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No morning headaches or fatigue. | [
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"medical_specialty": " Cardiovascular / Pulmonary"
} | Default | 2022-12-07T10:15:38.783524 | null |
No psychiatric diagnosis. | [
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"diagnosis",
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"medical_specialty": " Cardiovascular / Pulmonary"
} | Default | 2022-12-07T10:15:38.783854 | null |
No psoriasis, no lupus. | [
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"medical_specialty": " Cardiovascular / Pulmonary"
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Remainder of the review of systems is negative x14 systems except as described above. | [
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} | Default | 2022-12-07T10:15:38.784570 | null |
,PHYSICAL EXAMINATION:,GENERAL: She is a pleasant elderly woman, currently in no acute distress. | [
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,VITAL SIGNS: Height 4 feet 11 inches, weight 128 pounds, temperature 97.2 degrees Fahrenheit, blood pressure 142/70, pulse 47, respiratory rate 16, and O2 saturation 100%,HEENT: Cranium is normocephalic and atraumatic. | [
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} | Default | 2022-12-07T10:15:38.785494 | null |
She has moist mucosal membranes. | [
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There are no carotid bruits. | [
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,LUNGS: Clear to auscultation and percussion without wheezes. | [
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No significant murmurs, rubs or gallops. | [
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,ABDOMEN: Soft and nondistended. | [
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Bowel sounds present. | [
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} | Default | 2022-12-07T10:15:38.788537 | null |
,EXTREMITIES: Without significant clubbing, cyanosis or edema. | [
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} | Default | 2022-12-07T10:15:38.788890 | null |
Pulses grossly intact. | [
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} | Default | 2022-12-07T10:15:38.789223 | null |
Bilateral groins are inspected, status post as the right femoral artery was used for access for the diagnostic cardiac catheterization here and left femoral artery used for PCI and there is no evidence of hematoma or bruit and intact distal pulses. | [
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} | Default | 2022-12-07T10:15:38.789779 | null |
,LABORATORY DATA: , EKG reviewed which shows sinus bradycardia at the rate of 51 beats per minute and no acute disease. | [
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,Sodium 136, potassium 3.8, chloride 105, and bicarbonate 27. | [
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BUN 16 and creatinine 0.9. | [
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ALT 107 and AST 65 and these were normal on 08/15/08. | [
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INR is 0.89, PTT 20.9, white blood cell count 8.2, hematocrit 31 and it was 35 on 08/15/08, and platelet count 257,000.,IMPRESSION AND PLAN: ,The patient is a 68-year-old woman with exertional angina, characterized with arm pain, who underwent recent left anterior descending percutaneous coronary intervention and has now had recurrence of that arm pain post stenting to the left anterior descending artery and it may be that she is continuing to have collateral insufficiency of the right coronary artery. | [
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} | Default | 2022-12-07T10:15:38.792755 | null |
In any case, given this unstable presentation requiring three sublingual nitroglycerin before she was even pain free, I am going to admit her to the hospital and there is currently no evidence requiring acute reperfusion therapy. | [
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} | Default | 2022-12-07T10:15:38.793399 | null |
We will continue her beta-blocker and I cannot increase the dose because she is bradycardic already. | [
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I am going to add Imdur and watch headaches as she apparently had some on nitro paste before, and we will rule out MI, although there is a little suspicion. | [
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} | Default | 2022-12-07T10:15:38.794639 | null |
I suppose it is possible that she has non-cardiac arm pain, but that seems less likely as it has been nitrate responsive and seems exertionally related and the other possibility may be that we end up needing to put in a pacemaker, so we can maximize beta-blocker use for anti-anginal effect. | [
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"medical_specialty": " Cardiovascular / Pulmonary"
} | Default | 2022-12-07T10:15:38.795261 | null |
My concern is that there is persistent right coronary artery ischemia, not helped by left anterior descending percutaneous coronary intervention, which was severely stenotic and she does have normal LV function. | [
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She will continue the glucosamine for her arthritis, Claritin for allergies, and Detrol LA for urinary incontinence. | [
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,Total patient care time in the emergency department 75 minutes. | [
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} | Default | 2022-12-07T10:15:38.796693 | null |
HISTORY OF PRESENT ILLNESS: , Mr. ABC is a 60-year-old gentleman who had a markedly abnormal stress test earlier today in my office with severe chest pain after 5 minutes of exercise on the standard Bruce with horizontal ST depressions and moderate apical ischemia on stress imaging only. | [
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He required 3 sublingual nitroglycerin in total (please see also admission history and physical for full details).,The patient underwent cardiac catheterization with myself today which showed mild-to-moderate left main distal disease of 30%, moderate proximal LAD with a severe mid-LAD lesion of 99%, and a mid-left circumflex lesion of 80% with normal LV function and some mild luminal irregularities in the right coronary artery with some moderate stenosis seen in the mid to distal right PDA.,I discussed these results with the patient, and he had been relating to me that he was having rest anginal symptoms, as well as nocturnal anginal symptoms, and especially given the severity of the mid left anterior descending lesion, with a markedly abnormal stress test, I felt he was best suited for transfer for PCI. | [
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} | Default | 2022-12-07T10:15:38.800129 | null |
The patient is pain-free at this time. | [
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Metoprolol 50 mg once a day, but we have had to hold it because of relative bradycardia which he apparently has a history of. | [
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Zocor 40 mg once a day, and there is a fasting lipid profile pending at the time of this dictation. | [
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,Other medical history is inclusive for obstructive sleep apnea for which he is unable to tolerate positive pressure ventilation, GERD, arthritis,DISPOSITION: ,The patient and his wife have requested and are agreeable with transfer to Medical Center, and we are enclosing the CD ROM of his images. | [
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REASON FOR CONSULTATION: ,Abnormal echocardiogram findings and followup. | [
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Shortness of breath, congestive heart failure, and valvular insufficiency. | [
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,HISTORY OF PRESENT ILLNESS: ,The patient is an 86-year-old female admitted for evaluation of abdominal pain and bloody stools. | [
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The patient has colitis and also diverticulitis, undergoing treatment. | [
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During the hospitalization, the patient complains of shortness of breath, which is worsening. | [
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The patient underwent an echocardiogram, which shows severe mitral regurgitation and also large pleural effusion. | [
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This consultation is for further evaluation in this regard. | [
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As per the patient, she is an 86-year-old female, has limited activity level. | [
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She has been having shortness of breath for many years. | [
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She also was told that she has a heart murmur, which was not followed through on a regular basis. | [
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,CORONARY RISK FACTORS: , History of hypertension, no history of diabetes mellitus, nonsmoker, cholesterol status unclear, no prior history of coronary artery disease, and family history noncontributory. | [
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,PAST SURGICAL HISTORY: , No major surgery. | [
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,MEDICATIONS: , Presently on Lasix, potassium supplementation, Levaquin, hydralazine 10 mg b.i.d., | [
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antibiotic treatments, and thyroid supplementation. | [
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] | Argilla | null | null | null | {
"medical_specialty": " Cardiovascular / Pulmonary"
} | Default | 2022-12-07T10:15:38.810825 | null |
Does not consume alcohol. | [
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"alcohol",
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] | [
{
"end": 25,
"label": "KEYPHRASE",
"score": 0,
"start": 18
}
] | Argilla | null | null | null | {
"medical_specialty": " Cardiovascular / Pulmonary"
} | Default | 2022-12-07T10:15:38.811298 | null |
No history of recreational drug use. | [
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"drug",
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] | [
{
"end": 14,
"label": "KEYPHRASE",
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"start": 4
}
] | Argilla | null | null | null | {
"medical_specialty": " Cardiovascular / Pulmonary"
} | Default | 2022-12-07T10:15:38.811534 | null |
,PAST MEDICAL HISTORY: ,Basically GI pathology with diverticulitis, colitis, hypothyroidism, arthritis, questionable hypertension, no prior history of coronary artery disease, and heart murmur. | [
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] | Argilla | null | null | null | {
"medical_specialty": " Cardiovascular / Pulmonary"
} | Default | 2022-12-07T10:15:38.811903 | null |
,REVIEW OF SYSTEMS,CONSTITUTIONAL: Weakness, fatigue, and tiredness. | [
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] | Argilla | null | null | null | {
"medical_specialty": " Cardiovascular / Pulmonary"
} | Default | 2022-12-07T10:15:38.812224 | null |
,HEENT: History of cataract, blurred vision, and hearing impairment. | [
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] | Argilla | null | null | null | {
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} | Default | 2022-12-07T10:15:38.812503 | null |
,CARDIOVASCULAR: Shortness of breath and heart murmur. | [
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"medical_specialty": " Cardiovascular / Pulmonary"
} | Default | 2022-12-07T10:15:38.812776 | null |
No coronary artery disease. | [
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] | [
{
"end": 27,
"label": "KEYPHRASE",
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"start": 4
}
] | Argilla | null | null | null | {
"medical_specialty": " Cardiovascular / Pulmonary"
} | Default | 2022-12-07T10:15:38.813018 | null |
,RESPIRATORY: Shortness of breath. | [
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] | [
{
"end": 34,
"label": "KEYPHRASE",
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"start": 28
}
] | Argilla | null | null | null | {
"medical_specialty": " Cardiovascular / Pulmonary"
} | Default | 2022-12-07T10:15:38.813251 | null |
No pneumonia or valley fever. | [
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{
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"label": "KEYPHRASE",
"score": 0,
"start": 24
}
] | Argilla | null | null | null | {
"medical_specialty": " Cardiovascular / Pulmonary"
} | Default | 2022-12-07T10:15:38.813487 | null |
,GASTROINTESTINAL: No nausea, vomiting, hematemesis, or melena. | [
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"end": 63,
"label": "KEYPHRASE",
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"start": 57
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} | Default | 2022-12-07T10:15:38.813760 | null |
,UROLOGICAL: No frequency or urgency. | [
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{
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"label": "KEYPHRASE",
"score": 0,
"start": 30
}
] | Argilla | null | null | null | {
"medical_specialty": " Cardiovascular / Pulmonary"
} | Default | 2022-12-07T10:15:38.814020 | null |
,MUSCULOSKELETAL: Arthritis and severe muscle weakness. | [
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{
"end": 55,
"label": "KEYPHRASE",
"score": 0,
"start": 47
}
] | Argilla | null | null | null | {
"medical_specialty": " Cardiovascular / Pulmonary"
} | Default | 2022-12-07T10:15:38.814268 | null |
No seizure disorder. | [
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"disorder",
"."
] | [
{
"end": 20,
"label": "KEYPHRASE",
"score": 0,
"start": 4
}
] | Argilla | null | null | null | {
"medical_specialty": " Cardiovascular / Pulmonary"
} | Default | 2022-12-07T10:15:38.814885 | null |
,PHYSICAL EXAMINATION,VITAL SIGNS: Pulse of 84, blood pressure of 168/74, afebrile, and respiratory rate 16 per minute. | [
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} | Default | 2022-12-07T10:15:38.815398 | null |
,HEENT/NECK: Head is atraumatic and normocephalic. | [
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"start": 37
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} | Default | 2022-12-07T10:15:38.815719 | null |
Neck veins flat. | [
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] | [
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] | Argilla | null | null | null | {
"medical_specialty": " Cardiovascular / Pulmonary"
} | Default | 2022-12-07T10:15:38.815966 | null |
No significant carotid bruits appreciated. | [
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] | [
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"start": 16
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] | Argilla | null | null | null | {
"medical_specialty": " Cardiovascular / Pulmonary"
} | Default | 2022-12-07T10:15:38.816198 | null |
No obvious rales or wheezes. | [
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] | [
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] | Argilla | null | null | null | {
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} | Default | 2022-12-07T10:15:38.816629 | null |
,HEART: PMI displaced. | [
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] | [
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"end": 22,
"label": "KEYPHRASE",
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"start": 13
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] | Argilla | null | null | null | {
"medical_specialty": " Cardiovascular / Pulmonary"
} | Default | 2022-12-07T10:15:38.816860 | null |
S1, S2 with systolic murmur at the precordium, grade 2/6.,ABDOMEN: Soft and nontender. | [
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] | Argilla | null | null | null | {
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} | Default | 2022-12-07T10:15:38.817152 | null |
,EXTREMITIES: Chronic skin changes. | [
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"start": 23
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} | Default | 2022-12-07T10:15:38.817403 | null |
Feeble pulses distally. | [
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"score": 0,
"start": 15
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] | Argilla | null | null | null | {
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} | Default | 2022-12-07T10:15:38.817630 | null |
,DIAGNOSTIC DATA: , EKG: Normal sinus rhythm. | [
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} | Default | 2022-12-07T10:15:38.818073 | null |
BUN and creatinine within normal limits. | [
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} | Default | 2022-12-07T10:15:38.818905 | null |
Potassium within normal limits. | [
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"medical_specialty": " Cardiovascular / Pulmonary"
} | Default | 2022-12-07T10:15:38.819136 | null |
The patient admitted for gastrointestinal pathology, under working treatment. | [
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{
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] | Argilla | null | null | null | {
"medical_specialty": " Cardiovascular / Pulmonary"
} | Default | 2022-12-07T10:15:38.819582 | null |
History of prior heart murmur with echocardiogram findings as above. | [
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} | Default | 2022-12-07T10:15:38.820036 | null |
Basically revealed normal left ventricular function with left atrial enlargement, large pleural effusion, and severe mitral regurgitation and tricuspid regurgitation. | [
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} | Default | 2022-12-07T10:15:38.820371 | null |
From cardiac standpoint, conservative treatment. | [
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Possibility of a transesophageal echocardiogram to assess valvular insufficiency adequately well discussed extensively. | [
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} | Default | 2022-12-07T10:15:38.821105 | null |
After extensive discussion, given her age 86, limited activity level, and no intention of undergoing any treatment in this regard from a surgical standpoint, the patient does not wish to proceed with a transesophageal echocardiogram. | [
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She has a normal LV function. | [
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] | Argilla | null | null | null | {
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} | Default | 2022-12-07T10:15:38.822416 | null |
HISTORY OF PRESENT ILLNESS: , In short, the patient is a 55-year-old gentleman with long-standing morbid obesity, resistant to nonsurgical methods of weight loss with BMI of 69.7 with comorbidities of hypertension, atrial fibrillation, hyperlipidemia, possible sleep apnea, and also osteoarthritis of the lower extremities. | [
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"medical_specialty": " Bariatrics"
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He is currently smoking and he is planning to quit and at least he should do this six to eight days before for multiple reasons including decreasing the DVT, PE rates and marginal ulcer problems after surgery, which will be discussed later on. , | [
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PHYSICAL EXAMINATION: , On physical examination today, he weighs 514.8 pounds, he has gained 21 pounds since the last visit with us. | [
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His pulse is 78, temperature is 97.5, blood pressure is 132/74. | [
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He is a pleasant gentleman with stigmata of supermorbid obesity expected of his size. | [
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Abdomen is soft, nontender. | [
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No incisions. | [
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No umbilical hernia, no groin hernia, has a large abdominal pannus. | [
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No hepatosplenomegaly. | [
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Lower extremities; no pedal edema. | [
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No calf tenderness. | [
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Deep tendon reflexes are normal. | [
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Regular rate and rhythm. , | [
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DISCUSSION:, I had a long talk with the patient about laparoscopic gastric bypass possible open including risks, benefits, alternatives, need for long-term followup, need to adhere to dietary and exercise guidelines. | [
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I also explained to him complications including rare cases of death secondary to DVT, PE, leak, peritonitis, sepsis shock, multisystem organ failure, need for reoperations, need for endoscopy for bleeding or leak, operations which could be diagnostic laparoscopy, exploratory laparotomy, drainage procedure, gastrostomy, jejunostomy for feeding, bleeding requiring blood transfusion, myocardial infarction, pneumonia, atelectasis, respiratory failure requiring mechanical ventilation, rarely tracheostomy, rare cases of renal failure requiring dialysis, etc., | [
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All these are going to be at high risk for this patient secondary to his supermorbid obese condition. , | [
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I also explained to him specific gastric bypass related complications including gastrojejunal stricture requiring endoscopic dilatation, marginal ulcer secondary to smoking or antiinflammatory drug intake, which can progress on to perforation or bleeding, small bowel obstruction secondary to internal hernia or adhesions, signs and symptoms of which are described, so the patient could alert us for earlier intervention, symptomatic gallstone formation during rapid weight loss, how to avoid it by taking ursodiol, which will be prescribed in the postoperative period. , | [
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Long-term complication of gastric bypass including hair loss, excess skin, multivitamin and mineral deficiencies, protein-calorie malnutrition, weight regain, weight plateauing, psychosocial and marital issues, addiction transfer, etc., | [
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The patient is at higher risk than usual set of patients secondary to his supermorbid obesity of BMI nearing 70 and also major cardiopulmonary and metabolic comorbidities. | [
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Smoking of course does not help and increase the risk for cardiopulmonary complications and is at increased risk for cardiac risk. | [
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He will be seen by cardiologist, pulmonologist. | [
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