discharge summary

DISCHARGE SUMMARY

ADMITTING DIAGNOSIS: Large colloid goiter.

FINAL DIAGNOSIS: SameLarge colloid goiter.

PROCEDURE: Total thyroidectomy.

COMPLICATIONS: Bibasilar discoid atelectasis with probable pneumonitis.

HISTORY: This is a 68-year-old woman who was seen probably about three years ago, with pale a large colloid goiter. She was going to have surgery then but declined, and came back in more recently because of the increasing size of the goiter and the pressure symptoms in her neck and throat. Studies previously done showed this to be a non-toxic goiter. She was essentially euthyroid. Because of its increasing size, the possibility of malignancy had to be considered.

PHYSICAL EXAMINATION: Was Physical examination was not remarkable except the patient is being somewhat overweight and the large goiter which was visible and the right side being larger thatthan the left. The patient, because of religious customs would not allow pelvic or rectal examination.

Following surgery the patient had no problem speaking. He She is swallowing and eating solid food. Throat is sore. She did develop a temperature up to 101 and had some ronchirhonchi in both bases on auscultation.

Chest x-ray shows discoid atelectasis with probable pneumonitis. Her white count was elevated at a little over 12,000 with a left shift. Temperature this morning iswas 100 degrees. The wound is clean and dry. The drain has been removed, and ½one-half of the staples are removed. She will be continued on Tetracyclinetetracycline 500 mg q.i.d., and she iswas instructed to take her Lanoxin daily and her Dyazide as well. We are giving her Synthroid, and she is to take that every day. I have stressed the importance to her son of taking the Synthroid, as she should have no thyroid function. Her calcium was 8.6.

end of report

DISCHARGE SUMMARY

This was one of several admissions for the threethis nearly 3-year-old boy for bilateral inguinal hernia repairs. Impression for this nearly three-year-old boy for bilateral inguinal hernia repairs. Swelling in the left groin was noted several weeks prior toat admission. He has had pains in the groins on and off.

He is was found to have bilateral inguinal hernia repairs. The child is also followed because of congenital Addison’s disease. He is on Cortef and Florinef acetate. Acetate.

Because of the Addison’s disease, he iswas treated with cortisone acetate IM, 50 mg on admission, and
Solu-Cortef 50 mg IM one hour prior to surgery. A 50 mg of Solu-Cortef was ranrun during the surgery. Four hours after completion of the surgery, he received
12.5 mg of Solu-Cortef IM.

LABORATORY DATA: Hemoglobin 12.1. WBC 5,500. BUN 18 and electrolytes 140, 3.9, and 23.

DISCHARGE DIAGNOSIS:
1. Addison’s disease.
2. Bilateral inguinal hernias.

DISCHARGE MEDICATION: IncludedDischarge medication included only his usual medications for Addison’s disease.


end of report

DISCHARGE SUMMARY

ADMITTING DIAGNOSIS:
1. Diabetic Kioacidosisketoacidosis – mild to moderate in severity.
2.Type 1 Diabetes Mellitus.
2. Type 1 diabetes mellitus.
3. Bronchitis and gastroenteritis.
4. Mild dehydration.

DISCHARGE DIAGNOSIS:
1. Diabetic Kioacidosis – ketoacidosis –resolved.
2.Type 1 Diabetes Mellitus.
2. Type 1 diabetes mellitus.
3. Bronchitis and gastroenteritis.
4. Mild dehydration.

ADMITTING HISTORY AND PHYSICAL EXAMINATION: Physical findings - theFINDINGS: The patient is a 17-year-old white female, with eight 8-year history of type 1 diabetes, now on 14 units of old Proventil, Ultralente insulin and 13 units of regular Humulin q.a.m.,.; 12 unitunits of regular Humulin q. noon,; 14 units of old ProventilUltralente and 14 units of regular Humulin q. p.m. Who., who insists she is has been taking her insulin regularly andbut complains of two 2-to three weeks 3-week history of cough with yellow phlegm for two2 days and emesis and abdominal pain for the day prior to admission.

LABORATORY DATA: Atrial: Arterial blood gases ph: pH 7.2, APC 28, PCO2 29, PO2 85, bicarbonate 13, glucose. Glucose 626, urinalysis. Urinalysis unremarkable.

HOSPITAL COURSE: The patient was admitted to the medical floor and given I.V. insulin bolus of 10 units of regular and then placed on an insulin drip. Blood sugar rapidly normalized and her bicarbonate gradually rose to a level of 25. She was given IV fluid hydration with normal saline and potassium chloride initially. She received dietary counseling before discharge. She seemed to understand the instruction adequately. ForHer fasting blood sugar on the day of discharge and on her usual insulin dose was a 130. This was on a 2,000 -calorie ADA diet (patient states she had been taking a 2800 -calorie diet).

DISPOSITION: Discharge Discharged to home.

MEDICATIONS: Patient to continue the usual out-patient insulin dosage regimen. EpizoneAmpicillin 500 mg q.i.d. x 10 days. Patient was instructed to stop or minimize her smoking. She will see her endocrinologist in one week and will be seen by me in two2 weeks, as she has recently moved to this area. We wereShe was instructed to call upif blood sugarsugars run less than 80 or greater thatthan 300 –- she will be checking thisthese at home.


end of report

DISCHARGE SUMMARY

ADMITTING DIAGNOSIS: Cystocele with urinary incontinence.

FINAL DIAGNOSIS: Cystocele with urinary incontinence.

PROCEDURE: Anterior repair.

COMPLICATIONS: None.

HISTORY: This is a 65-year-old woman who had had a previous history of hysterectomy, who developed urinary incontinence, and was found to have a large cystocele.

Physical examination was unremarkable except for the cystocele.

Lab work, including a panel, CBC, EKG, and chest x-ray were, was essentially within normal limits.

Following surgery, the patient has done well. The vaginal pack iswas removed this date and a the Foley catheter. She will be checked for residual. If the residual is over 150 cc, the Foley will be replaced, and the patient taught to use athe catheter plug, and she will be discharged. She will be seen in the office in approximately one week for follow-up.


end of report

DISCHARGE SUMMARY

This patient was brought to the hospital outpatient ambulatory care center. The patient was brought to surgery, where she underwent arthroscopy of the right knee.

Arthroscopy of the right knee revealed the following problems. The patient was noted to have an acute hemarthrosis of the right knee. She was also found to have a partial tear of the anterior cruciate. An osteochondral fracture of the lateral femoral condyle was also present.

The patient did undergo a debridement of the right knee and also underwent an osteochondroplasty of the lateral femoral condyle.

The patient was then placed into a long leg immobilizer for the right leg.

The patient was fFurther mobilized with crutches when she awakened. She was able to be discharged from the hospital on the same day.

FINAL DIAGNOSIS:

1. Partial tear, anterior cruciate, right knee.
2. Osteochondral fracture, femoral condyle, right knee

The patient will require a healing period, as well as a rehabilitative exercise program for the right knee. A temporary total disability time of eight weeks is anticipated.

end of report

DISCHARGE SUMMARY

FINAL DISCHARGE DIAGNOSIS:
1. Cytomegalovirus retinitis, left eye
2. Molluscum contagiosum

HOSPITALIZATION: This 36-year-old white male with positive HIV antibody, acquired immune deficiency syndrome and prior Ppneumocystis carinii pneumonia was admitted to the hospital with progressive deterioration of vision in his left eye due to cytomegalovirus retinitis. After informed formal consent was obtained, the patient was started on antiviral therapy with gGanciclovir. At the time of initiation of therapy, the patient’s CBC showed hemoglobin of 11, hematocrit of 32.8, white blood cell count of 1600 with 41 6segs, one band, and platelets 158,000., Serum creatinine count was 1.0, and BUN was 8., Lliver function tests were normal.

Patient was given gGanciclovir 5mg/ per kg, twice a day. After two days of therapy, the patient’s WBC had dropped to 1600 with 28% segs 6,. Then again,and the gGanciclovir was held for 36 hours. Following this, his white blood cell count recovered well enough so that the Gganciclovir was re-started at the same dose. He received subsequent three days of gGanciclovir therapy in the hospital.

Prior to discharge, his final WBC was 1900 with 63% segs 6 and 2 bandsBUNs. Hhemoglobin was 11.9,. Hhematocrit, 35.6,. Pplatelets, 158,000.

Additional laboratory values showed negative serum RPR and negative tToxoplasma anti-body.

The patient was discharged to complete Gganciclovir therapy for two weeks at home.

DISCHARGE MEDICATION: Include Gganciclovir 300mg I.V. q.12h.rs for 14 days. pPentamidine aerosol 150 mg twice a month, Nizoral 200mg p.o. p.r.n.

I will see the patient back in the office in and follow-up in two weeks. Also, while the patient was in the hospital, he was seen in dermatology consultation and had cryotherapy to remove several lesions of molluscum contagiosum from the patient to affirm his face flies.


end of report