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117,0,"CHIEF COMPLAINT: , Nausea and feeling faint.,HPI:  ,The patient is a 74-year-old white female brought in by husband.  The patient is a vague historian at times.  She reports her appetite has been fair over the last several days.  Today, she complains of some nausea.  She feels weak.  No other specific complaints.,REVIEW OF SYSTEMS:  ,The patient denies fever, chills, sweats, ear pain, URI symptoms, cough, dyspnea, chest pain, vomiting, diarrhea, abdominal pain, melena, hematochezia, urinary symptoms, headache, neck pain, back pain, weakness or paresthesias in extremities.,CURRENT MEDICATIONS:  ,Diovan, estradiol, Norvasc, Wellbutrin SR inhaler, and home O2.,ALLERGIES: , MORPHINE CAUSES VOMITING.,PAST MEDICAL HISTORY:  ,COPD and hypertension.,HABITS:  ,Tobacco use, averages two cigarettes per day.  Alcohol use, denies.,LAST TETANUS IMMUNIZATION: , Not sure.,LAST MENSTRUAL PERIOD: , Status post hysterectomy.,SOCIAL HISTORY:  ,The patient is married and retired.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Temperature 98.2, pulse is 105, respirations 20, and BP 137/80.  GENERAL:  A well developed, well nourished, alert, cooperative, nontoxic, and appears hydrated.  SKIN:  Warm, dry, and good color.  EYES:  EOMI.  PERRL.  MOUTH:  Clear.  Mucous membranes moist.  NECK:  Supple.  No JVD.  LUNGS:  Reveal faint expiratory wheeze heard in the posterior lung fields.  HEART:  Slightly tachycardic without murmur.  ABDOMEN:  Soft, positive bowel sounds, and nontender.  No rebound or guarding is appreciated.  BACK:  No CVA tenderness.  EXTREMITIES:  Moves all four extremities.  No pretibial edema.  NEURO:  Cranial nerves II to XII, motor, and cerebellar are grossly intact and nonfocal.,LABORATORY STUDIES: , WBC 9200, differential with 82 neutrophils, 8 lymphocytes, 6 monocytes, and 4 eosinophils.  Hemoglobin 10.7 and hematocrit 31.2 both are decreased.  Comprehensive medical profile normal except for decreased sodium of 129, decreased chloride of 92, calcium decreased 8.4, total protein decreased 6.1, and albumin decreased 3.2.  Amylase and lipase both normal.  Clean catch urinalysis is unremarkable.  Review of EMR indicates on 05/09/06 hemoglobin was 12.1, on 05/10/07 hemoglobin was 9.9, and today hemoglobin is 10.7.  It seems to indicate that the patient had previous problems with anemia.,RADIOLOGY STUDIES: , Chest x-ray indicates chronic changes, reviewed by me, official report is pending.,ED STUDIES: , O2 sat on room air is 92%, which is satisfactory for this patient with COPD.  Monitor indicates sinus tachycardia at rate 103.  No ectopy.,ED COURSE:  ,The patient was assessed for orthostatic vital sign changes and none were detected by the nurse.  The patient was given albuterol unit dose small volume nebulizer treatment.  Repeat lung exam reveals resolution of expiratory wheezing.  The patient later had normal saline lock started by the nurse.  She was given IV fluids of normal saline 1L wide open over approximately one hour.  She was able to void urine indicating that she is well hydrated.  Rectal examination was performed with female nurse in attendance.  Good sphincter tone.  No masses.  The rectal secretions were heme negative.  The patient was reassessed.  She feels slightly better.  Monitor now shows normal sinus rhythm, rate 81, no ectopy.  Blood pressure is 136/66.  The patient is stable and will be discharged.,MEDICAL DECISION MAKING: , This patient presents with the above history.  Laboratory evaluation today indicates the following problems, anemia and hyponatremia.  This could contribute the patient's feelings of tiredness and not feeling well.  There is no evidence of rectal bleeding at this time.  The patient was advised that she needs to follow up with Dr. X to further investigate these problems.  The patient is hemodynamically stable and will be discharged.,ASSESSMENT:,1.  Acute tiredness.,2.  Anemia of unknown etiology.,3.  Acute hyponatremia.,PLAN:  ,The patient is advised to put salt on her food for the next week.  Should be given discharge instruction sheet for anemia.  Recommend follow up with personal physician, Dr. X in two to three days for recheck.  Return to ED sooner if condition changes or worsen anyway.  Discharged in stable condition."
52,1,"DIAGNOSIS:  ,Shortness of breath.  Fatigue and weakness.  Hypertension.  Hyperlipidemia.,INDICATION: , To evaluate for coronary artery disease.,"
195,1,"GENERAL EVALUATION: ,(Twin A),Fetal Cardiac Activity: Normal at 166 BPM,Fetal Lie: Twin A lies to the maternal left.,Fetal Presentation: Cephalic,Placenta: Posterior fused placenta Grade I-II,Uterus: Normal,Cervix: Closed,Adnexa: Not seen,Amniotic Fluid: There is a single 3.9cm anterior pocket.,BIOMETRY:,BPD: 8.7cm consistent with 35 weeks, 1 day,HC: 30.3cm consistent with 33 weeks, 5 days.,AC: 28.2cm consistent with 32 weeks, 1 day,FL:"
169,1,"REASON FOR EXAM: , Aortic valve replacement.  Assessment of stenotic valve.  Evaluation for thrombus on the valve.,PREOPERATIVE DIAGNOSIS:  ,Atrial valve replacement.,POSTOPERATIVE DIAGNOSES:,  Moderate stenosis of aortic valve replacement.  Mild mitral regurgitation.  Normal left ventricular function.,PROCEDURES IN DETAIL: , The procedure was explained to the patient with risks and benefits.  The patient agreed and signed the consent form.  The patient received a total of 3 mg of Versed and 50 mcg of fentanyl for conscious sedation and pain control.  The oropharynx anesthetized with benzocaine spray and lidocaine solution.,Esophageal intubation was done with no difficulty with the second attempt.  In a semi-Fowler position, the probe was passed to transthoracic views at about 40 to 42 cm.  Multiple pictures obtained.  Assessment of the peak velocity was done later.,The probe was pulled to the mid esophageal level.  Different pictures including short-axis views of the aortic valve was done.  Extubation done with no problems and no blood on the probe.  The patient tolerated the procedure well with no immediate postprocedure complications.,INTERPRETATION: , The left atrium was mildly dilated.  No masses or thrombi were seen.  The left atrial appendage was free of thrombus.  Pulse wave interrogation showed peak velocities of 60 cm per second.,The left ventricle was normal in size and contractility with mild LVH.  EF is normal and preserved.,The right atrium and right ventricle were both normal in size.,Mitral valve showed no vegetations or prolapse.  There was mild-to-moderate regurgitation on color flow interrogation.  Aortic valve was well-seated mechanical valve, bileaflet with acoustic shadowing beyond the valve noticed.  No perivalvular leak was noticed.  There was increased velocity across the valve with peak velocity of 3.2 m/sec with calculated aortic valve area by continuity equation at 1.2 cm2 indicative of moderate aortic valve stenosis based on criteria for native heart valves.,No AIC.,Pulmonic valve was somewhat difficult to see because of acoustic shadowing from the aortic valve.  Overall showed no abnormalities.  The tricuspid valve was structurally normal.,Interatrial septum appeared to be intact, confirmed by color flow interrogation as well as agitated saline contrast study.,The aorta and aortic arch were unremarkable.  No dissection.,IMPRESSION:,1.  Mildly dilated left atrium.,2.  Mild-to-moderate regurgitation.,3.  Well-seated mechanical aortic valve with peak velocity of 3.2 m/sec and calculated valve area of 1.2 cm2 consistent with moderate aortic stenosis.  Reevaluation in two to three years with transthoracic echocardiogram will be recommended."
198,1,"EXAM: , Single frontal view of the chest.,HISTORY: , Atelectasis.  Patient is status-post surgical correction for ASD.,TECHNIQUE: , A single frontal view of the chest was evaluated and correlated with the prior film dated mm/dd/yy.,FINDINGS:,  Current film reveals there is a right-sided central venous catheter, the distal tip appears to be in the superior vena cava.  Endotracheal tube with the distal tip appears to be in appropriate position, approximately 2 cm superior to the carina.  Sternotomy wires are noted.  They appear in appropriate placement.  There are no focal areas of consolidation to suggest pneumonia.  Once again seen is minimal amount of bilateral basilar atelectasis.  The cardiomediastinal silhouette appears to be within normal limits at this time.  No evidence of any pneumothoraces or pleural effusions.,IMPRESSION:,1.  There has been interval placement of a right-sided central venous catheter, endotracheal tube, and sternotomy wires secondary to patient's most recent surgical intervention.,2.  Minimal bilateral basilar atelectasis with no significant interval changes from the patient's most recent prior.,3.  Interval decrease in the patient's heart size which may be secondary to the surgery versus positional and technique."
184,1,"EXAM:,  CT of the facial bones without contrast.,REASON FOR EXAM:,  Hit in nose.,COMPARISON EXAM: , Plain films of the same date.,TECHNIQUE: , Multidetector helicoaxial images were acquired in the axial plane and were reconstructed in bone and soft tissue algorithms for viewing in multiplanar format.,FINDINGS: , There is a fracture of the frontal process of the maxilla on both sides with displacement with angulation to the right and very minimal displacement of the distal fragments.  In addition, there is slight comminution of the right nasal bone without displacement.  The bony portion of the nasal septum is intact, although it is bowed to the left.  Soft tissue swelling is seen overlying the left side of the nose.  There is no nasoseptal hematoma.  Moderate mucosal thickening is seen in both maxillary sinuses.  The right maxillary sinus is hypoplastic.  Moderate mucosal thickening is seen in the left ethmoid sinus and marked mucosal thickening in the left sphenoid sinus.  The right sphenoid sinus is hypoplastic.  No abnormality of the orbits is seen.  The imaged portions of the brain are unremarkable.,IMPRESSION:,1.  Bilateral fractures of the frontal process of the maxilla and with displacement to the right.,2.  The findings were reported to Dr. Xyz of the emergency room on 04/30/07 at 1715 hours."
100,0,"DATE OF ADMISSION:,  MM/DD/YYYY.,DATE OF DISCHARGE: , MM/DD/YYYY.,REFERRING PHYSICIAN: , AB CD, M.D.,ATTENDING PHYSICIAN AT DISCHARGE:,  X Y, M.D.,ADMITTING DIAGNOSES:,1.  Ewing sarcoma.,2.  Anemia.,3.  Hypertension.,4.  Hyperkalemia.,PROCEDURES DURING HOSPITALIZATION:  ,Cycle seven Ifosfamide, mesna, and VP-16 chemotherapy.,HISTORY OF PRESENT ILLNESS: , Ms. XXX is a pleasant 37-year-old African-American female with the past medical history of Ewing sarcoma, iron deficiency anemia, hypertension, and obesity.  She presented initially with a left frontal orbital swelling to Dr. XYZ on MM/DD/YYYY.  A biopsy revealed small round cells and repeat biopsy on MM/DD/YYYY also showed round cells consistent with Ewing sarcoma, genetic analysis indicated a T1122 translocation.  MRI on MM/DD/YYYY showed a 4 cm soft tissue mass without bony destruction.  CT showed similar result.  The patient received her first cycle of chemotherapy on MM/DD/YYYY.  On MM/DD/YYYY, she was admitted to the ED with nausea and vomitting and was admitted to the Hematology and Oncology A Service following her first course of chemotherapy.  She had her last course of chemotherapy on MM/DD/YYYY followed by radiation treatment to the ethmoid sinuses on MM/DD/YYYY.,HOSPITAL COURSE: ,1.  Ewing sarcoma, she presented for cycle seven of VP-16, ifosfamide, and mesna infusions, which she tolerated well throughout the admission.,2.  She was followed for hemorrhagic cystitis with urine dipsticks and only showed trace amounts of blood in the urine throughout the admission."
124,0,"SUBJECTIVE:,  The patient is a 2-year-old little girl who comes in with concerns about stuffiness, congestion and nasal drainage.  She does take Zyrtec on a fairly regular basis.  Mom is having some allergy trouble herself right now.  She does not know her colors.  She knows some of her shapes.  She speaks in sentences.  She is not showing much interest in the potty.  She is in the 80th percentile for height and weight, and still over 95th percentile for head circumference.  Mom has no other concerns.,ALLERGIES:,  Eggs and peanuts.,OBJECTIVE:,General:  Alert, very talkative little girl.,HEENT:  TMs clear and mobile.  Eyes:  PERRL.  Fundi benign.  Pharynx clear.  Mouth moist.  Nasal mucosa is pale with clear discharge.,Neck:  Supple without adenopathy.,Heart:  Regular rate and rhythm without murmur.,Lungs:  Clear.  No tachypnea, wheezing, rales or retractions.,Abdomen:  Soft and nontender without mass or organomegaly.,GU:  Normal female genitalia.  Tanner stage I.,Extremities:  No clubbing, cyanosis or edema.  Pulses 2+ and equal.,Hips:  Intact.,Neurological:  Normal.  DTRs are 2+.  Gait was normal.,Skin:  Warm and dry.  No rashes noted.,ASSESSMENT:,  Allergic rhinitis.  Otherwise healthy 2-year-old young lady.,PLAN:,  In addition to her Zyrtec, I put her on Nasonex spray one spray each nostril daily.  If this works for her, certainly she can do it through the ragweed season.  Otherwise she is doing well.  I talked about ways to improve her potty training.  She is a very good eater.  I will see her yearly or p.r.n.  Unfortunately she is not able to get the flu shot due to her egg allergy."
14,0,"DATE OF ADMISSION: , MM/DD/YYYY.,DATE OF DISCHARGE: , MM/DD/YYYY.,ADMITTING DIAGNOSIS:, Peritoneal carcinomatosis from appendiceal primary.,DISCHARGE DIAGNOSIS:  , Peritoneal carcinomatosis from appendiceal primary.,SECONDARY DIAGNOSIS: , Diarrhea.,ATTENDING PHYSICIAN: , AB CD, M.D.,SERVICE: , General surgery C, Surgery Oncology.,CONSULTING SERVICES:,  Urology.,PROCEDURES DURING THIS HOSPITALIZATION:,  On MM/DD/YYYY, ,1.  Cystoscopy, bilaterally retrograde pyelograms, insertion of bilateral externalized ureteral stents.,2.  Exploratory laparotomy, right hemicolectomy, cholecystectomy, splenectomy, omentectomy, IPHC with mitomycin-C.,HOSPITAL COURSE: , The patient is a pleasant 56-year-old gentleman with no significant past medical history who after an extensive workup for peritoneal carcinomatosis from appendiceal primary was admitted on MM/DD/YYYY.  He was admitted to General Surgery C Service for a routine preoperative evaluation including baseline labs, bowel prep, urology consult for ureteral stent placement.  The patient was taken to the operative suite on MM/DD/YYYY and was first seen by Urology for a cystoscopy with bilateral ureteral stent placement.  Dr. XYZ performed an exploratory laparotomy, right hemicolectomy, cholecystectomy, splenectomy, omentectomy, and IPHC with mitomycin-C.  The procedure was without complications.  The patient was observed closely in the ICU for one day postoperatively for persistent tachycardia after extubation.  He was then transferred to the floor where he has done exceptionally well.,On postoperative day #2, the patient passed flatus and we were able to start a clear liquid diet.  We advanced him as tolerated to a regular health select diet by postoperative day #4.  His pain was well controlled throughout this hospitalization, initially with a PCA pump, which he very seldomly used.  He was then switched over to p.o. pain medicines and has required very little for adequate pain control.  By postoperative date #2, the patient had been out of bed and ambulating in the hallways.  The patient's only problem was with some mild diarrhea on postoperative days #3 and 4.  This was thought to be a result of his right hemicolectomy.  A C. diff toxin was sent and came back negative and he was started on Imodium to manage his diarrhea.  His post-splenectomy vaccines including pneumococcal, HiB, and meningococcal vaccines were administered during his hospitalization.,On the day of discharge, the patient was resting comfortably in the bed without complaints.  He had been afebrile throughout his hospitalization and his vital signs were stable.  Pertinent physical exam findings include that his abdomen was soft, nondistended and nontender with bowel sounds present throughout.  His midline incision is clean, dry, and intact and staples are in place.  He is just six days postop, he will go home with his staples in place and they will be removed on his follow-up appointment.,CONDITION AT DISCHARGE:  ,The patient was discharged in good and stable condition.,DISCHARGE MEDICATIONS:,1.  Multivitamins daily.,2.  Lovenox 40 mg in 0.4 mL solution inject subcutaneously once daily for 14 days.,3.  Vicodin 5/500 mg and take one tablet by mouth every four hours as needed for pain.,4.  Phenergan 12.5 mg tablets, take one tablet by mouth every six hours p.r.n. for nausea.,5.  Imodium A-D tablets take one tablet by mouth b.i.d. as needed for diarrhea.,DISCHARGE INSTRUCTIONS:,  The patient was instructed to contact us with any questions or concerns that may arise.  In addition, he was instructed to contact us, if he would have fevers greater than 101.4, chills, nausea or vomitting, continuing diarrhea, redness, drainage, or warmth around his incision site.  He will be seen in about one week's time in Dr. XYZ's clinic and his staples will be removed at that time.,FOLLOW-UP APPOINTMENT: , The patient will be seen by Dr. XYZ in clinic in one week's time."
147,0,"CHIEF COMPLAINT:, Pressure decubitus, right hip.,HISTORY OF PRESENT ILLNESS:, This is a 30-year-old female patient presenting with the above chief complaint. She has a history of having had a similar problem last year which resolved in about three treatments. She appears to have residual from spina bifida, thus spending most of her time in a wheelchair. She relates recently she has been spending up to 16 hours a day in a wheelchair. She has developed a pressure decubitus on her right trochanter ischial area of several weeks' duration. She is now presenting for evaluation and management of same. Denies any chills or fever, any other symptoms.,PAST MEDICAL HISTORY:, Back closure for spina bifida, hysterectomy, breast reduction, and a shunt.,SOCIAL HISTORY:, She denies the use of alcohol, illicits, or tobacco.,MEDICATIONS:, Pravachol, Dilantin, Toprol, and Macrobid.,ALLERGIES:, SULFA AND LATEX.,REVIEW OF SYSTEMS:, Other than the above aforementioned, the remaining ROS is unremarkable.,PHYSICAL EXAMINATION:,GENERAL: A pleasant female with deformity of back.,HEENT: Head is normocephalic. Oral mucosa and dentition appear to be normal.,CHEST: Breath sounds equal and present bilateral.,CVS: Sinus.,GI: Obese, nontender, no hepatosplenomegaly.,EXTREMITIES: Deformity of lower extremities secondary to spina bifida.,SKIN: She has a full-thickness pressure decubitus involving the right hip which is 2 x 6.4 x 0.3, moderate amount of serous material, appears to have good granulation tissue.,PLAN:, Daily applications of Acticoat, pressure relief, at least getting out of the chair for half of the time, at least eight hours out of the chair, and we will see her in one week.,DIAGNOSIS:, Sequelae of spina bifida; pressure decubitus of right hip area."
178,1,"FINDINGS:,There is a large intrasellar mass lesion producing diffuse expansion of the sella turcica. This mass lesions measures approximately 16 x 18 x 18mm (craniocaudal x AP x mediolateral) in size."
154,1,"EXAM:,  Noncontrast CT scan of the lumbar spine,REASON FOR EXAM: , Left lower extremity muscle spasm.,COMPARISONS: , None.,FINDINGS: , Transaxial thin slice CT images of the lumbar spine were obtained with sagittal and coronal reconstructions on emergency basis, as requested.,No abnormal paraspinal masses are identified.,There are sclerotic changes with anterior effusion of the sacroiliac joints bilaterally.,There is marked intervertebral disk space narrowing at the L5-S1 level with intervertebral disk vacuum phenomenon and advanced endplate degenerative changes.  Posterior disk osteophyte complex is present, most marked in the left paracentral to lateral region extending into the lateral recess on the left.  This most likely will affect the S1 nerve root on the left.  There are posterior hypertrophic changes extending into the neural foramina bilaterally inferiorly.  There is mild neural foraminal stenosis present.  Small amount of extruded disk vacuum phenomenon is present on the left in the region of the exiting nerve root.  There is facet sclerosis bilaterally.  Mild lateral recess stenosis just on the right, there is prominent anterior spondylosis.,At the L4-5 level, mild bilateral facet arthrosis is present.  There is broad based posterior annular disk bulging or protrusion, which mildly effaces the anterior aspect of the thecal sac and extends into the inferior aspect of the neural foramina bilaterally.  No moderate or high-grade central canal or neural foraminal stenosis is identified.,At the L3-4 level anterior spondylosis is present.  There are endplate degenerative changes with mild posterior annular disk bulging, but no evidence of moderate or high-grade central canal or neural foraminal stenosis.,At the L2-3 level, there is mild bilateral ligamentum flavum hypertrophy.  Mild posterior annular disk bulging is present without evidence of moderate or high-grade central canal or neural foraminal stenosis.,At the T12-L1 and L1-2 levels, there is no evidence of herniated disk protrusion, central canal, or neural foraminal stenosis.,There is arteriosclerotic vascular calcification of the abdominal aorta and iliac arteries without evidence of aneurysm or dilatation.  No bony destructive changes or acute fractures are identified.,CONCLUSIONS:,1. Advanced degenerative disk disease at the L5-S1 level.,2. Probable chronic asymmetric herniated disk protrusion with peripheral calcification at the L5-S1 level, laterally in the left paracentral region extending into the lateral recess causing lateral recess stenosis.,3. Mild bilateral neural foraminal stenosis at the L5-S1 level.,4. Posterior disk bulging at the L2-3, L3-4, and L4-5 levels without evidence of moderate or high-grade central canal stenosis.,5. Facet arthrosis to the lower lumbar spine.,6. Arteriosclerotic vascular disease."
186,1,"EXAM:,  CT head.,REASON FOR EXAM:,  Seizure disorder.,TECHNIQUE:,  Noncontrast CT head.,FINDINGS: , There is no evidence of an acute intracranial hemorrhage or infarction.  There is no midline shift, intracranial mass, or mass effect.  There is no extra-axial fluid collection or hydrocephalus.  Visualized portions of the paranasal sinuses and mastoid air cells appear clear aside from mild right frontal sinus mucosal thickening.,IMPRESSION:,  No acute process in the brain."
111,0,"HISTORY OF PRESENT ILLNESS:,  Patient is a three years old male who about 45 minutes prior admission to the emergency room ingested about two to three tablets of Celesta 40 mg per tablets.  Mom called to the poison control center and the recommendation was to take the patient to the emergency room and be evaluated.  The patient was alert and did not vomit during the transport to the emergency room.  Mom left the patient and his little one-year-old brother in the room by themselves and she went outside of the house for a couple of minutes, and when came back, she saw the patient having the Celesta foils in his hands and half of tablet was moist and on the floor.  The patient said that the pills ""didn't taste good,"" so it is presumed that the patient actually ingested at least two-and-a-half tablets of Celesta, 40 mg per tablet.,PAST MEDICAL HISTORY:,  Baby was born premature and he required hospitalization, but was not on mechanical ventilation.  He doesn't have any hospitalizations after the new born.  No surgeries.,IMMUNIZATIONS: , Up-to-date.,ALLERGIES: , NOT KNOWN DRUG ALLERGIES.,PHYSICAL EXAMINATION,VITAL SIGNS:  Temperature 36.2 Celsius, pulse 112, respirations 24, blood pressure 104/67, weight 15 kilograms.,GENERAL:  Alert, in no acute distress.,SKIN:  No rashes.,HEENT:  Head:  Normocephalic, atraumatic.  Eyes:  EOMI, PERRL.  Nasal mucosa clear.  Throat and tonsils, normal.  No erythema, no exudates.,NECK:  Supple, no lymphadenopathy, no masses.,LUNGS:  Clear to auscultation bilateral.,HEART:  Regular rhythm and rate without murmur.  Normal S1, S2.,ABDOMEN:  Soft, nondistended, nontender, present bowel sounds, no hepatosplenomegaly, no masses.,EXTREMITIES:  Warm.  Capillary refill brisk.  Deep tendon reflexes present bilaterally.,NEUROLOGICAL:  Alert.  Cranial nerves II through XII intact.  No focal exam.  Normal gait.,RADIOGRAPHIC DATA: , Patient has had an EKG done at the admission and it was within normal limits for the age.,EMERGENCY ROOM COURSE: , Patient was under observation for 6 hours in the emergency room.  He had two more EKGs during observation in the emergency room and they were all normal.  His vital signs were monitored every hour and were within normal limits.  There was no vomiting, no diarrhea during observation.  Patient did not receive any medication or has had any other lab work besides the EKG.,ASSESSMENT AND PLAN: , Three years old male with accidental ingestion of Celesta.  Discharged home with parents, with a followup in the morning with his primary care physician."
47,0,"CHIEF COMPLAINT:,  Detox from heroin.,HISTORY OF PRESENT ILLNESS: , This is a 52-year-old gentleman with a long history of heroin abuse, who keeps relapsing, presents once again, trying to get off the heroin, last use shortly prior to arrival including cocaine.  The patient does have a history of alcohol abuse, but mostly he is concerned about the heroin abuse.,PAST MEDICAL HISTORY: , Remarkable for chronic pain.  He has had multiple stab wounds, gunshot wounds, and a variety of other injuries that resulted him having chronic pain and he states that is what triggers of him getting on heroin to try to get out of pain.  He has previously been followed by ABC but has not seen him for several years.,REVIEW OF SYSTEMS:  ,The patient states that he did use heroin as well as cocaine earlier today and feels under the influence.  Denies any headache or visual complaints.  No hallucinations.  No chest pain, shortness of breath, abdominal pain or back pain.  Denies any abscesses.,SOCIAL HISTORY: , The patient is a smoker.  Admits to heroin use, alcohol abuse as well.  Also admits today using cocaine.,FAMILY HISTORY:,  Noncontributory.,MEDICATIONS: , He has previously been on analgesics and pain medications chronically.  Apparently, he just recently got out of prison.  He has previously also been on Klonopin and lithium.  He was previously on codeine for this pain.,ALLERGIES: , NONE.,PHYSICAL EXAMINATION: , VITAL SIGNS:  The patient is afebrile.  He is markedly hypertensive, 175/104 and pulse 117 probably due to the cocaine onboard.  His respiratory rate is normal at 18.  GENERAL:  The patient is a little jittery but lucid, alert, and oriented to person, place, time, and situation.  HEENT:  Unremarkable.  Pupils are actually moderately dilated about 4 to 5 mm, but reactive.  Extraoculars are intact.  His oropharynx is clear.  NECK:  Supple.  His trachea is midline.  LUNGS:  Clear.  He has good breath sounds and no wheezing.  No rales or rhonchi.  Good air movement and no cough.  CARDIAC:  Without murmur.  ABDOMEN:  Soft and nontender.  He has multiple track marks, multiple tattoos, but no abscesses.  NEUROLOGIC:  Nonfocal.,IMPRESSION: , MEDICAL EXAMINATION FOR THE PATIENT WHO WILL BE DETOXING FROM HEROIN.,ASSESSMENT AND PLAN:  ,At this time, I think the patient can be followed up at XYZ.  I have written a prescription of clonidine and Phenergan for symptomatic relief and this has been faxed to the pharmacy.  I do not think he needs any further workup at this time.  He is discharged otherwise in stable condition."
60,1,"INDICATIONS:,  Atrial fibrillation, coronary disease.,STRESS TECHNIQUE:, The patient was infused with dobutamine to a maximum heart rate of 142.  ECG exhibits atrial fibrillation.,IMAGE TECHNIQUE:,  The patient was injected with 5.2 millicuries of thallous chloride and subsequently imaged on the gated tomographic SPECT system.,IMAGE ANALYSIS:,  It should be noted that the images are limited slightly by the patient's obesity with a weight of 263 pounds.  There is normal LV myocardial perfusion.  The LV systolic ejection fraction is normal at 65%.  There is normal global and regional wall motion.,CONCLUSIONS:,1.  Basic rhythm of atrial fibrillation with no change during dobutamine stress, maximum heart rate of 142.,2.  Normal LV myocardial perfusion.,3.  Normal LV systolic ejection fraction of 65%.,4.  Normal global and regional wall motion."
137,0,"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 CONDITIONS,1.  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 MEDICATIONS,1.  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 SYSTEMS,CONSTITUTIONAL:  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 EXAMINATION,CONSTITUTIONAL:  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."
67,1,"REASON FOR EXAMINATION: , Cardiac arrhythmia.,INTERPRETATION: , No significant pericardial effusion was identified.,The aortic root dimensions are within normal limits.  The four cardiac chambers dimensions are within normal limits.  No discrete regional wall motion abnormalities are identified.  The left ventricular systolic function is preserved with an estimated ejection fraction of 60%.  The left ventricular wall thickness is within normal limits.,The aortic valve is trileaflet with adequate excursion of the leaflets.  The mitral valve and tricuspid valve motion is unremarkable.  The pulmonic valve is not well visualized.,Color flow and conventional Doppler interrogation of cardiac valvular structures revealed mild mitral regurgitation and mild tricuspid regurgitation with an RV systolic pressure calculated to be 28 mmHg.  Doppler interrogation of the mitral in-flow pattern is within normal limits for age.,IMPRESSION:,1.  Preserved left ventricular systolic function.,2.  Mild mitral regurgitation.,3.  Mild tricuspid regurgitation."
121,0,"CHIEF COMPLAINT: , Headache.,HISTORY OF PRESENT ILLNESS:,  This is a 16-year-old white female who presents here to the emergency department in a private auto with her mother for evaluation of headache.  She indicates intense constant right frontal headache, persistent since onset early on Monday, now more than 48 hours ago.  Indicates pressure type of discomfort with throbbing component.  It is as high as a 9 on a 0 to 10 scale of intensity.  She denies having had similar discomfort in the past.  Denies any trauma.,Review of systems:  No fever or chills.  No sinus congestion or nasal drainage.  No cough or cold symptoms.  No head trauma.  Mild nausea.  No vomiting or diarrhea.  Other systems reviewed and are negative.,PMH: , Acne.  Psychiatric history is unremarkable.,PSH: , Right knee surgery.,SH: , The patient is single.  Living at home.  No smoking or alcohol.,FH: , Noncontributory.,ALLERGIES:  ,No drug allergies.,MEDICATIONS: , Accutane and Ovcon.,PHYSICAL EXAMINATION:,VITALS:  Temperature of 97.8 degrees F., pulse of 80, respiratory rate of 16, and blood pressure is 131/96.,GENERAL:  This is a 16-year-old white female.  She is awake, alert, and oriented x3.  She does appear bit uncomfortable.,HEAD:  Normocephalic and atraumatic.,EYES:  The pupils were equal and reactive to light.  Extraocular movements are intact.,ENT:  TMs are clear.  Nose and throat are unremarkable.,NECK:  There is no evidence of nuchal rigidity.  She does, however, have notable tenderness and spasm of the right trapezius and rhomboid muscles when she extends up to the right paracervical muscles.  Palpation clearly causes having exacerbation of her discomfort.,CHEST:  Thorax is unremarkable.,GI:  Abdomen is nontender.,MUSCLES:  Extremities are unremarkable.,NEURO:  Cranial nerves II through XII are grossly intact.  Motor and sensory are grossly intact.  ,SKIN:  Skin is warm and dry.,ED COURSE:,  The patient was given IV Norflex 60 mg, Zofran 4 mg, and morphine sulfate 4 mg and with that has significant improvement in her discomfort.,DIAGNOSES:,1.  Muscle tension cephalgia.,2.  Right trapezius and rhomboid muscle spasm.,PLAN: , Scripts were given for Darvocet-N 100 one every 4 to 6 hours #15, Soma one 4 times a day #20.  She was instructed to apply warm compresses and perform gentle massage.  Follow up with regular provider as needed.  Return if any problems."
162,1,"FINDINGS:,By dates the patient is 8 weeks, 2 days.,There is a gestational sac within the endometrial cavity measuring 2.1cm consistent with 6 weeks 4 days. There is a fetal pole measuring 7mm consistent with 6 weeks 4 days. There was no fetal heart motion on Doppler or on color Doppler.,There is no fluid within the endometrial cavity.,There is a 2.8 x 1.2cm right adnexal cyst.,IMPRESSION:,Gestational sac with a fetal pole but no fetal heart motion consistent with fetal demise at 6 weeks 4 days. By dates the patient is 8 weeks, 2 days.,A preliminary report was called by the ultrasound technologist to the referring physician."
32,0,"HISTORY OF PRESENT ILLNESS: , The patient is a 35-year-old lady who was admitted with chief complaints of chest pain, left-sided with severe chest tightness after having an emotional argument with her boyfriend.  The patient has a long history of psychological disorders.  As per the patient, she also has a history of supraventricular tachycardia and coronary artery disease, for which the patient has had workup done in ABC Medical Center.  The patient was evaluated in the emergency room.  The initial cardiac workup was negative.  The patient was admitted to telemetry unit for further evaluation.  In the emergency room, the patient was also noted to have a strongly positive drug screen including methadone and morphine.  The patient's EKG in the emergency room was normal and the patient had some relief from her chest pain after she got some nitroglycerin.,PAST MEDICAL HISTORY: , As mentioned above is significant for history of seizure disorder, migraine headaches, coronary artery disease, CHF, apparently coronary stenting done, mitral valve prolapse, supraventricular tachycardia, pacemaker placement, colon cancer, and breast cancer.  None of the details of these are available.,PAST SURGICAL HISTORY: , Significant for history of lumpectomy on the left breast, breast augmentation surgery, cholecystectomy, cardiac ablation x3, left knee surgery as well as removal of half the pancreas.,CURRENT MEDICATIONS AT HOME: , Included Dilantin 400 mg daily, Klonopin 2 mg 3 times a day, Elavil 300 mg at night, nitroglycerin sublingual p.r.n., Thorazine 300 mg 3 times a day, Neurontin 800 mg 4 times a day, and Phenergan 25 mg as tolerated.,OB HISTORY: , Her last menstrual period was 6/3/2009.  The patient is admitting to having a recent abortion done.  She is not too sure whether the abortion was completed or not, has not had a followup with her OB/GYN.,FAMILY HISTORY:  ,Noncontributory.,SOCIAL HISTORY:  ,She lives with her boyfriend.  The patient has history of tobacco abuse as well as multiple illicit drug abuse.,REVIEW OF SYSTEMS:  As mentioned above.,PHYSICAL EXAMINATION:,GENERAL:  She is alert, awake, and oriented.,VITAL SIGNS:  Her blood pressure is about 132/72, heart rate of about 87 per minute, respiratory rate of 16.,HEENT:  Shows head is atraumatic.  Pupils are round and reactive to light.  Extraocular muscles are intact.  No oropharyngeal lesions noted.,NECK:  Supple, no JV distention, no carotid bruits, and no lymphadenopathy.,LUNGS:  Clear to auscultation bilaterally.,CARDIAC:  Reveals regular rate and rhythm.,ABDOMEN:  Soft, nontender, nondistended.  Bowel sounds are normally present.,LOWER EXTREMITIES:  Shows no edema.  Distal pulses are 2+.,NEUROLOGICAL:  Grossly nonfocal.,LABORATORY DATA: , The database that is available at this point of time, WBC count is normal, hemoglobin and hematocrit are normal.  Sodium, potassium, chloride, glucose, bicarbonate, BUN and creatinine, and liver function tests are normal.  The patient's 3 sets of cardiac enzymes including troponin-I, CPK-MB, and myoglobulin have been normal.  EKG is normal, sinus rhythm without any acute ST-T wave changes.  As mentioned before, the patient's toxicology screen was positive for morphine, methadone, and marijuana.  The patient also had a head CT done in the emergency room, which was fairly unremarkable.  The patient's beta-hCG level was marginally elevated at about 48.,ASSESSMENT AND EVALUATION:,1.  Chest pains, appear to be completely noncardiac.  The patient does seem to have a psychosomatic component to her chest pain.  There is no evidence of acute coronary syndrome or unstable angina at this point of time.,2.  Possible early pregnancy.  The patient's case was discussed with OB/GYN on-call over the phone.  Some of the medications have to be held secondary to potential danger.  The patient will follow up on an outpatient basis with her primary OB/GYN as well as PCP for the workup of her pregnancy as well as continuation of the pregnancy and prenatal visits.,3.  Migraine headaches for which the patient has been using her routine medications and the headaches seem to be under control.  Again, this is an outpatient diagnosis.  The patient will follow up with her PCP for control of migraine headache.,Overall prognosis is too soon to predict.,The plan is to discharge the patient home secondary to no evidence of acute coronary syndrome."
30,0,"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."
3,0,"CHIEF COMPLAINT: , This is a previously healthy 45-year-old gentleman.  For the past 3 years, he has had some intermittent episodes of severe nausea and abdominal pain.  On the morning of this admission, he had the onset of severe pain with nausea and vomiting and was seen in the emergency department, where Dr. XYZ noted an incarcerated umbilical hernia.  He was able to reduce this, with relief of pain.  He is now being admitted for definitive repair.,PAST MEDICAL HISTORY: , Significant only for hemorrhoidectomy.  He does have a history of depression and hypertension.,MEDICATIONS: , His only medications are Ziac and Remeron.,ALLERGIES:,  No allergies.,FAMILY HISTORY: , Negative for cancer.,SOCIAL HISTORY:,  He is single.  He has 2 children.  He drinks 4-8 beers per night and smokes half a pack per day for 30 years.  He was born in Salt Lake City.  He works in an electronic assembly for Harmony Music.  He has no history of hepatitis or blood transfusions.,PHYSICAL EXAMINATION:,GENERAL:  Examination shows a moderate to markedly obese gentleman in mild distress since his initial presentation to the emergency department.,HEENT:  No scleral icterus.,NECK:  No cervical, supraclavicular, or axillary adenopathy.,LUNGS:  Clear.,HEART:  Regular.  No murmurs or gallops.,ABDOMEN:  As noted, obese with mildly visible bulging in the umbilicus at the superior position.  With gentle traction, we were able to feel both herniated contents, which when reduced, reveals an approximately 2-cm palpable defect in the umbilicus.,DIAGNOSTIC STUDIES:  ,Normal sinus rhythm on EKG, prolonged QT.  Chest x-ray was negative.  The abdominal x-rays were read as being negative.  His electrolytes were normal.  Creatinine was 0.9.  White count was 6.5, hematocrit was 48, and platelet count was 307.,ASSESSMENT AND PLAN:,  Otherwise previously healthy gentleman, who presents with an incarcerated umbilical hernia, now for repair with mesh."
109,0,"SUBJECTIVE:,  This is a 1-year-old male who comes in with a cough and congestion for the past two to three weeks.  Started off as a congestion but then he started coughing about a week ago.  Cough has gotten worsen.  Mother was also worried.  He had Pop Can just three days ago and she never found the top of that and was wondering if he had swallowed that, but his breathing has not gotten worse since that happened.  He is not running any fevers.,PAST MEDICAL HISTORY:,  Otherwise, reviewed.  Fairly healthy.,CURRENT MEDICATIONS:,  None.,ALLERGIES TO MEDICINES:,  None.,FAMILY SOCIAL HISTORY:,  The sister is in today with clinical sinusitis.  Mother and father have been healthy.,REVIEW OF SYSTEMS:,  He has been congested for about three weeks ago.  Coughing now but no fevers.  No vomiting.  Review of systems is otherwise negative.,PHYSICAL EXAMINATION:,General:  Well-developed male in no acute distress, afebrile.,Vital Signs:  Weight:  22 pounds 6 ounces.,HEENT:  Sclerae and conjunctivae are clear.  Extraocular muscles are intact.  TMs are clear.  Nares are very congested.  Oropharynx has drainage in the back of the throat.  Mucous membranes are moist.  Mild erythema though.,Neck:  Some shotty lymphadenopathy.  Full range of motion.  Supple.,Chest:  Clear.  No crackles.  No wheezes.,Cardiovascular:  Regular rate and rhythm.  Normal S1, S2.,Abdomen:  Positive bowel sounds and soft.,Dermatologic:  Clear.  Tone is good.  Capillary refill less than 3 seconds.,RADIOLOGY:,  Chest x-ray:  No foreign body noted as well.  No signs of pneumonia.,ASSESSMENT:,  Clinical sinusitis and secondary cough.,PLAN:,  Amoxicillin a teaspoon twice daily for 10 days.  Plenty of fluids.  Tylenol and Motrin p.r.n., as well as oral decongestant and if coughing is not improving."
161,1,"EXAM:,  Magnified airway.,CLINICAL HISTORY: , An 11-month-old female with episodes of difficulty in breathing, cough.,TECHNIQUE: , Multiple fluoroscopic spot images of the pharyngeal airway, trachea, and mainstem bronchi were performed in various phases of respiration.,FINDINGS:,  The airway is patent throughout its course.  Specifically, the trachea and both mainstem bronchi do not demonstrate evidence of dynamic collapse greater than 50%.,No filling defects are identified.,The vocal cords demonstrate normal opening and closing.,IMPRESSION: , Normal magnified airway examination."
46,0,"CURRENT HISTORY:,  A 94-year-old female from the nursing home with several days of lethargy and anorexia.  She was found to have evidence of UTI.  She also has renal insufficiency and digitalis toxicity.  She is admitted for further treatment.,Past medical history, social history, family history, physical examination can be seen on the admission H&P.,LABORATORIES ON ADMISSION: , White count 11,700, hemoglobin 12.8, hematocrit 37.2, BUN 91, creatinine 2.2, sodium 131, potassium 5.1.  Digoxin level of 4.1.,HOSPITAL COURSE: , The patient was admitted and intravenous fluids and antibiotics were administered.  Blood cultures were negative.  Urine cultures were nondiagnostic.  Renal function improved with creatinine down to 1 at the time of discharge.  Digoxin was restarted at a lower dose.  Her condition improved and she is stabilized and transferred back to assisted living in good condition.,PRIMARY DIAGNOSES:,1.  Urinary tract infection.,2.  Volume depletion.,3.  Renal insufficiency.,4.  Digitalis toxicity.,SECONDARY DIAGNOSES:,1.  Aortic valve stenosis.,2.  Congestive heart failure.,3.  Hypertension.,4.  Chronic anemia.,5.  Degenerative joint disease.,6.  Gastroesophageal reflux disease.,PROCEDURES:,  None.,COMPLICATIONS: , None.,DISCHARGE CONDITION: , Improved and stable.,DISCHARGE PLAN:  ,Physical activity:  With assistance.  ,Diet:  No restriction.  ,Medications:  Lasix 40 mg daily, lisinopril 5 mg daily, digoxin 0.125 mg daily, Augmentin 875 mg 1 tablet twice a day for 1 week, Nexium 40 mg daily, Elavil 10 mg at bedtime, Detrol 2 mg twice a day, potassium 10 mEq daily and diclofenac 50 mg twice a day.  ,Follow up:  She will see Dr. X in the office as scheduled."
98,1,"Grade II:  Atherosclerotic plaques are seen which appear to be causing 40-60% obstruction.,Grade III:  Atherosclerotic plaques are seen which appear to be causing greater than 60% obstruction.,Grade IV:  The vessel is not pulsating and the artery appears to be totally obstructed with no blood flow in it.,RIGHT CAROTID SYSTEM: , The common carotid artery and bulb area shows mild intimal thickening with no increase in velocity and no evidence for any obstructive disease.  The internal carotid artery shows intimal thickening with some mixed plaques, but no increase in velocity and no evidence for any significant obstructive disease.  The external carotid artery shows no disease.  The vertebral was present and was antegrade.,LEFT CAROTID SYSTEM: , The common carotid artery and bulb area shows mild intimal thickening, but no increase in velocity and no evidence for any significant obstructive disease. the internal carotid artery shows some intimal thickening with mixed plaques, but no increase in velocity and no evidence for any significant obstructive disease.  The external carotid artery shows no disease.  The vertebral was present and was antegrade.,IMPRESSION:,  Bilateral atherosclerotic changes with no evidence for any significant obstructive disease."
2,0,"SUBJECTIVE:,  This is a 12-year-old young man who comes in with about 10 days worth of sinus congestion.  He does have significant allergies including ragweed.  The drainage has been clear.  He had a little bit of a headache yesterday.  He has had no fever.  No one else is ill at home currently.,CURRENT MEDICATIONS:,  Advair and Allegra.  He has been taking these regularly.  He is not sure the Allegra is working for him anymore.  He does think though better than Claritin.,PHYSICAL EXAM:,General:  Alert young man in no distress.,HEENT:  TMs clear and mobile.  Pharynx clear.  Mouth moist.  Nasal mucosa pale with clear discharge.,Neck:  Supple without adenopathy.,Heart:  Regular rate and rhythm without murmur.,Lungs:  Lungs clear, no tachypnea, wheezing, rales or retractions.,Abdomen:  Soft, nontender, without masses or splenomegaly.,ASSESSMENT:,  I think this is still his allergic rhinitis rather than a sinus infection.,PLAN:,  Change to Zyrtec 10 mg samples were given.  He is not using nasal spray, but he has some at home.  He should restart this.  Continue to watch his peak flows to make sure his asthma does not come under poor control.  Call if any further problems."
72,1,"EXAM: , CT scan of the abdomen and pelvis with contrast.,REASON FOR EXAM: , Abdominal pain.,COMPARISON EXAM: , None.,TECHNIQUE: , Multiple axial images of the abdomen and pelvis were obtained.  5-mm slices were acquired after injection of 125 cc of Omnipaque IV.  In addition, oral ReadiCAT was given.  Reformatted sagittal and coronal images were obtained.,DISCUSSION:,  There are numerous subcentimeter nodules seen within the lung bases.  The largest measures up to 6 mm.  No hiatal hernia is identified.  Consider chest CT for further evaluation of the pulmonary nodules.  The liver, gallbladder, pancreas, spleen, adrenal glands, and kidneys are within normal limits.  No dilated loops of bowel.  There are punctate foci of air seen within the nondependent portions of the peritoneal cavity as well as the anterior subcutaneous fat.  In addition, there is soft tissue stranding seen of the lower pelvis.  In addition, the uterus is not identified.  Correlate with history of recent surgery.  There is no free fluid or lymphadenopathy seen within the abdomen or pelvis.  The bladder is within normal limits for technique.,No acute bony abnormalities appreciated.  No suspicious osteoblastic or osteolytic lesions.,IMPRESSION:,1.  Postoperative changes seen within the pelvis without appreciable evidence for free fluid.,2.  Numerous subcentimeter nodules seen within the lung bases.  Consider chest CT for further characterization."
166,1,"CC:, HA and vision loss.,HX: ,71 y/o RHM developed a cataclysmic headache on 11/5/92 associated with a violent sneeze. The headache lasted 3-4 days. On 11/7/92, he had acute pain and loss of vision in the left eye. Over the following day his left pupil enlarged and his left upper eyelid began to droop. He was seen locally and a brain CT showed no sign of bleeding, but a tortuous left middle cerebral artery was visualized. The patient was transferred to UIHC 11/12/92.,FHX:, HTN, stroke, coronary artery disease, melanoma.,SHX:, Quit smoking 15 years ago.,MEDS:, Lanoxin, Capoten, Lasix, KCL, ASA, Voltaren, Alupent MDI,PMH: ,CHF, Atrial Fibrillation, Obesity, Anemia, Duodenal Ulcer, Spinal AVM resection 1986 with residual T9 sensory level, hyperreflexia and bilateral babinski signs, COPD.,EXAM: ,35.5C, BP 140/91, P86, RR20. Alert and oriented to person, place, and time. CN: No light perception OS, Pupils: 3/7 decreasing to 2/7 on exposure to light (i.e., fixed/dilated pupil OS). Upon neutral gaze the left eye deviated laterally and inferiorly. There was complete ptosis OS. On downward gaze their was intorsion OS. The left eye could not move superiorly, medially or effectively downward, but could move laterally. EOM were full OD. The rest of the CN exam was unremarkable. Motor, Coordination, Station and Gait testing were unremarkable. Sensory exam revealed decreased pinprick and light touch below T9 (old). Muscle stretch reflexes were increased (3+/3+) in both lower extremities and there were bilateral babinski signs (old). The upper extremity reflexes were symmetrical (2/2). Cardiovascular exam revealed an irregularly irregular rhythm and lung sounds were coarse bilaterally. The rest of the general exam was unremarkable.,LAB:, CBC, PT/PTT, General Screen were unremarkable except for a BUN 21mg/DL. CSF: protein 88mg/DL, glucose 58mg/DL, RBC 2800/mm3, WBC 1/mm3. ANA, RF, TSH, FT4 were WNL.,IMPRESSION:, CN3 palsy and loss of vision. Differential diagnosis: temporal arteritis, aneurysm, intracranial mass.,COURSE:, The outside Brain CT revealed a tortuous left MCA. A four-vessel cerebral angiogram revealed a dolichoectatic basilar artery and tortuous LICA. There was no evidence of aneursym. Transesophageal Echocardiogram revealed atrial enlargement only. Neuroopthalmologic evaluation revealed: Loss of color vision and visual acuity OS, RAPD OS, bilateral optic disk pallor (OS > OD), CN3 palsy and bilateral temporal field loss, OS >> OD . ESR, CRP, MRI were recommended to rule out temporal arteritis and intracranial mass. ESR 29mm/Hr, CRP 4.3mg/DL (high) , The patient was placed on prednisone. Temporal artery biopsy showed no evidence of vasculitis. MRI scan could not be obtained due to patient weight. Sellar CT was done instead: coronal sections revealed sellar enlargement and upward bowing of the diaphragm sella suggesting a pituitary mass. In retrospect sellar enlargement could be seen on the angiogram X-rays. Differential consideration was given to cystic pituitary adenoma, noncalcified craniopharyngioma, or Rathke's cleft cyst with solid component. The patient refused surgery. He was seen in Neuroopthalmology Clinic 2/18/93 and was found to have mild recovery of vision OS and improved visual fields. Aberrant reinnervation of the 3rd nerve was noted as there was constriction of the pupil (OS) on adduction, downgaze and upgaze. The upper eyelid, OS, elevated on adduction and down gaze, OS. EOM movements were otherwise full and there was no evidence of ptosis. In retrospect he was felt to have suffered pituitary apoplexy in 11/92."
27,0,"GENERAL REVIEW OF SYSTEMS,General:  No fevers, chills, or sweats.  No weight loss or weight gain.,Cardiovascular:  No exertional chest pain, orthopnea, PND, or pedal edema.  No palpitations.,Neurologic:  No paresis, paresthesias, or syncope.,Eyes:  No double vision or blurred vision.,Ears:  No tinnitus or decreased auditory acuity.,ENT:  No allergy symptoms, such as rhinorrhea or sneezing.,GI:  No indigestion, heartburn, or diarrhea.  No blood in the stools or black stools.  No change in bowel habits.,GU:  No dysuria, hematuria, or pyuria.  No polyuria or nocturia.  Denies slow urinary stream.,Psych:  No symptoms of depression or anxiety.,Pulmonary:  No wheezing, cough, or sputum production.,Skin:  No skin lesions or nonhealing lesions.,Musculoskeletal:  No joint pain, bone pain, or back pain.  No erythema at the joints.,Endocrine:  No heat or cold intolerance.  No polydipsia.,Hematologic:  No easy bruising or easy bleeding.  No swollen lymph nodes.,PHYSICAL EXAM,Vitals:  Blood pressure today was *, heart rate *, respiratory rate *.,Ears:  TMs intact bilaterally.  Throat is clear without hyperemia.,Mouth:  Mucous membranes normal.  Tongue normal.,Neck:  Supple; carotids 2+ bilaterally without bruits; no lymphadenopathy or thyromegaly.,Chest:  Clear to auscultation; no dullness to percussion.,Heart:  Revealed a regular rhythm, normal S1 and S2.  No murmurs, clicks or gallops.,Abdomen:  Soft to palpation without guarding or rebound.  No masses or hepatosplenomegaly palpable.  Bowel sounds are normoactive.,Extremities:  Bilaterally symmetrical.  Peripheral pulses 2+ in all extremities.  No pedal edema.,Neurologic examination:  Essentially intact including cranial nerves II through XII intact bilaterally.  Deep tendon reflexes 2+ and symmetrical.,Breasts:  Bilaterally symmetrical without tenderness, masses.  No axillary tenderness or masses.,Pelvic examination:  Revealed normal external genitalia.  Pap smear obtained without difficulty.  Bimanual examination revealed no pelvic tenderness or masses.  No uterine enlargement.  Rectal examination revealed normal sphincter tone, no rectal masses.  Stool is Hemoccult negative."
163,1,"EXAM:,  Nuclear medicine tumor localization, whole body.,HISTORY: , Status post subtotal thyroidectomy for thyroid carcinoma, histology not provided.,FINDINGS: , Following the oral administration of 4.3 mCi Iodine-131, whole body planar images were obtained in the anterior and posterior projections at 24, 48, and 72 hours.,There is increased uptake in the left upper quadrant, which persists throughout the examination.  There is a focus of increased activity in the right lower quadrant, which becomes readily apparent at 72 hours.  Physiologic uptake in the liver, spleen, and transverse colon is noted.  Physiologic urinary bladder uptake is also appreciated.  There is low-grade uptake in the oropharyngeal region.,IMPRESSION:  ,Iodine-avid foci in the right lower quadrant and left upper quadrant medially suspicious for distant metastasis.  Anatomical evaluation, i.e., CT is advised to determine if there are corresponding mesenteric lesions.  Ultimately (provided that the original pathology of the thyroid tumor with iodine-avid) PET scanning may be necessary.  No evidence of iodine added locoregional metastasis."
138,0,"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."
18,0,"HISTORY OF PRESENT ILLNESS:,  Patient is a 76-year-old white male who presents with his wife stating that he was stung by a bee on his right hand, left hand, and right knee at approximately noon today.  He did not note any immediate reaction.  Since that time, he has noted some increasing redness and swelling to his left hand, but he denies any generalized symptoms such as itching, hives, or shortness of breath.  He denies any sensation of tongue swelling or difficulty swallowing.,The patient states he was stung approximately one month ago without any serious reaction.  He did windup taking Benadryl at that time.  He has not taken anything today for his symptoms, but he is on hydrochlorothiazide and metoprolol for hypertension as well as a baby aspirin each day.,ALLERGIES: , HE DOES HAVE MEDICATION INTOLERANCES TO SULFA DRUGS (HEADACHE), MORPHINE (NAUSEA AND VOMITING), AND TORADOL (ULCER).,SOCIAL HISTORY: , Patient is married and is a nonsmoker and lives with his wife, who is here with him.,Nursing notes were reviewed with which I agree.,PHYSICAL EXAMINATION,VITAL SIGNS:  Temp and vital signs are all within normal limits.,GENERAL:  In general, the patient is an elderly white male who is sitting on the stretcher in no acute distress.,HEENT:  Head is normocephalic and atraumatic.  The face shows no edema.  The tongue is not swollen and the airway is widely patent.,NECK:  No stridor.,HEART:  Regular rate and rhythm without murmurs, rubs, or gallops.,LUNGS:  Clear without rales, rhonchi, or wheezes.,EXTREMITIES:  Upper extremities, there is some edema and erythema to the dorsum of the left hand in the region of the distal third to fifth metacarpals.  There was some slight edema of the fourth digit, on which he still is wearing his wedding band.  The right hand shows no reaction.  The right knee is not swollen either.,The left fourth digit was wrapped in a rubber tourniquet to express the edema and using some Surgilube, I was able to remove his wedding band without any difficulty.  Patient was given Claritin 10 mg orally for what appears to be a simple local reaction to an insect sting.  I did explain to him that his swelling and redness may progress over the next few days.,ASSESSMENT: , Local reaction secondary to insect sting.,PLAN: , The patient was reassured that this is not a serious reaction to an insect sting and he should not progress to such a reaction.  I did urge him to use Claritin 10 mg once daily until the redness and swelling has gone.  I did explain that the swelling may worsen over the next two to three days, it may produce a large local reaction, but that anti-histamines were still the mainstay of therapy for such a reaction.  If he is not improved in the next four days, follow up with his PCP for a re-exam."
129,0,"CHIEF COMPLAINT: , Motor vehicle accident.,HISTORY OF PRESENT ILLNESS: , This is a 32-year-old Hispanic female who presents to the emergency department today via ambulance.  The patient was brought by ambulance following a motor vehicle collision approximately 45 minutes ago.  The patient states that she was driving her vehicle at approximately 40 miles per hour.  The patient was driving a minivan.  The patient states that the car in front of her stopped too quickly and she rear-ended the vehicle ahead of her.  The patient states that she was wearing her seatbelt.  She was driving.  There were no other passengers in the van.  The patient states that she was restrained by the seatbelt and that her airbag deployed.  The patient denies hitting her head.  She states that she does have some mild pain on the left aspect of her neck.  The patient states that she believes she may have passed out shortly after the accident.  The patient states that she also has some pain low in her abdomen that she believes is likely due to the steering wheel or deployment on the airbag.  The patient denies any pain in her knees, ankles, or feet.  She denies any pain in her shoulders, elbows, and wrists.  The patient does state that she is somewhat painful throughout the bones of her pelvis as well.  The patient did not walk after this accident.  She was removed from her car and placed on a backboard and immobilized.  The patient denies any chest pain or difficulty breathing.  She denies any open lacerations or abrasions.  The patient has not had any headache, nausea or vomiting.  She has not felt feverish or chilled.  The patient does states that there is significant deformity to the front of the vehicle that she was driving, which again was a minivan.  There were no oblique vectors or force placed on this accident.  The patient had straight rear-ending of the vehicle in front of her.  The pain in her abdomen is most significant pain currently and she ranks it at 5 out of 10.  The patient states that her last menstrual cycle was at the end of May.  She does not believe that she could be pregnant.  She is taking oral birth control medications and also has an intrauterine device to prevent pregnancy as the patient is on Accutane.,PAST MEDICAL HISTORY:,  No significant medical history other than acne.,PAST SURGICAL HISTORY:,  None.,SOCIAL HABITS: ,  The patient denies tobacco, alcohol or illicit drug usage.,MEDICATIONS:,  Accutane.,ALLERGIES: , No known medical allergies.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION:,GENERAL:  This is a Hispanic female who appears her stated age of 32 years.  She is well-nourished, well-developed, in no acute distress.  The patient is pleasant.  She is immobilized on a backboard and also her cervical spine is immobilized as well on a collar.  The patient is without capsular retractions, labored respirations or accessory muscle usage.  She responds well and spontaneously.,VITAL SIGNS:  Temperature 98.2 degrees Fahrenheit, blood pressure 129/84, pulse 75, respiratory rate 16, and pulse oximetry 97% on room air.,HEENT:  Head is normocephalic.  There is no crepitus.  No bony step-offs.  There are no lacerations on the scalp.  Sclerae are anicteric and noninjected.  Fundoscopic exam appears normal without papilledema.  External ocular movements are intact bilaterally without nystagmus or entrapment.  Nares are patent and free of mucoid discharge.  Mucous membranes are moist and free of exudate or lesions.,NECK:  Supple.  No thyromegaly.  No JVD.  No carotid bruits.  Trachea is midline.  There is no stridor.,HEART:  Regular rate and rhythm.  Clear S1 and S2.  No murmur, rub or gallop is appreciated.,LUNGS:  Clear to auscultation bilaterally.  No wheezes, rales, or rhonchi.,ABDOMEN:  Soft, nontender with the exception of mild-to-moderate tenderness in the bilateral lower pelvic quadrants.  There is no organomegaly here.  Positive bowel sounds are auscultated throughout.  There is no rigidity or guarding.  Negative CVA tenderness bilaterally.,EXTREMITIES:  No edema.  There are no bony abnormalities or deformities.,PERIPHERAL VASCULAR:  Capillary refill is less than two seconds in all extremities.  The patient does have intact dorsalis pedis and radial pulses bilaterally.,PSYCHIATRIC:  Alert and oriented to person, place, and time.  The patient recalls all events regarding the accident today.,NEUROLOGIC:  Cranial nerves II through XII are intact bilaterally.  No focal deficits are appreciated.  The patient has equal and strong distal and proximal muscle group strength in all four extremities.  The patient has negative Romberg and negative pronator drift.,LYMPHATICS:  No appreciable adenopathy.,MUSCULOSKELETAL:  The patient does have pain free range of motion at the bilateral ankles, bilateral knees, bilateral hips, bilateral shoulders, bilateral elbows, and bilateral wrists.  There are no bony abnormalities identified.  The patient does have some mild tenderness over palpation of the bilateral iliac crests.,SKIN:  Warm, dry, and intact.  No lacerations.  There are no abrasions other than a small abrasion on the patient's abdomen just inferior to the umbilicus.  No lacerations and no sites of trauma or bleeding are identified.,DIAGNOSTIC STUDIES: , The patient does have multiple x-rays done.  There is an x-ray of the pelvis, which shows normal pelvis and right hip.  There is also a CT scan of the cervical spine that shows no evidence of acute traumatic bony injury of the cervical spine.  There is some prevertibral soft tissue swelling from C5 through C7.  This is nonspecific and could be due to prominence of upper esophageal sphincter.  The CT scan of the brain without contrast shows no evidence of acute intracranial injury.  There is some mucus in the left sphenoid sinus.  The patient also has emergent CT scan without contrast of the abdomen.  The initial studies show some dependent atelectasis in both lungs.  There is also some low density in the liver, which could be from artifact or overlying ribs; however, a CT scan with contrast is indicated.  A CT scan with contrast is obtained and this is found to be normal without bleeding or intraabdominal or pelvic abnormalities.  The patient has laboratory studies done as well.  CBC is within normal limits without anemia, thrombocytopenia or leukocytosis.  The patient has a urine pregnancy test, which is negative and urinalysis shows no blood and is normal.,EMERGENCY DEPARTMENT COURSE: , The patient was removed from the backboard within the first half hour of her emergency department stay.  The patient has no significant bony deformities or abnormalities.  The patient is given a dose of Tylenol here in the emergency department for treatment of her pain.  Her pain is controlled with medication and she is feeling more comfortable and removed from the backboard.  The patient's CT scans of the abdomen appeared normal.  She has no signs of bleeding.  I believe, she has just a contusion and abrasion to her abdomen from the seatbelt and likely from the airbag as well.  The patient is able to stand and walk through the emergency department without difficulty.  She has no abrasions or lacerations.,ASSESSMENT AND PLAN:,  Multiple contusions and abdominal pain, status post motor vehicle collision.  Plan is the patient does not appear to have any intraabdominal or pelvic abnormities following her CT scans.  She has normal scans of the brain and her C-spine as well.  The patient is in stable condition.  She will be discharged with instructions to return to the emergency department if her pain increases or if she has increasing abdominal pain, nausea or vomiting.  The patient is given a prescription for Vicodin and Flexeril to use it at home for her muscular pain."
74,1,"COMPARISON STUDIES:, None.,MEDICATION: ,  Lopressor 5 mg IV.,HEART RATE AFTER MEDICATION:, 64bpm,EXAM:,TECHNIQUE: Tomographic images were obtained of the heart and chest with a 64 detector row scanner using slice thicknesses of less than 1 mm. 80cc’s of Isovue 370 was injected in the right arm.,TECHNICAL QUALITY:,Examination is limited secondary to extensive artifact from defibrillator wires.,There is good demonstration of the coronary arteries and there is good bolus timing.,FINDINGS:,LEFT MAIN CORONARY ARTERY:,The left main coronary artery is a moderate-sized vessel with a normal ostium. There is no calcific or non-calcific plaque. The vessel bifurcates into a left anterior descending artery and a left circumflex artery.,LEFT ANTERIOR DESCENDING ARTERY:,The left anterior descending artery is a moderate-sized vessel, with a small first diagonal branch and a large second diagonal branch. The vessel continues as a small vessel, tapering at the apex of the left ventricle. There is calcific plaque within the mid vessel, with dense calcific plaque at the bifurcation of the second diagonal branch. This limits evaluation of the vessel lumen, and although a flow-limiting lesion cannot be excluded, there is no evidence of a high-grade stenosis. There is ostial calcification within the second diagonal branch as well. The LAD distal to the second diagonal branch is small relative to the more proximal vessel, and this is worrisome for a proximal flow-limiting lesion.,In addition, there is marked tapering of the D2 branch distal to the proximal and ostial calcific plaque. This is worrisome for either occlusion or a high-grade stenosis. There is only minimal contrast that is identified in the distal vessel.,LEFT CIRCUMFLEX ARTERY:,The left circumflex artery is a moderate-sized vessel with a patent ostium. There is calcific plaque within the proximal vessel. There is dense calcific plaque at the bifurcation of the OM1, and the AV groove branch. The AV groove branch tapers as a small vessel at the base of the heart. The dense calcific plaque within the bifurcation of the OM1 and the AV groove branch limits evaluation of the vessel lumen. There is no demonstrated high-grade stenosis, but a flow-limiting lesion cannot be excluded here.,RIGHT CORONARY ARTERY:,The right coronary artery is a moderate-sized vessel with a patent ostium. There is proximal mixed calcific and non-calcific plaque, but there is no flow-limiting lesion. The vessel continues as a moderate-sized vessel to the crux of the heart, supplying a small posterior descending artery and moderate to large posterolateral ventricular branches.,There is scattered calcific plaque within the mid vessel and there is also calcific plaque within the distal vessel at the origin of the posterior descending artery. There is no flow-limited lesion demonstrated.,The right coronary artery is dominant.,NONCORONARY CARDIAC STRUCTURE:,CARDIAC CHAMBERS:, There is diffuse myocardial thinning within the left ventricle, particularly within the apex where there is subendocardial calcification, consistent with chronic infarction. There is ventricular enlargement. There is no demonstrated aneurysm or pseudoaneurysm.,CARDIAC VALVES: ,There is calcification within the left aortic valve cusp. The aortic valve is tri-leaflet. Normal mitral valve.,PERICARDIUM:, Normal.,GREAT VESSELS: ,There are atherosclerotic changes within the aorta.,VISUALIZED LUNG PARENCHYMA, MEDIASTINUM AND CHEST WALL: ,Normal.,IMPRESSION:,Limited examination secondary to extensive artifact from the pacemaker wires.,There is extensive calcific plaque within the left anterior descending artery as well as within the proximal second diagonal branch. There is marked tapering of the LAD distal to the bifurcation of the D1 and this is worrisome for a flow-limiting lesion, but there is no evidence of occlusion.,There is marked tapering of the D1 branch distal to the calcific plaque and occlusion cannot be excluded.,There is dense calcific plaque within the left circumflex artery, and although a flow-limiting lesion cannot be excluded here, there is no evidence of an occlusion or high-grade stenosis.,There is mixed soft and calcific plaque within the proximal RCA, but there is no flow limiting lesion demonstrated.,There is diffuse thinning of the left ventricular wall, most focal at the apex where there is also dense calcification, consistent with chronic infarction. There is no demonstrated aneurysm or pseudoaneurysm."
116,0,"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."
180,1,"INDICATION: , Aortic stenosis.,PROCEDURE: , Transesophageal echocardiogram.,INTERPRETATION:  ,Procedure and complications explained to the patient in detail.  Informed consent was obtained.  The patient was anesthetized in the throat with lidocaine spray.  Subsequently, 3 mg of IV Versed was given for sedation.  The patient was positioned and transesophageal probe was introduced without any difficulty.  Images were taken.  The patient tolerated the procedure very well without any complications.  Findings as mentioned below.,FINDINGS:,1.  Left ventricle is in normal size and dimension.  Normal function.  Ejection fraction of 60%.,2.  Left atrium and right-sided chambers are of normal size and dimension.,3.  Mitral, tricuspid, and pulmonic valves are structurally normal.,4.  Aortic valve reveals annular calcification with fibrocalcific valve leaflets with decreased excursion.,5.  Left atrial appendage is clean without any clot or smoke effect.,6.  Atrial septum intact.  Study was negative.,7.  Doppler study essentially benign.,8.  Aorta essentially benign.,9.  Aortic valve planimetry valve area average about 1.3 cm2 consistent with moderate aortic stenosis.,SUMMARY:,1.  Normal left ventricular size and function.,2.  Benign Doppler flow pattern.,3.  Aortic valve area of 1.3 cm2 planimetry.,"
183,1,"EXAM: , MRI of lumbar spine without contrast.,HISTORY:,  A 24-year-old female with chronic back pain.,TECHNIQUE: , Noncontrast axial and sagittal images were acquired through the lumbar spine in varying degrees of fat and water weighting.,FINDINGS: , The visualized cord is normal in signal intensity and morphology with conus terminating in proper position.  Visualized osseous structures are normal in marrow signal intensity and morphology without evidence for fracture/contusion, compression deformity, or marrow replacement process.  There are no paraspinal masses.,Disc heights, signal, and vertebral body heights are maintained throughout the lumbar spine.,L5-S1:  Central canal, neural foramina are patent.,L4-L5:  Central canal, neural foramina are patent.,L3-L4:  Central canal, neural foramen is patent.,L2-L3:  Central canal, neural foramina are patent.,L1-L2:  Central canal, neural foramina are patent.,The visualized abdominal aorta is normal in caliber.  Incidental note has been made of multiple left-sided ovarian, probable physiologic follicular cysts.,IMPRESSION: , No acute disease in the lumbar spine."
140,0,"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."
174,1,"EXAM:,  MRI head without contrast.,REASON FOR EXAM: , Severe headaches.,INTERPRETATION:,  Imaging was performed in the axial and sagittal planes using numerous pulse sequences at 1 tesla.  Correlation is made with the head CT of 4/18/05.,On the diffusion sequence, there is no significant bright signal to indicate acute infarction.  There is a large degree of increased signal involving the periventricular white matter extending around to the subcortical regions in symmetrical fashion consistent with chronic microvascular ischemic disease.  There is mild chronic ischemic change involving the pons bilaterally, slightly greater on the right, and when correlating with the recent scan, there is an old tiny lacunar infarct of the right brachium pontis measuring roughly 4 mm in size.  There are prominent perivascular spaces of the lenticulostriate distribution compatible with the overall degree of moderate to moderately advanced atrophy.  There is an old moderate-sized infarct of the mid and lateral aspects of the right cerebellar hemisphere as seen on the recent CT scan.  This involves mostly the superior portion of the hemisphere in the superior cerebellar artery distribution.  No abnormal mass effect is identified.  There are no findings to suggest active hydrocephalus.  No abnormal extra-axial collection is identified.  There is normal flow void demonstrated in the major vascular systems.,The sagittal sequence demonstrates no Chiari malformation.  The region of the pituitary/optic chiasm grossly appears normal.  The mastoids and paranasal sinuses are clear.,IMPRESSION:,1.  No definite acute findings identified involving the brain.,2.  There is prominent chronic cerebral ischemic change as described with mild chronic pontine ischemic changes.  There is an old moderate-sized infarct of the superior portion of the right cerebellar hemisphere.,3.  Moderate to moderately advanced atrophy."
36,0,"HISTORY OF PRESENT ILLNESS: , This is a 43-year-old black man with no apparent past medical history who presented to the emergency room with the chief complaint of weakness, malaise and dyspnea on exertion for approximately one month.  The patient also reports a 15-pound weight loss.  He denies fever, chills and sweats.  He denies cough and diarrhea.  He has mild anorexia.,PAST MEDICAL HISTORY:,  Essentially unremarkable except for chest wall cysts which apparently have been biopsied by a dermatologist in the past, and he was given a benign diagnosis.  He had a recent PPD which was negative in August 1994.,MEDICATIONS: , None.,ALLERGIES: , No known drug allergies.,SOCIAL HISTORY: , He occasionally drinks and is a nonsmoker.  The patient participated in homosexual activity in Haiti during 1982 which he described as ""very active."" Denies intravenous drug use.  The patient is currently employed.,FAMILY HISTORY:,  Unremarkable.,PHYSICAL EXAMINATION:,GENERAL:  This is a thin, black cachectic man speaking in full sentences with oxygen.,VITAL SIGNS:  Blood pressure 96/56, heart rate 120.  No change with orthostatics.  Temperature 101.6 degrees Fahrenheit.  Respirations 30.,HEENT:  Funduscopic examination normal.  He has oral thrush.,LYMPH:  He has marked adenopathy including right bilateral epitrochlear and posterior cervical nodes.,NECK:  No goiter, no jugular venous distention.,CHEST:  Bilateral basilar crackles, and egophony at the right and left middle lung fields.,HEART:  Regular rate and rhythm, no murmur, rub or gallop.,ABDOMEN:  Soft and nontender.,GENITOURINARY:  Normal.,RECTAL:  Unremarkable.,SKIN:  The patient has multiple, subcutaneous mobile nodules on the chest wall that are nontender.  He has very pale palms., ,LABORATORY AND X-RAY DATA: , Sodium 133, potassium 5.3, BUN 29, creatinine 1.8.  Hemoglobin 14, white count 7100, platelet count 515.  Total protein 10, albumin 3.1, AST 131, ALT 31.  Urinalysis shows 1+ protein, trace blood.  Total bilirubin 2.4, direct bilirubin 0.1.  Arterial blood gases:  pH 7.46, pC02 32, p02 46 on room air.  Electrocardiogram shows normal sinus rhythm.  Chest x-ray shows bilateral alveolar and interstitial infiltrates.,IMPRESSION:,1.  Bilateral pneumonia; suspect atypical pneumonia, rule out Pneumocystis carinii pneumonia and tuberculosis.,2.  Thrush.,3.  Elevated unconjugated bilirubins.,4.  Hepatitis.,5.  Elevated globulin fraction.,6.  Renal insufficiency.,7.  Subcutaneous nodules.,8.  Risky sexual behavior in 1982 in Haiti.,PLAN:,1.  Induced sputum, rule out Pneumocystis carinii pneumonia and tuberculosis.,2.  Begin intravenous Bactrim and erythromycin.,3.  Begin prednisone.,4.  Oxygen.,5.  Nystatin swish and swallow.,6.  Dermatologic biopsy of lesions.,7.  Check HIV and RPR.,8.  Administer Pneumovax, tetanus shot and Heptavax if indicated."
91,1,"HDR BRACHYTHERAPY,The intracavitary brachytherapy applicator was placed appropriately and secured after the patient was identified.  Simulation films were obtained, documenting its positioning.  The 3-dimensional treatment planning process was accomplished utilizing the CT derived data.  A treatment plan was selected utilizing sequential dwell positions within a single catheter.  The patient was taken to the treatment area.  The patient was appropriately positioned and the position of the intracavitary device was checked.  Catheter length measurements were taken.  Appropriate measurements of the probe dimensions and assembly were also performed.  The applicator was attached to the HDR after-loader device.  The device ran through its checking sequences appropriately and the brachytherapy was then delivered without difficulty or complication.  The brachytherapy source was appropriately removed back to the brachytherapy safe within the device.  Radiation screening was performed with the Geiger-Muller counter both prior to and after the brachytherapy procedure was completed and the results were deemed appropriate.,Following completion of the procedure, the intracavitary device was removed without difficulty.  The patient was in no apparent distress and was discharged home."
104,0,"FEMALE PHYSICAL EXAMINATION,HEENT:  Pupils equal, round and reactive to light and accommodation.  Extraocular movements are intact.  Sclerae are anicteric.  TMs are clear bilaterally.  Oropharynx is clear without erythema or exudate.,Neck:  Supple without lymphadenopathy or thyromegaly.  Carotids are silent.  There is no jugular venous distention.,Chest:  Clear to auscultation bilaterally.,Cardiovascular:  Regular rate and rhythm without S3, S4.  No murmurs or rubs are appreciated.  Peripheral pulses are +2 and equal bilaterally in all four extremities.,Abdomen:  Soft, nontender, nondistended with positive bowel sounds.  No masses, hepatomegaly or splenomegaly are appreciated.,GU:  Reveals normal female external genitalia.  Speculum exam reveals vaginal mucosa to be pink and rugous.  Cervix appears normal.  Bimanual exam reveals uterus to be within normal limits.  Adnexa are normal without masses appreciated.  There is no cervical motion tenderness.,Rectal Exam:  Normal rectal tone.  No masses are appreciated.  Hemoccult is negative.,Extremities:  Reveal no clubbing, cyanosis, or edema.,Joint Exam:  Reveals no tenosynovitis.,Integumentary:  Normal breast tissue without lumps or masses.  There are no skin changes over the breasts.  Axillae are free of masses.,Neurologic:  Cranial nerves II through XII are grossly intact.  Motor strength is 5/5 and equal in all four extremities.  Deep tendon reflexes are +2/4 and equal bilaterally.  Patient is alert and oriented times 3.,Psychiatric:  Grossly normal.,Dermatologic:  No lesions or rashes."
148,0,"SUBJECTIVE:,  This is a 2-year-old female who comes in for just rechecking her weight, her breathing status, and her diet.  The patient is in foster care, has a long history of the prematurity, born at 22 weeks.  She has chronic lung disease, is on ventilator, but doing sprints, has been doing very well, is up to 4-1/2 hours sprints twice daily and may go up 15 minutes every three days or so; which she has been tolerating fairly well as long as they kind of get her distracted towards the end, otherwise, she does get sort of tachypneic.  She is on 2-1/2 liters of oxygen and does require that.  Her diet has been fluctuating.  They have been trying to figure out what works best with her.  She has been on some Pediasure for the increased calories but that really makes her distended in the abdomen and constipates her.  They have been doing more pureed foods and that seems to loosen her up, so they have been doing more Isomil 24 cal and baby foods and not so much Pediasure.  She was hospitalized a couple of weeks back for the distension she had in the abdomen.  Dr. XYZ has been working with her G-tube, increasing her Mic-key button size, but also doing some silver nitrate applications, and he is going to evaluate her again next week, but they are happy with the way her G-tube site is looking.  She also has been seen Dr. Eisenbaum, just got of new pair of glasses this week and sees him in another couple of weeks for reevaluation.,CURRENT MEDICATIONS:,  Flagyl, vitamins, Zyrtec, albuterol, and some Colace.,ALLERGIES TO MEDICINES: , None.,FAMILY SOCIAL HISTORY:,  As mentioned, she is in foster care.  Foster mom is actually going to be out of town for a week the 19th through the 23rd, so she will probably be hospitalized in respite care because there are no other foster care situations that can handle the patient.  Biological Mom and Grandma do visit on Thursdays for about an hour.,REVIEW OF SYSTEMS:,  The patient has been eating fairly well, sleeping well, doing well with her sprints.  A little difficulty with her stools hard versus soft as mentioned with the diet situation up in HPI.,PHYSICAL EXAMINATION:,Vital Signs:  She is 28 pounds 8 ounces today, 33-1/2 inches tall.  She is on 2-1/2 liters, but she is not the vent currently, she is doing her sprints, and her respiratory rate is around 40.,HEENT:  Sclerae and conjunctivae are clear.  TMs are clear.  Nares are patent.  Oropharynx is clear.  Trach site is clear of any signs of infection.,Chest:  Coarse.  She has got little bit of wheezing going on, but she is moving air fairly well.,Abdomen:  Positive bowel sounds and soft.  The G-tube site looks fairly clean today and healthy.  No signs of infection.  Her tone is good.  Capillary refill is less than three seconds.,ASSESSMENT:,  A 2-year-old with chronic lung disease, doing the sprints, some bowel difficulties, also just weight gain issues because of the high-energy expenditure with the sprints that she is doing.,PLAN:,  At this point is to continue with the Isomil and pureed baby foods, a little bit of Pediasure.  They are going to see Dr. XYZ towards the end of this month and follow up with Dr. Eisenbaum.  I would like to see her in approximately six weeks again, but we do need to keep a close check on her weight and call if there are problems beforehand.  She is just doing wonderful progression on her development.  Each time I see her, I am very impressed, that relayed to foster mom.  Approximately 25 minutes spent with the patient, most of it counseling."
143,0,"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."
22,0,"DIAGNOSES:,1.  Pneumonia.,2.  Crohn disease.,3.  Anasarca.,4.  Anemia.,CHIEF COMPLAINT: , I have a lot of swelling in my legs.,HISTORY:  ,The patient is a 41-year-old gentleman with a long history of Crohn disease.  He has been followed by Dr. ABC, his primary care doctor, but he states that he has had multiple gastroenterology doctors and has not seen one in the past year to 18 months.  He has been treated with multiple different medications for his Crohn disease and most recently has been taking pulses of steroids off and on when he felt like he was having symptoms consistent with crampy abdominal pain, increased diarrhea, and low-grade fevers.  This has helped in the past, but now he developed symptoms consistent with pneumonia and was admitted to the hospital.  He has been treated with IV antibiotics and is growing Streptococcus.  At this time, he seems relatively stable although slightly dyspneic.  Other symptoms include lower extremity edema, pain in his ankles and knees, and actually symptoms of edema in his entire body including his face and upper extremities.  At this time, he continues to have symptoms consistent with diarrhea and malabsorption.  He also has some episodes of nausea and vomiting at times.  He currently has a cough and symptoms of dyspnea.  Further review of systems was not otherwise contributory.,MEDICATIONS:,1.  Prednisone.,2.  Effexor.,3.  Folic acid.,4.  Norco for pain.,PAST MEDICAL HISTORY: , As mentioned above, but he also has anxiety and depression.,PAST SURGICAL HISTORY:,1.  Small bowel resections.,2.  Appendectomy.,3.  A vasectomy.,ALLERGIES:  ,He has no known drug allergies.,SOCIAL HISTORY:  ,He does smoke two packs of cigarettes per day.  He has no alcohol or drug use.  He is a painter.,FAMILY HISTORY:  ,Significant for his father who died of IPF and irritable bowel syndrome.,REVIEW OF SYSTEMS: , As mentioned in the history of present illness and further review of systems is not otherwise contributory.,PHYSICAL EXAMINATION:,GENERAL:  He is a thin appearing man in very mild respiratory distress when his oxygen is off.,VITAL SIGNS:  His respiratory rate is approximately 18 to 20, his blood pressure is 100/70, his pulse is 90 and regular, he is afebrile currently at 96, and weight is approximately 163 pounds.,HEENT:  Sclerae anicteric.  Conjunctivae normal.  Nasal and oropharynx are clear.,NECK:  Supple.  No jugular venous pressure distention is noted.  There is no adenopathy in the cervical, supraclavicular or axillary areas.,CHEST:  Reveals some crackles in the right chest, in the base, and in the upper lung fields.  His left is relatively clear with decreased breath sounds.,HEART:  Regular rate and rhythm.,ABDOMEN:  Slightly protuberant.  Bowel sounds are present.  He is slightly tender and it is diffuse.  There is no organomegaly and no ascites appreciable.,EXTREMITIES:  There is a mild scrotal edema and in his lower extremities he has 2 to 3+ edema at pretibial and lateral feet.,DERMATOLOGIC:  Shows thin skin.  No ecchymosis or petechiae.,LABORATORY STUDIES: , Laboratory studies are pertinent for a total protein of 3 and albumin of 1.3.  There is no M-spike observed.  His B12 is 500 with a folic acid of 11.  His white count is 21 with a hemoglobin of 10, and a platelet count 204,000.,IMPRESSION AT THIS TIME:,1.  Pneumonia in the face of fairly severe Crohn disease with protein-losing enteropathy and severe malnutrition with anasarca.,2.  He also has anemia and leukocytosis, which may be related to his Crohn disease as well as his underlying pneumonia.,ASSESSMENT AND PLAN: , At this time, I believe evaluation of protein intake and dietary supplement will be most appropriate.  I believe that he needs a calorie count.  We will check on a sedimentation rate, C-reactive protein, LDH, prealbumin, thyroid, and iron studies in the morning with his laboratory studies that are already ordered.  I have recommended strongly to him that when he is out of the hospital, he return to the care of his gastroenterologist.  I will help in anyway that I can to improve the patient's laboratory abnormalities.  However, his lower extremity edema is primarily due to his marked hypoalbuminemia and I do not believe that diuretics will help him at this time.  I have explained this in detail to the patient and his family.  Everybody expresses understanding and all questions were answered.  At this time, follow him up during his hospital stay and plan to see him in the office as well."
99,0,"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.,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."
192,1,"CLINICAL INDICATIONS: , MRSA bacteremia, rule out endocarditis.  The patient has aortic stenosis.,DESCRIPTION OF PROCEDURE: , The transesophageal echocardiogram was performed after getting verbal and a written consent signed.  Then a multiplane TEE probe was introduced into the upper esophagus, mid esophagus, lower esophagus, and stomach and multiple views were obtained.  There were no complications.  The patient's throat was numbed with Cetacaine spray and IV sedation was achieved with Versed and fentanyl.,FINDINGS:,1.  Aortic valve is thick and calcified, a severely restricted end opening and there is 0.6 x 8 mm vegetation attached to the right coronary cusp.  The peak velocity across the aortic valve was 4.6 m/sec and mean gradient was 53 mmHg and peak gradient 84 mmHg with calculated aortic valve area of 0.6 sq cm by planimetry.,2.  Mitral valve is calcified and thick.  No vegetation seen.  There is mild-to-moderate MR present.  There is mild AI present also.,3.  Tricuspid valve and pulmonary valve are structurally normal.,4.  There is a mild TR present.,5.  There is no clot seen in the left atrial appendage.  The velocity in the left atrial appendage was 0.6 m/sec.,6.  Intraatrial septum was intact.  There is no clot or mass seen.,7.  Normal LV and RV systolic function.,8.  There is thick raised calcified plaque seen in the thoracic aorta and arch.,SUMMARY:,1.  There is a 0.6 x 0.8 cm vegetation present in the aortic valve with severe aortic stenosis.  Calculated aortic valve area was 0.6 sq. cm.,2.  Normal LV systolic function.,"
107,0,"HISTORY OF PRESENT ILLNESS:,  A 49-year-old female with history of atopic dermatitis comes to the clinic with complaint of left otalgia and headache.  Symptoms started approximately three weeks ago and she was having difficulty hearing, although that has greatly improved.  She is having some left-sided sinus pressure and actually went to the dentist because her teeth were hurting; however, the teeth were okay.  She continues to have some left-sided jaw pain.  Denies any headache, fever, cough, or sore throat.  She had used Cutivate cream in the past for the atopic dermatitis with good results and is needing a refill of that.  She has also had problems with sinusitis in the past and chronic left-sided headache.,FAMILY HISTORY:,  Reviewed and unchanged.,ALLERGIES: , To cephalexin.,CURRENT MEDICATIONS:,  Ibuprofen.,SOCIAL HISTORY:,  She is a nonsmoker.,REVIEW OF SYSTEMS:,  As above.  No nausea, vomiting, or diarrhea.,PHYSICAL EXAMINATION:,General:  A well-developed and well-nourished female, conscious, alert, and in no acute distress.,Vital Signs:  Weight:  121 pounds.  Temperature:  97.9 degrees.,Skin:  Reveals scattered erythematous plaques with some mild lichenification on the nuchal region and behind the knees.,Eyes:  PERRLA.  Conjunctivae are clear.,Ears:  Left TM with some effusion.  Right TM is clear.  Canals are clear.  External auricles are nontender to manipulation.,Nose:  Nasal mucosa is pink and moist without discharge.,Throat:  Nonerythematous.  No tonsillar hypertrophy or exudate.,Neck:  Supple without adenopathy or thyromegaly.,Lungs:  Clear.  Respirations are regular and unlabored.,Heart:  Regular rate and rhythm at rate of 100 beats per minute.,ASSESSMENT:,1.  Serous otitis.,2.  Atopic dermatitis.,PLAN:,1.  Nasacort AQ two sprays each nostril daily.,2.  Duraphen II one b.i.d.,3.  Refills Cutivate cream 0.05% to apply to affected areas b.i.d.  Recheck p.r.n."
101,0,"HISTORY OF PRESENT ILLNESS: , Goes back to yesterday, the patient went out for dinner with her boyfriend.  The patient after coming home all the family members had some episodes of diarrhea; it is unclear how many times the patient had diarrhea last night.  She was found down on the floor this morning, soiled her bowel movements.  Paramedics were called and the patient was brought to the emergency room.  The patient was in the emergency room noted to be in respiratory failure, was intubated.  The patient was in septic shock with metabolic acidosis and no blood pressure and very rapid heart rate with acute renal failure.  The patient was started on vasopressors.  The patient was started on IV fluids as well as IV antibiotic.  The CT of the abdomen showed ileus versus bowel distention without any actual bowel obstruction or perforation.  A General Surgery consultation was called who did not think the patient was a surgical candidate and needed an acute surgical procedure.  The patient underwent an ultrasound of the abdomen, which did not show any evidence of cholecystitis or cholelithiasis.  The patient was also noted to have acute rhabdomyolysis on the workup in the emergency room.,PAST MEDICAL HISTORY:  ,Significant for history of osteoporosis, hypertension, tobacco dependency, anxiety, neurosis, depression, peripheral arterial disease, peripheral neuropathy, and history of uterine cancer.,PAST SURGICAL HISTORY:  ,Significant for hysterectomy, bilateral femoropopliteal bypass surgeries as well as left eye cataract surgery and appendicectomy.,SOCIAL HISTORY: , She lives with her boyfriend.  The patient has a history of heavy tobacco and alcohol abuse for many years.,FAMILY HISTORY: , Not available at this current time.,REVIEW OF SYSTEMS: , As mentioned above.,PHYSICAL EXAMINATION:,GENERAL:  She is intubated, obtunded, gangrenous ears with gangrenous fingertips.,VITAL SIGNS:  Blood pressure is absent, heart rate of 138 per minute, and the patient is on the ventilator.,HEENT:  Examination shows head is atraumatic, pupils are dilated and very, very sluggishly reacting to light.  No oropharyngeal lesions noted.,NECK:  Supple.  No JVD, distention or carotid bruit.  No lymphadenopathy.,LUNGS:  Bilateral crackles and bruits.,ABDOMEN:  Distended, unable to evaluate if this is tender.  No hepatosplenomegaly.  Bowel sounds are very hyperactive.,LOWER EXTREMITIES:  Show no edema.  Distal pulses are decreased.,OVERALL NEUROLOGICAL:  Examination cannot be assessed.,LABORATORY DATA: , The database was available at this point of time.  WBC count is elevated at 19,000 with the left shift, hemoglobin of 17.7, and hematocrit of 55.8 consistent with severe dehydration.  PT INR is prolonged at 1.7 and aPTT is prolonged at 60.  Sodium was 143, BUN of 36, and creatinine of 2.5.  The patient's blood gas shows pH of 7.05, pO2 of 99.6, and pCO2 of 99.6.  Bicarb is 16.5.,ASSESSMENT AND EVALUATION:,1.  Septicemia with septic shock.,2.  Metabolic acidosis.,3.  Respiratory failure.,4.  Anuria.,5.  Acute renal failure.,The patient has no blood pressure at this point in time.  The patient is on IV fluids.  The patient is on vasopressors due to ventilator support, bronchodilators as well as IV antibiotics.  Her overall prognosis is extremely poor.  This was discussed with the patient's niece who is at bedside and will become indicated with her daughter when she arrives who is on the plane right now from Iowa.  The patient will be maintained on these supports at this point in time, but prognosis is poor."
149,1,"INDICATION FOR STUDY: , Elevated cardiac enzymes, fullness in chest, abnormal EKG, and risk factors.,MEDICATIONS:,  Femara, verapamil, Dyazide, Hyzaar, glyburide, and metformin.,BASELINE EKG: , Sinus rhythm at 84 beats per minute, poor anteroseptal R-wave progression, mild lateral ST abnormalities.,EXERCISE RESULTS:,1.  The patient exercised for 3 minutes stopping due to fatigue.  No chest pain.,2.  Heart rate increased from 84 to 138 or 93% of maximum predicted heart rate.  Blood pressure rose from 150/88 to 210/100.  There was a slight increase in her repolorization abnormalities in a non-specific pattern.,NUCLEAR PROTOCOL:  ,Same day rest/stress protocol was utilized with 11 mCi for the rest dose and 33 mCi for the stress test.,NUCLEAR RESULTS:,1.  Nuclear perfusion imaging, review of the raw projection data reveals adequate image acquisition.  The resting images showed decreased uptake in the anterior wall.  However the apex is spared of this defect.  There is no significant change between rest and stress images.  The sum score is 0.,2.  The Gated SPECT shows moderate LVH with slightly low EF of 48%.,IMPRESSION:,1.  No evidence of exercise induced ischemia at a high myocardial workload.  This essentially excludes obstructive CAD as a cause of her elevated troponin.,2.  Mild hypertensive cardiomyopathy with an EF of 48%.,3.  Poor exercise capacity due to cardiovascular deconditioning.,4.  Suboptimally controlled blood pressure on today's exam."
56,1,"EXAM: , Ultrasound abdomen, complete.,HISTORY: , 38-year-old male admitted from the emergency room 04/18/2009, decreased mental status and right upper lobe pneumonia.  The patient has diffuse abdominal pain.  There is a history of AIDS.,TECHNIQUE:,  An ultrasound examination of the abdomen was performed.,FINDINGS:,  The liver has normal echogenicity.  The liver is normal sized.  The gallbladder has a normal appearance without gallstones or sludge.  There is no gallbladder wall thickening or pericholecystic fluid.  The common bile duct has a normal caliber at 4.6 mm.  The pancreas is mostly obscured by gas.  A small portion of the head of pancreas is visualized which has a normal appearance.  The aorta has a normal caliber.  The aorta is smooth walled.  No abnormalities are seen of the inferior vena cava.  The right kidney measures 10.8 cm in length and the left kidney 10.5 cm.  No masses, cysts, calculi, or hydronephrosis is seen.  There is normal renal cortical echogenicity.  The spleen is somewhat prominent with a maximum diameter of 11.2 cm.  There is no ascites.  The urinary bladder is distended with urine and shows normal wall thickness without masses.  The prostate is normal sized with normal echogenicity.,IMPRESSION:  ,1.  Spleen size at the upper limits of normal.,2.  Except for small portions of pancreatic head, the pancreas could not be visualized because of bowel gas.  The visualized portion of the head had a normal appearance.,3.  The gallbladder has a normal appearance without gallstones.  There are no renal calculi."
125,0,"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."
48,0,"REASON FOR CONSULTATION:,  Coronary artery disease (CAD), prior bypass surgery.,HISTORY OF PRESENT ILLNESS: , The patient is a 70-year-old gentleman who was admitted for management of fever.  The patient has history of elevated PSA and BPH.  He had a prior prostate biopsy and he recently had some procedure done, subsequently developed urinary tract infection, and presently on antibiotic.  From cardiac standpoint, the patient denies any significant symptom except for fatigue and tiredness.  No symptoms of chest pain or shortness of breath.,His history from cardiac standpoint as mentioned below.,CORONARY RISK FACTORS: , History of hypertension, history of diabetes mellitus, nonsmoker.  Cholesterol elevated.  History of established coronary artery disease in the family and family history positive.,FAMILY HISTORY: , Positive for coronary artery disease.,SURGICAL HISTORY: , Coronary artery bypass surgery and a prior angioplasty and prostate biopsies.,MEDICATIONS:,1.  Metformin.,2.  Prilosec.,3.  Folic acid.,4.  Flomax.,5.  Metoprolol.,6.  Crestor.,7.  Claritin.,ALLERGIES:,  DEMEROL, SULFA.,PERSONAL HISTORY: , He is married, nonsmoker, does not consume alcohol, and no history of recreational drug use.,PAST MEDICAL HISTORY:,  Significant for multiple knee surgeries, back surgery, and coronary artery bypass surgery with angioplasty, hypertension, hyperlipidemia, elevated PSA level, BPH with questionable cancer.  Symptoms of shortness of breath, fatigue, and tiredness.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No history of fever, rigors, or chills except for recent fever and rigors.,HEENT:  No history of cataract or glaucoma.,CARDIOVASCULAR:  As above.,RESPIRATORY:  Shortness of breath.  No pneumonia or valley fever.,GASTROINTESTINAL:  Nausea and vomiting.  No hematemesis or melena.,UROLOGICAL:  Frequency, urgency.,MUSCULOSKELETAL:  No muscle weakness.,SKIN:  None significant.,NEUROLOGICAL:  No TIA or CVA.  No seizure disorder.,PSYCHOLOGICAL:  No anxiety or depression.,ENDOCRINE:  As above.,HEMATOLOGICAL:  None significant.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse of 75, blood pressure 130/68, afebrile, and respiratory rate 16 per minute.,HEENT:  Atraumatic, normocephalic.,NECK:  Veins flat.  No significant carotid bruits.,LUNGS:  Air entry bilaterally fair.,HEART:  PMI displaced.  S1 and S2 regular.,ABDOMEN:  Soft, nontender.  Bowel sounds present.,EXTREMITIES:  No edema.  Pulses are palpable.  No clubbing or cyanosis.,CNS:  Benign.,EKG:"
96,1,"CC:, Memory loss.,HX:, This 77 y/o RHF presented with a one year history of progressive memory loss. Two weeks prior to her evaluation at UIHC she agreed to have her sister pick her up for church at 8:15AM, Sunday morning. That Sunday she went to pick up her sister at her sister's home and when her sister was not there (because the sister had gone to pick up the patient) the patient left. She later called the sister and asked her if she (sister) had overslept. During her UIHC evaluation she denied she knew anything about the incident. No other complaints were brought forth by the patients family.,PMH:, Unremarkable.,MEDS:, None,FHX: ,Father died of an MI, Mother had DM type II.,SHX: , Denies ETOH/illicit drug/Tobacco use.,ROS:, Unremarkable.,EXAM:, Afebrile, 80BPM, BP 158/98, 16RPM. Alert and oriented to person, place, time. Euthymic. 29/30 on Folstein's MMSE with deficit on drawing. Recalled 2/6 objects at five minutes and could not recite a list of 6 objects in 6 trials. Digit span was five forward and three backward. CN: mild right lower facial droop only. MOTOR: Full strength throughout. SENSORY: No deficits to PP/Vib/Prop/LT/Temp. COORD: Poor RAM in LUE only. GAIT: NB and ambulated without difficulty. STATION: No drift or Romberg sign. REFLEXES: 3+ bilaterally with flexor plantar responses. There were no frontal release signs.,LABS:, CMB, General Screen, FT4, TSH, VDRL were all WNL.,NEUROPSYCHOLOGICAL EVALUATION, 12/7/92: ,Verbal associative fluency was defective. Verbal memory, including acquisition, and delayed recall and recognition, was severely impaired. Visual memory, including immediate and delayed recall was also severely impaired. Visuoperceptual discrimination was mildly impaired, as was 2-D constructional praxis.,HCT, 12/7/92: , Diffuse cerebral atrophy with associative mild enlargement of the ventricles consistent with patient's age. Calcification is seen in both globus pallidi and this was felt to be a normal variant."
50,1,"INTENSITY-MODULATED RADIATION THERAPY SIMULATION,The patient will receive intensity-modulated radiation therapy in order to deliver high-dose treatment to sensitive structures.  The target volume is adjacent to significant radiosensitive structures.,Initially, the preliminary isocenter is set on a fluoroscopically-based simulation unit.  The patient is appropriately immobilized using a customized immobilization device.  Preliminary simulation films are obtained and approved by me.  The patient is marked and transferred to the CT scanner.  Sequential images are obtained and transferred electronically to the treatment planning software.  Extensive analysis then occurs.  The target volume, including margins for uncertainty, patient movement and occult tumor extension are selected.  In addition organs at risk are outlined.  Appropriate doses are selected, both for the target, as well as constraints for organs at risk.  Inverse treatment planning is performed by the physics staff under my supervision.  These are reviewed by the physician and ultimately performed only following approval by the physician and completion of successful quality assurance."
0,0,"REASON FOR ADMISSION: , Fever of unknown origin.,HISTORY OF PRESENT ILLNESS: , The patient is a 39-year-old woman with polymyositis/dermatomyositis on methotrexate once a week.  The patient has also been on high-dose prednisone for an urticarial rash.  The patient was admitted because of persistent high fevers without a clear-cut source of infection.  She had been having temperatures of up to 103 for 8-10 days.  She had been seen at Alta View Emergency Department a week prior to admission.  A workup there including chest x-ray, blood cultures, and a transthoracic echocardiogram had all remained nondiagnostic, and were normal.  Her chest x-ray on that occasion was normal.  After the patient was seen in the office on August 10, she persisted with high fevers and was admitted on August 11 to Cottonwood Hospital.  Studies done at Cottonwood:  CT scan of the chest, abdomen, and pelvis.  Results:  CT chest showed mild bibasilar pleural-based interstitial changes.  These were localized to mid and lower lung zones.  The process was not diffuse.  There was no ground glass change.  CT abdomen and pelvis was normal.  Infectious disease consultation was obtained.  Dr. XYZ saw the patient.  He ordered serologies for CMV including a CMV blood PCR.  Next serologies for EBV, Legionella, Chlamydia, Mycoplasma, Coccidioides, and cryptococcal antigen, and a PPD.  The CMV serology came back positive for IgM.  The IgG was negative.  The CMV blood PCR was positive, as well.  Other serologies and her PPD stayed negative.  Blood cultures stayed negative.,In view of the positive CMV, PCR, and the changes in her CAT scan, the patient was taken for a bronchoscopy.  BAL and transbronchial biopsies were performed.  The transbronchial biopsies did not show any evidence of pneumocystis, fungal infection, AFB.  There was some nonspecific interstitial fibrosis, which was minimal.  I spoke with the pathologist, Dr. XYZ and immunopathology was done to look for CMV.  The patient had 3 nucleoli on the biopsy specimens that stained positive and were consistent with CMV infection.  The patient was started on ganciclovir once her CMV serologies had come back positive.  No other antibiotic therapy was prescribed.  Next, the patient's methotrexate was held.,A chest x-ray prior to discharge showed some bibasilar disease, showing interstitial infiltrates.  The patient was given ibuprofen and acetaminophen during her hospitalization, and her fever resolved with these measures.,On the BAL fluid cell count, the patient only had 5 WBCs and 5 RBCs on the differential.  It showed 43% neutrophils, 45% lymphocytes.,Discussions were held with Dr. XYZ, Dr. XYZ, her rheumatologist, and with pathology.,DISCHARGE DIAGNOSES:,1.  Disseminated CMV infection with possible CMV pneumonitis.,2.  Polymyositis on immunosuppressive therapy (methotrexate and prednisone).,DISCHARGE MEDICATIONS:,1.  The patient is going to go on ganciclovir 275 mg IV q.12 h. for approximately 3 weeks.,2.  Advair 100/50, 1 puff b.i.d.,3.  Ibuprofen p.r.n. and Tylenol p.r.n. for fever, and will continue her folic acid.,4.  The patient will not restart for methotrexate for now.,She is supposed to follow up with me on August 22, 2007 at 1:45 p.m.  She is also supposed to see Dr. XYZ in 2 weeks, and Dr. XYZ in 2-3 weeks.  She also has an appointment to see an ophthalmologist in about 10 days' time.  This was a prolonged discharge, more than 30 minutes were spent on discharging this patient."
53,1,"CC:, Difficulty with word finding.,HX: ,This 27y/o RHF experienced sudden onset word finding difficulty and slurred speech on the evening of 2/19/96. She denied any associated dysphagia, diplopia, numbness or weakness of her extremities. She went to sleep with her symptoms on 2/19/96, and awoke with them on 2/20/96. She also awoke with a headache (HA) and mild neck stiffness. She took a shower and her HA and neck stiffness resolved. Throughout the day she continued to have difficulty with word finding and had worsening of her slurred speech. That evening, she began to experience numbness and weakness in the lower right face. She felt like there was a ""rubber-band"" wrapped around her tongue.,For 3 weeks prior to presentation, she experienced transient episodes of a ""boomerang"" shaped field cut in the left eye. The episodes were not associated with any other symptoms. One week prior to presentation, she went to a local ER for menorrhagia. She had just resumed taking oral birth control pills one week prior to the ER visit after having stopped their use for several months. Local evaluation included an unremarkable carotid duplex scan. However, a HCT with and without contrast reportedly revealed a left frontal gyriform enhancing lesion. An MRI brain scan on 2/20/96 revealed nonspecific white matter changes in the right periventricular region. EEG reportedly showed diffuse slowing. CRP was reportedly ""too high"" to calibrate.,MEDS:, Ortho-Novum 7-7-7 (started 2/3/96), and ASA (started 2/20/96).,PMH:, 1)ventral hernia repair 10 years ago, 2)mild ""concussion"" suffered during a MVA; without loss of consciousness, 5/93, 3) Anxiety disorder, 4) One childbirth.,FHX: ,She did not know her father and was not in contact with her mother.,SHX:, Lives with boyfriend. Smokes one pack of cigarettes every three days and has done so for 10 years. Consumes 6 bottles of beers, one day a week. Unemployed and formerly worked at an herbicide plant.,EXAM: ,BP150/79, HR77, RR22, 37.4C.,MS: A&O to person, place and time. Speech was dysarthric with mild decreased fluency marked by occasional phonemic paraphasic errors. Comprehension, naming and reading were intact. She was able to repeat, though her repetition was occasionally marked by phonemic paraphasic errors. She had no difficulty with calculation.,CN: VFFTC, Pupils 5/5 decreasing to 3/3. EOM intact. No papilledema or hemorrhages seen on fundoscopy. No RAPD or INO. There was right lower facial weakness. Facial sensation was intact, bilaterally. The rest of the CN exam was unremarkable.,MOTOR: 5/5 strength throughout with normal muscle bulk and tone.,Sensory: No deficits.,Coord/Station/Gait: unremarkable.,Reflexes 2/2 throughout. Plantar responses were flexor, bilaterally.,Gen Exam: unremarkable.,COURSE:, CRP 1.2 (elevated), ESR 10, RF 20, ANA 1:40, ANCA <1:40, TSH 2.0, FT4 1.73, Anticardiolipin antibody IgM 10.8GPL units (normal <10.9), Anticardiolipin antibody IgG 14.8GPL (normal<22.9), SSA and SSB were normal. Urine beta-hCG pregnancy and drug screen were negative. EKG, CXR and UA were negative.,MRI brain, 2/21/96 revealed increased signal on T2 imaging in the periventricular white matter region of the right hemisphere. In addition, there were subtle T2 signal changes in the right frontal, right parietal, and left parietal regions as seen previously on her local MRI can. In addition, special FLAIR imaging showed increased signal in the right frontal region consistent with ischemia.,She underwent Cerebral Angiography on 2/22/96. This revealed decreased flow and vessel narrowing the candelabra branches of the RMCA supplying the right frontal lobe. These changes corresponded to the areas of ischemic changes seen on MRI. There was also segmental narrowing of the caliber of the vessels in the circle of Willis. There was a small aneurysm at the origin of the LPCA. There was narrowing in the supraclinoid portion of the RICA and the proximal M1 and A1 segments. The study was highly suggestive of vasculitis.,2/23/96, Neuro-ophthalmology evaluation revealed no evidence of retinal vasculitic change. Neuropsychologic testing the same day revealed slight impairment of complex attention only. She was started on Prednisone 60mg qd and Tagamet 400mg qhs.,On 2/26/96, she underwent a right frontal brain biopsy. Pathologic evaluation revealed evidence of focal necrosis (stroke/infarct), but no evidence of vasculitis. Immediately following the brain biopsy, while still in the recovery room, she experienced sudden onset right hemiparesis and transcortical motor type aphasia. Initial HCT was unremarkable. An EEG was consistent with a focal lesion in the left hemisphere. However, a 2/28/96 MRI brain scan revealed new increased signal on T2 weighted images in a gyriform pattern from the left precentral gyrus to the superior frontal gyrus. This was felt consistent with vasculitis.,She began q2month cycles of Cytoxan (1,575mg IV on 2/29/96. She became pregnant after her 4th cycle of Cytoxan, despite warnings to the contrary. After extensive discussions with OB/GYN it was recommended she abort the pregnancy. She underwent neuropsychologic testing which revealed no significant cognitive deficits. She later agreed to the abortion. She has undergone 9 cycles of Cytoxan ( one cycle every 2 months) as of 4/97. She had complained of one episode of paresthesias of the LUE in 1/97. MRI then showed no new signs ischemia."
177,1,"EXAM:,MRI LEFT KNEE,CLINICAL:,This is a 41 -year-old-male with knee pain, mobility loss and swelling. The patient had a twisting injury one week ago on 8/5/05. The examination was performed on 8/10/05,FINDINGS:,There is intrasubstance degeneration within the medial meniscus without a discrete surfacing tear.,There is intrasubstance degeneration within the lateral meniscus, and there is a probable small tear in the anterior horn along the undersurface at the meniscal root.,There is an interstitial sprain/partial tear of the anterior cruciate ligament. There is no complete tear or discontinuity, and the ligament has a celery stick appearance.,Normal posterior cruciate ligament.,Normal medial collateral ligament.,There is a sprain of the femoral attachment of the fibular collateral ligament, without complete tear or discontinuity. The fibular attachment is intact.,Normal biceps femoris tendon, popliteus tendon and iliotibial band.,Normal quadriceps and patellar tendons.,There are no fractures.,There is arthrosis, with high-grade changes in the patellofemoral compartment, particularly along the midline patellar ridge and lateral facet. There are milder changes within the medial femorotibial compartments. There are subcortical cystic changes subjacent to the tibial spine, which appear chronic.,There is a joint effusion. There is synovial thickening.,IMPRESSION:,Probable small tear in the anterior horn of the lateral meniscus at the meniscal root.,Interstitial sprain/partial tear of the anterior cruciate ligament.,Arthrosis, joint effusion and synovial hypertrophy.,There are several areas of focal prominent medullary fat within the medial and lateral femoral condyles."
35,0,"IDENTIFYING DATA:,  This is a 40-year-old male seen today for a 90-day revocation admission.  He had been reported by his case manager as being noncompliant with medications, refusing oral or IM medications, became agitated, had to be taken to ABCD for evaluation, admitted at that time to auditory hallucinations and confusion and was committed for admission at this time.  He has a psychiatric history of schizophrenia, was previously admitted here at XYZ on 12/19/2009, had another voluntary admission in ABCD in 1998.,MEDICATIONS: , Listed as Invega and Risperdal.,ALLERGIES: , None known to medications.,PAST MEDICAL HISTORY:  ,The only identified problem in his chart is that he is being treated for hyperlipidemia with gemfibrozil.  The patient is unaware and cannot remember what medications he had been taking or whether he had been taking them at all as an outpatient.,FAMILY HISTORY: , Listed as unknown in the chart as far as other psychiatric illnesses.  The patient himself states that his parents are deceased and that he raised himself in the Philippines.,SOCIAL HISTORY:,  He immigrated to this country in 1984, although he lists himself as having a green card still at this time.  He states he lives on his own.  He is a single male with no history of marriage or children and that he had high school education.  His recreational drug use in the chart indicates that he has had a history of methamphetamines.  The patient denies this at this time.  He also denies current alcohol use.  He does smoke.  He is unable to tell me of any PCP.  He is in counseling service with his case manager being XYZ.,LEGAL HISTORY:  ,  He had an assault in December 2009, which led to his previous detention.  It is unknown whether he is under legal constraints at this time.,OBJECTIVE FINDINGS:  ,VITAL SIGNS: , Blood pressure is 125/75.  His weight is 197 with height 5 feet 4 inches.,GENERAL:,  He is cooperative, although disorganized and focusing entirely and telling me that he is here because there was some confusion in how he took his medications.  He does not endorse any voices at this time.,HEENT: , His head exam is normal with normal scalp.  HEENT is unremarkable.  Pupils equal and reactive to light and accommodation.  TMs are normal.,NECK:,  Unremarkable with no masses or tenderness.,CARDIOVASCULAR:,  Normal S1 and S2.  No murmurs.,LUNGS:,  Clear.,ABDOMEN:  ,Negative with no scars.,GU:  ,Not done.,RECTAL:,  Not done.,DERM:,  He does have a scarring of acne lesions, both face and back.,EXTREMITIES:,  Otherwise negative.,NEUROLOGIC: , Cranial nerves II through X normal.  Reflexes are normal and gait is unremarkable.,LABORATORY DATA: , His labs done at ABCD showed his CMP to be normal with an elevated white count of 17.2.  Chest x-ray was indicated as being done and normal as was a UA and he did apparently receive hydration in the hospital with IV fluids.,ASSESSMENT: , History of hyperlipidemia with elevated triglycerides.  We will maintain his gemfibrozil 600 b.i.d. and for health maintenance issues, we will also maintain just a vitamin daily and we will obtain recheck on his labs and lipid levels in one week after treatment is initiated."
70,1,"CONCOMITANT CHEMORADIOTHERAPY FOR CURATIVE INTENT PATIENTS,This patient is receiving combined radiotherapy and chemotherapy in an effort to maximize the chance of control of this cancer.  The chemotherapy is given in addition to the radiotherapy, not only to act as a cytotoxic agent on its own, but also to potentiate and enhance the effect of radiotherapy on tumor cells.  It has been shown in the literature that this will maximize the chance of control.,During the course of the treatment, the patient's therapy must be closely monitored by the attending physician to be sure that the proper chemotherapy drugs are given at the proper time during the radiotherapy course.  It is also important to closely monitor the patient to know when treatment with either chemotherapy or radiotherapy needs to be held.  This combined treatment usually produces greater side effects than either treatment alone, and these need to be constantly monitored and treatment initiated on a timely basis to minimize these effects.  In accordance, this requires more frequency consultation and coordination with the medical oncologist.  Therefore, this becomes a very time intensive treatment and justifies CPT Code 77470."
113,0,"HISTORY OF PRESENT ILLNESS: ,This is the initial clinic visit for a 29-year-old man who is seen for new onset of right shoulder pain.  He states that this began approximately one week ago when he was lifting stacks of cardboard.  The motion that he describes is essentially picking up a stack of cardboard at his waist level, twisting to the right and delivering it at approximately waist level.  Sometimes he has to throw the stacks a little bit as well.  He states he felt a popping sensation on 06/30/04.  Since that time, he has had persistent shoulder pain with lifting activities.  He localizes the pain to the posterior and to a lesser extent the lateral aspect of the shoulder.  He has no upper extremity .  , ,REVIEW OF SYSTEMS: ,Focal lateral and posterior shoulder pain without a suggestion of any cervical radiculopathies.  He denies any chronic cardiac, pulmonary, GI, GU, neurologic, musculoskeletal, endocrine abnormalities.  , ,MEDICATIONS: , Claritin for allergic rhinitis.  , ,ALLERGIES: , None.  , ,PHYSICAL EXAMINATION:, Blood pressure 120/90, respirations 10, pulse 72, temperature 97.2.  He is sitting upright, alert and oriented, and in no acute distress.  Skin is warm and dry. Gross neurologic examination is normal.  ENT examination reveals normal oropharynx, nasopharynx, and tympanic membranes.  Neck: Full range of motion with no adenopathy or thyromegaly.  Cardiovascular:  Regular rate and rhythm.  Lungs:  Clear.  Abdomen: Soft."
4,0,"FINAL DIAGNOSES:,1.  Gastroenteritis.,2.  Autism.,DIET ON DISCHARGE:,  Regular for age.,MEDICATIONS ON DISCHARGE: , Adderall and clonidine for attention deficit hyperactivity disorder.,ACTIVITY ON DISCHARGE: , As tolerated.,DISPOSITION ON DISCHARGE: , Follow up with Dr. X in ABC Office in 1 to 2 weeks.,HISTORY OF PRESENT ILLNESS: , This 10-and-4/12-year-old Caucasian female has autism and is enrolled at ABC School, and she takes Adderall and clonidine for her hyperactivity.  She developed constipation one week prior to admission and mother gave her MiraLax and her constipation improved.  She developed vomiting 3 days prior to admission, but did not have diarrhea.  She voided on the day of admission.  When she presented to the office, her weight was 124 pounds, which was approximately 10 pounds below previous weights and even had a weight of 151.5 pounds, 05/30/2007 and weight of 137.5 pounds, 09/11/2007 with mother giving no good explanation as to why she had lost all this weight.  She was admitted because of the persistent vomiting, but there was concern about the weight loss.,Physical examination on admission was unremarkable except for the obvious signs autistic spectrum disorder.,LABORATORY DATA:  ,Laboratory data included sedimentation rate of 12, magnesium level of 2.2, TSH of 2.63 with normal being 0.34 to 5.60, free T4 of 1.68 with normal being 0.58 to 1.64.  Chest x-ray and abdominal films were unremarkable.  Hemoglobin 14.5, hematocrit 43.5, platelet count 400,000, white blood count 11,800.  Urinalysis was negative for ketones.  Specific gravity 1.023, and negative for protein.  Sodium 137, potassium 3.4, chloride 103, CO2 20, BUN 21, creatinine 0.9, and anion gap 14, glucose 90, total protein 8.1, albumin 4.5, calcium 8.8, bilirubin 1.5, AST 26, ALT 16, alkaline phosphatase 118.  Thyroid peroxidase antibody studies are pending.,HOSPITAL COURSE:  ,The child was observed on IV fluids and advanced to clear liquids and then regular diet as tolerated.  On the second hospital day, mother was comfortable taking her to home.  Mother did not have a good explanation for the weight loss.  In the hospital, her weight was 124 pounds, her height 58 inches, temperature 98.0 degree F., pulse 123, respirations 18, blood pressure 148/94.  Follow up blood pressure were some of them were in the 125 to 70 range making us think her hypertension as labile and perhaps related to the excitement of the admission.,She seem quite happy and in no distress at the time of discharge.  We will follow up in the office and try to further evaluate her for the unexplained weight loss.  She has been taking the Adderall for at least a year, and the mother does not think the Adderall is the cause of the weight loss.  The free T4 is borderline high and probably bears repeating along with further studies for Graves disease as an outpatient."
133,0,"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."
93,1,"CC: ,Episodic confusion.,HX: ,This 65 y/o RHM reportedly suffered a stroke on 1/17/92. He presented locally at that time with complaint of episodic confusion and memory loss lasting several minutes per episode. The ""stroke"" was reportedly verified on MRI scan dated 1/17/92. He was subsequently placed on ASA and DPH. He admitted that there had been short periods (1-2 days duration) since then, during which he had forgotten to take his DPH. However, even when he had been taking his DPH regularly, he continued to experience the spells mentioned above. He denied any associated tonic/clonic movement, incontinence, tongue-biting, HA, visual change, SOB, palpitation, weakness or numbness. The episodes of confusion and memory loss last 1-2 minutes in duration, and have been occurring 2-3 times per week.,PMH:, Bilateral Hearing Loss of unknown etiology, S/P bilateral ear surgery many years ago.,MEDS:, DPH and ASA,SHX/FHX:, 2-4 Beers/day. 1-2 packs of cigarettes per day.,EXAM:, BP 111/68, P 68BPM, 36.8C. Alert and Oriented to person, place and time, 30/30 on mini-mental status test, Speech fluent and without dysarthria. CN: Left superior quandranopia only. Motor: 5/5 strength throughout. Sensory: unremarkable except for mild decreased vibration sense in feet. Coordination: unremarkable. Gait and station testing were unremarkable. He was able to tandem walk without difficulty. Reflexes: 2+ and symmetric throughout. Flexor plantar responses bilaterally.,LAB:, Gen Screen, CBC, PT, PTT all WNL. DPH 4.6mcg/ml.,Review of outside MRI Brain done 1/17/92 revealed decreased T1 and increased T2 signal in the Right temporal lobe involving the uncus and adjacent hippocampus. The area did not enhance with gadolinium contrast.,CXR:, 8/31/92: 5 x 6 mm spiculated opacity in apex right lung.,EEG:, 8/24/92: normal awake and asleep,MRI Brain with/without contrast: 8/31/92: Decreased T1 and increased T2 signal in the right temporal lobe. The lesion increased in size and enhances more greatly when compared to the 1/17/92 MRI exam. There is also edema surrounding the affected area and associated mass effect.,NEUROPSYCHOLOGICAL TESTING:, Low-average digit symbol substitution, mildly impaired verbal learning, and severely defective delayed recall. There was relative preservation of other cognitive functions. The findings were consistent with left mesiotemporal dysfunction.,COURSE: ,Patient underwent right temporal lobectomy on 9/16/92 following initial treatment with Decadron. Pathologic analysis was consistent with a Grade 2 astrocytoma. GFAP staining positive. Following surgery he underwent 5040 cGy radiation therapy in 28 fractions to the tumor bed."
191,1,"CC:, Orthostatic lightheadedness.,HX:, This 76 y/o male complained of several months of generalized weakness and malaise, and a two week history of progressively worsening orthostatic dizziness. The dizziness worsened when moving into upright positions. In addition, he complained of intermittent throbbing holocranial headaches, which did not worsen with positional change, for the past several weeks. He had lost 40 pounds over the past year and denied any recent fever, SOB, cough, vomiting, diarrhea, hemoptysis, melena, hematochezia, bright red blood per rectum, polyuria, night sweats, visual changes, or syncopal episodes.,He had a 100+ pack-year history of tobacco use and continued to smoke 1 to 2 packs per day. He has a history of sinusitis.,EXAM:, BP 98/80 mmHg and pulse 64 BPM (supine); BP 70/palpable mmHG and pulse 84BPM (standing). RR 12, Afebrile. Appeared fatigued.,CN: unremarkable.,Motor and Sensory exam: unremarkable.,Coord: Slowed but otherwise unremarkable movements.,Reflexes: 2/2 and symmetric throughout all 4 extremities. Plantar responses were flexor, bilaterally.,The rest of the neurologic and general physical exam was unremarkable.,LAB:, Na 121 meq/L, K 4.2 meq/L, Cl 90 meq/L, CO2 20meq/L, BUN 12mg/DL, CR 1.0mg/DL, Glucose 99mg/DL, ESR 30mm/hr, CBC WNL with nl WBC differential, Urinalysis: SG 1.016 and otherwise WNL, TSH 2.8 IU/ML, FT4 0.9ng/DL, Urine Osmolality 246 MOSM/Kg (low), Urine Na 35 meq/L,,COURSE:, The patient was initially hydrated with IV normal saline and his orthostatic hypotension resolved, but returned within 24-48hrs. Further laboratory studies revealed: Aldosterone (serum)<2ng/DL (low), 30 minute Cortrosyn Stimulation test: pre 6.9ug/DL (borderline low), post 18.5ug/DL (normal stimulation rise), Prolactin 15.5ng/ML (no baseline given), FSH and LH were within normal limits for males. Testosterone 33ng/DL (wnl). Sinus XR series (done for history of headache) showed an abnormal sellar region with enlarged sella tursica and destruction of the posterior clinoids. There was also an abnormal calcification seen in the middle of the sellar region. A left maxillary sinus opacity with air-fluid level was seen. Goldman visual field testing was unremarkable. Brain CT and MRI revealed suprasellar mass most consistent with pituitary adenoma. He was treated with Fludrocortisone 0.05 mg BID and within 24hrs, despite discontinuation of IV fluids, remained hemodynamically stable and free of symptoms of orthostatic hypotension. His presumed pituitary adenoma continues to be managed with Fludrocortisone as of this writing (1/1997), though he has developed dementia felt secondary to cerebrovascular disease (stroke/TIA)."
61,1,"REASON FOR EXAM: , Right-sided abdominal pain with nausea and fever.,TECHNIQUE: , Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300.,CT ABDOMEN:  ,The liver, spleen, pancreas, gallbladder, adrenal glands, and kidney are unremarkable.,CT PELVIS: , Within the right lower quadrant, the appendix measures 16 mm and there are adjacent inflammatory changes with fluid in the right lower quadrant.  Findings are compatible with acute appendicitis.,The large and small bowels are normal in course and caliber without obstruction.  The urinary bladder is normal.  The uterus appears unremarkable.  Mild free fluid is seen in the lower pelvis.,No destructive osseous lesions are seen.  The visualized lung bases are clear.,IMPRESSION: , Acute appendicitis."
95,1,"EXAM: , AP abdomen and ultrasound of kidney.,HISTORY:,  Ureteral stricture.,AP ABDOMEN ,FINDINGS:,  Comparison is made to study from Month DD, YYYY.  There is a left lower quadrant ostomy.  There are no dilated bowel loops suggesting obstruction.  There is a double-J right ureteral stent, which appears in place.  There are several pelvic calcifications, which are likely vascular.  No definite pathologic calcifications are seen overlying the regions of the kidneys or obstructing course of the ureters.  Overall findings are stable versus most recent exam.,IMPRESSION: , Properly positioned double-J right ureteral stent.  No evidence for calcified renal or ureteral stones.,ULTRASOUND KIDNEYS,FINDINGS:,  The right kidney is normal in cortical echogenicity of solid mass, stone, hydronephrosis measuring 9.0 x 2.9 x 4.3 cm.  There is a right renal/ureteral stent identified.  There is no perinephric fluid collection.,The left kidney demonstrates moderate-to-severe hydronephrosis.  No stone or solid masses seen.  The cortex is normal.,The bladder is decompressed.,IMPRESSION:,1.  Left-sided hydronephrosis.,2.  No visible renal or ureteral calculi.,3.  Right ureteral stent."
194,1,"EXAM:,  CT cervical spine (C-spine) for trauma.,FINDINGS:,  CT examination of the cervical spine was performed without contrast.  Coronal and sagittal reformats were obtained for better anatomical localization.  Cervical vertebral body height, alignment and interspacing are maintained.  There is no evidence of fractures or destructive osseous lesions.  There are no significant degenerative endplate or facet changes.  No significant osseous central canal or foraminal narrowing is present.,IMPRESSION: , Negative cervical spine."
41,0,"REASON FOR CONSULTATION: , Hemoptysis.,HISTORY OF PRESENT ILLNESS: , The patient is an 80-year-old African-American male, very well known to my service, with a past medical history significant for asbestos exposure.  The patient also has a very extensive cardiac history that would be outlined below.  He is being admitted with worsening shortness of breath and constipation.  He is also complaining of cough and blood mixed with sputum production, but there is no fever.,PAST MEDICAL HISTORY,1.  Benign prostatic hypertrophy.,2.  Peptic ulcer disease.,3.  Atrial fibrillation.,4.  Coronary artery disease.,5.  Aortic valve replacement in 1991, St. Jude mechanical valve #23.,6.  ICD implantation.,7.  Peripheral vascular disease.,8.  CABG in 1991 and 1998.,9.  Congestive heart failure, EF 40%.,10.  Asbestos exposure.,MEDICATIONS,1.  Coumadin 6 mg alternating with 9 mg.,2.  Prevacid 30 mg once a day.,3.  Diovan 160 mg every day.,4.  Flomax 0.4 mg every day.,5.  Coreg 25 mg in the morning and 12.5 mg at night.,6.  Aldactone 25 mg a day.,7.  Lasix 20 mg a day.,8.  Zocor 40 mg every day.,ALLERGIES,1. DARVOCET.,2. CLONIDINE.,PHYSICAL EXAMINATION,GENERAL:  The patient is an elderly male; awake, alert, and oriented, in no acute distress.,VITAL SIGNS:  Blood pressure is 136/80, pulse is 70, respiratory rate is 20, temperature 99.3, pulse oximetry 96% on 2 L nasal cannula.,HEENT:  Significant for peripheral cyanosis.,NECK:  Supple.,LUNGS:  Bibasilar crackles with decreased breath sounds in the left base.,CARDIOVASCULAR:  Regular rate and rhythm with murmur and metallic click.,ABDOMEN:  Soft and benign.,EXTREMITIES:  1+ cyanosis.  No clubbing.  No edema.,LABORATORY DATA:,  Shows a white count of 6.9, hemoglobin 10.6, hematocrit 31.2, and platelet count 160,000.  CK 266, PTT 37, PT 34, and INR 3.7.  Sodium 141, potassium 4.2, chloride 111, CO2 23, BUN 18, creatinine 1.7, glucose 91, calcium 8.6, total protein 6.1, albumin 3.3, total bilirubin 1.4, alkaline phosphatase 56, and troponin I 0.085 and 0.074.,DIAGNOSTIC STUDIES: , Chest x-ray shows previous sternotomy with ICD implantation and aortic valve mechanical implant with left-sided opacification of the diaphragm worrisome for pleural effusion.,ASSESSMENT,1.  Hemoptysis.,2.  Acute bronchitis.,3.  Coagulopathy.,4.  Asbestos exposure.,5.  Left pleural effusion.,RECOMMENDATIONS,1.  Antibiotics."
33,0,"REASON FOR CONSULTATION:, Please evaluate stomatitis, possibly methotrexate related.,HISTORY OF PRESENT ILLNESS:, The patient is a very pleasant 57-year old white female, a native of Cuba, being seen for evaluation and treatment of sores in her mouth that she has had for the last 10-12 days.  The patient has a long history of severe and debilitating rheumatoid arthritis for which she has had numerous treatments, but over the past ten years she has been treated with methotrexate quite successfully.  Her dosage has varied somewhere between 20 and 25 mg per week.  About the beginning of this year, her dosage was decreased from 25 mg to 20 mg, but because of the flare of the rheumatoid arthritis, it was increased to 22.5 mg per week.  She has had no problems with methotrexate as far as she knows.  She also took an NSAID about a month ago that was recently continued because of the ulcerations in her mouth.  About two weeks ago, just about the time the stomatitis began she was placed on an antibiotic for suspected upper respiratory infection.  She does not remember the name of the antibiotic.  Although she claims she remembers taking this type of medication in the past without any problems.  She was on that medication three pills a day for three to four days.  She notes no other problems with her skin.  She remembers no allergic reactions to medication.  She has no previous history of fever blisters.  ,PHYSICAL EXAMINATION:, Reveals superficial erosions along the lips particularly the lower lips.  The posterior buccal mucosa along the sides of the tongue and also some superficial erosions along the upper and lower gingiva.  Her posterior pharynx was difficult to visualize, but I saw no erosions on the areas today.  There did however appear to be one small erosion on the soft palate.  Examination of the rest of her skin revealed no areas of dermatitis or blistering.  There were some macular hyperpigmentation on the right arm where she has had a previous burn, plus the deformities from her rheumatoid arthritis on her hands and feet as well as scars on her knees from total joint replacement surgeries.  ,IMPRESSION: , Erosive stomatitis probably secondary to methotrexate even though the medication has been used for ten years without any problems.  Methotrexate may produce an erosive stomatitis and enteritis after such a use. The patient also may have an enteritis that at this point may have become more quiescent as she notes that she did have some diarrhea about the time her mouth problem developed. She has had no diarrhea today, however. She has noted no blood in her stools and has had no episodes of nausea or vomiting.  ,I am not as familiar with the NSAID causing an erosive stomatitis.  I understand that it can cause gastrointestinal upset, but given the choice between the two, I would think the methotrexate is the most likely etiology for the stomatitis.  ,RECOMMENDED THERAPY: ,I agree with your therapeutic regimen regarding this condition with the use of prednisone and folic acid.  I also agree that the methotrexate must be discontinued in order to produce a resolution of this patients’ skin problem. However, in my experience, this stomatitis may take a number of weeks to go away completely if a patient been on methotrexate, for an extended period of time, because the medication is stored within the liver and in fatty tissue.  Topically I have prescribed Lidex gel, which I find works extremely well in stomatitis conditions.  It can be applied t.i.d.  ,Thank you very much for allowing me to share in the care of this pleasant patient.  I will follow her with you as needed."
42,0,"CHIEF COMPLAINT:, ""My potassium is high"",HISTORY OF PRESENT ILLNESS:, A 47-year-old Latin American man presented to the emergency room after being told to come in for a high potassium value drawn the previous day. He had gone to an outside clinic the day prior to presentation complaining of weakness and fatigue. Labs drawn there revealed a potassium of 7.0 and he was told to come here for further evaluation. At time of his assessment in the emergency room, he noted general malaise and fatigue for eight months. Over this same time period he had subjective fevers and chills, night sweats, and a twenty-pound weight loss. He described anorexia with occasional nausea and vomiting of non-bilious material along with a feeling of light-headedness that occurred shortly after standing from a sitting or lying position. He denied a productive cough but did note chronic left sided upper back pain located in the ribs that was worse with cough and better with massage. He denied orthopnea or paroxysmal nocturnal dyspnea but did become dyspneic after walking 2-3 blocks where before he had been able to jog 2-3 miles. He also noted that over the past year his left testicle had been getting progressively more swollen and painful. He had been seen for this at the onset of symptoms and given a course of antibiotics without improvement. Over the last several months there had been chronic drainage of yellowish material from this testicle. He denied trauma to this area. He denied diarrhea or constipation, changes in his urinary habits, rashes or skin changes, arthritis, arthralgias, abdominal pain, headache or visual changes.,PAST MEDICAL HISTORY:, None.,PAST SURGICAL HISTORY:, Mone.,MEDICATIONS:, Occasional acetaminophen.,ALLERGIES:, NKDA.,SOCIAL HISTORY:, He drank a 6 pack of beer per day for the past 30 years. He smoked a pack and a half of cigarettes per day for the past 35 years. He was currently unemployed but had worked as a mechanic and as a carpet layer in the past. He had been briefly incarcerated 5 years prior to admission. He denied intravenous drug use or unprotected sexual exposures.,FAMILY HISTORY:, There was a history of coronary artery disease and diabetes mellitus in the family.,PHYSICAL EXAM:,VITAL SIGNS - Temp 98.6° F, Respirations 16/minute Lying down - Blood pressure 109/70, pulse 70/minute Sitting - Blood pressure 78/65, pulse 79/minute Standing - Blood pressure 83/70, pulse 95/minute GENERAL: well developed, well nourished, no acute distress HEENT: Normocephalic, atraumatic. Sclerae anicteric. Oropharynx with hyperpigmented patches on the mucosa of the palate. No oral thrush. No lymphadenopathy. No jugular venous distension. No thyromegaly. Neck supple. LUNGS: Decreased intensity of breath sounds throughout without adventitious sounds. No dullness to percussion or changes in fremitus. CARDIOVASCULAR: Regular rate and rhythm. No murmurs, gallops, or rubs. Normal intensity of heart sounds. Normal peripheral pulses. ABDOMEN: Soft, non-tender, non-distended. Positive bowel sounds. No organomegaly. RECTAL: Normal sphincter tone. No masses. Normal prostate. Guaiac negative stool. GENITOURINARY: Left testicle indurated and painful to palpation with slight amount of pustular drainage expressible on anterior aspect. Right testicle normal. EXTREMITIES: Marked clubbing noted in fingers and toes. No cyanosis or edema. No rash or arthritis. LYMPHATICS: 1 x 1 cm mobile, firm, non-tender lymph node noted in left inguinal region. Otherwise no other palpable lymphadenopathy.,CHEST X-RAY:, Ill-defined reticular densities in both apices. No pleural effusions. Cardiomediastinal silhouette within normal range.,CHEST CT SCAN:, Multiple bilateral apical nodules/masses. Largest 3.2 x 1.6 cm in left apex. Several of these masses demonstrate spiculation. There is an associated 1 cm lymph node in the prevascular space as well as subcentimeter nodes in the pretracheal and subcarinal regions. There is a subcarinal node that demonstrates calcifications.,ABDOMINAL CT SCAN: ,Multiple hypodense lesions are noted throughout the liver. The right adrenal gland is full, measuring 1.0 x 2.3 cm. Otherwise the spleen, pancreas, left adrenal, and kidneys are free of gross mass. No significant lymphadenopathy or abnormal fluid collections are seen.,TESTICULAR ULTRASOUND: ,There is an enlarged irregular inhomogenous left epididymis with increased vascularity throughout the left epididymis and testis. There is a large septated hydrocele on the left. The right epididymis and testis is normal.,HOSPITAL COURSE:, The above-mentioned studies were obtained. Further laboratory tests and a diagnostic procedure were performed."
86,1,"PROCEDURE DONE:  ,Resting Myoview and adenosine Myoview SPECT.,INDICATIONS:,  Chest pain.,PROCEDURE:,  13.3 mCi of Tc-99m tetrofosmin was injected and resting Myoview SPECT was obtained.  Pharmacologic stress testing was done using adenosine infusion.  Patient received 38 mg of adenosine infused at 140 mcg/kg/minute over a period of four minutes.  Two minutes during adenosine infusion, 31.6 mCi of Tc-99m tetrofosmin was injected.  Resting heart rate was 90 beats per minute.  Resting blood pressure was 130/70.  Peak heart rate obtained during adenosine infusion was 102 beats per minute.  Blood pressure obtained during adenosine infusion was 112/70.  During adenosine infusion, patient experienced dizziness and shortness of breath.  No significant ST segment, T wave changes, or arrhythmias were seen.,Resting Myoview and adenosine Myoview SPECT showed uniform uptake of isotope throughout myocardium without any perfusion defect.  Gated dynamic imaging showed normal wall motion and normal systolic thickening throughout left ventricular myocardium.  Left ventricular ejection fraction obtained during adenosine Myoview SPECT was 77%.  Lung heart ratio was 0.40.  TID ratio was 0.88.,IMPRESSION:,  Normal adenosine Myoview myocardial perfusion SPECT.  Normal left ventricular regional and global function with left ventricular ejection fraction of 77%."
28,0,"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:"
182,1,"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."
21,0,"SUBJECTIVE: , The patient is a 20-year-old Caucasian male admitted via ABCD Hospital Emergency Department for evaluation of hydrocarbon aspiration.  The patient ingested ""tiki oil"" (kerosene, liquid paraffin, citronella oil) approximately two days prior to admission.  He subsequently developed progressive symptoms of dyspnea, pleuritic chest pain, hemoptysis with nausea and vomiting.  He was seen in the ABCD Hospital Emergency Department, toxic appearing with an abnormal chest x-ray demonstrating bilateral lower lobe infiltrates, greater on the right.  He had a temperature of 38.3 with tachycardia approximating 130.  White count was 59,300 with a marked left shift.  Arterial blood gases showed pH 7.48, pO2 79, and pCO2 35.  He was admitted for further medical management.,PAST MEDICAL HISTORY:,  Aplastic crisis during childhood requiring splenectomy and a cholecystectomy at age 9.,DRUG ALLERGIES: , NONE KNOWN.,CURRENT MEDICATIONS: , None.,FAMILY HISTORY:  ,Noncontributory.,SOCIAL HISTORY:  ,The patient works at a local Christmas tree farm.  He smokes cigarettes approximately one pack per day.,REVIEW OF SYSTEMS:,  Ten-system review significant for nausea, vomiting, fever, hemoptysis, and pleuritic chest pain.,PHYSICAL EXAMINATION,GENERAL:  A toxic-appearing 20-year-old Caucasian male, in mild respiratory distress.,VITAL SIGNS:  Blood pressure 122/74, pulse 130 and regular, respirations 24, temperature 38.3, and oxygen saturation 93%.,SKIN:  No rashes, petechiae or ecchymoses.,HEENT:  Within normal limits.  Pupils are equally round and reactive to light and accommodation.  Ears clean.  Throat clean.,NECK:  Supple without thyromegaly.  Lymph nodes are nonpalpable.,CHEST:  Decreased breath sounds bilaterally, greater on the right, at the right base.,CARDIAC:  No murmur or gallop rhythm.,ABDOMEN:  Mild direct diffuse tenderness without rebound.  No detectable masses, pulsations or organomegaly.,EXTREMITIES:  No edema.  Pulses are equal and full bilaterally.,NEUROLOGIC:  Nonfocal.,DATABASE: , Chest x-ray, bilateral lower lobe pneumonia, greater on the right.  EKG, sinus tachycardia, rate of 130, normal intervals, no ST changes.  Arterial blood gases on 2 L of oxygen, pH 7.48, pO2 79, and pCO2 35.,BLOOD STUDIES: , Hematocrit is 43, WBC 59,300 with a left shift, and platelet count 394,000.  Sodium is 130, potassium 3.8, chloride 97, bicarbonate 24, BUN 14, creatinine 0.8, random blood sugar 147, and calcium 9.4.,IMPRESSION,1.  Hydrocarbon aspiration.,2.  Bilateral pneumonia with pneumonitis secondary to aspiration.,3.  Asplenic patient.,PLAN,1.  ICU monitoring.,2.  O2 protocol.,3.  Hydration.,4.  Antiemetic therapy.,5.  Parenteral antibiotics.,6.  Prophylactic proton pump inhibitors.,The patient will need ICU monitoring and Pulmonary Medicine evaluation pending clinical course.,"
25,0,"HISTORY: , Patient is a 21-year-old white woman who presented with a chief complaint of chest pain.  She had been previously diagnosed with hyperthyroidism.  Upon admission, she had complaints of constant left sided chest pain that radiated to her left arm.  She had been experiencing palpitations and tachycardia.  She had no diaphoresis, no nausea, vomiting, or dyspnea.,She had a significant TSH of 0.004 and a free T4 of 19.3.  Normal ranges for TSH and free T4 are 0.5-4.7 µIU/mL and 0.8-1.8 ng/dL, respectively.  Her symptoms started four months into her pregnancy as tremors, hot flashes, agitation, and emotional inconsistency.  She gained 16 pounds during her pregnancy and has lost 80 pounds afterwards.  She complained of sweating, but has experienced no diarrhea and no change in appetite.  She was given isosorbide mononitrate and IV steroids in the ER.,FAMILY HISTORY:,  Diabetes, Hypertension, Father had a Coronary Artery Bypass Graph (CABG) at age 34.,SOCIAL HISTORY:,  She had a baby five months ago.  She smokes a half pack a day.  She denies alcohol and drug use.,MEDICATIONS:,  Citalopram 10mg once daily for depression; low dose tramadol PRN pain.,PHYSICAL EXAMINATION: , Temperature 98.4; Pulse 123; Respiratory Rate 16; Blood Pressure 143/74.,HEENT:  She has exophthalmos and could not close her lids completely.,Cardiovascular:  tachycardia.,Neurologic:  She had mild hyperreflexiveness.,LAB:,  All labs within normal limits with the exception of Sodium 133, Creatinine 0.2, TSH 0.004, Free T4 19.3 EKG showed sinus tachycardia with a rate of 122.  Urine pregnancy test was negative.,HOSPITAL COURSE: , After admission, she was given propranolol at 40mg daily and continued on telemetry.  On the 2nd day of treatment, the patient still complained of chest pain.  EKG again showed tachycardia.  Propranolol was increased from 40mg daily to 60mg twice daily., A I-123 thyroid uptake scan demonstrated an increased thyroid uptake of 90% at 4 hours and 94% at 24 hours.  The normal range for 4-hour uptake is 5-15% and 15-25% for 24-hour uptake.  Endocrine consult recommended radioactive I-131 for treatment of Graves disease.,Two days later she received 15.5mCi of I-131.  She was to return home after the iodine treatment.  She was instructed to avoid contact with her baby for the next week and to cease breast feeding.,ASSESSMENT / PLAN:,1. Treatment of hyperthyroidism.  Patient underwent radioactive iodine 131 ablation therapy.,2. Management of cardiac symptoms stemming from hyperthyroidism.  Patient was discharged on propranolol 60mg, one tablet twice daily.,3. Monitor patient for complications of I-131 therapy such as hypothyroidism.  She should return to Endocrine Clinic in six weeks to have thyroid function tests performed.  Long-term follow-up includes thyroid function tests at 6-12 month intervals.,4. Prevention of pregnancy for one year post I-131 therapy.  Patient was instructed to use 2 forms of birth control and was discharged an oral contraceptive, taken one tablet daily.,5. Monitor ocular health.  Patient was given methylcellulose ophthalmic, one drop in each eye daily.  She should follow up in 6 weeks with the Ophthalmology clinic.,6. Management of depression.  Patient will be continued on citalopram 10 mg."
142,0,"PROBLEM:,  Probable Coumadin hypersensitivity.,HISTORY OF PRESENT ILLNESS:,  The patient is an 82-year-old Caucasian female admitted to the Hospital for elective total left knee arthroplasty.  At the time of admission, the patient has a normal prothrombin time and INR of 13.4 seconds and 1.09 respectively and postoperatively, she was placed on Coumadin which is the usual orthopedic surgery procedure for reducing the risk of postoperative thromboembolic activity.  However, the patient's prothrombin time and INR rapidly rose to supratherapeutic levels.  Even though Coumadin was discontinued on 01/21/09, the patient's prothrombin time and INR has continued to rise.  Her prothrombin time is now 83.3 seconds with an INR of 6.52.  Hematology/Oncology consult was requested for recommendation regarding further evaluation and management.,SOCIAL HISTORY: , The patient is originally from Maine.  She has lived in Arizona for 4 years.  She has had 2 children; however, only one is living.  She had one child died from complications of ulcerative colitis.  She has been predominantly a homemaker during her life, but has done some domestic cleaning work in the past.,CHILDHOOD HISTORY: , Negative for rheumatic fever.  The patient has usual childhood illnesses.,ALLERGIES:  ,No known drug allergies.,FAMILY HISTORY: , The patient's mother died from gastric cancer.  She had a brother who died from mesothelioma.  He did have a positive asbestos exposure working in the shipyards.  The patient's father died from motor vehicle accident.  She had a sister who succumbed to pneumonia as a complication to Alzheimer disease.,HABITS: , No use of ethanol, tobacco, illicit, or recreational substances.,ADULT MEDICAL PROBLEMS: , The patient has a history of diabetes mellitus, hypertension, and hypercholesterolemia, which is all consistent with the metabolic syndrome X.  In addition, the patient's husband, who is present, knows that she has early dementia and has problems with memory and difficulty in processing new information.,SURGERIES: , The patient's only surgery is the aforementioned left knee arthroplasty and bilateral cataract surgery, otherwise negative.,MEDICATIONS: , The patient's medications on admission include:,1.  Fosamax.,2.  TriCor.,3.  Gabapentin.,4.  Hydrochlorothiazide.,5.  Labetalol.,6.  Benicar.,7.  Crestor.,8.  Detrol.,REVIEW OF SYSTEMS: , Unable to obtain review of systems as the patient was given a dose of morphine for postoperative pain and she is a bit obtunded at this time.  She is arousable, but not particularly conversant.,OBSERVATIONS:,GENERAL:  The patient is a drowsy, but arousable, nonconversant, elderly Caucasian female.,HEENT:  Pupils were equal, round, and reactive to light and accommodation.  Extraocular muscles are grossly intact.  Oropharynx benign.,NECK:  Supple.  Full range of motion without bruits or thyromegaly.,LUNGS:  Clear to auscultation and percussion.,BACK:  Without spine or CVA tenderness.,HEART:  Regular rate and rhythm without murmurs, rubs, thrills, or heaves.,ABDOMEN:  Soft and nontender.  Positive bowel sounds without mass or visceromegaly.,LYMPHATIC:  No appreciable adenopathy.,EXTREMITIES:  The patient has some postoperative fullness involving her left knee.  She has a dressing over the left knee.,SKIN:  Without lesions.,NEURO:  Unable to assess in light of post morphine obtunded state.,ASSESSMENT: , Hypersensitivity to Coumadin.,PLAN: , Gave the patient vitamin K at this time.  Literature suggested oral vitamin K is actually more efficacious than parenteral.  However, in light of the fact that the patient is obtunded and is not taking anything right now in the way of oral food or fluids, we will give this to her in an IM fashion.  Repeat prothrombin time and INR in a.m.  Once she has come down to a more therapeutic range, I would initiate low-molecular weight heparin in the form of Fragmin one time a day or Lovenox on a b.i.d. schedule for 4 to 6 weeks postoperatively."
7,0,"HISTORY OF PRESENT ILLNESS: , The patient is a 45-year-old male complaining of abdominal pain.  The patient also has a long-standing history of diabetes which is treated with Micronase daily.,PAST MEDICAL HISTORY: , There is no significant past medical history noted today.,PHYSICAL EXAMINATION:,HEENT:  Patient denies ear abnormalities, nose abnormalities and throat abnormalities.,Cardio:  Patient has history of elevated cholesterol, but does not have ASHD, hypertension and PVD.,Resp:  Patient denies asthma, lung infections and lung lesions.,GI:  Patient denies colon abnormalities, gall bladder problems, liver abnormalities and peptic ulcer disease.,GU:  Patient has history of Urinary tract disorder, but does not have Bladder disorder and Kidney disorder.,Endocrine:  Patient has history of diabetes, but does not have hormonal irregularities and thyroid abnormalities.,Dermatology:  Patient denies allergic reactions, rashes and skin lesions.,MEDS:,  Micronase 2.5 mg Tab PO QAM #30.  Bactrim 400/80 Tab PO BID #30.,SOCIAL HISTORY:,  No known history of drug or alcohol abuse.  Work, diet, and exercise patterns are within normal limits.,FAMILY HISTORY:,  No significant family history.,REVIEW OF SYSTEMS:,  Non-contributory.,Vital Signs:  Height = 72 in.  Weight =184 lbs.  Upright BP = 120/80 mmHg.  Pulse = 80 bpm.  Resp =12 pm.  Patient is afebrile.,Neck:  The neck is supple.  There is no jugular venous distension.  The thyroid is nontender, or normal size and conto.,Lungs:  Lung expansion and excursions are symmetric.  The lungs are clear to auscultation and percussion.,Cardio:  There is a regular rhythm.  SI and S2 are normal.  No abnormal heart sounds are detected.  Blood pressure is equal bilaterally.,Abdomen:  Normal bowel sounds are present.  The abdomen is soft; The abdomen is nontender; without organomegaly; There is no CVA tenderness.  No hernias are noted.,Extremities:  There is no clubbing, cyanosis, or edema.,ASSESSMENT: , Diabetes type II uncontrolled.  Acute cystitis.,PLAN: , Endocrinology Consult, complete CBC.  ,RX: , Micronase 2.5 mg Tab PO QAM #30, Bactrim 400/80 Tab PO BID #30."
146,0,"CHIEF COMPLAINT:,  Toothache.,HISTORY OF PRESENT ILLNESS:  ,This is a 29-year-old male who has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled.  Complains of new tooth pain.  The patient states his current toothache is to both upper and lower teeth on the left side for approximately three days.  The patient states that he would have gone to see his regular dentist but he has missed so many appointments that they now do not allow him to schedule regular appointments, he has to be on standby appointments only.  The patient denies any other problems or complaints.  The patient denies any recent illness or injuries.  The patient does have OxyContin and Vicodin at home which he uses for his knee pain but he wants more pain medicines because he does not want to use up that medicine for his toothache when he wants to say this with me.,REVIEW OF SYSTEMS: , CONSTITUTIONAL:  No fever or chills.  No fatigue or weakness.  No recent weight change.  HEENT:  No headache, no neck pain, the toothache pain for the past three days as previously mentioned.  There is no throat swelling, no sore throat, no difficulty swallowing solids or liquids.  The patient denies any rhinorrhea.  No sinus congestion, pressure or pain, no ear pain, no hearing change, no eye pain or vision change.  CARDIOVASCULAR:  No chest pain.  RESPIRATIONS:  No shortness of breath or cough.  GASTROINTESTINAL:  No abdominal pain.  No nausea or vomiting.  GENITOURINARY:  No dysuria.  MUSCULOSKELETAL:  No back pain.  No muscle or joint aches.  SKIN:  No rashes or lesions.  NEUROLOGIC:  No vision or hearing change.  No focal weakness or numbness.  Normal speech.  HEMATOLOGIC/LYMPHATIC:  No lymph node swelling has been noted.,PAST MEDICAL HISTORY: , Chronic knee pain.,CURRENT MEDICATIONS: , OxyContin and Vicodin.,ALLERGIES:,  PENICILLIN AND CODEINE.,SOCIAL HISTORY: , The patient is still a smoker.,PHYSICAL EXAMINATION:,  VITAL SIGNS:  Temperature 97.9 oral, blood pressure is 146/83, pulse is 74, respirations 16, oxygen saturation 98% on room air and interpreted as normal.  CONSTITUTIONAL:  The patient is well nourished and well developed.  The patient is a little overweight but otherwise appears to be healthy.  The patient is calm, comfortable, in no acute distress, and looks well.  The patient is pleasant and cooperative.  HEENT:  Eyes are normal with clear conjunctiva and cornea bilaterally.  There is no icterus, injection, or discharge.  Pupils are 3 mm and equally round and reactive to light bilaterally.  There is no absence of light sensitivity or photophobia.  Extraocular motions are intact bilaterally.  Ears are normal bilaterally without any sign of infection.  There is no erythema, swelling of canals.  Tympanic membranes are intact without any erythema, bulging or fluid levels or bubbles behind it.  Nose is normal without rhinorrhea or audible congestion.  There is no tenderness over the sinuses.  NECK:  Supple, nontender, and full range of motion.  There is no meningismus.  No cervical lymphadenopathy.  No JVD.  Mouth and oropharynx shows multiple denture and multiple dental caries.  The patient has tenderness to tooth #12 as well as tooth #21.  The patient has normal gums.  There is no erythema or swelling.  There is no purulent or other discharge noted.  There is no fluctuance or suggestion of abscess.  There are no new dental fractures.  The oropharynx is normal without any sign of infection.  There is no erythema, exudate, lesion or swelling.  The buccal membranes are normal.  Mucous membranes are moist.  The floor of the mouth is normal without any abscess, suggestion of Ludwig's syndrome.  CARDIOVASCULAR:  Heart is regular rate and rhythm without murmur, rub, or gallop.  RESPIRATIONS:  Clear to auscultation bilaterally without shortness of breath.  GASTROINTESTINAL:  Abdomen is normal and nontender.  MUSCULOSKELETAL:  No abnormalities are noted to back, arms and legs.  The patient has normal use of his extremities.  SKIN:  No rashes or lesions.  NEUROLOGIC:  Cranial nerves II through XII are intact.  Motor and sensory are intact to the extremities.  The patient has normal speech and normal ambulation.  PSYCHIATRIC:  The patient is alert and oriented x4.  Normal mood and affect.  HEMATOLOGIC/LYMPHATIC:  No cervical lymphadenopathy is palpated.,EMERGENCY DEPARTMENT COURSE: , The patient did request a pain shot and the patient was given Dilaudid of 4 mg IM without any adverse reaction.,DIAGNOSES:,1.  ODONTALGIA.,2.  MULTIPLE DENTAL CARIES.,CONDITION UPON DISPOSITION:  ,Stable.,DISPOSITION: , To home.,PLAN: , The patient was given a list of local dental clinics that he can follow up with or he can choose to stay with his own dentist that he wishes.  The patient was requested to have reevaluation within two days.  The patient was given a prescription for Percocet and clindamycin.  The patient was given drug precautions for the use of these medicines.  The patient was offered discharge instructions on toothache but states that he already has it.  He declined the instructions.  The patient was asked to return to the emergency room, should he have any worsening of his condition or develop any other problems or symptoms of concern."
175,1,"She has an extensive past medical history of rheumatoid arthritis, fibromyalgia, hypertension, hypercholesterolemia, and irritable bowel syndrome.  She has also had bilateral carpal tunnel release.,On examination, normal range of movement of C-spine.  She has full strength in upper and lower extremities.  Normal straight leg raising.  Reflexes are 2 and symmetric throughout.  No Babinski.  She has numbness to light touch in her right big toe.,NERVE CONDUCTION STUDIES:  The right median palmar sensory distal latencies are minimally prolonged with minimally attenuated evoked response amplitude.  Bilateral tibial motor nerves could not be obtained (technical).  The remaining nerves tested revealed normal distal latencies, evoked response amplitudes, conduction velocities, F-waves, and H. reflexes.,NEEDLE EMG:  Needle EMG was performed on the right arm and leg and lumbosacral and cervical paraspinal muscles and the left FDI.  It revealed 2+ spontaneous activity in the right APB and FDI and 1+ spontaneous activity in lower cervical paraspinals, lower and middle lumbosacral paraspinals, right extensor digitorum communis muscle, and right pronator teres.  There was evidence of chronic denervation in the right first dorsal interosseous, pronator teres, abductor pollicis brevis, and left first dorsal interosseous.,IMPRESSION:  This electrical study is abnormal.  It reveals the following:,1.  An active right C8/T1 radiculopathy.  Electrical abnormalities are moderate.,2.  An active right C6/C7 radiculopathy.  Electrical abnormalities are mild.,3.  Evidence of chronic left C8/T1 denervation.  No active denervation.,4.  Mild right lumbosacral radiculopathies.  This could not be further localized because of normal EMG testing in the lower extremity muscles.,5.  There is evidence of mild sensory carpal tunnel on the right (she has had previous carpal tunnel release).,Results were discussed with the patient.  It appears that she has failed conservative therapy and I have recommended to her that she return to Dr. X for his assessment for possible surgery to her C-spine.  She will continue with conservative therapy for the mild lumbosacral radiculopathies."
68,1,"EXAM: , Bilateral renal ultrasound.,CLINICAL INDICATION: , UTI.,TECHNIQUE: , Transverse and longitudinal sonograms of the kidneys were obtained.,FINDINGS:  ,The right kidney is of normal size and echotexture and measures 5.7 x 2.2 x 3.8 cm.  The left kidney is of normal size and echotexture and measures 6.2 x 2.8 x 3.0 cm.  There is no evidence for ,HYDRONEPHROSIS, or ,PERINEPHRIC ,fluid collections.  The bladder is of normal size and contour.  The bladder contains approximately 13 mL of urine after recent voiding.  This is a small postvoid residual.,IMPRESSION: , Normal renal ultrasound.  Small postvoid residual."
181,1,"MEDICATIONS: , Plavix, atenolol, Lipitor, and folic acid.,CLINICAL HISTORY:  ,This is a 41-year-old male patient who comes in with chest pain, had had a previous MI in 07/2003 and stents placement in 2003, who comes in for a stress myocardial perfusion scan.,With the patient at rest, 10.3 mCi of Cardiolite technetium-99 m sestamibi was injected and myocardial perfusion imaging was obtained.,PROCEDURE AND INTERPRETATION:  ,The patient exercised for a total of 12 minutes on the standard Bruce protocol.  The peak workload was 12.8 METS.  The resting heart rate was 57 beats per minute and the peak heart rate was 123 beats per minute, which was 69% of the age-predicted maximum heart rate response.  The blood pressure response was normal with a resting blood pressure of 130/100 and a peak blood pressure of 158/90.  The test was stopped due to fatigue and leg pain.  EKG at rest showed normal sinus rhythm.  The peak stress EKG did not reveal any ischemic ST-T wave abnormalities.  There was ventricular bigeminy seen during exercise, but no sustained tachycardia was seen.  At peak, there was no chest pain noted.  The test was stopped due to fatigue and left pain.  At peak stress, the patient was injected with 30.3 mCi of Cardiolite technetium-99 m sestamibi and myocardial perfusion imaging was obtained, and was compared to resting myocardial perfusion imaging.,MYOCARDIAL PERFUSION IMAGING:,1.  The overall quality of the scan was good.,2.  There was no diagnostic abnormality on the rest and stress myocardial perfusion imaging.,3.  The left ventricular cavity appeared normal in size.,4.  Gated SPECT images revealed mild septal hypokinesis and mild apical hypokinesis.  Overall left ventricular systolic function was low normal with calculated ejection fraction of 46% at rest.,CONCLUSIONS:,1.  Good exercise tolerance.,2.  Less than adequate cardiac stress.  The patient was on beta-blocker therapy.,3.  No EKG evidence of stress induced ischemia.,4.  No chest pain with stress.,5.  Mild ventricular bigeminy with exercise.,6.  No diagnostic abnormality on the rest and stress myocardial perfusion imaging.,7.  Gated SPECT images revealed septal and apical hypokinesis with overall low normal left ventricular systolic function with calculated ejection fraction of 46% at rest."
69,1,"CC:, Weakness.,HX:, This 30 y/o RHM was in good health until 7/93, when he began experiencing RUE weakness and neck pain. He was initially treated by a chiropractor and, after an unspecified length of time, developed atrophy and contractures of his right hand. He then went to a local neurosurgeon and a cervical spine CT scan, 9/25/92, revealed an intramedullary lesion at C2-3 and an extramedullary lesion at C6-7. He underwent a C6-T1 laminectomy with exploration and decompression of the spinal cord. His clinical condition improved over a 3 month post-operative period, and then progressively worsened. He developed left sided paresthesia and upper extremity weakness (right worse than left). He then developed ataxia, nausea, vomiting, and hyperreflexia. On 8/31/93, MRI C-spine showed diffuse enlargement of the cervical and thoracic spine and multiple enhancing nodules in the posterior fossa. On 9/1/93, he underwent suboccipital craniotomy with tumor excision, decompression, and biopsy which was consistent with hemangioblastoma. His symptoms stabilized and he underwent 5040 cGy in 28 fractions to his brain and 3600 cGy in 20 fractions to his cervical and thoracic spinal cord from 9/93 through 1/19/94.,He was evaluated in the NeuroOncology clinic on 10/26/95 for consideration of chemotherapy. He complained of progressive proximal weakness of all four extremities and dysphagia. He had difficulty putting on his shirt and raising his arms, and he had been having increasing difficulty with manual dexterity (e.g. unable to feed himself with utensils). He had difficulty going down stairs, but could climb stairs. He had no bowel or bladder incontinence or retention.,MEDS:, none.,PMH:, see above.,FHX:, Father with Von Hippel-Lindau Disease.,SHX:, retired truck driver. smokes 1-3 packs of cigarettes per day, but denied alcohol use. He is divorced and has two sons who are healthy. He lives with his mother.,ROS:, noncontributory.,EXAM:, Vital signs were unremarkable.,MS: A&O to person, place and time. Speech fluent and without dysarthria. Thought process lucid and appropriate.,CN: unremarkable exept for 4+/4+ strength of the trapezeii. No retinal hemangioblastoma were seen.,MOTOR: 4-/4- strength in proximal and distal upper extremities. There is diffuse atrophy and claw-hands, bilaterally. He is unable to manipulate hads to any great extent. 4+/4+ strength throughout BLE. There is also diffuse atrophy throughout the lower extremities though not as pronounced as in the upper extremities.,SENSORY: There was a right T3 and left T8 cord levels to PP on the posterior thorax. Decreased LT in throughout the 4 extremities.,COORD: difficult to assess due to weakness.,Station: BUE pronator drift.,Gait: stands without assistance, but can only manage to walk a few steps. Spastic gait.,Reflexes: Hyperreflexic on left (3+) and Hyporeflexic on right (1). Babinski signs were present bilaterally.,Gen exam: unremarkable.,COURSE: ,9/8/95, GS normal. By 11/14/95, he required NGT feeding due to dysphagia and aspiration risk confirmed on cookie swallow studies.MRI Brain, 2/19/96, revealed several lesions (hemangioblastoma) in the cerebellum and brain stem. There were postoperative changes and a cyst in the medulla.,On 10/25/96, he presented with a 1.5 week h/o numbness in BLE from the mid- thighs to his toes, and worsening BLE weakness. He developed decubitus ulcers on his buttocks. He also had had intermittent urinary retention for month, chronic SOB and dysphagia. He had been sitting all day long as he could not move well and had no daytime assistance. His exam findings were consistent with his complaints. He had had no episodes of diaphoresis, headache, or elevated blood pressures. An MRI of the C-T spine, 10/26/96, revealed a prominent cervicothoracic syrinx extending down to T10. There was evidence of prior cervical laminectomy of C6-T1 with expansion of the cord in the thecalsac at that region. Multiple intradural extra spinal nodular lesions (hyperintense on T2, isointense on T1, enhanced gadolinium) were seen in the cervical spine and cisterna magna. The largest of which measures 1.1 x 1.0 x 2.0cm. There are also several large ring enhancing lesions in cerebellum. The lesions were felt to be consistent with hemangioblastoma. No surgical or medical intervention was initiated. Visiting nursing was provided. He has since been followed by his local physician"
165,1,"EXAM: , CT of the abdomen and pelvis without contrast.,HISTORY: , Lower abdominal pain.,FINDINGS:,  Limited views of the lung bases demonstrate linear density most likely representing dependent atelectasis.  There is a 1.6 cm nodular density at the left posterior sulcus.,Noncontrast technique limits evaluation of the solid abdominal organs.  Cardiomegaly and atherosclerotic calcifications are seen.,Hepatomegaly is observed.  There is calcification within the right lobe of the liver likely related to granulomatous changes.  Subtle irregularity of the liver contour is noted, suggestive of cirrhosis.  There is splenomegaly seen.  There are two low-attenuation lesions seen in the posterior aspect of the spleen, which are incompletely characterized that may represent splenic cyst.  The pancreas appears atrophic.  There is a left renal nodule seen, which measures 1.9 cm with a Hounsfield unit density of approximately 29, which is indeterminate.,There is mild bilateral perinephric stranding.  There is an 8-mm fat density lesion in the anterior inner polar region of the left kidney, compatible in appearance with angiomyolipoma.  There is a 1-cm low-attenuation lesion in the upper pole of the right kidney, likely representing a cyst, but incompletely characterized on this examination.  Bilateral ureters appear normal in caliber along their visualized course.  The bladder is partially distended with urine, but otherwise unremarkable.,Postsurgical changes of hysterectomy are noted.  There are pelvic phlebolith seen.  There is a calcified soft tissue density lesion in the right pelvis, which may represent an ovary with calcification, as it appears continuous with the right gonadal vein.,Scattered colonic diverticula are observed.  The appendix is within normal limits.  The small bowel is unremarkable.  There is an anterior abdominal wall hernia noted containing herniated mesenteric fat.  The hernia neck measures approximately 2.7 cm.  There is stranding of the fat within the hernia sac.,There are extensive degenerative changes of the right hip noted with changes suggestive of avascular necrosis.  Degenerative changes of the spine are observed.,IMPRESSION:,1.  Anterior abdominal wall hernia with mesenteric fat-containing stranding, suggestive of incarcerated fat.,2.  Nodule in the left lower lobe, recommend follow up in 3 months.,3.  Indeterminate left adrenal nodule, could be further assessed with dedicated adrenal protocol CT or MRI.,4.  Hepatomegaly with changes suggestive of cirrhosis.  There is also splenomegaly observed.,5.  Low-attenuation lesions in the spleen may represent cyst, that are incompletely characterized on this examination.,6.  Fat density lesion in the left kidney, likely represents angiomyolipoma.,7.  Fat density soft tissue lesion in the region of the right adnexa, this contains calcifications and may represent an ovary or possibly dermoid cyst."
119,0,"CC:,  Fall and laceration.,HPI: , Mr. B is a 42-year-old man who was running to catch a taxi when he stumbled, fell and struck his face on the sidewalk.  He denies loss of consciousness but says he was dazed for a while after it happened.  He complains of pain over the chin and right forehead where he has abrasions.  He denies neck pain, back pain, extremity pain or pain in the abdomen.,PMH: , Hypertension.,MEDS:,  None.,ROS: , As above.  Otherwise negative.,PHYSICAL EXAM: , This is a gentleman in full C-spine precautions on a backboard brought by EMS.  He is in no apparent distress.  ,Vital Signs:  BP 165/95 HR 80 RR 12 Temp 98.4 SpO2 95% ,HEENT:  No palpable step offs, there is blood over the right fronto-parietal area where there is a small 1cm laceration and surrounding abrasion.  Also, 2 cm laceration over the base of the chin without communication to the oro-pharynx.  No other trauma noted.  No septal hematoma.  No other facial bony tenderness.  ,Neck:  Nontender ,Chest:  Breathing comfortably; equal breath sounds.  ,Heart:  Regular rhythm.,Abd:  Benign.,Ext:  No tenderness or deformity; pulses are equal throughout; good cap refill ,Neuro:  Awake and alert; slight slurring of speech and cognitive slowing consistent with alcohol; moves all extremities; cranial nerves normal.  ,COURSE IN THE ED:,  Patient arrived and was placed on monitors.  An IV had been placed in the field and labs were drawn.  X-rays of the C spine show no fracture and I've removed the C-collar.  The lacerations were explored and no foreign body found.  They were irrigated and closed with simple interrupted sutures.  Labs showed normal CBC, Chem-7, and U/A except there was moderate protein in the urine.  The blood alcohol returned at 0.146.  A banana bag is ordered and his care will be turned over to Dr. G for further evaluation and care."
81,1,"CARDIAC CT INCLUDING CORONARY CT ANGIOGRAPHY,PROCEDURE: , Breath hold cardiac CT was performed using a 64-channel CT scanner with a 0.5-second rotation time.  Contrast injection was timed using a 10 mL bolus of Ultravist 370 IV.  Then the patient received 75 mL of Ultravist 370 at a rate of 5 mL/sec.,Retrospective ECG gating was performed.  The patient received 0.4 milligrams of sublingual nitroglycerin prior to the to the scan.  The average heart rate was 62 beats/min.,The patient had no adverse reaction to the contrast.  Multiphase retrospective reconstructions were performed.  Small field of view cardiac and coronary images were analyzed on a 3D work station.  Multiplanar reformatted images and 3D volume rendering was performed by the attending physician for the purpose of defining coronary anatomy and determining the extent of coronary artery disease.,CORONARY CTA:,1.  The technical quality of the scan is adequate.,2.  The coronary ostia are in their normal position.  The coronary anatomy is right dominant.,3.  LEFT MAIN:  The left main coronary artery is patent without angiographic stenosis.,4.  LEFT ANTERIOR DESCENDING ARTERY:  The proximal aspect of the left anterior descending artery demonstrates a mixed plaque consisting of both calcified and noncalcified lesion which is less than 30% in stenosis severity.  Diagonal 1 and diagonal 2 branches of the left anterior descending artery demonstrate mild irregularities.,5.  The ramus intermedius is a small vessel with minor irregularities.,6.  LEFT CIRCUMFLEX:  The left circumflex and obtuse marginal 1 and obtuse marginal 2 branches of the vessel are patent without significant stenosis.,7.  RIGHT CORONARY ARTERY:  The right coronary artery is a large and dominant vessel.  It demonstrates within its mid-segment calcified atherosclerosis, less than 50% stenosis severity.  Left ventricular ejection fraction is calculated to be 69%.  There are no wall motion abnormalities.,8.  Coronary calcium score was calculated to be 79, indicating at least mild atherosclerosis within the coronary vessels.,ANCILLARY FINDINGS: , None.,FINAL IMPRESSION:,1.  Mild coronary artery disease with a preserved left ventricular ejection fraction of 69%.,2.  Recommendation is aggressive medical management consisting of aggressive lifestyle modifications and statin therapy.,Thank you for referring this patient to us."
130,0,"CHIEF COMPLAINT: , Nausea, vomiting, diarrhea, and fever.,HISTORY OF PRESENT ILLNESS: , This patient is a 76-year-old woman who was treated with intravenous ceftriaxone and intravenous clindamycin at a care facility for pneumonia.  She has developed worsening confusion, fever, and intractable diarrhea.  She was brought to the emergency department for evaluation.  Diagnostic studies in the emergency department included a CBC, which revealed a white blood cell count of 23,500, and a low potassium level of 2.6.  She was admitted to the hospital for treatment of profound hypokalemia, dehydration, intractable diarrhea, and febrile illness.,PAST MEDICAL HISTORY: , Recent history of pneumonia, urosepsis, dementia, amputation, osteoporosis, and hypothyroidism.,MEDICATIONS:  ,Synthroid, clindamycin, ceftriaxone, Remeron, Actonel, Zanaflex, and hydrocodone.,SOCIAL HISTORY: , The patient has been residing at South Valley Care Center.,REVIEW OF SYSTEMS: , The patient is unable answer review of systems.,PHYSICAL EXAMINATION:,GENERAL:  This is a very elderly, cachectic woman lying in bed in no acute distress.,HEENT:  Examination is normocephalic and atraumatic.  The pupils are equal, round and reactive to light and accommodation.  The extraocular movements are full.,NECK:  Supple with full range of motion and no masses.,LUNGS:  There are decreased breath sounds at the bases bilaterally.,CARDIOVASCULAR:  Regular rate and rhythm with normal S1 and S2, and no S3 or S4.,ABDOMEN:  Soft and nontender with no hepatosplenomegaly.,EXTREMITIES:  No clubbing, cyanosis or edema.,NEUROLOGIC:  The patient moves all extremities but does not communicate.,DIAGNOSTIC STUDIES: , The CBC shows a white blood cell count of 23,500, hemoglobin 13.0, hematocrit 36.3, and platelets 287,000.  The basic chemistry panel is remarkable for potassium 2.6, calcium 7.5, and albumin 2.3.,IMPRESSION/PLAN:,1.  Elevated white count.  This patient is admitted to the hospital for treatment of a febrile illness.  There is concern that she has a progression of pneumonia.  She may have aspirated.  She has been treated with ceftriaxone and clindamycin.  I will follow her oxygen saturation and chest x-ray closely.  She is allergic to penicillin.  Therefore, clindamycin is the appropriate antibiotic for possible aspiration.,2.  Intractable diarrhea.  The patient has been experiencing intractable diarrhea.  I am concerned about Clostridium difficile infection with possible pseudomembranous colitis.  I will send her stool for Clostridium difficile toxin assay.  I will consider treating with metronidazole.,3.  Hypokalemia.  The patient's profound hypokalemia is likely secondary to her diarrhea.  I will treat her with supplemental potassium.,4.  DNR status:  I have ad a discussion with the patient's daughter, who requests the patient not receive CPR or intubation if her clinical condition or of the patient does not respond to the above therapy.  ,"
89,1,"CT ABDOMEN WITHOUT CONTRAST AND CT PELVIS WITHOUT CONTRAST,REASON FOR EXAM: , Evaluate for retroperitoneal hematoma, the patient has been following, is currently on Coumadin.,CT ABDOMEN: , There is no evidence for a retroperitoneal hematoma.,The liver, spleen, adrenal glands, and pancreas are unremarkable.  Within the superior pole of the left kidney, there is a 3.9 cm cystic lesion.  A 3.3 cm cystic lesion is also seen within the inferior pole of the left kidney.  No calcifications are noted.  The kidneys are small bilaterally.,CT PELVIS: , Evaluation of the bladder is limited due to the presence of a Foley catheter, the bladder is nondistended.  The large and small bowels are normal in course and caliber.  There is no obstruction.,Bibasilar pleural effusions are noted.,IMPRESSION:,1. No evidence for retroperitoneal bleed.,2. There are two left-sided cystic lesions within the kidney, correlation with a postcontrast study versus further characterization with an ultrasound is advised as the cystic lesions appear slightly larger as compared to the prior exam.,3. The kidneys are small in size bilaterally.,4. Bibasilar pleural effusions."
102,0,"REASON FOR CONSULT:  ,I was asked to see the patient for C. diff colitis.,HISTORY OF PRESENTING ILLNESS: , Briefly, the patient is a very pleasant 72-year-old female with previous history of hypertension and also recent diagnosis of C. diff for which she was admitted here in 5/2009, who presents to the hospital on 6/18/2009 with abdominal pain, cramping, and persistent diarrhea.  After admission, she had a CT of the abdomen done, which showed evidence of diffuse colitis and she was started on IV Flagyl and also on IV Levaquin.  She was also placed on IV Reglan because of nausea and vomiting.  In spite of the above, her white count still continues to be elevated today.  On questioning the patient, she states the nausea and vomiting has resolved, but the diarrhea still present, but otherwise denies any other specific complaints except for some weakness.,PAST MEDICAL HISTORY: , Hypertension, hyperlipidemia, recent C. diff colitis, which had resolved based on speaking to Dr. X.  Two weeks ago, he had seen the patient and she was clinically well.,PAST SURGICAL HISTORY:  ,Noncontributory.,SOCIAL HISTORY:  ,No history of smoking, alcohol, or drug use.  She lives at home.,HOME MEDICATIONS:  ,She is on atenolol and Mevacor.,ALLERGIES:  NO KNOWN DRUG ALLERGIES.,REVIEW OF SYSTEMS:  ,Positive for diarrhea and abdominal pain, otherwise main other complaints are weakness.  She denies any cough, sputum production, or dysuria at this time.  Otherwise, a 10-system review is essentially negative.,PHYSICAL EXAM:,GENERAL:  She is awake and alert, currently in no apparent distress.,VITAL SIGNS:  She has been afebrile since admission, temperature today 96.5, heart rate 80, respirations 18, blood pressure 125/60, and O2 sat is 98% on 2 L.,HEENT:  Pupils are round and reactive to light and accommodation.,CHEST:  Clear to auscultation bilaterally.,CARDIOVASCULAR:  S1 and S2 are present.  No rales appreciated.,ABDOMEN:  She does have tenderness to palpation all over with some mild rebound tenderness also.  No guarding noted.  Bowel sounds present.,EXTREMITIES:  No clubbing, cyanosis, or edema.,CT of the abdomen and pelvis is also reviewed on the computer, which showed evidence of diffuse colitis.,LABORATORY: , White blood cell count today 21.5, hemoglobin 12.4, platelet count 284,000, and neutrophils 89.  UA on 6/18/2009 showed no evidence of UTI.  Sodium today 130, potassium 2.7, and creatinine 0.4.  AST and ALT on 6/20/2009 were normal.  Blood cultures from admission were negative.  Urine culture on admission was negative.  C. diff was positive.  Stool culture was negative.,ASSESSMENT:,1.  A 72-year-old female with Clostridium difficile colitis.,2.  Diarrhea secondary to above and also could be related Reglan, which was discontinued today.,3.  Leukocytosis secondary to above, mild improvement today though.,4.  Bilateral pleural effusion by CT of the chest, although could represent thickening.,5.  New requirement for oxygen, rule out pneumonia.,6.  Hypertension.,PLAN:,1.  Treat the C. diff aggressively especially given CT appearance and her continued leukocytosis and because of the Levaquin, which could have added additional antibiotic pressure, so I will restart the IV Flagyl.,2.  Continue p.o. vancomycin.  Add Florastor to help replenish the gut flora.,3.  Monitor WBCs closely and follow clinically and if there is any deterioration in her clinical status, I would recommend getting surgical evaluation immediately for surgery if needed.,4.  We will check a chest x-ray especially given her new requirement for oxygen."
187,1,"CC:, Progressive unsteadiness following head trauma.,HX:,  A7 7 y/o male fell, as he was getting out of bed, and struck his head, 4 weeks prior to admission. He then began to experience progressive unsteadiness and gait instability for several days after the fall. He was then evaluated at a local ER and prescribed meclizine. This did not improve his symptoms, and over the past one week prior to admission began to develop left facial/LUE/LLE weakness. He was seen by a local MD on the 12/8/92 and underwent and MRI Brain scan. This showed a right subdural mass. He was then transferred to UIHC for further evaluation.,PMH:, 1)cardiac arrhythmia. 2)HTN. 3) excision of lip lesion 1 yr ago.,SHX/FHX:, Unremarkable. No h/o ETOH abuse.,MEDS:, Meclizine, Procardia XL.,EXAM:, Afebrile, BP132/74 HR72 RR16,MS: A & O x 3. Speech fluent. Comprehension, naming, repetition were intact.,CN: Left lower facial weakness only.,MOTOR: Left hemiparesis, 4+/5 throughout.,Sensory: intact PP/TEMP/LT/PROP/VIB,Coordination: ND,Station: left pronator drift.,Gait: left hemiparesis evident by decreased LUE swing and LLE drag.,Reflexes: 2/3 in UE; 2/2 LE; Right plantar downgoing; Left plantar equivocal.,Gen Exam: unremarkable.,COURSE:, Outside MRI revealed a loculated subdural hematoma extending throughout the frontotemporoparieto-occipital regions on the right. There was effacement of the right lateral ventricle. and a 0.5 cm leftward midline shift.,He underwent a HCT on admission, 12/8/92, which showed a right subdural hematoma. He then underwent emergent evacuation of this hematoma. He was discharged home 6 days after surgery."
19,0,"REASON FOR THE CONSULT:,  Nonhealing right ankle stasis ulcer.,HISTORY OF PRESENT ILLNESS: , This is a 52-year-old native American-Indian man with hypertension, chronic intermittent bipedal edema, and recurrent leg venous ulcers, who was admitted on 01/27/09 for scheduled vascular surgery per Dr. X. I was consulted for nonhealing right ankle stasis ulcer.  There is a concern that the patient had a low-grade fever of 100.2 early this morning.  The patient otherwise feels well.  He was not even aware of the fever.  He does have some ankle pain, worse on the right than the left.  Old medical records were reviewed.  He has multiple hospitalizations for leg cellulitis.  Multiple wound cultures have repeatedly grown Pseudomonas, Enterococcus, and Stenotrophomonas in the past.  Klebsiella and Enterobacter have also grown in the few wound cultures at some point.  The patient has been following up at the wound center as an outpatient and was referred to Dr. X for definitive surgical management.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No malaise.  Positive recent low-grade fevers.  No chills.,HEENT:  No acute change in visual acuity, no diplopia, no acute hearing disturbances, and no sinus congestion.  No sore throat.,CARDIAC:  No chest pain or cough.,GASTROINTESTINAL:  No nausea, vomiting or diarrhea.,All other systems were reviewed and were negative.,PAST MEDICAL HISTORY:  ,Hypertension, exploratory laparotomy in 2004 for abdominal obstruction, cholecystectomy in 2005, chronic intermittent bipedal edema, venous insufficiency, chronic recurrent stasis ulcers.,SOCIAL HISTORY: , The patient admits to heavy alcohol drinking in the past, quit several years ago.  He is also a former cigarette smoker, quit several years ago.,ALLERGIES:,  None known.,CURRENT MEDICATIONS:,  Primaxin, daptomycin, clonidine, furosemide, potassium chloride, lisinopril, metoprolol, ranitidine, Colace, amlodipine, zinc sulfate, Lortab p.r.n., multivitamins with minerals.,PHYSICAL EXAMINATION:,CONSTITUTIONAL/VITAL SIGNS:  Heart rate 73, respiratory rate 20, blood pressure 104/67, temperature 98.3, and oxygen saturation 92% on room air.,GENERAL APPEARANCE:  The patient is awake, alert, and not in cardiorespiratory distress.  Height 6 feet 1.5 inches, body weight 125.26 kilos.,EYES:  Pink conjunctivae, anicteric 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 thrills or rubs.,GASTROINTESTINAL:  Normoactive bowel sounds.  Soft.  No guarding or rigidity.,LYMPHATIC:  No cervical lymphadenopathy.,MUSCULOSKELETAL:  Good range of motion of upper and lower extremities.,SKIN:  There is hyperpigmentation involving the distal calf of both legs.  There is an open wound on the right medial,malleolar area measuring 9 x 5cm with minimal serous drainage.  Periwound is hyperpigmented with a hint of erythema extending proximally to the medial aspect, distal third of the right lower leg.  There is warmth, but minimal tenderness on palpation of this area.  There is also a wound on the right lateral malleolar area measuring 4 x 3 cm, another open wound on the left medial malleolar area measuring 7 x 4 cm.  Wound edges are poorly defined.,PSYCHIATRIC:  Appropriate mood and affect, oriented x3.  Fair judgment and insight.,LABORATORY RESULTS: , White blood cell count from 01/28/09 is 5.8 with 64% neutrophils, H&H 11.3/33.8, and platelet count 176,000.  BUN and creatinine 9.2/0.52.  Albumin 3.6, AST 25, ALT 9, alk phos 87, and total bilirubin 0.6.  One wound culture from right leg wound culture from 01/27/09 noted with young growth.  Left leg wound culture from 01/27/09 also with young growth.,RADIOLOGY:,  Chest x-ray done on 01/28/09 showed chronic bibasilar subsegmental atelectasis likely related to elevated hemidiaphragm secondary to chronic ileus.  No absolute findings.,IMPRESSION:,1.  Fevers.,2.  Right leg/ankle cellulitis.,3.  Chronic recurrent bilateral ankle venous ulcers.,4.  Multiple previous wound cultures positive for Pseudomonas, Enterococcus, and Stenotrophomonas.,5.  Hypertension.,RECOMMENDATIONS:,1.  We have ordered 2 sets of blood cultures.,2.  Agree with daptomycin and Primaxin IV.,3.  Follow up result of wound cultures.,4.  I will order an MRI of the right ankle to check for underlying osteomyelitis.,Additional ID recommendations as appropriate upon followup."
78,1,"CC:, Seizures.,HX: ,The patient was initially evaluated at UIHC at 7 years of age. He had been well until 7 months prior to evaluation when he started having spells which were described as ""dizzy spells"" lasting from several seconds to one minute in duration. They occurred quite infrequently and he was able to resume activity immediately following the episodes. The spell became more frequent and prolonged, and by the time of initial evaluation were occurring 2-3 times per day and lasting 2-3 minutes in duration. In addition, in the 3 months prior to evaluation, the right upper extremity would become tonic and flexed during the episodes, and he began to experience post ictal fatigue.,BIRTH HX:, 32 weeks gestation to a G4 mother and weighed 4#11oz. He was placed in an incubator for 3 weeks. He was jaundiced, but there was no report that he required treatment.,PMH: ,Single febrile convulsion lasting ""3 hours"" at age 2 years.,MEDS: ,none.,EXAM:, Appears healthy and in no acute distress. Unremarkable general and neurologic exam.,Impression: Psychomotor seizures.,Studies: Skull X-Rays were unremarkable.,EEG showed ""minimal spike activity during hyperventilation, as well as random sharp delta activity over the left temporal area, in drowsiness and sleep. This record also showed moderate amplitude asymmetry ( left greater than right) over the frontal central and temporal areas, which is a peculiar finding."",COURSE:, The patient was initially treated with Phenobarbital; then Dilantin was added (early 1970's); then Depakene was added ( early 1980's) due to poor seizure control. An EEG on 8/22/66 showed ""Left mid-temporal spike focus with surrounding slow abnormality, especially posterior to the anterior temporal areas (sparing the parasagittal region). In addition, the right lateral anterior hemisphere voltage is relatively depressed. ...this suggests two separate areas of cerebral pathology."" He underwent his first HCT scan in Sioux City in 1981, and this revealed an right temporal arachnoid cyst. The patient had behavioral problems throughout elementary/junior high/high school. He underwent several neurosurgical evaluations at UIHC and Mayo Clinic and was told that surgery was unwarranted. He was placed on numerous antiepileptic medication combinations including Tegretol, Dilantin, Phenobarbital, Depakote, Acetazolamide, and Mysoline. Despite this he averaged 2-3 spells a month. He was last seen, 6/19/95, and was taking Dilantin and Tegretol. His typical spells were described as sudden in onset and without aura. He frequently becomes tonic or undergoes tonic-clonic movement and falls with associated loss of consciousness. He usually has rapid recovery and can return to work in 20 minutes. He works at a Turkey packing plant. Serial HCT scans showed growth in the arachnoid cyst until 1991, when growth arrest appeared to have occurred."
159,1,"TECHNIQUE: , Sequential axial CT images were obtained through the cervical spine without contrast.  Additional high resolution coronal and sagittal reconstructed images were also obtained for better visualization of the osseous structures.  ,FINDINGS: , The cervical spine demonstrates normal alignment and mineralization with no evidence of fracture, dislocation, or spondylolisthesis.  The vertebral body heights and disc spaces are maintained.  The central canal is patent.  The pedicles and posterior elements are intact.  The paravertebral soft tissues are within normal limits.  The atlanto-dens interval and the dens are intact.  The visualized lung apices are clear.,IMPRESSION: , No acute abnormalities."
120,0,"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."
123,0,"REASON FOR CONSULTATION: , Possible free air under the diaphragm.,HISTORY OF PRESENT ILLNESS: , The patient is a 77-year-old female who is unable to give any information.  She has been sedated with Ativan and came into the emergency room obtunded and unable to give any history.  On a chest x-ray for what appeared to be shortness of breath she was found to have what was thought to be free air under the right diaphragm.,PAST MEDICAL HISTORY: , Significant for alcohol abuse.  Unable to really gather any other information because she is so obtunded.,PAST SURGICAL HISTORY:  ,Looking at the medical chart, she had an appendectomy, right hip fracture from a fall in 2005, and TAH/BSO.,MEDICATIONS:,  Unable to evaluate.,ALLERGIES: , UNABLE TO EVALUATE.,SOCIAL HISTORY:  ,Significant history of alcohol abuse, according to the emergency room physician, who sees her on a regular basis.,REVIEW OF SYSTEMS: , Unable to obtain.,PHYSICAL EXAM,VITAL SIGNS:  Temp 98.3, heart rate 82, respiratory rate 24, and blood pressure 141/70.,GENERAL:  She is a very obtunded female who upon arousal is not able to provide any information of any use.,HEENT:  Atraumatic.,NECK:  Soft and supple.,LUNGS:  Bilaterally diminished.,HEART:  Regular.,ABDOMEN:  Soft, and with deep palpation I am unable to arouse the patient, unable to elicit any tenderness.,LABORATORY STUDIES: , Show a normal white blood cell count with no shift.  Elevated AST at 138, with a normal ALT at 38.  Alkaline phosphatase of 96, bilirubin 0.8.  Sodium is 107, with 68 chloride and potassium of 2.8.,X-ray of the chest shows the possibility of free air; therefore, a CT scan was obtained because of the patient's physical examination, which shows no evidence of intra-abdominal pathology.  The etiology of the air under the diaphragm is actually a colonic air that is anterior superior to the dome of the diaphragm, near the dome of the liver.,ASSESSMENT: , No intra-abdominal pathology.,PLAN:,  Have her admitted to the medical service for treatment of her hyponatremia."
5,0,"CHIEF COMPLAINT: , Swelling of lips causing difficulty swallowing.,HISTORY OF PRESENT ILLNESS:, This patient is a 57-year old white Cuban woman with a long history of rheumatoid arthritis.  She has received methotrexate on a weekly basis as an outpatient for many years.  Approximately two weeks ago, she developed a respiratory infection for which she received antibiotics.  She developed some ulcerations of the mouth and was instructed to discontinue the methotrexate approximately ten days ago.  She showed some initial improvement, but over the last 3-5 days has had malaise, a low-grade fever, and severe oral ulcerations with difficulty in swallowing although she can drink liquids with less difficulty.  ,The patient denies any other problems at this point except for a flare of arthritis since discontinuing the methotrexate.  She has rather diffuse pain involving both large and small joints.  ,MEDICATIONS:, Prednisone 7.5 mg p.o. q.d., Premarin 0.125 mg p.o. q.d., and Dolobid 1000 mg p.o. q.d., recently discontinued because of questionable allergic reaction.  HCTZ 25 mg p.o. q.o.d., Oral calcium supplements.  In the past she has been on penicillin, azathioprine, and hydroxychloroquine, but she has not had Azulfidine, cyclophosphamide, or chlorambucil. ,ALLERGIES: ,None by history.  ,FAMILY/SOCIAL HISTORY:, Noncontributory.,PHYSICAL EXAMINATION:, This is a chronically ill appearing female, alert, oriented, and cooperative.  She moves with great difficulty because of fatigue and malaise.  Vital signs: Blood pressure 107/80, heart rate: 100 and regular, respirations 22.  HEENT: Normocephalic. No scalp lesions.  Dry eyes with conjuctival injections.  Mild exophthalmos.  Dry nasal mucosa.  Marked cracking and bleeding of her lips with erosion of the mucosa.  She has a large ulceration of the mucosa at the bite margin on the left.  She has some scattered ulcerations on her hard and soft palette.  Tonsils not enlarged.  No visible exudate.  She has difficulty opening her mouth because of pain.  SKIN: She has some mild ecchymoses on her skin and some erythema; she has patches but no obvious skin breakdown.  She has some fissuring in the buttocks crease.  PULMONARY: Clear to percussion in auscultation.  CARDIOVASCULAR: No murmurs or gallops noted.  ABDOMEN: Protuberant no organomegaly and positive bowel sounds.  NEUROLOGIC EXAM: Cranial nerves II through XII are grossly intact. Diffuse hyporeflexia.  MUSCULOSKELATAL: Erosive, destructive changes in the elbows, wrist and hands consistent with rheumatoid arthritis.  She also has bilateral total knee replacements with stovepipe legs and parimalleolar pitting adema 1+.  I feel no pulse distally in either leg.  ,PROBLEMS: ,1.  Swelling of lips and dysphagia with questionable early Stevens-Johnson syndrome.,2.  Rheumatoid Arthritis class 3, stage 4.,3.  Flare of arthritis after discontinuing methotrexate.,4.  Osteoporosis with compression fracture.,5.  Mild dehydration.,6.  Nephrolithiasis.,PLAN:, Patient is admitted for IV hydration and treatment of oral ulcerations.  We will obtain a dermatology consult.  IV leucovorin will be started, and the patient will be put on high-dose corticosteroids."
168,1,"EXAM:,MRI CERVICAL SPINE,CLINICAL:, A57-year-old male. Received for outside consultation is an MRI examination performed on 11/28/2005.,FINDINGS:,Normal brainstem-cervical cord junction. Normal cisterna magna with no tonsillar ectopia. Normal clivus with a normal craniovertebral junction. Normal anterior atlantoaxial articulation.,C2-3: Normal intervertebral disc with no spondylosis or uncovertebral joint arthrosis. Normal central canal and intervertebral neural foramina with no cord or radicular impingement.,C3-4: There is disc desiccation with minimal annular bulging. The residual AP diameter of the central canal measures approximately 10mm. CSF remains present surrounding the cord.,C4-5: There is disc desiccation with endplate spondylosis and mild uncovertebral joint arthrosis. The residual AP diameter of the central canal measures approximately 8mm with effacement of the circumferential CSF cleft producing a borderline central canal stenosis but no cord distortion or cord edema. There is minimal uncovertebral joint arthrosis.,C5-6: There is disc desiccation with minimal posterior annular bulging and a right posterolateral preforaminal disc protrusion measuring approximately 2 x 8mm (AP x transverse). The disc protrusion produces minimal rightward ventral thecal sac flattening but no cord impingement.,C6-7: There is disc desiccation with mild loss of disc space height and posterior endplate spondylosis and annular bulging producing central canal stenosis. The residual AP diameter of the central canal measures 8 mm with effacement of the circumferential CSF cleft. There is a left posterolateral disc-osteophyte complex encroaching upon the left intervertebral neural foramen with probable radicular impingement upon the exiting left C7 nerve root.,C7-T1, T1-2: Minimal disc desiccation with no disc displacement or endplate spondylosis.,IMPRESSION:,Multilevel degenerative disc disease as described above.,C4-5 borderline central canal stenosis with mild bilateral foraminal compromise.,C5-6 disc desiccation with a borderline central canal stenosis and a right posterolateral preforaminal disc protrusion producing thecal sac distortion.,C6-7 degenerative disc disease and endplate spondylosis with a left posterolateral disc-osteophyte complex producing probable neural impingement upon the exiting left C7 nerve root with a borderline central canal stenosis.,Normal cervical cord."
57,1,"EXAM: , Coronary artery CTA with calcium scoring and cardiac function.,HISTORY: , Chest pain.,TECHNIQUE AND FINDINGS: , Coronary artery CTA was performed on a Siemens dual-source CT scanner.  Post-processing on a Vitrea workstation.  150 mL Ultravist 370 was utilized as the intravenous contrast agent.  Patient did receive nitroglycerin sublingually prior to the contrast.,HISTORY: , Significant for high cholesterol, overweight, chest pain, family history,Patient's total calcium score (Agatston) is 10. his places the patient just below the 75th percentile for age.,The LAD has a moderate area of stenosis in its midportion due to a focal calcified plaque.  The distal LAD was unreadable while the proximal was normal.  The mid and distal right coronary artery are not well delineated due to beam-hardening artifact.  The circumflex is diminutive in size along its proximal portion.  Distal is not readable.,Cardiac wall motion within normal limits.  No gross pulmonary artery abnormality however they are not well delineated.  A full report was placed on the patient's chart.  Report was saved to PACS."
105,0,"CHIEF COMPLAINT: , Nausea.,PRESENT ILLNESS: , The patient is a 28-year-old, who is status post gastric bypass surgery nearly one year ago.  He has lost about 200 pounds and was otherwise doing well until yesterday evening around 7:00-8:00 when he developed nausea and right upper quadrant pain, which apparently wrapped around toward his right side and back.  He feels like he was on it but has not done so.  He has overall malaise and a low-grade temperature of 100.3.  He denies any prior similar or lesser symptoms.  His last normal bowel movement was yesterday.  He denies any outright chills or blood per rectum.,PAST MEDICAL HISTORY: , Significant for hypertension and morbid obesity, now resolved.,PAST SURGICAL HISTORY: , Gastric bypass surgery in December 2007.,MEDICATIONS:  ,Multivitamins and calcium.,ALLERGIES: , None known.,FAMILY HISTORY:  ,Positive for diabetes mellitus in his father, who is now deceased.,SOCIAL HISTORY: , He denies tobacco or alcohol.  He has what sounds like a data entry computer job.,REVIEW OF SYSTEMS:  ,Otherwise negative.,PHYSICAL EXAMINATION:,  His temperature is 100.3, blood pressure 129/59, respirations 16, heart rate 84.  He is drowsy, but easily arousable and appropriate with conversation.  He is oriented to person, place, and situation.  He is normocephalic, atraumatic.  His sclerae are anicteric.  His mucous membranes are somewhat tacky.  His neck is supple and symmetric.  His respirations are unlabored and clear.  He has a regular rate and rhythm.  His abdomen is soft.  He has diffuse right upper quadrant tenderness, worse focally, but no rebound or guarding.  He otherwise has no organomegaly, masses, or abdominal hernias evident.  His extremities are symmetrical with no edema.  His posterior tibial pulses are palpable and symmetric.  He is grossly nonfocal neurologically.,STUDIES:,  His white blood cell count is 8.4 with 79 segs.  His hematocrit is 41.  His electrolytes are normal.  His bilirubin is 2.8.  His AST 349, ALT 186, alk-phos 138 and lipase is normal at 239.,ASSESSMENT: , Choledocholithiasis, ? cholecystitis.,PLAN: , He will be admitted and placed on IV antibiotics.  We will get an ultrasound this morning.  He will need his gallbladder out, probably with intraoperative cholangiogram.  Hopefully, the stone will pass this way.  Due to his anatomy, an ERCP would prove quite difficult if not impossible unless laparoscopic assisted.  Dr. X will see him later this morning and discuss the plan further.  The patient understands."
73,1,"INDICATIONS:,  Previously markedly abnormal dobutamine Myoview stress test and gated scan.,PROCEDURE DONE:,  Resting Myoview perfusion scan and gated myocardial scan.,MYOCARDIAL PERFUSION IMAGING:,  Resting myocardial perfusion SPECT imaging and gated scan were carried out with 32.6 mCi of Tc-99m Myoview.  Rest study was done and compared to previous dobutamine Myoview stress test done on Month DD, YYYY.  The lung heart ratio is 0.34.  There appears to be a moderate size inferoapical perfusion defect of moderate degree.  The gated myocardial scan revealed mild apical and distal inferoseptal hypokinesis with ejection fraction of 55%.,CONCLUSIONS:,  Study done at rest only revealed findings consistent with an inferior non-transmural scar of moderate size and moderate degree.  The left ventricular systolic function is markedly improved with much better regional wall motion of all left ventricular segments when compared to previous study done on Month DD, YYYY.  We cannot assess the presence of any reversible perfusion defects because no stress imaging was performed."
128,0,"CHIEF COMPLAINT: , Anxiety, alcohol abuse, and chest pain.,HISTORY OF PRESENT ILLNESS:,  This is a pleasant 40-year-old male with multiple medical problems, basically came to the hospital yesterday complaining of chest pain.  The patient states that he complained of this chest pain, which is reproducible, pleuritic in both chest radiating to the left back and the jaw, complaining of some cough, nausea, questionable shortness of breath.  The patient describes the pain as aching, sharp and alleviated with pain medications, not alleviated with any nitrates.  Aggravated by breathing, coughing, and palpation over the area.  The pain was 9/10 in the emergency room and he was given some pain medications in the ER and was basically admitted.  Labs were drawn, which were essentially, potassium was about 5.7 and digoxin level was drawn, which was about greater than 5.  The patient said that he missed 3 doses of digoxin in the last 3 days after being discharged from Anaheim Memorial and then took 3 tablets together.  The patient has a history prior digoxin overdose of the same nature.,MEDICATIONS:,  Digoxin 0.25 mg, metoprolol 50 mg, Naprosyn 500 mg, metformin 500 mg, lovastatin 40 mg, Klor-Con 20 mEq, Advair Diskus, questionable Coreg.,PAST MEDICAL HISTORY: , MI in the past and atrial fibrillation, he said that he has had one stent put in, but he is not sure.  The last cardiologist he saw was Dr. X and his primary doctor is Dr. Y.,SOCIAL HISTORY:,  History of alcohol use in the past.,He is basically requesting for more and more pain medications.  He states that he likes Dilaudid and would like to get the morphine changed to Dilaudid.  His pain is tolerable.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Stable.,GENERAL:  Alert and oriented x3, no apparent distress.,HEENT:  Extraocular muscles are intact.,CVS:  S1, S2 heard.,CHEST:  Clear to auscultation bilaterally.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  No edema or clubbing.,NEURO:  Grossly intact.  Tender to palpate over the left chest, no obvious erythema or redness, or abnormal exam is found.,EKG basically shows atrial fibrillation, rate controlled, nonspecific ST changes.,ASSESSMENT AND PLAN:,1.  This is a 40-year-old male with digoxin toxicity secondary to likely intentional digoxin overuse.  Now, he has had significant block with EKG changes as stated.  Continue to follow the patient clinically at this time.  The patient has been admitted to ICU and will be changed to DOU.,2.  Chronic chest pain with a history of myocardial infarction in the past, has been ruled out with negative cardiac enzymes.  The patient likely has opioid dependence and requesting more and more pain medications.  He is also bargaining for pain medications with me.  The patient was advised that he will develop more opioid dependence and I will stop the pain medications for now and give him only oral pain medications in the anticipation of the discharge in the next 1 or 2 days.  The patient was likely advised to also be seen by a pain specialist as an outpatient after being referred.  We will try to verify his pain medications from his primary doctor and his pharmacy.  The patient said that he has been on Dilaudid and Vicodin ES and Norco and all these medications in the past."
54,1,"EXAM:,1.  Diagnostic cerebral angiogram.,2.  Transcatheter infusion of papaverine.,ANESTHESIA: , General anesthesia,FLUORO TIME: , 19.5 minutes,CONTRAST:,  Visipaque-270, 100 mL,INDICATIONS FOR PROCEDURE: , The patient is a 13-year-old boy who had clipping for a left ICA bifurcation aneurysm.  He was referred for a routine postop check angiogram.  He is doing fine clinically.  All questions were answered, risks explained, informed consent taken and patient was brought to angio suite.,TECHNIQUE: , After informed consent was taken patient was brought to angio suite, both groin sites were prepped and draped in sterile manner.  Patient was placed under general anesthesia for entire duration of the procedure.  Groin access was obtained with a stiff micropuncture wire and a 4-French sheath was placed in the right common femoral artery and connected to a continuous heparinized saline flush.  A 4-French angled Glide catheter was then taken up into the descending thoracic aorta was double flushed and connected to a continuous heparinized saline flush.  The catheter was then taken up into the aortic arch and both common and internal carotid arteries were selectively catheterized followed by digital subtraction imaging in multiple projections.  The images showed spasm of the left internal carotid artery and the left A1, it was thought planned to infused papaverine into the ICA and the left A1.  After that the diagnostic catheter was taken up into the distal internal carotid artery.  SL-10 microcatheter was then prepped and was taken up with the support of Transcend platinum micro guide wire.  The microcatheter was then taken up into the internal carotid artery under biplane roadmapping and was taken up into the distal internal carotid artery and was pointed towards the A1.  60 mg of papaverine was then slowly infused into the internal carotid artery and the anterior cerebral artery.  Post-papaverine infusion images showed increased caliber of the internal carotid artery as well as the left A1.  The catheter was then removed from the patient, pressure was held for 10 minutes leading to hemostasis.  Patient was then transferred back to the ICU in the Children's Hospital where he was extubated without any deficits.,INTERPRETATION OF IMAGES:,1.  LEFT COMMON/INTERNAL CAROTID ARTERY INJECTIONS:  The left internal carotid artery is of normal caliber.  In the intracranial projection there is moderate spasm of the left internal carotid artery and moderately severe spasm of the left A1.  There is poor filling of the A2 through left internal carotid artery injection.  There is opacification of the ophthalmic and the posterior communicating artery MCA along with the distal branches are filling normally.  Capillary filling and venous drainage in MCA distribution is normal and it is very slow in the ACA distribution,2.  RIGHT INTERNAL CAROTID ARTERY INJECTION:  The right internal carotid artery is of normal caliber.  There is opacification of the right ophthalmic and the posterior communicating artery.  The right ACA A1 is supplying bilateral A2 and there is no spasm of the distal anterior cerebral artery.  Right MCA along with the distal branches are filling normally.  Capillary filling and venous drainage are normal.,3.  POST-PAPAVERINE INJECTION:  The post-papaverine injection shows increased caliber of the internal carotid artery as well as the anterior cerebral artery.  Of note the previously clipped internal carotid ICA bifurcation aneurysm is well clipped and there is no residual neck or filling of the dome of the aneurysm.,IMPRESSION:,1.  Well clipped left ICA bifurcation aneurysm.,2.  Moderately severe spasm of the internal carotid artery and left A1.  60 milligrams of papaverine infused leading to increased flow in the aforementioned vessels."
151,1,"CC:, Decreasing visual acuity.,HX: ,This 62 y/o RHF presented locally with a 2 month history of progressive loss of visual acuity, OD. She had a 2 year history of progressive loss of visual acuity, OS, and is now blind in that eye. She denied any other symptomatology. Denied HA.,PMH:, 1) depression. 2) Blind OS,MEDS:, None.,SHX/FHX: ,unremarkable for cancer, CAD, aneurysm, MS, stroke. No h/o Tobacco or ETOH use.,EXAM:, T36.0, BP121/85, HR 94, RR16,MS: Alert and oriented to person, place and time. Speech fluent and unremarkable.,CN: Pale optic disks, OU. Visual acuity: 20/70 (OD) and able to detect only shadow of hand movement (OS). Pupils were pharmacologically dilated earlier. The rest of the CN exam was unremarkable.,MOTOR: 5/5 throughout with normal bulk and tone.,Sensory: no deficits to LT/PP/VIB/PROP.,Coord: FNF-RAM-HKS intact bilaterally.,Station: No pronator drift. Gait: ND,Reflexes: 3/3 BUE, 2/2 BLE. Plantar responses were flexor bilaterally.,Gen Exam: unremarkable. No carotid/cranial bruits.,COURSE:, CT Brain showed large, enhancing 4 x 4 x 3 cm suprasellar-sellar mass without surrounding edema. Differential dx: included craniopharyngioma, pituitary adenoma, and aneurysm. MRI Brain findings were consistent with an aneurysm. The patient underwent 3 vessel cerebral angiogram on 12/29/92. This clearly revealed a supraclinoid giant aneurysm of the left internal carotid artery. Ten minutes following contrast injection the patient became aphasic and developed a right hemiparesis. Emergent HCT showed no evidence of hemorrhage or sign of infarct. Emergent carotid duplex showed no significant stenosis or clot. The patient was left with an expressive aphasia and right hemiparesis. SPECT scans were obtained on 1/7/93 and 2/24/93. They revealed hypoperfusion in the distribution of the left MCA and decreased left basal-ganglia perfusion which may represent in part a mass effect from the LICA aneurysm. She was discharged home and returned and underwent placement of a Selverstone Clamp on 3/9/93. The clamp was gradually and finally closed by 3/14/93. She did well, and returned home. On 3/20/93 she developed sudden confusion associated with worsening of her right hemiparesis and right expressive aphasia. A HCT then showed SAH around her aneurysm, which had thrombosed. She was place on Nimodipine. Her clinical status improved; then on 3/25/93 she rapidly deteriorated over a 2 hour period to the point of lethargy, complete expressive aphasia, and right hemiplegia. An emergent HCT demonstrated a left ACA and left MCA infarction. She required intubation and worsened as cerebral edema developed. She was pronounced brain dead. Her organs were donated for transplant."
6,0,"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."
38,0,"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."
13,0,"SUBJECTIVE:,  Mom brings the patient in today for possible ear infection.  He is complaining of left ear pain today.  He was treated on 04/14/2004, with amoxicillin for left otitis and Mom said he did seem to get better but just started complaining of the left ear pain today.  He has not had any fever but the congestion has continued to be very thick and purulent.  It has never really resolved.  He has a loose, productive-sounding cough but not consistently and not keeping him up at night.  No wheezing or shortness of breath.,PAST MEDICAL HISTORY:,  He has had some wheezing in the past but nothing recently.,FAMILY HISTORY: , All siblings are on antibiotics for ear infections and URIs.,OBJECTIVE:,General:  The patient is a 5-year-old male.  Alert and cooperative.  No acute distress.,Neck:  Supple without adenopathy.,HEENT:  Ear canals clear.  TMs, bilaterally, have distorted light reflexes but no erythema.  Gray in color.  Oropharynx pink and moist with a lot of postnasal discharge.  Nares are swollen and red.  Thick, purulent drainage.  Eyes are a little puffy.,Chest:  Respirations regular, nonlabored.,Lungs:  Clear to auscultation throughout.,Heart:  Regular rhythm without murmur.,Skin:  Warm, dry, pink.  Moist mucus membranes.  No rash.,ASSESSMENT:,  Ongoing purulent rhinitis.  Probable sinusitis and serous otitis.,PLAN:,  Change to Omnicef two teaspoons daily for 10 days.  Frequent saline in the nose.  Also, there was some redness around the nares with a little bit of yellow crusting.  It appeared to be the start of impetigo, so hold off on the Rhinocort for a few days and then restart.  Use a little Neosporin for now."
45,0,"CHIEF COMPLAINT: , Abdominal pain.,HISTORY OF PRESENT ILLNESS:  ,The patient is an 89-year-old white male who developed lower abdominal pain, which was constant, onset approximately half an hour after dinner on the evening prior to admission.  He described the pain as 8/10 in severity and the intensity varied.  The symptoms persisted and he subsequently developed nausea and vomiting at 3 a.m. in the morning of admission.  The patient vomited twice and he states that he did note a temporary decrease in pain following his vomiting.  The patient was brought to the emergency room approximately 4 a.m. and evaluation including the CT scan, which revealed dilated loops of bowel without obvious obstruction.  The patient was subsequently admitted for possible obstruction.  The patient does have a history of previous small bowel obstruction approximately 20 times all but 2 required hospitalization, but all resolved with conservative measures (IV fluid, NG tube decompression, bowel rest.)  He has had previous abdominal surgeries including colon resection for colon CA and cholecystectomy as well as appendectomy.,PAST HISTORY: , Hypertension treated with Cozaar 100 mg daily and Norvasc 10 mg daily.  Esophageal reflux treated with Nexium 40 mg daily.  Allergic rhinitis treated with Allegra 180 mg daily.  Sleep disturbances, depression and anxiety treated with Paxil 25 mg daily, Advair 10 mg nightly and Ativan 1 mg nightly.  Glaucoma treated with Xalatan drops.  History of chronic bronchitis with no smoking history for which he uses p.r.n. Flovent and Serevent.,PREVIOUS SURGERIES:  ,Partial colon resection of colon carcinoma in 1961 with no recurrence, cholecystectomy 10 years ago, appendectomy, and glaucoma surgery.,FAMILY HISTORY: , Father died at age 85 of ""old age,"" mother died at age 89 of ""old age.""  Brother died at age 92 of old age, 2 brothers died in their 70s of Parkinson disease.  Son is at age 58 and has a history of hypertension, hypercholesterolemia, rheumatoid arthritis, and glaucoma.,SOCIAL HISTORY:  ,The patient is widowed and a retired engineer.  He denies cigarettes smoking or alcohol intake.,REVIEW OF SYSTEMS: , Denies fevers or weight loss.  HEENT:  Denies headaches, visual abnormality, decreased hearing, tinnitus, rhinorrhea, epistaxis or sore throat.  Neck:  Denies neck stiffness, no pain or masses in the neck.  Respiratory:  Denies cough, sputum production, hemoptysis, wheezing or shortness of breath.  Cardiovascular:  Denies chest pain, angina pectoris, DOE, PND, orthopnea, edema or palpitation.  Gastrointestinal:  See history of the present illness.  Urinary:  Denies dysuria, frequency, urgency or hematuria.  Neuro:  Denies seizure, syncope, incoordination, hemiparesis or paresthesias.,PHYSICAL EXAMINATION:,GENERAL:  The patient is a well-developed, well-nourished elderly white male who is currently in no acute distress after receiving analgesics.,HEENT:  Atraumatic, normocephalic.  Eyes, EOMs full, PERRLA.  Fundi benign.  TMs normal.  Nose clear.  Throat benign.,NECK:  Supple with no adenopathy.  Carotid upstrokes normal with no bruits.  Thyroid is not enlarged.,LUNGS:  Clear to percussion and auscultation.,HEART:  Regular rate, normal S1 and S2 with no murmurs or gallops.  PMI is nondisplaced.,ABDOMEN:  Mildly distended with mild diffuse tenderness.  There is no rebound or guarding.  Bowel sounds are hypoactive.,EXTREMITIES:  No cyanosis, clubbing or edema.  Pulses are strong and intact throughout.,GENITALIA:  Atrophic male, no scrotal masses or tenderness.  Testicles are atrophic.  No hernia is noted.,RECTAL:  Unremarkable, prostate was not enlarged and there were no nodules or tenderness.,LAB DATA:,  WBC 12.1, hemoglobin and hematocrit 16.9/52.1, platelets 277,000.  Sodium 137, potassium 3.9, chloride 100, bicarbonate 26, BUN 27, creatinine 1.4, glucose 157, amylase 103, lipase 44.  Alkaline phosphatase, AST and ALT are all normal.  UA is negative.,Abdomen and pelvic CT showed mild stomach distention with multiple fluid-filled loops of bowel, no obvious obstruction noted.,IMPRESSION:,1.  Abdominal pain, nausea and vomiting, rule out recurrent small bowel obstruction.,2.  Hypertension.,3.  Esophageal reflux.,4.  Allergic rhinitis.,5.  Glaucoma.,PLAN: , The patient is admitted to the medical floor.  He has been kept NPO and will be given IV fluids.  He will also be given antiemetic medications with Zofran and an analgesic as necessary.  General surgery consultation was obtained.  Abdominal series x-ray will be done."
188,1,"CC:, Episodic mental status change and RUE numbness, and chorea (found on exam).,HX:, This 78y/o RHM was referred for an episode of unusual behavior and RUE numbness. In 9/91, he experienced near loss of consciousness, generalized weakness, headache and vomiting. Evaluation at that time revealed an serum glucose of >500mg/dL and he was placed on insulin therapy with subsequent resolution of his signs and symptoms. Since then, he became progressively more forgetful, and at the time of evaluation, 1/17/93, had lost his ability to perform his job repairing lawn mowers. His wife had taken over the family finances.,He had also been ""stumbling,"" when ambulating, for 2 months prior to presentation. He was noted to be occasionally confused upon awakening for last several months. On 1/15/93, he was lying on a couch when he suddenly began throwing pillows and blankets for no apparent reason. There had been no change in sleep, appetite, or complaint of depression.,In addition, for two months prior to presentation, he had been experiencing 10-15minute episodes of RUE numbness. There was no face or lower extremity involvement.,During the last year he had developed unusual movements of his extremities.,MEDS:, NPH Humulin 12U qAM and 6U qPM. Advil prn.,PMH:, 1) Traumatic amputation of the 4th and 5th digits of his left hand.  2) Hospitalized for an unknown ""nervous"" condition in the 1940's.,SHX/FHX:, Retired small engine mechanic who worked in a poorly ventilated shop. Married with 13 children. No history of ETOH, Tobacco or illicit drug use. Father had tremors following a stroke. Brother died of brain aneurysm. No history of depression, suicide, or Huntington's disease in family.,ROS:, no history of CAD, Renal or liver disease, SOB, Chest pain, fevers, chills, night sweats or weight loss. No report of sign of bleeding.,EXAM:, BP138/63 HR65 RR15 36.1C,MS: Alert and oriented to self, season; but not date, year, or place. Latent verbal responses and direction following. Intact naming, but able to repeat only simple but not complex phrases. Slowed speech, with mild difficulty with word finding. 2/3 recall at one minute and 0/3 at 3 minutes. Knew the last 3 presidents. 14/27 on MMSE: unable to spell ""world"" backwards. Unable to read/write for complaint of inability to see without glasses.,CN: II-XII appeared grossly intact. EOM were full and smooth and without unusual saccadic pursuits. OKN intact. Choreiform movements of the tongue were noted.,Motor: 5/5 strength throughout with Guggenheim type resistance. there were choreiform type movements of all extremities bilaterally. No motor impersistence noted.,Sensory: unreliable.,Cord: ""normal"" FNF, HKS, and RAM, bilaterally.,Station: No Romberg sign.,Gait: unsteady and wide-based.,Reflexes: BUE 2/2, Patellar 2/2, Ankles Trace/Trace, Plantars were flexor bilaterally.,Gen Exam: 2/6 Systolic ejection murmur in aortic area.,COURSE:, No family history of Huntington's disease could be elicited from relatives. Brain CT, 1/18/93: bilateral calcification of the globus pallidi and a high attenuation focus in the right occipital lobe thought to represent artifact. Carotid duplex, 1/18/93: RICA 0-15%, LICA 16-49% stenosis and normal vertebral artery flow bilaterally. Transthoracic Echocardiogram (TTE),1/18/93: revealed severe aortic fibrosis or valvular calcification with ""severe"" aortic stenosis in the face of ""normal"" LV function. Cardiology felt the patient the patient had asymptomatic aortic stenosis. EEG, 1/20/93, showed low voltage Delta over the left posterior quadrant and intermittent background slowing over the same region consistent with focal dysfunction in this quadrant. MRI Brain, 1/22/93: multiple focal and more confluent areas of increased T2 signal in the periventricular white matter, more prominent on the left; in addition, there were irregular shaped areas of increased T2 signal and decreased T1 signal in both cerebellar hemispheres; and age related atrophy; incidentally, there is a cavum septum pellucidum et vergae and mucosal thickening of the maxillary sinuses. Impression: diffuse bilateral age related ischemic change, age related atrophy and maxillary sinus disease. There were no masses or areas of abnormal enhancement. TSH, FT4, Vit B12, VDRL, Urine drug and heavy metal screens were unremarkable. CSF,1/19/93: glucose 102 (serum glucose 162mg/dL), Protein 45mg/dL, RBC O, WBC O, Cultures negative. SPEP negative. However serum and CSF beta2 microglobulin levels were elevated at 2.5 and 3.1mg/L, respectively. Hematology felt these may have been false positives. CBC, 1/17/93: Hgb 10.4g/dL (low), HCT 31% (low), RBC 3/34mil/mm3 (low), WBC 5.8K/mm3, Plt 201K/mm3. Retic 30/1K/mm3 (normal). Serum Iron 35mcg/dL (low), TIBC 201mcg/dL (low), FeSat 17% (low), CRP 0.1mg/dL (normal), ESR 83mm/hr (high). Bone Marrow Bx: normal with adequate iron stores. Hematology felt the finding were compatible with anemia of chronic disease. Neuropsychologic evaluation on 1/17/93 revealed significant impairments in multiple realms of cognitive function (visuospatial reasoning, verbal and visual memory, visual confrontational naming, impaired arrhythmatic, dysfluent speech marked by use of phrases no longer than 5 words, frequent word finding difficulty and semantic paraphasic errors) most severe for expressive language, attention and memory. The pattern of findings reveals an atypical aphasia suggestive of left temporo-parietal dysfunction. The patient was discharged1/22/93 on ASA 325mg qd. He was given a diagnosis of senile chorea and dementia (unspecified type). 6/18/93 repeat Neuropsychological evaluation revealed moderate decline in all areas tested reflecting severe dementia."
126,0,"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."
23,0,"CHIEF COMPLAINT:, ""Trouble breathing."",HISTORY OF PRESENT ILLNESS:, A 37-year-old German woman was brought to a Shock Room at the General Hospital with worsening shortness of breath and cough. Over the year preceding admission, the patient had begun to experience the insidious onset of shortness of breath. She had smoked one half pack of cigarettes per day for 20 years, but had quit smoking approximately 2 months prior to admission. Approximately 2 weeks prior to admission, she noted worsening shortness of breath and the development of a dry nonproductive cough. Approximately 1 week before admission, the shortness of breath became more severe and began to limit her activities. On the day of admission, her dyspnea had worsened to the point that she became markedly short of breath after walking a short distance, and she elected to seek medical attention. On arrival at the hospital, she was short of breath at rest and was having difficulty completing her sentences. She denied orthopnea, paroxysmal nocturnal dyspnea, swelling in her legs, chest pain, weight loss or gain, fever, chills, palpitations, and sick contacts. She denied any history of IVDA, tattoos, or high risk sexual behavior. She did report a distant history of pulmonary embolism in 1997 with recurrent venous thromboembolism in 1999 for which an IVC filter had been placed in Germany . She had been living in the United States for years, and had had no recent travel. She denied any occupational exposures. Before the onset of her shortness of breath she had been very active and had exercised regularly.,PAST MEDICAL HISTORY:,  Pulmonary embolism in 1997 which had been treated with thrombolysis in Germany. She reported that she had been on warfarin for 6 months after her diagnosis.  Recurrent venous thromboembolism in 1999 at which time an IVC filter had been placed.  Psoriasis.  She denied any history of miscarriage.,PAST SURGICAL HISTORY:,  IVC filter placement 1999."
40,0,"CHIEF COMPLAINT:, Left leg pain.,HISTORY OF PRESENT ILLNESS:, The patient is a 59-year-old gravida 1, para 0-0-1-0, with a history of stage IIIC papillary serous adenocarcinoma of the ovary who presented to the office today with left leg pain that started on Saturday. The patient noticed the pain in her left groin and left thigh and also noticed swelling in that leg. A Doppler ultrasound of her leg that was performed today noted a DVT. She is currently on course one, day 14 of 21 of Taxol and carboplatin. She is scheduled for intraperitoneal port placement for intraperitoneal chemotherapy to begin next week. She denies any chest pain or shortness of breath, nausea, vomiting, or dysuria. She has a positive appetite and ambulates without difficulty.,PAST MEDICAL HISTORY:,1. Gastroesophageal reflux disease.,2. Mitral valve prolapse.,3. Stage IIIC papillary serous adenocarcinoma of the ovaries.,PAST SURGICAL HISTORY:,1. A D and C.,2. Bone fragment removed from her right arm.,3. Ovarian cancer staging.,OBSTETRICAL HISTORY:, Spontaneous miscarriage at 3 months approximately 30 years ago.,GYNECOLOGICAL HISTORY: ,The patient started menses at age 12; she states that they were regular and occurred every month. She finished menopause at age 58. She denies any history of STDs or abnormal Pap smears. Her last mammogram was in April 2005 and was within normal limits.,FAMILY HISTORY:,1. A sister with breast carcinoma who was diagnosed in her 50s.,2. A father with gastric carcinoma diagnosed in his 70s.,3. The patient denies any history of ovarian, uterine, or colon cancer in her family.,SOCIAL HISTORY:, No tobacco, alcohol, or drug abuse.,MEDICATIONS:,1. Prilosec.,2. Tramadol p.r.n.,ALLERGIES:, NO KNOWN DRUG ALLERGIES.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature 97.3, pulse 91, respiratory rate 18, blood pressure 142/46, O2 saturation 99% on room air.,GENERAL: Alert, awake, and oriented times three, no apparent distress, a well-developed, well-nourished white female.,HEENT: Normocephalic and atraumatic. The oropharynx is clear. The pupils are equal, round, and reactive to light.,NECK: Good range of motion, nontender, no thyromegaly.,CHEST: Clear to auscultation bilaterally, no wheezes, rales, or rhonchi.,CARDIOVASCULAR: Regular rate and rhythm with a 2/6 systolic ejection murmur on her left side.,ABDOMEN: Positive bowel sounds, soft, nontender, nondistended, no hepatosplenomegaly, a well-healing midline incision.,EXTREMITIES: 2+ pulses bilaterally, right leg without swelling, nontender, no erythema, negative Homans' sign bilaterally, left thigh swollen, erythematous, and warm to the touch compared to the right. Her left groin is slightly tender to palpation.,LYMPHATICS: No axillary, groin, clavicular, or mandibular nodes palpated.,LABORATORY DATA:, White blood cell count 15.5, hemoglobin 11.4, hematocrit 34.5, platelets 159, percent neutrophils 88%, absolute neutrophil count 14,520. Sodium 142, potassium 3.3, chloride 103, CO2 26, BUN 15, creatinine 0.9, glucose 152, calcium 8.7. PT 13.1, PTT 28, INR 0.97.,ASSESSMENT AND PLAN:, Miss Bolen is a 59-year-old gravida 1, para 0-0-1-0 with stage IIIC papillary serous adenocarcinoma of the ovary. She is postop day 21 of an exploratory laparotomy with ovarian cancer staging. She is currently with a left leg DVT.,1. The patient is doing well and is currently without any complaints. We will start Lovenox 1 mg per kg subcu daily and Coumadin 5 mg p.o. daily. The patient will receive INR in the morning; the goal was obtain an INR between 2.5 and 3.0 before the Lovenox is instilled. The patient is scheduled for port placement for intraperitoneal chemotherapy and this possibly may be delayed.,2. Aranesp 200 mcg subcu was given today. The patient's absolute neutrophil count is 14,520."
114,0,"SUBJECTIVE:,  The patient is a 76-year-old white female who presents to the clinic today originally for hypertension and a med check.  She has a history of hypertension, osteoarthritis, osteoporosis, hypothyroidism, allergic rhinitis and kidney stones.  Since her last visit she has been followed by Dr. Kumar.  Those issues are stable.  She has had no fever or chills, cough, congestion, nausea, vomiting, chest pain, chest pressure.,PAST MEDICAL HISTORY:,  She has an intolerance to Prevacid.,CURRENT MEDICATIONS:,  Evista 60 daily, Levothroid 0.05 mg daily, Claritin 10 daily, Celebrex 200 daily, HCTZ 25 daily and amitriptyline p.r.n.,PAST SURGICAL HISTORY:,  Bilateral mastectomies, tonsillectomy, EGD, flex sig in 2001 and a heart cath.,FAMILY HISTORY: , Father passed away at 81; mother of multiple myeloma at 83.,SOCIAL HISTORY:,  She is married.  A 76-year-old who used to smoke a pack a day and quit in 1985.  She is retired.,REVIEW OF SYSTEMS:,  Essentially negative in HEENT, chest, cardiovascular, GI, GU, musculoskeletal, or neurologic.,OBJECTIVE:,  Temperature is 97.5 degrees.  Blood pressure is 168/70.  Pulse is 88.  Weight is 129 pounds.,GENERAL:  She is an elderly 76-year-old in no acute distress.,HEENT:  Atraumatic.  Extraocular muscles were intact.  Pupils equal, round and reactive to light and accommodation.  Tympanic membranes are clear, dry and intact.  Sinuses and throat are clear.  Neck is soft, supple.  No meningeal signs are present.  No thyromegaly is present.,CHEST:  Clear to auscultation.,CARDIOVASCULAR:  Regular rate and rhythm without murmur.,ABDOMEN:  Soft, nontender.  Bowel sounds are positive.  No organomegaly or peritoneal signs are present.,EXTREMITIES:  Moving all extremities.  Peripheral pulses are normal.  No edema is present.,NEUROLOGIC:  Alert and oriented.  Cranial nerves II-XII grossly intact.  Strength 5+/5 globally.  Reflexes 2+/IV globally.  Romberg is negative.  There is no numbness, tingling, weakness or other neurologic deficit present.,BREASTS:  Surgically absent but there are no lumps, lesions, masses, discharge or adenopathy present.,BACK:  Straight.,SKIN:  Clear.,GENITALIA:  Deferred as she has been followed by Dr. XYZ many times this year.  She does have a history of some elevated cholesterol.,ASSESSMENT:,1.  Hypertension, suboptimal control.,2.  Hypothyroidism.,3.  Arthritis.,4.  Allergic rhinitis.,5.  History of kidney stones.,6.  Osteoporosis.,PLAN:,1.  CBC, complete metabolic profile, UA for hypertension.,2.  Chest x-ray for history of breast cancer.,3.  DEXA scan, full body for osteoporosis.,4.  Flex is up to date.,5.  Pneumovax has been given in the last five years.,6.  Lipid profile for elevated cholesterol.,7.  Refill meds.,8.  Follow up every three to six months for blood pressure check or sooner p.r.n. problems."
145,0,"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."
88,1,"EXAM: , CT head without contrast.,INDICATIONS: , Assaulted, positive loss of consciousness, rule out bleed.,TECHNIQUE: , CT examination of the head was performed without intravenous contrast administration.  There are no comparison studies.,FINDINGS:  ,There are no abnormal extraaxial fluid collections.  There is no midline shift or mass effect.  Ventricular system demonstrates no dilatation.  There is no evidence of acute intracranial hemorrhage.  The calvarium is intact.  There is a laceration in the left parietal region of the scalp without underlying calvarial fractures.  The mastoid air cells are clear.,IMPRESSION:  ,No acute intracranial process."
97,1,"EXAM: , Barium enema.,CLINICAL HISTORY: , A 4-year-old male with a history of encopresis and constipation.,TECHNIQUE:  ,A single frontal scout radiograph of the abdomen was performed.  A rectal tube was inserted in usual sterile fashion, and retrograde instillation of barium contrast was followed via spot fluoroscopic images.  A post-evacuation overhead radiograph of the abdomen was performed.,FINDINGS:,  The scout radiograph demonstrates a nonobstructive gastrointestinal pattern.  There are no suspicious calcifications seen or evidence of gross free intraperitoneal air.  The visualized lung bases and osseous structures are within normal limits.,The rectum and colon is of normal caliber throughout its course.  There is no evidence of obstruction, as contrast is seen to flow without difficulty into the right colon and cecum.  A small amount of contrast is seen to opacify small bowel loops on the post-evacuation image.  There is also opacification of a normal-appearing appendix documented.,IMPRESSION: , Normal barium enema."
66,1,"EXAM:  ,Thoracic Spine.,REASON FOR EXAM: , Injury.,INTERPRETATION: , The thoracic spine was examined in the AP, lateral and swimmer's projections.  There is mild chronic-appearing anterior wedging of what is believed to represent T11 and 12 vertebral bodies.  A mild amount of anterior osteophytic lipping is seen involving the thoracic spine.  There is a suggestion of generalized osteoporosis.  The intervertebral disc spaces appear generally well preserved.,The pedicles appear intact.,IMPRESSION:,1. Mild chronic-appearing anterior wedging of what is believed to represent the T11 and 12 vertebral bodies.,2. Mild degenerative changes of the thoracic spine.,3. Osteoporosis."
144,0,"HISTORY OF PRESENT ILLNESS: , The patient is an 85-year-old male who was brought in by EMS with a complaint of a decreased level of consciousness.  The patient apparently lives with his wife and was found to have a decreased status since the last one day.  The patient actually was seen in the emergency room the night before for injuries of the face and for possible elderly abuse.  When the Adult Protective Services actually went to the patient's house, he was found to be having decreased consciousness for a whole day by his wife.  Actually the night before, he fell off his wheelchair and had lacerations on the face.  As per his wife, she states that the patient was given an entire mg of Xanax rather than 0.125 mg of Xanax, and that is why he has had decreased mental status since then.  The patient's wife is not able to give a history.  The patient has not been getting Sinemet and his other home medications in the last 2 days.  ,PAST MEDICAL HISTORY:  ,Parkinson disease.,MEDICATIONS:,  Requip, Neurontin, Sinemet, Ambien, and Xanax.,ALLERGIES: , No known drug allergies.,SOCIAL HISTORY: , The patient lives with his wife.,PHYSICAL EXAMINATION:,GENERAL:"
80,1,"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 36.0C,MS: 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."
139,0,"CHIEF COMPLAINT:,  Itchy rash.,HISTORY OF PRESENT ILLNESS: , This 34-year-old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms.  No facial swelling.  No tongue or lip swelling.  No shortness of breath, wheezing, or other associated symptoms.  He cannot think of anything that could have triggered this off.  There have been no changes in his foods, medications, or other exposures as far as he knows.  He states a couple of days ago he did work and was removing some insulation but does not remember feeling itchy that day.,PAST MEDICAL HISTORY: , Negative for chronic medical problems.  No local physician.  Has had previous back surgery and appendectomy, otherwise generally healthy.,REVIEW OF SYSTEMS: , As mentioned denies any oropharyngeal swelling.  No lip or tongue swelling.  No wheezing or shortness of breath.  No headache.  No nausea.  Notes itchy rash, especially on his torso and upper arms.,SOCIAL HISTORY: , The patient is accompanied with his wife.,FAMILY HISTORY: , Negative.,MEDICATIONS: , None.,ALLERGIES: , TORADOL, MORPHINE, PENICILLIN, AND AMPICILLIN.,PHYSICAL EXAMINATION: , VITAL SIGNS:  The patient was afebrile.  He is slightly tachycardic, 105, but stable blood pressure and respiratory rate.  GENERAL:  The patient is in no distress.  Sitting quietly on the gurney.  HEENT:  Unremarkable.  His oral mucosa is moist and well hydrated.  Lips and tongue look normal.  Posterior pharynx is clear.  NECK:  Supple.  His trachea is midline.  There is no stridor.  LUNGS:  Very clear with good breath sounds in all fields.  There is no wheezing.  Good air movement in all lung fields.  CARDIAC:  Without murmur.  Slight tachycardia.  ABDOMEN:  Soft, nontender.  SKIN:  Notable for a confluence erythematous, blanching rash on the torso as well as more of a blotchy papular, macular rash on the upper arms.  He noted some on his buttocks as well.  Remaining of the exam is unremarkable.,ED COURSE: , The patient was treated with epinephrine 1:1000, 0.3 mL subcutaneously along with 50 mg of Benadryl intramuscularly.  After about 15-20 minutes he states that itching started to feel better.  The rash has started to fade a little bit and feeling a lot more comfortable.,IMPRESSION:,  ACUTE ALLERGIC REACTION WITH URTICARIA AND PRURITUS.,ASSESSMENT AND PLAN: , The patient has what looks to be some type of allergic reaction, although the underlying cause is difficult to assess.  He will make sure he goes home to look around to see if there is in fact anything that changed recently that could have triggered this off.  In the meantime, I think he can be managed with some antihistamine over-the-counter.  He is responding already to Benadryl and the epinephrine that we gave him here.  He is told that if he develops any respiratory complaints, shortness of breath, wheezing, or tongue or lip swelling he will return immediately for evaluation.  He is discharged in stable condition."
153,1,"EXAM: , Carotid and cerebral arteriograms.,INDICATION: , Abnormal carotid duplex studies demonstrating occlusion of the left internal carotid artery.,IMPRESSION:,1.  Complete occlusion of the left common carotid artery approximately 3 cm distal to its origin.,2.  Mild stenosis of the right internal carotid artery measured at 20%.,3.  Patent bilateral vertebral arteries.,4.  No significant disease was identified of the anterior cerebral vessels.,DISCUSSION:  ,Carotid and cerebral arteriograms were performed on Month DD, YYYY, previous studies are not available for comparison.,The right groin was sterilely cleansed and draped.  Lidocaine 1% buffered with sodium bicarbonate was used as local anesthetic.  A 19-French needle was then advanced into the common femoral artery and a wire was advanced.  Over the wire, a sheath was placed.  A wire was then advanced into the abdominal aorta and over the wire and the flushed catheter was then advanced to the arch of the aorta over a wire.  Flushed arteriogram was performed.  Arteriogram demonstrated no significant disease of the great vessels at their origins.  There is demonstration of complete occlusion of the left common carotid artery approximately 3 cm distal to its origin.  The vertebral arteries were widely patent.  Following this, the flushed catheter was exchanged for ***** catheter and selective catheterization of the common carotid artery on the right was performed.  Carotid and cerebral arteriograms were performed.  The carotid arteriograms on the right demonstrated the carotid bulb to be unremarkable.  The external carotid artery on the right is quite tortuous in its appearance.  The internal carotid artery demonstrates a mild plaque creating stenosis, which is measured approximately 20%.  Cerebral arteriogram on the right demonstrated the A1 and M1 segments bilaterally to be normal.  No significant stenosis identified.  There is complete cross-filling into the left brain via the right.  No significant stenosis was appreciated.,Following this, the catheter was parked at the origin of the left common carotid artery and ejection demonstrated complete occlusion.,The patient tolerated the procedure well.  No complications occurred during or immediately after the procedure.  Stasis was achieved of the puncture site using a VasoSeal.  The patient will be observed for at least 2-1/2 hours prior to being discharged to home."
131,0,"ADMISSION DIAGNOSIS: , Upper respiratory illness with apnea, possible pertussis.,DISCHARGE DIAGNOSIS: , Upper respiratory illness with apnea, possible pertussis.,COMPLICATIONS: , None.,OPERATIONS: , None,BRIEF HISTORY AND PHYSICAL: , This is a one plus-month-old female with respiratory symptoms for approximately a week prior to admission.  This involved cough, post-tussive emesis, questionable fever, but only 99.7.  Their usual doctor prescribed amoxicillin over the phone.  The coughing persisted and worsened.  She went to the ER, where sats were normal at baseline, but dropped into the 80s with coughing spells.  They did witness some apnea.  They gave some Rocephin, did some labs, and the patient was transferred to hospital.,PHYSICAL EXAMINATION: , On admission, GENERAL:  Well-developed, well-nourished baby in no apparent distress. HEENT:  There was some nasal discharge.  Remainder of the HEENT was normal.  LUNG:  Had few rhonchi.  No retractions.  No significant coughing or apnea during the admission physical.  ABDOMEN:  Benign.  EXTREMITIES:  Were without any cyanosis.,SIGNIFICANT LABS AND X-RAYS:  ,She had a CBC done Garberville, which showed a white count of 12.4, with a differential of 10 segs, 82 lymphs, 8 monos, hemoglobin of 15, hematocrit 42, platelets 296,000, and a normal BMP.  An x-ray was done and I do not have an official interpretation, but to the admitting physician, Dr. X it showed no significant infiltrate.  Well at hospital, she had a rapid influenza swab done, which was negative.  She had a rapid RSV done, which is still not in the chart, but I believe I was told that it was negative.  She also had a pertussis PCR swab done and a pertussis culture done, neither of which has result in the chart.  I do know that the pertussis culture proved to be negative.,CONSULTATION: , Public Health Department was notified of a case of suspected pertussis.,HOSPITAL COURSE: , The baby was afebrile.  Required no oxygen in the hospital.  Actually fed reasonably well.  Did have one episode of coughing with slight emesis.  Appeared basically quite well between episodes.  Had no apnea witnessed and after overnight observation, the parents were anxious to go home.  The patient was started on Zithromax in the hospital.,CONDITION AND TREATMENT: , The patient was in stable condition and good condition on exam at the time and was discharged home on Zithromax to be followed up in the office within a week.,INSTRUCTIONS TO PATIENT:,  Include usual diet and to follow up within a week, but certainly sooner if the coughing is worse and there is cyanosis or apnea again."
157,1,"INDICATIONS:,  Peripheral vascular disease with claudication.,RIGHT:,  ,1.  Normal arterial imaging of right lower extremity.,2.  Peak systolic velocity is normal.,3.  Arterial waveform is triphasic.,4.  Ankle brachial index is 0.96.,LEFT:,1.  Normal arterial imaging of left lower extremity.,2.  Peak systolic velocity is normal.,3.  Arterial waveform is triphasic throughout except in posterior tibial artery where it is biphasic.,4.  Ankle brachial index is 1.06.,IMPRESSION,:,Normal arterial imaging of both lower extremities."
92,1,"EXAM: , Dobutamine Stress Test.,INDICATION: , Chest pain.,TYPE OF TEST: , Dobutamine stress test, as the patient was unable to walk on a treadmill, and allergic to adenosine.,INTERPRETATION: , Resting heart rate of 66 and blood pressure of 88/45.  EKG, normal sinus rhythm.  Post dobutamine increment dose, his peak heart rate achieved was 125, which is 87% of the target heart rate.  Blood pressure 120/42.  EKG remained the same.  No symptoms were noted.,IMPRESSION:,1. Nondiagnostic dobutamine stress test.,2. Nuclear interpretation as below.,NUCLEAR INTERPRETATION: , Resting and stress images were obtained with 10.8, 30.2 mCi of tetrofosmin injected intravenously by standard protocol.  Nuclear myocardial perfusion scan demonstrates homogeneous and uniform distribution of the tracer uptake without any evidence of reversible or fixed defect.  Gated and SPECT revealed normal wall motion and ejection fraction of 75%.  End-diastolic volume was 57 and end-systolic volume of 12.,IMPRESSION:,1. Normal nuclear myocardial perfusion scan.,2. Ejection fraction of 75% by gated SPECT."
16,0,"REASON FOR VISIT:,  Weight loss evaluation.,HISTORY OF PRESENT ILLNESS:,"
37,0,"ADMISSION DIAGNOSIS: , Symptomatic thyroid goiter.,DISCHARGE DIAGNOSIS:  ,Symptomatic thyroid goiter.,PROCEDURE PERFORMED DURING THIS HOSPITALIZATION: , Total thyroidectomy.,INDICATIONS FOR THE SURGERY:  ,Briefly, the patient is a 71-year-old female referred with increasingly symptomatic large nodular thyroid goiter.  She presented now after informed consent for the above procedure, understanding the inherent risks and complications and risk-benefit ratio.,HOSPITAL COURSE:  ,The patient underwent total thyroidectomy on 09/22/08, which she tolerated very well and remained stable in the postoperative period.  On postoperative day #1, she was tolerating her diet, began on thyroid hormone replacement, and remained afebrile with stable vital signs.  She required intravenous narcotics for pain control.  She was judged stable for discharge home on 09/25/08, tolerating a diet well, having no fever, stable vital signs, and good pain control.  The wound was clean and dry.  The drain was removed.  She was instructed to follow up in the surgical office within one week after discharge.  She was given prescription for Vicodin for pain and Synthroid thyroid hormone, and otherwise the appropriate wound care instructions per my routine wound care sheet."
118,0,"HISTORY OF PRESENT ILLNESS: , This is a 91-year-old male with a previous history of working in the coalmine and significant exposure to silica with resultant pneumoconiosis and fibrosis of the lung.  The patient also has a positive history of smoking in the past.  At the present time, he is admitted for continued,management of respiratory depression with other medical complications.  The patient was treated for multiple problems at Jefferson Hospital prior to coming here including abdominal discomfort due to a ureteral stone with resultant hydronephrosis and hydroureter.  In addition, he also developed cardiac complications including atrial fibrillation.  The patient was evaluated by the cardiologist as well as the pulmonary service and Urology.  He had a cystoscopy performed and a left ureteral stone was removed as well as insertion of a left ureteral stent on 07/23/2008.  He subsequently underwent cardiac arrest and he was resuscitated at that time.  He was intubated and placed on mechanical ventilatory support.  Subsequent weaning was unsuccessful.  He then had a tracheostomy placed.,CURRENT MEDICATIONS:,1.  Albuterol.,2.  Pacerone.,3.  Theophylline,4.  Lovenox.,5.  Atrovent.,6.  Insulin.,7.  Lantus.,8.  Zestril.,9.  Magnesium oxide.,10.  Lopressor.,11.  Zegerid.,12.  Tylenol as needed.,ALLERGIES:,  PENICILLIN.,PAST MEDICAL HISTORY:,1.  History of coal miner's disease.,2.  History of COPD.,3.  History of atrial fibrillation.,4.  History of coronary artery disease.,5.  History of coronary artery stent placement.,6.  History of gastric obstruction.,7.  History of prostate cancer.,8.  History of chronic diarrhea.,9.  History of pernicious anemia.,10.  History of radiation proctitis.,11.  History of anxiety.,12.  History of ureteral stone.,13.  History of hydronephrosis.,SOCIAL HISTORY: , The patient had been previously a smoker.  No other could be obtained because of tracheostomy presently.,FAMILY HISTORY: , Noncontributory to the present condition and review of his previous charts.,SYSTEMS REVIEW: , The patient currently is agitated.  Rapidly moving his upper extremities.  No other history regarding his systems could be elicited from the patient.,PHYSICAL EXAM:,General:  The patient is currently agitated with some level of distress.  He has rapid respiratory rate.  He is responsive to verbal commands by looking at the eyes.,Vital Signs:  As per the monitors are stable.,Extremities:  Inspection of the upper extremities reveals extreme xerosis of the skin with multiple areas of ecchymosis and skin tears some of them to the level of stage II especially over the dorsum of the hands and forearm areas.  There is also edema of the forearm extending up to the mid upper arm area.  Palpation of the upper extremities reveals fibrosis more prominent on the right forearm area with the maximum edema in the elbow area on the ulnar aspect.  There is also scabbing of some of the possibly from earlier skin tears in the upper side forearm area.,IMPRESSION:,1.  Ulceration of bilateral upper extremities.,2.  Cellulitis of upper extremities.,3.  Lymphedema of upper extremities.,4.  Other noninfectious disorders of lymphatic channels.,5.  Ventilatory-dependent respiratory failure."
11,0,"HISTORY OF PRESENT ILLNESS:,  Patient is a 72-year-old white male complaining of a wooden splinter lodged beneath his left fifth fingernail, sustained at 4 p.m. yesterday.  He attempted to remove it with tweezers at home, but was unsuccessful.  He is requesting we attempt to remove this for him.,The patient believes it has been over 10 years since his last tetanus shot, but states he has been allergic to previous immunizations primarily with ""horse serum.""  Consequently, he has declined to update his tetanus immunization.,MEDICATIONS: , He is currently on several medications, a list of which is attached to the chart, and was reviewed.  He is not on any blood thinners.,ALLERGIES: , HE IS ALLERGIC ONLY TO TETANUS SERUM.,SOCIAL HISTORY: , Patient is married and is a nonsmoker and lives with his wife.  ,Nursing notes were reviewed with which I agree.,PHYSICAL EXAMINATION,VITAL SIGNS:  Temp and vital signs are all within normal limits.,GENERAL:  The patient is a pleasant elderly white male who is sitting on the stretcher in no acute distress.,EXTREMITIES:  Exam of the left fifth finger shows a 5- to 6-mm splinter lodged beneath the medial aspect of the nail plate.  It does not protrude beyond the end of the nail plate.  There is no active bleeding.  There is no edema or erythema of the digit tip.  Flexion and extension of the DIP joint is intact.  The remainder of the hand is unremarkable.,TREATMENT: , I did attempt to grasp the end of the splinter with splinter forceps, but it is brittle and continues to break off.  In order to better grasp the splinter, will require penetration beneath the nail plate, which the patient cannot tolerate due to pain.  Consequently, the base of the digit tip was prepped with Betadine, and just distal to the DIP joint, a digital block was applied with 1% lidocaine with complete analgesia of the digit tip.  I was able to grasp the splinter and remove this.  No further foreign body was seen beneath the nail plate and the area was cleansed and dressed with bacitracin and bandage.,ASSESSMENT: , Foreign body of the left fifth fingernail (wooden splinter).,PLAN: , Patient was urged to clean the area b.i.d. with soap and water and to dress with bacitracin and a Band-Aid.  If he notes increasing redness, pain, or swelling, he was urged to return for re-evaluation."
84,1,"EXAM: , CT abdomen and pelvis without contrast, stone protocol, reconstruction.,REASON FOR EXAM: , Flank pain.,TECHNIQUE: , Noncontrast CT abdomen and pelvis with coronal reconstructions.,FINDINGS: , There is no intrarenal stone bilaterally.  However, there is very mild left renal pelvis and proximal ureteral dilatation with a small amount of left perinephric stranding asymmetric to the right.  The right renal pelvis is not dilated.  There is no stone along the course of the ureter.  I cannot exclude the possibility of recent stone passage, although the findings are ultimately technically indeterminate and clinical correlation is advised.  There is no obvious solid-appearing mass given the lack of contrast.,Scans of the pelvis disclose no evidence of stone within the decompressed bladder.  No pelvic free fluid or adenopathy.,There are few scattered diverticula.  There is a moderate amount of stool throughout the colon.  There are scattered diverticula, but no CT evidence of acute diverticulitis.  The appendix is normal.,There are mild bibasilar atelectatic changes.,Given the lack of contrast, visualized portions of the liver, spleen, adrenal glands, and the pancreas are grossly unremarkable.  The gallbladder is present.  There is no abdominal free fluid or pathologic adenopathy.,There are degenerative changes of the lumbar spine.,IMPRESSION:,1.Very mild left renal pelvic dilatation and proximal ureteral dilatation with mild left perinephric stranding.  There is no stone identified along the course of the left ureter or in the bladder.  Could this patient be status post recent stone passage?  Clinical correlation is advised.,2.Diverticulosis.,3.Moderate amount of stool throughout the colon.,4.Normal appendix."
103,0,"CHIEF COMPLAINT:  ,The patient does not have any chief complaint.,HISTORY OF PRESENT ILLNESS:,  This is a 93-year-old female who called up her next-door neighbor to say that she was not feeling well.  The next-door neighbor came over and decided that she should go to the emergency room to be check out for her generalized complaint of not feeling well.  The neighbor suspects that this may have been due to the patient taking too many of her Tylenol PM, which the patient has been known to do.  The patient was a little somnolent early this morning and was found only to be oriented x1 with EMS upon their arrival to the patient's house.  The patient states that she just simply felt funny and does not give any more specific details than this.  The patient denies any pain at any time.  She did not have any shortness of breath.  No nausea or vomiting.  No generalized weakness.  The patient states that all that has gone away since arrival here in the hospital, that she feels at her usual self, is not sure why she is here in the hospital, and thinks she should go.  The patient's primary care physician, Dr. X reports that the patient spoke with him yesterday and had complained of shortness of breath, nausea, dizziness, as well as generalized weakness, but the patient states that all this has resolved.  The patient was actually seen here two days ago for those same symptoms and was found to have exacerbation of her COPD and CHF.  The patient was discharged home after evaluation in the emergency room.  The patient does use home O2.,REVIEW OF SYSTEMS: , CONSTITUTIONAL:  The patient had complained of generalized fatigue and weakness two days ago in the emergency room and yesterday to her primary care physician.  The patient denies having any other symptoms today.  The patient denies any fever or chills.  Has not had any recent weight change.  HEENT:  The patient denies any headache.  No neck pain.  No rhinorrhea.  No sinus congestion.  No sore throat.  No any vision or hearing change.  No eye or ear pain.  CARDIOVASCULAR:  The patient denies any chest pain.  RESPIRATIONS:  No shortness of breath.  No cough.  No wheeze.  The patient did report having shortness of breath and wheeze with her presentation to the emergency room two days ago and shortness of breath to her primary care physician yesterday, but the patient states that all this has resolved.  GASTROINTESTINAL:  No abdominal pain.  No nausea or vomiting.  No change in the bowel movements.  There has not been any diarrhea or constipation.  No melena or hematochezia.  GENITOURINARY:  No dysuria, hematuria, urgency, or frequency.  MUSCULOSKELETAL:  No back pain.  No muscle or joint aches.  No pain or abnormalities to any portion of the body.  SKIN:  No rashes or lesions.  NEUROLOGIC:  The patient reported dizziness to her primary care physician yesterday over the phone, but the patient denies having any problems with dizziness over the past few days.  The patient denies any dizziness at this time.  No syncope or no near-syncope.  The patient denies any focal weakness or numbness.  No speech change.  No difficulty with ambulation.  The patient has not had any vision or hearing change.  PSYCHIATRIC:  The patient denies any depression.  ENDOCRINE:  No heat or cold intolerance.,PAST MEDICAL HISTORY:,  COPD, CHF, hypertension, migraines, previous history of depression, anxiety, diverticulitis, and atrial fibrillation.,PAST SURGICAL HISTORY:,  Placement of pacemaker and hysterectomy.,CURRENT MEDICATIONS: , The patient takes Tylenol PM for insomnia, Lasix, Coumadin, Norvasc, Lanoxin, Diovan, atenolol, and folic acid.,ALLERGIES:,  NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient used to smoke, but quit approximately 30 years ago.  The patient denies any alcohol or drug use although her son reports that she has had a long history of this in the past and the patient has abused prescription medication in the past as well according to her son.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Temperature 99.1 oral, blood pressure 139/65, pulse is 72, respirations 18, and oxygen saturation is 92% on room air and interpreted as low normal.  CONSTITUTIONAL:  The patient is well nourished and well developed.  The patient appears to be healthy.  The patient is calm, comfortable, in no acute distress, and looks well.  The patient is pleasant and cooperative.  HEENT:  Head is atraumatic, normocephalic, and nontender.  Eyes are normal with clear sclerae and cornea bilaterally.  Nose is normal without rhinorrhea or audible congestion.  Mouth and oropharynx are normal without any sign of infection.  Mucous membranes are moist.  NECK:  Supple and nontender.  Full range of motion.  There is no JVD.  No cervical lymphadenopathy.  No carotid artery or vertebral artery bruits.  CARDIOVASCULAR:  Heart is regular rate and rhythm without murmur, rub or gallop.  Peripheral pulses are +2.  The patient does have +1 bilateral lower extremity edema.  RESPIRATIONS:  The patient has coarse breath sounds bilaterally, but no dyspnea.  Good air movement.  No wheeze.  No crackles.  The patient speaks in full sentences without any difficulty.  The patient does not exhibit any retractions, accessory muscle use or abdominal breathing.  GASTROINTESTINAL:  Abdomen is soft, nontender, and nondistended.  No rebound or guarding.  No hepatosplenomegaly.  Normal bowel sounds.  No bruits, no mass, no pulsatile mass, and no inguinal lymphadenopathy.  MUSCULOSKELETAL:  No abnormalities noted to the back, arms or legs.  SKIN:  No rashes or lesions.  NEUROLOGICAL:  Cranial nerves II through XII are intact.  Motor is 5/5 and equal to bilateral arms and legs.  Sensory is intact to light touch.  The patient has normal speech and normal ambulation.  PSYCHIATRIC:  The patient is awake, alert, and oriented x3 although the patient first stated that the year was 1908, but did manage to correct herself up on addressing this with her.  The patient has normal mood and affect.  HEMATOLOGIC AND LYMPHATIC:  There is no evidence of lymphadenopathy.,EMERGENCY DEPARTMENT TESTING: , EKG is a rate of 72 with evidence of a pacemaker that has good capture.  There is no evidence of acute cardiac disease on the EKG and there is no apparent change in the EKG from 03/17/08.  CBC has no specific abnormalities of issue.  Chemistry has a BUN of 46 and creatinine of 2.25, glucose is 135, and an estimated GFR is 20.  The rest of the values are normal and unremarkable.  LFTs are all within normal limits.  Cardiac enzymes are all within normal limits.  Digoxin level is therapeutic at 1.6.  Chest x-ray noted cardiomegaly and evidence of congestive heart failure, but no acute change from her chest x-ray done two days ago.  CAT scan of the head did not identify any acute abnormalities.  I spoke with the patient's primary care physician, Dr. X who stated that he would be able to follow up with the patient within the next day.  I spoke with the patient's neighbor who contacted the ambulance service who stated that the patient just reported not feeling well and appeared to be a little somnolent and confused at the time, but suspected that she may have taken too many of her Tylenol PM as she often has done in the past.  The neighbor is XYZ and he says that he checks on her three times a day every day.  ABC is the patient's son and although he lives out of town he calls and checks on her every day as well.  He states that he spoke to her yesterday.  She sounded fine, did not express any other problems that she had apparently been in contact with her primary care physician.  She sounded her usual self to him.  Mr. ABC also spoke to the patient while she was here in the emergency room and she appears to be her usual self and has her normal baseline mental status to him.  He states that he will be able to check on her tomorrow as well.  Although it is of some concern that there may be problems with development of some early dementia, the patient is adamant about not going to a nursing home and has been placed in a Nursing Home in the past, but Dr. Y states that she has managed to be discharged after two previous nursing home placements.  The patient does have Home Health that checks on her as well as housing care in between the two services they share visits every single day  by them as well as the neighbor who checks on her three times a day and her son who calls her each day as well.  The patient although she lives alone, does appear to have good followup and the patient is adamant that she wishes to return home.,DIAGNOSES,1.  EARLY DEMENTIA.,2."
8,0,"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."
10,0,"CHIEF COMPLAINT:,  Abdominal pain.,HISTORY OF PRESENT ILLNESS:,  The patient is a 71-year-old female patient of Dr. X. The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent.  She was seen 3 to 4 days ago at ABC ER and underwent evaluation and discharged and had a CT scan at that time and she was told it was ""normal.""  She was given oral antibiotics of Cipro and Flagyl.  She has had no nausea and vomiting, but has had persistent associated anorexia.  She is passing flatus, but had some obstipation symptoms with the last bowel movement two days ago.  She denies any bright red blood per rectum and no history of recent melena.  Her last colonoscopy was approximately 5 years ago with Dr. Y. She has had no definite fevers or chills and no history of jaundice.  The patient denies any significant recent weight loss.,PAST MEDICAL HISTORY:  ,Significant for history of atrial fibrillation, under good control and now in normal sinus rhythm and on metoprolol and also on Premarin hormone replacement.,PAST SURGICAL HISTORY: , Significant for cholecystectomy, appendectomy, and hysterectomy.  She has a long history of known grade 4 bladder prolapse and she has been seen in the past by Dr. Chip Winkel, I believe that he has not been re-consulted.,ALLERGIES: , SHE IS ALLERGIC OR SENSITIVE TO MACRODANTIN.,SOCIAL HISTORY: , She does not drink or smoke.,REVIEW OF SYSTEMS: , Otherwise negative for any recent febrile illnesses, chest pains or shortness of breath.,PHYSICAL EXAMINATION:,GENERAL:  The patient is an elderly thin white female, very pleasant, in no acute distress.,VITAL SIGNS:  Her temperature is 98.8 and vital signs are all stable, within normal limits.,HEENT:  Head is grossly atraumatic and normocephalic.  Sclerae are anicteric.  The conjunctivae are non-injected.,NECK:  Supple.,CHEST:  Clear.,HEART:  Regular rate and rhythm.,ABDOMEN:  Generally nondistended and soft.  She is focally tender in the left lower quadrant to deep palpation with a palpable fullness or mass and focally tender, but no rebound tenderness.  There is no CVA or flank tenderness, although some very minimal left flank tenderness.,PELVIC:  Currently deferred, but has history of grade 4 urinary bladder prolapse.,EXTREMITIES:  Grossly and neurovascularly intact.,LABORATORY VALUES:  ,White blood cell count is 5.3, hemoglobin 12.8, and platelet count normal.  Alkaline phosphatase elevated at 184.  Liver function tests otherwise normal.  Electrolytes normal.  Glucose 134, BUN 4, and creatinine 0.7.,DIAGNOSTIC STUDIES:,  EKG shows normal sinus rhythm.,IMPRESSION AND PLAN: , A 71-year-old female with greater than one-week history of abdominal pain now more localized to the left lower quadrant.  Currently is a nonacute abdomen.  The working diagnosis would be sigmoid diverticulitis.  She does have a history in the distant past of sigmoid diverticulitis.  I would recommend a repeat stat CT scan of the abdomen and pelvis and keep the patient nothing by mouth.  The patient was seen 5 years ago by Dr. Y in Colorectal Surgery.  We will consult her also for evaluation.  The patient will need repeat colonoscopy in the near future and be kept nothing by mouth now empirically.  The case was discussed with the patient's primary care physician, Dr. X. Again, currently there is no indication for acute surgical intervention on today's date, although the patient will need close observation and further diagnostic workup."
110,0,"SUBJECTIVE:,  The patient complains of backache, stomachache, and dysuria for the last two days.  Fever just started today and cough.  She has history of kidney stones less than a year ago and had a urinary tract infection at that time.  Her back started hurting last night.,PAST MEDICAL HISTORY:,  She denies sexual activities since two years ago.  Her last menstrual period was 06/01/2004.  Her periods have been irregular.  She started menarche at 10 years of age and she is still irregular and it runs in Mom’s side of the family.  Mom and maternal aunt have had total hysterectomies.  She also is diagnosed with abnormal valve has to be on SBE prophylaxis, sees Dr. XYZ Allen.  She avoids decongestants.  She is limited on her activity secondary to her heart condition.,MEDICATION:,  Cylert.,ALLERGIES: , No known drug allergies.,OBJECTIVE:,Vital Signs:  Blood pressure is 124/72.  Temperature 99.2.  Respirations 20 unlabored.  Weight:  137 pounds.,HEENT:  Normocephalic.  Conjunctivae noninjected.  No mattering noted.  Her TMs are bilaterally clear, nonerythematous.  Throat clear, good mucous membrane moisture, but she did have erythema and edema at her posterior soft palate.,Neck:  Supple.  Increased lymphadenopathy noted in the submandibular nodes, but no axillary nodes and no hepatosplenomegaly.,Respiratory:  Clear.  No wheezes, no crackles, no tachypnea, and no retractions.,Cardiovascular:  Regular rate and rhythm.  S1 and S2 normal, no murmur.,Abdomen:  Soft.  No organomegaly.  She did have exquisite tenderness to palpation of the left upper quadrant and flank area, but the spleen was not palpable.  She has no suprapubic tenderness.,Extremities:  She has good range of motion of upper and lower extremities.  Good ambulation.,Her UA was positive for 2+ leukocyte esterase, positive nitrites, 1+ protein, 2+ ketones, 4+ blood, greater than 50 white blood cells, 10-20 rbc’s, and 1+ bacteria.  Culture and sensitivity is pending.  Her Strep test is negative.  Culture is pending.,ASSESSMENT:,1.  Urinary dysuria.,2.  Left flank pain.,3.  Pharyngitis.,PLAN:,  A 1 g of Rocephin IM was given.  Call Dr. B's office tomorrow morning incase a second IM dose is needed.  If not then she will fill a prescription for Omnicef 300 mg capsule 1 p.o. b.i.d. for 10 days total and then we will await the culture and sensitivity results to see if this is appropriate drug.  Push fluids.  Await strep culture report.  Follow up with Dr. XYZ if no better or symptoms worsen."
63,1,"INDICATION: , Lung carcinoma.,Whole body PET scanning was performed with 11 mCi of 18 FDG. Axial, coronal and sagittal imaging was performed over the neck, chest abdomen and pelvis.,FINDINGS:,There is normal physiologic activity identified in the myocardium, liver, spleen, ureters, kidneys and bladder.,There is abnormal FDG-avid activity identified in the posterior left paraspinal region best seen on axial images 245-257 with an SUV of 3.8, no definite bone lesion is identified on the CT scan or the bone scan dated 08/14/2007 (It may be purely lytic).,Additionally there is a significant area of activity corresponding to a mass in the region of the left hilum that is visible on the CT scan with an SUV of 18.1, the adjacent atelectasis as likely post obstructive in nature.,Additionally, although there is no definite lesion identified on CT , there is a tiny satellite nodule in the left upper lobe that is hypermetabolic with an SUV of 5.0. The spiculated density seen in the right upper lobe on the CT scan does not demonstrate FDG activity on this PET scan.,There is a hypermetabolic lymph node identified in the aorta pulmonary window with an SUV of 3.7 in the mediastinum.,IMPRESSION:,No prior PET scans for comparison, there is a large lesion identified in the area of the left hilum with an SUV of 18.1 likely causing the obstructive atelectasis seen on the CT scan.,There is a tiny satellite area of hypermetabolic FDG in the left upper lobe adjacent to the pleura with an SUV of 5.0.,There is a area of hypermetabolic activity in the left paraspinal soft tissues at the level of the lung apices which may represent a focal bone lesion. However no lesion is identified on bone scan or CT scan.,There is a hypermetabolic lymph node identified. The aorta pulmonary window with a corresponding finding on CT scan with an SUV of 3.7."
171,1,"NUCLEAR MEDICINE HEPATOBILIARY SCAN,REASON FOR EXAM: , Right upper quadrant pain.,COMPARISONS:  ,CT of the abdomen dated 02/13/09 and ultrasound of the abdomen dated 02/13/09.,Radiopharmaceutical 6.9 mCi of Technetium-99m Choletec.,FINDINGS:,  Imaging obtained up to 30 minutes after the injection of radiopharmaceutical shows a normal hepatobiliary transfer time.  There is normal accumulation within the gallbladder.,After the injection of 2.1 mcg of intravenous cholecystic _______, the gallbladder ejection fraction at 30 minutes was calculated to be 32% (normal is greater than 35%).  The patient experienced 2/10 pain at 5 minutes after the injection of the radiopharmaceutical and the patient also complained of nausea.,IMPRESSION:,1.  Negative for acute cholecystitis or cystic duct obstruction.,2.  Gallbladder ejection fraction just under the lower limits of normal at 32% that can be seen with very mild chronic cholecystitis."
173,1,"CC: ,Left hand numbness on presentation; then developed lethargy later that day.,HX: ,On the day of presentation, this 72 y/o RHM suddenly developed generalized weakness and lightheadedness, and could not rise from a chair. Four hours later he experienced sudden left hand numbness lasting two hours. There were no other associated symptoms except for the generalized weakness and lightheadedness. He denied vertigo.,He had been experiencing falling spells without associated LOC up to several times a month for the past year.,MEDS:, procardia SR, Lasix, Ecotrin, KCL, Digoxin, Colace, Coumadin.,PMH: ,1)8/92 evaluation for presyncope (Echocardiogram showed: AV fibrosis/calcification, AV stenosis/insufficiency, MV stenosis with annular calcification and regurgitation, moderate TR, Decreased LV systolic function, severe LAE. MRI brain: focal areas of increased T2 signal in the left cerebellum and in the brainstem probably representing microvascular ischemic disease. IVG (MUGA scan)revealed: global hypokinesis of the LV and biventricular dysfunction, RV ejection Fx 45% and LV ejection Fx 39%. He was subsequently placed on coumadin severe valvular heart disease), 2)HTN, 3)Rheumatic fever and heart disease, 4)COPD, 5)ETOH abuse, 6)colonic polyps, 7)CAD, 8)CHF, 9)Appendectomy, 10)Junctional tachycardia.,FHX:, stroke, bone cancer, dementia.,SHX: ,2ppd smoker since his teens; quit 2 years ago. 6-pack beer plus 2 drinks per day for many years: now claims he has been dry for 2 years. Denies illicit drug use.,EXAM: ,36.8C, 90BPM, BP138/56.,MS: Alert and oriented to person, place, but not date. Hypophonic and dysarthric speech. 2/3 recall. Followed commands.,CN: Left homonymous hemianopia and left CN7 nerve palsy (old).,MOTOR: full strength throughout.,SENSORY: unremarkable.,COORDINATION: dysmetric FNF and HKS movements (left worse than right).,STATION: RUE pronator drift and Romberg sign present.,GAIT: shuffling and bradykinetic.,REFLEXES: 1+/1+ to 2+/2+ and symmetric throughout. Plantar responses were flexor bilaterally.,HEENT: Neck supple and no carotid bruits.,CV: RRR with 3/6 SEM and diastolic murmurs throughout the precordium.,Lungs: bibasilar crackles.,LABS:, PT 19 (elevated) and PTT 46 (elevated).,COURSE:, Coumadin was discontinued on admission as he was felt to have suffered a right hemispheric stroke. The initial HCT revealed a subtle low density area in the right occipital lobe and no evidence of hemorrhage. He was scheduled to undergo an MRI Brain scan the same day, and shortly before the procedure became lethargic. By the time the scan was complete he was stuporous. MRI Scan then revealed a hypointense area of T1 signal in the right temporal lobe with a small foci of hyperintensity within it. The hyperintense area seen on T1 weighted images appeared hypointense on T2 weighted images. There was edema surrounding the lesion The findings were consistent with a hematoma. A CT scan performed 4 hours later confirmed a large hematoma with surrounding edema involving the right temporal/parietal/occipital lobes. The patient subsequently died."
156,1,"DUPLEX ULTRASOUND OF LEGS,RIGHT LEG:,  Duplex imaging was carried out according to normal protocol with a 7.5 Mhz imaging probe using B-mode ultrasound.  Deep veins were imaged at the level of the common femoral and popliteal veins.  All deep veins demonstrated compressibility without evidence of intraluminal thrombus or increased echogenicity.,The long saphenous system displayed compressibility without evidence of thrombosis.  The long saphenous vein measured * cm at the proximal thigh with reflux of * seconds after release of distal compression and * cm at the knee with reflux of * seconds after release of distal compression.  The small saphenous system measured * cm at the proximal calf with reflux of * seconds after release of distal compression.,LEFT LEG:,  Duplex imaging was carried out according to normal protocol with a 7.5 Mhz imaging probe using B-mode ultrasound.  Deep veins were imaged at the level of the common femoral and popliteal veins.  All deep veins demonstrated compressibility without evidence of intraluminal thrombus or increased echogenicity.,The long saphenous system displayed compressibility without evidence of thrombosis.  The long saphenous vein measured * cm at the proximal thigh with reflux of * seconds after release of distal compression and * cm at the knee with reflux of * seconds after release of distal compression.  The small saphenous system measured * cm at the proximal calf with reflux of * seconds after release of distal compression."
79,1,"CC: ,Sensory loss.,HX: ,25y/o RHF began experiencing pruritus in the RUE, above the elbow and in the right scapular region, on 10/23/92. In addition she had paresthesias in the proximal BLE and toes of the right foot. Her symptoms resolved the following day. On 10/25/92, she awoke in the morning and her legs felt ""asleep"" with decreased sensation. The sensory loss gradually progressed rostrally to the mid chest. She felt unsteady on her feet and had difficulty ambulating. In addition she also began to experience pain in the right scapular region. She denied any heat or cold intolerance, fatigue, weight loss.,MEDS:, None.,PMH:, Unremarkable.,FHX: ,GF with CAD, otherwise unremarkable.,SHX:, Married, unemployed. 2 children. Patient was born and raised in Iowa. Denied any h/o Tobacco/ETOH/illicit drug use.,EXAM:,  BP121/66 HR77 RR14 36.5C,MS: A&O to person, place and time. Speech normal with logical lucid thought process.,CN: mild optic disk pallor OS. No RAPD. EOM full and smooth. No INO. The rest of the CN exam was unremarkable.,MOTOR: Full strength throughout all extremities except for 5/4+ hip extensors. Normal muscle tone and bulk.,Sensory: Decreased PP/LT below T4-5 on the left side down to the feet. Decreased PP/LT/VIB in BLE (left worse than right). Allodynic in RUE.,Coord: Intact FNF, HKS and RAM, bilaterally.,Station: No pronator drift. Romberg's test not documented.,Gait: Unsteady wide-based. Able to TT and HW. Poor TW.,Reflexes: 3/3 BUE. Hoffman's signs were present bilaterally. 4/4 patellae. 3+/3+ Achilles with 3-4 beat nonsustained clonus. Plantar responses were extensor on the right and flexor on the left.,Gen. Exam: Unremarkable.,COURSE:, CBC, GS, PT, PTT, ESR, FT4, TSH, ANA, Vit B12, Folate, VDRL and Urinalysis were normal. MRI T-spine, 10/27/92, was unremarkable. MRI Brain, 10/28/92, revealed multiple areas of abnormally increased signal on T2 weighted images in the white matter regions of the right corpus callosum, periventricular region, brachium pontis and right pons. The appearance of the lesions was felt to be strongly suggestive of multiple sclerosis. 10/28/92, Lumbar puncture revealed the following CSF results: RBC 1, WBC 9 (8 lymphocytes, 1 histiocyte), Glucose 55mg/dl, Protein 46mg/dl (normal 15-45), CSF IgG 7.5mg/dl (normal 0.0-6.2), CSF IgG index 1.3 (normal 0.0-0.7), agarose gel electrophoresis revealed oligoclonal bands in the gamma region which were not seen on the serum sample. Beta-2 microglobulin was unremarkable. An abnormal left tibial somatosensory evoked potential was noted consistent with central conduction slowing. Visual and Brainstem Auditory evoked potentials were normal. HTLV-1 titers were negative. CSF cultures and cytology were negative. She was not treated with medications as her symptoms were primarily sensory and non-debilitating, and she was discharged home.,She returned on 11/7/92 as her symptoms of RUE dysesthesia, lower extremity paresthesia and weakness, all worsened. On 11/6/92, she developed slow slurred speech and had marked difficulty expressing her thoughts. She also began having difficulty emptying her bladder. Her 11/7/92 exam was notable for normal vital signs, lying motionless with eyes open and nodding and rhythmically blinking every few minutes. She was oriented to place and time of day, but not to season, day of the week and she did not know who she was. She had a leftward gaze preference and right lower facial weakness. Her RLE was spastic with sustained ankle clonus. There was dysesthetic sensory perception in the RUE. Jaw jerk and glabellar sign were present.,MRI brain, 11/7/92, revealed multiple enhancing lesions in the peritrigonal region and white matter of the centrum semiovale. The right peritrigonal region is more prominent than on prior study. The left centrum semiovale lesion has less enhancement than previously. Multiple other white matter lesions are demonstrated on the right side, in the posterior limb of the internal capsule, the anterior periventricular white matter, optic radiations and cerebellum. The peritrigonal lesions on both sides have increased in size since the 10/92 MRI. The findings were felt more consistent with demyelinating disease and less likely glioma. Post-viral encephalitis, Rapidly progressive demyelinating disease and tumor were in the differential diagnosis. Lumbar Puncture, 11/8/92, revealed: RBC 2, WBC 12 (12 lymphocytes), Glucose 57, Protein 51 (elevated), cytology and cultures were negative. HIV 1 titer was negative. Urine drug screen, negative. A stereotactic brain biopsy of the right parieto-occipital region was consistent with demyelinating disease. She was treated with Decadron 6mg IV qhours and Cytoxan 0.75gm/m2 (1.25gm). On 12/3/92, she has a focal motor seizure with rhythmic jerking of the LUE, loss of consciousness and rightward eye deviation. EEG revealed diffuse slowing with frequent right-sided sharp discharges. She was placed on Dilantin. She became depressed."