARISON: Prior chest CTs dated ___ and ___.\n\nFINDINGS: \n\nThe aorta and its major branch vessels are patent, with no evidence of\nstenosis, occlusion, dissection, or aneurysmal formation. There is no\nevidence of penetrating atherosclerotic ulcer or aortic arch atheroma present.\n\nThe pulmonary arteries are well opacified to the subsegmental level. Filling\ndefects within bilateral subsegmental pulmonary arteries are compatible\npulmonary emboli. Overall clot burden is unchanged or slightly decreased\ncompared with the prior study of ___. The main and right pulmonary\narteries are normal in caliber, and there is no evidence of right heart\nstrain.\n\nThere is no supraclavicular or axillary lymphadenopathy. The thyroid gland\nappears unremarkable.\n\nA moderate pericardial effusion with peripheral enhancement has increased\ncompared with the prior study, worrisome for malignant effusion. Trace\npleural effusions are noted bilaterally.\n\nA 2.5 x 2.4 cm heterogeneously enhancing pulmonary nodule in the left upper\nlobe is unchanged from the recent prior study and compatible with known\nadenocarcinoma (03:20). Extensive interlobular septal thickening and\nperibronchovascular thickening involving the left hilum and left lower lobe is\ncompatible with lymphangitic carcinomatosis, unchanged from the recent prior\nstudy. Fibrosis of the medial right upper is compatible with stable radiation\nchanges. The airways remain patent to the subsegmental level.\n\nLimited images of the upper abdomen are unremarkable.\n\nA sclerotic lesion in the posterior right seventh rib is stable (3:86).\n\nIMPRESSION:\n\n\n1. Interval increase in moderate pericardial effusion with associated\npericardial enhancement most consistent with a malignant effusion.\n2. Unchanged or slightly decreased extent of bilateral subsegmental pulmonary\nemboli.\n3. Short interval stability of left apical lung cancer with extensive\nlymphangitic carcinomatosis involving the left lung, particularly the left\nlower lobe. Infectious process at the left lung base may also be present.\n4. Unchanged sclerotic lesion within the posterior right seventh rib.\n', '13603593-RR-87', 87, 'axial multidetector ct images were obtained through the thorax\nafter the uneventful administration of intravenous contrast.\nreformatted coronal, sagittal, thin slice axial images, and oblique maximal\nintensity projection images were submitted to pacs and reviewed.']]

[[22632160, Timestamp('2134-07-30 07:00:00'), Timestamp('2134-07-31 18:00:00'), 'MAIN', 'Polyethylene Glycol', '034313', '11523726808', '17g Packet'], [22632160, Timestamp('2134-07-30 22:00:00'), Timestamp('2134-07-31 18:00:00'), 'MAIN', 'Mirtazapine', '046450', '51079008620', '15 mg Tablet'], [22632160, Timestamp('2134-07-30 07:00:00'), Timestamp('2134-07-31 18:00:00'), 'MAIN', 'Enoxaparin Sodium', '027994', '00075062280', '80mg Syringe'], [22632160, Timestamp('2134-07-30 07:00:00'), Timestamp('2134-07-31 18:00:00'), 'MAIN', 'Morphine SR (MS Contin)', '004096', '00406833062', '30mg Tablet'], [22632160, Timestamp('2134-07-30 07:00:00'), Timestamp('2134-07-31 18:00:00'), 'MAIN', 'Sodium Chloride 0.9% Flush', '', '0', '10 mL Syringe'], [22632160, Timestamp('2134-07-30 07:00:00'), Timestamp('2134-07-31 18:00:00'), 'MAIN', 'Morphine Sulfate IR', '004091', '00054023524', '15mg Tab'], [22632160, Timestamp('2134-07-30 11:00:00'), Timestamp('2134-07-31 18:00:00'), 'MAIN', 'Oxymetazoline', '008039', '00904571135', '0.05% 15mL'], [22632160, Timestamp('2134-07-30 14:00:00'), Timestamp('2134-07-31 18:00:00'), 'MAIN', 'Acetaminophen', '004490', '00904198861', '500mg Tablet'], [22632160, Timestamp('2134-07-30 08:00:00'), Timestamp('2134-07-31 18:00:00'), 'MAIN', 'Levofloxacin', '029928', '50458092510', '500 mg Tablet'], [22632160, Timestamp('2134-07-30 08:00:00'), Timestamp('2134-07-31 18:00:00'), 'MAIN', 'Aspirin', '004380', '00904404073', '81mg Tab']]

[]

['medicine']

[[51221, Timestamp('2134-07-31 07:10:00'), Timestamp('2134-07-31 08:16:00'), 'Hematocrit'], [51222, Timestamp('2134-07-31 07:10:00'), Timestamp('2134-07-31 08:16:00'), 'Hemoglobin'], [51248, Timestamp('2134-07-31 07:10:00'), Timestamp('2134-07-31 08:16:00'), 'MCH'], [51249, Timestamp('2134-07-31 07:10:00'), Timestamp('2134-07-31 08:16:00'), 'MCHC'], [51250, Timestamp('2134-07-31 07:10:00'), Timestamp('2134-07-31 08:16:00'), 'MCV'], [51265, Timestamp('2134-07-31 07:10:00'), Timestamp('2134-07-31 08:16:00'), 'Platelet Count'], [51277, Timestamp('2134-07-31 07:10:00'), Timestamp('2134-07-31 08:16:00'), 'RDW'], [51279, Timestamp('2134-07-31 07:10:00'), Timestamp('2134-07-31 08:16:00'), 'Red Blood Cells'], [51301, Timestamp('2134-07-31 07:10:00'), Timestamp('2134-07-31 08:16:00'), 'White Blood Cells'], [52172, Timestamp('2134-07-31 07:10:00'), Timestamp('2134-07-31 08:16:00'), 'RDW-SD'], [50861, Timestamp('2134-07-31 07:10:00'), Timestamp('2134-08-01 12:29:00'), 'Alanine Aminotransferase (ALT)'], [50863, Timestamp('2134-07-31 07:10:00'), Timestamp('2134-08-01 12:29:00'), 'Alkaline Phosphatase'], [50868, Timestamp('2134-07-31 07:10:00'), Timestamp('2134-07-31 09:05:00'), 'Anion Gap'], [50878, Timestamp('2134-07-31 07:10:00'), Timestamp('2134-08-01 12:29:00'), 'Asparate Aminotransferase (AST)'], [50882, Timestamp('2134-07-31 07:10:00'), Timestamp('2134-07-31 09:05:00'), 'Bicarbonate'], [50885, Timestamp('2134-07-31 07:10:00'), Timestamp('2134-08-01 12:29:00'), 'Bilirubin, Total'], [50902, Timestamp('2134-07-31 07:10:00'), Timestamp('2134-07-31 09:05:00'), 'Chloride'], [50912, Timestamp('2134-07-31 07:10:00'), Timestamp('2134-07-31 09:05:00'), 'Creatinine'], [50931, Timestamp('2134-07-31 07:10:00'), Timestamp('2134-07-31 09:05:00'), 'Glucose'], [50971, Timestamp('2134-07-31 07:10:00'), Timestamp('2134-07-31 09:05:00'), 'Potassium'], [50983, Timestamp('2134-07-31 07:10:00'), Timestamp('2134-07-31 09:05:00'), 'Sodium'], [50993, Timestamp('2134-07-31 07:10:00'), Timestamp('2134-08-01 12:29:00'), 'Thyroid Stimulating Hormone'], [50995, Timestamp('2134-07-31 07:10:00'), Timestamp('2134-08-01 12:29:00'), 'Thyroxine (T4), Free'], [51006, Timestamp('2134-07-31 07:10:00'), Timestamp('2134-07-31 09:05:00'), 'Urea Nitrogen']]

Question: A 66 M is admitted. He/she says he/she has shortness of breath . History of illness: HISTORY OF PRESENT ILLNESS: ___ yo male with a history of lung cancer and recent hospitalization for new pulmonary embolus and pneumonia who is admitted with shortness of breath. The patient was discharged home yesterday and states he felt a little short of breath doing things about his house but not bad and it would resolve when he took a break. However around 1am he got progressively short of breath and had his son call ___. He states he started coughing some and then the shortness of breath just kept getting worse. He states the shortness of breath is worse when he tries to lay down. He states then the paramedics got there they said his oxygen saturation was in the 50% on room air. He improved quickly when placed on a nonrebreather and was transitioned back to room air in the ED without further intervention. Of note he was recently hospitalized and discharged yesterday after having an episode of severe chest pain in the ___ clinic prior to any treatment. He was found to have pulmonary embolisms and was started on lovenox. He was also found to have a pneumonia and has been taking levaquin. He was found to have a small pericardial effusion that was thought to be possibly malignant but did not seem to cause any hemodynamic changes and no intervention was done. On arrival to the floor he feels much better but still very short of breath with any movement and does have a cough. REVIEW OF SYSTEMS: - All reviewed and negative except as noted in the HPI. Past Medical History: PAST ONCOLOGIC HISTORY (per OMR): His course began toward the end of this past ___ when he began to develop left lower back discomfort initially felt to be due to a muscle spasm. His discomfort persisted for several weeks prompting PCP ___. CXR was obtained and concerning for a parenchymal lesion, so CT scan was pursued (at ___) which revealed a 2.7cm mass and large left pleural effusion with blastic lesions in L1 and right ilium concerning for metastatic malignancy. PET/CT showed SUVmax of 9.8 compatible with malignancy. Outpatient thoracentesis was scheduled however he developed respiratory symptoms with dyspnea prompting ED presentation and hospitalization ___. Work-up was notable for CTA chest with large left pleural effusion, no PE. Chest tube was placed on ___ by IP with subsequent pleural biopsy and talc pleurodesis on ___. Biopsy and pleural cytology results revealed adenocarcinoma confirmed with TTF-1 and napsin-a positivity. - ___ - establish care in Thoracic Oncology, discussed enrollment into trial DF/HCC14-160; started palliative dexamethasone, mirtazapine, and B12/folate in anticipation of chemotherapy - Was to start trial drug but required hospitalization before this could occur. PAST MEDICAL HISTORY: - Hodgkin in ___ with radiation and splenectomy, no recurrence - HLD - microvascular angina - dizziness with autonomic dysregulation - cluster headache Social History: ___ Family History: - mother with breast cancer twice and lung cancer twice - maternal aunt and uncle with lung cancer, all extensive smoking history Allergies: wine What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Polyethylene Glycol Mirtazapine Enoxaparin Sodium Morphine SR (MS Contin) Sodium Chloride 0.9% Flush Morphine Sulfate IR Oxymetazoline Acetaminophen Levofloxacin Aspirin Target Lab Orders: Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells RDW-SD Alanine Aminotransferase (ALT) Alkaline Phosphatase Anion Gap Asparate Aminotransferase (AST) Bicarbonate Bilirubin, Total Chloride Creatinine Glucose Potassium Sodium Thyroid Stimulating Hormone Thyroxine (T4), Free Urea Nitrogen Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : ___ yo male with a history of lung cancer and recent hospitalization for new pulmonary embolus and pneumonia who is admitted with shortness of breath. A specific etiology to his shortness of breath was not found and it was thought that this may have been related to perhaps a mucous plug. Imaging did not show any worsening pulmonary problem. Echo showed only a very small pericardial effusion. He did not have a desaturations or episodes of shortness of breath while here and he was discharged home in good condition. Other Results: ___ 06:07AM BLOOD WBC-10.9* RBC-3.41* Hgb-10.9* Hct-33.4* MCV-98 MCH-32.0 MCHC-32.6 RDW-15.7* RDWSD-55.8* Plt ___ ___ 07:10AM BLOOD WBC-12.1* RBC-3.31* Hgb-10.6* Hct-32.5* MCV-98 MCH-32.0 MCHC-32.6 RDW-15.9* RDWSD-57.0* Plt ___ ___ 06:07AM BLOOD Glucose-86 UreaN-13 Creat-0.9 Na-137 K-4.3 Cl-102 HCO3-23 AnGap-16 ___ 07:10AM BLOOD Glucose-86 UreaN-13 Creat-1.0 Na-136 K-4.9 Cl-104 HCO3-26 AnGap-11 ___ 07:10AM BLOOD ALT-18 AST-23 AlkPhos-122 TotBili-0.2 ___ 06:07AM BLOOD Calcium-9.0 Phos-4.1 Mg-2.1 ___ 01:31AM BLOOD proBNP-769* ___ 01:31AM BLOOD cTropnT-<0.01 ___ 07:10AM BLOOD TSH-27* ___ 07:10AM BLOOD Free T4-0.66* IMAGING: CXR: Short interval stability of mid and lower left lung opacification related to lymphangitic carcinomatosis and a small pleural effusion. Superimposed infectious process is possible in the proper clinical setting. Chest CTA: 1. Interval increase in moderate pericardial effusion with associated pericardial enhancement most consistent with a malignant effusion. 2. Unchanged or slightly decreased extent of bilateral subsegmental pulmonary emboli. 3. Short interval stability of left apical lung cancer with extensive lymphangitic carcinomatosis involving the left lung, particularly the left lower lobe. Infectious process at the left lung base may also be present. 4. Unchanged sclerotic lesion within the posterior right seventh rib.

2170-02-02 18:22:00

ENGLISH

SINGLE

WHITE

F

[[20726545, Timestamp('2170-02-02 18:24:11'), '', 'EYE'], [20726545, Timestamp('2170-02-02 18:25:15'), 'EYE', 'MED']]

[[{'Medications on Admission': ':\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 650 mg PO/NG Q6H:PRN Pain - Mild \n2. amLODIPine 10 mg PO/NG DAILY \n3. Aspirin 81 mg PO/NG DAILY \n4. Bethanechol 5 mg NG TID \n5. FLUoxetine 40 mg PO DAILY \n6. FoLIC Acid 1 mg PO/NG BID \n7. HYDROmorphone (Dilaudid) 2 mg PO/NG Q6H:PRN Pain - Moderate \n8. Lisinopril 30 mg PO/NG DAILY \n9. LORazepam 0.5 mg PO/NG Q6H:PRN nausea \n10. Ondansetron 4 mg PO/NG Q8H:PRN nausea \n11. Pantoprazole 40 mg PO Q24H \n12. Promethazine 12.5 mg PO/NG Q6H:PRN nausea \n13. Rosuvastatin Calcium 20 mg PO QPM \n14. Zolpidem Tartrate 2.5 mg PO QHS \n15. NPH 4 Units Breakfast\nNPH 25 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin', 'Brief Hospital Course': ':\nInformation for Outpatient ___ woman with \nT1DM c/b severe retinopathy and gastroparesis s/p GJ tube and \nrecent admission for DKA, ESRD on HD with AV graft, RA, and HTN \nwho is transferred to Medicine after a vitrectomy for \nretinopathy and retinal detachment, for medical management \nincluding hemodialysis.\n\n#RIGHT EYE VITRECTOMY\nPatient had OD vitrectomy on ___ under general anesthesia due \nto gastroparesis. Tolerated procedure/anesthesia well. Eye patch \nin place. Seen by Ophthalmology on ___ day 1, concern \nfor continued retinal detachment in right eye. Seen in \nOphthalmology clinic on POD2 with plan for outpatient follow-up \non POD6.\n\n#ESRD ON HEMODIALYSIS\nPatient with elevated BUN, Cr, K, PO4 and systolic BP on ___ \nhaving not had dialysis since ___. Got HD on ___ with \nimprovement in electrolytes and HTN.\n\n#GASTROPARESIS\nPatient tolerated general anesthesia, tolerating clear liquids \nPO and tube feeds through J-tube.\n\n#TYPE 1 DIABETES MELLITUS\nPoor control of FSBG on home insulin lispro/NPH regimen, with \nFSBGs 56-340 in hospital. Patient notes diabetes is followed by \nPCP but will switch to management at ___.\n\n===============================\nTRANSITIONAL ISSUES\n===============================\n- Patient needs better control of diabetes as ___ in 300s while \npatient was inpatient (but also hypoglycemic to 56 and \nasymptomatic). Will need close follow up for this.\n- Poor control of blood glucose with persistent hyperglycemia on \ncurrent, unclear home insulin regimen. Insulin dosing/regimen \nshould be clarified/improved as outpatient.\n\n#CONTACT: ___, HCP ___\n#CODE: Full\n\n', 'Pertinent Results:': '\n========================\nADMISSION LABS\n========================\nHCV Ab-Negative\n___ 05:37AM BLOOD WBC-13.4* RBC-4.16# Hgb-12.7# Hct-39.8# \nMCV-96 MCH-30.5 MCHC-31.9* RDW-14.6 RDWSD-50.4* Plt ___\n___ 05:37AM BLOOD Glucose-393* UreaN-57* Creat-4.7*# \nNa-130* K-5.7* Cl-93* HCO3-23 AnGap-20\n___ 05:37AM BLOOD Calcium-9.1 Phos-5.4* Mg-2.9*\n\nHBsAg-Negative \nHBsAb-Negative \nHBcAb-Negative\n\n', 'Physical Exam:|Physical': '\nADMISSION PHYSICAL EXAM:\n========================\nVITALS: T 99.3 BP 174/83 HR 90 RR 16 SaO2 98% RA FSBG 271 @ \n15:45\nGENERAL: alert, oriented, tired-appearing but pleasant\nHEENT: large eye patch covering OD. OS pupil 3 to 2mm, \natraumatic\nNECK: supple, no JVD\nCARDIAC: RRR, nl S1/S2, no MRG\nLUNGS: CTAB\nABDOMEN: soft, very tender to palpation at epigastrium, \nnondistended, normoactive bowel sounds\nEXTREMITIES: no cyanosis/clubbing/edema, warm/well-perfused. \nbruit at LUE AV fistula\nSKIN: port-a-cath at R chest\nNEUROLOGIC: alert, oriented, moving all 4 extremities easily\nTUBES/LINES/DRAINS: No drains. Port-A-Cath in place at chest. \nG-tube and J-tube at abdomen.\n\nDISCHARGE PHYSICAL EXAM:\n========================\nVITALS: Tm 98.9 Tc 98.9 BP ___ (209/91 at 19:02 before \nstarting medications) HR ___ RR 18 SaO2 98% RA FSBG 306-340\nI/O: 580 in (120 PO), voiding\nGENERAL: alert, oriented, tired-appearing but pleasant\nHEENT: large eye patch covering OD. OS pupil 3 to 2mm, \natraumatic\nNECK: supple, no JVD\nCARDIAC: RRR, nl S1/S2, no MRG\nLUNGS: CTAB\nABDOMEN: soft, very tender to light palpation at epigastrium, \nnondistended, normoactive bowel sounds\nEXTREMITIES: no cyanosis/clubbing/edema, warm/well-perfused. \nbruit at LUE AV fistula\nSKIN: port-a-cath at R chest\nNEUROLOGIC: alert, oriented, moving all 4 extremities easily\nTUBES/LINES/DRAINS: No drains. Port-A-Cath in place at chest. \nG-tube and J-tube at abdomen.\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\nMs. ___ is a ___ woman with T1DM c/b severe \nretinopathy and gastroparesis s/p GJ tube and recent admission \nfor DKA, ESRD on HD with AV graft, RA, and HTN who is \ntransferred to Medicine after a vitrectomy for hemorrhage and \nretinal detachment, for medical management including \nhemodialysis.\n\nMs. ___ was admitted to ___ on ___ for \ngastroparesis and was discharged on ___. She presented with \nconstant vague abdominal pain with nausea and vomiting with poor \nPO intake after her dialysis on ___. She noted she had bowel \nmovements. She was admitted for poorly controlled T1DM and DKA \nlikely secondary to gastroparesis, and was treated by ___ \nprotocol and seen by Endocrinology there.\n\nShe was referred by her PCP for severe proliferative retinopathy \nand macula-threatening traction retinal detachment in both eyes, \nand was seen by Ophthalmology on ___. As her vision was ___ \nin the right eye the decision was made to intervene operatively \nwith 27-gauge pars plana vitrectomy with membrane peel and \nendolaser in the right eye (OD) but to plan for laser \nphotocoagulation on the left eye (OS) in the future.\n\nOn ___ AM, she underwent a vitrectomy in the right eye(OD) \nas well as severe proliferative diabetic retinopathy in the \nright eye (OD). She underwent panretinal photocoagulation \ntreatment and tolerated the procedure and general anesthesia \nwell.\n\nShe denies any fever, chills, chest pain, or shortness of \nbreath. Her nausea/vomiting and ___ abdominal pain are at her \nbaseline.\n\nHer ESRD is currently controlled with ESRD. As she has had poor \nperipheral venous access she has a Port-a-cath in place. She \nundergoes Hemodialysis every ___ in ___ has \nnot had HD since ___.\n\nShe has a history of RA and had a prednisone taper from ___ \nRheumatology in early ___. \n\nFor her gastroparesis, she last had a G-J tube exchanged at \n___ on ___. She notes she gets tube feeds at 50 mL/h \novernight from 9pm to 9am. She uses her J-tube for tube feeds \nand G-tube for venting (draining to gravity) when nauseous.\n\nUpon arrival to the floor, the patient is tired but pleasant. \nShe notes ___ pain at the R eye not radiating to the L eye, and \n___ abdominal pain consistent with her baseline pain.\n\nPast Medical History:\nPAST MEDICAL HISTORY: \n- Hypertension\n- Hyperlipidemia\n- End Stage Renal Disease (ESRD) on Hemodialysis\n- Type 1 Diabetes Mellitus complicated by:\n - retinopathy\n - neuropathy\n - Gastroparesis with GJ tube\n- Rheumatoid Arthritis c/b multiple pulmonary nodules + \nrecurrent pleural effusions\n- Fibromyalgia\n- Depression\n- Pulmonary Nodules\n- Tardive dyskinesia ___ metoclopramide\n- MRSA\n- DJD\n- Depression\n\nPAST SURGICAL HISTORY:\n- R eye vitrectomy ___\n- R knee surgery\n- Carpal tunnel release x2\n- bilateral shoulder surgery\n- Hysterectomy\n- Multiple ex-laps for endometriosis\n- Appendectomy\n\nSocial History:\n___\nFamily History:\nno history of malignancy or cardiac disease. mother died of \n"sepsis"\n\n', 'Chief Complaint:|Complaint:': '\nRight eye vitrectomy\n\n', 'Attending:': ' ___\n\n', 'Allergies:': ' \nRelafen / Leflunomide / metoclopramide / ceftriaxone\n\n'}, '18202111-DS-38', 38, 'medicine']]

[]

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5 mL Syringe'], [20726545, Timestamp('2170-02-02 20:00:00'), Timestamp('2170-02-04 21:00:00'), 'MAIN', 'Sodium Chloride 0.9% Flush', '', '0', '10 mL Syringe'], [20726545, Timestamp('2170-02-03 09:00:00'), Timestamp('2170-02-04 08:00:00'), 'BASE', 'Sodium Chloride 0.9%', '001210', '00338004904', 'Floor Stock Bag'], [20726545, Timestamp('2170-02-02 19:00:00'), Timestamp('2170-02-02 19:00:00'), 'MAIN', 'Sodium Chloride 0.9% Flush', '', '0', '10 mL Syringe'], [20726545, Timestamp('2170-02-02 21:00:00'), Timestamp('2170-02-04 21:00:00'), 'MAIN', 'Zolpidem Tartrate', '019187', '60505260400', '5mg Tablet'], [20726545, Timestamp('2170-02-02 20:00:00'), Timestamp('2170-02-04 21:00:00'), 'MAIN', 'Aspirin', '004380', '00904404073', '81mg Tab'], [20726545, Timestamp('2170-02-03 17:00:00'), Timestamp('2170-02-04 21:00:00'), 'MAIN', 'Insulin', '027413', '00002751001', '100 Units / mL - 10 mL Vial'], [20726545, Timestamp('2170-02-03 08:00:00'), Timestamp('2170-02-03 16:00:00'), 'MAIN', 'Insulin', '001740', '00002831501', '100 Units / mL - 10 mL Vial'], [20726545, Timestamp('2170-02-03 17:00:00'), Timestamp('2170-02-04 21:00:00'), 'MAIN', 'Insulin', '001740', '00002831501', '100 Units / mL - 10 mL Vial'], [20726545, Timestamp('2170-02-03 09:00:00'), Timestamp('2170-02-04 08:00:00'), 'MAIN', 'Doxercalciferol', '066970', '58468012601', '2 mcg / 1 mL Vial'], [20726545, Timestamp('2170-02-02 21:00:00'), Timestamp('2170-02-04 21:00:00'), 'MAIN', 'Dextrose 50%', '001989', '00409490234', '25 g / 50 mL Syringe'], [20726545, Timestamp('2170-02-02 21:00:00'), Timestamp('2170-02-03 16:00:00'), 'MAIN', 'Insulin', '027413', '00002751001', '100 Units / mL - 10 mL Vial'], [20726545, Timestamp('2170-02-03 18:00:00'), Timestamp('2170-02-04 21:00:00'), 'MAIN', 'PrednisoLONE Acetate 1% Ophth. Susp.', '007894', '61314063705', '1% Ophthalmic Suspension'], [20726545, Timestamp('2170-02-02 20:00:00'), Timestamp('2170-02-04 21:00:00'), 'MAIN', 'Heparin Flush (100 units/ml)', '006532', '64253033335', '100 Units/mL-5mL Syringe'], [20726545, Timestamp('2170-02-02 08:00:00'), Timestamp('2170-02-02 20:00:00'), 'MAIN', 'FoLIC Acid', '002366', '51079010520', '1 mg Tab'], [20726545, Timestamp('2170-02-03 14:00:00'), Timestamp('2170-02-03 16:00:00'), 'MAIN', 'Insulin', '027413', '00002751001', '100 Units / mL - 10 mL Vial'], [20726545, Timestamp('2170-02-02 19:00:00'), Timestamp('2170-02-02 20:00:00'), 'MAIN', 'Promethazine', '003878', '51079089520', '25 mg Tab'], [20726545, Timestamp('2170-02-02 19:00:00'), Timestamp('2170-02-04 21:00:00'), 'MAIN', 'Sodium Chloride 0.9% Flush', '', '0', '10 mL Syringe'], [20726545, Timestamp('2170-02-03 17:00:00'), Timestamp('2170-02-04 21:00:00'), 'MAIN', 'Insulin', '001740', '00002831501', '100 Units / mL - 10 mL Vial'], [20726545, Timestamp('2170-02-02 20:00:00'), Timestamp('2170-02-04 21:00:00'), 'MAIN', 'Influenza Vaccine Quadrivalent', '075715', '49281041688', '0.5 mL Syringe'], [20726545, Timestamp('2170-02-03 09:00:00'), Timestamp('2170-02-04 21:00:00'), 'MAIN', 'Lidocaine 1%', '003404', '00409427601', '20mL Vial'], [20726545, Timestamp('2170-02-03 08:00:00'), Timestamp('2170-02-04 21:00:00'), 'MAIN', 'Sodium Chloride 0.9% Flush', '', '0', '10 mL Syringe'], [20726545, Timestamp('2170-02-02 22:00:00'), Timestamp('2170-02-03 16:00:00'), 'MAIN', 'Insulin', '001740', '00002831501', '100 Units / mL - 10 mL Vial'], [20726545, Timestamp('2170-02-02 19:00:00'), Timestamp('2170-02-02 19:00:00'), 'MAIN', 'Influenza Vaccine Quadrivalent', '075715', '49281041688', '0.5 mL Syringe'], [20726545, Timestamp('2170-02-03 08:00:00'), Timestamp('2170-02-04 21:00:00'), 'MAIN', 'Heparin Flush (10 units/ml)', '060304', '08290306525', '10 Units/mL - 5 mL Syringe'], [20726545, Timestamp('2170-02-03 09:00:00'), Timestamp('2170-02-04 21:00:00'), 'MAIN', 'Heparin (Hemodialysis)', '006543', '25021040010', '1000 Units/mL- 10mL Vial']]

[]

['medicine']

[[50868, Timestamp('2170-02-03 05:37:00'), Timestamp('2170-02-03 07:43:00'), 'Anion Gap'], [50882, Timestamp('2170-02-03 05:37:00'), Timestamp('2170-02-03 07:43:00'), 'Bicarbonate'], [50893, Timestamp('2170-02-03 05:37:00'), Timestamp('2170-02-03 07:43:00'), 'Calcium, Total'], [50902, Timestamp('2170-02-03 05:37:00'), Timestamp('2170-02-03 07:43:00'), 'Chloride'], [50912, Timestamp('2170-02-03 05:37:00'), Timestamp('2170-02-03 07:43:00'), 'Creatinine'], [50920, Timestamp('2170-02-03 05:37:00'), Timestamp('2170-02-03 07:43:00'), 'Estimated GFR (MDRD equation)'], [50931, Timestamp('2170-02-03 05:37:00'), Timestamp('2170-02-03 07:43:00'), 'Glucose'], [50934, Timestamp('2170-02-03 05:37:00'), Timestamp('2170-02-03 07:43:00'), 'H'], [50940, Timestamp('2170-02-03 05:37:00'), Timestamp('2170-02-03 12:22:00'), 'Hepatitis B Surface Antibody'], [50941, Timestamp('2170-02-03 05:37:00'), Timestamp('2170-02-03 12:22:00'), 'Hepatitis B Surface Antigen'], [50942, Timestamp('2170-02-03 05:37:00'), Timestamp('2170-02-03 12:22:00'), 'Hepatitis B Virus Core Antibody'], [50943, Timestamp('2170-02-03 05:37:00'), Timestamp('2170-02-03 12:22:00'), 'Hepatitis C Virus Antibody'], [50947, Timestamp('2170-02-03 05:37:00'), Timestamp('2170-02-03 07:43:00'), 'I'], [50960, Timestamp('2170-02-03 05:37:00'), Timestamp('2170-02-03 07:43:00'), 'Magnesium'], [50970, Timestamp('2170-02-03 05:37:00'), Timestamp('2170-02-03 07:43:00'), 'Phosphate'], [50971, Timestamp('2170-02-03 05:37:00'), Timestamp('2170-02-03 07:43:00'), 'Potassium'], [50983, Timestamp('2170-02-03 05:37:00'), Timestamp('2170-02-03 07:43:00'), 'Sodium'], [51006, Timestamp('2170-02-03 05:37:00'), Timestamp('2170-02-03 07:43:00'), 'Urea Nitrogen'], [51657, Timestamp('2170-02-03 05:37:00'), Timestamp('2170-02-03 12:22:00'), 'HPE1'], [51658, Timestamp('2170-02-03 05:37:00'), Timestamp('2170-02-03 12:22:00'), 'HPE2'], [51659, Timestamp('2170-02-03 05:37:00'), Timestamp('2170-02-03 12:22:00'), 'HPE3'], [51663, Timestamp('2170-02-03 05:37:00'), Timestamp('2170-02-03 12:22:00'), 'HPE7'], [51678, Timestamp('2170-02-03 05:37:00'), Timestamp('2170-02-03 07:43:00'), 'L'], [51221, Timestamp('2170-02-03 05:37:00'), Timestamp('2170-02-03 06:50:00'), 'Hematocrit'], [51222, Timestamp('2170-02-03 05:37:00'), Timestamp('2170-02-03 06:50:00'), 'Hemoglobin'], [51248, Timestamp('2170-02-03 05:37:00'), Timestamp('2170-02-03 06:50:00'), 'MCH'], [51249, Timestamp('2170-02-03 05:37:00'), Timestamp('2170-02-03 06:50:00'), 'MCHC'], [51250, Timestamp('2170-02-03 05:37:00'), Timestamp('2170-02-03 06:50:00'), 'MCV'], [51265, Timestamp('2170-02-03 05:37:00'), Timestamp('2170-02-03 06:50:00'), 'Platelet Count'], [51277, Timestamp('2170-02-03 05:37:00'), Timestamp('2170-02-03 06:50:00'), 'RDW'], [51279, Timestamp('2170-02-03 05:37:00'), Timestamp('2170-02-03 06:50:00'), 'Red Blood Cells'], [51301, Timestamp('2170-02-03 05:37:00'), Timestamp('2170-02-03 06:50:00'), 'White Blood Cells'], [52172, Timestamp('2170-02-03 05:37:00'), Timestamp('2170-02-03 06:50:00'), 'RDW-SD']]

Question: A 43 F is admitted. He/she says he/she has Right eye vitrectomy . History of illness: Ms. ___ is a ___ woman with T1DM c/b severe retinopathy and gastroparesis s/p GJ tube and recent admission for DKA, ESRD on HD with AV graft, RA, and HTN who is transferred to Medicine after a vitrectomy for hemorrhage and retinal detachment, for medical management including hemodialysis. Ms. ___ was admitted to ___ on ___ for gastroparesis and was discharged on ___. She presented with constant vague abdominal pain with nausea and vomiting with poor PO intake after her dialysis on ___. She noted she had bowel movements. She was admitted for poorly controlled T1DM and DKA likely secondary to gastroparesis, and was treated by ___ protocol and seen by Endocrinology there. She was referred by her PCP for severe proliferative retinopathy and macula-threatening traction retinal detachment in both eyes, and was seen by Ophthalmology on ___. As her vision was ___ in the right eye the decision was made to intervene operatively with 27-gauge pars plana vitrectomy with membrane peel and endolaser in the right eye (OD) but to plan for laser photocoagulation on the left eye (OS) in the future. On ___ AM, she underwent a vitrectomy in the right eye(OD) as well as severe proliferative diabetic retinopathy in the right eye (OD). She underwent panretinal photocoagulation treatment and tolerated the procedure and general anesthesia well. She denies any fever, chills, chest pain, or shortness of breath. Her nausea/vomiting and ___ abdominal pain are at her baseline. Her ESRD is currently controlled with ESRD. As she has had poor peripheral venous access she has a Port-a-cath in place. She undergoes Hemodialysis every ___ in ___ has not had HD since ___. She has a history of RA and had a prednisone taper from ___ Rheumatology in early ___. For her gastroparesis, she last had a G-J tube exchanged at ___ on ___. She notes she gets tube feeds at 50 mL/h overnight from 9pm to 9am. She uses her J-tube for tube feeds and G-tube for venting (draining to gravity) when nauseous. Upon arrival to the floor, the patient is tired but pleasant. She notes ___ pain at the R eye not radiating to the L eye, and ___ abdominal pain consistent with her baseline pain. Past Medical History: PAST MEDICAL HISTORY: - Hypertension - Hyperlipidemia - End Stage Renal Disease (ESRD) on Hemodialysis - Type 1 Diabetes Mellitus complicated by: - retinopathy - neuropathy - Gastroparesis with GJ tube - Rheumatoid Arthritis c/b multiple pulmonary nodules + recurrent pleural effusions - Fibromyalgia - Depression - Pulmonary Nodules - Tardive dyskinesia ___ metoclopramide - MRSA - DJD - Depression PAST SURGICAL HISTORY: - R eye vitrectomy ___ - R knee surgery - Carpal tunnel release x2 - bilateral shoulder surgery - Hysterectomy - Multiple ex-laps for endometriosis - Appendectomy Social History: ___ Family History: no history of malignancy or cardiac disease. mother died of "sepsis" Allergies: Relafen / Leflunomide / metoclopramide / ceftriaxone What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Ondansetron Pantoprazole Ferric Gluconate FLUoxetine LORazepam Glucagon Heparin (Hemodialysis) FLUoxetine LORazepam Lisinopril amLODIPine Insulin HYDROmorphone (Dilaudid) Heparin Bethanechol Promethazine Pantoprazole Glucose Gel Heparin Acetaminophen Ondansetron Rosuvastatin Calcium Heparin Flush (10 units/ml) Sodium Chloride 0.9% Flush Sodium Chloride 0.9% Sodium Chloride 0.9% Flush Zolpidem Tartrate Aspirin Insulin Insulin Insulin Doxercalciferol Dextrose 50% Insulin PrednisoLONE Acetate 1% Ophth. Susp. Heparin Flush (100 units/ml) FoLIC Acid Insulin Promethazine Sodium Chloride 0.9% Flush Insulin Influenza Vaccine Quadrivalent Lidocaine 1% Sodium Chloride 0.9% Flush Insulin Influenza Vaccine Quadrivalent Heparin Flush (10 units/ml) Heparin (Hemodialysis) Target Lab Orders: Anion Gap Bicarbonate Calcium, Total Chloride Creatinine Estimated GFR (MDRD equation) Glucose H Hepatitis B Surface Antibody Hepatitis B Surface Antigen Hepatitis B Virus Core Antibody Hepatitis C Virus Antibody I Magnesium Phosphate Potassium Sodium Urea Nitrogen HPE1 HPE2 HPE3 HPE7 L Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells RDW-SD Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : Information for Outpatient ___ woman with T1DM c/b severe retinopathy and gastroparesis s/p GJ tube and recent admission for DKA, ESRD on HD with AV graft, RA, and HTN who is transferred to Medicine after a vitrectomy for retinopathy and retinal detachment, for medical management including hemodialysis. #RIGHT EYE VITRECTOMY Patient had OD vitrectomy on ___ under general anesthesia due to gastroparesis. Tolerated procedure/anesthesia well. Eye patch in place. Seen by Ophthalmology on ___ day 1, concern for continued retinal detachment in right eye. Seen in Ophthalmology clinic on POD2 with plan for outpatient follow-up on POD6. #ESRD ON HEMODIALYSIS Patient with elevated BUN, Cr, K, PO4 and systolic BP on ___ having not had dialysis since ___. Got HD on ___ with improvement in electrolytes and HTN. #GASTROPARESIS Patient tolerated general anesthesia, tolerating clear liquids PO and tube feeds through J-tube. #TYPE 1 DIABETES MELLITUS Poor control of FSBG on home insulin lispro/NPH regimen, with FSBGs 56-340 in hospital. Patient notes diabetes is followed by PCP but will switch to management at ___. =============================== TRANSITIONAL ISSUES =============================== - Patient needs better control of diabetes as ___ in 300s while patient was inpatient (but also hypoglycemic to 56 and asymptomatic). Will need close follow up for this. - Poor control of blood glucose with persistent hyperglycemia on current, unclear home insulin regimen. Insulin dosing/regimen should be clarified/improved as outpatient. #CONTACT: ___, HCP ___ #CODE: Full Other Results: ======================== ADMISSION LABS ======================== HCV Ab-Negative ___ 05:37AM BLOOD WBC-13.4* RBC-4.16# Hgb-12.7# Hct-39.8# MCV-96 MCH-30.5 MCHC-31.9* RDW-14.6 RDWSD-50.4* Plt ___ ___ 05:37AM BLOOD Glucose-393* UreaN-57* Creat-4.7*# Na-130* K-5.7* Cl-93* HCO3-23 AnGap-20 ___ 05:37AM BLOOD Calcium-9.1 Phos-5.4* Mg-2.9* HBsAg-Negative HBsAb-Negative HBcAb-Negative

2119-04-26 00:07:00

ENGLISH

MARRIED

ASIAN - CHINESE

F

[[20822196, Timestamp('2119-04-26 00:08:26'), '', 'GYN']]

[[{'Medications on Admission': ':\nnone', 'Brief Hospital Course': ':\nOn ___, Ms. ___ was admitted to the gynecology service \nfor observation for a known ectopic pregnancy not responding \nappropriately to multi-dose methotrexate therapy. She had her \nHCG and methotrexate labs repeated while admitted. She was kept \nNPO after midnight for possible surgical intervention if \nindicated. Her HCG downtrended to 9423 and she remained \nclinically stable and thus the decision was made to not proceed \nto the operating room. She was able to tolerate a regular diet \nand was discharged on hospital day 1 in stable condition with \noutpatient follow-up.\n\n', 'Pertinent Results:': '\n___ 10:02PM BLOOD WBC-8.4 RBC-4.11* Hgb-12.4 Hct-35.0* \nMCV-85 MCH-30.0 MCHC-35.2* RDW-12.4 Plt ___\n___ 10:02PM BLOOD Neuts-63.9 ___ Monos-4.3 Eos-2.0 \nBaso-0.5\n___ 10:02PM BLOOD ___ PTT-34.7 ___\n___ 06:10AM BLOOD UreaN-10 Creat-0.5\n___ 06:10AM BLOOD ALT-14 AST-15\n___ 06:10AM BLOOD HCG-9423\n\n', 'Physical Exam:|Physical': '\nOn day of discharge: \nafebrile, vital signs wnl\nGen: well appearing, NAD\nCV: RRR\nResp: CTAB\nAbd: soft, nondistended, nontender\nExt: no calf tenderness, no edema\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\n___ old ___ with right ectopic pregnancy currently on \nmultidose methotrexate presents to triage due to increasing HCGs \nand increasing size in adnexal mass. She did feel tired today, \nbut denies abdominal pain, vaginal bleeding, dizziness, N/V. Her \nonly other complaint today is constipation,\nlast BM 2 days ago. \n\n___ ___\n___ ___\n___ ___\n___ ___ \n\nShe started methotrexate on ___ and has been receiving the \nmultidose regimen with leucovorin rescue. Her last dose of MTX \nwas ___. \n\nHer most recent ultrasound was today which showed "No \nintrauterine gestational sac is identified. 2.4 x 1.7 x 1.7 cm \nechogenic mass in the right adnexa separate from the right \novary, most consistent with a right tubal ectopic pregnancy. \nTrace free fluid in the pelvis." \n\nUltrasound from ___ Ultrasound Consultants date ___ demonstrates "1.7cm extraovarian \nmass/trophoblastic ring seen adjacent to right ovary consistent \nwith a right tubal pregnancy. Trace amount of fluid seen. No \nintrauterine gestational sac seen, anterior myometrium is\nthickened and heterogeneous with tiny cysts seen, suggesting \nadenomyosis. Impression: Right ectopic pregnancy, 1.7cm in size \n(unruptured). Adenomyosis."\n\nPast Medical History:\nPMH: h/o kidney stones s/p stent placement\nPSH: D&C x2\nOBHx: SVD x2; SABx4, ___ s/p D&Cx2\nGYNHx: h/o abnl pap s/p colpo ___, normal since\n\nSocial History:\n___\nFamily History:\nNC\n\n', 'Chief Complaint:|Complaint:': '\nectopic pregnancy\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nNo Known Allergies / Adverse Drug Reactions\n\n'}, '12513220-DS-16', 16, 'obstetrics/gynecology']]

[]

[[20822196, Timestamp('2119-04-26 07:00:00'), Timestamp('2119-04-26 19:00:00'), 'BASE', 'Lactated Ringers', '001187', '00338011704', 'Floor Stock Bag'], [20822196, Timestamp('2119-04-26 01:00:00'), Timestamp('2119-04-26 19:00:00'), 'MAIN', 'Sodium Chloride 0.9% Flush', '', '0', '10 mL Syringe'], [20822196, Timestamp('2119-04-26 01:00:00'), Timestamp('2119-04-26 19:00:00'), 'MAIN', 'Influenza Vaccine Quadrivalent', '072514', '19515089452', '0.5 mL Syringe'], [20822196, Timestamp('2119-04-26 01:00:00'), Timestamp('2119-04-26 19:00:00'), 'MAIN', 'Milk of Magnesia', '003026', '00121043130', '30mL UD Cup'], [20822196, Timestamp('2119-04-26 01:00:00'), Timestamp('2119-04-26 19:00:00'), 'MAIN', 'Bisacodyl', '002947', '00536338101', '5 mg Tab']]

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['obstetrics/gynecology']

[[50861, Timestamp('2119-04-26 06:10:00'), Timestamp('2119-04-26 08:26:00'), 'Alanine Aminotransferase (ALT)'], [50878, Timestamp('2119-04-26 06:10:00'), Timestamp('2119-04-26 08:26:00'), 'Asparate Aminotransferase (AST)'], [50912, Timestamp('2119-04-26 06:10:00'), Timestamp('2119-04-26 08:26:00'), 'Creatinine'], [50946, Timestamp('2119-04-26 06:10:00'), Timestamp('2119-04-26 11:28:00'), 'Human Chorionic Gonadotropin'], [51006, Timestamp('2119-04-26 06:10:00'), Timestamp('2119-04-26 08:26:00'), 'Urea Nitrogen']]

Question: A 32 F is admitted. He/she says he/she has ectopic pregnancy . History of illness: ___ old ___ with right ectopic pregnancy currently on multidose methotrexate presents to triage due to increasing HCGs and increasing size in adnexal mass. She did feel tired today, but denies abdominal pain, vaginal bleeding, dizziness, N/V. Her only other complaint today is constipation, last BM 2 days ago. ___ ___ ___ ___ ___ ___ ___ ___ She started methotrexate on ___ and has been receiving the multidose regimen with leucovorin rescue. Her last dose of MTX was ___. Her most recent ultrasound was today which showed "No intrauterine gestational sac is identified. 2.4 x 1.7 x 1.7 cm echogenic mass in the right adnexa separate from the right ovary, most consistent with a right tubal ectopic pregnancy. Trace free fluid in the pelvis." Ultrasound from ___ Ultrasound Consultants date ___ demonstrates "1.7cm extraovarian mass/trophoblastic ring seen adjacent to right ovary consistent with a right tubal pregnancy. Trace amount of fluid seen. No intrauterine gestational sac seen, anterior myometrium is thickened and heterogeneous with tiny cysts seen, suggesting adenomyosis. Impression: Right ectopic pregnancy, 1.7cm in size (unruptured). Adenomyosis." Past Medical History: PMH: h/o kidney stones s/p stent placement PSH: D&C x2 OBHx: SVD x2; SABx4, ___ s/p D&Cx2 GYNHx: h/o abnl pap s/p colpo ___, normal since Social History: ___ Family History: NC Allergies: No Known Allergies / Adverse Drug Reactions What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Lactated Ringers Sodium Chloride 0.9% Flush Influenza Vaccine Quadrivalent Milk of Magnesia Bisacodyl Target Lab Orders: Alanine Aminotransferase (ALT) Asparate Aminotransferase (AST) Creatinine Human Chorionic Gonadotropin Urea Nitrogen Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : On ___, Ms. ___ was admitted to the gynecology service for observation for a known ectopic pregnancy not responding appropriately to multi-dose methotrexate therapy. She had her HCG and methotrexate labs repeated while admitted. She was kept NPO after midnight for possible surgical intervention if indicated. Her HCG downtrended to 9423 and she remained clinically stable and thus the decision was made to not proceed to the operating room. She was able to tolerate a regular diet and was discharged on hospital day 1 in stable condition with outpatient follow-up. Other Results: ___ 10:02PM BLOOD WBC-8.4 RBC-4.11* Hgb-12.4 Hct-35.0* MCV-85 MCH-30.0 MCHC-35.2* RDW-12.4 Plt ___ ___ 10:02PM BLOOD Neuts-63.9 ___ Monos-4.3 Eos-2.0 Baso-0.5 ___ 10:02PM BLOOD ___ PTT-34.7 ___ ___ 06:10AM BLOOD UreaN-10 Creat-0.5 ___ 06:10AM BLOOD ALT-14 AST-15 ___ 06:10AM BLOOD HCG-9423

2121-06-22 20:02:00

ENGLISH

MARRIED

WHITE

F

[[25563287, Timestamp('2121-06-22 20:30:14'), '', 'OBS']]

[[{'Medications on Admission': ':\nPNV', 'Brief Hospital Course': ':\nMs. ___ was transferred from the ED to Labor and Delivery. \nGiven significant fall and ongoing contractions, decision made \nto monitor x 24 hours on L&D. This was uneventful. At the end \nof this period, she was discharged home with close OB and ortho \nfollow-up.\n\n', 'Pertinent Results:': '\n___ 01:04PM FETAL HGB-0\n___ 01:02PM WBC-10.1* RBC-3.67* HGB-12.0 HCT-35.3 MCV-96 \nMCH-32.7* MCHC-34.0 RDW-13.1 RDWSD-46.1\n___ 01:02PM PLT COUNT-191\n___ 01:02PM ___ PTT-27.2 ___\n___ 01:02PM ___\n\n', 'Physical Exam:|Physical': '\nOn admission:\nVSS\nConstitutional: Gravid well developed, well nourished female,\nappearing in no acute distress \nAbdomen: no tenderness and no masses\nFundus: size equals dates, nontender and not irritable\nEFW:Average\nSterile speculum exam:\n Dilation: Closed\n Effacement: Long\nExtremity: Hand wrapped per ortho\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': "\nMs. ___ ___ yrs. G1, P0, Term0, Preterm0, Abt0, Sab0, Tab0,\nEct0, Live0 at 33w3d presented to ___ for evaluation\nafter fall. \n\nHPI: She was walking her dog this morning with a hot cocoa in \nher\nhand and tripped over uneven sidewalk. She landed on her right\nhand, right wrist and flank. She is not sure if she hit her\nabdomen, but doesn't think so. She was seen in ER and diagnosed\nwith Boxer's fracture of ___ metacarpal. Her hand was splinted\nand she was transferred to L and D for further evaluation. She\ndenies ctx, LOF, VB, abdominal pain. +FM.\n\nPast Medical History:\nPMH: ADHD\nPSH: Wisdom teeth removal\n\nSocial History:\n___\nFamily History:\nNon-contributory.\n\n", 'Chief Complaint:|Complaint:': '\ns/p fall\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nNo Known Allergies / Adverse Drug Reactions\n\n'}, '10053697-DS-7', 7, 'obstetrics/gynecology']]

[["INDICATION: History: ___ with fall and deformity to ring and small finger at\nMTP// ?fx or disloc\n\nTECHNIQUE: Three views of the right hand and three views of the right fifth\ndigit\n\nCOMPARISON: None.\n\nFINDINGS: \n\nThere is minimally displaced fracture involving the neck of the fifth\nmetacarpal, with slight volar angulation of the distal portion, boxer's\nfracture. Subtle deformity of the lateral base of the fifth proximal phalanx\nis of indeterminate age, and a nondisplaced fracture is not excluded. No\nacute fracture is identified elsewhere. There is no dislocation.\n\nIMPRESSION: \n\nMinimally displaced fracture of the distal aspect of the fifth metacarpal\nwithout intra-articular extension, with volar angulation of the distal\nportion.\n\nSubtle deformity of the lateral base of the fifth proximal phalanx is of\nindeterminate age, and a nondisplaced fracture is not excluded. No acute\nfracture identified elsewhere.\n", '10053697-RR-15', 15, 'three views of the right hand and three views of the right fifth\ndigit'], ["INDICATION: History: ___ with fall and deformity to ring and small finger at\nMTP// ?fx or disloc\n\nTECHNIQUE: Three views of the right hand and three views of the right fifth\ndigit\n\nCOMPARISON: None.\n\nFINDINGS: \n\nThere is minimally displaced fracture involving the neck of the fifth\nmetacarpal, with slight volar angulation of the distal portion, boxer's\nfracture. Subtle deformity of the lateral base of the fifth proximal phalanx\nis of indeterminate age, and a nondisplaced fracture is not excluded. No\nacute fracture is identified elsewhere. There is no dislocation.\n\nIMPRESSION: \n\nMinimally displaced fracture of the distal aspect of the fifth metacarpal\nwithout intra-articular extension, with volar angulation of the distal\nportion.\n\nSubtle deformity of the lateral base of the fifth proximal phalanx is of\nindeterminate age, and a nondisplaced fracture is not excluded. No acute\nfracture identified elsewhere.\n", '10053697-RR-16', 16, 'three views of the right hand and three views of the right fifth\ndigit']]

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[]

['obstetrics/gynecology']

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Question: A 32 F is admitted. He/she says he/she has s/p fall . History of illness: Ms. ___ ___ yrs. G1, P0, Term0, Preterm0, Abt0, Sab0, Tab0, Ect0, Live0 at 33w3d presented to ___ for evaluation after fall. HPI: She was walking her dog this morning with a hot cocoa in her hand and tripped over uneven sidewalk. She landed on her right hand, right wrist and flank. She is not sure if she hit her abdomen, but doesn't think so. She was seen in ER and diagnosed with Boxer's fracture of ___ metacarpal. Her hand was splinted and she was transferred to L and D for further evaluation. She denies ctx, LOF, VB, abdominal pain. +FM. Past Medical History: PMH: ADHD PSH: Wisdom teeth removal Social History: ___ Family History: Non-contributory. Allergies: No Known Allergies / Adverse Drug Reactions What is the best procedure plan for this patient?

TARGETS Target Prescriptions: NONE Target Lab Orders: NONE Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : Ms. ___ was transferred from the ED to Labor and Delivery. Given significant fall and ongoing contractions, decision made to monitor x 24 hours on L&D. This was uneventful. At the end of this period, she was discharged home with close OB and ortho follow-up. Other Results: ___ 01:04PM FETAL HGB-0 ___ 01:02PM WBC-10.1* RBC-3.67* HGB-12.0 HCT-35.3 MCV-96 MCH-32.7* MCHC-34.0 RDW-13.1 RDWSD-46.1 ___ 01:02PM PLT COUNT-191 ___ 01:02PM ___ PTT-27.2 ___ ___ 01:02PM ___

2123-04-28 19:33:00

ENGLISH

MARRIED

WHITE

F

[[22017070, Timestamp('2123-04-28 19:34:39'), '', 'CMED']]

[[{'Medications on Admission': ':\nThe Preadmission Medication list is accurate and complete.\n1. Mirtazapine 30 mg PO HS \n2. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID \n3. ZyrTEC (cetirizine) 10 mg oral daily \n4. Omeprazole 20 mg PO DAILY \n5. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation \nq4h prn SOB', 'Brief Hospital Course': ':\n___ with history of CAD s/p PCI to RCA in ___ and aortic \nstenosis who presented with non-exertional chest pain, elevated \ncardiac enzymes consistent with ___, now s/p PCI with 2 DES \nplaced in RCA.\n\n# ___: The patient presented with a 4 hour episode of \nnon-exertional cheat pain that resolved on its own. EKG showed Q \nwaves in III, aVF and sub-millimeter ST elevation in II, III, \nand aVF. Peak CK-MB was 19 on arrival and peak TnT was 1.29. She \nunderwent cardiac catheterization on ___ that showed normal \nLVEDP 11, proximal LAD lesion with 50% stenosis, mid LAD lesion \nwith 60-70% stenosis; 80% stenosis of proximal small OM1 off \nLCx; and RCA with 90% mid stenosis and 80% just proximal to PDA. \nTwo DES were placed in RCA rescue balloon angioplasty of the \njailed RPDA, with ultimately normal flow. An echocardiogram \nafter the catheterization showed LVEF of 45-50% with severe \nhypokinesis of the inferior and lateral walls consistent with \nPDA territory. The patient was discharged on aspirin, \nclopidogrel, beta blocker, and atorvastatin. An ACE inhibitor \nwas held due to low systolic blood pressures. The patient will \nneed follow up with cardiology for a stress test in 4 weeks to \nevaluate for ischemia from the residual LAD lesions (CX lesion \nfelt not suitable for PCI).\n\nCHRONIC ISSUES: \n# Asthma: No active issues. She was continued on \nfluticasone/salmeterol \n\n# Gastroesophageal reflux: Switched from omeprazole to \npantoprazole given clopidogrel use\n\n# Aortic stenosis: LVEDP 11 at left heart catheterization, ___ \n1.3 cm2 on echocardiogram\n\nTRANSITIONAL ISSUES:\n- ACE-inhibitor was held at discharge due to SBPs in ___\n- Patient with mid LAD lesion with 60-70% stenosis. Suggest \nstress testing in 4 weeks and if demonstrated ischemia, this \nlesion is suitable for PCI\n- Outpatient cardiac rehabilitation\n\n', 'Pertinent Results:': '\n___ 05:50PM BLOOD WBC-6.5 RBC-4.44 Hgb-13.4 Hct-42.9 MCV-97 \nMCH-30.3 MCHC-31.4 RDW-12.6 Plt ___\n___ 12:10AM BLOOD ___ PTT-35.0 ___\n___ 05:50PM BLOOD Glucose-86 UreaN-11 Creat-0.9 Na-141 \nK-3.3 Cl-103 HCO3-26 AnGap-15\n___ 07:20AM BLOOD Calcium-9.0 Phos-3.8 Mg-2.0\n\n___ 05:50PM BLOOD CK-MB-19* MB Indx-7.3*\n___ 05:50PM BLOOD cTropnT-1.09*\n___ 12:10AM BLOOD CK-MB-14* MB Indx-7.1* cTropnT-1.21*\n___ 07:20AM BLOOD CK-MB-11* MB Indx-7.6* cTropnT-1.29*\n___ 06:55AM BLOOD cTropnT-1.13*\n\n___ 06:55AM BLOOD WBC-4.5 RBC-3.73* Hgb-11.5* Hct-36.7 \nMCV-99* MCH-30.8 MCHC-31.3 RDW-12.9 Plt ___\n___ 06:55AM BLOOD Glucose-99 UreaN-10 Creat-0.6 Na-146* \nK-4.1 Cl-114* HCO3-25 AnGap-11\n___ 06:55AM BLOOD Calcium-8.5 Phos-3.6 Mg-1.9\n\nEKG ___\nSinus rhythm. Delayed R wave progression across the precordium, \nprobably normal variant. Old inferior wall myocardial \ninfarction. Low voltage in the limb leads. No previous tracing \navailable for comparison.\n\nCardiac catheterization ___:\nHemodynamic Measurements (mmHg)\nBaseline\nSite ___ ___ End Mean A Wave V Wave HR\n___\n\nCoronary angiography: right dominant\n LMCA: normal\n LAD: eccentric proximal lesion which does not appear >50%; mid \nfocal lesion 60-70%\n LCX: 80% proximal small OM1 branch with approx 50% disease in \nLCX at origin of branch\n RCA: mid 90% stenosis; 80% just proximal to PDA\nInterventional details\n Change for ___ FR sheath and JR4 guide. RCA lesions crossed with \nProwater wire and severe lesion dilated with 2.0 balloon and \nstented with 2.5x16 Premier stent postdilated to 2.75 mm. \nFollowing this, there appeared to be some distal stent edge \ndissection and the more distal lesion was appreciated. Therefore \nstented with overlapping 2.75x 12 Premier at 14 atm. This \nresulted in occlusion of jailed PDA which was crossed with Pilot \n50 wire and dilated with 2.0 balloon restoring flow with no \nresidual. Transient slow flow treated with ic nicardipine. Final \nresult with no residual, normal flow.\nAssessment & Recommendations\n 1. Successful drug-eluting stent of RCA\n 2. Moderately severe disease of LAD as above. Suggest stress \ntesting and if demonstrated ischemia, these lesions are suitable \nfor PCI\n 3. Severe disease of small OM branch not suitable for PCI\n 4. Continue aspirin indefinitely and clopidogrel minimum ___ \nyear.\n 5. Monitor and follow enzymes overnight.\n\nEchocardiogram ___:\nThe left atrium and right atrium are normal in cavity size. No \natrial septal defect is seen by 2D or color Doppler. The \nestimated right atrial pressure is ___ mmHg. Left ventricular \nwall thicknesses and cavity size are normal. There is mild \nregional left ventricular systolic dysfunction with severe \nhypokinesis of the basal half of the inferior and inferolateral \nwalls. The remaining segments contract normally (LVEF = 45-50 \n%). The estimated cardiac index is normal (>=2.5L/min/m2). \nTissue Doppler imaging suggests an increased left ventricular \nfilling pressure (PCWP>18mmHg). Right ventricular chamber size \nand free wall motion are normal. The aortic valve leaflets are \nmoderately thickened. There is mild aortic valve stenosis (valve \narea 1.3 cm2). Trace aortic regurgitation is seen. The mitral \nvalve appears structurally normal with trivial mitral \nregurgitation. Mild (1+) mitral regurgitation is seen. The \nestimated pulmonary artery systolic pressure is high normal. \nThere is no pericardial effusion.\nIMPRESSION: Normal left ventricular cavity size with regional \nsystolic dysfunction most c/w CAD (PDA distribution). Mild \nmitral regurgitation most likely due to papillary muscle \ndysfunction.\n\n', 'Physical Exam:|Physical': '\nOn admission \nGENERAL: WDWN elderly Caucasian woman in NAD. Oriented x3. Mood, \naffect appropriate.\nVS: T 97.7, BP 100/65, HR 70, RR 18, SaO2 100% on RA\nHEENT: NCAT. Sclerae anicteric. PERRL, EOMI. Conjunctivae were \npink, no pallor or cyanosis of the oral mucosa. No xanthelasma.\nNECK: Supple with JVP difficult to appreciate due to body \nhabitus.\nCARDIAC: RR, III/VI SEM throughout precordium, most appreciably \nat RUSB.\nLUNGS: No chest wall deformities, scoliosis or kyphosis. Resp \nwere unlabored, no accessory muscle use. CTAB--no crackles, \nwheezes or rhonchi.\nABDOMEN: Soft, non-tender, not distended. No HSM. \nEXTREMITIES: No no clubbing, cyanosis or edema. No femoral \nbruits. \nSKIN: Squamous cell carcinoma x2 involving inner thighs \nbilaterally. No stasis dermatitis, ulcers, scars, or xanthomas.\n\nAt discharge\nGENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate. \nVSS, SBP ___, HR ___\nNECK: No JVD \nCARDIAC: RR, III/VI SEM at ___. \nLUNGS: CTAB \nABDOMEN: Soft, non-tender, not distended. No HSM. \nEXTREMITIES: No edema\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\nMs. ___ is an ___ with history of CAD S/P PCI to RCA in \n___ and "mild" aortic stenosis ___ unavailable) who initially \npresented to an outside hospital with right-sided chest pain and \nwas transferred for further management of ___.\n\nShe was in her usual state of health until the day prior to \nadmission, when at approximately 4 am she developed sudden-onset \nright-sided chest "pressure" of uncertain intensity radiating to \nher right upper extremity, awakening her from sleep. Chest \npressure persisted uninterrupted for approximately 4 hours, \nresolving spontaneously thereafter and unassociated with \nlightheadedness, nausea, diaphoresis, or palpitations. She does \nnot recall her past anginal equivalent. Throughout the day prior \nto admission, she continued to feel "lousy" in a way she has \ndifficulty describing, endorsing only exertional lightheadedness \nand poor appetite. On the day of admission, she presented to her \nprimary care physician for routine preoperative evaluation in \nanticipation of elective resection of squamous cell carcinoma \ninvolving her lower extremities bilaterally and reported \nsensation of chest pressure, which had not recurred. She was \nadvised to proceed to the ___ for further evaluation. \nAt baseline, she is highly functional, denying chest pain at \nrest or on exertion, though she does experience occasional \nexertional dyspnea with strenuous housework, requiring her to \npause "after every project." She denies PND, orthopnea, or \nperipheral edema. She notes that she discontinued aspirin some \nmonths ago in discussion with her cardiologist due to abdominal \ndiscomfort attributed to gastroesophageal reflux/gastritis.\n\nIn the ___, initial vital signs were as follows: T 98, \nHR 82, BP 102/63, RR 18, SaO2 100% RA. Labs were notable for TnI \nof 4.83, platelets of 124 and otherwise unremarkable CBC, \nunremarkable Chem7, AST/ALT of 108/60, TBili of 1.4, and AlkP of \n102. EKG was interpreted as demonstrating "slight" ST elevation \nin III and aVF, Q waves in III and avF, and poor R wave \nprogression. AP CXR was negative for an acute cardiopulmonary \nprocess. She received aspirin 324 mg, clopidogrel 600 mg, \nenoxaparin 80 mg, and atorvastatin 80 mg prior to transfer to \n___ for further management of ___.\n\nIn the ED intial vital signs were as follows: T 96.0, HR 70, BP \n102/67, RR 18, SaO2 99% on RA. Admission labs were notable for \nTnT of 1.09, platelets of 129 and otherwise unremarkable CBC, \nand K of 3.3 and otherwise unremarkable Chem7. EKG was \ninterpreted as suggestive of inferoposterior MI. She received no \nfurther medications prior to admission for ___, but received \nNS 500 cc IV x2 for systolic blood pressure in the ___. She was \nseen in the ED by cardiology attending Dr. ___, with admission \nadvised for cardiac catheterization in the morning. Vital signs \nat transfer were as follows: BR 71, BP 94/57, RR 18, SaO2 99% on \nRA. On arrival to the cardiology ward, she was chest pain-free \nwithout complaints.\n\nPast Medical History:\n1. CAD RISK FACTORS: (-)Diabetes, (-)Dyslipidemia, \n(-)Hypertension\n2. CARDIAC HISTORY:\n- CABG: None\n- PERCUTANEOUS CORONARY INTERVENTIONS: PCI to RCA in ___\n- PACING/ICD: None\n- "Mild" aortic stenosis\n3. OTHER PAST MEDICAL HISTORY:\n-Asthma\n-Right sided lumbar radiculopathy\n-Breast cancer, Left, s/p lumpectomy and XRT in ___ at ___ (no \nchemo or hormonal therapy)\n-Ovarian abscess\n-Depression\n-Glucose intolerance\n-Colon polyps\n-S/P total abdominal hysterectomy-bilateral salpingooophorectomy\n\nSocial History:\n___\nFamily History:\nSon with recent ___.\n\n', 'Chief Complaint:|Complaint:': '\nChest pain\n\n', 'Attending:': ' ___\n\n', 'Allergies:': ' \nNo Known Allergies / Adverse Drug Reactions\n\n'}, '18573395-DS-19', 19, 'medicine']]

[]

[[22017070, Timestamp('2123-04-29 01:00:00'), Timestamp('2123-04-29 19:00:00'), 'BASE', '5% Dextrose', '', '0', 'HEPARIN BASE'], [22017070, Timestamp('2123-04-29 01:00:00'), Timestamp('2123-04-29 19:00:00'), 'MAIN', 'Heparin Sodium', '060301', '00264958720', '25,000 unit Premix Bag'], [22017070, Timestamp('2123-04-29 08:00:00'), Timestamp('2123-04-29 10:00:00'), 'MAIN', 'Omeprazole', '033530', '00904568461', '20mg DR Capsule'], [22017070, Timestamp('2123-04-29 10:00:00'), Timestamp('2123-04-30 09:00:00'), 'MAIN', 'Potassium Chloride', '001275', '00245004101', '10mEq ER Tablet'], [22017070, Timestamp('2123-04-29 08:00:00'), Timestamp('2123-04-30 21:00:00'), 'MAIN', 'Atorvastatin', '045772', '00071015892', '80mg Tablet'], [22017070, Timestamp('2123-04-29 08:00:00'), Timestamp('2123-04-30 10:00:00'), 'MAIN', 'Aspirin', '004376', '68016001129', '325mg Tablet'], [22017070, Timestamp('2123-04-29 00:00:00'), Timestamp('2123-04-30 21:00:00'), 'MAIN', 'Fluticasone-Salmeterol Diskus (250/50) ', '043367', '00173069604', '250/50mcg Diskus'], [22017070, Timestamp('2123-04-29 01:00:00'), Timestamp('2123-04-29 19:00:00'), 'MAIN', 'Heparin', '006549', '63323026201', '5000 Units / mL- 1mL Vial'], [22017070, Timestamp('2123-04-29 11:00:00'), Timestamp('2123-04-30 06:00:00'), 'MAIN', 'Metoprolol Tartrate', '050631', '51079025520', '12.5 mg Half Tablet'], [22017070, Timestamp('2123-04-29 11:00:00'), Timestamp('2123-04-30 21:00:00'), 'MAIN', 'Pantoprazole', '027462', '00008084199', '40mg Tablet'], [22017070, Timestamp('2123-04-29 00:00:00'), Timestamp('2123-04-30 21:00:00'), 'MAIN', 'Mirtazapine', '046451', '00052010730', '30 mg Tab'], [22017070, Timestamp('2123-04-29 16:00:00'), Timestamp('2123-04-30 02:00:00'), 'BASE', '0.45% Sodium Chloride', '001209', '00338004304', '1000mL Bag'], [22017070, Timestamp('2123-04-29 02:00:00'), Timestamp('2123-04-30 01:00:00'), 'MAIN', 'Potassium Chloride', '001275', '00245004101', '10mEq ER Tablet'], [22017070, Timestamp('2123-04-28 23:00:00'), Timestamp('2123-04-30 21:00:00'), 'MAIN', 'Sodium Chloride 0.9% Flush', '', '0', '10 mL Syringe']]

[]

['medicine']

[[51237, Timestamp('2123-04-29 00:10:00'), Timestamp('2123-04-29 00:45:00'), 'INR(PT)'], [51274, Timestamp('2123-04-29 00:10:00'), Timestamp('2123-04-29 00:45:00'), 'PT'], [51275, Timestamp('2123-04-29 00:10:00'), Timestamp('2123-04-29 00:45:00'), 'PTT'], [50908, Timestamp('2123-04-29 00:10:00'), Timestamp('2123-04-29 01:32:00'), 'CK-MB Index'], [50910, Timestamp('2123-04-29 00:10:00'), Timestamp('2123-04-29 01:32:00'), 'Creatine Kinase (CK)'], [50911, Timestamp('2123-04-29 00:10:00'), Timestamp('2123-04-29 01:32:00'), 'Creatine Kinase, MB Isoenzyme'], [51003, Timestamp('2123-04-29 00:10:00'), Timestamp('2123-04-29 01:32:00'), 'Troponin T'], [51221, Timestamp('2123-04-29 07:20:00'), Timestamp('2123-04-29 08:31:00'), 'Hematocrit'], [51222, Timestamp('2123-04-29 07:20:00'), Timestamp('2123-04-29 08:31:00'), 'Hemoglobin'], [51248, Timestamp('2123-04-29 07:20:00'), Timestamp('2123-04-29 08:31:00'), 'MCH'], [51249, Timestamp('2123-04-29 07:20:00'), Timestamp('2123-04-29 08:31:00'), 'MCHC'], [51250, Timestamp('2123-04-29 07:20:00'), Timestamp('2123-04-29 08:31:00'), 'MCV'], [51265, Timestamp('2123-04-29 07:20:00'), Timestamp('2123-04-29 08:31:00'), 'Platelet Count'], [51277, Timestamp('2123-04-29 07:20:00'), Timestamp('2123-04-29 08:31:00'), 'RDW'], [51279, Timestamp('2123-04-29 07:20:00'), Timestamp('2123-04-29 08:31:00'), 'Red Blood Cells'], [51301, Timestamp('2123-04-29 07:20:00'), Timestamp('2123-04-29 08:31:00'), 'White Blood Cells'], [50868, Timestamp('2123-04-29 07:20:00'), Timestamp('2123-04-29 09:03:00'), 'Anion Gap'], [50882, Timestamp('2123-04-29 07:20:00'), Timestamp('2123-04-29 09:03:00'), 'Bicarbonate'], [50893, Timestamp('2123-04-29 07:20:00'), Timestamp('2123-04-29 09:03:00'), 'Calcium, Total'], [50902, Timestamp('2123-04-29 07:20:00'), Timestamp('2123-04-29 09:03:00'), 'Chloride'], [50908, Timestamp('2123-04-29 07:20:00'), Timestamp('2123-04-29 09:03:00'), 'CK-MB Index'], [50910, Timestamp('2123-04-29 07:20:00'), Timestamp('2123-04-29 09:03:00'), 'Creatine Kinase (CK)'], [50911, Timestamp('2123-04-29 07:20:00'), Timestamp('2123-04-29 09:03:00'), 'Creatine Kinase, MB Isoenzyme'], [50912, Timestamp('2123-04-29 07:20:00'), Timestamp('2123-04-29 09:03:00'), 'Creatinine'], [50931, Timestamp('2123-04-29 07:20:00'), Timestamp('2123-04-29 09:03:00'), 'Glucose'], [50960, Timestamp('2123-04-29 07:20:00'), Timestamp('2123-04-29 09:03:00'), 'Magnesium'], [50970, Timestamp('2123-04-29 07:20:00'), Timestamp('2123-04-29 09:03:00'), 'Phosphate'], [50971, Timestamp('2123-04-29 07:20:00'), Timestamp('2123-04-29 09:03:00'), 'Potassium'], [50983, Timestamp('2123-04-29 07:20:00'), Timestamp('2123-04-29 09:03:00'), 'Sodium'], [51003, Timestamp('2123-04-29 07:20:00'), Timestamp('2123-04-29 09:03:00'), 'Troponin T'], [51006, Timestamp('2123-04-29 07:20:00'), Timestamp('2123-04-29 09:03:00'), 'Urea Nitrogen'], [51237, Timestamp('2123-04-29 07:20:00'), Timestamp('2123-04-29 08:41:00'), 'INR(PT)'], [51274, Timestamp('2123-04-29 07:20:00'), Timestamp('2123-04-29 08:41:00'), 'PT'], [51275, Timestamp('2123-04-29 07:20:00'), Timestamp('2123-04-29 08:41:00'), 'PTT']]

Question: A 80 F is admitted. He/she says he/she has Chest pain . History of illness: Ms. ___ is an ___ with history of CAD S/P PCI to RCA in ___ and "mild" aortic stenosis ___ unavailable) who initially presented to an outside hospital with right-sided chest pain and was transferred for further management of ___. She was in her usual state of health until the day prior to admission, when at approximately 4 am she developed sudden-onset right-sided chest "pressure" of uncertain intensity radiating to her right upper extremity, awakening her from sleep. Chest pressure persisted uninterrupted for approximately 4 hours, resolving spontaneously thereafter and unassociated with lightheadedness, nausea, diaphoresis, or palpitations. She does not recall her past anginal equivalent. Throughout the day prior to admission, she continued to feel "lousy" in a way she has difficulty describing, endorsing only exertional lightheadedness and poor appetite. On the day of admission, she presented to her primary care physician for routine preoperative evaluation in anticipation of elective resection of squamous cell carcinoma involving her lower extremities bilaterally and reported sensation of chest pressure, which had not recurred. She was advised to proceed to the ___ for further evaluation. At baseline, she is highly functional, denying chest pain at rest or on exertion, though she does experience occasional exertional dyspnea with strenuous housework, requiring her to pause "after every project." She denies PND, orthopnea, or peripheral edema. She notes that she discontinued aspirin some months ago in discussion with her cardiologist due to abdominal discomfort attributed to gastroesophageal reflux/gastritis. In the ___, initial vital signs were as follows: T 98, HR 82, BP 102/63, RR 18, SaO2 100% RA. Labs were notable for TnI of 4.83, platelets of 124 and otherwise unremarkable CBC, unremarkable Chem7, AST/ALT of 108/60, TBili of 1.4, and AlkP of 102. EKG was interpreted as demonstrating "slight" ST elevation in III and aVF, Q waves in III and avF, and poor R wave progression. AP CXR was negative for an acute cardiopulmonary process. She received aspirin 324 mg, clopidogrel 600 mg, enoxaparin 80 mg, and atorvastatin 80 mg prior to transfer to ___ for further management of ___. In the ED intial vital signs were as follows: T 96.0, HR 70, BP 102/67, RR 18, SaO2 99% on RA. Admission labs were notable for TnT of 1.09, platelets of 129 and otherwise unremarkable CBC, and K of 3.3 and otherwise unremarkable Chem7. EKG was interpreted as suggestive of inferoposterior MI. She received no further medications prior to admission for ___, but received NS 500 cc IV x2 for systolic blood pressure in the ___. She was seen in the ED by cardiology attending Dr. ___, with admission advised for cardiac catheterization in the morning. Vital signs at transfer were as follows: BR 71, BP 94/57, RR 18, SaO2 99% on RA. On arrival to the cardiology ward, she was chest pain-free without complaints. Past Medical History: 1. CAD RISK FACTORS: (-)Diabetes, (-)Dyslipidemia, (-)Hypertension 2. CARDIAC HISTORY: - CABG: None - PERCUTANEOUS CORONARY INTERVENTIONS: PCI to RCA in ___ - PACING/ICD: None - "Mild" aortic stenosis 3. OTHER PAST MEDICAL HISTORY: -Asthma -Right sided lumbar radiculopathy -Breast cancer, Left, s/p lumpectomy and XRT in ___ at ___ (no chemo or hormonal therapy) -Ovarian abscess -Depression -Glucose intolerance -Colon polyps -S/P total abdominal hysterectomy-bilateral salpingooophorectomy Social History: ___ Family History: Son with recent ___. Allergies: No Known Allergies / Adverse Drug Reactions What is the best procedure plan for this patient?

TARGETS Target Prescriptions: 5% Dextrose Heparin Sodium Omeprazole Potassium Chloride Atorvastatin Aspirin Fluticasone-Salmeterol Diskus (250/50) Heparin Metoprolol Tartrate Pantoprazole Mirtazapine 0.45% Sodium Chloride Potassium Chloride Sodium Chloride 0.9% Flush Target Lab Orders: INR(PT) PT PTT CK-MB Index Creatine Kinase (CK) Creatine Kinase, MB Isoenzyme Troponin T Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells Anion Gap Bicarbonate Calcium, Total Chloride CK-MB Index Creatine Kinase (CK) Creatine Kinase, MB Isoenzyme Creatinine Glucose Magnesium Phosphate Potassium Sodium Troponin T Urea Nitrogen INR(PT) PT PTT Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : ___ with history of CAD s/p PCI to RCA in ___ and aortic stenosis who presented with non-exertional chest pain, elevated cardiac enzymes consistent with ___, now s/p PCI with 2 DES placed in RCA. # ___: The patient presented with a 4 hour episode of non-exertional cheat pain that resolved on its own. EKG showed Q waves in III, aVF and sub-millimeter ST elevation in II, III, and aVF. Peak CK-MB was 19 on arrival and peak TnT was 1.29. She underwent cardiac catheterization on ___ that showed normal LVEDP 11, proximal LAD lesion with 50% stenosis, mid LAD lesion with 60-70% stenosis; 80% stenosis of proximal small OM1 off LCx; and RCA with 90% mid stenosis and 80% just proximal to PDA. Two DES were placed in RCA rescue balloon angioplasty of the jailed RPDA, with ultimately normal flow. An echocardiogram after the catheterization showed LVEF of 45-50% with severe hypokinesis of the inferior and lateral walls consistent with PDA territory. The patient was discharged on aspirin, clopidogrel, beta blocker, and atorvastatin. An ACE inhibitor was held due to low systolic blood pressures. The patient will need follow up with cardiology for a stress test in 4 weeks to evaluate for ischemia from the residual LAD lesions (CX lesion felt not suitable for PCI). CHRONIC ISSUES: # Asthma: No active issues. She was continued on fluticasone/salmeterol # Gastroesophageal reflux: Switched from omeprazole to pantoprazole given clopidogrel use # Aortic stenosis: LVEDP 11 at left heart catheterization, ___ 1.3 cm2 on echocardiogram TRANSITIONAL ISSUES: - ACE-inhibitor was held at discharge due to SBPs in ___ - Patient with mid LAD lesion with 60-70% stenosis. Suggest stress testing in 4 weeks and if demonstrated ischemia, this lesion is suitable for PCI - Outpatient cardiac rehabilitation Other Results: ___ 05:50PM BLOOD WBC-6.5 RBC-4.44 Hgb-13.4 Hct-42.9 MCV-97 MCH-30.3 MCHC-31.4 RDW-12.6 Plt ___ ___ 12:10AM BLOOD ___ PTT-35.0 ___ ___ 05:50PM BLOOD Glucose-86 UreaN-11 Creat-0.9 Na-141 K-3.3 Cl-103 HCO3-26 AnGap-15 ___ 07:20AM BLOOD Calcium-9.0 Phos-3.8 Mg-2.0 ___ 05:50PM BLOOD CK-MB-19* MB Indx-7.3* ___ 05:50PM BLOOD cTropnT-1.09* ___ 12:10AM BLOOD CK-MB-14* MB Indx-7.1* cTropnT-1.21* ___ 07:20AM BLOOD CK-MB-11* MB Indx-7.6* cTropnT-1.29* ___ 06:55AM BLOOD cTropnT-1.13* ___ 06:55AM BLOOD WBC-4.5 RBC-3.73* Hgb-11.5* Hct-36.7 MCV-99* MCH-30.8 MCHC-31.3 RDW-12.9 Plt ___ ___ 06:55AM BLOOD Glucose-99 UreaN-10 Creat-0.6 Na-146* K-4.1 Cl-114* HCO3-25 AnGap-11 ___ 06:55AM BLOOD Calcium-8.5 Phos-3.6 Mg-1.9 EKG ___ Sinus rhythm. Delayed R wave progression across the precordium, probably normal variant. Old inferior wall myocardial infarction. Low voltage in the limb leads. No previous tracing available for comparison. Cardiac catheterization ___: Hemodynamic Measurements (mmHg) Baseline Site ___ ___ End Mean A Wave V Wave HR ___ Coronary angiography: right dominant LMCA: normal LAD: eccentric proximal lesion which does not appear >50%; mid focal lesion 60-70% LCX: 80% proximal small OM1 branch with approx 50% disease in LCX at origin of branch RCA: mid 90% stenosis; 80% just proximal to PDA Interventional details Change for ___ FR sheath and JR4 guide. RCA lesions crossed with Prowater wire and severe lesion dilated with 2.0 balloon and stented with 2.5x16 Premier stent postdilated to 2.75 mm. Following this, there appeared to be some distal stent edge dissection and the more distal lesion was appreciated. Therefore stented with overlapping 2.75x 12 Premier at 14 atm. This resulted in occlusion of jailed PDA which was crossed with Pilot 50 wire and dilated with 2.0 balloon restoring flow with no residual. Transient slow flow treated with ic nicardipine. Final result with no residual, normal flow. Assessment & Recommendations 1. Successful drug-eluting stent of RCA 2. Moderately severe disease of LAD as above. Suggest stress testing and if demonstrated ischemia, these lesions are suitable for PCI 3. Severe disease of small OM branch not suitable for PCI 4. Continue aspirin indefinitely and clopidogrel minimum ___ year. 5. Monitor and follow enzymes overnight. Echocardiogram ___: The left atrium and right atrium are normal in cavity size. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is ___ mmHg. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with severe hypokinesis of the basal half of the inferior and inferolateral walls. The remaining segments contract normally (LVEF = 45-50 %). The estimated cardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (valve area 1.3 cm2). Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is high normal. There is no pericardial effusion. IMPRESSION: Normal left ventricular cavity size with regional systolic dysfunction most c/w CAD (PDA distribution). Mild mitral regurgitation most likely due to papillary muscle dysfunction.

2141-06-29 10:30:00

ENGLISH

MARRIED

WHITE

M

[[28966436, Timestamp('2141-06-29 01:07:21'), '', 'ENT'], [28966436, Timestamp('2141-07-01 15:07:15'), 'ENT', 'MED']]

[[{'Medications on Admission': ':\nPer Wife: \n___ ___ prn-ran out\nspiriva daily-intermittent\nibuprofen prn-took aftr ___ ran out\n\n7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) \nCapsule, Delayed Release(E.C.) PO DAILY (Daily). \n8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) \nTablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for \nconstipation. \n9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a \nday) as needed for constipation. \n10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID \n(2 times a day). \n11. Sodium Chloride 1 gram Tablet Sig: Two (2) Tablet PO TID (3 \ntimes a day). \n12. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. \n\nFacility:\n___', 'Brief Hospital Course': ':\n___ old male with h/o HTN, GERD, ETOH abuse with fatty liver, \ntobacco abuse and COPD, h/o seizure ___, recent dx of R SCC \nT1NOMO who was admitted ___ to ENT service and underwent \npartial glossectomy and neck dissection. POD#1 developed ETOH \nwithdrawal treated with ativan, hypoxia and thick phelgm, and \npossible neuro finding of anisocoria/ptosis, then t/f to Gen Med \non ___ for further management (see HPI). Was treated with \nativan for ETOH withdrawal. Neuro felt his anisocoria may have \nbeen old and his ptosis may have be due to the ativan. As his MS \nimproved off ativan, his neuro symptoms resolved. CT head and \nMRI stroke protocol did not show anything concerning. He was \ntreated with levaquin X5days for his pneumonia seen on CXR. He \nwas weaned off oxygen. He remained afebrile. ENT took out drain \nand staples. He recieved ___ and speech therapy. He needs ongoign \n___. He needs ongoing speech therapy as he is only on thin \nliquids and pureed diet at time of discharge. He was hesitant \nbut after convincing was agreeable to discharge to rehab. While \nhere, he had an episode of palpitations on ___ associated with \nCP. He has had these intermittently as outpt but never \ndiagnosed. On EKG was SVT rate 190s, likely AVNRT. Broke with \nlopressor 5mg IV. started on metoprolol 25mg bid. PCP ___. \nOnce more stable, will get referal to EP. Also developed hypoNa, \nlabs c/w SIADH. Fluid restricted 1L and salt tabs and ensure tid \nstarted per renal recs. Na fluctuating between 130-132 at time \nof discharge. Will need Na checks and titration of salt tabs at \nrehab and outpt. His follow up is at post D/c clinic and with \nonc/ENT. He was doing much better by time of discharge. Wife was \nupdated regularly along the way. \n.\nAbove issues are explained in more detail in progress note \nbelow: \n.\nNarrow complex Tachycardia: Occured on ___ for 30min, \nAflutter/RVR vs AVNRT. cant tell apart on EKG, no strip availabe \nat the time of lopressor and cant see rhythm on tele-but on EKG \nit is very regular with rates 180-190s->likley AVNRT. Converted \nwith lopressor 5mg IV X1. NOTE: Associated with chest pain and \nlateral STD on EKG likely demand in setting of underlying CAD. \nPer PCP, pt has h/o "palpitations" that they have never \ndiagnosed. Was ruled out for ACS as cause of chest pain. Was \nstarted on metoprolol 25mg bid. No more recurrence of SVT. On \nTele had frequent APBs, lytes repleted aggressively, and this \nimrpoved as well. Dr. ___, aware and will refer pt to EP \nonce he is more stable. Started on ASA for likely CAD as well. \nCan consider statin as outpt-defered here as pt is noncompliant \nwith meds. \n.\nAcute CAP/Pneumonia: CXR on admission ___ and repeat ___ \nshowed basilar infiltrates and patient had thick sputum as well \nas new hypoxia from baseline and rhonchi on exam. Since was \npresent on admission, treated as CAP. Also had mild COPD \nexacerbation. Improved with Levo 750mg X5days. Remained \nafebrile. Weaned off oxygen. duonebs converted to albuterol prn \nand spiriva continued. \n.\nHyponatremia, SIADH: Na 142->130-132. Initially thought \nhypovolemic given dec PO and Na improved with d/c ___ NS and \ngiving 1L NS. However Na dropped with furthter fluids ___ and \nUNa 212 with UOsm 503 suggests SIADH. likely ___ PNA, post op, \nand decreased solute intake. Renal saw pt while here. Kept on 1L \nfluid restriction, salt tabs started 2g TID, and placed on \nensure TID for increased solute intake. Na is fluctuating \n130-132. Needs q3day checks at rehab to titrate salt tabs, then \nPCP follow up. ___ note, TSH and cortisol was normal. \n.\nAcute Neuro Change: nurse noted ___ sided leaning, anisocoria, L \nptosis am ___. Pt was sedated from ativan overnight and not \nvery responsive. All symptoms have resolved now except v. mild L \nanisocoria but not sure if this is old. Ddx: med effect vs acute \nstroke/TIA vs seizure, though med effect and seizure would not \nexplain anisocoria. CT head w/o anything acute. Neuro saw pt, \nwere not impressed, recommended MRI. MRI ___ did not show \nanything concerning either. His MS and neuro exam was at his \nbaseline rest of hospital stay\n.\nETOH withdrawal: last drink ___ (drinks 1L vodka daily). Has \nh/o withdrawal in ___ when he was admitted for seizure \n(seizure happened while drinking per wife). ___ were \nsimilar then. Here he recieved total 12mg ativan from ___ to \n___, then 2mg from ___ to ___, then 3mg from ___, at \nwhich time ativan was stopped. He was seen by SW and is not \ninterested in quitty. He is kept on mvi/thiamine/folic acid\n.\nThrombocytopnia: Plt counts trended down after admisison to \nNadir 67. Coags normal. LIkely ___ etoh intox. There was no \nevidence of cirrhosis to suggest SM. They improved on their own \nand were 190s on d/c\n.\nPost op delirium: multifactorial: post-op, pneumonia, etoh \nwithdrawal, hypoNa. These issues were treated and patient \nimproved back to his baseline-A&OX3\n.\nDysphagia: typical after partial glossectomy. Was seen by speech \nwhile here, last reevaluation was on day of discharge ___: thin \nliquids okay, but needs to continue pureed meals until POD#14 \nper ENT, meds crushed in pureed, wash food with liquids, q4 oral \ncare. Needs outpt video eval once discharge from rehab. Was on \naspiration precautions\n.\nR tongue SCC: s/p partial glossectomy and R neck dissection \n___. ENT followed after service transfer. drain removed ___, \nstaple removed ___. Wound healing well. He has ___ set up wiht \nDr. ___. He is kept on \noxycodone/tylenol elixer for pain (with bowel regimen)\n.\nGERD: kept on prilosec, but per wife not taking at home, so \nlikely will no continue\n.\nHTN: not on home meds but started metoprolol as above with \nbetter BP/HR control. Should stay on this for his pSVT\n.\ndyslipidemia and likely CAD: not on statin (rx in past but not \ntaking) or ASA-> needs PCP ___ for further eval. started ASA 81. \n\n.\nHypoK/Mag/Phos: persistant for many days likely some refeeding \nfrom chronic ETOHism. \nHe was gressively repleted PO/IV\n.\nFatty liver; LFTs and coags okay\n.\nMacrocytic anemia: etoh related. nl b12/folate. \n.\ndispo/code: full code. HCP wife ___ ___ work ___, updated in detail ___. PCP ___ ___. \nWill be discharged to rehab today. \n\n', 'Pertinent Results:': "\nwbc ___\nhgb 11.3-->10s stable (baseline 12) with MCV 100s\nplt 102->86->69-->192\n.\nChem: Na 142->132-->after initial 1L 134-->130 after 1L more \nIVF-->132-->130->132\nK 3.9 mag 1.4->2.0 with IV mag\nBUN/Creat ___\nCa 8.5\nSOsm 271, UOsm 503->326->398\nUNa 212->122-->88\n.\nAST/ALT ___\nalkphos 90\nTbili 0.5\n.\nb12 342, folate 11.8\nTSH 3.4\ncortisol 13.1\n.\ntrop ___ (aflutter/rvr and chest pain): 0.01-->0.04-->0.03\n.\nINR 1.0\n.\nSputum: >25PMNs, <10epis, 2+ GPCs, Cx sparse OP flora\n.\nUA ___ negative \n.\n.\nImaging/results: \nEKG ___: Narrow complex tachycardia at a rate of 193. \nProbable paroxysmal A-V nodal tachycardia but atrial flutter \nwith 2:1 block cannot be excluded. Right axis deviation. \nPossible anteroseptal myocardial infarction of indeterminate \nage. Possible right ventricular hypertrophy. Non-specific \nrepolarization abnormalities consistent with tachycardia and/or \nischemia. Compared to the \nprevious tracing of ___ normal sinus rhythm at a rate of 89 \nhas given way to the aforementioned tachycardia and the \nventricular rate has doubled \n.\nEKG #2\nNormal sinus rhythm, rate 84. Compared to the previous tracing \nsinus \ntachycardia has replaced narrow complex supraventricular \ntachycardia and the rate has halved. Lateral repolarization \nabnormalities suggesting ischemia have resolved. There is \ncontinued suggestion of anteroseptal myocardial infarction of \nindeterminate age. There is continued right axis deviation and \npossible right ventricular hypertrophy \n.\n\nCXR ___: \nIMPRESSION: Worsening bibasilar lung opacities, concerning for \npneumonia (eg aspiration pneumonia) in the appropriate clinical \nsetting. Persistent small effusions. \n.\n___ CXR: New heterogeneous peribronchial opacification in both \nlower lungs could be due to aspiration, patient with diminished \nrespiratory reserve due to emphysema. Small bilateral pleural \neffusions are new. Heart size normal. Of note, previous left \nupper lobe atelectasis and consolidation has cleared, \ndemonstrating that previously questioned malignancy is unlikely \nin that location \n.\nCT head ___\nFINDINGS: There is no evidence of acute intracranial hemorrhage, \nedema, mass, mass effect, or large vascular territorial \ninfarction. Moderate prominence of the sulci and ventricles, \nunchanged since ___, and is compatible with diffuse \ncortical atrophy, within normal limits for this patient's age. \nThe white matter of the centrum semiovale is relatively \nhypodense, likely representing the sequelae of chronic \nmicrovascular ischemic disease. There is no acute fracture. The \nmiddle ear cavities and included views of the \nparanasal sinuses and mastoid air cells are clear. \n.\nMRI ___. No acute infarction. Extensive chronic microvascular infarcts \nin the supratentorial white matter. \n2. Nonvisualization of flow in the right vertebral artery could \nbe related to its nondominant status. If clinically indicated, \nthis finding may be better assessed by a CTA of the head and \nneck. Alternatively, contrast-enhanced neck MRA could be \nconsidered \n.\nspirometry notes ___\nImpression: Moderate obstructive ventilatory defect with a \nmoderate to marked gas exchange defect. TLC may be \nunderestimated and RV overestimated due to a suboptimal SVC \nmaneuver. Compared to the prior study of ___ the FVC has \ndecreased by 1.28 L (-38%), the TLC has decreased by 1.15 L \n(-17%) and the DLCO has decreased by 4.32 ml/min/mmHg (-30%). \n.\nEcho ___\nThe left atrium is normal in size. No atrial septal defect is \nseen by 2D or color Doppler. Left ventricular wall thickness, \ncavity size and regional/global systolic function are normal \n(LVEF >55%). There is no ventricular septal defect. Right \nventricular chamber size and free wall motion are normal. The \naortic root is mildly dilated at the sinus level. The aortic \nvalve leaflets (3) appear structurally normal with good leaflet \nexcursion and no aortic regurgitation. The mitral valve appears \nstructurally normal with trivial mitral regurgitation. Tricuspid \nregurgitation is present but cannot be quantified. There is mild \npulmonary artery systolic hypertension. There is a \ntrivial/physiologic pericardial effusion\n\n", 'Physical Exam:|Physical': '\nPhysical Exam: \nVitals on transfer: afebrile 97.5 119/79 90 24 98%3L (was \n90%4L before suctioning)\nGen: sedated, arousable, slurred speech\nEyes: both pupils equal size and reactive, L eyelid mild ptosis, \nEOMI, anicteric\nENT: mm dry, tongue swollen and deviated to left post surgical\nNeck: R neck incision clean with staples, wound with drain\nCV: distant, regular, no m appreciated\nResp: CTAB, very distant, +scattered rhonchi, L sided wheezing\nAbd: soft, nontender, nondistended, +BS, no HSM\nLymph: no cervical, axillary, inguinal LAD\nExt: no edema, good peripheral pulses, no cyanosis\nNeuro: A&OX2, please see neuro exam for full neuro exam, no \ntremors\nSkin: incision clean as above\npsych: calm currently\n.\n.\nOn discharge\nVitals: 97.3 134/94 96 18 100%RA\nPain: denies\nAccess: PIV\nGen: awake, doing well, stable slurred speech\nEyes:pupils equal and reactive, b/l droopy eyelids equal and \nnormal for patient, anicteric\nENT: mm dry, tongue R post surgical area healing\nNeck: R neck incision site looks good (staples and drain \nremoved)\nCV: RRR, no m appreciated\nResp: CTAB, very distant, no crackles or wheezing\nAbd: soft, nontender, nondistended, +BS\nExt: no edema\nNeuro: A&OX3, unsteady on feet but strength better, mild \nintention tremor\nSkin: incision clean as above\npsych: calm \n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\n___ old male with h/o HTN, GERD, ETOH abuse with fatty liver, \ntobacco abuse and COPD, h/o seizure ___, recent dx of R ___ \nT1NOMO who was admitted ___ to ENT service. Underwent partial \nglossectomy and neck dissection on ___. Immediate post op \ncourse was uncomplicated. POD#1 evening became acutely \nagitated/combative/tachycardic and there was concern for ETOH \nwithdrawal and DTs. He recieved ativan ___ IV throughout the \nnight for CIWA ___ (12mg total). Also was hypoxic and placed \non O2. This am was more somnolent when nurse ___ in. ___ \nrhonchi and gurgling so she suctioned him. This woke him up a \nbit but he was leaning to the left and found to have L ptosis \nand unreactive L pupil. They couldnt figure out if this was new \nas the nurse was new and wife not at bedside. Neuro was called \nand by the time of their arrival pupil was reactive but pt did \nhave mild ptosis. He did not recieve any more ativan during and \nis more awake. No witnezzed seizure. He is requiring 3L of O2 \nbut his O2 sats have improved during the day with suctioning \n(has thick phlegm). Medicine was consulted for ETOH withdrawal, \nnew neuro symptoms, and hypoxia. Decision made to transfer \npatient to medicine. He has been afebrile. Denies any pain \ncurrenlty. Difficulty to get history because speech is slurred \ndue to surgery and pt is still not fully alert, however, he \nappears oriented and knows where he is and why. Reports drinking \n1L vodka daily. \n.\nMeds on transfer to Medicine\nativan 1mg IV q6\nativan 2mg IV q1 prn CIWA >10\nfolic acid IV\nthiamine IV\nduonebs q6 prn\nspiriva daily\nasa 81\nheparin bid\npercocet ___ prn\nmorphine 2 IV q4prn\n\nPast Medical History:\nper chart\nETOH abuse-1L vodka daily\nCOPD not on home O2\nR tongue SCC dx ___ T1N0M0 \nHTN\nGERD\nseizure ___ (admitted to OSH, thought to be ___ etoh, MRI \nsuboptimal, ?EEG results)\nPulm nodule-?stable per notes\nLUL lung collapse and LAD s/p bronch on ___, neg \nfor malignancy\nFatty liver\nTobacco abuse 2PPD ___, quit ___ ago\nh/o palpitations\nR eye cataract sugery a couple years ago\n\nSocial History:\n___\nFamily History:\nfather died of CaP age ___\nMother died age ___\nTwo healthy brothers\nno FH of H&N cancers\n\n', 'Chief Complaint:|Complaint:': '\n___ ADMISSION HISTORY AND PHYSICAL\nPATIENT BEING TRANSFERED FROM ENT SERVICE\n.\n.\nPCP: ___. ___\n.\n.\nCC: ETOH WITHDRAWAL, HYPOXIA\ntransfer to medicine from ENT service\n.\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nPatient recorded as having No Known Allergies to Drugs\n\n'}, '12395743-DS-12', 12, 'medicine']]

[['AP CHEST 9:25 ___\n\nHISTORY: COPD and hypoxia. Rule out aspiration.\n\nIMPRESSION: AP chest compared to ___ and ___, read in\nconjunction with chest CT on ___:\n\nNew heterogeneous peribronchial opacification in both lower lungs could be due\nto aspiration, patient with diminished respiratory reserve due to emphysema. \nSmall bilateral pleural effusions are new. Heart size normal. Of note,\nprevious left upper lobe atelectasis and consolidation has cleared,\ndemonstrating that previously questioned malignancy is unlikely in that\nlocation.\n', '12395743-RR-31', 31, ''], ["INDICATION: Asymmetric pupil dilation and left ptosis.\n\nCOMPARISON: CT available from ___.\n\nTECHNIQUE: MDCT-acquired axial images of the head were obtained without the\nuse of IV contrast.\n\nFINDINGS: There is no evidence of acute intracranial hemorrhage, edema, mass,\nmass effect, or large vascular territorial infarction. Moderate prominence of\nthe sulci and ventricles, unchanged since ___, and is compatible with\ndiffuse cortical atrophy, within normal limits for this patient's age. The\nwhite matter of the centrum semiovale is relatively hypodense, likely\nrepresenting the sequelae of chronic microvascular ischemic disease. There is\nno acute fracture. The middle ear cavities and included views of the\nparanasal sinuses and mastoid air cells are clear.\n\nIMPRESSION: No acute intracranial process.\n", '12395743-RR-32', 32, 'mdct-acquired axial images of the head were obtained without the\nuse of iv contrast.'], ['TWO VIEW CHEST ___\n\nCOMPARISON: ___.\n\nINDICATION: COPD and hypoxia.\n\nFINDINGS: Worsening bibasilar lung opacities are present and are accompanied\nby persistent small bilateral pleural effusions. Lung volumes remain\nincreased with hyperlucency in the upper lobes suggesting underlying\nemphysema.\n\nIMPRESSION: Worsening bibasilar lung opacities, concerning for pneumonia\n(eg aspiration pneumonia) in the appropriate clinical setting. Persistent\nsmall effusions.\n', '12395743-RR-33', 33, ''], ['INDICATION: Anisocoria and left ptosis on ___.\n\nCOMPARISON: Non-contrast head CT dated ___ available for\ncorrelation.\n\nTECHNIQUE: Sagittal T1-weighted and axial T2-weighted, FLAIR, gradient echo,\nand diffusion-weighted images of the head. Three-dimensional time-of-flight\nMRA of the head.\n\nHEAD MRI: There is no acute infarction. There is no evidence of edema, mass\neffect, or blood products in the brain. There are confluent T2\nhyperintensities in the deep and periventricular white matter of the cerebral\nhemispheres, likely related to chronic microvascular infarcts at this age. \nThere is moderate cerebral atrophy with associated prominence of the\nventricles and sulci.\n\nHEAD MRA: There is minimal, if any, flow in the intracranial right vertebral\nartery. The left vertebral artery is large, suggesting that the right\nvertebral artery is nondominant. Some arterial flow in the distribution of\nthe right posterior inferior cerebral artery, but the origin of the blood\nsupply to these branches is not well seen. There is an anterior inferior\ncerebellar artery on the left. The basilar artery is tortuous but appears\npatent. The superior cerebellar and posterior cerebral arteries appear\npatent. No hemodynamically significant stenoses are seen in the anterior\ncirculation. There is no evidence of an aneurysm.\n\nIMPRESSION:\n1. No acute infarction. Extensive chronic microvascular infarcts in the\nsupratentorial white matter.\n2. Nonvisualization of flow in the right vertebral artery could be related to\nits nondominant status. If clinically indicated, this finding may be better\nassessed by a CTA of the head and neck. Alternatively, contrast-enhanced neck\nMRA could be considered.\n', '12395743-RR-35', 35, 'sagittal t1-weighted and axial t2-weighted, flair, gradient echo,\nand diffusion-weighted images of the head. three-dimensional time-of-flight\nmra of the head.']]

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[]

['medicine']

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Question: A 68 M is admitted. He/she says he/she has ___ ADMISSION HISTORY AND PHYSICAL PATIENT BEING TRANSFERED FROM ENT SERVICE . . PCP: ___. ___ . . CC: ETOH WITHDRAWAL, HYPOXIA transfer to medicine from ENT service . . History of illness: ___ old male with h/o HTN, GERD, ETOH abuse with fatty liver, tobacco abuse and COPD, h/o seizure ___, recent dx of R ___ T1NOMO who was admitted ___ to ENT service. Underwent partial glossectomy and neck dissection on ___. Immediate post op course was uncomplicated. POD#1 evening became acutely agitated/combative/tachycardic and there was concern for ETOH withdrawal and DTs. He recieved ativan ___ IV throughout the night for CIWA ___ (12mg total). Also was hypoxic and placed on O2. This am was more somnolent when nurse ___ in. ___ rhonchi and gurgling so she suctioned him. This woke him up a bit but he was leaning to the left and found to have L ptosis and unreactive L pupil. They couldnt figure out if this was new as the nurse was new and wife not at bedside. Neuro was called and by the time of their arrival pupil was reactive but pt did have mild ptosis. He did not recieve any more ativan during and is more awake. No witnezzed seizure. He is requiring 3L of O2 but his O2 sats have improved during the day with suctioning (has thick phlegm). Medicine was consulted for ETOH withdrawal, new neuro symptoms, and hypoxia. Decision made to transfer patient to medicine. He has been afebrile. Denies any pain currenlty. Difficulty to get history because speech is slurred due to surgery and pt is still not fully alert, however, he appears oriented and knows where he is and why. Reports drinking 1L vodka daily. . Meds on transfer to Medicine ativan 1mg IV q6 ativan 2mg IV q1 prn CIWA >10 folic acid IV thiamine IV duonebs q6 prn spiriva daily asa 81 heparin bid percocet ___ prn morphine 2 IV q4prn Past Medical History: per chart ETOH abuse-1L vodka daily COPD not on home O2 R tongue SCC dx ___ T1N0M0 HTN GERD seizure ___ (admitted to OSH, thought to be ___ etoh, MRI suboptimal, ?EEG results) Pulm nodule-?stable per notes LUL lung collapse and LAD s/p bronch on ___, neg for malignancy Fatty liver Tobacco abuse 2PPD ___, quit ___ ago h/o palpitations R eye cataract sugery a couple years ago Social History: ___ Family History: father died of CaP age ___ Mother died age ___ Two healthy brothers no FH of H&N cancers Allergies: Patient recorded as having No Known Allergies to Drugs What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Iso-Osmotic Dextrose CefazoLIN Albuterol 0.083% Neb Soln Ipratropium Bromide Neb Dexamethasone Chlorhexidine Gluconate 0.12% Oral Rinse Lorazepam Potassium Chloride Morphine Sulfate Ondansetron Lorazepam OxycoDONE-Acetaminophen Elixir Heparin D5 1/2NS Thiamine Tiotropium Bromide Aspirin SW Magnesium Sulfate Sodium Chloride 0.9% Flush Target Lab Orders: Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells Anion Gap Bicarbonate Calcium, Total Chloride Creatinine Estimated GFR (MDRD equation) Glucose Magnesium Phosphate Potassium Sodium Urea Nitrogen Anion Gap Bicarbonate Calcium, Total Chloride Creatinine Glucose Magnesium Phosphate Potassium Sodium Urea Nitrogen Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : ___ old male with h/o HTN, GERD, ETOH abuse with fatty liver, tobacco abuse and COPD, h/o seizure ___, recent dx of R SCC T1NOMO who was admitted ___ to ENT service and underwent partial glossectomy and neck dissection. POD#1 developed ETOH withdrawal treated with ativan, hypoxia and thick phelgm, and possible neuro finding of anisocoria/ptosis, then t/f to Gen Med on ___ for further management (see HPI). Was treated with ativan for ETOH withdrawal. Neuro felt his anisocoria may have been old and his ptosis may have be due to the ativan. As his MS improved off ativan, his neuro symptoms resolved. CT head and MRI stroke protocol did not show anything concerning. He was treated with levaquin X5days for his pneumonia seen on CXR. He was weaned off oxygen. He remained afebrile. ENT took out drain and staples. He recieved ___ and speech therapy. He needs ongoign ___. He needs ongoing speech therapy as he is only on thin liquids and pureed diet at time of discharge. He was hesitant but after convincing was agreeable to discharge to rehab. While here, he had an episode of palpitations on ___ associated with CP. He has had these intermittently as outpt but never diagnosed. On EKG was SVT rate 190s, likely AVNRT. Broke with lopressor 5mg IV. started on metoprolol 25mg bid. PCP ___. Once more stable, will get referal to EP. Also developed hypoNa, labs c/w SIADH. Fluid restricted 1L and salt tabs and ensure tid started per renal recs. Na fluctuating between 130-132 at time of discharge. Will need Na checks and titration of salt tabs at rehab and outpt. His follow up is at post D/c clinic and with onc/ENT. He was doing much better by time of discharge. Wife was updated regularly along the way. . Above issues are explained in more detail in progress note below: . Narrow complex Tachycardia: Occured on ___ for 30min, Aflutter/RVR vs AVNRT. cant tell apart on EKG, no strip availabe at the time of lopressor and cant see rhythm on tele-but on EKG it is very regular with rates 180-190s->likley AVNRT. Converted with lopressor 5mg IV X1. NOTE: Associated with chest pain and lateral STD on EKG likely demand in setting of underlying CAD. Per PCP, pt has h/o "palpitations" that they have never diagnosed. Was ruled out for ACS as cause of chest pain. Was started on metoprolol 25mg bid. No more recurrence of SVT. On Tele had frequent APBs, lytes repleted aggressively, and this imrpoved as well. Dr. ___, aware and will refer pt to EP once he is more stable. Started on ASA for likely CAD as well. Can consider statin as outpt-defered here as pt is noncompliant with meds. . Acute CAP/Pneumonia: CXR on admission ___ and repeat ___ showed basilar infiltrates and patient had thick sputum as well as new hypoxia from baseline and rhonchi on exam. Since was present on admission, treated as CAP. Also had mild COPD exacerbation. Improved with Levo 750mg X5days. Remained afebrile. Weaned off oxygen. duonebs converted to albuterol prn and spiriva continued. . Hyponatremia, SIADH: Na 142->130-132. Initially thought hypovolemic given dec PO and Na improved with d/c ___ NS and giving 1L NS. However Na dropped with furthter fluids ___ and UNa 212 with UOsm 503 suggests SIADH. likely ___ PNA, post op, and decreased solute intake. Renal saw pt while here. Kept on 1L fluid restriction, salt tabs started 2g TID, and placed on ensure TID for increased solute intake. Na is fluctuating 130-132. Needs q3day checks at rehab to titrate salt tabs, then PCP follow up. ___ note, TSH and cortisol was normal. . Acute Neuro Change: nurse noted ___ sided leaning, anisocoria, L ptosis am ___. Pt was sedated from ativan overnight and not very responsive. All symptoms have resolved now except v. mild L anisocoria but not sure if this is old. Ddx: med effect vs acute stroke/TIA vs seizure, though med effect and seizure would not explain anisocoria. CT head w/o anything acute. Neuro saw pt, were not impressed, recommended MRI. MRI ___ did not show anything concerning either. His MS and neuro exam was at his baseline rest of hospital stay . ETOH withdrawal: last drink ___ (drinks 1L vodka daily). Has h/o withdrawal in ___ when he was admitted for seizure (seizure happened while drinking per wife). ___ were similar then. Here he recieved total 12mg ativan from ___ to ___, then 2mg from ___ to ___, then 3mg from ___, at which time ativan was stopped. He was seen by SW and is not interested in quitty. He is kept on mvi/thiamine/folic acid . Thrombocytopnia: Plt counts trended down after admisison to Nadir 67. Coags normal. LIkely ___ etoh intox. There was no evidence of cirrhosis to suggest SM. They improved on their own and were 190s on d/c . Post op delirium: multifactorial: post-op, pneumonia, etoh withdrawal, hypoNa. These issues were treated and patient improved back to his baseline-A&OX3 . Dysphagia: typical after partial glossectomy. Was seen by speech while here, last reevaluation was on day of discharge ___: thin liquids okay, but needs to continue pureed meals until POD#14 per ENT, meds crushed in pureed, wash food with liquids, q4 oral care. Needs outpt video eval once discharge from rehab. Was on aspiration precautions . R tongue SCC: s/p partial glossectomy and R neck dissection ___. ENT followed after service transfer. drain removed ___, staple removed ___. Wound healing well. He has ___ set up wiht Dr. ___. He is kept on oxycodone/tylenol elixer for pain (with bowel regimen) . GERD: kept on prilosec, but per wife not taking at home, so likely will no continue . HTN: not on home meds but started metoprolol as above with better BP/HR control. Should stay on this for his pSVT . dyslipidemia and likely CAD: not on statin (rx in past but not taking) or ASA-> needs PCP ___ for further eval. started ASA 81. . HypoK/Mag/Phos: persistant for many days likely some refeeding from chronic ETOHism. He was gressively repleted PO/IV . Fatty liver; LFTs and coags okay . Macrocytic anemia: etoh related. nl b12/folate. . dispo/code: full code. HCP wife ___ ___ work ___, updated in detail ___. PCP ___ ___. Will be discharged to rehab today. Other Results: wbc ___ hgb 11.3-->10s stable (baseline 12) with MCV 100s plt 102->86->69-->192 . Chem: Na 142->132-->after initial 1L 134-->130 after 1L more IVF-->132-->130->132 K 3.9 mag 1.4->2.0 with IV mag BUN/Creat ___ Ca 8.5 SOsm 271, UOsm 503->326->398 UNa 212->122-->88 . AST/ALT ___ alkphos 90 Tbili 0.5 . b12 342, folate 11.8 TSH 3.4 cortisol 13.1 . trop ___ (aflutter/rvr and chest pain): 0.01-->0.04-->0.03 . INR 1.0 . Sputum: >25PMNs, <10epis, 2+ GPCs, Cx sparse OP flora . UA ___ negative . . Imaging/results: EKG ___: Narrow complex tachycardia at a rate of 193. Probable paroxysmal A-V nodal tachycardia but atrial flutter with 2:1 block cannot be excluded. Right axis deviation. Possible anteroseptal myocardial infarction of indeterminate age. Possible right ventricular hypertrophy. Non-specific repolarization abnormalities consistent with tachycardia and/or ischemia. Compared to the previous tracing of ___ normal sinus rhythm at a rate of 89 has given way to the aforementioned tachycardia and the ventricular rate has doubled . EKG #2 Normal sinus rhythm, rate 84. Compared to the previous tracing sinus tachycardia has replaced narrow complex supraventricular tachycardia and the rate has halved. Lateral repolarization abnormalities suggesting ischemia have resolved. There is continued suggestion of anteroseptal myocardial infarction of indeterminate age. There is continued right axis deviation and possible right ventricular hypertrophy . CXR ___: IMPRESSION: Worsening bibasilar lung opacities, concerning for pneumonia (eg aspiration pneumonia) in the appropriate clinical setting. Persistent small effusions. . ___ CXR: New heterogeneous peribronchial opacification in both lower lungs could be due to aspiration, patient with diminished respiratory reserve due to emphysema. Small bilateral pleural effusions are new. Heart size normal. Of note, previous left upper lobe atelectasis and consolidation has cleared, demonstrating that previously questioned malignancy is unlikely in that location . CT head ___ FINDINGS: There is no evidence of acute intracranial hemorrhage, edema, mass, mass effect, or large vascular territorial infarction. Moderate prominence of the sulci and ventricles, unchanged since ___, and is compatible with diffuse cortical atrophy, within normal limits for this patient's age. The white matter of the centrum semiovale is relatively hypodense, likely representing the sequelae of chronic microvascular ischemic disease. There is no acute fracture. The middle ear cavities and included views of the paranasal sinuses and mastoid air cells are clear. . MRI ___. No acute infarction. Extensive chronic microvascular infarcts in the supratentorial white matter. 2. Nonvisualization of flow in the right vertebral artery could be related to its nondominant status. If clinically indicated, this finding may be better assessed by a CTA of the head and neck. Alternatively, contrast-enhanced neck MRA could be considered . spirometry notes ___ Impression: Moderate obstructive ventilatory defect with a moderate to marked gas exchange defect. TLC may be underestimated and RV overestimated due to a suboptimal SVC maneuver. Compared to the prior study of ___ the FVC has decreased by 1.28 L (-38%), the TLC has decreased by 1.15 L (-17%) and the DLCO has decreased by 4.32 ml/min/mmHg (-30%). . Echo ___ The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. Tricuspid regurgitation is present but cannot be quantified. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion

2159-03-29 18:29:00

ENGLISH

MARRIED

BLACK/AFRICAN AMERICAN

F

[[29365494, Timestamp('2159-03-29 18:29:53'), '', 'TSURG'], [29365494, Timestamp('2159-03-30 09:13:53'), 'TSURG', 'MED']]

[[{'Medications on Admission': ':\nPreadmission medications listed are correct and complete. \nInformation was obtained from Patient.\n1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN dyspnea \n2. albuterol sulfate *NF* 90 mcg/actuation Inhalation 2 puffs \nBID \n3. Fluticasone Propionate NASAL 1 SPRY NU DAILY \n4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID \n5. Ipratropium Bromide MDI 1 PUFF IH Q6H \n6. Montelukast Sodium 10 mg PO DAILY \n7. ValACYclovir 500 mg PO PRN ulcers \n8. NuvaRing *NF* (etonogestrel-ethinyl estradiol) 0.12-0.015 \nmg/24 hr Vaginal monthly \n\nSecondary diagnosis: Anxiety', 'Brief Hospital Course': ':\nThis is a ___ yo F with hx of severe asthma who was admitted s/p \nbronchial thermoplasty for shortness of breath and wheezing. \n\n# Shortness of breath: Patient admitted s/p bronchial \nthemoplasty for shortness of breath and wheezing. She was \nmanaged with IV steroids, frequent nebulizers, and oxycodone and \nmorphine for pain. Her chest pain was evaluated with ECG and \ntroponins which were negative for ischemic. Overnight she became \ntachypneic and tachycardic prompting transfer to the MICU for \nclose monitoring. She was given heliox and ativan with \nimprovement of her symptoms. She had ___ for calf pain which \nwas negative for DVT. She was transferred back to the floor \nhowever returned to the MICU due to persistent dyspnea and \ntachycardia. She was evaluated by ENT who found the patient to \nhave paradoxical vocal fold motion which could be contributing \nto her symptoms. It was recommended that she start a reflux \nregimen and follow up with ENT in ___ weeks. She should also \nundergo respiratory retraining therapy. She was transitioned to \na po prednisone taper regimen and repeat bedside spirometry \nshowed improvement in her respiratory function. She was \ntransferred back to the floor and remained stable overnight. She \nwas discharged with plans to follow up with interventional \npulmonary and ENT. \n\n# Anxiety: Respiratory distress responded to ativan in MICU. \nPsychosocial triggers believed to be a significant contributor \nto vocal cord malfunction and episodes of dyspnea.\n. \nTRANSITIONAL ISSUES:\n- no labs pending at time of discharge \n- Follow up for PVFM evaluation and respiratory retraining\n- Follow up with interventional pulmonology as scheduled\n- patient full code during admission \n\n', 'Pertinent Results:': "\nadmission labs: \n___ 06:40AM BLOOD WBC-12.3*# RBC-3.34* Hgb-10.8* Hct-32.7* \nMCV-98 MCH-32.3* MCHC-33.0 RDW-12.8 Plt ___\n___ 06:40AM BLOOD Glucose-185* UreaN-8 Creat-0.7 Na-139 \nK-3.4 Cl-103 HCO3-22 AnGap-17\n___ 03:20PM BLOOD CK(CPK)-68\n___ 03:20PM BLOOD CK-MB-1 cTropnT-<0.01\n___ 06:40AM BLOOD Calcium-8.8 Phos-3.2 Mg-2.1\n\nABG:\n___ 02:16PM BLOOD Type-ART pO2-168* pCO2-32* pH-7.46* \ncalTCO2-23 Base XS-0\n___ 08:43PM BLOOD Type-ART pO2-103 pCO2-36 pH-7.47* \ncalTCO2-27 Base XS-2\n___ 04:55AM BLOOD Type-ART pO2-92 pCO2-34* pH-7.47* \ncalTCO2-25 Base XS-1\n\nstudies:\nCXR ___\nHeart size and mediastinum are grossly unchanged since the prior \nstudy, but\nthere is substantial interval development of perihilar opacities \nand bibasal\nconsolidations as well as relatively low lung volumes. These \nfindings are\nconcerning for multifocal infection and less likely pulmonary \nedema. Small\namount of pleural effusion cannot be excluded. Current study \nreveals no\nevidence of pneumothorax or pneumomediastinum within the \nlimitations of this\nportable AP radiograph.\n\n___\n1. No evidence of deep vein thrombosis in either leg.\n2. Superficial thrombophlebitis seen in the left calf at the \nsite of the patient's tenderness.\n\nCXR\nAs compared to the previous radiograph, there is no relevant \nchange. Relatively low lung volumes with parenchymal opacities \nat both lung bases, right more than left. The extent of the \nopacity is stable since the previous examination. Moderate \ncardiomegaly without evidence of pulmonary edema. No larger \npleural effusions. No pneumothorax.\n\n", 'Physical Exam:|Physical': '\nAdmission exam\nVitals: T:98.1 BP:114/59 P:103 R:18 O2:97%RA \nGeneral: Alert, oriented, difficulty breathing, but not using \naccessory muscles \nHEENT: Sclera anicteric, MMM, oropharynx clear \nNeck: supple, JVP not elevated, no LAD \nLungs: Diminished bilaterally on posterior, wheezing \nbilaterally, no rales or rhonchi \nCV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, \ngallops \nAbdomen: soft, non-tender, non-distended, bowel sounds present, \nno rebound tenderness or guarding, no organomegaly \nExt: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \nNeuro: Non focal\n\nDischarge exam\nVitals: T:99.0 BP:140/72 P:86 R:18 O2:99%RA \nGeneral: Alert, oriented, lying flat asleep\nHEENT: Sclera anicteric, MMM, oropharynx clear \nNeck: supple, JVP not elevated, no LAD \nLungs: Air movement increased bilaterally, less wheezing but \nstill some course breath sounds, no rales or rhonchi \nCV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops \nAbdomen: soft, non-tender, non-distended, bowel sounds present, \nno rebound tenderness or guarding, no organomegaly \nExt: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or \nedema \nNeuro: Non focal\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\n___ yo F with h/o severe persistent asthma, pericarditis, heart\nmurmur, ovarian cysts, C-section x2, enrolled in the PAS study,\ns/p bronchiothermoplasty of RLL with wheezing post procedure. \nShe has had severe asthma since her first pregnancy leading to \nseveral hospitalizations at ___, the last in ___ she was \nadmitted for 2 weeks despite being on maximal inhaled steroids \nand bronchodilators. She has completed several prednisone tapers \nafter hospital admission, with which she feels jittery and gains \nweight. \n\nOn the floor, patient is wheezing and feels very tight. \n\nPatient underwent her procedure today and postoperatively in the \nPACU she had chest pain and shortness of breath. Chest pain was \n___ in severity. She got albuterol and 1g IV tylenol and \nmorphine (total 5 mg) for pain with some relief. Glycopyrole to \nreduce secretions and prednisone preoperatively. \n\nPFTs preop were performed and her 4 hour postop PFTs were 60% of \nher preop PFTs. Per protocol, if PFTs less than 80% of \npreoperative values, then the patient requires admission for \nfurther evaluation. \n\nPast Medical History:\nAsthma (since childhood)\nHeart murmur\nPericarditis\nOvarian cysts\nC-section X 2 \n\nSocial History:\n___\nFamily History:\nDaughter has asthma, well controlled\n\n', 'Chief Complaint:|Complaint:': '\nwheezing s/p bronchial thermoplasty\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nAmoxicillin / bees / CT scan dye\n\n'}, '16244030-DS-16', 16, 'medicine']]

[['REASON FOR EXAMINATION: Asthma, respiratory distress.\n\nPortable AP radiograph of the chest was reviewed in comparison to ___.\n\nHeart size and mediastinum are grossly unchanged since the prior study, but\nthere is substantial interval development of perihilar opacities and bibasal\nconsolidations as well as relatively low lung volumes. These findings are\nconcerning for multifocal infection and less likely pulmonary edema. Small\namount of pleural effusion cannot be excluded. Current study reveals no\nevidence of pneumothorax or pneumomediastinum within the limitations of this\nportable AP radiograph.\n', '16244030-RR-21', 21, ''], ["HISTORY: ___ female with calf swelling.\n\nCOMPARISON: No previous exam for comparison.\n\nFINDINGS: Grayscale, color and Doppler images were obtained of bilateral\ncommon femoral, femoral, popliteal and tibial veins. Normal flow, compression\nand augmentation is seen in all of the deep veins.\n\nImages were also obtained of a superficial vein in the anterior left calf at a\nlocation the patient indicated is painful. This vein, which is a superficial\nvein, contains thrombus and does not demonstrate any vascular flow on color\nDoppler imaging.\n\nIMPRESSION: 1. No evidence of deep vein thrombosis in either leg.\n\n2. Superficial thrombophlebitis seen in the left calf at the site of the\npatient's tenderness.\n\n", '16244030-RR-23', 23, ''], ['CHEST RADIOGRAPH\n\nINDICATION: Status post bronchothermoplasty.\n\nCOMPARISON: ___.\n\nFINDINGS: As compared to the previous radiograph, there is no relevant\nchange. Relatively low lung volumes with parenchymal opacities at both lung\nbases, right more than left. The extent of the opacity is stable since the\nprevious examination. Moderate cardiomegaly without evidence of pulmonary\nedema. No larger pleural effusions. No pneumothorax.\n', '16244030-RR-24', 24, '']]

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[]

['medicine']

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Question: A 32 F is admitted. He/she says he/she has wheezing s/p bronchial thermoplasty . History of illness: ___ yo F with h/o severe persistent asthma, pericarditis, heart murmur, ovarian cysts, C-section x2, enrolled in the PAS study, s/p bronchiothermoplasty of RLL with wheezing post procedure. She has had severe asthma since her first pregnancy leading to several hospitalizations at ___, the last in ___ she was admitted for 2 weeks despite being on maximal inhaled steroids and bronchodilators. She has completed several prednisone tapers after hospital admission, with which she feels jittery and gains weight. On the floor, patient is wheezing and feels very tight. Patient underwent her procedure today and postoperatively in the PACU she had chest pain and shortness of breath. Chest pain was ___ in severity. She got albuterol and 1g IV tylenol and morphine (total 5 mg) for pain with some relief. Glycopyrole to reduce secretions and prednisone preoperatively. PFTs preop were performed and her 4 hour postop PFTs were 60% of her preop PFTs. Per protocol, if PFTs less than 80% of preoperative values, then the patient requires admission for further evaluation. Past Medical History: Asthma (since childhood) Heart murmur Pericarditis Ovarian cysts C-section X 2 Social History: ___ Family History: Daughter has asthma, well controlled Allergies: Amoxicillin / bees / CT scan dye What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Albuterol 0.083% Neb Soln Insulin Fluticasone-Salmeterol Diskus (500/50) Insulin Montelukast Sodium Docusate Sodium OxycoDONE (Immediate Release) OxycoDONE (Immediate Release) Glucagon MethylPREDNISolone Sodium Succ Senna Morphine Sulfate Ipratropium Bromide Neb Acetaminophen Dextrose 50% Insulin MethylPREDNISolone Sodium Succ Bag Magnesium Sulfate Morphine Sulfate Acetaminophen Ipratropium Bromide Neb Aspirin Sodium Chloride 0.9% Flush Fluticasone Propionate NASAL Heparin Morphine Sulfate Target Lab Orders: Anion Gap Bicarbonate Calcium, Total Chloride Creatinine Estimated GFR (MDRD equation) Glucose Magnesium Phosphate Potassium Sodium Urea Nitrogen Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells Base Excess Calculated Total CO2 pCO2 pH pO2 Specimen Type Creatine Kinase (CK) Creatine Kinase, MB Isoenzyme Troponin T Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : This is a ___ yo F with hx of severe asthma who was admitted s/p bronchial thermoplasty for shortness of breath and wheezing. # Shortness of breath: Patient admitted s/p bronchial themoplasty for shortness of breath and wheezing. She was managed with IV steroids, frequent nebulizers, and oxycodone and morphine for pain. Her chest pain was evaluated with ECG and troponins which were negative for ischemic. Overnight she became tachypneic and tachycardic prompting transfer to the MICU for close monitoring. She was given heliox and ativan with improvement of her symptoms. She had ___ for calf pain which was negative for DVT. She was transferred back to the floor however returned to the MICU due to persistent dyspnea and tachycardia. She was evaluated by ENT who found the patient to have paradoxical vocal fold motion which could be contributing to her symptoms. It was recommended that she start a reflux regimen and follow up with ENT in ___ weeks. She should also undergo respiratory retraining therapy. She was transitioned to a po prednisone taper regimen and repeat bedside spirometry showed improvement in her respiratory function. She was transferred back to the floor and remained stable overnight. She was discharged with plans to follow up with interventional pulmonary and ENT. # Anxiety: Respiratory distress responded to ativan in MICU. Psychosocial triggers believed to be a significant contributor to vocal cord malfunction and episodes of dyspnea. . TRANSITIONAL ISSUES: - no labs pending at time of discharge - Follow up for PVFM evaluation and respiratory retraining - Follow up with interventional pulmonology as scheduled - patient full code during admission Other Results: admission labs: ___ 06:40AM BLOOD WBC-12.3*# RBC-3.34* Hgb-10.8* Hct-32.7* MCV-98 MCH-32.3* MCHC-33.0 RDW-12.8 Plt ___ ___ 06:40AM BLOOD Glucose-185* UreaN-8 Creat-0.7 Na-139 K-3.4 Cl-103 HCO3-22 AnGap-17 ___ 03:20PM BLOOD CK(CPK)-68 ___ 03:20PM BLOOD CK-MB-1 cTropnT-<0.01 ___ 06:40AM BLOOD Calcium-8.8 Phos-3.2 Mg-2.1 ABG: ___ 02:16PM BLOOD Type-ART pO2-168* pCO2-32* pH-7.46* calTCO2-23 Base XS-0 ___ 08:43PM BLOOD Type-ART pO2-103 pCO2-36 pH-7.47* calTCO2-27 Base XS-2 ___ 04:55AM BLOOD Type-ART pO2-92 pCO2-34* pH-7.47* calTCO2-25 Base XS-1 studies: CXR ___ Heart size and mediastinum are grossly unchanged since the prior study, but there is substantial interval development of perihilar opacities and bibasal consolidations as well as relatively low lung volumes. These findings are concerning for multifocal infection and less likely pulmonary edema. Small amount of pleural effusion cannot be excluded. Current study reveals no evidence of pneumothorax or pneumomediastinum within the limitations of this portable AP radiograph. ___ 1. No evidence of deep vein thrombosis in either leg. 2. Superficial thrombophlebitis seen in the left calf at the site of the patient's tenderness. CXR As compared to the previous radiograph, there is no relevant change. Relatively low lung volumes with parenchymal opacities at both lung bases, right more than left. The extent of the opacity is stable since the previous examination. Moderate cardiomegaly without evidence of pulmonary edema. No larger pleural effusions. No pneumothorax.

2137-04-17 18:41:00

?

UNKNOWN

F

[[24096846, Timestamp('2137-04-17 18:42:32'), '', 'CSURG']]

[[{'Medications on Admission': ':\nIsoptin ER 250 mg BID \nAtorvastatin 80 mg daily \nAlbuterol 2 puff q4h prn \nAspirin 81 mg daily \nColace 100 mg BID prn constipation \nFlovent 1 puff BID \nLopressor 12.5 po BID \nNTG 0.4 SL Prn \nProtonix 40mg IV q12h \nHeparin drip \n\nFacility:\n___', 'Brief Hospital Course': ':\nMrs. ___ was brought to the operating room on ___ \nwhere she underwent Coronary bypass grafting x2 with the left \ninternal mammary artery to the left anterior descending artery, \nand reverse saphenous vein graft to the obtuse\nmarginal artery. The cardiopulmonary bypass time was 52 minutes \nwith a cross clamp of 110 minutes. He tolerated the operation \nwell and following surgery he was transferred to the CVICU for \ninvasive monitoring in stable condition. He remained \nhemodynamically stable, sedation was weaned, he awoke \nneurologically intact and was extubated. All other tubes, lines \nand drains were removed per cardiac surgery protocol without \ncomplication. He was started on Beta-blockers, diuretics and \nthese were titrated as needed. On POD1 he was transferred from \nthe ICU to the stepdown floor for continued recovery. A five \nday course of Cipro for urine PROTEUS MIRABILIS. The patient was \nevaluated by the physical therapy service for assistance with \nstrength and mobility. By the time of discharge on POD 4 the \npatient was ambulating freely, the wound was healing and pain \nwas controlled with oral analgesics. The patient was discharged \nhome with ___ in good condition with appropriate follow \nup instructions.\n\n', 'Pertinent Results:': '\nEchocardiogram ___\nPre-bypass:\nThe left atrium is mildly dilated. There is moderate regional \nleft ventricular systolic dysfunction with EF of 30%, and apical \nand inferolateral hypokinesis. Right ventricular chamber size \nand free wall motion are normal. The ascending, transverse and \ndescending thoracic aorta are normal in diameter and free of \natherosclerotic plaque. The diameters of aorta at the sinus, \nascending and arch levels are normal. The aortic valve leaflets \n(3) appear structurally normal with good leaflet excursion and \nno aortic stenosis. Mild (1+) aortic regurgitation is seen. The \nmitral valve leaflets are structurally normal. Mild (1+) mitral \nregurgitation is seen. Moderate [2+] tricuspid regurgitation is \nseen. There is an anterior space which most likely represents a \nprominent fat pad. \n\nPost-bypass:\nphenylephrine gtt \nLVEF 30%, RV structure and function normal. Valvular findings \nsame as pre-bypass. Aorta intact post decannulation. \n\nChest Film: ___\nThe lungs are well inflated and demonstrate bibasilar opacities. \n There is a moderate left pleural effusion with interval \nimprovement compared to the prior radiograph. Left-sided \ncentral line terminates in the distal SVC. Sternotomy wires \nremain unchanged. Bony thorax is unchanged. \n\nIMPRESSION: \nInterval mild improvement in left pleural effusion with \npersistent left \nretrocardiac opacity likely atelectasis and/ or consolidation. \nUnchanged right lower lobe linear atelectasis. Stable \ncardiomegaly. \n\nAdmit Labs\n___ WBC-13.1* RBC-3.43* Hgb-10.3* Hct-30.8* MCV-90 MCH-29.9 \nMCHC-33.3 RDW-13.2 Plt ___\n___ ___ PTT-29.9 ___\n___ Glucose-154* UreaN-12 Creat-0.7 Na-137 K-3.9 Cl-101 \nHCO3-25 \n___ AST-28 LD(LDH)-288* CK(CPK)-202* AlkPhos-69 \nTotBili-0.9\n___ CK-MB-5 cTropnT-1.05*\n___ Albumin-3.4* Calcium-9.0 Phos-2.8 Mg-1.8\n___ %HbA1c-5.6 eAG-114\n\n', 'Physical Exam:|Physical': "\nDischarge Exam:\nVS: T: 98.4 HR: 80-90's SR BP: 113/57 RR: 18 Sats: 96% RA\nWt: 85 Kg BS ___\nGeneral: ___ year-old female in no apparent distress\nHEENT: normocephalic, mucus membranes moist\nNeck; supple no lymphadenopathy\nCard: RRR normal S1,S2 no murmur\nResp: clear breath sounds throughout\nGI: benign\nExtr: trace bilateral edema, warm\nWounds: sternal and right lower extremity vasoview sites clean \ndry intact no erythema\nNeuro: awake, alert oriented\n\n", 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\n___ year old female presented to outside hospital with chest pain \nthat had persisted for greater than 24 hours. She has known \nhypertension that has been\ndifficult to control was seen by PCP ___ ___ which she did have \nchest pain with no EKG changes. Pain continued to come and go \npresented to ___, ruled in for NSTEMI with troponin 1.73 \nstarted on IV heparin. Underwent cardiac catheterization that \nrevealed multivessel disease with depressed EF, now referred for \nsurgical evaluation \n\nPast Medical History:\nCoronary Artery Disease\nHypertension \nAsthma \nGastroesophageal reflux disease \nAnemia \nLow Back pain \n\nSocial History:\n___\nFamily History:\nnon-contributory\n\n', 'Chief Complaint:|Complaint:': '\nChest pain with shortness of breath\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nclarithromycin / Penicillins\n\n'}, '15784035-DS-9', 9, 'cardiothoracic']]

[['EXAMINATION: CHEST (PA AND LAT)\n\nINDICATION: ___ year old woman with CAD // evalaute for effusion preop \nevalaute for effusion preop\n\nIMPRESSION: \n\nNo previous images. Cardiac silhouette is mildly enlarged, though there is no\ndefinite vascular congestion or acute focal infiltrate. Blunting of the left\ncostophrenic angle could represent small effusion or pleural thickening. Mild\nbasilar atelectatic changes are seen.\n', '15784035-RR-14', 14, ''], ['EXAMINATION: CHEST PORT. LINE PLACEMENT\n\nINDICATION: ___ year old woman with CAD s/p CABG. Please ___ at\n___ with abnormalities. // FAST TRACK EXTUBATION CARDIAC SURGERY, ?line\nplacement, r/o PTX/Effusion Contact name: ___: ___\n\nTECHNIQUE: AP view of the chest.\n\nCOMPARISON: Chest radiograph on ___\n\nFINDINGS: \n\nAn endotracheal tube terminates 5.1 cm above the carina. An enteric tube\ndescends below the field of view. A Swan-Ganz catheter terminates in the\ndistal right pulmonary artery. A left chest tube projects over the left hemi\nthorax. New lung volumes are low however the lungs are clear. There is no\npneumothorax, pleural effusion or focal consolidation identified. Mild\npulmonary vascularly congestion without edema.\n\nIMPRESSION: \n\nSwan-Ganz catheter terminates in the distal right pulmonary artery. Low lung\nvolumes, no focal consolidation.\n', '15784035-RR-15', 15, 'ap view of the chest.'], ['EXAMINATION: CHEST (PORTABLE AP)\n\nINDICATION: ___ year old woman with s/p cabg // left IJ tlc change overwire\n\nTECHNIQUE: AP view of the chest.\n\nCOMPARISON: Prior radiographs most recent on ___.\n\nFINDINGS: \n\nThere has been interval removal of an endotracheal tube, enteric tube and\nSwan-Ganz catheter. A left internal jugular catheter terminates in the\nproximal SVC. A left-sided chest tube is in unchanged position.\n\nLung volumes are low. There may be a small, bilateral effusions. Subtle\nbibasilar opacities could represent atelectasis. No pneumothorax. There is\nmild vascular congestion.\n\nIMPRESSION: \n\nLow lung volumes. Likely small bilateral effusions and bibasilar atelectasis. \nNo pneumothorax.\n', '15784035-RR-16', 16, 'ap view of the chest.'], ['EXAMINATION: CHEST (PORTABLE AP)\n\nINDICATION: ___ year old woman with s/p cabg // s/p ct removal\n\nTECHNIQUE: CHEST (PORTABLE AP)\n\nCOMPARISON: ___ obtained at 14:19\n\nIMPRESSION: \n\nLeft internal jugular line tip is at the level of mid SVC. Left chest tube has\nbeen discontinued with no evidence of pneumothorax. Bilateral, left more than\nright pleural effusions are re- demonstrated. Left retrocardiac opacity is\nmost likely consistent with a combination of pleural effusion and atelectasis.\nThere is no pulmonary edema.\n', '15784035-RR-17', 17, 'chest (portable ap)'], ['INDICATION: ___ year old woman POD3 CABG // evaluate for effusion\n\nTECHNIQUE: Chest PA and lateral\n\nCOMPARISON: ___\n\nFINDINGS: \n\nThe lungs are well inflated and demonstrate bibasilar opacities. There is a\nmoderate left pleural effusion with interval improvement compared to the prior\nradiograph. Left-sided central line terminates in the distal SVC. Sternotomy\nwires remain unchanged. Bony thorax is unchanged.\n\nIMPRESSION: \n\nInterval mild improvement in left pleural effusion with persistent left\nretrocardiac opacity likely atelectasis and/ or consolidation. Unchanged right\nlower lobe linear atelectasis. Stable cardiomegaly.\n', '15784035-RR-18', 18, 'chest pa and lateral']]

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[]

['cardiothoracic']

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[50862, Timestamp('2137-04-17 21:20:00'), Timestamp('2137-04-17 22:23:00'), 'Albumin'], [50863, Timestamp('2137-04-17 21:20:00'), Timestamp('2137-04-17 22:23:00'), 'Alkaline Phosphatase'], [50868, Timestamp('2137-04-17 21:20:00'), Timestamp('2137-04-17 22:23:00'), 'Anion Gap'], [50878, Timestamp('2137-04-17 21:20:00'), Timestamp('2137-04-17 22:23:00'), 'Asparate Aminotransferase (AST)'], [50882, Timestamp('2137-04-17 21:20:00'), Timestamp('2137-04-17 22:23:00'), 'Bicarbonate'], [50885, Timestamp('2137-04-17 21:20:00'), Timestamp('2137-04-17 22:23:00'), 'Bilirubin, Total'], [50893, Timestamp('2137-04-17 21:20:00'), Timestamp('2137-04-17 22:23:00'), 'Calcium, Total'], [50902, Timestamp('2137-04-17 21:20:00'), Timestamp('2137-04-17 22:23:00'), 'Chloride'], [50910, Timestamp('2137-04-17 21:20:00'), Timestamp('2137-04-17 22:23:00'), 'Creatine Kinase (CK)'], [50911, Timestamp('2137-04-17 21:20:00'), Timestamp('2137-04-17 22:23:00'), 'Creatine Kinase, MB Isoenzyme'], [50912, Timestamp('2137-04-17 21:20:00'), Timestamp('2137-04-17 22:23:00'), 'Creatinine'], [50920, Timestamp('2137-04-17 21:20:00'), Timestamp('2137-04-17 22:23:00'), 'Estimated GFR (MDRD equation)'], [50931, Timestamp('2137-04-17 21:20:00'), Timestamp('2137-04-17 22:23:00'), 'Glucose'], [50954, Timestamp('2137-04-17 21:20:00'), Timestamp('2137-04-17 22:23:00'), 'Lactate Dehydrogenase (LD)'], [50960, Timestamp('2137-04-17 21:20:00'), Timestamp('2137-04-17 22:23:00'), 'Magnesium'], [50970, Timestamp('2137-04-17 21:20:00'), Timestamp('2137-04-17 22:23:00'), 'Phosphate'], [50971, Timestamp('2137-04-17 21:20:00'), Timestamp('2137-04-17 22:23:00'), 'Potassium'], [50983, Timestamp('2137-04-17 21:20:00'), Timestamp('2137-04-17 22:23:00'), 'Sodium'], [51003, Timestamp('2137-04-17 21:20:00'), Timestamp('2137-04-17 23:03:00'), 'Troponin T'], [51006, Timestamp('2137-04-17 21:20:00'), Timestamp('2137-04-17 22:23:00'), 'Urea Nitrogen'], [51275, Timestamp('2137-04-18 06:45:00'), Timestamp('2137-04-18 07:41:00'), 'PTT'], [51275, Timestamp('2137-04-18 15:00:00'), Timestamp('2137-04-18 15:38:00'), 'PTT']]

Question: A 74 F is admitted. He/she says he/she has Chest pain with shortness of breath . History of illness: ___ year old female presented to outside hospital with chest pain that had persisted for greater than 24 hours. She has known hypertension that has been difficult to control was seen by PCP ___ ___ which she did have chest pain with no EKG changes. Pain continued to come and go presented to ___, ruled in for NSTEMI with troponin 1.73 started on IV heparin. Underwent cardiac catheterization that revealed multivessel disease with depressed EF, now referred for surgical evaluation Past Medical History: Coronary Artery Disease Hypertension Asthma Gastroesophageal reflux disease Anemia Low Back pain Social History: ___ Family History: non-contributory Allergies: clarithromycin / Penicillins What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Sodium Chloride 0.9% Flush Insulin 0.9% Sodium Chloride Heparin Sodium Morphine Sulfate Fluticasone Propionate 110mcg PNEUMOcoccal 23-valent polysaccharide vaccine Nitroglycerin SL 0.9% Sodium Chloride Heparin Sodium Albuterol Inhaler Atorvastatin Aspirin Glucagon Glucose Gel Metoprolol Tartrate Pantoprazole Verapamil SR Mupirocin Ointment 2% Dextrose 50% Hydrochlorothiazide Target Lab Orders: Amorphous Crystals Bacteria Bilirubin Blood Epithelial Cells Glucose Ketone Leukocytes Nitrite pH Protein RBC Specific Gravity Urine Appearance Urine Color Urobilinogen WBC Yeast Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells INR(PT) PT PTT % Hemoglobin A1c eAG Alanine Aminotransferase (ALT) Albumin Alkaline Phosphatase Anion Gap Asparate Aminotransferase (AST) Bicarbonate Bilirubin, Total Calcium, Total Chloride Creatine Kinase (CK) Creatine Kinase, MB Isoenzyme Creatinine Estimated GFR (MDRD equation) Glucose Lactate Dehydrogenase (LD) Magnesium Phosphate Potassium Sodium Troponin T Urea Nitrogen PTT PTT Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : Mrs. ___ was brought to the operating room on ___ where she underwent Coronary bypass grafting x2 with the left internal mammary artery to the left anterior descending artery, and reverse saphenous vein graft to the obtuse marginal artery. The cardiopulmonary bypass time was 52 minutes with a cross clamp of 110 minutes. He tolerated the operation well and following surgery he was transferred to the CVICU for invasive monitoring in stable condition. He remained hemodynamically stable, sedation was weaned, he awoke neurologically intact and was extubated. All other tubes, lines and drains were removed per cardiac surgery protocol without complication. He was started on Beta-blockers, diuretics and these were titrated as needed. On POD1 he was transferred from the ICU to the stepdown floor for continued recovery. A five day course of Cipro for urine PROTEUS MIRABILIS. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 4 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged home with ___ in good condition with appropriate follow up instructions. Other Results: Echocardiogram ___ Pre-bypass: The left atrium is mildly dilated. There is moderate regional left ventricular systolic dysfunction with EF of 30%, and apical and inferolateral hypokinesis. 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 diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is an anterior space which most likely represents a prominent fat pad. Post-bypass: phenylephrine gtt LVEF 30%, RV structure and function normal. Valvular findings same as pre-bypass. Aorta intact post decannulation. Chest Film: ___ The lungs are well inflated and demonstrate bibasilar opacities. There is a moderate left pleural effusion with interval improvement compared to the prior radiograph. Left-sided central line terminates in the distal SVC. Sternotomy wires remain unchanged. Bony thorax is unchanged. IMPRESSION: Interval mild improvement in left pleural effusion with persistent left retrocardiac opacity likely atelectasis and/ or consolidation. Unchanged right lower lobe linear atelectasis. Stable cardiomegaly. Admit Labs ___ WBC-13.1* RBC-3.43* Hgb-10.3* Hct-30.8* MCV-90 MCH-29.9 MCHC-33.3 RDW-13.2 Plt ___ ___ ___ PTT-29.9 ___ ___ Glucose-154* UreaN-12 Creat-0.7 Na-137 K-3.9 Cl-101 HCO3-25 ___ AST-28 LD(LDH)-288* CK(CPK)-202* AlkPhos-69 TotBili-0.9 ___ CK-MB-5 cTropnT-1.05* ___ Albumin-3.4* Calcium-9.0 Phos-2.8 Mg-1.8 ___ %HbA1c-5.6 eAG-114

2184-12-19 05:25:00

ENGLISH

MARRIED

WHITE

F

[[21433986, Timestamp('2184-12-19 05:27:00'), '', 'TRAUM']]

[[{'Medications on Admission': ":\nMEDS: HCTZ, lisinopril, atenolol \nALL: erithromycin: rash \n\n5. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO \nDAILY (Daily). \n6. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). \n7. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML's \nPO twice a day. \n8. Colace 60 mg/15 mL Syrup Sig: ___ (25) ML's PO twice \na day. \n9. Augmentin 250-62.5 mg/5 mL Suspension for Reconstitution Sig: \nTen (10) ML's PO three times a day for 3 days.\nDisp:*qs ML's* Refills:*0*\n\nFacility:\n___\n\n___ Diagnosis:\ns/p Fall\nMutliple facial fractures - ___ I & II\nFacial lacerations\nFacial nerve injury - CN VII ", 'Brief Hospital Course': ':\nShe was admitted to the ___ service; Plastics, Ophthalmology and \nOMFS were consulted given her extensive facial fractures. No \nocular injuries were identified by Ophthalmology. She was taken \nto the operating room on ___ for exploration of left \nparotid duct and left facial nerve and again on ___ for \nclosed reduction of maxillary fractures, insertion of custom \nsplint, application of arch bars, Left Leforte II procedure. \nThere were no complications. Because her jaws are wired shut she \nis on a liquid diet and is tolerating this. Nutritional \nsupplements were also being recommended.\n\nShe is ambulating independently; her home medications were \nrestarted. She is on an oral pain and bowel regimen. \n\nShe was seen by Social work for counseling re: alcohol use as a \npotential factor related to her fall.\n\nher disposition is home with services. Instructions for follow \nup were provided. \n\n', 'Pertinent Results:': '\n___ 03:05AM ASA-NEG ___ ACETMNPHN-NEG \nbnzodzpn-NEG barbitrt-NEG tricyclic-NEG\n___ 03:07AM GLUCOSE-118* LACTATE-2.5* NA+-139 K+-3.1* \nCL--97* TCO2-26\n___ 03:05AM UREA N-17 CREAT-0.8\n___ 03:05AM LIPASE-42\n___ 03:05AM WBC-7.8 RBC-4.39 HGB-14.6 HCT-40.3 MCV-92 \nMCH-33.2* MCHC-36.2* RDW-13.7\n___ 03:05AM ___ PTT-20.2* ___\n___ 03:05AM PLT COUNT-282\n___ 03:05AM ___\n\nCT C-Spine ___: no intracranial hemorrhage or other acute \nprocess. extensive facial fractures involving the left orbit, \nleft pterygoid, and bilateral maxillary sinuses. extensive blood \nin the sinuses and extensive secretinos in the posterior \nnasopharynx. rec facial CT for better characterization. \n\nCT Head ___: Questionable non-displaced fx involving the \nright superior facet of T1. no other cervical fx or traumatic \nmalalignment. prevretebral soft tissues unremarkable. deg change \nmost severe at C5-6 and ___ where there is mod canal narrowing. \nconsider mr if there is concern for cord or ligamentous injury. \n\nCT Sinus/Mandible/Maxilla ___: (PRELIM READ) complex facial \nfractures. on the right, there are minimally displaced fractures \nof the anterior, medial and lateral walls of the maxillary \nsinus, and extending into hard palate. the right pterygoid is \nintact. on the left, there is a complex fracture involving all \nwalls of the left max sinus, the pterygoid, the inferior and \nmedial orbital walls, and the zm complex. overall config most \nc/w bilat lefort 1 and left lefort 2 ___s left ___ fx. no \nevidence of orbital contents herniation or entrapment. extensive \nblood in the sinuses and retropharyngeal secretions. \n\n', 'Physical Exam:|Physical': '\nUpon presentation to ED:\nHR:65 O(2)Sat:98 normal \n\nConstitutional: Comfortable\nHEENT: Multiple facial lacs. \nMid face stable Extraocular muscles intact, Pupils equal, \nround and reactive to light\nOropharynx within normal limits\nChest: Clear to auscultation\nCardiovascular: Regular Rate and Rhythm\nAbdominal: Soft, Nontender, Nondistended\nGU/Flank: No costovertebral angle tenderness\nExtr/Back: No cyanosis, clubbing or edema\nSkin: No rash\nNeuro: Speech fluent\nPsych: Normal mood\n___: No petechiae\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': "\n___ found down s/p likely fall down ~15 stairs in early AM. Pt w \nno recollection of event but found by husband approximately 30 \nseconds following fall with patient conscious but disoriented. \nPatient became lucid within a minutes of fall and responded to \nhusband's questions appropriately. Patient brought by ambulance \nto ___ ED. Mentating well in ED. C/o L facial lacs, occipital \npain, neck pain, R wrist pain, R hip pain and dental \nmalocclusion. Admits to consuming wine prior to bed (BAC 0.158 \nin ED). Denies dizziness, lightheadedness, chest pain, shortness \nof breath, nausea, vomiting. \n\nPast Medical History:\n HTN \n\nSocial History:\n___\nFamily History:\nNoncontributory\n\n", 'Chief Complaint:|Complaint:': '\ns/p Fall\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nErythromycin Base\n\n'}, '18273440-DS-11', 11, 'surgery']]

[['INDICATION: ___ female status post fall. Evaluate for acute process.\n\nSUPINE PORTABLE CHEST RADIOGRAPH: The radiograph is technically limited. \nThere is an underlying trauma board, which obscures fine detail. There is\napparent widening of the mediastinal contour and the cardiac silhouette. The\nlung volumes are low, with resultant basilar atelectasis. There is no focal\npulmonary consolidation, and no large effusion or pneumothorax. Assessment of\nthe thoracic spine is limited by poor penetration.\n\nIMPRESSION: Limited radiograph, demonstrating no focal pulmonary\nconsolidation, effusion or pneumothorax. However, widened mediastinal\ncontours and suboptimal evaluation of the thoracic spine make it impossible to\nexclude bone or mediastinal injury. Further evaluation with repeat\nradiographs or cross-sectional imaging is recommended as clinically indicated.\n\nDiscussed with Dr ___ for the patient in ED at 9:30 AM ___.\n', '18273440-RR-33', 33, ''], ['INDICATION: ___ female status post fall.\n\nCOMPARISON: None available.\n\nSUPINE AP PELVIS: There is no fracture identified. Bony pelvis is intact.\nSacroiliac joints and pubic symphysis are intact. Bowel gas and stool\nobscures the sacrum, the visualized sacral ala are intact. There is\ndegenerative change in the lumbar spine and mild bilateral hip joint\ndegenerative change. There are no suspicious lytic or sclerotic osseous\nlesions or abnormal soft tissue calcifications.\n\nIMPRESSION: No evidence for fracture or other traumatic sequelae in the\npelvis.\n\n\n\n\n\n', '18273440-RR-34', 34, ''], ['INDICATION: Trauma.\n\nCOMPARISON: None available at the time of imaging.\n\nNON-CONTRAST HEAD CT: \n\nThere is no intracranial hemorrhage, and no parenchymal edema or mass effect. \nThere is no evidence of infarction. Periventricular and deep white matter\nhypodensities likely represent sequelae of chronic small vessel disease. \nThere is no shift of midline structures. The basal cisterns are patent.\n\nThere are no calvarial fractures or skull base fractures. The mastoids are\nwell aerated. There are, however, multiple facial fractures, involving the\nbilateral maxillary sinuses, nasal bones, left pterygoid, left orbit and left\nzygomatic complex. These are better characterized on concurrent CT of the\nfacial bones.\n\nIMPRESSION:\n\n1. No acute intracranial process.\n\n2. Multiple facial fractures, better characterized on concurrent CT of the\nfacial bones.\n', '18273440-RR-35', 35, ''], ['EXAMINATION: CT of the cervical spine.\n\nINDICATION: ___ female status post trauma. Evaluate for fracture.\n\nCOMPARISON: None available.\n\nTECHNIQUE: Non-contrast imaging of the cervical spine, with preparation and\nreview of multiplanar reformatted images.\n\nFINDINGS:\n\nThere is a subtle vertical lucent line through the right superior articular\nfacet of the T1 vertebral body, possibly artifactual versus a non-displaced\nfracture.\n\nThere are no further concerning findings in the cervical spine for traumatic\ninjury. The vertebral bodies are normal in height, and alignment is\npreserved. Atlantoaxial and atlanto-occipital articulations are maintained. \nThere is no prevertebral soft tissue swelling.\n\nSmall well-corticated fragments of the spinous processes of C6 and C7 are\nnoted, likely the sequelae of prior trauma.\n\nThere is multilevel degenerative change, with prominent posterior osteophytes\nat C4-5 and C5-6, which causes moderate canal narrowing. At C5-6 there is\nalso ossification of the posterior longitudinal ligament. There is also\nmultilevel neural foraminal narrowing noted throughout the cervical spine.\n\nMultiple facial fractures, characterized on concurrent CT of the facial bones,\nare again noted.\n\nIMPRESSION:\n\n1. Equivocal non-displaced fracture involving the superior articular facet of\nT1 on the right.\n\n2. No further cervical spine fractures or evidence of traumatic malalignment.\n\n3. Multilevel spondylosis, most severe at C4-5 and ___, where there is\nresultant moderate canal narrowing.\n', '18273440-RR-36', 36, 'non-contrast imaging of the cervical spine, with preparation and\nreview of multiplanar reformatted images.'], ['INDICATION: ___ female status post trauma. Evaluate for fracture.\n\nCOMPARISON: None available.\n\nRIGHT WRIST, FIVE VIEWS:\n\nThere is a comminuted fracture at the distal radius, with intra-articular\nextension. There is no significant displacement or angulation of the fracture\nfragments or articular surface. The carpal alignments are normal. The distal\nulna is intact. There is associated soft tissue swelling. There are no\nradiopaque foreign bodies.\n\nIMPRESSION: Comminuted intra-articular distal radial fracture, without\nsignificant angulation, impaction, or displacement.\n', '18273440-RR-37', 37, ''], ['3-D volume rendered images were also obtained, aiding in interpretation of the\nextensive facial fractures described above.\n\n', '18273440-AR-38', 38, ''], ['INDICATION: ___ female with facial fractures.\n\nCOMPARISON: None available.\n\nTECHNIQUE: MDCT imaging of the facial bones without intravenous contrast. \nMultiplanar reformats were prepared and reviewed.\n\nFINDINGS: \n\nThere are extensive facial fractures as detailed below.\n\nOn the right, fractures are most in keeping with ___ Fort 1 fracture pattern.\nThe right pterygoid and right zygomatic arch are intact. However, there are\nminimally displaced fractures involving the anterior, medial, and lateral\nwalls of the right maxillary sinus, as well as extending from anterior to\nposterior through the hard palate. There is additional fracture through the\nnasal septum. The right bony orbit is grossly intact, though there is a\nsubtle nondisplaced fracture of the inferior orbital wall, with associated\nfocus of intraorbital air. There is no significant displacement of orbital\nfracture fragments or evidence of herniation of orbital contents/entrapment. \nThe right conal fascia appears inteact. There is no intra-orbital hematoma,\nthough as above a small locule of intraorbital air is identified (401B:57).\n\nOn the left, fractures are more complex, overall compatible with ___ Fort 1,\nLefort 2 and ZMC fracture pattern. There are comminuted fractures through the\nanterior, medial and lateral wall of the maxillary sinus, as well as extending\nthough the nasal septum, as above. Additionally, fractures extend through the\ninferior and medial orbit and transversely through the left pterygoid,\nconsistent with ___ Fort 2 injury. There is also displaced fracture of the\nleft zygomatic arch and disruption of the zygomaticomaxillary and\nzygomaticosphenoid sutures. There is apparent superomedial displacement of\nthe sygoma.\n\nFractures involve the medial and inferior left orbital walls. There is\nintra-orbital air, but no intraorbial hematoma and no evidence for muscular\nentrapment. Rounding of the inferior rectus muscle does suggest injury to the\nconal fascia. Mild proptosis is noted, likely reflecting decrased orbital\nvolume due to medial displacement of the zygoma.\n\nThere are bilateral nasal bone fractures, as well as fractures of the nasal\nseptum and anterior nasal spine.\n\nThere is extensive hyperdense opacification of the sinuses, compatible with\nblood. There is extensive secretion in the posterior nasopharynx.\n\nThe mastoid air cells remain well aerated.\n\nIMPRESSION:\n1. Extensive facial fractures, with configuration most in keeping with\nbilateral ___ Fort 1, left ___ Fort 2, and left zygomaticomaxillary complex\nfractures, as detailed above.\n2. No evidence for entrapment or herniation of orbital muscles, though\nstranding of the fat surrounding of the left inferior rectus does suggest\ninjury to the conal fascia.\n3. Extensive hyperdense opacification of the sinuses, compatible with\nhemorrhage.\n4. Extensive secretions in the posterior nasopharynx.\n', '18273440-RR-38', 38, 'mdct imaging of the facial bones without intravenous contrast. \nmultiplanar reformats were prepared and reviewed.'], ['HISTORY: Pre-operative.\n\nFINDINGS: In comparison with the study of ___, there are continued low lung\nvolumes. Atelectatic streaks are seen at the left base above a somewhat\nelevated hemidiaphragm. Mediastinal contours are within normal limits at this\ntime. \n\nNo evidence of acute focal pneumonia or vascular congestion.\n', '18273440-RR-39', 39, '']]

[[21433986, Timestamp('2184-12-19 21:00:00'), Timestamp('2184-12-20 10:00:00'), 'MAIN', 'Metoprolol Tartrate', '019808', '00143987310', '5mg/5mL Vial'], [21433986, Timestamp('2184-12-19 06:00:00'), Timestamp('2184-12-21 07:00:00'), 'BASE', 'LR', '001187', '00338011704', '1000ml Bag'], [21433986, Timestamp('2184-12-19 11:00:00'), Timestamp('2184-12-20 10:00:00'), 'BASE', '0.9% Sodium Chloride', '001210', '00338004903', '500mL Bag'], [21433986, Timestamp('2184-12-19 11:00:00'), Timestamp('2184-12-20 10:00:00'), 'MAIN', 'Potassium Chloride', '001255', '00409665305', '2mEq/mL-20mL'], [21433986, Timestamp('2184-12-19 10:00:00'), Timestamp('2184-12-19 20:00:00'), 'MAIN', 'Lisinopril', '000390', '00172375910', '10mg Tablet'], [21433986, Timestamp('2184-12-19 10:00:00'), Timestamp('2184-12-19 20:00:00'), 'MAIN', 'Hydrochlorothiazide', '029832', '00603385521', '25mg Tablet'], [21433986, Timestamp('2184-12-19 10:00:00'), Timestamp('2184-12-19 20:00:00'), 'MAIN', 'Atenolol', '005139', '51079068420', '50 mg Tab'], [21433986, Timestamp('2184-12-19 06:00:00'), Timestamp('2184-12-30 20:00:00'), 'MAIN', 'Sodium Chloride 0.9% Flush', '', '0', 'Syringe'], [21433986, Timestamp('2184-12-19 11:00:00'), Timestamp('2184-12-20 10:00:00'), 'MAIN', 'Morphine Sulfate', '004070', '00409176230', '2mg Syringe'], [21433986, Timestamp('2184-12-19 11:00:00'), Timestamp('2184-12-20 10:00:00'), 'MAIN', 'Morphine Sulfate', '004072', '00409125830', '4mg Syringe']]

[]

['surgery']

[[51221, Timestamp('2184-12-24 05:30:00'), Timestamp('2184-12-24 06:21:00'), 'Hematocrit'], [51222, Timestamp('2184-12-24 05:30:00'), Timestamp('2184-12-24 06:21:00'), 'Hemoglobin'], [51248, Timestamp('2184-12-24 05:30:00'), Timestamp('2184-12-24 06:21:00'), 'MCH'], [51249, Timestamp('2184-12-24 05:30:00'), Timestamp('2184-12-24 06:21:00'), 'MCHC'], [51250, Timestamp('2184-12-24 05:30:00'), Timestamp('2184-12-24 06:21:00'), 'MCV'], [51265, Timestamp('2184-12-24 05:30:00'), Timestamp('2184-12-24 06:21:00'), 'Platelet Count'], [51277, Timestamp('2184-12-24 05:30:00'), Timestamp('2184-12-24 06:21:00'), 'RDW'], [51279, Timestamp('2184-12-24 05:30:00'), Timestamp('2184-12-24 06:21:00'), 'Red Blood Cells'], [51301, Timestamp('2184-12-24 05:30:00'), Timestamp('2184-12-24 06:21:00'), 'White Blood Cells'], [50861, Timestamp('2184-12-24 05:30:00'), Timestamp('2184-12-24 06:50:00'), 'Alanine Aminotransferase (ALT)'], [50862, Timestamp('2184-12-24 05:30:00'), Timestamp('2184-12-24 06:50:00'), 'Albumin'], [50863, Timestamp('2184-12-24 05:30:00'), Timestamp('2184-12-24 06:50:00'), 'Alkaline Phosphatase'], [50878, Timestamp('2184-12-24 05:30:00'), Timestamp('2184-12-24 06:50:00'), 'Asparate Aminotransferase (AST)'], [50885, Timestamp('2184-12-24 05:30:00'), Timestamp('2184-12-24 06:50:00'), 'Bilirubin, Total'], [50954, Timestamp('2184-12-24 05:30:00'), Timestamp('2184-12-24 06:50:00'), 'Lactate Dehydrogenase (LD)']]

Question: A 60 F is admitted. He/she says he/she has s/p Fall . History of illness: ___ found down s/p likely fall down ~15 stairs in early AM. Pt w no recollection of event but found by husband approximately 30 seconds following fall with patient conscious but disoriented. Patient became lucid within a minutes of fall and responded to husband's questions appropriately. Patient brought by ambulance to ___ ED. Mentating well in ED. C/o L facial lacs, occipital pain, neck pain, R wrist pain, R hip pain and dental malocclusion. Admits to consuming wine prior to bed (BAC 0.158 in ED). Denies dizziness, lightheadedness, chest pain, shortness of breath, nausea, vomiting. Past Medical History: HTN Social History: ___ Family History: Noncontributory Allergies: Erythromycin Base What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Metoprolol Tartrate LR 0.9% Sodium Chloride Potassium Chloride Lisinopril Hydrochlorothiazide Atenolol Sodium Chloride 0.9% Flush Morphine Sulfate Morphine Sulfate Target Lab Orders: Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells Alanine Aminotransferase (ALT) Albumin Alkaline Phosphatase Asparate Aminotransferase (AST) Bilirubin, Total Lactate Dehydrogenase (LD) Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : She was admitted to the ___ service; Plastics, Ophthalmology and OMFS were consulted given her extensive facial fractures. No ocular injuries were identified by Ophthalmology. She was taken to the operating room on ___ for exploration of left parotid duct and left facial nerve and again on ___ for closed reduction of maxillary fractures, insertion of custom splint, application of arch bars, Left Leforte II procedure. There were no complications. Because her jaws are wired shut she is on a liquid diet and is tolerating this. Nutritional supplements were also being recommended. She is ambulating independently; her home medications were restarted. She is on an oral pain and bowel regimen. She was seen by Social work for counseling re: alcohol use as a potential factor related to her fall. her disposition is home with services. Instructions for follow up were provided. Other Results: ___ 03:05AM ASA-NEG ___ ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 03:07AM GLUCOSE-118* LACTATE-2.5* NA+-139 K+-3.1* CL--97* TCO2-26 ___ 03:05AM UREA N-17 CREAT-0.8 ___ 03:05AM LIPASE-42 ___ 03:05AM WBC-7.8 RBC-4.39 HGB-14.6 HCT-40.3 MCV-92 MCH-33.2* MCHC-36.2* RDW-13.7 ___ 03:05AM ___ PTT-20.2* ___ ___ 03:05AM PLT COUNT-282 ___ 03:05AM ___ CT C-Spine ___: no intracranial hemorrhage or other acute process. extensive facial fractures involving the left orbit, left pterygoid, and bilateral maxillary sinuses. extensive blood in the sinuses and extensive secretinos in the posterior nasopharynx. rec facial CT for better characterization. CT Head ___: Questionable non-displaced fx involving the right superior facet of T1. no other cervical fx or traumatic malalignment. prevretebral soft tissues unremarkable. deg change most severe at C5-6 and ___ where there is mod canal narrowing. consider mr if there is concern for cord or ligamentous injury. CT Sinus/Mandible/Maxilla ___: (PRELIM READ) complex facial fractures. on the right, there are minimally displaced fractures of the anterior, medial and lateral walls of the maxillary sinus, and extending into hard palate. the right pterygoid is intact. on the left, there is a complex fracture involving all walls of the left max sinus, the pterygoid, the inferior and medial orbital walls, and the zm complex. overall config most c/w bilat lefort 1 and left lefort 2 ___s left ___ fx. no evidence of orbital contents herniation or entrapment. extensive blood in the sinuses and retropharyngeal secretions.

2145-12-21 22:10:00

ENGLISH

MARRIED

WHITE

M

[[26935993, Timestamp('2145-12-21 22:11:44'), '', 'OMED']]

[[{'Medications on Admission': ':\nThe Preadmission Medication list is accurate and complete.\n1. Ascorbic Acid ___ mg PO DAILY \n2. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain, cough \n3. Lorazepam 0.5 mg PO Q8H:PRN anxiety \n\nPlease check complete blood count, Chem10 (Na, K, Cl, HCO3, BUN, \nCr, glucose, Ca, Mg, P), and liver function tests and send to \nDr. ___ (phone ___ \nand Dr. ___ (Phone: ___ Fax: ___ for \nreview.\n\n7. Acetaminophen 650 mg PO Q8H \nRX *acetaminophen 650 mg 1 tablet extended release(s) by mouth \nup to three times a day as needed for pain Disp #*30 Tablet \nRefills:*0\n8. Benzonatate 100 mg PO TID:PRN cough \nRX *benzonatate 100 mg 1 capsule(s) by mouth up to three times a \nday as needed for cough Disp #*30 Capsule Refills:*0\n9. Bisacodyl 10 mg PO DAILY:PRN constipation \nRX *bisacodyl 5 mg 2 tablet,delayed release (___) by mouth \ndaily as needed for pain Disp #*20 Tablet Refills:*0\n10. Morphine SR (MS ___ 15 mg PO Q8H \n___ cause drowsiness. \nRX *morphine 15 mg 1 tablet extended release(s) by mouth three \ntimes a day for pain Disp #*30 Tablet Refills:*0\n11. Morphine Sulfate ___ 15 mg PO Q3H:PRN pain \n___ cause drowsiness. \nRX *morphine 15 mg 1 tablet(s) by mouth every three hours as \nneeded for pain Disp #*90 Tablet Refills:*0\n12. Senna 1 TAB PO BID constipation \nRX *sennosides 8.6 mg 1 tab by mouth twice a day to prevent \nconstipation Disp #*20 Tablet Refills:*0\n\nFacility:\n___\n\nSecondary: Renal cell carcinoma', 'Brief Hospital Course': ':\nMr. ___ is a ___ with history of RCC metastatic to lung, \nbrain, and bones who presented with melena, found to have \ngastric mass. \n\nHOSPITAL ISSUES:\n# Melena: Mr. ___ was admitted for melena and \nacute/subacute microcytic anemia, with improvement following 3 \nunits of packed red blood cells. CT abdomen/pelvis was negative \nfor retroperitoneal bleed, but did show several new likely \nmetastases, including one on the lesser curvature of the \nstomach. EGD revealed a gastric mass that, while not actively \nbleeding, was felt to be the source of his blood loss. He was \nevaluated by the surgical service for consideration of \nresection, which ultimately was not felt to be beneficial. He \nalso was evaluated by the radiation oncology service, and the \nutility of radiation therapy to his gastric mass will be \ndiscussed in the outpatient setting. \n\n# Endobronchial stent migration: Placement of his endobronchial \nstent also was assessed via CT scan and was felt by the \ninterventional pulmonology service to have migrated, and he \nunderwent stent replacement without complications. \n\n# Chest pain: was felt to be noncardiac in origin (reproducible \non palpation, EKG unchanged, cardiac enzymes unremarkable) \nrelated related to endobronchial stent and known osseous \nmetastases and responded to opioid analgesia. \n\n# Spine metastases: Imaging of his thoracic spine obtained at \nthe request of radiation oncology demonstrated worsening \nmetastatic burden with nerve impingement, but no evidence of \ncord compression.\n\n# Metastatic renal cell carcinoma: Per oncology note dated \n___, oral therapy has been held, and participation in \nclinical trial is to be discussed once acute anemia has \nresolved. Primary oncologist may restart pazopanib in the \noutpatient setting\n\n# Hypercalcemia: Likely from bone metastases. Corrected Ca was \n___ during this admission. Received one time 60mg \npamidronate iv. \n\n# Hyponatremia: Na of 129-134 this admission. Urine and serum \nosms consistent with SIADH in the setting of known brain and \npulmonary metastases. Mental status never altered.\n\n# Hyperbilirubinemia: 1.9 on ___, up from 0.3 ___. \nFractionated to about ___ direct, ___ indirect. ___ be related \nto blood transfusions from ___. \n\nTRANSITIONAL ISSUES:\n* Follow up with primary care and oncology, including for \nsurveillance of sodium (nadiring in low 130s, reflecting SIADH), \ncalcium (mildly elevated to approximately 11 corrected), \nhematocrit (approximately 25 at discharge), and liver function \ntests (total bilirubin mildly elevated to 1.6).\n* Follow up with interventional pulmonology and pain/palliative \ncare.\n\n', 'Pertinent Results:': '\nADMISSION LABS\n--------------\n___ 12:55PM BLOOD WBC-10.8# RBC-2.73* Hgb-6.4*# Hct-21.4*# \nMCV-78*# MCH-23.6*# MCHC-30.1* RDW-19.2* Plt ___\n___ 12:55PM BLOOD Neuts-85.7* Lymphs-6.9* Monos-6.8 Eos-0.4 \nBaso-0.3\n___ 12:55PM BLOOD UreaN-25* Creat-1.3* Na-130* K-5.2* \nCl-93* HCO3-26 AnGap-16\n___ 12:55PM BLOOD ALT-15 AST-14 AlkPhos-148* TotBili-0.4\n___ 12:55PM BLOOD Calcium-10.3 Phos-2.3* Mg-2.3\n\nIMAGING\n-------\n___ CT Abd/Pel w/o con: \n1. No abdominal fluid collection to suggest intra-abdominal \nbleed \n2. Worsening peritoneal metastatic disease burden of for example \nwith a large \nnecrotic metastatic lesion along the lesser curvature of the \nstomach today \nmeasuring 6.7 x 4.4 cm previously measuring 4.1 x 4.0 cm in \n___. \nSeveral other enlarged mesenteric lymph nodes appear larger than \nprior. A 1 cm subpleural nodule at the left lung base is \nincreased in size from prior exam small left-sided pleural \neffusion. \n3. Large fat containing left-sided inguinal hernia. \n4. Stable hypodense left hepatic lesion likely a cyst. \n5. Focal ectasia of the distal abdominal aorta to 2.8 cm. \n\n___ EGD: Mass in the fundus on lesser curve in upper fundus at \n55cm (biopsy). Otherwise normal EGD to third part of the \nduodenum \n\n___ Pathology from stomach biopsy:\nMetastatic renal cell carcinoma with clear cell featues, see \nnote.\nNote: The tumor has morphologic features, similar to the tumor\nbiopsied from the bronchi ___ and ___.\n\n___ CT Chest w/o con:\n1. Stable placement, right main bronchial stent with a wider \nlumen. Right hilar mass still occludes upper lobe bronchus, with \ngreater postobstructive consolidation. \n2. Progression of critical metastasis mid thoracic vertebral \nbody, virtually obliterating the vertebral canal. \n3. New pericardial or left ventricular metastasis. No \ntamponade. \n4. Significant acceleration of lympho-hematogenous metastasis, \npredominantly \nleft lung. \n5. Enlarging thyroid mass producing mild tracheal narrowing. \n\n___ MRI Thoracic spine w/ and w/o con: Preliminary Report\n1. Soft tissue metastatic lesion nearly completely replacing the \nT7 vertebral body with interval vertebral body height loss as \nwell as a significant increase in expansile soft tissue \ncomponent in the right lamina and transverse process completely \nobliterating the right neural foramen with contralateral \nextension into the left neural foramen with moderate narrowing. \nAdditional bony and soft tissue retropulsion focally contactS \nthe spinal cord without underlying cord signal abnormality. \n2. Multiple pulmonary parenchymal and pleural-based lesions are \npartially \nimaged and were better characterized on recent prior chest CT. \n\n', 'Physical Exam:|Physical': ' exam was notable for \nguiac-positive dark brown stool. EKG was interpreted as negative \nfor acute ischemic changes. FAST exam was negative. 2 units of \npRBC were type and crossed and given while patient was in the \nED. Per gastroenterology, PPI bolus followed by drip was \ninitiated, and he is to remain NPO after midnight for EGD in the \nmorning. CT abdomen/pelvis wet read showed worsening peritoneal \nmetastatic disease burden with a large necrotic metastatic \nlesion along the lesser curvature of the stomach, but no noted \nfluid collections suggesting intraperitoneal bleed. Hematocrit \ndirectly after second unit finished was 21.8, and patient was \nordered for two additional units PRBCs. Vital signs at transfer \nwere as follows: 98.5 83 121/59 20 96% RA. \n\nOn arrival to the floor, patient is complaining of abdominal \npain across the lower abdomen, ___, as well as back pain across \nthe lower back. Both are consistent with usual pains that he \nhas at home. There is no radiation of the back pain down the \nlegs or to the groin. He endorses fatigue and mild shortness of \nbreath, as well as right rib pain at the site of radiation and \noccupational injury 1 month prior to admission, but denies \nfevers/chills, chest pain, abdominal pain, dysuria, or back \npain. Patient does not drink alcohol and has not been using \nibuprofen. \n\nReview of Systems: \n(+) Per HPI \n(-) Denies fever, chills, night sweats, recent weight loss or \ngain. Denies blurry vision, diplopia, loss of vision, \nphotophobia. Denies headache, sinus tenderness, rhinorrhea or \ncongestion. Denies chest pain or tightness, palpitations, lower \nextremity edema. Denies wheezes. Denies nausea, vomiting, \ndiarrhea, hematemesis, hematochezia. Denies dysuria, stool or \nurine incontinence. Denies arthralgias or myalgias. Denies \nrashes or skin breakdown. No numbness/tingling in extremities. \nAll other systems negative. \n\nPast Medical History:\nPAST ONCOLOGIC HISTORY (per oncology note dated ___: \n-___: Left radical nephrectomy; grade II clear cell \ncarcinoma staged as T2NxMx. CT scan showed 6-mm noncalcified \nnodule in the anterior right middle lobe and a possible second \nnodule slightly more inferior; bone scan negative; PET CT showed \n\nactivity in left kidney tumor but no abnormal FDG uptake in the \n\nlungs. A single focus of increased activity in the left lobe of \n\nthe thyroid was noted and a thyroid ultrasound was recommended. \n\n-___: Surveillance CT scan showed multiple new pulmonary \nnodules and enlargement of previously noted nodules. The \nlargest of the nodules measured 1 cm. Referred for high-dose \nIL-2 treatment at ___ \n-___: Multiple R lung wedge resections; RML path shows ___ \n\nmets \n-___: IL2 Therapy at ___ \n-___: IL2 Therapy ___: Chest CT with post-obstructive consolidation, \nconcerning for endobronchial lesion causing obstruction. \n-___ - Flexible bronchoscopy with obstructing RUL \nendobronchial lesion and nonobstructing RLL endobronchial \nlesion. \n-___ - rigid bronchoscopy with mechanical and argon \nplasma \ncoagulation tumor debridement. Biopsy revealed clear cell \ncarcinoma. \n-___ - bronchoscopy and photodynamic therapy to RUL and \n\nRLL endobronchial lesions \n-___ - rigid bronchoscopy with mechanical tumor \ndebridement \n-___ - Cyberknife to right upper lobe lesion \n-___ - CT torso with slight interval increase in size \n\nof the dominant right upper lobe nodule with adjacent increased \n\nsoft tissue density surrounding the right upper lobe bronchus, \nconcerning for new adenopathy versus tumor extension. Increase \nin size of a nodule along the right middle lobe scar, now \nmeasuring 6 x 9 mm, previously barely visible. Stable size of \nmultiple other small pulmonary nodules as described above. \nAsymptomatic, plan to follow off of treatment. \n-___ - Craniotomy for L cerebellar metastasis. Presented \n\nwith severe headache, ataxia and dizziness. \n-___ - SRS treatment for both R and L cerebellar \nlesions \n-___ Bronchoscopy with cryodebridement and \nelectrocautery \n-___ Brain MRI shows new left frontal met \n-___ SRS to left frontal lesion \n-___ Brain MRI shows new right frontal lesion \n-___ SRS to right parietal lesion \n-___ Brain MRI shows new right occipital lobe lesion, \napproximately 0.6 x 1 cm. \n-___ SRS to right occipital lesion \n-___ Brain MRI shows new left temporal lesion \n-___ SRS to left temporal lesion \n-___ Brain MRI shows new right temporal lesion \n-___ SRS to right temporal lesion \n-___ SRS to new left parietal met \n-___ PDT to obstructing endobronchial lesion \n-___ SRS to new brain met \n-___ starts pazopanib \n-___ placement of endobronchial stent \n-___: MRI Head: Redemonstration of multiple bilateral \nsupra- and infra-tentorial intracranial enhancing lesions. \nThere is no evidence of new or enlarging focus of abnormal \nenhancement. \n-___: Silicone stent placement in RUL bronchus due to \nobstruction of previous stent by mass \n-___: CT Chest/A/P \n*left lower paratracheal lymph node 1.8 cm x 1.2 cm overall \nunchanged \n*Right and left perihilar lymphadenopathy is overall stable \ncompared to the prior exam. The heart size is normal. There is \n*diffuse metastatic disease consisting of multiple bilateral \nlung \nnodules, lymphangitic carcinomatosis, especially in the left \nupper lobe have slightly increased in size. \n*pleural-based metastasis in the right chest wall with evidence \n\nof bony destruction measuring 3.6 cm x 6.7 cm, overall increased \n\nin size compared to the prior exam, at which time this measured \n\n5.5 cm x 2.5 cm. \n*lesion in the posterior left hemithorax which now measures 4.7 \n\ncm x 2.3 cm which has increased in size compared to the prior \nexam, at which time this lesion measured 3.7 cm x 1.9 cm, series \n\n4A, image 118. \n*lingular nodule which measures 1.4 cm x 1.4 cm, series 4A, \nimage \n109, which has increased in size compared to the prior exam, at \n\nwhich time this nodule measured 1 cm x 0.8 cm. \n*lesion in the right middle lobe which measures 1.5 cm x 3.9 cm, \n\noverall increased in size compared to the prior exam, at which \ntime this measured 2.4 cm x 1.2 cm. \n*stent sitting in the bronchus intermedius is patent. Nodular \nopacities in the right upper lobe and right lower lobe could be \n\nsecondary to obstructive pneumonitis mixed with lymphangitic \nspread. Bulk of the right hilar mass is overall stable compared \n\nto the prior exam, now measuring 3.4-cm x 5.9-cm \n*Metastatic lesion adjacent to the transverse colon has \nincreased \nin size, now measuring 4.1 cm x 3.2 cm \n*necrotic metastatic focus in the hepatogastric ligament has \nalso \nincreased in size, now measuring 6.1 cm x 4.1 cm, \n*slight progression of the bilateral adrenal mets compared to \nthe \nprior exam. \n*interval worsening of the lytic soft tissue rib metastasis \noverlying the lateral portion of the fourth rib. The soft tissue \n\nlytic met to the vertebral body of T7 has also increased in size \n\nand appears to be projecting inside the central canal with \nnarrowing of the right neural foramen. \n-___: MRI T spine \n*T7 vertebral body is a metastatic lesion extending into the \nright pedicle, causing severe right neural foraminal narrowing. \n\nNo spinal cord compression \n-___: Dr. ___ a 30mm X 14mm Merit stent right \n\nmainstem bronchus. The stent was ballooned resulting in full \npatency and ventilation of the right lower lobe. \n-___: CXR: A stent is now present in the right \nmainstem bronchus and aeration of the right lung has improved \nconsiderably from ___. \n-___: Three CK treatments to C7 \n-___: Everolimus started at 10mg po daily; pazopanib \ndiscontinued \n-___: Unable to tolerate the everolimus due to \nmoderately severe stomach pain, nausea. He has discontinued the \n\ndrug with prompt improvement in his sx. \n\nPAST MEDICAL HISTORY (per oncology note dated ___: \nHypertension \nLeft inguinal hernia \n\nSocial History:\n___\nFamily History:\nFather with prostate cancer \n\nPhysical Exam:\nADMISSION EXAM\n--------------\nVS: T 98.5 BP 115/63 P 82 R 18 Sat 97%RA\nGEN: Alert, oriented to name, place and situation. Fatigued \nappearing but comfortable, no acute signs of distress.\nHEENT: NCAT, Pupils equal and reactive, sclerae anicteric, o/p \nclear, MMM.\nNeck: Supple, no JVD\nLymph nodes: No cervical, supraclavicular LAD.\nCV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops.\nRESP: Good air movement bilaterally, rhonchi present that clear \nwith coughing, no rales or wheezes\nABD: Soft, non-tender, mildly distended, + bowel sounds.\nBACK: no pain to palpation of flanks, patient able to lay flat\nEXTR: No lower leg edema, no clubbing or cyanosis\nDERM: No active rash.\nNeuro: non-focal.\nPSYCH: Appropriate and calm.\n\nDISCHARGE EXAM\n--------------\nVS: 98.3, 110-134/60-68, 84-93, 20, 96% RA \nGEN: Alert and conversant. NAD. \nHEENT: MMM. \nCV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops, \ntender to palpation at left lateral chest without obvious skin \nchanges. \nRESP: Good air movement bilaterally, no rales or wheezes.\nABD: Soft, non-tender, + bowel sounds. \nEXTR: No lower leg edema, no clubbing or cyanosis \n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\n___ year old male with history of RCC metastatic to lung, brain, \nand bones who presents with melena. He was reportedly in his \nusual state of health until the night prior to admission, when \nhe experienced loose black stool following several days of \nconstipation. In ___ clinic, initial labs obtained at \n12:55pm were remarkable for Na of 130 (versus recent baseline of \n136), K of 5.2, BUN/Hct of ___ (consistent with recent \nbaseline), normal AST/ALT, AlkP of 148 (up from 99 in ___, \nHgb/Hct of 6.4/21.4 with MCV of 78 (versus recent baseline of \n9.8/30.3 with MCV of 88), and platelet count of 545 (versus \nrecent baseline of 318). He was referred to the ED for further \nevaluation due to suspicion for GI bleed. \n\nIn the ED, initial vital signs were as follows: 99.6 82 123/55 \n16 100% RA. Repeat labs at 4:30pm were notable for Na of 129, \nBUN/Cr of ___, Hgb/Hct of ___, platelet count of 501, INR \nof 1.4, and negative UA. ', 'Chief Complaint:|Complaint:': '\n___\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nNo Known Allergies / Adverse Drug Reactions\n\n'}, '16571136-DS-12', 12, 'medicine']]

[['TYPE OF EXAMINATION: Chest PA and lateral.\n\nINDICATION: ___ male patient with metastatic renal cell carcinoma to\nlung and airways. Metallic stent in place, evaluate stent placement.\n\nFINDINGS: PA and lateral chest views were obtained with patient in upright\nposition. Analysis is performed in direct comparison with the next preceding\nportable single view chest examination of ___. Heart size is\nunchanged and the same holds for the appearance of the thoracic aorta. \nPreviously described right-sided perihilar mass, grossly unchanged. Within\nthis density one can identify the metallic structures of the stent, which has\nbeen placed in the right-sided main bronchus partially seen to occupy portions\nof the carina. There is no evidence of any airway obstruction through the\nstent. There is no evidence of new atelectasis distal to the stent which\nventilates the area of the right lower and middle lobes. Comparison of the\nfrontal views; however, suggests new local parenchymal density in the central\nportion of the right middle lobe as can be identified also on the lateral\nview. The previously identified increased interstitial markings in the left\nupper lobe persist and may have increased slightly. They are believed to\nrepresent interstitial carcinomatosis. The lateral and posterior pleural\nsinuses remain free, thus there is no evidence of significant pleural\neffusion. The on multiple previous examinations identified abnormalities and\nlocal pleural thickening in the right axillary area remain grossly unchanged.\n\nIMPRESSION: No evidence of main bronchus stent occlusion. Some progression\nof pulmonary abnormalities is, however, noted.\n', '16571136-RR-86', 86, ''], ['HISTORY: GI bleed, no response to blood. Evaluate for free fluid in abdomen.\n\n\nCOMPARISON: CT torso dated ___ and CT chest dated ___.\n. \n\nTECHNIQUE: Multidetector CT of the abdomen and pelvis was performed without\ncontrast. Coronal and sagittal reformats were provided. \n\nDLP: 694.4 mGy-cm.\n\nFINDINGS:\n\nABDOMEN: \n\nThe patient is status post left nephrectomy. There are large bilateral\nadrenal masses which were not present on the previous CT in ___ and have\nincreased markedly in size since ___. These measure 2.2 x 2 cm on the\nright (1.3 x 1 cm in ___ and 2.9 x 2.6 cm on the left (2.5 x 2 cm in\n___. The mass within the left adrenal gland is of high density\nmeasuring 53 Hounsfield units. \n\nThere is a 6.7 x 4.4 cm mass involving the fundus and body of the stomach\nwhich has a high attenuation rim and low attenuation center likely\nrepresenting central necrosis (2:22). This has substantially increased in size\nsince the previous CT in ___ when it measured 2 x 2 cm. It has also\nincreased in size since the previous chest CT in ___ when it measured\n4.1 x 4 cm. There is a further similar-appearing mass within the transverse\nmesocolon involving the posterior wall of the transverse colon which measures\n4.2 x 3.4 cm that was not present on the previous CT in ___ and is increased\nmarkedly in size since ___ when it measured 2.3 x 2.1 cm. The colon is\notherwise unremarkable. There is also a high-density lymph node in the\ngastrohepatic ligament measuring 1.7 x 1.4 cm which was not present on the\nprevious CTs (2:25). \n\nThere are multiple new pancreatic masses which are also of high density -\nthese measure 3.3 x 2.7 cm in the head of the pancreas (2:33) and 1.4 x 1.2 cm\nwithin the distal body of the pancreas (2:31). \n\nThere is a 1.2 cm low-attenuation lesion within segment III of the liver and a\n0.6 cm low attenuation lesion within segment II - both of these are unchanged\nsince the previous CT but are too small to further characterize. The liver is\notherwise unremarkable on this non-contrast examination. No intra or\nextrahepatic duct dilatation. The gallbladder is within normal limits. \n\nThere is a small area of low attenuation linear low attenuation within the\nperiphery of the spleen consistent with a small infarct (2:25). The spleen is\notherwise unremarkable. \n\nThe small bowel is within normal limits. Multiple mildly enlarged right\npara-aortic lymph nodes are identified and appear to have increased slightly\nin size since ___ with the largest measuring 0.9 cm in short-axis diameter\n(2:34). Note is made of a left-sided infrarenal inferior vena cava which\ndrains into the left renal vein. The infrarenal abdominal aorta is mildly\nectatic measuring 2.6 cm in AP diameter. Calcified atheromatous plaque is\nidentified within the infrarenal abdominal aorta. \n\nThere is a new small left pleural effusion with compressive atelectasis of the\nleft lower lobe. A 1 cm pleural-based nodule is identified within the left\nlower lobe and has increased in size since previous (previously 0.8 cm; 2:4).\nThe right lung base is unremarkable. There is a small pericardial effusion. \nThe attenuation of the blood within the heart chambers is low, likely\nreflecting anemia. The visualized portion of the heart and pericardium is\notherwise unremarkable. \n\nPELVIS: \n\nThe bladder is within normal limits. Foci of calcification are noted within\nthe central portion of the prostate gland. The prostate gland and seminal\nvesicles are otherwise unremarkable. No pelvic adenopathy. Note is made of\nan uncomplicated fat-containing indirect left inguinal hernia. \n\nOSSEOUS STRUCTURES: \n\nThere is a new lucent lesion within the left iliac bone (2:58). Degenerative\nchange is noted throughout the lumbar spine which is most marked at L5-S1 with\ndisc space loss and osteophyte formation. \n\nIMPRESSION:\n\n1. Significant interval progression of metastatic disease with increased size\nof metastases involving the fundus/body of the stomach and within the\ntransverse mesocolon. Increased bilateral adrenal metastases. New pancreatic\nmetastases. New gastrohepatic ligament metastatic lymph node. New left\npleural effusion and increased size of left lower lobe metastasis. \n\n2. New lucent lesion within the left iliac bone concerning for osseous\nmetastasis. \n\n3. No intraperitoneal or retroperitoneal hematoma. No free fluid within the\nabdomen. \n\n4. Small pericardial effusion. \n\n', '16571136-RR-87', 87, 'multidetector ct of the abdomen and pelvis was performed without\ncontrast. coronal and sagittal reformats were provided.'], ['CHEST CT, ___\n\nHISTORY: ___ man with metastatic renal cell carcinoma. Evaluate\nendobronchial stent.\n\nTECHNIQUE: Multidetector helical scanning of the chest was performed without\nintravenous contrast agent reconstructed as contiguous 5- and 1.25-mm thick\naxial and 5-mm thick coronal and parasagittal and 8 x 8 mm MIPs axial images\ncompared to chest CT scanning most recently ___.\n\nFINDINGS:\n\nTrachea is further displaced to the right at the thoracic inlet by a large\nmass involving the left lobe of the thyroid gland, currently 39 x 42 mm in\naggregate, previously 36 x 36 mm. The lower pole of the lesion narrows the\nairway diameter from 19 x 26 mm at the level of the cricoid to 13 x 25 mm,\npreviously 16 x 26 mm. Proximal end of the bronchial stent is 1 cm above the\ncarina, 2.5 cm into the right main bronchus, ending 1 cm beyond the orifice to\nthe right upper lobe bronchus. The latter is still occluded by tumor\ninvolving the upper pole of the right hilus and adjacent pleura, 55 x 50 mm in\naggregate, 3:23, previously 38 x 49 mm. The airway is stented fully open, to\na diameter of 10 mm, compared to 8 mm on ___. Tumor narrows the bronchus\nintermedius to 5.6 mm, previously 7 mm, the middle and superior segment and\nbasal trunk bronchi are fully patent. There has been a substantial increase in\npostobstructive consolidation in the right upper lobe.\n\n\nCentral adenopathy is relatively unchanged, 15 mm in the left lower\nparatracheal station, previously 14 mm, 15 x 20 mm in the subcarinal,\npreviously 11 x 12 mm at the point where the bronchus intermedius is now\nnarrowed. \n\nParamediastinal pleural tumor is more extensive, but does not impinge on vital\nstructures; specifically the SVC and pulmonary arteries are intact. Small\npericardial effusion is larger, and there is lobulation of the posterior\ncontour of the cardiac silhouette at the level of the left ventricle, 3:41\nthat could be due to tumor invasion, but would need gated, dedicated cardiac\nimaging to assess. There is no evidence of tamponade physiology. The major\npleural abnormality in the right hemithorax is local extension of a large rib\nmetastasis, just above the level of the carina at lateral chest wall also\ninvading the chest wall musculature, currently 44 x 71 mm, unchanged in\n___. Despite remote pleural implants along the posterior right pleural\nsurface at the level of the superior segment of the right lower lobe, there is\nno right pleural effusion. Small-to-moderate left pleural effusion has\ndeveloped, in the setting of stable 29 x 48 mm left pleural mass along the\nposterior pleural surface and smaller pleural implants inferiorly and growing\nparamediastinal pleural mass at the level of the aortopulmonic window. \n\nThe most significant lung change is the substantial increase in hematogenous\ntumor dissemination consisting of small irregular opacities and grossly\nthickened interstitial and lymphatic structures, most pronounced in the left\nupper lobe. \n\nA large metastasis to the body of a mid-thoracic vertebra, invading if not\nentirely occluding the thoracic vertebral canal has grown, from 24 x 39 mm to\n31 x 42 mm, 3:32. Findings below the diaphragm, including bilateral adrenal\nmasses will be discussed separately in the report of the concurrent chest\nabdomen CT.\n\nIMPRESSION:\n1. Stable placement, right main bronchial stent with a wider lumen. Right\nhilar mass still occludes upper lobe bronchus, with greater postobstructive\nconsolidation.\n\n2. Progression of critical metastasis mid thoracic vertebral body, virtually\nobliterating the vertebral canal.\n\n3. New pericardial or left ventricular metastasis. No tamponade.\n\n4. Significant acceleration of lympho-hematogenous metastasis, predominantly\nleft lung.\n\n5. Enlarging thyroid mass producing mild tracheal narrowing.\n', '16571136-RR-88', 88, 'multidetector helical scanning of the chest was performed without\nintravenous contrast agent reconstructed as contiguous 5- and 1.25-mm thick\naxial and 5-mm thick coronal and parasagittal and 8 x 8 mm mips axial images\ncompared to chest ct scanning most recently ___.'], ['MR OF THE THORACIC SPINE, WITHOUT AND WITH CONTRAST, ___\n\nHISTORY: Metastatic RCC with mets to the brain, lung and spine. One-month\nfollowup status post CyberKnife.\n\nCOMPARISON: MR thoracic spine ___, CT chest ___.\n\nTECHNIQUE: Multiplanar, multisequence MRI images of thoracic spine were\nacquired on a 1.5 Tesla magnet before and after the uneventful intravenous\nadministration of 7 cc Gadovist per routine ___ protocol.\n\nFINDINGS: Again identified is a metastatic lesion replacing the entirety of\nthe T7 vertebral body with mild interval roughly 20% loss of height. This\nlesion is expansile with a combination of posterior bony retropulsion and\nextraosseous soft tissue extension, narrowing the spinal canal and contacting\nthe spinal cord without underlying cord signal abnormality. This lesion\nextends into the right lamina and transverse process with soft tissue\nextension into the right neural foramen, inseparable from and apparently\ncompletely encasing the exiting right T7 nerve root. There is also soft\ntissue extension into the contralateral neural foramen with mild-to-moderate\nnarrowing. The spinal cord is normal in signal intensity and morphology.\n\nNo new bony lesion is identified. There is redemonstration of multilevel\ndegenerative changes including multilevel disc space narrowing and minimal\nmultilevel posterior disc protrusions which indent the ventral thecal sac,\nwithout causing significant canal stenosis.\n\nExtensive bilateral pulmonary parenchymal metastatic disease is incompletely\nimaged, and was better evaluated on recent chest CT from ___.\n\nIMPRESSION:\n1. Soft tissue metastatic lesion, nearly completely replacing the T7\nvertebral body with interval vertebral body height loss. There is a\nsignificant increase in expansile soft tissue component in the right lamina\nand transverse process, completely obliterating the right neural foramen with\ncontralateral extension into and moderate narrowing of the left neural foramen\nand possible exiting T7 neural impingement. \n\n2. Additional bony and soft tissue retropulsion focally contacts the spinal\ncord without underlying cord signal abnormality.\n\n3. Multiple pulmonary parenchymal and pleural-based lesions are partially\nimaged and were better characterized on recent prior chest CT.\n\nCOMMENT: Results were discussed with Dr. ___ (Medicine service) by\nDr. ___ over the telephone, at 3:30 p.m. on ___, at time\nof initial review.\n', '16571136-RR-89', 89, 'multiplanar, multisequence mri images of thoracic spine were\nacquired on a 1.5 tesla magnet before and after the uneventful intravenous\nadministration of 7 cc gadovist per routine ___ protocol.'], ['CHEST RADIOGRAPH\n\nINDICATION: Shortness of breath, partially displaced vent, evaluation.\n\nCOMPARISON: ___.\n\nFINDINGS: As compared to the previous examination, there is no relevant\nchange in appearance of the right mainstem bronchial stent as well as the\nlarge right hilar lesion, combines to a right lateral pleural opacity\naccompanying rib destruction. On the left, there is increasing evidence of\nmild fluid overload. New left retrocardiac atelectasis. No pneumothorax. No\npleural effusions. Unchanged appearance of the cardiac silhouette.\n', '16571136-RR-91', 91, '']]

[[26935993, Timestamp('2145-12-21 01:00:00'), Timestamp('2145-12-22 02:00:00'), 'MAIN', 'Sodium Chloride 0.9% Flush', '', '0', '10 mL Syringe'], [26935993, Timestamp('2145-12-22 03:00:00'), Timestamp('2145-12-25 19:00:00'), 'MAIN', 'Senna', '019964', '00904516561', '1 Tablet'], [26935993, Timestamp('2145-12-22 03:00:00'), Timestamp('2145-12-28 21:00:00'), 'MAIN', 'Docusate Sodium', '003009', '00904224461', '100mg Capsule'], [26935993, Timestamp('2145-12-22 02:00:00'), Timestamp('2145-12-28 21:00:00'), 'MAIN', 'Sodium Chloride 0.9% Flush', '', '0', '10 mL Syringe'], [26935993, Timestamp('2145-12-22 02:00:00'), Timestamp('2145-12-28 21:00:00'), 'BASE', '0.9% Sodium Chloride', '001210', '00338004938', '100mL Bag'], [26935993, Timestamp('2145-12-22 02:00:00'), Timestamp('2145-12-28 21:00:00'), 'MAIN', 'Pantoprazole', '047635', '00008092355', '40 mg Vial'], [26935993, Timestamp('2145-12-22 01:00:00'), Timestamp('2145-12-22 02:00:00'), 'MAIN', 'Lorazepam', '003757', '00904598061', '0.5mg Tablet'], [26935993, Timestamp('2145-12-22 02:00:00'), Timestamp('2145-12-28 21:00:00'), 'MAIN', 'PNEUMOcoccal 23-valent polysaccharide vaccine', '048548', '00006473900', '25mcg/0.5mL Vial'], [26935993, Timestamp('2145-12-22 02:00:00'), Timestamp('2145-12-28 21:00:00'), 'MAIN', 'Ascorbic Acid', '002151', '00904052361', '500 mg Tab'], [26935993, Timestamp('2145-12-22 03:00:00'), Timestamp('2145-12-28 21:00:00'), 'MAIN', 'Polyethylene Glycol', '034313', '11523726808', '17g Packet'], [26935993, Timestamp('2145-12-22 03:00:00'), Timestamp('2145-12-23 12:00:00'), 'MAIN', 'Morphine Sulfate', '004080', '00641607325', '5 mg Vial'], [26935993, Timestamp('2145-12-22 02:00:00'), Timestamp('2145-12-22 17:00:00'), 'BASE', '0.9% Sodium Chloride', '001210', '00338004938', '100mL Bag'], [26935993, Timestamp('2145-12-22 02:00:00'), Timestamp('2145-12-22 17:00:00'), 'MAIN', 'Pantoprazole', '047635', '00008092355', '40 mg Vial'], [26935993, Timestamp('2145-12-22 02:00:00'), Timestamp('2145-12-27 12:00:00'), 'MAIN', 'Influenza Virus Vaccine', '071215', '49281001350', '0.5 mL Syringe'], [26935993, Timestamp('2145-12-21 01:00:00'), Timestamp('2145-12-22 02:00:00'), 'MAIN', 'Influenza Virus Vaccine', '071215', '49281001350', '0.5 mL Syringe'], [26935993, Timestamp('2145-12-22 02:00:00'), Timestamp('2145-12-22 02:00:00'), 'BASE', 'Vial', '', '0', 'Send Vial'], [26935993, Timestamp('2145-12-22 02:00:00'), Timestamp('2145-12-22 02:00:00'), 'MAIN', 'Pantoprazole', '047635', '00008092355', '40 mg Vial']]

[]

['medicine']

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Question: A 62 M is admitted. He/she says he/she has ___ . History of illness: ___ year old male with history of RCC metastatic to lung, brain, and bones who presents with melena. He was reportedly in his usual state of health until the night prior to admission, when he experienced loose black stool following several days of constipation. In ___ clinic, initial labs obtained at 12:55pm were remarkable for Na of 130 (versus recent baseline of 136), K of 5.2, BUN/Hct of ___ (consistent with recent baseline), normal AST/ALT, AlkP of 148 (up from 99 in ___, Hgb/Hct of 6.4/21.4 with MCV of 78 (versus recent baseline of 9.8/30.3 with MCV of 88), and platelet count of 545 (versus recent baseline of 318). He was referred to the ED for further evaluation due to suspicion for GI bleed. In the ED, initial vital signs were as follows: 99.6 82 123/55 16 100% RA. Repeat labs at 4:30pm were notable for Na of 129, BUN/Cr of ___, Hgb/Hct of ___, platelet count of 501, INR of 1.4, and negative UA. Allergies: No Known Allergies / Adverse Drug Reactions What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Sodium Chloride 0.9% Flush Senna Docusate Sodium Sodium Chloride 0.9% Flush 0.9% Sodium Chloride Pantoprazole Lorazepam PNEUMOcoccal 23-valent polysaccharide vaccine Ascorbic Acid Polyethylene Glycol Morphine Sulfate 0.9% Sodium Chloride Pantoprazole Influenza Virus Vaccine Influenza Virus Vaccine Vial Pantoprazole Target Lab Orders: Anion Gap Bicarbonate Calcium, Total Chloride Creatinine Glucose Magnesium Phosphate Potassium Sodium Urea Nitrogen Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells Hematocrit Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : Mr. ___ is a ___ with history of RCC metastatic to lung, brain, and bones who presented with melena, found to have gastric mass. HOSPITAL ISSUES: # Melena: Mr. ___ was admitted for melena and acute/subacute microcytic anemia, with improvement following 3 units of packed red blood cells. CT abdomen/pelvis was negative for retroperitoneal bleed, but did show several new likely metastases, including one on the lesser curvature of the stomach. EGD revealed a gastric mass that, while not actively bleeding, was felt to be the source of his blood loss. He was evaluated by the surgical service for consideration of resection, which ultimately was not felt to be beneficial. He also was evaluated by the radiation oncology service, and the utility of radiation therapy to his gastric mass will be discussed in the outpatient setting. # Endobronchial stent migration: Placement of his endobronchial stent also was assessed via CT scan and was felt by the interventional pulmonology service to have migrated, and he underwent stent replacement without complications. # Chest pain: was felt to be noncardiac in origin (reproducible on palpation, EKG unchanged, cardiac enzymes unremarkable) related related to endobronchial stent and known osseous metastases and responded to opioid analgesia. # Spine metastases: Imaging of his thoracic spine obtained at the request of radiation oncology demonstrated worsening metastatic burden with nerve impingement, but no evidence of cord compression. # Metastatic renal cell carcinoma: Per oncology note dated ___, oral therapy has been held, and participation in clinical trial is to be discussed once acute anemia has resolved. Primary oncologist may restart pazopanib in the outpatient setting # Hypercalcemia: Likely from bone metastases. Corrected Ca was ___ during this admission. Received one time 60mg pamidronate iv. # Hyponatremia: Na of 129-134 this admission. Urine and serum osms consistent with SIADH in the setting of known brain and pulmonary metastases. Mental status never altered. # Hyperbilirubinemia: 1.9 on ___, up from 0.3 ___. Fractionated to about ___ direct, ___ indirect. ___ be related to blood transfusions from ___. TRANSITIONAL ISSUES: * Follow up with primary care and oncology, including for surveillance of sodium (nadiring in low 130s, reflecting SIADH), calcium (mildly elevated to approximately 11 corrected), hematocrit (approximately 25 at discharge), and liver function tests (total bilirubin mildly elevated to 1.6). * Follow up with interventional pulmonology and pain/palliative care. Other Results: ADMISSION LABS -------------- ___ 12:55PM BLOOD WBC-10.8# RBC-2.73* Hgb-6.4*# Hct-21.4*# MCV-78*# MCH-23.6*# MCHC-30.1* RDW-19.2* Plt ___ ___ 12:55PM BLOOD Neuts-85.7* Lymphs-6.9* Monos-6.8 Eos-0.4 Baso-0.3 ___ 12:55PM BLOOD UreaN-25* Creat-1.3* Na-130* K-5.2* Cl-93* HCO3-26 AnGap-16 ___ 12:55PM BLOOD ALT-15 AST-14 AlkPhos-148* TotBili-0.4 ___ 12:55PM BLOOD Calcium-10.3 Phos-2.3* Mg-2.3 IMAGING ------- ___ CT Abd/Pel w/o con: 1. No abdominal fluid collection to suggest intra-abdominal bleed 2. Worsening peritoneal metastatic disease burden of for example with a large necrotic metastatic lesion along the lesser curvature of the stomach today measuring 6.7 x 4.4 cm previously measuring 4.1 x 4.0 cm in ___. Several other enlarged mesenteric lymph nodes appear larger than prior. A 1 cm subpleural nodule at the left lung base is increased in size from prior exam small left-sided pleural effusion. 3. Large fat containing left-sided inguinal hernia. 4. Stable hypodense left hepatic lesion likely a cyst. 5. Focal ectasia of the distal abdominal aorta to 2.8 cm. ___ EGD: Mass in the fundus on lesser curve in upper fundus at 55cm (biopsy). Otherwise normal EGD to third part of the duodenum ___ Pathology from stomach biopsy: Metastatic renal cell carcinoma with clear cell featues, see note. Note: The tumor has morphologic features, similar to the tumor biopsied from the bronchi ___ and ___. ___ CT Chest w/o con: 1. Stable placement, right main bronchial stent with a wider lumen. Right hilar mass still occludes upper lobe bronchus, with greater postobstructive consolidation. 2. Progression of critical metastasis mid thoracic vertebral body, virtually obliterating the vertebral canal. 3. New pericardial or left ventricular metastasis. No tamponade. 4. Significant acceleration of lympho-hematogenous metastasis, predominantly left lung. 5. Enlarging thyroid mass producing mild tracheal narrowing. ___ MRI Thoracic spine w/ and w/o con: Preliminary Report 1. Soft tissue metastatic lesion nearly completely replacing the T7 vertebral body with interval vertebral body height loss as well as a significant increase in expansile soft tissue component in the right lamina and transverse process completely obliterating the right neural foramen with contralateral extension into the left neural foramen with moderate narrowing. Additional bony and soft tissue retropulsion focally contactS the spinal cord without underlying cord signal abnormality. 2. Multiple pulmonary parenchymal and pleural-based lesions are partially imaged and were better characterized on recent prior chest CT.

2123-05-13 02:47:00

ENGLISH

MARRIED

WHITE - OTHER EUROPEAN

M

[[27181431, Timestamp('2123-05-13 02:47:33'), '', 'ENT']]

[[{'Medications on Admission': ':\nThe Preadmission Medication list is accurate and complete.\n1. Fluticasone Propionate NASAL 2 SPRY NU DAILY \n2. Omeprazole 20 mg PO DAILY ', 'Brief Hospital Course': ':\n___ year old male underwent right superficial parotidectomy \nwithout complication. Recovered in the PACU and then \ntransitioned to hospital floor for observation. Diet advanced \nwithout complication. Tolerating bland diet. Pain well \ncontrolled with oral medications. Was taught how to care for, \nmeasure and record JP output. Discharged on POD1 with planned \nfollow up in Dr. ___ for removal of JP drain. At \ndischarge was AFVSS. \n\n', 'Pertinent Results:': '\nFinal surgical pathology -pending\n\n', 'Physical Exam:|Physical': '\nNAD \nNon-labored breathing \nWeakness of right buccal branch of CN VII, otherwise CNVII \nintact bilaterally \nIncision c/d/I \nJP with ss output \nneck soft, trachea midline\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\n___ year old male with history of right parotid mass. On FNA, \nconsistent with pleomorphic adenoma. \n\nPast Medical History:\nAsthma, Allergic Rhinitis, Atypical Chest Pain, ___ \nSyndrome, Heart Murmur, Low Back Pain, Positive PPD, s/p R ACL \nrepair, GERD, Verocele\n\nSocial History:\n___\nFamily History:\nNA\n\n', 'Chief Complaint:|Complaint:': '\nRight Parotid Mass \n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nNo Known Allergies / Adverse Drug Reactions\n\n'}, '19063054-DS-5', 5, 'otolaryngology']]

[]

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[]

['otolaryngology']

[]

Question: A 47 M is admitted. He/she says he/she has Right Parotid Mass . History of illness: ___ year old male with history of right parotid mass. On FNA, consistent with pleomorphic adenoma. Past Medical History: Asthma, Allergic Rhinitis, Atypical Chest Pain, ___ Syndrome, Heart Murmur, Low Back Pain, Positive PPD, s/p R ACL repair, GERD, Verocele Social History: ___ Family History: NA Allergies: No Known Allergies / Adverse Drug Reactions What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Ondansetron Influenza Vaccine Quadrivalent Oxymetazoline Prochlorperazine Omeprazole Senna Cephalexin OxycoDONE (Immediate Release) Fluticasone Propionate NASAL Lactated Ringers Acetaminophen Target Lab Orders: NONE Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : ___ year old male underwent right superficial parotidectomy without complication. Recovered in the PACU and then transitioned to hospital floor for observation. Diet advanced without complication. Tolerating bland diet. Pain well controlled with oral medications. Was taught how to care for, measure and record JP output. Discharged on POD1 with planned follow up in Dr. ___ for removal of JP drain. At discharge was AFVSS. Other Results: Final surgical pathology -pending

2133-07-07 09:30:00

ENGLISH

MARRIED

WHITE

M

[[21445110, Timestamp('2133-07-07 05:03:51'), '', 'GU']]

[[{'Medications on Admission': ':\nprozac, janumet, aspirin', 'Brief Hospital Course': ':\nPatient was admitted to Urology after undergoing radical \nadrenalectomy (LEFT)\nNo concerning intraoperative events occurred; please see \ndictated operative note for details. The patient received \nperioperative antibiotic prophylaxis. The patient was \ntransferred to the floor from the PACU in stable condition. On \nPOD0, pain was well controlled on PCA, hydrated for urine output \n>30cc/hour, and provided with pneumoboots and incentive \nspirometry for prophylaxis. On POD1, the patient ambulated, \nrestarted on home medications, basic metabolic panel and \ncomplete blood count were checked, pain control was transitioned \nfrom PCA to oral analgesics, diet was advanced to a clears/toast \nand crackers diet. On POD2, JP and urethral catheter (foley) \nwere removed without difficulty and diet was advanced as \ntolerated. The remainder of the hospital course was relatively \nunremarkable. The patient was discharged in stable condition, \neating well, ambulating independently, voiding without \ndifficulty, and with pain control on oral analgesics. On exam, \nincision was clean, dry, and intact, with no evidence of \nhematoma collection or infection. The patient was given explicit \ninstructions to follow-up in clinic with ___ ___ in 3 weeks.\n\nHe was discharged with instructionbs to resume his home \nmedications and with explicit instructios for taking prednisone \nand florinef per his endocrinologist. \n\n', 'Pertinent Results:': '\n___ 08:45AM BLOOD WBC-8.3 RBC-3.94* Hgb-12.1* Hct-34.5* \nMCV-88 MCH-30.7 MCHC-35.0 RDW-12.7 Plt ___\n___ 09:30AM BLOOD WBC-10.8 RBC-4.17* Hgb-12.8* Hct-36.5* \nMCV-88 MCH-30.6 MCHC-34.9 RDW-13.7 Plt ___\n___ 08:45AM BLOOD Glucose-145* UreaN-10 Creat-0.8 Na-139 \nK-4.0 Cl-104 HCO3-28 AnGap-11\n___ 09:30AM BLOOD Glucose-140* UreaN-13 Creat-0.9 Na-146* \nK-4.1 Cl-107 HCO3-32 AnGap-11\n___ 08:45AM BLOOD Calcium-8.6 Phos-1.7* Mg-1.8\n\n', 'Physical Exam:|Physical': '\nCurrently, there is no history of dysuria, gross hematuria, \nintermittency or\nhistory of urinary tract infection. No colorectal symptoms or\nhistory of peripheral edema.\n\nOn date of discharge AVSS and he was ambulating well without \nassistance, tolerating a regular diet and on oral pain \nmedicatons. \n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\n___ has a new metastatic focus in his left adrenal \ngland. ___ white male with a prior history of stage II \nrenal cell carcinoma (T2N0Mx) initially diagnosed on ___ \nin the setting of abdominal pain. He underwent a right \nnephrectomy with pathology demonstrating tumor confined to the \nkidney with no evidence for angiolymphatic invasion. Repeat \nimaging ___ demonstrated mediastinal lymph node enlargement and a \nthoracotomy revealed metastatic cancer. He subsequently \nunderwent IL-2 select therapy completed on ___ and since \nthen has done well. A routine CT scan ___ revealed \na 3.4 x 2.0 cm left adrenal nodule that was new since ___. There is no retroperitoneal adenopathy, although \nthere\nis reported increased periportal lymphadenopathy measuring 2.8 \ncm\ncompared to 2.6 cm in the ___ films. Additionally, there \nis\nan 11 mm hypodense lesion in the lower pole of the left kidney\nthat is stable, but appears suspicious. \n\nThe adrenal lesion was biopsied on ___ revealing \npoorly differentiated cancer consistent with metastatic renal \ncell cancer. \n\nHe presented ___ for a left adrenalectomy in the face of a\nprevious right nephro-adrenalectomy in ___. \n\nPast Medical History:\n - Renal cell ca s/p R nephrectomy in ___, found to have LN\ninvolvement in ___, now s/p IL-2 therapy with recently \ndiagnosed\nL adrenal nodule scheduled to undergo L adrenalectomy ___\n - DM\n - HTN\n - Hyperlipidemia\n\nPSH:\n - R nephrectomy ___\n - Umbilical hernia repair\n - Excision squamous cell ca of nose\n\nALLERG: NKDA\n\nSocial History:\n___\nFamily History:\nmother died of breast cancer\nfather died of cerebral hemorrhage\n\n', 'Chief Complaint:|Complaint:': '\nmetastatic focus in his left adrenal gland\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nPatient recorded as having No Known Allergies to Drugs\n\n'}, '16160008-DS-25', 25, 'urology']]

[['REASON FOR EXAMINATION: Evaluation of the patient first day after\nadrenalectomy.\n\nPortable AP chest radiograph was reviewed in comparison to ___,\nchest radiograph and CT torso from ___.\n\nFree air below the diaphragm, most likely related to recent surgery. Left\nchest tube is in place. There is no evidence of right pneumothorax. Heart\nsize is top normal, stable. Mediastinal contours are stable. Lungs are\nessentially clear except for left basal atelectasis.\n', '16160008-RR-48', 48, ''], ['REASON FOR EXAMINATION: Evaluation of the patient after chest tube removal.\n\nPortable AP chest radiograph was compared to prior study obtained the same day\nearlier at 1:22 p.m.\n\nAfter removal of the left chest tube, there has been minimal left pneumothorax\nsuspected, although this may represent summation of shadow. Repeated\nradiograph in several hours is recommended for documentation of absence or\nprogression or no evidence of pneumothorax.\n\nPneumoperitoneum related to recent surgery is redemonstrated.\n', '16160008-RR-49', 49, '']]

[[21445110, Timestamp('2133-07-07 22:00:00'), Timestamp('2133-07-11 20:00:00'), 'MAIN', 'Sodium Chloride 0.9% Flush', '', '0', 'Syringe'], [21445110, Timestamp('2133-07-07 22:00:00'), Timestamp('2133-07-10 13:00:00'), 'MAIN', 'Metoprolol Tartrate', '019808', '00143987310', '5mg/5mL Vial'], [21445110, Timestamp('2133-07-07 22:00:00'), Timestamp('2133-07-11 20:00:00'), 'MAIN', 'Dextrose 50%', '001989', '00409490234', '50mL Syringe'], [21445110, Timestamp('2133-07-07 22:00:00'), Timestamp('2133-07-10 12:00:00'), 'MAIN', 'DiphenhydrAMINE', '011582', '00904530661', '25mg Cap'], [21445110, Timestamp('2133-07-07 22:00:00'), Timestamp('2133-07-10 12:00:00'), 'MAIN', 'DiphenhydrAMINE', '011590', '00641037625', '50mg/mL Vial'], [21445110, Timestamp('2133-07-07 22:00:00'), Timestamp('2133-07-11 20:00:00'), 'MAIN', 'Pneumococcal Vac Polyvalent', '048548', '00006473900', '25mcg/0.5mL Vial'], [21445110, Timestamp('2133-07-07 22:00:00'), Timestamp('2133-07-08 11:00:00'), 'ADDITIVE', 'Bupivacaine 0.1%', '', '0', '250 mL Bag'], [21445110, Timestamp('2133-07-07 22:00:00'), Timestamp('2133-07-08 11:00:00'), 'BASE', 'Epidural Bag', '', '0', '250 mL Bag'], [21445110, Timestamp('2133-07-07 22:00:00'), Timestamp('2133-07-08 11:00:00'), 'MAIN', 'HYDROmorphone P.F.', '004100', '00074233326', '2000mcg/mL - 1mL Vial (Use this Package for Epidurals)'], [21445110, Timestamp('2133-07-07 22:00:00'), Timestamp('2133-07-09 18:00:00'), 'BASE', 'Iso-Osmotic Dextrose', '', '0', '50ml Bag'], [21445110, Timestamp('2133-07-07 22:00:00'), Timestamp('2133-07-09 18:00:00'), 'MAIN', 'CefazoLIN', '051880', '00264310311', '1g Froz.Bag'], [21445110, Timestamp('2133-07-07 22:00:00'), Timestamp('2133-07-08 09:00:00'), 'MAIN', 'Hydrocortisone Na Succ.', '051558', '00009090020', '100mg/2mL Vial'], [21445110, Timestamp('2133-07-07 22:00:00'), Timestamp('2133-07-10 12:00:00'), 'MAIN', 'HYDROmorphone (Dilaudid)', '004101', '00074233411', '12.5mg/50mL Syringe'], [21445110, Timestamp('2133-07-07 22:00:00'), Timestamp('2133-07-11 20:00:00'), 'MAIN', 'Insulin', '001723', '0', 'Dummy Package for Sliding Scale'], [21445110, Timestamp('2133-07-07 22:00:00'), Timestamp('2133-07-09 16:00:00'), 'BASE', 'D5LR', '002026', '00338012504', '1000mL Bag'], [21445110, Timestamp('2133-07-07 22:00:00'), Timestamp('2133-07-10 12:00:00'), 'MAIN', 'DiphenhydrAMINE', '011592', '00121048910', '25mg/10mL Cup'], [21445110, Timestamp('2133-07-07 22:00:00'), Timestamp('2133-07-11 20:00:00'), 'MAIN', 'Glucagon', '041660', '55390000401', '1mg Vial']]

[]

['urology']

[[50802, Timestamp('2133-07-07 13:29:00'), Timestamp('2133-07-07 13:34:00'), 'Base Excess'], [50804, Timestamp('2133-07-07 13:29:00'), Timestamp('2133-07-07 13:34:00'), 'Calculated Total CO2'], [50806, Timestamp('2133-07-07 13:29:00'), Timestamp('2133-07-07 13:35:00'), 'Chloride, Whole Blood'], [50808, Timestamp('2133-07-07 13:29:00'), Timestamp('2133-07-07 13:35:00'), 'Free Calcium'], [50809, Timestamp('2133-07-07 13:29:00'), Timestamp('2133-07-07 13:35:00'), 'Glucose'], [50810, Timestamp('2133-07-07 13:29:00'), Timestamp('2133-07-07 13:35:00'), 'Hematocrit, Calculated'], [50811, Timestamp('2133-07-07 13:29:00'), Timestamp('2133-07-07 13:35:00'), 'Hemoglobin'], [50813, Timestamp('2133-07-07 13:29:00'), Timestamp('2133-07-07 13:35:00'), 'Lactate'], [50817, Timestamp('2133-07-07 13:29:00'), Timestamp('2133-07-07 13:35:00'), 'Oxygen Saturation'], [50818, Timestamp('2133-07-07 13:29:00'), Timestamp('2133-07-07 13:34:00'), 'pCO2'], [50820, Timestamp('2133-07-07 13:29:00'), Timestamp('2133-07-07 13:34:00'), 'pH'], [50821, Timestamp('2133-07-07 13:29:00'), Timestamp('2133-07-07 13:34:00'), 'pO2'], [50822, Timestamp('2133-07-07 13:29:00'), Timestamp('2133-07-07 13:35:00'), 'Potassium, Whole Blood'], [50824, Timestamp('2133-07-07 13:29:00'), Timestamp('2133-07-07 13:35:00'), 'Sodium, Whole Blood'], [52033, Timestamp('2133-07-07 13:29:00'), Timestamp('2133-07-07 13:34:00'), 'Specimen Type'], [50802, Timestamp('2133-07-07 15:48:00'), Timestamp('2133-07-07 15:49:00'), 'Base Excess'], [50804, Timestamp('2133-07-07 15:48:00'), Timestamp('2133-07-07 15:49:00'), 'Calculated Total CO2'], [50806, Timestamp('2133-07-07 15:48:00'), Timestamp('2133-07-07 15:49:00'), 'Chloride, Whole Blood'], [50809, Timestamp('2133-07-07 15:48:00'), Timestamp('2133-07-07 15:49:00'), 'Glucose'], [50810, Timestamp('2133-07-07 15:48:00'), Timestamp('2133-07-07 15:49:00'), 'Hematocrit, Calculated'], [50811, Timestamp('2133-07-07 15:48:00'), Timestamp('2133-07-07 15:49:00'), 'Hemoglobin'], [50812, Timestamp('2133-07-07 15:48:00'), Timestamp('2133-07-07 15:48:00'), 'Intubated'], [50813, Timestamp('2133-07-07 15:48:00'), Timestamp('2133-07-07 15:49:00'), 'Lactate'], [50818, Timestamp('2133-07-07 15:48:00'), Timestamp('2133-07-07 15:49:00'), 'pCO2'], [50820, Timestamp('2133-07-07 15:48:00'), Timestamp('2133-07-07 15:49:00'), 'pH'], [50821, Timestamp('2133-07-07 15:48:00'), Timestamp('2133-07-07 15:49:00'), 'pO2'], [50822, Timestamp('2133-07-07 15:48:00'), Timestamp('2133-07-07 15:49:00'), 'Potassium, Whole Blood'], [50824, Timestamp('2133-07-07 15:48:00'), Timestamp('2133-07-07 15:49:00'), 'Sodium, Whole Blood'], [50828, Timestamp('2133-07-07 15:48:00'), Timestamp('2133-07-07 15:48:00'), 'Ventilator'], [52033, Timestamp('2133-07-07 15:48:00'), Timestamp('2133-07-07 15:48:00'), 'Specimen Type'], [51221, Timestamp('2133-07-07 17:22:00'), Timestamp('2133-07-07 17:52:00'), 'Hematocrit'], [51222, Timestamp('2133-07-07 17:22:00'), Timestamp('2133-07-07 17:52:00'), 'Hemoglobin'], [51248, Timestamp('2133-07-07 17:22:00'), Timestamp('2133-07-07 17:52:00'), 'MCH'], [51249, Timestamp('2133-07-07 17:22:00'), Timestamp('2133-07-07 17:52:00'), 'MCHC'], [51250, Timestamp('2133-07-07 17:22:00'), Timestamp('2133-07-07 17:52:00'), 'MCV'], [51265, Timestamp('2133-07-07 17:22:00'), Timestamp('2133-07-07 17:52:00'), 'Platelet Count'], [51277, Timestamp('2133-07-07 17:22:00'), Timestamp('2133-07-07 17:52:00'), 'RDW'], [51279, Timestamp('2133-07-07 17:22:00'), Timestamp('2133-07-07 17:52:00'), 'Red Blood Cells'], [51301, Timestamp('2133-07-07 17:22:00'), Timestamp('2133-07-07 17:52:00'), 'White Blood Cells'], [50868, Timestamp('2133-07-07 17:22:00'), Timestamp('2133-07-07 18:22:00'), 'Anion Gap'], [50882, Timestamp('2133-07-07 17:22:00'), Timestamp('2133-07-07 18:22:00'), 'Bicarbonate'], [50893, Timestamp('2133-07-07 17:22:00'), Timestamp('2133-07-07 18:22:00'), 'Calcium, Total'], [50902, Timestamp('2133-07-07 17:22:00'), Timestamp('2133-07-07 18:22:00'), 'Chloride'], [50912, Timestamp('2133-07-07 17:22:00'), Timestamp('2133-07-07 18:22:00'), 'Creatinine'], [50920, Timestamp('2133-07-07 17:22:00'), Timestamp('2133-07-07 18:22:00'), 'Estimated GFR (MDRD equation)'], [50931, Timestamp('2133-07-07 17:22:00'), Timestamp('2133-07-07 18:22:00'), 'Glucose'], [50960, Timestamp('2133-07-07 17:22:00'), Timestamp('2133-07-07 18:22:00'), 'Magnesium'], [50970, Timestamp('2133-07-07 17:22:00'), Timestamp('2133-07-07 18:22:00'), 'Phosphate'], [50971, Timestamp('2133-07-07 17:22:00'), Timestamp('2133-07-07 18:22:00'), 'Potassium'], [50983, Timestamp('2133-07-07 17:22:00'), Timestamp('2133-07-07 18:22:00'), 'Sodium'], [51006, Timestamp('2133-07-07 17:22:00'), Timestamp('2133-07-07 18:22:00'), 'Urea Nitrogen'], [51221, Timestamp('2133-07-08 07:05:00'), Timestamp('2133-07-08 08:06:00'), 'Hematocrit'], [51222, Timestamp('2133-07-08 07:05:00'), Timestamp('2133-07-08 08:06:00'), 'Hemoglobin'], [51248, Timestamp('2133-07-08 07:05:00'), Timestamp('2133-07-08 08:06:00'), 'MCH'], [51249, Timestamp('2133-07-08 07:05:00'), Timestamp('2133-07-08 08:06:00'), 'MCHC'], [51250, Timestamp('2133-07-08 07:05:00'), Timestamp('2133-07-08 08:06:00'), 'MCV'], [51265, Timestamp('2133-07-08 07:05:00'), Timestamp('2133-07-08 08:06:00'), 'Platelet Count'], [51277, Timestamp('2133-07-08 07:05:00'), Timestamp('2133-07-08 08:06:00'), 'RDW'], [51279, Timestamp('2133-07-08 07:05:00'), Timestamp('2133-07-08 08:06:00'), 'Red Blood Cells'], [51301, Timestamp('2133-07-08 07:05:00'), Timestamp('2133-07-08 08:06:00'), 'White Blood Cells'], [50868, Timestamp('2133-07-08 07:05:00'), Timestamp('2133-07-08 08:30:00'), 'Anion Gap'], [50882, Timestamp('2133-07-08 07:05:00'), Timestamp('2133-07-08 08:30:00'), 'Bicarbonate'], [50893, Timestamp('2133-07-08 07:05:00'), Timestamp('2133-07-08 08:30:00'), 'Calcium, Total'], [50902, Timestamp('2133-07-08 07:05:00'), Timestamp('2133-07-08 08:30:00'), 'Chloride'], [50912, Timestamp('2133-07-08 07:05:00'), Timestamp('2133-07-08 08:30:00'), 'Creatinine'], [50931, Timestamp('2133-07-08 07:05:00'), Timestamp('2133-07-08 08:30:00'), 'Glucose'], [50960, Timestamp('2133-07-08 07:05:00'), Timestamp('2133-07-08 08:30:00'), 'Magnesium'], [50970, Timestamp('2133-07-08 07:05:00'), Timestamp('2133-07-08 08:30:00'), 'Phosphate'], [50971, Timestamp('2133-07-08 07:05:00'), Timestamp('2133-07-08 08:30:00'), 'Potassium'], [50983, Timestamp('2133-07-08 07:05:00'), Timestamp('2133-07-08 08:30:00'), 'Sodium'], [51006, Timestamp('2133-07-08 07:05:00'), Timestamp('2133-07-08 08:30:00'), 'Urea Nitrogen']]

Question: A 67 M is admitted. He/she says he/she has metastatic focus in his left adrenal gland . History of illness: ___ has a new metastatic focus in his left adrenal gland. ___ white male with a prior history of stage II renal cell carcinoma (T2N0Mx) initially diagnosed on ___ in the setting of abdominal pain. He underwent a right nephrectomy with pathology demonstrating tumor confined to the kidney with no evidence for angiolymphatic invasion. Repeat imaging ___ demonstrated mediastinal lymph node enlargement and a thoracotomy revealed metastatic cancer. He subsequently underwent IL-2 select therapy completed on ___ and since then has done well. A routine CT scan ___ revealed a 3.4 x 2.0 cm left adrenal nodule that was new since ___. There is no retroperitoneal adenopathy, although there is reported increased periportal lymphadenopathy measuring 2.8 cm compared to 2.6 cm in the ___ films. Additionally, there is an 11 mm hypodense lesion in the lower pole of the left kidney that is stable, but appears suspicious. The adrenal lesion was biopsied on ___ revealing poorly differentiated cancer consistent with metastatic renal cell cancer. He presented ___ for a left adrenalectomy in the face of a previous right nephro-adrenalectomy in ___. Past Medical History: - Renal cell ca s/p R nephrectomy in ___, found to have LN involvement in ___, now s/p IL-2 therapy with recently diagnosed L adrenal nodule scheduled to undergo L adrenalectomy ___ - DM - HTN - Hyperlipidemia PSH: - R nephrectomy ___ - Umbilical hernia repair - Excision squamous cell ca of nose ALLERG: NKDA Social History: ___ Family History: mother died of breast cancer father died of cerebral hemorrhage Allergies: Patient recorded as having No Known Allergies to Drugs What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Sodium Chloride 0.9% Flush Metoprolol Tartrate Dextrose 50% DiphenhydrAMINE DiphenhydrAMINE Pneumococcal Vac Polyvalent Bupivacaine 0.1% Epidural Bag HYDROmorphone P.F. Iso-Osmotic Dextrose CefazoLIN Hydrocortisone Na Succ. HYDROmorphone (Dilaudid) Insulin D5LR DiphenhydrAMINE Glucagon Target Lab Orders: Base Excess Calculated Total CO2 Chloride, Whole Blood Free Calcium Glucose Hematocrit, Calculated Hemoglobin Lactate Oxygen Saturation pCO2 pH pO2 Potassium, Whole Blood Sodium, Whole Blood Specimen Type Base Excess Calculated Total CO2 Chloride, Whole Blood Glucose Hematocrit, Calculated Hemoglobin Intubated Lactate pCO2 pH pO2 Potassium, Whole Blood Sodium, Whole Blood Ventilator Specimen Type Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells Anion Gap Bicarbonate Calcium, Total Chloride Creatinine Estimated GFR (MDRD equation) Glucose Magnesium Phosphate Potassium Sodium Urea Nitrogen Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells Anion Gap Bicarbonate Calcium, Total Chloride Creatinine Glucose Magnesium Phosphate Potassium Sodium Urea Nitrogen Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : Patient was admitted to Urology after undergoing radical adrenalectomy (LEFT) No concerning intraoperative events occurred; please see dictated operative note for details. The patient received perioperative antibiotic prophylaxis. The patient was transferred to the floor from the PACU in stable condition. On POD0, pain was well controlled on PCA, hydrated for urine output >30cc/hour, and provided with pneumoboots and incentive spirometry for prophylaxis. On POD1, the patient ambulated, restarted on home medications, basic metabolic panel and complete blood count were checked, pain control was transitioned from PCA to oral analgesics, diet was advanced to a clears/toast and crackers diet. On POD2, JP and urethral catheter (foley) were removed without difficulty and diet was advanced as tolerated. The remainder of the hospital course was relatively unremarkable. The patient was discharged in stable condition, eating well, ambulating independently, voiding without difficulty, and with pain control on oral analgesics. On exam, incision was clean, dry, and intact, with no evidence of hematoma collection or infection. The patient was given explicit instructions to follow-up in clinic with ___ ___ in 3 weeks. He was discharged with instructionbs to resume his home medications and with explicit instructios for taking prednisone and florinef per his endocrinologist. Other Results: ___ 08:45AM BLOOD WBC-8.3 RBC-3.94* Hgb-12.1* Hct-34.5* MCV-88 MCH-30.7 MCHC-35.0 RDW-12.7 Plt ___ ___ 09:30AM BLOOD WBC-10.8 RBC-4.17* Hgb-12.8* Hct-36.5* MCV-88 MCH-30.6 MCHC-34.9 RDW-13.7 Plt ___ ___ 08:45AM BLOOD Glucose-145* UreaN-10 Creat-0.8 Na-139 K-4.0 Cl-104 HCO3-28 AnGap-11 ___ 09:30AM BLOOD Glucose-140* UreaN-13 Creat-0.9 Na-146* K-4.1 Cl-107 HCO3-32 AnGap-11 ___ 08:45AM BLOOD Calcium-8.6 Phos-1.7* Mg-1.8

2111-04-18 18:34:00

ENGLISH

SINGLE

WHITE

M

[[29240977, Timestamp('2111-04-18 18:34:56'), '', 'PSYCH']]

[[{'Medications on Admission': ':\nThe Preadmission Medication list is accurate and complete.\n1. This patient is not taking any preadmission medications', 'Brief Hospital Course': ":\nThis is a ___ year old man, history of mood disorder, prior \nsuicide attempt s/p prior hospitalization, benzodiazepine and \nalcohol use disorder who presents to ___ via EMS s/p \naltercation while intoxicated: subsequently admitted to \n___ for worsening depressive symptoms characterized by \nlow mood, poor energy, concentration, SI with reported plan to \ncut wrists, in the setting of ongoing psychosocial stressors \n(job loss, limited psychosocial support, loss of relationships) \nand active substance use. \n\n1. Legal: ___\n2. Medical: \n# Scalp laceration: staples placed on ___. Staples were \nremoved on ___ on the unit.\n\n# Asthma: Pt reports that he is well controlled and has \nexacerbations when exercising. He was continued on Albuterol PRN \nSOB.\n\n# Smoking: Patient was given nicotine lozenges on the unit and \nhe reported no cravings, with plans to not restart smoking upon \ndischarge.\n\n3. Psychiatric\n# MDD and dysthymia:\nOn presentation to ___ the patient was very dysphoric with a \nblunted affect, and showed evidence of poor insight and \njudgement. Upon admission to Deac4 the patient continued to \nappear dysphoric but was becoming more open and willing to work \nwith the team. The patient was able to open discuss his many \nstressors (loss of job, possibility of homelessness, loss of \nrelationship, and missing his mother) and how they have \ncontributed to his depression and drug use. The pt has not been \nin treatment in a long time and was motivated to get plugged in. \nWe started the patient on Wellbutrin and Sertraline to target \nhis mood and anxiety. The patient responded well to these \nmedications and he did not have any side effects. His mood \nimproved and he did not express any suicidality. The pt was set \nup with a therapist and psychiatrist, which he plans to continue \ngoing to, along with NA/AA meetings. He had many plans for his \nfuture with ways to avoid his triggers, stop using substances, \nand positive plans for housing and employment.\n\n4. Substance Abuse:\n# Substance use disorder:\nThe patient has a long history of using drugs and alcohol. Most \nrecently he had been drinking heavily and only recently started \nsniffing klonopin. Pt reports blacking out with this drug use, \nbut denies having seizures or DTs. Pt also stated that he was \nnot taking this combination to end his life, but that he was \ndoing it to numb his feelings. The patient was put on CIWA \nprotocol on the unit, but did not require any Ativan and this \nwas eventually discontinued. He was encouraged to avoid \ncombining drugs at all costs as they can result in death. \nAdditionally, we discussed the importance of going to AA and \nobtaining a sponsor, so that he can stay sober. We discussed how \nsubstances can alter ones mood and recommended that he stay away \nfrom all drugs and alcohol. He was in agreement with this plan, \nplans to stop using all substances (including quitting smoking), \nattend NA/AA meetings, and avoid triggers to using.\n\n5. Social/Milieu:\nPt was encouraged to participate in unit\x92s groups/milieu/therapy \nopportunities. Usage of coping skills and \nmindfulness/relaxation methods were encouraged. The patient \nattended a SMART group which he did not find particularly \nhelpful to him, but he does plan on pursuing NA/AA groups \noutpatient. \n\nHe was social with his peers on the unit, found comfort in their \nfriendship and says he plans on staying in touch with those he \nmet here through a facebook group they are planning on forming.\n\n6. Risk Assessment:\nAcute risk for self-harm/violence are both low. He feels stable \nafter his hospitalization and initiation on medications, and has \nmultiple positive plans for his future to minimize self risk.\n\nChronic risk factors include: \n-Male gender\n-White\n-Single\n-Previous suicide attempts\n-EtOH/drug use\n-Family structure disrupted\n-Tumultuous relationship with grandfather\n-___ grief from mother's death.\n\nModifiable risk factors include: \n-Now medicated for psychiatric illness with good effect - his \nsymptoms diminished and he no longer felt depressed, denied SI. \n-Set up with outpatient psychiatric providers \n-___ application initiated\n-Plans to attend NA/AA groups outpatient and avoid triggers for \nsubstance use. \n-Has plan for housing - will be living with a friend.\n-Has plan for employment - job interview at ___, would like to \ngo back to school to finish cosmetology degree\n-Plans to surround himself with his positive social supports\n\nProtective factors include:\n-Some positive support systems (numerous friends, family)\n-___ to engage in treatment\n-Skills he enjoys (cosmetology)\n\nPrognosis: Patient has overall good prognosis, despite his \nchronic risk factors. He is willing to engage with treatment \nteam both inpatient and outpatient, was self-driven in plans to \nmitigate his future risks and avoid triggers to his depression \nand substance use. Now on medications for his mood disorder with \ngood effect.\n\n7. Disposition: Patient to return to home. The patient will \nfollow up with ___ (new PCP), and then with \nAmbulatory Psychiatry clinic from there.\n\n8. Condition: Good\n\n", 'Pertinent Results:': '\n___ 03:55AM BLOOD WBC-9.1 RBC-5.20 Hgb-17.0 Hct-50.1 MCV-96 \nMCH-32.7* MCHC-33.9 RDW-13.9 Plt ___\n___ 03:55AM BLOOD Neuts-62.4 ___ Monos-4.5 Eos-2.6 \nBaso-1.2\n___ 03:55AM BLOOD Glucose-101* UreaN-10 Creat-0.9 Na-143 \nK-3.8 Cl-104 HCO3-22 AnGap-21*\n___ 03:55AM BLOOD ALT-29 AST-37 AlkPhos-115 TotBili-0.3\n___ 03:55AM BLOOD Calcium-9.6 Phos-3.7 Mg-2.5\n___ 03:55AM BLOOD ASA-NEG ___ Acetmnp-NEG \nBnzodzp-NEG Barbitr-NEG Tricycl-NEG\n___ 03:55AM URINE Color-Straw Appear-Clear Sp ___\n___ 03:55AM URINE Blood-NEG Nitrite-NEG Protein-NEG \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG\n___ 03:55AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG \ncocaine-NEG amphetm-NEG mthdone-NEG\n\n___ CT Head: IMPRESSION: No acute intracranial abnormality.\n\n', 'Physical Exam:|Physical': ' ___:\nADMISSION EXAM:\nVS: 97.2 147/87 82 18 98%RA \n\nGeneral: well nourished, well hydrated, in NAD \nSkin: no lesions or rashes noted\nHEENT: normocephalic, +staples in left posterolateral head that \nare c/d/i, EOMI, MMM\nNeck: supple \nLungs: CTAB, no wheezes, rhonchi \nCV: S1, S2, no m/r/g \nAbdomen: soft, non tender, +bowel sounds \nExtremities: no edema noted \n\nNeuro: \nCranial Nerves: II-XII intact \nMotor: ___ strength throughout upper and lower extremities \nReflexes: 2+ throughout \nSensation: grossly intact \nGait: normal gait and station \n\nNeuropsychiatric Examination:\n *Appearance: Overweight caucasian man. purple/multicolored\nmohawk. Black eyeliner. Wearing hospital gown and sitting \nupright\nin chair.\n Behavior: Cooperative. Good eye contact.\n *Mood and Affect: "sad" affect congruent with mood\n *Thought process: linear, absence of loose associations.\n *Thought Content: Not responding to internal stimuli. Denied\nAVH. No SI/HI \n *Judgment and Insight: poor/fair\n Cognition:\n *Attention: intact to MOYB \n *Orientation: intact to person, place and date. \n*Memory: grossy intact\n *Fund of knowledge: Intact to last 2 presidents\n Calculations: intact to $1.75\n Abstraction: intact to "grass isn\'t always greener" \n *Speech: Normal rate and volume\n *Language: Fluent\n\nDISCHARGE EXAM:\nVitals: T: 97.1, BP: 136/77, HR: 73, R: 16, O2: 97%\nNeurological:\n*station and gait: normal station and gait\n*tone and strength: antigravity in all ext\ncranial nerves: grossly intact\nabnormal movements: none observed\n\n*Appearance: Overweight young caucasian man, purple/pink mohawk, \nmultiple piercings and tattoos, wearing own clothes.\nBehavior: pleasant, cooperative, good eye contact, normal PMA\n*Mood and Affect: "very good," congruent affect - appropriately \nbright/euthymic, optimistic about the future\n*Thought process: linear, goal oriented, no LOA\n*Thought Content: Denies AVH. No SI/HI \n*Judgment and Insight: fair/fair\n\nCognition:\n*Attention: focused and attentive\n*Orientation: grossly intact \n*Memory: grossly intact\n*Speech: Normal rate and volume\n*Language: Fluent\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\nMr. ___ is a ___ year old man w/ history of depression, \nalcohol and benzodiazepine use disorders, prior suicide attempt \ns/p hospitalization in ___, who presented to ___ via EMS s/p \naltercation with worsening symptoms of depression and SI with \nplan to cut wrists with a kitchen knife.\n\nMr. ___ initially presented s/p head injury on ___ sustained \nat a night club in the setting of intoxication. The patient \nendorsed low mood, anxiety, lack of interest, poor energy, \ndifficulty concentrating, and thoughts of death for the past \nthree months, which worsened after he was fired from his job on \nthe ___ prior to presentation. He reported he "wouldn\'t end \nhis life," but endorsed thoughts of using a kitchen knife to cut \nhis wrists. He denied any history of mania or psychosis. Pt \nwould not provide means of contacting collateral.\n\nPer collateral obtained in the ED from the ___ friend, Mr. \n___, ___: Mr. ___ has had ups and downs, at times \nvery argumentative and isolated. Recently has deteriorated over \nthe last 1.5wk with loss of relationship, job, restarting \nklonopin use. Mr. ___ believed the ___ drinking is a \nproblem. States pt would "not be safe" if released.\n\nUpon arrival to Deac 4, pt confirmed hx as provided in the ED \nexcept denied reported plan to "cut his wrists with a knife". \nStated he has been suffering from depression for last ___ years \nsince his mother, who was HIV positive, passed away suddenly. \nLiving relatives include a grandfather who is verbally abusive \nand with whom he also has a tulmultuous relationship, a \ngrandmother who is ill with chronic kidney disease and an \nestranged younger brother. Patient lives in a boarding house and \nhas difficulty with finances. He has been drinking ___ pints of \nalcohol ___ per week and snorting ___ mg of klonopin daily to \ncope with depressed mood. \n\nOf note, patient has a history of blackouts with alcohol \nintoxication, but denies DTs, withdrawal seizures. Has had no \nprior detoxes. \n\nPast Medical History:\nPAST PSYCHIATRIC HISTORY:\nSx: depression, anxiety, and substance use\nHospitalizations: ___, including for dual diagnosis. ___ at ___ \nyears of age for SI at unknown site. Last admission in ___ at \n___.\nCurrent treaters and treatment: none\nMedication and ECT trials: last medication trial at ___ yo, \ncouldn\'t recall which medications\nSelf-injury: Two SA, one in ___ and another in ___. Used \nknife to cut wrist both times. ___ records indicate punching \nself in head.\nHarm to others: denies, note from ___ states he "put hands\non" his grandfather. Recent physical altercation with stranger \non the street.\nAccess to weapons: denies\n\nPAST MEDICAL HISTORY: \nnone\n-Denies HIV (last tested 3 months ago and negative)\n\nMEDICATIONS: \nnone\n\nALLERGIES: NKDA\n\nSocial History:\n___\nFamily History:\nAunt - bipolar, substance\nMother - substance\n___ note also lists schizophrenia in unknown family member\n\n', 'Chief Complaint:|Complaint:': '\n"I feel like I really want to end it"\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nNo Known Allergies / Adverse Drug Reactions\n\n'}, '14525464-DS-7', 7, 'psychiatry']]

[['EXAMINATION: CT HEAD W/O CONTRAST\n\nINDICATION: ___ man status post assault with head trauma and\nquestionable loss of consciousness. Please evaluate for intracranial bleeding\nor other evidence of trauma.\n\nTECHNIQUE: Contiguous multidetector CT scan through the head was performed\nwithout intravenous contrast. Axial images displayed as separate 5 mm and 2.5\nmm bone algorithm image series. Multiplanar reformation was performed to\nconstruct coronal and sagittal images.\n\nDOSE: DLP: 780.44 mGy-cm. CTDIvol: 55.53 mGy.\n\nCOMPARISON: None available.\n\nFINDINGS: \n\nThere is no evidence of hemorrhage, edema, mass effect, or infarction. The\nventricles and sulci are normal in size and configuration. There is a left\nfrontal scalp laceration but no fractures. There is mucosal thickening in the\nethmoid air cells and sphenoid sinuses with polypoid soft tissue at the right\nsphenoethmoidal recess (3:5). The mastoid air cells and middle ear cavities\nare clear.\n\nIMPRESSION: \n\nNo acute intracranial abnormality.\n', '14525464-RR-11', 11, 'contiguous multidetector ct scan through the head was performed\nwithout intravenous contrast. axial images displayed as separate 5 mm and 2.5\nmm bone algorithm image series. multiplanar reformation was performed to\nconstruct coronal and sagittal images.']]

[[29240977, Timestamp('2111-04-18 21:00:00'), Timestamp('2111-04-18 21:00:00'), 'MAIN', 'Diazepam', '003766', '51079028620', '10 mg Tab'], [29240977, Timestamp('2111-04-18 21:00:00'), Timestamp('2111-04-24 21:00:00'), 'MAIN', 'Acetaminophen', '004489', '51079000220', '325mg Tablet'], [29240977, Timestamp('2111-04-19 08:00:00'), Timestamp('2111-04-24 21:00:00'), 'MAIN', 'Thiamine', '002451', '00904054460', '100mg Tablet'], [29240977, Timestamp('2111-04-19 16:00:00'), Timestamp('2111-04-19 16:00:00'), 'MAIN', 'BuPROPion (Sustained Release)', '046238', '00591083960', '150mg SR Tablet'], [29240977, Timestamp('2111-04-18 22:00:00'), Timestamp('2111-04-21 15:00:00'), 'MAIN', 'Diazepam', '003766', '51079028620', '10 mg Tab'], [29240977, Timestamp('2111-04-18 21:00:00'), Timestamp('2111-04-24 21:00:00'), 'MAIN', 'Milk of Magnesia', '003026', '00121043130', '30mL UD Cup'], [29240977, Timestamp('2111-04-19 17:00:00'), Timestamp('2111-04-24 21:00:00'), 'MAIN', 'BuPROPion', '046236', '51079094320', '75mg Tab'], [29240977, Timestamp('2111-04-19 08:00:00'), Timestamp('2111-04-24 21:00:00'), 'MAIN', 'Multivitamins', '002532', '00904053061', '1 Tablet'], [29240977, Timestamp('2111-04-19 08:00:00'), Timestamp('2111-04-24 21:00:00'), 'MAIN', 'FoLIC Acid', '002366', '62584089701', '1 mg Tab'], [29240977, Timestamp('2111-04-18 23:00:00'), Timestamp('2111-04-24 21:00:00'), 'MAIN', 'Nicotine Lozenge', '048776', '00766150010', '2mg Lozenge'], [29240977, Timestamp('2111-04-19 16:00:00'), Timestamp('2111-04-24 21:00:00'), 'MAIN', 'Albuterol Inhaler', '028090', '00173068224', '8 g Inhaler']]

[]

['psychiatry']

[]

Question: A 22 M is admitted. He/she says he/she has "I feel like I really want to end it" . History of illness: Mr. ___ is a ___ year old man w/ history of depression, alcohol and benzodiazepine use disorders, prior suicide attempt s/p hospitalization in ___, who presented to ___ via EMS s/p altercation with worsening symptoms of depression and SI with plan to cut wrists with a kitchen knife. Mr. ___ initially presented s/p head injury on ___ sustained at a night club in the setting of intoxication. The patient endorsed low mood, anxiety, lack of interest, poor energy, difficulty concentrating, and thoughts of death for the past three months, which worsened after he was fired from his job on the ___ prior to presentation. He reported he "wouldn't end his life," but endorsed thoughts of using a kitchen knife to cut his wrists. He denied any history of mania or psychosis. Pt would not provide means of contacting collateral. Per collateral obtained in the ED from the ___ friend, Mr. ___, ___: Mr. ___ has had ups and downs, at times very argumentative and isolated. Recently has deteriorated over the last 1.5wk with loss of relationship, job, restarting klonopin use. Mr. ___ believed the ___ drinking is a problem. States pt would "not be safe" if released. Upon arrival to Deac 4, pt confirmed hx as provided in the ED except denied reported plan to "cut his wrists with a knife". Stated he has been suffering from depression for last ___ years since his mother, who was HIV positive, passed away suddenly. Living relatives include a grandfather who is verbally abusive and with whom he also has a tulmultuous relationship, a grandmother who is ill with chronic kidney disease and an estranged younger brother. Patient lives in a boarding house and has difficulty with finances. He has been drinking ___ pints of alcohol ___ per week and snorting ___ mg of klonopin daily to cope with depressed mood. Of note, patient has a history of blackouts with alcohol intoxication, but denies DTs, withdrawal seizures. Has had no prior detoxes. Past Medical History: PAST PSYCHIATRIC HISTORY: Sx: depression, anxiety, and substance use Hospitalizations: ___, including for dual diagnosis. ___ at ___ years of age for SI at unknown site. Last admission in ___ at ___. Current treaters and treatment: none Medication and ECT trials: last medication trial at ___ yo, couldn't recall which medications Self-injury: Two SA, one in ___ and another in ___. Used knife to cut wrist both times. ___ records indicate punching self in head. Harm to others: denies, note from ___ states he "put hands on" his grandfather. Recent physical altercation with stranger on the street. Access to weapons: denies PAST MEDICAL HISTORY: none -Denies HIV (last tested 3 months ago and negative) MEDICATIONS: none ALLERGIES: NKDA Social History: ___ Family History: Aunt - bipolar, substance Mother - substance ___ note also lists schizophrenia in unknown family member Allergies: No Known Allergies / Adverse Drug Reactions What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Diazepam Acetaminophen Thiamine BuPROPion (Sustained Release) Diazepam Milk of Magnesia BuPROPion Multivitamins FoLIC Acid Nicotine Lozenge Albuterol Inhaler Target Lab Orders: NONE Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : This is a ___ year old man, history of mood disorder, prior suicide attempt s/p prior hospitalization, benzodiazepine and alcohol use disorder who presents to ___ via EMS s/p altercation while intoxicated: subsequently admitted to ___ for worsening depressive symptoms characterized by low mood, poor energy, concentration, SI with reported plan to cut wrists, in the setting of ongoing psychosocial stressors (job loss, limited psychosocial support, loss of relationships) and active substance use. 1. Legal: ___ 2. Medical: # Scalp laceration: staples placed on ___. Staples were removed on ___ on the unit. # Asthma: Pt reports that he is well controlled and has exacerbations when exercising. He was continued on Albuterol PRN SOB. # Smoking: Patient was given nicotine lozenges on the unit and he reported no cravings, with plans to not restart smoking upon discharge. 3. Psychiatric # MDD and dysthymia: On presentation to ___ the patient was very dysphoric with a blunted affect, and showed evidence of poor insight and judgement. Upon admission to Deac4 the patient continued to appear dysphoric but was becoming more open and willing to work with the team. The patient was able to open discuss his many stressors (loss of job, possibility of homelessness, loss of relationship, and missing his mother) and how they have contributed to his depression and drug use. The pt has not been in treatment in a long time and was motivated to get plugged in. We started the patient on Wellbutrin and Sertraline to target his mood and anxiety. The patient responded well to these medications and he did not have any side effects. His mood improved and he did not express any suicidality. The pt was set up with a therapist and psychiatrist, which he plans to continue going to, along with NA/AA meetings. He had many plans for his future with ways to avoid his triggers, stop using substances, and positive plans for housing and employment. 4. Substance Abuse: # Substance use disorder: The patient has a long history of using drugs and alcohol. Most recently he had been drinking heavily and only recently started sniffing klonopin. Pt reports blacking out with this drug use, but denies having seizures or DTs. Pt also stated that he was not taking this combination to end his life, but that he was doing it to numb his feelings. The patient was put on CIWA protocol on the unit, but did not require any Ativan and this was eventually discontinued. He was encouraged to avoid combining drugs at all costs as they can result in death. Additionally, we discussed the importance of going to AA and obtaining a sponsor, so that he can stay sober. We discussed how substances can alter ones mood and recommended that he stay away from all drugs and alcohol. He was in agreement with this plan, plans to stop using all substances (including quitting smoking), attend NA/AA meetings, and avoid triggers to using. 5. Social/Milieu: Pt was encouraged to participate in unit’s groups/milieu/therapy opportunities. Usage of coping skills and mindfulness/relaxation methods were encouraged. The patient attended a SMART group which he did not find particularly helpful to him, but he does plan on pursuing NA/AA groups outpatient. He was social with his peers on the unit, found comfort in their friendship and says he plans on staying in touch with those he met here through a facebook group they are planning on forming. 6. Risk Assessment: Acute risk for self-harm/violence are both low. He feels stable after his hospitalization and initiation on medications, and has multiple positive plans for his future to minimize self risk. Chronic risk factors include: -Male gender -White -Single -Previous suicide attempts -EtOH/drug use -Family structure disrupted -Tumultuous relationship with grandfather -___ grief from mother's death. Modifiable risk factors include: -Now medicated for psychiatric illness with good effect - his symptoms diminished and he no longer felt depressed, denied SI. -Set up with outpatient psychiatric providers -___ application initiated -Plans to attend NA/AA groups outpatient and avoid triggers for substance use. -Has plan for housing - will be living with a friend. -Has plan for employment - job interview at ___, would like to go back to school to finish cosmetology degree -Plans to surround himself with his positive social supports Protective factors include: -Some positive support systems (numerous friends, family) -___ to engage in treatment -Skills he enjoys (cosmetology) Prognosis: Patient has overall good prognosis, despite his chronic risk factors. He is willing to engage with treatment team both inpatient and outpatient, was self-driven in plans to mitigate his future risks and avoid triggers to his depression and substance use. Now on medications for his mood disorder with good effect. 7. Disposition: Patient to return to home. The patient will follow up with ___ (new PCP), and then with Ambulatory Psychiatry clinic from there. 8. Condition: Good Other Results: ___ 03:55AM BLOOD WBC-9.1 RBC-5.20 Hgb-17.0 Hct-50.1 MCV-96 MCH-32.7* MCHC-33.9 RDW-13.9 Plt ___ ___ 03:55AM BLOOD Neuts-62.4 ___ Monos-4.5 Eos-2.6 Baso-1.2 ___ 03:55AM BLOOD Glucose-101* UreaN-10 Creat-0.9 Na-143 K-3.8 Cl-104 HCO3-22 AnGap-21* ___ 03:55AM BLOOD ALT-29 AST-37 AlkPhos-115 TotBili-0.3 ___ 03:55AM BLOOD Calcium-9.6 Phos-3.7 Mg-2.5 ___ 03:55AM BLOOD ASA-NEG ___ Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 03:55AM URINE Color-Straw Appear-Clear Sp ___ ___ 03:55AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 03:55AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG ___ CT Head: IMPRESSION: No acute intracranial abnormality.

2167-12-24 19:07:00

ENGLISH

WHITE

M

[[26949183, Timestamp('2167-12-24 19:08:20'), '', 'NSURG']]

[[{'Medications on Admission': ':\ncoumadin 7.5 mg daily\nolanzipine 10mg\nlithium 300mg bid\nacyclovir 400mg \ndexamethasone 4 mg TID (has not been taking for a week)\nFentanyl patch\n\nFacility:\n___', 'Brief Hospital Course': ':\nMr. ___ was brought to the ED from his rehab ___ back \npain. Seen by neurosurgery. MRI-T12 compression- question of \nepidural hematoma vs. compression\nfracture. ___ made aware CT Lspine and Tspine ordered and \nDexmathasone started. \n\n___: Mr. ___ was admitted to ___ 11. He underwent CT of the \nthoracic spine which showed a compression fracture at T12 and a \nlytic lesion consistent with multiple myeloma. The CT of the \nlumbar spine showed a compresssion fracture at L4 and T12 as \nwell as a lytic lesion at S1.\n\n___: A TLSO brace was ordered. His examination remained stable.\n\n___: The TLSO brace was fit. Standing x-rays of the thoracic \nand lumbar spine were ordered. INR was 2.6 and coumadin was not \nrestarted. \n\n___: ___ consult placed to determine disposition to rehab versus \nhome. INR 1.5, coumadin restarted.\n\n___: Mr. ___ was seen by physical therapy and occupational \ntherapy who recommended discharge to rehab.\n\n___: Antibiotic duration confirmed to be 3 weeks per OSH. New \n___ ordered secondary inadequate placement. Continue \ndisposition planning to rehab. \n\n___: Mr. ___ remained neurologically stable. Continue \ndisposition planning to rehab. \n\n___: At the time of discharge on ___, the patient was \ndoing well, afebrile with stable vital signs, tolerating a \nregular diet, ambulating, voiding without assistance, stable \nneuro exam and pain was well controlled. The patient was given \nwritten instructions concerning precautionary instructions and \nthe appropriate follow-up care. All questions were answered \nprior to discharge and the patient expressed readiness for \ndischarge.\n\n', 'Pertinent Results:': '\nMRI: ___\nT12 compression- question of epidural hematoma vs. compression\nfracture.\n\n___ CT-T spine-Compression fx T12, lytic lesion c/w Mult \nMyeloma\n\n___ CT-L spine-Compression fx L4 & T12, S1 lytic lesion 2.2 X \n1.7 cm\n\n___ X-rays Lumbar and Thoracic Spine:\nThere is severe compression of T12 as well as a less prominent \ncompression fracture of L4. Right PICC line extends into the \nneck. \nHypertrophic spurring is seen at several levels. In the \nabdomen, there is an area of focal dilatation of gas-filled \nloops in the midline from L1 through L4. This probably \nrepresents a focal ileus that could reflect inflammatory or \ninfectious changes in this region.\n\n___:\nSuccessful uncomplicated placement of right-sided 4 ___ \nsingle-lumen PICC, measuring 42 cm internally with tip in the \ndistal SVC. The line is ready to use. \n\nINR\n___ 1.8* \n___ 17:35 1.6* \n___ 05:15 1.3* \n___ 09:16 1.5* \n\n', 'Physical Exam:|Physical': '\nROS: Denies urinary or rectal incontience\n\nO: T:99 BP: 114/82 HR:86 R:14 96% O2Sats\nGen: WD/WN, comfortable, NAD.\nHEENT: Pupils: ___ EOMs\nNeck: Supple.\nExtrem: Warm and well-perfused.\nNeuro:\nMental status: Awake and alert, cooperative with exam, normal\naffect.\nOrientation: Oriented to person, place, and date.\nMotor:\n D B T WE WF IP Q H AT ___ G\nR 5 5 5 5 5 5 5 5- 5 5 5\nL 5 5 5 5 5 5 5 5 5 5 5\n\nSensation: Intact to light touch, propioception\n\nReflexes: 2\n\nPt has sustained clonus bilaterally R-side. ___ is \nnegative\n\nPropioception intact\nToes downgoing bilaterally\nRectal exam normal sphincter control\n\nPHYSICAL EXAMINATION ON DISCHARGE:\n\nPatient is alert and oriented to person, place and time. \nMotor:\n D B T WE WF IP Q H AT ___ G\nR 5 5 5 5 5 5 5 5 5 5 5\nL 5 5 5 5 5 5 5 5 5 5 5\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\n___ year old male with past medical history of multiple\nmyeloma and bipolar presents with lumar pain after a fall one to\ntwo weeks ago. Ms. ___ is unclear as to the circumstances of\nhis fall, but he knows that he fell backwards landing flat on \nhis\nback. Since that time, he has had the persistent pain which is\nworse when he walks and he has been avoiding walking as a \nresult.\nHe feels a pressure in his lower back when ambulating. He \ndenies\nany numbness, tingling, loss of bowel or bladder dysfunction. \n\nPast Medical History:\nbipolar\nmultiple myeloma\n\nSocial History:\n___\nFamily History:\nNon-Contributory\n\n', 'Chief Complaint:|Complaint:': '\nback pain \n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nNo Known Allergies / Adverse Drug Reactions\n\n'}, '18052457-DS-15', 15, 'neurosurgery']]

[['HISTORY: Known multiple myeloma with prior MRI demonstrating a fracture.\n\nTECHNIQUE: MDCT axial images were acquired through the thoracic spine without\nthe administration of IV contrast. Coronal and sagittal reformations are\nprovided and reviewed.\n\nDLP: 1406.40 mGy/cm.\nCTDIvol: 32.78.\n\nCOMPARISON: Lumbar spine MRI from ___ hospital ___ 8:22.\n\nFINDINGS: The thoracic spine maintains a normal alignment. A compression\nfracture with minimal retropulsion is seen at T12 as demonstrated on the prior\nMRI. The remaining vertebral body heights are maintained. Punctate, lytic\nlesions are seen throughout the thoracic spine and the imaged ribs, consistent\nwith multiple myeloma. There are no associated soft tissue masses. \n\nThe imaged lung bases demonstrate bibasilar atelectasis. A right central line\nis partially imaged.\n\nIMPRESSION: Compression fracture of T12 with minimal retropulsion. No other\nfractures identified on this exam. Punctate, lytic lesions involving the\nentire spine and the imaged ribs, compatible with multiple myeloma.\n\n', '18052457-RR-21', 21, 'mdct axial images were acquired through the thoracic spine without\nthe administration of iv contrast. coronal and sagittal reformations are\nprovided and reviewed.'], ['HISTORY: Multiple myeloma and recent MRI demonstrating a fracture.\n\nTECHNIQUE: MDCT axial images were acquired through the lumbar spine without\nthe administration of IV contrast. Coronal and sagittal reformations were\nprovided and reviewed.\n\nDLP: 1,263.49 mGy/cm. \nCTDIvol: 32.57 mGy. \n\nCOMPARISON: Lumbar spine MRI from ___ Hospital ___ 8:22.\n\nFINDINGS: There are compression fractures involving L4 and T12 as demonstrated\non the prior MRI. The fracture at T12 demonstrates minimal retropulsion. No\nretropulsion is seen at the L4 level. A lytic lesion measuring 2.2 x 1.7 cm\nis seen within S1. The remaining vertebral body heights and intervertebral\ndisc spaces are preserved. Punctate, lytic lucencies are seen at all levels\nof the lumbar spine, consistent with multiple myeloma.\n\nThere are mild degenerative changes of the lumbar spine with anterior\nosteophytosis. \n\nThe imaged lung bases demonstrate atelectasis. The imaged intra-abdominal\norgans are unremarkable.\n\nIMPRESSION:\n1. Compression fractures of L4 and T12. \n2. Larger lytic lesion involving S1. \n\n', '18052457-RR-22', 22, 'mdct axial images were acquired through the lumbar spine without\nthe administration of iv contrast. coronal and sagittal reformations were\nprovided and reviewed.'], ['HISTORY: PICC line.\n\nFINDINGS: No previous images. Right subclavian PICC line extends to the mid\nportion of the SVC. There are relatively low lung volumes with streaks of\natelectasis or fibrosis at the bases. No evidence of vascular congestion or\nacute focal pneumonia.\n', '18052457-RR-23', 23, ''], ['HISTORY: Lower extremity weakness.\n\nFINDINGS: There is severe compression of T12 as well as a less prominent\ncompression fracture of L4. Right PICC line extends into the neck.\n\nHypertrophic spurring is seen at several levels. In the abdomen, there is an\narea of focal dilatation of gas-filled loops in the midline from L1 through\nL4. This probably represents a focal ileus that could reflect inflammatory or\ninfectious changes in this region.\n', '18052457-RR-24', 24, ''], ['HISTORY: IJ catheter power flush.\n\nFINDINGS: The right subclavian catheter extends into the neck beyond the\nupper margin of the image at C6. Little change in the appearance of the heart\nand lungs.\n', '18052457-RR-25', 25, ''], ['REASON FOR EXAMINATION: Evaluation of the patient with PICC line placement.\n\nAP radiograph of the chest was reviewed in comparison to ___.\n\nThe PICC line tip terminates at the level of the axilla, most likely in the\naxillary vein. The heart size and mediastinum are stable in appearance. \nLinear atelectasis in the left lower lung is unchanged. There is no pleural\neffusion or pneumothorax.\n', '18052457-RR-26', 26, ''], ['INDICATION: Bacteremia, in need of intravenous antibiotics. Recent cathter\nplacement could not be advanced beyond subclavian vein at bedside. Request\nfor PICC placement.\n \nOPERATORS: ___, NP) and Dr. ___ (attending).\n\nPROCEDURE AND FINDINGS: The patient was brought to the angiographic suite and\nlaid supine on the fluoroscopic table. The right arm with indwelling catheter\nwas prepped and draped in the usual sterile fashion. A pre-procedure huddle\nand timeout were performed per ___ protocol.\n \nAn initial scout demonstrated presence of the indwelling catheter with tip in\nthe proximal subclavian vein. 1% lidocaine was infiltrated into the\nsubcutaneous tissues adjacent to the catheter insertion site. The catheter\nwas divided and a wire advanced to the IVC. The catheter remnant was removed\nand a peel away sheath placed. Appropriate measurements were then made and\nthe wire was again advanced to the IVC. The inner stiffener of the sheath was\nremoved and a single-lumen 4 ___ PICC with internal length of 42 cm was\nplaced with tip in the distal SVC. Final fluoroscopic image confirms\npositioning in distal SVC.\n \nThe patient tolerated the procedure well and there were no immediate\npost-procedure complications.\n \nIMPRESSION: Successful uncomplicated placement of right-sided 4 ___\nsingle-lumen PICC, measuring 42 cm internally with tip in the distal SVC. The\nline is ready to use.\n', '18052457-RR-27', 27, '']]

[[26949183, Timestamp('2167-12-24 22:00:00'), Timestamp('2167-12-31 15:00:00'), 'MAIN', 'Dexamethasone', '006789', '00054817525', '4mg Tab'], [26949183, Timestamp('2167-12-24 22:00:00'), Timestamp('2167-12-31 21:00:00'), 'MAIN', 'Sodium Chloride 0.9% Flush', '', '0', 'Syringe'], [26949183, Timestamp('2167-12-25 10:00:00'), Timestamp('2167-12-27 11:00:00'), 'MAIN', 'Warfarin', '006560', '00056017675', '2.5mg Tablet'], [26949183, Timestamp('2167-12-24 22:00:00'), Timestamp('2167-12-31 21:00:00'), 'MAIN', 'OxycoDONE (Immediate Release) ', '004225', '00406055262', '5mg Tablet'], [26949183, Timestamp('2167-12-24 23:00:00'), Timestamp('2167-12-31 21:00:00'), 'MAIN', 'Fentanyl Patch', '015880', '00591319872', '25mcg/hr Patch'], [26949183, Timestamp('2167-12-24 22:00:00'), Timestamp('2167-12-31 21:00:00'), 'BASE', 'Iso-Osmotic Dextrose', '', '0', '100ml Bag'], [26949183, Timestamp('2167-12-24 22:00:00'), Timestamp('2167-12-31 21:00:00'), 'MAIN', 'Nafcillin', '031535', '00338101948', '2g Frozen Bag'], [26949183, Timestamp('2167-12-24 20:00:00'), Timestamp('2167-12-24 22:00:00'), 'MAIN', 'Heparin', '006549', '63323026201', '5000 Units / mL- 1mL Vial'], [26949183, Timestamp('2167-12-24 22:00:00'), Timestamp('2167-12-31 21:00:00'), 'MAIN', 'Acyclovir', '016408', '00093894393', '400 mg Tablet'], [26949183, Timestamp('2167-12-24 20:00:00'), Timestamp('2167-12-31 21:00:00'), 'MAIN', 'Docusate Sodium', '003009', '00904224461', '100mg Capsule'], [26949183, Timestamp('2167-12-24 22:00:00'), Timestamp('2167-12-31 21:00:00'), 'MAIN', 'Senna', '019964', '00904516561', '1 Tablet'], [26949183, Timestamp('2167-12-24 20:00:00'), Timestamp('2167-12-31 21:00:00'), 'MAIN', 'Lithium Carbonate', '004001', '60505250403', '300 mg Cap'], [26949183, Timestamp('2167-12-24 22:00:00'), Timestamp('2167-12-24 22:00:00'), 'MAIN', 'Morphine Sulfate', '004080', '00641607325', '5 mg Vial'], [26949183, Timestamp('2167-12-24 23:00:00'), Timestamp('2167-12-31 21:00:00'), 'MAIN', 'Morphine SR (MS Contin)', '011887', '00406831562', '15mg Tab'], [26949183, Timestamp('2167-12-24 22:00:00'), Timestamp('2167-12-31 21:00:00'), 'MAIN', 'Acetaminophen', '004489', '51079000220', '325mg Tablet'], [26949183, Timestamp('2167-12-24 20:00:00'), Timestamp('2167-12-31 21:00:00'), 'MAIN', 'Famotidine', '011677', '51079096620', '20 mg Tablet'], [26949183, Timestamp('2167-12-24 10:00:00'), Timestamp('2167-12-24 22:00:00'), 'MAIN', 'OLANZapine', '027960', '00002411733', '10mg Tablet']]

[]

['neurosurgery']

[[50868, Timestamp('2167-12-25 05:20:00'), Timestamp('2167-12-25 07:20:00'), 'Anion Gap'], [50882, Timestamp('2167-12-25 05:20:00'), Timestamp('2167-12-25 07:20:00'), 'Bicarbonate'], [50893, Timestamp('2167-12-25 05:20:00'), Timestamp('2167-12-25 07:20:00'), 'Calcium, Total'], [50902, Timestamp('2167-12-25 05:20:00'), Timestamp('2167-12-25 07:20:00'), 'Chloride'], [50912, Timestamp('2167-12-25 05:20:00'), Timestamp('2167-12-25 07:20:00'), 'Creatinine'], [50931, Timestamp('2167-12-25 05:20:00'), Timestamp('2167-12-25 07:20:00'), 'Glucose'], [50960, Timestamp('2167-12-25 05:20:00'), Timestamp('2167-12-25 07:20:00'), 'Magnesium'], [50970, Timestamp('2167-12-25 05:20:00'), Timestamp('2167-12-25 07:20:00'), 'Phosphate'], [50971, Timestamp('2167-12-25 05:20:00'), Timestamp('2167-12-25 07:20:00'), 'Potassium'], [50983, Timestamp('2167-12-25 05:20:00'), Timestamp('2167-12-25 07:20:00'), 'Sodium'], [51006, Timestamp('2167-12-25 05:20:00'), Timestamp('2167-12-25 07:20:00'), 'Urea Nitrogen'], [51221, Timestamp('2167-12-25 05:20:00'), Timestamp('2167-12-25 09:15:00'), 'Hematocrit'], [51222, Timestamp('2167-12-25 05:20:00'), Timestamp('2167-12-25 09:15:00'), 'Hemoglobin'], [51248, Timestamp('2167-12-25 05:20:00'), Timestamp('2167-12-25 09:15:00'), 'MCH'], [51249, Timestamp('2167-12-25 05:20:00'), Timestamp('2167-12-25 09:15:00'), 'MCHC'], [51250, Timestamp('2167-12-25 05:20:00'), Timestamp('2167-12-25 09:15:00'), 'MCV'], [51265, Timestamp('2167-12-25 05:20:00'), Timestamp('2167-12-25 09:15:00'), 'Platelet Count'], [51277, Timestamp('2167-12-25 05:20:00'), Timestamp('2167-12-25 09:15:00'), 'RDW'], [51279, Timestamp('2167-12-25 05:20:00'), Timestamp('2167-12-25 09:15:00'), 'Red Blood Cells'], [51301, Timestamp('2167-12-25 05:20:00'), Timestamp('2167-12-25 09:15:00'), 'White Blood Cells'], [51237, Timestamp('2167-12-25 05:20:00'), Timestamp('2167-12-25 07:00:00'), 'INR(PT)'], [51274, Timestamp('2167-12-25 05:20:00'), Timestamp('2167-12-25 07:00:00'), 'PT'], [51275, Timestamp('2167-12-25 05:20:00'), Timestamp('2167-12-25 07:00:00'), 'PTT']]

Question: A 56 M is admitted. He/she says he/she has back pain . History of illness: ___ year old male with past medical history of multiple myeloma and bipolar presents with lumar pain after a fall one to two weeks ago. Ms. ___ is unclear as to the circumstances of his fall, but he knows that he fell backwards landing flat on his back. Since that time, he has had the persistent pain which is worse when he walks and he has been avoiding walking as a result. He feels a pressure in his lower back when ambulating. He denies any numbness, tingling, loss of bowel or bladder dysfunction. Past Medical History: bipolar multiple myeloma Social History: ___ Family History: Non-Contributory Allergies: No Known Allergies / Adverse Drug Reactions What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Dexamethasone Sodium Chloride 0.9% Flush Warfarin OxycoDONE (Immediate Release) Fentanyl Patch Iso-Osmotic Dextrose Nafcillin Heparin Acyclovir Docusate Sodium Senna Lithium Carbonate Morphine Sulfate Morphine SR (MS Contin) Acetaminophen Famotidine OLANZapine Target Lab Orders: Anion Gap Bicarbonate Calcium, Total Chloride Creatinine Glucose Magnesium Phosphate Potassium Sodium Urea Nitrogen Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells INR(PT) PT PTT Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : Mr. ___ was brought to the ED from his rehab ___ back pain. Seen by neurosurgery. MRI-T12 compression- question of epidural hematoma vs. compression fracture. ___ made aware CT Lspine and Tspine ordered and Dexmathasone started. ___: Mr. ___ was admitted to ___ 11. He underwent CT of the thoracic spine which showed a compression fracture at T12 and a lytic lesion consistent with multiple myeloma. The CT of the lumbar spine showed a compresssion fracture at L4 and T12 as well as a lytic lesion at S1. ___: A TLSO brace was ordered. His examination remained stable. ___: The TLSO brace was fit. Standing x-rays of the thoracic and lumbar spine were ordered. INR was 2.6 and coumadin was not restarted. ___: ___ consult placed to determine disposition to rehab versus home. INR 1.5, coumadin restarted. ___: Mr. ___ was seen by physical therapy and occupational therapy who recommended discharge to rehab. ___: Antibiotic duration confirmed to be 3 weeks per OSH. New ___ ordered secondary inadequate placement. Continue disposition planning to rehab. ___: Mr. ___ remained neurologically stable. Continue disposition planning to rehab. ___: At the time of discharge on ___, the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, stable neuro exam and pain was well controlled. The patient was given written instructions concerning precautionary instructions and the appropriate follow-up care. All questions were answered prior to discharge and the patient expressed readiness for discharge. Other Results: MRI: ___ T12 compression- question of epidural hematoma vs. compression fracture. ___ CT-T spine-Compression fx T12, lytic lesion c/w Mult Myeloma ___ CT-L spine-Compression fx L4 & T12, S1 lytic lesion 2.2 X 1.7 cm ___ X-rays Lumbar and Thoracic Spine: There is severe compression of T12 as well as a less prominent compression fracture of L4. Right PICC line extends into the neck. Hypertrophic spurring is seen at several levels. In the abdomen, there is an area of focal dilatation of gas-filled loops in the midline from L1 through L4. This probably represents a focal ileus that could reflect inflammatory or infectious changes in this region. ___: Successful uncomplicated placement of right-sided 4 ___ single-lumen PICC, measuring 42 cm internally with tip in the distal SVC. The line is ready to use. INR ___ 1.8* ___ 17:35 1.6* ___ 05:15 1.3* ___ 09:16 1.5*

2127-08-08 11:30:00

ENGLISH

MARRIED

WHITE

M

[[22747307, Timestamp('2127-08-08 05:25:15'), '', 'GU']]

[[{'Medications on Admission': ':\nmeds:Albuterol Sulfate \n90 mcg HFA Aerosol Inhaler \n2 inhalations(s) po four times a day as needed \n\nErgocalciferol (Vitamin D2) [Vitamin D] (Prescribed by Other \nProvider) \n1,000 unit Capsule \nCapsule(s) by mouth every other day \n\nTylenol Oral \n500 mg every 4 to 6 hours \nas needed for pain \n\nMultivitamins Oral \n1 tab-cap every day \n\nGlucosamine HCl-MSM Oral \n1 tab every day \n\nVitamin E Oral \n1 cap every day \n\nOmega-3 Fatty Acids Oral \n1 cap every day \n\nLutein Oral \n20 mg every day \nall:nkda ', 'Brief Hospital Course': ':\nMr. ___ was taken to OR for LEFT percutaneous \nnephrolithotomy. There were no intraporative complications but \nplease refer to the detailed operative note for details. \nHospital course was uncomplicated. \n\n', 'Pertinent Results:': '\n___ 09:30AM BLOOD ___ PTT-27.6 ___\n\n', 'Physical Exam:|Physical': '\nNAD\nAVSS\nAbdomen nt/nd\nextremities well perfused \n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\nThe patient is a ___ male with a history of a 1.1 cm \nleft renal calculus. The patient was explained alternatives and \nbenefits and elected to proceed with left percutaneous \nnephrolithotomy.\n\nPast Medical History:\nProstate CA s/p prostectomy (___), Hiatal Hernia/GERD (Dx 10 \nm/a), Basal Cell CA s/p Mohs (nose) (___), Headaches (many \nyears; Tx with motrin; triggered by EtOH)\nAsthma\n\nSocial History:\n___\nFamily History:\nGM - BRCA; GF - "Gut CA", suicide; ___ - Good health; Sis - \nAnorexia; No kids; No other sig FHx.\n\n', 'Chief Complaint:|Complaint:': '\nThe patient is a ___ male with a history of a 1.1 cm \nleft renal calculus. The patient was explained alternatives and \nbenefits and elected to proceed with left percutaneous \nnephrolithotomy.\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nMold/Yeast/Dust / Cat Hair Std Extract\n\n'}, '17237089-DS-17', 17, 'urology']]

[["PROCEDURE: Percutaneous wire placement into the left renal collecting system\nas guidance for percutaneous nephrolithotomy.\n\nHISTORY: ___ gentleman with left-sided renal calculus.\n\nANESTHESIA: Moderate sedation was provided by administering divided doses of\nfentanyl and Versed throughout the total intraservice time of 1 hour 10\nminutes during which the patient's hemodynamic parameters were continuously\nmonitored. The total dose of fentanyl was 150 mcg. The total dose of Versed\nwas 3 mg.\n\nRADIOLOGIST: Dr. ___, Dr. ___ and Dr. ___\nperformed the procedure. The attending radiologist, Dr. ___\nthe procedure.\n\nPROCEDURE AND FINDINGS: Informed consent was obtained outlining the risks and\nbenefits of the procedure involved. The operative site was marked clearly.\nFollowing this the patient was transferred to the angiography suite and placed\nprone on the angiography table. The left flank was prepped and draped in\nusual sterile fashion. A preprocedure huddle and timeout were performed as\nper ___ protocol. \n\nA scout flouroscopic image confirms a radiodense calculus in the left renal\ncollecting system.\nFollowing administration of 1% lidocaine into the skin and subcutaneous\ntissues the left renal collecting system was accessed under direct ultrasound\nguidance with a 21-gauge Cook access needle. An 0.018 nitinol wire was\nadvanced through this mid posterior calix into the renal pelvis and upper\nureter over which a 4 ___ AccuStick introducer system was advanced. An\n0.035 Glidewire was advanced into the urinary bladder through the AccuStick\nsheath, which was then removed. A Kumpe catheter was advanced into the bladder\nand the Glidewire exchanged for a super-stiff Amplatz wire which was coiled in\nthe bladder. The Kumpe catheter was then removed and a 5 ___ sheath was\nadvanced over the Amplatz wire. The inner stiffener was removed and an 0.035\n___ wire advanced through the sheath with the tip lying in the distal\nureter. All wire manipulations were continuously monitored under continuous\nfluoroscopic guidance. The external portions of the wires were resheathed and\nsecured to the patient's skin maintaining sterility. There were no immediate\ncomplications. A final fluoroscopic image demonstrates satisfactory position\nof the two guiding wires. The patient was transferred to the OR for\npercutaneous nephrolithotomy under general anesthesia.Findings were conveyed\nto the ___ service at time of procedure.\n\nIMPRESSION: Satisfactory placement of two percutaneous guidewires into the\nleft renal collecting system and bladder to aid percutaneous nephrolithotomy\nin the OR. \nThe patient tolerated the procedure well.\n\nThe staff radiologist has reviewed the report.\n\n\n", '17237089-RR-22', 22, ''], ['INDICATION: ___ male for percutaneous nephrolithotomy.\n\nCOMPARISON: Abdominal radiographs from ___.\n\nFINDINGS: Four fluoroscopic spot views were submitted for review. This\nprocedure was done without a radiologist present. The scout view shows a\nballoon catheter entering the right kidney from an inferior approach through\nthe ureter. A second catheter is seen being inserted percutaneously with\nsubsequent injection of contrast into the kidneys. There is extravasation of\ncontrast into the perinephric space.\n\nIMPRESSION: Percutaneous and transurethral catheterization of the kidney with\nsubsequent injection showing perinephric extravasation of contrast.\n', '17237089-RR-24', 24, '']]

[[22747307, Timestamp('2127-08-08 21:00:00'), Timestamp('2127-08-09 21:00:00'), 'BASE', 'Isotonic Sodium Chloride', '', '0', '50ml Bag'], [22747307, Timestamp('2127-08-08 21:00:00'), Timestamp('2127-08-09 21:00:00'), 'MAIN', 'Gentamicin', '009291', '00338050941', '80mg Premix'], [22747307, Timestamp('2127-08-08 21:00:00'), Timestamp('2127-08-09 08:00:00'), 'MAIN', 'Morphine Sulfate', '004067', '00338268975', '50mg/50mL Syringe'], [22747307, Timestamp('2127-08-08 21:00:00'), Timestamp('2127-08-09 21:00:00'), 'BASE', 'Iso-Osmotic Dextrose', '', '0', '50ml Bag'], [22747307, Timestamp('2127-08-08 21:00:00'), Timestamp('2127-08-09 21:00:00'), 'MAIN', 'CefazoLIN', '051880', '00264310311', '1g Froz.Bag'], [22747307, Timestamp('2127-08-08 21:00:00'), Timestamp('2127-08-09 08:00:00'), 'MAIN', 'Pneumococcal Vac Polyvalent', '048548', '00006473900', '25mcg/0.5mL Vial'], [22747307, Timestamp('2127-08-08 21:00:00'), Timestamp('2127-08-09 21:00:00'), 'MAIN', 'Oxycodone-Acetaminophen', '004222', '00406051262', '5mg/325mg Tablet'], [22747307, Timestamp('2127-08-09 10:00:00'), Timestamp('2127-08-09 21:00:00'), 'MAIN', 'Acetaminophen', '004490', '00904198861', '500mg Tablet'], [22747307, Timestamp('2127-08-08 21:00:00'), Timestamp('2127-08-09 21:00:00'), 'MAIN', 'Albuterol 0.083% Neb Soln', '005039', '49502069724', '0.083%;3mL Vial'], [22747307, Timestamp('2127-08-08 21:00:00'), Timestamp('2127-08-09 21:00:00'), 'MAIN', 'Sodium Chloride 0.9% Flush', '', '0', 'Syringe'], [22747307, Timestamp('2127-08-08 21:00:00'), Timestamp('2127-08-09 21:00:00'), 'MAIN', 'Morphine Sulfate', '004080', '10019017644', '5 mg Vial'], [22747307, Timestamp('2127-08-08 21:00:00'), Timestamp('2127-08-09 21:00:00'), 'MAIN', 'Ondansetron', '061716', '00781305714', '2mg/mL-2mL'], [22747307, Timestamp('2127-08-08 21:00:00'), Timestamp('2127-08-09 21:00:00'), 'BASE', 'D5LR', '002026', '00338012504', '1000mL Bag']]

[]

['urology']

[[51237, Timestamp('2127-08-08 09:30:00'), Timestamp('2127-08-08 10:39:00'), 'INR(PT)'], [51274, Timestamp('2127-08-08 09:30:00'), Timestamp('2127-08-08 10:39:00'), 'PT'], [51275, Timestamp('2127-08-08 09:30:00'), Timestamp('2127-08-08 10:39:00'), 'PTT']]

Question: A 76 M is admitted. He/she says he/she has The patient is a ___ male with a history of a 1.1 cm left renal calculus. The patient was explained alternatives and benefits and elected to proceed with left percutaneous nephrolithotomy. . History of illness: The patient is a ___ male with a history of a 1.1 cm left renal calculus. The patient was explained alternatives and benefits and elected to proceed with left percutaneous nephrolithotomy. Past Medical History: Prostate CA s/p prostectomy (___), Hiatal Hernia/GERD (Dx 10 m/a), Basal Cell CA s/p Mohs (nose) (___), Headaches (many years; Tx with motrin; triggered by EtOH) Asthma Social History: ___ Family History: GM - BRCA; GF - "Gut CA", suicide; ___ - Good health; Sis - Anorexia; No kids; No other sig FHx. Allergies: Mold/Yeast/Dust / Cat Hair Std Extract What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Isotonic Sodium Chloride Gentamicin Morphine Sulfate Iso-Osmotic Dextrose CefazoLIN Pneumococcal Vac Polyvalent Oxycodone-Acetaminophen Acetaminophen Albuterol 0.083% Neb Soln Sodium Chloride 0.9% Flush Morphine Sulfate Ondansetron D5LR Target Lab Orders: INR(PT) PT PTT Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : Mr. ___ was taken to OR for LEFT percutaneous nephrolithotomy. There were no intraporative complications but please refer to the detailed operative note for details. Hospital course was uncomplicated. Other Results: ___ 09:30AM BLOOD ___ PTT-27.6 ___

2128-03-08 16:34:00

ENGLISH

SINGLE

WHITE

F

[[20248756, Timestamp('2128-03-08 16:35:09'), '', 'TSURG']]

[[{'Medications on Admission': ':\nMethylPHENIDATE (Ritalin) 20 mg PO TID ', 'Brief Hospital Course': ':\n___ y/o female who was sent as a transfer from ___ with \npneumomediastinum with no preceeding event. After reviewing OSH \nimaging a barium swallow was ordered. It showed no esophageal \nperforation and she was clinically stable. However, due to \ncontinued pain and significant pneumomediastinum on CT scan she \nwas admitted overnight for observation and was held NPO \novernight.\n\nOn HD#2 her pain had improved and she continued to have stable \nvitals. Her diet was advanced from clears to regular diet and \nshe was discharged home. She should follow up with GI to work \nup potential eosinophillic esophagitis as possible cause of \npneumomediastinum. At the time of discharge her pain was \ncontrolled with tylenol, she was tolerating a regular diet and \nwas ambulatory.\n\n', 'Pertinent Results:': 'NIL', 'Physical Exam:|Physical': '\nDischarge Exam:\n\nV: 98.6, 78, 102/54, 18, 97%RA\nGen: NAD, A and OX3\nCV: RRR, no murmur, no TTP to anterior chest, no subcutaneous \nemphysema\nPulm: CTAB, no wheeze\nAbd: Soft, NT/ND, no rebound/guarding\nExt: WWP, no cyanosis.\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\n___ y/o female w/ history of anxiety presents as transfer from \n___ with pneumomediastinum. She describes acute onset of sharp, \nnon-radiating sub sternal and right anterior chest pain \nbeginning at 7pm on ___ while sitting at her computer writing \nan email. She ___ vomiting, wretching or any strenous \nmanuvers. She also denies associated SOB or dyspnea. She had \nnever experienced this before. \n\nShe went to the ___ ED and had a CT scan which showed \npneumomediastinum and she was transfered to ___. She was \nafebrile with benign labs and stable vitle signs at ___. \n\nPast Medical History:\nAnxiety\n\nSocial History:\n___\nFamily History:\nNon contributory\n\n', 'Chief Complaint:|Complaint:': '\nchest pain\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nNo Known Allergies / Adverse Drug Reactions\n\n'}, '16227344-DS-3', 3, 'cardiothoracic']]

[['EXAMINATION: Esophagram\n\nINDICATION: ___ year old woman with pneumomediastinum. // eval for esophageal\nperf with barium esophagogram\n\nTECHNIQUE: Barium esophagram.\n\nCOMPARISON: Outside CT of the chest ___\n\nFINDINGS: \n\nThe esophagus was evaluated with the patient upright using water-soluble\ncontrast initially followed by thin consistency barium. The esophagus was not\ndilated. There was no stricture within the esophagus. There was no esophageal\nmass. The esophageal mucosa appeared normal.\n\nThe primary peristaltic wave was normal, with contrast passing readily into\nthe stomach. The lower esophageal sphincter opened and closed normally. There\nis no hiatal hernia.\n\nLimited views of the stomach revealed no gross abnormality.\n\nIMPRESSION: \n\nNormal esophagram. No evidence of perforation.\n', '16227344-RR-2', 2, 'barium esophagram.']]

[[20248756, Timestamp('2128-03-08 19:00:00'), Timestamp('2128-03-08 20:00:00'), 'MAIN', 'Fentanyl Citrate', '041384', '00409909332', '100mcg/2mL Amp'], [20248756, Timestamp('2128-03-08 19:00:00'), Timestamp('2128-03-09 16:00:00'), 'MAIN', 'OxycoDONE (Immediate Release) ', '004225', '00406055262', '5mg Tablet'], [20248756, Timestamp('2128-03-08 19:00:00'), Timestamp('2128-03-09 16:00:00'), 'MAIN', 'Ondansetron', '061716', '00641608025', '2mg/mL-2mL'], [20248756, Timestamp('2128-03-08 19:00:00'), Timestamp('2128-03-09 16:00:00'), 'MAIN', 'Heparin', '006549', '63323026201', '5000 Units / mL- 1mL Vial'], [20248756, Timestamp('2128-03-08 19:00:00'), Timestamp('2128-03-08 20:00:00'), 'BASE', 'Iso-Osmotic Dextrose', '', '0', '100ml Bag'], [20248756, Timestamp('2128-03-08 19:00:00'), Timestamp('2128-03-08 20:00:00'), 'MAIN', 'Piperacillin-Tazobactam', '040819', '00206886202', '4.5 g Frozen Bag'], [20248756, Timestamp('2128-03-08 20:00:00'), Timestamp('2128-03-09 16:00:00'), 'BASE', 'D5 1/2NS', '002006', '00338008504', '1000mL Bag'], [20248756, Timestamp('2128-03-08 19:00:00'), Timestamp('2128-03-09 16:00:00'), 'MAIN', 'Sodium Chloride 0.9% Flush', '', '0', '10 mL Syringe'], [20248756, Timestamp('2128-03-08 19:00:00'), Timestamp('2128-03-09 16:00:00'), 'MAIN', 'Fentanyl Citrate', '041384', '00409909332', '100mcg/2mL Amp'], [20248756, Timestamp('2128-03-08 20:00:00'), Timestamp('2128-03-09 16:00:00'), 'MAIN', 'MethylPHENIDATE (Ritalin)', '004026', '00406112201', '10mg Tablet'], [20248756, Timestamp('2128-03-08 19:00:00'), Timestamp('2128-03-09 16:00:00'), 'MAIN', 'Acetaminophen', '004489', '51079000220', '325mg Tablet']]

[]

['cardiothoracic']

[]

Question: A 23 F is admitted. He/she says he/she has chest pain . History of illness: ___ y/o female w/ history of anxiety presents as transfer from ___ with pneumomediastinum. She describes acute onset of sharp, non-radiating sub sternal and right anterior chest pain beginning at 7pm on ___ while sitting at her computer writing an email. She ___ vomiting, wretching or any strenous manuvers. She also denies associated SOB or dyspnea. She had never experienced this before. She went to the ___ ED and had a CT scan which showed pneumomediastinum and she was transfered to ___. She was afebrile with benign labs and stable vitle signs at ___. Past Medical History: Anxiety Social History: ___ Family History: Non contributory Allergies: No Known Allergies / Adverse Drug Reactions What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Fentanyl Citrate OxycoDONE (Immediate Release) Ondansetron Heparin Iso-Osmotic Dextrose Piperacillin-Tazobactam D5 1/2NS Sodium Chloride 0.9% Flush Fentanyl Citrate MethylPHENIDATE (Ritalin) Acetaminophen Target Lab Orders: NONE Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : ___ y/o female who was sent as a transfer from ___ with pneumomediastinum with no preceeding event. After reviewing OSH imaging a barium swallow was ordered. It showed no esophageal perforation and she was clinically stable. However, due to continued pain and significant pneumomediastinum on CT scan she was admitted overnight for observation and was held NPO overnight. On HD#2 her pain had improved and she continued to have stable vitals. Her diet was advanced from clears to regular diet and she was discharged home. She should follow up with GI to work up potential eosinophillic esophagitis as possible cause of pneumomediastinum. At the time of discharge her pain was controlled with tylenol, she was tolerating a regular diet and was ambulatory. Other Results: NIL

2178-12-01 03:23:00

ENGLISH

DIVORCED

WHITE

F

[[20437472, Timestamp('2178-12-01 03:24:10'), '', 'PSYCH']]

[[{'Medications on Admission': ':\nHCTZ 25mg pO daily\nAvapro 150mg PO daily\n(brings in prescription bottle for Toprol XL 25mg daily, but is \nnot taking this)\n\n4. Risperdal 4 mg Tablet Sig: One (1) Tablet PO q8pm (at 8pm \ndaily). \n\nAppearance: Well-groomed. Sits properly in the chair.\nSpeech: Regular rate and rhythm, no dysarthria, sentences well \nformed.\nMood: "collected".\nAffect: Good range, though laughs nervously at times. Makes eye \ncontact.\nSafety: No c/o SI, HI.\nThought process: Linear. Able to convey her concerns clearly.\nThought content: No longer paranoid, no AVH.\nInsight: Good.\nJudgment: Good.', 'Brief Hospital Course': ':\n___ woman with history of MDD with psychotic features, breast \ncancer, presenting with paranoia, depression, anxiety, \ndifficulty making decisions, now significantly improved in terms \nof disorganization, paranoia, and anxiety. \n\n1. Legal: ___\n2. Psychiatric: \n- She was admitted with complaints of anxiety and depression, \nand was noted on examination to be paranoid and disorganized in \nthought and behavior. While in the hospital, she had no \nbehavioral problems. She participated in groups. \n- Given her depression, anxiety, and psychosis, she was started \non citalopram and risperidone. The risperidone was increased to \n4mg qhs over the course of her stay (she preferred to take the \nentire dose at night), while the citalopram remained at 20mg \ndaily. She felt "better" and appeared significantly more \norganized one day after starting the medications, and continued \nto improve over the course of her stay. She tolerated these \nmedications well with only mild nausea and somnolence noted. \nRisperidone was advanced to be taken at 8pm.\n- During her hospital stay, her course was discussed with her \n___ with her consent. She was encouraged to continue \nlooking for housing and making plans for her discharge. \n- On discharge, she had improved mood and organization (most \nnotable in speech and behavior, ability to make plans for after \ndischarge) and felt better in general.\n- She denied suicidal ideation throughout her admission. \n\n3. Medical: She had no acute medical issues during her stay. She \nhad an MRI performed to rule out brain metastases as an etiology \nof her behavioral change; the MRI was essentially unremarkable.\n\n', 'Pertinent Results:': '\nLabs: ___ 03:24PM \nCBC: WBC-5.1 RBC-4.17* Hgb-12.0 Hct-36.9 MCV-89 MCH-28.7 \nMCHC-32.5 RDW-13.5 Plt ___\nDiff: Neuts-79.5* Lymphs-13.0* Monos-3.1 Eos-4.0 Baso-0.3\nChem10: Glucose-96 UreaN-21* Creat-1.2* Na-140 K-3.8 Cl-104 \nHCO3-26 Calcium-9.2 Phos-3.7 Mg-2.1\nLFTs: ALT-35 AST-29 AlkPhos-86 TotBili-0.5\n VitB12-328 Folate-14.9 TSH-2.2\nStox: ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG \nTricycl-NEG\nU/A: Color-Straw Appear-Clear Sp ___ Blood-NEG \nNitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG \nUrobiln-NEG pH-7.0 Leuks-NEG RBC-0 WBC-0 Bacteri-NONE Yeast-NONE \nEpi-0\nUtox: bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG \namphetm-NEG mthdone-NEG\nURINE HCG-NEGATIVE\nRPR-Non-Reactive\n\nImaging:\n___ HCT: No acute intracranial hemorrhage, edema or mass \neffect. \nNon-contrast CT is limited in evaluation of small metastases, \nand if there \nremains clinical concern for metastasis, an MRI could be \nperformed. \n___ MRI head +/- contrast: 1. No acute intracranial process. \nNo masses. 2. Single punctate area in the right centrum \nsemiovale with high T2 and high FLAIR signal. This likely \nrepresents a nonspecific finding. \n\n', 'Physical Exam:|Physical': ' ___:\nOn admission:\n\nVITAL SIGNS: T 98.6, P 80, BP 154/80, R 18, SaO2 98% RA\n\nMENTAL STATUS EXAM\n APPEARANCE & FACIAL EXPRESSION: ___ yo woman, fair hygiene \nbut not well groomed, appears stated age\n POSTURE: laying in bed\n BEHAVIOR: no psychomotor agitation/retardation\n ATTITUDE: superficially cooperative, guarded, unwilling to \ngive much info \n SPEECH: normal rate and rhythm\n MOOD: "depressed" "stressed out"\n AFFECT: full range although not mood congruent initially, \npatient smiling not appearing dysthymic. Later on patient became \ntearful when she was informed she will have to come in to the \nhospital.\n THOUGHT FORM: linear\n THOUGHT CONTENT: patient appears paranoid and guarded \nduring the interview. She reports that her family and friends \nmake stories about her that are not true, she is concerned about \nthe ___ Police and is worried her phone might have been \ntaped. She is unwilling to elaborate on any more information \nstating "it\'s not important". No preoccupations, no thought \nbroadcasting, no ideas of referrence\n ABNORMAL PERCEPTIONS: denied\n NEUROVEGETATIVE SYMPTOMS: sleep is "on and off", appetite \nis good and energy is also on and off\n SUICIDALITY/HOMICIDALITY: denied any SI or HI\n INSIGHT AND JUDGMENT: limited, patient shows no \nunderstanding in her mental condition and is not willing to \naccept help or treatment.\n COGNITIVE ASSESSMENT:\n SENSORIUM: awake and alert\n ORIENTATION: ___, ___\n ATTENTION: DOWB intact\n MEMORY (SHORT- AND LONG-TERM): ___ at registration and \nat 5 min\n CALCULATIONS: $2.25 = 9 quarters\n FUND OF KNOWLEDGE: average\n PROVERB INTERPRETATION: "Don\'t judge a book by its \ncover -> you have to look deeper than the surface"\n SIMILARITIES/ANALOGIES: apples/oranges -> both fruit, \none you have to peel\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\n___ woman with a history of depression with psychotic features \nand PTSD who self-presented to the ED complaining of anxiety and \ndepressed mood for the past couple of weeks that have escalated \nover the past week. She describes that her anxiety comes and \ngoes, and when she feels anxious she becomes "impulsive" or she \nwill start crying. When asked to describe her impulsivity she \nstated that she will call people when she\'s anxious and say \nthings to them about herself that she later regrets. She also \ndescribed her coming to the ED tonight as an impulsive act \nbecause of getting overly anxious, and states that now she is \nmore anxious to go home. \n\nThe patient also reported having had a depressed mood on and off \nfor the past few weeks. She reports a recent hospitalization in \n___ (___) after which she feels she has not \nfully recovered. The patient attributes her low mood to her \nanxiety and stressors. She denied any changes in appetite. She \nstates sleep is on and off, and describes having had a few bad \nnights in a row. She reports that her energy is on and off as \nwell but again attributes that to her anxiety which has not \nallowed her to function the way she wishes she was. The patient \ndenied any SI/HI or any auditory or visual hallucinations. \n\nThe patient reports many recent stressors in her life lately \nthat have attributed to her anxiety. She had to leave her \napartment the day after presentation because she thought she was \ngoing to move out of ___ to ___ and ___ up her \napartment. The patient has been having these thoughts of moving \nout of ___ for the past few months mainly to be closer to her \n___ who lives in ___ but has been unable to make up \nher mind if she really wants to do that or not. She states that \nshe has been looking for other apartments but has been unable to \ncome to a decision as to where she would like to live. Now she \nno longer feels strongly about living close to her ___ \nand believes that maybe "he is too involved in my life". The \npatient has movers arranged to come in tomorrow and will be \nplacing her belongings in storage. She plans to live in a \nbed-and-breakfast by ___ and then also spend some nights \nat friends\' houses until she finds a place to live. She states \nthat this move has stressed her out but wants to go through with \nit at this point. The patient describes her immediate family \n(siblings and mother) and her ___ also being stressors in \nher life right now. She believes that they are overly concerned \nwith her and are not helping her in a meaningful way (unable to \nexplain what she would want). She reports a recent family \n___ a couple of weeks ago that she describes "was a mistake" \nbecause it added to her stress. Her ___ also sent her \npapers about the custody of their ___ yo daughter this past week \nwhich made Ms. ___ feel even worse. \n\nOf note, the patient appeared very guarded with giving \ninformation during the interview. During follow-up questions on \nvague statements she would repeatedly say "it\'s not important, I \ndon\'t want to talk about it". She was unwilling initially to \ngive her ___ contact number in fear that "I don\'t know \nwhat he\'s going to say about me". She also asked multiple times \nif this interview was confidential, and whether we were being \nwatched, although she quickly changed that statement to whether \nthe information will be seen by other people. The patient also \nappeared initially very flat and unemotional when talking about \nnot having a home from the day after presentation onwards. \n\nThe patient\'s ___, was contacted, who stated \nthat he is very concerned about his ex-wife. He believes that \nshe has had "an abrrupt decline" over the past few months that \nhe has been unable to explain. He describes that she has become \nvery paranoid, making statements about the FBI taping her phone. \nPer ___ the patient has been also having paranoid thoughts \nabout the ___ Police after she tried to report an incident \nat a ___ place (the patient did mention this incident to me \nas a recent trigger of old PTSD symptoms and did mention that \nthe police did not follow up on her reports against the person \nbut was unwilling to give more details, see Dr. ___ note \nfrom ___ for details on the event). During the incident with \nthe police, DSS was also involved in the patient\'s life because \nher ___ yo daughter was with her at the police station. Since \nthen, DSS has been involved once more during her ___ \nhospitalization after they received an anonymous phone call for \nconcerns about the safety of the child at home and potential \nneglect. Per ___, the patient has been unable to cook or \nclean her apartment for the last few months now, which he \ndiscovered when he tried to finish packing for her during her \nstay at ___. Mr. ___ is not actively concerned \nabout the patient\'s safety in terms of her harming herself but \nbelieves that she has not been functioning well and has been \nresistant to treatment (non-compliant with her meds or with \nfollow up after ___. He is also concerned about \nher inability to make decisions lately especially regarding her \nmoving but also on whether she wants to come in to the hospital \nor not and whether she wants treatment or not (patient has tried \nto come to ED multiple times and then changes her mind in the \nlast minute). Mr. ___ also reports that in the past ___ years \nthe patient has also not been able to follow up with her general \nmedical condition. Recently over the past few months she has \nchanged 3 PCPs, which Mr. ___ attributes to some paranoid \nfeelings towards them. Mr. ___ also describes that the patient \ncalls him or her friends 10x an hour, sometimes constantly \nremembering something else and feels the need to express it as \ntrivial as it might be. He states that she never used to be like \nthis and that it has become hard for him to handle. \n\n___ (___), the patient\'s friend from ___, was \nalso contacted. ___ is also concerned about how the patient has \nbeen doing lately. She reports that she has been paranoid about \nher family and her ___ wanting to harm her, and these \nlast few days she also mentioned that the FBI might be after \nher. ___ is also concerned because the patient has endorsed \ncomplete hopelessness to her although no suicidal ideation. She \nknows that the patient has thought of coming to the ED multiple \ntimes and has actually come here a few times over the past few \nmonths but has appeared very indecisive in terms of getting \ntreatment and help and following through with it. \n\nWhen the patient was re-interviewed after collateral information \nhad been gathered she avoided answering specific questions \nregarding the ___ police and her phone being taped by \nsaying constantly "it\'s not important I don\'t want to talk about \nit". She believes that people make up stories for her based on \nwhat they want to believe that are not true, and is very upset \nabout having to come into the hospital. At this point the \npatient showed emotions about potentially being homeless, as \nopposed to prior discussion where she had appeared flat when \ntalking about it. \n\nPast Medical History:\nPSYCHIATRIC HISTORY:\nHistory of PTSD and depression (per OMR). \nShe reports one psychiatric hospitalization at ___ \nin ___ for 11 days (beginning ___. Per her husband, \nshe was given diagnosis of MDD with psychotic features, however \nshe has been noncompliant with her treatment and follow up. The \npatient made an appointment with a therapist, ___, but \nhas only seen her once. No other treaters at the time of \nadmission.\nShe denied any suicidal attempts, history of violence, history \nof legal issues.\nPrior medication trials include Paxil, reportedly in the past \nand again at ___, which she stopped taking during \nhospitalization because it made her feel "funny and flat".\n\nPAST MEDICAL HISTORY: Hepatitis C, breast cancer (last treated \nin ___ status post mastectomy, XRT, and initial tamoxifen \n(self-discontinued), cataracts, hypertension, polycystic kidney \ndisease, hepatic cysts\n\nSocial History:\nBorn and raised in ___. Reports history of physical abuse \nwithin the family from her father at around age ___. She states \nit was probably because he did not know how to handle the fact \nthat she was growing up. The patient ran away from home at that \npoint. She says that she has made amends since then and is now \nclose to her mother and 4 siblings (all live in other ___). \nHer father died ___ years ago from medical complications but the \npatient had made ammends with him as well. The patient reported \nthat she never finished high school but got her GED and then \nwent on to college to study ___ and minor in math. \nThe patient is currently unemployed and survives on child \nsupport and savings. She has not been able to work due to her \nbreast cancer initially and then her depression. Prior to \nhaving her daughter the patient had worked as an ___ at a \n___. She had an apartment in \n___ that she gave up at the time of admission. She is \nunaware of where she is moving but will have her things kept in \nstorage (see HPI). The patient also has an ___ yo daughter who \nlived with her until her last\nhospitalization, and now is living with the patient\'s \n___. She has been divorced from her husband for ___ years \nnow. There had been an initial agreement on the custody of their \nchild. DSS has also been involved twice with the care of the \ndaughter but case has been closed per her ___. \n\nThe patient denied any current issues with alcohol or drugs. She \nreports having been a heavy drinker about ___ years ago but never \nwent into treatment. She has not drank in many years. She also \nreports having used marijuana, cocaine and heroin IV in the \npast, but nothing since her teenage years. \n\nFamily History:\nMother - ___, healthy\nFather - deceased at age ___ -- CVA/brain hemorrhage, PCKD\nPGM - alive at ___\nPGF - died in ___ of PCKD\nSiblings - 3 brothers and one sister: one brother with \ndepression, o/w healthy\nChildren - ___ yo daughter, healthy\n\n', 'Chief Complaint:|Complaint:': '\n"I\'ve been pretty anxious"\n\n', 'Attending:': ' ___\n\n', 'Allergies:': ' \nPatient recorded as having No Known Allergies to Drugs\n\n'}, '19944470-DS-13', 13, 'psychiatry']]

[['INDICATION: ___ with acute change in mental status. Rule out\nmetastases from breast cancer.\n\nNo prior examinations.\n\nNON-CONTRAST HEAD CT: There is no acute intracranial hemorrhage or edema. No\nmass effect. The gray-white matter differentiation is preserved. The\nventricles are normal in size and configuration. The visualized paranasal\nsinuses and mastoid air cells are normally pneumatized and aerated. There are\nno suspicious lytic or sclerotic lesions within the skull. The soft tissues\nare normal.\n\nIMPRESSION: No acute intracranial hemorrhage, edema or mass effect. \nNon-contrast CT is limited in evaluation of small metastases, and if there\nremains clinical concern for metastasis, an MRI could be performed.\n', '19944470-RR-24', 24, ''], ['HISTORY: ___ woman with acute paranoia and history of breast cancer.\nPlease evaluate for masses.\n\nTECHNIQUE: Brain MRI. Sagittal T1-weighted, axial T1-weighted, axial FLAIR,\naxial T2-weighted, axial susceptibility, diffusion technique images were\nobtained. Following administration of intravenous gadolinium contrast, axial\nT1 and sagittal, axial, and coronal MP-RAGE images were obtained.\n\nCOMPARISONS: CT head from ___.\n\nFINDINGS: Within the right centrum semiovale, there is a single punctate area\nof increased FLAIR and increased T2 signal. This area is too small to\ncharacterize and likely represents nonspecific findings. There are no other\nlesions of abnormal FLAIR or T2 signal. There is no evidence of hemorrhage,\nedema, masses, mass effect, or infarction. The ventricles and sulci are\nnormal in caliber and configuration. There are no diffusion abnormalities\ndetected. There is no abnormal enhancement after contrast administration.\nThere are mucus cysts within the right and left maxillary sinuses.\n\nIMPRESSION:\n1. No acute intracranial process. No masses.\n2. Single punctate area in the right centrum semiovale with high T2 and high\nFLAIR signal. This likely represents a nonspecific finding.\n', '19944470-RR-25', 25, 'brain mri. sagittal t1-weighted, axial t1-weighted, axial flair,\naxial t2-weighted, axial susceptibility, diffusion technique images were\nobtained. following administration of intravenous gadolinium contrast, axial\nt1 and sagittal, axial, and coronal mp-rage images were obtained.']]

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[]

['psychiatry']

[[50861, Timestamp('2178-12-02 06:50:00'), Timestamp('2178-12-02 08:39:00'), 'Alanine Aminotransferase (ALT)'], [50863, Timestamp('2178-12-02 06:50:00'), Timestamp('2178-12-02 08:39:00'), 'Alkaline Phosphatase'], [50878, Timestamp('2178-12-02 06:50:00'), Timestamp('2178-12-02 08:39:00'), 'Asparate Aminotransferase (AST)'], [50885, Timestamp('2178-12-02 06:50:00'), Timestamp('2178-12-02 08:39:00'), 'Bilirubin, Total'], [50893, Timestamp('2178-12-02 06:50:00'), Timestamp('2178-12-02 08:39:00'), 'Calcium, Total'], [50912, Timestamp('2178-12-02 06:50:00'), Timestamp('2178-12-02 08:39:00'), 'Creatinine'], [50925, Timestamp('2178-12-02 06:50:00'), Timestamp('2178-12-02 21:02:00'), 'Folate'], [50960, Timestamp('2178-12-02 06:50:00'), Timestamp('2178-12-02 08:39:00'), 'Magnesium'], [50970, Timestamp('2178-12-02 06:50:00'), Timestamp('2178-12-02 08:39:00'), 'Phosphate'], [50993, Timestamp('2178-12-02 06:50:00'), Timestamp('2178-12-02 21:02:00'), 'Thyroid Stimulating Hormone'], [51006, Timestamp('2178-12-02 06:50:00'), Timestamp('2178-12-02 08:39:00'), 'Urea Nitrogen'], [51010, Timestamp('2178-12-02 06:50:00'), Timestamp('2178-12-02 21:02:00'), 'Vitamin B12']]

Question: A 50 F is admitted. He/she says he/she has "I've been pretty anxious" . History of illness: ___ woman with a history of depression with psychotic features and PTSD who self-presented to the ED complaining of anxiety and depressed mood for the past couple of weeks that have escalated over the past week. She describes that her anxiety comes and goes, and when she feels anxious she becomes "impulsive" or she will start crying. When asked to describe her impulsivity she stated that she will call people when she's anxious and say things to them about herself that she later regrets. She also described her coming to the ED tonight as an impulsive act because of getting overly anxious, and states that now she is more anxious to go home. The patient also reported having had a depressed mood on and off for the past few weeks. She reports a recent hospitalization in ___ (___) after which she feels she has not fully recovered. The patient attributes her low mood to her anxiety and stressors. She denied any changes in appetite. She states sleep is on and off, and describes having had a few bad nights in a row. She reports that her energy is on and off as well but again attributes that to her anxiety which has not allowed her to function the way she wishes she was. The patient denied any SI/HI or any auditory or visual hallucinations. The patient reports many recent stressors in her life lately that have attributed to her anxiety. She had to leave her apartment the day after presentation because she thought she was going to move out of ___ to ___ and ___ up her apartment. The patient has been having these thoughts of moving out of ___ for the past few months mainly to be closer to her ___ who lives in ___ but has been unable to make up her mind if she really wants to do that or not. She states that she has been looking for other apartments but has been unable to come to a decision as to where she would like to live. Now she no longer feels strongly about living close to her ___ and believes that maybe "he is too involved in my life". The patient has movers arranged to come in tomorrow and will be placing her belongings in storage. She plans to live in a bed-and-breakfast by ___ and then also spend some nights at friends' houses until she finds a place to live. She states that this move has stressed her out but wants to go through with it at this point. The patient describes her immediate family (siblings and mother) and her ___ also being stressors in her life right now. She believes that they are overly concerned with her and are not helping her in a meaningful way (unable to explain what she would want). She reports a recent family ___ a couple of weeks ago that she describes "was a mistake" because it added to her stress. Her ___ also sent her papers about the custody of their ___ yo daughter this past week which made Ms. ___ feel even worse. Of note, the patient appeared very guarded with giving information during the interview. During follow-up questions on vague statements she would repeatedly say "it's not important, I don't want to talk about it". She was unwilling initially to give her ___ contact number in fear that "I don't know what he's going to say about me". She also asked multiple times if this interview was confidential, and whether we were being watched, although she quickly changed that statement to whether the information will be seen by other people. The patient also appeared initially very flat and unemotional when talking about not having a home from the day after presentation onwards. The patient's ___, was contacted, who stated that he is very concerned about his ex-wife. He believes that she has had "an abrrupt decline" over the past few months that he has been unable to explain. He describes that she has become very paranoid, making statements about the FBI taping her phone. Per ___ the patient has been also having paranoid thoughts about the ___ Police after she tried to report an incident at a ___ place (the patient did mention this incident to me as a recent trigger of old PTSD symptoms and did mention that the police did not follow up on her reports against the person but was unwilling to give more details, see Dr. ___ note from ___ for details on the event). During the incident with the police, DSS was also involved in the patient's life because her ___ yo daughter was with her at the police station. Since then, DSS has been involved once more during her ___ hospitalization after they received an anonymous phone call for concerns about the safety of the child at home and potential neglect. Per ___, the patient has been unable to cook or clean her apartment for the last few months now, which he discovered when he tried to finish packing for her during her stay at ___. Mr. ___ is not actively concerned about the patient's safety in terms of her harming herself but believes that she has not been functioning well and has been resistant to treatment (non-compliant with her meds or with follow up after ___. He is also concerned about her inability to make decisions lately especially regarding her moving but also on whether she wants to come in to the hospital or not and whether she wants treatment or not (patient has tried to come to ED multiple times and then changes her mind in the last minute). Mr. ___ also reports that in the past ___ years the patient has also not been able to follow up with her general medical condition. Recently over the past few months she has changed 3 PCPs, which Mr. ___ attributes to some paranoid feelings towards them. Mr. ___ also describes that the patient calls him or her friends 10x an hour, sometimes constantly remembering something else and feels the need to express it as trivial as it might be. He states that she never used to be like this and that it has become hard for him to handle. ___ (___), the patient's friend from ___, was also contacted. ___ is also concerned about how the patient has been doing lately. She reports that she has been paranoid about her family and her ___ wanting to harm her, and these last few days she also mentioned that the FBI might be after her. ___ is also concerned because the patient has endorsed complete hopelessness to her although no suicidal ideation. She knows that the patient has thought of coming to the ED multiple times and has actually come here a few times over the past few months but has appeared very indecisive in terms of getting treatment and help and following through with it. When the patient was re-interviewed after collateral information had been gathered she avoided answering specific questions regarding the ___ police and her phone being taped by saying constantly "it's not important I don't want to talk about it". She believes that people make up stories for her based on what they want to believe that are not true, and is very upset about having to come into the hospital. At this point the patient showed emotions about potentially being homeless, as opposed to prior discussion where she had appeared flat when talking about it. Past Medical History: PSYCHIATRIC HISTORY: History of PTSD and depression (per OMR). She reports one psychiatric hospitalization at ___ in ___ for 11 days (beginning ___. Per her husband, she was given diagnosis of MDD with psychotic features, however she has been noncompliant with her treatment and follow up. The patient made an appointment with a therapist, ___, but has only seen her once. No other treaters at the time of admission. She denied any suicidal attempts, history of violence, history of legal issues. Prior medication trials include Paxil, reportedly in the past and again at ___, which she stopped taking during hospitalization because it made her feel "funny and flat". PAST MEDICAL HISTORY: Hepatitis C, breast cancer (last treated in ___ status post mastectomy, XRT, and initial tamoxifen (self-discontinued), cataracts, hypertension, polycystic kidney disease, hepatic cysts Social History: Born and raised in ___. Reports history of physical abuse within the family from her father at around age ___. She states it was probably because he did not know how to handle the fact that she was growing up. The patient ran away from home at that point. She says that she has made amends since then and is now close to her mother and 4 siblings (all live in other ___). Her father died ___ years ago from medical complications but the patient had made ammends with him as well. The patient reported that she never finished high school but got her GED and then went on to college to study ___ and minor in math. The patient is currently unemployed and survives on child support and savings. She has not been able to work due to her breast cancer initially and then her depression. Prior to having her daughter the patient had worked as an ___ at a ___. She had an apartment in ___ that she gave up at the time of admission. She is unaware of where she is moving but will have her things kept in storage (see HPI). The patient also has an ___ yo daughter who lived with her until her last hospitalization, and now is living with the patient's ___. She has been divorced from her husband for ___ years now. There had been an initial agreement on the custody of their child. DSS has also been involved twice with the care of the daughter but case has been closed per her ___. The patient denied any current issues with alcohol or drugs. She reports having been a heavy drinker about ___ years ago but never went into treatment. She has not drank in many years. She also reports having used marijuana, cocaine and heroin IV in the past, but nothing since her teenage years. Family History: Mother - ___, healthy Father - deceased at age ___ -- CVA/brain hemorrhage, PCKD PGM - alive at ___ PGF - died in ___ of PCKD Siblings - 3 brothers and one sister: one brother with depression, o/w healthy Children - ___ yo daughter, healthy Allergies: Patient recorded as having No Known Allergies to Drugs What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Risperidone Citalopram Hydrobromide Hydrochlorothiazide Sodium Chloride 0.9% Flush Irbesartan Risperidone Milk of Magnesia Acetaminophen Irbesartan Target Lab Orders: Alanine Aminotransferase (ALT) Alkaline Phosphatase Asparate Aminotransferase (AST) Bilirubin, Total Calcium, Total Creatinine Folate Magnesium Phosphate Thyroid Stimulating Hormone Urea Nitrogen Vitamin B12 Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : ___ woman with history of MDD with psychotic features, breast cancer, presenting with paranoia, depression, anxiety, difficulty making decisions, now significantly improved in terms of disorganization, paranoia, and anxiety. 1. Legal: ___ 2. Psychiatric: - She was admitted with complaints of anxiety and depression, and was noted on examination to be paranoid and disorganized in thought and behavior. While in the hospital, she had no behavioral problems. She participated in groups. - Given her depression, anxiety, and psychosis, she was started on citalopram and risperidone. The risperidone was increased to 4mg qhs over the course of her stay (she preferred to take the entire dose at night), while the citalopram remained at 20mg daily. She felt "better" and appeared significantly more organized one day after starting the medications, and continued to improve over the course of her stay. She tolerated these medications well with only mild nausea and somnolence noted. Risperidone was advanced to be taken at 8pm. - During her hospital stay, her course was discussed with her ___ with her consent. She was encouraged to continue looking for housing and making plans for her discharge. - On discharge, she had improved mood and organization (most notable in speech and behavior, ability to make plans for after discharge) and felt better in general. - She denied suicidal ideation throughout her admission. 3. Medical: She had no acute medical issues during her stay. She had an MRI performed to rule out brain metastases as an etiology of her behavioral change; the MRI was essentially unremarkable. Other Results: Labs: ___ 03:24PM CBC: WBC-5.1 RBC-4.17* Hgb-12.0 Hct-36.9 MCV-89 MCH-28.7 MCHC-32.5 RDW-13.5 Plt ___ Diff: Neuts-79.5* Lymphs-13.0* Monos-3.1 Eos-4.0 Baso-0.3 Chem10: Glucose-96 UreaN-21* Creat-1.2* Na-140 K-3.8 Cl-104 HCO3-26 Calcium-9.2 Phos-3.7 Mg-2.1 LFTs: ALT-35 AST-29 AlkPhos-86 TotBili-0.5 VitB12-328 Folate-14.9 TSH-2.2 Stox: ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG U/A: Color-Straw Appear-Clear Sp ___ Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG RBC-0 WBC-0 Bacteri-NONE Yeast-NONE Epi-0 Utox: bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG URINE HCG-NEGATIVE RPR-Non-Reactive Imaging: ___ HCT: No acute intracranial hemorrhage, edema or mass effect. Non-contrast CT is limited in evaluation of small metastases, and if there remains clinical concern for metastasis, an MRI could be performed. ___ MRI head +/- contrast: 1. No acute intracranial process. No masses. 2. Single punctate area in the right centrum semiovale with high T2 and high FLAIR signal. This likely represents a nonspecific finding.

2137-01-25 23:43:00

ENGLISH

MARRIED

WHITE - OTHER EUROPEAN

M

[[25494051, Timestamp('2137-01-25 23:44:20'), '', 'OMED']]

[[{'Medications on Admission': ':\nThe Preadmission Medication list is accurate and complete.\n1. Ciprofloxacin HCl 500 mg PO Q12H \n2. Fluconazole 400 mg PO Q24H \n3. FoLIC Acid 1 mg PO DAILY \n4. Omeprazole 20 mg PO DAILY \n5. PredniSONE 5 mg PO DAILY \n6. Sulfameth/Trimethoprim SS 1 TAB PO DAILY \n7. Ursodiol 300 mg PO DAILY \n8. Magnesium Oxide 400 mg PO DAILY \n9. Multivitamins 1 TAB PO DAILY \n10. Acyclovir 400 mg PO Q12H \n11. MetRONIDAZOLE (FLagyl) 500 mg PO TID ', 'Brief Hospital Course': ":\nMr. ___ is a ___ year old gentleman with PMHx of CMML \nconversion to AML s/p allo-sct ___ presenting with \nfebrile neutropenia and diarrhea. Febrile neutropenia most \nlikely viral gastroenteritis (multiple family members with \nvomiting/diarrheal illness). There was also concern for GVHD or \nCMV colitis. C diff negative. Stool O+P, cultures negative. Noro \nPCR negative. Initially treated with broad spectrum antibiotics \nwhich were discontinued with improvement in symptoms and \nnegative culture data. Patient's diarrhea did not improve and GI \nwas consulted. Flex sig was performed with preliminary pathology \nreport showing continued evidence of GVHD. Patient started on \nBudesonide 9mg PO Daily, with excellent efficacy. Patient was \ndischarge home and will follow up with his primary Heme/Onc \nattending as an outpatient. \n\nHospitalization complicated by mild ___, most likely ___ \npre-renal vs intrinsic renal etiology ___ dehydration and poor \nPO intake, this improved with IV fluids. \n\nACUTE ISSUES\n\n# Neutropenic Fever/Diarrhea - Day +126. Most likely secondary \nto viral gastroenteritis given diarrhea and multiple family \nmembers with vomiting and diarrhea, noro virus PCR all negative. \nConcerned for GVHD or CMV colitis and symptoms did not improve \nwith loperamide making this more likely. CXR negative, stool \nculture and O+P negative, c diff negative, blood and urine \ncultures with no growth. Influenza A/B negative. Treated \nempirically with broad spectrum antibiotics vanc, cefepime, \nflagyl though these were discontinued with negative culture data \nand improvement in symptoms. Patient remained afebrile. Flex sig \nshowed mild GVHD consistent with prior biopsies. The patient was \nstarted on Budesonide with good affect. Patient will remain on \nbudesonide for at least one month. Given no significant \nworsening on biopsy, it is likely that the patient had \ngastroenteritis complicated by mild GVHD. Consider stopping \nbudesonide after one month given significant expense of the \nmedication. \n\n# Acute Kidney Injury- Baseline Cr 1.1 -> 1.6 on admission. \nPre-renal given diarrhea and poor PO intake vs intrinsic renal \ngiven recent history of AIN, urine eos positive, FeNa >1 \nsuggestive of intrinsic renal etiology, likely ATN ___ \nhypovolemia. Cr improved to 1.0 with IV fluids suggestive of \ndehydration as underlying etiology. \n\nCHRONIC ISSUES\n\n# CMML/AML, STATUS POST CORD TRANSPLANT: Currently at D+126 allo \nSCT. Patient has history of CMML with transformation to AML s/p \ndouble umbilical cord stem cell transplant on ___. \nReceiving decitabine with outpatient provider ___ \napproximately ___. Continued opportunistic infection \nprophylaxis with fluconazole, bactrim, and acyclovir. \n\n# Poor Nutrition: Patient with 1 week of poor PO intake, albumin \n3.3 with normal LFTs suggestive of malnutrition. Nutrition \nconsulted, recommended ensure TID with meals. Patient was eating \nwell at time of discharge. \n\n# H/o GVHD - Previous admission had diarrhea ___ GVHD as seen on \nflex sigmoidoscopy, currently tapering immunosuppression, only \non prednisone 5mg PO daily. Evidence of rejection with 12% \nchimerism early ___, resent in clinic ___. Flex sig \nduring admission showed persistent mild disease. Follow up final \nread of biopsy. Consider stopping Budesonide after one month. \n\n==============\nTRANSITIONAL ISSUES:\n==============\n[ ] CMML-> AML with concern for graft rejection, numerous blasts \nin peripheral blood, chimerism 12% when checked in early \n___ need to follow up with outpatient providers to \ndetermine further treatment plan\n[ ] ___- repeat creatinine at outpatient follow up to ensure \nstable renal function\n[ ] Patient will need to monitory for signs of worsening GVHD \nwith symptoms going forward\n[ ] If patient's symptoms continue to be mild or completely \nresolved please consider stopping budesonide as outpatient as it \nis very expensive\n[ ] CMV biopsies are pending at time of discharge\n[ ] please call your PCP and make ___ follow up appointment within \none month after leaving the hospital. \n[ ] increased omeprazole to 40mg daily due to worsening GERD in \nthe mornings after lying down (patient may take it before bed \nrather than in the AM)\n\n# CODE STATUS: Confirmed Full\n# EMERGENCY CONTACT: wife Mrs. ___ ___\n\n", 'Pertinent Results:': '\nLABS ON ADMISSION:\n\n___ 11:25PM BLOOD WBC-2.1* RBC-3.03* Hgb-8.3* Hct-25.6* \nMCV-85 MCH-27.3 MCHC-32.3 RDW-19.7* Plt Ct-58*\n___ 11:25PM BLOOD Neuts-41* Bands-0 ___ Monos-20* \nEos-0 Baso-0 ___ Myelos-2* Blasts-5* NRBC-4*\n___ 11:25PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-NORMAL \nMacrocy-1+ Microcy-NORMAL Polychr-1+\n___ 11:25PM BLOOD Plt Smr-LOW Plt Ct-58*\n___ 11:25PM BLOOD Glucose-150* UreaN-21* Creat-1.4* Na-133 \nK-4.1 Cl-99 HCO3-21* AnGap-17\n\nPERTINENT RESULTS:\n\n___ 08:30AM BLOOD IgG-575*\n___ 05:43AM BLOOD Vanco-17.3\n___ 08:30AM BLOOD tacroFK-2.0* rapmycn-LESS THAN \n___ 11:33PM BLOOD Lactate-2.1*\n\n___ 06:30AM BLOOD WBC-5.1 RBC-3.14* Hgb-8.5* Hct-26.2* \nMCV-84 MCH-27.2 MCHC-32.5 RDW-20.6* Plt Ct-55*\n___ 06:30AM BLOOD Neuts-44* Bands-0 ___ Monos-3 Eos-2 \nBaso-0 ___ Metas-9* Myelos-6* Promyel-4* Blasts-10* NRBC-9*\n___ 06:30AM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-NORMAL \nMacrocy-2+ Microcy-NORMAL Polychr-1+\n___ 06:30AM BLOOD Plt Smr-VERY LOW Plt Ct-55*\n___ 06:30AM BLOOD ___ PTT-28.3 ___\n___ 06:30AM BLOOD Glucose-120* UreaN-16 Creat-1.0 Na-139 \nK-3.9 Cl-107 HCO3-21* AnGap-15\n___ 06:30AM BLOOD ALT-6 AST-13 LD(LDH)-330* AlkPhos-51 \nTotBili-0.3\n___ 06:30AM BLOOD Calcium-8.9 Phos-2.2* Mg-1.9\n___ 06:00AM BLOOD Albumin-3.4* Calcium-8.8 Phos-3.5 Mg-2.1\n\nMICROBIOLOGY:\n\nStool Studies ___ 9:18 am STOOL CONSISTENCY: NOT APPLICABLE\n Source: Stool. \n\n MICROSPORIDIA STAIN (Pending): \n\n CYCLOSPORA STAIN (Final ___: NO CYCLOSPORA SEEN. \n\n C. difficile DNA amplification assay (Final ___: \n Negative for toxigenic C. difficile by the Illumigene DNA\n amplification assay. \n (Reference Range-Negative). \n\n FECAL CULTURE (Final ___: \n NO ENTERIC GRAM NEGATIVE RODS FOUND. \n NO SALMONELLA OR SHIGELLA FOUND. \n\n CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER \nFOUND. \n\n OVA + PARASITES (Final ___: \n NO OVA AND PARASITES SEEN. \n This test does not reliably detect Cryptosporidium, \nCyclospora or\n Microsporidium. While most cases of Giardia are detected \nby routine\n O+P, the Giardia antigen test may enhance detection when \norganisms\n are rare. \n\n Cryptosporidium/Giardia (DFA) (Final ___: \n NO CRYPTOSPORIDIUM OR GIARDIA SEEN. \n\n VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED. \n\nCMV Viral Load ___:\nCMV Viral Load (Final ___: \n CMV DNA not detected. \n\n___:\nInfluenza A by PCRNEGATIVE \nInfluenza B by PCRNEGATIVE\n\nEKG: ___:\n\nBorderline sinus tachycardia. Otherwise, within normal limits. \nNo change from\nprevious tracing.\n IntervalsAxes\n___\n___\n\nIMAGING:\n\nCXR ___:\nFINDINGS: \n\nThe right-sided PICC line has been removed. The lungs are \nclear. There is no\npneumothorax. The heart and mediastinum are within normal \nlimits.\n\nIMPRESSION: \n\nClear lungs.\n\n', 'Physical Exam:|Physical': '\nEXAM ON ADMISSION:\n\nVITAL SIGNS: T 99.7 BP 146/72 HR 105 RR 20 98%RA\nGeneral: NAD,. well appearing but thin and frail\nHEENT: MMM, no OP lesions, no cervical, supraclavicular, or\naxillary adenopathy, no thyromegaly\nCV: RR, NL S1S2 no S3S4 MRG\nPULM: CTAB\nGI: BS+, soft, mild tenderness to deep palpation of the lower\nquadrants bilaterally, no masses or hepatosplenomegaly\nLIMBS: No edema, clubbing, tremors, or asterixis; no inguinal\nadenopathy\nSKIN: No rashes or skin breakdown\nNEURO: Oriented x3. strength ___ throughout and symmetric,\ncoordination is intact.\n\nEXAM ON DISCHARGE:\nVITAL SIGNS: Tmax 98.3 Tc 97.9 HR 90 BP 122/60 16 99% on RA \nWt: <-140.4<-141 lbs\nBM: 0 BM in last 24hrs\nGeneral: Thin, comfortable appearing, no acute distress\nHEENT: PERRL, MMM, oropharynx without lesions or ulceration\nCV: RRR, s1, s2 no m/r/g\nPULM: CTAB no wheezes, crackles, rhonchi\nGI: BS+, soft, non tender to deep palpation, no masses or \nhepatosplenomegaly\nEXT: No edema, clubbing, tremors, or asterixis; no inguinal\nadenopathy\nSKIN: No rashes, stage I pressure ulcer on coccyx with dressing \nc/d/i\nNEURO: Oriented x3. strength ___ throughout and symmetric,\ncoordination is intact.\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\nMr. ___ is a ___ year old gentleman with PMHx of CMML \nconversion to AML s/p allo-sct ___ presenting to \nthe ED with fever at home of ___. He was seen in clinic today \nand was afebrile but on arrival home\nwife took his temperature and it was 101 so he came in to the ED\nas he was known to be neutropenic. He was feeling quite well. In\nfact he had no significant complaints other than some abdominal\ndistention and cramping over the last week and he has also had\nsome increasingly loose stools but no true diarrhea. No\nchills/rigors at home, no nausea/vomiting, no chest pain/sob, no\ncough, no sick contacts, no rhinorrhea or nasal congestion.\n\nRegarding his onc history: he has CMML with transformation to \nAML\nand is s/p double umbilical cord SCT ___. Of note his most\nrecent admission was ___ - ___ at which point he was\nadmitted with fever and found to have MSSA bacteremia and while\nTTE did not show e/o valvulvar vegetation, ID recommended\nempirically treating for endocarditis for 6 weeks rather than\npursue TEE given his cytopenias. Antibiotics (cefazolin) ran\nthrough ___. His hospital course was c/b GVHD in the form of\ndiarrhea - stool studies were negative and flex sig biopsy did\nshow mild GVHD. He was started on TPN and treated with \nmethylpred\nwhich was downtitrated and at the time of DC bowel movements \nwere\nnormal and he was back on a regular diet and off TPN. He was \nsent\nhome on prednisone due to appearance of blasts on peripheral\nsmear (sent ___ on 10mg pred daily). After noting the blasts his\nimmunosuppression was downtritated rapidly and bone marrow \nbiopsy\nshowed residual dysplasia and 53% donor cells so he underwent 5d\nof decitabine from ___ and then in early ___ \nreceived\nhis second cycle of decitabine locally with Dr. ___ \n___\ngiven on ___. At his most recent visit to his oncologist on\n___ it was noted that his cytopenias were responding nicely to\ndecitabine but that he does seem to be losing his graft based on\nperipheral blood chimerism. He c/o diarrhea at this visit but \nwas\ninstructed to continue completely holding sirolimus (stopped ___ and to decrease tacro to 0.5mg once daily and decrease\nprednisone to 6mg from 7mg daily (plan for eventual DC of \ntacro).\nBactrim was also started for ppx at that point and plan was for\nnext cycle of decitabine in ___.\n\nIn the ED his temp was 99.6 HR 111 and down to ___, Bp 110/64\n100% RA. Chem with BUn/creat ___, IgG 575, LFTs wnl, WBC 1.9\nwith 33% pmns and 0 bands. He received vanc/cefepime. Lactate \nwas\n2.1.\n\nREVIEW OF SYSTEMS:\nGENERAL: +fever as above but no chills, night sweats, recent\nweight changes.\nHEENT: No sores in the mouth, painful swallowing, intolerance to\nliquids or solids, sinus tenderness, rhinorrhea, or congestion.\nCARDS: No chest pain, chest pressure, exertional symptoms, or\npalpitations.\nPULM: No cough, shortness of breath, hemoptysis, or wheezing.\nGI: No nausea, vomiting, but + cramping/distention/gas per HPI\nabove. NO hematochezia, or melena.\nGU: No dysuria or change in bladder habits.\nMSK: No arthritis, arthralgias, myalgias, or bone pain.\nDERM: Denies rashes, itching, or skin breakdown.\nNEURO: No headache, visual changes, numbness/tingling,\nparesthesias, or focal neurologic symptoms.\nPSYCH: No feelings of depression or anxiety. All other review of\nsystems negative.\n\nPast Medical History:\nPAST ONCOLOGIC HISTORY:\n___ evaluated and followed for thrombocytopenia. ___\nevaluated abnormal IgM and continued thrombocytopenia with CT\nscan which revealed mild spleenomegaly. ___ peripheral smear\nconsistent with myeloproliferative disorder such as CMML. BM bx\nconcerning for AML vs CMML. ___ 5 Day course of Dacogen.\nSecondary to platelet count continuing to trend down and his\ndisease appeared to be more consistent with AML. ___ Started\nHydrea x 3 days. ___ admitted for induction with "7&3".\n___ dx. with a large left subdural hematoma which was\nevacuated by neurosurgery and he completed a total of "7&2". He\nremained in hospital for BMT. ___ HPC Cord blood transplant.\nDuring hospitalization in ___ noted blasts on \nperiphearl\nsmear and bone marrow biopsy showed residual dysplasia and 53%\ndonor cells so he underwent 5d of decitabine from ___. \n\nPAST MEDICAL HISTORY:\n-History of CMML transformed to AML s/p double cord transplant \n___ \n-History of polyp removal by colonoscopy in ___.\n-DJD in the neck and lower back.\n-History of elevated IgM.\n-Hyperlipidemia.\n-GERD.\n-Migraines.\n-Spontaneous subdural hemorrhage in ___ s/p neurosurgical\ncraniotomy and evacuation\n\nSocial History:\n___\nFamily History:\nMother died at the age of ___-CAD and breast cancer.\nFather: died in ___ from Alzheimer\'s. \nBrother: currently ___, currently on disability.\n\n', 'Chief Complaint:|Complaint:': '\nfever/diarrhea\n\n', 'Attending:': ' ___\n\n', 'Allergies:': ' \nnafcillin\n\n'}, '17445819-DS-6', 6, 'medicine']]

[['EXAMINATION: CHEST (PA AND LAT)\n\nINDICATION: ___ year old man with shortness of breathhx of AML s/p bone marrow\ntransplant // assess for consolidation or cardio pulm changes\n\nTECHNIQUE: PA and lateral radiographs of the chest from ___.\n\nCOMPARISON: ___.\n\nFINDINGS: \n\nThe right-sided PICC line has been removed. The lungs are clear. There is no\npneumothorax. The heart and mediastinum are within normal limits.\n\nIMPRESSION: \n\nClear lungs.\n', '17445819-RR-44', 44, 'pa and lateral radiographs of the chest from ___.']]

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[]

['medicine']

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[51137, Timestamp('2137-01-26 05:55:00'), Timestamp('2137-01-26 07:11:00'), 'Anisocytosis'], [51143, Timestamp('2137-01-26 05:55:00'), Timestamp('2137-01-26 07:10:00'), 'Atypical Lymphocytes'], [51144, Timestamp('2137-01-26 05:55:00'), Timestamp('2137-01-26 07:10:00'), 'Bands'], [51146, Timestamp('2137-01-26 05:55:00'), Timestamp('2137-01-26 07:10:00'), 'Basophils'], [51148, Timestamp('2137-01-26 05:55:00'), Timestamp('2137-01-26 07:10:00'), 'Blasts'], [51200, Timestamp('2137-01-26 05:55:00'), Timestamp('2137-01-26 07:10:00'), 'Eosinophils'], [51221, Timestamp('2137-01-26 05:55:00'), Timestamp('2137-01-26 06:31:00'), 'Hematocrit'], [51222, Timestamp('2137-01-26 05:55:00'), Timestamp('2137-01-26 06:31:00'), 'Hemoglobin'], [51233, Timestamp('2137-01-26 05:55:00'), Timestamp('2137-01-26 07:11:00'), 'Hypochromia'], [51244, Timestamp('2137-01-26 05:55:00'), Timestamp('2137-01-26 07:10:00'), 'Lymphocytes'], [51246, Timestamp('2137-01-26 05:55:00'), Timestamp('2137-01-26 07:11:00'), 'Macrocytes'], [51248, Timestamp('2137-01-26 05:55:00'), Timestamp('2137-01-26 06:31:00'), 'MCH'], [51249, Timestamp('2137-01-26 05:55:00'), Timestamp('2137-01-26 06:31:00'), 'MCHC'], [51250, Timestamp('2137-01-26 05:55:00'), Timestamp('2137-01-26 06:31:00'), 'MCV'], [51251, Timestamp('2137-01-26 05:55:00'), Timestamp('2137-01-26 07:10:00'), 'Metamyelocytes'], [51252, Timestamp('2137-01-26 05:55:00'), Timestamp('2137-01-26 07:11:00'), 'Microcytes'], [51254, Timestamp('2137-01-26 05:55:00'), Timestamp('2137-01-26 07:10:00'), 'Monocytes'], [51255, Timestamp('2137-01-26 05:55:00'), Timestamp('2137-01-26 07:10:00'), 'Myelocytes'], [51256, Timestamp('2137-01-26 05:55:00'), Timestamp('2137-01-26 07:10:00'), 'Neutrophils'], [51257, Timestamp('2137-01-26 05:55:00'), Timestamp('2137-01-26 07:10:00'), 'Nucleated Red Cells'], [51260, Timestamp('2137-01-26 05:55:00'), Timestamp('2137-01-26 07:11:00'), 'Ovalocytes'], [51265, Timestamp('2137-01-26 05:55:00'), Timestamp('2137-01-26 06:31:00'), 'Platelet Count'], [51266, Timestamp('2137-01-26 05:55:00'), Timestamp('2137-01-26 07:10:00'), 'Platelet Smear'], [51267, Timestamp('2137-01-26 05:55:00'), Timestamp('2137-01-26 07:11:00'), 'Poikilocytosis'], [51268, Timestamp('2137-01-26 05:55:00'), Timestamp('2137-01-26 07:11:00'), 'Polychromasia'], [51269, Timestamp('2137-01-26 05:55:00'), Timestamp('2137-01-26 07:10:00'), 'Promyelocytes'], [51277, Timestamp('2137-01-26 05:55:00'), Timestamp('2137-01-26 06:31:00'), 'RDW'], [51279, Timestamp('2137-01-26 05:55:00'), Timestamp('2137-01-26 06:31:00'), 'Red Blood Cells'], [51287, Timestamp('2137-01-26 05:55:00'), Timestamp('2137-01-26 07:11:00'), 'Schistocytes'], [51292, Timestamp('2137-01-26 05:55:00'), Timestamp('2137-01-26 07:11:00'), 'Spherocytes'], [51296, Timestamp('2137-01-26 05:55:00'), Timestamp('2137-01-26 07:11:00'), 'Teardrop Cells'], [51301, Timestamp('2137-01-26 05:55:00'), Timestamp('2137-01-26 07:12:00'), 'White Blood Cells'], [51463, Timestamp('2137-01-26 09:18:00'), Timestamp('2137-01-26 10:43:00'), 'Bacteria'], [51464, Timestamp('2137-01-26 09:18:00'), Timestamp('2137-01-26 10:43:00'), 'Bilirubin'], [51466, Timestamp('2137-01-26 09:18:00'), Timestamp('2137-01-26 10:43:00'), 'Blood'], [51476, Timestamp('2137-01-26 09:18:00'), Timestamp('2137-01-26 10:43:00'), 'Epithelial Cells'], [51478, Timestamp('2137-01-26 09:18:00'), Timestamp('2137-01-26 10:43:00'), 'Glucose'], [51484, Timestamp('2137-01-26 09:18:00'), Timestamp('2137-01-26 10:43:00'), 'Ketone'], [51486, Timestamp('2137-01-26 09:18:00'), Timestamp('2137-01-26 10:43:00'), 'Leukocytes'], [51487, Timestamp('2137-01-26 09:18:00'), Timestamp('2137-01-26 10:43:00'), 'Nitrite'], [51491, Timestamp('2137-01-26 09:18:00'), Timestamp('2137-01-26 10:43:00'), 'pH'], [51492, Timestamp('2137-01-26 09:18:00'), Timestamp('2137-01-26 10:43:00'), 'Protein'], [51493, Timestamp('2137-01-26 09:18:00'), Timestamp('2137-01-26 10:43:00'), 'RBC'], [51498, Timestamp('2137-01-26 09:18:00'), Timestamp('2137-01-26 10:43:00'), 'Specific Gravity'], [51506, Timestamp('2137-01-26 09:18:00'), Timestamp('2137-01-26 10:43:00'), 'Urine Appearance'], [51508, Timestamp('2137-01-26 09:18:00'), Timestamp('2137-01-26 10:43:00'), 'Urine Color'], [51512, Timestamp('2137-01-26 09:18:00'), Timestamp('2137-01-26 10:43:00'), 'Urine Mucous'], [51514, Timestamp('2137-01-26 09:18:00'), Timestamp('2137-01-26 10:43:00'), 'Urobilinogen'], [51516, Timestamp('2137-01-26 09:18:00'), Timestamp('2137-01-26 10:43:00'), 'WBC'], [51519, Timestamp('2137-01-26 09:18:00'), Timestamp('2137-01-26 10:43:00'), 'Yeast'], [51078, Timestamp('2137-01-26 09:18:00'), Timestamp('2137-01-26 19:35:00'), 'Chloride, Urine'], [51082, Timestamp('2137-01-26 09:18:00'), Timestamp('2137-01-26 19:35:00'), 'Creatinine, Urine'], [51087, Timestamp('2137-01-26 09:18:00'), NaT, 'Length of Urine Collection'], [51097, Timestamp('2137-01-26 09:18:00'), Timestamp('2137-01-26 19:35:00'), 'Potassium, Urine'], [51100, Timestamp('2137-01-26 09:18:00'), Timestamp('2137-01-26 19:35:00'), 'Sodium, Urine'], [51463, Timestamp('2137-01-26 09:18:00'), Timestamp('2137-01-26 10:43:00'), 'Bacteria'], [51464, Timestamp('2137-01-26 09:18:00'), Timestamp('2137-01-26 10:43:00'), 'Bilirubin'], [51466, Timestamp('2137-01-26 09:18:00'), Timestamp('2137-01-26 10:43:00'), 'Blood'], [51474, Timestamp('2137-01-26 09:18:00'), Timestamp('2137-01-26 11:45:00'), 'Eosinophils'], [51476, Timestamp('2137-01-26 09:18:00'), Timestamp('2137-01-26 10:43:00'), 'Epithelial Cells'], [51478, Timestamp('2137-01-26 09:18:00'), Timestamp('2137-01-26 10:43:00'), 'Glucose'], [51484, Timestamp('2137-01-26 09:18:00'), Timestamp('2137-01-26 10:43:00'), 'Ketone'], [51486, Timestamp('2137-01-26 09:18:00'), Timestamp('2137-01-26 10:43:00'), 'Leukocytes'], [51487, Timestamp('2137-01-26 09:18:00'), Timestamp('2137-01-26 10:43:00'), 'Nitrite'], [51491, Timestamp('2137-01-26 09:18:00'), Timestamp('2137-01-26 10:43:00'), 'pH'], [51492, Timestamp('2137-01-26 09:18:00'), Timestamp('2137-01-26 10:43:00'), 'Protein'], [51493, Timestamp('2137-01-26 09:18:00'), Timestamp('2137-01-26 10:43:00'), 'RBC'], [51498, Timestamp('2137-01-26 09:18:00'), Timestamp('2137-01-26 10:43:00'), 'Specific Gravity'], [51506, Timestamp('2137-01-26 09:18:00'), Timestamp('2137-01-26 10:43:00'), 'Urine Appearance'], [51508, Timestamp('2137-01-26 09:18:00'), Timestamp('2137-01-26 10:43:00'), 'Urine Color'], [51514, Timestamp('2137-01-26 09:18:00'), Timestamp('2137-01-26 10:43:00'), 'Urobilinogen'], [51516, Timestamp('2137-01-26 09:18:00'), Timestamp('2137-01-26 10:43:00'), 'WBC'], [51519, Timestamp('2137-01-26 09:18:00'), Timestamp('2137-01-26 10:43:00'), 'Yeast'], [51865, Timestamp('2137-01-26 11:46:00'), Timestamp('2137-01-26 20:29:00'), 'Influenza A by PCR'], [51873, Timestamp('2137-01-26 11:46:00'), Timestamp('2137-01-26 20:29:00'), 'Influenza B by PCR']]

Question: A 67 M is admitted. He/she says he/she has fever/diarrhea . History of illness: Mr. ___ is a ___ year old gentleman with PMHx of CMML conversion to AML s/p allo-sct ___ presenting to the ED with fever at home of ___. He was seen in clinic today and was afebrile but on arrival home wife took his temperature and it was 101 so he came in to the ED as he was known to be neutropenic. He was feeling quite well. In fact he had no significant complaints other than some abdominal distention and cramping over the last week and he has also had some increasingly loose stools but no true diarrhea. No chills/rigors at home, no nausea/vomiting, no chest pain/sob, no cough, no sick contacts, no rhinorrhea or nasal congestion. Regarding his onc history: he has CMML with transformation to AML and is s/p double umbilical cord SCT ___. Of note his most recent admission was ___ - ___ at which point he was admitted with fever and found to have MSSA bacteremia and while TTE did not show e/o valvulvar vegetation, ID recommended empirically treating for endocarditis for 6 weeks rather than pursue TEE given his cytopenias. Antibiotics (cefazolin) ran through ___. His hospital course was c/b GVHD in the form of diarrhea - stool studies were negative and flex sig biopsy did show mild GVHD. He was started on TPN and treated with methylpred which was downtitrated and at the time of DC bowel movements were normal and he was back on a regular diet and off TPN. He was sent home on prednisone due to appearance of blasts on peripheral smear (sent ___ on 10mg pred daily). After noting the blasts his immunosuppression was downtritated rapidly and bone marrow biopsy showed residual dysplasia and 53% donor cells so he underwent 5d of decitabine from ___ and then in early ___ received his second cycle of decitabine locally with Dr. ___ ___ given on ___. At his most recent visit to his oncologist on ___ it was noted that his cytopenias were responding nicely to decitabine but that he does seem to be losing his graft based on peripheral blood chimerism. He c/o diarrhea at this visit but was instructed to continue completely holding sirolimus (stopped ___ and to decrease tacro to 0.5mg once daily and decrease prednisone to 6mg from 7mg daily (plan for eventual DC of tacro). Bactrim was also started for ppx at that point and plan was for next cycle of decitabine in ___. In the ED his temp was 99.6 HR 111 and down to ___, Bp 110/64 100% RA. Chem with BUn/creat ___, IgG 575, LFTs wnl, WBC 1.9 with 33% pmns and 0 bands. He received vanc/cefepime. Lactate was 2.1. REVIEW OF SYSTEMS: GENERAL: +fever as above but no chills, night sweats, recent weight changes. HEENT: No sores in the mouth, painful swallowing, intolerance to liquids or solids, sinus tenderness, rhinorrhea, or congestion. CARDS: No chest pain, chest pressure, exertional symptoms, or palpitations. PULM: No cough, shortness of breath, hemoptysis, or wheezing. GI: No nausea, vomiting, but + cramping/distention/gas per HPI above. NO hematochezia, or melena. GU: No dysuria or change in bladder habits. MSK: No arthritis, arthralgias, myalgias, or bone pain. DERM: Denies rashes, itching, or skin breakdown. NEURO: No headache, visual changes, numbness/tingling, paresthesias, or focal neurologic symptoms. PSYCH: No feelings of depression or anxiety. All other review of systems negative. Past Medical History: PAST ONCOLOGIC HISTORY: ___ evaluated and followed for thrombocytopenia. ___ evaluated abnormal IgM and continued thrombocytopenia with CT scan which revealed mild spleenomegaly. ___ peripheral smear consistent with myeloproliferative disorder such as CMML. BM bx concerning for AML vs CMML. ___ 5 Day course of Dacogen. Secondary to platelet count continuing to trend down and his disease appeared to be more consistent with AML. ___ Started Hydrea x 3 days. ___ admitted for induction with "7&3". ___ dx. with a large left subdural hematoma which was evacuated by neurosurgery and he completed a total of "7&2". He remained in hospital for BMT. ___ HPC Cord blood transplant. During hospitalization in ___ noted blasts on periphearl smear and bone marrow biopsy showed residual dysplasia and 53% donor cells so he underwent 5d of decitabine from ___. PAST MEDICAL HISTORY: -History of CMML transformed to AML s/p double cord transplant ___ -History of polyp removal by colonoscopy in ___. -DJD in the neck and lower back. -History of elevated IgM. -Hyperlipidemia. -GERD. -Migraines. -Spontaneous subdural hemorrhage in ___ s/p neurosurgical craniotomy and evacuation Social History: ___ Family History: Mother died at the age of ___-CAD and breast cancer. Father: died in ___ from Alzheimer's. Brother: currently ___, currently on disability. Allergies: nafcillin What is the best procedure plan for this patient?

TARGETS Target Prescriptions: NS MetRONIDAZOLE (FLagyl) Sulfameth/Trimethoprim SS Iso-Osmotic Dextrose Vancomycin Ursodiol PredniSONE 0.9% Sodium Chloride (Mini Bag Plus) CefePIME Sulfameth/Trimethoprim SS Tacrolimus OSELTAMivir Omeprazole Acetaminophen Fluconazole Sodium Chloride 0.9% Flush Vancomycin Oral Liquid Sodium Chloride 0.9% Multivitamins Sodium Chloride 0.9% FoLIC Acid Ondansetron Iso-Osmotic Dextrose Vancomycin PredniSONE Acyclovir Target Lab Orders: Anion Gap Bicarbonate Calcium, Total Chloride Creatinine Glucose Magnesium Phosphate Potassium Sodium Urea Nitrogen Anisocytosis Atypical Lymphocytes Bands Basophils Blasts Eosinophils Hematocrit Hemoglobin Hypochromia Lymphocytes Macrocytes MCH MCHC MCV Metamyelocytes Microcytes Monocytes Myelocytes Neutrophils Nucleated Red Cells Ovalocytes Platelet Count Platelet Smear Poikilocytosis Polychromasia Promyelocytes RDW Red Blood Cells Schistocytes Spherocytes Teardrop Cells White Blood Cells Bacteria Bilirubin Blood Epithelial Cells Glucose Ketone Leukocytes Nitrite pH Protein RBC Specific Gravity Urine Appearance Urine Color Urine Mucous Urobilinogen WBC Yeast Chloride, Urine Creatinine, Urine Length of Urine Collection Potassium, Urine Sodium, Urine Bacteria Bilirubin Blood Eosinophils Epithelial Cells Glucose Ketone Leukocytes Nitrite pH Protein RBC Specific Gravity Urine Appearance Urine Color Urobilinogen WBC Yeast Influenza A by PCR Influenza B by PCR Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : Mr. ___ is a ___ year old gentleman with PMHx of CMML conversion to AML s/p allo-sct ___ presenting with febrile neutropenia and diarrhea. Febrile neutropenia most likely viral gastroenteritis (multiple family members with vomiting/diarrheal illness). There was also concern for GVHD or CMV colitis. C diff negative. Stool O+P, cultures negative. Noro PCR negative. Initially treated with broad spectrum antibiotics which were discontinued with improvement in symptoms and negative culture data. Patient's diarrhea did not improve and GI was consulted. Flex sig was performed with preliminary pathology report showing continued evidence of GVHD. Patient started on Budesonide 9mg PO Daily, with excellent efficacy. Patient was discharge home and will follow up with his primary Heme/Onc attending as an outpatient. Hospitalization complicated by mild ___, most likely ___ pre-renal vs intrinsic renal etiology ___ dehydration and poor PO intake, this improved with IV fluids. ACUTE ISSUES # Neutropenic Fever/Diarrhea - Day +126. Most likely secondary to viral gastroenteritis given diarrhea and multiple family members with vomiting and diarrhea, noro virus PCR all negative. Concerned for GVHD or CMV colitis and symptoms did not improve with loperamide making this more likely. CXR negative, stool culture and O+P negative, c diff negative, blood and urine cultures with no growth. Influenza A/B negative. Treated empirically with broad spectrum antibiotics vanc, cefepime, flagyl though these were discontinued with negative culture data and improvement in symptoms. Patient remained afebrile. Flex sig showed mild GVHD consistent with prior biopsies. The patient was started on Budesonide with good affect. Patient will remain on budesonide for at least one month. Given no significant worsening on biopsy, it is likely that the patient had gastroenteritis complicated by mild GVHD. Consider stopping budesonide after one month given significant expense of the medication. # Acute Kidney Injury- Baseline Cr 1.1 -> 1.6 on admission. Pre-renal given diarrhea and poor PO intake vs intrinsic renal given recent history of AIN, urine eos positive, FeNa >1 suggestive of intrinsic renal etiology, likely ATN ___ hypovolemia. Cr improved to 1.0 with IV fluids suggestive of dehydration as underlying etiology. CHRONIC ISSUES # CMML/AML, STATUS POST CORD TRANSPLANT: Currently at D+126 allo SCT. Patient has history of CMML with transformation to AML s/p double umbilical cord stem cell transplant on ___. Receiving decitabine with outpatient provider ___ approximately ___. Continued opportunistic infection prophylaxis with fluconazole, bactrim, and acyclovir. # Poor Nutrition: Patient with 1 week of poor PO intake, albumin 3.3 with normal LFTs suggestive of malnutrition. Nutrition consulted, recommended ensure TID with meals. Patient was eating well at time of discharge. # H/o GVHD - Previous admission had diarrhea ___ GVHD as seen on flex sigmoidoscopy, currently tapering immunosuppression, only on prednisone 5mg PO daily. Evidence of rejection with 12% chimerism early ___, resent in clinic ___. Flex sig during admission showed persistent mild disease. Follow up final read of biopsy. Consider stopping Budesonide after one month. ============== TRANSITIONAL ISSUES: ============== [ ] CMML-> AML with concern for graft rejection, numerous blasts in peripheral blood, chimerism 12% when checked in early ___ need to follow up with outpatient providers to determine further treatment plan [ ] ___- repeat creatinine at outpatient follow up to ensure stable renal function [ ] Patient will need to monitory for signs of worsening GVHD with symptoms going forward [ ] If patient's symptoms continue to be mild or completely resolved please consider stopping budesonide as outpatient as it is very expensive [ ] CMV biopsies are pending at time of discharge [ ] please call your PCP and make ___ follow up appointment within one month after leaving the hospital. [ ] increased omeprazole to 40mg daily due to worsening GERD in the mornings after lying down (patient may take it before bed rather than in the AM) # CODE STATUS: Confirmed Full # EMERGENCY CONTACT: wife Mrs. ___ ___ Other Results: LABS ON ADMISSION: ___ 11:25PM BLOOD WBC-2.1* RBC-3.03* Hgb-8.3* Hct-25.6* MCV-85 MCH-27.3 MCHC-32.3 RDW-19.7* Plt Ct-58* ___ 11:25PM BLOOD Neuts-41* Bands-0 ___ Monos-20* Eos-0 Baso-0 ___ Myelos-2* Blasts-5* NRBC-4* ___ 11:25PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-1+ ___ 11:25PM BLOOD Plt Smr-LOW Plt Ct-58* ___ 11:25PM BLOOD Glucose-150* UreaN-21* Creat-1.4* Na-133 K-4.1 Cl-99 HCO3-21* AnGap-17 PERTINENT RESULTS: ___ 08:30AM BLOOD IgG-575* ___ 05:43AM BLOOD Vanco-17.3 ___ 08:30AM BLOOD tacroFK-2.0* rapmycn-LESS THAN ___ 11:33PM BLOOD Lactate-2.1* ___ 06:30AM BLOOD WBC-5.1 RBC-3.14* Hgb-8.5* Hct-26.2* MCV-84 MCH-27.2 MCHC-32.5 RDW-20.6* Plt Ct-55* ___ 06:30AM BLOOD Neuts-44* Bands-0 ___ Monos-3 Eos-2 Baso-0 ___ Metas-9* Myelos-6* Promyel-4* Blasts-10* NRBC-9* ___ 06:30AM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-NORMAL Macrocy-2+ Microcy-NORMAL Polychr-1+ ___ 06:30AM BLOOD Plt Smr-VERY LOW Plt Ct-55* ___ 06:30AM BLOOD ___ PTT-28.3 ___ ___ 06:30AM BLOOD Glucose-120* UreaN-16 Creat-1.0 Na-139 K-3.9 Cl-107 HCO3-21* AnGap-15 ___ 06:30AM BLOOD ALT-6 AST-13 LD(LDH)-330* AlkPhos-51 TotBili-0.3 ___ 06:30AM BLOOD Calcium-8.9 Phos-2.2* Mg-1.9 ___ 06:00AM BLOOD Albumin-3.4* Calcium-8.8 Phos-3.5 Mg-2.1 MICROBIOLOGY: Stool Studies ___ 9:18 am STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. MICROSPORIDIA STAIN (Pending): CYCLOSPORA STAIN (Final ___: NO CYCLOSPORA SEEN. C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). FECAL CULTURE (Final ___: NO ENTERIC GRAM NEGATIVE RODS FOUND. NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final ___: NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. Cryptosporidium/Giardia (DFA) (Final ___: NO CRYPTOSPORIDIUM OR GIARDIA SEEN. VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED. CMV Viral Load ___: CMV Viral Load (Final ___: CMV DNA not detected. ___: Influenza A by PCRNEGATIVE Influenza B by PCRNEGATIVE EKG: ___: Borderline sinus tachycardia. Otherwise, within normal limits. No change from previous tracing. IntervalsAxes ___ ___ IMAGING: CXR ___: FINDINGS: The right-sided PICC line has been removed. The lungs are clear. There is no pneumothorax. The heart and mediastinum are within normal limits. IMPRESSION: Clear lungs.

2188-08-04 04:15:00

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MARRIED

WHITE

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[[27986620, Timestamp('2188-08-04 04:17:23'), '', 'NSURG']]

[[{'Medications on Admission': ':\nMedications prior to admission:\nVicoden ___ tabs Q4-6H PRN pain\nLevothyroxin 112 mcg Daily\nCitalopram 20 mg Daily\nOmeprazole 20 mg Daily\nDiclofenac 100 mg Daily\nVitamin D\n\n5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) \nTablet PO DAILY (Daily). \n6. Labetalol 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a \nday).\nDisp:*90 Tablet(s)* Refills:*2*\n7. Percocet ___ mg Tablet Sig: ___ Tablets PO every four (4) \nhours as needed for pain: do not drive while taking this \nmedication.\nDisp:*40 Tablet(s)* Refills:*0*\n8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) \nCapsule, Delayed Release(E.C.) PO once a day. \n9. Keppra 1,000 mg Tablet Sig: One (1) Tablet PO twice a day for \n6 weeks: you need to stay on this medication until follow up in \nthe neurosurgery office.\nDisp:*90 Tablet(s)* Refills:*0*', 'Brief Hospital Course': ':\nNEURO: Pt was admitted to ICU foloowing discovery of SAH on CT \nscan. Her VS and neuro status were monitored closely. On her \nday of admission ___ she underwent a CTA and angiogram of \nthe brain. No direct aneurysm of AVM was identified. \nIncidentally noted was that she had a Frontal brain mass which \nas this time is suspected to be a menigioma. She also has an \narachnoid cyst. She was kept in the ICU until follow up \nangiogram demonstrated that there was no defined aneurysm \nidentified. She was started on keppra for sz prophylaxis as \nwell as nimodipine. Ultimately she was transferred to the step \ndown unit and then to floor staus. Her exam remained stable \nduring the entire hosp stay.\n\nCV;No issues during this stay\n\nENDO: she had no issues during this stay - she was placed on SSI \ncoverage during the ICU stay.\n\nRESP: No issues\n\nRenal: UTI noted on ___. Cipro started. will complete course of \nabx at home.\n\nGEN: she was seen by ___ and deemed safe for discharge to home. \n\n', 'Pertinent Results:': '\nCT/MRI:\nSubarachnoid hemorrhage fills suprasellar cistern and ___\nventricle. No definite aneurysm seen on CTA.\n3.7 x 3.7 rounded dense lesion in right frontal lobe, most\nprobably extraaxial, with minimal mass effect on adjacent sulci,\nsmall internal ?calcifcation versus small focus of internal\nhemorrhage. Could be consistent with meningioma. Unclear if this\nis causally related to SAH, but thought ___ unlikely.\n\n___ 03:00AM GLUCOSE-192* UREA N-14 CREAT-0.6 SODIUM-143 \nPOTASSIUM-3.5 CHLORIDE-106 TOTAL CO2-24 ANION GAP-17\n___ 03:00AM CALCIUM-8.2* PHOSPHATE-2.9 MAGNESIUM-1.9\n___ 03:00AM WBC-14.2* RBC-4.22 HGB-12.6 HCT-37.0 MCV-88 \nMCH-29.9 MCHC-34.2 RDW-13.3\n___ 03:00AM NEUTS-76* BANDS-2 LYMPHS-15* MONOS-0 EOS-0 \nBASOS-1 ATYPS-6* ___ MYELOS-0\n___ 03:00AM HYPOCHROM-NORMAL ANISOCYT-NORMAL \nPOIKILOCY-NORMAL MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-1+\n___ 03:00AM PLT SMR-NORMAL PLT COUNT-274\n___ 03:00AM ___ PTT-23.1 ___\n___ 01:55AM URINE COLOR-Yellow APPEAR-Clear SP ___\n___ 01:55AM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG \nGLUCOSE-NEG KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 \nLEUK-MOD\n___ 01:55AM URINE ___ BACTERIA-NONE YEAST-NONE \n___\n\n RADIOLOGY Final Report\n\nCT HEAD W/O CONTRAST ___ 8:30 ___\n\nCT HEAD W/O CONTRAST\n\nReason: Follow up sor SAH \n\nUNDERLYING MEDICAL CONDITION:\n___ year old woman with SAH, for angiogram and craniotomy \ntomorrow \nREASON FOR THIS EXAMINATION:\nFollow up sor SAH \nCONTRAINDICATIONS for IV CONTRAST: None.\n\nHISTORY: ___ female with subarachnoid hemorrhage, for \nangiogram and craniotomy tomorrow.\n\nCOMPARISON: ___ and ___.\n\nTECHNIQUE: Contiguous axial images of the head were obtained \nwithout the administration of IV contrast.\n\nFINDINGS: There continues to be scattered foci of subarachnoid \nhemorrhage, most notably within the right parietal region, with \na small amount of dependent hemorrhage within the occipital \nhorns of the lateral ventricles, right greater than left. These \nare largely unchanged from prior study. No new foci of acute \nhemorrhage are identified. There is no evidence of hydrocephalus \nor acute major vascular territorial infarction.\n\nLarge hyperdense partially calcified right frontal extra-axial \nmass with displacement of the falx leftward and associated \nvasogenic edema is unchanged. Low- density lesion within the \nleft anterior temporal lobe is unchanged, most likely \nrepresenting an arachnoid cyst. Visualized paranasal sinuses and \nmastoid air cells are well aerated, with the right mastoid air \ncells being sclerotic. Osseous structures are unremarkable.\n\nIMPRESSION:\n\n1. Unchanged scattered foci of subarachnoid hemorrhage, with a \nsmall amount of hemorrhage layering within the occipital horn of \nthe lateral ventricles.\n\n2. No change in the right frontal meningioma and left anterior \ntemporal lobe arachnoid cyst.\n\nCardiology Report ECG Study Date of ___ 12:49:44 AM \n\nSinus rhythm. Non-diagnostic Q waves in the inferior leads. \nDiffuse ST-T wave \nchanges which are non-specific. No previous tracing available \nfor comparison. \n\nRead by: ___ \n\n Intervals Axes \nRate PR QRS QT/QTc P QRS T \n73 142 94 420/442 54 31 31 \n\n RADIOLOGY Final Report\n\nMRA BRAIN W/O CONTRAST ___ 10:00 ___\n\nMR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST\n\nReason: please eval for aneurysm, etiology of known SAH \nContrast: MAGNEVIST\n\nUNDERLYING MEDICAL CONDITION:\n___ year old woman with SAH \nREASON FOR THIS EXAMINATION:\nplease eval for aneurysm, etiology of known SAH \nCONTRAINDICATIONS for IV CONTRAST: None.\n\nMRI AND MRA BRAIN WITHOUT AND WITH CONTRAST, ___\n\nHISTORY: Subarachnoid hemorrhage. What is the etiology of this?\n\nSagittal and axial short TR, short TE spin echo imaging were \nperformed through the brain. Three-dimensional time-of-flight \nMRA was performed. After administration of gadolinium \nintravenous contrast, axial gradient echo, FLAIR, long TR, long \nTE fast spin echo, diffusion, short TR, short TE spin echo, and \nsagittal MP-RAGE imaging were performed. Comparison to a head CT \nof ___.\n\nFINDINGS: The extensive subarachnoid hemorrhage demonstrated on \nthe CT scans is less apparent on the MR, but is seen as areas of \nhyperintensity in the sulci on the FLAIR images. The FLAIR \nimages also reveal small bilateral subdural fluid collections \nwhose signal intensities suggest hematomas. There is \nintraventricular blood, as seen on the earlier head CT, but no \nevidence of new hemorrhage. The large right frontal meningioma \nis again identified. This appears to invade the falx and extends \nslightly through the falx into the left hemisphere.\n\nThe MRA examination demonstrates no vascular abnormalities. \nSpecifically, there is no evidence of aneurysm or AVM.\n\nIncidentally noted is a left anterior temporal arachnoid cyst.\n\nCONCLUSION: No findings to explain the subarachnoid hemorrhage. \nAgain identified is diffuse subarachnoid hemorrhage. Small \nsubdural hematomas are also seen. There is a left anterior \ntemporal arachnoid cyst and a large right frontal meningioma \nthat appears to extend through the falx.\n\n', 'Physical Exam:|Physical': '\nPHYSICAL EXAM:\nO: T:97.6 BP: 128/67 HR: 76 R: 16 O2Sats: 97% 2L\nGen: WD/WN, comfortable, NAD.\nHEENT: Pupils: PERRL ___ EOMs intact\nNeck: Supple.\nLungs: CTA bilaterally.\nCardiac: RRR. S1/S2.\nAbd: Soft, NT, BS+\nExtrem: Warm and well-perfused.\nNeuro:\nMental status: Awake and alert, cooperative with exam, normal\naffect.\nOrientation: Oriented to person, place (hospital, ___, and\ndate.\nRecall: ___ objects at 5 minutes.\nLanguage: Speech fluent with good comprehension and repetition.\nNaming intact. No dysarthria or paraphasic errors.\n\nCranial Nerves:\nI: Not tested\nII: Pupils equally round and reactive to light, 3 to 2 mm\nbilaterally. Visual fields are full to confrontation.\nIII, IV, VI: Extraocular movements intact bilaterally without\nnystagmus.\nV, VII: Facial strength and sensation intact and symmetric.\nVIII: Hearing intact to voice. Decreased on R, says baseline\nIX, X: Palatal elevation symmetrical.\nXI: Sternocleidomastoid and trapezius normal bilaterally.\nXII: Tongue midline without fasciculations.\n\nMotor: Normal bulk and tone bilaterally. No abnormal movements,\ntremors. Strength full power ___ throughout. No pronator drift\n\nSensation: Intact to light touch, propioception, pinprick and\nvibration bilaterally.\n\nReflexes: B T Br Pa Ac\nRight ___ 1 1\nLeft ___ 1 1\n\nToes downgoing bilaterally\n\nCoordination: normal on finger-nose-finger, rapid alternating\nmovements, heel to shin\n\nON DISCHARGE - ___ IS WITHOUT NEUROLOGICAL DEFICIT / NON FOCAL \nEXAM \n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\nHPI: ___ y/o F was at work this evening as ___ at ___ when at approx 10 ___ she experienced a sudden\nonset ___ headache which started in the bifrontal area and\nradiate to the back of the head. At the time she was trying to\nspeak forcefully. Became lightheaded with the headache but \nnever\nhad LOC. She did have nausea and one episode of vomitting. No\ntrauma. No visual changes. Some L tinnitus for past 2 days. \nCT\nscan obtained at ___ showed SAH and she was transferred \nto\n___ for further eval. At the OSH she was loaded with Dilantin,\ngiven 10 mg Decadron, zofran and morphine. On arrival here her\nheadache is ___. History obtained with son translating.\n\nPast Medical History:\nPMHx:?goiter, s/p thyroidectomy, anxiety, breast lumpectomy, \n?ear\nsurgery as a child\n\nSocial History:\n___\nFamily History:\nFamily Hx:Non-contributory\n\n', 'Chief Complaint:|Complaint:': '\nheadache\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nPatient recorded as having No Known Allergies to Drugs\n\n'}, '19955873-DS-14', 14, 'neurosurgery']]

[['EXAM: CT of the head.\n\nCLINICAL INFORMATION: Patient with subarachnoid hemorrhage.\n\nTECHNIQUE: Axial images of the head were obtained without contrast. Following\nthis, using departmental protocol CT angiography of the head was acquired.\nReformatted images were obtained.\n\nFINDINGS\n\nCT HEAD:\n\nThere is diffuse subarachnoid hemorrhage visualized in the basal cisterns\nextending from foramen magnum to the suprasellar and interpeduncular cistern\nwith blood visualized in the fourth ventricle. There is mild prominence of\ntemporal horns and ventricles identified indicative of developing\nhydrocephalus.\n\nThere is a approximately 4-cm extra-axial mass identified in the right frontal\nlobe with mass effect on the adjacent brain. There is a small SPECT area of\nhigh density indicating calcification seen within this lesion.\n\nCT ANGIOGRAPHY OF THE HEAD:\n\nThe CT angiography of the head demonstrates no evidence of vascular occlusion,\nstenosis or an aneurysm in the arteries of anterior and posterior circulation.\n\nIMPRESSION:\n1. CT head shows diffuse subarachnoid hemorrhage. Right frontal extra-axial\nmass most consistent with meningioma.\n2. No obvious abnormalities on CT angiography of the head.\n', '19955873-RR-15', 15, 'axial images of the head were obtained without contrast. following\nthis, using departmental protocol ct angiography of the head was acquired.\nreformatted images were obtained.'], ['TYPE OF STUDY/PROCEDURE: Right common carotid arteriogram, right internal\ncarotid arteriogram, left common carotid arteriogram, left internal carotid\narteriogram, left vertebral arteriogram.\n\nSTAFF: Dr. ___.\n\nFELLOW: Dr. ___.\n\nDr. ___ attending physician, was present and supervised throughout the\nprocedure.\n\nINDICATION: ___ female with subarachnoid hemorrhage presents for\nevaluation.\n\nTECHNIQUE: Written informed consent was obtained from the patient and her\nfamily after discussing the indications for the procedure, the risks of the\nprocedure, and alternative management. The discussed risks include stroke,\nloss of vision and/or speech, which may be temporary or permanent with\npossible treatment with stents and coils if needed. The patient was brought\nto the interventional neuroradiology suite and placed on the biplane table in\nsupine position. Both groins were prepped and draped in the usual sterile\nfashion. A pre-procedure timeout was performed using two patient identifiers.\nAccess to the right common femoral artery was obtained using a 19 gauge\nsingle-wall needle, with 1% lidocaine mixed with sodium bicarbonate for local\nanesthesia. A 0.35 ___ wire was introduced through the needle, and the\nneedle was removed. A 5 ___ vascular sheath was placed over the wire and\nconnected to a saline infusion (mixed with heparin 500 units in 500 cc of\nsaline) with a continuous drip. Through this sheath, a 4 ___ Berenstein\ncatheter was introduced and connected to a continuous saline infusion (mixed\nwith heparin 1000 units in 1000 cc of saline). The following vessels were\nselectively catheterized and arteriograms were performed from the following\nlocations: Right common carotid artery, right internal carotid artery, left\ncommon carotid artery, left internal carotid artery, and left vertebral\nartery. After review of the films, the catheter and sheath were withdrawn.\nHemostasis was achieved using manual compression. The patient tolerated the\nprocedure well without any immediate post-procedure complications.\n\nFINDINGS:\n\nRIGHT COMMON CAROTID ARTERY: The bifurcation of the common carotid artery is\nnormal. The right external carotid artery and its branches are normal. There\nis no evidence of vascular malformation.\n\nThere is a faint blush seen early on in the arterial phase in the region of\nthe right frontal extra-axial mass with delayed washout.\n\nRIGHT INTERNAL CAROTID ARTERY: The cervical, petrous, and cavernous segments\nof the internal carotid artery are normal. There is a 2 mm outpouching\narising from the supraclinoid segment of the right internal carotid artery in\nthe region of the superior hypophyseal artery origin. This likely represents\nan infundibulum or tiny aneurysm. The right middle cerebral and the right\nanterior cerebral arteries as well as their major branches are normal. The\nanterior communicating artery is partially visualized. There is no evidence\nof a vascular malformation.\n\nLEFT COMMON CAROTID ARTERY: The bifurcation of the common carotid artery is\nnormal. The left external carotid artery and its branches are normal. There\nis no evidence of vascular malformation.\n\nLEFT INTERNAL CAROTID ARTERY: The cervical, petrous, cavernous segments of\nthe internal carotid artery are normal. There is a small outpouching arising\nfrom the supraclinoid segment of the internal carotid artery in the region of\nthe superior hypophyseal artery origin, likely representing an infundibulum.\nOtherwise, the remaining supraclinoid segments of the internal carotid artery\nare normal. The left middle cerebral and left anterior cerebral arteries as\nwell as their major branches are normal. The anterior communicating artery is\npartially visualized. There is no evidence of an aneurysm or vascular\nmalformation.\n\nLEFT VERTEBRAL ARTERY: Left vertebral artery and the left posterior-inferior\ncerebellar arteries appear normal. The basilar artery, its brain stem\nbranches, both anterior-inferior cerebellar arteries, and both superior\ncerebellar arteries appear normal. There is no evidence of an aneurysm or\nvascular malformation.\n\nRIGHT VERTEBRAL ARTERY: Please note that the right vertebral artery origin is\nvery tortuous, thus a blood pressure cuff was placed on the right arm, and a\nright subclavian artery injection was performed for evaluation of the right\nvertebral artery. The right vertebral artery and the right posterior-inferior\ncerebellar artery appear normal. The basilar artery, its brain stem branches,\nboth anterior-inferior cerebellar arteries, and both superior cerebellar\narteries appear normal. There is no evidence of an aneurysm or vascular\nmalformation.\n\nIMPRESSION:\n1. Approximately 2 mm focal outpouching arising from the supraclinoid right\ninternal carotid artery in the region of the superior hypophyseal artery\norigin which likely represents an infundibulum but a tiny aneurysm cannot be\nexcluded. No large aneurysm is identified. No vascular malformation is seen.\n\n2. A faint blush is identified early on in the arterial phase with delayed\nwashout in the region of the right frontal extra-axial mass, which when\ncorrelated with CT head performed earlier on the same date is suggestive of a\nmeningioma.\n\n3. The right vertebral artery origin is tortuous with no significant\nstenosis.\n\n', '19955873-RR-18', 18, 'written informed consent was obtained from the patient and her\nfamily after discussing the indications for the procedure, the risks of the\nprocedure, and alternative management. the discussed risks include stroke,\nloss of vision and/or speech, which may be temporary or permanent with\npossible treatment with stents and coils if needed. the patient was brought\nto the interventional neuroradiology suite and placed on the biplane table in\nsupine position. both groins were prepped and draped in the usual sterile\nfashion. a pre-procedure timeout was performed using two patient identifiers.\naccess to the right common femoral artery was obtained using a 19 gauge\nsingle-wall needle, with 1% lidocaine mixed with sodium bicarbonate for local\nanesthesia. a 0.35 ___ wire was introduced through the needle, and the\nneedle was removed. a 5 ___ vascular sheath was placed over the wire and\nconnected to a saline infusion (mixed with heparin 500 units in 500 cc of\nsaline) with a continuous drip. through this sheath, a 4 ___ berenstein\ncatheter was introduced and connected to a continuous saline infusion (mixed\nwith heparin 1000 units in 1000 cc of saline). the following vessels were\nselectively catheterized and arteriograms were performed from the following\nlocations: right common carotid artery, right internal carotid artery, left\ncommon carotid artery, left internal carotid artery, and left vertebral\nartery. after review of the films, the catheter and sheath were withdrawn.\nhemostasis was achieved using manual compression. the patient tolerated the\nprocedure well without any immediate post-procedure complications.'], ['CLINICAL HISTORY: ___ female with subarachnoid hemorrhage status post\nangio.\n\nNON-CONTRAST HEAD CT: High-attenuation material is seen within the sulci of\nboth hemispheres, which is consistent with diffuse subarachnoid hemorrhage\nalthough given recent angiogram may represent a contrast enhancement. It is\nseen within the basal cistern, four ventricles and layering within the\nposterior horn of the lateral ventricles. Again seen is a large extra-axial\nmass adjacent to the right frontal lobe measuring 3.4 x 3.9 cm consistent with\na meningioma. The visualized paranasal sinuses and mastoid air cells remain\nnormally aerated.\n\nIMPRESSION:\n1. Since the prior exam, there is increased high-attenuation material within\nthe sulci of bilateral hemispheres, which may represent blood and combination\nof late enhancement from recent angiography.\n\n2. Right frontal meningioma.\n', '19955873-RR-19', 19, ''], ['MRI AND MRA BRAIN WITHOUT AND WITH CONTRAST, ___\n\nHISTORY: Subarachnoid hemorrhage. What is the etiology of this?\n\nSagittal and axial short TR, short TE spin echo imaging were performed through\nthe brain. Three-dimensional time-of-flight MRA was performed. After\nadministration of gadolinium intravenous contrast, axial gradient echo, FLAIR,\nlong TR, long TE fast spin echo, diffusion, short TR, short TE spin echo, and\nsagittal MP-RAGE imaging were performed. Comparison to a head CT of ___.\n\nFINDINGS: The extensive subarachnoid hemorrhage demonstrated on the CT scans\nis less apparent on the MR, but is seen as areas of hyperintensity in the\nsulci on the FLAIR images. The FLAIR images also reveal small bilateral\nsubdural fluid collections whose signal intensities suggest hematomas. There\nis intraventricular blood, as seen on the earlier head CT, but no evidence of\nnew hemorrhage. The large right frontal meningioma is again identified. This\nappears to invade the falx and extends slightly through the falx into the left\nhemisphere.\n\nThe MRA examination demonstrates no vascular abnormalities. Specifically,\nthere is no evidence of aneurysm or AVM.\n\nIncidentally noted is a left anterior temporal arachnoid cyst.\n\nCONCLUSION: No findings to explain the subarachnoid hemorrhage. Again\nidentified is diffuse subarachnoid hemorrhage. Small subdural hematomas are\nalso seen. There is a left anterior temporal arachnoid cyst and a large right\nfrontal meningioma that appears to extend through the falx.\n', '19955873-RR-20', 20, ''], ['HISTORY: Status post angiography with subarachnoid hemorrhage. Evaluate for\ninterval change.\n\nNON-CONTRAST HEAD CT\n\nComparison is made to prior head CT dated ___ and MRI from the same\nday.\n\nHigh-density material is again noted within the fourth ventricle,\nintrapedencular cistern and basal cisterns as noted on prior head CTs with\ndiffuse high attenuation within the sulci of both cerebral hemispheres less\napparent than on the prior study. Additional mild blood noted layering\ndependently within the posterior horns (right greater than left) is again\nnoted. Large hyperdense partially calcified right frontal mass lesion\ndisplacing the falx leftward is unchanged and no new areas of hemorrhage,\n infarction, shift of midline structures, or hydrocephalus are identified.\nMild low attenuation surrounding the right frontal mass consistent with edema\nis again noted and better appreciated on recently performed MRI. Soft tissues\nand osseous structures appear unremarkable. Visualized paranasal sinuses and\nmastoid air cells are well aerated, although the right mastoid air cells are\nagain noted to be sclerotic.\n\nIMPRESSION:\n\n1. No interval change in appearance of probable right frontal meningioma with\nmild surrounding edema.\n\n2. Unchanged diffuse subarachnoid hemorrhage as described above.\n', '19955873-RR-21', 21, ''], ['INDICATION: ___ with subarachnoid hemorrhage. Evaluate for aneurysm.\n\nCOMPARISON: CTA of the head ___, cerebral angiogram ___, and MRI\nof the brain ___.\n\nTECHNIQUE: Non-contrast head CT was performed followed by CTA of the head and\nneck following administration of 100 cc IV Optiray contrast. Dynamic\nperfusion images including mean transit time, blood flow, and blood volume\nwere obtained as well as volume rendered and MIP reconstructions of the circle\nof ___.\n\nFINDINGS:\n\nNON-CONTRAST HEAD CT: Hyperdense well-circumscribed right frontal mass\nmeasuring 4.4 x 3.6 cm is stable in size and appearance. There is again a\ndense focus within the posterior aspect of the mass, which likely represents\ncalcification. The mass is intimately related with the falx, which bulges to\nthe left. There is no mass effect on the underlying ventricles.\n\nScattered foci of subarachnoid hemorrhage remain, though decreased in the\ninterval. There is no new hemorrhage or infarct. The low-density lesion\nwithin the left anterior temporal lobe is consistent with an arachnoid cyst.\n\nCTA OF THE HEAD AND NECK: The carotid and vertebral arteries and their major\nbranches are patent with no evidence of stenoses. The distal cervical\ninternal carotid arteries measure 6 mm on the left and 6 mm on the right. No\nevidence of aneurysm or vascular abnormality. The probable posterior\ncommunicating artery infundibula seen on the cerebral angiogram are not well\nappreciated on this study. The dural venous sinuses appear patent, though the\nright frontal mass appears to compress the mid one-third of the anterior-\nsuperior sagittal sinus, and invasion into the sinus is possible.\n\nCT PERFUSION: The perfusion maps are normal with no evidence of delayed\ntransit time, reduced blood flow, or reduced blood volume.\n\nIMPRESSION:\n1. No aneurysm identified. The possible posterior communicating artery\ninfundibula seen on prior angiogram are not visualized on this study, likely\ndue to limited resolution.\n2. Persistent though decreased foci of subarachnoid hemorrhage. No new\nhemorrhage identified.\n3. Large right frontal mass, likely meningioma, which compresses the\nanterior- superior sagittal sinus and invasion of the sinus cannot be\nexcluded.\n4. No perfusion abnormalities to suggest ischemia.\n\n', '19955873-RR-22', 22, 'non-contrast head ct was performed followed by cta of the head and\nneck following administration of 100 cc iv optiray contrast. dynamic\nperfusion images including mean transit time, blood flow, and blood volume\nwere obtained as well as volume rendered and mip reconstructions of the circle\nof ___.'], ["DATE OF SERVICE: ___. \n\nINDICATION: Patient is a ___ woman with subarachnoid hemorrhage. A\nfollowup angiogram was requested by Dr. ___ as the patient had very\nsignificant subarachnoid hemorrhage and there was a concern about the right\nPCOM infundibulum. The study was limited by motion artifact.\n\nPROCEDURE PERFORMED: Right common carotid artery arteriogram, right internal\ncarotid artery arteriogram, left common carotid artery arteriogram, left\ninternal carotid artery arteriogram, left vertebral artery arteriogram. \n\nANESTHESIA: IV sedation.\n\nATTENDING: ___.\n\nASSISTANT: None.\n\nPROCEDURE: The patient was brought to the angiography suite. Both groins\nwere prepped and draped in a sterile fashion. Following this, access was\ngained to the right common femoral artery using a Seldinger technique. The\nvascular sheath was connected to a continuous saline infusion. We now passed\n___ 2 catheter coaxially over a glidewire into the aortic arch and the\nright common carotid artery, the right internal carotid artery, the left\ncommon carotid artery, left internal carotid artery and left vertebral artery\nwas cannulated and AP, lateral filming was done with three dimensional imaging\nwhere appropriate. This did not demonstrate any aneurysm. We still felt that\nthe right PCOM area was not sufficiently elucidated secondary to motion.\n\nThe vascular sheath was removed and manual compression applied to obtain\nfemoral artery closure.\n\nFINDINGS: Right common carotid artery arteriogram demonstrates significant\ntortuosity of the internal and external carotid artery in the neck. The\nexternal carotid artery and its branches fill well. The cervical carotid\nartery fills well along its cervical, petrous, cavernous and supraclinoid\nportion. The middle and anterior cerebral arteries are seen normally. There\nis no evidence of any aneurysms. There is no stenosis of the carotid\nbifurcation.\n\nThe right internal carotid artery arteriogram with three- dimensional imaging\ndemonstrates again an infundibulum or a small aneurysm at the right posterior\ncommunicating artery area measuring 2.5 mm in size.\n\nThe left common carotid artery arteriogram demonstrates normal external\ncarotid artery and its branches. The right internal carotid artery fills well\nalong its cervical, petrous, cavernous and supraclinoid portion. There is a\nsmall infundibulum which measures about 1.5 mm at the origin of the left\nposterior communicating artery. No aneurysms are visualized.\n\nLeft internal carotid artery arteriogram with three-dimensional imaging again\ndemonstrates a small infundibulum in the posterior communicating segment with\nno evidence of aneurysms.\n\nLeft vertebral artery arteriogram demonstrates normal filling of the left\nvertebral artery with reflux into the right vertebral artery. Both PICAs are\nseen normally. Both PCAs are seen normally. The basilar artery and its\nbranches are seen normally with no evidence of any aneurysm.\n\nMODERATE SEDATION was provided by administering divided doses of 75 mcg of\nfentanyl and 1.5 mg of Versed throughout the 50 minute intraservice time\nduring which the patient's hemodynamic parameters were continuously monitored.\n\nIMPRESSION: ___ underwent cerebral arteriography which failed\nto demonstrate an aneurysm or arteriovenous malformation which could account\nfor her subarachnoid hemorrhage.\n\n\n", '19955873-RR-23', 23, ''], ['AP CHEST, 6:43 P.M. on ___.\n\nHISTORY: Subarachnoid hemorrhage. Preop.\n\nIMPRESSION: AP chest reviewed in the absence of prior chest radiographs:\n\nPulmonary and mediastinal vascular congestion suggests borderline cardiac\nfunction. Heart size is top normal. There is no evidence of pleural\neffusion. Opacification at the base of the right lung is probably mild\natelectasis. No pneumothorax.\n', '19955873-RR-24', 24, ''], ['HISTORY: ___ female with subarachnoid hemorrhage, for angiogram and\ncraniotomy tomorrow.\n\nCOMPARISON: ___ and ___.\n\nTECHNIQUE: Contiguous axial images of the head were obtained without the\nadministration of IV contrast.\n\nFINDINGS: There continues to be scattered foci of subarachnoid hemorrhage,\nmost notably within the right parietal region, with a small amount of\ndependent hemorrhage within the occipital horns of the lateral ventricles,\nright greater than left. These are largely unchanged from prior study. No new\nfoci of acute hemorrhage are identified. There is no evidence of hydrocephalus\nor acute major vascular territorial infarction.\n\nLarge hyperdense partially calcified right frontal extra-axial mass with\ndisplacement of the falx leftward and associated vasogenic edema is unchanged.\nLow- density lesion within the left anterior temporal lobe is unchanged, most\nlikely representing an arachnoid cyst. Visualized paranasal sinuses and\nmastoid air cells are well aerated, with the right mastoid air cells being\nsclerotic. Osseous structures are unremarkable.\n\nIMPRESSION:\n\n1. Unchanged scattered foci of subarachnoid hemorrhage, with a small amount\nof hemorrhage layering within the occipital horn of the lateral ventricles.\n\n2. No change in the right frontal meningioma and left anterior temporal lobe\narachnoid cyst.\n', '19955873-RR-25', 25, 'contiguous axial images of the head were obtained without the\nadministration of iv contrast.'], ['DATE OF SERVICE: ___. \n\nINDICATIONS: The patient is a ___ female with a subarachnoid\nhemorrhage. Two cerebral angiograms had failed to resolve the source of the\nhemorrhage. There was concern about a right PCOM aneurysm versus\ninfundibulum. She was scheduled to be taken to the operating room for\nexploration of this area since the angiograms performed were suboptimal\nsecondary to movement artifact. We decided to do another cerebral angiogram\nunder general anesthesia fully paralyzed to get optimal pictures.\n\nPROCEDURE PERFORMED: Right internal carotid artery arteriogram, left internal\ncarotid artery arteriogram and right vertebral artery arteriogram and right\ncommon femoral artery arteriogram with Angio-seal closure of right common\nfemoral artery. \n\nANESTHESIA: General.\n\nPROCEDURE: The patient was brought to the angiography suite. Following this,\naccess was gained to the right common femoral artery using the Seldinger\ntechnique and a 5 ___ vascular sheath was placed in the right common\nfemoral artery. Through this vascular sheath, ___ 2 catheter was guided\ncoaxially over an 038 glidewire into the aortic arch and the right internal\ncarotid artery, left internal carotid artery and the right vertebral artery\nwere cannulated and AP, lateral filming done with three-dimensional imaging.\nThis failed to reveal an aneurysm. Therefore a right common femoral artery\narteriogram was done and an Angio-Seal 6 ___ device was used for closure\nand the operative procedure was canceled and the patient taken back to the\nICU.\n\nFINDINGS: Right internal carotid artery arteriogram shows normal right\ncervical, petrous, cavernous and supraclinoid portion of the internal carotid\nartery. In the supraclinoid portion an infundibulum is clearly demonstrated\nwith no evidence of aneurysm in the PCOM segment. The anterior and middle\ncerebral arteries are seen normally.\n\nThe left internal carotid artery arteriogram again demonstrates normal filling\nof the left internal carotid artery along its cervical, petrous, cavernous and\nsupraclinoid portion. The left anterior and middle cerebral arteries are seen\nnormally.\n\nThe right vertebral artery arteriogram demonstrates normal filling of the\nright vertebral artery along with reflux into the left vertebral artery. Both\nPICAs are seen well with no evidence of aneurysm. The basilar artery and its\nbranches are seen well. Both posterior cerebral arteries are seen well with\nno evidence of aneurysms.\n\nRight common femoral artery arteriogram demonstrates a completely patent right\ncommon femoral artery with superficial femoral artery and right profunda\nfemoris. \n\nIMPRESSION: ___ underwent cerebral angiography which\ndemonstrated no aneurysm. There is a 2-mm infundibulum in the right posterior\ncommunicating segment.\n\n', '19955873-RR-26', 26, '']]

[[27986620, Timestamp('2188-08-04 05:00:00'), Timestamp('2188-08-05 20:00:00'), 'MAIN', 'Morphine Sulfate', '004070', '00409176230', '2mg Syringe'], [27986620, Timestamp('2188-08-04 10:00:00'), Timestamp('2188-08-14 18:00:00'), 'MAIN', 'Vitamin D', '019166', '10432017002', '400 Unit Tablet'], [27986620, Timestamp('2188-08-04 05:00:00'), Timestamp('2188-08-10 20:00:00'), 'MAIN', 'Insulin', '001723', '0', 'Dummy Package for Sliding Scale'], [27986620, Timestamp('2188-08-04 05:00:00'), Timestamp('2188-08-06 10:00:00'), 'BASE', 'Potassium Chl 20 mEq / 1000 mL D5NS', '011988', '00338080304', '1000 mL Bag'], [27986620, Timestamp('2188-08-04 05:00:00'), Timestamp('2188-08-14 12:00:00'), 'MAIN', 'Nimodipine', '000579', '00555098040', '30mg Capsule'], [27986620, Timestamp('2188-08-04 08:00:00'), Timestamp('2188-08-08 05:00:00'), 'MAIN', 'Phenytoin', '004521', '51079090520', '100mg Capsule'], [27986620, Timestamp('2188-08-04 10:00:00'), Timestamp('2188-08-14 18:00:00'), 'MAIN', 'Citalopram Hydrobromide', '046203', '60505251903', '20mg Tablet'], [27986620, Timestamp('2188-08-04 05:00:00'), Timestamp('2188-08-06 10:00:00'), 'BASE', 'NS', '001210', '00338004902', '250mL Bag'], [27986620, Timestamp('2188-08-04 05:00:00'), Timestamp('2188-08-06 10:00:00'), 'MAIN', 'NiCARdipine IV', '021600', '67286081203', '2.5mg/mL;10mL Vial'], [27986620, Timestamp('2188-08-04 10:00:00'), Timestamp('2188-08-14 18:00:00'), 'MAIN', 'Levothyroxine Sodium', '006652', '00074929613', '112mcg Tablet'], [27986620, Timestamp('2188-08-04 08:00:00'), Timestamp('2188-08-14 18:00:00'), 'MAIN', 'Famotidine', '011677', '51079096620', '20mg Tablet']]

[]

['neurosurgery']

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Question: A 63 F is admitted. He/she says he/she has headache . History of illness: HPI: ___ y/o F was at work this evening as ___ at ___ when at approx 10 ___ she experienced a sudden onset ___ headache which started in the bifrontal area and radiate to the back of the head. At the time she was trying to speak forcefully. Became lightheaded with the headache but never had LOC. She did have nausea and one episode of vomitting. No trauma. No visual changes. Some L tinnitus for past 2 days. CT scan obtained at ___ showed SAH and she was transferred to ___ for further eval. At the OSH she was loaded with Dilantin, given 10 mg Decadron, zofran and morphine. On arrival here her headache is ___. History obtained with son translating. Past Medical History: PMHx:?goiter, s/p thyroidectomy, anxiety, breast lumpectomy, ?ear surgery as a child Social History: ___ Family History: Family Hx:Non-contributory Allergies: Patient recorded as having No Known Allergies to Drugs What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Morphine Sulfate Vitamin D Insulin Potassium Chl 20 mEq / 1000 mL D5NS Nimodipine Phenytoin Citalopram Hydrobromide NS NiCARdipine IV Levothyroxine Sodium Famotidine Target Lab Orders: Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells INR(PT) PT PTT Anion Gap Bicarbonate Calcium, Total Chloride Creatinine Glucose Magnesium Phosphate Potassium Sodium Urea Nitrogen Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : NEURO: Pt was admitted to ICU foloowing discovery of SAH on CT scan. Her VS and neuro status were monitored closely. On her day of admission ___ she underwent a CTA and angiogram of the brain. No direct aneurysm of AVM was identified. Incidentally noted was that she had a Frontal brain mass which as this time is suspected to be a menigioma. She also has an arachnoid cyst. She was kept in the ICU until follow up angiogram demonstrated that there was no defined aneurysm identified. She was started on keppra for sz prophylaxis as well as nimodipine. Ultimately she was transferred to the step down unit and then to floor staus. Her exam remained stable during the entire hosp stay. CV;No issues during this stay ENDO: she had no issues during this stay - she was placed on SSI coverage during the ICU stay. RESP: No issues Renal: UTI noted on ___. Cipro started. will complete course of abx at home. GEN: she was seen by ___ and deemed safe for discharge to home. Other Results: CT/MRI: Subarachnoid hemorrhage fills suprasellar cistern and ___ ventricle. No definite aneurysm seen on CTA. 3.7 x 3.7 rounded dense lesion in right frontal lobe, most probably extraaxial, with minimal mass effect on adjacent sulci, small internal ?calcifcation versus small focus of internal hemorrhage. Could be consistent with meningioma. Unclear if this is causally related to SAH, but thought ___ unlikely. ___ 03:00AM GLUCOSE-192* UREA N-14 CREAT-0.6 SODIUM-143 POTASSIUM-3.5 CHLORIDE-106 TOTAL CO2-24 ANION GAP-17 ___ 03:00AM CALCIUM-8.2* PHOSPHATE-2.9 MAGNESIUM-1.9 ___ 03:00AM WBC-14.2* RBC-4.22 HGB-12.6 HCT-37.0 MCV-88 MCH-29.9 MCHC-34.2 RDW-13.3 ___ 03:00AM NEUTS-76* BANDS-2 LYMPHS-15* MONOS-0 EOS-0 BASOS-1 ATYPS-6* ___ MYELOS-0 ___ 03:00AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-1+ ___ 03:00AM PLT SMR-NORMAL PLT COUNT-274 ___ 03:00AM ___ PTT-23.1 ___ ___ 01:55AM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 01:55AM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-MOD ___ 01:55AM URINE ___ BACTERIA-NONE YEAST-NONE ___ RADIOLOGY Final Report CT HEAD W/O CONTRAST ___ 8:30 ___ CT HEAD W/O CONTRAST Reason: Follow up sor SAH UNDERLYING MEDICAL CONDITION: ___ year old woman with SAH, for angiogram and craniotomy tomorrow REASON FOR THIS EXAMINATION: Follow up sor SAH CONTRAINDICATIONS for IV CONTRAST: None. HISTORY: ___ female with subarachnoid hemorrhage, for angiogram and craniotomy tomorrow. COMPARISON: ___ and ___. TECHNIQUE: Contiguous axial images of the head were obtained without the administration of IV contrast. FINDINGS: There continues to be scattered foci of subarachnoid hemorrhage, most notably within the right parietal region, with a small amount of dependent hemorrhage within the occipital horns of the lateral ventricles, right greater than left. These are largely unchanged from prior study. No new foci of acute hemorrhage are identified. There is no evidence of hydrocephalus or acute major vascular territorial infarction. Large hyperdense partially calcified right frontal extra-axial mass with displacement of the falx leftward and associated vasogenic edema is unchanged. Low- density lesion within the left anterior temporal lobe is unchanged, most likely representing an arachnoid cyst. Visualized paranasal sinuses and mastoid air cells are well aerated, with the right mastoid air cells being sclerotic. Osseous structures are unremarkable. IMPRESSION: 1. Unchanged scattered foci of subarachnoid hemorrhage, with a small amount of hemorrhage layering within the occipital horn of the lateral ventricles. 2. No change in the right frontal meningioma and left anterior temporal lobe arachnoid cyst. Cardiology Report ECG Study Date of ___ 12:49:44 AM Sinus rhythm. Non-diagnostic Q waves in the inferior leads. Diffuse ST-T wave changes which are non-specific. No previous tracing available for comparison. Read by: ___ Intervals Axes Rate PR QRS QT/QTc P QRS T 73 142 94 420/442 54 31 31 RADIOLOGY Final Report MRA BRAIN W/O CONTRAST ___ 10:00 ___ MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST Reason: please eval for aneurysm, etiology of known SAH Contrast: MAGNEVIST UNDERLYING MEDICAL CONDITION: ___ year old woman with SAH REASON FOR THIS EXAMINATION: please eval for aneurysm, etiology of known SAH CONTRAINDICATIONS for IV CONTRAST: None. MRI AND MRA BRAIN WITHOUT AND WITH CONTRAST, ___ HISTORY: Subarachnoid hemorrhage. What is the etiology of this? Sagittal and axial short TR, short TE spin echo imaging were performed through the brain. Three-dimensional time-of-flight MRA was performed. After administration of gadolinium intravenous contrast, axial gradient echo, FLAIR, long TR, long TE fast spin echo, diffusion, short TR, short TE spin echo, and sagittal MP-RAGE imaging were performed. Comparison to a head CT of ___. FINDINGS: The extensive subarachnoid hemorrhage demonstrated on the CT scans is less apparent on the MR, but is seen as areas of hyperintensity in the sulci on the FLAIR images. The FLAIR images also reveal small bilateral subdural fluid collections whose signal intensities suggest hematomas. There is intraventricular blood, as seen on the earlier head CT, but no evidence of new hemorrhage. The large right frontal meningioma is again identified. This appears to invade the falx and extends slightly through the falx into the left hemisphere. The MRA examination demonstrates no vascular abnormalities. Specifically, there is no evidence of aneurysm or AVM. Incidentally noted is a left anterior temporal arachnoid cyst. CONCLUSION: No findings to explain the subarachnoid hemorrhage. Again identified is diffuse subarachnoid hemorrhage. Small subdural hematomas are also seen. There is a left anterior temporal arachnoid cyst and a large right frontal meningioma that appears to extend through the falx.

2183-12-04 16:33:00

ENGLISH

MARRIED

WHITE

F

[[20741558, Timestamp('2183-12-04 16:34:04'), '', 'PSURG']]

[[{'Medications on Admission': ':\nEscitalopram 10mg daily\nButropion XL 75mg daily', 'Brief Hospital Course': ':\nMs. ___ is a ___ year old woman who presented \n___ s/p bilateral breast reduction with free nipple grafts \nwith Dr. ___ with left breast cellulitis. She was admitted \nto the Plastic Surgery Service for IV antibiotics with \nvancomycin, IV fluids for hydration, and serial breast exams. \nHer erythema and edema of her left breast slightly improved on \nthe AM of HD2, and the patient strongly preferred to continue \noral antibiotic treatment with MRSA coverage at home. She \ntolerated a diet without nausea or vomiting and voided \nappropriately.\n\n', 'Pertinent Results:': '\n___ 02:00PM ___ COMMENTS-GREEN TOP\n___ 02:00PM LACTATE-1.9\n___ 01:40PM GLUCOSE-87 UREA N-11 CREAT-0.5 SODIUM-139 \nPOTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-25 ANION GAP-13\n___ 01:40PM estGFR-Using this\n___ 01:40PM WBC-11.1* RBC-4.73# HGB-13.0# HCT-39.7# \nMCV-84 MCH-27.5 MCHC-32.7 RDW-13.9 RDWSD-42.9\n___ 01:40PM NEUTS-60.5 ___ MONOS-6.9 EOS-3.6 \nBASOS-0.4 IM ___ AbsNeut-6.71* AbsLymp-3.13 AbsMono-0.77 \nAbsEos-0.40 AbsBaso-0.05\n___ 01:40PM PLT COUNT-287\n\n', 'Physical Exam:|Physical': '\nGen: NAD, A&Ox3, resting in stretcher comfortably\nHEENT: Mucous membranes moist\nCV: RRR\nBreast: Left breast with blanching erythema of lower pole of\nbreast. Serous drainage from around areola and T-junction. Small \namount of serous drainage from surrounding right areola. \nDressings and Surgical bra replaced.\nR: Breathing comfortably on room air. No wheezing.\nExt: WWP \n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\nMs. ___ is a ___ year old woman who presents \n___\ns/p bilateral breast reduction with free nipple grafts with left\nbreast erythema, drainage, and fever. The patient underwent\nbilateral breast reduction with free nipple grafts and\nliposuction to the bilateral axillary rolls on ___. She\ntolerated the procedure well and was discharged that day on\nKeflex which she took through the morning of POD1. At her one\nweek postoperative visit, she was noted to have left nipple\ndrainage, for which she was prescribed 1 week of Keflex. Two\nweeks postoperative, she presented to her PCP for right nipple\ndrainage, for which she was restarted on Keflex. The morning of\nED presentation, she noted increased drainage from her left\nnipple and left T-junction, erythema of her left breast lower\npole, and fever to 100.4. She was encouraged to present to the \nED\nat ___ for further evaluation. On presentation to ___ ED, \nthe\npatient was afebrile, with stable vitals. She noted some pain\nalong the inferior pole of her breast, worsening erythema, and\nclear green-yellow drainage from around the areola and the\nT-junction. She denied difficulty breathing, shortness of \nbreath,\nchest pain, nausea, vomiting, diarrhea, and changes in urinary\nsymptoms.\n\nPast Medical History:\nDepression/Anxiety\nWeight loss\nMacromastia s/p breast reduction \n\nSocial History:\n___\nFamily History:\nnoncontributory\n\n', 'Chief Complaint:|Complaint:': '\nleft breast cellulitis\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \ncodeine / Reglan / shrimp / Topamax / coconut\n\n'}, '16350590-DS-19', 19, 'plastic']]

[]

[[20741558, Timestamp('2183-12-05 08:00:00'), Timestamp('2183-12-05 19:00:00'), 'MAIN', 'Escitalopram Oxalate', '050712', '51079054320', '10mg Tablet'], [20741558, Timestamp('2183-12-04 18:00:00'), Timestamp('2183-12-05 19:00:00'), 'BASE', 'D5 1/2NS', '002006', '00338008504', '1000mL Bag'], [20741558, Timestamp('2183-12-04 18:00:00'), Timestamp('2183-12-05 19:00:00'), 'MAIN', 'Acetaminophen', '004489', '00904198261', '325mg Tablet'], [20741558, Timestamp('2183-12-04 18:00:00'), Timestamp('2183-12-05 19:00:00'), 'MAIN', 'Influenza Vaccine Quadrivalent', '075715', '49281041688', '0.5 mL Syringe'], [20741558, Timestamp('2183-12-04 18:00:00'), Timestamp('2183-12-05 19:00:00'), 'MAIN', 'Sodium Chloride 0.9% Flush', '', '0', '10 mL Syringe'], [20741558, Timestamp('2183-12-04 18:00:00'), Timestamp('2183-12-05 19:00:00'), 'BASE', 'Iso-Osmotic Dextrose', '', '0', '200ml Bag'], [20741558, Timestamp('2183-12-04 18:00:00'), Timestamp('2183-12-05 19:00:00'), 'MAIN', 'Vancomycin', '043952', '00338355248', '1g Frozen Bag'], [20741558, Timestamp('2183-12-04 18:00:00'), Timestamp('2183-12-05 19:00:00'), 'BASE', 'Iso-Osmotic Dextrose', '', '0', '200ml Bag'], [20741558, Timestamp('2183-12-04 18:00:00'), Timestamp('2183-12-05 19:00:00'), 'MAIN', 'Vancomycin', '043952', '00338355248', '1g Frozen Bag'], [20741558, Timestamp('2183-12-04 18:00:00'), Timestamp('2183-12-05 19:00:00'), 'MAIN', 'OxyCODONE (Immediate Release)', '004225', '00904644461', '5mg Tablet']]

[]

['plastic']

[]

Question: A 38 F is admitted. He/she says he/she has left breast cellulitis . History of illness: Ms. ___ is a ___ year old woman who presents ___ s/p bilateral breast reduction with free nipple grafts with left breast erythema, drainage, and fever. The patient underwent bilateral breast reduction with free nipple grafts and liposuction to the bilateral axillary rolls on ___. She tolerated the procedure well and was discharged that day on Keflex which she took through the morning of POD1. At her one week postoperative visit, she was noted to have left nipple drainage, for which she was prescribed 1 week of Keflex. Two weeks postoperative, she presented to her PCP for right nipple drainage, for which she was restarted on Keflex. The morning of ED presentation, she noted increased drainage from her left nipple and left T-junction, erythema of her left breast lower pole, and fever to 100.4. She was encouraged to present to the ED at ___ for further evaluation. On presentation to ___ ED, the patient was afebrile, with stable vitals. She noted some pain along the inferior pole of her breast, worsening erythema, and clear green-yellow drainage from around the areola and the T-junction. She denied difficulty breathing, shortness of breath, chest pain, nausea, vomiting, diarrhea, and changes in urinary symptoms. Past Medical History: Depression/Anxiety Weight loss Macromastia s/p breast reduction Social History: ___ Family History: noncontributory Allergies: codeine / Reglan / shrimp / Topamax / coconut What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Escitalopram Oxalate D5 1/2NS Acetaminophen Influenza Vaccine Quadrivalent Sodium Chloride 0.9% Flush Iso-Osmotic Dextrose Vancomycin Iso-Osmotic Dextrose Vancomycin OxyCODONE (Immediate Release) Target Lab Orders: NONE Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : Ms. ___ is a ___ year old woman who presented ___ s/p bilateral breast reduction with free nipple grafts with Dr. ___ with left breast cellulitis. She was admitted to the Plastic Surgery Service for IV antibiotics with vancomycin, IV fluids for hydration, and serial breast exams. Her erythema and edema of her left breast slightly improved on the AM of HD2, and the patient strongly preferred to continue oral antibiotic treatment with MRSA coverage at home. She tolerated a diet without nausea or vomiting and voided appropriately. Other Results: ___ 02:00PM ___ COMMENTS-GREEN TOP ___ 02:00PM LACTATE-1.9 ___ 01:40PM GLUCOSE-87 UREA N-11 CREAT-0.5 SODIUM-139 POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-25 ANION GAP-13 ___ 01:40PM estGFR-Using this ___ 01:40PM WBC-11.1* RBC-4.73# HGB-13.0# HCT-39.7# MCV-84 MCH-27.5 MCHC-32.7 RDW-13.9 RDWSD-42.9 ___ 01:40PM NEUTS-60.5 ___ MONOS-6.9 EOS-3.6 BASOS-0.4 IM ___ AbsNeut-6.71* AbsLymp-3.13 AbsMono-0.77 AbsEos-0.40 AbsBaso-0.05 ___ 01:40PM PLT COUNT-287

2142-04-21 21:20:00

ENGLISH

SINGLE

WHITE

M

[[22836372, Timestamp('2142-04-21 21:21:17'), '', 'VSURG']]

[[{'Medications on Admission': ':\nMetformin (not taking)\n\nFacility:\n___', 'Brief Hospital Course': ':\nPatient was admitted with gangrene of the right foot. He had \nwhat appeared to be an active ongoing infection in his right \nfoot and in the emergency department had partial debridement of \nhis right ___ toe. He was admitted and continued on Vanc and \nUnasyn, which were started at ___. He was taken to the \noperating room on ___ and found to have extensive infection \nthrough the forefoot on the right and underwent right TMA. The \nwound was left open for drainage purposes and packed with WTD \ndressings. He was brought back to the floor and resumed on all \nof his preop medications, including Vanc and Unasyn. He was then \nbrought to the angio suite for evaluation of the vessels in his \nRLE and underwent ultrasound-guided puncture of left common \nfemoral artery, abdominal aortogram, second-order \ncatheterization of right external iliac artery, serial \narteriogram of right lower extremity, additional catheterization \nof right superficial femoral artery, balloon angioplasty and \nstenting of right superficial femoral artery, balloon \nangioplasty and stenting of aorta, Balloon angioplasty and \nstenting of left common iliac extending into the external iliac \nartery.\n\nPsychiatry was asked to come and see the patient as he was noted \nto be hostile at points and grabbed a SCH heparin needle out of \na nurses hand on ___, scratching the nurse with the needle. \nHe was not started on any psychiatric medicines during this \nhospitalization, nor diagnosed with any psychiatric disorders.\n\nHe subsequently was taken to the OR for a revision TMA on \n___. The operation proceeded uneventfully and he was \nbrought to the floor in stable condition, resumed on his diet \nand his home medications. The lateral aspect of his wound was \nopen and a wound VAC was placed. He had some incontinence of \nstool and loose stool and was started on IV flagyl and a stool \nculture was sent. He was seen by physical therapy.\n\n', 'Pertinent Results:': '\n___ 08:40AM BLOOD WBC-10.5 RBC-3.45* Hgb-9.6* Hct-30.2* \nMCV-88 MCH-27.7 MCHC-31.7 RDW-13.7 Plt ___\n___ 02:56PM BLOOD WBC-9.1 RBC-3.93* Hgb-11.1* Hct-36.0* \nMCV-92 MCH-28.2 MCHC-30.8* RDW-14.0 Plt ___\n___ 08:05AM BLOOD WBC-9.2 RBC-3.55* Hgb-10.0* Hct-31.7* \nMCV-89 MCH-28.3 MCHC-31.7 RDW-13.7 Plt ___\n___ 06:30PM BLOOD WBC-12.3* RBC-4.00* Hgb-11.2* Hct-35.8* \nMCV-89 MCH-28.0 MCHC-31.3 RDW-13.9 Plt ___\n___ 08:40AM BLOOD ___ PTT-30.2 ___\n___ 06:30PM BLOOD ___ PTT-31.8 ___\n___ 08:40AM BLOOD Glucose-188* UreaN-9 Creat-0.8 Na-136 \nK-4.0 Cl-99 HCO3-27 AnGap-14\n___ 02:56PM BLOOD Glucose-150* UreaN-9 Creat-0.9 Na-137 \nK-3.8 Cl-101 HCO3-26 AnGap-14\n___ 08:05AM BLOOD Glucose-192* UreaN-12 Creat-0.9 Na-136 \nK-4.0 Cl-99 HCO3-29 AnGap-12\n___ 06:30PM BLOOD Glucose-200* UreaN-14 Creat-1.0 Na-138 \nK-4.3 Cl-96 HCO3-28 AnGap-18\n___ 06:30PM BLOOD ALT-28 AST-22 AlkPhos-152* TotBili-0.3 \nDirBili-0.1 IndBili-0.2\n___ 08:40AM BLOOD CK-MB-2 cTropnT-<0.01\n___ 02:56PM BLOOD CK-MB-1 cTropnT-0.01\n___ 08:05AM BLOOD %HbA1c-8.0* eAG-183*\n___ 06:55PM BLOOD Lactate-1.7\n\nCXR ___: No acute cardiopulmonary process.\n\n', 'Physical Exam:|Physical': '\nOn discharge:\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\n ___ M transfer from OSH for gangrene R foot. Patient is a\npoor historian but reports about 6 weeks ago he was camping in\n___ and developed an infection of his R ___ toe thought to \nbe\ndue to an in-grown nail. He denies any other trauma to his foot\nat this time. He presented to a hospital in ___ for\nevaluation and underwent a R ___ toe amputation. He was\ndischarged to rehab where he developed a wound infection and\nbreakdown at his amputation site. He also noted his right fifth\ntoe became black and infected. He reports he was not treated\nwell at the outside hospital where "they did not give me\nantibiotics and just would wrap my foot". His daughter, who\nlives in ___ recommended he come here to be evaluated. \n\nHe presented to ___ where he an X-Ray of the\nfoot demonstrated no clear evidence of osteomyelitis. He was\nseen by a general surgeon who recommended he be transferred to\n___ for further management and evaluation by a vascular\nsurgeon.\n\nPast Medical History:\nPMH: DM-2 (borderline per patient), BPH\n\nPSH: R ___ toe amputation ___ (in ___\n\nSocial History:\n___\nFamily History:\nNon-contributory\n\n', 'Chief Complaint:|Complaint:': '\nright foot wet gangrene\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nNo Known Allergies / Adverse Drug Reactions\n\n'}, '15846065-DS-2', 2, 'surgery']]

[['INDICATION: ___ man with right foot gangrene.\n\nCOMPARISONS: None.\n\nFINDINGS: The lungs are well inflated and clear. No focal consolidation,\neffusion, or pneumothorax is present. The cardiac and mediastinal contours\nare normal.\n\nIMPRESSION: No acute cardiopulmonary process.\n', '15846065-RR-9', 9, ''], ['INDICATION: ___ male with right forefoot ischemia.\n\nBilateral lower extremity ABIs, Doppler waveforms, and PVRs were performed at\nrest.\n\nThe right ABI is 0.58/0.55 at DP and ___ respectively. The right femoral\nwaveform is biphasic with monophasic superficial femoral, popliteal, posterior\ntibial and dorsalis pedis waveforms. Waveforms are diminished at all levels,\nbut significantly diminished between the thigh and calf suggesting\nfemoropopliteal occlusive disease. The ankle and metatarsal PVRs are\nconsistent with moderately severe peripheral vascular disease.\n\nLEFT: The left ABI is 0.72/0.79 at ___ respectively. The left common\nfemoral waveform is blunted and monophasic with monophasic superficial\nfemoral, popliteal, posterior tibial and dorsalis pedis waveforms. The\nleft-sided PVRs are fairly symmetric when compared to the left, but indicate\nslightly greater degree of aortoiliac involvement.\n\nIMPRESSION: Moderately severe peripheral vascular disease on the right with\nmild aortoiliac and predominant femoropopliteal occlusive disease. On the\nleft, there is aortoiliac disease with moderate disease severity based on\nABIs. Based on PVRs, there is moderately severe disease symmetric compared to\nthe right.\n', '15846065-RR-10', 10, ''], ['INDICATION: ___ male with right lower extremity ischemia, in need of\nbypass.\n\nBilateral upper extremity vein mapping was performed. Mapping was limited in\nthe right cephalic due to placement of an IV at the antecubital fossa.\n\nRIGHT ARM: The right cephalic vein is patent with forearm diameters of 2.2 to\n2.8 mm. The upper arm cephalic is limited in evaluation, but measures 2.7,\n4.0 mm.\n\nThe right forearm basilic is less than 2 mm. The antecubital fossa to upper\narm basilic diameters are 3.3, 2.5, 2.4, 4.9 mm.\n\nLEFT ARM: The left arm cephalic vein is patent with diameters in the forearm\nof 1.6, 2.2, 2.0 mm. The upper arm diameters of 3.3, 2.4, 2.9 mm.\n\nThe left basilic vein diameters are less than 2 mm in the forearm. The\nantecubital to upper arm diameters are 2.2, 2.4, 2.2, 2.3 mm.\n\nIMPRESSION: Patent right and left basilic veins. Diameters as noted.\n', '15846065-RR-11', 11, ''], ['Bilateral lower extremity vein mapping was performed.\n\nFINDINGS:\n\nRIGHT LEG: The right greater saphenous vein is patent with diameters below\nthe knee ranging from 3.1 to 4.3 mm. The diameters above the knee are 4.3-6.8\nmm.\n\nThe right small saphenous vein has diameters of 2.4-3.1 mm.\n\nLEFT LEG: The left greater saphenous vein is patent with diameters below the\nknee of 2.7, 2.1, 1.8, 2.2 mm. The knee to groin diameters are 2.2, 1.9, 2.6,\n2.9, 3.4 mm.\n\nThe left small saphenous vein is patent with diameters of 1.7-2.1 mm.\n\nIMPRESSION: Widely patent right greater saphenous vein with good diameters\nfor conduit. The right small saphenous vein is also patent and usable. The\nleft greater saphenous vein is patent with small diameters at the knee and\nbelow the knee. Left small saphenous vein has small diameters.\n', '15846065-RR-12', 12, ''], ['STUDY: AP chest ___.\n\nCLINICAL HISTORY: ___ male with new PICC line.\n\nFINDINGS:\n\nThere is a new left-sided PICC line whose distal tip is in the distal SVC. \nThere are no pneumothoraces. The heart size and mediastinum are normal. \nLungs are grossly clear. Bony structures are intact.\n', '15846065-RR-13', 13, '']]

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[]

['surgery']

[[50852, Timestamp('2142-04-22 07:20:00'), Timestamp('2142-04-22 10:46:00'), '% Hemoglobin A1c'], [51613, Timestamp('2142-04-22 07:20:00'), Timestamp('2142-04-22 10:46:00'), 'eAG'], [50868, Timestamp('2142-04-22 08:05:00'), Timestamp('2142-04-22 09:20:00'), 'Anion Gap'], [50882, Timestamp('2142-04-22 08:05:00'), Timestamp('2142-04-22 09:20:00'), 'Bicarbonate'], [50893, Timestamp('2142-04-22 08:05:00'), Timestamp('2142-04-22 09:20:00'), 'Calcium, Total'], [50902, Timestamp('2142-04-22 08:05:00'), Timestamp('2142-04-22 09:20:00'), 'Chloride'], [50912, Timestamp('2142-04-22 08:05:00'), Timestamp('2142-04-22 09:20:00'), 'Creatinine'], [50931, Timestamp('2142-04-22 08:05:00'), Timestamp('2142-04-22 09:20:00'), 'Glucose'], [50960, Timestamp('2142-04-22 08:05:00'), Timestamp('2142-04-22 09:20:00'), 'Magnesium'], [50970, Timestamp('2142-04-22 08:05:00'), Timestamp('2142-04-22 09:20:00'), 'Phosphate'], [50971, Timestamp('2142-04-22 08:05:00'), Timestamp('2142-04-22 09:20:00'), 'Potassium'], [50983, Timestamp('2142-04-22 08:05:00'), Timestamp('2142-04-22 09:20:00'), 'Sodium'], [51006, Timestamp('2142-04-22 08:05:00'), Timestamp('2142-04-22 09:20:00'), 'Urea Nitrogen'], [50852, Timestamp('2142-04-22 08:05:00'), Timestamp('2142-04-22 11:12:00'), '% Hemoglobin A1c'], [51613, Timestamp('2142-04-22 08:05:00'), Timestamp('2142-04-22 11:12:00'), 'eAG'], [51221, Timestamp('2142-04-22 08:05:00'), Timestamp('2142-04-22 08:59:00'), 'Hematocrit'], [51222, Timestamp('2142-04-22 08:05:00'), Timestamp('2142-04-22 08:59:00'), 'Hemoglobin'], [51248, Timestamp('2142-04-22 08:05:00'), Timestamp('2142-04-22 08:59:00'), 'MCH'], [51249, Timestamp('2142-04-22 08:05:00'), Timestamp('2142-04-22 08:59:00'), 'MCHC'], [51250, Timestamp('2142-04-22 08:05:00'), Timestamp('2142-04-22 08:59:00'), 'MCV'], [51265, Timestamp('2142-04-22 08:05:00'), Timestamp('2142-04-22 08:59:00'), 'Platelet Count'], [51277, Timestamp('2142-04-22 08:05:00'), Timestamp('2142-04-22 08:59:00'), 'RDW'], [51279, Timestamp('2142-04-22 08:05:00'), Timestamp('2142-04-22 08:59:00'), 'Red Blood Cells'], [51301, Timestamp('2142-04-22 08:05:00'), Timestamp('2142-04-22 08:59:00'), 'White Blood Cells'], [50868, Timestamp('2142-04-22 14:56:00'), Timestamp('2142-04-22 15:44:00'), 'Anion Gap'], [50882, Timestamp('2142-04-22 14:56:00'), Timestamp('2142-04-22 15:44:00'), 'Bicarbonate'], [50893, Timestamp('2142-04-22 14:56:00'), Timestamp('2142-04-22 15:44:00'), 'Calcium, Total'], [50902, Timestamp('2142-04-22 14:56:00'), Timestamp('2142-04-22 15:44:00'), 'Chloride'], [50911, Timestamp('2142-04-22 14:56:00'), Timestamp('2142-04-22 15:44:00'), 'Creatine Kinase, MB Isoenzyme'], [50912, Timestamp('2142-04-22 14:56:00'), Timestamp('2142-04-22 15:44:00'), 'Creatinine'], [50931, Timestamp('2142-04-22 14:56:00'), Timestamp('2142-04-22 15:44:00'), 'Glucose'], [50960, Timestamp('2142-04-22 14:56:00'), Timestamp('2142-04-22 15:44:00'), 'Magnesium'], [50970, Timestamp('2142-04-22 14:56:00'), Timestamp('2142-04-22 15:44:00'), 'Phosphate'], [50971, Timestamp('2142-04-22 14:56:00'), Timestamp('2142-04-22 15:44:00'), 'Potassium'], [50983, Timestamp('2142-04-22 14:56:00'), Timestamp('2142-04-22 15:44:00'), 'Sodium'], [51003, Timestamp('2142-04-22 14:56:00'), Timestamp('2142-04-22 15:44:00'), 'Troponin T'], [51006, Timestamp('2142-04-22 14:56:00'), Timestamp('2142-04-22 15:44:00'), 'Urea Nitrogen'], [51221, Timestamp('2142-04-22 14:56:00'), Timestamp('2142-04-22 15:12:00'), 'Hematocrit'], [51222, Timestamp('2142-04-22 14:56:00'), Timestamp('2142-04-22 15:12:00'), 'Hemoglobin'], [51248, Timestamp('2142-04-22 14:56:00'), Timestamp('2142-04-22 15:12:00'), 'MCH'], [51249, Timestamp('2142-04-22 14:56:00'), Timestamp('2142-04-22 15:12:00'), 'MCHC'], [51250, Timestamp('2142-04-22 14:56:00'), Timestamp('2142-04-22 15:12:00'), 'MCV'], [51265, Timestamp('2142-04-22 14:56:00'), Timestamp('2142-04-22 15:12:00'), 'Platelet Count'], [51277, Timestamp('2142-04-22 14:56:00'), Timestamp('2142-04-22 15:12:00'), 'RDW'], [51279, Timestamp('2142-04-22 14:56:00'), Timestamp('2142-04-22 15:12:00'), 'Red Blood Cells'], [51301, Timestamp('2142-04-22 14:56:00'), Timestamp('2142-04-22 15:12:00'), 'White Blood Cells']]

Question: A 69 M is admitted. He/she says he/she has right foot wet gangrene . History of illness: ___ M transfer from OSH for gangrene R foot. Patient is a poor historian but reports about 6 weeks ago he was camping in ___ and developed an infection of his R ___ toe thought to be due to an in-grown nail. He denies any other trauma to his foot at this time. He presented to a hospital in ___ for evaluation and underwent a R ___ toe amputation. He was discharged to rehab where he developed a wound infection and breakdown at his amputation site. He also noted his right fifth toe became black and infected. He reports he was not treated well at the outside hospital where "they did not give me antibiotics and just would wrap my foot". His daughter, who lives in ___ recommended he come here to be evaluated. He presented to ___ where he an X-Ray of the foot demonstrated no clear evidence of osteomyelitis. He was seen by a general surgeon who recommended he be transferred to ___ for further management and evaluation by a vascular surgeon. Past Medical History: PMH: DM-2 (borderline per patient), BPH PSH: R ___ toe amputation ___ (in ___ Social History: ___ Family History: Non-contributory Allergies: No Known Allergies / Adverse Drug Reactions What is the best procedure plan for this patient?

TARGETS Target Prescriptions: D5 1/2NS Sodium Chloride 0.9% Flush Glucagon HYDROmorphone (Dilaudid) Heparin Sodium Chloride 0.9% Flush HYDROmorphone (Dilaudid) 0.9% Sodium Chloride (Mini Bag Plus) Ampicillin-Sulbactam Iso-Osmotic Dextrose Vancomycin Potassium Chl 20 mEq / 1000 mL D5 1/2 NS Insulin Dextrose 50% Pneumococcal Vac Polyvalent HydrALAzine Target Lab Orders: % Hemoglobin A1c eAG Anion Gap Bicarbonate Calcium, Total Chloride Creatinine Glucose Magnesium Phosphate Potassium Sodium Urea Nitrogen % Hemoglobin A1c eAG Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells Anion Gap Bicarbonate Calcium, Total Chloride Creatine Kinase, MB Isoenzyme Creatinine Glucose Magnesium Phosphate Potassium Sodium Troponin T Urea Nitrogen Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : Patient was admitted with gangrene of the right foot. He had what appeared to be an active ongoing infection in his right foot and in the emergency department had partial debridement of his right ___ toe. He was admitted and continued on Vanc and Unasyn, which were started at ___. He was taken to the operating room on ___ and found to have extensive infection through the forefoot on the right and underwent right TMA. The wound was left open for drainage purposes and packed with WTD dressings. He was brought back to the floor and resumed on all of his preop medications, including Vanc and Unasyn. He was then brought to the angio suite for evaluation of the vessels in his RLE and underwent ultrasound-guided puncture of left common femoral artery, abdominal aortogram, second-order catheterization of right external iliac artery, serial arteriogram of right lower extremity, additional catheterization of right superficial femoral artery, balloon angioplasty and stenting of right superficial femoral artery, balloon angioplasty and stenting of aorta, Balloon angioplasty and stenting of left common iliac extending into the external iliac artery. Psychiatry was asked to come and see the patient as he was noted to be hostile at points and grabbed a SCH heparin needle out of a nurses hand on ___, scratching the nurse with the needle. He was not started on any psychiatric medicines during this hospitalization, nor diagnosed with any psychiatric disorders. He subsequently was taken to the OR for a revision TMA on ___. The operation proceeded uneventfully and he was brought to the floor in stable condition, resumed on his diet and his home medications. The lateral aspect of his wound was open and a wound VAC was placed. He had some incontinence of stool and loose stool and was started on IV flagyl and a stool culture was sent. He was seen by physical therapy. Other Results: ___ 08:40AM BLOOD WBC-10.5 RBC-3.45* Hgb-9.6* Hct-30.2* MCV-88 MCH-27.7 MCHC-31.7 RDW-13.7 Plt ___ ___ 02:56PM BLOOD WBC-9.1 RBC-3.93* Hgb-11.1* Hct-36.0* MCV-92 MCH-28.2 MCHC-30.8* RDW-14.0 Plt ___ ___ 08:05AM BLOOD WBC-9.2 RBC-3.55* Hgb-10.0* Hct-31.7* MCV-89 MCH-28.3 MCHC-31.7 RDW-13.7 Plt ___ ___ 06:30PM BLOOD WBC-12.3* RBC-4.00* Hgb-11.2* Hct-35.8* MCV-89 MCH-28.0 MCHC-31.3 RDW-13.9 Plt ___ ___ 08:40AM BLOOD ___ PTT-30.2 ___ ___ 06:30PM BLOOD ___ PTT-31.8 ___ ___ 08:40AM BLOOD Glucose-188* UreaN-9 Creat-0.8 Na-136 K-4.0 Cl-99 HCO3-27 AnGap-14 ___ 02:56PM BLOOD Glucose-150* UreaN-9 Creat-0.9 Na-137 K-3.8 Cl-101 HCO3-26 AnGap-14 ___ 08:05AM BLOOD Glucose-192* UreaN-12 Creat-0.9 Na-136 K-4.0 Cl-99 HCO3-29 AnGap-12 ___ 06:30PM BLOOD Glucose-200* UreaN-14 Creat-1.0 Na-138 K-4.3 Cl-96 HCO3-28 AnGap-18 ___ 06:30PM BLOOD ALT-28 AST-22 AlkPhos-152* TotBili-0.3 DirBili-0.1 IndBili-0.2 ___ 08:40AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 02:56PM BLOOD CK-MB-1 cTropnT-0.01 ___ 08:05AM BLOOD %HbA1c-8.0* eAG-183* ___ 06:55PM BLOOD Lactate-1.7 CXR ___: No acute cardiopulmonary process.

2158-03-10 21:19:00

ENGLISH

WIDOWED

BLACK/AFRICAN

M

[[20112835, Timestamp('2158-03-10 21:19:51'), '', 'MED']]

[[{'Medications on Admission': ':\nThe Preadmission Medication list is accurate and complete.\n1. Cyanocobalamin 100 mcg PO DAILY \n2. Milk of Magnesia 30 mL PO Q12H:PRN constipation \n3. Digoxin 0.125 mg PO EVERY OTHER DAY \n4. Ferrous Sulfate 325 mg PO DAILY \n5. Aspirin 81 mg PO DAILY \n6. Methimazole 5 mg PO DAILY \n7. Acetaminophen 650 mg PO Q6H:PRN pain \n8. Bisacodyl 10 mg PR HS:PRN constipation \n9. Fleet Enema ___AILY:PRN constipation \n10. Magnesium Citrate 300 mL PO DAILY:PRN constipation \n11. Omeprazole 20 mg PO DAILY \n12. LeVETiracetam 1000 mg PO BID \n\nFacility:\n___', 'Brief Hospital Course': ":\n___ w/CHF (EF 15%), MDS, dementia, Afib, admitted to ___ on \n___ with presumed sepsis. Transfered to ___ for advanced \nendoscopy.\n\nSepsis: Patient's symptoms quickly resolved and it wasn't clear \nthat he was truly ever infected. He had no leukocytosis or \nbandemia on admission, never febile, tachycardic or tachypneic. \nHe may have had an aspiration event. He did transiently become \nhypoxic on ___, but quickly improved with aggressive diuresis.\n\nTransaminitis, hyperbilirubinemia: The advanced endoscopy \nservice was consulted and did not note any evidence of \nobstruction. Given the patient's severe CHF, they felt EUS was \nnot in his best interest. The patient's LFTs improved with \ndiuresis. Hepatology was consulted and felt that a congestive \nhepatopathy picture was the most likely reason for the patient's \nLFT abnormalities.\n\nAcute on Chronic Systolic Heart Failure: The patient has a known \nEF of 15%. He given IV fluids when he presented to ___. He \ndid develop hypoxia later in the hospitalization. He was \ndiuresed with IV lasix and his breathing improved. His blood \npressure goal is 90's systolic. His case was discussed with his \noutpatient cardiologist Dr. ___. \n\nDementia: Per ___, his health care proxy, his baseline \nmental status is alert and oriented to his name, able to feed \nhimself. He was at his baseline on discharge.\n\n___ on CKD: baseline ~1.3. Creatinine improved to 0.9 with \naggressive diuresis.\n\nAfib: Coumadin was restarted after discussion with patient's HCP \nand PCP and cardiologist. Though the patient has a history of \nCVA, he was not bridged as his PTT was almost therpeutic on \nsubcutaneous heparin. \n\nMDS: His hematocrit remained stable during the hospitalization. \nHe does receive Epo and transfusions as an outpatient.\n\nCode Status: DNR DNI, HCP is ___\n\n", 'Pertinent Results:': '\n___\n___\nCr 1.6\nWBC 12.8\nHgb 8.8\nLactate 3.6\n\n___ \nLactate 2.1\nTbili 4.2\nDBili 2.0\nAST 263\nALT 368\nAlk 135\n\n___\nALT 319, AST 164, Alk Phos 183, Bili 4, Direct 1.9\nCr 1.4\nINR 1.6\nEBC 13.4\nHgb 8.6\nPlt 100\nAmmonia 25\n\n___ blood cultures: negative\n\n___ 07:11AM BLOOD WBC-9.8 RBC-2.61* Hgb-9.2* Hct-29.4* \nMCV-113* MCH-35.4* MCHC-31.5 RDW-26.7* Plt Ct-98*\n___ 07:05AM BLOOD WBC-11.2* RBC-2.50* Hgb-8.9* Hct-28.5* \nMCV-114* MCH-35.5* MCHC-31.2 RDW-27.0* Plt Ct-90*\n___ 07:20AM BLOOD WBC-7.9 RBC-2.43* Hgb-8.6* Hct-28.6* \nMCV-118* MCH-35.6* MCHC-30.3* RDW-26.5* Plt ___\n___ 08:30AM BLOOD WBC-PND RBC-2.45* Hgb-8.7* Hct-28.7* \nMCV-117* MCH-35.6* MCHC-30.4* RDW-26.7* Plt ___\n___ 07:11AM BLOOD ___ PTT-36.7* ___\n___ 07:20AM BLOOD ___ PTT-46.8* ___\n___ 07:11AM BLOOD Glucose-139* UreaN-45* Creat-1.5* Na-144 \nK-3.7 Cl-108 HCO3-22 AnGap-18\n___ 07:35AM BLOOD Glucose-143* UreaN-49* Creat-1.7* Na-141 \nK-3.5 Cl-104 HCO3-24 AnGap-17\n___ 07:00AM BLOOD Glucose-112* UreaN-44* Creat-1.4* Na-140 \nK-3.1* Cl-103 HCO3-27 AnGap-13\n___ 07:20AM BLOOD Glucose-125* UreaN-39* Creat-1.2 Na-143 \nK-3.3 Cl-103 HCO3-30 AnGap-13\n___ 08:30AM BLOOD Glucose-109* UreaN-28* Creat-0.9 Na-140 \nK-3.5 Cl-101 HCO3-32 AnGap-11\n___ 07:11AM BLOOD ALT-278* AST-108* AlkPhos-185* \nTotBili-3.6*\n___ 07:05AM BLOOD ALT-217* AST-109* AlkPhos-214* \nTotBili-3.5* DirBili-2.1* IndBili-1.4\n___ 07:00AM BLOOD ALT-131* AST-72* AlkPhos-158* \nTotBili-2.6*\n___ 08:30AM BLOOD ALT-96* AST-63* AlkPhos-127 TotBili-1.7*\n___ 07:05AM BLOOD calTIBC-137* Ferritn-5670* TRF-105*\n___ 08:30AM BLOOD Calcium-8.3* Phos-2.6* Mg-1.8\n___ 02:30PM BLOOD ___ * Titer-1:40\n___ 02:30PM BLOOD AMA-NEGATIVE Smooth-NEGATIVE\n___ 07:05AM BLOOD IgG-___ IgM-41\n\nREASON FOR EXAMINATION: Systolic congestive heart failure. \n\nPortable AP radiograph of the chest was reviewed with no prior \nstudies \navailable for comparison. \n\nSubstantial cardiomegaly, severe is demonstrated, diffuse. \nThere is right \nperihilar and lower lobe consolidation as well as left basal \nconsolidations \nconcerning for infectious process, although asymmetric pulmonary \nedema cannot \nbe excluded. There is no definitive evidence of left pleural \neffusion, but \nright pleural effusion, most likely moderate is present. Upper \nzone \nredistribution of the vasculature is noted. No pneumothorax. \n\n', 'Physical Exam:|Physical': '\nVitals: T:98 BP:103/65 P:89 R:18 O2: 95%2L\nGEN: Fatigued but comfortable, no acute signs of distress. \nCV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops. \nRESP: clear anteriorly, comfortable \nABD: Soft, non-tender, non-distended, + bowel sounds. \nEXTR: +1 pitting edema to knees\nDERM: No active rash. \nNeuro: somnolent, arouses to name and light touch, oriented to \nperson only\n\nDischarge exam:\nVitals: afeb, 98.6, 93/57, 88, 18, 99%RA, I/O 1120/1500+ incont\nGen: Appears comfortable, sitting in chair, alert\nCV: irreg irreg\nPulm: Lungs with occ wheeze and rhonci at bases, much clearer\nAbd: soft, NT, ND, +BS\nExtrem: warm, + edema bilat ___\nGU: no foley\nSkin: no rash\nNeuro: Oriented to name, says he ate breakfast. He says he is \ncold. No facial droop. \n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\n___ w/CHF (EF 15%), MDS, dementia, Afib, recent pneumonia \ntreated with Levaquin, now admitted since ___ to ___ with \nsepsis, altered mental status, renal failure, lactic acidosis, \nelevated LFTs.\nOn admit pt hypoxic, started on HCAP coverage. Pulm consulted. \nCT w/ pleural effusions but no evidence of PNA, rec to stop Abx. \nHowever vanc/zosyn continued for sepsis with unknown source. GI \nconsulted for abd pain and inc. LFTs, rec CT scan and hep \nserologies. Abd US shows gallstones, no biliary dilation. HIDA \nwnl. CT/MRI also show no biliary dilation. All improved except \nLFTs. Pt no longer c/o abd pain. Pt transferred for EUS to r/o \nCBD stone, ERCP as needed.\n\nOn arrival to the floor pt is somnolent, appears comfortable. \nUnable to participate further in interview\n\nReview of sytems: \n(+) Per HPI \n(-) Denies fever, chills, night sweats, recent weight loss or \ngain. Denies headache, sinus tenderness, rhinorrhea or \ncongestion. Denies cough, shortness of breath. Denies chest pain \nor tightness, palpitations. Denies nausea, vomiting, diarrhea, \nconstipation or abdominal pain. No recent change in bowel or \nbladder habits. No dysuria. Denies arthralgias or myalgias. Ten \npoint review of systems is otherwise negative. \n\nPast Medical History:\n___ (EF 15%)\nMDS transfusion dependent\ndementia\nCVA in ___\nAfib, no longer on coumadin ___ prior GIB and anemia\nVentral hernia s/p repair\n\nSocial History:\n___\nFamily History:\nno early CAD\n\n', 'Chief Complaint:|Complaint:': '\nsepsis\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \ncodeine / Sulfa (Sulfonamide Antibiotics)\n\n'}, '11100682-DS-6', 6, 'medicine']]

[['REASON FOR EXAMINATION: Systolic congestive heart failure.\n\nPortable AP radiograph of the chest was reviewed with no prior studies\navailable for comparison.\n\nSubstantial cardiomegaly, severe is demonstrated, diffuse. There is right\nperihilar and lower lobe consolidation as well as left basal consolidations\nconcerning for infectious process, although asymmetric pulmonary edema cannot\nbe excluded. There is no definitive evidence of left pleural effusion, but\nright pleural effusion, most likely moderate is present. Upper zone\nredistribution of the vasculature is noted. No pneumothorax.\n', '11100682-RR-19', 19, '']]

[[20112835, Timestamp('2158-03-11 08:00:00'), Timestamp('2158-03-18 17:00:00'), 'MAIN', 'Heparin', '006549', '63323026201', '5000 Units / mL- 1mL Vial'], [20112835, Timestamp('2158-03-10 23:00:00'), Timestamp('2158-03-18 17:00:00'), 'MAIN', 'Magnesium Citrate', '003025', '00363069338', '300mL Bottle'], [20112835, Timestamp('2158-03-11 00:00:00'), Timestamp('2158-03-18 17:00:00'), 'MAIN', 'Digoxin', '000018', '24987024256', '0.125mg Tablet'], [20112835, Timestamp('2158-03-10 23:00:00'), Timestamp('2158-03-18 17:00:00'), 'MAIN', 'Fleet Enema', '002996', '11917007645', '1 Enema'], [20112835, Timestamp('2158-03-11 08:00:00'), Timestamp('2158-03-18 17:00:00'), 'MAIN', 'Aspirin', '004380', '00904404073', '81mg Tab'], [20112835, Timestamp('2158-03-11 08:00:00'), Timestamp('2158-03-18 17:00:00'), 'MAIN', 'LeVETiracetam', '044633', '50474059540', '500 mg Tablet'], [20112835, Timestamp('2158-03-10 23:00:00'), Timestamp('2158-03-18 17:00:00'), 'MAIN', 'Bisacodyl', '002944', '00574705050', '10mg Suppository'], [20112835, Timestamp('2158-03-10 23:00:00'), Timestamp('2158-03-18 17:00:00'), 'MAIN', 'Acetaminophen', '004489', '51079000220', '325mg Tablet'], [20112835, Timestamp('2158-03-11 08:00:00'), Timestamp('2158-03-18 17:00:00'), 'MAIN', 'Methimazole', '006675', '68084027501', '5 mg Tab'], [20112835, Timestamp('2158-03-10 23:00:00'), Timestamp('2158-03-18 17:00:00'), 'MAIN', 'Milk of Magnesia', '003026', '00121043130', '30mL UD Cup'], [20112835, Timestamp('2158-03-11 16:00:00'), Timestamp('2158-03-18 17:00:00'), 'MAIN', 'Docusate Sodium', '003009', '00904224461', '100mg Capsule'], [20112835, Timestamp('2158-03-10 23:00:00'), Timestamp('2158-03-18 17:00:00'), 'MAIN', 'Sodium Chloride 0.9% Flush', '', '0', '10 mL Syringe'], [20112835, Timestamp('2158-03-11 00:00:00'), Timestamp('2158-03-12 12:00:00'), 'BASE', '0.9% Sodium Chloride (Mini Bag Plus)', '001210', '00338055318', '100mL Bag'], [20112835, Timestamp('2158-03-11 00:00:00'), Timestamp('2158-03-12 12:00:00'), 'MAIN', 'Ampicillin-Sulbactam', '008921', '63323036920', '3g Vial'], [20112835, Timestamp('2158-03-11 08:00:00'), Timestamp('2158-03-18 17:00:00'), 'MAIN', 'Omeprazole', '033530', '00904568461', '20mg DR Capsule'], [20112835, Timestamp('2158-03-10 23:00:00'), Timestamp('2158-03-18 17:00:00'), 'MAIN', 'PNEUMOcoccal 23-valent polysaccharide vaccine', '048548', '00006473900', '25mcg/0.5mL Vial'], [20112835, Timestamp('2158-03-11 16:00:00'), Timestamp('2158-03-18 17:00:00'), 'MAIN', 'Senna', '019964', '00904516561', '8.6 mg Tablet']]

[]

['medicine']

[[50861, Timestamp('2158-03-11 07:11:00'), Timestamp('2158-03-11 08:57:00'), 'Alanine Aminotransferase (ALT)'], [50862, Timestamp('2158-03-11 07:11:00'), Timestamp('2158-03-11 08:57:00'), 'Albumin'], [50863, Timestamp('2158-03-11 07:11:00'), Timestamp('2158-03-11 08:57:00'), 'Alkaline Phosphatase'], [50868, Timestamp('2158-03-11 07:11:00'), Timestamp('2158-03-11 08:57:00'), 'Anion Gap'], [50878, Timestamp('2158-03-11 07:11:00'), Timestamp('2158-03-11 08:57:00'), 'Asparate Aminotransferase (AST)'], [50882, Timestamp('2158-03-11 07:11:00'), Timestamp('2158-03-11 08:57:00'), 'Bicarbonate'], [50885, Timestamp('2158-03-11 07:11:00'), Timestamp('2158-03-11 08:57:00'), 'Bilirubin, Total'], [50893, Timestamp('2158-03-11 07:11:00'), Timestamp('2158-03-11 08:57:00'), 'Calcium, Total'], [50902, Timestamp('2158-03-11 07:11:00'), Timestamp('2158-03-11 08:57:00'), 'Chloride'], [50912, Timestamp('2158-03-11 07:11:00'), Timestamp('2158-03-11 08:57:00'), 'Creatinine'], [50920, Timestamp('2158-03-11 07:11:00'), Timestamp('2158-03-11 08:57:00'), 'Estimated GFR (MDRD equation)'], [50931, Timestamp('2158-03-11 07:11:00'), Timestamp('2158-03-11 08:57:00'), 'Glucose'], [50960, Timestamp('2158-03-11 07:11:00'), Timestamp('2158-03-11 08:57:00'), 'Magnesium'], [50963, Timestamp('2158-03-11 07:11:00'), Timestamp('2158-03-11 17:32:00'), 'NTproBNP'], [50970, Timestamp('2158-03-11 07:11:00'), Timestamp('2158-03-11 08:57:00'), 'Phosphate'], [50971, Timestamp('2158-03-11 07:11:00'), Timestamp('2158-03-11 08:57:00'), 'Potassium'], [50983, Timestamp('2158-03-11 07:11:00'), Timestamp('2158-03-11 08:57:00'), 'Sodium'], [51006, Timestamp('2158-03-11 07:11:00'), Timestamp('2158-03-11 08:57:00'), 'Urea Nitrogen'], [51237, Timestamp('2158-03-11 07:11:00'), Timestamp('2158-03-11 08:44:00'), 'INR(PT)'], [51274, Timestamp('2158-03-11 07:11:00'), Timestamp('2158-03-11 08:44:00'), 'PT'], [51275, Timestamp('2158-03-11 07:11:00'), Timestamp('2158-03-11 08:44:00'), 'PTT'], [51137, Timestamp('2158-03-11 07:11:00'), Timestamp('2158-03-11 10:28:00'), 'Anisocytosis'], [51143, Timestamp('2158-03-11 07:11:00'), Timestamp('2158-03-11 10:21:00'), 'Atypical Lymphocytes'], [51144, Timestamp('2158-03-11 07:11:00'), Timestamp('2158-03-11 10:21:00'), 'Bands'], [51145, Timestamp('2158-03-11 07:11:00'), Timestamp('2158-03-11 10:28:00'), 'Basophilic Stippling'], [51146, Timestamp('2158-03-11 07:11:00'), Timestamp('2158-03-11 10:21:00'), 'Basophils'], [51200, Timestamp('2158-03-11 07:11:00'), Timestamp('2158-03-11 10:21:00'), 'Eosinophils'], [51221, Timestamp('2158-03-11 07:11:00'), Timestamp('2158-03-11 08:35:00'), 'Hematocrit'], [51222, Timestamp('2158-03-11 07:11:00'), Timestamp('2158-03-11 08:35:00'), 'Hemoglobin'], [51233, Timestamp('2158-03-11 07:11:00'), Timestamp('2158-03-11 10:28:00'), 'Hypochromia'], [51244, Timestamp('2158-03-11 07:11:00'), Timestamp('2158-03-11 10:21:00'), 'Lymphocytes'], [51246, Timestamp('2158-03-11 07:11:00'), Timestamp('2158-03-11 10:28:00'), 'Macrocytes'], [51248, Timestamp('2158-03-11 07:11:00'), Timestamp('2158-03-11 08:35:00'), 'MCH'], [51249, Timestamp('2158-03-11 07:11:00'), Timestamp('2158-03-11 08:35:00'), 'MCHC'], [51250, Timestamp('2158-03-11 07:11:00'), Timestamp('2158-03-11 08:35:00'), 'MCV'], [51251, Timestamp('2158-03-11 07:11:00'), Timestamp('2158-03-11 10:21:00'), 'Metamyelocytes'], [51252, Timestamp('2158-03-11 07:11:00'), Timestamp('2158-03-11 10:28:00'), 'Microcytes'], [51254, Timestamp('2158-03-11 07:11:00'), Timestamp('2158-03-11 10:21:00'), 'Monocytes'], [51255, Timestamp('2158-03-11 07:11:00'), Timestamp('2158-03-11 10:21:00'), 'Myelocytes'], [51256, Timestamp('2158-03-11 07:11:00'), Timestamp('2158-03-11 10:21:00'), 'Neutrophils'], [51257, Timestamp('2158-03-11 07:11:00'), Timestamp('2158-03-11 10:21:00'), 'Nucleated Red Cells'], [51261, Timestamp('2158-03-11 07:11:00'), Timestamp('2158-03-11 10:28:00'), 'Pappenheimer Bodies'], [51265, Timestamp('2158-03-11 07:11:00'), Timestamp('2158-03-11 10:30:00'), 'Platelet Count'], [51266, Timestamp('2158-03-11 07:11:00'), Timestamp('2158-03-11 10:25:00'), 'Platelet Smear'], [51267, Timestamp('2158-03-11 07:11:00'), Timestamp('2158-03-11 10:28:00'), 'Poikilocytosis'], [51268, Timestamp('2158-03-11 07:11:00'), Timestamp('2158-03-11 10:28:00'), 'Polychromasia'], [51269, Timestamp('2158-03-11 07:11:00'), Timestamp('2158-03-11 10:21:00'), 'Promyelocytes'], [51277, Timestamp('2158-03-11 07:11:00'), Timestamp('2158-03-11 08:35:00'), 'RDW'], [51279, Timestamp('2158-03-11 07:11:00'), Timestamp('2158-03-11 08:35:00'), 'Red Blood Cells'], [51287, Timestamp('2158-03-11 07:11:00'), Timestamp('2158-03-11 10:28:00'), 'Schistocytes'], [51294, Timestamp('2158-03-11 07:11:00'), Timestamp('2158-03-11 10:28:00'), 'Target Cells'], [51296, Timestamp('2158-03-11 07:11:00'), Timestamp('2158-03-11 10:28:00'), 'Teardrop Cells'], [51301, Timestamp('2158-03-11 07:11:00'), Timestamp('2158-03-11 10:30:00'), 'White Blood Cells']]

Question: A 91 M is admitted. He/she says he/she has sepsis . History of illness: ___ w/CHF (EF 15%), MDS, dementia, Afib, recent pneumonia treated with Levaquin, now admitted since ___ to ___ with sepsis, altered mental status, renal failure, lactic acidosis, elevated LFTs. On admit pt hypoxic, started on HCAP coverage. Pulm consulted. CT w/ pleural effusions but no evidence of PNA, rec to stop Abx. However vanc/zosyn continued for sepsis with unknown source. GI consulted for abd pain and inc. LFTs, rec CT scan and hep serologies. Abd US shows gallstones, no biliary dilation. HIDA wnl. CT/MRI also show no biliary dilation. All improved except LFTs. Pt no longer c/o abd pain. Pt transferred for EUS to r/o CBD stone, ERCP as needed. On arrival to the floor pt is somnolent, appears comfortable. Unable to participate further in interview Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Ten point review of systems is otherwise negative. Past Medical History: ___ (EF 15%) MDS transfusion dependent dementia CVA in ___ Afib, no longer on coumadin ___ prior GIB and anemia Ventral hernia s/p repair Social History: ___ Family History: no early CAD Allergies: codeine / Sulfa (Sulfonamide Antibiotics) What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Heparin Magnesium Citrate Digoxin Fleet Enema Aspirin LeVETiracetam Bisacodyl Acetaminophen Methimazole Milk of Magnesia Docusate Sodium Sodium Chloride 0.9% Flush 0.9% Sodium Chloride (Mini Bag Plus) Ampicillin-Sulbactam Omeprazole PNEUMOcoccal 23-valent polysaccharide vaccine Senna Target Lab Orders: Alanine Aminotransferase (ALT) Albumin Alkaline Phosphatase Anion Gap Asparate Aminotransferase (AST) Bicarbonate Bilirubin, Total Calcium, Total Chloride Creatinine Estimated GFR (MDRD equation) Glucose Magnesium NTproBNP Phosphate Potassium Sodium Urea Nitrogen INR(PT) PT PTT Anisocytosis Atypical Lymphocytes Bands Basophilic Stippling Basophils Eosinophils Hematocrit Hemoglobin Hypochromia Lymphocytes Macrocytes MCH MCHC MCV Metamyelocytes Microcytes Monocytes Myelocytes Neutrophils Nucleated Red Cells Pappenheimer Bodies Platelet Count Platelet Smear Poikilocytosis Polychromasia Promyelocytes RDW Red Blood Cells Schistocytes Target Cells Teardrop Cells White Blood Cells Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : ___ w/CHF (EF 15%), MDS, dementia, Afib, admitted to ___ on ___ with presumed sepsis. Transfered to ___ for advanced endoscopy. Sepsis: Patient's symptoms quickly resolved and it wasn't clear that he was truly ever infected. He had no leukocytosis or bandemia on admission, never febile, tachycardic or tachypneic. He may have had an aspiration event. He did transiently become hypoxic on ___, but quickly improved with aggressive diuresis. Transaminitis, hyperbilirubinemia: The advanced endoscopy service was consulted and did not note any evidence of obstruction. Given the patient's severe CHF, they felt EUS was not in his best interest. The patient's LFTs improved with diuresis. Hepatology was consulted and felt that a congestive hepatopathy picture was the most likely reason for the patient's LFT abnormalities. Acute on Chronic Systolic Heart Failure: The patient has a known EF of 15%. He given IV fluids when he presented to ___. He did develop hypoxia later in the hospitalization. He was diuresed with IV lasix and his breathing improved. His blood pressure goal is 90's systolic. His case was discussed with his outpatient cardiologist Dr. ___. Dementia: Per ___, his health care proxy, his baseline mental status is alert and oriented to his name, able to feed himself. He was at his baseline on discharge. ___ on CKD: baseline ~1.3. Creatinine improved to 0.9 with aggressive diuresis. Afib: Coumadin was restarted after discussion with patient's HCP and PCP and cardiologist. Though the patient has a history of CVA, he was not bridged as his PTT was almost therpeutic on subcutaneous heparin. MDS: His hematocrit remained stable during the hospitalization. He does receive Epo and transfusions as an outpatient. Code Status: DNR DNI, HCP is ___ Other Results: ___ ___ Cr 1.6 WBC 12.8 Hgb 8.8 Lactate 3.6 ___ Lactate 2.1 Tbili 4.2 DBili 2.0 AST 263 ALT 368 Alk 135 ___ ALT 319, AST 164, Alk Phos 183, Bili 4, Direct 1.9 Cr 1.4 INR 1.6 EBC 13.4 Hgb 8.6 Plt 100 Ammonia 25 ___ blood cultures: negative ___ 07:11AM BLOOD WBC-9.8 RBC-2.61* Hgb-9.2* Hct-29.4* MCV-113* MCH-35.4* MCHC-31.5 RDW-26.7* Plt Ct-98* ___ 07:05AM BLOOD WBC-11.2* RBC-2.50* Hgb-8.9* Hct-28.5* MCV-114* MCH-35.5* MCHC-31.2 RDW-27.0* Plt Ct-90* ___ 07:20AM BLOOD WBC-7.9 RBC-2.43* Hgb-8.6* Hct-28.6* MCV-118* MCH-35.6* MCHC-30.3* RDW-26.5* Plt ___ ___ 08:30AM BLOOD WBC-PND RBC-2.45* Hgb-8.7* Hct-28.7* MCV-117* MCH-35.6* MCHC-30.4* RDW-26.7* Plt ___ ___ 07:11AM BLOOD ___ PTT-36.7* ___ ___ 07:20AM BLOOD ___ PTT-46.8* ___ ___ 07:11AM BLOOD Glucose-139* UreaN-45* Creat-1.5* Na-144 K-3.7 Cl-108 HCO3-22 AnGap-18 ___ 07:35AM BLOOD Glucose-143* UreaN-49* Creat-1.7* Na-141 K-3.5 Cl-104 HCO3-24 AnGap-17 ___ 07:00AM BLOOD Glucose-112* UreaN-44* Creat-1.4* Na-140 K-3.1* Cl-103 HCO3-27 AnGap-13 ___ 07:20AM BLOOD Glucose-125* UreaN-39* Creat-1.2 Na-143 K-3.3 Cl-103 HCO3-30 AnGap-13 ___ 08:30AM BLOOD Glucose-109* UreaN-28* Creat-0.9 Na-140 K-3.5 Cl-101 HCO3-32 AnGap-11 ___ 07:11AM BLOOD ALT-278* AST-108* AlkPhos-185* TotBili-3.6* ___ 07:05AM BLOOD ALT-217* AST-109* AlkPhos-214* TotBili-3.5* DirBili-2.1* IndBili-1.4 ___ 07:00AM BLOOD ALT-131* AST-72* AlkPhos-158* TotBili-2.6* ___ 08:30AM BLOOD ALT-96* AST-63* AlkPhos-127 TotBili-1.7* ___ 07:05AM BLOOD calTIBC-137* Ferritn-5670* TRF-105* ___ 08:30AM BLOOD Calcium-8.3* Phos-2.6* Mg-1.8 ___ 02:30PM BLOOD ___ * Titer-1:40 ___ 02:30PM BLOOD AMA-NEGATIVE Smooth-NEGATIVE ___ 07:05AM BLOOD IgG-___ IgM-41 REASON FOR EXAMINATION: Systolic congestive heart failure. Portable AP radiograph of the chest was reviewed with no prior studies available for comparison. Substantial cardiomegaly, severe is demonstrated, diffuse. There is right perihilar and lower lobe consolidation as well as left basal consolidations concerning for infectious process, although asymmetric pulmonary edema cannot be excluded. There is no definitive evidence of left pleural effusion, but right pleural effusion, most likely moderate is present. Upper zone redistribution of the vasculature is noted. No pneumothorax.

2119-02-11 00:35:00

ENGLISH

WIDOWED

WHITE

F

[[26762630, Timestamp('2119-02-11 00:37:33'), '', 'PSURG']]

[[{'Medications on Admission': ':\n\nCalcium Carbonate 500 mg PO TID \nCitalopram 20 mg PO DAILY \nCyanocobalamin 1000 mcg PO DAILY \nFish Oil (Omega 3) 1000 mg PO BID \nFolIC Acid 1 mg PO DAILY \nLevothyroxine Sodium 112 mcg PO DAILY \nEnalipril\nHCTZ\nNabumetone 500 mg PO DAILY \nOmeprazole 20 mg PO DAILY \nVitamin D 400 UNIT PO DAILY \n\nFacility:\n___\n\n___ Diagnosis:\nRight ___ digit flexor tenosynovitis', 'Brief Hospital Course': ':\nMs. ___ was admitted to the Orthopaedic Hand service on ___ \nafter being evaluated in the Emergency Room and directly \ntransferred to operating room for Incision and Debribement Right \n___ digit and hand. Please see operative note for details. She \ntolerated the procedure well without complications. She \nrecovered well and transferred to the floor in stable condition.\n\nShe remained stable overnight with improved hand symptoms. She \nwas continued on Vanc/Unasyn, transitioned to PO pain control, \nand tolerated diet on POD1. She was evaluated by ___ and OT who \nprovided splint and edema control. On POD2, patient noted to \nhave atrial flutter, given IV lopressor and Diltiazem to achieve \nrate control. She remained asymptomatic throughout, with \nmoderate hypotension. Medicine service consulted, beta blockers \nand HCTZ held, continued on PO diltiazem. POD3, Cardiology \nevaluation without further intervention. Patient remained \nhemodynamically stable, though with intermittent short bursts of \ntachycardia for which she was started on Coumadin.\n\nShe was transitioned to Ancef, and PO antibiotics prior to \ndischarge for MSSA culture.\n\n', 'Pertinent Results:': '\n___ 07:30PM SED RATE-78*\n___ 07:30PM WBC-15.5* RBC-4.18* HGB-11.7* HCT-36.7 MCV-88 \nMCH-28.0 MCHC-31.9 RDW-14.8\n___ 07:30PM CRP-21.4*\n___ 05:48AM GLUCOSE-106* UREA N-24* CREAT-0.6 SODIUM-135 \nPOTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-27 ANION GAP-12\n___ 05:48AM WBC-12.4* RBC-3.66* HGB-10.1* HCT-31.6* \nMCV-86 MCH-27.7 MCHC-32.1 RDW-14.7\n\n', 'Physical Exam:|Physical': '\nAfeb\nNAD\nRUE - healing wounds tip and base of ___ digit with mild serous \ndrainage, minimal erythema, moderate edema improving daily. \nFlexion and extension of digit intact but limited by edema. \nSensation intact throughout, WWP, brisk capillary refill. Non \ntender to palpation flexor sheath.\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\n ___ year old right hand dominant female presents to ED with 1\nday history of finger swelling, pain, and erythema. Patient has\na remote history of a radical mastectomy and suffers from \nchronic\nRUE lymphedema. Over the past week she has had increasing\nswelling of her right arm, hand, and digits. Over the past 24\nhours her right middle finger has becoming increasing painful \nand\nerythematous. Denies any trauma to RUE.\n\nPast Medical History:\nParoxysmal atrial flutter\nHTN\nHyperlipidemia\nHypothyroidism\nDepression/anxiety\nBreast ca s/p R total mastectomy\nChronic RUE lymphedema.\n\nSocial History:\n___\nFamily History:\nN/C\n\n', 'Chief Complaint:|Complaint:': '\nPain Right ___ finger\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nNo Known Allergies / Adverse Drug Reactions\n\n'}, '13085426-DS-13', 13, 'plastic']]

[]

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[]

['plastic']

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Question: A 88 F is admitted. He/she says he/she has Pain Right ___ finger . History of illness: ___ year old right hand dominant female presents to ED with 1 day history of finger swelling, pain, and erythema. Patient has a remote history of a radical mastectomy and suffers from chronic RUE lymphedema. Over the past week she has had increasing swelling of her right arm, hand, and digits. Over the past 24 hours her right middle finger has becoming increasing painful and erythematous. Denies any trauma to RUE. Past Medical History: Paroxysmal atrial flutter HTN Hyperlipidemia Hypothyroidism Depression/anxiety Breast ca s/p R total mastectomy Chronic RUE lymphedema. Social History: ___ Family History: N/C Allergies: No Known Allergies / Adverse Drug Reactions What is the best procedure plan for this patient?

TARGETS Target Prescriptions: FoLIC Acid Aspirin Pneumococcal Vac Polyvalent Lactated Ringers OxycoDONE (Immediate Release) Ondansetron 0.9% Sodium Chloride (Mini Bag Plus) Ampicillin-Sulbactam Aspirin Senna traZODONE Omeprazole Morphine Sulfate Cyanocobalamin Multivitamins Nabumetone Citalopram Lorazepam Calcium Carbonate Fish Oil (Omega 3) Vitamin D Hydrochlorothiazide 0.9% Sodium Chloride Iso-Osmotic Dextrose Vancomycin Acetaminophen Sodium Chloride 0.9% Flush Docusate Sodium Levothyroxine Sodium Target Lab Orders: Light Green Top Hold Blue Top Hold Anion Gap Bicarbonate C-Reactive Protein Chloride Creatinine Estimated GFR (MDRD equation) Glucose Potassium Sodium Urea Nitrogen Basophils Eosinophils Hematocrit Hemoglobin Lymphocytes MCH MCHC MCV Monocytes Neutrophils Platelet Count RDW Red Blood Cells Sedimentation Rate White Blood Cells Green Top Hold (plasma) INR(PT) PT PTT INR(PT) PT PTT Anion Gap Bicarbonate Calcium, Total Chloride Creatinine Glucose Magnesium Phosphate Potassium Sodium Urea Nitrogen Basophils Eosinophils Hematocrit Hemoglobin Lymphocytes MCH MCHC MCV Monocytes Neutrophils Platelet Count RDW Red Blood Cells White Blood Cells Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : Ms. ___ was admitted to the Orthopaedic Hand service on ___ after being evaluated in the Emergency Room and directly transferred to operating room for Incision and Debribement Right ___ digit and hand. Please see operative note for details. She tolerated the procedure well without complications. She recovered well and transferred to the floor in stable condition. She remained stable overnight with improved hand symptoms. She was continued on Vanc/Unasyn, transitioned to PO pain control, and tolerated diet on POD1. She was evaluated by ___ and OT who provided splint and edema control. On POD2, patient noted to have atrial flutter, given IV lopressor and Diltiazem to achieve rate control. She remained asymptomatic throughout, with moderate hypotension. Medicine service consulted, beta blockers and HCTZ held, continued on PO diltiazem. POD3, Cardiology evaluation without further intervention. Patient remained hemodynamically stable, though with intermittent short bursts of tachycardia for which she was started on Coumadin. She was transitioned to Ancef, and PO antibiotics prior to discharge for MSSA culture. Other Results: ___ 07:30PM SED RATE-78* ___ 07:30PM WBC-15.5* RBC-4.18* HGB-11.7* HCT-36.7 MCV-88 MCH-28.0 MCHC-31.9 RDW-14.8 ___ 07:30PM CRP-21.4* ___ 05:48AM GLUCOSE-106* UREA N-24* CREAT-0.6 SODIUM-135 POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-27 ANION GAP-12 ___ 05:48AM WBC-12.4* RBC-3.66* HGB-10.1* HCT-31.6* MCV-86 MCH-27.7 MCHC-32.1 RDW-14.7

2166-08-16 04:02:00

ENGLISH

UNKNOWN

M

[[23397476, Timestamp('2166-08-16 04:02:41'), '', 'ENT']]

[[{'Medications on Admission': 'NIL', 'Brief Hospital Course': ":\nThe patient was admitted to the Otolaryngology-Head and Neck \nSurgery Service on ___y Systems:\n\nNeuro: Pain was well controlled while in house\nCardiovascular: Remained hemodynamically stable. \nPulmonary: Oxygen was monitored without issues and patient was \nambulating independently without supplemental oxygen prior to \ndischarge.\nHEENT: Trach was capped and subsequently decannulated without \ncomplication.\nGI: Diet was advanced as tolerated. Bowel regimen was given prn.\nGU: Patient was able to void independently.\nHeme: Received heparin subcutaneously and pneumatic compression \nboots for DVT prophylaxis.\nEndocrine: Monitored without any remarkable issues. \n\nOn morning of discharge patient's mother called ___ clinic \ncomplaining patient was becoming agitated and concern for \npossible suicidal ideation. Psychiatry was consulted and \npatient was cleared by psych for discharge. \n\nAt time of discharge, the patient was in stable condition, \nambulating and voiding independently, and with adequate pain \ncontrol. The patient was given instructions to follow-up in \nclinic with Dr. ___", 'Pertinent Results:': '\nPlease see OMR for pertinent results\n\n', 'Physical Exam:|Physical': '\nVitals: Reviewed\nGen: no acute distress\nCommunication: Mild gravelly quality\nEyes: extraocular muscles intact\nOral Cavity / Oropharynx: normal no masses / lesions\nNeck: ___ tracheal stoma patent and covered with \ndressing. Decannulated\nFace / Head: normal facial strength\nNeurologic: cranial nerves grossly intact\nRespiratory: no inspiratory stridor or expiratory wheezes\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\n___ suicide attempt via machete to the neck tx from ___\nto ___ OR now s/p bilateral neck exploration, epiglottopexy,\nrepair of supraglottic complete laceration via ___ stitches,\ntrachesotomy, repair of cricothyroidotomy, open g-tube,\nbronch/BAL ___ with serial SML procedures/steroid injections\n(___), trach change ___. He has been followed serially \nfor\nsupraglottic stenosis as a consequence of the penetrating neck\ntrauma. His trach has remained in place without difficulty and\ndoes not uncap. Overall he is doing very well and\nnotes some mild gravelly and is in his speaking voice though no\nother issues. He is being admitted for a capping trial and\ndecannulation.\n\nPast Medical History:\nDepression with prior involuntary admission after altercation \nwith mom and paranoid behavior\n\nSocial History:\n___\nFamily History:\nBPAD in father who tried to shoot self in chest\n\n', 'Chief Complaint:|Complaint:': '\n___ with penetrating neck trauma s/p epiglottopexy, repair of \nsupraglottic complete laceration and trach in ___, \nadmitted for cap trial.\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nNo Known Allergies / Adverse Drug Reactions\n\n'}, '13729774-DS-18', 18, 'otolaryngology']]

[]

[[23397476, Timestamp('2166-08-16 20:00:00'), Timestamp('2166-08-17 20:00:00'), 'MAIN', 'Sodium Chloride 0.9% Flush', '', '0', '10 mL Syringe']]

[]

['otolaryngology']

[]

Question: A 20 M is admitted. He/she says he/she has ___ with penetrating neck trauma s/p epiglottopexy, repair of supraglottic complete laceration and trach in ___, admitted for cap trial. . History of illness: ___ suicide attempt via machete to the neck tx from ___ to ___ OR now s/p bilateral neck exploration, epiglottopexy, repair of supraglottic complete laceration via ___ stitches, trachesotomy, repair of cricothyroidotomy, open g-tube, bronch/BAL ___ with serial SML procedures/steroid injections (___), trach change ___. He has been followed serially for supraglottic stenosis as a consequence of the penetrating neck trauma. His trach has remained in place without difficulty and does not uncap. Overall he is doing very well and notes some mild gravelly and is in his speaking voice though no other issues. He is being admitted for a capping trial and decannulation. Past Medical History: Depression with prior involuntary admission after altercation with mom and paranoid behavior Social History: ___ Family History: BPAD in father who tried to shoot self in chest Allergies: No Known Allergies / Adverse Drug Reactions What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Sodium Chloride 0.9% Flush Target Lab Orders: NONE Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : The patient was admitted to the Otolaryngology-Head and Neck Surgery Service on ___y Systems: Neuro: Pain was well controlled while in house Cardiovascular: Remained hemodynamically stable. Pulmonary: Oxygen was monitored without issues and patient was ambulating independently without supplemental oxygen prior to discharge. HEENT: Trach was capped and subsequently decannulated without complication. GI: Diet was advanced as tolerated. Bowel regimen was given prn. GU: Patient was able to void independently. Heme: Received heparin subcutaneously and pneumatic compression boots for DVT prophylaxis. Endocrine: Monitored without any remarkable issues. On morning of discharge patient's mother called ___ clinic complaining patient was becoming agitated and concern for possible suicidal ideation. Psychiatry was consulted and patient was cleared by psych for discharge. At time of discharge, the patient was in stable condition, ambulating and voiding independently, and with adequate pain control. The patient was given instructions to follow-up in clinic with Dr. ___ Other Results: Please see OMR for pertinent results

2154-09-01 08:00:00

ENGLISH

WIDOWED

WHITE

M

[[29053528, Timestamp('2154-09-01 00:34:49'), '', 'TSURG']]

[[{'Medications on Admission': ':\nAspirin 325mg qd, Plavix 75mg qd, Spiriva qd, dosazosin 4mg qhs, \nCartia XT 120 mg qhs, Lipitor, Prevacid 30mg qd, Enbrel SQ 50mg \nqweek, Voltaren prn\n\n9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) \nTablet, Chewable PO QID (4 times a day) as needed for GERD. \n10. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: \nOne (1) Inhalation Q4H (every 4 hours). \n11. Oxycodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO \nevery ___ hours as needed for pain .\nDisp:*70 Tablet(s)* Refills:*0*\n12. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H \n(every 24 hours) for 7 days.\nDisp:*7 Tablet(s)* Refills:*0*\n13. Oxygen\nHome Oxygen ___ LPM continuous via Nasal Cannula \nConserving Device for Portability\nRA Sats: 87-89%\n\nFacility:\n___\n\nCOPD, rheumatoid arthritis, bronchiectasis, rheumatic fever ___, \n\n___ esophagus, and bilateral cataracts. ', 'Brief Hospital Course': ':\nMr. ___ had an uneventful Flexible bronchoscopy; \nvideo-assisted thoracoscopic surgical right upper lobectomy; \nmediastinal lymph node dissection; bronchoscopy with \nbronchoalveolar lavage. He was extubated in the operating room, \nmonitored in the PACU prior to transfer to the floor. He had 2 \n___ drains, a foley and Dilaudid PCA for pain. On POD #1 his \n___ drains remained to suction. His foley was removed and he \nvoided without difficulty. His home medications were restarted \nand he resumed a regular diet. He was seen by physical therapy \nwho recommended home physical therapy. On POD #2 the posterior \n___ was removed. He had a productive cough and a sputum \nculture was sent. The gram stain showed GNR so he was started \non a 10 day course of Levofloxacin. On POD #3 the anterior \n___ was removed and a follow-up chest x-ray revealed small \nbilateral effusions and no pneumothorax. His saturations were \n88-89% on room air. On POD #4 he was discharged to home with \n___ Liters of oxygen via Nasal Cannula for Sats 87-89% on RA. \nHe will follow-up with Dr. ___ as an outpatient.\n\n', 'Pertinent Results:': '\n___ WBC-5.0 RBC-3.65* Hgb-10.7* Hct-31.6* Plt ___\n___ Glucose-124* UreaN-12 Creat-0.8 Na-137 K-4.0 Cl-103 \nHCO3-27\n\n___ SPUTUM Source: Expectorated. \n SPARSE GROWTH OROPHARYNGEAL FLORA. \n GRAM NEGATIVE ROD(S). SPARSE GROWTH. \n NO FUNGUS ISOLATED. \n\nChest X-Ray ___\nMild cardiomegaly is stable. The aorta is elongated. There is \nprominence of the main pulmonary arteries. Very small \npneumothorax. Bilateral pleural effusions are small. There is \nmild interstitial pulmonary edema. Right subcutaneous emphysema \nis moderate. Left lower lobe atelectasis has improved.\n\n', 'Physical Exam:|Physical': '\nVS: T 98.4 HR 92 SR BP: 130/60 Sats: 93% 2L, RA 87-89%\nGeneral: ___ year-old male in no apparent distress\nHEENT: normocephalic, mucus membranes moist\nNeck: supple, no lymphadenopathy\nCard: RRR, normal S1,S2 no murmur/gallop or rub\nResp: rhonchus breath sounds bilateral ___ up\nGI: benign\nExtr: warm \nIncision: Right thoracoscopy site clean/dry/intact, no erythema\nNeuro: non-focal\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\nMr. ___ is a ___ gentleman who has a right lower \nlobe lung nodule and FDG mildly avid mediastinal lymph nodes. \nIn ___ he underwent cervical mediastinoscopy which was negative \nfor carcinoma. He returns for right VATs right upper lobe \nlobectomy.\n\nPast Medical History:\nCOPD, rheumatoid arthritis, bronchiectasis, rheumatic fever ___,\n___ esophagus, and bilateral cataracts.\n\nPSH: bilateral hand surgery for osteoarthritis in ___, \nbilateral foot surgery in ___ and ___, left total knee \nreplacement, ___, partial colectomy for diverticulitis, ___, \nright carotid endarterectomy, ___, cholecystectomy, ___, back \nsurgery 1950s, incisional hernia repair in ___\n\nSocial History:\n___\nFamily History:\nMother died in an accident. Father had peptic ulcer disease and \nlived to over 100. He had a sister with pancreatic cancer and a \nson with rheumatic fever, MS, and back problems.\n\n', 'Chief Complaint:|Complaint:': '\nRight upper lobe nodule.\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nPatient recorded as having No Known Allergies to Drugs\n\n'}, '15651896-DS-20', 20, 'cardiothoracic']]

[['PROCEDURE: Chest portable AP on ___.\n\nCOMPARISON: ___.\n\nHISTORY: ___ man status post VATS, right upper lobectomy.\nPostoperative.\n\nFINDINGS:\n\nThe patient underwent a VATS (right upper lobectomy) with surgical changes new\nat the right hilar area. Two chest tubes apparently are visualized projected\nover the right hemithorax with no pneumothorax. A new left retrocardiac\natelectasis is seen in the left lung base. The heart size is mildly enlarged.\n\nIMPRESSION:\n1. Status post right upper lobectomy with postsurgical abnormal opacitiy seen\nat the right hilar area for which a short-term followup examination is\nrecommended.\n2. Two chest tubes with no right pneumothorax.\n3. New left retrocardiac atelectasis.\n\n\n', '15651896-RR-13', 13, ''], ['HISTORY: Right upper lobe lobectomy, now with air leak.\n\nFINDINGS: In comparison with earlier study of this date, the image presented\nas a substantial respiratory motion. No definite pneumothorax on this limited\nstudy. Large amount of subcutaneous gas is seen along the right lateral chest\nand upper abdominal wall.\n', '15651896-RR-15', 15, ''], ['HISTORY: New air leak status post right upper lobe lobectomy, to evaluate for\npneumothorax.\n\nFINDINGS: In comparison with the study of ___, there is little overall\nchange. No definite pneumothorax. Some reduction in the right subcutaneous\ngas along the lateral chest wall.\n\nNo evidence of acute focal pneumonia.\n', '15651896-RR-16', 16, ''], ['REASON FOR EXAM: S/P right upper lobectomy after chest tube removal.\n\nComparison is made with prior study, ___.\n\nMild cardiomegaly is stable. The aorta is elongated. There is prominence of\nthe main pulmonary arteries. There is no pneumothorax. Bilateral pleural\neffusions are small. There is mild interstitial pulmonary edema. Right\nsubcutaneous emphysema is moderate. Left lower lobe atelectasis has improved.\n\njr\n', '15651896-RR-18', 18, '']]

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[]

['cardiothoracic']

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09:43:00'), 'pH'], [50821, Timestamp('2154-09-01 09:40:00'), Timestamp('2154-09-01 09:43:00'), 'pO2'], [50822, Timestamp('2154-09-01 09:40:00'), Timestamp('2154-09-01 09:43:00'), 'Potassium, Whole Blood'], [50824, Timestamp('2154-09-01 09:40:00'), Timestamp('2154-09-01 09:43:00'), 'Sodium, Whole Blood'], [52033, Timestamp('2154-09-01 09:40:00'), Timestamp('2154-09-01 09:41:00'), 'Specimen Type'], [50868, Timestamp('2154-09-01 14:31:00'), Timestamp('2154-09-01 16:12:00'), 'Anion Gap'], [50882, Timestamp('2154-09-01 14:31:00'), Timestamp('2154-09-01 16:12:00'), 'Bicarbonate'], [50893, Timestamp('2154-09-01 14:31:00'), Timestamp('2154-09-01 16:12:00'), 'Calcium, Total'], [50902, Timestamp('2154-09-01 14:31:00'), Timestamp('2154-09-01 16:12:00'), 'Chloride'], [50912, Timestamp('2154-09-01 14:31:00'), Timestamp('2154-09-01 16:12:00'), 'Creatinine'], [50920, Timestamp('2154-09-01 14:31:00'), Timestamp('2154-09-01 16:12:00'), 'Estimated GFR (MDRD equation)'], [50931, Timestamp('2154-09-01 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Timestamp('2154-09-02 08:40:00'), 'Magnesium'], [50970, Timestamp('2154-09-02 07:10:00'), Timestamp('2154-09-02 08:40:00'), 'Phosphate'], [50971, Timestamp('2154-09-02 07:10:00'), Timestamp('2154-09-02 08:40:00'), 'Potassium'], [50983, Timestamp('2154-09-02 07:10:00'), Timestamp('2154-09-02 08:40:00'), 'Sodium'], [51006, Timestamp('2154-09-02 07:10:00'), Timestamp('2154-09-02 08:40:00'), 'Urea Nitrogen']]

Question: A 78 M is admitted. He/she says he/she has Right upper lobe nodule. . History of illness: Mr. ___ is a ___ gentleman who has a right lower lobe lung nodule and FDG mildly avid mediastinal lymph nodes. In ___ he underwent cervical mediastinoscopy which was negative for carcinoma. He returns for right VATs right upper lobe lobectomy. Past Medical History: COPD, rheumatoid arthritis, bronchiectasis, rheumatic fever ___, ___ esophagus, and bilateral cataracts. PSH: bilateral hand surgery for osteoarthritis in ___, bilateral foot surgery in ___ and ___, left total knee replacement, ___, partial colectomy for diverticulitis, ___, right carotid endarterectomy, ___, cholecystectomy, ___, back surgery 1950s, incisional hernia repair in ___ Social History: ___ Family History: Mother died in an accident. Father had peptic ulcer disease and lived to over 100. He had a sister with pancreatic cancer and a son with rheumatic fever, MS, and back problems. Allergies: Patient recorded as having No Known Allergies to Drugs What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Pantoprazole Doxazosin Diltiazem Acetaminophen Oxycodone-Acetaminophen Albuterol 0.083% Neb Soln Heparin Tiotropium Bromide Albuterol 0.083% Neb Soln Atorvastatin Clopidogrel Diltiazem Ipratropium Bromide Neb Aspirin Iso-Osmotic Dextrose CefazoLIN Oxycodone-Acetaminophen Morphine Sulfate Sodium Chloride 0.9% Flush SW Magnesium Sulfate Ketorolac D5 1/2NS Target Lab Orders: Base Excess Calculated Total CO2 Chloride, Whole Blood Free Calcium Glucose Hematocrit, Calculated Hemoglobin Intubated Lactate pCO2 pH pO2 Potassium, Whole Blood Sodium, Whole Blood Specimen Type Anion Gap Bicarbonate Calcium, Total Chloride Creatinine Estimated GFR (MDRD equation) Glucose Magnesium Phosphate Potassium Sodium Urea Nitrogen Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells INR(PT) PT PTT Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells Anion Gap Bicarbonate Calcium, Total Chloride Creatinine Glucose Magnesium Phosphate Potassium Sodium Urea Nitrogen Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : Mr. ___ had an uneventful Flexible bronchoscopy; video-assisted thoracoscopic surgical right upper lobectomy; mediastinal lymph node dissection; bronchoscopy with bronchoalveolar lavage. He was extubated in the operating room, monitored in the PACU prior to transfer to the floor. He had 2 ___ drains, a foley and Dilaudid PCA for pain. On POD #1 his ___ drains remained to suction. His foley was removed and he voided without difficulty. His home medications were restarted and he resumed a regular diet. He was seen by physical therapy who recommended home physical therapy. On POD #2 the posterior ___ was removed. He had a productive cough and a sputum culture was sent. The gram stain showed GNR so he was started on a 10 day course of Levofloxacin. On POD #3 the anterior ___ was removed and a follow-up chest x-ray revealed small bilateral effusions and no pneumothorax. His saturations were 88-89% on room air. On POD #4 he was discharged to home with ___ Liters of oxygen via Nasal Cannula for Sats 87-89% on RA. He will follow-up with Dr. ___ as an outpatient. Other Results: ___ WBC-5.0 RBC-3.65* Hgb-10.7* Hct-31.6* Plt ___ ___ Glucose-124* UreaN-12 Creat-0.8 Na-137 K-4.0 Cl-103 HCO3-27 ___ SPUTUM Source: Expectorated. SPARSE GROWTH OROPHARYNGEAL FLORA. GRAM NEGATIVE ROD(S). SPARSE GROWTH. NO FUNGUS ISOLATED. Chest X-Ray ___ Mild cardiomegaly is stable. The aorta is elongated. There is prominence of the main pulmonary arteries. Very small pneumothorax. Bilateral pleural effusions are small. There is mild interstitial pulmonary edema. Right subcutaneous emphysema is moderate. Left lower lobe atelectasis has improved.

2124-01-20 18:16:00

ENGLISH

SINGLE

WHITE

F

[[25125194, Timestamp('2124-01-20 18:16:56'), '', 'OMED']]

[[{'Medications on Admission': ':\nlevothyroxine 25 mcg daily\nlorazepam 0.5-1 mg q8h prn anxiety, nausea\nmilk of magnesia bid\nomeprazole 20 mg bid\naprepitant after chemo\ndexamethasone after chemo\n\n2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) \nCapsule, Delayed Release(E.C.) PO twice a day. \n3. lorazepam 0.5 mg Tablet Sig: ___ Tablets PO every eight (8) \nhours as needed for anxiety or nausea.', 'Brief Hospital Course': 'NIL', 'Pertinent Results:': 'NIL', 'Physical Exam:|Physical': '\nADMISSION EXAM:\nVS: T 97.5, BP 108/70, HR 93, RR 18, 99%RA\nGEN: middle-aged woman, AOx3, NAD, very pleasant\nHEENT: MMM. no LAD. no JVD. neck supple. No cervical, \nsupraclavicular, or axillary LAD\nCards: RR S1/S2 normal. no murmurs/gallops/rubs.\nPulm: No dullness to percussion, CTAB no crackles or wheezes\nAbd: BS+, soft, NT, no rebound/guarding, no HSM, no ___ \nsign\nExtremities: wwp, no edema. DPs, PTs 2+.\nSkin: no rashes or bruising\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\n___ woman with a history of relapsed ovarian cancer \ncurrently on carboplatin and liposomal doxorubicin, also history \nof internal hemorrhoids, presents with bright red blood per \nrectum for one month. In ___ patient noticed \nintermittent bright red blood with her stools for several days. \nLast week she re-noticed BRBPR, with every bowel movements. Also \nlast week she presented to ___ because of "fast heart \nrate," was found to have "a normal ECG" but "low blood count." \nShe reports feeling fatigued for the past two weeks, easily \ndyspneic on exertion. No hematemesis or hemoptysis. Reports poor \nappetite but still adequate PO intake.\n.\nShe has already had an outpatient colonoscopy scheduled for \n___. \n.\nIn the ED, T 99, HR 110, BP 121/46, RR 18, 100%RA. Rectal exam \nshowed minimal stool, guaiac negative. Hct was 26.9 from \nbaseline of 33-35. She was admitted for further management.\n.\nReview of Systems: \n(+) Per HPI \n(-) Review of Systems: GEN: No fever, chills, night sweats, \nrecent weight loss or gain. HEENT: No sinus tenderness, \nrhinorrhea or congestion. CV: No chest pain or tightness. PULM: \nNo cough, shortness of breath, or wheezing. GI: No nausea, \nvomiting, diarrhea, constipation or abdominal pain. GUI: No \ndysuria or change in bladder habits. MSK: No arthritis, \narthralgias, or myalgias. DERM: No rashes or skin breakdown. \nNEURO: No numbness/tingling in extremities. All other review of \nsystems negative.\n\nPast Medical History:\nONCOLOGIC HISTORY:\n# Ovarian cancer:\n- diagnosed with grade 3 stage IIIC papillary serous \nadenocarcinoma of the ovary at the time of exploratory \nlaparotomy on ___. She was suboptimally debulked and \ncompleted six cycles of intravenous dose carboplatin and \npaclitaxel, and the sixth cycle was administered on ___. \nShe started carboplatin-liposomal doxurubicin for relapsed \nplatinum sensitive ovarian cancer on ___, cycle 2 on \n___.\n.\nOTHER MEDICAL HISTORY:\ninternal hemorrhoids: grade II, seen on colonoscopy in ___\ndiverticulosis\nhypothyroidism\nh/o arrhythmia with negative Holter\ns/p hysterectomy in ___\ns/p tonsillectomy and adenoidectomy in ___\ns/p left knee arthroscopy in ___\ns/p bunionectomy on the right side in ___\n\nSocial History:\n___\nFamily History:\nHer mother developed breast cancer at the age of ___. Her father \nhad prostate\ncancer and leukemia.\n\n', 'Chief Complaint:|Complaint:': '\nBright red blood per rectum.\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nMorphine / Prochlorperazine / Shellfish Derived / Lactose / \nCefotetan / Levothyroxine Sodium\n\n'}, '12302518-DS-19', 19, 'medicine']]

[['PORTABLE CHEST, ___\n\nCOMPARISON: ___.\n\nFINDINGS: Heart size, mediastinal and hilar contours are normal, and lungs\nand pleural surfaces are clear.\n\nIMPRESSION: No findings to account for dyspnea.\n', '12302518-RR-32', 32, '']]

[[25125194, Timestamp('2124-01-21 03:00:00'), Timestamp('2124-01-22 02:00:00'), 'MAIN', 'Lorazepam', '003753', '00409198530', '2mg/mL Syringe'], [25125194, Timestamp('2124-01-20 21:00:00'), Timestamp('2124-01-22 19:00:00'), 'MAIN', 'Sodium Chloride 0.9% Flush', '', '0', 'Syringe'], [25125194, Timestamp('2124-01-20 20:00:00'), Timestamp('2124-01-21 19:00:00'), 'BASE', '1/2 NS', '001209', '00338004304', '1000mL Bag'], [25125194, Timestamp('2124-01-20 10:00:00'), Timestamp('2124-01-21 11:00:00'), 'MAIN', 'Levothyroxine Sodium', '006648', '00074434113', '25mcg Tablet'], [25125194, Timestamp('2124-01-20 21:00:00'), Timestamp('2124-01-21 20:00:00'), 'MAIN', 'Magnesium Citrate', '003025', '00363069338', '300mL Bottle'], [25125194, Timestamp('2124-01-20 21:00:00'), Timestamp('2124-01-21 20:00:00'), 'MAIN', 'Magnesium Citrate', '003025', '00363069338', '300mL Bottle'], [25125194, Timestamp('2124-01-20 22:00:00'), Timestamp('2124-01-21 08:00:00'), 'BASE', 'D5 1/2NS', '002006', '00338008504', '1000mL Bag'], [25125194, Timestamp('2124-01-21 10:00:00'), Timestamp('2124-01-22 19:00:00'), 'MAIN', 'Levoxyl', '006649', '', '50 mcg Tab'], [25125194, Timestamp('2124-01-20 21:00:00'), Timestamp('2124-01-22 19:00:00'), 'MAIN', 'Influenza Virus Vaccine', '066525', '33332001001', '0.5 mL Syringe'], [25125194, Timestamp('2124-01-21 13:00:00'), Timestamp('2124-01-22 19:00:00'), 'MAIN', 'Acetaminophen', '004489', '51079000220', '325mg Tablet']]

[]

['medicine']

[[51237, Timestamp('2124-01-21 08:10:00'), Timestamp('2124-01-21 09:18:00'), 'INR(PT)'], [51274, Timestamp('2124-01-21 08:10:00'), Timestamp('2124-01-21 09:18:00'), 'PT'], [51275, Timestamp('2124-01-21 08:10:00'), Timestamp('2124-01-21 09:18:00'), 'PTT'], [51218, Timestamp('2124-01-21 08:10:00'), Timestamp('2124-01-21 13:32:00'), 'Granulocyte Count'], [51221, Timestamp('2124-01-21 08:10:00'), Timestamp('2124-01-21 08:55:00'), 'Hematocrit'], [51222, Timestamp('2124-01-21 08:10:00'), Timestamp('2124-01-21 08:55:00'), 'Hemoglobin'], [51248, Timestamp('2124-01-21 08:10:00'), Timestamp('2124-01-21 08:55:00'), 'MCH'], [51249, Timestamp('2124-01-21 08:10:00'), Timestamp('2124-01-21 08:55:00'), 'MCHC'], [51250, Timestamp('2124-01-21 08:10:00'), Timestamp('2124-01-21 08:55:00'), 'MCV'], [51265, Timestamp('2124-01-21 08:10:00'), Timestamp('2124-01-21 08:55:00'), 'Platelet Count'], [51277, Timestamp('2124-01-21 08:10:00'), Timestamp('2124-01-21 08:55:00'), 'RDW'], [51279, Timestamp('2124-01-21 08:10:00'), Timestamp('2124-01-21 08:55:00'), 'Red Blood Cells'], [51301, Timestamp('2124-01-21 08:10:00'), Timestamp('2124-01-21 08:55:00'), 'White Blood Cells'], [50868, Timestamp('2124-01-21 08:10:00'), Timestamp('2124-01-21 09:10:00'), 'Anion Gap'], [50882, Timestamp('2124-01-21 08:10:00'), Timestamp('2124-01-21 09:10:00'), 'Bicarbonate'], [50893, Timestamp('2124-01-21 08:10:00'), Timestamp('2124-01-21 09:10:00'), 'Calcium, Total'], [50902, Timestamp('2124-01-21 08:10:00'), Timestamp('2124-01-21 09:10:00'), 'Chloride'], [50912, Timestamp('2124-01-21 08:10:00'), Timestamp('2124-01-21 09:10:00'), 'Creatinine'], [50931, Timestamp('2124-01-21 08:10:00'), Timestamp('2124-01-21 09:10:00'), 'Glucose'], [50960, Timestamp('2124-01-21 08:10:00'), Timestamp('2124-01-21 09:10:00'), 'Magnesium'], [50970, Timestamp('2124-01-21 08:10:00'), Timestamp('2124-01-21 09:10:00'), 'Phosphate'], [50971, Timestamp('2124-01-21 08:10:00'), Timestamp('2124-01-21 09:10:00'), 'Potassium'], [50983, Timestamp('2124-01-21 08:10:00'), Timestamp('2124-01-21 09:10:00'), 'Sodium'], [51006, Timestamp('2124-01-21 08:10:00'), Timestamp('2124-01-21 09:10:00'), 'Urea Nitrogen']]

Question: A 50 F is admitted. He/she says he/she has Bright red blood per rectum. . History of illness: ___ woman with a history of relapsed ovarian cancer currently on carboplatin and liposomal doxorubicin, also history of internal hemorrhoids, presents with bright red blood per rectum for one month. In ___ patient noticed intermittent bright red blood with her stools for several days. Last week she re-noticed BRBPR, with every bowel movements. Also last week she presented to ___ because of "fast heart rate," was found to have "a normal ECG" but "low blood count." She reports feeling fatigued for the past two weeks, easily dyspneic on exertion. No hematemesis or hemoptysis. Reports poor appetite but still adequate PO intake. . She has already had an outpatient colonoscopy scheduled for ___. . In the ED, T 99, HR 110, BP 121/46, RR 18, 100%RA. Rectal exam showed minimal stool, guaiac negative. Hct was 26.9 from baseline of 33-35. She was admitted for further management. . Review of Systems: (+) Per HPI (-) Review of Systems: GEN: No fever, chills, night sweats, recent weight loss or gain. HEENT: No sinus tenderness, rhinorrhea or congestion. CV: No chest pain or tightness. PULM: No cough, shortness of breath, or wheezing. GI: No nausea, vomiting, diarrhea, constipation or abdominal pain. GUI: No dysuria or change in bladder habits. MSK: No arthritis, arthralgias, or myalgias. DERM: No rashes or skin breakdown. NEURO: No numbness/tingling in extremities. All other review of systems negative. Past Medical History: ONCOLOGIC HISTORY: # Ovarian cancer: - diagnosed with grade 3 stage IIIC papillary serous adenocarcinoma of the ovary at the time of exploratory laparotomy on ___. She was suboptimally debulked and completed six cycles of intravenous dose carboplatin and paclitaxel, and the sixth cycle was administered on ___. She started carboplatin-liposomal doxurubicin for relapsed platinum sensitive ovarian cancer on ___, cycle 2 on ___. . OTHER MEDICAL HISTORY: internal hemorrhoids: grade II, seen on colonoscopy in ___ diverticulosis hypothyroidism h/o arrhythmia with negative Holter s/p hysterectomy in ___ s/p tonsillectomy and adenoidectomy in ___ s/p left knee arthroscopy in ___ s/p bunionectomy on the right side in ___ Social History: ___ Family History: Her mother developed breast cancer at the age of ___. Her father had prostate cancer and leukemia. Allergies: Morphine / Prochlorperazine / Shellfish Derived / Lactose / Cefotetan / Levothyroxine Sodium What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Lorazepam Sodium Chloride 0.9% Flush 1/2 NS Levothyroxine Sodium Magnesium Citrate Magnesium Citrate D5 1/2NS Levoxyl Influenza Virus Vaccine Acetaminophen Target Lab Orders: INR(PT) PT PTT Granulocyte Count Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells Anion Gap Bicarbonate Calcium, Total Chloride Creatinine Glucose Magnesium Phosphate Potassium Sodium Urea Nitrogen Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: NIL Other Results: NIL

2124-05-29 16:39:00

ENGLISH

MARRIED

WHITE

F

[[29543665, Timestamp('2124-05-29 16:40:41'), '', 'SURG']]

[[{'Medications on Admission': ':\n1. Acetaminophen 1000 mg PO Q8H \n2. Omeprazole 20 mg PO DAILY \n3. Ibuprofen 800 mg PO Q8H:PRN Pain - Severe \n Reason for PRN duplicate override: Alternating agents for \nsimilar severity\n4. Multivitamins 1 TAB PO DAILY \n5. Docusate Sodium 100 mg PO BID \n\nFacility:\n___', 'Brief Hospital Course': ':\nMrs. ___ is a ___ year old female with left lateral thigh \nmelanoma s/p wide local exision and left groin lymphadenectomy \nwho now presents from home with left groin seroma with pain and \nedema after JP drain removal. She was admitted from clinic and \ntaken to the operating room on hospital day two for incision and \ndrainage of the left groin seroma with packing of the wound with \nmoist-to-dry dressings. She tolerated the procedure well and was \nbrought to the postoperative recovery unit in stable condition. \nPlease see Dr. ___ report for more details. After a \nbrief stay in the PACU, she was transferred to the general \nsurgery floor where she remained throughout the remainder of her \nhospital course. Her dressings were changed daily to twice daily \nwhich were well tolerated. She was tolerating a regular diet and \nher pain was controlled on oral pain medications. At the time of \ndischarge, she was set up with ___ at home for twice daily \ndressing changes and will see Dr. ___ in clinic in 1 week from \ndischarge. \n\n', 'Pertinent Results:': '\n___ 05:50PM BLOOD WBC-6.2 RBC-3.95 Hgb-13.5 Hct-38.5 MCV-98 \nMCH-34.2* MCHC-35.1 RDW-11.9 RDWSD-42.8 Plt ___\n___ 07:07AM BLOOD WBC-5.5 RBC-3.28* Hgb-11.0* Hct-33.2* \nMCV-101* MCH-33.5* MCHC-33.1 RDW-12.1 RDWSD-45.3 Plt ___\n___ 06:16PM BLOOD Glucose-122* UreaN-6 Creat-0.5 Na-134 \nK-5.5* Cl-98 HCO3-26 AnGap-16\n___ 07:07AM BLOOD Glucose-86 UreaN-8 Creat-0.6 Na-143 K-4.1 \nCl-106 HCO3-28 AnGap-13\n\n', 'Physical Exam:|Physical': '\nON DISCHARGE:\nGen: Appears well, AAOx3\nCV: RRR, no m/r/g\nResp: Normal effort, no distress. CTABL, no adventitious sounds\nAbdomen: Soft, nondistended, nontender, no rebound or guarding\nWound: Left groin incision with WTD packing and outer ABD with\nserous staining. Left vulvar induration improved, tender. \nTube/Drain: none\nExt: Warm, well perfused. LLE edema improved, TEDs in place.\nMotor/sensory grossly intact. \n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\n___ with left lateral thigh melanoma s/p definitive wide \nexcision (___) of a 1.6 mm residual melanoma with negative \nmargins and 2 L inguinal SLNB, ___ which contained a microscopic \nmetastasis (T2bN1a-IIIB). PET scan showed residual focus of FDG \navidity within the L inguinal region. A head MRI was negative. \nShe underwent completion L lymphadenectomy ___ nodes with \nmelanoma. She was discharged ___ with a drain in place. \n\nShe was seen in clinic 2 weeks ago. Her LLU had improving edema, \ndrain was working and draining 200-300cc/d, therefore left in \nplace. Incision was clean, dry and intact. She was advised to \ntrend her drain output and return to clinic in 2 weeks for \npossible drain removal. \n\nOn ___, she noted that her drain bulb was not holding suction \nsecondary to a leak in the tubing. The drain was removed on ___ \nin a ED. In clinic today, se reports shooting pains in her left \ngroin and worsening swelling. No fevers. No wound discharge. On \nexam, there was tender edema of the left groin and left labia \nmajora. The incision looked healed except for two distict 2 mm \nareas of dehiscence. \n\nPast Medical History:\nMelanoma T2bN1a-IIIB s/p definitive wide excision and 2 L\ninguinal SLNB (___) and completion L lymphadenectomy (___), \nLeft breast milk duct resection for recurrent mastitis\nLeft knee multiple surgeries including ACL and meniscus\nRight leg vein stripping \nBenign lymph node or cyst removal left upper arm as a child\n\nSocial History:\n___\nFamily History:\n___ family history is significant for her maternal \ngrandmother who had ovarian cancer, but lived to an elderly age. \nThe maternal grandfather had "stomach cancer". She has two boys \nand two girls ranging from ___ years old who are well and a \nfifth child age ___, who is well. There are no family members \nwith melanoma or early heart disease.\n\n', 'Chief Complaint:|Complaint:': '\nleft groin seroma\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nepinephrine\n\n'}, '13458840-DS-15', 15, 'surgery']]

[]

[[29543665, Timestamp('2124-05-29 18:00:00'), Timestamp('2124-05-29 17:00:00'), 'MAIN', 'Acetaminophen', '004489', '00904198261', '325mg Tablet'], [29543665, Timestamp('2124-05-30 08:00:00'), Timestamp('2124-06-02 20:00:00'), 'MAIN', 'Docusate Sodium', '003009', '00904224461', '100mg Capsule'], [29543665, Timestamp('2124-05-29 18:00:00'), Timestamp('2124-05-31 07:00:00'), 'MAIN', 'Sodium Chloride 0.9% Flush', '', '0', '10 mL Syringe'], [29543665, Timestamp('2124-05-30 10:00:00'), Timestamp('2124-06-02 20:00:00'), 'MAIN', 'Sodium Chloride 0.9% Flush', '', '0', '10 mL Syringe'], [29543665, Timestamp('2124-05-29 18:00:00'), Timestamp('2124-06-01 09:00:00'), 'BASE', 'Iso-Osmotic Dextrose', '', '0', '50 mL Bag'], [29543665, Timestamp('2124-05-29 18:00:00'), Timestamp('2124-06-01 09:00:00'), 'MAIN', 'CeFAZolin', '068632', '00264310511', '2g Duplex Bag'], [29543665, Timestamp('2124-05-29 18:00:00'), Timestamp('2124-06-02 20:00:00'), 'MAIN', 'OxyCODONE (Immediate Release)', '004225', '00904644461', '5mg Tablet'], [29543665, Timestamp('2124-05-29 18:00:00'), Timestamp('2124-06-01 14:00:00'), 'MAIN', 'Ibuprofen', '008349', '00904585461', '600mg Tablet'], [29543665, Timestamp('2124-05-30 01:00:00'), Timestamp('2124-05-31 07:00:00'), 'BASE', 'D5 1/2NS', '002006', '00338008504', '1000mL Bag'], [29543665, Timestamp('2124-05-30 00:00:00'), Timestamp('2124-05-30 00:00:00'), 'BASE', 'Potassium Chl 40 mEq / 1000 mL D5 1/2 NS', '002005', '00338067504', '1000 mL Bag'], [29543665, Timestamp('2124-05-29 18:00:00'), Timestamp('2124-06-01 14:00:00'), 'MAIN', 'Acetaminophen', '004489', '00904198261', '325mg Tablet']]

[['0Y960ZX', 10, 1, Timestamp('2124-05-30 00:00:00'), 'Drainage of Left Inguinal Region, Open Approach, Diagnostic']]

['surgery']

[[51221, Timestamp('2124-05-29 17:50:00'), Timestamp('2124-05-29 18:27:00'), 'Hematocrit'], [51222, Timestamp('2124-05-29 17:50:00'), Timestamp('2124-05-29 18:27:00'), 'Hemoglobin'], [51248, Timestamp('2124-05-29 17:50:00'), Timestamp('2124-05-29 18:27:00'), 'MCH'], [51249, Timestamp('2124-05-29 17:50:00'), Timestamp('2124-05-29 18:27:00'), 'MCHC'], [51250, Timestamp('2124-05-29 17:50:00'), Timestamp('2124-05-29 18:27:00'), 'MCV'], [51265, Timestamp('2124-05-29 17:50:00'), Timestamp('2124-05-29 18:27:00'), 'Platelet Count'], [51277, Timestamp('2124-05-29 17:50:00'), Timestamp('2124-05-29 18:27:00'), 'RDW'], [51279, Timestamp('2124-05-29 17:50:00'), Timestamp('2124-05-29 18:27:00'), 'Red Blood Cells'], [51301, Timestamp('2124-05-29 17:50:00'), Timestamp('2124-05-29 18:27:00'), 'White Blood Cells'], [52172, Timestamp('2124-05-29 17:50:00'), Timestamp('2124-05-29 18:27:00'), 'RDW-SD'], [50868, Timestamp('2124-05-29 18:16:00'), Timestamp('2124-05-29 19:16:00'), 'Anion Gap'], [50882, Timestamp('2124-05-29 18:16:00'), Timestamp('2124-05-29 19:16:00'), 'Bicarbonate'], [50893, Timestamp('2124-05-29 18:16:00'), Timestamp('2124-05-29 19:16:00'), 'Calcium, Total'], [50902, Timestamp('2124-05-29 18:16:00'), Timestamp('2124-05-29 19:16:00'), 'Chloride'], [50912, Timestamp('2124-05-29 18:16:00'), Timestamp('2124-05-29 19:16:00'), 'Creatinine'], [50920, Timestamp('2124-05-29 18:16:00'), Timestamp('2124-05-29 19:16:00'), 'Estimated GFR (MDRD equation)'], [50931, Timestamp('2124-05-29 18:16:00'), Timestamp('2124-05-29 19:16:00'), 'Glucose'], [50934, Timestamp('2124-05-29 18:16:00'), Timestamp('2124-05-29 19:16:00'), 'H'], [50947, Timestamp('2124-05-29 18:16:00'), Timestamp('2124-05-29 19:16:00'), 'I'], [50960, Timestamp('2124-05-29 18:16:00'), Timestamp('2124-05-29 19:16:00'), 'Magnesium'], [50970, Timestamp('2124-05-29 18:16:00'), Timestamp('2124-05-29 19:16:00'), 'Phosphate'], [50971, Timestamp('2124-05-29 18:16:00'), Timestamp('2124-05-29 19:16:00'), 'Potassium'], [50983, Timestamp('2124-05-29 18:16:00'), Timestamp('2124-05-29 19:16:00'), 'Sodium'], [51006, Timestamp('2124-05-29 18:16:00'), Timestamp('2124-05-29 19:16:00'), 'Urea Nitrogen'], [51678, Timestamp('2124-05-29 18:16:00'), Timestamp('2124-05-29 19:16:00'), 'L']]

Question: A 49 F is admitted. He/she says he/she has left groin seroma . History of illness: ___ with left lateral thigh melanoma s/p definitive wide excision (___) of a 1.6 mm residual melanoma with negative margins and 2 L inguinal SLNB, ___ which contained a microscopic metastasis (T2bN1a-IIIB). PET scan showed residual focus of FDG avidity within the L inguinal region. A head MRI was negative. She underwent completion L lymphadenectomy ___ nodes with melanoma. She was discharged ___ with a drain in place. She was seen in clinic 2 weeks ago. Her LLU had improving edema, drain was working and draining 200-300cc/d, therefore left in place. Incision was clean, dry and intact. She was advised to trend her drain output and return to clinic in 2 weeks for possible drain removal. On ___, she noted that her drain bulb was not holding suction secondary to a leak in the tubing. The drain was removed on ___ in a ED. In clinic today, se reports shooting pains in her left groin and worsening swelling. No fevers. No wound discharge. On exam, there was tender edema of the left groin and left labia majora. The incision looked healed except for two distict 2 mm areas of dehiscence. Past Medical History: Melanoma T2bN1a-IIIB s/p definitive wide excision and 2 L inguinal SLNB (___) and completion L lymphadenectomy (___), Left breast milk duct resection for recurrent mastitis Left knee multiple surgeries including ACL and meniscus Right leg vein stripping Benign lymph node or cyst removal left upper arm as a child Social History: ___ Family History: ___ family history is significant for her maternal grandmother who had ovarian cancer, but lived to an elderly age. The maternal grandfather had "stomach cancer". She has two boys and two girls ranging from ___ years old who are well and a fifth child age ___, who is well. There are no family members with melanoma or early heart disease. Allergies: epinephrine What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Acetaminophen Docusate Sodium Sodium Chloride 0.9% Flush Sodium Chloride 0.9% Flush Iso-Osmotic Dextrose CeFAZolin OxyCODONE (Immediate Release) Ibuprofen D5 1/2NS Potassium Chl 40 mEq / 1000 mL D5 1/2 NS Acetaminophen Target Lab Orders: Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells RDW-SD Anion Gap Bicarbonate Calcium, Total Chloride Creatinine Estimated GFR (MDRD equation) Glucose H I Magnesium Phosphate Potassium Sodium Urea Nitrogen L Target Procedures: Drainage of Left Inguinal Region, Open Approach, Diagnostic DOCTOR'S NOTE Hospital Notes: : Mrs. ___ is a ___ year old female with left lateral thigh melanoma s/p wide local exision and left groin lymphadenectomy who now presents from home with left groin seroma with pain and edema after JP drain removal. She was admitted from clinic and taken to the operating room on hospital day two for incision and drainage of the left groin seroma with packing of the wound with moist-to-dry dressings. She tolerated the procedure well and was brought to the postoperative recovery unit in stable condition. Please see Dr. ___ report for more details. After a brief stay in the PACU, she was transferred to the general surgery floor where she remained throughout the remainder of her hospital course. Her dressings were changed daily to twice daily which were well tolerated. She was tolerating a regular diet and her pain was controlled on oral pain medications. At the time of discharge, she was set up with ___ at home for twice daily dressing changes and will see Dr. ___ in clinic in 1 week from discharge. Other Results: ___ 05:50PM BLOOD WBC-6.2 RBC-3.95 Hgb-13.5 Hct-38.5 MCV-98 MCH-34.2* MCHC-35.1 RDW-11.9 RDWSD-42.8 Plt ___ ___ 07:07AM BLOOD WBC-5.5 RBC-3.28* Hgb-11.0* Hct-33.2* MCV-101* MCH-33.5* MCHC-33.1 RDW-12.1 RDWSD-45.3 Plt ___ ___ 06:16PM BLOOD Glucose-122* UreaN-6 Creat-0.5 Na-134 K-5.5* Cl-98 HCO3-26 AnGap-16 ___ 07:07AM BLOOD Glucose-86 UreaN-8 Creat-0.6 Na-143 K-4.1 Cl-106 HCO3-28 AnGap-13

2165-12-06 12:30:00

ENGLISH

SINGLE

WHITE

M

[[26563588, Timestamp('2165-12-06 03:27:30'), '', 'DENT']]

[[{'Medications on Admission': ":\n-Reyatax 300'\n-Diclofenac 150''\n-Truvada 200-300'\n-Prenidolone\n-Norvir", 'Brief Hospital Course': ':\nHe was admitted to the surgical service under the care of Dr. \n___. He previously underwent placement of a reinforcing \nmandibular bone plate for debridement of osteomyelitis of the \nmandible which was complicated by\nnecrotizing fasciitis in the setting of an HIV infection during \n___ and ___. Subsequent surgery being planned by plastic \nsurgery service for a releasing\ngraft to correct scar contractures of neck which would enable \nhim to turn his head more freely and elevate his chin. On ___ \nhe was taken to the operating room by Dr. ___ removal of \nthe mandibular plate; there were no complications. \nPostoperatively he did have pain control issues for which oral \nnarcotics provided adequate relief. His initial dressing was \nchanged and rhe incision was clean and without any obvious signs \nof infection. He was discharged to home with follow up \ninstructions to see Dr. ___ on ___.\n\n', 'Pertinent Results:': 'NIL', 'Physical Exam:|Physical': 'NIL', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\n___ s/p mandibular bone plate removal for eventual \nreconstructive surgery with plastics. H/o necrotizing fasciitis \nof L ant neck s/p pectoralis flap. \n\nPast Medical History:\n-HIV, diagnosed ___, never on ARV, no Hx infections\n-Hx hemorrhoids, s/p "day surgery" x 3\n-iritis/uveitis\n-peripheral neuropathy\n-Necrotizing fasciitis\n\nSocial History:\n___\nFamily History:\nNC\n\n', 'Chief Complaint:|Complaint:': '\nThis is a ___ year old male with mandibular bone plate removal \nfor eventual plastic surgery reconstruction.\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nPatient recorded as having No Known Allergies to Drugs\n\n'}, '14759585-DS-11', 11, 'dental']]

[['CLINICAL INFORMATION: Evaluate for bone plate removal. History of\nosteomyelitis of mandible.\n\nFINDINGS:\n\nComparison is made to the prior study from ___. Since that time, the\nmandible plate and screws have been removed from the left side of the\nmandible. Screw tracts remain. The mandible has healed. No erosive changes\nto suggest osteomyelitis are identified at this time. The left aspect of the\nmandible is edentulous.\n', '14759585-RR-41', 41, '']]

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[]

['dental']

[[51221, Timestamp('2165-12-07 06:30:00'), Timestamp('2165-12-07 08:19:00'), 'Hematocrit'], [51222, Timestamp('2165-12-07 06:30:00'), Timestamp('2165-12-07 08:19:00'), 'Hemoglobin'], [51248, Timestamp('2165-12-07 06:30:00'), Timestamp('2165-12-07 08:19:00'), 'MCH'], [51249, Timestamp('2165-12-07 06:30:00'), Timestamp('2165-12-07 08:19:00'), 'MCHC'], [51250, Timestamp('2165-12-07 06:30:00'), Timestamp('2165-12-07 08:19:00'), 'MCV'], [51265, Timestamp('2165-12-07 06:30:00'), Timestamp('2165-12-07 08:19:00'), 'Platelet Count'], [51277, Timestamp('2165-12-07 06:30:00'), Timestamp('2165-12-07 08:19:00'), 'RDW'], [51279, Timestamp('2165-12-07 06:30:00'), Timestamp('2165-12-07 08:19:00'), 'Red Blood Cells'], [51301, Timestamp('2165-12-07 06:30:00'), Timestamp('2165-12-07 08:19:00'), 'White Blood Cells']]

Question: A 44 M is admitted. He/she says he/she has This is a ___ year old male with mandibular bone plate removal for eventual plastic surgery reconstruction. . History of illness: ___ s/p mandibular bone plate removal for eventual reconstructive surgery with plastics. H/o necrotizing fasciitis of L ant neck s/p pectoralis flap. Past Medical History: -HIV, diagnosed ___, never on ARV, no Hx infections -Hx hemorrhoids, s/p "day surgery" x 3 -iritis/uveitis -peripheral neuropathy -Necrotizing fasciitis Social History: ___ Family History: NC Allergies: Patient recorded as having No Known Allergies to Drugs What is the best procedure plan for this patient?

TARGETS Target Prescriptions: HYDROmorphone (Dilaudid) Sodium Chloride 0.9% Flush Ondansetron Potassium Chl 20 mEq / 1000 mL D5 1/2 NS PredniSONE Morphine Sulfate Haloperidol 0.9% Sodium Chloride (Mini Bag Plus) Ampicillin-Sulbactam Prochlorperazine Bacitracin Ointment Meperidine OxycoDONE-Acetaminophen Elixir Promethazine HCl Target Lab Orders: Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : He was admitted to the surgical service under the care of Dr. ___. He previously underwent placement of a reinforcing mandibular bone plate for debridement of osteomyelitis of the mandible which was complicated by necrotizing fasciitis in the setting of an HIV infection during ___ and ___. Subsequent surgery being planned by plastic surgery service for a releasing graft to correct scar contractures of neck which would enable him to turn his head more freely and elevate his chin. On ___ he was taken to the operating room by Dr. ___ removal of the mandibular plate; there were no complications. Postoperatively he did have pain control issues for which oral narcotics provided adequate relief. His initial dressing was changed and rhe incision was clean and without any obvious signs of infection. He was discharged to home with follow up instructions to see Dr. ___ on ___. Other Results: NIL

2151-05-24 07:15:00

ENGLISH

MARRIED

WHITE

M

[[26474843, Timestamp('2151-05-24 16:06:03'), '', 'NSURG']]

[[{'Medications on Admission': ':\nbupropion HCl SR 150 mg daily, Klonopin 1 mg tablet TID, \nmirtazapine 30 mg tablet qhs, Zoloft 100 mg tablet 1.5 tabs \ndaily, Nucynta ER 50 mg BID, Nucynta 50 mg tablet q6hr\n\nPatient to resume home medications including:\nNucynta ER 50 mg ER BID - patient has active script from \noutpatient Pain Clinic visit ___\nNucynta ___ 50mg Q6H prn - patient has active script from \noutpatient Pain Clinic visit ___\nClonazepam 1mg TID\nMirtazapine 30mg PO QHS\nSertraline 150mg Daily ', 'Brief Hospital Course': ':\n#Lumbar Spinal Stenosis\nThe patient was taken to the operating room on the day of \nadmission, ___ and underwent a L1-L2 Lumbar Laminectomy. \nHe tolerated the procedure well and was extubated in the \noperating room. He recovered in the PACU and later was \ntransferred to the Spine Floor for close neurologic monitoring.\nThe patient was alert and oriented throughout his \nhospitalization. On POD1 he was evaluated by ___, and able to \nambulate 20feet with a rolling walker, however his mobility was \nlargely limited by pain. \nHis pain regimen was modified and he was evaluated by Pain \nManagement inpatient consult service on the morning of POD2 who \nrecommended the additional of toradol IV while inpatient, as \nwell as a discharge pain regimen of:\nAcetminophen 650mg Q8H\nDiazepam 5mg PO Q6H prn for muscle spasm\nNucynta ER 50 mg ER BID - patient has active script from \noutpatient Pain Clinic visit ___\nNucynta ___ 50mg Q6H prn - patient has active script from \noutpatient Pain Clinic visit ___s resuming his home psychiatric medications of:\nBupropion 150mg SR BID\nClonazepam 1mg TID\nMirtazapine 30mg PO QHS\nSertraline 150mg Daily\n\nThe patient was provided the Pain Clinic office number and \ndirected to schedule an outpatient appointment if he felt he \nwished to be seen shortly after discharge.\n ___ also re-evaluated the patient on POD2. At that time he was \nable demonstrate independence with ambulation and found fit to \nbe discharged home under self care. Under the recommendation of \n___, the patient was provided a prescription to follow up with \noutpatient ___ services and directed to contact a ___ clinic of \nhis choosing. He was then discharged to home later that day on \n___.\n At the time of discharge, the patient was doing well, \nafebrile and hemodynamically stable. The patient was tolerating \na regular diet, ambulating, voiding without assistance, and pain \nwas well controlled. The patient received discharge teaching and \nfollow-up instructions with understanding verbalized and \nagreement with the discharge plan. \n\n', 'Pertinent Results:': '\nPlease see OMR for pertinent lab and imaging results. \n\n', 'Physical Exam:|Physical': '\nPHYSICAL EXAMINATION ON ADMISSION:\nMotor Examination: ___ in the upper and lower extremities \nbilaterally; sensation intact throughout all four extremities.\n\nPHYSICAL EXAMINATION ON DISCHARGE:\nGeneral:\n[ x]AVSS ___ 0722 Temp: 98.3 PO BP: 132/75 R Lying HR: 85\nRR: 18 O2 sat: 97% O2 delivery: Ra \n\nDrains:\nNone\n\nExam:\nOpens eyes: [ x]spontaneous [ ]to voice [ ]to noxious\nOrientation: [x ]Person [x ]Place [x ]Time\nFollows commands: [ ]Simple [ x]Complex [ ]None\nPupils: ERRL\nEOM: [x ]Full [ ]Restricted\nFace Symmetric: [ x]Yes [ ]NoTongue Midline: [ x]Yes [ ]No\nPronator Drift [ ]Yes [ x]No Speech Fluent: [x ]Yes [ ]No\nComprehension intact [ x]Yes [ ]No\n\nMotor:\nTrapDeltoidBicepTricepGrip\n___\n\nIPQuadHamATEHLGast\nRight___\nLeft5 5 5 5 5 5\n\n[ -]Clonus [ -___ [ +]Sensation intact to light touch\n[ +]Proprioception intact\n\nWound: \n primary dressings in place, CDI. Superficial closure with\nstaples.\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\n___ year old male, last seen in Pain Clinic on ___ with \nchief complaint of low back pain. His back pain radiates down \nthe posterior legs and calves. He describes the pain as sharp \nand increases with vacuuming and chores. He\nhas been on Nucynta 50mg ___ four times a day and 50mg ER BID. \nHe also takes clonazepam, mirtazapine, buproprion, sertraline. \nLast urine tox was ___ which was negative. \nHe has a history of prior fusion at\nL4-L5 with Dr. ___ had progressive stenosis with\nsevere neurogenic claudication. He can only walk about 100 feet\nover that he is having to sit, severe back pain and severe\nstenosis at L1-L2 and L2-L3. He has failed multiple different\ninjections, physical therapy and other conservative treatment. \nNucynta is helpful for him, but extremely expensive as his\ninsurance will not give him any substitute for that. Mr. ___ \nexpressed his desire to proceed with surgery. The risks and \nbenefits of surgery were reviewed in details with him in clinic. \nHe was booked for surgery ___\nDenies recent illness, fevers, chills, bowel or bladder changes\n\nPast Medical History:\n-prior OSA, resolved following gastric bypass\n-depression - followed by psychiatrist\n-anxiety\n-___t ___. \n-___ left knee arthroscopy at ___. \n-___ Cholecystectomy \n-___ Lumbar Laminectomy/Fusion\n\nSocial History:\n___\nFamily History:\nNC\n\n', 'Chief Complaint:|Complaint:': '\nLumbar Spinal Stenosis\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nPenicillins / Nortriptyline\n\n'}, '14494716-DS-18', 18, 'neurosurgery']]

[['EXAMINATION: LUMBAR SINGLE VIEW IN OR\n\nINDICATION: L1, L2 LAMINECTOMIES\n\nIMPRESSION: \n\nIntraoperative lateral view of the lumbar spine documents correct positioning\nof the surgical fixation devices. No radiologist was present.\n', '14494716-RR-19', 19, '']]

[[26474843, Timestamp('2151-05-24 18:00:00'), Timestamp('2151-05-26 17:00:00'), 'MAIN', 'Sodium Chloride 0.9% Flush', '', '0', '10 mL Syringe'], [26474843, Timestamp('2151-05-24 18:00:00'), Timestamp('2151-05-26 17:00:00'), 'MAIN', 'Influenza Vaccine Quadrivalent', '075715', '49281041688', '0.5 mL Syringe'], [26474843, Timestamp('2151-05-24 04:00:00'), Timestamp('2151-05-24 17:00:00'), 'MAIN', 'Celecoxib', '041286', '68084097601', '200mg Capsule'], [26474843, Timestamp('2151-05-24 04:00:00'), Timestamp('2151-05-24 17:00:00'), 'MAIN', 'Pregabalin', '057801', '00071101441', '75 mg Capsule'], [26474843, Timestamp('2151-05-24 18:00:00'), Timestamp('2151-05-26 17:00:00'), 'MAIN', 'HYDROmorphone (Dilaudid)', '062823', '00409128331', '1mg/1mL Syringe'], [26474843, Timestamp('2151-05-24 18:00:00'), Timestamp('2151-05-26 17:00:00'), 'MAIN', 'Acetaminophen', '004489', '00904198261', '325mg Tablet'], [26474843, Timestamp('2151-05-24 18:00:00'), Timestamp('2151-05-25 17:00:00'), 'MAIN', 'Lidocaine Jelly 2% (Glydo)', '038861', '25021067376', '6 mL Syringe'], [26474843, Timestamp('2151-05-24 18:00:00'), Timestamp('2151-05-26 17:00:00'), 'MAIN', 'Ondansetron', '016392', '51079052420', '4 mg Tablet'], [26474843, Timestamp('2151-05-24 04:00:00'), Timestamp('2151-05-24 17:00:00'), 'MAIN', 'Acetaminophen', '004490', '00904198861', '500mg Tablet'], [26474843, Timestamp('2151-05-24 18:00:00'), Timestamp('2151-05-25 12:00:00'), 'MAIN', 'OxyCODONE (Immediate Release)', '004225', '00904644461', '5mg Tablet'], [26474843, Timestamp('2151-05-24 04:00:00'), Timestamp('2151-05-24 17:00:00'), 'MAIN', 'OxyCODONE SR (OxyconTIN)', '072862', '59011041020', '10mg Tablet'], [26474843, Timestamp('2151-05-24 18:00:00'), Timestamp('2151-05-26 17:00:00'), 'MAIN', 'Diazepam', '003768', '00904588061', '5 mg Tab'], [26474843, Timestamp('2151-05-24 18:00:00'), Timestamp('2151-05-26 17:00:00'), 'BASE', 'Lactated Ringers', '001187', '00338011704', 'Floor Stock Bag'], [26474843, Timestamp('2151-05-24 20:00:00'), Timestamp('2151-05-25 11:00:00'), 'BASE', 'Iso-Osmotic Dextrose', '', '0', '100ml Bag'], [26474843, Timestamp('2151-05-24 20:00:00'), Timestamp('2151-05-25 11:00:00'), 'MAIN', 'CeFAZolin', '075120', '00338350841', '2 g / 100 mL Dextrose (iso-os)'], [26474843, Timestamp('2151-05-24 22:00:00'), Timestamp('2151-05-26 17:00:00'), 'MAIN', 'Mirtazapine', '046451', '00052010730', '30 mg Tab']]

[['01NB0ZZ', 10, 1, Timestamp('2151-05-24 00:00:00'), 'Release Lumbar Nerve, Open Approach']]

['neurosurgery']

[]

Question: A 57 M is admitted. He/she says he/she has Lumbar Spinal Stenosis . History of illness: ___ year old male, last seen in Pain Clinic on ___ with chief complaint of low back pain. His back pain radiates down the posterior legs and calves. He describes the pain as sharp and increases with vacuuming and chores. He has been on Nucynta 50mg ___ four times a day and 50mg ER BID. He also takes clonazepam, mirtazapine, buproprion, sertraline. Last urine tox was ___ which was negative. He has a history of prior fusion at L4-L5 with Dr. ___ had progressive stenosis with severe neurogenic claudication. He can only walk about 100 feet over that he is having to sit, severe back pain and severe stenosis at L1-L2 and L2-L3. He has failed multiple different injections, physical therapy and other conservative treatment. Nucynta is helpful for him, but extremely expensive as his insurance will not give him any substitute for that. Mr. ___ expressed his desire to proceed with surgery. The risks and benefits of surgery were reviewed in details with him in clinic. He was booked for surgery ___ Denies recent illness, fevers, chills, bowel or bladder changes Past Medical History: -prior OSA, resolved following gastric bypass -depression - followed by psychiatrist -anxiety -___t ___. -___ left knee arthroscopy at ___. -___ Cholecystectomy -___ Lumbar Laminectomy/Fusion Social History: ___ Family History: NC Allergies: Penicillins / Nortriptyline What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Sodium Chloride 0.9% Flush Influenza Vaccine Quadrivalent Celecoxib Pregabalin HYDROmorphone (Dilaudid) Acetaminophen Lidocaine Jelly 2% (Glydo) Ondansetron Acetaminophen OxyCODONE (Immediate Release) OxyCODONE SR (OxyconTIN) Diazepam Lactated Ringers Iso-Osmotic Dextrose CeFAZolin Mirtazapine Target Lab Orders: NONE Target Procedures: Release Lumbar Nerve, Open Approach DOCTOR'S NOTE Hospital Notes: : #Lumbar Spinal Stenosis The patient was taken to the operating room on the day of admission, ___ and underwent a L1-L2 Lumbar Laminectomy. He tolerated the procedure well and was extubated in the operating room. He recovered in the PACU and later was transferred to the Spine Floor for close neurologic monitoring. The patient was alert and oriented throughout his hospitalization. On POD1 he was evaluated by ___, and able to ambulate 20feet with a rolling walker, however his mobility was largely limited by pain. His pain regimen was modified and he was evaluated by Pain Management inpatient consult service on the morning of POD2 who recommended the additional of toradol IV while inpatient, as well as a discharge pain regimen of: Acetminophen 650mg Q8H Diazepam 5mg PO Q6H prn for muscle spasm Nucynta ER 50 mg ER BID - patient has active script from outpatient Pain Clinic visit ___ Nucynta ___ 50mg Q6H prn - patient has active script from outpatient Pain Clinic visit ___s resuming his home psychiatric medications of: Bupropion 150mg SR BID Clonazepam 1mg TID Mirtazapine 30mg PO QHS Sertraline 150mg Daily The patient was provided the Pain Clinic office number and directed to schedule an outpatient appointment if he felt he wished to be seen shortly after discharge. ___ also re-evaluated the patient on POD2. At that time he was able demonstrate independence with ambulation and found fit to be discharged home under self care. Under the recommendation of ___, the patient was provided a prescription to follow up with outpatient ___ services and directed to contact a ___ clinic of his choosing. He was then discharged to home later that day on ___. At the time of discharge, the patient was doing well, afebrile and hemodynamically stable. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Other Results: Please see OMR for pertinent lab and imaging results.

2166-02-26 17:49:00

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MARRIED

WHITE

M

[[25974789, Timestamp('2166-02-26 17:50:10'), '', 'CSURG']]

[[{'Medications on Admission': ':\nThe Preadmission Medication list is accurate and complete.\n1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever \n2. Aspirin EC 81 mg PO DAILY \n3. Metoprolol Succinate XL 25 mg PO DAILY \n4. Atorvastatin 40 mg PO QPM \n5. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob/wheezing \n6. Allopurinol ___ mg PO BID \n7. Colchicine 0.6 mg PO PRN gout flare \n8. Fluticasone Propionate NASAL 1 SPRY NU BID:PRN allergies \n9. Vitamin D ___ UNIT PO DAILY \n\nSecondary diagnosis \nCoronary Artery Disease s/p cabg \nHyperlipidemia\nHypertension\nRight Bundle Branch Block\nProstate cancer s/p radiation\nGout', 'Brief Hospital Course': ':\nPresented for evaluation of left effusion, with CTA that was \nconcerning for loculated hemothorax. He received hydration for \ncontrast and renal function was stable. ___ was consulted and \nplaced CT ___ with drainage however not full expansion of \nlung. CT chest was performed and reviewed by Dr ___. \n___ tube was removed with no pneumothorax post pull. He was \nclinically stable, plan for reimaging with ___ in few weeks and \nevaluation in clinic at this time no further intervention and \ndischarged home. He is ambulating without shortness of breath \n\n', 'Pertinent Results:': '\n___ 04:55AM BLOOD WBC-7.3 RBC-2.68* Hgb-7.5* Hct-24.0* \nMCV-90 MCH-28.0 MCHC-31.3* RDW-14.2 RDWSD-45.7 Plt ___\n___ 01:06PM BLOOD WBC-11.8* RBC-3.20* Hgb-9.1* Hct-29.5* \nMCV-92 MCH-28.4 MCHC-30.8* RDW-14.4 RDWSD-48.2* Plt ___\n___ 01:06PM BLOOD ___ PTT-30.4 ___\n___ 04:55AM BLOOD Glucose-98 UreaN-19 Creat-1.2 Na-140 \nK-4.1 Cl-104 HCO3-25 AnGap-11\n___ 01:06PM BLOOD Glucose-108* UreaN-20 Creat-1.3* Na-140 \nK-3.9 Cl-102 HCO3-22 AnGap-16\n___ 04:55AM BLOOD Calcium-8.7 Phos-4.0 Mg-1.8\n___ 05:05AM BLOOD Mg-1.7\n\nCT chest ___\nFINDINGS: \n\nHEART AND VASCULATURE: The thoracic aorta is normal in caliber. \n Mild \natherosclerotic calcifications of the thoracic aorta are \npresent. \nIntraluminal blood shows marked hypodensity compared to \nmyocardium and vessel \nwalls. The heart is normal in size. There is no pericardial \neffusion. \nPostsurgical changes of CABG are noted. \n\nAXILLA, HILA, AND MEDIASTINUM: Prominent nonenlarged prevascular \nand \nparatracheal lymph nodes are similar compared to prior \nexamination. No \naxillary or hilar lymphadenopathy is appreciated. No evidence \nof a \nmediastinal mass within the limitations of a nonenhanced study. \nMild fat \nstranding in the anterior mediastinum is nonspecific, similar to \nprior \nexamination. The esophagus shows normal course and caliber. A \nsmall hiatal \nhernia is present. \n\nPLEURAL SPACES: There is redemonstration of a left-sided pigtail \nchest tube \nwith interval decrease in size of the slightly complicated and \nintermediate \ndensity loculated effusion. As previously, there is associated \nleft lower \nlobe and lingular compressive atelectasis which is overall \nimproved. There is \nno pneumothorax. \n\nLUNGS/AIRWAYS: The central airways are patent. There is mild \nperibronchial \nthickening particularly in the lower lobes. Mild bronchiectasis \nis noted. \nStreaky opacities in the left lung base most likely relate to \natelectasis. \nOtherwise no focal consolidation is identified. A 5 mm nodule \nin the right \nmiddle lobe (302:131) likely relates to a fissural pulmonary \nlymph node. No \nother discrete pulmonary mass/nodule is identified. \n\nBASE OF NECK: Visualized portions of the base of the neck show \nno abnormality. \n\nABDOMEN: Included portion of the unenhanced upper abdomen again \ndemonstrates \na partially visualized simple right renal cyst measuring up to \n6.4 cm. \n\nBONES: No suspicious osseous abnormality is seen.? There is no \nacute fracture. \nPostsurgical changes of a sternotomy are noted. \n\nIMPRESSION: \n\n1. Stable left pleural pigtail catheter with interval decrease \nin size of the \nloculated hemothorax, which is now small in size. \n2. Improved aeration of the left lung with interval resolution \nof previously \nseen left upper lobe infiltrate. \n\n___ CTA \n\nFINDINGS: \n\nHEART AND VASCULATURE: Pulmonary vasculature is well opacified \nto the \nsegmental level without evidence of filling defect to indicate \nacute pulmonary \nembolus. Please note that the left lower lobe pulmonary arteries \nare not well \nevaluated. The thoracic aorta is normal in caliber with some \nirregular mural \nthrombus seen the distal portion (2:74). The patient is status \npost CABG. No \npericardial effusion. \n\nAXILLA, HILA, AND MEDIASTINUM: No axillary, hilar or mediastinal \n\nlymphadenopathy. Conspicuous, subcentimeter mediastinal nodes \nare nonspecific \nand possibly reactive. \n\nPLEURAL SPACES: There is heart, high density left pleural \neffusion causing \ncollapse of the left lower lobe (measuring up to 55 ___ \nunits \ninferiorly). This effusion is multi-loculated with a \npara-mediastinal \ncomponent (2:25). No focus of extravasation is seen within this \neffusion. No \nright pleural effusion. No pneumothorax. \n\nLUNGS/AIRWAYS: The central airways are patent. The large pleural \neffusion \nexerts mass effect on the is left upper lobe which remains \nwell-aerated. \nThere are multiple nodular opacities within the left upper lobe \nparenchyma \nwhich could reflect infection or aspiration (2:32). There is \ncollapse of the \nleft lower lobe secondary to the pleural effusion. The right \nlung is grossly \nclear aside from some chronic appearing fibrotic changes in the \npara-mediastinal right lower lobe (2:79). \n\nBASE OF NECK: Visualized portions of the base of the neck show \nno abnormality. \n\nABDOMEN: There is a partially visualized 6.2 cm simple cyst in \nthe right \nkidney (2:115). The visualized upper abdomen is otherwise \nunremarkable. \n\nBONES: No suspicious osseous abnormality is seen.? There is no \nacute fracture. \nHealed fracture of the left anterior second rib. Chronic \nappearing deformity \nseen in the lateral left sixth and seventh ribs. Sternotomy \nclips noted. \nPostsurgical changes anterior chest wall. \n\nIMPRESSION: \n\n1. Large, high-density loculated left pleural effusion causing \ncollapse of the \nleft lower lobe. \n2. Nodular opacities in the left upper lobe are suspicious for \ninfection or \naspiration. Clinical correlation is advised. \n3. The right lung is clear without pleural effusion. \n\n', 'Physical Exam:|Physical': '\nAdmission \n\nVital Signs sheet entries for ___: \nBP: 120/78. Heart Rate: 94. O2 Saturation%: 96. Resp. Rate: 18.\nPain Score: ___.\nHeight: 5\'2" Weight: 162lb\n\nGeneral: Well-developed male in no acute distress\nSkin: Dry [X] intact [X] sternum CDI no click\nHEENT: PERRLA [X] EOMI [X]\nNeck: Supple [X] Full ROM [X]\nChest: Lungs decreased bilaterally L> right []\nHeart: RRR [ x] [] Murmur [] grade ______ \nAbdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds \n+\n[X]\nExtremities: Warm [X], well-perfused [X] Edema [] none_____\nVaricosities: None [X]\nNeuro: Grossly intact [X]\nPulses:\nFemoral Right:+1 Left:+1\nDP Right:+1 Left:+1\n___ Right:+1 Left:+1\nRadial Right:+1 Left: +1\n\nCarotid Bruit: Right: - Left: -\n\nDischarge Examination \n\n24 HR Data (last updated ___ @ 1524)\n Temp: 98.0 (Tm 100.5), BP: 147/69 (106-147/67-71), HR: 79 \n(72-97), RR: 18, O2 sat: 96% (94-97), O2 delivery: Ra, Wt: \n158.07 lb/71.7 kg\nFluid Balance (last updated ___ @ 1257)\n Last 8 hours Total cumulative -205ml\n IN: Total 480ml, PO Amt 480ml\n OUT: Total 685ml, Urine Amt 675ml, CT 10ml\n Last 24 hours Total cumulative -860ml\n IN: Total 840ml, PO Amt 840ml\n OUT: Total 1700ml, Urine Amt 1550ml, CT ___\n\nGeneral: NAD \nNeurological: A/O x3 non-focal \nCardiovascular: RRR \nRespiratory: decrease left base No resp distress \nGI/Abdomen: Bowel sounds present Soft ND NT \nExtremities: \nRight Upper extremity Warm Edema none\nLeft Upper extremity Warm Edema none\nRight Lower extremity Warm Edema trace\nLeft Lower extremity Warm Edema trace\nPulses:\nDP Right: + Left: +\n___ Right: + Left: +\nRadial Right: + Left: +\nSternal: CDI no erythema or drainage Sternum stable \nLower extremity: Left CDI\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\nMr. ___ is a very nice ___ year old\nman with a history of hyperlipidemia and hypertension. He\nunderwent on ___ Coronary artery bypass grafting x 3,\nleft internal mammary artery graft to left anterior\ndescending, reverse saphenous vein graft to the posterior\ndescending artery and to marginal branch. His post-op course was\nuneventful except for creatinine peak from 1.3 to 1.7. He was\ndischarged to home on POD5 in stable condition with improving\nrenal function. According to the patient and his son he has been\nprogressing well except for the recent development of SOB with\npersistent dry cough that has worsened over the past week. He \nhas\nalso been more fatigued and his Lopressor was changed to \nextended\nrelease in an attempt to improve his fatigue.\nThe patient went to see his primary care doctor in ___ and\nhad a CT scan done without contrast which showed a moderate\nleft-sided effusion concerning for hemothorax. The son then \ndrove\nthe patient here. The patient is here having some mild cough and\nsome discomfort on the right side of his chest not the left.\nOtherwise no other symptoms. The patient does not have any leg\nswelling. \nRepeat imaging here today CTA/PA&Lat revealed large left\neffusion. Discussed with Dr. ___. Patient will be admitted \nto\n___ for left chest tube placement and monitoring.\n\nPast Medical History:\nCoronary Artery Disease\nHyperlipidemia\nHypertension\nRight Bundle Branch Block\nProstate cancer s/p radiation\nGout\n\nSocial History:\n___\nFamily History:\nMother - CAD s/p CABG at ___\nFather - N/C\nSiblings - Hyperlipidemia\n\n', 'Chief Complaint:|Complaint:': '\nShortness of breath \n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nlisinopril / losartan / omeprazole / ranitidine\n\n'}, '15818040-DS-14', 14, 'cardiothoracic']]

[['INDICATION: ___ with cough with L sided effusion c/f hemothorax s/p CABG in\n___ // cough with L sided effusion c/f hemothorax s/p CABG in ___\n\nTECHNIQUE: PA and lateral views the chest.\n\nCOMPARISON: Chest x-ray from ___.\n\nFINDINGS: \n\nThere has been interval increase in size of the now moderate to large\nleft-sided pleural effusion with evidence of loculation laterally and likely\nposteriorly. The right lung is clear. Patient is status post median\nsternotomy. No acute osseous abnormalities.\n\nIMPRESSION: \n\nInterval increase in size of moderate to large left pleural effusion which\nappears loculated.\n', '15818040-RR-20', 20, 'pa and lateral views the chest.'], ['EXAMINATION: CTA CHEST WITH CONTRAST\n\nINDICATION: ___ with shortness of breath and cough // ?hemothorax\n\nTECHNIQUE: Axial multidetector CT images were obtained through the thorax\nafter the uneventful administration of intravenous contrast. Reformatted\ncoronal, sagittal, thin slice axial images, and oblique maximal intensity\nprojection images were submitted to PACS and reviewed.\n\nDOSE: Acquisition sequence:\n 1) Stationary Acquisition 2.0 s, 0.5 cm; CTDIvol = 12.1 mGy (Body) DLP =\n6.1 mGy-cm.\n 2) Spiral Acquisition 4.2 s, 33.3 cm; CTDIvol = 15.3 mGy (Body) DLP = 508.0\nmGy-cm.\n Total DLP (Body) = 514 mGy-cm.\n\nCOMPARISON: Chest radiograph ___.\n\nFINDINGS: \n\nHEART AND VASCULATURE: Pulmonary vasculature is well opacified to the\nsegmental level without evidence of filling defect to indicate acute pulmonary\nembolus. Please note that the left lower lobe pulmonary arteries are not well\nevaluated. The thoracic aorta is normal in caliber with some irregular mural\nthrombus seen the distal portion (2:74). The patient is status post CABG. No\npericardial effusion.\n\nAXILLA, HILA, AND MEDIASTINUM: No axillary, hilar or mediastinal\nlymphadenopathy. Conspicuous, subcentimeter mediastinal nodes are nonspecific\nand possibly reactive.\n\nPLEURAL SPACES: There is heart, high density left pleural effusion causing\ncollapse of the left lower lobe (measuring up to 55 Hounsfield units\ninferiorly). This effusion is multi-loculated with a para-mediastinal\ncomponent (2:25). No focus of extravasation is seen within this effusion. No\nright pleural effusion. No pneumothorax.\n\nLUNGS/AIRWAYS: The central airways are patent. The large pleural effusion\nexerts mass effect on the is left upper lobe which remains well-aerated. \nThere are multiple nodular opacities within the left upper lobe parenchyma\nwhich could reflect infection or aspiration (2:32). There is collapse of the\nleft lower lobe secondary to the pleural effusion. The right lung is grossly\nclear aside from some chronic appearing fibrotic changes in the\npara-mediastinal right lower lobe (2:79).\n\nBASE OF NECK: Visualized portions of the base of the neck show no abnormality.\n\nABDOMEN: There is a partially visualized 6.2 cm simple cyst in the right\nkidney (2:115). The visualized upper abdomen is otherwise unremarkable.\n\nBONES: No suspicious osseous abnormality is seen.? There is no acute fracture.\nHealed fracture of the left anterior second rib. Chronic appearing deformity\nseen in the lateral left sixth and seventh ribs. Sternotomy clips noted. \nPostsurgical changes anterior chest wall.\n\nIMPRESSION:\n\n\n1. Large, high-density loculated left pleural effusion causing collapse of the\nleft lower lobe.\n2. Nodular opacities in the left upper lobe are suspicious for infection or\naspiration. Clinical correlation is advised.\n3. The right lung is clear without pleural effusion.\n', '15818040-RR-21', 21, 'axial multidetector ct images were obtained through the thorax\nafter the uneventful administration of intravenous contrast. reformatted\ncoronal, sagittal, thin slice axial images, and oblique maximal intensity\nprojection images were submitted to pacs and reviewed.'], ['EXAMINATION: CHEST (PORTABLE AP)\n\nINDICATION: ___ year old man with large loculated effusion // eval CT\nplacement and lung expansion\n\nTECHNIQUE: Portable chest radiograph\n\nCOMPARISON: Chest radiograph dated ___ at 13:27.\nChest CT dated ___ at 16:45\n\nIMPRESSION: \n\nThere has been interval placement of a chest tube in the left lung base. \nThere is a moderate sized left pleural effusion which demonstrates substantial\nimprovement compared to the prior radiograph. The right lung is clear. No\nother significant interval changes.\n', '15818040-RR-22', 22, 'portable chest radiograph'], ['EXAMINATION: CHEST (PA AND LAT)\n\nINDICATION: ___ year old man with cabgx3 readmitted for hemothorax // Assess\nleft lung post left chest tube ___\n\nIMPRESSION: \n\nIn comparison with the study of ___, the left pigtail catheter is in\nplace and there has been some decrease in the amount of pleural fluid and\nvolume loss in the lower lung. On the lateral view, there is opacification\noverlying the posterior aspect of the lower dorsal spine. This could\nrepresent a loculated component of pleural fluid.\nNo evidence of acute pneumonia or vascular congestion.\n', '15818040-RR-24', 24, ''], ['EXAMINATION: CT CHEST W/O CONTRAST\n\nINDICATION: ___ year old man with s/p cabg // evaluation of left lung concern\nfor persistent hemothorax after CT placement ? rind still present\n\nTECHNIQUE: Contiguous axial images were obtained through the chest without\nintravenous contrast. Coronal, sagittal and MIP reformats were performed.\n\nCOMPARISON: CTA of the chest of ___. Chest radiograph ___.\n\nFINDINGS: \n\nHEART AND VASCULATURE: The thoracic aorta is normal in caliber. Mild\natherosclerotic calcifications of the thoracic aorta are present. \nIntraluminal blood shows marked hypodensity compared to myocardium and vessel\nwalls. The heart is normal in size. There is no pericardial effusion. \nPostsurgical changes of CABG are noted.\n\nAXILLA, HILA, AND MEDIASTINUM: Prominent nonenlarged prevascular and\nparatracheal lymph nodes are similar compared to prior examination. No\naxillary or hilar lymphadenopathy is appreciated. No evidence of a\nmediastinal mass within the limitations of a nonenhanced study. Mild fat\nstranding in the anterior mediastinum is nonspecific, similar to prior\nexamination. The esophagus shows normal course and caliber. A small hiatal\nhernia is present.\n\nPLEURAL SPACES: There is redemonstration of a left-sided pigtail chest tube\nwith interval decrease in size of the slightly complicated and intermediate\ndensity loculated effusion. As previously, there is associated left lower\nlobe and lingular compressive atelectasis which is overall improved. There is\nno pneumothorax.\n\nLUNGS/AIRWAYS: The central airways are patent. There is mild peribronchial\nthickening particularly in the lower lobes. Mild bronchiectasis is noted. \nStreaky opacities in the left lung base most likely relate to atelectasis. \nOtherwise no focal consolidation is identified. A 5 mm nodule in the right\nmiddle lobe (302:131) likely relates to a fissural pulmonary lymph node. No\nother discrete pulmonary mass/nodule is identified.\n\nBASE OF NECK: Visualized portions of the base of the neck show no abnormality.\n\nABDOMEN: Included portion of the unenhanced upper abdomen again demonstrates\na partially visualized simple right renal cyst measuring up to 6.4 cm.\n\nBONES: No suspicious osseous abnormality is seen.? There is no acute fracture.\nPostsurgical changes of a sternotomy are noted.\n\nIMPRESSION: \n\n1. Stable left pleural pigtail catheter with interval decrease in size of the\nloculated hemothorax, which is now small in size.\n2. Improved aeration of the left lung with interval resolution of previously\nseen left upper lobe infiltrate.\n', '15818040-RR-25', 25, 'contiguous axial images were obtained through the chest without\nintravenous contrast. coronal, sagittal and mip reformats were performed.'], ['EXAMINATION: CHEST (PORTABLE AP)\n\nINDICATION: ___ year old man with hemothorax // eval for ptx s/p CT removal\n\nTECHNIQUE: Portable chest radiograph\n\nIMPRESSION: \n\nComparison made with chest radiograph dated ___ at 11:36 and\nchest CT dated ___ 15:35.\n\nThere has been interval removal of the right chest tube. No pneumothorax. No\nother significant interval changes. Stable left pleural effusion with\ncompressive atelectasis.\n', '15818040-RR-26', 26, 'portable chest radiograph']]

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[['0W9B30Z', 10, 1, Timestamp('2166-02-27 00:00:00'), 'Drainage of Left Pleural Cavity with Drainage Device, Percutaneous Approach']]

['cardiothoracic']

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Question: A 76 M is admitted. He/she says he/she has Shortness of breath . History of illness: Mr. ___ is a very nice ___ year old man with a history of hyperlipidemia and hypertension. He underwent on ___ Coronary artery bypass grafting x 3, left internal mammary artery graft to left anterior descending, reverse saphenous vein graft to the posterior descending artery and to marginal branch. His post-op course was uneventful except for creatinine peak from 1.3 to 1.7. He was discharged to home on POD5 in stable condition with improving renal function. According to the patient and his son he has been progressing well except for the recent development of SOB with persistent dry cough that has worsened over the past week. He has also been more fatigued and his Lopressor was changed to extended release in an attempt to improve his fatigue. The patient went to see his primary care doctor in ___ and had a CT scan done without contrast which showed a moderate left-sided effusion concerning for hemothorax. The son then drove the patient here. The patient is here having some mild cough and some discomfort on the right side of his chest not the left. Otherwise no other symptoms. The patient does not have any leg swelling. Repeat imaging here today CTA/PA&Lat revealed large left effusion. Discussed with Dr. ___. Patient will be admitted to ___ for left chest tube placement and monitoring. Past Medical History: Coronary Artery Disease Hyperlipidemia Hypertension Right Bundle Branch Block Prostate cancer s/p radiation Gout Social History: ___ Family History: Mother - CAD s/p CABG at ___ Father - N/C Siblings - Hyperlipidemia Allergies: lisinopril / losartan / omeprazole / ranitidine What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Metoprolol Succinate XL Magnesium Oxide Sodium Chloride 0.9% Metoprolol Succinate XL Fluticasone Propionate NASAL Aspirin EC Polyethylene Glycol Acetaminophen Albuterol Inhaler Allopurinol Bisacodyl Sodium Chloride 0.9% Flush Senna Docusate Sodium Atorvastatin Target Lab Orders: Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells RDW-SD Anion Gap Bicarbonate Chloride Creatinine Glucose H I Magnesium Potassium Sodium Urea Nitrogen L Hematocrit Cholesterol, Pleural Glucose, Pleural Lactate Dehydrogenase, Pleural Total Protein, Pleural proBNP, Pleural pH Eosinophils Hematocrit, Pleural Lymphocytes Macrophages Monos Other Polys Total Nucleated Cells, Pleural Target Procedures: Drainage of Left Pleural Cavity with Drainage Device, Percutaneous Approach DOCTOR'S NOTE Hospital Notes: : Presented for evaluation of left effusion, with CTA that was concerning for loculated hemothorax. He received hydration for contrast and renal function was stable. ___ was consulted and placed CT ___ with drainage however not full expansion of lung. CT chest was performed and reviewed by Dr ___. ___ tube was removed with no pneumothorax post pull. He was clinically stable, plan for reimaging with ___ in few weeks and evaluation in clinic at this time no further intervention and discharged home. He is ambulating without shortness of breath Other Results: ___ 04:55AM BLOOD WBC-7.3 RBC-2.68* Hgb-7.5* Hct-24.0* MCV-90 MCH-28.0 MCHC-31.3* RDW-14.2 RDWSD-45.7 Plt ___ ___ 01:06PM BLOOD WBC-11.8* RBC-3.20* Hgb-9.1* Hct-29.5* MCV-92 MCH-28.4 MCHC-30.8* RDW-14.4 RDWSD-48.2* Plt ___ ___ 01:06PM BLOOD ___ PTT-30.4 ___ ___ 04:55AM BLOOD Glucose-98 UreaN-19 Creat-1.2 Na-140 K-4.1 Cl-104 HCO3-25 AnGap-11 ___ 01:06PM BLOOD Glucose-108* UreaN-20 Creat-1.3* Na-140 K-3.9 Cl-102 HCO3-22 AnGap-16 ___ 04:55AM BLOOD Calcium-8.7 Phos-4.0 Mg-1.8 ___ 05:05AM BLOOD Mg-1.7 CT chest ___ FINDINGS: HEART AND VASCULATURE: The thoracic aorta is normal in caliber. Mild atherosclerotic calcifications of the thoracic aorta are present. Intraluminal blood shows marked hypodensity compared to myocardium and vessel walls. The heart is normal in size. There is no pericardial effusion. Postsurgical changes of CABG are noted. AXILLA, HILA, AND MEDIASTINUM: Prominent nonenlarged prevascular and paratracheal lymph nodes are similar compared to prior examination. No axillary or hilar lymphadenopathy is appreciated. No evidence of a mediastinal mass within the limitations of a nonenhanced study. Mild fat stranding in the anterior mediastinum is nonspecific, similar to prior examination. The esophagus shows normal course and caliber. A small hiatal hernia is present. PLEURAL SPACES: There is redemonstration of a left-sided pigtail chest tube with interval decrease in size of the slightly complicated and intermediate density loculated effusion. As previously, there is associated left lower lobe and lingular compressive atelectasis which is overall improved. There is no pneumothorax. LUNGS/AIRWAYS: The central airways are patent. There is mild peribronchial thickening particularly in the lower lobes. Mild bronchiectasis is noted. Streaky opacities in the left lung base most likely relate to atelectasis. Otherwise no focal consolidation is identified. A 5 mm nodule in the right middle lobe (302:131) likely relates to a fissural pulmonary lymph node. No other discrete pulmonary mass/nodule is identified. BASE OF NECK: Visualized portions of the base of the neck show no abnormality. ABDOMEN: Included portion of the unenhanced upper abdomen again demonstrates a partially visualized simple right renal cyst measuring up to 6.4 cm. BONES: No suspicious osseous abnormality is seen.? There is no acute fracture. Postsurgical changes of a sternotomy are noted. IMPRESSION: 1. Stable left pleural pigtail catheter with interval decrease in size of the loculated hemothorax, which is now small in size. 2. Improved aeration of the left lung with interval resolution of previously seen left upper lobe infiltrate. ___ CTA FINDINGS: HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the segmental level without evidence of filling defect to indicate acute pulmonary embolus. Please note that the left lower lobe pulmonary arteries are not well evaluated. The thoracic aorta is normal in caliber with some irregular mural thrombus seen the distal portion (2:74). The patient is status post CABG. No pericardial effusion. AXILLA, HILA, AND MEDIASTINUM: No axillary, hilar or mediastinal lymphadenopathy. Conspicuous, subcentimeter mediastinal nodes are nonspecific and possibly reactive. PLEURAL SPACES: There is heart, high density left pleural effusion causing collapse of the left lower lobe (measuring up to 55 ___ units inferiorly). This effusion is multi-loculated with a para-mediastinal component (2:25). No focus of extravasation is seen within this effusion. No right pleural effusion. No pneumothorax. LUNGS/AIRWAYS: The central airways are patent. The large pleural effusion exerts mass effect on the is left upper lobe which remains well-aerated. There are multiple nodular opacities within the left upper lobe parenchyma which could reflect infection or aspiration (2:32). There is collapse of the left lower lobe secondary to the pleural effusion. The right lung is grossly clear aside from some chronic appearing fibrotic changes in the para-mediastinal right lower lobe (2:79). BASE OF NECK: Visualized portions of the base of the neck show no abnormality. ABDOMEN: There is a partially visualized 6.2 cm simple cyst in the right kidney (2:115). The visualized upper abdomen is otherwise unremarkable. BONES: No suspicious osseous abnormality is seen.? There is no acute fracture. Healed fracture of the left anterior second rib. Chronic appearing deformity seen in the lateral left sixth and seventh ribs. Sternotomy clips noted. Postsurgical changes anterior chest wall. IMPRESSION: 1. Large, high-density loculated left pleural effusion causing collapse of the left lower lobe. 2. Nodular opacities in the left upper lobe are suspicious for infection or aspiration. Clinical correlation is advised. 3. The right lung is clear without pleural effusion.

2151-03-31 07:15:00

ENGLISH

MARRIED

WHITE

F

[[22124059, Timestamp('2151-03-31 02:47:24'), '', 'GU']]

[[{'Medications on Admission': 'NIL', 'Brief Hospital Course': ":\nPatient was admitted to Dr. ___ Dr. ___ service \nafter undergoing lap radical cystectomy and ileal conduit. No \nconcerning intraoperative events occurred; please see dictated \noperative note for details. Patient received perioperative \nantibiotic prophylaxis and deep vein thrombosis prophylaxis with \npneumoboots. With the passage of flatus, patient's diet was \nadvanced. The patient was ambulating and pain was controlled on \noral medications by this time. The ostomy nurse saw the patient \nfor ostomy teaching. At the time of discharge the wound was \nhealing well with no evidence of erythema, swelling, or purulent \ndrainage. The ostomy was perfused and patent. Patient is \nscheduled to follow up in one weeks time with in clinic for \nwound check.\n\n5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 \ntimes a day) for 20 days: Over the Counter.\nDisp:*40 Capsule(s)* Refills:*0*\n6. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) \nCapsule, Delayed Release(E.C.) PO DAILY (Daily). \n7. Estradiol 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). \n8. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: One (1) \nTablet Sustained Release 12 hr PO twice a day. \n9. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime for 5 \ndays: Over the Counter. Stop taking if having loose stools.\nDisp:*10 Tablet(s)* Refills:*0*\n10. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H \n(every 6 hours) as needed for pain, fever. \n11. Nitrofurantoin (Macrocryst25%) 100 mg Capsule Sig: One (1) \nCapsule PO once a day for 30 days.\nDisp:*30 Capsule(s)* Refills:*0*\n12. Oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 \nhours) as needed for pain.\nDisp:*30 Tablet(s)* Refills:*0*\n13. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO four times a \nday for 10 days: Take with food. Over the Counter - take three \n200 mg tablets.\nDisp:*40 Tablet(s)* Refills:*0*\n\nFacility:\n___", 'Pertinent Results:': 'NIL', 'Physical Exam:|Physical': 'NIL', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\n___ for cystectomy\n\nPast Medical History:\nPMH:\nChronic pelvic pain syndrome\nBladder cancer\nDiabetes type I\nHTN\nHigh cholestrol\n\nPSH:\nHysterectomy\nTURBT\nBladder biopsy\nCystoscopy and hydrodistention\n\nSocial History:\nno EtOH, no smoking, no IVDU\nretired ___\n\n', 'Chief Complaint:|Complaint:': '\nInterstitial Cystitis, Bladder Cancer\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nAdhesive Tape\n\n'}, '19937555-DS-9', 9, 'urology']]

[]

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[]

['urology']

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15:13:00'), Timestamp('2151-03-31 15:17:00'), 'Base Excess'], [50804, Timestamp('2151-03-31 15:13:00'), Timestamp('2151-03-31 15:17:00'), 'Calculated Total CO2'], [50806, Timestamp('2151-03-31 15:13:00'), Timestamp('2151-03-31 15:17:00'), 'Chloride, Whole Blood'], [50808, Timestamp('2151-03-31 15:13:00'), Timestamp('2151-03-31 15:17:00'), 'Free Calcium'], [50809, Timestamp('2151-03-31 15:13:00'), Timestamp('2151-03-31 15:17:00'), 'Glucose'], [50810, Timestamp('2151-03-31 15:13:00'), Timestamp('2151-03-31 15:17:00'), 'Hematocrit, Calculated'], [50811, Timestamp('2151-03-31 15:13:00'), Timestamp('2151-03-31 15:17:00'), 'Hemoglobin'], [50813, Timestamp('2151-03-31 15:13:00'), Timestamp('2151-03-31 15:17:00'), 'Lactate'], [50818, Timestamp('2151-03-31 15:13:00'), Timestamp('2151-03-31 15:17:00'), 'pCO2'], [50820, Timestamp('2151-03-31 15:13:00'), Timestamp('2151-03-31 15:17:00'), 'pH'], [50821, Timestamp('2151-03-31 15:13:00'), Timestamp('2151-03-31 15:17:00'), 'pO2'], [50822, Timestamp('2151-03-31 15:13:00'), Timestamp('2151-03-31 15:17:00'), 'Potassium, Whole Blood'], [50824, Timestamp('2151-03-31 15:13:00'), Timestamp('2151-03-31 15:17:00'), 'Sodium, Whole Blood'], [52033, Timestamp('2151-03-31 15:13:00'), Timestamp('2151-03-31 15:16:00'), 'Specimen Type'], [51237, Timestamp('2151-03-31 17:40:00'), Timestamp('2151-03-31 18:53:00'), 'INR(PT)'], [51274, Timestamp('2151-03-31 17:40:00'), Timestamp('2151-03-31 18:53:00'), 'PT'], [51275, Timestamp('2151-03-31 17:40:00'), Timestamp('2151-03-31 18:53:00'), 'PTT'], [51221, Timestamp('2151-03-31 17:40:00'), Timestamp('2151-03-31 18:19:00'), 'Hematocrit'], [51222, Timestamp('2151-03-31 17:40:00'), Timestamp('2151-03-31 18:19:00'), 'Hemoglobin'], [51248, Timestamp('2151-03-31 17:40:00'), Timestamp('2151-03-31 18:19:00'), 'MCH'], [51249, Timestamp('2151-03-31 17:40:00'), Timestamp('2151-03-31 18:19:00'), 'MCHC'], [51250, Timestamp('2151-03-31 17:40:00'), Timestamp('2151-03-31 18:19:00'), 'MCV'], [51265, Timestamp('2151-03-31 17:40:00'), Timestamp('2151-03-31 18:19:00'), 'Platelet Count'], [51277, Timestamp('2151-03-31 17:40:00'), Timestamp('2151-03-31 18:19:00'), 'RDW'], [51279, Timestamp('2151-03-31 17:40:00'), Timestamp('2151-03-31 18:19:00'), 'Red Blood Cells'], [51301, Timestamp('2151-03-31 17:40:00'), Timestamp('2151-03-31 18:19:00'), 'White Blood Cells'], [50868, Timestamp('2151-03-31 17:40:00'), Timestamp('2151-03-31 18:54:00'), 'Anion Gap'], [50882, Timestamp('2151-03-31 17:40:00'), Timestamp('2151-03-31 18:54:00'), 'Bicarbonate'], [50902, Timestamp('2151-03-31 17:40:00'), Timestamp('2151-03-31 18:54:00'), 'Chloride'], [50912, Timestamp('2151-03-31 17:40:00'), Timestamp('2151-03-31 18:54:00'), 'Creatinine'], [50920, Timestamp('2151-03-31 17:40:00'), Timestamp('2151-03-31 18:54:00'), 'Estimated GFR (MDRD equation)'], [50931, Timestamp('2151-03-31 17:40:00'), Timestamp('2151-03-31 18:54:00'), 'Glucose'], [50960, Timestamp('2151-03-31 17:40:00'), Timestamp('2151-03-31 18:54:00'), 'Magnesium'], [50971, Timestamp('2151-03-31 17:40:00'), Timestamp('2151-03-31 18:54:00'), 'Potassium'], [50983, Timestamp('2151-03-31 17:40:00'), Timestamp('2151-03-31 18:54:00'), 'Sodium'], [51006, Timestamp('2151-03-31 17:40:00'), Timestamp('2151-03-31 18:54:00'), 'Urea Nitrogen'], [50868, Timestamp('2151-04-01 06:00:00'), Timestamp('2151-04-01 06:59:00'), 'Anion Gap'], [50882, Timestamp('2151-04-01 06:00:00'), Timestamp('2151-04-01 06:59:00'), 'Bicarbonate'], [50902, Timestamp('2151-04-01 06:00:00'), Timestamp('2151-04-01 06:59:00'), 'Chloride'], [50912, Timestamp('2151-04-01 06:00:00'), Timestamp('2151-04-01 06:59:00'), 'Creatinine'], [50931, Timestamp('2151-04-01 06:00:00'), Timestamp('2151-04-01 06:59:00'), 'Glucose'], [50960, Timestamp('2151-04-01 06:00:00'), Timestamp('2151-04-01 06:59:00'), 'Magnesium'], [50971, Timestamp('2151-04-01 06:00:00'), Timestamp('2151-04-01 06:59:00'), 'Potassium'], [50983, Timestamp('2151-04-01 06:00:00'), Timestamp('2151-04-01 06:59:00'), 'Sodium'], [51006, Timestamp('2151-04-01 06:00:00'), Timestamp('2151-04-01 06:59:00'), 'Urea Nitrogen'], [51221, Timestamp('2151-04-01 06:00:00'), Timestamp('2151-04-01 06:28:00'), 'Hematocrit'], [51222, Timestamp('2151-04-01 06:00:00'), Timestamp('2151-04-01 06:28:00'), 'Hemoglobin'], [51248, Timestamp('2151-04-01 06:00:00'), Timestamp('2151-04-01 06:28:00'), 'MCH'], [51249, Timestamp('2151-04-01 06:00:00'), Timestamp('2151-04-01 06:28:00'), 'MCHC'], [51250, Timestamp('2151-04-01 06:00:00'), Timestamp('2151-04-01 06:28:00'), 'MCV'], [51265, Timestamp('2151-04-01 06:00:00'), Timestamp('2151-04-01 06:28:00'), 'Platelet Count'], [51277, Timestamp('2151-04-01 06:00:00'), Timestamp('2151-04-01 06:28:00'), 'RDW'], [51279, Timestamp('2151-04-01 06:00:00'), Timestamp('2151-04-01 06:28:00'), 'Red Blood Cells'], [51301, Timestamp('2151-04-01 06:00:00'), Timestamp('2151-04-01 06:28:00'), 'White Blood Cells']]

Question: A 53 F is admitted. He/she says he/she has Interstitial Cystitis, Bladder Cancer . History of illness: ___ for cystectomy Past Medical History: PMH: Chronic pelvic pain syndrome Bladder cancer Diabetes type I HTN High cholestrol PSH: Hysterectomy TURBT Bladder biopsy Cystoscopy and hydrodistention Social History: no EtOH, no smoking, no IVDU retired ___ Allergies: Adhesive Tape What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Acetaminophen Artificial Tears Lorazepam Ondansetron Zolpidem Tartrate Iso-Osmotic Dextrose CefazoLIN Oxycodone SR (OxyconTIN) Estradiol Sodium Chloride 0.9% Flush Docusate Sodium Milk of Magnesia Alprazolam Metoprolol Tartrate Sertraline Duloxetine Ketorolac Simvastatin HYDROmorphone (Dilaudid) NS MetRONIDAZOLE (FLagyl) Potassium Chl 20 mEq / 1000 mL D5 1/2 NS Cepacol (Menthol) Target Lab Orders: Base Excess Calculated Total CO2 Chloride, Whole Blood Free Calcium Glucose Hematocrit, Calculated Hemoglobin Lactate pCO2 pH pO2 Potassium, Whole Blood Specimen Type Base Excess Calculated Total CO2 Chloride, Whole Blood Free Calcium Glucose Lactate pCO2 pH pO2 Potassium, Whole Blood Sodium, Whole Blood Specimen Type Base Excess Calculated Total CO2 Chloride, Whole Blood Free Calcium Glucose Hematocrit, Calculated Hemoglobin Lactate pCO2 pH pO2 Potassium, Whole Blood Sodium, Whole Blood Specimen Type Base Excess Calculated Total CO2 Chloride, Whole Blood Free Calcium Glucose Hematocrit, Calculated Hemoglobin Lactate pCO2 pH pO2 Potassium, Whole Blood Sodium, Whole Blood Specimen Type Base Excess Calculated Total CO2 Chloride, Whole Blood Free Calcium Glucose Hematocrit, Calculated Hemoglobin Lactate pCO2 pH pO2 Potassium, Whole Blood Sodium, Whole Blood Specimen Type INR(PT) PT PTT Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells Anion Gap Bicarbonate Chloride Creatinine Estimated GFR (MDRD equation) Glucose Magnesium Potassium Sodium Urea Nitrogen Anion Gap Bicarbonate Chloride Creatinine Glucose Magnesium Potassium Sodium Urea Nitrogen Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : Patient was admitted to Dr. ___ Dr. ___ service after undergoing lap radical cystectomy and ileal conduit. No concerning intraoperative events occurred; please see dictated operative note for details. Patient received perioperative antibiotic prophylaxis and deep vein thrombosis prophylaxis with pneumoboots. With the passage of flatus, patient's diet was advanced. The patient was ambulating and pain was controlled on oral medications by this time. The ostomy nurse saw the patient for ostomy teaching. At the time of discharge the wound was healing well with no evidence of erythema, swelling, or purulent drainage. The ostomy was perfused and patent. Patient is scheduled to follow up in one weeks time with in clinic for wound check. 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 20 days: Over the Counter. Disp:*40 Capsule(s)* Refills:*0* 6. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. Estradiol 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO twice a day. 9. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime for 5 days: Over the Counter. Stop taking if having loose stools. Disp:*10 Tablet(s)* Refills:*0* 10. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, fever. 11. Nitrofurantoin (Macrocryst25%) 100 mg Capsule Sig: One (1) Capsule PO once a day for 30 days. Disp:*30 Capsule(s)* Refills:*0* 12. Oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 13. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO four times a day for 10 days: Take with food. Over the Counter - take three 200 mg tablets. Disp:*40 Tablet(s)* Refills:*0* Facility: ___ Other Results: NIL

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[[20696310, Timestamp('2198-01-14 18:29:31'), '', 'PSYCH']]

[[{'Medications on Admission': ':\nThe Preadmission Medication list is accurate and complete.\n1. Abacavir Sulfate 600 mg PO DAILY \n2. Aspirin 81 mg PO DAILY \n3. Atorvastatin 40 mg PO QPM \n4. Calcitriol 0.25 mcg PO DAILY \n5. ClonazePAM 1 mg PO BID \n6. Calcium Acetate 1334 mg PO TID W/MEALS \n7. Docusate Sodium 100 mg PO BID \n8. Doxepin HCl 25 mg PO HS \n9. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol \n10. Glucose Gel 15 g PO PRN hypoglycemia protocol \n11. Gabapentin 300 mg PO BID \n12. Lopinavir-Ritonavir 2 TAB PO BID \n13. Loratadine 10 mg PO DAILY \n14. Labetalol 200 mg PO BID \n15. Lunesta (eszopiclone) 2 mg oral QHS:PRN \n16. Lidocaine 1% 1 mL ID DAILY:PRN AVF/AVG needle insertion \n17. Pantoprazole 40 mg PO Q24H \n18. Raltegravir 400 mg PO BID \n19. Sertraline 200 mg PO DAILY \n20. amLODIPine 5 mg PO DAILY \n21. sevelamer CARBONATE 1600 mg PO TID W/MEALS \n22. Glargine 16 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin\n\napply to affected area twice daily \nRX *bacitracin zinc 500 unit/gram apply to right leg abrasion \ntwice daily Refills:*0 \n3. Dextroamphetamine 5 mg PO QAM \nRX *dextroamphetamine [Dexedrine] 5 mg 1 tablet(s) by mouth in \nthe morning Disp #*4 Tablet Refills:*0 \n4. Gauze Pad (gauze bandage) 4 X 4 topical BID \napply over right leg abrasion after bacitracin; change twice \ndaily \nRX *gauze bandage [Band-Aid Gauze Pads] 4" X 4" apply to right \nleg abrasion twice daily Disp #*1 Package Refills:*1 \n5. HydrOXYzine 50 mg PO QHS:PRN insomnia \ndo not take with other sedating medications for insomnia \nRX *hydroxyzine HCl 50 mg 1 package by mouth 50 mg at bedtime \nDisp #*4 Tablet Refills:*0 \n6. Nephrocaps 1 CAP PO DAILY \nRX *B complex with C#20-folic acid [Nephrocaps] 1 mg 1 \ncapsule(s) by mouth daily Disp #*20 Capsule Refills:*0 \n7. Calcitriol 0.5 mcg PO 3X/WEEK (___) \nRX *calcitriol 0.5 mcg 1 capsule(s) by mouth three times per \nweek on HD days Disp #*12 Capsule Refills:*0 \n8. Glargine 16 Units Bedtime\nInsulin SC Sliding Scale using HUM Insulin \n9. Loratadine 10 mg PO EVERY OTHER DAY \n10. Abacavir Sulfate 600 mg PO DAILY \n11. Aspirin 81 mg PO DAILY \n12. Atorvastatin 40 mg PO QPM \n13. Calcium Acetate 1334 mg PO TID W/MEALS \n14. ClonazePAM 1 mg PO BID \n15. Docusate Sodium 100 mg PO BID \nhold for loose stools \n16. Gabapentin 300 mg PO BID \n17. Labetalol 200 mg PO BID \n18. Lopinavir-Ritonavir 2 TAB PO BID \n19. Lunesta (eszopiclone) 2 mg oral QHS:PRN \ndo not take with other sedating medications for insomnia \n20. Pantoprazole 40 mg PO Q24H \n21. Raltegravir 400 mg PO BID \ntake after HD \n22. Sertraline 200 mg PO DAILY \n23. sevelamer CARBONATE 1600 mg PO TID W/MEALS \n\nFacility:\n___', 'Brief Hospital Course': ":\nPatient is a ___ yo man with a history of MDD with prior history \nof suicide attempt and passive self-injurious behavior by \nwithholding important medical care who presented via EMS for \nworsening depression and suicidal ideation with recent \nintentional non-adherence with his medications and thoughts of \noverdosing on sleeping pills.\n\nThe patient endorsed long-standing depression, which acutely \nworsened the week prior to admission and manifested with \nanhedonia, isolative behavior, sleep disturbances, poor \nappetite, and feeling overwhelmed. He identified several \npsychosocial stressors, including his recent second BKA, being \nalone in his apartment after his mother left, and having so many \nmedical appointments.\n\nThe presentation was consistent with an Adjustment Disorder with \nMixed Anxiety and Depression in the setting of both complicated \nmedical problems and psychosocial stressors.\n\nHe was admitted to the locked inpatient psychiatry unit for \nsafety, medication adjustments, and improvement in mood. He was \ntreated with individual, group and milieu therapy. Dexedrine was \nadded for mood and energy, and hydroxyzine was added for sleep. \nHe was discharged home with outpatient psychiatric follow up and \na coordinated medical plan with his outpatient team.\n\nDSM V Diagnosis:\n- Adjustment Disorder with Mixed Anxiety and Depression \n- Major Depressive Disorder, Recurrent, Severe\n- Unspecified Anxiety Disorder\n\n1. LEGAL & SAFETY: \nOn admission, the patient signed a conditional voluntary \nagreement (Section 10 & 11) and remained on that level \nthroughout their admission. They were also placed on 15 minute \nchecks status on admission and remained on that level of \nobservation throughout while being unit restricted. They were \ngreen sharps status throughout admission.\n\n2. PSYCHIATRIC:\n # Adjustment Disorder with Mixed Anxiety and Depression; Major \nDepressive Disorder, Recurrent, Severe; Unspecified Anxiety \nDisorder\n Interventions:\n- Provided individual, group, and milieu therapy\n- Dexedrine 5 mg short acting in the morning; should be taking \nprior to HD on dialysis days\n- Continue home psychiatric medications:\nSertraline 200 mg PO/NG DAILY\nClonazePAM 1 mg PO/NG BID\nHydrOXYzine 50 mg PO/NG QHS:PRN insomnia\n\n3. MEDICAL\n # Right stump abrasion - developed during admission, likely due \nto prosthetics, no sign of infection\n-bacitracin ointment twice daily, to be covered with gauze \ndressings\n-contacted Dr. ___ at ___ for \nurgent appointment for further evaluation and possible \nadjustment of prosthetics\n\n # Diabetes mellitus\n-Insulin Glargine 16u DAILY + SSI (patient should continue home \nsliding scale as recommended by PCP)\n-Aspirin 81 mg PO/NG DAILY\n-Atorvastatin 40 mg PO/NG QPM\n-Gabapentin 300 mg PO/NG BID\n\n # ESRD on HD\n-Calcium Acetate 1334 mg PO/NG TID W/MEALS\n-Calcitriol 0.5 mcg PO 3X/WEEK (___) - dosing changed at \nrecommendation of inpatient renal dialysis team\n-Nephrocaps 1 CAP PO/NG DAILY - added at recommendation of \ninpatient renal dialysis team\n-sevelamer CARBONATE 1600 mg PO TID W/MEALS\n\n # HIV - CD4 636 and VL undetectable in ___\n-Raltegravir 400 mg PO BID\n-Lopinavir-Ritonavir 2 TAB PO BID\n-Abacavir Sulfate 600 mg PO DAILY\n\n # GERD\n-Pantoprazole 40 mg PO Q24H\n\n # HTN\n-amLODIPine 5 mg PO/NG DAILY - medication stopped at \nrecommendation of inpatient renal dialysis team due to low blood \npressures (systolics ___ and ___, symptomatic with diaphoresis \nand lightheadedness once)\n-continue Labetalol 200 mg PO/NG BID\n\n # Seasonal allergies\n-Loratadine 10 mg PO EVERY OTHER DAY - dosing changed at \nrecommendation of inpatient renal dialysis team\n\n # OSA\n- not on home CPAP\n\n5. PSYCHOSOCIAL\n#) GROUPS/MILIEU: \nThe patient was encouraged to participate in the various groups \nand milieu therapy opportunities offered by the unit. The \npatient often attended these groups that focused on teaching \npatients various coping skills and usually was an active \nparticipant.\n\n#) COLLATERAL CONTACTS & FAMILY INVOLVEMENT\n- contacted outpatient PCP ___ ___ on \n___ and spoke with him re: medical treatment plan. He stated \nthat pt is better at managing HIV meds but poor at managing \ndiabetes.\n- Contacted outpatient therapist ___ at ___ \n___ and left voicemail on ___ and ___\n- Contacted outpatient psychiatrist Dr. ___ at ___ \n___ and spoke with him on ___. States \nthat wellbutrin in combination with SSRI has worked in the past \nbut not wellbutrin alone. Spoke with him again on ___ about \nmedication options and that stimulants had been tried in past as \nadjunctive therapy sometimes causing irritability but Dexedrine \nhad not been tried. The other option is venlafaxine instead of \nZoloft. Pt took venlafaxine in ___ but only up to 75 mg daily \nand was discontinued for unclear reasons. Phone for scheduling \nadmin is ___.\n- met with outpatient team ___ RN and ___ \n___ ___, fax ___ on ___ \nto review discharge plan and discharge resources\n\n#) INTERVENTIONS\n- Medications: started Dexedrine 5 mg in the morning\n- Psychotherapeutic Interventions: Individual, group, and milieu \ntherapy.\n- Coordination of aftercare: see attached list of follow up \nappointments\n\nINFORMED CONSENT: The team discussed the indications for, \nintended benefits of, and possible side effects and risks of \nstarting this medication, and risks and benefits of possible \nalternatives, including not taking the medication, with this \npatient. We discussed the patient's right to decide whether to \ntake this medication as well as the importance of the patient's \nactively participating in the treatment and discussing any \nquestions about medications with the treatment team, and I \nanswered the patient's questions. The patient appeared able to \nunderstand and consented to begin the medication.\n\nRISK ASSESSMENT\nOn presentation, the patient was evaluated and felt to be at an \nincreased risk of harm to herself and/or others based upon \nsuicidal ideation with plan but not intent, increased symptoms \nof depression (anhedonia, isolative behavior, sleep \ndisturbances, poor appetite, and feeling overwhelmed). Their \nstatic factors noted at that time include history of suicide \nattempts, chronic mental illness, history of substance abuse, \nmale gender, Caucasian race, single marital status, LGBT \nidentity, and chronic medical illness. The modifiable risk \nfactors were suicidal ideation with plan but no intent, \nintentional medication noncompliance, poorly controlled mental \nillness, hopelessness, agitation, limited social supports, \ninsomnia, and recent personal loss. These were addressed with \nmedication adjustments, group/milieu therapy, and individual \ntherapy including motivational interviewing. Finally, the \npatient is being discharged with many protective risk factors, \nincluding help-seeking nature, future-oriented viewpoint and \nstrong outpatient care team. Overall, based on the totality of \nour assessment at this time, the patient is not at an acutely \nelevated risk of self-harm nor danger to others. \n\nOur Prognosis of this patient is fair based on improvement in \nmood and lack of suicidal ideation resulting from medication \nadjustments and inpatient therapies.\n\n", 'Pertinent Results:': '\nAdmission labs:\n ___: Na: 140\n ___: K: 5.3\n ___: Cl: 97\n ___: CO2: 21\n ___: BUN: 48\n ___: Creat: 8.2\n ___: Glucose: 199\n\n ___: WBC: 6.2\n ___: HGB: 12.5*\n ___: HCT: 39.0*\n ___: Plt Count: 208\n\n ___: Urine Glucose (Hem): 100\n ___: Urine Protein (Hem): 300\n ___: Urine Bilirubin (Hem): NEG\n ___: Urobilinogen: NEG\n ___: Urine Ketone (Hem): NEG\n ___: Urine Blood (Hem): NEG\n ___: Urine Nitrite (Hem): NEG\n ___: Urine Leuks (Hem): NEG\n ___: TSH: 2.3\n\nSerum toxicology: Negative\nUrine toxicology: Patient Anuric\n\n', 'Physical Exam:|Physical': '\nAdmission Exam:\nVitals: T 97.7 HR69 BP 135/78 RR16 SaO2 96% RA\n *Station and Gait: Non-ambulatory.\n *Tone and Strength: Normal bulk and tone. Patient moves all 4\nextremities symmetrically, full apparent strength. No myoclonus\nor pronator drift. \n Abnormal Movements: no tics, tremors, evidence of EPS\n Frontal Release: not assessed \n Sensory: diffusely intact\n Reflexes: Not assessed.\n Cerebellar: No truncal ataxia.\n CN II-XII intact without evidence of focal deficits.\n\nCognition: \n Wakefulness/alertness: alert and engaged in interview \n *Attention (MOYB): correctly lists MOYB with no errors \n *Orientation: oriented x3 (self, location and date) \n *Memory: Intact to ___ immediate recall ("dog, red,\nhonesty"), ___ delayed recall \n *Fund of knowledge: appropriate - able to state current\npresident of the ___ and current presidential\ncandidates. \n Calculations: Correctly states 7 quarters in $1.75\n Abstraction: Appropriately interprets proverb, ___ judge a\nbook by its cover." \n Visuospatial: no gross deficits \n *Speech: normal tone, volume, rate and prosody\n *Language: fluent ___ speaker without paraphasic errors.\n\n Mental Status:\n *Appearance: Pt appears stated age, adequate grooming, \nwearing\na hospital ___\n ___: Cooperative, appropriate eye contact.\n *Mood and Affect: "overwhelmed;" Restricted, mood-congruent \n *Thought process / *associations: Grossly linear; no LOA\n *Thought Content: Report of SI with recent intentional med\nadherence to passively induce self harm, as well as plan to\noverdose on Lunesta without intent; No HI No AH/VH; patient\ndoes not appear to be responding to internal stimuli.\n *Judgment and Insight: Impaired/impaired.\n\nDischarge Exam:\nVitals: 97.9F, 126/75, 57, 16, 100%\n\n*Station and Gait: Non-ambulatory (bilateral BKA, needs to use\nwalker with prosthetics).\n *Tone and Strength: Normal bulk and tone. Patient moves all 4\nextremities symmetrically, full apparent strength. No \nmyoclonus.\n\n Abnormal Movements: no tics, tremors, evidence of EPS\n Cerebellar: No truncal ataxia.\n CN II-XII intact without evidence of focal deficits.\n\nCognition: \n Wakefulness/alertness: alert and engaged in interview \n *Attention: attentive to interview \n *Orientation: oriented to self and situation \n *Memory: Intact to recent and remote events \n *Fund of knowledge: appropriate \n *Speech: normal tone, volume, rate; prosody intact\n *Language: fluent ___ speaker without paraphasic errors.\n\n Mental Status:\n *Appearance: Caucasian man, increased abdominal girth,\nbilateral leg amputations, appears stated age, in shirt and gym\nshorts, mildly disheveled hair\n Behavior: Cooperative, calm, appropriate eye contact.\n *Mood and Affect: "I\'m okay;" Restricted, mood-congruent \n *Thought process / *associations: linear, at times\ncircumstantial\n *Thought Content: denies SI, HI. No AH/VH; patient\ndoes not appear to be responding to internal stimuli.\n *Judgment and Insight: poor/fair\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\nHISTORY OF PRESENT ILLNESS: Pt is a ___ male with personal and\nfamily histories of depressive and alcohol use disorders, also\nwith HIV, OSA, longstanding severe type II DM, ESRD on 3x/wk\ndialysis, recent second BKA, who arrived via EMS, and presents\nwith poor self care for one week and recent suicidal ideation\nwith plan but no intent.\n\nOn interview, patient initially states that he is "not caring\nanymore" and has "wanted something to happen to me." Reports\nthat he has been non-adherent with his medications for the past\nweek including his insulin, recognizing that this could be\nharmful and potentially lethal. Additionally, he reports recent\nlimited poor PO intake, which he also recognizes has potential\nconsequences. He recognizes that "maybe it will kill me," and \n"I\nguess I was okay with it." In addition, he reports recently\nmissing important medical appointments. He has been going to\ndialysis, but states he feels restless there and had wished he\nwasn\'t there.\n\nPatient identifies a number of stressors leading up to his\ncurrent presentation. His mother, who had been staying with him\nafter his second BKA to assist in his adjustment, left\napproximately one week ago. He adds that she was a source of\nstress when she was with him, but now he is feeling overwhelmed\nthat she has left. Also feels overwhelmed with the number of\nmedical appointments he has. Has been seeing his therapist\nweekly since he was last evaluated in our ED ~one month ago, but\nstates "maybe it\'s helpful, maybe it\'s bringing things up also." \n\nRecently set up a "homemaker" to come to his apartment to help\nout with cleaning, but felt overwhelmed when the time came to\nmake a schedule and felt that he was unable. \n\nRecently seen here in ___ - plan to be discharged with close\nfollow-up from Psychiatrist and Therapist. Reports doing okay\nfor awhile. Looking back to this, patient says he now feels\n"more blunted and depressed." \n\nReports that he is unable to "reason myself out of this." \nThought\nabout reaching out to people over the weekend - but was unable \nto\ndo so. Additionally hasn\'t been able to follow-through with\nfriends, family, etc with whom he made plans. Has been avoiding\nall telephone calls, including from his mother and sister, \nadding\nthat he "didn\'t want to talk to anybody." \n\nReports contemplating overdosing on his Lunesta multiple times\nover the past week. He states that "I wouldn\'t do it," and that\n"there is too much fear involved."\n\nCollateral: \nEMS Report: \n___. FOUND SEATED AT HOME W/ HOME NURSE, AOX4, WARM, DRY, GOOD\nSKIN COLOR C/O DEPRESSION AND S/I X1WK, HX OF THE SAME. ___.\nSTATES THIS WEEK HE HAS FELT LIKE HE DOES NOT WANT TO WAKE UP,\nHOPES HE JUST HAS A HEART ATTACK, NON MED COMPLIANT THIS WEEK.\n___. OVERWHELMED BY CURRENT MEDICAL PROBLEMS, W/ MOST RECENT\nBILATERAL KNEE AMPUTATIONS. ___. DENIES ANY TRAUMA OR INJURY,\nDENIES DOING ANYTHING TO HURT HIMSELF APART FROM NOT TAKING \nMEDS.\n___. COOPERATIVE, AGREED TO TRANSPORT, CARE TRANSFERRED TO BID\nSTAFF."\n\nContact Numbers\nHCP: ___ ___ or ___\nMother: ___, cell ___\nSister: ___ ___\nFather: ___ ___\nOther numbers listed as contacts, without names:\nPhone: ___\nCell phone: ___\nCase manager from ___: ___ at ___\nTherapist ___ at ___ ___, direct line\nPsychiatrist: Dr. ___ at ___, ___\n___ Services (___)\n\nPsychiatric ROS:\n- Depression - + sleep disturbances, overwhelmed, feeling things\nare unmanageable, isolation, anhedonia, active and passive SI\nwith plan, no intent.\n- Psychosis - denies symptoms including delusions (persecutory,\ngrandiose, thought broadcasting/insertion/withdrawal) or\nhallucinations (auditory, visual, olfactory, or tactile). \n- Mania- denies symptoms including elevated mood or \nirritability,\nmarked increases in goal-directed behavior, racing thoughts, a\ndecreased need for sleep, or social/economic indiscretion\n- Anxiety - Denies symptoms of panic attacks or agoraphobia. \n\nMedical ROS:\n- Positive for: tingling in his fingers; pain in right and left\narme ("tendonitis," has braces but haven\'t been using).\n- Otherwise, a 10-point ROS was negative, including: no fever,\nHA, eye pain, hearing deficit, chest pain, difficulty breathing,\nabdominal pain, constipation, diarrhea, musculoskeletal pain\n\nPast Medical History:\nPAST PSYCHIATRIC HISTORY (from my note dated ___ and updated\nwith patient as necessary):\n- Dx: MDD, Panic disorder with agoraphobia and anxiety per \nreview\nof records on OMR (Patient denies this diagnosis)\n- Hospitalizations: Most recently on Deac 4 in twice in ___ for SI and intentional excessive fluid intake and\nmedication non-compliance); previously at ___ ___ for\nsevere depression and initiation of ECT, again ___ and\n___, ___ in ___ for anxiety/depression, another\nadmission s/p OD in college. Reports the ECT was helpful in the\npast, but he is unsure whether he would do it again.\n-SA/SIB: h/o SA at age ___ by OD on "pills" in the context of \na\n"fight" with his mother regarding his "sexuality and \ndepression";\ndenies past SIB. Does not have access to firearms.\n-Medication Trials: Fluvoxamine, Ativan, Effexor, Cymbalta,\ntrazodone (caused priapism); found most antidepressants\nunhelpful, with the exception of Wellbutrin. Has not tried TCAs\n(with the exception of amitriptyline for insomnia).\nElectroconvulsive therapy x 8 during prior psych admission in\n___\n- Psychiatrist - Dr. ___ at ___\nAs per Dr. ___ note on ___:\n- Harm to self: in ___, HCP confirmed prir suicide attempt via\nOD for which patient was treated at ___\n- Harm to others: in ___, patient was noted for the first time\nto have threatened both his mother and his friend ___, his HCP.\n\nPAST MEDICAL HISTORY:\n- ESRD, on HD\n- Diabetes Mellitus 2 (x ___ yrs)\n- HIV- CD4 495 ___ - started regimen in ___ AZT\nnot compliant, then NFV/d4T/3TC until ___, then briefly for 2\nmonths on EFV but had important side effects and immediately\nchanged to NVP in ___ ddI/TDF/NVP - off ARV since ___ -->\nstarted ABC/LPV/RTV/RTGV ___\n- Lipodystrophy\n- Hypogonadism\n- Obesity\n- Hyperlipidemia\n- Asthma \n- Obstructive sleep apnea \n- Internal anal condylomata s/p excision (___)\n- s/p perianal abscess I+D ___\n- HPV\n- hidradenitis suppurativa\n- Heel spur\n- s/p Appendectomy (___)\n- s/p bilateral BKA\n- h/o HD line sepsis\n- h/o + PPD, took INH\n- diabetic retinopathy\n\nSocial History:\nSUBSTANCE ABUSE HISTORY:\n- ETOH - denies any current use, denies detoxes\n- Illicits - history of cocaine abuse in the past\n- Tobacco - Quit smoking in ___, 13 pack year history.\n\nFORENSIC HISTORY:\n___\nSOCIAL HISTORY:\n(from my note dated ___ and updated with patient as\nnecessary): \nPatient originally from ___ (just ___ of \n___\nbut grew up in ___. Parents divorced when pt was ___\nyears old, describes childhood as unsupportive, witnessed\nphysical abuse of his mother from ___ and also endured\nphysical and emotion abuse from ___ as well He currently\nlives alone in an apartment near ___ in ___. Graduated\ncollege, obtained ___ degree in ___. He is not\ncurrently working since ___ when he went on medical leave. He \nis\non SSI and receives food stamps. Has identified as gay at least\nsince age ___. \n\nAs per Dr. ___ note on ___:\n"Patient has family in ___. He has ___, home health aide, and has\na ___ form active for transport. He owns a wheelchair. ___ not\ncoming right now as mom is there, but he could access this. He\nhas not been sexually active in years and has not even tried\nmasturbating since second BKA."\n\nFamily History:\nFAMILY PSYCHIATRIC HISTORY:\n(from my note dated ___ and updated with patient as\nnecessary): \nPer OMR, brothers with EtOH addictions and father with \ndepression\n\n', 'Chief Complaint:|Complaint:': '\n"No one thing happened"\n\n', 'Attending:': ' ___\n\n', 'Allergies:': ' \nErythromycin Base\n\n'}, '14111050-DS-33', 33, 'psychiatry']]

[]

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[['5A1D60Z', 10, 1, Timestamp('2198-01-14 00:00:00'), 'Performance of Urinary Filtration, Multiple']]

['psychiatry']

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Question: A 41 M is admitted. He/she says he/she has "No one thing happened" . History of illness: HISTORY OF PRESENT ILLNESS: Pt is a ___ male with personal and family histories of depressive and alcohol use disorders, also with HIV, OSA, longstanding severe type II DM, ESRD on 3x/wk dialysis, recent second BKA, who arrived via EMS, and presents with poor self care for one week and recent suicidal ideation with plan but no intent. On interview, patient initially states that he is "not caring anymore" and has "wanted something to happen to me." Reports that he has been non-adherent with his medications for the past week including his insulin, recognizing that this could be harmful and potentially lethal. Additionally, he reports recent limited poor PO intake, which he also recognizes has potential consequences. He recognizes that "maybe it will kill me," and "I guess I was okay with it." In addition, he reports recently missing important medical appointments. He has been going to dialysis, but states he feels restless there and had wished he wasn't there. Patient identifies a number of stressors leading up to his current presentation. His mother, who had been staying with him after his second BKA to assist in his adjustment, left approximately one week ago. He adds that she was a source of stress when she was with him, but now he is feeling overwhelmed that she has left. Also feels overwhelmed with the number of medical appointments he has. Has been seeing his therapist weekly since he was last evaluated in our ED ~one month ago, but states "maybe it's helpful, maybe it's bringing things up also." Recently set up a "homemaker" to come to his apartment to help out with cleaning, but felt overwhelmed when the time came to make a schedule and felt that he was unable. Recently seen here in ___ - plan to be discharged with close follow-up from Psychiatrist and Therapist. Reports doing okay for awhile. Looking back to this, patient says he now feels "more blunted and depressed." Reports that he is unable to "reason myself out of this." Thought about reaching out to people over the weekend - but was unable to do so. Additionally hasn't been able to follow-through with friends, family, etc with whom he made plans. Has been avoiding all telephone calls, including from his mother and sister, adding that he "didn't want to talk to anybody." Reports contemplating overdosing on his Lunesta multiple times over the past week. He states that "I wouldn't do it," and that "there is too much fear involved." Collateral: EMS Report: ___. FOUND SEATED AT HOME W/ HOME NURSE, AOX4, WARM, DRY, GOOD SKIN COLOR C/O DEPRESSION AND S/I X1WK, HX OF THE SAME. ___. STATES THIS WEEK HE HAS FELT LIKE HE DOES NOT WANT TO WAKE UP, HOPES HE JUST HAS A HEART ATTACK, NON MED COMPLIANT THIS WEEK. ___. OVERWHELMED BY CURRENT MEDICAL PROBLEMS, W/ MOST RECENT BILATERAL KNEE AMPUTATIONS. ___. DENIES ANY TRAUMA OR INJURY, DENIES DOING ANYTHING TO HURT HIMSELF APART FROM NOT TAKING MEDS. ___. COOPERATIVE, AGREED TO TRANSPORT, CARE TRANSFERRED TO BID STAFF." Contact Numbers HCP: ___ ___ or ___ Mother: ___, cell ___ Sister: ___ ___ Father: ___ ___ Other numbers listed as contacts, without names: Phone: ___ Cell phone: ___ Case manager from ___: ___ at ___ Therapist ___ at ___ ___, direct line Psychiatrist: Dr. ___ at ___, ___ ___ Services (___) Psychiatric ROS: - Depression - + sleep disturbances, overwhelmed, feeling things are unmanageable, isolation, anhedonia, active and passive SI with plan, no intent. - Psychosis - denies symptoms including delusions (persecutory, grandiose, thought broadcasting/insertion/withdrawal) or hallucinations (auditory, visual, olfactory, or tactile). - Mania- denies symptoms including elevated mood or irritability, marked increases in goal-directed behavior, racing thoughts, a decreased need for sleep, or social/economic indiscretion - Anxiety - Denies symptoms of panic attacks or agoraphobia. Medical ROS: - Positive for: tingling in his fingers; pain in right and left arme ("tendonitis," has braces but haven't been using). - Otherwise, a 10-point ROS was negative, including: no fever, HA, eye pain, hearing deficit, chest pain, difficulty breathing, abdominal pain, constipation, diarrhea, musculoskeletal pain Past Medical History: PAST PSYCHIATRIC HISTORY (from my note dated ___ and updated with patient as necessary): - Dx: MDD, Panic disorder with agoraphobia and anxiety per review of records on OMR (Patient denies this diagnosis) - Hospitalizations: Most recently on Deac 4 in twice in ___ for SI and intentional excessive fluid intake and medication non-compliance); previously at ___ ___ for severe depression and initiation of ECT, again ___ and ___, ___ in ___ for anxiety/depression, another admission s/p OD in college. Reports the ECT was helpful in the past, but he is unsure whether he would do it again. -SA/SIB: h/o SA at age ___ by OD on "pills" in the context of a "fight" with his mother regarding his "sexuality and depression"; denies past SIB. Does not have access to firearms. -Medication Trials: Fluvoxamine, Ativan, Effexor, Cymbalta, trazodone (caused priapism); found most antidepressants unhelpful, with the exception of Wellbutrin. Has not tried TCAs (with the exception of amitriptyline for insomnia). Electroconvulsive therapy x 8 during prior psych admission in ___ - Psychiatrist - Dr. ___ at ___ As per Dr. ___ note on ___: - Harm to self: in ___, HCP confirmed prir suicide attempt via OD for which patient was treated at ___ - Harm to others: in ___, patient was noted for the first time to have threatened both his mother and his friend ___, his HCP. PAST MEDICAL HISTORY: - ESRD, on HD - Diabetes Mellitus 2 (x ___ yrs) - HIV- CD4 495 ___ - started regimen in ___ AZT not compliant, then NFV/d4T/3TC until ___, then briefly for 2 months on EFV but had important side effects and immediately changed to NVP in ___ ddI/TDF/NVP - off ARV since ___ --> started ABC/LPV/RTV/RTGV ___ - Lipodystrophy - Hypogonadism - Obesity - Hyperlipidemia - Asthma - Obstructive sleep apnea - Internal anal condylomata s/p excision (___) - s/p perianal abscess I+D ___ - HPV - hidradenitis suppurativa - Heel spur - s/p Appendectomy (___) - s/p bilateral BKA - h/o HD line sepsis - h/o + PPD, took INH - diabetic retinopathy Social History: SUBSTANCE ABUSE HISTORY: - ETOH - denies any current use, denies detoxes - Illicits - history of cocaine abuse in the past - Tobacco - Quit smoking in ___, 13 pack year history. FORENSIC HISTORY: ___ SOCIAL HISTORY: (from my note dated ___ and updated with patient as necessary): Patient originally from ___ (just ___ of ___ but grew up in ___. Parents divorced when pt was ___ years old, describes childhood as unsupportive, witnessed physical abuse of his mother from ___ and also endured physical and emotion abuse from ___ as well He currently lives alone in an apartment near ___ in ___. Graduated college, obtained ___ degree in ___. He is not currently working since ___ when he went on medical leave. He is on SSI and receives food stamps. Has identified as gay at least since age ___. As per Dr. ___ note on ___: "Patient has family in ___. He has ___, home health aide, and has a ___ form active for transport. He owns a wheelchair. ___ not coming right now as mom is there, but he could access this. He has not been sexually active in years and has not even tried masturbating since second BKA." Family History: FAMILY PSYCHIATRIC HISTORY: (from my note dated ___ and updated with patient as necessary): Per OMR, brothers with EtOH addictions and father with depression Allergies: Erythromycin Base What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Atorvastatin Acetaminophen Glucose Gel sevelamer CARBONATE Docusate Sodium amLODIPine Lopinavir-Ritonavir ClonazePAM Calcitriol Loratadine Insulin Insulin HydrOXYzine Gabapentin Glucagon Pantoprazole Labetalol Calcitriol Abacavir Sulfate Sertraline Aspirin Calcium Acetate Raltegravir Lidocaine 1% Target Lab Orders: Anion Gap Bicarbonate Calcium, Total Chloride Creatinine Glucose H I Magnesium Phosphate Potassium Sodium Urea Nitrogen L Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells RDW-SD Target Procedures: Performance of Urinary Filtration, Multiple DOCTOR'S NOTE Hospital Notes: : Patient is a ___ yo man with a history of MDD with prior history of suicide attempt and passive self-injurious behavior by withholding important medical care who presented via EMS for worsening depression and suicidal ideation with recent intentional non-adherence with his medications and thoughts of overdosing on sleeping pills. The patient endorsed long-standing depression, which acutely worsened the week prior to admission and manifested with anhedonia, isolative behavior, sleep disturbances, poor appetite, and feeling overwhelmed. He identified several psychosocial stressors, including his recent second BKA, being alone in his apartment after his mother left, and having so many medical appointments. The presentation was consistent with an Adjustment Disorder with Mixed Anxiety and Depression in the setting of both complicated medical problems and psychosocial stressors. He was admitted to the locked inpatient psychiatry unit for safety, medication adjustments, and improvement in mood. He was treated with individual, group and milieu therapy. Dexedrine was added for mood and energy, and hydroxyzine was added for sleep. He was discharged home with outpatient psychiatric follow up and a coordinated medical plan with his outpatient team. DSM V Diagnosis: - Adjustment Disorder with Mixed Anxiety and Depression - Major Depressive Disorder, Recurrent, Severe - Unspecified Anxiety Disorder 1. LEGAL & SAFETY: On admission, the patient signed a conditional voluntary agreement (Section 10 & 11) and remained on that level throughout their admission. They were also placed on 15 minute checks status on admission and remained on that level of observation throughout while being unit restricted. They were green sharps status throughout admission. 2. PSYCHIATRIC: # Adjustment Disorder with Mixed Anxiety and Depression; Major Depressive Disorder, Recurrent, Severe; Unspecified Anxiety Disorder Interventions: - Provided individual, group, and milieu therapy - Dexedrine 5 mg short acting in the morning; should be taking prior to HD on dialysis days - Continue home psychiatric medications: Sertraline 200 mg PO/NG DAILY ClonazePAM 1 mg PO/NG BID HydrOXYzine 50 mg PO/NG QHS:PRN insomnia 3. MEDICAL # Right stump abrasion - developed during admission, likely due to prosthetics, no sign of infection -bacitracin ointment twice daily, to be covered with gauze dressings -contacted Dr. ___ at ___ for urgent appointment for further evaluation and possible adjustment of prosthetics # Diabetes mellitus -Insulin Glargine 16u DAILY + SSI (patient should continue home sliding scale as recommended by PCP) -Aspirin 81 mg PO/NG DAILY -Atorvastatin 40 mg PO/NG QPM -Gabapentin 300 mg PO/NG BID # ESRD on HD -Calcium Acetate 1334 mg PO/NG TID W/MEALS -Calcitriol 0.5 mcg PO 3X/WEEK (___) - dosing changed at recommendation of inpatient renal dialysis team -Nephrocaps 1 CAP PO/NG DAILY - added at recommendation of inpatient renal dialysis team -sevelamer CARBONATE 1600 mg PO TID W/MEALS # HIV - CD4 636 and VL undetectable in ___ -Raltegravir 400 mg PO BID -Lopinavir-Ritonavir 2 TAB PO BID -Abacavir Sulfate 600 mg PO DAILY # GERD -Pantoprazole 40 mg PO Q24H # HTN -amLODIPine 5 mg PO/NG DAILY - medication stopped at recommendation of inpatient renal dialysis team due to low blood pressures (systolics ___ and ___, symptomatic with diaphoresis and lightheadedness once) -continue Labetalol 200 mg PO/NG BID # Seasonal allergies -Loratadine 10 mg PO EVERY OTHER DAY - dosing changed at recommendation of inpatient renal dialysis team # OSA - not on home CPAP 5. PSYCHOSOCIAL #) GROUPS/MILIEU: The patient was encouraged to participate in the various groups and milieu therapy opportunities offered by the unit. The patient often attended these groups that focused on teaching patients various coping skills and usually was an active participant. #) COLLATERAL CONTACTS & FAMILY INVOLVEMENT - contacted outpatient PCP ___ ___ on ___ and spoke with him re: medical treatment plan. He stated that pt is better at managing HIV meds but poor at managing diabetes. - Contacted outpatient therapist ___ at ___ ___ and left voicemail on ___ and ___ - Contacted outpatient psychiatrist Dr. ___ at ___ ___ and spoke with him on ___. States that wellbutrin in combination with SSRI has worked in the past but not wellbutrin alone. Spoke with him again on ___ about medication options and that stimulants had been tried in past as adjunctive therapy sometimes causing irritability but Dexedrine had not been tried. The other option is venlafaxine instead of Zoloft. Pt took venlafaxine in ___ but only up to 75 mg daily and was discontinued for unclear reasons. Phone for scheduling admin is ___. - met with outpatient team ___ RN and ___ ___ ___, fax ___ on ___ to review discharge plan and discharge resources #) INTERVENTIONS - Medications: started Dexedrine 5 mg in the morning - Psychotherapeutic Interventions: Individual, group, and milieu therapy. - Coordination of aftercare: see attached list of follow up appointments INFORMED CONSENT: The team discussed the indications for, intended benefits of, and possible side effects and risks of starting this medication, and risks and benefits of possible alternatives, including not taking the medication, with this patient. We discussed the patient's right to decide whether to take this medication as well as the importance of the patient's actively participating in the treatment and discussing any questions about medications with the treatment team, and I answered the patient's questions. The patient appeared able to understand and consented to begin the medication. RISK ASSESSMENT On presentation, the patient was evaluated and felt to be at an increased risk of harm to herself and/or others based upon suicidal ideation with plan but not intent, increased symptoms of depression (anhedonia, isolative behavior, sleep disturbances, poor appetite, and feeling overwhelmed). Their static factors noted at that time include history of suicide attempts, chronic mental illness, history of substance abuse, male gender, Caucasian race, single marital status, LGBT identity, and chronic medical illness. The modifiable risk factors were suicidal ideation with plan but no intent, intentional medication noncompliance, poorly controlled mental illness, hopelessness, agitation, limited social supports, insomnia, and recent personal loss. These were addressed with medication adjustments, group/milieu therapy, and individual therapy including motivational interviewing. Finally, the patient is being discharged with many protective risk factors, including help-seeking nature, future-oriented viewpoint and strong outpatient care team. Overall, based on the totality of our assessment at this time, the patient is not at an acutely elevated risk of self-harm nor danger to others. Our Prognosis of this patient is fair based on improvement in mood and lack of suicidal ideation resulting from medication adjustments and inpatient therapies. Other Results: Admission labs: ___: Na: 140 ___: K: 5.3 ___: Cl: 97 ___: CO2: 21 ___: BUN: 48 ___: Creat: 8.2 ___: Glucose: 199 ___: WBC: 6.2 ___: HGB: 12.5* ___: HCT: 39.0* ___: Plt Count: 208 ___: Urine Glucose (Hem): 100 ___: Urine Protein (Hem): 300 ___: Urine Bilirubin (Hem): NEG ___: Urobilinogen: NEG ___: Urine Ketone (Hem): NEG ___: Urine Blood (Hem): NEG ___: Urine Nitrite (Hem): NEG ___: Urine Leuks (Hem): NEG ___: TSH: 2.3 Serum toxicology: Negative Urine toxicology: Patient Anuric

2138-10-04 09:44:00

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[[29132587, Timestamp('2138-10-10 16:31:06'), '', 'DENT']]

[[{'Medications on Admission': ':\nnone', 'Brief Hospital Course': ":\nPt admitted to TRAUMA under Dr ___ ___. CT and panorex \nverified mandibular fractures. Patient's pain controlled and \ngiven a soft diet on HD1, to OR for closed reduction and IMF on \nHD2. Patient seen by SW before discharge given circumstances \nsurrounding assault. Patient tolerating liquid diet before d/c. \n\n", 'Pertinent Results:': '\n___ 09:42AM BLOOD WBC-7.0 RBC-3.55* Hgb-11.4* Hct-32.0* \nMCV-90 MCH-32.0 MCHC-35.4* RDW-13.0 Plt ___\n___ 09:42AM BLOOD Neuts-67.7 ___ Monos-3.7 Eos-0.6 \nBaso-0.3\n___ 09:42AM BLOOD ___ PTT-32.0 ___\n___ 09:42AM BLOOD Plt ___\n___ 09:42AM BLOOD Glucose-85 UreaN-8 Creat-0.6 Na-146* \nK-3.9 Cl-111* HCO3-22 AnGap-17\n___ 09:42AM BLOOD HCG-<5\n___ 09:23AM URINE Blood-LG Nitrite-NEG Protein-NEG \nGlucose-NEG Ketone-50 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG\n___ 09:23AM URINE RBC-0 ___ Bacteri-OCC Yeast-NONE \n___\nRadiographic studies:\nCT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST ___ \nIMPRESSION: \n1. Displaced fracture of the left mandibular ramus involving the \nalveolar \nnerve canal. Minimal inferior displacement of the condylar head \nwith respect to the glenoid fossa may be related to blood in the \ntemporomandibular joint. \n2. Nondisplaced fracture involving the right body of the \nmandible, disrupting the roots of the ___ tooth 29, and possibly \nalso ___ tooth 28. \n.\nMANDIBLE (PANOREX ONLY) ___ \nFINDINGS: Panorex demonstrates a displaced fracture through the \nleft mandible condylar neck. There is overlap of the fracture \nfragments on the submitted view. The temporomandibular fossa is \nnot included. There is a nondisplaced oblique fracture through \nthe right mandible, which extends between the first mandibular \nmolar and second premolar. No other fracture is identified. \nIMPRESSION: Mandibular fracture as described above. \n\n', 'Physical Exam:|Physical': '\ngen: pt uncomfortable\nvitals: 98.6 89 110/62 16 92%RA \nHEENT: PERRL, facial swelling L>R, tenderness over B/L mandibles \nL>R, dried blood around mouth, limited ability to open jaw, no \nevident dental fractures, no nasal septal hematoma, no \nhemotympanum.\nNeck: ROM wnl, no c-spine ttp\nResp: chest NTTP, CTA b/l\nCV: RRR no murmurs\nAbd: +BS, abd soft, NT\nExt: no other evident injuries, pelvis and ext stable. \n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\nPatient transferred from OSH w/L mandibular fracture. Pt had \nbeen punched in jaw the night before during an argument with a \nfriend. ETOH involved. No LOC. No other injuries.\n\nPast Medical History:\nnone\n\nSocial History:\n___\nFamily History:\nn/a\n\n', 'Chief Complaint:|Complaint:': '\nmandibular fracture\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nPatient recorded as having No Known Allergies to Drugs\n\n'}, '14748863-DS-6', 6, 'dental']]

[['INDICATION: ___ female with jaw fracture.\n\nCOMPARISON: None.\n\nTECHNIQUE: Non-contrast axial images of the facial bones were obtained with\nmultiplanar reformatted images.\n\nFINDINGS: An acute fracture of the left mandibular ramus demonstrates\noverriding of the fracture fragments, with the the condylar neck displaced\nlaterally relative to the ramus. The fracture involves the superior aspect of\nthe alveolar nerve canal. Minimal inferior displacement of the condylar head\nrelative to the glenoid fossa may be related to blood in the temporomandibular\njoint. The left masseter and pterygoid muscles are expanded, likely due to\nhematoma.\n\nA nondisplaced fracture of the right body of the mandible involves the bucchal\nand lingual cortices of the alveolar ridge, disrupting the roots of the ___\ntooth 29, and possibly also of the ___ tooth 28. The mental foramen does not\nappear disrupted. The right temporomandibular joint is intact. There is\nbucchal soft tissue swelling, right greater than left.\n\nA minimal amount of mucosal thickening is noted in the right maxillary sinus.\nThe remainder of the paranasal sinuses appear well aerated. The infundibulum\nof the right maxillary sinus is narrowed.\n\nIMPRESSION:\n\n1. Displaced fracture of the left mandibular ramus involving the alveolar\nnerve canal. Minimal inferior displacement of the condylar head with respect\nto the glenoid fossa may be related to blood in the temporomandibular joint.\n\n2. Nondisplaced fracture involving the right body of the mandible, disrupting\nthe roots of the ___ tooth 29, and possibly also ___ tooth 28.\n\n\n\n THE STUDY AND THE REPORT WERE REVIEWED BY THE STAFF RADIOLOGIST.\n\n ___. ___\n ___. ___ Approved: SAT ___ 5:41 ___\n', '14748863-RR-14', 14, 'non-contrast axial images of the facial bones were obtained with\nmultiplanar reformatted images.'], ['PANOREX, ___ AT 11:58 A.M.\n\nHISTORY: Mandibular fracture.\n\nCOMPARISON: None.\n\nFINDINGS: Panorex demonstrates a displaced fracture through the left mandible\ncondylar neck. There is overlap of the fracture fragments on the submitted\nview. The temporomandibular fossa is not included. There is a nondisplaced\noblique fracture through the right mandible, which extends between the first\nmandibular molar and second premolar. No other fracture is identified.\n\nIMPRESSION: Mandibular fracture as described above.\n', '14748863-RR-15', 15, ''], [' \n HISTORY: Question dislocation.\n\n Two views of the skull obtained portably in the OR. Report from a sinus CT\n from ___ described a displaced left mandibular ramus fracture and slight\n subluxation of the condylar head and a non-displaced fracture of the right\n body of the mandible. Assessment of fine detail is limited on these portable\n views.\n\n Allowing for this, the fracture of the left mandible is noted, with a small-\n to-moderate amount of displacement seen on the AP view. The right mandibular\n fracture appears non-displaced on the lateral view.\n\n\n ___. ___ Approved: MON ___ 12:01 ___\n', '14748863-RR-16', 16, ''], [' \nHISTORY: Jaw fracture status post repair.\n\nFINDINGS: The right mandibular fracture is not displaced on the lateral view.\nThe condylar fracture on the left is substantially displaced with only about\n10% apposition on the frontal view.\n\n ___. ___ Approved: MON ___ 12:14 ___\n(End of Report)\n', '14748863-RR-17', 17, '']]

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['dental']

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Question: A 25 F is admitted. He/she says he/she has mandibular fracture . History of illness: Patient transferred from OSH w/L mandibular fracture. Pt had been punched in jaw the night before during an argument with a friend. ETOH involved. No LOC. No other injuries. Past Medical History: none Social History: ___ Family History: n/a Allergies: Patient recorded as having No Known Allergies to Drugs What is the best procedure plan for this patient?

TARGETS Target Prescriptions: NONE Target Lab Orders: NONE Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : Pt admitted to TRAUMA under Dr ___ ___. CT and panorex verified mandibular fractures. Patient's pain controlled and given a soft diet on HD1, to OR for closed reduction and IMF on HD2. Patient seen by SW before discharge given circumstances surrounding assault. Patient tolerating liquid diet before d/c. Other Results: ___ 09:42AM BLOOD WBC-7.0 RBC-3.55* Hgb-11.4* Hct-32.0* MCV-90 MCH-32.0 MCHC-35.4* RDW-13.0 Plt ___ ___ 09:42AM BLOOD Neuts-67.7 ___ Monos-3.7 Eos-0.6 Baso-0.3 ___ 09:42AM BLOOD ___ PTT-32.0 ___ ___ 09:42AM BLOOD Plt ___ ___ 09:42AM BLOOD Glucose-85 UreaN-8 Creat-0.6 Na-146* K-3.9 Cl-111* HCO3-22 AnGap-17 ___ 09:42AM BLOOD HCG-<5 ___ 09:23AM URINE Blood-LG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-50 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 09:23AM URINE RBC-0 ___ Bacteri-OCC Yeast-NONE ___ Radiographic studies: CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST ___ IMPRESSION: 1. Displaced fracture of the left mandibular ramus involving the alveolar nerve canal. Minimal inferior displacement of the condylar head with respect to the glenoid fossa may be related to blood in the temporomandibular joint. 2. Nondisplaced fracture involving the right body of the mandible, disrupting the roots of the ___ tooth 29, and possibly also ___ tooth 28. . MANDIBLE (PANOREX ONLY) ___ FINDINGS: Panorex demonstrates a displaced fracture through the left mandible condylar neck. There is overlap of the fracture fragments on the submitted view. The temporomandibular fossa is not included. There is a nondisplaced oblique fracture through the right mandible, which extends between the first mandibular molar and second premolar. No other fracture is identified. IMPRESSION: Mandibular fracture as described above.

2152-05-09 00:00:00

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MARRIED

OTHER

M

[[23253531, Timestamp('2152-05-09 02:17:30'), '', 'DENT']]

[[{'Medications on Admission': 'NIL', 'Brief Hospital Course': ':\nPatient was admitted for elective iliac crest reconstruction of \nthe mandible. He underwent the procedure without complication. \nHe was admitted to PACU and then to the floor. He did well with \npain. He had issues with voiding and was straight-catheterized. \nHe also had a syncopal episode which was postural. He was \nresuscitated and ___ evaluation to help with ambulation. He had \nno further episodes in house. He was able to void, had good pain \ncontrol and was discharged to home POD 1. ', 'Pertinent Results:': '\nNone\n\n', 'Physical Exam:|Physical': '\nIn final note.\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': 'NIL', 'Chief Complaint:|Complaint:': '\nAdmitted for reconstruction\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nNo Known Allergies / Adverse Drug Reactions\n\n'}, '14885693-DS-9', 9, 'dental']]

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[['0NUT07Z', 10, 1, Timestamp('2152-05-09 00:00:00'), 'Supplement Right Mandible with Autologous Tissue Substitute, Open Approach'], ['0QB30ZZ', 10, 2, Timestamp('2152-05-09 00:00:00'), 'Excision of Left Pelvic Bone, Open Approach']]

['dental']

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Question: A 38 M is admitted. He/she says he/she has Admitted for reconstruction . History of illness: NIL Allergies: No Known Allergies / Adverse Drug Reactions What is the best procedure plan for this patient?

TARGETS Target Prescriptions: HYDROmorphone (Dilaudid) Lactated Ringers DiphenhydrAMINE Ondansetron ODT Lactated Ringers OxyCODONE (Immediate Release) Ketorolac Acetaminophen Influenza Vaccine Quadrivalent Sodium Chloride 0.9% Flush Iso-Osmotic Dextrose CeFAZolin Target Lab Orders: NONE Target Procedures: Supplement Right Mandible with Autologous Tissue Substitute, Open Approach Excision of Left Pelvic Bone, Open Approach DOCTOR'S NOTE Hospital Notes: : Patient was admitted for elective iliac crest reconstruction of the mandible. He underwent the procedure without complication. He was admitted to PACU and then to the floor. He did well with pain. He had issues with voiding and was straight-catheterized. He also had a syncopal episode which was postural. He was resuscitated and ___ evaluation to help with ambulation. He had no further episodes in house. He was able to void, had good pain control and was discharged to home POD 1. Other Results: None

2142-11-25 17:40:00

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[[24839680, Timestamp('2142-11-25 17:41:10'), '', 'SURG']]

[[{'Medications on Admission': ':\nnone', 'Brief Hospital Course': ':\nPatient admitted ___, managed conservatively overnight. No \nevidence of acute cholecystitis. RUQ U/S impacted stone \ngallbladder neck 2cm, second non-impacted stone. To OR on HD ___ for laparoscopic cholecystitis.\n\n', 'Pertinent Results:': '\n___ 03:40PM BLOOD Lipase-62*\n___ 03:40PM BLOOD ALT-53* AST-49* LD(LDH)-169 AlkPhos-71 \nTotBili-0.2 DirBili-0.1 IndBili-0.1\n___ 03:40PM BLOOD Glucose-85 UreaN-8 Creat-0.7 Na-141 K-4.0 \nCl-105 HCO3-26 AnGap-14\n___ 03:40PM BLOOD ___ PTT-26.9 ___\n___ 03:40PM BLOOD Neuts-68.5 ___ Monos-3.3 Eos-0.8 \nBaso-0.2\n___ 03:40PM BLOOD WBC-6.3 RBC-4.26 Hgb-13.2 Hct-37.8 MCV-89 \nMCH-30.9 MCHC-34.8 RDW-12.8 Plt ___\n\n', 'Physical Exam:|Physical': '\nVS-- 99.3 92 100/65 16 100% on RA\n\nGEN: Comfortable, NAD\nHEENT: EOMI, PERRL \nRESP: CTA Bilaterally\nCV: RRR S1S2 clear, no M/G/R\nGI: RUQ tenderness, min rebound, no guarding \nGU/flank: no CVAT\nMSK: no c/c/e\nNEURO: no focal deficits\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\n___ F presented with chief complaint of abdominal pain two days \nin duration. Pain radiates to the R side. Pain was described as \na ___ and crampy. Onset was gradual, severity moderate, \nisolated to RUQ. Went to OSH U/S found two stones. All other \nreview of systems was negative except per HPI\n\nPast Medical History:\nNo significant PMH\n\nSocial History:\n___\nFamily History:\nGallstones\n\n', 'Chief Complaint:|Complaint:': '\nRUQ pain, biliary colic\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nPatient recorded as having No Known Allergies to Drugs\n\n'}, '12658866-DS-19', 19, 'surgery']]

[['LIMITED GALLBLADDER ULTRASOUND\n\nINDICATION: ___ woman with known cholelithiasis. One or more stones\nmay be impacted, noted on outside hospital study, for further evaluation.\n\nCOMPARISON: Outside hospital study from earlier today was reviewed with ED\nstaff. The recommendation for re-imaging of the gallbladder only was made in\nconjunction with ED staff as it was unclear if there was an impacted\ngallstone.\n\nFINDINGS: Two gallstones are noted in the gallbladder in the neck region\nmeasuring approximately 2 cm. Mobility of only one of these stones is\ndemonstrated. The other stone appears impacted in the neck of the gallbladder.\nThere is gallbladder distension without gallbladder wall thickening or\npericholecystic fluid. Sonographic ___ sign was not present at the time of\nevaluation. Please note, the patient has pain on pain medication. The CBD is\nnondilated, measuring approximately 1.0 mm. \n\nIMPRESSION:\n\nImpacted gallstone measuring 2 cm in the gallbladder neck without findings to\nsuggest acute cholecystitis. Normal CBD.\n\nThese findings were entered on the ED dashboard at the time of the study.\n\n', '12658866-RR-9', 9, '']]

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['surgery']

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Question: A 20 F is admitted. He/she says he/she has RUQ pain, biliary colic . History of illness: ___ F presented with chief complaint of abdominal pain two days in duration. Pain radiates to the R side. Pain was described as a ___ and crampy. Onset was gradual, severity moderate, isolated to RUQ. Went to OSH U/S found two stones. All other review of systems was negative except per HPI Past Medical History: No significant PMH Social History: ___ Family History: Gallstones Allergies: Patient recorded as having No Known Allergies to Drugs What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Ketorolac HYDROmorphone (Dilaudid) HYDROmorphone (Dilaudid) Heparin Ondansetron Iso-Osmotic Dextrose CefazoLIN LR D5 1/2NS Heparin Sodium Chloride 0.9% Flush Oxycodone-Acetaminophen Bisacodyl Target Lab Orders: NONE Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : Patient admitted ___, managed conservatively overnight. No evidence of acute cholecystitis. RUQ U/S impacted stone gallbladder neck 2cm, second non-impacted stone. To OR on HD ___ for laparoscopic cholecystitis. Other Results: ___ 03:40PM BLOOD Lipase-62* ___ 03:40PM BLOOD ALT-53* AST-49* LD(LDH)-169 AlkPhos-71 TotBili-0.2 DirBili-0.1 IndBili-0.1 ___ 03:40PM BLOOD Glucose-85 UreaN-8 Creat-0.7 Na-141 K-4.0 Cl-105 HCO3-26 AnGap-14 ___ 03:40PM BLOOD ___ PTT-26.9 ___ ___ 03:40PM BLOOD Neuts-68.5 ___ Monos-3.3 Eos-0.8 Baso-0.2 ___ 03:40PM BLOOD WBC-6.3 RBC-4.26 Hgb-13.2 Hct-37.8 MCV-89 MCH-30.9 MCHC-34.8 RDW-12.8 Plt ___

2126-10-09 15:03:00

ENGLISH

SINGLE

WHITE

F

[[24118093, Timestamp('2126-10-09 15:03:50'), '', 'MED']]

[[{'Medications on Admission': ':\nThe Preadmission Medication list is accurate and complete.\n1. Lansoprazole Oral Disintegrating Tab 30 mg PO BID \n2. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID asthma \npt not taking \n3. Necon 0.5/35 (28) *NF* (norethindrone-ethin estradiol) 0.5-35 \nmg-mcg Oral daily \n4. Azathioprine 50 mg PO DAILY \n5. OxycoDONE (Immediate Release) 10 mg PO Q3H:PRN pain \n6. PredniSONE 60 mg PO DAILY \n7. Sucralfate 1 gm PO TID \n8. Infliximab Dose is Unknown IV 8 WEEKS \n9. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob/wheeze \n10. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN headache \n11. balsalazide *NF* 750 mg Oral TID \n3 tablets TID \n\nasthma \nmigraines ', 'Brief Hospital Course': ":\nPt is a ___ y.o female with h.o Crohn's, asthma, migraines who \npresented with abdominal pain and bloody diarrhea. \n\n#acute Crohn's flare:abdominal pain/nausea/bloody diarrhea-ddx \nincluded Crohn's flare vs. infectious (prior h.o C.diff but \nreportedly last test negative 2 weeks ago prior to admission). \nHowever, pt's presentation was felt to be consistent with a \nCrohn's flare. Stool cultures and CMV VL were negative. She was \nstarted on IV cyclosporine at 2mg/kg with good effect. The GI \nand colorectal services followed the patient during admission. \nShe was continued on prednisone at 60mg daily and started on PO \ncalcium and vitamin D. She was transitioned to Cyclosporine \n150mg BID (2.5mg/kg BID), decreased to prednisone 40mg daily, \nand restarted on Azathioprine 100mg daily (2mg/kg daily) on \ndischarge. She will taper her prednisone to 30mg daily on ___, \nthen 10mg weekly until she stops.\n- for pain, she required significant opiates. She was \ndischarged on Morphine ER 30mg q12 (due to insurance issues with \nOxyContin) and Oxycodone 10mg q6 prn pain. Side effects were \ndiscussed with her.\n- she will have repeat Cyclosporine level on ___, and follow up \nwith GI in 2 weeks.\n\n#acute blood loss anemia-Related to gastrointestinal bleeding \ndue to above. Trended HCT and pt remained hemodynamically \nstable. \n\n#leukocytosis/thrombocytosis-likely due to above as well as \nsteroids. Stool cultures did not reveal infection.\n\n#GERD-PPI, sucralfate \n\n#asthma, chronic stable-albuterol prn \n\n#h.o migraine headaches-Fioricet prn \n\n", 'Pertinent Results:': '\n___ 12:40PM UREA N-10 CREAT-0.7 SODIUM-138 POTASSIUM-4.6 \nCHLORIDE-99 TOTAL CO2-29 ANION GAP-15\n___ 12:40PM estGFR-Using this\n___ 12:40PM ALT(SGPT)-29 AST(SGOT)-21 ALK PHOS-109* TOT \nBILI-0.1\n___ 12:40PM MAGNESIUM-2.2 CHOLEST-202*\n___ 12:40PM WBC-17.6* RBC-3.97* HGB-11.1* HCT-34.2* \nMCV-86 MCH-27.9 MCHC-32.4 RDW-13.5\n___ 12:40PM PLT COUNT-640*\n.\n___ - MRE with rectal inflammation\n___ - Sigmoidoscopy with congestion, erosions, erythema,\nfriability, granularity, mucous, serpentine ulcerations in a\ncontinuous and circumferential patter from the anus to the\nsigmoid. No sparing.\n___ 06:40AM BLOOD WBC-14.1* RBC-3.75* Hgb-10.4* Hct-31.7* \nMCV-85 MCH-27.8 MCHC-32.8 RDW-13.9 Plt ___\n___ 06:40AM BLOOD Glucose-83 UreaN-10 Creat-0.7 Na-137 \nK-4.5 Cl-97 HCO3-27 AnGap-18\n___ 06:35AM BLOOD ALT-20 AST-13 AlkPhos-67 TotBili-0.1\n___ 06:40AM BLOOD Cyclspr-112\n\nCMV vl negative\nStool cx negative\n\n', 'Physical Exam:|Physical': '\nGen: well appearing, NAD\nvitals: T 98.4, BP 121/82, HR 102, RR 18 sat 100% on RA\nHEENT:Ncat eomi, dry MM\nneck: supple, no LAD\nchest: b/l ae no w/c/r\nheart: s1s2 rr no m/r/g\nabd: +bs, soft, +TTP diffusely, worse LLQ, no guarding or \nrebound\next: no c/c/2+pulses\nneuro: face symmetric, speech fluent\nGU: no foley\nskin: no rash\npsych: calm, cooperative\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\nPt is a ___ y.o female with h.o Crohn\'s disease, C.diff, asthma, \nmigraines who presents with diffuse, but highest in LLQ ___ \n"achy" "pressure" constant pain with nausea and diarrhea, \n___ of bloody mucus daily, and with heartburn type \nsymptoms. Pt reports good appetite (due to steroids) but 25lb \nweight loss since ___. She denies vomiting, constipation, \ndysuria, travel, sick contacts, new foods. Reports she was on \nremicade, last dose 2 weeks ago and was recently started on \nimuran 50mg daily, and had her steroid dose increased from 40mg \nto 60mg daily without any improvement in her symptoms. Pt \nreports that pain has become unmanageable at home, despite \noxycodone. \n.\nIn terms of other ROS, 10pt ROS reviewed in detail and negative \nfor headache, dizziness, ST, URI, CP, sob, palpitations, melena, \nhematuria, joint rash, paresthesias. Pt reports quad weakness \nsecondary to steroids.\n\nPast Medical History:\nCrohns disease\nc.diff ___\nasthma\nmigraines\n\nSocial History:\n___\nFamily History:\nCAD, GF with colon cancer, cousin with UC, another cousin with \nautoimmune hepatitis\n\n', 'Chief Complaint:|Complaint:': '\nabdominal pain, diarrhea\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nPenicillins / Augmentin\n\n'}, '12514324-DS-8', 8, 'medicine']]

[]

[[24118093, Timestamp('2126-10-09 18:00:00'), Timestamp('2126-10-10 00:00:00'), 'MAIN', 'HYDROmorphone (Dilaudid)', '004103', '00409131230', '2mg/mL Syringe'], [24118093, Timestamp('2126-10-09 17:00:00'), Timestamp('2126-10-11 15:00:00'), 'BASE', '5% Dextrose (EXCEL BAG)', '001972', '00264751020', '250mL (EXCEL)'], [24118093, Timestamp('2126-10-09 17:00:00'), Timestamp('2126-10-11 15:00:00'), 'MAIN', 'CycloSPORINE (Sandimmune)', '062197', '00078010901', '250mg/5mL Amp'], [24118093, Timestamp('2126-10-09 17:00:00'), Timestamp('2126-10-16 21:00:00'), 'MAIN', 'Albuterol Inhaler', '028090', '00173068254', '8 g Inhaler'], [24118093, Timestamp('2126-10-09 16:00:00'), Timestamp('2126-10-16 21:00:00'), 'MAIN', 'Sodium Chloride 0.9% Flush', '', '0', 'Syringe'], [24118093, Timestamp('2126-10-09 17:00:00'), Timestamp('2126-10-16 21:00:00'), 'MAIN', 'Pantoprazole', '027462', '00008084199', '40mg Tablet'], [24118093, Timestamp('2126-10-09 17:00:00'), Timestamp('2126-10-16 21:00:00'), 'MAIN', 'Acetaminophen-Caff-Butalbital', '004451', '00143178701', '1 Tablet'], [24118093, Timestamp('2126-10-09 16:00:00'), Timestamp('2126-10-13 08:00:00'), 'BASE', 'D5LR', '002026', '00338012504', '1000mL Bag'], [24118093, Timestamp('2126-10-10 03:00:00'), Timestamp('2126-10-11 02:00:00'), 'MAIN', 'Lorazepam', '003757', '00904598061', '0.5mg Tablet'], [24118093, Timestamp('2126-10-09 16:00:00'), Timestamp('2126-10-09 17:00:00'), 'MAIN', 'HYDROmorphone (Dilaudid)', '004103', '00409131230', '2mg/mL Syringe'], [24118093, Timestamp('2126-10-10 01:00:00'), Timestamp('2126-10-12 17:00:00'), 'MAIN', 'HYDROmorphone (Dilaudid)', '062823', '00409128331', '1mg/1mL Syringe'], [24118093, Timestamp('2126-10-09 16:00:00'), Timestamp('2126-10-12 15:00:00'), 'MAIN', 'Ondansetron', '061716', '00781305714', '2mg/mL-2mL'], [24118093, Timestamp('2126-10-09 10:00:00'), Timestamp('2126-10-16 21:00:00'), 'MAIN', 'Necon 0.5/35 (28)', '003294', '', '0.5 mg-35 mcg tablet'], [24118093, Timestamp('2126-10-09 22:00:00'), Timestamp('2126-10-16 21:00:00'), 'MAIN', 'Sucralfate', '002766', '63739026110', '1g Tablet'], [24118093, Timestamp('2126-10-09 10:00:00'), Timestamp('2126-10-13 16:00:00'), 'MAIN', 'PredniSONE', '006751', '00054001820', '20 mg Tablet'], [24118093, Timestamp('2126-10-09 17:00:00'), Timestamp('2126-10-10 16:00:00'), 'BASE', 'Lactated Ringers', '001187', '00338011704', '1000ml Bag'], [24118093, Timestamp('2126-10-09 16:00:00'), Timestamp('2126-10-16 21:00:00'), 'MAIN', 'Influenza Virus Vaccine', '069637', '33332001201', '0.5 mL Syringe']]

[]

['medicine']

[[50862, Timestamp('2126-10-10 09:20:00'), Timestamp('2126-10-10 12:50:00'), 'Albumin'], [50868, Timestamp('2126-10-10 09:20:00'), Timestamp('2126-10-10 10:07:00'), 'Anion Gap'], [50882, Timestamp('2126-10-10 09:20:00'), Timestamp('2126-10-10 10:07:00'), 'Bicarbonate'], [50902, Timestamp('2126-10-10 09:20:00'), Timestamp('2126-10-10 10:07:00'), 'Chloride'], [50912, Timestamp('2126-10-10 09:20:00'), Timestamp('2126-10-10 10:07:00'), 'Creatinine'], [50931, Timestamp('2126-10-10 09:20:00'), Timestamp('2126-10-10 10:07:00'), 'Glucose'], [50960, Timestamp('2126-10-10 09:20:00'), Timestamp('2126-10-10 10:07:00'), 'Magnesium'], [50970, Timestamp('2126-10-10 09:20:00'), Timestamp('2126-10-10 10:07:00'), 'Phosphate'], [50971, Timestamp('2126-10-10 09:20:00'), Timestamp('2126-10-10 10:07:00'), 'Potassium'], [50983, Timestamp('2126-10-10 09:20:00'), Timestamp('2126-10-10 10:07:00'), 'Sodium'], [51006, Timestamp('2126-10-10 09:20:00'), Timestamp('2126-10-10 10:07:00'), 'Urea Nitrogen'], [51221, Timestamp('2126-10-10 09:20:00'), Timestamp('2126-10-10 10:20:00'), 'Hematocrit'], [51222, Timestamp('2126-10-10 09:20:00'), Timestamp('2126-10-10 10:20:00'), 'Hemoglobin'], [51248, Timestamp('2126-10-10 09:20:00'), Timestamp('2126-10-10 10:20:00'), 'MCH'], [51249, Timestamp('2126-10-10 09:20:00'), Timestamp('2126-10-10 10:20:00'), 'MCHC'], [51250, Timestamp('2126-10-10 09:20:00'), Timestamp('2126-10-10 10:20:00'), 'MCV'], [51265, Timestamp('2126-10-10 09:20:00'), Timestamp('2126-10-10 10:20:00'), 'Platelet Count'], [51277, Timestamp('2126-10-10 09:20:00'), Timestamp('2126-10-10 10:20:00'), 'RDW'], [51279, Timestamp('2126-10-10 09:20:00'), Timestamp('2126-10-10 10:20:00'), 'Red Blood Cells'], [51301, Timestamp('2126-10-10 09:20:00'), Timestamp('2126-10-10 12:12:00'), 'White Blood Cells'], [50914, Timestamp('2126-10-10 12:31:00'), Timestamp('2126-10-10 14:54:00'), 'Cyclosporin']]

Question: A 24 F is admitted. He/she says he/she has abdominal pain, diarrhea . History of illness: Pt is a ___ y.o female with h.o Crohn's disease, C.diff, asthma, migraines who presents with diffuse, but highest in LLQ ___ "achy" "pressure" constant pain with nausea and diarrhea, ___ of bloody mucus daily, and with heartburn type symptoms. Pt reports good appetite (due to steroids) but 25lb weight loss since ___. She denies vomiting, constipation, dysuria, travel, sick contacts, new foods. Reports she was on remicade, last dose 2 weeks ago and was recently started on imuran 50mg daily, and had her steroid dose increased from 40mg to 60mg daily without any improvement in her symptoms. Pt reports that pain has become unmanageable at home, despite oxycodone. . In terms of other ROS, 10pt ROS reviewed in detail and negative for headache, dizziness, ST, URI, CP, sob, palpitations, melena, hematuria, joint rash, paresthesias. Pt reports quad weakness secondary to steroids. Past Medical History: Crohns disease c.diff ___ asthma migraines Social History: ___ Family History: CAD, GF with colon cancer, cousin with UC, another cousin with autoimmune hepatitis Allergies: Penicillins / Augmentin What is the best procedure plan for this patient?

TARGETS Target Prescriptions: HYDROmorphone (Dilaudid) 5% Dextrose (EXCEL BAG) CycloSPORINE (Sandimmune) Albuterol Inhaler Sodium Chloride 0.9% Flush Pantoprazole Acetaminophen-Caff-Butalbital D5LR Lorazepam HYDROmorphone (Dilaudid) HYDROmorphone (Dilaudid) Ondansetron Necon 0.5/35 (28) Sucralfate PredniSONE Lactated Ringers Influenza Virus Vaccine Target Lab Orders: Albumin Anion Gap Bicarbonate Chloride Creatinine Glucose Magnesium Phosphate Potassium Sodium Urea Nitrogen Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells Cyclosporin Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : Pt is a ___ y.o female with h.o Crohn's, asthma, migraines who presented with abdominal pain and bloody diarrhea. #acute Crohn's flare:abdominal pain/nausea/bloody diarrhea-ddx included Crohn's flare vs. infectious (prior h.o C.diff but reportedly last test negative 2 weeks ago prior to admission). However, pt's presentation was felt to be consistent with a Crohn's flare. Stool cultures and CMV VL were negative. She was started on IV cyclosporine at 2mg/kg with good effect. The GI and colorectal services followed the patient during admission. She was continued on prednisone at 60mg daily and started on PO calcium and vitamin D. She was transitioned to Cyclosporine 150mg BID (2.5mg/kg BID), decreased to prednisone 40mg daily, and restarted on Azathioprine 100mg daily (2mg/kg daily) on discharge. She will taper her prednisone to 30mg daily on ___, then 10mg weekly until she stops. - for pain, she required significant opiates. She was discharged on Morphine ER 30mg q12 (due to insurance issues with OxyContin) and Oxycodone 10mg q6 prn pain. Side effects were discussed with her. - she will have repeat Cyclosporine level on ___, and follow up with GI in 2 weeks. #acute blood loss anemia-Related to gastrointestinal bleeding due to above. Trended HCT and pt remained hemodynamically stable. #leukocytosis/thrombocytosis-likely due to above as well as steroids. Stool cultures did not reveal infection. #GERD-PPI, sucralfate #asthma, chronic stable-albuterol prn #h.o migraine headaches-Fioricet prn Other Results: ___ 12:40PM UREA N-10 CREAT-0.7 SODIUM-138 POTASSIUM-4.6 CHLORIDE-99 TOTAL CO2-29 ANION GAP-15 ___ 12:40PM estGFR-Using this ___ 12:40PM ALT(SGPT)-29 AST(SGOT)-21 ALK PHOS-109* TOT BILI-0.1 ___ 12:40PM MAGNESIUM-2.2 CHOLEST-202* ___ 12:40PM WBC-17.6* RBC-3.97* HGB-11.1* HCT-34.2* MCV-86 MCH-27.9 MCHC-32.4 RDW-13.5 ___ 12:40PM PLT COUNT-640* . ___ - MRE with rectal inflammation ___ - Sigmoidoscopy with congestion, erosions, erythema, friability, granularity, mucous, serpentine ulcerations in a continuous and circumferential patter from the anus to the sigmoid. No sparing. ___ 06:40AM BLOOD WBC-14.1* RBC-3.75* Hgb-10.4* Hct-31.7* MCV-85 MCH-27.8 MCHC-32.8 RDW-13.9 Plt ___ ___ 06:40AM BLOOD Glucose-83 UreaN-10 Creat-0.7 Na-137 K-4.5 Cl-97 HCO3-27 AnGap-18 ___ 06:35AM BLOOD ALT-20 AST-13 AlkPhos-67 TotBili-0.1 ___ 06:40AM BLOOD Cyclspr-112 CMV vl negative Stool cx negative

2192-09-17 21:23:00

ENGLISH

MARRIED

BLACK/AFRICAN

M

[[22469457, Timestamp('2192-09-17 21:24:04'), '', 'NMED']]

[[{'Medications on Admission': ':\n- torsemide 20mg po qd\n- Vitamin D3\n- atorvastatin 10mg po qd\n- trazodone 50mg po qpm \n- tamsulosin 0.4mg po qd\n- ASA 81mg po qd\n- amantadine HCl 100mg po BID\n- fluoxetine 10mg po qd\n- Brovana 1 vial BID\n- lactulose 15mL BID\n- metformin 500mg BID\n- omeprazole 40mg po qd\n- Urecholine\n- allopurinol ___ po qd\n- amlodipine 10mg po qd\n- Colace\n- Amaryl\n- imdur 60mg po qd\n- bethanechol 25mg po TID\n- lisinopril 40mg po qd\n- metoprolol succinate 50mg po qd\n- multivitamin\n- senna\n- SL NTG\n- warfarin 2.5-5mg po qd\n- keppra 750mg po BID\n\n15. Bethanechol 25 mg PO TID \n16. Atorvastatin 10 mg PO QPM \n17. arformoterol 15 mcg/2 mL inhalation Use 1 vial in Nebulizer \ntwice a day prn \n18. arformoterol 15 mcg/2 mL inhalation X2 PRN \n19. Amantadine 100 mg PO BID \n20. Allopurinol ___ mg PO DAILY \n21. LeVETiracetam Oral Solution 750 mg PO BID \n22. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY \n23. Labetalol 600 mg PO QID \n24. Isosorbide Dinitrate 30 mg PO QID \n25. Glargine 8 Units Bedtime\nInsulin SC Sliding Scale using REG Insulin\n26. HydrALAzine 25 mg PO Q6H \n27. Furosemide 60 mg PO BID \n\nFacility:\n___', 'Brief Hospital Course': ":\n===================================\nICU COURSE ___ - ___\n===================================\nMr. ___ is a ___ man with Afib on coumadin and history of \ntraumatic SAH who presented with acute onset slurred speech and \ngarbled speech. NCHCT showed a 6.3x3.5cm L posterior \ntemporal/parietal IPH in the setting of INR 3.0. He was reversed \nwith Kcentra and VitK. Interval NCHCT (+8hrs) did not show \nincrease in bleed size, though there was a slightly increased \namount of edema, mass effect, and midline shift. A NCHCT on \n___ was stable. His home Keppra was increased from 500mg BID \nto ___ BID due to a concern on admission of active seizures \ncharacterized by jaw twitching. \n\nHis neurological examination was significant for global aphasia, \nR field cut vs neglect, and R hemiparesis - with stabilization \non clinical and radiographic examinations. He remained in ICU \nfor BP goals (<140) and treatment of fluid overload.\n\nBP initially remained difficult to control and he was maintained \non a nicardipine drip. Home BP meds were restarted but required \nup-titration. Nicardipine drip was d/c'ed on ___, though \nrestarted on ___ for refractory HTN. Nicardipine drip d/c'ed \nagain on the morning of ___. Patient also required a lasix \ndrip overnight ___ for significant fluid overload. Diuresis \nwas achieved and he was then transitioned to standing lasix \nregimen. Discharged to the neurology floor after off both drips \nfor more than 6hrs. He was briefly treated for a UTI with \nceftriaxone, but this was discontinued. \n\n===================================\nFLOOR COURSE: ___\n\nOur impression was that this IPH was likely ___ coagulopathy and \nc/b uncontrolled HTN. His aspirin for CAD and stents was started \nafter more than 7 days after the bleed. He will be discharged \noff warfarin. His hospital course was complicated by difficulty \nswallowing and repeat failure of swallow evaluations. He was fed \nvia an NGT, and he eventually received a PEG. His \nantihypertensives were uptitrated to maintain a goal SBP of less \nthan 140. He was seen by ___, and his insulin regimen was \nmodified to get his blood glucose under control. His central \nline was maintained because peripheral access could not be \nobtained. His hospital course was also complicated by urinary \nretention, and he was discharged with a foley. \n\nHe has been ordered for a repeat MRI in ___. He will \nfollow-up with Dr. ___ in stroke clinic in ___. \n\nTransitional issues:\n-Will need to determine whether anticoagulation is needed for AF \nlong-term; home warfarin current d/c'd and discharged on ASA \n81mg (for CAD, stents) daily for now\n-Urinary retention requiring foley\n-Monitor fingersticks\n-Goal SBP<140\n-MRI in ___\n-Home torsemide 20mg daily held and discharged on furosemide \n60mg BID for volume overload\n-NPO with PEG tube (Glucerna 1.5 Cal Full strength; \n Starting rate:10 ml/hr; Advance rate by 10 ml q2h Goal rate:55 \nml/hr\n Residual Check:q4h Hold feeding for residual >= :200 ml\nFlush w/ 250 ml water q4h)\n\n===================================\nAHA/ASA Core Measures for Intracerebral Hemorrhage \n1. Dysphagia screening before any PO intake? (x) Yes - () No \n2. DVT Prophylaxis administered? (x) Yes - () No \n3. Smoking cessation counseling given? () Yes - (x) No [reason \n() non-smoker - (x) unable to participate] \n4. Stroke education (personal modifiable risk factors, how to \nactivate EMS for stroke, stroke warning signs and symptoms, \nprescribed medications, need for followup) given (verbally or \nwritten)? (x) Yes - () No \n5. Assessment for rehabilitation and/or rehab services \nconsidered? (x) Yes - () No\n\n", 'Pertinent Results:': '\n==============\nADMISSION LABS\n==============\n___ 04:30PM BLOOD WBC-9.7 RBC-4.08* Hgb-12.2* Hct-37.3* \nMCV-91 MCH-29.9 MCHC-32.7 RDW-15.2 RDWSD-50.4* Plt ___\n___ 04:30PM BLOOD ___ PTT-42.3* ___\n___ 04:30PM BLOOD UreaN-19\n___ 04:41PM BLOOD Creat-1.3*\n___ 11:42PM BLOOD Glucose-168* UreaN-16 Creat-1.0 Na-144 \nK-3.8 Cl-107 HCO3-23 AnGap-18\n___ 04:30PM BLOOD ALT-18 AST-26 AlkPhos-101 TotBili-0.3\n___ 04:30PM BLOOD Lipase-31\n___ 11:42PM BLOOD cTropnT-<0.01\n___ 04:30PM BLOOD Albumin-4.1\n___ 11:42PM BLOOD Calcium-11.3* Phos-2.1* Mg-2.4\n___ 04:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG \nBnzodzp-NEG Barbitr-NEG Tricycl-NEG\n___ 09:23PM URINE Blood-NEG Nitrite-NEG Protein-NEG \nGlucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG\n___ 09:23PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG \ncocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG\n\n==============\nOTHER LABS\n==============\n___ 05:22AM BLOOD WBC-7.8 RBC-3.47* Hgb-10.2* Hct-32.6* \nMCV-94 MCH-29.4 MCHC-31.3* RDW-15.1 RDWSD-51.7* Plt ___\n___ 05:22AM BLOOD Plt ___\n___ 07:34AM BLOOD ___ PTT-28.4 ___\n___ 05:22AM BLOOD Glucose-151* UreaN-42* Creat-1.3* Na-145 \nK-3.7 Cl-107 HCO3-32 AnGap-10\n___ 11:42PM BLOOD ALT-14 AST-16 AlkPhos-101 TotBili-0.5\n___ 05:22AM BLOOD Calcium-10.0 Phos-2.8 Mg-2.7*\n___ 06:01PM BLOOD Type-ART pO2-87 pCO2-33* pH-7.44 \ncalTCO2-23 Base XS-0\n___ 06:01PM BLOOD Lactate-0.7\n___ 06:01PM BLOOD freeCa-1.32\n\n=======\nIMAGING\n=======\nCTA H&N - ___ @ 4:30PM\n1. 6.3 cm left temporoparietal intraparenchymal hemorrhage with \ncentral low density peripheral focus suggestive of active, \nhyperacute bleeding. \n2. Edema and mass effect related to left temporoparietal \nhemorrhage with \nconcern for left temporal horn entrapment as described. \nRecommend clinical correlation. \n3. While no definite underlying mass identified, please note \nthat underlying mass cannot be excluded on the basis \nexamination. Recommend clinical correlation and imaging \nfollowup to resolution. Consider MRI for further \ncharacterization. \n4. Markedly narrowed and beaded appearance of the \nvertebrobasilar system with segments of absent limited \nenhancement within mid to superior basilar artery, concerning \nfor occlusion or slow flow. \n5. 3 mm fusiform aneurysm at the inferior basilar artery. \n6. Patent cervical vasculature with atherosclerosis changes of \nthe bilateral carotid bifurcations and bulbs, as described. \n7. Diminutive bilateral cervical vertebral arteries with \nsuggested narrowing and bilateral origins. \n8. Periapical lucency at the right maxillary first molar. \nRecommend follow-up with dentistry. \n\nCXR - ___\nRight IJ likely terminates in the upper SVC. No pneumothorax. \nMild vascular congestion. \n\nNCHCT - ___ @ 11:30PM\n1. No significant change in the size of a 6.3 cm left posterior \ntemporal \nintraparenchymal hemorrhage with surrounding edema. No new \nhemorrhage or \ninfarction identified. \n2. 3 mm of midline shift is stable from the prior study. \n\nNCHCT - ___\n1. No significant change in the size of the 6.4 cm left \nposterior temporal \nintraparenchymal hemorrhage with surrounding edema. No new \nhemorrhage or \ninfarction identified. \n2. Medial displacement of the left temporal lobe on the cistern. \n\nCXR - ___\nComparison to ___. In the interval, the patient has \ndeveloped \nmild to moderate pulmonary edema. Moderate cardiomegaly \npersists in unchanged manner. Platelike atelectasis at the left \nlung basis. No larger pleural effusions. \n\nNCHCT - ___\nStable large left parietal/occipital/ posterior temporal \nhemorrhage with \nstable surrounding edema and stable mass effect. \n\n___ CXR\nThe feeding tube courses below the diaphragm with the tip not \nidentified. \nRight internal jugular central line has its tip proximal to mid \nin the SVC. \nProminent hilar contours may represent engorged vessels, \nalthough \nlymphadenopathy cannot be excluded. There has been interval \nworsening of mild \npulmonary edema. Linear opacity in the left mid lung likely \nreflects scarring \nor subsegmental atelectasis. Probable small layering left \neffusion. No \npneumothorax. \n\n___ CXR\nComparison to ___. No relevant change. Moderate \ncardiomegaly. \nFeeding tube and right internal jugular vein catheter are in \ncorrect position. \nThe pre-existing signs of mild pulmonary edema are unchanged. \nMild \nretrocardiac atelectasis. No pleural effusions. \n\n', 'Physical Exam:|Physical': '\nADMISSION EXAMINATION:\nVitals: T: HR: 104 BP: 200/110 RR: 20 SaO2: 100% RA\nGeneral: in some distress, looking to the left constantly,\nawake, has some jaw twitching \nHEENT: atraumatic\n___: irregularly irregular, no M/R/G\nPulmonary: CTAB, no crackles or wheezes\nAbdomen: Soft, NT, ND, +BS, no guarding\nExtremities: Warm, no edema\n\nNeurologic Examination:\n- Mental status: not following commands, speaking gibberish, \ndoes\nnot seem to understand what people are saying, can say "hi"\n\n- Cranial Nerves: PERRL 3->2 brisk. BTT on L, does not BTT on R.\nR facial droop. \n\n- Motor: Normal bulk. Wiggles fingers and toes but does not \nlift\nlimbs against gravity (pt not following commands) \n\n- Reflexes: difficult to obtain due to body habitus\n [Bic] [Tri] [___] [Quad] [Gastroc]\n L 2+ 2+ 2+ 2+ 1\n R 2+ 2+ 2+ 2+ 1 \nPlantar response plantar bilaterally\n\n- Sensory: withdraws to pain in all 4 extremities\n\n- Coordination: unable to assess\n\n- Gait: unable to assess\n\n==============================================================\nICU EXAMINATION:\nGEN - elderly M, lying in bed awake\nHEENT - NC/AT, MMM\nNECK - +meningeal signs with neck flexion\nCV - RRR\nRESP - normal WOB\nABD - obese, soft, NT, ND\nEXTR - atraumatic, WWP\n\nNEUROLOGICAL EXAMINATION\nMS - wakes to voice this AM; L head and gaze deviation with \nsignificant R sided neglect; says "okay" and mumbles; cannot \nname or repeat; does not obey simple midline or appendicular \ncommands\nCN - no BTT over R hemifield; PERRL; L head and gaze deviation, \ncan come to midline volitionally, just able to cross with VOR; R \nfacial droop with weak R eye closure\nMOTOR - moves the LEFT hemibody spontaneously and antigravity \nbut is unable to comply with formal strength testing; RUE and \nRLE are just antigravity with scant spontaneous movement\nSENSORY - grimace to nox x4; withdraws and grimaces to nox over \nR hemibody, does localizes (poorly) to nox in the RUE; brisk \nlocalization and withdraw to nox over the L hemibody\n\n==========================================================\nDISCHARGE EXAM:\n?????????????????\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\nMr. ___ is a ___ man with HTN, hx traumatic SAH, CAD\ns/p 2 stents, DM2, and COPD, and afib who presents with aphasia.\nAt noon, he became confused but was speaking normally. At 2pm, \nhe\nstarted having slurred speech, and he was making up words. \nSpeech\nwas garbled, and he appeared to know what people were saying but\ncould not respond appropriately. Daughter called the NP at ___\'s\noffice who suggested checking his BG. BG was 90, and since\nsymptoms persisted, daughter brought him to the ED. She does not\nknow of any recent trauma, and he did not fall this morning. \n\nOn arrival to the ED, a code stroke was called. NIHSS 25, NCHCT\nshowed L intraparenchymal bleed. Kcentra and vitamin K were \ngiven\nfor INR reversal (INR 3.0 from coumadin). Pt was protecting his\nairway. \n\nPt on coumadin for afib. Most recent INR prior to admission \n___\nwas 2.1. Per ___ clinic calendar, he was taking 10mg\ncoumadin po qd. \n\nEarlier this year, he had a mechanical fall ___ leading to a \nR\nparietal SAH and blood along the basal cisterns that got \nslightly\nlarger. Had some weakness in LUE but was able to walk with a\nwalker while in rehab. Had some difficulty with speech at that\ntime as well as short term memory. Discharge exam showed "A&Ox3,\nPERRL, dysarthric with slow speech, upper lip swollen and L face\nL lid lad possibly ___ face swelling." L deltoid ___, L biceps\n___, Triceps ___, grip ___, IP 4+/5. \n\nSeen in ___ clinic ___ and instructed to stay on\nKeppra 500mg BID due to L sided face twitching concerning for\nfocal seizures. \n\nPer ___ note from ___, he has residual weakness in his\narm on the left side and weakness in his leg. Coumadin was held\nfor ___ in ___ and restarted. Gets around in wheelchair. Per\ndaughter, pt\'s baseline is that he can dress himself, someone is\nalways with him so he does not cook or drive. \n\nPast Medical History:\nHTN, asthma, spermatocele, OSA, obesity, DM2, afib on\nAC, gout, CAD s/p stent (single vessel CAD s/p RCA stent ___,\nHLD, cognitive impairment, colonic adenoma, spinal stenosis,\nanemia, total knee replacement, renal cysts\n\nSocial History:\n___\nFamily History:\nBrother died of heart failure in ___, sister of cancer (type \nunknown) in ___\n\n', 'Chief Complaint:|Complaint:': '\nCODE STROKE - slurred speech\n\n', 'Attending:': ' ___\n\n', 'Allergies:': ' \nPenicillins / clonidine patch / Erythromycin Base / Lasix / \nAmoxicillin / hydrochlorothiazide / aspirin\n\n'}, '19599279-DS-17', 17, 'neurology']]

[['EXAMINATION: CTA HEAD AND CTA NECK PQ147 CT HEADNECK\n\nINDICATION: ___ male with history of intracranial hemorrhage, now\nwith altered mental status slurred speech and not following commands. \nEvaluate for etiology.\n\nTECHNIQUE: Contiguous MDCT axial images were obtained through the brain\nwithout contrast material. Subsequently, helically acquired rapid axial\nimaging was performed from the aortic arch through the brain during the\ninfusion of 70 mL of Omnipaque intravenous contrast material.\nThree-dimensional angiographic volume rendered, curved reformatted and\nsegmented images were generated on a dedicated workstation. This report is\nbased on interpretation of all of these images.\n\nDOSE: Acquisition sequence:\n 1) CT Localizer Radiograph\n 2) CT Localizer Radiograph\n 3) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =\n802.7 mGy-cm.\n 4) CT Localizer Radiograph\n 5) CT Localizer Radiograph\n 6) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 43.6 mGy (Head) DLP =\n21.8 mGy-cm.\n 7) Spiral Acquisition 5.2 s, 41.1 cm; CTDIvol = 32.1 mGy (Head) DLP =\n1,318.2 mGy-cm.\n 8) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =\n802.7 mGy-cm.\n Total DLP (Head) = 2,945 mGy-cm.\n\nCOMPARISON: ___ noncontrast head CT.\n\nFINDINGS: \n\nCT HEAD WITHOUT CONTRAST:\nThere is a 6.3 (AP) x 3.5 (TV) x 4.4 (SI) cm hyperdense intraparenchymal\nhemorrhage within the posterior left temporal cortex which demonstrates\ninternal areas of hypodensity suggestive of fluid / fluid levels. There is\nassociated adjacent hypodense edema and mass effect which effaces the atria\nand occipital horn of the left lateral ventricle. There is asymmetric\nprominence of the left temporal horn lateral ventricle concerning for\nentrapment. There is sulcal effacement with, 3 mm of left-to-right midline\nshift without evidence of subfalcine or downward herniation.\n\nThere is extensive periventricular white matter hypodensity, likely\nrepresenting sequela of chronic microangiopathy.\n\nThe orbits, calvarium and soft tissues are unremarkable. Paranasal sinuses\nand mastoid air cells are clear.\n\nCTA HEAD:\nAgain seen is a 6.3 (AP) x 3.5 (TV) x 4.4 (SI) cm hyperdense intraparenchymal\nhemorrhage within the left posterior temporal cortex with curvilinear\npostcontrast enhancement at its posterior lateral margin near the cortical\nsurface measuring 4 mm (4:288), consistent with a CTA spot sign.\n\nThere is calcific atherosclerosis of the bilateral cavernous to communicating\nsegment internal carotid arteries without significant luminal stenosis. The\nanterior circulation is patent without evidence of occlusion, significant\nstenosis, dissection, or aneurysm. There are prominent bilateral posterior\ncommunicating arteries.\n\nThe bilateral vertebral arteries are diminutive with the left vertebral artery\nending in an ___ complex. There is focal calcification at the left\nV3-V4 junction. The right vertebral artery is diminutive with a fusiform\naneurysm at the vertebrobasilar junction measuring 3 mm (4:239). The basilar\nartery is for markedly narrowed and beaded and its appearance with short\nsegments of non filling at its mid to superior aspect.\n\nCTA NECK:\nThere is calcific and noncalcified atherosclerosis at the right carotid\nbifurcation carotid bulb with 40% stenosis at the carotid bulb by NASCET\ncriteria.\n\nThere is calcific atherosclerosis at the left carotid bulb without significant\nluminal stenosis by NASCET criteria.\n\nThe bilateral vertebral arteries are diminutive, but patent along their\ncervical course without evidence of occlusion, stenosis, aneurysm, or\ndissection. There is suggested narrowing and bilateral vertebral artery\norigins.\n\nThere is calcific atherosclerosis of the aortic arch. The visualized lung\napices are clear. The thyroid gland is unremarkable. There is no cervical\nlymphadenopathy by CT criteria. There is a periapical lucency at the right\nmaxillary first molar (04:20 2)\n\nIMPRESSION:\n\n\n1. 6.3 cm left temporoparietal intraparenchymal hemorrhage with central low\ndensity peripheral focus suggestive of active, hyperacute bleeding.\n2. Edema and mass effect related to left temporoparietal hemorrhage with\nconcern for left temporal horn entrapment as described. Recommend clinical\ncorrelation.\n3. While no definite underlying mass identified, please note that underlying\nmass cannot be excluded on the basis examination. Recommend clinical\ncorrelation and imaging followup to resolution. Consider MRI for further\ncharacterization.\n4. Markedly narrowed and beaded appearance of the vertebrobasilar system with\nsegments of absent limited enhancement within mid to superior basilar artery,\nconcerning for occlusion or slow flow.\n5. 3 mm fusiform aneurysm at the inferior basilar artery.\n6. Patent cervical vasculature with atherosclerosis changes of the bilateral\ncarotid bifurcations and bulbs, as described.\n7. Diminutive bilateral cervical vertebral arteries with suggested narrowing\nand bilateral origins.\n8. Periapical lucency at the right maxillary first molar. Recommend follow-up\nwith dentistry.\n\nRECOMMENDATION(S): Periapical lucency at the right maxillary first molar. \nRecommend follow-up with dentistry.\n', '19599279-RR-27', 27, 'contiguous mdct axial images were obtained through the brain\nwithout contrast material. subsequently, helically acquired rapid axial\nimaging was performed from the aortic arch through the brain during the\ninfusion of 70 ml of omnipaque intravenous contrast material.\nthree-dimensional angiographic volume rendered, curved reformatted and\nsegmented images were generated on a dedicated workstation. this report is\nbased on interpretation of all of these images.'], ['INDICATION: ___ with s/p RIJ\n\nTECHNIQUE: AP VIEW OF THE CHEST\n\nCOMPARISON: ___\n\nFINDINGS: \n\nA right internal jugular catheter likely terminates in the upper SVC.\n\nLung volumes are low which accentuates bronchovascular markings. There is\nmild pulmonary vascular congestion without frank pulmonary edema. There is\nmild right basal atelectasis. No large effusion or pneumothorax is\nidentified.\n\nIMPRESSION: \n\nRight IJ likely terminates in the upper SVC. No pneumothorax. Mild vascular\ncongestion.\n', '19599279-RR-28', 28, 'ap view of the chest'], ['EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD\n\nINDICATION: ___ year old man with intraparenchymal hemorrhage // please\nperform 11 ___ ___, assess for interval change\n\nTECHNIQUE: Contiguous axial images of the brain were obtained without\ncontrast.\n\nDOSE: Acquisition sequence:\n 1) CT Localizer Radiograph\n 2) CT Localizer Radiograph\n 3) Sequenced Acquisition 14.0 s, 14.3 cm; CTDIvol = 49.3 mGy (Head) DLP =\n702.4 mGy-cm.\n Total DLP (Head) = 702 mGy-cm.\n\nCOMPARISON: ___ CTA head and CTA neck\n___ CT head without contrast\n\nFINDINGS: \n\nAgain demonstrated is a 6.3 x 3.6 cm left posterior temporal intraparenchymal\nhemorrhage with surrounding edema and resultant rightward shift of midline\nstructures measuring 3 mm not significantly increased in size from CTA\nperformed at 16:40 today. No additional hemorrhage or infarction is\nidentified. There is mass effect upon the left lateral ventricle however\nthere is no evidence of herniation and the basal cisterns are patent.\n\n.\nThere is no evidence of fracture. The visualized portion of the paranasal\nsinuses, mastoid air cells, and middle ear cavities are clear. The visualized\nportion of the orbits are unremarkable.\n\nIMPRESSION:\n\n\n1. No significant change in the size of a 6.3 cm left posterior temporal\nintraparenchymal hemorrhage with surrounding edema. No new hemorrhage or\ninfarction identified.\n2. 3 mm of midline shift is stable from the prior study.\n', '19599279-RR-29', 29, 'contiguous axial images of the brain were obtained without\ncontrast.'], ['EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD\n\nINDICATION: ___ with PMH of A-fib (on coumadin), DM2, and HTN with a\nsupratherapeutic INR and L IPH. Evaluate for interval change.\n\nTECHNIQUE: Contiguous axial images of the brain were obtained without\ncontrast.\n\nDOSE: Acquisition sequence:\n 1) CT Localizer Radiograph\n 2) CT Localizer Radiograph\n 3) Sequenced Acquisition 4.5 s, 15.3 cm; CTDIvol = 48.6 mGy (Head) DLP =\n744.0 mGy-cm.\n Total DLP (Head) = 758 mGy-cm.\n\nCOMPARISON: CT from ___.\n\nFINDINGS: \n\nAgain seen is a 6.4 x 3.4 cm left posterior temporal intra parenchymal\nhemorrhage with surrounding edema with mild displacement of the medial portion\nof the left temporal lobe on the cistern, minimally increased from prior CT on\n___ (03:12). No additional hemorrhage or infarction is\nidentified. Mild mass effect upon the left lateral ventricle is again\ndemonstrated, unchanged from prior.\n\nThere is no evidence of fracture. The visualized portion of the paranasal\nsinuses, mastoid air cells, and middle ear cavities are clear. The visualized\nportion of the orbits are unremarkable.\n\nIMPRESSION:\n\n\n1. No significant change in the size of the 6.4 cm left posterior temporal\nintraparenchymal hemorrhage with surrounding edema. No new hemorrhage or\ninfarction identified.\n2. Medial displacement of the left temporal lobe on the cistern.\n', '19599279-RR-30', 30, 'contiguous axial images of the brain were obtained without\ncontrast.'], ['EXAMINATION: CHEST (PORTABLE AP)\n\nINDICATION: ___ year old man with IPH // ?fluid status ?fluid status\n\nIMPRESSION: \n\nComparison to ___. In the interval, the patient has developed\nmild to moderate pulmonary edema. Moderate cardiomegaly persists in unchanged\nmanner. Platelike atelectasis at the left lung basis. No larger pleural\neffusions.\n', '19599279-RR-31', 31, ''], ['EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 3 EXAMS\n\nINDICATION: ___ year old man with IPH s/p dobhoff placement // ?dobhoff\nplacement ?dobhoff placement\n\nIMPRESSION: \n\nThe third of 3 films documents correct position of the nasogastric catheter in\nthe stomach. No pneumothorax or other complications. Right internal jugular\nvein catheter is in unchanged position. No pleural effusions. Unchanged\nmoderate cardiomegaly. Unchanged moderate pulmonary edema.\n', '19599279-RR-32', 32, ''], ['EXAMINATION: CT HEAD W/O CONTRAST\n\nINDICATION: ___ with past medical history of atrial fibrillation (on\ncoumadin), diabetes, and hypertension, with a supratherapeutic INR and\nparenchymal hemorrhage, with progressive somnelence. Evaluate for interval\nchange.\n\nTECHNIQUE: Noncontrast head CT. DLP 848 mGy cm.\n\nCOMPARISON: ___ at 12:32.\n\nFINDINGS: \n\nLarge parenchymal hemorrhage involving the left parietal, occipital, and\nposterior temporal lobes appears stable compared to 1 day earlier, with\nunchanged surrounding edema.Effacement of the posterior components of the left\nlateral ventricle, partial effacement of the third ventricle, and mild\nrightward shift of midline structures are unchanged. Trace blood in the\noccipital horns of the lateral ventricles is unchanged as well. Mild medial\ndisplacement of the left medial temporal lobe, which abuts the midbrain, is\nunchanged. Diffuse supratentorial white matter hypoattenuation is unchanged,\nlikely sequela of chronic small vessel ischemic disease in this age group.\n\nThe bones are unremarkable. The imaged paranasal sinuses and mastoid air cells\nare grossly well aerated.\n\nIMPRESSION: \n\nStable large left parietal/occipital/ posterior temporal hemorrhage with\nstable surrounding edema and stable mass effect.\n', '19599279-RR-33', 33, 'noncontrast head ct. dlp 848 mgy cm.'], ['EXAMINATION: CHEST (PORTABLE AP)\n\nINDICATION: ___ year old man with stroke // ?pulm edema ?pulm edema\n\nCOMPARISON: Comparison to ___ at 07:35\n\nFINDINGS: \n\nPortable upright chest radiograph ___ at 12:00 is submitted.\n\nIMPRESSION: \n\nThe feeding tube courses below the diaphragm with the tip not identified. \nRight internal jugular central line has its tip proximal to mid in the SVC. \nProminent hilar contours may represent engorged vessels, although\nlymphadenopathy cannot be excluded. There has been interval worsening of mild\npulmonary edema. Linear opacity in the left mid lung likely reflects scarring\nor subsegmental atelectasis. Probable small layering left effusion. No\npneumothorax.\n', '19599279-RR-36', 36, ''], ['EXAMINATION: CHEST (PORTABLE AP)\n\nINDICATION: ___ year old man with left ICH, history of fluid overload.\n?crackles // ?pulm edema ?pulm edema\n\nIMPRESSION: \n\nComparison to ___. No relevant change. Moderate cardiomegaly. \nFeeding tube and right internal jugular vein catheter are in correct position.\nThe pre-existing signs of mild pulmonary edema are unchanged. Mild\nretrocardiac atelectasis. No pleural effusions.\n', '19599279-RR-38', 38, ''], ['INDICATION: ___ year old man with stroke. Now with lethargy. // ?PNA\n\nTECHNIQUE: Chest PA and lateral\n\nCOMPARISON: ___\n\nFINDINGS: \n\nComparison to ___. Moderate cardiomegaly.\nThe pre-existing signs of mild pulmonary edema are mildly improved. Mild\nbilateral subsegmental atelectasis. No pleural effusions. Free\nintraperitoneal air under the right hemidiaphragm and possibly the left\nhemidiaphragm are new.\n\nIMPRESSION: \n\nSlight improvement mild pulmonary edema.\n\nNew free air under the right hemidiaphragm related to recent PEG insertion.\n\nNOTIFICATION: The findings were discussed by Dr. ___ with Dr.\n___ on the ___ ___ at 3:43 ___, 20 minutes after discovery\nof the findings.\n', '19599279-RR-40', 40, 'chest pa and lateral']]

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[['30283B1', 10, 1, Timestamp('2192-09-17 00:00:00'), 'Transfusion of Nonautologous 4-Factor Prothrombin Complex Concentrate into Vein, Percutaneous Approach']]

['neurology']

[[51221, Timestamp('2192-09-17 23:42:00'), Timestamp('2192-09-18 00:00:00'), 'Hematocrit'], [51222, Timestamp('2192-09-17 23:42:00'), Timestamp('2192-09-18 00:00:00'), 'Hemoglobin'], [51248, Timestamp('2192-09-17 23:42:00'), Timestamp('2192-09-18 00:00:00'), 'MCH'], [51249, Timestamp('2192-09-17 23:42:00'), Timestamp('2192-09-18 00:00:00'), 'MCHC'], [51250, Timestamp('2192-09-17 23:42:00'), Timestamp('2192-09-18 00:00:00'), 'MCV'], [51265, Timestamp('2192-09-17 23:42:00'), Timestamp('2192-09-18 00:00:00'), 'Platelet Count'], [51277, Timestamp('2192-09-17 23:42:00'), Timestamp('2192-09-18 00:00:00'), 'RDW'], [51279, Timestamp('2192-09-17 23:42:00'), Timestamp('2192-09-18 00:00:00'), 'Red Blood Cells'], [51301, Timestamp('2192-09-17 23:42:00'), Timestamp('2192-09-18 00:00:00'), 'White Blood Cells'], [52172, Timestamp('2192-09-17 23:42:00'), Timestamp('2192-09-18 00:00:00'), 'RDW-SD'], [51237, Timestamp('2192-09-17 23:42:00'), Timestamp('2192-09-18 00:30:00'), 'INR(PT)'], [51274, Timestamp('2192-09-17 23:42:00'), Timestamp('2192-09-18 00:30:00'), 'PT'], [51275, Timestamp('2192-09-17 23:42:00'), Timestamp('2192-09-18 00:30:00'), 'PTT'], [50861, Timestamp('2192-09-17 23:42:00'), Timestamp('2192-09-18 01:17:00'), 'Alanine Aminotransferase (ALT)'], [50863, Timestamp('2192-09-17 23:42:00'), Timestamp('2192-09-18 01:17:00'), 'Alkaline Phosphatase'], [50868, Timestamp('2192-09-17 23:42:00'), Timestamp('2192-09-18 01:28:00'), 'Anion Gap'], [50878, Timestamp('2192-09-17 23:42:00'), Timestamp('2192-09-18 01:17:00'), 'Asparate Aminotransferase (AST)'], [50882, Timestamp('2192-09-17 23:42:00'), Timestamp('2192-09-18 01:28:00'), 'Bicarbonate'], [50885, Timestamp('2192-09-17 23:42:00'), Timestamp('2192-09-18 01:17:00'), 'Bilirubin, Total'], [50893, Timestamp('2192-09-17 23:42:00'), Timestamp('2192-09-18 01:17:00'), 'Calcium, Total'], [50902, Timestamp('2192-09-17 23:42:00'), Timestamp('2192-09-18 01:17:00'), 'Chloride'], [50912, Timestamp('2192-09-17 23:42:00'), Timestamp('2192-09-18 01:17:00'), 'Creatinine'], [50931, Timestamp('2192-09-17 23:42:00'), Timestamp('2192-09-18 01:17:00'), 'Glucose'], [50960, Timestamp('2192-09-17 23:42:00'), Timestamp('2192-09-18 01:17:00'), 'Magnesium'], [50970, Timestamp('2192-09-17 23:42:00'), Timestamp('2192-09-18 01:17:00'), 'Phosphate'], [50971, Timestamp('2192-09-17 23:42:00'), Timestamp('2192-09-18 01:17:00'), 'Potassium'], [50983, Timestamp('2192-09-17 23:42:00'), Timestamp('2192-09-18 01:17:00'), 'Sodium'], [51003, Timestamp('2192-09-17 23:42:00'), Timestamp('2192-09-18 01:17:00'), 'Troponin T'], [51006, Timestamp('2192-09-17 23:42:00'), Timestamp('2192-09-18 01:28:00'), 'Urea Nitrogen'], [50902, Timestamp('2192-09-18 16:06:00'), Timestamp('2192-09-18 19:18:00'), 'Chloride'], [50960, Timestamp('2192-09-18 16:06:00'), Timestamp('2192-09-18 19:18:00'), 'Magnesium'], [50971, Timestamp('2192-09-18 16:06:00'), Timestamp('2192-09-18 19:18:00'), 'Potassium'], [50983, Timestamp('2192-09-18 16:06:00'), Timestamp('2192-09-18 19:18:00'), 'Sodium']]

Question: A 70 M is admitted. He/she says he/she has CODE STROKE - slurred speech . History of illness: Mr. ___ is a ___ man with HTN, hx traumatic SAH, CAD s/p 2 stents, DM2, and COPD, and afib who presents with aphasia. At noon, he became confused but was speaking normally. At 2pm, he started having slurred speech, and he was making up words. Speech was garbled, and he appeared to know what people were saying but could not respond appropriately. Daughter called the NP at ___'s office who suggested checking his BG. BG was 90, and since symptoms persisted, daughter brought him to the ED. She does not know of any recent trauma, and he did not fall this morning. On arrival to the ED, a code stroke was called. NIHSS 25, NCHCT showed L intraparenchymal bleed. Kcentra and vitamin K were given for INR reversal (INR 3.0 from coumadin). Pt was protecting his airway. Pt on coumadin for afib. Most recent INR prior to admission ___ was 2.1. Per ___ clinic calendar, he was taking 10mg coumadin po qd. Earlier this year, he had a mechanical fall ___ leading to a R parietal SAH and blood along the basal cisterns that got slightly larger. Had some weakness in LUE but was able to walk with a walker while in rehab. Had some difficulty with speech at that time as well as short term memory. Discharge exam showed "A&Ox3, PERRL, dysarthric with slow speech, upper lip swollen and L face L lid lad possibly ___ face swelling." L deltoid ___, L biceps ___, Triceps ___, grip ___, IP 4+/5. Seen in ___ clinic ___ and instructed to stay on Keppra 500mg BID due to L sided face twitching concerning for focal seizures. Per ___ note from ___, he has residual weakness in his arm on the left side and weakness in his leg. Coumadin was held for ___ in ___ and restarted. Gets around in wheelchair. Per daughter, pt's baseline is that he can dress himself, someone is always with him so he does not cook or drive. Past Medical History: HTN, asthma, spermatocele, OSA, obesity, DM2, afib on AC, gout, CAD s/p stent (single vessel CAD s/p RCA stent ___, HLD, cognitive impairment, colonic adenoma, spinal stenosis, anemia, total knee replacement, renal cysts Social History: ___ Family History: Brother died of heart failure in ___, sister of cancer (type unknown) in ___ Allergies: Penicillins / clonidine patch / Erythromycin Base / Lasix / Amoxicillin / hydrochlorothiazide / aspirin What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Sodium Chloride 0.9% Amlodipine Isosorbide Mononitrate (Extended Release) Influenza Vaccine Quadrivalent Lisinopril Dextrose 50% Sodium Chloride 0.9% 0.9% Sodium Chloride LeVETiracetam Labetalol Metoprolol Tartrate Glucose Gel Insulin Labetalol Ipratropium-Albuterol Neb Glucagon Sodium Chloride 0.9% Flush 0.9% Sodium Chloride NiCARdipine IV 0.83% Sodium Chloride NiCARdipine IV HydrALAzine HydrALAzine Lidocaine Jelly 2% (Urojet) Labetalol Target Lab Orders: Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells RDW-SD INR(PT) PT PTT Alanine Aminotransferase (ALT) Alkaline Phosphatase Anion Gap Asparate Aminotransferase (AST) Bicarbonate Bilirubin, Total Calcium, Total Chloride Creatinine Glucose Magnesium Phosphate Potassium Sodium Troponin T Urea Nitrogen Chloride Magnesium Potassium Sodium Target Procedures: Transfusion of Nonautologous 4-Factor Prothrombin Complex Concentrate into Vein, Percutaneous Approach DOCTOR'S NOTE Hospital Notes: : =================================== ICU COURSE ___ - ___ =================================== Mr. ___ is a ___ man with Afib on coumadin and history of traumatic SAH who presented with acute onset slurred speech and garbled speech. NCHCT showed a 6.3x3.5cm L posterior temporal/parietal IPH in the setting of INR 3.0. He was reversed with Kcentra and VitK. Interval NCHCT (+8hrs) did not show increase in bleed size, though there was a slightly increased amount of edema, mass effect, and midline shift. A NCHCT on ___ was stable. His home Keppra was increased from 500mg BID to ___ BID due to a concern on admission of active seizures characterized by jaw twitching. His neurological examination was significant for global aphasia, R field cut vs neglect, and R hemiparesis - with stabilization on clinical and radiographic examinations. He remained in ICU for BP goals (<140) and treatment of fluid overload. BP initially remained difficult to control and he was maintained on a nicardipine drip. Home BP meds were restarted but required up-titration. Nicardipine drip was d/c'ed on ___, though restarted on ___ for refractory HTN. Nicardipine drip d/c'ed again on the morning of ___. Patient also required a lasix drip overnight ___ for significant fluid overload. Diuresis was achieved and he was then transitioned to standing lasix regimen. Discharged to the neurology floor after off both drips for more than 6hrs. He was briefly treated for a UTI with ceftriaxone, but this was discontinued. =================================== FLOOR COURSE: ___ Our impression was that this IPH was likely ___ coagulopathy and c/b uncontrolled HTN. His aspirin for CAD and stents was started after more than 7 days after the bleed. He will be discharged off warfarin. His hospital course was complicated by difficulty swallowing and repeat failure of swallow evaluations. He was fed via an NGT, and he eventually received a PEG. His antihypertensives were uptitrated to maintain a goal SBP of less than 140. He was seen by ___, and his insulin regimen was modified to get his blood glucose under control. His central line was maintained because peripheral access could not be obtained. His hospital course was also complicated by urinary retention, and he was discharged with a foley. He has been ordered for a repeat MRI in ___. He will follow-up with Dr. ___ in stroke clinic in ___. Transitional issues: -Will need to determine whether anticoagulation is needed for AF long-term; home warfarin current d/c'd and discharged on ASA 81mg (for CAD, stents) daily for now -Urinary retention requiring foley -Monitor fingersticks -Goal SBP<140 -MRI in ___ -Home torsemide 20mg daily held and discharged on furosemide 60mg BID for volume overload -NPO with PEG tube (Glucerna 1.5 Cal Full strength; Starting rate:10 ml/hr; Advance rate by 10 ml q2h Goal rate:55 ml/hr Residual Check:q4h Hold feeding for residual >= :200 ml Flush w/ 250 ml water q4h) =================================== AHA/ASA Core Measures for Intracerebral Hemorrhage 1. Dysphagia screening before any PO intake? (x) Yes - () No 2. DVT Prophylaxis administered? (x) Yes - () No 3. Smoking cessation counseling given? () Yes - (x) No [reason () non-smoker - (x) unable to participate] 4. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given (verbally or written)? (x) Yes - () No 5. Assessment for rehabilitation and/or rehab services considered? (x) Yes - () No Other Results: ============== ADMISSION LABS ============== ___ 04:30PM BLOOD WBC-9.7 RBC-4.08* Hgb-12.2* Hct-37.3* MCV-91 MCH-29.9 MCHC-32.7 RDW-15.2 RDWSD-50.4* Plt ___ ___ 04:30PM BLOOD ___ PTT-42.3* ___ ___ 04:30PM BLOOD UreaN-19 ___ 04:41PM BLOOD Creat-1.3* ___ 11:42PM BLOOD Glucose-168* UreaN-16 Creat-1.0 Na-144 K-3.8 Cl-107 HCO3-23 AnGap-18 ___ 04:30PM BLOOD ALT-18 AST-26 AlkPhos-101 TotBili-0.3 ___ 04:30PM BLOOD Lipase-31 ___ 11:42PM BLOOD cTropnT-<0.01 ___ 04:30PM BLOOD Albumin-4.1 ___ 11:42PM BLOOD Calcium-11.3* Phos-2.1* Mg-2.4 ___ 04:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 09:23PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG ___ 09:23PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG ============== OTHER LABS ============== ___ 05:22AM BLOOD WBC-7.8 RBC-3.47* Hgb-10.2* Hct-32.6* MCV-94 MCH-29.4 MCHC-31.3* RDW-15.1 RDWSD-51.7* Plt ___ ___ 05:22AM BLOOD Plt ___ ___ 07:34AM BLOOD ___ PTT-28.4 ___ ___ 05:22AM BLOOD Glucose-151* UreaN-42* Creat-1.3* Na-145 K-3.7 Cl-107 HCO3-32 AnGap-10 ___ 11:42PM BLOOD ALT-14 AST-16 AlkPhos-101 TotBili-0.5 ___ 05:22AM BLOOD Calcium-10.0 Phos-2.8 Mg-2.7* ___ 06:01PM BLOOD Type-ART pO2-87 pCO2-33* pH-7.44 calTCO2-23 Base XS-0 ___ 06:01PM BLOOD Lactate-0.7 ___ 06:01PM BLOOD freeCa-1.32 ======= IMAGING ======= CTA H&N - ___ @ 4:30PM 1. 6.3 cm left temporoparietal intraparenchymal hemorrhage with central low density peripheral focus suggestive of active, hyperacute bleeding. 2. Edema and mass effect related to left temporoparietal hemorrhage with concern for left temporal horn entrapment as described. Recommend clinical correlation. 3. While no definite underlying mass identified, please note that underlying mass cannot be excluded on the basis examination. Recommend clinical correlation and imaging followup to resolution. Consider MRI for further characterization. 4. Markedly narrowed and beaded appearance of the vertebrobasilar system with segments of absent limited enhancement within mid to superior basilar artery, concerning for occlusion or slow flow. 5. 3 mm fusiform aneurysm at the inferior basilar artery. 6. Patent cervical vasculature with atherosclerosis changes of the bilateral carotid bifurcations and bulbs, as described. 7. Diminutive bilateral cervical vertebral arteries with suggested narrowing and bilateral origins. 8. Periapical lucency at the right maxillary first molar. Recommend follow-up with dentistry. CXR - ___ Right IJ likely terminates in the upper SVC. No pneumothorax. Mild vascular congestion. NCHCT - ___ @ 11:30PM 1. No significant change in the size of a 6.3 cm left posterior temporal intraparenchymal hemorrhage with surrounding edema. No new hemorrhage or infarction identified. 2. 3 mm of midline shift is stable from the prior study. NCHCT - ___ 1. No significant change in the size of the 6.4 cm left posterior temporal intraparenchymal hemorrhage with surrounding edema. No new hemorrhage or infarction identified. 2. Medial displacement of the left temporal lobe on the cistern. CXR - ___ Comparison to ___. In the interval, the patient has developed mild to moderate pulmonary edema. Moderate cardiomegaly persists in unchanged manner. Platelike atelectasis at the left lung basis. No larger pleural effusions. NCHCT - ___ Stable large left parietal/occipital/ posterior temporal hemorrhage with stable surrounding edema and stable mass effect. ___ CXR The feeding tube courses below the diaphragm with the tip not identified. Right internal jugular central line has its tip proximal to mid in the SVC. Prominent hilar contours may represent engorged vessels, although lymphadenopathy cannot be excluded. There has been interval worsening of mild pulmonary edema. Linear opacity in the left mid lung likely reflects scarring or subsegmental atelectasis. Probable small layering left effusion. No pneumothorax. ___ CXR Comparison to ___. No relevant change. Moderate cardiomegaly. Feeding tube and right internal jugular vein catheter are in correct position. The pre-existing signs of mild pulmonary edema are unchanged. Mild retrocardiac atelectasis. No pleural effusions.

2163-10-05 06:46:00

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[[23092315, Timestamp('2163-10-05 06:47:19'), '', 'MED']]

[[{'Medications on Admission': ':\n1. Oscal+D 500mg/125IU PO once daily\n2. Prilosec 20mg PO BID\n3. Therems-M (MVI) 1 tab PO once daily\n4. Docusate Sodium 100mg capsule PO BID\n5. Senna 1 tab PO qhs\n6. Atenolol 12.5mg tab PO qd; Hold for SBP<100, HR <60\n7. Synthroid 50mcg tab 1 PO qd\n8. Ritalin 5mg PO BID\n9. Actonel 35mg tab q week\n10.Levothyroxine 50mcg tab PO qd\nPRN Bisacodyl, Milk of Mag, Fleet, Tylenol\n\n.\n4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a \nday)- STANDING. \n.\n5. Risedronate 35 mg Tablet Sig: One (1) Tablet PO ___ AMs \n(). \n.\n6. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 \ntimes a day)- STANDING; Titrate as needed to the production of \n___ good size stools daily. \n.\n7. Docusate Sodium 50 mg/5 mL Liquid Sig: ___ PO BID (2 times a \nday)- STANDING. \n.\n8. Erythromycin 250 mg Tablet Sig: One (1) Tablet PO see below \nfor 3 days: ___ tab PO TID\n___ tab PO BID\n___ tab PO once daily and STOP\nDisp:*10 Tablet(s)* Refills:*0*\n.\n9. Medication\nplease give warm soap water enema BID continuous\n.\n10. Medication\nplease give Fleet Enema standing BID x 3 days and then PRN\n.\n11.Outpatient Lab Work please follow H&H, CBC, and lytes - on \n___.\nReplace K PRN\n\nFacility:\n___', 'Brief Hospital Course': ":\nMrs. ___ was evaluated in the ER where pelvic exam revealed \natrophic vaginitis but no active bleeding. A rectal exam was \n(-) for palpable mass, stool obstruction, and internal \nhemorrhoids, but hem occult (+). She was found to have fever, \nelevated white count. U/A and CXR were WNL. CT abdomen/pelvis \nrevealed massively dilated rectum and sigmoid colon with \ncompression and displacement of bladder. Fever was felt to be \ndue to fecal impaction with colonic distension and was watched \novernight to resolution without antibiotic or antipyretic \ntherapy.\n.\nMrs. ___ was stabilized on the floor with gentle IV hydration \nand a rigorous bowel regimen (including PO and PR stool \nsofteners) that was minimally productive of soft green/brown, \nhem occult (-) stool over the first ___. The therapy was \nlimited by the patients poor PO intake and difficulty swallowing \nPO agents. NG/OG tube placement was attempted but could not be \npassed due to patient's inability to follow the command to \nswallow.\n.\nManual disimpaction was also attempted on two separate days \nwithout much production of stool. No fecalith was ever felt. GI \nconsultants felt no indication for scope intervention in this \npresentation and recommended continuation of conservative \ntherapy.\n.\nIn a family meeting with Mrs. ___ sister/health care proxy \n(___ and niece on ___ we discussed the dangers of \nmore aggressive prokinetic therapy given the patient's massive \ncolonic dilation, stretched bowel walls, and increased risk of \nbowel rupture with intra-abdominal fecal leak. The family \nwanted everything done and consented to more aggressive \npro-motility therapy with Erythromycin.\n.\nThe patient began putting out large volumes of soft formed stool \nthe morning after starting this therapy and was without bowel \npain, peritoneal signs, and fever on the morning of discharge. \nHer PO intake improved slightly and her nausea decreased after \nhaving several BMs on this therapy.\n.\nMs. ___ was discharged on a 3 day taper of Erythromycin in \naddition to standing multi agent bowel regimen to continue clean \nout and prevent recurrence of this problem.\n\n", 'Pertinent Results:': 'NIL', 'Physical Exam:|Physical': '\nVITALS: 98.1 | ___ | ___ | 20 | 94-100%\nGEN: cachectic appearing female, sleepy but easily arousable; \nNAD\nCARDIO: SEM at LLSB; normal S1S2; 2+ pulses equal bilat in all 4 \nextr\nPULM: CTA bilat\nABD: +BS, soft, NT; soft fullness of infraumbilical region; L \nabdominl wall hernia; no peritoneal signs\nMSK: spontaneous movement of head only; flexion contractures at \nelbows\nNEURO: 2+ reflexes equal bilat\nSKIN: good color, warm, moist; R gluteal decub c dressin c/d/i\nEXTR: well perfused\n\n***********STUDIES**************\n___ CXR- no acute cardiopulm process\n.\n___ CT abdomen,pelvis- Large impaction of stool causing \nanterior displacement of the bladder.\n.\n___ KUB - large amount of stool seen extending from the \nrectum up to the sigmoid c sigmoid extending up into the left \nupper quadrant; distal sigmoid measures up to 14 cm. \n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\nMs. ___ is an ___ yo F c complicated PMH (see below)who \nwas sent to ED from ___, ___, after a "fair \namount" of fresh blood was found in her diaper around 1am on \n___. She did not complain of pain at the time, but was \nthought to look pale by staff. \n.\nPer ___ staff, Ms. ___ has been declining over the past \nseveral weeks to months in regards to her baseline dementia. She \nhas recently had increasing trouble ambulating in addition to \nurinary and fecal incontinence for ___ months, and can no \nlonger feed herself. She is presently bed-bound. She has been \nhaving regular non-bloody soft stools ___ a day for the past \n___ days and was not thought to be ill by staff. \n.\nUnable to obtain more hx directly from patient due to patient \nbeing a poor historian. \n\nPast Medical History:\n___ per OMR review: \n1. Hypothyroidism \n2. GERD \n3. Diverticulosis \n4. Hypercholesterolemia \n5. Alzheimer\'s Dementia \n6. Hx of DVT \n7. Hematuria- worked up c ___ urology; normal cystoscopy - no \nmalignant cells in urine \n8. Atrophic Vaginitis \n9. Recently bedbound \n. \nPSurgHx per sister: \n1. Lung surgery for TB \n2. TAH c BO in twenties, elective \n3. Multiple hernia repairs x 3 \n\nSocial History:\n___\nFamily History:\nnoncontributory\n\n', 'Chief Complaint:|Complaint:': '\nBlood in Diaper per ___ staff\n\n', 'Attending:': ' ___\n\n', 'Allergies:': ' \nPatient recorded as having No Known Allergies to Drugs\n\n'}, '14083437-DS-9', 9, 'medicine']]

[['HISTORY: ___ female with rectal bleeding and fever. Please evaluate\nfor pneumonia.\n\nCOMPARISON: Chest radiograph ___.\n\nSINGLE PORTABLE UPRIGHT VIEW OF THE CHEST: The chest demonstrates a pectum\nexcavatum deformity, not changed since prior studies. The aorta is calcified.\nThere is no consolidation or effusion.\n\nIMPRESSION: No evidence of acute cardiopulmonary process.\n', '14083437-RR-45', 45, ''], ["HISTORY: ___ female with rectal bleeding and fever. Please evaluate\nfor source of fever and diverticulosis.\n\nCOMPARISON: CT abdomen and pelvis, ___.\n\nTECHNIQUE: Axial imaging was performed from the diaphragm to the pubic\nsymphysis following the uneventful administration of IV and oral contrast.\n\nCT ABDOMEN WITH IV CONTRAST: The lung bases demonstrate no nodule, opacity,\nor pleural effusion. The significant streak artifact from the patient's right\nhand jewelry and presence of right hand limits evaluation for a previously\nidentified left lobe enhancing lesion. A right posterior lobe hypoattenuating\nlesion measures 12 mm, and is unchanged (3:21). The spleen, pancreas, and\nadrenal glands are unremarkable. The kidneys demonstrate multiple unchanged\nlarge cysts. The common bile duct measures 10 mm in transverse dimension\n(3:32), but this is unchanged since the prior study. No intra- abdominal free\nfluid is identified.\n\nCT PELVIS WITH IV CONTRAST: A giant ball of stool measuring 13 cm is\nidentified (3:59), and displacing the bladder anteriorly and to the right.\nThere is diverticulosis, but no evidence of diverticulitis given the\nlimitations of lack of oral contrast reaching the colon. There is a Foley\ncatheter in the bladder, which is relatively decompressed and demonstrates air\nfrom instrumentation.\n\nOsseous structures demonstrate an S-shaped scoliosis and degenerative change\nof the lumbosacral spine and hips.\n\nIMPRESSION:\n\n1. Diverticulosis with no clear evidence of diverticulitis given the\nlimitations of the study.\n\n2. Large impaction of stool causing anterior displacement of the bladder.\n\n3. Enhancing and hypodense liver lesions in left and right lobes not well\nevaluated due to streak artifact from patient's jewelry. The depicted lesions\nare unchanged in size compared to ___.\n\n4. Multiple unchanged renal cysts.\n\nFindings posted to the ED dashboard at time of study completion, and reviewed\nin person with Dr. ___.\n\n", '14083437-RR-46', 46, 'axial imaging was performed from the diaphragm to the pubic\nsymphysis following the uneventful administration of iv and oral contrast.'], ['HISTORY: ___ with nausea, constipation. Question obstruction.\n\nFINDINGS: Frontal film demonstrates gas throughout the colon with a large\namount of stool seen extending from the rectum up to the sigmoid with the\nsigmoid extending up into the left upper quadrant. The distal sigmoid\nmeasures up to 14 cm. The lateral film demonstrates air-fluid levels, some of\nwhich are in colon and some are likely in small bowel. However, the overall\nimpression is that a large amount of stool. This finding was discussed with\nthe house staff at the time of dictating this report.\n', '14083437-RR-47', 47, ''], ['SUPINE AND ERECT ABDOMINAL RADIOGRAPHS\n\nINDICATION: Severe constipation and abdominal pain, ? obstruction or\nperforation.\n\nCOMPARISON: ___ and ___ (CT).\n\nFINDINGS: There is a large amount of stool in the rectum which is distending\nthe more proximal colon with stool and air and is not significantly changed\nfrom the study from four days ago. There is no evidence of free air.\n\nIMPRESSION: No ileus or obstruction. No free air. Large amount of stool in\nthe rectum as on prior study.\n', '14083437-RR-48', 48, ''], ['HISTORY: Pain.\n\nThree radiographs of the right wrist demonstrate diffuse demineralization. \nThere is moderate degenerative change involving the first CMC joint. Mild\ndegenerative change involves the triscaphe joint. There is chondrocalcinosis\ninvolving the triangular fibrocartilage. No acute fracture is evident. The\nregional soft tissues are unremarkable.\n', '14083437-RR-49', 49, ''], ['HISTORY: Pain.\n\nFive radiographs of the pelvis and bilateral hips demonstrate no fracture. \nAssessment of the sacrum and symphysis pubis is markedly limited by copious\nstool projecting over the pelvis. Femoral head contours are smooth.\n\nIMPRESSION:\n\nNo fracture.\n\nCopious stool projecting over the pelvis limits assessment of both the sacrum\nand the symphysis pubis.\n', '14083437-RR-50', 50, '']]

[[23092315, Timestamp('2163-10-05 08:00:00'), Timestamp('2163-10-05 09:00:00'), 'BASE', '1/2 NS', '001209', '00338004304', '1000mL Bag'], [23092315, Timestamp('2163-10-05 20:00:00'), Timestamp('2163-10-09 22:00:00'), 'MAIN', 'Docusate Sodium', '003009', '00904224461', '100mg Capsule'], [23092315, Timestamp('2163-10-05 10:00:00'), Timestamp('2163-10-11 21:00:00'), 'MAIN', 'Atenolol', '015864', '51079075920', '25 mg Tab'], [23092315, Timestamp('2163-10-05 10:00:00'), Timestamp('2163-10-11 21:00:00'), 'MAIN', 'Sodium Chloride 0.9% Flush', '', '0', 'Syringe'], [23092315, Timestamp('2163-10-05 10:00:00'), Timestamp('2163-10-11 21:00:00'), 'MAIN', 'Levothyroxine Sodium', '006648', '00074434113', '25mcg Tablet'], [23092315, Timestamp('2163-10-05 10:00:00'), Timestamp('2163-10-05 20:00:00'), 'BASE', 'NS', '001210', '00338004904', '1000mL Bag'], [23092315, Timestamp('2163-10-05 10:00:00'), Timestamp('2163-10-07 20:00:00'), 'MAIN', 'Vitamin D', '019166', '10432017002', '400 Unit Tablet'], [23092315, Timestamp('2163-10-05 20:00:00'), Timestamp('2163-10-09 22:00:00'), 'MAIN', 'Omeprazole', '033530', '51079000720', '20mg Cap'], [23092315, Timestamp('2163-10-05 20:00:00'), Timestamp('2163-10-05 13:00:00'), 'MAIN', 'Docusate Sodium (Liquid)', '003017', '00121054410', '100mg UD Cup'], [23092315, Timestamp('2163-10-05 20:00:00'), Timestamp('2163-10-11 21:00:00'), 'MAIN', 'Bisacodyl', '002947', '00182853489', '5 mg Tab'], [23092315, Timestamp('2163-10-05 10:00:00'), Timestamp('2163-10-11 21:00:00'), 'MAIN', 'Pneumococcal Vac Polyvalent', '048548', '00006494300', '25mcg/0.5mL Vial'], [23092315, Timestamp('2163-10-05 12:00:00'), Timestamp('2163-10-11 21:00:00'), 'MAIN', 'Risedronate', '050364', '00149047201', '35mg Tablet'], [23092315, Timestamp('2163-10-05 14:00:00'), Timestamp('2163-10-11 21:00:00'), 'MAIN', 'Heparin', '006549', '63323026201', '5000 Units / mL- 1mL Vial'], [23092315, Timestamp('2163-10-05 10:00:00'), Timestamp('2163-10-08 17:00:00'), 'MAIN', 'Calcium Carbonate', '002689', '66553000401', '500mg Tablet'], [23092315, Timestamp('2163-10-05 20:00:00'), Timestamp('2163-10-11 21:00:00'), 'MAIN', 'Senna', '019964', '00904516561', '1 Tablet']]

[]

['medicine']

[[50862, Timestamp('2163-10-05 16:30:00'), Timestamp('2163-10-05 17:25:00'), 'Albumin'], [50993, Timestamp('2163-10-05 16:30:00'), Timestamp('2163-10-05 23:36:00'), 'Thyroid Stimulating Hormone']]

Question: A 85 F is admitted. He/she says he/she has Blood in Diaper per ___ staff . History of illness: Ms. ___ is an ___ yo F c complicated PMH (see below)who was sent to ED from ___, ___, after a "fair amount" of fresh blood was found in her diaper around 1am on ___. She did not complain of pain at the time, but was thought to look pale by staff. . Per ___ staff, Ms. ___ has been declining over the past several weeks to months in regards to her baseline dementia. She has recently had increasing trouble ambulating in addition to urinary and fecal incontinence for ___ months, and can no longer feed herself. She is presently bed-bound. She has been having regular non-bloody soft stools ___ a day for the past ___ days and was not thought to be ill by staff. . Unable to obtain more hx directly from patient due to patient being a poor historian. Past Medical History: ___ per OMR review: 1. Hypothyroidism 2. GERD 3. Diverticulosis 4. Hypercholesterolemia 5. Alzheimer's Dementia 6. Hx of DVT 7. Hematuria- worked up c ___ urology; normal cystoscopy - no malignant cells in urine 8. Atrophic Vaginitis 9. Recently bedbound . PSurgHx per sister: 1. Lung surgery for TB 2. TAH c BO in twenties, elective 3. Multiple hernia repairs x 3 Social History: ___ Family History: noncontributory Allergies: Patient recorded as having No Known Allergies to Drugs What is the best procedure plan for this patient?

TARGETS Target Prescriptions: 1/2 NS Docusate Sodium Atenolol Sodium Chloride 0.9% Flush Levothyroxine Sodium NS Vitamin D Omeprazole Docusate Sodium (Liquid) Bisacodyl Pneumococcal Vac Polyvalent Risedronate Heparin Calcium Carbonate Senna Target Lab Orders: Albumin Thyroid Stimulating Hormone Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : Mrs. ___ was evaluated in the ER where pelvic exam revealed atrophic vaginitis but no active bleeding. A rectal exam was (-) for palpable mass, stool obstruction, and internal hemorrhoids, but hem occult (+). She was found to have fever, elevated white count. U/A and CXR were WNL. CT abdomen/pelvis revealed massively dilated rectum and sigmoid colon with compression and displacement of bladder. Fever was felt to be due to fecal impaction with colonic distension and was watched overnight to resolution without antibiotic or antipyretic therapy. . Mrs. ___ was stabilized on the floor with gentle IV hydration and a rigorous bowel regimen (including PO and PR stool softeners) that was minimally productive of soft green/brown, hem occult (-) stool over the first ___. The therapy was limited by the patients poor PO intake and difficulty swallowing PO agents. NG/OG tube placement was attempted but could not be passed due to patient's inability to follow the command to swallow. . Manual disimpaction was also attempted on two separate days without much production of stool. No fecalith was ever felt. GI consultants felt no indication for scope intervention in this presentation and recommended continuation of conservative therapy. . In a family meeting with Mrs. ___ sister/health care proxy (___ and niece on ___ we discussed the dangers of more aggressive prokinetic therapy given the patient's massive colonic dilation, stretched bowel walls, and increased risk of bowel rupture with intra-abdominal fecal leak. The family wanted everything done and consented to more aggressive pro-motility therapy with Erythromycin. . The patient began putting out large volumes of soft formed stool the morning after starting this therapy and was without bowel pain, peritoneal signs, and fever on the morning of discharge. Her PO intake improved slightly and her nausea decreased after having several BMs on this therapy. . Ms. ___ was discharged on a 3 day taper of Erythromycin in addition to standing multi agent bowel regimen to continue clean out and prevent recurrence of this problem. Other Results: NIL

2165-03-14 23:50:00

?

MARRIED

WHITE - RUSSIAN

F

[[28300483, Timestamp('2165-03-14 23:51:02'), '', 'OMED']]

[[{'Medications on Admission': ':\nALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 2 puffs inhaled\nPrior to pentamidine\nALLOPURINOL - 100 mg Tablet - 1 Tablet(s) by mouth once daily \nfor\n14 days starting the day before starting each cycle of\nchemotherapy\nDICYCLOMINE - (Prescribed by Other Provider) - 10 mg Capsule - \n1\nCapsule(s) by mouth once as needed for abdominal bloating,\nnausea, and loose stool.\nDIPHENOXYLATE-ATROPINE - 2.5 mg-0.025 mg Tablet - 2 Tablet(s) by\nmouth three times a day\nESSIAC - (Prescribed by Other Provider) (On Hold from \n___\nto unknown for avoid interactions with chemotherpay) - - 3\ncapsules each day - on hold\nLEVOTHYROXINE [SYNTHROID] - 100 mcg Tablet - 1 Tablet(s) by \nmouth\ndaily - No Substitution\nOMEPRAZOLE [PRILOSEC] - (Prescribed by Other Provider) - 20 mg\nCapsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth twice a\nday\nPENTAMIDINE [NEBUPENT] - 300 mg Recon Soln - 300 mg inhaled via\nnebulizer every 4 weeks\nPREDNISONE - 50 mg Tablet - 2 Tablet(s) by mouth daily for 4\nconsecutive days beginning the day following chemotherapy - \ncnfirms taking this after last cycle\nPROCHLORPERAZINE - 25 mg Suppository - 1 Suppository(s) rectally\nevery 8 hours as needed for vomiting\nPROCHLORPERAZINE MALEATE - 5 mg Tablet - ___ Tablet(s) by mouth\ntid 8 hours apart as needed for nausea\nSCALP PROSTHESIS FOR CHEMOTHERAPY INDUCED ALOPECIA -\nTRAMADOL - (Prescribed by Other Provider: Dr. ___ Dose\nadjustment - no new Rx) - 50 mg Tablet - 1 Tablet(s) by mouth\ntwice a day as needed for leg pain\nVALACYCLOVIR - 500 mg Tablet - 1 Tablet(s) by mouth twice a day\n\nMedications - OTC\nBIFIDOBACTERIUM INFANTIS [ALIGN] - (OTC) - 4 mg (1 billion \ncell)\nCapsule - 1 Capsule(s) by mouth once a day\nCETIRIZINE - (Prescribed by Other Provider; Dose adjustment - \nno\nnew Rx) - 10 mg Tablet - 1 Tablet(s) by mouth once as needed for\nrash\nVITAMIN A-VITAMIN C-VIT E-MIN [OCUVITE] - (Prescribed by Other\nProvider) - Tablet - 2 Tablet(s) by mouth daily\n\nFacility:\n___\n\nSecondary:\n1. Large B cell lymphoma', 'Brief Hospital Course': ":\n#Neutropenic fever- initially, UTI had to be ruled out as \npatient had a recent history of GU instrumentation s/p R \nureteral stent replacement. Patient was placed empirically on \nvancomycin and cefepime. UA was not very impressive and urine \nculture showed mixed bacterial flora (probably contaminant). \nSource of infection was found on CXR on ___ which showed RLL \npneumonia. Interventional pulmonology saw patient in house and \ncould not find fluid in RLL to tap. Patient deverfesced on \nhospital day on ___. The patient remainded afebrile, WBC \nincreased over 3,500, and Vanc/cefepime were d/c. Levaquin was \ncontinued and pt is to complete ___s an outpt, \nrequiring 3 doses as an oupt. \n\n#large B-cell transformation (Richter's transformation) of \nchronic lymphocytic leukemia (CLL): Patient was found to be \npancytopenic upon admission and received multiple blood \ntransfusions. Patient continued zoster prophylaxis throughout \nhospitalization and was stable. Patient was discharged with a \nfollow-up appointment with oncologist.\n\n#Macular degeneration; legally blind - chronic, stable\n\n#Chronic kidney disease III - IV. Baseline Cr approximately 1.7 \n - chronic, stable. Renally dosed all meds\n\n#Hypothyroidism: stable throughout admission on synthroid.\n\n#Chronic diastolic CHF with preserved EF:chronic, stable\n\n", 'Pertinent Results:': '\n___ 02:25PM URINE COLOR-Straw APPEAR-Clear SP ___\n___ 02:25PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 \nLEUK-NEG\n___ 02:25PM URINE RBC->182* WBC-5 BACTERIA-FEW YEAST-NONE \nEPI-<1\n___ 12:30PM UREA N-52* CREAT-1.8* SODIUM-145 \nPOTASSIUM-4.8 CHLORIDE-111* TOTAL CO2-23 ANION GAP-16\n___ 12:30PM ALBUMIN-4.2 CALCIUM-8.8 PHOSPHATE-3.0 \nMAGNESIUM-1.9\n___ 12:30PM WBC-0.4*# RBC-2.81* HGB-8.7* HCT-26.3* MCV-93 \nMCH-30.9 MCHC-33.2 RDW-15.4\n___ 12:30PM NEUTS-8* BANDS-1 LYMPHS-78* MONOS-2 EOS-9* \nBASOS-0 ATYPS-2* ___ MYELOS-0\n___ 12:30PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-OCCASIONAL \nMACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL \nTEARDROP-OCCASIONAL\n___ 12:30PM PLT SMR-VERY LOW PLT COUNT-78*\n.\nCXR: no acute cardiopulmonary process\n\n___ 05:46AM BLOOD WBC-4.0 RBC-2.79* Hgb-8.2* Hct-25.5* \nMCV-91 MCH-29.5 MCHC-32.3 RDW-15.7* Plt ___\n___ 05:46AM BLOOD Glucose-115* UreaN-18 Creat-1.4* Na-141 \nK-4.1 Cl-103 HCO3-31 AnGap-11\n\nASPERGILLUS ANTIGEN 0.1 <0.5\n\nB-Glucan (-)\n\n', 'Physical Exam:|Physical': '\nPhysical exam on Admission\n\nVS: T 100 bp 120/60 HR 66 RR 18 SaO2 96 RA\nGEN: looks fatigued, awake, alert \nHEENT: EOMI, sclera anicteric, conjunctivae clear, OP moist and \nwithout lesion\nNECK: Supple \nCV: Reg rate, normal S1, S2. No m/r/g. \nCHEST: Resp unlabored, no accessory muscle use. CTAB, no \ncrackles, wheezes or rhonchi. \nABD: Soft, NT, ND, no HSM, bowel sounds present\nMSK: normal muscle tone and bulk\nEXT: No c/c, normal perfusion\nSKIN: No rash, warm skin\nNEURO: oriented x 3, normal attention, no focal deficits, intact \nsensation to light touch\nPSYCH: appropriate\n\nPhysical exam on Discharge\nObjective: \nVitals - T97.9 BP 116/64 P RR 18 Sat: 95% on RA \nGENERAL: NAD, laying in bed. \nSKIN: warm and well perfused, no excoriations or lesions, no \nrashes \nHEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva, \npatent nares, MMM, good dentition \nNECK: nontender supple neck, no LAD, no JVD \nCARDIAC: RRR, S1/S2, no mrg \nLUNG: R Lung crackles in Lower and middle lobes. No w/r.\nABDOMEN: nondistended, +BS, nontender in all quadrants, no \nrebound/guarding, no hepatosplenomegaly \nPelvic: No suprapubic tenderness\nPULSES: 2+ DP pulses bilaterally \nNEURO: CN II-XII intact, strength ___ in all 4 ext, sensation \ngrossly intact \n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': "\n___ with large B-cell transformation (Richter's transformation) \nof chronic lymphocytic leukemia (CLL), being treated with \nR-CHOP, last chemo ___ presents to the ER with fever. She \nreported to the ER that she had chills, but later denies this on \nthe floor. She does complain of increased fatigue. She had a \nright ureteral obstruction and came in for cysto, right stent \nremoval, right retrograde and right stent replacement on ___ \nwhich was uncomplicated. She states that she has urinary \nfrequency (___) since the procedure but no burning. She \ndenies any other localizing symptoms including chest pain, \nshortness of breath, cough, rash, nausea, neck pain, vomiting, \nabdominal pain, diarrhea, dysuria. She has had hematuria since \nprocedure. Had mild HA this afternooon, but that has since \nresolved. Vitals in the ER: 101.5 78 143/42 18 99% RA. She \nreceived Tylenol and Vancomycin. \n.\nReview of Systems: \n(+) Per HPI \n(-) Denies night sweats, blurry vision, diplopia, loss of \nvision, photophobia. Denies headache, sinus tenderness, \nrhinorrhea or congestion. Denies chest pain or tightness. Denies \ncough, shortness of breath, or wheezes. Denies nausea, vomiting, \ndiarrhea, constipation, abdominal pain, melena, hematemesis, \nhematochezia. Denies dysuria, stool or urine incontinence. \nDenies arthralgias or myalgias. Denies rashes or skin breakdown. \nNo numbness/tingling in extremities. All other systems negative.\n\n.\n\nPast Medical History:\nONCOLOGY TREATMENT HISTORY: \n-- Her CLL presented as Rai stage 0 in ___. Due to progressive\nanemia, she received 5 cycles of fludarabine ending in ___.\n-- With recurrent anemia and advancing peripheral blood\nlymphocytosis and lymphadenopathy, she received 4 additional\n3-day cycles of fludarabine from ___ to ___.\n-- Hospitalized in ___ for multi-focal pneumonia; \nduring her evaluation pleural fluid analysis showed lymphocytes\nin her effusion, c/w with her known CLL. \n-- Hospitalized again ___ to ___ with increasing \nshortness of breath d/t a large recurrent R-sided pleural \neffusion.\nThoracentesis was performed, draining 3 liters fluid. CT of the\nchest on ___ reported worsening RML and RUL opacities, and \nLUL nodule. Bronchoscopy with BAL was done. Immunophenotyping of\nbronchial lavage was consistent with CD5 positive B cell\nlymphoproliferative disorder. Cytology of bronchial lavage \nshowed atypical cells; cytology of pleural fluid was consistent \nwith her CLL. Cultures were negative for legionella, PCP, \n___, CMV, and AFB smear; AFB culture were negative.\n-- On ___, CT of chest was repeated reporting interval\nimprovement since previous scan, an unchanged LUL opacity and\nreaccumulation of R-sided effusion. Thoracentesis was again\nperformed on ___ 1500 cc cloudy fluid was removed, raising\nthe question whether effusion was chylous. Another bronchoscopy\nwith biopsy and BAL was performed on ___. Cytology and\nculture results were consistent with previous results. Findings\nof a biopsy of LUL were consistent with a reactive lymphoid\ninfiltrate.\n-- Admitted to hospital ___ for pleuroscopy, talc \npleurodesis, pleurex catheter and chest tube placement after she \npresented to ___ clinic with worsening dyspnea due to \nreaccumulation of a R pleural effusion. 1.5 liters of turbid \nfluid was drained. Pleural fluid cytology showed involvement by \nCLL/SLL as did pleural biopsies. While in hospital, results of \nBAL culture for AFB from ___ returned positive. She was \nplace in respiratory isolation. PCR for ___ and TB came back \nnegative. Definitive AFB culture grew MAC, thought to be due to \nenvironmental contaminant.\n-- In ___, readmitted to hospital for a second attempt at\ntalc pleurodesis. Pleurodesis was successful as output from her\nPleurex catheter declined to the point where the catheter could\nbe removed on ___.\n-- On ___, she re-recommenced fludarabine IV on \ndays 1, 2 and 3 on a 28-day cycle.\n-- On ___, she received cycle 2 fludarabine.\n-- On ___, creatinine level elevated to 2.7 prompted\nhospitalization for acute on chronic renal failure. Evaluation\ndisclosed bulky adenopathy in the right hemipelvis obstructing\nthe right ureter with hydronephrosis, a new left renal lesion,\nand a new liver lesion compared with her ___ FDG-PET-CT \nscan; spleen and other lymph nodes were smaller, c/w mixed \nresponse of CLL to fludarabine. R ureter was stented. Core \nneedle biopsy of the new liver lesion on ___ showed findings \nc/w large B-cell transformation with a MIB-staining approaching \n100%.\n- Ms. ___ had difficulty during her cycle 2 day 1 rituximab \ninfusion on ___ with back pain, treated with\nfamotidine and dexamethasone, followed by abdominal discomfort,\nnausea and rigors that subsided with IV meperidine and IV\nondansetron. She subsequently received the remainder of the\nrituximab infusion and chemotherapy without incident. She\nreceived Neulasta on ___\n- On ___, she had PET-CT scan which documented decreased\nadenopathy and FDG avidity. Although a small new focus of FDG\nuptake was noted in her spleen, the spleen was overall reduced \nin size, and her liver appeared improved as well. \n- ___ Commence cycle 3 R-CHOP\n- Neulasta ___\n.\nPAST MEDICAL HISTORY:\n1. Macular degeneration; legally blind.\n2. Chronic renal failure.\n3. Hypothyroidism.\n4. Diabetes type II\n5. Hypertension.\n6. In ___, she was admitted to hospital with respiratory\ninfection due to H1N1 influenza A. She received 6 days of \nTamiflu\nand Levaquin with improvement in symptoms. Myelosuppression\nduring her viral illness improved. \n7. S/p hysterectomy at age ___\n8. S/p appendectomy\n9. S/p R thyroidectomy\n10. Chronic diastolic CHF with preserved EF\n\nSocial History:\n___\nFamily History:\nFather - h/o esophageal cancer\nMother - h/o skin cancer\nSister - h/o breast cancer\n\n", 'Chief Complaint:|Complaint:': '\nneutropenic fever\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nBactrim / acyclovir\n\n'}, '19608627-DS-14', 14, 'medicine']]

[['INDICATION: Patient with fever and neutropenia. Assess for pneumonia.\n\nCOMPARISONS: Chest radiograph of ___ and CT chest of ___.\n\nFINDINGS:\nFrontal and lateral views of the chest demonstrate normal lung volumes. Small\nright pleural effusion persists and cardiac silhouette is larger. There is no\nleft pleural effusion. Right infrahilar peribronchial opacification is either\nearly edema or mild pneumonia. Hilar and mediastinal silhouettes are\nunremarkable. Heart size is normal. Imaged upper abdomen is unremarkable.\n\nIMPRESSION:\n1. Small right pleural effusion is unchanged since ___ exam.\n2. New mild cardiomegaly and/or pericardial effusion.\n3. Right basal edema, or early pneumonia. Distinguishing between the two,\nand evaluating possible pericardial effusion could be achieved by Chest CT\nperformed with the patient prone.\n\nI discussed these findings by telephone with housestaff [details addended].\n', '19608627-RR-58', 58, ''], ['PORTABLE CHEST, ___\n\nCOMPARISON: ___ chest x-ray.\n\nFINDINGS: Right lower lobe consolidation has progressed compared to the prior\nstudy and is concerning for an evolving pneumonia in the setting of febrile\nneutropenia. It is associated with mild volume loss. Additional nonspecific\nopacity has developed in the left retrocardiac region and could be due to\neither atelectasis or an additional site of infection. Several linear areas\nof atelectasis are also present in the left lower lobe and lingular regions. \nSmall right pleural effusion appears slightly decreased compared to the prior\nstudy. No definite left pleural effusion. Cardiomediastinal and hilar\ncontours appear unchanged. Fullness of right hilar region is concerning for\nlymph node enlargement, and note is made of both mediastinal and hilar nodal\nabnormalities reported on prior PET-CT of ___.\n\nIMPRESSION:\n\n1. Evolving right lower lobe pneumonia with a component of mild volume loss. \nFollowup radiograph is suggested to document resolution following appropriate\ntherapy.\n\n2. Persistent small right pleural effusion.\n', '19608627-RR-59', 59, ''], ["INDICATION: ___ woman with Richter's transformation, CLL, now status\npost cycle 4 of R-CHOP chemotherapy. Cycle 4 was delayed by couple weeks due\nto prolonged gastroenteritis arising after cycle 3. Restage lymphoma.\n\nCOMPARISON: Comparison is made to multiple prior CT abdomen and pelvis, last\nperformed ___ as well as CT trachea performed ___.\n\nTECHNIQUE: Oral contrast-enhanced axial images were acquired from the\nthoracic inlet to the pelvic outlet. Intravenous contrast was not\nadministered due to renal insufficiency. Coronal and sagittal reformations\nwere provided.\n\nFINDINGS:\n\nCT CHEST: \nPatient is status post a right hemithyroidectomy. The remaining left thyroid\nlobe is unremarkable. Evaluation of lymphadenopathy is extremely limited\ngiven lack of intravenous contrast. Within this limitation, there is\nredemonstration of multiple prominent supraclavicular lymph nodes, none of\nwhich individually meet CT criteria for pathological enlargement. \n\n Prominent lymph nodes extend down into the mediastinum, the largest lymph\nnode is located in the right paratracheal space (2:22) measuring 10 mm\ncompared to 12 mm on prior study. Multiple subcentimeter prevascular lymph\nnodes identified. Decreased precarcinal lymph node conglomerate with\nindividual lymph nodes now discernible, the largest of which measures\n10-mm(2:28. Previously noted extensive subcarinal lymph node conglomerate is\nnotably decreased in size. Again without intravenous contrast, individual\nlymph nodes cannot be measured but mass measures approximately 47 x 9 mm\ncompared to 54 x 22 mm on prior study. No significant hilar lymphadenopathy\ndetected.\n\nExtensive arthrosclerotic changes are noted throughout the thoracic aorta\nwithout evidence of aneurysmal dilatation or dissection. Coronary artery\ncalcifications are also noted. Heart size is normal without pericardial\neffusion.\n\nThe previously noted subglottic tracheal wall thickening is not apparent on\ntoday's study. Airways are patent to the subsegmental level. Increased\ndilatation of the right lower lung bronchioles. Also noted in this location\nis interval development of right lower lung consolidative opacification with\nsurrounding ground-glass opacities and septal wall thickening. Previously\ndescribed right upper lobe and left lower lobe ground-glass opacifications are\nlargely resolved. Lingular left lower lung atelectasis persists with a more\nrounded contour in atelectasis anteriorly, possibly due to an underlying\nnodule measuring 1.8 x 1.4 cm compared to 1.8 x 2.0 on prior study (2:32). The\n2-mm left upper lobe pulmonary nodule reported on prior study is not evident\ntoday. No new pulmonary nodules identified.\n Interval increase in small left pleural effusion. Calcifications noted in\nright pleural space likely related to prior pleurodesis. \n\nCT ABDOMEN/PELVIS: \nGranuloma evident in the hepatic dome (2:49). No concerning liver lesion\nidentified on this non-contrast study. No intra- or extra-hepatic biliary\nductal dilatation definitely identified. The pancreas is unremarkable. The\nspleen is minimally enlarged, decreased compared to CT chest performed\n___. \n\nBilateral adrenal glands have normal limb thickness and are without convex\nmargin to suggest mass. The left kidney demonstrates a 1.3-cm rounded\nhypodensity in the inferior pole with Hounsfield measurement of 7, likely\nrepresenting a simple renal cyst. No left hydronephrosis or hydroureter\nevident. On the right, patient has a double-J nephroureteral stent in place. \nThere is significantly reduced hydronephrosis compared to prior study with\nonly residual minimal fullness of the collecting system. There is decreased\nsoft tissue thickening of the UPJ and proximal ureter. Small rounded 1-cm\nhyperdensity is noted in the interpolar region of the right kidney (2:69),\nunchanged since ___ and may represent a hemorrhagic cyst.\n\nThe stomach, small and large bowel are unremarkable. Numerous nodal\nconglomerates in the retroperitoneal, mesenteric, pelvic, and inguinal\nstations are again noted and minimally decreased compared to prior study. The\nlargest individual lymph node is identified within the right groin measuring\n1.2 cm in the short axis, stable compared to prior study (2:115).\n\nExtensive abdominal vascular atherosclerotic calcifications without evidence\nof aneurysmal dilatation or dissection. Extensive multilevel degenerative\nchanges are identified throughout the thoracolumbar spine with flowing\nanterior osteophyte formation, disc space narrowing and endplate sclerosis. \nStable mild retrolisthesis of L2 on L3 and L5 on S1. No suspicious lytic or\nblastic lesions are identified. No superficial soft tissue masses are\npresent.\n\nIMPRESSION:\n1. Interval development of right lower lung opacification and regional\nbronchial dilatation with near resolution of prior right upper and left lower\nlung opacifications. Findings are concerning for aspiration pneumonitis\nversus developing infectious process. \n2. Incompletely visualized smooth septal thickening, likely due to pulmonary\nedema.\n3. Persistent though notably decreased supraclavicular, mediastinal,\nretroperitoneal and mesenteric lymphadenopathy. Large right inguinal lymph\nnode is unchanged.\n4. Stable positioning of right double-J nephroureteral stent with notably\ndecreased hydronephrosis, hyoureter, and periureteral soft tissue\ninflammation.\n5. Decreased splenomegaly.\n", '19608627-RR-60', 60, 'oral contrast-enhanced axial images were acquired from the\nthoracic inlet to the pelvic outlet. intravenous contrast was not\nadministered due to renal insufficiency. coronal and sagittal reformations\nwere provided.'], ["CLINICAL HISTORY: ___ woman with Richter's transformation from CLL,\nnow status post cycle four of R-CHOP therapy. Restage lymphoma in relation to\nprior exams.\n\nCOMPARISON: Head CT ___ and CT neck ___.\n\nTECHNIQUE: Non-contrast MDCT axial images were acquired through the neck. \nCoronal and sagittal relations were obtained for evaluation. The patient was\nunable to receive intravenous contrast due to renal function.\n\nFINDINGS: Evaluation is limited by lack of intravenous contrast. Small\ncervical lymph nodes bilaterally at levels II, III and IV are not enlarged by\nCT size criteria and are similar to ___, and smaller compared to\n___. A 10 mm right supraclavicular lymph node and 11 mm left\nsupraclavicular lymph node are also unchanged from ___ (2:69). No new\nenlarged lymph nodes are identified. Mediastinal lymph nodes (2:82) are\nunchanged from ___ and better assessed on concurrent CT torso. \n\nThere is no evidence of an exophytic mucosal mass. The submandibular and\nparotid salivary glands are unremarkable. The patient is status post right\nhemithyroidectomy. Mild atherosclerotic calcifications are seen in the\ncarotid arteries bilaterally. \n\nThere is mucosal thickening versus a small mucus retention cyst in a right\nposterior ethmoid air cell. The left sphenoid sinus is small and completely\nopacified. Mild mucosal thickening is seen in the left maxillary sinus. The\nmastoid air cells and middle ear cavities are clear.\n\nNonspecific lucencies in the vertebral bodies of C4 and C6 are unchanged since\n___. \n\nA calcified granuloma is seen in the upper lobe of the left lung (2:68).\n\nIMPRESSION:\n\nNumerous small cervical lymph nodes, not enlarged by CT size criteria, are\nunchanged from ___, and decreased in size from ___. \n\n", '19608627-RR-61', 61, 'non-contrast mdct axial images were acquired through the neck. \ncoronal and sagittal relations were obtained for evaluation. the patient was\nunable to receive intravenous contrast due to renal function.']]

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[]

['medicine']

[[51087, Timestamp('2165-03-15 00:55:00'), NaT, 'Length of Urine Collection'], [51103, Timestamp('2165-03-15 00:55:00'), NaT, 'Uhold'], [50868, Timestamp('2165-03-15 05:40:00'), Timestamp('2165-03-15 06:57:00'), 'Anion Gap'], [50882, Timestamp('2165-03-15 05:40:00'), Timestamp('2165-03-15 06:57:00'), 'Bicarbonate'], [50893, Timestamp('2165-03-15 05:40:00'), Timestamp('2165-03-15 06:57:00'), 'Calcium, Total'], [50902, Timestamp('2165-03-15 05:40:00'), Timestamp('2165-03-15 06:57:00'), 'Chloride'], [50912, Timestamp('2165-03-15 05:40:00'), Timestamp('2165-03-15 06:57:00'), 'Creatinine'], [50931, Timestamp('2165-03-15 05:40:00'), Timestamp('2165-03-15 06:57:00'), 'Glucose'], [50935, Timestamp('2165-03-15 05:40:00'), Timestamp('2165-03-15 17:22:00'), 'Haptoglobin'], [50954, Timestamp('2165-03-15 05:40:00'), Timestamp('2165-03-15 17:22:00'), 'Lactate Dehydrogenase (LD)'], [50960, Timestamp('2165-03-15 05:40:00'), Timestamp('2165-03-15 06:57:00'), 'Magnesium'], [50970, Timestamp('2165-03-15 05:40:00'), Timestamp('2165-03-15 06:57:00'), 'Phosphate'], [50971, Timestamp('2165-03-15 05:40:00'), Timestamp('2165-03-15 06:57:00'), 'Potassium'], [50983, Timestamp('2165-03-15 05:40:00'), Timestamp('2165-03-15 06:57:00'), 'Sodium'], [51006, Timestamp('2165-03-15 05:40:00'), Timestamp('2165-03-15 06:57:00'), 'Urea Nitrogen'], [51218, Timestamp('2165-03-15 05:40:00'), Timestamp('2165-03-15 06:28:00'), 'Granulocyte Count'], [51221, Timestamp('2165-03-15 05:40:00'), Timestamp('2165-03-15 06:28:00'), 'Hematocrit'], [51222, Timestamp('2165-03-15 05:40:00'), Timestamp('2165-03-15 06:28:00'), 'Hemoglobin'], [51248, Timestamp('2165-03-15 05:40:00'), Timestamp('2165-03-15 06:28:00'), 'MCH'], [51249, Timestamp('2165-03-15 05:40:00'), Timestamp('2165-03-15 06:28:00'), 'MCHC'], [51250, Timestamp('2165-03-15 05:40:00'), Timestamp('2165-03-15 06:28:00'), 'MCV'], [51265, Timestamp('2165-03-15 05:40:00'), Timestamp('2165-03-15 06:28:00'), 'Platelet Count'], [51277, Timestamp('2165-03-15 05:40:00'), Timestamp('2165-03-15 06:28:00'), 'RDW'], [51279, Timestamp('2165-03-15 05:40:00'), Timestamp('2165-03-15 06:28:00'), 'Red Blood Cells'], [51301, Timestamp('2165-03-15 05:40:00'), Timestamp('2165-03-15 06:28:00'), 'White Blood Cells'], [51221, Timestamp('2165-03-15 12:50:00'), Timestamp('2165-03-15 13:42:00'), 'Hematocrit'], [51222, Timestamp('2165-03-15 12:50:00'), Timestamp('2165-03-15 13:42:00'), 'Hemoglobin'], [51248, Timestamp('2165-03-15 12:50:00'), Timestamp('2165-03-15 13:42:00'), 'MCH'], [51249, Timestamp('2165-03-15 12:50:00'), Timestamp('2165-03-15 13:42:00'), 'MCHC'], [51250, Timestamp('2165-03-15 12:50:00'), Timestamp('2165-03-15 13:42:00'), 'MCV'], [51265, Timestamp('2165-03-15 12:50:00'), Timestamp('2165-03-15 13:42:00'), 'Platelet Count'], [51277, Timestamp('2165-03-15 12:50:00'), Timestamp('2165-03-15 13:42:00'), 'RDW'], [51279, Timestamp('2165-03-15 12:50:00'), Timestamp('2165-03-15 13:42:00'), 'Red Blood Cells'], [51301, Timestamp('2165-03-15 12:50:00'), Timestamp('2165-03-15 13:55:00'), 'White Blood Cells'], [51237, Timestamp('2165-03-15 16:12:00'), Timestamp('2165-03-15 16:40:00'), 'INR(PT)'], [51274, Timestamp('2165-03-15 16:12:00'), Timestamp('2165-03-15 16:40:00'), 'PT'], [51275, Timestamp('2165-03-15 16:12:00'), Timestamp('2165-03-15 16:40:00'), 'PTT']]

Question: A 81 F is admitted. He/she says he/she has neutropenic fever . History of illness: ___ with large B-cell transformation (Richter's transformation) of chronic lymphocytic leukemia (CLL), being treated with R-CHOP, last chemo ___ presents to the ER with fever. She reported to the ER that she had chills, but later denies this on the floor. She does complain of increased fatigue. She had a right ureteral obstruction and came in for cysto, right stent removal, right retrograde and right stent replacement on ___ which was uncomplicated. She states that she has urinary frequency (___) since the procedure but no burning. She denies any other localizing symptoms including chest pain, shortness of breath, cough, rash, nausea, neck pain, vomiting, abdominal pain, diarrhea, dysuria. She has had hematuria since procedure. Had mild HA this afternooon, but that has since resolved. Vitals in the ER: 101.5 78 143/42 18 99% RA. She received Tylenol and Vancomycin. . Review of Systems: (+) Per HPI (-) Denies night sweats, blurry vision, diplopia, loss of vision, photophobia. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain or tightness. Denies cough, shortness of breath, or wheezes. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, melena, hematemesis, hematochezia. Denies dysuria, stool or urine incontinence. Denies arthralgias or myalgias. Denies rashes or skin breakdown. No numbness/tingling in extremities. All other systems negative. . Past Medical History: ONCOLOGY TREATMENT HISTORY: -- Her CLL presented as Rai stage 0 in ___. Due to progressive anemia, she received 5 cycles of fludarabine ending in ___. -- With recurrent anemia and advancing peripheral blood lymphocytosis and lymphadenopathy, she received 4 additional 3-day cycles of fludarabine from ___ to ___. -- Hospitalized in ___ for multi-focal pneumonia; during her evaluation pleural fluid analysis showed lymphocytes in her effusion, c/w with her known CLL. -- Hospitalized again ___ to ___ with increasing shortness of breath d/t a large recurrent R-sided pleural effusion. Thoracentesis was performed, draining 3 liters fluid. CT of the chest on ___ reported worsening RML and RUL opacities, and LUL nodule. Bronchoscopy with BAL was done. Immunophenotyping of bronchial lavage was consistent with CD5 positive B cell lymphoproliferative disorder. Cytology of bronchial lavage showed atypical cells; cytology of pleural fluid was consistent with her CLL. Cultures were negative for legionella, PCP, ___, CMV, and AFB smear; AFB culture were negative. -- On ___, CT of chest was repeated reporting interval improvement since previous scan, an unchanged LUL opacity and reaccumulation of R-sided effusion. Thoracentesis was again performed on ___ 1500 cc cloudy fluid was removed, raising the question whether effusion was chylous. Another bronchoscopy with biopsy and BAL was performed on ___. Cytology and culture results were consistent with previous results. Findings of a biopsy of LUL were consistent with a reactive lymphoid infiltrate. -- Admitted to hospital ___ for pleuroscopy, talc pleurodesis, pleurex catheter and chest tube placement after she presented to ___ clinic with worsening dyspnea due to reaccumulation of a R pleural effusion. 1.5 liters of turbid fluid was drained. Pleural fluid cytology showed involvement by CLL/SLL as did pleural biopsies. While in hospital, results of BAL culture for AFB from ___ returned positive. She was place in respiratory isolation. PCR for ___ and TB came back negative. Definitive AFB culture grew MAC, thought to be due to environmental contaminant. -- In ___, readmitted to hospital for a second attempt at talc pleurodesis. Pleurodesis was successful as output from her Pleurex catheter declined to the point where the catheter could be removed on ___. -- On ___, she re-recommenced fludarabine IV on days 1, 2 and 3 on a 28-day cycle. -- On ___, she received cycle 2 fludarabine. -- On ___, creatinine level elevated to 2.7 prompted hospitalization for acute on chronic renal failure. Evaluation disclosed bulky adenopathy in the right hemipelvis obstructing the right ureter with hydronephrosis, a new left renal lesion, and a new liver lesion compared with her ___ FDG-PET-CT scan; spleen and other lymph nodes were smaller, c/w mixed response of CLL to fludarabine. R ureter was stented. Core needle biopsy of the new liver lesion on ___ showed findings c/w large B-cell transformation with a MIB-staining approaching 100%. - Ms. ___ had difficulty during her cycle 2 day 1 rituximab infusion on ___ with back pain, treated with famotidine and dexamethasone, followed by abdominal discomfort, nausea and rigors that subsided with IV meperidine and IV ondansetron. She subsequently received the remainder of the rituximab infusion and chemotherapy without incident. She received Neulasta on ___ - On ___, she had PET-CT scan which documented decreased adenopathy and FDG avidity. Although a small new focus of FDG uptake was noted in her spleen, the spleen was overall reduced in size, and her liver appeared improved as well. - ___ Commence cycle 3 R-CHOP - Neulasta ___ . PAST MEDICAL HISTORY: 1. Macular degeneration; legally blind. 2. Chronic renal failure. 3. Hypothyroidism. 4. Diabetes type II 5. Hypertension. 6. In ___, she was admitted to hospital with respiratory infection due to H1N1 influenza A. She received 6 days of Tamiflu and Levaquin with improvement in symptoms. Myelosuppression during her viral illness improved. 7. S/p hysterectomy at age ___ 8. S/p appendectomy 9. S/p R thyroidectomy 10. Chronic diastolic CHF with preserved EF Social History: ___ Family History: Father - h/o esophageal cancer Mother - h/o skin cancer Sister - h/o breast cancer Allergies: Bactrim / acyclovir What is the best procedure plan for this patient?

TARGETS Target Prescriptions: TraMADOL (Ultram) 5% Dextrose Vancomycin 0.9% Sodium Chloride (Mini Bag Plus) CefePIME Prochlorperazine ValACYclovir Acetaminophen ValACYclovir Sodium Chloride 0.9% Flush DiCYCLOmine Ondansetron Allopurinol Levothyroxine Sodium Omeprazole Fexofenadine Target Lab Orders: Length of Urine Collection Uhold Anion Gap Bicarbonate Calcium, Total Chloride Creatinine Glucose Haptoglobin Lactate Dehydrogenase (LD) Magnesium Phosphate Potassium Sodium Urea Nitrogen Granulocyte Count Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells INR(PT) PT PTT Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : #Neutropenic fever- initially, UTI had to be ruled out as patient had a recent history of GU instrumentation s/p R ureteral stent replacement. Patient was placed empirically on vancomycin and cefepime. UA was not very impressive and urine culture showed mixed bacterial flora (probably contaminant). Source of infection was found on CXR on ___ which showed RLL pneumonia. Interventional pulmonology saw patient in house and could not find fluid in RLL to tap. Patient deverfesced on hospital day on ___. The patient remainded afebrile, WBC increased over 3,500, and Vanc/cefepime were d/c. Levaquin was continued and pt is to complete ___s an outpt, requiring 3 doses as an oupt. #large B-cell transformation (Richter's transformation) of chronic lymphocytic leukemia (CLL): Patient was found to be pancytopenic upon admission and received multiple blood transfusions. Patient continued zoster prophylaxis throughout hospitalization and was stable. Patient was discharged with a follow-up appointment with oncologist. #Macular degeneration; legally blind - chronic, stable #Chronic kidney disease III - IV. Baseline Cr approximately 1.7 - chronic, stable. Renally dosed all meds #Hypothyroidism: stable throughout admission on synthroid. #Chronic diastolic CHF with preserved EF:chronic, stable Other Results: ___ 02:25PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 02:25PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG ___ 02:25PM URINE RBC->182* WBC-5 BACTERIA-FEW YEAST-NONE EPI-<1 ___ 12:30PM UREA N-52* CREAT-1.8* SODIUM-145 POTASSIUM-4.8 CHLORIDE-111* TOTAL CO2-23 ANION GAP-16 ___ 12:30PM ALBUMIN-4.2 CALCIUM-8.8 PHOSPHATE-3.0 MAGNESIUM-1.9 ___ 12:30PM WBC-0.4*# RBC-2.81* HGB-8.7* HCT-26.3* MCV-93 MCH-30.9 MCHC-33.2 RDW-15.4 ___ 12:30PM NEUTS-8* BANDS-1 LYMPHS-78* MONOS-2 EOS-9* BASOS-0 ATYPS-2* ___ MYELOS-0 ___ 12:30PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL TEARDROP-OCCASIONAL ___ 12:30PM PLT SMR-VERY LOW PLT COUNT-78* . CXR: no acute cardiopulmonary process ___ 05:46AM BLOOD WBC-4.0 RBC-2.79* Hgb-8.2* Hct-25.5* MCV-91 MCH-29.5 MCHC-32.3 RDW-15.7* Plt ___ ___ 05:46AM BLOOD Glucose-115* UreaN-18 Creat-1.4* Na-141 K-4.1 Cl-103 HCO3-31 AnGap-11 ASPERGILLUS ANTIGEN 0.1 <0.5 B-Glucan (-)

2165-08-12 09:48:00

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[[20774115, Timestamp('2165-08-12 09:50:18'), '', 'NMED']]

[[{'Medications on Admission': ':\nThe Preadmission Medication list is accurate and complete.\n1. ClonazePAM 0.5 mg PO BID \n2. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL BID \n3. LamoTRIgine 400 mg PO BID \n4. LORazepam 1 mg PO Q8H:PRN anxiety/seizure \n5. Sertraline 200 mg PO DAILY \n6. Venlafaxine XR 37.5 mg PO DAILY ', 'Brief Hospital Course': ':\n___ male with right temporal epilepsy secondary to TBI in ___ \nin which he was injured in a fireworks accident and a piece of \nmetal penetrated his right eye and right temporal lobe. He is \ns/p right hemicraniectomy and partial right temporal lobectomy. \nOn admission it was thought that Mr. ___ was on ___ \n400mg BID, however upon further clarification it was determined \nthat he was not taking his medication as prescribed, but rather \ntaking Lamictal (Lamotrigine) 200mg BID.\n\nDuring this admission his Lamictal was weaned off and he was \nmonitored on EEG off Lamictal for over 48hrs without any seizure \nactivity. The patient did not have any auras either while on \nEEG. The pt was restarted on his Lamictal on ___. He was \ninstructed to take Lamictal 100mg BID x3d and beginning with the \nevening dose on ___ to increase to Lamictal 200mg BID.\n\nDuring this admission, he was started on Vitamin D 1000U daily \nfor decreased Vitamin D level. He was also started on a \nNicotine patch and Nicorette gum due to nicotine withdrawal.\n\nPrior to discharge, he had a skull XR, but was unable to \ncomplete a Head CT for co-registration of the EEG data. He will \nhave to have the Head CT completed at ___ as an outpatient.\n\nThis admission was ended suddenly due to patient request. \nUnable to fully uptitrate his lamictal back to home dosages, \ncomplete planned monitoring or get requested images.\n\nTransitional Issues:\nLamotrigine 100mg BID x3days. On ___, starting with the \nevening dose increase to Lamotrigine 200mg BID.\nPt should be monitored for new onset rash due to restarting \nLamotrigine.\nPt was started on Vitamin D 1000U daily.\nPt will require a Head CT as an outpatient for co-registration \nof the EEG data.\nPt should follow up with Dr. ___ as scheduled\n\n', 'Pertinent Results:': '\n___ 07:00PM GLUCOSE-130* UREA N-14 CREAT-0.8 SODIUM-139 \nPOTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-25 ANION GAP-18\n___ 07:00PM estGFR-Using this\n___ 07:00PM ALT(SGPT)-17 AST(SGOT)-15 LD(LDH)-133 ALK \nPHOS-48 TOT BILI-<0.2\n___ 07:00PM ALBUMIN-4.5 CALCIUM-9.3 PHOSPHATE-4.5 \nMAGNESIUM-1.9\n___ 07:00PM 25OH VitD-33\n___ 07:00PM WBC-7.1 RBC-4.43* HGB-12.9* HCT-37.6* MCV-85 \nMCH-29.1 MCHC-34.3 RDW-11.9 RDWSD-36.6\n___ 07:00PM PLT COUNT-192\n___ 05:45PM URINE HOURS-RANDOM\n___ 05:45PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG \ncocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG\n\nLAMOTRIGINE \n Test Result Reference \nRange/Units\nLAMOTRIGINE 2.4 L 4.0-18.0 \nmcg/mL\n\n', 'Physical Exam:|Physical': '\nPhysical exam: \nVitals: Tmax 98.3F, Tcurrent 97.4F ___\nRR:18 SaO2:>95% on RA \n\nGeneral: NAD \nHEENT: NCAT, no oropharyngeal lesions, neck supple \n___: no edema\nPulmonary: no increased WOB \nAbdomen: Soft, NT, ND\nExtremities: Warm and well perfused\n\nNeurologic Examination: \nMS: Awake, alert, oriented x 3. Speech is fluent with full\nsentences, No dysarthria. Normal prosody. Able to follow both\nmidline and appendicular commands. \n\nCranial Nerves - EOM full on left, no nystagmus. Right eye\nprosthesis currently not in place. V1-V3 without deficits to\nlight touch bilaterally. No facial movement asymmetry. Tongue\nmidline. \n\nMotor - Normal bulk and tone. No drift. No tremor or asterixis. \n [Delt] [Bic] [Tri] [WrFlx] [IP] [Quad] [Ham] [TA] [Gas]\n [C5] [C5] [C7] [C6] [L2] [L3] [L5] [L4] [S1]\n L 5 5 5 5* NT NT NT 5 5 \n R 5 5 5 5 NT NT NT 5 5 \n*left UE amputated at the wrist, but full\n\nSensory - No deficits to light touch bilaterally. \nDTRs: deferred \n___ - deferred \nGait - deferred\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\n___ right-handed man with right temporal epilepsy \nsecondary to traumatic brain injury presenting for scheduled EMU \nadmission for characterization of events as part of a \npre-surgical workup.\n\nAs per ___, in ___ he was hanging out with friends and they \nwere trying to use fireworks to blow up a tree stump in the \nwoods, when a firework exploded in his hand and a piece of the \nmetal pipe that he was placing the fireworks in ricocheted into \nhis right eye and entered his brain. He states that he had \nsurgery at ___ where they performed the hemicraniotomy and \npartial right temporal lobectomy. ___ states that he first \ndeveloped "auras" known as his simple partial seizures in ___. \nHe states that his auras occur in two flavors "mini" auras and \n"major" auras. He states that these auras are characterized by \nanxious feeling, sweating, nausea, palpitations and heavy \nbreathing. He states that he can sometimes prevent a mini-aura \nfrom progressing by taking deep breaths, but it does not always \nhelp. If he has a major aura, he often takes Ativan anywhere \nfrom ___ and this helps to calm his anxiety. He states that \nthe last major aura or simple partial seizure he had was in \nmid-late ___.\n\nHe states that he has also had "blackout" seizures which are \ncomplex partial seizures and generalized tonic-clonic seizures \nin the past, but he has not had any additional Complex partial \nseizures since ___ and no GTCs since ___.\n\nHe denies any recent illnesses, fever, cough, NC, vomiting, \ndiarrhea, rash, headache, numbness or tingling. He states that \nhe occasionally misses his Lamotrigine doses because either he \nwakes up late or he may forget to take the medication and will \nthen take the medication when he remembered next. He denies any \nrecent travel and no new trauma. He reports that he still \ndrives and that the biggest effect of these aura episodes is the \nanxiety they produce.\n\nHe states that he has not had any recent changes in his Suboxone \nor Sertaline use. His psychiatrist, Dr. ___ did \nrecently start him on Venlafaxine XR 37.5mg once daily 2months \nago. ___ admits that he is not taking all of his \nmedications as prescribed (see Medication list below).\n\nSeizure types:\n1. Simple partial: Jamais ___, tingling feeling in body or \nrushing\nfeeling through body, nausea, anxiety for ___ seconds, feels \nas\nif he is in an unfamiliar situation, increased respiratory rate\nand palpitations. No loss of consciousness or confusion. ___ per\nmonth in past, now ___ per month.\n2. Complex partial: Same aura, more nausea and déjà ___, then\nbehavioral arrest, brief loss of awareness, confusion.\nApproximately one per month in past, none ___. Most\nrecent ___.\n3. Secondarily generalized tonic-clonic: Same, then loss of\nconsciousness, upward eye deviation, generalized stiffening and\nshaking of his body, frothing of saliva, no tongue biting or\nincontinence. Total 5 episodes. Most recent in ___.\n\nAED:\nLamotrigine 400mg BID\n\nPrevious AEDs:\nHe has never been trialed on any other AEDs.\n\nPast Medical History:\nPMH: Traumatic Brain Injury (___), Anxiety, Depression, PTSD, \nRight temporal lobe epilepsy, Substance abuse on Suboxone, \nPrevious MRSA infection\n\nPSH: Hemicraniectomy, Partial right temporal lobectomy, right \neye prosthesis \n\nSocial History:\n___\nFamily History:\nFHx: No FHx of seizures.\n\n', 'Chief Complaint:|Complaint:': '\nCharacterization of seizure activity\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nNo Known Allergies / Adverse Drug Reactions\n\n'}, '17679009-DS-16', 16, 'neurology']]

[]

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[]

['neurology']

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Question: A 23 M is admitted. He/she says he/she has Characterization of seizure activity . History of illness: ___ right-handed man with right temporal epilepsy secondary to traumatic brain injury presenting for scheduled EMU admission for characterization of events as part of a pre-surgical workup. As per ___, in ___ he was hanging out with friends and they were trying to use fireworks to blow up a tree stump in the woods, when a firework exploded in his hand and a piece of the metal pipe that he was placing the fireworks in ricocheted into his right eye and entered his brain. He states that he had surgery at ___ where they performed the hemicraniotomy and partial right temporal lobectomy. ___ states that he first developed "auras" known as his simple partial seizures in ___. He states that his auras occur in two flavors "mini" auras and "major" auras. He states that these auras are characterized by anxious feeling, sweating, nausea, palpitations and heavy breathing. He states that he can sometimes prevent a mini-aura from progressing by taking deep breaths, but it does not always help. If he has a major aura, he often takes Ativan anywhere from ___ and this helps to calm his anxiety. He states that the last major aura or simple partial seizure he had was in mid-late ___. He states that he has also had "blackout" seizures which are complex partial seizures and generalized tonic-clonic seizures in the past, but he has not had any additional Complex partial seizures since ___ and no GTCs since ___. He denies any recent illnesses, fever, cough, NC, vomiting, diarrhea, rash, headache, numbness or tingling. He states that he occasionally misses his Lamotrigine doses because either he wakes up late or he may forget to take the medication and will then take the medication when he remembered next. He denies any recent travel and no new trauma. He reports that he still drives and that the biggest effect of these aura episodes is the anxiety they produce. He states that he has not had any recent changes in his Suboxone or Sertaline use. His psychiatrist, Dr. ___ did recently start him on Venlafaxine XR 37.5mg once daily 2months ago. ___ admits that he is not taking all of his medications as prescribed (see Medication list below). Seizure types: 1. Simple partial: Jamais ___, tingling feeling in body or rushing feeling through body, nausea, anxiety for ___ seconds, feels as if he is in an unfamiliar situation, increased respiratory rate and palpitations. No loss of consciousness or confusion. ___ per month in past, now ___ per month. 2. Complex partial: Same aura, more nausea and déjà ___, then behavioral arrest, brief loss of awareness, confusion. Approximately one per month in past, none ___. Most recent ___. 3. Secondarily generalized tonic-clonic: Same, then loss of consciousness, upward eye deviation, generalized stiffening and shaking of his body, frothing of saliva, no tongue biting or incontinence. Total 5 episodes. Most recent in ___. AED: Lamotrigine 400mg BID Previous AEDs: He has never been trialed on any other AEDs. Past Medical History: PMH: Traumatic Brain Injury (___), Anxiety, Depression, PTSD, Right temporal lobe epilepsy, Substance abuse on Suboxone, Previous MRSA infection PSH: Hemicraniectomy, Partial right temporal lobectomy, right eye prosthesis Social History: ___ Family History: FHx: No FHx of seizures. Allergies: No Known Allergies / Adverse Drug Reactions What is the best procedure plan for this patient?

TARGETS Target Prescriptions: LamoTRIgine LamoTRIgine Venlafaxine XR Buprenorphine-Naloxone (8mg-2mg) Heparin LORazepam Sodium Chloride 0.9% Flush Nicotine Patch Sertraline ClonazePAM Influenza Vaccine Quadrivalent Acetaminophen Target Lab Orders: Amphetamine Screen, Urine Barbiturate Screen, Urine Benzodiazepine Screen, Urine Cocaine, Urine Length of Urine Collection Methadone, Urine Opiate Screen, Urine Oxycodone UTX1 UTX2 UTX3 UTX4 UTX5 UTX6 UTX7 25-OH Vitamin D Alanine Aminotransferase (ALT) Albumin Alkaline Phosphatase Anion Gap Asparate Aminotransferase (AST) Bicarbonate Bilirubin, Total Calcium, Total Chloride Creatinine Estimated GFR (MDRD equation) Glucose H I Lactate Dehydrogenase (LD) Magnesium Phosphate Potassium Sodium Urea Nitrogen L Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells RDW-SD Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : ___ male with right temporal epilepsy secondary to TBI in ___ in which he was injured in a fireworks accident and a piece of metal penetrated his right eye and right temporal lobe. He is s/p right hemicraniectomy and partial right temporal lobectomy. On admission it was thought that Mr. ___ was on ___ 400mg BID, however upon further clarification it was determined that he was not taking his medication as prescribed, but rather taking Lamictal (Lamotrigine) 200mg BID. During this admission his Lamictal was weaned off and he was monitored on EEG off Lamictal for over 48hrs without any seizure activity. The patient did not have any auras either while on EEG. The pt was restarted on his Lamictal on ___. He was instructed to take Lamictal 100mg BID x3d and beginning with the evening dose on ___ to increase to Lamictal 200mg BID. During this admission, he was started on Vitamin D 1000U daily for decreased Vitamin D level. He was also started on a Nicotine patch and Nicorette gum due to nicotine withdrawal. Prior to discharge, he had a skull XR, but was unable to complete a Head CT for co-registration of the EEG data. He will have to have the Head CT completed at ___ as an outpatient. This admission was ended suddenly due to patient request. Unable to fully uptitrate his lamictal back to home dosages, complete planned monitoring or get requested images. Transitional Issues: Lamotrigine 100mg BID x3days. On ___, starting with the evening dose increase to Lamotrigine 200mg BID. Pt should be monitored for new onset rash due to restarting Lamotrigine. Pt was started on Vitamin D 1000U daily. Pt will require a Head CT as an outpatient for co-registration of the EEG data. Pt should follow up with Dr. ___ as scheduled Other Results: ___ 07:00PM GLUCOSE-130* UREA N-14 CREAT-0.8 SODIUM-139 POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-25 ANION GAP-18 ___ 07:00PM estGFR-Using this ___ 07:00PM ALT(SGPT)-17 AST(SGOT)-15 LD(LDH)-133 ALK PHOS-48 TOT BILI-<0.2 ___ 07:00PM ALBUMIN-4.5 CALCIUM-9.3 PHOSPHATE-4.5 MAGNESIUM-1.9 ___ 07:00PM 25OH VitD-33 ___ 07:00PM WBC-7.1 RBC-4.43* HGB-12.9* HCT-37.6* MCV-85 MCH-29.1 MCHC-34.3 RDW-11.9 RDWSD-36.6 ___ 07:00PM PLT COUNT-192 ___ 05:45PM URINE HOURS-RANDOM ___ 05:45PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG LAMOTRIGINE Test Result Reference Range/Units LAMOTRIGINE 2.4 L 4.0-18.0 mcg/mL

2118-10-15 04:00:00

ENGLISH

UNKNOWN

M

[[26401951, Timestamp('2118-10-15 04:01:28'), '', 'TRAUM']]

[[{'Medications on Admission': 'NIL', 'Brief Hospital Course': ":\nPatient presented to the ED on ___. He was admitted to the \n___ on ___. He had a ___ J collar in place per spine \nrecs, was kept NWB at LLE and RLE and given ancef per ortho \nrecs, received a R ankle CT non con for operative planning, and \neventually went to OR for Left knee irrigation and debridement, \nleft leg\nirrigation and debridement of an open fracture, application of \nmultiplanar spanning external fixator from the left femur to the \nleft ankle, irrigation and debridement of a right open ankle \nfracture, placement of a multiplanar external fixator in the \nright lower leg, immobilization of the left midshaft humerus \nfracture. See operative note for details. \n\nPatient had repeat head CT per neurosurgery that was stable. He \nwas kept on ancef until full operative fixation by orthopedics. \nHe had a CTA neck that showed no dissection. On ___, patient \nwent to OR again for IM of L femur, L tibia, and closed \nreduction of index MCP joint. He had serial hematocrits checked \ngiven concern for splenic bleed. With decrease in his \nhematocrit, he had a CTA torso that showed no active \nextravasation. On ___ ___, his ancef was discontinued per \northopedic recs. He was started on tube feeds. On ___, he \nspiked a fever at 101.3. He was pan cultured which yielded \nnegative. On ___, his OGT was replaced with an NGT. He received \nsome lasix for diuresis with goal net negative 1.5 liters. His \nH/H continued to slowly downtrend and he received pRBC as \nneeded. On ___, he continued diuresis with weaning of vent \nas tolerated. He spiked another fever T 102, repeat blood \ncultures were sent. On ___, he had MRI C spine that showed \nsuspected cervical ligamentous injury. He continued to spike \nfevers, thought to be central. On ___ he was extubated. On \n___ he continued to tolerate extubation. There was concern for \nsome erythema at LUE wound, but this improved overtime. He was \nstarted on vanc/cefepime for fever. On ___, patient was \ncontinued on antibiotics and did not spike any additional \nfevers. His foley catheter was also discontinued. He was \ntransferred to the floor for further care. \n\nThe patient arrived to the floor in stable condition. He was \nnoted to be lethargic/somnolent on ___ so his standing \nSeroquel was discontinued. He had a repeat head CT, which was \nstable from previous one. He failed his void trial x 3, so a \nfoley catheter was reinserted on ___. Overnight, he had \npulled out his NGT (for nutrition/TF) due to restlessness. He \nwas re-evaluated by the speech language pathologist on ___, \nwho cleared him for a ground pureed diet with nectar thick \nliquids and 1:1 supervision, so it was decided that his NGT \nwould not need to be replaced. He was eventually upgraded to a \nsoft diet with nectar thick liquids on ___. \n\nThere was concern for surgical site infection due to his \nerythema around his right ankle surgical incision, persistent \nleukocytosis, and intermittent fevers. The orthopedic surgery \nteam, who had been following the patient post-operatively, were \nby the bedside to look at surgical incisions and were not \nconcerned. The patient's foley was removed on ___ and he was \nstill having urinary retention but this subsequently resolved by \n___ when he was voiding on his own. A UA was sent but came \nback negative. \n\nOn ___, he was noted to have a persistent right ___ MCP joint \ndislocation. The hand team was re-consulted and it was decided \nthey would take him to surgery for reduction and stabilization. \nOn ___, he finished his 7 day course of empiric antibiotic \ntherapy. He was also seen by the ___ service for his severe TBI \nand polytrauma with recommendations for medication adjustment \nfor his TBI.\n\nHe went to the OR with the hand surgery service on ___ and \nhad a close reduction and pinning of ___, and ___ MCP joint \nand ORIF of ___ MCP joint. He tolerated the procedure well and \nreturned to the floor hemodynamically stable. On ___, the \npatient had his 2-week post-operative xrays completed per the \northopedic team. The patient was re-evaluated by speech and \nswallow on ___ and was upgraded to thin liquids. \n\nHe was otherwise doing well. He had repeat C-Spine films done on \n___ while upright with the hard C-Collar on. He was \ncomplaining of left ankle pain on ___. A left ankle xray was \nordered and showed post-operative changes, but nothing acute. He \ncontinued to work with physical therapy and occupational \ntherapy, who recommended acute rehabilitation when medically \ncleared for discharge. Case management was working on obtaining \nmedical insurance for the patient.\n\nOn ___, per ortho-spine the patient was cleared to take the \n___ J collar off for hygiene care (short periods) but will \nneed to keep the collar on for one more month with follow up. On \n___, Seroquel was discontinued since the patient was no \nlonger having periods of agitation. He was also started on \ngabapentin for some nerve pain in his lower extremities. \nGabapentin was then tirated up to 900 tid with nortryptaline, \nCase management continued to work on insurance approval and \nrehab bed placement. On ________ his insurance was approved and \nhe was offered placement at ________ which he accepted. During \nthis hospitalization, the patient voided without difficulty and \nworked with physical therapy as much as he could tolerate. The \npatient was adherent with respiratory toilet and incentive \nspirometry and actively participated in the plan of care. The \npatient received subcutaneous heparin for VTE prophylaxis. \n\nAt the time of discharge, the patient was doing well. He was \nafebrile and his vital signs were stable. The patient was \ntolerating a regular diet, voiding without assistance, and his \npain was well controlled. The patient was discharged to rehab to \ncontinue his recovery. Discharge teaching was completed and \nfollow-up instructions were reviewed with reported understanding \nand agreement.\n\nFacility:\n___", 'Pertinent Results:': '\nCHEST (SINGLE VIEW) Study Date of ___ \nEndotracheal tube terminates 5.2 cm above the carina. Bilateral \nairspace \nopacities, left greater than right wall are consistent with \npulmonary \ncontusions. Rib fractures better assessed on previous CT of the \nchest. \n\nCT C-SPINE W/O CONTRAST Study Date of ___ \n1. Comminuted fracture of the right transverse process of C2 \nwithout evidence of displaced fragments extending into the right \ntransverse foramina. However, the fracture lucencies do extend \nto the anterior margins of the foramina. \n2. No evidence of traumatic malalignment. \n\nCT HEAD W/O CONTRAST Study Date of ___ \n1. Right thalamic hemorrhage with extension into the right \nlateral ventricle, with dependent hemorrhage in the occipital \nhorn. Mild effacement of the right lateral ventricle is \nidentified secondary to edema of the right thalamus. \n2. Small hyperdensity of the left frontal lobe, which appears to \nbe either \nsulcal were cortical in nature, representing either subarachnoid \nhemorrhage or contusion. \n3. There are subtle sulcal hyperdensities involving the left \ntemporoparietal lobe, which may represent an additional region \nof subarachnoid hemorrhage.\n4. Additional regions of trace hyperdensity overlying the right \nfrontal \nconvexity and bilateral sylvian fissures may represent \nadditional regions of extra-axial hemorrhage versus volume \naveraging. \n5. The basilar cisterns remain patent. There is mild bilateral \ntonsillar \nectopia, which could be congenital in nature. However, close \nattention on \nfollow-up is recommended to exclude developing cerebral edema. \n6. Comminuted fracture of the nasal bone. No evidence of skull \nfracture. \n\nCT CHEST W/CONTRAST Study Date of ___ \n1. Multiple splenic lacerations measuring up to 2.4 cm with an \nadjacent large perisplenic hematoma. Foci of hyperdensity \nadjacent to the laceration may represent active extravasation. \nSmall volume free-fluid in the pelvis consistent with \nhemorrhage. \n2. Multiple bilateral pulmonary contusions. \n3. Multiple fractures of the lumbar spine as described above. \nMultiple Left rib fractures 8 through 11 and right ribs 6 \nthrough 8. Minimally displaced right inferior pubic ramus \nfracture. \n4. Undescended bilateral testicles. \n\nTIB/FIB (AP & LAT) LEFT Study Date of ___ \nTransverse fracture through the left tibia with medial \ndisplacement.\n\nFEMUR (AP & LAT) LEFT Study Date of ___ \nComminuted midshaft fracture of the left femur with lateral \ndisplacement. \nConcern for possible left knee dislocation. \n\nHUMERUS (AP & LAT) LEFT Study Date of ___ \nTransverse fracture through the midshaft of the left humerus \nlateral \ndisplacement. \n\nFOREARM (AP & LAT) RIGHT Study Date of ___ \nNo fracture.\n\nTIB/FIB (AP & LAT) RIGHT Study Date of ___ \nMildly displaced transverse fracture through the distal fibula. \nAdditional comminuted fractures through the lateral and medial \nmalleolus. \n\nHAND (PA,LAT & OBLIQUE) LEFT Study Date of ___ \nNormal left hand hand radiographs. \n\nCHEST (PORTABLE AP) Study Date of ___ \nInterval placement of right subclavian line terminates at the \nbrachiocephalic junction. No evidence pneumothorax. \n\nLOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST Study Date of \n___ \nIntraoperative images were obtained during internal fixation of \nthe femoral fracture. Please refer to the operative note for \ndetails of the procedure. \n\nCT HEAD W/O CONTRAST Study Date of ___ \n1. Mild increase in sulcal effacement compared to prior with \npatent basal \ncisterns, concerning for worsening cerebral edema. \n2. Slight interval decrease in size of a right thalamic \nhemorrhage with \nintraventricular extension, with dependent hemorrhage in \nbilateral occipital horns, and mild effacement of the right \nlateral ventricle. \n3. Redistribution of subarachnoid hemorrhage with concentration \nalong left \nfrontoparietal lobe and in the interpeduncular cistern. \n4. Additional areas of hyperdensity along the left frontal lobe \nand right \nfrontoparietal lobe may represent subarachnoid hemorrhage or \nvolume averaging. \n\nCT LOW EXT W/O C RIGHT Study Date of ___ \n1. Status post interval external fixation of the right ankle \nwith streak \nartifacts from the hardware limiting diagnostic evaluation. \n2. Comminuted fracture of the talus neck extending to the \nsubtalar joint and sinus tarsi with multiple fracture fragments \nin the sinus tarsi and posterior subtalar joint. \n3. Comminuted fractures through the medial and lateral malleoli \nwith \nintra-articular extension. There is associated fracture \nfragments and joint effusion within the tibiotalar joint. \n4. Anterior subluxation of the talus with respect to the tibia. \n5. Extensive subcutaneous edema/hematoma, subcutaneous air, and \nskin defect could be posttraumatic and/or post surgical. \n\nCTA NECK W&W/OC & RECONS Study Date of ___ \n1. No evidence of dissection. \n2. Patent bilateral cervical carotid and vertebral arteries \nwithout evidence of stenosis, occlusion. \n3. Unchanged fracture of the right C2 transverse process, better \ndepicted in the dedicated CT of the cervical spine dated ___. \n\nHAND (PA,LAT & OBLIQUE) RIGHT PORT Study Date of ___ \nDislocations of the second through fifth MCP is in a ulnar and \ndorsal \ndirection. No acute fracture identified. \n\nCTA ABD & PELVIS Study Date of ___ \n1. Redemonstration of grade 2 splenic lacerations with \nperisplenic hematoma without significant interval change. No \nevidence of active arterial extravasation. \n2. New small volume hemoperitoneum. No evidence of active \nextravasation. \n3. Partially imaged known hyperdense left upper lobe \nconsolidation consistent with pulmonary hemorrhage/contusion or \naspiration of blood. \n4. Redemonstration of small bilateral pleural effusions with \nassociated \ncompressive atelectasis. Intermediate density of left pleural \neffusion \nsuggests a component of hemorrhagic pleural effusion. \n5. Redemonstration of multiple fractures including ribs, lumbar \nspine, and \nright inferior pubic ramus. No evidence of new additional acute \nfractures. \n\nHAND (PA,LAT & OBLIQUE) RIGHT PORT Study Date of ___ \nIn comparison with the study of ___, the dislocations of \nthe \nsecond-fifth MCP joints are again seen though it is difficult to \ncompare due to different obliquities of the hands. Further \ninformation can be from the operative report. \n\nCT HEAD W/O CONTRAST Study Date of ___ \n1. Overall, no significant change compared to most recent \nnon-contrast head CT dated ___. \n2. There is a similar-appearing 1.0 cm right thalamic \nintraparenchymal \nhemorrhage with intraventricular extension and mass-effect on \nthe right \nlateral ventricle again seen. \n3. Subarachnoid hemorrhage again seen in the left frontoparietal \nlobe, \nunchanged in extent and distribution. \n\nCTA ABD & PELVIS Study Date of ___ \n1. Interval development of a right neck hematoma, superior \nmediastinal \nhematoma and anterior mediastinal hematoma. \n2. Minor effacement of the normal anterior convexity of the \nright and left \nventricles suggesting a degree of mass-effect from anterior \nmediastinal \nhematoma. \n3. Small volume pneumomediastinum, likely to be related to \ntraumatic line \nplacement. \n4. Interval increase in size of bilateral pleural effusions. \n5. Moderate increase in hemoperitoneum is noted. \n6. Stable perisplenic hematoma. No evidence of active \nextravasation of \ncontrast and no splenic artery pseudoaneurysm is seen. \n\nTransthoracic Echocardiogram Report: ___\nNo pericardial effusion. Normal left ventricular wall thickness \nand biventricular cavity sizes and regional/global biventricular \nsystolic function. Mild pulmonary hypertension. Leftpleural \neffusion.\n\n CHEST (PORTABLE AP) Study Date of ___ \nLines and support devices not significantly changed since the \nprior study. \nThere is stable mild cardiomegaly with bilateral pleural \neffusion and \npulmonary vascular congestion. No pneumothorax. \n\nCHEST (PORTABLE AP) Study Date of ___ \nEndotracheal tube has been removed. Nasogastric tube is \nunchanged in \nposition. There is improved aeration of the right paratracheal \nregion since prior. There has been decrease in the bilateral \npleural effusions. There remains a left retrocardiac opacity \nand subsegmental atelectasis at the lung bases. There are no \npneumothoraces. \n\nUNILAT UP EXT VEINS US LEFT PORT Study Date of ___ \nNo evidence of deep vein thrombosis in the left upper extremity.\n\nCT HEAD W/O CONTRAST Study Date of ___ \n1. No definite evidence of new intracranial hemorrhage or acute \nlarge \nterritorial infarction. \n2. Expected interval evolution of previously seen right thalamic \nhemorrhage, now demonstrating small focus of edema and minimal \nresidual blood products. \n3. Small amount of residual blood products layering within the \noccipital horns of the lateral ventricles. \n4. Slightly increased prominence of the right frontal subdural \nspace \ndemonstrates near CSF density, likely consistent with subdural \nhygroma. \n\nHAND (PA,LAT & OBLIQUE) RIGHT Study Date of ___ \nPersistent/recurrent dorsal dislocation of the small finger MCP \njoint. Second through fourth MCP joints appear congruent. \n\nHUMERUS (AP & LAT) LEFT Study Date of ___ \nThere is a fracture plate with associated screws fixating a \ntransverse \nfracture through the distal shaft of the left humerus. Small \nletter butterfly fragment is seen. Fracture line is still well \nvisualized. No definite hardware related complications are \npresent. \n\nANKLE (AP, MORTISE & LAT) RIGHT Study Date of ___ \nThere is an overlying fiberglass cast which limits fine bony \ndetail. Hardware within the distal fibula and tibia including \nsyndesmotic screws are seen. There are also two screws within \nthe talus fixating a talar neck fracture. No hardware related \ncomplications are seen. There is good anatomic alignment. \nFractures of the distal shaft of the fibula and of the distal \nfibular tip are also seen. \n\nTIB/FIB (AP & LAT) LEFT Study Date of ___ \nThere is an intramedullary rod proximal distal interlocking \nscrews fixating a transverse fracture involving the distal shaft \nof the tibia. There is a paucity of bridging callus. No new \nfractures are seen. Portion of the intramedullary rod in the \ndistal femur is visualized on the edge of the film. \n\nFEMUR (AP & LAT) LEFT Study Date of ___ \nThere has been placement of a retrograde intramedullary rod with \nproximal and distal interlocking screws fixating a comminuted \nfracture of distal left femoral shaft. There are no signs for \nhardware related complications. There is prominent soft tissue \nswelling about the fracture site. \n\nC-SPINE NON-TRAUMA ___ VIEWS Study Date of ___ \nStatic AP and lateral views of the cervical spine were obtained. \n See 1 \nthrough C7 were visualized on the lateral. There is \nstraightening of the \nnormal cervical lordosis. No prevertebral soft tissue swelling. \nNo fracture or subluxation. No flexion and extension views were \nincluded in the exam. \n\nANKLE (AP, MORTISE & LAT) LEFT Study Date of ___ \nPostoperative changes reflect intramedullary rod fixation tibia. \nHardware is intact. There is narrowing no periprosthetic \nlucency. Comminuted fracture of mid to distal left tibial \ndiaphysis is again seen. No substantial is appreciated. The \nmortise is congruent. \n\nDuplex US:\nIMPRESSION: \n\nNo evidence of deep venous thrombosis in the left lower \nextremity veins. \n\nXray R hand: \nThe patient is post interval reduction and pinning of the right \nsecond through \nfifth metacarpophalangeal joints. Overlying splint material \nobscures fine \nosseous detail. The hand at the level of the MCPs and \ninterphalangeal joints \nis in flexion. No obvious dislocation. No evidence of hardware \nrelated \ncomplications.. \n\n', 'Physical Exam:|Physical': '\nPHYSICAL EXAM ON ADMISSION:\nConstitutional: Intubated\nHEENT: L pupil has a L deviated gaze, Unreactive pupils, Very \nlarge lac to L eyebrow, 2 cm, dried blood around face, no \ncoronary reflexes. Blood around nasal cavity and oropharynx, \nC-collar intact, Trachea midline, Dried blood over neck, no gag \nreflexes \nChest: breath sounds bilaterally\nCardiovascular: No deformity in chest wall, no crepitus\nAbdominal: Abd soft, E fast positive for free fluid in the \nabdomen\nPelvic: Pelvis stable, No blood at meatus, ecchymosis over the \nbase of the penile shaft\nRectal: No blood in rectum, no tone\nExtr/Back: Radial pulses intact, Visible deformity of L\nforearm, Several road rash typical abrasions on RUE, Visible \ndeformity of R index finger, Road rash over RLE, Visible \ndeformity and swelling of left thigh, Abrasion over R knee, DP \npulse intact on LLE, Visible deformity of RLE at the\nankle, Very large lac 3 cm on his R medial ankle, Pulse intact \nat RLE, Deformity of L humerus, No abrasions or lacs to back, no \nvisible step off or deformity on palpation of spine, Lac of the \nfourth finger of the L hand, Lac over L patella, Lac over L \ntib/fib, Deformity and ecchymosis over L femur\nNeuro: intubated, no gag or corneal reflexes \n___: No petechiae\n\nPHYSICAL EXAM ON DISCHARGE:\nVS:\nGen: [x] NAD, [x] AAOx3\nCV: [x] RRR, [] murmur\nResp: [x] breaths unlabored, [] CTAB, [] wheezing, [] rales\nAbdomen: [x] soft, [] distended, [] tender, [] rebound/guarding\nWound: [x] incisions clean, dry, intact\nExt: [x] warm, [] tender, [] edema\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\nThis patient is a ___ year old male with unknown medical history \nwho complains of MVC. He was driving his car when he was \ninvolved in a high-speed head on collision. Prolonged \nextrication. Unknown if he was restrained. He had a GCS of 3 and \nwas intubated on scene. He was brought in to ___ from the \nscene by med flight, and received blood and IVF en route. They \nreported a L femur fracture, tibia/fibula fractures, head \ninjury, and a L humorous fracture. HPI is limited due to \nintubation and mental status.\n\nPast Medical History:\nPMH: None\n\nPSH: Wisdom teeth extraction, Appendectomy (early ___\n\nSocial History:\n___\nFamily History:\nFamily History:\nNon-Contributory\n\n', 'Chief Complaint:|Complaint:': '\nS/p MVC\n\n___: Left-I&D tibia and knee wounds, Left-Removal of \nexternal fixator, Left-IM nail femur, retrograde, Left-IM nail \ntibia antegrade, closed reduction right index MCP joint\n\n___: Left humerus ORIF, Right ankle ORIF \n\n___: Closed reduction and pinning right ___ \nmetacarpophalangeal joint dislocations, ORIF right hand ___ \ndigit metacarpophalangeal joint irreducible dislocation\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nNo Known Allergies / Adverse Drug Reactions\n\n'}, '18141668-DS-2', 2, 'surgery']]

[['EXAMINATION: CHEST (SINGLE VIEW) IN O.R.\n\nINDICATION: History: ___ with trauma// trauma\n\nTECHNIQUE: Chest PA and lateral\n\nCOMPARISON: CT of the torso from ___.\n\nFINDINGS: \n\nBilateral airspace opacities, left greater than right are consistent with\npulmonary contusions better assessed on previous CT torso. In addition, left\nrib fractures are better assessed on previous CT. No evidence of pleural\neffusion or pneumothorax. A endotracheal tube terminates 5.2 cm above the\ncarina.\n\nIMPRESSION: \n\nEndotracheal tube terminates 5.2 cm above the carina. Bilateral airspace\nopacities, left greater than right wall are consistent with pulmonary\ncontusions. Rib fractures better assessed on previous CT of the chest.\n', '18141668-RR-13', 13, 'chest pa and lateral'], ["EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD\n\nINDICATION: History: ___ with trauma// trauma\n\nTECHNIQUE: Contiguous axial images of the brain were obtained without\ncontrast.\n\nDOSE: Acquisition sequence:\n 1) Sequenced Acquisition 16.0 s, 16.5 cm; CTDIvol = 48.6 mGy (Head) DLP =\n802.7 mGy-cm.\n Total DLP (Head) = 803 mGy-cm.\n\nCOMPARISON: None.\n\nFINDINGS: \n\nFocus of hyperdensity in the left frontal lobe (series 2, image 22) appears to\nbe either sulcal or cortical in nature, representing either subarachnoid\nhemorrhage or contusion.\n\nA right thalamic hemorrhage extends into the right lateral ventricle, with\nmild effacement and prominent surrounding edema (series 602, image 36). There\nis dependent hemorrhage within the occipital horn of the right lateral\nventricle (series 602, image 29).\n\nThere is subtle sulcal hyperintensity overlying the left temporoparietal lobe\n(series 2, image 17; series 601, image 32), concerning for an additional\nregion of subarachnoid hemorrhage.\n\nTrace hyperdensity overlying the right frontal convexity at the level of the\ncorona radiata (series 2, image 18; series 601, image 50) may represent\nartifact, however attention on follow-up is recommended to exclude a small\nsubarachnoid/sub dural hemorrhage.\n\nSimilarly, there is subtle hyperdensity along the bilateral sylvian fissures\n(series 2, image 18) which may represent subarachnoid hemorrhage versus volume\naveraging.\n\nThere is no midline shift. No definite abnormal sulcal effacement given the\npatient's age. The basilar cisterns remain patent. However, there is mild\nbilateral tonsillar ectopia. Close attention on follow-up is recommended to\nexclude developing cerebral edema.\n\nComminuted fracture of the nasal bone (series 3, image 8). Partial\nopacification of the ethmoid air cells with mucosal thickening of the sphenoid\nsinuses.. The visualized portion of the paranasal sinuses, mastoid air cells,\nand middle ear cavities are clear. The visualized portion of the orbits are\nunremarkable.\n\nIMPRESSION:\n\n\n1. Right thalamic hemorrhage with extension into the right lateral ventricle,\nwith dependent hemorrhage in the occipital horn. Mild effacement of the right\nlateral ventricle is identified secondary to edema of the right thalamus.\n2. Small hyperdensity of the left frontal lobe, which appears to be either\nsulcal were cortical in nature, representing either subarachnoid hemorrhage or\ncontusion.\n3. There are subtle sulcal hyperdensities involving the left temporoparietal\nlobe, which may represent an additional region of subarachnoid hemorrhage. \nClose attention on follow-up is recommended.\n4. Additional regions of trace hyperdensity overlying the right frontal\nconvexity and bilateral sylvian fissures may represent additional regions of\nextra-axial hemorrhage versus volume averaging. Close attention is also\nrecommended.\n5. The basilar cisterns remain patent. There is mild bilateral tonsillar\nectopia, which could be congenital in nature. However, close attention on\nfollow-up is recommended to exclude developing cerebral edema.\n6. Comminuted fracture of the nasal bone. No evidence of skull fracture.\n\nNOTIFICATION: The findings were discussed with ACS team, M.D. by ___,\nM.D. in person on ___ at 4:37 am, 1 minutes after discovery of the\nfindings.\n\n The updated findings were discussed with ___, M.D. by ___,\nM.D. on the telephone on ___ at 4:38 am, 2 minutes after discovery of\nthe findings.\n", '18141668-RR-14', 14, 'contiguous axial images of the brain were obtained without\ncontrast.'], ['EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE\n\nINDICATION: History: ___ with trauma// trauma trauma\n\nTECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue\nand bone algorithm images were generated. Coronal and sagittal reformations\nwere then constructed.\n\nDOSE: Acquisition sequence:\n 1) Spiral Acquisition 5.8 s, 22.8 cm; CTDIvol = 23.0 mGy (Body) DLP = 523.6\nmGy-cm.\n Total DLP (Body) = 524 mGy-cm.\n\nCOMPARISON: None.\n\nFINDINGS: \n\nThere is a comminuted fracture of the right transverse process of C2. \nAlthough the fracture plane does not result in displaced fragments into the\nright transverse foramina, the fracture lucencies do extend to the anterior\nmargins. No additional fractures are identified. Cervical alignment is\nanatomic.There is no evidence of high-grade spinal canal or neural foraminal\nstenosis. There is no significant prevertebral soft tissue swelling.There is\nno evidence of cervical lymphadenopathy by size criteria. The visualized\nlungs are clear. The thyroid is unremarkable.\n\nA endotracheal tube is noted.\n\nIMPRESSION:\n\n\n1. Comminuted fracture of the right transverse process of C2 without evidence\nof displaced fragments extending into the right transverse foramina. However,\nthe fracture lucencies do extend to the anterior margins of the foramina.\n2. No evidence of traumatic malalignment.\n\nRECOMMENDATION(S): Recommend CTA neck to evaluate for vascular injury.\n\nNOTIFICATION: The findings were discussed with ACS team by ___, M.D. on\nthe telephone on ___ at 4:37 am, 1 minutes after discovery of the\nfindings.\n\nAdditional recommendation was discussed with Dr. ___ over the telepone\nby ___ on ___ at 09:20am.\n', '18141668-RR-15', 15, 'non-contrast helical multidetector ct was performed. soft tissue\nand bone algorithm images were generated. coronal and sagittal reformations\nwere then constructed.'], ['EXAMINATION: HUMERUS (AP AND LAT) LEFT\n\nINDICATION: History: ___ with trauma// trauma\n\nTECHNIQUE: Two views of the left humerus\n\nCOMPARISON: None\n\nFINDINGS: \n\nThere is a transverse fracture through the midshaft of the left humerus with\nlateral displacement of the distal fragment. There is varus angulation of the\ndistal end. The left elbow appears grossly intact.\n\nIMPRESSION: \n\nTransverse fracture through the midshaft of the left humerus lateral\ndisplacement.\n', '18141668-RR-16', 16, 'two views of the left humerus'], ['EXAMINATION: CT CHEST/ABD/PELVIS W/ CONTRAST\n\nINDICATION: History: ___ with trauma// trauma\n\nTECHNIQUE: MDCT axial images were acquired through the chest, abdomen and\npelvis following intravenous contrast administration with split bolus\ntechnique.\nOral contrast was not administered.\nCoronal and sagittal reformations were performed and reviewed on PACS.\n\nDOSE: Acquisition sequence:\n 1) Spiral Acquisition 9.2 s, 72.1 cm; CTDIvol = 22.6 mGy (Body) DLP =\n1,628.5 mGy-cm.\n Total DLP (Body) = 1,629 mGy-cm.\n\nCOMPARISON: None.\n\nFINDINGS: \n\nCHEST:\n\nHEART AND VASCULATURE: The thoracic aorta is normal in caliber without\nevidence of acute injury. The heart, pericardium, and great vessels are\nwithin normal limits. No pericardial effusion is seen.\n\nAXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar\nlymphadenopathy is present. No mediastinal mass or hematoma.\n\nPLEURAL SPACES: Trace left pleural effusion. No pneumothorax.\n\nLUNGS/AIRWAYS: Endotracheal tube distal tip within the proximal trachea. \nMultiple foci of pulmonary contusion throughout the right lung (Series 2,\nimage 94, 69, 56, 38). Left base atelectasis with a large region of pulmonary\ncontusion spanning the Left upper lobe. The airways are patent to the level\nof the segmental bronchi bilaterally.\n\nBASE OF NECK: Visualized portions of the base of the neck show no abnormality.\n\nABDOMEN:\n\nHEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. \nThere is no evidence of focal lesion or laceration. There is no evidence of\nintrahepatic or extrahepatic biliary dilatation. The gallbladder is within\nnormal limits.\n\nPANCREAS: The pancreas has normal attenuation throughout, without evidence of\nfocal lesions or pancreatic ductal dilatation. There is no peripancreatic\nstranding.\n\nSPLEEN: Multiple lacerations are noted through the spleen measuring up to 2.4\ncm. There is a large perisplenic hematoma measuring approximately 10.8 x 3.6\ncm. Foci of hyperdensity adjacent to the laceration likely represents active\nextravasation (series 3, image 117)..\n\nADRENALS: The right and left adrenal glands are normal in size and shape.\n\nURINARY: The kidneys are of normal and symmetric size with normal nephrogram. \nNo evidence of hydronephrosis. There is bilateral pelvic fullness. There is\nno evidence of focal renal lesions. There is no perinephric abnormality.\n\nGASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate\nnormal caliber, wall thickness, and enhancement throughout. The colon and\nrectum are within normal limits. The appendix is normal. There is no\nevidence of mesenteric injury.\n\nThere is no free fluid or free air in the abdomen.\n\nPELVIS:\nThe urinary bladder is distended the distal ureters are unremarkable. There\nis small volume high-density free fluid in the pelvis.\n\nREPRODUCTIVE ORGANS: Undescended left testicle.\n\nLYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There\nis no pelvic or inguinal lymphadenopathy.\n\nVASCULAR: There is no abdominal aortic aneurysm or retroperitoneal hematoma. \nMild atherosclerotic disease is noted.\n\nBONES: Nondisplaced right inferior pubic ramus fracture (series 3, image 257).\nMildly displaced fractures are noted on the lateral aspect of Left ribs 8\nthrough 11 and right ribs 6 through 8. Fracture through the bilateral\ntransverse process and pedicles of L5 and fracture through the Left lamina\nwith extension of a fracture through the left superior L5 articular facet. \nAdditional right transverse process fractures from L1 through L4 and Left L2. \nMinimally displaced right inferior pubic ramus fracture.\n\n\nSOFT TISSUES: Soft tissue stranding is noted along the anterior abdominal\nwall.\n\nIMPRESSION:\n\n\n1. Multiple splenic lacerations measuring up to 2.4 cm with an adjacent large\nperisplenic hematoma. Foci of hyperdensity adjacent to the laceration may\nrepresent active extravasation. Small volume free-fluid in the pelvis\nconsistent with hemorrhage.\n2. Multiple bilateral pulmonary contusions.\n3. Multiple fractures of the lumbar spine as described above. Multiple Left\nrib fractures 8 through 11 and right ribs 6 through 8. Minimally displaced\nright inferior pubic ramus fracture.\n4. Undescended bilateral testicles.\n\nNOTIFICATION: The findings were discussed with ACS team, M.D. by ___,\nM.D. in person on ___ at 4:47 am, 5 minutes after discovery of the\nfindings.\n\n The updated findings were discussed with ___, M.D. by ___,\nM.D. on the telephone on ___ at 9:36 am, 5 minutes after discovery of\nthe findings.\n', '18141668-RR-17', 17, 'mdct axial images were acquired through the chest, abdomen and\npelvis following intravenous contrast administration with split bolus\ntechnique.\noral contrast was not administered.\ncoronal and sagittal reformations were performed and reviewed on pacs.'], ['EXAMINATION: FEMUR (AP AND LAT) LEFT IN O.R.\n\nINDICATION: History: ___ with trauma// trauma\n\nTECHNIQUE: AP and lateral views of the left femur.\n\nCOMPARISON: None\n\nFINDINGS: \n\nThere is a comminuted midshaft fracture of the left femur. There is anterior\nand lateral displacement of the distal femur. Concern for possible left knee\ndislocation. The left hip appears grossly unremarkable.\n\nIMPRESSION: \n\nComminuted midshaft fracture of the left femur with lateral displacement. \nConcern for possible left knee dislocation.\n', '18141668-RR-18', 18, 'ap and lateral views of the left femur.'], ['EXAMINATION: TIB/FIB (AP AND LAT) LEFT\n\nINDICATION: History: ___ with trauma// trauma\n\nTECHNIQUE: Frontal and lateral view radiographs of left tibia fibula\n\nCOMPARISON: None\n\nFINDINGS: \n\nThere is a transverse fracture through the left tibia with medial\ndisplacement. The fibula is intact. No suspicious lytic lesion, sclerotic\nlesion, or periosteal new bone formation is detected. No soft tissue\ncalcification or radio-opaque foreign bodies are detected. Limited assessment\nof the ankle joint is unremarkable.\n\nIMPRESSION: \n\nTransverse fracture through the left tibia with medial displacement.\n', '18141668-RR-19', 19, 'frontal and lateral view radiographs of left tibia fibula'], ['EXAMINATION: FOREARM (AP AND LAT) RIGHT\nINDICATION: History: ___ with MVC// fractures\nTECHNIQUE: Two views of the right forearm\nCOMPARISON: None\nFINDINGS: \n\nNo fracture is detected in the radius or ulna. The proximal or distal\nradioulnar joints are congruent. No suspicious lytic or sclerotic lesion or\nperiosteal new bone formation is detected. No soft tissue calcification is\nseen. Limited assessment of the elbow and wrist joint is grossly unremarkable.\nIMPRESSION: \n\nNo fracture.\n', '18141668-RR-20', 20, 'two views of the right forearm\ncomparison: none\nfindings:'], ['EXAMINATION: DX TIB/FIB AND ANKLE\n\nINDICATION: History: ___ with MVC// fractures fractures \nfractures\n\nTECHNIQUE: AP view of the right knee and multiple views of the right ankle.\n\nCOMPARISON: None\n\nFINDINGS: \n\nThere is a mildly displaced transverse fracture through the distal right\nfibula. Additional comminuted mildly displaced fractures of the medial and\nlateral malleolus with extension into the articular surface. The ankle\nmortise is uneven. There are no significant degenerative changes. The tibial\ntalar joint space is preserved and no talar dome osteochondral lesion is\nidentified. No suspicious lytic or sclerotic lesion is identified. No soft\ntissue calcification or radiopaque foreign body is identified.\n\nIMPRESSION: \n\nMildly displaced transverse fracture through the distal fibula. Additional\ncomminuted fractures through the lateral and medial malleolus.\n', '18141668-RR-21', 21, 'ap view of the right knee and multiple views of the right ankle.'], ['EXAMINATION: HAND (PA,LAT AND OBLIQUE) LEFT\n\nINDICATION: History: ___ with MVC// fx?\n\nTECHNIQUE: Frontal, oblique, and lateral view radiographs of left hand\n\nCOMPARISON: None\n\nFINDINGS: \n\nNo fracture or dislocation is seen. There are no significant degenerative\nchanges. No bone erosion or periostitis is identified. No suspicious lytic or\nsclerotic lesion is identified. No soft tissue calcification or radio-opaque\nforeign bodies are detected.\n\nIMPRESSION: \n\nNormal left hand hand radiographs.\n', '18141668-RR-22', 22, 'frontal, oblique, and lateral view radiographs of left hand'], ['EXAMINATION: CHEST (PORTABLE AP)\n\nINDICATION: History: ___ with CVL// CVL\n\nTECHNIQUE: AP chest radiograph.\n\nCOMPARISON: Chest radiograph from ___.\n\nFINDINGS: \n\nInterval placement of a right subclavian line terminates at the\nbrachiocephalic junction. Endotracheal tube terminates 5.6 cm above the\ncarina. Interval placement of a nasogastric tube overlies the stomach. \nBilateral airspace opacities are unchanged from prior study. Cardiac\nsilhouette is unchanged. No evidence of pleural effusion or pneumothorax.\n\nIMPRESSION: \n\nInterval placement of right subclavian line terminates at the brachiocephalic\njunction. No evidence pneumothorax.\n', '18141668-RR-23', 23, 'ap chest radiograph.'], ['EXAMINATION: FEMUR (AP AND LAT) LEFT IN O.R.\n\nINDICATION: FEMUR (AP AND LAT) LEFT IN O.R.\n\nTECHNIQUE: X-ray femur in the OR.\n\nCOMPARISON: None\n\nFINDINGS: \n\n10 intraoperative images were acquired without a radiologist present.\n\nImages show internal fixation of the femoral fracture.\n\nIMPRESSION: \n\nIntraoperative images were obtained during internal fixation of the femoral\nfracture.. Please refer to the operative note for details of the procedure.\n', '18141668-RR-24', 24, 'x-ray femur in the or.'], ['EXAMINATION: CTA NECK WANDW/OC AND RECONS Q25 CT NECK.\n\nINDICATION: ___ year old man with MVC, IPH, ___// eval for bleeding/injury\nfrom C2 fx.\n\nTECHNIQUE: Helically acquired rapid axial imaging was performed from the\naortic arch through the skullbase during the infusion of 55 mL of Omnipaque\n350 nonionic intravenous contrast material. Three-dimensional angiographic\nvolume rendered, curved reformatted and segmented images were generated on a\ndedicated workstation. This report is based on interpretation of all of these\nimages.\n\nDOSE: Acquisition sequence:\n 1) Spiral Acquisition 2.1 s, 33.0 cm; CTDIvol = 13.1 mGy (Body) DLP = 430.1\nmGy-cm.\n 2) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 2.7 mGy (Body) DLP = 1.4\nmGy-cm.\n 3) Stationary Acquisition 1.5 s, 0.5 cm; CTDIvol = 8.1 mGy (Body) DLP = 4.1\nmGy-cm.\n Total DLP (Body) = 436 mGy-cm.\n\nCOMPARISON: CT of the cervical spine dated ___.\n\nFINDINGS: \n\nCTA NECK:\nBilateral carotid and vertebral artery origins are patent. There is no\nevidence of internal carotid stenosis by NASCET criteria.The\ncarotidandvertebral arteries and their major branches appear normal with no\nevidence of stenosis or occlusion.\n\nOTHER:\nPatient is intubated. There is opacification in the posterior aspect of the\nvisualized lung apices; this is nonspecific and could represent contusion\nversus atelectasis/infection, recommend correlation with prior chest\nradiograph. The visualized portion of the thyroid gland is within normal\nlimits. There is no lymphadenopathy by CT size criteria. Comminuted fracture\nof the right transverse C2 is unchanged.\n\nThere is mucosal thickening involving included lower aspect of bilateral\nmaxillary and sphenoid sinuses.\n\nIMPRESSION:\n\n\n1. No evidence of dissection.\n2. Patent bilateral cervical carotid and vertebral arteries without evidence\nof stenosis, occlusion.\n3. Unchanged fracture of the right C2 transverse process, better depicted in\nthe dedicated CT of the cervical spine dated ___.\n', '18141668-RR-26', 26, 'helically acquired rapid axial imaging was performed from the\naortic arch through the skullbase during the infusion of 55 ml of omnipaque\n350 nonionic intravenous contrast material. three-dimensional angiographic\nvolume rendered, curved reformatted and segmented images were generated on a\ndedicated workstation. this report is based on interpretation of all of these\nimages.'], ['EXAMINATION: assess for fixation, alignment\n\nINDICATION: ___ year old man with Right ankle fracture s/p fixation// assess\nfor fixation, alignment\n\nTECHNIQUE: Multidetector CT of the right ankle was performed without IV\ncontrast.\n\nCOMPARISON: Intraoperative fluoroscopic images dated ___\n\nFINDINGS: \n\nThere is interval external fixation of the right ankle. Hardware associated\nstreak artifacts limit diagnostic evaluation. There is comminuted fracture of\nthe medial malleolus with 6 mm displacement of the distal fracture fragment. \nThere is minimally displaced comminuted fracture of the lateral malleolus. \nThere are multiple fracture fragments noted in the tibiotalar joint measuring\nup to 3 mm. There is mildly displaced comminuted fracture of the talus neck\nextending to the subtalar joint and to sinus tarsi. Multiple fracture\nfragments are noted at the sinus tarsi measuring up to 5 mm (series 2, image\n90). A linear fracture fragment measuring 6 mm is noted at the posterior\nsubtalar joint (series 303, image 96). The talus is anteriorly subluxed\nrelative to the tibia. There is widening of the medial clear space. No\nadditional fracture, dislocation or subluxation. There are few ossifications\nmeasuring up to 5 mm medial to the image superior fibula near the syndesmosis.\n\nThere is small tibiotalar joint effusion. Foci subcutaneous air could be a\ncombination of posttraumatic and postsurgical. There is skin defect\nanteromedial to the distal tibia. There is extensive subcutaneous edema. \nThere is a 6.7 x 1.0 x 3.0 cm (AP by TV by CC) knee is hematoma along the\nsuperolateral aspect of the dorsum the foot, contacting the extensor digitorum\nlongus tendon. The extensive subcutaneous edema/hematoma limits diagnostic\nevaluation of soft tissue structures. Given the limitation, the visualized\ntendons are grossly intact.\n\nIMPRESSION: \n\n1. Status post interval external fixation of the right ankle with streak\nartifacts from the hardware limiting diagnostic evaluation.\n2. Comminuted fracture of the talus neck extending to the subtalar joint and\nsinus tarsi with multiple fracture fragments in the sinus tarsi and posterior\nsubtalar joint.\n3. Comminuted fractures through the medial and lateral malleoli with\nintra-articular extension. There is associated fracture fragments and joint\neffusion within the tibiotalar joint.\n4. Anterior subluxation of the talus with respect to the tibia.\n5. Extensive subcutaneous edema/hematoma, subcutaneous air, and skin defect\ncould be posttraumatic and/or post surgical.\n', '18141668-RR-27', 27, 'multidetector ct of the right ankle was performed without iv\ncontrast.'], ['EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD\n\nINDICATION: ___ year old man with MVC, IPH, ___// head bleed\n\nTECHNIQUE: Contiguous axial images of the brain were obtained without\ncontrast.\n\nDOSE: Acquisition sequence:\n 1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP =\n934.3 mGy-cm.\n Total DLP (Head) = 934 mGy-cm.\n\nCOMPARISON: CT from 8 hours prior\n\nFINDINGS: \n\nCompared to prior there has been redistribution of intracranial hemorrhage.\nA focal right thalamic hemorrhage measures approximately 1 x 0.5 cm,\npreviously 1.1 x 0.8 cm with surrounding edema and mild effacement of the\nright lateral ventricle. There is evidence of interventricular extension of\nhemorrhage which is seen layering in bilateral occipital horns.\nAreas of subarachnoid hemorrhage are again seen along the left frontal\nconvexity and along the left temporoparietal lobe (2; 23, 25, 32). Subtle\nareas of hyperdensity along the left frontal lobe and right frontoparietal\nlobe may represent additional foci of subarachnoid hemorrhage or artifact from\nvolume averaging (2; 28). A small amount of hemorrhage is also seen layering\nin the interpeduncular cistern.\nThere is no midline shift. Compared to prior there appears to be mildly\nincreased sulcal effacement allowing for differences in head positioning with\npreserved gray-white matter differentiation. The basal cisterns remain\npatent. Mild bilateral tonsillar ectopia is unchanged.\nThere is no evidence of acute territorial infarctionor mass.\n\nAn enteric tube and an ETT are partially visualized.\n\nAgain seen is a comminuted nasal bone fracture. There is opacification of\nseveral ethmoid air cells. There is moderate mucosal thickening of the\nbilateral maxillary and sphenoid sinuses. Submucosal retention cyst is seen\nin the left maxillary sinus. The visualized portion of the remaining\nparanasal sinuses, mastoid air cells, and middle ear cavities are clear. The\nvisualized portion of the orbits are unremarkable.\n\nIMPRESSION:\n\n\n1. Mild increase in sulcal effacement compared to prior with patent basal\ncisterns, concerning for worsening cerebral edema.\n2. Slight interval decrease in size of a right thalamic hemorrhage with\nintraventricular extension, with dependent hemorrhage in bilateral occipital\nhorns, and mild effacement of the right lateral ventricle.\n3. Redistribution of subarachnoid hemorrhage with concentration along left\nfrontoparietal lobe and in the interpeduncular cistern.\n4. Additional areas of hyperdensity along the left frontal lobe and right\nfrontoparietal lobe may represent subarachnoid hemorrhage or volume averaging.\n', '18141668-RR-28', 28, 'contiguous axial images of the brain were obtained without\ncontrast.'], ['EXAMINATION: HAND (PA,LAT AND OBLIQUE) RIGHT\n\nINDICATION: ___ year old man with mvc, polytrauma, R hand looks deformed//\ndeformity, mvc\n\nTECHNIQUE: Frontal, oblique, and lateral view radiographs of the right hand\n\nCOMPARISON: None\n\nFINDINGS: \n\nThere is no acute fracture visualized. The second through fifth\nmetacarpophalangeal joints appear subluxed posteriorly and medially (toward\nthe ulna). This is particularly pronounced around the fourth and fifth MCPs\nwhere they are frankly dislocated. There are no significant degenerative\nchanges. No bone erosion or periostitis is identified. No suspicious lytic or\nsclerotic lesion is identified. No soft tissue calcification or radio-opaque\nforeign bodies are detected.\n\nIMPRESSION: \n\nDislocations of the second through fifth MCP is in a ulnar and dorsal\ndirection. No acute fracture identified.\n', '18141668-RR-29', 29, 'frontal, oblique, and lateral view radiographs of the right hand'], ['EXAMINATION: CTA ABD AND PELVIS\n\nINDICATION: ___ year old man with poly trauma, known splenic lac. dropping\nhct.// spleen bleed\n\nTECHNIQUE: Abdomen and pelvis CTA: Non-contrast and multiphasic post-contrast\nimages were acquired through the abdomen and pelvis.\nOral contrast was not administered.\nMIP reconstructions were performed on independent workstation and reviewed on\nPACS.\n\nDOSE:\n Total DLP (Body) = 1,689 mGy-cm.\n\nCOMPARISON: CT abdomen pelvis ___.\n\nFINDINGS: \n\nVASCULAR:\n\nThere is no abdominal aortic aneurysm. There is minimal calcium burden in the\nabdominal aorta and great abdominal arteries. No evidence of active contrast\nextravasation to suggest active bleeding.\n\nLOWER CHEST: Again noted are small bilateral pleural effusions, the effusion\non the left being intermediate in density suggesting a component of\nhemothorax. Airspace opacification in the lingula is increased density which\nlikely representing pulmonary contusion or aspiration of hemorrhage. Mild\nbibasal atelectasis.\n\nABDOMEN:\n\nHEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There\nis no evidence of focal lesions. There is no evidence of intrahepatic or\nextrahepatic biliary dilatation. There is new small volume perihepatic\nintermediate density fluid likely representing hemoperitoneum.\n\nThe gallbladder demonstrates vicarious excretion of intravenous contrast from\nprior contrast enhanced study. Otherwise, is within normal limits, without\nstones or gallbladder wall thickening.\n\nPANCREAS: The pancreas has normal attenuation throughout, without evidence of\nfocal lesions or pancreatic ductal dilatation. There is no peripancreatic\nstranding.\n\nSPLEEN: Again demonstrated, are splenic laceration involving the inferior\nspleen measuring up to 2.5 cm in length/depth. There is a subcapsular\nperisplenic hematoma measuring 1.7 cm in thickness, similar to prior. No\nevidence of active extravasation. There is a small accessory spleen.\n\nADRENALS: The right and left adrenal glands are normal in size and shape.\n\nURINARY: The kidneys are of normal and symmetric size with normal nephrogram. \nThere are small stable bilateral renal cysts. Otherwise, there is no evidence\nof stones, solid renal lesions, or hydronephrosis. There are no urothelial\nlesions in the kidneys or ureters. There is no perinephric abnormality.\n\nGASTROINTESTINAL: An NG tube is seen terminating in the stomach. Otherwise,\nthe stomach is unremarkable. Small bowel loops demonstrate normal caliber,\nwall thickness, and enhancement throughout. There is new mild thickening of\nthe anterior ascending colonic walls, likely reactive. Otherwise, the\nremaining colon and rectum are within normal limits.\n\nRETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy.\n\nPELVIS: The urinary bladder containing a Foley catheter is decompressed and\ntherefore suboptimally assessed. Air in the urinary bladder is likely from\nrecent instrumentation. Otherwise, the distal ureters are grossly\nunremarkable. There is no evidence of pelvic or inguinal lymphadenopathy. \nThere is new small volume high-density pelvic free fluid representing\nhemoperitoneum.\n\nREPRODUCTIVE ORGANS: The prostate and seminal vesicles are grossly\nunremarkable.\n\nBONES: Again demonstrated, is nondisplaced fracture of the right inferior\npubic ramus, bilateral L5 transverse processes and pars interarticularis, left\nL5 lamina, right L4 transverse process, right L3 transverse process, right L2\ntransverse process, displaced left L2 transverse process, right L1 transverse\nprocess, minimally displaced anterolateral fractures of left 8 through 11\nribs, and minimally displaced anterolateral right sixth through eighth rib\nfractures. No evidence of new acute fractures.\n\nSOFT TISSUES: There is mild stranding of the anterior abdominal wall and left\ngroin soft tissues. Otherwise, the abdominal and pelvic wall is within normal\nlimits.\n\nIMPRESSION:\n\n\n1. Redemonstration of grade 2 splenic lacerations with perisplenic hematoma\nwithout significant interval change. No evidence of active arterial\nextravasation.\n2. New small volume hemoperitoneum. No evidence of active extravasation.\n3. Partially imaged known hyperdense left upper lobe consolidation consistent\nwith pulmonary hemorrhage/contusion or aspiration of blood.\n4. Redemonstration of small bilateral pleural effusions with associated\ncompressive atelectasis. Intermediate density of left pleural effusion\nsuggests a component of hemorrhagic pleural effusion.\n5. Redemonstration of multiple fractures including ribs, lumbar spine, and\nright inferior pubic ramus. No evidence of new additional acute fractures.\n', '18141668-RR-30', 30, 'abdomen and pelvis cta: non-contrast and multiphasic post-contrast\nimages were acquired through the abdomen and pelvis.\noral contrast was not administered.\nmip reconstructions were performed on independent workstation and reviewed on\npacs.'], ['EXAMINATION: CHEST (PORTABLE AP)\n\nINDICATION: ___ year old man with poly trama// routine routine\n\nIMPRESSION: \n\nComparison to ___. Stable correct position of the monitoring and\nsupport devices. The extensive parenchymal opacity on the left has decreased\nin extent and severity. No new parenchymal opacities and consolidations on\nthe right, documented on the CT examination from ___, have\ndecreased in extent and severity. There currently is no evidence for the\npresence of a pneumothorax. Unchanged position of the monitoring and support\ndevices, the tip of the endotracheal tube is relatively high, projecting 6 cm\nabove the carinal. The device should be advanced by 2-3 cm. The feeding tube\nshould be advanced by approximately 5 cm.\n', '18141668-RR-31', 31, ''], ['EXAMINATION: HAND (PA,LAT AND OBLIQUE) RIGHT\n\nINDICATION: ___ year old man with surgical planning// surgical planning\n\nIMPRESSION: \n\nIn comparison with the study of ___, the dislocations of the\nsecond-fifth MCP joints are again seen though it is difficult to compare due\nto different obliquities of the hands. Further information can be from the\noperative report.\n', '18141668-RR-32', 32, ''], ['INDICATION: Fracture\n\nTECHNIQUE: Fluoroscopic spot images of the left femur and tibia\n\nCOMPARISON: ___\n\nFINDINGS: \n\nMultiple fluoroscopic spot images are obtained for localization purposes and\ndemonstrate placement of an intramedullary rod across the comminuted tibial\nfractures as well as the comminuted femur fracture. There are interlocking\nscrews.\n\nThere are also fluoroscopic spot images of a hand.\n\nFor further details please see the intraoperative note.\n', '18141668-RR-33', 33, 'fluoroscopic spot images of the left femur and tibia'], ["EXAMINATION: MRI CERVICAL AND LUMBAR PT23 MR SPINE\n\nINDICATION: ___ year old man s/p MCC- IPH, g3 splenic lac, L5 SP fx, C2 TP fx,\n?___, nasal bone fx, ortho injuries// clearance for C-collar removal \nclearance for C-collar removal \nper NSGY- assessment of trauma burden in lumbar spine\n\nTECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique. \nAxial T2 imaging was performed. Axial GRE images of the cervical spine were\nperformed.\n\nCOMPARISON: CT torso from ___\n\nFINDINGS: \n\nCERVICAL:\nThere is a focal abnormal T2 STIR hyperintense signal intensity at the\nvicinity of apical ligament concerning for ligamentous injury. \nCervicomedullary junction show normal signal intensity and volume.\n\nAlignment is normal. Vertebral body and intervertebral disc signal intensity\nappear normal. The spinal cord appears normal in caliber and configuration.\nThere is no evidence of spinal canal or neural foraminal narrowing.\n\nLUMBAR:\nThere are bilateral pars interarticularis acute fractures with no underlying\nsagittal malalignment. There is incidental intraspinal lower sacral\nfluid-fluid levels related to patient's known subarachnoid/intraventricular\nhemorrhage.\n\nAlignment is normal. Vertebral body and intervertebral disc signal intensity\nappear normal apart from L5-S1 which shows mild barely degenerative\nchanges..The spinal cord appears normal in caliber and configuration. There is\nno evidence of spinal canal or neural foraminal narrowing. there is a small\nsize diffuse disc bulge at the level of L5-S1 with no significant spinal canal\nstenosis or neural foraminal narrowing. .\n\nIMPRESSION:\n\n\n1. There is suspicion of ligamentous injury at apical ligament with normal\nsignal intensity and volume of cervicomedullary junction.\n2. There are bilateral pars interarticularis acute fractures with no\nunderlying sagittal malalignment.\n", '18141668-RR-34', 34, 'sagittal imaging was performed with t2, t1, and stir technique. \naxial t2 imaging was performed. axial gre images of the cervical spine were\nperformed.'], ['EXAMINATION: CHEST PORT. LINE PLACEMENT\n\nINDICATION: ___ year old man with polytrauma// new line placement Contact\nname: ___: ___\n\nTECHNIQUE: AP portable chest radiograph\n\nCOMPARISON: ___\n\nFINDINGS: \n\nA new left subclavian central venous catheter courses along the left side of\nthe mediastinum concerning for arterial placement. The endotracheal tube and\nenteric tube are unchanged. Opacities at the left lung base likely reflect a\ncombination of atelectasis and consolidation. Similarly patchy opacities in\nthe periphery of the right midlung and medial right lung base may also reflect\natelectasis and/or consolidation. There is no pneumothorax identified. The\nsize of the cardiac silhouette is unchanged.\n\nIMPRESSION: \n\nA new left subclavian central venous catheter courses along the left\nmediastinum, concerning for intra-arterial placement.\n\nNOTIFICATION: The findings were discussed with ___, M.D. by ___\n___, M.D. on the telephone on ___ at 5:28 pm, 2 minutes after\ndiscovery of the findings.\n', '18141668-RR-35', 35, 'ap portable chest radiograph'], ['EXAMINATION: CHEST PORT. LINE PLACEMENT\n\nINDICATION: ___ year old man with line placement// line placement Contact\nname: ___: ___\n\nTECHNIQUE: AP portable chest radiograph\n\nCOMPARISON: Radiograph from earlier today\n\nFINDINGS: \n\nThe left subclavian line has been removed. No pneumothorax is identified. \nThe endotracheal and enteric tubes are unchanged.\nSlightly increased hazy opacification of the right hemithorax may reflect\nlayering pleural effusion fluid or evolving pulmonary contusions. A more\nfocal opacity in the periphery of the right midlung is unchanged. Dense\nretrocardiac opacification is re-demonstrated and unchanged. The size of the\ncardiac silhouette is within normal limits.\n\nIMPRESSION: \n\nThe left subclavian central line has been removed. No pneumothorax.\n\nIncreased hazy opacification of the right hemithorax may reflect layering\npleural fluid or evolving pulmonary contusions.\n', '18141668-RR-36', 36, 'ap portable chest radiograph'], ['EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD\n\nINDICATION: ___ year old man with per nsg// per nsg\n\nTECHNIQUE: Contiguous axial images of the brain were obtained without\ncontrast.\n\nDOSE: Acquisition sequence:\n 1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP =\n934.3 mGy-cm.\n Total DLP (Head) = 934 mGy-cm.\n\nCOMPARISON: Prior CT head dated ___.\n\nFINDINGS: \n\nRedemonstration of a 1.0 x 0.5 cm focus of intraparenchymal hemorrhage within\nthe right thalamus with mild surrounding edema and continued effacement of the\nbody of the right lateral ventricle. Additionally, there is intraventricular\nhemorrhage with layering hyperdensity seen within the posterior horns of the\nlateral ventricles bilaterally. There is also subarachnoid hemorrhage within\nthe left frontal and left frontoparietal lobes. There is no appreciable\nmidline shift or herniation identified. The degrees of sulcal effacement\nappears unchanged compared to most recent noncontrast head CT dated ___.\n\nThere is no evidence of acute large territory infarction.\n\nThere is no evidence of fracture. There is persistent mucosal thickening of\nthe bilateral maxillary, ethmoid, and sphenoid sinuses. Additionally, there\nis a mucosal retention cyst again seen in left maxillary sinus. The mastoid\nair cells and middle ear cavities are clear. The visualized portion of the\norbits are unremarkable.\n\nEndotracheal tube is partially visualized.\n\nIMPRESSION:\n\n\n1. Overall, no significant change compared to most recent noncontrast head CT\ndated ___.\n2. There is a similar-appearing 1.0 cm right thalamic intraparenchymal\nhemorrhage with intraventricular extension and mass-effect on the right\nlateral ventricle again seen.\n3. Subarachnoid hemorrhage again seen in the left frontoparietal lobe,\nunchanged in extent and distribution.\n', '18141668-RR-37', 37, 'contiguous axial images of the brain were obtained without\ncontrast.'], ['EXAMINATION: CTA TORSO\n\nINDICATION: ___ year old man with r/o arterial injury from left subclavian\nline and splenic bleed// r/o arterial injury from left subclavian line and\nsplenic bleed\n\nTECHNIQUE: Axial multidetector CT images were obtained through the thorax\nafter the uneventful administration of intravenous contrast in the arterial\nphase. Then, imaging was obtained through the abdomen and pelvis in the\nportal venous phase. Reformatted coronal and sagittal images through the\nchest, abdomen, and pelvis, and oblique maximal intensity projection images of\nthe chest were submitted to PACS and reviewed.\n\nDOSE: Acquisition sequence:\n 1) Spiral Acquisition 5.7 s, 75.7 cm; CTDIvol = 15.0 mGy (Body) DLP =\n1,131.3 mGy-cm.\n 2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7\nmGy-cm.\n 3) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 4.1 mGy (Body) DLP = 2.1\nmGy-cm.\n 4) Stationary Acquisition 4.8 s, 0.5 cm; CTDIvol = 33.1 mGy (Body) DLP =\n16.6 mGy-cm.\n Total DLP (Body) = 1,152 mGy-cm.\n\nCOMPARISON: CT scan dated ___\n\nFINDINGS: \n\nCHEST:\n\nBASE OF NECK: There is a large neck hematoma which is centered on the right\nside of the neck but extends to the left-side. No active extravasation of\ncontrast from the vessels in the neck is seen.\n\nAXILLA, HILA, AND MEDIASTINUM: There is a new mediastinal hematoma extending\nfrom the superior mediastinum and extending inferiorly into the anterior\nmediastinum. Interval development of small volume pneumomediastinum in the\nanterior and right lateral aspect of the superior mediastinum. No axillary,\nmediastinal, or hilar lymphadenopathy is present.\n\nHEART AND VASCULATURE:\nNo pericardial effusion is seen however, the mediastinal hematoma anterior to\nthe heart appears to exert mild pressure effect on the heart with flattening\nof the normal convex contour of the right and left ventricles.\nPulmonary vasculature is well opacified to the segmental level without filling\ndefect to indicate a pulmonary embolus. The thoracic aorta is normal in\ncaliber without evidence of dissection or intramural hematoma. The great\nvessels are within normal limits.\n\nPLEURAL SPACES: There are moderate volume bilateral which have increased in\nsize since the previous study.\n\nLUNGS/AIRWAYS: There is an endotracheal tube in-situ which terminates\napproximately 4 cm above the level of the carina. There is layering of\nfluid/secretions in the upper trachea, posterior endotracheal tube. The\nairways are patent to the level of the segmental bronchi bilaterally.\nThere is compressive atelectasis of the lower lobes bilaterally secondary to\nbilateral pleural effusions. Patchy consolidation in the lingula which is\nlikely to represent contusions has improved since the previous study.\n\nABDOMEN:\nThe images are partially degraded by beam hardening artifact\n\nPELVIS:\nInterval increase in volume of hemoperitoneum with high-density fluid now seen\nwithin the pelvis.\n\nSPLEEN: Re-demonstration of a laceration at the inferior aspect of the spleen\nis noted. No pseudoaneurysm or active extravasation of contrast is seen. The\npreviously demonstrated hematoma is stable in size.\n\nHEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. \nThere is no evidence of liver laceration or other focal abnormality. There is\nno evidence of intrahepatic or extrahepatic biliary dilatation. The\ngallbladder is within normal limits.\n\nPANCREAS: The pancreas has normal attenuation throughout, without evidence of\nfocal lesions or pancreatic ductal dilatation. There is no peripancreatic\nstranding.\n\nADRENALS: The right and left adrenal glands are normal in size and shape.\n\nURINARY: The kidneys are of normal and symmetric size with normal nephrogram. \nThere is no evidence of focal renal lesions or hydronephrosis. There is no\nperinephric abnormality.\n\nGASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate\nnormal caliber, wall thickness, and enhancement throughout. The colon and\nrectum are within normal limits. The appendix is normal. There is no free\nintraperitoneal fluid or free air.\n\n\nREPRODUCTIVE ORGANS: The prostate gland and the seminal vesicles appear normal\n\nLYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There\nis no pelvic or inguinal lymphadenopathy.\n\nVASCULAR: There is no abdominal aortic aneurysm or evidence of traumatic\ndissection in the abdomen.\n\nBONES AND SOFT TISSUES: Multiple fractures are again demonstrated. These\ninclude fractures of L5 transverse process bilaterally, bilateral L5 pars\nintercularis fractures, left L5 lamina fracture. L2 transverse process\nbilaterally, right transverse processes of L1, L3 and L4.\nThere are also minimally displaced fractures of the anterolateral aspect of\nthe left 8 to 11 th ribs and fractures of the right anterolateral aspect of\nthe right ___ to 8th ribs. There is also a nondisplaced fracture of the right\ninferior pubic ramus.\n\nIMPRESSION:\n\n\n1. Interval development of a right neck hematoma, superior mediastinal\nhematoma and anterior mediastinal hematoma.\n2. Minor effacement of the normal anterior convexity of the right and left\nventricles suggesting a degree of mass-effect from anterior mediastinal\nhematoma.\n3. Small volume pneumomediastinum, likely to be related to traumatic line\nplacement.\n4. Interval increase in size of bilateral pleural effusions.\n5. Moderate increase in hemoperitoneum is noted.\n6. Stable perisplenic hematoma. No evidence of active extravasation of\ncontrast and no splenic artery pseudoaneurysm is seen.\n\nRECOMMENDATION(S):\n1. An echocardiogram is recommended to assess risk tamponade from anterior\nmediastinal hematoma.\n2. Multiphase CT scan of the neck is recommended to exclude active bleeding\nfrom vascular structures in the neck.\n\nNOTIFICATION: The findings were discussed with ___ , M.D. By \n___, M.D. on the telephone on ___ at 8:50 am am, 10 minutes\nafter discovery of the findings.\n', '18141668-RR-39', 39, 'axial multidetector ct images were obtained through the thorax\nafter the uneventful administration of intravenous contrast in the arterial\nphase. then, imaging was obtained through the abdomen and pelvis in the\nportal venous phase. reformatted coronal and sagittal images through the\nchest, abdomen, and pelvis, and oblique maximal intensity projection images of\nthe chest were submitted to pacs and reviewed.'], ['EXAMINATION: CHEST (PORTABLE AP)\n\nINDICATION: ___ yo man mvc polytrauma. w IPH, grade 3 splenic lac, L5 SP fx,\nC2 TP fx, ?___, nasal bone fx, ortho injuries.// ?ETT displaced?\n\nTECHNIQUE: AP portable chest radiograph\n\nCOMPARISON: ___\n\nFINDINGS: \n\nThe tip of the endotracheal tube projects at the level of the clavicular\nheads. The enteric tube extends to the stomach.\n\nThere are layering bilateral pleural effusions with subjacent atelectasis\nand/or consolidation. No pneumothorax. The size of the cardiac silhouette is\nunchanged.\n\nIMPRESSION: \n\nThe tip of the endotracheal tube projects at the level of the clavicular\nheads, approximately 6 cm from the carina.\n\nUnchanged cardiopulmonary findings.\n', '18141668-RR-41', 41, 'ap portable chest radiograph'], ['EXAMINATION: HUMERUS (AP AND LAT) LEFT\n\nINDICATION: Left humeral fracture.\n\nTECHNIQUE: Fluoroscopic time 19.7 seconds.\n\nCOMPARISON: ___.\n\nFINDINGS: \n\n6 intraoperative images were acquired without a radiologist present.\n\nImages show steps related to ORIF for left humeral diaphyseal fracture..\n\nIMPRESSION: \n\nIntraoperative images were obtained during ORIF for left humeral diaphyseal\nfracture. Please refer to the operative note for details of the procedure.\n', '18141668-RR-42', 42, 'fluoroscopic time 19.7 seconds.'], ['EXAMINATION: ANKLE (AP, MORTISE AND LAT) RIGHT\n\nINDICATION: RT ANKLE/TALUS FX.ORIF\n\nTECHNIQUE: Multiple spot fluoroscopic intraoperative images of the right\nankle without radiologist present.\n\nCOMPARISON: Comparisons made to radiograph of the right ankle obtained ___ as well as CT the lower extremity.\n\nFINDINGS: \n\nMultiple spot fluoroscopic images taken intraoperatively show placement of\nmultiple screws within the talus as well as syndesmotic screws through the\ndistal shaft of the tibia and fibula with nails in the medial malleolus with\ncerclage wire with near anatomic alignment of the medial malleolar fracture. \nThere is a persistent displaced fracture of the distal shaft of the fibula.\n\nIMPRESSION: \n\nAs above. Please refer to operative report for full details.\n', '18141668-RR-43', 43, 'multiple spot fluoroscopic intraoperative images of the right\nankle without radiologist present.'], ['EXAMINATION: CHEST (PORTABLE AP)\n\nINDICATION: ___ year old man with polytrauma s/p MCC// assess position of ETT\n\nIMPRESSION: \n\nIn comparison with the study of ___, the tip of the endotracheal tube\nagain measures about 5.5 cm above the carina. Cardiomediastinal silhouette is\nstable. Diffuse haziness of the hemi thoraces with obscuration hemidiaphragms\nis again consistent with layering pleural fluid and underlying compressive\natelectasis. No evidence of pneumothorax.\n', '18141668-RR-44', 44, ''], ['EXAMINATION: CHEST (PORTABLE AP)\n\nINDICATION: ___ year old man with chest trauma// chest trauma chest\ntrauma\n\nIMPRESSION: \n\nET tube tip is 4 cm above the carina. NG tube tip is in the stomach. Heart\nsize and mediastinum are unchanged in appearance.\n\nThere is substantial pulmonary edema and bilateral pleural effusions that\nappear to be progressed since previous examination.\n', '18141668-RR-45', 45, ''], ['EXAMINATION: CHEST (PORTABLE AP)\n\nINDICATION: ___ year old man with ETT placement// ETT placement\n\nIMPRESSION: \n\nIn comparison with the study of 4 hours previously, the tip of the\nendotracheal tube now lies approximately 4.5 cm above the carina. The\nnasogastric tube extends beyond the lower margin of the image, with the side\nport mildly distal to the GE junction. The tube could be pushed forward\nanother 5-8 cm for more optimal positioning.\nThere again are bilateral pleural effusions with stable cardiomediastinal\nsilhouette.\n', '18141668-RR-46', 46, ''], ['EXAMINATION: CHEST (PORTABLE AP)\n\nINDICATION: ___ year old man with trauma// trauma\n\nIMPRESSION: \n\nIn comparison with the study of ___, there is now a single nasogastric\ntube that coils within the fundus of the stomach. Endotracheal tube tip lies\napproximately 4 cm above the carina. Cardiomediastinal silhouette is stable\nwith moderate pulmonary vascular congestion. Bilateral layering pleural\neffusions with compressive atelectasis, more prominent on the right.\n', '18141668-RR-48', 48, ''], ['EXAMINATION: CHEST (PORTABLE AP)\n\nINDICATION: ___ year old man with new ng tube// new ng tube\n\nIMPRESSION: \n\nIn comparison with the earlier study, there has been placement of a second\nnasogastric tube that extends to the mid to lower body of the stomach before\ncoiling back on itself so that the tip points upward just below the left\nhemidiaphragmatic contour.\nOtherwise, little change.\n', '18141668-RR-49', 49, ''], ['EXAMINATION: CHEST (PORTABLE AP)\n\nINDICATION: ___ yo man mvc polytrauma. w IPH, grade 3 splenic lac, L5 SP fx,\nC2 TP fx, ?___, nasal bone fx, ortho injuries// interval change- planning for\nextubation interval change- planning for extubation\n\nCOMPARISON: Chest x-ray ___\n\nFINDINGS: \n\nLines and support devices not significantly changed since the prior study. \nThere is stable mild cardiomegaly with bilateral pleural effusion and\npulmonary vascular congestion. No pneumothorax.\n', '18141668-RR-50', 50, ''], ['INDICATION: ___ year old man with mvc, intubated. possible extubation ___//\npulmonary processes\n\nCOMPARISON: Radiographs from ___\n\nIMPRESSION: \n\nSupport lines and tubes are unchanged in position. There has been worsening\nof the opacity along the right paratracheal region. There are large bilateral\npleural effusions, right greater than left.. There is a left retrocardiac\nopacity. There are no pneumothoraces.\n', '18141668-RR-51', 51, ''], ['EXAMINATION: CHEST (PORTABLE AP)\n\nINDICATION: ___ year old man with mvc, pulm contusions, intubated// increasing\nO2 requirements, secretions\n\nTECHNIQUE: AP radiograph of the chest.\n\nCOMPARISON: Chest radiograph ___ at 06:06. CTA torso ___.\n\nIMPRESSION: \n\nThe endotracheal tube terminates 5.3 cm above the carina. The nasogastric tube\nterminates in the fundus of the stomach.\n\nSmall bilateral pleural effusions are decreased compared to study from earlier\ntoday. Scattered parenchymal opacities appear unchanged and may represent\nparenchymal contusions. There is no new consolidation or pneumothorax. The\ncardiac silhouette remains mildly enlarged. There is central pulmonary\nvascular congestion without overt pulmonary edema. The osseous structures are\nunchanged.\n', '18141668-RR-52', 52, 'ap radiograph of the chest.'], ['INDICATION: ___ year old man with trauma// trauma\n\nCOMPARISON: Radiographs from ___\n\nIMPRESSION: \n\nEndotracheal tube has been removed. Nasogastric tube is unchanged in\nposition. There is improved aeration of the right paratracheal region since\nprior. There has been decrease in the bilateral pleural effusions. There\nremains a left retrocardiac opacity and subsegmental atelectasis at the lung\nbases. There are no pneumothoraces.\n', '18141668-RR-53', 53, ''], ['EXAMINATION: CHEST (PORTABLE AP)\n\nINDICATION: ___ year old man with pulm stats// pulm stats\n\nIMPRESSION: \n\nIn comparison with the study of ___, the cardiomediastinal silhouette\nis stable and the enteric tube is unchanged. Mild elevation in pulmonary\nvenous pressure with layering left effusion and compressive atelectasis at the\nbase.\n', '18141668-RR-54', 54, ''], ['EXAMINATION: UNILAT LOWER EXT VEINS LEFT\n\nINDICATION: ___ year old man with s/p MVC with polytrauma including L humerus\nORIF now with tensing and warmth of skin w/ some interval increased edema of\nLUE.// Please eval for thrombus.\n\nTECHNIQUE: Grey scale and Doppler evaluation was performed on the left upper\nextremity veins.\n\nCOMPARISON: None.\n\nFINDINGS: \n\nThere is normal flow with respiratory variation in the bilateral subclavian\nveins.\n\nThe left axillary, and brachial veins are patent, show normal color flow,\nspectral doppler, and compressibility. The Left internal jugular vein was\nunable to be assessed due to neck brace. The left basilic, and cephalic veins\nare patent, compressible and show normal color flow.\n\nIMPRESSION: \n\nNo evidence of deep vein thrombosis in the left upper extremity.\n', '18141668-RR-56', 56, 'grey scale and doppler evaluation was performed on the left upper\nextremity veins.'], ['EXAMINATION: CHEST (PORTABLE AP)\n\nINDICATION: ___ year old man with recurrent fevers, tachycardia, and erythema\nsurrounding wounds.// R/O consolidation and/or active pulmonary disease\n\nTECHNIQUE: AP radiograph of the chest.\n\nCOMPARISON: Chest radiograph ___ at 04:59.\n\nIMPRESSION: \n\nThe enteric tube is in stable position. There is central pulmonary vascular\ncongestion and mild pulmonary edema, which is overall improved compared to\nstudy from earlier today. The cardiomediastinal silhouette is stable in\nappearance. The retrocardiac opacity is decreased and most likely represents\nleft lower lobe atelectasis. Trace layering bilateral pleural effusions are\nunchanged. There is no pneumothorax. The osseous structures are unchanged.\n', '18141668-RR-57', 57, 'ap radiograph of the chest.'], ['EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD\n\nINDICATION: ___ year old man with head trauma on HD#12, somnolent. Evaluation\nfor interval change from previous exam.\n\nTECHNIQUE: Contiguous axial images of the brain were obtained without\ncontrast.\n\nDOSE: Acquisition sequence:\n 1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =\n747.5 mGy-cm.\n Total DLP (Head) = 747 mGy-cm.\n\nCOMPARISON: Comparison to multiple prior studies, including most recent\nnoncontrast head CT from ___.\n\nFINDINGS: \n\nSmall focus of edema with minimal residual blood products in the region of the\nright thalamus (02:16), consistent with expected interval evolution of\npreviously seen right thalamic hemorrhage. Persistent partial effacement of\nthe right lateral ventricle. Interval decrease in extent of intraventricular\nhemorrhage, with decrease in layering blood products seen within the occipital\nhorns of the lateral ventricles. The subarachnoid hemorrhage in the left\nfrontal and parietal lobes is no longer visualized. Slightly increased\nprominence of the right frontal subdural space demonstrates near CSF density,\nlikely consistent with subdural hygroma. No evidence of new intracranial\nhemorrhage or acute large territorial infarction. No significant midline\nshift.\n\nThere is no evidence of fracture. Minimal mucosal thickening of the bilateral\nmaxillary sinuses and ethmoid air cells. The visualized portion of the\nremaining paranasal sinuses, mastoid air cells, and middle ear cavities are\nclear. The visualized portion of the orbits are unremarkable. A right\nnasogastric tube is partially visualized.\n\nIMPRESSION:\n\n\n1. No definite evidence of new intracranial hemorrhage or acute large\nterritorial infarction.\n2. Expected interval evolution of previously seen right thalamic hemorrhage,\nnow demonstrating small focus of edema and minimal residual blood products.\n3. Small amount of residual blood products layering within the occipital horns\nof the lateral ventricles.\n4. Slightly increased prominence of the right frontal subdural space\ndemonstrates near CSF density, likely consistent with subdural hygroma.\n', '18141668-RR-58', 58, 'contiguous axial images of the brain were obtained without\ncontrast.'], ['EXAMINATION: CHEST PORT. LINE PLACEMENT\n\nINDICATION: ___ MVC, intubated on scene, w/ IPH, SAH, c/f ___, grade 3\nsplenic lac, L5 fx (b/l TP, pedicles, L articular facet), R L1-L4 and L L2 TP\nfx, C2 TP fx, nasal bone fx, R inf pubic ramus fx, L humerus fx, L femur fx, L\nopen distal tibia fx, R open ankle fx s/p L leg, L knee, and R ankle washout\nand b/l ___ external fixation.// check NGT placement\n\nTECHNIQUE: AP chest radiograph\n\nCOMPARISON: Multiple prior chest radiographs, most recently ___\n\nFINDINGS: \n\nThe enteric tube is within the right bronchial tree. Lungs are well expanded.\nSmall focus of opacification along the left heart border is improved compared\nto prior. Unchanged cardiomediastinal and hilar silhouettes. No pneumothorax\nor pleural effusion. Nonobstructive bowel gas pattern.\n\nIMPRESSION: \n\nThe enteric tube is within the right bronchial tree either right middle or\nlower lobe bronchi\n\nNOTIFICATION: The findings were discussed with ___, RN by ___,\nM.D. on the telephone on ___ at 10:19 am, 2 minutes after discovery of\nthe findings.\n', '18141668-RR-59', 59, 'ap chest radiograph'], ['EXAMINATION: HAND (PA,LAT AND OBLIQUE) RIGHT\n\nINDICATION: ___ year old man with multiple R MCP dislocations s/p reduction,\nto be re-splinted today.// ?MCP still reduced, ?alignment\n\nTECHNIQUE: Three views of the right hand.\n\nCOMPARISON: ___ and prior.\n\nFINDINGS: \n\nOverlying splint partially obscures fine bony detail. There is\npersistent/recurrent dorsal dislocation of the small finger MCP joint. The\nsecond through fourth MCP joints appear congruent.Joint spaces are preserved\nwithout significant degenerative changes.Type 2 lunate.Mild ulnar negative\nulnar variance.\n\nIMPRESSION: \n\nPersistent/recurrent dorsal dislocation of the small finger MCP joint. Second\nthrough fourth MCP joints appear congruent.\n', '18141668-RR-60', 60, 'three views of the right hand.'], ['EXAMINATION: Right hand radiographs, three views.\n\nINDICATION: Right fifth metacarpal ventral angio dislocation status post\nclose reduction.\n\nCOMPARISON: Earlier on the same day.\n\nFINDINGS: \n\nThe fifth metacarpophalangeal joint is again dislocated. No definite\nfracture. The fourth metacarpophalangeal joint remains reduced.\n\nIMPRESSION: \n\nPersistent dislocation of the fifth metacarpophalangeal joint.\n\nNOTIFICATION: The findings were discussed with ___ APN. By ___\n___, M.D. on the telephone on ___ at 10:24 pm, 50 minutes after\ndiscovery of the findings.\n', '18141668-RR-61', 61, ''], ['INDICATION: ___ year old man with R talus fx, s/p ORIF// ?alignment, ?healing\n2 wks post-op. Please obtain on ___ at 7:00.\n\nCOMPARISON: Compared to intraoperative study from ___\n\nIMPRESSION: \n\nThere is an overlying fiberglass cast which limits fine bony detail. Hardware\nwithin the distal fibula and tibia including syndesmotic screws are seen. \nThere are also two screws within the talus fixating a talar neck fracture. No\nhardware related complications are seen. There is good anatomic\nalignment.Fractures of the distal shaft of the fibula and of the distal\nfibular tip are also seen.\n', '18141668-RR-65', 65, ''], ['INDICATION: ___ year old man with L humeral shaft fx, s/p ORIF// ?alignment,\n?healing 2 wks post-op. Please obtain on ___ at 7:00.\n\nCOMPARISON: Intraoperative study from ___\n\nIMPRESSION: \n\nThere is a fracture plate with associated screws fixating a transverse\nfracture through the distal shaft of the left humerus. Small letter butterfly\nfragment is seen. Fracture line is still well visualized. No definite\nhardware related complications are present.\n', '18141668-RR-66', 66, ''], ['INDICATION: ___ year old man with L mid shaft femur fx, s/p Synthes retrograde\nnail// ?alignment, ?healing 2 wks post-op. Please obtain on ___ at 7:00.\n\nCOMPARISON: Intraoperative study from ___\n\nIMPRESSION: \n\nThere has been placement of a retrograde intramedullary rod with proximal and\ndistal interlocking screws fixating a comminuted fracture of distal left\nfemoral shaft. There are no signs for hardware related complications. There\nis prominent soft tissue swelling about the fracture site.\n', '18141668-RR-68', 68, ''], ['INDICATION: ___ year old man with L tibia fx, s/p antegrade IMN// ?alignment,\n?healing 2 wks post-op. Please obtain on ___ at 7:00.\n\nCOMPARISON: Intraoperative study from ___\n\nIMPRESSION: \n\nThere is an intramedullary rod proximal distal interlocking screws fixating a\ntransverse fracture involving the distal shaft of the tibia. There is a\npaucity of bridging callus. No new fractures are seen. Portion of the\nintramedullary rod in the distal femur is visualized on the edge of the film.\n', '18141668-RR-69', 69, ''], ['EXAMINATION: C-SPINE NON-TRAUMA ___ VIEWS\n\nINDICATION: ___ y/o M polytrauma w/ C1-2 ligamentous injury and bilateral pars\ninterarticularis acute fractures withno underlying sagittal malalignment//\nupright in ___ J collar upright flexion-extension radiographs per Spine\nrequest\n\nCOMPARISON: MRI cervical spine ___, CT scan cervical spine ___.\n\nFINDINGS: \n\nStatic AP and lateral views of the cervical spine were obtained. See 1\nthrough C7 were visualized on the lateral. There is straightening of the\nnormal cervical lordosis. No prevertebral soft tissue swelling. No fracture\nor subluxation. No flexion and extension views were included in the exam.\n', '18141668-RR-72', 72, ''], ['EXAMINATION: ANKLE (AP, MORTISE AND LAT) LEFT\n\nINDICATION: ___ MVC, intubated on scene, w/ IPH, SAH, c/f ___, grade 3\nsplenic lac, L5 fx (b/l TP, pedicles, L articular facet), R L1-L4 and L L2 TP\nfx, C2 TP fx, nasal bone fx, R inf pubic ramus fx, L humerus fx, L femur fx, L\nopen distal tibia fx, R open ankle fx s/p L leg, L knee, and R ankle washout\nand b/l ___ external fixation, now with increased L ankle pain// ?fracture \n?fracture\n\nCOMPARISON: ___\n\nFINDINGS: \n\nPostoperative changes reflect intramedullary rod fixation tibia. Hardware is\nintact. There is narrowing no periprosthetic lucency. Comminuted fracture of\nmid to distal left tibial diaphysis is again seen. No substantial is\nappreciated. The mortise is congruent.\n', '18141668-RR-73', 73, ''], ['EXAMINATION: UNILAT LOWER EXT VEINS LEFT\n\nINDICATION: ___ year old man with LLE trauma s/o surgical repair, now c/o LLE\npain, noted to be in saphenous vein distrubution // eval for DVT\n\nTECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed\non the left lower extremity veins.\n\nCOMPARISON: None.\n\nFINDINGS: \n\nThere is normal compressibility, color flow, and spectral doppler of the left\ncommon femoral, femoral, and popliteal veins. Normal color flow and\ncompressibility are demonstrated in the posterior tibial and peroneal veins.\n\nThere is normal respiratory variation in the common femoral veins bilaterally.\n\nNo evidence of medial popliteal fossa (___) cyst.\n\nIMPRESSION: \n\nNo evidence of deep venous thrombosis in the left lower extremity veins.\n', '18141668-RR-76', 76, 'grey scale, color, and spectral doppler evaluation was performed\non the left lower extremity veins.'], ['EXAMINATION: HAND (PA,LAT AND OBLIQUE) RIGHT\n\nINDICATION: ___ MVC, intubated on scene, w/ IPH, SAH, c/f ___, grade 3\nsplenic lac, L5 fx (b/l TP, pedicles, L articular facet), R L1-L4 and L L2 TP\nfx, C2 TP fx, nasal bone fx, R inf pubic ramus fx, L humerus fx, L femur fx, L\nopen distal tibia fx, R open ankle fx s/p L leg, L knee, and R ankle washout\nand b/l ___ external fixation. // post op follow up\n\nTECHNIQUE: Frontal, oblique, and lateral view radiographs of the right hand\n\nCOMPARISON: Multiple prior radiographs most recently dated ___\n\nFINDINGS: \n\nThe patient is post interval reduction and pinning of the right second through\nfifth metacarpophalangeal joints. Overlying splint material obscures fine\nosseous detail. The hand at the level of the MCPs and interphalangeal joints\nis in flexion. No obvious dislocation. No evidence of hardware related\ncomplications..\n', '18141668-RR-77', 77, 'frontal, oblique, and lateral view radiographs of the right hand'], ['EXAMINATION: FEMUR (AP AND LAT) LEFT\n\nINDICATION: ___ MVC, intubated on scene, w/ IPH, SAH, c/f ___, grade 3\nsplenic lac, L5 fx (b/l TP, pedicles, L articular facet), R L1-L4 and L L2 TP\nfx, C2 TP fx, nasal bone fx, R inf pubic ramus fx, L humerus fx, L femur fx, L\nopen distal tibia fx, R open ankle fx s/p L leg, L knee, and R ankle washout\nand b/l ___ external fixation. // eval for fracture fragment. please obtain\nfull length L femur film.\n\nTECHNIQUE: AP and lateral radiographs of the left femur\n\nCOMPARISON: ___\n\nFINDINGS: \n\nAgain visualized is an intramedullary rod and screws stabilizing a midshaft\nleft femoral fracture.\nThere is persistent callus formation at the fracture site, without complete\nbony fusion.\nHardware is intact.\nThe left hip joint appears intact.\n\nIMPRESSION: \n\nComminuted fracture, midshaft, left femur without complete bony fusion at the\nfracture site.\nIntact intramedullary rod and nails traversing the fracture site.\n', '18141668-RR-78', 78, 'ap and lateral radiographs of the left femur']]

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10 mL Vial'], [26401951, Timestamp('2118-10-15 14:00:00'), Timestamp('2118-10-20 02:00:00'), 'BASE', 'Soln', '', '0', '50 mL Vial'], [26401951, Timestamp('2118-10-15 14:00:00'), Timestamp('2118-10-20 02:00:00'), 'MAIN', 'Fentanyl Citrate', '048287', '61553011841', '2.5mg / 50 mL Premix Bag'], [26401951, Timestamp('2118-10-15 22:00:00'), Timestamp('2118-10-17 05:00:00'), 'BASE', 'Sodium Chloride 0.9%', '001210', '00338004904', 'Floor Stock Bag'], [26401951, Timestamp('2118-10-15 12:00:00'), Timestamp('2118-10-22 11:00:00'), 'BASE', '0.9% Sodium Chloride', '001210', '00338004938', '100 mL Bag'], [26401951, Timestamp('2118-10-15 12:00:00'), Timestamp('2118-10-22 11:00:00'), 'MAIN', 'LevETIRAcetam', '061005', '39822400001', '500mg/5mL Vial'], [26401951, Timestamp('2118-10-15 20:00:00'), Timestamp('2118-10-15 21:00:00'), 'MAIN', 'Rocuronium', '021727', '70860065110', '10mg/mL-10mL Vial'], [26401951, Timestamp('2118-10-15 12:00:00'), Timestamp('2118-10-15 19:00:00'), 'MAIN', 'Lidocaine Jelly 2% (Glydo)', '038861', '25021067376', '6 mL Syringe'], [26401951, Timestamp('2118-10-15 13:00:00'), Timestamp('2118-10-15 21:00:00'), 'BASE', 'Sodium Chloride 0.9%', '001210', '00338004904', 'Floor Stock Bag'], [26401951, Timestamp('2118-10-15 14:00:00'), Timestamp('2118-10-18 17:00:00'), 'BASE', 'SW', '', '0', '100ml Bag'], [26401951, Timestamp('2118-10-15 14:00:00'), Timestamp('2118-10-18 17:00:00'), 'MAIN', 'Potassium Chloride', '015362', '00409707426', '10mEq/100mL Premix'], [26401951, Timestamp('2118-10-15 12:00:00'), Timestamp('2118-10-15 11:00:00'), 'MAIN', 'Famotidine', '011677', '63739064510', '20 mg Tablet'], [26401951, Timestamp('2118-10-15 19:00:00'), Timestamp('2118-10-29 05:00:00'), 'MAIN', 'Glucagon', '066517', '00597026010', '1mg Vial'], [26401951, Timestamp('2118-10-15 20:00:00'), Timestamp('2118-10-23 11:00:00'), 'MAIN', 'Mouth Care Oral Rinse', '057959', '69339013819', '15 mL Cup'], [26401951, Timestamp('2118-10-15 14:00:00'), Timestamp('2118-10-25 18:00:00'), 'BASE', 'Bag', '', '0', '100 mL Bag'], [26401951, Timestamp('2118-10-15 14:00:00'), Timestamp('2118-10-25 18:00:00'), 'MAIN', 'Magnesium Sulfate', '063347', '00409672923', '4 g / 100 mL Premix Bag'], [26401951, Timestamp('2118-10-15 14:00:00'), Timestamp('2118-10-18 17:00:00'), 'BASE', 'SW', '', '0', '100ml Bag'], [26401951, Timestamp('2118-10-15 14:00:00'), Timestamp('2118-10-18 17:00:00'), 'MAIN', 'Potassium Chloride', '015362', '00409707426', '10mEq/100mL Premix'], [26401951, Timestamp('2118-10-15 12:00:00'), Timestamp('2118-10-17 10:00:00'), 'BASE', '5% Dextrose', '001972', '00338001738', '100 mL Bag'], [26401951, Timestamp('2118-10-15 12:00:00'), Timestamp('2118-10-17 10:00:00'), 'MAIN', 'CeFAZolin', '009066', '00143998303', '10g Bulk vial'], [26401951, Timestamp('2118-10-15 14:00:00'), Timestamp('2118-10-18 17:00:00'), 'BASE', 'SW', '', '0', '100ml Bag'], [26401951, Timestamp('2118-10-15 14:00:00'), Timestamp('2118-10-18 17:00:00'), 'MAIN', 'Potassium Chloride', '015362', '00409707426', '10mEq/100mL Premix'], [26401951, Timestamp('2118-10-15 14:00:00'), Timestamp('2118-10-25 18:00:00'), 'BASE', '0.9% Sodium Chloride', '001210', '00338004902', '250mL Bag'], [26401951, Timestamp('2118-10-15 14:00:00'), Timestamp('2118-10-25 18:00:00'), 'MAIN', 'Calcium Gluconate', '001356', '63323031119', '1g/10mL Vial'], [26401951, Timestamp('2118-10-15 14:00:00'), Timestamp('2118-10-25 18:00:00'), 'BASE', '0.9% Sodium Chloride', '001210', '00338004938', '100 mL Bag'], [26401951, Timestamp('2118-10-15 14:00:00'), Timestamp('2118-10-25 18:00:00'), 'MAIN', 'Calcium Gluconate', '001356', '63323031119', '1g/10mL Vial'], [26401951, Timestamp('2118-10-15 12:00:00'), Timestamp('2118-10-18 15:00:00'), 'MAIN', 'Sodium Chloride 0.9% Flush', '', '0', '10 mL Syringe'], [26401951, Timestamp('2118-10-15 12:00:00'), Timestamp('2118-10-17 12:00:00'), 'BASE', 'Iso-Osmotic Sodium Chloride', '', '0', '50ml Bag'], [26401951, Timestamp('2118-10-15 12:00:00'), Timestamp('2118-10-17 12:00:00'), 'MAIN', 'Famotidine', '021732', '00338519741', '20mg Premix Bag'], [26401951, Timestamp('2118-10-15 22:00:00'), Timestamp('2118-10-15 21:00:00'), 'MAIN', 'Rocuronium', '021727', '70860065110', '10mg/mL-10mL Vial']]

[['0QSC35Z', 10, 2, Timestamp('2118-10-15 00:00:00'), 'Reposition Left Lower Femur with External Fixation Device, Percutaneous Approach'], ['0QSG35Z', 10, 3, Timestamp('2118-10-15 00:00:00'), 'Reposition Right Tibia with External Fixation Device, Percutaneous Approach'], ['0QSH35Z', 10, 4, Timestamp('2118-10-15 00:00:00'), 'Reposition Left Tibia with External Fixation Device, Percutaneous Approach'], ['0JQP0ZZ', 10, 5, Timestamp('2118-10-15 00:00:00'), 'Repair Left Lower Leg Subcutaneous Tissue and Fascia, Open Approach'], ['0QHH34Z', 10, 6, Timestamp('2118-10-16 00:00:00'), 'Insertion of Internal Fixation Device into Left Tibia, Percutaneous Approach'], ['0QS936Z', 10, 11, Timestamp('2118-10-16 00:00:00'), 'Reposition Left Femoral Shaft with Intramedullary Internal Fixation Device, Percutaneous Approach'], ['0QSH36Z', 10, 12, Timestamp('2118-10-16 00:00:00'), 'Reposition Left Tibia with Intramedullary Internal Fixation Device, Percutaneous Approach'], ['5A1955Z', 10, 14, Timestamp('2118-10-15 00:00:00'), 'Respiratory Ventilation, Greater than 96 Consecutive Hours'], ['0JQQ3ZZ', 10, 15, Timestamp('2118-10-15 00:00:00'), 'Repair Right Foot Subcutaneous Tissue and Fascia, Percutaneous Approach'], ['0RSUXZZ', 10, 16, Timestamp('2118-10-15 00:00:00'), 'Reposition Right Metacarpophalangeal Joint, External Approach'], ['0QP9X5Z', 10, 17, Timestamp('2118-10-16 00:00:00'), 'Removal of External Fixation Device from Left Femoral Shaft, External Approach'], ['0QPHX5Z', 10, 18, Timestamp('2118-10-16 00:00:00'), 'Removal of External Fixation Device from Left Tibia, External Approach'], ['0RSUXZZ', 10, 19, Timestamp('2118-10-16 00:00:00'), 'Reposition Right Metacarpophalangeal Joint, External Approach']]

['surgery']

[[50802, Timestamp('2118-10-15 08:41:00'), Timestamp('2118-10-15 08:42:00'), 'Base Excess'], [50803, Timestamp('2118-10-15 08:41:00'), Timestamp('2118-10-15 08:45:00'), 'Calculated Bicarbonate, Whole Blood'], [50804, Timestamp('2118-10-15 08:41:00'), Timestamp('2118-10-15 08:42:00'), 'Calculated Total CO2'], [50806, Timestamp('2118-10-15 08:41:00'), Timestamp('2118-10-15 08:45:00'), 'Chloride, Whole Blood'], [50808, Timestamp('2118-10-15 08:41:00'), Timestamp('2118-10-15 08:45:00'), 'Free Calcium'], [50809, Timestamp('2118-10-15 08:41:00'), Timestamp('2118-10-15 08:45:00'), 'Glucose'], [50812, Timestamp('2118-10-15 08:41:00'), Timestamp('2118-10-15 08:42:00'), 'Intubated'], [50813, Timestamp('2118-10-15 08:41:00'), Timestamp('2118-10-15 08:45:00'), 'Lactate'], [50818, Timestamp('2118-10-15 08:41:00'), Timestamp('2118-10-15 08:42:00'), 'pCO2'], [50820, Timestamp('2118-10-15 08:41:00'), Timestamp('2118-10-15 08:42:00'), 'pH'], [50821, Timestamp('2118-10-15 08:41:00'), Timestamp('2118-10-15 08:42:00'), 'pO2'], [50822, Timestamp('2118-10-15 08:41:00'), Timestamp('2118-10-15 08:45:00'), 'Potassium, Whole Blood'], [50824, Timestamp('2118-10-15 08:41:00'), Timestamp('2118-10-15 08:45:00'), 'Sodium, Whole Blood'], [50828, Timestamp('2118-10-15 08:41:00'), Timestamp('2118-10-15 08:42:00'), 'Ventilator'], [50802, Timestamp('2118-10-15 09:37:00'), Timestamp('2118-10-15 09:40:00'), 'Base Excess'], [50804, Timestamp('2118-10-15 09:37:00'), Timestamp('2118-10-15 09:40:00'), 'Calculated Total CO2'], [50805, Timestamp('2118-10-15 09:37:00'), Timestamp('2118-10-15 09:41:00'), 'Carboxyhemoglobin'], [50806, Timestamp('2118-10-15 09:37:00'), Timestamp('2118-10-15 09:41:00'), 'Chloride, Whole Blood'], [50808, Timestamp('2118-10-15 09:37:00'), Timestamp('2118-10-15 09:41:00'), 'Free Calcium'], [50809, Timestamp('2118-10-15 09:37:00'), Timestamp('2118-10-15 09:41:00'), 'Glucose'], [50810, Timestamp('2118-10-15 09:37:00'), Timestamp('2118-10-15 09:41:00'), 'Hematocrit, Calculated'], [50811, Timestamp('2118-10-15 09:37:00'), Timestamp('2118-10-15 09:41:00'), 'Hemoglobin'], [50813, Timestamp('2118-10-15 09:37:00'), Timestamp('2118-10-15 09:41:00'), 'Lactate'], [50814, Timestamp('2118-10-15 09:37:00'), Timestamp('2118-10-15 09:41:00'), 'Methemoglobin'], [50817, Timestamp('2118-10-15 09:37:00'), Timestamp('2118-10-15 09:41:00'), 'Oxygen Saturation'], [50818, Timestamp('2118-10-15 09:37:00'), Timestamp('2118-10-15 09:40:00'), 'pCO2'], [50820, Timestamp('2118-10-15 09:37:00'), Timestamp('2118-10-15 09:40:00'), 'pH'], [50821, Timestamp('2118-10-15 09:37:00'), Timestamp('2118-10-15 09:40:00'), 'pO2'], [50822, Timestamp('2118-10-15 09:37:00'), Timestamp('2118-10-15 09:41:00'), 'Potassium, Whole Blood'], [50824, Timestamp('2118-10-15 09:37:00'), Timestamp('2118-10-15 09:41:00'), 'Sodium, Whole Blood'], [52033, Timestamp('2118-10-15 09:37:00'), Timestamp('2118-10-15 09:38:00'), 'Specimen Type'], [51221, Timestamp('2118-10-15 10:58:00'), Timestamp('2118-10-15 11:48:00'), 'Hematocrit'], [51222, Timestamp('2118-10-15 10:58:00'), Timestamp('2118-10-15 11:48:00'), 'Hemoglobin'], [51248, Timestamp('2118-10-15 10:58:00'), Timestamp('2118-10-15 11:48:00'), 'MCH'], [51249, Timestamp('2118-10-15 10:58:00'), Timestamp('2118-10-15 11:48:00'), 'MCHC'], [51250, Timestamp('2118-10-15 10:58:00'), Timestamp('2118-10-15 11:48:00'), 'MCV'], [51265, Timestamp('2118-10-15 10:58:00'), Timestamp('2118-10-15 11:48:00'), 'Platelet Count'], [51277, Timestamp('2118-10-15 10:58:00'), Timestamp('2118-10-15 11:48:00'), 'RDW'], [51279, Timestamp('2118-10-15 10:58:00'), Timestamp('2118-10-15 11:48:00'), 'Red Blood Cells'], [51301, Timestamp('2118-10-15 10:58:00'), Timestamp('2118-10-15 11:48:00'), 'White Blood Cells'], [52172, Timestamp('2118-10-15 10:58:00'), Timestamp('2118-10-15 11:48:00'), 'RDW-SD'], [51237, Timestamp('2118-10-15 10:58:00'), Timestamp('2118-10-15 13:27:00'), 'INR(PT)'], [51274, Timestamp('2118-10-15 10:58:00'), Timestamp('2118-10-15 13:27:00'), 'PT'], [51275, Timestamp('2118-10-15 10:58:00'), Timestamp('2118-10-15 13:27:00'), 'PTT'], [50868, Timestamp('2118-10-15 10:58:00'), Timestamp('2118-10-15 12:38:00'), 'Anion Gap'], [50882, Timestamp('2118-10-15 10:58:00'), Timestamp('2118-10-15 12:38:00'), 'Bicarbonate'], [50893, Timestamp('2118-10-15 10:58:00'), Timestamp('2118-10-15 12:38:00'), 'Calcium, Total'], [50902, Timestamp('2118-10-15 10:58:00'), Timestamp('2118-10-15 12:38:00'), 'Chloride'], [50912, Timestamp('2118-10-15 10:58:00'), Timestamp('2118-10-15 12:38:00'), 'Creatinine'], [50920, Timestamp('2118-10-15 10:58:00'), Timestamp('2118-10-15 12:38:00'), 'Estimated GFR (MDRD equation)'], [50931, Timestamp('2118-10-15 10:58:00'), Timestamp('2118-10-15 12:38:00'), 'Glucose'], [50934, Timestamp('2118-10-15 10:58:00'), Timestamp('2118-10-15 12:38:00'), 'H'], [50947, Timestamp('2118-10-15 10:58:00'), Timestamp('2118-10-15 12:38:00'), 'I'], [50960, Timestamp('2118-10-15 10:58:00'), Timestamp('2118-10-15 12:38:00'), 'Magnesium'], [50970, Timestamp('2118-10-15 10:58:00'), Timestamp('2118-10-15 12:38:00'), 'Phosphate'], [50971, Timestamp('2118-10-15 10:58:00'), Timestamp('2118-10-15 12:38:00'), 'Potassium'], [50983, Timestamp('2118-10-15 10:58:00'), Timestamp('2118-10-15 12:38:00'), 'Sodium'], [51006, Timestamp('2118-10-15 10:58:00'), Timestamp('2118-10-15 12:38:00'), 'Urea Nitrogen'], [51678, Timestamp('2118-10-15 10:58:00'), Timestamp('2118-10-15 12:38:00'), 'L'], [50802, Timestamp('2118-10-15 11:19:00'), Timestamp('2118-10-15 11:24:00'), 'Base Excess'], [50804, Timestamp('2118-10-15 11:19:00'), Timestamp('2118-10-15 11:24:00'), 'Calculated Total CO2'], [50808, Timestamp('2118-10-15 11:19:00'), Timestamp('2118-10-15 11:24:00'), 'Free Calcium'], [50813, Timestamp('2118-10-15 11:19:00'), Timestamp('2118-10-15 11:24:00'), 'Lactate'], [50818, Timestamp('2118-10-15 11:19:00'), Timestamp('2118-10-15 11:24:00'), 'pCO2'], [50820, Timestamp('2118-10-15 11:19:00'), Timestamp('2118-10-15 11:24:00'), 'pH'], [50821, Timestamp('2118-10-15 11:19:00'), Timestamp('2118-10-15 11:24:00'), 'pO2'], [52033, Timestamp('2118-10-15 11:19:00'), Timestamp('2118-10-15 11:21:00'), 'Specimen Type'], [51221, Timestamp('2118-10-15 14:10:00'), Timestamp('2118-10-15 14:31:00'), 'Hematocrit'], [51221, Timestamp('2118-10-15 17:45:00'), Timestamp('2118-10-15 17:58:00'), 'Hematocrit'], [51221, Timestamp('2118-10-15 21:30:00'), Timestamp('2118-10-15 21:42:00'), 'Hematocrit'], [50802, Timestamp('2118-10-15 21:40:00'), Timestamp('2118-10-15 21:42:00'), 'Base Excess'], [50804, Timestamp('2118-10-15 21:40:00'), Timestamp('2118-10-15 21:42:00'), 'Calculated Total CO2'], [50813, Timestamp('2118-10-15 21:40:00'), Timestamp('2118-10-15 21:43:00'), 'Lactate'], [50818, Timestamp('2118-10-15 21:40:00'), Timestamp('2118-10-15 21:42:00'), 'pCO2'], [50820, Timestamp('2118-10-15 21:40:00'), Timestamp('2118-10-15 21:42:00'), 'pH'], [50821, Timestamp('2118-10-15 21:40:00'), Timestamp('2118-10-15 21:42:00'), 'pO2'], [52033, Timestamp('2118-10-15 21:40:00'), Timestamp('2118-10-15 21:41:00'), 'Specimen Type'], [51221, Timestamp('2118-10-16 01:23:00'), Timestamp('2118-10-16 01:59:00'), 'Hematocrit'], [51222, Timestamp('2118-10-16 01:23:00'), Timestamp('2118-10-16 01:59:00'), 'Hemoglobin'], [51248, Timestamp('2118-10-16 01:23:00'), Timestamp('2118-10-16 01:59:00'), 'MCH'], [51249, Timestamp('2118-10-16 01:23:00'), Timestamp('2118-10-16 01:59:00'), 'MCHC'], [51250, Timestamp('2118-10-16 01:23:00'), Timestamp('2118-10-16 01:59:00'), 'MCV'], [51265, Timestamp('2118-10-16 01:23:00'), Timestamp('2118-10-16 05:12:00'), 'Platelet Count'], [51266, Timestamp('2118-10-16 01:23:00'), Timestamp('2118-10-16 05:12:00'), 'Platelet Smear'], [51277, Timestamp('2118-10-16 01:23:00'), Timestamp('2118-10-16 01:59:00'), 'RDW'], [51279, Timestamp('2118-10-16 01:23:00'), Timestamp('2118-10-16 01:59:00'), 'Red Blood Cells'], [51301, Timestamp('2118-10-16 01:23:00'), Timestamp('2118-10-16 01:59:00'), 'White Blood Cells'], [52172, Timestamp('2118-10-16 01:23:00'), Timestamp('2118-10-16 01:59:00'), 'RDW-SD'], [50868, Timestamp('2118-10-16 01:23:00'), Timestamp('2118-10-16 02:17:00'), 'Anion Gap'], [50882, Timestamp('2118-10-16 01:23:00'), Timestamp('2118-10-16 02:17:00'), 'Bicarbonate'], [50893, Timestamp('2118-10-16 01:23:00'), Timestamp('2118-10-16 02:17:00'), 'Calcium, Total'], [50902, Timestamp('2118-10-16 01:23:00'), Timestamp('2118-10-16 02:17:00'), 'Chloride'], [50912, Timestamp('2118-10-16 01:23:00'), Timestamp('2118-10-16 02:17:00'), 'Creatinine'], [50931, Timestamp('2118-10-16 01:23:00'), Timestamp('2118-10-16 02:17:00'), 'Glucose'], [50934, Timestamp('2118-10-16 01:23:00'), Timestamp('2118-10-16 02:17:00'), 'H'], [50947, Timestamp('2118-10-16 01:23:00'), Timestamp('2118-10-16 02:17:00'), 'I'], [50960, Timestamp('2118-10-16 01:23:00'), Timestamp('2118-10-16 02:17:00'), 'Magnesium'], [50970, Timestamp('2118-10-16 01:23:00'), Timestamp('2118-10-16 02:17:00'), 'Phosphate'], [50971, Timestamp('2118-10-16 01:23:00'), Timestamp('2118-10-16 02:17:00'), 'Potassium'], [50983, Timestamp('2118-10-16 01:23:00'), Timestamp('2118-10-16 02:17:00'), 'Sodium'], [51006, Timestamp('2118-10-16 01:23:00'), Timestamp('2118-10-16 02:17:00'), 'Urea Nitrogen'], [51678, Timestamp('2118-10-16 01:23:00'), Timestamp('2118-10-16 02:17:00'), 'L'], [51237, Timestamp('2118-10-16 01:23:00'), Timestamp('2118-10-16 02:00:00'), 'INR(PT)'], [51274, Timestamp('2118-10-16 01:23:00'), Timestamp('2118-10-16 02:00:00'), 'PT'], [51275, Timestamp('2118-10-16 01:23:00'), Timestamp('2118-10-16 02:00:00'), 'PTT'], [50802, Timestamp('2118-10-16 01:29:00'), Timestamp('2118-10-16 01:32:00'), 'Base Excess'], [50804, Timestamp('2118-10-16 01:29:00'), Timestamp('2118-10-16 01:32:00'), 'Calculated Total CO2'], [50808, Timestamp('2118-10-16 01:29:00'), Timestamp('2118-10-16 01:33:00'), 'Free Calcium'], [50813, Timestamp('2118-10-16 01:29:00'), Timestamp('2118-10-16 01:33:00'), 'Lactate'], [50818, Timestamp('2118-10-16 01:29:00'), Timestamp('2118-10-16 01:32:00'), 'pCO2'], [50820, Timestamp('2118-10-16 01:29:00'), Timestamp('2118-10-16 01:32:00'), 'pH'], [50821, Timestamp('2118-10-16 01:29:00'), Timestamp('2118-10-16 01:32:00'), 'pO2'], [52033, Timestamp('2118-10-16 01:29:00'), Timestamp('2118-10-16 01:30:00'), 'Specimen Type']]

Question: A 29 M is admitted. He/she says he/she has S/p MVC ___: Left-I&D tibia and knee wounds, Left-Removal of external fixator, Left-IM nail femur, retrograde, Left-IM nail tibia antegrade, closed reduction right index MCP joint ___: Left humerus ORIF, Right ankle ORIF ___: Closed reduction and pinning right ___ metacarpophalangeal joint dislocations, ORIF right hand ___ digit metacarpophalangeal joint irreducible dislocation . History of illness: This patient is a ___ year old male with unknown medical history who complains of MVC. He was driving his car when he was involved in a high-speed head on collision. Prolonged extrication. Unknown if he was restrained. He had a GCS of 3 and was intubated on scene. He was brought in to ___ from the scene by med flight, and received blood and IVF en route. They reported a L femur fracture, tibia/fibula fractures, head injury, and a L humorous fracture. HPI is limited due to intubation and mental status. Past Medical History: PMH: None PSH: Wisdom teeth extraction, Appendectomy (early ___ Social History: ___ Family History: Family History: Non-Contributory Allergies: No Known Allergies / Adverse Drug Reactions What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Dextrose 50% SW Potassium Chloride Sodium Chloride 0.9% Flush 0.9% Sodium Chloride Calcium Gluconate Bag Magnesium Sulfate 0.9% Sodium Chloride PHENYLEPHrine Sodium Chloride 0.9% Fentanyl Citrate Propofol Glucose Gel Insulin Soln Fentanyl Citrate Sodium Chloride 0.9% 0.9% Sodium Chloride LevETIRAcetam Rocuronium Lidocaine Jelly 2% (Glydo) Sodium Chloride 0.9% SW Potassium Chloride Famotidine Glucagon Mouth Care Oral Rinse Bag Magnesium Sulfate SW Potassium Chloride 5% Dextrose CeFAZolin SW Potassium Chloride 0.9% Sodium Chloride Calcium Gluconate 0.9% Sodium Chloride Calcium Gluconate Sodium Chloride 0.9% Flush Iso-Osmotic Sodium Chloride Famotidine Rocuronium Target Lab Orders: Base Excess Calculated Bicarbonate, Whole Blood Calculated Total CO2 Chloride, Whole Blood Free Calcium Glucose Intubated Lactate pCO2 pH pO2 Potassium, Whole Blood Sodium, Whole Blood Ventilator Base Excess Calculated Total CO2 Carboxyhemoglobin Chloride, Whole Blood Free Calcium Glucose Hematocrit, Calculated Hemoglobin Lactate Methemoglobin Oxygen Saturation pCO2 pH pO2 Potassium, Whole Blood Sodium, Whole Blood Specimen Type Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells RDW-SD INR(PT) PT PTT Anion Gap Bicarbonate Calcium, Total Chloride Creatinine Estimated GFR (MDRD equation) Glucose H I Magnesium Phosphate Potassium Sodium Urea Nitrogen L Base Excess Calculated Total CO2 Free Calcium Lactate pCO2 pH pO2 Specimen Type Hematocrit Hematocrit Hematocrit Base Excess Calculated Total CO2 Lactate pCO2 pH pO2 Specimen Type Hematocrit Hemoglobin MCH MCHC MCV Platelet Count Platelet Smear RDW Red Blood Cells White Blood Cells RDW-SD Anion Gap Bicarbonate Calcium, Total Chloride Creatinine Glucose H I Magnesium Phosphate Potassium Sodium Urea Nitrogen L INR(PT) PT PTT Base Excess Calculated Total CO2 Free Calcium Lactate pCO2 pH pO2 Specimen Type Target Procedures: Reposition Left Lower Femur with External Fixation Device, Percutaneous Approach Reposition Right Tibia with External Fixation Device, Percutaneous Approach Reposition Left Tibia with External Fixation Device, Percutaneous Approach Repair Left Lower Leg Subcutaneous Tissue and Fascia, Open Approach Insertion of Internal Fixation Device into Left Tibia, Percutaneous Approach Reposition Left Femoral Shaft with Intramedullary Internal Fixation Device, Percutaneous Approach Reposition Left Tibia with Intramedullary Internal Fixation Device, Percutaneous Approach Respiratory Ventilation, Greater than 96 Consecutive Hours Repair Right Foot Subcutaneous Tissue and Fascia, Percutaneous Approach Reposition Right Metacarpophalangeal Joint, External Approach Removal of External Fixation Device from Left Femoral Shaft, External Approach Removal of External Fixation Device from Left Tibia, External Approach Reposition Right Metacarpophalangeal Joint, External Approach DOCTOR'S NOTE Hospital Notes: : Patient presented to the ED on ___. He was admitted to the ___ on ___. He had a ___ J collar in place per spine recs, was kept NWB at LLE and RLE and given ancef per ortho recs, received a R ankle CT non con for operative planning, and eventually went to OR for Left knee irrigation and debridement, left leg irrigation and debridement of an open fracture, application of multiplanar spanning external fixator from the left femur to the left ankle, irrigation and debridement of a right open ankle fracture, placement of a multiplanar external fixator in the right lower leg, immobilization of the left midshaft humerus fracture. See operative note for details. Patient had repeat head CT per neurosurgery that was stable. He was kept on ancef until full operative fixation by orthopedics. He had a CTA neck that showed no dissection. On ___, patient went to OR again for IM of L femur, L tibia, and closed reduction of index MCP joint. He had serial hematocrits checked given concern for splenic bleed. With decrease in his hematocrit, he had a CTA torso that showed no active extravasation. On ___ ___, his ancef was discontinued per orthopedic recs. He was started on tube feeds. On ___, he spiked a fever at 101.3. He was pan cultured which yielded negative. On ___, his OGT was replaced with an NGT. He received some lasix for diuresis with goal net negative 1.5 liters. His H/H continued to slowly downtrend and he received pRBC as needed. On ___, he continued diuresis with weaning of vent as tolerated. He spiked another fever T 102, repeat blood cultures were sent. On ___, he had MRI C spine that showed suspected cervical ligamentous injury. He continued to spike fevers, thought to be central. On ___ he was extubated. On ___ he continued to tolerate extubation. There was concern for some erythema at LUE wound, but this improved overtime. He was started on vanc/cefepime for fever. On ___, patient was continued on antibiotics and did not spike any additional fevers. His foley catheter was also discontinued. He was transferred to the floor for further care. The patient arrived to the floor in stable condition. He was noted to be lethargic/somnolent on ___ so his standing Seroquel was discontinued. He had a repeat head CT, which was stable from previous one. He failed his void trial x 3, so a foley catheter was reinserted on ___. Overnight, he had pulled out his NGT (for nutrition/TF) due to restlessness. He was re-evaluated by the speech language pathologist on ___, who cleared him for a ground pureed diet with nectar thick liquids and 1:1 supervision, so it was decided that his NGT would not need to be replaced. He was eventually upgraded to a soft diet with nectar thick liquids on ___. There was concern for surgical site infection due to his erythema around his right ankle surgical incision, persistent leukocytosis, and intermittent fevers. The orthopedic surgery team, who had been following the patient post-operatively, were by the bedside to look at surgical incisions and were not concerned. The patient's foley was removed on ___ and he was still having urinary retention but this subsequently resolved by ___ when he was voiding on his own. A UA was sent but came back negative. On ___, he was noted to have a persistent right ___ MCP joint dislocation. The hand team was re-consulted and it was decided they would take him to surgery for reduction and stabilization. On ___, he finished his 7 day course of empiric antibiotic therapy. He was also seen by the ___ service for his severe TBI and polytrauma with recommendations for medication adjustment for his TBI. He went to the OR with the hand surgery service on ___ and had a close reduction and pinning of ___, and ___ MCP joint and ORIF of ___ MCP joint. He tolerated the procedure well and returned to the floor hemodynamically stable. On ___, the patient had his 2-week post-operative xrays completed per the orthopedic team. The patient was re-evaluated by speech and swallow on ___ and was upgraded to thin liquids. He was otherwise doing well. He had repeat C-Spine films done on ___ while upright with the hard C-Collar on. He was complaining of left ankle pain on ___. A left ankle xray was ordered and showed post-operative changes, but nothing acute. He continued to work with physical therapy and occupational therapy, who recommended acute rehabilitation when medically cleared for discharge. Case management was working on obtaining medical insurance for the patient. On ___, per ortho-spine the patient was cleared to take the ___ J collar off for hygiene care (short periods) but will need to keep the collar on for one more month with follow up. On ___, Seroquel was discontinued since the patient was no longer having periods of agitation. He was also started on gabapentin for some nerve pain in his lower extremities. Gabapentin was then tirated up to 900 tid with nortryptaline, Case management continued to work on insurance approval and rehab bed placement. On ________ his insurance was approved and he was offered placement at ________ which he accepted. During this hospitalization, the patient voided without difficulty and worked with physical therapy as much as he could tolerate. The patient was adherent with respiratory toilet and incentive spirometry and actively participated in the plan of care. The patient received subcutaneous heparin for VTE prophylaxis. At the time of discharge, the patient was doing well. He was afebrile and his vital signs were stable. The patient was tolerating a regular diet, voiding without assistance, and his pain was well controlled. The patient was discharged to rehab to continue his recovery. Discharge teaching was completed and follow-up instructions were reviewed with reported understanding and agreement. Facility: ___ Other Results: CHEST (SINGLE VIEW) Study Date of ___ Endotracheal tube terminates 5.2 cm above the carina. Bilateral airspace opacities, left greater than right wall are consistent with pulmonary contusions. Rib fractures better assessed on previous CT of the chest. CT C-SPINE W/O CONTRAST Study Date of ___ 1. Comminuted fracture of the right transverse process of C2 without evidence of displaced fragments extending into the right transverse foramina. However, the fracture lucencies do extend to the anterior margins of the foramina. 2. No evidence of traumatic malalignment. CT HEAD W/O CONTRAST Study Date of ___ 1. Right thalamic hemorrhage with extension into the right lateral ventricle, with dependent hemorrhage in the occipital horn. Mild effacement of the right lateral ventricle is identified secondary to edema of the right thalamus. 2. Small hyperdensity of the left frontal lobe, which appears to be either sulcal were cortical in nature, representing either subarachnoid hemorrhage or contusion. 3. There are subtle sulcal hyperdensities involving the left temporoparietal lobe, which may represent an additional region of subarachnoid hemorrhage. 4. Additional regions of trace hyperdensity overlying the right frontal convexity and bilateral sylvian fissures may represent additional regions of extra-axial hemorrhage versus volume averaging. 5. The basilar cisterns remain patent. There is mild bilateral tonsillar ectopia, which could be congenital in nature. However, close attention on follow-up is recommended to exclude developing cerebral edema. 6. Comminuted fracture of the nasal bone. No evidence of skull fracture. CT CHEST W/CONTRAST Study Date of ___ 1. Multiple splenic lacerations measuring up to 2.4 cm with an adjacent large perisplenic hematoma. Foci of hyperdensity adjacent to the laceration may represent active extravasation. Small volume free-fluid in the pelvis consistent with hemorrhage. 2. Multiple bilateral pulmonary contusions. 3. Multiple fractures of the lumbar spine as described above. Multiple Left rib fractures 8 through 11 and right ribs 6 through 8. Minimally displaced right inferior pubic ramus fracture. 4. Undescended bilateral testicles. TIB/FIB (AP & LAT) LEFT Study Date of ___ Transverse fracture through the left tibia with medial displacement. FEMUR (AP & LAT) LEFT Study Date of ___ Comminuted midshaft fracture of the left femur with lateral displacement. Concern for possible left knee dislocation. HUMERUS (AP & LAT) LEFT Study Date of ___ Transverse fracture through the midshaft of the left humerus lateral displacement. FOREARM (AP & LAT) RIGHT Study Date of ___ No fracture. TIB/FIB (AP & LAT) RIGHT Study Date of ___ Mildly displaced transverse fracture through the distal fibula. Additional comminuted fractures through the lateral and medial malleolus. HAND (PA,LAT & OBLIQUE) LEFT Study Date of ___ Normal left hand hand radiographs. CHEST (PORTABLE AP) Study Date of ___ Interval placement of right subclavian line terminates at the brachiocephalic junction. No evidence pneumothorax. LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST Study Date of ___ Intraoperative images were obtained during internal fixation of the femoral fracture. Please refer to the operative note for details of the procedure. CT HEAD W/O CONTRAST Study Date of ___ 1. Mild increase in sulcal effacement compared to prior with patent basal cisterns, concerning for worsening cerebral edema. 2. Slight interval decrease in size of a right thalamic hemorrhage with intraventricular extension, with dependent hemorrhage in bilateral occipital horns, and mild effacement of the right lateral ventricle. 3. Redistribution of subarachnoid hemorrhage with concentration along left frontoparietal lobe and in the interpeduncular cistern. 4. Additional areas of hyperdensity along the left frontal lobe and right frontoparietal lobe may represent subarachnoid hemorrhage or volume averaging. CT LOW EXT W/O C RIGHT Study Date of ___ 1. Status post interval external fixation of the right ankle with streak artifacts from the hardware limiting diagnostic evaluation. 2. Comminuted fracture of the talus neck extending to the subtalar joint and sinus tarsi with multiple fracture fragments in the sinus tarsi and posterior subtalar joint. 3. Comminuted fractures through the medial and lateral malleoli with intra-articular extension. There is associated fracture fragments and joint effusion within the tibiotalar joint. 4. Anterior subluxation of the talus with respect to the tibia. 5. Extensive subcutaneous edema/hematoma, subcutaneous air, and skin defect could be posttraumatic and/or post surgical. CTA NECK W&W/OC & RECONS Study Date of ___ 1. No evidence of dissection. 2. Patent bilateral cervical carotid and vertebral arteries without evidence of stenosis, occlusion. 3. Unchanged fracture of the right C2 transverse process, better depicted in the dedicated CT of the cervical spine dated ___. HAND (PA,LAT & OBLIQUE) RIGHT PORT Study Date of ___ Dislocations of the second through fifth MCP is in a ulnar and dorsal direction. No acute fracture identified. CTA ABD & PELVIS Study Date of ___ 1. Redemonstration of grade 2 splenic lacerations with perisplenic hematoma without significant interval change. No evidence of active arterial extravasation. 2. New small volume hemoperitoneum. No evidence of active extravasation. 3. Partially imaged known hyperdense left upper lobe consolidation consistent with pulmonary hemorrhage/contusion or aspiration of blood. 4. Redemonstration of small bilateral pleural effusions with associated compressive atelectasis. Intermediate density of left pleural effusion suggests a component of hemorrhagic pleural effusion. 5. Redemonstration of multiple fractures including ribs, lumbar spine, and right inferior pubic ramus. No evidence of new additional acute fractures. HAND (PA,LAT & OBLIQUE) RIGHT PORT Study Date of ___ In comparison with the study of ___, the dislocations of the second-fifth MCP joints are again seen though it is difficult to compare due to different obliquities of the hands. Further information can be from the operative report. CT HEAD W/O CONTRAST Study Date of ___ 1. Overall, no significant change compared to most recent non-contrast head CT dated ___. 2. There is a similar-appearing 1.0 cm right thalamic intraparenchymal hemorrhage with intraventricular extension and mass-effect on the right lateral ventricle again seen. 3. Subarachnoid hemorrhage again seen in the left frontoparietal lobe, unchanged in extent and distribution. CTA ABD & PELVIS Study Date of ___ 1. Interval development of a right neck hematoma, superior mediastinal hematoma and anterior mediastinal hematoma. 2. Minor effacement of the normal anterior convexity of the right and left ventricles suggesting a degree of mass-effect from anterior mediastinal hematoma. 3. Small volume pneumomediastinum, likely to be related to traumatic line placement. 4. Interval increase in size of bilateral pleural effusions. 5. Moderate increase in hemoperitoneum is noted. 6. Stable perisplenic hematoma. No evidence of active extravasation of contrast and no splenic artery pseudoaneurysm is seen. Transthoracic Echocardiogram Report: ___ No pericardial effusion. Normal left ventricular wall thickness and biventricular cavity sizes and regional/global biventricular systolic function. Mild pulmonary hypertension. Leftpleural effusion. CHEST (PORTABLE AP) Study Date of ___ Lines and support devices not significantly changed since the prior study. There is stable mild cardiomegaly with bilateral pleural effusion and pulmonary vascular congestion. No pneumothorax. CHEST (PORTABLE AP) Study Date of ___ Endotracheal tube has been removed. Nasogastric tube is unchanged in position. There is improved aeration of the right paratracheal region since prior. There has been decrease in the bilateral pleural effusions. There remains a left retrocardiac opacity and subsegmental atelectasis at the lung bases. There are no pneumothoraces. UNILAT UP EXT VEINS US LEFT PORT Study Date of ___ No evidence of deep vein thrombosis in the left upper extremity. CT HEAD W/O CONTRAST Study Date of ___ 1. No definite evidence of new intracranial hemorrhage or acute large territorial infarction. 2. Expected interval evolution of previously seen right thalamic hemorrhage, now demonstrating small focus of edema and minimal residual blood products. 3. Small amount of residual blood products layering within the occipital horns of the lateral ventricles. 4. Slightly increased prominence of the right frontal subdural space demonstrates near CSF density, likely consistent with subdural hygroma. HAND (PA,LAT & OBLIQUE) RIGHT Study Date of ___ Persistent/recurrent dorsal dislocation of the small finger MCP joint. Second through fourth MCP joints appear congruent. HUMERUS (AP & LAT) LEFT Study Date of ___ There is a fracture plate with associated screws fixating a transverse fracture through the distal shaft of the left humerus. Small letter butterfly fragment is seen. Fracture line is still well visualized. No definite hardware related complications are present. ANKLE (AP, MORTISE & LAT) RIGHT Study Date of ___ There is an overlying fiberglass cast which limits fine bony detail. Hardware within the distal fibula and tibia including syndesmotic screws are seen. There are also two screws within the talus fixating a talar neck fracture. No hardware related complications are seen. There is good anatomic alignment. Fractures of the distal shaft of the fibula and of the distal fibular tip are also seen. TIB/FIB (AP & LAT) LEFT Study Date of ___ There is an intramedullary rod proximal distal interlocking screws fixating a transverse fracture involving the distal shaft of the tibia. There is a paucity of bridging callus. No new fractures are seen. Portion of the intramedullary rod in the distal femur is visualized on the edge of the film. FEMUR (AP & LAT) LEFT Study Date of ___ There has been placement of a retrograde intramedullary rod with proximal and distal interlocking screws fixating a comminuted fracture of distal left femoral shaft. There are no signs for hardware related complications. There is prominent soft tissue swelling about the fracture site. C-SPINE NON-TRAUMA ___ VIEWS Study Date of ___ Static AP and lateral views of the cervical spine were obtained. See 1 through C7 were visualized on the lateral. There is straightening of the normal cervical lordosis. No prevertebral soft tissue swelling. No fracture or subluxation. No flexion and extension views were included in the exam. ANKLE (AP, MORTISE & LAT) LEFT Study Date of ___ Postoperative changes reflect intramedullary rod fixation tibia. Hardware is intact. There is narrowing no periprosthetic lucency. Comminuted fracture of mid to distal left tibial diaphysis is again seen. No substantial is appreciated. The mortise is congruent. Duplex US: IMPRESSION: No evidence of deep venous thrombosis in the left lower extremity veins. Xray R hand: The patient is post interval reduction and pinning of the right second through fifth metacarpophalangeal joints. Overlying splint material obscures fine osseous detail. The hand at the level of the MCPs and interphalangeal joints is in flexion. No obvious dislocation. No evidence of hardware related complications..

2157-03-08 21:05:00

ENGLISH

UNKNOWN

M

[[26784490, Timestamp('2157-03-08 21:05:52'), '', 'TRAUM']]

[[{'Medications on Admission': ':\nAsa 325mg po \nProzac 80 \nNeurontin 900 tid \nClonazepam 1 tid \nRisperidone 0.25 bid', 'Brief Hospital Course': ":\n___: The patient was admitted to the Trauma ICU from the ED. He \nwas initially maintained on an oxygen facemask. Neurosurgey was \nconsulted for his SAH and SDH and felt reimaging the next day \nwas appropriate and surgical intervention was not intubated at \nthat time. His head CT was repeated and showed just \nredistribution of blood.\n\n___: Epidural placement was attempt for discomfort and \ndifficulty breathing but the patient was unable to tolerate \nprocedure. His respiratory status worsened with desaturations \ndespite 100% O2 facemask and he was ultimately intubated for \nairway protection. \n\n___: A left sided paravertebral catheter was placed to help with \npain control given desaturations on CPAP ventilator mode. His \npost-placement CXR demonstrated worsening of his previously seen \nleft sided pneumothorax and a left sided chest tube was placed \nwith 300cc of old blood out and improvement in his pneumothorax.\n\n___: A repeat head CT was obtained given change in mental status \nwhich was unrevealing, and neurology was consulted. A head MRI \nwas obtained which demonstrated moderate ___. The patient was \nminimally responsive at that time and mental status failed to \nsignificantly improve throughout the rest of his \nhospitalization. Sputum cultures were sent which demonstrated \nH.influenza and moderate streptococcus pneumonia, and he was \nstarted on levaquin. He continued to spike fevers and was \nchanged to vanco and zosyn. Free water flushes were added for \nhypernatremia.\n\n___: A family meeting was held and the patient was made DNR with \nno further escalation in care. He respiratory status continued \nto decline with inability to tolerate CPAP and thick secretions.\n\n___: Propofol was added for dysynchrony on the ventilator - \nsedatives had previously been held for concern for depressed \nmental status. Discussions were made to hold a family meeting \non ___.\n\n___: His paravertebral catheter was dc'ed and fentanyl and \noxycodone were added. His chest tube was dc'ed. His tube feeds \nwere held for high residuals.\n\n___: His respiratory status continued to worsen despite \ndiuresis. He continued to be unable to tolerate tube feeds.\n\n___: A family meeting was held with the patient's daughter, \ngrandchildren and girlfriend. The decision was made to make the \npatient CMO with terminal extubation. The patient expired \nshortly thereafter.\n\n", 'Pertinent Results:': '\nCT head (___): Left tentorial and parafalcine subdural \nhemorrhage and left frontal and parietal subarachnoid \nhemorrhage. Punctate amount of intraventricular hemorrhage \nwithin the left occipital horn. \n\nCT cspine (___): No acute fracture or malalignment; no \nsignificant canal stenosis.\n\nCT torso (___): Small left hemopneumothorax with extensive \nleft-sided rib fractures including segmental fractures of ribs \ntwo through six, as well as rib eight. Mildly displaced \nfracture of the inferior body of the left scapula. Comminuted \nleft distal clavicular fracture. 4.8 x 4.6 cm infrarenal aortic \naneurysm. Mild pulmonary edema with bibasilar atelectasis. \n\nCT head (___): Partial interval resorption and/or \nredistribution of left frontal lobe subarachnoid hemorrhage. \nTiny layering hemorrhage within the occipital horns of the \nlateral ventricles is new on the right and increased on the \nleft. New right frontal lobe hyperdensity could be represent \nredistributed SAH or a small focus of parenchymal hemorrhage at \nthe grey-white matter junction, perhaps secondary to diffuse \naxonal ("shear") injury. SDH overlying the left leaflet of the \ntentorium cerebelli is unchanged, while parafalcine SDH is \ndecreased. \n\nCT head (___): No new acute intracranial hemorrhage or major \nvascular territory infarction. Interval \nredistribution/resorption of subarachnoid and subdural \nhemorrhage. Probable minimal increase in blood products within \nthe occipital horn of the left lateral ventricle. Possible shear \ninjury involving the posterior corpus callosum. Consider MRI for \nfurther evaluation as clinically indicated. \n\nMRI head (___): Subarachnoid and subdural blood products \nidentified as on the prior CT. Signal changes in the splenium of \ncorpus callosum, left frontal lobe as well as susceptibility \nabnormalities along the gray-white matter junction are \nsuggestive of diffuse axonal injury. No territorial infarcts are \nseen. \n\nCXR (___): ET tube is in standard placement, no less than 7 \ncm from the carina, although it is at the level of the lower \nmargin of the clavicles. Pulmonary edema superimposed on \nresidual abnormalities in both lungs due to ARDS and multifocal \npneumonia has improved slightly since earlier today. Small right \npleural effusion is likely. Heart size is top normal and \nmediastinal veins are still distended. No pneumothorax. \nNasogastric tube passes into the stomach and out of view. \n\n', 'Physical Exam:|Physical': '\n(on admission)\n\nGen: C-spine collar,lethargic but easily arousable, cooperative\nwith exam\nHEENT: few abrasians\nNeck: Hard Collar\nLungs: Decreased breath sounds on the left with occ. Wheeze\nCardiac: RRR. S1/S2.\nAbd: Soft, NT, BS+\nExtrem: Warm and well-perfused.\nNeuro:\nMental status: Lethargic but arousable\nOrientation: Oriented to self only, spells first and last name,\nconfused to place, time, president\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\n___ yo male with hx of dementia, CAD, recent falls transferred \nfrom an OSH after sustaining an unwitnessed fall on ___ \n___. Patient was found down in the garden and does not \nrecall event. At OSH, patient was found to have a SDH and SAH as \nwell as multiple rib fx. Patient was transferred to ___ for \nfurther management. Upon arrival here, patient was pan scanned \nand seen by neurosurgery. He was loaded with keppra. His TLS \nspine was cleared but his c-spine is still in a collar. Patient \nalso has significant EtOH hx per report, though EtOH negative \nhere. Per further discussion with the family it seemed as \nthough there was a ladder nearby and he may have fallen and then \ntried to walk home before collapsing. His toxicology screen on \nadmission was negative.\n\nINJURIES: \nSm L PTX and apical HTX \nL medial rib fxs ___ \nL ___ rib fxs ___ at trans proc artic \nL tentorial and inf sagittal sinus SDH \nL fronto-parietal SAH \nL clavicular fx close to scapula \nMildly displaced fracture of inferior left scapula \n\nPast Medical History:\nPMH: CAD, MI, infrarenal AAA (5x4.6cm), congenital single R \nkidney, h/o past falls\n\nPSH: Cardiac stents\n\nSocial History:\n___\nFamily History:\nNon-contributory\n\n', 'Chief Complaint:|Complaint:': '\nPolytrauma - found down likely after fall from ladder\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nNo Known Allergies / Adverse Drug Reactions\n\n'}, '12332280-DS-10', 10, 'surgery']]

[['INDICATION: Trauma.\n\nCOMPARISON: None.\n\nSUPINE AP VIEW OF THE CHEST: Overlying trauma board limits evaluation. \nCardiac silhouette is mildly enlarged. There is widening of the mediastinum,\nand indistinctness of the aortic arch. Small amount of fluid is seen\noverlying the left apex. Increased interstitial opacities are noted\nbilaterally which suggests mild pulmonary edema. Multiple left sided rib\nfractures are noted. No sizable pneumothorax is present. Displaced left\ndistal clavicular fracture is also visualized.\n\nIMPRESSION: Multiple bilateral rib fractures with left apical fluid, likely\nhemothorax. Indistinctness of the aortic arch and widening of the mediastinum\nfor which aortic injury is not excluded. Left clavicular fracture. Chest CTA\nis recommended for further evaluation.\n', '12332280-RR-21', 21, ''], ['INDICATION: ___ man found down. Please assess for traumatic injury\non outside hospital CT torso.\n\nCOMPARISON: None available.\n\nTECHNIQUE: MDCT images were acquired through the chest, abdomen and pelvis\nwith IV contrast at an outside hospital. Multiplanar reformations were\nobtained and reviewed.\n\nCT OF THE CHEST WITH IV CONTRAST:\n\nThe thyroid gland is unremarkable. There is no axillary or mediastinal\nlymphadenopathy by CT size criteria. The heart and great vessels are\nunremarkable. There are coronary artery calcifications and a stent is noted\nin the proximal LAD. No pericardial effusions or anterior mediastinal\nhematoma is present.\n\nSmall left hemothorax is present with a loculated component in the left apex.\nNo pneumomediastinum is present.\n\nThe lungs show mild bilateral ground-glass opacity with interlobular septal\nthickening. There is a small left pneumothorax as well as small likely\nloculated apical pneumothorax. Bilateral lower lobe opacitis likely reflect\natelectasis, with the airways demonstrating mild wall thickening and probable\nmucus plugging in both lower lobes.\n\nCT OF THE ABDOMEN WITH IV CONTRAST:\n\nThe liver has a granuloma in segment VIII (2:45). Also noted are multiple\nhypodensities in the liver (2:52 and 46), which most likely represent cysts. \nThe spleen, both adrenals, pancreas, and gallbladder are unremarkable. The\nright kidney has an exophytic simple cyst within its upper pole (2:58). The\nleft kidney is developmentally absent. No abdominal, retroperitoneal, or\nmesenteric lymphadenopathy by CT size criteria is present. No abdominal free\nfluid or free air is present. The small and large bowel loops are\nunremarkable. There is a 4.8 x 4.6 cm infrarenal aortic aneurysm with mural\nthrombus. The celiac, SMA, and ___ are patent. The common left iliac artery is\naneurysmally dilated to 2.4 cm. Scattered atherosclerotic disease is noted\nwithin the aorta and iliac branches.\n\nCT OF THE PELVIS WITH IV CONTRAST:\n\nThe rectum, bladder, and prostate are unremarkable. There is a Foley catheter\nwithin the bladder. Sigmoid colon shows diverticulosis without\ndiverticulitis. There are simple bilateral fat-containing inguinal hernias.\n\nOSSEOUS STRUCTURES:\n\nThere is a comminuted fracture of the distal left clavicle. In addition, also\nnoted is a mildly displaced fracture of the inferior body of the left scapula.\nThere are fractures of the left first through tenth ribs including segmental\nfractures of the left second through sixth ribs, as well as eighth rib, with\nfractures identified through the proximal aspects of the second through sixth\nribs at their articulation with the transverse processes. The left fifth rib\nalso has an anterior fracture causing the presence of a butterfly segment in\nthe mid portion. No vertebral body fractures or pelvic fractures are noted.\n\nIMPRESSION:\n\n1. Small left hemopneumothorax with extensive left-sided rib fractures\nincluding segmental fractures of ribs two through six, as well as rib eight.\n\n2. Mildly displaced fracture of the inferior body of the left scapula.\n\n3. Comminuted left distal clavicular fracture.\n\n4. 4.8 x 4.6 cm infrarenal aortic aneurysm.\n\n5. Mild pulmonary edema with bibasilar atelectasis.\n', '12332280-RR-22', 22, 'mdct images were acquired through the chest, abdomen and pelvis\nwith iv contrast at an outside hospital. multiplanar reformations were\nobtained and reviewed.'], ['INDICATION: ___ man found down. Please assess for traumatic injury.\n\nCOMPARISON: None available.\n\nTECHNIQUE: MDCT images were acquired through the head without contrast. Bone\nkernel reconstructions and multiplanar reformations were obtained and\nreviewed.\n\nFINDINGS:\n\nThere is a parafalcine and left tentorial subdural hemorrhage. Also noted is\na left frontal and parietal subarachnoid hemorrhage. Punctate intraventricular\nhemorrhage is noted within the occipital horn of the left lateral ventricle.\nNo acute large vascular territory infarct, shift of midline structures or mass\neffect is present. The ventricles and sulci are prominent consistent with\nage-related involutional changes. The visible paranasal sinuses and mastoid\nair cells show a mucous retention cyst in the right frontal sinus. There is\nmild hypoattenuation of the subcortical white matter likely representing\nsequelae of small vessel ischemic disease. No fractures are present.\n\nIMPRESSION:\n\nLeft tentorial and parafalcine subdural hemorrhage and left frontal and\nparietal subarachnoid hemorrhage. Punctate amount of intraventricular\nhemorrhage within the left occipital horn.\n', '12332280-RR-23', 23, 'mdct images were acquired through the head without contrast. bone\nkernel reconstructions and multiplanar reformations were obtained and\nreviewed.'], ['INDICATION: ___ male status post fall. Evaluate for fracture or\ndislocation.\n\nCOMPARISON: No prior study available for comparison.\n\nTECHNIQUE: Contiguous axial images were obtained through the cervical spine\nwithout IV contrast. Coronal and sagittal reformats were displayed. \n\nFINDINGS: C1 through T1 are visualized. There is preservation of the\ncervical lordosis and alignment. There is no acute fracture. There is no\nprevertebral soft tissue edema. Mild multilevel degenerative change is noted,\nwith predominantly anterior endplate osteophyte formation and no spinal canal\nstenosis. Though CT is not able to provide intrathecal detail comparable to\nMRI, the visualized outline of the thecal sac is unremarkable.\n\nIMPRESSION: No acute fracture or malalignment; no significant canal stenosis.\n', '12332280-RR-26', 26, 'contiguous axial images were obtained through the cervical spine\nwithout iv contrast. coronal and sagittal reformats were displayed.'], ["CHEST RADIOGRAPH\n\nINDICATION: Multiple rib fractures, pneumothorax, evaluation for interval\nchange.\n\nCOMPARISON: No comparison available at the time of dictation.\n\nFINDINGS: Multiple displaced left lateral rib fractures, as documented on a\nCT examination from ___, 7:07 p.m. Moderate left pleural effusion\nand left apical pleural thickening, but without evidence of abnormalities at\nthe level of the aortic arch. These findings are unchanged as compared to\nyesterday's CT. Also unchanged are bilateral parenchymal opacities. On\ntoday's examination, no overt pneumothorax is seen. Moderate cardiomegaly.\n", '12332280-RR-27', 27, ''], ['INDICATION: Status post recent fall with subdural and subarachnoid hematoma. \nEvaluate interval change.\n\nTECHNIQUE: Sequential axial images were acquired through the head without\nadministration of intravenous contrast.\n\nCOMPARISON: CT head from ___.\n\nFINDINGS: Since the prior study approximately 15 hours ago, there has been\nslight interval resorption or redistribution of subarachnoid hemorrhage\noverlying the left frontal lobe and within the parafalcine region. A tiny\nquantity of hemorrhage within the occipital horn of the left lateral ventricle\nis increased while a similar quantity of hemorrhage within the occipital horn\nof the right lateral ventricle is new. There may be a tiny focus of right\nfrontal lobe subarachnoid hemorrhage or focal intraparenchymal hemorrhage at\nthe grey-white matter junction (2:26), new since the prior study. Parafalcine\nSDH is decreased, while SDH overlying the left leaflet of the tentorium\ncerebelli is not significantly changed. \n\nThere is no evidence of acute large vascular territorial infarction, change in\nventricular size or configuration, edema, or shift of normally midline\nstructures. There is no uncal or transtentorial herniation. Slight asymmetry\nof the ventricular size, left greater than right, is likely\ncongenital/developmental in etiology. Opacification of multiple bilateral\nethmoidal air cells is noted. There are mucus retention cysts within the left\nfrontal sinus. The remainder of the visualized portions of the paranasal\nsinuses and mastoid air cells are well aerated. The imaged osseous structures\nare unremarkable.\n\nIMPRESSION:\n\n1. Partial interval resorption and/or redistribution of left frontal lobe\nsubarachnoid hemorrhage. Tiny layering hemorrhage within the occipital horns\nof the lateral ventricles is new on the right and increased on the left.\n\n2. New right frontal lobe hyperdensity could be represent redistributed SAH\nor a small focus of parenchymal hemorrhage at the grey-white matter junction,\nperhaps secondary to diffuse axonal ("shear") injury. \n\n3. SDH overlying the left leaflet of the tentorium cerebelli is unchanged,\nwhile parafalcine SDH is decreased.\n', '12332280-RR-28', 28, 'sequential axial images were acquired through the head without\nadministration of intravenous contrast.'], ['SINGLE AP PORTABLE VIEW OF THE CHEST\n\nREASON FOR EXAM: Multiple rib fractures and left hydropneumothorax. Need\nfollowup.\n\nComparison is made with prior study performed 10 hours earlier.\n\nMild-to-moderate pulmonary edema has minimally improved. Worsening right\nupper lobe opacity at the periphery is worrisome for aspiration. Left lower\nlobe atelectasis has improved. A small left pleural effusion with loculation\nin the apex is unchanged. Cardiomediastinal contours are within normal\nlimits. ET tube tip is 7.3 cm above the carina, can be advanced couple of\ncentimeters for more standard position. NG tube tip is in the stomach.\n', '12332280-RR-29', 29, ''], ['SINGLE AP PORTABLE VIEW OF THE CHEST\n\nREASON FOR EXAM: Assess ET tube.\n\nComparison is made with prior study performed the same day earlier in the\nmorning.\n\nNew ET tube is in standard position. The tip is 6.9 cm above the carina. NG\ntube tip is in the stomach, but the sidehole is at the GE junction and should\nbe advanced. A widened mediastinum has improved. Mild cardiomegaly is\nstable. Diffuse pulmonary opacities consistent with mild-to-moderate\npulmonary edema are unchanged. Left lower lobe atelectasis is stable. Left\nsmall pleural effusion is stable. Loculation of the left pleural effusion at\nthe apex is again noted.\n', '12332280-RR-30', 30, ''], ['AP CHEST, 6:12 A.M., ON ___\n\nHISTORY: ___ man with multiple fractures and subdural hematoma,\nintubated for respiratory failure. Evaluate for interval change particularly\natelectasis.\n\nIMPRESSION: AP chest compared to ___ and ___:\n\nPulmonary edema which developed between ___ and ___ subsequently\nimproved and now has worsened again, making the right upper lobe consolidation\nwhich developed on ___ less obvious. Left lower lobe consolidation has\nimproved over the past two days, and was presumably atelectasis. The initial\nleft apical hematoma has virtually resolved and there is no large left\nhemothorax in its place. There is new subcutaneous emphysema in the left\nchest wall accompanying the now evident small left apical pneumothorax. Left\nrib fractures posterolateral aspects of the middle ribs are more displaced\nthan previously. ET tube is in standard placement. Nasogastric tube passes\ninto the stomach and out of view. Mediastinal silhouette, previously\nengorged, is now normal.\n', '12332280-RR-31', 31, ''], ['AP CHEST 10:57 ___\n\nHISTORY: Hypoxia.\n\nIMPRESSION: AP chest compared to ___ through ___ at 6:12 a.m.:\n\nMild-to-moderate pulmonary edema and small left apical pneumothorax unchanged\nsince earlier in the day. Heart size normal. ET tube in standard placement. \nNasogastric tube passes into the stomach and out of view.\n', '12332280-RR-32', 32, ''], ['INDICATION: A ___ man with hypoxia, evaluate for DVT.\n\nCOMPARISON: No previous exam for comparison.\n\nFINDINGS: Grayscale, color and Doppler images were obtained of bilateral\ncommon femoral, superficial femoral, popliteal and tibial veins. There is\nnormal flow, compression and augmentation seen in all of the vessels.\n\nIMPRESSION: No evidence of deep vein thrombosis in either leg.\n', '12332280-RR-33', 33, ''], ['REASON FOR EXAMINATION: Evaluation of the patient with multiple rib fractures\nafter trauma.\n\nPortable AP radiograph of the chest was reviewed in comparison to prior study\nobtained the same day earlier.\n\nThere is significant interval increase of pneumothorax, currently moderate to\nlarge with right mediastinal shift worrisome for tension pneumothorax ,\ncompression of left lung and significant subcutaneous air within the left\nchest wall. The rest of the findings are unchanged. Findings were discussed\nwith Dr. ___ over the phone by Dr. ___ at 2:46 p.m. on ___.\n', '12332280-RR-34', 34, ''], ['HISTORY: Enlarging pneumothorax with chest tubes, to evaluate for change.\n\nFINDINGS: In comparison with the study of earlier in this date, there is a\nnew left chest tube with substantial decrease in the degree of pneumothorax. \nSubcutaneous emphysema is again seen on the left. Little change in the\nextensive parenchymal opacifications. Endotracheal tube and orogastric tube\nremain in standard position.\n', '12332280-RR-35', 35, ''], ['INDICATION: ___ male status post traumatic fall with known\nsubarachnoid hemorrhage thought to be resolving presents with worsening mental\nstatus over the last 24 hours. Evaluate for change in intracranial bleeding\nversus stroke.\n\nCOMPARISON: ___.\n\nTECHNIQUE: Contiguous axial images were obtained through the brain without IV\ncontrast.\n\nFINDINGS: There has been expected interval resorption and redistribution of\nblood products layering within the left frontal lobe. Blood products within\nthe left parafalcine region and possibly at the right cranial vertex are less\nconspicuous on the current exam. A small amount of hemorrhage in the occipital\nhorn of the left ventricle may be slightly increased from the prior study. A\ntiny focus of blood products within the right occipital horn is also again\nnoted. An 11 x 10 mm hypodensity in the posterior corpus callosum (2a:18) is\nmore apparent and raises concern for shear injury in the setting of trauma.\nThere is no new hemorrhage or major vascular territory infarction. \n\nPeriventricular white matter hypodensity suggests small vessel ischemic\ndisease. Ventricles and sulci are normal in size. Basilar cisterns are\npreserved.\n\nA mucous retention cyst is noted in the right frontal sinus. There is mucosal\nthickening in the bilateral ethmoid sinuses. The remainder of the visualized\nparanasal sinuses and mastoid air cells are well aerated. No suspicious lytic\nor sclerotic osseous lesion is identified.\n\nIMPRESSION:\n\n1. No new acute intracranial hemorrhage or major vascular territory\ninfarction.\n\n2. Interval redistribution/resorption of subarachnoid and subdural\nhemorrhage. Probable minimal increase in blood products within the occipital\nhorn of the left lateral ventricle.\n\n3. Possible shear injury involving the posterior corpus callosum. Consider\nMRI for further evaluation as clinically indicated.\n\nFindings discussed with Dr. ___ by phone at 8:59 pm on ___.\n', '12332280-RR-36', 36, 'contiguous axial images were obtained through the brain without iv\ncontrast.'], ['EXAM: MRI of the brain.\n\nCLINICAL INFORMATION: Patient with status post fall, intubation for\nrespiratory failure, now with worsening mental status changes. Concern for\nsubdural hematoma, subarachnoid hemorrhage and stroke.\n\nTECHNIQUE: T1 sagittal and FLAIR, T2 susceptibility and diffusion axial\nimages of the brain were acquired. Correlation was made with CT of ___.\n\nFINDINGS: There is a large area of restricted diffusion identified in the\nsplenium of corpus callosum in the midline. Additional tiny areas of\nrestricted diffusion seen in the left frontal subcortical white matter. \nAdditionally, several small areas of susceptibility low signal are seen at the\ngray-white matter junction in the left frontal lobe and parietal lobes as well\nas the left side of the superior cerebellar peduncle. There are blood\nproducts in the ventricles and along the sulci indicating subarachnoid\nhemorrhage. Periventricular hyperintensities as well as hyperintensities in\nthe pons are indicative of small vessel disease. There are soft tissue\nchanges in both mastoid air cells. Soft tissue changes are also seen in the\nright frontal sinus. There are no territorial infarcts identified. Small\nsubdural collection is seen in the left parietooccipital region.\n\nIMPRESSION: Subarachnoid and subdural blood products identified as on the\nprior CT. Signal changes in the splenium of corpus callosum, left frontal\nlobe as well as susceptibility abnormalities along the gray-white matter\njunction are suggestive of diffuse axonal injury. No territorial infarcts\nare seen.\n', '12332280-RR-37', 37, 't1 sagittal and flair, t2 susceptibility and diffusion axial\nimages of the brain were acquired. correlation was made with ct of ___.'], ['HISTORY: Diabetic with fall.\n\nFINDINGS: In comparison with the study of ___, there may be a small apical\npneumothorax. Otherwise, little change.\n', '12332280-RR-38', 38, ''], ['HISTORY: ARDS, to assess for change.\n\nFINDINGS: In comparison with the study of ___, there is little change. \nDiffuse bilateral pulmonary opacifications persist. Left chest tube remains\nin place and there may be a tiny apical pneumothorax. Monitoring and support\ndevices remain in good position.\n', '12332280-RR-39', 39, ''], ['HISTORY: Left chest tube and ARDS.\n\nFINDINGS: In comparison with the study of ___, there again is diffuse\nbilateral pulmonary opacifications bilaterally with left chest tube in place\nand no definite pneumothorax. There is suggestion of some increasing\nopacification at the left base. This could be merely a technical difference\nor be evidence of developing pneumonia in this region.\n', '12332280-RR-40', 40, ''], ['CHEST RADIOGRAPH\n\nINDICATION: ARDS, assessment for interval change.\n\nCOMPARISON: ___.\n\nFINDINGS: As compared to the previous radiograph, there is no relevant\nchange. Bilateral diffuse parenchymal opacities consistent with the clinical\ndiagnosis of ARDS. The opacities are constant in severity and distribution. \nUnchanged position of the left chest tube and of the endotracheal and\nnasogastric tube. Unchanged size of the cardiac silhouette.\n', '12332280-RR-41', 41, ''], ['AP CHEST, 5:01 A.M., ___\n\nHISTORY: ___ man with pneumonia. Intubated.\n\nIMPRESSION: AP chest compared to ___:\n\nThe lung volumes are lower, mediastinal vasculature is more dilated, and\ntherefore a new relatively diffuse interstitial abnormality is most likely\nvolume related pulmonary edema. House staff was paged. ET tube in standard\nplacement. Nasogastric tube passes as far as the lower esophagus and out of\nview. Pleural effusions are presumed but not substantial. No pneumothorax.\n', '12332280-RR-42', 42, ''], ['HISTORY: Left chest tube on waterseal.\n\nFINDINGS: In comparison with the earlier study of this date, with the chest\ntube on waterseal, there is no evidence of pneumothorax. Little change in the\nappearance of the heart and lungs.\n', '12332280-RR-43', 43, ''], ['AP CHEST, 5:07 P.M., ___\n\nHISTORY: Left chest tube removed. Rule out pneumothorax.\n\nIMPRESSION: AP chest compared to ___ through ___, 4:07 p.m.:\n\nNo pneumothorax following removal of the left pleural tube. Pleural effusion\nis minimal if any. Extensive heterogeneous opacification in the right lung\nand left base is improving, probably multifocal pneumonia. ET tube in\nstandard placement. Nasogastric tube can be traced as far as the distal\nesophagus but the tip cannot be seen. Heart size normal.\n', '12332280-RR-44', 44, ''], ['AP CHEST, 9:32 A.M., ___\n\nHISTORY: Check repositioned ET tube.\n\nIMPRESSION: AP chest compared to ___ through ___ at 5:01 a.m.:\n\nET tube is in standard placement, no less than 7 cm from the carina, although\nit is at the level of the lower margin of the clavicles. Pulmonary edema\nsuperimposed on residual abnormalities in both lungs due to ARDS and\nmultifocal pneumonia has improved slightly since earlier today. Small right\npleural effusion is likely. Heart size is top normal and mediastinal veins\nare still distended. No pneumothorax. Nasogastric tube passes into the\nstomach and out of view.\n', '12332280-RR-45', 45, '']]

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[26784490, Timestamp('2157-03-08 22:00:00'), Timestamp('2157-03-17 08:00:00'), 'MAIN', 'Calcium Gluconate', '001356', '63323031110', '1g/10mL Vial'], [26784490, Timestamp('2157-03-09 13:00:00'), Timestamp('2157-03-17 08:00:00'), 'MAIN', 'Albuterol 0.083% Neb Soln', '005039', '49502069724', '0.083%;3mL Vial'], [26784490, Timestamp('2157-03-09 14:00:00'), Timestamp('2157-03-17 08:00:00'), 'MAIN', 'Lorazepam', '003753', '00409198530', '2mg/mL Syringe'], [26784490, Timestamp('2157-03-08 22:00:00'), Timestamp('2157-03-17 08:00:00'), 'BASE', 'SW', '', '0', '100ml Bag'], [26784490, Timestamp('2157-03-08 22:00:00'), Timestamp('2157-03-17 08:00:00'), 'MAIN', 'Potassium Chloride', '015362', '00338070948', '10mEq/100mL Premix'], [26784490, Timestamp('2157-03-09 12:00:00'), Timestamp('2157-03-10 10:00:00'), 'BASE', 'Iso-Osmotic Sodium Chloride', '', '0', '50ml Bag'], [26784490, Timestamp('2157-03-09 12:00:00'), Timestamp('2157-03-10 10:00:00'), 'MAIN', 'Famotidine', '021732', '00338519741', '20mg Premix Bag'], [26784490, Timestamp('2157-03-09 12:00:00'), Timestamp('2157-03-17 08:00:00'), 'MAIN', 'Acetaminophen', '004489', '51079000220', '325mg Tablet'], [26784490, Timestamp('2157-03-08 20:00:00'), Timestamp('2157-03-09 08:00:00'), 'BASE', '0.9% Sodium Chloride', '001210', '00338004938', '100mL Bag'], [26784490, Timestamp('2157-03-08 20:00:00'), Timestamp('2157-03-09 08:00:00'), 'MAIN', 'LeVETiracetam', '061005', '62756051344', '500mg/5mL Vial'], [26784490, Timestamp('2157-03-09 18:00:00'), Timestamp('2157-03-13 10:00:00'), 'MAIN', 'Propofol', '016796', '63323026920', '200mg/20mL Vial'], [26784490, Timestamp('2157-03-08 22:00:00'), Timestamp('2157-03-17 08:00:00'), 'BASE', 'Bag', '', '0', '50 mL Bag'], [26784490, Timestamp('2157-03-08 22:00:00'), Timestamp('2157-03-17 08:00:00'), 'MAIN', 'Magnesium Sulfate', '016546', '00409672924', '2 g / 50 mL Premix Bag']]

[]

['surgery']

[[50868, Timestamp('2157-03-09 01:36:00'), Timestamp('2157-03-09 02:48:00'), 'Anion Gap'], [50882, Timestamp('2157-03-09 01:36:00'), Timestamp('2157-03-09 02:48:00'), 'Bicarbonate'], [50893, Timestamp('2157-03-09 01:36:00'), Timestamp('2157-03-09 02:48:00'), 'Calcium, Total'], [50902, Timestamp('2157-03-09 01:36:00'), Timestamp('2157-03-09 02:48:00'), 'Chloride'], [50908, Timestamp('2157-03-09 01:36:00'), Timestamp('2157-03-10 00:33:00'), 'CK-MB Index'], [50910, Timestamp('2157-03-09 01:36:00'), Timestamp('2157-03-10 00:33:00'), 'Creatine Kinase (CK)'], [50911, Timestamp('2157-03-09 01:36:00'), Timestamp('2157-03-10 00:33:00'), 'Creatine Kinase, MB Isoenzyme'], [50912, Timestamp('2157-03-09 01:36:00'), Timestamp('2157-03-09 02:48:00'), 'Creatinine'], [50931, Timestamp('2157-03-09 01:36:00'), Timestamp('2157-03-09 02:48:00'), 'Glucose'], [50960, Timestamp('2157-03-09 01:36:00'), Timestamp('2157-03-09 02:48:00'), 'Magnesium'], [50970, Timestamp('2157-03-09 01:36:00'), Timestamp('2157-03-09 02:48:00'), 'Phosphate'], [50971, Timestamp('2157-03-09 01:36:00'), Timestamp('2157-03-09 02:48:00'), 'Potassium'], [50983, Timestamp('2157-03-09 01:36:00'), Timestamp('2157-03-09 02:48:00'), 'Sodium'], [51003, Timestamp('2157-03-09 01:36:00'), Timestamp('2157-03-10 00:33:00'), 'Troponin T'], [51006, Timestamp('2157-03-09 01:36:00'), Timestamp('2157-03-09 02:48:00'), 'Urea Nitrogen'], [51221, Timestamp('2157-03-09 01:36:00'), Timestamp('2157-03-09 02:12:00'), 'Hematocrit'], [51222, Timestamp('2157-03-09 01:36:00'), Timestamp('2157-03-09 02:12:00'), 'Hemoglobin'], [51248, Timestamp('2157-03-09 01:36:00'), Timestamp('2157-03-09 02:12:00'), 'MCH'], [51249, Timestamp('2157-03-09 01:36:00'), Timestamp('2157-03-09 02:12:00'), 'MCHC'], [51250, Timestamp('2157-03-09 01:36:00'), Timestamp('2157-03-09 02:12:00'), 'MCV'], [51265, Timestamp('2157-03-09 01:36:00'), Timestamp('2157-03-09 02:12:00'), 'Platelet Count'], [51277, Timestamp('2157-03-09 01:36:00'), Timestamp('2157-03-09 02:12:00'), 'RDW'], [51279, Timestamp('2157-03-09 01:36:00'), Timestamp('2157-03-09 02:12:00'), 'Red Blood Cells'], [51301, Timestamp('2157-03-09 01:36:00'), Timestamp('2157-03-09 02:12:00'), 'White Blood Cells'], [50802, Timestamp('2157-03-09 14:49:00'), Timestamp('2157-03-09 14:53:00'), 'Base Excess'], [50804, Timestamp('2157-03-09 14:49:00'), Timestamp('2157-03-09 14:53:00'), 'Calculated Total CO2'], [50818, Timestamp('2157-03-09 14:49:00'), Timestamp('2157-03-09 14:53:00'), 'pCO2'], [50820, Timestamp('2157-03-09 14:49:00'), Timestamp('2157-03-09 14:53:00'), 'pH'], [50821, Timestamp('2157-03-09 14:49:00'), Timestamp('2157-03-09 14:53:00'), 'pO2'], [50801, Timestamp('2157-03-09 19:48:00'), Timestamp('2157-03-09 19:50:00'), 'Alveolar-arterial Gradient'], [50802, Timestamp('2157-03-09 19:48:00'), Timestamp('2157-03-09 19:50:00'), 'Base Excess'], [50804, Timestamp('2157-03-09 19:48:00'), Timestamp('2157-03-09 19:50:00'), 'Calculated Total CO2'], [50812, Timestamp('2157-03-09 19:48:00'), Timestamp('2157-03-09 19:49:00'), 'Intubated'], [50813, Timestamp('2157-03-09 19:48:00'), Timestamp('2157-03-09 19:50:00'), 'Lactate'], [50816, Timestamp('2157-03-09 19:48:00'), Timestamp('2157-03-09 19:49:00'), 'Oxygen'], [50817, Timestamp('2157-03-09 19:48:00'), Timestamp('2157-03-09 19:50:00'), 'Oxygen Saturation'], [50818, Timestamp('2157-03-09 19:48:00'), Timestamp('2157-03-09 19:50:00'), 'pCO2'], [50819, Timestamp('2157-03-09 19:48:00'), Timestamp('2157-03-09 19:49:00'), 'PEEP'], [50820, Timestamp('2157-03-09 19:48:00'), Timestamp('2157-03-09 19:50:00'), 'pH'], [50821, Timestamp('2157-03-09 19:48:00'), Timestamp('2157-03-09 19:50:00'), 'pO2'], [50823, Timestamp('2157-03-09 19:48:00'), Timestamp('2157-03-09 19:50:00'), 'Required O2'], [50826, Timestamp('2157-03-09 19:48:00'), Timestamp('2157-03-09 19:49:00'), 'Tidal Volume'], [50827, Timestamp('2157-03-09 19:48:00'), Timestamp('2157-03-09 19:49:00'), 'Ventilation Rate'], [52023, Timestamp('2157-03-09 19:48:00'), Timestamp('2157-03-09 19:49:00'), 'Assist/Control'], [52033, Timestamp('2157-03-09 19:48:00'), Timestamp('2157-03-09 19:49:00'), 'Specimen Type']]

Question: A 77 M is admitted. He/she says he/she has Polytrauma - found down likely after fall from ladder . History of illness: ___ yo male with hx of dementia, CAD, recent falls transferred from an OSH after sustaining an unwitnessed fall on ___ ___. Patient was found down in the garden and does not recall event. At OSH, patient was found to have a SDH and SAH as well as multiple rib fx. Patient was transferred to ___ for further management. Upon arrival here, patient was pan scanned and seen by neurosurgery. He was loaded with keppra. His TLS spine was cleared but his c-spine is still in a collar. Patient also has significant EtOH hx per report, though EtOH negative here. Per further discussion with the family it seemed as though there was a ladder nearby and he may have fallen and then tried to walk home before collapsing. His toxicology screen on admission was negative. INJURIES: Sm L PTX and apical HTX L medial rib fxs ___ L ___ rib fxs ___ at trans proc artic L tentorial and inf sagittal sinus SDH L fronto-parietal SAH L clavicular fx close to scapula Mildly displaced fracture of inferior left scapula Past Medical History: PMH: CAD, MI, infrarenal AAA (5x4.6cm), congenital single R kidney, h/o past falls PSH: Cardiac stents Social History: ___ Family History: Non-contributory Allergies: No Known Allergies / Adverse Drug Reactions What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Chlorhexidine Gluconate 0.12% Oral Rinse 0.9% Sodium Chloride Potassium Phosphate 0.9% Sodium Chloride Potassium Phosphate 0.9% Sodium Chloride Succinylcholine Bag Magnesium Sulfate Senna Glucagon Fentanyl Citrate Calcium Gluconate Dextrose 50% Propofol Bag Magnesium Sulfate Bag Magnesium Sulfate Calcium Gluconate 0.9% Sodium Chloride Potassium Phosphate Acetaminophen Fentanyl Citrate Docusate Sodium Insulin Sodium Chloride 0.9% Flush Soln Fentanyl Citrate SW Potassium Chloride 0.9% Sodium Chloride Potassium Phosphate 0.9% Sodium Chloride LeVETiracetam Etomidate Pneumococcal Vac Polyvalent Bag Magnesium Sulfate SW Potassium Chloride Calcium Gluconate Albuterol 0.083% Neb Soln Lorazepam SW Potassium Chloride Iso-Osmotic Sodium Chloride Famotidine Acetaminophen 0.9% Sodium Chloride LeVETiracetam Propofol Bag Magnesium Sulfate Target Lab Orders: Anion Gap Bicarbonate Calcium, Total Chloride CK-MB Index Creatine Kinase (CK) Creatine Kinase, MB Isoenzyme Creatinine Glucose Magnesium Phosphate Potassium Sodium Troponin T Urea Nitrogen Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells Base Excess Calculated Total CO2 pCO2 pH pO2 Alveolar-arterial Gradient Base Excess Calculated Total CO2 Intubated Lactate Oxygen Oxygen Saturation pCO2 PEEP pH pO2 Required O2 Tidal Volume Ventilation Rate Assist/Control Specimen Type Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : ___: The patient was admitted to the Trauma ICU from the ED. He was initially maintained on an oxygen facemask. Neurosurgey was consulted for his SAH and SDH and felt reimaging the next day was appropriate and surgical intervention was not intubated at that time. His head CT was repeated and showed just redistribution of blood. ___: Epidural placement was attempt for discomfort and difficulty breathing but the patient was unable to tolerate procedure. His respiratory status worsened with desaturations despite 100% O2 facemask and he was ultimately intubated for airway protection. ___: A left sided paravertebral catheter was placed to help with pain control given desaturations on CPAP ventilator mode. His post-placement CXR demonstrated worsening of his previously seen left sided pneumothorax and a left sided chest tube was placed with 300cc of old blood out and improvement in his pneumothorax. ___: A repeat head CT was obtained given change in mental status which was unrevealing, and neurology was consulted. A head MRI was obtained which demonstrated moderate ___. The patient was minimally responsive at that time and mental status failed to significantly improve throughout the rest of his hospitalization. Sputum cultures were sent which demonstrated H.influenza and moderate streptococcus pneumonia, and he was started on levaquin. He continued to spike fevers and was changed to vanco and zosyn. Free water flushes were added for hypernatremia. ___: A family meeting was held and the patient was made DNR with no further escalation in care. He respiratory status continued to decline with inability to tolerate CPAP and thick secretions. ___: Propofol was added for dysynchrony on the ventilator - sedatives had previously been held for concern for depressed mental status. Discussions were made to hold a family meeting on ___. ___: His paravertebral catheter was dc'ed and fentanyl and oxycodone were added. His chest tube was dc'ed. His tube feeds were held for high residuals. ___: His respiratory status continued to worsen despite diuresis. He continued to be unable to tolerate tube feeds. ___: A family meeting was held with the patient's daughter, grandchildren and girlfriend. The decision was made to make the patient CMO with terminal extubation. The patient expired shortly thereafter. Other Results: CT head (___): Left tentorial and parafalcine subdural hemorrhage and left frontal and parietal subarachnoid hemorrhage. Punctate amount of intraventricular hemorrhage within the left occipital horn. CT cspine (___): No acute fracture or malalignment; no significant canal stenosis. CT torso (___): Small left hemopneumothorax with extensive left-sided rib fractures including segmental fractures of ribs two through six, as well as rib eight. Mildly displaced fracture of the inferior body of the left scapula. Comminuted left distal clavicular fracture. 4.8 x 4.6 cm infrarenal aortic aneurysm. Mild pulmonary edema with bibasilar atelectasis. CT head (___): Partial interval resorption and/or redistribution of left frontal lobe subarachnoid hemorrhage. Tiny layering hemorrhage within the occipital horns of the lateral ventricles is new on the right and increased on the left. New right frontal lobe hyperdensity could be represent redistributed SAH or a small focus of parenchymal hemorrhage at the grey-white matter junction, perhaps secondary to diffuse axonal ("shear") injury. SDH overlying the left leaflet of the tentorium cerebelli is unchanged, while parafalcine SDH is decreased. CT head (___): No new acute intracranial hemorrhage or major vascular territory infarction. Interval redistribution/resorption of subarachnoid and subdural hemorrhage. Probable minimal increase in blood products within the occipital horn of the left lateral ventricle. Possible shear injury involving the posterior corpus callosum. Consider MRI for further evaluation as clinically indicated. MRI head (___): Subarachnoid and subdural blood products identified as on the prior CT. Signal changes in the splenium of corpus callosum, left frontal lobe as well as susceptibility abnormalities along the gray-white matter junction are suggestive of diffuse axonal injury. No territorial infarcts are seen. CXR (___): ET tube is in standard placement, no less than 7 cm from the carina, although it is at the level of the lower margin of the clavicles. Pulmonary edema superimposed on residual abnormalities in both lungs due to ARDS and multifocal pneumonia has improved slightly since earlier today. Small right pleural effusion is likely. Heart size is top normal and mediastinal veins are still distended. No pneumothorax. Nasogastric tube passes into the stomach and out of view.

2200-04-06 05:35:00

ENGLISH

MARRIED

WHITE

M

[[25661770, Timestamp('2200-04-06 05:36:36'), '', 'NMED']]

[[{'Medications on Admission': 'NIL', 'Brief Hospital Course': ":\n___ is a ___ man with a h/o atrial fibrillation, \nprevious large right MCA stroke c/b epilepsy, HTN, and HLD who \npresented after being found down, found to have a new infarct in \nthe distribution of the inferior division of the left MCA, \ncomplicated by hemorrhagic transformation. \n\nHe was initially monitored in the neurologic ICU where he was \nmaintained on strict blood pressure goal <160. Upon extubation, \nhe had severe agitation and encephalopathy which was felt \nsecondary to the stroke. He was given IV Haldol which controlled \nhis agitation, and this subsequently improved over admission. He \nwas then transferred to the neurology Stroke floor, where he \nexhibited severe nonfluent aphasia and dysphagia, failing \nseveral swallow evaluations due to significant risk of \naspiration. Extensive conversations were held with his daughter \nand son-in-law with the assistance of Palliative Care regarding \nthe patient's wishes of care. Eventually it was established that \nthe patient would not have wanted any aggressive medical \ntherapies and interventions including a feeding tube, and that \nhe would want his care to center around maximizing comfort. The \npatient and his family were clear that he wanted to eat for \npleasure despite the aspiration risk, and therefore he was \nrestarted on an oral diet. Decision was made not to restart \nanticoagulant therapy or other medications to control his blood \npressure, etc. The only medications that were restarted were his \nlamotrigine and allopurinol to prevent seizures and gout \nattacks.\n\nOther complications of his hospital course included ___ and \nrhabdomyolysis, which resolved with fluids, a T1 transverse \nprocess fracture for which Neurosurgery recommended no \nintervention or therapeutic device, and right shoulder \nsubluxation (no acute fracture) with ecchymoses, for which a \nsling was recommended but patient declined.\n\nTransitional issues:\n[ ] Patient was made CMO and had his antihypertensive \nmedications stopped. He was continued on medications for \nprevention of seizures and gout attacks which would like be \nextremity uncomfortable. Please continue to titrate meds with \ncomfort care in mind.\n[ ] Can consider pharmacologic therapy for his labile mood (felt \nto reflect pseudobulbar affect) such as nuedexta.\n[ ] Contact: daughter ___ ___\n\n___ on Admission:\nThe Preadmission Medication list is accurate and complete.\n1. Losartan Potassium 100 mg PO DAILY \n2. Allopurinol ___ mg PO DAILY \n3. Furosemide 20 mg PO DAILY \n4. Omeprazole 20 mg PO DAILY \n5. LaMOTrigine 150 mg PO BID \n6. QUEtiapine Fumarate 50 mg PO BID \n7. Simvastatin 40 mg PO QPM \n8. Rivaroxaban 15 mg PO QPM \n9. LOPERamide ___ mg PO AS DIRECTED \n\nFacility:\n___", 'Pertinent Results:': '\nADMISSION LABS:\n___ 01:00PM cTropnT-0.04*\n___ 07:45AM LACTATE-1.4\n___ 07:30AM GLUCOSE-92 UREA N-48* CREAT-1.8* SODIUM-146* \nPOTASSIUM-3.9 CHLORIDE-110* TOTAL CO2-23 ANION GAP-17\n___ 07:30AM ALT(SGPT)-25 AST(SGOT)-70* CK(CPK)-1560* ALK \nPHOS-77 TOT BILI-1.5\n___ 07:30AM LIPASE-19\n___ 07:30AM ALBUMIN-3.3*\n___ 07:30AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG \nbnzodzpn-NEG barbitrt-NEG tricyclic-NEG\n___ 07:30AM WBC-9.7 RBC-3.90* HGB-11.8* HCT-36.8* MCV-94 \nMCH-30.3 MCHC-32.1 RDW-14.8 RDWSD-50.3*\n___ 07:30AM NEUTS-75.4* LYMPHS-11.9* MONOS-11.9 EOS-0.1* \nBASOS-0.3 IM ___ AbsNeut-7.32* AbsLymp-1.15* AbsMono-1.15* \nAbsEos-0.01* AbsBaso-0.03\n___ 07:30AM PLT COUNT-177\n___ 07:30AM ___ PTT-32.1 ___\n___ 03:45AM TYPE-ART ___ TIDAL VOL-430 PEEP-5 \nO2-50 PO2-105 PCO2-38 PH-7.39 TOTAL CO2-24 BASE XS--1 \n-ASSIST/CON INTUBATED-INTUBATED\n___ 03:45AM LACTATE-1.9\n___ 03:23AM LACTATE-2.4*\n___ 02:51AM GLUCOSE-97 UREA N-46* CREAT-1.9* SODIUM-147* \nPOTASSIUM-3.9 CHLORIDE-107 TOTAL CO2-25 ANION GAP-19\n___ 02:51AM ALT(SGPT)-27 AST(SGOT)-87* CK(CPK)-2336* ALK \nPHOS-89 TOT BILI-2.0*\n___ 02:51AM LIPASE-19\n___ 02:51AM cTropnT-0.06*\n___ 02:51AM ALBUMIN-3.8\n___ 02:51AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG \nbnzodzpn-NEG barbitrt-NEG tricyclic-NEG\n___ 02:51AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG \ncocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG\n___ 02:51AM WBC-14.1* RBC-4.29*# HGB-13.0*# HCT-40.2# \nMCV-94 MCH-30.3 MCHC-32.3 RDW-14.7 RDWSD-49.2*\n___ 02:51AM NEUTS-81.4* LYMPHS-8.3* MONOS-9.8 EOS-0.0* \nBASOS-0.1 IM ___ AbsNeut-11.43* AbsLymp-1.17* AbsMono-1.38* \nAbsEos-0.00* AbsBaso-0.02\n___ 02:51AM PLT COUNT-196\n___ 02:51AM ___ PTT-30.4 ___\n___ 02:51AM URINE COLOR-Yellow APPEAR-Hazy SP ___\n___ 02:51AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-300 \nGLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 \nLEUK-NEG\n___ 02:51AM URINE RBC-37* WBC-2 BACTERIA-FEW YEAST-NONE \nEPI-1\n___ 02:51AM URINE GRANULAR-4* HYALINE-11*\n___ 02:51AM URINE MUCOUS-RARE\n\n**********\n\nIMAGING:\nCXR ___: \nModerate cardiomegaly with particularly severe left atrial \ndilatation is chronic. Pulmonary vasculature is dilated \ncentrally, but not peripherally, a finding seen with pulmonary \narterial hypertension. There is no pulmonary edema. \nAtelectasis at the left base is mild. Pleural effusion minimal \nif any. No pneumothorax.\n\nNCHCT ___:\nAcute to subacute left parietal infarct with hemorrhagic \nconversion. The \nextent of hemorrhage is unchanged, and no new hemorrhagic focus \nis identified. Increased edema, without significant mass effect \nupon the adjacent ventricle. \n\nMRI Brain ___: \nMRI of the brain shows acute left posterior division middle \ncerebral artery infarct with hemorrhage. A punctate acute \ninfarct is also seen on the right side of the corpus callosum. \nChronic right MCA infarct is identified. MRA of the head \ndemonstrates diminished flow signal within both middle cerebral \narteries consequent to presence of infarcts. MRA of the neck \ndemonstrates mild atherosclerotic disease, otherwise no evidence \nof high-grade stenosis or occlusion. \n\nShoulder XR ___:\nWidening of the acromioclavicular joint with superior \nsubluxation of the \ndistal clavicle consistent with at least a grade 3 sprain. \n\n', 'Physical Exam:|Physical': '\nADMISSION EXAM:\nGeneral: Intubated, recently sedated. Multiple ecchymosis and\ninjuries, most notable his chest.\nHEENT: NC/AT,MMM, no lesions noted in oropharynx\nNeck: Cervical hard collar in place. \nPulmonary: Lungs CTA bilaterally Cardiac: Irregularly irregular,\nnl. S1S2, no M/R/G noted\nAbdomen: soft, NT/ND.\nExtremities: Multiple ecchymosis noted. Otherwise WWP..\nSkin: no rashes or lesions noted.\n\nNeurologic:\n\n-Mental Status: Follows no commands. Prior to intubation I am\ntold there was no spoken language, no following of commands\n\n-Cranial Nerves:\nII, III, IV, VI: PERRL 1.5mm and minimally reactive. Both eyes\nmedially deviated. Unable to assess for VoRs given cervical\ncollar.. No clear BTT.\nV: + Corneals b/l\nVII: Face symmetric around tube.\nVIII: Unable to assess.\nIX, X: + Cough, Gag.\nXI: Unable to assess.\nXII: Unable to assess.\n\n-Motor: Normal bulk, decreased throughout. Unable to assess\npronator drift. REsponds to noxious in all 4 extremities, but\nresponds more briskly in the LUE and LLE. No antigravity motion\nseen, but per ED, prior to intubation was moving all 4\nsymmetrically and antigravity.\n\n-Sensory:\n\n-DTRs:\n Bi Tri ___ Pat Ach\nL 3 2 2+ 3 3\nR 2 2 2 3 3\nPlantar response was flexor bilaterally.\n3 beats of clonus b/l\n\n-Coordination: Unable to assess\n\n-Gait: Unable to assess\n\n****************\n\nDISCHARGE EXAMINATION:\n\nGeneral: Awake, alert, NAD. Appears comfortable.\nHEENT: NC/AT,MMM, no lesions noted in oropharynx\nNeck: Supple.\nPulmonary: Lungs CTA bilaterally Cardiac: Irregularly irregular,\nnl. S1S2, no M/R/G noted\nAbdomen: soft, NT/ND.\nExtremities: Multiple ecchymosis noted. Otherwise WWP.\nSkin: no rashes or lesions noted.\n\nNeurologic:\n- Mental status: alert, attentive. Comprehends well and follows \ncommands. No verbal output. Labile affect with alternating \ntearfulness and elation.\n- Cranial nerves: PERRL, looks in all directions of gaze. \nProminent right facial droop. Oral motor apraxia.\n- Motor: moves RUE against gravity proximally, no movement in \nwrist or fingers. LUE and BLE full strength to confrontation.\n- Sensory: appears intact bilaterally to light touch.\n- Cerebellar: no evidence of ataxia or dysmetria.\n- Gait: not assess.\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\nMr. ___ is a ___ man with a past medical history of\natrial fibrillation on xarelto, prior Right MCA stroke, CKD, \nhtn,\nHLD and unclear history of focal seizures who presents following\nbeing found down with NCHCT demonstrated left MCA infarction \nwith\nhemorrhagic conversion. \n\nHistory is limited and gathered from his daughter.\n\nEssentially, he has been at his baseline state of health\nrecently. He was last known well the morning of the ___ when \nhe\nwas seen by his neighbor. On the evening of the ___ and ___, \nhe\nmissed his evening calls with his daughter. She called and \nasked\na neighbor to check on him, and he was found down, naked and\nconfused. His house was "trashed". EMS was called and he was\nbrought to OSH.\n\nThere he was obtunded and confused. He received a total of 9mg\nAtivan for agitation there. He underwent CT pan scan, which\nfound a Left MCA infarction with concern for hemorrhagic\nconversion.\n\nHe was transferred here and received versed en route for\nagitation. He was agitated with poor saturations (80s) and\nintubated for airway protection. While in the ED he was seen by\ntrauma with fast scan\n\nPast Medical History:\n- CAD \n- CABG x3\n- Redo CABGx3 \n- Chronic AFib on Xarelto\n- Seizures (following infarction)\n- Hx of Right MCA infarction ___ per daughter)\n- Hx of RP bleed\n- HTN\n- Hyperlipidemia\n- Hx Hiatal hernia\n- Hx nonobstructive Schatzki ring\n- CKD\n- GERD\n- ? AAA repair?\n\nSocial History:\n___\nFamily History:\nnon-contributory\n\n', 'Chief Complaint:|Complaint:': '\nstroke\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nNorvasc / Zestril / Coumadin\n\n'}, '17900392-DS-5', 5, 'neurology']]

[['INDICATION: Evaluate endotracheal tube placement in a patient with altered\nmental status and intubated for airway protection.\n\nCOMPARISON: Chest radiographs from ___.\n\nFINDINGS: \n\nA portable semi-erect frontal chest radiograph demonstrates an endotracheal\ntube which terminates approximately 2.5 cm from the carina. An enteric tube\nterminates in the stomach, but the side port remains in the mid esophagus. \nHeart size is mildly enlarged. There is bibasilar atelectasis.\n\nIMPRESSION:\n\n\n1. Endotracheal tube terminating 2.5 cm from the carina.\n2. Enteric tube terminating in the stomach, with the side port in the mid\nesophagus.\n\nNOTIFICATION: These findings were communicated via telephone by Dr.\n___ to Dr. ___ at 04:43 on ___, approximately 5\nminutes after discovery.\n', '17900392-RR-15', 15, ''], ['EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD\n\nINDICATION: Evaluate for interval change in a patient with hemorrhagic\ntransformation of a left parietal stroke.\n\nTECHNIQUE: Contiguous axial images of the brain were obtained without\ncontrast. Coronal and sagittal reformations as well as bone algorithm\nreconstructions were provided and reviewed.\n\nDOSE: Acquisition sequence:\n 1) Sequenced Acquisition 18.0 s, 19.3 cm; CTDIvol = 46.7 mGy (Head) DLP =\n903.1 mGy-cm.\n Total DLP (Head) = 903 mGy-cm.\n\nCOMPARISON: Outside hospital CTA head from ___.\n\nFINDINGS: \n\nAgain seen is hypodensity involving the left parietal lobe, consistent with\nacute infarct. Hyperdensity within this region is compatible with hemorrhagic\nconversion, difficult to measure but similar in distribution and size compared\nto prior CT head. A focus of slightly increased hyperdensity within this\nhemorrhagic collection (2:25, 601b:68, 602b:66) was probably present on the\nprior exam as well, not well seen on axial view but present on sagittal images\n(10:30). There is mildly increased surrounding edema, without significant\nmass effect upon the adjacent ventricle. Basal cisterns are patent. \nHypodensity of the right temporal and parietal lobes is compatible with\nencephalomalacia related to prior infarct. No new focus of hemorrhage is\nidentified. Prominent ventricles and sulci are suggestive of age-related\ninvolutional change, with periventricular white matter hypodensities\nconsistent with chronic small vessel ischemic disease.\nThere is no evidence of fracture. The visualized portion of the paranasal\nsinuses, mastoid air cells, and middle ear cavities are clear. The visualized\nportion of the orbits are unremarkable.\n\nIMPRESSION: \n\nAcute to subacute left parietal infarct with hemorrhagic conversion. The\nextent of hemorrhage is unchanged, and no new hemorrhagic focus is identified.\nIncreased edema, without significant mass effect upon the adjacent ventricle.\n', '17900392-RR-16', 16, 'contiguous axial images of the brain were obtained without\ncontrast. coronal and sagittal reformations as well as bone algorithm\nreconstructions were provided and reviewed.'], ['INDICATION: Evaluate enteric tube positioned after adjustment.\n\nCOMPARISON: Chest radiographs from approximately 2 hours prior on the same\nday, as well as ___.\n\nFINDINGS: \n\nA portable frontal chest radiograph demonstrates interval advancement of an\nenteric tube, now in appropriate position. The endotracheal tube terminates\n2.9 cm from the carina. The remainder of the exam is unchanged.\n\nIMPRESSION: \n\nInterval advancement of an enteric tube, now folded in the stomach. \nEndotracheal tube terminating 3 cm from the carina.\n', '17900392-RR-17', 17, ''], ['EXAMINATION: MRI AND MRA BRAIN AND MRA NECK\n\nINDICATION: Mr. ___ is a ___ man with a past medical history of\natrial fibrillation on xarelto, prior Right MCA stroke, CKD, htn, HLD and\nunclear history of focal seizures who presents following being found down with\nNCHCT demonstrated left MCA infarction with hemorrhagic conversion. // eval\nfor extent of stroke\n\nTECHNIQUE: T1 sagittal and FLAIR, T2, susceptibility and diffusion axial\nimages of the brain were acquired. 3D time-of-flight MRA of the circle of\n___ was obtained. Gadolinium enhanced MRA of the neck was acquired.\n\nCOMPARISON: CT of ___ and outside CT ___.\n\nFINDINGS: \n\nThere is an acute left parietal lobe infarct identified as seen on the recent\nCT with blood products within the area of infarct indicative of associated\nhemorrhage. A punctate area of restricted diffusion is seen to the right of\nmidline along the corpus callosum (06:23) which is difficult to assess on the\nADC map given its small size but could also be due to an acute infarct. A\nchronic right middle cerebral artery infarct is identified. Extends to brain\natrophy and small vessel disease are seen. There is no midline shift or\nhydrocephalus.\n\nMRA of the head shows diminished flow signal in both middle cerebral arteries.\nThe diminished flow signal in the right middle cerebral artery appears to be\nconsequent to the large chronic infarct in the right middle cerebral artery\nterritory. The diminished flow signal in the left MCA appears to be\nartifactual secondary to diminished flow from acute infarct in the region. No\nmajor vascular occlusion is seen. Within the posterior circulation the\nbasilar artery. As well as both posterior cerebral arteries are patent.\n\nMRA of the neck shows normal flow in the carotid and vertebral arteries. No\nevidence of stenosis or occlusion or dissection seen. Mild atherosclerotic\ndisease is seen at the left carotid bifurcation.\n\nIMPRESSION: \n\nMRI of the brain shows acute left posterior division middle cerebral artery\ninfarct with hemorrhage. A punctate acute infarct is also seen on the right\nside of the corpus callosum. Chronic right MCA infarct is identified. MRA of\nthe head demonstrates diminished flow signal within both middle cerebral\narteries consequent to presence of infarcts. MRA of the neck demonstrates\nmild atherosclerotic disease, otherwise no evidence of high-grade stenosis or\nocclusion.\n', '17900392-RR-18', 18, 't1 sagittal and flair, t2, susceptibility and diffusion axial\nimages of the brain were acquired. 3d time-of-flight mra of the circle of\n___ was obtained. gadolinium enhanced mra of the neck was acquired.'], ['EXAMINATION: CHEST (PORTABLE AP)\n\nINDICATION: ___ year old man with R MCA infarction, intubated, plan for\nextubation ___ // please evaluate for acute process or interval change \nplease evaluate for acute process or interval change\n\nIMPRESSION: \n\nCompared to chest radiographs since ___. Most recently ___ at 04:28.\n\nModerate cardiomegaly with particularly severe left atrial dilatation is\nchronic. Pulmonary vasculature is dilated centrally, but not peripherally, a\nfinding seen with pulmonary arterial hypertension. There is no pulmonary\nedema. Atelectasis at the left base is mild. Pleural effusion minimal if\nany. No pneumothorax.\n\nET tube and transesophageal drainage tubes in standard placements respectively\n', '17900392-RR-19', 19, ''], ['EXAMINATION: DX SHOULDER AND CLAVICLE\n\nINDICATION: ___ man with a h/o atrial fibrillation, previous right MCA\nstroke c/b epilepsy, HTN, and HLD who presented after being found down, found\nto have a new infarct in the distribution of the inferior division of the left\nMCA, complicated by hemorrhagic transformation. Exam notable for right\nshoulder asymmetry with pain and brusing // eval for fracture of dislocation \neval for fracture of dislocation \neval for fracture\n\nTECHNIQUE: Three views of the right shoulder/clavicle\n\nCOMPARISON: No prior studies for comparison. Chest radiograph ___\n\nFINDINGS: \n\nNo acute fracture or dislocation. There is widening of the acromioclavicular\njoint measuring approximately 1.2 cm and of the coracoclavicular space (16\nmm), with superior subluxation of the distal clavicle in relation to the\nacromion. Limited evaluation of the right lung is grossly clear.\n\nIMPRESSION: \n\nWidening of the acromioclavicular joint with superior subluxation of the\ndistal clavicle consistent with at least a grade 3 sprain.\n', '17900392-RR-20', 20, 'three views of the right shoulder/clavicle']]

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[['5A1945Z', 10, 1, Timestamp('2200-04-06 00:00:00'), 'Respiratory Ventilation, 24-96 Consecutive Hours'], ['0BH17EZ', 10, 2, Timestamp('2200-04-06 00:00:00'), 'Insertion of Endotracheal Airway into Trachea, Via Natural or Artificial Opening']]

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Question: A 77 M is admitted. He/she says he/she has stroke . History of illness: Mr. ___ is a ___ man with a past medical history of atrial fibrillation on xarelto, prior Right MCA stroke, CKD, htn, HLD and unclear history of focal seizures who presents following being found down with NCHCT demonstrated left MCA infarction with hemorrhagic conversion. History is limited and gathered from his daughter. Essentially, he has been at his baseline state of health recently. He was last known well the morning of the ___ when he was seen by his neighbor. On the evening of the ___ and ___, he missed his evening calls with his daughter. She called and asked a neighbor to check on him, and he was found down, naked and confused. His house was "trashed". EMS was called and he was brought to OSH. There he was obtunded and confused. He received a total of 9mg Ativan for agitation there. He underwent CT pan scan, which found a Left MCA infarction with concern for hemorrhagic conversion. He was transferred here and received versed en route for agitation. He was agitated with poor saturations (80s) and intubated for airway protection. While in the ED he was seen by trauma with fast scan Past Medical History: - CAD - CABG x3 - Redo CABGx3 - Chronic AFib on Xarelto - Seizures (following infarction) - Hx of Right MCA infarction ___ per daughter) - Hx of RP bleed - HTN - Hyperlipidemia - Hx Hiatal hernia - Hx nonobstructive Schatzki ring - CKD - GERD - ? AAA repair? Social History: ___ Family History: non-contributory Allergies: Norvasc / Zestril / Coumadin What is the best procedure plan for this patient?

TARGETS Target Prescriptions: LaMOTrigine Insulin Bag Magnesium Sulfate D5 1/2NS Omeprazole 0.9% Sodium Chloride Calcium Gluconate Acetaminophen Dextrose 50% Influenza Vaccine Quadrivalent PNEUMOcoccal 23-valent polysaccharide vaccine Allopurinol 0.83% Sodium Chloride NiCARdipine IV Furosemide SW Potassium Chloride SW Potassium Chloride Glucagon Losartan Potassium Bag Magnesium Sulfate Propofol Sodium Chloride 0.9% Sodium Chloride 0.9% Flush Propofol Simvastatin SW Potassium Chloride 0.9% Sodium Chloride Calcium Gluconate Vial Pantoprazole Glucose Gel 0.9% Sodium Chloride Calcium Gluconate Fentanyl Citrate Bag Magnesium Sulfate Target Lab Orders: Acetaminophen Alanine Aminotransferase (ALT) Albumin Alkaline Phosphatase Anion Gap Asparate Aminotransferase (AST) Barbiturate Screen Benzodiazepine Screen Bicarbonate Bilirubin, Total Chloride Creatine Kinase (CK) Creatinine Ethanol Glucose Lipase Potassium Salicylate Sodium Tricyclic Antidepressant Screen Urea Nitrogen INR(PT) PT PTT Absolute Lymphocyte Count Basophils Eosinophils Hematocrit Hemoglobin Lymphocytes MCH MCHC MCV Monocytes Neutrophils Platelet Count RDW Red Blood Cells White Blood Cells Absolute Basophil Count Absolute Eosinophil Count Absolute Monocyte Count Absolute Neutrophil Count Immature Granulocytes RDW-SD Lactate Troponin T Alanine Aminotransferase (ALT) Alkaline Phosphatase Anion Gap Asparate Aminotransferase (AST) Bicarbonate Calcium, Total Chloride Creatine Kinase (CK) Creatinine Glucose Magnesium Phosphate Potassium Sodium Urea Nitrogen INR(PT) PT Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells RDW-SD Target Procedures: Respiratory Ventilation, 24-96 Consecutive Hours Insertion of Endotracheal Airway into Trachea, Via Natural or Artificial Opening DOCTOR'S NOTE Hospital Notes: : ___ is a ___ man with a h/o atrial fibrillation, previous large right MCA stroke c/b epilepsy, HTN, and HLD who presented after being found down, found to have a new infarct in the distribution of the inferior division of the left MCA, complicated by hemorrhagic transformation. He was initially monitored in the neurologic ICU where he was maintained on strict blood pressure goal <160. Upon extubation, he had severe agitation and encephalopathy which was felt secondary to the stroke. He was given IV Haldol which controlled his agitation, and this subsequently improved over admission. He was then transferred to the neurology Stroke floor, where he exhibited severe nonfluent aphasia and dysphagia, failing several swallow evaluations due to significant risk of aspiration. Extensive conversations were held with his daughter and son-in-law with the assistance of Palliative Care regarding the patient's wishes of care. Eventually it was established that the patient would not have wanted any aggressive medical therapies and interventions including a feeding tube, and that he would want his care to center around maximizing comfort. The patient and his family were clear that he wanted to eat for pleasure despite the aspiration risk, and therefore he was restarted on an oral diet. Decision was made not to restart anticoagulant therapy or other medications to control his blood pressure, etc. The only medications that were restarted were his lamotrigine and allopurinol to prevent seizures and gout attacks. Other complications of his hospital course included ___ and rhabdomyolysis, which resolved with fluids, a T1 transverse process fracture for which Neurosurgery recommended no intervention or therapeutic device, and right shoulder subluxation (no acute fracture) with ecchymoses, for which a sling was recommended but patient declined. Transitional issues: [ ] Patient was made CMO and had his antihypertensive medications stopped. He was continued on medications for prevention of seizures and gout attacks which would like be extremity uncomfortable. Please continue to titrate meds with comfort care in mind. [ ] Can consider pharmacologic therapy for his labile mood (felt to reflect pseudobulbar affect) such as nuedexta. [ ] Contact: daughter ___ ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Losartan Potassium 100 mg PO DAILY 2. Allopurinol ___ mg PO DAILY 3. Furosemide 20 mg PO DAILY 4. Omeprazole 20 mg PO DAILY 5. LaMOTrigine 150 mg PO BID 6. QUEtiapine Fumarate 50 mg PO BID 7. Simvastatin 40 mg PO QPM 8. Rivaroxaban 15 mg PO QPM 9. LOPERamide ___ mg PO AS DIRECTED Facility: ___ Other Results: ADMISSION LABS: ___ 01:00PM cTropnT-0.04* ___ 07:45AM LACTATE-1.4 ___ 07:30AM GLUCOSE-92 UREA N-48* CREAT-1.8* SODIUM-146* POTASSIUM-3.9 CHLORIDE-110* TOTAL CO2-23 ANION GAP-17 ___ 07:30AM ALT(SGPT)-25 AST(SGOT)-70* CK(CPK)-1560* ALK PHOS-77 TOT BILI-1.5 ___ 07:30AM LIPASE-19 ___ 07:30AM ALBUMIN-3.3* ___ 07:30AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 07:30AM WBC-9.7 RBC-3.90* HGB-11.8* HCT-36.8* MCV-94 MCH-30.3 MCHC-32.1 RDW-14.8 RDWSD-50.3* ___ 07:30AM NEUTS-75.4* LYMPHS-11.9* MONOS-11.9 EOS-0.1* BASOS-0.3 IM ___ AbsNeut-7.32* AbsLymp-1.15* AbsMono-1.15* AbsEos-0.01* AbsBaso-0.03 ___ 07:30AM PLT COUNT-177 ___ 07:30AM ___ PTT-32.1 ___ ___ 03:45AM TYPE-ART ___ TIDAL VOL-430 PEEP-5 O2-50 PO2-105 PCO2-38 PH-7.39 TOTAL CO2-24 BASE XS--1 -ASSIST/CON INTUBATED-INTUBATED ___ 03:45AM LACTATE-1.9 ___ 03:23AM LACTATE-2.4* ___ 02:51AM GLUCOSE-97 UREA N-46* CREAT-1.9* SODIUM-147* POTASSIUM-3.9 CHLORIDE-107 TOTAL CO2-25 ANION GAP-19 ___ 02:51AM ALT(SGPT)-27 AST(SGOT)-87* CK(CPK)-2336* ALK PHOS-89 TOT BILI-2.0* ___ 02:51AM LIPASE-19 ___ 02:51AM cTropnT-0.06* ___ 02:51AM ALBUMIN-3.8 ___ 02:51AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 02:51AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG ___ 02:51AM WBC-14.1* RBC-4.29*# HGB-13.0*# HCT-40.2# MCV-94 MCH-30.3 MCHC-32.3 RDW-14.7 RDWSD-49.2* ___ 02:51AM NEUTS-81.4* LYMPHS-8.3* MONOS-9.8 EOS-0.0* BASOS-0.1 IM ___ AbsNeut-11.43* AbsLymp-1.17* AbsMono-1.38* AbsEos-0.00* AbsBaso-0.02 ___ 02:51AM PLT COUNT-196 ___ 02:51AM ___ PTT-30.4 ___ ___ 02:51AM URINE COLOR-Yellow APPEAR-Hazy SP ___ ___ 02:51AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-300 GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 02:51AM URINE RBC-37* WBC-2 BACTERIA-FEW YEAST-NONE EPI-1 ___ 02:51AM URINE GRANULAR-4* HYALINE-11* ___ 02:51AM URINE MUCOUS-RARE ********** IMAGING: CXR ___: Moderate cardiomegaly with particularly severe left atrial dilatation is chronic. Pulmonary vasculature is dilated centrally, but not peripherally, a finding seen with pulmonary arterial hypertension. There is no pulmonary edema. Atelectasis at the left base is mild. Pleural effusion minimal if any. No pneumothorax. NCHCT ___: Acute to subacute left parietal infarct with hemorrhagic conversion. The extent of hemorrhage is unchanged, and no new hemorrhagic focus is identified. Increased edema, without significant mass effect upon the adjacent ventricle. MRI Brain ___: MRI of the brain shows acute left posterior division middle cerebral artery infarct with hemorrhage. A punctate acute infarct is also seen on the right side of the corpus callosum. Chronic right MCA infarct is identified. MRA of the head demonstrates diminished flow signal within both middle cerebral arteries consequent to presence of infarcts. MRA of the neck demonstrates mild atherosclerotic disease, otherwise no evidence of high-grade stenosis or occlusion. Shoulder XR ___: Widening of the acromioclavicular joint with superior subluxation of the distal clavicle consistent with at least a grade 3 sprain.

2181-04-03 06:13:00

ENGLISH

MARRIED

WHITE

F

[[29571256, Timestamp('2181-04-03 06:13:48'), '', 'OBS']]

[[{'Medications on Admission': ':\nMedications - Prescription\nEPINEPHRINE [EPIPEN 2-PAK] - EpiPen 2-Pak 0.3 mg/0.3 mL \n(1:1,000)\ninjection,auto-injector. 0.3 mg im prn anaphylaxis\nEPINEPHRINE [EPIPEN] - EpiPen 0.3 mg/0.3 mL (1:1,000)\ninjection,auto-injector. use in case of severe reaction and call\n___ (use only once) DISPENSE EPI-PEN TWO PACK\nHYDROXYZINE HCL - hydroxyzine HCl 25 mg tablet. 2 tablet(s) by\nmouth twice daily\nINTERFERON ALFA-2B [INTRON A] - Intron A 10 million unit (1 mL)\nsolution for injection. 0.24 cc sc three times per week\nLIGHT BOX FOR SEASONAL AFFECTIVE DISORDER - light box for\nseasonal affective disorder . use daily in the morning 30 min\ndaily use for sad as it relates to mastocytosis flares and\nhospitalizations\nMONTELUKAST [SINGULAIR] - Singulair 10 mg tablet. 1 (One)\nTablet(s) by mouth once a day\nPREDNISONE - prednisone 10 mg tablet. up to 5 (Five) tablet(s) \nby\nmouth daily, taper as directed 90 pills is a 30 day supply\nRANITIDINE HCL - RANITIDINE HCL 150MG tablet. ONE TABLET BY \nMOUTH\nTWICE A DAY\n\nMedications - OTC\nCETIRIZINE - cetirizine 10 mg tablet. 1 tablet(s) by mouth twice\ndaily - (Prescribed by Other Provider)\nDIPHENHYDRAMINE HCL - diphenhydramine 25 mg tablet. ___ \nTablet(s)\nby mouth four times a day as needed for severe flushing, nausea \n-\n(OTC)', 'Brief Hospital Course': ":\nThe patient is a ___, G1, P0 who presented at 37 weeks 6 \ndays to OB triage for evaluation of absent fetal movement and a \nmastocytosis flare and was noted to\nhave fetal bradycardia in the ___. Ultrasound at the bedside \nconfirmed true fetal bradycardia which did not recover, and \ndecision was made to proceed with stat cesarean delivery. The \npatient was verbally consented prior to proceeding.\n\nIn terms of her mastocytosis, she received 100 mg IV \nhydrocortisone at time of delivery. She received an epidural for \npain control postop (section under GA), which was discontinued \n___ AM. She also received Tylenol because she could not get \nNSAIDs or narcotics. She experienced a mastocytosis flare (___) \nand received IV benadryl, solumedrol, famotidine. She was then \nmainatained on IV benadryl Q4H PRN, IV phenergen PRN, PO home \nmeds (zyrtec, singulair, zantec) and interferon (own injection). \nPer her regular allergist, plan was made for 40 solumedrol \n(___) -> prednisone taper (starting at 40 on ___, 30 on \n___ and ___. She also received heparin BID for DVT \nprophylaxis.\n\nPatient's course was also complicated by gestational \nhypertension and headache. Headache was suspected to be \nmusculoskeletal, but postpartum pre-eclampsia and spinal \nheadache were also considered. She was assessed by general \nanesthesia and felt to not have epidural related headache. She \nalso received pre-eclampsia labs x2 which remained normal. \nHeadache improved with sitting and standing, valium, flexeril.\n\nPatient also developed rash on buttocks that was felt to be due \nto episodes of incontinence while on L&D. Improved with \nfluconazole, clotimazole. Patient was discharged to home in \nstable condition on ___.\n\n", 'Pertinent Results:': '\n___ 06:35AM TYPE-ART PO2-13* PCO2-85* PH-7.06* TOTAL \nCO2-26 BASE XS--11 COMMENTS-CORD ___\n___ 06:32AM ___ PO2-14* PCO2-81* PH-7.08* TOTAL \nCO2-26 BASE XS--10 COMMENTS-CORD VEIN\n___ 06:05AM WBC-14.9*# RBC-4.56 HGB-13.6 HCT-38.0 MCV-83 \nMCH-29.8 MCHC-35.8 RDW-13.2 RDWSD-39.5\n___ 06:05AM PLT COUNT-256\n\n', 'Physical Exam:|Physical': '\nGen: A&O, comfortable\nCV: RRR\nLungs: CTA\nAbd: soft, non-tender, incision c/d/I\nExt: no edema, tenderness\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\n___ yo G1P0 at 37w6d presenting with decreased FM for 30\nminutes after waking up, also felt like she was having a\nmastocytosis flare and needed IV hydration.\n\nPast Medical History:\n-Mastocytosis:\nMrs. ___ mastocytosis was diagnosed in ___, although she \nreports onset of symptoms in ___ that took time to diagnose. \nAs mentioned previously, she describes typically needing to be \nhospitalized ___ times per year for her condition, and notes \nthat in addition she has ___ flares per year that do not require \nhospitalization that she treats with high dose Prednisone (60 \nmg) and Benadryl. She notes that in the past year she has not \nrequired as many hospitalizations but that she has had more \nflare-ups at home. Triggers for flare-ups include emotional \nstress or anxiety, extreme temperatures (particularly prolonged \nexposure to cold air), alcohol, and several medications \n(documented under allergies), though notes that some of her \nflares occur without obvious trigger. In general, she is more \nlikely to get a flare in the winter months compared with the \nsummer and in the evening compared with the morning. She sees \nDr. ___, an allergist, for ongoing management of her \nmastocytosis. \n\n- Anxiety/Depression: \nIn late ___ of last year, Mrs. ___ began taking ___ \n150 mg/day as a preventative measure prior to heading into the \n___ months. She describes anxiety as a trigger to her \nmastocytosis and hoped that controlling the anxiety with Zoloft \nmight decrease the number of mastocytosis flare-ups. She feels \nthat the Zoloft did help this winter, but she did not want to be \non more medications than necessary especially as she anticipated \nfewer flare-ups in the summer. Thus, she had begun a taper of \nZoloft from 150 mg to 100 mg at the beginning of ___ and from \n100 mg to 50 mg at the beginning of ___.\n\nPast Surgical History: tonsillectomy, thumb surgery after a \nskiing accident\n\nSocial History:\n___\nFamily History:\nNo family history of mastocytosis\nMother (___): multiple sclerosis, breast cancer\nFather (___): ligament cancer requiring removal of his shoulder\nSister (___): mild allergies, otherwise healthy\n\n', 'Chief Complaint:|Complaint:': '\ndecreased fetal movement\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nAspirin / Iodine / Nsaids / Opioids-Morphine & Related\n\n'}, '15846912-DS-43', 43, 'obstetrics/gynecology']]

[]

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Timestamp('2181-04-04 00:00:00'), 'MAIN', 'DiphenhydrAMINE', '011582', '00904530661', '25mg Cap'], [29571256, Timestamp('2181-04-03 13:00:00'), Timestamp('2181-04-03 12:00:00'), 'MAIN', 'MethylPREDNISolone Sodium Succ', '065977', '00009003928', '40mg Vial'], [29571256, Timestamp('2181-04-04 01:00:00'), Timestamp('2181-04-09 18:00:00'), 'MAIN', 'Sarna Lotion', '023766', '54162055007', '222mL Bottle'], [29571256, Timestamp('2181-04-03 12:00:00'), Timestamp('2181-04-09 18:00:00'), 'MAIN', 'Docusate Sodium', '003009', '00904224461', '100mg Capsule'], [29571256, Timestamp('2181-04-03 12:00:00'), Timestamp('2181-04-09 18:00:00'), 'MAIN', 'Acetaminophen', '004490', '00904198861', '500mg Tablet'], [29571256, Timestamp('2181-04-04 04:00:00'), Timestamp('2181-04-04 12:00:00'), 'MAIN', 'Naloxone', '004516', '00409121501', '0.4mg/1mL AMP'], [29571256, Timestamp('2181-04-04 02:00:00'), Timestamp('2181-04-04 01:00:00'), 'MAIN', 'DiphenhydrAMINE', '011590', '00641037625', '50mg/mL Vial'], [29571256, Timestamp('2181-04-04 00:00:00'), Timestamp('2181-04-04 00:00:00'), 'BASE', '0.9% Sodium Chloride', '001210', '00338004931', '50 mL Bag'], [29571256, Timestamp('2181-04-04 00:00:00'), Timestamp('2181-04-04 00:00:00'), 'MAIN', 'Famotidine (IV)', '011675', '00641602110', '10mg/mL;20mL'], [29571256, Timestamp('2181-04-03 12:00:00'), Timestamp('2181-04-09 18:00:00'), 'MAIN', 'Milk of Magnesia', '003026', '00121043130', '30mL UD Cup'], [29571256, Timestamp('2181-04-03 12:00:00'), Timestamp('2181-04-04 00:00:00'), 'MAIN', 'Tetanus-DiphTox-Acellular Pertuss (Adacel)', '063901', '49281040015', '0.5 mL Injection'], [29571256, Timestamp('2181-04-03 13:00:00'), Timestamp('2181-04-04 00:00:00'), 'MAIN', 'DiphenhydrAMINE', '011590', '00641037625', '50mg/mL Vial'], [29571256, Timestamp('2181-04-04 01:00:00'), Timestamp('2181-04-06 09:00:00'), 'BASE', 'Lactated Ringers', '001187', '00338011704', 'Floor Stock Bag'], [29571256, Timestamp('2181-04-04 00:00:00'), Timestamp('2181-04-04 00:00:00'), 'MAIN', 'Sarna Lotion', '023766', '54162055007', '222mL Bottle'], [29571256, Timestamp('2181-04-04 02:00:00'), Timestamp('2181-04-07 17:00:00'), 'MAIN', 'DiphenhydrAMINE', '011590', '00641037625', '50mg/mL Vial']]

[]

['obstetrics/gynecology']

[[50802, Timestamp('2181-04-03 06:32:00'), Timestamp('2181-04-03 06:35:00'), 'Base Excess'], [50804, Timestamp('2181-04-03 06:32:00'), Timestamp('2181-04-03 06:35:00'), 'Calculated Total CO2'], [50818, Timestamp('2181-04-03 06:32:00'), Timestamp('2181-04-03 06:35:00'), 'pCO2'], [50820, Timestamp('2181-04-03 06:32:00'), Timestamp('2181-04-03 06:35:00'), 'pH'], [50821, Timestamp('2181-04-03 06:32:00'), Timestamp('2181-04-03 06:35:00'), 'pO2'], [52033, Timestamp('2181-04-03 06:32:00'), Timestamp('2181-04-03 06:34:00'), 'Specimen Type'], [50802, Timestamp('2181-04-03 06:35:00'), Timestamp('2181-04-03 06:36:00'), 'Base Excess'], [50804, Timestamp('2181-04-03 06:35:00'), Timestamp('2181-04-03 06:36:00'), 'Calculated Total CO2'], [50818, Timestamp('2181-04-03 06:35:00'), Timestamp('2181-04-03 06:36:00'), 'pCO2'], [50820, Timestamp('2181-04-03 06:35:00'), Timestamp('2181-04-03 06:36:00'), 'pH'], [50821, Timestamp('2181-04-03 06:35:00'), Timestamp('2181-04-03 06:36:00'), 'pO2'], [52033, Timestamp('2181-04-03 06:35:00'), Timestamp('2181-04-03 06:36:00'), 'Specimen Type']]

Question: A 29 F is admitted. He/she says he/she has decreased fetal movement . History of illness: ___ yo G1P0 at 37w6d presenting with decreased FM for 30 minutes after waking up, also felt like she was having a mastocytosis flare and needed IV hydration. Past Medical History: -Mastocytosis: Mrs. ___ mastocytosis was diagnosed in ___, although she reports onset of symptoms in ___ that took time to diagnose. As mentioned previously, she describes typically needing to be hospitalized ___ times per year for her condition, and notes that in addition she has ___ flares per year that do not require hospitalization that she treats with high dose Prednisone (60 mg) and Benadryl. She notes that in the past year she has not required as many hospitalizations but that she has had more flare-ups at home. Triggers for flare-ups include emotional stress or anxiety, extreme temperatures (particularly prolonged exposure to cold air), alcohol, and several medications (documented under allergies), though notes that some of her flares occur without obvious trigger. In general, she is more likely to get a flare in the winter months compared with the summer and in the evening compared with the morning. She sees Dr. ___, an allergist, for ongoing management of her mastocytosis. - Anxiety/Depression: In late ___ of last year, Mrs. ___ began taking ___ 150 mg/day as a preventative measure prior to heading into the ___ months. She describes anxiety as a trigger to her mastocytosis and hoped that controlling the anxiety with Zoloft might decrease the number of mastocytosis flare-ups. She feels that the Zoloft did help this winter, but she did not want to be on more medications than necessary especially as she anticipated fewer flare-ups in the summer. Thus, she had begun a taper of Zoloft from 150 mg to 100 mg at the beginning of ___ and from 100 mg to 50 mg at the beginning of ___. Past Surgical History: tonsillectomy, thumb surgery after a skiing accident Social History: ___ Family History: No family history of mastocytosis Mother (___): multiple sclerosis, breast cancer Father (___): ligament cancer requiring removal of his shoulder Sister (___): mild allergies, otherwise healthy Allergies: Aspirin / Iodine / Nsaids / Opioids-Morphine & Related What is the best procedure plan for this patient?

TARGETS Target Prescriptions: DiphenhydrAMINE Ondansetron Ondansetron Sodium Chloride 0.9% Flush DiphenhydrAMINE Simethicone Ondansetron Lactated Ringers Heparin Iso-Osmotic Sodium Chloride Famotidine Ondansetron MethylPREDNISolone Sodium Succ Yellow CADD Cassette Bupivacaine 0.1% Promethazine Bisacodyl Calcium Carbonate Yellow CADD Cassette Bupivacaine 0.1% DiphenhydrAMINE MethylPREDNISolone Sodium Succ Sarna Lotion Docusate Sodium Acetaminophen Naloxone DiphenhydrAMINE 0.9% Sodium Chloride Famotidine (IV) Milk of Magnesia Tetanus-DiphTox-Acellular Pertuss (Adacel) DiphenhydrAMINE Lactated Ringers Sarna Lotion DiphenhydrAMINE Target Lab Orders: Base Excess Calculated Total CO2 pCO2 pH pO2 Specimen Type Base Excess Calculated Total CO2 pCO2 pH pO2 Specimen Type Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : The patient is a ___, G1, P0 who presented at 37 weeks 6 days to OB triage for evaluation of absent fetal movement and a mastocytosis flare and was noted to have fetal bradycardia in the ___. Ultrasound at the bedside confirmed true fetal bradycardia which did not recover, and decision was made to proceed with stat cesarean delivery. The patient was verbally consented prior to proceeding. In terms of her mastocytosis, she received 100 mg IV hydrocortisone at time of delivery. She received an epidural for pain control postop (section under GA), which was discontinued ___ AM. She also received Tylenol because she could not get NSAIDs or narcotics. She experienced a mastocytosis flare (___) and received IV benadryl, solumedrol, famotidine. She was then mainatained on IV benadryl Q4H PRN, IV phenergen PRN, PO home meds (zyrtec, singulair, zantec) and interferon (own injection). Per her regular allergist, plan was made for 40 solumedrol (___) -> prednisone taper (starting at 40 on ___, 30 on ___ and ___. She also received heparin BID for DVT prophylaxis. Patient's course was also complicated by gestational hypertension and headache. Headache was suspected to be musculoskeletal, but postpartum pre-eclampsia and spinal headache were also considered. She was assessed by general anesthesia and felt to not have epidural related headache. She also received pre-eclampsia labs x2 which remained normal. Headache improved with sitting and standing, valium, flexeril. Patient also developed rash on buttocks that was felt to be due to episodes of incontinence while on L&D. Improved with fluconazole, clotimazole. Patient was discharged to home in stable condition on ___. Other Results: ___ 06:35AM TYPE-ART PO2-13* PCO2-85* PH-7.06* TOTAL CO2-26 BASE XS--11 COMMENTS-CORD ___ ___ 06:32AM ___ PO2-14* PCO2-81* PH-7.08* TOTAL CO2-26 BASE XS--10 COMMENTS-CORD VEIN ___ 06:05AM WBC-14.9*# RBC-4.56 HGB-13.6 HCT-38.0 MCV-83 MCH-29.8 MCHC-35.8 RDW-13.2 RDWSD-39.5 ___ 06:05AM PLT COUNT-256

2132-12-25 23:11:00

ENGLISH

SINGLE

WHITE

F

[[20738530, Timestamp('2132-12-25 23:15:22'), '', 'PSYCH']]

[[{'Medications on Admission': ':\nYaz, OCP daily', 'Brief Hospital Course': ':\nLegal: ___\nPsych: She openly described her feelings of depression and \nsuicidal ideation and appeared psychomotor retarded and with \nrestricted affect on intial interview. Given her history of ? \nhypomanic/manic episodes, she was started on Seroquel for its \nmood stabilizing and antidepressant effects. She talked alot \nabout her family dynamics, the death of several friends, and her \nfeeling bored and isolated living in ___ during her ___ \nbreak from college. She spoke openly about how she wanted to be \ncloser to her father, but his drinking had turned their \nrelationship into one where he was very critical of her. She \ndescribed how she would use drugs to "numb her feelings and \nrelieve her boredom." Over the course of her hospitalization, \nshe gradually appeared brighter and was more active in groups \nand with getting to know others on the unit. For example, she \nwas observed playing the piano for another patient, the day \nbefore discharge. She had daily visits from friends and her \nparents and she began to look forward to discharge. Her \nsuicidal ideations abated, and she started to make plans for the \nnext few months. She decided that she wanted to not return to \nschool, this semester, instead she would lease a horse from a \nfriend and take care of it daily. She declined to participate \nin a partial program upon discharge, but did express interest in \npsychotherapy and following up with a psychiatrist at ___ \nCounselling. She also went to her first AA meeting here on the \nunit and said she found it "interesting." She said that she was \nplanning to avoid using illicit drugs and that she understood \nthat these were risky given her mood instability and recent \nSuicide attempts. She was given information on outpatient \nsubstance abuse programs/resources and partial programs (if she \nchanged her mind) upon discharge. \n\nMedical: no active issues. \n\nFamily meeting: the patient\'s mother met with social worker, \n___ and the patient prior to discharge. \n\n', 'Pertinent Results:': '\n___ 08:15PM GLUCOSE-109* UREA N-12 CREAT-1.0 SODIUM-137 \nPOTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-26 ANION GAP-11\n___ 08:15PM estGFR-Using this\n___ 08:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG \nbnzodzpn-NEG barbitrt-NEG tricyclic-NEG\n___ 08:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG \nbnzodzpn-NEG barbitrt-NEG tricyclic-NEG\n___ 08:15PM URINE HOURS-RANDOM\n___ 08:15PM URINE HOURS-RANDOM\n___ 08:15PM URINE GR HOLD-HOLD\n___ 08:15PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG \ncocaine-NEG amphetmn-NEG mthdone-NEG\n___ 08:15PM WBC-5.5 RBC-4.04* HGB-12.7 HCT-34.4* MCV-85 \nMCH-31.5 MCHC-37.1* RDW-12.8\n___ 08:15PM NEUTS-46.8* LYMPHS-46.5* MONOS-3.2 EOS-3.1 \nBASOS-0.4\n___ 08:15PM PLT COUNT-268\n___ 08:15PM URINE COLOR-Yellow APPEAR-Clear SP ___\n___ 08:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 \nLEUK-NEG\n\n', 'Physical Exam:|Physical': '\nCleared by ___ ED staff for admission. \n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\n___ y/o female with no formal psychiatric history who states that\nshe overdosed on 18 Klonopins (1 mg each) 2 days ago in a \nsuicide\nattempt, drank a bottle of Robitussin this AM to numb herself,\nand then climbed into a tree in her yard and attempted to hang\nherself. She say the rope blew out of her hands, which became\nvery cold from the weather and then she fell out of the tree (~8\nfeet) onto her back, without reported injury or pain. She also\nsays that over the past two days she has been scratching her\nforearms "to relieve frustration." She does have superficial\nscratches on b/l forearms. She says that she has been under \nalot\nof stress secondary to her parents getting divorced, her father\n(who is an alcoholic) and away in ___ getting treatment,\nand she has had 4 friends die in a little over the year (three \nin\nDUI accidents and one by overdose several days ago). She says \n"I\nfeel like a burden on my parents...I\'m like my dad and I love\nhim, but that scares me." She says the suicide attempts have\nbeen precipitated by arguments she has had with her mother. She\nsays she has been feeling depressed for ___ years, but also\nendorses several episodes where she has had elevated mood, \nracing\nthoughts, excessive spending, and decreased need for sleep for\n___ weeks/episode. Currently she endorses anhedonia, poor\nconcentration, low energy, hopelessness, SI x one month, and\nincreased sleeping. She also says that she feels that she has\nhad about 4 panic attacks in the past. She describes these as\ncoming out of the blue, lasting 10 minutes, with SOB, triple\nvision, and jaw clenching. \n Spoke to mother ___, who confirms the story of her\nfalling from tree and finding the rope that she says she used to\nhang self. Says she has had periods of mood lability and\ndespondency, and that she admitted to her today that she had\ntried to overdose on the klonopins. She said she has tried\nseveral times to get her an appointment to see a psychiatrist. \n\nPast Psychiatric History:\n\nDiagoses: none \nPrior Hospitalizations: none\nPrevious Medications trials: none\nOutpatient treaters: none currently, says she has an \nappointment\nin ___ at ___. \n\nPast Medical History:\nGERD\nACNE, chronic\nh/o viral meningitis ___ years ago. \n\nSocial History:\nSUBSTANCE ABUSE HISTORY (INCLUDE HISTORY OF D.T.\'S, WITHDRAWAL\nSEIZURES, BLACKOUTS, DETOX TREATMENT, I.V. USAGE):\nETOH: none recent, but previously in binge drinking pattern.\nPercocets and Klonopins: Takes every couple of weeks to "numb\nherself."\nMJ: weekly\nCocaine and Ectasy: every couple of months.\nNo IVDU. \n\nSOCIAL HISTORY (FAMILY OF ORIGIN, CHILDHOOD, PHYSICAL/SEXUAL\nABUSE HISTORY, EDUCATION, EMPLOYMENT, RELATIONSHIPS, SEXUAL\nHISTORY/STD RISKS, MILITARY RECORD, LEGAL HISTORY, ETC.):\nB/R in ___. ___ at ___ in ___, studies ___ and Antropology. Says she \ngets\nA\'s and B\'s in school. Currently at home on ___ break. \nParents are getting a divorce. Also has younger brother age ___. \n\n___ current legal problems, but was arrested for possession \nof\ndrug paraphenalia (pipe). Denies h/o of abuse. \n\nFamily History:\nFather alcoholic, believes he may have bipolar d/o\nyounger brother with depression\n\n', 'Chief Complaint:|Complaint:': '\n"I have been trying to kill myself." \n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nMorphine And Related\n\n'}, '17753742-DS-13', 13, 'psychiatry']]

[]

[[20738530, Timestamp('2132-12-26 19:00:00'), Timestamp('2132-12-27 18:00:00'), 'MAIN', 'Lorazepam', '003758', '00904150161', '1mg Tablet'], [20738530, Timestamp('2132-12-26 02:00:00'), Timestamp('2132-12-31 20:00:00'), 'MAIN', 'Aluminum-Magnesium Hydrox.-Simethicone', '002701', '00121176130', '30 mL UDCup'], [20738530, Timestamp('2132-12-26 11:00:00'), Timestamp('2132-12-31 20:00:00'), 'MAIN', 'Quetiapine Fumarate', '034187', '00310027539', '25mg Tablet'], [20738530, Timestamp('2132-12-26 00:00:00'), Timestamp('2132-12-26 11:00:00'), 'MAIN', 'Sodium Chloride 0.9% Flush', '', '0', 'Syringe'], [20738530, Timestamp('2132-12-26 08:00:00'), Timestamp('2132-12-31 20:00:00'), 'MAIN', 'YAZ 28', '060548 ', '', '3-20'], [20738530, Timestamp('2132-12-26 02:00:00'), Timestamp('2132-12-27 01:00:00'), 'MAIN', 'Tuberculin Protein', '009700', '49281075221', '0.1mL Syringe'], [20738530, Timestamp('2132-12-26 02:00:00'), Timestamp('2132-12-31 20:00:00'), 'MAIN', 'Acetaminophen', '004489', '00182844789', '325mg Tablet'], [20738530, Timestamp('2132-12-26 02:00:00'), Timestamp('2132-12-31 20:00:00'), 'MAIN', 'Milk of Magnesia', '003026', '66689036430', '30mL UD Cup'], [20738530, Timestamp('2132-12-26 20:00:00'), Timestamp('2132-12-27 15:00:00'), 'MAIN', 'Quetiapine Fumarate', '034187', '00310027539', '25mg Tablet']]

[]

['psychiatry']

[[51221, Timestamp('2132-12-26 05:55:00'), Timestamp('2132-12-26 06:30:00'), 'Hematocrit'], [51222, Timestamp('2132-12-26 05:55:00'), Timestamp('2132-12-26 06:30:00'), 'Hemoglobin'], [51248, Timestamp('2132-12-26 05:55:00'), Timestamp('2132-12-26 06:30:00'), 'MCH'], [51249, Timestamp('2132-12-26 05:55:00'), Timestamp('2132-12-26 06:30:00'), 'MCHC'], [51250, Timestamp('2132-12-26 05:55:00'), Timestamp('2132-12-26 06:30:00'), 'MCV'], [51265, Timestamp('2132-12-26 05:55:00'), Timestamp('2132-12-26 06:30:00'), 'Platelet Count'], [51277, Timestamp('2132-12-26 05:55:00'), Timestamp('2132-12-26 06:30:00'), 'RDW'], [51279, Timestamp('2132-12-26 05:55:00'), Timestamp('2132-12-26 06:30:00'), 'Red Blood Cells'], [51301, Timestamp('2132-12-26 05:55:00'), Timestamp('2132-12-26 06:30:00'), 'White Blood Cells'], [50861, Timestamp('2132-12-26 05:55:00'), Timestamp('2132-12-26 06:48:00'), 'Alanine Aminotransferase (ALT)'], [50863, Timestamp('2132-12-26 05:55:00'), Timestamp('2132-12-26 06:48:00'), 'Alkaline Phosphatase'], [50868, Timestamp('2132-12-26 05:55:00'), Timestamp('2132-12-26 06:48:00'), 'Anion Gap'], [50878, Timestamp('2132-12-26 05:55:00'), Timestamp('2132-12-26 06:48:00'), 'Asparate Aminotransferase (AST)'], [50882, Timestamp('2132-12-26 05:55:00'), Timestamp('2132-12-26 06:48:00'), 'Bicarbonate'], [50885, Timestamp('2132-12-26 05:55:00'), Timestamp('2132-12-26 06:48:00'), 'Bilirubin, Total'], [50893, Timestamp('2132-12-26 05:55:00'), Timestamp('2132-12-26 06:48:00'), 'Calcium, Total'], [50902, Timestamp('2132-12-26 05:55:00'), Timestamp('2132-12-26 06:48:00'), 'Chloride'], [50912, Timestamp('2132-12-26 05:55:00'), Timestamp('2132-12-26 06:48:00'), 'Creatinine'], [50931, Timestamp('2132-12-26 05:55:00'), Timestamp('2132-12-26 06:48:00'), 'Glucose'], [50946, Timestamp('2132-12-26 05:55:00'), Timestamp('2132-12-26 06:49:00'), 'Human Chorionic Gonadotropin'], [50960, Timestamp('2132-12-26 05:55:00'), Timestamp('2132-12-26 06:48:00'), 'Magnesium'], [50970, Timestamp('2132-12-26 05:55:00'), Timestamp('2132-12-26 06:48:00'), 'Phosphate'], [50971, Timestamp('2132-12-26 05:55:00'), Timestamp('2132-12-26 06:48:00'), 'Potassium'], [50983, Timestamp('2132-12-26 05:55:00'), Timestamp('2132-12-26 06:48:00'), 'Sodium'], [50993, Timestamp('2132-12-26 05:55:00'), Timestamp('2132-12-26 12:07:00'), 'Thyroid Stimulating Hormone'], [51006, Timestamp('2132-12-26 05:55:00'), Timestamp('2132-12-26 06:48:00'), 'Urea Nitrogen'], [50924, Timestamp('2132-12-26 13:36:00'), Timestamp('2132-12-26 21:12:00'), 'Ferritin'], [50952, Timestamp('2132-12-26 13:36:00'), Timestamp('2132-12-26 21:12:00'), 'Iron'], [50953, Timestamp('2132-12-26 13:36:00'), Timestamp('2132-12-26 21:12:00'), 'Iron Binding Capacity, Total'], [50998, Timestamp('2132-12-26 13:36:00'), Timestamp('2132-12-26 21:12:00'), 'Transferrin']]

Question: A 20 F is admitted. He/she says he/she has "I have been trying to kill myself." . History of illness: ___ y/o female with no formal psychiatric history who states that she overdosed on 18 Klonopins (1 mg each) 2 days ago in a suicide attempt, drank a bottle of Robitussin this AM to numb herself, and then climbed into a tree in her yard and attempted to hang herself. She say the rope blew out of her hands, which became very cold from the weather and then she fell out of the tree (~8 feet) onto her back, without reported injury or pain. She also says that over the past two days she has been scratching her forearms "to relieve frustration." She does have superficial scratches on b/l forearms. She says that she has been under alot of stress secondary to her parents getting divorced, her father (who is an alcoholic) and away in ___ getting treatment, and she has had 4 friends die in a little over the year (three in DUI accidents and one by overdose several days ago). She says "I feel like a burden on my parents...I'm like my dad and I love him, but that scares me." She says the suicide attempts have been precipitated by arguments she has had with her mother. She says she has been feeling depressed for ___ years, but also endorses several episodes where she has had elevated mood, racing thoughts, excessive spending, and decreased need for sleep for ___ weeks/episode. Currently she endorses anhedonia, poor concentration, low energy, hopelessness, SI x one month, and increased sleeping. She also says that she feels that she has had about 4 panic attacks in the past. She describes these as coming out of the blue, lasting 10 minutes, with SOB, triple vision, and jaw clenching. Spoke to mother ___, who confirms the story of her falling from tree and finding the rope that she says she used to hang self. Says she has had periods of mood lability and despondency, and that she admitted to her today that she had tried to overdose on the klonopins. She said she has tried several times to get her an appointment to see a psychiatrist. Past Psychiatric History: Diagoses: none Prior Hospitalizations: none Previous Medications trials: none Outpatient treaters: none currently, says she has an appointment in ___ at ___. Past Medical History: GERD ACNE, chronic h/o viral meningitis ___ years ago. Social History: SUBSTANCE ABUSE HISTORY (INCLUDE HISTORY OF D.T.'S, WITHDRAWAL SEIZURES, BLACKOUTS, DETOX TREATMENT, I.V. USAGE): ETOH: none recent, but previously in binge drinking pattern. Percocets and Klonopins: Takes every couple of weeks to "numb herself." MJ: weekly Cocaine and Ectasy: every couple of months. No IVDU. SOCIAL HISTORY (FAMILY OF ORIGIN, CHILDHOOD, PHYSICAL/SEXUAL ABUSE HISTORY, EDUCATION, EMPLOYMENT, RELATIONSHIPS, SEXUAL HISTORY/STD RISKS, MILITARY RECORD, LEGAL HISTORY, ETC.): B/R in ___. ___ at ___ in ___, studies ___ and Antropology. Says she gets A's and B's in school. Currently at home on ___ break. Parents are getting a divorce. Also has younger brother age ___. ___ current legal problems, but was arrested for possession of drug paraphenalia (pipe). Denies h/o of abuse. Family History: Father alcoholic, believes he may have bipolar d/o younger brother with depression Allergies: Morphine And Related What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Lorazepam Aluminum-Magnesium Hydrox.-Simethicone Quetiapine Fumarate Sodium Chloride 0.9% Flush YAZ 28 Tuberculin Protein Acetaminophen Milk of Magnesia Quetiapine Fumarate Target Lab Orders: Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells Alanine Aminotransferase (ALT) Alkaline Phosphatase Anion Gap Asparate Aminotransferase (AST) Bicarbonate Bilirubin, Total Calcium, Total Chloride Creatinine Glucose Human Chorionic Gonadotropin Magnesium Phosphate Potassium Sodium Thyroid Stimulating Hormone Urea Nitrogen Ferritin Iron Iron Binding Capacity, Total Transferrin Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : Legal: ___ Psych: She openly described her feelings of depression and suicidal ideation and appeared psychomotor retarded and with restricted affect on intial interview. Given her history of ? hypomanic/manic episodes, she was started on Seroquel for its mood stabilizing and antidepressant effects. She talked alot about her family dynamics, the death of several friends, and her feeling bored and isolated living in ___ during her ___ break from college. She spoke openly about how she wanted to be closer to her father, but his drinking had turned their relationship into one where he was very critical of her. She described how she would use drugs to "numb her feelings and relieve her boredom." Over the course of her hospitalization, she gradually appeared brighter and was more active in groups and with getting to know others on the unit. For example, she was observed playing the piano for another patient, the day before discharge. She had daily visits from friends and her parents and she began to look forward to discharge. Her suicidal ideations abated, and she started to make plans for the next few months. She decided that she wanted to not return to school, this semester, instead she would lease a horse from a friend and take care of it daily. She declined to participate in a partial program upon discharge, but did express interest in psychotherapy and following up with a psychiatrist at ___ Counselling. She also went to her first AA meeting here on the unit and said she found it "interesting." She said that she was planning to avoid using illicit drugs and that she understood that these were risky given her mood instability and recent Suicide attempts. She was given information on outpatient substance abuse programs/resources and partial programs (if she changed her mind) upon discharge. Medical: no active issues. Family meeting: the patient's mother met with social worker, ___ and the patient prior to discharge. Other Results: ___ 08:15PM GLUCOSE-109* UREA N-12 CREAT-1.0 SODIUM-137 POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-26 ANION GAP-11 ___ 08:15PM estGFR-Using this ___ 08:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 08:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 08:15PM URINE HOURS-RANDOM ___ 08:15PM URINE HOURS-RANDOM ___ 08:15PM URINE GR HOLD-HOLD ___ 08:15PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG ___ 08:15PM WBC-5.5 RBC-4.04* HGB-12.7 HCT-34.4* MCV-85 MCH-31.5 MCHC-37.1* RDW-12.8 ___ 08:15PM NEUTS-46.8* LYMPHS-46.5* MONOS-3.2 EOS-3.1 BASOS-0.4 ___ 08:15PM PLT COUNT-268 ___ 08:15PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 08:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG

2150-10-13 18:25:00

ENGLISH

WIDOWED

BLACK/AFRICAN AMERICAN

F

[[25673006, Timestamp('2150-10-13 18:26:18'), '', 'EYE'], [25673006, Timestamp('2150-10-13 18:28:15'), 'EYE', 'MED']]

[[{'Medications on Admission': ':\nThe Preadmission Medication list is accurate and complete.\n1. Atorvastatin 40 mg PO QPM \n2. Timolol Maleate 0.5% 1 DROP LEFT EYE BID \n3. Valsartan 80 mg PO DAILY \n4. Glargine 14 Units Breakfast\n5. Artificial Tears ___ DROP LEFT EYE PRN dry eye \n6. Aspirin 81 mg PO DAILY \n\nFacility:\n___', 'Brief Hospital Course': ':\n# S/p enucleation of the right eye \nThere were no complications and the patient tolerated the \nprocedure well. Her pain was controlled with Tylenol. She was \ngiven instructions on how to care for the eye at home. She will \nfollow-up with Ophthalmology in 1 week. While hospitalized, she \nwas seen by ___, OT and social work. She was sent home with home \n___ and OT, ___ and services for the blind. \n\n# Hyperlipidemia-atorvastatin 40 mg PO QPM\n\n# Glaucoma-Timolol Maleate 0.5% 1 DROP LEFT EYE BID\n\n# Hypertension-valsartan 80 mg PO/NG DAILY\n\n# Insulin-dependent diabetes-continue Lantus and sliding scale \ninsulin\n\n# Dry eye-continue artificial tears in left eye\n\n', 'Pertinent Results:': '\n___ 06:41AM BLOOD WBC-7.3 RBC-4.29 Hgb-11.2 Hct-37.4 MCV-87 \nMCH-26.1 MCHC-29.9* RDW-13.2 RDWSD-41.3 Plt ___\n___ 06:41AM BLOOD Neuts-67.9 ___ Monos-8.1 Eos-0.1* \nBaso-0.4 Im ___ AbsNeut-4.96 AbsLymp-1.69 AbsMono-0.59 \nAbsEos-0.01* AbsBaso-0.03\n___ 06:41AM BLOOD Glucose-126* UreaN-22* Creat-1.2* Na-141 \nK-5.1 Cl-104 HCO3-24 AnGap-13\n___ 06:41AM BLOOD Calcium-9.3 Phos-3.8 Mg-1.9\n\n', 'Physical Exam:|Physical': '\nMentation: Alert, speaks in full sentences\nEyes: Bandage in place over right eye\nEars/Nose/Mouth/Throat: MMM\nNeck: Supple, no JVD or carotid bruits appreciated\nResp: CTA bilat\nCV: RRR, normal S1S2\nGI: Soft, NT/ND, normoactive bowel sounds, no masses or \norganomegaly noted\nGU: WNL\nRectal: Guaiac neg\nSkin: No rashes or lesions noted; no pressure ulcers\nExtremities: No edema. 2+ radial, 1+ DP pulses bilaterally\nLymph/Heme/Immun: No cervical ___ noted\nNeuro:\n- Mental Status: Alert & oriented x3. Able to relate history\nwithout difficulty\n-Cranial Nerves: III-XII intact\n-Motor: Normal bulk, strength and tone throughout. No abnormal\nmovements noted\n-Sensory: No deficits to light touch throughout.\nPsych: WNL\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\n___ with PMH of IDDM2, hypertension, alcohol abuse, papillary \nthyroid carcinoma status post hemithyroidectomy, congenital \ncataracts with exotropia and glaucoma, and retinal detachment \nwho presents after scheduled R eye enucleation.\n\nPt was seen in Ophthalmology clinic in ___ for end stage \nglaucoma. She was found to have total retinal detachment with \nvitreous hemorrhage possibly associated with a scleral abscess. \nDr. ___ who has been following her for many years \nevaluated her and recommended proceeding with enucleation in the \nright eye under general endotracheal anesthesia as the best way \nof decreasing pain, removing a possibly infected globe, reducing \nthe risk of systemic infection or meningitis, and decreasing \nswelling in the right orbit.\n\nOn ROS, patient denies fever, chills, shortness of breath, \nrashes or changes in bowel habits, nausea, vomiting. Patient \ndoes endorse continued right eye that radiates to her temple. \n\nOperative report:\nNo orbital inflammation or abscess detected. Globe intact and\nsent to pathology. No bleeding during closure. \n\nPast Medical History:\nDM\nGlaucoma\nCataracts\nRetinal detachment\nHTN\nHLD\nOsteoporosis\nAlcohol abuse\nPapillary thyroid carcinoma, status post hemithyroidectomy \n___\nRight hip fracture ___\n\nStatus post CCY\n\nSocial History:\n___\nFamily History:\nMother died in her ___ from complications of DM; father died in \nhis ___ of unknown causes. Both parents and all siblings had DM.\n\n', 'Chief Complaint:|Complaint:': '\nPost-op from right eye enucleation\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nLisinopril\n\n'}, '10448029-DS-20', 20, 'medicine']]

[]

[[25673006, Timestamp('2150-10-13 20:00:00'), Timestamp('2150-10-15 20:00:00'), 'MAIN', 'Dextrose 50%', '001989', '00409490234', '25 g / 50 mL Syringe'], [25673006, Timestamp('2150-10-14 08:00:00'), Timestamp('2150-10-15 20:00:00'), 'MAIN', 'Valsartan', '048401', '00078035834', '80mg Tablet'], [25673006, Timestamp('2150-10-13 20:00:00'), Timestamp('2150-10-15 20:00:00'), 'MAIN', 'Glucagon', '066517', '00597026010', '1mg Vial'], [25673006, Timestamp('2150-10-13 20:00:00'), Timestamp('2150-10-15 20:00:00'), 'MAIN', 'Acetaminophen', '004489', '00904198261', '325mg Tablet'], [25673006, Timestamp('2150-10-14 08:00:00'), Timestamp('2150-10-13 22:00:00'), 'MAIN', 'Aspirin', '004380', '00904628889', '81mg Tab'], [25673006, Timestamp('2150-10-13 20:00:00'), Timestamp('2150-10-15 20:00:00'), 'MAIN', 'Insulin', '001723', '00002821501', '100 Units / mL - 10 mL Vial'], [25673006, Timestamp('2150-10-13 20:00:00'), Timestamp('2150-10-14 16:00:00'), 'MAIN', 'OxyCODONE (Immediate Release)', '004225', '00904644461', '5mg Tablet'], [25673006, Timestamp('2150-10-13 20:00:00'), Timestamp('2150-10-15 20:00:00'), 'MAIN', 'Glucose Gel', '001781', '38396055018', '15 g Tube'], [25673006, Timestamp('2150-10-13 20:00:00'), Timestamp('2150-10-13 19:00:00'), 'MAIN', 'Artificial Tears', '030016', '00023050601', '0.4 mL DROPPERETTE'], [25673006, Timestamp('2150-10-13 19:00:00'), Timestamp('2150-10-13 22:00:00'), 'MAIN', 'Heparin', '006549', '63323026201', '5000 Units / mL- 1mL Vial'], [25673006, Timestamp('2150-10-13 20:00:00'), Timestamp('2150-10-15 20:00:00'), 'MAIN', 'Heparin', '006549', '63323026201', '5000 Units / mL- 1mL Vial'], [25673006, Timestamp('2150-10-13 20:00:00'), Timestamp('2150-10-15 20:00:00'), 'MAIN', 'Atorvastatin', '029969', '00904629261', '40mg Tablet'], [25673006, Timestamp('2150-10-13 20:00:00'), Timestamp('2150-10-15 20:00:00'), 'MAIN', 'Timolol Maleate 0.5%', '007856', '61314022705', '5 mL Bottle'], [25673006, Timestamp('2150-10-13 08:00:00'), Timestamp('2150-10-15 20:00:00'), 'MAIN', 'Insulin', '047780', '00088222033', '100 Units / mL - 10 mL Vial'], [25673006, Timestamp('2150-10-13 20:00:00'), Timestamp('2150-10-15 20:00:00'), 'MAIN', 'Artificial Tears', '030016', '00023050601', '0.4 mL DROPPERETTE']]

[]

['medicine']

[[51133, Timestamp('2150-10-14 06:41:00'), Timestamp('2150-10-14 08:43:00'), 'Absolute Lymphocyte Count'], [51146, Timestamp('2150-10-14 06:41:00'), Timestamp('2150-10-14 08:43:00'), 'Basophils'], [51200, Timestamp('2150-10-14 06:41:00'), Timestamp('2150-10-14 08:43:00'), 'Eosinophils'], [51221, Timestamp('2150-10-14 06:41:00'), Timestamp('2150-10-14 08:43:00'), 'Hematocrit'], [51222, Timestamp('2150-10-14 06:41:00'), Timestamp('2150-10-14 08:43:00'), 'Hemoglobin'], [51244, Timestamp('2150-10-14 06:41:00'), Timestamp('2150-10-14 08:43:00'), 'Lymphocytes'], [51248, Timestamp('2150-10-14 06:41:00'), Timestamp('2150-10-14 08:43:00'), 'MCH'], [51249, Timestamp('2150-10-14 06:41:00'), Timestamp('2150-10-14 08:43:00'), 'MCHC'], [51250, Timestamp('2150-10-14 06:41:00'), Timestamp('2150-10-14 08:43:00'), 'MCV'], [51254, Timestamp('2150-10-14 06:41:00'), Timestamp('2150-10-14 08:43:00'), 'Monocytes'], [51256, Timestamp('2150-10-14 06:41:00'), Timestamp('2150-10-14 08:43:00'), 'Neutrophils'], [51265, Timestamp('2150-10-14 06:41:00'), Timestamp('2150-10-14 08:43:00'), 'Platelet Count'], [51277, Timestamp('2150-10-14 06:41:00'), Timestamp('2150-10-14 08:43:00'), 'RDW'], [51279, Timestamp('2150-10-14 06:41:00'), Timestamp('2150-10-14 08:43:00'), 'Red Blood Cells'], [51301, Timestamp('2150-10-14 06:41:00'), Timestamp('2150-10-14 08:43:00'), 'White Blood Cells'], [52069, Timestamp('2150-10-14 06:41:00'), Timestamp('2150-10-14 08:43:00'), 'Absolute Basophil Count'], [52073, Timestamp('2150-10-14 06:41:00'), Timestamp('2150-10-14 08:43:00'), 'Absolute Eosinophil Count'], [52074, Timestamp('2150-10-14 06:41:00'), Timestamp('2150-10-14 08:43:00'), 'Absolute Monocyte Count'], [52075, Timestamp('2150-10-14 06:41:00'), Timestamp('2150-10-14 08:43:00'), 'Absolute Neutrophil Count'], [52135, Timestamp('2150-10-14 06:41:00'), Timestamp('2150-10-14 08:43:00'), 'Immature Granulocytes'], [52172, Timestamp('2150-10-14 06:41:00'), Timestamp('2150-10-14 08:43:00'), 'RDW-SD'], [50868, Timestamp('2150-10-14 06:41:00'), Timestamp('2150-10-14 09:06:00'), 'Anion Gap'], [50882, Timestamp('2150-10-14 06:41:00'), Timestamp('2150-10-14 09:06:00'), 'Bicarbonate'], [50893, Timestamp('2150-10-14 06:41:00'), Timestamp('2150-10-14 09:06:00'), 'Calcium, Total'], [50902, Timestamp('2150-10-14 06:41:00'), Timestamp('2150-10-14 09:06:00'), 'Chloride'], [50912, Timestamp('2150-10-14 06:41:00'), Timestamp('2150-10-14 09:06:00'), 'Creatinine'], [50920, Timestamp('2150-10-14 06:41:00'), Timestamp('2150-10-14 09:06:00'), 'Estimated GFR (MDRD equation)'], [50931, Timestamp('2150-10-14 06:41:00'), Timestamp('2150-10-14 09:06:00'), 'Glucose'], [50934, Timestamp('2150-10-14 06:41:00'), Timestamp('2150-10-14 09:06:00'), 'H'], [50947, Timestamp('2150-10-14 06:41:00'), Timestamp('2150-10-14 09:06:00'), 'I'], [50960, Timestamp('2150-10-14 06:41:00'), Timestamp('2150-10-14 09:06:00'), 'Magnesium'], [50970, Timestamp('2150-10-14 06:41:00'), Timestamp('2150-10-14 09:06:00'), 'Phosphate'], [50971, Timestamp('2150-10-14 06:41:00'), Timestamp('2150-10-14 09:06:00'), 'Potassium'], [50983, Timestamp('2150-10-14 06:41:00'), Timestamp('2150-10-14 09:06:00'), 'Sodium'], [51006, Timestamp('2150-10-14 06:41:00'), Timestamp('2150-10-14 09:06:00'), 'Urea Nitrogen'], [51678, Timestamp('2150-10-14 06:41:00'), Timestamp('2150-10-14 09:06:00'), 'L'], [51237, Timestamp('2150-10-14 06:41:00'), Timestamp('2150-10-14 09:08:00'), 'INR(PT)'], [51274, Timestamp('2150-10-14 06:41:00'), Timestamp('2150-10-14 09:08:00'), 'PT'], [51275, Timestamp('2150-10-14 06:41:00'), Timestamp('2150-10-14 09:09:00'), 'PTT']]

Question: A 69 F is admitted. He/she says he/she has Post-op from right eye enucleation . History of illness: ___ with PMH of IDDM2, hypertension, alcohol abuse, papillary thyroid carcinoma status post hemithyroidectomy, congenital cataracts with exotropia and glaucoma, and retinal detachment who presents after scheduled R eye enucleation. Pt was seen in Ophthalmology clinic in ___ for end stage glaucoma. She was found to have total retinal detachment with vitreous hemorrhage possibly associated with a scleral abscess. Dr. ___ who has been following her for many years evaluated her and recommended proceeding with enucleation in the right eye under general endotracheal anesthesia as the best way of decreasing pain, removing a possibly infected globe, reducing the risk of systemic infection or meningitis, and decreasing swelling in the right orbit. On ROS, patient denies fever, chills, shortness of breath, rashes or changes in bowel habits, nausea, vomiting. Patient does endorse continued right eye that radiates to her temple. Operative report: No orbital inflammation or abscess detected. Globe intact and sent to pathology. No bleeding during closure. Past Medical History: DM Glaucoma Cataracts Retinal detachment HTN HLD Osteoporosis Alcohol abuse Papillary thyroid carcinoma, status post hemithyroidectomy ___ Right hip fracture ___ Status post CCY Social History: ___ Family History: Mother died in her ___ from complications of DM; father died in his ___ of unknown causes. Both parents and all siblings had DM. Allergies: Lisinopril What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Dextrose 50% Valsartan Glucagon Acetaminophen Aspirin Insulin OxyCODONE (Immediate Release) Glucose Gel Artificial Tears Heparin Heparin Atorvastatin Timolol Maleate 0.5% Insulin Artificial Tears Target Lab Orders: Absolute Lymphocyte Count Basophils Eosinophils Hematocrit Hemoglobin Lymphocytes MCH MCHC MCV Monocytes Neutrophils Platelet Count RDW Red Blood Cells White Blood Cells Absolute Basophil Count Absolute Eosinophil Count Absolute Monocyte Count Absolute Neutrophil Count Immature Granulocytes RDW-SD Anion Gap Bicarbonate Calcium, Total Chloride Creatinine Estimated GFR (MDRD equation) Glucose H I Magnesium Phosphate Potassium Sodium Urea Nitrogen L INR(PT) PT PTT Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : # S/p enucleation of the right eye There were no complications and the patient tolerated the procedure well. Her pain was controlled with Tylenol. She was given instructions on how to care for the eye at home. She will follow-up with Ophthalmology in 1 week. While hospitalized, she was seen by ___, OT and social work. She was sent home with home ___ and OT, ___ and services for the blind. # Hyperlipidemia-atorvastatin 40 mg PO QPM # Glaucoma-Timolol Maleate 0.5% 1 DROP LEFT EYE BID # Hypertension-valsartan 80 mg PO/NG DAILY # Insulin-dependent diabetes-continue Lantus and sliding scale insulin # Dry eye-continue artificial tears in left eye Other Results: ___ 06:41AM BLOOD WBC-7.3 RBC-4.29 Hgb-11.2 Hct-37.4 MCV-87 MCH-26.1 MCHC-29.9* RDW-13.2 RDWSD-41.3 Plt ___ ___ 06:41AM BLOOD Neuts-67.9 ___ Monos-8.1 Eos-0.1* Baso-0.4 Im ___ AbsNeut-4.96 AbsLymp-1.69 AbsMono-0.59 AbsEos-0.01* AbsBaso-0.03 ___ 06:41AM BLOOD Glucose-126* UreaN-22* Creat-1.2* Na-141 K-5.1 Cl-104 HCO3-24 AnGap-13 ___ 06:41AM BLOOD Calcium-9.3 Phos-3.8 Mg-1.9

2127-03-12 11:20:00

ENGLISH

SINGLE

ASIAN

M

[[28757511, Timestamp('2127-03-12 11:21:33'), '', 'TRAUM']]

[[{'Medications on Admission': ':\nThe Preadmission Medication list is accurate and complete.\n1. This patient is not taking any preadmission medications\n\nFacility:\n___\n\n___ Diagnosis:\nRight intra-articular distal radius fracture 2 or more \nfragments.\nMetatarsal base fracture (left ___ digits)', 'Brief Hospital Course': ':\nMr. ___ was admitted to the hospital after a motor \nvehicle collision. In the ED he received a trauma CXR, a CT of \nhis Head, a CT of his chest, a CT of his cervical spine, Lower \nextremity plain films, Upper extremity plain films. This imaging \nrevealed revealed that his wrist was displaced completely \nbecause of a distal radius fracture, and fractures involving the \nbase of the second, third, and \nlikely fourth metatarsals concerning for Lisfranc fracture \ndislocation. The wrist was reduced surgically in the emergency \nroom. This provided an improvement in his median nerve symptoms \nto the point in preop he had intact sensation. Given the \ndisplacement and instability the patient was taken to the OR for \noperative fixation, please see operative note for details. An \nxray of his foot revealed a left foot metatarsal fracture, for \nthis he was fitted with an aircast. Post operatively, he was \ntransferred to the floor for observation. He did well and was \nstarted on a clear liquid diet. He tolerated this well without \npain or nausea and was subsequently advanced to a regular diet. \nOn ___ the patient worked with occupational therapy and \nphysical therapy who cleared the patient for home with support. \nOn ___ the patient was afebrile, ambulating with his \ncrutches, and tolerating a regular diet. He was educated on his \npost operative care and follow up and verbalized understanding \nand agreement with this plan. On ___ Mr. ___ was \ndischarged home with ___ services.\n\n', 'Pertinent Results:': '\n___ 03:35AM WBC-15.2* RBC-5.36 HGB-15.4 HCT-46.3 MCV-86 \nMCH-28.8 MCHC-33.3 RDW-12.5\n\n', 'Physical Exam:|Physical': '\nOn Admission:\n\nConstitutional: Comfortable, GCS 15, boarded and collared\nHEENT: Normocephalic, atraumatic, Pupils equal, round and\nreactive to light\nCcollar in place, no TTP\nChest: Clear to auscultation, no CW TTP/crepitus\nCardiovascular: Regular Rate and Rhythm\nAbdominal: Mild lower abd TTP\nRectal: Heme Negative\nGU/Flank: no blood at meatus\nExtr/Back: sig deformed R wrist, swollen R foot, pulses\nintact throughout\nSkin: 6cm curvilinear laceration distal aspect of R lateral\nthigh\nNeuro: Speech fluent, ___ intact\nPsych: Normal mood\n\nOn Discharge:\n\nGeneral: Awake, alert and oriented to person place and time. No \nacute distress.\nCardiovascular: Pulses intact, Regular rate and rhythm. No extra \nheart sounds.\nPulmonary: Clear to auscultation\nAbdomen: Soft, not tender, not distended\nExtremities: Left lower extremity, casted, no erythema, digits \nwarm and wel perfused and sensate. Right lower extremity WNL. \nRight upper extremity casted, dressings clean and dry.\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\nThis patient is a ___ year old male s/p MVC. Patient restrained \ndriver high speed MVC with multiple significantly injured \npassengers, requiring airlift from\nscene. Positive airbag deployment. Does not fully recall \nevent,extricated by EMS. C/o pain in wrist, leg, and lower \nabdomen.\n\nPast Medical History:\n-none-\n\nSocial History:\nPt works full time and is in school part-time for his MBA.\n\n', 'Chief Complaint:|Complaint:': '\nMotor Vehicle Collision\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nNo Known Allergies / Adverse Drug Reactions\n\n'}, '10205544-DS-10', 10, 'surgery']]

[['INDICATION: Status post MVA. Assess for fracture.\n\nCOMPARISON: CT torso from ___.\n\nAP CHEST AND AP PELVIS: A trauma board slightly limits evaluation of this\nstudy. The lungs are clear. The heart size is normal. The mediastinal\ncontours are normal. There are no pleural effusions. No pneumothorax is\nseen.\n\nThere is no acute fracture involving the bony pelvis or proximal femurs. \nThere is no dislocation. The bilateral femoroacetabular joints spaces are\npreserved. Keys project over the right proximal femur.\n\nIMPRESSION:\n\n1. No acute cardiac or pulmonary process.\n\n2. No acute fracture or dislocation involving the pelvic girdle.\n', '10205544-RR-14', 14, ''], ['INDICATION: Status post MVC. Assess for acute intracranial process.\n\nTECHNIQUE: Sequential axial images were acquired through the head without\nadministration of intravenous contrast material. Multiplanar reformats were\nperformed.\n\nCOMPARISON: None.\n\nFINDINGS: There is no evidence of intracranial hemorrhage, edema, shift of\nnormally midline structures, hydrocephalus, or acute large vascular\nterritorial infarction. The visualized portions of the orbits are\nunremarkable. The imaged aspects of the paranasal sinuses and mastoid air\ncells are well aerated. There is no acute fracture.\n\nIMPRESSION: No acute intracranial process.\n', '10205544-RR-15', 15, 'sequential axial images were acquired through the head without\nadministration of intravenous contrast material. multiplanar reformats were\nperformed.'], ['INDICATION: Status post MVC. Assess for fracture or malalignment.\n\nCOMPARISON: None.\n\nTECHNIQUE: MDCT axial images were acquired through the cervical spine without\nadministration of intravenous contrast material. Multiplanar reformats were\nperformed.\n\nFINDINGS: There is no acute fracture. Straightening of the cervical spine is\nlikely secondary to a cervical collar. There is otherwise no malalignment. \nNo prevertebral soft tissue edema or hematoma is seen. The visualized\nportions of the lung apices are clear. The thyroid gland is unremarkable. \nThere are no pathologically enlarged cervical lymph nodes. The visualized\naspects of the maxillary sinuses and mastoid air cells are well aerated.\n\nIMPRESSION:\n\n1. No acute fracture.\n\n2. Straightening of the cervical spine, likely secondary to cervical collar. \nOtherwise, no malalignment.\n', '10205544-RR-16', 16, 'mdct axial images were acquired through the cervical spine without\nadministration of intravenous contrast material. multiplanar reformats were\nperformed.'], ['INDICATION: Status post MVC. Assess for acute injury.\n\nCOMPARISON: None.\n\nTECHNIQUE: MDCT axial images were acquired through the chest, abdomen, and\npelvis during administration of 130 cc of intravenous Omnipaque contrast\nmaterial. Multiplanar reformats were performed.\n\nTOTAL DLP: 488 mGy-cm.\n\nCHEST CT: The visualized portion of the thyroid gland is unremarkable. The\nthoracic aorta is normal in caliber, and otherwise unremarkable. The right\nventricular outflow tract and its central branches are patent. The heart size\nis normal. There is no pericardial effusion. There is no mediastinal\nhematoma or pneumomediastinum. No pathologically enlarged mediastinal, hilar,\nor axillary lymph nodes are seen.\n\nThere is minimal bilateral lower lobe dependent atelectasis. The lungs are\notherwise clear. The tracheobronchial tree is patent to the segmental level\nbilaterally. There are no pleural effusions. No pneumothorax is seen.\n\nAn 8-mm simple cyst is seen within the left hepatic lobe. No additional\nhepatic lesions are identified. There was no intrahepatic biliary duct\ndilatation. The portal vein is patent. The gallbladder, spleen, pancreas,\nadrenal glands, and kidneys are normal. The thoracic esophagus is mildly\npatulous, without associated wall thickening. The stomach is unremarkable. \nThere are several fluid-filled loops of small bowel in the mid abdomen, with\nassociated mild wall thickening and mild surrounding mesenteric stranding,\nnonspecific in nature, but concerning for bowel injury (2:78). The small\nbowel is otherwise normal. The colon and appendix are normal. There is no\nfree fluid or free air in the abdomen. No pathologically enlarged abdominal\nlymph nodes are seen. The abdominal aorta is normal in caliber.\n\nPELVIS CT: The bladder is unremarkable. There is a small quantity of\nintraperitoneal high-density free fluid in the pelvis (2:107), likely\nhemorrhagic in nature. There are no pathologically enlarged pelvic lymph\nnodes.\n\nBONE WINDOW: There is no acute fracture. Mild deformity of the\nsuperoposterior aspect of the L2 vertebral body is likely degenerative in\nnature.\n\nIMPRESSION:\n\n1. Loops of mid-to-distal small bowel in the mid abdomen demonstrate mild\ndistension and slight wall thickening. There is minimal surrounding\nmesenteric stranding. These findings are nonspecific in nature, but\nconcerning for bowel injury.\n\n2. Small quantity of intraperitoneal hemorrhagic material in the dependent\nportion of the pelvis.\n\n3. No acute process in the chest.\n', '10205544-RR-17', 17, 'mdct axial images were acquired through the chest, abdomen, and\npelvis during administration of 130 cc of intravenous omnipaque contrast\nmaterial. multiplanar reformats were performed.'], ['INDICATION: Status post trauma with obvious deformity of the right wrist. \nEvaluate for fracture.\n\nCOMPARISON: None.\n\nRIGHT WRIST, FOREARM, AND ELBOW, 10 VIEWS TOTAL: There is a transverse\nfracture through the distal right radius with dorsal and proximal displacement\nof the dominant fracture fragment, including overriding of the fracture\nfragments by 2.5 cm. The radius aligns appropriately with the lunate abd\ncapitate as seen on the lateral view. There is dislocation of the distal\nradioulnar joint, with widening of the joint space to 8 mm. There is no\ndefinite right elbow joint effusion. No fracture or dislocation of the right\nelbow. Bone mineralization is normal. There is marked soft tissue swelling\nabout the wrist.\n\nIMPRESSION: Fracture dislocation of the right wrist, fully described above.\n', '10205544-RR-18', 18, ''], ['INDICATION: Status post MVC, assess for fracture or dislocation.\n\nCOMPARISON: None.\n\nBILATERAL FEMURS, TIBIAS, FIBULAS, AND ANKLES, 18 VIEWS TOTAL: There is a\ndorsal avulsion fracture through one of the left cuneiform/midfoot bones. No\nadditional acute fracture is identified. There is no dislocation. No knee\njoint effusions are seen. Mild soft tissue swelling is seen along the dorsum\nof the left mid foot. Unchanged right os acetabulare.\n\nIMPRESSION:\n\n1. Dorsal avulsion fracture of one of the left cuneiform/midfoot bones. \nFurther evaluation with dedicated left foot radiographs is recommended.\n\n2. No additional fractures are seen in either lower extremity.\n', '10205544-RR-19', 19, ''], ['RIGHT WRIST RADIOGRAPH PERFORMED ON ___ \n\nCOMPARISON: Prior exam from earlier today.\n\nCLINICAL HISTORY: Post-reduction, assess alignment.\n\nFINDINGS: Post-reduction views of the right wrist with AP, lateral, oblique\nprojections were obtained. Overlying plaster splint is in place, which\nsomewhat limits the evaluation of fine bony detail. There has been interval\nreduction with improvement in alignment at the distal radius. However, there\nis persistent dorsal angulation of the radiocarpal joint with impaction of the\nproximal and distal fracture fragments. Ulnar styloid fracture is\nre-demonstrated.\n', '10205544-RR-20', 20, ''], ['LEFT FOOT RADIOGRAPH PERFORMED ON ___ \n\nCOMPARISON: None.\n\nCLINICAL HISTORY: Pain in the left foot. Assess fracture.\n\nFINDINGS: There are fractures involving the base of the second, third, and\nlikely fourth metatarsals concerning for Lisfranc fracture dislocation. Also\nnoted is a fracture lucency, transverse in orientation through the proximal\nshaft of the second metatarsal. Associated soft tissue swelling is seen and\nmay be a mild subluxation of the mid foot as seen on the lateral projection. \nCT is advised.\n', '10205544-RR-21', 21, ''], ['STUDY: Right wrist, ___.\n\nCLINICAL HISTORY: Patient with distal radius ORIF.\n\nFINDINGS: Several images of the right wrist in the operating room demonstrate\nplacement of a volar fracture plate and associated screws fixating a fracture\nof the distal radius. There is good anatomic alignment, and there are no\nsigns for hardware-related complications. The total intraservice fluoroscopic\ntime was 68.8 seconds. Please refer to the operative note for additional\ndetails.\n', '10205544-RR-22', 22, '']]

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[]

['surgery']

[[51221, Timestamp('2127-03-13 00:21:00'), Timestamp('2127-03-13 00:40:00'), 'Hematocrit'], [51221, Timestamp('2127-03-13 01:21:00'), Timestamp('2127-03-13 04:47:00'), 'Hematocrit'], [50813, Timestamp('2127-03-13 01:37:00'), Timestamp('2127-03-13 01:37:00'), 'Lactate'], [50813, Timestamp('2127-03-13 04:30:00'), Timestamp('2127-03-13 04:31:00'), 'Lactate'], [51221, Timestamp('2127-03-13 06:50:00'), Timestamp('2127-03-13 08:49:00'), 'Hematocrit'], [51222, Timestamp('2127-03-13 06:50:00'), Timestamp('2127-03-13 08:49:00'), 'Hemoglobin'], [51248, Timestamp('2127-03-13 06:50:00'), Timestamp('2127-03-13 08:49:00'), 'MCH'], [51249, Timestamp('2127-03-13 06:50:00'), Timestamp('2127-03-13 08:49:00'), 'MCHC'], [51250, Timestamp('2127-03-13 06:50:00'), Timestamp('2127-03-13 08:49:00'), 'MCV'], [51265, Timestamp('2127-03-13 06:50:00'), Timestamp('2127-03-13 08:49:00'), 'Platelet Count'], [51277, Timestamp('2127-03-13 06:50:00'), Timestamp('2127-03-13 08:49:00'), 'RDW'], [51279, Timestamp('2127-03-13 06:50:00'), Timestamp('2127-03-13 08:49:00'), 'Red Blood Cells'], [51301, Timestamp('2127-03-13 06:50:00'), Timestamp('2127-03-13 08:49:00'), 'White Blood Cells'], [50868, Timestamp('2127-03-13 06:50:00'), Timestamp('2127-03-13 09:00:00'), 'Anion Gap'], [50882, Timestamp('2127-03-13 06:50:00'), Timestamp('2127-03-13 09:00:00'), 'Bicarbonate'], [50893, Timestamp('2127-03-13 06:50:00'), Timestamp('2127-03-13 09:00:00'), 'Calcium, Total'], [50902, Timestamp('2127-03-13 06:50:00'), Timestamp('2127-03-13 09:00:00'), 'Chloride'], [50912, Timestamp('2127-03-13 06:50:00'), Timestamp('2127-03-13 09:00:00'), 'Creatinine'], [50931, Timestamp('2127-03-13 06:50:00'), Timestamp('2127-03-13 09:00:00'), 'Glucose'], [50960, Timestamp('2127-03-13 06:50:00'), Timestamp('2127-03-13 09:00:00'), 'Magnesium'], [50970, Timestamp('2127-03-13 06:50:00'), Timestamp('2127-03-13 09:00:00'), 'Phosphate'], [50971, Timestamp('2127-03-13 06:50:00'), Timestamp('2127-03-13 09:00:00'), 'Potassium'], [50983, Timestamp('2127-03-13 06:50:00'), Timestamp('2127-03-13 09:00:00'), 'Sodium'], [51006, Timestamp('2127-03-13 06:50:00'), Timestamp('2127-03-13 09:00:00'), 'Urea Nitrogen'], [51221, Timestamp('2127-03-13 09:15:00'), Timestamp('2127-03-13 09:50:00'), 'Hematocrit'], [51222, Timestamp('2127-03-13 09:15:00'), Timestamp('2127-03-13 09:50:00'), 'Hemoglobin'], [51248, Timestamp('2127-03-13 09:15:00'), Timestamp('2127-03-13 09:50:00'), 'MCH'], [51249, Timestamp('2127-03-13 09:15:00'), Timestamp('2127-03-13 09:50:00'), 'MCHC'], [51250, Timestamp('2127-03-13 09:15:00'), Timestamp('2127-03-13 09:50:00'), 'MCV'], [51265, Timestamp('2127-03-13 09:15:00'), Timestamp('2127-03-13 09:50:00'), 'Platelet Count'], [51277, Timestamp('2127-03-13 09:15:00'), Timestamp('2127-03-13 09:50:00'), 'RDW'], [51279, Timestamp('2127-03-13 09:15:00'), Timestamp('2127-03-13 09:50:00'), 'Red Blood Cells'], [51301, Timestamp('2127-03-13 09:15:00'), Timestamp('2127-03-13 09:50:00'), 'White Blood Cells'], [50813, Timestamp('2127-03-13 09:32:00'), Timestamp('2127-03-13 09:33:00'), 'Lactate'], [50813, Timestamp('2127-03-13 10:47:00'), Timestamp('2127-03-13 10:50:00'), 'Lactate']]

Question: A 34 M is admitted. He/she says he/she has Motor Vehicle Collision . History of illness: This patient is a ___ year old male s/p MVC. Patient restrained driver high speed MVC with multiple significantly injured passengers, requiring airlift from scene. Positive airbag deployment. Does not fully recall event,extricated by EMS. C/o pain in wrist, leg, and lower abdomen. Past Medical History: -none- Social History: Pt works full time and is in school part-time for his MBA. Allergies: No Known Allergies / Adverse Drug Reactions What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Senna Influenza Virus Vaccine Heparin Lactated Ringers Acetaminophen Morphine Sulfate Sodium Chloride 0.9% Flush Acetaminophen Potassium Chl 20 mEq / 1000 mL NS Sodium Chloride 0.9% Flush Enoxaparin Sodium OxycoDONE (Immediate Release) Target Lab Orders: Hematocrit Hematocrit Lactate Lactate Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells Anion Gap Bicarbonate Calcium, Total Chloride Creatinine Glucose Magnesium Phosphate Potassium Sodium Urea Nitrogen Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells Lactate Lactate Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : Mr. ___ was admitted to the hospital after a motor vehicle collision. In the ED he received a trauma CXR, a CT of his Head, a CT of his chest, a CT of his cervical spine, Lower extremity plain films, Upper extremity plain films. This imaging revealed revealed that his wrist was displaced completely because of a distal radius fracture, and fractures involving the base of the second, third, and likely fourth metatarsals concerning for Lisfranc fracture dislocation. The wrist was reduced surgically in the emergency room. This provided an improvement in his median nerve symptoms to the point in preop he had intact sensation. Given the displacement and instability the patient was taken to the OR for operative fixation, please see operative note for details. An xray of his foot revealed a left foot metatarsal fracture, for this he was fitted with an aircast. Post operatively, he was transferred to the floor for observation. He did well and was started on a clear liquid diet. He tolerated this well without pain or nausea and was subsequently advanced to a regular diet. On ___ the patient worked with occupational therapy and physical therapy who cleared the patient for home with support. On ___ the patient was afebrile, ambulating with his crutches, and tolerating a regular diet. He was educated on his post operative care and follow up and verbalized understanding and agreement with this plan. On ___ Mr. ___ was discharged home with ___ services. Other Results: ___ 03:35AM WBC-15.2* RBC-5.36 HGB-15.4 HCT-46.3 MCV-86 MCH-28.8 MCHC-33.3 RDW-12.5

2169-02-11 08:00:00

ENGLISH

SINGLE

BLACK/AFRICAN AMERICAN

F

[[28482551, Timestamp('2169-02-11 01:24:00'), '', 'SURG']]

[[{'Medications on Admission': ':\nNone.', 'Brief Hospital Course': ':\nPt was takent to the operating room for a laparoscopic left \ncolectomy for recurrent diverticulitis on ___. She did well \npost-operatively with pain initially controlled on a PCA. She \nwas kept NPO and was given IV fluid hydration. She began \nambulating on post-operative day 1. Her pain was well controlled \nthroughout her hospitalization. On POD 2 pt was noted to have \nsinus tachycardia and a cardiology consult was obtained. They \nrecommended continued pain control and ruling out any infectious \netiology. A CXR was done which showed only atelectasis. Pt had \nno respiratory symptoms during her stay and has been afebrile. \nHe heart rate subsequently came down to within a normal range. \nOn post operative day 3 pt was tolerating diet by mouth and was \nambulating and had evidence of bwoel function. On POD 4 pt \ncontinued to do well with pain controlled on oral pain medicine. \nShe had normal bowel function and was discharged home to follow \nup with Dr. ___ in ___ weeks.\n\n', 'Pertinent Results:': '\n___ 08:01PM SODIUM-142 POTASSIUM-4.1 CHLORIDE-106\n___ 08:01PM MAGNESIUM-2.2\n___ 08:01PM HCT-33.6*\n\n', 'Physical Exam:|Physical': '\nVitals-Afebrile, vital signs within normal limits\nNAD, AxOx3\nRRR, No MRG\nCTABL\nSoft abdomen, non-distended, non-tender, +bowel sounds\nExt-No c/c/e\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\n___ yo F with history of recurrent diverticulitis starting in \n___. She has had three attacks requiring \nhospitalization and IV antibiotics. She continued to have \nnagging left lower quadrant abdominal pain.\n\nPast Medical History:\ns/p bil Tubal ligation\nhemorrhoids\nh/o GERD\ns/p breast reduction surgery\nstatus exostectomy of the left mid foot\nh/o pericarditis\n\nSocial History:\n___\nFamily History:\npositive for arthrits and aunt with heart disease\n\n', 'Chief Complaint:|Complaint:': '\nDiverticulitis\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nPatient recorded as having No Known Allergies to Drugs\n\n'}, '18736757-DS-12', 12, 'surgery']]

[['HISTORY: ___ status post laparoscopic left colectomy for\ndiverticulitis with tachycardia.\n\nTECHNIQUE: Chest radiograph, two views.\n\nCOMPARISON: Chest radiograph, ___.\n\nFINDINGS: There is subtle linear opacities at the left lung base could be\natelectasis; cannot rule out aspiration. There is no pneumonia, pleural\neffusion, or pneumothorax. Hilar, mediastinal, and cardiac silhouette within\nnormal limits.\n\nIMPRESSION: Subtle opacity at the left lung base, could be atelectasis;\nhowever, cannot exclude focal area of aspiration.\n', '18736757-RR-17', 17, 'chest radiograph, two views.']]

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[]

['surgery']

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Question: A 40 F is admitted. He/she says he/she has Diverticulitis . History of illness: ___ yo F with history of recurrent diverticulitis starting in ___. She has had three attacks requiring hospitalization and IV antibiotics. She continued to have nagging left lower quadrant abdominal pain. Past Medical History: s/p bil Tubal ligation hemorrhoids h/o GERD s/p breast reduction surgery status exostectomy of the left mid foot h/o pericarditis Social History: ___ Family History: positive for arthrits and aunt with heart disease Allergies: Patient recorded as having No Known Allergies to Drugs What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Metoclopramide LR Ondansetron Sodium Chloride 0.9% Flush Heparin Influenza Virus Vaccine HYDROmorphone (Dilaudid) Target Lab Orders: Chloride Magnesium Potassium Sodium Hematocrit Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells Anion Gap Bicarbonate Calcium, Total Chloride Creatinine Estimated GFR (MDRD equation) Glucose Magnesium Phosphate Potassium Sodium Urea Nitrogen Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : Pt was takent to the operating room for a laparoscopic left colectomy for recurrent diverticulitis on ___. She did well post-operatively with pain initially controlled on a PCA. She was kept NPO and was given IV fluid hydration. She began ambulating on post-operative day 1. Her pain was well controlled throughout her hospitalization. On POD 2 pt was noted to have sinus tachycardia and a cardiology consult was obtained. They recommended continued pain control and ruling out any infectious etiology. A CXR was done which showed only atelectasis. Pt had no respiratory symptoms during her stay and has been afebrile. He heart rate subsequently came down to within a normal range. On post operative day 3 pt was tolerating diet by mouth and was ambulating and had evidence of bwoel function. On POD 4 pt continued to do well with pain controlled on oral pain medicine. She had normal bowel function and was discharged home to follow up with Dr. ___ in ___ weeks. Other Results: ___ 08:01PM SODIUM-142 POTASSIUM-4.1 CHLORIDE-106 ___ 08:01PM MAGNESIUM-2.2 ___ 08:01PM HCT-33.6*

2173-10-23 16:32:00

ENGLISH

MARRIED

WHITE

M

[[21964920, Timestamp('2173-10-23 16:33:10'), '', 'PSURG']]

[[{'Medications on Admission': ':\nmetformin 1000 mg twice daily\nlisinopril 5 mg daily\nactos 30 mg daily\nglyburide (5 mg AM, 2.5 mg ___\nlipitor 10 mg HS\nVitamin D 1000 unit QD\n\n1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 \ntimes a day).\nDisp:*30 Capsule(s)* Refills:*2*\n2. metformin 1,000 mg Tablet Sig: One (1) Tablet PO BID (2 times \na day). \n3. glyburide 5 mg Tablet Sig: One (1) Tablet PO QAM (once a day \n(in the morning)). \n4. glyburide 2.5 mg Tablet Sig: One (1) Tablet PO QPM (once a \nday (in the evening)). \n5. cefadroxil 500 mg Capsule Sig: One (1) Capsule PO every \ntwelve (12) hours for 7 days.\nDisp:*14 Capsule(s)* Refills:*0*\n6. acetaminophen 325 mg Tablet Sig: ___ Tablets PO every ___ \nhours as needed for pain: Max 12/day. Each tab has 325mg of \nTylenol. Do not exceed 4gms/4000mgs of Tylenol per day. . \n7. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at \nbedtime). \n8. pioglitazone 30 mg Tablet Sig: One (1) Tablet PO DAILY \n(Daily). \n9. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). \n\n10. Vitamin D 1,000 unit Capsule Sig: One (1) Capsule PO DAILY \n(Daily). \n11. hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q3H (every 3 \nhours) as needed for pain.\nDisp:*80 Tablet(s)* Refills:*0*\n12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a \nday) as needed for constipation.\nDisp:*30 Tablet(s)* Refills:*2*\n13. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 \nhours) as needed for pain.\nDisp:*30 Tablet(s)* Refills:*0*', 'Brief Hospital Course': ":\nThe patient was admitted to the plastic surgery service on \n___ and had a completion amputation left ___ and ___ digits \nand repair of complex lacerations of ___ and ___ digits. The \npatient tolerated the procedure well. \n.\nNeuro: Post-operatively, the patient received morphine IV with \ngood effect and adequate pain control. When tolerating oral \nintake, the patient was transitioned to percocet but found \nlittle relief with this medication. Percocet was discontinued \nand patient was started on Dilaudid ___ PO Q3h PRN and \nIbuprofen 600mg PO Q6h. He reported good pain relief with this \nregimen.\n.\nCV: The patient was stable from a cardiovascular standpoint; \nvital signs were routinely monitored.\n.\nPulmonary: The patient was stable from a pulmonary standpoint; \nvital signs were routinely monitored.\n.\nGI/GU: Post-operatively, the patient was given IV fluids until \ntolerating oral intake. His diet was advanced when appropriate, \nwhich was tolerated well. He was also started on a bowel regimen \nto encourage bowel movement. Intake and output were closely \nmonitored. \n.\nID: Post-operatively, the patient was started on IV cefazolin, \nthen switched to PO cefadroxil x 7 days for discharge home. The \npatient's temperature was closely watched for signs of \ninfection. \n.\nProphylaxis: The patient was encouraged to get up and ambulate \nas early as possible. \n.\nAt the time of discharge on POD#1, the patient was doing well, \nafebrile with stable vital signs, tolerating a regular diet, \nambulating, voiding without assistance, and pain was well \ncontrolled. \n\n", 'Pertinent Results:': '\n___ 03:10PM GLUCOSE-138* UREA N-23* CREAT-1.1 SODIUM-140 \nPOTASSIUM-4.9 CHLORIDE-106 TOTAL CO2-27 ANION GAP-12\n___ 03:10PM estGFR-Using this\n___ 03:10PM WBC-9.2 RBC-4.17* HGB-13.2* HCT-39.0* MCV-94 \nMCH-31.7 MCHC-33.9 RDW-13.5\n___ 03:10PM NEUTS-85.4* LYMPHS-10.0* MONOS-2.6 EOS-0.5 \nBASOS-1.3\n___ 03:10PM PLT COUNT-335\n___ 03:10PM ___ PTT-21.2* ___\n.\nRADIOLOGY:\nRadiology Report HAND (AP, LAT & OBLIQUE) LEFT Study Date of \n___ 6:16 ___ \nIMPRESSION: \n1. Amputations of the index and middle fingers at the DIP \njoints; possible \npartial amputation of the distal ring finger. Correlate \nclinically. \n2. Fractures of the distal phalanx of the ring finger and middle \nphalanges of the ring and middle fingers. \n3. Fractures of the index and middle distal phalanges in the \nfinger remnants. \n4. Soft tissue defect over the little finger distal tuft. \n\n', 'Physical Exam:|Physical': '\nAfebrile HR 73 BP 123/70 RR 16 SaO2 95% RA\nGen: AAOx3\nLeft Hand: Volar oblique lacerations at the DIP joints of the \n___ and ___ digit. The ___ digit has a volar/ulnar oblique \nlaceration in the level of the pulp, distal to the DIP crease. \n2.5 cm complex laceration extending from ulnar to radial volar \naspect of the ___ digit with no sensation distal to the complex\nlaceration. Motor function intact.\n.\nAmputated remnants ___ and ___ digit are in a moist gauze in \nplastic bag in ice water, mangled. \n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\nMr. ___ is a ___ year old left-hand dominant man who injured \nhis left hand in a snowblower this morning at 11:30 AM, \nsustaining amputations to the distal ___ and ___ fingers and \nlacerations to his ___ and ___ finger. The amputated distal\nportion of his fingers remained in his glove and were found \nafter he was rushed to ___ where he recieved a \ntetanus shot and antibiotics. He was transferred to ___ for \nfurther care. Reports pain, some decreased sensation.\n\nPast Medical History:\nType II Diabetes\nHypertension\nHyperlipidemia\n.\nPSH: \nLaparoscopic hernia repair\n\nSocial History:\n___\nFamily History:\nnon-contributory\n\n', 'Chief Complaint:|Complaint:': '\nTraumatic snowblower injury to left hand: amputations to the \ndistal ___ and ___ fingers and lacerations to his ___ and ___ \nfingers.\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nNo Known Allergies / Adverse Drug Reactions\n\n'}, '14157429-DS-17', 17, 'plastic']]

[['HISTORY: ___ male with left hand injury from a snowblower.\n\nSTUDY: Three views of the left hand, one view of digit remnants.\n\nCOMPARISON: None.\n\nFINDINGS: There has been amputation of the index and middle fingers at the\nDIP joints. There may also be partial amputation at the ring finger.\nAdditionally, transverse fracture lines are seen through the middle finger\nmid-phalanx as well as the ring finger mid and distal phalanges. Additionally\na soft tissue defect is seen over the little finger distal tuft. There are no\nradiopaque foreign bodies. The finger remnants show the fractures of the\ndistal phalanges. A well-corticated body at the ulnar styloid may be sequela\nof prior trauma.\n\nIMPRESSION:\n1. Amputations of the index and middle fingers at the DIP joints; possible\npartial amputation of the distal ring finger. Correlate clinically.\n2. Fractures of the distal phalanx of the ring finger and middle phalanges of\nthe ring and middle fingers.\n3. Fractures of the index and middle distal phalanges in the finger remnants.\n4. Soft tissue defect over the little finger distal tuft.\n\n', '14157429-RR-5', 5, ''], ['INDICATION: Amputation of the left second and fifth fingers.\n\nCOMPARISON: ___.\n\nThree fluoroscopic spot images of the left hand were submitted for review. \nPatient is status post percutaneous pinning of the comminuted fractures of the\nring finger distal and middle phalanges. Alignment is improved. Patient has\nalso had amputation of the long and index fingers at the level of the middle\nphalanx base and mid shaft respectively. A soft tissue defect is seen over\nthe small finger tuft. For further details please see the intraoperative\nreport.\n', '14157429-RR-7', 7, '']]

[[21964920, Timestamp('2173-10-24 10:00:00'), Timestamp('2173-10-24 20:00:00'), 'MAIN', 'Lisinopril', '000393', '00172375810', '5mg Tablet'], [21964920, Timestamp('2173-10-23 20:00:00'), Timestamp('2173-10-23 22:00:00'), 'MAIN', 'Sodium Chloride 0.9% Flush', '', '0', 'Syringe'], [21964920, Timestamp('2173-10-24 14:00:00'), Timestamp('2173-10-24 20:00:00'), 'MAIN', 'Senna', '019964', '00904516561', '1 Tablet'], [21964920, Timestamp('2173-10-24 13:00:00'), Timestamp('2173-10-24 20:00:00'), 'MAIN', 'HYDROmorphone (Dilaudid)', '004110', '00054839224', '2mg Tablet'], [21964920, Timestamp('2173-10-24 10:00:00'), Timestamp('2173-10-24 20:00:00'), 'MAIN', 'Pioglitazone', '042943', '64764015105', '15mg Tablet'], [21964920, Timestamp('2173-10-24 08:00:00'), Timestamp('2173-10-24 20:00:00'), 'MAIN', 'GlyBURIDE', '001775', '00182264789', '5 mg Tab'], [21964920, Timestamp('2173-10-24 14:00:00'), Timestamp('2173-10-24 20:00:00'), 'MAIN', 'Ibuprofen', '008349', '00904585461', '600mg Tablet'], [21964920, Timestamp('2173-10-23 20:00:00'), Timestamp('2173-10-24 20:00:00'), 'MAIN', 'Influenza Virus Vaccine', '066525', '33332001001', '0.5 mL Syringe'], [21964920, Timestamp('2173-10-24 01:00:00'), Timestamp('2173-10-24 20:00:00'), 'BASE', 'Iso-Osmotic Dextrose', '', '0', '50ml Bag'], [21964920, Timestamp('2173-10-24 01:00:00'), Timestamp('2173-10-24 20:00:00'), 'MAIN', 'CefazoLIN', '051880', '00264310311', '1g Froz.Bag'], [21964920, Timestamp('2173-10-23 23:00:00'), Timestamp('2173-10-24 20:00:00'), 'BASE', '0.9% Sodium Chloride', '001210', '00338004904', '1000mL Bag'], [21964920, Timestamp('2173-10-23 23:00:00'), Timestamp('2173-10-24 20:00:00'), 'MAIN', 'Dextrose 50%', '001989', '00409490234', '50mL Syringe'], [21964920, Timestamp('2173-10-23 20:00:00'), Timestamp('2173-10-24 20:00:00'), 'MAIN', 'Docusate Sodium', '003009', '00904224461', '100mg Capsule'], [21964920, Timestamp('2173-10-23 23:00:00'), Timestamp('2173-10-24 20:00:00'), 'MAIN', 'Insulin', '001723', '0', 'Dummy Package for Sliding Scale'], [21964920, Timestamp('2173-10-24 10:00:00'), Timestamp('2173-10-24 20:00:00'), 'MAIN', 'Vitamin D', '019166', '10432017002', '400 Unit Tablet'], [21964920, Timestamp('2173-10-24 13:00:00'), Timestamp('2173-10-24 20:00:00'), 'MAIN', 'HYDROmorphone (Dilaudid)', '004112', '00074241612', '4mg Tablet'], [21964920, Timestamp('2173-10-24 10:00:00'), Timestamp('2173-10-24 09:00:00'), 'MAIN', 'Pioglitazone', '042943', '64764015105', '15mg Tablet'], [21964920, Timestamp('2173-10-23 23:00:00'), Timestamp('2173-10-24 20:00:00'), 'MAIN', 'Morphine Sulfate', '004080', '10019017644', '5 mg Vial'], [21964920, Timestamp('2173-10-23 23:00:00'), Timestamp('2173-10-24 20:00:00'), 'MAIN', 'Sodium Chloride 0.9% Flush', '', '0', 'Syringe'], [21964920, Timestamp('2173-10-23 23:00:00'), Timestamp('2173-10-24 20:00:00'), 'MAIN', 'Glucagon', '041660', '55390000401', '1mg Vial'], [21964920, Timestamp('2173-10-23 23:00:00'), Timestamp('2173-10-24 20:00:00'), 'MAIN', 'Ondansetron', '061716', '00781305714', '2mg/mL-2mL'], [21964920, Timestamp('2173-10-23 20:00:00'), Timestamp('2173-10-23 22:00:00'), 'MAIN', 'Morphine Sulfate', '004080', '10019017644', '5 mg Vial'], [21964920, Timestamp('2173-10-24 10:00:00'), Timestamp('2173-10-24 09:00:00'), 'MAIN', 'Atorvastatin', '029968', '00071015640', '20mg Tablet'], [21964920, Timestamp('2173-10-23 23:00:00'), Timestamp('2173-10-24 12:00:00'), 'MAIN', 'Oxycodone-Acetaminophen', '004222', '00406051262', '5mg/325mg Tablet']]

[]

['plastic']

[]

Question: A 61 M is admitted. He/she says he/she has Traumatic snowblower injury to left hand: amputations to the distal ___ and ___ fingers and lacerations to his ___ and ___ fingers. . History of illness: Mr. ___ is a ___ year old left-hand dominant man who injured his left hand in a snowblower this morning at 11:30 AM, sustaining amputations to the distal ___ and ___ fingers and lacerations to his ___ and ___ finger. The amputated distal portion of his fingers remained in his glove and were found after he was rushed to ___ where he recieved a tetanus shot and antibiotics. He was transferred to ___ for further care. Reports pain, some decreased sensation. Past Medical History: Type II Diabetes Hypertension Hyperlipidemia . PSH: Laparoscopic hernia repair Social History: ___ Family History: non-contributory Allergies: No Known Allergies / Adverse Drug Reactions What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Lisinopril Sodium Chloride 0.9% Flush Senna HYDROmorphone (Dilaudid) Pioglitazone GlyBURIDE Ibuprofen Influenza Virus Vaccine Iso-Osmotic Dextrose CefazoLIN 0.9% Sodium Chloride Dextrose 50% Docusate Sodium Insulin Vitamin D HYDROmorphone (Dilaudid) Pioglitazone Morphine Sulfate Sodium Chloride 0.9% Flush Glucagon Ondansetron Morphine Sulfate Atorvastatin Oxycodone-Acetaminophen Target Lab Orders: NONE Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : The patient was admitted to the plastic surgery service on ___ and had a completion amputation left ___ and ___ digits and repair of complex lacerations of ___ and ___ digits. The patient tolerated the procedure well. . Neuro: Post-operatively, the patient received morphine IV with good effect and adequate pain control. When tolerating oral intake, the patient was transitioned to percocet but found little relief with this medication. Percocet was discontinued and patient was started on Dilaudid ___ PO Q3h PRN and Ibuprofen 600mg PO Q6h. He reported good pain relief with this regimen. . CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. . Pulmonary: The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. . GI/GU: Post-operatively, the patient was given IV fluids until tolerating oral intake. His diet was advanced when appropriate, which was tolerated well. He was also started on a bowel regimen to encourage bowel movement. Intake and output were closely monitored. . ID: Post-operatively, the patient was started on IV cefazolin, then switched to PO cefadroxil x 7 days for discharge home. The patient's temperature was closely watched for signs of infection. . Prophylaxis: The patient was encouraged to get up and ambulate as early as possible. . At the time of discharge on POD#1, the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. Other Results: ___ 03:10PM GLUCOSE-138* UREA N-23* CREAT-1.1 SODIUM-140 POTASSIUM-4.9 CHLORIDE-106 TOTAL CO2-27 ANION GAP-12 ___ 03:10PM estGFR-Using this ___ 03:10PM WBC-9.2 RBC-4.17* HGB-13.2* HCT-39.0* MCV-94 MCH-31.7 MCHC-33.9 RDW-13.5 ___ 03:10PM NEUTS-85.4* LYMPHS-10.0* MONOS-2.6 EOS-0.5 BASOS-1.3 ___ 03:10PM PLT COUNT-335 ___ 03:10PM ___ PTT-21.2* ___ . RADIOLOGY: Radiology Report HAND (AP, LAT & OBLIQUE) LEFT Study Date of ___ 6:16 ___ IMPRESSION: 1. Amputations of the index and middle fingers at the DIP joints; possible partial amputation of the distal ring finger. Correlate clinically. 2. Fractures of the distal phalanx of the ring finger and middle phalanges of the ring and middle fingers. 3. Fractures of the index and middle distal phalanges in the finger remnants. 4. Soft tissue defect over the little finger distal tuft.

2172-12-02 07:15:00

?

MARRIED

WHITE - RUSSIAN

F

[[27495289, Timestamp('2172-12-02 14:13:44'), '', 'GYN']]

[[{'Medications on Admission': ':\n1. conjugated estrogens [Premarin]\n0.625 mg tablet 60 Tablet 1 tablet(s) by mouth twice a day \n2. conjugated estrogens [Premarin]\n0.625 mg/gram Cream insert 1 gram per vagina weekly \n3. diclofenac sodium\n50 mg tablet,delayed release (___) 1 tablet,delayed \nrelease (___) by mouth once a day as needed for pain \n4. esomeprazole magnesium [Nexium]\n40 mg capsule,delayed ___ 60 Tablet 1 \ncapsule,delayed ___ by mouth twice a day \n5. ketoconazole\n2 % Shampoo 1 Bottle use topically once a day \n6. lorazepam\n1 mg tablet 1 (One) tablet(s) by mouth at bedtime \n7. olmesartan [Benicar]\n20 mg tablet 30 Tablet 1 tablet(s) by mouth daily \n8. oxybutynin chloride\n10 mg tablet extended release 24hr 30 Tablet ___ MD \n 1 Tablet(s) by mouth once a day ___ hr before breakfast \n\nCurrent List of Over the Counter Medications \nMedication Dispense Prescribed By Take \nB complex-folic acid [Balanced B-100]\n0.4 mg tablet 30 Tablet ___ NP 1 (One) tablet(s) \nby mouth once a day \ncholecalciferol (vitamin D3)\n2,000 unit capsule 30 Capsule ___ NP 1 (One) \ncapsule(s) by mouth once a day \nfish oil-vit E-fat acid5-___ [Flax, Fish & Borage Oil]\n400 mg-5 unit capsule 1 (One) capsule(s) by mouth once a \nday \nglucosamine sulfate\n500 mg tablet 30 Tablet ___ NP 1 (One) tablet(s) \nby mouth once a day \nsalmon oil-omega-3 fatty acids [Salmon Oil-1000]\n1,000 mg-200 mg capsule 1 (One) capsule(s) by mouth once \na day \nsennosides [senna]\n8.6 mg tablet 120 Tablet ___ NP 1 to 2 tablet(s) \nby mouth twice a day ', 'Brief Hospital Course': ':\n On ___, Ms. ___ was admitted to the gynecology \nservice after undergoing vaginal colpectomy, tension-free \nvaginal tape (TVT) Exact sling, high perineorrhaphy, and \ncystoscopy. Please see the operative report for full details. \n\n Her post-operative course was uncomplicated. Immediately \npost-op, her pain was controlled with IV dilaudid. On \npost-operative day 1, her urine output was adequate and her \nFoley was removed with a voiding trial, the results of which are \nas follows: Instilled 300 mL, voided 250 mL with some leaking, \nthen scanned for 17mL residual.\n\n Her diet was advanced without difficulty and she was \ntransitioned to tylenol and oxycodone. By post-operative day 1, \nshe was tolerating a regular diet, ambulating independently, and \npain was controlled with oral medications. She was then \ndischarged home in stable condition with outpatient follow-up \nscheduled.\n\n', 'Pertinent Results:': 'NIL', 'Physical Exam:|Physical': '\nOn day of discharge\nGeneral: NAD\nCV: RRR\nLUNGS: CTABl\nABD: soft, nondistended, appropriately tender, +BS\nEXT: NE, NT\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\nThe patient is a ___, gravida 4, para 1, who was \nreferred to Dr. ___ by Dr. ___ vaginal \nprolapse. The patient was complaining of pressure and bulging \nthat was affecting her ability to walk and have bowel movement. \nHer symptoms had been present for approximately ___ years, and \nthey had become worse over the past 5 months. She reported \ndaily incontinent events even with minimal exertion such as \nwalking. She was examined and was found to have a third-degree \ncystocele, a second-degree vault prolapse, and a positive empty \nsupine stress test, suggestive of intrinsic sphincter \ndeficiency. The patient was referred for multichannel urodynamic \ntesting, which confirmed that she had stress urinary \nincontinence, ureteral hypermobility and unstable detrusor. The \npatient was counseled extensively regarding our evaluation. She \nelected to proceed with surgical management. The risks, \nbenefits, and alternatives to her management were discussed with\nthe patient.\n\nPast Medical History:\nPAST MEDICAL HISTORY:\n 1. Anxiety/Depression\n 2. GERD\n 3. Chronic back pain\n\nPAST SURGICAL HISTORY\n 1. TAH BSO ___\n 2. ___ (? vaginal sling Dr. ___\n 3. Appendectomy\n 4. Cholecystectomy\n 5. Parathyroid lobe excision\n 6. Melanoma excision x 2\n\nFamily History:\nFAMILY HISTORY\nHer family history is unremarkable for Breast/Ovarian or Colon\ncancer.\n\n', 'Chief Complaint:|Complaint:': '\nvaginal prolaps\n\n', 'Attending:': ' ___\n\n', 'Allergies:': ' \nPenicillins / iodine\n\n'}, '10641592-DS-9', 9, 'obstetrics/gynecology']]

[['HISTORY: Status post vaginal surgery with abdominal pain, concerning for free\nair under the diaphragm. \n\nCOMPARISON: Comparison is made with pelvic radiograph from ___. \n\n\nFINDINGS: One supine and one upright frontal image of the abdomen were\nobtained. Images demonstrate a non-specific bowel gas pattern. There is no\npneumatosis or free air under the diaphragm. Degenerative changes and\nlevoconvex curvature of the lower lumbar spine are again noted. \n\nIMPRESSION: No evidence of free air under the diaphragm. \n\nFindings were communicated to Dr. ___ at 9:55 a.m. on ___ by phone. \n\n', '10641592-RR-30', 30, '']]

[[27495289, Timestamp('2172-12-02 15:00:00'), Timestamp('2172-12-03 18:00:00'), 'MAIN', 'Pantoprazole', '027462', '00008084199', '40mg Tablet'], [27495289, Timestamp('2172-12-02 20:00:00'), Timestamp('2172-12-03 18:00:00'), 'MAIN', 'Lidocaine 5% Patch', '043256', '63481068706', 'Patch'], [27495289, Timestamp('2172-12-02 14:00:00'), Timestamp('2172-12-03 18:00:00'), 'MAIN', 'Sodium Chloride 0.9% Flush', '', '0', '10 mL Syringe'], [27495289, Timestamp('2172-12-02 19:00:00'), Timestamp('2172-12-03 18:00:00'), 'MAIN', 'OxycoDONE (Immediate Release) ', '004225', '00406055262', '5mg Tablet'], [27495289, Timestamp('2172-12-02 15:00:00'), Timestamp('2172-12-03 18:00:00'), 'MAIN', 'PNEUMOcoccal 23-valent polysaccharide vaccine', '048548', '00006473900', '25mcg/0.5mL Vial'], [27495289, Timestamp('2172-12-03 01:00:00'), Timestamp('2172-12-03 18:00:00'), 'MAIN', 'Simethicone', '002821', '00182864389', '80mg Tablet'], [27495289, Timestamp('2172-12-02 14:00:00'), Timestamp('2172-12-02 19:00:00'), 'MAIN', 'Ketorolac', '039499', '10019002902', '15mg/mL Vial'], [27495289, Timestamp('2172-12-02 19:00:00'), Timestamp('2172-12-03 18:00:00'), 'MAIN', 'Acetaminophen', '004490', '00904198861', '500mg Tablet'], [27495289, Timestamp('2172-12-03 07:00:00'), Timestamp('2172-12-03 18:00:00'), 'MAIN', 'Aluminum-Magnesium Hydrox.-Simethicone', '002701', '00121176130', '30 mL UDCup'], [27495289, Timestamp('2172-12-02 15:00:00'), Timestamp('2172-12-03 18:00:00'), 'BASE', 'Lactated Ringers', '001187', '00338011704', '1000ml Bag'], [27495289, Timestamp('2172-12-03 07:00:00'), Timestamp('2172-12-03 18:00:00'), 'MAIN', 'Lorazepam', '003757', '00904598061', '0.5mg Tablet'], [27495289, Timestamp('2172-12-02 14:00:00'), Timestamp('2172-12-03 18:00:00'), 'MAIN', 'HYDROmorphone (Dilaudid)', '062823', '00409128331', '1mg/1mL Syringe'], [27495289, Timestamp('2172-12-02 14:00:00'), Timestamp('2172-12-03 18:00:00'), 'MAIN', 'Lorazepam', '003757', '00904598061', '0.5mg Tablet'], [27495289, Timestamp('2172-12-02 14:00:00'), Timestamp('2172-12-03 18:00:00'), 'MAIN', 'Docusate Sodium', '003009', '00904224461', '100mg Capsule']]

[]

['obstetrics/gynecology']

[[50868, Timestamp('2172-12-03 08:25:00'), Timestamp('2172-12-03 09:11:00'), 'Anion Gap'], [50882, Timestamp('2172-12-03 08:25:00'), Timestamp('2172-12-03 09:11:00'), 'Bicarbonate'], [50893, Timestamp('2172-12-03 08:25:00'), Timestamp('2172-12-03 09:11:00'), 'Calcium, Total'], [50902, Timestamp('2172-12-03 08:25:00'), Timestamp('2172-12-03 09:11:00'), 'Chloride'], [50912, Timestamp('2172-12-03 08:25:00'), Timestamp('2172-12-03 09:11:00'), 'Creatinine'], [50920, Timestamp('2172-12-03 08:25:00'), Timestamp('2172-12-03 09:11:00'), 'Estimated GFR (MDRD equation)'], [50931, Timestamp('2172-12-03 08:25:00'), Timestamp('2172-12-03 09:11:00'), 'Glucose'], [50960, Timestamp('2172-12-03 08:25:00'), Timestamp('2172-12-03 09:11:00'), 'Magnesium'], [50970, Timestamp('2172-12-03 08:25:00'), Timestamp('2172-12-03 09:11:00'), 'Phosphate'], [50971, Timestamp('2172-12-03 08:25:00'), Timestamp('2172-12-03 09:11:00'), 'Potassium'], [50983, Timestamp('2172-12-03 08:25:00'), Timestamp('2172-12-03 09:11:00'), 'Sodium'], [51006, Timestamp('2172-12-03 08:25:00'), Timestamp('2172-12-03 09:11:00'), 'Urea Nitrogen'], [51146, Timestamp('2172-12-03 08:25:00'), Timestamp('2172-12-03 09:02:00'), 'Basophils'], [51200, Timestamp('2172-12-03 08:25:00'), Timestamp('2172-12-03 09:02:00'), 'Eosinophils'], [51221, Timestamp('2172-12-03 08:25:00'), Timestamp('2172-12-03 09:02:00'), 'Hematocrit'], [51222, Timestamp('2172-12-03 08:25:00'), Timestamp('2172-12-03 09:02:00'), 'Hemoglobin'], [51244, Timestamp('2172-12-03 08:25:00'), Timestamp('2172-12-03 09:02:00'), 'Lymphocytes'], [51248, Timestamp('2172-12-03 08:25:00'), Timestamp('2172-12-03 09:02:00'), 'MCH'], [51249, Timestamp('2172-12-03 08:25:00'), Timestamp('2172-12-03 09:02:00'), 'MCHC'], [51250, Timestamp('2172-12-03 08:25:00'), Timestamp('2172-12-03 09:02:00'), 'MCV'], [51254, Timestamp('2172-12-03 08:25:00'), Timestamp('2172-12-03 09:02:00'), 'Monocytes'], [51256, Timestamp('2172-12-03 08:25:00'), Timestamp('2172-12-03 09:02:00'), 'Neutrophils'], [51265, Timestamp('2172-12-03 08:25:00'), Timestamp('2172-12-03 09:02:00'), 'Platelet Count'], [51277, Timestamp('2172-12-03 08:25:00'), Timestamp('2172-12-03 09:02:00'), 'RDW'], [51279, Timestamp('2172-12-03 08:25:00'), Timestamp('2172-12-03 09:02:00'), 'Red Blood Cells'], [51301, Timestamp('2172-12-03 08:25:00'), Timestamp('2172-12-03 09:02:00'), 'White Blood Cells'], [50853, Timestamp('2172-12-03 08:25:00'), Timestamp('2172-12-05 14:03:00'), '25-OH Vitamin D'], [51010, Timestamp('2172-12-03 08:25:00'), Timestamp('2172-12-04 23:38:00'), 'Vitamin B12']]

Question: A 70 F is admitted. He/she says he/she has vaginal prolaps . History of illness: The patient is a ___, gravida 4, para 1, who was referred to Dr. ___ by Dr. ___ vaginal prolapse. The patient was complaining of pressure and bulging that was affecting her ability to walk and have bowel movement. Her symptoms had been present for approximately ___ years, and they had become worse over the past 5 months. She reported daily incontinent events even with minimal exertion such as walking. She was examined and was found to have a third-degree cystocele, a second-degree vault prolapse, and a positive empty supine stress test, suggestive of intrinsic sphincter deficiency. The patient was referred for multichannel urodynamic testing, which confirmed that she had stress urinary incontinence, ureteral hypermobility and unstable detrusor. The patient was counseled extensively regarding our evaluation. She elected to proceed with surgical management. The risks, benefits, and alternatives to her management were discussed with the patient. Past Medical History: PAST MEDICAL HISTORY: 1. Anxiety/Depression 2. GERD 3. Chronic back pain PAST SURGICAL HISTORY 1. TAH BSO ___ 2. ___ (? vaginal sling Dr. ___ 3. Appendectomy 4. Cholecystectomy 5. Parathyroid lobe excision 6. Melanoma excision x 2 Family History: FAMILY HISTORY Her family history is unremarkable for Breast/Ovarian or Colon cancer. Allergies: Penicillins / iodine What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Pantoprazole Lidocaine 5% Patch Sodium Chloride 0.9% Flush OxycoDONE (Immediate Release) PNEUMOcoccal 23-valent polysaccharide vaccine Simethicone Ketorolac Acetaminophen Aluminum-Magnesium Hydrox.-Simethicone Lactated Ringers Lorazepam HYDROmorphone (Dilaudid) Lorazepam Docusate Sodium Target Lab Orders: Anion Gap Bicarbonate Calcium, Total Chloride Creatinine Estimated GFR (MDRD equation) Glucose Magnesium Phosphate Potassium Sodium Urea Nitrogen Basophils Eosinophils Hematocrit Hemoglobin Lymphocytes MCH MCHC MCV Monocytes Neutrophils Platelet Count RDW Red Blood Cells White Blood Cells 25-OH Vitamin D Vitamin B12 Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : On ___, Ms. ___ was admitted to the gynecology service after undergoing vaginal colpectomy, tension-free vaginal tape (TVT) Exact sling, high perineorrhaphy, and cystoscopy. Please see the operative report for full details. Her post-operative course was uncomplicated. Immediately post-op, her pain was controlled with IV dilaudid. On post-operative day 1, her urine output was adequate and her Foley was removed with a voiding trial, the results of which are as follows: Instilled 300 mL, voided 250 mL with some leaking, then scanned for 17mL residual. Her diet was advanced without difficulty and she was transitioned to tylenol and oxycodone. By post-operative day 1, she was tolerating a regular diet, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled. Other Results: NIL

2187-12-16 09:15:00

ENGLISH

MARRIED

WHITE

M

[[23003951, Timestamp('2187-12-16 01:31:30'), '', 'NSURG']]

[[{'Medications on Admission': ':\nCLONAZEPAM GABAPENTIN HYDROXYCHLOROQUINE LISINOPRIL METAXALONE \nOMEPRAZOLE OXYCODONE-ACETAMINOPHEN SIMVASTATIN ', 'Brief Hospital Course': ':\nMr. ___ was taken to the OR on ___ with Dr. ___ \n___ a ___ C4-6 laminectomy, foramintomies and fusion with \nhardware. He was placed in an Aspen collar and extubated \npost-operatively. He was transfered to the PACU. He was on a PCA \novernight and was transitioned to po dilaudid on ___. He \nfailed a voiding trial overnight.\n\nOn POD1 he was tolerating a regualr diet. He had X-ray imaging \nwhich was reviewed by Dr. ___ was satisfactory. A \nsecond voiding trial was performed on ___ with no difficulty.\nHe was seen by ___ and OT and cleared for home.\n\nHe was discharged to home on ___.\n\n', 'Pertinent Results:': '\nCspine AP/LAT ___:\nTWO VIEWS, CERVICAL SPINE: Patient is status post C4 through C6 \nfusion by \npedicle screws and spinal rods. There is no evidence of early \nhardware \nfailure. Loss of disc height is most pronounced at C5/6. There \nare anterior osteophytes at C5 and C6. Prevertebral soft tissue \nswelling and subcutaneous air are expected post-surgical \nfindings. \n\n', 'Physical Exam:|Physical': ' therapy did not\nhelp. MRI of his C-spine was reviewed and this is significant\nfor C3-C6 stenosis, worse at C5-C6 with mild cord compression at\nthis level, probably associated with DISH syndromes. The \npatient\nhad an epidural steroid injection in the neck without \nsignificant benefit and he agreed to procede with surgery.\n\nPast Medical History:\nDiffuse idiopathic skeletal hyperostosis.\nOsteoarthritis of the hands.\nRight shoulder rotator tendinopathy.\nDiscoid lupus.\nhtn\nhyperlipidemia\nanxiety\nbasialr aneurysm\n\nSocial History:\n___\nFamily History:\nNC\n\nPhysical Exam:\nOn discharge: \nAlert and oriented. MAE with no motor deficit. Incision is C/D/I \nwith staples. \n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\nThis is a ___ male with neck pain radiating to the \nshoulder for several years. Every time he turns his neck, he \ngets\nleft more than right shoulder pain. ', 'Chief Complaint:|Complaint:': '\nNeck and shoulder pain\n\n', 'Attending:': ' ___\n\n', 'Allergies:': ' \nPatient recorded as having No Known Allergies to Drugs\n\n'}, '17265599-DS-21', 21, 'neurosurgery']]

[['HISTORY: Check level on the operative study.\n\nFINDINGS: Images from the operating suite show placement of a posterior\nfusion spanning C4 through C6. Further information can be gathered from the\noperative report.\n', '17265599-RR-15', 15, ''], ['INDICATION: Cervical spine fusion.\n\nCOMPARISON: ___.\n\nTWO VIEWS, CERVICAL SPINE: Patient is status post C4 through C6 fusion by\npedicle screws and spinal rods. There is no evidence of early hardware\nfailure. Loss of disc height is most pronounced at C5/6. There are anterior\nosteophytes at C5 and C6. Prevertebral soft tissue swelling and subcutaneous\nair are expected post-surgical findings.\n', '17265599-RR-16', 16, '']]

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[]

['neurosurgery']

[[50868, Timestamp('2187-12-17 05:05:00'), Timestamp('2187-12-17 06:35:00'), 'Anion Gap'], [50882, Timestamp('2187-12-17 05:05:00'), Timestamp('2187-12-17 06:35:00'), 'Bicarbonate'], [50902, Timestamp('2187-12-17 05:05:00'), Timestamp('2187-12-17 06:35:00'), 'Chloride'], [50912, Timestamp('2187-12-17 05:05:00'), Timestamp('2187-12-17 06:35:00'), 'Creatinine'], [50931, Timestamp('2187-12-17 05:05:00'), Timestamp('2187-12-17 06:35:00'), 'Glucose'], [50971, Timestamp('2187-12-17 05:05:00'), Timestamp('2187-12-17 06:35:00'), 'Potassium'], [50983, Timestamp('2187-12-17 05:05:00'), Timestamp('2187-12-17 06:35:00'), 'Sodium'], [51006, Timestamp('2187-12-17 05:05:00'), Timestamp('2187-12-17 06:35:00'), 'Urea Nitrogen'], [51221, Timestamp('2187-12-17 05:05:00'), Timestamp('2187-12-17 06:09:00'), 'Hematocrit'], [51222, Timestamp('2187-12-17 05:05:00'), Timestamp('2187-12-17 06:09:00'), 'Hemoglobin'], [51248, Timestamp('2187-12-17 05:05:00'), Timestamp('2187-12-17 06:09:00'), 'MCH'], [51249, Timestamp('2187-12-17 05:05:00'), Timestamp('2187-12-17 06:09:00'), 'MCHC'], [51250, Timestamp('2187-12-17 05:05:00'), Timestamp('2187-12-17 06:09:00'), 'MCV'], [51265, Timestamp('2187-12-17 05:05:00'), Timestamp('2187-12-17 06:09:00'), 'Platelet Count'], [51277, Timestamp('2187-12-17 05:05:00'), Timestamp('2187-12-17 06:09:00'), 'RDW'], [51279, Timestamp('2187-12-17 05:05:00'), Timestamp('2187-12-17 06:09:00'), 'Red Blood Cells'], [51301, Timestamp('2187-12-17 05:05:00'), Timestamp('2187-12-17 06:09:00'), 'White Blood Cells']]

Question: A 55 M is admitted. He/she says he/she has Neck and shoulder pain . History of illness: This is a ___ male with neck pain radiating to the shoulder for several years. Every time he turns his neck, he gets left more than right shoulder pain. Allergies: Patient recorded as having No Known Allergies to Drugs What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Docusate Sodium Acetaminophen Bisacodyl Clonazepam Hydroxychloroquine Sulfate Bisacodyl Gabapentin Senna Sodium Chloride 0.9% Flush Simvastatin HYDROmorphone (Dilaudid) Ondansetron Lisinopril Clonazepam Cyclobenzaprine Skelaxin HYDROmorphone (Dilaudid) HYDROmorphone (Dilaudid) Potassium Chl 20 mEq / 1000 mL NS Milk of Magnesia Omeprazole Target Lab Orders: Anion Gap Bicarbonate Chloride Creatinine Glucose Potassium Sodium Urea Nitrogen Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : Mr. ___ was taken to the OR on ___ with Dr. ___ ___ a ___ C4-6 laminectomy, foramintomies and fusion with hardware. He was placed in an Aspen collar and extubated post-operatively. He was transfered to the PACU. He was on a PCA overnight and was transitioned to po dilaudid on ___. He failed a voiding trial overnight. On POD1 he was tolerating a regualr diet. He had X-ray imaging which was reviewed by Dr. ___ was satisfactory. A second voiding trial was performed on ___ with no difficulty. He was seen by ___ and OT and cleared for home. He was discharged to home on ___. Other Results: Cspine AP/LAT ___: TWO VIEWS, CERVICAL SPINE: Patient is status post C4 through C6 fusion by pedicle screws and spinal rods. There is no evidence of early hardware failure. Loss of disc height is most pronounced at C5/6. There are anterior osteophytes at C5 and C6. Prevertebral soft tissue swelling and subcutaneous air are expected post-surgical findings.

2185-09-12 16:25:00

ENGLISH

SINGLE

BLACK/CARIBBEAN ISLAND

F

[[24285218, Timestamp('2185-09-12 16:25:53'), '', 'OBS']]

[[{'Medications on Admission': ':\nPNV', 'Brief Hospital Course': ':\nMs. ___ was admitted to the ___ service after a D&E \nfor a septic abortion at 17 weeks. Please see operative report \nfor full details. \n\nPatient presented at ___ GA with vaginal bleeding and leakage \nof fluid. On admission, patient developed a fever concerning for \nseptic abortion. She was started on amp/gent/clinda and blood \ncultures, CBC, lactate drawn. She then underwent an \nultrasound-guided D&E. Please see operative report for full \ndetails. She received Tylenol and Toradol for pain control \nimmediately post-operatively. She also received PO doxycycline \nfollowing the procedure. She was continued on IV gentamycin, \nclindamycin, ampicillin for 24 hours. Her WBC was trended and \ndecreased from 25.8 to 13.8 prior to discharge. \n\nBy post-operative day #2, she was tolerating a regular diet, \nvoiding spontaneously, ambulating independently, and pain was \ncontrolled with oral medications. She was then discharged home \nin stable condition with outpatient follow-up scheduled.\n\n', 'Pertinent Results:': '\n___ WBC-12.5 RBC-3.97 Hgb-12.1 Hct-36.8 MCV-93 Plt-269\n___ WBC-19.5 RBC-3.20 Hgb-10.0 Hct-30.1 MCV-94 Plt-223\n___ Neuts-89.1 ___ Monos-7.6 Eos-0.0* Baso-0.1 Im \n___ AbsNeut-17.40* AbsLymp-0.42 AbsMono-1.48 AbsEos-0.00* \nAbsBaso-0.02\n___ WBC-25.8 RBC-2.92 Hgb-9.0 Hct-26.9* MCV-92 MCH-30.8 \nMCHC-33.5 RDW-12.8 RDWSD-42.6 Plt ___\n___ Neuts-88 Bands-0 ___ Monos-7 Eos-0 Baso-0 Atyps-0 \n___ Myelos-0 AbsNeut-22.70 AbsLymp-1.29 AbsMono-1.81* \nAbsEos-0.00* AbsBaso-0.00\n___ WBC-13.8 RBC-2.77* Hgb-8.6* Hct-25.8* MCV-93 MCH-31.0 \nMCHC-33.3 RDW-13.1 RDWSD-44.6 Plt ___\n___ Neuts-85.2* Lymphs-6.4* Monos-5.9 Eos-0.6* Baso-0.2 Im \n___ AbsNeut-11.74 AbsLymp-0.89* AbsMono-0.82* AbsEos-0.08 \nAbsBaso-0.03\n\n___ BLOOD Creat-0.7\n___ BLOOD Lactate-1.2\n\n___ URINE Blood-MOD* Nitrite-NEG Protein-NEG Glucose-NEG \nKetone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG\n___ URINE RBC-34* WBC-2 Bacteri-FEW* Yeast-NONE Epi-1\n\nURINE CULTURE (Final ___: \n MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH\n SKIN AND/OR GENITAL CONTAMINATION\n\nBlood Culture, Routine (Pending): No growth to date\nBlood Culture, Routine (Pending): No growth to date\n\n', 'Physical Exam:|Physical': '\nOn admission:\n95/57, HR 103, Afebrile\nNAD\nAbd: soft, NTTP, no rebound, no guarding, fundus firm below\numbilicus\nGU: NEFG, SSE demonstrates a visually closed cervix with no \nobvious leakage of fluid, question of trialing membranes, small \namount of blood at os\nExt: NTTP\n\nBedside US: performed with Dr. ___. Femur length consistent \nwith 17w5d GA (similar to above dating). Anhydrmnios present. ___ \nvisualized. Vertex presentation\n-----------\nOn discharge:\nVS: 98.3, 106/74, 95, 18, O2 99%\nGen NAD\nAbd soft, ND/NT; no fundal tenderness\nExt warm well perfused\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\nThis is a ___ yo G1P0 presents with vaginal bleeding and leakage \nof fluid. She reports uncertain ___, and uncertain LMP. OSH \ntoday performed an US that dates pregnancy at 17w2d, consistent \nwith our ultrasound below. Patient states she has not had any \nprior ultrasounds. \n\nPatient reports that at 430a today she experienced a gush of \nfluid, felt wet and noted both fluid and blood in her bed. \nPresented to ___ where she was found to have pooling of blood \ntinged fluid on exam. Unable to determine if ferns present. \nRadiology ultrasound demonstrated anhydramnios with a 17w2d \nfetus\nat CHA. She denies any current abdominal pain, cramping, \ncontractions. Denies fevers or chills. Denies recent abdominal \ntrauma. Overall comfortable appearing.\n\nShe initially had one visit in a clinic in ___ for \nprenatal care and is scheduled to have an intake with Dr. \n___ this month, yet she has not had regular prenatal \ncare for this pregnancy.\n\nPast Medical History:\nOBHx: G1 current, as above, uncomplicated per patient\nDenies SABs or TABs\nGynHx: denies STD hx\nPMH: denies\nPSH: denies\n\nSocial History:\n___\nFamily History:\nnon-contributory\n\n', 'Chief Complaint:|Complaint:': '\nleaking of fluid and vaginal bleeding\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nNo Known Allergies / Adverse Drug Reactions\n\n'}, '14082328-DS-13', 13, 'obstetrics/gynecology']]

[]

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[['10A07Z6', 10, 1, Timestamp('2185-09-12 00:00:00'), 'Abortion of Products of Conception, Vacuum, Via Natural or Artificial Opening']]

['obstetrics/gynecology']

[[51133, Timestamp('2185-09-12 19:30:00'), Timestamp('2185-09-12 20:09:00'), 'Absolute Lymphocyte Count'], [51146, Timestamp('2185-09-12 19:30:00'), Timestamp('2185-09-12 20:09:00'), 'Basophils'], [51200, Timestamp('2185-09-12 19:30:00'), Timestamp('2185-09-12 20:09:00'), 'Eosinophils'], [51221, Timestamp('2185-09-12 19:30:00'), Timestamp('2185-09-12 20:09:00'), 'Hematocrit'], [51222, Timestamp('2185-09-12 19:30:00'), Timestamp('2185-09-12 20:09:00'), 'Hemoglobin'], [51244, Timestamp('2185-09-12 19:30:00'), Timestamp('2185-09-12 20:09:00'), 'Lymphocytes'], [51248, Timestamp('2185-09-12 19:30:00'), Timestamp('2185-09-12 20:09:00'), 'MCH'], [51249, Timestamp('2185-09-12 19:30:00'), Timestamp('2185-09-12 20:09:00'), 'MCHC'], [51250, Timestamp('2185-09-12 19:30:00'), Timestamp('2185-09-12 20:09:00'), 'MCV'], [51254, Timestamp('2185-09-12 19:30:00'), Timestamp('2185-09-12 20:09:00'), 'Monocytes'], [51256, Timestamp('2185-09-12 19:30:00'), Timestamp('2185-09-12 20:09:00'), 'Neutrophils'], [51265, Timestamp('2185-09-12 19:30:00'), Timestamp('2185-09-12 20:09:00'), 'Platelet Count'], [51277, Timestamp('2185-09-12 19:30:00'), Timestamp('2185-09-12 20:09:00'), 'RDW'], [51279, Timestamp('2185-09-12 19:30:00'), Timestamp('2185-09-12 20:09:00'), 'Red Blood Cells'], [51301, Timestamp('2185-09-12 19:30:00'), Timestamp('2185-09-12 20:09:00'), 'White Blood Cells'], [52069, Timestamp('2185-09-12 19:30:00'), Timestamp('2185-09-12 20:09:00'), 'Absolute Basophil Count'], [52073, Timestamp('2185-09-12 19:30:00'), Timestamp('2185-09-12 20:09:00'), 'Absolute Eosinophil Count'], [52074, Timestamp('2185-09-12 19:30:00'), Timestamp('2185-09-12 20:09:00'), 'Absolute Monocyte Count'], [52075, Timestamp('2185-09-12 19:30:00'), Timestamp('2185-09-12 20:09:00'), 'Absolute Neutrophil Count'], [52135, Timestamp('2185-09-12 19:30:00'), Timestamp('2185-09-12 20:09:00'), 'Immature Granulocytes'], [52172, Timestamp('2185-09-12 19:30:00'), Timestamp('2185-09-12 20:09:00'), 'RDW-SD'], [51133, Timestamp('2185-09-13 05:48:00'), Timestamp('2185-09-13 07:53:00'), 'Absolute Lymphocyte Count'], [51137, Timestamp('2185-09-13 05:48:00'), Timestamp('2185-09-13 07:54:00'), 'Anisocytosis'], [51143, Timestamp('2185-09-13 05:48:00'), Timestamp('2185-09-13 07:53:00'), 'Atypical Lymphocytes'], [51144, Timestamp('2185-09-13 05:48:00'), Timestamp('2185-09-13 07:53:00'), 'Bands'], [51146, Timestamp('2185-09-13 05:48:00'), Timestamp('2185-09-13 07:53:00'), 'Basophils'], [51200, Timestamp('2185-09-13 05:48:00'), Timestamp('2185-09-13 07:53:00'), 'Eosinophils'], [51221, Timestamp('2185-09-13 05:48:00'), Timestamp('2185-09-13 06:36:00'), 'Hematocrit'], [51222, Timestamp('2185-09-13 05:48:00'), Timestamp('2185-09-13 06:36:00'), 'Hemoglobin'], [51233, Timestamp('2185-09-13 05:48:00'), Timestamp('2185-09-13 07:54:00'), 'Hypochromia'], [51244, Timestamp('2185-09-13 05:48:00'), Timestamp('2185-09-13 07:53:00'), 'Lymphocytes'], [51246, Timestamp('2185-09-13 05:48:00'), Timestamp('2185-09-13 07:54:00'), 'Macrocytes'], [51248, Timestamp('2185-09-13 05:48:00'), Timestamp('2185-09-13 06:36:00'), 'MCH'], [51249, Timestamp('2185-09-13 05:48:00'), Timestamp('2185-09-13 06:36:00'), 'MCHC'], [51250, Timestamp('2185-09-13 05:48:00'), Timestamp('2185-09-13 06:36:00'), 'MCV'], [51251, Timestamp('2185-09-13 05:48:00'), Timestamp('2185-09-13 07:53:00'), 'Metamyelocytes'], [51252, Timestamp('2185-09-13 05:48:00'), Timestamp('2185-09-13 07:54:00'), 'Microcytes'], [51254, Timestamp('2185-09-13 05:48:00'), Timestamp('2185-09-13 07:53:00'), 'Monocytes'], [51255, Timestamp('2185-09-13 05:48:00'), Timestamp('2185-09-13 07:53:00'), 'Myelocytes'], [51256, Timestamp('2185-09-13 05:48:00'), Timestamp('2185-09-13 07:53:00'), 'Neutrophils'], [51265, Timestamp('2185-09-13 05:48:00'), Timestamp('2185-09-13 06:36:00'), 'Platelet Count'], [51266, Timestamp('2185-09-13 05:48:00'), Timestamp('2185-09-13 07:53:00'), 'Platelet Smear'], [51267, Timestamp('2185-09-13 05:48:00'), Timestamp('2185-09-13 07:54:00'), 'Poikilocytosis'], [51268, Timestamp('2185-09-13 05:48:00'), Timestamp('2185-09-13 07:54:00'), 'Polychromasia'], [51277, Timestamp('2185-09-13 05:48:00'), Timestamp('2185-09-13 06:36:00'), 'RDW'], [51279, Timestamp('2185-09-13 05:48:00'), Timestamp('2185-09-13 06:36:00'), 'Red Blood Cells'], [51301, Timestamp('2185-09-13 05:48:00'), Timestamp('2185-09-13 06:36:00'), 'White Blood Cells'], [52069, Timestamp('2185-09-13 05:48:00'), Timestamp('2185-09-13 07:53:00'), 'Absolute Basophil Count'], [52073, Timestamp('2185-09-13 05:48:00'), Timestamp('2185-09-13 07:53:00'), 'Absolute Eosinophil Count'], [52074, Timestamp('2185-09-13 05:48:00'), Timestamp('2185-09-13 07:53:00'), 'Absolute Monocyte Count'], [52075, Timestamp('2185-09-13 05:48:00'), Timestamp('2185-09-13 07:53:00'), 'Absolute Neutrophil Count'], [52172, Timestamp('2185-09-13 05:48:00'), Timestamp('2185-09-13 06:36:00'), 'RDW-SD'], [50813, Timestamp('2185-09-13 06:14:00'), Timestamp('2185-09-13 06:16:00'), 'Lactate'], [50912, Timestamp('2185-09-13 13:05:00'), Timestamp('2185-09-13 15:03:00'), 'Creatinine'], [50920, Timestamp('2185-09-13 13:05:00'), Timestamp('2185-09-13 15:03:00'), 'Estimated GFR (MDRD equation)'], [50934, Timestamp('2185-09-13 13:05:00'), Timestamp('2185-09-13 15:03:00'), 'H'], [50947, Timestamp('2185-09-13 13:05:00'), Timestamp('2185-09-13 15:03:00'), 'I'], [51678, Timestamp('2185-09-13 13:05:00'), Timestamp('2185-09-13 15:03:00'), 'L']]

Question: A 28 F is admitted. He/she says he/she has leaking of fluid and vaginal bleeding . History of illness: This is a ___ yo G1P0 presents with vaginal bleeding and leakage of fluid. She reports uncertain ___, and uncertain LMP. OSH today performed an US that dates pregnancy at 17w2d, consistent with our ultrasound below. Patient states she has not had any prior ultrasounds. Patient reports that at 430a today she experienced a gush of fluid, felt wet and noted both fluid and blood in her bed. Presented to ___ where she was found to have pooling of blood tinged fluid on exam. Unable to determine if ferns present. Radiology ultrasound demonstrated anhydramnios with a 17w2d fetus at CHA. She denies any current abdominal pain, cramping, contractions. Denies fevers or chills. Denies recent abdominal trauma. Overall comfortable appearing. She initially had one visit in a clinic in ___ for prenatal care and is scheduled to have an intake with Dr. ___ this month, yet she has not had regular prenatal care for this pregnancy. Past Medical History: OBHx: G1 current, as above, uncomplicated per patient Denies SABs or TABs GynHx: denies STD hx PMH: denies PSH: denies Social History: ___ Family History: non-contributory Allergies: No Known Allergies / Adverse Drug Reactions What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Sodium Chloride 0.9% Ondansetron Ibuprofen 0.9% Sodium Chloride (Mini Bag Plus) Ampicillin Sodium Ondansetron Doxycycline Hyclate Acetaminophen Influenza Vaccine Quadrivalent 0.9% Sodium Chloride Gentamicin Sulfate Lactated Ringers Lactated Ringers Iso-Osmotic Dextrose Clindamycin Acetaminophen Ondansetron ODT Ketorolac Calcium Carbonate Acetaminophen Sodium Chloride 0.9% Flush Iso-Osmotic Dextrose Clindamycin Docusate Sodium Oxazepam Influenza Vaccine Quadrivalent 0.9% Sodium Chloride (Mini Bag Plus) Ampicillin Sodium Ibuprofen Target Lab Orders: Absolute Lymphocyte Count Basophils Eosinophils Hematocrit Hemoglobin Lymphocytes MCH MCHC MCV Monocytes Neutrophils Platelet Count RDW Red Blood Cells White Blood Cells Absolute Basophil Count Absolute Eosinophil Count Absolute Monocyte Count Absolute Neutrophil Count Immature Granulocytes RDW-SD Absolute Lymphocyte Count Anisocytosis Atypical Lymphocytes Bands Basophils Eosinophils Hematocrit Hemoglobin Hypochromia Lymphocytes Macrocytes MCH MCHC MCV Metamyelocytes Microcytes Monocytes Myelocytes Neutrophils Platelet Count Platelet Smear Poikilocytosis Polychromasia RDW Red Blood Cells White Blood Cells Absolute Basophil Count Absolute Eosinophil Count Absolute Monocyte Count Absolute Neutrophil Count RDW-SD Lactate Creatinine Estimated GFR (MDRD equation) H I L Target Procedures: Abortion of Products of Conception, Vacuum, Via Natural or Artificial Opening DOCTOR'S NOTE Hospital Notes: : Ms. ___ was admitted to the ___ service after a D&E for a septic abortion at 17 weeks. Please see operative report for full details. Patient presented at ___ GA with vaginal bleeding and leakage of fluid. On admission, patient developed a fever concerning for septic abortion. She was started on amp/gent/clinda and blood cultures, CBC, lactate drawn. She then underwent an ultrasound-guided D&E. Please see operative report for full details. She received Tylenol and Toradol for pain control immediately post-operatively. She also received PO doxycycline following the procedure. She was continued on IV gentamycin, clindamycin, ampicillin for 24 hours. Her WBC was trended and decreased from 25.8 to 13.8 prior to discharge. By post-operative day #2, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled. Other Results: ___ WBC-12.5 RBC-3.97 Hgb-12.1 Hct-36.8 MCV-93 Plt-269 ___ WBC-19.5 RBC-3.20 Hgb-10.0 Hct-30.1 MCV-94 Plt-223 ___ Neuts-89.1 ___ Monos-7.6 Eos-0.0* Baso-0.1 Im ___ AbsNeut-17.40* AbsLymp-0.42 AbsMono-1.48 AbsEos-0.00* AbsBaso-0.02 ___ WBC-25.8 RBC-2.92 Hgb-9.0 Hct-26.9* MCV-92 MCH-30.8 MCHC-33.5 RDW-12.8 RDWSD-42.6 Plt ___ ___ Neuts-88 Bands-0 ___ Monos-7 Eos-0 Baso-0 Atyps-0 ___ Myelos-0 AbsNeut-22.70 AbsLymp-1.29 AbsMono-1.81* AbsEos-0.00* AbsBaso-0.00 ___ WBC-13.8 RBC-2.77* Hgb-8.6* Hct-25.8* MCV-93 MCH-31.0 MCHC-33.3 RDW-13.1 RDWSD-44.6 Plt ___ ___ Neuts-85.2* Lymphs-6.4* Monos-5.9 Eos-0.6* Baso-0.2 Im ___ AbsNeut-11.74 AbsLymp-0.89* AbsMono-0.82* AbsEos-0.08 AbsBaso-0.03 ___ BLOOD Creat-0.7 ___ BLOOD Lactate-1.2 ___ URINE Blood-MOD* Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG ___ URINE RBC-34* WBC-2 Bacteri-FEW* Yeast-NONE Epi-1 URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION Blood Culture, Routine (Pending): No growth to date Blood Culture, Routine (Pending): No growth to date

2154-01-24 16:32:00

ENGLISH

SINGLE

WHITE

M

[[22971511, Timestamp('2154-01-24 16:33:49'), '', 'DENT']]

[[{'Medications on Admission': ':\nNone', 'Brief Hospital Course': ':\nPatient was admitted to the plastic surgery service following \nORIF of mandible, left ZF, lateral buttress, inferior orbital \nrim and orbital floor. For full details of this procedure, \nplease refer to the operative report. He was monitored \npostoperatively with Q1 hour vision checks, which remianed \nstable, without any changes in vision or color perception. He \nwas started on a diet of clear liquids which he tolerated well. \nHe was given unasy for antibiotic prophylaxis. He had good pain \ncontrol with oral medication. On the monring of POD 1, his exam \nremained stable and he was feeling well. His JP drain was \ndiscontinued. He was deemed appropriate for discharge at this \ntime, with scheduled follow up with Dr. ___ in one week.\n\n', 'Pertinent Results:': 'NIL', 'Physical Exam:|Physical': '\nUpon Discharge:\n\nVitals: 98.8, 83, 155/79, 16, 100RA\nGen: NAD, AOx3\nHEENT: R eye swollen, EOMI, PERRLA, no visual or color changes, \nincisions c/d/i, no erythema/induration, JP x 1 thin serosang, \nremoved prior to dispo\nCV: RRR\nPulm: unlabored respirations\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\n___ with history of previous fracture left mandible s/o ORIF \nwith Dr. ___ s/p altercation with left mandibular \nangle fracture and right ZMC. \n\nPast Medical History:\nceliac disease\nORIF L mandible\n\nSocial History:\n___\nFamily History:\nNC\n\n', 'Chief Complaint:|Complaint:': '\nFacial fractures\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nGluten\n\n'}, '11258755-DS-5', 5, 'dental']]

[['INDICATION: Status post ORIF of the left mandible, right zygomatic suture\nfracture, inferior orbital rim, orbital floor, and maxilla. Evaluate\nreduction.\n\nCOMPARISONS: CT of the head from ___, obtained at an outside\nhospital. CT of the facial bones from ___.\n\nTECHNIQUE: Contiguous helical axial MDCT images were obtained through the\nfacial bones without the administration of IV contrast. Sagittal and coronal\nreformatted images were obtained and reviewed.\n\nDLP: 295 mGy-cm.\n\nFINDINGS: Since the prior exam, the patient has undergone a repair of the\nfracture of the right orbital floor. Radiodense mesh-like surgical material\nextends from the right medial rectus muscle downward to the orbital floor. \nThe inferior rectus muscle appears slightly enlarged in comparison to the\nleft, likely from hematoma. A punctate density just medial to the inferior\nrectus muscle (602a, 60), may be resolving hematoma or a tiny fracture\nfragment. There is no CT evidence for entrapment.\n\nA new plate and screws transverses the right zygomatic suture. The alignment\nof the fracture is grossly unchanged in comparison to the prior exam. The\nfracture of the posterior portion of the arch is unchanged.\n\nA new plate and screws transfix the right anterior maxillary sinus wall. \nSince the prior exam, the alignment of this wall has improved. The right\nlateral maxillary sinus wall demonstrates a depressed fracture. The degree of\ndepression is slightly increased. It measures approximately 4 mm (4, 101),\nwhereas it previously measured 2 mm. There is increased opacification of the\nright maxillary sinus with heterogeneous dense material, consistent with\nhematoma. Multiple fracture fragments are noted within the sinus. Two new\nscrews are noted bilaterally in the roof of the maxilla (4, 76).\n\nA plate and screws transfix the left mandibular body fracture. Alignment is\nnear anatomic. Several of these screws extend through the bone (4, 82). A\nplate and screws along the right mandible are unchanged from the prior exam.\n\nThe fracture of the right lamina papyracea is unchanged. The cribriform\nplates are intact. Nasal bone fractures are also unchanged. No new fracture\nis identified.\n\nA large pocket of subcutaneous air in soft tissues of the right cheek is\ncontiguous with the air in the maxillary sinus (3, 108). This may be\npost-surgical. Smaller locules of subcutaneous air overlying the right\nfrontal bone and left mandible are likely post-surgical.\n\nThere is mucosal thickening in the right frontal sinus, ethmoidal air cells,\nand left maxillary sinus. There are no fluid levels within the sinuses. The\nmastoid air cells are clear.\n\nThe globes are intact. Soft tissue hematoma overlying the right globe and\ncheek has slightly increased. \nThe imaged portions of the brain are normal. The parotid and submandibular\nglands are unremarkable. Prominent cervical lymph nodes are noted, though are\nnormal finding in a patient of this age.\n\nIMPRESSION:\n1. Post-surgical changes as described above. Alignment in the right anterior\nmaxiallary sinus is improved. The alignment is otherwise grossly unchanged\nfrom the preoperative CT.\n2. A locule of air in the right cheek is contiguous with the right maxillary\nsinus.\n3. Increased opacification of the right maxillary sinus is likely increased\nhematoma. Several fracture fragments are noted within the sinus.\n4. No CT evidence for entrapment. No new fracture.\n', '11258755-RR-16', 16, 'contiguous helical axial mdct images were obtained through the\nfacial bones without the administration of iv contrast. sagittal and coronal\nreformatted images were obtained and reviewed.']]

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[]

['dental']

[]

Question: A 23 M is admitted. He/she says he/she has Facial fractures . History of illness: ___ with history of previous fracture left mandible s/o ORIF with Dr. ___ s/p altercation with left mandibular angle fracture and right ZMC. Past Medical History: celiac disease ORIF L mandible Social History: ___ Family History: NC Allergies: Gluten What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Lactated Ringers 0.9% Sodium Chloride (Mini Bag Plus) Ampicillin-Sulbactam OxycoDONE Liquid Chlorhexidine Gluconate 0.12% Oral Rinse Influenza Virus Vaccine Morphine Sulfate Ondansetron Acetaminophen (Liquid) Sodium Chloride 0.9% Flush Target Lab Orders: NONE Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : Patient was admitted to the plastic surgery service following ORIF of mandible, left ZF, lateral buttress, inferior orbital rim and orbital floor. For full details of this procedure, please refer to the operative report. He was monitored postoperatively with Q1 hour vision checks, which remianed stable, without any changes in vision or color perception. He was started on a diet of clear liquids which he tolerated well. He was given unasy for antibiotic prophylaxis. He had good pain control with oral medication. On the monring of POD 1, his exam remained stable and he was feeling well. His JP drain was discontinued. He was deemed appropriate for discharge at this time, with scheduled follow up with Dr. ___ in one week. Other Results: NIL

2189-04-01 07:15:00

ENGLISH

MARRIED

WHITE

F

[[22873062, Timestamp('2189-04-01 00:38:39'), '', 'GYN']]

[[{'Medications on Admission': ':\nThe Preadmission Medication list is accurate and complete.\n1. Famotidine 20 mg PO BID \n2. Acetaminophen 500 mg PO Q6H:PRN pain \n\nMental Status: Clear and coherent.\nLevel of Consciousness: Alert and interactive.\nActivity Status: Ambulatory - Independent.', 'Brief Hospital Course': ':\nDr. ___ was admitted to the gynecologic oncology service \nfollowing a total abdominal hysterectomy, omentectomy, pelvic \nlymph node dissection, and cystoscopy, please see operative \nreport for details. Immediately following surgery, she become \nhypotensive requiring pressors and albumin transfusion in the \nrecovery room. She subsequently remained hemodynamically stable \nand was able to use an epidural for postoperative pain \nmanagement. She advanced without difficulty and by \npostoperative day 2 was tolerating a regular diet, using oral \npain medications, and ambulating well. Her foley was replaced \nfor mild urinary retention, and she subsequently voided without \ndifficulty the next day on postoperative day #3, upon which she \nwas discharged in good condition with follow arranged. \n\n', 'Pertinent Results:': '\n___ 07:50PM BLOOD WBC-18.6*# RBC-4.38 Hgb-13.6 Hct-39.4 \nMCV-90 MCH-31.0 MCHC-34.4 RDW-13.3 Plt ___\n___ 06:40AM BLOOD WBC-11.8* RBC-3.82* Hgb-11.7* Hct-34.5* \nMCV-90 MCH-30.5 MCHC-33.8 RDW-13.2 Plt ___\n___ 07:00AM BLOOD WBC-8.1 RBC-3.97* Hgb-12.3 Hct-35.3* \nMCV-89 MCH-31.0 MCHC-34.8 RDW-13.1 Plt ___\n___ 07:00AM BLOOD Glucose-99 UreaN-5* Creat-0.5 Na-138 \nK-3.9 Cl-105 HCO3-25 AnGap-12\n___ 07:00AM BLOOD Calcium-8.0* Phos-2.5* Mg-1.7\n\nFinal pathology pending\n\n', 'Physical Exam:|Physical': '\nOn Discharge: \nAVSS \nNAD\nRRR, CTAB\nAbdomen soft, NT, ND, vertical midline incision c/d/i with \nstaples\nExt NT NE\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\nThis patient is felt to be at risk for endometrial, ovarian, and \ncolon cancer. She underwent a laparoscopic colectomy where an \nadenoma was removed. There was no evidence of cancer. She was \ncounseled as to options for risk reducing surgery. She chose \nsurveillance. She developed abdominal swelling and imaging \nstudies revealed an abdominal pelvic mass. An endometrial \nbiopsy was normal. Prior to being brought to the operating room, \nthe risks, benefits, and alternatives were explained to the \npatient. She signed a consent.\n\nPast Medical History:\nmild preeclampsia with pregnancy\nHNPCC\nprophylactic subtotal colectomy\n\nFamily History:\nMaternal grandmother - colon cancer\n2 maternal great aunts - colon cancer\nMother - colon cancer at age ___\nBrother - stage IV rectal cancer with liver mets\n\n', 'Chief Complaint:|Complaint:': '\npelvic mass\n\n', 'Attending:': ' ___\n\n', 'Allergies:': ' \nNo Known Allergies / Adverse Drug Reactions\n\n'}, '11726100-DS-20', 20, 'obstetrics/gynecology']]

[]

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[]

['obstetrics/gynecology']

[[51221, Timestamp('2189-04-01 19:50:00'), Timestamp('2189-04-01 20:02:00'), 'Hematocrit'], [51222, Timestamp('2189-04-01 19:50:00'), Timestamp('2189-04-01 20:02:00'), 'Hemoglobin'], [51248, Timestamp('2189-04-01 19:50:00'), Timestamp('2189-04-01 20:02:00'), 'MCH'], [51249, Timestamp('2189-04-01 19:50:00'), Timestamp('2189-04-01 20:02:00'), 'MCHC'], [51250, Timestamp('2189-04-01 19:50:00'), Timestamp('2189-04-01 20:02:00'), 'MCV'], [51265, Timestamp('2189-04-01 19:50:00'), Timestamp('2189-04-01 20:02:00'), 'Platelet Count'], [51277, Timestamp('2189-04-01 19:50:00'), Timestamp('2189-04-01 20:02:00'), 'RDW'], [51279, Timestamp('2189-04-01 19:50:00'), Timestamp('2189-04-01 20:02:00'), 'Red Blood Cells'], [51301, Timestamp('2189-04-01 19:50:00'), Timestamp('2189-04-01 20:02:00'), 'White Blood Cells'], [50868, Timestamp('2189-04-01 19:50:00'), Timestamp('2189-04-01 21:06:00'), 'Anion Gap'], [50882, Timestamp('2189-04-01 19:50:00'), Timestamp('2189-04-01 21:06:00'), 'Bicarbonate'], [50893, Timestamp('2189-04-01 19:50:00'), Timestamp('2189-04-01 21:06:00'), 'Calcium, Total'], [50902, Timestamp('2189-04-01 19:50:00'), Timestamp('2189-04-01 21:06:00'), 'Chloride'], [50912, Timestamp('2189-04-01 19:50:00'), Timestamp('2189-04-01 21:06:00'), 'Creatinine'], [50920, Timestamp('2189-04-01 19:50:00'), Timestamp('2189-04-01 21:06:00'), 'Estimated GFR (MDRD equation)'], [50931, Timestamp('2189-04-01 19:50:00'), Timestamp('2189-04-01 21:06:00'), 'Glucose'], [50960, Timestamp('2189-04-01 19:50:00'), Timestamp('2189-04-01 21:06:00'), 'Magnesium'], [50970, Timestamp('2189-04-01 19:50:00'), Timestamp('2189-04-01 21:06:00'), 'Phosphate'], [50971, Timestamp('2189-04-01 19:50:00'), Timestamp('2189-04-01 21:06:00'), 'Potassium'], [50983, Timestamp('2189-04-01 19:50:00'), Timestamp('2189-04-01 21:06:00'), 'Sodium'], [51006, Timestamp('2189-04-01 19:50:00'), Timestamp('2189-04-01 21:06:00'), 'Urea Nitrogen'], [51221, Timestamp('2189-04-02 04:40:00'), Timestamp('2189-04-02 05:09:00'), 'Hematocrit'], [51222, Timestamp('2189-04-02 04:40:00'), Timestamp('2189-04-02 05:09:00'), 'Hemoglobin'], [51248, Timestamp('2189-04-02 04:40:00'), Timestamp('2189-04-02 05:09:00'), 'MCH'], [51249, Timestamp('2189-04-02 04:40:00'), Timestamp('2189-04-02 05:09:00'), 'MCHC'], [51250, Timestamp('2189-04-02 04:40:00'), Timestamp('2189-04-02 05:09:00'), 'MCV'], [51265, Timestamp('2189-04-02 04:40:00'), Timestamp('2189-04-02 05:09:00'), 'Platelet Count'], [51277, Timestamp('2189-04-02 04:40:00'), Timestamp('2189-04-02 05:09:00'), 'RDW'], [51279, Timestamp('2189-04-02 04:40:00'), Timestamp('2189-04-02 05:09:00'), 'Red Blood Cells'], [51301, Timestamp('2189-04-02 04:40:00'), Timestamp('2189-04-02 05:09:00'), 'White Blood Cells'], [50868, Timestamp('2189-04-02 04:40:00'), Timestamp('2189-04-02 05:29:00'), 'Anion Gap'], [50882, Timestamp('2189-04-02 04:40:00'), Timestamp('2189-04-02 05:29:00'), 'Bicarbonate'], [50893, Timestamp('2189-04-02 04:40:00'), Timestamp('2189-04-02 05:29:00'), 'Calcium, Total'], [50902, Timestamp('2189-04-02 04:40:00'), Timestamp('2189-04-02 05:29:00'), 'Chloride'], [50912, Timestamp('2189-04-02 04:40:00'), Timestamp('2189-04-02 05:29:00'), 'Creatinine'], [50931, Timestamp('2189-04-02 04:40:00'), Timestamp('2189-04-02 05:29:00'), 'Glucose'], [50960, Timestamp('2189-04-02 04:40:00'), Timestamp('2189-04-02 05:29:00'), 'Magnesium'], [50970, Timestamp('2189-04-02 04:40:00'), Timestamp('2189-04-02 05:29:00'), 'Phosphate'], [50971, Timestamp('2189-04-02 04:40:00'), Timestamp('2189-04-02 05:29:00'), 'Potassium'], [50983, Timestamp('2189-04-02 04:40:00'), Timestamp('2189-04-02 05:29:00'), 'Sodium'], [51006, Timestamp('2189-04-02 04:40:00'), Timestamp('2189-04-02 05:29:00'), 'Urea Nitrogen']]

Question: A 44 F is admitted. He/she says he/she has pelvic mass . History of illness: This patient is felt to be at risk for endometrial, ovarian, and colon cancer. She underwent a laparoscopic colectomy where an adenoma was removed. There was no evidence of cancer. She was counseled as to options for risk reducing surgery. She chose surveillance. She developed abdominal swelling and imaging studies revealed an abdominal pelvic mass. An endometrial biopsy was normal. Prior to being brought to the operating room, the risks, benefits, and alternatives were explained to the patient. She signed a consent. Past Medical History: mild preeclampsia with pregnancy HNPCC prophylactic subtotal colectomy Family History: Maternal grandmother - colon cancer 2 maternal great aunts - colon cancer Mother - colon cancer at age ___ Brother - stage IV rectal cancer with liver mets Allergies: No Known Allergies / Adverse Drug Reactions What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Heparin 0.9% Sodium Chloride Sodium Phosphate Bupivacaine 0.1% Yellow CADD Cassette HYDROmorphone Iso-Osmotic Sodium Chloride Famotidine Albumin 5% (25g / 500mL) Ketorolac Bag Magnesium Sulfate Acetaminophen IV Sodium Chloride 0.9% Flush Lactated Ringers Ketorolac Target Lab Orders: Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells Anion Gap Bicarbonate Calcium, Total Chloride Creatinine Estimated GFR (MDRD equation) Glucose Magnesium Phosphate Potassium Sodium Urea Nitrogen Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells Anion Gap Bicarbonate Calcium, Total Chloride Creatinine Glucose Magnesium Phosphate Potassium Sodium Urea Nitrogen Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : Dr. ___ was admitted to the gynecologic oncology service following a total abdominal hysterectomy, omentectomy, pelvic lymph node dissection, and cystoscopy, please see operative report for details. Immediately following surgery, she become hypotensive requiring pressors and albumin transfusion in the recovery room. She subsequently remained hemodynamically stable and was able to use an epidural for postoperative pain management. She advanced without difficulty and by postoperative day 2 was tolerating a regular diet, using oral pain medications, and ambulating well. Her foley was replaced for mild urinary retention, and she subsequently voided without difficulty the next day on postoperative day #3, upon which she was discharged in good condition with follow arranged. Other Results: ___ 07:50PM BLOOD WBC-18.6*# RBC-4.38 Hgb-13.6 Hct-39.4 MCV-90 MCH-31.0 MCHC-34.4 RDW-13.3 Plt ___ ___ 06:40AM BLOOD WBC-11.8* RBC-3.82* Hgb-11.7* Hct-34.5* MCV-90 MCH-30.5 MCHC-33.8 RDW-13.2 Plt ___ ___ 07:00AM BLOOD WBC-8.1 RBC-3.97* Hgb-12.3 Hct-35.3* MCV-89 MCH-31.0 MCHC-34.8 RDW-13.1 Plt ___ ___ 07:00AM BLOOD Glucose-99 UreaN-5* Creat-0.5 Na-138 K-3.9 Cl-105 HCO3-25 AnGap-12 ___ 07:00AM BLOOD Calcium-8.0* Phos-2.5* Mg-1.7 Final pathology pending

2144-04-18 21:47:00

ENGLISH

MARRIED

WHITE

F

[[21722052, Timestamp('2144-04-18 21:48:08'), '', 'SURG']]

[[{'Medications on Admission': ':\nLisinopril, Hydrochlorothiazide, Paroxetine\n\n2. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO \nDAILY (Daily). \n3. Paroxetine HCl 30 mg Tablet Sig: One (1) Tablet PO DAILY \n(Daily). \n4. Hydromorphone 2 mg Tablet Sig: ___ Tablets PO every four (4) \nhours as needed for pain.\nDisp:*60 Tablet(s)* Refills:*0*\n5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 \ntimes a day).\nDisp:*60 Capsule(s)* Refills:*2*\n6. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a \nday for 7 days.\nDisp:*14 Tablet(s)* Refills:*0*\n\nFacility:\n___', 'Brief Hospital Course': ":\nThe patient was admitted to the plastic surgery service on \n___ and had irrigation and debridement of multiple \nlacerations to face, upper extremities and trunk secondary to \ndog attack. The patient tolerated the procedure well.\n\nNeuro: Post-operatively, the patient received Dilaudid IV/PCA \nwith good effect and adequate pain control. When tolerating oral \nintake, the patient was transitioned to oral pain medications. \n\nCV: The patient was stable from a cardiovascular standpoint; \nvital signs were routinely monitored.\n\nPulmonary: The patient was stable from a pulmonary standpoint; \nvital signs were routinely monitored.\n\nGI/GU: Post-operatively, the patient was given IV fluids until \ntolerating oral intake. Her diet was advanced when appropriate, \nwhich was tolerated well. She was also started on a bowel \nregimen to encourage bowel movement. Foley was removed on POD#1. \nIntake and output were closely monitored. \n\nID: Pre-operatively, the patient was started on IV Unasyn, then \nswitched to PO augmentin on POD#1. Patient also initiated rabies \nvaccine protocol as there was concern for rabies in attacking \ndog. Per patient, dog evaluated by authorities and found not to \nhave rabies. Rabies vaccine discontinued at this time. The \npatient's temperature was closely watched for signs of \ninfection. \n\nPsychiatry/Social Work: Patient discussed coping mechanisms with \nsocial work team on several occasions during admission due to \ntraumatic nature of dog attack. \n\nProphylaxis: The patient received subcutaneous heparin during \nthis stay, and was encouraged to get up and ambulate as early as \npossible. \n\nAt the time of discharge on POD#4, the patient was doing well, \nafebrile with stable vital signs, tolerating a regular diet, \nambulating, voiding without assistance, and pain was well \ncontrolled. \n\n", 'Pertinent Results:': '\nXR LUE (___): cortical defect in L distal radius from \npuncture \n\n', 'Physical Exam:|Physical': '\nOn Admission:\nPt is laying supine with C-collar in place\nface is stained by blood.\nPERRLA, EOMI\nR mandibular border jagged skin laceration, approx 5cm obliquely\nfrom superolaterally to inferomedially along her jawline. Small\nlaceration across her right medial upper ___ border,\nseveral smaller superficial lacerations to her neck area.\nNl CN VII function throughout. Decreased sensation around R\nmandibular wound and along R mandibular border.\nno intraoral lesions, intact parotid duct ostium\n\nLeft forearm with large soft tissue defect on volar proximal\nforearm, muscle bellies exposed. Smaller dorsal lacerations\naround elbow area. Multiple teethmarks throughout her forearm\nIntact neurosensory exam, intact motor exam. Some pain in mid\nforearm on passive extension of fingers.\n\nRight forearm with several lacerations, and multiple bitemarks.\nNeurovasc exam intact. Bitemark with surrounding swelling at\nvolar base of right middle finger.\n\nMultiple bitemarks to bilateral thighs, and abdomen.\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\n___ yo F who was babysitting a ___ year old child when her own\n___ Bulldog started attacking the child. The pt promptly\nintervened to seperate the dog from the child, the dog turned on\nher and started chewing on her like "a piece of meat" according\nto pt\'s description. She managed to keep the dog from the child\nby holding it down with her hand in its mouth, while 911 was\ncontacted and she was released by emergency personnel, followed\nby termination of the dog.\nAccording to the pt, the dog had not received vaccines.\nPt was brought to the hospital with multiple dogbite wounds to\nher head/neck, LUE, abd, lower extremities.\n\nPast Medical History:\nHTN\n\nSocial History:\n___\nFamily History:\nNon-contributory\n\n', 'Chief Complaint:|Complaint:': '\nDog Bite\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nPatient recorded as having No Known Allergies to Drugs\n\n'}, '12429058-DS-6', 6, 'plastic']]

[["LEFT WRIST FOUR VIEWS, RIGHT WRIST FOUR VIEWS, ___ AT 1815 HOURS.\n\nHISTORY: Trauma from dog attack.\n\nCOMPARISON: None.\n\nFINDINGS:\n\nLEFT WRIST: Extensive soft tissue injury is apparent in the medial aspects of\nthe included more proximal mid forearm. There is a defect along the ulnar\nvolar aspect of the distal radius just proximal to the distal radial\nmetaphysis. This may indicate a focal cortical disruption and is therefore a\nsuspect for possible seeding of infection. The carpal bones themselves are in\nnormal aligned, with no definite fracture identified.\n\nRIGHT WRIST: An IV catheter is noted along the dorsal hand. The carpal bones\nare normally aligned, with no fracture present. Extensive soft tissue injury\nis noted in the more proximal included forearm. Soft tissues of the wrist\nproper are relatively unremarkable.\n\nIMPRESSION: Extensive soft injury of the more proximal forearms bilaterally. \nThere is a focal defect in the cortex of the distal left radial diaphysis,\nwhich would be consistent with a possible puncture from the dog's tooth, for\nexample. If present, this represents essential assured nidus for infection\nand osteomyelitis. Correlate clinically.\n", '12429058-RR-5', 5, ''], ['INDICATION: ___ female post fall and dog attack.\n\nNo prior examinations for comparison.\n\nTECHNIQUE: Helical MDCT images were acquired through the brain without\nintravenous contrast. Axial, coronal, and sagittal multiplanar reformations\nwere generated in 5- and 2.5 mm slice intervals, using bone and soft tissue\nkernels.\n\nFINDINGS: There is no acute hemorrhage, edema, mass effect, or infarct. The\nventricles and sulci are normal in size and morphology. The paranasal sinuses\nand mastoid air cells are clear. No osseous fractures are visualized.\n\nIMPRESSION: No acute intracranial process.\n', '12429058-RR-6', 6, 'helical mdct images were acquired through the brain without\nintravenous contrast. axial, coronal, and sagittal multiplanar reformations\nwere generated in 5- and 2.5 mm slice intervals, using bone and soft tissue\nkernels.'], ['INDICATION: ___ female post fall and dog attack.\n\nNo prior examinations for comparison.\n\nTECHNIQUE: Helical MDCT images were acquired through the paranasal sinuses. \nAxial, coronal, and sagittal multiplanar reformations were generated, using 2\nand 1.25-mm slice thicknesses, in bone and soft tissue kernels.\n\nFINDINGS: Severe open lacerations of the chin and neck are present, with\nmarked soft tissue irregularity and overlying bandages. Multiple locules of\ngas are seen dissecting into the submental space and right lateral neck,\nincluding deep to the carotid space. There are diffuse inflammatory changes,\nwith fascial thickening and stranding. The airway remains intact. No obvious\nvascular injury is noted, although examination is not optimized for such an\nassessment. \n\nNo osseous fractures are visualized. The paranasal sinuses and mastoid air\ncells are clear.\n\nIMPRESSION:\n1. Severe open lacerations of chin and right neck.\n2. No apparent osseous, vascular, or airway injury within limitations of a\nnoncontrast enhanced scan.\n', '12429058-RR-7', 7, 'helical mdct images were acquired through the paranasal sinuses. \naxial, coronal, and sagittal multiplanar reformations were generated, using 2\nand 1.25-mm slice thicknesses, in bone and soft tissue kernels.'], ['INDICATION: ___ female post fall and dog attack.\n\nNo prior examinations for comparison.\n\nTECHNIQUE: Helical MDCT images were acquired through the cervical spine, from\nthe skull base through the T2 vertebral body. Axial, coronal, and sagittal\nmultiplanar reformations were generated, using 2.5-mm slice thickness, in bone\nand soft tissue kernels.\n\nFINDINGS: Severe open lacerations of the chin and neck are seen, with marked\nsoft tissue irregularity and overlying bandages. Multiple locules of gas are\nseen dissecting through the fascia into the submental space, superior\nmediastinum, and right lateral neck extending deep to the carotid space. \nThere is associated inflammatory soft tissue stranding. No obvious vascular\ninjury is present, although the examination is not tailored for vascular\nevaluation. The airway remains patent.\n\nThere are no acute cervical spine fractures. Straightening of the normal\ncervical lordosis is noted. Mild degenerative changes are present, with\nanterior osteophytes most prominent at C6-7. The spinal canal and foramina\nappear widely patent.\n\nIMPRESSION:\n1. Severe lacerations of chin and neck.\n2. No apparent osseous, vascular, or airway injury within limitations of a\nnoncontrast enhanced scan.\n', '12429058-RR-8', 8, 'helical mdct images were acquired through the cervical spine, from\nthe skull base through the t2 vertebral body. axial, coronal, and sagittal\nmultiplanar reformations were generated, using 2.5-mm slice thickness, in bone\nand soft tissue kernels.']]

[[21722052, Timestamp('2144-04-19 01:00:00'), Timestamp('2144-04-19 17:00:00'), 'MAIN', 'Oxycodone-Acetaminophen', '004222', '00406051262', '5mg/325mg Tablet'], [21722052, Timestamp('2144-04-19 01:00:00'), Timestamp('2144-04-19 02:00:00'), 'MAIN', 'Morphine Sulfate', '004070', '00409176230', '2mg Syringe'], [21722052, Timestamp('2144-04-19 08:00:00'), Timestamp('2144-04-22 18:00:00'), 'MAIN', 'Heparin', '006549', '63323026201', '5000 Units / mL- 1mL Vial'], [21722052, Timestamp('2144-04-19 01:00:00'), Timestamp('2144-04-19 02:00:00'), 'MAIN', 'HYDROmorphone (Dilaudid)', '062823', '00409128331', '1mg/1mL Syringe'], [21722052, Timestamp('2144-04-19 01:00:00'), Timestamp('2144-04-19 01:00:00'), 'MAIN', 'Morphine Sulfate', '004070', '00409176230', '2mg Syringe'], [21722052, Timestamp('2144-04-19 10:00:00'), Timestamp('2144-04-22 18:00:00'), 'MAIN', 'Paroxetine', '046224', '00904567861', '30mg Tablet'], [21722052, Timestamp('2144-04-19 10:00:00'), Timestamp('2144-04-22 18:00:00'), 'MAIN', 'Hydrochlorothiazide', '029832', '00603385521', '25mg Tablet'], [21722052, Timestamp('2144-04-19 01:00:00'), Timestamp('2144-04-19 02:00:00'), 'MAIN', 'Promethazine HCl', '003870', '00641092825', '25mg/mL Amp'], [21722052, Timestamp('2144-04-19 01:00:00'), Timestamp('2144-04-19 02:00:00'), 'MAIN', 'Ondansetron', '061716', '00781305714', '2mg/mL-2mL'], [21722052, Timestamp('2144-04-19 08:00:00'), Timestamp('2144-04-20 15:00:00'), 'BASE', '0.9% Sodium Chloride (Mini Bag Plus)', '001210', '00338055318', '100mL Bag'], [21722052, Timestamp('2144-04-19 08:00:00'), Timestamp('2144-04-20 15:00:00'), 'MAIN', 'Ampicillin-Sulbactam', '008921', '63323036920', '3g Vial'], [21722052, Timestamp('2144-04-19 08:00:00'), Timestamp('2144-04-22 18:00:00'), 'MAIN', 'Docusate Sodium', '003009', '00904224461', '100mg Capsule'], [21722052, Timestamp('2144-04-19 01:00:00'), Timestamp('2144-04-19 02:00:00'), 'MAIN', 'Haloperidol', '003970', '63323047401', '5mg/mL Vial'], [21722052, Timestamp('2144-04-19 01:00:00'), Timestamp('2144-04-19 09:00:00'), 'BASE', 'LR', '001187', '00338011704', '1000ml Bag'], [21722052, Timestamp('2144-04-19 09:00:00'), Timestamp('2144-04-22 18:00:00'), 'MAIN', 'Milk of Magnesia', '003026', '00121043130', '30mL UD Cup'], [21722052, Timestamp('2144-04-19 18:00:00'), Timestamp('2144-04-20 09:00:00'), 'MAIN', 'HYDROmorphone (Dilaudid)', '004110', '00054839224', '2mg Tablet'], [21722052, Timestamp('2144-04-19 02:00:00'), Timestamp('2144-04-19 11:00:00'), 'MAIN', 'HYDROmorphone (Dilaudid)', '062823', '00409128331', '1mg/1mL Syringe'], [21722052, Timestamp('2144-04-19 01:00:00'), Timestamp('2144-04-19 01:00:00'), 'MAIN', 'Morphine Sulfate', '004072', '00409125830', '4mg Syringe'], [21722052, Timestamp('2144-04-19 07:00:00'), Timestamp('2144-04-19 06:00:00'), 'MAIN', 'HYDROmorphone (Dilaudid)', '004103', '00409131230', '2mg/mL Syringe'], [21722052, Timestamp('2144-04-19 07:00:00'), Timestamp('2144-04-20 06:00:00'), 'MAIN', 'HYDROmorphone (Dilaudid)', '004103', '00409131230', '2mg/mL Syringe'], [21722052, Timestamp('2144-04-19 01:00:00'), Timestamp('2144-04-22 18:00:00'), 'MAIN', 'Sodium Chloride 0.9% Flush', '', '0', 'Syringe'], [21722052, Timestamp('2144-04-19 12:00:00'), Timestamp('2144-04-22 18:00:00'), 'MAIN', 'HYDROmorphone (Dilaudid)', '004103', '00409131230', '2mg/mL Syringe'], [21722052, Timestamp('2144-04-19 01:00:00'), Timestamp('2144-04-19 02:00:00'), 'MAIN', 'Meperidine', '059794', '00409117830', '50mg Syringe'], [21722052, Timestamp('2144-04-19 10:00:00'), Timestamp('2144-04-22 18:00:00'), 'MAIN', 'Lisinopril', '000391', '00172376010', '20mg Tablet'], [21722052, Timestamp('2144-04-19 02:00:00'), Timestamp('2144-04-19 07:00:00'), 'BASE', '0.9% Sodium Chloride (Mini Bag Plus)', '001210', '00338055318', '100mL Bag'], [21722052, Timestamp('2144-04-19 02:00:00'), Timestamp('2144-04-19 07:00:00'), 'MAIN', 'Ampicillin-Sulbactam', '008921', '63323036920', '3g Vial'], [21722052, Timestamp('2144-04-19 01:00:00'), Timestamp('2144-04-19 02:00:00'), 'MAIN', 'Prochlorperazine', '003837', '55390007710', '10mg/2mL Vial']]

[]

['plastic']

[]

Question: A 39 F is admitted. He/she says he/she has Dog Bite . History of illness: ___ yo F who was babysitting a ___ year old child when her own ___ Bulldog started attacking the child. The pt promptly intervened to seperate the dog from the child, the dog turned on her and started chewing on her like "a piece of meat" according to pt's description. She managed to keep the dog from the child by holding it down with her hand in its mouth, while 911 was contacted and she was released by emergency personnel, followed by termination of the dog. According to the pt, the dog had not received vaccines. Pt was brought to the hospital with multiple dogbite wounds to her head/neck, LUE, abd, lower extremities. Past Medical History: HTN Social History: ___ Family History: Non-contributory Allergies: Patient recorded as having No Known Allergies to Drugs What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Oxycodone-Acetaminophen Morphine Sulfate Heparin HYDROmorphone (Dilaudid) Morphine Sulfate Paroxetine Hydrochlorothiazide Promethazine HCl Ondansetron 0.9% Sodium Chloride (Mini Bag Plus) Ampicillin-Sulbactam Docusate Sodium Haloperidol LR Milk of Magnesia HYDROmorphone (Dilaudid) HYDROmorphone (Dilaudid) Morphine Sulfate HYDROmorphone (Dilaudid) HYDROmorphone (Dilaudid) Sodium Chloride 0.9% Flush HYDROmorphone (Dilaudid) Meperidine Lisinopril 0.9% Sodium Chloride (Mini Bag Plus) Ampicillin-Sulbactam Prochlorperazine Target Lab Orders: NONE Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : The patient was admitted to the plastic surgery service on ___ and had irrigation and debridement of multiple lacerations to face, upper extremities and trunk secondary to dog attack. The patient tolerated the procedure well. Neuro: Post-operatively, the patient received Dilaudid IV/PCA with good effect and adequate pain control. When tolerating oral intake, the patient was transitioned to oral pain medications. CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. GI/GU: Post-operatively, the patient was given IV fluids until tolerating oral intake. Her diet was advanced when appropriate, which was tolerated well. She was also started on a bowel regimen to encourage bowel movement. Foley was removed on POD#1. Intake and output were closely monitored. ID: Pre-operatively, the patient was started on IV Unasyn, then switched to PO augmentin on POD#1. Patient also initiated rabies vaccine protocol as there was concern for rabies in attacking dog. Per patient, dog evaluated by authorities and found not to have rabies. Rabies vaccine discontinued at this time. The patient's temperature was closely watched for signs of infection. Psychiatry/Social Work: Patient discussed coping mechanisms with social work team on several occasions during admission due to traumatic nature of dog attack. Prophylaxis: The patient received subcutaneous heparin during this stay, and was encouraged to get up and ambulate as early as possible. At the time of discharge on POD#4, the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. Other Results: XR LUE (___): cortical defect in L distal radius from puncture

2186-01-24 22:50:00

?

WIDOWED

UNKNOWN

F

[[20055925, Timestamp('2186-01-24 22:50:35'), '', 'GYN'], [20055925, Timestamp('2186-01-29 06:41:35'), 'GYN', 'MED'], [20055925, Timestamp('2186-01-31 10:44:02'), 'MED', 'SURG']]

[[{'Medications on Admission': ':\n- Colace\n- Meclizine 12.5 mg BID PRN\n- Metoprolol tartrate 50mg PO qhs\n- Serax 10 mg po qhs prn\n- Tolterodine 4 mg PO QHS\n- Losartan 100 mg daily\n- atorvastatin 10 mg PO QHS\n- Amlodipine 5 mg PO daily\n- MVI', 'Brief Hospital Course': ':\nMs. ___ was admitted into the gynecology oncology service for \npre-operative evaluation of pelvic mass.\n\nPre-operatively: Her imaging was uploaded and reviewed with one \nof the radiology fellows. It was unclear what the primary source \nof her pelvic mass was. Her tumor markers came back with a very \nelevated CEA of 206. A GI consult was therefore made. They \nrecommended a sigmoidoscopy, which revealed no explanation for \nthe pelvic mass. She was noted to have diverticulosis and \ninternal hemorrhoids. She therefore underwent a colonoscopy, \nwhich also demonstrated no explanation for the lasrge pelvic \nmass seen on CT scan. She was therefore consented for a \nlaparascopy, possible laparatomy and possible staging for large \npelvic mass.\n\nOn ___, she underwent a laparascopy, which was converted to an \nopen laparatomy, total abdominal hysterectomy, bilateral \nsalpingo-oophorectomy, bowel resection x 2 with reanastomosis \nand repair of anterior bladder wall defect. The case was \ncomplicated by large intra-operative blood loss requiring \ntransfusion of 4 units of packed red cells and 750cc of albumin. \nPlease refer to operative note for full details of the \nprocedure. She was transferred to the intensive care unit \nintubated.\n\nIn the FICU, she was tachy and febrile on ___ and had a repeat \noperation where she was found to have an open enterotomy with \nspillage of stool into the peritoneum. This was repaired and she \nwas sent back to the ICU. She received 7L of fluid within 24h \nand had not made urine. She was continued on \nvanco/Cefepime/flagyl, but was transferred to ___ \nfor further surgical mgmt, returned to the ___ on ___ for a \nwashout and noted to have extensive necrosis of the abdominal \nwall; this fascia was debrided. She returned to the ___ again on \n___ for repeat exploration, washout, debridement and closure of \nthe abdominal wall. Also, a G-tube was placed.\n\nThe family at this point expressed their preference that she not \nbe treated with further surgical intervention and that she be \nmanaged non-operatively. The team articulated to the family \nthat would likely not be a feasible option.\n\nOver the coming days, her fluid status was managed with lasix \nand albumin, she received blood transfusions, she spiked fevers \nand was started on broad spectrum antibiotics with antifungal \ncoverage, and she received numerous blood transfusions for \nanemia and tachycardia. Her wound looked progressively more \nnecrotic and eventually was noted to have frank stool coming \nthrough the wound. Repeated family meetings were held and with \nthe outcome consistent -- no surgical intervention but continue \ncurrent management.\n\nOn ___, her urine output decreased to zero for several hours, \nshe was persistently hypotensive throughout the day. Her \nabdomen was noted to be increasingly firm and distended. A \nrepeat family meeting was held and she was made CMO on ___. \nShe was transferred to the floor on ___. She expired on \n___. The medical examiner declined the case.\n\n', 'Pertinent Results:': '\n___ 06:15AM BLOOD WBC-12.2* RBC-4.41 Hgb-12.6 Hct-38.6 \nMCV-88 MCH-28.6 MCHC-32.7 RDW-14.4 Plt ___\n___ 06:20AM BLOOD WBC-9.1 RBC-4.32 Hgb-12.5 Hct-38.1 MCV-88 \nMCH-28.9 MCHC-32.7 RDW-15.1 Plt ___\n___ 06:25AM BLOOD WBC-7.8 RBC-4.36 Hgb-12.6 Hct-38.8 MCV-89 \nMCH-28.9 MCHC-32.5 RDW-15.5 Plt ___\n___ 06:15AM BLOOD WBC-8.9 RBC-4.14* Hgb-11.6* Hct-36.2 \nMCV-88 MCH-27.9 MCHC-31.9 RDW-14.6 Plt ___\n___ 06:15AM BLOOD ___ PTT-35.9 ___\n___ 06:15AM BLOOD ___\n___ 06:15AM BLOOD Glucose-86 UreaN-6 Creat-0.6 Na-141 K-3.8 \nCl-108 HCO3-25 AnGap-12\n___ 06:20AM BLOOD Glucose-80 UreaN-8 Creat-0.7 Na-142 K-3.5 \nCl-108 HCO3-26 AnGap-12\n___ 06:25AM BLOOD Glucose-73 UreaN-7 Creat-0.5 Na-140 K-4.1 \nCl-105 HCO3-24 AnGap-15\n___ 06:15AM BLOOD Glucose-88 UreaN-7 Creat-0.6 Na-140 K-3.8 \nCl-104 HCO3-27 AnGap-13\n___ 06:15AM BLOOD Calcium-8.8 Phos-2.5* Mg-1.8\n___ 06:20AM BLOOD Calcium-8.8 Phos-2.5* Mg-1.7\n___ 06:25AM BLOOD Calcium-8.9 Phos-2.3* Mg-2.0\n___ 06:15AM BLOOD Calcium-8.8 Phos-2.5* Mg-1.9\n___ 06:15AM BLOOD CEA-206* ___*\n\n', 'Physical Exam:|Physical': '\nOn admission: \n\nVS: T-98.9 HR-66 BP-170/84 (due for ___ meds) RR-18 O2-97%RA\nGeneral: NAD, A+Ox3\nHEENT: NCAT, EOMI, PERRL\nNeck: Normal thyroid, 1 cm left, nonmobile supraclavicular node\npalpated otherwise no lymphadenopathy\nCV: RRR, no murmurs\nPulm: crackles at the right lung base, otherwise CTAB\nBreasts: symmetric, no masses felt\nAbd: +BS, Soft, mild tenderness to palpation in the left lower\nquadrant, nondistended. No rebound or guarding\nExt: nontender, no edema. \nNodes: small, mobile left inguinal node felt.\nPelvic: deferred until am\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\n___ year old G7P7 who initially presented to OSH s/p fall with \nlower abdominal discomfort and pain who was subsequently found \nto have large pelvic mass. The patient has been having lower \nabdominal pain for 2 weeks now that fluctuates in intensity and \nis sharp and crampy and nonradiating. She also reports scant\nvaginal bleeding over the last few weeks but is unclear on the \ntime frame. \n\nOn presentation she had a CT scan done which revealed a large \n15cm pelvic mass concerning for malignancy versus abscess. She \nwas started on levo/flagyl given concern for infection. The \npatient\'s family reports that she had a fever while hospitalized \nbut the fever is not documented in the records sent. While the \npatient was hospitalized she received 2U PRBC, presumably for \ndecreased HCT from 34.6 on ___ to 27.3 on ___, however this was \nnot clearly documented. Lastly, she had a +UCx for GBS. \n\nShe notes dysuria and small amount of vaginal bleeding. She \ndenies any weight loss, fever, chills prior to her \nhospitalization. She did have decreased appetite but denies any \nabdominal bloating. She also reported mild constipation. She \ndenies any changes in urinary habits, chest pain, shortness of \nbreath, diarrhea, weakness or numbness in her extremities. \n\nPast Medical History:\nGYNH: \n- Menopause: "years ago"\n- Has not seen a GYN ever. Has never had a pap smear. Denies hx\nof STIs. \n- Is not sexually active\n\nOBH: ___\n- SVD x7\n- One child died at ___ year old and the other died of cervical\ncancer at age ___\n\nPMH: \n- hx of UTIs\n- HTN\n- Hypercholesterolemia\n- Osteoarthritis\n- Anxiety\n\nHealth Maintenance: \n- ___: has never had a mammogram. Pt declined. \n- Colonoscopy: pt had one ___ years ago that was reportedly \nnormal.\n\nPSURGH: \n- Left nephrectomy for staghorn calculi\n\nSocial History:\n___\nFamily History:\nDaughter died of cervical cancer at age ___. Otherwise denies hx \nof breast, uterine or ovary cancers. \n\n', 'Chief Complaint:|Complaint:': '\n"Large pelvic mass"\n\n___ 1. Abdominal washout and reclosure with full-thickness \nskin flaps. 2. Continued debridement of abdominal \nmusculofascial wall. 3. ___ gastrostomy. \n\n___ Exploratory laparotomy, adhesiolysis, resection of \nnecrotizing fasciitis of the abdominal wall.\n\n___ Exploratory laparotomy and small-bowel\nanastomosis.\n\n___ Laparoscopy converted to exploratory laparotomy,\nextensive lysis of adhesions, total abdominal hysterectomy,\nbilateral salpingo-oophorectomy, small-bowel resection with\nprimary reanastomosis x2, repair of serosal injury of\nbladder, cystoscopy.\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nBactrim\n\n'}, '14272441-DS-3', 3, 'surgery']]

[['INDICATION: ___ woman with large pelvic mass, preop chest radiograph.\n\nCOMPARISONS: ___. Abdominal CT ___.\n\nFINDINGS: Two PA and one lateral chest radiograph were obtained. AP diameter\nof the chest is widened by significant kyphosis. The lungs are well expanded\nand clear. No focal consolidation, effusion, or pneumothorax is present. \nCalcified lymph nodes are noted. The descending aorta is ectatic and widened\nto a maximum diameter of 4.5 cm and better seen on prior abdominal CT. \nLeftward deviation of the trachea can be seen with thyroid enlargement.\n\nIMPRESSION:\n1. No acute cardiopulmonary process.\n2. Ectatic descending aorta\n3. Thyroid ultrasound could be considered if clinically indicated.\n', '14272441-RR-2', 2, ''], ['CHEST RADIOGRAPH\n\nINDICATION: Orogastric tube placement for evaluation.\n\nTECHNIQUE: Semi-erect portable chest view was read in comparison with prior\nchest radiograph from ___.\n\nFINDINGS:\nOrogastric tube tip is at gastroesophageal junction with its side port in the\nmid/lower esophagus. \nConsider advancing the orogastric tube by 6-7 cm for better seating. \nEndotracheal tube ends 2.4 cm above the carina and is appropriately\npositioned. Increasing retrocardiac density is most likely atelectasis. \nPleural effusion if any is minimal on the left side. Heart size is top\nnormal, stable since prior studies through ___. Aorta is generally\ntortuous and moderately calcified.\n\nDr. ___ discussed findings with ___, NP by phone on ___ at approximately 9:35 a.m.\n', '14272441-RR-3', 3, 'semi-erect portable chest view was read in comparison with prior\nchest radiograph from ___.'], ['CHEST RADIOGRAPH\n\nINDICATION: ___ woman with nasogastric tube advancement, to look for\nposition.\n\nTECHNIQUE: Single upright portable chest view was read in comparison with\nradiograph done on ___, approximately eight hours apart.\n\nFINDINGS: Orogastric tube tip is at gastroesophageal junction and side port\nin the lower esophagus. Consider advancing the orogastric tube by 6-7 cm for\nappropriate seating. Endotracheal tube tip is 3 cm above the carina and is\nadequately positioned. Pulmonary interstitial edema is mild and stable. \nIncreased retrocardiac density and left lower lung opacities, improved over\nlast eight hours, is mostly atelectasis. Top normal heart size is unchanged. \nThoracic aorta has a general tortuous course and is moderately calcified.\n\n___ communicated findings to ___, NP on ___\nat 9.20 AM.\n', '14272441-RR-4', 4, 'single upright portable chest view was read in comparison with\nradiograph done on ___, approximately eight hours apart.'], ['AP CHEST, 11:38 A.M., ___\n\nHISTORY: New right PICC line.\n\nIMPRESSION: AP chest compared to ___:\n\nTip of the new right PICC line is in the right atrium, and should be withdrawn\nat least 4 cm to be confident that it lies in the low SVC. Small left pleural\neffusion is new. Moderate enlargement of the cardiac silhouette may have\nincreased following tracheal extubation. Right lung clear.\n', '14272441-RR-5', 5, ''], ['AP CHEST, 12:51 P.M., ___\n\nHISTORY: Large pelvic mass. New PICC placement.\n\nIMPRESSION: AP chest compared to ___, 11:38 a.m.:\n\nRight PICC line has been withdrawn 4 cm to the low SVC. Moderate cardiomegaly\nand small bilateral pleural effusion is unchanged. No pneumothorax. Lungs\nclear. Dr. ___ this positioning of the catheter with nurse,\n___, at 2:18 p.m.\n', '14272441-RR-6', 6, ''], ['AP CHEST, 6:44 ___, ___\n\nINDICATION: An ___ woman with a new central venous line.\n\nIMPRESSION: AP chest compared to ___ at 12:51 p.m.:\n\nMild pulmonary edema is new. A 3.5-cm lower lobe opacity projecting over the\nlower pole of the right hilus is probably composite of dilated artery and\nveins. It clears on the subsequent chest radiograph performed 5:49 a.m. on\n___, available at the time of this review.\n\nModerate left lower lobe atelectasis is unchanged. Pleural effusions are\nsmall if any. Severe cardiomegaly is longstanding.\n\nTip of the endotracheal tube is no less than 15 mm from the carina and should\nbe withdrawn 2 cm to avoid inadvertent unilateral intubation with a change in\nhead and neck position. Right jugular line is new, ending low in the SVC. No\npneumothorax, mediastinal widening, or pleural effusion. Right PIC line ends\nin the low SVC as before.\n', '14272441-RR-7', 7, ''], ['AP CHEST 5:49 A.M. ___ \n\nHISTORY: Status post bowel resection. Check ET tube placement.\n\nIMPRESSION: With the chin in neutral position, the tip of the endotracheal\ntube is no less than 2.5 cm from the carina. The tube should not be advanced\nfrom this point. Right jugular and right PIC lines both end low in the SVC. \nPrevious mild pulmonary edema is stable. Severe cardiomegaly is chronic. \nModerate to severe left lower lobe atelectasis is unchanged. Pleural effusion\nis small if any. No pneumothorax.\n', '14272441-RR-8', 8, ''], ['INDICATION: Complex pelvis mass status post resection. Sepsis/pleural\neffusion.\n\nTECHNIQUE: Semi-erect portable chest was read in comparison with prior chest\nradiographs, with the most recent from ___ acquired approximately 24\nhours apart.\n\nFINDINGS:\n\nEndotracheal tube tip is 4.1 cm above the carina, right internal jugular line\ntip is in mid SVC and right PICC line tip can be traced to mid SVC. Severe\ncardiomegaly is stable. Increased retrocardiac density is mostly severe\natelectasis as indicated by an indistinct right heart margin secondary to some\nmediastinal shift to the left side. Previously mild pulmonary edema has\nimproved. Pleural effusions if any are small bilaterally. No pneumothorax.\n', '14272441-RR-9', 9, 'semi-erect portable chest was read in comparison with prior chest\nradiographs, with the most recent from ___ acquired approximately 24\nhours apart.'], ['CHEST RADIOGRAPH\n\nINDICATION: ___ woman with sepsis, interval change.\n\nTECHNIQUE: Portable semi-erect chest view was read in comparison with the\nmost recent radiograph from ___.\n\nFINDINGS: Endotracheal tube tip is 4 cm above the carina, right internal\njugular line ends at lower SVC and the tip of right PICC line ends\napproximately at mid SVC. Mild-to-moderate right pleural effusion has\nincreased since yesterday. Increased retrocardiac density reflecting left\nlower lung atelectasis and/or consolidation is overall unchanged. Due to the\nrotation, assessment of the cardiomediastinal silhouette was limited.\n', '14272441-RR-10', 10, 'portable semi-erect chest view was read in comparison with the\nmost recent radiograph from ___.'], ['INDICATION: ___ female, intubated with sepsis.\n\n___.\n\nCHEST, AP: Endotracheal tube has been advanced, and now terminates 2.7 cm\nabove the carina. Again seen are right internal jugular catheter in the lower\nSVC and right PICC at the mid SVC. New right upper lobe opacity is present,\nand left lower lobe opacity persists. There is continued mild cardiomegaly,\ncentral venous congestion, and interstitial edema. Bilateral pleural\neffusions are present, right greater than left. There is a tortuous and\ncalcified aorta.\n\nIMPRESSION:\n1. New right upper lobe and stable left lower lobe opacities, which could\nrepresent atelectasis or pneumonia.\n2. Mild pulmonary edema.\n', '14272441-RR-11', 11, ''], ['INDICATION: ___ woman with intra-abdominal abscess status post ex lap\nand subsequent bile leak.\n\nCOMPARISON: ___ through ___.\n\nFINDINGS: The endotracheal tube remains in the upper airway. A right\ninternal jugular catheter terminate in the lower SVC. A right-sided PICC line\nends in the mid SVC. Hilar opacities have increased. New pulmonary opacities\nin the right lower and left upper lobe are identified. The moderate\ncardiomegaly has increased. Bilateral layering pleural effusions are also\nincreased.\n\nIMPRESSION:\n1. Increased cardiomegaly and pleural effusions consistent with worsening\nCHF.\n2. Multifocal pulmonary opacities could reflect multiple foci of atelectasis\nin the setting of worsening edema.\n\n', '14272441-RR-12', 12, ''], ['INDICATION: ___ female post multiple bowel resections, new tachypnea.\n\n___ at 4:12.\n\nCHEST, AP SEMI-UPRIGHT: Again seen are right internal jugular catheter, right\nPICC, and endotracheal tube in standard position. Moderate interstitial and\nairspace pulmonary edema have slightly increased. Bibasilar opacities likely\nrepresent atelectasis, though superimposed infection cannot be excluded. \nModerate cardiomegaly, central venous congestion, and moderate bilateral\npleural effusions are unchanged. Aorta is tortuous and calcified. \n\nIMPRESSION: Slightly increased pulmonary edema.\n', '14272441-RR-13', 13, ''], ['STUDY: AP chest, ___.\n\nCLINICAL HISTORY: ___ woman with multiple exploratory laparotomies\nfor pelvic mass. Status post repair of enterotomies and delayed abdominal\nwound closure.\n\nFINDINGS: Comparison is made to prior study from ___.\n\nThe endotracheal tube, IJ and subclavian central venous lines are unchanged in\nposition. There is unchanged cardiomegaly. There are persistent bilateral\npleural effusions and a left retrocardiac opacity as well as moderate\npulmonary edema, stable.\n', '14272441-RR-14', 14, ''], ['STUDY: AP chest performed on ___.\n\nCLINICAL HISTORY: ___ woman with resection of pelvic mass complicated\nby postop course of tachypnea. Increased ventilation settings.\n\nFINDINGS: Comparison is made to previous study performed on ___.\n\nThere are right IJ and right subclavian central venous line and an\nendotracheal tube and a feeding tube which are all stable. Heart size is\nenlarged. There are again seen diffuse airspace opacities. The opacities in\nthe right upper lung field are more confluent, however, there has been\nimprovement at the left retrocardiac region. Findings can be due to infection\nor pulmonary edema.\n', '14272441-RR-15', 15, ''], ['STUDY: Portable abdomen ___.\n\nCLINICAL HISTORY: ___ woman status post pelvic surgery as well as\nfascial debridement, now with bilious emesis.\n\nFINDINGS: There is a nasogastric tube whose tip and side port are within the\nbody of the stomach. A single loop is seen within the tube. There is also a\nPEF tube with balloon in the body of the stomach. Small amount of gas in the\nstomach is seen. The rest of the bowel is quite featureless, without\nsignificant gas is the small bowel loops or colon. This is a nonspecific\nbowel gas pattern. Degenerative changes of the spine are identified.\n', '14272441-RR-16', 16, ''], ['STUDY: AP chest, ___.\n\nCLINICAL HISTORY: ___ woman status post multiple abdominal\noperations, may be diuresed.\n\nFINDINGS: Comparison is made to previous study from ___.\n\nThe right IJ and right subclavian central venous line, endotracheal tube,\nnasogastric tubes are all unchanged in position. The nasogastric tube has\nmigrated more proximally and the tip is pointing towards the GE junction.\nThere is unchanged cardiomegaly. There are diffuse airspace opacity\nthroughout both lung fields. The airspace opacities in the left perihilar\nregion and bases have worsened. Extensive pulmonary fluid overload is seen\nand overlying infection is not entirely excluded.\n', '14272441-RR-17', 17, ''], ['HISTORY: ___ female status post ex lap and multiple enterotomies. \nRule out abscess.\n\nCOMPARISON: ___.\n\nTECHNIQUE: Multidetector helical acquisition was obtained through the abdomen\nand pelvis with intravenous contrast.\n\nABDOMEN: There is bibasilar airspace disease with small right greater than\nleft bilateral pleural effusions. The heart is of normal size. There is\ndiffuse anasarca. There is a nasogastric tube and a G-tube within the\nstomach. There are multiple stable hypodensities within the liver which\nlikely represent cysts or hemangiomas. There is a stable cyst within the\nupper pole of the right kidney. The left kidney is absent. The adrenals,\npancreas, spleen, and gallbladder appear normal. There is dense\natherosclerotic disease of the aorta and branch vessels with high-grade\nstenosis of the celiac artery. The small bowel is fluid filled with multiple\nanastomoses. There is a small-to-moderate amount of free fluid within the\nabdomen. There is no retroperitoneal adenopathy. The left rectus muscle is\ncompletely atrophic and there is extensive atrophy of the right anterior\nrectus muscle with diastasis of the anterior abdominal wall which contains\nbowel and fluid. There is no evidence of small-bowel obstruction.\n\nPELVIS: There is free fluid within the pelvis. There is no pelvic\nadenopathy. There is a Foley catheter within the bladder. The bones appear\nrarefied.\n\nIMPRESSION:\n1. No evidence of intra-abdominal abscess.\n\n2. Postoperative changes to the bowel with diffuse anasarca and fluid within\nthe abdomen. No evidence of bowel obstruction.\n\n3. High-grade celiac artery stenosis.\n\n4. Bibasilar airspace disease with small pleural effusions.\n\n5. Rarefied bones raising concern for a marrow process versus osteoporosis.\n', '14272441-RR-18', 18, 'multidetector helical acquisition was obtained through the abdomen\nand pelvis with intravenous contrast.'], ['INDICATION: Patient with complex pelvic mass, sepsis, respiratory failure,\nand altered mental status.\n\nCOMPARISONS: CT head from ___ dated ___.\n\nTECHNIQUE:\n\nMDCT-acquired contiguous images through the head were obtained without\nintravenous contrast at 5-mm slice thickness. Coronally and sagittally\nreformatted images were displayed.\n\nFINDINGS:\n\nThere is no evidence of acute intracranial hemorrhage, mass effect, edema or\nloss of gray-white matter differentiation. The sulci and ventricles are\nprominent, likely age-related involutional changes. Confluent hypodensities\nin subcortical, deep and and periventricular white matter likely reflect\nsequela of small vessel ischemic disease. Extensive arterial calcifications\nare noted. \n\nNo suspicious lytic or sclerotic bone lesions are seen. Frontal sinuses are\nunder-pneumatized. The left sphenoid sinus demonstrates mild circumferential\nmucosal thickening with secretions, new since ___. Mastoid air cells and\nmiddle ear cavities are partially opacified, also new since ___. \n\nIMPRESSION:\n1. No evidence of an acute intracranial process.\n2. Partial opacification of middle ear cavities and mastoid air cells. Mild\nsecretions in the left sphenoid sinus. These findings could be related to\nprolonged supine positioning, but please correlate clinically regarding the\npossibility of an infection.\n', '14272441-RR-19', 19, ''], ['AP CHEST 4:33 A.M. ___ \n\nHISTORY: ___ woman with abdominal abscesses after multiple surgeries,\nevaluate for change.\n\nIMPRESSION: AP chest compared to ___:\n\nSevere pulmonary edema, somewhat asymmetrically and irregularly distributed on\n___ has improved substantially. Continued surveillance is recommended to\nexclude concurrent pneumonia that might be revealed as the edema clears\nfurther. Moderate cardiomegaly and small bilateral pleural effusions are\nstill present. ET tube in standard placement. Nasogastric tube loops in the\nstomach. Right jugular and right PIC lines both end in the mid SVC. No\npneumothorax.\n', '14272441-RR-20', 20, ''], ['INDICATION: ___ woman with draining abdominal wound.\n\nCOMPARISONS: ___ to ___.\n\nFINDINGS: An endotracheal tube tip remains 3 cm above the carina. An enteric\ncatheter remains coiled within the stomach. A right-sided internal jugular\nline and right-sided PICC line remain in the low SVC. Asymmetric, right\ngreater than left, perihilar opacities are unchanged. Moderate cardiomegaly\nand small bilateral pleural effusions are similar. No pneumothorax is\npresent.\n\nIMPRESSION: Persistent asymmetric, right greater than left, perihilar\nopacities compatible with CHF. Focal consolidation cannot be excluded.\n', '14272441-RR-21', 21, ''], ['SINGLE FRONTAL VIEW OF THE CHEST\n\nREASON FOR EXAM: Status post resection of pelvic mass, wound infection and\nmultiple enterotomies.\n\nComparison is made with prior study ___.\n\nET tube tip is 2.6 cm above the carina. NG tube tip is in the stomach, the\nside port is at the GE junction and advancement of few centimeters is\nrecommended for standard position. Right PICC tip is in the mid SVC. Right\nIJ catheter tip is in the lower SVC. There is no pneumothorax. Small\nbilateral pleural effusions are unchanged. There is mild interval improvement\nin asymmetric right greater than left perihilar opacities most likely due to\npulmonary edema. Bibasilar opacities greater on the left side are grossly\nunchanged. This could be due to atelectasis but superimposed infection cannot\nbe excluded.\n', '14272441-RR-22', 22, ''], ['CHEST\n\nHISTORY: Ventilator-dependent pneumonia.\n\nFINDINGS: Compared to the study from the prior day, there is no significant\ninterval change.\n', '14272441-RR-23', 23, '']]

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[]

['surgery']

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Question: A 91 F is admitted. He/she says he/she has "Large pelvic mass" ___ 1. Abdominal washout and reclosure with full-thickness skin flaps. 2. Continued debridement of abdominal musculofascial wall. 3. ___ gastrostomy. ___ Exploratory laparotomy, adhesiolysis, resection of necrotizing fasciitis of the abdominal wall. ___ Exploratory laparotomy and small-bowel anastomosis. ___ Laparoscopy converted to exploratory laparotomy, extensive lysis of adhesions, total abdominal hysterectomy, bilateral salpingo-oophorectomy, small-bowel resection with primary reanastomosis x2, repair of serosal injury of bladder, cystoscopy. . History of illness: ___ year old G7P7 who initially presented to OSH s/p fall with lower abdominal discomfort and pain who was subsequently found to have large pelvic mass. The patient has been having lower abdominal pain for 2 weeks now that fluctuates in intensity and is sharp and crampy and nonradiating. She also reports scant vaginal bleeding over the last few weeks but is unclear on the time frame. On presentation she had a CT scan done which revealed a large 15cm pelvic mass concerning for malignancy versus abscess. She was started on levo/flagyl given concern for infection. The patient's family reports that she had a fever while hospitalized but the fever is not documented in the records sent. While the patient was hospitalized she received 2U PRBC, presumably for decreased HCT from 34.6 on ___ to 27.3 on ___, however this was not clearly documented. Lastly, she had a +UCx for GBS. She notes dysuria and small amount of vaginal bleeding. She denies any weight loss, fever, chills prior to her hospitalization. She did have decreased appetite but denies any abdominal bloating. She also reported mild constipation. She denies any changes in urinary habits, chest pain, shortness of breath, diarrhea, weakness or numbness in her extremities. Past Medical History: GYNH: - Menopause: "years ago" - Has not seen a GYN ever. Has never had a pap smear. Denies hx of STIs. - Is not sexually active OBH: ___ - SVD x7 - One child died at ___ year old and the other died of cervical cancer at age ___ PMH: - hx of UTIs - HTN - Hypercholesterolemia - Osteoarthritis - Anxiety Health Maintenance: - ___: has never had a mammogram. Pt declined. - Colonoscopy: pt had one ___ years ago that was reportedly normal. PSURGH: - Left nephrectomy for staghorn calculi Social History: ___ Family History: Daughter died of cervical cancer at age ___. Otherwise denies hx of breast, uterine or ovary cancers. Allergies: Bactrim What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Lactated Ringers Ondansetron TraMADOL (Ultram) Atorvastatin Paroxetine Tolterodine Docusate Sodium Levofloxacin Bisacodyl Heparin Acetaminophen MetRONIDAZOLE (FLagyl) Bisacodyl Fleet Enema Morphine Sulfate Calcium Carbonate Losartan Potassium Multivitamins Acetaminophen Sodium Chloride 0.9% Flush Amlodipine Senna Meclizine Oxazepam Metoprolol Tartrate Pneumococcal Vac Polyvalent MoviPrep Target Lab Orders: Bacteria Bilirubin Blood Epithelial Cells Glucose Ketone Leukocytes Nitrite pH Protein RBC Specific Gravity Urine Appearance Urine Color Urobilinogen WBC Yeast Anion Gap Bicarbonate CA-125 Calcium, Total Carcinoembyronic Antigen (CEA) Chloride Creatinine Estimated GFR (MDRD equation) Glucose Magnesium Phosphate Potassium Sodium Urea Nitrogen Fibrinogen, Functional INR(PT) PT PTT Basophils Eosinophils Hematocrit Hemoglobin Lymphocytes MCH MCHC MCV Monocytes Neutrophils Platelet Count RDW Red Blood Cells White Blood Cells Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : Ms. ___ was admitted into the gynecology oncology service for pre-operative evaluation of pelvic mass. Pre-operatively: Her imaging was uploaded and reviewed with one of the radiology fellows. It was unclear what the primary source of her pelvic mass was. Her tumor markers came back with a very elevated CEA of 206. A GI consult was therefore made. They recommended a sigmoidoscopy, which revealed no explanation for the pelvic mass. She was noted to have diverticulosis and internal hemorrhoids. She therefore underwent a colonoscopy, which also demonstrated no explanation for the lasrge pelvic mass seen on CT scan. She was therefore consented for a laparascopy, possible laparatomy and possible staging for large pelvic mass. On ___, she underwent a laparascopy, which was converted to an open laparatomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, bowel resection x 2 with reanastomosis and repair of anterior bladder wall defect. The case was complicated by large intra-operative blood loss requiring transfusion of 4 units of packed red cells and 750cc of albumin. Please refer to operative note for full details of the procedure. She was transferred to the intensive care unit intubated. In the FICU, she was tachy and febrile on ___ and had a repeat operation where she was found to have an open enterotomy with spillage of stool into the peritoneum. This was repaired and she was sent back to the ICU. She received 7L of fluid within 24h and had not made urine. She was continued on vanco/Cefepime/flagyl, but was transferred to ___ for further surgical mgmt, returned to the ___ on ___ for a washout and noted to have extensive necrosis of the abdominal wall; this fascia was debrided. She returned to the ___ again on ___ for repeat exploration, washout, debridement and closure of the abdominal wall. Also, a G-tube was placed. The family at this point expressed their preference that she not be treated with further surgical intervention and that she be managed non-operatively. The team articulated to the family that would likely not be a feasible option. Over the coming days, her fluid status was managed with lasix and albumin, she received blood transfusions, she spiked fevers and was started on broad spectrum antibiotics with antifungal coverage, and she received numerous blood transfusions for anemia and tachycardia. Her wound looked progressively more necrotic and eventually was noted to have frank stool coming through the wound. Repeated family meetings were held and with the outcome consistent -- no surgical intervention but continue current management. On ___, her urine output decreased to zero for several hours, she was persistently hypotensive throughout the day. Her abdomen was noted to be increasingly firm and distended. A repeat family meeting was held and she was made CMO on ___. She was transferred to the floor on ___. She expired on ___. The medical examiner declined the case. Other Results: ___ 06:15AM BLOOD WBC-12.2* RBC-4.41 Hgb-12.6 Hct-38.6 MCV-88 MCH-28.6 MCHC-32.7 RDW-14.4 Plt ___ ___ 06:20AM BLOOD WBC-9.1 RBC-4.32 Hgb-12.5 Hct-38.1 MCV-88 MCH-28.9 MCHC-32.7 RDW-15.1 Plt ___ ___ 06:25AM BLOOD WBC-7.8 RBC-4.36 Hgb-12.6 Hct-38.8 MCV-89 MCH-28.9 MCHC-32.5 RDW-15.5 Plt ___ ___ 06:15AM BLOOD WBC-8.9 RBC-4.14* Hgb-11.6* Hct-36.2 MCV-88 MCH-27.9 MCHC-31.9 RDW-14.6 Plt ___ ___ 06:15AM BLOOD ___ PTT-35.9 ___ ___ 06:15AM BLOOD ___ ___ 06:15AM BLOOD Glucose-86 UreaN-6 Creat-0.6 Na-141 K-3.8 Cl-108 HCO3-25 AnGap-12 ___ 06:20AM BLOOD Glucose-80 UreaN-8 Creat-0.7 Na-142 K-3.5 Cl-108 HCO3-26 AnGap-12 ___ 06:25AM BLOOD Glucose-73 UreaN-7 Creat-0.5 Na-140 K-4.1 Cl-105 HCO3-24 AnGap-15 ___ 06:15AM BLOOD Glucose-88 UreaN-7 Creat-0.6 Na-140 K-3.8 Cl-104 HCO3-27 AnGap-13 ___ 06:15AM BLOOD Calcium-8.8 Phos-2.5* Mg-1.8 ___ 06:20AM BLOOD Calcium-8.8 Phos-2.5* Mg-1.7 ___ 06:25AM BLOOD Calcium-8.9 Phos-2.3* Mg-2.0 ___ 06:15AM BLOOD Calcium-8.8 Phos-2.5* Mg-1.9 ___ 06:15AM BLOOD CEA-206* ___*

2202-09-08 04:05:00

?

MARRIED

WHITE - OTHER EUROPEAN

M

[[25710110, Timestamp('2202-09-08 04:10:03'), '', 'SURG']]

[[{'Medications on Admission': ':\nAspirin 81mg daily, seroquel 37.5mg qam\n\nFacility:\n___', 'Brief Hospital Course': ":\nMr. ___ was admitted to the inpatient ward under the Acute \nCare Surgery service for further evaluation of his abdominal \npain and fevers. On presentation he had mild leukocytosis and a \nmildly elevated Tbili of 1.5. He underwent a RUQ US and CT scan \nwhich revealed cholelithiasis, dilated CBD up to 15mm, with mild \nintrahepatic ductal dilatation. There was no evidence of \npericholecystic fluid or wall thickening. He was initiated on \nUnasyn and then cipro/flagyl. An ERCP was attempted, but could \nnot access his ampulla due to his reconstructed anatomy. \nInstead a PTBD was placed, during which cholangiography \ndemonstrated stenosis of his\ndistal CBD, and brushings were performed. A clamping trial of \nthe PTBD was attempted, but the insertion site began to leak \nbiliary fluid. On further evaluation, it was found that the \nPTBD drain became clogged, which required him to return to \nInterventional Radiology for placement of a larger drain. \nDuring the same procedure, the patient underwent a balloon \ndilation of his ampulla. Brushings and biopsy specimens were \nobtained as well. At the time of this writing, the patient's \nalk phos was stable at 361. His lipase continues to downtrend, \nnow at a level of 104. \n\nPrior to this admission, Mr. ___ recently underwent a right \nknee replacement on ___. From an orthopedic standpoint, \nthe patient has progressed well. Physical therapy was consulted \nand has worked with the patient multiple times while an \ninpatient. His staples have been removed and the wound is \nhealing well. His is weight bearing as tolerated to the right \nlower extremity.\n\nOn the evening prior to discharge, Mr. ___ stated he had \nchest pain. His ECG had no acute findings. Troponin levels \nwere normal. Blood cultures were also drawn (results pending). \nHe has had no further instances of chest pain since that time. \nHis hematocrit level is stable at 31 (max low of 23.9 on \nadmission).\n\nAt the time of discharge, Mr. ___ is hemodynamically stable \nand afebrile. He did complain of some gum soreness, so his \ncardiac diet was changed to one with soft consistencies. \nViscous lidocaine has been ordered PRN for short-term pain \nrelief. He should be further evaluated if he continued to have \npain when wearing his dentures. His pain has been managed well \nwith narcotic and non-narcotic analgesics. His last dose of \nciprofloxacin and metronidazole will be tomorrow, ___. He \nhas no leukocytosis. He has received pantoprazole for GI \nprophylaxis and subcutaneous heparin for DVT prophylaxis.\n\nMr. ___ is now being discharged to a rehabilitation \nfacility. He is in no acute distress and is expected to recover \nwell. His right lower quadrant drain remains in place. An \nappointment has been made with Dr. ___ of ___ \nservice for follow-up within one week. He should also follow up \nwith orthopedics regarding his prior knee replacement surgery. \nLastly, the patient will need to follow up with Interventional \nRadiology for a likely dilation of his ampulla.\n\n", 'Pertinent Results:': '\n___ 11:00PM BLOOD WBC-13.2*# RBC-2.64* Hgb-7.9* Hct-24.2* \nMCV-92# MCH-29.9 MCHC-32.7 RDW-15.6* Plt ___\n___ 06:20AM BLOOD WBC-10.2 RBC-2.66* Hgb-7.7* Hct-23.9* \nMCV-90 MCH-29.1 MCHC-32.4 RDW-16.0* Plt ___\n___ 02:23AM BLOOD WBC-10.5 RBC-2.84* Hgb-8.6* Hct-25.3* \nMCV-89 MCH-30.3 MCHC-34.0 RDW-16.2* Plt ___\n___ 05:53AM BLOOD WBC-11.6* RBC-2.99* Hgb-8.7* Hct-26.8* \nMCV-90 MCH-28.9 MCHC-32.3 RDW-15.8* Plt ___\n___ 08:50AM BLOOD WBC-12.7* RBC-3.41* Hgb-9.9* Hct-30.6* \nMCV-90 MCH-29.0 MCHC-32.4 RDW-15.7* Plt ___\n___ 06:04AM BLOOD WBC-11.1* RBC-3.11* Hgb-9.1* Hct-28.0* \nMCV-90 MCH-29.1 MCHC-32.3 RDW-16.0* Plt ___\n___ 05:32AM BLOOD WBC-7.7 RBC-2.98* Hgb-8.6* Hct-26.8* \nMCV-90 MCH-28.7 MCHC-32.0 RDW-15.8* Plt ___\n___ 07:35AM BLOOD WBC-6.7 RBC-3.43* Hgb-9.8* Hct-31.0* \nMCV-90 MCH-28.5 MCHC-31.6 RDW-15.6* Plt ___\n___ 09:15AM BLOOD WBC-6.9 RBC-3.57* Hgb-10.2* Hct-31.9* \nMCV-89 MCH-28.6 MCHC-32.0 RDW-15.5 Plt ___\n___ 11:00PM BLOOD Neuts-94.0* Lymphs-3.8* Monos-2.0 Eos-0 \nBaso-0.1\n___ 11:00PM BLOOD Plt ___\n___ 11:21PM BLOOD ___ PTT-30.0 ___\n___ 09:15AM BLOOD ___ PTT-31.0 ___\n___ 09:15AM BLOOD Plt ___\n___ 02:23AM BLOOD ___\n___ 11:00PM BLOOD Glucose-103* UreaN-27* Creat-0.9 Na-142 \nK-4.2 Cl-104 HCO3-27 AnGap-15\n___ 09:15AM BLOOD Glucose-104* UreaN-15 Creat-0.8 Na-138 \nK-3.9 Cl-101 HCO3-26 AnGap-15\n___ 11:00PM BLOOD ALT-159* AST-279* AlkPhos-470* \nTotBili-1.5\n___ 06:20AM BLOOD ALT-119* AST-170* CK(CPK)-51 AlkPhos-360* \nTotBili-1.1\n___ 11:03AM BLOOD ALT-115* AST-136* AlkPhos-319* \nTotBili-1.1 DirBili-0.6* IndBili-0.5\n___ 02:23AM BLOOD ALT-90* AST-88* AlkPhos-289* TotBili-0.9\n___ 05:13AM BLOOD ALT-77* AST-114* LD(___)-373* \nAlkPhos-752* TotBili-0.9\n___ 06:04AM BLOOD ALT-58* AST-62* AlkPhos-581* TotBili-0.8\n___ 05:32AM BLOOD ALT-49* AST-44* AlkPhos-503* TotBili-0.8\n___ 05:16AM BLOOD ALT-40 AST-35 AlkPhos-445* TotBili-0.8\n___ 06:55AM BLOOD ALT-32 AST-27 AlkPhos-404* TotBili-0.8\n___ 07:35AM BLOOD ALT-28 AST-30 LD(LDH)-400* AlkPhos-383* \nTotBili-0.8\n___ 05:27AM BLOOD ALT-23 AST-23 AlkPhos-339* TotBili-0.7\n___ 09:15AM BLOOD ALT-25 AST-26 CK(CPK)-13* AlkPhos-361* \nTotBili-0.8\n___ 11:00PM BLOOD Lipase-34\n___ 06:04AM BLOOD Lipase-574*\n___ 05:32AM BLOOD Lipase-121*\n___ 05:16AM BLOOD Lipase-73*\n___ 06:55AM BLOOD Lipase-104*\n___ 11:00PM BLOOD proBNP-958*\n___ 11:00PM BLOOD cTropnT-<0.01\n___ 06:20AM BLOOD CK-MB-3 cTropnT-<0.01\n___ 09:15AM BLOOD CK-MB-2 cTropnT-<0.01\n___ 11:00PM BLOOD Albumin-3.4*\n___ 06:20AM BLOOD Albumin-2.8* Calcium-7.1* Phos-3.1 Mg-1.8\n___ 09:15AM BLOOD Calcium-8.7 Phos-3.6 Mg-2.1\n___ 01:30PM BLOOD CEA-2.5\n\nIMAGING:\n\n___ ECG\nSinus rhythm. Left bundle-branch block. Compared to the previous \ntracing \nof ___ ventricular ectopy is no longer recorded. Otherwise, \nno diagnostic interim change.\n\n___ CTA abdomen and pelvis\nDistended gallbladder with cholelithiasis and a significantly \ndilated \ncommon bile duct and pancreatic duct. There is no definite \npericholecystic fluid or gallbladder wall thickening. Moderate \nintrahepatic biliary duct dilatation. \n\n2. No evidence of pulmonary embolism. \n\n3. Stable pulmonary nodules. \n\n4. Right lower lobe consolidation may represent aspiration. \n\n___ Liver/gallbladder U/S\nVery distended gallbladder filled with sludge and stones and a \nvery dilated common bile duct. This may represent acute \ncholecystitis. \n\n___ Common bile duct, distal, forceps biopsy:\n1. Fragments of benign biliary mucosa.\n2. Multiple levels have been examined.\n\n___ Common bile duct (distal), brushing: \nATYPICAL. Hypocellular specimen with rare groups of atypical \nglandular \ncells. \n\n___ Biliary Drain Placement\nUncomplicated right lobe percutaneous transhepatic biliary drain \nas above with biopsies and ___ internal-external drain placement. \n As above the findings suggest ampullary stricture versus \nsphincter of Oddi dysfunction; pathology will be pending. Of \nnote, the cystic duct appeared patent. \n\n___ile duct brushing results pending\n\n', 'Physical Exam:|Physical': '\nOn admission:\n\nPE: 97.9, 60, 84/48, 18, 100% on room air\nGen: no distress, alert and oriented x 3\nHEENT: PERLA, EOMI, anicteric\nChest: RRR, lungs clear bilaterally\nAbd: soft, nontender, nondistended, well healed midline incision\nwith no obvious hernia appreciated\nRectal:\nExt: warm, well perfused, no edema\n\nOn discharge:\n\nVS 99.6, 65, 107/65, 16, 96% on room air\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\nMr. ___ is a ___ year old male presenting from a \nrehabilitation facility after a right TKA on ___. He was \ntransferred to ___ for evaluation of his abdominal pain and a \nreported fever > 100. He states that he has been having \nintermittent abdominal pain located in his RUQ for the past 2 \nmonths. He also reports some right shoulder pain as well. He \ndenies any association with food. The pain usually resolved on \nits own and is "crampy" in nature. He did have a temperature of \n> 100 today at rehab. He also endorses recent bouts of nausea \nbut no emesis. He is tolerating a diet with normal bowel \nfunction. He denies jaundice, diarreha, and melena. He does \nhave a known history of gallstones but denies any similar \nattacks in the past. EMS found\nhim to be "hypotensive" but no BP is recorded. His BP here was \nnoted to be 84/48 which is responsive to IVF resuscitation. Of \nnote he did well postoperatively after his right TKA. He was \ndischarged to rehab with a Hct of 24.\n\nPast Medical History:\nPMH: Osteoarthritis right knee, h/o peptic ulcers, known \ngallstones, CAD with ? MI ___ years ago, anxiety\n\nPSH: Gastric resection for perforated peptic ulcer ___ years ago \nat ___, ventral incisional hernia repair x 2 (most recent one \n___ years ago at ___\n\nSocial History:\n___\nFamily History:\nPositive for father having had cancer. Mother had heart disease.\n\n', 'Chief Complaint:|Complaint:': '\nAbdominal pain, fevers.\n\n___\n1. Percutaneous transhepatic biliary drainage via right lobe \naccess. \n2. Crossing of distal CBD stenosis \n3. Brush and forcep biopsies of the distal CBD. \n\n___ \n1. Cholangiogram. \n2. Brushings and forceps biopsy. \n3. Balloon dilation at the ampulla up to 10 mm. \n4. Exchange of the 8 ___ drain for a 10 ___ \ninternal-external biliary drain. \n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nPenicillins / quetiapine\n\n'}, '10080928-DS-8', 8, 'surgery']]

[['INDICATION: Shortness of breath and chest pain, abdominal pain, evaluate for\npulmonary embolism and large abdominal aneurysm.\n\nCOMPARISON: CT chest on ___ and CT abdomen and pelvis on\n___.\n\nTECHNIQUE: MDCT images were obtained through the chest, abdomen and pelvis\nfollowing the administration of IV contrast.\n\nFINDINGS:\n\nCHEST: There is no axillary, mediastinal, or hilar lymphadenopathy. The\naorta is normal in caliber. There are no filling defects in the pulmonary\nartery to the subsegmental level. The airways are patent to the subsegmental\nlevel. The esophagus appears normal. There is no pleural effusion or\npneumothorax. The heart and pericardium are unremarkable. There are coronary\nartery calcifications. There is streaky atelectasis at the lung bases. No\nfocal consolidation is seen. There is a 5 mm nodule seen in the right middle\nlobe, similar to study on ___. A subpleural nodule is seen\nmeasuring 4 mm (2, 50), similar to ___.\n\nABDOMEN: A calcified granuloma is seen in the liver, similar to prior study. \nThere is perfusion anomaly in the posterior right lobe. There is significant\nintrahepatic biliary duct dilatation, mainly involving the left lobe. There\nis significant dilation of the common bile duct measuring up to 1.5 cm in\ndiameter. The gallbladder is significantly distended with cholelithiasis. \nThere is no evidence of bowel wall thickening or pericholecystic fluid. The\npancreas is unremarkable. The spleen is normal. There is a 1.3 cm cyst in\nthe upper pole of the left kidney. Otherwise, the kidneys are unremarkable. \nThere is no hydronephrosis. There is no mesenteric or retroperitoneal\nlymphadenopathy. The pancreatic duct is dilated.\n\nThe stomach appears normal. There are dilated loops of small and large bowel,\nindicating possible ileus. There is no evidence of obstruction.\n\nPELVIS: The bladder and terminal ureters are unremarkable. Prostate and\nseminal vesicles are normal. The rectum is unremarkable. There is no free\nfluid in the pelvis. There is no pelvic or inguinal lymphadenopathy.\n\nCTA: The intra-abdominal vasculature is patent. There are scattered aortic\ncalcifications. There are no aneurysms identified. No evidence of\ndissection.\n\nThe celiac artery and its major branches are patent. SMA and its major\nbranches are patent. Some calcifications of the splenic artery. The ___ is\npatent.\n\nIMPRESSION:\n1. Distended gallbladder with cholelithiasis and a significantly dilated\ncommon bile duct and pancreatic duct. There is no definite pericholecystic\nfluid or gallbladder wall thickening. Moderate intrahepatic biliary duct\ndilatation. \n\n2. No evidence of pulmonary embolism.\n\n3. Stable pulmonary nodules.\n\n4. Right lower lobe consolidation may represent aspiration. \n\n\n', '10080928-RR-66', 66, 'mdct images were obtained through the chest, abdomen and pelvis\nfollowing the administration of iv contrast.'], ['INDICATION: History of knee surgery last week, question effusion or fracture.\n\nCOMPARISON: Knee radiographs on ___.\n\nFINDINGS: Again seen is total knee replacement and the hardware appears in\nappropriate position without evidence of complication. There is no fracture\nidentified. There is a moderate-sized joint effusion, decreased from the\nprior study. Skin staples are again seen anteriorly. \n\nIMPRESSION: No evidence of hardware complication.\n', '10080928-RR-67', 67, ''], ['INDICATION: Hypotension and LFT abnormality, question of acute cholecystitis.\n\nCOMPARISON: CTA torso on ___.\n\nAbdominal ultrasound on ___.\n\nFINDINGS: The liver is of normal echogenicity, and there are no focal liver\nlesions. The gallbladder is very distended and filled with likely sludge and\nstones. There is no definite pericholecystic fluid or wall thickening. The\ncommon bile duct is very dilated and measures 1.1 cm in diameter.\n\nIMPRESSION: Very distended gallbladder filled with sludge and stones and a\nvery dilated common bile duct. This may represent acute cholecystitis.\n', '10080928-RR-68', 68, ''], ['INDICATION: Right IJ line placement, question pneumothorax.\n\nCOMPARISON: Chest radiograph on ___ at 22:53.\n\nFINDINGS: There is mild right basilar atelectasis. Right internal jugular\ncentral venous catheter ends at or just below the cavoatrial junction. There\nis no focal consolidation. There is no pleural effusion or pneumothorax. \nThere is a slight increase in density in the right paratracheal area which may\nrepresent mild bleeding from line placement. The heart size is normal.\n\nIMPRESSION: \n1. Right IJ ends either at or just below the superior cavoatrial junction. \nSlight increase in density in the right paratracheal mediastinum may represent\nmild bleeding from line placement. Attention on follow up.\n\n2. Right basilar atelectasis. No focal consolidation. \n', '10080928-RR-69', 69, ''], ['INDICATION: ___ male with abdominal pain, dilated gallbladder and\ncommon bile duct, ERCP failed secondary to prior post-surgical anatomy. \nPatient also had fevers recently.\n\nPHYSICIANS: ___, M.D., fellow, performed the procedure. ___\n___, M.D., attending, was present and supervising the procedure.\n\nMEDICATIONS: General anesthesia was administered by the anesthesiologist.In\naddition the patient received 10 mL of 0.5% bupivacaine along the access path.\n\nPROCEDURES: \n1. Percutaneous transhepatic biliary drainage via right lobe access.\n2. Crossing of distal CBD stenosis\n3. Brush and forcep biopsies of the distal CBD.\n\nPROCEDURE DETAILS: Informed consent was obtained from the patient. He was\npositioned supine. Following anesthesia timeout, anesthesia was induced. The\narea was then prepped and draped in sterile fashion. We then had procedural\ntimeout. Fluoroscopy was used intermittently.\n\nWith ultrasound guidance multiple passes were made with a 21-gauge Cook needle\ninto the lower right hepatic lobe in a mid axillary line below the rib cage.\nCare was taken to avoid the dilated gallbladder .A prominent right posterior\nduct was opacified . With a second puncture, a duct in the lower right lobe\nwas targeted and accessed first with the needle. Injection of contrast\nconfirmed position and an 035 nitinol wire was then passed centrally. Aver the\nwire the AccuStick sheath was placed. Through the sheath an 0.035 wire was\nthen positioned into the common bile duct and over this wire, a 6 ___ x 35\ncm sheath was placed. Contrast injection was done intermittently to confirm\nposition within the biliary tree. See below regarding findings. With minimal\nmanipulation, we managed to advance the wire through the ampulla into the\nduodenum. We then advanced the sheath into the bowel and placed a safety wire\ninto the bowel and then replaced the sheath over the second working wire. \nOver this wire, we performed a limited over-the-wire cholangiogram to define\nthe narrowing of the distal common bile duct. Several passes were made with\nthe a biopsy brush system at the distal common bile duct stricture as well as\nwith the forceps radial jaw device. Samples were sent to cytology and\npathology, respectively. \nWe then placed an internal-external 8 ___ biliary drain which was attached\nto the skin with a zero silk suture and adhesive device and covered with an\nappropriate dressing. This was connected to leg bag for gravity drainage. \nThe patient was extubated in the room and transferred to the PACU in good\ncondition. \nThere were no immediate complications.\n\nFINDINGS: \nMild intrahepatic bile duct dilatation. As seen on prior imaging the common\nbile duct was quite dilated as was gallbladder. Interestingly, the contrast\ninjected into the common bile duct rapidly flowed into the gallbladder\nsuggesting a widely patent cystic duct, however, no flow was seen through the\nampulla into the duodenum. The resistance of this was so low that it was\ndifficult to see if there was truly obstruction at the ampulla or not as all\nthe contrast injected instead flowed into the gallbladder. However, given the\noverall clinical picture, there is suspicion for ampullary stenosis versus\nsphincter of Oddi dysfunction. \n\nCONCLUSION: \nUncomplicated right lobe percutaneous transhepatic biliary drain as above with\nbiopsies and ___ internal-external drain placement. \nAs above the findings suggest ampullary stricture versus sphincter of Oddi\ndysfunction; pathology will be pending. \nOf note, the cystic duct appeared patent. \nPlan for gravity bag drainage for the immediate future and can consider\ncapping trial on ___ hours.\n', '10080928-RR-70', 70, ''], ["INDICATION: ___ man with cholangitis and PTBD with leakage from\naround the PTBD when capped. Please perform cholangiogram with possible tube\nchange.\n\nCOMPARISON: PTBD placement ___.\n\nPHYSICIANS: Dr. ___ (resident) and Dr. ___ (attending)\nperformed the procedure. Dr. ___ was present for and supervised the entire\nprocedure.\n\nMEDICATIONS: A total of 150 mcg fentanyl and 2 mg Versed were administered\nover a total in-service time of 55 minutes, during which time the patient's\nhemodynamic parameters were continuously monitored.\n\nFLUOROSCOPY TIME: 7.3 minutes.\n\nPROCEDURES:\n1. Cholangiogram.\n2. Brushings and forceps biopsy.\n3. Balloon dilation at the ampulla up to 10 mm.\n4. Exchange of the 8 ___ drain for a 10 ___ internal-external biliary\ndrain.\n\nPROCEDURE DETAILS: After discussing the risks, benefits and alternatives to\nthe procedure, written informed consent was obtained. The patient was brought\nto the angiography suite and placed supine on the imaging table. The right\nupper quadrant at the existing catheter site was prepped and draped in the\nusual sterile fashion. A preprocedure timeout was performed using three\nunique patient identifiers per ___ protocol. Fluoroscopy was used\nintermittently.\n\nContrast was injected into the existing 8 ___ biliary drain for the\ncholangiogram, demonstrating occlusion of the distal 8 ___ catheter with\nopacification of the bile ducts only. Multiple projections during the\ncholangiogram showed a shelf-like ampulla. The existing 8 ___ catheter was\ncut at the hub and ___ wire was advanced via the catheter into the\nbowel. The existing catheter was exchanged for a 6 ___ sheath. An Amplatz\nwire was advanced through the sheath as a safety wire. The sheath was removed\nand advanced over the ___ wire only. Due to the shelf-like ampulla,\nbrushings and forceps were performed. The sheath was removed and advanced\nover the Amplatz wire. Balloon dilation was performed using 8 mm and 10 mm\nballoons, which showed a minimal waist, which resolved with balloon dilation. \nThe balloon and 6 ___ sheath were removed. A new 10 ___\ninternal-external biliary drain was advanced over the Amplatz wire. The wire\nwas removed, and the pigtail formed. The biliary drain was attached to the\nskin with 0 silk suture. A sterile dressing was applied and the drain was\nconnected to a bag for gravity drainage.\n\nThe patient tolerated the procedure well without immediate post-procedure\ncomplications.\n\nKEY FINDINGS:\n1. Existing 8 ___ distal internal-external biliary drain is clogged.\n2. Persistent patulous common bile duct. On some images, the ampulla appeared\nmore shelf-like, so additional brush and forcep biopsies were obtained. \nDilatation of the ampulla demonstrated a minimal waist when dilated upto a 10\nmm balloon. Shelf-like ampulla on some projections.\n3. ___ PTBD placed.\n\nIMPRESSION: Exchange of existing malfunctioning ___ PTBD for a larger ___\nPRBD, with additional sampling and dilatation of the ampulla as described.\n\nThe findings and procedure were discussed with Dr. ___\n(surgery intern) upon procedure completion at 5:45 p.m., ___.\n", '10080928-RR-71', 71, '']]

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[]

['surgery']

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Timestamp('2202-09-07 23:57:00'), 'Monocytes'], [51256, Timestamp('2202-09-07 23:00:00'), Timestamp('2202-09-07 23:57:00'), 'Neutrophils'], [51265, Timestamp('2202-09-07 23:00:00'), Timestamp('2202-09-07 23:47:00'), 'Platelet Count'], [51277, Timestamp('2202-09-07 23:00:00'), Timestamp('2202-09-07 23:47:00'), 'RDW'], [51279, Timestamp('2202-09-07 23:00:00'), Timestamp('2202-09-07 23:47:00'), 'Red Blood Cells'], [51301, Timestamp('2202-09-07 23:00:00'), Timestamp('2202-09-07 23:47:00'), 'White Blood Cells'], [50861, Timestamp('2202-09-07 23:00:00'), Timestamp('2202-09-08 00:06:00'), 'Alanine Aminotransferase (ALT)'], [50862, Timestamp('2202-09-07 23:00:00'), Timestamp('2202-09-08 00:06:00'), 'Albumin'], [50863, Timestamp('2202-09-07 23:00:00'), Timestamp('2202-09-08 00:06:00'), 'Alkaline Phosphatase'], [50868, Timestamp('2202-09-07 23:00:00'), Timestamp('2202-09-08 00:06:00'), 'Anion Gap'], [50878, Timestamp('2202-09-07 23:00:00'), Timestamp('2202-09-08 00:06:00'), 'Asparate Aminotransferase (AST)'], [50882, Timestamp('2202-09-07 23:00:00'), Timestamp('2202-09-08 00:06:00'), 'Bicarbonate'], [50885, Timestamp('2202-09-07 23:00:00'), Timestamp('2202-09-08 00:06:00'), 'Bilirubin, Total'], [50902, Timestamp('2202-09-07 23:00:00'), Timestamp('2202-09-08 00:06:00'), 'Chloride'], [50912, Timestamp('2202-09-07 23:00:00'), Timestamp('2202-09-08 00:06:00'), 'Creatinine'], [50920, Timestamp('2202-09-07 23:00:00'), Timestamp('2202-09-08 00:06:00'), 'Estimated GFR (MDRD equation)'], [50931, Timestamp('2202-09-07 23:00:00'), Timestamp('2202-09-08 00:06:00'), 'Glucose'], [50956, Timestamp('2202-09-07 23:00:00'), Timestamp('2202-09-08 00:06:00'), 'Lipase'], [50963, Timestamp('2202-09-07 23:00:00'), Timestamp('2202-09-08 00:06:00'), 'NTproBNP'], [50971, Timestamp('2202-09-07 23:00:00'), Timestamp('2202-09-08 00:06:00'), 'Potassium'], [50983, Timestamp('2202-09-07 23:00:00'), Timestamp('2202-09-08 00:06:00'), 'Sodium'], [51006, Timestamp('2202-09-07 23:00:00'), Timestamp('2202-09-08 00:06:00'), 'Urea Nitrogen'], [50813, Timestamp('2202-09-07 23:14:00'), Timestamp('2202-09-07 23:16:00'), 'Lactate'], [51237, Timestamp('2202-09-07 23:21:00'), Timestamp('2202-09-07 23:42:00'), 'INR(PT)'], [51274, Timestamp('2202-09-07 23:21:00'), Timestamp('2202-09-07 23:42:00'), 'PT'], [51275, Timestamp('2202-09-07 23:21:00'), Timestamp('2202-09-07 23:42:00'), 'PTT'], [51463, Timestamp('2202-09-07 23:40:00'), Timestamp('2202-09-08 00:42:00'), 'Bacteria'], [51464, Timestamp('2202-09-07 23:40:00'), Timestamp('2202-09-08 00:42:00'), 'Bilirubin'], [51466, Timestamp('2202-09-07 23:40:00'), Timestamp('2202-09-08 00:42:00'), 'Blood'], [51476, Timestamp('2202-09-07 23:40:00'), Timestamp('2202-09-08 00:42:00'), 'Epithelial Cells'], [51478, Timestamp('2202-09-07 23:40:00'), Timestamp('2202-09-08 00:42:00'), 'Glucose'], [51479, Timestamp('2202-09-07 23:40:00'), Timestamp('2202-09-08 00:42:00'), 'Granular Casts'], [51482, Timestamp('2202-09-07 23:40:00'), Timestamp('2202-09-08 00:42:00'), 'Hyaline Casts'], [51484, Timestamp('2202-09-07 23:40:00'), Timestamp('2202-09-08 00:42:00'), 'Ketone'], [51486, Timestamp('2202-09-07 23:40:00'), Timestamp('2202-09-08 00:42:00'), 'Leukocytes'], [51487, Timestamp('2202-09-07 23:40:00'), Timestamp('2202-09-08 00:42:00'), 'Nitrite'], [51491, Timestamp('2202-09-07 23:40:00'), Timestamp('2202-09-08 00:42:00'), 'pH'], [51492, Timestamp('2202-09-07 23:40:00'), Timestamp('2202-09-08 00:42:00'), 'Protein'], [51493, Timestamp('2202-09-07 23:40:00'), Timestamp('2202-09-08 00:42:00'), 'RBC'], [51498, Timestamp('2202-09-07 23:40:00'), Timestamp('2202-09-08 00:42:00'), 'Specific Gravity'], [51506, Timestamp('2202-09-07 23:40:00'), Timestamp('2202-09-08 00:42:00'), 'Urine Appearance'], [51508, Timestamp('2202-09-07 23:40:00'), Timestamp('2202-09-08 00:42:00'), 'Urine Color'], [51512, Timestamp('2202-09-07 23:40:00'), Timestamp('2202-09-08 00:42:00'), 'Urine Mucous'], [51514, Timestamp('2202-09-07 23:40:00'), Timestamp('2202-09-08 00:42:00'), 'Urobilinogen'], [51516, Timestamp('2202-09-07 23:40:00'), Timestamp('2202-09-08 00:42:00'), 'WBC'], [51519, Timestamp('2202-09-07 23:40:00'), Timestamp('2202-09-08 00:42:00'), 'Yeast'], [50861, Timestamp('2202-09-08 06:20:00'), Timestamp('2202-09-08 07:02:00'), 'Alanine Aminotransferase (ALT)'], [50862, Timestamp('2202-09-08 06:20:00'), Timestamp('2202-09-08 07:02:00'), 'Albumin'], [50863, Timestamp('2202-09-08 06:20:00'), Timestamp('2202-09-08 07:02:00'), 'Alkaline Phosphatase'], [50868, Timestamp('2202-09-08 06:20:00'), Timestamp('2202-09-08 07:02:00'), 'Anion Gap'], [50878, Timestamp('2202-09-08 06:20:00'), Timestamp('2202-09-08 07:02:00'), 'Asparate Aminotransferase (AST)'], [50882, Timestamp('2202-09-08 06:20:00'), Timestamp('2202-09-08 07:02:00'), 'Bicarbonate'], [50885, Timestamp('2202-09-08 06:20:00'), Timestamp('2202-09-08 07:02:00'), 'Bilirubin, Total'], [50893, Timestamp('2202-09-08 06:20:00'), Timestamp('2202-09-08 07:02:00'), 'Calcium, Total'], [50902, Timestamp('2202-09-08 06:20:00'), Timestamp('2202-09-08 07:02:00'), 'Chloride'], [50910, Timestamp('2202-09-08 06:20:00'), Timestamp('2202-09-08 08:48:00'), 'Creatine Kinase (CK)'], [50911, Timestamp('2202-09-08 06:20:00'), Timestamp('2202-09-08 08:48:00'), 'Creatine Kinase, MB Isoenzyme'], [50912, Timestamp('2202-09-08 06:20:00'), Timestamp('2202-09-08 07:02:00'), 'Creatinine'], [50931, Timestamp('2202-09-08 06:20:00'), Timestamp('2202-09-08 07:02:00'), 'Glucose'], [50960, Timestamp('2202-09-08 06:20:00'), Timestamp('2202-09-08 07:02:00'), 'Magnesium'], [50970, Timestamp('2202-09-08 06:20:00'), Timestamp('2202-09-08 07:02:00'), 'Phosphate'], [50971, Timestamp('2202-09-08 06:20:00'), Timestamp('2202-09-08 07:02:00'), 'Potassium'], [50983, Timestamp('2202-09-08 06:20:00'), Timestamp('2202-09-08 07:02:00'), 'Sodium'], [51003, Timestamp('2202-09-08 06:20:00'), Timestamp('2202-09-08 08:48:00'), 'Troponin T'], [51006, Timestamp('2202-09-08 06:20:00'), Timestamp('2202-09-08 07:02:00'), 'Urea Nitrogen'], [51221, Timestamp('2202-09-08 06:20:00'), Timestamp('2202-09-08 06:49:00'), 'Hematocrit'], [51222, Timestamp('2202-09-08 06:20:00'), Timestamp('2202-09-08 06:49:00'), 'Hemoglobin'], [51248, Timestamp('2202-09-08 06:20:00'), Timestamp('2202-09-08 06:49:00'), 'MCH'], [51249, Timestamp('2202-09-08 06:20:00'), Timestamp('2202-09-08 06:49:00'), 'MCHC'], [51250, Timestamp('2202-09-08 06:20:00'), Timestamp('2202-09-08 06:49:00'), 'MCV'], [51265, Timestamp('2202-09-08 06:20:00'), Timestamp('2202-09-08 06:49:00'), 'Platelet Count'], [51277, Timestamp('2202-09-08 06:20:00'), Timestamp('2202-09-08 06:49:00'), 'RDW'], [51279, Timestamp('2202-09-08 06:20:00'), Timestamp('2202-09-08 06:49:00'), 'Red Blood Cells'], [51301, Timestamp('2202-09-08 06:20:00'), Timestamp('2202-09-08 06:49:00'), 'White Blood Cells'], [50861, Timestamp('2202-09-08 11:03:00'), Timestamp('2202-09-08 11:57:00'), 'Alanine Aminotransferase (ALT)'], [50863, Timestamp('2202-09-08 11:03:00'), Timestamp('2202-09-08 11:57:00'), 'Alkaline Phosphatase'], [50878, Timestamp('2202-09-08 11:03:00'), Timestamp('2202-09-08 11:57:00'), 'Asparate Aminotransferase (AST)'], [50883, Timestamp('2202-09-08 11:03:00'), Timestamp('2202-09-08 11:57:00'), 'Bilirubin, Direct'], [50884, Timestamp('2202-09-08 11:03:00'), Timestamp('2202-09-08 11:57:00'), 'Bilirubin, Indirect'], [50885, Timestamp('2202-09-08 11:03:00'), Timestamp('2202-09-08 11:57:00'), 'Bilirubin, Total'], [51214, Timestamp('2202-09-09 02:23:00'), Timestamp('2202-09-09 04:22:00'), 'Fibrinogen, Functional'], [51237, Timestamp('2202-09-09 02:23:00'), Timestamp('2202-09-09 04:22:00'), 'INR(PT)'], [51274, Timestamp('2202-09-09 02:23:00'), Timestamp('2202-09-09 04:22:00'), 'PT'], [51275, Timestamp('2202-09-09 02:23:00'), Timestamp('2202-09-09 04:22:00'), 'PTT'], [50861, Timestamp('2202-09-09 02:23:00'), Timestamp('2202-09-09 04:51:00'), 'Alanine Aminotransferase (ALT)'], [50863, Timestamp('2202-09-09 02:23:00'), Timestamp('2202-09-09 04:51:00'), 'Alkaline Phosphatase'], [50868, Timestamp('2202-09-09 02:23:00'), Timestamp('2202-09-09 04:51:00'), 'Anion Gap'], [50878, Timestamp('2202-09-09 02:23:00'), Timestamp('2202-09-09 04:51:00'), 'Asparate Aminotransferase (AST)'], [50882, Timestamp('2202-09-09 02:23:00'), Timestamp('2202-09-09 04:51:00'), 'Bicarbonate'], [50885, Timestamp('2202-09-09 02:23:00'), Timestamp('2202-09-09 04:51:00'), 'Bilirubin, Total'], [50893, Timestamp('2202-09-09 02:23:00'), Timestamp('2202-09-09 04:51:00'), 'Calcium, Total'], [50902, Timestamp('2202-09-09 02:23:00'), Timestamp('2202-09-09 04:51:00'), 'Chloride'], [50912, Timestamp('2202-09-09 02:23:00'), Timestamp('2202-09-09 04:51:00'), 'Creatinine'], [50931, Timestamp('2202-09-09 02:23:00'), Timestamp('2202-09-09 04:51:00'), 'Glucose'], [50960, Timestamp('2202-09-09 02:23:00'), Timestamp('2202-09-09 04:51:00'), 'Magnesium'], [50970, Timestamp('2202-09-09 02:23:00'), Timestamp('2202-09-09 04:51:00'), 'Phosphate'], [50971, Timestamp('2202-09-09 02:23:00'), Timestamp('2202-09-09 04:51:00'), 'Potassium'], [50983, Timestamp('2202-09-09 02:23:00'), Timestamp('2202-09-09 04:51:00'), 'Sodium'], [51006, Timestamp('2202-09-09 02:23:00'), Timestamp('2202-09-09 04:51:00'), 'Urea Nitrogen'], [51009, Timestamp('2202-09-09 02:23:00'), Timestamp('2202-09-09 06:12:00'), 'Vancomycin'], [51221, Timestamp('2202-09-09 02:23:00'), Timestamp('2202-09-09 04:06:00'), 'Hematocrit'], [51222, Timestamp('2202-09-09 02:23:00'), Timestamp('2202-09-09 04:06:00'), 'Hemoglobin'], [51248, Timestamp('2202-09-09 02:23:00'), Timestamp('2202-09-09 04:06:00'), 'MCH'], [51249, Timestamp('2202-09-09 02:23:00'), Timestamp('2202-09-09 04:06:00'), 'MCHC'], [51250, Timestamp('2202-09-09 02:23:00'), Timestamp('2202-09-09 04:06:00'), 'MCV'], [51265, Timestamp('2202-09-09 02:23:00'), Timestamp('2202-09-09 04:06:00'), 'Platelet Count'], [51277, Timestamp('2202-09-09 02:23:00'), Timestamp('2202-09-09 04:06:00'), 'RDW'], [51279, Timestamp('2202-09-09 02:23:00'), Timestamp('2202-09-09 04:06:00'), 'Red Blood Cells'], [51301, Timestamp('2202-09-09 02:23:00'), Timestamp('2202-09-09 04:06:00'), 'White Blood Cells']]

Question: A 79 M is admitted. He/she says he/she has Abdominal pain, fevers. ___ 1. Percutaneous transhepatic biliary drainage via right lobe access. 2. Crossing of distal CBD stenosis 3. Brush and forcep biopsies of the distal CBD. ___ 1. Cholangiogram. 2. Brushings and forceps biopsy. 3. Balloon dilation at the ampulla up to 10 mm. 4. Exchange of the 8 ___ drain for a 10 ___ internal-external biliary drain. . History of illness: Mr. ___ is a ___ year old male presenting from a rehabilitation facility after a right TKA on ___. He was transferred to ___ for evaluation of his abdominal pain and a reported fever > 100. He states that he has been having intermittent abdominal pain located in his RUQ for the past 2 months. He also reports some right shoulder pain as well. He denies any association with food. The pain usually resolved on its own and is "crampy" in nature. He did have a temperature of > 100 today at rehab. He also endorses recent bouts of nausea but no emesis. He is tolerating a diet with normal bowel function. He denies jaundice, diarreha, and melena. He does have a known history of gallstones but denies any similar attacks in the past. EMS found him to be "hypotensive" but no BP is recorded. His BP here was noted to be 84/48 which is responsive to IVF resuscitation. Of note he did well postoperatively after his right TKA. He was discharged to rehab with a Hct of 24. Past Medical History: PMH: Osteoarthritis right knee, h/o peptic ulcers, known gallstones, CAD with ? MI ___ years ago, anxiety PSH: Gastric resection for perforated peptic ulcer ___ years ago at ___, ventral incisional hernia repair x 2 (most recent one ___ years ago at ___ Social History: ___ Family History: Positive for father having had cancer. Mother had heart disease. Allergies: Penicillins / quetiapine What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Vial Pantoprazole 0.9% Sodium Chloride (Mini Bag Plus) CefePIME Quetiapine Fumarate Morphine Sulfate Senna NS MetRONIDAZOLE (FLagyl) HYDROmorphone (Dilaudid) 5% Dextrose Ciprofloxacin IV Lactated Ringers Heparin Iso-Osmotic Dextrose Vancomycin Quetiapine Fumarate Sodium Chloride 0.9% Flush 5% Dextrose NORepinephrine Docusate Sodiu Lactated Ringers Famotidine Docusate Sodiu Bisacodyl Target Lab Orders: Blue Top Hold Light Green Top Hold Troponin T Basophils Eosinophils Hematocrit Hemoglobin Lymphocytes MCH MCHC MCV Monocytes Neutrophils Platelet Count RDW Red Blood Cells White Blood Cells Alanine Aminotransferase (ALT) Albumin Alkaline Phosphatase Anion Gap Asparate Aminotransferase (AST) Bicarbonate Bilirubin, Total Chloride Creatinine Estimated GFR (MDRD equation) Glucose Lipase NTproBNP Potassium Sodium Urea Nitrogen Lactate INR(PT) PT PTT Bacteria Bilirubin Blood Epithelial Cells Glucose Granular Casts Hyaline Casts Ketone Leukocytes Nitrite pH Protein RBC Specific Gravity Urine Appearance Urine Color Urine Mucous Urobilinogen WBC Yeast Alanine Aminotransferase (ALT) Albumin Alkaline Phosphatase Anion Gap Asparate Aminotransferase (AST) Bicarbonate Bilirubin, Total Calcium, Total Chloride Creatine Kinase (CK) Creatine Kinase, MB Isoenzyme Creatinine Glucose Magnesium Phosphate Potassium Sodium Troponin T Urea Nitrogen Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells Alanine Aminotransferase (ALT) Alkaline Phosphatase Asparate Aminotransferase (AST) Bilirubin, Direct Bilirubin, Indirect Bilirubin, Total Fibrinogen, Functional INR(PT) PT PTT Alanine Aminotransferase (ALT) Alkaline Phosphatase Anion Gap Asparate Aminotransferase (AST) Bicarbonate Bilirubin, Total Calcium, Total Chloride Creatinine Glucose Magnesium Phosphate Potassium Sodium Urea Nitrogen Vancomycin Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : Mr. ___ was admitted to the inpatient ward under the Acute Care Surgery service for further evaluation of his abdominal pain and fevers. On presentation he had mild leukocytosis and a mildly elevated Tbili of 1.5. He underwent a RUQ US and CT scan which revealed cholelithiasis, dilated CBD up to 15mm, with mild intrahepatic ductal dilatation. There was no evidence of pericholecystic fluid or wall thickening. He was initiated on Unasyn and then cipro/flagyl. An ERCP was attempted, but could not access his ampulla due to his reconstructed anatomy. Instead a PTBD was placed, during which cholangiography demonstrated stenosis of his distal CBD, and brushings were performed. A clamping trial of the PTBD was attempted, but the insertion site began to leak biliary fluid. On further evaluation, it was found that the PTBD drain became clogged, which required him to return to Interventional Radiology for placement of a larger drain. During the same procedure, the patient underwent a balloon dilation of his ampulla. Brushings and biopsy specimens were obtained as well. At the time of this writing, the patient's alk phos was stable at 361. His lipase continues to downtrend, now at a level of 104. Prior to this admission, Mr. ___ recently underwent a right knee replacement on ___. From an orthopedic standpoint, the patient has progressed well. Physical therapy was consulted and has worked with the patient multiple times while an inpatient. His staples have been removed and the wound is healing well. His is weight bearing as tolerated to the right lower extremity. On the evening prior to discharge, Mr. ___ stated he had chest pain. His ECG had no acute findings. Troponin levels were normal. Blood cultures were also drawn (results pending). He has had no further instances of chest pain since that time. His hematocrit level is stable at 31 (max low of 23.9 on admission). At the time of discharge, Mr. ___ is hemodynamically stable and afebrile. He did complain of some gum soreness, so his cardiac diet was changed to one with soft consistencies. Viscous lidocaine has been ordered PRN for short-term pain relief. He should be further evaluated if he continued to have pain when wearing his dentures. His pain has been managed well with narcotic and non-narcotic analgesics. His last dose of ciprofloxacin and metronidazole will be tomorrow, ___. He has no leukocytosis. He has received pantoprazole for GI prophylaxis and subcutaneous heparin for DVT prophylaxis. Mr. ___ is now being discharged to a rehabilitation facility. He is in no acute distress and is expected to recover well. His right lower quadrant drain remains in place. An appointment has been made with Dr. ___ of ___ service for follow-up within one week. He should also follow up with orthopedics regarding his prior knee replacement surgery. Lastly, the patient will need to follow up with Interventional Radiology for a likely dilation of his ampulla. Other Results: ___ 11:00PM BLOOD WBC-13.2*# RBC-2.64* Hgb-7.9* Hct-24.2* MCV-92# MCH-29.9 MCHC-32.7 RDW-15.6* Plt ___ ___ 06:20AM BLOOD WBC-10.2 RBC-2.66* Hgb-7.7* Hct-23.9* MCV-90 MCH-29.1 MCHC-32.4 RDW-16.0* Plt ___ ___ 02:23AM BLOOD WBC-10.5 RBC-2.84* Hgb-8.6* Hct-25.3* MCV-89 MCH-30.3 MCHC-34.0 RDW-16.2* Plt ___ ___ 05:53AM BLOOD WBC-11.6* RBC-2.99* Hgb-8.7* Hct-26.8* MCV-90 MCH-28.9 MCHC-32.3 RDW-15.8* Plt ___ ___ 08:50AM BLOOD WBC-12.7* RBC-3.41* Hgb-9.9* Hct-30.6* MCV-90 MCH-29.0 MCHC-32.4 RDW-15.7* Plt ___ ___ 06:04AM BLOOD WBC-11.1* RBC-3.11* Hgb-9.1* Hct-28.0* MCV-90 MCH-29.1 MCHC-32.3 RDW-16.0* Plt ___ ___ 05:32AM BLOOD WBC-7.7 RBC-2.98* Hgb-8.6* Hct-26.8* MCV-90 MCH-28.7 MCHC-32.0 RDW-15.8* Plt ___ ___ 07:35AM BLOOD WBC-6.7 RBC-3.43* Hgb-9.8* Hct-31.0* MCV-90 MCH-28.5 MCHC-31.6 RDW-15.6* Plt ___ ___ 09:15AM BLOOD WBC-6.9 RBC-3.57* Hgb-10.2* Hct-31.9* MCV-89 MCH-28.6 MCHC-32.0 RDW-15.5 Plt ___ ___ 11:00PM BLOOD Neuts-94.0* Lymphs-3.8* Monos-2.0 Eos-0 Baso-0.1 ___ 11:00PM BLOOD Plt ___ ___ 11:21PM BLOOD ___ PTT-30.0 ___ ___ 09:15AM BLOOD ___ PTT-31.0 ___ ___ 09:15AM BLOOD Plt ___ ___ 02:23AM BLOOD ___ ___ 11:00PM BLOOD Glucose-103* UreaN-27* Creat-0.9 Na-142 K-4.2 Cl-104 HCO3-27 AnGap-15 ___ 09:15AM BLOOD Glucose-104* UreaN-15 Creat-0.8 Na-138 K-3.9 Cl-101 HCO3-26 AnGap-15 ___ 11:00PM BLOOD ALT-159* AST-279* AlkPhos-470* TotBili-1.5 ___ 06:20AM BLOOD ALT-119* AST-170* CK(CPK)-51 AlkPhos-360* TotBili-1.1 ___ 11:03AM BLOOD ALT-115* AST-136* AlkPhos-319* TotBili-1.1 DirBili-0.6* IndBili-0.5 ___ 02:23AM BLOOD ALT-90* AST-88* AlkPhos-289* TotBili-0.9 ___ 05:13AM BLOOD ALT-77* AST-114* LD(___)-373* AlkPhos-752* TotBili-0.9 ___ 06:04AM BLOOD ALT-58* AST-62* AlkPhos-581* TotBili-0.8 ___ 05:32AM BLOOD ALT-49* AST-44* AlkPhos-503* TotBili-0.8 ___ 05:16AM BLOOD ALT-40 AST-35 AlkPhos-445* TotBili-0.8 ___ 06:55AM BLOOD ALT-32 AST-27 AlkPhos-404* TotBili-0.8 ___ 07:35AM BLOOD ALT-28 AST-30 LD(LDH)-400* AlkPhos-383* TotBili-0.8 ___ 05:27AM BLOOD ALT-23 AST-23 AlkPhos-339* TotBili-0.7 ___ 09:15AM BLOOD ALT-25 AST-26 CK(CPK)-13* AlkPhos-361* TotBili-0.8 ___ 11:00PM BLOOD Lipase-34 ___ 06:04AM BLOOD Lipase-574* ___ 05:32AM BLOOD Lipase-121* ___ 05:16AM BLOOD Lipase-73* ___ 06:55AM BLOOD Lipase-104* ___ 11:00PM BLOOD proBNP-958* ___ 11:00PM BLOOD cTropnT-<0.01 ___ 06:20AM BLOOD CK-MB-3 cTropnT-<0.01 ___ 09:15AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 11:00PM BLOOD Albumin-3.4* ___ 06:20AM BLOOD Albumin-2.8* Calcium-7.1* Phos-3.1 Mg-1.8 ___ 09:15AM BLOOD Calcium-8.7 Phos-3.6 Mg-2.1 ___ 01:30PM BLOOD CEA-2.5 IMAGING: ___ ECG Sinus rhythm. Left bundle-branch block. Compared to the previous tracing of ___ ventricular ectopy is no longer recorded. Otherwise, no diagnostic interim change. ___ CTA abdomen and pelvis Distended gallbladder with cholelithiasis and a significantly dilated common bile duct and pancreatic duct. There is no definite pericholecystic fluid or gallbladder wall thickening. Moderate intrahepatic biliary duct dilatation. 2. No evidence of pulmonary embolism. 3. Stable pulmonary nodules. 4. Right lower lobe consolidation may represent aspiration. ___ Liver/gallbladder U/S Very distended gallbladder filled with sludge and stones and a very dilated common bile duct. This may represent acute cholecystitis. ___ Common bile duct, distal, forceps biopsy: 1. Fragments of benign biliary mucosa. 2. Multiple levels have been examined. ___ Common bile duct (distal), brushing: ATYPICAL. Hypocellular specimen with rare groups of atypical glandular cells. ___ Biliary Drain Placement Uncomplicated right lobe percutaneous transhepatic biliary drain as above with biopsies and ___ internal-external drain placement. As above the findings suggest ampullary stricture versus sphincter of Oddi dysfunction; pathology will be pending. Of note, the cystic duct appeared patent. ___ile duct brushing results pending

2165-08-08 20:07:00

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[[22152129, Timestamp('2165-08-08 20:08:28'), '', 'PSURG']]

[[{'Medications on Admission': ':\n1. Acetaminophen 650 mg PO Q6H:PRN headache, pain \n2. cefaDROXil 500 mg oral Q12H \n3. Enoxaparin Sodium 80 mg SC Q12H Start: Today - ___, \nFirst Dose: Next Routine Administration Time \n4. Lorazepam 0.5 mg PO Q4H:PRN anxiety \n5. Omeprazole 20 mg PO DAILY reflux \n6. Ondansetron 8 mg PO Q8H:PRN naseua \n7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain \n\nFacility:\n___', 'Brief Hospital Course': ":\nThe patient was admitted to the plastic surgery service on \n___ for observation of some bleeding from her left axillary \nJP and from left breast flap incision. Patient also complained \nof feeling weak and lightheaded. Left breast flap was firm with \nsome tenderness along axillary boarder. Left and right breast \nflaps viable with strong doppler signals.\n.\nNeuro: The patient's pain was well controlled on home pain \nmedications. \n.\nCV: The patient arrived hypotensive with blood pressure \n80's/40's, HR 85, O2sat 99% on RA. Patient responded well to 1L \nIVF bolus and pressure came up to 100's/50's.\n.\nPulmonary: The patient was stable from a pulmonary standpoint; \nvital signs were routinely monitored.\n.\nGI/GU: The patient was given IV fluids until tolerating oral \nintake. She tolerated a regular diet. Intake and output were \nclosely monitored. \n.\nID: The patient was given keflex PO while in hospital and then \nadvised to complete her cefadroxil prescription upon discharge. \nThe patient's temperature was closely watched for signs of \ninfection. \n.\nProphylaxis: The patient was continued on her therapeutic \nlovenox during this stay, based upon available data on Factor V \nLeiden and free flaps. She was advised to continue this regimen \nat home until entire 2 week prescription was finished. She was \nencouraged to get up and ambulate as much as possible and \ncontinue her ADLs. She was advised to avoid strenuous activity \nat this time including heavy lifting and upper extremity \nstretching.\n.\nAt the time of discharge on hospital day #2, the patient was \ndoing well, afebrile with stable vital signs, tolerating a \nregular diet, ambulating, voiding without assistance, and pain \nwas well controlled. Left breast bleeding from incision and \ninto drain was minimal.\n\n", 'Pertinent Results:': '\n___ 06:15PM URINE HOURS-RANDOM\n___ 06:15PM URINE HOURS-RANDOM\n___ 06:15PM URINE UHOLD-HOLD\n___ 06:15PM URINE GR HOLD-HOLD\n___ 06:15PM URINE COLOR-Straw APPEAR-Clear SP ___\n___ 06:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG \nGLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 \nLEUK-SM \n___ 06:15PM URINE RBC-0 WBC-6* BACTERIA-FEW YEAST-NONE \nEPI-2\n___ 06:15PM URINE MUCOUS-RARE\n___ 02:40PM LACTATE-1.3\n___ 02:30PM GLUCOSE-123* UREA N-8 CREAT-0.7 SODIUM-142 \nPOTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-27 ANION GAP-15\n___ 02:30PM cTropnT-<0.01\n___ 02:30PM CALCIUM-8.9 PHOSPHATE-3.7 MAGNESIUM-1.9\n___ 02:30PM WBC-12.0*# RBC-3.38* HGB-9.7* HCT-30.8* \nMCV-91 MCH-28.6 MCHC-31.4 RDW-14.6\n___ 02:30PM NEUTS-75.8* LYMPHS-16.4* MONOS-3.5 EOS-3.8 \nBASOS-0.5\n___ 02:30PM PLT COUNT-483*#\n___ 02:30PM ___ PTT-43.1* ___\n\n', 'Physical Exam:|Physical': '\nVITAL SIGNS: afebrile, 80, 105/70, 18, 98%RA\nGENERAL: ___ is pale in mild distress, anxious.\nShe is alert and oriented x3. \nNormal mood and affect.\nBREASTS: Incision are c,d,i on R. On left after evacuation of \nclot there is a small approx 1.5 cm area of dehiscence with sang \ndrainage to pad. There is no surrounding erythema of the skin \nindicating infxn. There is widespread ecchymosis L>R. Drains on \nR serosang/patent. Drain JP 2 on L sang drainage. L breast \nlarger and more swollen, tense then R. A hematoma can be \npalpated under the skin. Drainage and swelling seem to have \nstabilized. incisions are still closed save for the \naforementioned small area of planned opening from previous \nevacuation. Dopplers strong on flaps bilaterally.\nABDOMEN: Soft, nontender. No evidence of masses, hernias,\nhepatosplenomegaly.\nBACK: Unremarkable.\nCARDIOVASCULAR: There is no evidence of any extremity\nvaricosities.\nLUNGS: Respiratory effort is normal with no intercostal\nretractions.\nEXTREMITIES; No evidence of any peripheral edema, digital\ncyanosis, or lymphadenopathy.\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\n___ yo F w/ L breast cancer s/p prior lumpectomy + margins, h/o \nfactor V Leiden currently on therapeutic Lovenox, now ___ s/p \nB/L mastect and ___ flap recon ___ Dr. ___, post-op course \ncomplicated by hematoma development of L breast requiring 2 \nbedside hematoma evacuations, placement of breast drain, and \ntransfusion 2U pRBCs with appropriate Hct bump. pt returned home \non ___, was improving and presented to ED today after BRB \nfrom incision site in shower and an acute increase in sang \ndrainage from JP#2 of approx 80cc over 4 hours.\n.\nPt felt lightheaded, came to ED, systolic 88; responded to 1L \nbolus. Plastics was ___ denies any fevers, chills or \nmalaise. Pt does feel weak as expected postoperatively.\n\nPast Medical History:\nfactor V Leiden\n.\nPSH: C-section, tonsil, partial hysterectomy.\n\nSocial History:\n___\nFamily History:\nBreast cancer, stroke, depression, and heart disease.\n\n', 'Chief Complaint:|Complaint:': '\nLightheadedness, bleeding\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nPenicillins\n\n'}, '17696921-DS-3', 3, 'plastic']]

[]

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[]

['plastic']

[]

Question: A 54 F is admitted. He/she says he/she has Lightheadedness, bleeding . History of illness: ___ yo F w/ L breast cancer s/p prior lumpectomy + margins, h/o factor V Leiden currently on therapeutic Lovenox, now ___ s/p B/L mastect and ___ flap recon ___ Dr. ___, post-op course complicated by hematoma development of L breast requiring 2 bedside hematoma evacuations, placement of breast drain, and transfusion 2U pRBCs with appropriate Hct bump. pt returned home on ___, was improving and presented to ED today after BRB from incision site in shower and an acute increase in sang drainage from JP#2 of approx 80cc over 4 hours. . Pt felt lightheaded, came to ED, systolic 88; responded to 1L bolus. Plastics was ___ denies any fevers, chills or malaise. Pt does feel weak as expected postoperatively. Past Medical History: factor V Leiden . PSH: C-section, tonsil, partial hysterectomy. Social History: ___ Family History: Breast cancer, stroke, depression, and heart disease. Allergies: Penicillins What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Lorazepam OxycoDONE (Immediate Release) Lorazepam OxycoDONE (Immediate Release) Cephalexin Lactated Ringers Omeprazole Sodium Chloride 0.9% Acetaminophen Sodium Chloride 0.9% Flush Enoxaparin Sodium Ondansetron OxycoDONE (Immediate Release) HYDROmorphone (Dilaudid) Target Lab Orders: NONE Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : The patient was admitted to the plastic surgery service on ___ for observation of some bleeding from her left axillary JP and from left breast flap incision. Patient also complained of feeling weak and lightheaded. Left breast flap was firm with some tenderness along axillary boarder. Left and right breast flaps viable with strong doppler signals. . Neuro: The patient's pain was well controlled on home pain medications. . CV: The patient arrived hypotensive with blood pressure 80's/40's, HR 85, O2sat 99% on RA. Patient responded well to 1L IVF bolus and pressure came up to 100's/50's. . Pulmonary: The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. . GI/GU: The patient was given IV fluids until tolerating oral intake. She tolerated a regular diet. Intake and output were closely monitored. . ID: The patient was given keflex PO while in hospital and then advised to complete her cefadroxil prescription upon discharge. The patient's temperature was closely watched for signs of infection. . Prophylaxis: The patient was continued on her therapeutic lovenox during this stay, based upon available data on Factor V Leiden and free flaps. She was advised to continue this regimen at home until entire 2 week prescription was finished. She was encouraged to get up and ambulate as much as possible and continue her ADLs. She was advised to avoid strenuous activity at this time including heavy lifting and upper extremity stretching. . At the time of discharge on hospital day #2, the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. Left breast bleeding from incision and into drain was minimal. Other Results: ___ 06:15PM URINE HOURS-RANDOM ___ 06:15PM URINE HOURS-RANDOM ___ 06:15PM URINE UHOLD-HOLD ___ 06:15PM URINE GR HOLD-HOLD ___ 06:15PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 06:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-SM ___ 06:15PM URINE RBC-0 WBC-6* BACTERIA-FEW YEAST-NONE EPI-2 ___ 06:15PM URINE MUCOUS-RARE ___ 02:40PM LACTATE-1.3 ___ 02:30PM GLUCOSE-123* UREA N-8 CREAT-0.7 SODIUM-142 POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-27 ANION GAP-15 ___ 02:30PM cTropnT-<0.01 ___ 02:30PM CALCIUM-8.9 PHOSPHATE-3.7 MAGNESIUM-1.9 ___ 02:30PM WBC-12.0*# RBC-3.38* HGB-9.7* HCT-30.8* MCV-91 MCH-28.6 MCHC-31.4 RDW-14.6 ___ 02:30PM NEUTS-75.8* LYMPHS-16.4* MONOS-3.5 EOS-3.8 BASOS-0.5 ___ 02:30PM PLT COUNT-483*# ___ 02:30PM ___ PTT-43.1* ___

2144-08-20 12:35:00

ENGLISH

SINGLE

WHITE

F

[[27920108, Timestamp('2144-08-20 12:35:26'), '', 'NMED']]

[[{'Medications on Admission': ':\nThe Preadmission Medication list is accurate and complete.\n1. Topiramate (Topamax) 25 mg PO BID \n2. Multivitamins 1 TAB PO DAILY ', 'Brief Hospital Course': ':\nMs. ___ was admitted to the hospital due to persistent \nheadaches that did not respond to outpatient management with \nnortriptyline, steroid burst, or topamax. MRI of the brain and \nMRV was obtained and did not show any acute abnormalities. We \nincreased the dose of topamax to 50mg twice daily. The headaches \nwere treated with migraine cocktail consisting of ketolorac, \ntylenol, IV fluids, as well as zofran. Patient reported mild \nimprovement of symptoms. We also repeated LP to evaluate these \nongoing headache, especially given recent history of aseptic \nmeningitis. Opening pressure was 26. The labs from ___ were sent \nand we will follow-up on the results. Patient reported \nimprovement of headache immediately following the LP.\n\nTransitional issues:\n- dose of topamax increased to 50mg BID\n- CSF studies are pending\n- Needs f/u with Neurology in ___ weeks\n\nPatient seen and discussed with ___ Team, under \nsupervision of Dr. ___.\n\n___, MD\n___ Neurology\n\n', 'Pertinent Results:': '\nAdmission: \n\n___ 11:00AM BLOOD WBC-10.7* RBC-4.88 Hgb-14.1 Hct-44.0 \nMCV-90 MCH-28.9 MCHC-32.0 RDW-12.7 RDWSD-41.6 Plt ___\n___ 11:00AM BLOOD Neuts-63.6 ___ Monos-7.4 Eos-1.0 \nBaso-0.7 Im ___ AbsNeut-6.81* AbsLymp-2.86 AbsMono-0.79 \nAbsEos-0.11 AbsBaso-0.07\n___ 11:00AM BLOOD ___ PTT-31.6 ___\n___ 11:00AM BLOOD Glucose-80 UreaN-16 Creat-0.7 Na-140 \nK-4.5 Cl-100 HCO3-24 AnGap-16\n___ 11:00AM BLOOD ALT-12 AST-15 AlkPhos-82 TotBili-0.4\n___ 11:00AM BLOOD Albumin-4.5\n___ 11:20AM URINE Color-Yellow Appear-Hazy* Sp ___\n___ 11:20AM URINE Blood-NEG Nitrite-NEG Protein-TR* \nGlucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG\n___ 11:20AM URINE RBC-1 WBC-2 Bacteri-FEW* Yeast-NONE Epi-3\n___ 11:20AM URINE Mucous-RARE*\n___ 11:20AM URINE Hours-RANDOM\n___ 11:20AM URINE UCG-NEG\n___ 11:20AM URINE CULTURE (Final ___: MIXED BACTERIAL \nFLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL \nCONTAMINATION. \n\nDischarge: \n\n___ 05:35AM BLOOD WBC-10.4* RBC-4.29 Hgb-12.4 Hct-37.7 \nMCV-88 MCH-28.9 MCHC-32.9 RDW-12.6 RDWSD-40.1 Plt ___\n___ 03:00PM BLOOD ___ PTT-31.2 ___\n___ 05:35AM BLOOD Glucose-77 UreaN-14 Creat-0.8 Na-142 \nK-4.3 Cl-105 HCO3-25 AnGap-12\n___ 05:35AM BLOOD Calcium-9.6 Phos-4.3 Mg-2.0\n___ 09:35AM CEREBROSPINAL FLUID (CSF) TNC-5 RBC-19* \nPolys-PND Lymphs-PND Monos-PND\n___ 09:35AM CEREBROSPINAL FLUID (CSF) TNC-3 RBC-239* \nPolys-PND Lymphs-PND Monos-PND\n___ 09:35AM CEREBROSPINAL FLUID (CSF) TotProt-41 Glucose-51\n___ 09:35AM CEREBROSPINAL FLUID (CSF) CSF HOLD-PND\n\nPending Labs: Viral culture, fluid culture, Gram stain\n\nImaging: \n___ MR HEAD W & W/O CONTRAST\n1. No acute intracranial abnormality on contrast enhanced MRI \nbrain. No\nabnormal enhancement, parenchymal signal abnormality, acute \ninfarct or mass.\n2. The dural venous sinuses are patent.\n3. Mild paranasal sinus disease as described above.\n4. Degenerative changes of C5-C6 results in apparent moderate \nspinal canal\nnarrowing. If the patient is clinically symptomatic, this could \nbe further\nevaluated with MRI cervical spine.\n\n___ LUMBAR PUNCTURE (W/ FLUORO)\n1. Lumbar puncture at L3-4 without complication.\n2. Opening pressure of 26 mm Hg.\n\n', 'Physical Exam:|Physical': '\nPhysical Exam on Admission: \n\nVitals: T: 97.6 HR: 94 BP: 146/88 RR: 18 SaO2: 100% on RA\nGeneral: NAD, friendly, smiling and joking with her mother at\nbedside. She is obese\nHEENT: NCAT, no oropharyngeal lesions, neck supple\n___: RRR, no M/R/G\nPulmonary: CTAB, no crackles or wheezes\nAbdomen: Soft, NT, ND, +BS, no guarding\nExtremities: Warm, no edema\n\nNeurologic Examination:\n- Mental status: Awake, alert, oriented x 3. Able to relate\nhistory without difficulty. Attentive, able to name ___ backward\nwithout difficulty. Speech is fluent with full sentences, intact\nrepetition, and intact verbal comprehension. Naming intact. No\nparaphasias. No dysarthria. Normal prosody. Able to register 3\nobjects and recall ___ at 5 minutes. No apraxia. No evidence of\nhemineglect. No left-right confusion. Able to follow both \nmidline\nand appendicular commands.\n\n- Cranial Nerves: PERRL 3->2 brisk. VF full to number counting.\nEOMI, no nystagmus. Funduscopic exam was difficult given \npatient\ndiscomfort. V1-V3 without deficits to light touch bilaterally.\nNo facial movement asymmetry. Hearing intact to finger rub\nbilaterally. Palate elevation symmetric. SCM/Trapezius strength\n___ bilaterally. Tongue midline.\n\n- Motor: Normal bulk and tone. No drift. No tremor or \nasterixis.\n [___]\nL 5 5 5 5 ___ 5 5 5 5 5\nR 5 5 5 5 ___ 5 5 5 5 5 \n\n- Reflexes: \n [Bic] [Tri] [___] [Quad] [Gastroc]\n L 2+ 2+ 2+ 2+ 1\n R 2+ 2+ 2+ 2+ 1 \n\nPlantar response flexor bilaterally \n\n- Sensory: No deficits to light touch, pin, or proprioception\nbilaterally. No extinction to DSS.\n\n- Coordination: No dysmetria with finger to nose testing\nbilaterally. Good speed and intact cadence with rapid \nalternating\nmovements.\n\n- Gait: Normal initiation. Narrow base. Normal stride length and\narm swing. Stable without sway. Negative Romberg.\n\nPhysical Exam at Discharge:\n\nVitals: T 97.7, BP 111/74, HR 78, RR 18, O2 Sat 100% RA\n\nGeneral: NAD, appears comfortable, cheerful and interactive. \nProne s/p LP. \nHEENT: NCAT. MMM. \n___: RRR, normal S1, S2. No murmurs, rubs, gallops. Cap refill < \n2 sec.\nPulmonary: No increased WOB on room air observed. \nAbdomen: Non-distended.\nExtremities: No edema.\n\nNeurologic Examination:\n- Mental status: Awake, alert, oriented x 3. Able to relate\nrecent events without difficulty. Attentive. Speech is fluent \nwith full\nsentences and intact verbal comprehension. No paraphasias. No\ndysarthria. Normal prosody. No evidence of\nhemineglect. No left-right confusion. Able to follow both \nmidline\nand appendicular commands.\n\n- Cranial Nerves: PERRL 3->2 brisk. EOMI, no nystagmus. V1-V3 \nwithout deficits to light touch bilaterally. No facial movement \nasymmetry.\nSCM/Trapezius strength ___ bilaterally.\n\n- Motor: Normal bulk and tone. No tremor.\n [___]\nL 5 5 5 5 ___ 5 5 5 5 5\nR 5 5 5 5 ___ 5 5 5 5 5 \n\n- Reflexes: \n [Bic] [Tri] [___] [Quad] [Gastroc]\n L 2+ 2+ 2+ 2+ 1\n R 2+ 2+ 2+ 2+ 1 \n\nPlantar response flexor bilaterally \n\n- Sensory: No deficits to light touch bilaterally. \n\n- Coordination: No ataxia\n\n- Gait: Normal initiation. Narrow base. Normal stride length and \narm swing. Stable without sway. \n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': "\n___ is a ___ woman with PCOS, obesity \nstatus post lap banding procedure, recent diagnosis of aseptic\nmeningitis in ___, who presents to referral from neurology\nclinic for workup and management of her ongoing headaches.\n\nMs. ___ reports that her headaches never significantly \nimproved\nsince the admission in late ___. At this time, she presented\nwith headaches and nausea as well as blurry vision, and had a\nbrain MRI with and without contrast with MPRAGE sequences which\ndid not reveal venous sinus thrombosis or significant\nintracranial pathology. LP was difficult given anatomy, and\nultimately required ___ guided tap. This revealed a total cell\ncount of 600, PO2 56, with a lymphocytic pleocytosis. Bacterial\nculture and Gram stain were negative. HSV, VZV were negative.\n\nAfter discharge, at best her headaches were rated ___ out of \n10.\nShe describes them as a persistent, throbbing headache that\ninitially was involving the front of her head, and migrating\ntowards the back as well as behind the ear. She does note that\nher headaches worsen with coughing or bending over. Straining \non\nthe bathroom does make her headaches worse. There is no\nsignificant diurnal variation to her headaches other than \nmaximal\nintensity usually during the midday, she frequently has \nheadaches\nwhen she wakes up, although they do not wake her up from sleep. \nShe denies any focal weakness or numbness with these headaches. \nShe has not had fevers. In addition, she has ongoing blurry\nvision in her eyes bilaterally, which has not changed in quality\nsince her admission back in ___. With her current headaches,\nthere is no significant photophobia or phonophobia. She denies\nrecent travel. Sleep has been an issue, she often only gets ___\nhours per night initially, currently up to ___ hours. She notes\nthat she has had difficulty falling asleep due to her \nheadaches.\nAdditionally, nausea has been a significant part of her\nheadaches, and she has had reduced oral intake of food recently,\nrelying mostly on soup for nourishment as she has been unable to\ntolerate solid foods without vomiting. She has not been \nsexually\nactive, but has not been taking her OCPs since the initiation of\nTopamax for her headaches.\n\nShe has been followed by Dr. ___ as an outpatient for\nmanagement of her headaches. Upon discharge, she was trialed on\nnortriptyline 10 mg which did not significantly improve her\nheadaches after ___ weeks, and was subsequently discontinued. \nShe underwent a CT to rule out low pressure causing her\nheadaches, which was unremarkable. She was also trialed on a\nsteroid burst taper in early ___ with no significant\nimprovement. She was then started on Topamax 25 mg twice daily\nfor consideration of possible migrainous headaches or IIH for \nthe\npast 3 weeks, which has not had significant effect on her\nheadaches. Of note, she was advised to see ophthalmology for\ndilated eye exam as well as visual fields given the slightly\nelevated opening pressure on ___ guided LP in ___ (opening\npressure was 23.7 cmH2O, with her in a prone position given the\ndifficulty of her tap. Of note, she noted mild improvement of\nher symptoms after the LP). She has not seen ophthalmology yet;\nno papilledema was seen on clinic visits. \n\nHer headaches have prevented her from fully going back to work\nand she continues to work part time.\n\nPast Medical History:\nPCOS\nobesity \nanxiety\nchronic headaches\n___ Malformation\nGERD\ndyslipidemia\nh/o B12 deficiency anemia\npsoriasis\nrecurrent otitis externa\nirritable bowel syndrome\npatellofemoral syndrome\n\nSocial History:\n___\nFamily History:\nMom and mom's sister with breast cancer.\nMom with diabetes. \nMom with MI in age ___.\nMom with migraines.\n\n", 'Chief Complaint:|Complaint:': '\nHeadache\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nSulfa (Sulfonamide Antibiotics) / Codeine / Valium / Penicillins \n/ Milk / Benadryl / NSAIDS (Non-Steroidal Anti-Inflammatory \nDrug)\n\n'}, '12253379-DS-6', 6, 'neurology']]

[["EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD\n\nINDICATION: ___ year old woman with persistent headaches// rule out venous\nsinus thrombosis. please add MPRAGE sequences to look for clot\n\nTECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After\nadministration of 10 mL of Gadavist intravenous contrast, axial imaging was\nperformed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal\nMPRAGE imaging was performed and re-formatted in axial and coronal\norientations.\n\nCOMPARISON: CT head without contrast of ___, MRI head with without\ncontrast of ___.\n\nFINDINGS: \n\nThere is no intra or extra-axial mass, acute infarct or intracranial\nhemorrhage. The sulci, ventricles and cisterns are within expected limits for\nthe patient's age. There is no abnormal postcontrast enhancement or\nparenchymal FLAIR signal abnormality. The pituitary is small but unchanged\nfrom examination of ___ and within the range of normal.. The major\nintracranial flow voids are preserved. The dural venous sinuses are patent. \nOpacification of a left concha bullosa is noted. There is mild mucosal\nthickening of the ethmoid air cells. The orbits are unremarkable. The\nmastoid air cells are essentially clear.\n\nNot completely within the field of view is degenerative spondylosis of the\nC5-C6 cervical level, resulting in what appears to be at least moderate spinal\ncanal narrowing. Clinical correlation is recommended.\n\nIMPRESSION:\n\n\n1. No acute intracranial abnormality on contrast enhanced MRI brain. No\nabnormal enhancement, parenchymal signal abnormality, acute infarct or mass.\n2. The dural venous sinuses are patent.\n3. Mild paranasal sinus disease as described above.\n4. Degenerative changes of C5-C6 results in apparent moderate spinal canal\nnarrowing. If the patient is clinically symptomatic, this could be further\nevaluated with MRI cervical spine.\n", '12253379-RR-75', 75, 'sagittal and axial t1 weighted imaging were performed. after\nadministration of 10 ml of gadavist intravenous contrast, axial imaging was\nperformed with gradient echo, flair, diffusion, and t1 technique. sagittal\nmprage imaging was performed and re-formatted in axial and coronal\norientations.'], ["EXAMINATION: LUMBAR PUNCTURE (W/ FLUORO) N8 RF SPINE\n\nINDICATION: ___ year old woman with intractable headache and recent aseptic\nmeningitis, no venous pulsations on visual field exam // ?IIH vs meningitis,\nPLEASE PERFORM IN LATERAL DECUBITUS POSITION FOR ACCURATE OPENING PRESSURE.\n\nTECHNIQUE: After informed consent was obtained from the patient explaining \nthe risks, benefits, and alternatives to the procedure, the patient was laid \nin prone position on the fluoroscopic table. A pre-procedure time-out was\nperformed confirming the patient's identity, relevant history, procedure to be\nperformed and labs.\n\nPuncture was performed at L3-4.\n\nApproximately 5 cc of 1% lidocaine was administered for local anesthesia.\nUnder fluoroscopic guidance, a 20 gauge spinal needle was inserted into the\nthecal sac. There was good return of clear CSF. Opening pressure was measured\nat 26 mm Hg. 9 mls of CSF were collected in 4 tubes and dropped off at the\ncytology lab for requested analysis.\n\nCOMPARISON: Lumbar puncture under fluoroscopy dated ___, MR ___ ___.\n\nFINDINGS: \n\nOpening pressure of 26 mm Hg. 9 mls of CSF were collected in 4 tubes.\n\nIMPRESSION:\n\n\n1. Lumbar puncture at L3-4 without complication.\n2. Opening pressure of 26 mm Hg.\nI, Dr. ___ supervised the trainee during the key components of\nthe above procedure and I reviewed and agree with the trainee's findings and\ndictation.\n", '12253379-RR-77', 77, "after informed consent was obtained from the patient explaining \nthe risks, benefits, and alternatives to the procedure, the patient was laid \nin prone position on the fluoroscopic table. a pre-procedure time-out was\nperformed confirming the patient's identity, relevant history, procedure to be\nperformed and labs."]]

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[['009U3ZX', 10, 1, Timestamp('2144-08-22 00:00:00'), 'Drainage of Spinal Canal, Percutaneous Approach, Diagnostic']]

['neurology']

[[50868, Timestamp('2144-08-21 05:35:00'), Timestamp('2144-08-21 06:50:00'), 'Anion Gap'], [50882, Timestamp('2144-08-21 05:35:00'), Timestamp('2144-08-21 06:50:00'), 'Bicarbonate'], [50893, Timestamp('2144-08-21 05:35:00'), Timestamp('2144-08-21 06:50:00'), 'Calcium, Total'], [50902, Timestamp('2144-08-21 05:35:00'), Timestamp('2144-08-21 06:50:00'), 'Chloride'], [50912, Timestamp('2144-08-21 05:35:00'), Timestamp('2144-08-21 06:50:00'), 'Creatinine'], [50931, Timestamp('2144-08-21 05:35:00'), Timestamp('2144-08-21 06:50:00'), 'Glucose'], [50934, Timestamp('2144-08-21 05:35:00'), Timestamp('2144-08-21 06:50:00'), 'H'], [50947, Timestamp('2144-08-21 05:35:00'), Timestamp('2144-08-21 06:50:00'), 'I'], [50960, Timestamp('2144-08-21 05:35:00'), Timestamp('2144-08-21 06:50:00'), 'Magnesium'], [50970, Timestamp('2144-08-21 05:35:00'), Timestamp('2144-08-21 06:50:00'), 'Phosphate'], [50971, Timestamp('2144-08-21 05:35:00'), Timestamp('2144-08-21 06:50:00'), 'Potassium'], [50983, Timestamp('2144-08-21 05:35:00'), Timestamp('2144-08-21 06:50:00'), 'Sodium'], [51006, Timestamp('2144-08-21 05:35:00'), Timestamp('2144-08-21 06:50:00'), 'Urea Nitrogen'], [51678, Timestamp('2144-08-21 05:35:00'), Timestamp('2144-08-21 06:50:00'), 'L'], [51221, Timestamp('2144-08-21 05:35:00'), Timestamp('2144-08-21 06:29:00'), 'Hematocrit'], [51222, Timestamp('2144-08-21 05:35:00'), Timestamp('2144-08-21 06:29:00'), 'Hemoglobin'], [51248, Timestamp('2144-08-21 05:35:00'), Timestamp('2144-08-21 06:29:00'), 'MCH'], [51249, Timestamp('2144-08-21 05:35:00'), Timestamp('2144-08-21 06:29:00'), 'MCHC'], [51250, Timestamp('2144-08-21 05:35:00'), Timestamp('2144-08-21 06:29:00'), 'MCV'], [51265, Timestamp('2144-08-21 05:35:00'), Timestamp('2144-08-21 06:29:00'), 'Platelet Count'], [51277, Timestamp('2144-08-21 05:35:00'), Timestamp('2144-08-21 06:29:00'), 'RDW'], [51279, Timestamp('2144-08-21 05:35:00'), Timestamp('2144-08-21 06:29:00'), 'Red Blood Cells'], [51301, Timestamp('2144-08-21 05:35:00'), Timestamp('2144-08-21 06:29:00'), 'White Blood Cells'], [52172, Timestamp('2144-08-21 05:35:00'), Timestamp('2144-08-21 06:29:00'), 'RDW-SD']]

Question: A 28 F is admitted. He/she says he/she has Headache . History of illness: ___ is a ___ woman with PCOS, obesity status post lap banding procedure, recent diagnosis of aseptic meningitis in ___, who presents to referral from neurology clinic for workup and management of her ongoing headaches. Ms. ___ reports that her headaches never significantly improved since the admission in late ___. At this time, she presented with headaches and nausea as well as blurry vision, and had a brain MRI with and without contrast with MPRAGE sequences which did not reveal venous sinus thrombosis or significant intracranial pathology. LP was difficult given anatomy, and ultimately required ___ guided tap. This revealed a total cell count of 600, PO2 56, with a lymphocytic pleocytosis. Bacterial culture and Gram stain were negative. HSV, VZV were negative. After discharge, at best her headaches were rated ___ out of 10. She describes them as a persistent, throbbing headache that initially was involving the front of her head, and migrating towards the back as well as behind the ear. She does note that her headaches worsen with coughing or bending over. Straining on the bathroom does make her headaches worse. There is no significant diurnal variation to her headaches other than maximal intensity usually during the midday, she frequently has headaches when she wakes up, although they do not wake her up from sleep. She denies any focal weakness or numbness with these headaches. She has not had fevers. In addition, she has ongoing blurry vision in her eyes bilaterally, which has not changed in quality since her admission back in ___. With her current headaches, there is no significant photophobia or phonophobia. She denies recent travel. Sleep has been an issue, she often only gets ___ hours per night initially, currently up to ___ hours. She notes that she has had difficulty falling asleep due to her headaches. Additionally, nausea has been a significant part of her headaches, and she has had reduced oral intake of food recently, relying mostly on soup for nourishment as she has been unable to tolerate solid foods without vomiting. She has not been sexually active, but has not been taking her OCPs since the initiation of Topamax for her headaches. She has been followed by Dr. ___ as an outpatient for management of her headaches. Upon discharge, she was trialed on nortriptyline 10 mg which did not significantly improve her headaches after ___ weeks, and was subsequently discontinued. She underwent a CT to rule out low pressure causing her headaches, which was unremarkable. She was also trialed on a steroid burst taper in early ___ with no significant improvement. She was then started on Topamax 25 mg twice daily for consideration of possible migrainous headaches or IIH for the past 3 weeks, which has not had significant effect on her headaches. Of note, she was advised to see ophthalmology for dilated eye exam as well as visual fields given the slightly elevated opening pressure on ___ guided LP in ___ (opening pressure was 23.7 cmH2O, with her in a prone position given the difficulty of her tap. Of note, she noted mild improvement of her symptoms after the LP). She has not seen ophthalmology yet; no papilledema was seen on clinic visits. Her headaches have prevented her from fully going back to work and she continues to work part time. Past Medical History: PCOS obesity anxiety chronic headaches ___ Malformation GERD dyslipidemia h/o B12 deficiency anemia psoriasis recurrent otitis externa irritable bowel syndrome patellofemoral syndrome Social History: ___ Family History: Mom and mom's sister with breast cancer. Mom with diabetes. Mom with MI in age ___. Mom with migraines. Allergies: Sulfa (Sulfonamide Antibiotics) / Codeine / Valium / Penicillins / Milk / Benadryl / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Ondansetron Ketorolac Heparin Acetaminophen Acetaminophen Sodium Chloride 0.9% Flush Ondansetron Prochlorperazine Influenza Vaccine Quadrivalent Sodium Chloride 0.9% Topiramate (Topamax) Target Lab Orders: Anion Gap Bicarbonate Calcium, Total Chloride Creatinine Glucose H I Magnesium Phosphate Potassium Sodium Urea Nitrogen L Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells RDW-SD Target Procedures: Drainage of Spinal Canal, Percutaneous Approach, Diagnostic DOCTOR'S NOTE Hospital Notes: : Ms. ___ was admitted to the hospital due to persistent headaches that did not respond to outpatient management with nortriptyline, steroid burst, or topamax. MRI of the brain and MRV was obtained and did not show any acute abnormalities. We increased the dose of topamax to 50mg twice daily. The headaches were treated with migraine cocktail consisting of ketolorac, tylenol, IV fluids, as well as zofran. Patient reported mild improvement of symptoms. We also repeated LP to evaluate these ongoing headache, especially given recent history of aseptic meningitis. Opening pressure was 26. The labs from ___ were sent and we will follow-up on the results. Patient reported improvement of headache immediately following the LP. Transitional issues: - dose of topamax increased to 50mg BID - CSF studies are pending - Needs f/u with Neurology in ___ weeks Patient seen and discussed with ___ Team, under supervision of Dr. ___. ___, MD ___ Neurology Other Results: Admission: ___ 11:00AM BLOOD WBC-10.7* RBC-4.88 Hgb-14.1 Hct-44.0 MCV-90 MCH-28.9 MCHC-32.0 RDW-12.7 RDWSD-41.6 Plt ___ ___ 11:00AM BLOOD Neuts-63.6 ___ Monos-7.4 Eos-1.0 Baso-0.7 Im ___ AbsNeut-6.81* AbsLymp-2.86 AbsMono-0.79 AbsEos-0.11 AbsBaso-0.07 ___ 11:00AM BLOOD ___ PTT-31.6 ___ ___ 11:00AM BLOOD Glucose-80 UreaN-16 Creat-0.7 Na-140 K-4.5 Cl-100 HCO3-24 AnGap-16 ___ 11:00AM BLOOD ALT-12 AST-15 AlkPhos-82 TotBili-0.4 ___ 11:00AM BLOOD Albumin-4.5 ___ 11:20AM URINE Color-Yellow Appear-Hazy* Sp ___ ___ 11:20AM URINE Blood-NEG Nitrite-NEG Protein-TR* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 11:20AM URINE RBC-1 WBC-2 Bacteri-FEW* Yeast-NONE Epi-3 ___ 11:20AM URINE Mucous-RARE* ___ 11:20AM URINE Hours-RANDOM ___ 11:20AM URINE UCG-NEG ___ 11:20AM URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. Discharge: ___ 05:35AM BLOOD WBC-10.4* RBC-4.29 Hgb-12.4 Hct-37.7 MCV-88 MCH-28.9 MCHC-32.9 RDW-12.6 RDWSD-40.1 Plt ___ ___ 03:00PM BLOOD ___ PTT-31.2 ___ ___ 05:35AM BLOOD Glucose-77 UreaN-14 Creat-0.8 Na-142 K-4.3 Cl-105 HCO3-25 AnGap-12 ___ 05:35AM BLOOD Calcium-9.6 Phos-4.3 Mg-2.0 ___ 09:35AM CEREBROSPINAL FLUID (CSF) TNC-5 RBC-19* Polys-PND Lymphs-PND Monos-PND ___ 09:35AM CEREBROSPINAL FLUID (CSF) TNC-3 RBC-239* Polys-PND Lymphs-PND Monos-PND ___ 09:35AM CEREBROSPINAL FLUID (CSF) TotProt-41 Glucose-51 ___ 09:35AM CEREBROSPINAL FLUID (CSF) CSF HOLD-PND Pending Labs: Viral culture, fluid culture, Gram stain Imaging: ___ MR HEAD W & W/O CONTRAST 1. No acute intracranial abnormality on contrast enhanced MRI brain. No abnormal enhancement, parenchymal signal abnormality, acute infarct or mass. 2. The dural venous sinuses are patent. 3. Mild paranasal sinus disease as described above. 4. Degenerative changes of C5-C6 results in apparent moderate spinal canal narrowing. If the patient is clinically symptomatic, this could be further evaluated with MRI cervical spine. ___ LUMBAR PUNCTURE (W/ FLUORO) 1. Lumbar puncture at L3-4 without complication. 2. Opening pressure of 26 mm Hg.

2153-08-04 09:15:00

ENGLISH

MARRIED

WHITE

F

[[27642908, Timestamp('2153-08-04 02:30:49'), '', 'ORTHO']]

[[{'Medications on Admission': ':\nLisinopril\n\n4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) \nML PO Q6H (every 6 hours) as needed. ', 'Brief Hospital Course': ':\nMs ___ was admitted to the service of Dr. ___ for a \ncircumfrential lumbar fusion. She was informed and consented \nand elected to proceed. Please see Operative Note for procedure \nin detail. \nPost-operatively she was given antibiotics and pain medication. \nHer hematocrit was noticed to be low and she was transfused \nPRBCs. A hemovac drain was placed intra-operatively and this \nwas removed POD 2. Her bladder catheter was removed POD 3 and \nher diet was advanced without difficulty. She was able to work \nwith physical therapy for strength and balance. She was \ndischarged in good condition and will follow up in the \nOrthopaedic Spine clinic.\n\n', 'Pertinent Results:': '\n___ 04:50AM BLOOD Hct-27.4*\n___ 05:35AM BLOOD Hct-24.4*\n___ 05:06AM BLOOD WBC-6.9 RBC-3.24* Hgb-10.4* Hct-30.3* \nMCV-93 MCH-32.2* MCHC-34.5 RDW-13.0 Plt ___\n\n', 'Physical Exam:|Physical': '\nA&O X 3; NAD\nRRR\nCTA B\nAbd soft NT/ND\nBUE- good strength at deltoid, biceps, triceps, wrist \nflexion/extension, finger flexion/extension and intrinics; \nsensation intact C5-T1 dermatomes; - ___, reflexes \nsymmetric at biceps, triceps and brachioradialis\nBLE- good strength at hip flexion/extension, knee \nflexion/extension, ankle dorsiflexion and plantar flexion, \n___ sensation intact L1-S1 dermatomes; - clonus, reflexes \ndiminished at quads and Achilles\n\n', 'History of Present Illness:|Past Medical History:|Social History:|Family History:': '\nMs. ___ has a long history of back and leg pain. She has \nattempted conservative therapy including physical therapy and \nhas failed. She now presents for surgical intervention.\n\nPast Medical History:\nHTN, left leg pain/numbness, L5-S1 spondylolisthesis \nspondylolysis \n\nSocial History:\n___\nFamily History:\nN/C\n\n', 'Chief Complaint:|Complaint:': '\nBack and leg pain\n\n', 'Attending:': ' ___.\n\n', 'Allergies:': ' \nPatient recorded as having No Known Allergies to Drugs\n\n'}, '16313269-DS-5', 5, 'orthopaedics']]

[['\nSTUDY: Lumbar spine ___.\n\nHISTORY: Patient with lumbar fusion.\n\nFINDINGS: Three lateral views of the lateral lumbar spine from the operating\nroom demonstrates interval placement of metallic disc prosthesis at the two\nlowest lumbar disc levels. There are no signs for hardware-related\ncomplications. Please refer to the operative note for additional details.\n\n\n\n\n', '16313269-RR-18', 18, ''], ['HISTORY: Laminectomy and fusion.\n\nFINDINGS: Multiple views from the operating suite show placement of a\nposterior fusion at L4-S1 with interbody spacers in place. Further\ninformation can be gathered from the operative report.\n', '16313269-RR-19', 19, '']]

[[27642908, Timestamp('2153-08-04 10:00:00'), Timestamp('2153-08-10 17:00:00'), 'MAIN', 'Bisacodyl', '002947', '00182853489', '5 mg Tab'], [27642908, Timestamp('2153-08-04 10:00:00'), Timestamp('2153-08-10 17:00:00'), 'MAIN', 'Lisinopril', '000393', '00172375810', '5mg Tablet'], [27642908, Timestamp('2153-08-04 22:00:00'), Timestamp('2153-08-10 17:00:00'), 'MAIN', 'Sodium Chloride 0.9% Flush', '', '0', 'Syringe'], [27642908, Timestamp('2153-08-04 10:00:00'), Timestamp('2153-08-10 17:00:00'), 'MAIN', 'Bisacodyl', '002944', '00574705050', '10mg Suppository'], [27642908, Timestamp('2153-08-04 22:00:00'), Timestamp('2153-08-05 21:00:00'), 'BASE', 'Iso-Osmotic Dextrose', '', '0', '50ml Bag'], [27642908, Timestamp('2153-08-04 22:00:00'), Timestamp('2153-08-05 21:00:00'), 'MAIN', 'CefazoLIN', '051880', '00264310311', '1g Froz.Bag'], [27642908, Timestamp('2153-08-04 22:00:00'), Timestamp('2153-08-10 17:00:00'), 'MAIN', 'Acetaminophen', '004489', '00182844789', '325mg Tablet'], [27642908, Timestamp('2153-08-04 22:00:00'), Timestamp('2153-08-08 10:00:00'), 'MAIN', 'HYDROmorphone (Dilaudid)', '004101', '00074233411', '12.5mg/50mL Syringe'], [27642908, Timestamp('2153-08-04 22:00:00'), Timestamp('2153-08-10 17:00:00'), 'MAIN', 'Influenza Virus Vaccine', '064182', '58160087546', '0.5mL Syringe'], [27642908, Timestamp('2153-08-04 22:00:00'), Timestamp('2153-08-10 17:00:00'), 'BASE', 'Potassium Chl 20 mEq / 1000 mL D5 1/2 NS', '002003', '00338067104', '1000 mL Bag']]

[]

['orthopaedics']

[[51221, Timestamp('2153-08-05 05:06:00'), Timestamp('2153-08-05 07:36:00'), 'Hematocrit'], [51222, Timestamp('2153-08-05 05:06:00'), Timestamp('2153-08-05 07:36:00'), 'Hemoglobin'], [51248, Timestamp('2153-08-05 05:06:00'), Timestamp('2153-08-05 07:36:00'), 'MCH'], [51249, Timestamp('2153-08-05 05:06:00'), Timestamp('2153-08-05 07:36:00'), 'MCHC'], [51250, Timestamp('2153-08-05 05:06:00'), Timestamp('2153-08-05 07:36:00'), 'MCV'], [51265, Timestamp('2153-08-05 05:06:00'), Timestamp('2153-08-05 07:36:00'), 'Platelet Count'], [51277, Timestamp('2153-08-05 05:06:00'), Timestamp('2153-08-05 07:36:00'), 'RDW'], [51279, Timestamp('2153-08-05 05:06:00'), Timestamp('2153-08-05 07:36:00'), 'Red Blood Cells'], [51301, Timestamp('2153-08-05 05:06:00'), Timestamp('2153-08-05 07:36:00'), 'White Blood Cells']]

Question: A 51 F is admitted. He/she says he/she has Back and leg pain . History of illness: Ms. ___ has a long history of back and leg pain. She has attempted conservative therapy including physical therapy and has failed. She now presents for surgical intervention. Past Medical History: HTN, left leg pain/numbness, L5-S1 spondylolisthesis spondylolysis Social History: ___ Family History: N/C Allergies: Patient recorded as having No Known Allergies to Drugs What is the best procedure plan for this patient?

TARGETS Target Prescriptions: Bisacodyl Lisinopril Sodium Chloride 0.9% Flush Bisacodyl Iso-Osmotic Dextrose CefazoLIN Acetaminophen HYDROmorphone (Dilaudid) Influenza Virus Vaccine Potassium Chl 20 mEq / 1000 mL D5 1/2 NS Target Lab Orders: Hematocrit Hemoglobin MCH MCHC MCV Platelet Count RDW Red Blood Cells White Blood Cells Target Procedures: NONE DOCTOR'S NOTE Hospital Notes: : Ms ___ was admitted to the service of Dr. ___ for a circumfrential lumbar fusion. She was informed and consented and elected to proceed. Please see Operative Note for procedure in detail. Post-operatively she was given antibiotics and pain medication. Her hematocrit was noticed to be low and she was transfused PRBCs. A hemovac drain was placed intra-operatively and this was removed POD 2. Her bladder catheter was removed POD 3 and her diet was advanced without difficulty. She was able to work with physical therapy for strength and balance. She was discharged in good condition and will follow up in the Orthopaedic Spine clinic. Other Results: ___ 04:50AM BLOOD Hct-27.4* ___ 05:35AM BLOOD Hct-24.4* ___ 05:06AM BLOOD WBC-6.9 RBC-3.24* Hgb-10.4* Hct-30.3* MCV-93 MCH-32.2* MCHC-34.5 RDW-13.0 Plt ___