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"content": "On admission the Baby Lucas is well appearing",
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"content": " no jaundice . He has bilateral breath sounds that are clear and equal . The heart rate is regular without murmur . Pulses are 2 and symmetrical . The abdomen is soft and nontender with no hepatosplenomegaly . His weight is 3.160 kilograms 7 pounds 3 ounces at birth . He is circumcised with testes descended bilaterally . His hips are stable . His tone is normal . Normal neonatal reflexes . He is tolerating his feedings well . <NOTE_END>",
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"content": "He is allergic",
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"content": " to Penicillin Inderal and also to Procan . Patient has a seventy pack year history of smoking which he quit ten years ago and he has previously had problems with alcohol . <NOTE_END>",
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"content": "Mr. Hohlt is a 76 year-old man with a history of hypertension hyperlipidemia and prior myocardial infarction with a percutaneous transluminal coronary angioplasty of the right coronary artery in 2005 at the Cambridge Health Alliance . He states that he has experienced pain and tightness in his back radiating into both shoulders starting on 2016-09-02 . The patient denies shortness of breath dizziness diaphoresis or nausea . The pain lasted for 30 seconds following pushing a wheelbarrow",
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"content": " and resolved with rest . The patient denied any prior episodes of pain or any since 2005 following the initial episode of pain . The patient informs his primary care provider who referred him to the emergency room . He then presented to Mass. Mental Health Center where he was ruled out for an myocardial infarction by enzymes and electrocardiograms . The patient also underwent a negative evaluation for dissecting aortic aneurysm . On 2016-09-03 the patient began experiencing continuing chest pain of increasing intensity . He was treated with nitroglycerin paste and IV Integrelin as well as Plavix . At that time he ruled in for an NST EMI with a peak CK of 412 and a troponin of 6.23 . Electrocardiograms progressed to inverted T waves in V5 and V6 . The patient is now transferred to Cambridge Health Alliance for cardiac catheterization . PAST MEDICAL HISTORY Hypertension hyperlipidemia IMI in 2005 . PAST SURGICAL HISTORY Partial thyroidectomy herniorrhaphy percutaneous transluminal coronary angioplasty of the RCA in 2005 left knee surgery as well as tonsil and adenoid surgery . <NOTE_END>",
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"content": "Sodium 140 potassium 4.0 chloride 104 CO2 28 BUN 14 creatinine 1.1 glucose 243 .",
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"content": " Cholesterol 197 triglycerides 118 HDL 31 LDL 142 total protein 6.2 bilirubin 1.0 alkaline phosphatase 72 SGOT 23 . Hematocrit on admission was 43 with a white blood count of 6600 . MCV was 85 . <NOTE_END>",
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"content": "1. cerebrovascular accident . The patient suffered some mild weakness which was attributed to stenosis of the distal right internal carotid artery . This was determined by head CT head MRI head MRA carotid noninvasive studies transcranial Dopplers . The possibility of a cardiac origin was evaluated by echocardiogram and Holter monitor . Her echocardiogram curiously showed a normal left ventricular size and systolic function a patent foramen ovale with a trace right to left shunt as determined by bubble study trace MR was present . Previous echoes have shown MVP at the Ona Hospital . Her Holter showed up to 12 beats of SVT but was otherwise unremarkable . The patient had a normal B12 negative syphilis serologies and normal thyroid function during this hospitalization . She was anticoagulated with heparin and after several days Coumadin was started . Her exact Coumadin dose is undetermined at this point however it looks like it will be something around 5 mg a day . Her pro time and PTT have normalized at the time of discharge . She needs to be given 5 mg of Coumadin tonight 5 22 92 . In addition heparin should be started to drip on arrival at 400 units an hour . It is discontinued at the time of transport . The patient has received physical therapy and occupational therapy and her recovery is near complete . During evaluation of her neurologic status it was determined that for several months prior to admission the patient has been too unsteady to ambulate . On our exam she is found to have a significant amount of ataxia especially in the midline and the exact cause of this is unknown . There are multiple possible contributions and this is where her need for careful internal medical evaluation has arisen . At the time we were to embark on this evaluation the patient &aposs family strongly requested that she be transferred to the Sas General Hospital . What follows is a summary of her medical problems and their possible relationship to her ataxia . Her ataxia is likely due to some cerebellar function though this is not certain . Moreover her MRI did not show any discrete cerebellar lesions . Our leading theory at this point is that her cerebellar dysfunction relates to perineoplastic syndrome relating to her history of breast Ca . As I mentioned above her evaluation was limited by her cardiologic status at the time . While mammogram and CA-15.3 and breast exam are all normal the idea of a perineoplastic syndrome with or without concomitant breast Ca has reared its head . Two possible markers are anti-Hu syndrome and anti-Yo antibody . These tests were sent on the 18th and are pending at the time of discharge . The results can be obtained by paging me Do A. Joasscchird M.D. at 834-364-2251 . I will be happy to furnish the results . The patient has a history of MI in 1989 . Echocardiogram no longer shows wall motion abnormalities . EKG when the patient goes out of left bundle branch block transiently shows an anterolateral Q wave inversion . We would like to discontinue her Isordil to improve upon some orthostatic hypotension but we are not certain whether her heart will tolerate this . Persantine thallium is scheduled at this time but is yet to be performed . The patient has a history of orthostatic hypotension x many years . It has been evaluated in the past without success . During her hospitalization we confirmed the presence of this even when she was hydrated with saline to a fractional excretion of sodium of 2 . Studies of her autonomic system did not document any dysautonomia . Studies of skin galvanic conduction were normal and her RR interval evaluation was not abnormal . This is a chronic problem but may be contributing to her current weakness and inability to walk . Florinef is to be considered however stopping the Isordil is one goal . The patient has a history of bronchiectasis from a childhood pneumonia . In addition there is a distant history of M. kansasaii infection . This has been evaluated by Dr. Screen at Sas General Hospital and probably relates to her lung xray . CT at the Ona Hospital in 1989 showed",
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"content": " similar findings . A chest CT was to be performed and may be yielding . A PPD was placed and is to be read on Saturday 4 26th . The left volar forearm has the PPD just proximal to the wrist crease and a candida albicans placed just distal to the antecubital fossa . The patient has a history of deep venous thrombosis in 1990 for which she received 6 months of Coumadin . Dopplers of her lower extremities were negative on this admission . It is doubtful that she has chronic PE but this is one consideration . It is likely that she has pulmonary hypertension from her lung disease and so this is a consideration . The patient had mild hyponatremia during this hospitalization with a sodium as low as 131 . We think this is likely due to an SIADH as she is euvolemic . This can be evaluated further and is not a problem at this time . The patient has glaucoma . Her medications are as listed below . Her ophthalmologist is aware of transfer . His name is Ettrent Can and he can be reached at 678-233-5033 b 549 . DOCTORS DISCHARGE ORDERS Propanolol 5 mg. p.o. t.i.d. hold for SBP less than 110 Isosorbide 5 mg. p.o. t.i.d. hold for SBP less than 110 Colace 100 mg. p.o. b.i.d. Pilocarpine 4 one drop q.i.d. O.D. Pilocarpine 2 one drop b.i.d. O.S. Betasan 0.5 one drop b.i.d. O.D. . Bacitracin ointment one drop O.D. q.h.s. Ciprofloxacin 500 mg. one p.o. b.i.d. x four more days until 5 25 92 for recently discovered siderobacter UTI . Coumadin 5 mg. p.o. q.h.s. She needs her dose on 5 22 92 . Heparin i.v. drip at 400 units per hour on her arrival . In addition the patient requires occupational therapy and physical therapy . <NOTE_END>",
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"content": "Is as follows History of coronary artery disease with",
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"content": " status post two-vessel CABG in 1986 also he was treated for congestive heart failure hypertension aortic valve replacement and mitral valve replacement with St. Jude &aposs valve in 09 2001 atrial fibrillation history of prior GI bleed requiring blood transfusions during which he also had a colonoscopy on 05 2003 which demonstrated no neoplasia and scattered diverticuli . The patient also following his first GI bleed had an EEG done in 07 2003 which showed gastritis with oozing and evidence of a recent bleed <NOTE_END>",
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"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 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",
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"content": " 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>",
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"content": "The patient was taken to the operating room by Dr. Suot N. Dragtente on 02-21-91 where a left",
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"content": " radical nephrectomy was performed . At operation there was no gross adenopathy or renal vein involvement and it was felt that the tumor was completely excised . The patient thereafter had a benign convalescence and was discharged on the 5th postoperative day . The oncology fellows from Venbonlea Health followed her course and recommended holding off on her Hydrea while she is hospitalized and they will follow her as an outpatient and restart her Hydrea when her hematocrit is over 40 . DISPOSITION The patient was discharged to home . The patient was discharged on a regular diet . CONDITION ON DISCHARGE was stable . FOLLOW-UP will be with Dr. Suot N. Dragtente and with her Venbonlea Health oncology fellows . MEDICATIONS ON DISCHARGE included Percocet 1 to 2 tablets by mouth every 4 hours as needed for pain Colace 100 milligrams by mouth twice a day . PL926 1533 SUOT N. DRAGTENTE M.D. GJ7 D 02 26 91 Batch 8776 Report P9055V6 T 03 02 91 Dicatated By ESPEXIINE BRIZ <NOTE_END>",
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"content": "Coumadin Lipitor Toprol XL ASA Zoloft Glucophage",
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"content": " Aricept Namenda Artificial Tears Discharge Medications Not applicable . Discharge Disposition Extended Care Facility Patient deceased . Discharge Diagnosis Not applicable patient deceased . Discharge Condition Not applicable . Discharge Instructions Not applicable . Followup Instructions Not applicable . William William MD PHD 13-279 Completed by Barbara Josephine MD 21-547 2013-11-15 1413 Signed electronically by DR. Exie Culbreath on MON 2013-11-18 1006 AM <NOTE_END>",
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"content": "The patient is a pleasant white female in no acute distress . She is afebrile with stable vital signs . The head eyes ears nose throat examination was",
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"content": " unremarkable . Neck shows a well healed low collar incision without adenopathy or bruit . The lungs showed mild inspiratory wheeze and moderate expiratory wheezes . Breath sounds are present bilaterally . Cardiovascular exam regular rate and rhythm . The abdomen was soft nontender nondistended . Extremities no clubbing cyanosis or edema . The rectal examination is guaiac negative with a minimal amount of stool . <NOTE_END>",
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"content": "The patient was admitted to the Tau Memorial Hospital . She was seen by Dr. Freiermthalskush of the renal service for management of her chronic renal insufficiency . On 02 22 she underwent angiography which revealed minimal right internal carotid artery disease and proximal left internal carotid artery stenosis 2 cm in length for the 1 mm residual lumen . The left anterior communicating artery fell from the right . She was also seen by Cardiology and she underwent cardiac catheterization as part of her preop evaluation which revealed normal resting hemodynamics and a moderate posterior descending artery and obtuse marginal stenoses . She was therefore cleared for the operating room and on",
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"content": " 3 3 92 she underwent a left carotid endarterectomy with continuous electroencephalogram monitoring and vein patch angioplasty which was uneventful . Her postoperative course was marked only by prolonged ileus perhaps secondary to constipation with persistent vomiting requiring intravenous fluids however on 03 07 92 she had a large bowel movement after aggressive bowel regime felt significantly better was able to tolerate PO &aposs . She is now able to be discharged home on her admission medications with the exception of the fact that Vasotec was increased to 10 mg PO bid . SHERMENE JESCSELC M.D. DICTATING FOR LENNI BREUTZOLN M.D. . TR pv bmot DD 03 08 92 TD 03 10 92 CC <NOTE_END>",
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"content": "Pulmonary On admission the infant required CPAP 6 cm of water 30 oxygen . Initial capillary blood gas was pH 7.29 CO2 47 . Infant was intubated on day of life two for increased respiratory distress', 'and received one dose of surfactant . Infant was extubated on day of life four to CPAP and transitioned to room air on day of life six . The infant has remained in room air throughout the hospitalization .', 'Caffeine citrate was started on day of life six and was discontinued on 05-23 day of life 18 . The last apnea and bradycardia was on 06-10 . 2. Cardiovascular The infant has remained hemodynamically', 'stable throughout this hospitalization no murmur . Heart rate 150 to 160 mean blood pressure 40 to 54 . 3.', 'Fluid electrolytes and nutrition Infant was initially nothing by mouth receiving 80 cc per kilogram per day of D10W intravenously .', 'Infant was started on enteral feedings on day of life four and advanced to full volume feedings of 150 cc per kilogram per day by day of life seven .', 'During feeding advancement infant was given parenteral nutrition and intralipids . The infant tolerated feeding advancement without difficulty .', 'Infant was advanced to maximum caloric density of breast milk or premature Enfamil 26 calories per ounce with ProMod by day of life 11 .', 'Infant is currently on breast milk or Enfamil 24 calories per ounce po minimum 140 cc per kilogram per day . The most recent weight is 2525 g.', 'Head circumference 24.5 cm length 45.5 cm . The most recent electrolytes on day of life five were sodium 145 chloride 115 potassium 4 TCO2 of 21 .', 'On day of life 25 calcium 10.1 phosphorus 6.9 alkaline phosphatase 341 . 4. Gastrointestinal Infant was started on double phototherapy on day of life two for a maximum",
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"content": " bilirubin level of 8.1 with', 'a direct of 0.3 . Infant decreased to single phototherapy and phototherapy was discontinued on day of life six . Rebound bilirubin level on day of life seven was 5.3 with a direct of 0.3 . 5.', 'Hematology The infant did not receive any blood transfusions this hospitalization . The most recent hematocrit on day of life two was 47 . CBC on admission white blood cell count 8.9 hematocrit 47', 'platelets 243 000 6 neutrophils 0 bands . Repeat CBC on day of life two showed a white blood cell count of 8.4 platelets 95 41 neutrophils 0 bands . Repeat platelet count on day of life three', 'was 229 . 6. Infectious disease The infant received 48 hours of ampicillin and gentamicin for rule out sepsis . Blood cultures remained negative to date . Infant has not had any issues with sepsis this', 'hospitalization . 7. Neurology Head ultrasound on day of life seven showed no intraventricular hemorrhage . A repeat head ultrasound on day of life 33 06-07 showed a slight increase of echogenicity', 'in the caudothalamic groove which may represent tiny bilateral germinal matrix hemorrhages no periventricular leukomalacia . A repeat head ultrasound is recommended in one month .', 'Normal neurological examination . Sensory hearing screening was performed with automated auditory brain stem responses . Infant passed both ears . Ophthalmology', 'eyes examined most recently on 05-30 revealing immaturity of the retinal vessels but no ROP as of yet . A follow up examination should be scheduled for the week of 06-20 .', 'Ophthalmologist is Dr. Cruea Franklin . 8. Psycho social Parents involved . Triplet number one is still in the Neonatal Intensive Care Unit and triplet number three is home with family', 'and there is also a 2 year-old sibling .', 'CONDITION ON DISCHARGE', 'Stable on room air . <NOTE_END>",
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"content": "Patient &aposs hospital course is as follows Patient is an 84-year-old male who was transferred from an outside hospital with a low hematocrit of 21 and with guaiac-positive stool . The day prior to admission he experienced dyspnea on exertion and on the day of admission he collapsed and complained of substantial weakness . He denied any melana any hematemesis nausea or vomiting . He was taken to an outside hospital at the time at which time it was found that his hematocrit was 21 blood pressure 90 60 and his INR was 3.3 . Of note he is anti-coagulated for an artificial heart valve . He was at that point given 1 unit of packed red blood cells . On further questioning the patient reported that he started to feel " different " several days ago with slowing and difficult ambulation progressing to complete inability to ambulate . He was also short of breath with ambulation but he does have baseline shortness of breath with exertion . He denied any chest pain dysuria loss of consciousness fevers chills or any history of myocardial infarction . Patient was last admitted to Padrugmoff Hospital with a hematocrit of 24.5 and was asymptomatic prior to admission . At that time he had guaiac-positive and had a small bowel follow through which was negative . He was transfused 4 units during that admission and discharged with a hematocrit of 34 on vitamin C and iron sulfate . EXAM ON ARRIVAL IN THE LO HOSPITAL EMERGENCY ROOM On arrival at the Lo Hospital Emergency Room He was found to have a temperature of 97.4 heart rate 65 pressure 107 52 respiratory rate 22 and saturating 100 on 2 L of a nasal cannula . General exam at the time was notable for pale mucous membranes left lateral",
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"content": " eye deviation clear lungs 2 6 holosystolic murmur best heard at the apex abdomen was mildly distended but was soft and nontender and his extremities were without edema and skin without any rashes . <NOTE_END>",
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"content": "Patient is a 49 year old previously healthy",
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"content": " female who was diagnosed in June 1992 with a breast carcinoma after she presented with some breast discomfort on the left side . She underwent a wide resection of a left breast mass by Dr. Ausguall on 8 17 93 . Pathology of this resection revealed a Grade III III infiltrating ductal carcinoma . She now presents for left axillary node dissection to complete her staging . She has no complaints at the time of presentation . <NOTE_END>",
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"content": "On admission the sodium was 144 potassium 2.6 chloride 114 bicarbonate 12.3 BUN 30 creatinine 4.0 glucose 89 . The SGOT was 994 LDH 1 888 alkaline phosphatase 92 total bilirubin 2.9 and direct bilirubin 11.2 . Lactate was 6.3 acetone negative ammonia 26 uric acids 26.9 albumin 4.0 globulin 3.0 amylase 259 lipase 34 magnesium 3.5 phosphorus 1.9 calcium 9.4. The white blood count was 19.7 with 89",
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"content": " polys 7 bands 4 lymphs with toxic granulations . Hematocrit was 45.2 with a platelet count of 132 000 falling rapidly to 24 000 . The MCV is 88 . The prothrombin time is 27.7 partial thromboplastin time is greater than 100 . The urinalysis revealed a specific gravity of 1.15 pH 5.0 and 4 albumin positive occult blood with 0-5 granular casts and 5-10 RBCs and 3-5 WBCs . The CK was 17 890 with 0.6 MB . The urine sodium was 147 . The serum toxicology was positive for Cocaine on admission to the Fairm of Ijordcompmac Hospital as well as the Sephsandpot Center . The electrocardiogram revealed normal sinus rhythm at 85 with a prolonged QT at 0.572 . An I-head CT revealed left sphenoid and left maxillary sinusitis with mild cerebral edema and no focal hemorrhages . The abdominal CT revealed mesenteric adenopathy normal bowels hepatosplenomegaly and ? fatty liver . Chest x-ray revealed early interstitial edema . <NOTE_END>",
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"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 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.",
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"content": " 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>",
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"content": "Fentanyl 75-mcg per hour patch q.72h. Zoloft 50 mg by mouth once per day . Wellbutrin 200 mg by mouth twice per day . Dilaudid one to two tablets by mouth q.4-6h. as needed for pain . Ernest K. Gardner M.D. 09 -697 Dictated By Sarah Z Stephens",
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"content": " M.D. MEDQUIST36 D 2015-03-26 1808 T 2015-03-26 2153 JOB 81804 Signed electronically by DR. Billie SCHNEIDER on FRI 2015-03-27 1101 AM <NOTE_END>",
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"content": "The patient was admitted to the hospital and received two units of packed red blood cells for her hematocrit of 26 and had a magnesium repleted . The patient received three days of chemotherapy consisting of 45 mg. of Cisplatin 160 mg. of VP 16 and tolerated chemotherapy resonably well . Serial PTs were obtained and the patient was noted to have an initial PT of 10.9 on admission despite Coumadin at home . She was given 10 mg. on hospital day 1 and 5 mg. on hospital day 2 and back to 2.5 qhs . The patient &aposs pro time bumped to 19.5 on hospital day 3 and the patient was instructed to continue with 2 1 2 mg. qhs and is to followup with Anticoagulation Clinic in one week for further pro time checks and adjustments . The patient did develop some hypertension during infusion of her VP 16 to the 170 100 range which apparently happened during her prior chemotherapy . The patient was instructed to followup with her internist regarding",
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"content": " further evaluation of her hypertension and should be assessed regarding further management as an inpatient or while receiving chemotherapy . <NOTE_END>",
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"content": "Diabeta 10 mg. po. bid . Serax 20 mg. po. qhs . Sudafed 30 mg. po. bid . Theo-dur 300 mg.",
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"content": " 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. q4hours prn . Proventil 2 puffs q6hours prn . PAST SURGICAL HISTORY includes and abdominoperineal resection in 1989 . ALLERGIES no known drug allergies PHYSICAL EXAMINATION demonstrated an obese man in no acute distress . The blood pressure 140 75 pulse 90 and irregular respirations 20 . The head eyes ears nose throat and neck examinations were unremarkable . Cardiac examination was remarkable for frequent ectopic beats . The lung examination was clear but breath sounds were more pronounced on the left than the right . Abdomen soft obese with mild epigastric and right upper quadrant tenderness . An intact colostomy was present . No masses could be palpated secondary to the patient &aposs extreme obesity . Extremities unremarkable . The neurological examination was remarkable for a peripheral neuropathy including decreased sensation in the lower extremities with decreased strength in the upper and lower extremities most pronounced in the legs and feet . A chest X-ray demonstrated right hemidiaphragmatic elevation . The electrocardiogram was remarkable for trigeminy at 91 per minute . <NOTE_END>",
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"content": "Thromboembolus to the right profunda femoris and right",
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"content": " superficial femoral artery . MA JAMTLANDBRANTESSLIGH M.D. DICTATING FOR COR TLAND M.D. TR qa bmot DD 07 02 92 TD <NOTE_END>",
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"content": "The patient is a 73 year old female who was transferred for cardiac catheterization after ventricular fibrillation arrest in the setting of an acute inferior myocardial infarction and a urinary tract infection . The patient was admitted on 3-16-93 to",
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"content": " Diy Hospital for an E. coli urinary tract infection . The patient was readmitted on 3-20-93 because of fever chills and a sudden onset of ventricular fibrillation arrest successfully cardioverted back to rapid atrial fibrillation and finally to sinus rhythm where an electrocardiogram then showed ST elevation in inferior leads . Peak CPK was 2494 with 18 MB s . She required intubation for mild to moderate congestive heart failure treated with diuretics intravenous nitroglycerin and heparin . She had post-infarction angina was transferred here for angiography and possible percutaneous transluminal coronary angioplasty . <NOTE_END>",
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"content": "Brothers with William cancer and a MI . Father with emphysema",
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"content": " . Mother with lung cancer . <NOTE_END>",
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"content": "On physical exam the patient is a well appearing elderly white female in no acute distress . The blood pressure is 120 82 heart rate 88 weight 125",
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"content": " pounds . The head eyes ears nose throat exam was notable for alopecia otherwise unremarkable . Chest was clear bilateral cardiac exam showed regular rate and rhythm abdomen was soft nontender except for mild left upper quadrant tenderness with a well healed midline abdominal scar . No other lower quadrant tenderness . Extremities were unremarkable . Neurological exam was nonfocal and there was no significant lymphadenopathy . <NOTE_END>",
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"content": "The patient",
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"content": " had complaint of headaches in the past She has fibromyalgia and a history of slurred speech . Her last menstrual period was on 2017-08-29 <NOTE_END>",
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"content": "Aricept 10 mg qd Aspirin 81 mg qd Folic acid Gabapentin 200 mg tid Lopressor 12.5 mg bid Lisinopril 5 mg qd Daptomycin 420 mg IV qd Protonix 40 mg qd Seroquel 50 mg tid Heparin 5000 units SQ tid Colace 100 mg bid Lactulose 15 mg bid Comtan 200 mg qd Mirapex 1.5 mg tid Sinemet 50 200 mg tid Discharge Medications 1. Furosemide 20 mg Tablet Sig One 1 Tablet PO once a day for 2 weeks . Potassium Chloride 20 mEq Packet Sig One 1 Packet PO once a day for 2 weeks . Docusate Sodium 100 mg Capsule Sig One 1 Capsule PO BID 2 times a day . 4. Pantoprazole 40 mg Tablet Delayed Release E.C. Sig One 1 Tablet Delayed Release E.C. PO Q24H every 24 hours . 5. Aspirin 81 mg Tablet Delayed Release E.C. Sig One 1 Tablet Delayed Release E.C. PO DAILY Daily . 6. Magnesium Hydroxide 400 mg 5 mL Suspension Sig Thirty 30 ML PO HS at bedtime as needed for constipation . 7. Entacapone 200 mg Tablet Sig One 1 Tablet PO TID 3 times a day . 8. Pramipexole 0.25 mg Tablet Sig Six 6 Tablet PO TID 3 times a day . 9. Carbidopa Levodopa 50 200 mg Tablet Sustained Release Sig One 1 Tablet PO TID 3 times a day . Quetiapine 25 mg Tablet Sig Two 2 Tablet PO DAILY Daily . Procainamide 250 mg Capsule Sig Three 3 Capsule PO Q6H every 6 hours x 6 weeks . 12. Acetaminophen Codeine 300-30 mg Tablet Sig One 1 Tablet PO Q4H every 4 hours as needed . Warfarin 1 mg Tablet Sig as directed Tablet PO DAILY Daily . Daptomycin 500 mg Recon Soln Sig Four 90y 480 mg Intravenous Q24H every 24 hours thru 05-02 . Discharge Disposition Extended Care Discharge Diagnosis mitral valve endocarditis s p",
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"content": " MV replacement HTN s p CVA Spinal stenosis s p Lumbar Laminectomy Parkingson s h o paranoid delusions MGUS vs MM Discharge Condition good Discharge Instructions May take shower . Wash incisions with warm water and gentle soap . Do no take bath or swim . Do not apply lotions creams ointments or powders to incision . Do not drive for 1 month . Do not lift more than 10 pounds for 2 months . Please contact office if you develop a fever more than 101.5 or notice drainage from chest incision . Followup Instructions Dr. Portsche in 4 weeks Dr. Bravo PCP in 1-2 weeks Infectious disease Provider Marsha Harriet MD Phone 574-5036 Date Time 2019-04-29 1000 Jeffrey Everett MD 23-815 Completed by MARK Carolyn NP 80-AUO 2019-03 -26 1033 Signed electronically by DR. <NOTE_END>",
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"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",
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"content": " mg po q 8 hours prn . FOAnterP The patient will follow-up in the wound care clinic in two weeks . The patient will also follow-up with Dr. Fairchild her primary care physician in three weeks . The patient will follow-up with Dr. vel Diaz in 3-4 weeks . Briley von der Ross M.D. 67 -576 Dictated By Emily O Ennis M.D. MEDQUIST36 D 2013-01-08 1646 T 2013-01 -08 1708 JOB 67252 Signed electronically by DR. <NOTE_END>",
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"content": "On",
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{
"content": " admission included Percocet Prinovil Dapsone Mycelex troches . <NOTE_END>",
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[
{
"content": "His father had prostate cancer . Mother had breast cancer . Has a cousin with a brain tumor . No family history of leukemia or lymphoma . He has one sister and one brother who are alive and well . They",
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{
"content": " are not HLA matched . <NOTE_END>",
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"content": "Patient is a 72 year old female with known carotid stenosis and recent carotid noninvasives at an outside hospital which showed 90 left sided stenosis . She",
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"content": " has not had a stroke or transient ischemic attack . She was recently discharged from the Per Naplesspecrycet Hospital after an admission for congestive heart failure . <NOTE_END>",
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"content": "The patient was admitted to the Hospital and underwent an approximate 1.5 liter diuresis within the first 24 hours with improvement in his symptoms and improvement in his oxygen saturations . After a long discussion with the patient and his family it was determined that a cardiac catheterization would be prudent . Prior to catheterization a VQ scan was performed which revealed a moderate probability for PE with a subsegmental defect in the lingular on the left lung . Subsequent lower extremities noninvasive studies and D-dimer test were both negative rendering the probability of acute pulmonary embolism less than 2 percent",
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"content": " . It was not felt that the patient would be in need of chronic Coumadin therapy in lieu of this low probability findings in toto . Coronary angiography revealed occlusion of the right coronary artery proximally with insignificant plaquing in the left anterior descending artery and circumflex arteries . After a approximate 3 liter total diuresis the right atrial pressure was 5 pulmonary capillary wedge pressure 14 pulmonary vacuolar resistance 353 and the cardiac output depressed at 2.95 liters per minute or a cardiac index of 1.7 liters per minute . Based upon these findings it was felt that Mr. State most likely has multi-factorial dyspnea owing to both his ventilatory limitation and to a chronic low output state . In Hospital he was seen by both Speech Therapy physical therapy and the Uspend Harmemewood Medical Center Congestive Heart Failure Nurse Practitioner Program . His Isordil was increased in Hospital and blood pressure control was relative episodic with systolic pressures ranging between 100 and 160 . Future adjustments will be made at home pending his blood pressure measures . At a goal weight of 142 pounds Mr. State &aposs filling pressures appeared ideal with a wedge pressure of 14 and his goal weight range will be between 142 and 44 pounds at home . The patient will be followed by Dr. State within a week of discharge and by Nieie Naebrand Freierm of the Dyathenslycha Medical Center . <NOTE_END>",
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"content": "Timolol .5 Discharge Disposition Extended Care Discharge Diagnosis Right lower extremity necrosing fascitis history of prostate cancer s p TURP glaucoma Discharge Condition Fair Discharge Instructions If you have any fevers chills nausea vomiting chest pain foot pain please seek medical attention . Followup Instructions Please follow up with Dr. Mallard in one week call 421-3721 for an appointment . Follow up with Dr. Adner in 2 weeks call 763-9180 for an appointment . Mark William MD 19-081 Completed by Shane Gabrielle MD 73-971 2016-04-01",
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"content": " 0836 Signed electronically by DR. Robert Howell on WED 2016-05-18 <NOTE_END>",
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[
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"content": "On admission the white blood count was",
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{
"content": " 67.3 with a differential of 21 polys 16 bands 3 lymphocytes 2 monocytes 57 eosinophils and 1 myelocytes . Her hematocrit was 38.8 hemoglobin 13.7 platelet count 155 000 PT 12.7 10.1 PTT 33.9 erythrocyte sedimentation rate 18 calcium 7.5 phosphorus 3.5 sodium 136 potassium 3.7 BUN 15 total protein 5.9 albumin 2.3 globulin 3.6 alkaline phosphatase 379 SGOT 37 Digoxin level 0.7 . <NOTE_END>",
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"content": "The patient is an 83 year-old male with a history of diabetes steroid-treated polymyalgia rheumatica hypertension benign prostatic hypertrophy and high cholesterol without presented to the hospital for lower extremity angiograph however that was deferred due to new onset renal failure . 1. RENAL FAILURE The patient was initially thought to be prerenal and his renal status improved after hydration and increased oral intake . He did have a magnetic resonance angiography of his kidneys which showed mild right-sided renal artery stenosis . His renal function fluctuated throughout his hospital stay and when he was in the Medical Intensive Care Unit he did have decreased urine output in the setting of cardiogenic shock . CARDIOVASCULAR The patient with severe peripheral vascular disease . During his hospital stay he developed some nonsustained ventricular tachycardia . He also became hypotensive on 07-02 in the setting of infection . The patient had a central line placed and went into sustained ventricular tachycardia that was treated with lidocaine . After being treated with lidocaine the patient became apneic requiring intubation and transfer to the Coronary Care Unit . His nonsustained ventricular tachycardia was treated with a lidocaine drip . It was found that he had elevated troponins and likely an ischemic event on the 07-02 . A repeat echocardiogram showed a decreased ejection fraction from prior . He had a cardiac catheterization which revealed 3-vessel disease . Cardiothoracic Surgery was consulted and due to the patient s acute illness they wanted to re-evaluate after the patient was extubated . The patient continued to have intermittent episodes of ventricular tachycardia . He was continued on lidocaine and eventually changed over to amiodarone . He was noted to be cardiogenic shock requiring pressors . Of note he likely suffered a second ischemic event during his Coronary Care Unit stay . The patient did have a Swan-Ganz catheter in place and had a low cardiac output . The patient s family eventually decided to withdraw care and the patient was extubated and passed away on 2009-07-12 . 2. INFECTIOUS DISEASE The patient was initially treated with levofloxacin for a left lower",
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"content": " lobe infiltrate and a urinary tract infection . He then developed positive blood cultures with Staphylococcus aureus sensitive to levofloxacin and that was continued . When the patient became hypotensive and required intubation and pressors his antibiotics were broadened and he was put on stress-dose steroids . He was found to have bilateral Staphylococcus pneumonia . 3. PULMONARY The patient required intubation in the setting of hypotension and ventricular tachycardia . He was actually extubated on 07-09 but then reintubated one hour later due to hypoxia . He was also found to have a bilateral Staphylococcus pneumonia . DISCHARGE DISPOSITION On 07-12 after and extensive family meeting the family decided to extubate the patient and make him comfortable and he passed away at 520 on 2009-07-12 . Hattie L Breaux M.D. 33 -679 Dictated By Larry W. Nagy M.D. MEDQUIST36 D 2009-12 -03 0918 T 2009-12-08 1047 JOB 32151 Signed electronically by DR. <NOTE_END>",
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"content": "BY SYSTEM 1. PULMONARY She was treated with albuterol and Atrovent continuous nebulizers and was weaned then to intermittent nebulizer treatments and then to her meter-dosed inhalers taking them q.4h. at the time of discharge . She was continued on salmeterol and Flovent . She was continued on Solu-Medrol 80 mg q.8h. then converted to prednisone at 60 mg p.o. q.d. She was started",
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"content": " on Singulair 10 mg p.o. q.d. Serial arterial blood gases were followed after an arterial line was placed . Her PCO2 gradually declined to the 48 range . Despite episodes of somnolence the first night which were presumably due to having spent the entire night in the Emergency Department she never became more hypercarbic and her PCO2 trended to 48 by the time the arterial line was discontinued . On the night of admission and thereafter she was noted to have a very stridorous sounding breathing when the patient was asleep . This would disappear whenever she was awake . Her case was discussed with Ear Nose Throat and the Medical Intensive Care Unit attending . She was given a trial of 80 20 mixed helium oxygen to decrease the stridor but had minimal effect . Ear Nose Throat recommended not considering this an airway problem unless she was stridorous while awake . The patient was to arrange for Pulmonary and Medicine followup through her primary care physician upon discharge as she has not been seen in the Pulmonary Clinic in two years . 2. CARDIOVASCULAR The patient ruled out for myocardial infarction with serial creatine kinases although these did rise to 816 . MB was negative . She was treated with captopril for hypertension and this was switched to Norvasc 7.5 mg p.o. q.d. on discharge . She had an echocardiogram which showed a hyperdynamic left ventricular of normal thickness and size and no significant valvular disease . She apparently did not have a cardiovascular component to her wheezing or shortness of breath however she was to go home on Lasix 20 mg p.o. q.d. to help with lower extremity edema as she experiences discomfort with this and the team felt this may be a limiting factor with her prednisone compliance . 3. ENDOCRINE She was treated with a sliding-scale of regular insulin while she was in house . She was given 500 mg p.o. q.d. of metformin to treat her steroid-induced diabetes on discharge . This should be followed up by her primary care physician . 4. INFECTIOUS DISEASE She was treated briefly with levofloxacin because of the gram-positive cocci in her sputum culture however her symptoms were felt to be consistent with a viral upper respiratory infection and levofloxacin was continued at the time of discharge . MEDICATIONS ON DISCHARGE Lasix 20 mg p.o. q.d. Combivent meter-dosed inhaler 2 puffs q.4h. weaning to albuterol meter-dosed inhaler 2 puffs q.4h. Salmeterol 2 puffs q.12h. Flovent 220 mcg 2 puffs q.12h. Prednisone 40 mg p.o. q.d. with taper . Fentress 60 mg p.o. b.i.d. Singulair 10 mg p.o. q.d. Univasc 7.5 mg p.o. q.d. Metformin 500 mg p.o. q.d. Dyazide was discontinued . DISCHARGE STATUS Discharge services included visiting nursing which was to assess in her inhaler technique monitor her fasting blood sugars as well as her blood pressure monitor her peak flows and assess her mobility and activities of daily living at home . DISCHARGE FOLLOWUP She was also to seek the next available appointment with Dr. Jeanette Barr or to see another resident in the Saint Vincent Hospital Clinic if she cannot get an appointment within one week . CONDITION AT DISCHARGE Condition on discharge was good .. CODE STATUS Full code . DISCHARGE DIAGNOSES Asthma flare . Hypertension . Steroid-induced diabetes . James Z Berg M.D. 19-421 Dictated By Melanie L.W. Palevic M.D. MEDQUIST36 D 2011-06-18 1633 T 2011-06-21 1534 JOB 92012 Signed electronically by DR. Andrea Trotter on <NOTE_END>",
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"content": "Patient is being sent home on Ecotrin one q.d. Digoxin 0. l25 mg every three days Quinidine 648 mg q.a.m. and 324 mg q.p.m. and q.h.s. Mevacor 20 mg p.o. q.d. Carafate one gram p.o. q.i.d. Colace l00 mg p.o. t.i.d. Lasix 80 mg p.o. q.d. Potassium 20 mEq p.o. q.d. and iron supplements . Patient has follow-up with Dr. Merkel and with his private medical doctor . EV956 4659 RISHAN M. MERKEL M.D. BS9 D 01 02 92 Batch 3669 Report F6644X53 T 01",
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"content": " 02 92 Dicatated By RAMA R. KOTEOBE M.D. cc 1. <NOTE_END>",
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[
{
"content": "Digoxin .25 mg PO QD Ecotrin 325 mg QD Coumadin 2.5 mg PO QD Lisinopril 2.5 mg PO QD Micronase 5 mg",
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},
{
"content": " PO BID . <NOTE_END>",
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[
{
"content": "Imdur 120 mg. PO q.d. Captopril 100mg. PO t.i.d. Lasix 80 mg. PO q.d. Potassium chloride 40 mEq. PO q.d. Coreg 12.5 mg. b.i.d. Cozaar 100 mg. b.i.d. Plavix 75 mg. q.d. Allopurinol 300 mg. q.d. Pulmacort and Serevent inhalers 2 puffs b.i.d. Zocor 20 mg. q.d. Prilosec 20 mg. q.d.",
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"content": " Colace 100 mg. t.i.d. FOLLOW UP The patient will see Dr. State as noted in follow up . AKA G STATE M.D. CARDIAC TRANSPLANT STEMSTRICTALLE MEDICAL CENTER Electronically Signed AKA G STATE M.D. 11 17 2000 1246 ?? TR rij DD 11 09 2000 TD 11 14 2000 109 P cc <NOTE_END>",
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[
{
"content": "Breast cancer",
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{
"content": " in multiple female relatives . <NOTE_END>",
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[
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"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 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",
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"content": " 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>",
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[
{
"content": "Coronary artery disease status post coronary artery bypass graft four vessels . Congestive heart failure",
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{
"content": " . Klebsiella pneumonia . Failed swallow study status post percutaneous endoscopic gastrostomy tube placement . Central line culture positive for coagulase negative Staphylococcus aureus status post a 14 day treatment with vancomycin and removal of the line . <NOTE_END>",
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{
"content": "Includes diabetes diagnosed at age 14 Multiple episodes of diabetic ketoacidosis in the past",
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{
"content": " migraine headaches and attention deficit disorder . MEDICATIONS AT HOME Included Wellbutrin Imitrex Tylenol Humalog sliding scale and NPH insulin two units in the morning 7 units at noon and 13 units at bedtime <NOTE_END>",
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"content": "The patient was admitted to the Fairm of Ijordcompmac Hospital . The patient was brought to the Operating Room on January 3 1994 where she underwent a median sternotomy with removal of her mediastinal mass . This mass was situated in the aortopulmonary window and was sent to pathology . The frozen section analysis revealed this to be adenocarcinoma metastatic disease from the colon most likely . She had a chest tube placed intraoperatively and another placed postoperatively in the recovery room for what was presumed to be a left pleural effusion . This tube drained only a small amount of fluid and it was likely that the effusion was",
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"content": " made to look more severe in the presence of left hemidiaphragm elevation . This additional chest tube was removed the following day . Her postoperative hematocrit was 31 compared to a preoperative level of 43 . Her postoperative recovery was really quite remarkable . Mediastinal chest tube was removed on postoperative day three . The patient was discharged home in stable condition on postoperative day six . DOCTORS DISCHARGE ORDERS Percocet for pain . Follow up with Dr. Fede Duhenile . She will have a home health aide to visit and help her with meals . CA SHUFF M.D. DICTATING FOR FEDE LEVEL M.D. TR kw bmot DD 1-9-94 TD <NOTE_END>",
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[
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"content": "Coronary artery disease status post coronary artery bypass grafting times 4 with LIMA to the LAD saphenous vein",
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"content": " graft to OM1 saphenous vein graft to OM2 and saphenous vein graft to the diagonal . Hypertension . Hypercholesterolemia . Status post partial thyroidectomy . Status post hernia repair . Status post left knee surgery . Status post tonsil and adenoid surgery . DISCHARGE MEDICATIONS 1. Atorvastatin 10 mg q.d. 2. Plavix 75 mg q.d. times 3 months . Aspirin 325 mg q.d. Lasix 20 mg q.d. times two weeks . Potassium chloride 20 mEq q.d. times two weeks . Metoprolol 12.5 mg b.i.d. Percocet 1 to 2 tabs q. 4 hours p.r.n . The patient is to be discharged home with visiting nurses . He is to have follow up in the wound clinic in two weeks and follow up with Dr. Brewster in two to three weeks and follow up with Dr. Rota in 4 weeks . Herbert Jesus Georgia 01835 Dictated By Scott OK Astarita M.D. MEDQUIST36 D 2016-09-14 125227 T 2016-09-14 132805 Job 15604 Signed electronically by DR. Richard Gomez on FRI 2016-09-16 <NOTE_END>",
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"content": "On physical examination she is an elderly but spry white female in no acute distress . Her sclera were nonicteric . Her oropharynx was clear . Her neck was supple without masses or bruits noted . Her lungs were clear to auscultation . Her cardiac examination was unremarkable . Examination of her abdomen revealed a flat nontender abdomen without palpable masses . There were multiple well healed surgical scars . She was guaiac negative . There was no cva tenderness or",
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{
"content": " spinal tenderness noted . Her pulses were intact throughout . <NOTE_END>",
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[
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"content": "On physical examination she is an elderly but spry white female in no acute distress . Her sclera were nonicteric . Her oropharynx was clear . Her",
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},
{
"content": " neck was supple without masses or bruits noted . Her lungs were clear to auscultation . Her cardiac examination was unremarkable . Examination of her abdomen revealed a flat nontender abdomen without palpable masses . There were multiple well healed surgical scars . She was guaiac negative . There was no cva tenderness or spinal tenderness noted . Her pulses were intact throughout . <NOTE_END>",
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"content": "Son died at 50 of diabetes and myocardial infarction . PHYSICAL EXAM In the emergency room vitals were temperature 96.4 pulse 40-50 blood pressure 154-58 satting 86 on room air 99 on 3 liters of 3 liters cannula . Rate 28 . HEENT Anicteric . Extraocular movements intact . 2 plus carotids . No delayed upstroke . Oropharynx is clear without lymphadenopathyin the neck . Jugular venous distention to the jaw . Positive hepatojugular reflexes . LUNGS Crackles 1 3 up bilaterally . CARDIAC Regular rate and rhythm . Normal S1 and S2 . 3 6 crescendo decrescendo murmur at the right upper sternal border with radiation to the carotids . No rubs or gallops . ABDOMEN Soft obese nontender nondistended normal active bowel sounds . No hepatosplenomegaly . EXTREMITIES 3 plus pitting edema to the knee bilaterally with areas of darkened erythema which is crusted indented . A shallow chronic ulcer in the right shin with desquamation bilaterally around the ankle and half way up the shin . 1 x 2 cm ulcer with clean sharp borders to the dermatome on the left posterior thigh . NEUROLOGICAL Alert and oriented x 3 . Cranial nerves II-XII intact . 4 5 lower extremity bilaterally . 5 5 strength upper extremities bilaterally . Unable to assess reflexes due to",
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"content": " the knee deformities . 2 plus reflexes in the upper extremities symmetrically bilaterally . Toes downgoing . LABORATORY DATA ON ADMISSION Sodium 134 potassium 4.0 chloride 91 bicarbonate 33 BUN 21 creatinine 1.1 glucose 99 CK 22 troponin 0 . Calcium 8.8 white blood cell count 10.6 hematocrit 37.1 platelets 289 . INR 1.1 PTT 30.3. Chest x-ray shows cardiomegaly . Small left effusion . Lobular density at the right hilum . No pneumonia . Electrocardiogram shows normal sinus rhythm at 50 . Normal axis . primary AV block . Left ventricular hypertrophy . <NOTE_END>",
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"content": "The patient was admitted to the GYN Oncology Service under the care of Dr. Top on June 26 1994 . On that day she was taken to the operating room where she underwent an exam under anesthesia an exploratory laparotomy with lysis of adhesions tumor debulking and bilateral pelvic lymph node dissection . An abdominal wall hernia was also repaired . The patient tolerated the procedure well without any complications . Her postoperative course was unremarkable . Her vaginal pack was removed on the second postoperative day as well as the Foley catheter . By postoperative day three she had return of normal bowel function and was able to tolerate a regular diet without any difficulty . Her Jackson-Pratt drain",
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"content": " was removed on June 30 1994 postoperative day four . On that day she was feeling well enough eating well and voiding without difficulty . As a result she was able to be discharged home on June 30 1994 . FOLLOW-UP She will follow up with Dr. Top in his office . <NOTE_END>",
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"content": "The patient was taken to the operating room on March 11 2002 and underwent an uncomplicated right total hip replacement . The patient tolerated the procedure well and was transferred to the Post Anesthesia Care Unit and then to the floor in stable condition . On postoperative check he was doing well . He was afebrile and his vital signs were stable . He was neurovascularly intact . His hematocrit was 34.7 . He was started on Coumadin for DVT prophylaxis and Ancef for routine antimicrobial coverage . He was made partial weight-bearing for his right lower extremity . He was placed on posterior hip dislocation precautions and was out of bed with physical therapy and occupational therapy . On postoperative day one there were no active issues . He was afebrile . His vital signs were stable . He was neurovascularly intact . On postoperative day two he",
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"content": " 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>",
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"content": "Obstructive-sleep apnea ? Morbid obesity . Congestive heart failure unknown EF Hypertension . Diabetes",
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{
"content": " mellitus Depression . Nursing home resident Dyspnea on exertion . History of fibroids Hypercholesterolemia . <NOTE_END>",
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[
{
"content": "Expired",
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{
"content": " TO DO PLAN No dictated summary ENTERED BY NELLFYFE SHATAYE I M.D. PH.D. IY150 01 20 02 <NOTE_END>",
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[
{
"content": "Percocet 5 325 one to two q4hours p.r.n. Plavix 75 mg once daily . Aspirin 325 mg once daily . Bactrim double strength one tablet once daily . Prednisone 5 mg once daily . Lipitor 10 mg once daily . Lopressor 25 mg twice a day . Hydralazine 75 mg q6hours . Cyclosporin 75 mg twice a day . Rosiglitazone 4 mg once daily . DISCHARGE INSTRUCTIONS The patient is to",
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{
"content": " follow-up with Dr. Herrick in four weeks time . He should follow-up with his cardiologist in one to two weeks for optimization of his medications . The patient should return or contact the office if he has a fever sternal discharge or other significant chest pain . Ellen Z Neher M.D. 65-969 Dictated By Ann C Vinson M.D. MEDQUIST36 D 2016-02-21 1142 T 2016-02-21 1333 JOB 94475 Signed electronically by DR. <NOTE_END>",
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[
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"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",
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},
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"content": " 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 bmot DD 01-21-92 TD 01 22 92 CC <NOTE_END>",
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"content": "None . CAR SEAT POSITION SCREENING Recommended prior to discharge . STATE NEWBORN SCREEN Screens",
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"content": " have been sent and results are pending . IMMUNIZATIONS The infant has not received any immunizations this hospitalization . IMMUNIZATIONS RECOMMENDED Synagis RSV prophylaxis should be considered from October through April for infants who meet any of the following three criteria Born at less than 32 weeks . Born between 32 and 35 weeks with two of the following a. Day Care during RSV season . b. A smoker in the household c. neuromuscular disease d. airway abnormalities or e. a school age sibling . 3. With chronic lung disease . DISCHARGE DIAGNOSES Prematurity 32 and 4 7 weeks Twin 1 . Rule out sepsis ruled out . Apnea of prematurity . Indirect hyperbilirubinemia . Gregory R Godfrey M.D. 28-526 Dictated By Crystal K. Carter M.D. MEDQUIST36 D 2016-02-21 0953 T 2016-02-21 1012 JOB 02200 Signed electronically by DR. Cynthia Short on MON 2016-02 <NOTE_END>",
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"content": "Morphine prn . Ativan prn . Tylenol prn . Albuterol and Atrovent nebs prn . Rice S.F. Thrash M.D. 15-419 Dictated By Brett E.X. Im M.D. MEDQUIST36 D 2012-06-29 0115 T 2012-06-29 0547 JOB 44693 Signed electronically by DR. Vicki Baker",
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"content": " on TUE 2012-07-03 823 AM <NOTE_END>",
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"content": "The patient was admitted to a telemetry bed and started on heparin . Around 400 AM the next day an acute decompensation in respiratory status was noted . Lung examination at that point showed good air entry no wheezing coarse breath sounds throughout . Neurologically the patient was not following commands . Eyes were closed . He was moving the right arm and leg spontaneously though less than before . Withdrawal to pain was still present . Both plantars were upgoing . A blood gas at this point showed a pH of 7.49 pO2 61 pCO2 of 33 on 100 non-rebreather mask . EKG showed sinus tachycardia . The patient &aposs temperature was 102 degrees . A repeat CAT scan of the head was performed . This showed continued evolution of the right posterior cerebral artery infarction now extending into the right cerebellar hemisphere . There was also a high density adjacent to the right cerebellar infarction suggesting the presence of hemorrhage . At this point the patient was transferred to the intensive care unit . An MRI and MRA of the head was arranged to evaluate the extent of his stroke and the posterior circulation . The MRI showed infarct of the cerebellar hemispheres bilaterally the right occipital lobe the right",
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"content": " thalamus and bilateral pons . The MRA of the intracranial circulation demonstrated gross patency of the internal carotid arteries bilaterally and the basilar arteries . The left vertebral artery was not visualized . There was a dominant right vertebral artery . There was mildly reduced flow in the branches of the right middle cerebral artery compared to the left . There was visualization of flow within both posterior cerebral arteries . Clinically the patient continued to deteriorate . Neurosurgery was consulted however the neurosurgeons felt that there was no surgical option since even in the case of cerebellar swelling there would be no improvement from decompensation . The patient was therefore treated conservatively with fluid restriction and blood pressure management . Heparin was discontinued because of the risk of intercerebral hemorrhage . The aspiration pneumonia was treated with Cefotaxime and Metronidazole . The patient &aposs family was involved and they decided to opt for DNR DNI in view of the poor prognosis . The patient passed away at 645 AM on June 12 1998 . CONDITION ON DISCHARGE Deceased . DISCHARGE ORDERS None . Dictated By GREGSIS STREETS M.D. SQ51 Attending CHLINO B. SHAM M.D. NI76 LN647 8356 Batch 57390 Index No. TCVBBUJ1Y D 07 09 98 T 07 10 98 CC 1. <NOTE_END>",
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"content": "Coronary artery disease status post MI x2 CABG x2 in 02 89 and 2 21 history",
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"content": " of arthritis history of bilateral rotator cuff degeneration and tears history of hypertension history of hyperlipidemia . <NOTE_END>",
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"content": "at time of admission hematocrit 32.7 white blood count 9 000 platelet count 336 000 sodium 126 potassium 4.3 chloride 93 CO2 19 BUN 36 creatinine 1.5 blood sugar 84",
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"content": " calcium 11.7 the chest X-ray normal . KUB consistent with adynamic ileus . <NOTE_END>",
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"content": "Hyperthyroid disease status post radioactive iodine ablation now hypothyroid on Levoxyl History of pulmonary embolism etiology unknown . It was thought to be induced by frequent flying to California The patient was started on Coumadin five months prior to this admission . 3. Hypercholesterolemia Well controlled on Lipitor . Last total cholesterol was 168 in 2015-08-24 . 4 Paroxysmal atrial fibrillation",
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"content": " in the setting of pulmonary embolism . PAST SURGICAL HISTORY 1 Only significant for a right inguinal hernia repair . ALLERGIES Penicillin OUTPATIENT MEDICATIONS Lipitor 10 mg three times a week Aspirin 81 . Propranolol 10 mg three times a day Coumadin 6.25 mg once a day . Levoxyl 100 mEq q. day Ambien p.r.n. Vitamins Vioxx times three weeks . <NOTE_END>",
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"content": "Preoperatively the patient underwent chemo-embolization for his hepatocellular carcinoma . The remainder of his preoperative course was benign . On July 15 1992 a liver became available and the patient underwent hepatectomy and orthotopic liver transplant . His operation was complicated by severe coagulopathy requiring fifty-nine units of packed red blood cells 64 units of FFP and 34 units of platelets . Postoperatively the patient continued to have a coagulopathy requiring re-exploration on postoperatively day 2 with findings only of hematoma and no active bleeding . Initially the patient did well in the Intensive Care Unit mentally alert and oriented however he continued to be coagulopathic and was requiring large amounts of blood and FFP transfusions with a resultant pulmonary edema . He developed renal failure felt to be ATN secondary to ischemia of his kidneys . The patient remained intubated in the Intensive Care Unit for twelve days prior to his death . He had daily transfusions of FFP and blood and continued coagulopathy . He also developed thrombocytopenia requiring persistent platelet transfusions on a daily basis . His immunosuppression was OKT3 and Solu Medrol and he underwent hemodialysis and ultra filtration to remove fluid . While in the ICU he developed seizures requiring large amounts of intravenous Valium to break his seizures and he was maintained on Tegretol and Dilantin . However he became progressively more mentally obtunded . During the seizure he bit his tongue resulting in a large bleed",
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"content": " from his tongue which was sutured by the ENT Service however his continued coagulopathy resulted in bleeding from his nasopharynx which could never be identified and also upper gastrointestinal bleeding . Endoscopy never revealed specific sources of bleeding although he appeared to have a diffuse duodenitis . He was started on Pitressin to try to control the gastrointestinal bleeding but he continued to have severe bleeding and became progressively hypotensive with eventual bradycardia and cardiac arrest . He was pronounced dead at 349 PM on July 15 1992 . STA TITCHEGRIESESC M.D. DICTATING FOR KIVERL NA CANTSLEDDJESC M.D. TR wj bmot DD 07 28 92 <NOTE_END>",
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"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 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",
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"content": " 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>",
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"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 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",
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"content": " an ovarian cyst in 1988 . MEDICATIONS ON ADMISSION None . <NOTE_END>",
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"content": "No known drug allergies . CURRENT MEDICATIONS Hydrochlorothiazide 25 mg q.d. and Decadron 25 mg b.i.d. PHYSICAL EXAMINATION On admission demonstrated a well-developed well-nourished female in no apparent distress dragging her right foot . HEENT Head was atraumatic and normocephalic with pupils equal round and reactive to light . LUNGS Clear to auscultation . HEART Examination demonstrated a regular rate and rhythm without any murmurs noted . ABDOMEN Benign with a hysterectomy scar which was well healed . NEUROLOGICAL Examination showed that the patient was noted to be alert and oriented times three short term memory was deficient patient remembered zero out of three things to remember at one minute speech was noted to be fluent and cranial nerves II-XII were intact . On motor examination",
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"content": " patient was noted to be of normal motor function throughout except for a slight weakness of the right dorsi flexion and plantar flexion both noted to be about 4 5 and sensory examination was intact throughout . Patient s gait was noted to have a right foot drag as well as right foot drop . <NOTE_END>",
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"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",
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"content": " electrocardiogram which showed no acute ischemic change . His chest X-ray ruled out acute cardiopulmonary process . Left foot changes consistent with osteomyelitis of the left great toe . <NOTE_END>",
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"content": "This 75 year old male had been noted to be anemic with an abnormal white blood count since at least November 1993 while he was living in Aersing Rocuch Sun and his physicians there had begun to manage him with transfusions and low dose hydroxyurea . Apparently a bone marrow biopsy at the time confirmed the diagnosis of chronic myelomonocytic leukemia . He came to this",
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"content": " country in late December 1994 to live with his son for a few months and was referred to me for follow up . He had been noting night sweats increasing fatigue anorexia and dyspnea which were not particularly improved by increased transfusions or alterations of hydroxy urea . He became profoundly thrombocytopenic and ultimately was admitted to the hospital on 2 15 with headache and weakness . <NOTE_END>",
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"content": "Stable . DISCHARGE STATUS Leona Wheeler is to be transferred on 2015-07-17 to a rehabilitation facility . DISCHARGE DIAGNOSIS 1. Status post CABG times four . Meghan G. Bardin M.D. 43 -132 Dictated By Louise B. Robertson M.D. MEDQUIST36 D 2015-07-17 0839 T 2015-07-22 1029 JOB 72575 Signed electronically by DR. Derek",
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"content": " Vildosola on WED 2015-07-29 115 PM <NOTE_END>",
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"content": "HIV times 13 years Last CD4 count of 268 viral load undetectable followed at the Boston Regional Medical Centerr Clinic by Dr. Taylor",
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"content": " . History of anal warts and rectal abscesses and fistula <NOTE_END>",
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"content": "Family history is not significant for any early history of coronary artery disease . PHYSICAL EXAMINATION ON PRESENTATION Examination on admission to the Coronary Care Unit revealed blood pressure was 100 57 with a mean arterial pressure of 75 heart rate was sinus rhythm at 75 temperature was 97.6 oxygen saturation was 99 on assist control with a tidal volume of 600 on 60 FIO2 5 of positive end-expiratory pressure . In general she was sedated at the time responsive to stimuli and was following commands . She had moist mucous membranes . Her carotids were 2 bilaterally . Her lungs were clear to auscultation anteriorly . Her heart revealed a regular rate and rhythm with a faint second heart sound and second heart sound . No audible extra heart sounds . Her abdomen was obese and had positive bowel sounds . It was soft and nontender . She had peripheral edema with 2 peripheral pulses bilaterally . PERTINENT LABORATORY DATA ON PRESENTATION Her laboratories at the time of transfer to Saint Vincent Hospital revealed white blood cell count was 11.5 hematocrit was 42 on admission platelets were 242 . Chemistry-7 was unremarkable . Creatine kinase on admission was 309 with a MB of 19.6 an index of 6.3 and an initial troponin of 0.73 . RADIOLOGY IMAGING A chest x-ray revealed an enlarged mediastinum with clear lung fields bilaterally . Initial electrocardiogram showed a normal sinus rhythm at 65 normal axis 2-mm ST elevations in lead III 1-mm ST elevations in aVF and V1 1-mm ST depressions in I and aVL consistent with an inferior and right ventricular infarction . Right-sided electrocardiograms showed 1-mm ST elevations in V4 consistent with a right ventricular infarct . Electrocardiogram status post percutaneous coronary intervention revealed a normal sinus rhythm at 84 with a normal axis and normalizing of the inferior ST segments with Q waves evolving in leads III and aVF . An echocardiogram status post percutaneous coronary intervention revealed an akinetic inferior wall and right ventricle mild mitral regurgitation and ascending aorta measuring 5 cm . There was no effusion . HOSPITAL COURSE 1. CARDIOVASCULAR SYSTEM On the night of admission the patient experienced post catheterization hypotension which required intravenous fluids and dopamine . Electrocardiogram the following morning revealed normalization of her ST segments with evolution of Q waves . Her dopamine was weaned off the following day and her heparin was discontinued secondary to a right groin hematoma which had developed after the sheath had been pulled out by the fellow . Her creatine kinases climbed reaching a peak of 3523 which was down to 1500 at the time of discharge . Also noted on the day of 11-20 the patient self-extubated herself . For her coronary artery disease status post",
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"content": " catheterization she was given Integrilin for 18 hours . She was continued on aspirin Plavix and Lipitor . For her rhythm amiodarone was discontinued as she was maintained in sinus rhythm after moving to the floor . For pump once transferred out of the Coronary Care Unit on 2011-11-20 a beta blocker was begun at 12.5 mg of Lopressor p.o. b.i.d. which was titrated to 25 mg at the time of discharge . Also at the time of discharge for increased afterload reduction she was started on lisinopril 5 mg p.o. q.d. On 2011-11-21 the patient experienced atypical chest pain which was made worse with inspiration and movement . It was not associated with any nausea or vomiting . It did not radiate . It was felt to be pain secondary to her self-extubation and noncardiac chest pain . An electrocardiogram was checked which revealed no ST changes and there was no increase in her downward trending creatine phosphokinases . No further intervention was done . The patient was treated with Tylenol orally as well as Ativan for anxiety that she had about going home . She was pain free on the day of discharge . Regarding her aortic ascending aneurysm Cardiothoracic Surgery was consulted regarding further workup . At their request a CT scan of the chest with contrast was performed on the day of discharge . Dr. Streeter from Cardiothoracic Surgery will follow up with the patient for further management in approximately one month as an outpatient . His office will contact her to make that appointment . 2. PULMONARY SYSTEM As stated above the patient self-extubated herself . She complained of a sore throat which was likely the etiology of her atypical chest complaints . This resolved with Tylenol and as needed doses of oxycodone . Her lungs remained clear to auscultation bilaterally throughout the remainder of her hospital course . At the time of this dictation the CT of her chest was still pending . The official result was not yet in . 3. FLUIDS ELECTROLYTES NUTRITION The patient s electrolytes sere managed daily and repleted on an as needed basis . She did receive intravenous K-Phos for a low phosphorous of 1.5 . Her phosphorous rose appropriately to 3.6 at the time of discharge . DISCHARGE FOLLOWUP 1. The patient has an appointment to initiate primary care as she no longer had a primary care physician . Claire was to see Dr. Michael Majerowski at the Sturdy Memorial Clinic on the east campus on Bissonette Six in the South Suite on 31-05-03 at 1130 a.m. 2. In addition as stated above Dr. Hastings office from Cardiothoracic Surgery will be in contact with Ms. Williams to arrange followup for her ascending aortic aneurysm in approximately one month . <NOTE_END>",
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"content": "DISCHARGE DISPOSITION Home .follow up VNA and pediatric primary",
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"content": " care physician appointments to be scheduled prior to discharge . <NOTE_END>",
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"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 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",
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"content": " 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>",
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"content": "1 Bronchiolitis obliterans organizing pneumonia The video assisted thoracoscopic study at the outside hospital was consistent with bronchiolitis obliterans organizing pneumonia . The patient was continued on steroids throughout the course of her stay . This was changed to Solu-Medrol part way through the course due to her hematologic problems see below . By discharge she was returned to 40 mg of Prednisone q. day times one month to be followed by a slow taper . The patient &aposs bronchiolitis obliterans organizing pneumonia appeared to improve slowly throughout her hospital course however on July 12 1998 after starting dialysis see below the patient desaturated and required supplemental oxygen . Repeat chest x-rays and chest CT scans appeared consistent with pulmonary edema from volume overload given her renal failure and eventually the patient &aposs pulmonary status did improve after significant volume removal with dialysis for several weeks . At the time of her discharge the patient was still requiring two liters of supplemental oxygen to maintain her oxygen saturations in the mid 90 . 2 Thrombotic thrombocytopenic purpura The patient was initially admitted with platelet count of 28 hematocrit of 32 LDH of 496 with 2 schistocytes and 2 spherocytes on her smear . This was felt to be consistent with thrombotic thrombocytopenic purpura and on June 20 1998 she was started on daily plasma exchange which continued through July 27 1999 . She was also changed to intravenous Solu-Medrol 50 mg q. day which was changed back to 40 mg of Prednisone prior to discharge . Her platelet count initially rose to a maximum of 159 on July 3 1998 then they steadily fell to a low of 60 on July 20 1999 . Her LDH which peaked at 1255 decreased to the mid 200s but remained elevated . She continued to have a few schistocytes on her smear but it was much decreased . The patient also required red blood cell transfusions approximately two units every seven to ten days to maintain her hematocrit . Eventually her plasma exchange was tapered to a smaller and smaller dose each day and then discontinued altogether after July 27 1999 . After this the patient &aposs platelet count",
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"content": " rose to a maximum of 177 on discharge . It is felt that the patient &aposs thrombotic thrombocytopenic purpura has resolved . She will continue on her Prednisone for one month as above for the bronchiolitis obliterans organizing pneumonia with a very slow taper . 3 Renal The patient presented in acute renal failure with a BUN of 101 and a creatinine of 3.7 . Throughout the month of June she had a rising Potassium phosphate and increasing volume overload with decreasing response to diuretics and she was finally initiated on dialysis with ultrafiltration on July 12 1998 . The opinion of the Renal consult was that this was permanent and non-reversible renal failure since it did not improve with dialysis and the patient will continue on dialysis three times per week . She required approximately five liters of ultrafiltration fluid removal at each dialysis session due to her significant volume overload . During the course of her dialysis she had a great improvement in her lower extremity edema and her oxygen saturation . 4 Infectious disease The patient had multiple line infections during her admission including a confirmed coag. negative Staphylococcus line infection with positive blood cultures on June 23 1998 July 4 1998 July 8 1998 and July 9 1998 . The patient eventually had a left subclavian Tesio catheter placed and a right brachial PICC line placed on July 10 1998 which remained patent and uninfected . She received a full three week course of Vancomycin and also received a three week course of Ceftazidime . In addition she had a fungal urinary tract infection treated with Amphojel bladder irrigation which was followed by a Klebsiella urinary tract infection for which she received Levofloxacin times fourteen days . She also received a fourteen day course of Acyclovir which was begun on June 21 1998 for perianal lesions consistent with herpes simplex virus . She was also on Fluconazole for some oral thrush which was inadvertently continued for a total of thirty days . The patient was also started on Bactrim one double strength tablet q.o.d. as prophylaxis for Pneumocystis carinii pneumonia while on her high dose steroids . 5 Rheumatology The patient was admitted with a question of lupus given her ANA of 1640 although her rheumatoid factor and ANCA were negative . Unfortunately throughout her admission we were unable to test any more titers since she was receiving daily plasma exchange . A repeat ANA rheumatoid factor and ANCA may be repeated as an outpatient . FOLLOW-UP 1 The patient will follow-up with her primary care physician Dr. Tamarg Study in Arvus after she is discharged from rehabilitation . 2 The patient is being discharged to A Hospital where she will receive onsite hemodialysis three times per week on Monday Wednesday and Friday . The nephrologist who will follow her there is Dr. Study . 3 The patient will continue to have her CBC LDH bilirubin chem-7 and magnesium and calcium checked with each dialysis and the results will be faxed to Dr. Ian Zineisfreierm the hematology attending at fax number 751-329-8840 . 4 The patient will eventually need a permanent dialysis fistula . The left subclavian Tesio which she has in place will last for several months in the mean time . She would like to arrange to have her fistula placed at Pre Health and the vascular surgeons there should be contacted regarding this . 5 The patient will need packed red blood cell transfusions with dialysis when her hematocrit falls below 26 . 6 The patient will continue her Prednisone at 40 mg p.o. q. day times one month this was started on July 27 1999 and then she will begin a slow taper as guided by Pulmonary . 7 The patient has a follow-up appointment in the Pulmonary Clinic with Dr. Cedwi Stone at 336-2931 on August 30 1999 at 140 PM . 8 The patient has a follow-up appointment with Dr. Ian Zineisfreierm at the We Erthunt Hospital at 180-0455 on August 15 1999 at 1230 PM . MEDICATIONS ON DISCHARGE 1 Calcitriol 0.25 mcg p.o. q. day . 2 TUMS 1250 mg p.o. t.i.d. 3 Premarin 0.625 mg p.o. q. day . 4 Colace 100 mg p.o. b.i.d. 5 Humulin sliding scale q.a.c. and q.h.s. 6 Labetalol 400 mg p.o. t.i.d. 7 Omeprazole 20 mg p.o. q. day . 8 Serax 15 mg p.o. q.h.s. p.r.n. insomnia . 9 Prednisone 40 mg p.o. q. day times thirty days beginning on July 27 1999 to be followed by a slow taper as directed by the pulmonologist . 10 Metamucil one packet p.o. q. day . 11 Amlodipine 10 mg p.o. q. day . 12 Bactrim Double Strength one tablet p.o. q.o.d. 13 Nephrocaps one tablet p.o. q. day . 14 Epogen 1 000 units subcutaneously three times per week . 15 Iron sulfate 300 mg p.o. t.i.d. Dictated By CHELA FYFENEIGH M.D. NY5 Attending LENNI E. NECESSARY M.D. BE1 IZ845 6789 Batch 7665 Index No. YQGKGG4LST D 08 01 98 T 08 01 98 CC CEDWI STONE MD BMH PULMONARY CLINIC TAMARG STUDY MD Port O <NOTE_END>",
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"content": "The patient &aposs past medical history is unremarkable . PAST SURGICAL HISTORY As above including an embolectomy in",
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{
"content": " June 1992 <NOTE_END>",
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"content": "Brother with MI at age 35 Father with MI CABG died at age 60 . Physical Exam Vitals BP 144 90 HR 64 RR 14 General well developed male in no acute distress HEENT oropharynx benign poor dental health Neck supple no JVD Heart regular rate normal s1s2 no murmur Lungs clear bilaterally Abdomen soft nontender normoactive bowel sounds Ext warm no edema no varicosities Pulses 2 distally Neuro nonfocal Pertinent Results 2014 -04-24 0730AM BLOOD Hct 25.9 2014-04-23 0705AM BLOOD WBC 5.9 RBC 2.72 Hgb 8.6 Hct 25.2 MCV 93 MCH 31.5 MCHC 34.0 RDW 13.0 Plt Ct 150 2014-04-23 0705AM BLOOD Plt Ct 150 2014-04-24 0730AM BLOOD UreaN 11 Creat 0.8 K 4.4 2014-04-21 ECHO No spontaneous echo contrast is seen in the body of the left atrium . No mass thrombus is seen in the left atrium or left atrial appendage . No spontaneous echo contrast is seen in the body of the right atrium . A patent foramen ovale secundum ASD is present . A left-to-right shunt across the interatrial septum is seen at rest . A right-to-left shunt across the interatrial septum is seen at rest with injection of agitated saline contrast . The inferior vena cava is dilated >2.5 cm . Left ventricular wall thickness cavity size and systolic function are normal LVEF >55 . Left ventricular wall thicknesses are normal . Regional left ventricular wall motion is normal . Overall left ventricular systolic function is normal LVEF>55 . Right ventricular chamber size and free wall motion are normal . The ascending transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque . The aortic valve leaflets 3 appear structurally normal with good leaflet excursion and no aortic regurgitation . No aortic regurgitation is seen . The mitral valve appears structurally normal with trivial mitral regurgitation . The mitral valve leaflets are structurally normal . There is no pericardial effusion . POST BYPASS Flow across the interatrial septum is no longer visualized with color flow doppler or with injection of agitatated saline at rest or with valsalva . The study is otherwise unchanged from pre-bypass . 2014-04-22 CXR Previous right pneumothorax has resolved except for what is either a small fissural component or a bulla adjacent to the minor fissure . May be a small right pleural effusion . Right apical pleural tube in place . Left lung clear from basal atelectasis . Paratracheal mediastinal hematoma is resolving . Heart size is normal . Tip of the left internal jugular line projects over the SVC . Brief Hospital Course Mr. Freeman was admitted to the Nantucket Cottage Hospital on 2014-04-21 for surgical management of his PFO . He was taken to the operating room where he underwent a mini-thoracotomy with closure of his patent foramen ovale PFO . Postoperatively he was taken to the cardiac surgical intensive care unit for monitoring . Within a few hours he woke neurologically intact and was extubated . Aspirin was resumed. On postoperative day one he was transferred to the cardiac surgical step down unit . He was gently diuresed towards his preoperative weight . The physical therapy service was consulted for assistance with his postoperative strength and mobility . Iron and vitamin C were started for postoperative anemia . Mr. Freeman maintained stable hemodynamics with a normal sinus rhythm throughout his postoperative course . He continued to make steady progress and was discharged home on postoperative day three . He will follow-up with Dr. de la Cisneros Dr. Belt his cardiologist and his primary care physician as an outpatient . Medications on Admission Plavix 75mg daily aspirin 81mg daily Discharge Medications 1. Potassium Chloride 10 mEq Capsule Sustained Release Sig Two 2 Capsule Sustained Release PO Q12H every 12 hours for 5 days . Disp 10 Capsule Sustained Release s Refills 0 2. Docusate Sodium 100 mg Capsule Sig One 1 Capsule PO BID 2 times a day . Disp 60 Capsule s Refills 0 3. Aspirin 81 mg Tablet Delayed Release E.C. Sig One 1 Tablet Delayed Release E.C. PO DAILY Daily . Disp 30 Tablet Delayed Release E.C. s Refills 2 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig 1-2 Tablets PO every 4-6 hours as needed for pain . Disp",
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"content": " 50 Tablet s Refills 0 5. Ferrous Sulfate 325 65 mg Tablet Sig One 1 Tablet PO DAILY Daily Take for one month then stop . Disp 30 Tablet s Refills 0 6. Camphor-Menthol 0.5-0.5 Lotion Sig One 1 Appl Topical TID 3 times a day as needed . Disp qs qs Refills 0 7. Ascorbic Acid 500 mg Tablet Sig One 1 Tablet PO BID 2 times a day Take for one month then stop . Disp 60 Tablet s Refills 0 8. Furosemide 20 mg Tablet Sig One 1 Tablet PO BID 2 times a day for 5 days . Disp 10 Tablet s Refills 0 Discharge Disposition Home with Service Discharge Diagnosis PFO TIA lung nodule followed by Dr. Belt s p fissurectomy skull Fx Discharge Condition Good Discharge Instructions 1 Shower wash incisions with mild soap and water and pat dry . No lotions creams or powders to incisions . Call with fever >101 redness or drainage from incision or weight gain more than 2 pounds in one day or five pounds in one week . 3 No driving while on narcotics . Take lasix twice daily with potassium for five days then stop . Take Vitamin C with iron for one month then stop . Call with any questions or concerns . Followup Instructions Follow up with Dr. Heird in four weeks 671 745 2553 Follow up with Dr. Knowlton in 1-2 weeks 246 828-4417 Follow up with Dr. Eckman in 2-3 weeks 506 946-4576 Call all providers for appointments . CAT SCAN Phone 476 713 6117 Date Time 2014-10-16 915 Edna Arnold MD Phone 300 922-6590 Date Time 2014-10-16 230 Melonson de la Donnelly MD 08-301 Completed by Jeremy N. P. Moschella PA 80-BYE 2014-04-24 1103 Signed electronically by DR. Dorothy au Pratt on FRI 2014-06-06 1027 AM <NOTE_END>",
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"content": "eedings breast milk or Enfamil 24 calories per",
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"content": " ounce breast milk mixed with 4 calories per ounce of Enfamil powder', 'minimum of 140 cc per kilogram per day po <NOTE_END>",
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"content": "Spironolactone 50 mg p.o. b.i.d. 2",
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"content": " Advil p.r.n. 3 Topical steroids for eczema p.r.n. ALLERGIES The patient had no known drug allergies . <NOTE_END>",
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"content": "The patient was a 53-year-old male with a longstanding history of renal disease with multiple complications and problems related to vascular access and hypercoagulable state . These culminated in an attempted cadaveric kidney transplant undertaken on 12 16 97 which was complicated by thrombosis and necrosis of the cadaveric renal vein within 24 hours . This required a transplant nephrectomy . HOSPITAL COURSE AND TREATMENT The patient &aposs course was subsequently",
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"content": " characterized by recurrent pneumonias possibly due to aspiration and by hemodynamic instability . He was transferred to the Medical Intensive Care Unit from the Transplant Service for ventilatory management in the setting of hypotension . On transfer the patient was not sedated but was unresponsive and extremely dyssynchronous with the ventilator . The patient was found to have substantial auto PEEP with an elevated dead space . A pulmonary arteriogram on 01 03 98 demonstrated multiple pulmonary emboli likely less than one week old possibly introduced at the time of the renal vein thrombosis of 12 19 97 . An inferior vena cava filter was placed lower extremity noninvasive studies were negative . The patient required high pressures to ventilate adequately possibly related to an abdominal compartment syndrome . The patient had undergone two abdominal procedures following explantation . The physiology at the time of transfer to the Medical Intensive Care Unit was consistent with a septic process . CT scan demonstrated retroperitoneal collection containing both free air and extravasated contrast material . For the concern of a perforated viscus the patient was taken to exploratory laparotomy on 01 06 98 during which the bowel was run without evidence of perforation . The patient remained unstable . He was taken to fluoroscopy where oral contrast was demonstrated to be extravasating through a posterior duodenum . For this reason he was taken again to the operating room on 01 08 98 at which time a gastrojejunostomy was performed with stapling across the gastroduodenal junction introduction of five Jackson-Pratt drains into the retroperitoneal mass cholecystotomy tube gastrostomy tube and jejunostomy tube . The patient had an extensive estimated blood loss requiring multiple blood products and fluid resuscitation therapy . Accompanying this during this period were elevations in liver function studies and amylase and lipase consistent with pancreatic inflammation . The patient was aggressively treated with fluid resuscitation and pressors for his septic physiology . There was no evidence of cardiac tamponade or specific underlying coronary dysfunction . He was treated with appropriate antibiotics for his Serratia pneumonia as well as for his abdominal process . The patient was felt to have an underlying hypercoagulable state thought to be the source for the repeated clots . Because of the bleeding problems however it was felt that full heparinization would not be prudent and the patient was treated with pneumo-boots and subcutaneous heparin . Attention was paid to a variety of metabolic and electrolyte abnormalities which were corrected appropriately . Nonetheless Mr. Less continued to remain critically ill with only very transient mild improvement with drainage of additional retroperitoneal fluid . He remained pressor dependent as well as dependent upon mechanical ventilatory assistance . His course was complicated by atrial fibrillation requiring cardioversion . He had an ongoing requirement for high volume resuscitation and was persistently acidotic despite CV-VVH in the face of bicarbonate replenishment . The patient also appeared to have stool from his Jackson-Pratt site and right oblique incision . Bloody drainage from his increasingly distended abdomen was noted . Extensive discussions were carried out with Mrs. Less condition was irretrievable . It was felt that the patient had continued massive retroperitoneal contamination and probable multiple enteric fistulae from an ischemic bowel . Dr. Cantsleddjesc felt that no surgical approach to this problem or further intervention or radiologic procedures would be helpful . All physicians and the family were in agreement that the most appropriate approach was to institute comfort measures . This was done and the patient appeared to be comfortable at the time of death with his family at his side on 1 16 98 . I L. STERPSKOLK M.D. TR vcp DD 05 25 98 TD 05 30 98 830 A cc LE FREIERM JR M.D. KIVERL NA CANTSLEDDJESC M.D. I LYNIN STERPSKOLK M.D. ETI CHAELKA MULKEVI M.D. cc <NOTE_END>",
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"content": "The patient was afebrile his vital signs were stable . His neck was supple he had no jugular venous distention . His carotids were two plus bilaterally without bruits . His lungs were clear . His heart was regular rate and rhythm with no murmurs rubs or gallops . His abdomen was soft nontender nondistended . Bowel sounds are present . He had bilateral femoral bruits and",
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"content": " he had one plus popliteal pulses . His pedal pulses are absent . LABORATORY On admission his BUN was 13 creatinine 1.7 hematocrit 43 and the cholesterol was 208 . <NOTE_END>",
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"content": "The patient was transferred to Medical Intensive Care Unit for further management for acute GI bleed . 1. Gastrointestinal bleed The patient continued to receive blood transfusions on the floor and serial hematocrits with serial INR checks were drawn . As he was receiving his third unit of packed red blood cells the patient became tachycardic and short of breath . His temperature raised from 98.6 F. to 101.0 F. He was shown to have rigors . The transfusion was stopped and the patient was given Tylenol 1 mg with epinephrine 100 mg of hydrocortisone 25 mg of Benadryl and Demerol 15 as well as Pepcid . He had emesis times three of 75 cc of coffee ground material . The patient also desaturated to the low 80 s and was started on a non-rebreather mask . His saturations improved quickly on 100 non-rebreather mask within 15 to 20 minutes . Shortly after his mental status changed he became disoriented and euphoric and continued to be in this state for two more hours . After that period of time his mental status gradually improved and he continued to receive his blood transfusions requiring a total of ten units of packed red blood cells and four units of fresh frozen plasma to reach a hematocrit of 30.0 which remained stable for the duration of his stay . On admission the patient was started on high dose proton pump inhibitors for prophylaxis . On Wednesday 11-25 an esophagogastroduodenoscopy was performed and was significant for the following findings Medium hiatal hernia Barretts esophagus erosion of the gastroesophageal junction granularity erythema and congestion of the antrum in the pre-pyloric region compatible with gastritis . Erosions in the antrum and pre-pyloric region granularity erythema and congestion of the anterior bulb and posterior bulb compatible with duodenitis . It was recommended by Gastroenterology that the patient is to stay off aspirin for at least four to six weeks at discharge to prevent further bleeding . 2. Cardiovascular During transfusion reaction episode the patient had an episode of tachycardia ranging from 134 to 158 for one to two hours . EKG during this episode was taken and showed sinus tachycardia however serial enzymes were significant for CK peaking at 1075 MB peaking at 114 and MB index peaking at 10.8 consistent with myocardial damage . The day following this episode EKG showed loss of R wave progression in anterior leads and Q waves in leads III and AVF consistent with anteroseptal myocardial infarction . The patient s blood pressures remained stable during his stay . He had no episodes of arrhythmia on Telemetry . Cardiology consultation was obtained . The myocardial infarction was attributed to demand ischemia secondary to acute hematocrit drop exacerbated by tachycardia secondary to blood transfusion reaction . Further Cardiologic work-up was suggested as an outpatient at four to six weeks post discharge . The patient was started on Lopressor Lipitor and Lisinopril . 3. After ten units of packed red blood cells and four units of fresh frozen plasma transfusions the patient s hematocrit remained stable at above 30 . His INR decreased to 1.3 at the time of discharge . He required no blood transfusions for four days prior to discharge . 4. History of pulmonary embolism likely secondary to frequent flying . The need for further anti-coagulation was discussed with the patient s attending Dr. Coleman and it was decided not to continue anti-coagulation due to increased risk of gastrointestinal bleeding . The patient remained symptom free during his stay in the hospital saturating well in room air . 5. Endocrine The patient was restarted on Levothyroxine soon after admission . His hemoglobin A1C was sent and it was pending at the time of discharge . 6. Single mental status change times two hours during episode of blood transfusion reaction . Was most likely due to multiple",
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"content": " drugs administered during the episode including Demerol . After this episode the patient s mental status remained clear for the rest of the duration of his stay . 7. Prophylaxis The patient was sent home on proton pump inhibitors . His Helicobacter pylori serology was sent and was pending at the time of discharge . CONDITION AT DISCHARGE Good . DISPOSITION The patient was discharged to home on the following medications . <NOTE_END>",
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"content": "Coumadin Lipitor Toprol XL ASA Zoloft Glucophage Aricept Namenda Artificial Tears Discharge Medications Not applicable . Discharge Disposition Extended Care Facility Patient deceased . Discharge Diagnosis Not applicable patient deceased . Discharge Condition Not applicable . Discharge Instructions Not applicable . Followup Instructions Not applicable . William William MD",
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"content": " PHD 13-279 Completed by Barbara Josephine MD 21-547 2013-11-15 1413 Signed electronically by DR. Exie Culbreath on MON 2013-11-18 1006 AM <NOTE_END>",
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"content": "On admission vital signs were temperature 100.1 heart rate",
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"content": " 83 and sinus rhythm blood pressure 108 50 respiratory rate 25 oxygen saturation 97 on three liters . Generally he was a pleasant man with mild respiratory distress . Lungs had decreased breath sounds on the left . Cardiac examination showed regular rate and rhythm S1 and S2 . Chest incision was with Steri-Strips open to air clean and dry . Abdomen was soft and nontender nondistended with positive bowel sounds . Extremities had bilateral pedal edema . Right leg wound had Steri-Strips open to air clean and dry . <NOTE_END>",
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"content": "Aricept 10 mg qd Aspirin 81 mg qd Folic acid Gabapentin 200 mg tid Lopressor 12.5 mg bid Lisinopril 5 mg qd Daptomycin 420 mg IV qd Protonix 40 mg qd Seroquel 50 mg tid Heparin 5000 units SQ tid Colace 100 mg bid Lactulose 15 mg bid Comtan 200 mg qd Mirapex 1.5 mg tid Sinemet 50 200 mg tid Discharge Medications 1. Furosemide 20 mg Tablet Sig One 1 Tablet PO once a day for 2 weeks . Potassium Chloride 20 mEq Packet Sig One 1 Packet PO once a day for 2 weeks . Docusate Sodium 100 mg Capsule Sig One 1 Capsule PO BID 2 times a day . 4. Pantoprazole 40 mg Tablet Delayed Release E.C. Sig One 1 Tablet Delayed Release E.C. PO Q24H every 24 hours . 5. Aspirin 81 mg Tablet Delayed Release E.C. Sig One 1 Tablet Delayed Release E.C. PO DAILY Daily . 6. Magnesium Hydroxide 400 mg 5 mL Suspension Sig Thirty 30 ML PO HS at bedtime as needed for constipation . 7. Entacapone 200 mg Tablet Sig One 1 Tablet PO TID 3 times a day . 8. Pramipexole 0.25 mg Tablet Sig Six 6 Tablet PO TID 3 times a day . 9. Carbidopa Levodopa 50 200 mg Tablet Sustained Release Sig One 1 Tablet PO TID 3 times a day . Quetiapine 25 mg Tablet Sig Two 2 Tablet PO DAILY Daily . Procainamide 250 mg Capsule Sig Three 3 Capsule PO Q6H every 6 hours x 6 weeks . 12. Acetaminophen Codeine 300-30 mg Tablet Sig One 1 Tablet PO Q4H every 4 hours as needed . Warfarin 1 mg Tablet Sig as directed Tablet PO DAILY Daily . Daptomycin 500 mg Recon Soln Sig Four 90y 480 mg Intravenous Q24H every 24 hours thru 05-02 . Discharge Disposition Extended Care Discharge Diagnosis mitral valve endocarditis s p MV replacement HTN s p CVA Spinal stenosis s p Lumbar Laminectomy Parkingson s h o paranoid delusions MGUS vs MM Discharge Condition good Discharge Instructions May take shower . Wash incisions with warm water and gentle soap . Do no take bath or swim . Do not apply lotions creams ointments or powders to incision . Do not drive for 1 month . Do not lift more than 10 pounds for 2 months . Please contact office if you develop a fever more than 101.5 or notice drainage from",
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"content": " chest incision . Followup Instructions Dr. Portsche in 4 weeks Dr. Bravo PCP in 1-2 weeks Infectious disease Provider Marsha Harriet MD Phone 574-5036 Date Time 2019-04-29 1000 Jeffrey Everett MD 23-815 Completed by MARK Carolyn NP 80-AUO 2019-03 -26 1033 Signed electronically by DR. <NOTE_END>",
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"content": "The patient has no known drug allergies . MEDICATIONS ON TRANSFER Amiodarone 200 mg q.d. Lasix 20 mg b.i.d. Potassium chloride 20 mEq b.i.d. Ampicillin 2 grams q. 4 hours . Albuterol and Atrovent p.r.n. Aspirin 325 q.d. Coumadin 5 q.d. Nystatin swish and swallow 5 cc t.i.d. Colace 100 b.i.d. 10. Percocet 5 325 1-2 tablets q. 4 hours p.r.n. LABORATORY DATA White count 12.6 hematocrit 28.9 platelet count",
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"content": " 259 PT 21.4 PTT 40.2 INR 3.0 sodium 137 potassium 4.2 chloride 100 CO2 27 BUN 26 creatinine 1.3 glucose 120 . Chest x-ray shows a large left pleural effusion . <NOTE_END>",
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"content": "at time of admission the blood pressure 100 65 head eyes ears",
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"content": " nose throat no masses neck revealed lymphadenopathy . The lungs were clear heart normal . Abdomen liver massively enlarged down 15 cm . Extremities normal neurological examination generally intact . <NOTE_END>",
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"content": "Sarcoidosis since 2001 She is status post cholecystectomy . Status post tubal ligation Status post left arteriovenous graft placement for hemodialysis . Insulin-dependent diabetes mellitus times 32 years . Hypertension Coronary artery disease",
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"content": " status post myocardial infarction in 2012-05-06 . End-stage renal disease on hemodialysis for 1.5 years <NOTE_END>",
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"content": "Cardiac catheterization performed on 2013-01-03 Three vessel disease in the right dominant system . Left main coronary artery with short vessel without significant lesions . The LAD diffusely diseased proximal section up to 50 with focal 70 mid segment lesion . D1 was mildly diseased diffusely . Left circumflex had 80 stenosis in a large OM1 branch . The right coronary artery was diffusely diseased in the mid segment with serial 80-90 stenosis . Limited hemodynamics showed elevated LV and diastolic pressure 21 mmHg . Left ventriculogram demonstrates a mild mitral regurgitation and left ventricular ejection fraction of 58 with normal regional wall motion . HOWeaver COURSE The patient was admitted to Edith Nourse Rogers Memorial VA Hospital and brought to the operating room on 2013-01-04 by Dr. van der Talbot where she received a coronary artery bypass graft times three . She had an anastomosis between the left internal mammary artery and the left anterior descending artery saphenous vein",
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"content": " graft to RCA saphenous vein graft to OM . The patient tolerated the procedure well and was transported to the cardiac surgery recovery room . The patient was extubated on arrival in the cardiac surgery recovery room but was on no drips . The patient s postoperative course was uncomplicated and she was extubated on the first postoperative day . On the first postoperative day her diet was advanced as tolerated and she was transferred to the patient care floor . On postoperative day 2 her Foley catheter and chest tubes were discontinued . By postoperative day 3 she began ambulating with some great hesitancy . Foley catheter was removed . By postoperative day 5 she was ambulating at level IV was tolerating po was able to void and felt comfortable to go to rehab . CONDITION ON DISCHARGE Stable . DISCHARGE STATUS Discharged to rehab . DISCHARGE DIAGNOSIS 1. Status post coronary artery bypass graft times three on 2013-01-04 . <NOTE_END>",
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"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",
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"content": " 12 and her right atrial pressure was 4 and pulmonary artery pressure 44 17 . Her left ventricular contraction showed akinesis of the anterior wall with dyskinesis of the apex . She had preserved inferior contraction and basal contraction . Her native right and left anterior descending vessels were occluded as was an obtuse marginal branch . The saphenous vein to the high diagonal or high obtuse marginal was occluded . The left internal mammary artery to the left anterior descending was also occluded . The saphenous vein graft to the second obtuse marginal was open with no significant stenosis but there was an outflow lesion in the obtuse marginal 2 as well as severe distal lesion as the obtuse marginal 2 fed the posterior descending artery . This was considered her culprit lesion . This was considered too high risk for angioplasty because of the severe disease in the graft . In addition it was noted that she had saphenous vein harvested from both thighs . Her left internal mammary artery was also unused . It was also noted that she had failure to sense with the atrial lead . She would not sense the atrial contraction and the fire and this occasionally led to competition of firing . This was intermittent . The P wave amplitude was .6 and this could not be totally sensed . The patient was admitted for management of her coronary artery disease and evaluation of her pacemaker . It was noted that she became very symptomatic when she was not on a beta blocker but that on a beta blocker she had significant pacemaker failure . Her pacemaker was set to a VVI mode which sensed appropriately . She was in sinus rhythm with most of the time . When her pacemaker was in a sinus rhythm without a beta blocker she had significant angina . Carotid non-invasive testing was unremarkable . The situation was reviewed with Dr. Niste Graft . He felt the patient was not a coronary artery bypass graft candidate because of the lack of conduit and because of the presence of a large anterior myocardial infarction . For this reason it was decided to maximize her beta blockers and nitrates . The situation was reviewed with Dr. No of the Pacemaker Service . On August 20 under local anesthesia the right pectoral region was explored and the leads disconnected and the pulse generator changed to a CPI unit in which the sensitivity could be adjusted to .15 mm. which permitted appropriate atrial sensing . There was nothing wrong with the prior generator and nothing wrong with the leads . It just needed a unit that could have more sensitivity in the atrial mode . She tolerated this well . Her medications were resumed . She ambulated without difficulty and was discharged to home to be followed medically for her coronary artery disease following two failed bypass graft procedure by Dr. Brendniungand Asilbekote in Bi Masase KS . ACHASTHA N. GRAFT M.D. TR hfr DD 08 22 1998 TD 08 27 1998 356 P cc ACHASTHA NICEMAEN GRAFT M.D. GITTETUMN DARNNAMAN <NOTE_END>",
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"content": "On admission he was on Isordil 10 tid and enteric coated",
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"content": " aspirin but he was not taking either of these medications . HABITS The patient smokes one pack per day and has a history of heavy alcohol use . <NOTE_END>",
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"content": "Morphine prn . Ativan prn . Tylenol prn . Albuterol and Atrovent nebs prn . Rice S.F. Thrash M.D. 15-419 Dictated By Brett E.X. Im M.D. MEDQUIST36 D 2012-06-29 0115 T 2012-06-29",
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"content": " 0547 JOB 44693 Signed electronically by DR. Vicki Baker on TUE 2012-07-03 823 AM <NOTE_END>",
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"content": "The patient had no known drug",
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"content": " allergies . <NOTE_END>",
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"content": "Sandostatin 100 mcg subcu. b.i.d. Percocet 1-2 tabs q.3 -4h. p.r.n. pain Axid 150 mg p.o. b.i.d. Colace 100 mg p.o. b.i.d. DISCHARGE FOLLOW-UP The patient has been instructed to follow-up with Dr. Red in one week and in the Urology Clinic in three weeks . DISCHARGE DISPOSITION The patient is discharged to home on 7 10 98 . CONDITION ON DISCHARGE Stable condition .",
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"content": " Dictated By MALICHARLEAR KROENER M.D. EB85 Attending LEAND L. KROENER M.D. QW18 FO508 6558 Batch 54270 Index No. YCCYST5DG2 D 07 10 98 T 07 12 98 CC 1. <NOTE_END>",
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"content": "The patient was started on ceftazidime nafcillin and Flagyl for concern of a soft tissue infection . Neutropenic precautions were taken . The patient had a bone marrow biopsy which showed myeloid arrest and probable neutropenia from a drug-related cause presumed to be the sulfasalazine . Over the course of the hospitalization the patient &aposs white blood cell count rose from 0.4 to 6.3 after he was given G-CSF a course lasting from 9 28 01 until 9 30 01 . After the G-CSF the absolute neutrophil count was greater than 8000 . On 10 3 01 the patient had a repeat head and neck CT which showed a right parotitis and left submandibular lymphadenopathy with some necrosis . No frank abscesses . The patient &aposs antibiotics were changed to clindamycin 300 mg q.i.d. and patient was also put on sialagogue . Over the course of the hospitalization the swelling and tenderness and erythema have steadily decreased .",
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"content": " Recommendations on antibiotics were made by infectious disease team who was consulted . Rheumatology was also consulted for patient and after workup it was believed that arthritis may be a rheumatoid factor negative rheumatoid polyarthritis . Rheumatology recommended a taper of his prednisone to 20 mg q.d. and the patient will be followed by the rheumatology service . The oncology service was also consulted for patient and performed a bone marrow biopsy . Throughout his course during this hospitalization the patient was also followed by the ENT service . The ENT physicians did not recommend any procedures incision and drainage for his right parotitis or left submandibular cervical lymph node necrosis . The ENT team recommended watching patient in-house for two days after his repeat imaging on 10 3 01 and to continue antibiotic coverage with clindamycin . The patient had no positive blood cultures during his hospitalization and remained afebrile after the second day of admission . <NOTE_END>",
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"content": "The patient was admitted placed on intravenous fluids . He was continued on his imipenem intravenously . The patient was started on total parenteral nutrition . On 4 17 95 GI Interventional Radiology performed drainage of the peripancreatic fluid collection . Approximately one liter of brownish fluid was obtained and sent for culture . The drainage catheter was left in a pseudocyst . The patient was evaluated by Cardiology . A Persantine Thallium study demonstrated a large infarct involving the posteroseptal anteroseptal areas . Left ventricular aneurysm was also noted however no ischemia was seen . An echocardiogram was done . The echocardiogram showed terrible left ventricular function with left ventricular aneurysm . The right ventricle appeared to be acceptable . The percutaneous drainage catheter continued to have high output . The fluid was sent for amylase which came back 53 230 . On 4 28 95 the patient had new onset of abdominal pain . His white count had bumped from 8.3 on admission to 18.5 on 4 27 . A computerized tomography scan of the abdomen was performed . Approximately 100 cc.&aposs of thick brownish material was aspirated through the indwelling catheter . The computerized tomography scan showed the catheter tip in good position . Because of the patient &aposs deteriorating state the patient was brought to the operating room on 4 28 95 . An exploratory laparotomy was performed . The splenic flexure had a purulent exudative process along the antimesenteric surface . Thus the splenic flexure and a portion of the descending colon were resected . The patient underwent a left colectomy with end transverse colostomy and oversewing of the descending colon . Drainage of",
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"content": " the pancreatic necrosis was also done . The patient tolerated the procedure fairly well and was transferred to the Intensive Care Unit . In the Intensive Care Unit the patient had a prolonged course . The patient was then extubated on postoperative day 2 but remained pressor-dependent . He remained on imipenem and Vancomycin was also started . Thereafter the patient had a long and complicated postoperative course . He was eventually transferred to the floor where he remained meta-stable . He had repeated episodes of hypotension to 80-90 systolic 40-50 diastolic . These resolved without incident . He also had repeated temperature spikes . After repeated work ups it was felt that these were probably due to remaining infection in the peripancreatic area . His drainage tube from the peripancreatic area was gradually advanced and eventually discontinued . Mr. Mass was placed on multiple courses of antibiotics . Most recently he was on a 28 day course of Vancomycin ofloxacin and Flagyl for blood cultures that were positive for gram positive cocci and enteric and non-enteric gram negative rods . This 28 day course was completed on 07 15 95 . The patient was also treated initially with amphotericin-B and then with fluconazole for a computerized tomography guided aspirate of a small fluid collection around his pancreas which grew Candida albicans . The patient also had several episodes of fungal cystitis with Torulopsis glabrata going from his urine . He was treated with amphotericin-B bladder washes for this . Mr. Mass was initially anticoagulated for his left ventricular aneurysm . He remained stable from a cardiac fashion . He did have problems with po intake . He had repeated bouts of small-volume emesis that may have been secondary to reflux . He was treated with a variety of anti-emetics most recently Granisetron with only mild success . He remained total parenteral nutrition-dependent throughout his hospital course . By the end of June it became clear that Mr. Mass would require aggressive surgical intervention in order to eradicate his intra-abdominal bursts of intermittent sepsis however long discussions with the patient and his wife who was his health-care proxy revealed that they felt that no further aggressive intervention be attempted . The patient had been made a do not resuscitate do not intubate patient earlier in his hospital stay . Multiple discussions were held between Dr. Mass the rest of the surgical team and the patient &aposs wife with this same result . After discussion with the patient &aposs primary doctor Dr. Douet at Vassdiysey Medical Center it was felt that the patient and his family would be best served if the patient were transferred to Vassdiysey Medical Center . Of note given the patient &aposs do not resuscitate status and the risk for bleeding the patient &aposs Coumadin was stopped without incident several weeks before transfer . DOCTORS DISCHARGE INSTRUCTIONS MEDICATIONS 1. Heparin 5 000 units sc b.i.d. 2. Lisinopril 20 mg po qD . 3. Isordil 10 mg po t.i.d. Nitropaste 1 inch to chest wall q8h. Carafate one gram po or per nasogastric tube q.i.d. Cardizem 30 mg. po q6h digoxin 0.25 mg. po or intravenously qD fluconazole 200 mg qD for five more days after transfer for a total of a 14 day course total parenteral nutrition to meet the patient &aposs nutritional needs . The patient has an ostomy appliance around the former site of his pancreatic fistula drain . This area has continued to drain and it is felt that it could be best managed by an ostomy appliance and stoma care . The patient is also treated with shots of morphine for intermittent pain . I DRAIN M.D. DICTATING FOR LIASUN L. MASS M.D. TR aet bmot DD 07 16 95 TD 07 15 95 CC STAT discharge summary . Copies to Dr. Liasun Mass Dr. Tomedankell New of Cardiology and Dr. Scosthuang of Vassdiysey Medical Center . <NOTE_END>",
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[
{
"content": "Mr. Vessels is a 49-year-old man status post orthotopic heart transplantation in 1991 at Dautenorwe Stuart Erec",
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},
{
"content": " Hillpa Of Hospital who is admitted with dyspnea and severe heart failure . Mr. Vessels &aposs postoperative course has been marked by CMV infection hypertension poorly controlled lipids peripheral vascular disease and chronic renal insufficiency with a creatinine of 1.8 or so . Recently he had documented coronary angiography based on a catheterization performed in January 1996 with moderate to diffuse atherosclerosis . A repeat angiogram performed a year later showed marked progression of coronary allograft disease . A biopsy at that time revealed grade 1B rejection with endothelialitis and eosinophils . He was treated with pulsed IV steroids and Imuran was augmented with mycophenolate Mofetil . Chest x-ray showed cariogenic pulmonary edema and he was faring poorly . Prior to admission he was seen approximately 1 week in the office with mild congestive heart failure . An echocardiogram then revealed an ejection fraction of 40 and an endomyocardial biopsy revealed no ejection . <NOTE_END>",
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[
{
"content": "Vital signs Blood pressure 140 80 heart rate 86 . She is a pleasant obese black female in no apparent distress . There is no lymphadenopathy . Her skin is intact without lesions . Her HEENT examination is benign . Her neck is slightly tender with a firm thyroid but no masses or bruits . Her lungs have decreased sounds bilaterally in the upper lung fields . Her heart is regular rate and rhythm . She has a well healed umbilical hernia scar for approximately 2 1 2 cm . She has no clubbing cyanosis or edema on her extremities . LABORATORY Pulmonary function tests on September 27 1997 revealed an FVC of 2.7 which is 112 and FEV1 of 2.23 which is 123 . Her admission laboratory data includes serum chemistries with a sodium of 144 potassium 4.1 chloride 101 bicarbonate 28 BUN 10 creatinine 0.9",
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{
"content": " and glucose of 93 . White blood cell count is 7.65 hematocrit of 42 and platelets of 345 . Her urinalysis shows 2 bacteria and 2 squamous epithelium with greater than 10 000 mixed bacteria . Chest x-ray on August 6 1997 revealed multiple pulmonary nodules increased in size as previously mentioned . PT was 11.7 PTT 26.7 and INR of 0.9 . <NOTE_END>",
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[
{
"content": "1.Respiratory . Without issues on this admission . Breath sounds are clear and equal . 2. Cardiovascular . Without issues on this admission . He had a regular heart rate and rhythm no murmur', 'pulses were 2 and symmetric . 3. Fluids electrolytes and nutrition . The baby s weight was 3.160 kilograms 7 pounds 3 ounces . He is breast and bottle feeding every 3 hours with expressed breast milk', 'and or Enfamil . He is feeding well . His discharge weight is 3025 gm and has been stable for past 2 days . 4. Gastrointestinal . The baby s bilirubin on 2018-12-31 was 15.5', '0.5 at which time double phototherapy was started . On 01-01 his bilirubin was 17.3 0.4 at which time triple phototherapy was started and then his subsequent bilirubins are 16.5', '0.4 on 2019-01-01 and 16.2 0.5 on 2019-01-02 . Phototherapy was discontinued on 2019-01-04 for a bilirubin of 12.1 and a rebound bilirubin will be checked on 01-05 . 5. Hematology .', 'The hematocrit",
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},
{
"content": " on 01-02 was 61 with a reticulocyte of 2.6 . His blood type is A Coombs negative . 6. Infectious disease . No issues on this admission . 7. Neurological .', 'The baby has been appropriate for gestational age with normal newborn reflexes . 8.', 'Sensory Auditory hearing screening was performed with automated brainstem responses . The infant passed both ears on 2018-12-30 . 9. Psychosocial . The family is invested and involved .' <NOTE_END>",
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[
{
"content": "Non-insulin-requiring diabetes mellitus",
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},
{
"content": " and hypercholesterolemia . PAST SURGICAL HISTORY As given above . <NOTE_END>",
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] |
[
{
"content": "Aspirin under which she develops worsening of her shortness of breath and asthma flare tetracycline sulfa Demerol . MEDICATIONS Diovan 106 mg q.d. Advair 500 50 two puffs b.i.d. Plavix",
"role": "user"
},
{
"content": " 75 mg q.d. Crestor 20 mg q.d. Neurontin 300 mg t.i.d. Prilosec 20 mg b.i.d. Vicodin as needed . Trazodone 50 mg q.d. Singulair 10 mg q.d. Flexeril 10 mg t.i.d. 11. Lopressor 75 mg b.i.d. Humibid 3600 b.i.d. Colace 100 mg b.i.d. Zetia 10 mg q.d. Benadryl as needed . Tricor 106 mg q.d. Premarin 0.3 mg q.d. Prozac 40 mg q.d. 19. Omega-3 fatty acids t.i.d. 1. Chest pain The patient ruled out for myocardial infarction . However with her history of disease patient underwent a cardiac catheterization .', 'The patient was found at cardiac catheterization to have mild diffuse instent restenosis in the mid stent otherwise hemodynamically normal and the coronary arteries', 'otherwise were without flow-limiting stenoses . The patient was then continued on her cardiac medications . It was felt that if we attempted aspirin desensitize her while an inpatient', 'then she would benefit from the use of aspirin and Plavix . The patient was sent to the CCU and underwent aspirin desensitization protocol which she tolerated well .', 'She had mild worsening of her asthma attacks which was relieved by Benadryl and occasionally albuterol . The patient found that if she took the aspirin in the evening with her Benadryl', 'that she takes for sleep that the asthma exacerbation did not occur . Aspirin no longer should be considered an allergy for this patient and she is going to take this as an outpatient .', '2. Hyperlipidemia The patient s Lipitor was increased to 80 mg q.d. 3. Back pain This is a chronic issue and was controlled with Flexeril and Vicodin . DISPOSITION To home . <NOTE_END>",
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[
{
"content": "Currently on no medications . State newborn screen was sent on 2013-07-26 and is pending . Has not received",
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},
{
"content": " any immunization . <NOTE_END>",
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] |
[
{
"content": "His hematocrit was 44.4 with white blood count of 11.9 and platelet count of 410 . His MCV was 92 MCH 32.1 and MCHE 34.8 . His chest X-ray did not reveal",
"role": "user"
},
{
"content": " any abnormality . A electrocardiogram showed nonspecific T-wave abnormalities otherwise it was normal . <NOTE_END>",
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] |
[
{
"content": "On admission birth weight 1630 grams 50th percentile length 43.5 cm 50th percentile head circumference 31.5 cm 75th percentile . Infant with non dysmorphic facies palate intact . Anterior fontanel soft and flat moderate nasal flaring . Chest with moderate intercostal retractions fair breath sounds bilaterally no crackles . Cardiovascular is well",
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},
{
"content": " perfused with regular rate and rhythm and normal S1 and S2 no murmur normal pulses and perfusion . Abdomen soft not distended . No organomegaly or masses . Bowel sounds are active patent anus three vessel umbilical cord . Genitourinary normal female genitalia . Skin without rashes or lesions . Spine intact . Hips stable . Active alert responding to stimulation . Tone decreased slightly in symmetric distribution moves all extremities equally . Suck and gag present . Grasp symmetric . SUMMARY OF HOSPITAL COURSE BY SYSTEMS Initially was placed on continuous positive airway pressure 40 oxygen . Due to increasing respiratory distress was intubated placed on conventional ventilation and pressures of 24 6 rate of 25 . She received one dose of Survanta and then weaned well on ventilator settings . She was extubated to room air at 13 hours of age . Has remained in room air since with comfortable work of breathing respiratory rates in the 40 s to 70 s. No apnea . Cardiovascular has been hemodynamically stable throughout hospital stay . Heart rates range in the 140 to 160 s no heart murmur . Recent blood pressure 71 31 with a mean of 48 . Fluids electrolytes nutrition Was initially NPO on receiving D10-W by peripheral intravenous . Enteral feeds were started on day of life one and she advanced to full volume feeds of breast milk or special care formula on day of life six 2013-07-29 without problems . She is presently receiving breast milk or special care formula 24 cal at 150 mls per kilo per day with tolerance . Voiding and stooling appropriately . Most recent electrolytes done on day of life one showed a sodium of 132 potassium 6.1 chloride 100 Co2 20 . Discharge weight is 1700 grams up 15 grams .. Gastrointestinal Received phototherapy from 07-27 to 2013-07-28 for a peak bilirubin of 8.1 . Phototherapy was discontinued when bilirubin was a total of 4.7 . Most recent bilirubin on 2013-07-29 total of 4.2 direct .4 . Hematology Hematocrit on admission 47 . No transfusions given . Infectious Disease Received 48 hours of Ampicillin and gentamicin for rule out sepsis . CBC on admission showed a white count of 9.3 with 37 polys 0 bands platelets 399 000 . The blood culture was negative . Neurology Head ultrasound not indicated . Sensory A hearing screening has not been performed will need prior to discharge home . CONDITION ON DISCHARGE Stable 7 day old former 32-5 7 week and now 33-5 7 weeks age . DISPOSITION Saint Vincent Hospital Hospital . PEDIATRICIAN Dr. Manuel Burke 1 Parkway Fall River New Mexico 57362 . CARE AND RECOMMENDATIONS Feeds . Breast milk or special care formula 24 calories per ounce at 150 mls per kilo per day with plans to advance calories . 2. <NOTE_END>",
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[
{
"content": "Mr. Gach is an 80 year old man with aprevious history of coronary artery disease who was transferred from Linghs County Medical Center to Oaksgekesser Memorial Hospital because of an apparent infected wound including the PICC line in his right elbow and positive blood cultures for Staph. aureus associated with fever . He has a history of myocardial infarctions in 1981 1992 and 08 97 with thelast episode complicated by anoxic encephalopathy . He gradually improved but had recurrent angina requiring cardiac catheterization demonstrating 90 left main 95 ostial LAD and 30 to 40 mid-LAD with an occluded RCA . CABG surgery with two vessel bypass was done on 11 18 97 . He was then transferred to Linghs County Medical Center . A PICC line was placed in his left antecubital fossa and on the day of New Years Eve he developed a fever of 102 and became lethargic . The PICC line site was erythematous . Blood cultures grew out 4 out of 4 bottles for gram positive cocci which thereafter proved to be Staph. aureus Methicillin sensitive . He had no chest pain",
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{
"content": " shortness of breath or diarrhea . PAST MEDICAL HISTORY Includes ischemic cardiomyopathy with an echocardiogram done on 11 13 97 showing an ejection fraction of 28 and LV that is diffusely hypokinetic . OTHER MEDICAL PROBLEMS Dementia 2 paroxysmal atrial fibrillation 3 hypertension 4 peripheral vascular disease with previous left femoral popliteal bypass 5 diabetes mellitus 6 chronic renal insufficiency 7 COPD 8 previous abdominal aortic aneurysm repair in 1981 9 benign prostatic hypertrophy status post TURP surgery in 1982 . <NOTE_END>",
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] |
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