"","NOTE_ID","NOTE_TYPE","TEXT" "1",1,"History and Physical","CHIEF COMPLAINT: Dog bite to his right lower leg. HISTORY OF PRESENT ILLNESS: This 50-year-old white male earlier this afternoon was attempting to adjust a cable that a dog was tied to. Dog was a German shepherd, it belonged to his brother, and the dog spontaneously attacked him. He sustained a bite to his right lower leg. Apparently, according to the patient, the dog is well known and is up-to-date on his shots and they wanted to confirm that. The dog has given no prior history of any reason to believe he is not a healthy dog. The patient himself developed a puncture wound with a flap injury. The patient has a flap wound also below the puncture wound, a V-shaped flap, which is pointing towards the foot. It appears to be viable. The wound is open about may be roughly a centimeter in the inside of the flap. He was seen by his medical primary care physician and was given a tetanus shot and the wound was cleaned and wrapped, and then he was referred to us for further assessment. PAST MEDICAL HISTORY (PMH): Significant for history of pulmonary fibrosis and atrial fibrillation. He is status post bilateral lung transplant back in 2004 because of the pulmonary fibrosis. ALLERGIES: There are no known allergies. MEDS: Include multiple medications that are significant for his lung transplant including Prograf, CellCept, prednisone, omeprazole, Bactrim which he is on chronically, folic acid, vitamin D, Mag-Ox, Toprol-XL, calcium 500 mg, vitamin B1, Centrum Silver, verapamil, and digoxin. FAMILY HISTORY Consistent with a sister of his has ovarian cancer and his father had liver cancer. Heart disease in the patient's mother and father, and father also has diabetes and diabetic retinopathy. SOCIAL HISTORY: He is a non-cigarette smoker. He has occasional glass of wine. He is married. He has one biological child and three stepchildren. He works for ABCD. ROS: He denies any chest pain. He does admit to exertional shortness of breath. He denies any GI or GU problems. He denies any bleeding disorders. PHYSICAL EXAMINATIONGENERAL: Presents as a well-developed, well-nourished 50-year-old white male who appears to be in mild distress. HEENT: Unremarkable. NECK: Supple. There is no mass, adenopathy or bruit. CHEST: Normal excursion. LUNGS: Clear to auscultation and percussion. COR: Regular. There is no S3 or S4 gallop. There is no obvious murmur. ABDOMEN: Soft. It is nontender. Bowel sounds are present. There is no tenderness. SKIN: He does have like a Chevron incisional scar across his lower chest and upper abdomen. It appears to be well healed and unremarkable. GENITALIA: Deferred. RECTAL: Deferred. EXTREMITIES: He has about 1+ pitting edema to both legs and they have been present since the surgery. In the right leg, he has an about midway between the right knee and right ankle on the anterior pretibial area, he has a puncture wound that measures about may be centimeter around that appears to be relatively clean, and just below that about may be 3 cm below, he has a flap traumatic injury that measures about may be 4 cm to the point of the flap. The wound is spread apart about may be a centimeter all along that area and it is relatively clean. There was some bleeding when I removed the dressing and we were able to pretty much control that with pressure and some silver nitrate. There were exposed subcutaneous tissues, but there was no exposed tendons that we could see, etc. The flap appeared to be viable. NEUROLOGIC: Without focal deficits. The patient is alert and oriented. IMPRESSION: A 50-year-old white male with dog bite to his right leg with a history of pulmonary fibrosis, status post bilateral lung transplant several years ago. He is on multiple medications and he is on chronic Bactrim. We are going to also add some fluoroquinolone right now to protect the skin and probably going to obtain an Infectious Disease consult. We will see him back in the office early next week to reassess his wound. He is to keep the wound clean with the moist dressing right now. He may shower several times a day." "2",2,"History and Physical","CHIEF COMPLAINT: Left hip pain. HISTORY OF PRESENT ILLNESS The patient is a 32-year-old male seen by Dr. ABC several weeks ago for persistent left hip pain. He has a long eight to ten year history of pain into the left hip. He has been worked up by several specialists and evaluated. He was thought initially to have low back pain with radiculopathy. He does have a history of antibiotic steroid use as well as heavy drinking. He reports his symptoms started approximately eight years ago when he was doing some construction at which time he began to have left hip pain. He has had difficulties on and off ever since then. On the last visit, radiographs revealed severe degenerative changes of the left hip joint with apparent AVN of the left femoral head. He was given some pain medication and discussion took place regarding referring him to a specialist for evaluation of possible hip resurfacing versus conventional total hip replacement. He came for a second opinion in the area and we discussed his problems further. He continues to have primarily groin pain, which limits his daily activities. He has used a cane in the past for a short period and he continues to have difficulty with the left hip. PAST MEDICAL HISTORY Diabetes and high blood pressure. PAST SURGICAL HISTORY He had a history of surgery for an undescended testicle. MEDICATIONS Metformin, Prozac, lisinopril, Norco, and glimepiride. ALLERGIES No know drug allergies. SOCIAL HISTORY The patient current smokes. PHYSICAL EXAMINATION Reveals significant limited internal rotation of the left hip. He essentially has 0 degrees of internal rotation compared to the contralateral hip, which has approximately 30 degrees. He has significant pain with hip range of motion. There is no significant leg length discrepancy. He has no numbness or tingling distal and 2+ pulses.X- RAYS Review of films taken previously reveals severe degenerative changes consistent with AVN. ASSESSMENT Left hip avascular necrosis. PLAN I had a long discussion with the patient regarding his problem and he voiced understanding. We discussed the possibility of hip arthrodesis versus hip replacement versus hip resurfacing and the high likelihood that any one of these procedures may require further operations throughout his life secondary to his young age and high activity level. We discussed a referral to a hip specialist, who performs resurfacing procedures specifically Dr. XYZ in Houston. Referral will be arranged for him. All questions were answered to his satisfaction. He was also given a prescription of Norco 10/325, #60 and Flexeril until he is able to arrange an appointment with a hip specialist." "3",3,"Discharge Summary","CC: Dysarthria HX: This 52y/o RHF was transferred from a local hospital to UIHC on 10/28/94 with a history of progressive worsening of vision, dysarthria, headache, and incoordination beginning since 2/94. Her husband recalled her first difficulties became noticeable after a motor vehicle accident in 2/94. She was a belted passenger in a car struck at a stop. There was no reported head or neck injury or alteration of consciousness. She was treated and released from a local ER the same day. Her husband noted the development of mild dysarthria, incoordination, headache and exacerbation of preexisting lower back pain within 2 week of the accident. In 4/94 she developed stress urinary incontinence which spontaneously resolved in June. In 8/94, her HA changed from a dull constant aching in the bitemporal region to a sharper constant pain in the nuchal/occipital area. She also began experiencing increased blurred vision, worsening dysarthria, peripheral neuropathy, and difficulty hand writing. In 9/94 she was evaluated by a local physician. Examination then revealed incoordination, generalized fatigue, and dysarthria. Soon after this she became poorly arousable and increasingly somnolent. She had difficulty walking and generalized weakness. On 10/14/94, she lost the ability to walk by herself. Evaluation at a local hospital revealed: 1)Normal electronystagmography, 2)two lumbar punctures which revealed some atypical mononuclear cells suggestive of ""tumor or reactive lymphocytosis."" One of these CSF analysis showed: Glucose 16, Protein 99, WBC 14, RBC 114. Echocardiogram was normal. Bone marrow biopsy was normal except for decreased iron. Abdominal-Pelvic CT scan, CXR, Mammogram, PPD, ANA, TFT, and RPR were unremarkable. A 10/31/94 MRI brain scan a 5x10mm area of increased signal on T2 weighted images in the right remporal lobe lateral to the anterior aspect of the temporal horn, right posterolateral aspect of the midbrain, pons, and bilateral inferior surface of the cerebellum involving gray and white matter. These areas did not enhance with gadolinium contrast on T1 weighted images. MEDS: none. PMH: 1)G3P3, 2)last menses one year ago. FHX: Mother suffered stroke in her 70's. DM and Htn in family. SHX: Married, Secretary, No h/o tobacco/ETOH/illicit drug use. ROS: no weight loss, fever, chills, nightsweats, cough, dysphagia. EXAM: BP139/74, HR 90, RR20, 36.8 CMS: Drowsy to somnolent, occasionally ""giddy."" Oriented to person, place, time. Minimal dysarthric speech, but appropriate. MMSE 27/30 (copy of exam not in chart). CN: Pupils 4/4 decreasing to 2/2 on exposure to light. Optic disks were flat and without sign of papilledema. VFFTC. EOM intact. No nystagmus. The rest of the CN exam was unremarkable.Motor: 5/5 strength throughout. Normal muscle tone and bulk.Sensory: No deficit to LT/PP/VIB/PROP.Coord: difficulty with RAM in BUE, and ataxia on FNF and HKS in all extremities.Station: Romberg sign present.Gait: unsteady, wide-based, with notable difficulty on TW, TT and HW.Reflexes: 2/2 BUE, 0/1 patellae, trace at both archilles, Plantars responses were flexor, bilaterally.Gen Exam: unremarkable. COURSE: CSF analysis by lumbar puncture, 10/31/94: Protein 131mg/dl (normal 15-45), Albumin 68 (normal 14-20), IgG10mg/dl (normal <6.2), IgG index -O.1mg/24hr (normal),No oligoclonal bands seen, WBC 33 (19lymphocytes, 1 neutrophil), RBC 29, Glucose 13, Cultures (bacteria, fungal, AFB) were negative, crytococcal Ag negative. The elevated CSF total protein, IgG, and albumin suggested breakdown of the blood brain barrier or blockage of CSF flow. The normal IgG synthesis rate and lack of oligoclonal banding did not suggest demylination. A second CSF analysis on 11/2/94 revealed similar findings; and in addition Anti-purkinje cell and Anti-neuronal antibodies (Yo and Ho) were not found; Beta-2 microglobulin was 1.8 (normal); histoplasmosis Ag negative. Serum ACE, SPEP, Urine histoplasmin were negative.Neuropsychologic assessment, 10/28/94, raised a question of a demential syndrome, but given her response style on the MMPI (marked defensiveness, with unwillingness to admit to even very common human faults) prevented such a diagnosis. Severe defects in memory, fine motor skills, and constructional praxis were noted.Chest-Abdominal-Pelvic CT scans were negative. 11/4/94 cerebral angiogram noted variable caliber in the RMCA, LACA and Left AICA distributions. It was intially thought that thismight be suggestive of a vasculopathy and she was treated with a short course of IV steroids. Temporal artery biopsy was unremarkable.She underwent multiple MRI brain scans at UIHC: 11/4/94, 11/9/94, 11/16/94. All scans consistently showed increase in T2 signal in the brainstem, cerebellar peduncles and temporal lobes bilaterally. These areas did not enhance with gadolinium contrast. These findings were felt most suggestive of glioma.She underwent left temporal lobe brain biopsy on 11/10/94: This study was inconclusive and showed evidence of atypical mononuclear cells and lymphocytes in the perivascular and subarachnoid spaces. Despite cytologic atypia the cells were felt to be reactive in nature, since immunohistochemical stains failed to disclose lymphoid clonality or non-leukocytic phenomena. Little sign of vasculopathy or tumor was found. Bacterial, fungal , HSV, CMV and AFB cultures were negative. HSV, and VZV antigen was negative.Her neurological state progressively worsened throughout her hospital stay. By time of discharge, 12/2/94, she was very somnolent and difficult to arouse and required NGT feeding and 24hour supportive care. She was made DNR after family request prior to transfer to a care facility." "4",4,"Operative Note","PRE-OP DIAGNOSIS: Osteoporosis, pathologic fractures T12- L2 with severe kyphosis. POST-OP DIAGNOSIS: Osteoporosis, pathologic fractures T12- L2 with severe kyphosis. PROCEDURE:1. KYPHON Balloon Kyphoplasty at T12 and L1evels Insertion of KYPHON HV-R bone cement under low pressure at T12 and L1 levels.2. Bone biopsy (medically necessary). ANESTHESIA: General COMPLICATIONS: None BLOOD LOSS: Minimal INDICATIONS: Mrs. Smith is a 75-year-old female who has had severe back pain that began approximately three months ago and is debilitating. She has been unresponsive to nonoperative treatment modalities including bed rest and analgesics. She presents with and is on medication therapy for COPD, diabetes and hypertension (other co-morbidities may be present upon admission and should be documented in the operative note).Radiographic imaging including MRI confirms multiple compression fractures of the thoracolumbar spine including T12, L1 and L2. In addition to the fractures, she presents with kyphotic posture. Films on 1/04 demonstrated L1 and L2 osteoporotic fractures. Films on 2/04 demonstrated increased loss of height at L1. Films on 3/04 demonstrated a new compression fracture at T12 and further collapse of L1. The L2 fracture is documented on radiographic studies as being chronic and a year or more old. The T12 fracture has the most significant kyphotic deformity. Based on these findings, we have decided to perform KYPHON Balloon Kyphoplasty on the L1 and T12 fractures. PROCEDURE: The patient was brought to the operating room/radiology suite and general anesthesia/local sedation with endotracheal intubation was performed. The patient was positioned prone on the Jackson table. The back was prepped and draped. The image intensifier (C-arm) was brought into position and the T12 pedicles were identified and marked with a skin marker. In view of the collapse of T12, a transpedicular approach to the vertebral body was appropriate. An 11-gauge needle was advanced through the T12 pedicle to the junction of the pedicle and vertebral body on the right side. Positioning was confirmed on the AP and lateral plane. Following satisfactory placement of the needle, the stylet was removed. A guide pin was inserted through the 11g to a point 3mm from the anterior cortex. AP and lateral images were taken to verify position and trajectory. Alongside of the guide pin a 1-cm paramedian incision was made. The needle was then removed leaving the guide pin in place. The osteointroducer was placed over the guide pin and advanced through the pedicle. Once I was at the junction of the pedicle and the vertebral body, a lateral image was taken to insure that the cannula was positioned approximately 1cm past the vertebral body wall. Through the cannula, a drill was advanced into the vertebral body under fluoroscopic guidance toward the anterior cortex, creating a channel. The anterior cortex was probed with the guide pin to ensure no perforations in the anterior cortex. After completing the entry into the vertebral body, a 15 mm inflatable bone tamp was inserted through the cannula and advanced under fluoroscopic guidance into the vertebral body near the anterior cortex. The radiopaque marker bands on the bone tamp were identified using AP and lateral images. The above sequence of instrument placement was then repeated on the left side of the T12 vertebral body. Once both bone tamps were in position, they were inflated to 0.5 cc and 50 psi. Expansion of the bone tamps was done sequentially in increments of 0.25 to 0.5 cc of contrast, with careful attention being paid to the inflation pressures and balloon position. The inflation was monitored with AP and lateral imaging. The final balloon volume was 3.5 cc on the right side and 3 cc on the left. There was no breach of the lateral wall or anterior cortex of the vertebral body. Direct reduction of the fracture was achieved, end plate movement was noted and approximately 5 mm of height restoration was achieved. Under fluoroscopic imaging, and the use of the bone void fillers, internal fixation was achieved through a low-pressure injection of KYPHON HV-R bone cement. The cavity was filled with a total volume of 3.5 cc on the right side and 3 cc on the left side. Once the bone cement had hardened, the cannulas were then removed.At this time, we proceeded to perform a balloon kyphoplasty at L1 using the same sequence of steps as on T12. An entry needle was placed bilaterally through the pedicle into the vertebral body, a cortical window was created, inflation of the bone tamps directly reduced the fracture, the bone tamps were removed, and internal fixation by bone void filler insertion was achieved. Throughout the procedure, AP and lateral imaging monitored positioning.Post-procedure, all incisions were closed with sutures. The patient was kept in the prone position for approximately 10 minutes post cement injection. She was then turned supine, monitored briefly and returned to the floor. She was moving both her lower extremities at this time.Throughout the procedure, there were no intraoperative complications. Estimated blood loss was minimal." "5",5,"Discharge Summary","CC: Left hemibody numbness. HX: This 44y/o RHF awoke on 7/29/93 with left hemibody numbness without tingling, weakness, ataxia, visual or mental status change. She had no progression of her symptoms until 7/7/93 when she notices her right hand was stiff and clumsy. She coincidentally began listing to the right when walking. She denied any recent colds/flu-like illness or history of multiple sclerosis. She denied symptoms of Lhermitte's or Uhthoff's phenomena. MEDS: none. PMH: 1)Bronchitis twice in past year (last 2 months ago). FHX: Father with HTN and h/o strokes at ages 45 and 80; now 82 years old. Mother has DM and is age 80. SHX: Denies Tobacco/ETOH/illicit drug use. EXAM: BP112/76 HR52 RR16 36.8 CMS: unremarkable. CN: unremarkable.Motor: 5/5 strength throughout except for slowing of right hand fine motor movement. There was mildly increased muscle tone in the RUE and RLE.Sensory: decreased PP below T2 level on left and some dysesthesias below L1 on the left.Coord: positive rebound in RUE.Station/Gait: unremarkable.Reflexes: 3+/3 throughout all four extremities. Plantar responses were flexor, bilaterally.Rectal exam not done.Gen exam reportedly ""normal."" COURSE: GS, CBC, PT, PTT, ESR, Serum SSA/SSB/dsDNA, B12 were all normal. MRI C-spine, 7/145/93, showed an area of decreased T1 and increased T2 signal at the C4-6 levels within the right lateral spinal cord. The lesion appeared intramedullary and eccentric, and peripherally enhanced with gadolinium. Lumbar puncture, 7/16/93, revealed the following CSF analysis results: RBC 0, WBC 1 (lymphocyte), Protein 28mg/dl, Glucose 62mg/dl, CSF Albumin 16 (normal 14-20), Serum Albumin 4520 (normal 3150-4500), CSF IgG 4.1mg/dl (normal 0-6.2), CSF IgG, % total CSF protein 15% (normal 1-14%), CSF IgG index 1.1 (normal 0-0.7), Oligoclonal bands were present. She was discharged home.The patient claimed her symptoms resolved within one month. She did not return for a scheduled follow-up MRI C-spine." "6",6,"Operative Note","PREOPERATIVE DIAGNOSIS: Left renal mass, left renal bleed. POSTOPERATIVE DIAGNOSIS: Left renal mass, left renal bleed. PROCEDURE PERFORMED: Left laparoscopic hand-assisted nephrectomy. ANESTHESIA: General endotracheal. EBL: 100 mL.The patient had a triple-lumen catheter A-line placed. BRIEF HISTORY: The patient is a 54-year-old female with history of diabetic nephropathy, diabetes, hypertension, left BKA, who presented with abdominal pain with left renal bleed. The patient was found to have a complex mass in the upper pole and the lower pole of the kidney. MRI and CAT scan showed questionable renal mass, which could be malignant. Initial plan was to let the patient stabilize for 2 weeks and perform the nephrectomy. At this point, the patient was unable to go home. The patient continually complained of pain. The patient required about 3 to 4 units of blood transfusions prior. The patient initially came in with hemoglobin less than 5. The hemoglobin prior to surgery was 10.Risks of anesthesia, bleeding, infection, pain, MI, DVT, PE, respiratory failure, morbidity and mortality of the procedure due to her low ejection fraction were discussed. Cardiac clearance was obtained. The patient was high risk, family and the patient knew about the risk. The recommendation from the pulmonologist, cardiologist, and medical team was to get the kidney out at this point because the patient and the family stated that they would not do well at home without any intervention. The patient and family understood all the risks and benefits in order to proceed with the surgery. DETAILS OF THE PROCEDURE: The patient was brought to the OR. Anesthesia was applied. The patient had A-line triple-lumen catheter. The patient was placed in left side up, right side down oblique position. All the pressure points were well padded. The right fistula was carefully padded completely around it. Axilla was protected. The fistula was checked throughout the procedure to ensure that it was stable. The arms, ankles, knees, and joints were all padded with foam. The patient was taped to the table using 2-inch wide tape. OG and a Foley catheter were in place. A supraumbilical incision was made about 6 cm in size and incision was carried through the subcutaneous tissue and through the fascia and peritoneum was entered sharply. There were some adhesions where the omentum was into the umbilical hernia, which was completely stuck. The omentum was released out of that just so we could obtain pneumoperitoneum. Pneumoperitoneum was obtained after using GelPort. Two 12-mm ports were placed in the left anterior axillary line, and mid clavicular line. The colon was reflected medially. Kidney was dissected laterally behind and inferiorly. There was large hematoma visualized with significant amount of old blood, which was irrigated out. Dissection was carried superiorly and the spleen was reflected medially. The spleen and colon were all intact at the end of the procedure. They were stable all throughout. Using endovascular GIA stapler, all the medial and lateral dissection was carried through the stapler to ensure that the patient had minimal bleeding due to low cardiac reserve. Hemostasis was obtained. The renal vein and the renal artery were stapled and there was excellent hemostasis.The dissection was carried lateral to the adrenal and medial to the right kidney. The adrenal was preserved. The entire kidney was removed through the hand port. Irrigation was performed. There was excellent hemostasis at the end of the nephrectomy. Fibrin glue and Surgicel were applied just in case the patient had delayed DIC. The colon was placed back and 12-mm ports were closed under direct palpation using 0 Vicryl. The fascia was closed using loop #1 PDS in a running fashion and was tied in the middle. Please note that prior to the fascial closure, the peritoneum was closed using 0 Vicryl in running fashion. The subcuticular tissue was brought together using 4-0 Vicryl. The skin was closed using 4-0 Monocryl. Dermabond was applied. The patient was brought to the recovery in a stable condition." "7",7,"Operative Note","S - An 84-year-old diabetic female, 5'7-1/2"" tall, 148 pounds, history of hypertension and diabetes. She presents today with complaint of a very painful left foot because of the lesions on the bottom of the foot. She also has a left great toenail that is giving her problems as well.O - Plantar to the left first metatarsal head is a very panful hyperkeratotic lesion that measures 1.1 cm in diameter. There is a second lesion plantar to the fifth plantarflex metatarsal head which also measures 1.1 cm in diameter. These lesions have become so painful that the patient is now having difficulty walking wearing shoes or even doing gardening. The first and fifth metatarsal heads are plantarflexed. Vibratory sensation appears to be absent. Dorsal pedal pulses are nonpalpable. Varicose veins are visible to the skin on the patient's feet that are very thin, almost transparent. The medial aspect of the left great toenail has dried blood under the nail. The nail itself is very opaque, loose from the nailbed almost rotten, opaque, discolored, hypertrophic. All of the patient's toenails are elongated and discolored and opaque as well. There is dried blood under the medial aspect of the left great toenail.A - 1. Painful feet. 2. Painful plantar lesions. 3. Painful benign lesions. 4. Plantarflex metatarsal heads. 5. Onychocryptosis. 6. Onychomycosis. 7. Onychogryphosis. 8. Neuropathy.P - Aseptic technique was used and the benign lesions were excised from the area plantar to the first and fifth left plantarflexed metatarsal heads. The medial aspect of the left great toenail was excised where the portion of the nail matrix blood loss was less than 5 cc. Hemostasis was achieved. The wounds were dressed with Neosporin ointment and absorbent dressing. The patient's remaining nine toenails required manual as well as electric debridement. ""How to Care for Your Toe after Ingrown Nail Surgery"" pamphlet was given to the patient with instructions to soak her foot in warm Epsom salts water b.i.d and to use no hydrogen peroxide and to use no Band-Aid on the toe, but to use an absorbent gauze dressing and a small amount of Neosporin ointment. I have also prescribed for the patient accommodative prescription diabetic orthotics and shoes within the combination for the first and fifth left metatarsal heads. She is to follow up at this office in one week for a recheck visit." "8",8,"History and Physical","HISTORY OF PRESENT ILLNESS: The patient is a 41-year-old white male with a history of HIV disease. His last CD4 count was 425, viral load was less than 50 in 08/07. He was recently hospitalized for left gluteal abscess, for which he underwent I&D and he has newly diagnosed diabetes mellitus. He also has a history of hypertension and hypertriglyceridemia. He had been having increased urination and thirst. He was seen in the hospital by the endocrinology staff and treated with insulin while hospitalized and getting treatment for his perirectal abscess. The endocrine team apparently felt that insulin might be best for this patient, but because of financial issues, elected to place him on Glucophage and glyburide. The patient reports that he has been taking the medication. He is in general feeling better. He says that his gluteal abscess is improving and he will be following up with Surgery today. CURRENT MEDICATIONS:1. Gabapentin 600 mg at night.2. Metformin 1000 mg twice a day.3. Glipizide 5 mg a day.4. Flagyl 500 mg four times a day.5. Flexeril 10 mg twice a day.6. Paroxetine 20 mg a day.7. Atripla one at night.8. Clonazepam 1 mg twice a day.9. Blood pressure medicine, name unknown. REVIEW OF SYSTEMS: He otherwise has a negative review of systems. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 36.6, blood pressure 145/90, pulse 123, respirations 20, and weight is 89.9 kg (198 pounds.) HEENT: Unremarkable except for some submandibular lymph nodes. His fundi are benign. NECK: Supple. LUNGS: Clear to auscultation and percussion. CARDIAC: Reveals regular rate and rhythm without murmur, rub or gallop. ABDOMEN: Soft and nontender without organomegaly or mass. EXTREMITIES: Show no cyanosis, clubbing or edema. GU: Examination of the perineum revealed an open left gluteal wound that appears clear with no secretions. IMPRESSION:1. Human immunodeficiency virus disease with stable control on Atripla.2. Resolving left gluteal abscess, completing Flagyl.3. Diabetes mellitus, currently on oral therapy.4. Hypertension.5. Depression.6. Chronic musculoskeletal pain of unclear etiology. PLAN: The patient will continue his current medications. He will have laboratory studies done in 3 to 4 weeks, and we will see him a few weeks thereafter. He has been encouraged to keep his appointment with his psychologist." "9",9,"History and Physical","REASON FOR CONSULTATION: Management of blood pressure. HISTORY OF PRESENT ILLNESS: The patient is a 38-year-old female admitted following a delivery. The patient had a cesarean section. Following this, the patient was treated for her blood pressure. She was sent home and she came back again apparently with uncontrolled blood pressure. She is on multiple medications, unable to control the blood pressure. From cardiac standpoint, the patient denies any symptoms of chest pain, or shortness of breath. She complains of fatigue and tiredness. The child had some congenital anomaly, was transferred to Hospital, where the child has had surgery. The patient is in intensive care unit. CORONARY RISK FACTORS: History of HTN, history of gestational DM, nonsmoker, and cholesterol is normal. No history of established coronary artery disease and family history noncontributory for coronary disease. FAMILY HISTORY: Nonsignificant. SURGICAL HISTORY: No major surgery except for C-section. MEDICATIONS: Presently on Cardizem and metoprolol were discontinued. Started on hydralazine 50 mg t.i.d., and labetalol 200 mg b.i.d., hydrochlorothiazide, and insulin supplementation. ALLERGIES: None. PERSONAL HISTORY: Nonsmoker. Does not consume alcohol. No history of recreational drug use. PMH: HTN, gestational DM, pre-eclampsia, this is her third child with one miscarriage. REVIEW OF SYSTEMS: CONSTITUTIONAL: No history of fever, rigors, or chills. HEENT: No history of cataract, blurry vision, or glaucoma. CARDIOVASCULAR: No congestive heart. No arrhythmia. RESPIRATORY: No history of pneumonia or valley fever. GASTROINTESTINAL: No epigastric discomfort, hematemesis, or melena. UROLOGIC: No frequency or urgency. MUSCULOSKELETAL: No arthritis or muscle weakness. SKIN: Nonsignificant. NEUROLOGICAL: No TIA. No CVA. No seizure disorder. PHYSICAL EXAM: VITAL SIGNS: Pulse of 86, blood pressure 175/86, afebrile, and respiratory rate 16 per minute. HEENT: Atraumatic and normocephalic. NECK: Neck veins are flat. LUNGS: Clear. HEART: S1 and S2 regular. ABDOMEN: Soft and nontender. EXTREMITIES: No edema. Pulses palpable. LABORATORY DATA: EKG shows sinus tachycardia with nonspecific ST-T changes. Labs were noted. BUN and creatinine within normal limits. IMPRESSION:1. Preeclampsia, status post delivery with Cesarean section with uncontrolled blood pressure.2. No prior history of cardiac disease except for borderline gestational diabetes mellitus. RECOMMENDATIONS:1. We will get an echocardiogram for assessment left ventricular function.2. The patient will start on labetalol and hydralazine to see how see fairs.3. Based on response to medication, we will make further adjustments. Discussed with the patient regarding plan of care, fully understands and consents for the same. All the questions answered in detail." "10",10,"Operative Note","PREOPERATIVE DIAGNOSIS: Hematemesis in a patient with longstanding diabetes. POSTOPERATIVE DIAGNOSIS: Mallory-Weiss tear, submucosal hemorrhage consistent with trauma from vomiting and grade 2 esophagitis. PROCEDURE: The procedure, indications explained and he understood and agreed. He was sedated with Versed 3, Demerol 25 and topical Hurricane spray to the oropharynx. A bite block was placed. The Pentax video gastroscope was advanced through the oropharynx into the esophagus under direct vision. Esophagus revealed distal ulcerations. Additionally, the patient had a Mallory-Weiss tear. This was subjected to bicap cautery with good ablation. The stomach was entered, which revealed areas of submucosal hemorrhage consistent with trauma from vomiting. There were no ulcerations or erosions in the stomach. The duodenum was entered, which was unremarkable. The instrument was then removed. The patient tolerated the procedure well with no complications. IMPRESSION: Mallory-Weiss tear, successful BICAP cautery. We will keep the patient on proton pump inhibitors. The patient will remain on antiemetics and be started on a clear liquid diet." "11",11,"History and Physical","CHIEF COMPLAINT: Recurrent bladder tumor. HISTORY OF PRESENT ILLNESS: The patient is a 79-year-old woman, the patient of Dr. X, who on recent followup cystoscopy for transitional cell carcinomas of the bladder neck was found to have a 5-cm area of papillomatosis just above the left ureteric orifice. The patient underwent TUR of several transitional cell carcinomas of the bladder on the bladder neck in 2006. This was followed by bladder instillation of BCG. At this time, the patient denies any voiding symptoms or hematuria. The patient opting for TUR and electrofulguration of the recurrent tumors. ALLERGIES: None known. MEDICATIONS: Atenolol 5 mg daily. OPERATIONS: Status post bilateral knee replacements and status post TUR of bladder tumors. REVIEW OF SYSTEMS: Other than some mild hypertension, the patient is in very, very good health. No history of diabetes, shortness of breath or chest pain. PHYSICAL EXAMINATION: Well-developed and well-nourished woman, alert and oriented. Her lungs are clear. Heart, regular sinus rhythm. Back, no CVA tenderness. Abdomen, soft and nontender. No palpable masses. IMPRESSION: Recurrent bladder tumors. PLAN: The patient to have CBC, chem-6, PT, PTT, EKG, and chest x-ray beforehand." "12",12,"Operative Note","PREOPERATIVE DIAGNOSES1. End-stage renal disease.2. Nephropathy 2/2 Diabetes. POSTOPERATIVE DIAGNOSES1. End-stage renal disease.2. Diabetes.OPERATIVE PROCEDURECreation of right brachiocephalic arteriovenous fistula.INDICATIONS FOR THE PROCEDUREThis patient has end-stage renal disease. Although, the patient is right-handed, preoperative vein mapping demonstrated much better vein in the right arm. Hence, a right brachiocephalic fistula is being planned.OPERATIVE FINDINGSThe right cephalic vein at the elbow is chosen to be suitable. It is slightly sporadic, but of an adequate size. An end-to-side right brachiocephalic arteriovenous fistula was created. At completion, there was a great thrill.OPERATIVE PROCEDURE IN DETAILAfter informed consent was obtained, the patient was taken to the operating room. The patient was placed in the supine position. The patient received a regional nerve block. The patient also received intravenous sedation. The right arm was prepped and draped in the usual sterile fashion.We made a small transverse incision in the right cubital fossa. The cephalic vein was identified and mobilized. The fascia was incised, and the brachial artery was also identified and mobilized. The brachial artery was free off significant disease. A good pulse was noted. The cephalic vein was mobilized proximally and distally. The brachial artery was mobilized proximally and distally. We did not give heparin. The brachial artery was then clamped proximally and distally. The cephalic vein was also clamped proximally and distally. Longitudinal arteriotomy was made in brachial artery, and a longitudinal venotomy was made in the cephalic vein. We then sewn the vein to the artery in a side-to-side fashion using a running 7-0 Prolene suture.Just prior to completion of the anastomosis, it was flushed, and the anastomosis was then completed. A great thrill was noted. We then ligated the cephalic vein beyond the arteriovenous anastomosis and divided it. This surrounded the anastomosis as an end-to-side functionally. A great thrill remained in the fistula. Hemostasis was secured. We then closed the wound using interrupted PDS sutures for the fascia and a running 4-0 Monocryl subcuticular suture for the skin. Sterile dry dressing was applied.The patient tolerated the procedure well. There were no operative complications. The sponge, instrument, and needle counts were correct at the end of the case. I was present and participated in all aspects of the procedure. The patient was then transferred to the recovery room in satisfactory condition. A great thrill was felt in the fistula completion. There was also a palpable radial pulse distally." "13",13,"Operative Note","PREOPERATIVE DIAGNOSES1. End-stage renal disease, hypertension, diabetes, need for chronic arteriovenous access.2. Ischemic cardiomyopathy, ejection fraction 20%.POSTOPERATIVE DIAGNOSES1. End-stage renal disease, hypertension, diabetes, need for chronic arteriovenous access.2. Ischemic cardiomyopathy, ejection fraction 20%.OPERATIONLeft forearm arteriovenous fistula between cephalic vein and radial artery.INDICATION FOR SURGERYThis is a patient referred by Dr. Michael Campbell. He is a 44-year-old African-American, who has end-stage renal disease after a long history of poorly controlled DM and also ischemic cardiomyopathy. This morning, he received coronary angiogram by Dr. A, which was reportedly normal, after which, he was brought to the operating room for an AV fistula. All the advantages, disadvantages, risks, and benefits of the procedure were explained to him for which he had consented.ANESTHESIAMonitored anesthesia care.DESCRIPTION OF PROCEDUREThe patient was identified, brought to the operating room, placed supine, and IV sedation given. This was done under monitored anesthesia care. He was prepped and draped in the usual sterile fashion. He received local infiltration of 0.25% Marcaine with epinephrine in the region of the proposed incision.Incision was about 2.5 cm long between the cephalic vein and the distal part of the forearm and the radial artery. Incision was deepened down through the subcutaneous fascia. The vein was identified, dissected for a good length, and then the artery was identified and dissected. Heparin 5000 units was given. The artery clamped proximally and distally, opened up in the middle. It was found to have Monckeberg's arteriosclerosis of a moderate intensity. The vein was of good caliber and size.The vein was clipped distally, fashioned to size and shape, and arteriotomy created in the distal radial artery and end-to-side anastomosis was performed using 7-0 Prolene and bled prior to tying it down. Thrill was immediately felt and heard.The incision was closed in two layers and sterile dressing applied." "14",14,"History and Physical","CHIEF COMPLAINT: Bladder cancer. HISTORY OF PRESENT ILLNESS: The patient is a 68-year-old Caucasian male with a history of gross hematuria. The patient presented to the emergency room near his hometown on 12/24/2007 for evaluation of this gross hematuria. CT scan was performed, which demonstrated no hydronephrosis or upper tract process; however, there was significant thickening of the left and posterior bladder wall. Urology referral was initiated and the patient was sent to be evaluated by Dr. X. He eventually underwent a bladder biopsy on 01/18/08, which demonstrated high-grade transitional cell carcinoma without any muscularis propria in the specimen. Additionally, the patient underwent workup for a right adrenal lesion, which was noted on the initial CT scan. This workup involved serum cortisol analysis as well as potassium and aldosterone and ACTH level measurement. All of this workup was found to be grossly negative. Secondary to the absence of muscle in the specimen, the patient was taken back to the operating room on 02/27/08 by Dr. X and the tumor was noted to be very large with significant tumor burden as well as possible involvement of the bladder neck. At that time, the referring urologist determined the tumor to be too large and risky for local resection, and the patient was referred to ABCD Urology for management and diagnosis. The patient presents today for evaluation by Dr. Y. PAST MEDICAL HISTORY: Includes condyloma, hypertension, neuopathic pain secondary to diabetes mellitus, hyperlipidemia, undiagnosed COPD, peripheral vascular disease, and claudication. The patient denies coronary artery disease. PAST SURGICAL HISTORY: Includes bladder biopsy on 01/18/08 without muscularis propria in the high-grade TCC specimen and a gun shot wound in 1984 followed by exploratory laparotomy x2. The patient denies any bowel resection or GU injury at that time; however, he is unsure. CURRENT MEDICATIONS:1. Metoprolol 100 mg b.i.d.2. Diltiazem 120 mg daily.3. Hydrocodone 10/500 mg p.r.n.4. Pravastatin 40 mg daily.5. Lisinopril 20 mg daily.6. Hydrochlorothiazide 25 mg daily. FAMILY HISTORY: Negative for any GU cancer, stones or other complaints. The patient states he has one uncle who died of lung cancer. He denies any other family history. SOCIAL HISTORY: The patient smokes approximately 2 packs per day times greater than 40 years. He does drink occasional alcohol approximately 5 to 6 alcoholic drinks per month. He denies any drug use. He is a retired liquor store owner. PHYSICAL EXAMINATION: GENERAL: He is a well-developed, well-nourished Caucasian male, who appears slightly older than stated age. VITAL SIGNS: Temperature is 96.7, blood pressure is 108/57, pulse is 75, and weight of 193.8 pounds. HEAD AND NECK: Normocephalic atraumatic. LUNGS: Demonstrate decreased breath sounds globally with small rhonchi in the inferior right lung, which is clear somewhat with cough. HEART: Regular rate and rhythm. ABDOMEN: Soft and nontender. The liver and spleen are not palpably enlarged. There is a large midline defect covered by skin, of which the fascia has numerous holes poking through. These small hernias are of approximately 2 cm in diameter at the largest and are nontender. GU: There is some tenderness to palpation near the meatus where 20-French Foley catheter is in place. Testes are bilaterally descended and there are no masses or tenderness. There is bilateral mild atrophy. Epididymidis are grossly within normal limits bilaterally. Spermatic cords are grossly within normal limits. There are no palpable inguinal hernias. RECTAL: The prostate is mildly enlarged with a small focal firm area in the midline near the apex. There is however no other focal nodules. The prostate is grossly approximately 35 to 40 g and is globally firm. Rectal sphincter tone is grossly within normal limits and there is stool in the rectal vault. EXTREMITIES: Demonstrate no cyanosis, clubbing or edema. There is dark red urine in the Foley bag collection. LABORATORY EXAM: Review of laboratory from outside facility demonstrates creatinine of 2.38 with BUN of 42. Additionally, laboratory exam demonstrates a grossly normal serum cortisol, ACTH, potassium, aldosterone level during lesion workup. CT scan was reviewed from outside facility, report states there is left kidney atrophy without hydro or stones and there is thickened left bladder wall and posterior margins with a balloon inflated in the prostate at the time of the exam. There is a 3.1 cm right heterogeneous adrenal nodule and there are no upper tract lesions or stones noted. IMPRESSION: Bladder cancer. PLAN: The patient will undergo a completion TURBT on 03/20/08 with bilateral retrograde pyelograms at the time of surgery. Preoperative workup and laboratory as well as paper work were performed in clinic today with Dr. Y. The patient will be scheduled for anesthesia preop. The patient will have urine culture redrawn from his Foley at the time of preoperative evaluation with anesthesia. The patient was counseled extensively approximately 45 minutes on the nature of his disease and basic prognostic indicators and need for additional workup and staging. The patient understands these instructions and also agrees to quit smoking prior to his next visit. This patient was seen in evaluation with Dr. Y who agrees with the impression and plan." "15",15,"History and Physical","CHIEF COMPLAINT: Right-sided weakness. HISTORY OF PRESENT ILLNESS: The patient was doing well until this morning when she was noted to have right-sided arm weakness with speech difficulties. She was subsequently sent to ABC Medical Center for evaluation and treatment. At ABC, the patient was seen by Dr. H including labs and a head CT which is currently pending. The patient has continued to have right-sided arm and hand weakness, and has difficulty expressing herself. She does seem to comprehend words. The daughter states the patient is in the Life Care Center, and she believes this started this morning. The patient denies headache, visual changes, chest pain and shortness of breath. These changes have been constant since onset this morning, have not improved or worsened, and the patient notes no modifying factors. ALLERGIES: NO KNOWN DRUG ALLERGIES. MEDICATIONS: Medications are taken from the paperwork from Life Care Center and include: Lortab 3-4 times a day for pain, Ativan 0.25 mg by mouth every 12 hours p.r.n. pain, Depakote ER 250 mg p.o. q nightly, Actos 15 mg p.o. t.i.d., Lantus 35 units subcu q nightly, Glipizide 10 mg p.o. q day, Lanoxin 0.125 mg p.o. q day, Lasix 40 mg p.o. q day, Lopressor 50 mg p.o. b.i.d., insulin sliding scale, Lunesta 1 mg p.o. q nightly, Sorbitol 15 mg p.o. q day, Zoloft 50 mg p.o. q nightly, Dulcolax as needed for constipation. PAST MEDICAL HISTORY: Significant for moderate to severe aortic stenosis, urinary tract infection, hypertension, chronic kidney disease (although her creatinine is near normal). SOCIAL HISTORY: The patient lives at Life Care Center. She does not smoke, drink or use intravenous drugs. FAMILY HISTORY: Negative for cerebrovascular accident or cardiac disease. REVIEW OF SYSTEMS: As in HPI. Patient and daughter also deny weight loss, fevers, chills, sweats, nausea, vomiting, abdominal pain. She has had some difficulty expressing herself, but seems to comprehend speech as above. The patient has had a history of chronic urinary tract infections and her drainage is similar to past episodes when she has had such infection. PHYSICAL EXAMINATION: VITAL SIGNS: The patient is currently with a temperature of 99.1, blood pressure 138/59, pulse 69, respirations 15. She is 95% on room air. GENERAL: This is a pleasant elderly female who appears stated age, in mild distress. HEENT: Oropharynx is dry. NECK: Supple with no jugular venous distention or thyromegaly. RESPIRATORY: Clear to auscultation. No wheezes, rubs or crackles. CARDIOVASCULAR: A 4/6 systolic ejection murmur best heard at the 2nd right intercostal space with radiation to the carotids. ABDOMEN: Soft. Normal bowel sounds. EXTREMITIES: No clubbing, cyanosis or edema. She does have bilateral above knee amputations. NEUROLOGIC: Strength 2/5 in her right hand, 4/5 in her left hand. She does have mild right facial droop and an expressive aphasia. VASCULAR: The patient has good capillary refill in her fingertips. LABORATORY DATA: BUN 52, creatinine 1.3. Normal coags. Glucose 220. White blood cell count 10,800. Urinalysis has 608 white cells, 625 RBCs. Head CT is currently pending. EKG shows normal sinus rhythm with mild ST-depression and biphasic T-waves diffusely. ASSESSMENT AND PLAN:1. Right-sided weakness with an expressive aphasia, at this time concerning for a left-sided middle cerebral artery cerebrovascular accident/transient ischemic attach given the patient's serious vascular disease. At this point we will hydrate, treat her urinary tract infection, check an MRI, ultrasound of her carotids, and echocardiogram to reevaluate valvular and left ventricular function. Start antiplatelet therapy and ask Neuro to see the patient.2. Urinary tract infection. Will treat with ceftriaxone, check urine culture data and adjust as needed.3. Dehydration. Will hydrate with IV fluids and follow p.o. intake while holding diuretics.4. Diabetes mellitus type 2 uncontrolled. Her sugar is 249. We will continue Lantus insulin and sliding scale coverage, and check hemoglobin A1c to gauge prior control.5. Prophylaxis. Will institute low molecular weight heparin and follow activity levels." "16",16,"History and Physical","CHIEF COMPLAINT: Buttock abscess. HISTORY OF PRESENT ILLNESS: This patient is a 24-year-old African-American female who presented to the hospital with buttock pain. She started off with a little pimple on the buttock. She was soaking it at home without any improvement. She came to the hospital on the first. The patient underwent incision and drainage in the emergency department. She was admitted to the hospitalist service with elevated blood sugars. She has had positive blood cultures. Surgery is consulted today for evaluation. PAST MEDICAL HISTORY: Diabetes type II, poorly controlled, high cholesterol. PAST SURGICAL HISTORY: C-section and D&C. ALLERGIES: NO KNOWN DRUG ALLERGIES. MEDICATIONS: Insulin, metformin, Glucotrol, and Lipitor. FAMILY HISTORY: Diabetes, hypertension, stroke, Parkinson disease, and heart disease. REVIEW OF SYSTEMS: Significant for pain in the buttock. Otherwise negative. PHYSICAL EXAMINATION: GENERAL: This is an overweight African-American female not in any distress. VITAL SIGNS: She has been afebrile since admission. Vital signs have been stable. Blood sugars have been in the 200 range. HEENT: Normal to inspection. NECK: No bruits or adenopathy. LUNGS: Clear to auscultation. CV: Regular rate and rhythm. ABDOMEN: Protuberant, soft, and nontender. EXTREMITIES: No clubbing, cyanosis or edema. RECTAL EXAM: The patient has a drained abscess on the buttock cheek. There is some serosanguineous drainage. There is no longer any purulent drainage. The wound appears relatively clean. I do not see a lot of erythema. ASSESSMENT AND PLAN: Left buttock abscess, status post incision and drainage. I do not believe surgical intervention is warranted. I have recommended some local wound care. Please see orders for details." "17",17,"History and Physical","CHIEF COMPLAINT: Chronic otitis media, adenoid hypertrophy. HISTORY OF PRESENT ILLNESS: The patient is a 2-1/2-year-old, with a history of persistent bouts of otitis media, superimposed upon persistent middle ear effusions. He also has a history of chronic mouth breathing and heroic snoring with examination revealing adenoid hypertrophy. He is being admitted to the operating room at this time for adenoidectomy and bilateral myringotomy and insertion of PE tubes. ALLERGIES: None. MEDICATIONS: Antibiotics p.r.n. FAMILY HISTORY: Diabetes, heart disease, hearing loss, allergy and cancer. MEDICAL HISTORY: Unremarkable. SURGICAL HISTORY: None. SOCIAL HISTORY: Some minor second-hand tobacco exposure. There are no pets in the home. PHYSICAL EXAMINATION: Ears are well retracted, immobile. Tympanic membranes with effusions present bilaterally. No severe congestions, thick mucoid secretions, no airflow. Oral cavity: Oropharynx 2 to 3+ tonsils. No exudates. Floor of mouth and tongue are normal. Larynx and pharynx not examined. Neck: No nodes, masses or thyromegaly. Lungs: Reveal rare rhonchi, otherwise, clear. Cardiac exam: Regular rate and rhythm. No murmurs. Abdomen: Soft, nontender. Positive bowel sounds. Neurologic exam: Nonfocal. IMPRESSION: Chronic eustachian tube dysfunction, chronic otitis media with effusion, recurrent acute otitis media, adenoid hypertrophy. PLAN: The patient will be admitted to the operating room for adenoidectomy and bilateral myringotomy and insertion of PE tubes." "18",18,"Operative Note","PREOPERATIVE DIAGNOSES:1. Left diabetic foot abscess and infection.2. Left calcaneus fracture with infection.3. Right first ray amputation. POSTOP DIAGNOSES:1. Left diabetic foot abscess and infection.2. Left calcaneus fracture with infection.3. Right first ray amputation. OPERATION AND PROCEDURE:1. Left below-the-knee amputation.2. Dressing change, right foot. ANESTHESIA: General. BLOOD LOSS: Less than 100 mL. TOURNIQUET TIME: 24 minutes on the left, 300 mmHg. COMPLICATIONS: None. DRAINS: A one-eighth-inch Hemovac. INDICATIONS FOR SURGERY: The patient is a 62 years of age with diabetic nerve pain. He developed left heel abscess. He had previous debridements, developed a calcaneal fracture and has now had several debridement with placement of the antibiotic beads. After re-inspecting the wound last week, the plan was for possible debridement and he desired below-the-knee amputation. We are going to change the dressing on the right side also. The risks, benefits, and alternatives of surgery were discussed. The risks of bleeding, infection, damage to nerves and blood vessels, persistent wound healing problems, and the need for future surgery. He understood all the risks and desired operative treatment. OPERATIVE PROCEDURE IN DETAIL: After appropriate informed consent obtained, the patient was taken to the operating room and placed in the supine position. General anesthesia induced. Once adequate anesthesia had been achieved, cast padding placed on the left proximal thigh and tourniquet was applied. The right leg was redressed. I took the dressing down. There was a small bit of central drainage, but it was healing nicely. Adaptic and new sterile dressings were applied.The left lower extremity was then prepped and draped in usual sterile fashion.A transverse incision made about the mid shaft of the tibia. A long posterior flap was created. It was taken to the subcutaneous tissues with electrocautery. Please note that tourniquet had been inflated after exsanguination of the limb. Superficial peroneal nerve identified, clamped, and cut. Anterior compartment was divided. The anterior neurovascular bundle identified, clamped, and cut. The plane was taken between the deep and superficial compartments. The superficial compartment was reflected posteriorly. Tibial nerve identified, clamped, and cut. Tibial vessels identified, clamped, and cut.Periosteum of the tibia elevated proximally along with the fibula. The tibia was then cut with Gigli saw. It was beveled anteriorly and smoothed down with a rasp. The fibula was cut about a cm and a half proximal to this using a large bone cutter. The remaining posterior compartment was divided. The peroneal bundle identified, clamped, and cut. The leg was then passed off of the field. Each vascular bundle was then doubly ligated with 0 silk stick tie and 0 silk free tie. The nerves were each pulled at length, injected with 0.25% Marcaine with epinephrine, cut, and later retracted proximally. The tourniquet was released. Good bleeding from the tissues and hemostasis obtained with electrocautery. Copious irrigation performed using antibiotic-impregnated solution. A one-eighth-inch Hemovac drain placed in the depth of wound adhering on the medial side. A gastroc soleus fascia brought up and attached to the anterior fascia and periosteum with #1 Vicryl in an interrupted fashion. The remaining fascia was closed with #1 Vicryl. Subcutaneous tissues were then closed with 2-0 PDS suture using 2-0 Monocryl suture in interrupted fashion. Skin closed with skin staples. Xeroform gauze, 4 x 4, and a padded soft dressing applied. He was placed in a well-padded anterior and posterior slab splint with the knee in extension. He was then awakened, extubated, and taken to recovery in stable condition. There were no immediate operative complications, and he tolerated the procedure well." "19",19,"History and Physical","HISTORY OF PRESENT ILLNESS: The patient comes in today because of feeling lightheaded and difficulty keeping his balance. He denies this as a spinning sensation that he had had in the past with vertigo. He just describes as feeling very lightheaded. It usually occurs with position changes such as when he stands up from the sitting position or stands up from a lying position. It tends to ease when he sits down again, but does not totally resolve for another 15 to 30 minutes and he feels shaky and weak all over. Lorazepam did not help this sensation. His blood pressure has been up lately and his dose of metoprolol was increased. They feel these symptoms have gotten worse since metoprolol was increased. PAST MEDICAL HISTORY: Detailed on our H&P form. Positive for elevated cholesterol, diabetes, glaucoma, cataracts, hypertension, heart disease, vertigo, stroke in May of 2005, congestive heart failure, CABG, and cataract removed right eye. CURRENT MEDICATIONS: Detailed on the H&P form. PHYSICAL EXAMINATION: His blood pressure sitting down was 180/80 with a pulse rate of 56. Standing up blood pressure was 160/80 with a pulse rate of 56. His general exam and neurological exam were detailed on our H&P form. Pertinent positives on his neurological exam were decreased sensation in his left face, and left arm and leg. IMPRESSION AND PLAN: This lightheaded, he exquisitely denies vertigo, the vertigo that he has had in the past. He states this is more of a lightheaded type feeling. He did have a mild blood pressure drop here in the office. We are also concerned that bradycardia might be contributing to his feeling of lightheadedness. We are going to suggest that he gets a Holter monitor and he should speak to his general practitioner as well as his cardiologist regarding the lightheaded feeling.We will schedule him for the Holter monitor and refer him back to his cardiologist." "20",20,"History and Physical","REASON FOR ADMISSION: A 54-year-old patient, here for evaluation of new-onset swelling of the tongue. PAST MEDICAL HISTORY:1. Diabetes type II.2. High blood pressure.3. High cholesterol.4. Acid reflux disease.5. Chronic back pain. PAST SURGICAL HISTORY:1. Lap-Band done today.2. Right foot surgery. MEDICATIONS:1. Percocet on a p.r.n. basis.2. Keflex 500 mg p.o. t.i.d.3. Clonidine 0.2 mg p.o. b.i.d.4. Prempro, dose is unknown.5. Diclofenac 75 mg p.o. daily.6. Enalapril 10 mg p.o. b.i.d.7. Amaryl 2 mg p.o. daily.8. Hydrochlorothiazide 25 mg p.o. daily.9. Glucophage 100 mg p.o. b.i.d.10. Nifedipine extended release 60 mg p.o. b.i.d.11. Omeprazole 20 mg p.o. daily.12. Zocor 20 mg p.o. at bedtime. ALLERGIES: No known allergies. HISTORY OF PRESENT COMPLAINT: This 54-year-old patient had had Lap-Band at Tempe St Luke this morning. She woke up at home this evening with massive swelling of the left side of the tongue. The patient therefore came to the emergency room for evaluation. The patient was almost intubated on clinical grounds. Anesthesia was called to see the patient and they decided to give a trial of conservative management of Decadron and racemic epinephrine. REVIEW OF SYSTEMS: GENERAL: The patient denies any itching of the skin or urticaria. She has not noticed any new rashes. She denies fever, chill, or malaise. HEENT: The patient denies vision difficulty. RESPIRATORY: No cough or wheezing. CARDIOVASCULAR: No palpitations or syncopal episodes. GASTROINTESTINAL: The patient denies swallowing difficulty.Rest of the review of systems not remarkable. SOCIAL HISTORY: The patient does not smoke nor drink alcohol. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: GENERAL: Obese 54-year-old lady, not in acute distress at this time. VITAL SIGNS: On arrival in the emergency room, blood pressure was 194/122, pulse was 94, respiratory rate of 20, and temperature was 96.6. O2 saturation was 95% on room air. HEAD AND NECK: Face is symmetrical. Tongue is still swollen, especially on the left side. The floor of the mouth is also indurated. There is no cervical lymphadenopathy. There is no stridor. CHEST: Clear to auscultation. No wheezing. No crepitations. CARDIOVASCULAR: First and second heart sounds were heard. No murmurs appreciated. ABDOMEN: Benign. EXTREMITIES: There is no swelling. NEUROLOGIC: The patient is alert and oriented x3. Examination is nonfocal. ASSESSMENT AND PLAN:1. Angioedema with tongue swelling. Airways are currently not compromised. We will admit the patient to the intensive care unit for close monitoring. We will continue Decadron IV boluses.2. Hypertension, uncontrolled. We will discontinue lisinopril in view of angioedema. We will continue clonidine and nifedipine.3. Diabetes type II. We will put the patient on insulin sliding scale. Monitor blood glucose closely while she was on Decadron.4. GI prophylaxis with Prilosec.5. DVT prophylaxis. We will encourage ambulation.6. High cholesterol. Continue statins. We will avoid NSAIDs. Diclofenac will be discontinued. DISPOSITION: The patient is admitted to the intensive care unit. We would monitor." "21",21,"Discharge Summary","DIAGNOSIS: Refractory anemia that is transfusion dependent. CHIEF COMPLAINT: I needed a blood transfusion. HISTORY: The patient is a 78-year-old gentleman with no substantial past medical history except for diabetes. He denies any comorbid complications of the diabetes including kidney disease, heart disease, stroke, vision loss, or neuropathy. At this time, he has been admitted for anemia with hemoglobin of 7.1 and requiring transfusion. He reports that he has no signs or symptom of bleeding and had a blood transfusion approximately two months ago and actually several weeks before that blood transfusion, he had a transfusion for anemia. He has been placed on B12, oral iron, and Procrit. At this time, we are asked to evaluate him for further causes and treatment for his anemia. He denies any constitutional complaints except for fatigue, malaise, and some dyspnea. He has no adenopathy that he reports. No fevers, night sweats, bone pain, rash, arthralgias, or myalgias. PAST MEDICAL HISTORY: Diabetes. PAST SURGICAL HISTORY: Hernia repair. ALLERGIES: He has no allergies. MEDICATIONS: Listed in the chart and include Coumadin, Lasix, metformin, folic acid, diltiazem, B12, Prevacid, and Feosol. SOCIAL HISTORY: He is a tobacco user. He does not drink. He lives alone, but has family and social support to look on him. FAMILY HISTORY: Negative for blood or cancer disorders according to the patient. PHYSICAL EXAMINATION: GENERAL: He is an elderly gentleman in no acute distress. He is sitting up in bed eating his breakfast. He is alert and oriented and answering questions appropriately. VITAL SIGNS: Blood pressure of 110/60, pulse of 99, respiratory rate of 14, and temperature of 97.4. He is 69 inches tall and weighs 174 pounds. HEENT: Sclerae show mild arcus senilis in the right. Left is clear. Pupils are equally round and reactive to light. Extraocular movements are intact. Oropharynx is clear. No retinopathy. NECK: Supple. Trachea is midline. No jugular venous pressure distention is noted. No adenopathy in the cervical, supraclavicular, or axillary areas. CHEST: Clear. HEART: Regular rate and rhythm. ABDOMEN: Soft and nontender. There may be some fullness in the left upper quadrant, although I do not appreciate a true spleen with inspiration. EXTREMITIES: No clubbing, but there is some edema, but no cyanosis. NEUROLOGIC: Noncontributory. DERMATOLOGIC: Noncontributory. CARDIOVASCULAR: Noncontributory. IMPRESSION: At this time is refractory anemia, which is transfusion dependent. He is on B12, iron, folic acid, and Procrit. There are no sign or symptom of blood loss and a recent esophagogastroduodenoscopy, which was negative. His creatinine was 1. My impression at this time is that he probably has an underlying myelodysplastic syndrome or bone marrow failure. His creatinine on this hospitalization was up slightly to 1.6 and this may contribute to his anemia. RECOMMENDATIONS: At this time, my recommendation for the patient is that he undergoes further serologic evaluation with reticulocyte count, serum protein, and electrophoresis, LDH, B12, folate, erythropoietin level, and he should undergo a bone marrow aspiration and biopsy. I have discussed the procedure in detail which the patient. I have discussed the risks, benefits, and successes of that treatment and usefulness of the bone marrow and predicting his cause of refractory anemia and further therapeutic interventions, which might be beneficial to him. He is willing to proceed with the studies I have described to him. We will order an ultrasound of his abdomen because of the possible fullness of the spleen, and I will probably see him in follow up after this hospitalization.As always, we greatly appreciate being able to participate in the care of your patient. We appreciate the consultation of the patient." "22",22,"History and Physical","REASON FOR THE CONSULT: Sepsis, possible SBP. HISTORY OF PRESENT ILLNESS: This is a 53-year-old Hispanic man with diabetes, morbid obesity, hepatitis C, cirrhosis, history of alcohol and cocaine abuse, who presented in the emergency room on 01/07/09 for ground-level fall secondary to weak knees. He complained of bilateral knee pain, but also had other symptoms including hematuria and epigastric pain for at least a month. He ran out of prescription medications 1 month ago. In the ER he was initially afebrile, but then spiked up to 101.3 with heart rate of 130, respiratory rate of 24. White blood cell count was slightly low at 4 and platelet count was only 22,000. Abdominal ultrasound showed mild-to-moderate ascites. He was given 1 dose of Zosyn and then started on levofloxacin and Flagyl last night. Dr. X was called early this morning due to hypotension, SBP in the 70s. He then changed antibiotic regiment to vancomycin and doripenem. PAST MEDICAL HISTORY: Hepatitis C, cirrhosis, coronary artery disease, hyperlipidemia, chronic venous stasis, gastroesophageal reflux disease, history of exploratory laparotomy for stab wounds, chronic recurrent leg wounds, and hepatic encephalopathy. SOCIAL HISTORY: The patient is a former smoker, reportedly quit in 2007. He used cocaine in the past, reportedly quit in 2005. He also has a history of alcohol abuse, but apparently quit more than 10 years ago. ALLERGIES: None known. CURRENT MEDICATIONS: Vancomycin, doripenem, thiamine, Protonix, potassium chloride p.r.n., magnesium p.r.n., Zofran. p.r.n., norepinephrine drip, and vitamin K. REVIEW OF SYSTEMS: Not obtainable as the patient is drowsy and confused. PHYSICAL EXAMINATION:CONSTITUTIONAL/ VITAL SIGNS: Heart rate 101, respiratory rate 17, blood pressure 92/48, temperature 97.5, and oxygen saturation 98% on 2 L nasal cannula. GENERAL APPEARANCE: The patient is drowsy. Morbidly obese. Height 5 feet 8 inches, body weight 182 kilos. EYES: Slightly pale conjunctivae, icteric sclerae. Pupils equal, brisk reaction to light.EARS, NOSE, MOUTH AND THROAT: Intact gross hearing. Moist oral mucosa. No oral lesions. NECK: No palpable neck masses. Thyroid is not enlarged on inspection. RESPIRATORY: Regular inspiratory effort. No crackles or wheezes. CARDIOVASCULAR: Regular cardiac rhythm. No rales or rubs. Positive bipedal edema, 2+, right worse than left. GASTROINTESTINAL: Globular abdomen. Soft. No guarding, no rigidity. Tender on palpation of n right upper quadrant and epigastric area. Mildly tender on palpation of right upper quadrant and epigastric area. LYMPHATIC: No cervical lymphadenopathy. SKIN: Positive diffuse jaundice. No palpable subcutaneous nodules. PSYCHIATRIC: Poor judgment and insight. LABORATORY DATA: White blood cell count from 01/08/09 is 9 with 68% neutrophils, 20% bands, H&H 9.7/28.2, platelet count 24,000. INR 3.84, PTT more than 240. BUN and creatinine 26.8/1.2. AST 76, ALT 27, alkaline phosphatase 48, total bilirubin 17.85. Total CK 1198.6, LDH 873.2. Troponin 0.09, myoglobin 2792. Urinalysis from 01/07/09 shows small leucocyte esterase, positive nitrites, 1 to 3 wbc's, 0 to 1 rbc's, 2+ bacteria. Two sets of blood cultures from 01/07/09 still pending. RADIOLOGY: Chest x-ray from 01/07/09 did not show any pathologic abnormalities of the heart, mediastinum, lung fields, bony or soft tissue structures. Left knee x-rays on 01/07/09 showed advanced osteoarthritis. Abdominal ultrasound on 01/07/09 showed mild-to-moderate ascites, mild prominence of the gallbladder with thickened ball and pericholecystic fluid. Preliminary report of CAT scan of the abdomen showed changes consistent to liver cirrhosis and portal hypertension with mild ascites, splenomegaly, and dilated portal/splenic and superior mesenteric vein. Appendix was not clearly seen, but there was no evidence of pericecal inflammation. IMPRESSION:1. Septic shock.2. Possible urinary tract infection.3. Ascites, rule out spontaneous bacterial peritenonitis.4. Hyperbilirubinemia, consider cholangitis.5. Alcoholic liver disease.6. Thrombocytopenia.7. Hepatitis C.8. Cryoglobulinemia. RECOMMENDATIONS:1. Continue with vancomycin and doripenem at this point.2. Agree with paracentesis.3. Send ascitic fluid for cell count, differential and cultures.4. Follow up with result of blood cultures.5. We will get urine culture from the specimen on admission.6. The patient needs hepatitis A vaccination.Additional ID recommendations as appropriate upon followup." "23",23,"Operative Note","S: The patient presents for evaluation at the request of his primary physician for treatment for nails. He has last seen the primary physician in December 2006. PRIMARY MEDICAL HISTORY: Femoral embolectomy, GI bleed, hypertension, PVD, hypothyroid, GERD, osteoarthritis, diabetes, CAD, renal artery stenosis, COPD, and atrial fibrillation. MEDICATIONS: Refer to chart. O: The patient presents in wheelchair, verbal and alert. Vascular: He has absent pedal pulses bilaterally. Trophic changes include absent hair growth and dystrophic nails. Skin texture is dry and shiny. Skin color is rubor. Classic findings include temperature change and edema +2. Nails: Thickened and hypertrophic, #1, #2, #3, #4, and #5 right and #1, #2, #3, #4, and #5 left. A:1. Dystrophic nails.2. Peripheral vascular disease as per classic findings.3. Pain on palpation.4. Diabetes. P: Nails #1, #2, #3, #4, and #5 right and #1, #2, #3, #4, and #5 left were debrided. The patient will be seen at the request of the nursing staff for therapeutic treatment of dystrophic nails." "24",24,"Operative Note","PREOPERATIVE DIAGNOSIS: Gangrene osteomyelitis, right second toe. POSTOPERATIVE DIAGNOSIS: Gangrene osteomyelitis, right second toe. OPERATIVE REPORT: The patient is a 58-year-old female with poorly controlled diabetes with severe lower extremity lymphedema. The patient has history of previous right foot infection that went unreported for three months due to neuropathy complications. This infection required first ray resection. The patient has ulcerations of right second toe dorsally at the proximal interphalangeal joint, which has failed to respond to conservative treatment. The patient now has exposed bone and osteomyelitis in the second toe. The patient has been on IV antibiotics as an outpatient and has failed to respond to these and presents today for surgical intervention.After an IV was started by the Department of Anesthesia, the patient was taken back to the operating room and placed on the operative table in the supine position. A restraint belt was placed around the patient's waist using copious amounts of Webril and an ankle pneumatic tourniquet was placed around the patient's right ankle and the patient was made comfortable by the Department of Anesthesia. After adequate amounts of sedation had been given to the patient, we administered a block of 10 cc of 0.5% Marcaine plain in proximal digital block around the second digit. The foot and ankle were then prepped in the normal sterile orthopedic manner. The foot was elevated and an Esmarch bandage applied to exsanguinate the foot. The tourniquet was then inflated to 250 mmHg and the foot was brought back onto the table. Using Band-Aid scissors, the stockinet was cut and reflected and using a wet and dry sponge, the foot was wiped, cleaned, and the second toe identified.Using a skin scrape, a racket type incision was planned around the second toe to allow also remodelling of previous operative site. Using a fresh #10 blade, skin incision was made circumferentially in the racket-shaped manner around the second digit. Then, using a fresh #15 blade, the incision was deepened and was taken down to the level of the second metatarsophalangeal joint. Care was taken to identify bleeders and cautery was used as necessary for hemostasis. After cleaning up all the soft tissue attachments, the second digit was disarticulated down to the level of the metatarsophalangeal joint. The head of the second metatarsal was inspected and was noted to have good glistening white cartilage with no areas of erosion evident by visual examination. Attention was then directed to closure of the wound. All remaining tissue was noted to be healthy and granular in appearance with no necrotic tissue evident. Areas of subcutaneous tissue were then removed through a sharp dissection in order to allow better approximation of the skin edges. Due to long-standing lower extremity lymphedema and postoperative changes on previous surgery, I thought that we were unable to close the incision in entirety. Therefore, after copious amounts of irrigation using sterile saline, it was determined to use modified dental rolls using #4-0 gauze to remove tension from the skin. Deep vertical mattress sutures were used in order to reapproximate more closely, the skin edges and bring the plantar flap of skin up to the dorsal skin. This was obtained using #2-0 nylon suture. Following this, the remaining exposed tissue from the wound was covered using moist to dry saline soaked 4 x 4 gauze. The wound was then dressed using 4 x 4 gauze fluffed with abdominal pads, then using Kling and Kerlix and an ACE bandage to provide compression. The tourniquet was deflated at 42 minutes' time and hemostasis was noted to be achieved. The ACE bandage was extended up to just below the knee and no bleeding striking to the bandages was appreciated. The patient tolerated the procedure well and was escorted to the Postanesthesia Care Unit with vital signs stable and vascular status intact, as was evidenced by capillary bleeding, which was present during the procedure. Sedation was given postoperative introductions, which include to remain nonweightbearing to her right foot. The patient was instructed to keep the foot elevated and to apply ice behind her knee as necessary, no more than 20 minutes each hour. The patient was instructed to continue her regular medications. The patient was to continue IV antibiotic course and was given prescription for Vicoprofen to be taken q.4h. p.r.n. for moderate to severe pain #30. The patient will followup with Podiatry on Monday morning at 8:30 in the Podiatry Clinic for dressing change and evaluation of her foot at that time.The patient was instructed as to signs and symptoms of infection, was instructed to return to the Emergency Department immediately if these should present. The second digit was sent to Pathology for gross and micro." "25",25,"History and Physical","CHIEF COMPLAINT: Arm and leg jerking. HISTORY OF PRESENT ILLNESS: The patient is a 10-day-old Caucasian female here for approximately 1 minute bilateral arm and leg jerks, which started at day of life 1 and have occurred 6 total times since then. Mom denies any apnea, perioral cyanosis, or color changes. These movements are without any back arching. They mainly occur during sleep, so mom is unaware of any eye rolling. Mom is able to wake the patient up during this periods and stop the patient's extremity movements.Otherwise, this patient has been active, breast-feeding well, although she falls asleep at the breast. She is currently taking in 15 to 20 minutes of breast milk every 2 to 3 hours. She is having increased diapers up to 8 wet and 6 to 7 dirty-yellow stools per day. REVIEW OF SYSTEMS: Negative fever, negative fussiness, tracks with her eyes, some sneezing and hiccups. This patient has developed some upper airway congestion in the past day. She has not had any vomiting or diarrhea. Per mom, she does not spit up, and mom is also unable to notice any relationship between these movements and feeds. This patient has not had any rashes. Mom was notified by the nurses at birth that her temperature may be low of approximately 97.5 degrees Fahrenheit. Otherwise, the above history of present illness and other review of systems negative.BIRTH/ PAST MEDICAL HISTORY: The patient was an 8 pound 11 ounce baby, ex-41-weeker born via vaginal delivery without vacuum assist or forceps. There were no complications during pregnancy such as diabetes or hypertension. Prenatal care started at approximately 3 weeks, and mom maintained all visits. She also denies any smoking, alcohol, or drug use during the pregnancy. Mom was GBS status positive, but denies any other infections such as urinary tract infections. She did not have any fever during labor and received inadequate intrapartum antibiotics prophylaxis. After delivery, this patient did not receive antibiotics secondary to ""borderline labs."" She was jaundiced after birth and received photo treatments. Her discharge bilirubin level was approximately 11. Mom and child stayed in the hospital for approximately 3-1/2 days.Mom denies any history of sexually transmitted disease in her or dad. She specifically denies any blistering, herpetic genital lesions. She does have a history though of human papillomavirus warts (vaginal), removed 20 years ago. PAST SURGICAL HISTORY: Negative. ALLERGIES: No known drug allergies. MEDICATIONS: None. SOCIAL HISTORY: At home live mom, dad, and 18-, 16-, 14-, 12-year-old brothers, and a 3-year-old sister. All the residents at home are sick currently with cold, cough, runny nose, except for mom. At home also live 2 dogs and 2 outside cats. Mom denies any recent travel history, especially during the recent holidays and no smoke exposures. FAMILY HISTORY: Dad is with a stepdaughter with seizures starting at 14 years old, on medications currently. The patient's 16-year-old brother has incessant nonsustained ventricular tachycardia. The maternal grandmother is notable for hypertension and diabetes. There are no other children in the family who see a specialist or no child death less than 1 year of age. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature was 97.5, heart rate was 150, blood pressure was 88/53, respiratory rate was 37 on room air. Weight was 4 kg, this placed her at the 75th to 90th percentile; the length was 52 cm, this places her at the 75th to 90th percentile, and head circumference was 36 cm, which places her at the 75th percentile. GENERAL: In no acute distress, alert, nonfussy, active, breast-feeding well. HEENT: Normocephalic, atraumatic head. Negative for any cephalohematomas. The anterior fontanelle was soft, open, and flat. Bilateral red reflexes were positive. The extraocular muscles were intact. The tympanic membranes were clear. Negative rhinorrhea. The oropharynx is clear with intact hard and soft palates. There was an Epstein pearl approximately 1 to 2 o'clock on the upper palate. NECK: Negative for swelling or clavicular crepitus. CARDIOVASCULAR: Heart was regular rate and rhythm without any murmurs. Femoral pulses were positive. Capillary refill was less than 2 seconds. LUNGS: Clear to auscultation bilaterally without any increased work of breathing. There was some upper airway congestion. ABDOMEN: Bowel sounds positive, nontender and nondistended, negative for hepatosplenomegaly. GU: Tanner stage I female. SKIN: There was mild jaundice and positive erythema toxicum to the face and upper torso. NEUROLOGIC: There were positive Moro and suck reflexes with good upper and lower extremity tone and strength. The patient moves all extremities equally and well. LABORATORY DATA: CBC showed a white blood cell count of 7.5 with a differential of 13% segmental cells, 5% bands, 60% lymphocytes, hemoglobin was 20.2, hematocrit was 57.9, and a platelet count was slightly elevated at 437,000. A CRP was less than 0.3. CMP showed a sodium of 136, potassium of 5.3, chloride of 106, bicarbonate of 23, BUN of 5, creatinine of 0.4, glucose of 93, calcium was 11.1. T and direct bilirubin were 8.4 and 0. Liver function tests include an AST of 50, an ALT of 10, and an alkaline phosphatase of 173.A urinalysis was negative only showing 0 to 5 epithelial cells and trace crystals.Current pending studies include CSF studies such as a Gram stain, culture, glucose, protein, cell count, and HSV PCR. Also, pending include a head CT and a blood and urine culture. ASSESSMENT: A 10-day-old neonate with:1. Seizure-like activity.2. Physiologic jaundice of the newborn. DIFFERENTIAL DIAGNOSES: In this patient includes:1. Infantile spasms.2. Benign neonatal sleep myoclonus - this patient's movements occur during sleep and consist of extremity jerking. Also compatible with this diagnosis includes the fact that mom is able to stop these movements.3. Hyperekplexia - this patient though is without any startle movements or stiffness.4. Trauma - possibilities include any type of intracranial hemorrhage, subdural or epidural. This patient though is without any rapidly declining neurologic deficits currently.5. Neonatal hypoxemia - there is no history of hypoxemic events at birth.6. Central nervous system infection or bacteremia - possibilities include bacterial meningitis. The most likely bacteria include group B streptococcus, Escherichia coli, and Listeria. Also to consider include herpes simplex virus encephalitis or urosepsis. This patient though is with a normal urinalysis currently, normal CBC without fever or lethargy in her history and not toxic appearing currently.7. Metabolic causes causing seizures including hypocalcemia and hypoglycemia - this patient is with a normal complete metabolic panel.8. Congenital brain abnormality - so far this patient is with a normal neuro and developmental exam.9. Drug withdrawal or intoxication - this could always be a possibility, but the patient's parents are seemingly good parents with a good social history not raising any flags for abuse. PLAN:1. Currently this patient has pending CSF studies including a culture plus blood and urine culture. Also, pending right now is an HSV PCR. In the meantime, we will start antibiotics including ampicillin, gentamicin, and acyclovir to cover for the most likely bacterial and viral pathogens, especially herpes virus.2. We will obtain a head CT tonight to rule out any trauma or bleeds in brain.3. We will place this patient on continuous cardiorespiratory and pulse oximetry monitoring and document vitals during any seizure-like activity.4. We will obtain an EEG in the morning in addition to a neurology consult.5. We will continue to monitor this patient's jaundice, which has decreased since her discharge from the hospital.6. These initial plans were all discussed with mom at the bedside, including the risks and benefits of a lumbar puncture, which has already been performed." "26",26,"History and Physical","REASON FOR EVALUATION: Evaluation for chronic pain program. COMPENSABLE INJURY: Left knee. CHIEF COMPLAINT: Left knee and low back pain. HISTORY OF PRESENT ILLNESS: Ms. XYZ is an otherwise fairly healthy 44-year-old right-handed aircraft mechanic. On her date of injury, she reports that she was working on an aircraft when she fell between the airplane and a stand with about an 18-inch gap in between. She injured her left knee and underwent two arthroscopic procedures followed by patellar replacement and subsequently a left total knee arthroplasty in Month DD, YYYY.The patient is seen with no outside images, but an MRI report of the left knee and office notes from Dr. ABCD.The patient reports that she has undergone a full course of physical therapy and complains primarily of pain in the anterior aspect of the left knee and primarily over the medial and lateral tibial components with pain extending proximally to the distal femur and distally down into the anterior tibial plateau area. She has intermittent numbness and tingling in the posterolateral thigh and no symptoms at all into her feet. She has axial low back pain as an ancillary symptom. Her pain is worse with walking and is associated with swelling, popping and grinding. She complains of pins and needles sensation over the area of the common peroneal nerve overlying the fibular head. She has no dysesthetic or allodynic symptoms with light touch over the remainder of the knee and the femoral nerve area. Heavy pressure and light percussion of the fibular head produce painful numbness, tingling, and pins and needles sensation.The patient underwent a left knee MRI in September of 2006 revealing nonspecific edema anterior to the patellar tendon, but no evidence of an acute fracture or a femoropatellar ligament avulsion or abnormality. She has continued to complain of persistent instability and pain. She is not working. She has a number of allergies to different pain medications and feels that her back has been bothersome mostly due to her gait disturbances relating to her knee. Her pain is described as constant, shooting, cramping, aching, throbbing, pulling, sharp, and stabbing in nature. It occasionally awakens her at night. It is better in recumbency with her leg elevated. Exacerbating factors include standing, walking, pushing, puling. VAS pain scale is rated as 6/10 for her average and current pain, 10/10 for worst pain, and 3/10 for her least pain. OSWESTRY PAIN INVENTORY: Significant impact on every aspect of her quality of life. The patient is not working and relates no particular functional goals. She does relate that she has put on quite a bit of weight since her injury.Apparently, Dr. ABCD has entertained the possibility of having of revising her tibial tray with a taller one. She has finished physical therapy and continues at home with quadriceps and hamstrings exercises. She has discontinued use of her knee brace. She would like to avoid surgery, if at all possible. PAST MEDICAL HISTORY: Otherwise, negative. PAST SURGICAL HISTORY: Otherwise, negative. MEDICATIONS: No medications. ALLERGIES: Phenergan, morphine, Flexeril, Keflex, Bactrim, general anesthetics, Benadryl, and pain meds. FAMILY HISTORY: Remarkable for cervical cancer, heart disease, COPD, dementia, diabetes, and CHF. SOCIAL HISTORY: The patient is not working. Rates her stress level as an 8/10. She is single with no children. Does not smoke, drink, or utilize illicit substances. REVIEW OF SYSTEMS: A thirteen-point review of systems was surveyed including constitutional, HEENT, cardiac, pulmonary, GI, GU, endocrine, integument, hematological, immunological, neurological, musculoskeletal, psychological and rheumatological. Review of systems is otherwise, negative. See as per HPI. PHYSICAL EXAMINATION: Weight 255 pounds, temp 97.6, pulse 74, BP 140/94. The patient walks with an antalgic gait to the left. She has pain vocalization with standing, walking, and range of motion of the knee. Head is normocephalic and atraumatic. Cranial nerves II through XII are grossly intact. Lungs are clear to auscultation. Heart has regular rate and rhythm with normal S1, S2. No murmurs, rubs, or gallops are appreciated. The abdomen is obese, though nontender, nondistended without palpable organomegaly or pulsatile masses. The skin is warm and dry to the touch with peripheral pulses equally palpable over the radial, dorsalis pedis and posterior tibial areas.Neurological examination of the upper extremities is grossly intact to sensory and motor testing. Lower extremity neurologic exam reveals positive Tinel's features over the lateral aspect of the left fibular head. There is sensitivity over the distal aspect of her midline scar. No dystrophic features are evident. There is edema over the anterior tibial plateau and tenderness over both the medial, as well as lateral aspects of the tibial plateau. There is no discernible erythema over the knee. No discoloration. No trophic changes. She can extend almost to roughly about 10 and can flex to just at around 90 with pain behaviors. The patient is able to perform a straight leg lift and has otherwise normal engagement of all her distal musculature.Palpation of her axial skeleton reveals no bony step-off, skin tags, clefts or deformities. There is mild lumbar facetal features at the lumbosacral junction with extension and lateral bending. I can detect no clear pelvic asymmetry. IMPRESSION AND PLAN: Status post left knee injury with subsequent knee replacement and continued chronic painful left knee, mostly mechanical low back pain without evidence of radicular features. I think she may have a small sensory neuralgia of her left common peroneal nerve and has ongoing pain over her tibial plateau. The patient is not yet a year out from her surgery and understands that it may take several more months for her knee to settle down. There is no MR evidence of marrow edema or ligamentous disruption. She may have patellofemoral and/or tibial plateau related pain as well. She may do extremely well on a chronic pain program and is intolerant to most oral analgesics. She has worked since her date of injury and will need a graduated incremental return to her normal activities of daily living. Therefore, I have referred her for a chronic pain program through the Pain Care Center to be seen in followup upon completion." "27",27,"History and Physical","CHIEF COMPLAINT: Penile discharge, infected-looking glans. HISTORY OF PRESENT ILLNESS: The patient is a 67-year-old African-American male, who was recently discharged from the hospital on July 21, 2008 after being admitted for altered mental status and before that after undergoing right above knee amputation for wet gangrene 2/2 to diabetic neuropathy. The patient was transferred to Nursing Home and presents today from the nursing home with complaints of bleeding from the right AKA stump and penile discharge. As per the patient during his hospitalizations over here, he had indwelling Foley catheter for a few days and when he was discharged at the nursing home he was discharged without the catheter. However, the patient was brought back to the ED today when he suffered fall yesterday and started bleeding from his stump. While placing the catheter in the ED on retraction of foreskin purulent discharge was seen from the penis and the glans appeared infected, so urology consult was placed. REVIEW OF SYSTEMS: Negative except as in the HPI. PAST MEDICAL HISTORY: Significant for end-stage renal disease on dialysis, hypertension, peripheral vascular disease, coronary artery disease, congestive heart failure, diabetes, and hyperlipidemia. PAST SURGICAL HISTORY: Right AKAMEDICATIONS: Novolin, Afrin, Nephro-Vite, Neurontin, lisinopril, furosemide, Tums, labetolol, Plavix, nitroglycerin, Aricept, omeprazole, oxycodone, Norvasc, Renagel, and morphine. ALLERGIES: PENICILLIN and ADHESIVE TAPE. FAMILY HISTORY: Significant for hypertension, hyperlipidemia, diabetes, chronic renal insufficiency, and myocardial infarction. SOCIAL HISTORY: The patient lives alone. He is unemployed, disabled. He has history of tobacco use in the past. He denies alcohol or drug abuse. PHYSICAL EXAMINATION: GENERAL: A well-appearing African-American male lying comfortably in bed, in acute distress. NECK: Supple. LUNGS: Clear to auscultation bilaterally. CARDIOVASCULAR: S1 and S2, normal. ABDOMEN: Soft, nondistended, and nontender. GENITOURINARY: Penis is not circumcised. Currently, indwelling Foley catheter in place. On retraction of the foreskin, pale-looking glans tip with areas of yellow-white tissue. The proximal glans appeared pink. The patient currently has indwelling Foley catheter and glans slightly tender to touch. However, no purulent discharge was seen on compression of the glans. Otherwise on palpation, no other deformity noticed. Bilateral testes descended. No palpable abnormality. No evidence of infection in his perineal area. EXTREMITIES: Right AKA. NEUROLOGIC: Awake, alert, and oriented. No sensory or motor deficit. LABORATORY DATA: I independently reviewed the lab work done on the patient. The patient had a UA done in the ED which showed few bacteria, white blood cells 6 to 12, and a few epithelial cells which were negative. His basic metabolic panel with creatinine of 7.2 and potassium of 5, otherwise normal. CBC with a white blood cell count of 11.5, hemoglobin of 9.5, and INR of 1.13. IMPRESSION: A 67-year-old male with multiple comorbidities with penile discharge and pale-appearing glans. It seems that the patient has had multiple catheterizations recently and has history of peripheral vascular disease. I think it is due to chronic ischemic changes. RECOMMENDATIONS: Our recommendation would be:1. To remove the Foley catheter.2. Local hygiene.3. Local application of bacitracin ointment.4. Antibiotic for urinary tract infection.5. Follow up as needed. Of note, it was explained to the patient that the appearance of this glans may improve or may get worsened but at this point, there is no indication to operate on him. If increased purulent discharge, the patient was asked to call us sooner, otherwise follow up as scheduled." "28",28,"Discharge Summary","CC: Falls. HX: This 51y/o RHF fell four times on 1/3/93, because her ""legs suddenly gave out."" She subsequently noticed weakness involving the right leg, and often required the assistance of her arms to move it. During some of these episodes she appeared mildly pale and felt generally weak; her husband would give her 3 teaspoons of sugar and she would appear to improve, thought not completely. During one episode she held her RUE in an ""odd fisted posture."" She denied any other focal weakness, sensory change, dysarthria, diplopia, dysphagia or alteration of consciousness. She did not seek medical attention despite her weakness. Then, last night, 1/4/93, she fell again ,and because her weakness did not subsequently improve she came to UIHC for evaluation on 1/5/93. MEDS: Micronase 5mg qd, HCTZ, quit ASA 6 months ago (tired of taking it). PMH: 1)DM type 2, dx 6 months ago. 2)HTN. 3)DJD. 4)s/p Vitrectomy and retinal traction OU for retinal detachment 7/92. 5) s/p Cholecystemomy,1968. 6) Cataract implant, OU,1992. 7) s/p C-section. FHX: Grand Aunt (stroke), MG (CAD), Mother (CAD, died MI age 63), Father (with unknown CA), Sisters (HTN), No DM in relatives. SHX: Married, lives with husband, 4 children alive and well. Denied tobacco/ETOH/illicit drug use. ROS: intermittent diarrhea for 20 years. EXAM: BP164/82 HR64 RR18 36.0 CMS: A & O to person, place, time. Speech fluent and without dysarthria. Intact naming, comprehension, reading. CN: Pupils 4.5 (irregular)/4.0 (irregular) and virtually fixed. Optic disks flat. EOM intact. VFFTC. Right lower facial weakness. The rest of the CN exam was unremarkable.Motor: 5/5 BUE with some question of breakaway. LE: HF and HE 4+/5, KF5/5, AF and AE 5/5. Normal muscle bulk and tone.Sensory: intact PP/VIB/PROP/LT/T/graphesthesia.Coord: slowed FNF and HKS (worse on right).Station: no pronator drift or Romberg sign.Gait: Unsteady wide-based gait. Unable to heel walk on right.Reflexes: 2/2+ throughout (Slightly more brisk on right). Plantar responses were downgoing bilaterally. HEENT: N0 Carotid or cranial bruits.Gen Exam: unremarkable. COURSE: CBC, GS (including glucose), PT/PTT, EKG, CXR on admission, 1/5/93, were unremarkable. HCT, 1/5/93, revealed a hypodensity in the left caudate consistent with ischemic change. Carotid Duplex: 0-15%RICA, 16-49%LICA; antegrade vertebral artery flow, bilaterally. Transthoracic echocardiogram showed borderline LV hypertrophy and normal LV function. No valvular abnormalities or thrombus were seen.The patient's history and exam findings of right facial and RLE weakness with sparing of the RUE would invoke a RACA territory stroke with recurrent artery of Heubner involvement causing the facial weakness." "29",29,"History and Physical","REASON FOR CONSULTATION: Syncope. HISTORY OF PRESENT ILLNESS: The patient is a 69-year-old gentleman, a good historian, who relates that he was brought in the Emergency Room following an episode of syncope. The patient relates that he may have had a seizure activity prior to that. Prior to the episode, he denies having any symptoms of chest pain or shortness of breath. No palpitation. Presently, he is comfortable, lying in the bed. As per the patient, no prior cardiac history. CORONARY RISK FACTORS: History of hypertension. No history of diabetes mellitus. Nonsmoker. Cholesterol status is borderline elevated. No history of established coronary artery disease. Family history noncontributory. PAST MEDICAL HISTORY: Hypertension, hyperlipidemia, recently diagnosed with Parkinson's, as a Parkinson's tremor, admitted for syncopal evaluation. PAST SURGICAL HISTORY: Back surgery, shoulder surgery, and appendicectomy. FAMILY HISTORY: Nonsignificant. MEDICATIONS:1. Pain medications.2. Thyroid supplementation.3. Lovastatin 20 mg daily.4. Propranolol 20 b.i.d.5. Protonix.6. Flomax. ALLERGIES: None. PERSONAL HISTORY: He is married. Nonsmoker. Does not consume alcohol. No history of recreational drug use. REVIEW OF SYSTEMSCONSTITUTIONAL: No weakness, fatigue, or tiredness. HEENT: No history of cataract or glaucoma. CARDIOVASCULAR: No congestive heart failure. No arrhythmias. RESPIRATORY: No history of pneumonia or valley fever. GASTROINTESTINAL: No nausea, vomiting, hematemesis, or melena. UROLOGICAL: No frequency or urgency. MUSCULOSKELETAL: Arthritis and muscle weakness. SKIN: Nonsignificant. NEUROLOGIC: No TIA or CVA. No seizure disorder.ENDOCRINE/ HEMATOLOGIC: Nonsignificant. PHYSICAL EXAMINATIONVITAL SIGNS: Pulse of 93, blood pressure of 158/93, afebrile, and respiratory rate 16 per minute. HEENT: Atraumatic and normocephalic. NECK: Neck veins are flat. No significant carotid bruits. LUNGS: Air entry is bilaterally decreased. HEART: PMI is displaced. S1 and S2 are regular. ABDOMEN: Soft and nontender. Bowel sounds are present. EXTREMITIES: No edema. Pulses are palpable. No clubbing or cyanosis. The patient is moving all extremities; however, the patient has tremors. RADIOLOGICAL DATA: EKG reveals normal sinus rhythm with underlying nonspecific ST-T changes secondary to tremors. LABORATORY DATA: H&H stable. White count of 14. BUN and creatinine are within normal limits. Cardiac enzyme profile is negative. Ammonia level is elevated at 69. CT angiogram of the chest, no evidence of pulmonary embolism. Chest x-ray is negative for acute changes. CT of the head, unremarkable, chronic skin changes. Liver enzymes are within normal limits. IMPRESSION:1. The patient is a 69-year-old gentleman, admitted with syncopal episode and possible seizure disorder.2. Elevated ammonia, unclear etiology, possible encephalopathy.3. Cardiac risk factors of hypertension and borderline hyperlipidemia. No prior history of documented coronary artery disease. RECOMMENDATIONS:1. From cardiac standpoint, echocardiogram with LV function.2. Conservative treatment.3. Neurological evaluation." "30",30,"History and Physical","HISTORY OF PRESENT ILLNESS: The patient is a 71-year-old Caucasian female with a history of diabetes, osteoarthritis, atrial fibrillation, hypertension, asthma, obstructive sleep apnea on CPAP, diabetic foot ulcer complicated by neuropathy, anemia and left lower extremity cellulitis. She was brought in by the EMS service to Erlanger emergency department with pulseless electrical activity. Her husband states that he was at home with his wife, when she presented to him complaining of fever and chills. She became acutely unresponsive. She was noted to have worsening of her breathing. She took several of her MDIs and then was placed on her CPAP. He went to notify EMS and when he returned, she was found to not be breathing. He stated that she was noted to have no breathing in excess of 10 minutes. He states that the EMS system arrived at the home and she was found not breathing. The patient was intubated at the scene and upon arrival to Erlanger Medical Center, she was found to have pupils fixed and dilated. She was seen by me in the emergency department and was on Neo-Synephrine, dopamine with a blood pressure of 97/22 with a rapid heart rate and again, in an unresponsive state. REVIEW OF SYSTEMS: Review of systems was not obtainable. PAST MEDICAL HISTORY: Diabetes, osteoarthritis, hypertension, asthma, atrial fibrillation, diabetic foot ulcer and anemia. PAST SURGICAL HISTORY: Noncontributory to above. FAMILY HISTORY: Mother with history of coronary artery disease. SOCIAL HISTORY: The patient is married. She uses no ethanol, no tobacco and no illicits. She has a very support family unit. MEDICATIONS: Augmentin; Detrol LA; lisinopril. IMMUNIZATIONS: Immunizations were up to date for influenza, negative for Pneumovax. ALLERGIES: PENICILLIN. LABORATORY AT PRESENTATION: White blood cell count 11, hemoglobin 10.5, hematocrit 32.2, platelets 175,000. Sodium 148, potassium 5.2, BUN 30, creatinine 2.2 and glucose 216. PT was 22.4. RADIOLOGIC DATA: Chest x-ray revealed a diffuse pulmonary edema. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 97/52, pulse of 79, respirations 16, O2 sat 100%. HEENT: The patient's pupils were again, fixed and dilated and intubated on the monitor. CHEST: Poor air movement bilateral with bilateral rales. CARDIOVASCULAR: Regular rate and rhythm. ABDOMEN: The abdomen was obese, nondistended and nontender. EXTREMITIES: Left diabetic foot had oozing pus drainage from the foot. GU: Foley catheter was in place. IMPRESSION AND PLAN:1. Acute cardiac arrest with pulseless electrical activity with hypotensive shock and respiratory failure: Will continue ventilator support. Will rule out pulmonary embolus, rule out myocardial infarction. Continue pressors. The patient is currently on dopamine, Neo-Synephrine and Levophed.2. Acute respiratory distress syndrome: Will continue ventilatory support.3. Questionable sepsis: Will obtain blood cultures, intravenous vancomycin and Rocephin given.4. Hypotensive shock: Will continue pressors. Will check random cortisol. Hydrocortisone was added.Further inpatient management for this patient will be provided by Dr. R. The patient's status was discussed with her daughter and her husband. The husband states that his wife has been very ill in the past with multiple admissions, but he had never seen her as severely ill as with this event. He states that she completely was not breathing at all and he is aware of the severity of her illness and the gravity of her current prognosis. Will obtain the assistance with cardiology with this admission and will continue pressors and supportive therapy. The family will make an assessment and final decision concerning her long-term management after a 24 hour period." "31",31,"Operative Note","PREOPERATIVE DIAGNOSES1. Open wound from right axilla to abdomen with a prosthetic vascular graft, possibly infected.2. Diabetes.3. Peripheral vascular disease.POSTOPERATIVE DIAGNOSES1. Open wound from right axilla to abdomen with a prosthetic vascular graft, possibly infected.2. Diabetes.3. Peripheral vascular disease.OPERATIONS1. Wound debridement with removal of Surgisis xenograft and debridement of skin and subcutaneous tissue.2. Secondary closure of wound, complicated.3. VAC insertion. DESCRIPTION OF PROCEDURE: After obtaining an informed consent, the patient was brought to the operating room where a general anesthetic was given. A time-out process was followed. All the staples holding the xenograft were removed as well as all the dressings and the area was prepped with Betadine soap and then painted with Betadine solution and draped in usual fashion.The xenograft was not adhered at all and was easily removed. There was some, what appeared to be a seropurulent exudate at the bottom of the incision. This was towards the abdominal end, under the xenograft.The graft was fully exposed and it was pulsatile. We then proceeded to use a pulse spray with bacitracin clindamycin solution to clean up the graft. A few areas of necrotic skin and subcutaneous tissue were debrided. Prior to this, samples were taken for aerobic and anaerobic cultures.Normal saline 3000 cc was used for the irrigation and at the end of that the wound appeared much cleaner and we proceeded to insert the sponges to put a VAC system to it. There was a separate incision, which was bridged __________ to the incision of the abdomen, which we also put a sponge in it after irrigating it and we put the VAC in the main wound and we created a bridge to the second and more minor wound. Prior to that, I had inserted a number of Vesseloops through the edges of the skin and I proceeded to approximate those on top of the VAC sponge. Multiple layers were applied to seal the system, which was suctioned and appeared to be working satisfactorily.The patient tolerated the procedure well and was sent to the ICU for recovery." "32",32,"History and Physical","HISTORY OF PRESENT ILLNESS: The patient has a known case of marginal B-cell lymphoma for which he underwent splenectomy two years ago. The patient, last year, developed a diffuse large B-cell lymphoma which was treated with CHOP/reduction. The patient again went into complete remission. The patient has been doing well until recently, few days ago, late last week, when he developed swelling of the left testicle. The patient states he has been having fever and chills for the last few days. The patient felt weak and felt unwell. The patient with these complaints came to the emergency room. The patient has been having fever and chills and the patient states that the pain in the left testicle is rather severe. No history of trauma to the testicle. PAST MEDICAL HISTORY:1. Status post splenectomy.2. History of marginal B-cell lymphoma.3. History of diffuse large cell lymphoma. ALLERGIES: None. PERSONAL HISTORY: Used to smoke and drink alcohol but at present does not. FAMILY HISTORY: Noncontributory. REVIEW OF SYSTEMS: HEENT: Has slight headache. CARDIOVASCULAR: No history of hypertension, MI, etc. RESPIRATORY: No history of cough, asthma, TB, shortness of breath. GI: Unremarkable. GU: As above, has developed painful swelling of the left testicle over the last few days. ENDOCRINE: Known case of type II diabetes mellitus. PHYSICAL EXAMINATION: HEENT: No conjunctival pallor or icterus. NECK: No adenopathy. No carotid bruits. LUNGS: Clear. HEART: No gallop or murmur. ABDOMEN: A midline scar is present. EXTREMITIES: Unremarkable. GENITALIA: Right testicle is markedly erythematous and swollen and tender. LABORATORY DATA: WBC 13.8, hemoglobin 14.3, hematocrit 42.4, platelets 235,000. SMA-7 shows a potassium of 3.9. Glucose was 213 on September 18, 2007. ASSESSMENT:1. Left testicular swelling. It is tender. Etiology - possible epididymitis or possible torsion of the testis.2. History of diffuse large cell lymphoma and remission.3. History of marginal B-cell lymphoma, status post splenectomy two years ago.4. History of diabetes mellitus. PLAN:1. Ultrasound of scrotum.2. Urology consult.3. Ultrasound of abdomen.4. IV antibiotics.5. We will arrange CT scan of the abdomen and pelvis in the future." "33",33,"History and Physical","MM/DD/YYYYXYZ, D.C.Re: ABCDear Dr. XYZ:I had the pleasure of seeing your patient, ABC, today MM/DD/YYYY in consultation. He is an unfortunate 19-year-old right-handed male who was injured in a motor vehicle accident on MM/DD/YYYY, where he was the driver of an automobile, which was struck on the front passenger's side. The patient sustained impact injuries to his neck and lower back. There was no apparent head injury or loss of consciousness and he denied any posttraumatic seizures. He was taken to Hospital, x-rays were taken, apparently which were negative and he was released.At the present time, he complains of neck and lower back pain radiating into his right arm and right leg with weakness, numbness, paraesthesia, and tingling in his right arm and right leg. He has had no difficulty with bowel or bladder function. He does experience intermittent headaches associated with his neck pain with no other associated symptoms. PAST HEALTH: He was injured in a prior motor vehicle accident on MM/DD/YYYY. At the time of his most recent injuries, he was completely symptom free and under no active therapy. There is no history of hypertension, diabetes, heart disease, neurological disorders, ulcers or tuberculosis. SOCIAL HISTORY: He denies tobacco or alcohol consumption. ALLERGIES: No known drug allergies. CURRENT MEDICATIONS: None. FAMILY HISTORY: Otherwise noncontributory. FUNCTIONAL INQUIRY: Otherwise noncontributory. REVIEW OF DIAGNOSTIC STUDIES: Includes an MRI scan of the cervical spine dated MM/DD/YYYY which showed evidence for disc bulging at the C6-C7 level. MRI scan of the lumbar spine on MM/DD/YYYY, showed evidence of a disc herniation at the L1-L2 level as well as a disc protrusion at the L2-L3 level with disc herniations at the L3-L4 and L4-L5 level and disc protrusion at the L5-S1 level. PHYSICAL EXAMINATION: Reveals an alert and oriented male with normal language function. Vital Signs: Blood pressure was 105/68 in the left arm sitting. Heart rate was 70 and regular. Height was 5 feet 8 inches. Weight was 182 pounds. Cranial nerve evaluation was unremarkable. Pupils were equal and reactive. Funduscopic evaluation was clear. There was no evidence for nystagmus. There was decreased range of motion noted in both the cervical and lumbar regions to a significant degree, with tenderness and spasm in the paraspinal musculature. Straight leg raising was limited to 45 degrees on the right and 90 degrees on the left. Motor strength was 5/5 on the MRC scale. Reflexes were 2+ symmetrical and active. No pathological responses were noted. Sensory examination showed a diffuse decreased sensation to pinprick in the right upper extremity. Cerebellar function was normal. There was normal station and gait. Chest and cardiovascular evaluations were unremarkable. Heart sounds were normal. There were no extra sounds or murmurs. Palpable trigger points were noted in the right trapezius and right cervical and lumbar paraspinal musculature. CLINICAL IMPRESSION: Reveals a 19-year-old male suffering from a posttraumatic cervical and lumbar radiculopathy, secondary to traumatic injuries sustained in a motor vehicle accident on MM/DD/YYYY. In view of the persistent radicular complaints associated with the weakness, numbness, paraesthesia, and tingling as well as the objective sensory loss noted on today's evaluation as well as the non-specific nature of the radiculopathy, I have scheduled him for an EMG study on his right upper and right lower extremity in two week's time to rule out any nerve root irritation versus any peripheral nerve entrapment or plexopathy as the cause of his symptoms. Palpable trigger points were noted on today's evaluation. He is suffering from ongoing myofascitis. His treatment plan will consist of a series of trigger point injections to be initiated at his next follow up visit in two weeks' time. I have encouraged him to continue with his ongoing treatment program under your care and supervision. I will be following him in two weeks' time. Once again, thank you kindly for allowing me to participate in this patient's care and management.Yours sincerely," "34",34,"Operative Note","PREOPERATIVE DIAGNOSIS: Osteomyelitis, right hallux. POSTOPERATIVE DIAGNOSIS: Osteomyelitis, right hallux. PROCEDURE PERFORMED: Amputation distal phalanx and partial proximal phalanx, right hallux. ANESTHESIA: TIVA/local. HISTORY: This 44-year-old male patient was admitted to ABCD General Hospital on 09/02/2003 with a diagnosis of osteomyelitis of the right hallux and cellulitis of the right lower extremity. The patient has a history of diabetes with peripheral neuropathy and has had a chronic ulceration to the right hallux and has been on outpatient antibiotics, which he failed. The patient after a multiple conservative treatments such as wound care antibiotics, the patient was given the option of amputation as a treatment for the chronic resistant osteomyelitis. The patient desires to attempt a surgical correction. The risks versus benefits of the procedure were discussed with the patient in detail by Dr. X. The consent was available on the chart for review. PROCEDURE IN DETAIL: After patient was taken to the operating room via cart and placed on the operating table in the supine position, a safety strap was placed across his waist. Adequate IV sedation was administered by the Department of Anesthesia and a total of 3.5 cc of 1:1 mixture 1% lidocaine and 0.5% Marcaine plain were injected into the right hallux as a digital block. The foot was prepped and draped in the usual aseptic fashion lowering the operative field.Attention was directed to the hallux where there was a full-thickness ulceration to the distal tip of the hallux measuring 0.5 cm x 0.5 cm. There was a ________ tract, which probed through the distal phalanx and along the sides of the proximal phalanx laterally. The toe was 2.5 times to the normal size. There were superficial ulcerations in the medial arch of both feet secondary to history of a burn, which were not infected. The patient had dorsalis pedis and posterior tibial pulses that were found to be +2/4 bilaterally preoperatively. X-ray revealed complete distraction of the distal phalanx and questionable distraction of the lateral aspect of the proximal phalanx. A #10 blade was used to make an incision down the bone in a transverse fashion just proximal to the head of the proximal phalanx. The incision was carried mediolaterally and plantarly encompassing the toe leaving a large amount of plantar skin intact. Next, the distal phalanx was disarticulated at the interphalangeal joint and removed. The distal toe was amputated and sent to laboratory for bone culture and sensitivity as well as tissue pathology. Next, the head of the proximal phalanx was inspected and found to be soft on the distal lateral portion as suspected. Therefore, a sagittal saw was used to resect approximately 0.75 cm of the distal aspect of head of the proximal phalanx. This bone was also sent off for culture and was labeled proximal margin. Next, the flexor hallucis longus tendon was identified and retracted as far as possible distally and transected. The flexor tendon distally was gray discolored and was not viable. A hemostat was used to inspect the flexor sheath to ensure no infection tracking up the sheath proximally. None was found. No purulent drainage or abscess was found. The proximal margin of the surgical site tissue was viable and healthy. There was no malodor. Anaerobic and aerobic cultures were taken and passed this as a specimen to microbiology. Next, copious amounts of gentamicin and impregnated saline were instilled into the wound.A #3-0 Vicryl was used to reapproximate the deep subcutaneous layer to release skin tension. The plantar flap was viable and was debulked with Metzenbaum scissors. The flap was folded dorsally and reapproximated carefully with #3-0 nylon with a combination of simple interrupted and vertical mattress sutures. Iris scissors were used to modify and remodel the plantar flap. An excellent cosmetic result was achieved. No tourniquet was used in this case. The patient tolerated the above anesthesia and surgery without apparent complications. A standard postoperative dressing was applied consisting of saline-soaked Owen silk, 4x4s, Kerlix, and Coban. The patient was transported via cart to Postanesthesia Care Unit with vital signs able and vascular status intact to right foot. He will be readmitted to Dr. Katzman where we will continue to monitor his blood pressure and regulate his medications. Plan is to continue the antibiotics until further IV recommendations.He will be nonweightbearing to the right foot and use crutches. He will elevate his right foot and rest the foot, keep it clean and dry. He is to follow up with Dr. X on Monday or Tuesday of next week." "35",35,"Discharge Summary","REASON FOR CONSULTATION: Syncope. HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old lady followed by Dr. X in our practice with history of coronary artery disease, status post coronary artery bypass grafting in 2005 presented to the emergency room following a syncopal episode. According to the patient and the daughter who was with her, she was shopping when she felt abdominal discomfort with nausea, profuse sweating, and passed out. As soon as she was laid on the floor and her leg raised up, she woke up with no post-event confusion. According to the daughter, she has had episodes of weakness, but no syncope. She has blood pressure medications and has had some postural hypotensions, which has been managed by Dr. X. She also states there was a history of pulmonary embolism and the presentation at that time was very similar when she had a syncopal episode. At that time, she was admitted at Hospital, had a V/Q scan, which was positive for PE. Initial V/Q scan done at Hospital was negative. She was anticoagulated with Coumadin resulting in severe GI bleed. Anticoagulation was stopped and an IVC filter was placed at that time. She has a history of malignant hypertension and has had a renal stent placed in February 2007. She also has peripheral vascular disease with stent placements. There is a history of spinal canal stenosis and iron deficiency anemia, currently on Procrit injections every two weeks done by Dr. Y. The patient denies any chest pain or any worsening of any shortness of breath. There are no acute EKG changes or cardiac enzyme elevations. She has had no stress test done following a bypass surgery.PAST MEDICAL HISTORY1. Coronary artery disease, status post coronary artery bypass grafting.2. History of mitral regurgitation, unable to repair the valve.3. History of paroxysmal atrial fibrillation, on amiodarone.4. Gastroesophageal reflux disease.5. Hypertension.6. Hyperlipidemia.7. History of abdominal aortic aneurysm.8. Carotid artery disease, mild-to-moderate on recent carotid ultrasound.9. Peripheral vascular disease.10. Hypothyroidism.11. Pulmonary embolism.PAST SURGICAL HISTORY1. Coronary artery bypass grafting.2. Hysterectomy.3. IVC filter.4. Tonsillectomy and adenoidectomy.5. Cosmetic surgery to breast and abdomen.HOME MEDICATIONS1. Aspirin 81 mg once a day.2. Klor-Con 10 mEq once a day.3. Lasix 40 mg once a day.4. Levothyroxine 125 mcg once a day.5. Lisinopril 20 mg once a day.6. Pacerone 200 mg once a day.7. Protonix 40 mg once a day.8. Toprol 50 mg once a day.9. Vitamin B once a day.10. Zetia 10 mg once a day.11. Zyrtec 10 mg once a day. ALLERGIES: CODEINE, ERYTHROMYCIN, SULFA, VICODIN, AND ZOCOR. REVIEW OF SYSTEMSCONSTITUTIONAL: The patient denies any fevers, chills, recent weight gain or weight loss. She has had abdominal symptoms with diarrhea. EYES: Decreased visual acuity. ENT: Sinus drainage. CARDIOVASCULAR: As described above. Denies any chest pains. RESPIRATORY: He has chronic shortness of breath. No cough or sputum production. GI: History of reflux symptoms. GU: No history of dysuria or hematuria. ENDOCRINE: No history of diabetes. MUSCULOSKELETAL: Denies arthritis, but has leg pain. SKIN: No history of rash. PSYCHIATRIC: No history of anxiety or depression. CNS: History of strokes and MRI, but no focal deficits.Review of other systems is essentially unremarkable. FAMILY HISTORY: Father died at the age of 75 following a motor vehicle accident. Mother died at the age of 32, no known heart problems. One brother died of cancer, one sister with cancer. SOCIAL HISTORY: History of tobacco use, smoked for 20 years, and quit 30 years ago. Alcohol one to two drinks monthly. PHYSICAL EXAMINATIONGENERAL: Elderly lady in no acute distress. VITAL SIGNS: Heart rate 50 to 60s, weight is 180 pounds, temperature 98.6, blood pressure 155/57, and O2 saturations 98% on room air. Telemetry shows sinus rhythm. HEENT: Pupils are equal and reactive to light and accommodation. Extraocular movements are intact. NECK: Had no jugular venous distention. Right carotid bruit. HEART: Apical impulse is normal. First and second sounds heard normally. He had a soft ejection systolic murmur. LUNGS: Normal chest expansion, with clear to auscultation bilaterally. ABDOMEN: Soft, nontender, no palpable organomegaly. EXTREMITIES: No edema, clubbing or cyanosis. CNS: The patient is alert oriented x3, no focal neurological deficits. LABORATORY DATA: EKG shows sinus rhythm with right bundle-branch block, rate of 60. Hemoglobin 9.6, hematocrit 29.3, and platelets 326,000. WBC 7.2. CK 67 and 59. Troponin negative x 2. Sodium 137, potassium 4.4, chloride 101, bicarbonate 28, BUN 19, creatinine 2.1, and glucose 112. LFTs were negative. BNP was 366. DIAGNOSTIC DATA: CT showed chronic microvascular ischemic changes. Ultrasound of the abdomen showed a small abdominal aortic aneurysm of 3.3 cm, no change from 2002.ASSESSMENT AND PLAN1. Syncope, suspect vasovagal in the setting of dehydration due to diuretics, diarrhea, and her blood medications. A recent echocardiogram has been done, which showed mildly depressed left ventricular systolic function, ejection fraction between 45% and 50%. At this time, we would rehydrate with IV fluids and reassess.2. Coronary artery disease, status post coronary artery bypass surgery, clinically stable with no angina.3. History of pulmonary embolism in the past with presentation similar to this. In view of this history although her clinical presentation is atypical, would do a V/Q scan to exclude this.4. History of iron deficiency anemia, probably secondary to chronic kidney disease followed by Dr. Y, receiving Procrit injections.5. Chronic kidney disease, baseline creatinine usually in the 1.8 to 1.9 range, today it is 2.1. We will reassess after IV fluids.6. Hypertension, continue current medications.7. Hypothyroidism, on replacement." "36",36,"History and Physical","CHIEF COMPLAINT: I have blood in my urine. HEMATURIA HISTORY: The patient describes the sudden onset of gross painless hematuria. The character of the urine is red with clots. The hematuria is in the total urinary stream. The patient has urinary symptoms that include hesitancy and urgency. The patient denies any associated abdominal, back, flank, or pelvic pain. No fever or chills have been recorded by the patient with the hematuria. PAST MEDICAL HISTORY: Type II Diabetes Mellitus, on insulin. Chronic sinusitis. Urolithiasis. PAST SURGICAL HISTORY: Appendectomy (1997). Laparoscopic Cholecystectomy (1998). FAMILY MEDICAL HISTORY: The patient's mother with history of Diabetes and breast cancer. OCCUPATIONAL HISTORY: Self employed. SOCIAL HISTORY: Divorced and sexually active. Smokes 1-2 packs/cigarettes per day and drinks alcohol socially. ALLERGIES: Intolerance�s / Antibiotic (s): Keflex. Intolerance/Analgesic (s): Codeine. MEDICATIONS: Diabeta. Insulin. REVIEW OF SYSTEMS:Constitutional: Generally healthy. Weight is stable. The patient is a good historian.Cardiovascular: The patient has no history of any cardiovascular problems and denies any present problems.Gastrointestinal: Patient denies any present or past gastrointestinal problems.Genitourinary: See chief complaint and history of present illness.Endocrine: Diabetes, Type 2 but on insulin supplementation. PHYSICAL EXAMINATION:Constitutional: General Appearance: Healthy, moderately overweight for habitus and anxious.Cardiovascular: Regular heart rate and rhythm without murmur or gallop.Abdomen/Flank: The abdomen is soft without tenderness or palpable masses. The liver and spleen are not palpable. Bowel sounds are active and normal.Genitalia Male: Scrotum: rash consistent with tinea cruris and Angiomata Scroti. Testes: Both testes are normally descended and normal size.Prostate: For age of the patient, the prostate is normal in size and symmetry. The prostate is not tender and there is no palpable induration. Seminal vesicles not palpable. LAB: Chemstix of the urine is positive for 3+non hemolyzed blood and 1+ glucose. Microscopic U/ A: 50-100 RBCs. Cystoscopy: A lesion consistent with Transitional Cell Cancer. TC lesion located: dome.IMPRESSION / DIAGNOSIS: Transitional Cell Cancer of the Bladder (188.9). Diabetes, Type II Insulin. (250.00). MEDICATIONS PRESCRIBED: Noroxin 400mg and Detrol 2mg #2 of each.DISCUSSION/ TREATMENT PLAN: Explained the diagnosis, possible etiologies, and treatment plan. The patient indicates they understand and agree with the proposed treatment plan.PROCEDURE (S) SCHEDULED: TURBT. Outpatient surgery scheduled at Hospital, 3/10/01." "37",37,"History and Physical","TYPE OF CONSULTATION: Wound care consult. HISTORY OF PRESENT ILLNESS: The patient is a 62-year-old woman with a past medical history significant for prior ileojejunal bypass for weight loss (1980) and then subsequent gastric banding (2002 Dr. X) who was transferred to this facility following a complicated surgical and postoperative course after takedown of the prior gastroplasty and bypass (07/08/2008, Dr. Y). The patient has been followed by Cardiothoracic Surgery (Dr. Z) as an outpatient. She had a history of daily postprandial vomiting, regurgitation, and heartburn. She underwent a preop assessment of her GERD and postprandial vomiting including nuclear gastric emptying studies, which showed increased esophageal retention with normal gastric emptying. Preoperative barium swallow demonstrated moderated esophageal dysmotility with incomplete emptying and a small hiatal hernia. It was recommended that she undergo an exploratory laparotomy and possible redo fundoplication and possible gastrectomy. She had already undergone multiple EGDs with dilatations without success. She continued to have abdominal discomfort.On 07/07/2008, she was admitted to hospital. She underwent an exploratory laparotomy with esophagogastrectomy with esophagogastric anastomosis and Dor fundoplication, repair of hiatal hernia, small bowel resection x2 with primary anastomosis, extensive lysis of adhesions, insertion of a red-rubber J tube, and esophagogastroduodenoscopy. She also had her ileojejunal bypass reversed. Postoperatively, she was able to be extubated. She was started on TPN, given the risk of not being able to tolerate enteral nutrition. Her operative note confirmed that the stomach pouch was enlarged with outlet obstruction where the band was. There was 2 hours of extensive lysis of adhesions. It took 2 hours to identify the colon. A defect was repaired in the transverse colon. The bypass segment of the anastomosis was seen between the proximal jejunum and the distal ileum, which was divided and the proximal jejunum was reconnected to the atretic blind limb of the small bowel. A red feeding tube was placed proximal to the anastomosis then tended to cross the anastomosis into the distal atretic small bowel for enteral feeds. The hiatal hernia was repaired as noted. The obstructed proximal gastric segment was resected. An anastomosis was made between the proximal intestine and the stomach and distal esophagus with Dor fundoplication. Omentectomy was performed due to devascularization. The wound was able to be closed with staples.Postoperatively, the patient was started on IV antibiotics. She was able to be extubated. However, on 07/14/2008, she coded with shortness of breath and chest pain. She had respiratory failure, required endotracheal intubation and ICU management. CT scan of the abdomen and the pelvis confirmed that she had an anastomotic leak. Sputum cultures were positive ESBL Klebsiella. Blood cultures were negative. She was managed closely for sepsis with an elevated white cell count. She was also febrile. Her chest x-ray also showed left lower lobe consolidation. She had scattered contrast material in the anterior abdomen and left upper quadrant due to the anastomotic leak. Her antibiotics were adjusted. Of note, the patient did have a JP drain placed out to the surface during her initial surgery. Followup CT scan on 07/16/2008 confirmed the anastomosis as the likely site of a fistula, as there was continued extraluminal enteric contrast seen within anterior abdomen just beneath the peritoneum as well as the left upper quadrant adjacent to the spleen. No enteric contrast was seen surrounding the patient's known GE junction leak. A JP drain was noted at the posterior aspect of the fundoplication. There was only a small amount of pelvic fluid. Follow up scan again on 07/25/2008 showed no abscess formation. On 08/05/2008, she did underwent an advancement of the #14 French red-rubber catheter feeding tube distal to the dehiscence of fistula into the distal small bowel. At the beginning of the procedure, the catheter did appear to traverse through an anastomotic suture line in the wound dehiscence. At some point during her course, the patient did undergo a second operative procedure, but I do not have any operative note at this time. She subsequently was left with a large open abdominal defect, which was being managed by the wound care nurses, which at the time of her transfer to this facility was being managed with a ""wound manager system."" to low-continuous wall suction. She was also transferred on tube feedings via the red rubber catheter 20 mL per hour. She is only to have her tube feeds increased by 10 mL a week to ensure tolerance. During her course, she was started on TPN. She was transferred on TPN here.At the time of her transfer, the patient was no longer on IV antibiotics. She is on Fragmin for DVT prophylaxis. During her course, she did have to undergo a tracheostomy. This has subsequently been removed and this site is healing. The tracheostomy was removed on 08/06/2008, I believe. At the time of her tracheostomy (on 07/22/2008), the patient also underwent a flexible bronchoscopy, which showed some secretions in the left airway (right was clear), which did not appear to be purulent. Of note also, pathology of her partial stomach resection showed Helicobacter pylori gastritis. There were no other significant abnormalities noted in the small intestine or omentum. On 08/11/2008, the patient was transferred to HealthSouth Monroeville LTAC for continued medical management, wound care, and rehab therapies.1 PAST MEDICAL HISTORY: History of diabetes with peripheral neuropathy - on Lyrica and Cymbalta preoperatively. History of hypothyroidism, history of B12 deficiency related to prior gastric surgeries, history of osteoarthritis, history of valvular disease (no details available), and cardiac arrhythmias. PAST SURGICAL HISTORY: Status post bilateral total knee replacements, status post right rotator cuff repair, status post sigmoid colectomy - no further details available, status post right breast lumpectomy for benign lesion, history of bladder repair, status post hysterectomy/tonsillectomy/appendectomy, history of lumbar spinal fusion - no further details available. History of MRSA in knees (previous surgery). ALLERGIES: MULTIPLE INCLUDING TETRACYCLINE, ERYTHROMYCIN, MORPHINE, SULFA DRUGS, BETADINE, ADHESIVE TAPES, AND BANDAGE. SOCIAL HISTORY: Prior to admission, the patient lived alone in a one storied dwelling. She does have some equipment at home including a powered wheelchair, which she uses for longer distance. She does have some ambulatory devices also. She used to smoke, but quit about 10 years ago. She smoked 1 to 2 packs a day from age 18 to 54. She does not smoke. FAMILY HISTORY: Remarkable for cardiac disease with early death of her father at age 43 and mother had Alzheimer. REVIEW OF SYSTEMS: According to her notes, the patient's weight 07/10/2008 was 256 pounds. She has a BMI of 44 indicating morbid obesity. She had had a significant weight loss in the 6 months prior to this of 7%. As noted, she is on TPN and enteral feeds. Her prealbumin level noted on 07/10/2008 was low at 7. Prior to admission, the patient ate a regular diet, but had most likely weight loss and inadequate intake due to her chronic postprandial vomiting and esophageal dysmotility. She is currently NPO with NG to suction. The patient has no complaints of abdominal pain or discomfort at the time of this exam. She was awake and alert. MRSA screen on 07/14/2008 was negative. PHYSICAL EXAMINATION:General: The patient is a morbidly obese woman, who is in no acute distress at the time of this exam. She is lying comfortably on a low air loss mattress. She had just been assisted with cleaning up and had no complaints of pain or discomfort.Vital Signs: Temperature is 98.9, pulse is 95, blood pressure is 123/69, and weight is 239 pounds. HEENT: Normocephalic/atraumatic. Extraocular muscles intact. Her mentation is good.Neck: Stout. There is good range of motion.Cor: Regular rate and rhythm. No murmurs appreciated.Lungs: Fairly clear anteriorly.Abdomen: Remarkable for a large open abdominal wound with a collection system in place covering the entire wound in midline. There is a JP drain and a red rubber catheter present. At present, the wound manager system is somewhat collapsed. She had just been on her side. It is connected to low continuous wall suction and removing fluid.Musculoskeletal: There is PICC line present in the right upper extremity. No significant pedal edema. Bilateral knee scars from prior surgeries.Skin: Reported intact at this time (not seen by me).Neurological: Cranial nerves II through XII grossly intact. She is able to answer questions appropriately. She is able to raise both arms over head. She is able to raise her legs, but does need assistance. She has fair bed mobility and requires much assistance for any turning. Gait and transfers not tested. SUMMARY: In summary, the patient is a 62-year-old woman with a remote history of ileojejunal bypass followed by gastric banding to facilitate weight loss. However, she subsequently developed reflux associated with postprandial vomiting, which was found to be secondary to esophageal retention. On 07/08/2008, she underwent exploratory laparotomy with esophagogastrectomy with esophagogastric anastomosis and Dor fundoplication, hiatal hernia repair, small bowel resection, and lysis of adhesions. She has had a fairly rocky postoperative course and has subsequently underwent some type of re-exploration after she was noted to have enteric contents draining from her JP drain with confirmed anastomotic leak. She has undergone placement on an NG tube. At present, she is on enteral feeds as well as TPN. During all these, she also coded and had respiratory failure, requiring vent management, but this has improved. Her trach has been removed and this site is healing. From the wound standpoint, her largest problem at this point is the abdominal wound, which is open. A wound manager system is currently in place, which is connected to low intermittent wall suction for drainage of the enteral contents still present. At present, the drainage is quite yellow in appearance. She has no significant complaints of pain at this time. At some point in her notes, there was mention of a negative pressure wound therapy being used to this wound, but this cannot be confirmed at this time. I will plan to contact Dr. Z's office to see whether or not they wanted to resume a wound VAC system to this wound. For now, we will continue with wound manager system. We will need to keep track of in's and out's of drainage from this site. Her fluid status will need to be monitored. In an attempt to get her mobilized, we will need extra care to be sure that this wound dressing/management system stays in place. She is eager and motivated to get mobilized. We will plan to ask Plastic (Dr. A) to be involved in following this wound also. Again, I will plan to call the surgeon's office for further directions. She is to follow up with Dr. Z in 2 weeks.Later in afternoon, I was able to reach Dr. Z's office. I was called back by one of his nurses, who advised me that a wound VAC (negative pressure wound therapy) was not to be used on this wound. They are using the wound manager system. She did report that the confusion came about with the inability during her discharge summary dictation that she was only able to cite a ""wound VAC"" when describing the system that was in place on the patient. She was using a formatted discharge summary program. At present, the patient has had some leakage from the system. According to my discussion with our wound care coordinator at this time, this system has been removed, with leakage repaired, and replaced with another wound manager system with suctioning continuing. Pictures were also taken of the wound bed. There were several staples apparently in place. I was not present at the time that this system had to be changed." "38",38,"History and Physical","SUBJECTIVE: The patient is in with several medical problems. She complains of numbness, tingling, and a pain in the toes primarily of her right foot described as a moderate pain. She initially describes it as a sharp quality pain, but is unable to characterize it more fully. She has had it for about a year, but seems to be worsening. She has little bit of paraesthesias in the left toe as well and seem to involve all the toes of the right foot. They are not worse with walking. It seems to be worse when she is in bed. There is some radiation of the pain up her leg. She also continues to have bilateral shoulder pains without sinus allergies. She has hypothyroidism. She has thrombocythemia, insomnia, and hypertension. PAST MEDICAL HISTORY: Surgeries include appendectomy in 1933, bladder obstruction surgery in 1946, gallbladder surgery in 1949, another gallbladder surgery in 1954, C-section in 1951, varicose vein surgery in 1951 and again in 1991, thyroid gland surgery in 1964, hernia surgery in 1967, bilateral mastectomies in 1968 for benign disease, hysterectomy leaving her ovaries behind in 1970, right shoulder surgery x 4 and left shoulder surgery x 2 between 1976 and 1991, and laparoscopic bowel adhesion removal in October 2002. She had a Port-A-Cath placed in June 2003, left total knee arthroplasty in June 2003, and left hip pinning due to fracture in October 2003, with pins removed in May 2004. She has had a number of colonoscopies; next one is being scheduled at the end of this month. She also had a right total knee arthroplasty in 1993. She was hospitalized for synovitis of the left knee in April 2004, for zoster and infection of the left knee in May 2003, and for labyrinthitis in June 2004. ALLERGIES: Sulfa, aspirin, Darvon, codeine, NSAID, amoxicillin, and quinine. CURRENT MEDICATIONS: Hydroxyurea 500 mg daily, Metamucil three teaspoons daily, amitriptyline 50 mg at h.s., Synthroid 0.1 mg daily, Ambien 5 mg at h.s., triamterene/hydrochlorothiazide 75/50 daily, and Lortab 5/500 at h.s. p.r.n. SOCIAL HISTORY: She is a nonsmoker and nondrinker. She has been widowed for 18 years. She lives alone at home. She is retired from running a restaurant. FAMILY HISTORY: Mother died at age 79 of a stroke. Father died at age 91 of old age. Her brother had prostate cancer. She has one brother living. No family history of heart disease or diabetes. REVIEW OF SYSTEMS:General: Negative. HEENT: She does complain of some allergies, sneezing, and sore throat. She wears glasses.Pulmonary history: She has bit of a cough with her allergies.Cardiovascular history: Negative for chest pain or palpitations. She does have hypertension.GI history: Negative for abdominal pain or blood in the stool.GU history: Negative for dysuria or frequency. She empties okay.Neurologic history: Positive for paresthesias to the toes of both feet, worse on the right.Musculoskeletal history: Positive for shoulder pain.Psychiatric history: Positive for insomnia.Dermatologic history: Positive for a spot on her right cheek, which she was afraid was a precancerous condition.Metabolic history: She has hypothyroidism.Hematologic history: Positive for essential thrombocythemia and anemia. OBJECTIVE:General: She is a well-developed, well-nourished, elderly female in no acute distress.Vital Signs: Her age is 81. Temperature: 98.0. Blood pressure: 140/70. Pulse: 72. Weight: 127. HEENT: Head was normocephalic. Pupils equal, round, and reactive to light. Extraocular movements are intact. Fundi are benign. TMs, nares, and throat were clear.Neck: Supple without adenopathy or thyromegaly.Lungs: Clear.Heart: Regular rate and rhythm without murmur, click, or rub. No carotid bruits are heard.Abdomen: Normal bowel sounds. It is soft and nontender without hepatosplenomegaly or mass.Breasts: Surgically absent. No chest wall mass was noted, except for the Port-A-Cath in the left chest. No axillary adenopathy is noted.Extremities: Examination of the extremities reveals no ankle edema or calf tenderness x 2 in lower extremities. There is a cyst on the anterior portion of the right ankle. Pedal pulses were present.Neurologic: Cranial nerves II-XII grossly intact and symmetric. Deep tendon reflexes were 1 to 2+ bilaterally at the knees. No focal neurologic deficits were observed.Pelvic: BUS and external genitalia were atrophic. Vaginal rugae were atrophic. Cervix was surgically absent. Bimanual exam confirmed the absence of uterus and cervix and I could not palpate any ovaries.Rectal: Exam confirmed there is brown stool present in the rectal vault.Skin: Clear other than actinic keratosis on the right cheek.Psychiatric: Affect is normal. ASSESSMENT:1. Peripheral neuropathy primarily of the right foot.2. Hypertension.3. Hypothyroidism.4. Essential thrombocythemia.5. Allergic rhinitis.6. Insomnia. PLAN: I prescribed Neurontin 100 mg dispensed 30 with five refills one to two p.o. q.h.s. p.r.n. peripheral neuropathy. I offered Anodyne physical therapy, but she was not interested yet at this point. I suspect that her peripheral neuropathy may be due to her essential thrombocythemia. We did send her to lab for a CBC due to her anemia and essential thrombocythemia and she needs sed rate due to her peripheral neuropathy, ferritin due to her anemia, and Hemoccult cards x 3 due to anemia. She needs a DT immunization. Recheck with me in about three months. I refilled her Ambien 5 mg at h.s. for one year. She may get a flu shot next month." "39",39,"History and Physical","SUBJECTIVE: The patient comes in today for a comprehensive evaluation. She is well-known to me. I have seen her in the past multiple times.PAST MEDICAL HISTORY/SOCIAL HISTORY/ FAMILY HISTORY: Noted and reviewed today. They are on the health care flow sheet. She has significant anxiety which has been under fair control recently. She has a lot of stress associated with a son that has some challenges. There is a family history of hypertension and strokes. CURRENT MEDICATIONS: Currently taking Toprol and Avalide for hypertension and anxiety as I mentioned. REVIEW OF SYSTEMS: Significant for occasional tiredness. This is intermittent and currently not severe. She is concerned about the possibly of glucose abnormalities such diabetes. We will check a glucose, lipid profile and a Hemoccult test also and a mammogram. Her review of systems is otherwise negative. PHYSICAL EXAMINATION: VITAL SIGNS: As above. GENERAL: The patient is alert, oriented, in no acute distress. HEENT: PERRLA. EOMI. TMs clear bilaterally. Nose and throat clear. NECK: Supple without adenopathy or thyromegaly. Carotid pulses palpably normal without bruit. CHEST: No chest wall tenderness. BREAST EXAM: No asymmetry, skin changes, dominant masses, nipple discharge, or axillary adenopathy. HEART: Regular rate and rhythm without murmur, clicks, or rubs. LUNGS: Clear to auscultation and percussion. ABDOMEN: Soft, nontender, bowel sounds normoactive. No masses or organomegaly. GU: External genitalia without lesions. BUS normal. Vulva and vagina show just mild atrophy without any lesions. Her cervix and uterus are within normal limits. Ovaries are not really palpable. No pelvic masses are appreciated. RECTAL: Negative. BREASTS: No significant abnormalities. EXTREMITIES: Without clubbing, cyanosis, or edema. Pulses within normal limits. NEUROLOGIC: Cranial nerves II-XII intact. Strength, sensation, coordination, and reflexes all within normal limits. SKIN: Noted to be normal. No subcutaneous masses noted. LYMPH SYSTEM: No lymphadenopathy. ASSESSMENT: Generalized anxiety and hypertension, both under fair control. PLAN: We will not make any changes in her medications. I will have her check a lipid profile as mentioned, and I will call her with that. Screening mammogram will be undertaken. She declined a sigmoidoscopy at this time. I look forward to seeing her back in a year and as needed." "40",40,"History and Physical","SUBJECTIVE: The patient is well-known to me. He comes in today for a comprehensive evaluation. Really, again he borders on health crises with high blood pressure, diabetes, and obesity. He states that he has reached a critical decision in the last week that he understands that he cannot continue with his health decisions as they have been made, specifically the lack of exercise, the obesity, the poor eating habits, etc. He knows better and has been through some diabetes training. In fact, interestingly enough, with his current medications which include the Lantus at 30 units along with Actos, glyburide, and metformin, he achieved ideal blood sugar control back in August 2004. Since that time he has gone off of his regimen of appropriate eating, and has had sugars that are running on average too high at about 178 over the last 14 days. He has had elevated blood pressure. His other concerns include allergic symptoms. He has had irritable bowel syndrome with some cramping. He has had some rectal bleeding in recent days. Also once he wakes up he has significant difficulty in getting back to sleep. He has had no rectal pain, just the bleeding associated with that.MEDICATIONS/ ALLERGIES: As above.PAST MEDICAL/ SURGICAL HISTORY: Reviewed and updated - see Health Summary Form for details. FAMILY AND SOCIAL HISTORY: Reviewed and updated - see Health Summary Form for details. REVIEW OF SYSTEMS: Constitutional, Eyes, ENT/Mouth, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Skin/Breasts, Neurologic, Psychiatric, Endocrine, Heme/Lymph, Allergies/Immune all negative with the following exceptions: None. PHYSICAL EXAMINATION: VITAL SIGNS: As above. GENERAL: The patient is alert, oriented, well-developed, obese male who is in no acute distress. HEENT: PERRLA. EOMI. TMs clear bilaterally. Nose and throat clear. NECK: Supple without adenopathy or thyromegaly. Carotid pulses palpably normal without bruit. CHEST: No chest wall tenderness or breast enlargement. HEART: Regular rate and rhythm without murmur, clicks, or rubs. LUNGS: Clear to auscultation and percussion. ABDOMEN: Significantly obese without any discernible organomegaly. GU: Normal male genitalia without testicular abnormalities, inguinal adenopathy, or hernia. RECTAL: Smooth, nonenlarged prostate with just some irritation around the rectum itself. No hemorrhoids are noted. EXTREMITIES: Some slow healing over the tibia. Without clubbing, cyanosis, or edema. Peripheral pulses within normal limits. NEUROLOGIC: Cranial nerves II-XII intact. Strength, sensation, coordination, and reflexes all within normal limits. SKIN: Noted to be normal. No subcutaneous masses noted. LYMPH SYSTEM: No lymphadenopathy noted. BACK: He has pain in his back in general.ASSESSMENT/ PLAN:1. Diabetes and hypertension, both under less than appropriate control. In fact, we discussed increasing the Lantus. He appears genuine in his desire to embark on a substantial weight-lowering regime, and is going to do that through dietary control. He knows what needs to be done with the absence of carbohydrates, and especially simple sugar. He will also check a hemoglobin A1c, lipid profile, urine for microalbuminuria and a chem profile. I will need to recheck him in a month to verify that his sugars and blood pressure have come into the ideal range. He has allergic rhinitis for which Zyrtec can be used.2. He has irritable bowel syndrome. We will use Metamucil for that which also should help stabilize the stools so that the irritation of the rectum is lessened. For the bleeding I would like to obtain a sigmoidoscopy. It is bright red blood.3. For his insomnia, I found there is very little in the way of medications that are going to fix that, however I have encouraged him in good sleep hygiene. I will look forward to seeing him back in a month. I will call him with the results of his lab. His medications were made out. We will use some Elocon cream for his seborrheic dermatitis of the face. Zyrtec and Flonase for his allergic rhinitis." "41",41,"History and Physical","REASON FOR VISIT: Acute kidney failure. HISTORY OF PRESENT ILLNESS: The patient is a 68-year-old Korean gentleman with a history of coronary artery disease, hypertension, diabetes and stage III CKD with a creatinine of 1.8 in May 2006 corresponding with the GFR of 40-41 mL/min. The patient had blood work done at Dr. XYZ's office on June 01, 2006, which revealed an elevation in his creatinine up to 2.3. He was asked to come in to see a nephrologist for further evaluation. I am therefore asked by Dr. XYZ to see this patient in consultation for evaluation of acute on chronic kidney failure. The patient states that he was actually taking up to 12 to 13 pills of Chinese herbs and dietary supplements for the past year. He only stopped about two or three weeks ago. He also states that TriCor was added about one or two months ago but he is not sure of the date. He has not had an ultrasound but has been diagnosed with prostatic hypertrophy by his primary care doctor and placed on Flomax. He states that his urinary dribbling and weak stream had not improved since doing this. For the past couple of weeks, he has had dizziness in the morning. This is then associated with low glucose. However the patient's blood glucose this morning was 123 and he still was dizzy. This was worse on standing. He states that he has been checking his blood pressure regularly at home because he has felt so bad and that he has gotten under 100/60 on several occasions. His pulses remained in the 60s. ALLERGIES: None. MEDICATIONS: Imdur 20 mg two to three times daily, nitroglycerin p.r.n., insulin 70/30 40/45 units daily, Zetia 10 mg daily, ? Triglide 50 mg daily, Prevacid 30 mg daily, Plavix 75 mg daily, potassium 10 mEq daily, Lasix 60 mg daily, folate 1 mg b.i.d., Niaspan 500 mg daily, atenolol 50 mg daily, enalapril 10 mg b.i.d., glyburide 10 mg b.i.d., Xanax 0.25 mg b.i.d., aspirin 325 mg daily, Tylenol p.r.n., Zantac 150 mg b.i.d., Crestor 5 mg daily, TriCor 145 mg daily, Digitek 0.125 mg daily, Celexa 20 mg daily, and Flomax 0.4 mg daily. PAST MEDICAL HISTORY:1. Coronary artery disease status post CABG x 5 in December 2001.2. Three stents last placed approximately 2002.3. Heart failure, ejection fraction of 30%.4. Hypertension since 1985.5. Diabetes since 1985 with history of laser surgery.6. Moderate mitral regurgitation.7. GI bleed.8. Hyperlipidemia.9. BPH.10. Back surgery.11. Sleep apnea. SOCIAL HISTORY: He is a former tailor from Korea. He is divorced. He has one daughter who has brain injury status post severe seizure as a child. He is the primary caregiver. No drug abuse. He quit tobacco and alcohol 15 years ago. FAMILY HISTORY: Parents both died in Korea. Has one sister with hypertension and the other sister lives in Detroit and is healthy. REVIEW OF SYSTEMS: He has lost about 10 pounds over the past month. He has been fatigue and weak with no appetite. He has occasional chest pain and dyspnea on exertion on fast walking. His lower extremity edema has improved with higher doses of furosemide. He does complain of some early satiety. He complains of urinary frequency, nocturia, weak stream and dribbling. He has never passed the stone. He gets dizzy when his blood sugars are in the 40s to 60s but now this is continuing with him running, glucose is in the 120s. He has some right back pain today and complains of farsightedness. The remainder of review of systems is done and negative per the patient. PHYSICAL EXAMINATION: VITAL SIGNS: Pulse 78. Blood pressure 116/60. Height 5'7"" per the patient. Weight 78.6 kg. Supine pulse 60 with blood pressure 128/55. Standing pulse 60 with blood pressure of 132/50. GENERAL: He is in no apparent distress, but he is dizzy on standing for prolonged period. Eyes: Pupils equal, round and reactive to light. Extraocular movements are intact. Sclerae not icteric. HEENT: He wears upper and lower dentures. Lips acyanotic. Hearing is grossly intact. Oropharynx is otherwise clear. NECK: Supple. No JVD. No bruits. No masses. HEART: Regular rate and rhythm. No murmurs, rubs or gallops. LUNGS: Clear bilaterally. ABDOMEN: Active bowel sounds. Soft, nontender, and nondistended. No suprapubic tenderness. EXTREMITIES: No clubbing, cyanosis or edema. MUSCULOSKELETAL: 5/5 strength bilaterally. No synovitis, arthritis or gait disturbance. SKIN: Old scars in his low back as well as his left lower extremity. No active rashes, purpura or petechiae. Midline sternotomy scar is well healed. NEUROLOGIC: Cranial nerves II through XII are intact. Reflexes are poor to 1+ bilaterally. 10 g monofilament sensation is intact except for the big toes bilaterally. No asterixis. Finger-to-nose testing is intact. PSYCHIATRIC: Fully alert and oriented. LABORATORY DATA: December 2004, creatinine was 1.5. Per report May 2006, creatinine was 1.8 with a BUN of 28. Labs dated 06/01/06, hematocrit was 32.3, white blood cell count 7.2, platelets 263,000, sodium 139, potassium 4.9, chloride 100, CO2 25, BUN 46, creatinine 2.3, glucose 162, albumin 4.7, LFTs are normal. CK was elevated at 653. A1c is 7.6%. LDL cholesterol is 68, HDL is 35. Urinalysis reveals microalbumin to creatinine ratio 59.8. UA was otherwise negative with a pH of 5. Today his urinalysis showed specific gravity 1.020, negative glucose, bilirubin, ketones and blood, 30 mg/dL of protein, pH of 5, negative nitrates, leukocyte esterase. Microscopic exam was bland. IMPRESSION:1. Acute on chronic kidney failure. He has underlying stage III CKD with the GFR approximately 41 mL/min. He has episodic hypotension at home and low diastolic pressure here. His weight is down 2 to 3 Kg from June and he may be prerenal. He also has a history of prostatic hypertrophy and obstruction must be investigated. I am also concerned about his use of Chinese herbs which can cause chronic interstitial nephritis, which I think is more likely that diabetic nephropathy. There is no evidence of pyuria today although this can present with a fairly bland sediment. An additional concern is that TriCor can cause an artifactual increase in the creatinine due to changes in metabolism. I think this would be a diagnosis of exclusion.2. Orthostatic hypotension. He is maintaining systolic but his diastolic pressures are gotten in to a point where he may not be perfusing his brain well.3. Elevated creatine kinase consistent with myositis. It could be a result of Crestor alone or combination of TriCor and Crestor. I do not think this is enough to cause rhabdomyolysis, however. RECOMMENDATIONS:1. The patient was cautioned about using NSAIDs and told to avoid any further Chinese herbs.2. Recheck labs including CBC with differential, SPEP, uric acid and renal panel.3. Decrease atenolol to 25 mg daily.4. Decrease enalapril to 10 mg daily.5. Decrease Lasix to 20 mg daily.6. Stop Crestor.7. Check renal ultrasound.8. See him back in two weeks for review of the studies." "42",42,"History and Physical","HISTORY OF PRESENT ILLNESS: The patient is a 71-year-old woman with history of coronary artery disease for which she has had coronary artery bypass grafting x2 and percutaneous coronary intervention with stenting x1. She also has a significant history of chronic renal insufficiency and severe COPD. The patient and her husband live in ABC but they have family in XYZ. She came to our office today as she is in the area visiting her family. She complains of having shortness of breath for the past month that has been increasingly getting worse. She developed a frequent nonproductive cough about 2 weeks ago. She has also had episodes of paroxysmal nocturnal dyspnea, awaking in the middle of the night, panicking from dyspnea and shortness of breath. She has also gained about 15 pounds in the past few months and has significant peripheral edema. In the office, she is obviously dyspnea and speaking in 2 to 3 word sentences. PAST MEDICAL HISTORY: Coronary artery disease, anemia secondary to chronic renal insufficiency, stage IV chronic kidney disease, diabetic nephropathy, hypertension, hyperlipidemia, COPD, insulin-dependent diabetes, mild mitral valve regurgitation, severe tricuspid valve regurgitation, sick sinus syndrome, gastritis, and heparin-induced thrombocytopenia. PAST SURGICAL HISTORY: Status post pacemaker implantation, status post CABG x4 in 1999 and status post CABG x2 in 2003, status post PCA stenting x1 to the left anterior descending artery, cholecystectomy, back surgery, bladder surgery, and colonic polypectomies. SOCIAL HISTORY: The patient is married. Lives with her husband. They are retired from ABC. MEDICATIONS:1. Plavix 75 mg p.o. daily.2. Aspirin 81 mg p.o. daily.3. Isosorbide mononitrate 60 mg p.o. daily.4. Colace 100 mg p.o. b.i.d.5. Atenolol 50 mg p.o. daily.6. Lantus insulin 15 units subcutaneously every evening.7. Protonix 40 mg p.o. daily.8. Furosemide 40 mg p.o. daily.9. Norvasc 5 mg p.o. daily. ALLERGIES: SHE IS ALLERGIC TO HEPARIN AGENTS, WHICH CAUSE HEPARIN-INDUCED THROMBOCYTOPENIA. REVIEW OF SYSTEMSCONSTITUTIONAL: Positive for generalized fatigue and malaise. HEAD AND NECK: Negative for diplopia, blurred vision, visual disturbances, hearing loss, tinnitus, epistaxis, vertigo, sinusitis, and gum or oral lesions. CARDIOVASCULAR: Positive for epigastric discomfort x2 weeks, negative for palpitations, syncope or near-syncopal episodes, chest pressure, and chest pain. RESPIRATORY: Positive for dyspnea at rest, paroxysmal nocturnal dyspnea, orthopnea, and frequent nonproductive cough. Negative for wheezing. ABDOMEN: Negative for abdominal pain, bloating, nausea, vomiting, constipation, melena, or hematemesis. GENITOURINARY: Negative for dysuria, polyuria, hematuria, or incontinence. MUSCULOSKELETAL: Negative for recent trauma, stiffness, deformities, muscular weakness, or atrophy. SKIN: Negative for rashes, petechiae, and hair or nail changes. Positive for easy bruising on forearms. NEUROLOGIC: Negative for paralysis, paresthesias, dysphagia, or dysarthria. PSYCHIATRIC: Negative for depression, anxiety, or mood swings.All other systems reviewed are negative. PHYSICAL EXAMINATIONVITAL SIGNS: Her blood pressure in the office was 188/94, heart rate 70, respiratory rate 18 to 20, and saturations 99% on room air. Her height is 63 inches. She is weighs 195 pounds and her BMI is 34.6. CONSTITUTIONAL: A 71-year-old woman in significant distress from shortness of breath and dyspnea at rest. HEENT: Eyes: Pupils are reactive. Sclera is nonicteric. Ears, nose, mouth, and throat. NECK: Supple. No lymphadenopathy. No thyromegaly. Swallow is intact. CARDIOVASCULAR: Positive JVD at 45 degrees. Heart tones are distant. S1 and S2. No murmurs. EXTREMITIES: Have 3+ edema in the feet and ankles bilaterally that extends up to her knees. Femoral pulses are weakly palpable. Posterior tibial pulses are not palpable. Capillary refill is somewhat sluggish. RESPIRATORY: Breath sounds are clear with some bilateral basilar diminishment. No rales and no wheezing. Speaking in 2 to 3 word sentences. Diaphragmatic excursions are limited. AP diameter is expanded. ABDOMEN: Soft and nontender. Active bowel sounds x4 quadrants. No hepatosplenomegaly. No masses are appreciated. GENITOURINARY: Deferred. MUSCULOSKELETAL: Adequate range of motion along with extremities. SKIN: Warm and dry. No lesions or ulcerations are noted. NEUROLOGIC: Alert and oriented x3. Head is normocephalic and atraumatic. No focal, motor, or sensory deficits. PSYCHIATRIC: Normal affect.IMPRESSION1. Coronary artery disease.2. Stage IV chronic renal insufficiency.3. Acute symptoms of congestive heart failure with 15 pound weight gain.4. Dyspnea on exertion and dyspnea at rest.5. Indigestion x2 weeks, which could be anginal equivalent.PLAN1. Routine labs to rule out acute myocardial infarction.2. Serial EKGs.3. Echocardiogram.4. Consider nuclear stress testing." "43",43,"History and Physical","CHIEF COMPLAINT: Multiple problems, main one is chest pain at night. HISTORY OF PRESENT ILLNESS: This is a 60-year-old female with multiple problems as numbered below:1. She reports that she has chest pain at night. This happened last year exactly the same. She went to see Dr. Murphy, and he did a treadmill and an echocardiogram, no concerns for cardiovascular disease, and her symptoms resolved now over the last month. She wakes in the middle of the night and reports that she has a pressure. It is mild-to-moderate in the middle of her chest and will stay there as long she lies down. If she gets up, it goes away within 15 minutes. It is currently been gone on for the last week. She denies any fast heartbeats or irregular heartbeats at this time.2. She has been having stomach pains that started about a month ago. This occurs during the daytime. It has no relationship to foods. It is mild in nature, located in the mid epigastric area. It has been better for one week as well.3. She continues to have reflux, has noticed that if she stops taking Aciphex, then she has symptoms. If she takes her Aciphex, she seems that she has the reflux belching, burping, and heartburn under control.4. She has right flank pain when she lies down. She has had this off and on for four months. It is a dull achy pain. It is mild in nature.5. She has some spots on her shoulder that have been present for a long time, but over the last month have been getting bigger in size and is elevated whereas they had not been elevated in the past. It is not painful.6. She has had spots in her armpits initially on the right side and then going to the left side. They are not itchy.7. She is having problems with urgency of urine. When she has her bladder full, she suddenly has an urge to use the restroom, and sometimes does not make it before she begins leaking. She is wearing a pad now.8. She is requesting a colonoscopy for screening as well. She is wanting routine labs for following her chronic leukopenia, also is desiring a hepatitis titer.9. She has had pain in her thumbs when she is trying to do fine motor skills, has noticed this for the last several months. There has been no swelling or redness or trauma to these areas. REVIEW OF SYSTEMS: She has recently been to the eye doctor. She has noticed some hearing loss gradually. She denies any problems with swallowing. She denies episodes of shortness of breath, although she has had a little bit of chronic cough. She has had normal bowel movements. Denies any black or bloody stools, diarrhea, or constipation. Denies seeing blood in her urine and has had no urinary problems other than what is stated above. She has had no problems with edema or lower extremity numbness or tingling. SOCIAL HISTORY: She works at nursing home. She is a nonsmoker. She is currently trying to lose weight. She is on the diet and has lost several pounds in the last several months. She quit smoking in 1972. FAMILY HISTORY: Her father has type I diabetes and heart disease. She has a brother who had heart attack at the age of 52. He is a smoker. PAST MEDICAL HISTORY: Episodic leukopenia and mild irritable bowel syndrome. CURRENT MEDICATIONS: Aciphex 20 mg q.d. and aspirin 81 mg q.d. ALLERGIES: No known medical allergies. OBJECTIVE:Vital Signs: Weight: 142 pounds. Blood pressure: 132/78. Pulse: 72.General: This is a well-developed adult female who is awake, alert, and in no acute distress. HEENT: Her pupils are equally round and reactive to light. Conjunctivae are white. TMs look normal bilaterally. Oropharynx appears to be normal. Dentition is excellent.Neck: Supple without lymphadenopathy or thyromegaly.Lungs: Clear with normal respiratory effort.Heart: Regular rhythm and rate without murmur. Radial pulses are normal bilaterally.Abdomen: Soft, nontender, and nondistended without organomegaly.Extremities: Examination of the hands reveals some tenderness at the base of her thumbs bilaterally as well as at the PIP joint and DIP joint. Her armpits are examined. She has what appears to be a tinea versicolor rash present in the armpits bilaterally. She has a lesion on her left shoulder, which is 6 mm in diameter. It has diffuse borders and is slightly red. It has two brown spots in it. In her lower extremities, there is no cyanosis or edema. Pulses at the radial and posterior tibial pulses are normal bilaterally. Her gait is normal.Psychiatric: Her affect is pleasant and positive.Neurological: She is grossly intact. Her speech seems to be clear. Her coordination of upper and lower extremities is normal.ASSESSMENT/ PLAN:1. Chest pain. At this point, because of Dr. Murphy�s evaluation last year and the symptoms exactly the same, I think this is noncardiac. My intonation is that this is reflux. I am going have her double her Aciphex or increase it to b.i.d., and I am going to have her see Dr. XYZ for possible EGD if he thinks that would be appropriate. She is to let me know if her symptoms are getting worse or if she is having any severe episodes.2. Stomach pain, uncertain at this point, but I feel like this is probably related as well to chest pain.3. Suspicious lesions on the left shoulder. We will do a punch biopsy and set her up for an appointment for that.4. Tinea versicolor in the axillary area. I have prescribed selenium sulfide lotion to apply 10 minutes a day for seven days.5. Cystocele. We will have her see Dr. XYZ for further discussion of repair due to her urinary incontinence.6. History of leukopenia. We will check a CBC.7. Pain in the thumbs, probably arthritic in nature, observe for now.8. Screening. We will have her see Dr. XYZ for discussion of colon cancer screening.9. Gastroesophageal reflux disease. I have increased Aciphex to b.i.d. for now." "44",44,"History and Physical","HISTORY OF PRESENT ILLNESS: The patient is a 61-year-old right-handed gentleman who presents for further evaluation of feet and hand cramps. He states that for the past six months he has experienced cramps in his feet and hands. He describes that the foot cramps are much more notable than the hand ones. He reports that he develops muscle contractions of his toes on both feet. These occur exclusively at night. They may occur about three times per week. When he develops these cramps, he stands up to relieve the discomfort. He notices that the toes are in an extended position. He steps on the ground and they seem to ""pop into place."" He develops calf pain after he experiences the cramp. Sometimes they awaken him from his sleep.He also has developed cramps in his hands although they are less severe and less frequent than those in his legs. These do not occur at night and are completely random. He notices that his thumb assumes a flexed position and sometimes he needs to pry it open to relieve the cramp.He has never had any symptoms like this in the past. He started taking Bactrim about nine months ago. He had taken this in the past briefly, but has never taken it as long as he has now. He cannot think of any other possible contributing factors to his symptoms.He has a history of HIV for 21 years. He was taking antiretroviral medications, but stopped about six or seven years ago. He reports that he was unable to tolerate the medications due to severe stomach upset. He has a CD4 count of 326. He states that he has never developed AIDS. He is considering resuming antiretroviral treatment. PAST MEDICAL HISTORY: He has diabetes, but this is well controlled. He also has hepatitis C and HIV. CURRENT MEDICATIONS: He takes insulin and Bactrim. ALLERGIES: He has no known drug allergies. SOCIAL HISTORY: He lives alone. He recently lost his partner. This happened about six months ago. He denies alcohol, tobacco, or illicit drug use. He is now retired. He is very active and walks about four miles every few days. FAMILY HISTORY: His father and mother had diabetes. REVIEW OF SYSTEMS: A complete review of systems was obtained and was negative except for as mentioned above. This is documented in the handwritten notes from today's visit. PHYSICAL EXAMINATION:Vital Signs: Blood pressure 130/70 HR 80 RR 18 Wt 153 poundsGeneral Appearance: Patient is well appearing, in no acute distress.Cardiovascular: There is a regular rhythm without murmurs, gallops, or rubs. There are no carotid bruits.Chest: The lungs are clear to auscultation bilaterally.Skin: There are no rashes or lesions.Musculoskeletal: There are no joint deformities or scoliosis. NEUROLOGICAL EXAMINATION:Mental Status: Speech is fluent without dysarthria or aphasia. The patient is alert and oriented to name, place, and date. Attention, concentration, registration, recall, and fund of knowledge are all intact.Cranial Nerves: Pupils are equal, round, and reactive to light and accommodation. Optic discs are normal. Visual fields are full. Extraocular movements are intact without nystagmus. Facial sensation is normal. There is no facial, jaw, palate, or tongue weakness. Hearing is grossly intact. Shoulder shrug is full.Motor: There is normal muscle bulk and tone. There is no atrophy or fasciculations. There is no action or percussion myotonia or paramyotonia. Manual muscle testing reveals MRC grade 5/5 strength in all proximal and distal muscles of the upper and lower extremities.Sensory: Sensation is intact to light touch, pinprick, temperature, vibratory sensation, and joint position sense. Romberg is absent.Coordination: There is no dysmetria or ataxia on finger-nose-finger or heel-to-shin testing.Reflexes: Deep tendon reflexes are 2+ at the biceps, triceps, brachioradialis, patellas and ankles. Plantar reflexes are flexor. There are no finger flexors, Hoffman's sign, or jaw jerk.Gait and Stance: Casual gait is normal. Heel, toe, and tandem walking are all normal. LABORATORY DATA: August 06, 2008: Glucose 122. BUN 23. CR 1.16. Ca 7.8. K 4.6. Na 135. ALT 85. AST 192. HIV positive. Hemoglobin A1c 5.5. CD4 326. HPV positive. HCT 37.9. PLT 129. ESR 34. ASSESSMENT: The patient is a 61-year-old gentleman with a longstanding history of HIV, who developed a recent history of nocturnal cramps in his feet and less frequent cramps in his hands. His neurological examination today is normal. I think it is possible that the cramps are related to the Bactrim. This is a very rare side effect, but it has been reported in the literature that patients can develop cramps due to this medication. He does not have any obvious metabolic abnormalities such as hypocalcemia, hypomagnesemia, or hypokalemia that can cause muscle cramps. He also does not have any evidence of an underlying neuromuscular disorder as I would expect him to have weakness or other abnormalities if this were the case. Certain metabolic myopathies can be associated with normal neurological examination and muscle cramps. This can be seen in the HIV patients who are taking antiretrovirals, but he has not been taking any of these medications for a long time. RECOMMENDATIONS:1. I think that he should try to stop taking the Bactrim and see if his symptoms improve. I told him that I would defer to his primary care physician for this option. Specifically, if there is another medication that he could take instead of Bactrim, this would be most desirable. He will discuss this with his primary care physician. If he cannot stop the medication, then I am not sure we would figure out if this is a true cause.2. I gave him a prescription for Neurontin. I discussed the side effects of the medication with the patient. I instructed him to slowly taper the dose over several days to 300 mg t.i.d. I am hopeful this will provide some symptomatic relief. If this does not, I would consider starting on baclofen.3. If he stops taking the medication and his pain improves, then I would consider pulling back on the Neurontin and seeing if he is completely asymptomatic. However, if he continues to be symptomatic despite stopping Bactrim, then I would consider performing further diagnostic testing such as an EMG and nerve conduction studies and ordering additional serologic testing such as a CPK." "45",45,"History and Physical","CHIEF COMPLAINT: Joints are hurting all over and checkup. HISTORY OF PRESENT ILLNESS: A 77-year-old white female who is having more problems with joint pain. It seems to be all over decreasing her mobility, hands and wrists. No real swelling but maybe just a little more uncomfortable than they have been. The Daypro generic does not seem to be helping at all. No fever or chills. No erythema.She actually is doing better. Her diarrhea now has settled down and she is having less urinary incontinence, less pedal edema. Blood sugars seem to be little better as well.The patient also has gotten back on her Zoloft because she thinks she may be depressed, sleeping all the time, just not herself and really is disturbed that she cannot be more mobile in things. She has had no polyuria, polydipsia, or other problems. No recent blood pressure checks. PAST MEDICAL HISTORY: Little over a year ago, the patient was found to have lumbar discitis and was treated with antibiotics and ended up having debridement and instrumentation with Dr. XYZ and is doing really quite well. She had a pulmonary embolus with that hospitalization. PAST SURGICAL HISTORY: She has also had a hysterectomy, salpingoophorectomy, appendectomy, tonsillectomy, two carpal tunnel releases. She also has had a parathyroidectomy but still has had some borderline elevated calcium. Also, hypertension, hyperlipidemia, as well as diabetes. She also has osteoporosis. SOCIAL HISTORY: The patient still smokes about a third of a pack a day, also drinks only occasional alcoholic drinks. The patient is married. She has three grown sons, all of which are very successful in professional positions. One son is a gastroenterologist in San Diego, California. MEDICATIONS: Nifedipine-XR 90 mg daily, furosemide 20 mg half tablet b.i.d., lisinopril 20 mg daily, gemfibrozil 600 mg b.i.d., Synthroid 0.1 mg daily, Miacalcin one spray in alternate nostrils daily, Ogen 0.625 mg daily, Daypro 600 mg t.i.d., also Lortab 7.5 two or three a day, also Flexeril occasionally, also other vitamin. ALLERGIES: She had some adverse reactions to penicillin, sulfa, perhaps contrast medium, and some mycins. FAMILY HISTORY: As far as heart disease there is none in the family. As far as cancer two cousins had breast cancer. As far as diabetes father and grandfather had type II diabetes. Son has type I diabetes and is struggling with that at the moment. REVIEW OF SYSTEMS:General: No fever, chills, or night sweats. Weight stable. HEENT: No sudden blindness, diplopia, loss of vision, i.e., in one eye or other visual changes. No hearing changes or ear problems. No swallowing problems or mouth lesions.Endocrine: Hypothyroidism but no polyuria or polydipsia. She watches her blood sugars. They have been doing quite well.Respiratory: No shortness of breath, cough, sputum production, hemoptysis or breathing problems.Cardiovascular: No chest pain or chest discomfort. No paroxysmal nocturnal dyspnea, orthopnea, palpitations, or heart attacks. GI: As mentioned, has had diarrhea though thought to be possibly due to Clostridium difficile colitis that now has gotten better. She has had some irritable bowel syndrome and bowel abnormalities for years. GU: No urinary problems, dysuria, polyuria or polydipsia, kidney stones, or recent infections. No vaginal bleeding or discharge.Musculoskeletal: As above.Hematological: She has had some anemia in the past.Neurological: No blackouts, convulsions, seizures, paralysis, strokes, or headaches. PHYSICAL EXAMINATION:Vital Signs: Weight is 164 pounds. Blood pressure: 140/64. Pulse: 72. Blood pressure repeated by me with the patient sitting taken on the right arm is 148/60, left arm 136/58; these are while sitting on the exam table.General: A well-developed pleasant female who is comfortable in no acute distress otherwise but she does move slowly. HEENT: Skull is normocephalic. TMs intact and shiny with good auditory acuity to finger rub. Pupils equal, round, reactive to light and accommodation with extraocular movements intact. Fundi benign. Sclerae and conjunctivae were normal.Neck: No thyromegaly or cervical lymphadenopathy. Carotids are 2+ and equal bilaterally and no bruits present.Lungs: Clear to auscultation and percussion with good respiratory movement. No bronchial breath sounds, egophony, or rales are present.Heart: Regular rhythm and rate with no murmurs, gallops, rubs, or enlargement. PMI normal position. All pulses are 2+ and equal bilaterally.Abdomen: Obese, soft with no hepatosplenomegaly or masses.Breasts: No predominant masses, discharge, or asymmetry.Pelvic Exam: Normal external genitalia, vagina and cervix. Pap smear done. Bimanual exam shows no uterine enlargement and is anteroflexed. No adnexal masses or tenderness. Rectal exam is normal with soft brown stool Hemoccult negative.Extremities: The patient does appear to have some doughiness of all of the MCP joints of the hands and the wrists as well. No real erythema. There is no real swelling of the knees. No new pedal edema.Lymph nodes: No cervical, axillary, or inguinal adenopathy.Neurological: Cranial nerves II-XII are grossly intact. Deep tendon reflexes are 2+ and equal bilaterally. Cerebellar and motor function intact in all extremities. Good vibratory and positional sense in all extremities and dermatomes. Plantar reflexes are downgoing bilaterally. LABORATORY: CBC shows a hemoglobin of 10.5, hematocrit 35.4, otherwise normal. Urinalysis is within normal limits. Chem profile showed a BUN of 54, creatinine 1.4, glucose 116, calcium was 10.8, cholesterol 198, triglycerides 171, HDL 43, LDL 121, TSH is normal, hemoglobin A1C is 5.3. ASSESSMENT:1. Arthralgias that are suspicious for inflammatory arthritis, but certainly seems to be more active and bothersome. I think we need to look at this more closely.2. Diarrhea that seems to have resolved. Whether this is related to the above is unclear.3. Diabetes mellitus type II, really fairly well controlled.4. Hypertension, fair.5. Hypercholesterolemia, could be a little better, particularly with the diabetes. We may need to address that further but at this point I want to work on some of the other things.6. Hyperparathyroidism that has been a persistent problem despite having the parathyroidectomy. Whether this has anything to do with the arthralgias is unclear.7. Osteoporosis, being treated.8. Depression, possibly. I agree with going back on the Zoloft for which she is taking 50 mg daily. PLAN: We will obtain an x-ray of both hands. We will also obtain a sedimentation rate, rheumatoid factor, and have her see Dr. Mortensen. Continue other medication. We will also have her return in three months and we will go from there. Continue all of her other medications at this point." "46",46,"History and Physical","CHIEF COMPLAINT: Weak and shaky. HISTORY OF PRESENT ILLNESS: The patient is a 75-year-old, Caucasian female who comes in today with complaint of feeling weak and shaky. When questioned further, she described shortness of breath primarily with ambulation. She denies chest pain. She denies cough, hemoptysis, dyspnea, and wheeze. She denies syncope, presyncope, or palpitations. Her symptoms are fairly longstanding but have been worsening as of late. PAST MEDICAL HISTORY: She has had a fairly extensive past medical history but is a somewhat poor historian and is unable to provide details about her history. She states that she has underlying history of heart disease but is not able to elaborate to any significant extent. She also has a history of hypertension and type II diabetes but is not currently taking any medication. She has also had a history of pulmonary embolism approximately four years ago, hyperlipidemia, peptic ulcer disease, and recurrent urinary tract infections. Surgeries include an appendectomy, cesarean section, cataracts, and hernia repair. CURRENT MEDICATIONS: She is on two different medications, neither of which she can remember the name and why she is taking it. ALLERGIES: She has no known medical allergies. FAMILY HISTORY: Remarkable for coronary artery disease, stroke, and congestive heart failure. SOCIAL HISTORY: She is a widow, lives alone. Denies any tobacco or alcohol use. REVIEW OF SYSTEMS: Dyspnea on exertion. No chest pain or tightness, fever, chills, sweats, cough, hemoptysis, or wheeze, or lower extremity swelling. PHYSICAL EXAMINATION:General: She is alert but seems somewhat confused and is not able to provide specific details about her past history.Vital Signs: Blood pressure: 146/80. Pulse: 68. Weight: 147 pounds. HEENT: Unremarkable.Neck: Supple without JVD, adenopathy, or bruit.Chest: Clear to auscultation.Cardiovascular: Regular rate and rhythm.Abdomen: Soft.Extremities: No edema. LABORATORY: O2 sat 100% at rest and with exertion. Electrocardiogram was normal sinus rhythm. Nonspecific S-T segment changes. Chest x-ray pending.ASSESSMENT/ PLAN:1. Dyspnea on exertion, uncertain etiology. Mother would be concerned about the possibility of coronary artery disease given the patient�s underlying risk factors. We will have the patient sign a release of records so that we can review her previous history. Consider setting up for a stress test.2. Hypertension, blood pressure is acceptable today. I am not certain as to what, if the patient’s is on any antihypertensive agents. We will need to have her call us what the names of her medications, so we can see exactly what she is taking.3. History of diabetes. Again, not certain as to whether the patient is taking anything for this particular problem when she last had a hemoglobin A1C. I have to obtain some further history and review records before proceeding with treatment recommendations." "47",47,"History and Physical","HISTORY OF PRESENT ILLNESS: A 50-year-old female comes to the clinic with complaint of mood swings and tearfulness. This has been problematic over the last several months and is just worsening to the point where it is impairing her work. Her boss asks her if she was actually on drugs in which she said no. She stated may be she needed to be, meaning taking some medications. The patient had been prescribed Wellbutrin in the past and responded well to it; however, at that time it was prescribed for obsessive-compulsive type disorder relating to overeating and therefore her insurance would not cover the medication. She has not been on any other antidepressants in the past. She is not having any suicidal ideation but is having difficulty concentrating, rapid mood swings with tearfulness, and insomnia. She denies any hot flashes or night sweats. She underwent TAH with BSO in December of 2003. FAMILY HISTORY: Benign breast lump in her mother; however, her paternal grandmother had breast cancer. The patient denies any palpitations, urinary incontinence, hair loss, or other concerns. She was recently treated for sinusitis. ALLERGIES: She is allergic to Sulfa. CURRENT MEDICATIONS: Recently finished Minocin and Duraphen II DM. PHYSICAL EXAMINATION:General: A well-developed and well-nourished female, conscious, alert, oriented times three in no acute distress. Mood is dysthymic. Affect is tearful.Skin: Without rash.Eyes: PERRLA. Conjunctivae are clear.Neck: Supple with adenopathy or thyromegaly.Lungs: Clear.Heart: Regular rate and rhythm without murmur. ASSESSMENT:1. Postsurgical menopause.2. Mood swings. PLAN: I spent about 30 minutes with the patient discussing treatment options. I do believe that her moods would greatly benefit from hormone replacement therapy; however, she is reluctant to do this because of family history of breast cancer. We will try starting her back on Wellbutrin XL 150 mg daily. She may increase to 300 mg daily after three to seven days. Samples provided initially. If she is not obtaining adequate relief from medication alone, we will then suggest that we explore the use of hormone replacement therapy. I also recommended increasing her exercise. We will also obtain some screening lab work including CBC, UA, TSH, chemistry panel, and lipid profile. Follow up here in two weeks or sooner if any other problems. She is needing her annual breast exam as well." "48",48,"Discharge Summary","CHIEF COMPLAINT: Headache and pain in the neck and lower back. HISTORY OF PRESENT ILLNESS: The patient is a 34 year old white man with AIDS (CD4 -67, VL -341K) and Castleman’s Disease who presents to the VA Hospital complaining of headaches, neck pain, and lower back pain over the last 2-3 weeks. He was hospitalized 3 months prior to his current presentation with abdominal pain and diffuse lymphadenopathy. Excisional lymph node biopsy during that admission showed multicentric Castleman’s Disease. He was started on cyclophosphamide and prednisone and his lymphadenopathy dramatically improved. His hospitalization was complicated by the development of acute renal failure from tumor lysis syndrome and he required hemodialysis for only a few sessions. The patient was discharged on HAART and later returned for 2 cycles of modified CHOP chemotherapy.Approximately five weeks prior to his current presentation, the patient was involved in a motor vehicle accident at 40 mph. He said he was not wearing his seatbelt and had hit his head on the roof of the car. He did not lose consciousness. The patient went to the VA ER but left against medical advice prior to being fully evaluated. Records showed that the patient had complained of some neck soreness but he was able to move his neck without any difficulty.Two weeks later, the patient started having headaches, neck and lower back pain during a road trip with his family to Mexico . He returned to Houston and approximately one week prior to admission, the patient presented to the VA ER for further evaluation. Spinal films were unremarkable and the patient was sent home on pain medications with a diagnosis of muscle strain. The patient followed up with his primary care physician and was admitted for further workup.On the day of admission, the patient complains of severe pain that is worse in the lower back than in the neck. The pain is 7-8 out of 10 and does not radiate. He also complains of diffuse headaches and intermittent blurriness of his vision. He complains of having a very stiff neck that hurts when he bends it. He denies any fevers, chills, or night sweats. He denies any numbness or tingling of his extremities and he denies any bowel or bladder incontinence. None of the medications that he takes provides adequate relief of his pain.Regarding his AIDS and Castleman’s Disease, his lymphadenopathy have completely resolved by physical exam. He no longer has any of the symptoms from his previous hospitalization. He is scheduled to have his next cycle of chemotherapy during the week of his current admission. He has been noncompliant with his HAART and has been off the medications for >3 weeks.Past Medical History: HIV diagnosed 11 years ago. No history of opportunistic infections. Recently diagnosed with Castleman’s Disease (9/03) from excisional lymph node biopsy s/p cyclophosphamide/prednisone ( 9/25/03 ) and modified CHOP ( 10/15/03 , 11/10/03 ). Last CD4 count is 67 and viral load is 341K (9/03). Currently is off HAART x 3 weeks because of noncompliance. PAST SURGICAL HISTORY: Excisional lymph node biopsy (9/03). FAMILY HISTORY: There was no history of hypertension, coronary artery disease, stroke, cancer or diabetes. SOCIAL HISTORY: Patient is single and he lives alone. He is heterosexual and has a history of sexual encounter with prostitutes in Japan. He works as a plumber over the last 5 years. He smokes and drinks occasionally and denies any history of IV drug use. No blood transfusion. No history of incarceration. Recently traveled to Mexico . MEDICATION: Tylenol #3 q6h prn, ibuprofen 800 mg q8h prn, methocarbamol 750 mg qid. ALLERGIES: Sulfa (rash). REVIEW OF SYSTEMS: The patient complains of feeling weak and fatigued. He has no appetite over the past week and has lost 8 pounds during this period. No chest pain, palpitations, shortness of breath or coughing. He denies any nausea, vomiting, or abdominal pain. No focal neuro deficits. Otherwise, as stated in HPI. PHYSICAL EXAM: VS: T 98 BP 121/89 P 80 R 20 O2 Sat 100% on room air.Ht: 5'9"" Wt: 159 lbs. GEN: Well developed man in no apparent distress. Alert and Oriented X 3. HEENT: Pupils equally round and reactive to light. Extra-ocular movements intact. Anicteric. Papilledema present bilaterally. Moist mucous membranes. No oropharyngeal lesions. NECK: Stiff, difficulty with neck flexion; no lymphadenopathy LUNGS: Clear to auscultation bilaterally. CV: Regular rate and rhythm. No murmurs, gallops, rubs. ABD: Soft with active bowel sounds. Nontender/Nondistended. No rebound or guarding. No hepatosplenomegaly. EXT: No clubbing, cyanosis, or edema. 2+ pulses bilaterally. BACK: No point tenderness to spine NEURO: Cranial nerves intact. 2+ DTRs bilaterally and symmetrically. Motor strength and sensation within the normal limits. LYMPH: No cervical, axillary, or inguinal lymph nodes palpated SKIN: warm, no rashes, no lesions STUDIES:C-spine/lumbosacral spine (11/30): Within normal limits.CXR (12/8): Normal heart size, no infiltrate. Hila and mediastinum are not enlarged.CT Head with and without contrast (12/8): Ventriculomegaly and potentially minor hydrocephalus. Otherwise normal CT scan of the brain. No evidence of abnormal enhancement of the brain or mass lesions within the brain or dura. HOSPITAL COURSE: The patient was admitted to the medicine floor and a lumbar puncture was performed. The opening pressure was greater than 55. The CSF results are shown in the table. A diagnostic study was sent." "49",49,"Discharge Summary","CHIEF COMPLAINT: ""I can�t walk as far as I used to."" HISTORY OF PRESENT ILLNESS: The patient is a 66-year-old African American gentleman with a past medical history of atrial fibrillation and arthritis who presented c/o progressively worsening shortness of breath. The patient stated that he had been in his usual state of health six years ago at which time he had been able to walk more than five blocks without difficulty. Approximately five years prior to admission, he began to note a decreased tolerance to exercise. This progressed with a gradual worsening in his functional capacity such that he is presently unable to walk for more than 25 feet. Over the two years prior to admission, he has been having a gradually worsening non-productive cough associated with shortness of breath. His shortness of breath is worse when he lies flat, and he periodically wakes at night gasping for air. He sleeps with three pillows. He has also noted swelling of his legs and states that he has had two episodes of syncope at home for which he has not sought medical attention. Approximately one month prior to admission he was seen in an outside clinic where he states that he was started on medications for heart failure. He stated that he had had a brother who died of heart failure at age 72.He did report that he had had an episode of hemoptysis approximately 2 years prior to admission for which he did not seek medical attention. He denied any history of chest pain and did not report any history of myocardial infarction. He denied fever, chills, and night sweats. He denied diarrhea, dysuria, hematuria, urgency and frequency. He denied any history of rash. He had been diagnosed with osteoarthritis of the knees and had undergone arthroscopy years prior to admission. PAST MEDICAL HISTORY : Atrial fibrillation on anticoagulation, osteoarthritis of the knees bilaterally, h/o retinal tear. PAST SURGICAL HISTORY : Hernia repair, bilateral arthroscopic evaluation, h/o surgical correction of retinal tear. FAMILY HISTORY: The Father of the patient died at age 69 with a CVA. The Mother of the patient died at age 79 when her ""heart stopped"". There were 12 siblings. Four siblings have died, two due to diabetes, one cause unknown, and one brother died at age 72 with heart failure. The patient has four children with no known medical problems. SOCIAL HISTORY: The patient retired one year PTA due to his disability. He was formerly employed as an electronic technician for the US postal service. The patient lives with his wife and daughter in an apartment. He denied any smoking history. He used to drink alcohol rarely but stopped entirely with the onset of his symptoms. He denied any h/o drug abuse. He denied any recent travel history. MEDICATIONS:1. Spironolactone 25 mg po qd.2. Digoxin 0.125 mg po qod.3. Coumadin 3 mg Monday and Tuesday and 4.5 mg Saturday and Sunday.4. Metolazone 10 mg po qd.5. Captopril 25 mg po tid.6. Torsemide 40 mg po qam and 20 mg po qpm.7. Carvedilol 3.125 mg po bid. ALLERGIES: No known drug allergies. REVIEW OF SYSTEMS: No headaches. No visual, hearing, or swallowing difficulties. No changes in bowel or urinary habits. PHYSICAL EXAM:Temperature: 98.4 degrees Fahrenheit.Blood pressure: 134/84.Heart rate: 98 beats per minute.Respiratory rate: 18 breaths per minute.Pulse oximetry: 92% on 2L O 2 via nasal canula. GEN: Elderly gentleman lying in bed in mild respiratory distress, thin, tired appearing, wife and daughter present at bedside, articulate. HEENT: The right eye was opacified. The left pupil was reactive to light. There was mild bitemporal wasting. The tongue was moist. There was no lymphadenopathy. The sclerae were anicteric. The oropharynx was clear. The conjunctivae were pink. NECK: The neck was supple with 15 cm of jugular venous distension. HEART: Irregularly irregular. No murmurs, gallops, rubs. No displaced PMI. LUNGS: Breath sounds were absent over two thirds of the right lower lung field. There were trace crackles at the left base. ABDOMEN: Soft, nontender, nondistended, bowel sounds were present. There was no hepatosplenomegaly. No rebound or guarding. EXT: Bilateral pitting edema to the thighs with diminished peripheral pulses bilaterally. NEURO: The patient was alert and oriented x three. Cranial nerves were intact. The DTRs were 2+ bilaterally and symmetrically. Motor strength and sensation were within normal limits. LYMPH: No cervical, axillary, or inguinal lymph nodes were present. SKIN: Warm, no rashes, no lesions; no tattoos. MUSCULOSKELETAL: No synovitis. There were no joint deformities. Full range of motion b/l throughout. STUDIES: CXR: Large right sided pleural effusion. A small pleural effusion with atelectatic changes are seen on the left. The heart size is borderline. ECHO: LV size is normal. There is severe concentric LV hypertrophy. Global hypokinesis. LV function is severely depressed. Estimate EF is 20-24%. There is RV hypertrophy. RV size is mildly enlarged. RV function is severely depressed. RV wall motion is severely hypokinetic. LA size is moderately enlarged. RA size is mildly enlarged. Trace aortic regurgitation. Moderate tricuspid regurgitation. Estimated PA systolic pressure is 46-51 mmHg, assuming a mean RAP of 15-20mmHg. Small anterior and posterior pericardial effusion. HOSPITAL COURSE: The patient was admitted to the hospital for workup and management. A diagnostic procedure was performed." "50",50,"Discharge Summary","CHIEF COMPLAINT: Abdominal pain and discomfort for 3 weeks. HISTORY OF PRESENT ILLNESS: The patient is a 38 year old white female with no known medical problems who presents complaining of abdominal pain and discomfort for 3 weeks. She had been in her normal state of health when she started having this diffuse abdominal pain and discomfort which is mostly located in the epigastrium and right upper quadrant. She also complains of indigestion and right scapular pain during this same period. None of these complaints are alleviated or aggravated by food. She denies any NSAIDs use. The patient went to an outside hospital where a right upper quadrant ultrasound showed no gallbladder disease, but was suspicious for a liver mass. A CT and MRI of the abdomen and pelvis showed a 12.5 X 10.9 X 11.1 cm right suprarenal mass and a 7.1 X 5.4 X 6.5 cm intrahepatic mass in the region of the dome of the liver. CT of the chest revealed multiple small (<5 mm) bilateral lung nodules. Total body bone scan had no abnormal uptake. She was transferred to Methodist for further care.The patient reports having a good appetite and denies any weight loss. She denies having any fever or chills. She has noticed increasing dyspnea with moderate exercise, but not at rest. She denies having palpitations. She occasionally has nausea, but no vomiting, constipation, or diarrhea. Over the last 2 months, she has noticed increasing facial hair and a mustache.There is an extensive family history of colon and other cancers in her family. She was told there is a genetic defect in her family but cannot recall the name of the syndrome. She had a colonoscopy and a polyp removed at the age of 14 years old. Her last colonoscopy was 2 months ago and was unremarkable. PAST MEDICAL HISTORY : None. No history of hypertension, diabetes, heart disease, liver disease or cancer. PAST SURGICAL HISTORY: Bilateral tubal ligation in 2001, colon polyp removed at 14 years old. GYN HISTORY: Gravida 2, Para 2, Ab 0. Menstrual periods have been regular, last menstrual period almost 1 month ago. No menorrhagia. Never had a mammogram. Has yearly Pap smears which have all been normal. FAMILY HISTORY: Mother is 61 years old and brother is 39 years old, both alive and well. Father died at 48 of colon cancer and questionable pancreatic cancer. One paternal uncle died at 32 of colon cancer and bile duct cancer. One paternal uncle had colon cancer in his 40s. Thirty cancers are noted on the father�s side of the family, many are colon; two women had breast cancer. The family was told that there is a genetic syndrome in the family, but no one remembers the name of the syndrome. SOCIAL HISTORY: No tobacco, alcohol or illicit drug use. Patient is born and raised in Oklahoma . No known exposures. Married with 2 children. MEDICATION: None. REVIEW OF SYSTEMS: No headaches. No visual, hearing, or swallowing difficulties. No cough or hemoptysis. No chest pain, PND, orthopnea. No changes in bowel or urinary habits. Otherwise, as stated in HPI. PHYSICAL EXAM: VS: T 97.6 BP 121/85 P 84 R 18 O2 Sat 100% on room air GEN: Pleasant, thin woman in mild distress secondary to abdominal pain and discomfort. HEENT: Pupils equally round and reactive to light. Extra-ocular movements intact. Anicteric. Sclerae clear. Pink conjunctiva. Moist mucous membranes. No oropharyngeal lesions. NECK: Supple, no masses, jugular venous distention or bruits. LUNGS: Clear to auscultation bilaterally. HEART: Regular rate and rhythm. No murmurs, gallops, rubs. BREASTS: Symmetric, no skin changes, no discharge, no masses ABDOMEN: Soft with active bowel sounds. There is minimal diffuse tenderness on examination. No masses palpated. There is fullness in the right upper quadrant with negative Murphy’s sign. No rebound or guarding. The liver span is 12 cm by percussion, but not palpable below the costal margin. No splenomegaly. PELVIC: not done EXT: No clubbing, cyanosis, or edema. 2+ pulses bilaterally. NEURO: Cranial nerves intact. 2+ DTRs bilaterally and symmetrically. Motor strength and sensation within the normal limits. LYMPH: No cervical, axillary, or inguinal lymph nodes palpated SKIN: warm, no rashes, no lesions; no tattoos STUDIES:CT Chest: Multiple bilateral small (<5 mm) pulmonary nodules, no mediastinal mass or hilar adenopathy.MRI Abdomen: 12.5 x 10.9 x 11.1 cm suprarenal mass, 7.1 x 5.4 x 6.5 cm intrahepatic lesion in the region of the dome of the liver, abnormal signal intensity within the inferior vena cava at the level of porta hepatic worrisome for thrombus.Total Body Bone Scan: No abnormal uptake. HOSPITAL COURSE: The patient was transferred from an outside hospital for further workup and management. She was taken to the Operating Room for abdominal exploration. A liver biopsy was done." "51",51,"History and Physical","CHIEF COMPLAINT: Mental changes today. HISTORY OF PRESENT ILLNESS: This patient is a resident from Mazatlan, Mexico, visiting her son here in Utah, with a history of diabetes. She usually does not take her meal on time, and also not having her regular meals lately. The patient usually still takes her diabetic medication. Today, the patient was found to have decrease in mental alertness, but no other GI symptoms. Some sweating and agitation, but no fever or chills. No other rash. Because of the above symptoms, the patient was treated in the emergency department here. She was found to glucose in 30 range, and hypertension. There was some question whether she also take her blood pressure medication or not. Because of the above symptoms, the patient was admitted to the hospital for further care. The patient was given labetalol IV and also Norvasc blood pressure, and also some glucose supplement. At this time, the patient's glucose was in the 175 range. PAST MEDICAL HISTORY: Diabetes, hypertension. PAST SURGICAL HISTORY: None. FAMILY HISTORY: Unremarkable. ALLERGIES: No known drug allergies. MEDICATIONS: In Spanish label. They are the diabetic medication, and also blood pressure medication. She also takes aspirin a day. SOCIAL HISTORY: The patient is a Mazatlan, Mexico resident, visiting her son here. PHYSICAL EXAMINATION: GENERAL: The patient appears to be no acute distress, resting comfortably in bed, alert, oriented x3, and coherent through interpreter. HEENT: Clear, atraumatic, normocephalic. No sinus tenderness. No obvious head injury or any laceration. Extraocular movements are intact. Dry mucosal linings. HEART: Regular rate and rhythm, without murmur. Normal S1, S2. LUNGS: Clear. No rales. No wheeze. Good excursion. ABDOMEN: Soft, active bowel sounds in 4 quarters, nontender, no organomegaly. EXTREMITIES: No edema, clubbing, or cyanosis. No rash. LABORATORY FINDINGS: On Admission: CPK, troponin are negative. CMP is remarkable for glucose of 33. BMP is remarkable for BUN of 60, creatinine is 4.3, potassium 4.7. Urinalysis shows specific gravity of 10.30. CT of the brain showed no hemorrhage. Chest x-ray showed no acute cardiomegaly or any infiltrates. IMPRESSION:1. Hypoglycemia due to not eating her meals on a regular basis.2. Hypertension.3. Renal insufficiency, may be dehydration, or diabetic nephropathy. PLAN: Admit the patient to the medical ward, IV fluid, glucometer checks, and adjust the blood pressure medication and also diabetic medication." "52",52,"History and Physical","CHIEF COMPLAINT: A 74-year-old female patient admitted here with altered mental status. HISTORY OF PRESENT ILLNESS: The patient started the last 3-4 days to do poorly. She was more confused, had garbled speech, significantly worse from her baseline. She has also had decreased level of consciousness since yesterday. She has had aphasia which is baseline but her aphasia has gotten significantly worse. She eventually became unresponsive and paramedics were called. Her blood sugar was found to be 40 because of poor p.o. intake. She was given some D50 but that did not improve her mental status, and she was brought to the emergency department. By the time she came to the emergency department, she started having some garbled speech. She was able to express her husband's name and also recognize some family members, but she continued to be more somnolent when she was in the emergency department. When seen on the floor, she is more awake, alert. PAST MEDICAL HISTORY: Significant for recurrent UTIs as she was recently to the hospital about 3 weeks ago for urinary tract infection. She has chronic incontinence and bladder atony, for which eventually it was decided for the care of the patient to put a Foley catheter and leave it in place. She has had right-sided CVA. She has had atrial fibrillation status post pacemaker. She is a type 2 diabetic with significant neuropathy. She has also had significant pain on the right side from her stroke. She has a history of hypothyroidism. Past surgical history is significant for cholecystectomy, colon cancer surgery in 1998. She has had a pacemaker placement. REVIEW OF SYSTEMS: GENERAL: No recent fever, chills. No recent weight loss. PULMONARY: No cough, chest congestion. CARDIAC: No chest pain, shortness of breath. GI: No abdominal pain, nausea, vomiting. No constipation. No bleeding per rectum or melena. GENITOURINARY: She has had frequent urinary tract infection but does not have any symptoms with it. ENDOCRINE: Unable to assess because of patient's bed-bound status. MEDICATIONS: Percocet 2 tablets 4 times a day, Neurontin 1 tablet b.i.d. 600 mg, Cipro recently started 500 b.i.d., Humulin N 30 units twice a day. The patient had recently reduced that to 24 units. MiraLax 1 scoop nightly, Avandia 4 mg b.i.d., Flexeril 1 tablet t.i.d., Synthroid 125 mcg daily, Coumadin 5 mg. On the medical records, it shows she is also on ibuprofen, Lasix 40 mg b.i.d., Lipitor 20 mg nightly, Reglan t.i.d. 5 mg, Nystatin powder. She is on oxygen chronically.SOCIAL/ FAMILY HISTORY: She is married, lives with her husband, has 2 children that passed away and 4 surviving children. No history of tobacco use. No history of alcohol use. Family history is noncontributory. PHYSICAL EXAMINATION: GENERAL: She is awake, alert, appears to be comfortable. VITAL SIGNS: Blood pressure 111/43, pulse 60 per minute, temperature 37.2. Weight is 98 kg. Urine output is so far 1000 mL. Her intake has been fairly similar. Blood sugars are 99 fasting this morning. HEENT: Moist mucous membranes. No pallor NECK: Supple. She has a rash on her neck. HEART: Regular rhythm, pacemaker could be palpated. CHEST: Clear to auscultation. ABDOMEN: Soft, obese, nontender. EXTREMITIES: Bilateral lower extremities edema present. She is able to move the left side more efficiently than the right. The power is about 5 x 5 on the left and about 3-4 x 5 on the right. She has some mild aphasia. DIAGNOSTIC STUDIES: BUN 48, creatinine 2.8. LFTs normal. She is anemic with a hemoglobin of 9.6, hematocrit 29. INR 1.1, pro time 14. Urine done in the emergency department showed 20 white cells. It was initially cloudy but on the floor it has cleared up. Cultures from the one done today are pending. The last culture done on August 20 showed guaiac negative status and prior to that she has had mixed cultures. There is a question of her being allergic to Septra that was used for her last UTI.IMPRESSION/ PLAN:1. Cerebrovascular accident as evidenced by change in mental status and speech. She seems to have recovered at this point. We will continue Coumadin. The patient's family is reluctant in discontinuing Coumadin but they do express the patient since has overall poor quality of life and had progressively declined over the last 6 years, the family has expressed the need for her to be on hospice and just continue comfort care at home.2. Recurrent urinary tract infection. Will await culture at this time, continue Cipro.3. Diabetes with episode of hypoglycemia. Monitor blood sugar closely, decrease the dose of Humulin N to 15 units twice a day since intake is poor. At this point, there is no clear evidence of any benefit from Avandia but will continue that for now.4. Neuropathy, continue Neurontin 600 mg b.i.d., for pain continue the Percocet that she has been on.5. Hypothyroidism, continue Synthroid.6. Hyperlipidemia, continue Lipitor.7. The patient is not to be resuscitated. Further management based on the hospital course." "53",53,"History and Physical","MEDICAL PROBLEM LIST:1. Status post multiple cerebrovascular accidents and significant left-sided upper extremity paresis in 2006.2. Dementia and depression.3. Hypertension.4. History of atrial fibrillation. The patient has been in sinus rhythm as of late. The patient is not anticoagulated due to fall risk.5. Glaucoma.6. Degenerative arthritis of her spine.7. GERD.8. Hypothyroidism.9. Chronic rhinitis (the patient declines nasal steroids).10. Urinary urge incontinence.11. Chronic constipation.12. Diabetes type II, 2006.13. Painful bunions on feet bilaterally. CURRENT MEDICINES: Aspirin 81 mg p.o. daily, Cymbalta 60 mg p.o. daily, Diovan 80 mg p.o. daily, felodipine 5 mg p.o. daily, omeprazole 20 mg daily, Toprol-XL 100 mg daily, Levoxyl 50 mcg daily, Lantus insulin 12 units subcutaneously h.s., simvastatin 10 mg p.o. daily, AyrGel to both nostrils twice daily, Senna S 2 tablets twice daily, Timoptic 1 drop both eyes twice daily, Tylenol 1000 mg 3 times daily, Xalatan 0.005% drops 1 drop both eyes at bedtime, and Tucks to rectum post BMs. ALLERGIES: NO KNOWN DRUG ALLERGIES. ACE INHIBITOR MAY HAVE CAUSED A COUGH. CODE STATUS: Do not resuscitate, healthcare proxy, palliative care orders in place. DIET: No added salt, no concentrated sweets, thin liquids. RESTRAINTS: None. The patient has declined use of chair check and bed check. INTERVAL HISTORY: Overall, the patient has been doing reasonably well. She is being treated for some hemorrhoids, which are not painful for her. There has been a note that she is constipated.Her blood glucoses have been running reasonably well in the morning, perhaps a bit on the high side with the highest of 188. I see a couple in the 150s. However, I also see one that is in the one teens and a couple in the 120s range.She is not bothered by cough or rib pain. These are complaints, which I often hear about.Today, I reviewed Dr. Hudyncia's note from psychiatry. Depression responded very well to Cymbalta, and the plan is to continue it probably for a minimum of 1 year.She is not having problems with breathing. No neurologic complaints or troubles. Pain is generally well managed just with Tylenol. PHYSICAL EXAMINATION: Vitals: As in chart. The patient is pleasant and cooperative. She is in no apparent distress. Her lungs are clear to auscultation and percussion. Heart sounds regular to me. Abdomen: Soft. Extremities without any edema. At the rectum, she has a couple of large hemorrhoids, which are not thrombosed and are not tender. ASSESSMENT AND PLAN:1. Hypertension, good control, continue current.2. Depression, well treated on Cymbalta. Continue.3. Other issues seem to be doing pretty well. These include blood pressure, which is well controlled. We will continue the medicines. She is clinically euthyroid. We check that occasionally. Continue Tylenol.4. For the bowels, I will increase the intensity of regimen there. I have a feeling she would not tolerate either the FiberCon tablets or Metamucil powder in a drink. I will try her on annulose and see how she does with that." "54",54,"History and Physical","Chief Complaint: Dark urine and generalized weakness.History of Present Illness:40 year old Hispanic male presented to the emergency room complaining of generalized weakness, fatigue and dark urine for one week. In addition, he stated that his family had noticed yellowing of his skin and eyes, though he himself had not noticed.He did complain of subjective fever and chills along with occasional night sweats during the prior week or so and he noted anorexia for 3-4 weeks leading to 26 pound weight loss (213 lbs. to 187 lbs.). He was nauseated but denied vomiting. He did admit to intermittent abdominal discomfort which he could not localize. In addition, he denied any history of liver disease, but had undergone cholecystectomy many years previous.Past Medical History: DM II-HbA1c unknownPast Surgical History: Cholecystectomy without complicationFamily History: Mother with diabetes and hypertension. Father with diabetes. Brother with cirrhosis (etiology not documented).Social History: He was unemployed and denied any alcohol or drug use. He was a prior �mild” smoker, but quit 10 years previous.Medications: Insulin (unknown dosage)Allergies: No known drug allergies.Physical Exam:Temperature: 98.2Blood pressure:118/80Heart rate: 95Respiratory rate: 18 GEN: Middle age Latin-American Male, jaundice, alert and oriented to person/place/time. HEENT: Normocephalic, atraumatic. Icteric sclerae, pupils equal, round and reactive to light. Clear oropharynx. NECK: Supple, without jugular venous distension, lymphadenopathy, thyromegaly or carotid bruits. CV: Regular rate and rhythm, normal S1 and S2. No murmurs, gallops or rubs PULM: Clear to auscultation bilaterally without rhonchi, rales or wheezes ABD: Soft with mild RUQ tenderness to deep palpation, Murphy’s sign absent. Bowel sounds present. Hepatomegaly with liver edge 3 cm below costal margin. Splenic tip palpable. RECTAL: Guaiac negative EXT: Shotty inguinal lymphadenopathy bilaterally, largest node 2cm NEURO: Strength 5/5 throughout, sensation intact, reflexes symmetric. No focal abnormality identified. No asterixis SKIN: Jaundice, no rash. No petechiae, gynecomastia or spider angiomata.Hospital Course:The patient was admitted to the hospital to begin workup of liver failure. Initial labs were considered to be consistent with an obstructive pattern, so further imaging was obtained. A CT scan of the abdomen and pelvis revealed lymphadenopathy and a markedly enlarged liver. His abdominal pain was controlled with mild narcotics and he was noted to have decreasing jaundice by hospital day 4. An US guided liver biopsy revealed only acute granulomatous inflammation and fibrosis. The overall architecture of the liver was noted to be well preserved.Gastroenterology was consulted for EGD and ERCP. The EGD was normal and the ERCP showed normal biliary anatomy without evidence of obstruction. In addition, they performed an endoscopic ultrasound-guided fine needle aspiration of two lymph-nodes, one in the subcarinal region and one near the celiac plexus. Again, pathologic results were insufficient to make a tissue diagnosis.By the second week of hospitalization, the patient was having intermittent low-grade fevers and again experiencing night-sweats. He remained jaundice. Given the previous negative biopsies, surgery was consulted to perform an excisional biopsy of the right groin lymph node, which revealed no evidence of carcinoma, negative AFB and GMS stains and a single noncaseating granuloma.By his fourth week of hospitalization, he remained ill with evidence of ongoing liver failure. Surgery performed an open liver biopsy and lymph node resection.STUDIES (HISTORICAL):CT abdomen: Multiple enlarged lymph nodes near the porta hepatis and peri-pancreatic regions. The largest node measures 3.5 x 3.0 cm. The liver is markedly enlarged (23cm) with a heterogenous pattern of enhancement. The spleen size is at the upper limit of normal. Pancreas, adrenal glands and kidneys are within normal limits. Visualized portions of the lung parenchyma are grossly normal.CT neck: No abnormalities notedCT head: No intracranial abnormalitiesRUQ US (for biopsy): Heterogenous liver with lymphadenopathy. ERCP: No filling defect noted; normal pancreatic duct visualized. Normal visualization of the biliary tree, no strictures. Normal exam." "55",55,"Discharge Summary","Chief Complaint: Abdominal pain, nausea and vomiting.History of Present Illness: A 50-year-old Asian female comes to The Methodist Hospital on January 2, 2001, complaining of a 3-day history of abdominal pain. The pain is described as crampy in the central part of her abdomen, and is associated with nausea and vomiting during the previous 24 hours. The patient denied passing any stool or gas per rectum for the previous 24 hours. She had been admitted recently to the hospital from December 19 to December 23, 2000, with a three-week history of fevers to 101.8, diaphoresis, anorexia, malaise and skin ""lumps"". She described a total of three ""lumps"". The first one started as a pin-sized lesion that grew up and then disappeared, the other two didn't resolve. They were described as ""erythematous nodular lesions on the extensor surface of the left arm."" A punch biopsy was obtained from these skin lesions, showing deep dermis and subcutaneous adipose tissue that contained ""multiple granulomas composed of histiocytes and multinucleated giant cells without caseating necrosis"". However, one granuloma in the deep dermis, showed a hint of central necrosis. Special stains for acid - fast bacilli and fungi were reported as negative. No atypia or malignancy was noted. A CT scan of the chest was obtained on December 19, 2000 and showed numerous masses with spiculated borders bilaterally, predominately in the upper lobes and superior segments of the lower lobes. No cavitary lesions, mediastinal masses or definite hilar adenopathy were reported. The patient underwent bronchoscopy and transbronchial biopsy which showed fragments of bronchial mucosa and wall with underlying lung parenchyma. Minimal to mild interstitial lymphocytes with a few microfoci of neutrophils were seen. They were also able to appreciate intra-alveolar fibrinous exudates. One of the blood cultures drawn on December 19, 2000 grew Streptococcus mitis.The patient was discharged on ethambutol 1200 mg po qd, clarithromycin 500 mg po bid, ampicillin 500 mg po q 6h and fluconazole 200 mg po qd.Past Medical History:1. Post-streptococcal glomerulonephritis at age 10.2. End stage renal disease diagnosed in 1994, on peritoneal dialysis until 1996.3. Cadaveric transplant in October 19964. Steroid induced diabetes mellitus5. HypertensionPast Surgical History:1. Total abdominal hysterectomy in January 19962. Cesarean section X2 in 1996 and 19973. Appendectomy in 19714. Insertion of peritoneal dialysis catheter in 19945. Cadaveric transplant in October 1996Social History:The patient denies a history of smoking, drinking or intravenous drug use. She came to the United States in 1973. She works as a nurse in a newborn nursery. Her hobby is gardening. She traveled to Las Vegas on May 2000 and stayed for 6 months. She denied ill contacts or pets.Allergies: Ciprofloxacin and Enteric coated aspirinMedications: prednisone 20 mg po qd, enalapril 2.5 mg po qd, clonidine patch TTS 3 1/week, Prograf 5 mg po bid, ranitidine 150 mg po bid, furosemide 40 mg po bid, atorvastatin 10 mg po qd, multivitamins 1 tab po qd, estrogen patch, fluconazole 200 mg po qd, metformin 500 mg po bid, glyburide 10 mg po qd, clarithromycin 500 mg po bid, ethambutol 1200 mg po qd, ampicillin 500 mg po q 6h.Family History: She described a family history of hypertension. Her mother died after a myocardial infarction at age 59. Her father was diagnosed with congestive heart failure and had a pacemaker placed.Review of systems: Non-contributory. The patient denied fever, chills, ulcers, liver disease or history of gallstones.Vaccines: The patient was vaccinated with BCG before starting elementary school in the Philippines.Physical Examination: At the time of the examination the patient was alert and oriented times three and in no acute distress. She was well nourished.BP 106/60 lying down; HR 86; RR 12; T 96.1° F; Hgt. =5' 2""; Wgt. =121 lbs. SKIN: There was no rash or skin lesions. HEENT: She had no oral lesions and moist mucous membranes. No icterus was noted. NECK: Her neck was supple without lymphadenopathy or thyromegaly. LUNGS: Crackles at the right lower base with normal respiratory excursion and no dullness to percussion. HEART: IV/VI crescendo - decrescendo systolic murmur was heard at the second intercostal space with radiation to the neck. ABDOMEN: The abdomen was distended. Bowel sounds were normal. No hepatosplenomegaly, tenderness or rebound tenderness could be detected during the examination. EXTREMITIES: No cyanosis, clubbing or edema was noted. RECTAL: Normal rectal exam. Guaiac negative. NEUROLOGIC: Normal and non-focal.Hospital Course: The patient was admitted and a nasogastric tube was placed. IV fluids were started. A KUB was obtained showing an abnormal bowel gas pattern. Multiple loops of distended bowel were noted in the mid abdomen. Air and feces were noted within the colon in the right side. An Abdominal CT scan was obtained. There was a small amount of perihepatic fluid noted. The liver and spleen were normal. The kidneys were atrophic. The gallbladder was moderately distended. There was marked dilatation of the small bowel proximally and distally. There was gas and contrast material in the colon. A diagnostic procedure was performed." "56",56,"History and Physical","CHIEF COMPLAINT: Altered mental status. HISTORY OF PRESENT ILLNESS: The patient is a 69-year-old male transferred from an outlying facility with diagnosis of a stroke. History is taken mostly from the emergency room record. The patient is unable to give any history and no family member is present for questioning. When asked why he came to the emergency room, the patient replies that it started about 2 PM yesterday. However, he is unable to tell me exactly what started at 2 PM yesterday. The patient's speech is clear, but he speaks nonsensically using words in combinations that don't make any sense. No other history of present illness is available. PAST MEDICAL HISTORY: Per the emergency room record, significant for atrial fibrillation, hypertension, and hyperlipidemia. PAST SURGICAL HISTORY: Unknown. FAMILY HISTORY: Unknown. SOCIAL HISTORY: The patient denies smoking and drinking. MEDICATIONS: Per the emergency room record, medications are Lotensin 20 mg daily, Toprol 50 mg daily, Plavix 75 mg daily and aspirin 81 mg daily. ALLERGIES: UNKNOWN. REVIEW OF SYSTEMS: Unobtainable secondary to the patient's condition. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature: 97.9. Pulse: 79. Respiratory rate: 20. Blood pressure: 117/84. GENERAL: Well-developed, well-nourished male in no acute distress. HEENT: Eyes: Pupils are equal, round and reactive. There is no scleral icterus. Ears, nose and throat: His oropharynx is moist. His hearing is normal. NECK: No JVD. No thyromegaly. CARDIOVASCULAR: Irregular rhythm. No lower extremity edema. RESPIRATORY: Clear to auscultation bilaterally with normal effort. ABDOMEN: Nontender. Nondistended. Bowel sounds are positive. MUSCULOSKELETAL: There is no clubbing of the digits. The patient's strength is 5/5 throughout. NEUROLOGICAL: Babinski's are downgoing bilaterally. Deep tendon reflexes are 2+ throughout. LABORATORY DATA: By report, head CT from the outlying facility was negative. An EKG showed atrial fibrillation with a rate of 75. There is no indication of any acute cardiac ischemia. A chest x-ray shows no acute pulmonary process, but does show cardiomegaly.Labs are as follows: White count 9.4, hemoglobin 17.2, hematocrit 52.5, platelet count 219. PTT 24, PT 13, INR 0.96. Sodium 135, potassium 3.6, chloride 99, bicarb 27, BUN 13, creatinine 1.4, glucose 161, calcium 9, magnesium 1.9, total protein 7, albumin 3.7, AST 22, ALT 41, alkaline phosphatase 85, total bilirubin 0.7, total cholesterol 193. Cardiac isoenzymes are negative times one with a troponin of 0.09. ASSESSMENT AND PLAN:1. Probable stroke. The patient has an expressive aphasia. He does not have dysarthria, however. Also, his strength is not affected. I suspect that the patient has had strokes or TIAs in the past because he was taking aspirin and Plavix at home. Head CT is reportedly negative. I will ask our radiologist to re-read the head CT. I will also order MRI and MRA, carotid Doppler ultrasound and echocardiogram in addition to a fasting lipid profile. I will consult neurology to evaluate and continue his aspirin and Plavix.2. Atrial fibrillation. The patient's rate is controlled currently. I will continue him on his amiodarone 200 mg twice daily and consult CHI to evaluate him.3. Hypertension. I will continue his home medications and add clonidine as needed.4. Hyperlipidemia. The patient takes no medications for this currently. I will check a fasting lipid profile.5. Hyperglycemia. It is unknown whether the patient has a history of diabetes. His glucose is currently 171. I will start him on sliding scale insulin for now and monitor closely.6. Renal insufficiency. It is also unknown whether the patient has a history of this and what his baseline creatinine might be. Currently he has only mild renal insufficiency. This does not appear to be prerenal. Will monitor for now." "57",57,"History and Physical","HISTORY AND CLINICAL DATA: The patient is an 88-year-old gentleman followed by Dr. X, his primary care physician, Dr. Y for the indication of CLL and Dr. Z for his cardiovascular issues. He presents to the Care Center earlier today with approximately a one-week history of increased progressive shortness of breath, orthopnea over the course of the past few nights, mild increase in peripheral edema, and active wheezing with dyspnea presenting this morning.He reports no clear-cut chest discomfort or difficulty with angina. He has had no dizziness, lightheadedness, no near or true syncope, nothing supportive of CVA, TIA, nor peripheral vascular claudication. REVIEW OF SYSTEMS: General review of system is significant for difficulty with intermittent constipation, which has been problematic recently. He reports no fever, shaking chills, nothing supportive of GI or GU blood loss, no productive or nonproductive cough. PAST MEDICAL HISTORY: Remarkable for hypertension, diabetes, prostate cancer, status post radium seed implant, COPD, single vessel coronary disease, esophageal reflux, CLL, osteopenia, significant hearing loss, anxiety, and degenerative joint disease. SOCIAL HISTORY: Remarkable for being married, retired, quit smoking in 1997, rare use of alcohol, lives locally with his wife. MEDICATIONS AT HOME: Include, Lortab 7.5 mg up to three times daily for chronic arthritic discomfort, Miacalcin nasal spray once daily, omeprazole 20 mg daily, Diovan 320 mg daily, Combivent two puffs t.i.d., folate, one adult aspirin daily, glyburide 5 mg daily, atenolol 50 mg daily, furosemide 40 mg daily, amlodipine 5 mg daily, hydralazine 50 mg p.o. t.i.d., in addition to Tekturna 150 mg daily, Zoloft 25 mg daily. ALLERGIES: He has known history of allergy to clonidine, Medifast does fatigue. DIAGNOSTIC AND LABORATORY DATA: Chest x-ray upon presentation to the Ellis Emergency Room this evening demonstrate significant congestive heart failure with moderate-sized bilateral pleural effusions.A 12-lead EKG, sinus rhythm at a rate of 68 per minute, right bundle-branch block type IVCV with moderate nonspecific ST changes. Low voltage in the limb leads.WBC 29,000, hemoglobin 10.9, hematocrit 31, platelets 187,000. Low serum sodium at 132, potassium 4, BUN 28, creatinine 1.2, random glucose 179. Low total protein 5.7. Magnesium level 2.3, troponin 0.404 with the B-natriuretic peptide of 8200. PHYSICAL EXAMINATION: He is an elderly gentleman, who appears to be in no acute distress, lying comfortably flat at 30 degrees, measured pressure of 150/80 with a pulse of 68 and regular. JVD difficult to assess. Normal carotids with obvious bruits. Conjunctivae pink. Oropharynx clear. Mild kyphosis. Diffusely depressed breath sounds halfway up both posterior lung fields. No active wheezing. Cardiac Exam: Regular, soft, 1-2/6 early systolic ejection murmur best heard at the base. Abdomen: Soft, nontender, protuberant, benign. Extremities: 2+ bilateral pitting edema to the level of the knees. Neuro Exam: Appears alert, oriented x3. Appropriate manner and affect, exceedingly hard of hearing. OVERALL IMPRESSION: An 88-year-old white male with the following major medical issues:1. Presentation consists with subclinical congestive heart failure possibly systolic, no recent echocardiogram available for review.2. Hypertension with suboptimal controlled currently.3. Diabetes.4. Prostate CA, status post radium seed implant.5. COPD, on metered-dose inhaler.6. CLL followed by Dr. Y.7. Single-vessel coronary disease, no recent anginal quality chest pain, no changes in ECG suggestive of acute ischemia; however, initial troponin 0.4 - to be followed with serial enzyme determinations and telemetry.8. Hearing loss, anxiety.9. Significant degenerative joint disease. PLAN:1. Admit to A4 with telemetry, congestive heart failure pathway, intravenous diuretic therapy.2. Strict I&O, Foley catheter has already been placed.3. Daily BMP.4. Two-dimensional echocardiogram to assess left ventricular systolic function. Serum iron determination to exclude the possibility of a subclinical ischemic cardiac event. Further recommendations will be forthcoming pending his clinical course and hospital." "58",58,"Discharge Summary","HISTORY: A 69-year-old female with past history of type II diabetes, atherosclerotic heart disease, hypertension, carotid stenosis. The patient was status post coronary artery bypass surgery aortic valve repair at Shadyside Hospital. The patient subsequently developed CVA. She also developed thrombosis of the right arm, which ultimately required right hand amputation. She was stabilized and eventually transferred to HealthSouth for further management. PHYSICAL EXAMINATION:Vital Signs: Pulse of 90 and blood pressure 150/70.Heart: Sounds were heard, grade 2/6 systolic murmur at the precordium.Chest: Clinically clear.Abdomen: Some suprapubic tenderness. Evidence of right lower arm amputation.The patient was started on Prevacid 30 mg daily, levothyroxine 75 mcg a day, Toprol 25 mg twice a day, Zofran 4 mg q.6 h, Coumadin dose at 5 mg and was adjusted. She was given a pain control using Vicodin and Percocet, amiodarone 200 mg a day, Lexapro 20 mg a day, Plavix 75 mg a day, fenofibrate 145 mg, Lasix 20 mg IV twice a day, Lantus 50 units at bedtime and Humalog 10 units a.c. and sliding scale insulin coverage. Wound care to the right heel was supervised by Dr. X. The patient initially was fed through NG tube, which was eventually discontinued. Physical therapy was ordered. The patient continued to do well. She was progressively ambulated. Her meds were continuously adjusted. The patient's insulin was eventually changed from Lantus to Levemir 25 units twice a day. Dr. Y also followed the patient closely for left heel ulcer. LABORATORY DATA: The latest cultures from left heel are pending. Her electrolytes revealed sodium of 135 and potassium of 3.2. Her potassium was switched to K-Dur 40 mEq twice a day. Her blood chemistries are otherwise closely monitored. INRs were obtained and were therapeutic. Throughout her hospitalization, multiple cultures were also obtained. Urine cultures grew Klebsiella. She was treated with appropriate antibiotics. Her detailed blood work is as in the chart. Detailed radiological studies are as in the chart. The patient made a steady progress and eventually plans were made to transfer the patient to ABC furthermore aggressive rehabilitation. FINAL DIAGNOSES:1. Atherosclerotic heart disease, status post coronary artery bypass graft.2. Valvular heart disease, status post aortic valve replacement.3. Right arm arterial thrombosis, status post amputation right lower arm.4. Hypothyroidism.5. Uncontrolled diabetes mellitus, type 2.6. Urinary tract infection.7. Hypokalemia.8. Heparin-induced thrombocytopenia.9. Peripheral vascular occlusive disease.10. Paroxysmal atrial fibrillation.11. Hyperlipidemia.12. Depression.13. Carotid stenosis." "59",59,"History and Physical","HISTORY OF PRESENT ILLNESS: This patient is an 80-year-old white female with a known past medical history of diabetes mellitus type 2 for the past 9 year. She was now admitted following a complex medical course for respiratory failure and enterocutaneous fistula. The patient has been in several hospitals over the past 3 months. Has had 3 episodes of respiratory failure in the 3 months for congestive heart failure, sepsis, and also secondary to sleep apnea. The patient currently is receiving feedings via tube and also she has a tracheostomy in place. The patient also has a chest tube in the left chest wall for significant pleural effusion. PAST MEDICAL HISTORY: Include:1. Type II diabetes mellitus.2. Hypertension.3. Hyperlipidemia.4. Gastroesophageal reflux disease.5. Renal insufficiency.6. Degenerative joint disease, status post bilateral hip and bilateral knee replacements.7. Enterocutaneous fistula.8. Respiratory failure.9. History of atrial fibrillation.10. Obstructive sleep apnea.11. History of uterine cancer, status post total hysterectomy.12. History of ventral hernia repair for incarcerated hernia. SOCIAL HISTORY: The patient has been admitted to multiple hospitals over the last several months. FAMILY HISTORY: Positive for diabetes mellitus type 2 in both mother and her sister. MEDICATIONS: Currently include,1. Albuterol inhaler q.4 h.2. Paradox swish and spit mouthwash twice a day.3. Digoxin 0.125 mg daily.4. Theophylline 50 mg q.6 h.5. Prozac 20 mg daily.6. Lasix 40 mg daily.7. Humulin regular high dose sliding scale insulin subcu. q.6 h.8. Atrovent q.4 h.9. Lantus 12 units subcu. q.12 h.10. Lisinopril 10 mg daily.11. Magnesium oxide 400 mg three times a day.12. Metoprolol 25 mg twice daily.13. Nitroglycerin topical q.6 h.14. Zegerid 40 mg daily.15. Simvastatin 10 mg daily. ALLERGIES: Percocet, Percodan, oxycodone, and Duragesic. REVIEW OF SYSTEMS: The patient currently denies any pain, denies any headache or blurred vision. Denies chest pain or shortness of breath. She denies any nausea or vomiting. Otherwise, systems are negative. PHYSICAL EXAM:General: The patient is awake, alert, and oriented. She is in no apparent respiratory distress.Vital Signs: Temperature 97.6, blood pressure is 139/53, pulse 100, respirations 24. The patient has a tracheostomy in place. She will also have an esophageal gastric tube in place.Cardiac: Regular rate and rhythm without audible murmurs, rubs or gallops. Lungs are clear to auscultation bilaterally with slightly diminished breath sounds on the bases. No adventitious sounds are noted.Abdomen: Obese. There is an open wound on the ventral abdomen overlying the midline abdominal incision from previous surgery. The area is covered with bandage with serosanguineous fluid. Abdomen is nontender to palpation. Bowel sounds are heard in all 4 quadrants.Extremities: Bilateral lower extremities are edematous and very cool to touch. LABORATORY DATA: Pending. Capillary blood sugars thus far have been 132 and 135. ASSESSMENT: This is an 80-year-old female with an unfortunate past medical history with recent complications of sepsis and respiratory failure who is now receiving tube feeds. PLAN: For her diabetes mellitus, we will continue the patient on her current regimen of Lantus 12 units subcu. q.12 h. and Regular Insulin at a high dose sliding scale every 6 hours. The patient had been previously controlled on this. We will continue to check her sugars every 6 hours and adjust insulin as necessary." "60",60,"History and Physical","REASON FOR CONSULT: For evaluation of left-sided chest pain, 5 days post abdominal surgery. PAST MEDICAL HISTORY: None. HISTORY OF PRESENT COMPLAINT: This 87-year-old patient has been admitted in this hospital on 12/03/08. The patient underwent laparoscopic appendicectomy by Dr. X. The patient had postoperative paralytic ileus, which has resolved. The patient had developed left-sided chest pain yesterday. In the postoperative period, the patient has had fluid retention, had gain about 25 pounds, and he had swelling of the lower extremities. REVIEW OF SYSTEMS: CONSTITUTIONAL SYMPTOMS: No recent fever. ENT: Unremarkable. RESPIRATORY: He denies cough but develop this left-sided chest pain, which does not increase with inspiration, pain is located on the left posterior axillary line and over the fourth and fifth rib. CARDIOVASCULAR: No known heart problems. GASTROINTESTINAL: The patient denies nausea or vomiting. He is status post laparoscopic appendicectomy, and he is tolerating oral diet. GENITOURINARY: No dysuria, no hematuria. ENDOCRINE: Negative for diabetes or thyroid problems. NEUROLOGIC: No history of CVA or TIA.Rest of review of systems unremarkable. SOCIAL HISTORY: The patient is a nonsmoker. He denies use of alcohol. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: GENERAL: An 87-year-old gentleman, not toxic looking. HEAD AND NECK: Oral mucosa is moist. CHEST: Clear to auscultation. No wheezing. No crepitations. There is reproducible tenderness over the left posterior-lateral axis. CARDIOVASCULAR: First and second heart sounds were heard. No murmurs appreciated. ABDOMEN: Slightly distended. Bowel sounds are positive. EXTREMITIES: He has 2+ to 3+ pedal swelling. NEUROLOGIC: The patient is alert and oriented x3. Examination is nonfocal. LABORATORY DATA: White count is 12,500, hemoglobin is 13, hematocrit is 39, and platelets 398,000. Glucose is 123, total protein is 6, and albumin is 2.9. ASSESSMENT AND PLAN:1. Ruptured appendicitis. The patient is 6 days post surgery. He is tolerating oral fluids and moving bowels.2. Left-sided chest pain, need to rule out PE by distance of pretty low probability. The patient, however, has low-oxygen saturation. We will do ultrasound of the lower extremity and if this is positive we would proceed with the CT angiogram.3. Fluid retention, manage as per surgeon.4. Paralytic ileus, resolving.5. Leukocytosis, we will monitor." "61",61,"History and Physical","HISTORY: The patient presents today for medical management. The patient presents to the office today with complaints of extreme fatigue, discomfort in the chest and the back that is not related to any specific activity. Stomach gets upset with pain. She has been off her supplements for four weeks with some improvement. She has loose bowel movements. She complains of no bladder control. She has pain in her hips. The peripheral neuropathy is in both legs, her swelling has increased and headaches in the back of her head. DIAGNOSES:1. Type II diabetes mellitus.2. Generalized fatigue and weakness.3. Hypertension.4. Peripheral neuropathy with atypical symptoms.5. Hypothyroidism.6. Depression.7. Long-term use of high-risk medications.8. Postmenopausal age-related symptoms.9. Abdominal pain with nonspecific irritable bowel type symptoms, intermittent diarrhea. CURRENT MEDICATIONS: Her list of medicines is as noted on 04/22/03. There is a morning and evening lift. PAST SURGICAL HISTORY: As listed on 04/22/04 along with allergies 04/22/04. FAMILY HISTORY: Basically unchanged. Her father died of an MI at 65, mother died of a stroke at 70. She has a brother, healthy. SOCIAL HISTORY: She has two sons and an adopted daughter. She is married long term, retired from Avon. She is a nonsmoker, nondrinker. REVIEW OF SYSTEMS: GENERAL: Certainly at the present time on general exam no fever, sweats or chills and no significant weight change. She is 189 pounds currently and she was 188 pounds in January. HEENT: HEENT, there is no marked decrease in visual or auditory function. ENT, there is no change in hearing or epistaxis, sore throat or hoarseness. RESPIRATORY: Chest, there is no history of palpitations, PND or orthopnea. The chest pains are nonspecific, tenderness to palpation has been reported. There is no wheezing or cough reported. CARDIOVASCULAR: No PND or orthopnea. Thromboembolic disease history. GASTROINTESTINAL: Intermittent symptoms of stomach pain, they are nonspecific. No nausea or vomiting noted. Diarrhea is episodic and more related to nerves. GENITOURINARY: She reports there is generally poor bladder control, no marked dysuria, hematuria or history of stones. MUSCULOSKELETAL: Peripheral neuropathy and generalized muscle pain, joint pain that are sporadic. NEUROLOGICAL: No marked paralysis, paresis or paresthesias. SKIN: No rashes, itching or changes in the nails. BREASTS: No report of any lumps or masses. HEMATOLOGY AND IMMUNE: No bruising or bleeding-type symptoms. PHYSICAL EXAMINATION: WEIGHT: 189 pounds. BP: 140/80. PULSE: 76. RESPIRATIONS: 20. GENERAL APPEARANCE: Well developed, well nourished. No acute distress. HEENT: Head is normocephalic. Ears, nose, and throat, normal conjunctivae. Pupils are reactive. Ear canals are patent. TMs are normal. Nose, nares patent. Septum midline. Oral mucosa is normal in appearance. No tonsillar lesions, exudate or asymmetry. Neck, adequate range of motion. No thyromegaly or adenopathy. CHEST: Symmetric with clear lungs clear to auscultation and percussion. HEART: Rate and rhythm is regular. S1 and S2 audible. No appreciable murmur or gallop. ABDOMEN: Soft. No masses, guarding, rigidity, tenderness or flank pain. GU: No examined. EXTREMITIES: No cyanosis, clubbing or edema currently. SKIN AND INTEGUMENTS: Intact. No lesions or rashes. NEUROLOGIC: Nonfocal to cranial nerve testing II through XII, motor, sensory, gait and random motion.Additional information, the patient has been off metformin for few months and this is not part of her medication list. IMPRESSION: As above. PLAN:1. Labs are CBC, CMP, A1c, microalbumin and UA. Stool for C&S, Gram stain, ova and parasites with intermittent diarrhea. She has planned CT of the abdomen and pelvis with and without.2. She will continue with the current medications. She uses her diuretics at night.3. Follow up will be in three months, sooner if indicated." "62",62,"History and Physical","HISTORY OF PRESENT ILLNESS: This is a 70-year-old female with a past medical history of chronic kidney disease, stage 4; history of diabetes mellitus; diabetic nephropathy; peripheral vascular disease, status post recent PTA of right leg, admitted to the hospital because of swelling of the right hand and left foot. The patient says that the right hand was very swollen, very painful, could not move the fingers, and also, the left foot was very swollen and very painful, and again could not move the toes, came to emergency room, diagnosed with gout and gouty attacks. I was asked to see the patient regarding chronic kidney disease. PAST MEDICAL HISTORY:1. Diabetes mellitus type 2.2. Diabetic nephropathy.3. Chronic kidney disease, stage 4.4. Hypertension.5. Hypercholesterolemia and hyperlipidemia.6. Peripheral vascular disease, status post recent, last week PTA of right lower extremity. SOCIAL HISTORY: Negative for smoking and drinking. CURRENT HOME MEDICATIONS: NovoLog 20 units with each meal, Lantus 30 units at bedtime, Crestor 10 mg daily, Micardis 80 mg daily, Imdur 30 mg daily, Amlodipine 10 mg daily, Coreg 12.5 mg b.i.d., Lasix 20 mg daily, Ecotrin 325 mg daily, and calcitriol 0.5 mcg daily. REVIEW OF SYSTEMS: The patient denies any complaints, states that the right hand and left foot was very swollen and very painful, and came to emergency room. Also, she could not urinate and states as soon as they put Foley in, 500 mL of urine came out. Also they started her on steroids and colchicine, and the pain is improving and the swelling is getting better. Denies any fever and chills. Denies any dysuria, frequency or hematuria. States that the urine output was decreased considerably, and she could not urinate. Denies any cough, hemoptysis or sputum production. Denies any chest pain, orthopnea or paroxysmal nocturnal dyspnea. PHYSICAL EXAMINATION:General: The patient is alert and oriented, in no acute distress.Vital Signs: Blood pressure 126/67, temperature 97.9, pulse 71, and respirations 20. The patient's weight is 105.6 kg.Head: Normocephalic.Neck: Supple. No JVD. No adenopathy.Chest: Symmetric. No retractions.Lungs: Clear.Heart: RRR with no murmur.Abdomen: Obese, soft, and nontender. No rebound. No guarding.Extremity: She has 2+ pretibial edema bilaterally at the lower extremity, but also the left foot, in dorsum of left foot and also right hand is swollen and very tender to move the toes and also fingers in those extremities. LAB TESTS: Showed that urine culture is negative up to date. The patient's white cell is 12.7, hematocrit 26.1. The patient has 90% segs and 0% bands. Serum sodium 133, potassium 5.9, chloride 100, bicarb 21, glucose 348, BUN 57, creatinine is 2.39, calcium 8.9, and uric acid yesterday was 10.9. Sed rate was 121. BNP was 851. Urinalysis showed 15 to 20 white cells, 3+ protein, 3+ blood with 25 to 30 red blood cells also. IMPRESSION:1. Urinary tract infection.2. Acute gouty attack.3. Diabetes mellitus with diabetic nephropathy.4. Hypertension.5. Hypercholesterolemia.6. Peripheral vascular disease, status post recent PTA in the right side.7. Chronic kidney disease, stage 4. PLAN: At this time is I agree with treatment. We will add allopurinol 50 mg daily. This is secondary to the patient is already on colchicine, and also we will discontinue Micardis, we will increase Lasix to 40 b.i.d., and we will follow with the lab results." "63",63,"History and Physical","CHIEF COMPLAINT: Leg pain. HISTORY OF PRESENT ILLNESS: This is a 56-year-old female who has pain in her legs at nighttime and when she gets up it comes and goes, radiates from her buttocks to her legs, sometimes it is her ankle. She has noticed it since she has been on Lipitor. She has had some night sweats occasionally. She has had a little bit of fever and nausea. She has noticed her blood sugars have been low. She has lost over 30 pounds after exercising doing water aerobics at Genesis in Wichita. She has noticed her fasting blood sugars have been ranging from 100 to 120. Blood sugars one and a half hours after meals have been 185. She is coming in for a diabetic checkup in one month and wants lab prior to that time. She has been eating more meat recently and has not been on a diet for cholesterol. CURRENT MEDICATIONS: Include Lipitor 80 mg q.d. discontinued today, Vioxx 25 mg q.d., Maxzide 37/25 q.d., Protonix 40 mg q.d., hydroxyzine pamoate 50 mg at h.s., aspirin 81 mg q.d., Glucovance 1.25/250 b.i.d. decreased to one a day today, Monopril 20 mg q.d., estradiol one mg q.d., and glucosamine 1000 mg q.d. ALLERGIES: Cipro, sulfa, Bactrim, and Demerol. OBJECTIVE:Vital Signs: Weight is 248 pounds which is a 12-pound drop from January. Blood pressure 120/70. Pulse 68.General: This is a well-developed adult female, awake, alert, and in no acute distress. HEENT: Oropharynx and HEENT are within normal limits.Lungs: Clear.Heart: Regular rhythm and rate.Abdomen: Soft, nontender, and nondistended without organomegaly. GU: Palpation of femurs do not cause pain, rotation of hips do not cause pain, and compression of the hips do not cause pain.Neurologic: Deep tendon reflexes are normal.Extremities: Pulses in lower extremities are normal. Straight leg lifts are normal.ASSESSMENT/ PLAN:1. Leg pain/bone pain, I am going to check her CMP. I think this possibly is a side effect from Lipitor. We will stop Lipitor, have her follow up in one month which she has already got planned for diabetes appointment and check symptoms at that time. Certainly if her pain improves might consider something like Crestor, which is more water soluble, which may cause less adverse effects. We will check her comprehensive metabolic panel to make sure the alkaline phosphatase is okay, may need an x-ray of back, hip, and legs at that time if symptoms are not gone.2. Hypercholesterolemia, this is somewhat bothersome as she is a diabetic. Did discuss with her that we need to stick to the diet especially after going off of Lipitor. We will see how she does with her bone pain/leg pain off of Lipitor. If she has improvement may consider Crestor in one month. I am going to check her lipid panel and a CMP. Apparently, she is going to get this at a different site, Mapleridge in Wichita.3. Type II diabetes. We will decrease her Glucovance because she is having frequent low blood sugars. Her previous hemoglobin A1c was 5.6 so we will see if this improves her symptoms. I am also going to check a hemoglobin A1c at Mapleridge in Wichita and have a followup here in one month for that diabetes appointment." "64",64,"History and Physical","REASON FOR REFERRAL: Evaluation for right L4 selective nerve root block. CHIEF COMPLAINT: Right lower extremity pain and back pain. HISTORY OF PRESENT ILLNESS: Ms. XYZ is a 76-year-old resident of ASDF. She is seen at the request of Dr. ABC. She carries a diagnosis of hyperlipidemia, hypertension, and atherosclerotic cerebrovascular disease. She underwent an L3-4 decompression in Month DD, YYYY by Dr. Stanley Gertzbein for back and bilateral lower extremity pain. Shortly after surgery, she began having pain in the right L4 distribution and is seen today with an outside lumbar MRI only. I have a report of a lumbar CT myelogram as well, but no films. She has apparently spondylolisthesis and L4-5 stenosis with right posterior surgical fusion changes evident at both levels. According to Dr. Reitman's notes, she is being sent for an L4 selective nerve root block to rule out whether or not she would be a candidate for a TLIF at L4-5. Her MRI films are reviewed. These reveal grade 2 L4 anterior spondylolisthesis without significant canal stenosis, though she has facet joint arthropathy at this level and dorsal postoperative changes. She has a foraminal disc protrusion on the right, as well as a severely degenerated disc at L3-4.The patient complains essentially of pain along the anterior tibia and along the right hip, which his burning, shooting, aching and constant in nature. It is worse with standing and walking. She can walk about a block before her symptoms become debilitating. She is more comfortable in recumbency. She denies bowel or bladder dysfunction, saddle area hypoesthesia, numbness, tingling, weakness or Valsalva related exacerbation. She rates her pain as 9/10 in average and her daily level of intensity and 5/10 for her least level of pain. Alleviating factors include sitting, recumbency, sleeping, and massage. She treats her pain with Tylenol currently. OSWESTRY PAIN INVENTORY: Significant impact on almost every aspect of her quality of life. PAST MEDICAL HISTORY: As per above. Adult-onset diabetes. PAST SURGICAL HISTORY: Eye surgery, cataract surgery and lumbar decompression. MEDICATIONS: Lotrel, Diovan, Pravastatin, Toprol, Actos, aspirin. ALLERGIES: No known drug allergies. No shellfish or iodine allergy. FAMILY HISTORY: Family history is remarkable for heart disease, cerebrovascular disease, diabetes, and hypertension. SOCIAL HISTORY: The patient is retired. She is married with three grown children. Has a high school level education. She does not smoke, drink or utilize illicit substances. REVIEW OF SYSTEMS: A thirteen-point review of systems was surveyed and is otherwise negative. The patient denies any other constitutional symptom. PHYSICAL EXAMINATION: Temp 97.7, pulse 78, BP 143/80. The patient walks with a slight forward stooped gait. There is no spasticity or ataxia. She has mild antalgia after a few steps to the right lower extremity. She has limited lumbar flexion, lumbar extension and right ipsilateral bending with provocable right leg pain. There is no clear pelvic asymmetry. Her gait is forward stooped.Head is normocephalic and atraumatic. Cranial nerves II through XII are grossly intact. There is no occipitalgic tenderness. The neck is supple with a slight limitation of cervical extension and lateral bending. She has a cervicothoracic kyphotic posture with internal rotation of the shoulders.Lungs are clear to auscultation. Heart has regular rate and rhythm with normal S1, S2. No murmurs, rubs, or gallops. The abdomen is obese, nontender, nondistended without palpable organomegaly or pulsatile masses. The skin is warm and dry to touch. There is no cyanosis, clubbing, or edema. Degenerative changes are noted in the joints of the hands, knees and ankles. Brisk capillary refill is noted to all nailbeds.Inspection and palpation of her axial skeleton reveals a well-healed midline lumbar scar with slight bony step-off evident at the upper edge of the scar. No skin tags or clefts are noted. There is mild lumbar paraspinous hypertonicity, which appears to be more prominent on the right. There is mild midline tenderness over the surgical scar, as well as mild PSIS tenderness.Motor and sensory examination of the lower extremities is intact. She has hypoactive, but elicitable upper and lower extremity reflexes, though no Achilles reflexes can be elicited. Upper extremity range of motion and neurologic exam is within normal limits. No long tract signs are evident. There is no fasciculation, atrophy, or clonus.In the supine position, straight leg raise testing produces axial low back pain. There is no sciatic notch tenderness and no particular greater trochanteric bursal tenderness. IMPRESSION: 1. Lumbar spondylolisthesis.2. Lumbar spinal stenosis.3. Lumbar radiculopathy. PLAN: The risks and benefits of right L4 selective nerve root block were discussed in detail with the patient and they include failure of pain relief, need for further procedures, infection, bleeding, damage to the spinal nerves or abdominal viscera, and postdural puncture headaches. She wished to proceed." "65",65,"History and Physical","PRINCIPAL DIAGNOSES:1. A 61-year-old white male with a diagnosis of mantle cell lymphoma, diagnosed in 2001, status post autologous transplant with BEAM regimen in 04/02 followed by relapse.2. Allogeneic peripheral stem cell transplant from match-related brother and the patient is 53 months out from transplant.3. Graft versus host disease involving GI tracts, skin, and liver presently off immunosuppression.4. Diabetes.5. Bipolar disorder.6. Chronic muscle aches.7. Chronic lower extremity edema.8. ECOG performance status 1. INTERIM HISTORY: The patient comes to the clinic today for followup. I am seeing him once every 4 to 8 weeks. He is off of all immunosuppression. He does have mild chronic GVHD but not enough to warrant any therapy and the disease has been under control and he is 4-1/2-years posttransplant.He has multiple complaints. He has had hematochezia. I referred him to gastroenterology. They did an upper and lower endoscopy. No evidence of ulcers or any abnormality was found. Some polyps were removed. They were benign. He may have mild iron deficiency, but he is fatigued and has several complaints related to his level of activity. CURRENT MEDICATIONS:1. Paxil 40 mg once daily.2. Cozaar.3. Xanax 1 mg four times a day.4. Prozac 20 mg a day.5. Lasix 40 mg a day.6. Potassium 10 mEq a day.7. Mirapex two tablets every night.8. Allegra 60 mg twice a day.9. Avandamet 4/1000 mg daily.10. Nexium 20 mg a day.11. NovoLog 25/50. REVIEW OF SYSTEMS: Fatigue, occasional rectal bleeding, and obesity. Other systems were reviewed and were found to be unremarkable. PHYSICAL EXAMINATION: VITAL SIGNS: Today revealed that temperature 35.8, blood pressure 120/49, pulse 85, and respirations 18. HEENT: Oral cavity, no mucositis. NECK: No nodes. AXILLA: No nodes. LUNGS: Clear. CARDIAC: Regular rate and rhythm without murmurs. ABDOMEN: No palpable masses. Morbid obesity. EXTREMITIES: Mild lower extremity edema. SKIN: Mild dryness. CNS: Grossly intact. LABORATORY DATA: White count 4.4, hemoglobin 10.1, platelet count 132,000, sodium 135, potassium 3.9, chloride 105, bicarbonate 24, BUN 15, and creatinine 0.9. Normal alkaline phosphatase 203, AST 58, and ALT 31. ASSESSMENT AND PLAN:1. The patient with mantle cell lymphoma who is 4-1/2 years post allotransplant. He is without evidence of disease at the present time. Since he is 4-1/2 years posttransplant, I do not plan to scan him or obtain chimerisms unless there is reason to.2. He is slightly anemic, may be iron deficient. He has had recurrent rectal bleeding. I told him to take multivitamin with iron and see how that helps the anemia.3. Regarding the hematochezia, he had an endoscopy. I reviewed the results from the previous endoscopy. It appears that he has polyps, but there is no evidence of graft versus host disease.4. Regarding the fatigue, I just reassured him that he should increase his activity level, but I am not sure how realistic that is going to be.5. He is followed for his diabetes by his internist.6. If he should have any fever or anything suggestive of infection, I advised him to call me. I will see him back in about 2 months from now." "66",66,"History and Physical","REASON FOR CONSULTATION: New murmur with bacteremia. HISTORY OF PRESENT ILLNESS: The patient is an 84-year-old female admitted with jaundice and a pancreatic mass who was noted to have a new murmur, bacteremia, and fever. The patient states that apart from the fever, she was having no other symptoms and denies any previous cardiac history. She denies any orthopnea or paroxysmal nocturnal dyspnea. Denies any edema, chest pain, palpitations, or syncope. She has had TIAs in the past, but none recently. PAST MEDICAL HISTORY: Significant for diabetes, hypertension, and TIA. MEDICATIONS: Include:1. Acidophilus supplement.2. Cholestyramine.3. Creon 20 three times daily.4. Diovan 160 mg twice daily.6. Lantus 10 daily.7. Norvasc 5 mg daily.8. NovoLog 70/30, 10 units at 12 noon daily.9. Pamelor 15 mL every evening.10. Vitamin D3 one tablet weekly. ALLERGIES: THE PATIENT IS ALLERGIC TO CODEINE, COREG, AND VANCOMYCIN. FAMILY HISTORY: The patient's daughter apparently has history of a murmur, but no diagnosis of congenital heart disease. The patient's father died in his 80s of CHF. SOCIAL HISTORY: The patient denies ever having smoked, denies any significant alcohol use, and lives with her daughter in Pasadena. REVIEW OF SYSTEMS: The patient has had fever and chills. She has also had some jaundice. Denies any nausea or vomiting. Denies any chest pain or abdominal pain. Denies orthopnea, paroxysmal nocturnal dyspnea or edema. She has had TIAs in the past, but denies any recent neurological symptoms such as motor weakness or focal sensory deficits. Denies melena or hematochezia. All other systems were reviewed and were found to be negative. PHYSICAL EXAMINATIONGENERAL: An elderly Caucasian female, awake and alert, and in no distress. VITAL SIGNS: Temperature is 98.8, heart rate 96, sinus, blood pressure 138/55, respiratory rate 20, and oxygen saturation 92%. HEAD AND NECK: Her head is atraumatic. She is normocephalic. Her neck is supple. There is no JVD. No palpable adenopathy or thyromegaly. There is some icterus of the sclerae bilaterally. Oral mucosa is moist. CHEST: Symmetrical expansion with normal percussion note. There are no inspiratory crackles or expiratory wheeze. CARDIAC: Heart sounds S1 and S2 are regular. There is a 2/6 systolic murmur heard through the precordium. There is no gallop or rub. There is no palpable thrill or retrosternal lift. ABDOMEN: Soft, nondistended, and nontender with normal bowel sounds. No audible bruits. EXTREMITIES: No pitting edema, no clubbing, no cyanosis, and peripheral pulses are 2+. NEUROLOGIC: She exhibits no focal motor or sensory findings. LABORATORY DATA: The patient's sodium was 133, potassium 2.8, chloride 99, bicarbonate 31, glucose 75, BUN 12, creatinine 0.8, calcium 8.6, total bilirubin 3.2, AST 63, and ALT 43. White count 5.4, hemoglobin 9.1, hematocrit 26.6, and platelet count 128,000. Lipase less than 10. DIAGNOSTIC IMAGING: The patient had a CT scan of the abdomen that demonstrated a pancreatic mass with biliary obstruction. Previous biliary stent was present.EKG shows normal sinus rhythm. There are no acute ST-T changes. ASSESSMENT: This is an 84-year-old female with newly found murmur. No previous history of heart disease. This murmur has occurred in the setting of fever and bacteremia. The patient also has a pancreatic mass with jaundice, history of hypertension, and now has hyponatremia and hypokalemia. PLAN: The patient should undergo an echocardiogram to assess for the possibility of endocarditis, which may be contributing to her symptoms. Blood pressure control should be maintained with Diovan and Norvasc. Potassium should be replaced, and hyponatremia should be on proactive." "67",67,"History and Physical","REASON FOR CONSULTATION: Pericardial effusion. HISTORY OF PRESENT ILLNESS: The patient is an 84-year-old female presented to emergency room with shortness of breath, fatigue, and tiredness. Low-grade fever was noted last few weeks. The patient also has chest pain described as dull aching type in precordial region. No relation to exertion or activity. No aggravating or relieving factors. A CT of the chest was done, which shows pericardial effusion. This consultation is for the same. The patient denies any lightheadedness or dizziness. No presyncope or syncope. Activity is fairly stable. CORONARY RISK FACTORS: History of borderline hypertension. No history of diabetes mellitus. Nonsmoker. Cholesterol status is within normal limits. No history of established coronary artery disease. Family history noncontributory. FAMILY HISTORY: Nonsignificant. PAST SURGICAL HISTORY: Hysterectomy and bladder surgery. MEDICATIONS AT HOME: Aspirin and thyroid supplementation. ALLERGIES: None. PERSONAL HISTORY: She is a nonsmoker. She does not consume alcohol. No history of recreational drug use. PAST MEDICAL HISTORY:1. Hypothyroidism.2. Borderline hypertension.3. Arthritis.4. Presentation at this time with chest pain and shortness of breath. REVIEW OF SYSTEMSCONSTITUTIONAL: Weakness, fatigue, and tiredness. HEENT: No history of cataract, blurring of vision, or glaucoma. CARDIOVASCULAR: Chest pain. No congestive heart failure. No arrhythmia. RESPIRATORY: No history of pneumonia in the past, valley fever. GASTROINTESTINAL: Epigastric discomfort. No hematemesis or melena. UROLOGICAL: Frequency. No urgency. No hematuria. MUSCULOSKELETAL: Arthritis and muscle weakness. CNS: No TIA. No CVA. No seizure disorder. ENDOCRINE: Nonsignificant. HEMATOLOGICAL: Nonsignificant. PHYSICAL EXAMINATIONVITAL SIGNS: Pulse of 86, blood pressure 93/54, afebrile, respiratory rate 16 per minute. HEENT: Atraumatic and normocephalic. NECK: Supple. Neck veins flat. No significant carotid bruit. LUNGS: Air entry bilaterally fair. HEART: PMI displaced. S1 and S2 regular. ABDOMEN: Soft and nontender. EXTREMITIES: No edema. Pulses palpable. No clubbing or cyanosis. CNS: Grossly intact. LABORATORY DATA: White count of 20 and H&H 13 and 39. BUN and creatinine within normal limits. Cardiac enzyme profile negative. RADIOGRAPHIC STUDIES: CT of the chest preliminary report, pericardial effusion. Echocardiogram shows pericardial effusion, which appears to be chronic. There is no evidence of hemodynamic compromise. IMPRESSION:1. The patient is an 84-year-old female admitted with chest pain and shortness of breath, possibly secondary to pulmonary disorder. She has elevated white count, possible infection.2. Pericardial effusion without any hemodynamic compromise, could be chronic.3. Cardiac risk factors minimum, except for age and borderline hypertension. RECOMMENDATIONS:1. Antibiotic treatment and see how she fares.2. Based on response, we will consider cardiac workup in terms of stress test once she is stable.3. As for the pericardial effusion, continue with observation." "68",68,"History and Physical","CHIEF COMPLAINT: Severe back pain and sleepiness.The patient is not a good historian and history was obtained from the patient's husband at bedside. HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old obese Caucasian female with past medical conditions that includes hypertension, history of urinary incontinence, dementia, and chronic back pain, basically brought by the husband to the emergency room because of having excruciating back pain. As per the husband, the patient has this back pain for about almost 1 year and seeing Dr. X in Neurosurgery and had an epidural injection x2, and then the patient's pain somewhat got better between, but last time the patient went to see Dr. X, the patient given injection and the patient passed out, so the doctor stopped giving any other epidural injection. The patient has severe pain and all in all, the patient cries at home. As per the husband, the patient woke up in the morning with severe pain, unable to eat, drink today, and crying in the morning, so brought her to the emergency room for further evaluation. The patient denied any history of fever, cough, chest pain, diarrhea, dysuria or polyuria. While I was examining the patient, the patient explained about possible diagnosis and treatment plan and possible nursing home discharge for pain control. The patient passed out for about 3 to 4 minutes, unable to respond to even painful stimuli. The patient's heart rate went down to 50s and blood pressure was 92 systolic, so the patient was later on given IV fluid and blood pressure checked. The patient woke up after 5 to 6 minutes, so the patient was later on evaluated for admission because of near syncopal episode. PAST MEDICAL CONDITIONS: Include hypertension, dementia, urinary incontinence, chronic back pain, and degenerative joint disease of the spine. No history of diabetes, stroke or coronary artery disease. SURGICAL HISTORY: Include left total hip replacement many years ago, history of hysterectomy, and appendectomy in the young age. ALLERGIES: DENIED. CURRENT MEDICATIONS: According to the list shows the patient takes hydrocodone 10/325 mg every 6 hours, Flexeril 10 mg p.o. at bedtime, and Xanax 0.25 mg p.o. 4 times a day. The patient also takes Neurontin 200 mg 3 times a day, propranolol 10 mg twice a day, oxybutynin 5 mg p.o. twice a day, Namenda 10 mg p.o. daily, and Aricept 10 mg p.o. daily. SOCIAL HISTORY: She lives with her husband, usually walks with a walker and wheelchair-bound, does not walk much as per the husband knows. No history of alcohol abuse or smoking. PHYSICAL EXAMINATION: GENERAL: Currently lying in the bed without apparent distress, very lethargic. VITAL SIGNS: Pulse rate of 55, blood pressure is 92/52, after IV fluid came up to 105/58. CHEST: Shows bilateral air entry present, clear to auscultate. HEART: S1 and S2 regular. ABDOMEN: Soft, nondistended, and nontender. EXTREMITIES: Shows the patient's straight leg raising to be only up to 30% causing the patient severe back pain. IMAGING: The patient's x-ray of the lumbosacral spine done shows there is a L1 compression fracture with some osteophyte formation in the lumbar spine suggestive of degenerative joint disease. LABORATORY DATA: The patient's lab test is not done currently, but previous lab test done in 3/2009 seems to be in acceptable range. IMPRESSION: The patient, because of near syncopal episode and polypharmacy, almost passed out for about 3 to 4 minutes in front of me with a low blood pressure.1. Vasovagal syncope versus polypharmacy because of 3 to 4 medications and muscle relaxants.2. Osteoporosis of the spine with L1 compression fracture causing the patient severe pain.3. Hypertension, now hypotension.4. Incontinence of the bladder.5. Dementia, most likely Alzheimer type. PLAN AND SUGGESTION: Initial plan was to send the patient to the nursing home, but because of the patient's low blood pressure and heart rate low, we will admit the patient to DOU for 23-hour observation, start the patient on IV fluid, normal saline, 20 mEq KCl, and Protonix 40 mg, and we will also continue the patient's Namenda and Aricept. I will hold the patient's hydrocodone. I will hold the Flexeril and I will also hold gabapentin at this moment. We will give the patient's pain control with Percocet and very minimal morphine sulfate as needed. Also give the patient calcium with vitamin D and physical therapy. We will also order a blood test and further management will be based on the patient's all test results. I also explained to the husband that tomorrow if the patient is better and more alert and awake, then we will send her to the nursing care versus home, it depends on the pain control." "69",69,"Discharge Summary","DIAGNOSES PROBLEMS:1. Orthostatic hypotension.2. Bradycardia.3. Diabetes.4. Status post renal transplant secondary polycystic kidney disease in 1995.5. Hypertension.6. History of basal cell ganglia cerebrovascular event in 2004 with left residual.7. History of renal osteodystrophy.8. Iron deficiency anemia.9. Cataract status post cataract surgery.10. Chronic left lower extremity pain.11. Hyperlipidemia.12. Status post hysterectomy secondary to uterine fibroids. PROCEDURES: Telemetry monitoring. HISTORY FINDINGS HOSPITAL COURSE: The patient was originally hospitalized on 04/26/07, secondary to dizziness and disequilibrium. Extensive workup during her first hospitalization was all negative, but a prominent feature was her very blunted affect and real anhedonia. She was transferred briefly to Psychiatry, however, on the second day in Psychiatry, she became very orthostatic and was transferred acutely back to the medicine. She briefly was on Cymbalta; however, this was discontinued when she was transferred back. She was monitored back medicine for 24 hours and was given intravenous fluids and these were discontinued. She was able to maintain her pressures then was able to ambulate without difficulty. We had wanted to pursue workup for possible causes for autonomic dysfunction; however, the patient was not interested in remaining in the hospital anymore and left really against our recommendations. DISCHARGE MEDICATIONS:1. CellCept - 500 mg twice a daily.2. Cyclosporine - 25 mg in the morning and 15 mg in the evening.3. Prednisone - 5 mg once daily.4. Hydralazine - 10 mg four times a day.5. Pantoprazole - 40 mg once daily.6. Glipizide - 5 mg every morning.7. Aspirin - 81 mg once daily. FOLLOWUP CARE: The patient is to follow up with Dr. X in about 1 week's time." "70",70,"History and Physical","SUBJECTIVE: This is a 62-year-old female who comes for dietary consultation for carbohydrate counting for type I diabetes. The patient reports that she was hospitalized over the weekend for DKA. She indicates that her blood sugar on Friday night was 187 at bedtime and that when she woke up in the morning her blood sugar was 477. She gave herself, in smaller increments, a total of 70 extra units of her Humalog. Ten of those units were injectable; the others were in the forms of pump. Her blood sugar was over 600 when she went to the hospital later that day. She is here at this consultation complaining of not feeling well still because she has a cold. She realizes that this is likely because her immune system was so minimized in the hospital. OBJECTIVE: Current insulin doses on her insulin pump are boluses set at 5 units at breakfast, 6 units at lunch and 11 units at supper. Her basal rates have not been changed since her last visit with Charla Yassine and totaled 30.5 units per 24 hours. A diet history was obtained. I instructed the patient on carbohydrate counting at 1 unit of insulin for every 10 g carbohydrate ratio was recommended. A correction dose of approximately 1 unit of insulin to bring the blood sugars down 30 mg/dl was also recommended. The Lilly guide for meal planning was provided and reviewed. Additional carbohydrate counting book was provided. ASSESSMENT: The patient was taught an insulin-to-carbohydrate ratio of 1 unit to 10 g of carbohydrates as recommended at the previous visit two years ago, which she does not recall. It is based on the 500 rule which suggests this ratio. We did identify carbohydrate sources in the food supply, recognizing 15-g equivalents. We also identified the need to dose her insulin at the time that she is eating her carbohydrate sources. She does seem to have a pattern of fixing blood sugars later in the day after they are elevated. We discussed the other option of trying to eat a consistent amount of carbohydrates at meals from day to day and taking a consistent amount of insulin at those meals. With this in mind, she was recommended to follow with three servings or 45 g of carbohydrate at breakfast, three servings or 45 g of carbohydrate at lunch and four servings or 60 g of carbohydrate at dinner. Joanne Araiza joined our consultation briefly to discuss whether her pump was working appropriately. The patient was given an 800 number for the pump to contact should there be any question about its failure to deliver insulin appropriately. PLAN: Recommend the patient use 1 unit of insulin for every 10-g carbohydrate load consumed. Recommend the patient either use this as a carbohydrate counting tool or work harder at keeping carbohydrate content consistent at meals from day to day. This was a one-hour consultation. Provided my name and number should additional needs arise." "71",71,"Discharge Summary","ADMISSION DIAGNOSIS (ES):1. Chronic obstructive pulmonary disease.2. Pneumonia.3. Congestive heart failure.4. Diabetes mellitus.5. Neuropathy.6. Anxiety.7. Hypothyroidism.8. Depression.9. Hypertension.DISCHARGE DIAGNOSIS (ES):1. Severe chronic obstructive pulmonary disease.2. Diabetes mellitus.3. Hypothyroidism.4. Altered mental status, less somnolent, likely secondary to medications, resolved.5. Lower gastrointestinal bleed.6. Status post episode of atrial fibrillation.7. Status post diverticular bleed. DISCHARGE MEDICATIONS:1. Albuterol inhaler q.i.d.2. Xanax 1 mg t.i.d.3. Cardizem CD 120 mg daily.4. Colace 100 mg b.i.d.5. Iron sulfate 325 mg b.i.d.6. NPH 10 units subcutaneous b.i.d.7. Atrovent inhaler q.i.d.8. Statin oral suspension p.o. q.i.d., swish and spit.9. Paxil 10 mg daily.10. Prednisone 20 mg daily.11. Darvocet Darvocet-N 100, one q.4h PRN pain.12. Metamucil one pack b.i.d.13. Synthroid 50 mcg daily.14. Nexium 40 mg daily. HOSPITAL COURSE: The patient was a 66-year-old who presented with complaints of shortness of breath and was found to have acute COPD exacerbation. She had previously been at outlying hospital and had left AMA after 10 sets of BiPAP use. Here she was able to be kept off BiPAP later and slowly improved her exacerbation of COPD with the assistance of pulmonary. She was thought to have bronchitis as well and was treated with antibiotics. During hospitalization she developed acute lower GI bleed and was transferred to intensive care unit and transfused packed red blood cells. GI was consulted, performed endoscopy, revealing diverticular disease of the sigmoid colon, with this being the suspected cause of hemorrhage. Plavix is being held for at least 10 days. Lovenox held as well. No further signs of bleeding. The patient's respiratory status did slowly improve to baseline. She is discharged and given the above noted medications. Followup with Dr. Pesce, of diagnostic pulmonary, in the outpatient setting. She will also followup with Dr. Pesce, in the outpatient setting." "72",72,"Discharge Summary","ADMISSION DATE: MM/DD/ YYYYDISCHARGE DATE: MM/DD/ YYYYHISTORY OF PRESENT ILLNESS: Mr. ABC is a 60-year-old white male veteran with multiple comorbidities, who has a history of bladder cancer diagnosed approximately two years ago by the VA Hospital. He underwent a resection there. He was to be admitted to the Day Hospital for cystectomy. He was seen in Urology Clinic and Radiology Clinic on MM/DD/YYYY. HOSPITAL COURSE: Mr. ABC presented to the Day Hospital in anticipation for Urology surgery. On evaluation, EKG, echocardiogram was abnormal, a Cardiology consult was obtained. A cardiac adenosine stress MRI was then proceeded, same was positive for inducible ischemia, mild-to-moderate inferolateral subendocardial infarction with peri-infarct ischemia. In addition, inducible ischemia seen in the inferior lateral septum. Mr. ABC underwent a left heart catheterization, which revealed two vessel coronary artery disease. The RCA, proximal was 95% stenosed and the distal 80% stenosed. The mid LAD was 85% stenosed and the distal LAD was 85% stenosed. There was four Multi-Link Vision bare metal stents placed to decrease all four lesions to 0%. Following intervention, Mr. ABC was admitted to 7 Ardmore Tower under Cardiology Service under the direction of Dr. XYZ. Mr. ABC had a noncomplicated post-intervention hospital course. He was stable for discharge home on MM/DD/YYYY with instructions to take Plavix daily for one month and Urology is aware of the same. DISCHARGE EXAM: VITAL SIGNS: Temperature 97.4, heart rate 68, respirations 18, blood pressure 133/70. HEART: Regular rate and rhythm. LUNGS: Clear to auscultation. ABDOMEN: Obese, soft, nontender. Lower abdomen tender when touched due to bladder cancer. RIGHT GROIN: Dry and intact, no bruit, no ecchymosis, no hematoma. Distal pulses are intact. DISCHARGE LABS: CBC: White count 5.4, hemoglobin 10.3, hematocrit 30, platelet count 132, hemoglobin A1c 9.1. BMP: Sodium 142, potassium 4.4, BUN 13, creatinine 1.1, glucose 211. Lipid profile: Cholesterol 157, triglycerides 146, HDL 22, LDL 106. PROCEDURES:1. On MM/DD/YYYY, cardiac MRI adenosine stress.2. On MM/DD/YYYY, left heart catheterization, coronary angiogram, left ventriculogram, coronary angioplasty with four Multi-Link Vision bare metal stents, two placed to the LAD in two placed to the RCA. DISCHARGE INSTRUCTIONS: Mr. ABC is discharged home. He should follow a low-fat, low-salt, low-cholesterol, and heart healthy diabetic diet. He should follow post-coronary artery intervention restrictions. He should not lift greater than 10 pounds for seven days. He should not drive for two days. He should not immerse in water for two weeks. Groin site care reviewed with patient prior to being discharged home. He should check groin for bleeding, edema, and signs of infection. Mr. ABC is to see his primary care physician within one to two weeks, return to Dr. XYZ's clinic in four to six weeks, appointment card to be mailed him. He is to follow up with Urology in their clinic on MM/DD/YYYY at 10 o'clock and then to scheduled CT scan at that time. DISCHARGE DIAGNOSES:1. Coronary artery disease status post percutaneous coronary artery intervention to the right coronary artery and to the LAD.2. Bladder cancer.3. Diabetes.4. Dyslipidemia.5. Hypertension.6. Carotid artery stenosis, status post right carotid endarterectomy in 2004.7. Multiple resections of the bladder tumor.8. Distant history of appendectomy.9. Distant history of ankle surgery." "73",73,"History and Physical","CHIEF COMPLAINT: Recurrent dizziness x1 month. HISTORY OF PRESENT ILLNESS: This is a 77-year-old African-American female with multiple medical problems including CHF (O2 dependent), atrial fibrillation, diabetes mellitus, hypothyroidism, possible stroke, multiple joint disease including gout, arthritis, both rheumatoid and DJD, who presents with a complaint of one month of dizziness. She reports a rotational sensation upon arising from the bed or chair that lasts for several minutes and requires her to sit back down and stay in one place. She gets similar symptoms when she rolls over in bed. She is not able to describe what direction she feels like she is spinning. At times, she also feels as though she is going to pass out. These sensations stop if she just sits in one place or lies down for several minutes. She does note that it is worse when she turns to the right and when she turns to the left. She also complains that she gets similar sensations when she looks up. She denies any recent fever, chills, earache, diplopia, dysarthria, dysphagia, other change in vision, or recent new headaches. She also notes occasional tinnitus to her right ear. PAST MEDICAL HISTORY:1. CHF (uses portable oxygen).2. Atrial fibrillation.3. Gout.4. Arthritis (DJD/rheumatoid).5. Diabetes mellitus.6. Hypothyroidism.7. Hypertension.8. GERD.9. Possible stroke treated in 2003 at University of Maryland with acute onset of presyncopal sensations, sharp pains in the left side of her head and right-sided hemiparesis and numbness. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: She is married. She does not smoke, use alcohol or use illicit drugs. MEDICATIONS: Please see medication sheet in the chart. It includes potassium, Pravachol, Prevacid, Synthroid, Diovan, Amaryl, Vitamin B12, Coreg, Coumadin, furosemide, Actos, aspirin, colchicine, Cipro, Percocet, Ultram (has held the latter two medications for the past two weeks due to concerns of exacerbating dizziness). REVIEW OF SYSTEMS: Please see note in chart essentially entirely positive including cardiovascular problems of shortness of breath, PND and palpitations, chronic lack of energy, weight gain, the dizziness for which she presented. Tinnitus in the right ear. Diabetes and hypothyroidism. Chronic nausea. Chronic severe musculoskeletal pains to all extremities as well as to chest and abdomen and back. Right-sided numbness as well as complaints of bilateral lower extremity numbness and difficulty walking. She says her mood is sad and may be depressed and she is also extremely anxious. She has chronic shortness of breath and coughs easily when has to breathe deeply. She also endorses poor sleep. PHYSICAL EXAMINATION: VITAL SIGNS: Sitting BP 112/84 with a pulse of 84, standing after two minutes 130/90 with a pulse of 66. Respiratory rate is 20. Weight is 257 pounds. Pain scale is 7. GENERAL: This is a somewhat anxious elderly African-American female who tends to amplify findings on examination. It is a difficult examination due to the fact that no matter where the patient was touched she would wince in pain and withdraw. She is obese. HEENT: She is normocephalic and atraumatic. Conjunctivae and sclerae are clear. Tympanic membranes were visualized bilaterally. There is tenderness to palpation of any sinus region. There are no palpable cervical nodes. NECK: Supple although she complains of pain when rotating her neck. CHEST: Clear to auscultation bilaterally. HEART: Heart sounds are distant. There are no carotid bruits. EXTREMITIES: She has 1-2+ pitting edema to the mid shins bilaterally. NEUROLOGIC EXAMINATION: MENTAL STATUS: She is alert and oriented x3. Her speech is fluent; however, she is extremely tangential. She is unable to give a cogent medical history including details of hospitalization one month ago when she was admitted for a gout attack and urinary tract infection and underwent several days of rehabilitation. CRANIAL NERVES: Cranial nerves are intact throughout; specifically there is no nystagmus, her gaze is conjugate, there is no diplopia, visual fields are full to confrontation, pupils are equal, round and reactive to light and accommodation, extraocular movements are intact, facial sensation and expression are symmetric, vestibuloocular reflexes are intact, hearing is intact to finger rub bilaterally, palate rises symmetrically, normal cough, shoulder shrug is symmetric which shows easy breakaway give, and tongue protrudes in the midline. MOTOR: This is a limited exam due to easy breakaway gait and pain that appears exaggerated to movement of any extremity. There is suggestion of some mild right-sided paresis; however, the degree was inconsistent and her phasic strength is estimated at 4-4+ throughout. Her tone is normal throughout. SENSORY: She appears to have diffuse light tough and pinprick and temperature to the right arm and proximal leg. She also reports that she is numb in both feet; however, sensation testing of light tough, pinprick and vibration was intact. COORDINATION: There is no obvious dysmetria. GAIT: She uses a walker to stand up, and several near falls when asked to stand unassisted and can only ambulate with a walker. There are some mild right lower extremity circumduction present. REFLEXES: Biceps 1, triceps trace, brachioradialis 1, patella and ankle absent. Toes are equivocal. OTHER: Barany maneuver was attempted; however, when the patient was placed supine she immediately began screaming, ""Oh my back, oh my back"", and was unable to complete the maneuver. Brief inspection of her eyes failed to show any nystagmus at that time. IMPRESSION AND PLAN: This is a 77-year-old African-American female with multiple medical problems who presents with episodic positionally related dizziness of unclear etiology. Most certainly there is significant exaggeration of the underlying problem and her neurological examination is compounded by much functional overlay, limiting the interpretation of my findings. I suspect this is just a mild benign positional vertigo, although I cannot rule out vertebrobasilar compromise. I agree with symptomatic treatment with Antivert.We will schedule her for CT of head, CT angiogram to evaluate for possible brain stroke and vertebrobasilar insufficiency. In addition, we will attempt to get further objective data by ENG testing. I will see the patient again after these tests are completed and she has a trial of the Antivert." "74",74,"History and Physical","HISTORY OF PRESENT ILLNESS: I was kindly asked to see Ms. ABC by Dr. X for cardiology consultation regarding preoperative evaluation for right hip surgery. She is a patient with a history of coronary artery disease status post bypass surgery in 1971 who tripped over her oxygen last p.m. she states and fell. She suffered a right hip fracture and is being considered for right hip replacement. The patient denies any recent angina, but has noted more prominent shortness of breath.Past cardiac history is significant for coronary artery disease status post bypass surgery, she states in 1971, I believe it was single vessel. She has had stress test done in our office on September 10, 2008, which shows evidence of a small apical infarct, no area of ischemia, and compared to study of December of 2005, there is no significant change. She had a transthoracic echocardiogram done in our office on August 29, 2008, which showed normal left ventricular size and systolic function, dilated right ventricle with septal flattening of the left ventricle consistent with right ventricular pressure overload, left atrial enlargement, severe tricuspid regurgitation with estimated PA systolic pressure between 75-80 mmHg consistent with severe pulmonary hypertension, structurally normal aortic and mitral valve. She also has had some presumed atrial arrhythmias that have not been sustained. She follows with Dr. Y my partner at Cardiology Associates. PAST MEDICAL HISTORY: Other medical history includes severe COPD and she is oxygen dependent, severe pulmonary hypertension, diabetes, abdominal aortic aneurysm, hypertension, dyslipidemia. Last ultrasound of her abdominal aorta done June 12, 2009 states that it was fusiform, infrarenal shaped aneurysm of the distal abdominal aorta measuring 3.4 cm unchanged from prior study on June 11, 2008. MEDICATIONS: As an outpatient:1. Lanoxin 0.125 mg, 1/2 tablet once a day.2. Tramadol 50 mg p.o. q.i.d. as needed.3. Verapamil 240 mg once a day.4. Bumex 2 mg once a day.5. ProAir HFA.6. Atrovent nebs b.i.d.7. Pulmicort nebs b.i.d.8. Nasacort 55 mcg, 2 sprays daily.9. Quinine sulfate 325 mg p.o. q.h.s. p.r.n.10. Meclizine 12.5 mg p.o. t.i.d. p.r.n.11. Aldactone 25 mg p.o. daily.12. Theo-24 200 mg p.o., 2 in the morning.13. Zocor 40 mg once a day.14. Vitamin D 400 units twice daily.15. Levoxyl 125 mcg once a day.16. Trazodone 50 mg p.o. q.h.s. p.r.n.17. Janumet 50/500, 1 tablet p.o. b.i.d. ALLERGIES: To medications are listed as:1. LEVAQUIN.2. AZITHROMYCIN.3. ADHESIVE TAPE.4. BETA BLOCKERS. When I talked to the patient about the BETA BLOCKER, she states that they made her more short of breath in the past.She denies shrimp, seafood or dye allergy. FAMILY HISTORY: Significant for heart problems she states in her mother and father. SOCIAL HISTORY: She used to smoke cigarettes and smoked from the age of 14 to 43 and quit at the time of her bypass surgery. She does not drink alcohol nor use illicit drugs. She lives alone and is widowed. She is a retired custodian at University. Of note, she is accompanied with her verbal consent by her daughter and grandson at the bedside. REVIEW OF SYSTEMS: Unable to obtain as the patient is somnolent from her pain medication, but she is alert and able to answer my direct questions. PHYSICAL EXAM: Height 5'2"", weight 160 pounds, temperature is 99.5 degrees ranging up to 101.6, blood pressure 137/67 to 142/75, pulse 92, respiratory rate 16, O2 saturation 93-89%. On general exam, she is an elderly, chronically ill appearing woman in no acute distress. She is able to lie flat, she does have pain if she moves. HEENT shows the cranium is normocephalic, atraumatic. She has dry mucosal membranes. Neck veins are not distended. There are no carotid bruits. Visible skin is warm and she appears pale. Affect appropriate and she is somnolent from her pain medications, but arouses easily and answers my direct questions appropriately. Lungs are clear to auscultation anteriorly, no wheezes. Cardiac exam S1, S2 regular rate, soft holosystolic murmur heard over the tricuspid region. No rub nor gallop. PMI is nondisplaced, unable to appreciate RV heave. Abdomen soft, mildly distended, appears benign. Extremities with trivial peripheral edema. Pulses grossly intact. She has quite a bit of pain at the right hip fracture.DIAGNOSTIC/ LABORATORY DATA: Sodium 135, potassium 4.7, chloride 99, bicarbonate 33, BUN 22, creatinine 1.3, glucose 149, troponin was 0.01 followed by 0.04. Theophylline level 16.6 on January 23, 2009. TSH 0.86 on March 10, 2009. INR 1.06. White blood cell count 9.5, hematocrit 35, platelet count 160.EKG done July 16, 2009 at 7:31:15, shows sinus rhythm, which showed PR interval of about 118 milliseconds, nonspecific T wave changes. When compared to EKG done July 15, 2009 at 1948, previously there more frequent PVCs seen. This ECG appears similar to the ones she has had done previously in our office including on June 11, 2009, although the T wave changes are a bit more prominent, which is a nonspecific finding. IMPRESSION: She is an 81-year-old woman with severe O2 requiring chronic obstructive pulmonary disease with evidence of right heart overload, as well as known coronary artery disease status post single-valve bypass in 1971 suffering a right hip fracture for whom a right hip replacement is being considered. I have had a long discussion with the patient, as well as her daughter and grandson at the bedside today. There are no clear absolute cardiac contraindications that I can see. Of note at the time of this dictation a chest x-ray report is pending. With that being said, however, she is extremely high risk more from a pulmonary than cardiac standpoint. We did also however review that untreated hip fractures themselves have very high morbidity and mortality incidences. The patient is deciding on surgery and is clearly aware that she is very high risk for proposed surgery, as well as if she were to not pursue surgery.PLAN/ RECOMMENDATIONS:1. The patient is going to decide on surgery. If she does have the right hip surgery, I would recommend overnight observation in the intensive care unit.2. Optimize pulmonary function and pursue aggressive DVT prophylaxis.3. Continue digoxin and verapamil. Again, the patient describes clear INTOLERANCE TO BETA BLOCKERS by her history.4. I would recommend long-term avoidance of theophylline if able, as well as quinine as both are proarrhythmic and consider alternative bronchoactive therapy to the theophylline.5. Long-term, consider, aspirin 81 mg once a day for secondary prophylaxis of an adverse CVS event, given known history of CAD status post bypass in 1971.6. I think continuing digoxin is reasonable for now as she had been on as an outpatient.Many thanks for this kind cardiac consultation opportunity. All of this has been discussed in detail with the patient, her daughter and her grandson. They were all given the opportunity to ask questions, which I have tried to answer for them. Please do not hesitate to contact me if you have any questions or concerns regarding her cardiac consultative care.To be clear, the patient has severe pulmonary hypertension, estimated PA systolic pressure of 75-80 mmHg as described above on echocardiogram with findings consistent with RV volume and/or pressure overload, so be careful to avoid over diuresis." "75",75,"History and Physical","HISTORY AND REASON FOR CONSULTATION: For evaluation of this patient for colon cancer screening. HISTORY OF PRESENT ILLNESS: Mr. A is a 53-year-old gentleman who was referred for colon cancer screening. The patient said that he occasionally gets some loose stools. Other than that, there are no other medical problems. PAST MEDICAL HISTORY: The patient does not have any serious medical problems at all. He denies any hypertension, diabetes, or any other problems. He does not take any medications. PAST SURGICAL HISTORY: Surgery for deviated nasal septum in 1996. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Does not smoke, but drinks occasionally for the last five years. FAMILY HISTORY: There is no history of any colon cancer in the family. REVIEW OF SYSTEMS: Denies any significant diarrhea. Sometimes he gets some loose stools. Occasionally there is some constipation. Stools caliber has not changed. There is no blood in stool or mucus in stool. No weight loss. Appetite is good. No nausea, vomiting, or difficulty in swallowing. Has occasional heartburn. PHYSICAL EXAMINATION: The patient is alert and oriented x3. Vital signs: Weight is 214 pounds. Blood pressure is 111/70. Pulse is 69 per minute. Respiratory rate is 18. HEENT: Negative. Neck: Supple. There is no thyromegaly. Cardiovascular: Both heart sounds are heard. Rhythm is regular. No murmur. Lungs: Clear to percussion and auscultation. Abdomen: Soft and nontender. No masses felt. Bowel sounds are heard. Extremities: Free of any edema. IMPRESSION: Routine colorectal cancer screening. RECOMMENDATIONS: Colonoscopy. I have explained the procedure of colonoscopy with benefits and risks, in particular the risk of perforation, hemorrhage, and infection. The patient agreed for it. We will proceed with it. I also explained to the patient about conscious sedation. He agreed for conscious sedation." "76",76,"History and Physical","REASON FOR CONSULTATION: Abnormal EKG and rapid heart rate. HISTORY OF PRESENT ILLNESS: The patient is an 86-year-old female. From the last few days, she is not feeling well, fatigue, tiredness, weakness, nausea, no vomiting, no hematemesis or melena. The patient relates to have some low-grade fever. The patient came to the emergency room. Initially showed atrial fibrillation with rapid ventricular response. It appears that the patient has chronic atrial fibrillation. As per the medications, they are not very clear. Husband has gone out to brief her medications. She denies any specific chest pain. Her main complaint is shortness of breath and symptoms as above. CORONARY RISK FACTORS: No hypertension or diabetes mellitus. Nonsmoker. Cholesterol status is normal. Questionable history of coronary artery disease. Family history noncontributory. FAMILY HISTORY: Nonsignificant. PAST SURGICAL HISTORY: Questionable coronary artery bypass surgery versus valve replacement. MEDICATIONS: Unclear at this time, but she does take Coumadin. ALLERGIES: ASPIRIN. PERSONAL HISTORY: She is married, nonsmoker. Does not consume alcohol. No history of recreational drug use. PAST MEDICAL HISTORY: Symptoms as above, atrial fibrillation, history of open heart surgery, possible bypass surgery; however, after further query, husband relates that she may had just a valve surgery. REVIEW OF SYSTEMSCONSTITUTIONAL: Weakness, fatigue, and tiredness. HEENT: No history of cataract, history of blurry vision and hearing impairment. CARDIOVASCULAR: Irregular heart rhythm with congestive heart failure, questionable coronary artery disease. RESPIRATORY: Shortness of breath, questionable pneumonia. No valley fever. GASTROINTESTINAL: No nausea, no vomiting, hematemesis or melena. UROLOGICAL: No frequency or urgency. MUSCULOSKELETAL: Arthritis, muscle weakness. CNS: No TIA. No CVA. No seizure disorder. SKIN: Nonsignificant. PSYCHOLOGIC: Anxiety and depression. ALLERGIES: Nonsignificant except as mentioned above for medications. PHYSICAL EXAMINATIONVITAL SIGNS: Pulse of 122, blood pressure 148/78, afebrile, and respiratory rate 18 per minute. HEENT AND NECK: Neck is supple. Atraumatic and normocephalic. Neck veins are flat. No thyromegaly. LUNGS: Air entry bilaterally fair. Decreased breath sounds especially in the right basilar areas. Few crackles. HEART: Normal S1 and S2, irregular. ABDOMEN: Soft and nontender. EXTREMITIES: No edema. Pulse is palpable. No clubbing or cyanosis. CNS: Grossly intact. MUSCULOSKELETAL: Arthritic changes. PSYCHOLOGICAL: None significant. DIAGNOSTIC DATA: EKG, atrial fibrillation with rapid ventricular response, and nonspecific ST-T changes. INR of 4.5, H and H 10 and 30. BUN and creatinine are within normal limits. Chest x-ray confirmed right lower lobe patchy infiltrate, and trace of pneumonia. IMPRESSION:1. The patient is an 86-year-old female who has questionable bypass surgery, questionable valve surgery with a rapid atrial heart rate, chronic atrial fibrillation with rapid ventricular response, exacerbated by most likely underlying pneumonia by chest x-ray findings.2. Symptoms as above. RECOMMENDATIONS:1. We will start her on a low dose of beta-blocker for rate control and antibiotic for pneumonia. Once, if she is stable, we will consider further cardiac workup.2. We will also obtain an echocardiogram to assess valves such as whether she had a prior valve surgery versus coronary artery bypass surgery.3. Discussed with the patient's husband regarding plan of care, fully understood, and consents for the same. All the questions answered in detail." "77",77,"Discharge Summary","ADMISSION DIAGNOSES: Hyperglycemia, cholelithiasis, obstructive sleep apnea, diabetes mellitus, and hypertension. DISCHARGE DIAGNOSES: Hyperglycemia, cholelithiasis, obstructive sleep apnea, diabetes mellitus, hypertension, and cholecystitis. PROCEDURE: Laparoscopic cholecystectomy. SERVICE: Surgery. HISTORY OF PRESENT ILLNESS: Ms. ABC is a 57-year-old woman. She suffers from morbid obesity. She also has diabetes and obstructive sleep apnea. She was evaluated in the Bariatric Surgical Center for placement of a band. During her workup, she was noted to have evidence of cholelithiasis. It was felt that the patient would benefit from removal of her gallbladder prior to having band placement secondary to her diabetes and the risk of infection of the band. The patient was scheduled to undergo her procedure on 12/31/09; however, at blood glucose check, the patient was noted to be hyperglycemic, her sugar was 438. She was admitted to the hospital for treatment of her hyperglycemia. HOSPITAL COURSE: Ms. ABC was admitted to the hospital. She was seen by Dr. A. He put her on an insulin drip. Her sugars slowly did come down to normal down to between 115 and 134. On the next day, she was then taken to the operating room, where she underwent her laparoscopic cholecystectomy. She was noted to be a difficult intubation for the procedure. There were some indications of chronic cholecystitis, a little bit of edema, mild edema and adhesions of omentum around the gallbladder. She underwent the procedure. She tolerated without difficulty. She was recovered in the Postoperative Care Unit and then returned to the floor. Her blood sugar postprocedure was noted to be 233. She was started back on a sliding scale insulin. She continued to do well and was felt to be stable for discharge following the procedure. DISCHARGE INSTRUCTIONS: To return to the Medifast diet. To continue with her blood glucose. She needs to follow up with Dr. B, and she will see me next week on Friday. We will determine if we will proceed with her lap band at that time. She may shower. She needs to keep her wounds clean and dry. No heavy lifting. No driving on narcotic pain medicines. She needs to continue with her CPAP machine and continue to monitor her sugars." "78",78,"Discharge Summary","ADMITTING DIAGNOSES:1. Bradycardia.2. Dizziness.3. Diabetes.4. Hypertension.5. Abdominal pain. DISCHARGE DIAGNOSIS: Sick sinus syndrome. The rest of her past medical history remained the same. PROCEDURES DONE: Permanent pacemaker placement after temporary internal pacemaker. HOSPITAL COURSE: The patient was admitted to the intensive care unit. Dr. X was consulted. A temporary intracardiac pacemaker was placed. Consultation was requested to Dr. Y. He considered the need to have a permanent pacemaker after reviewing electrocardiograms and telemetry readings. The patient remained in sinus rhythm with severe bradycardias, but all of them one to one transmission. This was considered to be a sick sinus syndrome. Permanent pacemaker was placed on 09/05/2007 with right atrium appendage and right ventricular apex electrode placement. This is a Medtronic pacemaker. After this, the patient remained with pain in the left side of the chest in the upper area as expected, but well controlled. Right femoral artery catheter was removed. The patient remained with good pulses in the right lower extremity with no hematoma. Other problem was the patient's blood pressure, which on 09/05/2007 was found at 180/90. Medication was adjusted to benazepril 20 mg a day. Norvasc 5 mg was added as well. Her blood pressure has remained better, being today 144/74 and 129/76. FINAL DIAGNOSES: Sick sinus syndrome. The rest of her past medical history remained without change, which are:1. Diabetes mellitus.2. History of peptic ulcer disease.3. Hypertension.4. Insomnia.5. Osteoarthritis. PLAN: The patient is discharged home to continue her previous home medications, which are:1. Actos 45 mg a day.2. Bisacodyl 10 mg p.o. daily p.r.n. constipation.3. Cosopt eye drops, 1 drop in each eye 2 times a day.4. Famotidine 20 mg 1 tablet p.o. b.i.d.5. Lotemax 0.5% eye drops, 1 drop in each eye 4 times a day.6. Lotensin (benazepril) increased to 20 mg a day.7. Triazolam 0.125 mg p.o. at bedtime.8. Milk of Magnesia suspension 30 mL daily for constipation.9. Tylenol No. 3, one to two tablets every 6 hours p.r.n. pain.10. Promethazine 25 mg IM every 6 hours p.r.n. nausea or vomiting.11. Tylenol 325 mg tablets every 4 to 6 hours as needed for pain.12. The patient will finish cefazolin 1 g IV every 6 hours, total 5 dosages after pacemaker placement. DISCHARGE INSTRUCTIONS: Follow up in the office in 10 days for staple removal. Resume home activities as tolerated with no starch, sugar-free diet." "79",79,"Discharge Summary","ADMISSION DIAGNOSES:1. Atypical chest pain.2. Nausea.3. Vomiting.4. Diabetes.5. Hypokalemia.6. Diarrhea.7. Panic and depression.8. Hypertension. DISCHARGE DIAGNOSES:1. Serotonin syndrome secondary to high doses of Prozac.2. Atypical chest pain with myocardial infarction ruled out.3. Diabetes mellitus.4. Hypertension.5. Diarrhea resolved. ADMISSION SUMMARY: The patient is a 53-year-old woman with history of hypertension, diabetes, and depression. Unfortunately her husband left her 10 days prior to admission and she developed severe anxiety and depression. She was having chest pains along with significant vomiting and diarrhea. Of note, she had a nuclear stress test performed in February of this year, which was normal. She was readmitted to the hospital to rule out myocardial infarction and for further evaluation. ADMISSION PHYSICAL: Significant for her being afebrile. Apparently there was one temperature registered mildly high at 100. Her blood pressure was 140/82, heart rate 83, oxygen saturation was 100%. She was tearful. HEART: Heart sounds were regular. LUNGS: Clear. ABDOMEN: Soft. Apparently there were some level of restlessness and acathexia. She was also pacing. ADMISSION LABS: Showed CBC with a white count of 16.9, hematocrit of 46.9, platelets 318,000. She had 80% neutrophils, no bands. UA on 05/02 came out negative. Chemistry panel shows sodium 138, potassium 3.5, creatinine 0.6, calcium 8.3, lactate 0.9, ALT was 39, AST 38, total bilirubin 0.6. Her initial CK came out at 922. CK-MB was low. Troponin was 0.04. She had a normal amylase and lipase. Previous TSH few days prior was normal. Chest x-ray was negative. HOSPITAL COURSE:1. Serotonin syndrome. After reevaluation of the patient including evaluation of the lab abnormalities it was felt that she likely had serotonin syndrome with obvious restlessness, increased bowel activity, agitation, and elevated white count and CPK. She did not have fever, tremor or hyperreflexia. Her CPK improved with IV fluids. She dramatically improved with this discontinuation of her Prozac. Her white count came back down towards normal. At time of discharge, she was really feeling back to normal.2. Depression and anxiety with history of panic attacks exacerbated by her husband leaving her 2 weeks ago. We discussed this. Also, discussed the situation with a psychiatrist who is available on Friday and I discussed the situation with the patient. In regards to her medications, we are discontinuing the Prozac and she is being reevaluated by Dr. X on Monday or Tuesday. Cymbalta has been recommended as a good alternative medication for her. The patient does have a counselor. It is going to be difficult for her to go home alone. I discussed the resources with her. She has a daughter who will be coming to town in a couple of weeks, but she does have a friend that she can call and stay the next few days with.3. Hypertension. She will continue on her usual medications.4. Diabetes mellitus. She will continue on her usual medications.5. Diarrhea resolved. Her electrolyte abnormalities resolved. She had received fluid rehydration. DISPOSITION: She is being discharged to home. She will stay with a friend for a couple of days. She will be following up with Dr. X on Monday or Tuesday. Apparently Dr. Y has already discussed the situation and the plan with her. She will continue on her usual medications except for discontinuing the Prozac. DISCHARGE MEDICATIONS: Include1. Omeprazole 20 mg daily.2. Temazepam 15 mg at night.3. Ativan 1 mg one-half to one three times a day as needed.4. Cozaar 50 daily.5. Prandin 1 mg before meals.6. Aspirin 81 mg.7. Multivitamin daily.8. Lantus 60 units at bedtime.9. Percocet 10/325 one to two at night for chronic pain. She is running out of that, so we are calling a prescription for #10 of those." "80",80,"History and Physical","REASON FOR ADMISSION: Hepatic encephalopathy. HISTORY OF PRESENT ILLNESS: The patient is a 51-year-old Native American male with known alcohol cirrhosis who presented to the emergency room after an accidental fall in the bathroom. He said that he was doing fine prior to that and denied having any complaints. He was sitting watching TV and he felt sleepy. So, he went to the bathroom to urinate before going to bed and while he was trying to lift the seat, he tripped and fell and hit his head on the back. His head hit the toilet seat. Then, he started having bleeding and had pain in the area with headache. He did not lose consciousness as far as he can tell. He went and woke up his sister. This happened somewhere between 10:30 and 11 p.m. His sister brought a towel and covered the laceration on the back of his head and called EMS, who came to his house and brought him to the emergency room, where he was found to have a laceration on the back of his head, which was stapled and a CT of the head was obtained and ruled out any acute intracranial pathology. On his lab work, his ammonia was found to be markedly elevated at 106. So, he is being admitted for management of this. He denied having any abdominal pain, change in bowel habits, GI bleed, hematemesis, melena, or hematochezia. He said he has been taking his medicines, but he could not recall those. He denied having any symptoms prior to this fall. He said earlier today he also fell. He also said that this was an accidental fall caused by problem with his walker. He landed on his back at that time, but did not have any back pain afterwards. PAST MEDICAL HISTORY:1. Liver cirrhosis caused by alcohol. This is per the patient.2. He thinks he is diabetic.3. History of intracranial hemorrhage. He said it was subdural hematoma. This was traumatic and happened seven years ago leaving him with the right-sided hemiparesis.4. He said he had a seizure back then, but he does not have seizures now. PAST SURGICAL HISTORY:1. He has a surgery on his stomach as a child. He does not know the type.2. Surgery for a leg fracture.3. Craniotomy seven years ago for an intracranial hemorrhage/subdural hematoma. MEDICATIONS: He does not remember his medications except for the lactulose and multivitamins. ALLERGIES: Dilantin. SOCIAL HISTORY: He lives in Sacaton with his sister. He is separated from his wife who lives in Coolidge. He smokes one or two cigarettes a day. Denies drug abuse. He used to be a heavy drinker, quit alcohol one year ago and does not work currently. FAMILY HISTORY: Negative for any liver disease. REVIEW OF SYSTEMS: GENERAL: Denies fever or chills. He said he was in Gilbert about couple of weeks ago for fever and was admitted there for two days. He does not know the details. ENT: No visual changes. No runny nose. No sore throat. CARDIOVASCULAR: No syncope, chest pain, or palpitations. RESPIRATORY: No cough or hemoptysis. No dyspnea. GI: No abdominal pain. No nausea or vomiting. No GI bleed. History of alcoholic liver disease. GU: No dysuria, hematuria, frequency, or urgency. MUSCULOSKELETAL: Denies any acute joint pain or swelling. SKIN: No new skin rashes or itching. CNS: Had a seizure many years ago with no recurrences. Left-sided hemiparesis after subdural hematoma from a fight/trauma. ENDOCRINE: He thinks he has diabetes but does not know if he is on any diabetic treatment. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 97.7, heart rate 83, respiratory rate 18, blood pressure 125/72, and saturation 98% on room air. GENERAL: The patient is lying in bed, appears comfortable, very pleasant Native American male in no apparent distress. HEENT: His skull has a scar on the left side from previous surgery. On the back of his head, there is a laceration, which has two staples on. It is still oozing minimally. It is tender. No other traumatic injury is noted. Eyes, pupils react to light. Sclerae anicteric. Nostrils are normal. Oral cavity is clear with no thrush or exudate. NECK: Supple. Trachea midline. No JVD. No thyromegaly. LYMPHATICS: No cervical or supraclavicular lymphadenopathy. LUNGS: Clear to auscultation bilaterally. HEART: Normal S1 and S2. No murmurs or gallops. Regular rate and rhythm. ABDOMEN: Soft, distended, nontender. No organomegaly or masses. LOWER EXTREMITIES: +1 edema bilaterally. Pulses strong bilaterally. No skin ulcerations noted. No erythema. SKIN: Several spider angiomas noted on his torso and upper extremities consistent with liver cirrhosis. BACK: No tenderness by exam. RECTAL: No masses. No abscess. No rectal fissures. Guaiac was performed by me and it was negative. NEUROLOGIC: He is alert and oriented x2. He is slow to some extent in his response. No asterixis. Right-sided spastic hemiparesis with increased tone, increased reflexes, and weakness. Increased tone noted in upper and lower extremities on the right compared to the left. Deep tendon reflexes are +3 on the right and +2 on the left. Muscle strength is decreased on the right, more pronounced in the lower extremity compared to the upper extremity. The upper extremity is +4/5. Lower extremity is 3/5. The left side has a normal strength. Sensation appears to be intact. Babinski is upward on the right, equivocal on the left. PSYCHIATRIC: Flat affect. Mood appeared to be appropriate. No active hallucinations or psychotic symptoms. LABORATORY DATA: White count 4, hemoglobin 14.2, hematocrit 40.2%, platelets 85,000, PT is 13.4, INR is 1, BUN 7.8, glucose 105, sodium 141, potassium 3.9, bicarbonate 22.3, calcium 8.7, albumin 3.6, AST 39, ALT 27, alkaline phosphatase 140, total bilirubin is 0.9, and ammonia level is 106. IMAGING STUDIES: CT of the head. Film was reviewed. The report mentioned, status post frontal craniotomy and a small focus of encephalomalacia involving the left frontal lobe. This is likely consistent with residuals from his previous head injury. There is also mild generalized atrophy and changes consistent with chronic small vessel disease. No other findings on his CT. The skull is unremarkable except for the surgery changes. No acute abnormalities overall. ASSESSMENT AND PLAN:1. Hepatic encephalopathy. Trigger is unclear at this time. Could be noncompliance. No evidence of GI bleed and his electrolytes are normal. I am not sure if he is taking any sedatives, as he does not recall the medication that he is on. The patient will be admitted to the hospital for management. He will be started on lactulose. I will give him 30 mL every two hours until he has a bowel movement. Then, we will adjust the dose to target three bowel movements daily and we will monitor his ammonia level and ensure that it is trending down. We will monitor his electrolyte and correct as needed and I will hydrate him, as hypovolemia is also a possible trigger. We will obtain an ultrasound of his abdomen to see if there is any ascites. At this time, there is no clinical evidence of SBP, but if he develops any fever may consider tapping his belly if there is ascites to rule out that possibility.2. Thrombocytopenia likely due to cirrhosis. We will monitor the level. No need for transfusion at this time.3. Macrocytosis also due to liver disease. I will check his vitamin levels, however, to ensure that he does not need any supplementation.4. History of diabetes as per the patient. His glucose is 105. This can be clarified in the morning with his primary care physician. We will monitor his glucose for now.5. Skull laceration. This was stapled by the ER physician and we will watch it for now, appear to be stable. No evidence of any other trauma.6. We will watch him on the telemetry floor to ensure that he has no arrhythmias leading to his two falls, which appear to be incidental as per the patient.7. Right-sided hemiparesis appear to be chronic and not an acute issue. The patient already has a walker at home.8. We can try to obtain more information in the morning about his past medical history, medication, etc., from his family and/or his primary care physician at Sacaton.Time spent in evaluation and management of this patient in the emergency room exceeds 70 minutes." "81",81,"Discharge Summary","HISTORY OF PRESENT ILLNESS: The patient is an 84-year-old woman with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension, mild aortic stenosis, and previously moderate mitral regurgitation although not seen recently and I was asked to perform cardiology consultation for her because there was concern for atrial fibrillation after a fall. Basically the patient states that yesterday she fell and she is not certain about the circumstances, on her driveway, and on her left side hit a rock. When she came to the emergency room, she was found to have a rapid atrial tachyarrhythmia, and was put on Cardizem with reportedly heart rate in the 50s, so that was stopped. Review of EKGs from that time shows what appears to be multifocal atrial tachycardia with followup EKG showing wandering atrial pacemaker. An ECG this morning showing normal sinus rhythm with frequent APCs. Her potassium at that time was 3.1. She does recall having palpitations because of the pain after the fall, but she states she is not having them since and has not had them prior. She denies any chest pain nor shortness of breath prior to or since the fall. She states clearly she can walk and she would be able to climb 2 flights of stairs without problems. PAST CARDIAC HISTORY: She is followed by Dr. X in our office and has a history of severe tricuspid regurgitation with mild elevation and PA pressure. On 05/12/08, preserved left and right ventricular systolic function, aortic sclerosis with apparent mild aortic stenosis, and bi-atrial enlargement. She has previously had a Persantine Myoview nuclear rest-stress test scan completed at ABCD Medical Center in 07/06 that was negative. She has had significant mitral valve regurgitation in the past being moderate, but on the most recent echocardiogram on 05/12/08, that was not felt to be significant. She has a history of hypertension and EKGs in our office show normal sinus rhythm with frequent APCs versus wandering atrial pacemaker. She does have a history of significant hypertension in the past. She has had dizzy spells and denies clearly any true syncope. She has had bradycardia in the past from beta-blocker therapy. MEDICATIONS ON ADMISSION:1. Multivitamin p.o. daily.2. Aspirin 325 mg once a day.3. Lisinopril 40 mg once a day.4. Felodipine 10 mg once a day.5. Klor-Con 20 mEq p.o. b.i.d.6. Omeprazole 20 mg p.o. daily presumably for GERD.7. MiraLax 17 g p.o. daily.8. Lasix 20 mg p.o. daily. ALLERGIES: PENICILLIN. IT IS LISTED THAT TOPROL HAS CAUSED SHORTNESS OF BREATH IN HER OFFICE CHART AND I BELIEVE SHE HAS HAD SIGNIFICANT BRADYCARDIA WITH THAT IN THE PAST. FAMILY HISTORY: She states her brother died of an MI suddenly in his 50s. SOCIAL HISTORY: She does not smoke cigarettes, abuse alcohol, nor use any illicit drugs. She is retired from Morse Chain and delivering newspapers. She is widowed. She lives alone but has family members who live either on her property or adjacent to it. REVIEW OF SYSTEMS: She denies a history of stroke, cancer, vomiting of blood, coughing up blood, bright red blood per rectum, bleeding, stomach ulcers. She does not recall renal calculi, nor cholelithiasis, denies asthma, emphysema, pneumonia, tuberculosis, sleep apnea, home oxygen use. She does note occasional peripheral edema. She is not aware of prior history of MI. She denies diabetes. She does have a history of GERD. She notes feeling depressed at times because of living alone. She denies rheumatologic conditions including psoriasis or lupus. Remainder of review of systems is negative times 15 except as described above. PHYSICAL EXAM: Height 5 feet 0 inches, weight 123 pounds, temperature 99.2 degrees Fahrenheit, blood pressure has ranged from 160/87 with pulses recorded at being 144, and currently ranges 101/53 to 147/71, pulse 64, respiratory rate 20, O2 saturation 97%. On general exam, she is a pleasant elderly woman who is hard of hearing, but is alert and interactive. HEENT: Shows cranium is normocephalic and atraumatic. She has moist mucosal membranes. Neck veins were not distended. There are no carotid bruits. Lungs: Clear to auscultation anteriorly without wheezes. She is relatively immobile because of her left hip fracture. Cardiac Exam: S1, S2, regular rate, frequent ectopic beats, 2/6 systolic ejection murmur, preserved aortic component of the second heart sound. There is also a soft holosystolic murmur heard. There is no rub or gallop. PMI is nondisplaced. Abdomen is soft and nondistended. Bowel sounds present. Extremities without significant clubbing, cyanosis, and there is trivial to 1+ peripheral edema. Pulses appear grossly intact. Affect is appropriate. Visible skin warm and perfused. She is not able to move because of left hip fracture easily in bed.DIAGNOSTIC STUDIES/ LAB DATA: Pertinent labs include chest x-ray with radiology report pending but shows only a calcified aortic knob. No clear pulmonary vascular congestion. Sodium 140, potassium 3.7, it was 3.1 on admission, chloride 106, bicarbonate 27, BUN 17, creatinine 0.9, glucose 150, magnesium was 2 on 07/13/06. Troponin was 0.03 followed by 0.18. INR is 0.93, white blood cell count 10.2, hematocrit 36, platelet count 115,000.EKGs are reviewed. Initial EKG done on 08/19/08 at 1832 shows MAT, heart rate of 104 beats per minute, no ischemic changes. She had a followup EKG done at 20:37 on 08/19/08, which shows wandering atrial pacemaker and some lateral T-wave changes, not significantly changed from prior. Followup EKG done this morning shows normal sinus rhythm with frequent APCs. IMPRESSION: She is an 84-year-old female with a history of hypertension, severe tricuspid regurgitation with mild pulmonary hypertension and mild aortic stenosis admitted after a fall with left hip fracture and she will require surgery. Telemetry now reviewed, shows predominantly normal sinus rhythm with frequent APCs _____ earlier yesterday evening showed burst of multifocal atrial tachycardia and I suspect that was exacerbated by prior hypokalemia, which has been corrected. There has been no atrial fibrillation documented. I do not feel these troponins are significant given the stress or fall in prior multifocal atrial tachycardia with increased rate especially in the absence of chest pain or shortness of breath. She actually describes feeling good exercise capacity prior to this fall. Given favorable risk to benefit ratio for needed left hip surgery, I feel she may proceed with needed left hip surgery from a cardiac standpoint with continued verapamil, which has been started, which should help control the multifocal atrial tachycardia, which she had and would watch for heart rate with that. Continued optimization of electrolytes. The patient cannot take beta-blockers as previously Toprol reportedly caused shortness of breath, although, there was some report that it caused bradycardia so we would watch her heart rate on the verapamil. The patient is aware of the cardiac risks, certainly it is moderate, and wishes to proceed with needed surgery. I do not feel any further cardiac evaluation is needed at this time and the patient may followup with Dr. X after discharge. Regarding her mild thrombocytopenia, I would defer that to hospitalist and continue proton pump inhibitors for history of gastroesophageal reflux disease, management of left hip fracture as per orthopedist." "82",82,"Discharge Summary","Chief Complaint: Back and hip pain.History of Present Illness: The patient is a 73 year old Caucasian male with a history of hypertension, end-stage renal disease secondary to reflux nephropathy / restriction of bladder neck requiring hemodialysis and eventual cadaveric renal transplant now on chronic immunosuppression, peripheral vascular disease with non-healing ulcer of right great toe, and peripheral neuropathy who initially presented to his primary care physician in May 2001 with complaints of low back pain and bilateral hip pain. The pain was described as a constant pain in the middle to lower back and hips. The pain was exacerbated by climbing stairs and in the morning after sleeping. He reported occasional radiation of pain from back into buttocks (greatest on the right side). He has history of chronic feet and leg numbness and paraesthesias related to his neuropathy, but he denied any recent changes in these symptoms in relation to the back pain. He denied any history of trauma. He was treated symptomatically with Acetaminophen with only some relief. He continued to complain intermittently of pain in his back and hips, and occasionally even in his elbows during the next 8 months. In January 2002, plain pelvic films showed no fracture or dislocation of the hips. Elbow films also showed no acute injury, but there were some erosions along the posterior aspect of the olecranon. An MRI was performed of his lumbar spine which showed degenerative disk disease, spondylosis, and annular bulging/herniation at L4-L5 with resultant encroachment on the neural foramen. He was evaluated by neurosurgery, who felt he should not have surgery at this time. His pain continued and progressively worsened, becoming unresponsive to medical therapy including narcoticsIn May 2002, as part of a vascular work-up for the patient�s non-healing right toe, an MRA showed extensive vascular disease in the vessels of both legs below the knees and evidence of bilateral trochanteric bursitis. It also revealed an abnormal enhancing lesion in the left proximal femur, the left iliac bone, the right iliac bone, and possibly the right tibia.Past Medical History:End stade renal disease secondary to reflux nephropathya. numerous related urinary tract infectionsb. hemodialysis (1983-1988)c. s/p cadaveric renal transplant (1988)d. baseline creatinine about 2.3.HypertensionPeripheral vascular diseasea. history of right foot infected toenail and non-healing ulcer since 2000; receiving hyperbaric oxygen therapy; recent surgery on infected toe in March, 2002Peripheral NeuropathyChronic anemia (on Epogen injections)History of several partial small bowel obstructions - six times during the last 10 yearsPast Surgical History:1. Tonsillectomy and adenoidectomy (1943)2. Left ureter re-implantation (1960)3. Repair of splenic artery aneurysm (1968)4. Left arm AV fistula graft placement and numerous procedures for dialysis access (1983-1988)5. Cadaveric renal transplant (1988)6. Cataract surgery in bilateral eyesMedications:1. Imuran 100mg po QD2. Prednisone 7.5mg po QD3. Aspirin 81mg po QD4. Trental 400mg po TID5. Norvasc 5mg po BID6. Prinivil 20mg po BID7. Hydralazine 50mg po Q6H8. Clonidine TTS III on Thursdays9. Terasozin 5mg po BID10. Elavil 30mg po QHS11. Vicodin 1-2tabs po Q6H prn12. Epoetin SR 10,000Units SQ QM and F13. Sodium bicarbonate 648mg po QD14. Calcium carbonate 2gm po QID15. Docusate sodium 100mg po QD16. Chocolate Ensure one can po QID17. Multivitamin18. Vitamin ESocial History: The patient is married with five children and lives with his wife. He is a retired engineer and real estate broker. He denies tobacco use. He drinks alcohol occasionally with up to three drinks a week. No history of drug abuse.Allergies: No known drug allergies.Family History: : His father died of colon and thyroid cancers at age 52. One brother died of stomach cancer at age 53 and one brother committed suicide. Five other siblings are all healthy. Negative for coronary heart disease, hypertension, diabetes, or kidney disease.Allergies: CiprofloxacinReview of systems: Denies fever, chills. Reports 15 to 20 pound weight loss slowly over 10 years (no recent change). Occasional mild shortness of breath with exercising. Denies chest pain, cough, abdominal pain, nausea, vomiting, recent change in baseline bowel movements, or dysuria. Denies any bleeding. Several year history of erectile dysfunction.Physical Exam: BP - 124/70, HR - 72, RR - 14, T - 97.8Gen: Well nourished, pleasant male in no acute distress. HEENT: Extra-ocular muscles intact. Pupils equal, round, and reactive to light. Oropharynx clear. No funduscopic exam recorded.Neck: Supple. No thyromegaly, bruits, or elevation of jugular venous pressure.Lungs: Clear to auscultation bilaterally. CV: Regular rate and rhythm. 1/6 systolic ejection murmur at left sternal border. No gallops, rubs, or clicks. Normal pulses.Abd: Soft and non-distended. Non-tender. Normoactive bowel sounds in all four quadrants. Midline surgical scar. Kidney palpable in left lower quadrant. No hepatosplenomegaly and no masses.Exts: No cyanosis, clubbing, or edema. Right great toe ulcer on medial aspect, mildly erythematous but no drainage.Back: Some pain with palpation over left iliac bone.Rectal: Normal sphincter tone. Prostate smooth with no nodules.Skin: No lesions.Lymph nodes: No lymphadenopathy.Neuro: Alert and oriented. No focal deficits. DTRs 1+ bilaterally. Strength 5/5. STUDIES:1/02 MRI Lumbar spine without contrast:1. Spondylosis at L2-3 with marked narrowing of the disk space, grade I/IV degenerative retrolisthesis, and moderately severe central spinal canal and bilateral foraminal stenosis.2. Degenerative disk disease at L4-5 with diffuse annular bulging and a broad based right lateral foraminal and extra-foraminal far lateral herniation which results in significant encroachment on the right lateral recess and neural foramen, and this deserves clinical correlation for right L4 and L5 radiculopathy. Degenerative facet joint changes and ligamentum flavum thickening are noted bilaterally at this level, but the central canal is adequate.3. Spondylosis with annular bulging and facet joint degenerative disease at L5-S1, L3-L4, and L1-L2 to a mild degree without significant stenosis.4. Note is made of probable cyst of the upper pole of the right kidney which measures 1.8cm in diameter. There is decrease in size of the right kidney which may be due to chronic renal disease.1/02 Left Elbow Films (2 views):Rather extensive vascular calcification in the soft tissues. There is no evidence of an acute injury. There is, however, what appears to be some erosion along the posterior aspect of the olecranon.1/02 Pelvis films:There is no fracture or dislocation of the hip identified. Extensive vascular calcification noted.5/02 MRA Lower Extremity with and without contrast:1. Minimal atherosclerotic narrowing of the bilateral superficial femoral arteries. Severe atherosclerotic disease of bilateral popliteal, anterior tibial, peroneal, and posterior tibial arteries (right greater than left).2. Abnormal enhancing lesion in the left proximal femur, the left iliac bone, and the right iliac bone. There may be a similar lesion in the right tibia.3. Abnormal enhancement in the trochanteric bursa of both femurs consistent with bursitis.4. The vertebral bodies demonstrate abnormal enhancement adjacent to the end-plates likely due to degenerative disk disease. There are questionable abnormal enhancing lesions in the vertebral bodies.6/02 Chest X-rayThere are no compression fractures identified. The lungs are adequately expanded. Two densities in right hemithorax that appear to represent healing rib fractures. The one involving the right 7th rib posteriorly could be a pathologic fracture. No lung nodules or lymphadenopathy.6/02 Whole Body Bone Scan:Areas of increased tracer activity are noted in the right proximal humerus, the left scapula at the region of the glenoid, the anterior aspect of the right third rib, the posterior aspect of the sixth, seventh, eighth, and ninth ribs, the left lateral aspect of the T10 vertebra, the L3 vertebra, the right lateral aspect of the L5 vertebra, the left iliac crest, both SI joints, the right ischial bone, the left proximal and mid femur, the right distal femur and the left proximal tibia.Irregular tracer activity is noted in the cervical and thoracic spine consistent with degenerative changes.Tracer in the left lower quadrant of the abdomen consistent with a kidney transplant.A diagnostic procedure was performed as an outpatient on 7/10/02." "83",83,"History and Physical","REASON FOR CONSULTATION: Abnormal echocardiogram findings and followup. Shortness of breath, congestive heart failure, and valvular insufficiency. HISTORY OF PRESENT ILLNESS: The patient is an 86-year-old female admitted for evaluation of abdominal pain and bloody stools. The patient has colitis and also diverticulitis, undergoing treatment. During the hospitalization, the patient complains of shortness of breath, which is worsening. The patient underwent an echocardiogram, which shows severe mitral regurgitation and also large pleural effusion. This consultation is for further evaluation in this regard. As per the patient, she is an 86-year-old female, has limited activity level. She has been having shortness of breath for many years. She also was told that she has a heart murmur, which was not followed through on a regular basis. CORONARY RISK FACTORS: History of hypertension, no history of diabetes mellitus, nonsmoker, cholesterol status unclear, no prior history of coronary artery disease, and family history noncontributory. FAMILY HISTORY: Nonsignificant. PAST SURGICAL HISTORY: No major surgery. MEDICATIONS: Presently on Lasix, potassium supplementation, Levaquin, hydralazine 10 mg b.i.d., antibiotic treatments, and thyroid supplementation. ALLERGIES: AMBIEN, CARDIZEM, AND IBUPROFEN. PERSONAL HISTORY: She is a nonsmoker. Does not consume alcohol. No history of recreational drug use. PAST MEDICAL HISTORY: Basically GI pathology with diverticulitis, colitis, hypothyroidism, arthritis, questionable hypertension, no prior history of coronary artery disease, and heart murmur. REVIEW OF SYSTEMSCONSTITUTIONAL: Weakness, fatigue, and tiredness. HEENT: History of cataract, blurred vision, and hearing impairment. CARDIOVASCULAR: Shortness of breath and heart murmur. No coronary artery disease. RESPIRATORY: Shortness of breath. No pneumonia or valley fever. GASTROINTESTINAL: No nausea, vomiting, hematemesis, or melena. UROLOGICAL: No frequency or urgency. MUSCULOSKELETAL: Arthritis and severe muscle weakness. SKIN: Nonsignificant. NEUROLOGICAL: No TIA or CVA. No seizure disorder.ENDOCRINE/ HEMATOLOGICAL: As above. PHYSICAL EXAMINATIONVITAL SIGNS: Pulse of 84, blood pressure of 168/74, afebrile, and respiratory rate 16 per minute.HEENT/ NECK: Head is atraumatic and normocephalic. Neck veins flat. No significant carotid bruits appreciated. LUNGS: Air entry bilaterally fair. No obvious rales or wheezes. HEART: PMI displaced. S1, S2 with systolic murmur at the precordium, grade 2/6. ABDOMEN: Soft and nontender. EXTREMITIES: Chronic skin changes. Feeble pulses distally. No clubbing or cyanosis. DIAGNOSTIC DATA: EKG: Normal sinus rhythm. No acute ST-T changes.Echocardiogram report was reviewed. LABORATORY DATA: H&H 13 and 39. BUN and creatinine within normal limits. Potassium within normal limits. BNP 9290. IMPRESSION:1. The patient admitted for gastrointestinal pathology, under working treatment.2. History of prior heart murmur with echocardiogram findings as above. Basically revealed normal left ventricular function with left atrial enlargement, large pleural effusion, and severe mitral regurgitation and tricuspid regurgitation. RECOMMENDATIONS:1. From cardiac standpoint, conservative treatment. Possibility of a transesophageal echocardiogram to assess valvular insufficiency adequately well discussed extensively.2. After extensive discussion, given her age 86, limited activity level, and no intention of undergoing any treatment in this regard from a surgical standpoint, the patient does not wish to proceed with a transesophageal echocardiogram.3. Based on the above findings, we will treat her medically with ACE inhibitors and diuretics and see how she fares. She has a normal LV function." "84",84,"History and Physical","CHIEF COMPLAINT: Followup of hospital discharge for Guillain-Barre syndrome. HISTORY OF PRESENT ILLNESS: This is a 62-year-old right-handed woman with hypertension, diabetes mellitus, a silent stroke involving right basal ganglia who was in her usual state of baseline health until late June of 2006 when she had onset of blurred vision, diplopia, and possible weakness in the right greater than left arm and left-sided ptosis. She was admitted to the hospital. The MRI showed only an old right basal ganglion infarct. She subsequently had a lumbar puncture, which showed increased protein, and an EMG/nerve conduction study performed by Dr. X on July 3rd, showed early signs of AIDP. The patient was treated with intravenous gamma globulin and had some mild improvement in her symptoms. Her vital capacities were normal during the hospitalization. Her chest x-ray was negative for any acute process. She was discharged to rehab from July 12, 2006 to July 20, 2006. She made some progress in which she notes that her walking is definitely better. However, she notes that she still has some problems with eye movement and her vision. This is possibly her main problem. She also reports tightness and pain in her mid back. REVIEW OF SYSTEMS: Documented in the clinic note. The patient has problems with diabetes, double vision, blurry vision, muscle pain, weakness, trouble walking, and headaches about two to three times per week. PAST MEDICAL HISTORY:1. Hypertension.2. Diabetes mellitus.3. Stroke involving the right basal ganglion.4. Guillain-Barre syndrome diagnosed in June of 2006.5. Bilateral knee replacements.6. Total abdominal hysterectomy and cholecystectomy. FAMILY HISTORY: Multiple family members have diabetes mellitus. SOCIAL HISTORY: The patient is retired on disability due to her knee replacements. She does not smoke, drink or use any illicit drugs. MEDICATIONS: Percocet 5/325 mg 4-6 hours p.r.n., Neurontin 100 mg per day, insulin, Protonix 40 mg per day, Toprol-XL 50 mg q.d., Norvasc 10 mg q.d., glipizide 10 mg q.d., fluticasone 50 mcg nasal spray, Lasix 20 mg b.i.d., and Zocor 1 mg q.d. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: Blood pressure 122/74, heart rate 68, respiratory rate 16, and weight 228 pounds. Pain scale 5/10. Please see the written note for details. General exam is benign other than mild obesity. On neuro examination, mental status is normal. Cranial nerves are significant for full visual fields and pupils are equal and reactive. However, extraocular movements are very limited. She has some adduction of the left eye and she has minimal upgaze of both eyes, but otherwise the eyes do not move. Face is symmetric. Sensation is intact. Tongue and uvula are in midline. Palate is elevated symmetrically. Shoulder shrug is strong. The patient's muscle exam shows normal bulk and tone throughout. She has no weakness of the left upper extremity. In the right upper extremity, she has only about 2/5 strength in the right shoulder, but is otherwise 5/5. There is no drift or orbit. Reflexes are absent throughout. Sensory exam is intact to light touch, pinprick, vibration, and proprioception is normal. There is no dysmetria. Gait is somewhat limited possibly by her vision and possibly also by her balance problems. PERTINENT DATA: As reviewed previously. DISCUSSION: This is a 62-year-old woman with hypertension, diabetes mellitus, prior stroke who has what sounds like Guillain-Barre syndrome, likely the Miller-Fisher variant. The patient has shown some improvement with IVIG and continues to show some gradual improvement. I discussed with the patient the course of disease, which is often weeks to about a month or so of worsening followed by many months of gradual improvement.I told her that it is possible she may not recover 100%, but that certainly there is still plenty of time for her to have additional recovery over what she has right now. She is scheduled to see an ophthalmologist. I think it is reasonable for close followup of her visual symptoms progress. However, I certainly would not take any corrective measures at this point as I suspect her vision will improve gradually.I discussed with the patient that with respect to her back pain certainly the Neurontin is relatively at low dose and this could be increased further. I wanted her to start taking the Neurontin 300 mg per day and then 300 mg b.i.d. after one week. She will call me in approximately three weeks' time to let me know how she is doing and if needed we will titrate up further.She was apparently given some baclofen by her internist and I think this is not unreasonable. I definitely hope to get her off the Percocet in the future. IMPRESSION:1. Guillain-Barre Miller-Fisher variant.2. Hypertension.3. Diabetes mellitus.4. Stroke. RECOMMENDATIONS:1. The patient is to start taking aspirin 162 mg per day.2. Followup with ophthalmology.3. Increase Neurontin to 300 mg per day x 1 week and then 300 mg b.i.d.4. Followup by phone in three to four weeks.5. Followup in this clinic in approximately two months' time.6. Call for any questions or problems." "85",85,"History and Physical","CHIEF COMPLAINT: Intractable nausea and vomiting. HISTORY OF PRESENT ILLNESS: This is a 43-year-old black female who was recently admitted and discharged yesterday for the same complaint. She has a long history of gastroparesis dating back to 2000, diagnosed by gastroscopy. She also has had multiple endoscopies revealing gastritis and esophagitis. She has been noted in the past multiple times to be medically noncompliant with her medication regimen. She also has very poorly controlled hypertension, diabetes mellitus and she also underwent a laparoscopic right adrenalectomy due to an adrenal adenoma in January, 2006. She presents to the emergency room today with elevated blood pressure and extreme nausea and vomiting. She was discharged on Reglan and high-dose PPI yesterday, and was instructed to take all of her medications as prescribed. She states that she has been compliant, but her symptoms have not been controlled. It should be noted that on her hospital admission she would have times where she would feel extremely sick to her stomach, and then soon after she would be witnessed going outside to smoke. PAST MEDICAL HISTORY:1. Diabetes mellitus (poorly controlled).2. Hypertension (poorly controlled).3. Chronic renal insufficiency secondary to DM.4. Adrenal mass.5. Obstructive sleep apnea.6. Arthritis.7. Hyperlipidemia. PAST SURGICAL HISTORY:1. Removal of ovarian cyst.2. Hysterectomy.3. Multiple EGDs with biopsies over the last six years. Her last EGD was in June, 2005, which showed esophagitis and gastritis.4. Colonoscopy in June, 2005, showing diverticular disease.5. Cardiac catheterization in February, 2002, showing normal coronary arteries and no evidence of renal artery stenosis.6. Laparoscopic adrenalectomy in January, 2006. MEDICATIONS:1. Reglan 10 mg orally every 6 hours.2. Nexium 20 mg orally twice a day.3. Labetalol.4. Hydralazine.5. Clonidine.6. Lantus 20 units at bedtime.7. Humalog 30 units before meals.8. Prozac 40 mg orally daily. SOCIAL HISTORY: She has a 27 pack year smoking history. She denies any alcohol use. She does have a history of chronic marijuana use. FAMILY HISTORY: Significant for diabetes and hypertension. ALLERGIES: NO KNOWN DRUG ALLERGIES. REVIEW OF SYSTEMS: HEENT: See has had headaches, and some dizziness. She denies any vision changes. CARDIAC: She denies any chest pain or palpitations. RESPIRATORY: She denies any shortness of breath. GI: She has had persistent nausea and vomiting. She denies diarrhea, melena or hematemesis. NEUROLOGICAL: She denies any neurological deficits.All other systems were reviewed and were negative unless otherwise mentioned in HPI. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure: 220/130. Heart rate: 113. Respiratory rate: 18. Temperature: 98. GENERAL: This is a 43-year-old obese African-American female who appears in no acute distress. She has a depressed mood and flat affect, and does not answer questions elaborately. She will simply state that she does not feel well. HEENT: Normocephalic, atraumatic, anicteric. PERRLA. EOMI. Mucous membranes moist. Oropharynx is clear. NECK: Supple. No JVD. No lymphadenopathy. LUNGS: Clear to auscultation bilaterally, nonlabored. HEART: Regular rate and rhythm. S1 and S2. No murmurs, rubs, or gallops. ABDOMEN: Obese. Soft. Slight diffuse tenderness. Bowel sounds are present. Unable to properly assess for organomegaly based on the patient's size. EXTREMITIES: Full range of motion. Acyanotic. No peripheral edema.NEURO/ PSYCH: Cranial nerves 2 through 12 grossly intact. She moves all extremities and has a nonfocal examination. Her cognition is intact. She does express a depressed mood and flat affect. LABORATORY DATA: White blood cell count: 16.3, hemoglobin 11.2, hematocrit 33.8, platelets 751,000. PT 12.9, INR 0.95, PTT 33. Urinalysis is remarkable for 99 white blood cells, 68 red blood cells, leukocyte esterase positive and moderate amount of bacteria. Glucose is negative in the urine, and she has greater than 300 albumin. Sodium 140, potassium 3.6, chloride 107, CO2 22, BUN 16, creatinine 2.2, glucose 137, calcium 9.1, magnesium 1.9, total protein 7.4, albumin 2.9, AST 23, ALT 50, alkaline phosphatase 181, total bilirubin 0.2. Amylase and lipase are still pending. Her cardiac enzymes are negative times one set. Urine drug screen is positive for cannabis.Arterial blood gas shows pH 7.42, pCO2 34, PaO2 83, O2 sat 96% on room air. ASSESSMENT AND PLAN:1. Intractable nausea and vomiting/history of diabetic gastroparesis/multiple endoscopies revealing gastritis and esophagitis. We will make the patient NPO for now. IV fluids. Give antiemetics as needed. She will be continued on Reglan 10 mg IV every 6 hours and she will be started on erythromycin 250 mg orally 3 times a day to help increase peristalsis. We will consider obtaining a GI consult in the morning. We will also check an abdominal ultrasound to rule out any gallbladder disease or biliary colic.2. Hypertension. She will be started on labetalol 10 mg IV every 4 hours and will receive hydralazine 10 mg IV every 6 hours as needed. She will also be started on Catapres patch 0.1 mg for 24 hours.3. Diabetes mellitus. The patient will receive sliding scale insulin of Humalog every 6 hours while NPO. We will restart her Lantus 20 units at bedtime with supplemental sliding scale when she is tolerating a diet.4. Chronic renal insufficiency. Her creatinine is 2.2, which is right near her baseline of 2. We will continue to hydrate her and monitor her BMP closely.5. Urinary tract infection/hemorrhagic cystitis. She will be started on Cipro 400 mg IV daily. We will await the report of the abdominal ultrasound. Other things to consider would be pyelonephritis or renal stone.6. Obstructive sleep apnea. She will be continued on CPAP as previously ordered when she was an inpatient yesterday.7. Depression. We will consider a psych consult in the morning. She may have a psychological component to her nausea and vomiting.8. Case management to evaluate medication options. We need to make sure that she can afford all of her medications upon discharge.This case was presented and thoroughly discussed with the senior resident who agrees with all medications and treatment." "86",86,"History and Physical","The patient returns to our office today because of continued problems with her headaches. She was started on Zonegran on her last visit and she states that initially she titrated upto 100 mg q.h.s. Initially felt that the Zonegran helped, but then the pain in her head returned. It is an area of tenderness and sensitivity in her left parietal area. It is a very localized pain. She takes Motrin 400 mg b.i.d., which helped.She also had EMG/nerve conduction studies since she was last seen in our office that showed severe left ulnar neuropathy, moderate right ulnar neuropathy, bilateral mild-to-moderate carpal tunnel and diabetic neuropathy. She was referred to Dr. XYZ and will be seeing him on August 8, 2006.She was also never referred to the endocrine clinic to deal with her poor diabetes control. Her last hemoglobin A1c was 10. PAST MEDICAL HISTORY: Diabetes, hypertension, elevated lipids, status post CVA, and diabetic retinopathy. MEDICATIONS: Glyburide, Avandia, metformin, lisinopril, Lipitor, aspirin, metoprolol and Zonegran. PHYSICAL EXAMINATION: Blood pressure was 140/70, heart rate was 76, respiratory rate was 18, and weight was 226 pounds. On general exam she has an area of tenderness on palpation in the left parietal region of her scalp. Neurological exam is detailed on our H&P form. Her neurological exam is within normal limits. IMPRESSION AND PLAN: For her headaches we are going to titrate Zonegran up to 200 mg q.h.s. to try to maximize the Zonegran therapy. If this is not effective, when she comes back on August 7, 2006 we will then consider other anticonvulsants such as Neurontin or Lyrica. We also discussed with Ms. Hawkins the possibility of nerve block injection; however, at this point she is not interested.She will be seeing Dr. XYZ for her neuropathies.We made an appointment in endocrine clinic today for a counseling in terms of better diabetes control and she is responsible for trying to get her referral from her primary care physician to go for this consult." "87",87,"History and Physical","REASON FOR CONSULTATION: Lightheaded, dizziness, and palpitation. HISTORY OF PRESENT ILLNESS: The patient is a 50-year-old female who came to the Emergency Room. This morning, the patient experienced symptoms of lightheaded, dizziness, felt like passing out; however, there was no actual syncope. During the episode, the patient describes symptoms of palpitation and fluttering of chest. She relates the heart was racing. By the time when she came into the Emergency Room, her EKG revealed normal sinus rhythm. No evidence of arrhythmia. The patient had some cardiac workup in the past, results are as mentioned below. Denies any specific chest pain. Activities fairly stable. She is actively employed. No other cardiac risk factor in terms of alcohol consumption or recreational drug use, caffeinated drink use or over-the-counter medication usage. CORONARY RISK FACTORS: No history of hypertension or diabetes mellitus. Nonsmoker. Cholesterol normal. No history of established coronary artery disease and family history noncontributory. FAMILY HISTORY: Nonsignificant. SURGICAL HISTORY: Tubal ligation. MEDICATIONS: On pain medications, ibuprofen. ALLERGIES: SULFA. PERSONAL HISTORY: She is a nonsmoker. Does not consume alcohol. No history of recreational drug use. PAST MEDICAL HISTORY: History of chest pain in the past. Had workup done including nuclear myocardial perfusion scan, which was reportedly abnormal. Subsequently, the patient underwent cardiac catheterization in 11/07, which was also normal. An echocardiogram at that time was also normal. At this time, presentation with lightheaded, dizziness, and palpitation. REVIEW OF SYSTEMS: CONSTITUTIONAL: No history of fever, rigors, or chills. HEENT: No history of cataract, blurry vision, or glaucoma. CARDIOVASCULAR: As above. RESPIRATORY: Shortness of breath. No pneumonia or valley fever. GASTROINTESTINAL: No epigastric discomfort, hematemesis or melena. UROLOGICAL: No frequency or urgency. MUSCULOSKELETAL: Nonsignificant. NEUROLOGICAL: No TIA. No CVA. No seizure disorder.ENDOCRINE/ HEMATOLOGIC: Nonsignificant. PHYSICAL EXAMINATION: VITAL SIGNS: Pulse of 69, blood pressure 127/75, afebrile, and respiratory rate 16 per minute. HEENT: Atraumatic and normocephalic. NECK: Neck veins flat. No carotid bruits. No thyromegaly. No lympyhadenopathy. LUNGS: Air entry bilaterally fair. HEART: PMI normal. S1 and S2 regular. ABDOMEN: Soft and nontender. Bowel sounds present. EXTREMITIES: No edema. Pulses palpable. No clubbing or cyanosis. CNS: Benign. PSYCHOLOGICAL: Normal. MUSCULOSKELETAL: Nonsignificant. EKG: Normal sinus rhythm, incomplete right bundle-branch block. LABORATORY DATA: H&H stable. BUN and creatinine within normal limits. Cardiac enzyme profile negative. Chest x-ray unremarkable. IMPRESSION:1. Lightheaded, dizziness in a 50-year-old female. No documented arrhythmia with the symptoms of palpitation.2. Normal cardiac structure by echocardiogram a year and half ago.3. Normal cardiac catheterization in 11/07.4. Negative workup so far for acute cardiac event in terms of EKG, cardiac enzyme profile. RECOMMENDATIONS:1. From cardiac standpoint, observation, no other investigation at this juncture.2. The patient was started on low dose of beta-blocker and see how she fares. Fortunately, no arrhythmia documented. If there is no documentation of arrhythmia, we will do observation. The patient was started empirically on beta-blocker and workup on outpatient basis explained to her. As mentioned above, she does not have any cardiac risk factors." "88",88,"History and Physical","The patient is an 84-year-old retired male who is referred to our office by Dr. O. He comes in today with the chief complaint of low back pain which started about six to eight months ago. He states that he does live here and also travels between here and Iowa and he does have a family in Iowa, which he is very active with his grandchildren doing shopping and plenty of walking. He also recently cut down some trees. He states that he started noticing some pain in his back and his hips and difficulty when beginning ambulation after getting up from a seated position due to the hip pains and the back pains. He states he has not had any treatment for this problem. He just does take Aleve. He states that he began to wear a back brace, which only helps him some. He says his pain is pretty manageable and low when he is not active, but it does increase with more activity that he does. He is very leery about any surgical procedure, even a referral to come see us today for his brother most recently died from complications of back surgery. He states that his back pain is intermittent. On a 1 to 10 pain scale, he rates it a 2. He has tried Aleve, which only helps him some. On the body image drawing, he draws low back pain and bilateral hip pain, no radiating pain down the legs. He describes his pain as 100% in low back and hip. Lying down is the only alleviating factor. Walking, light and heavy exercise exacerbate his pain. FAMILY HISTORY: His parents are deceased. He has two brothers ages 68 and 77 years old, who are healthy. He has siblings, a brother and a sister who were twins who died at birth. He has two sons 54 and 57 years old who are healthy. He describes history of diabetes and heart attack in his family. SOCIAL HISTORY: He is married and has support at home. He denies tobacco and illicit drug use and drinks two to three alcoholic beverages a day and up to four to nine per week. ALLERGIES: Garamycin. MEDICATIONS: Insulin 20 to 25 units twice a day. Lorazepam 0.05 mg, he has a history of using this medication, but most recently stopped taking it. Glipizide 5 mg with each meal, Advair 250 as needed, aspirin q.h.s., cod liver oil b.i.d., Centrum AZ q.d. PAST MEDICAL HISTORY: The patient has been diabetic for 35 years, has been insulin-dependent for the last 20 years. He also has a history of prostate cancer, which was treated by radiation. He says his PSA is at 0.01. PAST SURGICAL HISTORY: In 1985, he had removal of a testicle due to enlarged testicle, he is not quite sure of the cause but he states it was not cancer. REVIEW OF SYSTEMS: Musculoskeletal: He is right-handed. Respiratory: For shortness of breath. Urinary: For frequent urination. GI: He denies any bowel or bladder dysfunction. Genital: He denies any loss of sensation or erectile problems. HEENT: Negative and noncontributory. Hem-Onc: Negative and noncontributory. Cardiac: Negative and noncontributory. Vascular: Negative and noncontributory. Psychiatric: Negative and noncontributory. PHYSICAL EXAMINATION: He is 5 feet 10 inches tall. Current weight is 204 pounds, weight one year ago was 212. BP is 130/66. Pulse is 78. On physical exam, the patient is alert and oriented with normal mentation and appropriate speech, in no acute distress. HEENT exam, head is atraumatic and normocephalic. Eyes, sclerae are anicteric. Teeth, poor dentition. Cranial nerves II, III, IV, and VI, vision intact, visual fields full to confrontation, EOMs full bilaterally, and pupils are equal, round, and reactive to light. Cranial nerves V and VII, normal facial sensation and symmetrical facial movements. Cranial nerve VIII, hearing is intact. Cranial nerves IX, X, and XII, tongue protrudes midline and palate elevates symmetrically. Cardiac, regular rate, a holosystolic murmur is also noted which is about grade 1 to 2. Chest and lungs are clear bilaterally. Skin is warm and dry, normal turgor and texture. No rashes or lesions are noted. Peripheral vascular, no cyanosis, clubbing, or edema is noted. General musculoskeletal exam reveals no gross deformities, fasciculations, or atrophy. Station and gait are appropriate. He ambulates well without any difficulties or assistance. No antalgic or spastic gait is noted. Examination of the low back reveals no paralumbar spasms. He is nontender to palpation over his spinous process, SI joints, or paralumbar musculature. Deep tendon reflexes are 2+ bilaterally at the knees and 1+ at the ankles. No ankle clonus is elicited. Babinski, toes are downgoing. Sensation is intact.He does have some decreased sensation to pinprick, dull versus sharp over the right lower extremity compared to that of the left. Strength is 5/5 and equal bilateral lower extremities. He is able to ambulate on his toes and his heels without any weakness noted. He has negative straight leg raising bilaterally. FINDINGS: The patient brings in lumbar spine MRI for 11/15/2007, which demonstrates degenerative disc disease throughout. At L4-L5 and L5-S1 he has severe disc space narrowing. At L3-L4, he has degenerative changes of the facet with ligamentum flavum hypertrophy and annular disc bulge, which caused moderate neuroforaminal narrowing. At L4-L5, degenerative changes within the facets with ligamentum flavum hypertrophy as well causing neuroforaminal narrowing and central stenosis. At L5-S1, there is an annular disc bulge more to the right causing right-sided neuroforaminal stenosis, which is quite severe compared to that on the left. ASSESSMENT: Low back pain, degenerative disc disease, spinal stenosis, diabetes, and history of prostate cancer status post radiation. PLAN: We discussed treatment options with this patient including:1. Do nothing.2. Conservative therapies.3. Surgery.The patient states that his pain is very well tolerated by minimizing his activity and would like to do just pain management with some pain pills only as needed. We went ahead and obtained an EKG in the office today due to the fact that I heard a murmur on exam. I did phone the patient's primary care doctor, Dr. O. Unfortunately Dr. O is out of the country, and I did speak with Dr. K, who is covering for Dr. O. I informed Dr. K that the patient had a new-onset murmur and that I did have some concerns for the patient does not recollect having this diagnosis before, so I obtained an EKG. A copy was provided to the patient and the patient was referred back to his primary care physician for workup. He was also released from our care at this time to a p.r.n. basis, but the patient does not wish to proceed with any neurosurgical intervention nor any conservative measures besides medications, which he will receive from his primary doctor.All questions and concerns were addressed. If he should have any further questions, concerns, or complications, he will contact our office immediately. Otherwise, we will see him p.r.n. Warning signs and symptoms were gone over with him. Case was reviewed and discussed with Dr. L." "89",89,"History and Physical","She is a 14-year-old G0, LMP November 25, 2006. She comes in today in consultation from ABC, nurse practitioner. She comes in because of irregular periods and cyst on her ovaries. She comes in with her mother from whom most of the history is taken.She started her periods at age 13. She is complaining of a three-month history of lower abdominal pain for which she has been to the emergency room twice. She describes the pain as bilateral, intermittent, and non-radiating. It decreases slightly when she eats and increases with activity. She states the pain when it comes can last for half-a-day. It is not associated with movement, but occasionally the pain was so bad that it was associated with vomiting. She has tried LactAid, which initially helped, but then the pain returned. She has tried changing her diet and Pepcid AC. She was seen at XYZ where blood work was done. At that time, she had a normal white count and a normal H&H. She was given muscle relaxants, which did not work.Approximately two weeks ago, she was seen in the emergency room at XYZ where a pelvic ultrasound was done. This showed a 1.9 x 1.4-cm cyst on the right with no free fluid. The left ovary and uterus appeared normal. Two days later, the pain resolved and she has not had a recurrence. She denies constipation and diarrhea. She has had some hot flashes, but has not taken her temperature.In addition, she states that her periods have been very irregular coming between four and six weeks. They are associated with cramping which she is not happy about.She has never had a pelvic exam. She states she is not sexually active and declined having her mother leave the room, so she was not questioned regarding this without her mother present. She is very interested in not having pain with her periods and if this was a cyst that caused her pain, she is interested in starting birth control pills to prevent this from happening again. PAST MEDICAL HX: Pneumonia in 2002, depression diagnosed in 2005, and seizures as an infant. PAST SURGICAL HX: Plastic surgery on her ear after a dog bite in 1997. MEDICATIONS: Zoloft 50 mg a day and LactAid. ALLERGIES: NO KNOWN DRUG ALLERGIES. SOCIAL HX: She enjoys cooking and scrapbooking. She does have a boyfriend; again she states she is not sexually active. She also states that she exercises regularly, does not smoke cigarettes, use drugs, or drink alcohol. FAMILY HX: Significant for her maternal grandfather with adult-onset diabetes, a maternal grandmother with hypertension, mother with depression, and a father who died of colon cancer at 32 years of age. She also has a paternal great grandfather who was diagnosed with colon cancer. PE: VITALS: Height: 5 feet 5 inches. Weight: 190 lb. Blood Pressure: 120/88. GENERAL: She is well-developed, well-nourished with normal habitus and no deformities. NECK: Without thyromegaly or lymphadenopathy. LUNGS: Clear to auscultation bilaterally. HEART: Regular rate and rhythm without murmurs. ABDOMEN: Soft, nontender, and nondistended. There is no organomegaly or lymphadenopathy. PELVIC: Deferred.A/ P: Abdominal pain, unclear etiology. I expressed my doubt that her pain was secondary to this 1.9-cm ovarian cyst given the fact that there was no free fluid surrounding this. However, given that she has irregular periods and they are painful for her, I think it is reasonable to start her on a low-dose birth control pill. She has no personal or familial contraindications to start this. She was given a prescription for Lo/Ovral, dispensed 30 with refill x 4. She will come back in six weeks for blood pressure check as well as in six months to followup on her pain and her bleeding patterns.If she should have the recurrence of her pain, I have advised her to call." "90",90,"History and Physical","CHIEF COMPLAINT: Newly diagnosed T-cell lymphoma. HISTORY OF PRESENT ILLNESS: The patient is a very pleasant 40-year-old gentleman who reports swelling in his left submandibular region that occurred all of a sudden about a month and a half ago. He was originally treated with antibiotics as a possible tooth abscess. Prior to this event, in March of 2010, he was treated for strep throat. The pain at that time was on the right side. About a month ago, he started having night sweats. The patient reports feeling hot, when he went to bed he fall asleep and would wake up soaked. All these symptoms were preceded by overwhelming fatigue and exhaustion. He reports being under significant amount of stress as he and his mom just recently moved from their house to a mobile home. With the fatigue, he has had some mild chest pain and shortness of breath, and has also noted a decrease in his appetite, although he reports his weight has been stable. He also reports occasional headaches with some stabbing and pain in his feet and legs. He also complains of some left groin pain. PAST MEDICAL HISTORY: Significant for HIV diagnosed in 2000. He also had mononucleosis at that time. The patient reports being on anti-hepatitis viral therapy period that was very intense. He took the meds for about six months, he reports stopping, and prior to 2002 at one point during his treatment, he was profoundly weak and found to have hemoglobin less than 4 and required three units of packed red blood cells. He reports no other history of transfusions. He has history of spontaneous pneumothorax. The first episode was 1989 on his right lung. In 1990 he had a slow collapse of the left lung. He reports no other history of pneumothoraces. In 2003, he had shingles. He went through antiviral treatment at that time and he also reports another small outbreak in 2009 that he treated with topical therapy. FAMILY HISTORY: Notable for his mother who is currently battling non-small cell lung cancer. She is a nonsmoker. His sister is Epstein-Barr virus positive. The patient's mother also reports that she is Epstein-Barr virus positive. His maternal grandfather died from complications from melanoma. His mother also has diabetes. SOCIAL HISTORY: The patient is single. He currently lives with his mother in house for several both in New York and here in Colorado. His mother moved out to Colorado eight years ago and he has been out here for seven years. He currently is self employed and does antiquing. He has also worked as nurses' aide and worked in group home for the state of New York for the developmentally delayed. He is homosexual, currently not sexually active. He does have smoking history as about a thirteen and a half pack year history of smoking, currently smoking about a quarter of a pack per day. He does not use alcohol or illicit drugs. REVIEW OF SYSTEMS: As mentioned above his weight has been fairly stable. Although, he suffered from obesity as a young teenager, but through a period of anorexia, but his weight has been stable now for about 20 years. He has had night sweats, chest pain, and is also suffering from some depression as well as overwhelming fatigue, stabbing, short-lived headaches and occasional shortness of breath. He has noted some stool irregularity with occasional loose stools and new onset of pain predominantly in left neck. He has had fevers as well. The rest of his review of systems is negative. PHYSICAL EXAM: VITALS: BP: 100/64. HEART RATE: 72. TEMP: 97. Weight: 61.4 kg. GEN: He is a very pleasant gentleman, in no acute distress. HEENT: He has obvious mass in submandibular region on the left. His pupils are equal, round and reactive to light. He has a nevus just below his orbit on the right hand side that has some irregularity. His pupils are equal, round and reactive to light. Sclerae anicteric. His oropharynx is clear. He has several missing teeth. NECK: Supple. He has large palpable mass in the submandibular region and firm. He has some shotty lymphadenopathy in the posterior cervical chain bilaterally. LUNGS: Clear to auscultation bilaterally. CV: Regular rate, normal S1, S2, no murmurs. ABDOMEN: Soft. He has positive bowel sounds. No hepatosplenomegaly. He has shotty axillary adenopathy and shotty inguinal adenopathy. EXT: Lower extremity is without edema.His CT scan of the chest showed prominent axillary lymph nodes bilaterally, largest on the left measuring 12 x 29 mm. He has borderline enlarge right superior hilar lymph node measuring 9 x 11 mm. His lungs are benign appearing by apical pleural parenchymal scarring and very mild peri-septal emphysema. Bones shows mild disk degenerative changes in the inferior thoracic spine. IMPRESSION: 1. Borderline enlarged right superior hilar and left axillary lymph nodes, otherwise it unremarkable CT of the chest. CT of the neck shows 4.1 x 3.0 x 3.9 cm heterogenously enhancing lesion in the left submandibular space with central necrosis. The lesion appears to be separate from the submandibular gland with displacement of the glands superiorly and posteriorly. This lesion is most suspicious for an enlarged lymph node. Also, numerous other enlarged enhancing lymph nodes in the anterior and posterior cervical chains and left supraclavicular region.2. Prominent palatine tonsils and lingular tonsillar tissue bilaterally which may be reactive or could indicate lymphomatous involvement if the patient does have lymphoma.3. Rim-enhancing lesions in the right parotid gland. These could be Warthin tumors or potentially necrotic intraparotid lymph nodes related to the previously described process in the neck. Pathology for fine needle aspiration of the left mandible shows an atypical cell population, the atypical cell population is difficult to define. A neoplastic process is favored. While they are fairly large, they are still within the realm of being lymphoid in nature, and they are also discohesive, which also favours of lymphoid neoplasm. He then had a biopsy of the right maxillary alveolar ridge. This was positive for high grade lymphoma most consistent with peripheral T-cell lymphoma.ASSESSMENT/ PLAN: This is a very pleasant 40-year-old gentleman with certain onset of swelling in his left neck, biopsies consistent with T-cell lymphoma. I plan at this point time is to complete the staging. He will check HTLV-1 serology. We will also send pro for blood for flow cytometry and analysis for atypical cells. We will obtain a CBC, comprehensive metabolic panel and LDH. We will also send his stool for parasites and obtain a PET CT scan. We were to preliminarily stage this he is at least stage 2 lymph nodes in the neck and the axilla seen on skin. On physical exam lymph nodes are palpable in inguinal region. He does have these symptoms with the drenching night sweats and fever. We will also check viral load and hepatitis B and C panel. The patient has not established care with infectious disease physician. We will need to reformed ID as if he true he has HIV positive, we can do some help in coordinating HIV treatment as well as treatment for what appears to be a T-cell lymphoma. Once we get these preliminary labs back then we will discuss the need for bone marrow biopsy and lumbar puncture." "91",91,"History and Physical","CHIEF COMPLAINT: ""I have had trouble breathing for the past 3 days"" HISTORY: 69-year-old Caucasian male complaining of difficulty breathing for 3 days. He also states that he has been coughing accompanying with low-grade type fever. He also admits to having intermittent headaches and bilateral chest pain that does not radiate to upper extremities and jaws but worse with coughing. Patient initially had this type of episodes about 10 months ago but has intermittently getting worse since. PMH: DM, HTN, COPD, CADPSH: CABG, appendectomy, tonsillectomy FH: Non-contributory SOCH: Divorce and live alone, retired postal worker, has 3 children, 7 grandchildren. He smokes 1 pack a day of Newport for 30 years and is a social drinker. He denies any illicit drug use. TRAVEL HISTORY: Denies any recent travel overseas ALLERGIES: Denies any drug allergies HOME MEDICATIONS: Advair 1 puff bid Lisinopril 10 mg qd Lopressor 50 mg bid Aspirin 81 mg qd Plavix 75 mg qd Multivitamins Feso4 1 tab qd Colace 100 mg qd REVIEW OF SYSTEMS REVEALS: Same as above PHYSICAL EXAM:Vital signs are: Temp. 99.3 F / BP 138/92, Resp. 22, P 88General: Patient is in mild acute respiratory distress HEENT:Head: Atraumatic, normocephalic,Eyes: Conjunctiva clear; pupils 3 mm in size, EOMI, PERLLAEars: Tympanic membranes are pearly gray; no TM inflammation or perforation.Nose: Nasal congestion with thick yellow rhinorrhea; swollen, erythematous nasal turbinates; septum midlineThroat: Pharyngeal erythema; post-nasal drainage; tonsils mildly enlarged; there are no pustules, ulcers or exudate.Face: Symmetrical; no maxillary or frontal sinus tendernessNeck: Supple, no anterior or posterior cervical lymphadenopathy; thyroid is not palpable; trachea is midline; no JVDHeart: regular rhythm; normal S1 and S2; no S3 or S4; no murmurs, gallops or rubs.Lungs: Bi-basilar crackles left > right, diffuse wheezes.Abdomen: No distention; no tenderness to palpation; no masses or organomegaly; bowel sounds present in four quadrants; no bruits auscultated; no inguinal adenopathy.Extremities: Warm, strong pulses throughoutNeuro: Moving all extremities well, 2+/4 reflexes throughout. OSTEOPATHIC STRUCTURAL EXAM: He has bilateral paravertebral spasm, greater on the right, T10-L5. The spine is flattened T10-L2. Generalized restriction of the lumbar to spring towards rotation and sidebending both directions. Restriction to extension (restriction to anterior spring) T10-L3. Articular restriction is greatest T10-12. T4 ESrRr, T2 FSlRl. Twelfth ribs held in exhalation at an extremely acute angle static with respiration. Ribs 8-10 are held in inhalation bilaterally. 1st and 2nd ribs are elevated on the right with right clavicle elevated. The left 2nd rib is held in exhalation and there is bogginess to the tissues in the area of the second ribs. The thorax has general restriction to exhalation. The diaphragm was extremely tense and depressed with virtually no discernable movement during respiration." "92",92,"History and Physical","CHIEF COMPLAINT: Achilles ruptured tendon. HISTORY: Mr. XYZ is 41 years of age, who works for Chevron and lives in Angola. He was playing basketball in Angola back last Wednesday, Month DD, YYYY, when he was driving toward the basket and felt a pop in his posterior leg. He was seen locally and diagnosed with an Achilles tendon rupture. He has been on crutches and has been nonweightbearing since that time. He had no pain prior to his injury. He has had some swelling that is mild. He has just been on aspirin a day due to his traveling time. Pain currently is minimal. PAST MEDICAL HISTORY: Denies diabetes, cardiovascular disease, or pulmonary disease. CURRENT MEDICATIONS: Malarone, which is an anti-malarial. ALLERGIES: NKDASOCIAL HISTORY: He is a petroleum engineer for Chevron. Drinks socially. Does not use tobacco. PHYSICAL EXAM: Pleasant gentleman in no acute distress. He has some mild swelling on the right ankle and hindfoot. He has motion that is increased into dorsiflexion. He has good plantarflexion. Good subtalar, Chopart and forefoot motion. His motor function is intact although weak into plantarflexion. Sensation is intact. Pulses are strong. In the prone position, he has diminished tension on the affected side. There is some bruising around the posterior heel. He has a palpable defect about 6-8 cm proximal to the insertion site that is tender for him. Squeezing the calf causes no plantarflexion of the foot. RADIOGRAPHS: Of his right ankle today show a preserved joint space. I don't see any evidence of fracture noted. Radiographs of the heel show no fracture noted with good alignment. IMPRESSION: Right Achilles tendon rupture. PLAN: I have gone over with Mr. XYZ the options available. We have discussed the risks, benefits and alternatives to operative versus nonoperative treatment. Based on his age and his activity level, I think his best option is for operative fixation. We went over the risks of bleeding, infection, damage to nerves and blood vessels, rerupture of the tendon, weakness and the need for future surgery. We have discussed doing this as an outpatient procedure. He would be nonweightbearing in a splint for 10 days, nonweightbearing in a dynamic brace for 4 weeks, and then a walking boot for another six weeks with a lift until three months postop when we can get him into a shoe with a ¼"" lift. He understands a 6-9 month return to sports overall. He will also need to be on some Lovenox for a week after surgery and then on an aspirin as he is going to travel back to Angola. Today we will put him in a high tide boot that he will need at six weeks, and we will put him in a 1"" lift also. He can weight bear until surgery and we will have it set up this week. His questions were all answered today." "93",93,"Operative Note","DIAGNOSIS: Aortic valve stenosis with coronary artery disease associated with congestive heart failure. The patient has diabetes and is morbidly obese. PROCEDURES: Aortic valve replacement using a mechanical valve and two-vessel coronary artery bypass grafting procedure using saphenous vein graft to the first obtuse marginal artery and left radial artery graft to the left anterior descending artery. ANESTHESIA: General endotracheal INCISION: Median sternotomy INDICATIONS: The patient presented with severe congestive heart failure associated with the patient's severe diabetes. The patient was found to have moderately stenotic aortic valve. In addition, The patient had significant coronary artery disease consisting of a chronically occluded right coronary artery but a very important large obtuse marginal artery coming off as the main circumflex system. The patient also has a left anterior descending artery which has moderate disease and this supplies quite a bit of collateral to the patient's right system. It was decided to perform a valve replacement as well as coronary artery bypass grafting procedure. FINDINGS: The left ventricle is certainly hypertrophied· The aortic valve leaflet is calcified and a severe restrictive leaflet motion. It is a tricuspid type of valve. The coronary artery consists of a large left anterior descending artery which is associated with 60% stenosis but a large obtuse marginal artery which has a tight proximal stenosis.The radial artery was used for the left anterior descending artery. Flow was excellent. Looking at the targets in the posterior descending artery territory, there did not appear to be any large branches. On the angiogram these vessels appeared to be quite small. Because this is a chronically occluded vessel and the patient has limited conduit due to the patient's massive obesity, attempt to bypass to this area was not undertaken. The patient was brought to the operating room PROCEDURE: The patient was brought to the operating room and placed in supine position. A median sternotomy incision was carried out and conduits were taken from the left arm as well as the right thigh. The patient weighs nearly three hundred pounds. There was concern as to taking down the left internal mammary artery. Because the radial artery appeared to be a good conduit The patient would have arterial graft to the left anterior descending artery territory. The patient was cannulated after the aorta and atrium were exposed and full heparinization.The patient went on cardiopulmonary bypass and the aortic cross-clamp was applied Cardioplegia was delivered through the coronary sinuses in a retrograde manner. The patient was cooled to 32 degrees. Iced slush was applied to the heart. The aortic valve was then exposed through the aortic root by transverse incision. The valve leaflets were removed and the #23 St. Jude mechanical valve was secured into position by circumferential pledgeted sutures. At this point, aortotomy was closed.The first obtuse marginal artery was a very large target and the vein graft to this target indeed produced an excellent amount of flow. Proximal anastomosis was then carried out to the foot of the aorta. The left anterior descending artery does not have severe disease but is also a very good target and the radial artery was anastomosed to this target in an end-to-side manner. The two proximal anastomoses were then carried out to the root of the aorta.The patient came off cardiopulmonary bypass after aortic cross-clamp was released. The patient was adequately warmed. Protamine was given without adverse effect. Sternal closure was then done using wires. The subcutaneous layers were closed using Vicryl suture. The skin was approximated using staples." "94",94,"History and Physical","HISTORY OF PRESENT ILLNESS: The patient is a 58-year-old right-handed gentleman who presents for further evaluation of right arm pain. He states that a little less than a year ago he developed pain in his right arm. It is intermittent, but has persisted since that time. He describes that he experiences a dull pain in his upper outer arm. It occurs on a daily basis. He also experiences an achy sensation in his right hand radiating to the fingers. There is no numbness or paresthesias in the hand or arm.He has had a 30-year history of neck pain. He sought medical attention for this problem in 2006, when he developed ear pain. This eventually led to him undergoing an MRI of the cervical spine, which showed some degenerative changes. He was then referred to Dr. X for treatment of neck pain. He has been receiving epidural injections under the care of Dr. X since 2007. When I asked him what symptom he is receiving the injections for, he states that it is for neck pain and now the more recent onset of arm pain. He also has taken several Medrol dose packs, which has caused his blood sugars to increase. He is taking multiple other pain medications. The pain does not interfere significantly with his quality of life, although he has a constant nagging pain. PAST MEDICAL HISTORY: He has had diabetes since 2003. He also has asthma, hypertension, and hypercholesterolemia. CURRENT MEDICATIONS: He takes ACTOplus, albuterol, AndroGel, Astelin, Diovan, Dolgic Plus, aspirin 81 mg, fish oil, Lipitor, Lorazepam, multivitamins, Nasacort, Pulmicort, ranitidine, Singulair, Viagra, Zetia, Zyrtec, and Uroxatral. He also uses Lidoderm patches and multiple eye drops and creams. ALLERGIES: He states that Dyazide, Zithromax, and amoxicillin cause him to feel warm and itchy. FAMILY HISTORY: His father died from breast cancer. He also had diabetes. He has a strong family history of diabetes including diabetic complications of retinopathy and DKD. His mother is 89. He has a sister with diabetes. He is unaware of any family members with neurological disorders. SOCIAL HISTORY: He lives alone. He works full time in Human Resources for the State of Maryland. He previously was an alcoholic, but quit in 1984. He also quit smoking cigarettes in 1984, after 16 years of smoking. He has a history of illicit drug use, but denies IV drug use. He denies any HIV risk factors and states that his last HIV test was over two years ago. REVIEW OF SYSTEMS: He has intermittent chest discomfort. He has chronic tinnitus. He has urinary dribbling. Otherwise, a complete review of systems was obtained and was negative except for as mentioned above. This is documented in the handwritten notes from today's visit. PHYSICAL EXAMINATION:Vital Signs: HR 72. RR 16.General Appearance: Patient is well appearing, in no acute distress.Cardiovascular: There is a regular rhythm without murmurs, gallops, or rubs. There are no carotid bruits.Chest: The lungs are clear to auscultation bilaterally.Skin: There are no rashes or lesions. NEUROLOGICAL EXAMINATION:Mental Status: Speech is fluent without dysarthria or aphasia. The patient is alert and oriented to name, place, and date. Attention, concentration, registration, recall, and fund of knowledge are all intact.Cranial Nerves: Pupils are equal, round, and reactive to light and accommodation. Optic discs are normal. Visual fields are full. Extraocular movements are intact without nystagmus. Facial sensation is normal. There is no facial, jaw, palate, or tongue weakness. Hearing is grossly intact. Shoulder shrug is full.Motor: There is normal muscle bulk and tone. There is no atrophy or fasciculations. There is no action or percussion myotonia or paramyotonia. Manual muscle testing reveals MRC grade 5/5 strength in all proximal and distal muscles of the upper and lower extremities.Sensory: Sensation is intact to light touch, pinprick, temperature, vibratory sensation, and joint position sense. Romberg is absent.Coordination: There is no dysmetria or ataxia on finger-nose-finger or heel-to-shin testing.Deep Tendon Reflexes: Deep tendon reflexes are 2+ at the biceps, triceps, brachioradialis, patellas and ankles. Plantar reflexes are flexor. There are no finger flexors, Hoffman's sign, or jaw jerk.Gait and Stance: Casual gait is normal. Heel, toe, and tandem walking are all normal. RADIOLOGIC DATA: MRI of the cervical spine, 05/19/08: I personally reviewed this film, which showed narrowing of the foramen on the right at C4-C5 and other degenerative changes without central stenosis. IMPRESSION: The patient is a 58-year-old gentleman with one-year history of right arm pain. He also has a longstanding history of neck pain. His neurological examination is normal. He has an MRI that shows some degenerative changes. I do believe that his symptoms are probably referable to his neck. However, I do not think that they are severe enough for him to undergo surgery at this point in time. Perhaps another course of physical therapy may be helpful for him. I probably would not recommend anymore invasive procedure, such as a spinal stimulator, as this pain really is minimal. We could still try to treat him with neuropathic pain medications. RECOMMENDATIONS:1. I scheduled him to return for an EMG and nerve conduction studies to determine whether there is any evidence of nerve damage, although I think the likelihood is low.2. I gave him a prescription for Neurontin. I discussed the side effects of the medication with him.3. We can discuss his case tomorrow at Spine Conference to see if there are any further recommendations." "95",95,"History and Physical","CHIEF REASON FOR CONSULTATION: Evaluate recurrent episodes of uncomfortable feeling in the left upper arm at rest, as well as during exertion for the last one month. HISTORY OF PRESENT ILLNESS: This 57-year-old black female complains of having pain and discomfort in the left upper arm, especially when she walks and after heavy meals. This lasts anywhere from a few hours and is not associated with shortness of breath, palpitations, dizziness, or syncope. Patient does not get any chest pain or choking in the neck or pain in the back. Patient denies history of hypertension, diabetes mellitus, enlarged heart, heart murmur, history suggestive of previous myocardial infarction, or acute rheumatic polyarthritis during childhood. Her exercise tolerance is one to two blocks for shortness of breath and easy fatigability. MEDICATIONS: Patient does not take any specific medications. PAST HISTORY: The patient underwent hysterectomy in 1986. FAMILY HISTORY: The patient is married, has four children who are doing fine. Family history is positive for hypertension, congestive heart failure, obesity, cancer, and cerebrovascular accident. SOCIAL HISTORY: The patient smokes one pack of cigarettes per day and takes drinks on social occasions. ALLERGIES: THE PATIENT IS ALLERGIC TO CODEINE. REVIEW OF SYSTEMS: Remarkable for heavy snoring, daytime sleepiness, and easy fatigability. PHYSICAL EXAMINATION: GENERAL: Well-built, well-nourished black female in no acute distress. VITAL SIGNS: Blood pressure is 120/80. Respirations 18 per minute. Heart rate 70 beats per minute. Patient weighs 226 pounds, height 68 inches. BMI is 34. HEENT: Head normocephalic. Eyes, no evidence of anemia or jaundice. Oral hygiene is good. NECK: Supple. No cervical lymphadenopathy. Carotid upstroke is good. No bruit heard over the carotid or subclavian arteries. Trachea in midline. Thyroid not enlarged. JVP flat at 45°. CHEST: Chest is symmetrical on both sides, moves well with respirations. Vesicular breath sounds heard over the lung fields. No wheezing, crepitation, or pleural friction rub heard. CARDIOVASCULAR SYSTEM: PMI felt in fifth left intercostal space within midclavicular line. First and second heart sounds are normal in character. There is no murmur, gallop, or pericardial friction rub heard. ABDOMEN: Soft. There is no hepatosplenomegaly or ascites. No bruit heard over the aorta or renal vessels. EXTREMITIES: No pedal edema or calf muscle tenderness. Proximal and distal arterial pulsations are well felt.EKG shows normal sinus rhythm, negative T waves in leads 1, aVL, V4-V6. IMPRESSION: 1. Abnormal EKG showing diffuse anterior wall ischemia.2. Discomfort left upper arm highly suggestive of angina pectoris.3. Obesity.4. Obstructive sleep apnea syndrome. PLAN: 1. Stress Myoview SPECT, echocardiogram.2. Sleep apnea study.3. Routine blood tests.4. Patient will be seen again in my office in two weeks." "96",96,"History and Physical","CHIEF REASON FOR CONSULTATION: Evaluate exercise-induced chest pain, palpitations, dizzy spells, shortness of breath, and abnormal EKG. HISTORY OF PRESENT ILLNESS: This 72-year-old female had a spell of palpitations that lasted for about five to ten minutes. During this time, patient felt extremely short of breath and dizzy. Palpitations lasted for about five to ten minutes without any recurrence. Patient also gives history of having tightness in the chest after she walks briskly up to a block. Chest tightness starts in the retrosternal area with radiation across the chest. Chest tightness does not radiate to the root of the neck or to the shoulder, lasts anywhere from five to ten minutes, and is relieved with rest. Patient gives history of having hypertension for the last two months. Patient denies having diabetes mellitus, history suggestive of previous myocardial infarction, or cerebrovascular accident. MEDICATIONS: 1. Astelin nasal spray.2. Evista 60 mg daily.3. Lopressor 25 mg daily.4. Patient was given a sample of Diovan 80 mg daily for the control of hypertension from my office. PAST HISTORY: The patient underwent right foot surgery and C-section. FAMILY HISTORY: The patient is married, has six children who are doing fine. Father died of a stroke many years ago. Mother had arthritis. SOCIAL HISTORY: The patient does not smoke or take any drinks. ALLERGIES: THE PATIENT IS NOT ALLERGIC TO ANY MEDICATIONS. REVIEW OF SYSTEMS: Otherwise negative. PHYSICAL EXAMINATION: GENERAL: Well-built, well-nourished white female in no acute distress. VITAL SIGNS: Blood pressure is 160/80. Respirations 18 per minute. Heart rate 70 beats per minute. Patient weighs 133 pounds, height 64 inches. BMI is 22. HEENT: Head normocephalic. Eyes, no evidence of anemia or jaundice. Oral hygiene is good. NECK: Supple. No cervical lymphadenopathy. Carotid upstroke is good. No bruit heard over the carotid or subclavian arteries. Trachea in midline. Thyroid not enlarged. JVP flat at 45°. CHEST: Chest is symmetrical on both sides, moves well with respirations. Vesicular breath sounds heard over the lung fields. No wheezing, crepitation, or pleural friction rub heard. CARDIOVASCULAR SYSTEM: PMI felt in fifth left intercostal space within midclavicular line. First and second heart sounds are normal in character. There is a II/VI systolic murmur best heard at the apex. There is no diastolic murmur or gallop heard. ABDOMEN: Soft. There is no hepatosplenomegaly or ascites. No bruit heard over the aorta or renal vessels. EXTREMITIES: No pedal edema. Femoral arterial pulsations are 3+, popliteal 2+. Dorsalis pedis and posterior tibialis are 1+ on both sides. NEURO: Normal.EKG from Dr. Xyz's office shows normal sinus rhythm, ST and T wave changes. Lipid profile, random blood sugar, BUN, creatinine, CBC, and LFTs are normal. IMPRESSION: 1. Exercise-induced chest pain.2. Palpitations with dizziness.3. Abnormal EKG.4. Hypertension.5. Heart murmur. PLAN: 1. Adenosine Myoview SPECT, 24-hour Holter monitor, echocardiogram.2. Carotid ultrasound.3. Micro-T wave alternans test.4. Diovan 80 mg has been given to the patient from our sample closet for the control of hypertension.5. Patient will be seen again in my office in two weeks." "97",97,"History and Physical","HISTORY OF PRESENT ILLNESS: The patient is known to me secondary to atrial fibrillation with slow ventricular response, partially due to medications, at least when I first saw him in the office on 01/11/06. He is now 77 years old. He is being seen on the Seventh Floor. The patient is in Room 7607. The patient has a history of recent adenocarcinoma of the duodenum that was found to be inoperable, since it engulfed the porta hepatis. The workup began with GI bleeding. He was seen in my office on 01/11/06 for preop evaluation due to leg edema. A nonocclusive DVT was diagnosed in the proximal left superficial femoral vein. Both legs were edematous, and bilateral venous insufficiency was also present. An echocardiogram demonstrated an ejection fraction of 50%. The patient was admitted to the hospital and treated with a Greenfield filter since anticoagulant was contraindicated. Additional information on the echocardiogram, where a grossly dilated left atrium, moderately severely dilated right atrium. The rhythm was, as stated before, atrial fibrillation with slow atrioventricular conduction and an intraventricular conduction delay on the monitor strip. There was mild to moderate tricuspid regurgitation, mild pulmonic insufficiency. The ejection fraction was considered low normal, since it was estimated 50 to 54%. The patient received blood while in the hospital due to anemia. The leg edema improved while lying down, suggesting that the significant element of venous insufficiency was indeed present. The patient, who was diabetic, received consultation by Dr. R. He was also a chronic hypertensive and was treated for that with ACE inhibitors. The atrial fibrillation was slow, and no digitalis or beta blockers were recommended at the same time. As a matter of fact, they were discontinued. Now, the patient denied any shortness of breath or chest pain throughout this hospitalization, and cardiac nuclear studies performed earlier demonstrated no reversible ischemia. ALLERGIES: THE PATIENT HAS NO KNOWN DRUG ALLERGIES.His diabetes was suspected to be complicated with neuropathy due to tingling in both feet. He received his immunizations with flu in 2005 but did not receive Pneumovax. SOCIAL HISTORY: The patient is married. He had 1 child who died at the age of 26 months of unknown etiology. He quit smoking 6 years ago but dips (smokeless) tobacco. FAMILY HISTORY: Mother had cancer, died at 70. Father died of unknown cause, and brother died of unknown cause. FUNCTIONAL CAPACITY: The patient is wheelchair bound at the time of his initial hospitalization. He is currently walking in the corridor with assistance. Nocturia twice to 3 times per night. REVIEW OF SYSTEMS: OPHTHALMOLOGIC: Uses glasses. ENT: Complains of occasional sinusitis. CARDIOVASCULAR: Hypertension and atrial fibrillation. RESPIRATORY: Normal. GI: Colon bleeding. The patient believes he had ulcers. GENITOURINARY: Normal. MUSCULOSKELETAL: Complains of arthritis and gout. INTEGUMENTARY: Edema of ankles and joints. NEUROLOGICAL: Tingling as per above. Denies any psychiatric problems. ENDOCRINE: Diabetes, NIDDM. HEMATOLOGIC AND LYMPHATIC: The patient does not use any aspirin or anticoagulants and is not of anemia. LABORATORY: Current EKG demonstrates atrial fibrillation with incomplete left bundle branch block pattern. Q waves are noticed in the inferior leads. Nonprogression of the R-wave from V1 to V4 with small R-waves in V5 and V6 are suggestive of an old anterior and inferior infarcts. Left ventilator hypertrophy and strain is suspected. PHYSICAL EXAMINATION: GENERAL: On exam, the patient is alert, oriented and cooperative. He is mildly pale. He is an elderly gentleman who is currently without diaphoresis, pallor, jaundice, plethora, or icterus. VITAL SIGNS: Blood pressure is 159/69 with a respiratory rate of 20, pulse is 67 and irregularly irregular. Pulse oximetry is 100. NECK: Without JVD, bruit, or thyromegaly. The neck is supple. CHEST: Symmetric. There is no heave or retraction. HEART: The heart sounds are irregular and no significant murmurs could be auscultated. LUNGS: Clear to auscultation. ABDOMEN: Exam was deferred. LEGS: Without edema. Pulses: Dorsalis pedis pulse was palpated bilaterally. MEDICATIONS: Current medications include enalapril, low dose enoxaparin, Fentanyl patches. He is no longer on fluconazole. He is on a sliding scale as per Dr. Holden. He is on lansoprazole (Prevacid), Toradol, piperacillin/tazobactam, hydralazine p.r.n., Zofran, Dilaudid, Benadryl, and Lopressor p.r.n. ASSESSMENT AND PLAN: The patient is a very pleasant elderly gentleman with intractable/inoperable malignancy. His cardiac issues are chronic and most likely secondary to long term hypertension and diabetes. He has chronic atrial fibrillation. I do not envision a scenario whereby he will become a candidate for management of this arrhythmia beyond weight control. He is also not a candidate for anticoagulation, which is, in essence, a part and parcel of the weight control. Reason being is high likelihood for GI bleeding, especially given the diagnosis of invasive malignancy with involvement of multiple organs and lymph nodes. At this point, I agree with the notion of hospice care. If his atrioventricular conduction becomes excessive, occasional nondihydropyridine calcium channel blocker such as diltiazem or beta blockers would be appropriate; otherwise, I would keep him off those medications due to evidence of slow conduction in the presence of digitalis and beta blockers." "98",98,"History and Physical","REASON FOR CONSULTATION: Cardiac evaluation. HISTORY: This is a 42-year old Caucasian male with no previous history of hypertension, diabetes mellitus, rheumatic fever, rheumatic heart disease, or gout. Patient used to take medicine for hyperlipidemia and then that was stopped. He used to live in Canada and he moved to Houston four months ago. He started complaining of right-sided upper chest pain, starts at the right neck and goes down to the right side. It lasts around 10-15 minutes at times. It is 5/10 in quality. It is not associated with shortness of breath, nausea, vomiting, or sweating. It is not also associated with food. He denies exertional chest pain, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, or pedal edema. No palpitations, syncope or presyncope. He said he has been having little cough at night and he went to see an allergy doctor who prescribed several medications for him and told him that he has asthma. No fever, chills, cough, hemoptysis, hematemesis or hematochezia. His EKG shows normal sinus rhythm, normal EKG. PAST MEDICAL HISTORY: Unremarkable, except for hyperlipidemia. SOCIAL HISTORY: He said he quit smoking 20 years ago and does not drink alcohol. FAMILY HISTORY: Positive for high blood pressure and heart disease. His father died in his 50s with an acute myocardial infarction. MEDICATION: Ranitidine 300 mg daily, Flonase 50 mcg nasal spray as needed, Allegra 100 mg daily, Advair 500/50 bid. ALLERGIES: No known allergies. REVIEW OF SYSTEMS: As mentioned above EXAMINATION: This is a 42-year old male awake, alert, and oriented x3 in no acute distress.Wt: 238 BP: 144/82 HR: 69 HEENT: Normocephalic and atraumatic. NECK: Supple, no jugular venous distension. LUNGS: Good breath sounds bilaterally. HEART: Regular rate and rhythm, S1 and S2, no murmurs, rubs, or gallops. ABDOMEN: Soft, no organomegalies, bowel sounds positive. EXTREMITIES: No clubbing, edema, or cyanosis. IMPRESSION:1. Right-sided chest pain, rule out coronary artery disease, rule out C-spine radiculopathy, rule out gallbladder disease.2. Borderline elevated high blood pressure.3. History of hyperlipidemia.4. Obesity. PLAN: Will schedule patient for heart catheterization. Will see him after the above is completed." "99",99,"History and Physical","REASON FOR REFERRAL: Cardiac evaluation and treatment in a patient who came in the hospital with abdominal pain. HISTORY: This is a 77-year-old white female patient whom I have known for the last about a year or so who has underlying multiple medical problems including hypertension, hyperlipidemia, diabetes mellitus, coronary artery disease status post aortocoronary bypass surgery about eight years ago at Halifax Medical Center where she had triple vessel bypass surgery with left internal mammary artery to the left anterior descending artery, saphenous vein graft to the left circumflex and right coronary arteries. Since then, she has generally done well. She used to be seeing another cardiologist and apparently she had a stress test in September 2008 and she was otherwise cardiac catheterization and coronary angiography, but the patient declined to have one done and since then she has been on medical therapy.The patient had been on medical therapy at home and generally doing well. Recently, she had no leg swelling, undue exertional dyspnea, orthopnea, or paroxysmal nocturnal dyspnea. She denies any rest or exertional chest discomfort. Yesterday evening, she had her dinner and she was sitting around and she felt discomfort in the chest at about 7:00 p.m. The discomfort was a crampy pain in the left lower quadrant area, which seemed to radiating to the center of the abdomen and to the right side and it was off and on lasting for a few minutes at a time and then subsiding. Later on she was nauseous, but she did not have any vomiting. She denied any diarrhea. No history of fever or chills. Since the pain seemed to persist, the patient came to the hospital emergency room at 11:35 p.m. where she was seen and admitted for the same. She was given morphine, Zofran, Demerol, another Zofran, and Reglan as well as Demerol again and she was given intravenous fluids. Subsequently, her pain finally went away and she does not have any pain since about 7:00 a.m. this morning. The patient was admitted however for further workup and treatment. At the time of my examination this afternoon, the patient is sitting, lying in bed and comfortable and has no abdominal pain of any kind. She has not been fed any food, however. The patient also had had pelvis and abdominal CT scan performed, which has been described to be partial small bowel obstruction, internal hernia, volvulus or adhesion most likely in the left flank area. The patient has had left nephrectomy and splenectomy, which has been described. A 1.5-mm solid mass is described to be in the lower pole of the kidney. The patient also has been described to have diverticulosis without diverticulitis on this finding.Currently however, the patient has no clinical symptoms according to her. PAST MEDICAL HISTORY: She has had hypertension and hyperlipidemia for the last 15 years, diabetes mellitus for the last eight years, and coronary artery disease for last about eight years or so. She had a chest and back pain about eight years ago for about two weeks and then subsequently she was reported to be evaluated. She has a small myocardial infarction and then she was under the care of Dr. A and she had aortocoronary bypass surgery at Halifax Medical Center by Dr. B, which was a three-vessel bypass surgery with left internal mammary artery to the left descending artery and saphenous vein graft to the left circumflex and distal right coronary artery respectively.She had had nuclear stress test with Dr. C on September 3, 2008, which was described to be abnormal with ischemic defects, but I do not think the patient had any further cardiac catheterization and coronary angiography after that. She has been treated medically.This patient also had an admission to this hospital in May 2008 also for partial small bowel obstruction and cholelithiasis and sigmoid diverticulosis. She was described to have had a hemorrhagic cyst of the right kidney. She has mild arthritis for the last 10 or 15 years. She has a history of GERD for the last 20 years, and she also has a history of peptic ulcer disease in the duodenum, but never had any bleeding. She has a history of diverticulosis as mentioned. No history of TIA or CVA. She has one kidney. She was in a car accident in 1978 and afterwards she had to have left nephrectomy as well as splenectomy because of rupture. The patient has a history of pulmonary embolism once about eight years ago after her aortocoronary bypass surgery. She describes this to be a clot on left lung. I am not sure if she had any long-term treatment, however.In the past, the patient had aortocoronary bypass surgery in 2003 and incisional hernia surgery in 1979 as well as hysterectomy in 1979 and she had splenectomy and nephrectomy as described in 1978. FAMILY HISTORY: Her father died at age of 65 of massive heart attack and mother died at age of 62 of cancer. She had a one brother who died of massive heart attack in his 50s, a brother died at the age of 47 of cancer, and another brother died in his 60s of possible rupture of appendix. SOCIAL HISTORY: The patient is a widow. She lives alone. She does have three daughters, two of them live in Georgia and one lives in Tennessee. She did smoke in the past up to one to one and a half packs of cigarettes per day for about 10 years, but she quit long time ago. She never drank any alcohol. She likes to drink one or two cups of tea in a day. ALLERGIES: PAXIL. MEDICATIONS: Her home medications prior to coming in include some of the following medications, although the exact list is not available in the chart at this stage, but they have been on glyburide, Januvia, lisinopril, metformin, metoprolol, simvastatin, ranitidine, meloxicam, and furosemide. REVIEW OF SYSTEMS: Appetite is good. She sleeps good at night. She has no headaches and she has mild joint pains from arthritis. PHYSICAL EXAMINATION: VITAL SIGNS: Pulse 90 per minute and regular, blood pressure 140/90 mmHg, respirations 18, and temperature of 98.5 degree Fahrenheit. Moderate obesity is present. CARDIAC: Carotid upstroke is slightly diminished, but no clear bruit heard. LUNGS: Slightly decreased air entry at both bases. No rales or rhonchi heard. CARDIOVASCULAR: PMI in the left fifth intercostal space in the midclavicular line. Regular heart rhythm. S1 and S2 normal. S4 is present. No S3 heard. Short ejection systolic murmur grade I/VI is present at the left lower sternal border of the apex, peaking in LV systole, no diastolic murmur heard. ABDOMEN: Soft, obese, no tenderness, no masses felt. Bowel sounds are present. EXTREMITIES: Bilateral trace edema. The extremities are heavy. There is no pitting at this stage. No clubbing or cyanosis. Distal pulses are fair. CENTRAL NERVOUS SYSTEM: Without any obvious focal deficits. LABORATORY DATA: Includes an electrocardiogram, which shows normal sinus rhythm, left atrial enlargement, and right bundle branch block. This is overall unchanged compared to previous electrocardiogram, which also has the same present. Nuclear stress test from 2008 was described to show ejection fraction of 49% and inferior and posterolateral ischemia. Otherwise, laboratory data includes on this patient at this stage WBC 18.3, hemoglobin 15.5, hematocrit is 47.1, and platelet count is 326,000. Electrolytes, sodium 137, potassium 5.2, chloride 101, CO2 27, BUN 34, creatinine 1.2, calcium 9.5, and magnesium 1.7. AST and ALT are normal. Albumin is 4.1. Lipase and amylase are normal. INR is 0.92. Urinalysis is relatively unremarkable except for trace protein. Chest x-ray has been described to show elevated left hemidiaphragm and median sternotomy sutures. No infiltrates seen. Abdomen and pelvis CAT scan findings are as described before with suggestion of partial small bowel obstruction and internal hernia. Volvulus or adhesions have been considered. Left nephrectomy and splenectomy demonstrated right kidney has a 1.5 cm solid mass at the lower pole suspicious for neoplasm according to the radiologist's description and there is diverticulosis. IMPRESSION:1. Coronary artery disease and prior aortocoronary bypass surgery, currently clinically the patient without any angina.2. Possible small old myocardial infarction.3. Hypertension with hypertensive cardiovascular disease.4. Non-insulin-dependent diabetes mellitus.5. Moderate obesity.6. Hyperlipidemia.7. Chronic non-pitting leg edema.8. Arthritis.9. GERD and positive history of peptic ulcer disease. CONCLUSION:1. Past left nephrectomy and splenectomy after an accident and injury and rupture of the spleen.2. Abnormal nuclear stress test in September 2008, but no further cardiac studies performed, such as cardiac catheterization.3. Lower left quadrant pain, which could be due to diverticulosis.4. Diverticulosis and partial bowel obstruction. RECOMMENDATION:1. At this stage, the patient's cardiac medication should be continued if the patient is allowed p.o. intake.2. The patient should have gastroenterology and surgical consultation evaluation.3. The patient can have an echocardiogram performed with cardiac function at this stage. The patient will be in a mild-to-moderate cardiovascular risk should she need any surgery and anesthesia due to all her above comorbid problems as mentioned.4. Dr. C will follow this patient in my absence over the next 3-4 days.5. Additional recommendations will follow if needed." "100",100,"History and Physical","HISTORY OF PRESENT ILLNESS: The patient is a 41-year-old African-American male previously well known to me. He has a previous history of aortic valve disease, status post aortic valve replacement on 10/15/2007, for which he has been on chronic anticoagulation. There is a previous history of paroxysmal atrial fibrillation and congestive heart failure, both of which have been stable prior to this admission. He has a previous history of transient ischemic attack with no residual neurologic deficits.The patient has undergone surgery by Dr. X for attempted nephrolithotomy. The patient has experienced significant postoperative bleeding, for which it has been necessary to discontinue all anticoagulation. The patient is presently seen at the request of Dr. X for management of anticoagulation and his above heart disease. PAST MEDICAL AND SURGICAL HISTORY:1. Type I diabetes mellitus.2. Hyperlipidemia.3. Hypertension.4. Morbid obesity.5. Sleep apnea syndrome.6. Status post thyroidectomy for thyroid carcinoma. REVIEW OF SYSTEMS:General: Unremarkable.Cardiopulmonary: No chest pain, shortness of breath, palpitations, or dizziness.Gastrointestinal: Unremarkable.Genitourinary: See above.Musculoskeletal: Unremarkable.Neurologic: Unremarkable. FAMILY HISTORY: There are no family members with coronary artery disease. His mother has congestive heart failure. SOCIAL HISTORY: The patient is married. He lives with his wife. He is employed as a barber. He does not use alcohol, tobacco, or illicit drugs. MEDICATIONS PRIOR TO ADMISSION:1. Clonidine 0.3 mg b.i.d.2. Atenolol 50 mg daily.3. Simvastatin 80 mg daily.4. Furosemide 40 mg daily.5. Metformin 1000 mg b.i.d.6. Hydralazine 25 mg t.i.d.7. Diovan 320 mg daily.8. Lisinopril 40 mg daily.9. Amlodipine 10 mg daily.10. Lantus insulin 50 units q.p.m.11. KCl 20 mEq daily.12. NovoLog sliding scale insulin coverage.13. Warfarin 7.5 mg daily.14. Levothyroxine 0.2 mg daily.15. Folic acid 1 mg daily. ALLERGIES: None. PHYSICAL EXAMINATION:General: A well-appearing, obese black male.Vital Signs: BP 140/80, HR 88, respirations 16, and afebrile. HEENT: Grossly normal.Neck: Normal. Thyroid, normal. Carotid, normal upstroke, no bruits.Chest: Midline sternotomy scar.Lungs: Clear.Heart: PMI fifth intercostal space mid clavicular line. Normal S1 and prosthetic S2. No murmur, rub, gallop, or click.Abdomen: Soft and nontender. No palpable mass or hepatosplenomegaly.Extremities: Normal. No edema. Pulses bilaterally intact, carotid, radial, femoral, and dorsalis pedis.Neurologic: Mental status, no gross cranial nerve, motor, or sensory deficits. ELECTROCARDIOGRAM: Normal sinus rhythm. Right bundle-branch block. Findings compatible with old anteroseptal and lateral wall myocardial infarction._______ nonspecific ST-T abnormality. IMPRESSION:1. Status post nephrolithotomy with postoperative hematuria.2. Aortic valve disease, status post aortic valve replacement on 10/15/2007.3. Congestive heart failure, diastolic, chronic, stable, NYSHA class I to II.4. Paroxysmal atrial fibrillation.5. Status post remote transient ischemic attack with no residual neurologic deficits.6. Type I diabetes mellitus.7. Hyperlipidemia.8. Hypertension.9. Morbid obesity.10. Sleep apnea syndrome.11. Chronic therapeutic anticoagulation. RECOMMENDATIONS: Until resolution of the hematuria, I agree with the necessity of discontinuation of all anticoagulation. There is obvious risk both due to prosthetic aortic valve and paroxysmal atrial fibrillation with continuation of anticoagulation; however, the risk of uncontrolled bleeding is essentially worse.Continue other medications." "101",101,"Discharge Summary","REASON FOR TRANSFER: Need for cardiac catheterization done at ABCD. TRANSFER DIAGNOSES:1. Coronary artery disease.2. Chest pain.3. History of diabetes.4. History of hypertension.5. History of obesity.6. A 1.1 cm lesion in the medial aspect of the right parietal lobe.7. Deconditioning. CONSULTATIONS: Cardiology. PROCEDURES:1. Echocardiogram.2. MRI of the brain.3. Lower extremity Duplex ultrasound. HOSPITAL COURSE: Please refer to my H&P for full details. In brief, the patient is a 64-year-old male with history of diabetes, who presented with 6 hours of chest pressure. He was brought in by a friend. The friend states that the patient deteriorated over the last few weeks to the point that he is very short of breath with exertion. He apparently underwent a cardiac workup 6 months ago that the patient states he barely passed. His vital signs were stable on admission. He was ruled out for myocardial infarction with troponin x2. An echocardiogram showed concentric LVH with an EF of 62%. I had Cardiology come to see the patient, who reviewed the records from Fountain Valley. Based on his stress test in the past, Dr. X felt the patient needed to undergo a cardiac cath during his inpatient stay.The patient on initial presentation complained of, what sounded like, amaurosis fugax. I performed an MRI, which showed a 1 cm lesion in the right parietal lobe. I was going to call Neurology at XYZ for evaluation. However, secondary to his indication for transfer, this could be followed up at ABCD with Dr. Y.The patient is now stable for transfer for cardiac cath.Discharged to ABCD. DISCHARGE CONDITION: Stable. DISCHARGE MEDICATIONS:1. Aspirin 325 mg p.o. daily.2. Lovenox 40 mg p.o. daily.3. Regular Insulin sliding scale.4. Novolin 70/30, 15 units b.i.d.5. Metformin 500 mg p.o. daily.6. Protonix 40 mg p.o. daily. DISCHARGE FOLLOWUP: Followup to be arranged at ABCD after cardiac cath." "102",102,"History and Physical","REASON FOR CONSULTATION: Chest pain. HISTORY OF PRESENT ILLNESS: The patient is a 37-year-old gentleman admitted through emergency room. He presented with symptoms of chest pain, described as a pressure-type dull ache and discomfort in the precordial region. Also, shortness of breath is noted without any diaphoresis. Symptoms on and off for the last 3 to 4 days especially when he is under stress. No relation to exertional activity. No aggravating or relieving factors. His history is significant as mentioned below. His workup so far has been negative. CORONARY RISK FACTORS: No history of hypertension or diabetes mellitus. Active smoker. Cholesterol status, borderline elevated. No history of established coronary artery disease. Family history positive. FAMILY HISTORY: His father died of coronary artery disease. SURGICAL HISTORY: No major surgery except for prior cardiac catheterization. MEDICATIONS AT HOME: Includes pravastatin, Paxil, and BuSpar. ALLERGIES: None. SOCIAL HISTORY: Active smoker. Does not consume alcohol. No history of recreational drug use. PAST MEDICAL HISTORY: Hyperlipidemia, smoking history, and chest pain. He has been, in October of last year, hospitalized. Subsequently underwent cardiac catheterization. The left system was normal. There was a question of a right coronary artery lesion, which was thought to be spasm. Subsequently, the patient did undergo nuclear and myocardial perfusion scan, which was normal. The patient continues to smoke actively since in last 3 to 4 days especially when he is stressed. No relation to exertional activity. REVIEW OF SYSTEMS: CONSTITUTIONAL: No history of fever, rigors, or chills. HEENT: No history of cataract, blurring vision, or glaucoma. CARDIOVASCULAR: As above. RESPIRATORY: Shortness of breath. No pneumonia or valley fever. GASTROINTESTINAL: No epigastric discomfort, hematemesis, or melena. UROLOGICAL: No frequency or urgency. MUSCULOSKELETAL: No arthritis or muscle weakness. CNS: No TIA. No CVA. No seizure disorder. ENDOCRINE: Nonsignificant. HEMATOLOGICAL: Nonsignificant. PHYSICAL EXAMINATION: VITAL SIGNS: Pulse of 75, blood pressure of 112/62, afebrile, and respiratory rate 16 per minute. HEENT: Head is atraumatic and normocephalic. Neck veins flat. LUNGS: Clear. HEART: S1 and S2, regular. ABDOMEN: Soft and nontender. EXTREMITIES: No edema. Pulses palpable. No clubbing or cyanosis. CNS: Benign. PSYCHOLOGICAL: Normal. MUSCULOSKELETAL: Within normal limits. DIAGNOSTIC DATA: EKG, normal sinus rhythm. Chest x-ray unremarkable. LABORATORY DATA: First set of cardiac enzyme profile negative. H&H stable. BUN and creatinine within normal limits. IMPRESSION:1. Chest pain in a 37-year-old gentleman with negative cardiac workup as mentioned above, questionably right coronary spasm.2. Hyperlipidemia.3. Negative EKG and cardiac enzyme profile. RECOMMENDATIONS:1. The patient is treated with medications with low-dose of calcium channel blockers and statins and asked him how he feels.2. No further investigation unless there is a positive cardiac enzyme profile, subsequently so far it has been negative.3. Life style modification, diet, activity, weight reduction, and especially smoking cessation discussed. Compliance to medications was stressed. All the questions were answered in detail." "103",103,"History and Physical","CHIEF COMPLAINT: Right hydronephrosis. HISTORY OF PRESENT ILLNESS: The patient is a 56-year-old female who has a history of uterine cancer, breast cancer, mesothelioma. She is scheduled to undergo mastectomy in two weeks. In September 1999, she was diagnosed with right breast cancer and underwent lumpectomy and axillary node dissection and radiation. Again, she is scheduled for mastectomy in two weeks. She underwent a recent PET scan for Dr. X, which revealed marked hydronephrosis on the right possibly related to right UPJ obstruction and there is probably a small nonobstructing stone in the upper pole of the right kidney. There was no dilation of the right ureter noted. Urinalysis today is microscopically negative. PAST MEDICAL HISTORY: Uterine cancer, mesothelioma, breast cancer, diabetes, hypertension. PAST SURGICAL HISTORY: Lumpectomy, hysterectomy. MEDICATIONS: Diovan HCT 80/12.5 mg daily, metformin 500 mg daily. ALLERGIES: None. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: She is retired. Does not smoke or drink. REVIEW OF SYSTEMS: I have reviewed his review of systems sheet and it is on the chart. PHYSICAL EXAMINATION: Please see the physical exam sheet I completed. Abdomen is soft, nontender, nondistended, no palpable masses, no CVA tenderness. IMPRESSION AND PLAN: Marked right hydronephrosis without hydruria. She believes she had a CT scan of the abdomen and pelvis at Hospital in 2005. I will try to obtain the report to see if the right kidney was evaluated at that time. She will need evaluation with an IVP and renal scan to determine the point of obstruction and renal function of the right kidney. She is quite anxious about her upcoming surgery and would like to delay any evaluation of this until the surgery is completed. She will call us back to schedule the x-rays. She understands the great importance and getting back in touch with us to schedule these x-rays due to the possibility that it may be somehow related to the cancer. There is also a question of a stone present in the kidney. She voiced a complete understanding of that and will call us after she recovers from her surgery to schedule these tests." "104",104,"History and Physical","REASON FOR CONSULTATION: ICU management. HISTORY OF PRESENT ILLNESS: The patient is a 43-year-old gentleman who presented from an outside hospital with complaints of right upper quadrant pain in the abdomen, which revealed possible portal vein and superior mesenteric vein thrombus leading to mesenteric ischemia. The patient was transferred to the ABCD Hospital where he had a weeklong course with progressive improvement in his status after aggressive care including intubation, fluid resuscitation, and watchful waiting. The patient clinically improved; however, his white count remained elevated with the intermittent fevers prompting a CT scan. Repeat CT scan showed a loculated area of ischemic bowel with perforation in the left upper abdomen. The patient was taken emergently to the operating room last night by the General Surgery Service where proximal half of the jejunum was noted to be liquified with 3 perforations. This section of small bowel was resected, and a wound VAC placed for damage control. Plan was to return the patient to the Operating Room tomorrow for further exploration and possible re-anastomosis of the bowel. The patient is currently intubated, sedated, and on pressors for septic shock and in the down ICU. PAST MEDICAL HISTORY: Prior to coming into the hospital for this current episode, the patient had hypertension, diabetes, and GERD. PAST SURGICAL HISTORY: Included a cardiac cath with no interventions taken. HOME MEDICATIONS: Include Lantus insulin as well as oral hypoglycemics. CURRENT MEDS: Include Levophed, Ativan, fentanyl drips, cefepime, Flagyl, fluconazole, and vancomycin. Nexium, Synthroid, hydrocortisone, and Angiomax, which is currently on hold. REVIEW OF SYSTEMS: Unable to be obtained secondary to the patient's intubated and sedated status. ALLERGIES: None. FAMILY HISTORY: Includes diabetes on his father side of the family. No other information is provided. SOCIAL HISTORY: Includes tobacco use as well as alcohol use. PHYSICAL EXAMINATION: GENERAL: The patient is currently intubated and sedated on Levophed drip. VITAL SIGNS: Temperature is 100.6, systolic is 110/60 with MAP of 80, and heart rate is 120, sinus rhythm. NEUROLOGIC: Neurologically, he is sedated, on Ativan with fentanyl drip as well. He does arouse with suctioning, but is unable to open his eyes to commands. HEAD AND NECK EXAMINATION: His pupils are equal, round, reactive, and constricted. He has no scleral icterus. His mucous membranes are pink, but dry. He has an EG tube, which is currently 24-cm at the lip. He has a left-sided subclavian vein catheter, triple lumen. NECK: His neck is without masses or lymphadenopathy or JVD. CHEST: Chest has diminished breath sounds bilaterally. ABDOMEN: Abdomen is soft, but distended with a wound VAC in place. Groins demonstrate a left-sided femoral outline. EXTREMITIES: His bilateral upper extremities are edematous as well as his bilateral lower extremities; however, his right is more than it is in the left. His toes are cool, and pulses are not palpable. LABORATORY EXAMINATION: Laboratory examination reveals an ABG of 7.34, CO2 of 30, O2 of 108, base excess of -8, bicarb of 16.1, sodium of 144, potassium of 6.5, chloride of 122, CO2 18, BUN 43, creatinine 2.0, glucose 172, calcium 6.6, phosphorus 1.1, mag 1.8, albumin is 1.6, cortisone level random is 22. After stimulation with cosyntropin, they were still 22 and then 21 at 30 and 60 minutes respectively. LFTs are all normal. Amylase and lipase are normal. Triglycerides are 73, INR is 2.2, PTT is 48.3, white count 20.7, hemoglobin 9.6, and platelets of 211. UA was done, which also shows a specific gravity of 1.047, 1+ protein, trace glucose, large amount of blood, and many bacteria. Chest x-rays performed and show the tip of the EG tube at level of the carina with some right upper lobe congestion, but otherwise clear costophrenic angles. Tip of the left subclavian vein catheter is appropriate, and there is no pneumothorax noted. ASSESSMENT AND PLAN: This is a 43-year-old gentleman who is acutely ill, in critical condition with mesenteric ischemia secondary to visceral venous occlusion. He is status post small bowel resection. We plan to go back to operating room tomorrow for further debridement and possible closure. Neurologically, the patient initially had question of encephalopathy while in the hospital secondary to slow awakening after previous intubation; however, he did clear eventually, and was able to follow commands. I did not suspect any sort of pathologic abnormality of his neurologic status as he has further CT scan of his brain, which was normal. Currently, we will keep him sedated and on fentanyl drip to ease pain and facilitate ventilation on the respirator. We will form daily sedation holidays to assess his neurologic status and avoid over sedating with Ativan.1. Cardiovascular. The patient currently is in septic shock requiring vasopressors maintained on MAP greater than 70. We will continue to try to wean the vasopressin after continued volume loading, also place SvO2 catheter to assess his oxygen delivery and consumption given his state of shock. Currently, his rhythm is of sinus tachycardia, I do not suspect AFib or any other arrhythmia at this time. If he does not improve as expected with volume resuscitation and with resolution of his sepsis, we will obtain an echocardiogram to assess his cardiac function. Once he is off the vasopressors, we will try low-dose beta blockade as tolerated to reduce his rate.2. Pulmonology. Currently, the patient is on full vent support with a rate of 20, tidal volume of 550, pressure support of 10, PEEP of 6, and FiO2 of 60. We will wean his FiO2 as tolerated to keep his saturation greater than 90% and wean his PEEP as tolerated to reduce preload compromise. We will keep the head of bed elevated and start chlorhexidine as swish and swallow for VAP prevention.3. Gastrointestinal. The patient has known mesenteric venous occlusion secondary to the thrombus formation at the portal vein as well as the SMV. He is status post immediate resection of jejunum leaving a blind proximal jejunum and blind distal jejunum. We will maintain NG tube as he has a blind stump there, and we will preclude any further administration of any meds through this NG tube. I will keep him on GI prophylaxis as he is intubated. We will currently hold his TPN as he is undergoing a large amount of volume changes as well as he is undergoing electrolyte changes. He will have a long-term TPN after this acute episode. His LFTs are all normal currently. Once he is postop tomorrow, we will restart the Angiomax for his venous occlusion.4. Renal. The patient currently is in the acute renal insufficiency with anuria and an increase in his creatinine as well as his potassium. His critical hyperkalemia which is requiring dosing of dextrose insulin, bicarb, and calcium; we will recheck his potassium levels after this cocktail. He currently is started to make more urine since being volume resuscitated with Hespan as well as bicarb drip. Hopefully given his increased urine output, he will start to eliminate some potassium and will not need dialysis. We will re-consult Nephrology at this time.5. Endocrine. The patient has adrenal insufficiency based on lack of stem to cosyntropin. We will start hydrocortisone 50 q.6h.6. Infectious Disease. Currently, the patient is on broad-spectrum antibiotic prophylaxis imperially. Given his bowel ischemia, we will continue these, and appreciate ID service's input.7. Hematology. Hematologically, the patient has a hypercoagulable syndrome, also had HIT secondary to his heparin administration. We will restart the Angiomax once he is back from the OR tomorrow. Currently, his INR is 2.2. Therefore, he should be covered at the moment. Appreciate the Hematology's input in this matter.Please note the total critical care time spent at the bedside excluding central line placement was 1 hour." "105",105,"History and Physical","SUBJECTIVE: This is a 54-year-old female who comes for dietary consultation for weight reduction secondary to diabetes. She did attend diabetes education classes at Abc Clinic. She comes however, wanting to really work at weight reduction. She indicates that she has been on the Atkins' diet for about two years and lost about ten pounds. She is now following a veggie diet which she learned about in Poland originally. She has been on it for three weeks and intends to follow it for another three weeks. This does not allow any fruits or grains or starchy vegetables or meats. She does eat nuts for protein. She is wanting to know if she is at risk of having a severe low blood sugar reaction in this form of diet. She also wants to know that if she gets skinny enough, if the diabetes will go away. Her problem time, blood sugar wise, is in the morning. She states that if she eats too much in the evening that her blood sugars are always higher the next morning. OBJECTIVE: Weight: 189 pounds. Reported height: 5 feet 5 inches. BMI is approximately 31-1/2. Diabetes medications include metformin 500 mg daily. Lab from 5/12/04: Hemoglobin A1C was 6.4%.A diet history was obtained. I instructed the patient on dietary guidelines for weight reduction. A 1200-calorie meal plan was recommended. ASSESSMENT: Patient's diet history reflects that she is highly restricting carbohydrates in her food intake. She does not have blood sugar records with her for me to review, but we discussed strategies for improving blood sugar control in the morning. This primarily included a recommendation of including some solid protein with her bedtime snack which could be done in the form of nuts. She is doing some physical activity two to three times a week. This includes aerobic walking with weights on her arms and her ankles. She is likely going to need to increase frequency in this area to help support weight reduction. Her basal metabolic rate was estimated at 1415 calories a day. Her total calorie requirements for weight maintenance are estimated at 1881 calories a day. A 1200-calorie meal plan should support a weight loss of at least one pound a week. PLAN: Recommend patient increase the frequency of her walking to five days a week. Encouraged a 30-minute duration. Also recommend patient include some solid protein with her bedtime snack to help address fasting blood sugar elevations. And lastly, I encouraged caloric intake of just under 1200 calories daily. Recommend keeping food records and tracking caloric intake. It is unlikely that her blood sugars would drop significantly low on the current dose of Glucophage. However, I encouraged her to be careful not to reduce calories below 1000 calories daily. She may want to consider a multivitamin as well. This was a one-hour consultation." "106",106,"Discharge Summary","PROCEDURES:1. Chest x-ray on admission, no acute finding, no interval change.2. CT angiography, negative for pulmonary arterial embolism.3. Nuclear myocardial perfusion scan, abnormal. Reversible defect suggestive of ischemia, ejection fraction of 55%. DIAGNOSES ON DISCHARGE:1. Chronic obstructive pulmonary disease exacerbation improving, on steroids and bronchodilators.2. Coronary artery disease, abnormal nuclear scan, discussed with Cardiology Dr. X, who recommended to discharge the patient and follow up in the clinic.3. Diabetes mellitus type 2.4. Anemia, hemoglobin and hematocrit stable.5. Hypokalemia, replaced.6. History of coronary artery disease status post stent placement 2006-2008.7. Bronchitis. HOSPITAL COURSE: The patient is a 65-year-old American-native Indian male, past medical history of heavy tobacco use, history of diabetes mellitus type 2, chronic anemia, COPD, coronary artery disease status post stent placement, who presented in the emergency room with increasing shortness of breath, cough productive for sputum, and orthopnea. The patient started on IV steroid, bronchodilator as well as antibiotics.He also complained of chest pain that appears to be more pleuritic with history of coronary artery disease and orthopnea. He was evaluated by Cardiology Dr. X, who proceeded with stress test. Stress test reported positive for reversible ischemia, but Cardiology decided to follow up the patient in the clinic. The patient's last cardiac cath was in 2008.The patient clinically significantly improved and wants to go home. His hemoglobin on admission was 8.8, and has remained stable. He is afebrile, hemodynamically stable. ALLERGIES: LISINOPRIL AND PENICILLIN. MEDICATIONS ON DISCHARGE:1. Prednisone tapering dose 40 mg p.o. daily for three days, then 30 mg p.o. daily for three days, then 20 mg p.o. daily for three days, then 10 mg p.o. daily for three days, and 5 mg p.o. daily for two days.2. Levaquin 750 mg p.o. daily for 5 more days.3. Protonix 40 mg p.o. daily.4. The patient can continue other current home medications at home. FOLLOWUP APPOINTMENTS:1. Recommend to follow up with Cardiology Dr. X's office in a week.2. The patient is recommended to see Hematology Dr. Y in the office for workup of anemia.3. Follow up with primary care physician's office tomorrow. SPECIAL INSTRUCTIONS:1. If increasing shortness of breath, chest pain, fever, any acute symptoms to return to emergency room.2. Discussed about discharge plan, instructions with the patient by bedside. He understands and agreed. Also discussed discharge plan instructions with the patient's nurse." "107",107,"Discharge Summary","CHIEF COMPLAINT: Stomach pain for 2 weeks. HISTORY OF PRESENT ILLNESS: The patient is a 45yo Mexican man without significant past medical history who presents to the emergency room with complaints of mid-epigastric and right upper quadrant abdominal pain for the last 14 days. The pain was initially crampy and burning in character and was relieved with food intake. He also reports that it initially was associated with a sour taste in his mouth. He went to his primary care physician who prescribed cimetidine 400mg qhs x 5 days; however, this did not relieve his symptoms. In fact, the pain has worsened such that the pain now radiates to the back but is waxing and waning in duration. It is relieved with standing and ambulation and exacerbated when lying in a supine position. He reports a decrease in appetite associated with a 4 lb. wt loss over the last 2 wks. He does have nausea with only one episode of non-bilious, non-bloody emesis on day of admission. He reports a 2 wk history of subjective fever and diaphoresis. He denies any diarrhea, constipation, dysuria, melena, or hematochezia. His last bowel movement was during the morning of admission and was normal. He denies any travel in the last 9 years and sick contacts. PAST MEDICAL HISTORY: Right inguinal groin cyst removal 15 years ago. Unknown etiology. No recurrence. PAST SURGICAL HISTORY: Left femoral neck fracture with prosthesis secondary to a fall 4 years ago. FAMILY HISTORY: Mother with diabetes. No history of liver disease. No malignancies. SOCIAL HISTORY: The patient was born in central Mexico but moved to the United States 9 years ago. He is on disability due to his prior femoral fracture. He denies any tobacco or illicit drug use. He only drinks alcohol socially, no more than 1 drink every few weeks. He is married and has 3 healthy children. He denies any tattoos or risky sexual behavior. ALLERGIES: NKDA. MEDICATIONS: Tylenol prn (1-2 tabs every other day for the last 2 wks), Cimetidine 400mg po qhs x 5 days. REVIEW OF SYSTEMS: No headache, vision changes. No shortness of breath. No chest pain or palpitations. PHYSICAL EXAMINATION:Vitals: T 100.9-102.7 BP 136/86 Pulse 117 RR 12 98% sat on room airGen: Well-developed, well-nourished, no apparent distress. HEENT: Pupils equal, round and reactive to light. Anicteric. Oropharynx clear and moist.Neck: Supple. No lymphadenopathy or carotid bruits. No thyromegaly or masses. CHEST: Clear to auscultation bilaterally. CV: Tachycardic but regular rhythm, normal S1/S2, no murmurs/rubs/gallops.Abd: Soft, active bowel sounds. Tender in the epigastrium and right upper quadrant with palpation associated with slight guarding. No rebound tenderness. No hepatomegaly. No splenomegaly.Rectal: Stool was brown and guaiac negative.Ext: No cyanosis/clubbing/edema.Neurological: He was alert and oriented x3. CN II-XII intact. Normal 2+ DTRs. No focal neurological deficit.Skin: No jaundice. No skin rashes or lesions. IMAGING DATA:CT Abdomen with contrast ( 11/29/03 ): There is a 6x6 cm multilobular hypodense mass seen at the level of the hepatic hilum and caudate lobe which is resulting in mass effect with dilatation of the intrahepatic radicals of the left lobe of the liver. The rest of the liver parenchyma is homogeneous. The gallbladder, pancreas, spleen, adrenal glands and kidneys are within normal limits. The retroperitoneal vascular structures are within normal limits. There is no evidence of lymphadenopathy, free fluid or fluid collections. HOSPITAL COURSE: The patient was admitted to the hospital for further evaluation. A diagnostic procedure was performed." "108",108,"Discharge Summary","ADMISSION DIAGNOSIS: End-stage renal disease (ESRD). DISCHARGE DIAGNOSIS: End-stage renal disease (ESRD). PROCEDURE: Cadaveric renal transplant. HISTORY OF PRESENT ILLNESS: This is a 46-year-old gentleman with end-stage renal disease (ESRD) secondary to diabetes and hypertension, who had been on hemodialysis since 1993 and is also status post cadaveric kidney transplant in 1996 with chronic rejection. PAST MEDICAL HISTORY: 1. Diabetes mellitus diagnosed 12 years ago.2. Hypertension.3. Coronary artery disease with a myocardial infarct in September of 2006.4. End-stage renal disease. PAST SURGICAL HISTORY: Coronary artery bypass graft x5 in 1995 and cadaveric renal transplant in 1996. SOCIAL HISTORY: The patient denies tobacco or ethanol use. FAMILY HISTORY: Hypertension. PHYSICAL EXAMINATION: GENERAL: The patient was alert and oriented x3 in no acute distress, healthy-appearing male. VITAL SIGNS: Temperature 96.6, blood pressure 166/106, heart rate 83, respiratory rate 18, and saturations 96% on room air. CARDIOVASCULAR: Regular rate and rhythm. PULMONARY: Clear to auscultation bilaterally. ABDOMEN: Soft, nontender, and nondistended with positive bowel sounds. EXTREMITIES: No clubbing, cyanosis, or edema. PERTINENT LABORATORY DATA: White blood cell count 6.4, hematocrit 34.6, and platelet count 182. Sodium 137, potassium 5.4, BUN 41, creatinine 7.9, and glucose 295. Total protein 6.5, albumin 3.4, AST 51, ALT 51, alk phos 175, and total bilirubin 0.5. COURSE IN HOSPITAL: The patient was admitted postoperatively to the surgical intensive care unit. Initially, the patient had a decrease in hematocrit from 30 to 25. The patient's hematocrit stabilized at 25. During the patient's stay, the patient's creatinine progressively decreased from 8.1 to a creatinine at the time of discharge of 2.3. The patient was making excellent urine throughout his stay. The patient's Jackson-Pratt drain was removed on postoperative day #1 and he was moved to the floor. The patient was advanced in diet appropriately. The patient was started on Prograf by postoperative day #2. Initial Prograf levels came back high at 18. The patient's Prograf doses were changed accordingly and today, the patient is deemed stable to be discharged home. During the patient's stay, the patient received four total doses of Thymoglobulin. Today, he will complete his final dose of Thymoglobulin prior to being discharged. In addition, today, the patient has an elevated blood pressure of 198/96. The patient is being given an extra dose of metoprolol for this blood pressure. In addition, the patient has an elevated glucose of 393 and for this reason he has been given an extra dose of insulin. These labs will be rechecked later today and once his blood pressure has decreased to systolic blood pressure less than 116 and his glucose has come down to a more normal level, he will be discharged to home. DISCHARGE INSTRUCTIONS: The patient is discharged with instructions to seek medical attention in the event if he develops fevers, chills, nausea, vomiting, decreased urine output, or other concerns. He is discharged on a low-potassium diet with activity as tolerated. He is instructed that he may shower; however, he is to undergo no underwater soaking activities for approximately two weeks. The patient will be followed up in the Transplant Clinic at ABCD tomorrow, at which time, his labs will be rechecked. The patient's Prograf levels at the time of discharge are pending; however, given that his Prograf dose was decreased, he will be followed tomorrow at the Renal Transplant Clinic." "109",109,"History and Physical","REASON FOR CONSULTATION: Abnormal cardiac enzyme profile. HISTORY OF PRESENT ILLNESS: The patient is a 66-year-old gentleman, was brought into emergency room with obtundation. The patient was mechanically ventilated originally. His initial diagnosis was septic shock. His labs showed elevated cardiac enzyme profile. This is a consultation for evaluation of the same. The patient is unable to give history. History obtained through the family members. As per the patient's son, he does not have history of cardiac disease. He lives in Utah, presently spending few months in Arizona. As I understand, he has been followed by a physician back in Utah and believes that he had some workup done from cardiac standpoint which has been negative so far. No prior history of chest pain, shortness of breath as per the family members. CORONARY RISK FACTORS: History of hypertension, no history of diabetes mellitus, ex-smoker, cholesterol status borderline elevated, no prior history of coronary artery disease, and family history noncontributory. FAMILY HISTORY: Nonsignificant. SURGICAL HISTORY: Foot surgery as per the family members. MEDICATIONS:1. Vitamin supplementation.2. Prednisone.3. Cyclobenzaprine.4. Losartan 50 mg daily.5. Nifedipine 90 mg daily.6. Lasix.7. Potassium supplementation. ALLERGIES: SULFA. PERSONAL HISTORY: He is an ex-smoker. Does not consume alcohol. PAST MEDICAL HISTORY: Pulmonary fibrosis, on prednisone, oxygen-dependent cellulitis status post foot surgery with infection recuperating from the same. Presentation today with respiratory acidosis, septicemia and septic shock, presently on mechanical ventilation. No prior cardiac history. Elevated cardiac enzyme profile. REVIEW OF SYSTEMS: Limited. PHYSICAL EXAMINATION: VITAL SIGNS: Pulse of 94, blood pressure 98/57, respiratory rate as per setting. HEENT: Atraumatic and normocephalic. NECK: Supple. Neck veins flat. LUNGS: Air entry bilaterally clear, rales are scattered. HEART: PMI displaced. S1, S2 regular. Systolic murmur, grade 2/6. ABDOMEN: Soft, nontender. EXTREMITIES: Chronic skin changes, markings in the lower extremities noted. Pulses found palpable. Dressing also noted. LABORATORY AND DIAGNOSTIC DATA: EKG, normal sinus rhythm with wide complex. Labs, white count of 20,000, H&H 10 and 33, platelets of 163, INR 1.36, BUN of 158, creatinine 8.7, potassium 7.3, of bicarbonate is 11. Cardiac enzyme profile, troponin 0.05, total CK 312, myoglobin 1423. Chest x-ray, no acute changes. IMPRESSION:1. The patient is a 66-year-old gentleman with pulmonary fibrosis, on prednisone, oxygen dependent with respiratory acidosis.2. Septicemia, septic shock secondary to cellulitis of the leg.3. Acute renal shutdown.4. Elevated cardiac enzyme profile without prior cardiac history possibly due to sepsis and also acute renal failure. RECOMMENDATIONS:1. Echocardiogram to assess LV function to rule out any cardiac valvular involvement.2. Aggressive medical management including dialysis.3. From cardiac standpoint, conservative treatment at this juncture. His cardiac enzyme profile could be elevated secondary to sepsis and also underlying renal failure.4. Explained to patient's family in detail regarding condition which is critical which they are aware of." "110",110,"Discharge Summary","REASON FOR CONSULTATION: This is a 66-year-old patient who came to the emergency room because she was feeling dizzy and was found to be tachycardic and hypertensive. PAST MEDICAL HISTORY: Hypertension. The patient noncompliant HISTORY OF PRESENT COMPLAINT: This 66-year-old patient has history of hypertension and has not taken medication for several months. She is a smoker and she drinks alcohol regularly. She drinks about 5 glasses of wine every day. Last drink was yesterday evening. This afternoon, the patient felt palpitations and generalized weakness and came to the emergency room. On arrival in the emergency room, the patient's heart rate was 121 and blood pressure was 195/83. The patient received 5 mg of metoprolol IV, after which heart rate was reduced to the 70 and blood pressure was well controlled. On direct questioning, the patient said she had been drinking a lot. She had not had any withdrawal before. Today is the first time she has been close to withdrawal. REVIEW OF SYSTEMS: CONSTITUTIONAL: No fever. ENT: Not remarkable. RESPIRATORY: No cough or shortness of breath. CARDIOVASCULAR: The patient denies chest pain. GASTROINTESTINAL: No nausea. No vomiting. No history of GI bleed. GENITOURINARY: No dysuria. No hematuria. ENDOCRINE: Negative for diabetes or thyroid problems. NEUROLOGIC: No history of CVA or TIA.Rest of review of systems is not remarkable. SOCIAL HISTORY: The patient is a smoker and drinks alcohol daily in considerable amounts. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: GENERAL: This is a 66-year-old lady with telangiectasia of the face. She is not anxious at this moment and had no tremors. CHEST: Clear to auscultation. No wheezing. No crepitations. Chest is tympanitic to percussion. CARDIOVASCULAR: First and second heart sounds were heard. No murmur was appreciated. ABDOMEN: Soft and nontender. Bowel sounds are positive. EXTREMITIES: There is no swelling. No clubbing. No cyanosis. NEUROLOGIC: The patient is alert and oriented x3. Examination is nonfocal. DIAGNOSTIC DATA: EKG shows sinus tachycardia, no acute ST changes. LABORATORY DATA: White count is 6.3, hemoglobin is 12.4, hematocrit 38, and platelets 488,000. Glucose is 124, BUN is 18, creatinine is 1.07, sodium is 146, and potassium is 3.4. Liver enzymes are within normal limits. TSH is normal. ASSESSMENT AND PLAN:1. Uncontrolled hypertension. We will start the patient on beta-blockers. The patient is to see her primary physician within 1 week's time.2. Tachycardia, probable mild withdrawal to alcohol. The patient is stable now. We will discharge home with diazepam p.r.n. The patient had been advised that she should not take alcohol if she takes the diazepam.3. Tobacco smoking disorder. The patient has been counseled. She is not contemplating quitting at this time. DISPOSITION: The patient is discharged home. DISCHARGE MEDICATIONS:1. Atenolol 50 mg p.o. b.i.d.2. Diazepam 5 mg tablet 1 p.o. q.8h. p.r.n., total of 5 tablets.3. Thiamine 100 mg p.o. daily." "111",111,"Discharge Summary","ADMISSION DIAGNOSIS: Right tibial plateau fracture. DISCHARGE DIAGNOSES: Right tibial plateau fracture and also medial meniscus tear on the right side. PROCEDURES PERFORMED: Open reduction and internal fixation (ORIF) of right Schatzker III tibial plateau fracture with partial medial meniscectomy. CONSULTATIONS: To rehab, Dr. X and to Internal Medicine for management of multiple medical problems including hypothyroid, diabetes mellitus type 2, bronchitis, and congestive heart failure. HOSPITAL COURSE: The patient was admitted and consented for operation, and taken to the operating room for open reduction and internal fixation of right Schatzker III tibial plateau fracture and partial medial meniscectomy performed without incidence. The patient seemed to be recovering well. The patient spent the next several days on the floor, nonweightbearing with CPM machine in place, developed a brief period of dyspnea, which seems to have resolved and may have been a combination of bronchitis, thick secretions, and fluid overload. The patient was given nebulizer treatment and Lasix increased the same to resolve the problem. The patient was comfortable, stabilized, breathing well. On day #12, was transferred to ABCD. DISCHARGE INSTRUCTIONS: The patient is to be transferred to ABCD after open reduction and internal fixation of right tibial plateau fracture and partial medial meniscectomy. DIET: Regular. ACTIVITY AND LIMITATIONS: Nonweightbearing to the right lower extremity. The patient is to continue CPM machine while in bed along with antiembolic stockings. The patient will require nursing, physical therapy, occupational therapy, and social work consults. DISCHARGE MEDICATIONS: Resume home medications, but increase Lasix to 80 mg every morning, Lovenox 30 mg subcu daily x2 weeks, Vicodin 5/500 mg one to two every four to six hours p.r.n. pain, Combivent nebulizer every four hours while awake for difficulty breathing, Zithromax one week 250 mg daily, and guaifenesin long-acting one twice a day b.i.d. FOLLOWUP: Follow up with Dr. Y in 7 to 10 days in office. CONDITION ON DISCHARGE: Stable." "112",112,"History and Physical","REASON FOR CONSULTATION: Renal failure evaluation for possible dialysis therapy. HISTORY OF PRESENT ILLNESS: This is a 47-year-old gentleman, who works offshore as a cook, who about 4 days ago noted that he was having some swelling in his ankles and it progressively got worse over the past 3 to 4 days, until he was swelling all the way up to his mid thigh bilaterally. He also felt like he could not make much urine, and his wife, who is a nurse instructed him to force fluids. While he was there, he was drinking cranberry juice, some Powerade, but he also has a history of weightlifting and had been taking on a creatine protein drink on a daily basis for some time now. He presented here with very decreased urine output until a Foley catheter was placed and about 500 mL was noted in his bladder. He did have a CPK level of about 234 while his BUN and creatinine on admission were 109 and 6.9. Despite IV hydration fluids, his potassium has gone up from 5.4 to 6.1. He did not put out any significant urine and his weight was documented at 103 kg. He was given a dose of Kayexalate. His potassium came down to like about 5.9 and urine studies were ordered. His urinalysis did show that he had microscopic hematuria and proteinuria and his protein-creatinine ratio was about 9 gm of protein consistent with nephrotic range proteinuria. He did have a low albumin of 1.9. He denied any nonsteroidal usage, any recreational drug abuse, and his urine drug screen was unremarkable, and he denied any history of hypertension or any other medical problems. He has not had any blood work except for drug screens that are required by work and no work up by any primary care physician because he has not seen one for primary care. He is very concerned because his mother and father were both on dialysis, which he thinks were due to diabetes and both parents have expired. He denied any hemoptysis, gross hematuria, melena, hematochezia, hemoptysis, hematemesis, no seizures, no palpitations, no pruritus, no chest pain. He did have a decrease in his appetite, which all started about Thursday. We were asked to see this patient in consultation by Dr. X because of his renal failure and the need for possible dialysis therapy. He was significantly hypertensive on admission with a blood pressure of 162/80. PAST MEDICAL HISTORY: Unremarkable. PAST SURGICAL HISTORY: Unremarkable. FAMILY HISTORY: Both mother and father were on dialysis of end-stage renal disease. SOCIAL HISTORY: He is married. He does smoke despite understanding the risks associated with smoking a pack every 6 days. Does not drink alcohol or use any recreational drug use. He was on no prescribed medications. He did have a fairly normal PSA of about 119 and I had ordered a renal ultrasound which showed fairly normal-sized kidneys and no evidence of hydronephrosis or mass, but it was consistent with increased echogenicity in the cortex, findings representative of medical renal disease. PHYSICAL EXAMINATION:Vital signs: Blood pressure is 153/77, pulse 66, respiration 18, temperature 98.5.General: He was alert and oriented x 3, in no apparent distress, well-developed male. HEENT: Normocephalic, atraumatic. Pupils are equal, round, and reactive to light. Extraocular muscles intact.Neck: Supple. No JVD, adenopathy, or bruit.Chest: Clear to auscultation.Heart: Regular rate and rhythm without a rub.Abdomen: Soft, nontender, nondistended. Positive bowel sounds.Extremities: Showed no clubbing, cyanosis. He did have 2+ pretibial edema in both lower extremities.Neurologic: No gross focal findings.Skin: Showed no active skin lesions. LABORATORY DATA: Sodium 138, potassium 6.1, chloride 108, CO2 22, glucose 116, BUN 111, creatinine 7.29, estimated GFR 10 mL/minute. Calcium 7.4 with an albumin of 1.9. Mag normal at 2.2. Urine culture negative at 12 hours. His Random urine sodium was low at 12. Random urine protein was 4756, and creatinine in the urine was 538. Urine drug screen was unremarkable. Troponin was within normal limits. Phosphorus slightly elevated at 5.7. CPK level was 234, white blood cells 6.5, hemoglobin 12.2, platelet count 188,000 with 75% segs. PT 10.0, INR 1.0, PTT at 27.3. B-natriuretic peptide 718. Urinalysis showed 3+ protein, 4+ blood, negative nitrites, and trace leukocytes, 5 to 10 wbc's, greater than 100 rbc's, occasional fine granular casts, and moderate transitional cells. IMPRESSION:1. Acute kidney injury of which etiology is unknown at this time, with progressive azotemia unresponsive to IV fluids.2. Hyperkalemia due to renal failure, slowly improving with Kayexalate.3. Microscopic hematuria with nephrotic range proteinuria, more consistent with a glomerulonephropathy nephritis.4. Hypertension. PLAN: I will give him Kayexalate 15 gm p.o. q.6h. x 2 more doses since he is responding and his potassium is already down to 5.2. I will also recheck a urinalysis, consult the surgeon in the morning for temporary hemodialysis catheter placement, and consult case managers to start work on a transfer to ABCD Center per the patient and his wife's request, which will occur after his second dialysis treatment if he remains stable. We will get a BMP, phosphorus, mag, CBC in the morning since he was given 80 mg of Lasix for fluid retention. We will also give him 10 mg of Zaroxolyn p.o. Discontinue all IV fluids. Check an ANCA hepatitis profile, C3 and C4 complement levels along with CH 50 level. I did discuss with the patient and his wife the need for kidney biopsy and they would like the kidney biopsy to be performed closer to home at Ochsner where his family is, since he only showed up here because of the nearest hospital located to his offshore job. I do agree with getting him transferred once he is stable from his hyperkalemia and he starts his dialysis.I appreciate consult. I did discuss with him the importance of the kidney biopsies to direct treatment, finding the underlying etiology of his acute renal failure and to also give him prognostic factors of renal recovery." "113",113,"Operative Note","PREOPERATIVE DIAGNOSIS: Left carpal tunnel syndrome. POSTOPERATIVE DIAGNOSIS: Left carpal tunnel syndrome. OPERATIVE PROCEDURE PERFORMED: Left carpal tunnel release. FINDINGS: Showed severe compression of the median nerve on the left at the wrist. SPECIMENS: None. FLUIDS: 500 mL of crystalloids. URINE OUTPUT: No Foley catheter. COMPLICATIONS: None. ANESTHESIA: General through a laryngeal mask. ESTIMATED BLOOD LOSS: None. CONDITION: Resuscitated with stable vital signs. INDICATION FOR THE OPERATION: This is a case of a very pleasant 65-year-old forensic pathologist who I previously had performed initially a discectomy and removal of infection at 6-7, followed by anterior cervical discectomy with anterior interbody fusion at C5-6 and C6-7 with spinal instrumentation. At the time of initial consultation, the patient was also found to have bilateral carpal tunnel and for which we are addressing the left side now. Operation, expected outcome, risks, and benefits were discussed with him for most of the risk would be that of infection because of the patient's diabetes and a previous history of infection in the form of pneumonia. There is also the possibility of bleeding as well as the possibility of injury to the median nerve on dissection. He understood this risk and agreed to have the procedure performed. DESCRIPTION OF THE PROCEDURE: The patient was brought to the operating room, awake, alert, not in any form of distress. After smooth induction of anesthesia and placement of a laryngeal mask, he remained supine on the operating table. The left upper extremity was then prepped with Betadine soap and antiseptic solution. After sterile drapes were laid out, an incision was made following inflation of blood pressure cuff to 250 mmHg. Clamp time approximately 30 minutes. An incision was then made right in the mid palm area between the thenar and hypothenar eminence. Meticulous hemostasis of any bleeders were done. The fat was identified. The palmar aponeurosis was identified and cut and this was traced down to the wrist. There was severe compression of the median nerve. Additional removal of the aponeurosis was performed to allow for further decompression. After this was all completed, the area was irrigated with saline and bacitracin solution and closed as a single layer using Prolene 4-0 as interrupted vertical mattress stitches. Dressing was applied. The patient was brought to the recovery." "114",114,"History and Physical","CHIEF COMPLAINT: Lump in the chest wall. HISTORY OF PRESENT ILLNESS: This is a 56-year-old white male who has been complaining of having had a lump in the chest for the past year or so and it has been getting larger and tender according to the patient. It is tender on palpation and also he feels like, when he takes a deep breath also, it hurts.CHRONIC/INACTIVE CONDITIONS1. Hypertension.2. Hyperlipidemia.3. Glucose intolerance.4. Chronic obstructive pulmonary disease?5. Tobacco abuse.6. History of anal fistula. ILLNESSES: See above. PREVIOUS OPERATIONS: Anal fistulectomy, incision and drainage of perirectal abscess, hand surgery, colonoscopy, arm nerve surgery, and back surgery. PREVIOUS INJURIES: He had a broken ankle in the past. They questioned the patient who is a truck driver whether he has had an auto accident in the past, he said that he has not had anything major. He said he bumped his head once, but not his chest, although he told the nurse that a car fell on his chest that is six years ago. He told me that he hit a moose once, but he does not remember hitting his chest. ALLERGIES: TO BACTRIM, SIMVASTATIN, AND CIPRO.CURRENT MEDICATIONS1. Lisinopril.2. Metoprolol.3. Vitamin B12.4. Baby aspirin.5. Gemfibrozil.6. Felodipine.7. Levitra.8. Pravastatin. FAMILY HISTORY: Positive for hypertension, diabetes, and cancer. Negative for heart disease, obesity or stroke. SOCIAL HISTORY: The patient is married. He works as a truck driver and he drives in town. He smokes two packs a day and he has two beers a day he says, but not consuming illegal drugs. REVIEW OF SYSTEMSCONSTITUTIONAL: Denies weight loss/gain, fever or chills. ENMT: Denies headaches, nosebleeds, voice changes, blurry vision or changes in/loss of vision. CV: See history of present illness. Denies chest pain, SOB supine, palpitations, edema, varicose veins or leg pains. RESPIRATORY: He has a chronic cough. Denies shortness of breath, wheezing, sputum production or bloody sputum. GI: Denies heartburn, blood in stools, loss of appetite, abdominal pain or constipation. GU: Denies painful/burning urination, cloudy/dark urine, flank pain or groin pain. MS: Denies joint pain/stiffness, backaches, tendon/ligaments/muscle pains/strains, bone aches/pains or muscle weakness. NEURO: Denies blackouts, seizures, loss of memory, hallucinations, weakness, numbness, tremors or paralysis. PSYCH: Denies anxiety, irritability, apathy, depression, sleep disturbances, appetite disturbances or suicidal thoughts. INTEGUMENTARY: Denies unusual hair loss/breakage, skin lesions/discoloration or unusual nail breakage/discoloration. PHYSICAL EXAMINATIONCONSTITUTIONAL: Blood pressure 140/84, pulse rate 100, respiratory rate 20, temperature 97.2, height 5 feet 10 inches, and weight 218 pounds. The patient is well developed, well nourished, and with fair attention to grooming. The patient is moderately overweight. NECK: The neck is symmetric, the trachea is in the midline, and there are no masses. No crepitus is palpated. The thyroid is palpable, not enlarged, smooth, moves with swallowing, and has no palpable masses. RESPIRATION: Normal respiratory effort. There is no intercostal retraction or action by the accessory muscles. Normal breath sounds bilaterally with no rhonchi, wheezing or rubs. There is a localized 2-cm diameter hard mass in relationship to the costosternal cartilages in the lower most position in the left side, just adjacent to the sternum. CARDIOVASCULAR: The PMI is palpable at the 5ICS in the MCL. No thrills on palpation. S1 and S2 are easily audible. No audible S3, S4, murmur, click, or rub. Carotid pulses 2+ without bruits. Abdominal aorta is not palpable. No audible abdominal bruits. Femoral pulses are 2+ bilaterally, without audible bruits. Extremities show no edema or varicosities. BREASTS: Breasts are symmetric, without skin retraction or nipple discharge. No masses or tenderness in either breasts or axillae. GASTROINTESTINAL: No palpable tenderness or masses. Liver and spleen are percussed but not palpable under the costal margins. No evidence for umbilical or groin herniae. LYMPHATIC: No nodes over 3 mm in the neck, axillae or groins. MUSCULOSKELETAL: Normal gait and station. There is an old traumatic amputation of his right fifth digit. Symmetric muscle strength and normal tone, without signs of atrophy or abnormal movements. SKIN: There are no rashes, lesions, or ulcers. No induration or subcutaneous nodules to palpation. PSYCHIATRIC: Oriented to time, place and person. Appropriate mood and affect. LABS: The only significant finding in the ultrasound of the area is that it shows this to be related to bone.DIAGNOSES1. Chest wall mass.2. Hypertension.3. Hyperlipidemia.4. Glucose intolerance.5. Chronic obstructive pulmonary disease?6. Tobacco abuse.PLANS/ RECOMMENDATIONS: The most likely explanation on this lump is that this is probably an old fracture of the area with callus formation. We need to rule out the possibility of a tumor. Therefore, I have ordered the patient to have a CT of the chest. He will come back to the office next time after this is done." "115",115,"History and Physical","PRESENT ILLNESS: The patient is a very pleasant 69-year-old Caucasian male whom we are asked to see primarily because of a family history of colon cancer, but the patient also has rectal bleeding on a weekly basis and also heartburn once every 1 or 2 weeks. The patient states that he had his first colonoscopy 6 years ago and it was negative. His mother was diagnosed with colon cancer probably in her 50s, but she died of cancer of the esophagus at age 86. The patient does have hemorrhoidal bleed about once a week. Otherwise, he denies any change in bowel habits, abdominal pain, or weight loss. He gets heartburn mainly with certain food such as raw onions and he has had it for years. It will typically occur every couple of weeks. He has had no dysphagia. He has never had an upper endoscopy. MEDICAL HISTORY: Remarkable for hypertension, adult-onset diabetes mellitus, hyperlipidemia, and restless legs syndrome. SURGICAL HISTORY: Appendectomy as a child and cholecystectomy in 2003. MEDICATIONS: His medications are lisinopril 40 mg daily, hydrochlorothiazide 25 mg daily, metformin 1000 mg twice a day, Januvia 100 mg daily, clonazepam 10 mg at bedtime for restless legs syndrome, Crestor 10 mg nightly, and Flomax 0.4 mg daily. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient is retired. He is married. He had 4 children. He quite smoking 25 years ago after a 35-year history of smoking. He does not drink alcohol. FAMILY HISTORY: Mother had colon cancer in her 50s, esophageal cancer in her 80s. Her mother smoked and drank. Father got a mesothelioma at age 65. There is a brother of 65 with hypertension. REVIEW OF SYSTEMS: He has had prostatitis with benign prostatic hypertrophy. He has some increased urinary frequency from a history of prostatitis. He has the heartburn, which is diet dependent and the frequent rectal bleeding. He also has restless legs syndrome at night. No cardio or pulmonary complaints. No weight loss. PHYSICAL EXAMINATION: Reveals a well-developed, well-nourished man in no acute distress. BP 112/70. Pulse 80 and regular. Respirations non-labored. Height 5 feet 7-1/2 inches. Weight 209 pounds. HEENT exam: Sclerae are anicteric. Pupils equal, conjunctivae clear. No gross oropharyngeal lesions. Neck is supple without lymphadenopathy, thyromegaly, or JVD. Lungs are clear to percussion and auscultation. Heart sounds are regular without murmur, gallop, or rub. The abdomen is soft and nontender. There are no masses. There is no hepatosplenomegaly. The bowel sounds are normal. Rectal examination: Deferred. Extremities have no clubbing, cyanosis or edema. Skin is warm and dry. The patient is alert and oriented with a pleasant affect and no gross motor deficits. IMPRESSION:1. Family history of colon cancer.2. Rectal bleeding.3. Heartburn and a family history of esophageal cancer. PLAN: I agree with the indications for repeat colonoscopy, which should be done at least every 5 years. Also, discussed IRC to treat bleeding and internal hemorrhoids if he is deemed to be an appropriate candidate at the time of his colonoscopy and the patient was agreeable. I am also a little concerned about his family history of esophageal cancer and his personal history of heartburn and suggested that we check him once for Barrett's esophagus. If he does not have it now then it should not be a significant risk in the future. The indications and benefits of EGD, colonoscopy, and IRC were discussed. The risks including sedation, bleeding, infection, and perforation were discussed. The importance of a good bowel prep so as to minimize missing any lesions was discussed. His questions were answered and informed consent obtained. It was a pleasure to care for this nice patient." "116",116,"Discharge Summary","CC: Progressive memory and cognitive decline. HX: This 73 y/o RHF presented on 1/12/95, with progressive memory and cognitive decline since 11/94.Her difficulties were first noted by family the week prior to Thanksgiving, when they were taking her to Vail, Colorado to play ""Murder She Wrote"" at family gathering. Unbeknownst to the patient was the fact that she had been chosen to be the ""assassin."" Prior to boarding the airplane her children hid a toy gun in her carry-on luggage. As the patient walked through security the alarm went off and within seconds she was surrounded, searched and interrogated. She and her family eventually made their flight, but she seemed unusually flustered and disoriented by the event. In prior times they would have expected her to have brushed off the incident with a ""chuckle.""While in Colorado her mentation seemed slow and she had difficulty reading the lines to her part while playing ""Murder She Wrote."" She needed assistance to complete the game. The family noted no slurring of speech, difficulty with vision, or focal weakness at the time.She returned to work at a local florist shop the Monday following Thanksgiving, and by her own report, had difficulty carrying out her usual tasks of flower arranging and operating the cash register. She quit working the next day and never went back.Her mental status appeared to remain relatively stable throughout the month of November and December and during that time she was evaluated by a local neurologist. Serum VDRL, TFTs, GS, B12, Folate, CBC, CXR, and MRI of the Brain were all reportedly unremarkable. The working diagnosis was ""Dementia of the Alzheimer's Type.""One to two weeks prior to her 1/12/95 presentation, she became repeatedly lost in her own home. In addition, she, and especially her family, noticed increased difficulty with word finding, attention, and calculation. Furthermore, she began expressing emotional lability unusual for her. She also tended to veer toward the right when walking and often did not recognize the location of people talking to her. MEDS: None. PMH: Unremarkable. FHX: Father and mother died in their 80's of ""old age."" There was no history of dementing illness, stroke, HTN, DM, or other neurological disease in her family. She has 5 children who were alive and well. SHX: She attained a High School education and had been widowed for over 30 years. She lived alone for 15 years until to 12/94, when her daughters began sharing the task of caring for her. She had no history of tobacco, alcohol or illicit drug use. EXAM: Vitals signs were within normal limits. MS: A&O to person place and time. At times she seemed in absence. She scored 20/30 on MMSE and had difficulty with concentration, calculation, visuospatial construction. Her penmanship was not normal, and appeared ""child-like"" according to her daughters. She had difficulty writing a sentence and spoke in a halting fashion; she appeared to have difficulty finding words. In addition, while attempting to write, she had difficulty finding the right margin of the page. CN: Right homonymous inferior quadrantanopsia bordering on a right homonymous hemianopsia. The rest of the CN exam was unremarkable.Motor: 5/5 strength throughout with normal muscle tone and bulk.Sensory: extinguishing of RUE sensation on double simultaneous stimulation, and at times she appeared to show sign of RUE neglect. There were no unusual spontaneous movements noted.Coord: unremarkable except for difficulty finding the target on FNF exercise when the target was moved into the right side visual field.Station: No sign of Romberg or pronator drift. There was no truncal ataxia.Gait: decreased RUE swing and a tendency to veer and circumambulate to the right when asked to walk toward a target.Reflexes: 2/2 and symmetric throughout all four extremities. Plantar responses were equivocal, bilaterally. COURSE: CBC, GS, PT, PTT, ESR, UA, CRP, TSH, FT4, and EKG were unremarkable. CSF analysis revealed: 38 RBC, 0 WBC, Protein 36, glucose 76. The outside MRI was reviewed and was found to show increased signal on T2 weighted images in the gyri of the left parietal-occipital regions. Repeat MRI, at UIHC, revealed the same plus increased signal on T2 weighted images in the left frontal region as well. CXR, transthoracic echocardiogram and 4 vessel cerebral angiogram were unremarkable. A 1/23/95, left frontal brain biopsy revealed spongiform changes without sign of focal necrosis, vasculitis or inflammatory changes. The working diagnosis became Creutzfeldt-Jakob Disease (Heidenhaim variant). The patient died on 2/15/95. Brain tissue was sent to the University of California at San Francisco. Analysis there revealed diffuse vacuolization throughout most of the cingulate gyrus, frontal cortex, hypothalamus, globus pallidus, putamen, insula, amygdala, hippocampus, cerebellum and medulla. This vacuolization was most severe in the entorhinal cortex and parahippocampal gyrus. Hydrolytic autoclaving technique was used with PrP-specific antibodies to identify the presence of protease resistant PrP (CJD). The patient's brain tissue was strongly positive for PrP (CJD)." "117",117,"History and Physical","Sample Doctor, M.D.Sample AddressRe: Mrs. Sample PatientDear Sample Doctor:I had the pleasure of seeing your patient, Mrs. Sample Patient , in my office today. Mrs. Sample Patient is a 48-year-old, African-American female with a past medical history of hypertension and glaucoma, who was referred to me to be evaluated for intermittent rectal bleeding. The patient denies any weight loss, does have a good appetite, no nausea and no vomiting. PAST MEDICAL HISTORY: Significant for hypertension and diabetes. PAST SURGICAL HISTORY: The patient denies any past surgical history. MEDICATIONS: The patient takes Cardizem CD 240-mg. The patient also takes eye drops. ALLERGIES: The patient denies any allergies. SOCIAL HISTORY: The patient smokes about a pack a day for more than 25 years. The patient drinks alcohol socially. FAMILY HISTORY: Significant for hypertension and strokes. REVIEW OF SYSTEMS: The patient does have a good appetite and no weight loss. She does have intermittent rectal bleeding associated with irritation in the rectal area. The patient denies any nausea, any vomiting, any night sweats, any fevers or any chills.The patient denies any shortness of breath, any chest pain, any irregular heartbeat or chronic cough.The patient is chronically constipated. PHYSICAL EXAMINATION: This is a 48 year-old lady who is awake, alert and oriented x 3. She does not seem to be in any acute distress. Her vital signs are blood pressure is 130/70 with a heart rate of 75 and respirations of 16. HEENT is normocephalic, atraumatic. Sclerae are non-icteric. Her neck is supple, no bruits, no lymph nodes. Lungs are clear to auscultation bilaterally, no crackles, no rales and no wheezes. The cardiovascular system has a regular rate and rhythm, no murmurs. The abdomen is soft and non-tender. Bowel sounds are positive and no organomegaly. Extremities have no edema. IMPRESSION: This is a 48-year-old female presenting with painless rectal bleeding not associated with any weight loss. The patient is chronically constipated.1. Rule out colon cancer.2. Rule out colon polyps. 3. Rule out hemorrhoids, which is the most likely diagnosis. RECOMMENDATIONS: Because of the patient's age, the patient will need to have a complete colonoscopy exam.The patient will also need to have a CBC check and monitor.The patient will be scheduled for the colonoscopy at Sample Hospital and the full report will be forwarded to your office.Thank you very much for allowing me to participate in the care of your patient.Sincerely yours,Sample Doctor, MD" "118",118,"History and Physical","CHIEF COMPLAINT: Followup on diabetes mellitus, status post cerebrovascular accident. SUBJECTIVE: This is a 70-year-old male who has no particular complaints other than he has just discomfort on his right side. We have done EMG studies. He has noticed it since his stroke about five years ago. He has been to see a neurologist. We have tried different medications and it just does not seem to help. He checks his blood sugars at home two to three times a day. He kind of adjusts his own insulin himself. Re-evaluation of symptoms is essentially negative. He has a past history of heavy tobacco and alcohol usage. MEDICATIONS: Refer to chart. ALLERGIES: Refer to chart. PHYSICAL EXAMINATION: Vitals: Wt; 118 lbs, B/P; 108/72, T; 96.5, P; 80 and regular. General: A 70-year-old male who does not appear to be in acute distress but does look older than his stated age. He has some missing dentition.Skin: Dry and flaky. CV: Heart tones are okay, adequate carotid pulsations. He has 2+ pedal pulse on the left and 1+ on the right.Lungs: Diminished but clear.Abdomen: Scaphoid.Rectal: His prostate check was normal per Dr. Gill.Neuro: Sensation with monofilament testing is better on the left than it is on the right. IMPRESSION:1. Diabetes mellitus.2. Neuropathy 2/2 NIDDM.3. Status post cerebrovascular accident. PLAN: Refill his medications x 3 months. We will check an A1c and BMP. I have talked to him several times about a colonoscopy, which he has refused, and so we have been doing stools for occult blood. We will check a PSA. Continue with yearly eye exams, foot exams, Accu-Cheks, and we will see him in three months and p.r.n." "119",119,"History and Physical","CHIEF COMPLAINT: Followup on diabetes mellitus, hypercholesterolemia, and sinusitis. SUBJECTIVE: A 70-year-old female who was diagnosed with diabetes mellitus last fall. She has been checking her Accu-Cheks generally once a day, and they range from 82 to a high of 132. She feels well. She walks 1-2 miles most days. If the weather is bad, they go to a local mall. Otherwise they walk outside. She does complain of some sinus congestion and drainage for the last several days. She is up-to-date on her mammogram that she had at the Baylis Building. She sees Dr. Cheng for her gynecological care. She is a nonsmoker. Denies abdominal pain, nausea, vomiting, diarrhea, constipation, blood in her urine, blood in her stools. She has nocturia x 1. Denies swelling in her ankles. She checks her feet regularly. PAST MEDICAL HISTORY: Refer to chart. MEDICATIONS: Refer to chart. ALLERGIES: Refer to chart. PHYSICAL EXAMINATION: Vitals: Wt: 185 B/ P: 142/70. When she checks it at the mall and other places, it is usually about 120/56. T: 96.5 P: 84 and regular.General: A 70-year-old female who does not appear to be in acute distress. HEENT: She has frontal and maxillary sinus tenderness on the right to palpation. The right TM is slightly dull. Neck: Supple. Heart: Clear.Lungs: Clear. Abdomen: Large, nontender. No swelling. IMPRESSION: 1. Hypercholesterolemia.2. Diabetes mellitus.3. Sinusitis. PLAN: 1. Allegra D 1 p.o. b.i.d. x 3 days.2. Allegra 180 mg daily x 7 days.3. Check an A1c, BMP, lipid profile, TSH. 4. She was given a copy of Partners in Prevention. 5. We discussed colonoscopy, and she is not ready to do that right now.6. Will check stools for occult blood x 3. She is aware that a colonoscopy could pick up an early cancer.7. Diet, exercise, weight loss stressed. We will let her know the results of her tests.8. Refilled her prescriptions x 6 months." "120",120,"History and Physical","SUBJECTIVE: The patient is in complaining of headaches and dizzy spells, as well as a new little rash on the medial right calf. She describes her dizziness as both vertigo and lightheadedness. She does not have a headache at present but has some intermittent headaches, neck pains, and generalized myalgias. She has noticed a few more bruises on her legs. No fever or chills with slight cough. She has had more chest pains but not at present. She does have a little bit of nausea but no vomiting or diarrhea. She complains of some left shoulder tenderness and discomfort. She reports her blood sugar today after lunch was 155. CURRENT MEDICATIONS: She is currently on her nystatin ointment to her lips q.i.d. p.r.n. She is still using a triamcinolone 0.1% cream t.i.d. to her left wrist rash and her Bactroban ointment t.i.d. p.r.n. to her bug bites on her legs. Her other meds remain as per the dictation of 07/30/2004 with the exception of her Klonopin dose being 4 mg in a.m. and 6 mg at h.s. instead of what the psychiatrist had recommended which should be 6 mg and 8 mg. ALLERGIES: Sulfa, erythromycin, Macrodantin, and tramadol. OBJECTIVE:General: She is a well-developed, well-nourished, obese female in no acute distress.Vital Signs: Her age is 55. Temperature: 98.2. Blood pressure: 110/70. Pulse: 72. Weight: 174 pounds. HEENT: Head was normocephalic. Throat: Clear. TMs clear.Neck: Supple without adenopathy.Lungs: Clear.Heart: Regular rate and rhythm without murmur.Abdomen: Soft, nontender without hepatosplenomegaly or mass.Extremities: Trace of ankle edema but no calf tenderness x 2 in lower extremities is noted. Her shoulders have full range of motion. She has minimal tenderness to the left shoulder anteriorly.Skin: There is bit of an erythematous rash to the left wrist which seems to be clearing with triamcinolone and her rash around her lips seems to be clearing nicely with her nystatin. ASSESSMENT:1. Headaches.2. Dizziness.3. Atypical chest pains.4. Chronic renal failure.5. Type II diabetes.6. Myalgias.7. Severe anxiety (affect is still quite anxious.) PLAN: I strongly encouraged her to increase her Klonopin to what the psychiatrist recommended, which should be 6 mg in the a.m. and 8 mg in the p.m. I sent her to lab for CPK due to her myalgias and pro-time for monitoring her Coumadin. Recheck in one week. I think her dizziness is multifactorial and due to enlarged part of her anxiety. I do note that she does have a few new bruises on her extremities, which is likely due to her Coumadin." "121",121,"History and Physical","SUBJECTIVE: The patient is a 62-year-old white female with multiple chronic problems including hypertension and a lipometabolism disorder. She follows with Dr. XYZ on her hypertension, as well as myself. She continues to gain weight. Diabetes is therefore a major concern. In fact, her dad had diabetes and she has a brother who has diabetes. The patient also has several additional concerns she brings up today. One is that her left knee continues to bother her and it hurts. She cannot really isolate where the pain is, it just seems to hurt through her knee. She has had this for some time now and in fact as we reviewed her records, her left knee has been x-rayed in 1999. There was some minimal narrowing of the weightbearing joint with some minor hypertrophic spurring medially. She would like to have this x-rayed again today. She is certainly not interested in any surgery. She has noted that it particularly hurts to kneel. In addition, she complains of her stools being a baby-yellow. She has rectal bleeding off and on. It is bright red. She had a colonoscopy done in 1999. She does have a family history of colon cancer questionable in her mother, who is deceased. She complains of some diffuse abdominal pain off and on. She has given up fast foods and her pop and this has not seemed to help. She does admit however, that she is not eating right. Sometimes her stools are hard. Sometimes they are runny. The blood does not really seem to be related to necessarily a hard stool. It is always bright red and will sometimes drip into the toilet. Over the last couple of days, she had also been sneezing and has had an itchy throat. She tried some Claritin and this did not help. She has had some body aches. She is finally feeling better today with this. She also is questioning whether she has some sleep apnea. She will awaken suddenly in the middle of the night. She was told that she does snore. She does not smoke. As stated, she has gained significant weight. GYNECOLOGICAL HISTORY: She does not bleed. She has both ovaries, as well as her uterus and cervix. She is on no hormonal therapy. PREVENTATIVE HISTORY: She is not exercising. She does not do self breast examinations. She has recently had her mammogram and it was unremarkable. She does take her low-dose aspirin daily as well as her multivitamin. She does wear her seatbelt. As previously noted, she does not smoke or drink alcohol.PAST MEDICAL, FAMILY AND SOCIAL HISTORY: Per health summary sheet, unchanged. REVIEW OF SYSTEMS: Unremarkable with the exception of that above. ALLERGIES: No known drug allergies. CURRENT MEDICATIONS: Benicar 20 mg daily; multivitamin; glucosamine; vitamin B complex; vitamin E and a low-dose aspirin. OBJECTIVE:General: Well-nourished, well-developed, a very pleasant 61-year-old in no acute distress.Vitals: Her weight today is 246 pounds. In March of 2002 she weighed 231 pounds. In March 2001 she weighed 203 pounds. Her blood pressure is 160/78. Pulse is 84. Respiratory rate of 20. She is afebrile. HEENT: Head is of normocephalic, atraumatic. PERLA. Conjunctivae clear. TMs are unremarkable and canals are patent. Nasal mucosa is slightly reddened. Nares are patent. Throat shows some clear posterior pharyngeal drainage. Throat is slightly reddened. Non-exudative. No oral lesions or dental caries noted.Neck: Supple, No adenopathy. Thyroid without any nodules or enlargements, no JVD or carotid bruits.Heart: Regular rate and rhythm without murmurs, clicks or rubs. PMI is nondisplaced.Lungs: Clear to A&P. No CVA tenderness.Breast exam: Negative for any axillary nodes, skin changes, discrete nodules or nipple discharge. Breasts were examined both lying and sitting.Abdomen: Soft, nondistended, normoactive bowel sounds, no hepatosplenomegaly or masses. Non tender.Pelvic exam: BUS unremarkable. Speculum exam shows normal physiologic discharge. There are some atrophic vaginal changes. Cervix visualized, no gross abnormalities. Pap smear obtained. Bimanual is negative for any adnexal masses or tenderness. Rectal exam is negative for any adnexal masses or tenderness. No rectal masses. She does have some external hemorrhoids, none of which are inflamed at this time. No palpable rectal masses.Neuromusculoskeletal exam: Cranial nerves II-XII are grossly intact. No cerebellar signs are noted. No evidence of a gait disturbance. DTRs are 1+/4+ and equal throughout. Good uptoeing. Skin: Inspection of her skin, subcuticular tissues negative for any concerning skin lesions, rashes or subcuticular masses. ASSESSMENT:1. Weight-gain.2. Hypertension.3. Lipometabolism disorder.4. Rectal bleeding.5. Left knee pain.6. Question of sleep apnea.7. Upper respiratory infection, improving.8. Gynecological examination is unremarkable for her age. PLAN: We discussed at length, the issue of sleep apnea and its negative sequela. I have recommended that she be referred for a sleep study. She is certainly at risk for sleep apnea. She refuses this. I do not think that her upper respiratory tract infection needs any further treatment at this time since she is feeling better. I did x-ray her knee and with the exception of some degenerative changes, it was unremarkable. I reviewed this with her. I do think that since she is having rectal bleeding, while this is not real unusual for her, with her family history of colon cancer, I am going to have her discuss this further with Dr. XYZ and leave further studies up to them. I will dictate Dr. XYZ a note. I am not going to order any further studies at this time in terms of her yellow stools and right upper quadrant discomfort. She has had a gallbladder sonogram done in the past, this has been unremarkable and these symptoms really have not changed for her. This however, has been some time ago. I suspect she has an element of irritable bowel syndrome. I have strongly encouraged weight reduction, both through diet and exercise. I would like to see her back in the office in six months. I did retake her blood pressure today and it was 130/70. She is fasting this morning, so we will get a fasting blood sugar, chem-12, lipid profile, and CPK. I will her mail the results. I have strongly encouraged medication management if her lipids are elevated. I think she is amenable to this. Her DEXA scan is up to date having been done on 04/09/03. I do not recommend one this year." "122",122,"History and Physical","REASON FOR CONSULTATION: Post-surgical medical management. PROCEDURE DONE: Right total knee replacement. MEDICAL HISTORY:1. Arthritis of the right knee.2. Hypertension. PAST SURGICAL HISTORY: Hysterectomy, Cesarean section, left hip arthroplasty, and breast biopsy. MEDICATIONS: Hyzaar 12.5 mg p.o. daily, Femara 2.5 mg p.o. daily, Fosamax 70 mg p.o. every week, aspirin 81 mg p.o. daily, and vitamin. ALLERGIES: MORPHINE. HISTORY OF PRESENT COMPLAINT: This 84-year-old patient with history of arthritis underwent right total knee replacement yesterday. The patient is admitted today to the surgical floor for postoperative management. The patient tolerated the procedure well. REVIEW OF SYSTEMS: CONSTITUTIONAL: No fever, chills, or malaise. ENT: Unremarkable. RESPIRATORY: The patient denies shortness of breath, cough, or wheezing. CARDIOVASCULAR: No known heart problems. No orthopnea, palpitations, syncopal episode, or pedal swelling. GASTROINTESTINAL: She denies nausea or vomiting. No history of GI bleed. GENITOURINARY: No dysuria, no hematuria. ENDOCRINE: Negative for diabetes or thyroid problems. NEUROLOGICAL: No history of seizure or TIA. Cognitive function is intact. SOCIAL HISTORY: The patient does not smoke. She consumes alcohol moderately. FAMILY HISTORY: Positive for cancer. PHYSICAL EXAMINATION: GENERAL: This is an 84-year-old lady who looks young for her age. VITAL SIGNS: Blood pressure of 138/53, pulse is 73, respiratory rate of 20, and O2 saturation is 95% on room air. She is afebrile. HEAD AND NECK: Face is symmetrical. Cranial nerves are intact. No distended neck veins. No palpable neck masses. CHEST: Clear to auscultation. No wheezing. No crepitations. CARDIOVASCULAR: First and second heart sounds were heard. No murmur is appreciated. ABDOMEN: Soft and nontender. Bowel sounds are positive. EXTREMITIES: There is no pedal swelling. LABORATORY DATA: Hemoglobin has dropped from 12.6 to 10.2. Hematocrit is 30. Glucose is 125. BUN is 15.9, creatinine is 0.6, sodium is 134, and potassium is 3.8. ASSESSMENT AND PLAN:1. Right knee arthritis status post right total knee replacement. The patient tolerated the procedure well.2. Anemia due to stated operative blood loss, would not require transfusion at this point.3. Hypertension, under control. Continue current home medications.4. Deep vein thrombosis risk, prophylaxis as per surgeon.5. Gastrointestinal prophylaxis.6. Debility. Continue physical therapy and occupational therapy." "123",123,"History and Physical","REASON FOR CONSULTATION: Management of pain medications. HISTORY OF PRESENT ILLNESS: This is a 60-year-old white male with history of coronary artery disease, status post CABG in 1985 with subsequent sternal dehiscence with rewiring in December 2005 and stent placement in LAD region in 2005, who developed sudden chest pain and was taken to San Jacinto via ambulance where he was diagnosed with acute MI and then went into atrial fibrillation. An intraaortic balloon pump was placed for cardiogenic shock, and then he was transferred to the ABCD Hospital on October 22, 2006, for continued critical care. He was in a state of cardiogenic shock and multiorgan system failure including respiratory failure and acute renal insufficiency when he was transferred. He is currently on dialysis due to end-stage renal disease and has a tracheostomy. He is receiving fentanyl since he has been here for back pain, leg pain, abdominal pain, and pain in the feet. He states that he is currently in pain and the fentanyl only helps for about an hour or so before the pain resumes. He currently rates his pain as 7 out of 10. He denies a depressed mood or anxiety and states that he knows he is getting better. He describes his sleep as erratic and states that he will sleep for 1 hour after giving fentanyl IV and then will wake up until he gets another fentanyl. He has PEG for tube feeding. He has weakness on left side of his body as well as both legs since his MI. He has been switched from fentanyl IV q.2h. to the fentanyl patch today. He also has been started on Seroquel 12.5 mg p.o. at bedtime and will receive his first dose on the evening of Monday, February 12, 2007. He denies any other psychiatric symptoms including auditory or visual hallucinations or delusions. His wife was present in the room and both him and his wife seemed to be offended by the suggestion of any psychiatric history or any psychiatric problems. PAST MEDICAL HISTORY:1. DVT in December 2005.2. Three MI's (1996, 2005, and 2006).3. Diabetes for 5 years.4. Coronary artery disease for 10 years. PAST SURGERIES:1. Appendectomy as a child.2. CABG x3, November 2005.3. Sternal rewiring, December 2005. MEDICATIONS:1. Restoril 7.5 mg p.o. at bedtime p.r.n.2. Acetaminophen 650 mg p.o. q.6h. p.r.n. fever.3. Aspirin 81 mg p.o. daily.4. Bisacodyl suppository 10 mg per rectum daily.5. Erythropoietin injection 100 mcg subcutaneously every week at 5 p.m.6. Esomeprazole 40 mg IV q.12h.7. Fentanyl patch 25 mcg per hour.8. Transderm patch every 72 hours.9. Heparin IV.10. Lactulose 30 mL p.o. daily p.r.n. constipation.11. Metastron injection 4 mg IV q.6h. p.r.n. nausea.12. Seroquel 12 mg p.o. at bedtime.13. Saliva substitute 30 mL spray p.o. q.3h. p.r.n. dry mouth.14. Simethicone drops 80 mg per G-tube p.r.n. gas pain.15. Bactrim suspension p.o. daily.16. Insulin medium dose sliding scale.17. Albumin 25% IV p.r.n. hemodialysis.18. Ipratropium solution for nebulizer. ALLERGIES: No known drug allergies. PAST PSYCHIATRIC HISTORY: The patient denies any past psychiatric problems. No medications. He denies any outpatient visits or inpatient hospitalizations for psychiatric reasons. SOCIAL HISTORY: He lives with his wife in New Jersey. He has 2 children. One son in Texas City and 1 daughter in Florida. He is a master mechanic for a trucking company since 1968. He retired in the May 2006. The highest level of education that he received was 1 year in college.Ethanol, tobacco, or drugs; he smoked 2 packs per day for 40 years, but quit in 1996. He occasionally has a beer, but denies any continuous use of alcohol. He denies any illicit drug use. FAMILY HISTORY: Both parents died with myocardial infarctions. He has 2 sisters and a brother with diabetes mellitus and coronary artery disease. He denies any history of psychiatric problems in family. MENTAL STATUS EXAMINATION: The patient was sitting in his bed in hospital gown with tracheostomy and receiving tube feeding. The patient's appearance was appropriate with fair-to-good grooming and hygiene. He had little-to-no psychomotor activity secondary to weakness post MI. He had good eye contact. His speech was of decreased rate volume and flexion secondary to tracheostomy. The patient was cooperative. He described his mood is not good in congruent stable and appropriate affect with decreased range. His thought process is logical and goal directed. His thought content was negative for delusions, phobias, obsessions, suicidal ideation, or homicidal ideation. He denied any perceptional disturbances including any auditory or visual hallucinations. He was alert and oriented x3.Mini mental status exams not completed. ASSESSMENT: AXIS I: Pain with physical symptoms and possibly psychological symptoms. AXIS II: Deferred. AXIS III: See above. AXIS IV: Stress associated with medical illnesses. AXIS V: GAF indeterminate.This is a 60-year-old white male with history of coronary artery disease, recurrent MI's, diabetes mellitus, and DVT who has experienced multiorgan failure secondary to cardiogenic shock, complaining of pain, and inability to sleep secondary to pain. PLAN:1. The patient and his wife were surprised to see that psychiatry was consultant and did not seem to be happy to see us.2. The patient has agreed to discuss in psychiatric consultation with Dr. Abc and we will be called if we can be of any further assistance.Thank you for consulting." "124",124,"History and Physical","HISTORY: I had the pleasure of meeting and evaluating the patient today, referred for evaluation of tracheostomy tube placement and treatment recommendations. As you are well aware, he is a pleasant 64-year-old gentleman who unfortunately is suffering from end-stage COPD, who required tracheostomy tube placement about three months ago when being treated for acute exacerbation of COPD and having difficulty coming off ventilatory support. He now resides in an extended care facility with a capped tracheostomy tube, and he unfortunately states he has had not had to use the tracheostomy tube since his discharge and admission to the extended care facility. He requires constant oxygen administration and has been having no problems with shortness of breath, worsening, requiring opening the tracheostomy tube site. He states there has been some tenderness associated with the tracheostomy tube and difficulty with swallowing and he wishes to have it removed. Apparently there is no history of any airway issues while sleeping or need for uncapping the tube and essentially the tube has just remained present for months capped in his neck. No history of any previous tracheostomy tube insertion. PAST MEDICAL HISTORY: COPD, history of hypercarbic hypoxemia, history of coronary artery disease, history of previous myocardial infarction, and history of liver cirrhosis secondary to alcohol use. PAST SURGICAL HISTORY: Tonsillectomy, adenoidectomy, cholecystectomy, appendectomy, hernia repair, and tracheostomy. FAMILY HISTORY: Strong for heart disease, coronary artery disease, hypertension, diabetes mellitus, and cerebrovascular accident. CURRENT MEDICATIONS: Prevacid, folic acid, aspirin, morphine sulfate, Pulmicort, Risperdal, Colace, clonazepam, Lotrisone, Roxanol, Ambien, Zolpidem tartrate, simethicone, Robitussin, and prednisone. ALLERGIES: Nitroglycerin. SOCIAL HISTORY: The patient has a 25-year-smoking history, which I believe is quite heavy and he has a significant alcohol use in the past. PHYSICAL EXAMINATION: VITAL SIGNS: Age 64, blood pressure is 110/78, pulse 96, and temperature is 98.6. GENERAL: The patient was examined in his wheelchair, resting comfortably, in no acute distress. HEAD: Normocephalic. No masses or lesions noted. FACE: No facial tenderness or asymmetry noted. EYES: Pupils are equal, round and reactive to light and accommodation bilaterally. Extraocular movements are intact bilaterally. EARS: The tympanic membranes are intact bilaterally with a good light reflex. The external auditory canals are clear with no lesions or masses noted. Weber and Rinne tests are within normal limits. NOSE: The nasal cavities are patent bilaterally. The nasal septum is midline. There are no nasal discharges. No masses or lesions noted. THROAT: The oral mucosa appears healthy. Dental hygiene is maintained well. No oropharyngeal masses or lesions noted. No postnasal drip noted. NECK: The patient has a stable-appearing tracheostomy tube site and the stoma appears to be without signs of infection. The previous incision was vertical in nature and there is no hypertrophic scar formation. No adenopathy noted. No stridor noted. NEUROLOGIC: Cranial nerve VII intact bilaterally. No signs of tremor. LUNGS: Diminished breath sounds in all four quadrants. No wheezes noted. HEART: Regular rate and rhythm. PROCEDURE: Limited bronchoscopy and then fiberoptic laryngoscopy. IMPRESSION: 1. End-stage chronic obstructive pulmonary disease with a history of respiratory failure requiring mechanical ventilatory support with tracheostomy tube placement.2. Difficulty tolerating tracheostomy tubes secondary to swallow discomfort and neck irritation with no further need for tracheostomy tube over the past few months with the patient tolerating capped tracheostomy tube 24 hours a day.3. History of coronary artery disease.4. History of myocardial infarction.5. History of cirrhosis of liver. RECOMMENDATIONS: I discussed with the patient in detail after fiberoptic laryngoscopy and limited bronchoscopy was performed in the office whether or not to pull out the tracheostomy tube. His vocal cords moved well, and I do not see any signs of granuloma or airway obstruction either in the supraglottic or subglottic region, and I felt he would tolerate the tube being removed with close monitoring by nursing at his extended care facility. I did impress the fact that I believe he probably will have other events requiring airway support, which could include intubation, and if the intubation is prolonged a tracheostomy may be needed. Creation of a long-term tracheostoma may be beneficial whereas the patient would not need such a long tracheostomy tube, and I informed the patient there are other options other than the tube he has at the present time. The patient still wished to have the tube removed and he is aware he may need to have it replaced or he may have trouble with the area healing or scarring or he could end up having an emergent airway situation with the tube gone, but wishes to have it removed, and I did remove it today. Dressing was applied and we will see him back next week to make sure everything is healing properly." "125",125,"Operative Note","PREOPERATIVE DIAGNOSIS: Left chest wall tumor, spindle cell histology. POSTOPERATIVE DIAGNOSIS: Left chest wall tumor, spindle cell histology with pathology pending. PROCEDURE: Resection of left chest wall tumor, partial resection of left diaphragm, left lower lobe lung wedge resection, left chest wall reconstruction with Gore-Tex mesh. ANESTHESIA: General endotracheal. SPECIMEN: Left chest wall with tumor and left lower lobe lung wedge resection to pathology. INDICATIONS FOR PROCEDURE: The patient is a 79-year-old male who began to experience back pain approximately 2 years ago, which increased. Chest x-ray and CT scan revealed a 3 cm x 4 cm mass abutting the left chest wall inferior to the left scapula with pleural thickening. A biopsy was performed at an outside hospital (Kaiser) and pathology was consistent with mesothelioma. The patient had a metastatic workup, which was negative including a brain MRI and bone scan. The bone scan showed only signal positivity in the left 9th rib near the tumor. The patient has a significant past medical history consisting of coronary artery disease, hypertension, non-insulin dependent diabetes, longstanding atrial fibrillation, anemia, and hypercholesterolemia. He and his family were apprised of the high-risk nature of this surgery preoperatively and informed consent was obtained. PROCEDURE IN DETAIL: The patient was brought to the operating room and placed in the supine position. The patient was intubated with a double-lumen endotracheal tube. Intravenous antibiotics were given. A Foley catheter was placed. The patient was placed in the right lateral decubitus position and the left chest was prepped and draped in the usual sterile fashion. An incision approximately 8 inches long was made centered over the mass and extending slightly obliquely over the mass. The skin and subcutaneous tissues were dissected sharply with the electrocautery. Good hemostasis was obtained. The tumor was easily palpable and clearly involving the 8th to 9th rib. A thoracotomy was initially made above the mass in approximately the 7th intercostal space. Inspection of the pleural cavity revealed multiple adhesions, which were taken down with a combination of blunt and sharp dissection. The thoracotomy was extended anteriorly and posteriorly. It was clear that in order to obtain an adequate resection of the tumor, approximately 4 rib segment of the chest wall would need to be resected. The ribs of the chest wall were first cut at their anterior aspect. The ribs 7, 8, 9, and 10 were serially transected after the interspaces were dissected with electrocautery. Hemostasis was obtained with both electrocautery and clips. The chest wall segment to be resected was retracted laterally and posteriorly. It was clear that there were at least 2 areas where the tumor was invading the lung and a lengthy area of diaphragmatic involvement. Inferiorly, the diaphragm was divided to provide a margin of at least 1 to 2 cm around the areas of tumor. The spleen and the stomach were identified and were protected. Inferiorly, the resection of the chest wall was continued in the 10th interspace. The dissection was then carried posteriorly to the level of the spine. The left lung at this point was further dissected out and multiple firings of the GIA 75 were used to perform a wedge resection of the left lower lobe, which provided a complete resection of all palpable and visible tumor in the lung. A 2-0 silk tie was used to ligate the last remaining corner of lung parenchyma at the corner of the wedge resection. Posteriorly, the chest wall segment was noted to have an area at the level of approximately T8 and T9, where the tumor involved the vertebral bodies. The ribs were disarticulated, closed to or at their articulations with the spine. Bleeding from the intercostal vessels was controlled with a combination of clips and electrocautery. There was no disease grossly involving or encasing the aorta.The posterior transection of the ribs was completed and the specimen was passed off of the field as a specimen to pathology for permanent section. The specimen was oriented for the pathologist who came to the room. Hemostasis was obtained. The vent in the diaphragm was then closed primarily with a series of figure-of-8 #1 Ethibond sutures. This produced a satisfactory diaphragmatic repair without undue tension. A single 32-French chest tube was placed in the pleural cavity exiting the left hemithorax anteriorly. This was secured with a #1 silk suture. The Gore-Tex mesh was brought on to the field and was noted to be of adequate size to patch the resulting chest wall defect. A series of #1 Prolene were placed in an interrupted horizontal mattress fashion circumferentially and tied down individually. The resulting mesh closure was snug and deemed adequate. The serratus muscle was reapproximated with figure-of-8 0 Vicryl. The latissimus was reapproximated with a two #1 Vicryl placed in running fashion. Of note, two #10 JP drains were placed over the mesh repair of the chest wall. The subcutaneous tissues were closed with a running 3-0 Vicryl suture and the skin was closed with a 4-0 Monocryl. The wounds were dressed. The patient was brought from the operating room directly to the North ICU, intubated in stable condition. All counts were correct." "126",126,"History and Physical","HISTORY OF PRESENT ILLNESS: The patient is a 63-year-old white male who was admitted to the hospital with CHF and lymphedema. He also has a history of obesity, hypertension, sleep apnea, chronic low back pain, cataracts, and past history of CA of the lung. This consultation was made for better control of his blood sugars. On questioning, the patient says that he does not have diabetes. He says that he has never been told about diabetes except during his last admission at Jefferson Hospital. Apparently, he was started on glipizide at that time. His blood sugars since then have been good and he says when he went back to Jefferson three weeks later, he was told that he does not have a sugar problem. He is not sure. He is not following any specific diet. He says ""my doctor wants me to lose 30-40 pounds in weight"" and he would not mind going on a diet. He has a long history of numbness of his toes. He denies any visual problems. PAST MEDICAL HISTORY: As above that includes CA of the lung, COPD, bilateral cataracts. He has had chronic back pain. There is also a history of bilateral hip surgeries, penile implant and removal, umbilical hernia repair, and back pain with two surgeries with details of which are unknown. SOCIAL HISTORY: The patient has been a smoker since the age of 10. So, he was smoking 2-3 packs per day. Since being started on Chantix, he says he has cut it down to half a pack per day. He does not abuse alcohol. MEDICATIONS: 1. Glipizide 5 mg p.o. daily.2. Theophylline.3. Z-Pak.4. Chantix.5. Januvia 100 mg daily.6. K-Lor.7. OxyContin.8. Flomax.9. Lasix.10. Advair.11. Avapro.12. Albuterol sulfate.13. Vitamin B tablet.14. OxyContin and oxycodone for pain. FAMILY HISTORY: Positive for diabetes mellitus in the maternal grandmother. REVIEW OF SYSTEMS: As above. He says he has had numbness of toes for a long time. He denies any visual problems. His legs have been swelling up from time to time for a long time. He also has history of COPD and gets short of breath with minimal activity. He is also not able to walk due to his weight. He has had ulcers on his legs, which he gets discharge from. He has chronic back pain and takes OxyContin. He denies any constipation, diarrhea, abdominal pain, nausea or vomiting. There is no chest pain. He does get short of breath on walking. PHYSICAL EXAMINATION:The patient is a well-built, obese, white male in no acute distress.Vital signs: Pulse rate of 89 per minute and regular. Blood pressure of 113/69, temperature is 98.4 degrees Fahrenheit, and respirations are 18. HEENT: Head is normocephalic and atraumatic. Eyes, PERRLA. EOMs intact. Fundi were not examined.Neck: Supple. JVP is low. Trachea central. Thyroid small in size. No carotid bruits.Heart: Shows normal sinus rhythm with S1 and S2.Lungs: Show bilateral wheezes with decreased breath sounds at the bases.Abdomen: Soft and obese. No masses. Bowel sounds are present.Extremities: Show bilateral edema with changes of chronic venostasis. He does have some open weeping sores. Pulses could not be palpated due to leg swelling.IMPRESSION/ PLAN:1. Diabetes mellitus, type 2, new onset. At this time, the patient is on Januvia as well as glipizide. His blood sugar right after eating his supper was 101. So, I am going to discontinue glipizide, continue on Januvia, and add no-concentrated sweets to the diet. We will continue to follow his blood sugars closely and make adjustments as needed.2. Neuropathy, peripheral, likely due to untreated diabetes.3. Lymphedema.4. Recurrent cellulitis.5. Obesity, morbid.6. Tobacco abuse. He was encouraged to cut his cigarettes down to 5 cigarettes a day. He says he feels like smoking after meals. So, we will let him have it after meals first thing in the morning and last thing at night.7. Chronic venostasis.8. Lymphedema. We would check his lipid profile also.9. Hypertension.10. Backbone pain, status post back surgery.11. Status post hernia repair.12. Status post penile implant and removal.13. Umbilical hernia repair." "127",127,"History and Physical","HISTORY: The patient is a 15-year-old female who was seen in consultation at the request of Dr. X on 05/15/2008 regarding enlarged tonsils. The patient has been having difficult time with having two to three bouts of tonsillitis this year. She does average about four bouts of tonsillitis per year for the past several years. She notes that throat pain and fever with the actual infections. She is having no difficulty with swallowing. She does have loud snoring, though there have been no witnessed observed sleep apnea episodes. She is a mouth breather at nighttime, however. The patient does feel that she has a cold at today's visit. She has had tonsil problems again for many years. She does note a history of intermittent hoarseness as well. This is particularly prominent with the current cold that she has had. She had been seen by Dr. Y in Muskegon who had also recommended a tonsillectomy, but she reports she would like to get the surgery done here in the Ludington area as this is much closer to home. For the two tonsillitis, she is on antibiotics again on an average about four times per year. They do seem to help with the infections, but they tend to continue to recur. The patient presents today for further workup, evaluation, and treatment of the above-listed symptoms. REVIEW OF SYSTEMS:ALLERGY/ IMMUNOLOGIC: Negative. CARDIOVASCULAR: Negative. PULMONARY: Negative. GASTROINTESTINAL: Negative. GENITOURINARY: Negative. NEUROLOGIC: Negative. VISUAL: Negative. DERMATOLOGIC: Negative. ENDOCRINE: Negative. MUSCULOSKELETAL: Negative. CONSTITUTIONAL: Negative. PAST SURGICAL HISTORY: Pertinent for previous cholecystectomy. FAMILY HISTORY: No family history of bleeding disorder. She does have a sister with a current ear infection. There is a family history of cancer, diabetes, heart disease, and hypertension. CURRENT MEDICATIONS: None. ALLERGIES: She has no known drug allergies. SOCIAL HISTORY: The patient is single. She is a student. Denies tobacco or alcohol use. PHYSICAL EXAMINATION: VITAL SIGNS: Pulse is 80 and regular, temperature 98.4, weight is 184 pounds. GENERAL: The patient is an alert, cooperative, obese, 15-year-old female, with a normal-sounding voice and good memory.HEAD & FACE: Inspected with no scars, lesions or masses noted. Sinuses palpated and are normal. Salivary glands also palpated and are normal with no masses noted. The patient also has full facial function. CARDIOVASCULAR: Heart regular rate and rhythm without murmur. RESPIRATORY: Lungs auscultated and noted to be clear to auscultation bilaterally with no wheezing or rubs and normal respiratory effort. EYES: Extraocular muscles were tested and within normal limits. EARS: The external ears are normal. The ear canals are clean and dry. The drums are intact and mobile. Hearing is grossly normal. Tuning fork examination with normal speech reception thresholds noted. NASAL: She has clear drainage, large inferior turbinates, no erythema. ORAL: Her tongue, lip, floor of mouth are noted to be normal. Oropharynx does reveal very large tonsils measuring 3+/4+; they were exophytic. Mirror examination of the larynx reveals some mild edema of the larynx at this time. The nasopharynx could not be visualized on mirror exam today. NECK: Obese, supple. Trachea is midline. Thyroid is nonpalpable. NEUROLOGIC: Cranial nerves II through XII evaluated and noted to be normal. Patient oriented times 3. DERMATOLOGIC: Evaluation reveals no masses or lesions. Skin turgor is normal. IMPRESSION: 1. Chronic adenotonsillitis with adenotonsillar hypertrophy.2. Upper respiratory tract infection with mild acute laryngitis.3. Obesity. RECOMMENDATIONS: We are going to go ahead and proceed with an adenotonsillectomy. All risks, benefits, and alternatives regarding the surgery have been reviewed in detail with the patient and her family. This includes risk of bleeding, infection, scarring, regrowth of the adenotonsillar tissue, need for further surgery, persistent sore throat, voice changes, etc. The parents are agreeable to the planned procedure, and we will schedule this accordingly at Memorial Medical Center here within the next few weeks. We will make further recommendations afterwards." "128",128,"History and Physical","HISTORY OF PRESENT ILLNESS: Ms. ABC is a 34-year-old gravida 2 para 1-0-0-1 at unknown gestational age who presents to the ED after a suicide attempt. The patient states that she took 28 Ambien and 4 tramadol pills on her way to the hospital in attempt to commit suicide. She states that she and her daughter's father had been in an argument over the state of their relationship. She states that she first threatened to shoot herself. However, he took the gun away from her. Then, she attempted to cut her wrist with a knife. However, he also got the weapon away from her. She states that in the car, on the way to the hospital for evaluation, that she took the remainder of her Ambien and tramadol tablets.The patient states that she has abnormal menstrual periods and cannot remember the first day of her last normal menstrual period. She states that she had spotting for three months daily until approximately two weeks ago, when she believes that she passed a fetus. She states that upon removal of a tampon, she saw a tadpole like structure and believed it to be a fetus. However, she states she did not know that she was pregnant at this time. She denies any abdominal pain or vaginal bleeding. She states that the pregnancy is unplanned; however, she would desire to continue the pregnancy. PAST MEDICAL HISTORY: Diabetes mellitus which resolved after weight loss associated with gastric bypass surgery. PAST SURGICAL HISTORY:1. Gastric bypass.2. Bilateral carpal tunnel release.3. Laparoscopic cholecystectomy.4. Hernia repair after gastric bypass surgery.5. Thoracotomy.6. Knee surgery. MEDICATIONS:1. Lexapro 10 mg daily.2. Tramadol 50 mg tablets two by mouth four times a day.3. Ambien 10 mg tablets one by mouth at bedtime. ALLERGIES: AMOXICILLIN CAUSES THROAT SWELLING. AVELOX CAUSES IV SITE SWELLING. SOCIAL HISTORY: The patient denies tobacco, ethanol, or drug use. She is currently separated from her partner who is the father of her 21-month-old daughter. She currently lives with her parents in Greenville. However, she was visiting the estranged boyfriend in Wilkesboro, this week. GYN HISTORY: The patient denies history of abnormal Pap smears or STDs. OBSTETRICAL HISTORY: Gravida 1 was a term spontaneous vaginal delivery, complicated only by increased blood pressures at the time of delivery. Gravida 2 is current. REVIEW OF SYSTEMS: The 14-point review of systems was negative with the exception as noted in the HPI. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 134/45, pulse 130, respirations 28. Oxygen saturation 100%. GENERAL: Patient lying quietly on a stretcher. No acute distress. HEENT: Normocephalic, atraumatic. Slightly dry mucous membranes. CARDIOVASCULAR EXAM: Regular rate and rhythm with tachycardia. CHEST: Clear to auscultation bilaterally. ABDOMEN: Soft, nontender, nondistended with positive bowel sounds. No rebound or guarding. SKIN: Normal turgor. No jaundice. No rashes noted. EXTREMITIES: No clubbing, cyanosis, or edema. NEUROLOGIC: Cranial nerves II through XII grossly intact. PSYCHIATRIC: Flat affect. Normal verbal response. ASSESSMENT AND PLAN: A 34-year-old Caucasian female, gravida 2 para 1-0-0-1, at unknown gestation who presents after suicide attempt.1. Given the substances taken, medications are unlikely to affect the development of the fetus. There have been no reported human anomalies associated with Ambien or tramadol use. There is, however, a 4% risk of congenital anomalies in the general population.2. Recommend quantitative HCG and transvaginal ultrasound for pregnancy dating.3. Recommend prenatal vitamins.4. The patient to follow up as an outpatient for routine prenatal care." "129",129,"History and Physical","PROBLEM LIST:1. Type 1 diabetes mellitus, insulin pump.2. Hypertension.3. Hyperlipidemia. HISTORY OF PRESENT ILLNESS: The patient is a 39-year-old woman returns for followup management of type 1 diabetes mellitus. Her last visit was approximately 4 months ago. Since that time, the patient states her health had been good and her glycemic control had been good, however, within the past 2 weeks she had a pump malfunction, had to get a new pump and was not certain of her pump settings and has been having some difficulty with glycemic control over the past 2 weeks. She is not reporting any severe hypoglycemic events, but is having some difficulty with hyperglycemia both fasting and postprandial. She is not reporting polyuria, polydipsia or polyphagia. She is not exercising at this point and has a diet that is rather typical of woman with twins and a young single child as well. She is working on a full-time basis and so eats on the run a lot, probably eats more than she should and not making the best choices, little time for physical activity. She is keeping up with all her other appointments and has recently had a good eye examination. She had lab work done at her previous visit and this revealed persistent hyperlipidemic state with a LDL of 144. CURRENT MEDICATIONS:1. Zoloft 50 mg p.o. once daily.2. Lisinopril 40 mg once daily.3. Symlin 60 micrograms, not taking at this point.4. Folic acid 2 by mouth every day.5. NovoLog insulin via insulin pump about 90 units of insulin per day. REVIEW OF SYSTEMS: She denies fever, chills, sweats, nausea, vomiting, diarrhea, constipation, abdominal pain, chest pain, shortness of breath, difficulty breathing, dyspnea on exertion or change in exercise tolerance. She is not having painful urination or blood in the urine. She is not reporting polyuria, polydipsia or polyphagia. PHYSICAL EXAMINATION: GENERAL: Today showed a very pleasant, well-nourished woman, in no acute distress. VITAL SIGNS: Temperature not taken, pulse 98, respirations 20, blood pressure 148/89, and weight 91.19 kg. THORAX: Revealed lungs clear, PA and lateral without adventitious sounds. CARDIOVASCULAR: Demonstrated regular rate and rhythm. S1 and S2 without murmur. No S3, no S4 auscultated. ABDOMEN: Nontender. EXTREMITIES: Showed no clubbing, cyanosis or edema. SKIN: Intact and do not appear atrophic. Deep tendon reflexes were 2+/4 without a delayed relaxation phase. LABORATORY DATA: Dated 10/05/08 showed a total cholesterol of 223, triglyceride 140, HDL 54, and LDL 144. The hemoglobin A1c was 6.4 and the spot urine for microalbumin was 9.2 micrograms of protein, 1 mg of creatinine. Sodium 136, potassium 4.5, chloride 102, CO2 30 mEq, BUN 11 mg/dL, creatinine 0.6 mg, estimated GFR greater than 60, blood sugar 118, calcium 9.4, and her LFTs were unremarkable. TSH is 1.07 and free T4 is 0.81. ASSESSMENT AND PLAN:1. This is a return visit to the endocrine clinic for the patient, a 39-year-old woman with history as noted above. Plan today is to make adjustments to her pump based on a total daily dose of 90 units of insulin. Basal rate is as follows, 12 a.m. 1.5, 02:30 a.m. 1.75, and 6 a.m. 1.5. Her correction factor is 19. Her carb/insulin ratio is 6. Her active insulin time is 5 and her targets are at 12 a.m. 110 and 6 a.m. to midnight is 100. We made adjustments to her pump and the plan will be to see her back in approximately 2 months.2. Hyperlipidemia. The patient is not taking statin, therefore, we will prescribe Lipitor 20 mg one p.o. once daily. Have her watch for side effects from the medication and plan to do a fasting lipid panel and CMP approximately 8 weeks from now.3. We will get a hemoglobin A1c and spot urine for albumin in 8 weeks as well." "130",130,"History and Physical","HISTORY: The patient is a 52-year-old female with a past medical history of diet-controlled diabetes, diffuse arthritis, plantar fasciitis, and muscle cramps who presents with a few-month history of numbness in both big toes and up the lateral aspect of both calves. Symptoms worsened considerable about a month ago. This normally occurs after being on her feet for any length of time. She was started on amitriptyline and this has significantly improved her symptoms. She is almost asymptomatic at present. She dose complain of longstanding low back pain, but no pain that radiates from her back into her legs. She has had no associated weakness.On brief examination, straight leg raising is normal. The patient is obese. There is mild decreased vibration and light touch in distal lower extremities. Strength is full and symmetric. Deep tendon reflexes at the knees are 2+ and symmetric and absent at the ankles. NERVE CONDUCTION STUDIES: Bilateral sural sensory responses are absent. Bilateral superficial sensory responses are present, but mildly reduced. The right radial sensory response is normal. The right common peroneal and tibial motor responses are normal. Bilateral H-reflexes are absent. NEEDLE EMG: Needle EMG was performed on the right leg and lumbosacral paraspinal muscles and the left tibialis posterior using a concentric disposable needle. It revealed increased insertional activity in the right tibialis posterior muscle with signs of mild chronic denervation in bilateral peroneus longus muscles and the right tibialis posterior muscle. Lumbar paraspinals were attempted, but were too painful to get a good assessment. IMPRESSION: This electrical study is abnormal. It reveals the following:1. A very mild, purely sensory length-dependent peripheral neuropathy.2. Mild bilateral L5 nerve root irritation. There is no evidence of active radiculopathy.Based on the patient's history and exam, her new symptoms are consistent with mild bilateral L5 radiculopathies. Symptoms have almost completely resolved over the last month since starting Elavil. I would recommend MRI of the lumbosacral spine if symptoms return. With respect to the mild neuropathy, this is probably related to her mild glucose intolerance/early diabetes. However, I would recommend a workup for other causes to include the following: Fasting blood sugar, HbA1c, ESR, RPR, TSH, B12, serum protein electrophoresis and Lyme titer." "131",131,"History and Physical","CHIEF COMPLAINT: The patient is here for two-month followup. HISTORY OF PRESENT ILLNESS: The patient is a 55-year-old Caucasian female. She has hypertension. She has had no difficulties with chest pain. She has some shortness of breath only at walking up the stairs. She has occasional lightheadedness only if she bends over then stands up quickly. She has had no nausea, vomiting, or diarrhea. She does have severe osteoarthritis of the left knee and is likely going to undergo total knee replacement with Dr. XYZ in January of this coming year. The patient is wanting to lose weight before her surgery. She is concerned about possible coronary disease or stroke risk. She has not had any symptoms of cardiac disease other than some shortness of breath with exertion, which she states has been fairly stable. She has had fairly normal lipid panel, last being checked on 11/26/2003. Cholesterol was 194, triglycerides 118, HDL 41, and LDL 129. The patient is a nonsmoker. Her fasting glucose in November 2003 was within normal limits at 94. Her fasting insulin level was normal. Repeat nonfasting glucose was 109 on 06/22/2004. She does not have history of diabetes. She does not exercise regularly and is not able to because of knee pain. She also has had difficulties with low back pain. X-ray of the low back did show a mild compression fracture of L1. She has had no falls that would contribute to a compression fracture. She has had a normal DEXA scan on 11/07/2003 that does not really correlate with having a compression fracture of the lumbar spine; however, it is possible that arthritis could contribute to falsely high bone density reading on DEXA scan. She is wanting to consider treatment for prevention of further compression fractures and possible osteoporosis. CURRENT MEDICATIONS: Hydrochlorothiazide 12.5 mg a day, Prozac 20 mg a day, Vioxx 25 mg a day, vitamin C 250 mg daily, vitamin E three to four tablets daily, calcium with D 1500 mg daily, multivitamin daily, aspirin 81 mg daily, Monopril 40 mg daily, Celexa p.r.n. ALLERGIES: Bactrim, which causes nausea and vomiting, and adhesive tape. PAST MEDICAL HISTORY:1. Hypertension.2. Depression.3. Myofascitis of the feet.4. Severe osteoarthritis of the knee.5. Removal of the melanoma from the right thigh in 1984.6. Breast biopsy in January of 1997, which was benign.7. History of Holter monitor showing ectopic beat. Echocardiogram was normal. These were in 1998.8. Compression fracture of L1, unknown cause. She had had no injury. Interestingly, DEXA scan was normal 11/07/2003, which is somewhat conflicting. SOCIAL HISTORY: The patient is married. She is a nonsmoker and nondrinker. REVIEW OF SYSTEMS: As per the HPI. PHYSICAL EXAMINATION:General: This is a well-developed, well-nourished, pleasant Caucasian female, who is overweight.Vital signs: Weight: Refused. Blood pressure: 148/82, on recheck by myself with a large cuff, it was 125/60. Pulse: 64. Respirations: 20. Temperature: 96.3.Neck: Supple. Carotids are silent.Chest: Clear to auscultation.Cardiovascular: Revealed a regular rate and rhythm without murmur, S3, or S4.Extremities: Revealed no edema.Neurologic: Grossly intact. RADIOLOGY: EKG revealed normal sinus rhythm, rate 61, borderline first degree AV block, and poor R-wave progression in the anterior leads. ASSESSMENT:1. Hypertension, well controlled.2. Family history of cerebrovascular accident.3. Compression fracture of L1, mild.4. Osteoarthritis of the knee.5. Mildly abnormal chest x-ray. PLAN:1. We will get a C-reactive protein cardiac.2. We discussed weight loss options. I would recommend Weight Watchers or possibly having her see a dietician. She will think about these options. She is not able to exercise regularly right now because of knee pain.3. We would recommend a screening colonoscopy. She states that we discussed this in the past and she canceled her appointment to have that done. She will go ahead and make an appointment to see Dr. XYZ for screening colonoscopy.4. We will start Fosamax 70 mg once weekly. She is to take this in the morning on an empty stomach with full glass of water. She is not to eat, lie down, or take other medications for at least 30 minutes after taking Fosamax.5. I would like to see her back in one to two months. At that time, we can do preoperative evaluation and we will probably send her to a cardiologist because of mildly abnormal EKG for preoperative cardiac testing. One would also consider preoperative beta-blocker for cardiac protection." "132",132,"History and Physical","SUBJECTIVE: The patient is a 66-year-old female who presents to the clinic today for a five-month recheck on her type II diabetes mellitus, as well as hypertension. While here she had a couple of other issues as well. She stated that she has been having some right shoulder pain. She denies any injury but certain range of motion does cause it to hurt. No weakness, numbness or tingling. As far as her diabetes she states that she only checks her blood sugars in the morning and those have all been ranging less than 100. She has not been checking any two hours after meals. Her blood pressures when she does check them have been running normal as well but she does not have any record of these present with her. No other issues or concerns. Upon review of her chart it did show that she had a benign breast biopsy done back on 06/11/04 and was told to have a repeat mammogram in six months but she has never had that done so she is needing to have this done as well. ALLERGIES: None. MEDICATIONS: She is on Hyzaar 50/12.5 one-half p.o. daily, coated aspirin daily, lovastatin 40 mg one-half tab p.o. daily, multivitamin daily, metformin 500 mg one tab p.o. b.i.d.; however, she has been skipping her second dose during the day. SOCIAL HISTORY: She is a nonsmoker. REVIEW OF SYSTEMS: As noted above. OBJECTIVE:Vital Signs: Temperature: 98.2. Pulse: 64. Respirations: 16. Blood pressure: 110/56. Weight: 169.General: Alert and oriented x 3. No acute distress noted.Neck: No lymphadenopathy, thyromegaly, JVD or bruits.Lungs: Clear to auscultation.Heart: Regular rate and rhythm without murmur or gallops present.Breasts: Exam performed with a female nurse present. The breasts do have some scars present underneath them bilaterally from prior breast reduction surgery. There is no axillary adenopathy or tenderness. Breasts appear to be symmetric. There was no nipple discharge or retraction. No breast tissue retraction noted in either the sitting or the supine position. Upon palpation there were no palpable lumps or bumps and no palpable discharge.Musculoskeletal: She did have full range of motion of her shoulders. She did have tenderness upon palpation over the right bicipital tendon. There is no swelling, crepitus or discoloration noted. MEDICAL DECISION MAKING: Most recent hemoglobin A1c was 5.6% back in October 2004. Most recent lipid checks were obtained back in July 2004. We have not had this checked since that time. ASSESSMENT:1. Type II diabetes mellitus.2. Hypertension.3. Right shoulder pain.4. Hyperlipidemia. PLAN:1. She is going to go to lab to obtain a hemoglobin A1c, BMP, lipids, CPK, liver enzymes and quantitative microalbumin.2. We are going to set her up for a diagnostic bilateral mammogram due to a history of abnormal mammogram in the past which subsequently showed a benign breast cyst.3. I told her for her shoulder to take ibuprofen 600 mg three times daily with her meals for a minimum of the next one week.4. She is going to follow up in the clinic in three months for a complete comprehensive examination. If any questions, concerns or problems arise between now and then she should let us know." "133",133,"History and Physical","SUBJECTIVE: The patient states she is feeling a bit better. OBJECTIVE: VITAL SIGNS: Temperature is 95.4. Highest temperature recorded over the past 24 hours is 102.1. CHEST: Examination of the chest is clear to auscultation. CARDIOVASCULAR: First and second heart sounds were heard. No murmurs appreciated. ABDOMEN: Benign. Right renal angle is tender. Bowel sounds are positive. EXTREMITIES: There is no swelling. NEUROLOGIC: The patient is alert and oriented x3. Examination is nonfocal. LABORATORY DATA: White count is down from 35,000 to 15.5. Hemoglobin is 9.5, hematocrit is 30, and platelets are 269,000. BUN is down to 22, creatinine is within normal limits. ASSESSMENT AND PLAN:1. Sepsis due to urinary tract infection. Urine culture shows Escherichia coli, resistant to Levaquin. We changed to doripenem.2. Urinary tract infection, we will treat with doripenem, change Foley catheter3. Hypotension. Resolved, continue intravenous fluids.4. Ischemic cardiomyopathy. No evidence of decompensation, we with monitor.5. Diabetes type 2. Uncontrolled. Continue insulin sliding scale.6. Recent pulmonary embolism, INR is above therapeutic range, Coumadin is on hold, we will monitor.7. History of coronary artery disease. Troponin indeterminate. Cardiologist intends no further workup. Continue medical treatment. Most likely troponin is secondary to impaired clearance." "134",134,"History and Physical","CHIEF COMPLAINT: Non-healing surgical wound to the left posterior thigh. HISTORY OF PRESENT ILLNESS: This is a 49-year-old white male who sustained a traumatic injury to his left posterior thighthis past year while in ABCD. He sustained an injury from the patellar from a boat while in the water. He was air lifted actually up to XYZ Hospital and underwent extensive surgery. He still has an external fixation on it for the healing fractures in the leg and has undergone grafting and full thickness skin grafting closure to a large defect in his left posterior thigh, which is nearly healed right in the gluteal fold on that left area. In several areas right along the graft site and low in the leg, the patient has several areas of hypergranulation tissue. He has some drainage from these areas. There are no signs and symptoms of infection. He is referred to us to help him get those areas under control. PAST MEDICAL HISTORY: Essentially negative other than he has had C. difficile in the recent past. ALLERGIES: None. MEDICATIONS: Include Cipro and Flagyl. PAST SURGICAL HISTORY: Significant for his trauma surgery noted above. FAMILY HISTORY: His maternal grandmother had pancreatic cancer. Father had prostate cancer. There is heart disease in the father and diabetes in the father. SOCIAL HISTORY: He is a non-cigarette smoker and non-ETOH user. He is divorced. He has three children. He has an attorney. REVIEW OF SYSTEMS: CARDIAC: He denies any chest pain or shortness of breath. GI: As noted above. GU: As noted above. ENDOCRINE: He denies any bleeding disorders. PHYSICAL EXAMINATION: GENERAL: He presents as a well-developed, well-nourished 49-year-old white male who appears to be in no significant distress. HEENT: Unremarkable. NECK: Supple. There is no mass, adenopathy, or bruit. CHEST: Normal excursion. LUNGS: Clear to auscultation and percussion. COR: Regular. There is no S3, S4, or gallop. There is no murmur. ABDOMEN: Soft. It is nontender. There is no mass or organomegaly. GU: Unremarkable. RECTAL: Deferred. EXTREMITIES: His right lower extremity is unremarkable. Peripheral pulse is good. His left lower extremity is significant for the split thickness skin graft closure of a large defect in the posterior thigh, which is nearly healed. The open areas that are noted above __________ hypergranulation tissue both on his gluteal folds on the left side. There is one small area right essentially within the graft site, and there is one small area down lower on the calf area. The patient has an external fixation on that comes out laterally on his left thigh. Those pin sites look clean. NEUROLOGIC: Without focal deficits. The patient is alert and oriented. IMPRESSION: Several multiple areas of hypergranulation tissue on the left posterior leg associated with a sense of trauma to his right posterior leg. PLAN: Plan would be for chemical cauterization of these areas. Series of treatment with chemical cauterization till these are closed." "135",135,"History and Physical","MM/DD/YYYYXYZ, O.D. RE: ABCDOB: MM/DD/YYYYDear XYZ:Thank you very much for your kind referral of Mrs. ABC who you referred to me for narrow angles and possible associated glaucoma. I examined Mrs. ABC initially on MM/DD/YYYY. At that time, she expressed a chief concern of occasional pain around her eye, but denied any flashing lights, floaters, halos, or true brow ache. She reports a family history of glaucoma in her mother, but is unsure of the specific kind. Her past ocular history has been fairly unremarkable. As you know, she has a history of non-insulin dependent diabetes. She is unaware of her last hemoglobin A1c levels, but reports a blood sugar of 158 taken on the morning of her appointment with me. She is followed by Dr. X here locally.Upon examination, her visual acuity measured 20/20-1 in either eye with her glasses. Presenting intraocular pressures were14 mmHg in either eye at 2:03 p.m. Pupillary reactions, confrontational visual fields, and ocular motility were normal. The slit lamp exam revealed narrow anterior chambers and on gonioscopy only the buried anterior trabecular meshwork was visible in either eye, but the angle deepened with gonio-compression suggesting appositional and not synechial closure. I deferred the dilated portion of the exam on that day.We proceeded with peripheral iridectomies and following this upon her most recent visit on MM/DD/YYYY, I was able to safely dilate her eyes as her chambers had deepened and the PIs were patent. I note that she has an increased CD ratio measuring 0.65 in the right eye and 0.7 in the left and although her FDT visual fields and GDX testing were normal at your office, she does have an enlarged blind spot in either eye on Humphrey visual fields and retinal tomography also shows some suspicious changes. Therefore, I feel she has sustained some optic nerve damage perhaps from under controlling her diabetes. In summary, Mrs. ABC has a history of narrow angles not successfully treated with laser PIs. Her intraocular pressures have remained stable. I will continue to monitor her closely.Thank you very much once again for allowing me to have shared in her care. If I can provide any additional information or be of further service, do let me know.Sincerely," "136",136,"History and Physical","MM/DD/YYYYXYZ, M.D. RE: ABCDOB: MM/DD/YYYYDear Dr. XYZ:Thank you for your kind referral for patient ABC. The patient is being referred for evaluation of diabetic retinopathy. The patient was just diagnosed with diabetes; however, he does not have any serious visual complaints at this time.On examination, the patient is seeing 20/40 OD pinholing to 20/20. The vision in the left eye is 20/20 uncorrected. Applanation pressures are normal at 17 mmHg bilaterally. Visual fields are full to count fingers OU and there is no relative afferent pupillary defect. Slit lamp examination was within normal limits, other than trace to 1+ nuclear sclerosis OU. On dilated examination, the patient shows a normal cup-to-disc ratio that is symmetric bilaterally. The macula, vessels, and periphery are also within normal limits.In conclusion, Mr. ABC does not show any evidence of diabetic retinopathy at this time. We recommended him to have his eyes dilated once a year. I have advised him to follow up with you for his regular check-ups. Again, thank you for your kind referral of Mr. ABC and we should check on him once a year at this time.Sincerely," "137",137,"History and Physical","Thank you very much for referring Mr. Y for pulmonary evaluation. As you know, he is an 85-year-old man who has been referred for complaints of significant coughing and wheezing. The patient was originally seen on 15/02/2008. At that time he was complaining of the same symptoms as well as a recent CBA. The patient had a respiratory evaluation six months ago that was reported to be okay but he still complains of still some difficulty at the time of swallowing. His followup today was done after the patient underwent initial swallowing evaluation. He is still complaining of cough, wheezing, and congestion. PAST MEDICAL HISTORY: Unremarkable, except for diabetes and atherosclerotic vascular disease. ALLERGIES: PENICILLIN. CURRENT MEDICATIONS: Include Glucovance, Seroquel, Flomax, and Nexium. PAST SURGICAL HISTORY: Appendectomy and exploratory laparotomy. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: The patient is a non-smoker. No alcohol abuse. The patient is married with no children. REVIEW OF SYSTEMS: Significant for an old CVA. PHYSICAL EXAMINATION: The patient is an elderly male alert and cooperative. Blood pressure 96/60 mmHg. Respirations were 20. Pulse 94. Afebrile. O2 was 94% on room air. HEENT: Normocephalic and atraumatic. Pupils are reactive. Oral mucosa is grossly normal. Neck is supple. Lungs: Decreased breath sounds. Disturbed breath sounds with poor exchange. Heart: Regular rhythm. Abdomen: Soft and nontender. No organomegaly or masses. Extremities: No cyanosis, clubbing, or edema. LABORATORY DATA: Oropharyngeal evaluation done on 11/02/2006 revealed mild oropharyngeal dysphagia with no evidence of laryngeal penetration or aspiration with food or liquid. Slight reduction in tongue retraction resulting in mild residual remaining in the palatal sinuses, which clear with liquid swallow and double-saliva swallow. ASSESSMENT:1. Cough probably multifactorial combination of gastroesophageal reflux and recurrent aspiration.2. Old CVA with left hemiparesis.3. Oropharyngeal dysphagia.4. Diabetes. PLAN: At the present time, the patient is recommended to continue on a regular diet, continue speech pathology evaluation as well as perform double-swallow during meals with bolus sensation. He may use Italian lemon ice during meals to help clear sinuses as well. The patient will follow up with you. If you need any further assistance, do not hesitate to call me." "138",138,"History and Physical","SUBJECTIVE: This patient presents to the office today because of some problems with her right hand. It has been going tingling and getting numb periodically over several weeks. She just recently moved her keyboard down at work. She is hoping that will help. She is worried about carpal tunnel. She does a lot of repetitive type activities. It is worse at night. If she sleeps on it a certain way, she will wake up and it will be tingling then she can usually shake out the tingling, but nonetheless it is very bothersome for her. It involves mostly the middle finger, although, she says it also involves the first and second digits on the right hand. She has some pain in her thumb as well. She thinks that could be arthritis. OBJECTIVE: Weight 213.2 pounds, blood pressure 142/84, pulse 92, respirations 16. General: The patient is nontoxic and in no acute distress. Musculoskeletal: The right hand was examined. It appears to be within normal limits and the appearance is similar to the left hand. She has good and equal grip strength noted bilaterally. She has negative Tinel's bilaterally. She has a positive Phalen's test. The fingers on the right hand are neurovascularly intact with a normal capillary refill. ASSESSMENT: Numbness and tingling in the right upper extremity, intermittent and related to the positioning of the wrist. I suspect carpal tunnel syndrome. PLAN: The patient is going to use Anaprox double strength one pill every 12 hours with food as well as a cock-up wrist splint. We are going to try this for two weeks and if the condition is still present, then we are going to proceed with EMG test at that time. She is going to let me know. While she is here, I am going to also get her the blood test she needs for her diabetes. I am noting that her blood pressure is elevated, but improved from the last visit. I also noticed that she has lost a lot of weight. She is working on diet and exercise and she is doing a great job. Right now for the blood pressure we are going to continue to observe as she carries forward additional measures in her diet and exercise to lose more weight and I expect the blood pressure will continue to improve." "139",139,"Operative Note","PROCEDURE PERFORMED:1. Left heart catheterization with coronary angiography, vein graft angiography and left ventricular pressure measurement and angiography.2. Right femoral selective angiogram.3. Closure device the seal the femoral arteriotomy using an Angio-Seal. INDICATIONS FOR PROCEDURE: The patient with known coronary atherosclerotic heart disease and multiple risk factors of coronary disease, who had her last coronary arteriogram performed in 2004. She has had complaints of progressive chest discomfort, and has ongoing risks including current smoking, diabetes, hypertension, hyperlipidemia to name a few. The decision was made to proceed on with percutaneous evaluation and possible intervention given her known disease and the possibility of disease progression. DESCRIPTION OF PROCEDURE: After informed consent was obtained, The patient was taken to cardiac catheterization lab where her procedure was performed. She was prepped and prepared on the table; after which, her right groin was locally anesthetized with 1% lidocaine. Then, a 6-French sheath was inserted into the right femoral artery over a standard 0.035 guide wire. Coronary angiography and left ventricular measurement and angiography were performed using a 6-French JL4 diagnostic catheter to image the left coronary artery. A 6-French JR4 diagnostic catheter to image the right groin and her artery and the saphenous vein graft conduit. Subsequently, a 6-French angled pigtail catheter was used to measure left ventricular pressures and to perform a power injection, a left ventriculogram at 8 mL per second for a total of 30 mL. At the conclusion of the diagnostic evaluation, the patient had selective arteriography of her right femoral artery, which showed the right femoral artery to be free of significant atherosclerotic plaque. Did have a normal bifurcation into the superficial femoral and profunda femoris arteries and to have an arteriotomy that was in the common femoral artery away from the bifurcation. As such, an initial attempt to advance a Perclose device failed to allow the device descend to _____ tract and into the appropriate position within the artery. As such, the Perclose was never deployed and was removed intact over the wire from the system. We then replaced this with a 6-French Angio-Seal which was used to seal the femoral arteriotomy with achievement of hemostasis. The patient was subsequently dispositioned back to the MAC Unit where she will complete her bedrest prior to her disposition to home. HEMODYNAMIC DATA: Opening aortic pressure 125/60, left ventricular pressure 108/4 with an end-diastolic pressure of 16. There was no significant gradient across the aortic valve on pullback from the left ventricle. Left ventricular ejection fraction was 55%. Mitral regurgitation was less than or equal to 1+. There was normal wall motion in the RAO projection. CORONARY ANGIOGRAM: The left main coronary artery had mild atherosclerotic plaque. The proximal LAD was 100% occluded. The left circumflex had mild diffuse atherosclerotic plaque. The obtuse marginal branch which operates as an OM-2 had a mid approximately 80% stenosis at a kink in the artery. This appears to be the area of a prior anastomosis, the saphenous vein graft to the OM. This is a very small-caliber vessel and is 1.5-mm in diameter at best. The right coronary artery is dominant. The native right coronary artery had mild proximal and mid atherosclerotic plaque. The distal right coronary artery has an approximate 40% stenosis. The posterior left ventricular branch has a proximal 50 to 60% stenosis. The proximal PDA has a 40 to 50% stenosis. The saphenous vein graft to the right PDA is widely patent. There was competitive flow noted between the native right coronary artery and the saphenous vein graft to the PDA. The runoff from the PDA is nice with the native proximal PDA and PLV disease as noted above. There is also some retrograde filling of the right coronary artery from the runoff of this graft. The saphenous vein graft to the left anterior descending is widely patent. The LAD beyond the distal anastomosis is a relatively small-caliber vessel. There is some retrograde filling that allows some filling into a more proximal diagonal branch. The saphenous vein graft to the obtuse marginal was known to be occluded from the prior study in 2004. Overall, this study does not look markedly different than the procedure performed in 2004. CONCLUSION: 100% proximal LAD mild left circumflex disease with an OM that is a small-caliber vessel with an 80% lesion at a kink that is no amenable to percutaneous intervention. The native right coronary artery has mild to moderate distal disease with moderate PLV and PDA disease. The saphenous vein graft to the OM is known to be 100% occluded. The saphenous vein graft to the PDA and the saphenous vein graft to the LAD are open. Normal left ventricular systolic function. PLAN: The plan will be for continued medical therapy and risk factor modification. Aggressive antihyperlipidemic and antihypertensive control. The patient's goal LDL will be at or below 70 with triglyceride level at or below 150, and it is very imperative that the patient stop smoking.After her bedrest is complete, she will be dispositioned to home, after which, she will be following up with me in the office within 1 month. We will also plan to perform a carotid duplex Doppler ultrasound to evaluate her carotid bruits." "140",140,"History and Physical","HISTORY OF PRESENT ILLNESS: This 66-year-old white male was seen in my office on Month DD, YYYY. Patient was recently discharged from Doctors Hospital at Parkway after he was treated for pneumonia. Patient continues to have severe orthopnea, paroxysmal nocturnal dyspnea, cough with greenish expectoration. His exercise tolerance is about two to three yards for shortness of breath. The patient stopped taking Coumadin for reasons not very clear to him. He was documented to have recent atrial fibrillation. Patient has longstanding history of ischemic heart disease, end-stage LV systolic dysfunction, and is status post ICD implantation. Fasting blood sugar this morning is 130. PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure is 120/60. Respirations 18 per minute. Heart rate 75-85 beats per minute, irregular. Weight 207 pounds. HEENT: Head normocephalic. Eyes, no evidence of anemia or jaundice. Oral hygiene is good. NECK: Supple. JVP is flat. Carotid upstroke is good. LUNGS: Severe inspiratory and expiratory wheezing heard throughout the lung fields. Fine crepitations heard at the base of the lungs on both sides. CARDIOVASCULAR: PMI felt in fifth left intercostal space 0.5-inch lateral to midclavicular line. First and second heart sounds are normal in character. There is a II/VI systolic murmur best heard at the apex. ABDOMEN: Soft. There is no hepatosplenomegaly. EXTREMITIES: Patient has 1+ pedal edema. MEDICATIONS: 1. Ambien 10 mg at bedtime p.r.n.2. Coumadin 7.5 mg daily.3. Diovan 320 mg daily.4. Lantus insulin 50 units in the morning.5. Lasix 80 mg daily.6. Novolin R p.r.n.7. Toprol XL 100 mg daily.8. Flovent 100 mcg twice a day. DIAGNOSES:1. Atherosclerotic coronary vascular disease with old myocardial infarction.2. Moderate to severe LV systolic dysfunction.3. Diabetes mellitus.4. Diabetic nephropathy and renal failure.5. Status post ICD implantation.6. New onset of atrial fibrillation.7. Chronic Coumadin therapy. PLAN:1. Continue present therapy.2. Patient will be seen again in my office in four weeks." "141",141,"History and Physical","REASON FOR VISIT: This is a routine return appointment for this 71-year-old woman with chronic atrial fibrillation. Her chief complaint today is shortness of breath. HISTORY OF PRESENT ILLNESS: I last saw her in 09/2008. Since then, she has been admitted to ABCD Hospital from 11/05/2008 through 11/08/2008 for a near syncopal episode. She was found to have a fast heart rate in the atrial fibrillation. She was also found to be in heart failure and so they diuresed her. They wanted to send her home on furosemide 40 mg daily, but unfortunately they never gave her a prescription for this and so she now is not on any furosemide and since being discharged she has regained fluid to no one's great surprise. My plan advent is to control her heart rate. This has been a bit difficult with her retaining fluid. We will try again to diurese her as an outpatient and go forward from there with rate control and anticoagulation. She may need to have a pacemaker placed and her AV node ablated if this does not work.She notes the shortness of breath and wheezing at nights. I think these are manifestations of heart failure. She has peripheral edema. She is short of breath when she tries to walk a city block. I believe she takes her medications as directed, but I am never sure she actually is taking them correctly. In any case, she did not bring her medications with her today.Today, she had an ECG which shows atrial fibrillation with a ventricular response of 117 beats per minute. There is a nonspecific IVCD. This is unchanged from her last visit except that her heart rate is faster. In addition, I reviewed her echocardiogram done at XYZ. Her ejection fraction is 50% and she has paradoxical septal motion. Her right ventricular systolic pressure is normal. There are no significant valvular abnormalities. MEDICATIONS: 1. Fosamax - 70 mg weekly.2. Lisinopril - 20 mg daily.3. Metformin - 850 mg daily.4. Amlodipine - 5 mg daily.5. Metoprolol - 150 mg twice daily.6. Warfarin - 5 mg daily.7. Furosemide - none.8. Potassium - none.9. Magnesium oxide - 200 mg daily. ALLERGIES: Denied. MAJOR FINDINGS: On my comprehensive cardiovascular examination, she again looks the same which is in heart failure. Her blood pressure today was 130/60 and her pulse 116 blood pressure and regular. She is 5 feet 11 inches and her weight is 167 pounds, which is up from 158 pounds from when I saw her last visit. She is breathing 1two times per minute and it is unlabored. Eyelids are normal. She has vitiligo. Pupils are round and reactive to light. Conjunctivae are clear and sclerae are anicteric. There is no oral thrush or central cyanosis. She has marked keloid formation on both sides of her neck, the left being worse than the right. The jugular venous pressure is elevated. Carotids are brisk are without bruits. Lungs are clear to auscultation and percussion. The precordium is quiet. The rhythm is irregularly irregular. She has a variable first and second heart sounds. No murmurs today. Abdomen is soft without hepatosplenomegaly or masses, although she does have hepatojugular reflux. She has no clubbing or cyanosis, but does have 1+ peripheral edema. Distal pulses are good. On neurological examination, her mentation is normal. Her mood and affect are normal. She is oriented to person, place, and time. ASSESSMENTS: She has chronic atrial fibrillation and heart failure now. PROBLEMS DIAGNOSES: 1. Chronic atrial fibrillation, anticoagulated and the plan is rate control.2. Heart failure and she needs more diuretic.3. High blood pressure controlled.4. Hyperlipidemia.5. Diabetes mellitus type 2.6. Nonspecific intraventricular conduction delay.7. History of alcohol abuse.8. Osteoporosis.9. Normal left ventricular function. PROCEDURES AND IMMUNIZATIONS: None today. PLANS: I have restarted her Lasix at 80 mg daily and I have asked her to return in about 10 days to the heart failure clinic. There, I would like them to recheck her heart rate and if still elevated, and she is truly on 150 mg of metoprolol twice a day, one could switch her amlodipine from 5 mg daily to diltiazem 120 mg daily. If this does not work, in terms of controlling her heart rate, then she will need to have a pacemaker and her AV node ablated.Thank you for asking me to participate in her care. MEDICATION CHANGES: See the above."