PARSED "Admission Date: 2174-12-26 Discharge Date: 2175-1-9 Date of Birth: 2174-12-26 Sex: M Service: NEONATOLOGY HISTORY OF PRESENT ILLNESS: Baby Candice Kyle Virginia is a 2600 gram boy born at 34-4/7 weeks gestational age to a 34-year-old G2, P0-1 mother. Prenatal screens were notable for maternal blood type B positive, antibody negative, hepatitis B surface antigen negative, RPR nonreactive, Rubella immune, GBS unknown. No reported pregnancy complications. Delivery was done for concerns of ""leaking fluid."" No other risk factors. Delivery by cesarean section due to breech positioning. Apgars of 7 at one minute and 9 at five minutes. The infant was initially sent to the Newborn Nursery for questions of whether gestational age was actually greater than 35 weeks. However, in the Newborn Nursery, poor regulation of temperature and grunting was noted and the patient was transferred to the Neonatal Intensive Care Unit for further management. PHYSICAL EXAMINATION ON ADMISSION: Weight 2600 grams (75th percentile). General: Pink, grunting with no retractions or flaring. HEENT: Anterior fontanelle soft and flat, palate intact. Clavicles intact. No ear anomalies. Neck supple. Lungs clear to auscultation with good aeration. Regular rate and rhythm with no murmur noted, 2+ femoral pulses. Soft abdomen with bowel sounds present and no hepatosplenomegaly. There was bruising of the left flank and inguinal area. Normal male genitalia with bilaterally descended testes. Penis patent with no sacral anomalies. Hips hyperflexed with knees hyperextended- typical breech positioning. Hips stable with negative Ortolani and Barlow signs. Extremities pink and well-perfused. Tone and activity normal. HOSPITAL COURSE BY SYSTEM: 1. Respiratory: The grunting resolved within the first day of life and Dr. Geisler has been stable with saturations greater than 96% with room air without any respiratory distress for the remainder of the hospitalization. No active respiratory issues. There has been no apnea of prematurity noted. 2. Cardiovascular: Dr. Geisler has remained cardiovascularly stable with an intermittent very soft murmur of no apparant clinical significance. On the discharge exam the murmur was not audible. 3. Fluids, Electrolytes and Nutrition: On admission, we initially attempted ad lib p.o. feeds of Premature Enfamil-20 (mother decided not to breast feed). However, he was unable to maintain adequate p.o. intake and was started on p.o. and p.g. feeds. By nine days of age his p.o. intake was improving markedly and he was switched to ad lib p.o. Enfamil-20 with 140 cc/kg/day minimum. At the time of discharge he was taking in ad lib p.o. Enfamil-20 at 166 cc per kilo per day. At discharge, his weight was 2595 grams (still down five grams from birth weight). 4. Gastrointestinal: Dr. Geisler was noted to be jaundiced and phototherapy was started when he was five days old for a bilirubin of 12.8 total over 0.4 direct. Phototherapy was discontinued on 1-2. He was seven days old with subsequent bilirubins off phototherapy declining from 5.6 down to 5.3 on 1-5. 5. Hematology: Maternal blood type was B positive. Baby's blood type is not known. Hematocrit on admission was 48. No transfusions had been required. 6. Infectious Disease: Initial sepsis evaluation included a CBC which showed a white blood cell count of 9.7 with 46% polys, 1% bands, hematocrit 48, platelets 230. Blood culture was negative. Antibiotics were not initiated given the absence of significant sepsis risk factors. He has not had any active infectious disease issues. 7. Sensory: Hearing screening was performed with automated auditory brainstem responses with pass in both ears. CONDITION AT DISCHARGE: Stable. DISCHARGE DISPOSITION: Home. PRIMARY PEDIATRICIAN: Dr. Karl Stephens, Gonzalez Memorial Hospital. Phone number 291-383-8038. CARE/RECOMMENDATIONS: 1. Feeds at discharge are Enfamil-20 p.o. ad lib. 2. No medications. 3. Car seat position screening passed. 4. State newborn screen last sent on 12-29 with results pending. 5. Hepatitis B immunization #1 administered on 1-2. 6. Synagis RSV prophylaxis should be considered from December through November for any of the following three criteria: A. Born at less than 32 weeks gestational age; B. Born between 32 and 35 weeks gestational age with two of the following risk factors: planned daycare, smoker in the house, neuromuscular disease, airway abnormality or school age siblings; C. with chronic lung disease. FOLLOW-UP APPOINTMENTS: Schedule includes: 1. An appointment with the primary care physician on 1-10 at 1:30. 2. Additional follow up should include an ultrasound of the hips at approximately six weeks of age due to the breech presentation and according to the latest AAP guidelines. DISCHARGE DIAGNOSES: 1. Prematurity at 34-3/7 weeks gestational age. 2. Mild early respiratory distress consistent with transient tachypnea of the newborn. 3. Intermittent soft murmur. 4. Immature feeding. 5. Physiologic hyperbilirubinemia. 6. Sepsis ruled out (off antibiotics). 5. Breech positioning in utero. Charles Keith, M.D. D13268118 Dictated By:Bobby MEDQUIST36 D: 2175-1-9 12:42 T: 2175-1-9 12:46 JOB#: Job Number 52585 " "Admission Date: 2133-1-28 Discharge Date: 2133-1-31 Date of Birth: 2063-3-16 Sex: F Service: CCU CHIEF COMPLAINT: Chest pain. HISTORY OF PRESENT ILLNESS: Ms. Eva is a 69-year-old woman who was recently discharged from Butler Clinic one week ago with chest pain and electrocardiogram changes in the inferior leads. She was then transferred to the cardiac catheterization laboratory and had a catheterization which revealed she had a right-dominant system with a 70% proximal lesion and a 95% mid lesion. The two lesions were dilated with difficulty. The ostial lesion was easily stented. However, the mid lesion stenting was initially complicated by dissection and slow flow but was then stented with an additional two stents. Because the ostial stent had migrated distally, another stent was placed proximally to reopen the ostial lesion. She received a total of five since the RCA approximately one week ago with dissection mid to distally. She presents tonight with acute recurrence of her chest pain with 5-mm to 10-mm ST elevations in the inferior leads, and was again taken to the catheterization laboratory emergently this evening. In the cardiac catheterization laboratory, it was noted that between two of the mid right coronary artery stents, where some dissection remained, there was a large fresh thrombus. Due to technical reasons, this was unable to be stented or receive Angio-Jet but was amenable to balloon angioplasty. TIMI-III flow resulted after angioplasty. There was a stable 70% long tubular lesion of the left anterior descending artery noted upon the last catheterization. During the procedure, the patient experienced transient hypotension to the 70s and bradycardia which was quickly relieved with atropine, intravenous fluids, and dopamine. The dopamine was turned off at the end of the case, and the patient recovered with systolic blood pressures in the mid 120s. She arrived in the Coronary Care Unit without any complaints. PAST MEDICAL HISTORY: 1. Prominent coronary artery disease, status post catheterization 17 years ago which was reported as negative; and as above in the History of Present Illness. 2. Hypertension. 3. Hypercholesterolemia. MEDICATIONS ON ADMISSION: Aspirin 325 mg p.o. q.d., Plavix 75 mg p.o. q.d. times 90 days, Lovenox 30 mg subcutaneous b.i.d., atenolol 25 mg p.o. q.d., Lipitor 80 mg p.o. q.d., Prinzide 20/12.5 1 tablet p.o. q.d. ALLERGIES: CODEINE and BENADRYL. SOCIAL HISTORY: Denies any tobacco. Admits to drinking alcohol socially. PHYSICAL EXAMINATION ON PRESENTATION: On physical examination her pulse was 80, blood pressure of 124/52, respiratory rate of 16, satting 100% on 2 liters. In general, she was comfortable, in no apparent distress, lying flat. Head, eyes, ears, nose, and throat revealed pupils were equally round and reactive to light. Sclerae were anicteric. The oropharynx was clear. Neck revealed jugular venous pulsation was approximately 4 cm at 10 degrees. Respiratory was clear to auscultation bilaterally. Cardiovascular revealed a regular rate and rhythm. No murmurs, rubs or gallops. Abdominal examination was benign. Extremities revealed no cyanosis, clubbing or edema. She had good distal pulses. RADIOLOGY/IMAGING: Her electrocardiogram revealed that she was in normal sinus rhythm at a rate of 84. She had 5-mm to 10-mm ST elevations in leads II, III, and aVF; with reciprocal ST depressions in V1, V2, and V3. Post catheterization electrocardiogram revealed that she was in normal sinus rhythm with left axis deviation, Q waves inferiorly, with resolving ST-T wave changes. HOSPITAL COURSE: Her hematocrit was found to be 26.9 post catheterization and she was transfused 2 units of packed red blood cells which increased her hematocrit to 35.7. She was then transferred to the floor for further observation. A transthoracic echocardiogram revealed that her left atrium was moderately dilated. There was mild symmetric left ventricular hypertrophy with a normal left ventricular cavity size. There was mild regional left ventricular systolic dysfunction with hypokinesis/akinesis of the inferior septum and inferoposterior wall. She ejection fraction was noted to be 40% to 45%. Her right ventricular size and systolic function were normal. She had 1+ mild aortic regurgitation and moderate 2+ mitral regurgitation. Examination of her groin revealed no hematoma. Her femoral and distal pulses were 2+. Because a left femoral bruit was heard on auscultation, a femoral ultrasound was obtained which revealed no evidence of left inguinal pseudoaneurysm or arteriovenous fistula. Her creatine kinases steadily trended downward, and her creatinine remained stable status post catheterization. CONDITION AT DISCHARGE: Condition on discharge at the time of discharge was stable. DISCHARGE STATUS: Discharged to home. MEDICATIONS ON DISCHARGE: 1. Prinzide 20/12.5 1 tablet p.o. q.d. 2. Atenolol 25 mg p.o. q.d. 3. Lovenox 60 mg subcutaneous b.i.d. times two weeks. 4. Lipitor 80 mg p.o. q.d. 5. Plavix 75 mg p.o. q.d. times six months. 6. Aspirin 325 mg p.o. q.d. 7. Sublingual nitroglycerin 0.4 mg sublingually q.5min. times three p.r.n. for chest pain. DISCHARGE INSTRUCTIONS: Return to the hospital if you develop worsening chest pain or shortness of breath, or if you develop worsening back pain, leg pain, or flank pain. DISCHARGE FOLLOWUP: Follow up with your cardiologist Dr. Woolery at Sanders Medical Center Hospital in one week. DISCHARGE DIAGNOSES: 1. Coronary artery disease. 2. Hypertension. 3. Hypercholesterolemia. Walter Gutierrez, M.D. T37912963 Dictated By:Hancock MEDQUIST36 D: 2133-2-3 14:59 T: 2133-2-3 18:51 JOB#: Job Number 104258 cc:Sorrell Memorial Hospital" "Admission Date: 2181-4-25 Discharge Date: 2181-5-4 Service: MEDICINE Allergies: Amiodarone / Quinidine/Quinine Attending:Gregory Chief Complaint: CC:CC Contact Info 94136 Major Surgical or Invasive Procedure: hemodialysis History of Present Illness: HPI: This is a 88My.o male with h/o of afib on comadin, CHF, OSA, and advance prostate CA s/p TURP, h/o urosepsis sp b/l stents, seen in clinic c/foul smelling urine today. . Patient describes that over the last 2 days he has been feeeling more tired, lack of energy and his urine is coming out ""milky and foul smelling"". He was given two doses of TMP/SMX or ?Cipro last night and one this morning. . He denies any fever, chills, nausea, vomit, diaphroesis, shortness of breath, chest pain, back pain, diarrhea, aabdominal pain, but reported 10 lb wt loss in the past 3 months due to loss of appetite from lost of taste budd. When asked about his bruise on his left forehead, he said that he bumped his head on Sunday with the refrigerator. He did not lose any conciousness. Denies any headachees, blurred vision or unsteady gait associated after the episode. . In ED, hemodynamically stable, has +UA, received Levoflox, and cefepime. Past Medical History: PMH - - OSA - History of sinus infections. - Prostate CA s/p XRT/resection - DM2 - A. fib on Coumadin - Right cataract. - Left retinal tear. - Macular degeneration status post laser treatment. - Gout. - Clarence Mcdonald tear. - Squamous cell carcinoma of ear followed by derm - IBS w/chronic diarrhea for years/lactulose intolerance - myelodysplasia . PSH - - Spontaneous pneumothorax 15 years ago. - s/p cholecystectomy - s/p left inguinal hernia repair, - s/p hemorrhoidectomy - Prostate CA s/p TURP and XRT s/p urethral stricture - back surgery Social History: SH - Retired psychiatrist. Lives at home with his wife. Quit tobacco many years ago. No EtOH, no illicits. Family History: FH - NC Physical Exam: Physical Exam: Vitals: T 96.9 P: 67 BP 146/66 RR 17 Sats 96%RA General: Awake, alert, NAD. HEENT: dry oral mucose. echimosis on his left forehead. Neck: supple, no JVD, left side adenopathy x 2, small, non tender, mobile. Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: BS+, soft, obese non tender, mildly distended. Liver 1cm below costal margin. Extremities: asymetric bilateral LLE edema 2+. Neurologic: -mental status: Alert, oriented x 3. CNII-XII intact. Movilizing all extremities. Pertinent Results: Laboratory Data: see below EKG: afib, with VR 70x, left axis, no st changes, difuse flattenin t waves on v4-v5-v6. QTC 460 . Radiologic Data: Renal US: pending . 2181-4-25 05:40PM BLOOD WBC-12.1* RBC-4.64 Hgb-12.5* Hct-40.4 MCV-87 MCH-26.9* MCHC-30.8* RDW-17.3* Plt Ct-258 2181-5-4 04:21AM BLOOD WBC-19.7* RBC-3.46* Hgb-9.9* Hct-29.9* MCV-87 MCH-28.6 MCHC-33.0 RDW-18.5* Plt Ct-93* 2181-4-25 05:40PM BLOOD PT-74.7* PTT-42.8* INR(PT)-9.7* 2181-4-25 05:40PM BLOOD Plt Smr-NORMAL Plt Ct-258 2181-5-4 04:21AM BLOOD PT-23.7* PTT-29.7 INR(PT)-2.4* 2181-5-4 04:21AM BLOOD Plt Smr-LOW Plt Ct-93* 2181-4-25 05:40PM BLOOD Glucose-304* UreaN-59* Creat-2.4* Na-136 K-4.2 Cl-101 HCO3-20* AnGap-19 2181-5-3 05:41AM BLOOD Glucose-89 UreaN-63* Creat-3.7* Na-125* K-6.6* Cl-94* HCO3-10* AnGap-28* 2181-5-4 04:21AM BLOOD Glucose-116* UreaN-60* Creat-3.6* Na-130* K-5.2* Cl-91* HCO3-13* AnGap-31* 2181-4-27 06:45AM BLOOD ALT-32 AST-57* LD(LDH)-529* AlkPhos-312* TotBili-1.0 2181-5-4 04:21AM BLOOD ALT-476* AST-PND LD(LDH)-PND AlkPhos-573* TotBili-1.9* 2181-5-4 04:21AM BLOOD Albumin-2.2* Calcium-7.2* Phos-8.5* Mg-2.0 2181-4-27 06:45AM BLOOD PSA-<0.1 2181-5-3 12:51PM BLOOD Type-ART pO2-81* pCO2-25* pH-7.04* calHCO3-7* Base XS--23 2181-5-3 07:11PM BLOOD Type-Smith Temp-35.0 O2 Flow-3 pO2-37* pCO2-28* pH-7.20* calHCO3-11* Base XS--16 Intubat-NOT INTUBA Brief Hospital Course: 87 y/o male with advanced prostate CA s/p TURP, h/o bilateral hydronephrosis due to tumor at trigone s/p post stents (Right), OSA, afib on coumadin who presents with UTI and ARF on CRI, and elevated INR. Given worsening renal failure secondary to underlying metatstaic malingnancy and poor prognosis, Cory wife and family decided to concentrate on comfort and avoid aggressive measures. After several sessions of hemodialysis, Family chose to further withdrawl care. Pt pronounced dead at 15:36 on 2181-5-4. Family present in the room. Autopsy deferred . #. Acute on chronic renal failure - Patient has a baseline Cr of 1.6 with an elevation in BUN/Cr to 59/2.4. Pt with progressive renal failure 1-18 to underlying malignancy and associated obstruction. Pt initiated on Hemodialysis which he tolerated well. Discussed with urology who recomended revision of uretral stents which was not pursued as family wished to stress comfort. . # UTI: u/a compatible with urinary tract infection. Given prior history of VRE and gram negative bacteremia (pseudomona) in recent past, Pt was covered broadly. . #. Anion Gap Acidosis: Mixed lactic acidosis with acute renal failure. BG elevated on presentation, but urine ketones negative. Pt started on NaHCO3 and HD with little improvement in acidosis. Worsening lactic acidosis 1-18 tumor necrosis Medications on Admission: . Medications: Lasix 60 mg a day, Glipizide ER 10 mg, Lipitor 10 mg, Casodex 50 mg, Allopurinol 100 mg, potassium 10 mEq, Verapamil 40 mg, Prilosec OTC 20 mg, vitamin B-12, Coumadin, 1-2.5 mg as dosed by his INR, folic acid 1 mg a day, cholestyramine 1 pack daily, ferrous sulfate, nitrofurantoin which he just finished as I mentioned, and Ambien XL 6.25 mg. Discharge Medications: na Discharge Disposition: Home with Service Discharge Diagnosis: renal failure hyperkalemia Discharge Condition: deceased Discharge Instructions: none Followup Instructions: NA " "Admission Date: 2182-7-23 Discharge Date: 2182-7-29 Service: This is an 84-year-old female who was initially evaluated for progressive claudication and rest pain. She was hospitalized 2182-7-11 to 2182-7-12 during this admission she was evaluated by Cardiology because of her known extensive coronary artery disease. She underwent a P-Thal at that time which showed no angina symptoms or ischemic electrocardiogram changes though the nuclear report was negative for a reversal ischemic effect however, due to the patient's high risk Cardiology recommended a cardiac catheterization for further evaluation. The patient refused cardiac catheterization and chose to be discharged to home to take care of ""personal matters""before undergoing any vascular surgery. The patient returns now for elective surgery. PAST MEDICAL HISTORY: No known drug allergies. ADMISSION MEDICATIONS: 1. Colace 100 mg at h.s. 2. Milk of Magnesia 30 cc's p.o. p.r.n. 3. Dulcolax suppository p.r.n. 4. Vicodin tablets, one q 4 hours p.r.n. 5. Nitroglycerin sublingual 0.4 mg p.r.n. 6. Glucotrol 10 mg b.i.d. 7. Lopressor 12.5 mg p.o. b.i.d. 8. Flagyl 500 mg three times a day. 9. Aspirin 325 mg p.o. daily. 10. Levaquin 500 mg q day. 11. Vitamin D complex 100 mg q day. 12. Vitamin C 500 mg q day. 13. Vitamin E 400 units q day. 14. Lasix 20 mg q day. 15. Oxycontin 20 mg q 12 hours. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post myocardial infarction in 2182-3-25, status post cardiac catheterization with Triple vessel disease. 2. Diabetes mellitus Type II. 3. Hypertension. 4. Osteoarthritis. 5. Radiculopathy. 6. Psoriasis. PAST SURGICAL HISTORY: Status post hysterectomy and bilateral oophorectomy in 2160. Status post cholecystectomy. Status post Cesarean section times four. Status post bilateral cataract surgery. PHYSICAL EXAMINATION: General appearance, alert and cooperative female in no acute distress. Vital signs: 98.5, 98, 62, blood pressure 110/60. Respiratory rate 18, O2 sat 95% on room air. Head, eyes, ears, nose and throat examination: Pupils are small, minimally reactive, equal bilateral. Cardiac exam is regular rate and rhythm with no murmurs. Respiratory: Clear the auscultation bilateral. Abdominal exam is unremarkable. Extremities show right great toe gangrene, some erythema on the right foot. Pulse exam shows Dopplerable posterior tibial pulse. Left leg there is no dorsalis pedis pulse on the right or the left and there is no posterior tibial pulse on the right. The femoral pulses are dopplerable bilaterally. HOSPITAL COURSE: The patient was brought to the preoperative holding area. She underwent on 2182-7-23 a right iliofemoral bypass graft with 8 mm Dacron and a right first toe amputation. Her intraoperative course was complicated by massive bleed requiring 11 units of packed red blood cells of FFP and 750 cc's of crystalloid. The patient was admitted to the SICU postoperatively for continued care. Her postop CBC was white count 10.1, hematocrit 45.5, platelet count 48 K. BUN 20, creatinine 1.1, K 4.1. Blood gases: 7.30, 39, 180, 18, -7. The Troponin was less than .3. Chest x-ray was without pneumothorax, Swann-Ganz was in good position. Exam showed arm Dopplerable biphasic pulses, popliteal, no Dorsalis pedis or posterior tibial. The patient remained in the Intensive Care Unit postoperative day one. Overnight events is low urinary output requiring volume supplementation. White count 15.8, hematocrit 40.5 with a platelet count of 55. BUN and creatinine remained stable. Coags were normal. The right foot was warm with Dopplerable biphasic posterior tibial but no dorsalis pedis, she had a palpable femoral and the wounds were clean, dry and intact. The patient remained in the SICU, intubated until her acidosis was corrected. She remained on Levofloxacin and Flagyl perioperatively while lines were in place. Postoperative day two there were no overnight events. She remained hemodynamically stable. Her white count was 16.6, hematocrit 38.3. BUN and creatinine remained stable. K of 3.9 which was supplemented. She was weaned and extubated. She required Lasix for diuresis. Postop day three, the patient was transferred to the MICU for continued monitor and care. Postoperative day four there were no overnight events. She continued to do well, her hematocrit was 36.9, BUN 26, creatinine 1.0, K 3.6. She was tolerating orals well, her fluids were Hep-locked. Her Levofloxacin and Flagyl were discontinued and Kefzol was begun. The patient was transferred to the regular nursing floor. Physical therapy was consulted for assessment for discharge planning. Postoperative day two she continued to do well, she remained afebrile, hemodynamically stable, incisions were clean, dry and intact. Her amputation site was clean, dry and intact. She had a dopplerable pulses bilaterally. Case management began screening. The patient was transferred to rehabilitation for continuing monitoring and care. Condition was stable. At the time of discharge her hematocrit was 36.2. DISCHARGE MEDICATIONS: 1. Lasix 40 mg q day. 2. Acetaminophen 325 mg to 650 mg q day. 3. Heparin 5000 units subcutaneously q 12 hours. 4. Aspirin 325 mg q day. 5. Insulin sliding scale, please see flow sheet. 6. Albuterol and Ipratropium inhalers one to two puffs q 4 hours p.r.n. 7. Metoprolol 12.5 mg b.i.d. hold for systolic blood pressure of less than 100, heart rate less than 60. 8. Percocet tablets 5/325 mg one to two q 4 to 6 hours p.r.n. for pain. DISCHARGE DIAGNOSIS: 1. Right iliac occlusion with first right toe gangrene. Status post right ileofem bypass with 8 mm Dacron and a right first toe amputation. 2. Blood loss anemia, corrected. 3. Thrombocytopenia secondary to multiple transfusions, stabilized. 4. Coronary artery disease stable. 5. Type 2 diabetes mellitus stable. 6. Hypertension controlled. 7. Osteoarthritis stable. Charles Wells, M.D. N52931579 Dictated By:Ellis MEDQUIST36 D: 2182-7-29 13:44 T: 2182-7-29 16:12 JOB#: Job Number " "Unit No: 70286 Admission Date: 2155-5-2 Discharge Date: 2155-5-11 Date of Birth: 2097-3-27 Sex: M Service: ENT PRIMARY DIAGNOSIS: Invasive thyroid cancer. PRIMARY PROCEDURE: Total thyroidectomy, central neck dissection, resection of cricothyroid membrane. HISTORY OF PRESENT ILLNESS: Mr. Lloyd Tory is a 58-year- old gentleman with a large anterior neck mass, known to be a thyroid cancer. This mass is invasive into his cricothyroid membrane. He presents for surgical correction. PAST MEDICAL HISTORY: 1. Urinary stricture. 2. Type 2 diabetes. MEDICATIONS: None ALLERGIES: No known drug allergies. COURSE IN HOSPITAL: Mr. Tory was taken to the operating room on 2155-5-2. He underwent a total thyroidectomy with central lymph node dissection, as well as cricotracheal resection. The start of the case was delayed as the nurses and residents were unable to place a Foley catheter. Intraoperative urology consultation was obtained. The patient underwent a rigid cystoscopy in order to place a Foley catheter. Dense strictures throughout his urethra were found. Postoperatively, Mr. Tory was observed in the PAC unit for two nights. He was kept intubated until postoperative day #3. No NG tube was placed for fear of damaging the area of the cricotracheal resection and reconstruction. On postoperative day #1 Mr. Tory was noted to have some runs of supraventricular tachycardia. An EKG was done and was normal. His electrolytes were managed and this spontaneously resolved. On postoperative day #2 Mr. Horace calcium was noted to trend down. He was started on calcium intravenously, as he was still intubated. On postoperative day #3 Mr. Tory was weaned off the ventilator, however, after extubation he became stridorous with increasing work of breathing. He required reintubation. For this reason he underwent a tracheostomy on the same day. Hematology oncology consultation was requested given the invasive nature of the patient's thyroid carcinoma. On postoperative day #4 Mr. Tory was successfully weaned off the vent and onto a tracheostomy collar. As his calcium started to drop further, he was started on calcium twice a day, as well as Rocaltrol 0.5 mcg daily. On postoperative day #5 the patient's cuff was taken down and he was started on calcium, as well as Rocaltrol for dropping calcium. He was seen by the speech and swallow team. The patient was noted to have gross aspiration on his first few days of swallow on 2155-5-7. However, the speech and swallow team had a Passy-Muir valve placed for the patient, which he did well with while awake and not eating. The patient was given a Passy-Muir valve by the speech and swallow team, which he did well with when he was awake. On postoperative day #6 the patient was started on p.o. He could also be started on p.o. medication including liothyroxine 50 mcg p.o. daily and his calcium was increased to 2 gm twice a day. His Rocaltrol was also increased to 0.5 mcg p.o. daily. On postoperative day #6 urology was reconsulted to see if there was any further recommendations to be made about his Foley catheter. They recommended discontinuing his Foley and catheterizing himself once per day. The patient received adequate teaching in hospital and was prepared to do this task by the time he went home. On 5-8, the endocrine service was consulted because of Mr. Horace hypocalcemia. They recommended increasing his calcium carbonate to 500 mg p.o. four times daily and continue his Calcitrol at 0.5 mcg daily. They also recommended changing the parathyroid hormone level. On postoperative day #7, Mr. Tory did have his Foley removed and was taught to straight catheterize. His blood sugars came under better control as he was started on metformin. A radiation oncology consultation was obtained to see if radiation would be of benefit for Mr. Tory, given the aggressiveness of his cancer. On 2155-5-9, Mr. Tory was seen by speech and swallow again. His speech and swallow examination revealed minimal penetration with liquids and trace aspiration. They recommended him receiving an oral diet, which he did successfully. He was able to have his nasogastric tube removed and was discharged home in stable condition on 2155-5-10. CONDITION ON DISCHARGE: Afebrile. Vital signs stable. Patient was tolerating a full soft solid diet. His neck was flat. His incision was clean, dry and intact. The tracheostomy site was clean. Cranial nerves V-VII and Dr. Zbinden-XII were intact. INSTRUCTIONS ON DISCHARGE: Mr. Tory is to followup with Dr. Wheeler. He was instructed to call and make an appointment. He is to call Dr.Erin office or proceed to the closest emergency room if he experiences fever, wound redness or drainage or any other significant problems. Mr. Tory is to straight catheterize himself once per day in order to keep his urethra patent. He is to followup with a urologist, which will be coordinated by his primary care physician. Mandi is also to followup with Dr. Drake, of radiation oncology. The patient also has his own private endocrinologist, whom he is to followup with. MEDICATIONS ON DISCHARGE: 1. Levoxyl 100 mcg p.o. daily 2. Calcitrol 0.25 mcg p.o. twice a day 3. Percocet 1-2 tablets p.o. q.4-6h p.r.n. for pain. 4. Famotidine 20 mg p.o. twice a day. 5. Metformin 500 mg p.o. q.a.m. 6. Calcium carbonate 1250 mg p.o. twice a day. Christopher Martinez, V48469443 Dictated By:Lamb MEDQUIST36 D: 2155-6-3 10:14:44 T: 2155-6-3 15:05:13 Job#: Job Number 33224 " "Admission Date: 2183-12-31 Discharge Date: 2184-1-11 Service: ADMISSION DIAGNOSIS: Right colon cancer. HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old woman with a history of diabetes mellitus, hypertension and elevated cholesterol who, on an evaluation as an outpatient, was found to be anemic and a colonoscopy revealed a right colon cancer in 2183-12-18. The patient was then scheduled for elective right colectomy. PAST MEDICAL HISTORY: As above. MEDICATIONS ON ADMISSION: Procardia 60 mg p.o. q.d. Captopril 50 mg p.o. t.i.d. Lipitor 10 mg p.o. q.d. Insulin 409 units of NPH q.a.m. PAST SURGICAL HISTORY: The patient had an open cholecystectomy in 2162. ALLERGIES: The patient had an allergy to penicillin. PHYSICAL EXAMINATION: Vital signs revealed a temperature of 98.8??????F, a heart rate of 100, a blood pressure of 136/59, respirations of 18 and an oxygen saturation of 100% on room air. In general, the patient was a pleasant, obese, elderly woman. On head, eyes, ears, nose and throat examination, the mucous membranes were moist. The neck had no lymphadenopathy. The heart had a regular rate and rhythm. The lungs were clear. The abdomen was soft. There was mild right sided tenderness and the abdomen was nondistended. LABORATORY: The patient had a white blood cell count of 13,100 with a hematocrit of 35.5 and a platelet count of 543,000. Potassium was 4.0. BUN was 12 and creatinine was 0.7. Glucose was 130. RADIOLOGY: A chest x-ray showed no evidence of infiltrate or metastatic disease. ELECTROCARDIOGRAM: An electrocardiogram had sinus rhythm at 100. HOSPITAL COURSE: The patient was admitted for bowel prep and tolerated the bowel prep. On 2184-1-2, she underwent right colectomy without complications. Postoperatively on that night, the patient was stable. However, she required intravenous fluid bolus for low urine output. On postoperative day #1, the patient continued to require intravenous fluid boluses for urine output and developed a persistent tachycardia. After receiving intravenous fluid resuscitating without good response to intravenous fluid bolus, the patient became short of breath and was transferred to the Intensive Care Unit for further management. The patient was treated for congestive heart failure and was ruled in for a myocardial infarction with electrocardiogram changes and elevated levels of troponin. A cardiology consultation was requested and an echocardiogram was performed, which revealed a significantly decreased ejection fraction of approximately 15% with severe hypokinesis and akinesis of the inferior and lateral walls. The patient was started on beta blocker and ACE inhibitor for afterload reduction to optimize her hemodynamics. The patient was also started on aspirin. Once her hemodynamics were optimized and diuresis of fluid was initiated, the patient improved and, on postoperative day #4, she was transferred back to the hospital floor. The patient then soon passed flatus and was slowly advanced to a regular diet. She was continued on Lasix diuresis as well as beta blockade, afterload reduction and aspirin. The patient continued to do well with good response to diuresis and improved pulmonary function and was saturating well on room air and breathing comfortably. On postoperative day #9, the patient was tolerating a regular diet and was ambulatory with physical therapy. However, the patient required significant assistance, which indicated a rehabilitation transfer. On postoperative day #7, an ultrasound of the right upper extremity was performed, which showed a cephalic vein deep vein thrombosis, and the patient was started on Coumadin at that time for treatment of the deep vein thrombosis as well as for prophylaxis for the severe wall motion abnormality of the heart. DISCHARGE DIAGNOSIS: 1. Right colon cancer. 2. Status post right colectomy on 2184-1-2. 3. Postoperative myocardial infarction. 4. Diabetes mellitus. 5. Hypertension. 6. Elevated cholesterol. 7. Right cephalic vein deep vein thrombosis. DISCHARGE MEDICATIONS: 1. Lopressor 25 mg p.o. b.i.d. 2. Captopril 50 mg p.o. t.i.d. 3. Coumadin, adjust for INR of 2 to 3. 4. Lasix 40 mg p.o. b.i.d. 5. Daniel Finlay 20 mEq p.o. b.i.d. 6. Percocet one to two tablets p.o. every three to four hours p.r.n. for pain. 7. Aspirin. 8. Clonidine patch. 9. Subcutaneous heparin. 10. Insulin sliding scale. Richard Lavender, M.D. H33349570 Dictated By:Jordan MEDQUIST36 D: 2184-1-10 22:06 T: 2184-1-10 22:56 JOB#: Job Number 104767 " "Name: William, Joshua Unit No: 82021 Admission Date: 2125-7-3 Discharge Date: 2125-7-8 Date of Birth: 2044-5-5 Sex: M Service: ADDENDUM: CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM (CONTINUED): 4. CORONARY ARTERY DISEASE ISSUES: The patient was switched from his home atenolol to metoprolol while in house. His Isordil was held, and he was continued on his home dose of Pravachol. His cardiac enzymes were cycled on admission and remained negative. A repeat cycling of enzymes was done following an episode of pulmonary edema. His troponin T peaked at 0.1, but creatine kinase and CK/MB levels remained negative. The patient was ultimately discharged on metoprolol 50 mg by mouth twice per day in addition to lisinopril 10 mg by mouth once per day. 5. STATUS POST FEMORAL-POPLITEAL BYPASS ISSUES: For this history, the patient received perioperative ampicillin prior to undergoing esophagogastroduodenoscopy. 6. ATRIAL FIBRILLATION ISSUES: The patient's anticoagulation was reversed with fresh frozen plasma and vitamin K. Plan for continuation off of anticoagulation for the several weeks considering the severity of his gastrointestinal bleed. CONDITION AT DISCHARGE: Ambulating independently. His hematocrit remained stable overnight with a discharge hematocrit of 36.8. DISCHARGE STATUS: The patient was discharged to home. DISCHARGE DIAGNOSES: 1. Gastrointestinal bleed. 2. Atrial fibrillation. 3. Anemia secondary to blood loss. 4. Congestive heart failure. 5. Coagulopathy secondary to anticoagulation with Coumadin. MEDICATIONS ON DISCHARGE: 1. Pravastatin 40 mg by mouth at hour of sleep. 2. Timolol 0.25% drops one drop each eye twice per day. 3. Metoprolol 50 mg by mouth twice per day. 4. Protonix 40 mg by mouth once per day. 5. Lisinopril 10 mg by mouth once per day. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was instructed to contact his primary care physician to schedule followup within one to two weeks. 2. The patient was informed that it was imperative to follow up with his primary care physician to Charles his anticoagulation. Joseph Nelson, M.D. I38071681 Dictated By:Elmer MEDQUIST36 D: 2125-10-3 17:05 T: 2125-10-4 07:13 JOB#: Job Number 18338 " "Unit No: 19413 Admission Date: 2197-8-9 Discharge Date: 2197-8-9 Date of Birth: 2197-8-9 Sex: F Service: NB HISTORY: Baby Girl Judy is the 2.025 kg infant born via C- section for failure to progress at 34-3/7 weeks gestation with an estimated date of confinement of 2197-9-17. She was born to a 30-year-old gravida 1, para 0 mother with prenatal screens blood type B negative, antibody negative, RPR nonreactive, rubella immune, hepatitis B negative and GBS unknown. Pregnancy was complicated by a late diagnosis on fetal ultrasound of polyhydramnios and duodenal atresia. The mom was seen and brought to the hospital. She was noted to have fetal anomaly. She was transferred to Anderson Memorial Hospital for further management. The mom reported that she had been leaking amniotic fluid for the past 2 weeks, but prior to deliver, she was noted to have a bulging bag which was ruptured at 10 p.m. the night before delivery. The infant was born again by cesarean section for failure to progress with Apgar scores of 7 and 8. In the delivery room, there was late clampage of the cord with a minimal amount of blood loss. The infant was transferred to the NICU for further management. FAMILY HISTORY: Mom has history of HSV with her last outbreak 9 years ago. The family has a 9-year-old niece who has trisomy 21. SOCIAL HISTORY: The parents are married. The mother denied any tobacco, alcohol or drugs. PHYSICAL EXAMINATION ON ADMISSION: The infant was in bed in no apparent distress. Some facies typical of Down syndrome or trisomy 21. Her temperature was 98.5, heart rate 175, respiratory rate 46, blood pressure 63/49 with a mean of 54, oxygen saturation 100% on room air. Her D-stick was 66. Her weight was 2215 gm which is the 50th percentile. The head circumference was 31.5 cm which is 25th-50th percentile, and her length was 47 cm which is the 90th percentile. HEENT: There was molding of the head with a moderate caput noted on the left temporoparietal region. Her anterior fontanelle was open and flat. Her palate was intact. She had flat facies with slanted palpebra fissures. Her red reflux was present bilaterally. No Brushfield spots were noted. Her tongue was protruding, and her ears were small. Her neck was supple. Her skin was pink, clear. Her lungs were clear to auscultation bilaterally. CV had regular rate and rhythm with no murmur. Femoral pulses were 2+ bilaterally. GU: She had immature female external genitalia. Her anus was patent. Her spine was midline. Her clavicles were intact. Her extremities were warm and well perfused with brisk capillary refill. She had mild clinodactyly noted on bilateral fifth digits, left greater than right. She had normal palmar creases. She had sandal toes present. Neurologically, she had globally decreased tone, but she had a normal suck. HOSPITAL COURSE: Respiratory: She was on room air and remained comfortable throughout the hospitalization. Cardiovascular: She was stable without issues. She should likely have an echocardiogram for evaluation. Fluids, electrolytes and nutrition: Her D-stick was stable. She was made n.p.o. She was maintained on IV fluid of D10 at 60 mL/kg per day. GI: She was noted to have duodenal atresia confirmed by x- ray. Surgery was consulted. Hematology: She had a hematocrit of 41 and plt count 231 prior to discharge. Infectious disease: There is a potential history of prolonged rupture of membranes. She had a CBC that showed wbc count 12.2 (69P 0B 27L). Blood cultures were sent prior to discharge. She did not start on antibiotics. Neurology: She seemed neurologically intact at the time. Genetics: She had a karyotype and a FISH for trisomy 21 sent prior to discharge. Sensory: Hearing screen was not performed. We recommend one prior to her discharge to home. CONDITION ON DISCHARGE: Stable. DISCHARGE DISPOSITION: To Vasquez Hospital NICU. PRIMARY CARE PEDIATRICIAN: The parents cannot recall at this time, but they said that physician is in Lynda. CARE AND RECOMMENDATIONS: 1. Feeds at time of discharge: N.p.o. on IV fluids. 2. Medications: None. 3. Car seat positioning should probably be done prior to discharge. 4. State newborn screen: One was drawn prior to discharge but because the infant was less than 24 hours old and not yet feeding, a repeat will need to be done. 5. Immunizations received: None. 6. Immunization recommendations: RSV prophylaxis should be considered from March through December for infants who meet any of the following 4 criteria - (a) born at less than 32 weeks; (b) born between 32 and 35 weeks with 2 of the following - daycare during RSV season, a smoker in the household, neuromuscular disease, airway abnormalities, school age siblings; (c) chronic lung disease; (d) hemodynamically significant chronic lung disease. 7. Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. Before this age and for the first 6 months of the child's life, immunization against influenza is recommended for household contacts and out of home caregivers. 8. This infant has not received Rotavirus vaccine. The American Academy of Pediatrics recommends initial vaccination of preterm infants at or following discharge from the hospital if they are clinically stable and at least 6 weeks but fewer than 12 weeks of age. DISCHARGE DIAGNOSES: 1. Prematurity at 34-3/7 weeks. 2. Possible trisomy 21. 3. Possible sepsis. 4. Duodenal atresia. Robert Pamela, MD N25676134 Dictated By:Tobin MEDQUIST36 D: 2197-8-9 14:49:15 T: 2197-8-9 15:19:36 Job#: Job Number 74014 " "Admission Date: 2118-4-26 Discharge Date: 2118-5-6 Date of Birth: 2068-7-18 Sex: F Service: #58 HISTORY OF PRESENT ILLNESS: The patient is a 49 year-old woman diagnosed with metastatic renal cell cancer with spinal and pelvic mets on 2118-3-27. The patient had a bony destruction of the left pedicle of L3 as well as posterior elements on the left side of L3 with impingement on the L3 nerve root without evidence of cord compression. The patient is preoped for lumbar embolization, renal embolization followed by left radical nephrectomy and removal of the L3 vertebra and L2-L4 spinal fusion. PAST MEDICAL HISTORY: None. PAST SURGICAL HISTORY: None. MEDICATIONS: 1. Oxycontin SR. 2. Percocet. 3. Colace. 4. Ambien. PHYSICAL EXAMINATION: In general, the patient was awake, alert and oriented times three, pleasant, cachectic looking female. Temperature 100. Blood pressure 120/62. Heart rate 117. Respiratory rate 18. Sat 98%. Pupils are equal, round and reactive to light. Mucous membranes are moist. Neck was supple. Pulmonary clear bilaterally. Cardiac tachy S1 and S2 within normal limits. Abdomen soft, nontender, nondistended. Positive bowel sounds. Extremities no edema. Back there was no swelling in the lumbar area. Neurologically the patient was awake, alert and oriented times three. Cranial nerves II through XII were intact, mildly symmetric. She had no drift. Her strength was 5 out of 5 in all muscle groups. Her sensation was intact to light touch. She was hyperreflexic throughout with clonus of the left lower extremity. PREOPERATIVE LABORATORIES: Sodium was 137, K 4.9, chloride 99, CO2 29, BUN 15, creatinine .8, glucose 154. HOSPITAL COURSE: The patient was preoped for a embolization of her lumbar spine area, which was done on 2118-4-28 without complications. The patient was monitored in the Intensive Care Unit postoperatively. The patient then underwent an embolization of her right kidney on 2118-4-28 without complications. She was again monitored in the Intensive Care Unit and then preoped for the Operating Room for left nephrectomy and L3 vertebrectomy with L2 to L4 fusion. She had this on 2118-4-29. She tolerated the procedure well. There were no intraoperative complications. She was again monitored in the Intensive Care Unit. Postoperatively she was fitted for a TLSO brace. She remained on flat bed rest. She was moving both lower extremities with good strength. Her dressings were clean, dry and intact. She had a chest tube in place, which was draining serosanguinous fluid. She also had a JP drain in place. JP drain was removed on 2118-5-2. The patient's brace was brought in on 2118-5-2 and the patient was out of bed on 2118-5-2. Chest tube was removed on 2118-5-3 and she was out of bed in her brace. Her strength remained 5 out of 5 in all muscle groups. She was awake, alert and oriented times three and afebrile. She was transferred to the floor on 2118-5-3 and continued to do well and continued to be followed by physical therapy and occupational therapy and was found to be safely discharged to home. She was discharged to home on 2118-5-6 in stable condition with follow up with Dr. Riddle on Tuesday the 17th at 10:40 a.m. for staple removal. She will follow up with Dr. Mcdavid on 5-23 and with the oncology people on 5-18. CONDITION ON DISCHARGE: Stable. She was afebrile. Her dressing was clean, dry and intact. MEDICATIONS ON DISCHARGE: 1. Percocet one to two tabs po q 4 hours prn. 2. Nystatin 5 cc q.i.d. prn. 3. Lasix 20 mg po q.d. times one day and then discontinued. 4. Hydrocodone sustained release 30 mg po q.a.m. 5. Hydrocodone 40 mg one tab at bedtime. 6. Calcium carbonate 500 mg t.i.d. 7. Phosphorus one packet b.i.d. for three days. 8. Zolpidem tartrate 5 mg at h.s. prn. 9. Lorazepam .5 mg q 4 to 6 hours prn. Laura Clark, M.D. M16484198 Dictated By:Imai MEDQUIST36 D: 2118-5-6 11:48 T: 2118-5-6 12:13 JOB#: Job Number 48401 " "Unit No: 96586 Admission Date: 2157-1-29 Discharge Date: 2157-1-31 Date of Birth: 2157-1-29 Sex: F Service: NB HISTORY: This infant was born at 34-6/7 weeks gestation with an EDC of 2157-3-7 born to a 29-year-old G3, P0 (now 1) mother with a prenatal screen as follows: Blood type A+, antibody negative, RPR nonreactive, rubella immune, GBS negative. Mother had a history of positive PPD on 2152-6-21 which she was treated for 9 months at that time and a follow-up chest x-ray was negative. This pregnancy was complicated by possible rupture of membrane on 2157-1-29. There was also some concern for maternal UTI on 2157-1-25 due to increased urinary frequency. The morning of delivery, the mother was induced due to PPROM. Labor was uncomplicated. The infant was vigorous at birth and received only blow-by oxygen in the Delivery Room. She had Apgars of 7 and 8 at 1 and 5 minutes and was transferred to the NICU for further management of prematurity. FAMILY HISTORY: Mom was treated for chlamydia in 2156-5-4 but otherwise noncontributory. SOCIAL HISTORY: Mom smokes 7 cigarettes daily. Father of the baby is mother's boyfriend, Donald. MEASURES AT BIRTH: Weight of 2550 gm which is 75th percentile, head circumference of 30 cm which is 10th-25th percentile, length of 47 cm which is 50th-75th percentile. DISCHARGE PHYSICAL EXAMINATION: Active, alert female infant. HEENT: Anterior fontanel soft and flat with mild __________ molding, small caput. Intact palate. Normal facies. Bilateral red reflexes. Respiratory: Breath sounds clear and equal with slight retractions, comfortable respirations. Cardiac: Normal rate and rhythm. Normal S1/S2, no murmur. Normal pulses. Brisk capillary refill. Abdomen: Soft and round with active bowel sounds. Patent anus. GU: Normal preterm female. Musculoskeletal: Normal spine. Straight spine. No sacral dimple. Intact hips. Moves all extremities well. Neuro: Normal reflexes, tone. Good suck. SUMMARY OF HOSPITAL COURSE BY SYSTEMS: 1. Respiratory: Breath sounds are clear and equal. This infant has remained on room air since admission to the NICU. Has had no issues with apnea, bradycardia, or desaturations. 2. Cardiovascular: Infant has had no cardiovascular issues. Normal heart rates and blood pressures have been observed. 3. Fluid/electrolytes/nutrition: The infant was started on ad lib p.o. feedings with ___________ 20 cal/ounce. She is voiding and stooling normally. The weight at discharge is 2475 gm which is down 25 gm from birth weight. No electrolytes have been measured on this baby. 4. GI: Bilirubin was done at 40 hours of age and the bilirubin was 9.4/0.3. It is recommended to do a repeat bilirubin check on 2157-2-1 with the pediatrician. 5. Hematology: Mother's blood type is A+, DAT negative. Infant's blood typing was not done. There was a CBC drawn at birth to rule out sepsis. The hematocrit on that CBC was 62 with 285,000 platelets. There have been no further hematocrits or platelets measured. Infant has required no blood product transfusions. 6. Infectious disease: CBC and blood culture were screened on admission due to the PPROM and preterm labor. The CBC was benign. The infant received 48 hours of ampicillin and gentamycin which were subsequently discontinued when the blood culture remained negative at that time. 7. Neurology: The infant has maintained normal neurologic exam for gestational age. 8. Sensory: a. Audiology: A hearing screen was performed with automated auditory brain stem responses and the infant passed in both ears. 9. Psychosocial: There are no active issues at this time. Parents are unmarried. Father of the baby is involved. If there are any psychosocial concerns, the social worker can be reached at 349-753-6799. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: Home with parents. PRIMARY PEDIATRICIAN: Sharon Brunson, 439-643-4464. CARE RECOMMENDATIONS: Ad lib p.o. feedings of ___________ 20 cal/ounce. Medications: None. IRON AND VITAMIN D SUPPLEMENTATION: 1. Iron supplementation is recommended for preterm and low birth weight infants until 12 months corrected age. 2. All infants fed predominantly breast milk should receive vitamin D supplementation at 200 international units which may be provided as a multivitamin preparation daily until 12 months corrected age. __________ This infant has passed the car seat position screening test. State newborn screen was sent on 2156-10-31: Result is pending. Immunizations received: ____________. Immunizations recommended: ____________. A follow-up appointment is recommended with the pediatrician on 2157-2-1. DISCHARGE DIAGNOSES: 1. Prematurity born at 34-6/7 weeks gestation. 2. Sepsis ruled out. 3. Mild hyperbilirubinemia ongoing. Dr. West Dr. West E M.D P79910145 Dictated By:Mary MEDQUIST36 D: 2157-1-31 13:01:51 T: 2157-1-31 14:05:08 Job#: Job Number 76433 " "Admission Date: 2130-4-14 Discharge Date: 2130-4-17 Date of Birth: 2082-12-11 Sex: M Service: #58 HISTORY OF PRESENT ILLNESS: Mr. Jefferson is a 47 year-old man with extreme obesity with a body weight of 440 pounds who is 5'7"" tall and has a BMI of 69. He has had numerous weight loss programs in the past without significant long term effect and also has significant venostasis ulcers in his lower extremities. He has no known drug allergies. His only past medical history other then obesity is osteoarthritis for which he takes Motrin and smoker's cough secondary to smoking one pack per day for many years. He has used other narcotics, cocaine and marijuana, but has been clean for about fourteen years. He was admitted to the General Surgery Service status post gastric bypass surgery on 2130-4-14. The surgery was uncomplicated, however, Mr. Jefferson was admitted to the Surgical Intensive Care Unit after his gastric bypass secondary to unable to extubate secondary to a respiratory acidosis. The patient had decreased urine output, but it picked up with intravenous fluid hydration. He was successfully extubated on 4-15 in the evening and was transferred to the floor on 2130-4-16 without difficulty. He continued to have slightly labored breathing and was requiring a face tent mask to keep his saturations in the high 90s. However, was advanced according to schedule and tolerated a stage two diet and was transferred to the appropriate pain management. He was out of bed without difficulty and on postoperative day three he was advanced to a stage three diet and then slowly was discontinued. He continued to use a face tent overnight, but this was discontinued during the day and he was advanced to all of the usual changes for postoperative day three gastric bypass patient. He will be discharged home today postoperative day three in stable condition status post gastric bypass. DISCHARGE MEDICATIONS: Vitamin B-12 1 mg po q.d., times two months, Zantac 150 mg po b.i.d. times two months, Actigall 300 mg po b.i.d. times six months and Roxicet elixir one to two teaspoons q 4 hours prn and Albuterol Atrovent meter dose inhaler one to two puffs q 4 to 6 hours prn. He will follow up with Dr. Morrow in approximately two weeks as well as with the Lowery Medical Center Clinic. Kevin Gonzalez, M.D. R35052373 Dictated By:Dotson MEDQUIST36 D: 2130-4-17 08:29 T: 2130-4-18 08:31 JOB#: Job Number 20340"