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"content": "His past medical history included hypertension and non-insulin diabetes mellitus which is diet controlled",
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"content": " . PAST SURGICAL HISTORY His past surgical history had included gastric ulcer surgery and appendectomy <NOTE_END>",
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"content": "Revealed an obtunded white muscular man who was intubated and sedated . The vital signs showed a blood pressure of 69 pulse 80 respirations 14 and temperature 99.8 . There is a contusion over the right eye but no laceration abrasion of her left shoulder no flank discoloration blanching papules over the knees bilaterally without central necrosis . He had multiple tattoos . Lymphatic-he had shotty cervical adenopathy . The head eyes ears nose throat exam was normocephalic with trauma as described pupils were 2 mm bilaterally which were minimally reactive fundi was not seen conjunctivae without erythema sclerae anicteric positive corneal reflexes noted . Ears-the tympanic membranes were clear with no hemorrhage at the time of admission . Nose-no sinus discharge no hemorrhage . The oropharynx was intubated . Lungs-clear with good air movement bilaterally . He had scattered wheezes following a 3 liter bolus for hypotension . No effusion or rub was heard . The cardiac exam showed point of maximal impulse was not displaced regular rate and rhythm with normal S1 S2 no S3 or S4 a grade II VI systolic murmur was heard at the left upper sternal border without radiation likely representing a flow murmur . No peripheral edema was noted . The jugular venous pressure was not assessed secondary to cervical collar being in place . The carotid pulses were brisk bilaterally . The vascular exam showed normal pulses bilaterally without bruits . The abdomen was soft bowel sounds of normal character and there was mild percussion tenderness and tenderness to modest palpation in all four quadrants . It was unclear whether this was due to superficial tenderness or abdominal tenderness . He had marked voluntary guarding without rigidity and no masses were felt . The genitourinary exam showed normal penis with normal testicles which were nontender . There was no urethritis no balinitis normal prostate nontender . There was tan guaiac positive stool with no masses . The musculoskeletal exam showed well developed symmetrical muscular development with no fasciculations no joint erythema no effusions . Neuro exam the Mental Status Exam was variable intermittently responsive unable to follow commands . He nods appropriately and was able to confirm known history . The cranial nerves II-XII grossly intact",
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"content": " bilaterally symmetric . The motor exam-moves all four extremities easily and on command . The sensory exam revealed no focal deficits to limited exam . Reflexes were trace in the upper extremities and absent in the knees with downgoing toes bilaterally . <NOTE_END>",
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"content": "Albuterol nebulizers 2.5 mg q.4h. and Atrovent nebulizers 0.5 mg q.4h. please alternate albuterol and Atrovent Rocaltrol 0.25 mcg per NG tube q.d. calcium carbonate 1250 mg per NG tube",
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"content": " q.i.d. vitamin B12 1000 mcg IM q. month next dose is due Nov 18 diltiazem 60 mg per NG tube t.i.d. ferrous sulfate 300 mg per NG t.i.d. Haldol 5 mg IV q.h.s. hydralazine 10 mg IV q.6h. p.r.n. hypertension lisinopril 10 mg per NG tube q.d. Ativan 1 mg per NG tube q.h.s. Lopressor 25 mg per NG tube t.i.d. Zantac 150 mg per NG tube b.i.d. multivitamin 10 ml per NG tube q.d. Macrodantin 100 mg per NG tube q.i.d. x 10 days beginning on 11 3 00 . CONDITION Stable with active problems being respiratory failure urinary tract infection and bleeding diathesis . DISCHARGE LABS On the day of discharge sodium 145 potassium 4.1 chloride 109 bicarb 31 creatinine 0.7 BUN 43 glucose 116 . CBC 14.9 29.2 which is stable and 398 . PT 12 PTT 27 and INR 1.0 . Magnesium of 1.9 . Calcium 8.1 . COMPLICATIONS None . DISPOSITION The patient is being discharged to an acute rehab facility . She should follow-up with Dr. Ryna Jescdrig as well as Dr. Lenni Lung in the Vascular Surgery Department in approximately three to four weeks . Please call the Surgical Intensive Care Unit at Verg Medical Center for any further details that may be needed . You can also page Sta Lung M.D. as I am the dictating physician who has been taking care of Ms. Shuffa for quite some time now . I would be happy to answer any questions . My pager number at Verg Medical Center is number 54930 . Dictated By STA LUNG M.D. HU53 Attending RYNA R. JESCDRIG M.D. GN3 QE555 1531 Batch 77428 Index No. DXXJ8U8529 D <NOTE_END>",
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"content": "On physical examination the patient was both chronically and acutely ill dyspneic mildly febrile and with coarse rales in both bases . He was in chronic atrial fibrillation and his vital signs were otherwise stable . His abdomen was negative . His prostate enlarged and",
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"content": " he had no peripheral edema . <NOTE_END>",
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"content": "Persistent atrial fibrillation . Coronary artery disease . Coronary artery bypass grafting times two . HISTORY OF THE PRESENT ILLNESS The patient is a 63 year-old man with a history of hypertension and prior history of atrial fibrillation secondary to hyperthyroidism who presented to an outside hospital with a history of left-sided chest pain at rest .",
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"content": " The patient awoke with chest pressure radiating to the right chest associated with diaphoresis . The patient was found to have a blood pressure of 170 108 with atrial fibrillation and rapid ventricular response to a heart rate of 140s . The patient was rate controlled and transferred to the Stillman Infirmary for emergent cardiac catheterization . <NOTE_END>",
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"content": "Aspirin 325 mg. PO q.d. Lipitor 80 mg. PO q.d. Toprol XL 50 mg. PO q.d. Lasix 80 mg. q.a.m. and 40 mg. q.p.m. Potassium chloride 20 mEq. PO b.i.d. Citracal 1 packet q.d. Imdur 60 mg. PO q.d. Vitamin E 400 international units q.d. Prilosec 20 mg. PO q.d. HISTORY OF PRESENT ILLNESS Breunlinke is a 70-year-old patient of Dr. Brendniungand Asilbekote in California . She is referred for progressive angina . She had rheumatoid fever as a child and a heart murmur noted but no further testing . She has used antibiotic prophylaxis since 1980 . In 1980 she had quadruple coronary artery bypass graft surgery by Dr. Elks at Feargunwake Otacaa Community Hospital and did well until 1988 when she had exertional angina and a positive stress test and found that three or four grafts were occluded . In October 1989 Dr. No re-did her bypass operation . She had a left internal mammary artery graft to the left anterior descending saphenous vein graft to the obtuse marginal 1 and a saphenous vein graft to the obtuse marginal 2 . In 1993 she had a DDD pacemaker for complete heart block . She had exertional angina at that time . In November 1997 she had a small myocardial infarction as was transferred to Ona Hospital where a cardiac catheterization showed a tight left internal mammary artery to left anterior descending stenosis high grade saphenous vein graft to obtuse marginal 1 stenosis and patent obtuse marginal 2 graft . She had normal left ventricular function with apical tip akinesis . Since that time she has continued to have exertional left chest burning radiating to the left neck and arm relieved by nitroglycerin . She was turned down for re-do surgery at that time and did not have a percutaneous transluminal coronary angioplasty . Because these symptoms have been increasing particularly at cardiac rehabilitation she was referred here . In May 1998 she had an exercise tolerance test in which her heart rate went to 112 and her blood pressure fell to 95 systolic . She had diffuse ischemic ST segment changes and increased lung uptake and a reversible anterior and lateral defect . She has had no syncope . Her cardiac risk factors are hypertension and elevated cholesterol . She has a very strong family history of coronary artery disease with a mother sister and brother",
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"content": " dying of myocardial infarction . She is a remote cigarette smoker . She also has a history of lactose intolerance peptic ulcer disease with a remote gastrointestinal bleed and multiple ectopic pregnancies and mid term miscarriages . She has had a total abdominal hysterectomy . <NOTE_END>",
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"content": "Cigarette smoking Insulin dependent diabetes mellitus . Proteinuria Aortic stenosis . Cellulitis Gangrene of his left second toe in 2010-06-06 followed by an",
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"content": " amputation . Left common femoral dorsalis pedis bypass graft Right leg bypass graft in 1999 . Right below the knee amputation in 2008 <NOTE_END>",
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"content": "Admission laboratories were notable for a white count of 13.1 hematocrit 34.0 platelet count 280 000 . Chemistries were notable for a sodium of 143 potassium 3.2 chloride and bicarbonate of 104 and 24 respectively with blood urea nitrogen and creatinine of 7 and 0.4 respectively . Blood glucose was 116 . Her admission coagulation studies were notable for a prothrombin time INR of 11.8 and 0.9 respectively with a partial thromboplastin time of 25.2 . Admission lactate was 0.8 . Amylase was 87 . Fibrinogen was 346 . HCG was negative . Serum toxicology and urine toxicology were negative . Urinalysis obtained on admission was additionally negative . She had three views of the cervical spine that were negative . Chest x-ray was negative . Pelvis film was negative . Head CT from the outside hospital just revealed a small right parietal subdural blood . She was evaluated . Her cervical spine was cleared . She was off TLS precautions . She was sent to the Intensive Care Unit for monitoring overnight for neural checks and neurosurgical consultation was obtained . Neurosurgical evaluation just recommended serial neurologic checks and a repeat CAT scan on the second day of admission to see if there was any evidence of progression of the bleeding . On 2010-02-05 the patient had a repeat CAT scan of the head revealing no change in the subdural bleed . Her neurologic examination remained nonfocal . She was kept in the hospital for an additional 24 hours for further evaluation . By 2010-02-06 which would correlate with hospital day number two the patient had no complaints except for some small frontal pressure in the region of where the bleed had been localized on the right side . She remained afebrile and hemodynamically . She was tolerating diet and able to ambulate without difficulty . She had no other complaints by examination . Her neurologic examination remained completely nonfocal and otherwise normal . She was seen by",
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"content": " the trauma attending with Dr. Walters and she was cleared for discharge to home . MEDICATIONS ON DISCHARGE 1. Tylenol 3 one to two tablets p.o. q 4-6 hours p.r.n. Motrin as needed . Prozac 20 mg p.o. once daily . 4. Tetracycline which she was taking for her acne . FOLLOW-UP She will follow-up with Dr. Langley in approximately one month . Her trauma clinic follow-up is strictly p.r.n. DISCHARGE DIAGNOSES Right parietal subdural bleed status post fall from standing position with no loss of consciousness and no neurologic deficits or progression . Depression . Acne . DISCHARGE STATUS The patient was discharged to home in stable condition . Charles I. . Sanders M.D. 76-364 Dictated By Hayden Y. Ferguson M.D. MEDQUIST36 D 2010 -02-06 0859 T 2010 -02-06 0910 JOB 73118 Signed electronically by DR. Theresa MOORMAN on FRI 2010-02 <NOTE_END>",
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"content": "The patient was nonverbal but was able to open her eyes and nod . No respiratory distress . Her temperature was 102.2 blood pressure 135 64 pulse rate 108 respirations 24 oxygen saturations on room air",
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"content": " 94 . The head eyes ears nose and throat examination revealed no ocular abnormalities . Neck no lymphadenopathy no carotid bruits jugular venous pressure not elevated no goiter . Chest reduced breath sounds at the bases with faint inspiratory rhonchi anteriorly . Cardiac regular rate and rhythm with frequent premature beats and a 2 6 systolic ejection murmur at the apex . The abdomen was non-tender nondistended no hepatomegaly normal bowel sounds . Extremities 1 edema 2 pulses . Skin intact with diaper . <NOTE_END>",
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"content": "He was admitted and found to have a significant hematocrit drop from 33.8 to 24.3 . He was found operation be short of breath and was taken to dialysis for apparent fluid overload . His gastrointestinal bleeding issues were investigated with an upper endoscopy which revealed multiple superficial gastric ulcerations consistent with an non-steroidal anti-inflammatory drugs gastropathy . He had been discharged on one aspirin a day with 20 of Prilosec b.i.d. The aspirin was discontinued and he had no further problems with gastrointestinal bleeding and a stable hematocrit the rest of his hospitalization . During the course of his hospitalization he became increasingly lethargic . An extensive work-up was done for any metabolic abnormalities which was unrevealing . He responded somewhat to lactulose for hepatic encephalopathy . He had one positive blood culture for Vancomycin resistant enterococcus . In the few days prior to his demise he was intermittently somewhat lethargic buton the morning of June 25 1999 his white count was noted to have increased from 8 to 13 000 . That day he was found to be acutely short of breath with a respiratory rate of 40 and oxygen saturations in the mid seventies . He was put on 100 nonrebreather and his oxygen saturations improved to the low nineties . Nasal trumpet suction was done and he was found to have food like material that was easily suctioned out . He was also found to havesome pieces of toast in his mouth . Blood gases were done and he was found to have a pH of 7.2 with a pCO2 of 21 . Fingerstick glucose revealed a sugar of 12 . A stat panel 7 confirmed that the sugar was 23 and that he had a new anion gap of 40 . Repeat blood gas was done which was almost identical to the first . The family was called and came in to see the patient . An extensive family meeting was held and the family agreed that it did not make sense to intubate",
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"content": " the patient and send him to the Intensive Care Unit . In the acute setting he had been started on levofloxacin Flagyl and Vancomycin . These antibiotics were continued but the family decided that they wanted us to emphasize the comfort of the patient and pursue no further invasive measures . The patient was made do not resuscitate do not intubate . At 230 on June 26 1999 I was called to see the patient who had expired . DISPOSITION The family was notified and came in to see the patient . The family declined an autopsy saying that they felt that the patient had been through enough . The patient &aposs attending physician Dr. Erm Neidwierst was notified as well . Dictated By CONRELLIE KOTERUDES M.D. UK0 Attending ERM K. NEIDWIERST M.D. QQ62 OC499 5391 Batch 15168 Index No. VKRPJQ81J6 D 06 26 99 T <NOTE_END>",
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"content": "The patient was admitted to the Service of Dr. Fede A. Duhenile . On 1 12 92 she was taken to the operating room where she underwent a neart total gastrectomy with a retrocolic Bill-Roth II gastrojejunostomy reconstruction . In addition a small ventral hernia was noted upon abdominal exploration",
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"content": " within a previous surgical incision . This was repaired . A needle jejunostomy catheter was placed at the time of her operation to facilitate postoperative nutrition . With regards to the cancer there was a large mass along the greater curvature in the body of the stomach and several perigastric lymph nodes which were taken with the specimen . In addition there were at least two lymph nodes within the porta hepatis which were dissected free and taken en bloc with the specimen . The remainder of her abdomen was unremarkable without evidence of metastatic spread elsewhere including the liver . The patient tolerated the procedure well and was taken to the recovery room in good condition . The patient s postoperative course was for the most part unremarkable . Her wounds healed well without incident and the needle jejunostomy tube was utilized on the first postoperative day right up until the time of discharge infusing Vivonex T.E.N. The patient tolerated this without difficulty . The patient s nasogastric tube was removed on the 3rd postoperative day and with the passage of flatus and good bowel sounds noted she was started on a liquid diet which was advanced slowly . She was seen by the dietician and was advised with regard to needing numerous small meals during the day rather than 3 larger meals as she previously was used to . Her ambulation and mobilization increased gradually and by the time of discharge she was walking in the halls without assistance . As mentioned her wounds healed well without incident and the staples were removed on the 10th postoperative day just prior to discharge . She had some difficulties with confusion in the early postoperative period which were attributable to her advanced age and a sundowning effect . These problems resolved by the 4th or 5th postoperative day and she remained lucid and alert for the remainder of her hospital stay . Surgical pathology report was completed prior to discharge which revealed poorly differentiated adenocarcinoma ulcerating and extending through the wall into the serosa of the stomach . Metastatic carcinoma was present in 3 of 3 lymph nodes . The gastric resection margins were free of carcinoma . The patient was set for discharge on the 11th postoperative day doing well . On the day prior to discharge she complained of some dysuria a urine specimen was obtained which showed numerous white cells consistent with a urinary tract infection . She was started empirically on Bactrim while culture and sensitivity results were pending and remained pending at the time of this dictation . She will be discharged to home and will be seen in follow-up by her regular physicians as well as Dr. Ko . <NOTE_END>",
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"content": "Nonischemic dilated cardiomyopathy . MEDICATIONS ON DISCHARGE 1. Digoxin 375 mcg and 250 mcg alternating doses each day . Lisinopril 40 mg p.o. q.d. Toprol XL 75 mg p.o. q.d. Flovent 110 mcg two puffs b.i.d. 5. Albuterol 1-2 puffs q.6h. prn . 6. Coumadin 10 mg p.o. q.h.s. Lasix 40 mg p.o. q.d. Keflex 500 mg x6 doses . FOLLOW-UP INSTRUCTIONS The patient will follow up in EP Clinic on 2012-03-19 . She will also be seen in the Heart Failure Clinic on 2012-03-28 . Patient will also followup with her primary",
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"content": " care provider Dr. Sandra Lamar for check of her INR in one week s time . Felix Weiss M.D. 95 -771 Dictated By Randy EB Brooks M.D. MEDQUIST36 D 2012-03-13 1225 T 2012-03-13 1400 JOB 15824 Signed electronically by DR. <NOTE_END>",
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"content": "82 119 60 22 and 99 on room air . Well appearing in no apparent distress . Pupils are equal round and reactive to light . Moist mucous membranes . No JVD . Regular rate and rhythm .', 'Positive tenderness to sternum . Chest was clear to auscultation bilaterally . Abdomen Obese soft . Extremities show no edema 2 dorsalis pedis 1 femoral pulses .'Troponin-T less than 0.01. EKG Sinus 84 normal axis QTc 430 Q s in III and aVF",
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"content": " no ST changes as compared to 2017-05-01 EKG . <NOTE_END>",
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"content": "Sodium 139 potassium 3.7 and BUN of 19 . Her hematocrit was 37.2 with a white blood count of 6.6 . Her Bilirubin",
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"content": " direct and total were 0.1 and 0.3 respectively . Her alkaline phosphatase was 134 . Her electrocardiogram demonstrated normal sinus rhythm without acute ischemic changes . Chest X-Ray was unremarkable . The assessment at the time of admission was that of an 86 year old female with poorly differentiated gastric adenocarcinoma admitted for resection . <NOTE_END>",
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"content": "Patient is a 28 year old gravida IV para 2 with metastatic cervical cancer admitted with a question of malignant pericardial effusion . Patient underwent a total abdominal hysterectomy in 02 90 for a 4x3.6x2 cm cervical mass felt to be a fibroid at Vanor . Pathology revealed poorly differentiated squamous cell carcinoma of the cervix with spots of vaginal margins and metastatic squamous cell carcinoma in the cardinal ligaments with extensive lymphatic invasion . Patient was felt to have stage 2B disease and post-operatively she",
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"content": " was treated with intracavitary and external beam radiation therapy and low dose Cisplatin . On ultrasound in 02 91 the patient was found to have bilateral cystic adnexal masses confirmed on physical examination . She underwent exploratory laparotomy and had a bilateral salpingo-oophorectomy and appendectomy . Pathology was negative for tumor and showed peritubal and periovarian adhesions . The patient now presents with a three to four week history of shortness of breath and a dry non-productive cough . She was evaluated by Dr. Mielke a Pulmonologist who found her to be wheezing and performed pulmonary function tests which showed an FEV1 of 1.1 and an FVC of 1.8 . She was admitted to Weekscook University Medical Center with a diagnosis of possible asthma . Room air arterial blood gas showed a pO2 of 56 a pCO2 of 35 and a pH of 7.52 . EKG showed sinus tachycardia at 100 and echo revealed pericardial effusion a 10 mm pulsus paradoxus was noted and no evidence of tamponade . Given the patient &aposs history of cervical cancer the pericardial effusion was felt most likely to be malignant . She was therefore transferred to the Retelk County Medical Center for further care . <NOTE_END>",
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"content": "Birth weight 1865 grams . HOSPITAL COURSE 1. Respiratory The infant has remained in room air throughout this hospitalization with respiratory rates 40 s to 50 s oxygen saturation greater than 94 . One apnea and bradycardia event which was self resolved on day of life four . 2. Cardiovascular The infant was",
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"content": " noted on CR-monitor to have premature ventricular contractions which resolved spontaneously . A twelve lead electrocardiogram was recommended if this persists . No murmur . Heart rates 140 s to 150 s. Mean blood pressure has been 46 to 54 . 3. Fluid electrolytes and nutrition The infant was started on enteral feedings on day of life one and advanced to full volume feedings by day of life four . The infant was initially started on 80 cc kg day of intravenous fluid D10W and advanced to 150 cc kg day by day of life four . The infant tolerated feeding advancement without difficulty . The infant did not receive parenteral nutrition . The most recent electrolytes on day of life two showed a sodium of 145 chloride 111 potassium 3.8 bicarbonate 21 . The infant is currently receiving breast milk 22 calories per ounce or premature Enfamil 22 calories per ounce 150 cc kg day p.o. and gavage . The most recent weight today is 1810 grams which was no change from the previous day . 4. Gastrointestinal The infant was started on single phototherapy on day of life two for a maximum bilirubin level of 9.1 with a direct of 0.3 . Phototherapy was discontinued on day of life five and the rebound bilirubin level on day of life six is 7.7 with a direct of 0.2 . 5. Hematology The most recent hematocrit on day of life two was 45.8 . Hematocrit on admission was 54.0 . The infant has not received any blood transfusions this hospitalization . 6. Infectious disease The infant received 48 hours of Ampicillin and Gentamicin for rule out sepsis . The complete blood count on admission showed a white blood cell count of 8.0 hematocrit 54.0 platelet count 190 000 11 neutrophils 0 bands . A repeat complete blood count on day of life two showed a white blood cell count of 6.3 hematocrit 45.8 platelet count 199 000 37 neutrophils 0 bands 53 lymphocytes . Blood cultures remained negative to date . 7. Neurology Normal neurologic examination . The infant does not meet criteria for head ultrasound . Sensory Hearing screening is recommended prior to discharge . Psychosocial As noted above paternal aunt was the gestational carrier . The infants are legally under the parents names and they are involved with the infant s care . The gestational carrier is not involved . Noted in the chart are legal documents . The contact social worker can be reached at 756 599-4849 . CONDITION ON DISCHARGE 32 and 4 7 weeks now day of life six stable in room air . DISCHARGE DISPOSITION To nursery at VA Hospital Jamaica Plain Hospital . PRIMARY PEDIATRICIAN Dr. James Ramos telephone 346 741 2728 . FEEDINGS AT DISCHARGE 150 cc kg day of breast milk 22 calories or premature Enfamil 22 calories per ounce . <NOTE_END>",
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"content": "On admission the sodium was 136",
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"content": " potassium 3.0 chloride 98 CO2 20 BUN 8 creatinine 0.8 and glucose 94 ALT 5 AST 10 LDH 166 alkaline phosphatase 81 total bili 0.6 direct bili .3 albumin 3.3 calcium 8.8 and uric acid 3.1 . She had CA-125 which was pending at the time of discharge . Her hematocrit was 31.1 WBC 11.6 and 151 000 platelets . <NOTE_END>",
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"content": "Methylprednisolone 4 mg q. a.m.",
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"content": " and 2 mg p.o. q.h.s. spironolactone 50 mg p.o. q.d. metformin 1500 mg p.o. q.h.s. Pravastatin 10 mg p.o. q.h.s. lisinopril 20 mg p.o. q. a.m. Lasix 80 mg p.o. q. a.m. Tylenol as needed insulin regular 22 units in the morning and 12 units at night lispro regular . <NOTE_END>",
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"content": "Coumadin 5 mg po alternating with 2.5 mg po prednisolone 30 mg po bid hydrochlorothiazide 50 mg po bid potassium chloride 40 mEq po bid Augmentin 500 mg po tid Digoxin 0.125 mg po qd Tylenol 650 mg po q4h prn Carafate 1 gram po bid Synthroid 0.125 mg po qd . DISPOSITION The patient was discharged home with Terchestlumnesamp Medical Center referral for weekly blood tests potassium and PT . The patient is also to keep her left arm elevated and to remain on a low sodium diet . She will be maintained on a PT between 15 and 17 with Coumadin",
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"content": " . Arrangements will be made for radiation therapy to the right neck and right iliac crest . The prognosis for rehabilitation potential is guarded . LENNI BRAIN M.D. DICTATING FOR ERTCA TRIAL M.D. TR ak bmot DD 05 15 93 TD 05 15 93 CC <NOTE_END>",
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"content": "On admission in general the patient was in no acute distress comfortable",
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"content": " . Vital signs showed temperature 96.3 pulse 64 blood pressure 170 70 respiratory rate 20 oxygen saturation 98 in room air . Head eyes ears nose and throat examination is normocephalic and atraumatic . Extraocular movements are intact . The pupils are equal round and reactive to light and accommodation . Anicteric . Throat is clear . The chest is clear to auscultation bilaterally . Neck was supple with no lymphadenopathy . Cardiovascular shows grade II VI systolic ejection murmur regular rate and rhythm . The abdomen is soft nontender nondistended with a small umbilical hernia . Extremities are warm noncyanotic and nonedematous times four . There is no peripheral edema . <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",
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"content": " 2 weeks call 763-9180 for an appointment . Mark William MD 19-081 Completed by Shane Gabrielle MD 73-971 2016-04-01 0836 Signed electronically by DR. Robert Howell on WED 2016-05-18 <NOTE_END>",
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"content": "The patient was admitted for rule out myocardial infarction . The patient ruled in for myocardial infarction with CPK maximum on hospital day number one peak of 186 and iso of 23.8 and index of 12.8 on September 2 1994 . The patient was seen in consultation by Dr. Signs for Dr. Churlaunt of Cardiology . The patient received the appropriate protocol for myocardial infarction intravenous heparin aspirin and beta blockers for rate and blood pressure control . The patient on the date of September 5 1994 had cardiac catheterization which showed normal resting hemodynamics . The patient has a small non-dominant right coronary artery left anterior descending showed severe proximal lesion with more distal lesions of diagonal one . The left circumflex was dominant with severe disease of obtuse marginal one with moderate mid-circumflex stenosis and moderate posterior descending artery lesion . The left ventriculography shows anterior akinesis and apical severe hypokinesis with a moderately depressed ejection fraction cardiac output of 3.9 index of 2.0 . The patient was seen in consultation by Cardiac Surgery for evaluation of coronary artery bypass grafting . The patient had stable hematocrit of 38 on intravenous heparin . The carotid noninvasives preoperatively were negative . Dental consult was negative . On the date of September 11 1994 patient underwent a coronary artery bypass grafting with saphenous vein graft to the posterior descending artery circumflex and diagonal and left internal mammary artery to the left anterior descending . The patient had a bypass time of one hour and fifty minutes with good urine output and pre-bypass cardiac output of 4.0 post-chest closure 5.3 arrived to the Surgical Intensive Care Unit on Nipride Lidocaine of 1 and Fentanyl Versed of 10 . The postoperative hematocrit was 26 . The patient had a routine postoperative course in the Surgical Intensive Care Unit with a postoperative BUN and creatinine of 11 and 1.2 with good urine output of",
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"content": " over 100 an hour and patient received two units of packed red blood cells fresh frozen plasma and platelets for increasing chest tube drainage . The patient on the date of postoperative day number one September 13 1994 was transferred from the Surgical Intensive Care Unit up to the FIH 18 floor . The patient &aposs only post-Surgical Intensive Care Unit course was remarkable for hypertension requiring Nipride and bleeding which was controlled with fresh frozen plasma platelets . The patient had a stable hematocrit of 30 with CPK &aposs postoperatively maximum MB fraction of 78 . On postoperative day number three patient went into atrial fibrillation which was treated appropriately with metoprolol and digoxin and converted back to sinus rhythm . The patient continued to need diuresis . The postoperative medications up on FIH were Coumadin baby aspirin Isordil 10 PO t.i.d. Digoxin .25 q.day metoprolol 25 PO b.i.d. Chest tubes and wires were all discontinued according to protocol on postoperative day number four . The Isordil was also discontinued . The patient &aposs incisions sternal and right leg were clean and healing well normal sinus rhythm at 70-80 with blood pressure 98-110 60 and patient was doing well recovering ambulating tolerating regular diet and last hematocrit prior to discharge was 39 with a BUN and creatinine of 15 and 1.0 prothrombin time level of 13.8 chest X-ray prior to discharge showed small bilateral effusions with mild cardiomegaly and subsegmental atelectasis bibasilar and electrocardiogram showed normal sinus rhythm with left atrial enlargement and no acute ischemic changes on electrocardiogram . Note patient needs anticoagulation for large saphenous vein graft to prevent any possibility of thrombosis . The patient was discharged home in stable condition and will follow up with his cardiologist and will follow up with Dr. Hemp and Dr. Signs . A NECESSARY M.D. DICTATING FOR G HEMP M.D. TR ee bmot DD 9-18-94 TD 09 19 94 CC <NOTE_END>",
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"content": "The patient is a 65-year-old man with refractory CLL status post non-myeloblative stem cell transplant approximately nine months prior to admission and status post prolonged recent Retelk County Medical Center stay for Acanthamoeba infection of skin and sinuses complicated by ARS due to medication toxicity as well as GVHD and recent CMV infection readmitted for new fever increasing creatinine hepatomegaly and fluid surge spacing in the setting of hyponatremia . Patient initially presented in 1991 with cervical lymphadenopathy was treated with MACE CytaBOM and did well until 1997 when he received six cycles of fludarabine for progressive disease . In November 2001 he progressed to leukemic phase received Rituxan and CVP . Started Campath in July 2001 complicated by lymphopenia neutropenia and CMV infection and underwent MUD stem cell transplant in December 2002 . The patient had bone marrow biopsy August 2003 for persistent pancytopenia revealing mild hypercelluarity with 80 leukemic cells . He was again treated with Campath had recurrent fever in association with sinus symptoms with CT scan showing left maxillary sinusitis in association with new skin nodules on right elbow and buttocks . Patient was hospitalized September 26 to November 11 for what was diagnosed by skin biopsy and sinus washings as Acanthamoeba infection of skin and sinuses without any progression to neurologic infection as assessed by head CT and MRI . ID consult was obtained and he was initially treated with azithromycin itraconazole and pentamidine with progression of skin infection . Subsequent discontinuance of azithromycin trial of 5-FC with increasing neutropenia requiring discontinuance change if itraconazole to voriconazole given continued neutropenia and trial of sulfadiazine discontinued for increasing ARS . Patient was maintained on p.o. voriconazole and IV pentamidine with pentamidine nasal washings with re-CT of sinuses near end of stay showing no change in disease burden . He has had recurrent CMB infection in the setting of Campath therapy requiring IV Foscarnet therapy during stay with inability to tolerate valganciclovir maintenance suppression subsequently due to increasing ARS . Hypercapture near end of stay was negative . Patient experienced acute renal failure on chronic renal insufficiency with previous baseline creatinine 1.6 felt to be due to medication toxicity requiring Kayexalate and Phoslo to manage electrolytes but never any need for hemodialysis with mild improvement of creatinine by discharge with peak creatinine 3.4 discharge creatinine 2.6 . Patient struggled with GVHD with extensive skin involvement taking Cellcept prednisone and cyclosporine at time of last admission . Cellcept was discontinued in the setting of infection but attempts to decrease prednisone or cyclosporine were unsuccessful . Patient returns from rehabilitation after discharge on November 11 with new fever up to 102.0 in DSCI clinic increasing hepatomegaly as assessed by examination in clinic and increasing creatinine",
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{
"content": " . Patient reports no significant changes in how he feels over the past week . Denies cough shortness of breath chest pain nausea vomiting diarrhea dysuria neck stiffness new skin lesions worsening red petechiae or increasing sinus symptoms . Patient reports persistent mild right upper quadrant discomfort recent poor appetite . <NOTE_END>",
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[
{
"content": "This 68 year old female has rheumatic heart disease . Mitral and possibly tricuspid valve surgery is scheduled for Labor Day by Dr. Riemund C. Kennedy . Her history is detailed in the discharge summary of August 10 of this year . She is admitted now for a neuro-interventional radiology procedure to decrease the",
"role": "user"
},
{
"content": " likelihood of epistaxis on Coumadin . <NOTE_END>",
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] |
[
{
"content": "Notable for a BUN and creatinine of 78 1.7 for a sodium potassium 139 and 3.6 chloride and bicarb 108 21 . White count 7 hematocrit 24.2 platelet count was 183 . His INR was",
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},
{
"content": " also 3.4 . PTT was 55 . His EKG was notable for right bundle branch block left axis deviation but was in sinus rhythm . His UA had 10-17 white blood cells trace leukocyte esterase hyaline casts numbering 60-70 . His chest x-ray was notable for clear lungs with no edema or infiltrates and small bilateral effusions . OTHER NOTALBE LABS Patient was found to have a troponin of 0.71 on admission with a CK of 46 and CKMB of 3.4 . <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 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",
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{
"content": " 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": "The patient is allergic to Percodan which",
"role": "user"
},
{
"content": " gives him itchiness . <NOTE_END>",
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}
] |
[
{
"content": "1 Lasix 20 mg. PO q.d. 2 Sinemet 25 100 1 t.i.d. 3 Cogentin 0.5 mg. 1 tabs PO q.a.m. and 1 q.noon as well as 1 q.h.s. 4 Eldepryl 5 mg. PO b.i.d.",
"role": "user"
},
{
"content": " 5 Enteric coated aspirin 325 mg. PO q.d. 6 Potassium chloride 10 mEq. PO q.d. <NOTE_END>",
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}
] |
[
{
"content": "The patient is a 47 year old patient of Dr. Laymie Fournier and Dr. Leebjescobe in Co In Saorlirv Frea West Virginia who was well until a bout of double pneumonia in May 1992 at which time he was hospitalized at Centdick Naco Hospital",
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{
"content": " Medical Center . He also has a history of hypertension and diabetes mellitus . He had a transient episode of headache and disorientation at that time . A CT and MRI scan corroborated multiple cerebral infarcts . He was started on aspirin . He has a family history of hypertension as well . He was also placed on Vasotec . A Holter monitor showed ventricular ectopy . A thallium stress test showed tachycardia and severe dyspnea as well as a fall in blood pressure with low level exercise . An echocardiogram showed global hypokinesis . Accordingly he was referred for further evaluation . <NOTE_END>",
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] |
[
{
"content": "Currently on",
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},
{
"content": " no medications . State newborn screen was sent on 2013-07-26 and is pending . Has not received any immunization . <NOTE_END>",
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}
] |
[
{
"content": "Metastatic",
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},
{
"content": " papillary thyroid carcinoma . <NOTE_END>",
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}
] |
[
{
"content": "Menthol Cetylpyridinium lozenges 1 as needed . Tenofovir 300 mg p.o. q.d. Didanosine 250 mg p.o. q.d. Atazanavir 300 mg p.o. q.d. Ritonavir 100 mg p.o. q.d. Calcium carbonate 500 mg p.o. q.d. Methylprednisolone 4 mg tablets per taper regimen . The patient was to take one 4 mg tablet dinner and at bedtime the day of discharge then the next day take one 4 mg tablet in the morning lunch time and with dinner and then at bedtime then the third day to take 4 mg tablet in the morning lunch and bedtime the fourth day to take one tablet in the morning and",
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{
"content": " dinner and in the last day take one 4 mg tablet in the morning . He was also discharged on Augmentin XR 1000 mg 62.5 mg sustained release 1 tablet q. 12h . for 2 weeks . FOLLOW-UP The patient was to follow up with his PCP A. L. . Taylor in 7 to 10 days and the patient was to call Dr. Thibodeau CMED CSRU doctor to follow up in 2 weeks time . Teddy Stephen Louisiana 32870 Dictated By Judy J Johnston M.D. MEDQUIST36 D 2011-07-12 155531 T 2011-07-13 111452 Job 79962 Signed electronically by DR. Ruth Gibson on MON 2011-07-18 748 AM <NOTE_END>",
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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",
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{
"content": " physical exercise no heavy exertion . No driving while taking prescription pain medications . The patient is to have his Coumadin managed by his primary care provider Dr. Jerold Esqueda for a target INR of 2.5 . The patient is to report to Dr. Jones office on 2010-06-14 for an initial blood draw and subsequent Coumadin titration Coumadin levels are to be monitored per his PCP David . The patient is to follow-up with Dr. Leanne Larimore in Cardiology within two to three weeks following discharge . The patient is to follow-up with Dr. Brenda Hummer four weeks following discharge . The patient is to call to schedule all appointments . Tracy X. Carmen M.D. 76-050 Dictated By Gerald R. Quiroz M.D. MEDQUIST36 D 2010-06-12 0200 T 2010 -06-12 1421 JOB 47222 Signed electronically by DR. Tiffany D. Picklesimer on WED 2010-07-28 <NOTE_END>",
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}
] |
[
{
"content": "1 Aspirin 81 mg p.o. q. day . 2 Os-Cal 1250 mg p.o. three times a day . 3 Lasix 40 mg p.o. q.o.d. 4 Plaquenil 200 mg p.o. q. day . 5 Ibuprofen 400 mg p.o. t.i.d. 6 Levoxyl 100 mg p.o. q. day . 7 Arava 20 mg p.o. q. day . 8 Zantac",
"role": "user"
},
{
"content": " 150 mg p.o. b.i.d. 9 Isosorbide dinitrate unclear dose . 10 Diltiazem 240 mg p.o. q. day . 11 Epogen q. two weeks . <NOTE_END>",
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}
] |
[
{
"content": "Assessment was continued with laboratory studies which showed the patient to have a white blood cell count of 9 hematocrit",
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},
{
"content": " 39 and platelets 470 . The patient had a normal amylase and lipase and a normal basic metabolic panel . The patient had KUB that showed multiple dilated loops of small bowel and was admitted for a partial small bowel obstruction . An nasogastric tube was placed and had an H2 blocker started and was admitted for bowel rest and decompression . The patient tolerated the nasogastric tube well . The nasogastric tube was removed on hsp day 3 . The pain improved quickly and the patient was started on a clear liquid diet which was advanced as tolerated . On 7 9 99 the patient was tolerating a house diet . The patient had some minimal back pain that occurred after food but with negative urinalysis and negative fever spikes over the entire course of this stay . The patient will be discharged home on Zantac Simethicone and preoperative medications with follow-up with Dr. Ur in two weeks . Dictated By NISTE BLOCKER M.D. AQ36 Attending STIE FYFE M.D. BW3 BL436 5666 Batch 85114 Index No. FNQXCX58 EM D 07 09 99 T <NOTE_END>",
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] |
[
{
"content": "Dexedrine",
"role": "user"
},
{
"content": " 5 mg per day and Motrin 600 mg tid . <NOTE_END>",
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}
] |
[
{
"content": "Hypertension Gastroesophageal reflux disease H. pylori positive status post therapy Osteoarthritis . PAST SURGICAL HISTORY Craniotomy for meningoma February 1994 Laparoscopic cholecystectomy in May 2002 MEDICATIONS ON ADMISSION 1. Aspirin 81 mg PO qd Atenolol 25 mg PO qd",
"role": "user"
},
{
"content": " Protonics 40 mg PO qd <NOTE_END>",
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}
] |
[
{
"content": "Sodium 131 potassium 4.5 BUN 45 creatinine 2.0 glucose 134 bilirubin 0.4. Blood gas on 5 liters nasal o2 PO2 106 PCO227 pH 7.41 . Blood cultures were obtained urine cultures were",
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},
{
"content": " obtained . Chest x-ray low lung volumes bibasilar opacities no evidence of heart failure . EKG technically poor tracing with what appears to be normal sinus rhythm with very small P waves there are Q-waves in leads V1 and V2 as well as in V3 . There are non-specific ST T wave changes. The blood cultures at Linghs County Medical Center grew out Staph. aureus sensitive to methicillin . The blood cultures obtained a Oaksgekesser Memorial Hospital were negative . An echocardiogram obtained at Oaksgekesser Memorial Hospital obtained as a transthoracic echocardiogram showed an ejection fraction of 33 wall thickness 12 mms at the septum posterior wall 11 mms. left atrial size 40 mms . There is anteroseptal hypokinesis with mid and apical akinesis . HOSPITAL COURSE AND TREATMENT The patient was treated with intravenous antibiotics . A lumbar puncture was obtained which showed normal pressure and no cells . The CSF culture was negative . A stool assay was taken for Clostridium difficile which was negative . The patient gradually improved on the current therapy and was quite awake and alert though still appeared to have some evidence of dementia and disorientation . He was encouraged to eat and it was decided not to place either a feeding tube or to start TPN . Dr. Rhalttland was called at Sondi Memorial to update him on the patient &aposs condition . He still needs much intensive rehabilitation encouragement to eat and encouragement to get out of bed to use the bathroom rather than abed pain or a diaper . He is being transferred to Linghs County Medical Center for further care . CONDITION Stable and improved . LAKO C. WARM M.D. STAT TR lv DD 01 06 98 TD 01 06 98 <NOTE_END>",
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] |
[
{
"content": "The patient is a 65 year old male who sustained a small myocardial infarction first in 1978 with course thereafter including a coronary artery bypass graft by Dr. Wierst at Noughwell Entanbon Health in 1986 . In 1991 he presented with congestive heart failure and he underwent porcine aortic valve replacement . In the seven to",
"role": "user"
},
{
"content": " eight months preceding admission he developed recurrent angina with dyspnea on exertion . The patient was admitted for cardiac catheterization in early December 1993 . <NOTE_END>",
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] |
[
{
"content": "VITAL SIGNS BP 120 80 temp 96 pulse 78 respiratory rate 18 . GENERAL No acute distress . SKIN The skin is jaundiced . NODES No lymph nodes palpated . HEENT Notable for scleral icterus . LUNGS Clear to auscultation bilaterally no wheezes rales or",
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},
{
"content": " rhonchi . HEART Regular rate and rhythm no murmur . ABDOMEN Soft bowel sounds present tenderness present in epigastrium to moderate palpation . There was no rebound and no hepatosplenomegaly . No incisional scars . EXTREMITIES Warm with no edema and palpable pulses bilaterally . <NOTE_END>",
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] |
[
{
"content": "DISPOSITION MEDICATIONS at the time of discharge are G-CSF 300 micrograms subcu q. day Acyclovir 200 mg p.o. b.i.d. Erythromycin 500 mg p.o. b.i.d. Dapsone 50 mg p.o. Monday Wednesday and Friday Imodium 1-2 tablets p.o. q. 6",
"role": "user"
},
{
"content": " hours p.r.n. Nystatin 5 cc swish and swallow q.i.d Serax 50 mg p.o. q. 6 hours p.r.n. and Kay-Ceil 40 mEq p.o. b.i.d. The patient needs to have his blood drawn the day after discharge to check a potassium and magnesium which he has been wasting secondary to Amphotericine . He will probably need potassium and magnesium replacement . He will need follow up lytes drawn throughout the week . CR887 2594 TRANGCA FERCI CHIRDSTEN M.D. UO2 D 09 07 92 Batch 5346 Report P4722W3 T 09 09 92 Dicatated <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",
"role": "user"
},
{
"content": " MCHE 34.8 . His chest X-ray did not reveal any abnormality . A electrocardiogram showed nonspecific T-wave abnormalities otherwise it was normal . <NOTE_END>",
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] |
[
{
"content": "The physical examination on admission revealed a blood pressure of 110 70 a heart rate of 66 respirations of 24 temperature of 98 . The HEENT exam revealed the extra ocular movements intact . The pupils equal round reactive to light . The oropharynx was clear and the fundi were normal . There were no hypertensive or diabetic changes . The neck was suppled with no lymphadenopathy and no jugular venous distention . The carotids were 1 without bruits . The heart was regular rate and rhythm S4 S1 S2 with a I VI systolic murmur at the left lower sternal border . The lungs were clear except for a few dry crackles bibasilarly . The abdomen revealed a midline scar and a right lower quadrant scar and it was soft and nontender wit positive bowel sounds . The liver edge was 2 cm below the right costal margin but smooth and nontender . There was no splenomegaly . The femoral pulses were diminished . He had bilateral intertrigo in his femoral region as well as his axillae . The extremities revealed no clubbing cyanosis or edema . The",
"role": "user"
},
{
"content": " pulses were 1 bilaterally . The skin exam revealed changes consistent with vitiligo . The rectal examination was guaiac negative . <NOTE_END>",
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}
] |
[
{
"content": "ON ADMISSION General The patient was in no acute distress well developed",
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},
{
"content": " . Vital signs Stable afebrile . HEENT Normocephalic atraumatic . PERRL anicteric EOMI . The throat was clear . Neck Supple midline without masses or lymphadenopathy . No bruit or JVD . Cardiovascular Irregularly irregular without murmurs rubs or gallops . Chest Clear to auscultation bilaterally . Abdomen Soft nontender nondistended without masses or organomegaly . Extremities Warm noncyanotic nonedematous times four . Neurological Grossly intact . ADMISSION LABORATORY DATA CBC 11.3 15.7 44.6 183 . PT 14 INR 1.3 PTT 115 . Chemistries 137 4.3 104 22 14 0.7 155 . ALT 27 AST 21 alkaline phosphatase 72 total bilirubin 1.2 amylase 47 . The U A was negative . <NOTE_END>",
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}
] |
[
{
"content": "The patient was medically managed initially and then underwent on 2013-08-09 coronary artery bypass grafting x2 and a mitral valve annuloplasty with placement of intra-aortic balloon pump . He was transferred to the Intensive Care Unit in relatively stable condition . On postoperative day 1 his balloon pump was weaned and the patient was transferred at 2 units of packed red blood cells . He also began to wean off the ventilator . On postoperative day 1 in the evening the patient was noted to go into atrial fibrillation for which he was controlled and started on amiodarone after which he converted again to normal sinus rhythm . He was extubated during postoperative day 1 . On postoperative day 2 the patient was noted to be relatively stable . His balloon pump had already been removed and on postoperative day 3 he was transferred to the floor on Lopressor and amiodarone in normal sinus rhythm . On the floor the patient was noted to do extremely well . Physical therapy was consulted and the patient was ambulating extremely well with minimal assistance . On postoperative day 4 he remained afebrile with stable vital signs on Lopressor at 25 mg po bid and an amiodarone dose . His left chest tube was discontinued at this time and his right chest tube was removed the following day on postoperative day 5 . Currently the patient is postoperative day 6 .",
"role": "user"
},
{
"content": " He remains afebrile with stable vital signs and the patient is ambulating to a level 5 with physical therapy and wishes to be discharged home today . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "No known drug allergies .",
"role": "user"
},
{
"content": " FAMILY HISTORY GERD and PUD . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Slow-Mag 2 tablets PO bid Ativan 1 mg sublingually q4h prn",
"role": "user"
},
{
"content": " nausea . GUABENFRANDA D. PO M.D. TR ff bmot DD 06-07-93 TD <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Triamcinolone one tablet PO b.i.d. dosage",
"role": "user"
},
{
"content": " unknown Xanax one tablet PO t.i.d. prn anxiety dosage unknown MS Contin prn . PAST MEDICAL HISTORY Distant peptic ulcer disease thumb and middle finger lost secondary to lawnmower accident at age five years no peripheral vascular disease . PAST SURGICAL HISTORY The patient is status post partial gastrectomy for peptic ulcer disease in 1965 . <NOTE_END>",
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}
] |
[
{
"content": "Atrial fibrillation 2 s",
"role": "user"
},
{
"content": " p MVR mechanical 3 CHF EF 15 4 HTN 5 multiple CVA s last 1998 6 Hypercholesterolemia 7 Type II DM 8 Multiple prior UTI Social History Lives in Danvers with wife denies Timothy or alcohol <NOTE_END>",
"role": "assistant"
}
] |
[
{
"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",
"role": "user"
},
{
"content": " 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 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": "Satisfactory TO DO PLAN 1 Follow-up esophageal biopsy results 2 Schedule GI follow-up if biopsy results abnormal or if continued bleeding . 3 Consider",
"role": "user"
},
{
"content": " oncology follow-up if biopsies suggestive of malignancy 4 Omeprazole 40 mg po bid x6 wks . No dictated summary ENTERED BY ZISKFUSCJALK ACRI M.D. <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Vital signs He was afebrile blood pressure 154 75 on Nipride drip heart rate 81 oxygen saturation 97 . General He was intubated and sedated at the time . Neurological Pinpoint pupils intact corneal reflexes bilaterally . Doll s eyes . He withdrew both lower extremities to peripheral stimulation",
"role": "user"
},
{
"content": " as well as his upper extremities to peripheral stimulation . He also withdrew his left upper extremity to peripheral stimulation but not his right upper extremity . His reflexes were brisk in his patellas bilaterally and he had upgoing toes bilaterally . IMAGING Head CT showed diffuse subarachnoid hemorrhage . <NOTE_END>",
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}
] |
[
{
"content": "Continue breast feeding with post-feed supplemental EBM . Follow-up bilirubin in 1 day f u with PMD in 1-3 days . Medications Not applicable . Car seat position and screening', 'Not applicable . State newborn screens were sent on 2018-12-31 and the results are pending . Immunizations received Hepatitis B vaccine on 12-31 2006 .', 'Immunization recommended Influenza immunization is recommended annually in the fall for all infants once they reach 6 months",
"role": "user"
},
{
"content": " of age . Before this age and for the first 24 months of the child s life', 'immunization against influenza is recommended for all household contacts and out of home caregivers . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "n a Discharge Condition n a Discharge Instructions n a Followup Instructions n a Ruby",
"role": "user"
},
{
"content": " Eric MD 73-490 Completed by Verna Richard MD 01-822 2016-04-04 2005 Signed electronically by DR. <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Cefuroxime 1.5 grams intravenously q8h Solu-Medrol 62.5 mg intravenously q8h Ventolin",
"role": "user"
},
{
"content": " metered dose inhaler 2 puffs PO q.i.d. Pepcid 20 mg intravenously b.i.d. <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "The patient denies shortness of breath",
"role": "user"
},
{
"content": " chest pain orthopnea no dysuria hematuria no visual changes no rashes no blurry vision . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "He",
"role": "user"
},
{
"content": " is to follow up with Dr. Rach Breutznedeaisscarvwierst in Clinic. <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "He was a chronically ill appearing elderly man with a respiratory rate of 30 temperature 99.6 pulse 100 and irregularly irregular blood pressure 148 71 . He had some petechiae on his extremities as well as in his mucosal membranes with some hemorrhagic bullae . There were bibasilar rales with some wheezing . He had no cardiac murmur . His abdomen was distended with massive hepatosplenomegaly which was somewhat tender . The neurological examination",
"role": "user"
},
{
"content": " aside from the blind right eye was unremarkable . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Breast cancer diagnosed in 2010 Stage I status post left lumpectomy on 2012-05-08 and repeat surgery with sentinel node dissection on 2012-06-05 Invasive mucinous carcinoma with estrogen receptor positivity and HER2 NEU negative . Left chest radiation on Tamoxifen therapy She is followed by Dr. Alonso Naugle . Question of vertebral basilar cerebrovascular accident in 2016-08-17 with associated limb ataxia Magnetic resonance imaging was negative except for some microvascular cerebral white matter changes . Question peripheral vertigo takes Meclizine p.r.n. Hypothyroidism Hypertension . Hypercholesterolemia Glaucoma . Cataract Osteopenia . Left hip arthritis History of urinary tract infections . Anemia with a baseline hematocrit of 31.0 with a TIBC that was low and a high ferritin Echocardiogram in 2016-09-16 with preserved ejection fraction of 60 percent with trivial mitral regurgitation and mild",
"role": "user"
},
{
"content": " left atrial enlargement . Cardiac stress test in 2016-03-17 that was negative for inducible ischemia <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "The patient is admitted to this hospital through the Podiatry Service however the stress test showed multi-vessel disease . Podiatry continued to follow for evaluation of his left foot ulcer . At the time of discharge he was having acetic acid wet-to-dry dressing changes 0.25 q. day . Vascular Surgery was following at the same time and decided that bilateral iliac stenting would be the most optimum treatment currently and suggested that the patient should be worked up for cardiac disease prior to re-vascularization . Medicine was also consulted at that time for high blood pressure and for the biceps pain . While having angiography he had a transient increase in his blood pressure and became diaphoretic and thus precipitated the evaluation for cardiac disease . Cardiology was consulted at that time to evaluate his heart . The patient was managed on the Medical Service for his drop in blood pressure and cardiac evaluation . He was also followed by Podiatry and Vascular Surgery . He was taken to the Cardiac Catheterization Laboratory which showed multi-vessel disease and Cardiothoracic Surgery was consulted . The patient was taken to the Operating Room on 2013-09-04 where a coronary artery bypass graft times four was performed left internal mammary artery to left anterior descending saphenous vein graft to diagonal saphenous vein graft to obtuse marginal and saphenous vein graft to PC by Dr. Wright . The patient was transferred to the CSRU postoperatively where he did well . He was slowly weaned from his ventilator and was able to be extubated . The patient was able to be weaned to six liters nasal cannula after extubation however it was noted on chest x-ray that he had a small apical pneumothorax . A repeat chest x-ray showed resolution of that pneumothorax . The patient was continued on an insulin drip for his diabetes mellitus but continued to improve . His chest tube was in place for a high chest tube output . His Foley catheter was removed and the patient was transferred to the Floor . Physical Therapy was consulted in order to assess the patient s ambulation and mobility however with his foot infection and associated pain it was difficult to assess at that time . After arriving on the Floor the patient had an episode of rapid atrial fibrillation which was treated with amiodarone and Lopressor . The patient resolved however Lasix was also given due to some pulmonary edema and increasing oxygen need . The patient continued to have episodes of rapid atrial fibrillation while on the Floor which required continued diuresis as well as intravenous Lopressor . His chest tube and Foley catheter were removed on postoperative day number three and the patient had aggressive chest Physical Therapy and nebulizer treatments . His dressing changes for his foot continued per the Podiatry Service and his leg ulcer was noted to be slowly healing . The patient had multiple episodes of rapid atrial fibrillation which again required intravenous Lopressor . Amiodarone boluses were given and the patient was started on 400 three times a day of p.o. amiodarone aggressive pulmonary toilet and continued diuresis was done however the patient continued to have respiratory difficulties when in rapid atrial fibrillation . The patient was evaluated on postoperative day number five and it was decided at that time that the patient should be transferred back to the Intensive Care Unit for respiratory difficulties . He was transferred back to the Surgical Intensive Care Unit where he was aggressively diuresed as well as his rate was controlled and chest Physical Therapy and nebulizer treatments were done . The patient improved slowly . Also his white blood cell count was found to rise to 32.0 this was most likely due to a secondary infection of his foot and Zosyn was started . The patient continued to do well and his recurrent atrial fibrillation slowly improved p.o. doses of Lopressor slowly increased to get better control of his rate and the patient was able to be controlled with a heart rate in the 50s to 60s with Lopressor . Following initiation of his Zosyn the white count continued to improve and the patient was planned for a PICC line for long-term intravenous antibiotics . The patient was started on Lopressor 75 mg p.o. twice a day with good control with a heart rate of 50s to 60s . He is in sinus rhythm . He was also started on his preoperative medications of Amlodipine and Losartan with improvement of his blood pressure . The patient was also reduced to 400 mg q. day of amiodarone . Pulmonary was consulted at this time for this difficulty of diuresis and pulmonary edema . They continued to agree with the management of the patient and with aggressive pulmonary toilet as well as diuresis and nebulizer treatment . The patient was transferred back from the Intensive Care Unit on 2013-09-13 and upon arriving on the floor he continued to do well . Pulmonary toilet and aggressive chest Physical Therapy was continued and the patient was able to be weaned from his oxygen . Furthermore his Foley catheter was removed and he was started on anti-coagulation for his episodes of atrial fibrillation . He had been started on heparin in the Intensive Care Unit and that was continued . Coumadin was then begun with a goal INR of 2.0 to 3.0 . At that time he was stabilized from a cardiac perspective . Podiatry and Vascular Surgery were reconsulted to assess the patient s needs for revascularization and for his foot ulcer . It was decided at that time that the patient could be discharged in follow-up with Vascular Surgery for revascularization and Podiatry thereafter . On 2013-08-28 the patient had a PICC line",
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},
{
"content": " placed for a six week course of intravenous Zosyn for his foot ulcer and his Coumadin was also continued . The patient did well and was discharged to a rehabilitation facility at that time . His discharge date is pending . CURRENT DISCHARGE MEDICATIONS Regular insulin sliding scale . Coumadin 7.5 mg p.o. q.d. for an INR goal of 2.0 to 3.0 and adjust the dose accordingly . Acetic acid 0.25 wet-to-dry dressing changes q. day for his left foot ulcer . Amiodarone 400 mg q. day . Albuterol nebulizers q. four hours and q. two hours p.r.n. Losartan 50 mg p.o. q. day . Iron 325 mg p.o. q. day . Albuterol ipratropium two puffs four times a day . 9. Zosyn 4.5 grams intravenously q. six hours times six weeks started on 09-10 . Lipitor 10 mg p.o. q. day . Amlodipine 10 mg p.o. q. day . Nortriptyline 25 mg p.o. q. h.s. Mecsazopam 15 to 30 mg p.o. q. h.s. p.r.n. 14. Dulcolax 10 mg p.o. or p.r. q. day p.r.n. 15. Milk of Magnesia 30 cc p.o. q. h.s. p.r.n. 16. Percocet one to two tablets p.o. q. four hours p.r.n. 17. Zantac 150 p.o. twice a day . 18. Colace 100 mg p.o. twice a day . Alexandria Daly 20 mEq p.o. twice a day . Lasix 20 mg intravenous twice a day . Lopressor 75 mg p.o. twice a day . DISCHARGE STATUS The patient is discharged to rehabilitation . CONDITION AT DISCHARGE Stable condition . DISCHARGE INSTRUCTIONS He is instructed to follow-up with Dr. Holloway in four weeks . He is to follow-up with his primary care physician in one to two weeks . Follow-up with Cardiologist in four weeks . He is also instructed to follow-up with Vascular Surgery and Podiatry for revascularization at the appropriate time frame . DISCHARGE DIAGNOSES Coronary artery disease status post myocardial infarction status post percutaneous transluminal coronary angioplasty status post coronary artery bypass graft . Diabetes mellitus type 2 now currently on insulin . Chronic renal insufficiency . Peripheral vascular disease status post bilateral iliac stenting . Hypertension . High cholesterol . Question tendonitis with left biceps pain . Left foot ulcer status post debridement . PLEASE SEE ADDENDUM FOR ANY CHANGE IN MEDICATIONS AND DISCHARGE DATE . Donna B. Christensen M.D. 31-932 Dictated By Ervin Y. Nobles M.D. MEDQUIST36 D 2013-09-16 1600 T 2013-09-16 1611 JOB 82277 Signed electronically by DR. Kenneth Din on TUE 2013-09-17 1114 AM <NOTE_END>",
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] |
[
{
"content": "Hypertension Gastroesophageal reflux disease H. pylori positive status post therapy Osteoarthritis . PAST SURGICAL HISTORY Craniotomy for meningoma February 1994 Laparoscopic cholecystectomy in May 2002 MEDICATIONS ON ADMISSION 1. Aspirin",
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},
{
"content": " 81 mg PO qd Atenolol 25 mg PO qd Protonics 40 mg PO qd <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "On admission revealed a cachetic woman in no acute distress with stable vital signs . She was afebrile . She was not orthostatic . Blood pressure 110 80 . HEENT exam was within normal limits . Lungs were clear to auscultation and percussion bilaterally . Cardiovascular exam revealed a regular rate and rhythm without murmur . Abdomen was soft nontender nondistended with positive bowel sounds . There was no hepatosplenomegaly",
"role": "user"
},
{
"content": " . Extremities revealed a 2 x 3 cm tender mass in the lateral left calf medial 1 cm mass above her knee . There was no evidence of edema . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "significant for a white blood count of 6.0 hematocrit 35.9 electrolytes within normal limits BUN and creatinine of 13 and 0.8 amylase of 56 . The patient had an",
"role": "user"
},
{
"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>",
"role": "assistant"
}
] |
[
{
"content": "Sulfasalazine prednisone",
"role": "user"
},
{
"content": " 20 mg q.d. Naprosyn 500 mg t.i.d. Zestril 10 mg q.d. Lopressor 50 mg b.i.d. and iron supplementation . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Subarachnoid",
"role": "user"
},
{
"content": " hemorrhage posttraumatic . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Remarkable for a white cell count of 0.4 with 0 neutrophils 0 bands 19 lymphs 0 monos hematocrit 28.8 platelets 300 000 . ALT 141 AST 40 alk phos 108 and a total bili of 1.0. Total protein was 5.7 albumin",
"role": "user"
},
{
"content": " 2.5 and globulin 3.2 . His electrolyte panel of sodium 135 sodium 4.1 chloride 99 bicarb 30 BUN 15 creatinine 2.1 blood glucose of 196 . Iron studies included a ferritin of 607 an iron of 10 and a TIBC of 239 . EKG showed tachycardia with a sinus rhythm of 103 normal axis normal intervals no Q-waves no ST-T wave changes . The patient had a history from 7 12 01 of a normal white blood cell count with a normal absolute neutrophil count . The patient &aposs chest x-ray at the outside hospital was unremarkable . <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 . 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",
"role": "user"
},
{
"content": " 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>",
"role": "assistant"
}
] |
[
{
"content": "ON ADMISSION General The patient was in no acute distress well developed . Vital signs Stable afebrile . HEENT Normocephalic atraumatic . PERRL anicteric EOMI . The throat was clear . Neck Supple midline without masses or lymphadenopathy . No bruit or JVD . Cardiovascular Irregularly irregular without murmurs rubs or gallops . Chest Clear to auscultation bilaterally . Abdomen Soft nontender nondistended without masses or organomegaly . Extremities Warm noncyanotic nonedematous times four . Neurological Grossly intact . ADMISSION LABORATORY DATA CBC 11.3 15.7 44.6 183 . PT 14 INR 1.3 PTT 115 . Chemistries 137 4.3 104 22 14 0.7 155 . ALT 27 AST 21 alkaline phosphatase",
"role": "user"
},
{
"content": " 72 total bilirubin 1.2 amylase 47 . The U A was negative . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "Positive",
"role": "user"
},
{
"content": " for coronary artery disease and MI . No history of cancer . <NOTE_END>",
"role": "assistant"
}
] |
[
{
"content": "The patient was admitted with a diagnosis of prostate CA for fluid rehydration . Initially the patient was begun on Bactrim for presumptive urinary tract infection and the initial course of his hospitalization he took p.o. s poorly . The patient remained afebrile however and his electrolytes were within normal limits . By hospital day number six however the patient became febrile to 100.7 and repeat urinalysis showed 20-30 white blood cells and 1 bacteria . Antibiotics were switched to IV Ciprofloxacin and the patient defervesced however by hospital day number seven the patient was found to be passing very little urine through his condom catheter and electrolyte screen and electrolytes from hospital day number seven showed a BUN of 27 and a creatinine of 2.7 . The patient was vigorously fluid rehydrated however by hospital day number nine BUN was 22 creatinine was 3.5 . A Foley catheter was placed at that time with the recovery of approximately 800 cc of urine . Subsequently the patient began",
"role": "user"
},
{
"content": " vigorously diuresing with 4 liters urine recovered the following hospital day . Blood electrolytes were remarkable for a sodium of 148 and a potassium of 5.1 . The patient s fluid hydration from D5 one-half normal saline with 20 mEq of K to D5W and acuchecks from this time showed blood sugars routinely between 20 and 50 . The patient was given one Amp of D50 for each acucheck for blood sugars of less than 40 . Gradually over the course of the following days the patient s electrolytes again normalized however as the patient continues to take p.o. s poorly the patient remained on IV hydration therapy . On hospital day number fourteen electrolytes were sodium of 140 potassium 3.9 BUN of 11 creatinine 1.3 with a blood sugar of 125 and a magnesium of 1.9 . The patient was taking 470 cc of liquid p.o. and is now in stable condition and ready for transfer to El Hospital to continue his recovery . DISPOSITION The patient is transferred to El Hospital still receiving IV hydration at a rate currently of 50 cc an hour of D5 one-half normal with 20 mEq of K . Should the patient s p.o. intake drop to below 500 the patient should be hydrated at 75 cc hour . If the patient s p.o. intake drop below 300 cc per day the patient should be hydrated at 100 cc an hour . The Foley catheter was in place and the Bacitracin ointment should be applied to the urethral meatus twice a day . Periodic urinalysis should be conducted to monitor the development of possible urinary tract infection . It should be noted that while in the hospital the patient received an abdominal ultrasound which is significant for a grossly enlarged liver with multiple foci of cancer . The patient is discharged on Mylanta 30 cc with meals Carafate 1 gm q. 6 Heparin 5000 units subcutaneous b.i.d. until the patient regains full activity and IV hydration . The Foley should be in place until a follow-up appointment with Dr. Aarhalt can be scheduled in approximately one to two weeks at which time a decision regarding the status of the patient s urinary obstruction will be addressed . Dictated By CHIEROBEBREUTZ M.D. AA578 3804 CONRELLIE S. KOTERUDES M.D. KQ9 D 03 22 92 T 03 22 92 Batch <NOTE_END>",
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}
] |
[
{
"content": "The history of this 49 year old male is provided in",
"role": "user"
},
{
"content": " detail in the typed admission note dated June 30 1992 . <NOTE_END>",
"role": "assistant"
}
] |
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