Professional Documents
Culture Documents
STATUS: COMPLETED
**********************************
*
**********************************
- Hypertension
- Hyperlipidemia
- Gout
- Esophageal Reflux
- Peptic ulcer of unspecified site, unspecified as acute or chronic, without m
- Exogenous Obesity
- Male erectile disorder
- Refraction Error
- Impotence of organic origin (ICD-9-CM 607.84)
- Diabetes Mellitus
- Arthritis
- OVERWEIGHT
- SENSORINEURAL HEARING LOSS, BILATERAL
- Presbyopia
- Astigmatism, NOS
- Myopia
- Blepharitis * (ICD-9-CM 373.00)
- Senile nuclear sclerosis (ICD-9-CM 366.16)
- Open angle with borderline glaucoma findings (ICD-9-CM 365.01)
- DM Type II, No Retinopathy
- Diabetic Neuropathies (ICD-9-CM 250.60/357.2)
- Coronary Artery Disease * (ICD-9-CM 414.9)
- Microscopic Hematuria (ICD-9-CM 599.72)
- Intermittent Claudication * (ICD-9-CM 443.9)
- Impacted cerumen * (ICD-9-CM 380.4)
- Joint pain
- Paronychia
- Family bereavement
- Onychomycosis of toenails
- Ingrowing toenail
**********************************
*
Active Medications
**********************************
Status
==================================================
==================
1) ATORVASTATIN CALCIUM 40MG TAB TAKE ONE-HALF TABLET BY ACTIVE
MOUTH AT BEDTIME FOR CHOLESTEROL , AVOID GRAPEFRUIT
JUICE
2) CEPHALEXIN 500MG CAP TAKE ONE CAPSULE BY MOUTH EVERY ACTIVE
12 HOURS FOR INFECTION
3) CLOTRIMAZOLE 1% TOP SOLN APPLY A SMALL AMOUNT TO
ACTIVE
ACTIVE
ACTIVE
ACTIVE
FOR DIABETES
8) LISINOPRIL 20MG TAB TAKE ONE-HALF TABLET BY MOUTH
ACTIVE
ACTIVE
ACTIVE
ACTIVE
Status
==================================================
==================
1) ALBUTEROL SO4 0.083% INHL 3ML USE 3 MILLILITERS IN
PENDING
PENDING
PENDING
BY MOUTH
Status
==================================================
==================
1) Non-VA ASPIRIN 81MG EC TAB 81MG MOUTH EVERY DAY
2) Non-VA NO NON-VA MEDICATIONS/HERBALS/OTC's
MISCELLANEOUS
18 Total Medications
**********************************
* Allergies/Adverse Reactions *
ACTIVE
ACTIVE
**********************************
**********************************
* HISTORY OF PRESENT ILLNESS *
**********************************
**********************************
*
REVIEW OF SYSTEM
**********************************
refer to HPI
**********************************
*
PHYSICAL EXAM
**********************************
Vital Signs:
DATE/TIME
TEMP
PULSE
1/4/16 @ 0721
97.6
1/4/16 @ 0721
PULSE OXIMETRY: 94
52
RESP
16
BP
213/84
-General Appearance:
Fully awake and cooperative, oriented x 3, in no
apparent distress.
anxious and tearful
-Head and Neck:
PERRLA (pupils equal round, and reactive
PAIN
0
**********************************
*
DIAGNOSTIC RESULTS
**********************************
**********************************
* IMPRESSION AND ASSESSMENT
**********************************
76 y/o male with SOB and chest pain with suicidal ideation
and plan.
**********************************
*
PLAN
**********************************
ST Item Ordered
Requestor Start
Stop
==================================================
==============================
MARTINEZ-RAMIREZ,WALTER 580-58-4562
RUIZ-ROD,D 01/04/16
PHYSICIAN
Typ:ELECTRONICALLY ENT Sgn:ELECTRONIC
"
01/04/16
07:46
#1616372
DRR
"
Typ:ELECTRONICALLY ENT Sgn:ELECTRONIC
"
01/04/16 02/03
NOW FOR
"
HEART STAT
Quantity: 1 Refills: 0
DRR
"
01/04/16 02/03
"
"
01/04/16 02/03
"
GIVEN AT ER
Quantity: 1 Refills: 0
DRR
"
"
01/04/16 01/05
07:48 07:48
WC LB #1616369
DRR
"
DRR
"
"
07:48
"
DRR
01/04/16
#1616369
DRR
"
"
01/04/16
07:48
DRR
"
07:48
07:48
01/04/16
07:48
07:46
01/04/16
07:48
"
#1616366
"
"
01/04/16
07:48
==================================================
==============================
MARTINEZ-RAMIREZ,WALTER 580-58-4562
ST Item Ordered
Requestor Start
Stop
==================================================
==============================
MARTINEZ-RAMIREZ,WALTER 580-58-4562 (cont.)
"
DRR
"
01/04/16
07:49
RUIZ-ROD,D 01/04/16
PHYSICIAN
DRR
07:58
WC LB #1616370
DRR
"
WC LB #1616371
"
01/04/16
08:18
DRR
"
DRR
07:48
01/04/16
08:03
"
#1616367
"
"
01/04/16
15:48
"
01/04/16
07:48
#1616368
DRR
"
23:48
* END OF ORDERS *
==================================================
==============================
MARTINEZ-RAMIREZ,WALTER 580-58-4562
01/04/2016 ADDENDUM
STATUS: COMPLETED
TEMP
97.6
PULSE
52
RESP
16
BP
213/84
PAIN
0
F/U: PAtient reevaluated and found with right lung pneumonia, labs with
leukocytosis and shifting with elevated pro BNP. PAtient was started on IV
antibiotics and oriented about lab findings, will consult IM for admission.
Patient also with depressive mood due to loss of wife and had suicidal ideation
with a plan. Patient and daughter were oriented about plan, understood and agree
with disposition.
CREATININE: 0.77
SODIUM: 141
POTASSIUM: 4.8
CHLORIDE: 103
CO2: 24
CALCIUM: 9.9
PROTEIN,TOTAL: 7.2
ALBUMIN: 4.1
BILIRUBIN,TOTAL: 0.79
ALKALINE PHOSPHATASE: 65
SGOT: 13
SGPT: 14
CK-MB 3/5/01: 5.38 H
pro-BNP 3/26/2003: 3202 H
EGFR 10/31/06: 98
TROPONIN-T: <0.01
EKG Interpretation:
STATUS: COMPLETED
==================================================
===========================
IM CONSULT
==================================================
===========================
Last discharge: OCT 09, 2011@12:34:99
ALLERGIES:
Patient has answered NKA
- Hypertension
- Hyperlipidemia
- Gout
- Esophageal Reflux
- Exogenous Obesity
- Diabetes Mellitus
- SENSORINEURAL HEARING LOSS, BILATERAL
- Presbyopia
- Astigmatism, NOS
- Coronary Artery Disease * (ICD-9-CM 414.9)
- Intermittent Claudication * (ICD-9-CM 443.9)
MEDICATION RECONCILIATION:
Active Outpatient Medications (including Supplies):
Status
==================================================
==================
1) ALBUTEROL SO4 0.083% INHL 3ML USE 3 MILLILITERS IN
ACTIVE
ACTIVE
ACTIVE
ACTIVE
ACTIVE
ACTIVE
FOR DIABETES
10) LISINOPRIL 20MG TAB TAKE ONE-HALF TABLET BY MOUTH
ACTIVE
ACTIVE
ACTIVE
ACTIVE
IMMEDIATELY
14) MUPIROCIN 2% OINT APPLY A THIN FILM TO AFFECTED AREA ACTIVE
THREE TIMES A DAY FOR INFECTION
15) RANITIDINE HCL 150MG TAB TAKE ONE TABLET BY MOUTH AT ACTIVE
BEDTIME FOR STOMACH
16) TRAMADOL HCL 50MG TAB (CS-IV) TAKE ONE TABLET BY
ACTIVE
Status
==================================================
==================
1) TRAMADOL HCL 50MG TAB (CS-IV) TAKE TWO TABLETS BY
PENDING
Status
==================================================
==================
1) Non-VA ASPIRIN 81MG EC TAB 81MG MOUTH EVERY DAY
2) Non-VA NO NON-VA MEDICATIONS/HERBALS/OTC's
ACTIVE
ACTIVE
MISCELLANEOUS
19 Total Medications
Service Branch
ARMY
Service #
50176263
Entered
Separated
Discharge
HONORABLE
VITAL SIGNS:
============
DATE/TIME
TEMP
1/4/16 @ 1155
1/4/16 @ 0721
12/22/15 @ 0730
PULSE
52
97.6
98.1
RESP
18
52
62
BP
138/60
16
18
PAIN
0
213/84
135/76
0
3
PHYSICAL EXAMINATION:
=====================
GENERAL: ALERT, ORIENTED X3, IN NO ACUTE DISTRESS
HEENT: MMM, PERRL, EOMI, + JVD AT 45 DEGREES
HEART: RRR, NO MURMMURS OR GALLOPS
LUNGS: DECREASED BREATH SOUNDS AT BOTH BASES, MILD SCATERRED
EXPIRATORY
WHEEZES.
ABDOMEN: GLOBOUS, BS+, S&D, NON TENDER TO PALPATION
EXT: +1 EDEMA, NO CYANOSIS, PULSES SYMMETRICALLY PRESENT
**LABS**
========
ANCILLARY TROPONIN I: 0.11 H*
WBC: 10.0 H
RBC: 5.00
HGB: 15.3
HCT: 44.5
MCV: 89.0
MCH: 30.6
MCHC: 34.4
RDW: 13.1
PLT: 219
MPV: 12.9
SEGS: 81.2 H
LYMPHS: 10.8 L
MONOCYTES: 5.0
EOSINO: 2.8
BASO: 0.2
LYMPHS, ABSOLUTE: 1.08
MONOS, ABSOLUTE: 0.5
EOSINO, ABSOLUTE: 0.28
BASO, ABSOLUTE: 0.02
SEGS, ABSOLUTE: 8.09 H
GLUCOSE: 153 H
UREA NITROGEN: 17.3
CREATININE: 0.77
SODIUM: 141
POTASSIUM: 4.8
CHLORIDE: 103
CO2: 24
CALCIUM: 9.9
PROTEIN,TOTAL: 7.2
ALBUMIN: 4.1
BILIRUBIN,TOTAL: 0.79
ALKALINE PHOSPHATASE: 65
SGOT: 13
SGPT: 14
CK-MB 3/5/01: 5.38 H
pro-BNP 3/26/2003: 3202 H
EGFR 10/31/06: 98
TROPONIN-T: <0.01
CHEST XRAY:
----------Impression:
**EKG**
SINUS BRADYCARDIA, RATE 51, LVH, NO ACUTE ISCHEMIC CHANGES.
__________________
INITIAL IMPRESSION:
DECOMPENSATED CONGESTIVE HEART FAILURE
COMMUNITY ACQUIRED PNEUMONIA
CURB 65-1
__________________
ASSESTMENT:
===========
76 Y/O MALE PATIENT WITH ABOVE MEDICAL CONDITIONS THAT CAME TO ER
COMPLAINING OF
PATIENT WAS EVALUATED BEDSIDE AND WAS FOUND ALERT, ORIENTED X3, IN NO
DISTRESS.
DENIES RECURRANCE OF CHEST PAIN. PHYSICAL EXAM WITH RRR, LUNGS WITH
DECREASED
BREATH SOUNDS AT BOTH BASES, MILD SCATERRED EXPIRATORY WHEEZES, +BS,
NO
TENDERNESS TO PALPATION, +1 PITTING EDEMA.
D-CHF
-----EKG WITH LVH, NO ACUTE ISCHEMIC CHANGES. 2D ECHO WITH NO EVIDENCE OF
SYSTOLIC
DYSFUNCTION. CHEST XRAY IS SUGGESTIVE OF PULMONARY EDEMA AND THERE IS
ELEVATED
PRO-BMP LEVELS. NEW ECHOCARDIOGRAM REQUESTED.
CAP
PLAN:
========================
ADMIT TO: MEDICINE WARD
SEE ORDERS
STATUS: COMPLETED
********* ***
***
*******
**********
***
***
***
*** ***
***
*** ***
*****
**** ***
********* ***
***
********* ***
***
*** *****
****** ***
*************************************************************************
Chief Complaint:
*************************************************************************
Vine porque desde que fui al casino me sentia mal
*************************************************************************
History of Present Illness:
*************************************************************************
Mr. MARTINEZ-RAMIREZ is a 76-year-old MALE with the below mentioned medical
conditions who was in his usual state of health which consists of self-care,
*************************************************************************
Past medical history:
*************************************************************************
- Hypertension
- Hyperlipidemia
- Gout
- Esophageal Reflux
- Diabetes Mellitus type II
- Arthritis
- Sensorineural bilateral hearing loss
- Coronary Artery Disease
*************************************************************************
Medications:
*************************************************************************
Active Inpatient Medications (including Supplies):
Status
==================================================
==================
1) ASPIRIN ENTERIC COATED TAB,EC 81MG PO DAILY
ACTIVE
ACTIVE
ACTIVE
Status
==================================================
==================
1) 5% DEXTROSE/WATER,USP INJ,SOLN in 5% DEXTROSE/WATER
PENDING
PENDING
PENDING
PENDING
PENDING
PENDING
PENDING
PENDING
PENDING
PENDING
PENDING
PENDING
17 Total Medications
Active Outpatient Medications (including Supplies):
Status
==================================================
==================
1) ALBUTEROL SO4 0.083% INHL 3ML USE 3 MILLILITERS IN
ACTIVE
ACTIVE
ACTIVE
ACTIVE
ACTIVE
ACTIVE
FOR DIABETES
10) LISINOPRIL 20MG TAB TAKE ONE-HALF TABLET BY MOUTH
ACTIVE
ACTIVE
ACTIVE
ACTIVE
IMMEDIATELY
14) MUPIROCIN 2% OINT APPLY A THIN FILM TO AFFECTED AREA ACTIVE
THREE TIMES A DAY FOR INFECTION
15) RANITIDINE HCL 150MG TAB TAKE ONE TABLET BY MOUTH AT ACTIVE
ACTIVE
Status
==================================================
==================
1) Non-VA ASPIRIN 81MG EC TAB 81MG MOUTH EVERY DAY
2) Non-VA NO NON-VA MEDICATIONS/HERBALS/OTC's
ACTIVE
ACTIVE
MISCELLANEOUS
18 Total Medications
*************************************************************************
Objective:
*************************************************************************
Vital signs:
------------Blood pressure
Heart rate
Respiratory rate
: 18 (01/04/2016 11:55)
Temperature
Pain
: 0 (01/04/2016 11:55)
Height
Weight
BMI
Physical exam:
-------------General: Active, alert, oriented x3. In no acute distress
HEENT: PERRL, EOMI, moist oral mucosa.
Neck: Supple. No JVD at 45 degrees.
Heart: Slow rate and rhythm. No murmurs, gallops, or rub.
Lungs: Left lower lung crackles.
Abdomen: Abdominal hernia. Bowel sounds positive, soft and depressible, no
tenderness to palpation. No involuntary guarding or rebound tenderness.
Extremities: No cyanosis or edema. Distal pulses present bilaterally +2.
Neurologic: No gross focal neurological deficits.
*********************************************************************
Laboratories:
*********************************************************************
---- CBC PROFILE ----
BLOOD
Jan 04
Dec 22
Sep 30
Jul 27
2016
2015
2015
2015
08:10
05:46
14:24
08:07
Units
Reference
Ranges
------------------------------------------------------------------------------WBC
10.0 H
RBC
5.0
6.7
5.0
5.8
5.0
HGB
15.3
15.2
15.0
15.5
HCT
44.5
44.2
43.8
45.5
MCV
89.0
88.6
88.0
90.1
fL 81 - 102
MCH
30.6
30.5
30.1
30.7
pg 26 - 34
37.9 - 54.5
MCHC
34.4
34.4
34.2
34.1
RDW
13.1
13.0
13.1
12.3
219.0
244.0
259.0
250.0
MPV
12.9
12.3
11.7
12.2
fL 9 - 12.9
SEGS
81.2 H
PLT
57.7
63.4
29.0
g/dl 31 - 36.5
%
55.2
10.8 L
MONOS
5.0
7.6
9.0
7.0
2 - 12
EOSINO
2.8
5.1
4.7
5.7
0-7
BASO
0.2
SEGS#
8.09 H
3.85
3.68
1.08
1.94
1.3
LYMPHS#
EOS#
BASO#
0.28
0.34
0.02
MONOS#
0.5
0.3
1.94
17 - 48
0 - 1.4
X 10-3 1 - 3.5
0.35 X10-3/ul 0 - .4
0.03
0.51
0.27
0.04
0.5
31.8
34 - 74
LYMPHS
0.6
22.4
11 - 15
0.02 X10-3/ul 0 - .1
0.52
0.43 X10-3/ul .2 - 1
SERUM
Jan 04
Dec 22
Sep 30
Jul 27
2016
2015
2015
2015
08:10
05:46
14:24
08:07
Units
Reference
Ranges
------------------------------------------------------------------------------GLUCOSE
153 H
127 H
127 H
124 H mg/dL 70 - 99
BUN
17.3
23.9
22.0
CREA
0.8
0.8
0.8
NA+
141
144
K+
4.8
4.6
CL-
103
104
17.5
0.8
140
4.5
MG/DL .7 - 1.5
144
4.3
104
mEq/L 3.5 - 5
100
CO2
24
21 L
SGPT
14
24
20
U/L
0 - 45
SGOT
13
22
16
U/L
0 - 40
CK-MBEGFR
CA++
ALB
TP
CHOL EZ
HDL
NON HDL
CHOL/HD
LDL CHO
VLDL
TRIGLYC
25
5.38 H
98
ALK PHO
T BILI
21 L
mg/dL 10 - 26
ng/mL. 0 - 4.94
91
65
0.8
9.9
4.1
7.2
mEq/l 24 - 32
100
94
69
58
0.6
9.8
4.3
7.3
196
44.2
151.3 H
4.4
119.0 H
32.0 H
160 H
0.7
9.5
U/L 30 - 115
MG/DL .2 - 1.3
10.0
4.2
7.3
G/DL 6 - 8.5
173
37.2 L MG/DL 39 - 60
135.8 H mg/dL Ref: <=130
4.7
99.0
*********************************************************************
Radiology:
*********************************************************************
*********************************************************************
EKG:
*********************************************************************
Sinus rhythm with high degree AV block with junctional rhythm. Vent rate of
45bpm, QRS 90ms, QTc 394ms.
*********************************************************************
Diagnostic impression:
*********************************************************************
*********************************************************************
Assessment and Plan:
*********************************************************************
Upon arriving to the IM ward, patient was evaluated at bedside and was
found alert, awake, afebrile, hemodynamically stable and in no acute distress.
Vital signs evident of bradycardia. Physical exam left basilar crackles,
abdominal hernia, and benign rest of exam. ECG with high degree AV block,
negative chronotropism. Patient at the moment asymptomatic, referring he was
feeling better than when he arrived. Labs with leukocytosis, stable hemoglobin
and platelets. Chem profile with stable renal function and no major electrolyte
abnormalities. Probnp elevated at 3202. Due to AV block, patient was started on
telemetry, and bedside cardiac defibrillator on pacemaker mode placed.
Third degree AV block: Patient with fatigue and dyspnea that could be secondary
to this block. Patient's previous ECGs without AV block and heart rates over
60bpm. Patient at the moment of evaluation at IM ward referred no symptoms and
had stable vital signs despite bradycardia. Treatment for a complete AV block is
pacemaker placement. Therefore temporarily a bedside monitor in pacemaker
placed. Cardiology services called and consulted for further evaluation,
recommendations and if possible for placement of pacemaker. Patient had
metoprolol ordered at the ER, however never administered, it was quickly
discontinued.
Rule out of CHF vs CAP: Although patient was admitted with this rule out
diagnosis. I did not find the patient with signs of volume overload (JVD,
bilateral crackles, peripheral edema). Patient could lay down in his bed flat in
supine position. In addition patient denied cough, he has not had fever, does
present borderline high leukocytosis. CXR does not rule out any infectious or
effusion. Therefore I did not suspected CAP, reason for which he was not started
on antibiotic therapy. Echocardiogram ordered. Last echo from 2010 with
*********************************************************************
Admission orders:
*********************************************************************
ADMIT TO: Medicine
DIAGNOSIS: See above
CONDITION: Stable
PROGNOSIS: Guarded
VITALS: Q8H on chart
ACTIVITY: Bed rest
NURSING: See orders
DIET: See orders
IN/OUTS: Q8H on chart
IV FLUIDS: See orders
LABS: See orders
IMAGINGS: See orders
CONSULTS: None
Allergies: Patient has answered NKA
--------------------------------------------------------------------Medication Reconciliation
--------------------------------------------------------------------MEDICATIONRECONCILIATION
Inpatient Medications:
Admission Medication Reconciliation
Outpatient includes Prescriptions and Non-VA meds
Inpatient includes Unit Dose and IV
po daily
po daily
STATUS: COMPLETED
****** ****** *
** ** **
* ****** **
** ** **
* **
**
**
* **
**
**
* * **
**
**
** ** **
****** ******
** **
********
**
**
** **
**
**
**
**
** **
**
**
**
**
**
**
**
**
******
**
**
**
****** **
**
jumping off the roof of my house". Patient reported that since his pain is not
well controlled he has this thought on an almost daily basis. Patient also
reported that 2 days ago he was at the casino, and a Trio was playing some "sad
songs" and he started to feel very sad because it reminded him of his wife.
Patient reported "after her death I am trying to carry on my life the same way,
I keep going to the casino, and to the horse tracks, I keep myself very active".
Patient reported that he has been feeling sad and depressed for "Some time now,
even before her death, I came to PIC many years ago for that too". Patient
denied difficulty sleeping or decreaed appetite. He reported good compliance
with medications. Denied active suicidal ideas, but reported that "I do not
control when the Ideas come, because they come with the pain". Patient denied
homicidal ideas, denied hearing or seeing things not perceived by others.
Patient denied feeling anxious, denied manic or hypomanic symptoms.
- OVERWEIGHT
- SENSORINEURAL HEARING LOSS, BILATERAL
- Presbyopia
- Astigmatism, NOS
- Myopia
- Blepharitis
- Senile nuclear sclerosis
- Open angle with borderline glaucoma findings
- DM Type II, No Retinopathy
- Diabetic Neuropathies
- Coronary Artery Disease
- Microscopic Hematuria
- Intermittent Claudication
- Impacted cerumen
- Joint pain
- Paronychia
- Family bereavement
- Onychomycosis of toenails
- Ingrowing toenail
ALLERGIES:
Patient has answered NKA
REVIEW OF SYSTEMS:
see H&P MEDICAL SERVICE NOTE dated 1/4/2016
SUBSTANCE HISTORY:
Patient denies active alcohol, nicotine or illicit drug use.
PSYCHIATRIC MEDICATIONS:
None
SOCIAL HISTORY:
Patient denies legal problems, denies access to weapons or firearms.
VITALS:
DATE/TIME
TEMP
1/5/16 @ 0054
PULSE
45
RESP
BP
162/79
1/4/16 @ 2356
1/4/16 @ 2356
97.9
42
19
171/74
PAIN
1/4/16 @ 2003
96
1/4/16 @ 1155
46
52
20
18
148/68
138/60
0
0
4) Mood: "better"
5)Affect: restricted
9)Cognitive: awake, alert, and oriented in person, time, and place. Immediate,
recent, and remote memory intact.
10)Insight: poor
11)Judgment: poor
LETHALITY ASSESMENT:
RISK FACTORS (select yes or no when present)
1. Previous suicide attempts/gestures
2. Family history of suicide
no
no
no
no
yes
yes
yes
no
no
no
yes
yes
no
yes
no
Depression
no
(x)
()
()
()
AIMS:
0 (zero) = normal
LABSORATORIES:
Specimen Collection Date: Dec 22, 2015@05:46
Test name
TSH
Result
4.550
units
uIU/mL
0.46 - 4.98
[672]
==================================================
=============================
Result
units
WBC
7.0
[672]
RBC
4.7
[672]
HGB
14.2
g/dL
HCT
42.2
12.6 - 17.8
37.9 - 54.5
[672]
[672]
MCV
89.8
fL
81 - 102
[672]
MCH
30.2
pg
26 - 34
[672]
MCHC
RDW-CV
33.6
31 - 36.5
[672]
11 - 15
[672]
155 - 371
[672]
13.0
PLT
232
MPV
11.8
SEGS%
g/dl
X10-3
fL
60.3
9.0 - 12.9
[672]
34 - 74
[672]
LYMPHS%
27.0
17 - 48
MONOS%
8.0
2 - 12
EOSINO%
4.6
0-7
[672]
0 - 1.4
[672]
BASO%
SEGS ABSOLUTE#
0.1
%
4.19
[672]
[672]
LYMPHS ABSOLUTE#
1.88
X 10-3
MONOS ABSOLUTE#
0.56
[672]
EOSINO ABSOLUTE#
0.32
[672]
BASO ABSOLUTE#
0.01
1.0 - 3.5
[672]
[672]
[672]
==================================================
=============================
ASSESSMENT:
Geriatric male patient with history of Unspecified Depressive Disorder
who is presenting on/off suicidal ideas with plan in the context of physical
health and pain. In addition, patient is experiencing changes in life style
after recent death of his wife. Patient, even though he is not actively
suicidal, he was unreliable at time of questioning about suicide ideas, since
this thoughts come on a regular basis to him. Therefore, we recommend to
continue Constant 1:1 observation. Patient with previous use of SSRI for
DIAGNOSTIC IMPRESSION:
Unspecified Depressive Disorder
Bereavement
Global Assessment Functioning: 40
RECOMMENDATIONS:
=================
1. Ensure safety, keep in constant 1:1 observation
2. Falls precautions
4. Medication:
START Sertraline 25mg oral in the morning with food
Patient discussed with attending psychiatrist Dr. Febeles, who agrees with
diagnosis, assessment and recommendations.
01/05/2016 ADDENDUM
STATUS: COMPLETED
I was the attending on call when resident evaluated this patient. This case was
discussed with me by phone during the call. I agree with resident's evaluation
and management of this case.
STATUS: COMPLETED
1/5/2016
PRESENTATION
WHEN HE HEARD THE MUSIC THAT REMEMBERS HIS WIFE THAT DIED 4 MONTHS
AGO. DENIED
OTHER PREVIOUS EPSIDOES OF CHEST DISCOMFORT. AT ER HE WAS FOUND WITH
TROP I IN
0.11, TROP T NEGATVIE X3 AND CPK MB IN 5. AT VAER HE WAS OFUND WITH AN
EKG
WITH HIGH DEGREE AV BLOCK . VITALS WERE FOUND STABLE,
ASYMPTOMATIC. BUT IN VIEW OF CURRENT FINDINGS HE WILL BE SCHEDULE FOR
PERMANENT PACEMAKER.
PRESENTATION SUMMARY
Other
NYHA Functional Class I
No cardiogenic shock
No prior CHF, No prior MI, No prior CABG, No prior PCI, No prior Cardiac Cath,
No prior Valve Surgery, No prior Valve Treatment (TVT),
No prior Cardiac Transplant
COMORBID CONDITIONS
PVD
LVEF
Nuclear (2011) EF=55%, Normal systolic function, Normal wall motion
PHYSICAL EXAM
BP:
HR:
42 bpm
(01/05/2016 08:06)
Height: 68 inches
(11/02/2015 09:41)
1.9 m2
(01/04/2016 23:56)
(01/04/2016 23:56)
Neck:
Bilateral carotid bruits
Lungs:
No rales present
Cardiac:
No extra heart sound present
No murmur
Extremities:
No femoral bruits
Leg Pulses:
Normal left femoral pulse
Normal right femoral pulse
Normal left dorsalis pedis pulse
Normal right dorsalis pedis pulse
Normal left posterior tibial pulse
Normal right posterior tibial pulse
Arm Pulses:
Normal left radial pulse
Normal right radialpulse
Normal left brachial pulse
Normal right brachial pulse
LABS
BNP
: 3202
(01/04/2016 08:10)
Creatinine
: 0.77
(01/04/2016 08:10)
Potassium
: 4.8
(01/04/2016 08:10)
CK-MB
: 5.38
(01/04/2016 08:10)
Troponin T
: <0.01
(01/05/2016 05:34)
Hematocrit
: 42.2
(01/05/2016 03:15)
Platelets
: 232
(01/05/2016 03:15)
INR
: 1.18
(01/05/2016 08:3)
PTT
: 30.5
(01/05/2016 08:3)
WBC
: 7
(01/05/2016 03:15)
Cholesterol total
: 196
(12/22/2015 05:46)
LDL (calculated)
: 119
(12/22/2015 05:46)
HDL Cholesterol
Triglycerides
: 44.2
: 160
(12/22/2015 05:46)
(12/22/2015 05:46)
INPATIENT MEDICATIONS
HEPARIN INJ,SOLN expires: 01/11/2016
Give: 5000UNIT/1ML SC Q8H
OUTPATIENT MEDICATIONS
VANCOMYCIN INJ Qty: 1
Sig: ADMINISTER 1GM INTRAVENOUS USE ONCE FOR INFECTION
Sig: TAKE ONE-HALF TABLET BY MOUTH EVERY DAY FOR HEART OR FOR HIGH
BLOOD
PRESSURE
ALLERGIES/ADVERSE REACTIONS
No known allergies
SEDATION/CONSENT
Planned sedation: Moderate
Mallampati Class 2: faucial pillars, soft palate visible
Mouth: Teeth
Airway: Normal
Jaw/Neck mobility: Normal
All questions have been answered and the patient/surrogate understands the
potential risks and benefits and consents to the procedure and the plan
for sedation.
SUMMARY
STATUS: COMPLETED
CT SURGERY
PLEASANT 76 YRS OLD PT. VERY ACTIVE ADMITTED WHITH
SYMTOMS OF CHF,SOB AND FOUND WHITH COMPLETE A/V BLOCK. THERE IS NO HX
OF MI OR
MEDICATIONS THAH COULD PRECITITATE HIS HEART BLOCK. PPM IMPLANT IS BEEN
ADVISED.PROECEDURE BENEFITS AND RISKS EXPLAINED HE UNDERTANDS AND
WANTS TO
PROCED.
/es/ ONEILL-RIVERA,JOSE G, MD
Physician,Surgical Service/Thoracic Surgery
Signed: 01/05/2016 10:22
STATUS: COMPLETED
Levels of Involvement:
() Level A: Attending doing the operation: The staff practitioner
performs the case, but may be assisted by a resident.
4.2mV
9.8 MV
.7V
.4V
715 oHMS
1,229 oHMS
ADDITIONAL COMMENTS:
() NO (X) YES, The key portion(s) of this procedure was (were) performed
in my presence.
/es/ ONEILL-RIVERA,JOSE G, MD
Physician,Surgical Service/Thoracic Surgery
Signed: 01/05/2016 12:15
STATUS: COMPLETED
MARTINEZ-RAMIREZ,WALTER
SURGEON: DR A CEDENO
ASSISTANT: DR J ONEILL
ANESTHESIA:GETA
SPECIMENS: NONE,
COMPLICATIONS: NONE,
DRAINS:NONE,
/es/ ONEILL-RIVERA,JOSE G, MD
Physician,Surgical Service/Thoracic Surgery
Signed: 01/05/2016 12:17
Result
1.18
Eval:
units
14.4
Secs.
30.5
11.8 - 15.0
Secs.
[672]
22.4 - 38.3
[672]
==================================================
=============================
Result
units
136
70 - 99
[672]
==================================================
=============================
Result
units
161
70 - 99
[672]
==================================================
=============================
Result
units
<0.01
ng/mL.
[672]
Eval: Effective 3/9/09: For patients with new Troponin-T elevations greater
Eval: than 0.1 ng/ml (and clinical findings consistent with ACS), the provider
Eval: must document discussion with cardiology within 24 hours (include name
Eval: of cardiologist in note). Contact numbers:
Eval: Regular work shift ext: 31788 Off-regular work shift: 787-510-0614.
==================================================
=============================
Specimen: BLOOD.
Result
units
WBC
7.0
[672]
RBC
4.7
[672]
HGB
14.2
g/dL
HCT
42.2
37.9 - 54.5
MCV
89.8
fL
81 - 102
[672]
MCH
30.2
pg
26 - 34
[672]
MCHC
RDW-CV
33.6
232
MPV
11.8
SEGS%
[672]
31 - 36.5
[672]
11 - 15
[672]
155 - 371
[672]
X10-3
fL
60.3
[672]
g/dl
13.0
PLT
12.6 - 17.8
9.0 - 12.9
[672]
34 - 74
[672]
LYMPHS%
27.0
17 - 48
MONOS%
8.0
2 - 12
EOSINO%
4.6
0-7
[672]
0 - 1.4
[672]
BASO%
SEGS ABSOLUTE#
0.1
%
4.19
[672]
[672]
LYMPHS ABSOLUTE#
1.88
X 10-3
MONOS ABSOLUTE#
0.56
[672]
EOSINO ABSOLUTE#
0.32
[672]
BASO ABSOLUTE#
0.01
1.0 - 3.5
[672]
[672]
[672]
==================================================
=============================
Result
MAGNESIUM
PRO-BNP
units
1.73 L mg/dL
3.7
G/DL
CALCIUM
9.0
MG/DL
CREATININE
eGFR
SODIUM
1.8 - 2.4
1801 H pg/mL
ALBUMIN
PO4
3.9
0.72
106
142
Ref: <=450
2.6 - 5.2
2.5 - 4.5
MG/DL
[672]
mEq/L
135 - 145
[672]
[672]
3.5 - 5.0
CHLORIDE
103
mEq/l
100 - 110
UREA NITROGEN
[672]
Ref: >=60
mEq/L
GLUCOSE
[672]
mL/min
4.1
24
[672]
.7 - 1.5
POTASSIUM
CO2
[672]
[672]
8.5 - 10.5
mg/dL
[672]
mEq/l
24 - 32
136 H mg/dL
16.2
mg/dL
[672]
[672]
70 - 99
10 - 26
[672]
[672]
==================================================
=============================
Result
0.02
units
ng/mL.
0 - 0.1
[672]
Eval: Effective 3/9/09: For patients with new Troponin-T elevations greater
Eval: than 0.1 ng/ml (and clinical findings consistent with ACS), the provider
Eval: must document discussion with cardiology within 24 hours (include name
Eval: of cardiologist in note). Contact numbers:
Eval: Regular work shift ext: 31788 Off-regular work shift: 787-510-0614.
==================================================
=============================
Result
units
ANCILLARY TROPONIN I
0.11 H* ng/mL
0.00 - 0.079
[672]
Comment: MD Notified
==================================================
=============================
Collection sample: BLOOD CULTURE BOTTLECollection date: Jan 04, 2016 08:25
Site/Specimen: BLOOD
Provider: RUIZ-RODRIGUEZ,DORCAS L
==================================================
=============================
Result
units
WBC
RBC
5.0
HGB
15.3
g/dL
HCT
44.5
37.9 - 54.5
MCV
89.0
fL
81 - 102
[672]
MCH
30.6
pg
26 - 34
[672]
MCHC
34.4
RDW-CV
219
MPV
12.9
SEGS%
[672]
[672]
31 - 36.5
[672]
11 - 15
[672]
155 - 371
[672]
X10-3
fL
9.0 - 12.9
81.2 H %
LYMPHS%
[672]
g/dl
13.1
PLT
12.6 - 17.8
[672]
10.8 L %
[672]
34 - 74
17 - 48
[672]
[672]
MONOS%
5.0
2 - 12
EOSINO%
2.8
0-7
[672]
0 - 1.4
[672]
BASO%
0.2
SEGS ABSOLUTE#
LYMPHS ABSOLUTE#
1.08
MONOS ABSOLUTE#
EOSINO ABSOLUTE#
BASO ABSOLUTE#
[672]
1.0 - 3.5
[672]
0.5
[672]
0.28
[672]
0.02
X 10-3
[672]
[672]
==================================================
=============================
Result
units
5.38 H ng/mL.
0 - 4.94
3202 H pg/mL
PROTEIN,TOTAL
7.2
4.1
G/DL
CALCIUM
9.9
MG/DL
CREATININE
0.77
98
BILIRUBIN,TOTAL
65
[672]
8.5 - 10.5
[672]
.7 - 1.5
[672]
Ref: >=60
[672]
MG/DL
ALKALINE PHOSPHATASE
[672]
2.6 - 5.2
mL/min
[672]
6.0 - 8.5
MG/DL
0.79
[672]
Ref: <=450
G/DL
ALBUMIN
eGFR
.2 - 1.3
U/L
[672]
30 - 115
[672]
SGOT
13
U/L
0 - 40
[672]
SGPT
14
U/L
0 - 45
[672]
SODIUM
141
mEq/L
135 - 145
[672]
[672]
POTASSIUM
4.8
mEq/L
3.5 - 5.0
CHLORIDE
103
mEq/l
100 - 110
CO2
GLUCOSE
UREA NITROGEN
24
mEq/l
24 - 32
153 H mg/dL
17.3
mg/dL
[672]
[672]
70 - 99
10 - 26
[672]
[672]
==================================================
=============================
Result
TROPONIN-T
units
<0.01
ng/mL.
0 - 0.1
[672]
Eval: Effective 3/9/09: For patients with new Troponin-T elevations greater
Eval: than 0.1 ng/ml (and clinical findings consistent with ACS), the provider
Eval: must document discussion with cardiology within 24 hours (include name
Eval: of cardiologist in note). Contact numbers:
Eval: Regular work shift ext: 31788 Off-regular work shift: 787-510-0614.
==================================================
=============================
Collection sample: BLOOD CULTURE BOTTLECollection date: Jan 04, 2016 08:10
Site/Specimen: BLOOD
Provider: RUIZ-RODRIGUEZ,DORCAS L
==================================================
=============================
Clinical History:
76 y/o male with sob, cough and chest pressure that worsened
yesterday
Report:
Chest - PA and Lateral views:
Impression:
Clinical History:
Report:
Portable chest on 1/5/2016 at 1234 hours, compared to examination
dated 1/4/2016.
Findings:
Impression:
Interval placement of a permanent pacemaker as noted. No
complications are observed.