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[ { "content": "The patient is an 82 year-old right handed gentleman who has a past medical history of hypertension and tobacco use presented to the emergency room with", "role": "user" }, { "content": " acute change in mental status . He was well until the evening prior to presentation to the emergency room when he complained of headache across the forehead . On the day of presentation he was then found by his daughter lying on his bed groaning being relatively unresponsive and unable to speak . The family reported one episode of vomiting at home . <NOTE_END>", "role": "assistant" } ]
[ { "content": "Aspirin 325 mg po q day . Vasotec 7.5 mg po q day . Humalog insulin sliding scale with meals and at bedtime . Humulin Walters insulin 24 units subcutaneous q A.M. and 8 to 16 in the evening depending upon where his blood sugar has been . Preoperative laboratory values were unremarkable . The patient underwent cardiac catheterization on 2011-10-17 which revealed a 20 left vein osteal lesion as well as 70 LAD lesion and an 80 right coronary . The patient was taken to the operating room on 2011-10-18 where he underwent an aortic valve replacement with 23 mm pericardial valve as well as coronary artery bypass graft times two with a LIMA to the LAD and saphenous vein to the acute marginal . Postoperatively the patient was transported to the cardiac surgery recovery unit on Milrinone Neo-Synephrine and Levophed drip . The patient was weaned from mechanical ventilation and subsequently extubated on the night of surgery . He remained on Levophed Milrinone and Neo-Synephrine drips and was hemodynamically stable . N. Saez clinic consult was obtained due to hyperglycemia and the need for insulin drip in the Intensive Care Unit . On postoperative day the", "role": "user" }, { "content": " Milrinone was weaned down . The Levophed had been discontinued as the Neo-Synephrine and the patient was beginning to progress hemodynamically . Upon discontinuation of the Milrinone the patient s SV02 had dropped significantly in the low 50 s. The patient had decreased exercise tolerance and therefore was placed back on his milrinone to keep his cardiac index greater than 2.0 . Over the next couple of days it was very slowly decreased as his Ace inhibitors were increased orally . The patient ultimately was weaned off the Milrinone transitioned to Captopril on postoperative day five and remained hemodynamically stable . Once the patient had remained off of inotropics for approximately 24 hours he had been given diuretics and Ace inhibitors and remained hemodynamically stable he was transferred from the Intensive Care Unit to the Telemetry floor on postoperative day six . A physical therapy evaluation was obtained for assistance and mobility . Cardiac rehabilitation was initiated at that time . On 2011-10-24 postoperative day six consultation heart failure cardiology service was obtained . It was their recommendation to continue Ace inhibitors to continue daily weights to switch the patient to a long acting beta-blocker and to enroll the patient in postoperative cardiac rehabilitation as well as to make sure the patient was on statin drugs . These measures were all instituted . The patient continued to progress from cardiac rehabilitation and physical therapy standpoint while on the floor . The patient remained hemodynamically stable over the next few days continued to increase with physical therapy and ambulation . His blood sugars were followed by the Cape Cod Hospital Clinic service and insulin has been adjusted accordingly . Today 2011-10-31 postoperative day 13 the patient remains stable and ready for discharge to home . The patient s condition today is as follows Temperature 96.9 F pulse 84 respiratory rate 18 blood pressure 106 59 . Most recent laboratory values are from 2011-10-25 which revealed a white blood cell count 8.4000 hematocrit 35 platelet count 202 000. Sodium 133 potassium 4.4 chloride 93 CO2 30 BUN 24 creatinine 0.7 glucose 198 . The patient s finger stick blood glucose levels range from 151 to 390 over the past 24 hours and his insulin scale has been adjusted upward to compensate for that . Neurologically the patient is grossly intact . Pulmonary exam he is clear upper lobes diminished bilateral bases left greater than right . Coronary exam is regular rate and rhythm . His abdomen is benign . His sternum is stable. His incision is clean and dry Steri Strips intact . His extremities are warm and well perfused with minimal edema of his left foot as well as his right stump . He is able to apply his prosthesis and ambulate as well . <NOTE_END>", "role": "assistant" } ]
[ { "content": "bilirubin to", "role": "user" }, { "content": " be .6 . SGOT of 80 . <NOTE_END>", "role": "assistant" } ]
[ { "content": "GENERAL She is a well-developed well-nourished female . She is 5 foot 4 inches and 159 pounds . BREASTS No masses . LUNGS Clear to auscultation . HEART Regular rate and rhythm . ABDOMEN Soft mildly obese with Pfannenstiel scar visualized . PELVIC", "role": "user" }, { "content": " Normal introitus normal appearing cervix a small mobile uterus . No additional masses or nodules appreciated on exam . <NOTE_END>", "role": "assistant" } ]
[ { "content": "On admission included Percocet Prinovil Dapsone", "role": "user" }, { "content": " Mycelex troches . <NOTE_END>", "role": "assistant" } ]
[ { "content": "All systems", "role": "user" }, { "content": " were reviewed and were negative except as given above . MEDICATIONS Metformin Zocor and analgesics . ALLERGIES None . <NOTE_END>", "role": "assistant" } ]
[ { "content": "Stable TO DO PLAN No dictated summary ENTERED BY STENVERS IMARL M.D. AW45 01", "role": "user" }, { "content": " 07 04 <NOTE_END>", "role": "assistant" } ]
[ { "content": "Coumadin 5 mg po alternating with 2.5 mg po prednisolone 30 mg po bid hydrochlorothiazide 50 mg po bid potassium chloride 40 mEq po bid Augmentin 500 mg po tid Digoxin 0.125 mg po qd Tylenol 650 mg po q4h prn Carafate 1 gram", "role": "user" }, { "content": " po bid Synthroid 0.125 mg po qd . DISPOSITION The patient was discharged home with Terchestlumnesamp Medical Center referral for weekly blood tests potassium and PT . The patient is also to keep her left arm elevated and to remain on a low sodium diet . She will be maintained on a PT between 15 and 17 with Coumadin . Arrangements will be made for radiation therapy to the right neck and right iliac crest . The prognosis for rehabilitation potential is guarded . LENNI BRAIN M.D. DICTATING FOR ERTCA TRIAL M.D. TR ak bmot DD 05 15 93 TD 05 15 93 CC <NOTE_END>", "role": "assistant" } ]
[ { "content": "A cachectic white female . T 100.1 P 104 blood pressure 130 90 heart rate of 16 she was sating 95 on room air . HEENT Pupils were miotic measuring 2 mm but responsive to light . Neck Tender on the leftside with no lymphadenopathy or thyromegaly . Lungs were clear . Chest actually had a 5 x 7 cm necrotic area on the left chest wall with some pus . Cardiovascular Normal . Abdomen Normal . There was no HSM . Extremities Her left arm was very swollen . It was tested with no voluntary movement except at the finger tips . There was no edema elsewhere in", "role": "user" }, { "content": " her extremities only the left arm . Neuro The patient was oriented to place but had difficulty with recent memory . She also had mild weakness in the left extremities both upper and lower . Cranial nerves II XII were grossly intact . Toes were downgoing . <NOTE_END>", "role": "assistant" } ]
[ { "content": "Review of systems was significant for menopausal symptoms for which she has attempted hormone replacement therapy discontinued in 2014 . She also reports difficulty sleeping daytime sleepiness . She sleeps on elevated pillows", "role": "user" }, { "content": " secondary to her gastroesophageal reflux disease . Occasional paroxysmal nocturnal dyspnea in the past but none recently . Occasional lower extremity edema left greater than right . No abdominal or urinary complaints . <NOTE_END>", "role": "assistant" } ]
[ { "content": "Hydralazine 10 mgs PO t.i.d. Digoxin 0.125 mgs PO q.d. thiamine 100 mgs PO q.d. multi-vitamin 1 tab. PO q.d. Peri Colace 100", "role": "user" }, { "content": " mgs PO t.i.d. folate 1 mg PO q.d. Norvasc 2.5 mgs PO q. HS Ritalin 10 mgs PO b.i.d. Trazodone 25 mgs PO q. HS Nafcillin 2 gramsIV q.4H which wil conclude at the end of the day on 1 16 98 Atroventnebulizer PRN Albuterol nebulizer PRN Tylenol 650 mgs PO q.4H PRN pain . <NOTE_END>", "role": "assistant" } ]
[ { "content": "Continue ad lib feeding . Follow up with pediatrician at SCCHC on Tuesday 2018-05-15 . Medications Not applicable . Car seat positioning screen Not applicable .', 'State newborn screens were sent on 2018-05-09 and results are pending . On his previous admission', 'Terrance received hepatitis B vaccine on 2018-05-09 .", "role": "user" }, { "content": " 6. Immunization recommended Influenza immunization is recommended annually in the Fall for all infants once they reach 6 months of age .', 'Before this age and for the first 24 months of the child s life immunization against influenza is recommended for household contacts and out of home caregivers . <NOTE_END>", "role": "assistant" } ]
[ { "content": "Coumadin 5 mg PO q.day Digoxin 0.25 mg PO q.day Metoprolol 25 mg PO b.i.d Baby aspirin 80 mg PO q.day . The patient will be followed by the Anticoagulation Clinic for prothrombin time level evaluations and appropriate Coumadin doses . IDENTIFYING DATA The patient is a 66 year old Portuguese speaking gentleman with a history of hypertension diabetes mellitus increasing cholesterol and history of tobacco use who is status post myocardial infarction in September of 1993 and February of 1993 who presented with new onset of left chest pain and arm pain for two days . Apparently patient was in his usual state of health until two days prior to admission when he noted new onset of chest pain and arm pain confined to his left side . The chest pain was considered mild but persistent with episodes lasting twenty minutes . He came to the emergency room with chest pain on July 22 1994 relieved with sublingual nitroglycerin . No history of nausea and vomiting or shortness of breath . Denies fevers pleuritic chest pain or cough . The electrocardiogram showed pseudonormalization of T waves in V1 through V6 and Q waves in V1 through V3 . The patient &aposs past cardiac history is significant for an anterior myocardial infarction in September of 1993 and a non-Q wave myocardial infarction in February of 1993 . The patient in September of 1993 had 3-4 millimeter ST segment elevation in V1 through V4 and depression in II III and AVF . At the time patient had bright red blood per rectum as well and patient had cardiac catheterization at the time which showed 95 left anterior descending which was percutaneous transluminal coronary angioplastied and had intra-aortic balloon pump placement . He had a CPK of over 5000 with MB fraction of 26.7 . The echocardiogram showed a 44 ejection fraction with anterior akinesis and septal hypokinesis . He had a positive exercise tolerance test with Thallium and repeat cardiac catheterization showed", "role": "user" }, { "content": " left anterior descending being patent and distal posterior descending artery lesion with circumflex lesion after the obtuse marginal 1 . In February of 1993 patient again presented with chest pain shortness of breath ruled in for a non-Q wave myocardial infarction with CPK peak of 219 and MB of 20.9 . Repeat cardiac catheterization showed re-stenosis of proximal left anterior descending that had been percutaneous transluminal coronary angioplastied and a lesion in the first obtuse marginal and a moderate to severe left circumflex lesion after the third obtuse marginal . He also had an akinetic anterolateral and apical ventricle . CARDIAC RISK FACTORS Again patient &aposs cardiac risk factors include hypertension diabetes mellitus increasing cholesterol and a positive family history and tobacco use . In the past patient had been noted to be non-compliant with cardiac medications and continues to smoke . <NOTE_END>", "role": "assistant" } ]
[ { "content": "The patient is a 65 year old female with post thoracotomy syndrome that occurred on the site of her thoracotomy incision . She had a thoracic aortic aneurysm repaired in the past and subsequently developed neuropathic pain at the incision site . She is currently on Vicodin one to two tablets every four hours p.r.n", "role": "user" }, { "content": " Fentanyl patch 25 mcg an hour change of patch every 72 hours Elavil 50 mgq .h.s Neurontin 600 mg p.o. t.i.d. with still what she reports as stabbing left-sided chest pain that can be as severe as a 7 10. She has failed conservative therapy and is admitted for a spinal cord stimulator trial . <NOTE_END>", "role": "assistant" } ]
[ { "content": "ON ADMISSION General The patient was in no acute distress well developed . Vital signs Stable afebrile . HEENT Normocephalic atraumatic . PERRL anicteric EOMI . The throat was clear . Neck Supple midline without masses or lymphadenopathy . No bruit or JVD . Cardiovascular Irregularly irregular without murmurs rubs or gallops . Chest Clear to auscultation bilaterally . Abdomen Soft nontender nondistended without masses or organomegaly . Extremities Warm noncyanotic nonedematous times four . Neurological Grossly intact . ADMISSION LABORATORY DATA CBC 11.3 15.7 44.6 183 . PT 14 INR 1.3 PTT 115 . Chemistries 137 4.3 104 22 14 0.7 155 . ALT 27 AST 21 alkaline phosphatase", "role": "user" }, { "content": " 72 total bilirubin 1.2 amylase 47 . The U A was negative . <NOTE_END>", "role": "assistant" } ]
[ { "content": "Neurontin . Propanolol . Tylenol 3 . Butalbital . Morphine . Protonix . Doxepin . Dilaudid . Inderal . Skelaxin . Zantac . Flexeril . MS Contin . PHYSICAL EXAM Temperature 96.8 heart rate 81 blood pressure 92 47 and saturating 100 on 40 FIO2 . General Patient is intubated and sedated . HEENT Pupils are equal round and reactive to light . Cardiovascular Regular rate and rhythm no murmurs . Pulmonary is clear to auscultation bilaterally . Abdomen is soft nontender", "role": "user" }, { "content": " and nondistended . Extremities No edema . LABORATORIES White count 20.0 hematocrit 52 platelets 439 . Chem-7 141 5.6 104 24 23 0.8 118 . Urinalysis negative except for large blood . EKG Sinus bradycardia left bundle branch block prolonged QRS . Urine tox positive for barbiturates opiates and methadone . Serum Tylenol level is 8.3 . Positive for serum barbiturates . CK 15 000 . ALT 77 AST 159 amylase 153 alkaline phosphatase 216 total bilirubin 0.6 . INR 1.1 . <NOTE_END>", "role": "assistant" } ]
[ { "content": "Significant for metastatic breast cancer complicated by fever", "role": "user" }, { "content": " and neutropenia UTIs obstruction of the right subclavian vein and right brachial cephalic vein herpes zoster . Status post ovarian cyst resection in 1975 She had menarche at age 15 . She used the pill for five years in the past She is G 2 P 2 with spontaneous vaginal deliveries . She has a history of easy bruis ability She is allergic to Augmentin which gives her a rash . MEDICATIONS MS Contin MSIR and Percocet FAMILY HISTORY Noncontributory . <NOTE_END>", "role": "assistant" } ]
[ { "content": "The patient was admitted and placed in isolation on neutropenic precautions . He was transfused with 1 2 units of packed red blood cells and given Lasix periodically to prevent him from going into congestive heart failure has he had on his prior transfusion . Because his need for multiple transfusionsm he was transfused with radiated Leuco four units . The patient had a good bump in his hematocrit more than expected from 22 to high 20 &aposs range next day after 3 1 2 units but later that evening had a drop in his hematocrit so was given 4 more 1 2 units at this point for a total of 4 units packed red blood cells . He again did not bump his hematocrit sufficiently and remained in the high 20 &aposs after a total of 4 units so he was given 2 more total units in 1 2 units segments the following day . His hematocrit subsequently bumped to greater than 30 and was discharged with hematocrit of 32 on 11-7-93 . The patient remained asymptomatic from", "role": "user" }, { "content": " a CHF stand point and felt much better after the transfusions . It is unclear why the patient did not bump his hematocrit more but he did not appear to be hemolyzing from laboratory data that is his LDH was within normal limits . In addition multiple stools were guaiaced and were all guaiac negative . The patient was discharged with follow-up with his Hematologist Dr. Eci Area and Rheumatologist Dr. Taange Peter and Cardiologist Dr. Peter . <NOTE_END>", "role": "assistant" } ]
[ { "content": "On 12 12 96 she had an uncomplicated total abdominal hysterectomy and bilateral salpingo-oophorectomy . Estimated blood loss was 100 cc and she tolerated the procedure well . On postop day number one she was afebrile and doing well with a PCA for pain control . On postop day number two she was also afebrile and had not passed any flatus yet . She was ambulating frequently . Her hematocrit was 34.2 and stable from her preoperative value . On postop day number three her abdomen was noted to be distended with a few bowel sounds and she still had not passed gas . The patient decreased the amount of Demerol she was using and supplemented with Tylenol and continued her frequent ambulation . On postop day number four she had passed flatus and was feeling much better . She was discharged to home in good condition on the following medications . DISCHARGE MEDICATIONS Demerol for pain . Motrin for pain . Colace stool softener . DISPOSITION The patient should follow-up with Dr. Side in two weeks . Dictated By IEDEARC SIDE M.D. LB28 Attending MITERY D. LOSS M.D. CB51", "role": "user" }, { "content": " II795 2112 Batch 42100 Index No. ZMFX3O4G1 D 01 04 97 T 01 06 97 CC 1. MITERY D. LOSS M.D. NT11 <NOTE_END>", "role": "assistant" } ]
[ { "content": "Prednisone 60 mg daily", "role": "user" }, { "content": " for 4 days . Continue inhalers as prescribed . Disposition Follow up and Instructions to Patient Call Dr. Linketerf tomorrow and make an appointment for follow-up on the lung nodule . THIS IS VERY IMPORTANT . <NOTE_END>", "role": "assistant" } ]
[ { "content": "The patient was taken to the operating room on March 11 2002 and underwent an uncomplicated right total hip replacement .", "role": "user" }, { "content": " The patient tolerated the procedure well and was transferred to the Post Anesthesia Care Unit and then to the floor in stable condition . On postoperative check he was doing well . He was afebrile and his vital signs were stable . He was neurovascularly intact . His hematocrit was 34.7 . He was started on Coumadin for DVT prophylaxis and Ancef for routine antimicrobial coverage . He was made partial weight-bearing for his right lower extremity . He was placed on posterior hip dislocation precautions and was out of bed with physical therapy and occupational therapy . On postoperative day one there were no active issues . He was afebrile . His vital signs were stable . He was neurovascularly intact . On postoperative day two he was afebrile vital signs were stable . His incision was clean dry and intact with no erythema . He remained neurovascularly intact . His hematocrit was 34.8 . On postoperative day three lower extremity noninvasive ultrasounds were performed which showed no evidence of deep venous thrombosis in the lower extremities . The remainder of his hospitalization was uncomplicated . CONDITION ON DISCHARGE Stable . <NOTE_END>", "role": "assistant" } ]
[ { "content": "Chem-7 Na 139 K 3.7 Cl 99 bicarb 28 BUN 15 creatinine 0.9 glucose 89 . Liver function tests were significant for an ALT 41 AST 31 alk phos 76 T. bili 0.7 D. bili 0.2 amylase 345 lipase 2510 T. protein 8.1 albumin 4.9 globulin 3.2 Ca 9.9 . CBC White blood cell count 8.82 hemoglobin 15.2 hematocrit 43 and platelets 322 . Imaging studies Abdominal CT scan on 2 21 00 Study revealed a prominent pancreas with associated mesenteric stranding . No abscess or pseudocyst . A small gallstone was noted in the gallbladder neck . Bilateral pleural effusion were seen with associated compression atelectasis . Abdominal ultrasound on 2 23 00 This study revealed gallbladder sludge but no", "role": "user" }, { "content": " cholelithiasis . There was swelling of the body and tail of the pancreas . Portable chest on 2 23 00 Lungs were clear . Heart was normal . There was no pleural effusion . Chest PA and lateral on 2 25 00 Lungs were clear . There was no infiltrates or consolidation . <NOTE_END>", "role": "assistant" } ]
[ { "content": "Lopressor 25 mg p.o. b.i.d. Lasix 20 mg p.o. q. 12 hours times seven days . 3. Potassium chloride 20 mEq p.o. q. 12 hours times seven days . Colace 100 mg p.o. b.i.d. Metformin 500 mg p.o. b.i.d. Percocet 5 325 one to two tablets p.o. q. four to six hours p.r.n. Celexa 20 mg p.o. q.d. Lipitor 20 mg p.o. q.d. Warfarin 5 mg p.o. q.d. times four days after which point the patient s dosage schedule is to be coordinated by", "role": "user" }, { "content": " his PCP Dr. Jerold Esqueda . DISCHARGE INSTRUCTIONS The patient is to maintain his incisions clean and dry at all times . The patient may shower but should pat dry incisions afterwards no bathing or swimming until further notice . The patient may resume a Heart Healthy Diet . The patient had been advised to limit his physical exercise no heavy exertion . No driving while taking prescription pain medications . The patient is to have his Coumadin managed by his primary care provider Dr. Jerold Esqueda for a target INR of 2.5 . The patient is to report to Dr. Jones office on 2010-06-14 for an initial blood draw and subsequent Coumadin titration Coumadin levels are to be monitored per his PCP David . The patient is to follow-up with Dr. Leanne Larimore in Cardiology within two to three weeks following discharge . The patient is to follow-up with Dr. Brenda Hummer four weeks following discharge . The patient is to call to schedule all appointments . Tracy X. Carmen M.D. 76-050 Dictated By Gerald R. Quiroz M.D. MEDQUIST36 D 2010-06-12 0200 T 2010 -06-12 1421 JOB 47222 Signed electronically by DR. Tiffany D. Picklesimer on WED 2010-07-28 <NOTE_END>", "role": "assistant" } ]
[ { "content": "Aspirin 325 mgs PO q.d. Prilosec 20 mgs PO q.d. Azmacort 2 puffs q.i.d. PRN Atrovent 2 puffs q.i.d. PRN heparin 5 000 units subcu. b.i.d. Digoxin 0.125 mgs PO q.d. Wellbutrin", "role": "user" }, { "content": " 37.5 mgs PO b.i.d. Kaopectate PRN Betoptic 0.25 OU q.d. Ritalin 10 mgs PO q.a.m. and at noon time Norvasc 2.5 mgs PO q.d. The patient reported disorientation with Ambien and Halcyon . <NOTE_END>", "role": "assistant" } ]
[ { "content": "Plavix 75 mg q.d. Aspirin 325 mg q.d. DISCHARGE INSTRUCTIONS She is to continue taking medications as prescribed . She is to undergo no strenuous activity until follow-up in 2 weeks . FINAL DIAGNOSIS She is status post coiling with stent placement for left carotid ophthalmic aneurysm . RECOMMENDED FOLLOW-UP She is following up with Dr. Mcmaster on 2017-09-29 at 1130 a.m. She is also to follow up with her primary care physician to review her hypertensive medications . SURGICAL INTERVENTION Coiling with a stent placement for left carotid artery aneurysm", "role": "user" }, { "content": " . CONDITION ON DISCHARGE She is neurologically stable . Helen Cynthia New York 10969 Dictated By Scott T Little M.D. MEDQUIST36 D 2017-09-15 092845 T 2017-09-15 153705 Job 23470 Signed electronically by DR. Mae Behlmer on MON 2017-10-09 518 AM <NOTE_END>", "role": "assistant" } ]
[ { "content": "He is 5 feet 9 inches 225 pounds . He walks", "role": "user" }, { "content": " with a limp related to his right hip . His right hip is irritable with a 10-degree fixed flexion contracture . He is able to flex his right hip to 100 degrees . He has 10 degrees of internal and external rotation . He has intact distal pulses and 5 5 muscle strength in all major muscle groups . His X-rays show advanced osteoarthritis of his right hip . IMPRESSION AND PLAN This is a 62-year-old male with severe osteoarthritis of the right hip who after discussion including the nature risks benefits and alternative treatment plans signed informed consent for a right total hip replacement . <NOTE_END>", "role": "assistant" } ]
[ { "content": "Toprol XL 100 mg daily", "role": "user" }, { "content": " Hydralazine 25 mg daily Lasix 40 mg twice a day digoxin 0.75 mg daily Lovenox 40 mg twice daily subcutaneously and albuterol p.r.n. Peter Richard MD Dictated By Michael O. Tucker M.D. MEDQUIST36 D 2016-01-29 090727 T 2016-01-29 094948 Job 72842 Signed electronically by DR. <NOTE_END>", "role": "assistant" } ]
[ { "content": "On initial exam her left shoulder was tender to palpation over the proximal humerus with decreased range of motion . She was without the ability to move her left lower extremity with decreased sensation in the left leg . The right leg was with decreased range of motion of thigh flexion and extension . The back was notable for tenderness at the level of L3-L5 . LABORATORY EXAMINATION Initial radiologic evaluation showed negative C-spine thoracic spine and lumbosacral spine films . Abdominal CT was negative except for right hydronephrosis with mild right hydroureter . Back MRI was", "role": "user" }, { "content": " negative . Film of the left humerus was also negative . <NOTE_END>", "role": "assistant" } ]
[ { "content": "Negative . PHYSICAL EXAMINATION Showed a 71 year old white", "role": "user" }, { "content": " female in no acute distress . The vital signs were blood pressure 155 82 pulse 88 temperature 96.0. Her right foot was without capillary refill with a marked change of temperature at a level of the mid calf . There was decreased sensation to touch over the entire foot . She was able to move her foot and toes . Radial carotid and femoral pulses were symmetric and strong . The popliteal pulse on the right side was diminished . There was no dorsal pedal pulse on the right . <NOTE_END>", "role": "assistant" } ]
[ { "content": "Menthol Cetylpyridinium lozenges 1 as needed . Tenofovir 300 mg p.o. q.d. Didanosine 250 mg p.o. q.d. Atazanavir 300 mg p.o.", "role": "user" }, { "content": " q.d. Ritonavir 100 mg p.o. q.d. Calcium carbonate 500 mg p.o. q.d. Methylprednisolone 4 mg tablets per taper regimen . The patient was to take one 4 mg tablet dinner and at bedtime the day of discharge then the next day take one 4 mg tablet in the morning lunch time and with dinner and then at bedtime then the third day to take 4 mg tablet in the morning lunch and bedtime the fourth day to take one tablet in the morning and dinner and in the last day take one 4 mg tablet in the morning . He was also discharged on Augmentin XR 1000 mg 62.5 mg sustained release 1 tablet q. 12h . for 2 weeks . FOLLOW-UP The patient was to follow up with his PCP A. L. . Taylor in 7 to 10 days and the patient was to call Dr. Thibodeau CMED CSRU doctor to follow up in 2 weeks time . Teddy Stephen Louisiana 32870 Dictated By Judy J Johnston M.D. MEDQUIST36 D 2011-07-12 155531 T 2011-07-13 111452 Job 79962 Signed electronically by DR. Ruth Gibson on MON 2011-07-18 748 AM <NOTE_END>", "role": "assistant" } ]
[ { "content": "On admission includes an electrocardiogram that shows DDD pacing . Hematocrit 39 percent white blood cell count 4500 PT and PTT normal . Sodium 140 potassium 4.2 chloride 105 carbon dioxide 30 BUN 24 creatinine 1.0 . HOSPITAL COURSE AND TREATMENT The patient was admitted to the Cardiac Catheterization Laboratory . There her pulmonary wedge pressure was 12 and her right atrial pressure was 4 and pulmonary artery pressure 44 17 . Her left ventricular contraction showed akinesis of the anterior wall with dyskinesis of the apex . She had preserved inferior contraction and basal contraction . Her native right and left anterior descending vessels were occluded as was an obtuse marginal branch . The saphenous vein to the high diagonal or high obtuse marginal was occluded . The left internal mammary artery to the left anterior descending was also occluded . The saphenous vein graft to the second obtuse marginal was open with no significant stenosis but there was an outflow lesion in the obtuse marginal 2 as well as severe distal lesion as the obtuse marginal 2 fed the posterior descending artery . This was considered her culprit lesion . This was considered too high risk for angioplasty because of the severe disease in the graft . In addition it was noted that she had saphenous vein harvested from both thighs . Her left internal mammary artery was also unused . It was also noted that she had failure to sense with the atrial lead . She would not sense the atrial contraction and the fire and this occasionally led to competition of firing . This was intermittent . The P wave amplitude was .6 and this could not be totally sensed . The patient was admitted for management of her coronary artery disease and evaluation of her pacemaker . It was noted that she became very symptomatic when she was not on a beta blocker but that on a beta blocker she had significant pacemaker failure . Her pacemaker was set to a VVI mode which sensed appropriately . She was in sinus rhythm with most of the time . When her pacemaker was in a sinus rhythm without a beta blocker she had significant angina . Carotid non-invasive testing was unremarkable . The situation was reviewed with Dr. Niste Graft . He felt the patient was not a coronary artery bypass graft candidate because of the lack of conduit and because of the presence of a large anterior myocardial infarction . For this reason it was decided to maximize her beta blockers and nitrates . The situation was reviewed with Dr. No of the Pacemaker Service . On August 20 under local anesthesia the right pectoral region was explored and the leads disconnected and the pulse generator changed to a CPI unit in which the sensitivity could be adjusted to .15 mm. which permitted appropriate atrial sensing . There was nothing wrong with the prior generator and nothing wrong with the leads . It just needed a unit that could have more sensitivity in the atrial mode . She tolerated this well . Her medications were", "role": "user" }, { "content": " resumed . She ambulated without difficulty and was discharged to home to be followed medically for her coronary artery disease following two failed bypass graft procedure by Dr. Brendniungand Asilbekote in Bi Masase KS . ACHASTHA N. GRAFT M.D. TR hfr DD 08 22 1998 TD 08 27 1998 356 P cc ACHASTHA NICEMAEN GRAFT M.D. GITTETUMN DARNNAMAN <NOTE_END>", "role": "assistant" } ]
[ { "content": "The patient has a history of MI in 1989 no angina before or after She had a normal exercise thallium test in 08 89 per Ona Hospital . The phone no at the Ona Hospital is 337-4296 936 area code . 2 History of M. kansasaii with workup by Dr. Screen at Sas General Hospital proceeding currently . 3", "role": "user" }, { "content": " History of breast cancer . In December 1990 she had a lumpectomy from left breast and XRT x 35 No axillary dissection was done because she was status post MI . She received Tamoxifen briefly Mammogram was normal 7 92 and 5 92 . She is allergic to Amoxicillin having developed a rash does not smoke does not drink <NOTE_END>", "role": "assistant" } ]
[ { "content": "On physical examination on admission the blood pressure was 146 80 weight 146 temperature 98.6 and pulse of 92 . The skin was normal . The neck was supple . The cardiac examination demonstrated single S1 S2 no murmurs . The lungs were clear", "role": "user" }, { "content": " . The abdominal examination was within normal limits . The extremities were normal . The neurological examination was nonfocal . <NOTE_END>", "role": "assistant" } ]
[ { "content": "On admission the sodium was 136 potassium 3.0 chloride 98 CO2 20 BUN 8 creatinine 0.8 and glucose 94 ALT 5 AST 10 LDH 166 alkaline phosphatase 81 total bili 0.6 direct bili", "role": "user" }, { "content": " .3 albumin 3.3 calcium 8.8 and uric acid 3.1 . She had CA-125 which was pending at the time of discharge . Her hematocrit was 31.1 WBC 11.6 and 151 000 platelets . <NOTE_END>", "role": "assistant" } ]
[ { "content": "SMA-7 was unremarkable aside form a creatinine of 1.6 and a glucose of 207 otherwise was within normal limits . Hematocrit was 22.4 white count .59 platelets 84. The patient had an absolute neutropenia with a ANC of 318 differential revealed", "role": "user" }, { "content": " 48 segs 6 bands 40 lymphs 4 monos . Digoxin level was 1.4 . Theo-Dur level was 15 . PT was 12.5 PTT 27.0 . Urinalysis was within normal limits . Chest x-ray showed enlarged heart with mild pulmonary vascular redistribution no gross congestive heart failure was noted . EKG showed question of MAT vs. atrial fibrillation with a ventricular response of 118 axis was 0 degrees . There was ST scooping in the lateral leads consistent with Dig vs. a question of chronic ischemia changes . There was no significant change from his baseline EKG . <NOTE_END>", "role": "assistant" } ]
[ { "content": "Notable for sodium 141 potassium 4.2 chloride 109 bicarb 19.8 BUN 38 creatinine 1.2 and glucose 388 . She had a pneumonia of 31 calcium was 7.5 phosphorous 3.0 magnesium 1.3 . Her bilirubin was 1.4 total 0.2 direct . alkaline phosphatase 101 . SGPT 22 SGOT 41 amylase 31 lipase less than 1 . LDH was 38.9 CK was 66 her hematocrit was 27.4 white count was 8.0 and her platelets were 55 . PT was 14.5 PTT 25.5 . HOSPITAL COURSE AND TREATMENT As described above the patient was transfused an additional 2 units in the Intensive Care Unit and the patient also received an upper endoscopy study and her varices were banded . On transfer to the Lemgarson Hospital service her hematocrit was 31.2 white count 11.1 and a platelet count 80 . Her PT was 13.1 PTT 26.7 . The rest of her labs were unremarkable . She was watched very closely while on the floor . She was on GI bleed precautions at all times was too large for IV . She had a clot at the blood bank and she had BID hematocrits checked . She was kept NPO until January 26 when she began to feel hungry . At that time clear liquids were started . All of her stools were guaiaced . She also began Nadolol 40 mg QD to reduce her portal hypertension . The GI consult team continued to follow her . We also tried to contact her physician at Va Sit Namar Healthcare and was unsuccessful . Therefore we decided to work up her cirrhosis . She was described as having cirrhosis and we decided that we wanted to try to figure out the etiology . Her ferritin and iron studies did not reveal any evidence of hemochromatosis and her hep serologies were all negative . She also had negative antimitochondrial antibody and she also had no evidence of ceruloplasmin . Over the course of her admission were also sent an alpha-1-antitrypsin which was negative . She did very well over the course of her admission with no evidence of further bleeding . Her hematocrit stayed stable at approximately 32 . We also did an ultrasound guided paracentesis . The peritoneal fluid showed a glucose of 244 total protein 0.8 and a albumin of 0.5 globulin 0.3 amylase 16 LDH of 51 . The serum albumin gradient was 1.8 consistent with portal hypertension . The cell count showed a white blood cell count of 160 with 16 polys . She therefore criteria for a spontaneous", "role": "user" }, { "content": " bacterial peritonitis . Her platelet count stayed persistently low and we decided that it might be due to Cimetidine . Therefore we switched her Cimetidine to Prilosec . By the 2th the patient was feeling very well and desired to transfer or discharge to home . She wanted to be closer to North Dakota . After discussion with her private physician Dr. Joasscchird tel. 090-249-6079 at Va Sit Namar Healthcare and Dr. Acrookesjo at Do Of Hospital the patient was judged to be fit for discharge and she was sent home with AH and physical therapy . She was quite able to climb stairs on her own in the hospital . She is to follow up with Dr. Acrookesjo in one week and Dr. Work the gastrointestinal fellow here at PUOMC in 2 weeks . She may require a repeat upper endoscopy study to see if she needs any rebanding . The patient however complained of a persistent wheeze with beta blocker therefore it was agreed that we would stop the beta blocker until the patient was followed up as an outpatient . <NOTE_END>", "role": "assistant" } ]
[ { "content": "None . She denies cigarette use and ethanol use as well", "role": "user" }, { "content": " as a recreational drug use . <NOTE_END>", "role": "assistant" } ]
[ { "content": "Cardiac arrest His arrest was of unknown etiology at the time of admission . No further history was ever gained about his cardiac arrest throughout his hospitalization . CT angiogram had been negative for pulmonary embolism . The patient had an echocardiogram on 2013-04-26 which showed a normal ejection fraction and trivial mitral regurgitation otherwise no obvious abnormalities were seen . Given the patient had an out of hospital arrest remained unresponsive despite hemodynamic stability he was treated with induced hypothermia and with cold packs and a cooling blanket were placed with goals of reducing his core body temperature to 32 degrees Celsius for a period of twelve hours at which point he would be rewarmed over the subsequent six hours . This was done however as in problem number two below we were not successful in any neurologic recovery . Neurology The patient remained unresponsive after the induced hypothermia the patient was noticed to develop myoclonic jerks and occasional fluttering of his eyelids . Electroencephalogram revealed the patient was experiencing persistent seizure activity . Neurology was consulted and the patient was treated very aggressively loaded with multiple drugs including Ativan and Propofol drips . The patient continued to demonstrate seizure activity despite this . He was loaded with Dilantin and ultimately was treated with a Pentobarb coma . After multiple attempts of weaning the Pentobarb the patient was continually reverting to status epilepticus which was never able to be", "role": "user" }, { "content": " suppressed . Infectious disease Over the course of his hospital stay the patient s white blood cell count rose to a peak of 17 . Multiple cultures were done and the patient was ultimately found to have methicillin resistant Staphylococcus aureus bacteremia pneumonia and urinary tract infection . For all these infections the patient was treated with Vancomycin and he was also on Levofloxacin and Flagyl for presumed aspiration pneumonia at the time of his admission . Blood cultures cleared by 2013-05-03 . Sputum culture as late as 2013-05-10 however was still positive for coagulase positive Staphylococcus which was methicillin resistant Staphylococcus aureus . The patient remained gravely ill throughout his hospital stay and had multiple meetings were held with his family with his son being his next of kin . Ultimately it was decided that the patient s wishes would be to not be maintained in a vegetative state and given his poor prognosis ultimately the decision was made to pursue comfort measures only . With these goals of care the patient expired on 2013-05-11 . The family did consent to a postmortem examination . DISCHARGE DIAGNOSES Cardiac arrest . Anoxic brain injury Status epilepticus Methicillin resistant Staphylococcus aureus pneumonia . MRSA urinary tract infection . MRSA Bacteremia . Steven Welch Montana 61528 Dictated By Julie DD George M.D. MEDQUIST36 D 2013-12-24 135505 T 2013-12-24 204707 Job 52892 Signed electronically by DR. Patricia Henley on Maxine 2014-01-02 1045 AM <NOTE_END>", "role": "assistant" } ]
[ { "content": "Albuterol nebulizers 2.5 mg q.4h. and Atrovent nebulizers 0.5 mg q.4h. please alternate albuterol and Atrovent Rocaltrol 0.25 mcg per NG tube q.d. calcium carbonate 1250 mg per NG tube q.i.d. vitamin B12 1000 mcg IM q. month next dose is due Nov 18 diltiazem 60 mg per NG tube t.i.d. ferrous sulfate 300 mg per NG t.i.d. Haldol 5 mg IV q.h.s. hydralazine 10 mg IV q.6h. p.r.n. hypertension lisinopril 10 mg per NG tube q.d. Ativan 1 mg per NG tube q.h.s. Lopressor 25 mg per NG tube t.i.d. Zantac 150 mg per NG tube b.i.d. multivitamin 10 ml per NG tube q.d. Macrodantin 100 mg per NG tube q.i.d. x 10 days beginning on 11 3 00 . CONDITION Stable with active problems being respiratory failure urinary tract infection and bleeding diathesis . DISCHARGE LABS On the day of discharge sodium 145 potassium 4.1 chloride 109 bicarb 31 creatinine 0.7 BUN 43 glucose 116 . CBC 14.9 29.2 which is stable and 398 . PT 12 PTT 27 and INR 1.0 . Magnesium of 1.9 . Calcium 8.1 . COMPLICATIONS None . DISPOSITION The patient is being discharged to an acute rehab facility . She should follow-up with Dr. Ryna Jescdrig as well as Dr. Lenni Lung in the Vascular Surgery Department in approximately three to four weeks . Please call the Surgical Intensive Care Unit at Verg Medical Center for any further details that may be needed . You can also page Sta Lung M.D. as I am the dictating physician who has been taking care of Ms. Shuffa for quite some time now . I would be happy to answer any questions .", "role": "user" }, { "content": " My pager number at Verg Medical Center is number 54930 . Dictated By STA LUNG M.D. HU53 Attending RYNA R. JESCDRIG M.D. GN3 QE555 1531 Batch 77428 Index No. DXXJ8U8529 D <NOTE_END>", "role": "assistant" } ]
[ { "content": "Digoxin 0.25 mg . Hytrin 2mg at bedtime . Ticlid 0.25 g po bid . Bronchodilators as needed . DOCTOR &aposS", "role": "user" }, { "content": " DISCHARGE ORDERS Strict aspiration precautions with avoidance of clear liquids and all other liquids thickened . Increased ambulation with assistance and daily pulmonary physical therapy . TOOB OBESTIMEUPH M.D. TR ua DD 09 16 96 TD 09 16 96 410 P cc DOJE EED BOLMSHI M.D. TOOB I OBESTIMEUPH <NOTE_END>", "role": "assistant" } ]
[ { "content": "The patient is a 65 year old male who sustained a small myocardial infarction first in 1978 with course thereafter including a coronary artery", "role": "user" }, { "content": " bypass graft by Dr. Wierst at Noughwell Entanbon Health in 1986 . In 1991 he presented with congestive heart failure and he underwent porcine aortic valve replacement . In the seven to eight months preceding admission he developed recurrent angina with dyspnea on exertion . The patient was admitted for cardiac catheterization in early December 1993 . <NOTE_END>", "role": "assistant" } ]
[ { "content": "The patient is a 20 year old black female who was a pedestrian when struck by a car at apparent high speed . There was apparent loss of consciousness at the scene and significant deformity of the anterior portion of the motorvehicle with positive starring of the windshield . The patient was conscious", "role": "user" }, { "content": " on the scene when evaluated by EMT &aposs but at the scene the patient was apparently paraplegic below the umbilicus with absence of movement and sensation below the umbilicus . PAST MEDICAL HISTORY None . PAST SURGICAL HISTORY Status post laparotomy for an ovarian cyst in 1988 . MEDICATIONS ON ADMISSION None . <NOTE_END>", "role": "assistant" } ]
[ { "content": "On examination on transfer to the Intensive Care Unit she is febrile with a low grade temperature of 100.1 tachycardic to 110 hypotensive 85 49 tachypneic into the 50 s and 60 s 95 on nonrebreather . In general she is extremely tachypneic difficulty in speaking words . Her heart is regular without murmurs rubs or gallops slightly tachycardic . Her pulmonary examination shows she has bronchial breath sounds with dry crackles at the bases . Abdominal examination was benign . Extremities no clubbing cyanosis or edema . She is alert and following commands . LABORATORY White blood cell count 3.2 hematocrit 26.6 platelets 130 chemistry is 131 potassium 3.0 chloride 105 bicarb", "role": "user" }, { "content": " 17 BUN 10 creatinine 0.5 glucose 105 . Calcium 7.3 phos 1.8 magnesium 1.5 . She had a gas showing 7.36 31 96 . She had a CT from the 29th of her abdomen and pelvis showing marked increased consolidations at the left lung base and question of new left sided pleural effusion . HOSPITAL COURSE 1. Pulmonary The patient was transferred to the Intensive Care Unit for respiratory distress and febrile hypotension with a question of a new infiltrate on her chest x-ray . The exact etiology of the patient s respiratory distress was presumed to be questionable multifactorial . There was concern about possible pneumonia . Also she had a history of PE and also there was concern about possible lymphangitic spread of her breast CA . Given her fevers and shortness of breath the patient was treated with broad spectrum antibiotics initially started on Ceptaz Levaquin and and Clindamycin . Lab two antibiotics were added considering the patient was thought to be a relatively high risk for PCP Douglas . The patient was initially trialed on BiPAP but the patient was increasingly dyspneic increased respiratory stress and ultimately needed to be intubated on 06-22 . Earlier during her Intensive Care Unit course she underwent bronchoscopy which was sent for cytology and multiple bacterial pathogens all of which were negative . Ultimately her Intensive Care Unit course continued and she began to defervesce and her bacterial studies particulaly from BAL lavage were found to be negative . The patient had multiple antibiotics withdrawn . Clindamycin and was discontinued early in hospital course . Her PCP was thought to be negative . In addition Vancomycin Levaquin were also discontinued . She was later continued on Ceftazidine and Clindamycin for possible gram negative infection and also for possible post obstructive picture that she would be at risk for given her pulmonary anatomy . As the Hubbard Regional Hospital hospital course went on the patient s respiratory did not show mild improvement on the ventilator . She was able to oxygenate originally . Unfortunately her mental status failed to improve despite having been off all sedative medications for several days . Later in her Intensive Care Unit course family meetings took place and given the patient s overall poor prognosis with decreased mental status it was decided that the patient would become CMO . Subsequently she was extubated on 06-28 . The patient continues to actually ventilate well off of the respiratory . However she is CMO and will not be intubated for respiratory distress . 2. Cardiovascular The patient was initially transferred to the Intensive Care Unit thought to be exhibiting septic physiology respiratory distress and hypotensive . She required aggressive intravenous fluids and later required pressor support with neo-synephrine . Later during her Intensive Care Unit course she was felt to be somewhat overloaded and intravenous fluids were cut back . It was quite difficult weaning her off of neo-synephrine . She was also given stress dose steroids . Later in her hospital course she also had an echocardiogram for question of new ECG findings in her inferior leads . Her echocardiogram however was essentially normal with an ejection fraction of 55 without any gross wall motion abnormalities or valvular pathology . As mentioned above the patient s hemodynamic status was tenuous throughout her hospital course as it was difficult to wean the patient off of neo-synephrine . By 06-28 however the patient had been off of neo-synephrine but at this time as mentioned above the patient was deemed to be CMO per discussion with physicians and her husband health care proxy . 3. Hematology Patient with a history of known malignancy and also a history of pulmonary embolisms from 2012-04-23 . Earlier in her Intensive Care Unit course the team was concerned about possible pulmonary embolisms as a possible source of the patient s respiratory decompensation . However the patient also had brain metastasis and at this point anticoagulation was thought to be a contraindication given risk for hemorrhage into these tumors . She did have lower extremity doppler ultrasounds which were negative . 4. Infectious disease As mentioned above patient initially hypotension febrile and in respiratory distress presumed to be septic source likely pulmonary . Initially the patient was treated with broad spectrum antibiotics including Vancomycin Ceptaz Levaquin Clindamycin and . All of her cultures are negative to date . She was negative for PCP and subsequently was continued and Clindamycin was changed for anaerobic coverage . In addition her Vancomycin and Levaquin were also discontinued . The patient remained afebrile during the majority of her hospital course . By virtue of discussions on 06-28 the patient was deemed to be CMO and all antibiotics were withdrawn at this point . 5. Gastroenterology The patient had an abdominal CT earlier in her Intensive Care Unit course which was essentially negative for an intraabdominal pathology . She was initially supported with tube feeds during her Intensive Care Unit course but at this point the patient is CMO and tube feeds have been subsequently discontinued . DISPOSITION The patient s attending physician was in constant communication with the patient s health care proxy her husband . As her Intensive Care Unit course continued and the patient showed minimal signs of meaningful improvement continued discussions were had with the family about possibly changing code status . Ultimately it was decided by 06-28 that the patient had shown minimal improvement and minimal evidence of improvement status it was decided at this point for the patient to be extubated and to move toward CMO care . Subsequently all antibiotics blood draws and supportive blood pressure medications were withdrawn . Currently she is comfortable with morphine and Ativan prn. Currently plans are in the making for arranging for the patient to have home hospice care . Please see discharge addendum for further developments in the patient s care . DISCHARGE DIAGNOSES Metastatic breast cancer end stage . Respiratory failure unclear etiology presumed secondary to possible pneumonia questionable lymphangitic spread . 3. Sepsis presumed pulmonary source . DISCHARGE CONDITION Grim . <NOTE_END>", "role": "assistant" } ]
[ { "content": "ON ADMISSION On admission Thomas was well-appearing though slightly sleepy with jaundice . He had bilateral breath sounds that were clear and equal . The heart rate was regular without murmur and pulses were 2 and symmetrical . The abdomen was soft and nontender with no hepatosplenomegaly . His weight was 3.505 7 pounds 12 ounces on readmission . He had normal male genitalia with bilaterally descended testes . His hips were stable . His tone was normal with normal neonatal reflexes . He is tolerating his feedings well . SUMMARY OF HOSPITAL COURSE RESPIRATORY Without issues on this admission . Breath sounds are clear and equal . CARDIOVASCULAR Without issues on this admission . He had a regular heart rate and rhythm no murmur and pulses were 2 and symmetric . FLUIDS ELECTROLYTES AND NUTRITION Alleyne birth weight was 3.710 kg 8 pounds 3 ounces . His weight on this admission was 3.505 kg 7 pounds 12 ounces . Linda is breast feeding every 3 hours and supplementing with expressed breast milk . He is feeding well . His discharge weight is 3585 grams 7 pounds 13 ounces . GASTROINTESTINAL Alleyne bilirubin on 2018-05-09 was 10.4 at which time he was discharged to home . At the primary pediatrician s office on 2018-05-12 his bilirubin had been 23 at which time he was readmitted to the HealthSouth Rehab Hospital of Western Mass. and double phototherapy was started . His bilirubin on 05-13 was 18.4 and on 05-14 it was 14.7 . Phototherapy was discontinued on 2018-05-14 and a rebound bilirubin will be checked in the pediatrician s office . HEMATOLOGY The hematocrit on 05-12 was 48.7 with a reticulocyte count of 1.9 and his blood type is O Coombs negative . INFECTIOUS DISEASE No issues on this admission . NEUROLOGICAL The infant has been appropriate for gestational age . SENSORY Auditory hearing screening was performed with automated auditory brain stem responses and the infant passed both ears on his previous admission . Hearing screens were repeated on 2018-05-13 and he passed both ears . PSYCHOSOCIAL Family is invested and involved . CONDITION ON DISCHARGE Stable . DISCHARGE DISPOSITION To home . SOURCE OF PRIMARY PEDIATRIC CARE South Cove Community Health Center at", "role": "user" }, { "content": " 5368 W. Sixth Rd Burlington Oregon 55832 telephone number 391-5273 . CARE RECOMMENDATIONS Continue ad lib feeding . Follow up with pediatrician at SCCHC on Tuesday 2018-05-15 . Medications Not applicable . Car seat positioning screen Not applicable . State newborn screens were sent on 2018-05-09 and results are pending . On his previous admission Terrance received hepatitis B vaccine on 2018-05-09 . 6. Immunization recommended Influenza immunization is recommended annually in the Fall for all infants once they reach 6 months of age . Before this age and for the first 24 months of the child s life immunization against influenza is recommended for household contacts and out of home caregivers . DISCHARGE DIAGNOSES Term appropriate for gestational age male neonate . Exaggerated physiologic hyperbilirubinemia responsive to phototherapy . Jennifer Martin North Dakota 07287 Dictated By Jean TE Fletcher M.D. MEDQUIST36 D 2018-05-13 130731 T 2018-05-13 142441 Job 75582 Signed electronically by DR. Deloris O. Williams on MON 2018-05-14 <NOTE_END>", "role": "assistant" } ]
[ { "content": "On admission vital signs Temperature 101.4 blood pressure 101", "role": "user" }, { "content": " 62 pulse 80 respiratory rate 19 on a ventilator with settings of assist control at 500 12 and a PEEP of 5 . General The patient is intubated and sedated but easily arousable . HEENT Pupils equally round and reactive to light . Sclerae are anicteric . ET tube is in place . Neck Soft and supple . Cardiovascular Normal . Chest Faint scattered wheezes bilaterally . Abdomen Benign . Extremities Warm with good distal pulses . There is no edema . Neurologic Able to follow simple commands . <NOTE_END>", "role": "assistant" } ]
[ { "content": "The patient is a 63 year-old woman transferred from Pre Health on June 19 1998 to the Verg Medical Center Intensive Care Unit for evaluation of thrombotic thrombocytopenic purpura and bronchiolitis obliterans organizing pneumonia . On May 12 1998 the patient presented to Pre", "role": "user" }, { "content": " Health with fever cough dyspnea and a chest x-ray revealing a patchy infiltrate in the right lung . She was treated with Clindamycin and Erythromycin which were changed to Trovan and then transferred to A Hospital . On May 27 1998 the patient desaturated to 40 with a temperature of 100.5 degrees . Her oxygen saturations improved to only 92 on 100 face mask and she was admitted to Pre Health Intensive Care Unit . Chest x-ray there revealed bilateral pulmonary infiltrates with increasing pleural effusion . A VQ scan was high probability but no pulmonary angiogram was done and an echocardiogram revealed a normal left ventricle with no wall motion abnormality and an ejection fraction of 75 . On May 24 1998 the patient had a CT scan of the chest which revealed diffuse alveolar infiltrates at the right base mediastinal lymphadenopathy and bilateral pleural effusions . At this point a diagnosis of lupus was considered and her ANA was 1640 and her rheumatoid factor and ANCA were negative . She was started on a steroid trial at that point . Her pleural fluid was tapped and it was negative for malignancy . On June 11 1998 the patient had a video assisted thoracoscopic study of the right lung which revealed chronic interstitial pneumonitis with a bronchiolitis obliterans organizing pneumonia-like reaction and a chest tube was placed . The patient was then started on 40 mg of Prednisone q. day . From May 27 1998 through June 19 1998 the patient had a decline in her platelets from 394 to 28 with a stable hematocrit of 32 to 33 and a rise in creatinine from 1.0 to 3.8 . On June 19 1998 she was transferred to the Verg Medical Center Medical Intensive Care Unit for evaluation of possible thrombotic thrombocytopenic purpura . PAST MEDICAL HISTORY 1 Cerebrovascular accident in 1995 in the pontine region secondary to hypertension . 2 Hypertension . 3 Status post hysterectomy . 4 Status post appendectomy . MEDICATIONS ON TRANSFER 1 Albuterol inhaler 4 puffs q.i.d. 2 Lasix p.r.n. 3 Prednisone 40 mg p.o. q. day . 4 Inderal 40 mg p.o. q.i.d. 5 Thiamine . 6 Lasix p.r.n. 7 Atrovent inhaler 4 puffs q.i.d. 8 Folic acid . 9 Premarin 0.625 mg p.o. q. day . 10 Omeprazole 20 mg p.o. q. day . 11 Insulin sliding scale . <NOTE_END>", "role": "assistant" } ]
[ { "content": "Neurological Alert and oriented times 3 . Moves all extremities and follows commands . Respiratory Clear to auscultation bilaterally . Cardiovascular Regular rate and rhythm S1 and S2 . No murmurs . Sternum is stable incision with staples opened to air clean and dry . Abdomen Soft and nontender nondistended with positive bowel sounds . Extremities Warm and well profuse with 1 to 2 plus edema . Right saphenous vein graft site with Steri-strips open to air clean and dry .", "role": "user" }, { "content": " The patient s condition at discharge is good . <NOTE_END>", "role": "assistant" } ]
[ { "content": "The plan was for right radical vulvectomy . 1. Vulvectomy The patient on", "role": "user" }, { "content": " 2 8 90 underwent a right radical vulvectomy with excellent results and negative margins on frozen section . Her postoperative course was unremarkble . She was kept on bedrest for two days and then was ambulating and voiding well without trouble on postoperative day number three when the Foley catheter was discontinued . She has been doing Betadine paint and blow drying the area several times a day and after each bowel movement and urine without incident . DISPOSITION The discharge is to home . The patient will follow-up with Dr. Friednantflirt . She will have AH for support . YT844 9769 LAKO SCARVTWI M.D. TH0 D 02 12 90 Batch 7753 Report Y6201H2 T 02 13 90 Dicatated <NOTE_END>", "role": "assistant" } ]
[ { "content": "The physical examination on admission revealed a blood pressure of 110 70 a heart rate of 66 respirations of 24 temperature of 98 . The HEENT exam revealed the extra ocular movements intact . The pupils equal round reactive to light . The oropharynx was clear and the fundi were normal . There were no hypertensive or diabetic changes . The neck was suppled with no lymphadenopathy and no jugular venous distention . The carotids were 1 without bruits . The heart was regular rate and rhythm S4 S1 S2 with a I VI systolic murmur at the left lower sternal border . The lungs were clear except for a few dry crackles bibasilarly . The abdomen revealed a midline scar and a right lower quadrant scar and it was soft and nontender wit positive bowel sounds . The liver edge was 2 cm below the right", "role": "user" }, { "content": " costal margin but smooth and nontender . There was no splenomegaly . The femoral pulses were diminished . He had bilateral intertrigo in his femoral region as well as his axillae . The extremities revealed no clubbing cyanosis or edema . The pulses were 1 bilaterally . The skin exam revealed changes consistent with vitiligo . The rectal examination was guaiac negative . <NOTE_END>", "role": "assistant" } ]
[ { "content": "He was a chronically ill appearing elderly man with a respiratory rate of 30 temperature 99.6 pulse 100 and irregularly irregular blood pressure 148", "role": "user" }, { "content": " 71 . He had some petechiae on his extremities as well as in his mucosal membranes with some hemorrhagic bullae . There were bibasilar rales with some wheezing . He had no cardiac murmur . His abdomen was distended with massive hepatosplenomegaly which was somewhat tender . The neurological examination aside from the blind right eye was unremarkable . <NOTE_END>", "role": "assistant" } ]
[ { "content": "On admission he had no upper respiratory tract symptoms recent infections chest pain shortness of breath nausea or vomiting change in bowel habits or abdomen pain .", "role": "user" }, { "content": " He did complain of frequent headaches . Following his recent bone marrow harvest he had protracted episodes of nausea and vomiting . All other systems were negative . <NOTE_END>", "role": "assistant" } ]
[ { "content": "Toprol 75 mg po bid Furosemide 20 mg po bid times one week potassium chloride 20 mEq po bid while on Lasix Colace 100 mg po bid while on Percocet enteric coated Aspirin 325 mg po q day Indocin 25 mg po bid Sarna cream applied to affected area prn Percocet 1-2 tabs po q 4-6 hours prn Ibuprofen 400 mg po q 6 hours prn Tylenol 650 mg po q 4-6 hours prn Ativan 0.5 mg po q 8 hours prn . FOAnterP The patient will follow-up in the wound care clinic in two weeks . The patient will also follow-up with Dr. Fairchild her", "role": "user" }, { "content": " primary care physician in three weeks . The patient will follow-up with Dr. vel Diaz in 3-4 weeks . Briley von der Ross M.D. 67 -576 Dictated By Emily O Ennis M.D. MEDQUIST36 D 2013-01-08 1646 T 2013-01 -08 1708 JOB 67252 Signed electronically by DR. <NOTE_END>", "role": "assistant" } ]
[ { "content": "A quantitative V Q scan was also done preoperatively and Pulmonary consult was obtained preoperatively . Pulmonary recommended that he just be started on Albuterol and Atrovent metered dose inhalers 2 puffs q6h prior to surgery . The patient underwent his procedure on 12-4-93 without complications . Findings included thickened pleura with multiple adhesions and an abscess near the margin major fissure . He had a firm nodule in the left lower lobe . The patient", "role": "user" }, { "content": " was transferred to the Respiratory Intensive Care Unit in stable condition and had an uneventful stay there . He had oxygen saturations of 99 with an Fi02 of 40 and had no complaints . He was transferred to the floor on postoperative day number one and tolerated his PO&aposs well . His left lower lobe micro results revealed alpha hemolytic Streptococcus on culture and he was then switched to penicillin and Gentamicin after being started on triples of Flagyl Ampicillin and Gentamicin . He had low grade temperatures though did not spike a high temperature during his hospital course . His hospital course was otherwise uneventful and the patient was discharged in stable condition on postoperative day afebrile . The chest X-ray on the morning of discharge was unchanged from the previous day with slight increase in left pleural fluid . He had completed six days of penicillin and Gentamicin and was discharged on Ciprofloxacin and Flagyl for the next seven days . He stayed at the local Comfort Inn before his return back to Aujer Cin . <NOTE_END>", "role": "assistant" } ]
[ { "content": "On admission was remarkable for an abdomen which was soft and non-tender .", "role": "user" }, { "content": " There was a pulsatile mass felt in the right upper quadrant near the midline . He had dopplerable lower extremity pulses on the left and on the right they were palpable . <NOTE_END>", "role": "assistant" } ]
[ { "content": "The patient is a 43-year-old gravida II para", "role": "user" }, { "content": " II white female referred by Dr. Ca Shuff for evaluation . She was in her usual state of good health until December when she was seen emergently for treatment of a perforated colon cancer . That area was resected with no evidence of metastatic disease . She has had subsequent CEA&aposs and scans which were negative . A tumor was noted on her vulva which was biopsied and revealed squamous cell carcinoma in situ . <NOTE_END>", "role": "assistant" } ]
[ { "content": "1 Amiodarone 400 mg p.o. q. day . 2 Captopril 50 mg p.o. t.i.d. 3 Digoxin 0.125 mg p.o. q. day . 4 Colace 100 mg p.o. t.i.d. 5 Lasix 80 mg p.o. b.i.d. 6 Potassium chloride 40 mEq p.o. b.i.d. 7 Glucophage 500 mg p.o. q. day . 8 Glucotrol XL 10 mg p.o. b.i.d. 9 Coumadin 5 mg p.o. q. day . FOLLOW-UP The patient", "role": "user" }, { "content": " was instructed to follow-up with Dr. Lumar Jongguild . Dictated By RAMAG TROISQUARCKAYS M.D. JB48 Attending LUMAR R. JONGGUILD M.D. NJ48 RO267 6080 Batch 5076 Index No. KHQTW3FS3 D <NOTE_END>", "role": "assistant" } ]
[ { "content": "Patient is an 88 year old female with fatigue and decreased short term memory for the past six months . The past six weeks she has also been complaining of hot sensation and tingling sensation in the hands bilaterally . For the past five weeks the patient has experienced dragging of the right leg with weakness throughout that side . Head CT was done which patient reported demonstrated three lesions in the left parietal region of the brain . Bone scan CT of the abdomen chest X-Ray and mammogram were all negative . Patient noted the foot dragging to have worsened over the past few weeks but improved since on Decadron the past week before admission . Patient is now admitted for elective left parietal stereotactic biopsy of the tumor . PAST MEDICAL SURGICAL HISTORY Significant for a history", "role": "user" }, { "content": " of hypertension basal cell carcinoma of the nose six years ago cataracts and a hysterectomy . <NOTE_END>", "role": "assistant" } ]
[ { "content": "Hypertension Hypothyroidism . Paraplegia status post thoracic aortic aneurysm repair Left hemidiaphragmatic paralysis history of recurrent lung infections . Sacral decubitus", "role": "user" }, { "content": " ulcer Home oxygen at two liters a minute when she is at home she does not use the oxygen when she is in a wheelchair or is out of the house MEDICATIONS ON DISCHARGE 1. Atrovent nebulizers 0.5 mg mixed with albuterol nebulizer is given every six hours . 2. Norvasc 2.5 mg p.o q day . Colistin 30 mg nebulizer twice a day give 30 minutes post albuterol and Atrovent Pressure dermal ulcer care b.i.d. dressing change with antibiotic solution . 5 Neurontin 600 mg p.o. t.i.d Colace 100 mg p.o. b.i.d. Fentanyl patch 25 mcg an hour change patch every 72 hours . Albuterol neb 2.5 mg every six hours 30 minutes before Colistin Amitriptyline 50 mg q.h.s. 9 Vitamin C 500 mg p.o. b.i.d. 10 Calcium carbonate 125.0 mg Folate 1 mg p.o q day . 13. Synthroid 50 mcg p.o q day . 14. Zinc sulfate 220 mg p.o q day . Multivitamin one tablet p.o. q day Hydrocodone 5 mg with Tylenol one to two tablets every four hours p.r.n. pain . Milk of Magnesia 30 cc p.o. q day constipation . ALLERGIES PENICILLIN <NOTE_END>", "role": "assistant" } ]
[ { "content": "White blood cell count 5.8 hematocrit 23.5 platelet count 118 . Sodium 140 potassium 3.9 chloride 103 bicarbonate 18 BUN 11 creatinine 0.8 glucose 144 . PT 29 INR 1.1 and PTT 22.9 . Neurologically the patient is alert and oriented times three anxious . Neurological examination is non-focal . Heart is regular rate and rhythm without rub or murmur . Respiratory breath sounds are clear bilaterally decreased at the bases . Abdomen with positive bowel sounds soft nontender nondistended tolerating a regular diet . Sternal incision staples are intact and open to air . Incision is clean and dry . There is no erythema and sternum is stable . Right lower extremity vein harvest site has a moderate", "role": "user" }, { "content": " amount of ecchymosis at the very distal portion of the incision at the ankle . There is a minimum amount of serosanguinous drainage . There is no erythema . DISCHARGE DIAGNOSES Coronary artery disease . Status post coronary artery bypass graft times four . Type 2 diabetes mellitus . Postoperative anemia . <NOTE_END>", "role": "assistant" } ]
[ { "content": "The patient was taken to the Operating Room the day of admission . He underwent a left bronchoscopy and lower lobectomy of the left side . The operation was subsequently complicated by a postoperative bleeding . The patient had to be taken back to the Operating Room where a repair of the left pulmonary artery was performed . The patient was then transferred to the CSRU intubated in stable condition . Vascular Surgery Service was also consulted . During the operation", "role": "user" }, { "content": " the patient received 13 units of packed red blood cells four units of fresh frozen plasma and one unit of platelets with an estimated blood loss of 1500 cc . The patient remained to be stable on the floor with subsequent monitoring of hematocrit within a normal stable range . He is successfully extubated on 08-12 and hypertension transferred to the floor in stable condition where the Pain Service is managing his epidural with very good effect and he is tolerating a regular p.o. diet and is making adequate amount of urine . His recovery was essentially unremarkable . His epidural was successfully discontinued and he is discharged to home on 08-15 with instructions to follow-up with Dr. Cordova in the office within the next one to two weeks . He is discharged to home with pain medication which is percocet . CONDITION ON DISCHARGE Stable . DISCHARGE STATUS To home without service . DISCHARGE DIAGNOSES Left lung mass status post resection . Harriet D. Buffington M.D. 51 -721 Dictated By Steven L. Ibarra M.D. MEDQUIST36 D 2015-08-17 1050 T 2015-08-21 1628 JOB 00413 Signed electronically by DR. Natasha Toth on <NOTE_END>", "role": "assistant" } ]
[ { "content": "Atenolol 25 mg p.o. q. day . Lasix 20 mg p.o. q. day times seven days . 3. Potassium chloride 20 mEq p.o. q. day times seven days . 4. Niferex 150 mg p.o. q. day times one month . 5. Vitamin C 500 mg p.o. twice a day times one month . 6. Multivitamin one p.o. q. day times one month . Ambien 5 mg p.o. q. h.s. p.r.n. Colace 100 mg p.o. twice a day . Avandia 4 mg p.o. q. day . Glucophage 500 mg p.o. twice a day . Lipitor 20 mg p.o. q. day . Zantac 150 mg p.o. twice a day . 13. Niaspan 500 mg p.o. q. day . 14. Percocet 5 325 one to two p.o. q. four to six hours p.r.n. DISPOSITION The patient is to be discharged to home . CONDITION ON DISCHARGE Stable condition . DISCHARGE INSTRUCTIONS The patient is to follow-up with Dr. Neri in", "role": "user" }, { "content": " one to two weeks . The patient is to follow-up with Dr. Rota in three to four weeks . The patient is to return to Smith on or about 05-17 to have his staples removed . Gabriela E. D. Castillo M.D. 05-025 Dictated By Julia Q Mcafee M.D. MEDQUIST36 D 2017-05-01 1506 T 2017-05-01 1537 JOB 59432 Signed electronically by DR. Kathy Brendel on TUE 2017-05-02 808 AM <NOTE_END>", "role": "assistant" } ]
[ { "content": "The patient worsened rapidly following admission and it was clear to his family and to his physician that he was pre-terminal . All efforts were directed to his comfort and he", "role": "user" }, { "content": " died on July 1 1992 . Autopsy permission was declined by the family . NU L. GALL M.D. TR vb bmot DD 7-30-92 TD 08 03 92 CC DR. VERD CHURLAUNT DR. <NOTE_END>", "role": "assistant" } ]
[ { "content": "The patient was admitted for rule out myocardial infarction . The patient ruled in for myocardial infarction with CPK maximum on hospital day number one peak of 186 and iso of 23.8 and index of 12.8 on September 2 1994 . The patient was seen in consultation by Dr. Signs for Dr. Churlaunt of Cardiology . The patient received the appropriate protocol for myocardial infarction intravenous heparin aspirin and beta blockers for rate and blood pressure control . The patient on the date of September 5 1994 had cardiac catheterization which showed normal resting hemodynamics . The patient has a small non-dominant right coronary artery left anterior descending showed severe proximal lesion with more distal lesions of diagonal one . The left circumflex was dominant with severe disease of obtuse marginal one with moderate mid-circumflex stenosis and moderate posterior descending artery lesion . The left ventriculography shows anterior akinesis and apical severe hypokinesis with a moderately depressed ejection fraction cardiac output of 3.9 index of 2.0 . The patient was seen in consultation by Cardiac Surgery for evaluation of coronary artery bypass grafting . The patient had stable hematocrit of 38 on", "role": "user" }, { "content": " intravenous heparin . The carotid noninvasives preoperatively were negative . Dental consult was negative . On the date of September 11 1994 patient underwent a coronary artery bypass grafting with saphenous vein graft to the posterior descending artery circumflex and diagonal and left internal mammary artery to the left anterior descending . The patient had a bypass time of one hour and fifty minutes with good urine output and pre-bypass cardiac output of 4.0 post-chest closure 5.3 arrived to the Surgical Intensive Care Unit on Nipride Lidocaine of 1 and Fentanyl Versed of 10 . The postoperative hematocrit was 26 . The patient had a routine postoperative course in the Surgical Intensive Care Unit with a postoperative BUN and creatinine of 11 and 1.2 with good urine output of over 100 an hour and patient received two units of packed red blood cells fresh frozen plasma and platelets for increasing chest tube drainage . The patient on the date of postoperative day number one September 13 1994 was transferred from the Surgical Intensive Care Unit up to the FIH 18 floor . The patient &aposs only post-Surgical Intensive Care Unit course was remarkable for hypertension requiring Nipride and bleeding which was controlled with fresh frozen plasma platelets . The patient had a stable hematocrit of 30 with CPK &aposs postoperatively maximum MB fraction of 78 . On postoperative day number three patient went into atrial fibrillation which was treated appropriately with metoprolol and digoxin and converted back to sinus rhythm . The patient continued to need diuresis . The postoperative medications up on FIH were Coumadin baby aspirin Isordil 10 PO t.i.d. Digoxin .25 q.day metoprolol 25 PO b.i.d. Chest tubes and wires were all discontinued according to protocol on postoperative day number four . The Isordil was also discontinued . The patient &aposs incisions sternal and right leg were clean and healing well normal sinus rhythm at 70-80 with blood pressure 98-110 60 and patient was doing well recovering ambulating tolerating regular diet and last hematocrit prior to discharge was 39 with a BUN and creatinine of 15 and 1.0 prothrombin time level of 13.8 chest X-ray prior to discharge showed small bilateral effusions with mild cardiomegaly and subsegmental atelectasis bibasilar and electrocardiogram showed normal sinus rhythm with left atrial enlargement and no acute ischemic changes on electrocardiogram . Note patient needs anticoagulation for large saphenous vein graft to prevent any possibility of thrombosis . The patient was discharged home in stable condition and will follow up with his cardiologist and will follow up with Dr. Hemp and Dr. Signs . A NECESSARY M.D. DICTATING FOR G HEMP M.D. TR ee bmot DD 9-18-94 TD 09 19 94 CC <NOTE_END>", "role": "assistant" } ]
[ { "content": "On physical examination blood pressure is 130 80 pulse 74 and regular respirations 14 . Her chest demonstrated bibasilar crackles . Cardiovascular exam the jugular venous pressure was seven centimeters carotid upstroke normal . The heart exam revealed a normal Sl and", "role": "user" }, { "content": " S2 was normally split . There was an S4 no S3 grade II VI apical murmur in systole no rubs . The abdomen was benign unremarkable . Extremities no calf tenderness or peripheral edema . Peripheral pulses were 2 and symmetrical bilaterally . <NOTE_END>", "role": "assistant" } ]
[ { "content": "No known drug allergies PHYSICAL EXAMINATION The head eyes ears nose and throat unremarkable . The lungs were clear . Heart regular rate and rhythm . The abdomen was soft and non-tender . Left hip shows flexion and extension 40 . Right hip flexion and extension 40 and 0 . IMPRESSION Right hip pain degenerative joint disease for right total hip replacement . HOSPITAL COURSE AND TREATMENT The patient was admitted to the hospital as a postoperative admit on December 7 for total hip replacement . For further details of this procedure see operative note . Postoperatively he did well initially in the first 12 hours . However he had a report of emesis of coffee grounds on postoperative night 1 . This with no electrocardiogram changes . Due to this GI was consulted and felt that he would be a candidate for esophagogastroduodenoscopy . He was placed nothing by mouth and the esophagogastroduodenoscopy was done by the", "role": "user" }, { "content": " GI Service . Findings showed a Mallory Weiss tear nonspecific duodenitis . He was placed on Zantac 150 mg. PO b.i.d. and H Pylori serology was sent . Post EGD his diet was advanced slowly and he did exceptionally well . At the time of discharge he was tolerating a full diet out of bed with pain tolerated on po. medications . His wound was intact with no evidence of infection . Distal neurovascular status was intact . There was no calf tenderness and lower extremity arterial non-invasive studies were negative . He was generally well in all regards . The physical examination was unremarkable and he had no recurrent symptoms of coffee ground emesis . He was doing exceptionally well at discharge with plans to follow up with Dr. Rhalttland . Discharge instructions have been given . ROYNEO WALLA M.D. DICTATING FOR LI RHALTTLAND M.D. TR hbq DD 12 12 96 TD 12 12 96 900 A cc <NOTE_END>", "role": "assistant" } ]
[ { "content": "Metastatic gallbladder cancer . Status post cholecystectomy . Status post transverse colectomy with anastomosis . G tube placement . Feeding jejunostomy . Hypothyroidism . Blood loss", "role": "user" }, { "content": " requiring transfusion . <NOTE_END>", "role": "assistant" } ]
[ { "content": "Aspirin 325 mg po q day . Vasotec 7.5 mg po q day . Humalog insulin sliding scale with meals and at bedtime . Humulin Walters insulin 24 units subcutaneous q A.M. and 8 to 16 in the evening depending upon where his blood sugar has been . Preoperative laboratory values were unremarkable . The patient underwent cardiac catheterization on 2011-10-17 which revealed a 20 left vein osteal lesion as well as 70 LAD lesion and an 80 right coronary . The patient was taken to the operating room on 2011-10-18 where he underwent an aortic valve replacement with 23 mm pericardial valve as well as coronary artery bypass graft times two with a LIMA to the LAD and saphenous vein to the acute marginal . Postoperatively the patient was transported to the cardiac surgery recovery unit on Milrinone Neo-Synephrine and Levophed drip . The patient was weaned from mechanical ventilation and subsequently extubated on the night of surgery . He remained on Levophed Milrinone and Neo-Synephrine drips and was hemodynamically stable . N. Saez clinic consult was obtained due to hyperglycemia and the need for insulin drip in the Intensive Care Unit . On postoperative day the Milrinone was weaned down . The Levophed had been discontinued as the Neo-Synephrine and the patient was beginning to progress hemodynamically . Upon discontinuation of the Milrinone the patient s SV02 had dropped significantly in the low 50 s. The patient had decreased exercise tolerance and therefore was placed back on his milrinone to keep his cardiac index greater than 2.0 . Over the next couple of days it was very slowly decreased as his Ace inhibitors were increased orally . The patient ultimately was weaned off the Milrinone transitioned to Captopril on postoperative day five and remained hemodynamically stable . Once the patient had remained off of inotropics for approximately 24 hours he had been given diuretics and Ace inhibitors and remained hemodynamically stable he was transferred from the Intensive Care Unit to the Telemetry floor on postoperative day six . A physical therapy evaluation was obtained for assistance and mobility . Cardiac rehabilitation was initiated at that time . On 2011-10-24 postoperative day six consultation heart failure cardiology service was obtained . It was their recommendation to continue Ace inhibitors to continue daily weights to switch the patient to a long acting beta-blocker and to enroll the patient in postoperative cardiac rehabilitation as well as to make sure the patient was on statin drugs . These measures were all instituted . The patient continued to progress from cardiac rehabilitation and physical therapy standpoint while on the floor . The patient remained hemodynamically stable over the next few days continued to increase with physical therapy and ambulation . His blood sugars were followed by", "role": "user" }, { "content": " the Cape Cod Hospital Clinic service and insulin has been adjusted accordingly . Today 2011-10-31 postoperative day 13 the patient remains stable and ready for discharge to home . The patient s condition today is as follows Temperature 96.9 F pulse 84 respiratory rate 18 blood pressure 106 59 . Most recent laboratory values are from 2011-10-25 which revealed a white blood cell count 8.4000 hematocrit 35 platelet count 202 000. Sodium 133 potassium 4.4 chloride 93 CO2 30 BUN 24 creatinine 0.7 glucose 198 . The patient s finger stick blood glucose levels range from 151 to 390 over the past 24 hours and his insulin scale has been adjusted upward to compensate for that . Neurologically the patient is grossly intact . Pulmonary exam he is clear upper lobes diminished bilateral bases left greater than right . Coronary exam is regular rate and rhythm . His abdomen is benign . His sternum is stable. His incision is clean and dry Steri Strips intact . His extremities are warm and well perfused with minimal edema of his left foot as well as his right stump . He is able to apply his prosthesis and ambulate as well . <NOTE_END>", "role": "assistant" } ]
[ { "content": "On admission revealed a white blood cell count of 9.46 with 89 polys 2 bands 7 lymphocytes 2 monocytes . Cyclosporin A level on admission was 179 . Microscopic exam", "role": "user" }, { "content": " showed 4 Staph . <NOTE_END>", "role": "assistant" } ]
[ { "content": "Bactrim single strength one p.o. b.i.d. times 10 days initiated 9 27 92 Synthroid 0.1 mg p.o. q.day Ferrous Gluconate 300 mg p.o. t.i.d. and Folate 1 mg p.o. q. day . She will be seen by Visiting Nurses Association to help with general aspects of daily living as well as adequate diet planning following her gastric resection . TOMEDANKELL FLOWAYLES M.D. TR cdw", "role": "user" }, { "content": " bmot DD 01-21-92 TD 01 22 92 CC <NOTE_END>", "role": "assistant" } ]
[ { "content": "On admission vital signs Temperature 101.4 blood pressure 101 62 pulse 80 respiratory rate 19 on a ventilator with settings of assist control at 500 12 and a PEEP", "role": "user" }, { "content": " of 5 . General The patient is intubated and sedated but easily arousable . HEENT Pupils equally round and reactive to light . Sclerae are anicteric . ET tube is in place . Neck Soft and supple . Cardiovascular Normal . Chest Faint scattered wheezes bilaterally . Abdomen Benign . Extremities Warm with good distal pulses . There is no edema . Neurologic Able to follow simple commands . <NOTE_END>", "role": "assistant" } ]
[ { "content": "Levoxine 0.125 mg PO q.day Vasotec 10 mg PO b.i.d. Maxzide 75", "role": "user" }, { "content": " 50 30 mg PO q.day . <NOTE_END>", "role": "assistant" } ]
[ { "content": "He is healthy looking . The", "role": "user" }, { "content": " general physical examination did not reveal any abnormality . Heart chest and abdominal examinations were normal . The right knee examination showed some effusion . The range of motion was 15 to 120 degree on the right side and on the left side it was zero to 135 . There was normal muscle power . The peripheral pulses were palpable . <NOTE_END>", "role": "assistant" } ]
[ { "content": "Nonischemic dilated cardiomyopathy . MEDICATIONS ON DISCHARGE 1. Digoxin 375 mcg and 250 mcg alternating doses each day . Lisinopril 40 mg p.o. q.d. Toprol XL 75 mg p.o. q.d. Flovent 110 mcg two puffs b.i.d. 5. Albuterol 1-2", "role": "user" }, { "content": " puffs q.6h. prn . 6. Coumadin 10 mg p.o. q.h.s. Lasix 40 mg p.o. q.d. Keflex 500 mg x6 doses . FOLLOW-UP INSTRUCTIONS The patient will follow up in EP Clinic on 2012-03-19 . She will also be seen in the Heart Failure Clinic on 2012-03-28 . Patient will also followup with her primary care provider Dr. Sandra Lamar for check of her INR in one week s time . Felix Weiss M.D. 95 -771 Dictated By Randy EB Brooks M.D. MEDQUIST36 D 2012-03-13 1225 T 2012-03-13 1400 JOB 15824 Signed electronically by DR. <NOTE_END>", "role": "assistant" } ]
[ { "content": "Included his pre-admission medications", "role": "user" }, { "content": " . A HAS M.D. TR yy bmot DD 10-21-92 TD <NOTE_END>", "role": "assistant" } ]
[ { "content": "The patient is a 50-year-old female with history of low back pain radiating to both legs . She had increasing symptoms overtime not controlled by conservative management . She therefore elected to undergo surgical treatment . PAST MEDICAL HISTORY Her past medical history is notable for bilateral lower extremity venous insufficiency with edema hypertension . She takes lisinopril hydrochlorothiazide 20 25 mg p.o. q.d. Vioxx 50 mg p.o. q.d. Lipitor 10 mg p.o. q.d. Nortriptyline", "role": "user" }, { "content": " 25 mg p.o. q.h.s. Neurontin 300 mg p.o. t.i.d. <NOTE_END>", "role": "assistant" } ]
[ { "content": "The patient is an 87-year-old male with stage D prostate was cancer was admitted for fluid hydration on the 10th of March The patient was initially diagnosed with prostate cancer in August of 1989 . He presented with gross hematuria at that time Subsequent prostatic biopsy revealed a Gleason s IV plus V tumor and the CT showed an irregular large prostate with tumor invasion into the bladder and evidence of bilateral retroperitoneal lymph node spread . There was also evidence of bone metastasis at that time The patient was admitted in October of 1991 for urinary retention and acute renal failure and was treated with fluid rehydration and Foley catheter placement . Over the past one month prior to admission the patient s wife has noticed a marked decrease in p.o. intake and also noted a weight loss of approximately ten pounds in the preceding two weeks The patient has been lethargic and bed ridden for the past two weeks although there was no evidence of fever or chills over this time . The patient is now admitted for fluid rehydration therapy and observation", "role": "user" }, { "content": " The patient is an 87-year-old male with stage D prostate was cancer was admitted for fluid hydration on the 10th of March The patient was initially diagnosed with prostate cancer in August of 1989 . He presented with gross hematuria at that time Subsequent prostatic biopsy revealed a Gleason s IV plus V tumor and the CT showed an irregular large prostate with tumor invasion into the bladder and evidence of bilateral retroperitoneal lymph node spread . There was also evidence of bone metastasis at that time The patient was admitted in October of 1991 for urinary retention and acute renal failure and was treated with fluid rehydration and Foley catheter placement . Over the past one month prior to admission the patient s wife has noticed a marked decrease in p.o. intake and also noted a weight loss of approximately ten pounds in the preceding two weeks The patient has been lethargic and bed ridden for the past two weeks although there was no evidence of fever or chills over this time . The patient is now admitted for fluid rehydration therapy and observation <NOTE_END>", "role": "assistant" } ]
[ { "content": "Coronary artery disease Myocardial infarction x3 Coronary artery bypass graft Systemic lupus erythematosus in remission HOME MEDICATIONS 1. Coreg 6.25 mg po bid 2 Lasix 25 mg po qd 3 Imdur 30 mg po qd K-Dur 10 milliequivalents po", "role": "user" }, { "content": " qd Zestril 2.5 mg po bid Multivitamin Folate ALLERGIES He has no known drug allergies . PHYSICAL EXAM VITAL SIGNS He was afebrile with stable vital signs HEART Regular rate and rhythm with a 2 out of 6 systolic ejection murmur heard loudest at the apex . LUNGS Clear to auscultation . ABDOMEN Soft nontender nondistended . EXTREMITIES No cyanosis clubbing or edema . Palpable DP s bilaterally PERTINENT LABS His hematocrit was 44 White count was 8 . Potassium was 3.9 BUN and creatinine was 18 and 0.9 . His troponin was 29.7 <NOTE_END>", "role": "assistant" } ]
[ { "content": "Include Neupogen 480", "role": "user" }, { "content": " mcg. subq. q.d. and usual medications . <NOTE_END>", "role": "assistant" } ]
[ { "content": "At the time of admission", "role": "user" }, { "content": " laboratories were remarkable for a partial thromboplastin time of 31.7 INR 1.4 potassium 3.2 glucose 182 lactate was initially 6.6 . Urine toxicology screen was negative . Serum toxicology screen was positive for TCA s. Tylenol level was 15 . Alcohol level was 199 . Initial blood gas was 7.31 46 500 77 . <NOTE_END>", "role": "assistant" } ]
[ { "content": "On admission includes an electrocardiogram that shows DDD pacing . Hematocrit 39 percent white blood cell count 4500 PT and PTT normal . Sodium 140 potassium 4.2 chloride 105 carbon dioxide 30 BUN 24 creatinine 1.0 . HOSPITAL COURSE AND TREATMENT The patient was admitted to the Cardiac Catheterization Laboratory . There her pulmonary wedge pressure was 12 and her right atrial pressure was 4 and pulmonary artery pressure 44 17 . Her left ventricular contraction showed akinesis of the anterior wall with dyskinesis of the apex . She had preserved inferior contraction and basal contraction . Her native right and left anterior descending vessels were occluded as was an obtuse marginal branch . The saphenous vein to the high diagonal or high obtuse marginal was occluded . The left internal mammary artery to the left anterior descending was also occluded . The saphenous vein graft to the second obtuse marginal was open with no significant stenosis but there was an outflow lesion in the obtuse marginal 2 as well as severe distal lesion as the obtuse marginal 2 fed the posterior descending artery . This was considered her culprit lesion . This was considered too high risk for angioplasty because of the severe disease in the graft . In addition it was noted that she had saphenous vein harvested from both thighs . Her left internal mammary artery was also unused . It was also noted that she had failure to sense with the atrial lead . She would not sense the atrial contraction and the fire and this occasionally led to competition of firing . This was intermittent . The P wave amplitude was .6 and this could not be totally sensed . The patient was admitted", "role": "user" }, { "content": " for management of her coronary artery disease and evaluation of her pacemaker . It was noted that she became very symptomatic when she was not on a beta blocker but that on a beta blocker she had significant pacemaker failure . Her pacemaker was set to a VVI mode which sensed appropriately . She was in sinus rhythm with most of the time . When her pacemaker was in a sinus rhythm without a beta blocker she had significant angina . Carotid non-invasive testing was unremarkable . The situation was reviewed with Dr. Niste Graft . He felt the patient was not a coronary artery bypass graft candidate because of the lack of conduit and because of the presence of a large anterior myocardial infarction . For this reason it was decided to maximize her beta blockers and nitrates . The situation was reviewed with Dr. No of the Pacemaker Service . On August 20 under local anesthesia the right pectoral region was explored and the leads disconnected and the pulse generator changed to a CPI unit in which the sensitivity could be adjusted to .15 mm. which permitted appropriate atrial sensing . There was nothing wrong with the prior generator and nothing wrong with the leads . It just needed a unit that could have more sensitivity in the atrial mode . She tolerated this well . Her medications were resumed . She ambulated without difficulty and was discharged to home to be followed medically for her coronary artery disease following two failed bypass graft procedure by Dr. Brendniungand Asilbekote in Bi Masase KS . ACHASTHA N. GRAFT M.D. TR hfr DD 08 22 1998 TD 08 27 1998 356 P cc ACHASTHA NICEMAEN GRAFT M.D. GITTETUMN DARNNAMAN <NOTE_END>", "role": "assistant" } ]
[ { "content": "At that time it was felt that the patient was likely having a repeat GI bleed and while he was hemodynamically stable he had evidently lost a substantial", "role": "user" }, { "content": " amount of blood . <NOTE_END>", "role": "assistant" } ]
[ { "content": "The patient had complaint of headaches in the past She has fibromyalgia and a history of slurred speech", "role": "user" }, { "content": " . Her last menstrual period was on 2017-08-29 <NOTE_END>", "role": "assistant" } ]
[ { "content": "significant for a white blood count of 6.0 hematocrit 35.9 electrolytes within normal limits BUN and creatinine of 13 and 0.8 amylase of 56 . The patient had an electrocardiogram which showed no acute ischemic change . His chest X-ray", "role": "user" }, { "content": " ruled out acute cardiopulmonary process . Left foot changes consistent with osteomyelitis of the left great toe . <NOTE_END>", "role": "assistant" } ]
[ { "content": "Renal tubular acidosis distal type I shock severe acidosis and severe electrolyte imbalance seizure disorder rule out sepsis varicella . HISTORY OF PRESENT ILLNESS Date of birth 10 4 88 . This patient is a 5 year old white female with a history of type I renal tubular acidosis on nephrocalcinosis who was admitted to Noughwell Entanbon Health of Washington on 9 5 93 at 2116 hours with a 2-3 day history of chills fevers cough vomiting and weakness unable to walk . At Noughwell Entanbon", "role": "user" }, { "content": " Health her temperature was 101 pulse 135 blood pressure 94 74 respiratory rate 20 . Positive findings of physical examination include chicken pox lesions on thorax sunken eyes thick nasal discharge dry lips tongue and mucous membranes red tonsils . The remainder of the physical examination was considered within normal limits . Admission diagnosis at Ni Hospital &aposs vomiting and dehydration hypokalemia hyponatremia tonsillitis . A peripheral intravenous line was started on Labor Day in the a.m. No respiratory distress was noted . Oral cyanosis and shallow respirations were noted on 9 7 93 at 245 a.m. Therefore the patient was intubated at 345 a.m. on 9 7 93 . Chest x-ray was unremarkable . Cardiovascular stable significant hypertension was noted on 9 7 93 at 510 a.m. and therefore 10 cc&aposs per kilo albumin was given . The patient was admitted was started on clear fluids tolerated with D5 normal saline plus 40 mEq per liter of KCL at a rate of 50 cc &aposs per hour for 9 hours . 100 cc&aposs per kilo . Sodium and potassium at this time were 128 1.5 . At Labor Day 930 a.m. the fluids were increased to 100 cc&aposs per hour 200 cc&aposs per kilo for 5 hours . Electrolytes at this point were sodium 132 potassium 1.8 . At 9 6 93 230 p.m. fluids were decreased to 75 cc&aposs per hour 150 cc&aposs per kilo 40 mEq of K phosphate added to the intravenous fluids . Electrolytes at this point were a sodium of 143 and potassium 1.7 . On 9 6 93 2200 fluids were changed to D5 normal saline plus 40 KCL and 40 K phosphate at 75 cc &aposs per hour . This rate was maintained for 11 hours . Electrolytes at this time were a sodium of 148 potassium 1.7 . At 9 7 93 100 a.m. intravenous fluids rate was decreased to 50 cc&aposs per hour total fluids given during the first 24 hours were 140 to 150 cc&aposs per kilo per day . At this time sodium was 147 potassium 2.6 total sodium given during the first 24 hours 20 mEq per kilo per day . On 9 7 93 at 400 a.m. albumin bolus 5 10 cc&aposs per kilo was given a total of 120 cc&aposs electrolytes were sodium 155 potassium 3.1 . At 9 7 93 at 500 a.m. sodium bicarbonate given 60 mEq calcium bolus 10 cc&aposs given . On 9 7 530 a.m. D5 quarter normal saline and 40 of K phosphate at 100 cc&aposs per hour was given . The patient was taking PO initially until 9 6 93 at 1745 . There were no abnormal findings in abdominal exam . On 9 5 93 hematocrit 48 white blood count 11.2 neutrophiles 67 bands 14 lymphs 11 monos 6 meta 2 platelets 220 000 . Copious urine output BUN 1.0 creatinine .8 . Normal neurologic exam on admission then lethargic on 9 6 93 at 1745 then patient became unresponsive areflexic and limp at 9 6 93 at 1745 to 2200 . Patient was having seizures twitching of face and rapid movements of eyes . Pupils dilated and sluggish . Valium was given at 9 7 93 0002 . IV ampicillin chloramphenicol ceftriaxone and culture were sent . Finally Fairm of Ijordcompmac Hospital transport team was called and transport team arrived on 9 7 93 630 a.m. and on arrival patient was seizing with rhythmic eye movement to left . The patient was unresponsive poor perfusion . Temperature was 101.8 . A second intravenous was started and given normal saline bolus change in intravenous fluids to D5 water with 80 mEq of bicarbonate plus 40 mEq of KCL at 45 cc&aposs per hour bicarbonate given 2 mEq per kilo attempted to start dopa for poor perfusion but worsening perfusion . Therefore dopa was stopped . Total volume given as bolus 50 cc&aposs per kilo sodium bicarbonate at 2 mEq per kilo was given . Last ABG there was 6.98 31 171 bicarbonate of 7 . Phenobarbital and Dilantin given for seizure control . Electrolytes before departure for Fairm of Ijordcompmac Hospital was a sodium of 176 potassium 2.5 chloride 140 bicarbonate 14 calcium 7.2 magnesium 2.7 . Admission to the Pediatric Intensive Care Unit at Fairm of Ijordcompmac Hospital was 9 7 93 1115 a.m. Lines placed were a right femoral triple lumen endotracheal tube 4.0 arterial line right radial line Foley placed peripheral intravenous line nasogastric tube . On admission to Fairm of Ijordcompmac Hospital temperature 100.2 pulse 149 respiratory rate 50 blood pressure 98 66 mean arterial pressure of 73 weight 12 kilos . <NOTE_END>", "role": "assistant" } ]
[ { "content": "Iodine and shellfish cause throat", "role": "user" }, { "content": " tightening . <NOTE_END>", "role": "assistant" } ]
[ { "content": "By systems Respiratory . After receiving brief blow by oxygen in the delivery room the patient had no further episodes of ventilatory assistance required with good respiratory rate consistently . The patient was never placed on caffeine . He is stable in room air at this time . Cardiovascular . No active issues . No history of hypotension . On no medications at this time . Notably with respect to apnea and bradycardia of prematurity the patient has reached 5 days without significant apneic or bradycardic spells as of the time of discharge . Fluids electrolytes and nutrition . The patient reached full volume feeds by day of life 6 and had calories increased to maximum of 26 kilocalories per ounce of Similac special care until 2014-12-03 at which point this was weaned to 24 kilocalories per ounce of straight Similac . This is the baby s discharge feedings and he is p.o. ad lib with", "role": "user" }, { "content": " a minimum of 130 ml kg day the patient has taken on an average greater than 150 ml kg day ad lib over each of the past 5 days . GI . The patient with peak bilirubin of 6.5 on day of life 3 . No phototherapy was required . Hematology Infectious Disease . The patient s hematocrit at delivery was 48 with a white count of 11.2 and platelets of 301 000 . Initial differential was 35 polys and zero bands not suspicious for infectious condition . The patient was initially treated with 48 hours of ampicillin and gentamicin until blood cultures were negative . The infant has had no antibiotics since that time . Neurology . No issues . Sensory . Hearing screen was performed with automated auditory brainstem responses and was normal on 2014-11-24 . Ophthalmology . The patient did not qualify for routine ophthalmology exams due to his gestational age at birth . <NOTE_END>", "role": "assistant" } ]
[ { "content": "The patient was a 71 year old white female with a history of carcinoid lung cancer who presented for evaluation of a tracheoesophageal fistula . The patient was initially diagnosed in 1978 with atypical small cell carcinoma of the lung and treated with chemotherapy and radiation therapy until 1980 . She did well for approximately twelve years until she was diagnosed with carcinoid cancer of the same right upper lobe . This may have been the initial primary cancer although it is unclear at present . Bronchoscopy at that time showed an endobronchial tumor of the right upper lobe bronchus and it was felt to be unresectable . She underwent four treatments of brachytherapy in March through May of 1993 . She had been doing reasonably well until", "role": "user" }, { "content": " December of 1993 when she presented with persistent and worsening cough and near strangulation on attempts at eating solids or drinking liquids . A bronchoscopy showed a tracheoesophageal fistula with an opening into the trachea above the carina and no tumor in the right upper lobe . She has been on total parenteral nutrition and has been nothing by mouth since then . A barium swallow prior to admission showed the presence of a tracheoesophageal fistula with entrance into the right mainstem bronchus below the carina . PAST MEDICAL HISTORY Bronchitis asthma carcinoid cancer no history of coronary artery disease or cerebrovascular accident . PAST SURGICAL HISTORY The patient is status post appendectomy hysterectomy and right salpingo-oophorectomy bladder suspension and a tumor removal from the right neck . <NOTE_END>", "role": "assistant" } ]
[ { "content": "Patient has allergies to penicillin . She gets hives . Bactrim she gets hives", "role": "user" }, { "content": " . Percocet and erythromycin she gets gastrointestinal upset and Keflex she gets hives . <NOTE_END>", "role": "assistant" } ]
[ { "content": "Discharge medications Baclofen 10 p.o. t.i.d. MVI one tablet p.o. q.d. Mycostatin powder TP q.d. to be applied to the rash in her left groin area also dilaudid 8 mg p.o. q2h Colace 100 mg p.o. b.i.d.', 'coumadin 2.5 mg p.o. q.h.s. fentanyl patch 75 micrograms per hour topical q72", "role": "user" }, { "content": " hours atenolol 100 mg p.o. q.d. <NOTE_END>", "role": "assistant" } ]
[ { "content": "The patient was nonverbal but was able to open her eyes and", "role": "user" }, { "content": " nod . No respiratory distress . Her temperature was 102.2 blood pressure 135 64 pulse rate 108 respirations 24 oxygen saturations on room air 94 . The head eyes ears nose and throat examination revealed no ocular abnormalities . Neck no lymphadenopathy no carotid bruits jugular venous pressure not elevated no goiter . Chest reduced breath sounds at the bases with faint inspiratory rhonchi anteriorly . Cardiac regular rate and rhythm with frequent premature beats and a 2 6 systolic ejection murmur at the apex . The abdomen was non-tender nondistended no hepatomegaly normal bowel sounds . Extremities 1 edema 2 pulses . Skin intact with diaper . <NOTE_END>", "role": "assistant" } ]
[ { "content": "The patient was admitted with a right occipital cerebral infarction . The patient was started on intravenous heparin and had the studies as described above for rule out source of embolic strokes including carotid noninvasives transcranial Dopplers Holter electrocardiogram and echocardiogram . The patient also had serial electrocardiogram which showed no change . The patient also had serial creatinine kinase with MB fractions studied which revealed MB fraction too low to be tested . The patient also experienced a feeling of moving back and forth when lying down with neck extended during the magnetic resonance imaging study and also in bed . This moving sense with normal electroencephalogram was thought to be a mild vestibular dysfunction or from the acute episode of the stroke . The patient will have these symptoms only when the eyes are closed . Our opinion was not to intervene or have any further studies for acute period and to continued to observe . The patient did have a hypotensive episode and the systolic blood pressure was 80 after the patient received his regular cardiac medications . The patient had been off his regular medications since during the admission and will be discharged off his medications . Otherwise there were no further episodes of blurred", "role": "user" }, { "content": " vision . The patient was stable with an unchanged neurological and physical examination and was discharged on aspirin 325 mg po qd on May 14 1995 . The patient will be randomized on the Wars study early next week by the Stroke Service at Ph University Of Medical Center . CONDITION ON DISCHARGE The patient was stable with the physical examination as described above . DISCHARGE ORDERS Medications aspirin 325 mg po qd Glipizide 25 mg po qd . The patient will be discharged home without his regular cardiac medications . The patient will be followed by Dr. Ketyvi Liftjesc of the Neurology Service at Ph University Of Medical Center on May 17 1995 for randomization on the Wars study . The patient will be also followed by Dr. Joseet Gelineau of the Neurology Service at Ph University Of Medical Center . The patient will also be followed by Dr. Margmimaui Gelineau his primary care physician at Ochtuheihugh Put University Medical Center within one week after discharge . The patient will also be followed by his regular Urologist at Ochtuheihugh Put University Medical Center within one week after discharge for his continuing hematuria . JOSEET GELINEAU M.D. TR lj bmot DD 05 13 95 TD 05 17 95 CC <NOTE_END>", "role": "assistant" } ]
[ { "content": "Included Lasix Lopressor Coumadin Diovan torsemide Flomax Protonix Senekot potassium vitamin C iron and a", "role": "user" }, { "content": " multivitamin . <NOTE_END>", "role": "assistant" } ]
[ { "content": "Coronary artery disease", "role": "user" }, { "content": " status post MI x2 CABG x2 in 02 89 and 2 21 history of arthritis history of bilateral rotator cuff degeneration and tears history of hypertension history of hyperlipidemia . <NOTE_END>", "role": "assistant" } ]
[ { "content": "Evista 60 mg p.o. daily . 2. Tamoxifen 20 mg p.o. daily . 3. Lisinopril 5 mg p.o. daily . 4. Triamterene Hydrochlorothiazide 37.5 25 mg p.o. daily . 5. Enteric Coated Aspirin 325 mg p.o. daily . 6. Meclizine 25 mg q8hours p.r.n. Aggrenox twice a day the dose was not known . Synthroid 125 mcg daily . Levofloxacin 250 mg p.o. daily to complete a fourteen day course . She was given", "role": "user" }, { "content": " a prescription for ten more days . DISCHARGE DIAGNOSES Influenza A . Hypotension secondary to volume depletion . Anemia . Hypothyroidism . CONDITION ON DISCHARGE The patient was breathing comfortably in room air . She was normotensive and her hematocrit was stable at her baseline upon discharge . Linette Randall Mississippi 82499 Dictated By Jason L Parra M.D. MEDQUIST36 D 2016-12-28 162542 T 2016-12-28 201126 Job 74466 Signed electronically by DR. Wanda PARKS on <NOTE_END>", "role": "assistant" } ]
[ { "content": "The patient was admitted to the Step Down Unit for a rule out MI protocol . He was treated with aspirin heparin and intravenous nitroglycerin . No beta blockers was started because of his history of hypertension with beta blockers and because his blood pressure of only 110 70 . The patient ruled in for myocardial infarction with a peak CPK of 219 and 20.9 MB fraction . This was a non-Q wave myocardial infarction as there were no diagnostic electrocardiogram changes . on 10-27-93 the patient went to the cath lab which revealed a small nondominant right coronary artery without any lesions a restenosis of the proximal left anterior descending lesion that had been PTCA &aposd a lesion in the first OM and a moderately severe left circumflex lesion after the OM3 . The left ventriculogram revealed an akinetic anterolateral and apical ventricle . Given the results of this cardiac catheterization which were not significantly changed from his previous cardiac catheterization prior to the PTCA it was elected to attempt to medically manage the patient . He was ambulated progressively", "role": "user" }, { "content": " on the floor . A beta blocker was started with Metoprolol initially at 25 mg PO bid and eventually increased to 50 mg PO bid . The patient ambulated extensively on the FIH 20 floor each day without any episodes of chest pain or shortness of breath . On 11-2-93 the patient underwent a low level treadmill exercise test with Thallium imaging . This treadmill test was done on medications including beta blockers in hopes to assess an amount of ischemia on treatment . The patient was able to exercise for approximately nine minutes on a modified Bruce protocol however he did not reach his predicted maximal heart rate while he was on the beta blockade . There were no diagnostic electrocardiogram changes during the treadmill exercise test although he did have 0.5 to 1 mm ST depression in II III and AVF . The study was halted for shortness of breath and there was no chest pain . Thallium images revealed a moderate sized region of ischemic but viable myocardium involving the anteroseptal and lateral segments of the left ventricle . There was also some evidence of left ventricular dysfunction during the test . These images were essentially unchanged compared with the previous Thallium images in May 1993 . After extensive discussion between myself Dr. Amesin and Dr. Scgach it was elected to discharge the patient to home with medical management . The patient was extremely reluctant to undergo surgery although he understands that this may become necessary in the future . Dr. Amesin had a long discussion with the patient &aposs daughters revolving primarily around issues of the patient &aposs compliance . Previously he had not taken any of his medicines and smoked heavily on the outside and not kept any of his appointments . The importance of quitting smoking as well as continuing to follow his medical regimen was emphasized to the daughter and to the patient . She will be actively involved in encouraging the patient to comply with this medical regimen and also to follow up with Dr. Amesin as well as Dr. Lfsquarc on the outside . The patient remained guaiac negative throughout the entire hospitalization . Despite being on heparin for a short time his hematocrit remained very stable with only a small dip after the catheterization was done . He will need to be followed up as an out patient for guaiac positive stools and possibly worked up for this in the future . CAGHALA UINTEELE M.D. TR yf bmot DD 11-3-93 TD 11 04 93 CC <NOTE_END>", "role": "assistant" } ]
[ { "content": "As above and once transferred to the floor patient had fingersticks monitored every four hours", "role": "user" }, { "content": " with a sliding scale . Patient reached goal of fingersticks between 50 and 300 which is what she maintains at home . Sliding scale was adjusted as necessary . Patient was continued on intravenous fluids until taking good po . Infectious Disease The patient had an elevated white count upon admission however white count came down to 7.1 and prior to discharge patient was afebrile and no clear etiology for elevated white blood cell on admission questionably secondary to short gastrointestinal infection however patient is completely symptom free upon discharge . Fluid electrolytes and nutrition The patient s electrolytes were repleted as necessary . Potassium was given with her intravenous fluids and phosphate will be repleted as patient increases her po intake . CONDITION OF DISCHARGE Good . DISCHARGE STATUS To home . DISCHARGE DIAGNOSES Diabetic ketoacidosis . Viral gastroenteritis . <NOTE_END>", "role": "assistant" } ]
[ { "content": "The patient was admitted and underwent celiac and superior mesenteric artery angiography which demonstrated a patent celiac and superior mesenteric artery with normal branching pattern . His preoperative workup was completed and included a normal white count hematocrit 42 . normal electrolytes normal coags and normal renal function . On 10-02-94 the patient was brought to the operating room where he underwent exploratory laparotomy and left hepatectomy and cholecystectomy by Dr. Duhenile . The patient tolerated the procedure well with a 2000 cc. blood loss and was autotransfused two units of blood . In the postoperative course Mr. Fyfe did surprisingly well given his underlying medical condition He did require two units of transfused blood but otherwise did quite well and was extubated on the night of surgery . He remained in the Intensive Care Unit for two days but was hemodynamically stable throughout . He continued to manifest occasional premature ventricular contractions but these were unchanged from preoperatively and the patient otherwise did well . His nasogastric tube was discontinued and he was begun on", "role": "user" }, { "content": " clear liquids and subsequently advanced to a regular diet without difficulty . Both of his Jackson-Pratt drains were removed without incident . By postoperative day 7 Mr. Fyfe was tolerating a regular ADA 1800 kilocalorie diet without difficulty with all of his tubes and drains removed . His wound was noted to be healing well and his colostomy functioning appropriately without significant difficulty . He is being transferred back to the Per Naplesspecrycet Hospital in stable condition on the same medications which he was on preoperatively . These include Diabeta 10 mg. po. bid . Serax 20 mg. po. qhs . Sudafed 30 po. bid . Theo-dur 300 mg. po. bid . Betoptic 0.5 one drop OU bid Propene 0.1 one drop OU bid . Pred-Forte 1 one drop OS bid . Percocet two tabs po. q4h prn . Proventil 2 puffs q6hours prn .. The patient will followup with Dr. Fede Duhenile in two weeks in Dr. Duhenile &aposs office . LENNI BREUTZOLN M.D. DICTATING FOR FEDE A. DUHENILE M.D. TR eb bmot DD 10-10-94 TD <NOTE_END>", "role": "assistant" } ]
[ { "content": "Penicillin Erythromycin Valium Compazine Demerol Percodan . MEDICATIONS", "role": "user" }, { "content": " ON ADMISSION 1. Levothyroxine 50 mcg p.o. once daily . Combivent two puffs four times a day . Flovent two puffs four times a day . Protonix 40 mg once daily . Lisinopril 5 mg p.o. once daily . Norvasc 5 mg twice a day . Lasix 40 mg once daily . Senna one once daily . Dulcolax 10 mg once daily p.r.n. 10 . TUMS 500 mg twice a day . <NOTE_END>", "role": "assistant" } ]
[ { "content": "BY SYSTEM Respiratory The baby was intubated in the Delivery Room received two doses of surfactant . Radiograph revealed bilateral diffuse granular pattern consistent with surfactant deficiency . Maximum mechanical ventilation PIP 26 PEEP 6 rate of 25 maximum FIO2 35 percent . Mychelia was extubated to a CPAP of 6 cm on day of life two where she remained until day of life 20 . On day of life two she was also loaded with caffeine and continues on caffeine at time of transfer . She was transitioned to a nasal cannula on day of life 20 and remains on nasal cannula O2 100 percent at 13 cc flow . She averaged 2-3 apnea episodes a day with bradycardia and desaturations . She has a comfortable respiratory rate and good air exchange . Cardiovascular She received a normal saline bolus times one initially for poor perfusion and was started on dopamine with a maximum infusion rate of 6 mcg per kg per hour . This was discontinued on day of life two to maintain a mean arterial pressure of greater than 33 . She has remained hemodynamically stable during the remainder of her hospitalization here . Fluids electrolytes nutrition Initially maintained NPO . UAC and UVC lines were placed upon admission to the CMED . The UAC was left in place until day of life two and was removed after wean from dopamine . UVC remained in place through day of life six and was utilized to administer parenteral nutrition . Electrolytes and glucose remained in the normal range throughout the first week . She was started on enteral feeds on day of life six with a slow advance secondary to increased abdominal girth which was felt to be due to CPAP . She passed meconium . She achieved full feeds on day of life 13 . Calories were gradually increased to breast milk 30 calories with ProMod consisting of four of human milk fortifier four of MCT and two of Polycose with a 12-28 teaspoon of ProMod per 50 ml of breast milk or 60 ml of formula . On day of life six due to concerns for hyperglycemia and abdominal distention sepsis evaluation was obtained . She was noted at this time to have hyperglycemia requiring two subcutaneous doses of insulin and a decreased glucose infusion rate to achieve euglycemia . This resolved that same day . Urine output was always noted to be of sufficient quantity . Gastrointestinal Mychelia demonstrated slow gastrointestinal motility and abdominal distention felt to be due to CPAP . She was slow to advance on enteral feeds and gradually attained full enteral volume on day of life 13 . On day of life 15 she was made NPO for a distended abdomen and a bilious spit . Serial KUBs revealed nonspecific changes with dilated loops . No pneumatosis or free air was seen . She was noted to", "role": "user" }, { "content": " have bluish discoloration thought to perhaps be a bruise on her left lower quadrant . There was no radiographic correlation with this . Feeds were restarted . Again she was advanced to full volume but was made NPO on day of life 20 for abdominal distention . This NPO was temporary for that day and she then resumed feedings and has been tolerating full enteral feeds well improved since off of CPAP passing normal stools guaiac negative . Mychelia was also treated for physiologic jaundice . She was started under phototherapy on day of life one through day of life three with a peak serum bilirubin of 4.7 0.3 . This issue resolved . Hematologic and Infectious Disease Initial CBC was notable for a white count of 5.5 with 49 polys 1 band and 47 lymphs . Initial hematocrit was 46.3 percent and platelets 320 000 . Her initial blood culture remained negative and she received 48 hours of ampicillin and gentamicin . As previously noted on day of life six with hyperglycemia abdominal distention a CBC and blood culture were again obtained revealing a white count of 9.1 with 30 polys 0 bands and 58 lymphs . Hematocrit at that time was noted to be 31 and platelets 370 000 . Blood culture grew staph coagulase negative and the baby received seven days of vancomycin and gentamicin . A lumbar puncture was also performed to rule out meningitis . This culture remained negative with normal cell counts and chemistries . Antibiotic levels were monitored and doses adjusted accordingly . Mychelia required two transfusions during her hospital stay . On day of life 15 for a hematocrit of 29 she received 20 cc of packed red blood cells . She started on iron and vitamin E supplements on day of life 25 and continues on that at this time of transfer . However on day of life 34 12-04 she was noted to be pale and less stress tolerant mottling easily with care . A hematocrit and reticulocyte count showed a hematocrit of 23 percent and a reticulocyte count of 1.9 percent . Therefore with blood available from the first aliquot a second 20 cc per kg of packed red blood cells were infused without incident . Neurological Initial head ultrasound on day of life seven was normal . At one month of age on 12-03 she was noted to have an absent septum pellucidum . An MRI obtained and reviewed by the Hallmark Health System Radiology Department revealed focal gyral morphology consistent with prematurity normal midline structures normal myelination no lesions no signal abnormalities or extracerebral collections . The cortical ribbon is intact . The major vascular structures at the skull base are normal . The septal leaflets may be partially absent but there are no coronal images provided for confirmation and the pituitary stalk is present . An Ophthalmology consult was obtained to determine the presence of optic nerves . These were both determined to be present and intact . Endocrine was also consulted . Several labs were ordered . Electrolytes and thyroid studies were noted to be in the normal range with serum sodium of 136 potassium 4.7 chloride 98 and CO2 34 . She had a calcium of 10.3 a phosphorus of 4.8 and alkaline phosphatase of 440 . Thyroid function studies revealed a TSH of 2.2 T4 of 5.7 T3 of 101 and a cortisol level of 43 all within the normal range . A growth hormone was sent and the results were pending at time of transfer . In addition an FSH and LH were obtained on 12-10 and results are pending at time of transfer . Please contact lab control at Mattapan Community Health Center for results 409 238-8236 . The baby s neurologic examination is appropriate for corrected gestational age which is 33 and 6 7 weeks on day of transfer . By mother s report a maternal cousin also has an absent septum pellucidum . Given normal pituitary tests thus far and normal optic nerve no evidence of septic optic dysplasia . Pediatrician should have low threshold for endocrinology reconsult if any signs of pituitary problems . Sensory Audiology hearing has not yet been obtained . This is recommended prior to discharge from hospital to home . Ophthalmology Initial ROP screen was done on 12-02 and revealed immature retinas to zone 2 bilaterally . They recommended follow-up examination due on the week of 12 20 . Psychosocial Gardner State Hospital social worker has assisted in working with this family . The contact may be reached at 754 791 7976 . Parents have been very involved and appropriate with infant and have eagerly learned to care for their baby . Condition at time of transfer is good . Discharge disposition is to level 2 nursery at Jordan Hospital Hospital . Name of primary pediatrician is Ashley Daley of Village Pediatrics in Stockbridge . Feedings at the time of transfer include breast milk 30 with ProMod at 150 cc per kg per day all gavage given over one hour . Medications include Fer-In-Norman vitamin E 5 international units each day and caffeine citrate once a day . Car seat positioning screening has not been obtained . Newborn state screens have been sent per protocol . Results have been in the normal range . IMMUNIZATIONS RECEIVED Mychelia received hepatitis B vaccine on 11-02 due to unknown maternal hepatitis B surface antigen status . She also received hepatitis B immune globulin on 11-02 . On 12-06 she received her second hepatitis B vaccine . Her two month immunizations have not yet been given . IMMUNIZATIONS RECOMMENDED Synagis RSV prophylaxis should be considered from November through March for infants who meet any of the following three criteria 1 born at less than 32 weeks 2 born at between 32 and 35 weeks with two of the following Daycare during RSV season a smoker in the household neuromuscular disease airway abnormalities or school age siblings or 3 infants with chronic lung disease . Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age . Before this age and for the first 24 months of the infant s life immunization against influenza is recommended for household contacts and out of home caregivers . Follow-up appointments recommended with the primary pediatrician Dr. Marilyn Daley of Stockbridge Village Pediatrics Dr. Lynn Warren of Neurology from Emerson Hospital and Ophthalmology to follow her ophthalmology status . DISCHARGE DIAGNOSES Prematurity at 28-2 7 weeks . Surfactant deficiency . Hypotension . Sepsis suspect . Physiologic jaundice . Coagulase negative bacteremia . Anemia of prematurity . Apnea of prematurity . Absent septum pellucidum . Rosalie Gloria North Dakota 67177 Dictated By George D Gregory M.D. MEDQUIST36 D 2013-12-10 124122 T 2013-12-10 140332 Job <NOTE_END>", "role": "assistant" } ]
[ { "content": "The patient is a 52 year-old female with no known history of cardiac disease presenting with dyspnea on exertion and chest tightness who was admitted for evaluation and management of her symptoms . 1. CARDIOVASCULAR The patient was admitted for complaints of dyspnea on exertion and chest pressure which could be consistent with angina . However given the long duration of the symptoms and negative workup in the past", "role": "user" }, { "content": " it was thought to be unlikely . However the patient was started on an aspirin as well as a beta blocker and a rule out myocardial infarction protocol was initiated . A stress thallium was planned for the day following admission . However on the night of admission the patient was found lying in her bed diaphoretic and obtunded and a code was called . Further examination revealed a strong palpable pulse with a systolic blood pressure in the 130 s and a heart rate in the 80 s. Over the course of the next few minutes the patient became increasingly more responsive . She was treated with a fluid bolus . The patient quickly responded to a fluid bolus and became interactive . She reported that she was sitting on the commode urinating and began to feel nauseous and presyncopal . She was able to get to bed at which point she passed out . She denied any chest pain or pressure and no shortness of breath during this event . A rhythm check obtained during the time of this event demonstrated a pause of six seconds followed by a junctional escape rhythm . An electrocardiogram obtained after the code demonstrated no acute changes . Her acute bradycardic event was felt likely secondary to her new beta blocker in conjunction with a vagal response . It was determined to stop the beta blocker and atropine was placed at the bedside . On the following day the patient underwent an echocardiogram which demonstrated dilated right ventricle secondary to chronic dysfunction and a pulmonary artery pressure of greater than 100 . Her stress test was cancelled . A CT angiogram was ordered to evaluate for chronic thromboembolic disease as a potential cause of her pulmonary hypertension . She was ruled out for myocardial infarction with three sets of normal enzymes and continued to be monitored on telemetry . A Pulmonary consultation was obtained to evaluate for possible etiology of the patient s hypotension . There was little evidence to suggest any cardiac disease and given the patient s Graves disease an autoimmune process was felt to be possible . In addition consideration was given to sarcoidosis human immunodeficiency virus and drug-induced given her history of herbal medication use . It was recommended that the patient begin anticoagulation given the severity of her pulmonary hypertension . It was also planned to undergo a right heart catheterization with a vasodilation trial by the catheterization laboratory . A right heart catheterization was performed on 2014-12-05 . A pharmacologic pulmonary vasodilator challenge was performed with a positive response . In addition a CT angiogram of the chest with pulmonary embolism protocol showed no intravascular filling defect but did show a right upper lobe ground-glass and scattered adenopathy . Therefore in the end left atrial hypertension was essentially ruled out as a primary cause . Chronic pulmonary embolus was less likely given her negative CT angiogram . Chronic lung disease was unlikely given the patient s normal pulmonary function tests and DLCO in 2012 as well as a normal CT angiogram . Collagen vascular disease could not be definitively ruled out however given the patient s lack of connective tissue disorder stigmata it was thought to be less likely and the patient s human immunodeficiency virus test was negative . Therefore it was felt that the patient was most likely experiencing a primary pulmonary hypertension . Consideration was given to treating the patient with a course of calcium channel blocker however given the patient s poor response to Lopressor it was determined that this would not be optimal treatment for the patient s pulmonary hypertension . Therefore her insurance company was contacted regarding the potential of Flolan as a treatment .Plan <NOTE_END>", "role": "assistant" } ]

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