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Patient Name: Date of Birth: Sex: Health Record Number: Account Number: Patient Type: Race:
Admit Date· 07/24/20XX
Admitting Diagnosis Elevated cardiac enzymes
Final (Principal) Diagnosis
Anna Mosity 11/11/85 years ago Female 145230
Inpatient Caucasian
Sinclair Memorial Hospital 444 West Third Street
Dayton, Ohio 45402-1460
:: ~ ..... . . . . . """'!#
CODES
Non ST-elevation myocardial infarction, postoperative complication
Secondary Diagnoses and Complications Hepatocellular carcinoma Congestrive Heart failure exacerbation Acute and chronic respiratory failure Diabetes Hypertension Gastroesophageal reflux disorder Anxiety I Depression Dementia Gastroparesis Coronary artery disease Status post CABG Hypothyroidism Urinary retention Hyperlipidemia Operations/Procedures DruQ-elutinQ doxorubicin bead hepatic embolization
Date Discharged: 07/27/20XX SIGNATURE OF ATIENDING PHYSICIAN DATE
[gJ DISMISSED 0 EXPIRED 0 DISMISSED-ICF 0 DISMISSED TO SNF 0SIGNED SELF OUT 0 DISMISSED SPECIALITY UNIT 0 DISMISSED TO ANOTHER HOSPITAL 0 DISMISSED TO HOME UNDER 0 DISMISSED- OTHER
ADV DIRECTIVES: Y or N ADMITTING PHYS: FAMILY PHYS:
INSURANCE INFORMATION: PATIENT EMPLOYER 1::; 1 CARRIER: [gJ MEDICARE POLICY HOLDER: GROUP NAME:
2ND CARRIER: 0 MEDICARE POLICY HOLDER: GROUP NAME:
3RD CARRIER: 0 MEDICARE POLICY HOLDER: GROUP NAME:
HOME HELA TH CARE
ATIENDING PHYS:
0 MEDICAID 0 : INSURED'S EMPLOYER:
GROUP NUMBER: POLICY#: EFFECTIVE DATE:
0 MEDICAID 0: INSURED'S EMPLOYER:
GROUP NUMBER: POLICY#: EFFECTIVE DATE:
0 MEDICAID 0 : INSURED'S EMPLOYER:
GROUP NUMBER: POLICY#: EFFECTIVE DATE:
Legal Copy-If 'none' or 'b lank' under header N/ A to this encounter Sinclair Memorial Hospital 444 West Third Street Dayton, Ohio 45402-1460
Inpatient (Adm: 07 /24, }) N/A
Patient Demo raphics ._. Address
Reg Status Verified
Phone
pro
937-L08-7::i l9
Date Last Verified MD 08/24/
Sex
Medi cal SESE
Female
Employer UNEMPLOYED
Next Review Date 09/23/'
-Accountlnfo~rmliaiti~o~n~-----F~~~f~~----------·-Afi~~jR~~~~~;~;~----------------~~~~~~~~-H.AR:--·--·----
• Pnmary Payor Affiliated Recurring Accounts Combmed from HAR MEDICARE [1035] None None
Admissi on Information -Hospital AccounUPatient Record None -;, ., Elective f\C.'l :'"SIO
None None
MD
;r. .... :a.r 1 !S v c '3ervicr: A ea
Discharge Information - Hospital AccounUPatient Record
07/24 I 7:27AM Physician Referral Medical
111D
DischamP Date/Time Discharge D1spos1tion Discharge Destmat1on nischarae Prov1der , MD 071271: 4:57PM Routine- Die Home Other
Hospital Account Visits
I Prim/Cur Patient Class Visit Type Admission Date [Statusl
Surgical Appointment 07/24/~ Outpatient [Compto,arl] Surgical Appointment 07/24/ Outpatient [Completed]
[P] Inpatient Admit: Elective 07/24/' [Confi'"'"uj
Medical Problems
No n-Hosp ital Problem Priority Class Problem List Liver Mass [789 318]
Right Renal Mass [593 9DX]
OM (Diabetes Mellttus) [250 008VJ
CAD (Coronary Artery Disease) [414 OOAE]
Never Reviewed
ADT Events Date/Time Unit
07/24/1 '0727 ~ ATA
07/24( , 2156 ~ ATA 07124r- 2156 I SESE
07126 l 1150 I SESE
071271 1657 SESE
Trea tment Team Provider Role
. MD Admttling Provtder
• "D Attendtng Provtd•.t
1. RN Care Coordtnato.
Room
ATA22
ATA22
5508
5508
5~08
' DTR Dtetettc Techntctan Regtstere~
Discharge Summary Notes
08/01, 1950 DISCHARGE SUMMARY By .MD
Printed by [412] al
Bed
ATA-22
ATA-22
5508-8
5508-8
5508-8
From To
07i25/: 1858 N/A 071271 I 1015 N/A
07/27 1245 NIA
D,scharge Date [Status]
[Completed]
[Completed]
07/27/ [Confirmed]
Noted
6/2~
6/2:
612:
6/2:
Service
Medtcal
Medtcal
Medtcal
Medtcal
Medical
07/26/ 11 :50 AM None 1\l,.,ne
5ese
MD
Unit 5ese
Hospital Un1t I Dept
At a
Special Proc
5ese
[Add/Ed1t Comment]
Event
Admtsston-Update
Transfer Out-Ongtnal
Transfer ln-Ortgmal
Patten! Update-Ortgtnal
Otscharge-Origtnal
D/C Summaries signed by , MD
r IE•d 08/01 I 1950
Rei2tE, Original Note by : Notes
DATE OF ADMISSION
07 12L\
DATE OF DISCHARGE
07/27;
PRIMARY CARE PHYSICIAN .. MD
CONSULT
Card iology.
DIAGNOSES
, MD at 08/01; ._.:...::19:..=5.....:..1 ____ --=-:--:-:----·
(none) T ~ Physician 08/01/ 1950
, MDfiledat08/01/ 1950
Sinclair Memorial Hospital 444 West Third Street Dayton, Ohio 45402-1460
DISCHARGE SUMMARY
l. Non-ST -elevation myocardial infarct ion.
' Hepatocellular carcinoma, status post drug-eluting bead embolization on 07/24/2009.
3. Congestive heart failure exacerbation.
4. Acute on chronic respiratory failure.
5. Diabetes.
6. Hypertension.
7. Gastroesophageal reflux disease.
8. Anxiety.
9. Dementia.
1 0. Gastroparesis.
11. Coronary artery disease.
12. Hypothyroidism.
13. Uri nary retention requiring chronic Fo ley .
ADMISSION HISTORY AND PHYSICAL
An 85-year-old white female who came in for drug-eluting bead hepatic embolization on 07/24; She was to be observed after the procedure for nausea. vo miting. ar.d abdominal pain . She states she did not have any pain at the time of evaluation. ~he \vas swallowing air almost as if she was
hiccuping.
PHYSICAL EXAMINA TTON VITAL SIGNS: Temperature 97.5. pulse 73, respiratory rate 16. and blood pressure is 142/76. She is
Printed by [412] at
satting 97% on 2 L nasal cannula.
GENERAL: She is alert, in no acute distress. Swallowing air multiple times during exam as if she was hiccuping but no sounds or belching. CARDIOVASCULAR: Has sternotomy scar. Regular rate and rhythm. No murmurs. LUNGS: Clear. ABDOMEN: Positive bowel sounds. mild tenderness in right mid quadrant. Cannot palpate liver.
MUSCULOSKELETAL: Revealed 3/5 strength and hip flexors. 5/5 in other groups.
SKIN: Showed multiple ecchymoses from prior heparin injection.
HOSPITAL COURSE 1. Non-ST -elevation MI. The patient developed epigastric and right upper quadrant abdominal pain.
This was thought to be secondary to the procedure initially. To rule out other etiologies. cardiac enzymes were done and liver function tests. Cardiac enzymes were initially negative, and then they came back with positive troponin at 9.85 and went up to 18.48. In the next check following day. it was decreasing to 13.4. She was put on appropriate medications including aspirin. Arixtra, beta blocker. nitro, oxygen, statin. and morphine; also put on insulin drip for tight glucose control. EKG showed no ST elevations. Cardiology was consulted and recommended medical management. The patient developed acute on chronic hypoxic respiratory failure during hospital stay secondary to myocardial infarction. She was diuresed and was back on her home oxygen at the time of discharge. Prior to discharge, cardiology recommended getting an echocardiogram for evaluation of her ejection fraction. Her son was adamant to bring her back to the assisted living facility she came from and did not want the echocardiogram done. He felt that she did not need it.
2. Hepatocellular carcinoma, status post drug-eluting bead embolization. The patient underwent drug-eluting bead embolization of doxorubicin beads on 07/24/ . After the procedure. she had nausea and vomiting and right upper quadrant epigastric pain. which began to improve. During her hospital stay. her nausea and vomiting decreased. She was tolerating po.
3. CHF exacerbation with acute on chronic respiratory failure. The patient developed hypoxia; oxygen saturation decreased, and she required 4 L of oxygen. Chest x-ray was consistent with pulmonary edema. She was given Lasix IV and diuresed appropriately. This was likely
secondary to her non-ST -elevation J'v1I. Beta blocker was increased after she was diuresed.
4. Diabetes. The patient was put on insulin drip during hospital stay because she was on Decadron
for the procedure. Blood sugars appeared to have been well controlled on home regimen.
5. The patient had nausea and vomiting with coffee-ground emesis during visit. At that time, her Decadron and Arixtra were stopped. The aspirin was also stopped. Her hemoglobin was monitored but remained stable. She had no further emesis. She was started on PPl 40 twice a day for possibility of peptic ulcer disease. Other medical issues were stable during hospital stay.
MEDICATIO S
1. Amitriptyline 20 mg at bedtime.
2. Lasix 40 mg twice a day.
3. Metoprolol 75 mg twice a day.
4. Prilosec 40 mg twice a day.
5. Aspirin 81 mg daily to be started on 07/30/2009. 6. Lantus 60 units subcutaneously at bt:dtime. 7. Xalatan 0.005 one drop left eye at bedtime. 8. atural Tears as needed for eyes. 9. Tylenol 500 mg every 8 hours as needed for pain.
10. Robitussin 5 mL every 4 hours as needed for cough.
11. Aricept 10 mg at bedtime.
12. BuSpar 7.5 mg twice a day.
13. Omega-3 fatty acid/vitamin E 1 capsule twice a day.
14. Flonase 50 meg spray each nostril daily . 15. Alamast 0.01% one drop into each eye twice a day. 16. lsordil 30 mg sustained release daily. 17. Synthroid 75 meg daily.
18. Reglan 10 mg 4 times a day.
19. Remeron 7.5 mg at bedtime.
20. Prenatal vitamin daily. 21. Zocor 40 mg at bedtime.
22. NovoLog 24 units at breakfast. 14 at lunch. 24 at dinner.
23. Bentyl 10 mg 3 times a day.
24. Pepcid 10 mg twice a day as needed for reflux .
25. MiraLax 17 g every other day as needed for constipation.
26. Phenergan 12.5 mg by mouth every 12 hours as needed for nausea and vomiting. 25 mg rectally every 6 hours as needed for nausea and vomiting.
27. Darvocet-N 100 one tablet every 8 hours as needed.
DISCHARGE DIET ADA 1800.
DISCHARGE ACTIVITY As tolerated with assistance. She is to get physical therapy and occupational therapy at ECF. Oxygen 2 to 3 L to keep sats greater than 89%. She has a Foley catheter in for urinary retention that needs to be changed every 2 weeks. She is to have a BMP in 3 days.
FOLLOWUP
Followup appointment witt· in cardiology in I week and per ECF physician.
The signature of the Al!ending physician serres as a cozmtersignaturefor the Author ofthe document unless the Attending is the Author .
D: 07/27/ T: 07/28/
DG/hrt/djw
001128528
2116640
CC:
. MD 4:24 p
1:37 A
.MD .MD
MD
Page 3
H&P signed by , ___ __ MD ~_!_Q_?/2~.{_--~~~'!__ _______________________ ___ ..... ---------··-··----· , MD " (none) {\J • Jt Physician
~led 07/261 1554 :'ltC 07/26/ 1554
-(t:, t Original Note by: 1\ct' ·
PRIMARY CARE PHYSICIAN ,MD
CHIEF COMPLAINT
MDfiledat07/26/ 1554
Sinclair Memorial Hospital 444 West Third Street Dayton, Ohio 45402-1460
HISTORY AND PHYSICAL
The patient is status post drug-eluting bead hepatic embolization today on 07/24/
for observation overnight.
HISTORY OF PRESENT ILLNESS
, being admitted
Eighty-five-year-old white female with history of hepatocellular carcinoma came in Cor drug-eluting bead with hepatic embolization today. She underwent the procedure without any significant complications. She will be admitted for observation overnight to control any adverse reactions to the procedure including nausea or emesis. The patient has significant medical history of coronary artery disease, status post CABG 7 years ago: diabetes: history of congestive heart failure; hypertension: dementia; anxiety/depression; hypothyroidism: and gastroesophageal reflux disease. The patient reports that these problems have been stable or less. She denies any current chest pain. shortness of breath. nausea. or vomiting. but she does have what appear to be hiccups during examination. She keeps swallowing air. She is alert and able to answers questions appropriately.
REVIEW OF SYSTEMS GENERAL: She reports no recent weight changes. EYES: She reports no vision changes. No photophobia. She does report having cataract surgery in the
past.
EARS. NOSE. AND THROAT: She denies any changes in hearing or sores in the mouth.
NECK: She denies any stiffness or swelling.
CARDIOVASCULAR: She denies any chest pain or palpitations.
PULMONARY: She reports some shortness of breath, which has been a chronic problem vvith
chronic cough. She is unable to bring any thing up with the cough.
GASTROINTESTINAL: She reports no nausea or vomiting. No significant abdominal pain. GENITOURINARY: She reports having a chronic indwelling Foley for the last 2 years. MUSCULOSKELETAL: She reports weakness in her lower extrem!ties and she has to walk vvith a walker and is in a wheelchair most of the time.
EUROLOGIC: She denies any seizures or paresthesias.
SKIN: She denies any recent rashes on her skin. She denies any sores on her back or buttock.
HEMATOLOGIC: She denies any easy bruising or bleeding.
PAST MEDICAL HISTORY
Printed by [ 41 T
1. Coronary artery disease, status post CABG 7 years ago.
2. History of CHF. 3. Diabetes mellitus.
4. Hypertension.
5. Hypothyroidism.
6. Gastroesophageal reflux disease.
7. Hepatocellular carcinoma with a mass of 5.5 em, status post procedure today. See below. 8. Chronic respiratory failure . on home oxygen 2 to 3 L at night. 9. Questionable history of pulmonary fibrosis.
10. Chronic cough.
11. Anxiety/depression.
12. Dementia.
13. Hyperlipidemia.
PAST SURGICAL HISTORY 1. Hernia repair.
2. Hysterectomy.
3. Cholecystectomy.
4. C-section.
5. Coronary artery bypass graft today, which was a drug-eluting bead hepatic embolization using
cloxorubicin.
ALLERGIES
1. Penicillin.
2. Sulfa.
3. Macrobid.
MEDICATIONS
1. Tylenol as needed for fever or pain . 2. Elavil 20 mg at bedtime. 3. Aspirin 8 1 mg daily. 4. Remeron 7.5 daily. 5. Bentyl 10 mg 3 times a clay as needed. 6. Aricept 10 mg daily . 7. Nexium 20 mg daily .
8. Pepcicl 10 mg twice a clay.
9. Flonase 2 sprays each nostril daily. 10. Furosemide 40 mg daily. l I . Guaifenesin 5 mL as needed for cough.
12. Lantus 60 units at bedtime.
13 . Aspart 14 units with lunch, 24 with breakfast and dinner. slidi ng scale insulin.
14. Imdur 30 mg daily. 15 . Xalatan 0.005 left eye at bedtime. 16. Synthroid 75 meg daily.
Printed by [412]
1 7. Reglan 1 0 mg 4 times a clay.
18. Lopressor 25 mg twice a clay.
19. MiraLax as needed for constipation.
20. Phenergan as needed for nausea or vomiting. 21. Zocor 40 mg daily.
SOCIAL HISTORY
1. She lives in a nursing home.
2. No alcohol. tobacco, or illicit drugs. 3. She walks with a walker and needs V\heelchair.
FAMILY HISTORY
1. She reports her parents died of old age, natural causes.
2. Her daughter is a pediatrician in Texas. 3. Her son is her health care power of attorney who lives in this area.
PHYSICAL EXAMINATION VITAL SIGNS: Temperature is 97.5, pulse is 73, sinus rhythm, respiratory rate 16, and blood
pressure is 142/76. She is satting 97% on 2 L nasal cannula.
GENERAL: She is alert and oriented white female. appears stated age. swallowing air during the
examination multiple times, but no hiccups or belching.
EYES: Pupils are smalL but appear to be equally reactive. Extraocular muscles are intact. EARS, NOSE. A D THROAT: Oropharynx is clear. Mucous membranes are moist.
ECK: Supple. No lymphadenopathy. No thyromegaly. CARDIOVASCULAR: Sternotomy scar. Regular rate and rhythm. I did not hear murmurs. Positive pulses.
LUNGS: Clear to auscultation bilaterally. She is wearing oxygen 2 L nasal cannula .
ABDOMEN: Multiple areas of bruising from heparin injections. Positive bowel sounds. Mild
tenderness in the right mid quadrant. I cannot palpate liver.
GENITOURINARY: She has a Foley catheter in place draining yellow urine.
MUSCULOSKELETAL: She has 5/5 strength in upper e>..tremities and 3/5 in hip flexors.
NEUROLOGIC: Cranial nerves are intact. Reflexes are symmetric. SKIN: Reveals no decubitus ulcers. o rashes. Multiple seborrheic keratoses. Ecchymosis of the abdomen from prior heparin injections. The right femoral site is covered from the procedure clone today. .
LABORATORY STUDIES Prior to procedure, she had creatinine. which was I . Coagulations within normal. Blood sugar v.as 124. She did receive Decaclron during the surgery.
ASSESSMENT /\NO PLAN Eighty-five-year-old white female with hepatoceilulat carcinoma. status post drug-eluti ng bead hepatic embolization today, being admitted for owrnigln obsenation .
1. Hepatocellular carcinoma. status post hepatic bead embolization with doxorubicin. 'W e '" ill monitor for any adverse reactions to this procedure including right upper quadrant pain. nausea. or vomiting. Treat as needed. She will be receiving Decndrott status post this procedure as well as antibiotics. We will monitor blood sugars dose!; and gi\e insulin as needed Cor
Printed by [412] at
hyperglycemia. 2. Coronary artery disease. The patient does appear to be s1ahle. The patient is on beta-blocker.
statin, nitroglycerin, and oxygen. 3. History of congestive heart failure, which appears well compensated at this point. 4. Diabetes. We will continue her home regimen. Add sliding scale insulin as needed.
5. Dementia. Continue Aricept. 6. Anxiety/depression. Continue home medications. 7. Hypothyroidism. Continue Synthroid .
8. Gastroparesis. Continue Reglan.
9. Hyperlipidemia. Continue Zocor. I 0. Continue eye drops. 11. Prophylaxis. We will put her on SCDs and heparin starting tomorrow.
Her heal thcare power of attorney, can be reached at
The signature of the At/ending physician serves as a coun/ersignaturefor the Author ofthe document unless the Attending is the Author .
D: 07/24/ T: 07/25/
DG/hrt
00 112 7960
2115829
CC:
. MD 6:33 p
2:34 A
. l'vfD .. ,MD
MD
07/26/ 1554 HISTORY & PHYSICAL By
End of Report
Printed by [412]
, MD
Consults signed -'-b.Ly---::-:-=- MD at 08/10 1010
I rj 07/26l l, MD
1434 \oote T r1t:
DATE OF CONSULTATION 07/26t'
CONSULTA T .MD
REFERRING PHYSICIAN MD
REASON FOR CONSULTATION Elevated troponin.
BRIEF CLINICAL SYNOPSIS
---- --:--(none) 07/26/ 1434
Sinclair Memorial Hospital 444 West Third Street Dayton, Ohio 45402-1 460
CONSULTATION
Physician
The patient is a pleasant 85-year-old female patient with multiple medical problems including atherosclerotic heart disease. came with the history of hepatocellular carcinoma for drug-eluting bead placement with hepatic embolization. She underwent the procedure without any significant complications. She was admitted for observation to control any episode of abnormal reactions to the procedure. She denies any chest pain, chest tightness, or chest pressure. She does complain of some nausea. She denies any significant symptoms. Has limited ambulation capacity. She has an indwelling Foley catheter for several years.
REVIEW OF SYSTEMS Otherwise negative.
PAST MEDICAL HISTORY I. CAD status post CABG 7 years ago. 2. CHF. 3. Diabetes mellitus. 4. Hypertension.
5. Hypothyroidism.
6. Hepatocellular carcinoma.
PAST SURGICAL HISTORY I. Coronary artery bypass surgery.
2. Cholecystectomy.
3. Hysterectomy.
CURRENT MEDICATIONS IN THE HOSPITAL
Printed by [ 412] at
Include:
1. Aricept.
2. exlllm.
3. Flonase.
4. Arixtra 7.5 mg. 5. Hydralazine as needed.
6. Insulin.
7. lsosorbide mononitrate. 8. Metered-dose inhalers. 9. Metoprolol 50 mg 2 times a day.
PHYSICAL EXAMI ATION
GENERAL: The patient is resting comfortably in bed.
VITAL SIGNS: Blood pressure of 137/73, heart rate of80 beats per minute. HEAD, EYES. EARS. OSE, AND THROAT: Some pallor was noted in the eyes. Some mild icterus was noted. NECK: No jugular distention or carotid bruits. HEART: Soft first and second heart sounds. LUNGS: Few scattered crackles at both bases. ABDOMEN: Mildly distended with some tenderness.
EXTREMITIES: Lower extremities had I to 2+ ankle edema.
BACK AND SPINE: Not examined.
NEUROLOGIC: Grossly intact.
DIAGNOSTIC DATA EKG shows nonspecific ST-T changes.
LA BORA TORY DATA Lab results are as follows: Sodium 140, potassium 3.8, BUN and creatinine of 19 and 0.9. Troponin maxed out at 18.47.
The patient had a 2D echocardiogram in 2003 which showed ejection fraction of 50% .
ASSESSMENT AND PLAN The patient with known coronary artery disease, who was electively admitted after procedure for her hepatocellular carcinoma, had significant elevation of cardiac enzymes, which is probably consistent with non-ST elevation myocardial infarction. Initially, we started her on antithrombotic treatment as well as aspirin but she has had some coffee-ground, so I think we can stop the antithrombotic treatment at this time. Her telemetry does show some appearance of nonsustained ventricular tachycardia for which she is already on a beta-blocker. In light of her advanced disease and do not resuscitate comfort care status, we will be conservative as far as her management goes to respect her wishes. I will. however, get a transthoracic echocardiogram again to get an overall sense of what degree of left ventricular dysfunction she has at this time which is probably a result of her myocardial infarction. Aspirin, we will continue. Plan of care was discussed with the patient who appears to be quite alert at this time.
Printed by [412] at . . _ _ _ _
I have examined this patient and available medical records on this date and have made the above observations, conclusions and recommendations.
The signature of the Attending physician serves as a countersignature for the Author of the document unless the Attending is the Author.
0: 07/26/' __ T: 07/26/ MC/hrt 001128182 2116187 CC:
,MD 9:02 A
2:08 p
t,MD ,MD
End of Report
Printed by [412] at .
Legal Copy-If'none' or 'blank' under header ,'-..J/A to thi s encounter
H&P Summary Notes 071261 1554 HISTORY & PHYSICAL By MD
Consult Notes 07/26/ 1434CONSULTATION By: .MD
Procedure Notes No notes of this type ex ist for this admission .
Procedure Notes 07/24' 0745 PHYSICIAN ORDERS- SOLCOM By. Scan Sclcorn 07/27 2102 ELECTROCARDIOGRAM- SOLCOM By Scan Solcom 07128 '2157 ELECTROCARDIOGRAM- SOLCOM By Scan Solcom 07/30, l 1822 ECHOCARDIOGRAM By , MD
No pended notes ex1st for th1s encounter
Medical Staff Progress Notes
Medical Staff Progress Note signed by r, MD
Pended Notes
, MD at 07/24/ 1428 (none) 07/24/' 1425
Sinclair Memorial Hospital
Medical Imaging: Outpatient Presedation Assessment
7/241
Phys ician
Outpatient H&P: 85 yo WF with right hepatic lobe HCC. Presents for DEB embolization Procedure: Hepatic Drug Eluting Bead Embolization Chief Complaint/Indications: As above
v I
• CAD (Coronary Artery Disease) • Heart Failure • Vancomycin Resistant Enterococcus Infection • Pneumonia , Organism Unspecified • Hypothyroid • Diabetes • Anxiety • Ulcer • Unspecified Essential Hypertension • Anesthesia
coma for 4 months • Malignancies
kidney
• Lap ,inguinal hernia repr,initial • Total abdom hysterectomy • Pice catheter insertion
LEFT DUAL 41CM READY TO USE • Removal gallbladder
Printed by [412] at
6/23/
2002
09/101
Legal Copy-If 'none' or 'blank' under header ! 1/ A to thi s encounter
• Cesarean delivery only • Other surgical history
OPEN HEART • Other surgical history
Feeding tube insertion • Other surgical history
Removal of feeding tube
Admission Date:
• insulin glargine (LANTUS) 100 unit/mL vial
60 Units by Subcutaneous route at bedtime.
• omeprazole (PRI LOSEC) 20 Take by mouth at mg Tab EC bedtime.
• latanoprost (XALATAN) 0.005 1 Drop by Left eye route % eye drops at bedtime.
• polyvinyl alcohol (AKWA- place 1 Drop into each TEARS) eye drops eye.
• acetaminophen (TYLENOL Take 500 mg by mouth EXTRA STR) 500 mg tablet every 8 hours as
needed
Allergtes
• Pen (Penicillins) • Sulfa (Sulfonamides) • Macrodantin (Nitrofurantoin
Macrocrystal) • Ace Inhibitors
Also ARB causes severe cough
History - t~l'lr SF.,... ~riCS
• Tobacco Use: • Alcohol Use:
No family history on file .
Review of Systems: Mental Status: A+Ox3
Hives Hives Hives
Cough
Resp: denies cough or shortness of breath Cardiac: denies chest pain Abdomen: denies abdominal pain or bloating
Physical Exam: v· 1 s· tta tgns:
01/18/
2002
2003
,_,. '>P n
Never No
~ ! •
Temp: 97.5 o Temp BP: 131/64 Pulse: 68 Resp: 28 Sp02: 91 % F (36.4 °C) Max: 97.5 o (7/24/09 F (36.4 oC) 8:10AM) General: NPO: yes
ASA: Ill
mmHg (7/24/09 (7/24/09 (7/24/09 8:10 (7/24/09 8:10AM) 8:10AM) fA,M) 8:10AM)
MALLAMPATI: II = Visibility of hard and soft palate, upper portion of tonsils and uvu la Heart: RRR Lungs: Clear
Printed by [412] at
Legal Copy-If 'none' or 'blank' under header N ! A to thi s encounter
Vascular/Pulses: femoral right 2+
Labs: CBC: ... ab Results
• PLATELETS • WBC • RBC • HEMOGLOBIN • HEMATOCRIT • MCV • MCH • MCHC • ROW
BMP: lab Results
\Ja ue 172 6.8 4.25 13.7 40.0 94.0 32.2 34.3 13.8
• CA 9.6 • POTASSIUM 4.5 • NA 138 • CL 103 • C02 25 • CREATININE 1.0 • GLUCOSE 124 • GLUCOSE 63 • BUN 28
COAG PROFILE: .... ab Results
• PROA • INR • PTTA
10.3 1.0 26.0
6/27/f\ 0731 6/27/' 0731 6/27/, ' 0731 6/27/ 0731 6/27/ ' 0731 6/27/ 0731 6/27/ )< 0731 6/27/ 0731 6/27/ 0731
dl ! " ·t:
7/5/ 0610 7/5/ 0610 7/5/ - 0610 7/5/ 0610 7/5/ 0610 7/24/ 0820 7/24/ . 1144 7/5/ 0610 7/5/ 0610
'Tl!
7/24/ ' 0820 7/24/ 0820 7/24/ 0820
Impression & Plan: 5cm right hepatic lobe HCC. Plan drug eluting bead embolization with 1 vial of 300-500 micron beads mixed with 50mg Doxirubicin.
The patient's record including available labs and procedures, medications and allergies have been reviewed. The proposed procedure above, with indications, risks , benefits and alternatives have been discussed. The patient and/or their representative have had their questions answered to their satisfaction and the best of my ability . They appear to , and have stated their understanding of the risks and alternatives, and have indicated their willingness to proceed.
The site of the procedure has been confirmed with the patient and is known from CT and will be identified by vascular supply ..
Anesthesia Plan: Following above consent, patient re-evaluated prior to initiating anesthesia or sedation .
MD, 7/24/ 2:25PM
MedicaiS~ffProqressNotesinn9~d~b~y_:~~~~~~-·~,M~D~at~0~7~~~4~/~1~71~7~~~~~~~~~~~~~~~~ : MD (none) Physician
U7/'241 ' 1717 07/24/ 1714
Sinclair Memorial Hospital
Printed by [ 412] at
Legal Copy-If 'none' or 'blank' under header 1\J / A to this encounter
General Post-procedure Note
7 /24/~
MRN: 000-99-04-1 DOA: 7/24/
Indications: right lobe hepatocellular carcinoma
Procedure: Drug eluting bead hepatic embolization
Provider: , MD Access site: right femoral artery Anesthesia: Following consent, patient reevaluated and procedure performed using IV Sedation and Local
anesthesia. Medications: Fentanyl 75mcg , Versed 1.5mg and Lidocaine 10 ml Estimated Blood Loss: Minimal Specimens: none
Complications: none Preliminary Report/Findings: (Complete report dictated) Right hepatic lobe (seg 5) HCC RX with 1 vial 300-500 micron beads mixed with iodinated contrast and 50mg Doxirubicin . Recommendations: Pain and nausea control. Orders written. IR to follow . Appreciate Hospitalist assistance.
Electronically signed by , MD, 7/24/ 5:14PM
Medical Staff F'---·--- ••-•- · igned by ' , MD at 07/24/09 1839
"' MD (none) Physician ·&7t2.41 1839 07/24/ 1835
I I I 1115'\dmit note
85yo WF with multiple medical issues in for over night observation s/p Drug eluting bead hepatic embolization for hepatocellular Ca by IR. Given doxyrubicin. Medical issues are CAD, Hx CHF, OM , HTN , HLP, GERD, anxiety , dementia , gastroparesis , chronic resp failure on home 02, chronic cough .
A/P : 1. Hepatocellular Ca s/p embolization with drJg eluding beads: Monitor for NN, RUQ pain , bleeding . Tx Sx.
Cont decadron , Ab per IR. 2. CAD BB, statin , nitrate , 02 . 3. OM Home regimine + SSI 4. Other issues per H&P 1127960.
Electronically signed by: MD, 7/24/ · 6:39PM
Medical Staff Progress ~ote s:.;;igc;;n~ed::....::.bYL __ ~--=-..::· ·..:;:-:...:· ":.!..' :.:M;.::D:....:a:.:t..:::0.:.:7/~2.::::5'_..:::.J9:::..:3::...:1 ___ -:::-_ _ -=---:--:-----------MD (none) Physician
Of/25/ 0931 07/25/ 0918 Revised Addendum by: , , MD, note time at 07/25/ 0918
Sinclair Memorial Hospital-
Subjective Pt. seen and examined. She reports RUQ and epigastric pain , NN. She denies chest pain , shortness of breath . She has not been asking for nausea medications. Discussed plan.
Printed by [ 412] at
BP 138/94 mmHg
I
Pulse: 1 05 (7/25/09
Resp : 20 Sp02 92 % 1(7/25/09 7 51 1(7/25/09
Legal Copy-If'none' or 'blank' under header \. /A hi this encounter
7:51AM) M)
1/0 last 3 completed shifts: In: 0 Out: 1825 (1825 Urine) Baseline Wt- Scale: 82.101 kg (181 lb) (7/24/09 8:10AM) Most recent Wt- Scale 82.101 kg (181 lb) (7/24/09 8:10AM)
Tele: sinus tachy, RBBB.
02 91% RA.
Exam:
17:56 AM)
GENERAL APPEARANCE: Alert , tachypnic, keeps swallowing , uncomfortable. HEENT PERRL, EOMI , MMM Neck: Supple. CV: Tachycardia , reg rhythm . Pulm: CTA B Abd: +BS, TTP RUQ , no rebound , no guarding . GU: Foley, yellow urine. Extr: Stockings
Labs pending
EKG: RBBB, PVC, ST depressions ant lat. Similar to EKG 1n June 2009
Medications Reviewed
Scheduled meds ondansetron (ZOFRAN) injection 4 mg 4 mg Intravenous EVERY 6 HOURS; morphine injection syringe 4 rng 4 mg Intravenous NOW; levofloxacin (LEVAQUiN) IVPB 500 mg 500 mg Intravenous DAILY; metronidazole (FLAGYL) IVPB 500 mg 500 mg Intravenous TWO TIMES A DAY; dexamethasone (DECADRON) injection 8 mg 8 mg Intravenous EVERY 8 HOURS: amitriptyline (ELAVIL) tablet 20 mg 20 mg Oral AT BEDTIME; donepezil (ARICEPT) tablet 10 mg 10 mg Oral AT BEDTIME famotidine (PEPCID) tablet 10 mg 10 mg Oral TWO TIMES A DAY; fluticasone (FLONASE) nasal spray 2 Spray 2 Spray Each Nostril DAILY; isosorbide MONOnitrate (IMDUR) SR-tablet 30 mg 30 mg Oral DAILY; latanoprost (XALATAN) 0.005% eye drops 1 Drop 1 Drop Left eye AT BEDTIME; levothyroxine (LEVOTHROID/SYNTHROID) tablet 75 meg 75 meg Oral DAILY BEFORE BREAKFAST; metoclopramide (REGLAN) tablet 10 mg 10 mg Oral FOUR TIMES A DAY metoprolol tartrate (LOPRESSOR) tablet 25 mg 25 mg Oral TWO TIMES A DAY; mirtazapine (R EMERON) tablet 7.5 mg 7.5 mg Oral AT BEDTIME; insulin aspart (NOVOLOG) SQ injection 24 Units 24 Units Subcutaneous DAILY WITH BREAKFAST; insulin aspart (NOVOLOG) SQ injection 14 Units 14 Units Subcutaneous DAiLY WITH LUNCH ; insulin aspart (NOVOLOG) SQ injection 24 Units 24 Units Subcutaneous DAILY WITH EVENING MEAL esomeprazole (NEXIUM) enteric-coated capsule 20 mg 20 mg Oral DAILY; simvastatin (ZOCOR) tablet 40 mg 40 mg Oral AT BEDTIME; heparin injection solution 5.000 Units 5000 Units Subcutaneous EVERY 8 HOURS; insulin aspart (NOVOLOG) for sliding scale Subcuta neous THREE TIMES A DAY WITH MEALS AND AT BEDTIME; saline flush 1 Syringe 1 Syringe Intravenous EVERY 8 HOURS; insulin glargine (LANTUS) SO injection 40 Units 40 Units Subcutaneous AT BEDTIME Continuous infusions: NaCI 0.9% PRN meds hydrALAZINE (APRESOLI NE) injection solution 10 mg ; morphine injection syringe 2-4 mg; promethazine (PHENERGAN) injection solution 12.5 mg ; ondansetron (ZOFRAN) injection 4 mg ; oxycodone (ROXICODONE) tablet 5 mg; acetaminophen (TYLENOL EXTRA. STR) tablet 500 mg; propoxyphene n-acetaminophen (DARVOCET-N) 100-650 mg tablet 1 Tab; dicyclomine (BENTYL) capsule 10 mg ; guaifenesin (ROBITUSSIN ) LIQUID 100 mg polyethylene glycol (MIRALAX) packet 17 g; promethazine (PHENERGAN) suppository 25 mg ; promethazine (PHENERGAN) tablet 25 mg ; alum & mag hydroxide with simethicone (MAALOX,MYLANTA) suspension 30 mL; dextrose (GLUTOSE) gel 15 g; dextrose 50% in water (D50W) intravenous syringe 25 g; glucagon (GLUCAGON) injection recon solution 1 mg; dextran 70-hypromellose (TEARS NATURALE FREE) 0.1-0.3 %eye drops 1 Drop lidocaine (pf) 2% (20 mg/mL) 123.2 mg , atrop1ne syringe 0.5 mg ; saline flush 1 Syringe; albuterol (PROVENTIL) nebulizer solution 2.5 mg: albuterol (PROVENTIL) nebulizer solution 2.5 mg
Printed by [412]
Legal Copy-If'none' or 'blank' under headt:r \~//\in 1his encounte r
(Meds that have been ordered and completed are not included above)
Assessment/ Plan : 1. Hepatocellular Ca s/p embol ization with doxyrubicin eluding beads: Patient has sig nausea but not asking for
meds. Also with RUQ pa in. Give morphine, schedule Zofran . Check labs to R/0 other etiologies of N!V, pain . IR to see pt today .
2. CAD: BB, statin , nitrate , 02 . EKG ST depression but similar to prior, will R/0 Ml as sig Hx. Most likely pain , N!V 2' procedure .
3. OM: BG running on high side 2' steroid . Pt was given aspart but not eating . Monitor BG . 4. HTN: BP high 2' pain , give meds, monitor trend . 5. GERD: PPI 6. Anxiety : Tx prn . Cont home meds 7. Dementia : Cont aricept. 8. Gastroparesis : Reglan 9. Hypothyroid synthroid .
10. Chronic resp failure: 02 at night. 11 . Prophylaxis: Heparin .
Will speak with son today .
Electronically signed by :
Medical Staff Progress Note signed by , MD
o·r 12 51 1653 Original Note by :
Subjective
MD, 7/25/ 9:18AM
. MD at 07/25/, · 1653 (none) 07125/ 0918
. MD , note time at 07/2 5/ 0931
Sinclair Memorial Hospital
Physic1an
Pt. seen and examined. She reports RUQ and epigastric pain , N!V She denies chest pain , shortness of breath . She has not been asking for nausea medications. Discussed plan .
Objective Vital Si ns:
emp 96.6 Temp oF (35 .9 oC) Max: 97.9 (7 /25/09 OF (36 .6 ° 7:51 AM C
BP: 138/94 mmHg (7/25/09 7:51AM
1/0 last 3 completed shifts: In : 0 Out: 1825 ( 1825 Urine)
Pulse : 105 (7/25/09 7 51 AM)
Resp: 20 !Sp02: 92 % I (7/25/09 7:51 (7/25/09
M) 7 56 AM )
BaselineWt-Scale: 82.101 kg(181\b)(7/24/09 8:10 AM ) Most recent Wt- Scale : 82 .101 kg (181 \b) (7/24/09 8:10AM)
Tele : sinus tachy , RBBB .
0291 % RA.
Exam :
GENERAL APPEARANCE: Alert , tachypnic, l<eeps swallowing , uncomfortable. HEENT: PERRL, EOM\ , MMM Neck: Supple. CV: Tachycardia , reg rhythm . Pulm: CTA B Abd : +BS, TTP RUQ, no rebound , no guarding. GU : Foley, yellow urine. Extr: Stockings
Printed by [412] at _
Legal Copy-If'none' or 'blank' under header ;-..J ,A w this encounter
Labs: pending
EKG: RBBB , PVC, ST depressions ant lat. Similar to EKG in June 2009
Medications Reviewed
Scheduled meds: ondansetron (ZOFRAN) injection 4 mg 4 mg Intravenous EVERY 6 HOURS; morphine injection syringe 4 mg 4 mg Intravenous NOW; levofloxacin (LEVAQUIN) IVPB 500 mg 500 mg Intravenous DAILY; metronidazole (FLAGYL) IVPB 500 mg 500 mg Intravenous TWO TIMES A DAY; dexamethasone (DECADRON) injection 8 mg 8 mg Intravenous EVERY 8 HOURS; amitriptyline (ELAVIL) tablet 20 mg 20 mg Oral AT BEDTIME; donepezil (ARICEPT) tablet 10 mg 10 mg Oral AT BEDTIME famotidine (PEPCID) tablet 10 mg 10 mg Oral TWO TIMES A DAY; fluticasone (FLONASE) nasal spray 2 Spray 2 Spray Each Nostril DAILY; isosorbide MONOnitrate (IMDUR) SR-tablet 30 mg 30 mg Oral DAILY ; latanoprost (XALATAN) 0.005% eye drops 1 Drop 1 Drop Left eye AT BEDTIME; levothyroxine (LEVOTHROID/SYNTHROID) tablet 75 meg 75 meg Oral DAILY BEFORE BREAKFAST; metoclopramide (REGLAN) tablet 10 mg 10 mg Oral FOUR TIMES A DAY metoprolol tartrate (LOPRESSOR) tablet 25 mg 25 mg Oral TWO TIMES A DAY; mirtazapine (REMERON) tablet 7.5 mg 7.5 mg Oral AT BEDTIME; insulin aspart (NOVOLOG) SO injection 24 Units 24 Units Subcutaneous DAILY WITH BREAKFAST; insulin aspart (NOVOLOG) SQ injection 14 Units 14 Units Subcutaneous DAILY WITH LUNCH ; insulin aspart (NOVOLOG) SQ injection 24 Units 24 Units Subcutaneous DAILY WITH EVENING MEAL esomeprazole (NEXIUM) enteric-coated capsu le 20 mg 20 mg Oral DAILY; simvastatin (ZOCOR) tablet 40 mg 40 mg Oral AT BEDTIME; heparin injection solution 5,000 Units 5000 Units Subcutaneous EVERY 8 HOURS; insulin aspart (NOVOLOG) for sliding scale Subcutaneous THREE TIMES A DAY WITH MEALS AND AT BEDTIME; saline flush 1 Syringe 1 Syringe Intravenous EVERY 8 HOURS; insulin glargine (LANTUS) SQ injection 40 Units 40 Units Subcutaneous AT BEDTIME Continuous infusions: NaCI 0.9% PRN meds: hydrALAZINE (APRESOLINE) injection solution 10 mg; morphine injection syringe 2-4 mg ; promethazine (PHENERGAN) injection solution 12.5 mg ; ondansetron (ZOFRAN) injection 4 mg; oxycodone (ROXICODONE) tablet 5 mg; acetaminophen (TYLENOL EXTRA STR) tablet 500 mg; propoxyphene n-acetaminophen (DARVOCET-N) 100-650 mg tablet 1 Tab ; dicyclomine (BENTYL) capsule 10 mg; guaifenesin (ROBITUSSIN) LIQUID 100 mg polyethylene glycol (MIRALAX) packet 17 g; promethazine (PHENERGAN) suppository 25 mg, promethazine (PHENERGAN) tablet 25 mg; alum & mag hydroxide with s1methicone (MAALOX,MYLANTA) suspension 30 mL; dextrose (GLUTOSE) gel 15 g; dextrose 50% in water (DSOW) intravenous syringe 25 g; glucagon (GLUCAGON) injection recon solution 1 mg; dextran 70-hypromellose (TEARS NATURALE FREE) 0.1-0.3 % eye drops 1 Drop lidocaine (pf) 2% (20 mg/mL) 123.2 mg; atropine syringe 0.5 mg; saline flush 1 Syringe; albuterol (PROVENTIL) nebulizer solution 2.5 mg ; albuterol (PROVENTIL) nebulizer solution 2.5 mg (Meds that have been ordered and completed are not included above)
Assessment/ Plan : 1. Hepatocellular Ca s/p embolization with doxyrubicin eluding beads Patient has sig nausea but not asking for
meds. Also with RUQ pain . Give morphine, schedule Zofran . Check labs to R/0 other etiologies of NIV, pain . IR to see pt today.
2. CAD: BB, statin , nitrate, 02 . EKG ST depression but similar to prior, will R/0 Ml as sig Hx. Most likely pain , NIV 2' procedure.
3. OM: BG running on high side 2' steroid . Pt was given aspart but not eating. Monitor BG. 4. HTN: BP high 2' pain , give meds, monito r trend . 5. GERD: PPI 6. Anxiety: Tx prn . Cont home meds 7. Dementia : Cont aricept. 8. Gastroparesis : Reglan 9. Hypothyroid: synthroid.
10. Chronic resp failure : 02 at night 11 . Prophylaxis: Heparin .
Will speak with son today .
Electronically signed by: MD. 71251 9:18AM
Printed by [412] at
Legal Copy-If 'none' or 'blank' under header :'~ /A to thi s encounter
Lab work initially come back WNL then 2nd set Troponins + EKG shows improvement in her ST depressions .i n precordial leads. C/w NSTEMI. MEdical management- Arixtra , ASA, BB, Nitro, 02 , statm , morphine. Would like tight BG control. Added insulin drip. Dr. to see patient.
Spoke with son , pt is DNR
Electronically signed by: .. MD, 7/251' . 4:53 PM
Med~aiS~ffProqre~No~siane~d~b~y~~~~~--~'·~M~D~M~0~7~n~~~-~J~09~5=0~~~~~~~~~~~~~~~~ MD (none) Physician
Ufi'L!:J, 0950 07/25/ 0944
S: Nausea, Vomiting x 1. Mild RUQ pain . 0: BP increased . Othervise VSS.
Abd soft/nUnd Right groin c/d/i
A: one day post drug eluting bead hepatic embolization . Nausea expected however needs to be under control prior to discharge. P Will keep in house one more day. Cant anti emetics. Spoke with Dr. . Appreciate his help.
Medical Staff Progress Note signed by ;-:..M=D-=a7t ..::.07-=/=-26::..:./---'0:...::8-=4-=7 ~~--,-~~~--::-:---:-:-~~~~~~~~-MD ·(none) Physician
07/26/ 084 7 071261 ' 0842
Sinclair Memorial Hospital
Medical Oncology Hematology Progress Note 7/26/
Subjective Pt. seen and examined. Chart reviewed . Patient has T ACE procedure on 7/24 and subsequently admitted for observation . Yesterday , her cardiac enzymes increased suggesting myocardial injury. Today , the patient reports shortness of breath ; also nausea ..
Objective Exam :
Vital Signs:
f1 emp: 96.9 o F (36.1 oc) (7/26/09 5:44AM)
st
07/17/:
lfemp Max: 97.7 o F (36.5 OC)
BP: 138/73 Pulse: 83 mmHg (7/26/09 (7/26/09 5:44AM) 5:44AM)
1.676 m (5' 6")
... ast 1 Encounter W Readmgc;;
07 /17/' 82 .101 kg (1811b)
1/0 last 3 completed shifts:
Resp: 24 (7/26/09 5:44AM)
In: 2421 (360 P.O. 2061 I.V.) Out: 2850 (2850 Urine)
Printed by [412] at
Sp02 : 94% (7 /26/09 5:44 f.A,M)
Legal Copy-lf'none' or 'blank' under he8der , '/A to this encounter
Mentation : alert and cooperative
CV: regular rate and rhythm PUL: bibasilar rales ABO: Abdomen soft , non-tender. BS normal. No masses or organomegaly Extremities: Bilateral lower extremity edema pitting , 1 +
Scheduled meds: ondansetron (ZOFRAN) injection 4 mg 4 mg Intravenous EVERY 6 HOURS; fondaparinux (ARIXTRA) syringe 7.5 mg 7.5 mg Subcutaneous DAILY; insulin aspa:t (NOVOLOG) injection 14 Units 14 Units Subcutaneous DAILY WITH LUNCH ; insulin aspart (NOVOLOG) injection 24 Units 24 Units Subcutaneous DAILY WITH BREAKFAST; insulin aspart (NOVOLOG) injection 24 Units 24 Units Subcutaneous DAILY WITH EVENING MEAL metoprolol tartrate (LOPRESSOR) tablet 50 mg 50 mg Oral TWO TIMES A DAY; levofloxacin (LEVAQUIN) IVPB 500 mg 500 mg Intravenous DAILY; metronidazole (FLAGYL) IVPB 500 mg 500 mg Intravenous TWO TIMES A DAY; dexamethasone (DECADRON) injection 8 mg 8 mg Intravenous EVERY 8 HOURS; amitriptyline (ELAVIL) tablet 20 mg 20 mg Oral AT BEDTIME; donepezil (ARICEPT) tablet 10 mg 10 mg Oral AT BEDTIME famotidine (PEPCID) tablet 10 mg 10 mg Oral TWO TIMES A DAY; fluticasone (FLONASE) nasal spray 2 Spray 2 Spray Each Nostril DAILY; isosorbide MONOnitrate (IMDUR) SR-tablet 30 mg 30 mg Oral DAILY; latanoprost (XALATAN) 0.005% eye drops 1 Drop 1 Drop Left eye AT BEDTIME; levothyroxine (LEVOTHROID/SYNTHROID) tablet 75 meg 75 meg Oral DAILY BEFORE BREAKFAST; metoclopramide (REG LAN) tablet 10 mg 10 mg Oral FOUR TIMES A DAY mirtazapine (REMERON) tablet 7.5 mg 7.5 mg Oral AT BEDTIME; esomeprazole (NEXIUM) enteric-coated capsule 20 mg 20 mg Oral DAILY; simvastatin (ZOCOR) tablet 40 mg 40 mg Oral AT BEDTIME; saline flush 1 Syringe 1 Syringe Intravenous EVERY 8 HOURS; insulin glargine (LANTUS) SO injection 40 Units 40 Units Subcutaneous AT BEDTIME
Labs:
CBC WITH DIFFERENTIAL No results found for this basename: 38858 in the last 36 hours BMP
SODIUM
POTASSIUM
CHLORIDE CARBON DIOXIDE
GLUCOSE
BUN
' CREATININE BUN/CREAT RATIO
CALCIUM
Imaging Studies: None.
Other Studies: none
Assessment & Plan: Patient Active Hospital Problem List: * No active hospital problems. *
140
3.8
107
22 1os· 15
0.9
17
8.9
1) Hepatocellular carcinoma s/p TACE with doxorub1cin-eluding beads: got 50 mg dose.
Printed by [ 412] a
Legal Copy-If 'none' or 'blank' under heade r ~ / A to thi s encounter ..... ---·-2) Cardiac: elevated troponins; possibly Ml as postop complication : sometimes enzymes might go up after TACE; pt stable at this time .
Electronically signed by: 1, MD, 7/26/ 8:42AM
Medical Staff Progress Note signed by - -··-- .. ·····-·-- - ---- - ----- \-Mo·· - MD at 07/26, 0~---- - -----.... ·----: ·---·-----·--.. -·---(none) Phys ician
07/26/ 1014 07/26/ 0956
Sinclair Memorial Hospital
Hospitalist Progress Note
Subjective Pt. seen and examined. She reports improvement in RUQ and epigastric pam. +shortness of breath . + NNcoffe ground emesis per nurse. Cards saw pt, gave recs.
Objective v·t Is· 1a 1gns: !Temp: 96.9 °F (36.1 °C} (7/26/09 0544)
!Temp BP: 138/73 Max 97.7 o mmHg F (36.5 o (7/26/09 C) 0544)
1/0 last 3 completed shifts:
Pulse : 87 Resp: 26 (7/26/09 (7/26/09 0858) 0858)
In : 2421 (360 P.O. 2061 IV) Out: 2850 (2850 Urine) Baseline Wt- Scale: 82.101 kg (181 lb) (7/24/09 0810) Most recent Wt- Scale: 82 .101 kg (181 lb) (7/24/09 0810)
Tele : sinus, short runs NSVT.
02 94% 4L NC
Exam: GENERAL APPEARANCE: Alert , tachypnea HEENT PERRL, EOMI , MMM CV: RRR , Pulm: Bibasi lar crackles. Abd : +BS, mod TTP RUQ , no rebound , no guarding. Extr: Stockings
Labs:
CBC I" l
WBC COUNT 8.3 RBC COUNT 4.53
HEMOGLOBIN 15.1
HEMATOCRIT 42 g
MCV 94.6
MCH 33Y
MCHC 35.2
ROW 14.5 PLATELET COUNT : 1 I,~
Printed by [412] a
Sp02: 94 % (7/26/09 0544)
--
-
Legal Copy-lf 'none' or 'blank' under header ':·; A t\) this encounter
BMP
SODIUM
POTASSIUM
CHLORIDE CARBON DIOXIDE
GLUCOSE
' BUN
CREATININE BUN/CREAT RATIO
CALCIUM
CARDIAC ENZYMES
' CK MB ADD ON rnt L
CKMB • RELATIVE INDEX
Medications Reviewed
Scheduled meds·
140
3.8
107
22 10S"
15
0.9
17
8.9
400'
G4 3·
16.1 "
ondansetron (ZOFRAN) injection 4 mg 4 mg In travenous EVERY 6 HOURS; insulin aspart (NOVOLOG) injection 14 Units 14 Units Subcutaneous DAILY WITH LUNCH; insulin aspart (NOVOLOG) injection 24 Units 24 Units Subcutaneous DAILY WITH BREAKFAST; insulin aspart (NOVOLOG) injection 24 Units 24 Units Subcutaneous DAILY WITH EVENING MEAL; metoprolol tartrate (LOPRESSOR) tablet 50 mg 50 mg Oral TWO TIMES A DAY levofloxacin (LEVAQUIN) IVPB 500 mg 500 mg Intravenous DAILY; metronidazole (FLAGYL) IVPB 500 mg 500 mg Intravenous TWO TIMES A DAY; dexamethasone (DECADRON) injection 8 mg 8 mg Intravenous EVERY 8 HOURS; amitriptyline (ELAVIL) tablet 20 mg 20 mg Oral AT BEDTIME; donepezil (ARICEPT) tablet 10 mg 10 mg Oral AT BEDTIME; famotidine (PEPCID) tablet10 mg 10 mg Oral TWO TIMES A DAY fluticasone (FLONASE) nasal spray 2 Spray 2 Spray Each Nostril DAILY; isosorbide MONOnitrate (IMDUR) SRtablet 30 mg 30 mg Oral DAILY; latanoprost (XALATAN) 0.005% eye drops 1 Drop 1 Drop Left eye AT BEDTIME; levothyroxine (LEVOTHROID/SYNTHROID) tablet 75 meg 75 meg Oral DAILY BEFORE BREAKFAST, metoclopramide (REGLAN) tablet 10 mg 10 mg Oral FOUR TIMES A DAY; mirtazapine ( REMERON ~ tablet 7.5 mg 7.5 mg Oral AT BEDTIME esomeprazole (NEXIUM) enteric-coated capsu le 20 mg 20 mg Oral DAILY; simvastatin (ZOCOR) tablet 40 mg 40 mg Oral AT BEDTIME; saline flush 1 Syringe 1 Syringe Intravenous EVERY 8 HOURS· insulin glargine (LANTUS) SQ injection 40 Units 40 Units Subcutaneous AT BEDTIME Continuous infusions: NaCI 0.9% Last Rate 50 mllhr (07/26/09 0759) ; insulin human regular 250 units in NaCI 0.9% 250 ml Last Rate : 2.5 Units/hr (7/26/09 0915) PRN meds: hydrALAZINE (APRESOLI NE) injection solution 10 mg; morphine injection syringe 2-4 mg ; D1 OW; dextrose 50% in water (D50W) intravenous syringe 12.5 g; levalbuterol (XOPENEX) nebulizer soln 1.25 mg ; levalbuterol (XOPENEX) nebulizer soln 1.25 mg ; metoprolol tartrate (LOPRESSOR) intr3venous solution 2.5 mg; phenol 14% (CHLORASEPTIC) mucous membrane spray 1 Spray· zolpiciern (AM BIEN) tablet 5 mg ; promethazine (PHENERGAN ) injection solution 12.5 mg ondansetron (ZOFRAN) injection 4 mg ; oxycodone (ROXICODONE) tablet 5 mg , acetaminophen (TYLENOL EXTRA STR) tablet 500 mg ; propoxyphene n-acetaminophen (DARVOCET -N) 100-650 mg tablet ~ Tab: dicyclomine (BENTYL) capsule 10 mg ; guaifenesin (ROBITUSSIN) LIQUID 100 mg; polyethylene glycol (MIRALAX) packet 17 g: promethazine (PHENERGAN) suppository 25 mg: promethazine (PHENERGAN) tablet 25 mg alum & mag hydroxide with simethicone (MAALOX,MYLANTA) suspension ;)0 mL; dextrose (GLUTOSE) gel 15 g; dextrose 50% in water (D50W) intravenous syringe 25 g; glucagon (GLUCAGON) injection recon solution 1 mg ; dextran 70-hypromellose (TEARS NATURALE FREE) 0.1-0.3 % eye drops 1 Drop; lidocaine (pf) 2 % (20 mg/mL) 123.2 mg; atropine syringe 0.5 mg ; saline flush 1 Syringe (Meds that have been ordered and completed are not included above)
Printed by [412] at
Legal Copy-If' none' or 'blank' under header N/A to thi s encoumer
Assessment/ Plan : 1. Hepatocellular Ca s/p embolization with doxyrubici~ eluding beads: Patient has sig nausea but not asking fo r
meds. Also with RUQ pa in. Give morph ine, Zofran . 2. Coffee ground emesis per nurse: D/C steroid, Arixtra. Monitor Hbg. 3. Acute on chronic hypoxic resp failure : Appears hypervolemic. Give Lasix. Wean 02 down to home level 2-3L. 4. NSTEMI , CAD: Cards consulted . BB, statin , nitrate , 02 , ASA 0 /C Ari xtra as possible Gl bleeding . 5. OM : BG better on insulin drip . Req 55 units. Lantus not given last PM . Give NPH 30 units. Premeal insulin .
D/C drip. 6. HTN: BP better. 7. GERD: PPI 8. Anxiety: Tx prn . Cont home meds 9. Dementia: Cont aricept.
10 Gastroparesis : Reglan 11 . Hypothyroid: synthroid . 12. Prophylaxis: Heparin.
Son aware of pt's condition.
Electronically signed by: . MD, 7/26/ :56 AM
Medical Staff Progress Note signed by 1, MD at 07/27, _ J 1038 -------------- --·- . MD -·------·-,~;-:,~.---·---·- -(none ) ---------t~---.--P-hvsiclan--·------------
07/271 1038 07/27/ 1027
Sinclair Memorial Hospital
Medical Oncology Hematology Progress Note 7/27/
Subjective Pt. seen and examined . The patient reports less nausea; feels little better. no chest pain ..
Objective Exam:
Vital Signs:
Temp: 96.1 o Temp BP: 133/73 ~~ulse : 82 Resp 18 Sp02: 92 % F (35.6 °C} Max: 97.2 o mmHg (7/27/09 (7/27/09 (7/27/09 8:39 (7/27/09 F (36 .2 °C) (7/27/09 16:00 AM) 6:00AM) AM) 6 :00AM) 6:00AM)
Last 1 Encounter Ht Readings:
07/17/~ 1.676 m (5' 6")
a un W
07/17 I 82.1 01 kg (1811b)
1/0 last 3 completed shifts: In: 2733.93 (480 P.O. 2253.93 I.V.) Out: 2800 (2800 Urine)
Printed by [ 412] at
Legal Copy-If 'none' or 'blank' under header ~ ; A to this encounter
Mentation: alert and oriented X 2 CV: regular rate and rhythm and S1 , S2 normal PUL: bibasilar rales ABO: Abdomen soft, non-tender. BS normal. No masses or organomegaly Extremities: Bilateral lower extremity edema pitting , 1 +
Scheduled meds: insulin aspart (NOVOLOG) injection 18 Units 18 Units Subcutaneous DAILY WITH LUNCH ; insulin aspart (NOVOLOG) injection 28 Units 28 Units Subcutaneous DAILY WITH BREAKFAST; insulin aspart (NOVOLOG) injection 28 Units 28 Units Subcutaneous DAILY WITH EVENING MEAL; furosemide (LASIX) tablet 40 mg 40 mg Oral TWO TIMES A DAY; esomeprazole (NEXIUM) enteric-coated capsule 40 mg 40 mg Oral TWO TIMES A DAY ondansetron (ZOFRAN) injection 4 mg 4 mg Intravenous EVERY 6 HOURS; metoprolol tartrate (LOPRESSOR) tablet 50 mg 50 mg Oral TWO TIMES A DAY; amitriptyline (ELAVIL) tablet 20 mg 20 mg Ora l AT BEDTIME; donepezil (ARICEPT) tablet 10 mg 10 mg Oral AT BEDTIME; famotidine (PEPCID) tablet 10 mg 10 mg Oral TWO TIMES A DAY; fluticasone (FLONASE) nasal spray 2 Spray 2 Spray Each Nostri l DAILY isosorbide MONOnitrate (IMDUR) SR-tablet 30 mg 30 mg Oral DAILY; latanoprost (XALATAN) 0.005% eye drops 1 Drop 1 Drop Left eye AT BEDTIME; levothyroxine (LEVOTHROID/SYNTHROID) tab let 75 meg 75 meg Oral DAILY BEFORE BREAKFAST; metoclopramide (REGLAN) tablet 10 mg 10 mg Oral FOUR TIMES A DAY; mirtazapine (REMERON) tablet 7.5 mg 7.5 mg Oral AT BEDTIME; simvastatin (ZOCOR) tablet 40 mg 40 mg Oral AT BEDTIME saline flush 1 Syringe 1 Syringe Intravenous EVERY 8 HOURS; insulin glargine (LANTUS) SQ injection 40 Units 40 Units Subcutaneous AT BEDTIME
Labs:
None
Imaging Studies: None.
Other Studies: none
Assessment & Plan: Patient Active Hospital Problem List:
1) Hepatocellular carcinoma s/p TACE with doxorubicin-eluding beads; got 50 mg dose.
2) Cardiac: elevated troponins; possibly Ml secondary to beads; sometimes enzymes might go up after TACE; pt stable at this time .
Electronically signed by :
l!".edica!. ?taff Progress Note signed by , MD
07/27/ 1101 Addendum by : .
Hospitalist Progress Note
Subjective
N
, MD, 7/27/' 0:27AM
I, MD at 07/27, 1101 ---··-----{non.e)-------·-----·-·-···-····--pEyS-fCTan-····---------···-··-··· ······-···--·-···· .. --··········-···· 07 /27/ 1046 Revised
, MD, note time at 07/27/ 1046
Sinclair Memorial Hospital .
Pt seen and examined . She reports improvement in RUQ and epigastric pain Shortness of breath is better. No
Printed by [ 412] a
Legal Copy-If'none' or 'blank' under header N/A to this encounter
NIV. Feels better. Discussed medical issues and plan .
Objective Vital Siqns: Temp 96.1 !Temp BP: 133/73 Pulse: 82 Resp : 18 OF (35.6 °C) Max 97.2 a mmHg (7/27/09 (7/27/09 (7/27/09 F (36.2 o (7/27/09 0600) 0600) 06001 C) 0600)
1/0 last 3 completed shifts: In: 2733.93 (480 P.O. 2253.93 I.V.) Out: 2800 (2800 Urine) Baseline Wt- Scale: 82.101 kg (181 lb) (7/24/09 0810) Most recent Wt- Scale : 82 .101 kg (181 lb) (7/24/09 081 0)
Tele: sinus, no arrhythmias.
02 93% 3L NC
Exam: GENERAL APPEARANCE: Alert, NAD. HEENT: PERRL, EOMI , MMM CV: RRR, Pulm : Sparse bibasilar crackles , sig improvement from yesterday . Abd +BS, mod TTP RUQ, no rebound , no guarding . Extr: Stockings
Labs:
CBC No results found for this basename: 38856 in the last 36 hours BMP
SODIUM 140
POTASSIUM 3.8
CHLORIDE 107
CARBON DIOXIDE 22
' GLUCOSE 108'
BUN 15
CREATININE 0.9
BUN/CREAT RATIO 17
CALCIUM 8.9
CARDIAC ENZYMES ,, e t a s
' CK
MBADDON 'i rt 1bs
CKMB
RELATIVE INDEX
Medications Reviewed
Scheduled meds:
400'
64 3"
16.1'
Sp02: 92 % (7/27/09 0839)
insulin aspart (NOVOLOG) injection 18 Units 18 Units Subcutaneous DAILY WITH LUNCH ; insulin aspart (NOVO LOG) injection 28 Units 28 Units Subcutaneous DAILY WITH BREAKFAST: insulin aspart (NOVO LOG) injection 28 Units 28 Units Subcutaneous DAILY WITH EVENING MEAL; furosemide (LASIX) tablet 40 mg 40 mg Oral TWO TIMES A DAY; esomeprazole (NEXIUM) enteric-coated capsule 40 mg 40 mg Oral TWO TIMES A DAY
Printed by [ 412]
Legal Copy-If 'none' or 'blank' under header N/ A to thi s encounter
ondansetron (ZOFRAN) injection 4 mg 4 mg Intravenous EVERY 6 HOURS; metoprolol tartrate (LOPRESSOR) tablet 50 mg 50 mg Oral TWO TIMES A DAY; amitripty li ne (ELAVIL) tablet 20 mg 20 mg Oral AT BEDTIME; donepezil (ARICE PT) tablet 10 mg 10 mg Oral AT BEDTIME; famotidine (PEPCID) tablet 10 mg 10 mg Oral TWO TIMES A DAY; fluticasone (FLONASE) nasal spray 2 Spray 2 Spray Each Nostril DAILY isosorbide MONOnitrate (IMDUR) SR-tablet 30 mg 30 mg Oral DAILY; latanoprost (XALATAN) 0.005 % eye drops 1 Drop 1 Drop Left eye AT BEDTIME; levothyroxine (LEVOTHROID/SYNTHROID) tablet 75 meg 75 meg Oral DAILY BEFORE BREAKFAST; metoclopramide (REGLAN) tablet 10 mg 10 mg Oral FOUR TIMES A DAY; mirtazapine (REMERON) tablet 7.5 mg 7.5 mg Oral AT BEDTIME; simvastatin (ZOCOR) tablet 40 mg 40 mg Oral AT BEDTIME saline flush 1 Syringe 1 Syringe Intravenous EVERY 8 HOURS; insulin glargine (LANTUS) SQ injection 40 Units 40 Units Subcutaneous AT BEDTIME Continuous infusions: NaCI 0.9% Last Rate : 50 mllhr (07/27/09 0609) PRN meds: hydrALAZINE (APRESOLINE) injection solution 10 mg; morphine injection syringe 2-4 mg ; 01 OW; dextrose 50% in water (D50W) intravenous syringe 12.5 g; levalbuterol (XOPENEX) nebulizer soln 1.25 mg ; levalbuterol (XOPENEX) nebulizer soln 1.25 mg ; metoprolol tartrate (LOPRESSOR) intravenous solution 2.5 mg; phenol 1.4% (CHLORASEPTIC) mucous membrane spray 1 Spray; zolpidem (AMBIEN) tablet 5 mg; promethazine (PHE NERGAN) injection solution 12.5 mg ondansetron (ZOFRAN) injection 4 mg; oxycodone (ROXICODONE) tablet 5 mg; acetaminophen (TYLENOL EXTRA STR) tablet 500 mg; propoxyphene n-acetaminophen (DARVOCET -N) 100-650 mg tablet 1 Tab ; dicyclomine (BENTYL) capsule 10 mg; guaifenesin (ROBITUSSIN) LIQUID 100 mg; polyethylene glycol (MIRALAX) packet 17 g; promethazine (PHENERGAN) suppository 25 mg; promethazine (PHENERGAN) tablet 25 mg alum & mag hydroxide with simethicone (MAALOX,MYLANTA) suspension 30 mL; dextrose (GLUTOSE) gel 15 g; dextrose 50% in water (D50W) intravenous syringe 25 g; glucagon (GLUCAGON) injection recon solution 1 mg ; dextran 70-hypromellose (TEARS NATURALE FREE) 0.1-0.3 % eye drops 1 Drop; lidocaine (pf) 2 % (20 mg/mL) 123.2 mg ; atropine syringe 0.5 mg; saline flush 1 Syringe (Meds that have been ordered and completed are not included above)
Assessment/ Plan : 1. Hepatocellular Ca s/p embolization with doxyrubicin eluding beads: Pt doing well. F/U with Oncology. 2. S/p coffee ground emesis per nurse: No recurrence. Hbg stable. Cont PPI at 0 /C. 3. Acute on chronic hypoxic resp failure : Wean 02 . Pulm exam improving. Wean 02. 4. OM : BG better control. Would increase Lantus to 45. Cont premeal + SSI. 5. HTN BP stable . 6. GERD: PPI 7. Anxiety: Tx prn . Coni home meds 8. Dementia : Cont aricept. 9. Gastroparesis: Reglan
10. Hypothyroid: synthroid . 11 . NSTEMI , CAD Cards following . BB, statin , nitrate, 02. ASAwas on hold as 1X coffee ground emesis . D/w
Cards about restart ASA and plan . 12. Prophylaxis: Heparin .
Dispo: ECF pending further Cards recs.
Electronically signed by : MD, 7/271" 10:46 AM
VID at 07/27/ 1631 M~9J.~! Staff Progre~~-~~~-~.!_~_r::~?._!)J ·. MD ------ -·-·-·---·--·---· ··---·-··-··-········-··-----------·-·· (none\ Phys ic1an
071271 1631 r-.· 07/2: '/ 1046 Original Note by: MD, note timt:: at 07/27/ 1101
Sinclair Memorial Hospital
Hospitalist Progress Note ~ ~--- - .,. - - .
Subjective Pt. seen and examined . She reports improvement in RUQ and epigastric pain . Shortness of breath is better. No
Printed by [412] a
Legal Copy-If 'none' or 'blank' under hc:~dcr :·'-!. 1 J\ rn this encounter
NIV. Feels better. Discussed medical issues and plan .
Objective V"t IS 1a 1gns: [Temp: 96.1 OF (35.6 °C) (7/27/09 06001
Temp BP: 133/73 Max: 97.2 o mmHg F (36.2 o (7/27/09 C) 06001
1/0 last 3 completed shifts:
Pulse 82 Resp 18 (7/27/09 (7/27/09 0600) 0600)
In: 2733.93 (480 P.O. 2253.93 IV) Out: 2800 (2800 Urine) Baseline Wt- Scale: 82.101 kg (181 lb) (7/24/C•9 0810) Most recent Wt- Scale : 82.101 kg (181 lb) (7/24/09 0810)
Tele: sinus, no arrhythmias.
02 93% 3L NC
Exam :
GENERAL APPEARANCE Alert, NAD. HEENT: PERRL, EOMI , MMM CV: RRR , Pulm : Sparse bibasilar crackles , sig improvement from yesterday . Abd : +BS, mod TTP RUQ, no rebound , no guarding. Extr Stockings
Labs:
CBC No results found for this basename: 38856 in tt1e last 36 hours BMP
SODIUM
POTASSIUM
CHLORIDE CARBON DIOXIDE
GLUCOSE
BUN
CREATININE
BUN/CREAT RATIO
CALCIUM
CARDIAC ENZYMES
' CK
MB ADD ON '"' :u L s
CKMB
RELATIVE INDEX
Medications Reviewed
Scheduled meds:
140
3.8
107
22 10€'
'i5
0.9
17
8.9
400'
Sp02 : 92% (7/27/09 0839)
insulin aspart (NOVOLOG) injection 18 Units 18 Units Subcutaneous DAILY WITH LUNCH ; insulin aspart (NOVO LOG) injection 28 Units 28 Units Subcutaneous DAILY WITH BREAKFAST; insulin aspart tNOVOLOG) injection 28 Units 28 Un1ts Subcutaneous DA!!_ Y WITH EVENING MEAL , furosemide (LASIX 1 tablet 40 mg 40 mg Oral TWO TIMES A DAY; esomeprazole (NEXIUMl entenc-coated capsule 40 mg 40 mg Oral TINO TIMES A DAY
Printed by [ 412]
Legal Copy-lf'none' or 'blank' under header i~/A w tll i:-. encounter
ondansetron (ZOFRAN) injection 4 mg 4 mg Intravenous EVERY 6 HOURS; metoprolol tartrate (LOPRESSOR) tablet 50 mg 50 mg Oral TWO TIMES A DAY; amitriptyline (ELAVIL) tablet 20 mg 20 mg Oral AT BEDTIME; donepezil (ARICEPT) tablet 10 mg 10 mg Oral AT BEDTIME; famotidine (PEPCID) tablet 10 mg 10 mg Oral TWO TIMES A DAY; fluticasone (FLONASE) nasal spray 2 Spray 2 Spray Each Nostril DAILY isosorbide MONOnitrate (IMDUR) SR-tablet 30 mg 30 mg Oral DAILY; latanoprost (XALATAN) 0.005% eye drops 1 Drop 1 Drop Left eye AT BEDTIME; levothyroxine (LEVOTHROID/SYNTHROIO) tablet 75 meg 75 meg Oral OAIL Y BEFORE BREAKFAST; metoclopramide (REG LAN) tablet 10 mg 10 mg Oral FOUR TIMES A DAY; mirtazapine (REMERON) tablet 7.5 mg 7.5 mg Oral AT BEDTIME; simvastatin (ZOCOR) tablet 40 mg 40 mg Oral AT BEDTIME saline flush 1 Syringe 1 Syringe Intravenous EVERY 8 HOURS; insulin glargine (LANTUS) SQ injection 40 Units 40 Units Subcutaneous AT BEDTIME Continuous infusions: NaCI 0.9% Last Rate: 50 mllhr (07/27/09 0609) PRN meds: hydrALAZINE (APRESOLINE) injection solution 10 mg; morphine inJection syringe 2-4 mg ; 01 OW; dextrose 50% in water (050W) intravenous syringe 12.5 g; levalbuterol (XOPENEX) nebulizer soln 1.25 mg; levaibuterol (XOPENEX) nebulizer soln 1.25 mg; metoprolol tartrate (LOPRESSOR) intravenous solution 2 5 mg; phenol 1 4 % (CHLORASEPTIC) mucous membrane SiJray 1 Spray; zolpidem (AM BIEN) tablet 5 mg promethazine (PHENERGAN) injection solution 12.5 mg ondansetron (ZOFRAN) injection 4 mg; oxycodone (ROXICOOONE) tablet 5 mg; acetaminophen (TYLENOL EXTRA STR) tablet 500 mg ; propoxyphene n-3cetaminophen (DARVOCET -N) 100-650 mg tablet 1 Tab; dicyclomine (BENTYL) capsule 10 mg; guaifenesin (ROBITUSSIN) LIQUID 100 mg; polyethylene glycol (MIRALAX) packet 17 g; promethazine (PHENERGAN) suppository 25 mg ; promethazine (PHENERGAN) tablet 25 mg alum & mag hydroxide with simethicone (MAALOX,MYLANTA) suspension 30 mL; dextrose (GLUTOSE) gel 15 g; dextrose 50% in water (050W) intravenous synnge 25 g; glucagon (GLUCAGON) injection recon solution 1 mg; dextran 70-hypromellose (TEARS NATURALE FREE) 0.1-0.3% eye drops 1 Drop; lidocaine (pf) 2% (20 mg/mL) 123.2 mg; atropine syringe 0.5 mg ; saline flush 1 Syringe (Meds that have been ordered and completed are not included above)
Assessment/ Plan : 1. Hepatocellular Ca s/p embolization with doxyrubicin eluding beads: Pt doing well . F/U with Oncology. 2. S/p coffee ground emesis per nurse: No recurrence Hbg stable . Cont PPI at 0 /C. 3. Acute on chronic hypoxic resp failure: Wean 02 . Pulm exam improving Wean 02 . 4. OM BG better control. Would increase Lantus to 45 Cont premeal + SSI. 5. HTN: BP stable . 6. GERD: PPI 7. Anxiety Tx prn . Cont home meds 8. Dementia: Cont aricept. 9. Gastroparesis: Reglan
10. Hypothyroid : synthroid . 11 . NSTEMI , CAD: Cards following . BB, stalin , nitrate, 02. ASA was on hold as 1X coffee ground emesis. 0/w
Cards about restart ASA and plan . 12. Prophylaxis Heparin
Dispo: ECF pending further Cards recs.
Electronically signed by: V10 , 7/271 10:46 AM
Cardiology rec Echo now to assess EF then agreed to 0 /C with close outpt F/U 1 wk.
0/C sum # 1128528
Time spent on 0 /C 40 min
Electronically signed by :
Medical Staff Progress Note signed by _ , RN
I' 071271 1412
I , MD, 7/27 4:30PM
, RN at 07127/~ J 1412 (none) ---------·-
0/127/ 1405 Cosigned by : ' , MD, note time a: 07/27; 1405
Printed by [ 412
Reg1stered Nurse Revised
Legal Copy-If 'none' or 'blank' under heade r , I A to thi s encounter
Not Addendum by
Cardiology Progress Note 7/27/
Assessment
1. Elevated TN! / NSTEMI
1, MD, note time at 07/27, 1405
Sinclair Memorial Hospital
2. CAD status post CABG 7 years ago.
3. CHF.
4. Diabetes mellitus .
5. Hypertension .
6. Hypothyroidism.
7. Hepatocellular carcinoma
Plan • Son would like for patient to discharged today
Subjective Alert and oriented X3 , some SOB, denies any chest pain
Objective Vitals: Temp Max: 97.2 OF (36.2 °C) BP: 133/73 mmHg (7/27/C i:OO AM )Pulse : 82 (7/27/: • 6:00 AM )Resp: 18 (7/27/ 6:00 AM )Sp02: 93 % (7/27/ l 10:51 AM )Wt- Scale: 82 .101 kg (181 lb) (7/24/! 8:10 AM )I/0 last 3 completed sh ifts In : 2733.93 (480 P.O. 2253.93 I.V. ) Out: 2800 (2800 Urine)
Cardiac Medications Scheduled meds: insulin glargine (LANTUS) SQ injection 45 Units 45 Units Subcutaneous AT BEDTIME; insulin aspart (NOVOLOG) injection 18 Units 18 Units Subcutaneous DAILY WITH LUNCH ; insulin aspart (NOVO LOG) injection 28 Units 28 Units Subcutaneous DAILY WITH BREAKFAST; insulin aspart (NOVOLOG) injection 28 Units 28 Units Subcutaneous DAILY WITH EVENING MEAL; furosemide (LASIX) tablet 40 mg 40 mg Oral TWO TIMES A DAY esomeprazole (NEXIUM) enteric-coated capsu le 40 mg 40 mg Oral TWO TIMES A DAY; ondansetron (ZOFRAN) injection 4 mg 4 mg Intravenous EVERY 6 HOURS; metoprolol tartrate (LOPRESSOR) tablet 50 mg 50 mg Oral TWO TIMES A DAY; amitriptyline (ELAVIL) tablet 20 mg 20 mg Oral AT BEDTIME; donepezil (ARICEPT) tablet 10 mg 10 mg Oral AT BEDTIME; famotidine (PEPCID) tablet 10 mg 10 mg Oral TWO TIMES A DAY fluticasone (FLONASE) nasal spray 2 Spray 2 Spray Each Nostril DAILY; isosorbide MONOnitrate (IMDUR) SRtablet 30 mg 30 mg Oral DAILY; latanoprost (XALATAN) 0.005 % eye drops 1 Drop 1 Drop Left eye AT BEDTIME; levothyroxine (LEVOTHROID/SYNTHROID) tablet 75 meg 75 meg Oral DAILY BEFORE BREAKFAST; metoclopramide (REGLAN) tablet 10 mg 10 mg Oral FOUR TIMES A DAY; mirtazapine (REMERON) tablet 7.5 mg 7.5 mg Oral AT BEDTIME simvastatin (ZOCOR) tablet 40 mg 40 mg Oral AT BEDTIME; saline flush 1 Syringe 1 Syringe Intravenous EVERY 8 HOURS Continuous infusions: NaCI 0.9 % Last Rate : 50 ml/hr (07/27t 0609)
Telemetry Monitoring
Printed by [ 412]
Legal Copy-lf 'none' or 'b lank' under header N/ A t) Lhi :-; encounter
Rhythm: normal sinus
Rate: normal 68-84
Ectopy: premature ventricular contractions (unifocal) , NSVT
Exam: GENERAL APPEARANCE: appropriate appearance for age, pale and pleasant NECK:Jugular venous pulsations: normal RESPIRATORY:crackles/rales moderate in lung bases
HEART:Regular rate and rhythm VASCULAR: Pedal pulse: diminished bilaterally ABDOMEN : normoactive bowel sounds, soft, nondistended and nontender EXTREMITIES: edema involving bilateral lower extremities , grade II and no cyanosis
Labs: Reviewed
IY.!.~.9.~C::-~!_ St~!!_f:'!:_C?.~! f:l_!:!~-~?!~~i~_r::~~-~:~:..:..-'------!.c..IY.!D at 071271 __ 1_4_26 _____ ··-·---·-··-·--·-··--·--·-···----·-·-·-------···-- , MD (none)
07/27/ 1426 ,, 07127/ 1405 Related Note by:
Original Note by :
Cardiology Progress Note 71271
DOA: 7/24/
Assessment
1. Elevated TNI/ NSTEMI
RN , note t1me at 071271 1405
'· RN , note t1me at 071271 1412
Sinclair Memorial Hospital
2. CAD status post CABG 7 years ago.
3. CHF.
4 . Diabetes mellitus.
5. Hypertension .
6. Hypothyroidism.
7. Hepatocellular carcinoma
Plan • Son would like for patient to discharged today • 2 D echo today • Increase Lopressor to 75 mg BID
T "' Physician
-- • OK to discharge to assisted living per her wishes . follow up at the office next week
Printed by [412]
Legal Copy-If 'none' or 'b lank' under header N/ A tv thi s encounter
Subjective Alert and oriented X3 , some SOB, denies any chest pain
Objective Vitals: Temp Max: 97.2 OF (36.2 °C) BP: 133/73 mmHg (7/27/( 6:00 AM)Pulse: 82 (7/27/ 6:00 AM)Resp: 18 (7/27/' 6:00 AM)Sp02 93 % (7/271 10:51 AM)Wt- Scale : 82.101 kg (181 lb) (7/24/ 8:1 0 AM)I/0 last 3 completed sh ifts : In : 2733 .93 (480 P 0 . 2253.93 IV) Out: 2800 (2800 Urine)
Cardiac Medications Scheduled meds: insulin glargine (LANTUS) SQ injection 45 Units 45 Units Subcutaneous AT BEDTIME; insulin aspart (NOVOLOG) injection 18 Units 18 Units Subcutaneous DAILY WITH LUNCH; insulin aspart (NOVOLOG) injection 28 Units 28 Units Subcutaneous DAILY WITH BREAKFAST; insulin aspart (NOVOLOG) injection 28 Units 28 Units Subcutaneous DAILY WITH EVENING MEAL; furosemide (LASIX) tablet 40 mg 40 mg Oral TWO TIMES A DAY esomeprazole (NEXIUM) enteric-coated capsule 40 mg 40 mg Oral TWO TIMES A DAY; ondansetron (ZOFRAN) injection 4 mg 4 mg Intravenous EVERY 6 HOURS; metoprolol tartrate (LOPRESSOR) tablet 50 mg 50 mg Oral TWO TIMES A DAY; amitriptyline (ELAVIL) tablet 20 mg 20 mg Oral AT BEDTIME; donepezii (AR!CEPT) tablet 10 mg 10 mg Oral AT BEDTIME; famotidine (PEPCID) tablet 10 mg 10 mg Oral TWO TIMES A DAY fluticasone (FLONASE) nasal spray 2 Spray 2 Spray Each Nostril DAILY; isosorbide MONOnitrate (IMDUR) SRtablet 30 mg 30 mg Oral DAILY; latanoprost (XALATAN) 0.005% eye drops 1 Drop 1 Drop Left eye AT BEDTIME; levothyroxine (LEVOTHROID/SYNTHROID) tablet 75 meg 75 meg Oral DAILY BEFORE BREAKFAST; metoclopramide (REGLAN) tablet 10 mg 10 mg Oral FOUR TIMES A DAY; mirtazapine (REMERON) tablet 7.5 mg 7.5 mg Oral AT BEDTIME simvastatin (ZOCOR) tablet 40 mg 40 mg Oral AT BEDTIME; saline flush 1 Syringe 1 Syringe Intravenous EVERY 8 HOURS Continuous infusions: NaCI 0.9 % Last Rate : 50 mllhr (07/27/ 0609)
Telemetry Monitoring
Rhythm: normal sinus
Rate: normal 68-84
Ectopy: premature ventricular contractions (un1focal) , NSVT
Exam: GENERAL APPEARANCE:appropriate appearance for age, pale and pleasant NECK: Jugular venous pulsations: normal RESPIRATORY:crackles/rales moderate in !ung bases
HEART:Regular rate and rhythm
VASCULAR: Pedal pulse: diminished bilaterally ABDOMEN : normoactive bowel sounds, soft, nondistended and nontender EXTREMITIES: edema involving bilateral lower extremities , grade II and no cyanosis
Labs: Reviewed
Printed by [41 ::Z) at .
Legal Copy-If 'none' or 'blank' under header '1-~ /A LO this encounkt
Progress Notes
Progress Notes s igned by -'-' :._:R:._:N__:a:.:t-=.0.:..:71.:_2:..::41~....:1=.2=;2 6:._ _ _______ -:--::---:----;:;-=-=:-::;;::::::J---- ----------····· , RN (none) Reg istered Nurse
07/24/ 1226 07/24/ 1225
Thigh high ted hose on bilaterally . Foley catheter in on admission . Drainingm clear yellow unine.
0837 ____ _;;,a'-'-t -'-07/25/ (none) -------- ·-- _, _________ ---s!Ucie niResp iraiOry-The rapist
07/25 0837 07/25/, 0730
Nurse called me to romm saying patient was having difficulty breathing and was requesting a treatment Upon arrival to the room patient seemed to be SOB but did not complain of SOB when asked. Treatment of albuterol and n.s. Given via mask and svn . Breath sounds were clear in the apical lobes bilaterally and diminished in the bases , Sp02 93-95% on 3L nc, Heart rate 93. Patient complamed of being extremely nauseated I notified the nurse of all the above information .
Progress Notes signed by
07/25/ 1459
at 07/25/ r 1459 (none) 07 '25/' - 1455
Student Respiratory Therapist
Nurse called me to the room . Upon arrival patient was tachypn1c and SOB, states that her SOB IS not different then what she is used to. Increased Os from 3 LPM to 4LPM to keep Sp02 above 92%. Breath sounds were clear in the apical lobes with decreased expiratory wheezes heard in the bases bilaterally. PRN albuterol breathing treatment administered . HR 83-85, RR 20-22, Sp02 94% on 4 LPM NC. Strong nonproductive cough Post treatment. Patient states that the treatment seems to help her but onle "some". Nurse notified of the above information .
Progress Notes signed by , MD at 07/26.' 0859 , MD _ J!c (none) Physician
07/26/ 0859 07/26/r 0857
85 yo with cad with ele tni nl cpk. No sig ecg changes. Tele w1th short run of NSVT. Nurse repo ~ed coffee grounds. Willd/c acs dose of fragmin . May continue dvt prophylaxis. Continue beta blockers .
Prowess Notes signed bL RN at Oi/27 1 1100 RN (none) Integrative Care Manager
07/27/ " 11 00 07/27/ 1054
ICM Note: Chart reviewed . 85 yo female with hx of hepatocel lular carcinoma s/p TACE with doxorubicm-eluding beads; got 50 mg dose, admitted obs post-procedure . Pt with positive troponin yesterday, dx new MI. Pt had coffee ground emesis yesterday . Met with pt at bedside. Pt from living, pt has resided there for several years , was at ECF briefly after last hospital d/c and does not want to go back to ECF Pt plans to return to Assisted living, has oxygen at facility , states wears at night at 3L. Pt currently on 02 at 3L and continues to remain sob. PCT at bedside checking pulse oximetry . Pt denies having any therapy at facility . States son can transport her back to AL. Called son and left message to return call to confirm d/c plan .
Progress Notes signed by at 071271 1337 (none) ,, 071271 1337 07/26/ 0000
PASTORAL CARE VISIT NOTE
SITUATION Referral: EPIC Referral Purpose: Pastoral visit and Sacramental Needs. Family: Not present
APPRAISAL Spirituality: Catholic Dynamics: Open to spiritual support? : yes Concerns of patient/family : Patient desired to rece1ve Holy Commun1on
PASTORAL MINISTRY
Printed by [ 412] 2
Legal Copy-If 'none' or 'blank' under header •·J ; A tu •.h!s e!l~n unte c
Care orovid~d: Care and support, Prayer and Sacramental mimstry Holy Communion Follow~ . - needed , for patient and \/ •sit aga1 n
CHAPLAIN NOTES
Progress Notes ~!_gned by RN at 07127/f 1447 :..:.=..::::..:::..'-------,R=-N,..,--·~· (no.ne) -----·-----·-· ·· --····-··-·-·-·-·---·-·--Integrative Care Mana ger -- - -----·-
07/271 1447 07!271 1445
ICM Note: CC had received message back from son stating that he wants pt to be d/c home today as well as pt wanting to go home. Spoke with Dr. ~who stated that he would speak w1th son later after he has cardiology recommendations and pt may d/c home later today per thoir wish<><> rc"nt::.rtprl snn and informed of conversation with MD. agrees to plan for return to will transport and has portable oxygen for transfer. SW was notif1ed of plan.
Progress Notes signed by , MSW at 07i271 .. !~------- --::--:-,-:-c-_--,----------(none) Social Worker · , MSW
07127r 1618 07/27/ 1614
Sw reviewed chart, pt Is a resident of Assistant Living Facili '(y . and will return today. Her son will provide the transportation . SIN copied the chart and faxed orders to admissions. Sw met with pt at the bedside who is very anx1ous to return home No further 11eeds noted.
Progress Notes signed by , RDCS at 071~..:..___!_~3 ____ _ , RDCS ~ v (ncne)
07/27/ 1743 N'k- I " 07i27/ 1742
ECHO NOTE
Patient name: Age 85 year old Medical Record Number:
Diagnosis: No diagnosis found .
Procedure performed: Echocardiogram
Exam performed at bedside. Patient is cooperative . Results complete.
Cardiac indications/history: chest pain/left ventricular function . General indications: previous cardiac or vascu lar surgery
Initial Assessments
No notes of this type ex1st for this admission .
RT Progress Notes
No notes of this type exist for this admission .
Result Summary for ECHO WITH DOPPLER Transcription Type ID Date and Time
ECHOCARDIOGRAM - .28 J 34 t,M
Printed by [ 4 I 2)
Diagnostic Sonographer
Autnor MD
Legal Copy-If 'none' or 'blank' under header ~;A to this encounter
Authenticated by , MD on 07/30/ a< 1822 This document replaces document 2117259 Sinclair Memorial Hospital Document Text 444 West Third Street
Dayton, Ohio 45402-1460 ECHOCARDIOGH\:\-1
Admiss ion Date 07/24/ Disc harge Date 07/27/ Procedure Date 07/27.' DIAGNOSIS: NSTEI\11, HTN, CAD, C \BG , CI-IF. assess L\'/valve function PROCEDURE: i\1-Mode/2D/Doppler (incl. color flow)
i\1-MODE/2D STUDY: L,\ -1.19 em. Aortic ntsp scraratiGn 1.-19 em. i\t1rtic roGt 2.85 em. LV rosh.:rior 11all thid.ncss cnd-diastok 0.9 em. LV diasto lic dimc1bion -U I em. IV s..:pwm cnd-dia~tolc 1.1 em. R \ internal dim<:n>ion is 2.-12 ern. rhcrc is thinrnng of the septum and ~u1ten"eptal and apic<li h) pokinc>ia. I dt 'cntrindar
eject ion ti·action is estimated at 30°'o to 35°o. I here are no intramural thrombi. I he re is tracc:-hHllild pericardia! .:t'i'u>inn. but ..;ince it is ci rcumlcrential. it i' technical!)
moderate. ot' no hemodynamic signi ticancc. The uotiic valve has 3 cusps 11 ith mild sckmtic change-;. normal opening. Pu lmon ic 'all'c is thlt m.:ll visualiz.ed. t\lild mitral 1<Jile ring cakilication. Tricu,;pid vail c leaflets appcur to be normal.
DOPPLER S I'LDY (1:\CL COLOR FLOW 1\IAGI'<G): Doppkr in, ·c~tig ;Jt ion ol' aortic 1 alvc revc:1h nw\imun; 1 cloc i t~ ol' 1.36 nt s~.:L 11 ith no 'I idenc.: ot' ann ic insu l'licienc~. Doppl.:r in1 estigatinn of mitral vah e rc1 ca:s non idc:n<.:<:' of mitral rc:gurgilatio11 . I -to-\ ratio 0.23 11 ith I -to-\ prime bcing almost equal: hOI\CICr. the C. [prime is 23. This i,; comparati1cl~ elc1atcd ktt 1cntricular cnd-dia>tnlic pre~surc. I here is mild pulmonic in,ut'tlc i cnc~. l'h..:rc is mild tricuspid regurgitation. RV S) sttJiiL: pn:sslll'c i~ cstimatcd at 37 mmllg. assuming RA pressure of I 0 mmll ~.
SUMMARY: I. Mild to moderate pericardia! e!Tusion with no signs oftamponmk. 2. Anteroseptalund apical hypoki nesia 11ith septal thinning. rhe ejection fraction estimated at 30°o to 35° o.
3. Aort ic stenosis with no cvilknce or stenosi s or insuftleit:nc).
~ilclleft atrial dilation. -1. (.,
. ... ~ 5. Mild pulmonary hypertension. ...~' h. When thi s is compared to the echocardiogram clone on 0~ tt7 ejection fraction seems to have decreased further.
although the anterior apical and septa: h: pokinesia 11as alrc<Jd~ presen t 011thc previous echo. 7. Moderate pericardia ! e!Tusion is nc11 11 ith nr1 ..:1 idence of hcnwd) namic compromise.
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Transcription Type
9:3-1 !\ -1:05 I'
ELECTROCARDIOGRAMSOL COM
11,11)
MD
Result Summary for ELECTROCARDIOGRAM - SOLCOM
ID Date and Time
20090727BBOT1035783122 7/27/ 9 00 PM
Authenticated by Scan Solcom on 07/27/ at 21 ~0
Transcription Type
ELECTROCARDIOGRAM -SOL COM
Result Summary for ELECTROCARDIOGRAM - SOLCOM
ID Date and Time
20090728BCDR 1035783122 7128! 9 55 PM
Authenticated by Scan Solcom on 07128/ at 21 55
Prin ted by [4 12] at
Author
Scan Solcom
Author
Scan Solcom
Legal Copy-If 'none' or 'blank' under header , I A to this encounter
Attending Provider: - Pen. Sulfa
MD (none)
Prior
Add/Edit Comment --·------- --1.67Trli-(5;-6~i-----·-----·------ --.. --·--·-----2921 kg 1m2 -- --
82 .101 kg (181 I b) (none) 1.96 m 2
(sulfonamides), Macrodantin. Ace Inhibitors
All Flowsheet Templates (all
recorded)
PCT Flowsheet Flowsheet
Mtntrnum Data Set Flowsneet
Contacts Flowsheet
Admtsston Dtrecttves Flowsheet
Property Dtsposttton Flowsheet
Learning Assessment Flowsheel
Ambulatory Record of Care Flowsheet
.Adm•ss1on Assessment Flowsheet
PREOP Nurs1ng Un1t Rev!ew Flowsl1eet
IV Flowsl1eet Flowsheet
Intake/Output Flowsheet
Spectal Procedure Flowsheet
MIS Documentation Flows11eet
ThromboSIS R1sk Assessment Flowsheet
Resp Protocol Flowsheet
RT Documentatton Flowsl1eet
Pa111 Flowsheet
Dtscharge Assessment Flowsneet
Med Nutntton Tx- INPT Flowsheet
Pastoral Care Fiowsheet
VENTILATOR DATA VENTILATOR DATA
Encounter-Level Documents-tllllilillil : AN IMPORTANT MESSAGE-FROM MEDICARE- SOLCOM- Scan on~ by Soicom. Scan
Consent to TreaUFmancial Agreement- Scan on~'by So!com Scan
Order-Level Documen.ts-
ELECTROCARDIOGRAM- SOLCOM- Scan on li'JMAII'~ 9 55 PM by
ELECTROCARDIOGRAM- SOLCOM- Scan on~ 9 00 PM~.
Valid Phystctan Order- Scan o,
Patient-Level There are no pattent-level documents Documents:
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End of Report
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