ROW_ID
string | SUBJECT_ID
string | HADM_ID
string | CHARTDATE
string | CHARTTIME
string | STORETIME
string | CATEGORY
string | DESCRIPTION
string | CGID
string | ISERROR
string | TEXT
string | MASK
string | MASK_LABEL
string | binary_label
string | input_text
string | Chunks
string |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
174
|
22532
|
167853.0
|
2151-08-04
|
Discharge summary
|
Report
|
Admission Date: [**2151-7-16**] Discharge Date: [**2151-8-4**]
Service:
ADDENDUM:
RADIOLOGIC STUDIES: Radiologic studies also included a chest
CT, which confirmed cavitary lesions in the left lung apex
consistent with infectious process/tuberculosis. This also
moderate-sized left pleural effusion.
HEAD CT: Head CT showed no intracranial hemorrhage or mass
effect, but old infarction consistent with past medical
history.
ABDOMINAL CT: Abdominal CT showed lesions of
T10 and sacrum most likely secondary to osteoporosis. These can
be followed by repeat imaging as an outpatient.
[**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1775**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1776**]
Dictated By:[**Hospital 1807**]
MEDQUIST36
D: [**2151-8-5**] 12:11
T: [**2151-8-5**] 12:21
JOB#: [**Job Number 1808**]
|
Admission Date: <Date>1924-11-21</Date> Discharge Date: <Date>1981-5-29</Date>
Service:
ADDENDUM:
RADIOLOGIC STUDIES: Radiologic studies also included a chest
CT, which confirmed cavitary lesions in the left lung apex
consistent with infectious process/tuberculosis. This also
moderate-sized left pleural effusion.
HEAD CT: Head CT showed no intracranial hemorrhage or mass
effect, but old infarction consistent with past medical
history.
ABDOMINAL CT: Abdominal CT showed lesions of
T10 and sacrum most likely secondary to osteoporosis. These can
be followed by repeat imaging as an outpatient.
<Name>Isabella</Name> <Name>Reba</Name> <Name>White</Name>, M.D. <MD Number>48143768</MD Number>
Dictated By:<Hospital>Moore LLC Health System</Hospital>
MEDQUIST36
D: <Date>1975-2-7</Date> 12:11
T: <Date>1975-2-7</Date> 12:21
JOB#: <Job Number>Medina, Haynes and Martinez-1904-904257</Job Number>
|
0000000000000000011111111110000000000000000000000001111111110000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000001111111101111011111000000001111111100000000000000111111111111111111111110000000000000000011111111000000000000111111110000000000000001111111111111111111111111111111111111110
|
Admission Date: 1924-11-21 Discharge Date: 1981-5-29
Service:
ADDENDUM:
RADIOLOGIC STUDIES: Radiologic studies also included a chest
CT, which confirmed cavitary lesions in the left lung apex
consistent with infectious process/tuberculosis. This also
moderate-sized left pleural effusion.
HEAD CT: Head CT showed no intracranial hemorrhage or mass
effect, but old infarction consistent with past medical
history.
ABDOMINAL CT: Abdominal CT showed lesions of
T10 and sacrum most likely secondary to osteoporosis. These can
be followed by repeat imaging as an outpatient.
Isabella Reba White, M.D. 48143768
Dictated By:Moore LLC Health System
MEDQUIST36
D: 1975-2-7 12:11
T: 1975-2-7 12:21
JOB#: Medina, Haynes and Martinez-1904-904257
|
['Admission Date: 1924-11-21 Discharge Date: 1981-5-29\n\n\nService:\nADDENDUM:\n\nRADIOLOGIC STUDIES: Radiologic studies also included a chest\nCT, which confirmed cavitary lesions in the left lung apex\nconsistent with infectious process/tuberculosis. This also\nmoderate-sized left pleural effusion.\n\nHEAD CT: Head CT showed no intracranial hemorrhage or mass\neffect, but old infarction consistent with past medical\nhistory.\n\nABDOMINAL CT: Abdominal CT showed lesions of\nT10 and sacrum most likely secondary to osteoporosis. These can\nbe followed by repeat imaging as an outpatient.\n\n\n\n Isabella Reba White, M.D. 48143768\n\nDictated By:Moore LLC Health System\nMEDQUIST36\n\nD: 1975-2-7 12:11\nT: 1975-2-7 12:21\nJOB#: Medina, Haynes and Martinez-1904-904257\n']
|
|||||
175
|
13702
|
107527.0
|
2118-06-14
|
Discharge summary
|
Report
|
Admission Date: [**2118-6-2**] Discharge Date: [**2118-6-14**]
Date of Birth: Sex: F
Service: MICU and then to [**Doctor Last Name **] Medicine
HISTORY OF PRESENT ILLNESS: This is an 81-year-old female
with a history of emphysema (not on home O2), who presents
with three days of shortness of breath thought by her primary
care doctor to be a COPD flare. Two days prior to admission,
she was started on a prednisone taper and one day prior to
admission she required oxygen at home in order to maintain
oxygen saturation greater than 90%. She has also been on
levofloxacin and nebulizers, and was not getting better, and
presented to the [**Hospital1 18**] Emergency Room.
In the [**Hospital3 **] Emergency Room, her oxygen saturation was
100% on CPAP. She was not able to be weaned off of this
despite nebulizer treatment and Solu-Medrol 125 mg IV x2.
Review of systems is negative for the following: Fevers,
chills, nausea, vomiting, night sweats, change in weight,
gastrointestinal complaints, neurologic changes, rashes,
palpitations, orthopnea. Is positive for the following:
Chest pressure occasionally with shortness of breath with
exertion, some shortness of breath that is positionally
related, but is improved with nebulizer treatment.
PAST MEDICAL HISTORY:
1. COPD. Last pulmonary function tests in [**2117-11-3**]
demonstrated a FVC of 52% of predicted, a FEV1 of 54% of
predicted, a MMF of 23% of predicted, and a FEV1:FVC ratio of
67% of predicted, that does not improve with bronchodilator
treatment. The FVC, however, does significantly improve with
bronchodilator treatment consistent with her known reversible
air flow obstruction in addition to an underlying restrictive
ventilatory defect. The patient has never been on home
oxygen prior to this recent episode. She has never been on
steroid taper or been intubated in the past.
2. Lacunar CVA. MRI of the head in [**2114-11-4**]
demonstrates "mild degree of multiple small foci of high T2
signal within the white matter of both cerebral hemispheres
as well as the pons, in the latter region predominantly to
the right of midline. The abnormalities, while nonspecific
in etiology, are most likely secondary to chronic
microvascular infarction. There is no mass, lesion, shift of
the normal midline strictures or hydrocephalus. The major
vascular flow patterns are preserved. There is moderate
right maxillary, moderate bilateral ethmoid, mild left
maxillary, minimal right sphenoid, and frontal sinus mucosal
thickening. These abnormalities could represent an allergic
or some other type of inflammatory process. Additionally
noted is a moderately enlarged subtotally empty sella
turcica".
3. Angina: Most recent stress test was in [**2118-1-3**]
going for four minutes with a rate pressure product of
10,000, 64% of maximum predicted heart rate without evidence
of ischemic EKG changes or symptoms. The imaging portion of
the study demonstrated no evidence of myocardial ischemia and
a calculated ejection fraction of 84%. The patient denies
angina at rest and gets angina with walking a few blocks.
Are alleviated by sublingual nitroglycerin.
4. Hypothyroidism on Synthroid.
5. Depression on Lexapro.
6. Motor vehicle accident with head injury approximately 10
years ago.
MEDICATIONS ON ADMISSION:
1. Hydrochlorothiazide 25 q.d.
2. Prednisone 60 mg, 50 mg, 40 mg, 20 mg.
3. Levofloxacin 500 mg q.d.
4. Imdur 60 mg q.d.
5. Synthroid 75 mcg q.d.
6. Pulmicort nebulizer b.i.d.
7. Albuterol nebulizer q.4. prn.
8. Lexapro 10 mg q.d.
9. Protonix 40 mg q.d.
10. Aspirin 81 mg q.d.
ALLERGIES: Norvasc leads to lightheadedness and headache.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: Lives with her husband, Dr. [**Known lastname 1809**] an
eminent Pediatric Neurologist at [**Hospital3 1810**]. The
patient is a prior smoker, but has not smoked in over 10
years. She has no known alcohol use and she is a full code.
PHYSICAL EXAM AT TIME OF ADMISSION: Blood pressure 142/76,
heart rate 100 and regular, respirations at 17-21, and 97%
axillary temperature. She was saturating at 100% on CPAP
with dry mucous membranes. An elderly female in no apparent
distress. Pupils are equal, round, and reactive to light and
accommodation. Extraocular movements are intact. Oropharynx
difficult to assess due to CPAP machine. No evidence of
jugular venous pressure, however, the strap from the CPAP
machine obscures the neck exam. Cranial nerves II through
XII are grossly intact. Neck is supple without
lymphadenopathy. Heart exam: Tachycardic, regular, obscured
by loud bilateral wheezing with increase in the expiratory
phase as well as profuse scattered rhonchi throughout the
lung fields. Positive bowel sounds, soft, nontender,
nondistended, obese, no masses. Mild edema of the lower
extremities without clubbing or cyanosis, no rashes. There
is a right hand hematoma. Strength is assessed as [**5-9**] in the
lower extremities, [**5-9**] in the upper extremities with a normal
mental status and cognition.
LABORATORY STUDIES: White count 19, hematocrit 41, platelets
300. Chem-7: 127, 3.6, 88, 29, 17, 0.6, 143. Troponin was
negative. CKs were negative times three. Initial blood gas
showed a pH of 7.4, pO2 of 66, pCO2 of 54.
Chest x-ray demonstrates a moderate sized hiatal hernia,
segmental atelectasis, left lower lobe infiltrate versus
segmental atelectasis.
EKG shows normal sinus rhythm at 113 beats per minute, normal
axis, no evidence of ST-T wave changes.
BRIEF SUMMARY OF HOSPITAL COURSE:
1. COPD/dyspnea/pneumonia: The patient was initially placed
on an aggressive steroid taper and admitted to the Medical
Intensive Care Unit due to her difficulty with oxygenation
despite CPAP machine. She was also given nebulizer
treatments q.4h. as well as chest PT. The nebulizers were
increased to q.1h. due to the fact that she continued to have
labored breathing.
Due to persistent respiratory failure and labored breathing,
the patient was intubated on [**2118-6-7**] in order to improve
oxygenation, ventilation, and ability to suction. A
bronchoscopy was performed on [**2118-6-7**], which demonstrated
marked narrowing of the airways with expiration consistent
with tracheomalacia.
On [**2118-6-9**], two silicone stents were placed, one in the left
main stem (12 x 25 and one in the trachea 16 x 40) by Dr.
[**First Name (STitle) **] [**Name (STitle) **] under rigid bronchoscopy with general anesthesia.
On [**2118-6-11**], the patient was extubated to a cool mist shovel
mask and her oxygen was titrated down to 2 liters nasal
cannula at which time she was transferred to the medical
floor. On the medical floor, the steroids were weaned to off
on [**2118-6-14**], and the patient was saturating at 97% on 2
liters, 92% on room air.
On [**2118-6-14**], the patient was seen again by the Interventional
Pulmonology service, who agreed that she looked much improved
and recommended that she go to pulmonary rehabilitation with
followup within six weeks' time status post placement of
stents in respiratory failure.
2. Cardiovascular: The patient was ruled out for a MI. She
did have another episode on the medical floor of chest pain,
which showed no evidence of EKG changes and negative
troponin, negative CKs x3. She was continued on aspirin,
Imdur, and diltiazem for rate control per her outpatient
regimen.
3. Hypertension: She was maintained on diltiazem and
hydrochlorothiazide with adequate blood pressure control and
normalization of electrolytes.
4. Hematuria: The patient had intermittent hematuria likely
secondary to Foley placement. The Foley catheter was
discontinued on [**2118-6-14**]. She had serial urinalyses, which
were all negative for signs of infection.
5. Hyperglycemia: Patient was placed on insulin-sliding
scale due to hyperglycemia, which was steroid induced. This
worked quite well and her glucose came back to normal levels
once the steroids were tapered to off.
6. Leukocytosis: Patient did have a profound leukocytosis of
20 to 22 during much of her hospital course. As the steroids
were tapered to off, her white blood cell count on [**2118-6-14**]
was 15,000. It was felt that the leukocytosis was secondary
to both steroids as well as question of a left lower lobe
pneumonia.
7. For the left lower lobe pneumonia, the patient had
initially received a course of levofloxacin 500 p.o. q.d.
from [**2118-6-4**] to [**2118-6-10**]. This was restarted on [**2118-6-12**]
for an additional seven day course given the fact that she
still had the leukocytosis and still had marked rales at the
left lower lobe.
8. Hypothyroidism: The patient was continued on outpatient
medical regimen.
9. Depression: The patient was continued on Lexapro per
outpatient regimen. It is recommended that she follow up
with a therapist as an outpatient due to the fact that she
did have a blunted affect throughout much of the hospital
course, and did appear clinically to be depressed.
10. Prophylaxis: She was maintained on proton-pump inhibitor
with subQ Heparin.
11. Sore throat: The patient did have a sore throat for much
of the hospital course post extubation. This was treated
with Cepacol lozenges as well as KBL liquid (a solution
containing Kaopectate, Bismuth, and lidocaine) at bedtime.
12. Communication/code status: The patient was full code
throughout her hospital course, and communication was
maintained with the patient and her husband.
13. Muscle weakness: The patient did have profound muscle
weakness and was evaluated by Physical Therapy, and was found
to have impaired functional mobility, impaired
musculoskeletal performance, impaired gas exchange, impaired
endurance, impaired ventilation, and needed help with supine
to sit. However, she was able to tolerate sitting in a chair
for approximately one hour.
On motor exam, her flexors and extensors of the lower
extremities were [**4-8**] at the knee, [**4-8**] at the ankle, [**4-8**] at
the elbows, and [**4-8**] hips. It was felt that this weakness was
most likely due to a combination of steroid myopathy as well
as muscle atrophy secondary to deconditioning after a
prolonged hospital course.
14. Speech/swallow: The patient had a Speech and Swallow
evaluation showing no evidence of dysphagia, no evidence of
vocal cord damage status post tracheal stent placement.
DISCHARGE CONDITION: The patient was able to oxygenate on
room air at 93% at the time of discharge. She was profoundly
weak, but was no longer tachycardic and had a normal blood
pressure. Her respirations were much improved albeit with
transmitted upper airway sounds.
DISCHARGE STATUS: The patient will be discharged to [**Hospital1 **]
for both pulmonary and physical rehabilitation.
DISCHARGE MEDICATIONS:
1. Levothyroxine 75 mcg p.o. q.d.
2. Citalopram 10 mg p.o. q.d.
3. Aspirin 81 mg p.o. q.d.
4. Fluticasone 110 mcg two puffs inhaled b.i.d.
5. Salmeterol Diskus one inhalation b.i.d.
6. Acetaminophen 325-650 mg p.o. q.4-6h. prn.
7. Ipratropium bromide MDI two puffs inhaled q.2h. prn.
8. Albuterol 1-2 puffs inhaled q.2h. prn.
9. Zolpidem tartrate 5 mg p.o. q.h.s. prn.
10. Isosorbide dinitrate 10 mg p.o. t.i.d.
11. Diltiazem 60 mg p.o. q.i.d.
12. Pantoprazole 40 mg p.o. q.24h.
13. Trazodone 25 mg p.o. q.h.s. prn.
14. SubQ Heparin 5000 units subcutaneous b.i.d. until such
time that the patient is able to get out of bed twice a day.
15. Cepacol lozenges q.2h. prn.
16. Levofloxacin 500 mg p.o. q.d. for a seven day course to
be completed on [**2118-6-21**].
17. Kaopectate/Benadryl/lidocaine 5 mL p.o. b.i.d. prn, not
to be given around mealtimes for concern of dysphagia induced
by lidocaine.
18. Lorazepam 0.5-2 mg IV q.6h. prn.
FOLLOW-UP PLANS: The patient is recommended to followup with
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1407**], [**Telephone/Fax (1) 1408**] within two weeks of leaving
of the hospital. She is also recommended to followup with
the Interventional Pulmonary service for followup status post
stent placement. She is also recommended to followup with a
neurologist if her muscle weakness does not improve within
one week on physical therapy with concern for steroid-induced
myopathy.
FINAL DIAGNOSES:
1. Tracheomalacia status post tracheal and left main stem
bronchial stent placement.
2. Hypertension.
3. Hypothyroidism.
4. Restrictive lung defect.
5. Depression.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-207
Dictated By:[**Last Name (NamePattern1) 1811**]
MEDQUIST36
D: [**2118-6-14**] 11:30
T: [**2118-6-14**] 11:33
JOB#: [**Job Number 1812**]
|
Admission Date: <Date>1995-1-11</Date> Discharge Date: <Date>2011-4-19</Date>
Date of Birth: Sex: F
Service: MICU and then to <Doctor Name>Dr.Luu</Doctor Name> Medicine
HISTORY OF PRESENT ILLNESS: This is an 81-year-old female
with a history of emphysema (not on home O2), who presents
with three days of shortness of breath thought by her primary
care doctor to be a COPD flare. Two days prior to admission,
she was started on a prednisone taper and one day prior to
admission she required oxygen at home in order to maintain
oxygen saturation greater than 90%. She has also been on
levofloxacin and nebulizers, and was not getting better, and
presented to the <Hospital>Barry, Johnson and Clark Health System</Hospital> Emergency Room.
In the <Hospital>Moody-Conner Health System</Hospital> Emergency Room, her oxygen saturation was
100% on CPAP. She was not able to be weaned off of this
despite nebulizer treatment and Solu-Medrol 125 mg IV x2.
Review of systems is negative for the following: Fevers,
chills, nausea, vomiting, night sweats, change in weight,
gastrointestinal complaints, neurologic changes, rashes,
palpitations, orthopnea. Is positive for the following:
Chest pressure occasionally with shortness of breath with
exertion, some shortness of breath that is positionally
related, but is improved with nebulizer treatment.
PAST MEDICAL HISTORY:
1. COPD. Last pulmonary function tests in <Date>1938-6-14</Date>
demonstrated a FVC of 52% of predicted, a FEV1 of 54% of
predicted, a MMF of 23% of predicted, and a FEV1:FVC ratio of
67% of predicted, that does not improve with bronchodilator
treatment. The FVC, however, does significantly improve with
bronchodilator treatment consistent with her known reversible
air flow obstruction in addition to an underlying restrictive
ventilatory defect. The patient has never been on home
oxygen prior to this recent episode. She has never been on
steroid taper or been intubated in the past.
2. Lacunar CVA. MRI of the head in <Date>1913-1-14</Date>
demonstrates "mild degree of multiple small foci of high T2
signal within the white matter of both cerebral hemispheres
as well as the pons, in the latter region predominantly to
the right of midline. The abnormalities, while nonspecific
in etiology, are most likely secondary to chronic
microvascular infarction. There is no mass, lesion, shift of
the normal midline strictures or hydrocephalus. The major
vascular flow patterns are preserved. There is moderate
right maxillary, moderate bilateral ethmoid, mild left
maxillary, minimal right sphenoid, and frontal sinus mucosal
thickening. These abnormalities could represent an allergic
or some other type of inflammatory process. Additionally
noted is a moderately enlarged subtotally empty sella
turcica".
3. Angina: Most recent stress test was in <Date>2016-10-24</Date>
going for four minutes with a rate pressure product of
10,000, 64% of maximum predicted heart rate without evidence
of ischemic EKG changes or symptoms. The imaging portion of
the study demonstrated no evidence of myocardial ischemia and
a calculated ejection fraction of 84%. The patient denies
angina at rest and gets angina with walking a few blocks.
Are alleviated by sublingual nitroglycerin.
4. Hypothyroidism on Synthroid.
5. Depression on Lexapro.
6. Motor vehicle accident with head injury approximately 10
years ago.
MEDICATIONS ON ADMISSION:
1. Hydrochlorothiazide 25 q.d.
2. Prednisone 60 mg, 50 mg, 40 mg, 20 mg.
3. Levofloxacin 500 mg q.d.
4. Imdur 60 mg q.d.
5. Synthroid 75 mcg q.d.
6. Pulmicort nebulizer b.i.d.
7. Albuterol nebulizer q.4. prn.
8. Lexapro 10 mg q.d.
9. Protonix 40 mg q.d.
10. Aspirin 81 mg q.d.
ALLERGIES: Norvasc leads to lightheadedness and headache.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: Lives with her husband, Dr. <Name>Anderson</Name> an
eminent Pediatric Neurologist at <Hospital>Scott LLC Medical Center</Hospital>. The
patient is a prior smoker, but has not smoked in over 10
years. She has no known alcohol use and she is a full code.
PHYSICAL EXAM AT TIME OF ADMISSION: Blood pressure 142/76,
heart rate 100 and regular, respirations at 17-21, and 97%
axillary temperature. She was saturating at 100% on CPAP
with dry mucous membranes. An elderly female in no apparent
distress. Pupils are equal, round, and reactive to light and
accommodation. Extraocular movements are intact. Oropharynx
difficult to assess due to CPAP machine. No evidence of
jugular venous pressure, however, the strap from the CPAP
machine obscures the neck exam. Cranial nerves II through
XII are grossly intact. Neck is supple without
lymphadenopathy. Heart exam: Tachycardic, regular, obscured
by loud bilateral wheezing with increase in the expiratory
phase as well as profuse scattered rhonchi throughout the
lung fields. Positive bowel sounds, soft, nontender,
nondistended, obese, no masses. Mild edema of the lower
extremities without clubbing or cyanosis, no rashes. There
is a right hand hematoma. Strength is assessed as <Date>11-10</Date> in the
lower extremities, <Date>11-10</Date> in the upper extremities with a normal
mental status and cognition.
LABORATORY STUDIES: White count 19, hematocrit 41, platelets
300. Chem-7: 127, 3.6, 88, 29, 17, 0.6, 143. Troponin was
negative. CKs were negative times three. Initial blood gas
showed a pH of 7.4, pO2 of 66, pCO2 of 54.
Chest x-ray demonstrates a moderate sized hiatal hernia,
segmental atelectasis, left lower lobe infiltrate versus
segmental atelectasis.
EKG shows normal sinus rhythm at 113 beats per minute, normal
axis, no evidence of ST-T wave changes.
BRIEF SUMMARY OF HOSPITAL COURSE:
1. COPD/dyspnea/pneumonia: The patient was initially placed
on an aggressive steroid taper and admitted to the Medical
Intensive Care Unit due to her difficulty with oxygenation
despite CPAP machine. She was also given nebulizer
treatments q.4h. as well as chest PT. The nebulizers were
increased to q.1h. due to the fact that she continued to have
labored breathing.
Due to persistent respiratory failure and labored breathing,
the patient was intubated on <Date>2009-12-31</Date> in order to improve
oxygenation, ventilation, and ability to suction. A
bronchoscopy was performed on <Date>2009-12-31</Date>, which demonstrated
marked narrowing of the airways with expiration consistent
with tracheomalacia.
On <Date>2007-12-5</Date>, two silicone stents were placed, one in the left
main stem (12 x 25 and one in the trachea 16 x 40) by Dr.
<Name>Joe</Name> <Name>Chloe Miller</Name> under rigid bronchoscopy with general anesthesia.
On <Date>1921-5-11</Date>, the patient was extubated to a cool mist shovel
mask and her oxygen was titrated down to 2 liters nasal
cannula at which time she was transferred to the medical
floor. On the medical floor, the steroids were weaned to off
on <Date>2011-4-19</Date>, and the patient was saturating at 97% on 2
liters, 92% on room air.
On <Date>2011-4-19</Date>, the patient was seen again by the Interventional
Pulmonology service, who agreed that she looked much improved
and recommended that she go to pulmonary rehabilitation with
followup within six weeks' time status post placement of
stents in respiratory failure.
2. Cardiovascular: The patient was ruled out for a MI. She
did have another episode on the medical floor of chest pain,
which showed no evidence of EKG changes and negative
troponin, negative CKs x3. She was continued on aspirin,
Imdur, and diltiazem for rate control per her outpatient
regimen.
3. Hypertension: She was maintained on diltiazem and
hydrochlorothiazide with adequate blood pressure control and
normalization of electrolytes.
4. Hematuria: The patient had intermittent hematuria likely
secondary to Foley placement. The Foley catheter was
discontinued on <Date>2011-4-19</Date>. She had serial urinalyses, which
were all negative for signs of infection.
5. Hyperglycemia: Patient was placed on insulin-sliding
scale due to hyperglycemia, which was steroid induced. This
worked quite well and her glucose came back to normal levels
once the steroids were tapered to off.
6. Leukocytosis: Patient did have a profound leukocytosis of
20 to 22 during much of her hospital course. As the steroids
were tapered to off, her white blood cell count on <Date>2011-4-19</Date>
was 15,000. It was felt that the leukocytosis was secondary
to both steroids as well as question of a left lower lobe
pneumonia.
7. For the left lower lobe pneumonia, the patient had
initially received a course of levofloxacin 500 p.o. q.d.
from <Date>1941-12-6</Date> to <Date>1919-3-23</Date>. This was restarted on <Date>1941-3-21</Date>
for an additional seven day course given the fact that she
still had the leukocytosis and still had marked rales at the
left lower lobe.
8. Hypothyroidism: The patient was continued on outpatient
medical regimen.
9. Depression: The patient was continued on Lexapro per
outpatient regimen. It is recommended that she follow up
with a therapist as an outpatient due to the fact that she
did have a blunted affect throughout much of the hospital
course, and did appear clinically to be depressed.
10. Prophylaxis: She was maintained on proton-pump inhibitor
with subQ Heparin.
11. Sore throat: The patient did have a sore throat for much
of the hospital course post extubation. This was treated
with Cepacol lozenges as well as KBL liquid (a solution
containing Kaopectate, Bismuth, and lidocaine) at bedtime.
12. Communication/code status: The patient was full code
throughout her hospital course, and communication was
maintained with the patient and her husband.
13. Muscle weakness: The patient did have profound muscle
weakness and was evaluated by Physical Therapy, and was found
to have impaired functional mobility, impaired
musculoskeletal performance, impaired gas exchange, impaired
endurance, impaired ventilation, and needed help with supine
to sit. However, she was able to tolerate sitting in a chair
for approximately one hour.
On motor exam, her flexors and extensors of the lower
extremities were <Date>5-14</Date> at the knee, <Date>5-14</Date> at the ankle, <Date>5-14</Date> at
the elbows, and <Date>5-14</Date> hips. It was felt that this weakness was
most likely due to a combination of steroid myopathy as well
as muscle atrophy secondary to deconditioning after a
prolonged hospital course.
14. Speech/swallow: The patient had a Speech and Swallow
evaluation showing no evidence of dysphagia, no evidence of
vocal cord damage status post tracheal stent placement.
DISCHARGE CONDITION: The patient was able to oxygenate on
room air at 93% at the time of discharge. She was profoundly
weak, but was no longer tachycardic and had a normal blood
pressure. Her respirations were much improved albeit with
transmitted upper airway sounds.
DISCHARGE STATUS: The patient will be discharged to <Hospital>Chambers, Knight and Torres Clinic</Hospital>
for both pulmonary and physical rehabilitation.
DISCHARGE MEDICATIONS:
1. Levothyroxine 75 mcg p.o. q.d.
2. Citalopram 10 mg p.o. q.d.
3. Aspirin 81 mg p.o. q.d.
4. Fluticasone 110 mcg two puffs inhaled b.i.d.
5. Salmeterol Diskus one inhalation b.i.d.
6. Acetaminophen 325-650 mg p.o. q.4-6h. prn.
7. Ipratropium bromide MDI two puffs inhaled q.2h. prn.
8. Albuterol 1-2 puffs inhaled q.2h. prn.
9. Zolpidem tartrate 5 mg p.o. q.h.s. prn.
10. Isosorbide dinitrate 10 mg p.o. t.i.d.
11. Diltiazem 60 mg p.o. q.i.d.
12. Pantoprazole 40 mg p.o. q.24h.
13. Trazodone 25 mg p.o. q.h.s. prn.
14. SubQ Heparin 5000 units subcutaneous b.i.d. until such
time that the patient is able to get out of bed twice a day.
15. Cepacol lozenges q.2h. prn.
16. Levofloxacin 500 mg p.o. q.d. for a seven day course to
be completed on <Date>2016-5-12</Date>.
17. Kaopectate/Benadryl/lidocaine 5 mL p.o. b.i.d. prn, not
to be given around mealtimes for concern of dysphagia induced
by lidocaine.
18. Lorazepam 0.5-2 mg IV q.6h. prn.
FOLLOW-UP PLANS: The patient is recommended to followup with
Dr. <Name>Omer</Name> <Name>Wilson</Name>, <Telephone>663-918-8473</Telephone> within two weeks of leaving
of the hospital. She is also recommended to followup with
the Interventional Pulmonary service for followup status post
stent placement. She is also recommended to followup with a
neurologist if her muscle weakness does not improve within
one week on physical therapy with concern for steroid-induced
myopathy.
FINAL DIAGNOSES:
1. Tracheomalacia status post tracheal and left main stem
bronchial stent placement.
2. Hypertension.
3. Hypothyroidism.
4. Restrictive lung defect.
5. Depression.
DR.<Name>Moblo</Name>,<Name>Percy</Name> 12-207
Dictated By:<Name>Ngo</Name>
MEDQUIST36
D: <Date>2011-4-19</Date> 11:30
T: <Date>2011-4-19</Date> 11:33
JOB#: <Job Number>Sanchez PLC-2016-791366</Job Number>
|
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|
Admission Date: 1995-1-11 Discharge Date: 2011-4-19
Date of Birth: Sex: F
Service: MICU and then to Dr.Luu Medicine
HISTORY OF PRESENT ILLNESS: This is an 81-year-old female
with a history of emphysema (not on home O2), who presents
with three days of shortness of breath thought by her primary
care doctor to be a COPD flare. Two days prior to admission,
she was started on a prednisone taper and one day prior to
admission she required oxygen at home in order to maintain
oxygen saturation greater than 90%. She has also been on
levofloxacin and nebulizers, and was not getting better, and
presented to the Barry, Johnson and Clark Health System Emergency Room.
In the Moody-Conner Health System Emergency Room, her oxygen saturation was
100% on CPAP. She was not able to be weaned off of this
despite nebulizer treatment and Solu-Medrol 125 mg IV x2.
Review of systems is negative for the following: Fevers,
chills, nausea, vomiting, night sweats, change in weight,
gastrointestinal complaints, neurologic changes, rashes,
palpitations, orthopnea. Is positive for the following:
Chest pressure occasionally with shortness of breath with
exertion, some shortness of breath that is positionally
related, but is improved with nebulizer treatment.
PAST MEDICAL HISTORY:
1. COPD. Last pulmonary function tests in 1938-6-14
demonstrated a FVC of 52% of predicted, a FEV1 of 54% of
predicted, a MMF of 23% of predicted, and a FEV1:FVC ratio of
67% of predicted, that does not improve with bronchodilator
treatment. The FVC, however, does significantly improve with
bronchodilator treatment consistent with her known reversible
air flow obstruction in addition to an underlying restrictive
ventilatory defect. The patient has never been on home
oxygen prior to this recent episode. She has never been on
steroid taper or been intubated in the past.
2. Lacunar CVA. MRI of the head in 1913-1-14
demonstrates "mild degree of multiple small foci of high T2
signal within the white matter of both cerebral hemispheres
as well as the pons, in the latter region predominantly to
the right of midline. The abnormalities, while nonspecific
in etiology, are most likely secondary to chronic
microvascular infarction. There is no mass, lesion, shift of
the normal midline strictures or hydrocephalus. The major
vascular flow patterns are preserved. There is moderate
right maxillary, moderate bilateral ethmoid, mild left
maxillary, minimal right sphenoid, and frontal sinus mucosal
thickening. These abnormalities could represent an allergic
or some other type of inflammatory process. Additionally
noted is a moderately enlarged subtotally empty sella
turcica".
3. Angina: Most recent stress test was in 2016-10-24
going for four minutes with a rate pressure product of
10,000, 64% of maximum predicted heart rate without evidence
of ischemic EKG changes or symptoms. The imaging portion of
the study demonstrated no evidence of myocardial ischemia and
a calculated ejection fraction of 84%. The patient denies
angina at rest and gets angina with walking a few blocks.
Are alleviated by sublingual nitroglycerin.
4. Hypothyroidism on Synthroid.
5. Depression on Lexapro.
6. Motor vehicle accident with head injury approximately 10
years ago.
MEDICATIONS ON ADMISSION:
1. Hydrochlorothiazide 25 q.d.
2. Prednisone 60 mg, 50 mg, 40 mg, 20 mg.
3. Levofloxacin 500 mg q.d.
4. Imdur 60 mg q.d.
5. Synthroid 75 mcg q.d.
6. Pulmicort nebulizer b.i.d.
7. Albuterol nebulizer q.4. prn.
8. Lexapro 10 mg q.d.
9. Protonix 40 mg q.d.
10. Aspirin 81 mg q.d.
ALLERGIES: Norvasc leads to lightheadedness and headache.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: Lives with her husband, Dr. Anderson an
eminent Pediatric Neurologist at Scott LLC Medical Center. The
patient is a prior smoker, but has not smoked in over 10
years. She has no known alcohol use and she is a full code.
PHYSICAL EXAM AT TIME OF ADMISSION: Blood pressure 142/76,
heart rate 100 and regular, respirations at 17-21, and 97%
axillary temperature. She was saturating at 100% on CPAP
with dry mucous membranes. An elderly female in no apparent
distress. Pupils are equal, round, and reactive to light and
accommodation. Extraocular movements are intact. Oropharynx
difficult to assess due to CPAP machine. No evidence of
jugular venous pressure, however, the strap from the CPAP
machine obscures the neck exam. Cranial nerves II through
XII are grossly intact. Neck is supple without
lymphadenopathy. Heart exam: Tachycardic, regular, obscured
by loud bilateral wheezing with increase in the expiratory
phase as well as profuse scattered rhonchi throughout the
lung fields. Positive bowel sounds, soft, nontender,
nondistended, obese, no masses. Mild edema of the lower
extremities without clubbing or cyanosis, no rashes. There
is a right hand hematoma. Strength is assessed as 11-10 in the
lower extremities, 11-10 in the upper extremities with a normal
mental status and cognition.
LABORATORY STUDIES: White count 19, hematocrit 41, platelets
300. Chem-7: 127, 3.6, 88, 29, 17, 0.6, 143. Troponin was
negative. CKs were negative times three. Initial blood gas
showed a pH of 7.4, pO2 of 66, pCO2 of 54.
Chest x-ray demonstrates a moderate sized hiatal hernia,
segmental atelectasis, left lower lobe infiltrate versus
segmental atelectasis.
EKG shows normal sinus rhythm at 113 beats per minute, normal
axis, no evidence of ST-T wave changes.
BRIEF SUMMARY OF HOSPITAL COURSE:
1. COPD/dyspnea/pneumonia: The patient was initially placed
on an aggressive steroid taper and admitted to the Medical
Intensive Care Unit due to her difficulty with oxygenation
despite CPAP machine. She was also given nebulizer
treatments q.4h. as well as chest PT. The nebulizers were
increased to q.1h. due to the fact that she continued to have
labored breathing.
Due to persistent respiratory failure and labored breathing,
the patient was intubated on 2009-12-31 in order to improve
oxygenation, ventilation, and ability to suction. A
bronchoscopy was performed on 2009-12-31, which demonstrated
marked narrowing of the airways with expiration consistent
with tracheomalacia.
On 2007-12-5, two silicone stents were placed, one in the left
main stem (12 x 25 and one in the trachea 16 x 40) by Dr.
Joe Chloe Miller under rigid bronchoscopy with general anesthesia.
On 1921-5-11, the patient was extubated to a cool mist shovel
mask and her oxygen was titrated down to 2 liters nasal
cannula at which time she was transferred to the medical
floor. On the medical floor, the steroids were weaned to off
on 2011-4-19, and the patient was saturating at 97% on 2
liters, 92% on room air.
On 2011-4-19, the patient was seen again by the Interventional
Pulmonology service, who agreed that she looked much improved
and recommended that she go to pulmonary rehabilitation with
followup within six weeks' time status post placement of
stents in respiratory failure.
2. Cardiovascular: The patient was ruled out for a MI. She
did have another episode on the medical floor of chest pain,
which showed no evidence of EKG changes and negative
troponin, negative CKs x3. She was continued on aspirin,
Imdur, and diltiazem for rate control per her outpatient
regimen.
3. Hypertension: She was maintained on diltiazem and
hydrochlorothiazide with adequate blood pressure control and
normalization of electrolytes.
4. Hematuria: The patient had intermittent hematuria likely
secondary to Foley placement. The Foley catheter was
discontinued on 2011-4-19. She had serial urinalyses, which
were all negative for signs of infection.
5. Hyperglycemia: Patient was placed on insulin-sliding
scale due to hyperglycemia, which was steroid induced. This
worked quite well and her glucose came back to normal levels
once the steroids were tapered to off.
6. Leukocytosis: Patient did have a profound leukocytosis of
20 to 22 during much of her hospital course. As the steroids
were tapered to off, her white blood cell count on 2011-4-19
was 15,000. It was felt that the leukocytosis was secondary
to both steroids as well as question of a left lower lobe
pneumonia.
7. For the left lower lobe pneumonia, the patient had
initially received a course of levofloxacin 500 p.o. q.d.
from 1941-12-6 to 1919-3-23. This was restarted on 1941-3-21
for an additional seven day course given the fact that she
still had the leukocytosis and still had marked rales at the
left lower lobe.
8. Hypothyroidism: The patient was continued on outpatient
medical regimen.
9. Depression: The patient was continued on Lexapro per
outpatient regimen. It is recommended that she follow up
with a therapist as an outpatient due to the fact that she
did have a blunted affect throughout much of the hospital
course, and did appear clinically to be depressed.
10. Prophylaxis: She was maintained on proton-pump inhibitor
with subQ Heparin.
11. Sore throat: The patient did have a sore throat for much
of the hospital course post extubation. This was treated
with Cepacol lozenges as well as KBL liquid (a solution
containing Kaopectate, Bismuth, and lidocaine) at bedtime.
12. Communication/code status: The patient was full code
throughout her hospital course, and communication was
maintained with the patient and her husband.
13. Muscle weakness: The patient did have profound muscle
weakness and was evaluated by Physical Therapy, and was found
to have impaired functional mobility, impaired
musculoskeletal performance, impaired gas exchange, impaired
endurance, impaired ventilation, and needed help with supine
to sit. However, she was able to tolerate sitting in a chair
for approximately one hour.
On motor exam, her flexors and extensors of the lower
extremities were 5-14 at the knee, 5-14 at the ankle, 5-14 at
the elbows, and 5-14 hips. It was felt that this weakness was
most likely due to a combination of steroid myopathy as well
as muscle atrophy secondary to deconditioning after a
prolonged hospital course.
14. Speech/swallow: The patient had a Speech and Swallow
evaluation showing no evidence of dysphagia, no evidence of
vocal cord damage status post tracheal stent placement.
DISCHARGE CONDITION: The patient was able to oxygenate on
room air at 93% at the time of discharge. She was profoundly
weak, but was no longer tachycardic and had a normal blood
pressure. Her respirations were much improved albeit with
transmitted upper airway sounds.
DISCHARGE STATUS: The patient will be discharged to Chambers, Knight and Torres Clinic
for both pulmonary and physical rehabilitation.
DISCHARGE MEDICATIONS:
1. Levothyroxine 75 mcg p.o. q.d.
2. Citalopram 10 mg p.o. q.d.
3. Aspirin 81 mg p.o. q.d.
4. Fluticasone 110 mcg two puffs inhaled b.i.d.
5. Salmeterol Diskus one inhalation b.i.d.
6. Acetaminophen 325-650 mg p.o. q.4-6h. prn.
7. Ipratropium bromide MDI two puffs inhaled q.2h. prn.
8. Albuterol 1-2 puffs inhaled q.2h. prn.
9. Zolpidem tartrate 5 mg p.o. q.h.s. prn.
10. Isosorbide dinitrate 10 mg p.o. t.i.d.
11. Diltiazem 60 mg p.o. q.i.d.
12. Pantoprazole 40 mg p.o. q.24h.
13. Trazodone 25 mg p.o. q.h.s. prn.
14. SubQ Heparin 5000 units subcutaneous b.i.d. until such
time that the patient is able to get out of bed twice a day.
15. Cepacol lozenges q.2h. prn.
16. Levofloxacin 500 mg p.o. q.d. for a seven day course to
be completed on 2016-5-12.
17. Kaopectate/Benadryl/lidocaine 5 mL p.o. b.i.d. prn, not
to be given around mealtimes for concern of dysphagia induced
by lidocaine.
18. Lorazepam 0.5-2 mg IV q.6h. prn.
FOLLOW-UP PLANS: The patient is recommended to followup with
Dr. Omer Wilson, 663-918-8473 within two weeks of leaving
of the hospital. She is also recommended to followup with
the Interventional Pulmonary service for followup status post
stent placement. She is also recommended to followup with a
neurologist if her muscle weakness does not improve within
one week on physical therapy with concern for steroid-induced
myopathy.
FINAL DIAGNOSES:
1. Tracheomalacia status post tracheal and left main stem
bronchial stent placement.
2. Hypertension.
3. Hypothyroidism.
4. Restrictive lung defect.
5. Depression.
DR.Moblo,Percy 12-207
Dictated By:Ngo
MEDQUIST36
D: 2011-4-19 11:30
T: 2011-4-19 11:33
JOB#: Sanchez PLC-2016-791366
|
['Admission Date: 1995-1-11 Discharge Date: 2011-4-19\n\nDate of Birth: Sex: F\n\nService: MICU and then to Dr.Luu Medicine\n\nHISTORY OF PRESENT ILLNESS: This is an 81-year-old female\nwith a history of emphysema (not on home O2), who presents\nwith three days of shortness of breath thought by her primary\ncare doctor to be a COPD flare. Two days prior to admission,\nshe was started on a prednisone taper and one day prior to\nadmission she required oxygen at home in order to maintain\noxygen saturation greater than 90%. She has also been on\nlevofloxacin and nebulizers, and was not getting better, and\npresented to the Barry, Johnson and Clark Health System Emergency Room.\n\nIn the Moody-Conner Health System Emergency Room, her oxygen saturation was\n100% on CPAP. She was not able to be weaned off of this\ndespite nebulizer treatment and Solu-Medrol 125 mg IV x2.', '\n\nReview of systems is negative for the following: Fevers,\nchills, nausea, vomiting, night sweats, change in weight,\ngastrointestinal complaints, neurologic changes, rashes,\npalpitations, orthopnea. Is positive for the following:\nChest pressure occasionally with shortness of breath with\nexertion, some shortness of breath that is positionally\nrelated, but is improved with nebulizer treatment.\n\nPAST MEDICAL HISTORY:\n1. COPD. Last pulmonary function tests in 1938-6-14\ndemonstrated a FVC of 52% of predicted, a FEV1 of 54% of\npredicted, a MMF of 23% of predicted, and a FEV1:FVC ratio of\n67% of predicted, that does not improve with bronchodilator\ntreatment. The FVC, however, does significantly improve with\nbronchodilator treatment consistent with her known reversible\nair flow obstruction in addition to an underlying restrictive\nventilatory defect.', ' The patient has never been on home\noxygen prior to this recent episode. She has never been on\nsteroid taper or been intubated in the past.\n2. Lacunar CVA. MRI of the head in 1913-1-14\ndemonstrates "mild degree of multiple small foci of high T2\nsignal within the white matter of both cerebral hemispheres\nas well as the pons, in the latter region predominantly to\nthe right of midline. The abnormalities, while nonspecific\nin etiology, are most likely secondary to chronic\nmicrovascular infarction. There is no mass, lesion, shift of\nthe normal midline strictures or hydrocephalus. The major\nvascular flow patterns are preserved. There is moderate\nright maxillary, moderate bilateral ethmoid, mild left\nmaxillary, minimal right sphenoid, and frontal sinus mucosal\nthickening. These abnormalities could represent an allergic\nor some other type of inflammatory process.', ' Additionally\nnoted is a moderately enlarged subtotally empty sella\nturcica".\n3. Angina: Most recent stress test was in 2016-10-24\ngoing for four minutes with a rate pressure product of\n10,000, 64% of maximum predicted heart rate without evidence\nof ischemic EKG changes or symptoms. The imaging portion of\nthe study demonstrated no evidence of myocardial ischemia and\na calculated ejection fraction of 84%. The patient denies\nangina at rest and gets angina with walking a few blocks.\nAre alleviated by sublingual nitroglycerin.\n4. Hypothyroidism on Synthroid.\n5. Depression on Lexapro.\n6. Motor vehicle accident with head injury approximately 10\nyears ago.\n\nMEDICATIONS ON ADMISSION:\n1. Hydrochlorothiazide 25 q.d.\n2. Prednisone 60 mg, 50 mg, 40 mg, 20 mg.\n3. Levofloxacin 500 mg q.d.\n4. Imdur 60 mg q.', 'd.\n5. Synthroid 75 mcg q.d.\n6. Pulmicort nebulizer b.i.d.\n7. Albuterol nebulizer q.4. prn.\n8. Lexapro 10 mg q.d.\n9. Protonix 40 mg q.d.\n10. Aspirin 81 mg q.d.\n\nALLERGIES: Norvasc leads to lightheadedness and headache.\n\nFAMILY HISTORY: Noncontributory.\n\nSOCIAL HISTORY: Lives with her husband, Dr. Anderson an\neminent Pediatric Neurologist at Scott LLC Medical Center. The\npatient is a prior smoker, but has not smoked in over 10\nyears. She has no known alcohol use and she is a full code.\n\nPHYSICAL EXAM AT TIME OF ADMISSION: Blood pressure 142/76,\nheart rate 100 and regular, respirations at 17-21, and 97%\naxillary temperature. She was saturating at 100% on CPAP\nwith dry mucous membranes. An elderly female in no apparent\ndistress. Pupils are equal, round, and reactive to light and\naccommodation.', ' Extraocular movements are intact. Oropharynx\ndifficult to assess due to CPAP machine. No evidence of\njugular venous pressure, however, the strap from the CPAP\nmachine obscures the neck exam. Cranial nerves II through\nXII are grossly intact. Neck is supple without\nlymphadenopathy. Heart exam: Tachycardic, regular, obscured\nby loud bilateral wheezing with increase in the expiratory\nphase as well as profuse scattered rhonchi throughout the\nlung fields. Positive bowel sounds, soft, nontender,\nnondistended, obese, no masses. Mild edema of the lower\nextremities without clubbing or cyanosis, no rashes. There\nis a right hand hematoma. Strength is assessed as 11-10 in the\nlower extremities, 11-10 in the upper extremities with a normal\nmental status and cognition.\n\nLABORATORY STUDIES: White count 19, hematocrit 41, platelets\n300.', ' Chem-7: 127, 3.6, 88, 29, 17, 0.6, 143. Troponin was\nnegative. CKs were negative times three. Initial blood gas\nshowed a pH of 7.4, pO2 of 66, pCO2 of 54.\n\nChest x-ray demonstrates a moderate sized hiatal hernia,\nsegmental atelectasis, left lower lobe infiltrate versus\nsegmental atelectasis.\n\nEKG shows normal sinus rhythm at 113 beats per minute, normal\naxis, no evidence of ST-T wave changes.\n\nBRIEF SUMMARY OF HOSPITAL COURSE:\n1. COPD/dyspnea/pneumonia: The patient was initially placed\non an aggressive steroid taper and admitted to the Medical\nIntensive Care Unit due to her difficulty with oxygenation\ndespite CPAP machine. She was also given nebulizer\ntreatments q.4h. as well as chest PT. The nebulizers were\nincreased to q.1h. due to the fact that she continued to have\nlabored breathing.', '\n\nDue to persistent respiratory failure and labored breathing,\nthe patient was intubated on 2009-12-31 in order to improve\noxygenation, ventilation, and ability to suction. A\nbronchoscopy was performed on 2009-12-31, which demonstrated\nmarked narrowing of the airways with expiration consistent\nwith tracheomalacia.\n\nOn 2007-12-5, two silicone stents were placed, one in the left\nmain stem (12 x 25 and one in the trachea 16 x 40) by Dr.\nJoe Chloe Miller under rigid bronchoscopy with general anesthesia.\n\nOn 1921-5-11, the patient was extubated to a cool mist shovel\nmask and her oxygen was titrated down to 2 liters nasal\ncannula at which time she was transferred to the medical\nfloor. On the medical floor, the steroids were weaned to off\non 2011-4-19, and the patient was saturating at 97% on 2\nliters, 92% on room air.', "\n\nOn 2011-4-19, the patient was seen again by the Interventional\nPulmonology service, who agreed that she looked much improved\nand recommended that she go to pulmonary rehabilitation with\nfollowup within six weeks' time status post placement of\nstents in respiratory failure.\n\n2. Cardiovascular: The patient was ruled out for a MI. She\ndid have another episode on the medical floor of chest pain,\nwhich showed no evidence of EKG changes and negative\ntroponin, negative CKs x3. She was continued on aspirin,\nImdur, and diltiazem for rate control per her outpatient\nregimen.\n\n3. Hypertension: She was maintained on diltiazem and\nhydrochlorothiazide with adequate blood pressure control and\nnormalization of electrolytes.\n\n4. Hematuria: The patient had intermittent hematuria likely\nsecondary to Foley placement.", ' The Foley catheter was\ndiscontinued on 2011-4-19. She had serial urinalyses, which\nwere all negative for signs of infection.\n\n5. Hyperglycemia: Patient was placed on insulin-sliding\nscale due to hyperglycemia, which was steroid induced. This\nworked quite well and her glucose came back to normal levels\nonce the steroids were tapered to off.\n\n6. Leukocytosis: Patient did have a profound leukocytosis of\n20 to 22 during much of her hospital course. As the steroids\nwere tapered to off, her white blood cell count on 2011-4-19\nwas 15,000. It was felt that the leukocytosis was secondary\nto both steroids as well as question of a left lower lobe\npneumonia.\n\n7. For the left lower lobe pneumonia, the patient had\ninitially received a course of levofloxacin 500 p.o. q.d.\nfrom 1941-12-6 to 1919-3-23.', ' This was restarted on 1941-3-21\nfor an additional seven day course given the fact that she\nstill had the leukocytosis and still had marked rales at the\nleft lower lobe.\n\n8. Hypothyroidism: The patient was continued on outpatient\nmedical regimen.\n\n9. Depression: The patient was continued on Lexapro per\noutpatient regimen. It is recommended that she follow up\nwith a therapist as an outpatient due to the fact that she\ndid have a blunted affect throughout much of the hospital\ncourse, and did appear clinically to be depressed.\n\n10. Prophylaxis: She was maintained on proton-pump inhibitor\nwith subQ Heparin.\n\n11. Sore throat: The patient did have a sore throat for much\nof the hospital course post extubation. This was treated\nwith Cepacol lozenges as well as KBL liquid (a solution\ncontaining Kaopectate, Bismuth, and lidocaine) at bedtime.', '\n\n12. Communication/code status: The patient was full code\nthroughout her hospital course, and communication was\nmaintained with the patient and her husband.\n\n13. Muscle weakness: The patient did have profound muscle\nweakness and was evaluated by Physical Therapy, and was found\nto have impaired functional mobility, impaired\nmusculoskeletal performance, impaired gas exchange, impaired\nendurance, impaired ventilation, and needed help with supine\nto sit. However, she was able to tolerate sitting in a chair\nfor approximately one hour.\n\nOn motor exam, her flexors and extensors of the lower\nextremities were 5-14 at the knee, 5-14 at the ankle, 5-14 at\nthe elbows, and 5-14 hips. It was felt that this weakness was\nmost likely due to a combination of steroid myopathy as well\nas muscle atrophy secondary to deconditioning after a\nprolonged hospital course.', '\n\n14. Speech/swallow: The patient had a Speech and Swallow\nevaluation showing no evidence of dysphagia, no evidence of\nvocal cord damage status post tracheal stent placement.\n\nDISCHARGE CONDITION: The patient was able to oxygenate on\nroom air at 93% at the time of discharge. She was profoundly\nweak, but was no longer tachycardic and had a normal blood\npressure. Her respirations were much improved albeit with\ntransmitted upper airway sounds.\n\nDISCHARGE STATUS: The patient will be discharged to Chambers, Knight and Torres Clinic\nfor both pulmonary and physical rehabilitation.\n\nDISCHARGE MEDICATIONS:\n1. Levothyroxine 75 mcg p.o. q.d.\n2. Citalopram 10 mg p.o. q.d.\n3. Aspirin 81 mg p.o. q.d.\n4. Fluticasone 110 mcg two puffs inhaled b.i.d.\n5. Salmeterol Diskus one inhalation b.i.d.\n6. Acetaminophen 325-650 mg p.', 'o. q.4-6h. prn.\n7. Ipratropium bromide MDI two puffs inhaled q.2h. prn.\n8. Albuterol 1-2 puffs inhaled q.2h. prn.\n9. Zolpidem tartrate 5 mg p.o. q.h.s. prn.\n10. Isosorbide dinitrate 10 mg p.o. t.i.d.\n11. Diltiazem 60 mg p.o. q.i.d.\n12. Pantoprazole 40 mg p.o. q.24h.\n13. Trazodone 25 mg p.o. q.h.s. prn.\n14. SubQ Heparin 5000 units subcutaneous b.i.d. until such\ntime that the patient is able to get out of bed twice a day.\n15. Cepacol lozenges q.2h. prn.\n16. Levofloxacin 500 mg p.o. q.d. for a seven day course to\nbe completed on 2016-5-12.\n17. Kaopectate/Benadryl/lidocaine 5 mL p.o. b.i.d. prn, not\nto be given around mealtimes for concern of dysphagia induced\nby lidocaine.\n18. Lorazepam 0.5-2 mg IV q.6h. prn.\n\nFOLLOW-UP PLANS: The patient is recommended to followup with\nDr. Omer Wilson, 663-918-8473 within two weeks of leaving\nof the hospital.', ' She is also recommended to followup with\nthe Interventional Pulmonary service for followup status post\nstent placement. She is also recommended to followup with a\nneurologist if her muscle weakness does not improve within\none week on physical therapy with concern for steroid-induced\nmyopathy.\n\nFINAL DIAGNOSES:\n1. Tracheomalacia status post tracheal and left main stem\nbronchial stent placement.\n2. Hypertension.\n3. Hypothyroidism.\n4. Restrictive lung defect.\n5. Depression.\n\n\n DR.Moblo,Percy 12-207\n\n\nDictated By:Ngo\nMEDQUIST36\n\nD: 2011-4-19 11:30\nT: 2011-4-19 11:33\nJOB#: Sanchez PLC-2016-791366\n']
|
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176
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13702
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167118.0
|
2119-05-25
|
Discharge summary
|
Report
|
Admission Date: [**2119-5-4**] Discharge Date: [**2119-5-25**]
Service: CARDIOTHORACIC
Allergies:
Amlodipine
Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
81 yo F smoker w/ COPD, severe TBM, s/p tracheobronchoplasty [**5-5**]
s/p perc trach [**5-13**]
Major Surgical or Invasive Procedure:
bronchoscopy 3/31,4/2,3,[**6-12**], [**5-17**], [**5-19**]
s/p trachealplasty [**5-5**]
percutaneous tracheostomy [**5-13**] after failed extubation
down size trach on [**5-25**] to size 6 cuffless
History of Present Illness:
This 81 year old woman has a history of COPD. Over the past five
years she has had progressive difficulties with her breathing.
In
[**2118-6-4**] she was admitted to [**Hospital1 18**] for respiratory failure
due
to a COPD exacerbation. Due to persistent hypoxemia, she
required
intubation and a eventual bronchoscopy on [**2118-6-9**] revealed marked
narrowing of the airways on expiration consistent with
tracheomalacia.
She subsequently underwent placement of two
silicone stents, one in the left main stem and one in the
trachea. During the admission the patient had complaints of
chest
pain and ruled out for an MI. She was subsequently discharged to
[**Hospital1 **] for physical and pulmonary rehab. Repeat bronchoscopy
on
[**2118-8-1**] revealed granulation tissue at the distal right lateral
wall of the tracheal stent. There was significant malacia of the
peripheral and central airways with complete collapse of the
airways on coughing and forced expiration. Small nodules were
also noted on the vocal cords. She has noticed improvement in
her
respiratory status, but most recently has been in discussion
with Dr. [**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) 952**] regarding possible tracheobronchial plasty
with mesh. Tracheal stents d/c [**2119-4-19**] in anticipation of
surgery.
In terms of symptoms, she describes many years of intermittent
chest pain that she describes as left sided and occurring at any
time. Currently, she notices it about three times a week, and
states that it seems to resolve after three nitroglycerin.
She currently is dependent on oxygen and wears 1.5-2 liters
around the clock. She has frequent coughing and brings up "dark
sputum".
Past Medical History:
COPD flare [**6-7**] s/p intubation, s/p distal tracheal to Left Main
Stem stents placed [**2118-6-9**]. Stents d/c'd [**2119-4-19**], CAD w/ atypical
angina (LAD 30%, RCA 30%, EF 63%), ^chol, hypothyroidism, htn,
hiatal hernia, lacunar CVA, s/p ped struck -> head injury & rib
fx, depression
PMH:
COPD, s/p admit [**6-7**] for exacerbation requiring intubation
tracheobronchomalacia, s/p bronchial stenting
Large hiatal hernia
Lacunar CVA
Hypothyroidism by records in CCC, although patient denies and is
not taking any medication
Depression
MVA, s/p head injury approximately 10 years ago
Hypertension
Hysterectomy
Social History:
Social History: The patient is married and worked as a clinical
psychologist. Her husband is a pediatric neurologist at
[**Hospital3 **]. They have several children, one of which is
a nurse.
Family History:
Family History: (+) FHx CAD; Father with an MI in his 40's, died
of a CVA at age 59
Physical Exam:
Admit H+P
General-lovely 81 yr old feamle in NAD.
Neuro- intermittently anxious, MAE, PERRLA, L eye ptosis,
symetrical smile, gossly intact.
HEENT-PERRLA, sclera anicteric, pharynx- no exud or erythema
Resp-clear upper, diffuse ronchi, intermit exp wheezes
Cor- RRR, No M, R, G
Abd- soft, NT, ND, no masses. Slight protrusion at area of
hiatal hernia
Ext- no edema or clubbing
Brief Hospital Course:
82 y/o female admitted [**2119-5-4**] for consideration of
tracheoplasty.
Bronchoscopy done [**5-4**] confirming severe TBM. Underwent
tracheoplasty [**5-5**], complicated by resp failure d/t mucous
plugging, hypoxia requiring re-intubation resulting in prolonged
ICU and hospital course. Also developed right upper extrem DVT
from mid line.
Pain- Epidural accidently d/c'd POD#1, pt briefly used dilaudid
PCA intermittently w/ fair pain control. Pt required
re-intubation for resp failure d/t secretions and PCA d/c at
that time. Propofol for sedation while intubated. Sedation d/c'd
[**5-12**] for weaning trial w/ ETT- failed trial. Trach [**5-13**]-weaning
efforts as below. Minimal c/o pain since [**5-13**]. Presently pain
free.
Neuro- Initially intact- post op aggitation, inhibiting weaning
efforts [**5-16**]. Psych eval [**5-18**]-Started on zyprexa and ativan w/
improvement in anxiety. Presently A+Ox3- cooperative and lovely.
Resp- Extubated POD#2 then required re-intub [**5-7**] for hypoxia
d/t poor cough and mucous plugging. SIMV/PS alt w/CMV at night
x4-5d, with CPAP attempts during day.
Bronchoscopy qd [**Date range (1) 1813**] for secretion management. Bronch [**5-9**]
revealed swollen epiglottis, bronch [**5-10**] - good leak w/ ETT cuff
deflated. Bronch [**5-13**] for eval/trach placement. Last bronch [**5-19**]
w/ min secretions present, sputum sent.
[**5-13**] perc trach done(#8 Portex- cuffed low pressure maintained to
preserve tracheoplasty site). [**5-13**] CPAP15/peep5 initiated post
trach placement. Weaning ongoing. [**Date range (1) 1814**]- Aggressive weaning
w/ increasing episodes of CPAP, progressing to Trach Mask.
[**2033-5-20**]-Trach mask overnight w/ no episodes of SOB, or
hemodynamic instability. Trach changed to #6 portex- capped and
[**Last Name (un) 1815**] well x48hrs on 2LNP. productive cough. Aggressive PT as
well w/ OOB > chair [**Hospital1 **]-tid to total 4-6hr qd. Ambulation
~100-120 ft [**5-22**] w/ PT assist.
ID- Vancomycin started post-op for graft prophylaxis. Fever
spike [**2119-5-8**] w/ BAl & sputum sent> + MRSA. Vanco cont to [**4-7**]
weeks post trachealplasty. Fever low grade [**5-12**], [**5-15**]> cultured-
no new results. [**5-19**]- WBC 20.8 .
Cardiac-Hypertension controlled w/ hydralazine IV, then d/c and
cont controlled. HR 65-75 NSR. Avoiding B Blockers. Lasix 20mg
IV qd.
[**5-15**]- RUE redness and swelling at site of midline, RUE DVT by
ultrasound, midline d/c; heparin gtt started and therapeutic
range monitored. [**5-22**] changed to Lovenox sq [**Hospital1 **]. Coags in good
control [**5-23**] (48.2/13.8/1.2)
Access- R midline placed [**2119-5-9**] for access- clotted [**2119-5-15**] and
d/c'd. RUE redness and swelling and DVT via ultrasound. [**5-15**]- L
brachial PICC line placed- TPN resumed.
GI-Large hiatal hernia- unable to place enteral feeding tube at
bedside or underfluoro. Re-attempt [**5-17**] by EGD doboff tube
placed distal esophagus, dislodged in 12hours and removed.
Nutrition- PPN/TPN initiated [**2119-5-8**]- [**2119-5-25**]. PICC placed
[**2119-5-15**]. Speech and Swallow eval [**5-22**]- rec change trach form #8
to #6 Portex to allow improved epiglotis and oropharyngeal
movement to assist w/ swallowing. Then re-eval. Trach changed
[**5-23**] to #6 cuffless portex trach. Passed repeat swallow eval and
[**Last Name (un) 1815**] diet of regular solids w/ thin liquids- CHIN TUCK to
swallow thin liquids. Give meds whole w/ apple sauce. WOULD
RECOMMEND repeat video swallow eval in [**8-17**] days to possibly
eliminate chin tuck- see page 3 referral.
Endo- Hypothyroid, maintained on levoxyl.
Muscu/Skel- OOB> chair 4-6hours/day, PT consulting.
Medications on Admission:
advair 250/50", atrovent, imdur 60', lasix 40', lexapro 20',
lipitor 10', prilosec 20', mucinex 600", synthroid 75', detrol
LA 4', ambien 5', trazadone 75', melatonin prn
Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing.
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing.
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
5. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
7. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**2-5**] Sprays Nasal
QID (4 times a day) as needed.
8. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
9. Enoxaparin Sodium 60 mg/0.6mL Syringe Sig: One (1)
Subcutaneous Q12H (every 12 hours).
10. Trazodone HCl 50 mg Tablet Sig: 1.5 Tablets PO HS (at
bedtime) as needed.
11. Escitalopram Oxalate 10 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
12. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
13. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
14. Tolterodine Tartrate 2 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
15. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
16. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
COPD, Coronary Artery Disease/atypical angina (LAD 30%, RCA 30%,
EF 63%), hypercholesterolemia, hypothyroidism, Hypertension,
hiatal hernia, Cerebral Vascular Accident,s/p Motor Vehicle
Colision-> head injury & rib fracture.
TBM- s/p tracheoplasty.
Discharge Condition:
good
Discharge Instructions:
please update Dr.[**Name (NI) 1816**] [**Telephone/Fax (1) 170**] office for: fever,
shortness of breath, chest pain , productive cough or if you
have any questions or concerns.
Completed by:[**2119-5-25**]
|
Admission Date: <Date>1962-9-15</Date> Discharge Date: <Date>1965-9-18</Date>
Service: CARDIOTHORACIC
Allergies:
Amlodipine
Attending:<Name>Pleasant</Name>
Chief Complaint:
81 yo F smoker w/ COPD, severe TBM, s/p tracheobronchoplasty <Date>1-28</Date>
s/p perc trach <Date>7-7</Date>
Major Surgical or Invasive Procedure:
bronchoscopy 3/31,4/2,3,<Date>9-8</Date>, <Date>12-13</Date>, <Date>11-8</Date>
s/p trachealplasty <Date>1-28</Date>
percutaneous tracheostomy <Date>7-7</Date> after failed extubation
down size trach on <Date>12-9</Date> to size 6 cuffless
History of Present Illness:
This 81 year old woman has a history of COPD. Over the past five
years she has had progressive difficulties with her breathing.
In
<Date>1946-12-15</Date> she was admitted to <Hospital>Smith and Sons Hospital</Hospital> for respiratory failure
due
to a COPD exacerbation. Due to persistent hypoxemia, she
required
intubation and a eventual bronchoscopy on <Date>1975-9-16</Date> revealed marked
narrowing of the airways on expiration consistent with
tracheomalacia.
She subsequently underwent placement of two
silicone stents, one in the left main stem and one in the
trachea. During the admission the patient had complaints of
chest
pain and ruled out for an MI. She was subsequently discharged to
<Hospital>Austin PLC Medical Center</Hospital> for physical and pulmonary rehab. Repeat bronchoscopy
on
<Date>1980-1-10</Date> revealed granulation tissue at the distal right lateral
wall of the tracheal stent. There was significant malacia of the
peripheral and central airways with complete collapse of the
airways on coughing and forced expiration. Small nodules were
also noted on the vocal cords. She has noticed improvement in
her
respiratory status, but most recently has been in discussion
with Dr. <Name>Jackson</Name> <Name>Lockett</Name> regarding possible tracheobronchial plasty
with mesh. Tracheal stents d/c <Date>1941-2-15</Date> in anticipation of
surgery.
In terms of symptoms, she describes many years of intermittent
chest pain that she describes as left sided and occurring at any
time. Currently, she notices it about three times a week, and
states that it seems to resolve after three nitroglycerin.
She currently is dependent on oxygen and wears 1.5-2 liters
around the clock. She has frequent coughing and brings up "dark
sputum".
Past Medical History:
COPD flare <Date>7-2</Date> s/p intubation, s/p distal tracheal to Left Main
Stem stents placed <Date>1975-9-16</Date>. Stents d/c'd <Date>1941-2-15</Date>, CAD w/ atypical
angina (LAD 30%, RCA 30%, EF 63%), ^chol, hypothyroidism, htn,
hiatal hernia, lacunar CVA, s/p ped struck -> head injury & rib
fx, depression
PMH:
COPD, s/p admit <Date>7-2</Date> for exacerbation requiring intubation
tracheobronchomalacia, s/p bronchial stenting
Large hiatal hernia
Lacunar CVA
Hypothyroidism by records in CCC, although patient denies and is
not taking any medication
Depression
MVA, s/p head injury approximately 10 years ago
Hypertension
Hysterectomy
Social History:
Social History: The patient is married and worked as a clinical
psychologist. Her husband is a pediatric neurologist at
<Hospital>Lyons-Nolan Medical Center</Hospital>. They have several children, one of which is
a nurse.
Family History:
Family History: (+) FHx CAD; Father with an MI in his 40's, died
of a CVA at age 59
Physical Exam:
Admit H+P
General-lovely 81 yr old feamle in NAD.
Neuro- intermittently anxious, MAE, PERRLA, L eye ptosis,
symetrical smile, gossly intact.
HEENT-PERRLA, sclera anicteric, pharynx- no exud or erythema
Resp-clear upper, diffuse ronchi, intermit exp wheezes
Cor- RRR, No M, R, G
Abd- soft, NT, ND, no masses. Slight protrusion at area of
hiatal hernia
Ext- no edema or clubbing
Brief Hospital Course:
82 y/o female admitted <Date>1962-9-15</Date> for consideration of
tracheoplasty.
Bronchoscopy done <Date>7-13</Date> confirming severe TBM. Underwent
tracheoplasty <Date>1-28</Date>, complicated by resp failure d/t mucous
plugging, hypoxia requiring re-intubation resulting in prolonged
ICU and hospital course. Also developed right upper extrem DVT
from mid line.
Pain- Epidural accidently d/c'd POD#1, pt briefly used dilaudid
PCA intermittently w/ fair pain control. Pt required
re-intubation for resp failure d/t secretions and PCA d/c at
that time. Propofol for sedation while intubated. Sedation d/c'd
<Date>4-12</Date> for weaning trial w/ ETT- failed trial. Trach <Date>7-7</Date>-weaning
efforts as below. Minimal c/o pain since <Date>7-7</Date>. Presently pain
free.
Neuro- Initially intact- post op aggitation, inhibiting weaning
efforts <Date>4-8</Date>. Psych eval <Date>8-21</Date>-Started on zyprexa and ativan w/
improvement in anxiety. Presently A+Ox3- cooperative and lovely.
Resp- Extubated POD#2 then required re-intub <Date>9-18</Date> for hypoxia
d/t poor cough and mucous plugging. SIMV/PS alt w/CMV at night
x4-5d, with CPAP attempts during day.
Bronchoscopy qd <Date Range>1916-3-19 to 2014-6-18</Date Range> for secretion management. Bronch <Date>11-26</Date>
revealed swollen epiglottis, bronch <Date>3-6</Date> - good leak w/ ETT cuff
deflated. Bronch <Date>7-7</Date> for eval/trach placement. Last bronch <Date>11-8</Date>
w/ min secretions present, sputum sent.
<Date>7-7</Date> perc trach done(#8 Portex- cuffed low pressure maintained to
preserve tracheoplasty site). <Date>7-7</Date> CPAP15/peep5 initiated post
trach placement. Weaning ongoing. <Date Range>1939-7-26 to 1962-6-13</Date Range>- Aggressive weaning
w/ increasing episodes of CPAP, progressing to Trach Mask.
<Date>2008-3-15</Date>-Trach mask overnight w/ no episodes of SOB, or
hemodynamic instability. Trach changed to #6 portex- capped and
<Name>Kibler</Name> well x48hrs on 2LNP. productive cough. Aggressive PT as
well w/ OOB > chair <Hospital>Austin PLC Medical Center</Hospital>-tid to total 4-6hr qd. Ambulation
~100-120 ft <Date>3-12</Date> w/ PT assist.
ID- Vancomycin started post-op for graft prophylaxis. Fever
spike <Date>1951-7-9</Date> w/ BAl & sputum sent> + MRSA. Vanco cont to <Date>2-24</Date>
weeks post trachealplasty. Fever low grade <Date>4-12</Date>, <Date>9-9</Date>> cultured-
no new results. <Date>11-8</Date>- WBC 20.8 .
Cardiac-Hypertension controlled w/ hydralazine IV, then d/c and
cont controlled. HR 65-75 NSR. Avoiding B Blockers. Lasix 20mg
IV qd.
<Date>9-9</Date>- RUE redness and swelling at site of midline, RUE DVT by
ultrasound, midline d/c; heparin gtt started and therapeutic
range monitored. <Date>3-12</Date> changed to Lovenox sq <Hospital>Austin PLC Medical Center</Hospital>. Coags in good
control <Date>4-20</Date> (48.2/13.8/1.2)
Access- R midline placed <Date>1971-6-20</Date> for access- clotted <Date>1965-7-15</Date> and
d/c'd. RUE redness and swelling and DVT via ultrasound. <Date>9-9</Date>- L
brachial PICC line placed- TPN resumed.
GI-Large hiatal hernia- unable to place enteral feeding tube at
bedside or underfluoro. Re-attempt <Date>12-13</Date> by EGD doboff tube
placed distal esophagus, dislodged in 12hours and removed.
Nutrition- PPN/TPN initiated <Date>1951-7-9</Date>- <Date>1965-9-18</Date>. PICC placed
<Date>1965-7-15</Date>. Speech and Swallow eval <Date>3-12</Date>- rec change trach form #8
to #6 Portex to allow improved epiglotis and oropharyngeal
movement to assist w/ swallowing. Then re-eval. Trach changed
<Date>4-20</Date> to #6 cuffless portex trach. Passed repeat swallow eval and
<Name>Kibler</Name> diet of regular solids w/ thin liquids- CHIN TUCK to
swallow thin liquids. Give meds whole w/ apple sauce. WOULD
RECOMMEND repeat video swallow eval in <Date>1-16</Date> days to possibly
eliminate chin tuck- see page 3 referral.
Endo- Hypothyroid, maintained on levoxyl.
Muscu/Skel- OOB> chair 4-6hours/day, PT consulting.
Medications on Admission:
advair 250/50", atrovent, imdur 60', lasix 40', lexapro 20',
lipitor 10', prilosec 20', mucinex 600", synthroid 75', detrol
LA 4', ambien 5', trazadone 75', melatonin prn
Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing.
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing.
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation <Hospital>Austin PLC Medical Center</Hospital> (2 times a day).
4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
5. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
7. Sodium Chloride 0.65 % Aerosol, Spray Sig: <Date>12-10</Date> Sprays Nasal
QID (4 times a day) as needed.
8. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
9. Enoxaparin Sodium 60 mg/0.6mL Syringe Sig: One (1)
Subcutaneous Q12H (every 12 hours).
10. Trazodone HCl 50 mg Tablet Sig: 1.5 Tablets PO HS (at
bedtime) as needed.
11. Escitalopram Oxalate 10 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
12. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical <Hospital>Austin PLC Medical Center</Hospital>
(2 times a day).
13. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
14. Tolterodine Tartrate 2 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
15. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
16. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
Discharge Disposition:
Extended Care
Facility:
<Hospital>Brown-Lee Hospital</Hospital> & Rehab Center - <Hospital>Jacobs LLC Hospital</Hospital>
Discharge Diagnosis:
COPD, Coronary Artery Disease/atypical angina (LAD 30%, RCA 30%,
EF 63%), hypercholesterolemia, hypothyroidism, Hypertension,
hiatal hernia, Cerebral Vascular Accident,s/p Motor Vehicle
Colision-> head injury & rib fracture.
TBM- s/p tracheoplasty.
Discharge Condition:
good
Discharge Instructions:
please update Dr.<Name>Miriam Edward</Name> <Telephone>783-584-2272</Telephone> office for: fever,
shortness of breath, chest pain , productive cough or if you
have any questions or concerns.
Completed by:<Date>1965-9-18</Date>
|
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Admission Date: 1962-9-15 Discharge Date: 1965-9-18
Service: CARDIOTHORACIC
Allergies:
Amlodipine
Attending:Pleasant
Chief Complaint:
81 yo F smoker w/ COPD, severe TBM, s/p tracheobronchoplasty 1-28
s/p perc trach 7-7
Major Surgical or Invasive Procedure:
bronchoscopy 3/31,4/2,3,9-8, 12-13, 11-8
s/p trachealplasty 1-28
percutaneous tracheostomy 7-7 after failed extubation
down size trach on 12-9 to size 6 cuffless
History of Present Illness:
This 81 year old woman has a history of COPD. Over the past five
years she has had progressive difficulties with her breathing.
In
1946-12-15 she was admitted to Smith and Sons Hospital for respiratory failure
due
to a COPD exacerbation. Due to persistent hypoxemia, she
required
intubation and a eventual bronchoscopy on 1975-9-16 revealed marked
narrowing of the airways on expiration consistent with
tracheomalacia.
She subsequently underwent placement of two
silicone stents, one in the left main stem and one in the
trachea. During the admission the patient had complaints of
chest
pain and ruled out for an MI. She was subsequently discharged to
Austin PLC Medical Center for physical and pulmonary rehab. Repeat bronchoscopy
on
1980-1-10 revealed granulation tissue at the distal right lateral
wall of the tracheal stent. There was significant malacia of the
peripheral and central airways with complete collapse of the
airways on coughing and forced expiration. Small nodules were
also noted on the vocal cords. She has noticed improvement in
her
respiratory status, but most recently has been in discussion
with Dr. Jackson Lockett regarding possible tracheobronchial plasty
with mesh. Tracheal stents d/c 1941-2-15 in anticipation of
surgery.
In terms of symptoms, she describes many years of intermittent
chest pain that she describes as left sided and occurring at any
time. Currently, she notices it about three times a week, and
states that it seems to resolve after three nitroglycerin.
She currently is dependent on oxygen and wears 1.5-2 liters
around the clock. She has frequent coughing and brings up "dark
sputum".
Past Medical History:
COPD flare 7-2 s/p intubation, s/p distal tracheal to Left Main
Stem stents placed 1975-9-16. Stents d/c'd 1941-2-15, CAD w/ atypical
angina (LAD 30%, RCA 30%, EF 63%), ^chol, hypothyroidism, htn,
hiatal hernia, lacunar CVA, s/p ped struck -> head injury & rib
fx, depression
PMH:
COPD, s/p admit 7-2 for exacerbation requiring intubation
tracheobronchomalacia, s/p bronchial stenting
Large hiatal hernia
Lacunar CVA
Hypothyroidism by records in CCC, although patient denies and is
not taking any medication
Depression
MVA, s/p head injury approximately 10 years ago
Hypertension
Hysterectomy
Social History:
Social History: The patient is married and worked as a clinical
psychologist. Her husband is a pediatric neurologist at
Lyons-Nolan Medical Center. They have several children, one of which is
a nurse.
Family History:
Family History: (+) FHx CAD; Father with an MI in his 40's, died
of a CVA at age 59
Physical Exam:
Admit H+P
General-lovely 81 yr old feamle in NAD.
Neuro- intermittently anxious, MAE, PERRLA, L eye ptosis,
symetrical smile, gossly intact.
HEENT-PERRLA, sclera anicteric, pharynx- no exud or erythema
Resp-clear upper, diffuse ronchi, intermit exp wheezes
Cor- RRR, No M, R, G
Abd- soft, NT, ND, no masses. Slight protrusion at area of
hiatal hernia
Ext- no edema or clubbing
Brief Hospital Course:
82 y/o female admitted 1962-9-15 for consideration of
tracheoplasty.
Bronchoscopy done 7-13 confirming severe TBM. Underwent
tracheoplasty 1-28, complicated by resp failure d/t mucous
plugging, hypoxia requiring re-intubation resulting in prolonged
ICU and hospital course. Also developed right upper extrem DVT
from mid line.
Pain- Epidural accidently d/c'd POD#1, pt briefly used dilaudid
PCA intermittently w/ fair pain control. Pt required
re-intubation for resp failure d/t secretions and PCA d/c at
that time. Propofol for sedation while intubated. Sedation d/c'd
4-12 for weaning trial w/ ETT- failed trial. Trach 7-7-weaning
efforts as below. Minimal c/o pain since 7-7. Presently pain
free.
Neuro- Initially intact- post op aggitation, inhibiting weaning
efforts 4-8. Psych eval 8-21-Started on zyprexa and ativan w/
improvement in anxiety. Presently A+Ox3- cooperative and lovely.
Resp- Extubated POD#2 then required re-intub 9-18 for hypoxia
d/t poor cough and mucous plugging. SIMV/PS alt w/CMV at night
x4-5d, with CPAP attempts during day.
Bronchoscopy qd 1916-3-19 to 2014-6-18 for secretion management. Bronch 11-26
revealed swollen epiglottis, bronch 3-6 - good leak w/ ETT cuff
deflated. Bronch 7-7 for eval/trach placement. Last bronch 11-8
w/ min secretions present, sputum sent.
7-7 perc trach done(#8 Portex- cuffed low pressure maintained to
preserve tracheoplasty site). 7-7 CPAP15/peep5 initiated post
trach placement. Weaning ongoing. 1939-7-26 to 1962-6-13- Aggressive weaning
w/ increasing episodes of CPAP, progressing to Trach Mask.
2008-3-15-Trach mask overnight w/ no episodes of SOB, or
hemodynamic instability. Trach changed to #6 portex- capped and
Kibler well x48hrs on 2LNP. productive cough. Aggressive PT as
well w/ OOB > chair Austin PLC Medical Center-tid to total 4-6hr qd. Ambulation
~100-120 ft 3-12 w/ PT assist.
ID- Vancomycin started post-op for graft prophylaxis. Fever
spike 1951-7-9 w/ BAl & sputum sent> + MRSA. Vanco cont to 2-24
weeks post trachealplasty. Fever low grade 4-12, 9-9> cultured-
no new results. 11-8- WBC 20.8 .
Cardiac-Hypertension controlled w/ hydralazine IV, then d/c and
cont controlled. HR 65-75 NSR. Avoiding B Blockers. Lasix 20mg
IV qd.
9-9- RUE redness and swelling at site of midline, RUE DVT by
ultrasound, midline d/c; heparin gtt started and therapeutic
range monitored. 3-12 changed to Lovenox sq Austin PLC Medical Center. Coags in good
control 4-20 (48.2/13.8/1.2)
Access- R midline placed 1971-6-20 for access- clotted 1965-7-15 and
d/c'd. RUE redness and swelling and DVT via ultrasound. 9-9- L
brachial PICC line placed- TPN resumed.
GI-Large hiatal hernia- unable to place enteral feeding tube at
bedside or underfluoro. Re-attempt 12-13 by EGD doboff tube
placed distal esophagus, dislodged in 12hours and removed.
Nutrition- PPN/TPN initiated 1951-7-9- 1965-9-18. PICC placed
1965-7-15. Speech and Swallow eval 3-12- rec change trach form #8
to #6 Portex to allow improved epiglotis and oropharyngeal
movement to assist w/ swallowing. Then re-eval. Trach changed
4-20 to #6 cuffless portex trach. Passed repeat swallow eval and
Kibler diet of regular solids w/ thin liquids- CHIN TUCK to
swallow thin liquids. Give meds whole w/ apple sauce. WOULD
RECOMMEND repeat video swallow eval in 1-16 days to possibly
eliminate chin tuck- see page 3 referral.
Endo- Hypothyroid, maintained on levoxyl.
Muscu/Skel- OOB> chair 4-6hours/day, PT consulting.
Medications on Admission:
advair 250/50", atrovent, imdur 60', lasix 40', lexapro 20',
lipitor 10', prilosec 20', mucinex 600", synthroid 75', detrol
LA 4', ambien 5', trazadone 75', melatonin prn
Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing.
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing.
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation Austin PLC Medical Center (2 times a day).
4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
5. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
7. Sodium Chloride 0.65 % Aerosol, Spray Sig: 12-10 Sprays Nasal
QID (4 times a day) as needed.
8. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
9. Enoxaparin Sodium 60 mg/0.6mL Syringe Sig: One (1)
Subcutaneous Q12H (every 12 hours).
10. Trazodone HCl 50 mg Tablet Sig: 1.5 Tablets PO HS (at
bedtime) as needed.
11. Escitalopram Oxalate 10 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
12. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical Austin PLC Medical Center
(2 times a day).
13. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
14. Tolterodine Tartrate 2 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
15. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
16. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
Discharge Disposition:
Extended Care
Facility:
Brown-Lee Hospital & Rehab Center - Jacobs LLC Hospital
Discharge Diagnosis:
COPD, Coronary Artery Disease/atypical angina (LAD 30%, RCA 30%,
EF 63%), hypercholesterolemia, hypothyroidism, Hypertension,
hiatal hernia, Cerebral Vascular Accident,s/p Motor Vehicle
Colision-> head injury & rib fracture.
TBM- s/p tracheoplasty.
Discharge Condition:
good
Discharge Instructions:
please update Dr.Miriam Edward 783-584-2272 office for: fever,
shortness of breath, chest pain , productive cough or if you
have any questions or concerns.
Completed by:1965-9-18
|
['Admission Date: 1962-9-15 Discharge Date: 1965-9-18\n\n\nService: CARDIOTHORACIC\n\nAllergies:\nAmlodipine\n\nAttending:Pleasant\nChief Complaint:\n81 yo F smoker w/ COPD, severe TBM, s/p tracheobronchoplasty 1-28\ns/p perc trach 7-7\n\nMajor Surgical or Invasive Procedure:\nbronchoscopy 3/31,4/2,3,9-8, 12-13, 11-8\ns/p trachealplasty 1-28\npercutaneous tracheostomy 7-7 after failed extubation\ndown size trach on 12-9 to size 6 cuffless\n\n\nHistory of Present Illness:\nThis 81 year old woman has a history of COPD. Over the past five\n\nyears she has had progressive difficulties with her breathing.\nIn\n1946-12-15 she was admitted to Smith and Sons Hospital for respiratory failure\ndue\nto a COPD exacerbation. Due to persistent hypoxemia, she\nrequired\nintubation and a eventual bronchoscopy on 1975-9-16 revealed marked\n\nnarrowing of the airways on expiration consistent with\ntracheomalacia.', '\nShe subsequently underwent placement of two\nsilicone stents, one in the left main stem and one in the\ntrachea. During the admission the patient had complaints of\nchest\npain and ruled out for an MI. She was subsequently discharged to\n\nAustin PLC Medical Center for physical and pulmonary rehab. Repeat bronchoscopy\non\n1980-1-10 revealed granulation tissue at the distal right lateral\nwall of the tracheal stent. There was significant malacia of the\n\nperipheral and central airways with complete collapse of the\nairways on coughing and forced expiration. Small nodules were\nalso noted on the vocal cords. She has noticed improvement in\nher\nrespiratory status, but most recently has been in discussion\nwith Dr. Jackson Lockett regarding possible tracheobronchial plasty\n\nwith mesh. Tracheal stents d/c 1941-2-15 in anticipation of\nsurgery.', '\nIn terms of symptoms, she describes many years of intermittent\nchest pain that she describes as left sided and occurring at any\n\ntime. Currently, she notices it about three times a week, and\nstates that it seems to resolve after three nitroglycerin.\nShe currently is dependent on oxygen and wears 1.5-2 liters\naround the clock. She has frequent coughing and brings up "dark\nsputum".\n\n\n\nPast Medical History:\nCOPD flare 7-2 s/p intubation, s/p distal tracheal to Left Main\nStem stents placed 1975-9-16. Stents d/c\'d 1941-2-15, CAD w/ atypical\nangina (LAD 30%, RCA 30%, EF 63%), ^chol, hypothyroidism, htn,\nhiatal hernia, lacunar CVA, s/p ped struck -> head injury & rib\nfx, depression\nPMH:\nCOPD, s/p admit 7-2 for exacerbation requiring intubation\ntracheobronchomalacia, s/p bronchial stenting\nLarge hiatal hernia\nLacunar CVA\nHypothyroidism by records in CCC, although patient denies and is\n\nnot taking any medication\nDepression\nMVA, s/p head injury approximately 10 years ago\nHypertension\nHysterectomy\n\n\nSocial History:\nSocial History: The patient is married and worked as a clinical\npsychologist.', " Her husband is a pediatric neurologist at\nLyons-Nolan Medical Center. They have several children, one of which is\n\na nurse.\n\n\nFamily History:\nFamily History: (+) FHx CAD; Father with an MI in his 40's, died\n\nof a CVA at age 59\n\n\nPhysical Exam:\nAdmit H+P\nGeneral-lovely 81 yr old feamle in NAD.\nNeuro- intermittently anxious, MAE, PERRLA, L eye ptosis,\nsymetrical smile, gossly intact.\nHEENT-PERRLA, sclera anicteric, pharynx- no exud or erythema\nResp-clear upper, diffuse ronchi, intermit exp wheezes\nCor- RRR, No M, R, G\nAbd- soft, NT, ND, no masses. Slight protrusion at area of\nhiatal hernia\nExt- no edema or clubbing\n\nBrief Hospital Course:\n82 y/o female admitted 1962-9-15 for consideration of\ntracheoplasty.\nBronchoscopy done 7-13 confirming severe TBM. Underwent\ntracheoplasty 1-28, complicated by resp failure d/t mucous\nplugging, hypoxia requiring re-intubation resulting in prolonged\nICU and hospital course.", " Also developed right upper extrem DVT\nfrom mid line.\n\nPain- Epidural accidently d/c'd POD#1, pt briefly used dilaudid\nPCA intermittently w/ fair pain control. Pt required\nre-intubation for resp failure d/t secretions and PCA d/c at\nthat time. Propofol for sedation while intubated. Sedation d/c'd\n4-12 for weaning trial w/ ETT- failed trial. Trach 7-7-weaning\nefforts as below. Minimal c/o pain since 7-7. Presently pain\nfree.\n\nNeuro- Initially intact- post op aggitation, inhibiting weaning\nefforts 4-8. Psych eval 8-21-Started on zyprexa and ativan w/\nimprovement in anxiety. Presently A+Ox3- cooperative and lovely.\n\nResp- Extubated POD#2 then required re-intub 9-18 for hypoxia\nd/t poor cough and mucous plugging. SIMV/PS alt w/CMV at night\nx4-5d, with CPAP attempts during day.\nBronchoscopy qd 1916-3-19 to 2014-6-18 for secretion management.", ' Bronch 11-26\nrevealed swollen epiglottis, bronch 3-6 - good leak w/ ETT cuff\ndeflated. Bronch 7-7 for eval/trach placement. Last bronch 11-8\nw/ min secretions present, sputum sent.\n7-7 perc trach done(#8 Portex- cuffed low pressure maintained to\npreserve tracheoplasty site). 7-7 CPAP15/peep5 initiated post\ntrach placement. Weaning ongoing. 1939-7-26 to 1962-6-13- Aggressive weaning\nw/ increasing episodes of CPAP, progressing to Trach Mask.\n2008-3-15-Trach mask overnight w/ no episodes of SOB, or\nhemodynamic instability. Trach changed to #6 portex- capped and\nKibler well x48hrs on 2LNP. productive cough. Aggressive PT as\nwell w/ OOB > chair Austin PLC Medical Center-tid to total 4-6hr qd. Ambulation\n~100-120 ft 3-12 w/ PT assist.\n\nID- Vancomycin started post-op for graft prophylaxis. Fever\nspike 1951-7-9 w/ BAl & sputum sent> + MRSA.', " Vanco cont to 2-24\nweeks post trachealplasty. Fever low grade 4-12, 9-9> cultured-\nno new results. 11-8- WBC 20.8 .\n\nCardiac-Hypertension controlled w/ hydralazine IV, then d/c and\ncont controlled. HR 65-75 NSR. Avoiding B Blockers. Lasix 20mg\nIV qd.\n9-9- RUE redness and swelling at site of midline, RUE DVT by\nultrasound, midline d/c; heparin gtt started and therapeutic\nrange monitored. 3-12 changed to Lovenox sq Austin PLC Medical Center. Coags in good\ncontrol 4-20 (48.2/13.8/1.2)\nAccess- R midline placed 1971-6-20 for access- clotted 1965-7-15 and\nd/c'd. RUE redness and swelling and DVT via ultrasound. 9-9- L\nbrachial PICC line placed- TPN resumed.\n\nGI-Large hiatal hernia- unable to place enteral feeding tube at\nbedside or underfluoro. Re-attempt 12-13 by EGD doboff tube\nplaced distal esophagus, dislodged in 12hours and removed.", '\n\nNutrition- PPN/TPN initiated 1951-7-9- 1965-9-18. PICC placed\n1965-7-15. Speech and Swallow eval 3-12- rec change trach form #8\nto #6 Portex to allow improved epiglotis and oropharyngeal\nmovement to assist w/ swallowing. Then re-eval. Trach changed\n4-20 to #6 cuffless portex trach. Passed repeat swallow eval and\nKibler diet of regular solids w/ thin liquids- CHIN TUCK to\nswallow thin liquids. Give meds whole w/ apple sauce. WOULD\nRECOMMEND repeat video swallow eval in 1-16 days to possibly\neliminate chin tuck- see page 3 referral.\n\nEndo- Hypothyroid, maintained on levoxyl.\n\nMuscu/Skel- OOB> chair 4-6hours/day, PT consulting.\n\n\nMedications on Admission:\nadvair 250/50", atrovent, imdur 60\', lasix 40\', lexapro 20\',\nlipitor 10\', prilosec 20\', mucinex 600", synthroid 75\', detrol\nLA 4\', ambien 5\', trazadone 75\', melatonin prn\n\nDischarge Medications:\n1.', ' Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation\nQ6H (every 6 hours) as needed for wheezing.\n2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation\nQ6H (every 6 hours) as needed for wheezing.\n3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:\nOne (1) Disk with Device Inhalation Austin PLC Medical Center (2 times a day).\n4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation\nQ6H (every 6 hours) as needed.\n5. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)\nPuff Inhalation QID (4 times a day).\n6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every\n4 to 6 hours) as needed.\n7. Sodium Chloride 0.65 % Aerosol, Spray Sig: 12-10 Sprays Nasal\nQID (4 times a day) as needed.\n8. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical\nTID (3 times a day) as needed.', '\n9. Enoxaparin Sodium 60 mg/0.6mL Syringe Sig: One (1)\nSubcutaneous Q12H (every 12 hours).\n10. Trazodone HCl 50 mg Tablet Sig: 1.5 Tablets PO HS (at\nbedtime) as needed.\n11. Escitalopram Oxalate 10 mg Tablet Sig: Two (2) Tablet PO\nDAILY (Daily).\n12. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical Austin PLC Medical Center\n(2 times a day).\n13. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)\nSig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24\nhours).\n14. Tolterodine Tartrate 2 mg Tablet Sig: One (1) Tablet PO BID\n(2 times a day).\n15. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO\nDAILY (Daily).\n16. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One\n(1) ML Intravenous DAILY (Daily) as needed.\n\n\nDischarge Disposition:\nExtended Care\n\nFacility:\nBrown-Lee Hospital & Rehab Center - Jacobs LLC Hospital\n\nDischarge Diagnosis:\nCOPD, Coronary Artery Disease/atypical angina (LAD 30%, RCA 30%,\nEF 63%), hypercholesterolemia, hypothyroidism, Hypertension,\nhiatal hernia, Cerebral Vascular Accident,s/p Motor Vehicle\nColision-> head injury & rib fracture.', '\nTBM- s/p tracheoplasty.\n\n\nDischarge Condition:\ngood\n\nDischarge Instructions:\nplease update Dr.Miriam Edward 783-584-2272 office for: fever,\nshortness of breath, chest pain , productive cough or if you\nhave any questions or concerns.\n\n\nCompleted by:1965-9-18']
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13702
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196489.0
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2124-08-18
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Discharge summary
|
Report
| "Admission Date: [**2124-7-21**] Discharge Date: [**2124-8-18**]\n\n\nService: MEDIC(...TRUNCATED)
| "Admission Date: <Date>1906-7-15</Date> Discharge Date: <Date>1903-2-31</Date>\n\n\n(...TRUNCATED)
| "000000000000000001111111110000000000000000000000000000000011111111100000000000000000000000000000000(...TRUNCATED)
| "Admission Date: 1906-7-15 Discharge Date: 1903-2-31\n\n\nService: MEDICINE\n\nAller(...TRUNCATED)
| "[\"Admission Date: 1906-7-15 Discharge Date: 1903-2-31\\n\\n\\nService: MEDICINE\\n(...TRUNCATED)
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135453.0
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2162-03-25
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Report
| "Admission Date: [**2162-3-3**] Discharge Date: [**2162-3-25**]\n\nDate of Birth: [(...TRUNCATED)
| "Admission Date: <Date>1989-8-1</Date> Discharge Date: <Date>1909-12-28</Date>\n\nDa(...TRUNCATED)
| "000000000000000001111111100000000000000000000000000000000111111111100000000000000000011111111100000(...TRUNCATED)
| "Admission Date: 1989-8-1 Discharge Date: 1909-12-28\n\nDate of Birth: 1990-3-12 (...TRUNCATED)
| "['Admission Date: 1989-8-1 Discharge Date: 1909-12-28\\n\\nDate of Birth: 1990-3-1(...TRUNCATED)
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179
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170490.0
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2172-03-08
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|
Report
| "Admission Date: [**2172-3-5**] Discharge Date: [**2172-3-8**]\n\nDate of Birth: [*(...TRUNCATED)
| "Admission Date: <Date>1933-8-28</Date> Discharge Date: <Date>1951-10-10</Date>\n\nD(...TRUNCATED)
| "000000000000000001111111110000000000000000000000000000000011111111110000000000000000001111111110000(...TRUNCATED)
| "Admission Date: 1933-8-28 Discharge Date: 1951-10-10\n\nDate of Birth: 2015-8-18 (...TRUNCATED)
| "[\"Admission Date: 1933-8-28 Discharge Date: 1951-10-10\\n\\nDate of Birth: 2015-8(...TRUNCATED)
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180
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134727.0
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2112-12-10
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Discharge summary
|
Report
| "Admission Date: [**2112-12-8**] Discharge Date: [**2112-12-10**]\n\n\nService: MEDI(...TRUNCATED)
| "Admission Date: <Date>1995-12-10</Date> Discharge Date: <Date>1931-3-22</Date>\n\n\(...TRUNCATED)
| "000000000000000001111111111000000000000000000000000000000001111111110000000000000000000000000000000(...TRUNCATED)
| "Admission Date: 1995-12-10 Discharge Date: 1931-3-22\n\n\nService: MEDICINE\n\nAlle(...TRUNCATED)
| "['Admission Date: 1995-12-10 Discharge Date: 1931-3-22\\n\\n\\nService: MEDICINE\\n(...TRUNCATED)
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42130
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114236.0
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2150-03-01
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Discharge summary
|
Report
| "Admission Date: [**2150-2-25**] Discharge Date: [**2150-3-1**]\n\nDate of Birth: [(...TRUNCATED)
| "Admission Date: <Date>2014-1-6</Date> Discharge Date: <Date>2015-12-27</Date>\n\nDa(...TRUNCATED)
| "000000000000000001111111100000000000000000000000000000000111111111100000000000000000011111111100000(...TRUNCATED)
| "Admission Date: 2014-1-6 Discharge Date: 2015-12-27\n\nDate of Birth: 1999-12-1 (...TRUNCATED)
| "['Admission Date: 2014-1-6 Discharge Date: 2015-12-27\\n\\nDate of Birth: 1999-12-(...TRUNCATED)
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163469.0
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2118-08-12
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Discharge summary
|
Report
| "Admission Date: [**2118-8-10**] Discharge Date: [**2118-8-12**]\n\nDate of Birth: (...TRUNCATED)
| "Admission Date: <Date>1911-9-19</Date> Discharge Date: <Date>1958-3-14</Date>\n\nDa(...TRUNCATED)
| "000000000000000001111111110000000000000000000000000000000011111111100000000000000000011111111110000(...TRUNCATED)
| "Admission Date: 1911-9-19 Discharge Date: 1958-3-14\n\nDate of Birth: 1966-12-12 (...TRUNCATED)
| "['Admission Date: 1911-9-19 Discharge Date: 1958-3-14\\n\\nDate of Birth: 1966-12-(...TRUNCATED)
|
|||||
183
|
56174
|
189681.0
|
2118-12-09
|
Discharge summary
|
Report
| "Admission Date: [**2118-12-7**] Discharge Date: [**2118-12-9**]\n\nDate of Birth: (...TRUNCATED)
| "Admission Date: <Date>1926-4-8</Date> Discharge Date: <Date>1953-6-27</Date>\n\nDat(...TRUNCATED)
| "000000000000000001111111100000000000000000000000000000000111111111000000000000000000111111111000000(...TRUNCATED)
| "Admission Date: 1926-4-8 Discharge Date: 1953-6-27\n\nDate of Birth: 1920-7-11 (...TRUNCATED)
| "['Admission Date: 1926-4-8 Discharge Date: 1953-6-27\\n\\nDate of Birth: 1920-7-11(...TRUNCATED)
|
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