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OPERATIVE
REPORT
Patient Name: XXXXX
Hospital No.:
XXXX
Date of Surgery:
03/25/----
Admitting
Physician: Lisa Kelly, M.D.
Surgeons:
Wong Delgato, M.D.
Preoperative
Diagnosis: Tachybrady Syndrome.
Postoperative
Diagnosis: Tachybrady Syndrome.
Operative
Procedure: Insertion Transvenous Pacemaker.
Anesthesia:
Local
PROCEDURE AND
GROSS FINDINGS: The patient=s chest was prepped with
Betadine solution and a small amount of Lidocaine infiltrated. In the left subclavian
region, a subclavian stick was performed without difficulty, and a wire was inserted. Fluoroscopy confirmed the presence of
the wire in the superior vena cava. An introducer was then placed over the wire. The wire was removed and replace by a ventricular lead that was seated under Fluoroscopy.
Following calibration, the lead was attached to a pacemaker generator that was inserted in a subcutaneous pocket in the left
subclavian area.
The subcutaneous tissues
were irrigated and closed with Interrupted 4-O Vicryl, and the skin was closed with staples.
Sterile dressings were placed, and the patient was returned to the ICU in good condition.
_________________________
Wong Delgato,
M.D.
WD:mw
D:03/25/----
T:03/25/----
RADIOLOGY REPORT
Patient Name: XXXX XXXX
Hospital No.: 13246
X-ray No.: 98-8025
Admitting Physician: Leon Medina, M.D.
Procedure: Chest PA and lateral views.
Date: 6/22/----
CLINICAL
INFORMATION: Dehydration. Possible
Stevens-Johnson syndrome. Routine admission chest film.
PA
and lateral views of the chest revealed a normal-sized heart. The lungs are clear
of any active infiltrations. Elongated aorta noted. Thoracic kyphosis with wedging of multiple vertebral bodies. Arthritic
changes noted in the left shoulder.
IMPRESSION: No active chest process.
_________________________
Raymond Westin, M.D.
RW:mw
D:06/23/----
T:06/23/----
HISTORY
AND PHYSICAL EXAMINATION (H&P)
Patient Name: XXXXX
Hospital Number: 13246
Room No.: 541
Date of Admission: 06/22/----
Admitting Physician: Leon Medina, M.D.
Admitting Diagnosis: Stomatitis possibly methotrexate related.
CHIEF
COMPLAINT: Swelling of lips causing difficulty swallowing.
HISTORY
OF PRESENT ILLNESS: This patient is a 57-year old white Cuban woman with a long history of rheumatoid arthritis. She has received methotrexate on a weekly basis as an outpatient for many years. Approximately two weeks ago, she developed a respiratory infection for which she received antibiotics. She developed some ulcerations of the mouth and was instructed to discontinue the
methotrexate approximately ten days ago. She showed some initial improvement,
but over the last 3-5 days has had malaise, a low-grade fever, and severe oral ulcerations with difficulty in swallowing although
she can drink liquids with less difficulty.
The
patient denies any other problems at this point except for a flare of arthritis since discontinuing the methotrexate. She has rather diffuse pain involving both large and small joints.
MEDICATIONS:
Prednisone 7.5 mg p.o. q.d., Premarin 0.125 mg p.o. q.d., and Dolobid 1000 mg p.o. q.d., recently discontinued because of
questionable allergic reaction. HCTZ 25 mg p.o. q.o.d., Oral calcium supplements. In the past she has been on penicillin, azathioprine, and hydroxychloroquine, but
she has not had Azulfidine, cyclophosphamide, or chlorambucil.
ALLERGIES:
None by history.
FAMILY/SOCIAL
HISTORY: Noncontributory.
PHYSICAL
EXAMINATION: This is a chronically ill appearing female, alert, oriented, and cooperative.
She moves with great difficulty because of fatigue and malaise. Vital
signs: Blood pressure 107/80, heart rate: 100 and regular, respirations 22. HEENT:
Normocephalic. No scalp lesions. Dry eyes with conjuctival injections. Mild exophthalmos. Dry nasal mucosa. Marked cracking and bleeding of her lips with erosion of the mucosa.
She has a large ulceration of the mucosa at the bite margin on the left. She
has some scattered ulcerations on her hard and soft palette. TONSILS not enlarged. No visible exudate. She has difficulty
opening her mouth because of pain. SKIN: She has some mild ecchymoses on her
skin and some erythema; she has patches but no obvious skin breakdown.
(Continued)
HISTORY
AND PHYSICAL EXAMINATION
Patient
Name: XXXXX
Hospital No.: 13246
Page
2
She
has some fissuring in the buttocks crease. PULMONARY: Clear to percussion in
auscultation. CARDIOVASCULAR: No murmurs or gallops noted. ABDOMEN: Protuberant no organomegaly and positive bowel sounds. NEUROLOGIC
EXAM: Cranial nerves II through XII are grossly intact. Diffuse hyporeflexia. MUSCULOSKELATAL:
Erosive, destructive changes in the elbows, wrist and hands consistent with rheumatoid arthritis. She also has bilateral total knee replacements with stovepipe legs and parimalleolar pitting adema 1+. I feel no pulse distally in either leg.
PROBLEMS: 1. Swelling of lips and dysphagia with questionable early Stevens-Johnson syndrome.
2. Rheumatoid Arthritis class 3, stage 4.
3. Flare of arthritis after discontinuing methotrexate.
4. Osteoporosis with compression fracture.
5. Mild dehydration.
6. Nephrolithiasis.
PLAN:
Patient is admitted for IV hydration and treatment of oral ulcerations. We will
obtain a dermatology consult. IV leucovorin will be started, and the patient
will be put on high-dose corticosteroids.
_________________________
Leon Medina, M.D.
LD:mw
D:06/22/----
T:06/22/----
DISCHARGE SUMMARY
Patient Name: XXXXXXX
Hospital No.: 11546
Admitted: 08/15/----
Discharged: 08/17/----
Consultations: None.
Procedures: Cystourethroscopy and transurethral resection of prostate.
Complications: None.
Admitting Diagnosis: Difficulty voiding.
HISTORY:
This 67-year old Hispanic male patient was admitting because of enlarged prostate and symptoms of bladder neck obstruction. Physical examination revealed normal heart and lungs.
Abdomen was negative for abnormal findings.
LABORATORY
DATA: BUN 19 and creatinine 1.1. Blood group was A, Rh positive, Hemoglobin 13,
Hematocrit 32.1, Prothrobin time 12.6 seconds, PTT 37.1. Discharge hemoglobin 11.4, and hematocrit 33.3. Chest x-ray calcified
old granulomatous disease, otherwise normal. EKG was normal.
COURSE
IN THE HOSPITAL: The patient had a cysto and TUR of the prostate. Postoperative
course was uncomplicated. The pathology report is pending at the time of dictation.
He is being discharged in satisfactory condition with a good urinary stream, minimal hematuria, and on Bactrim DS one
a day for ten days with a standard postprostatic surgery instruction sheet.
DISCHARGE
DIAGNOSIS: Enlarged prostate with benign bladder neck obstruction.
To
be followed in my office in one week and by Dr. Mendez next available as an outpatient.
______________________________________
Nancy Lawrence, M.D.
NL:mw
D:08/17/----
T:08/17/----
PATHOLOGY REPORT
Patient Name: XXXXX
Hospital No.: 11546
Pathology Report No.: S-98-1745
Admitting Physician: Nancy Lawrence, M.D.
Preoperative Diagnosis: Enlarged prostate with bladder neck obstruction.
Postoperative Diagnosis: Enlarged prostate with bladder neck obstruction.
Specimen Submitted: Prostatic tissue.
Date Received: 08/16/----
Date Reported: 08/17/----
MACROSCOPIC
EXAM: The specimen consists of 14.4 g. of pink-tan apparent prostatic tissue. Two
cassettes are taken.
MICROSCOPIC
EXAM: Multiple sections of the prostatic tissue revealed marked hyperplasia. The glands’ slides closed together, but afebrile’s stroma separates them. Corpora amylase is present within numerous glands.
Papillary epithelia hyperplasia is noted. Some of the ducts are dilated
and a periductal mononuclear cells infiltrate is noted.
PATHOLOGIC
DIAGNOSIS: Benign glandular hyperplasia of the prostate.
_________________________
Charles Mendez, M.D.
AG:mw
D:08/16/----
T:08/16/----
REQUEST FOR CONSULTATION
Patient Name: XXXXX
Hospital No.: 13246
Consultant: Sachi Kato, M.D., Dermatology
Requesting Physician: Leon Medina, M.D., Internal Medicine
Date: 06/23/----
Reason for Consultation: Please evaluate stomatitis possibly methotrexate related.
HISTORY
OF PRESENT ILLNESS: The patient is a very pleasant 57-year old white female, a native of Cuba,
being seen for evaluation and treatment of sores in her mouth that she has had for the last 10-12 days. The patient has a long history of severe and debilitating rheumatoid arthritis for which she has had numerous
treatments, but over the past ten years she has been treated with methotrexate quite successfully. Her dosage has varied somewhere between 20 and 25 mg per week. About
the beginning of this year, her dosage was decreased from 25 mg to 20 mg, but because of the flare of the rheumatoid arthritis,
it was increased to 22.5 mg per week. She has had no problems with methotrexate
as far as she knows. She also took an NSAID about a month ago that was recently
continued because of the ulcerations in her mouth. About two weeks ago, just
about the time the stomatitis began she was placed on an antibiotic for suspected upper respiratory infection. She does not remember the name of the antibiotic. Although
she claims she remembers taking this type of medication in the past without any problems.
She was on that medication three pills a day for three to four days. She
notes no other problems with her skin. She remembers no allergic reactions to
medication. She has no previous history of fever blisters.
PHYSICAL
EXAMINATION: Reveals superficial erosions along the lips particularly the lower lips.
The posterior buccal mucosa along the sides of the tongue and also some superficial erosions along the upper and lower
gingiva. Her posterior pharynx was difficult to visualize, but I saw no erosions
on the areas today. There did however appear to be one small erosion on the soft
palate. Examination of the rest of her skin revealed no areas of dermatitis or
blistering. There were some macular hyperpigmentation on the right arm where
she has had a previous burn, plus the deformities from her rheumatoid arthritis on her hands and feet as well as scars on
her knees from total joint replacement surgeries.
IMPRESSION: Erosive stomatitis probably secondary to methotrexate even though the medication has
been used for ten years without any problems. Methotrexate may produce an erosive
stomatitis and enteritis after such a use. The patient also may have an enteritis that at this point may have become more
quiescent as she notes that she did have some diarrhea about the time her mouth problem developed.
(Continued)
REQUEST
FOR CONSULTATION
Patient
Name: XXXXX
Hospital No.: 13246
Page
2
She
has had no diarrhea today, however. She has noted no blood in her stools and has had no episodes of nausea or vomiting.
I
am not as familiar with the NSAID causing an erosive stomatitis. I understand
that it can cause gastrointestinal upset, but given the choice between the two, I would think the methotrexate is the most
likely etiology for the stomatitis.
RECOMMENDED
THERAPY: I agree with your therapeutic regimen regarding this condition with the use of prednisone and folic acid. I also agree that the methotrexate must be discontinued in order to produce a resolution of this patients’
skin problem. However, in my experience, this stomatitis may take a number of weeks to go away completely if a patient been
on methotrexate, for an extended period of time, because the medication is stored within the liver and in fatty tissue. Topically I have prescribed Lidex gel, which I find works extremely well in stomatitis
conditions. It can be applied t.i.d.
Thank
you very much for allowing me to share in the care of this pleasant patient. I
will follow her with you as needed.
_________________________
Sachi Kato, M.D.
SK:mw
D:06/23/----
T:06/23/----
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