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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Chest pain and right eye blurry vision
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old lady with lupus anticoagulant,
history of recurrent PE (___), and long-standing
anxiety/panic attacks currently on coumadin who presents today
with 1.5 days of chest pain acutely worsening today accompanied
by monocular blurry vision out of the right eye.
As per Ms. ___, she has been having intermittent chest pains
___ times/week for the last month. Pain occurs when she takes a
shallow breath and then worsens when she takes a deep breath. It
usually resolves in 5 minutes and rated ___. However, 2 days
ago she developed this usual pain but it took about 30min to
resolve. There was associated tenderness to palpation under her
left breast and she felt a lump as well. There was no inciting
factor. The following day she again had the same event. Today,
she had no pain at all AM, and as per her PCP's recommendations
underwent a mammogram this afternoon. A few minutes after the
mammogram, she developed intense chest pain that felt like a
deep pain (she describes it as intermittent like "labor pains").
This then became a crushing, pressure like pain like "someone
sat on her chest." This now radiated to her right scapula and
her back and rated ___.
Along with this disabling chest pain she developed blurry vision
out of her right eye. She presented to the ER where her NIHSS=0
but she was noted to have weakness of right hand grip. She
denies any diplopia, or any vision changes out of the left eye.
She endorses photophobia in the right eye, right periorbital
pressure, as well as a migraine like headache in her left
forehead. As per her, her most recent INR was 2.6.
On neuro ROS, the patient endorses headache, and blurred vision
from R eye as well as photophoba in that eye. Denies diplopia,
dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or
hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness, numbness,
parasthesiae. No bowel or bladder incontinence or retention.
Denies difficulty with gait.
On general review of systems, the patient endorses night sweats,
chest pain and palpiations. Denies recent fever or chills. No
recent weight loss or gain. Denies cough, shortness of breath.
Denies nausea, vomiting, diarrhea, constipation or abdominal
pain. No recent change in bowel or bladder habits. No dysuria.
Denies arthralgias or myalgias. Psoriatic rash on lateral left
thigh.
Past Medical History:
Lupus anticoagulant positive
Recurrent pulmonary embolism, (___)
Hypothyroidism
Psoriasis
Panic attacks
Anxiety
PSHx:
Emergency C-section ___
Social History:
___
Family History:
Multiple PE events on both sides of the family. Mother died from
PE. Father still alive and recently had an MI. Paternal uncle
died from complications of DMII. No history of cancer in the
family.
Physical Exam:
ADMISSION EXAM:
Vitals: T:97.4 P:86 R: 24 BP:126/90 SaO2: 98% 3L NC
General: Awake, cooperative, NAD.
HEENT: NC/AT MMM, no lesions noted in oropharynx. R conjunctival
injection.
Neck: Supple. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl.
Abdomen: soft, NT/ND.
Extremities: Warm and well perfused
Skin: Large, erthematous scaly plaques on thighs.
-----------
Neurologic:
-----------
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Able
to read without difficulty from left eye but has difficulty with
right eye. Speech was not dysarthric. Able to follow both
midline and appendicular commands. The pt had good knowledge of
current events. There was no evidence of apraxia or neglect.
-Cranial Nerves:
II: visual acuity ___ out of left eye but ___ out of right
eye. PERRL 2.5mm to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades. Pain
behind right eye on EOM.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact grossly
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. Mild right drift but no
pronation.
Delt Bic Tri WrE FE FFl IP Quad Ham TA Gastroc
L 5 ___ ___ 5 5 5 5
R 5 ___ 5- ___ 5 5 5
-Sensory: No deficits to light touch or cold sensation
throughout. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was mute bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
---------------
Ophthalmologic:
---------------
Visual Acuity;
OD (sc): ___ ph ___
OS (sc): ___
Pupils (mm)
Relative afferent pupillary defect: [x] none [ ] present
OD: ___
OS: ___
Extraocular motility: Full ___
Visual fields by confrontation: Full to counting fingers ___
Color Vision (___ pseudo-isochromatic plates):
OD: ___
OS: ___
No red desat
Intraocular pressure (mm Hg):
OD: 8
OS: 8
External Exam: [x ] NL
Anterior Segment (portable slitlamp)
Lids/Lashes/Lacrimal:
OD: Normal
OS: Normal
Conjunctiva:
OD: tr injection
OS: tr injection
Cornea:
OD: Clear, no epithelial defects
OS: Clear, no epithelial defects
Anterior Chamber:
OD: Deep and quiet
OS: Deep and quiet
___:
OD: Flat
OS: Flat
Lens:
OD: Clear
OS: Clear
Fundus (Indirect Ophthalmoscopy using 20D lens): Dilation
approved by BI ER team
PLEASE NOTE, PUPILS WILL REMAIN DILATED FOR AT LEAST ___ HRS
Media/Vitreous:
OD: Clear
OS: Clear
Discs:
OD: pink, sharp margins 0.2
OS: pink, sharp margins ___
Maculae:
OD: flat, normal foveal light reflex, no emboli seen
OS: flat, normal foveal light reflex, cotton wool spot along
inferior arcade, no emboli seen
Periphery
OD: no heme, breaks or other notable lesions
OS: no heme, breaks or other notable lesions
DISCHARGE EXAM:
Unchanged from above except:
No pupillary abnormalities, red supersaturation in the right eye
(appears purple)
Pertinent Results:
___ 11:50AM GLUCOSE-123* UREA N-10 CREAT-0.7 SODIUM-137
POTASSIUM-3.6 CHLORIDE-102 TOTAL CO2-24 ANION GAP-15
___ 12:07PM URINE UCG-NEGATIVE
___ 11:50AM CALCIUM-8.2* PHOSPHATE-2.7 MAGNESIUM-2.1
___ 11:50AM WBC-4.0 RBC-3.57* HGB-11.9* HCT-36.3 MCV-102*
MCH-33.5* MCHC-32.9 RDW-14.0
___ 09:56AM ___ PTT-30.9 ___
___ 02:10AM cTropnT-<0.01
___ 07:33PM LACTATE-3.1*
___ 07:30PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 07:30PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-MOD
___ 07:30PM URINE RBC-1 WBC-2 BACTERIA-FEW YEAST-NONE
EPI-5
___ 07:15PM ALT(SGPT)-13 AST(SGOT)-21 ALK PHOS-32* TOT
BILI-0.8
___ 07:15PM cTropnT-<0.01
___ 07:15PM ___ PTT-31.6 ___
IMAGING
***
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 2 mg PO DAILY16
2. Levothyroxine Sodium 200 mcg PO DAILY
3. Prenatal Vitamins 1 TAB PO DAILY
4. Ketoconazole 2% 1 Appl TP BID
5. Fluocinonide 0.05% Ointment 1 Appl TP BID
6. Desonide 0.05% Cream 1 Appl TP BID PRN skin irritation
Discharge Medications:
1. Levothyroxine Sodium 200 mcg PO DAILY
2. Warfarin 7 mg PO 3X/WEEK ___, T, Th
3. Warfarin 6 mg PO 4X/WEEK (___)
4. ALPRAZolam 0.5 mg PO BID:PRN anxiety
RX *alprazolam 0.5 mg 1 tablet(s) by mouth twice a day Disp #*10
Tablet Refills:*0
5. ClonazePAM 0.5 mg PO BID
RX *clonazepam 0.5 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
6. Sertraline 25 mg PO DAILY
RX *sertraline 25 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*3
7. Desonide 0.05% Cream 1 Appl TP BID PRN skin irritation
8. Fluocinonide 0.05% Ointment 1 Appl TP BID
9. Ketoconazole 2% 1 Appl TP BID
10. Prenatal Vitamins 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Eye pain, blurry vision, chest pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MRI BRAIN AND ORBITS
INDICATION: ___ year old woman with new onset blurry vision // assess for
inflammatory lesions
TECHNIQUE: Multisequence, multiplanar MRI of the brain and orbits with and
without intravenous gadolinium.
COMPARISON: CTA head ___.
FINDINGS:
There is no evidence of acute intracranial hemorrhage or mass effect. The
ventricles and basal cisterns appear normal.
There is no evidence of acute ischemia based on diffusion-weighted imaging.
The brain parenchymal volume is within normal limits. There are normal
vascular flow voids. There is no abnormal brain parenchymal or leptomeningeal
enhancement.
The globes are intact. The optic nerves are symmetric without abnormal
enhancement. The extraocular muscles appear normal in size. The optic chiasm
appears normal.
The skull base and paranasal sinuses appear unremarkable.
IMPRESSION:
Normal MRI of the brain and orbits.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Chest pain, Dyspnea, Anxiety
Diagnosed with CHEST PAIN NOS, VISUAL DISTURBANCES NEC, LONG TERM USE ANTIGOAGULANT
temperature: 97.4
heartrate: 86.0
resprate: 24.0
o2sat: 98.0
sbp: 126.0
dbp: 90.0
level of pain: 6
level of acuity: 2.0 | Ms. ___ is a ___ year old right-handed female with a
significant history of lupus anticoagulant, recurrent PEs ___,
___, and longstanding anxiety/panic attacks who presented on
___ with acute onset chest pain and right eye blurry
vision.
# NEURO: She was admitted to Neurology for workup of the blurred
vision in her right eye which had developed in the ED. MRI brain
and orbits with/without contrast showed no evidence of optic
neuritis. Ophthalmology eveluated her twice with dilated
fundoscopy and found no evidence of vascular lesions. ESR/CRP
were normal.
Visual acuity varied throughout hospitalization, between ___
- ___ in the right eye over the course of hours and between
___ and ___ in the left eye over course of hours, with
inconsistencies (e.g. still able to count fingers in the right
eye despite acuity of ___. No evidence of keratitis or
corneal abrasions. ESR/CRP unremarkable. Etiology of the vision
changes was ultimately unclear but there was concern for
functional element.
# CARDIOVASC: Initial presentation to ED was for chest pain
(developed vision changes while in the ED). Troponins negative x
3, with CTA chest showing no pulmonary emboli. EKG WNL. Of note
her INR was 1, which may have been due to significant weight
gain and pt eating large amounts of leafy greens. She will see
her PCP ___ ___ to increase her Coumadin dose.
# ENDOCRINE: TSH elevated to 16 in setting of pt stopping her
Levothyroxine several months ago (just restarted two days PTA).
She will continue Levothyroxine 200mg daily on discharge. Needs
recheck TSH in ___ weeks.
# PSYCH: Started Sertraline 25mg daily for significant anxiety
and panic attacks. Also gave small prescription for LZP 0.25mg
PRN anxiety. She will follow up with her PCP and is strongly
encouraged to pursue further mental health care.
=======================
TRANSITIONS OF CARE:
-- Needs recheck TSH in ___ weeks
-- Will need Coumadin increased by PCP (he has been emailed)
-- Has f/u with PCP ___ on ___ at
9:10 am. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
nasal spray
Attending: ___
Chief Complaint:
pleuritic chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr ___ is a ___ year old man with a history of complete heart
block s/p pacemaker, hyperlipidemia, hypertension, mitral valve
prolapse s/p MVR ___, OSA, possible SIADH, recently admitted
for respiratory failure due to CHF and severe MR, discharged to
rehab, presenting with one day of pleuritic bilateral chest pain
and dyspnea.
Briefly, he was admitted from ___ to ___ after requiring
intubation for respiratory failure related to CHF and severe
mitral regurgitation. Had acute renal failure in setting of
attempted diuresis so required CVVH for fluid removal. Multiple
extubation attempts failed due to recurrent flash pulmonary
edema on zero-PEEP trials, and he was treated with broad
spectrum abx for potential pneumonia, with eventually negative
bronch/infectious work-up. IABP was placed ___ for afterload
reduction. On ___ had MV repair with P2 triangular resection
and annuloplasty, and b/l drainage of pleural effusions.
Post-operatively, he again failed trial of extubation. Then had
R sided PTX requiring pigtail & eventually required VATS in
setting of acute Hct drop & RUL infiltrate w/ evacuation of
hematoma on ___. Extubated on ___. Also noted to be somnolent
and confused w/ neg head CT & EEG showing evidence of
encephalopathy. CCU course also complicated by persistent
fevers, attributed to cefepime (fevers stopped once cefepime
switched to zosyn). He was discharged on intermittent
hemodialysis via a temporary line, which was discontinued while
at rehab and HD was stopped.
___ notes indicate that he has had significant
swallowing issues, and has had low-grade fevers and cough. Chest
XR showed new pleural effusion but no infiltrate (unclear what
date of CXR was). He was treated with levaquin x5 days starting
___, and with bumex given the effusions.
He has had slow recovery of swallowing function at rehab, and
is still on modified diet with thickened liquids and ground
solids. He denies any recent frank aspiration events.
One day prior to presentation, he started to have mild
shortness of breath, and cough (minimally productive) with
pleuritic pain in the left posterior lower ribs and mid-right
chest. No chest tightness or pressure. His breathing has been
"hard" but denies wheezing or choking on secretions.
Denies fevers, chills, sore throat, rhinorrhea, nausea,
vomiting, abdominal pain, BRBPR, melena, constipation,
distention, urinary complaints, lower extremity edema,
orthopnea, leg pain. He notes he has had watery diarrhea for the
past week or so.
In the ED, initial vitals were: T 98.2 HR 65, BP 110/67 RR 20
SPO2 97% RA
- Exam notable for: nonreproducible chest pain, murmur c/w MV
replacement, no HSM, no ___ edema, lungs coarse at bases. No
respiratory distress.
- Labs notable for:
--WBC 12.9 (78% PMNs), Hgb 9.4, plt 417
--INR 1.3
--Na 133, K 4.1, HCO3 21, creatinine 1.0, BUN 16, glucose 100,
anion gap 19
--pro BNP 383, troponin T <0.01
--urinalysis: trace protein, few bacteria, otherwise negative
- Imaging was notable for: CXR demonstrated bibasilar
consolidations, worrisome for pneumonia, with atelectasis.
- Patient was given: cefepime 2g, vancomycin IV. He had to be
given diphenhydramine for itching, which was attributed to
vancomycin, and so the rate of vanco infusion was slowed.
Past Medical History:
Anxiety
Complete Heart Block status post PPM placement
Depression
Empty Sella Syndrome
Hyperlipidemia
Hypertension
Hyponatremia with possible SIADH
Hypothyroid
Mitral Regurgitation
Mitral Valve Prolapse
Obstructive Sleep Apnea
Social History:
___
Family History:
No premature coronary artery disease
Mother - conduction abnormality -- PPM in her ___
Physical Exam:
ADMISSION EXAM:
===============
Vital Signs: T97.9, BP 113 / 73, HR 73 RR20, SPO2 94 ra
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Bilateral lower to mid lung fields with rhonchi and
rales. No wheezing. Shallow breathing, without tachypnea. Deep
breaths provoke coughing and wincing in pain.
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. No asymmetry in diameter of calves.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
DISCHARGE EXAM:
===============
PHYSICAL EXAM: I/O:1392/900
Weight: 205.69 lb from 94.8 kg (___)
Vitals: 97.3 PO 116/61 63 ___ RA
General: Alert and oriented, no acute distress, intermittent
cough
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP at 5 cm with bed at 30 degrees, no LAD
Lungs: bibasilar crackles
CV: Distant heart sounds; Regular rate and rhythm, normal S1 +
S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: No obvious lesions appreciated
Neuro: alert and oriented X3, CNII-XII grossly intact; BLE and
UE strength intact.
Pertinent Results:
ADMISSION LABS:
==============
___ 01:30PM BLOOD WBC-12.9* RBC-3.16* Hgb-9.4* Hct-28.8*
MCV-91 MCH-29.7 MCHC-32.6 RDW-14.6 RDWSD-49.0* Plt ___
___ 01:30PM BLOOD Neuts-78.4* Lymphs-9.3* Monos-7.1 Eos-3.8
Baso-0.5 Im ___ AbsNeut-10.12*# AbsLymp-1.20 AbsMono-0.91*
AbsEos-0.49 AbsBaso-0.06
___ 01:30PM BLOOD ___ PTT-30.2 ___
___ 01:30PM BLOOD Glucose-100 UreaN-16 Creat-1.0# Na-133
K-4.1 Cl-98 HCO3-21* AnGap-18
___ 06:10AM BLOOD ALT-67* AST-33 AlkPhos-93 TotBili-0.2
___ 01:30PM BLOOD proBNP-383*
___ 06:10AM BLOOD Albumin-PND Calcium-8.6 Phos-4.5 Mg-2.2
IMAGING:
=======
CXR ___ FINDINGS:
Patient is status post median sternotomy and cardiac valve
replacement. Dual lead left-sided pacemaker is seen with lead
extending 2 the expected positions of the right atrium right
ventricle. Bibasilar opacities are seen worrisome for
consolidation, possibly due to pneumonia or aspiration. Linear
right upper lobe opacity most likely represents
Atelectasis/scarring. No pleural effusion is seen. There is no
evidence of pneumothorax. Cardiac size is borderline.
The mediastinum is not widened.
IMPRESSION:
Bibasilar consolidations, worrisome for pneumonia or aspiration,
with likely some atelectasis.
VIDEO SWALLOW ___
1. Asymmetric swallowing with left-sided pharyngeal weakness.
Recommend
direct visual inspection with laryngoscopy.
2. Delayed swallow initiation with all consistencies.
3. Penetration of consecutively sipped thin liquids, improved
with head turn, chin-tuck, or single sip maneuvers.
4. No aspiration.
Please refer to the speech and swallow division note in OMR for
full details, assessment, and recommendations.
RECOMMENDATION(S): Asymmetric swallowing with left-sided
pharyngeal weakness. Recommend direct visual inspection with
laryngoscopy.
CXR ___:
IMPRESSION:
No gross change compared with ___.
Status post sternotomy, with dual lead pacemaker.
Cardiomediastinal
silhouette is unchanged.
As before, the basilar opacities raise the possibility of
infectious
infiltrates or changes related to aspiration pneumonitis.
Minimal, if any, pleural fluid.
Mild vascular plethora suggesting mild CHF, also similar to the
prior study.
No pneumothorax detected. Likely ___ artifact adjacent to the
aortic knob.
MICRO:
======
Sputum ___ 10:12 am SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
___ PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final ___:
TEST CANCELLED, PATIENT CREDITED.
Urine ___ 10:00 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
BCx ___
NGTD
DISCHARGE LABS:
=============
___ 06:14AM BLOOD WBC-8.9 RBC-2.79* Hgb-8.3* Hct-25.7*
MCV-92 MCH-29.7 MCHC-32.3 RDW-14.6 RDWSD-49.4* Plt ___
___ 06:14AM BLOOD Glucose-85 UreaN-12 Creat-1.0 Na-135
K-4.5 Cl-102 HCO3-23 AnGap-15
___ 06:14AM BLOOD Calcium-8.6 Phos-3.8 Mg-2.2
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 200 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
4. Escitalopram Oxalate 10 mg PO DAILY
5. Levothyroxine Sodium 175 mcg PO DAILY
6. Metoprolol Tartrate 25 mg PO TID
7. Miconazole 2% Cream 1 Appl TP BID
8. Omeprazole 20 mg PO DAILY
9. Polyethylene Glycol 17 g PO DAILY
10. amLODIPine 10 mg PO DAILY
11. ClonazePAM 1 mg PO DAILY
12. TraZODone 50 mg PO QHS
13. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Mild
14. Bisacodyl 10 mg PR QHS:PRN constipation
15. LORazepam 0.5 mg PO Q8H:PRN anxiety
16. Furosemide 20 mg PO DAILY
17. Saccharomyces boulardii 250 mg oral BID
18. Tamsulosin 0.4 mg PO QHS
19. Benzonatate 100 mg PO TID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
HCAP
Chronic diastolic CHF
Dysphagia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with chest pain// eval for infiltrate
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
Patient is status post median sternotomy and cardiac valve replacement. Dual
lead left-sided pacemaker is seen with lead extending 2 the expected positions
of the right atrium right ventricle. Bibasilar opacities are seen worrisome
for consolidation, possibly due to pneumonia or aspiration. Linear right upper
lobe opacity most likely represents atelectasis/scarring. No pleural effusion
is seen. There is no evidence of pneumothorax. Cardiac size is borderline.
The mediastinum is not widened.
IMPRESSION:
Bibasilar consolidations, worrisome for pneumonia or aspiration, with likely
some atelectasis.
Radiology Report
EXAMINATION: Oropharyngeal swallowing video fluoroscopy
INDICATION: ___ year old man with dysphagia.
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the speech and swallow division. Multiple consistencies of
barium were administered.
DOSE: Fluoro time: 03:45 min.
COMPARISON: None.
FINDINGS:
There is delayed swallow initiation with all consistencies. Swallowing was
asymmetric in the frontal view with left-sided weakness. There was
penetration of consecutively sipped thin liquids, which improved with head
turn, chin-tuck, or single sip maneuvers. A moderate amount of residue
collected within the bilateral piriform sinuses. No aspiration.
IMPRESSION:
1. Asymmetric swallowing with left-sided pharyngeal weakness. Recommend
direct visual inspection with laryngoscopy.
2. Delayed swallow initiation with all consistencies.
3. Penetration of consecutively sipped thin liquids, improved with head turn,
chin-tuck, or single sip maneuvers.
4. No aspiration.
Please refer to the speech and swallow division note in OMR for full details,
assessment, and recommendations.
RECOMMENDATION(S): Asymmetric swallowing with left-sided pharyngeal weakness.
Recommend direct visual inspection with laryngoscopy.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with prior bibasilar opacities// evolution of
prior bibasilar opacities
COMPARISON: Chest x-ray from ___ at 14:08.
FINDINGS:
Dual lead left-sided pacemaker in place, with lead tips over right atrium
right ventricle. Status post sternotomy, with prosthetic valve. Heart size
is at the upper limits of normal. The cardiomediastinal silhouette is
unchanged.
Again seen is vascular plethora, suggesting mild CHF.
There are also opacities at both bases, similar to the prior study.
Corresponding patchy opacities noted in the lower lobe on lateral view.
Blunting of the costophrenic angles, without gross effusion, similar to prior.
Again seen is platelike atelectasis in the right upper zone.
No conventional pneumothorax is detected. Curvilinear lucency along the
aortic knob raises possibility of a small amount of mediastinal air, but is
similar to the appearance on the ___ and ___ radiographs
and may represent ___ artifact.
IMPRESSION:
No gross change compared with ___.
Status post sternotomy, with dual lead pacemaker. Cardiomediastinal
silhouette is unchanged.
As before, the basilar opacities raise the possibility of infectious
infiltrates or changes related to aspiration pneumonitis. Minimal, if any,
pleural fluid.
Mild vascular plethora suggesting mild CHF, also similar to the prior study.
No pneumothorax detected. Likely ___ artifact adjacent to the aortic knob.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Chest pain, Dyspnea
Diagnosed with Pneumonia, unspecified organism
temperature: 98.2
heartrate: 65.0
resprate: 20.0
o2sat: 97.0
sbp: 110.0
dbp: 67.0
level of pain: 10
level of acuity: 2.0 | Mr. ___ ___ yo M with history of CHB s/p pacemaker ___,
HLD, HTN, OSA on CPAP who presents from ___ after a
recent admission for respiratory failure due to CHF and severe
MR ___ repaired with CSURG ___ with cough and
bilateral pleuritic chest pain. Admission CXR consistent with
pneumonia so patient treated with HAP coverage vanc/ceftazidime
with significant improvement. Sputum samples did not ultimately
provide an organism. De-escalated abx and returns to rehab
___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
___
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a pleasant ___ yo woman with medical history of
HTN who was transferred from an OSH for management of a new
thalamic IPH. Per reports she was in her usual state of health
today, and developed mild confusion. So her family took her to
___. There a NCHCT showed intraparenchymal hemorrhage.
At the time she was noted to have an SBP of 200, so she was
started on nicardipine gtt.
Per daughter picked her up a 2:30pm to go to laudromat. She
noted her to be somewhat confused. Saying she was not ok but
then saying that she was. They went to the Laudromat, and then
she allowed her daughter to drive her home which is out of
character. She was off balance per the daughter "kind of
staggering". She left her at home and when returned she seemed
confused. She was following commands but felt tired. She did not
have issues with her speech just confusion. At baseline she has
cataracts and difficulty with vision so she attributed her
unsteadiness to this. She did not answer correctly to her
daughter asking who the president was. She was taken to an OSH
where her NCHCT showed an IPH.
Past Medical History:
1. DMII
2. HTN
3. HLD
Social History:
___
Family History:
Son: With AVM
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals:
T: 98.3
HR: 76
BP: 139/66
RR: 18
SaO2: 98% RA
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
Awake, alert, oriented to person and place but not date. Able to
relate history with dauhgters assistance. Attentive, able to
name ___ backward without difficulty. Speech is fluent with full
sentences, intact repetition, and intact verbal comprehension.
Naming intact. No paraphasias. No dysarthria. Normal prosody.
Able to register 3 objects and recall ___ at 5 minutes. No
apraxia. No evidence of hemineglect. No left-right confusion.
Able to follow both midline and appendicular commands.
- Cranial Nerves - PERRL 3->2 brisk. VF full to number counting.
EOMI, no nystagmus. V1-V3 without deficits to light touch
bilaterally. No facial movement asymmetry. Hearing intact to
finger rub bilaterally. Palate elevation symmetric.
SCM/Trapezius strength ___ bilaterally. Tongue midline.
- Motor - Normal bulk and decreased tone. No drift. No tremor or
asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 4 ___ ___ 4 5 5 5 5 5
R 4 ___ ___ 4 5 5 5 5 5
- Sensory - No deficits to light touch, pin, or proprioception
bilaterally. No exinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response flexor bilaterally.
- Coordination - No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating movements.
- Gait - Deferred.
==========================================================
DISCHARGE PHYSICAL EXAM:
98.3 BP 133-164/59-62 HR ___ RR ___ SAT 98% RA GLUCOSE
143-177
Neurologic Examination:
Awake, alert, oriented to person, place and time. Had trouble
remembering why she was in the hospital. Attentive, able to name
MOW backward without difficulty. Speech is fluent with full
sentences, intact repetition, and intact verbal comprehension.
Naming intact. No paraphasias. No dysarthria. Normal prosody.
Able to register 3 objects and recall ___ at 5 minutes. No
apraxia. No evidence of hemineglect. No left-right confusion.
Able to follow both midline and appendicular commands.
- Cranial Nerves - PERRL 3->2 brisk. VF full to number counting.
EOMI, no nystagmus. V1-V3 without deficits to light touch
bilaterally. No facial movement asymmetry. Hearing intact to
finger rub bilaterally. Palate elevation symmetric.
SCM/Trapezius strength ___ bilaterally. Tongue midline.
- Motor - Normal bulk and decreased tone. No drift. No tremor or
asterixis.
No drift.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 4 5 5 5 5
R 5 ___ ___ 4 5 5 5 5
- Sensory - No deficits to light touch.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response flexor bilaterally.
- Coordination - No dysmetria with finger to nose testing
bilaterally.
- Gait - Walks unassisted with good stride, normal step height.
Pertinent Results:
ADMISSION LABS:
___ 01:35AM URINE COLOR-Straw APPEAR-Hazy SP ___
___ 01:35AM URINE BLOOD-TR NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-LG
___ 01:35AM URINE RBC-2 WBC-5 BACTERIA-FEW YEAST-NONE
EPI-11
___ 12:45AM GLUCOSE-164* UREA N-9 CREAT-0.6 SODIUM-140
POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-26 ANION GAP-15
___ 12:45AM cTropnT-<0.01
___ 12:45AM WBC-6.0 RBC-4.44 HGB-12.8 HCT-39.0 MCV-88
MCH-28.8 MCHC-32.8 RDW-12.9 RDWSD-41.1
___ 12:45AM NEUTS-65.2 LYMPHS-18.8* MONOS-8.5 EOS-6.0
BASOS-1.0 IM ___ AbsNeut-3.91 AbsLymp-1.13* AbsMono-0.51
AbsEos-0.36 AbsBaso-0.06
___ 12:45AM PLT COUNT-242
___ 12:45AM ___ PTT-31.2 ___
IMAGING:
CT HEAD ___:
1. No significant interval change.
2. Persistent left thalamic intraparenchymal hemorrhage without
evidence of new hemorrhage.
3. Persistent, active paranasal sinus disease.
DISCHARGE LABS:
___ 03:25AM BLOOD WBC-6.3 RBC-4.32 Hgb-12.2 Hct-38.1 MCV-88
MCH-28.2 MCHC-32.0 RDW-13.2 RDWSD-42.9 Plt ___
___ 03:25AM BLOOD Glucose-120* UreaN-16 Creat-0.6 Na-144
K-3.3 Cl-107 HCO3-27 AnGap-13
___ 03:25AM BLOOD Calcium-9.1 Phos-3.7 Mg-2.1
___ 03:25AM BLOOD %HbA1c-6.4* eAG-137*
___ 03:25AM BLOOD TSH-5.1*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 30 mg PO DAILY
2. GlipiZIDE 5 mg PO DAILY
3. Metoprolol Succinate XL 25 mg PO BID
Discharge Medications:
1. Lisinopril 40 mg PO DAILY
RX *lisinopril 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*2
2. GlipiZIDE 5 mg PO DAILY
3. Metoprolol Tartrate 25 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left thalamic intraparenchymal hemorrhage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ woman with hypertension ending new thalamic
intraparenchymal hemorrhage. Evaluate for interval change.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.8 s, 16.5 cm; CTDIvol = 51.4 mGy (Head) DLP =
848.0 mGy-cm.
Total DLP (Head) = 848 mGy-cm.
COMPARISON: Noncontrast head CT performed at an outside facility, ___
___, dated ___ and uploaded onto PACS.
FINDINGS:
No significant interval change from the prior CT.
Hyperdensity in the left thalamus corresponds to the known acute
intraparenchymal hemorrhage and is overall similar in size in appearance to
the prior exam (series 3, image 15). No new hemorrhage. A focal hypodensity
in the periventricular white matter are of the right frontal lobe is unchanged
from the prior exam and has density similar to CSF, likely reflecting a old
infarct (series 3, image 19). A small hypodensity in the left basal ganglia
is most likely a dilated perivascular space rather than an old lacunar
infarct, unchanged (series 3, image 13). Bilateral periventricular white
matter hypodensities are nonspecific but most likely reflect sequelae of
chronic small vessel ischemic disease, unchanged. Gray-white matter
differentiation appears preserved. Incidental bilateral calcifications of the
cavernous internal carotid artery is are moderate.
No shift of normally midline structures. The basal cisterns are patent. The
overall configuration and size of the ventricles are unchanged with background
bilateral prominence of the ventricles and sulci consistent with age-related
involutional change.
No evidence of fracture. Air-fluid level in the right and air slice
secretions in the left frontal sinuses are overall unchanged and suggests
active inflammation. There is mucosal thickening and partial opacification of
some of the bilateral ethmoidal air cells, similar the prior exam. The
remaining incompletely visualized paranasal sinus clear. The mastoid air
cells and middle ear cavities are clear. The visualized portion of the orbits
are unremarkable.
IMPRESSION:
1. No significant interval change.
2. Persistent left thalamic intraparenchymal hemorrhage without evidence of
new hemorrhage.
3. Persistent, active paranasal sinus disease.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: SAH, Transfer
Diagnosed with Other nontraumatic intracerebral hemorrhage
temperature: 98.3
heartrate: 76.0
resprate: 18.0
o2sat: 98.0
sbp: 139.0
dbp: 66.0
level of pain: 0
level of acuity: 2.0 | ___ is an ___ yo woman with medical history of DM and HTN
was transferred from an OSH for management of a new thalamic
IPH.
# Thalamic Intraparenchymal Hemorrhage:
She presented to the ED after developing mild confusion and gait
unsteadiness. Head CT showed intraparenchymal hemorrhage. She
was started on nicardipine gtt for SBP of 200. Her initial
neurologic exam was remarkable for mild inattention, as well as
mild right sided weakness. Etiology of the IPH is likely HTN
given the location and hypertension at presentation. The
differential diagnosis also includes vascular abnormality (like
AVM or cavernoma), underlying tumor, amyloid, or underlying
stroke but all of those are much less likely. She was admitted
to the ICU for close blood pressure control with a nicardipine
drip to maintain systolic blood pressure under 140.
Patient was transitioned to the floor and her home medications
were restarted and uptitrated as needed to maintain her blood
pressure goals. She was evaluated by ___ who thought she would
benefit from rehab given her cognitive impairment. Her exam was
normal except for impairment in memory and mild impairment in
gait when distracted prior to discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Laparoscopic converted to open cholecystectomy
History of Present Illness:
___ w/ PMH of CKD, DM, HTN who was recently discharged from
the ortho service s/p left total knee arthroplasty who presents
to the ED with a several hour history of RUQ pain. He states
that
he has never had similar pain in the past. The pain is constant,
is unrelated to meals and radiates to his shoulderblade. He
denies any recent fevers, chills, changes in his bowel habbits
or
shortness of breath. He does feel nauseated. No prior abdominal
surgeries. CT of the torso was concerning for a distended
gallbladder with wall edema concerning for cholecystitis. He
does
report a one year history of occasional heartburn with meals.
Past Medical History:
OSA (has CPAP, not used much), dyslipid, OA, DM, renal
cyst, CRI (baseline Cr 1.3)
Social History:
___
Family History:
NC
Physical Exam:
Vitals: 98.1 88 157/79 18 97RA
GEN: A&Ox3, NAD
HEENT: No scleral icterus
CV: RRR, no m/r/g
PULM: CTAB
ABD: Soft, nondistended, mildly tender to palpation near
incision sites, incisions c/d/i, no rebound orguarding
Ext: 1+ ___ to mid shin, no clubbing or cyanosis
Pertinent Results:
___ 10:43PM BLOOD ALT-22 AST-33 AlkPhos-82 TotBili-0.5
___ 07:30AM BLOOD ALT-237* AST-334* AlkPhos-145*
TotBili-2.4*
___ 07:25AM BLOOD ALT-199* AST-129* AlkPhos-150* Amylase-45
TotBili-4.6*
___ 07:30AM BLOOD ALT-141* AST-85* LD(LDH)-171 AlkPhos-135*
Amylase-16 TotBili-3.1*
___ 09:40AM BLOOD ALT-93* AST-44* AlkPhos-126 TotBili-2.2*
___ 07:40AM BLOOD ALT-82* AST-50* AlkPhos-162* TotBili-1.7*
___ 07:50AM BLOOD ALT-75* AST-48* AlkPhos-166* TotBili-1.5
___ 09:00AM BLOOD ALT-70* AST-42* AlkPhos-177* TotBili-1.6*
___ 08:00AM BLOOD ALT-57* AST-31 AlkPhos-158* TotBili-1.2
___ 12:58AM BLOOD CK-MB-2 cTropnT-0.01
___ 07:40AM BLOOD cTropnT-0.01
___ 12:58AM BLOOD Glucose-117* UreaN-13 Creat-0.8 Na-132*
K-4.1 Cl-98 HCO3-22 AnGap-16
___ CTA Chest w/wo Contrast; CT Abd/Pelvis:
1. No evidence of pulmonary embolism to the segmental level.
Evaluation of the subsegmental pulmonary arteries is limited by
respiratory motion
2. Distended gallbladder with gallbladder wall edema could be
consistent with cholecystitis in the correct clinical setting
3. No evidence of bowel perforation.
4. 2.5 cm hypodense lesion within the liver with enhancing
septation is
incompletely characterized. Recommend further evaluation with
nonemergent
ultrasound.
___ RUQ US:
Sludge within a distended gallbladder with gallbladder wall
edema and positive sonographic ___ sign compatible with acute
cholecystitis. No biliary dilatation.
___
Sinus tachycardia with frequent ventricular premature
contractions. Compared to the previous tracing of ___ the
findings are similar, although the ventricular premature
contractions are less frequent and the QRS voltage in the
lateral precordial leads is less prominent.
Medications on Admission:
1. Acetaminophen 1000 mg PO Q8H
2. Fluticasone Propionate NASAL 2 SPRY NU DAILY
3. Lisinopril 5 mg PO DAILY
4. MetFORMIN (Glucophage) 1000 mg PO DAILY
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Simvastatin 20 mg PO DAILY
8. Docusate Sodium 100 mg PO BID
9. Enoxaparin Sodium 40 mg SC DAILY Duration: 28 Days
10. Senna 8.6 mg PO BID
11. Gabapentin 300 mg PO HS
12. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
13. Tamsulosin 0.4 mg PO HS
14. Aspirin 81 mg PO DAILY
15. Triamcinolone Acetonide 0.1% Cream 1 Appl TP PRN rash
16. Pseudoephedrine 30 mg PO Q6H:PRN allergy symptoms
17. phenylephrine HCl 10 mg oral Q6H:PRN allergy symptoms
18. nystatin 100,000 unit/gram topical BID:PRN rash
19. Fish Oil (Omega 3) 1200 mg PO DAILY
20. DiphenhydrAMINE 25 mg PO Q6H:PRN allergy symptom
Discharge Medications:
1. Acetaminophen 325 mg PO Q4H
RX *acetaminophen 325 mg 1 tablet(s) by mouth every 4 hours Disp
#*100 Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
3. Calcium Carbonate 500 mg PO QID:PRN indigestion
4. Enoxaparin Sodium 40 mg SC DAILY
Start: Today - ___, First Dose: Next Routine Administration
Time
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. Gabapentin 300 mg PO HS
7. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every 4
hours Disp #*50 Tablet Refills:*0
8. Lisinopril 5 mg PO DAILY
9. MetFORMIN (Glucophage) 1000 mg PO DAILY
10. Metoprolol Succinate XL 25 mg PO DAILY
11. Simvastatin 20 mg PO DAILY
12. Tamsulosin 0.4 mg PO HS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Gangrenous cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with RUQ abd pain // eval for cholecystitis, duct
dilation
TECHNIQUE: Grey scale and color Doppler ultrasound images of thegallbladder
were obtained.
COMPARISON: CT abdomen and pelvis dated ___
FINDINGS:
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 5 mm.
GALLBLADDER: There is gallbladder wall edema with sludge within the distended
gallbladder and a positive sonographic ___ sign.
The patient was unable to tolerate the remainder of the exam due to pain.
IMPRESSION:
Sludge within a distended gallbladder with gallbladder wall edema and positive
sonographic ___ sign compatible with acute cholecystitis. No biliary
dilatation.
Radiology Report
STUDY: AP chest ___.
CLINICAL HISTORY: ___ man with frequent PVCs, now with new-onset
chest pain, post-op day 2.
FINDINGS: Comparison is made to prior study from ___.
There are low lung volumes. There is a right-sided pleural effusion. There
has been improvement of the pulmonary edema since the prior study. There is
atelectasis at the lung bases. There are no pneumothoraces.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: RUQ abdominal pain
Diagnosed with ACUTE CHOLECYSTITIS, ATRIAL FIBRILLATION, DIABETES UNCOMPL ADULT, HYPERTENSION NOS
temperature: 98.2
heartrate: 100.0
resprate: 20.0
o2sat: 100.0
sbp: 181.0
dbp: 101.0
level of pain: 10
level of acuity: 3.0 | The patient was admitted to the ___ Surgery Service from the
Emergency Department on ___. Please refer to the HPI for
details of his initial presentation. Patient's Abd CT scan with
oral and IV contrast in the ED a distended gallbladder with
gallbladder wall edema consistent with cholecystitis. On
hosptial day (HD) 1 (___), he had a RUQ US that showed
sludge (no stones) within a distended gallbladder with
gallbladder wall edema, and no biliary dilatation. On HD1 he
also had an ERCP done by GI where he had a sphincterotomy and
sludge extracted with relief of symptoms. On HD2 his Tbili and
AlkPhos were increased from the day prior. At that time, it was
decided that his symptoms would be best treated with operative
managment. He was taken to the OR later that evening for a
cholecystectomy. It was originally planned for him to have a lap
chole, which was turned to an open chole given his gangrenous
and necrotic gallbladder. The operation was other wise
uncomplicated. The patient recovered in the PACU and was
transferred back up to the surgical floor when he was stable.
Immediately post-op, the patient was made NPO and was given IV
meds for pain control. His foley remained in. On post-op day
(POD) 1 his diet was advanced to sips and later to clears, which
were well-tolerated. PO pain meds were added to his pain regimen
for optimal pain control. On POD2, his foley was d/c and he
voided. The morning of POD3 the patient was complaining of chest
discomfort. At that time, a cardica work-up was sent, the
results of which were all negative (please see the Pertinent
Results section for lab values and studies). Later that morning
he was complaining of abdominal distention. He had not yet
passed flatus. At that time, his diet was switched back to sips
until he was more comfortable. He was also written for senna and
colace to promote bowel function. On POD4, the patient was
feeling better. He passed flatus and had a BM. His diet was
advnaced as tolerated. His IVF were d/c, and his JP drain was
d/c. POD5 the patient continued to recover well. He was
requiring less pain medication and continued to tolerate his
regular diabetic diet. POD7 his LFT's continued to downtrend and
his vital signs were stable. His staples were d/c and steri
strips were placed. Overall, he was ready for discharge to
rehab. |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
Defibrillation
Cardiac catheterization
History of Present Illness:
___ w/ hx of lumbar stenosis s/p lumbar laminectomy on ___,
hypothyroidism, depression p/w headache and syncope.
Of note, patient underwent bilateral L4 hemilaminectomy and
L5-S1 laminectomy on ___ for spinal stenosis c/b by deep
MSSA intraspinal abscess requiring debridement, bilateral L2
hemilaminectomy, L3 laminectomy, revision L4 bilateral
hemilaminectomy and repair of dural leak on ___. Patient was
then to continue IV nafcillin until ___.
Since then patient has had intermittent headaches and pain at
lumbar spine, with occasional tingling and pain of his bilateral
thighs. Today, the patient had a worse than typical headache
which was bifrontal and radiated to his bilateral temples, as
well as low back pain which was worse than typical. He also had
a brief syncopal episode at work where he fell onto carpet
floor. He denies any new numbess, tingling or focal weakness. He
denies any recent fevers or chills. He has been getting his IV
Nafcillin as prescribed. Patient denies and bowel or bladder
incontinence or changes in habits.
In the ED, initial vitals were ___ 160/90 20. He had another
2 syncopal episodes, these episodes lasted approximately 5
seconds. During the first episode he was noted to have small
jerking motions of his upper extremities which only occured when
he was momentarily unresponsive. After regaining consciousness
he was not confused and was completely alert and oriented. He
had no tongue biting or bowel or bladder incontinence. During
his second syncopal episode he had been placed on telemetry and
was noted to have a 5 second run of torsades. Spine saw him and
recommended inpatient MRI.
ECG was sinus with 1st degree AV block, LAD and LBBB. Labs
notable for potassium 2.7 and magnesium of 2.6, CRP 6.8,
negative troponin and lactate. Imaging notable for negative Head
CT. Patient received 4mg Zofran, 1mg dilaudid, 40mEq IV
potassium, 40mEq PO potatssium and 2g magnesium.
On the floor, the pt complains of headache and nausea which are
improved from previously. he continues to have pain in his lower
back which did not start until the spinal surgeons were
palpating his back in the ED. Nothing seems to improve this new
pain. For the past six weeks he has also had diarrhea from the
nafcillin, which has improved over the last few days using
probiotics.
Past Medical History:
Hypothyroidism - pt reports he is on thyroid replacement
empirically for thyroid nodules but has never had low thyroid
hormone
Depression
Spinal stenosis s/p laminectomy ___ c/b post-op wound infection
and requiring repair of dural leak and debridement on IV
nafcillin x 6 wks
Onychomycosis
Social History:
___
Family History:
No history of heart disease or sudden death in the family.
Variety of cancers.
Physical Exam:
Admission physical exam:
VS- T=99 BP=147/98 HR=96 RR=18 O2 sat= 99% RA
GENERAL- Thin apearing Caucasian male in NAD. Oriented x3. Mood,
affect appropriate.
HEENT- NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK- Supple with no JVD. No CLAD.
CARDIAC- PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, split S2. No m/r/g. No thrills, lifts. No
S3 or S4.
LUNGS- No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN- Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
BACK- midline lumbar spinal incision, well healed. TTP diffusely
near incision. No swelling or erythema.
EXTREMITIES- No c/c/e.
SKIN- No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES-
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
NEURO: CNII-XII grossly intact. ___ strength, normal sensation.
ROM limited by pain in back.
Discharge physical exam:
VS - TC 98.6 TM 98.7 BP 127/93 HR 82 RR 16 SAO2 97RA
I/O - 680/650+BR
Wt - 67kg ___ yesterday)
GENERAL- Thin apearing Caucasian male in NAD. Oriented x3. Mood,
affect appropriate.
HEENT- NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK- Supple with no JVD. No CLAD. Pt has difficulty bending
neck to touch chin.
CARDIAC- PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, split S2. No m/r/g. No thrills, lifts. No
S3 or S4.
LUNGS- No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, bibasilar soft
crackles, wheezes or rhonchi.
ABDOMEN- Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
BACK- midline lumbar spinal incision, well healed. TTP diffusely
near incision. No swelling or erythema.
EXTREMITIES- No c/c/e.
SKIN- No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES-
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
NEURO: CNII-XII grossly intact. ___ strength, normal sensation.
ROM limited by pain in back.
Pertinent Results:
Admission labs:
___ 11:30AM BLOOD WBC-9.8 RBC-3.58*# Hgb-12.8*# Hct-37.8*#
MCV-106* MCH-35.8* MCHC-33.9 RDW-14.7 Plt ___
___ 11:30AM BLOOD Neuts-72.7* ___ Monos-5.1 Eos-3.3
Baso-0.5
___ 11:30AM BLOOD ___ PTT-27.6 ___
___ 11:30AM BLOOD Glucose-96 UreaN-9 Creat-0.7 Na-142 K-4.3
Cl-99 HCO3-26 AnGap-21*
___ 03:10AM BLOOD proBNP-___*
___ 12:55PM BLOOD cTropnT-<0.01
___ 11:30AM BLOOD Calcium-9.1 Phos-3.2 Mg-2.0
___ 05:00AM BLOOD calTIBC-231* Ferritn-72 TRF-178*
___ 03:45PM BLOOD Osmolal-264*
___ 12:07AM BLOOD TSH-5.2*
___ 05:00AM BLOOD Free T4-1.0
___ 04:44AM BLOOD Cortsol-19.2
___ 11:30AM BLOOD CRP-6.8*
___ 05:00AM BLOOD PEP-NO SPECIFI
___ 05:00AM BLOOD HIV Ab-NEGATIVE
___ 01:07PM BLOOD Lactate-2.0
Discharge labs:
___ 03:10AM BLOOD WBC-9.7 RBC-3.54* Hgb-12.6* Hct-36.6*
MCV-103* MCH-35.6* MCHC-34.5 RDW-13.9 Plt ___
___ 09:25AM BLOOD Neuts-87.3* Lymphs-8.1* Monos-3.9 Eos-0.3
Baso-0.5
___ 04:44AM BLOOD ___
___ 03:10AM BLOOD Glucose-106* UreaN-16 Creat-0.8 Na-130*
K-4.3 Cl-94* HCO3-27 AnGap-13
___ 03:10AM BLOOD Calcium-9.1 Phos-4.7* Mg-2.1
URINE CHEMISTRYHoursUreaNCreatNaKClTotProt
___ 20:52 ___
Source: ___
___ 16:35 RANDOM 12
Source: ___
OTHER URINE CHEMISTRYU-PEPOsmolal
___ 20:52 611
Source: ___
___ 16:35 NO PROTEIN1
Source: ___
Pertinent micro/path:
Blood cultures neg x2
Pertinent imaging:
Head CT: No acute intracranial process
EKG: sinus at 80, QTc 467, LAD with LBBB, does not meet
Sgarbossa's criteria
TTE ___:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
moderately dilated. There is global LV hypokinesis with relative
preservation of systolic function of tha basal to mid lateral
wall. The septum and inferior walls appear akinetic. Overall
left ventricular systolic function is severely depressed (LVEF=
25 %). There is LV dysychrony (LBBB). No masses or thrombi are
seen in the left ventricle. There is no ventricular septal
defect. Right ventricular chamber size is normal. with
borderline normal free wall function. The diameters of aorta at
the sinus, ascending and arch levels are normal. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Trace aortic regurgitation is seen. The mitral
valve leaflets are structurally normal. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The pulmonary
artery systolic pressure could not be determined. There is a
very small pericardial effusion. There are no echocardiographic
signs of tamponade.
IMPRESSION: Cardiomyopathy.
___ MR ___ SPINE:
Since the previous MRI, there has been superior extension of the
laminectomy with a posterior epidural fluid collection causing
moderate-to-severe canal stenosis, worst at L4-L5 where there is
an anterior disc protrusion which contributes to the canal
narrowing. The differential would include a postoperative
seroma/resolving hematoma, although superimposed infection
cannot be excluded.
Preliminary Catheterization Report
Patient Information
Patient Name ___, ___ ___ ___
Study Date ___ Number ___
Date of Birth ___ ___ Years
GenderMale Race
Height170 cm (5'7'')Weight67 kg (148 lbs)
BSA1.78 M2
Procedures: Catheter placement, Coronary Angiography
Indications: Dilated Cardiomyopathy
Staff
Diagnostic ___, MD
___, RN
Technologist___, RTR
___, MD
___, RN
___, MD
___, CVT
Technical
Anesthesia: Local
Specimens: None
Catheter placement via 5 ___ sheath right femoral artery and
right femoral vein
Coronary angiography using 5 ___ JL4 and JR4
Blood Oximetry Information
TimeSiteHgb (gm/dL)Sat (%)PO2
(mmHg)Content
(ml per dl)
6:51 PMPA ___
7:09 PMART 12.3099.6016.66
Cardiac Output Results
PhaseFick
C.O.(l/min)Fick
C.I. (l/min /m2)TD
CO (l/min)TD
CI (l/min/m2)
3.632.04
Hemodynamic Measurements (mmHg)
SiteSysDiasEndMeanA WaveV WaveHR
___ ___ ___
RV ___
RA ___
LV ___ ___
Contrast Summary
ContrastTotal (ml)
Omnipaque (300 mg/ml)50
Radiation Dosage
Effective Equivalent Dose Index (mGy)___
Radiology Summary
Total Runs
Total Fluoro Time (minutes)7.3
Findings
ESTIMATED blood loss: < 25 cc
Hemodynamics (see above): The left heart pressures were
substantially elevated (PCWP 31 mmHg).
Coronary angiography: right dominant
LMCA: Normal
LAD: Normal. The LAD had minimal lumen irregularities.
The ___ diagonal branch had minimal lumen irregularities
LCX: Normal/ There was a large ___ obtuse marginal branch
and a large ___ posterolateral branch.
RCA: Normal. It gave rise to a PDA and large posterolateral
Assessment & Recommendations
1.Dilated cardiomyopathy
2.Elevated left heart filling pressures (PCWP 31 mmHg)
3.Normal coronary arteries
4.Diuresis
Medications on Admission:
The Preadmissions Medication list may be inaccurate and require
further investigation.
1. Nafcillin 2 g IV Q4H Duration: 6 Weeks
last day ___. terbinafine *NF* 250 mg Oral daily
3. Levothyroxine Sodium 150 mcg PO DAILY
4. Citalopram 30 mg PO DAILY
5. HYDROmorphone (Dilaudid) ___ mg PO Frequency is Unknown
6. Acetaminophen 650 mg PO Q6H:PRN pain, fever
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain, fever
2. Levothyroxine Sodium 150 mcg PO DAILY
3. Ferrous Gluconate 325 mg PO DAILY
RX *ferrous gluconate 325 mg (37.5 mg) 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
4. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. Lisinopril 20 mg PO DAILY
Please hold SBP < 100
RX *lisinopril 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
6. Metoprolol Succinate XL 50 mg PO DAILY
hold for SBP <95 or HR <55
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
7. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN breakthrough
pain
RX *oxycodone 5 mg 2 tablet(s) by mouth every 8 hours Disp #*20
Tablet Refills:*0
8. Senna 1 TAB PO BID:PRN constipation
9. Outpatient Lab Work
425.5 Chem 10. Please contact Dr. ___ at ___ with the
results.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
Torsades
Hypokalemia
Hyponatremia
Cardiomyopathy
SECONDARY
Lumbar stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Sudden-onset headache and syncope. Of note, patient had recent
spinal surgery in ___ complicated by postop wound infection and CSF leak.
Evaluate for acute intracranial process.
COMPARISON: None.
TECHNIQUE: Sequential axial images were acquired through the head without
administration of intravenous contrast material. Multiplanar reformats were
performed.
FINDINGS: There is no evidence of intracranial hemorrhage, edema, shift of
normally midline structures, hydrocephalus, or acute large vascular
territorial infarction. The imaged portions of the orbits are unremarkable.
There is minimal mucosal thickening within a right anterior ethmoidal air
cell. The remainder of the visualized portions of the paranasal sinuses and
mastoid air cells are well aerated. The imaged osseous structures are
unremarkable.
IMPRESSION: No acute intracranial process.
Radiology Report
HISTORY: PICC placement.
FINDINGS: The right PICC line extends to the upper portion of the SVC. There
is continued enlargement of the cardiac silhouette with poor definition of
lower lung vessels consistent with elevated pulmonary venous pressure. No
evidence of acute focal pneumonia. Clips from previous thyroid surgery are
again seen in the lower cervical region.
Radiology Report
TECHNIQUE: MRI of the complete spine without and with gad.
HISTORY: Previous surgery, now still with headaches and back pain. Assess
for resolution of abscess.
___.
FINDINGS:The patient is status post L2 through L5 laminectomy. The
laminectomy appears to extend more superiorly than on the previous MRI. There
is posterior epidural fluid collection extending from L2 through L5 causing
moderate spinal canal narrowing. There is severe spinal canal narrowing at
L4-L5 due to the posterior fluid collection as well as a central disc
protrusion. The collection contains some areas of low signal within it and
could potentially represent a resolving hematoma or a seroma, although
superimposed infection cannot be excluded. Diffuse disc bulge with central
disc protrusion at L2-L3 persist.
No definite cord signal abnormality is seen.
Degenerative endplate changes in the lumbar spine are stable.
Evaluation of the cervical spine demonstrates multilevel disc osteophyte
complexes causing mild-to-moderate effacement of the ventral thecal sac at
multiple levels as well as foraminal narrowing in the mid cervical spine.
There are apparent hepatic cysts.
IMPRESSION:
Since the previous MRI, there has been superior extension of the laminectomy
with a posterior epidural fluid collection causing moderate-to-severe canal
stenosis, worst at L4-L5 where there is an anterior disc protrusion which
contributes to the canal narrowing. The differential would include a
postoperative seroma/resolving hematoma, although superimposed infection
cannot be excluded.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: H/A
Diagnosed with SYNCOPE AND COLLAPSE, PAROX VENTRIC TACHYCARD
temperature: 98.0
heartrate: 80.0
resprate: 20.0
o2sat: nan
sbp: 160.0
dbp: 90.0
level of pain: 3
level of acuity: 2.0 | CCU Course:
___ with recent lumbar laminectomy c/b wound infection and
dural tear with CSF leak s/p repair presenting with headache,
back pain and syncopal episodes accompanied by torsades on
telemetry found to have prolonged QTc and hypokalemia,
transferred to CCU for monitoring following code blue due to
torsades.
# Rhythm: Multiple episodes of torsades on telemetry, likely the
cause of his syncope. Cause likley multifactorial. Patient
hypokalemic to 2.7 on presentation, possibly due to recent
history of diarrhea on nafcillin. QTc also significantly
prolonged on EKG. QTc prolongation also seen in EKG from ___
(only other study in the system), so appears to be somewhat
chronic in nature, although may have been exacerbated by Zofran
given in the ED. SSRIs can prolong QT, so citalopram also a
possible contributor. No known family history of cardiac
arrhythmias or sudden death. The patient's citalopram was
stopped. PCP was corresponded with and old EKG from ___ was
obtained that showed normal QTc. K and Mg were followed closely
and repleted prn for a goal K of 4.5. Monitored on telemetry and
no further episodes of torsades in CCU.
# Coronaries: No known history of CAD, although does have LBBB
(not new from EKG in ___, however not present on EKG from
___ obtained from PCP. Troponin negative on admission. ECHO was
obtained that showed global LV hypokinesis, EF=25%, 1+ MR, very
small effusion. Coronaries clean on cath.
# Pump: Newly diagnosed cardiomyopathy on TTE ___ - dilated LV
with EF 25%. No CAD noted on cath yesterday. RHC showed elevated
wedge pressure to 31mmHg. Started BB and ACEI, low dose lasix.
Cardiomyopathy workup pertinent for negative SPEP, negative
UPEP, low ferritin, nl T4, HIV negative.
# Headache/back pain: Pt with hx of spinal abscess as surgical
complication (also hx of CSF leak) finishing course of nafcillin
on day of admission. Concern for recurrent infection, but
patient has been afebrile, white count only mildly elevated, sed
rate and CRP still downtrending from previous. Neuro exam
non-focal, Ortho Spine service is following. ID consulted and
said ok to stop antibiotics as previously course indicated and
recommended obtaining MRI to r/u recurrence of infection. MRI
showed small pocket of fluid likely seroma per the density on
the scan. Pt continued to be afebrile so this fluid was not
drained and cultured. Blood cultures taken in ED were NGTD.
# Hypothyroidism: T4 normal but continued home levothyroxine
# Depression: held citalopram due to possibly QT prolonging
effect
# Anemic with low Fe and Ferritin: started pt on iron
supplementation. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
___- left heart catheterization
History of Present Illness:
Mr. ___ is a ___ year old man with HTN who presents with one
month of chest burning.
The patient shares that he first noticed the chest burning the
___. His work involves carrying heavy
objects, and he first noticed the sensation with work. The first
time he ever got it it lasted somewhere from ___ minutes. The
feeling is a burning sensation in the ___ his chest,
radiates to his left neck, has occasionally radiated down both
arms, no paresthesias, no nausea, no diaphoresis, no shortness
of breath. Since then, he says he has also gotten the burning in
the morning when he wakes up. On days he works he has the pain
about 3 times per day, and on days he does not work about time
per day. He is clear that the pain does not only occur with
exertion and will happen with rest. And since the first episode,
the pain usually lasts about 5 minutes (sometimes shorter). He
thought the pain was heartburn, but says when he has heartburn
his symptoms usually last longer. He is unsure if anything makes
the pain worse or better; he has taken tums for the pain, but
says he is unsure if it works because the pain is short lasting
either way. Because the pain was not improving, he therefore
decided to present to the ED.
In the ED initial vitals were 97.4 78 134/86 18 100 RA. Labs
were notable for Troponin <0.01, normal CBC and chem panel. EKG
showed TWI aVL, biphasic TWs V2-V4, ST changes V2-V4. CXR with
no acute cardiopulmonary abnormality. He was started on a
heparin gtt and given aspirin 325 mg.
Upon arrival to the floor the patient shares the last time he
had chest pain was the morning of presentation. He has only had
one episode of chest pain in the past 24H.
Past Medical History:
HTN
Social History:
___
Family History:
FAMILY HISTORY:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death that he knows of.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T98.3 BP114/84 HR62 RR18 O2 98 RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: No JVD.
CARDIAC: RR, normal S1, S2. No murmurs/rubs/gallops. No
thrills, lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
LABS: reviewed, see below
MICRO: none
DISCHARGE PHSYCIAL EXAM:
VS: 98 116/73 59 16 98% RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa
NECK: No JVD.
CARDIAC: RR, normal S1, S2. No murmurs/rubs/gallops. No
thrills, lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No rash
LABS: reviewed, see below
MICRO: none
Pertinent Results:
ADMISSION LABS:
___ 06:45PM BLOOD WBC-6.7# RBC-4.85 Hgb-14.2 Hct-44.0
MCV-91 MCH-29.3 MCHC-32.3 RDW-13.2 RDWSD-43.1 Plt ___
___ 06:45PM BLOOD Neuts-65.0 ___ Monos-9.1 Eos-0.7*
Baso-0.3 Im ___ AbsNeut-4.34 AbsLymp-1.64 AbsMono-0.61
AbsEos-0.05 AbsBaso-0.02
___ 06:45PM BLOOD ___ PTT-31.1 ___
___ 06:45PM BLOOD Plt ___
___ 06:45PM BLOOD Glucose-124* UreaN-8 Creat-0.8 Na-139
K-4.5 Cl-101 HCO3-28 AnGap-15
___ 06:45PM BLOOD cTropnT-<0.01
___ 06:49PM BLOOD D-Dimer-378
INTERVAL LABS:
___ 03:10AM BLOOD %HbA1c-5.4 eAG-108
___ 03:10AM BLOOD Triglyc-91 HDL-56 CHOL/HD-3.6 LDLcalc-125
___ 03:10AM BLOOD CK-MB-2 cTropnT-<0.01
___ 09:37AM BLOOD cTropnT-<0.01
___ 12:57AM BLOOD cTropnT-<0.01
DISCHARGE LABS:
___ 06:15AM BLOOD WBC-4.0 RBC-4.42* Hgb-13.2* Hct-39.6*
MCV-90 MCH-29.9 MCHC-33.3 RDW-13.3 RDWSD-43.6 Plt ___
___ 06:15AM BLOOD Plt ___
___ 06:15AM BLOOD Glucose-98 UreaN-16 Creat-0.8 Na-138
K-4.0 Cl-101 HCO3-28 AnGap-13
___ 06:15AM BLOOD Triglyc-100 HDL-46 CHOL/HD-4.0
LDLcalc-116
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
3. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
4. TiCAGRELOR 90 mg PO BID
IT IS VERY IMPORTANT TO TAKE THIS MEDICINE EVERY DAY
RX *ticagrelor [Brilinta] 90 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
5. Lisinopril 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
- Acute coronary syndrome with 80% occlusion of left anterior
descending coronary artery
SECONDARY DIAGNOSIS
- hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with chest pain
TECHNIQUE: Chest PA and lateral
COMPARISON: None.
FINDINGS:
Heart size is normal. The mediastinal and hilar contours are normal. The
pulmonary vasculature is normal. Lungs are clear. No pleural effusion or
pneumothorax is seen. There are no acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary abnormality.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Chest pain, Abnormal EKG
Diagnosed with Other chest pain
temperature: 97.4
heartrate: 78.0
resprate: 18.0
o2sat: 100.0
sbp: 134.0
dbp: 86.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ year old man with HTN who presented with one
month of chest burning concerning for ACS, found to have ST
elevations V2-V3 concerning for ACS.
# CORONARIES: S/p cath on ___ w/ ___ in LAD
# PUMP: LVEF > 55% (TTE ___
# RHYTHM: NSR
#CAD: Chest pain resolved upon admission to hospital and
troponins were negative x2, ECG changes very concerning for ACS.
He underwent left heart catheterization on ___, which showed
80% occlusion of LAD; 1 DES was placed, and he was loaded with
aspirin & Ticagrelor. Post-procedural TTE showed normal EF with
no wall motion abnormalities. At time of discharge, he was free
of chest pain and vital signs were stable. He was discharged on
ASA, atorvastatin, metoprolol, and lisinopril and referred to
cardiac ___.
#HTN: His BP remained well controlled while in the hospital on
lisinopril. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
lisinopril / Cozaar / amiodarone
Attending: ___.
Chief Complaint:
Left lower extremity cellulitis.
Claudication
Major Surgical or Invasive Procedure:
Left Lower Extremity Angiogram
History of Present Illness:
Mr. ___ is an ___ with multiple medical comorbidities
including ischemic cardiomyopathy and PVD s/p fem-fem bypass at
an outside institution in ___. He presented to ___
___ three weeks prior to admission to ___ with worsening
left lower extremity cellulitis and mental status changes. On
admission he was also noted to have a pneumonia and was in acute
renal failure. He was resuscitated and started on antibiotics.
When he failed to improve on rocephin he was transitioned to
clindamycin with improvement in the cellulitis. He was also
started on zosyn for nosocomial pneumonia and ultimately
discharged to rehab after ten days in the hospital on a seven
day course of clindamycin, augmentin and flagyl. While at the
rehab facility he was doing well until a few days
ago when he again noticed increased redness and pain in his left
lower extremity. He was evaluated by his vascular surgeon, Dr.
___ from ___ in ___, who recommended
he come to the ___ ED for further evaulation and treatment. In
the ___ ED he reports ___ pain in his left calf and foot. He
also has claudication in his feet at baseline after walking a
few blocks but over the previous few weeks had been unable to
walk due to the pain associated with the infection and
non-healing ulcers. When asked about venous insufficiency he
reported significant swelling in his ankles at the end of the
day which resolved with leg elevation. He denies
fevers, chills or signs of systemic illness.
Past Medical History:
ischemic cardiomyopathy, MI, arrhythmia, CHF, TIA, hypertension,
gout, PVD, hyperlipidemia, pneumonia, hypertension, BPH
PSH:
operative report unavailable but per verbal report
femoral-femoral bypass with Dr. ___ Family ___, left CEA
___ Dr. ___, CABG x ___, ICD ___, bilateral hernia repair
___
Social History:
___
Family History:
Cardiac Disease
Physical Exam:
Vital Signs: 98.4 76 100/38 12 96% RA
General: awake, alert, NAD
HEENT: NCAT, EOMI, anicteric
Heart: RRR, NMRG
Lungs: CTAB, normal excursion, no respiratory distress
Back: no vertebral tenderness, no CVAT
Abdomen: soft, NT, ND, no mass, no hernia
Extremities: non-healing ulcers over the LLE with 1+ edema and
evidence of venous stasis changes. Resolved erythema. Loss
of sensation at the toes.
Pulse Exam (P=Palpation, D=Dopplerable, N=None)
RLE Femoral: P. Popliteal: P. AT D. ___: D.
LLE Femoral: P. Popliteal: P. DP: mono. ___: D. Graft: D
Pertinent Results:
___ 06:55AM GLUCOSE-95 UREA N-13 CREAT-0.7 SODIUM-139
POTASSIUM-3.5 CHLORIDE-106 TOTAL CO2-27 ANION GAP-10
___ 06:55AM CALCIUM-8.2* PHOSPHATE-2.8 MAGNESIUM-2.0
___ 06:55AM WBC-5.1 RBC-2.92* HGB-10.3* HCT-31.0*
MCV-106* MCH-35.3* MCHC-33.3 RDW-14.8
___ 06:55AM PLT COUNT-159
___ 10:30PM URINE COLOR-Amber APPEAR-Cloudy SP ___
___ 06:55AM ___ PTT-36.8* ___
___ 10:30PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-LG
___ 10:30PM URINE RBC-107* WBC-71* BACTERIA-FEW YEAST-NONE
EPI-0
___ 10:30PM URINE HYALINE-142*
___ 10:30PM URINE CA OXAL-MANY
___ 09:28PM LACTATE-0.9
___ 09:16PM GLUCOSE-105* UREA N-19 CREAT-0.7 SODIUM-138
POTASSIUM-3.4 CHLORIDE-106 TOTAL CO2-29 ANION GAP-6*
___ 09:16PM estGFR-Using this
___ 09:16PM WBC-6.6 RBC-2.97* HGB-10.8* HCT-31.4*
MCV-106* MCH-36.4* MCHC-34.4 RDW-14.9
___ 09:16PM NEUTS-63.4 ___ MONOS-5.2 EOS-2.0
BASOS-0.3
___ 09:16PM PLT COUNT-164
Medications on Admission:
allopurinol ___ daily, norvasc 2.5 daily, ASA 325 daily, coreg
12.5 twice daily, colchicine 0.6 daily, lasix 60 daily, KCl
daily, zantac 150 twice daily, zocor 10 nightly, flomax 0.4
daily
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8HRS:PRN Pain
2. Amlodipine 10 mg PO DAILY
hold for SBP<120
3. Aspirin EC 325 mg PO DAILY
4. Carvedilol 12.5 mg PO BID
5. Docusate Sodium 100 mg PO BID
Patient may refuse. Hold if patient has loose stools.
6. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
7. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
8. Ranitidine 150 mg PO BID
9. Simvastatin 10 mg PO QHS
10. Tamsulosin 0.4 mg PO HS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Peripheral Arterial Disease
Left Leg Cellulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
STUDY: Lower extremity arterial noninvasives at rest.
REASON: Non-healing left lower extremity ulcers. History of fem-fem bypass.
FINDINGS: Doppler waveform analysis reveals monophasic waveforms throughout
bilateral lower extremities. ABIs are 0.51 on the right and 0.57 on the left.
Pulse volume recordings show mild dampening in the left thigh and moderate
dampening in the right thigh. There is further dampening at the calf level on
the right, but an absence of calf augmentation on the left.
IMPRESSION: Bilateral aortoiliac and SFA disease.
Radiology Report
INDICATION: ___ man with right leg shortening.
COMPARISONS: None.
TECHNIQUE: Bilateral hips, three views.
FINDINGS: There is no evidence of fracture or dislocation. There are
significant degenerative changes in the bilateral hips. There are vascular
calcifications. There are degenerative changes at the SI joints bilaterally
and the pubic symphysis. Degenerative changes are seen in the lumbar spine.
IMPRESSION:
1. No acute fracture or dislocation.
2. Degenerative changes in the bilateral hips.
3. Would recommend 3 FOOT Radiographs to assess leg/length stability if
clinically indicated.
Radiology Report
CLINICAL HISTORY: ___ man status post fem-fem bypass, cellulitis of
the left lower extremity.
COMPARISON: None.
TECHNIQUE: CT of the lower extremities was performed in arterial phase along
with a runoff.
FINDINGS:
CT OF THE PELVIS: Imaged soft tissues in the pelvis to include the lower pole
of the right kidney which is unremarkable and loops of small and large bowel
with fecal loading in the large bowel, an otherwise unremarkable exam. A
Foley catheter is seen within the bladder which is unremarkable. No pelvic or
inguinal lymphadenopathy is noted.
CTA: The right common iliac artery is occluded with reconstitution of flow at
the bifurcation of the external and internal common iliac (3a:31). The left
common iliac as well as external and internal iliacs are patent. A fem-fem
bypass graft is patent. On the left, there is a fem-pop bypass with patent
graft. In the popliteal fossa, there is a short segment of the popliteal
artery which appears occluded followed by two-vessel runoff with partial
occlusion of the anterior tibial artery. On the right, there is occlusion of
the superficial femoral artery with reconstitution at the popliteal and again
two-vessel runoff with occlusion of the anterior tibial artery. Extensive
arthrosclerotic disease is seen throughout the arterial vasculature of both
legs.
There is soft tissue edema with no drainable fluid collections in the left mid
calf (3a:210).
BONES: The bones are diffusely demineralized; however, no suspicious lytic or
sclerotic lesions are seen.
IMPRESSION:
1. Extensive vascular disease with two-vessel runoff in each extremity.
2. Patent fem-fem bypass as well as patent left-sided fem-pop bypass.
3. Occlusion of the right common iliac with reconstitution of flow at the
bifurcation of the internal-external iliac.
4. Occlusion of the right superficial femoral artery with reconstitution at
the popliteal.
5. Left lower leg soft tissue edema without any drainable fluid collections.
Radiology Report
HISTORY: Cardiac disease with symptoms of pneumonia.
FINDINGS: In comparison with the study of ___, there is little change.
Enlargement of the cardiac silhouette in a patient with CABG and dual-channel
pacemaker device in place. Opacification in the retrocardiac region is
consistent with some volume loss in the left lower lobe. No appreciable
pulmonary vascular congestion.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: LLE CELLULITIS
Diagnosed with CELLULITIS OF LEG, HYPERTENSION NOS, AICD STATUS
temperature: 97.2
heartrate: 81.0
resprate: 14.0
o2sat: 99.0
sbp: 111.0
dbp: 94.0
level of pain: 13
level of acuity: 3.0 | Mr. ___ was admitted to ___ on ___ for the management
of his unresolving LLE cellulitis and his history of
claudication. He was admitted to the vascular surgery service
and started on broad spectrum antibiotics Vanc, Cipro, Flagyl.
Because of his history of bypass surgery, there was a low index
of suspicion of graft insufficiency and he was scheduled for
non-invasive testing. The testing demonstrated bilateral
aortoiliac and SFA disease with ABIs of .51 on the right and .57
on the left. Because of his equivocal exam, he was continued on
antibiotics over the weekend to resolve his underlying infection
and was scheduled for a CTA on ___ to further delineate the
extent of his disease. His CTA on demonstrated . Extensive
vascular disease with two-vessel runoff in each extremity, a
patent fem-fem bypass as well as patent left-sided fem-pop
bypass, occlusion of the right common iliac with reconstitution
of flow at the bifurcation of the internal-external iliac and
occlusion of the right superficial femoral artery with
reconstitution at the popliteal. At this time the decision was
made to schedule Mr. ___ for an angiography. ___ saw this
patient in anticipation of his eventual dispo and recommended
that he would likely need rehab secondary to his deconditioning
because of his extended and multiple hospital courses. His
subsequent angio on ___ demonstrated disease unamenable to
stenting or angioplasty. Because of this, the decision was made
to allow the patient to finish his antibiotic course for his
cellulitis and non-healing wounds and follow up with Dr.
___ in a month for the exploration of grafting/bypass
options. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Flagyl
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
colonoscopy with biopsies on ___
History of Present Illness:
Ms. ___ is a ___ female with past medical history
of uveitis who presents with subacute worsening abdominal pain,
multi-year history of intermittent hematochezia who presents
with
worsening abdominal pain, nausea.
HPI: The patient reported that around three weeks ago she woke
up
with abdominal pain and vomiting that later remitted. Then,
___, she woke up with another episode of abdominal pain, with
associated nausea and vomiting. The pain was present throughout
her abdomen but was worse on the right side. The pain was sharp
and cramping and began in her upper abdomen and then moved to
her
lower abdomen. It persisted throughout the day, and, at its
worst
was ___. She also felt light-headed at the time. The pain
continued, and the patient presented to an OSH ED ___, where
she had CT scan with reported terminal ileitis. She was referred
for urgent outpatient GI work up.
On follow up with GI the next day there was concern for Crohn's
disease given history of uveitis and subacute nature of
abdominal
pain and ___ year history of hematochezia. Scheduled for MR
enterography in early ___ and outpatient colonoscopy for
further workup. She was prescribed ciprofloxacin and Flagyl.
Patient reports initial mild improvement with antibiotics. She
began having burning sensation of soles bilaterally and
discussed
with GI doc and flagyl was discontinued ___ AM last dose.
Pain
subsequently worsened evening of ___, the abdominal pain
worsened again, causing the patient to present. She reported
recent-onset bloating but denied any vomiting, diarrhea,
constipation, hematochezia, or fever. The patient currently
rates
the pain at ___ and reports that it is worse when sitting up.
She denies pain with driving/bumps on the road. She states she
has improvement in pain when laying flat but that episodes of
pain can wake her from sleep.
The patient reports having a "sensitive stomach" for many years.
She states for past ___ years she has had intermittent bloody
bowel
movements. These have red blood mixed within the stool rather.
She denies red streaking on the surface. Per the patient, she
recently tried reducing her gluten and dairy intake
(___), with no relief. Patient states that in the ___
she was recommended to have celiac testing done but that she had
not gotten labs drawn.
In the ED:
- Her initial vitals were notable for temperature 97.4 heart
rate 67 blood pressure 138/67 respiratory rate 18 satting 98% on
room air.
- Her exam in the ED was notable for:
"diffuse tenderness to mild palpation with absence of peritoneal
signs or rebound or guarding. Her right lower quadrant was
notably more tender with negative Rovsing's, obturator, psoas
signs. No CVA tenderness."
- Labs in the ED were notable for:
Normal CBC with white blood cell count of 6.0, normal LFTs,
normal BMP, CRP of 7.4. UA was obtained which demonstrated small
leuk esterase, small blood, negative nitrites, moderate
bacteria,
11 white blood cells.
- Imaging notable for:
___ KUB with no evidence of bowel obstruction or
intraperitoneal free air.
- Patient was given Toradol and Zofran 1X each in the ED.
- GI was consulted in ED who recommended NPO for colonoscopy,
stool studies, continuing antibiotics
On arrival to the floor, the patient reported no improvement to
toradol. She provides history as written above.
In regards to reaction to flagyl she states it felt like a
warmth
on the bottom of her feet bilaterally. She denied rash. She last
experienced it yesterday afternoon. She last took flagyl
yesterday AM.
REVIEW OF SYSTEMS:
General: Chills/sweats, although only while in severe pain.
GI: Patient denies hematemesis. Reported pain while straining to
have a bowel movement last week. Reported less frequent bowel
movements since beginning abx. Reported recent onset of
bloating.
GU: Denies any dysuria, hematuria, or mucous/discharge in urine.
GYN: Denies any vaginal discharge or bleeding.
Past Medical History:
Terminal ileitis diagnosed 1 week prior to admission
Uveitis: Patient reports diagnosed as child, affected bilateral
eyes, had followed mass eye and ear for many years, s/p
treatment
with methotrexate
Migraine headaches
Social History:
___
Family History:
Sister: IBS
Physical ___:
ADMISSION PHYSICAL EXAM:
VS: ___ 1700 Temp: 98.4 PO BP: 127/81 R Sitting HR: 71 RR:
18 O2 sat: 98% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score:
___
GENERAL: Pleasant, lying in bed comfortably
HEENT: PERRL, EOMI. Oropharynx clear, with moist mucous
membranes.
CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops
LUNG: No increased work of breathing. Lungs clear to
auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Normoactive bowel sounds. Soft abdomen. Tympanic on
percussion. Diffusely tender throughout with no rebound
tenderness. No guarding Varying locations of most tender areas,
initially right sided and then left sided
EXT: Warm, well perfused, no lower extremity edema
PULSES: 2+ radial pulses, 2+ ___ pulses
NEURO: Alert, oriented, face symmetric at rest and with
activation, full sensation throughout, motor and sensory
function
grossly intact, symmetric palate elevation
SKIN: No significant rashes
DISCHARGE PHYSICAL EXAM:
___ ___ Temp: 98.3 PO BP: 135/84 HR: 71 RR: 18 O2 sat: 99%
GENERAL: Pleasant, lying in bed comfortably
HEENT: NC/AT EOMI MMM sclera nonicteric
CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi
ABD: BS+ nondistended. Moderate TTP in RLQ without rebound or
guarding; + Rovsing sign
BACK: No CVA tenderness
EXT: Warm, well perfused, trace bilat ankle edema
PULSES: 2+ radial pulses, 2+ ___ pulses, 2+ DP pulses
NEURO: Alert, oriented
SKIN: No significant rashes
Pertinent Results:
ADMISSION LABS:
===============
___ 12:32PM URINE HOURS-RANDOM
___ 12:32PM URINE UCG-NEGATIVE
___ 12:32PM URINE COLOR-Yellow APPEAR-Hazy* SP ___
___ 12:32PM URINE BLOOD-SM* NITRITE-NEG PROTEIN-30*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-SM*
___ 12:32PM URINE RBC-4* WBC-11* BACTERIA-MOD* YEAST-NONE
EPI-5
___ 12:32PM URINE MUCOUS-RARE*
___ 12:30PM GLUCOSE-87 UREA N-10 CREAT-1.1 SODIUM-136
POTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-21* ANION GAP-12
___ 12:30PM estGFR-Using this
___ 12:30PM ALT(SGPT)-14 AST(SGOT)-26 ALK PHOS-45 TOT
BILI-0.3
___ 12:30PM LIPASE-34
___ 12:30PM ALBUMIN-4.1 CALCIUM-9.5 PHOSPHATE-3.4
MAGNESIUM-2.0
___ 12:30PM CRP-7.4*
___ 12:30PM WBC-6.0 RBC-4.95 HGB-14.1 HCT-41.8 MCV-84
MCH-28.5 MCHC-33.7 RDW-11.8 RDWSD-35.6
___ 12:30PM NEUTS-53.7 ___ MONOS-9.5 EOS-0.5*
BASOS-0.5 IM ___ AbsNeut-3.21 AbsLymp-2.13 AbsMono-0.57
AbsEos-0.03* AbsBaso-0.03
___ 12:30PM PLT COUNT-196
PERTINENT RESULTS:
==================
___ Gastroenterology Colonoscopy
Normal mucosa in the whole colon and 15cm into the terminal
ileum.
MAC anesthesia for future endoscopies.
DISCHARGE LABS:
===============
___ 05:40AM BLOOD WBC-5.7 RBC-4.38 Hgb-12.5 Hct-36.8 MCV-84
MCH-28.5 MCHC-34.0 RDW-11.8 RDWSD-35.8 Plt ___
___ 05:40AM BLOOD Glucose-89 UreaN-8 Creat-1.2* Na-139
K-3.8 Cl-108 HCO3-21* AnGap-10
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Norethindrone-Estradiol 1 TAB PO DAILY
2. Ciprofloxacin HCl 500 mg PO Q12H
3. MetroNIDAZOLE 500 mg PO BID
Discharge Medications:
1. DICYCLOMine 10 mg PO TID:PRN cramps
RX *dicyclomine 10 mg 1 capsule(s) by mouth three times a day
Disp #*30 Capsule Refills:*1
2. Ondansetron ODT 4 mg PO Q6H
RX *ondansetron 4 mg 1 tablet(s) by mouth every six (6) hours
Disp #*30 Tablet Refills:*0
3. Norethindrone-Estradiol 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
ABDOMINAL PAIN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with abdominal pain// Eval for signs of bowel
obstruction or free air
TECHNIQUE: Supine and upright AP views of the abdomen
COMPARISON: None.
FINDINGS:
A nonobstructive bowel gas pattern is present. Air is seen within scattered
nondilated loops of large and small bowel. Moderate amount of stool is noted
throughout the colon. No differential air-fluid levels, free intraperitoneal
air, or concerning soft tissue calcifications are evident. No acute osseous
abnormality. Umbilical piercing is incidentally noted.
IMPRESSION:
No evidence for bowel obstruction or free intraperitoneal air.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Nausea
Diagnosed with Other specified noninfective gastroenteritis and colitis, Right lower quadrant pain, Unspecified abdominal pain
temperature: 97.4
heartrate: 67.0
resprate: 18.0
o2sat: 98.0
sbp: 138.0
dbp: 67.0
level of pain: 8
level of acuity: 3.0 | Ms. ___ is a ___ year old female with fairly recent diagnosis
of terminal ileitis with unclear etiology admitted following 1
week of worsening abdominal pain and nausea, not responsive to
outpatient antibiotics. She underwent colonoscopy, which
demonstrated normal terminal ileum, biopsies taken and results
pending.
TRANSITIONAL ISSUES
[ ] Ms. ___ did require narcotic pain medications while
inpatient. We have transitioned her to Bentyl for further pain
control
[ ] At discharge, Ms. ___ has biopsies from colonoscopy
pending. Please followup to ensure she gets these results
[ ] Ms. ___ reportedly developed neuropathic symptoms with
metronidazole (this is a side effect, not an allergy). Would
consider further trial (when clinically warranted) as this is an
uncommon side effect and she may require metronidazole for
future GI pathology
[ ] stool studies pending but already s/p 6 days ciprofloxacin
[ ] ttg is pending at time of diagnosis if negative would
confirm no IgA deficiency, defer further work-up to GI (doubt
celiac given unremarkable colonoscopy)
ACUTE ISSUES
#Terminal Ileitis
Found to have terminal ileitis 1 week prior to arrival on OSH CT
AP (per report). Since saw our GI department here, broad ddx
including infectious and inflammatory causes. Colonoscopy here
while inpatient grossly normal with pending mucosal biopsies.
She was discharged on bentyl for pain control
#Foot burning
patient reported a foot burning/warmth in her feet a few days
after starting metronidazole and improved after stopping this. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
apples
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___: Upper EUS
___: Laparoscopic cholecystectomy
History of Present Illness:
___ w depression who presents with abdominal pain. Pt was
in USOH until 3d ago when had sudden onset of severe abdominal
pain in epigastrum/RUQ/LUQ which radiates into back bilaterally.
Never had before, worse with moving around, better when lying
down, severe, radiates up into chest. Associated with episode of
nausea at onset but none since. No vomiting. Is still hungry.
Denies jaundice. TAH in the past, but otherwise no surgeries in
abdomen. No diarrhea or constipation. No jaundice, no dark
urine,
no light stools. No melena/hematochezia. Reports fevers for 2
days up to 103 at home, no chills. Mild HA at times. No
confusion. No sick contacts. No wheeze, no cough. Only pain is
chest is at the same time as the abdominal pain. Does have some
tingling in her arms and face with this abdominal pain. No
dysuria, urgency, back pain (other than above radiation). No
rash, joint pain.
At OSH AVSS. tender epigastrum/RUQ. WBC 11, hct 38, plts 273, ,
Na 140, K 3.9, bicarb 24, AP 316, TB 3.9, AST 233, ALT 296, UA
neg. Was given levo/flagyl, 1L NS.
OSH CT: distended gallbladder with small stones and borderline
wall thickening (c/f early cholecystitis), hepatic steatosis,
small hiatal hernia. No biliary ductal dilatation.
Had an unread HIDA scan.
Transferred to ___. In ___, AVSS. Was seen by surgery who
looked at HIDA and thought she likely has cholecystitis and will
need surgery likely during this admission, recommended admit to
medicine with MRCP, consult ERCP and abx.
She reports no pain now other than when people push on her
abdomen. She is hungry and thirsty.
Past Medical History:
depression
hysterectomy
Social History:
___
Family History:
CAD and DM
otherwise reviewed and non-contributory to current presentation
Physical Exam:
ADMISSION PHYSICAL EXAM:
Constitutional: VS reviewed, NAD
HEENT: eyes anicteric, normal hearing, nose unremarkable, MMM
without exudate
CV: RRR no mrg
Resp: CTAB
GI: soft, mild to mod ttp RUQ, mildly ttp epigastrum and RLQ, +
___, non-distended, NABS, no rebound
GU: no foley
MSK: no obvious synovitis
Ext: wwp, neg edema in BLEs
Skin: no rash grossly visible
Neuro: A&Ox3, DOWB intact, ___ BUE/BLE, SILT BUE/BLE, EOMI, no
droop
Psych: normal affect, pleasant
Discharge Physical Exam:
VS: 98, 121/59, 73, 18, 94%
Gen: A&O x3, lying comfortably in NAD
CV: HRR
Pulm: LS ctab
Abdl soft, NT/ND. Lap sites CDI
Ext: no edema
Pertinent Results:
ADMISSION LABS:
=============
___ 10:07PM BLOOD WBC-8.7 RBC-3.69* Hgb-11.4 Hct-35.6
MCV-97 MCH-30.9 MCHC-32.0 RDW-13.8 RDWSD-49.2* Plt ___
___ 10:07PM BLOOD Neuts-74.1* Lymphs-13.2* Monos-7.9
Eos-4.0 Baso-0.5 Im ___ AbsNeut-6.46* AbsLymp-1.15*
AbsMono-0.69 AbsEos-0.35 AbsBaso-0.04
___ 09:00AM BLOOD ___ PTT-29.7 ___
___ 10:07PM BLOOD Glucose-104* UreaN-8 Creat-0.8 Na-142
K-4.8 Cl-109* HCO3-19* AnGap-14
___ 10:07PM BLOOD ALT-221* AST-196* AlkPhos-294*
TotBili-2.6* DirBili-1.5* IndBili-1.1
___ 10:07PM BLOOD cTropnT-<0.01
___ 10:07PM BLOOD Albumin-3.6
___ 10:20PM BLOOD Lactate-1.1
IMAGING/STUDIES:
================
___ CXR:
The cardiac silhouette is within normal limits and there
is no evidence of vascular congestion, pleural effusion, or
acute focal
pneumonia. Specifically, no evidence of pneumothorax.
___ Upper EUS:
Impression:No evidence of a CBD stone at present. However, a
passed CBD stone appears most likely clinically.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. lithium carbonate 450 mg oral QHS
2. ALPRAZolam 0.5 mg PO QAM
3. ALPRAZolam 1 mg PO QHS
4. Mirtazapine 15 mg PO QHS
5. DULoxetine 40 mg PO DAILY
6. Vitamin D Dose is Unknown PO DAILY
7. Fluticasone Propionate NASAL 1 SPRY NU BID
8. Furosemide 20 mg PO DAILY:PRN swelling
9. Omeprazole 40 mg PO DAILY
10. rOPINIRole 1 mg PO QPM
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*30 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*20 Capsule Refills:*0
3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*15 Tablet Refills:*0
4. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth once a
day Disp #*14 Packet Refills:*0
5. Vitamin D 1000 UNIT PO DAILY
6. ALPRAZolam 0.5 mg PO QAM
7. ALPRAZolam 1 mg PO QHS
8. DULoxetine 40 mg PO DAILY
9. Fluticasone Propionate NASAL 1 SPRY NU BID
10. Furosemide 20 mg PO DAILY:PRN swelling
11. Lithium Carbonate 450 mg oral QHS
12. Mirtazapine 15 mg PO QHS
13. Omeprazole 40 mg PO DAILY
14. rOPINIRole 1 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with abd pain, fever// r/o ptx, pna
IMPRESSION:
No previous images. The cardiac silhouette is within normal limits and there
is no evidence of vascular congestion, pleural effusion, or acute focal
pneumonia. Specifically, no evidence of pneumothorax.
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: Abd pain
Diagnosed with Cholangitis, Right upper quadrant pain
temperature: 98.0
heartrate: 81.0
resprate: 16.0
o2sat: 98.0
sbp: 129.0
dbp: 62.0
level of pain: 0
level of acuity: 3.0 | ___ w depression who presents with abdominal pain, found to
have cholecystitis and mild bili elevation c/f cholangitis vs
more likely passed CBD stone with reactive changes. Patient was
hemodynamically stable. No ductal dilation on OSH CT which did
show early cholecystitis. GI was consulted, patient underwent
EUS that showed no CBD stone and multiple gallstones.
Presentation most consistent with cholecystitis and passed CBD
stone. No need for MRCP at this time. General Surgery was
consulted. The patient underwent laparoscopic cholecystectomy,
which went well without complication (reader referred to the
Operative Note for details). After a brief, uneventful stay in
the PACU, the patient arrived on the floor tolerating sips, on
IV fluids, and oral for pain control. The patient was
hemodynamically stable.
.
Pain was well controlled. Diet was progressively advanced as
tolerated to a regular diet with good tolerability. The patient
voided without problem. During this hospitalization, the patient
ambulated early and frequently, was adherent with respiratory
toilet and incentive spirometry, and actively participated in
the plan of care. The patient received subcutaneous heparin and
venodyne boots were used during this stay.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors / nifedipine / Lipitor
Attending: ___.
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ ___ speaking female with a
history of benign paroxysmal positional vertigo, afib on
Flecainide, atrial flutter s/p ablation, DM, and HTN presenting
with altered mental status.
She had an admission for similar concerns ___ weeks ago with a
negative workup which included: "CT head without any evidence of
CVA. CXR without pneumonia. EKG was without acute changes and
troponin was negative. Vit B12 level normal, RPR negative. TSH
was 0.13 consistent with prior labs and Free T4 pending on
discharge."
She is interviewed with her son, ___, who is translating. She
is unaware of any issues with confusion. Her only complaint is
her usual arthritis pain. She denies fevers or chills. No
changes in urination or bowel movements but does have some
urinary frequency. No headaches or vision changes. Sometimes she
feels weak in her legs or gets twitching in her hands. She has
noticed that she will drop things (like a towel) after picking
them up and this seems to happen more frequently in the last
several weeks.
Normal appetite
The son notes that she was completely normal 3 months ago. She
has episodes of confusion and bizarre behavior (trying to put
pants on as a shirt, not realizing she was not wearing pants,
using the TV remote as a phone). He also thinks she has had some
clumsiness and decreased hand strength (like when picking up a
tea pot) and is more "wobbly" when walking. She also has trouble
with short term memory loss (like being unable to remember what
she ate for breakfast). No obvious personality changes but she
seems to get frustrated more easily.
In between these episodes, she has periods where she still
seems completely normal.
She also has bruising on her stomach and behind her arms. This
is not new but has happened again in the last few weeks. No
obvious trauma but may have fallen out of bed several days ago.
Per ED report, there was some concern over SI. In discussion
with the son, the patient was expressing that she is tired of
being sick all the time and going to the hospital. She felt like
there was no help for her and wanted to give up.
In the ED, initial vitals were: 98.2 67 121/71 18 89% RA
Labs notable for: Negative toxicology screen, Plt 98, Cr 1.5,
Bicarb 16, Glu 291, Lactate 2.1.
Patient was given:
___ 21:32 IVF 1000 mL LR 1000 mL
On the floor, she is well appearing and able to answer
questions appropriately.
ROS: Per HPI
Past Medical History:
- Atrial fibrillation
- Mitral regurgitation
- Atrial flutter w/ resultant ventricular tachycardia: s/p
ablation
- Diabetes
- Peripheral arterial disease
- HTN
- HLD
- Thyroid CA - s/p total thyroidectomy on ___ -
multifocal papillary carcinoma of the thyroid, follicular
variant, in the left lobe of the thyroid.
- Endometrial cancer - s/p TAH-BSO ___, pelvic XRT
- Bilateral knee DJD s/p L TKR
- CKD
Social History:
___
Family History:
mother - uterine ca
No family history of heart disease.
Physical Exam:
ADMISSION EXAM
Vital Signs: T 98.1, BP 124/64, HR 70, RR 18, O2 99/RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic
murmur
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, no clubbing, cyanosis or edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, steady gait.
DISCHARGE EXAM
Vitals 98.0 118-124/59-63 59-66 18 100RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic murmur
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, no clubbing, cyanosis or edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
patient has normal gait and is AOx3
Pertinent Results:
ADMISSION LABS
___ 02:25PM BLOOD WBC-5.5 RBC-4.80 Hgb-12.6 Hct-41.7 MCV-87
MCH-26.3 MCHC-30.2* RDW-16.9* RDWSD-53.5* Plt Ct-98*
___ 06:40AM BLOOD ___ PTT-35.8 ___
___ 02:25PM BLOOD Glucose-291* UreaN-25* Creat-1.5* Na-139
K-4.6 Cl-109* HCO3-16* AnGap-19
___ 06:40AM BLOOD ALT-19 AST-33 LD(LDH)-238 AlkPhos-126*
TotBili-0.9
___ 06:40AM BLOOD Albumin-3.5 Calcium-9.5 Phos-3.3 Mg-2.3
___ 06:40AM BLOOD TSH-0.20*
___ 06:40AM BLOOD Free T4-1.7
DISCHARGE LABS
___ 06:30AM BLOOD WBC-3.9* RBC-4.02 Hgb-10.9* Hct-34.1
MCV-85 MCH-27.1 MCHC-32.0 RDW-16.5* RDWSD-50.9* Plt Ct-83*
___ 06:30AM BLOOD Glucose-167* UreaN-26* Creat-1.5* Na-141
K-4.0 Cl-108 HCO3-24 AnGap-13
___ 06:30AM BLOOD ALT-29 AST-49* LD(LDH)-239 AlkPhos-148*
TotBili-1.0
___ 06:30AM BLOOD Albumin-3.6 Calcium-9.5 Phos-3.9 Mg-2.3
MICROBIOLOGY:
___ ___ negative
IMAGING & STUDIES: None.
CT HEAD
No hemorrhage or evidence of acute infarct. Probable sequelae
of chronic small vessel ischemic disease.
CXR
No acute cardiopulmonary process.
MRI/MRA HEAD ___. Motion artifact degrades space resolution.
2. Patchy periventricular and subcortical white matter FLAIR
hyperintensity, likely reflecting sequela chronic
microangiopathy.
3. No acute intracranial abnormality without infarct,
hemorrhage, or mass.
4. Patent intracranial and neck vasculature, without carotid
stenosis by NASCET criteria.
5. T1 hyperintensity within the bilateral basal ganglia which is
a nonspecific finding which may be seen in the setting of liver
disease, hyperglycemia, and parenteral nutrition, amongst
others. Given reported intermittent consider episodic hepatic
encephalopathy. Recommend clinical correlation
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with delirium // eval ? infiltrate, edema
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
The patient arterial no focal consolidation is seen. No pleural effusion or
pneumothorax. The cardiac and mediastinal silhouettes are stable.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ woman with confusion. Evaluate for hemorrhage.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Total DLP (Head) = 803 mGy-cm.
COMPARISON: Head CT dated ___.
FINDINGS:
No evidence of acute infarction, hemorrhage, edema, or mass effect.
Periventricular and subcortical white matter hypodensities are nonspecific and
likely sequelae of chronic small vessel ischemic disease, unchanged. The
ventricles and sulci are normal in size and configuration.
Mild to moderate bilateral cavernous internal carotid calcifications are
unchanged.
No evidence of fracture. Mucosal thickening in the bilateral posterior
ethmoidal air cells is mild. The right frontal sinus is hypoplastic. The
visualized portion of the remaining paranasal sinuses, mastoid air cells, and
middle ear cavities are clear. The visualized portion of the orbits are
unremarkable.
IMPRESSION:
No hemorrhage or evidence of acute infarct. Probable sequelae of chronic
small vessel ischemic disease.
Radiology Report
EXAMINATION: MRI AND MRA BRAIN AND MRA NECK PT11 MR ___
INDICATION: ___ year old woman with recurrent brief episodes of confusion; CT
Head negative, infectious work up negative // vascular process or other to
explain AMS.
TECHNIQUE: Three dimensional time of flight MR arteriography was performed
through the brain with maximum intensity projection reconstructions.
Dynamic MRA of the neck was performed during administration of 18 mL of
Multihance intravenous contrast.
Brain imaging was performed with sagittal T1 and axial FLAIR, T2, gradient
echo and diffusion technique.
Three dimensional maximum intensity projection and segmented images were
generated. This report is based on interpretation of all of these images. The
examination was performed using a 1.5T MRI.
COMPARISON: ___ head CT. ___ head MRI.
FINDINGS:
Study is moderately degraded by motion, especially on postcontrast imaging.
MRI HEAD:
There is patchy periventricular and subcortical white matter FLAIR
hyperintensity, which is nonspecific but likely secondary to sequela of
chronic microangiopathy. There is no evidence of infarct, hemorrhage, mass,
or mass effect. There is T1 hyperintensity within the bilateral basal
ganglia. There is no abnormal parenchymal enhancement. The ventricles and
cortical sulci are normal in caliber configuration. The extra-axial spaces
are unremarkable. The vascular flow voids are preserved.
The orbits, soft tissues, and calvarium are unremarkable. There is mild
mucosal thickening within the paranasal sinuses. There is no abnormal fluid
signal within the mastoid air cells or middle ears.
MRA HEAD:
There is motion artifact which degrades spatial resolution.
The bilateral intracranial internal carotid arteries are patent. The anterior
communicating artery is visualized. The bilateral posterior communicating
arteries are not definitively seen. There are codominant vertebral arteries.
There is segmental low signal within the right V3 and inferior V4 segments of
the right vertebral artery which is patent on the subsequent dynamic neck MRA,
therefore consistent with artifact. The anterior and posterior arterial
circulations are patent without occlusion, dissection, stenosis, or aneurysm.
There is no evidence of vascular malformation.
MRA NECK:
There is a 3 vessel aortic arch. The carotid arteries are patent without
stenosis by NASCET criteria. The vertebral arteries are patent. There is
normal venous contrast enhancement.
IMPRESSION:
1. Study is moderately degraded by motion.
2. Probable small vessel ischemic changes as described.
3. No acute intracranial abnormality without infarct, hemorrhage, or mass.
4. Grossly patent intracranial and cervical vasculature, without carotid
stenosis by NASCET criteria.
5. Nonspecific bilateral basal ganglia findings as described. Differential
considerations include liver disease, hyperglycemia, and parenteral nutrition.
Question episodic hepatic encephalopathy. Recommend correlation with hepatic
function testing.
RECOMMENDATION(S): Nonspecific bilateral basal ganglia findings as described.
Differential considerations include liver disease, hyperglycemia, and
parenteral nutrition. Question episodic hepatic encephalopathy. Recommend
correlation with hepatic function testing.
Gender: F
Race: ASIAN - CHINESE
Arrive by WALK IN
Chief complaint: Altered mental status
Diagnosed with Altered mental status, unspecified
temperature: 98.2
heartrate: 67.0
resprate: 18.0
o2sat: 99.0
sbp: 121.0
dbp: 71.0
level of pain: 0
level of acuity: 3.0 | ___ yo F with history of AFib on flecainide, T2DM, CKD admitted
for recurrent episodes of confusion that resolve spontaneously.
Patient had recent admission for similar complaints, and
extensive workup was negative. We obtained MRI/MRA of head which
did not show findings to explain symptoms. Discharged home with
encouragement to follow up with PCP. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lactose
Attending: ___.
Chief Complaint:
Mechanical fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with Parkinsons disease (nonverbal at baseline), HTN, HLD
had a witnessed mechanical fall at her nursing home and is now
presenting from an OSH with concern for ICH on ___.
Per nursing home documentation, the patient was being
transferred to her wheelchair by staff and experienced a
mechanical fall. No loss of consciousness or seizure. +
Headstrike. She was noted to be at her baseline neurologic
status thereafter. She was then taken to ___, where CT
scan of the head showed small cortical ICH and intrafalcine
blood without shift.
Patient is essentially nonverbal and is unable to provide
further history.
In the ___ initial vitals were: 98.1 110 121/76 18 96% RA. Pt
spiked temp to 101.6. HR stayed in the 100s.
- Labs were significant for positive UA, Na 146, normal lactate.
- CXR showed RLL opacity felt to be atelectasis.
- Patient was given 1g IV CTX. Blood cultures drawn.
- Neurosurgery was consulted who said no need for surgical
intervention at this time.
Vitals prior to transfer were: 98.9 109 141/78 23 98% RA.
On arrival to the floor, pt is able to give a thumbs down when
asked if her head hurts or if she has any pain.
Past Medical History:
# ICH (___) s/p fall
# Hypertension
# Hyperlipidemia
# Breast CA s/p breast-conserving surgery followed by
postoperative XRT with arimidex therapy
# Stasis dermatitis with ulceration and previous cellulitis
# Hip fracture
# Gait disorder
# Speech disorder
# CKD
# Osteoarthritis
# Skin cancer
Social History:
___
Family History:
Negative for breast and ovarian cancer.
Physical Exam:
ADMISSION PE:
Vitals: 98, 136/58, 113, 25, 99% on 3L
GENERAL: NAD, resting comfortably in bed, interactive,
cooperates with exam, following commands. Makes noises with her
lips but is unable to speak.
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: exam limited. clear anterolaterally. no wheezes, rales,
rhonchi, breathing comfortably without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII grossly intact. moving all extremities with
purpose. resting tremor and cogwheel rigidity in the b/l UEs.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PE:
Vitals: 98.3; 150/71; 92; 22; 93RA
Otherwise unchanged exam
Pertinent Results:
ADMISSION LABS:
___ 02:45PM BLOOD WBC-7.3 RBC-3.65* Hgb-12.0 Hct-36.6
MCV-100* MCH-32.8* MCHC-32.7 RDW-14.5 Plt ___
___ 02:45PM BLOOD ___ PTT-27.8 ___
___ 02:45PM BLOOD Glucose-95 UreaN-19 Creat-1.0 Na-146*
K-4.1 Cl-110* HCO3-24 AnGap-16
___ 02:45PM BLOOD Calcium-9.4 Phos-2.8 Mg-1.9
DISCHARGE LABS:
___ 07:00AM BLOOD WBC-4.4 RBC-3.30* Hgb-10.7* Hct-33.1*
MCV-100* MCH-32.3* MCHC-32.2 RDW-14.5 Plt ___
___ 07:00AM BLOOD Plt ___
___ 07:00AM BLOOD Glucose-86 UreaN-14 Creat-0.8 Na-146*
K-4.5 Cl-110* HCO3-25 AnGap-16
___ 07:00AM BLOOD Calcium-9.2 Phos-3.0 Mg-1.8
MICRO:
Blood Cx/Urine Cx pending at discharge
Studies/Imaging:
CT Head: OSH imaging report
CXR:
Low lung volumes with right lung opacity laterally potentially
atelectasis although clinical correlation is suggested regarding
possibility of infection. Otherwise no evidence of acute
cardiopulmonary process.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Cyanocobalamin 100 mcg PO DAILY
3. Loratadine 10 mg PO DAILY
4. Polyethylene Glycol 17 g PO DAILY
5. Vitamin D ___ UNIT PO DAILY
6. Acetaminophen 650 mg PO Q6H:PRN pain or fever
7. Fluticasone Propionate 110mcg 2 PUFF IH BID
8. Acidophilus (L.acidoph & ___
acidophilus) oral BID
9. Guaifenesin ER 1200 mg PO Q12H
10. Sinemet (carbidopa-levodopa) ___ mg oral TID
11. Docusate Sodium 100 mg PO BID
12. Ferrous Sulfate 325 mg PO DAILY
13. Simvastatin 20 mg PO DAILY
14. Atenolol 50 mg PO DAILY
15. Senna 8.6 mg PO DAILY:PRN constipation
16. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN wheeze
17. LOPERamide 2 mg PO QID:PRN loose stool
18. Benzonatate 200 mg PO TID:PRN cough
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain or fever
2. Aspirin 325 mg PO DAILY
3. Atenolol 50 mg PO DAILY
4. Benzonatate 200 mg PO TID:PRN cough
5. Cyanocobalamin 100 mcg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Ferrous Sulfate 325 mg PO DAILY
8. Fluticasone Propionate 110mcg 2 PUFF IH BID
9. Guaifenesin ER 1200 mg PO Q12H
10. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN wheeze
11. Loratadine 10 mg PO DAILY
12. Polyethylene Glycol 17 g PO DAILY
13. Simvastatin 20 mg PO DAILY
14. Vitamin D ___ UNIT PO DAILY
15. Acidophilus (L.acidoph &
___ acidophilus) 0 ORAL BID
16. LOPERamide 2 mg PO QID:PRN loose stool
17. Senna 8.6 mg PO DAILY:PRN constipation
18. Sinemet (carbidopa-levodopa) ___ mg oral TID
19. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 1 Day
2 doses for ___
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth twice a day Disp #*2 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
- Intracerebral Hemorrhage
Secondary Diagnosis:
- Parkinsons
- Hyperlipidemia
- Hypertension
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with fall, fever // presence of infiltrate
TECHNIQUE: AP and lateral views of the chest.
COMPARISON: ___ chest x-ray and left humerus films from ___.
FINDINGS:
Low lung volumes are noted with secondary crowding of the bronchovascular
markings. Right midlung opacity seen laterally could potentially represent
atelectasis. There is no effusion or pulmonary edema. The cardiomediastinal
silhouette is within normal limits. Atherosclerotic calcifications noted at
the aortic arch with tortuosity of the descending thoracic aorta. Chronic
changes seen at the proximal left humerus which is incompletely visualized,
suggestive of Paget's disease as on prior dedicated views.
IMPRESSION:
Low lung volumes with right lung opacity laterally potentially atelectasis
although clinical correlation is suggested regarding possibility of infection.
Otherwise no evidence of acute cardiopulmonary process.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, Head injury
Diagnosed with BRAIN HEM NEC W/O COMA, FALL RESULTING IN STRIKING AGAINST OTHER OBJECT, URIN TRACT INFECTION NOS, PARKINSON'S DISEASE
temperature: 98.1
heartrate: 110.0
resprate: 18.0
o2sat: 96.0
sbp: 121.0
dbp: 76.0
level of pain: 13
level of acuity: 2.0 | ___ with Parkinsons disease (nonverbal at baseline), HTN, HLD
had a witnessed mechanical fall at her nursing home and is now
presenting from an OSH with concern for ICH on ___, also
febrile in the ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Weight loss
Major Surgical or Invasive Procedure:
EGD/Colonoscopy
History of Present Illness:
___ F with hx depression, HTN, alpha thalassemia trait
(baseline
Hgb 10.7) and HFrEF (43%) presenting from clinic after noted ___
on labs iso dizziness, nausea, weakness, and abdominal pain.
She had been having one month of dizziness, lightheadedness, and
L sided abdominal pain as well as diffuse weakness and nausea
with 1 episode of vomiting. Due to her nausea, she reports that
she has been having poor PO intake. The dizziness worse upon
standing. When she eats, she feels full and bloated and has
vague
left abdominal pain. She reports loose stools but no diarrhea.
She endorses SOB concurrent with her dizziness, but no DOE,
chest
pain, orthopnea, ___ edema. She also endorses a dry cough for
the last few days but denies congestion, sore throat, fevers,
chills, palpitations, black/bloody stools, or changes in stool
caliber. She reports having dysuria a few times a day. She has
unintentionally lost 23 lbs since ___. Of note, she was
supposed to have a colonoscopy but did not because she was too
weak. She went to her PCP ___ ___, and given a BP of 79/48 in
clinic, her home lisinopril and carvedilol were held. She had
labs drawn and was found to have Cr of 2.79 (baseline Cr 0.8),
so
her PCP called her and asked that she present to the ED.
In the ED:
Her vital signs were notable for: Afebrile (97.6F), HR 77, BP
103/80 initially but dropped to 82/46 and recovered to 102/58
with IVFs, RR 18, 98% on room air
Exam notable for: conjunctival pallor, clear lungs, no ___ edema,
no CVA tenderness
Labs were notable for: Na 134, Hgb 8.3, no leukocytosis, lactate
of 2.6, urine electrolytes with Na<20, proBNP 310, UA negative,
and blood/urine cultures were obtained
Studies performed include: Renal U/S wnl
EKG: normal sinus rhythm with no ischemic changes, QTc 460
Patient was given 3L IVF with downtrend in lactate from 2.6 to
1.9.
ED consults: Nephrology
Upon arrival to the floor, she reports feeling much better
without any dizziness s/p fluids. She denies any pain, including
abdominal pain, and is not currently nauseous.
Past Medical History:
-HTN (baseline on treatment is 120s-130s/80 in clinic)
-HFrEF
-arthritis
-anemia
-depression
-Anal fissure
-Hemorrhoids
-Alpha thalassemia trait
Social History:
___
Family History:
Non contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: T 97.9 HR 64 BP 131/76 RR 18 SpO2 99% on room air
GENERAL: Alert and interactive, well appearing sitting in bed
HEENT: PERRL, EOMI. Sclera anicteric and without injection. Good
dentition
NECK: JVD not appreciated
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing. Symmetric chest excursion
BACK: No spinous process tenderness. No CVA tenderness.
ABDOMEN: Soft, nontender, nondistended. No organomegaly. Loose,
extra skin c/w weight loss
EXTREMITIES: Warm and well perfused, DP/Radial 2+ bilaterally.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Speech is
fluent with no gross deficits. Pleasant and warm affect
DISCHARGE PHYSICAL EXAM:
Vitals: 24 HR Data (last updated ___ @ 827)
Temp: 98.6 (Tm 98.6), BP: 124/75 (106-134/69-87), HR: 72
(67-99), RR: 16 (___), O2 sat: 100% (99-100), O2 delivery: Ra,
Wt: 156 lb/70.76 kg
General: Alert and interactive, well appearing, sitting in bed
eating breakfast
HEENT: PERRL, EOMI. Sclera anicteric and without injection. Good
dentition.
Lungs: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
CV: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
GI: Soft, nontender, nondistended. No organomegaly.
Ext: Warm and well perfused, no edema.
Neuro: AOx3, strength and sensation grossly intact.
Pertinent Results:
___ 11:50AM BLOOD WBC-3.7* RBC-3.64* Hgb-8.3* Hct-26.5*
MCV-73* MCH-22.8* MCHC-31.3* RDW-17.2* RDWSD-44.4 Plt ___
___ 07:24AM BLOOD WBC-9.4 RBC-3.20* Hgb-7.4* Hct-23.3*
MCV-73* MCH-23.1* MCHC-31.8* RDW-17.3* RDWSD-44.1 Plt ___
___ 06:15AM BLOOD WBC-4.7 RBC-3.02* Hgb-7.0* Hct-22.4*
MCV-74* MCH-23.2* MCHC-31.3* RDW-17.3* RDWSD-45.8 Plt ___
___ 07:32AM BLOOD ___
___ 07:45AM BLOOD Ret Aut-1.7 Abs Ret-0.06
___ 01:24PM BLOOD Ret Aut-2.1* Abs Ret-0.06
___ 11:50AM BLOOD Glucose-122* UreaN-36* Creat-3.9* Na-134*
K-5.1 Cl-98 HCO3-17* AnGap-19*
___ 07:45AM BLOOD Glucose-96 UreaN-19 Creat-1.3*# Na-144
K-5.2 Cl-112* HCO3-19* AnGap-13
___ 06:15AM BLOOD Glucose-91 UreaN-12 Creat-0.9 Na-140
K-4.3 Cl-101 HCO3-28 AnGap-11
___ 11:50AM BLOOD ALT-17 AST-30 AlkPhos-59 TotBili-0.3
___ 11:50AM BLOOD Lipase-65*
___ 11:50AM BLOOD proBNP-310
___ 11:50AM BLOOD Albumin-4.2 Iron-88
___ 07:24AM BLOOD Hapto-105
___ 07:45AM BLOOD ___ Folate->20 Hapto-70
___ 11:50AM BLOOD calTIBC-281 Ferritn-563* TRF-216
___ 07:45AM BLOOD %HbA1c-5.3 eAG-105
___ 06:15AM BLOOD TSH-2.1
___ 07:45AM BLOOD Cortsol-9.6
___ 06:15AM BLOOD IgA-194
___ 06:15AM BLOOD tTG-IgA-PND
___ 11:50AM BLOOD LtGrnHD-HOLD
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ranitidine 150 mg PO QHS
2. Aspirin 81 mg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Hydrocortisone Cream 2.5% 1 Appl TP BID Anal fissure
5. FLUoxetine 20 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Maalox/Diphenhydramine/Lidocaine Dose is Unknown PO QID:PRN
oral sores
8. amLODIPine 10 mg PO DAILY
9. mometasone 0.1 % topical DAILY
10. clotrimazole-betamethasone ___ % topical BID
11. Senna 8.6 mg PO BID:PRN Constipation - First Line
12. Lisinopril 40 mg PO DAILY
13. Carvedilol 6.25 mg PO BID
Discharge Medications:
1. Maalox/Diphenhydramine/Lidocaine ___ mL PO QID:PRN oral
sores
2. Aspirin 81 mg PO DAILY
3. clotrimazole-betamethasone ___ % topical BID
4. FLUoxetine 20 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Hydrocortisone Cream 2.5% 1 Appl TP BID Anal fissure
7. mometasone 0.1 % topical DAILY
8. Multivitamins 1 TAB PO DAILY
9. Ranitidine 150 mg PO QHS
10. Senna 8.6 mg PO BID:PRN Constipation - First Line
11. HELD- amLODIPine 10 mg PO DAILY This medication was held.
Do not restart amLODIPine until your doctor tells you to do so.
12. HELD- Carvedilol 6.25 mg PO BID This medication was held.
Do not restart Carvedilol until your doctor tells you to do so.
13. HELD- Lisinopril 40 mg PO DAILY This medication was held.
Do not restart Lisinopril until your doctor tells you to do so.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Weight loss, unexplained
Incidental renal mass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old woman with HTN, depression, anemia, HFrEF presenting
with ___ (baseline 0.8, now 3.7), nausea, dizziness, and hypotension//
bilateral ultrasound with Doppler iso rapidly rising Cr
TECHNIQUE: Grey scale, color and spectral Doppler ultrasound images of the
kidneys were obtained.
COMPARISON: None.
FINDINGS:
There is no hydronephrosis, stones, or masses bilaterally. Normal cortical
echogenicity and corticomedulary differentiation are seen bilaterally.
Right kidney: 8.8 cm
Left kidney: 8.7 cm
Renal Doppler: Intrarenal arteries show normal waveforms with sharp systolic
peaks and continuous antegrade diastolic flow. The resistive indices of the
right intra renal arteries range from 0.72-0.8. The resistive indices on the
left range from 0.71-0.75. Bilaterally, the main renal arteries are patent
with normal waveforms. The peak systolic velocity on the right is 60.2
centimeters/second. The peak systolic velocity on the left is 62.1
centimeters/second. Main renal veins are patent bilaterally with normal
waveforms.
The bladder is moderately well distended and normal in appearance.
IMPRESSION:
Normal renal ultrasound. No evidence of renal artery stenosis.
Radiology Report
INDICATION: ___ yo female presenting with weight loss and early satiety, got
EGD/colonoscopy this morning and suddenly has fevers/rigors, concern for
aspiration pneumonitis// ? Pneumonitis/pneumonia causing fevers/rigors
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
There is new elevation of the left hemidiaphragm suggestive left lower lobe
atelectasis. Patchy opacities however throughout the left mid lower lung
raise concern for superimposed aspiration/pneumonia. There is no pleural
effusion or pneumothorax. No focal consolidation is seen within the right
lung. The size of the cardiac silhouette is within normal limits. Tortuosity
of the thoracic aorta.
IMPRESSION:
Elevated left hemidiaphragm likely reflect left lower lobe atelectasis. There
are however superimposed ill-defined patchy opacities within the left mid and
lower lung which raise concern for superimposed aspiration/pneumonia.
Radiology Report
EXAMINATION: Abdominal pelvis CT
INDICATION: ___ yo female with h/o HFrEF (EF 43%), alpha thalassemia trait,
HTN who presents with 1 month of dizziness and L abdominal pain iso poor PO
intake with nausea/vomiting, found to have ___ and acute on chronic
microcytic anemia, admitted for workup of FTT/weight loss.// ?malignancy or
other explanation for early satiety and weight loss
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.9 s, 64.7 cm; CTDIvol = 12.2 mGy (Body) DLP = 790.9
mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7
mGy-cm.
3) Stationary Acquisition 7.2 s, 0.5 cm; CTDIvol = 40.3 mGy (Body) DLP =
20.1 mGy-cm.
Total DLP (Body) = 813 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Please refer to the chest CT done the same day.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
Small 7 mm lesion at the periphery of segment 8 too small to be characterized.
There is no evidence of intrahepatic or extrahepatic biliary dilatation. The
gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is a 12 x 10 mm hypodense lesion in the inferior aspect of left the
kidney with indeterminate density (65 ___ unit). There is a 8 mm cyst
in the inferior aspect of the right kidney. There is no perinephric
abnormality. No hydronephrosis.
GASTROINTESTINAL: The stomach is not well-distended which limit the evaluation
of this organ. This is to be correlated to an endoscopy if clinically
pertinent. small bowel loops demonstrate normal caliber, wall thickness, and
enhancement throughout. The colon and rectum are within normal limits. The
appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: 2 cm anterior fundic fibroid and 1 calcified measuring 11
mm in the posterior fundus.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: Degenerative changes in the lower lumbar spine.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
-No acute intra-abdominal process.
-Indeterminate 1.2 cm left renal lesion not seen on the ultrasound done the ___ to be further characterized by MRI.
-
RECOMMENDATION(S): Abdominal MRI to characterize left renal lesion.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: Weight loss. Early satiety. Malignancy or other explanation?
TECHNIQUE: Chest CT with IV contrast.
DOSE: Found no primary dose record and no dose record stored with the sibling
of a split exam.
!If this Fluency report was activated before the completion of the dose
transmission, please reinsert the token called CT DLP Dose to load new data.
COMPARISON: None
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: Unremarkable
UPPER ABDOMEN: Please refer to the abdominal CT done the same day.
MEDIASTINUM: No mediastinal adenopathy. Simple fluid in the superior
pericardial recess which is within normal limits.
HILA: No hilar adenopathy.
HEART and PERICARDIUM: No cardiomegaly. No pericardial effusion.
PLEURA: No pleural effusion
LUNG:
-PARENCHYMA: Nodular ground-glass opacities with a peribronchovascular
distribution predominantly in the lingula and left lower lobe with a
consolidation in the lateral segment of the left lower lobe concerning for
pneumonia.
-AIRWAYS: Patent
-VESSELS: Unremarkable
CHEST CAGE: No worrisome bone lesion.
IMPRESSION:
-No concerning lesion for malignancy.
-Multifocal left lung opacity predominantly in the lingula and the left lower
lobe with consolidation concerning for pneumonitis. follow-up with imaging
post treatment is recommended.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Abnormal labs, Dizziness, Weakness
Diagnosed with Hypotension, unspecified, Hypovolemia, Acute kidney failure, unspecified
temperature: 97.6
heartrate: 77.0
resprate: 18.0
o2sat: 98.0
sbp: 103.0
dbp: 80.0
level of pain: 0
level of acuity: 3.0 | ___ h/o HFrEF (EF 43%), alpha thalassemia trait, HTN who
presented with 1 month of dizziness, weakness, and L abdominal
pain iso poor PO intake with nausea/vomiting, found to have ___
admitted for rehydration and workup of
FTT/weight loss. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Briefly, Mr. ___ was treated in ___ for community
acquired pneumonia with levofloxacin for 7 and subsequently
presented to the ___ ED on ___ with the
sudden onset of fever, chills, shortness of breath. In the ED at
___ he was found to have new atrial fibrillation. He was also
found to be leukopenic with WBC count of 2.68, a Lactate of 4.0
and Troponin 0 0.079. He was initially started with broad
spectrum antibiotics including vancomycin, metronidazole and
cefepime. Blood cultures grew gram-negative diplococci
(speciated as Moraxella catarrhalis sensitive to ceftriaxone)
and TEE showed no evidence of endocarditis and showed normal
valve function. Given no other identifiable source of infection
and high likelihood of endocarditis infectious disease
recommended continuing 6 weeks of IV antibiotics with
ceftriaxone (to end on ___. Further, during this
admission the patient appeared volume overloaded Patient volume
overloaded on physical examination and a TTE revealed new
reduced ejection fraction of 30 to 35%. He was started on
furosemide, lisinopril and his metoprolol increased to 75 mg
daily. Finally, during this admission, the patient was observed
to have paroxysmal atrial fibrillation during first day of
hospital stay, but throughout his stay, telemetry mostly
revealed normal sinus rhythm. His TEE showed left atrial
fibrosis and likely concern for transthyretin amyloidosis. Given
high risk of stroke and paroxysmal atrial fibrillation
cardiology recommended initiating anticoagulation with apixaban.
Patient discharged on apixaban 5 mg twice daily. The patient was
ultimately discharged after a 5 day hospital stay on ___.
The patient presents to ___ complaining of chest pain and
shortness of breath. He reports that he has had dyspnea on
exertion and heaviness in his chest which have worsened over the
last 3 days. His symptoms tend to go away with rest. The patient
reports that these symptoms became increasingly frequent and
severe in the few days leading up to presentation. The patient
described his chest discomfort as a heaviness that did not
radiate and resolved with rest. He denied nausea, vomiting,
diaphoresis and fevers.
In the ED, the patient was asymptomatic an well appearing with
vitals that were all within normal limits. Given his symptoms,
however, there was concern for atypical chest pain/unstable
angina. His EKG showed EKG borderline lateral depressions. Trop
0.04 (of note Trop during hospitalization (~5 weeks ago) peaked
at 0.48). Given concerns about the patient's chest pain,
symptoms, trops, and EKG, he was admitted to cardiology.
On arrival to the floor, the patient is resting comfortably in
bed and appears well. He endorses the above history. He
continues to endorse intermittent shortness of breath and chest
tightness with activity. He denies chest pain currently. He
states that he is extraordinarily fatigued.
Past Medical History:
Heart Failure with Reduced Ejection Fraction
Atrial Fibrillation
Diabetes Mellitus
Mild CAD
Aortic Stenosis s/p AVR
Hypercholesterolemia
History of TIA
BPH
Thalassemia Trait
Carpal tunnel syndrome
Social History:
___
Family History:
Brother: ___ cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: Reviewed in POE
GENERAL: Well appearing elderly male in no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: JVP ~10cm. No thyromegaly. No LAD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: No CVA tenderness.
ABDOMEN: Soft, non-tender, non-distended. +Bowel sounds.
EXTREMITIES: Trace to 1+ edema. Pulses DP/Radial 2+ bilaterally.
SKIN: Warm. No rashes.
NEUROLOGIC: AOx3. CN2-12 intact. ___ strength throughout. Normal
sensation.
DISCHARGE PHYSICAL EXAM
=========================
Physical Exam:
VS: Temp: 99.1 PO BP: 122/72 R Sitting HR: 79 RR: 18 O2 sat: 98%
O2 delivery: RA FSBG: 130
CV: Regular rhythm. No murmurs, rubs, gallops. Normal S1/S2.
Elevated JVP with distended EJ.
PULM: CTAB. no wheezes/rales. Normal work of breathing.
ABD: Soft, non-distended. Non-tender to palpation.
EXT: Warm and well-perfused. ___ +2 pitting edema to mid-shin
bilaterally, improved from prior.
Pertinent Results:
ADMISSION LABS
___ 09:00PM cTropnT-0.04*
___ 03:47PM CK-MB-3 proBNP-8446*
___ 03:47PM WBC-7.4 RBC-4.07* HGB-9.2* HCT-28.9* MCV-71*
MCH-22.6* MCHC-31.8* RDW-16.1* RDWSD-40.8
___ 03:47PM PLT COUNT-175
___ 03:47PM NEUTS-72.3* LYMPHS-18.3* MONOS-7.5 EOS-1.1
BASOS-0.3 IM ___ AbsNeut-5.36 AbsLymp-1.36 AbsMono-0.56
AbsEos-0.08 AbsBaso-0.02
___ 03:47PM GLUCOSE-130* UREA N-23* CREAT-1.0 SODIUM-131*
POTASSIUM-4.1 CHLORIDE-93* TOTAL CO2-25 ANION GAP-13
___ 03:47PM CALCIUM-8.7 PHOSPHATE-3.5 MAGNESIUM-1.8
DISCHARGE LABS
___ 04:44AM BLOOD WBC-9.0 RBC-4.01* Hgb-9.0* Hct-28.1*
MCV-70* MCH-22.4* MCHC-32.0 RDW-15.7* RDWSD-38.7 Plt ___
___ 04:44AM BLOOD Glucose-134* UreaN-24* Creat-0.9 Na-133*
K-4.1 Cl-94* HCO3-25 AnGap-14
___ 04:44AM BLOOD Calcium-8.3* Phos-3.7 Mg-2.2
MICRO: none
IMAGING: none
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Apixaban 5 mg PO BID
2. Aspirin 81 mg PO DAILY
3. beclomethasone dipropionate 40 mcg/actuation inhalation BID
4. CefTRIAXone 2 gm IV Q24H
5. Finasteride 5 mg PO DAILY
6. Lisinopril 10 mg PO DAILY
7. MetFORMIN (Glucophage) 1000 mg PO BID
8. Metoprolol Succinate XL 50 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Pravastatin 40 mg PO QPM
11. Tamsulosin 0.4 mg PO QHS
12. Furosemide 40 mg PO BID
13. Spironolactone 12.5 mg PO DAILY
14. Vitamin D 1000 UNIT PO DAILY
15. Cyanocobalamin 1000 mcg PO DAILY
16. Ascorbic Acid ___ mg PO Frequency is Unknown
Discharge Medications:
1. Torsemide 20 mg PO BID
PLEASE TAKE ONE PILL TWO TIMES PER DAY. THIS WILL MAKE YOU HAVE
TO URINATE.
RX *torsemide 20 mg 1 tablet(s) by mouth twice a day Disp #*14
Tablet Refills:*0
2. Ascorbic Acid ___ mg PO DAILY
3. Apixaban 5 mg PO BID
4. Aspirin 81 mg PO DAILY
5. beclomethasone dipropionate 40 mcg/actuation inhalation BID
6. CefTRIAXone 2 gm IV Q24H
7. Cyanocobalamin 1000 mcg PO DAILY
8. Finasteride 5 mg PO DAILY
9. Lisinopril 10 mg PO DAILY
10. MetFORMIN (Glucophage) 1000 mg PO BID
11. Metoprolol Succinate XL 50 mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Pravastatin 40 mg PO QPM
14. Spironolactone 12.5 mg PO DAILY
15. Tamsulosin 0.4 mg PO QHS
16. Vitamin D 1000 UNIT PO DAILY
17. HELD- Furosemide 40 mg PO BID This medication was held. Do
not restart Furosemide until your primary care provider tells
you to restart.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Heart failure exacerbation
SECONDARY DIAGNOSIS
===================
Moraxella catarrhalis Bacteremia
Atrial Fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with chest pain, dyspnea, cough// eval pna, volume
overload
TECHNIQUE: Chest PA and lateral
COMPARISON: Multiple prior chest radiographs, most recently ___.
FINDINGS:
No focal consolidation is seen. Trace left pleural effusion. No
pneumothorax. Prominence of the cardiomediastinal silhouette without evidence
of overt edema. Heart size is mildly enlarged. Status post aortic valve
replacement. Median sternotomy wires are present. Left-sided PICC line
appears to terminate in the mid SVC.
IMPRESSION:
1. Trace left pleural effusion; possible trace right pleural effusion.
2. No evidence of overt pulmonary edema. Mild cardiomegaly.
3. Left-sided PICC line terminates in the mid SVC.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Chest pain, Dyspnea
Diagnosed with Chest pain, unspecified, Type 2 diabetes mellitus without complications, Unspecified atrial fibrillation
temperature: 96.6
heartrate: 70.0
resprate: 18.0
o2sat: 100.0
sbp: 124.0
dbp: 63.0
level of pain: 0
level of acuity: 2.0 | PATIENT SUMMARY
===============
___ with multiple cardiovascular risk factors including T2DM,
HTN, HLD, prior stroke and TIA, pAF, reduced LVEF of ___ of
unclear etiology with global hypokinesis in the setting of
Moraxella bacteremia now completing 6 weeks of CTX, history of
bioprosthetic aVR (TEE negative for endocarditis), no
significant obstructive CAD on catheterization in ___,
presenting with SOB and chest discomfort. Etiology of HFrEF
unclear, question of possible infiltrative
cardiomyopathy/amyloidosis. He underwent IV diuresis with
furosemide during this admission with good response (-1.5L). His
kidney function remained within normal limits during this
admission (BUN: 24, Cr: 0.9 on discharge). He was considered a
good candidate for dry diuresis and will be discharged home on
torsemide 20mg twice per day.
ACUTE ISSUES ADDRESSED
=====================
# Shortness of Breath / Chest Discomfort: Patient presenting
with multiple days of chest tightness, fatigue, and shortness of
breath exacerbated by climbing three flights of stairs at a ___
appointment. ___ recently diagnosed in ___ at ___. Was on
40mg furosemide, however patient reports effect of medication
has been less pronounced recently. BNP elevated at 8664, however
baseline unclear. Given clinical presentation, orthopnea,
observable JVD and peripheral edema, patient likely experiencing
an episode of HF exacerbation (per below). Patient has been in
sinus rhythm. Low suspicion for ACS given EKG with lateral
ST-depressions unchanged from previous EKG and Trop 0.04. Mild
response to furosemide 40 mg IV, dose subsequently increased to
80 mg IV QD on ___. Electrolytes were monitored and repleted as
needed. Discharged on torsemide 20mg BID.
# Heart Failure w/ Reduced Ejection Fraction: Diagnosed in ___
at ___ with TTE showing EF ___ with moderate LV hypokinesis
and severe LVH. Concern for infiltrative process with left
atrial fibrosis. Bioprosthetic AV well seated, normal gradients,
trace AR, mitral leaflets moderately thickened with trace to
mild MR and mild TR. ___ stress test for chest pain in ___
showed EF 60%. MRI likely to provide more information with
respect to infiltrative etiology vs. MIBI or cath. Plan for
cardiac MRI as outpatient. There was no indication for TTE or
TEE. Home medications were continued, other than diuretic, which
was managed as outlined above.
# Atrial Fibrillation: Diagnosed in ___ at ___ during critical
illness. Patient has had regular rhythm during hospitalization
with brief episodes of sinus tachycardic to low 100s and SVT to
130s on telemetry. Continued home apixaban and metoprolol
(fractionated).
# Moraxella catarrhalis Bacteremia: Patient admitted to ___ in
___ for Moraxella bacteremia. Blood cultures grew gram-negative
diplococci (speciated as Moraxella catarrhalis sensitive to
ceftriaxone). TEE showed no evidence of endocarditis and showed
normal valve function. Patient continued CTX 2g IV Q24h x 6
weeks (to end on ___. He will get his last dose day after
discharge, home ___ resumed on discharge. Plan for PICC to be
pulled ___.
PERTINENT CHRONIC ISSUES
======================
# Diabetes Mellitus: Held home Metformin, placed on insulin
sliding scale.
# History of TIA vs. CVA: Continued home aspirin, pravastatin
# CAD: Continued home aspirin, pravastatin
# Hypercholesterolemia: Continued home pravastatin
# BPH: Continued home tamsulosin
TRANSITIONAL ISSUES
================= |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Keflex / Capoten / Calan / Ciprofloxacin /
Pneumococcal Vaccine
Attending: ___.
Chief Complaint:
shortness of breath and fatigue
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo female with history of CAD s/p stent placement x 7,
diastolic CHF (LVEF>55% in ___ and hypertension presents
with fatigue and dyspnea. She noted the shortness of breath
today after waking up from a nap after breakfast. The fatigue
began several weeks ago and has been worsening slowly. Patient
has a recent CHF diagnosis (___). There is no chest pain,
cough, abdominal complaints or fevers.
In the ED, initial vs were: 99.0 81 156/70 20 100% 2L Nasal
Cannula. Labs were remarkable for hematocrit of 24 from baseline
of 32, with MCV of 73. INR was mildly elevated at 1.2. BNP was
1171, troponin was <0.01. Urinalysis was unremarkable. She was
transfused one unit PRBCs over four hours and given 20 mg IV
furosemide. Rectal exam showed normal tone, guaiac negative.
Chest X-ray showed small left pleural effusion (c/w prior) and
mild pulmonary edema. ECG showed normal sinus rhythm, with RBBB
and inferior TWI consistent with prior. Patient has one 18g IV
in right AC. Vitals on Transfer: 98.0 78 151/78 18 100%. On the
floor, vs were: T 98.1 P 80 BP 132/86 R 22 O2 sat 100% on 2L.
Currently, the patient reports her shortness of breath has
improved since arrival to the hospital. Has not noted any blood
in the urine or stool. Denies hematochezia, melena, or BRBPR.
Last bowel movement was this morning and it was normal. Does not
take NSAIDs but uses asprin and plavix. Last colonoscopy was in
___ -- it showed diverticulosis of the sigmoid colon, polyps in
the proximal ascending colon but was otherwiase a normal
colonoscopy.
Denies waking up during the night with shortness of breath. She
normally sleeps in a recliner -- due to problems with getting in
and out of bed with her osteoarthritis. When she naps in bed,
she uses 2 pillows. Follows low salt diet. No worsening of leg
swelling.
Past Medical History:
CATARACTS s/p bilateral cataract surgery
CONGESTIVE HEART FAILURE
CORONARY ARTERY DISEASE: LAD, RCA, LCX drug-eluting stents ___
DIABETES TYPE II -- induced by steroids
Uveitis
HYPERLIPIDEMIA
HYPERTENSION
OSTEOARTHRITIS
VENOUS INSUFFICIENCY s/p failed vein stripping
ANEMIA
PROTEINURIA
MACULAR DEGENERATION
h/o renal artery stenosis
elevated ESR of unclear etiology; autoimmune work up negative
PAST SURGICAL HISTORY:
FEMORAL HERNIA REPAIR
CHOLECYSTECTOMY
Vein stripping in ___
Social History:
___
Family History:
Father with DM2
Mother lived to age ___ non malignant pancreas mass
Brother with bladder cancer
Sister with CVA
Sons with HTN and CAD
Physical Exam:
Physical exam at admission:
T 98.1 P 80 BP 132/86 R 22 O2 sat 100% on 2L.
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: +crackles L>R through the mid lung fields; no wheezes,
rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing or cyanosis, +
edema to below level of knees bilaterally
Skin: erythematous violaceous skin changes in bilateral feet to
level of lower calf
Neuro:alert, oriented x3; strenght and sensation symmetric in
upper and lower extremities
GU: foley catheter in place with yellow to clear liquid in
collection box
Physical exam at discharge:
98.5 65 18 180/77 95% on RA
I/0: ___ yesterday
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated
Lungs: +crackles -- scant in bilateral bases, no wheezes or
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing or cyanosis, +
trace edema to level of mid calves
Skin: erythematous violaceous skin changes in bilateral feet to
level of lower calf
Pertinent Results:
Labs at admission:
___ 01:25PM BLOOD WBC-6.7 RBC-3.32* Hgb-7.4*# Hct-24.1*#
MCV-73*# MCH-22.3*# MCHC-30.7* RDW-17.7* Plt ___
___ 01:25PM BLOOD Neuts-74.2* Lymphs-17.6* Monos-6.2
Eos-1.8 Baso-0.2
___ 02:19PM BLOOD ___ PTT-29.9 ___
___ 01:25PM BLOOD Glucose-140* UreaN-20 Creat-1.0 Na-138
K-4.0 Cl-99 HCO3-28 AnGap-15
___ 05:40AM BLOOD ALT-10 AST-24 LD(LDH)-311* AlkPhos-92
TotBili-0.4
___ 01:25PM BLOOD Calcium-8.7 Phos-4.0 Mg-2.1 Iron-20*
Pertinent labs:
___ 01:25PM BLOOD cTropnT-<0.01
___ 01:25PM BLOOD proBNP-1171*
___ 12:04AM BLOOD calTIBC-364 Hapto-236* Ferritn-11*
TRF-280
___ 01:25PM BLOOD calTIBC-368 VitB12-906* Folate-GREATER TH
Ferritn-11* TRF-283
Labs at discharge:
___ 05:50AM BLOOD WBC-8.2 RBC-4.10* Hgb-9.9* Hct-30.7*
MCV-75* MCH-24.3* MCHC-32.3 RDW-18.1* Plt ___
___ 05:50AM BLOOD ___ PTT-30.5 ___
___ 05:50AM BLOOD Glucose-122* UreaN-21* Creat-0.9 Na-139
K-3.4 Cl-98 HCO3-30 AnGap-14
___ 05:50AM BLOOD Calcium-8.6 Phos-3.8 Mg-2.1
Imaging:
CXR ___:
IMPRESSION:
1. Mild interstitial pulmonary edema. No focal consolidation.
2. Moderate cardiomegaly, not significantly changed.
3. Unchanged small left pleural effusion.
EKG ___:
Sinus rhythm. Prolonged A-V conduction. Left axis deviation.
Left
ventricular hypertrophy. Right bundle-branch block. Left
anterior fascicular block. Non-specific inferior T wave
abnormalities. Prolonged A-V conduction. Compared to the
previous tracing of ___ voltage has increased slightly, now
meeting criteria for left ventricular hypertrophy. Otherwise,
findings are similar.
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from
PatientFamily/CaregiverwebOMR.
1. Amlodipine 10 mg PO DAILY
2. Atenolol 100 mg PO DAILY
3. bromfenac *NF* 0.09 % ___ 1 drop BID in R eye
4. Clopidogrel 75 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Furosemide 40 mg PO BID
7. GlipiZIDE 5 mg PO DAILY
8. Lisinopril 40 mg PO DAILY
9. Losartan Potassium 50 mg PO DAILY
10. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN breakthrough
hip pain
11. Simvastatin 20 mg PO QHS
12. TraMADOL (Ultram) 50 mg PO Q6H:PRN hip pain
13. Acetaminophen 500 mg PO Q8H:PRN pain
14. Aspirin 81 mg PO DAILY
15. Ranitidine 150 mg PO DAILY
Discharge Medications:
1. Acetaminophen 500 mg PO Q8H:PRN pain
2. Amlodipine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atenolol 100 mg PO DAILY
5. Clopidogrel 75 mg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Lisinopril 40 mg PO DAILY
8. Losartan Potassium 50 mg PO DAILY
9. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN breakthrough
hip pain
10. Ranitidine 150 mg PO DAILY
11. Simvastatin 20 mg PO QHS
12. TraMADOL (Ultram) 50 mg PO Q6H:PRN hip pain
13. Bisacodyl 10 mg PO DAILY
RX *bisacodyl 5 mg 1 tablet(s) by mouth as needed daily for
constipation Disp #*30 Tablet Refills:*0
14. Ferrous Sulfate 325 mg PO TID
Please give with orange juice.
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
three time a day Disp #*90 Tablet Refills:*0
15. Senna 2 TAB PO HS
Patient may refuse. Hold if patient has loose stools.
RX *sennosides 8.6 mg 1 tablet by mouth daily as needed for
constipation Disp #*30 Tablet Refills:*0
16. bromfenac *NF* 0.09 % ___ 1 drop BID in R eye
17. Furosemide 40 mg PO DAILY
18. GlipiZIDE 5 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Iron deficiency anemia
Secondary:
Diastolic heart failure
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: Shortness of breath and cough.
COMPARISON: Chest radiograph from ___.
FINDINGS: Frontal and lateral radiographs of the chest were acquired. There
is a diffuse interstitial abnormality, with a perihilar predominance,
suggestive of mild interstitial pulmonary edema. Moderate enlargement of the
cardiac silhouette is not significantly changed. A small left pleural
effusion is not significantly changed. There is no definite right pleural
effusion. The mediastinal contours are unchanged. There is a small hiatal
hernia, not significantly changed. There is no pneumothorax. Surgical clips
project over the upper abdomen on the lateral radiograph. Multilevel
degenerative changes of the thoracolumbar spine are noted. Anterior wedging
of a lower thoracic vertebral body is not significantly changed.
IMPRESSION:
1. Mild interstitial pulmonary edema. No focal consolidation.
2. Moderate cardiomegaly, not significantly changed.
3. Unchanged small left pleural effusion.
Gender: F
Race: OTHER
Arrive by AMBULANCE
Chief complaint: SHORTNESS OF BREATH
Diagnosed with ANEMIA NOS, CONGESTIVE HEART FAILURE, UNSPEC, CAD UNSPEC VESSEL, NATIVE OR GRAFT
temperature: 99.0
heartrate: 81.0
resprate: 20.0
o2sat: 100.0
sbp: 156.0
dbp: 70.0
level of pain: 0
level of acuity: 3.0 | ___ year old woman with history of CAD s/p stent placement x 7,
diastolic CHF (LVEF>55% in ___ and hypertension presenting
withshortness of breath and fatigue which was likely
multifactorial -- Fe defiency anemia inconjuction with volume
overloaded state related to diastolic CHF. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Hip Pain
Major Surgical or Invasive Procedure:
Hip Fixation with 7.3-mm cannulated screws
History of Present Illness:
___ yo F with h/o Ulcerative proctitis on prednisone, recent PE
on coumadin, GERD, osteoporosis presents with R hip and ankle
pain after a fall. Had been seated in a recliner for several
hours, went to stand up but leg was 'asleep' and fell down onto
R hip and twisted R ankle. No other injuries (specifically
denies head injury, neck injury). No syncope, no preceeding LH,
dizziness, CP, SOB. PMH notable for ulcerative proctitis with
chronic anemia. Of NOte the patient had symptomatic PE 2 months
ago after prolonged airline travel and is currently being
treated with warfarin last inr of 1.5 on ___, and also has
chronic prednisone use of ulcerative proctitis. Which she says
she is on a taper for.
ED COURSE:
triage v/s ___ 56 142/82 20 99% ra
Labs pertinent for
chem 141/3.9; 105/24; ___ <86
cbc 8.7>35.6 (b/l 39) <311
ECG: sinus at 84, RBBB with NSST, no sign change from ___
radigraphs: + R hip femur fracture.
Ortho was consulted, because of complicated medical issues was
admitted to medicine.
Pt received 4mg IV morphine for pain control.
On the floor pt complains of right sided hip pain but no other
complaints. Pain is ___ when lying still and ___ with any
movement.
ROS: positive for some shortness of breath
No chest pain, light headedness, dizziness, numbness, tingling,
Past Medical History:
Ulcerative proctitis on Colonoscopy ___
Shingles ___ waiste right side
cholecystectomy
appendectomy
umbilical hernia times two
surgery for tubal pregnancy.
Vertigo.
Hearing loss.
Osteoporosis.
Chronic low back pain.
GERD.
Hypercholesteremia.
vestibular neuritis
Zoster vaccine ___
Social History:
___
Family History:
No history of UC.
Physical Exam:
ADMISSION PHYSICAL EXAM
98.2 131/71 96 20 100%RA
GENERAL - ___ female unfocomfortable with leg pain
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, Dry MM, OP clear
NECK - supple, no thyromegaly, JVD not assesed, no carotid
bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWPM no C/E/E. Right hip very TTP. No ecchymoses
or gross defomrities.
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ in UE. ___ not checked ___ pain. Sensation grossly intact
throughout,
DISCHARGE PHYSICAL EXAM
T98.3| BP 150/84| HR 91| RR 18 satting 100% on RA
GENERAL - ___ female unfocomfortable with right hip pain
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, JVD not assesed, no carotid
bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWPM no C/E/E. Right hip wound CDI. No bleeding.
Minimal erythema. No ecchymoses. Tender.
NEURO - awake, A&Ox3, able to converse and do days of week
backwards, CNs II-XII grossly intact, muscle strength ___ in UE.
___ not checked ___ pain. Sensation grossly intact
throughout.
Pertinent Results:
___ 11:15PM BLOOD WBC-8.7 RBC-4.40 Hgb-12.1 Hct-35.6*
MCV-81* MCH-27.6 MCHC-34.1 RDW-14.1 Plt ___
___ 11:15PM BLOOD Neuts-71.6* ___ Monos-6.6 Eos-0.5
Baso-0.4
___ 11:15PM BLOOD ___ PTT-37.5* ___
___ 11:15PM BLOOD Glucose-86 UreaN-16 Creat-0.7 Na-141
K-3.9 Cl-105 HCO3-24 AnGap-16
___ 03:32AM BLOOD WBC-6.2 RBC-3.49* Hgb-9.8* Hct-29.2*
MCV-84 MCH-28.0 MCHC-33.5 RDW-14.8 Plt ___
___ 08:50AM BLOOD PTT-72.7*
___ 03:32AM BLOOD Plt ___
___ 03:32AM BLOOD ___ PTT-73.4* ___
___ 03:32AM BLOOD Glucose-92 UreaN-9 Creat-0.6 Na-141 K-3.7
Cl-109* HCO3-25 AnGap-11
___ 03:32AM BLOOD Phos-3.3 Mg-2.0
___ 11:15PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
___ 11:15PM URINE Color-Straw Appear-Hazy Sp ___
EKG ___
Sinus rhythm. Right bundle-branch block. Diffuse non-specific ST
segment
changes. Possible prior lateral myocardial infarction of
indeterminate age.
Compared to the previous tracing of ___ the ventricular
rate is faster.
Rate PR QRS QT/QTc P QRS T
81 ___ 94 121 66
HIP XRAY/PELVIS/ANKLE XRAY ___:
FINDINGS: There is a transverse fracture at the midcervical
level of the
right femoral neck. The fracture is minimally displaced. No
other fractures
are identified. There are mild degenerative changes of the
bilateral hips.
The sacroiliac joints and pubic symphysis are intact. There is
no fracture in
the visualized portions of the tibia and fibula. The ankle
mortise and
syndesmosis are intact. The bowel gas pattern is normal.
IMPRESSION: Transverse mildly displaced fracture through right
femoral neck.
PREOPERATIVE CXR ___
FINDINGS: In comparison to prior radiograph, there is no
significant change.
Mild diffuse interstitial abnormalities are stable. There is
underlying
emphysema. There is no consolidation, pleural effusion,
pulmonary edema, or
pneumothorax. The aorta is calcified and tortuous. The heart
size is
minimally enlarged.
IMPRESSION:
1. No acute cardiopulmonary process.
2. Stable mild cardiomegaly.
3. Stable interstitial disease and emphysema.
POST OPERATIVE HIP XRAY ___
FINDINGS: Comparison is made to prior study of ___.
Two fluoroscopic images of the right hip from the operating room
demonstrates
interval placement of three cannulated screws and washers
fixating a fracture
involving the junction of the femoral head and neck. There is
good anatomic
alignment and no signs of hardware-related complications. The
total
fluoroscopic time was 132.6 seconds. Please refer to the
operative note for
additional details.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Centrum Silver *NF* (multivitamin-minerals-lutein;<br>mv with
min-lycopene-lutein;<br>mv-min-folic acid-lutein) 0.4-300-250
mg-mcg-mcg Oral qday
2. risedronate *NF* 150 mg Oral qmonth
Takes on the ___ of each month.
3. Warfarin 8 mg PO DAILY16
4. Vitamin D 400 UNIT PO DAILY
5. Omeprazole 40 mg PO DAILY
6. Calcium Carbonate 600 mg PO DAILY
7. Sarna Lotion 1 Appl TP TID:PRN pruritus
8. PredniSONE 10 mg PO EVERY ___ DAY Duration: 7 Days
Should get last dose of prednisone ___
Tapered dose - DOWN
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
2. Calcium Carbonate 500 mg PO TID
3. PredniSONE 10 mg PO EVERY ___ DAY Duration: 7 Days
Should get last dose of prednisone ___
Tapered dose - DOWN
4. Warfarin 10 mg PO DAILY16
5. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
6. Docusate Sodium 100 mg PO BID
7. Morphine Sulfate ___ mg IV Q4H:PRN pain
8. Centrum Silver *NF* (multivitamin-minerals-lutein;<br>mv with
min-lycopene-lutein;<br>mv-min-folic acid-lutein) 0.4-300-250
mg-mcg-mcg Oral qday
9. Omeprazole 40 mg PO DAILY
10. risedronate *NF* 150 mg Oral qmonth
Takes on the ___ of each month.
11. Sarna Lotion 1 Appl TP TID:PRN pruritus
12. Vitamin D 800 UNIT PO DAILY
13. traZODONE 50 mg PO HS:PRN insomnia
14. Senna 1 TAB PO DAILY
15. Polyethylene Glycol 17 g PO DAILY:PRN constipation
16. Oxycodone SR (OxyconTIN) 10 mg PO Q12H
17. OxycoDONE (Immediate Release) 5 mg PO Q3H:PRN pain
18. Enoxaparin Sodium 60 mg SC Q12H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: Hip Fracture
Secondary: Pulmonary Embolism
Ulcerative Proctitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: Right hip pain.
COMPARISONS: None.
FINDINGS: There is a transverse fracture at the midcervical level of the
right femoral neck. The fracture is minimally displaced. No other fractures
are identified. There are mild degenerative changes of the bilateral hips.
The sacroiliac joints and pubic symphysis are intact. There is no fracture in
the visualized portions of the tibia and fibula. The ankle mortise and
syndesmosis are intact. The bowel gas pattern is normal.
IMPRESSION: Transverse mildly displaced fracture through right femoral neck.
Radiology Report
INDICATION: Preoperative chest radiograph for right femur repair.
COMPARISONS: CT chest, ___. Chest radiograph, ___.
FINDINGS: In comparison to prior radiograph, there is no significant change.
Mild diffuse interstitial abnormalities are stable. There is underlying
emphysema. There is no consolidation, pleural effusion, pulmonary edema, or
pneumothorax. The aorta is calcified and tortuous. The heart size is
minimally enlarged.
IMPRESSION:
1. No acute cardiopulmonary process.
2. Stable mild cardiomegaly.
3. Stable interstitial disease and emphysema.
Radiology Report
STUDY: Right hip intraoperative study, ___.
CLINICAL HISTORY: Patient with right hip fracture ORIF.
FINDINGS: Comparison is made to prior study of ___.
Two fluoroscopic images of the right hip from the operating room demonstrates
interval placement of three cannulated screws and washers fixating a fracture
involving the junction of the femoral head and neck. There is good anatomic
alignment and no signs of hardware-related complications. The total
fluoroscopic time was 132.6 seconds. Please refer to the operative note for
additional details.
Radiology Report
PORTABLE AP CHEST X-RAY
INDICATION: COPD, PE on Coumadin, pulmonary hypertension, shortness of
breath.
COMPARISON: Chest x-rays from ___ to ___. Chest
CTA, ___.
FINDINGS:
Lungs are clear. There is no pulmonary edema or lung consolidation. Cardiac
contour is mildly enlarged. There is no pleural effusion or pneumothorax.
CONCLUSION:
There are no acute cardiopulmonary findings.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: LOWER EXTREMITY PAIN
Diagnosed with FX NECK OF FEMUR NOS-CL, UNSPECIFIED FALL
temperature: 97.2
heartrate: 56.0
resprate: 20.0
o2sat: 99.0
sbp: 142.0
dbp: 82.0
level of pain: 5
level of acuity: 3.0 | Femoral neck fracture: Had femoral neck fracture seen on
imaging. Ortho placed 3 pins for hip stabalization. Operation
without complications. ___ saw patient and recommended in
patient rehab (ortho has recommended weight bearing as
tolerated). Pain was controlled with PCA Hydromorphone
initially, with transition to oxycontin/oxycodone for pain
control. Occassionally required IV morphine as well for
exquisite pain with ambulation/hip movement.
-titrate pain control as needed at rehab (On
oxycontin/oxycodone/acetaminophen/morphine IV for extreme pain)
-keep on bowel regimen to avoid narcotic induced constipation
-___ per physical therapy recommendations
Pulmonary Emoblism: came into the hospital on warfarin.
Discontinued warfarin periprocedurally and placed on heparin
drip post procedurally. INR was subtherapeutic at time of
discharge, and warfarin dose was increased from 8 mg daily to 10
mg daily. Also placed on enoxaparin injection BID ___
injection around 12 ___ ___ in lieu of heparin drip while
INR becomes therapeutic.
-Please continue enoxaparin while INR is subtherapeutic.
-Please DISCONTINUE enoxaparin once INR is greater than 2
-continue pulmonary embolism treatment at least until ___
Delirium risk: given age and acute hospitalization, at risk for
delirium.
-encourage circadian sleep/wake cycles (trazadone 50 mg qhs for
sleep aid)
-assure appropriate pain control per above
-frequent reorientation
-ambulate with ___
Ulcerative proctitis: occassional BRBPR at home. Presented on a
predisone taper
10 mg every third day. Increased to 10 mg daily while in house
periprocedurally to avoid stress induced adrenal insufficiency.
At time of discharge, back on prednisone taper of 10 mg every 3
days. Last dose of prednisone should be on ___.
Rash: Developed heat rash on back by HD 4. Warm/small papules
consistent with heat rash. Advised to keep area cool/dry to
avoid exacerbation.
Osteoporosis: Takes Risendronate every ___ of the month. Also
on calcium and vitamin D.
TRANSITIONAL ISSUES: Minimal changes in home meds, including
calcium and vitamin D dosing were not optimal. Changed to
Calcium Carbonate 500 mg TID as well as Vitamin D 800 U qday.
Continued omeprazole at patient's request due to dyspepsia.
CODE: Confirmed DNR/DNI
CONTACT: patient's sister Mrs. ___ ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ hx AS, pAF, COPD on nocturnal O2, PVD, AAA s/p ___ ___,
3 vessel CAD s/p PCI on plavix, CKD, sCHF (LVEF ___, TAVR
(___), DM, HTN, prostate cancer, HL who p/w hypoxia at ___'s
office on morning of admission. Pt has had increased SOB over
the last few days. Apparently he had diet indiscretions during
the ___ and had gained about 4 pounds. His O2 sats
are normally in the ___ but had dropped to the mid ___ for the
past few nights. This morning he had SOB upon waking. He sleeps
with 3L of oxygen and at ___ degrees for the few years. He had
appointment with PCP to discuss his amiodarone given concern for
symptoms he was having blue gray coloring of the skin and nose
bleeds. His PCP found him to have low oxygen saturations with
xray showing fluid overload and as such sent him to the ED.
No CP, no wheezing/ cough/ fevers. Already took his 40mg PO
lasix this morning.
In the ED intial vitals were: 98.0 62 161/66 18 88% 5L NC
Labs were notable for: proBNP: ___, Trop-T: <0.01
CXR showed: Mild to moderate pulmonary edema, worse compared to
the previous study, with small right pleural effusion.
Patient was given: Duonebs and 125mg of methylprednisolone, 20mg
IV lasix Vitals on transfer: 98.2 73 175/86 25 93% Nasal Cannula
On the floor patient looks stable and on 6L of oxygen at 93%
ROS: On review of systems, s/he denies any prior history of
stroke, TIA, deep venous thrombosis, pulmonary embolism,
bleeding at the time of surgery, myalgias, joint pains, cough,
hemoptysis, black stools or red stools. S/he denies recent
fevers, chills or rigors. S/he denies exertional buttock or calf
pain. All of the other review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
CAD with 3 vessel disease s/p PCI of the LAD and RCA
sCHF EF 27%
Paroxysmal atrial fibrillation
3. OTHER PAST MEDICAL HISTORY:
Hypertension
Prediabetes
Coronary Artery Disease - 3 vessel disease s/p PCI in ___
Prostate Cancer
Hyperlipidemia
AAA s/p stent graft repair (___) done with a Zenith graft
COPD
CHF
CKD stage III
Social History:
___
Family History:
Grandmother died of diabetes and aunt of scleroderma. No family
history of early MI, arrhytmia or cardiomyopathy
Physical Exam:
Admission physical exam:
VS: T= 98.5 BP= 176/78 HR=81 RR= 20 O2 sat= 93% on 6L
Weight: (Dry weight 160.27Ibs) 76.9kg
GENERAL: WDWN man in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP difficult to appreciate ~ 4cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No murmurs/rubs/gallops appreciated. No
thrills, lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Significant crackles at
bases, no wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: Trace edema. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: 2+ pedal pulses
Discharge physical exam:
VS: 98.4 129/55 (116-139/50-61) 18 94% on 3L (Other sats as
above)
Wt: 75 -> 71 kg ->74.6 kg -> 74.7kg -> 72.8kg -> 72.7kg -> 73kg
((Dry weight 160.27Ibs, 72 kg)
I/O: 8h /___
GENERAL: WDWN man in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP difficult to appreciate but ~ 4cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No murmurs/rubs/gallops appreciated. No
thrills, lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Still minor crackles at
bases, no wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No edema. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: 2+ pedal pulses
Pertinent Results:
Admission labs
___ 12:00PM BLOOD WBC-6.7 RBC-4.27*# Hgb-11.8*# Hct-36.6*#
MCV-86 MCH-27.6 MCHC-32.1 RDW-15.9* Plt ___
___ 12:00PM BLOOD ___ PTT-32.3 ___
___ 12:00PM BLOOD Glucose-113* UreaN-14 Creat-1.1 Na-141
K-3.7 Cl-102 HCO3-30 AnGap-13
___ 09:00PM BLOOD Calcium-9.1 Mg-2.0
___ 12:38PM BLOOD Lactate-1.6
Discharge labs
___ 07:06AM BLOOD WBC-7.5 RBC-4.03* Hgb-11.3* Hct-34.7*
MCV-86 MCH-28.0 MCHC-32.6 RDW-15.8* Plt ___
___ 07:06AM BLOOD ___ PTT-29.5 ___
___ 07:06AM BLOOD Glucose-104* UreaN-26* Creat-1.1 Na-143
K-3.5 Cl-105 HCO3-30 AnGap-12
___ 07:06AM BLOOD Calcium-8.8 Phos-3.9 Mg-2.2
Imaging
FINDINGS:
The patient is status post median sternotomy with aortic
___ device again noted in unchanged position. Cardiac
silhouette remains unchanged, mildly enlarged. The aorta is
tortuous and diffusely calcified. Mild to
moderate pulmonary edema is somewhat worse compared to the
previous exam. Small right pleural effusion is noted. Bibasilar
atelectasis is demonstrated. No pneumothorax is identified.
Multilevel degenerative changes are seen in the thoracic spine.
IMPRESSION:
Mild to moderate pulmonary edema, worse compared to the previous
study, with small right pleural effusion.
CARDIAC ECHO ___
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
are normal. The left ventricular cavity is mildly dilated. There
is moderate to severe global left ventricular hypokinesis (LVEF
= 30 %). The estimated cardiac index is depressed
(<2.0L/min/m2). Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size is normal. Tricuspid annular plane
systolic excursion is normal (>2.0cm) consistent with normal
right ventricular systolic function. The ascending aorta is
mildly dilated. An aortic ___ prosthesis is present. The
aortic valve prosthesis appears well seated, with normal
leaflet/disc motion and transvalvular gradients. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of ___ the
findings are similar (there may be increased regional
dysfunction in the inferior wall but the hypokinesis is
primarily global).
Chest xray ___
IMPRESSION:
As compared to the previous radiograph, the lung volumes have
increased. Bilateral areas of parenchymal opacities at both the
left and the right lung base have decreased in extent and
severity. No new parenchymal opacities. No pulmonary edema. No
larger pleural effusions. Known an unchanged scarring in the
left upper lobe. Normal size of the heart, status post aortic
valve replacement. Status post sternotomy. Mild elongation of
the descending aorta
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Carvedilol 12.5 mg PO BID
4. Clopidogrel 75 mg PO DAILY
5. Cyanocobalamin 500 mcg PO DAILY
6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
7. Magnesium Oxide 400 mg PO DAILY
8. Tiotropium Bromide 1 CAP IH DAILY
9. Amiodarone 200 mg PO DAILY
10. Albuterol-Ipratropium ___ PUFF IH Q6H:PRN dyspnea
11. Furosemide 40 mg PO DAILY
12. Lisinopril 40 mg PO DAILY
Discharge Medications:
]
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Carvedilol 18.75 mg PO BID
RX *carvedilol 6.25 mg 3 tablet(s) by mouth Twice a day Disp
#*90 Tablet Refills:*1
4. Clopidogrel 75 mg PO DAILY
5. Cyanocobalamin 500 mcg PO DAILY
6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
7. Lisinopril 40 mg PO DAILY
8. Tiotropium Bromide 1 CAP IH DAILY
9. Magnesium Oxide 400 mg PO DAILY
10. Albuterol-Ipratropium ___ PUFF IH Q6H:PRN dyspnea
11. Pantoprazole 20 mg PO Q24H
___ hour before breakfast
12. Amlodipine 10 mg PO DAILY
13. Outpatient Lab Work
Check Chem 10 (especially K+) on ___ and please fax
results to Dr ___ ___ & ___ fax 617-ICD-9
Code 428.0
14. Spironolactone 12.5 mg PO DAILY
RX *spironolactone [Aldactone] 25 mg 0.5 (One half) tablet(s) by
mouth Daily Disp #*40 Tablet Refills:*1
15. Torsemide 40 mg PO DAILY
RX *torsemide 20 mg 2 tablet(s) by mouth Daily Disp #*80 Tablet
Refills:*1
16. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours
Hold for K > 4.5
RX *potassium chloride [Klor-Con M20] 20 mEq 1 tablet(s) by
mouth Daily Disp #*30 Tablet Refills:*1
17. Oxygen
Ambulatory O2 sat is 86%.
Home O2 at 3L continuous; 3L during sleep.
Please provide home oxygen tank. ICD-9 code ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Acute systolic heart failure
Secondary:
Coronary artery disease
chronic obstructive pulmonary disease
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - with walker
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with shortness of breath and wheezing
TECHNIQUE: Upright AP view of the chest
COMPARISON: ___
FINDINGS:
The patient is status post median sternotomy with aortic ___ device
again noted in unchanged position. Cardiac silhouette remains unchanged,
mildly enlarged. The aorta is tortuous and diffusely calcified. Mild to
moderate pulmonary edema is somewhat worse compared to the previous exam.
Small right pleural effusion is noted. Bibasilar atelectasis is demonstrated.
No pneumothorax is identified. Multilevel degenerative changes are seen in the
thoracic spine.
IMPRESSION:
Mild to moderate pulmonary edema, worse compared to the previous study, with
small right pleural effusion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with PMHx notable for congestive heart failure (EF ___,
aortic stenosis s/p TAVR (___), 3-vessel coronary artery disease (s/p PCI
of the LAD and RCA), paroxysmal afib (previously on amio), COPD on home
oxygen, AAA s/p ___ ___ admitted for shortness of breath. // Evaluate for
pulmonary edema progression given O2 requirement. Evaluate for pulmonary
edema progression given O2 requiremen
IMPRESSION:
In comparison with the study of ___, the core valve is again seen with
continued elevation of pulmonary venous pressure. Bibasilar opacification is
consistent with atelectasis. In the appropriate clinical setting, coalescent
areas at the left and possibly right base could raise the possibility of
developing aspiration or infectious pneumonia.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with PMHx notable for congestive heart failure (EF ___,
aortic stenosis s/p TAVR (___), 3-vessel coronary artery disease (s/p PCI
of the LAD and RCA), paroxysmal afib (previously on amio), COPD on home
oxygen, AAA s/p ___ ___ admitted for shortness of breath. // ? lung
infiltrate
COMPARISON: ___
IMPRESSION:
As compared to the previous radiograph, the lung volumes have increased.
Bilateral areas of parenchymal opacities at both the left and the right lung
base have decreased in extent and severity. No new parenchymal opacities. No
pulmonary edema. No larger pleural effusions. Known an unchanged scarring in
the left upper lobe. Normal size of the heart, status post aortic valve
replacement. Status post sternotomy. Mild elongation of the descending aorta.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with RESPIRATORY ABNORM NEC
temperature: 98.0
heartrate: 62.0
resprate: 18.0
o2sat: 88.0
sbp: 161.0
dbp: 66.0
level of pain: nan
level of acuity: 2.0 | ASSESSMENT AND PLAN: ___ with PMHx notable for congestive heart
failure (EF ___, aortic stenosis s/p TAVR (___),
3-vessel coronary artery disease (s/p PCI of the LAD and RCA),
paroxysmal afib (previously on amio), COPD on home oxygen, AAA
s/p ___ ___ admitted for shortness of breath.
ACTIVE ISSUES
===========================
# Dyspnea: Etiology of dyspnea is most likely acute on chronic
systolic CHF exacerbation in the setting of diet indiscretion
over christmas and weight gain. Given new EKG changes (new
LBBB), concern of cardiac disease is also worsening and causing
further CHF exacerbation. Note patient on nocturnal 3L of
oxygen. Lasix redosed to 80mg daily and diuresed. Echo showed
compared with the prior study (images reviewed) of ___ the
findings are similar (there may be increased regional
dysfunction in the inferior wall but the hypokinesis is
primarily global). Diuresed on IV lasix and discharged on
torsemide 40mg daily. Discharged on home oxygen for ambulation
and sleep. Although the LBBB is new, there were no signs of AV
block. If there are recurrent CHF exacerbations, then
consideration can be given to implanting ___ CRT device.
# CAD: history of 3 vessel disease s/p PCI in ___. Continued
on atorvastatin, clopidogrel (increased dose to 18.75mg daily),
aspirin and lisinopril.
# COPD: Denies frequent COPD exacerbations. Current presentation
was less likely to be COPD. On nocturnal 3L oxygen at home.
Continued tiotropium and fluticasone/salmeterol
# Hypertension: Lisinopril, continue cavedilol. Restarted
Amlodipine 10.
CHRONIC ISSUES
==============================
# CKD: baseline creatinine 1.0-1.2 Dosed medication renally
# Hyperlipidemia: Continued atorvastatin.
## TRANSITIONAL ISSUES
- Amiodarone was stopped
- Lasix was switched to torsemide 40mg
- Starded on spirolactone 12.5mg
- Started on daily K+ 40meq
- Discharged on home oxygen. Ambulatory O2 requirement ~3L and
Night O2 requirement ~3L
- Needs labs check for electrolyes (especially K) on ___
in the setting of increased lasix |
Name: ___ Unit ___: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aspirin / Nsaids / atenolol-chlorthalidone / Penicillins
Attending: ___.
Chief Complaint:
Fever, cough, total body pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms ___ is a ___ woman with HTN, HFpEF (EF 60% in ___,
dementia, osteopenia, multinodular goiter, and recent admission
to ___ ___ for multifocal pneumonia and DVT, who
presented to the ED from rehab after being found with fever to
102.5, worsening respiratory distress, and total body pain.
Reportedly, the patient developed a fever at rehab today to
102.5, for which she received Tylenol. She also reportedly
developed a cough, became tachypneic to RR 28, and tachycardic
to 110s. Per her grandson, ___, she had 1 small BM on ___
and ___.
Importantly, pt was recently admitted to ___ (___) after
presenting with weakness, cough, vomiting, and diarrhea. She
subsequently developed acute hypoxic respiratory failure
requiring brief intubation and ICU admission. She was ultimately
found to be flu positive and sputum cultures were negative
(though gram stain showed GPCs and GNRs). She completed courses
of oseltamivir 75mg Q12H(5 days, ___ and Levofloxacin (7
days, ___. Her hospital course was complicated by
intermittent tachypnea (most likely due to mucus plugging), low
grade fevers, and DVT for which she was started on apixaban
(loading scheduled to finish ___ ___ with plan to take 2.5mg BID
___ until ___. She was discharged to rehab on 2L NC (not
on any O2 at home). Per her family, her mental status never went
back to normal after that hospitalization.
In ED initial VS:
- Pain ___, T 98.0, HR 115, BP 129/48, RR 26, 96% 2L NC
- Exam: notable for coarse cough, tachypneic, coarse breath
sounds,
tender abdomen, slight swelling of left ankle
- Labs notable for:
+ WBC: 15.1 Hgb: 9.2 Platelets: 610 with 70.5% PMNs
+ Chem:
132 | 94 | 11
-------------<118
4.6 | 26 |0.7
+ LFTs: ALT 23, AST 52, alkp 85, Tbili 0.7, Alb 2.4, Lip 18
+ Lactate: 1.5
- Imaging notable for:
+ CT A/P
1. Multifocal pneumonia.
2. Stercoral colitis without evidence of perforation or
drainable fluid collection.
3. Air in bladder.
+ CXR: Re-demonstrated bibasilar opacities, with possible slight
improvement in aeration at the left lung base.
- Patient was given: 2g cefepime, 1g vancomycin, 1L IVF, IV
metronidazole
- Consults: Surgery (stercoral colitis):NTD
- VS prior to transfer: HR 113, 124/48, RR 22, 100% 4L NC
On arrival to the MICU, pt was lying in bed, breathing slightly
fast with occasional coarse coughing.
Past Medical History:
HTN
Multinodular goiter
Osteopenia
Degenerative joint disease
Back pain
Pulmonary nodule
HFpEF by TEE in ___
Vertigo
Social History:
___
Family History:
Per OMR "both parents lived until 'old age up to ___. OA runs
in the family. Other family history ounknown."
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: T 98.9, HR 109, BP 145/63, RR 21, 99% on 4L NC
GENERAL: frail elderly woman, lying in bed on O2 by NC.
Somnolent.
HEENT: NC/AT, EOMI grossly, sclera anicteric
LUNGS: rapid rate, coarse breath sounds b/l, occasional coarse
coughing
CV: tachycardic, regular rhythm, ___ murmurs, rubs or gallops
ABD: +BS, tender to palpation in LLQ, non-distended
EXT: WWP, 2+ DP pulses, asymmetric swelling of LLE>RLE
SKIN: ___ lesions, rashes, or ulcers appreciated
NEURO: moving all extremities
DISCHARGE PHYSICAL EXAM:
=========================
Vitals: 98.5 113/54 98 16 95% RA
General: Frail, elderly woman. Awake, lying in bed, mildly
tachypneic but otherwise in ___ distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, ___ LAD
Lungs: Diminished breath sounds at R base, otherwise ___ wheezes,
rales, rhonchi
CV: Regular rate and rhythm, normal S1 + S2, ___ murmurs, rubs,
gallops
Abdomen: soft, mild suprapubic tenderness, bowel sounds present,
___ rebound tenderness or guarding, ___ organomegaly
Ext: Warm, well perfused, 2+ pulses, ___ clubbing, cyanosis or
edema. Mild tenderness to palpation in L ankle
Skin: ___ rashes/lesions
Pertinent Results:
ADMISSION LABS:
=======================
___ 04:14AM BLOOD WBC-14.1* RBC-2.93* Hgb-8.3* Hct-25.3*
MCV-86 MCH-28.3 MCHC-32.8 RDW-15.4 RDWSD-48.1* Plt ___
___ 08:35PM BLOOD WBC-15.1* RBC-3.22* Hgb-9.2* Hct-27.0*
MCV-84 MCH-28.6 MCHC-34.1 RDW-15.1 RDWSD-46.0 Plt ___
___ 04:14AM BLOOD Neuts-81.0* Lymphs-9.1* Monos-8.7
Eos-0.2* Baso-0.2 Im ___ AbsNeut-11.45* AbsLymp-1.28
AbsMono-1.23* AbsEos-0.03* AbsBaso-0.03
___ 08:35PM BLOOD Neuts-70.5 Lymphs-15.6* Monos-12.3
Eos-0.2* Baso-0.3 Im ___ AbsNeut-10.66* AbsLymp-2.35
AbsMono-1.85* AbsEos-0.03* AbsBaso-0.04
___ 04:14AM BLOOD Plt ___
___ 04:14AM BLOOD ___ PTT-25.1 ___
___ 08:35PM BLOOD Plt ___
___ 04:14AM BLOOD Glucose-139* UreaN-8 Creat-0.5 Na-138
K-3.9 Cl-104 HCO3-24 AnGap-14
___ 08:35PM BLOOD Glucose-118* UreaN-11 Creat-0.7 Na-132*
K-4.6 Cl-94* HCO3-26 AnGap-17
___ 08:35PM BLOOD ALT-23 AST-52* AlkPhos-85 TotBili-0.7
___ 04:14AM BLOOD Calcium-7.9* Phos-2.8 Mg-2.2
___ 08:35PM BLOOD Albumin-2.4*
___ 04:50AM BLOOD ___ Temp-37.2 O2 Flow-4 pO2-49*
pCO2-44 pH-7.41 calTCO2-29 Base XS-2 Intubat-NOT INTUBA
Comment-NASAL ___
OTHER LABS:
====================
___ 05:53AM BLOOD calTIBC-105* Hapto-408* Ferritn-1730*
TRF-81*
___ 05:53AM BLOOD Ret Aut-1.9 Abs Ret-0.05
___ 04:14AM BLOOD WBC-14.1* RBC-2.93* Hgb-8.3* Hct-25.3*
MCV-86 MCH-28.3 MCHC-32.8 RDW-15.4 RDWSD-48.1* Plt ___
___ 05:53AM BLOOD WBC-11.3* RBC-2.64* Hgb-7.5* Hct-22.5*
MCV-85 MCH-28.4 MCHC-33.3 RDW-15.3 RDWSD-47.9* Plt ___
___ 06:27AM BLOOD Hct-UNABLE TO
___ 04:14AM BLOOD Neuts-81.0* Lymphs-9.1* Monos-8.7
Eos-0.2* Baso-0.2 Im ___ AbsNeut-11.45* AbsLymp-1.28
AbsMono-1.23* AbsEos-0.03* AbsBaso-0.03
___ 08:15AM BLOOD ___ PTT-58.3* ___
___ 06:27AM BLOOD ___ PTT-27.5 ___
___ 04:14AM BLOOD Glucose-139* UreaN-8 Creat-0.5 Na-138
K-3.9 Cl-104 HCO3-24 AnGap-14
___ 05:53AM BLOOD Glucose-90 UreaN-9 Creat-0.5 Na-142 K-3.6
Cl-107 HCO3-24 AnGap-15
___ 06:27AM BLOOD Glucose-80 UreaN-8 Creat-0.6 Na-142 K-3.6
Cl-105 HCO3-24 AnGap-17
___ 05:53AM BLOOD Calcium-7.9* Phos-2.7 Mg-2.2 Iron-20*
___ 06:27AM BLOOD Calcium-8.1* Phos-2.7 Mg-2.3
MICROBIOLOGY:
=====================
___ 4:14 am URINE Source: Catheter.
URINE CULTURE (Final ___: ___ GROWTH.
___ 4:14 am URINE Source: Catheter.
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
MRSA SCREEN (Final ___: ___ MRSA isolated.
Respiratory Viral Antigen Screen (Final ___:
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
___ 8:07 am BLOOD CULTURE Source: Venipuncture #1.
Blood Culture, Routine (Pending at time of discharge)
___ 12:15 pm SPUTUM Source: Expectorated.
GRAM STAIN (Final ___:
>25 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final ___:
TEST CANCELLED, PATIENT CREDITED.
___: URINE CULTURE (Pending at time of discharge)
IMAGING/STUDIES:
=====================
___: CT Abdomen and Pelvis w/Contrast
1. Mild stercoral colitis without evidence of perforation or
drainable fluid collection.
2. Air in the bladder. Please correlate with recent
instrumentation.If none, urinalysis to assess for infection
3. Partially imaged multifocal pneumonia, improving.
___: CXR
Re-demonstrated bibasilar opacities, with possible slight
improvement in
aeration at the left lung base.
___: CT Head
___ evidence for acute intracranial abnormalities.
___: Video swallow
Normal oropharyngeal swallowing videofluoroscopy.
___: CXR
Bibasal consolidations appear to be even more pronounced than on
___. There is also more conspicuous opacity in the left
upper lobe. Small bilateral pleural effusions are unchanged.
DISCHARGE LABS:
=====================
___ 06:25AM BLOOD WBC-9.7 RBC-2.79* Hgb-7.8* Hct-23.9*
MCV-86 MCH-28.0 MCHC-32.6 RDW-15.5 RDWSD-47.8* Plt ___
___ 06:25AM BLOOD Glucose-85 UreaN-9 Creat-0.6 Na-141 K-4.2
Cl-106 HCO3-22 AnGap-17
___ 06:25AM BLOOD Albumin-2.2* Calcium-8.3* Phos-2.7 Mg-2.1
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Apixaban 2.5 mg PO BID
2. cromolyn 4 % ophthalmic TID
3. Lisinopril 20 mg PO DAILY
4. Simvastatin 40 mg PO QPM
5. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
2. Docusate Sodium 100 mg PO BID
3. GuaiFENesin ___ mL PO Q6H:PRN cough, congestion
4. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN dyspnea
5. Multivitamins W/minerals 1 TAB PO DAILY
6. Polyethylene Glycol 17 g PO BID
7. Senna 8.6 mg PO BID constipatio
8. Apixaban 2.5 mg PO BID
9. cromolyn 4 % ophthalmic TID
10. Lisinopril 20 mg PO DAILY
11. Simvastatin 40 mg PO QPM
12. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute hypoxic respiratory failure
Aspiration pneumonitis
Stercoral colitis
Anemia of chronic inflammation
History of recent deep vein thrombosis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with respiratory failure and altered mental
status. Assess for hemorrhage.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.3 mGy-cm.
Total DLP (Head) = 747 mGy-cm.
COMPARISON: CT head from ___
FINDINGS:
Evaluation of the vertex is limited by patient motion. There is no evidence
for acute hemorrhage, edema, or mass effect. A chronic infarction is again
seen in the left cerebellum. Multiple coarse calcifications are again seen
along the cortex, as well as in the basal ganglia and midbrain, suggestive of
prior infection. There are extensive supratentorial white matter
hypodensities, as before, nonspecific but likely sequela of chronic small
vessel ischemic disease in this age group. There is age-related global
parenchymal volume loss with prominent ventricles and sulci.
There is no evidence of acute fracture. There are aerosolized secretions in
the left maxillary sinus and partial bilateral mastoid air cell opacification,
which may be secondary to prolonged supine positioning in the inpatient
setting.
IMPRESSION:
No evidence for acute intracranial abnormalities.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with cough, AMS// Pneumonia vs. pneumonitis
IMPRESSION:
In comparison with the study ___, there are continued low lung volumes
that accentuate the prominence of the transverse diameter of the heart. Mild
pulmonary vascular congestion is again seen.
Areas of opacification at the bases, especially the right, are worrisome for
developing pneumonia. On the left, some of the retrocardiac opacification
could merely reflect volume loss in the left lower lobe.
Radiology Report
EXAMINATION: VIDEO OROPHARYNGEAL SWALLOW
INDICATION: ___ year old woman with pneumonia// ?aspirating?
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the speech and swallow division. Multiple consistencies of
barium were administered.
DOSE: Fluoro time: 3.02 min.
COMPARISON: None
FINDINGS:
Barium passes freely through the oropharynx and esophagus without evidence of
obstruction. There is mild delay in initiation of swallow however there was
no gross aspiration or penetration.
IMPRESSION:
Normal oropharyngeal swallowing videofluoroscopy.
Please refer to the speech and swallow division note in OMR for full details,
assessment, and recommendations.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with pneumonia vs pneumonitis// Pneumonia vs
pneumonitis Pneumonia vs pneumonitis
IMPRESSION:
Bibasal consolidations appear to be even more pronounced than on ___.
There is also more conspicuous opacity in the left upper lobe. Small
bilateral pleural effusions are unchanged.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Dyspnea, Fever
Diagnosed with Pneumonia, unspecified organism
temperature: 98.0
heartrate: 115.0
resprate: 26.0
o2sat: 96.0
sbp: 129.0
dbp: 48.0
level of pain: 8
level of acuity: 2.0 | Ms ___ is a ___-speaking ___ woman with HTN,
HFpEF (EF 60% in ___, dementia, osteopenia, multinodular
goiter, and recent admission to ___ ___ for multifocal
pneumonia and DVT, who presented to the ED from rehab after
being
found with fever to 102.5, worsening respiratory distress, and
pain. She was initially admitted to the MICU for respiratory
distress on ___, then transferred to the floor on
___ given clinical stability.
# Acute hypoxic respiratory failure
# Aspiration pneumonitis
# Leukocytosis with multifocal consolidations on CT
Likely aspiration pneumonitis considering patient's mental
status and
___ speech and swallow evaluation with concern for silent
aspiration. Mucous plugging also likely given her episodes of
respiratory distress which usually resolve with coughing and
mucous clearance. Infection (HAP) less likely as she has
improved rapidly with ~24 hours antibiotics. A procalcitonin was
pending at time of discharge. She was able to pass a video
swallow study and remained stable from a respiratory standpoint
after leaving the ICU. She was given nebulizers, chest ___, and
expectorants to support her respiratory status.
# Stercoral colitis:
Found to have stercoral colitis after CT was obtained for
abdominal pain. Evaluated by surgery in the ED, who did not
think she needed surgical intervention. ___ evidence of
perforation on imaging. On ___, ___ stool in rectal vault to
disimpact. However, with aggressive bowel regimen patient was
having bowel movements.
# LLE DVT. Found to have LLE DVT on ultrasound ___ after being
noted to have low grade fevers and elevated D-dimer. DVT was
thought to be provoked in the setting of prolonged
immobilization. Was on heparin drip in ICU, and per
speech/swallow recs was allowed to take pills and so restarted
on her apixiban after her video swallow on ___.
# Anemia, normocytic:
Patient's hemoglobin has slowly trended down from ~12 (one month
ago) to 8 currently. ___ obvious signs of bleeding. Likely due to
chronic inflammation with poor marrow reserve. This is supported
by low reticulocyte count. ___ evidence of hemolysis.
# Dementia/Delirium:
Patient w/dementia and has had progressive decline. Head CT on
___ did not show any acute changes. She was placed on delirium
precautions while inpatient.
CHRONIC ISSUES
===============
# Arm pain: Superficial thrombosis of the left cephalic vein
found on US on previous admission. Elevation of arm and cold
compressions as needed
#HTN:
Stable. Held anti-hypertensives.
#Glaucoma: Stable. Continued home timolol eye drops
# Moderate to severe malnutrition (Albumin 2.4 on admission).
Nutrition consulted, and recommended supplementation with
multivitamins and Ensure Enlive.
#Gout: Has h/o R ankle pain, on colchicine which was held at
discharge ___ given ___ ongoing pain. She was given Tylenol for
pain as needed. |
Name: ___ Unit ___: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aspirin / Naprosyn / Lithium / Cephalexin / Neurontin / Depakote
/ Haldol
Attending: ___
Chief Complaint:
Abdominal pain, blood per rectum
Major Surgical or Invasive Procedure:
Colonoscopy, EGD (___)
History of Present Illness:
Ms. ___ is a ___ female w/ PMHx remarkable for
breast, uterine, endometrial cancers (in remission), and
multiple
psychiatric diagnoses (PTSD, ADHD, delusional disorder,
depression, borderline personality traits, and dissociative
identity disorder), now brought into the ER by EMS, found at
home
"rolling in stool and blood on the floor."
Pt's history is difficult to take, and details are not entirely
clear. ___ one is available to corroborate history at the time of
admission.
Per pt, she has had lower abdominal / LRQ pain x36hrs,
worsening.
She explains that she had an "obstruction" that felt like her
prior SBOs. She states that she used her fingers to manually
disimpact herself, removing hard stool from her rectum. She
states that she considered, but did not use, the round end of a
butter knife, a coat hanger, and dental surgical equipment (the
pt is reportedly a dentist) to remove the stool, but was
successful with her fingers. Nonetheless, the pain continued.
At some point yesterday evening (time course is not clear), the
pt reports having "stool just pouring out so fast I couldn't
even
control it." She states that she "slipped" in her stool, and
fell
on the floor, continuing to defecate uncontrollably. She states
that there was "bright red liquid blood" in addition to some
formed stool. Per pt, she called EMS, and they found her "on the
floor in my stool."
These reports seem to be consistent with what EMS told ER MDs
upon arrival, although that history was not taken by myself.
At time of interview, pt states that she has persistent lower
abdominal pain, worst in LRQ, but that it is much better than
prior. ___ bleeding or BM since arrival in the ER.
Past Medical History:
PAST PSYCHIATRIC HISTORY:
- Sx:PTSD, ADHD, delusional disorder, depression, borderline
personality traits, and dissociative identity disorder
- Hospitalizations: ___ (6 months ago - doesn't
remember why); HRI, ___ ___ years ago
- Current treaters and treatment: Dr. ___
(has an intake appointment on ___ with a new one)
- Medication and ECT trials: Geodone, Risperidone - didn't work
- Self-injury/Suicide attempts: Self-cutting behavior (last time
___ years ago); 2 suicide attempts (overdosing on steroids) many
years ago
- Harm to others: None
- Access to weapons: Denies
- Spritual - Loves to read the bible.
PAST MEDICAL HISTORY:
History Uterine Ca - in remission
History of Breast CA - in remission
History of Ovarian CA - in remission
HTN
GYN-ONC provider: Dr. ___ at ___
Social History:
___
Family History:
BRCApos. Twin sister died at ___ of
BRCA-associated cancer, per OMR.
Physical Exam:
ADMISSION EXAM
==============
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in ___ apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, ___ murmur, ___ S3, ___ S4. ___ JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended. Hypoactive BS throughout.
Midline surgical scar cdi. Mild TTP at lower abdomen / LRQ.
GU: ___ suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: ___ rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
DISCHARGE EXAM
==============
24 HR Data (last updated ___ @ 1154)
Temp: 97.9 (Tm 98.4), BP: 98/65 (96-128/65-86), HR: 82 (58-82),
RR: 20 (___), O2 sat: 96% (95-97), O2 delivery: Ra
GENERAL - NAD
EYES - anicteric
ENT - moist membranes
CV - RRR, normal S1/S2, ___ murmur, rubs, gallop
RESPIRATORY - clear bilaterally, unlabored
GI - soft, + BS, only minimal TTP in RUQ and b/l RLQ/LLQ, ND, ___
R/G
MUSCULOSKELETAL - warm extremities without edema
NEUROLOGIC - AOx3, CN II-XII intact, ___ strength all
extremities, sensation grossly intact, gait deferred
PSYCHIATRIC - pleasant, appropriate
INTEGUMENTARY - ___ rash
Pertinent Results:
ADMISSION LABS
==============
___ 06:17AM BLOOD WBC-23.3*# RBC-6.24*# Hgb-18.3*#
Hct-53.9*# MCV-86 MCH-29.3 MCHC-34.0 RDW-14.2 RDWSD-43.3 Plt
___
___ 06:17AM BLOOD Neuts-89.1* Lymphs-5.1* Monos-4.7*
Eos-0.0* Baso-0.3 Im ___ AbsNeut-20.77*# AbsLymp-1.19*
AbsMono-1.10* AbsEos-0.00* AbsBaso-0.08
___ 06:17AM BLOOD ___ PTT-22.8* ___
___ 06:17AM BLOOD Glucose-188* UreaN-32* Creat-1.3* Na-141
K-4.1 Cl-93* HCO3-21* AnGap-27*
___ 06:17AM BLOOD ALT-63* AST-70* AlkPhos-435* TotBili-1.1
___ 06:17AM BLOOD Lipase-24
___ 06:17AM BLOOD cTropnT-<0.01
___ 06:17AM BLOOD Albumin-4.1 Calcium-10.2 Phos-5.5*
Mg-3.0*
___ 06:17AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
RELEVANT INTERVAL LABS
======================
___ 03:15PM BLOOD WBC-5.8 RBC-3.79* Hgb-11.2 Hct-34.4
MCV-91 MCH-29.6 MCHC-32.6 RDW-13.9 RDWSD-45.4 Plt ___
IMAGING
=======
___
-- CHEST XR
___ evidence of pneumoperitoneum. Clear lungs.
-- CT HEAD W/O CONTRAST
___ acute intracranial process.
-- CTA ABDOMEN/PELVIS
1. Proctocolitis extending from the midportion of the transverse
colon through the rectum. Given the long segment involvement,
infectious or inflammatory etiologies are favored, however an
ischemic etiology is not excluded. There is associated
mesenteric engorgement. There is ___ free air. The mucosa
enhances throughout, without evidence of ischemia.
2. 9 mm fat containing lesion within the head of the pancreas is
new, as well as a similar lesion in the tail, which may
represent than intrapancreatic lipoma and further evaluation
with MRCP is recommended.
3. Distal esophagus is thickened, which may be secondary to
reflux. Please correlate clinically
4. Approximately 2 mm right lower lobe pulmonary nodules
unchanged in
comparison to the prior exam. ___ follow-up needed.
-- CT C-SPINE W/O CONTRAST
___ acute fracture or traumatic malalignment.
___
-- MRCP
1. Previously identified masses within the pancreas represent 9
mm lipomas
within the pancreatic neck and pancreatic tail. These are
benign require ___ additional imaging follow-up.
2. Few less than 2 mm pancreatic cystic lesions, possibly
represent small
intraductal papillary mucinous neoplasms or sequela of
pancreatitis. Per
current guidelines, ___ additional follow-up recommended at this
small size.
3. Splenic hemangiomas measuring up to 2 cm and stable renal
cysts.
EGD (___):
Irregular Z line with erosions at the GE junction (biopsy)
Erythema and linear erosions in the stomach body and antrum
compatible with gastritis (biopsy)
Erythema and erosions in the duodenal bulb compatible with
duodenitis (biopsy)
Polyp in the duodenal bulb (biopsy)
Otherwise normal EGD to third part of the duodenum
Colonoscopy (___):
Erythema and linear erosions in the rectum, sigmoid colon and
descending colon compatible with colitis (biopsy)
Otherwise normal colonoscopy to cecum
DISCHARGE LABS
==============
WBC 5.3, Hct 39.9, Plt 204
BMP WNL
O&P (___): pending
Stool cx (___): negative, crypto/giardia pending
C.diff (___): negative
UCx (___): mixed flora
UCx (___): mixed flora
BCx (___): pending x 2
Path ___ and EGD, ___: pending
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. ClonazePAM 1 mg PO BID:PRN anxiety
2. CloNIDine 0.3 mg PO TID
3. Methadone 20 mg PO QAM
4. Methadone 10 mg PO QPM
5. QUEtiapine Fumarate 200 mg PO QHS
6. Latuda (lurasidone) 40 mg oral QPM
7. BuPROPion XL (Once Daily) 200 mg PO DAILY
Discharge Medications:
1. Omeprazole 40 mg PO BID Duration: 6 Weeks
RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*90
Capsule Refills:*0
2. BuPROPion XL (Once Daily) 200 mg PO DAILY
3. ClonazePAM 1 mg PO BID:PRN anxiety
4. CloNIDine 0.3 mg PO TID
5. Latuda (lurasidone) 40 mg oral QPM
6. Methadone 20 mg PO QAM
7. Methadone 10 mg PO QPM
8. QUEtiapine Fumarate 200 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Proctocolitis
Gastritis
Duodenitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with abd pain, brbpr// ?air under diaphragm
TECHNIQUE: Single AP radiograph of the chest.
COMPARISON: Chest radiograph dated ___.
FINDINGS:
The lungs are well inflated and clear. No focal consolidations. Rounded
opacity projecting over the lower lung fields bilaterally likely represent
nipple shadows. No pulmonary edema. Normal cardiomediastinal silhouette. No
pleural effusion. No pneumothorax. No evidence of pneumoperitoneum.
IMPRESSION:
No evidence of pneumoperitoneum. Clear lungs.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with fall// ?head bleed ?fx
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Total DLP (Head) = 803 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of acute large territorial infarction or hemorrhage.
There is no evidence of edema or large mass. The ventricles and sulci are
prominent, compatible with age related involutional changes. Periventricular
and subcortical white matter hypodensities are felt to likely represent the
sequela of chronic small vessel ischemic disease.
There is no evidence fracture. Visualized portion of the paranasal sinuses,
mastoid air cells and middle ear cavities are clear. Visualized portion of
the orbits are unremarkable.
IMPRESSION:
No acute intracranial process.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ with fall// ?head bleed ?fx
TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Total DLP (Body) = 481 mGy-cm.
COMPARISON: CT C-spine dated ___.
FINDINGS:
No acute fracture or traumatic malalignment. There is no prevertebral edema.
There are multiple, multilevel degenerative changes about the cervicothoracic
spine including osteophyte formation, uncovertebral hypertrophy and loss of
inter vertebral disc height at the level of C5-C6. There is no critical
spinal canal narrowing. There is multilevel moderate bilateral neural
foraminal stenosis secondary to uncovertebral hypertrophy, for example most
prominent at the level of C5 on the right.
Visualized thyroid gland is unremarkable. The visualized lung apices are
clear. The distal esophagus is mildly thickened. No soft tissue abnormality
seen within the neck.
IMPRESSION:
No acute fracture or traumatic malalignment.
Radiology Report
EXAMINATION: CTA ABD AND PELVIS
INDICATION: ___ with GI bleed// ?source of bleed ?air in diaphragm
?mesenteric ischemia
TECHNIQUE: Abdomen and pelvis CTA: Non-contrast and multiphasic post-contrast
images were acquired through the abdomen and pelvis.Oral contrast was not
administered.MIP reconstructions were performed on independent workstation and
reviewed on PACS.
DOSE: Total DLP (Body) = 839 mGy-cm.
COMPARISON: None.
FINDINGS:
VASCULAR: There is no abdominal aortic aneurysm. There is minimal calcium
burden in the abdominal aorta and great abdominal arteries.
LOWER CHEST: Minimal atelectasis is noted in the lung bases. There is no
pleural or pericardial effusion. The distal esophagus is thickened, without
evidence of hiatal hernia (3:9). A approximately 2 mm right lower lobe
pulmonary nodules unchanged in comparison to the prior exam.
ABDOMEN:
HEPATOBILIARY: The liver is decreased in attenuation consistent with fatty
infiltration. No focal lesions are identified. There is no evidence of
intrahepatic or extrahepatic biliary dilatation. The gallbladder is within
normal limits, without stones or gallbladder wall thickening.
PANCREAS: There is a 9 mm fat density lesion within the body of the pancreas
new in comparison to the prior exam (03:46). Additional fat density lesion is
seen within the pancreatic tail. Otherwise, the pancreas has normal
attenuation throughout, without evidence of focal lesions or pancreatic ductal
dilatation. There is no peripancreatic stranding.
SPLEEN: A 1.6 cm hypodensity within the spleen is slightly larger in
comparison to the prior exam. The spleen shows normal size and attenuation
throughout, without evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There are multiple cystic-appearing hypodensities within the right kidney, the
largest of which is a 1.5 cm hypodensity within the midpole of the right
kidney, which likely represents a simple cyst. There is a retroaortic left
renal vein. There is no evidence of stones, focal renal lesions, or
hydronephrosis. There are no urothelial lesions in the kidneys or ureters.
There is no perinephric abnormality.
GASTROINTESTINAL: Stomach is decompressed. Small bowel loops demonstrate
normal caliber, wall thickness and enhancement throughout. There is long
segment wall thickening and mucosal hyperemia involving the distal transverse,
descending and sigmoid colon and rectum with associated mesenteric
engorgement. There is no evidence of free air to suggest perforation. Mucosa
enhances throughout without evidence of ischemia. Given the long segment
involvement, infectious or inflammatory etiologies are favored, however an
ischemic etiology is not excluded. The appendix contains air, has normal
caliber without evidence of fat stranding. There is no evidence of mesenteric
lymphadenopathy. No unexplained foreign bodies identified.
RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy.
Multiple prior surgical clips are seen throughout the omentum and along the
retroperitoneal chain.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in the
pelvis.
REPRODUCTIVE ORGANS: The uterus is not visualized. No adnexal abnormalities
identified.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Proctocolitis extending from the midportion of the transverse colon through
the rectum. Given the long segment involvement, infectious or inflammatory
etiologies are favored, however an ischemic etiology is not excluded. There
is associated mesenteric engorgement. There is no free air. The mucosa
enhances throughout, without evidence of ischemia.
2. 9 mm fat containing lesion within the head of the pancreas is new, as well
as a similar lesion in the tail, which may represent than intrapancreatic
lipoma and further evaluation with MRCP is recommended.
3. Distal esophagus is thickened, which may be secondary to reflux. Please
correlate clinically
4. Approximately 2 mm right lower lobe pulmonary nodules unchanged in
comparison to the prior exam. No follow-up needed.
Radiology Report
EXAMINATION: MRCP
INDICATION: ___ year old woman with pancreatic mass on CT// Eval pancreatic
mass
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
Intravenous contrast: 8 mL Gadavist.
COMPARISON: CT abdomen pelvis ___.
FINDINGS:
Lower Thorax: No pleural effusions.
Liver: The liver is unremarkable except for diffuse steatosis with regions of
sparing around the gallbladder fossa.
Biliary: Few stones in the level of the gallbladder neck. Mild central
biliary prominence is stable.
Pancreas: There is a 9 mm fat density lesion in the pancreatic neck and
pancreatic tail which represent pancreatic neck lipomas and are benign. There
is no suspicious pancreatic mass and no main ductal dilatation. Two
pancreatic cystic lesions are seen in the distal body, for example on series
4, image 21, however measuring up to 2 mm each.
Spleen: There are three T2 hyperintense masses within the spleen which fill in
on delayed contrast imaging with the largest in the lateral spleen measuring 2
cm compatible with hemangiomas. The spleen is not enlarged.
Adrenal Glands: Unremarkable.
Kidneys: No hydronephrosis. Right renal cysts measuring up to 1.5 cm are
present and the kidneys are otherwise unremarkable.
Gastrointestinal Tract: No bowel obstruction in the upper abdomen. The
findings of colitis seen on prior CT are less conspicuous on MRI. Trace
ascites.
Lymph Nodes: No abdominal adenopathy.
Vasculature: The aorta and IVC are normal caliber. The portal and hepatic
veins are patent.
Osseous and Soft Tissue Structures: No suspicious osseous lesion. Ventral
hernia mesh repair changes are again noted.
IMPRESSION:
1. Previously identified masses within the pancreas represent 9 mm lipomas
within the pancreatic neck and pancreatic tail. These are benign require no
additional imaging follow-up.
2. Few less than 2 mm pancreatic cystic lesions, possibly represent small
intraductal papillary mucinous neoplasms or sequela of pancreatitis. Per
current guidelines, no additional follow-up recommended at this small size.
3. Splenic hemangiomas measuring up to 2 cm and stable renal cysts.
Gender: F
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: BRBPR, Coffee ground emesis
Diagnosed with Noninfective gastroenteritis and colitis, unspecified
temperature: 96.7
heartrate: 117.0
resprate: 18.0
o2sat: 97.0
sbp: 165.0
dbp: 112.0
level of pain: 10
level of acuity: 2.0 | ___ w/ h/o BRCA-associated cancers (breast, uterine,
endometrial;
all in remission reportedly), multiple psychiatric disorders
(PTSD, ADHD, delusional disorder, depression, borderline
personality traits, and dissociative identity disorder)
presenting with abdominal pain and GI bleeding, found to have
proctocolitis by imaging and gastritis, duodenitis, and colitis
by EGD/colonoscopy.
# Abdominal pain:
# Proctocolitis:
# Gastritis:
# Duodenitis:
Ms. ___ presented with abdominal pain and hematochezia. CT of
the abdomen showed evidence of proctocolitis, possibly in the
setting of prior abdominal radiation for uterine/endometrial
cancer). EGD and colonoscopy performed on ___ showed evidence
of gastritis, duodenitis, and colitis. Biopsies were taken, with
results pending at the time of discharge. C.diff was negative.
Stool culture was negative, with crypto/giardia and O&P pending
at the time of discharge. She was started on omeprazole 40mg BID
x 6 weeks, at which time she can likely transition to once daily
dosing. Her abdominal pain improved, and she was tolerating a
regular diet at discharge without further hematochezia. Hct was
39.9 on ___. A GI ___ appointment was pending at discharge for
review of pathology and further management.
# ___:
Patient presented with Cr 1.3 from b/l 0.7. Likely due to
dehydration in setting of GI bleed as above. Resolved with
fluids. Cr at discharge 0.7.
# PTSD
# ADHD
# Borderline
# DID
# Depression:
Ms. ___ was recently admitted ___ in the setting of a
manic episode. Her medications were adjusted during that
admission (latuda discontinued, benztropine, divalproex, Haldol
initiated). The patient reports that she had paradoxical
reactions to these new medications and stopped taking her
medications entirely (confirmed by the ___ covering
psychiatry NP ___ and ___ worker at ___. On admission, she was restarted on her ___
hospitalization regimen. Psychiatry was consulted, who agreed
with continuation of this regimen at discharge and determined
that she did not meet ___ criteria. Of note, Ritalin,
which the patient had previously been taking, was not continued
at discharge; decision regarding re-initiation of this
medication
was deferred to the ___ primary psychiatry team (Dr. ___ and NP ___, ___. The ___
outreach worker, ___, was updated and will follow along
closely. ___ with Ms. ___ is scheduled for ___ with
PCP
___ in 1 week. QTC was 462 on ___.
# Neuropathy:
Home methadone was continued at 20mg qAM and 10mg qPM.
# Pancreatic lipomas:
Pancreatic lesions confirmed as lipomas on MRCP. 9mm in size.
Benign and require ___.
# Pancreatic cystic lesions:
Seen on MRCP, few less than 2mm in size, likely intraductal
papillary mucinous neoplasms or sequela of pancreatitis. ___
needed at this size.
** TRANSITIONAL **
[ ] omeprazole 40mg BID x 6 weeks, then transition to daily
dosing
[ ] ___ cryptosporidium/giardia testing
[ ] ___ O&P
[ ] ___ with GI for results of EGD/colonoscopy biopsies
[ ] psychiatry ___ for medication adjustments as needed
[ ] monitor QTC on Seroquel and methadone. QTC was 462 on ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
L foot pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with hx of COPD, carotid artery disease, urinary retention,
distant ureteral cell cancer, s/p prostate surgery for BPH, and
poor nutrition who is presenting by EMS from home with left foot
pain and inability to ambulate after episode of left lower
extremity weakness leading to fall. Pt reports he was at stop
and
shop yesterday when his left leg suddenly went weak. He sat down
for a short time to rest before trying to get up again and ended
up falling to the ground, denies LOC/headstrike. He required
assistance of bystanders to help him to his car and then his
neighbor to help him into his house and park his car. When he
woke up this morning he noted pain the left foot and was not
able
to walk well. He called his pcp who recommended that he be seen,
but the patient was in too much pain to walk and EMS was called
and brought him to the ED for evaluation. He denies syncopal
episode, dizziness, chest pain or palpitations with the leg
symptoms. He denies fevers, n/v/d.
In the ED, initial VS were:
97.8 90 116/60 18 97% RA
Exam notable for:
PE: Mild tenderness to left foot palpation over the plantar
aspect of the sole of the foot near the ___ and ___ toe. No
edema, erythema, drainage or obvious foreign body. No tenderness
of the legs or hips, full ROM, no signs of trauma.
Labs showed:
UA with moderate bacteria, WBC >182, 15 RBC, Large leuk and
Nitrite positive
WBC 6.5, Hgb 12.3, Plt 143
Chem 7 notable for BUN/Cr ___
Imaging showed:
XR foot
IMPRESSION:
No acute findings to account for pain.
Patient received:
___ 18:07 IV CefTRIAXone 1 gm
___ 20:13 PO Tamsulosin .4 mg
Transfer VS were:
98.5 78 110/60 18 95% RA
On arrival to the floor, patient reports the above history. He
added that after the fall, every time he would go to the
bathroom
and make food, he noted that his left foot was hurting him, but
he did not have weakness anymore. He had no other associated
symptoms like arm weakness, or slurring speech or visual
changes.
The only other complaint he had was urinary retention in the
past
couple of days. he could urinate but not as much as usual. He
also notes social stressors from his sister's grandchildren.
REVIEW OF SYSTEMS:
10 point ROS reviewed and negative except as per HPI
Past Medical History:
COPD
Carotid artery stenosis with h/o amaurosis fugax
AAA (4.5x4.7 cm)
Ureteral tumor s/p distal ureterectomy and reimplantation
Alcohol abuse
Tobacco use
Depression
Anxiety disorder
Anemia
Inguinal hernia s/p mesh repair ___
Urinary Retention s/p TURP ___: seen by Dr. ___ at ___
Peripheral vascular disease
Constipation
Cataract surgery ___
Social History:
___
Family History:
-Mother: ___ Disease, scarlet fever
-Father: ___ Abuse
-Sister: ___ and leg amputation
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VS: 145 / 78 81 20 94
GENERAL: NAD, temporal wasting
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
dry mucous membranes. right lid droop
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, with transmitted upper airway sounds, and minor
expiratory wheezes, no rhonchi, speaking in full sentences
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis or edema, muscle atrophy present. Pt
without tenderness to palpation between left ___ and ___ toes.
Some minor discomfort upon palpation of plantar aspect bw ___
and
___ toes. No bruising noted. No edema, erythema, drainage or
obvious foreign body.
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose. CNII-XII
intact, but some lid droop on right side. Lower and upper
extremities with ___ strength.
SKIN: warm and well perfused, multiple echymosses scattered. no
rashes
DISCHARGE PHYSICAL EXAM
========================
VS: 98.2 PO 93/60 L Lying 79 18 89 RA
GENERAL: NAD, temporal wasting
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
dry mucous membranes.
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, with transmitted upper airway sounds, and minor
expiratory wheezes, no rhonchi
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, edema, left foot nontender
with full ROM
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, nonfocal
SKIN: warm and well perfused, multiple echymosses scattered. no
rashes
Pertinent Results:
ADMISSION LABS
================
___ 04:20PM BLOOD WBC-6.5 RBC-3.87* Hgb-12.3* Hct-38.0*
MCV-98 MCH-31.8 MCHC-32.4 RDW-12.7 RDWSD-45.3 Plt ___
___ 04:20PM BLOOD Neuts-67.8 Lymphs-17.7* Monos-10.6
Eos-2.9 Baso-0.5 Im ___ AbsNeut-4.39 AbsLymp-1.15*
AbsMono-0.69 AbsEos-0.19 AbsBaso-0.03
___ 04:20PM BLOOD Plt ___
___ 04:20PM BLOOD Glucose-92 UreaN-12 Creat-1.2 Na-140
K-3.9 Cl-100 HCO3-28 AnGap-12
DISCHARGE LABS
===============
___ 05:02AM BLOOD WBC-5.4 RBC-3.81* Hgb-11.7* Hct-35.7*
MCV-94 MCH-30.7 MCHC-32.8 RDW-12.4 RDWSD-43.1 Plt ___
___ 05:02AM BLOOD Plt ___
___ 05:02AM BLOOD Glucose-81 UreaN-14 Creat-1.4* Na-139
K-4.9 Cl-99 HCO3-30 AnGap-10
___ 05:02AM BLOOD Calcium-8.9 Phos-3.4 Mg-2.2
IMAGING
========
___ L Foot Xray
FINDINGS:
Three views the left foot provided. At the site of tenderness
along the
plantar aspect of the fourth and fifth toes, there is no
radiopaque foreign
body, fracture or dislocation. Mild loss of joint space at the
first MTP
joint. No acute fractures. No heel spurs. Soft tissues appear
normal.
IMPRESSION:
No acute findings to account for pain.
___ CT head
FINDINGS:
There is no evidence of acute hemorrhage, edema, mass effect, or
loss of
gray/white matter differentiation. Periventricular, deep, and
subcortical
white matter hypodensities are similar to the prior CT,
nonspecific but
compatible with sequela of chronic small vessel ischemic disease
in this age group. Age-related parenchymal volume loss is again
seen with prominent
ventricles and sulci.
There is no evidence of fracture. There is evidence of left
cataract surgery. There are mucous retention cysts and mild
mucosal thickening in the partially visualized right maxillary
sinus, and partially visualized polypoid mucosal thickening and
in the included portion of the left maxillary sinus. There is
mild mucosal thickening in the ethmoid air cells, as well as
within the left frontal sinus along the septum. Mastoid air
cells and middle ear cavities
appear grossly well-aerated.
IMPRESSION:
1. No evidence for acute intracranial abnormalities. Stable
appearance of the brain compared to ___.
2. Paranasal sinus disease.
___ CXR
FINDINGS:
Again demonstrated is hyperinflation of the lungs with
flattening of the
bilateral hemidiaphragms. There is no consolidation, effusion,
or
pneumothorax. The cardiomediastinal silhouette is normal.
IMPRESSION:
No evidence of pneumonia.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Senna 8.6 mg PO BID
2. Simvastatin 40 mg PO QPM
3. Clopidogrel 75 mg PO DAILY
4. amLODIPine 5 mg PO DAILY
5. Lisinopril 10 mg PO DAILY
6. ClonazePAM 1 mg PO TID:PRN anxiety
7. Docusate Sodium 100 mg PO BID:PRN constipation
8. Tamsulosin 0.4 mg PO QHS
Discharge Medications:
1. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 6 Days
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg one
tablet(s) by mouth twice a day Disp #*10 Tablet Refills:*0
2. ClonazePAM 1 mg PO TID:PRN anxiety
3. Clopidogrel 75 mg PO DAILY
4. Docusate Sodium 100 mg PO BID:PRN constipation
5. Lisinopril 10 mg PO DAILY
6. Senna 8.6 mg PO BID
7. Simvastatin 40 mg PO QPM
8. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY
L FOOT PAIN
FAILURE TO THRIVE
UTI
SECONDARY
COPD
HTN
PVD
ANXIETY
DEPRESSION
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with left foot tenderness to palpation on plantar aspect
near ___ and ___ toes.// ? foreign body, fracture
COMPARISON: No priors
FINDINGS:
Three views the left foot provided. At the site of tenderness along the
plantar aspect of the fourth and fifth toes, there is no radiopaque foreign
body, fracture or dislocation. Mild loss of joint space at the first MTP
joint. No acute fractures. No heel spurs. Soft tissues appear normal.
IMPRESSION:
No acute findings to account for pain.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man who presents with foot pain after episode of left
lower extremity weakness with fall (no head strike or loss of consciousness)
yesterday. Evaluate cause for weakness.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.3 cm; CTDIvol = 49.3 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: CT head without contrast ___.
FINDINGS:
There is no evidence of acute hemorrhage, edema, mass effect, or loss of
gray/white matter differentiation. Periventricular, deep, and subcortical
white matter hypodensities are similar to the prior CT, nonspecific but
compatible with sequela of chronic small vessel ischemic disease in this age
group. Age-related parenchymal volume loss is again seen with prominent
ventricles and sulci.
There is no evidence of fracture. There is evidence of left cataract surgery.
There are mucous retention cysts and mild mucosal thickening in the partially
visualized right maxillary sinus, and partially visualized polypoid mucosal
thickening and in the included portion of the left maxillary sinus. There is
mild mucosal thickening in the ethmoid air cells, as well as within the left
frontal sinus along the septum. Mastoid air cells and middle ear cavities
appear grossly well-aerated.
IMPRESSION:
1. No evidence for acute intracranial abnormalities. Stable appearance of the
brain compared to ___.
2. Paranasal sinus disease.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old man with COPD// worsening COPD? PNA?
TECHNIQUE: Chest PA and lateral
COMPARISON: Comparison is made to ___.
FINDINGS:
Again demonstrated is hyperinflation of the lungs with flattening of the
bilateral hemidiaphragms. There is no consolidation, effusion, or
pneumothorax. The cardiomediastinal silhouette is normal.
IMPRESSION:
No evidence of pneumonia.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: L Leg pain, L Leg weakness
Diagnosed with Urinary tract infection, site not specified
temperature: 97.8
heartrate: 90.0
resprate: 18.0
o2sat: 97.0
sbp: 116.0
dbp: 60.0
level of pain: 2
level of acuity: 3.0 | Mr. ___ is a ___ w PMHx of COPD, carotid artery disease,
urinary retention, frequent UTIs and malnutrition who presents
with one episode of unilateral leg weakness, fall, and
subsequent foot pain. Problems addressed during his
hospitalization are listed below:
#L lower extremity weakness
#L foot pain:
Patient had sudden onset left lower leg weakness that was focal.
Subsequently had foot pain after fall which has since resolved,
without evidence of injury on xray or physical exam. Etiology of
fall most likely hypoglycemia/dehydration from underlying
malnutrition and poor PO intake, less likely TIA/stoke given
nonfocal neurologic exam and benign head CT and lack of other
neurologic symptoms. However, does have significant risk factors
for CVA event(smoking, carotid stenosis, HTN), but reassuringly
on statin and anticoagulation. Foot pain resolved at discharge,
was able to ambulate independently, did not require formal ___
consult.
# Urinary retention
# BPH
# Urinary tract infection
Patient has had history of UTIs in setting of BPH and urinary
retention. Seen by urology at ___. Noted that he has had
urinary retention for last two days. UA positive in-house.
Received IV CTX x1 day, transitioned to PO Bactrim to complete
7d course (___). Continued tamsulosin 0.4 mg QHS.
# Severe protein calorie malnutrition
# Failure to thrive
# Poor social support
Malnutrition has been an ongoing issue for patient, lives alone,
does not know how to cook. His sister previously cooked his
meals
but recently stopped because she developed illness, has been
eating mostly fast food. At discharge, provided with ___
services, will be followed by elder services.
#COPD: patient noncompliant with albuterol and symbicort
inhalers. Saturated 89-95% RA in-house, asymptomatic. CXR
consistent with COPD. Refused albuterol/nebs in-house and at
discharge.
#HTN:
Discontinued amlodipine iso SBP <110 during admission, continued
lisinopril
# PVD, AAA, carotid artery stenosis:
continued Plavix and simvastatin
# Anxiety/depression: continued clonazepam.
# Normocytic anemia: stable at baseline (Hg 11 range) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
metformin
Attending: ___.
Chief Complaint:
Foot pain, fever
Major Surgical or Invasive Procedure:
___ RLE angiogram, R ___ angioplasty x3, R peroneal
angioplasty
___ R TMA
History of Present Illness:
___ male with history of Type 2 DM, CVA, PVD, HTN, and ESRD
(___) and recent admission to ___ for R foot cellulitis/dry
gangrene s/p partial ___ and ___ toe amputations who was
transferred from ___ with possible gas gangrene of R foot.
Patient reports he presented to his weekly podiatry appointment
at ___ on ___. His doctor examined his foot and requested X
ray. X ray reportedly showed evidence of gas and he was directed
to ___. ___ the ED he was started on vancomycin and ceftriaxone
and sent to ___ for surgical evaluation. Patient reports that
he has been feeling well at home, with no fevers, chills or foot
pain. He did spike a fever at HD on the day of presentation.
___ the ___ ED, initial vitals were: 101 78 107/59 16 97% RA
LABS: WBC 18 Hgb 11.4 Cr 4.8 BUN 24
IMAGING:
R foot xray:
1. findings c/w suppurative arthritis involving ___ mtp joint
w/ osteo of distal end of ___ metatarsal; also appears to be gas
___ the soft tissues between first and second rays; fracture of
the base of ___ metatarsal
CT foot:
-Air within the distal second metatarsal and second proximal
phalynx,
concerning for osteomyelitis. There is suggestion of bony
irregularity to the lateral aspect of the distal second
metatarsal, however a evaluation is limited without prior
studies available for comparison.
-Subcutaneous emphysema between the first and second, and
second and third rays, and along the plantar aspect of the foot.
-Nondisplaced fracture of the base of fifth metatarsal.
-Diffuse subcutaneous edema and extensive vascular
calcification.
Podiatry was consulted:
"Performed bedside I+D, ___ toe amputation. Micro and Path
specimens sent. Packed open with betadine/DSD. Added on to OR
___ for open TMA, but will discuss with vascular surgery ___
regards to limb salvage vs BKA. Will follow closely. ___
___ "
Vascular was consulted and recommended:
"Pt seen and evaluated. Appreciate podiatry recommendations and
debridement of toe gangrene.
- Agree with admission to medicine w/ broad spectrum
antibiotics.
- Obtain records regarding prior vascular surgery intervention
from ___
- Bilateral ___ vascular studies (___) and
arterial duplex of RLE ___ am
- Vascular will follow for revascularization vs amputation.
Patient was given Acetaminophen and Ceftriaxone and admitted to
medicine for further management. On the floor, patient feeling
well with no acute complaints.
Past Medical History:
Diabetes
CVA
Peripheral vascular disease
CKD
Hypertension
ESRD on HD (___)
PTSD
HTN
Social History:
___
Family History:
Father: diabetes
Mother: pancreatic CA
Physical Exam:
ADMISSION EXAM:
===========
Vital Signs: 98.0 PO 122 / 68 62 20 97 RA
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear
CV: RRR, no m/r/g
Lungs: clear to auscultation anteriorly
Abdomen: Soft, ___
Ext: Warm, R foot wrapped.
Neuro: No focal deficits
DISCHARGE EXAM:
============
Vital Signs: Temp 98.2 153 / 69 78 20 96% RA
General: Alert, oriented, and ___ no acute distress
HEENT: Sclerae anicteric, dry mucous membranes, oropharynx clear
CV: RRR, normal S1 and S2 with no murmus, rubs, or gallops
Lungs: Clear to auscultation bilaterally
Abdomen: Soft, ___, and nondistended with normoactive
bowel sounds.
Ext: Warm, R foot wrapped ___ dressings that were clear, dry, and
intact. L upper extremity fistula site dressing c/d/I, with
audible bruit, palpable thrill
Neuro: No focal deficits
Pertinent Results:
ADMISSION LABS:
===============
___ 09:25PM BLOOD ___
___ Plt ___
___ 09:25PM BLOOD ___
___ Im ___
___
___ 09:25PM BLOOD ___
___
NOTABLE LABS
============
___ 09:25PM BLOOD ___
___ Plt ___
___ 06:25AM BLOOD ___
___ Plt ___
___ 07:12AM BLOOD ___
___ Plt ___
___ 09:25PM BLOOD ___ ___
___ 06:25AM BLOOD ___ ___
___ 09:25PM BLOOD ___
___
___ 06:25AM BLOOD ___
___
___ 07:12AM BLOOD ___
___
___ 06:25AM BLOOD ___
___
___ 09:50PM BLOOD ___
___ 10:10AM STOOL ___
DISCHARGE LABS
==============
___ 05:28AM BLOOD ___
___ Plt ___
___ 05:28AM BLOOD Plt ___
___ 05:28AM BLOOD ___
___
___ 05:28AM BLOOD ___
MICROBIOLOGY:
================
__________________________________________________________
___ 6:25 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 12:55 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 6:35 am BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 12:04 am SWAB Source: R foot.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___.
WOUND CULTURE (Final ___:
STAPH AUREUS COAG +. SPARSE GROWTH.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
VIRIDANS STREPTOCOCCI. SPARSE GROWTH.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
ANAEROBIC CULTURE (Final ___:
ANAEROBIC GRAM POSITIVE COCCUS(I). MODERATE GROWTH.
(formerly Peptostreptococcus species).
NO FURTHER WORKUP WILL BE PERFORMED.
__________________________________________________________
___ 9:35 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 9:25 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING/STUDIES:
================
FOOT AP,LAT & OBL RIGHT ___
Postsurgical changes of transmetatarsal amputation are
demonstrated. There is
soft tissue swelling and irregularity compatible with recent
surgery. Small
amount of gas ___ projects over the soft tissues overlying the
first and second
metatarsal amputation sites. There is vascular calcification.
There is mild
talonavicular degenerative change.
There is a fracture at the base of the fifth metatarsal,
extending to the
fifth tarsometatarsal joint as noted on recent CT ___.
IMPRESSION:
Postsurgical changes. Soft tissue swelling and some gas
overlying the medial
metatarsals.
Fifth metatarsal base fracture.
CT ___ ___:
1. Air within the distal second metatarsal and second proximal
phalynx,
concerning for osteomyelitis. There is suggestion of bony
irregularity to the lateral aspect of the distal second
metatarsal, however evaluation is limited without prior studies
available for comparison.
2. Subcutaneous emphysema between the first and second, and
second and third rays, and along the plantar aspect of the foot.
3. Nondisplaced fracture of the base of fifth metatarsal.
4. Diffuse subcutaneous edema and extensive vascular
calcification.
5. Prior third and fourth metatarsal amputation.
R ___ ___:
Evidence of moderate to severe bilateral pedal ischemia, worse
on the right related to tibioperoneal occlusive disease.
On the right, the common femoral artery is patent with a peak
velocity of 92. The SFA is patent with velocities of 16 to91
cm/sec. There is no velocity elevation to suggest stenosis.
The popliteal artery is patent with a highest velocity of 95.
Cm/sec.
The posterior tibial and anterior tibial arteries are patent
with velocities of 57 to 109 cm/sec.
Radiology Report
EXAMINATION: Lower extremity arterial duplex US.
INDICATION: ___ year old man with gas gangrene in R foot. // RLE arterial
duplex per vascular
TECHNIQUE: Real-time grayscale, color, and spectral Doppler ultrasound
imaging of the right lower extremity arteries was obtained.
FINDINGS:
On the right, the common femoral artery is patent with a peak velocity of 92.
The SFA is patent with velocities of 16 to91 cm/sec. There is no velocity
elevation to suggest stenosis.
The popliteal artery is patent with a highest velocity of 95. Cm/sec.
The posterior tibial and anterior tibial arteries are patent with velocities
of 57 to 109 cm/sec.
IMPRPRESSION: Patent right lower extremity arteries without evidence of
stenosis.
Radiology Report
INDICATION: ___ year old man with gas gangrene in R foot. // ABI/PVR per
vascular
TECHNIQUE: Non-invasive evaluation of the arterial system in the lower
extremities was performed with Doppler signal recording, pulse volume
recordings and segmental limb pressure measurements.
FINDINGS:
On the right side, Doppler waveforms are seen in the common femoral but
biphasic at the popliteal and monophasic at the posterior tibial artery. The
ABI was not obtainable due to calcification. The digit PPG waveform is flat
and therefore no toe pressure could be obtained.
On the left side, triphasic Doppler waveforms are seen at the common femoral,
popliteal, and posterior tibial arteries. Mild monophasic waveforms are seen
in the dorsalis pedis artery. The ABI could not be obtained due to
calcification. The digit
Pulse volume recordings showed normal phasic patterns in the thigh calf and
ankle but flat waveforms in the metatarsal and digit level bilaterally.
IMPRESSION:
Evidence of moderate to severe bilateral pedal ischemia, worse on the right
related to tibioperoneal occlusive disease.
Radiology Report
EXAMINATION: FOOT AP,LAT AND OBL RIGHT
INDICATION: ___ year old man s/p R foot TMA // postop
TECHNIQUE: Three views of the right for
COMPARISON: No prior radiographs are available for comparison.
FINDINGS:
Postsurgical changes of transmetatarsal amputation are demonstrated. There is
soft tissue swelling and irregularity compatible with recent surgery. Small
amount of gas in projects over the soft tissues overlying the first and second
metatarsal amputation sites. There is vascular calcification. There is mild
talonavicular degenerative change.
There is a fracture at the base of the fifth metatarsal, extending to the
fifth tarsometatarsal joint as noted on recent CT ___.
IMPRESSION:
Postsurgical changes. Soft tissue swelling and some gas overlying the medial
metatarsals.
Fifth metatarsal base fracture.
Gender: M
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: Wound eval, Transfer
Diagnosed with Gangrene, not elsewhere classified
temperature: 101.0
heartrate: 78.0
resprate: 16.0
o2sat: 97.0
sbp: 107.0
dbp: 59.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ y/o man with PMH of ESRD on dialysis (T,
TH, ___, Type 2 DM, PVD s/p RLE angioplasty, HTN, and CVA who
presented to OSH with right foot wet gangrene with
osteomyelitis, s/p right partial ___ and ___ toe amputation and
now s/p ___ toe amputation and later TMA.
# Right foot wet gangrene with osteomyelitis: Likely secondary
to diabetic foot infection complicated by peripheral vascular
disease. Seen by podiatry ___ ED and underwent bedside I+D and
___ toe amputation. Underwent angiogram with angioplasty of R ___
followed by transmetatarsal amputation by podiatry. TMA with 700
cc blood loss, and 2 point drop ___ hemoglobin, requiring
transfusion with 1 unit pRBCs. Wound cultures grew MSSA and
strep viridans. Patient with initial leukocytosis of 17.9,
trended down to 12.5 on discharge. Was trialed on several
antibiotics and eventually transitioned to cefazolin IV and
metronidazole PO for at least 14 days from ___, with projected
2 week course (end date ___, however final course to be
determined by Dr. ___ based on clinical exam.
#ESRD on HD ___ diabetic nephropathy: HD ___ at ___
___. Continued on home schedule, but last received HD on ___
___ with plan to continue home schedule ___.
#PVD s/p stenting of posterior tibial artery ___ angioplasty
of ___ ___. Started on clopidogrel 75mg daily following
angioplasty. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
R hip fracture
Major Surgical or Invasive Procedure:
___ R TFN
History of Present Illness:
___ female presents with the above fracture s/p mechanical
fall. Was obtaining clothes from her closet in her apartment
when
she fell from standing height, impacting her right hip. She had
immediate pain on her right side and was unable to stand
thereafter, calling life-alert at approximately 7AM. Denies head
impact, LOC, neck pain, right upper extremity pain. Endorses
mild
L hip pain.
Denies recent illness or additional injury. Grandson is with pt
who endorses she is at her mental baseline of mild-moderate
dementia, A&O to self, location, month, birthday.
Past Medical History:
-Scoliosis
-Osteoarthritis
-Squamous cell cancer s/p Mohs surgery
-Colitis (___)
-Cholecystitis (___)
-Falls without headstrike
Social History:
___
Family History:
non-contributory
Physical Exam:
right lower extremity:
- inc cdi
- knee and ankle w/ intact ROM and nontender
- Fires ___
- SILT S/S/SP/DP/T distributions
- 1+ ___ pulses, WWP
Radiology Report
INDICATION: ___ with fall, right hip deformity // Eval for injury
TECHNIQUE: AP view of the pelvis. AP and cross-table lateral views of the
right leg.
COMPARISON: CTA abdomen pelvis from ___.
FINDINGS:
There is an acute comminuted intratrochanteric fracture through the right
femoral neck. There is varus angulation of the main fracture fragments.
Lesser trochanter is seen as a separate fracture fragment. Femoral head is
anatomically aligned with the acetabulum. Pubic symphysis and SI joints are
preserved. Degenerative changes noted in the lower lumbar spine.
Atherosclerotic calcifications are noted.
IMPRESSION:
Acute angulated, comminuted intertrochanteric right femoral fracture.
Radiology Report
INDICATION: ___ with fall, right hip deformity // Eval for injury
TECHNIQUE: Single AP supine view of the chest.
COMPARISON: ___.
FINDINGS:
Lower lung volumes seen on the current exam. The lungs are clear without
focal consolidation or edema. Cardiomediastinal silhouette is stable given
differences in technique, noting accentuation of the cardiac silhouette.
Lumbar dextroscoliosis is noted as well as degenerative changes in the spine.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with fall, right hip deformity. Evaluate for injury.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Total DLP (Head) = 1,304 mGy-cm.
COMPARISON: CT from ___.
FINDINGS:
There is no evidence of acute infarction, hemorrhage, edema, or mass. There is
prominence of the ventricles and sulci suggestive of involutional changes,
unchaged from prior. Periventricular, and subcortical hypodensities are
consistent with chronic small vessel ischemic disease. Chronic bilateral
thalamic and right caudate head lacunar infarcts are seen, unchanged from
prior.
There is no fracture. There is mild mucosal thickening of the right maxillary
sinus. The visualized portion of the other paranasal sinuses, mastoid air
cells, and middle ear cavities are clear. The visualized portion of the
orbits are unremarkable. There is evidence of bilateral lens replacements.
IMPRESSION:
No acute intracranial abnormality.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ with fall, right hip deformity. Evaluate for injury.
TECHNIQUE: Non-contrast helical multidetector CT was performed.Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Total DLP (Body) = 1,011 mGy-cm.
COMPARISON: None.
FINDINGS:
3 mm anterolisthesis of C7 over T1, likely degenerative changes given severe
facet arthropathy of the level.Other vertebral bodies are aligned. No
fractures are identified. There is no prevertebral soft tissue swelling.
There are degenerative changes at the craniocervical junction with a large
degenerative pannus formation at C1-C2. There is moderate to severe multilevel
degenerative changes of the spine, worse at C3 through 7, with mild vertebral
body height loss, severe disc height loss, anterior and posterior osteophytes,
and uncovertebral and facet arthropathy without critical spinal canal
narrowing.
The thyroid appears grossly normal and lung apices are clear..
IMPRESSION:
1. No acute fractures.
2. 3 mm anterolisthesis of C7 over T1, likely degenerative given severe facet
arthropathy at that level. Please correlated clinically.
3. Severe degenerative changes of the cervical spine as noted above.
Radiology Report
INDICATION: ___ with R hip fracture, persistent tenderness @ L femur, R
knee // eval ? injury
TECHNIQUE: AP and lateral views of the proximal distal left femur.
COMPARISON: None.
FINDINGS:
There is no fracture or focal osseous abnormality. Femoroacetabular joint is
anatomically aligned. Soft tissues notable for vascular calcifications.
IMPRESSION:
No fracture.
Radiology Report
INDICATION: ___ with R hip fracture, persistent tenderness @ L femur, R
knee // eval ? injury
TECHNIQUE: Oblique and cross-table lateral views of the distal right femur.
COMPARISON: Correlation made to pelvis and hip films from earlier the same
day.
FINDINGS:
There is no acute fracture of the distal right femur. No significant
degenerative changes seen at the knee. Vascular calcifications are noted.
IMPRESSION:
No distal right fibular fracture.
Radiology Report
EXAMINATION: Intraoperative fluoroscopy.
INDICATION: Right hip ORIF
TECHNIQUE: Screening provided in operating room without a radiologist
present.
COMPARISON: Earlier same day
FINDINGS:
Images demonstrate fixation of the right intertrochanteric femoral fracture
with a gamma nail. Total fluoroscopy time 50.2 seconds.
IMPRESSION:
Screen for procedure guidance, for details of procedure please see operative
report.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: s/p Fall, R Hip pain
Diagnosed with Displaced intertrochanteric fracture of right femur, init, Other fall on same level, initial encounter
temperature: 96.9
heartrate: 98.0
resprate: 22.0
o2sat: 100.0
sbp: 179.0
dbp: 102.0
level of pain: 10
level of acuity: 2.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have R hip frx and was admitted to the orthopedic surgery
service. The patient was taken to the operating room on ___
for R TFN, which the patient tolerated well. For full details of
the procedure please see the separately dictated operative
report. The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to rehab was appropriate. The ___ hospital
course included transf 1 u pRBCs on ___ for Hct 22.5.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
WBAT in the RL extremity, and will be discharged on lovenox for
DVT prophylaxis. The patient will follow up with Dr. ___
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course
including reasons to call the office or return to the hospital,
and all questions were answered. The patient was also given
written instructions concerning precautionary instructions and
the appropriate follow-up care. The patient expressed readiness
for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
ACE Inhibitors / lisinopril
Attending: ___
Chief Complaint:
chest and arm pain
Major Surgical or Invasive Procedure:
Hemodialysis
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
___ male with history of hypertensive nephropathy on
dialysis MWF (at ___) presenting with left arm and chest pain
for 3 weeks. The patient had a graft in the left upper extremity
which was in place for ___ years but was not under use. This was
removed about 3 weeks ago by transplant surgery. He reports that
since the surgery he has had left upper extremity pain. It has
been radiating into the chest. It is pleuritic and worse when
outside in the cold. He denies any shortness of breath. The pain
is nonexertional. He denies any fevers, cough, hemoptysis. He
denies any leg swelling. He received dialysis this morning and
felt like the pain was coming on too frequently, so EMS was
called at dialysis. He elected to go to ___ this is where
PCP and transplant surgery are.
He is on Coumadin for history of unprovoked PE ___. Has
history of HTN diagnosed in jail many years ago. Says his
kidney disease is ___ HTN.
-EKG: SR, NA, normal intervals, anterior Qwaves, nonspecific STT
changes, improved lateral ST depressions from prior
He has a complicated access history for which he initially had
an
HD catheter and then a right brachiocephalic fistula placed in
___ but due to stenosis and right sided swelling and pain, he
had a left arm graft placed in ___. Right sided swelling and
pain has since resolved, and he now uses the RUE AVF for
dialysis. L arm HERO removed ___ due to clotting and
thought of its contribution to possible PE.
In the ED, initial vitals were: 98.7 78 194/118 18 100% RA
Imaging notable for
LUE dopper: Clot filled expanded and thrombosed cephalic vein
graft.
CTA:
1. Previously seen bilateral pulmonary emboli are no longer
visualized. No new pulmonary embolism.
2. Redemonstration of right rim calcified mass and cortical
hypodensities bilaterally, incompletely imaged, unchanged.
Patient was given
___ 14:29 PO Acetaminophen 1000 mg ___
___ 14:29 PO Aspirin 324 mg ___
Patient was seen by who recommended
TRANSPLANT:
Patient with very chronic LUE/L chest pain. Palpable pulse, no
difficulty with dialysis via RUE AVF. If admission needed,
please admit to medicine and have patient follow-up with Dr.
___ as an outpatient. ___ ___
Decision was made to admit for ACS r/o?
Vitals notable for
98.1 84 96/61 20 100% RA 1747
75 154/39 18 100% RA 1842
On the floor, patient is comfortable. States this chest/arm
pain comes and goes randomly except reliably comes on when
breathing in cold air. Denies shortness of breath. Feels like
this is more pain rather than shortness of breath like his
previous PE episode. No diarrhea. No dysuria.
Review of systems:
Complete and thorough review of systems obtained and is
otherwise negative.
Past Medical History:
-PE diagnosed ___
-ESRD ___ HTN on MWF hemodialysis since ___
-HTN diagnosed in ___ at age ___ while in jail, urgency episode
in ___ (c/b pulmonary edema requiring intubation)
-Substance abuse
-HLD
Past Surgical History:
-left upper extremity HeRO graft ___, ___)
-Left brachiocephalic AV fistula ___, ___
-Right brachiocephalic AV fistula ___, ___
-Placement of LUE HeRO graft ___, ___)
-Appendectomy complicated by postop ?leak/abscess requiring
emergent exploratory laparotomy
-? angioplasty of L brachiocephalic & SVC ___
Social History:
___
Family History:
Father - Died at age ___ from unknown cancer
Mother - Died at age ___ of MI, had HTN
Maternal grandmother - on hemodialysis for end-stage renal
disease.
Physical Exam:
ADMISSION:
VS: 98.2 149/72 72 18 100RA
Gen: well-appearing man in NAD
HEENT: PERRL though eyes a bit dilated for room light; poor
dentition
CV: systolic murmurs appreciated at bilateral upper sternal
borders
Pulm: CTAB no wheezes rales or rhonchi
Abd: midline scar c/w prior ex lap, otherwise NTND NABS
Ext: patient has fistula on R arm that has overlying gauze; L
arm has several well-healed scars along with 2 bumps which
patient reports is from hero graft; also has lateral upper arm
bruise
Neuro: AOx3, answers all questions appropriately
DISCHARGE:
VS: 98.5 118-148/47-57 ___ 18 99RA
Wt 59.5 (61.6)
Gen: well-appearing man in NAD
CV: faint holosystolic murmurs appreciated at bilateral upper
sternal borders
Pulm: CTAB no wheezes rales or rhonchi
Abd: midline scar c/w prior ex lap, otherwise NTND NABS
Ext: patient has fistula on R arm that has overlying gauze; L
arm has several well-healed scars along with 2 bumps which
patient reports is from hero graft; also has lateral upper arm
bruise
Neuro: AOx3, answers all questions appropriately
Pertinent Results:
ADMISSION:
___ 01:15PM BLOOD WBC-5.2 RBC-3.25* Hgb-8.6* Hct-29.3*
MCV-90 MCH-26.5 MCHC-29.4* RDW-20.0* RDWSD-65.2* Plt ___
___ 01:15PM BLOOD ___ PTT-58.3* ___
___ 01:15PM BLOOD Glucose-69* UreaN-58* Creat-13.9*# Na-138
K-5.7* Cl-89* HCO3-32 AnGap-23*
___ 01:15PM BLOOD CK-MB-5 cTropnT-0.29*
___ 11:55PM BLOOD CK-MB-4 cTropnT-0.28*
___ 06:17AM BLOOD CK-MB-4 cTropnT-0.28*
___ 06:17AM BLOOD Calcium-8.9 Phos-7.9* Mg-2.6
___ 01:27PM BLOOD Lactate-1.4
DISCHARGE
___ 06:09AM BLOOD WBC-4.4 RBC-3.49* Hgb-9.0* Hct-31.8*
MCV-91 MCH-25.8* MCHC-28.3* RDW-20.0* RDWSD-66.5* Plt ___
___ 06:09AM BLOOD ___ PTT-42.5* ___
___ 06:09AM BLOOD Glucose-64* UreaN-33* Creat-8.5*# Na-137
K-5.2* Cl-89* HCO3-31 AnGap-22*
___ 01:15PM BLOOD CK-MB-5 cTropnT-0.29*
___ 11:55PM BLOOD CK-MB-4 cTropnT-0.28*
___ 06:17AM BLOOD CK-MB-4 cTropnT-0.28*
___ 06:09AM BLOOD Calcium-10.3 Phos-5.7* Mg-2.4
LUE US ___
Expanded and thrombosed cephalic vein graft.
CXR ___
No acute cardiopulmonary process.
CTA CHEST ___
1. Previously seen bilateral pulmonary emboli are no longer
visualized. No new pulmonary embolism.
2. Redemonstration of right rim calcified mass and cortical
hypodensities in the kidneys bilaterally, incompletely imaged,
unchanged.
L SHOULDER XRAY ___
No fracture or dislocation.
PHARMACOLOGIC STRESS MIBI ___
1. No evidence of reversible perfusion defect.
2. Mild fixed defect in the inferior and apical walls is
possibly secondary to attenuation, unchanged.
3. Dilated left ventricular cavity, similar to prior study, with
ejection
fraction of 52%
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Calcium Acetate ___ mg PO TID W/MEALS
4. Calcium Acetate 667 mg PO BID with snacks
5. Carvedilol 25 mg PO BID
6. Nephrocaps 1 CAP PO DAILY
7. Warfarin 10 mg PO DAILY
8. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
9. sevelamer CARBONATE 800 mg PO TID W/MEALS
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Calcium Acetate ___ mg PO TID W/MEALS
4. Calcium Acetate 667 mg PO BID with snacks
5. Warfarin 10 mg PO DAILY
6. sevelamer CARBONATE 800 mg PO TID W/MEALS
7. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours
Disp #*30 Tablet Refills:*0
8. Carvedilol 25 mg PO BID
9. Nephrocaps 1 CAP PO DAILY
10. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
RX *isosorbide mononitrate 30 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
11. Ezetimibe 10 mg PO DAILY
RX *ezetimibe [Zetia] 10 mg 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Left arm pain
Hyperkalemia
ESRD
Secondary:
Hypertension
History of PE
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ male with left sided chest and arm pain. Patient has
a history of unprovoked pulmonary embolism. Evaluate for congestive heart
failure or pneumonia.
TECHNIQUE: PA and lateral chest radiographs were obtained.
COMPARISON: Chest radiograph ___ and ___.
FINDINGS:
The lungs are clear without focal consolidation, pleural effusion or
pneumothorax. There is no pulmonary edema. The heart is normal in size, and
the mediastinal contours are normal.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: VENOUS DUP UPPER EXT UNILATERAL LEFT
INDICATION: ___ year old man with left upper extremity pain. history of prior
PE // eval for DVT
TECHNIQUE: Grey scale and Doppler evaluation was performed on the left upper
extremity veins.
COMPARISON: None.
FINDINGS:
There is normal flow with respiratory variation in the bilateral subclavian
vein.
The left internal jugular and axillary veins are patent, show normal color
flow and compressibility. The left brachial and basilic veins are patent,
compressible and show normal color flow and augmentation. The cephalic vein
is dilated, expanded, and filled with noncompressible clot.
IMPRESSION:
Expanded and thrombosed cephalic vein graft.
Radiology Report
INDICATION: ___ with chest pain and history of PE // eval for PE
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: Total DLP (Body) = 317 mGy-cm.
COMPARISON: CTA chest dated ___
FINDINGS:
The imaged thyroid gland is homogeneous in attenuation without a focal lesion
identified. There is no axillary or supraclavicular adenopathy. Central
nodes are not pathologically enlarged. There is stranding within the right
axillary region, similar compared to prior.
The ascending aorta is non aneurysmal. The main pulmonary artery is within
normal limits in caliber. Heart size is normal. There is no pericardial
effusion. The esophagus is unremarkable.
The pulmonary arteries are opacified to the subsegmental level. Previously
present filling defects within the bilateral upper lobe pulmonary arteries are
no longer present. No filling defect is identified to suggest acute or new
pulmonary embolism.
The airways are patent to the subsegmental level. Paraseptal emphysema is
mild and upper lobe predominant. A punctate calcified nodule within the right
middle lobe (3:110) and left lower lobe medially (3:167) likely reflect
calcified granulomas. Bibasilar atelectasis is mild and symmetric. There is
no focal consolidation. There is no pleural effusion or pleural abnormality.
There are no osseous lesions worrisome for malignancy or infection within the
chest cage.
Although study is not tailored for subdiaphragmatic evaluation, imaged upper
abdomen demonstrates partially rim calcified right upper pole renal mass
measuring 3.6 x 3.5 cm (2:99), not significantly change relative to prior
studies. Innumerable renal hypodensities are incompletely characterized or
imaged. Incidental note is made of an accessory or replaced left hepatic
vein, its origin from the left gastric artery.
IMPRESSION:
1. Previously seen bilateral pulmonary emboli are no longer visualized. No
new pulmonary embolism.
2. Redemonstration of right rim calcified mass and cortical hypodensities in
the kidneys bilaterally, incompletely imaged, unchanged.
Radiology Report
EXAMINATION: SHOULDER ___ VIEWS NON TRAUMA LEFT
INDICATION: ___ year old man with L arm pain, s/p fall 1week ago and has a
protuberance with bruise lateral aspect of upper arm // acute process to
explain L arm pain' please include majority of humerus
TECHNIQUE: Three views of the left shoulder.
COMPARISON: None available.
FINDINGS:
No fracture, dislocation, or degenerative change is detected involving the
glenohumeral or AC joint. No suspicious lytic or sclerotic lesion is
identified. Vascular calcifications are noted.
IMPRESSION:
No fracture or dislocation.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: L Arm pain, Chest pain
Diagnosed with Other chest pain, Shortness of breath
temperature: 98.7
heartrate: 78.0
resprate: 18.0
o2sat: 100.0
sbp: 194.0
dbp: 118.0
level of pain: 4
level of acuity: 3.0 | ___ yo M with history of ESRD d/t HTN who presents with L
chest/arm pain who had biphasic T waves in V3, underwent pharm
stress MIBI which showed no reversible defects. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hematuria, BRBPR
Major Surgical or Invasive Procedure:
Cystoscopy ___
History of Present Illness:
___ with hx metastatic prostate cancer (not currently undergoing
treatment), colon polyps, ureteral stricture s/p dilation in
___ presenting with 2 days hematuria and bloody stools. He
reports that he was feeling well until ___, when he began
prep for colonoscopy (with magnesium citrate) and developed
diarrhea. ___, began having gross hematuria and constant,
small volume urinary incontinence. Also developed bloody stools
(small amount of bright red blood mixed in at the same time).
However, patient states that he has a history of hemorrhoids and
has occasional BRBPR. Now complaining of dizziness, weakness.
Also with anorexia. No falls. Denies fevers, chills, chest pain,
change in back pain (has chronic back pain). Two days ago, he
also developed dysuria and went to PCP who diagnosed him with
UTI and prescribed him ciprofloxacin for 10 days (he completed 8
days). Reports no change in dysuria or hematuria while on
ciprofloxacin.
In ED, initial vitals are 98.8 60 112/45 18 98% RA. On exam,
abdomen initially firm and tender. Foley placed (difficult
placement), drained approximately 400cc frank blood. Abdomen
signficantly softer and less tender. Rectal exam done, pt with
normal tone, small amount gross blood mixed with mucus. No stool
in rectal vault. HCT 25 from 34 at baseline. Patient consented
for blood, typed and crossed for 3 units. Labs notable for Cr
2.1, BUN 77, WBC 14.4, Hct 25, Troponin 0.02, INR 1.1, PTT 27.5.
UA positive for 11 WBC, positive nitrite, large blood RBC >182,
protein >300, trace ketone, moderate bili, few bacteria.
Currently, patient states that he is feeling well. + dysuria and
frequency. Denies lightheadedness/dizziness, f/c, n/v/d,
abdominal pain, back pain.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, melena.
Past Medical History:
-Colon resection ___ years ago: he reports having multiple polyps
with a 'slight trace' of cancer that required a partial
resection of left-sided colon. Was not treated subsequently with
further therapy.
-Status post bilateral carotid endarterectomies
-Blind in right eye after retinal detachment as a teenager
-Status post left eye cataract surgery
-Dry eyes
-Status post bilateral foot fractures after fall from ladder at
approx ___ years ago requiring operative repair
-Compression fracture in lower L-spine ___ years ago
Oncology history
- ___: diagnosed with prostate adenocarcinoma, PSA 2.5, ___
3+4=7, T2b.
- ___: completed external beam radiation and concurrent
hypothermia protocol, PSA decreased
- ___: PSA began to rise to 2.6 ___. Findings
consistent with prostate cancer at the right base and mid gland,
centered in the central gland and extending to the right
peripheral zone with apparent extracapsular extension.
- ___ Bone scan: focal increased tracer uptake in L2
through
L5 suggestive of compression fractures, diffuse increased sacral
tracer uptake, and uptake in the ___ left posterior rib
probably
related to trauma.
- ___: MRI fusion-guided biopsy revealed residual prostate
adenocarcinoma, ___ 8 with perineural invasion.
- ___: brachytherapy seed implantation. PSA began to rise
to 7.1 on ___.
- ___ bone scan: resolved areas of uptake in the lumbar
spine. CT Torso done on the same day showed two hyperenhancing
left inguinal lymph nodes measuring 1.2 and 1.3 cm, concerning
for metastatic disease.
- ___: Started Lupron 7.5mg IM (1 month injection)
- ___: Lupron 22.5mg (3 month injection)
Social History:
___
Family History:
Is one of 10 children, had 6 brothers and 3 sisters. Two
brothers and sisters currently living. Reports both brother with
prostate cancer. 1 brother with colon cancer in his ___ who
passed away.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS - 99.3, 108/40, 72, 18, 94% RA
GENERAL - elderly, underweight male, NAD, comfortable,
appropriate
HEENT - NC/AT, R eye with glassy lens (post surgery), L eye with
pupil reactive to light and accomodation, EOMI, sclerae
anicteric, dry MM, OP clear
NECK - supple, no thyromegaly, no LD, JVP ~7
LUNGS - decreased lung sounds throughout but CTA bilat, no
r/rh/wh appreciated, resp unlabored, no accessory muscle use
BACK - no CVA tenderness
HEART - RRR, no MRG appreciated
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, 2+ edema up to thigh, 1+ peripheral pulses
(radials, DPs). One large bruise in L forearm secondary to
bumping arm to a sink. B/l chronic onychomycosis with long
nails. Small 1cm blister on L lateral dorsum of foot.
SKIN - dried skin in b/l lower extremities
GU - foley in place draining dark red, bloody urine
NEURO - awake, A&Ox3, CNs III-XII grossly intact, muscle
strength ___ throughout, sensation grossly intact throughout
RECTAL - rectal sphincter with normal tone, noted to have
external hemorrhoids, no stools in vault, positive small amount
of BRBPR, no prostate tenderness
DISCHARGE PHYSICAL EXAM
VS - 98.2 ___ 18 98%RA
GENERAL - NAD
HEENT - MMM, R eye with glassy lens (post surgery)
LUNGS - decreased lung sounds throughout but CTA bilat, no
r/rh/wh appreciated, resp unlabored, no accessory muscle use
HEART - S1S2 RRR, no MRG appreciated
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e
NEURO - awake, A&Ox3, CNs II-XII intact, strength ___ in
bilateral upper and lower extremities, bracheoradialias reflex
intact, decreased sensation to light touch over left hand, with
inability to flex left wrist
Pertinent Results:
ADMISSION LABS
___ 12:50PM BLOOD WBC-14.4*# RBC-2.33*# Hgb-8.0*#
Hct-25.0*# MCV-107* MCH-34.5* MCHC-32.2 RDW-14.5 Plt ___
___ 12:50PM BLOOD Neuts-85.0* Lymphs-8.4* Monos-6.3 Eos-0.1
Baso-0.1
___ 01:44PM BLOOD ___ PTT-27.5 ___
___ 12:50PM BLOOD Glucose-122* UreaN-77* Creat-2.1*# Na-143
K-4.0 Cl-105 HCO3-26 AnGap-16
___ 05:30AM BLOOD CK(CPK)-425*
___ 12:50PM BLOOD CK-MB-5
___ 12:50PM BLOOD cTropnT-0.02*
___ 03:56AM BLOOD Calcium-7.4* Phos-3.7 Mg-2.7*
NOTABLE LABS
___ 12:50PM BLOOD CK-MB-5
___ 12:50PM BLOOD cTropnT-0.02*
___ 07:30PM BLOOD CK-MB-4 cTropnT-0.01
___:30AM BLOOD CK-MB-3 cTropnT-0.03*
___ 12:50PM BLOOD Hct-25.0*#
___ 05:00PM BLOOD Hct-21.7*
___ 03:56AM BLOOD Hct-27.2*#
___ 05:30AM BLOOD Hct-27.8*
___ 05:20PM BLOOD Hct-24.8*
___ 05:25AM BLOOD Hct-31.0*
___ 03:00PM BLOOD Hct-30.7*
URINE
___ 01:30PM URINE Color-Red Appear-Cloudy Sp ___
___ 01:30PM URINE Blood-LG Nitrite-POS Protein->300
Glucose-NEG Ketone-TR Bilirub-MOD Urobiln-1 pH-6.0 Leuks-NEG
___ 01:30PM URINE RBC->182* WBC-11* Bacteri-FEW Yeast-NONE
Epi-0
DISCHARGE LABS
___ 07:15AM BLOOD WBC-6.8 RBC-2.72* Hgb-8.9* Hct-28.0*
MCV-103* MCH-32.6* MCHC-31.7 RDW-16.0* Plt Ct-98*
___ 07:15AM BLOOD Glucose-84 UreaN-23* Creat-0.8 Na-144
K-4.3 Cl-108 HCO3-26 AnGap-14
___ 07:15AM BLOOD Calcium-8.3* Phos-2.6* Mg-1.6
MICRO
URINE CULTURE (Final ___: NO GROWTH.
PATHOLOGY
DIAGNOSIS: Papillary urothelial carcinoma, high grade, with
invasion into muscularis propria (See B level 2);
adenocarcinoma/mucinous differentiation.
IMAGING
___ CXR
IMPRESSION: Mild to moderate pulmonary edema with trace pleural
effusions. In this setting, slightly more focal opacity in the
right lower lung could
reflect asymmetric edema; however, an infectious process could
be better
assessed for after diuresis with repeat radiographs.
___ RENAL ULTRASOUND
IMPRESSION:
1. Moderate bilateral hydronephrosis and hydroureter.
2. Markedly enlarged prostate, though some of the surrounding
echogenic
material could reflect blood clot, which may be suspected.
___ ECHO
MPRESSION: Normal regional and global left ventricular systolic
function. Mild to moderate mitral regurgitation. Dilated right
ventricle with normal systolic function, moderate tricuspid
regurgitation and moderate pulmonary artery systolic
hypertension. Small amount of pericardial fluid without evidence
of tamponade physiology. LVEF >55%
___ HAND XRAY (AP, LAT & OBLIQUE) - Negative for fx
___ FOREARM (AP & LAT) LEFT - Negative for fx
___ UPPER EXTREMITY VENOUS ULTRASOUND
IMPRESSION: No left upper extremity deep venous thrombosis.
___ MR ___
1. Acute-to-subacute infarct centered at the right
temporoparietal junction. No hemorrhagic conversion. No
significant mass effect.
2. Left frontal encephalomalacia with old blood products from an
old infarct.
3. Superimposed chronic microvascular ischemic disease.
4. Diffuse right hemispheric subdural collection, most
compatible with a
hygroma.
5. Asymmetrically small right globe with evidence of old
retinal/subchoroidal hemorrhage. Recommend clinical
correlations.
___. No evidence of cord compression. No acute malalignment.
2. Moderate multilevel cervical spondylosis. Mild-to-moderate
C4-C5 and
C5-C6 spinal canal stenosis, mildly in contact with the cord but
without
significant cord deformity.
___ Carotid US
Impression: Right ICA 60-69% stenosis.
Left ICA 60-69% stenosis.
___ MRA ___
1. Motion degraded study.
2. Significant intracranial atherosclerotic disease as described
above. In particular, there are multifocal attenuations at the
right M2 branches. No evidence of intracranial aneurysm or
arteriovenous malformation.
3. Moderate atherosclerotic disease in the neck, most
significantly affected the distal common carotid arteries, right
worse than left. A focal stenosis at the origin of the left
vertebral artery. Major cervical vessels remain patent.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO BID
2. Atenolol 100 mg PO DAILY
3. Chlorthalidone 25 mg PO DAILY
4. Lisinopril 40 mg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. Ciprofloxacin HCl 500 mg PO Q24H
7. Amlodipine 10 mg PO DAILY
8. traZODONE 50 mg PO HS
9. OxycoDONE (Immediate Release) Dose is Unknown PO Frequency
is Unknown
10. Senna 1 TAB PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Senna 2 TAB PO HS
3. OxycoDONE (Immediate Release) 2.5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg half tablet(s) by mouth every six (6) hours
Disp #*30 Tablet Refills:*0
4. Vitamin D 1000 UNIT PO DAILY
5. Acetaminophen 1000 mg PO Q6H:PRN pain
6. Calcium Carbonate 1000 mg PO TID ON EMPTY STOMACH
7. Milk of Magnesia 30 mL PO Q6H:PRN constipation
8. Polyethylene Glycol 17 g PO DAILY
9. Pravastatin 20 mg PO DAILY
10. Sarna Lotion 1 Appl TP QID:PRN pruritis
11. Lidocaine 5% Patch 1 PTCH TD DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY: hematuria, BRBPR, urinary tract infection, left hand
weakness
SECONDARY: metastatic prostate adenocarcinoma, hypertension,
osteoporosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: Elevated white blood cell count, assess for pneumonia.
COMPARISON: ___.
FINDINGS: 2 views were obtained of the chest. Mediastinal vascular
engorgement and interstitial abnormality bilaterally is consistent with
mild-to-moderate pulmonary edema accompanied by trace pleural effusions.
Slightly more focal opacity in the right base could reflect developing
infectious process or asymmetric edema. The heart is mildly enlarged with
normal cardiomediastinal contours aside for mild aortic tortuosity and
calcification. Old right rib fractures are identified. Exaggerated thoracic
kyphosis is noted.
IMPRESSION: Mild to moderate pulmonary edema with trace pleural effusions. In
this setting, slightly more focal opacity in the right lower lung could
reflect asymmetric edema; however, an infectious process could be better
assessed for after diuresis with repeat radiographs.
Radiology Report
HISTORY: Prostate cancer with hematuria and crit drop.
COMPARISON: CT abdomen pelvis ___.
FINDINGS: The right kidney measures 9.2 cm. The left kidney measures 10.1 cm.
Small interpolar region echogenic focus in the right kidney could reflect a 4
mm nonobstructing stone. Moderate bilateral hydronephrosis and hydroureter is
seen without demonstration of a specific obstructing entity. A large bladder
mass contiguous with the prostate measures 7.2 x 2.5 x 7.3 cm; it may
respresent prostatic tumor, a hematoma or combination of both. No vascular
flow is elicited within it. The bladder wall is trabeculated with Foley
catheter and small bladder diverticulum noted. Echogenic debris within the
bladder is not specific but may reflect hemorrhage.
IMPRESSION:
1. Moderate bilateral hydronephrosis and hydroureter.
2. Markedly enlarged prostate, though some of the surrounding echogenic
material could reflect blood clot, which may be suspected.
Radiology Report
HISTORY: Known metastatic prostate adenocarcinoma, presenting with left
forearm and wrist pain and swelling. Evaluation for source of pain and
swelling.
COMPARISON: Bone scan from ___.
FINDINGS:
Left hand: AP, lateral and oblique views show no evidence of fracture,
dislocation or destructive bony lesions. There is moderate degenerative
disease involving the ___ carpometacarpal joint, an mild scattered
degenerative disease involving the distal interphalangeal joints. Regional
soft tissues are grossly unremarkable.
Left elbow/forearm: AP and lateral views show no evidence of fracture,
dislocation or destructive bony lesions. There is nonspecific calcification
within the soft tissues lateral to the distal elbow.
IMPRESSION:
Nonspecific calcification involving the soft tissues lateral to the distal
ulnar (of unclear significance, but may be dystrophic from old trauma).
Degenerative changes involving the wrist and hand. Otherwise, no acute
pathology seen.
Radiology Report
HISTORY: Left arm swelling.
COMPARISON: No relevant comparisons available.
FINDINGS: Gray scale and color Doppler sonograms with spectral analysis of the
bilateral subclavian veins and the left internal jugular, axillary, brachial,
basilic and cephalic veins were performed. There is normal compressibility,
flow, and augmentation.
IMPRESSION: No left upper extremity deep venous thrombosis.
Radiology Report
HISTORY: ___ year-old with history of metastatic prostate cancer. Acute
symptoms of stroke.
TECHNIQUE: Noncontrast multiplanar multisequence MR images were acquired
through the brain. Diffusion-weighted images and ADC maps were also obtained
40 variation.
COMPARISON: None.
FINDINGS: There is a DWI-right and ADC-dark area centered at the right
temporoparietal junction, compatible with acute-to-subacute infarct. There is
no evidence of acute hemorrhage. There is associated FLAIR signal
abnormality, but without significant mass effect. There is left frontal
encephalomalacia with old blood product, representing an old infarct.
There are superimposed scattered subcortical and confluent periventricular
white matter T2/hyperintensities, nonspecific but compatible with chronic
microvascular ischemic disease.
There is a diffuse right subdural collection along the right hemispheric
convexity, measuring 6-mm in maximum thickness. The collection follows CSF
signal intensity in all sequences, representing a hygroma.
The ventricles and sulci as are prominent, compatible with age related
atrophy. There is no shift of normally midline structures. Major vascular
flow voids are present. The visualized mastoid air cells are clear. There is
a small amount of fluid in the left maxillary sinus.
The right globe is asymmetrically small, with abnormal FLAIR hyperintensity
and evidence of old retinal and/or subchoroidal hemorrhage.
IMPRESSION:
1. Acute-to-subacute infarct centered at the right temporoparietal junction.
No hemorrhagic conversion. No significant mass effect.
2. Left frontal encephalomalacia with old blood products from an old infarct.
3. Superimposed chronic microvascular ischemic disease.
4. Diffuse right hemispheric subdural collection, most compatible with a
hygroma.
5. Asymmetrically small right globe with evidence of old retinal/subchoroidal
hemorrhage. Recommend clinical correlations.
Dr. ___ has discussed the findings with primary team Dr. ___
___ at 11 AM on ___, shortly after the preliminary
interpretation of the study.
Radiology Report
HISTORY: ___ man, with history of metastatic prostate cancer. Now
presents with stroke-like symptoms. Also concern for spinal cord compression.
COMPARISON: None.
TECHNIQUE: Non-contrast multiplanar, multisequence T1- and T2-weighted images
were acquired through the cervical spine.
FINDINGS: There is no evidence of cord compression. There is slightly
exaggerated cervical lordosis. The craniocervical junction is preserved.
There are cortical irregularity and sclerosis at the posterior aspect of the
odontoid process, chronic in appearance and of doubtful clinical significance.
The vertebral body heights are overall preserved. Marrow signal is slightly
heterogeneous, reflecting degenerative changes. There is diffuse disc
desiccation.
At C2-3, there are no significant degenerative changes.
At C3-4, there is moderate loss of the intervertebral disc height. There is a
small disc-osteophyte complex with focal ligamentum flavum thickening,
resulting in mild spinal canal narrowing. There is no significant neural
foraminal narrowing.
At C4-5, there is a mild disc central protrusion. In combination with focal
ligamentum flavum thickening, there is mild-to-moderate canal stenosis. There
is no significant cord deformity. There is bilateral uncovertebral
arthropathy, resulting in mild-to-moderate bilateral neural foraminal
narrowing.
At C5-C6, there is significant loss of the intervertebral disc height. There
is a small posterior disc-osteophyte complex. In combination with focal
ligamentum flavum thickening, there is mild-to-moderate spinal canal
narrowing. There is a left uncovertebral arthropathy, resulting in severe
left neural foraminal narrowing. There is mild right neural foraminal
narrowing.
At C6-C7, there is moderate loss of intervertebral disc height with a small
central disc protrusion. There is, however, no significant spinal canal
stenosis. There is mild bilateral neural foraminal narrowing.
At C7-T1, there are no significant degenerative changes.
In the visualized upper thoracic spine, there is a mild T4 anterior wedge
compression deformity, incompletely assessed.
The prevertebral soft tissues are grossly normal. There is no evidence of
acute ligamentous injury. A 4-mm left cystic thyroid nodule is noted. A
trace amount of fluid is noted in the trachea.
IMPRESSION:
1. No evidence of cord compression. No acute malalignment.
2. Moderate multilevel cervical spondylosis. Mild-to-moderate C4-C5 and
C5-C6 spinal canal stenosis, mildly in contact with the cord but without
significant cord deformity.
Radiology Report
___
Department of Radiology
Standard Report Carotid US
Study: Carotid Series Complete
Reason: ___ year old man with new actue to subacute stroke, eval for emboli.
Findings: Duplex evaluation was performed of bilateral carotid arteries. On
the right there is moderate heterogeneous plaque in the ICA. On the left
there is moderate heterogeneous plaque seen in the ICA.
On the right systolic/end diastolic velocities of the ICA proximal, mid and
distal respectively are 213/30, 166/28, 118/27 cm/sec. CCA peak systolic
velocity is 179/23 cm/sec. ECA peak systolic velocity is 180 cm/sec. The
ICA/CCA ratio is 1.18. These findings are consistent with 60-69% stenosis.
On the left systolic/end diastolic velocities of the ICA proximal, mid and
distal respectively are 175/31, 172/25, 123/30 cm/sec. CCA peak systolic
velocity is 142/27 cm/sec. ECA peak systolic velocity is 250 cm/sec. The
ICA/CCA ratio is 1.23 . These findings are consistent with 60-69% stenosis.
Right antegrade vertebral artery flow.
Left antegrade vertebral artery flow.
Impression: Right ICA 60-69% stenosis.
Left ICA 60-69% stenosis.
Radiology Report
HISTORY: ___ man, with acute or subacute stroke. Assess for vessels.
COMPARISON: MR head on ___.
TECHNIQUE: Non-contrast 3D time-of-flight images were acquired through the
head per standard MRA head protocol. Dedicated 3D rendering was performed to
better assess the underlying vessels.
MRA NECK: Coronal images of the neck were acquired before and after
administration of IV gadolinium contrast per standard MRA neck protocol.
Dedicated 3D rendering was performed to better assess the underlying vessels.
FINDINGS:
MRA HEAD: The image quality is moderately limited by patient's motion.
Allowing for the limitation, there is diffuse atherosclerotic disease most
notable with luminal irregularities along the petrous and cavernous segments
of the internal carotid arteries bilaterally. There are also luminal
irregularities in the M1 segment of the middle cerebral arteries bilaterally.
Multifocal irregular attenuation of the distal M2 segments are right worse
than left.
In the posterior circulation, there is a hypoplastic right V4 segment, with a
dominant left vertebral artery. The basilar artery is patent and normal in
caliber. There is appearance of a patulous basilar tip with the P1s and
superior cerebellar arteries arising from a common origin. There is mild
atherosclerotic disease in the left P1 segment.
There is no aneurysm greater than 3 mm or arteriovenous malformation.
MRA NECK: There is a normal three-vessel aortic arch. A focal stenosis is
noted at the origin of the left vertebral artery. There are right worse than
left atherosclerotic plaques along the common carotid arteries, most
significantly in the distal cervical portion just proximal to the carotid
bifurcations. There is no evidence of occlusion, dissection, or aneurysm.
Major cervical vessels remain patent.
There are small bilateral pleural effusions.
IMPRESSION:
1. Motion degraded study.
2. Significant intracranial atherosclerotic disease as described above. In
particular, there are multifocal attenuations at the right M2 branches. No
evidence of intracranial aneurysm or arteriovenous malformation.
3. Moderate atherosclerotic disease in the neck, most significantly affected
the distal common carotid arteries, right worse than left. A focal stenosis
at the origin of the left vertebral artery. Major cervical vessels remain
patent.
Radiology Report
HISTORY: Bladder cancer, for staging.
TECHNIQUE: CT images were obtained from the thoracic inlet to the pubic
symphysis after the uneventful intravenous administration of 130 cc of
Omnipaque contrast media and oral contrast. Additionally noncontrast and 3
minute delayed postcontrast images were obtained of the abdomen. Multiplanar
reformats were prepared of the images through the torso.
COMPARISON: ___ and ___.
FINDINGS:
CT CHEST WITH CONTRAST: The thyroid gland is normal with symmetric
enhancement. The aorta and major branches are patent and normal in caliber
with conventional 3 vessel branching arch. Diffuse severe aortic
atherosclerotic calcification is seen along with noncalcified plaque most
pronounced along descending thoracic aorta (2:40). The heart and pericardium
are normal without pericardial effusion. Moderate coronary vascular
calcification noted. There is no pathologic mediastinal, axillary or hilar
lymph node enlargement with prominent left subcarinal lymph node measuring 9
mm in short axis, similar in appearance to the ___ study (3:31). The trachea
and central airways appear patent to the segmental level. Diffuse moderate
centrilobular emphysema is noted within large right apical bleb. Bibasilar
atelectasis and nonhemorrhagic small-to-moderate bilateral pleural effusions
are noted. No suspicious pulmonary nodules are identified. The esophagus is
unremarkable with a small axial hiatal hernia noted.
CT ABDOMEN WITH AND WITHOUT CONTRAST: The liver is nodular suggestive of
cirrhosis without focal lesion, intra or extrahepatic biliary ductal
dilatation. Gallbladder is decompressed with multiple calcified gallstones
noted. The pancreas and bilateral adrenal glands are unremarkable. Linear
splenic hypodensity compatible with evolving infarct with multiple splenic
calcifications noted. The kidneys enhance symmetrically within diffuse
vascular calcification and moderate left hydroureteronephrosis.
The stomach is largely decompressed with unchanged, nonspecific hypodensity
within the fundal wall (3:52). The small and large bowel appear grossly
unremarkable. A small to moderate volume of nonhemorrhagic ascites is seen.
No free intraperitoneal air is seen. Diffuse atherosclerotic calcification is
seen along without unchanged focal infrarenal aortic dissection which is
partially thrombosed as before. Severe celiac arterial stenosis is seen with
large noncalcified plaque at the ostium (601b:26). Mild infrarenal aortic
ectasia is noted to 2.5 x 2.4 cm with severe right and moderate left external
iliac arterial stenosis. Mild renal arterial calcifications are seen
bilaterally. There is no mesenteric pathologic lymph node enlargement with
retroperitoneal lymph nodes measuring up to 1 cm (3:69).
CT PELVIS WITH CONTRAST: The bladder is heterogeneous within enhancing
component along the left ureteral orifice (3:100), which appears to be the
site of left ureteral obstruction. It is uncertain if this enhancement is due
to ulcerated lesion or postsurgical changes. Air in the bladder and Foley
catheter are noted. The bladder wall is circumferentially thickened, though
this assessment is somewhat limited due to under distention. The prostate and
periprostatic tissue contains brachytherapy seeds eccentrically to the right.
The rectum is unremarkable. A small volume of free pelvic fluid and presacral
edema is noted. No pathologic inguinal or pelvic lymph nodes are noted.
Diffuse body wall edema is consistent with a anasarca.
OSSEOUS STRUCTURES: Multiple compression fractures are seen in the mid
thoracic as well as lumbar spine. Fractures at L1, L4 and L5 have progressed.
T12 and L2 fractures are unchanged. T7 compression fracture is mildly
increased as well without change to T5 and T6. No suspicious lytic or blastic
bony lesions are identified to suggest osseous malignancy. Old rib fractures
are seen bilaterally. Sternal fenestration is noted.
IMPRESSION:
1. Moderate left hydronephrosis and hydroureter terminating in an area of
bladder wall hyperenhancement at the left ureteral orifice which could relate
to ulcerated and enhancing tumor or postprocedural changes.
2. Retroperitoneal nodes are few in number and less than 1 cm without
specific evidence for metastatic disease.
3. Cirrhotic liver with small volume ascites. Diffuse body wall edema and
small to moderate bilateral pleural effusions consistent of anasarca.
4. Moderate-to-severe centrilobular emphysema.
5. Severe atherosclerotic calcification without high-grade celiac artery
stenosis, severe right and moderate left external iliac stenosis and unchanged
focal infrarenal dissection.
5. Multiple compression fractures of the thoracolumbar spine, some of which
have progressed since ___.
6. Cholelithiasis without cholecystitis.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: RECTAL BLEEDING
Diagnosed with HEMATURIA, UNSPECIFIED, ACUTE KIDNEY FAILURE, UNSPECIFIED, RECTAL & ANAL HEMORRHAGE, HYPERTENSION NOS
temperature: 98.8
heartrate: 60.0
resprate: 18.0
o2sat: 98.0
sbp: 112.0
dbp: 45.0
level of pain: 0
level of acuity: 2.0 | ___ M with hx of metastatic prostate adenocarcinoma and h/o
ureteral stricture presenting with 2 days hematuria and bloody
stools, found to have bladder cancer; also found to have a new
subacute CVA during admission.
# Bladder Cancer: Initially presented with hematuria, initially
thought to be a combination of UTI (positive UA and dysuria)
and radiation cystitis given his hx of radiation for prostate
cancer; but also at risk for cancer given smoking history.
Renal/bladder ultrasound showed moderate bilateral
hydronephrosis and enlarged prostate with ? surrounding blood
clot. Urology was consulted and recommended cystoscopy. Penile
pain was controlled with urojet and oxycodone:PRN and anemia
from hematuria was supported with blood transfusions. He
underwent cystoscopy on ___ which demonstrated a small 2-3cm
bladder tumor on the L lateral side of the bladder. It was
excised and hemostasis was acheived. Pathology returned
confirming papillary urothelial carcinoma, high grade, with
invasion into muscularis propria; adenocarcinoma/mucinous
differentiation. Hematuria resolved after cystoscopy. Family and
patient were informed of the results and decision was made to
pursue imaging (CT Torso) with goal of staging the cancer.
Patient will have follow-up with Dr. ___ in 2 weeks for
further management/evaluation of the bladder mass. Will also f/u
with Oncology.
# Subacute Stroke: Pt was noted to be unable to hold a walker
while working with ___ on ___. On exam he was unable to extend
L wrist along with L ___ and ___ digit interosseious weakness.
On further inquiry, patient reported having symptoms for the
last ten days. Neuro was consulted and initially thought it
could be secondary to chronic spinal cord compression /
radiculopathy however complete workup. MRI ___ showed a new
acute-to-subacute infarct centered at the right temporoparietal
junction w/ no hemorrhagic conversion. Stroke team was consulted
who deferred on anti-platelet tx given active
hemorrhage/hematuria. EKG/tele ruled out afib or other
arrhythmia as a possibile etiology for a cardioembolic stroke.
Carotid UA and MRA ___ demonstrated significant
athlersclerotic disease which appears to have been the source of
emboli. ___ followed pt during admission. A1C was 5.6 and LDL
was 52. Pt was deemed a poor candidate for a procedure on his
carotids (given prior CEA, his age, and his co-morbidities).
Piror to discharge, pt was started on statin (LDL was 42, ALT
slightly elevated in the ___ as per stroke due to his
significant atherosclerotic disease. In regards to anti-platelet
therapy, in the setting of recent active hemorrhage,
anti-platelet therapy is contraindicated due to risk of
hemorrhage. As per stroke team, approximate risk of recurrent is
___ per year.
# BRBPR: Could be also secondary to radiation proctitis or
hemorrhoids. Patient states that his last colonoscopy was ___
years ago at OSH and and had multiple polyps that were removed,
but no other abnormalities. Prior to admission patient had been
prepping for colonoscopy, but given hematuria / cancer diagnosis
and stroke diagnosis, colonoscopy was cancelled. Patient had no
further rectal bleeding. Can reschedule colonoscopy in the
future if consistent with goals of care and/or if recurrent
rectal bleeding.
# Acute Blood Loss Anemia: Patient with ~ 10 point hct drop and
bright red blood draining from foley on admisison. On arrival to
the floor, patient was mentating well with soft blood pressure
in the 100s systolic and ___ diastolic. Rectal exam positive for
bright red blood. He was transfused a total of 3u pRBC.
Following cystoscopy his hematuria resolved and hematocrit
stabilized (___).
# ST Depressions: EKG on admission showed new ST depression in
V2-V6 not present in prior EKG from ___. Denied any cardiac
symptoms and no PMH of cardiac events. Initial troponin was
0.02, 0.01, 0.03. ST depressions resolved with blood
transfusion. Monitored on telemetry with no events. TTE
obtained showed normal L ventricular wall thickness, normal EF,
mild to moderate mitral regurgitation, dilated right ventricle
with normal systolic function, moderate tricuspid regurgitation,
moderate pulmonary artery systolic hypertension, and small
amount of pericardial fluid without evidence of tamponade
physiology. There was no LV thrombus. In the setting of acute
blood loss, the ST depressions are likely due to acute blood
loss leading to demand ischemia.
# ___: Initial creatinine was 2.1 with BUN of 77. Most likely
secondary to prerenal from blood loss as it improved to 1.4 and
BUN of 55 after administration of 2u of pRBC. Stable now with a
creatinine of 1 after correcting hematuria. Discharged with
creatinine at baseline.
CHRONIC ISSUES
# Metastatic prostate adenocarcinoma: Last seen by heme/onc on
___. PSA at the time was 0.8 and no treatment was indicated.
Recent imaging in ___ showed no metastatic lesions to the
bone.
# HTN: Atenolol, lisinopril, chlorthalidone, amlodipine were
held as patient with low BP and acute blood loss.
# Osteoporosis: Continued with vitamin D
TRANSITIONAL ISSUES
-Outpt Colonoscopy deferred. However, GI team is aware and
please arrange colonoscopy pending outpatient oncology workup
and if acute GI bleed.
-F/u final read of CT Torso
-F/u with Urology, Oncology, and Neurology
*) CODE STATUS: DNR/DNI
*) CONTACT: ___ (sister in law): ___
*) MEDICATION CHANGES:
- STARTED pravastatin, lidocaine patch
- HELD amlodipine, atenolol, chlothalidone, lisinopril,
trazodone
*) Followup: Pt has followup appointments with neurology,
urology and oncology. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
milk
Attending: ___.
Chief Complaint:
Right renal inferior pole infarct.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a ___ year-old male who was in his usual state of health
until 5 days ago when he presented to an OSH with the abrupt
onset of RIGHT flank pain. Per patient, the OSH ___, CT),
performed a CT scan which was negative for abnormalities, but
the patient was discharged w/ therapy which he was told was for
nephrolithiasis.
He reports that his pain was initially improved with this
treatment, but as time went on was only partially relieved by
Percocet. On the evening of ___, the patient was at home
after working all day, and developed a similar sudden onset of
worsening RIGHT flank pain which did not (at all) respond to
Percocet. The patient also endorsed subjective fevers earlier
that day as well as nausea, but no vomiting. His last bowel
movement was prior to the initial pain presentation 5 days ago
at the OSH. He denies hematuria or other urinary symptoms. He
denies chest pain, shortness of breath, neurological deficits,
seizures, palpitations, blurred vision, and blood in his stool.
In the ED, vital signs were: 98.4, 76, 166/112, 18, 100% RA. A
UA returned negative, CT abd/pelv w/ contrast demonstrated a
RIGHT renal inferior pole infarct with, "no definite arterial
flow in the lower pole of the right kidney," seen on renal
doppler ultrasound. He received 30mg Ketorolac IV, 5mg Morphine
IV, and 4mg Zofran IV. For fluids, a total of 1L NS was given.
On arrival to the medicine floor, vital signs were: 98.2, 72,
168/110, 20, 100%RA. The patient's pain was controlled, but
started to return towards the end of our initial interview.
ROS:
Denies chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, vomiting, diarrhea,
BRBPR, melena, hematochezia, dysuria, hematuria. All other
10-system review negative in detail.
Past Medical History:
# Vasculitis: ___, confirmed with skin biopsy at ___
___; took Prednisone per Atrius records
# Prostatitis: ___ years prior to admission
# Herpes zoster infection
# Fractures: femur fracture at ___ broken rib in ___ grade
# Bilateral hernia: at ___. repaired surgically
Social History:
___
Family History:
# Kidney stones (Father)
# Congenital absence of one kidney (Father)
# Hypertension (Father)
# Crohns (Mother)
# Miscarriage w/ unknown trimester (Mother 1x, Sister 1x)
* No known family history of clots
Physical Exam:
ON ADMISSION:
Vitals: 98.2, 72, 168/110, 20, 100%RA
Mental Status: a&ox3
Gen: Very pleasant, comfortable, speaking in full sentences
H/E: NCAT, EOMI
Mouth/Neck: clear OP, no carotid bruits, no masses
Lungs: CTAB, no increased work of breathing
CV: No mrg, RRR, S1/S2, no S3/S4
Abd: obese, NABS, soft, ND, very TTP diffusely, no HSM
Extr: WWP, good cap refill, 2+ distal pulses. No c/c/e. No TTP.
ON DISCHARGE:
afebrile
Gen: Well appearing adult in NAD. Pleasant and cooperative.
AOx3.
Neck: Supple. No cervical LAP.
HEENT: PERRLA, EOMI, MMM, OP pink w/o ulcers injection or
exudates.
Chest: CTA w/o W/R/R.
Cor: RRR, S1S2, No MRG.
Abd: S/ND/NT, no HSM.
Extrem: Warm, 2+ radial and pedal pulses, no C/C/E.
Pertinent Results:
LABS ON ADMISSION:
# ___ 05:30AM WBC-10.0 RBC-4.58* HGB-14.5 HCT-40.8 MCV-89
MCH-31.6 MCHC-35.5* RDW-12.1
# ___ 07:47AM K+-4.2
# ___ 06:40AM K+-5.5*
# ___ 05:30AM NEUTS-82.5* LYMPHS-10.5* MONOS-6.3 EOS-0.4
BASOS-0.3
# ___ 05:30AM PLT COUNT-167
# ___ 08:45AM URINE COLOR-Straw APPEAR-Clear SP
___
# ___ 08:45AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
# ___ 08:45AM URINE RBC-1 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
# ___ 05:30AM GLUCOSE-108* UREA N-14 CREAT-1.0 SODIUM-133
POTASSIUM-5.6* CHLORIDE-95* TOTAL CO2-26 ANION GAP-18
# ___ 07:10AM BLOOD ___ PTT-32.1 ___
# ___ 07:10AM BLOOD ESR-63*
# ___ 02:55PM LACTATE-2.3*
# ___ 05:30AM CRP-177.0*
# ___ 07:10AM BLOOD Triglyc-73 HDL-33 CHOL/HD-4.5
LDLcalc-100
# ___ 07:10AM BLOOD C3-146 C4-25
MICROBIOLOGY:
___ ED Blood cultures: NGTD
___ RPR: NEGATIVE
IMAGING:
___ CT ABD/PELV: 1. Geographic hypoperfusion of the lower
pole of the right kidney, with neighboring perinephric
stranding, compatible with infarct. There is mild chronic upper
pole scarring. 2. Large amount of fluid and stool within the
ascending colon, with reflux of stool across the ileocecal valve
into the terminal ileum. No bowel obstruction detected. 3.
Normal appendix.
___ RENAL U/S w/ DOPPLER: 1. Decreased arterial flow in the
lower pole of the right kidney which is concordant with the
recent CT findings and consistent with a segmental renal
infarction. 2. Increased echogenicity in the lower pole of the
right kidney. This corresponds to the abnormality seen on the
prior CT, and also consistent with
infarction. 3. Normal Doppler evaluation of the left kidney.
___ ECHO (TTE): Normal biventricular cavity sizes with
preserved global and regional biventricular systolic function.
Borderline pulmonary artery hypertension. No definite structural
cardiac source of embolism identified.
___: CXR: Normal heart, lungs, hila, mediastinum and pleural
surfaces. No evidence of intrathoracic infection.
___: CTA CHEST: Normal chest CTA, without dissection, or
significant
atherosclerosis.
___: MRA RENAL: There are three renal arteries identified on
the right side. The upper two accessory arteries supply the
upper pole of the right kidney and are patent. No flow is
identified in the distal one-third of the lower renal artery and
may represent an embolus or focal dissection. Further
confirmation with conventional angiogram recommended. No intimal
thickening to suggest vasculitis or irregularity to sugguest
fibromuscular dysplasia. The right renal vein is patent.
LABS ON DISCHARGE:
___ 07:55AM BLOOD ___ PTT-33.1 ___
___ 09:00AM BLOOD ESR-51*
___ 07:10AM BLOOD ESR-63*
___ 07:55AM BLOOD Lupus-NEG
___ 07:10AM BLOOD ACA IgG-4.2 ACA IgM-6.6
___ 07:25AM BLOOD Creat-1.1
___ 08:10AM BLOOD LD(LDH)-480*
___ 08:10AM BLOOD Calcium-8.2* Phos-3.6 Mg-2.2
___ 07:10AM BLOOD Triglyc-73 HDL-33 CHOL/HD-4.5 LDLcalc-100
___ 07:10AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
___ 09:00AM BLOOD ANCA-NEGATIVE B
___ 09:00AM BLOOD ___
___ 07:10AM BLOOD CRP-130.5*
___ 05:30AM BLOOD CRP-177.0*
___ 07:10AM BLOOD C3-146 C4-25
___ 07:10AM BLOOD HCV Ab-NEGATIVE
___ 07:10AM BLOOD BETA-2-GLYCOPROT 1 ABS (IGA, IGM,
IGG)-NEGATIVE
Medications on Admission:
Percocet, zofran, flomax (all from OSH 5 days ago)
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
while taking narcotics.
Disp:*30 Capsule(s)* Refills:*0*
3. senna 8.6 mg Tablet Sig: ___ Tablets PO twice a day as needed
for constipation: while taking narcotics.
Disp:*30 Tablet(s)* Refills:*0*
4. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain: Do not drink alcohol or drive while
taking this medication.
Disp:*20 Tablet(s)* Refills:*0*
5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
segmental renal infarction
hypertension (benign)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Right flank pain.
No comparison studies available.
TECHNIQUE: MDCT-acquired 5-mm axial images of the abdomen and pelvis were
obtained following the uneventful administration of oral contrast and 130 cc
of Omnipaque intravenous contrast. Coronal and sagittal reformations were
performed at 5-mm slice thickness.
CT OF THE ABDOMEN WITH IV CONTRAST:
Included views of the lung bases are clear. There is no pericardial or
pleural effusion. The heart size is top normal.
There is geographic hypoperfusion of the lower pole of the right kidney
(601B:46). There is no hydronephrosis. Mild neighboring perinephric fat
stranding is present (2:43). Mild focal cortical thinning within the right
upper pole reflects chronic scarring, either from infection or infarction. No
renal or ureteral calculi are identified. There is no hydronephrosis.
The liver, gallbladder, pancreas, adrenal glands, left kidney, spleen, and
stomach are normal. There is no mesenteric or retroperitoneal
lymphadenopathy, and no free air or free fluid.
Contrast progresses through the jejunum, which is mildly distended (601B:33)
but not dilated. There is a moderate amount of stool within the ileum
(601B:22). A large amount of fluid and stool extends across the ascending
colon (601B:32) and transverse colon. No bowel wall thickening is seen. The
appendix is normal (601B:42). There is no free air or free fluid.
CT OF THE PELVIS WITH IV CONTRAST:
The urinary bladder, prostate, rectum, and sigmoid colon are normal.
Scattered colonic diverticula are present, with no evidence of diverticulitis.
There is no intrapelvic free fluid or lymphadenopathy.
OSSEOUS STRUCTURES: There is no acute fracture. No concerning blastic or
lytic lesions are identified.
IMPRESSION:
1. Geographic hypoperfusion of the lower pole of the right kidney, with
neighboring perinephric stranding, compatible with infarct. There is mild
chronic upper pole scarring.
2. Large amount of fluid and stool within the ascending colon, with reflux of
stool across the ileocecal valve into the terminal ileum. No bowel obstruction
detected.
3. Normal appendix.
Radiology Report
INDICATION: Right flank pain and infarct seen on recent CT.
COMPARISONS: CT abdomen and pelvis ___ at 7:06 a.m.
FINDINGS: In the lower pole of the right kidney, there is some increased
echogenicity, which corresponds to the region of concern on the recent CT
abdomen and is likely related to the infarction. Also in the lower pole,
there is decreased arterial flow, which is concordant with the finding of
infarction on the CT. There is normal arterial flow in the upper and mid pole
of the right kidney. The main renal artery has a normal flow. The resistive
indices are normal. The main renal vein is patent. The right kidney measures
11.7 cm.
The Doppler evaluation of the left kidney is unremarkable with normal arterial
and venous flows. There is no renal mass or parenchymal abnormality. The
left kidney measures 12.2 cm. The bladder is unremarkable.
IMPRESSION:
1. Decreased arterial flow in the lower pole of the right kidney which is
concordant with the recent CT findings and consistent with a segmental renal
infarction.
2. Increased echogenicity in the lower pole of the right kidney. This
corresponds to the abnormality seen on the prior CT, and also consistent with
infarction.
3. Normal Doppler evaluation of the left kidney.
Radiology Report
PA AND LATERAL CHEST ON ___
HISTORY: ___ man with a right lower pole renal infarct. Evaluate
possible infection.
IMPRESSION: PA and lateral chest reviewed in the absence of prior chest
radiographs:
Normal heart, lungs, hila, mediastinum and pleural surfaces. No evidence of
intrathoracic infection.
Radiology Report
HISTORY: ___ male with right renal infarction. Please evaluate for
dissection, atheroma, vasculitis.
COMPARISON: CT of the abdomen and pelvis performed ___.
TECHNIQUE: Helical CT images were acquired of the chest after the
administration of contrast and reformatted into coronal and sagittal planes.
FINDINGS: The imaged portions of the lungs are clear. There is no pleural
effusion. The central airways appear patent. There is minimal basilar
atelectasis.
The heart is normal in size and configuration. There is no pericardial
effusion. The aorta is normal in appearance, without acute aortic injury or
significant atherosclerotic change. The pulmonary arteries are patent to
subsegmental levels. Central lymph nodes are not enlarged ranging in short
axis diameter up to 6mm in the paraesophageal mediastinal station. The
visualized bones are normal.
While this exam is not tailored for an evaluation of infradiaphragmatic
structures, no abnormality is seen.
IMPRESSION: Normal chest CTA, without dissection, or significant
atherosclerosis.
Radiology Report
RENAL MRA
INDICATION: Right renal infarct. Query vasculitis.
COMPARISON: CTA of ___, renal ultrasound of ___, and CT abdomen and
pelvis of ___.
TECHNIQUE: Multiplanar T1- and T2-weighted imaging were acquired on a 1.5
Tesla magnet including dynamic 3D imaging obtained prior to, during, and after
the uneventful intravenous administration of 18 cc of Multihance.
FINDINGS:
There are three renal arteries identified on the right side. The two upper
accessory renal arteries supply the upper pole of the right kidney (series 7,
image 17) and are patent. The larger third renal artery is patent in its
proximal and middle third; however, it comes to an abrupt cutoff at the
junction of the middle and distal one-third (series 7, image 20). No flow is
identified within this distally; however, there is some reconstitution of flow
noted just as it enters the renal pelvis (series 7, image 25) likely from
collateralization from the upper accessory renal arteries (series 753, image
74). A focal short dissection or embolus cannot be entirely excluded and
conventional angiogram is recommended. No intimal thickening or delayed
enhancement to suggest vasculitis. There is no vessel irregularity to sugguest
fibromuscular dysplasia. The right renal vein is patent.
Differential signal intensity noted in the interpolar and lower pole of the
right kidney in keeping with recent infarction. Region of cortical scarring
is identified in the upper pole of the right kidney which may represent a
region of old infarction or scarring from prior infection (series 3, image
15). The visualized liver, gallbladder, spleen, adrenal glands, and pancreas
are unremarkable. The left kidney is normal with a single renal artery
identified on the left side. There are no retroperitoneal masses or
adenopathy. No abnormally dilated or thickened small or large bowel loop in
the visualized abdomen. There is no free fluid.
Bone marrow signal is normal and there are no osseous lesions.
IMPRESSION:
There are three renal arteries identified on the right side. The upper two
accessory arteries supply the upper pole of the right kidney and are patent.
No flow is identified in the distal one-third of the lower renal artery and
may represent an embolus or focal dissection. Further confirmation with
conventional angiogram recommended. No intimal thickening to suggest
vasculitis or irregularity to sugguest fibromuscular dysplasia. The right
renal vein is patent.
Findings were discussed at the time of the finding by Dr. ___
with Dr. ___, pager ___ on ___ at 2:40 p.m.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: RIGHT FLANK PAIN
Diagnosed with ABDOMINAL PAIN OTHER SPECIED
temperature: 98.4
heartrate: 76.0
resprate: 18.0
o2sat: 100.0
sbp: 166.0
dbp: 112.0
level of pain: 6
level of acuity: 3.0 | ___ year old male with history of one episode of leukocytoclastic
vasculitis presenting with flank pain and found to have right
renal pole infarct.
# Right lower pole infarct in kidney: Renal ultrasound with
Doppler and CT w/ contrast showed right lower pole infarct in
kidney. Work-up so far has not revealed etiology of the renal
infarct, but there was no flow in the distal ___ of the lower
renal artery on MRA kidney. Normal TTE, Telemetry and CXR makes
cardiac etiology less likely for embolic source. Normal lipid
panel makes atherosclerotic etiology less likely. Negative ___
and ANCA and other rheumatalogic tests decrease, or do not favor
rheumatological etiology. However, his history of vasculitis
makes rheumatological etiologies such as Hypersensitivity
angiitis, Microscopic polyangiitis, and Lupus slightly more
possible. Although coag tests were normal, hypercoagulable
states remains on the differential and will be worked-up as an
outpatient.
# Leukocytoclastic vasculitis: Pt reports history of vasculitis
about ___ PTA when he has a rash/scar on his leg related to
this. Biopsy showed leukocytoclastic vasculitis and rash
resolved with Prednisone per Atrius records. The pt is not
currently on prednisone and does not remember the duration of
intial therapy. The location of the initial rash on his leg is
now a brawny scar. He reports persistent skin blotching in the
area, but no recurrence of the original rash.
# High blood pressure: elevated blood pressure in ED 166/112 and
pt reports being told that he had elevated blood pressure at a
remote office visit. Increase pain and damage to renal arteries
can contribute to increased blood pressure. He does not report
taking any medications to control his BP at home. Patient was
initially started on Captopril this admission, but was switched
to Amlodipine 5mg daily to protect remaining renal function. His
BPs were in the 130s/90s on discharge.
# Constipation: pt reports no bowel movement since 5days PTA. Pt
reports the only change was starting Percocet, Tamsulosin, and
Ondansetron on ___. He felt discomfort in the periumbilical
regional bilaterally. He did have bowel movemet prior to
discharge with considerable improvement in this discomfort.
Percocet was likely the cause of his constipation because it
resolved with the appropriate bowel regimen
Patient admitted without insurance or PCP. Both were attained
for patient in house. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ hypertension, asthma, diabetes, chronic renal insufficiency
presents with shortness of breath starting the morning of
admission. She felt tired the day before and has had a cough
productive of white sputum since ___. She has 3-pillow
orthopnea and PND particularly in the morning. She notes a
weight of 265lbs last ___. She otherwise had been feeling
well.
Per ED documentation, facility call-in noted a 30 lb weight gain
in the last month. Per nursing home documentation, Wt on ___ was
221.5lbs, on ___ was 253 lbs and on ___ was 253 lbs. Lasix
was increased to 40mg BID. On ___ metolazone was started QOD
at 3.5mg. Today, she was noted to be lethargic and had tremors.
She went down to the ___ on RA, NRB started at 5L, with
increases to 92 to 95. Metolazone was discontinued ___.
In the ED intial vitals were: 98.1 80 156/72 18 100% 8L. Labs
were significant for BNP 896, Cr 2.4, trop 0.02 -> 0.03, lactate
1.2. CXR was obtained, which showed cardiomegaly, pulmonary
edema with small bilateral pleural effusions. Patient was given
albuterol/ipratropium neb and IV lasix, to which she put out 1L.
Vitals on transfer: 98 72 133/50 22 98% Nasal Cannula.
On the floor pt was drowsy but arousable. She had no acute
complaints.
ROS: On review of systems, s/he denies any prior history of
stroke, TIA, deep venous thrombosis, pulmonary embolism, She
denies recent fevers, chills or rigors. She denies exertional
buttock or calf pain. All of the other review of systems were
negative.
Cardiac review of systems is notable for absence of chest pain,
palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
- CABG:
- PERCUTANEOUS CORONARY INTERVENTIONS:
- PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
Bilateral carotid stenosis
Aortic stenosis
Asthma
Obesity
s/p hysterectomy
Chronic renal insufficiency (1.5-1.7)
Obstructive sleep apnea (has a machine but doesn't use it due to
discomfort)
Urinary incontinence
Anemia
Social History:
___
Family History:
Sister - DM
Daughter - HTN
Daughter - ___
Physical ___:
ON ADMISSION
VS: 98.2 133/44 66 20 93 2L
General: NAD, drowsy but arousable
HEENT: Pupils small but equal. MMM, OP clear
Neck: No LAD
CV: RRR no appreciable murmurs/rubs/gallops
Lungs: Coarse rhonchi bilaterally with diffuse expiratory
wheezes
Abdomen: Soft, NT, ND. +BS
GU: Foley draining clear yellow urine
Ext: 2+ bilateral pedal edema R > L
ON DISCHARGE
VS: T98 BP144/54 P55 RR18 100RA
Wt: 109.7kg (109.6kg ___ (112.5kg ___ (117.3kg 2 days ago)
I/O since midnight: ___
I/O over 24H: ___, net negative 1.5L
GENERAL: Laying in bed, sleeping but easily arousable. Appears
comfortable. No acute distress.
NECK: Supple. JVP not elevated, although difficult to assess due
to body habitus.
CARDIAC: RRR, normal S1, S2. ___ mid systolic murmur at LUSB
with radiation to carotids. No S3, no S4.
LUNGS: Bibasilar crackles at the bases.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: Warm and well perfused. Pulses 2+. Trace-1+ pitting
edema in lower extremities.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
ON ADMISSION
___ 12:43PM BLOOD WBC-8.8 RBC-3.17* Hgb-8.7* Hct-29.8*
MCV-94 MCH-27.4 MCHC-29.1* RDW-19.1* Plt ___
___ 12:43PM BLOOD ___ PTT-33.6 ___
___ 12:43PM BLOOD Glucose-168* UreaN-59* Creat-2.4* Na-142
K-3.7 Cl-97 HCO3-33* AnGap-16
___ 12:43PM BLOOD CK-MB-2 proBNP-896*
___ 12:43PM BLOOD cTropnT-0.02*
___ 12:43PM BLOOD Calcium-8.9 Phos-4.0 Mg-1.9
ON DISCHARGE
___ 07:00AM BLOOD WBC-5.2 RBC-2.99* Hgb-8.3* Hct-28.2*
MCV-94 MCH-27.8 MCHC-29.4* RDW-17.8* Plt ___
___ 07:00AM BLOOD Glucose-106* UreaN-74* Creat-2.4* Na-142
K-4.9 Cl-96 HCO3-37* AnGap-14
___ 07:00AM BLOOD Calcium-9.4 Phos-4.6* Mg-2.3
STUDIES:
CXR:
Cardiomegaly, pulmonary edema with small bilateral pleural
effusions.
RIGHT LOWER EXTREMITY U/S
No evidence of deep vein thrombosis in the right lower
extremity.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Bisacodyl 10 mg PR Q72H
2. Fluticasone Propionate NASAL 1 SPRY NU DAILY
3. Omeprazole 20 mg PO BID
4. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
5. Atorvastatin 80 mg PO DAILY
6. Ascorbic Acid ___ mg PO DAILY
7. Doxazosin 1 mg PO HS
8. Ferrous Sulfate 325 mg PO DAILY
9. Acetaminophen 650 mg PO Q6H:PRN pain
10. fluticasone 110 mcg/actuation INHALATION 2 PUFFS BID
11. GlipiZIDE 5 mg PO DAILY
12. NIFEdipine CR 60 mg PO DAILY
13. Oxybutynin 5 mg PO DAILY
14. Lactulose 15 mL PO BID
15. Senna 2 TAB PO BID
16. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze
17. Aspirin 325 mg PO DAILY
18. Calcium Carbonate 500 mg PO TID
19. Fleet Enema ___AILY:PRN constipation
20. Guaifenesin ___ mL PO Q6H:PRN cough
21. Multivitamins 1 TAB PO DAILY
22. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
23. Sodium Chloride Nasal 1 SPRY NU DAILY
24. Allopurinol ___ mg PO DAILY
25. Colchicine 0.3 mg PO DAILY
26. Gabapentin 300 mg PO BID
27. Furosemide 40 mg PO BID
28. Ayr Saline Gel (sodium chloride-aloe ___ 1 spray nasal
daily: prn nasal dryness
29. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze
3. Allopurinol ___ mg PO DAILY
4. Bisacodyl ___AILY constipation
5. Calcium Carbonate 500 mg PO TID
6. Colchicine 0.3 mg PO DAILY
7. Doxazosin 1 mg PO HS
8. Ferrous Sulfate 325 mg PO DAILY
9. Fleet Enema ___AILY:PRN constipation
10. Fluticasone Propionate NASAL 1 SPRY NU DAILY
11. Gabapentin 300 mg PO Q24H
12. Lactulose 15 mL PO BID
13. Multivitamins 1 TAB PO DAILY
14. NIFEdipine CR 60 mg PO DAILY
15. Omeprazole 20 mg PO BID
16. Oxybutynin 5 mg PO DAILY
17. Senna 2 TAB PO BID
18. Sorbitol 70 30mL PO DAILY
19. Vitamin D 1000 UNIT PO DAILY
20. Isosorbide Dinitrate 30 mg PO TID
21. Polyethylene Glycol 17 g PO DAILY
22. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
23. Ayr Saline Gel (sodium chloride-aloe ___ 1 spray nasal
daily: prn nasal dryness
24. GlipiZIDE 5 mg PO DAILY
25. Guaifenesin ___ mL PO Q6H:PRN cough
26. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
27. Sodium Chloride Nasal 1 SPRY NU DAILY
28. Ascorbic Acid ___ mg PO DAILY
29. Aspirin 325 mg PO DAILY
30. Atorvastatin 80 mg PO DAILY
31. fluticasone 110 mcg/actuation INHALATION 2 PUFFS BID
32. Torsemide 30 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Acute diastolic CHF
Acute kidney injury
SECONDARY DIAGNOSIS:
Hypertension
Asthma
Hyperlipidemia
Diabetes Mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH PERFORMED ON ___
COMPARISON: Prior exam dated ___.
CLINICAL HISTORY: Hypoxemia, shortness of breath, question pneumonia.
FINDINGS: Portable AP upright chest radiograph provided. Cardiomegaly is
noted with diffuse pulmonary edema. Bilateral pleural effusions also noted
which are small in overall volume. No pneumothorax is seen. Mediastinal
contour is grossly unremarkable. Bony structures are intact.
IMPRESSION: Cardiomegaly, pulmonary edema with small bilateral pleural
effusions.
Radiology Report
HISTORY: Congestive heart failure and right greater than left lower leg
swelling. Assess for DVT.
TECHNIQUE: Grayscale, color and spectral Doppler evaluation was performed of
the right lower extremity veins.
COMPARISON: ___.
FINDINGS:
There is normal compressibility, flow and augmentation of the right common
femoral, proximal femoral, mid femoral, distal femoral, and popliteal veins.
Normal color flow and compressibility are demonstrated in the posterior tibial
and peroneal veins. There is normal respiratory variation in the common
femoral veins bilaterally.
IMPRESSION:
No evidence of deep vein thrombosis in the right lower extremity.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: DYSPNEA
Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC
temperature: 98.1
heartrate: 80.0
resprate: 18.0
o2sat: 100.0
sbp: 156.0
dbp: 72.0
level of pain: 0
level of acuity: 2.0 | ___ with PMH significant for HTN, DM, CKD who presents with
shortness of breath and 30lb weight gain over 1 month.
# Acute on chronic diastolic CHF exacerbation:
As evidenced by 30lb weight gain, dyspnea on exertion, elevated
JVP, and CXR findings. Recent echo (___) with preserved
ejection fraction (LVEF >55%), therefore CHF likely due to
diastolic dysfunction secondary to longstanding hypertension and
aortic stenosis. Etiology of acute exacerbation likely secondary
to dietary noncompliance, as patient reports eating salty foods.
Other etiologies include ACS vs worsening valvular disease. ACS
felt to be less likely given negative troponins and normal EKG.
Patient was aggressively diuresed with lasix 40mg IV BID. This
was later transitioned to torsemide 30mg daily when euvolemic.
She was also started on diamox 500mg daily x 3 days as she
developed contraction alkalosis. This is now improving. Patient
remained hemodynamically stable. Discharge weight 109.7kg.
# Chest pain:
Patient developed substernal, crushing chest pain on ___ while
at rest. SBP at that time was 170s. EKG without ST-changes, and
troponins remained flat. Chest pain improved with sublingual
nitrogen. Likely angina in the setting of hypertension. Other
diagnoses to consider include GERD as was also given maalox with
resolution of symptoms.
# ___: Baseline Cr appears to be 1.5-1.6. Cr on admission 2.4,
with BUN:Cr >20, indicating pre-renal etiology. ___ be secondary
to poor forward flow in setting of acute CHF. Cr remained stable
at 2.1-2.2. This may be her new baseline.
# HTN:
Continued doxazosin and nifedepine. She is not on a beta-blocker
due to asthma. Isosorbide dinitrate 30mg TID was started as
patient developed chest pain in the setting of elevated BP.
# Asthma:
Well controlled. She was continued on albuterol/ipratropium
nebulizers and fluticasone nasal inhaler.
# H/o Gout: Continued allopurinol, which was renally dosed.
# HLD: Continued atorvastatin.
# Anemia: H/H at baseline. Continued ferrous sulfate.
# DM: Oral hypoglycemics held. She was placed on humalog insulin
sliding scale.
# Bladder spasm: Continued oxybutynin.
# Constipation: Continued on outpatient bowel regime:
senna/colace, miralax, bisacodyl PR, lactulose, sorbitol, and
fleet enema PRN.
# HCM: Continued other home medications- ascorbic acid,
multivitamin, and aspirin. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
tetanus toxoid, adsorbed
Attending: ___.
Chief Complaint:
unsteadiness/weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with history of treated diffuse large B-cell
lymphoma in ___, s/p 6 cycles of R-CHOP, XRT to mesenteric
mass.
Patient recently noted to have relapsed disease, s/p 2 cycle of
ICE course c/b persistent emesis, lack of appetite,
deconditioning, depression, biliary obstruction s/p ERCP w/stent
x 2, proximal RTA causing hypophosphatemia, and FN. He was
recently admitted ___ to ___ for worsening abdominal pain and
C2 ICE. He presented to the ED with worsening unsteadiness and
weakness that started on ___. He had received transfusion of 2U
PRBCs on ___ and started to feel better. He also reports mild
dry cough and diffuse upper abdominal pain that is chronic and
stable.
Past Medical History:
Large B-cell lymphoma, hearing loss,
hypertension, obstructive sleep apnea.
Social History:
___
Family History:
No significant family history of malignancy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Temp: 99.1 HR: 124 BP: 126/82 Resp: 18 O(2)Sat: 100 Normal
Constitutional: chronically ill-appearing
HEENT: Pupils equal, round and reactive to light,
Normocephalic, atraumatic
Chest: Clear to auscultation
Cardiovascular: tachycardic
Abdominal: Soft, Nondistended, epigastric and left upper
quadrant tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: Warm and dry, No rash
Neuro: Speech fluent, steady gait. cranial nerve to 12
intact, muscle strength out of 5 in upper and lower
extremities
Psych: Normal mood, Normal mentation
DISCHARGE PHYSICAL EXAM:
GEN: NAD
VS: T 98.4 HR 92 BP 118/64 Resp 18 spO2 100%
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary LAD
CV: Regular, normal S1 and S2 no S3, S4, or murmurs
PULM: Clear to auscultation bilaterally
ABD: BS+, soft, non-tender, non-distended, no masses, no
hepatosplenomegaly
LIMBS: No edema, no inguinal adenopathy
SKIN: No rashes or skin breakdown
NEURO: Grossly nonfocal, alert and oriented
Pertinent Results:
___ 12:00AM BLOOD WBC-11.6* RBC-2.81* Hgb-8.2* Hct-22.5*
MCV-80* MCH-29.2 MCHC-36.5* RDW-17.5* Plt Ct-23*
___ 02:20PM BLOOD WBC-0.7*# RBC-2.34* Hgb-6.6* Hct-18.4*
MCV-78* MCH-28.2 MCHC-35.9* RDW-17.4* Plt ___
___ 12:00AM BLOOD Neuts-85* Bands-2 Lymphs-4* Monos-7 Eos-0
Baso-0 ___ Metas-2* Myelos-0
___ 02:20PM BLOOD Neuts-56 Bands-2 ___ Monos-13*
Eos-0 Baso-4* ___ Myelos-0
___ 12:00AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-1+ Spheroc-1+ Ovalocy-1+
Schisto-OCCASIONAL
___ 02:15PM BLOOD Hypochr-OCCASIONAL Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-OCCASIONAL Ovalocy-1+
___ 12:00AM BLOOD Glucose-118* UreaN-8 Creat-0.5 Na-138
K-5.5* Cl-107 HCO3-25 AnGap-12
___ 02:20PM BLOOD Glucose-183* UreaN-25* Creat-0.5 Na-136
K-3.1* Cl-103 HCO3-21* AnGap-15
___ 12:00AM BLOOD ALT-43* AST-31 LD(LDH)-239 AlkPhos-273*
TotBili-0.3
___ 02:20PM BLOOD ALT-26 AST-16 LD(LDH)-120 AlkPhos-298*
TotBili-0.6 DirBili-0.3 IndBili-0.3
___ 12:00AM BLOOD Albumin-3.1* Calcium-7.9* Phos-1.7*
Mg-1.9
___ 02:20PM BLOOD TotProt-5.4* Albumin-3.4* Globuln-2.0
Calcium-8.5 Phos-1.9* Mg-1.6
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO TID
2. LaMIVudine 100 mg PO DAILY
3. Lorazepam 0.5-1 mg PO Q4H:PRN nausea
4. Ondansetron 8 mg PO Q8H:PRN nausea
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
6. Docusate Sodium 100 mg PO BID
7. Polyethylene Glycol 17 g PO EVERY OTHER DAY constipation
8. Senna 8.6 mg PO BID
9. TraZODone 25 mg PO QHS:PRN insomnia
10. Atorvastatin 40 mg PO QAM
11. Gemfibrozil 600 mg PO DAILY
12. Metoclopramide 10 mg PO TID nausea
13. Simethicone 40-80 mg PO QID:PRN bloating
14. Filgrastim 300 mcg SC Q24H
15. Ranitidine 150 mg PO DAILY
16. Neutra-Phos 1 PKT PO BID
17. Ciprofloxacin HCl 500 mg PO Q12H
Discharge Medications:
1. Acyclovir 400 mg PO TID
2. Atorvastatin 40 mg PO QAM
3. Docusate Sodium 100 mg PO BID
4. LaMIVudine 100 mg PO DAILY
5. Lorazepam 0.5-1 mg PO Q4H:PRN nausea
6. Ondansetron 8 mg PO Q8H:PRN nausea
7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
8. Polyethylene Glycol 17 g PO EVERY OTHER DAY constipation
9. Ranitidine 150 mg PO DAILY
10. Senna 8.6 mg PO BID
11. Simethicone 40-80 mg PO QID:PRN bloating
12. TraZODone 25 mg PO QHS:PRN insomnia
13. Gemfibrozil 600 mg PO DAILY
14. Neutra-Phos 1 PKT PO BID
15. Metoclopramide 10 mg PO BID nausea
Discharge Disposition:
Home
Discharge Diagnosis:
lymphoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History of lymphoma on chemotherapy. Weakness. Evaluate for
pneumonia.
TECHNIQUE: Two views of chest are submitted.
COMPARISON: ___.
FINDINGS:
Right-sided central line tip is unchanged and is in the right atrium. The
cardiomediastinal silhouette is within normal limits. The lungs are clear.
There is no focal consolidation or pleural effusion. There is no
pneumothorax.
IMPRESSION:
No acute cardiopulmonary process. No interval change.
Radiology Report
INDICATION: NO_PO contrast; History: ___ with neutropenia, p/w vomitingNO_PO
contrast // eval for abd infection, typhilitis
TECHNIQUE: MDCT images were obtained from the lung bases to the pubic
symphysis after administration of IV Omnipaque contrast. Oral contrast was
not administered. Axial images were interpreted in conjunction with coronal
and sagittal reformats.
DLP: 353 mGy-cm
COMPARISON: CT abdomen pelvis of ___. MRCP of ___.
FINDINGS:
The visualized heart is normal. Lung bases are clear. No pericardial or
pleural effusion.
ABDOMEN:
The liver parenchyma is unremarkable without focal lesion. Moderate
pneumobilia is similar to prior and attests to patency of a CBD stent which
appears in stable position. Moderate gallbladder wall thickening is similar
to prior. Mild prominence of the pancreatic duct is stable. The pancreas is
otherwise unremarkable. The spleen and adrenal glands are normal. 6.9 cm
simple renal cyst in lower pole the right kidney is unchanged. There is
persistent cortical thinning of the lower pole of the left kidney.
The stomach is unremarkable. Wall thickening of the jejunum in the left upper
quadrant is similar to ___. The small and large bowel are otherwise
unremarkable. The appendix is normal.
Large infiltrative mesenteric soft tissue mass based in the left mid abdomen
is similar in size compared to ___ and extends into the
retroperitoneum. Calcifications are again noted inferiorly within the mass.
The lesions extends to encase the SMA, SMV, and main portal vein. There is
severe attenuation the SMV at the level of the mass, but this remains patent
distally. The portal and intra-abdominal systemic vasculature are otherwise
unremarkable.
Small but complex fat containing anterior abdominal wall hernia is stable. No
pneumoperitoneum. Interval decrease of intra-abdominal ascites with trace
remaining fluid along the paracolic gutters.
PELVIS: The bladder and terminal ureters are normal. No pelvic side-wall or
inguinal lymphadenopathy. Trace pelvic ascites. No inguinal hernia.
OSSEOUS STRUCTURES: No focal lytic or sclerotic lesion concerning for
malignancy. Stable sclerosis of the left sacrum.
IMPRESSION:
1. No evidence of intra-abdominal abscess or typhlitis.
2. Stable size of large infiltrative mesenteric soft tissue mass extending
from the left mid abdomen to the porta hepatis. The mass continues to encase
the SMA and main portal vein, which are patent. The SMV is markedly
attenuated at the level of the mass but distal branches remain opacified.
3. Jejunal wall thickening in the left upper quadrant, not significantly
changed since ___. Given proximity to the infiltrative mesenteric
mass, this may reflect lymphatic congestion from tumor involvement, causing
fold thickening and edema in proximal small bowel, but probably unchanged.
4. Patent CBD stent with stable pneumobilia.
Radiology Report
EXAMINATION: HEAD CT
INDICATION: Pancytopenia on chemotherapy for lymphoma, presenting with
unsteadiness.
TECHNIQUE: Non-contrast head CT.
DOSE: 935 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of intracranial hemorrhage. There is no mass effect,
hydrocephalus or shift of the normally midline structures. Gray-white matter
distinction appears preserved. Cavernous carotid vascular calcifications are
noted. Surrounding soft tissue structures are unremarkable. There is no
evidence of fracture or bone destruction. Minimal aerosolized secretion is
noted in a posterior right ethmoid air cell. Mastoid air cells appear clear.
IMPRESSION:
No evidence of acute intracranial process.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by WALK IN
Chief complaint: Weakness, Nausea
Diagnosed with NEUTROPENIA, UNSPECIFIED , FEVER, UNSPECIFIED, OTHER MALAISE AND FATIGUE
temperature: 99.1
heartrate: 124.0
resprate: 18.0
o2sat: 100.0
sbp: 126.0
dbp: 82.0
level of pain: 3
level of acuity: 2.0 | Mr ___ is a ___ yr old male with hx of
DLBCL s/p 6C of R-CHOP, XRT to meseneteric mass in ___
presenting with new onset abdominal pain, CT scan consistent
with widespread lymphadenopathy and mesenteric mass, exploratory
laparotomy consistent with recurrent lymphoma, now s/p ERCP with
pancreatic stenting and C2 ICE. Admitted for weakness and
unsteadiness while counts at nadir.
C2D16 ICE
#Weakness/unsteadiness: no true fever documented but with
neutropenia concern for infection. initaited vanc/cefe
empirically, d/c after neg cultures >48hrs
-b culture NTD, u culture contaminate, repeat PND
-CT head neg, CT torso stable, no acute source of infection
found
-symptoms improved with count recovery, IVF
# Abdominal pain: Improved. Was of unclear etiology esp given
extensive w/u last admission, had ERCP w/ stent patent on ___,
no ulcers on endoscopy. No signs of bowel obstruction. PET
improved therefore unlikely secondary to disease. abd u/s neg
for cholecystitis. Drug rxn vs intermittent, partial
obstruction?
- continue oxycodone +/- simethicone, as responding well to
these
# Relpased DLBCL: s/p C2 of ICE c/b FN and RTA from C1. PET
stable to improved s/p C1 of ICE. Plan to restage and screen for
auto with recovery after this most recent cycle.
-PET/echo/PFTs outpatient ___, f/u for labs ___ and to see Dr.
___ on ___
# Fanconi's syndrome/RTA history: monitor for recurrence with
most recent cycle of chemo. Type 1 proximal renal tubular
acidosis secondary to ___ s/p C1. Renal consulted last
admission, improved w/ po phos bid and less aggressive IV phos
repletion (<1 or symptomatic).
- lytes stable this AM
- aggressive lyte sliding scales prn, check lytes BID only if
deficiencies noted on routine labs
# Hypophosphetemia: likely some degree of fanconis syndrome as
above, replete prn, repeat lytes from afternoon PND
#Hypokalemia: as above secondary to RTA, replete prn
# HBV history: on lamivudine suppression post rituxan, VL in
___ neg, recheck in ___ neg
# Gastroparesis: Prev requiring TPN/reglan. IV reglan prn for
now. PO intake has now improved
- Encouraging po intake
- antiemetics prn
# Infectious prophylaxis:
- HSV/VZV: acyclovir |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo M with CAD s/p stent to RCA in ___, AAA, HTN, HLD,
pre-diabetes, bipolar d/o, CKD Stage 4, presents with chest
pain. The patient reports feeling chest discomfort yesterday
while doing his taxes. He had a total of two episodes yesterday
afternoon. He treated with SL NTG 2 tabs x 3. Has been CP free
since before dinner yesterday. He cannot describe the pain well,
but notes that it was similar to the "time he had angioplasty".
It was not associated with any SOB, nausea or diaphoresis. There
was no radiation from the substernal area.
He is very active and denies any recent CP or dyspnea on
exertion. His last ETT was ___. Though he had no chest pain
today, he felt he should come in and get it checked out and
possibly get a stress test.
In the ED, initial vitals: 98 67 121/43 18 98%
- he was given ASA 81 x 3
- he had an EKG that was NSR with no ischemic changes
- Trops neg x 2
- CXR showed
- follow-up CT showed a large RLL mass c/f malignancy.
He was therefore admitted for further work-up.
ROS:
- reports weight loss of ~ 30lbs over last couple years, but
intentional, no night sweats, fever or chills.
- denies cough, sputum or hemoptysis. No SOB
All other systems reviewed and were negative
Past Medical History:
CAD
- s/p cardiac catheterization in ___ with PCI to the RCA.
Last cardiac catheterization in ___, which revealed no flow
limiting disease, but the distal LAD was found to be diffusely
diseased.
Hyperlipidemia
Bipolar disorder, seen by psychiatrist every 4 months at the ___
Tremor
Parkinsonism
Impaired glucose tolerance
Cluster headaches
Chronic renal failure, baseline creatinine 2.5-3.6, seen by Dr.
___
Social History:
___
Family History:
mother died of MI @ ___, father died of MI @ ___
Physical Exam:
Admission Physical Exam
Vitals- 97.0 151/74 89 20 100%/RA
General- Alert, oriented, no acute distress
HEENT- PERRL, Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- CTAB no wheezes, rales, rhonchi
CV- RRR, Nl S1, S2, No MRG
Abdomen- soft, NT/ND bowel sounds present, no rebound
tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
- left upper arm fistula with palpable thrill and bruit
Neuro- CNs2-12 intact, motor function grossly normal
LABS: see below
Discharge Physical Exam
Vitals- 97.6 147/56 73 18 98%/RA
General- Alert, oriented, no acute distress
HEENT- PERRL, Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- CTAB no wheezes, rales, rhonchi
CV- RRR, Nl S1, S2, No MRG
Abdomen- soft, NT/ND bowel sounds present, no rebound
tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
- left upper arm fistula with palpable thrill and bruit
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
--------------------
Pertinent Labs
--------------------
___ 11:40AM BLOOD WBC-6.7 RBC-3.49* Hgb-10.1* Hct-32.4*
MCV-93 MCH-29.1 MCHC-31.3 RDW-14.3 Plt ___
___ 07:40AM BLOOD ___ PTT-43.2* ___
___ 07:40AM BLOOD Ret Aut-1.5
___ 11:40AM BLOOD Glucose-78 UreaN-42* Creat-3.6* Na-138
K-5.7* Cl-108 HCO3-20* AnGap-16
___ 07:40AM BLOOD ALT-9 AST-17 LD(LDH)-198 AlkPhos-76
TotBili-0.2
___ 07:40AM BLOOD Albumin-3.4* Calcium-9.0 Phos-3.8 Mg-2.5
Iron-43*
___ 07:40AM BLOOD calTIBC-283 Ferritn-192 TRF-218
___ 11:40AM BLOOD cTropnT-<0.01
___ 05:25PM BLOOD cTropnT-<0.01
___ 07:40AM BLOOD cTropnT-<0.01
Imaging, Other Studies
EKG: Sinus rhythm. Normal ECG. Compared to the previous tracing
of ___ the rate has increased. Otherwise, no diagnostic
interim change.
**
CXR (___)
There is a prominent opacity projecting over the superior right
lower lobe, new from ___. CT is recommended for further
evaluation. Differential diagnosis includes mass or infection.
There may be minimal pulmonary edema as evidenced by prominence
of
interstitium and central vessels. The cardiac silhouette is
mildly enlarged and increased slightly in size from ___.
Blunting of the posterior diaphragmatic sulci is unchanged and
may reflect scarring, though, small bilateral pleural effusions
cannot be entirely excluded. No pneumothorax. The appearance of
the mediastinum is unchanged.
**
Chest CT w/o contrast ___:
1. Right lower lobe mass with a central necrotic component
concerning for
malignancy. Infection cannot be excluded.
2. Paraseptal and centrilobular emphysema
**
Exercise Stress (___):
This was an inactive ___ year old DM2 man with CAD
(stents ___, HTN, HLD, AAA repair, stage IV CKD and remote
smoking and
ETOH, who was referred to the lab from the inpatient floor for
an
evaluation of chest discomforts. He exercised for 7.0 minutes of
a
Gervino protocol ___ METs) and requested to stop due to leg
fatigue and
mild shortness of breath. This represents a fair functional
capacity for
his age. He denied any chest, arm, neck or back discomforts,
inappropriate shortness of breath, palpitations or symptoms of
exercise
intolerance throughout the study. There were no changes in ST
segments
or T waves noted during exercise or in recovery. The rhythm was
sinus
with one single APB and one single PVC seen in early recovery.
The heart
rate and blood pressure responses were mildy blunted (beta
blockade) to
exercise.
IMPRESSION: No ischemic ECG changes with no anginal type
symptoms to
achieved workload. Mildly blunted hemodynamic response to
exercise. Fair
functional capacity demonstrated. Echo report sent separately.
**
Stress ECHO (___)
This was an inactive ___ year old DM2 man with CAD
(stents ___, HTN, HLD, AAA repair, stage IV CKD and remote
smoking and
ETOH, who was referred to the lab from the inpatient floor for
an
evaluation of chest discomforts. He exercised for 7.0 minutes of
a
Gervino protocol ___ METs) and requested to stop due to leg
fatigue and
mild shortness of breath. This represents a fair functional
capacity for
his age. He denied any chest, arm, neck or back discomforts,
inappropriate shortness of breath, palpitations or symptoms of
exercise
intolerance throughout the study. There were no changes in ST
segments
or T waves noted during exercise or in recovery. The rhythm was
sinus
with one single APB and one single PVC seen in early recovery.
The heart
rate and blood pressure responses were mildy blunted (beta
blockade) to
exercise.
IMPRESSION: No ischemic ECG changes with no anginal type
symptoms to
achieved workload. Mildly blunted hemodynamic response to
exercise. Fair
functional capacity demonstrated. Echo report sent separately.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Calcitriol 0.25 mcg PO DAILY
3. Divalproex (DELayed Release) 1000 mg PO HS
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Propranolol 10 mg PO DAILY:PRN tremor
6. QUEtiapine Fumarate 100 mg PO QHS
7. Rosuvastatin Calcium 20 mg PO DAILY
8. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Calcitriol 0.25 mcg PO DAILY
4. Divalproex (DELayed Release) 1000 mg PO HS
5. Metoprolol Succinate XL 50 mg PO DAILY
6. QUEtiapine Fumarate 100 mg PO QHS
7. Rosuvastatin Calcium 20 mg PO DAILY
8. Propranolol 10 mg PO DAILY:PRN tremor
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnosis: chest pain
lung mass
secondary diagnosis: CAD
HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Chest pain with history of aortic aneurysm and coronary artery
disease, now with chest pain.
COMPARISON: Chest radiograph ___.
FRONTAL AND LATERAL VIEWS OF THE CHEST: There is a prominent opacity
projecting over the superior right lower lobe, new from ___. CT is
recommended for further evaluation. Differential diagnosis includes mass or
infection.
There may be minimal pulmonary edema as evidenced by prominence of
interstitium and central vessels. The cardiac silhouette is mildly enlarged
and increased slightly in size from ___. Blunting of the posterior
diaphragmatic sulci is unchanged and may reflect scarring, though, small
bilateral pleural effusions cannot be entirely excluded. No pneumothorax.
The appearance of the mediastinum is unchanged.
These findings were discussed with Dr. ___ by Dr. ___ at 2:20 p.m. on
___ by telephone five minutes after discovery.
Radiology Report
INDICATION: Posterior mediastinal opacity seen on chest x-ray.
COMPARISON: Chest radiograph ___.
TECHNIQUE: Axial MDCT images were taken through the chest without the
administration of IV contrast. Coronal and sagittal reformats as well as thin
section lung algorithm images were examined.
DLP: 559.57 mGy-cm.
CTDIvol: 16.89 mGy.
FINDINGS: A 5.3 x 3.8 cm mass is present in the posterior aspect of the
superior segment of the right lower lobe, corresponding to abnormality seen on
the same day chest radiograph. This lesion has a subtle hypodense center,
concerning for necrosis. There is adjacent pleural reaction with a small
pleural effusion. No other concerning lung nodules or masses are seen.
Paraseptal and centrilobular emphysematous changes are seen.
There is no pleural effusion. Scattered mediastinal lymph nodes are noted in
the AP window, pretracheal, and precarinal locations, which are not
pathologically enlarged. The largest lymph node is at the subcarinal station,
measuring 9 mm in the short axis. Aortic valve and coronary artery
calcifications are noted.
The upper abdomen is unremarkable. Specifically, no lesion is seen in the
visualized portions of the adrenal glands. No suspicious lesions are seen in
visualized osseous structures. Multilevel degenerative changes are seen.
IMPRESSION:
1. Right lower lobe mass with a central necrotic component concerning for
malignancy. Infection cannot be excluded.
2. Paraseptal and centrilobular emphysema.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Chest pain
Diagnosed with CHEST PAIN NOS
temperature: 98.0
heartrate: 67.0
resprate: 18.0
o2sat: 98.0
sbp: 121.0
dbp: 43.0
level of pain: 0
level of acuity: 2.0 | ___ yo M with CAD s/p stent to RCA in ___, AAA, HTN, HLD,
pre-diabetes, bipolar d/o, CKD Stage 4, presents with chest
pain. The patient reports feeling chest discomfort yesterday
while doing his taxes.
# Chest pain - He was ruled out for ACS with three serial
troponins that were negative. His EKG showed no signs of
ischemia. He had an exercise stress ECHO that also showed no
signs of ischemia. He remained chest pain free his entire
admission. There were no changes made to his medications.
# Lung mass - During his work-up, he had a CXR that showed a
right posterior mediastinal opacity. A subsequent Chest CT
showed a 5.3 x 3.8 cm mass is present in the superior segment of
the right lower lobe. We recommended a diagnostic biospy, but
the patient wished to pursue further work-up at the ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
S/p Fall
Major Surgical or Invasive Procedure:
Placement of RIJ temporary HD catheter ___
Temporary Dialysis Catheter removed ___
History of Present Illness:
___ AF with Coumadin, recent h/o Cdiff, ESRD s/p LURT ___,
RAS s/p stenting, HTN, HL, DM2, carotid stenosis, PVD, prostate
CA s/p XRT, SCC of skin, CAD s/p DESx 2 to proximal-LAD ___,
s/p ___ 2 to mid-LAD ___ who fell from flight of stairs, +
dizziness prior to fall, + LOC, found down by wife, with Right
rib fractures.
Past Medical History:
Past Medical History:
Cardiovascular Issues:
1. Coronary artery disease (s/p ___ 2 to proximal-LAD ___,
s/p ___ 2 to mid-LAD ___.
2. Diastolic congestive heart failure.
3. Hypertension.
4. Dyslipidemia.
5. Claudication/Aorto iliac occlusive disease (ABI 0.88/0.76).
6. Morbid obesity.
7. diabetes
8 Obstructive sleep apnea
9. C diff enterocolitis
10 renal artery stenosis
11. s/p kidney transplant with CKD stage IV transplanted kidney
12. Klepbsiella UTI
13. Prostate cancer
14. Hyperparathyroidism
Social History:
___
Family History:
Father: ___, gout
Mother: ___, ESRD on hemodialysis
Brothers: Lung cancer and CAD
His father died at age ___ of dementia. His mother died at age
___
of heart failure. She also had a history of stroke and
hypertension. He has two brothers, two sisters, and no
children.
One of his brothers had an MI in his late ___. There is no
family
history notable for hyperlipidemia, diabetes,or sudden cardiac
death.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
===========================
VS: 98.5 143 / 66 75 16 93 RA
GENERAL: WNWD male in NAD
HEENT: pupils miotic, reactive, EOMI, anicteric sclera, pink
conjunctiva, MMM
NECK: bruising/small hematoma right neck, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB anteriorly, symmetrical chest rise anteriorly, pain
on deep inspiration
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: WWP, no edema, moving all 4 extremities with
purpose
PHYSICAL EXAM ON DISCHARGE:
===========================
VS: ___ 0527 Temp: 98.3 PO BP: 118/58 HR: 67 RR: 18 O2 sat:
96% O2 delivery: Ra
GENERAL: NAD, pleasant
HEENT: MMM, clear OP.
NECK: RIJ removed, no bleeding or skin changes surrounding the
insertion site, no JVD
HEART: RRR, S1/S2, no mrg
LUNGS: CTABL
ABDOMEN: soft, NDNT, +BS
EXTREMITIES: WWP, no edema, moving all 4 extremities with
purpose
Pertinent Results:
LAB RESULTS ON ADMISSION:
=========================
___ 05:24AM BLOOD WBC-12.8* RBC-4.11* Hgb-11.3* Hct-35.5*
MCV-86 MCH-27.5 MCHC-31.8* RDW-15.6* RDWSD-48.9* Plt ___
___ 07:55AM BLOOD Neuts-87.9* Lymphs-5.1* Monos-4.8*
Eos-1.5 Baso-0.3 Im ___ AbsNeut-12.18* AbsLymp-0.71*
AbsMono-0.67 AbsEos-0.21 AbsBaso-0.04
___ 05:24AM BLOOD ___ PTT-18.7* ___
___ 05:24AM BLOOD UreaN-42* Creat-1.9*
___ 07:55AM BLOOD ALT-8 AST-17 LD(LDH)-331* AlkPhos-108
TotBili-0.3
___ 05:24AM BLOOD Lipase-35
___ 05:24AM BLOOD cTropnT-0.08*
___ 07:50AM BLOOD Calcium-8.8 Phos-4.7* Mg-1.4*
___ 05:24AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-11
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
PERTINENT INTERVAL LABS:
========================
___ 06:26AM BLOOD Glucose-93 UreaN-86* Creat-6.1* Na-139
K-5.1 Cl-94* HCO3-23 AnGap-22*
___ 07:15PM BLOOD Glucose-121* UreaN-75* Creat-5.9* Na-135
K-5.4* Cl-92* HCO3-23 AnGap-20*
___ 06:26AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
IMAGING:
========
CT HEAD WITHOUT CONTRAST ___
1. No acute intracranial abnormality on noncontrast head CT.
Specifically no large territory infarct or intracranial
hemorrhage.
2. Left frontal subgaleal hematoma without underlying acute
displaced
calvarial fracture.
3. Additional findings as described above.
CT C-SPINE WITHOUT CONTRAST ___
1. No acute intracranial abnormality on noncontrast head CT.
Specifically no large territory infarct or intracranial
hemorrhage.
2. Left frontal subgaleal hematoma without underlying acute
displaced
calvarial fracture.
3. Additional findings as described above.
CT CHEST ABDOMEN PELVIS WITH CONSTRAT ___
1. Ground-glass opacity in the right lung base adjacent to right
posterior rib fractures may represent pulmonary contusion.
2. Small right pneumothorax and minimal pneumomediastinum.
3. Moderate subcutaneous emphysema overlying the right
posterolateral lower chest and upper abdomen.
4. Multiple right-sided rib fractures: Right posterior ninth,
tenth, eleventh, and twelfth rib fractures are fractured at 2
sites along each rib and demonstrate mild-to-moderate
displacement. A right posterolateral eighth rib fracture is also
noted.
5. Minimally displaced fracture of the right L2 transverse
process.
6. 5mm hypodensity in the body/tail of the pancreas may
represent IPMN.
7. Nonspecific nodularity of the left adrenal gland.
8. Mild pelvic free fluid, nonspecific.
9. Moderate pericardial effusion.
FINGER X RAY L ___
No fracture or dislocation detected involving the left fourth
digit.
Degenerative changes and soft tissue swelling noted.
If symptoms persist, consider followup radiographs in ___ days
to assess for changes about an occult bony injury.
FEMUR X RAY LEFT ___ffusion.
RENAL TRANSPLANT ULTRASOUND ___
1. Elevated intrarenal artery resistive indices throughout the
transplant
kidney with parvus tardus waveforms and absent diastolic flow,
raising the
possibility of transplant rejection. The transplant renal
artery and vein are patent with normal flow.
2. Mild hydronephrosis within the transplant kidney.
RENAL TRANSPLANT ULTRASOUND ___
1. Patent transplant vasculature however diastolic flow is
absent in all of the arteries including the main renal artery.
2. Mild fullness of the renal pelvis is noted with focal
caliectasis at the upper pole.
TTE ___
---------------
There is mild symmetric left ventricular hypertrophy with normal
cavity size and global systolic function (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets are mildly thickened (?#). The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is a small circumferential without
echocardiographic signs of tamponade.
IMPRESSION: Small circumferential pericardial effusion without
echocardiographic evidence for tamponade physiology. Mild
symmetric left ventricular hypertrophy with preserved global
biventricular systolic function. Mild mitral regurgitation.
CT HEAD WITHOUT CONTRAST ___
Probably late subacute or chronic small cortical infarct right
parietal lobe. Mild-to-moderate chronic small vessel ischemic
changes. Generalized brain parenchymal atrophy.
CXR ___ (prior to placement of R IJ temporary HD
catheter)
---------------
Previous moderate cardiomegaly has improved and there is no
longer any
pulmonary edema. Heavy calcification of the mitral annulus is
noted,
sometimes responsible for mitral regurgitation or rhythm
disturbances. There is no appreciable pleural effusion or
pneumothorax. Opacification at the right lung base is probably
atelectasis, but there is no lobar collapse or consolidation.
Slight leftward displacement of the trachea just above the
thoracic inlet
could be due to an enlarged thyroid. If patient has had a
recent attempt at right internal jugular line insertion, it
could be in indication of hematoma. Clinical correlation and
follow-up advised.
DISCHARGE LABS
===============
___ 06:08AM BLOOD WBC-9.4 RBC-3.10* Hgb-8.4* Hct-27.1*
MCV-87 MCH-27.1 MCHC-31.0* RDW-15.9* RDWSD-49.9* Plt ___
___ 10:52AM BLOOD ___
___ 06:08AM BLOOD Plt ___
___ 06:08AM BLOOD Glucose-209* UreaN-44* Creat-1.5* Na-139
K-4.2 Cl-100 HCO3-24 AnGap-15
___ 06:08AM BLOOD Calcium-8.0* Phos-2.5* Mg-1.9
___ 06:08AM BLOOD tacroFK-2.5*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Mycophenolate Mofetil 250 mg PO BID
5. PredniSONE 5 mg PO DAILY
6. Tacrolimus 2 mg PO Q12H
7. Torsemide 100 mg PO DAILY
8. Warfarin 1.5 mg PO DAILY16
9. Vancomycin Oral Liquid ___ mg PO DAILY
10. Allopurinol ___ mg PO DAILY
11. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
12. Pantoprazole 40 mg PO Q24H
13. Potassium Chloride 20 mEq PO DAILY
14. Pravastatin 40 mg PO QPM
15. Tamsulosin 0.4 mg PO QHS
16. Vitamin D ___ UNIT PO 1X/WEEK (___)
17. Carvedilol 37.5 mg PO BID
Discharge Medications:
1. Ciprofloxacin HCl 250 mg PO Q12H Duration: 9 Days
End date ___
2. Glargine 35 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
3. Allopurinol ___ mg PO DAILY
4. Carvedilol 25 mg PO BID
5. Aspirin 81 mg PO DAILY
6. Clopidogrel 75 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Mycophenolate Mofetil 250 mg PO BID
9. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
10. Pantoprazole 40 mg PO Q24H
11. Pravastatin 40 mg PO QPM
12. PredniSONE 5 mg PO DAILY
13. Tacrolimus 2 mg PO Q12H
14. Tamsulosin 0.4 mg PO QHS
15. Vancomycin Oral Liquid ___ mg PO DAILY
16. Vitamin D ___ UNIT PO 1X/WEEK (___)
17. Warfarin 1.5 mg PO DAILY16
18. HELD- Potassium Chloride 20 mEq PO DAILY This medication
was held. Do not restart Potassium Chloride until cleared by
your primary care physician.
19. HELD- Torsemide 100 mg PO DAILY This medication was held.
Do not restart Torsemide until cleared by primary care
physician.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Contrast induced nephropathy/Acute tubular necrosis
Complicated urinary tract infection in transplanted kidney
Toxic-metabolic encephalopathy due to the above
Fall c/b right posterolateral eighth, posterior ninth, tenth,
eleventh, and twelfth rib fractures, L2 transverse process
fracture, and left frontal subgaleal hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with fall from flight of stairs// trauma
TECHNIQUE: Single frontal view of the chest
COMPARISON: None.
FINDINGS:
Moderate cardiomegaly. The lungs are clear. There is no pneumothorax or
pleural effusion. No evidence of acute rib fractures.
IMPRESSION:
Moderate cardiomegaly. Please review chest CT obtained on ___ at
17:49 for pre size assessment of the right rib fractures and small right
pneumothorax.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with fall// trauma
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 18.0 s, 19.3 cm; CTDIvol = 46.8 mGy (Head) DLP =
903.1 mGy-cm.
Total DLP (Head) = 903 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no intra or extra-axial mass effect, acute hemorrhage or large
territorial infarct. There are periventricular and subcortical white matter
hypodensities, which are nonspecific, but compatible with chronic
microangiopathy in a patient of this age. More prominent hypodensity of the
right parietal occipital lobe (series 2, image 20) and left frontal lobe
(series 2, image 19) likely represents sequela of prior infarcts. The sulci,
ventricles and cisterns are within expected limits for the patient's mild
senescent related global cerebral volume loss. Left frontal subgaleal
hematoma measuring approximately 5 mm in greatest thickness is identified
without underlying calvarial fracture. The visualized paranasal sinuses are
essentially clear. The mastoid air cells middle ears are well pneumatized and
clear. The orbits are unremarkable.
IMPRESSION:
1. No acute intracranial abnormality on noncontrast head CT. Specifically no
large territory infarct or intracranial hemorrhage.
2. Left frontal subgaleal hematoma without underlying acute displaced
calvarial fracture.
3. Additional findings as described above.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: History: ___ with fall// trauma
TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.0 s, 19.5 cm; CTDIvol = 22.5 mGy (Body) DLP = 439.8
mGy-cm.
Total DLP (Body) = 440 mGy-cm.
COMPARISON: None.
FINDINGS:
Cervical alignment is anatomic.. No acute fractures. Well corticated
fragment of the anterior C3 endplate is compatible with chronic degenerative
change. Mild anterior wedge shape of C4 with superior endplate Schmorl's node
and subcortical cystic change is also compatible with chronic degenerative
change. The remainder of the vertebral body heights are preserved. In
addition, congenital posterior element fusion abnormality of the C6 vertebral
body and congenital abnormality of the C5 and C6 facets (series 602, image 25)
is identified. Anterior to themild degenerative changes worse at C3-4.There
is no evidence of high-grade spinal canal or neural foraminal narrowing.There
is no prevertebral soft tissue swelling.
There is no cervical lymphadenopathy by size criteria. The right thyroid is
asymmetrically enlarged relative to the left without focal lesion. The
visualized aerodigestive tract is unremarkable. Incidental note is made of a
1.3 x 0.8 cm left suboccipital intramuscular lipoma (series 2, image 60).
IMPRESSION:
1. No evidence of acute fracture or traumatic malalignment.
2. Mild anterior wedge shape of C3 is felt to be almost certainly
degenerative.
3. Additional findings as described above.
Radiology Report
EXAMINATION: CT torso
INDICATION: History: ___ with fall from flight of stairs// trauma
TECHNIQUE: MDCT axial images were acquired through the chest, abdomen and
pelvis following intravenous contrast administration with split bolus
technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 9.7 s, 76.6 cm; CTDIvol = 20.6 mGy (Body) DLP =
1,579.2 mGy-cm.
Total DLP (Body) = 1,579 mGy-cm.
COMPARISON: None.
FINDINGS:
CHEST:
HEART AND VASCULATURE: The thoracic aorta is normal in caliber without
evidence of acute injury. The heart is moderately large. Dense mitral valve
calcifications are noted. Coronary artery calcifications are noted. A
moderate pericardial effusion is present.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. Minimal foci of air along the right mediastinum
compatible with pneumomediastinum. Along the lower right chest posterolateral
chest there is subcutaneous emphysema overlying multiple displaced rib
fractures.
PLEURAL SPACES: A small anterior right pneumothorax is noted. There is no
pleural effusion.
LUNGS/AIRWAYS: Mild ground-glass opacification in the right lung base adjacent
to right posterior rib fractures may represent pulmonary contusion. The
airways are patent to the level of the segmental bronchi bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesion or laceration. There is no evidence of
intrahepatic or extrahepatic biliary dilatation. The gallbladder is within
normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without pancreatic
ductal dilatation. A 1.0 cm hypodensity in the body/tail of the pancreas is
noted (601:57). There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesion or laceration.
ADRENALS: The right adrenal gland is normal in size and shape. Nonspecific
nodularity of the left adrenal gland.
URINARY: Bilateral kidneys are atrophic. A right hemipelvis kidney transplant
is noted. Cortical thinning along superior aspect of renal transplant may
reflect prior infarct. Subcentimeter hypodensities in the kidneys are too
small to characterize. There is no evidence of hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. Diverticulosis of
the sigmoid colon is noted, without evidence of wall thickening and fat
stranding. The appendix is normal. There is no evidence of mesenteric
injury.
There is no free fluid or free air in the abdomen.
PELVIS:
The urinary bladder and distal ureters are unremarkable. There is trace free
fluid in the pelvis.
REPRODUCTIVE ORGANS: Brachytherapy seeds are noted within the prostate.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm or retroperitoneal hematoma.
Mild atherosclerotic disease is noted.
BONES: Multiple right-sided rib fractures are noted:
A right posterolateral eighth rib fracture is noted.
The right ninth rib fracture is nondisplaced at the costovertebral junction
and significantly displaced posterolaterally.
The right tenth rib fracture is nondisplaced at the costovertebral junction
and significantly displaced posterolaterally.
The right eleventh rib fracture is minimally displaced at the costovertebral
junction and significantly displaced with overlap of posterolaterally.
The right twelfth rib fracture is nondisplaced at the costovertebral junction
and nondisplaced posteriorly.
There is minimally displaced fracture of the right L2 transverse process.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Ground-glass opacity in the right lung base adjacent to right posterior rib
fractures may represent pulmonary contusion.
2. Small right pneumothorax and minimal pneumomediastinum.
3. Moderate subcutaneous emphysema overlying the right posterolateral lower
chest and upper abdomen.
4. Multiple right-sided rib fractures: Right posterior ninth, tenth, eleventh,
and twelfth rib fractures are fractured at 2 sites along each rib and
demonstrate mild-to-moderate displacement. A right posterolateral eighth rib
fracture is also noted.
5. Minimally displaced fracture of the right L2 transverse process.
6. 5mm hypodensity in the body/tail of the pancreas may represent IPMN.
7. Nonspecific nodularity of the left adrenal gland.
8. Mild pelvic free fluid, nonspecific.
9. Moderate pericardial effusion.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with multiple right rib fx, small apical ptx//
interval change
IMPRESSION:
No previous images. Although very difficult to see, there may be a small
residual right apical pneumothorax in this patient with multiple rib fractures
that are difficult to detect on the frontal radiograph.
Cardiac silhouette is at the upper limits of normal or mildly enlarged. No
vascular congestion or acute focal pneumonia.
Radiology Report
INDICATION: ___ year old M s/p fall down stairs w/ left upper leg and left
knee pain// r/o fx
COMPARISON: None
FINDINGS:
There is no fracture. There is no dislocation. There may be a trace joint
effusion. Contrast is seen within the bladder. Clips are seen in the lower
pelvis. There is a of op the at the insertion of the quadriceps tendon.
Vascular calcification is noted.
IMPRESSION:
Possible trace effusion.
Radiology Report
EXAMINATION: FINGER(S),2+VIEWS LEFT
INDICATION: ___ year old M s/p fall down stairs w/ left ring finger bruising
and swelling// r/o fx
TECHNIQUE: Left ring finger three views.
COMPARISON: None.
FINDINGS:
No acute fracture or dislocation detected in the left ring finger (fourth
digit), from the level of the distal metacarpal through the distal tuft.
There is narrowing of the PIP joint, likely reflecting degenerative changes.
Allowing for this, the joints remain congruent. Mild soft tissue swelling is
likely present. No soft tissue calcification or radiopaque foreign body
detected. No bone erosion identified.
IMPRESSION:
No fracture or dislocation detected involving the left fourth digit.
Degenerative changes and soft tissue swelling noted.
If symptoms persist, consider followup radiographs in ___ days to assess for
changes about an occult bony injury.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
IMPRESSION:
In comparison with the study of ___, there is no convincing evidence of
right apical pneumothorax. Continued low lung volumes with the cardiac
silhouette at the upper limits of normal or mildly enlarged. There is mild
indistinctness of pulmonary vessels, which could reflect some mild elevation
in pulmonary venous pressure.
Radiology Report
EXAMINATION: RENAL TRANSPLANT U.S.
INDICATION: ___ year old man with ESRD s/p transplant in ___ with ___//
?transplant function
TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images
of the renal transplant were obtained.
COMPARISON: None.
FINDINGS:
There is mild right iliac fossa renal transplant hydronephrosis. No
nephrolithiasis or focal lesion identified. No focal or diffuse cortical
thinning.
The resistive index of intrarenal arteries ranges from 0.79 to 0.87, elevated.
There are parvus tardus waveforms with absent diastolic flow. The main renal
artery shows a normal waveform, with prompt systolic upstroke and continuous
antegrade diastolic flow, with peak systolic velocity of 56. Vascularity is
symmetric throughout transplant. The transplant renal vein is patent and shows
normal waveform.
IMPRESSION:
1. Elevated intrarenal artery resistive indices throughout the transplant
kidney with parvus tardus waveforms and absent diastolic flow, raising the
possibility of transplant rejection. The transplant renal artery and vein are
patent with normal flow.
2. Mild hydronephrosis within the transplant kidney.
Radiology Report
EXAMINATION: RENAL TRANSPLANT U.S.
INDICATION: ___ year old man with ESRD s/p transplant in ___ with ___ and
mild hydronephrosis on prior renal ultrasound// ?interval change in
hydronephrosis
TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images
of the renal transplant were obtained.
COMPARISON: Renal transplant ultrasound ___
FINDINGS:
The right transplant kidney measures 11.7 cm and the renal morphology is
normal. Specifically, the cortex is of normal thickness and echogenicity,
pyramids are normal, there is no urothelial thickening, and renal sinus fat is
normal. Mild fullness of the renal pelvis is incidentally noted with focal
caliectasis in the upper pole..
Diastolic flow is absent in the main renal artery and in the intrarenal
arteries. The resistive index of intrarenal arteries measures 1.0. The main
renal artery demonstrates prompt systolic upstroke with peak systolic velocity
of 49 cm/sec. The transplant renal vein is patent and shows normal waveform.
IMPRESSION:
1. Patent transplant vasculature however diastolic flow is absent in all of
the arteries including the main renal artery.
2. Mild fullness of the renal pelvis is noted with focal caliectasis at the
upper pole.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with recent fall, ESRD s/p LURT, and worsening
AMS. Likely from worsening ___ but would like to r/o intracranial process//
r/o bleed, strokeany other etiology for AMS?
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 11.0 s, 18.7 cm; CTDIvol = 48.8 mGy (Head) DLP =
911.9 mGy-cm.
Total DLP (Head) = 927 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. Moderate
chronic small vessel ischemic changes. Small late subacute or chronic
cortical infarct posteromedial right parietal lobe generalized brain
parenchymal atrophy.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
Probably late subacute or chronic small cortical infarct right parietal lobe.
Mild-to-moderate chronic small vessel ischemic changes. Generalized brain
parenchymal atrophy.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with hypoxia, rib fractures, pneumothorax// ?
etiology of hypoxia ? etiology of hypoxia
IMPRESSION:
Compared to chest radiographs ___ and ___.
Previous moderate cardiomegaly has improved and there is no longer any
pulmonary edema. Heavy calcification of the mitral annulus is noted,
sometimes responsible for mitral regurgitation or rhythm disturbances. There
is no appreciable pleural effusion or pneumothorax. Opacification at the
right lung base is probably atelectasis, but there is no lobar collapse or
consolidation.
Slight leftward displacement of the trachea just above the thoracic inlet
could be due to an enlarged thyroid. If patient has had a recent attempt at
right internal jugular line insertion, it could be in indication of hematoma.
Clinical correlation and follow-up advised.
NOTIFICATION: The findings were discussed with ___ , M.D. by ___
___, M.D. on the telephone on ___ at 8:59 am, 2 minutes after
discovery of the findings.
Radiology Report
INDICATION: ___ year old man with ESRD s/p LURT, now with worsening ___ from
likely CIN/ATN, anticipate will likely need dialysis// Temporary HD line
placement
COMPARISON: None available
TECHNIQUE: OPERATORS: Dr. ___ radiologist performed the
procedure.
ANESTHESIA: 1% lidocaine was injected in the skin and subcutaneous tissues
overlying the access site.
MEDICATIONS: 1% lidocaine local anesthesia
CONTRAST: No contrast.
FLUOROSCOPY TIME AND DOSE: 2 min, 19 mGy
PROCEDURE: PROCEDURE DETAILS: Following the explanation of the risks,
benefits and alternatives to the procedure, written informed consent was
obtained from the healthcare proxy. The patient was then brought to the
angiography suite and placed supine on the exam table. A pre-procedure
time-out was performed per ___ protocol. The neck was prepped and draped in
the usual sterile fashion.
Under continuous ultrasound guidance, the patent right internal jugular vein
was compressible and accessed using a micropuncture needle. Permanent
ultrasound images were obtained before and after intravenous access, which
confirmed vein patency. Subsequently a Nitinol wire was passed into the right
atrium using fluoroscopic guidance. The needle was exchanged for a
micropuncture sheath.
The Nitinol wire was removed and a short ___ wire was advanced into the IVC.
After sequential dilation of the soft tissue tract using 12 ___ and 14
___ dilators, a triple lumen 14 ___ hemodialysis catheter was advanced
over the wire into the superior vena cava with the tip in the distal SVC. All
access ports were aspirated, flushed and capped. The catheter was secured to
the skin with a 0 silk suture and sterile dressings were applied. Final spot
fluoroscopic image demonstrating good alignment of the catheter and no
kinking.
The patient tolerated the procedure well without immediate complications.
FINDINGS:
Patent right internal jugular vein. Final fluoroscopic image showing triple
lumen temporary hemodialysis catheter with catheter tip terminating in the
distal superior vena cava.
IMPRESSION:
Successful placement of a right internal jugular approach triple lumen
temporary hemodialysis catheter. The line is read to use.
Radiology Report
INDICATION: ___ year old man with CIN/ATN on iHD, now with renal recovery//
please remove HD line
COMPARISON: TEMPORARY DIALYSIS LINE PLACEMENT ON ___
TECHNIQUE: OPERATORS: Dr. ___ (interventional radiology fellow) and Dr.
___ radiology attending) performed the procedure. The
attending, Dr. ___ was present and supervising throughout the procedure
CONTRAST: None
FLUOROSCOPY TIME AND DOSE: None
PROCEDURE: 1. Right chest temporary dialysis catheter removal.
PROCEDURE DETAILS: The patient was brought to the angiography holding area
and positioned with his head upright on a stretcher. The Right chest temporary
line site was cleaned and draped in standard sterile fashion. The catheter was
removed with gentle traction while manual pressure was held at the venotomy
site. Hemostasis was achieved after 5 min of manual pressure. A clean sterile
dressing was applied. The patient tolerated the procedure well. There were no
immediate postprocedural complications.
FINDINGS:
Expected appearance after temporary line removal.
IMPRESSION:
Successful removal of a right chest temporary line.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall
Diagnosed with Unsp fracture of first lumbar vertebra, init for clos fx, Multiple fractures of ribs, left side, init for clos fx, Traumatic pneumothorax, initial encounter, Syncope and collapse, Long term (current) use of anticoagulants, Unspecified atrial fibrillation
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: uta
level of acuity: 1.0 | Mr. ___ is a ___ PMHx afib on Coumadin, ESRD s/p LURT ___
c/b CKD IV, RAS s/p stenting, HLD, HTN, DM2, carotid stenosis,
PVD, prostate cancer s/p XRT, CAD s/p ___ 2 to ___ LAD
___, s/p ___ 2 to mid-LAD ___, recurrent Cdiff colitis
infection on PO vancomycin taper who was initially admitted to
___ on ___ after he fell from a flight of stairs and sustained
R ___ fractures, L2 transverse process fracture and small right
apical PTX and pulmonary contusion. His course has been
complicated by renal failure secondary to CIN/ ATN s/p temp RIJ
HD catheter placement (___) and HD (___), as well as
altered mental status and complicated Citrobacter UTI. His renal
function improved and he had no further dialysis needs. His
catheter was removed on ___.
# ___ on CKD, likely ___ CIN/ATN and Citrobacter UTI
# ESRD s/p LURT
Baseline Cr ~2, uptrended to peak BUN/Cr 86/6.1 ___ in the
setting of contrast exposure while he was volume depleted
(orthostatic). Urine with +muddy brown casts. As patient
developed worsening encephalopathy with asterixis, anuria,
decision made to initiate iHD with placement of temp RIJ HD line
on ___. He received HD ___, with improvement of mental
status. His renal function improved and he had no further
dialysis needs. His catheter was removed on ___. He is also
treated for Citrobacter UTI as below. Patient has baseline CKD4
in transplanted kidney, with transplant glomerulopathy (biopsy
proven in ___. Currently on tacrolimus, cellcept, and
prednisone for immunosuppression which were continued during
admission. His home tacrolimus dose was reduced to 1.5 mg BID
while admitted and resumed at 2 mg BID on discharge given low
troughs. His cellcept was continued at home dose. Last tacro
level 2.5 mg.
# Toxic-Metabolic Encephalopathy
# Urinary tract infection, pansensitive citrobacter
Likely multifactorial including renal failure, possible
citrobacter UTI. Significantly improved after HD and treatment
of UTI. In terms of other possible contributors, we d/c tramadol
which could cause confusion, tacro is therapeutic, LFTs WNL.
Obtained a CTH which showed subacute chronic/R parietal infarct
which per wife is chronic. For UTI treatment, he received
ceftriaxone x 2 days followed by ciprofloxacin 250 mg q24H for
total of 14 days ending ___. Once his renal function improved,
he was switched to BID dosing of the ciprofloxacin.
# Fall, complicated by:
# Multiple right-sided rib fractures
# Pulmonary contusion
# Small right pneumothorax and minimal pneumomediastinum, now
resolved
# Minimally displaced fracture of the right L2 transverse
process
Per wife and patient, he took Tylenol ___,, got confused, and
tripped while going downstairs. Syncope work up unremarkable
without arrhythmia on telemetry, TTE with small pericardial
effusion similar to prior. He was pneumothorax. Trauma work up
revealed multiple right sided rib fractures. His pain was
controlled with Tylenol and oxycodone PRN which he did not
require for >72 hours at the time of discharge and he was
encouraged to use IS.
# Recurrent Cdiff colitis: Continued long taper since this is
___ recurrence. His taper is as below.
- 125 mg once every other day for 8 days (4 doses) ___,
___
- 125 mg once every 3 days for 15 days (5 doses) ___,
___ with plan for follow-up with Dr. ___
transplant consultation ___.
# Past Afib on AC, recent DCCV ___: sinus throughout stay,
continued warfarin 1.5 mg daily & carvedilol. INR on discharge
1.6. Please adjust warfarin dosing as necessary.
# HFpEF: Torsemide held since admit as was orthostatic and on
discharge as patient was autodiuresing in setting of ___.
# DVT left peroneal: diagnosed ___: INR sub therapeutic on
___, not bridging given distal DVT and >3 month AC already.
# HFpEF
# CAD s/p ___ 2 to ___ LAD ___, s/p ___ 2 to mid-LAD
___. Continued ASA, Plavix, statin.
# T2DM: His insulin was adjusted to 35 units of Lantus with
sliding scale.
# Gout
- Held on last admission home allopurinol in the setting of
changing renal function and ___. Renal function stable on
discharge, resumed at 150 mg daily on discharge.
# HLD: Continued Statin.
# ?R parietal subacute to chronic CVA: Continued ASA, statin,
and anticoagulation as above.
TRANSTIONAL ISSUES
===================
- Vancomycin taper for recurrent C. diff as below. Appointment
with Dr. ___ in ___ for fecal transplant consultation.
- 125 mg once every other day for 8 days (4 doses) ___,
___
- 125 mg once every 3 days for 15 days (5 doses) ___,
___
- Last day of ciprofloxacin ___. Please adjust dosage
according to renal function and monitor QTc - last 436.
- Resumed home dose of tacro on discharge 2 mg BID, last tacro
level 2.5 (does not reflect adjustment)
- Adjust warfarin dosing as needed. Last INR 1.6.
- Resumed home allopurinol at 150 mg. Please adjust according to
renal function.
- Last tacro level on discharge 2.5 (reflects reduced dose of
1.5 mg BID), increased to home dose of 2 mg BID on discharge.
Please adjust dose as necessary.
- Holding home torsemide on discharge given diarrhea and
autodiuresis from ATN. Resume when able.
- Adjusted insulin regimen to 35 mg of lantus and ISS.
- Please recheck a BMP, tacro level on ___. Please call or fax
results to the office of patient's transplant nephrologist, Dr.
___. ___, Fax: ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / cefepime
Attending: ___.
Chief Complaint:
Pancytopenia
Major Surgical or Invasive Procedure:
___ Bone marrow biopsy
___ Bone marrow biopsy
___ Skin biopsy of right arm
___ Bone marrow biopsy
History of Present Illness:
This is a ___ with history of lower back pain who presents for
expedited work-up and management of pancytopenia.
He has been in his usual state of health without unintentional
weight loss (lost ~9 pounds associated with healthy diet),
fever,
chills, or other notable symptoms with the exception of
intermittent R lower back pain with some radiation down his leg
when he sits for long periods of time. No recent viral illness,
and he is not on any medications. As part of management of his
back pain, he had labs drawn in early ___. These returned with
an
ANC of ~400, hemoglobin of 12.4 and platelets of 125. Per
hematology notes he previously had an ANC of 1700 and normal
hemoglobin and platelets in ___.
He was therefore referred to a hematologist. Outside lab work-up
and results include:
- Direct antiglobulin test: Negative
- Absolute reticulocyte count of 0.084 M/uL (2.33% of RBC count)
- PTT/INR: 30.___
- LDH: 421
- HIV ___ antibody screen: Negative
- Vitamin B12: 385 pg/mL
- folate: 18 ng/mL
- SPEP: total protein 7.0, albumin 4.4, no M-spike detected
- bone marrow biopsy flow cytometry with 33-34% myeloblasts
concerning for AML; bone marrow core results not available yet
He made appointments at other ___ in ___, but was
unable to secure an appointment until later next week. He
therefore presented to the ___ ED for evaluation.
On arrival to the ED, initial vitals were 97.5 79 132/63 18 100%
RA
- Exam was unremarkable
- CXR and U/A were unremarkable, and chemistries were WNL
- INR was 1.2, PTT 29.6, uric acid 4.4
- CBC with ANC 440, H/H 12.1/35.5, PLT 125
Prior to transfer vitals were stable.
On arrival to the floor, patient endorses the above story.
Patient denies fevers/chills, night sweats, headache, vision
changes, dizziness/lightheadedness, weakness/numbnesss,
shortness
of breath, cough, hemoptysis, chest pain, palpitations,
abdominal
pain, nausea/vomiting, diarrhea, hematemesis,
hematochezia/melena, dysuria, hematuria, and new rashes.
Past Medical History:
___ Syndrome
IBS
BPH
Hyperlipidemia
NAFLD
elevated alkaline phosphatase
lower back pain
Social History:
___
Family History:
Brother died at age ___ from colon cancer
Mother alive, anemia
Physical Exam:
ADMISSION EXAM
===============
VS: ___ Temp: 97.8 PO BP: 125/79 HR: 75 RR: 18 O2 sat:
100% O2 delivery: Ra
GENERAL: Pleasant man, in no distress, lying in bed comfortably.
HEENT: Anicteric, PERLL, OP clear.
CARDIAC: RRR, normal s1/s2, no m/r/g.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Soft, non-tender, non-distended, normal bowel sounds, no
hepatomegaly, no splenomegaly.
EXT: Warm, well perfused, no lower extremity edema, erythema or
tenderness.
NEURO: A&Ox3, good attention and linear thought, CN II-XII
intact. Strength full throughout. Sensation to light touch
intact.
MSK: Negative straight leg raise. Unable to reproduce lower back
pain with palpation. Patient is asymptomatic with regards to
back
pain at this time.
SKIN: No significant rashes.
ACCESS: PIV
DISCHARGE EXAM
================
VS: Temp 98 BP 117/74 HR 83 RR 18 99% O2 sat on RA
GENERAL: Pleasant man, in no distress
HEENT: MMM without lesions. Lips chapped but no open sores, No
lesions or redness of tongue. EOMI. Vision fine when looking
straight ahead and testing directly.
CARDIAC: NR, RR. No m/r/g
LUNG: CTAB, no crackles, wheezes, or rhonchi
ABD: Soft, non tender, non distended, BS+
EXT: WWP, no edema.
SKIN: Improving dry skin along feet.
NEURO: A&Ox3
Pertinent Results:
ADMISSION LABS
=================
___ 02:25PM BLOOD WBC-1.5* RBC-3.61* Hgb-12.1* Hct-35.5*
MCV-98 MCH-33.5* MCHC-34.1 RDW-14.2 RDWSD-50.4* Plt ___
___ 02:25PM BLOOD Neuts-29.1* Lymphs-63.6* Monos-4.0*
Eos-2.6 Baso-0.7 AbsNeut-0.44* AbsLymp-0.96* AbsMono-0.06*
AbsEos-0.04 AbsBaso-0.01
___ 02:37PM BLOOD ___ PTT-29.6 ___
___ 02:25PM BLOOD Glucose-99 UreaN-14 Creat-1.0 Na-141
K-4.5 Cl-103 HCO3-26 AnGap-12
___ 02:25PM BLOOD ALT-21 AST-18 LD(LDH)-179 AlkPhos-130
TotBili-1.5
___ 02:25PM BLOOD Lipase-57
PERTINENT LABS
================
___ 06:00AM BLOOD Albumin-4.3 Calcium-9.3 Phos-2.9 Mg-2.4
UricAcd-4.2 Iron-117
___ 06:00AM BLOOD calTIBC-252* ___ Ferritn-394
TRF-194*
___ 06:00AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG
___ 06:00AM BLOOD HCV Ab-NEG
___ 06:00AM BLOOD ___ 06:00AM BLOOD G6PD-NORMAL
___ 06:00AM BLOOD Ret Aut-3.3* Abs Ret-0.11*
___ 06:20AM BLOOD ___
___ 06:20AM BLOOD TSH-2.8
___ 06:30AM BLOOD HIV Ab-NEG
DISCHARGE LABS
=================
___ 12:00AM BLOOD WBC-9.7 RBC-2.57* Hgb-7.5* Hct-22.4*
MCV-87 MCH-29.2 MCHC-33.5 RDW-12.8 RDWSD-39.8 Plt ___
___ 12:00AM BLOOD Neuts-31* Bands-0 ___ Monos-34*
Eos-0 Baso-0 ___ Metas-4* Myelos-2* Blasts-2* NRBC-2*
AbsNeut-3.01 AbsLymp-2.62 AbsMono-3.30* AbsEos-0.00*
AbsBaso-0.00*
___ 12:00AM BLOOD Glucose-138* UreaN-14 Creat-0.9 Na-143
K-4.5 Cl-106 HCO3-23 AnGap-14
___ 12:00AM BLOOD ALT-39 AST-31 LD(LDH)-451* AlkPhos-206*
TotBili-0.2
___ 12:00AM BLOOD Albumin-3.1* Calcium-8.4 Phos-3.2 Mg-1.9
UricAcd-4.7
STUDIES/IMAGING
=================
___ CXR
No acute intrathoracic process.
___ TTE
The left atrium is mildly dilated. A prominent Eustachian valve
is present (normal variant). There is normal left ventricular
wall thickness with a normal cavity size. There is normal
regional left ventricular
systolic function. Quantitative biplane left ventricular
ejection fraction is 56 %. Left ventricular cardiac index is
normal (>2.5 L/min/m2). There is no resting left ventricular
outflow tract gradient. No ventricular septal defect is seen.
There is normal diastolic function. Normal right ventricular
cavity size with normal free wall motion. The aortic sinus
diameter is normal for gender with normal ascending aorta
diameter for gender. The aortic arch diameter is normal. There
is no evidence for an aortic arch coarctation. The aortic valve
leaflets (3) appear structurally normal. There is no aortic
valve stenosis. There is no aortic regurgitation. The mitral
leaflets are mildly thickened with no mitral valve prolapse.
There is trivial mitral regurgitation. The tricuspid valve
leaflets appear structurally normal. There is physiologic
tricuspid regurgitation. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
___ LS Spine XR
1. Degenerative changes as described.
2. 5 mm calcification projects over the upper pole the right
kidney, this
could potentially reflect a right renal calculus
___ Imaging TEMPORARY CENTRAL LINE
Successful placement of a temporary triple lumen catheter via
the right
internal jugular venous approach. The tip of the catheter
terminates in the
distal superior vena cava. The catheter is ready for use.
___BD & PELVIS WITH CO
No source of infection is identified within the abdomen or
pelvis.
___ Cardiovascular Transthoracic Echo Report
The left atrial volume index is normal. The inferior vena cava
diateter is normal. There is normal left
ventricular wall thickness with a normal cavity size. There is
normal regional left ventricular systolic function.
There is no resting left ventricular outflow tract gradient.
Normal right ventricular cavity size with normal free
wall motion. The aortic sinus diameter is normal for gender with
normal ascending aorta diameter for gender.
The aortic arch diameter is normal. The aortic valve leaflets
(3) are mildly thickened. There is no aortic valve
stenosis. There is trace aortic regurgitation. The mitral valve
leaflets are mildly thickened with no mitral valve
prolapse. There is trivial mitral regurgitation. The tricuspid
valve leaflets appear structurally normal. There is
trivial tricuspid regurgitation. There is mild pulmonary artery
systolic hypertension. There is no pericardial
effusion.
IMPRESSION:
Suboptimal image quality. Normal biventricular cavity sizes,
regional/global systolic function.
No valvular pathology or pathologic flow identified. Mild
pulmonary artery systolic hypertension.
Compared with the prior TTE
(images reviewed) of
, there is now mild pulmonary hypertension noted
MICROBIOLOGY
==============
**FINAL REPORT ___
___ VIRUS VCA-IgG AB (Final ___: POSITIVE
BY EIA.
___ VIRUS EBNA IgG AB (Final ___: POSITIVE
BY EIA.
___ VIRUS VCA-IgM AB (Final ___:
NEGATIVE <1:10 BY IFA.
INTERPRETATION: RESULTS INDICATIVE OF PAST EBV INFECTION.
In most populations, 90% of adults have been infected at
sometime
with EBV and will have measurable VCA IgG and EBNA
antibodies.
Antibodies to EBNA develop ___ weeks after primary
infection and
remain present for life. Presence of VCA IgM antibodies
indicates
recent primary infection.
**FINAL REPORT ___
CRYPTOCOCCAL ANTIGEN (Final ___:
CRYPTOCOCCAL ANTIGEN NOT DETECTED.
(Reference Range-Negative).
Test performed by Lateral Flow Assay.
A negative serum does not rule out localized or
disseminated
cryptococcal infection.
Appropriate specimens should be sent for culture.
**FINAL REPORT ___
CMV IgG ANTIBODY (Final ___:
NEGATIVE FOR CMV IgG ANTIBODY BY EIA.
<4 AU/ML.
Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml.
CMV IgM ANTIBODY (Final ___:
NEGATIVE FOR CMV IgM ANTIBODY BY EIA.
INTERPRETATION: NO ANTIBODY DETECTED.
Greatly elevated serum protein with IgG levels ___ mg/dl
may cause
interference with CMV IgM results.
___ 3:23 pm TISSUE Source: Skin biopsy.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
Medications on Admission:
None.
Discharge Medications:
1. Acyclovir 400 mg PO Q12H
RX *acyclovir 400 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
2. Posaconazole Delayed Release Tablet 300 mg PO DAILY
RX *posaconazole [Noxafil] 100 mg 3 tablet(s) by mouth qday Disp
#*90 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
=========
AML
Pancytopenia
Neutropenic Fever
SECONDARY
============
Hyponatremia
Increased thirst/urination
Folliculitis
Tinea pedis
Tinea cruris
Lower back pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with new AML and will start chemo// ?pna
COMPARISON: None
FINDINGS:
PA and lateral views of the chest provided.
There is no focal consolidation, effusion, or pneumothorax. The
cardiomediastinal silhouette is normal. Imaged osseous structures are intact.
No free air below the right hemidiaphragm is seen.
IMPRESSION:
No acute intrathoracic process.
Radiology Report
EXAMINATION: LUMBO-SACRAL SPINE (AP AND LAT)
INDICATION: ___ year old man with low back pain and new diagnosis of AML//
Assess for bone lesions, fracture, spondylilothesis
TECHNIQUE: AP and lateral views of the lumbar spine
COMPARISON: None available
FINDINGS:
There are 5 non-rib-bearing lumbar-type vertebrae. There is preservation of
the normal lumbar lordosis. There is mild multilevel degenerative disc
disease throughout the lumbar spine with small anterior osteophytes seen at
L2-L3 and L3-L4. Mild facet arthropathy seen also in the lower lumbar spine.
Mild degenerative changes at the bilateral sacroiliac joints and bilateral hip
joints. No fracture seen. No destructive lytic or sclerotic bone lesions. A
5 mm calcification projects over the upper pole the right kidney, nonspecific
in appearance but could potentially reflect a small renal calculus.
Nonobstructive bowel gas pattern.
IMPRESSION:
1. Degenerative changes as described.
2. 5 mm calcification projects over the upper pole the right kidney, this
could potentially reflect a right renal calculus
Radiology Report
INDICATION: ___ year old man with AML
COMPARISON: Chest x-ray ___
TECHNIQUE: OPERATORS: Dr. ___ and Dr.
___ radiologist performed the procedure. Dr. ___
supervised the trainee during the key components of the procedure and has
reviewed and agrees with the trainee's findings.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
0.5 mg of midazolam throughout the total intra-service time of 9 minutes
during which the patient's hemodynamic parameters were continuously monitored
by an independent trained radiology nurse. 1% lidocaine was injected in the
skin and subcutaneous tissues overlying the access site.
MEDICATIONS: None
CONTRAST: None
FLUOROSCOPY TIME AND DOSE: 0.3 min, 1 mGy
PROCEDURE: PROCEDURE DETAILS: Following the explanation of the risks,
benefits and alternatives to the procedure, written informed consent was
obtained from the patient. The patient was then brought to the angiography
suite and placed supine on the exam table. A pre-procedure time-out was
performed per ___ protocol. The right neck was prepped and draped in the
usual sterile fashion.
Under continuous ultrasound guidance, the patent right internal jugular vein
was compressible and accessed using a micropuncture needle. Permanent
ultrasound images were obtained before and after intravenous access, which
confirmed vein patency. Subsequently a Nitinol wire was passed into the right
atrium using fluoroscopic guidance. The needle was exchanged for a
micropuncture sheath.
The Nitinol wire was removed and a short ___ wire was advanced into the IVC.
A triple-lumen central venous catheter was advanced over the wire into the
superior vena cava with the tip in the cavoatrial junction. All 3 access ports
were aspirated, flushed and capped. The catheter was secured to the skin with
a 0 silk suture and sterile dressings were applied. Final spot fluoroscopic
image demonstrating good alignment of the catheter and no kinking. The patient
tolerated the procedure well without immediate complications.
FINDINGS:
Patent right internal jugular vein. Final fluoroscopic image showing triple
lumen central venous catheter with catheter tip terminating in the distal
superior vena cava.
IMPRESSION:
Successful placement of a temporary triple lumen catheter via the right
internal jugular venous approach. The tip of the catheter terminates in the
distal superior vena cava. The catheter is ready for use.
Radiology Report
INDICATION: ___ year old man with febrile neutropenia// eval for pna
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Lungs are clear. Heart size is normal. There is no pleural effusion. No
pneumothorax is seen. Right-sided central line projects to the SVC.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ year old man with AML, neutropenic fevers.// Eval for PNA,
abscess.
TECHNIQUE: Axial helical multi detector CT images were acquired of the chest
after the uneventful intravenous administration of contrast. Multiplanar
reformats were generated in the coronal and sagittal planes as well as axial
MIPS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.2 s, 40.4 cm; CTDIvol = 7.3 mGy (Body) DLP = 291.2
mGy-cm.
Total DLP (Body) = 291 mGy-cm.
COMPARISON: Chest radiograph ___, ___.
FINDINGS:
The thyroid gland is unremarkable.
Heart size is normal without significant pericardial effusion. A right
internal jugular approach central venous catheter terminates in the low SVC.
Thoracic aorta and pulmonary arteries are normal caliber. There is no
significant atherosclerotic calcification.
There is no supraclavicular, axillary, hilar, or mediastinal lymphadenopathy
by CT size criteria.
The airways are patent. There is a punctate calcified granuloma in the base
of the right middle lobe. There is another punctate calcified granuloma in
the posterior left upper lobe. Lungs are otherwise clear without suspicious
focal consolidation or nodule. There is no effusion or pneumothorax.
Although this study is not tailored for subdiaphragmatic analysis, the
visualized upper abdomen demonstrates no gross acute abnormalities.
Thoracic cage is intact without acute fracture or suspicious focal bone
lesion.
IMPRESSION:
Unremarkable contrast-enhanced chest CT. Clear lungs. No lymphadenopathy.
No infectious source.
Radiology Report
EXAMINATION: CT SINUS/MANDIBLE/MAXILLOFACIAL W/ CONTRAST
INDICATION: ___ year old man with AML, neutropenic fevers, dental implant R
lower molar.// Eval for gingival/dental infection.
TECHNIQUE: Helical axial images were acquired through the facial bones. Bone
and soft tissue reconstructed images were generated. Coronal and sagittal
reformatted images were also obtained.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.4 s, 22.3 cm; CTDIvol = 32.9 mGy (Head) DLP = 713.1
mGy-cm.
Total DLP (Head) = 713 mGy-cm.
COMPARISON: None.
FINDINGS:
The study is limited due to streak artifact from dental amalgam. Included
paranasal sinuses are clear. Included extracranial soft tissues are
unremarkable. No large dental caries are seen. There is no periapical
lucency. There is no fracture.
The paranasal sinuses are normally aerated, with no mucosal thickening or
air-fluid levels identified. The ostiomeatal units are patent. The cribriform
plates are intact. The lamina papyracea are intact. The temporomandibular
joints are anatomically aligned. The orbits are unremarkable.
IMPRESSION:
The study is limited due to streak artifact from dental amalgam. Within this
limitation, there is no soft tissue stranding or drainable fluid collection to
suggest odontogenic infection.
Radiology Report
EXAMINATION: CT abdomen and pelvis with contrast
INDICATION: ___ year old man with neutropenic fevers and positive Beta
Glucan.// Eval for fungal infection or other infectious source.
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9
mGy-cm.
2) Stationary Acquisition 1.3 s, 0.2 cm; CTDIvol = 22.2 mGy (Body) DLP =
4.4 mGy-cm.
3) Spiral Acquisition 8.8 s, 57.4 cm; CTDIvol = 11.5 mGy (Body) DLP = 649.9
mGy-cm.
Total DLP (Body) = 656 mGy-cm.
COMPARISON: Patient has no prior similar imaging examinations for comparison
at this institution.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion. There is a punctate calcified
granuloma at the base of the right upper lobe.
ABDOMEN:
HEPATOBILIARY: The liver and gallbladder are unremarkable.
PANCREAS: The pancreas is unremarkable.
SPLEEN: The spleen is normal in size and attenuation.
ADRENALS: The right and left adrenal glands are unremarkable.
URINARY: The kidneys are unremarkable. No hydronephrosis.
GASTROINTESTINAL: No bowel obstruction. No ascites. The appendix is within
normal limits.
PELVIS: No pelvic free-fluid
.
LYMPH NODES: No lymphadenopathy in the abdomen or pelvis.
VASCULAR: There is no abdominal aortic aneurysm.
BONES: There is no evidence of worrisome osseous lesions.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits. Fatty
atrophy with coarse calcification noted at the lateral aspect of the right
rectus femoris muscle, likely sequela of prior trauma.
IMPRESSION:
No source of infection is identified within the abdomen or pelvis.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Neutropenia
Diagnosed with Other neutropenia
temperature: 97.5
heartrate: 79.0
resprate: 18.0
o2sat: 100.0
sbp: 132.0
dbp: 63.0
level of pain: 0
level of acuity: 2.0 | ___ with lower back pain, ___ disease, and NAFLD who was
admitted for expedited work-up of pancytopenia, which was
revealing for AML. He underwent 7+3 induction therapy starting
on ___, followed by re-inducing with 5+2 starting ___.
ACUTE PROBLEMS
================
# Pancytopenia
# AML
Slow decline in WBC over several years. Prior to admission, lab
work as outpatient revealed new pancytopenia. BM Biopsy
performed at OSH and consistent with AML. Markers not consistent
with MDS. ___ in DC/AML vaccine trial and started 7+3
induction therapy on ___. Given acyclovir, levofloxacin
(when not on meropenem) and posaconazole for prophylaxis. Repeat
BM at day ___ showed hypocellular marrow with persistent leukemic
involvement and he was started on 5+2 on ___. QTc was monitored
closely over admission. His counts began to recover on ___, and
on ___ a repeat bone marrow biopsy was obtained, after which he
was felt appropriate for discharge. The results of this was
pending at time of discharge.
# increased urination:
Patient with increased thirst and urination. Sodium was normal.
Per med review, no medications to cause this side effect.
Admission weight was 194 lbs and had been downtrending. Urine
osms with high concentration abnormal for iatrogenic volume
overload unless patient with high solute load intake.
Furthermore, urine osms did not change after fluid restriction.
Given normal Na, SIADH less likely but could have mixed picture.
Renal consulted and recommended decreasing IVF. The patient's
urinary output slowly decreased over admission. With resolution
of his symptoms no further workup was felt necessary.
# Neutropenic Fever
Developed fever evening of ___. Started on Vanc/Cefepime.
Continued to be febrile and CT Chest + Mandible performed,
negative for infection. Developed another erythematous macular
rash consistent with allergic reaction to Cefepime and
transitioned to Meropenem. Vancomycin was discontinued due to
concern for drug fever on ___. CT A/P was negative for
infection. Beta-glucan was positive but galactomannan negative,
and thus he was started on posaconzole. Negative urine
histo/blasto, crypto. Cocciodo negative. CMV negative. EBV with
<200. Given patient stability and lack of fevers, meropenem was
discontinued ___ and the patient was started on just levaquin
prophylaxis. This was transitioned to ciprofloxacin as below,
and discontinued prior to discharge.
#. Erythematous Viral Rash
New rash developed on ___ that did not follow the same pattern
as his previous rash. There was concern for another drug rash.
Levaquin and posaconzole were initially held, and dermatology
was consulted. A biopsy was done on ___, with initial results
consistent with a viral etiology, and less likely a drug or
chemo reaction. Ciprofloxacin was restarted, as well as
posaconazole following discussion with infectious disease. He
was given a hydrocortisone cream, and over time the rash
continued to improve until complete resolution at time of
discharge.
# Transaminitis
While admitted, the patient was observed to have a rise in
tranaminases with relatively normal bilirubin. This was felt to
be likely due to medication effect from medications or
chemotherapy. Allopurinol was held and the patient LFT
abnormalities improved.
# Folliculitis
Physical exam was notable for two rashes that the patient had
from admission. Dermatology was consulted. There was an
erythematous papular rash on lower back, which per dermatology,
was folliculitis. He also had a mildly pruritic rash on groin
and scale on his feet that was felt to be tinea cruris and tinea
pedis, respectively. He was given topical clindamycin for the
folliculitis and topical clotrimazole for the tinea, with
significant improvement.
# Hematochezia:
Patient intermittently reported a few drops of blood with bowel
movements throughout hospitalization. Rectal exam was fairly
unremarkable with no visible hemorrhoids. Patient has history of
hemorrhoids before with similar presentation and symptoms. No
acute intervention seemed warranted given the benign and stable
presentation.
CHRONIC CONDITIONS
===================
# ___ syndrome
The patient has a history of ___ syndrome. Bilirubin was
trended and noted to be normal to mildly elevated.
# Dental implant
The patient had a tooth implanted in ___. He complained of
occasional irritation at the site as it can easily get food or
other particles lodged in it. Per OMFS, there was no indication
for prophylactic removal of the implant and it was recommended
that he continue with good oral hygiene.
# Chronic lower back pain
The patient was asymptomatic throughout admission. A lumbosacral
spine XR (___) showed only mild degenerative changes.
Therefore, thought most likely due to sciatica.
TRANSITIONAL ISSUES
======================
- Patient will continue to require weekly B glucan
- Patient will require QTc monitoring weekly
- New medications: Acyclovir, Posaconazole
- Follow-up results from bone marrow biopsy from ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
citrus fruits / tree nuts / Penicillins / Cymbalta / Bactrim
Attending: ___
Chief Complaint:
acute on chronic back pain
Major Surgical or Invasive Procedure:
R breast collection aspiration
PICC placement
History of Present Illness:
Ms. ___ is a ___ with PMH notable for invasive ductal
carcinoma of the right breast (diagnosed in ___, ER+,
HER2+, confirmed by core biopsy) s/p multiple palliative
treatments and palliative R mastectomy ___ (Dr. ___,
lumbar spinal stenosis L2 to S1, s/p lumbar decompression L2-S1
laminectomy with bilateral medial facetectomy and foraminotomy,
posterior
lumbar arthrodesis L2-L5, bilateral lower extremity
radiculopathy who presents with acute on chronic back pain.
The patient indicates that she has had ___ non-radiating lower
back pain since ___. Initially, she was doing well at
home on opioids and muscle relaxants but over the past month,
she has had worsening of her back pain uncontrolled with her
meds. No alleviating factors, worse with movement. The patient
had a fall on her right shoulder on ___ but no head strike;
since then, she has had shoulder pain. Patient's oncologist (Dr.
___
recommended coming in to the ED. No numbness, weakness, urinary
or bowel incontinence. Denies any fevers, chills, chest pain,
sob, abdominal pain.
In the ED,
- Initial Vitals:
Temp 98.2, HR 118, BP 129/66, RR 16, SpO2 98% RA
Desatted to low ___ on RA and subsequently put on 3L NC.
Persistently tachy to 130s. Tmax 102.9 in the ED.
- Exam: writhing in pain, appears uncomfortable, no neurological
deficits
- Labs: WBC 6.0, Hgb 11.9, PC ___ AGap=16
4.0 17 1.0
Ca: 8.7, Mg: 1.3, P: 1.8
___: 14.7, INR: 1.4
Trop <0.01
Lactate 2.8 --> 2.1
proBNP 505
UA: 0 epi, 1 WBC, neg ___, neg nitr, trace blood
Urine culture, blood culture pending
- Imaging:
CTA chest, CT A/P w/ contrast:
1. No evidence of pulmonary embolism or acute aortic
abnormality.
2. Increased size of postsurgical fluid collection within the
right mastectomy surgical bed measuring 17.2 x 2.9 cm,
previously
13.5 x 1.4 cm. Please note, infection of this collection cannot
be excluded on the basis of this imaging exam.
3. 0.5 cm left lower lobe ground-glass nodule may be
inflammatory. Consider three-month follow-up chest CT to assess
stability.
4. No acute findings within the abdomen or pelvis.
5. Similar appearance of T11 vertebra metastasis without loss of
vertebral body height. No new osseous metastases.
Xray Right shoulder:
No acute fracture.
Chest xray:
No acute process.
- Consults: Breast surgery: no acute intervention at this time
- Interventions:
Tylenol ___ PO x1
Dilaudid 0.5mg IV x6
2L LR, 1L NS
Zofran 4mg IV x1
Clindamycin 650mg IV x1
Flagyl 500mg IV x1
Vancomycin 1.5g IV x1
Given CTA showing fluid collection in right chest wall, coupled
with tachycardia and blood pressures in the 100s, ED felt that
patient should come to ICU.
Past Medical History:
T2DM
HTN
Depression
DL
Back pain
Metastatic breast CA
Social History:
___
Family History:
- mother breast cancer
- extensive diabetes mellitus in family
Physical Exam:
Admission exam
VS: Temp 98.4, HR 148, BP 155/61, O2 sat 92% 3L NC
GEN: Lying in bed, uncomfortable, somnolent
HENNT: Moist mucous membranes.
CV: Tachycardic, regular rhythm, no murmurs.
RESP: CTAB with no crackles or increased work of breathing.
GI: Abdomen soft, nontender, nondistended, normoactive bs.
SKIN: Right breast surgical site notable for dark scabbing, no
warmth or tenderness to palpation around site and no drainage of
pus. Left chest wall port clean and dry.
EXT: Warm and well perfused, no ___ edema.
NEURO: Moving bilateral extremities spontaneously, unable to
conduct thorough neuro exam given somnolence.
Discharge exam
VS: Temp 98.5, HR 102, BP 137/64, O2 sat 93% RA
GENERAL: Alert, NAD
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
MSK: R shoulder painful to palpation anteriorly, mild soft
tissue
swelling
SKIN: R breast with healing surgical wound, small amount of
slough and drainage, minimal surrounding erythema, L chest port
without
erythema or drainage
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: appropriate affect
Pertinent Results:
Admission labs
___ 11:24AM BLOOD WBC-6.0 RBC-4.22 Hgb-11.9 Hct-36.1 MCV-86
MCH-28.2 MCHC-33.0 RDW-14.7 RDWSD-45.8 Plt ___
___ 11:24AM BLOOD Glucose-217* UreaN-32* Creat-1.3* Na-134*
K-4.6 Cl-100 HCO3-19* AnGap-15
___ 11:24AM BLOOD proBNP-505
___ 11:24AM BLOOD cTropnT-<0.01
___ 04:00PM BLOOD Lipase-9
___ 04:00PM BLOOD ALT-17 AST-17 AlkPhos-49 TotBili-1.0
___ 04:00PM BLOOD Albumin-3.6 Calcium-8.7 Phos-1.8* Mg-1.3*
___ 04:12PM BLOOD Lactate-2.8*
Discharge labs (Most recent labs)
___ 05:02AM BLOOD WBC-7.5 RBC-3.67* Hgb-10.1* Hct-32.8*
MCV-89 MCH-27.5 MCHC-30.8* RDW-15.3 RDWSD-50.1* Plt ___
___ 05:02AM BLOOD Glucose-169* UreaN-15 Creat-0.8 Na-140
K-4.4 Cl-102 HCO3-26 AnGap-12
___ 05:02AM BLOOD ALT-34 AST-22 AlkPhos-114* TotBili-0.2
Imaging
====================================
X-ray R shoulder
INDINGS:
Three views of the right shoulder were provided. No fracture or
dislocation. Mineralization adjacent to the lateral right
humeral head is unchanged and may reflect chronic tendinopathy
of the supraspinatus insertion. Mild inferior right glenoid
spurring is noted. Mild bony hypertrophy at the right AC joint
consistent with mild osteoarthritis. No fracture is seen. No
discrete osseous metastatic lesion is identified.
IMPRESSION:
No acute fracture.
CXR ___
FINDINGS:
AP upright and lateral views of the chest provided. Left chest
wall
Port-A-Cath is noted with catheter tip in the region of the mid
SVC. The
heart is normal in size. Lungs are clear without focal
consolidation, large effusion or pneumothorax.
Cardiomediastinal silhouette appears stable. No signs of
congestion or edema. Bony structures are intact. Known osseous
metastatic lesions are not well visualized.
IMPRESSION:
No acute intrathoracic process.
CTA chest ___
IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic
abnormality.
2. Increased size of postsurgical fluid collection within the
right mastectomy surgical bed measuring 17.2 x 2.9 cm,
previously 13.5 x 1.4 cm. Please note, infection of this
collection cannot be excluded on the basis of this imaging exam.
3. 0.5 cm left lower lobe ground-glass nodule may be
inflammatory. Consider
three-month follow-up chest CT to assess stability.
4. No acute findings within the abdomen or pelvis.
5. Similar appearance of T11 vertebra metastasis without loss of
vertebral
body height. No new osseous metastases.
MRI T and L spine ___
IMPRESSION:
1. Metastasis involving T11 vertebral body, posterior elements,
paraspinal, epidural tumor. Severe central canal narrowing,
mild cord flattening, mild cord edema.
2. Postcontrast images would be helpful.
3. Incomplete lumbar spine MRI, mild central canal narrowing,
arachnoiditis, multilevel significant foraminal narrowing.
TTE ___
The left atrium is elongated. There is normal left ventricular
wall thickness with a normal cavity size. There is suboptimal
image quality to assess regional left ventricular function.
Overall left ventricular systolic function is normal. The
visually estimated left ventricular ejection fraction is 70%.
There is no resting left ventricular outflow tract gradient.
Normal right ventricular cavity size with normal free wall
motion. The aortic sinus diameter is normal for gender with
normal ascending aorta diameter for gender. The aortic arch
diameter is normal. The aortic valve leaflets (?#) are mildly
thickened. There is no aortic valve stenosis. There is no aortic
regurgitation. The mitral valve leaflets appear structurally
normal with no mitral valve prolapse.
There is trivial mitral regurgitation. The tricuspid valve
leaflets appear structurally normal. There is physiologic
tricuspid regurgitation. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
MRI T and L spine ___
1. Metastatic disease involving the T11 vertebra with epidural
and paraspinal soft tissue changes. There is severe spinal
stenosis at this level with compression of the spinal cord.
Previously suspected increased signal within the spinal cord
could not be confirmed.
2. Laminectomies in the lower lumbar region with evidence of
arachnoiditis in the lower lumbar spine with clumping of the
nerve roots. The findings have progressed since the MRI of ___. There also appears to be a new laminectomy at
L2-3 level since that study.
3. Degenerative changes and foraminal narrowing from L3-4 to
L5-S1 levels as described above.
Breast US ___
IMPRESSION:
Fluid collection measuring up to 4.8 cm in the right mastectomy
bed which
subsequently underwent drainage, which is dictated under
separate report.
RECOMMENDATION(S): Ultrasound guided fluid drainage.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ascorbic Acid ___ mg PO BID
2. MetFORMIN (Glucophage) 1000 mg PO BID
3. Acetaminophen 650 mg PO Q6H
4. amLODIPine 5 mg PO DAILY
5. Atenolol 25 mg PO DAILY
6. Baclofen 10 mg PO TID
7. Gabapentin 600 mg PO BID
8. Levothyroxine Sodium 100 mcg PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Rosuvastatin Calcium 20 mg PO QPM
11. Sertraline 50 mg PO DAILY
12. Aspirin 81 mg PO DAILY
13. Anastrozole 1 mg PO QHS
14. Cyclobenzaprine 10 mg PO TID:PRN pain
15. HYDROmorphone (Dilaudid) 2 mg PO DAILY:PRN Pain - Moderate
16. Lidocaine 5% Patch 1 PTCH TD QPM
17. methenamine hippurate 1 gram oral BID
18. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
19. TraZODone 50 mg PO QHS:PRN insomnia
20. Vitamin D 1000 UNIT PO DAILY
21. Glargine 24 Units Bedtime
Humalog 8 Units Breakfast
Humalog 8 Units Lunch
Humalog 8 Units Dinner
Humalog 8 Units Bedtime
Discharge Medications:
1. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line
2. CefTRIAXone 2 gm IV Q 24H
EOT ___
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 g IV daily
Disp #*6 Intravenous Bag Refills:*0
3. Docusate Sodium 100 mg PO BID
4. Polyethylene Glycol 17 g PO DAILY
5. Senna 8.6 mg PO BID:PRN Constipation - First Line
6. Acetaminophen 1000 mg PO TID
7. HYDROmorphone (Dilaudid) 4 mg PO Q4H
RX *hydromorphone [Dilaudid] 4 mg 1 tablet(s) by mouth every
four (4) hours Disp #*60 Tablet Refills:*0
8. Glargine 24 Units Bedtime
Humalog 8 Units Breakfast
Humalog 8 Units Lunch
Humalog 8 Units Dinner
Humalog 8 Units Bedtime
9. Anastrozole 1 mg PO QHS
10. Ascorbic Acid ___ mg PO BID
11. Aspirin 81 mg PO DAILY
12. Baclofen 10 mg PO TID
13. Gabapentin 600 mg PO BID
14. Levothyroxine Sodium 100 mcg PO DAILY
15. Lidocaine 5% Patch 1 PTCH TD QPM
16. MetFORMIN (Glucophage) 1000 mg PO BID
17. methenamine hippurate 1 gram oral BID
18. Omeprazole 20 mg PO DAILY
19. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
20. Rosuvastatin Calcium 20 mg PO QPM
21. Sertraline 50 mg PO DAILY
22. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
GBS BSI
Breast surgical site infection
metastatic cancer pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ with fall, R shoulder pain// ?fx
COMPARISON: PET-CT scan from ___
FINDINGS:
Three views of the right shoulder were provided. No fracture or dislocation.
Mineralization adjacent to the lateral right humeral head is unchanged and may
reflect chronic tendinopathy of the supraspinatus insertion. Mild inferior
right glenoid spurring is noted. Mild bony hypertrophy at the right AC joint
consistent with mild osteoarthritis. No fracture is seen. No discrete
osseous metastatic lesion is identified.
IMPRESSION:
No acute fracture.
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: ___ with tachycardia, weakness, history of metastatic breast
cancer
COMPARISON: Chest CT from ___
FINDINGS:
AP upright and lateral views of the chest provided. Left chest wall
Port-A-Cath is noted with catheter tip in the region of the mid SVC. The
heart is normal in size. Lungs are clear without focal consolidation, large
effusion or pneumothorax. Cardiomediastinal silhouette appears stable. No
signs of congestion or edema. Bony structures are intact. Known osseous
metastatic lesions are not well visualized.
IMPRESSION:
No acute intrathoracic process.
Radiology Report
INDICATION: History: ___ with met breast cancer p/w persistent tachycardia,
febrile to 102 with some abdominal pain// CTA: eval for PECTAP: eval for
intraabdominal infection
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast in the arterial
phase. Then, imaging was obtained through the abdomen and pelvis in the
portal venous phase. Reformatted coronal and sagittal images through the
chest, abdomen, and pelvis, and oblique maximal intensity projection images of
the chest were submitted to PACS and reviewed.
Oral contrast was not administered.
DOSE: Acquisition sequence:
1) Stationary Acquisition 1.0 s, 0.5 cm; CTDIvol = 4.1 mGy (Body) DLP = 2.0
mGy-cm.
2) Spiral Acquisition 3.5 s, 27.5 cm; CTDIvol = 9.1 mGy (Body) DLP = 248.7
mGy-cm.
3) Spiral Acquisition 6.4 s, 50.1 cm; CTDIvol = 20.3 mGy (Body) DLP =
1,018.2 mGy-cm.
Total DLP (Body) = 1,269 mGy-cm.
COMPARISON: PET-CT ___
FINDINGS:
CHEST:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
subsegmental level without filling defect to indicate a pulmonary embolus.
The thoracic aorta is normal in caliber without evidence of dissection or
intramural hematoma. The heart is mildly enlarged. Otherwise, the heart,
pericardium, and great vessels are within normal limits. No pericardial
effusion is seen. Tip of left chest Port-A-Cath terminates in the right
atrium.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: There is mild bibasilar atelectasis. No focal consolidation.
An ovoid 0.5 cm ground-glass nodule within the left lower lobe (03:39) is
unchanged since the previous study of ___ but was not seen on
studies prior to this, and may be inflammatory in nature. The airways are
patent to the level of the segmental bronchi bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
CHEST WALL: A fluid collection in the right chest wall appears increased in
size, previously measuring 13.5 x 1.4 cm in the axial plane, now measuring
17.2 x 2.9 cm in the axial plane (5:7), and exhibits mild peripheral
enhancement with stranding of the surrounding subcutaneous fat.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. Mild periportal low attenuation is likely
secondary to fluid resuscitation. The gallbladder is within normal limits.
PANCREAS: The pancreas is atrophic but otherwise has normal attenuation
throughout, without evidence of focal lesions or pancreatic ductal dilatation.
There is no peripancreatic stranding.
SPLEEN: The spleen is top normal in size and exhibits normal attenuation
throughout, without evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is normal. There is no free
intraperitoneal fluid or free air.
PELVIS:
Apparent bladder wall thickening is likely due to its decompressed state. The
distal ureters are unremarkable. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES AND SOFT TISSUES: Heterogeneous sclerosis with soft tissue component
involving the T11 vertebral body and right transverse process appears similar
to the PET-CT dated ___. There is unchanged multilevel
anterolisthesis from the L2 to L5 levels. The patient is status post L2
through S1 laminectomy. Postsurgical soft tissue changes appear grossly
similar. There is no acute fracture. Small fat containing umbilical hernia.
IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic abnormality.
2. Increased size of postsurgical fluid collection within the right mastectomy
surgical bed measuring 17.2 x 2.9 cm, previously 13.5 x 1.4 cm. Please note,
infection of this collection cannot be excluded on the basis of this imaging
exam.
3. 0.5 cm left lower lobe ground-glass nodule may be inflammatory. Consider
three-month follow-up chest CT to assess stability.
4. No acute findings within the abdomen or pelvis.
5. Similar appearance of T11 vertebra metastasis without loss of vertebral
body height. No new osseous metastases.
Radiology Report
EXAMINATION: MRI THORACIC AND LUMBAR PT6 MR SPINE
INDICATION: ___ year old woman with breast cancer c/b metastasis to T11
(stable based on PET), bilateral lower extremity radiculopathy, lumbar spinal
stenosis L2 to S1, L2-L3/ L3-L4/ L4-L5 grade I spondylolisthesis, s/p
posterior lumbar decompression via L2 to S1 laminectomywith bilateral medial
facetectomy and foraminotomy and posterior lumbar arthrodesis L2-L5 using
local autograft and allograft who presents with worsening back pain without
relief to home pain meds, found to be tachycardic and febrile to 103 with GPC
in blood.// please assess for abscess please assess for abscess
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique,
followed by axial T2 imaging.
COMPARISON: MRI thoracic spine ___, CT lumbar spine ___,
MRI lumbar spine ___.. PET scan ___.
CT chest on pelvis ___.
FINDINGS:
Thoracic spine:
Metastasis involving T11 vertebral body,, posterior elements, probable
extension into the posterior paraspinal soft tissues and within right greater
than left T10-T11, T11-T12 foramina. Findings are progressed since ___,
___, and stable since today, recent PET scan. Abnormal fullness in the right
ventral, right lateral, right dorsal epidural space at T11, most consistent
with epidural tumor, it is brighter than typical, which may represent
posttreatment changes, postcontrast images would be helpful further
evaluation, there is severe central canal narrowing, complete loss of CSF
within thecal sac at this level. Mild cord edema, mild cord flattening.
No other masses in the thoracic spine. No evidence of disc space infection.
Multilevel degenerative changes thoracic spine, diffuse disc bulges, posterior
element hypertrophic changes contribute to mild central canal narrowing,
minimal flattening of the cord few levels, well preserved CSF about cord
dorsally. No other areas of cord signal abnormality. Other foramina in the
thoracic spine are patent.
Lumbar spine:
Incomplete exam, patient terminated the exam prematurely secondary to pain.
Only sagittal T2 with axial reconstructed images were obtained.
Arachnoiditis in the lumbar spine, new since ___. Degenerative changes
lumbar spine mild L3-L4, L4-5 anterolisthesis, degenerative in etiology,
similar. Minimal retrolisthesis L5-S1, similar. Multilevel diffuse disc
bulges. Lumbar facet arthritis. L2-L5 laminectomy.
Mild central canal narrowing L3-L4 level.
Central canal patent at other levels in the lumbar spine. Multilevel
foraminal narrowing, most prominent and moderate to severe at the right L3-L4
foramen. Moderate to severe left and moderate right L2-L3, moderate to severe
bilateral L3-L4, moderate to severe left and moderate right L4-5, mild left
and moderate to severe right foraminal narrowing.
IMPRESSION:
1. Metastasis involving T11 vertebral body, posterior elements, paraspinal,
epidural tumor. Severe central canal narrowing, mild cord flattening, mild
cord edema.
2. Postcontrast images would be helpful.
3. Incomplete lumbar spine MRI, mild central canal narrowing, arachnoiditis,
multilevel significant foraminal narrowing.
Radiology Report
EXAMINATION: MRI THORACIC AND LUMBAR PT6 MR SPINE
INDICATION: ___ year old woman with metastatic breast CA, acute on chronic
back pain// ___ hardware and lesion at T11 ___ hardware and lesion
at T11 ___ hardware and
lesion at t11
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique,
followed by axial T2 imaging. T1 sagittal and axial images were obtained
following gadolinium.
COMPARISON: Thoracic spine MRI of ___.
FINDINGS:
T11 vertebra demonstrates low T1 and high inversion recovery signal with mild
compression. There is anterior epidural and paraspinal soft tissue
enhancement identified (14:21). There is displacement and compression and
deformity of the spinal cord. No definite increased signal is visualized
within the spinal cord.
No other foci of abnormal signal are seen within the lumbar vertebral bodies.
From T12-L1 to L1-2 levels no abnormalities are seen. At L2-3 mild disc
bulging seen. At L3-L4 to L5-S1 levels the patient has undergone
laminectomies. Disc bulging is identified at L3-4 with moderate-to-severe
bilateral foraminal narrowing with disc bulging and moderate to severe left
and moderate right foraminal narrowing at L4-5 and severe right and mild left
foraminal narrowing at L5-S1 level. The canal is patent. However, there is
clumping of the nerve roots with somewhat segmented CSF posteriorly indicative
of arachnoiditis. Postcontrast images also demonstrate some enhancement of
the nerve roots consistent with arachnoiditis.
IMPRESSION:
1. Metastatic disease involving the T11 vertebra with epidural and paraspinal
soft tissue changes. There is severe spinal stenosis at this level with
compression of the spinal cord. Previously suspected increased signal within
the spinal cord could not be confirmed.
2. Laminectomies in the lower lumbar region with evidence of arachnoiditis in
the lower lumbar spine with clumping of the nerve roots. The findings have
progressed since the MRI of ___. There also appears to be a new
laminectomy at L2-3 level since that study.
3. Degenerative changes and foraminal narrowing from L3-4 to L5-S1 levels as
described above.
Radiology Report
EXAMINATION: RIGHT MASTECTOMY BED ULTRASOUND
INDICATION: ___ woman status post right mastectomy presents for
evaluation of possible fluid collection in the right mastectomy bed seen on
prior PET and CTA Chest.
COMPARISON: Correlation with PET dated ___ and CTA chest dated ___.
TECHNIQUE: Targeted breast ultrasound was performed in the area of concern on
recent PET imaging. Selected images were obtained.
FINDINGS:
Targeted ultrasound of the right mastectomy bed demonstrates an anechoic,
avascular fluid collection measuring 4.8 x 1 x 3.6 cm. This was subsequently
drained and the aspirate was sent for culture and sensitivity.
IMPRESSION:
Fluid collection measuring up to 4.8 cm in the right mastectomy bed which
subsequently underwent drainage, which is dictated under separate report.
RECOMMENDATION(S): Ultrasound guided fluid drainage.
NOTIFICATION: Findings and recommendation for drainage were reviewed with the
patient who agreed with the plan. The drainage was performed immediately
following completion of the diagnostic ultrasound.
BI-RADS: 2 Benign.
Radiology Report
EXAMINATION: RIGHT BREAST ULTRASOUND GUIDED ASPIRATION
INDICATION: ___ woman admitted with sepsis has a fluid collection
along the right mastectomy scar. Ultrasound-guided aspiration for the
purposes of microbiology was requested.
COMPARISON: The relevant images for this procedure were available for review.
FINDINGS:
Please see information from same day ultrasound performed immediately prior to
this procedure.
PROCEDURE: The procedure, risks, benefits and alternatives were discussed
with the patient and written informed consent was obtained.
Time-out certification: Performed using three patient identifiers. Allergies
and/or Medications: Reviewed prior to the procedure.
Clinicians: ___, NP and ___. ___, MD.
Description: Using ultrasound guidance, aseptic technique and 1% lidocaine for
local anesthesia, an 16 gauge needle was advanced to the fluid collection at
the lateral aspect of her mastectomy scar. 5 cc of thin opaque yellow fluid
was aspirated. Manual compression along the mastectomy scar upon aspiration
yielded no additional fluid. There is a thin amount of fluid collection along
the mastectomy scar remaining with multiple loculations. The needle was
removed and hemostasis was achieved.
Estimated blood loss: < 1 cc.
Specimens: None.
Anesthesia: ___ cc 1% lidocaine
Complications: No immediate complications.
Post procedure diagnosis: Aspirated fluid collection right breast
IMPRESSION:
Technically successful US-guided aspiration of the right breast fluid
collection.
Standard post care instructions were provided to the patient.
Radiology Report
EXAMINATION: RIGHT BREAST/CHEST WALL ULTRASOUND
INDICATION: Right mastectomy with subsequent breast surgical site infection,
status post aspiration of breast fluid collection. Request was made to
reassess the mastectomy bed.
COMPARISON: Prior ultrasounds of ___.
TECHNIQUE: Targeted ultrasound of the mastectomy bed was performed. Selected
images were obtained.
FINDINGS:
Targeted sonographic examination of the mastectomy bed near the scar was
performed. There is a heterogeneous fluid collection seen in the mastectomy
bed along the scar, medially, centrally and laterally. Unlike previous, the
cavity today has multiple internal echoes and septations and is complicated.
Medially the collection measures 13 mm in AP dimension, centrally it measures
3-4 mm in AP dimension, and laterally it measures 10 mm in AP dimension.
IMPRESSION:
Complicated fluid collection along the mastectomy scar. Given the internal
complexity, it is unlikely that fluid could be aspirated from this area.
Findings were called to Dr. ___ clinician, by ___,
nurse practitioner at the time of the exam. A decision was made to perform no
intervention at this time.
RECOMMENDATION(S): Per referring clinician and breast care team.
NOTIFICATION: Findings reviewed with the patient at the completion of the
study.
BI-RADS: 2 Benign.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Back pain, R Shoulder pain
Diagnosed with Low back pain, Unsp injury of right shoulder and upper arm, init encntr, Tachycardia, unspecified, Exposure to other specified factors, initial encounter
temperature: 98.2
heartrate: 118.0
resprate: 16.0
o2sat: 98.0
sbp: 129.0
dbp: 66.0
level of pain: 10
level of acuity: 3.0 | Ms. ___ is a ___ with PMH notable for invasive ductal
carcinoma of the right breast (ER+, HER2+, confirmed by core
biopsy) s/p R mastectomy ___, multiple spinal surgeries who
presents with acute on chronic back pain in the setting of high
fevers, decreased PO intake, tachycardia, transfered to the FICU
due to sinus tachycardia, and found to have GPC bacteremia for
which she was treated with vanc/levoquin initially, then found
to have group B strep bacteremia and underwent uncomplicated
desensitization to ceftriaxone.
#R mastectomy site fluid collection
# Group B strep Bacteremia
Growing GPCs in pairs/chains multiple bottles, with concern with
infection in the back given her past procedures. Obtained MRI of
the spine - no evidence of hardware infection or soft tissue
infection. She was noted to have purulent drainage from R
mastectomy site which was cultured - and ultimately grew group B
strep as well. ID consulted for GPC bacteremia and TTE was
ordered - no e/o of endocarditis. She was initially treated with
IV vanc and Levaquin then transitioned to ceftriaxone after
desensitization in ICU. Patient underwent aspiration of R breast
fluid collection. She will complete a two week course of
ceftriaxone from date of fluid aspiration (EOT ___. Patient
will follow up in ___ clinic.
#Mestatatic breast CA to T11
#Acute on chronic back pain
Unclear if related to tumor burden and progression of disease
vs. chronic degenerative changes. Images reviewed by patient's
oncologist and orthopedic surgeon and T11 lesion felt to be
larger and now with spinal cord compression (although patient
with stable neuro exam over past several months). Rad Onc was
consulted and patient was start on radiation therapy on ___.
Given ongoing severe back pain and difficulty with achieving
adequate analgesia in the past, CPS consulted and recommended
pain regimen ultimately consisting of Dilaudid 4 mg Q4H PO PRN
pain (#60 tabs prescribed).
#R shoulder pain - patient reports pain after fall, X-ray
without acute abnormality and no obvious soft tissue swelling.
Reviewed CT chest with radiology - shoulder not fully visualized
however no discernible effusion for arthrocentesis, less concern
for septic arthritis Her pain improved with Tylenol and ice
packs TID.
#Sinus tachycardia - improved after fever broke with IVF and
treatment of infection as above |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Macrobid / codeine / daptomycin
Attending: ___
Chief Complaint:
Fever, N/V
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old gentleman with complicated past medical history
including recurrent UTIs (MDR pseudomonas, ESBL E. coli,
stenotrophomonas) ___ obstructive uropathy and L ureteral
stricture requiring chronic Foley and L nephrostomy tube
placement, ESRD on TTS HD, atrial fibrillation, possible CHB
with
junctional escape (no PPM), eosinopilic pneumonia thought ___
daptomycin, who presents for fevers at home.
Patient reports that he developed fevers, chills for the past
___
days, with a tmax of 102.7 associated with chills. He also
reports nausea and few episodes of NBNB emesis. Denies any
cough,
shortness of breath. At baseline wears 2LNC at night for
comfort.
He reports having pain at the tip of penis, which is his usual
symptom of UTI. He has been having BM every ___ days, which is
his normal and denies any melena/hematochezia. He denies any new
pain, swelling, redness at his L knee, where he recently had
washout. No issues with his LUE PICC, no swelling, erythema,
irritation at the site. Denies any neck stiffness, headaches. He
reports feeling otherwise well besides the fever, and is
frustrated at being at the hospital, hoping not to be admitted
for long.
In the ED, initial vitals: 98.2 108 146/11 18 98% RA
- Exam notable for:
CHEST: HD catheter site on R side of chest, surrounding area is
clean and dry
RESP: lungs clear
EXT: LUE with PICC in place with no surrounding erythema, LLE
with vertical incision with no surrounding erythema or
induration
- Labs notable for:
7.9
7.2>----<190
134 96 31 AGap=16
------------< 111
4.6 22 3.8
INR 2.9
UA w/ 43 WBC, 16 RBC, no bacteria, Lg leuk, neg nit
Flu negative
- Imaging notable for:
CXR: Mild to moderate pulmonary vascular congestion
- Pt given: vancomycin, cefepime, home lorazepam, oxybutynin,
oxycodone, atorvastatin
Upon arrival to the floor, the patient reports history as above.
Past Medical History:
- ESRD on HD (AIN, IgA nephropathy, obstructive nephropathy)
- L ureteral stricture (s/p L perc nephrostomy)
- Chronic bladder outlet obstruction (s/p TURP c/b urinary
retention and chronic foley)
- Multiple UTIs (MDR pseudomonas, ESBL E. coli,
stenotrophomonas)
- L knee septic arthritis
- Acute eosinophilic pneumonia (thought ___ daptomycin)
- Atrial fibrillation
- CHB with junctional escape
- Hypothyroidism
- Hypertension
- Hyperlipidemia
- Crush injury resultng in multiple spine/ortho surgeries, ___
weakness
- PF4 Heparin Ab positive, Serotonin Release Assay Negative
- DVT
- Anemia of chronic disease
- Gout
- BPH
- OSA on CPAP
- B12 deficiency
Social History:
___
Family History:
- Mother died of liver cancer
- Father died of MI at age ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 99.8 135/68 60 18 97% RA
General: laying in bed comfortably in no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: No neck stiffness
CV: RRR. S1, S2. No mrG
Chest: Right tunneled HD line c/d/i
Lungs: Unlabored breathing. CTA b/l.
Abdomen: +BS. Soft, NTND
GU: +foley. L perc nephrostomy c/d/i
Ext: Warm, well perfused. No ___ edema. L knee surgical site
c/d/i. LUE PICC c/d/I. no erythema
Skin: Warm, dry, no rashes or notable lesions.
Neuro: CNII-XII grossly intact. no focal deficits.
DISCHARGE PHYSICAL EXAM:
24 HR Data (last updated ___ @ 1318)
Temp: 98.3 (Tm 99.2), BP: 102/53 (99-126/49-75), HR: 55
(49-65), RR: 18 (___), O2 sat: 98% (97-99), O2 delivery: 2l
General: Laying in bed comfortably in no acute distress
CV: RRR. S1, S2. Systolic ejection murmur radiating to carotids.
Chest: Right tunneled HD line c/d/i
Lungs: CTAB
Abdomen: Soft, NTND, +BS
GU: +foley. L perc nephrostomy site covered with clean bandage.
Ext: Warm, well perfused. No ___ edema. L knee surgical site
c/d/I.
Skin: Warm, dry, no rashes.
Neuro: AOx3, moving all extremities.
Pertinent Results:
ADMISSION LABS:
===============
___ 03:31PM BLOOD WBC-7.2 RBC-2.64* Hgb-7.9* Hct-25.0*
MCV-95 MCH-29.9 MCHC-31.6* RDW-16.9* RDWSD-58.3* Plt ___
___ 09:05PM BLOOD ___ PTT-41.2* ___
___ 03:31PM BLOOD Glucose-111* UreaN-31* Creat-3.8* Na-134*
K-4.6 Cl-96 HCO3-22 AnGap-16
___ 03:31PM BLOOD ALT-25 AST-43* AlkPhos-28* TotBili-0.5
INTERVAL LABS:
==============
___ 05:19AM BLOOD CRP-219.5*
___ 03:31PM BLOOD calTIBC-135* TRF-104*
___ 05:30AM BLOOD Hapto-252*
___ 05:30AM BLOOD Ret Aut-1.7 Abs Ret-0.05
DISCHARGE LABS:
===============
___ 06:45AM BLOOD WBC-7.6 RBC-2.45* Hgb-7.1* Hct-22.7*
MCV-93 MCH-29.0 MCHC-31.3* RDW-17.8* RDWSD-59.6* Plt ___
___ 06:45AM BLOOD Glucose-100 UreaN-32* Creat-3.7* Na-130*
K-4.0 Cl-92* HCO3-26 AnGap-12
___ 05:19AM BLOOD ALT-16 AST-27 LD(LDH)-222 AlkPhos-33*
TotBili-0.3
___ 06:45AM BLOOD Calcium-8.6 Phos-4.2 Mg-1.7
MICRO:
======
___ 2:16 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
STENOTROPHOMONAS MALTOPHILIA. >100,000 CFU/mL.
YEAST. QUANTITATION NOT AVAILABLE.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STENOTROPHOMONAS MALTOPHILIA
|
TRIMETHOPRIM/SULFA---- <=1 S
___ BLOOD CULTURE: NO GROWTH
___ BLOOD CULTURE: NO GROWTH
___ BLOOD CULTURE: NO GROWTH
___ BLOOD CULTURE: NO GROWTH
IMAGING:
========
___ MRI L KNEE
1. Study is limited due to motion degradation artifact. Within
this
limitation, there are multiple areas of osteonecrosis about the
left knee
involving the distal femur, proximal tibia, and patella. No
evidence of
osteomyelitis.
2. Limited evaluation of the knee joint is notable for severe
tricompartmentaldegenerative changes. ACL is not well
visualized and a tear is difficult to exclude.
3. Extensive muscle atrophy. No drainable Fluid collection or
rim enhancing abscess seen.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. amLODIPine 10 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Docusate Sodium 100 mg PO BID
5. Finasteride 5 mg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Furosemide 40 mg PO 4X/WEEK (___)
8. Levothyroxine Sodium 50 mcg PO DAILY
9. LORazepam 1 mg PO Q6H:PRN anxiety
10. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain -
Moderate
11. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
12. Senna 8.6 mg PO BID
13. Sertraline 150 mg PO DAILY
14. Acetaminophen 1000 mg PO Q8H
15. Piperacillin-Tazobactam 2.25 g IV Q12H
16. Polyethylene Glycol 17 g PO DAILY
17. Cyanocobalamin 500 mcg PO DAILY
18. Fosfomycin Tromethamine 3 g PO WEEKLY
19. Oxybutynin 5 mg PO BID
20. Vitamin D 1000 UNIT PO DAILY
21. Warfarin 3 mg PO DAILY16
22. Vancomycin 1000 mg IV HD PROTOCOL
23. Nystatin Cream 1 Appl TP BID
Discharge Medications:
1. Miconazole 2% Cream 1 Appl TP BID
RX *miconazole nitrate 2 % twice daily Refills:*0
2. Warfarin 1 mg PO DAILY16
3. Acetaminophen 1000 mg PO Q8H
4. Allopurinol ___ mg PO DAILY
5. Atorvastatin 20 mg PO QPM
6. Cyanocobalamin 500 mcg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Finasteride 5 mg PO DAILY
9. FoLIC Acid 1 mg PO DAILY
10. Fosfomycin Tromethamine 3 g PO WEEKLY
11. Furosemide 40 mg PO 4X/WEEK (___)
12. Levothyroxine Sodium 50 mcg PO DAILY
13. LORazepam 1 mg PO Q6H:PRN anxiety
14. Nystatin Cream 1 Appl TP BID
15. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain -
Moderate
16. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
17. Polyethylene Glycol 17 g PO DAILY
18. Senna 8.6 mg PO BID
19. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Fevers
L knee osteonecrosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: KNEE (AP, LAT AND OBLIQUE) LEFT
INDICATION: ___ year old man with L septic knee s/p washout on ___ now
with recurrent fevers// eval for effusion, evidence of osteo
TECHNIQUE: Frontal, oblique, and lateral view radiographs of the left knee
COMPARISON: None
FINDINGS:
No fracture or dislocation is seen. There is severe degenerative changes about
the knee, most pronounced in the medial and lateral compartments. A moderate
joint effusion is present. Evaluation for osteomyelitis or septic joint is
not possible on this exam. There is mottled osseous mineralization, likely
secondary to the extensive degenerative change.
IMPRESSION:
Severe degenerative changes about the left knee. If there is clinical concern
for septic joint, further evaluation with direct fluid sampling is
recommended.
Radiology Report
EXAMINATION: MR KNEE W/O CONTRAST LEFT
INDICATION: ___ year old man with ESRD on dialysis and left septic knee s/p OR
washout, with elevated ESR/CRP concerning for osteomyelitis. Per discussion
over the phone, plan is to start study without contrast and proceed to
contrast if needed.// Please evaluate for osteomyelitis
TECHNIQUE: Multiplanar images of the knee were performed without the
administration of intravenous contrast using a mass infection MRI knee
protocol
COMPARISON: Left knee radiographs ___
FINDINGS:
Study is limited due to motion.
There is no acute fracture or dislocation. No T1 hypointense bone marrow
replacement signal to suggest osteomyelitis or significant bone marrow edema.
Geographic areas with serpiginous STIR hyperintense rim is identified in the
distal femur, proximal tibia, and patella. The largest such area is partially
imaged in the tibia. These areas the areas in the patella, posterior medial
femoral condyle, and medial tibial plateau appear to extend to the articular
surfaces without any clear evidence of cortical disruption or subchondral
collapse.
Evaluation of knee structures such as ligaments, menisci are limited as the
study was tailored for detection of infection and image quality is degraded by
patient motion artifact. Within this limitation, PCL, quadriceps tendon,
patellar tendon appear intact. There is no joint effusion ___ cyst.
ACL is not visualized and injury is difficult to exclude. Anterior horn of
the lateral meniscus appears heterogeneous, suspicious for tear. There is
also irregularity of the lateral meniscus posterior horn near the root
attachment and fraying of the free edge. The medial appearance of the
posterior horn the medial meniscus may be related to degenerative tearing
versus prior partial meniscectomy
There is near denuding of the medial compartment and extensive full-thickness
loss as well in the patellofemoral and lateral compartments.
Tricompartmental marginal osteophytes are present.
There is extensive muscle atrophy. No drainable Fluid collection or rim
enhancing abscess seen.
IMPRESSION:
1. Study is limited due to motion degradation artifact. Within this
limitation, there are multiple areas of osteonecrosis about the left knee
involving the distal femur, proximal tibia, and patella. No evidence of
osteomyelitis.
2. Limited evaluation of the knee joint is notable for severe tricompartmental
degenerative changes. ACL is not well visualized and a tear is difficult to
exclude.
3. Extensive muscle atrophy. No drainable Fluid collection or rim enhancing
abscess seen.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with ESRD, rec UTIs with fever and productive
cough.// ? pneumonia ? pneumonia
IMPRESSION:
Left PICC line tip is at the level of junction of left brachycephalic vein and
SVC. Heart size is enlarged. Mediastinum is stable. Right internal jugular
line tip is in the proximal right atrium.
There is no evidence of pulmonary edema. No appreciable pleural effusion or
pneumothorax.
Gender: M
Race: WHITE - EASTERN EUROPEAN
Arrive by AMBULANCE
Chief complaint: Fever, N/V
Diagnosed with Fever, unspecified
temperature: 98.2
heartrate: 108.0
resprate: 18.0
o2sat: 96.0
sbp: 146.0
dbp: 111.0
level of pain: 0
level of acuity: 3.0 | ___ year old gentleman with L septic knee s/p recent washout,
ESRD on TTS HD, recurrent MDR UTIs ___ obstructive uropathy and
L ureteral stricture requiring chronic Foley and L nephrostomy
tube placement, AFlutter, CHB with junctional escape (no PPM),
hx eosinophilic pneumonia ___ daptomycin, who presented for 5
days of fever at home despite IV antibiotics. No infectious
source was identified and his antibiotics were stopped on ___
at the recommendation of the ID team with no fevers for 5 days
prior to discharge. L knee MRI showed no evidence of infection.
TRANSITIONAL ISSUES
===================
[] Sertraline held due to QTc prolongation, follow up QTc and
consider restarting if improved
[] Follow up with cardiology for Aflutter and ?CHB w/ junctional
escape, consider need for PPM
[] Will need nephrostomy tube replacement, appointment being
scheduled
ACUTE ISSUES
============
#Fevers
He was admitted with 5 days onset of fevers while on
broad-spectrum antibiotics with vancomycin and Zosyn for
treatment of a septic joint. DDX course fevers included line
infection, UTI, recurrence of septic joint. He completed his
last day of his antibiotics course on ___. At that point,
antibiotics were discontinued and he was monitored for signs of
fever per ID recommendations. Urine culture was positive for
Stenotrophomonas but this was thought rather to represent
colonization than true infection given his lack of associated
symptoms. L knee MRI was obtained which showed osteonecrosis but
no evidence of infection. Blood cultures showed no growth,
influenza negative, CXR w/o signs of pneumonia. He was afebrile
until ___ when he had an isolated T100.8 after HD. He was
afebrile with no growth on blood cultures for 48 hours and was
discharged with ID follow-up.
#Chronic L ureteral stricture s/p chronic L PCN:
#Chronic bladder outlet obstruction s/p TURP c/b urinary
retention and chronic foley
#History of recurrent UTI:
Has left pan-ureteral stricture of unclear etiology requiring
chronic L PCN and chronic Foley. His Foley was exchanged on
admission. He was continued on preventative fosfomycin. His
nephrostomy tube was scheduled to be replaced, but the patient
refused this while inpatient preferring to have this done as an
outpatient. An appointment is being scheduled at time of
discharge. Urine culture was positive for Stenotrophomonas but
this was thought rather to represent colonization than true
infection given his lack of associated symptoms.
#ESRD on HD (___)
#Chronic bladder outlet obstruction s/p TURP c/b urinary
retention and chronic foley
#L ureteral stricture s/p L perc nephrostomy
He was continued on his regular HD schedule while inpatient
(___), home Lasix 40mg on non-HD days, and home sevelamer.
#L knee septic joint s/p washout ___
#L knee ostenecrosis
Seen by orthopedics who felt the surgical wound is healing well
and there were no signs of septic joint. MRI ___ showed no
evidence of osteomyelitis but did show osteonecrosis. Seen by
ortho with no indication for surgery at this time.
___ embolization
Patient had previously discussed with urologist the possibility
of a L renal embolization vs nephrectomy to reduce the risk of
recurrent UTIs, requesting to revisit this issue as an
outpatient.
#Balanitis
His was started on topical miconazole for treatment. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
atorvastatin / Seroquel / Klonopin
Attending: ___.
Chief Complaint:
chills, shaking
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ is a ___ yr old PMH diabetes, HTN, sleep apnea,
osteoarthritis who is presenting 2 days after a tooth extraction
with rigors, chills, and feeling unwell.
She reports that on ___ of this week she had a crown come
out
so on ___ she had her tooth extracted on her lower left
mouth. As soon as the novicane wore off she started feeling
chills. She felt weak as well so she drank OJ and glucerna. She
initially felt better. Then on ___ she was still low
energy.
She presented to her acupuncturist who helped "fix her energy",
but it did make her feel better. She began having more chills
and
shaking. According to her daughter she was not breathing well
either. Her neighbor is a pediatrician and came over and said
she
looked pale and unwell, that coupled with her daughter's
thoughts
resulted in them calling an ambulance to go to the hospital. The
daughter noted that the patient was confused. She noted that she
felt febrile at that time.
In the ED, initial vitals showed a temperature to 103, HR 124,
BP
125/81, 20 on 100% non-rebreather. The exam was non-focal. She
was mildly confused and unable to recall certain events.
Labs notable for a stable chemistry, a WBC count to 11.1, normal
LFTs, negative trop, lactate 2.0, negative flu, and UA w/ 6 WBC,
few bact, sm leuk, and 2 epis.
A CXR showed mild pulmonary vascular congestion, no focal
consolidation.
Pt given acetaminophen 1000 mg, 2 L NS, Zosyn, vanco,
notrtriptyline 50 mg.
Vitals prior to transfer: 98.3, HR 78, BP 106/55, RR 15, 99% Ra.
Upon arrival to the floor, the patient reports she is feeling
much better. She denies fever, chills, headaches, shortness of
breath, nausea, vomiting, further shaking. She says she no
longer
feels confused. She denies sick contacts. She denies ever
feeling
this way before.
On ROS she denies dizziness, lightheadness, chest pain,
palpitations, difficulty laying flat, leg edema, nausea,
vomiting, diarrhea, constipation, urinary frequency, burning w/
urination, rashes, joint pain (other than her chronic back
pain).
Past Medical History:
OSA
Pre-DM
HTN
HLD
Anxiety
Depression
Osteoarthritis
Social History:
___
Family History:
non- contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: 24 HR Data (last updated ___ @ 139)
Temp: 98.0 (Tm 98.0), BP: 116/67, HR: 75, RR: 17, O2 sat:
97%, O2 delivery: Ra
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD, mouth with no obvious
deformities in socket, she does have poor dentition overall.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Warm, dry, no rashes or notable lesions.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally.
DISCHARGE PHYSICAL EXAM
=======================
VITALS: 24 HR Data (last updated ___ @ 744)
Temp: 98.1 (Tm 98.5), BP: 118/70 (118-133/65-76), HR: 75
(75-87), RR: 18 (___), O2 sat: 94% (94-97), O2 delivery: Ra
General: Sitting up in chair, NAD
HEENT: Sclerae anicteric, oropharynx clear, site of L lower
tooth extraction without erythema, exudate, or induration,
non-tender.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
Ext: Warm, well perfused, no clubbing, cyanosis or edema
Skin: Warm, dry, no rashes or notable lesions.
Pertinent Results:
ADMISSION LABS
==============
___ 08:00PM BLOOD WBC-11.1* RBC-4.19 Hgb-11.9 Hct-36.5
MCV-87 MCH-28.4 MCHC-32.6 RDW-15.4 RDWSD-48.6* Plt ___
___ 08:00PM BLOOD Neuts-84.6* Lymphs-10.0* Monos-4.2*
Eos-0.6* Baso-0.2 Im ___ AbsNeut-9.40* AbsLymp-1.11*
AbsMono-0.47 AbsEos-0.07 AbsBaso-0.02
___ 08:00PM BLOOD Glucose-126* UreaN-25* Creat-0.8 Na-138
K-4.1 Cl-98 HCO3-23 AnGap-17
___ 08:00PM BLOOD ALT-17 AST-14 AlkPhos-73 TotBili-0.3
___ 08:00PM BLOOD Albumin-4.1 Calcium-9.8 Phos-2.6* Mg-1.9
___ 08:09PM BLOOD ___ Temp-38.6 pO2-40* pCO2-31*
pH-7.51* calTCO2-26 Base XS-1
___ 08:09PM BLOOD Lactate-2.0
REPORTS
=======
CHEST (PA & LAT) Study Date of ___
The lungs are clear without focal consolidation. There is mild
pulmonary
vascular congestion without frank pulmonary edema. No pleural
effusion or
pneumothorax is seen. The cardiac and mediastinal silhouettes
are
unremarkable. There are degenerative changes of the bilateral
shoulders.
Blood culture ___: NGTD
Blood culture ___: NGTD
Blood culture ___: NGTD
Urine culture ___: NGTD
DISCHARGE LABS
==============
___ 07:19AM BLOOD WBC-6.7 RBC-3.74* Hgb-10.5* Hct-33.7*
MCV-90 MCH-28.1 MCHC-31.2* RDW-15.6* RDWSD-51.8* Plt ___
___ 07:19AM BLOOD Glucose-101* UreaN-13 Creat-0.8 Na-143
K-4.2 Cl-106 HCO3-22 AnGap-15
___ 07:19AM BLOOD Calcium-9.2 Phos-3.1 Mg-2.2
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
2. Fexofenadine 60 mg PO DAILY
3. Ibuprofen 200 mg PO Q6H:PRN Pain - Mild
4. Magnesium Oxide 200 mg PO BID
5. amLODIPine 5 mg PO DAILY
6. Nortriptyline 60 mg PO QHS
7. BuPROPion 100 mg PO DAILY
8. MetFORMIN (Glucophage) 500 mg PO BID
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 6 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tab-cap by mouth
twice a day Disp #*12 Tablet Refills:*0
2. amLODIPine 5 mg PO DAILY
3. BuPROPion 100 mg PO DAILY
4. Fexofenadine 60 mg PO DAILY
5. Ibuprofen 200 mg PO Q6H:PRN Pain - Mild
6. Magnesium Oxide 200 mg PO BID
7. MetFORMIN (Glucophage) 500 mg PO BID
8. Nortriptyline 60 mg PO QHS
9. HELD- Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY This
medication was held. Do not restart Triamterene-HCTZ (37.5/25)
until discussing with your doctor.
Discharge Disposition:
Home
Discharge Diagnosis:
Sepsis likely secondary to oropharyngeal source
Diabetes mellitus
Hypertension
Obstructive sleep apnea
Osteoarthritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MR ___ SPINE W/O CONTRAST ___ MR SPINE
INDICATION: ___ year old woman with left lumbar radicular distribution pain
and weakness// left lumbar radicular symptoms with pain and assoc weakness, ?
nerve compression left lumbar radicular symptoms with pain and assoc
weakness,
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique,
followed by axial T2 imaging.
COMPARISON: None.
FINDINGS:
Degenerative changes lumbar spine. Congenital narrowing spinal canal..
Lumbar curve convex to the left centered at L2-L3. Grade 1 L4-5
anterolisthesis, degenerative. Multilevel endplate hypertrophic change, disc
space narrowing, diffuse disc bulges. Advanced lumbar facet arthritis.
Effusions bilateral L4-5 facet joints. Normal visualized cord. No worrisome
osseous lesions.
At L1-L2, patent central canal, patent foramina.
At L2-L3, mild-to-moderate central canal narrowing, preserved CSF. Moderate
right, mild left foraminal narrowing.
At L3-L4, moderate central canal narrowing, incomplete effacement of CSF.
Moderate to severe right foraminal narrowing, mild flattening of the exiting
L3 nerve best seen on sagittal images. Mild-to-moderate left foraminal
narrowing.
At L4-5, diffuse disc bulge. Moderate central canal narrowing, preserved CSF.
Advanced left facet arthritis, mass-effect on both traversing L5 nerves, left
greater than right. Severe left, moderate right foraminal narrowing.
At L5-S1, patent central canal. Moderate to severe left foraminal narrowing,
flattening of exiting left L5 nerve. Moderate right foraminal narrowing.
Benign parapelvic cyst left kidney. Cholelithiasis.
IMPRESSION:
1. Advanced degenerative changes lumbar spine.
2. Congenital narrowing spinal canal.
3. Moderate central canal narrowing L3-L4, L4-5 levels.
4. Multilevel significant foraminal narrowing, as above.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, Hypoxia
Diagnosed with Fever, unspecified
temperature: 103.0
heartrate: 124.0
resprate: 20.0
o2sat: 100.0
sbp: 125.0
dbp: 81.0
level of pain: uta
level of acuity: 2.0 | ___ is a ___ yr old woman with PMH diabetes, HTN, sleep apnea,
osteoarthritis who is presenting 2 days after a tooth extraction
with rigors, chills, and feeling unwell, found to have transient
fever, hypotension, and tachycardia concerning for transient
bacteremia after tooth extraction.
#Sepsis
#Tooth extraction
On presentation, patient was hypotensive compared to baseline,
febrile, tachycardic with elevated RR and leukocytosis, but
without localizing symptoms. CXR without evidence of PNA, UA not
concerning for infection. Bcx currently NGTD. Notably, she has
poor dentition and did have a tooth extraction (left lower
molar) on ___ of last week which is concerning for a
transient bacteremia secondary to dental manipulation. Fevers,
chills, hypotension, and leukocytosis have resolved after IVF
and antibiotic administration and patient is feeling back to
baseline. Blood culture have been without growth to date. She
was transitioned from unasyn to augmentin for a total of 7 day
course of antibiotics (___).
#DM
Pre-diabetes per patient w/ HA1c < 6. Held home metformin,
receive ISS in house.
#HTN:
Presented hypotenstive and home anti-hypertensives were held.
Restarted amlodipine in house. Patient instructed to hold
Triamterene-HCTZ (37.5/25) until PCP follow up.
#OSA
Continued CPAP at night
#osteoarthritis
Continued Tylenol PRN
#CODE: Full (presumed)
#CONTACT: Daughter ___ ___
TRANSITIONAL ISSUES
===================
[] Patient's Triamterene-HCTZ was held due to normotension. Can
consider restarting as an outpatient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Benadryl / Compazine / Droperidol / Percocet / Vicodin /
Dilaudid
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with CKD, DM, and CAD presents for AMS.
Patient awoke this morning and followed her usual routine of
taking a shower. She took her AM insulin 35u then became
increasingly weak, diaphoretic, and confused and laid down in
bed and awoke 4 hours later with confusion and called her son.
He noticed that patient was behaving abnormally over phone, so
he called EMS, who found her to hypoglycemic to BS ___ and
patient was sent to ___ for further management.
In the ED, initial vitals were 95.3 62 155/63 16 100% RA. Labs
were notable for Chem-7 with K 5.4 Cr 1.2 (within baseline) and
Glu 66, CBC with WBC 16.6 with 91% PMNs, LFTS with AST 62
otherwise wnl, lactate 1.9, UA without evidence of infection but
with 500Glu. CXR without cardiopulmonary process, Head CT with
acute intracranial process, EKG with SR 90 but without evidence
of acute ischemia. Patient was administered 1 amp dextrose with
improvement in BS 210 then 141. However, patient remained sleepy
and is being admitted to Medicine for further management of AMS.
VS prior to transfer 97.2 72 152/60 16 100% RA
On the floor, VS 98.2 147/65 77 20 100%RA. Patient is tired with
mild headache but otherwise without systemic complaints. ROS
notable recently azithromycin course for URI symptoms. Since
then, patient has had mild SOB for which she is on increased
dose of Advair inhaler. Denies fevers, chills, chest pain,
abdominal pain, nausea, vomiting, diarrhea.
Past Medical History:
Rheumatoid arthritis - on Methotrexate
Vit D Deficiency
Vitligo
Sinusitis
Back pain
Chronic bronchitis
Chest pain
H/O Optic neuritis
Anemia of Chronic Disease
CKD
Colonic adenoma
Constipation
CAD
DM
HSV II
Hyperparathyroidism
Hypertension
Osteoarthritis
Social History:
___
Family History:
Grandmother with rheumatoid arthritis. Mother with lung cancer.
Otherwise noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM
=================
Vitals: 98.2 147/65 77 20 100%RA
General: Well-appearing elderly lady, pleasant, tired, NAD
HEENT: NC/AT, PERRL, EOMI, dry MM, oropharynx clear
Neck: Supple
CV: RRR, +S1/S2, I/VI SEM
Lungs: CTAB
Abdomen: +BS, soft, NT/ND
GU: No foley
Ext: WWP, DP 2+, no edema
Neuro: CN II-XII intact, moving all extremities, no focal
deficits
Skin: Vitilago, otherwise no concerning lesions
DISCHARGE PHYSICAL EXAM
=================
General: Well-appearing elderly lady, pleasant, tired, NAD
HEENT: NC/AT, PERRL, EOMI, dry MM, oropharynx clear
Neck: Supple
CV: RRR, +S1/S2, I/VI SEM
Lungs: CTAB
Abdomen: +BS, soft, NT/ND
GU: No foley
Ext: WWP, DP 2+, no edema
Neuro: CN II-XII intact, moving all extremities, no focal
deficits
Skin: Vitaligo, otherwise no concerning lesions
Pertinent Results:
ADMISSION LABS
==============
___ 11:35AM BLOOD WBC-16.6*# RBC-3.53* Hgb-11.3* Hct-36.1
MCV-102* MCH-31.9 MCHC-31.2 RDW-13.1 Plt ___
___ 11:35AM BLOOD Neuts-90.7* Lymphs-5.4* Monos-3.6 Eos-0.2
Baso-0.2
___ 11:35AM BLOOD Glucose-66* UreaN-18 Creat-1.2* Na-143
K-5.4* Cl-109* HCO3-23 AnGap-16
___ 11:35AM BLOOD ALT-28 AST-62* AlkPhos-64 TotBili-0.2
___ 11:35AM BLOOD Albumin-4.0
___ 11:46AM BLOOD Lactate-1.9
DISCHARGE LABS
==============
___ 08:10AM BLOOD WBC-9.1 RBC-3.26* Hgb-10.0* Hct-32.8*
MCV-101* MCH-30.8 MCHC-30.6* RDW-13.6 Plt ___
___ 08:10AM BLOOD Glucose-141* UreaN-15 Creat-1.1 Na-140
K-4.7 Cl-106 HCO3-25 AnGap-14
REPORTS
=======
___ CT Head w/o contrast
No acute intracranial abnormality.
___ Chest X-Ray
No acute cardiopulmonary process. No significant interval
change.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing, sob
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN coughing, wheezing
3. Amlodipine 5 mg PO DAILY
4. Benzonatate 100 mg PO TID:PRN cough
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Gabapentin 600 mg PO TID
8. Lidocaine 5% Patch 1 PTCH TD QAM lower back
9. Lisinopril 30 mg PO DAILY
10. Methotrexate 10 mg PO 1X/WEEK (SA)
11. Omeprazole 40 mg PO DAILY
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
13. Simvastatin 10 mg PO DAILY
14. valsartan-hydrochlorothiazide 160-12.5 mg oral daily
15. Aspirin 81 mg PO DAILY
16. capsaicin 0.075 % topical Q8H:PRN pain
17. Vitamin D 1000 UNIT PO DAILY
18. dihydroxyacetone unkown topical unknown
19. Docusate Sodium 100 mg PO BID
20. HumuLIN N (NPH insulin human recomb) 100 unit/mL
subcutaneous see below
21. Senna 8.6 mg PO BID:PRN constipation
22. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN coughing, wheezing
2. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing, sob
3. Amlodipine 5 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Benzonatate 100 mg PO TID:PRN cough
6. Docusate Sodium 100 mg PO BID
7. Fluticasone Propionate NASAL 2 SPRY NU DAILY
8. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
9. FoLIC Acid 1 mg PO DAILY
10. Lidocaine 5% Patch 1 PTCH TD QAM lower back
11. Lisinopril 30 mg PO DAILY
12. Omeprazole 40 mg PO DAILY
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
14. Senna 8.6 mg PO BID:PRN constipation
15. Simvastatin 10 mg PO DAILY
16. Vitamin D 1000 UNIT PO DAILY
17. Methotrexate 10 mg PO 1X/WEEK (SA)
18. Gabapentin 600 mg PO TID
19. dihydroxyacetone 1 unknown TOPICAL Frequency is Unknown
20. capsaicin 0.075 % topical Q8H:PRN pain
21. Hydrochlorothiazide 12.5 mg PO DAILY
RX *hydrochlorothiazide 12.5 mg 1 capsule(s) by mouth daily Disp
#*30 Capsule Refills:*0
22. NPH 17 Units Breakfast
NPH 6 Units Dinner
Insulin SC Sliding Scale using REG Insulin
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
Hypoglyemia
Insulin-dependent diabetes
SECONDARY
Hypertension
Rheumatoid arthritis
Chronic bronchitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Altered mental status. Evaluate for pneumonia.
COMPARISON: ___.
FINDINGS: AP portable view of the chest. Cardiac, mediastinal and hilar
contours are normal. No focal consolidation, pleural effusion or
pneumothorax.
IMPRESSION: No acute cardiopulmonary process. No significant interval
change.
Radiology Report
INDICATION: Altered mental status.
COMPARISONS: None.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of IV contrast. Sagittal, coronal, and
thin-section bone reformatted images were obtained and reviewed.
TOTAL DLP: 1003.14 mGy-cm.
CTDI VOLUME: 55.61 mGy-cm.
FINDINGS: There is no evidence of hemorrhage, edema, mass, mass effect, or
large vascular territory infarction. The ventricles and sulci are normal in
size and configuration for the patient's age. The basal cisterns are patent.
There is preservation of gray-white matter differentiation. Atherosclerotic
calcifications are noted in the carotid arteries.
No fracture is identified. The visualized paranasal sinuses, mastoid air
cells, and middle ear cavities are clear.
IMPRESSION: No acute intracranial abnormality.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Hypoglycemia
Diagnosed with ALTERED MENTAL STATUS , DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN
temperature: 95.3
heartrate: 62.0
resprate: 16.0
o2sat: 100.0
sbp: 155.0
dbp: 63.0
level of pain: 0
level of acuity: 1.0 | ___ woman with chronic kidney disease, insulin-dependent
diabetes, and coronary artery disease who presented with altered
mental status in the setting of hypoglycemia.
# Altered Mental Status: The patient presented with altered
mental status in the setting of hypoglycemia to blood sugars ___
after she took her scheduled morning insulin without eating
afterwards. Notably, patient had been dieting recently and also
had a recent upper respiratory tract infection resulting in
decreased PO intake. Patient's altered mental status resolved
with treatment of hypoglycemia (see below). The ___ diabetes
team saw the patient and recommended a decreased insulin regimen
(see below). Notably, head CT in ED without evidence of acute
process. On admission, patient had leukocytosis with negative
infectious (chest X-ray and urinalysis), with leukocytosis
resolving the day after admission suggesting a stress response.
# Insulin-dependent Diabetes complicated by hypoglycemia: The
patient developed severe hypoglycemia of not eating after
morning insulin dose as well as dieting and recent illness.
Patient was administered dextrose and she started eating with
correction of hypoglycemia. The ___ diabetes team saw the
patient and recommended a decreased insulin regimen of 17 units
NPH QAM, 6 units NPH QPM, and regular insulin sliding scale at
breakfast lunch and dinner but NOT at bedtime. Patient was
advised that she needs to eat after administering insulin to
prevent further episodes of hypoglycemia.
# Chronic bronchitis: Patient had recent worsening of chronic
bronchitis in the setting of upper respiratory tract infection
treated with doxycycline. Respiratoy status was monitored and
remained stable during this admission. She was continued on her
home inhaler regimen without complications.
# Chronic kidney disease: Patient's renal function was monitored
and creatinine remained within her baseline of 1.2-1.5.
# Hypertension: Patient's blood pressure was monitored and
remained stable. She was continued on her home lisinopril 30mg
daily. Given unclear reason why patient was on both an
angiotensive receptor blocker and ___, Diovan was
discontinued and patient continued only on equivalent dose of
hydrochlorothiazide.
# Constipation: Remained stable. Patient was continued on home
regimen of colace, senna, miralax without complications.
============================
TRANSITIONAL ISSUES
============================
- Unclear why patient is on ___ and ___
discontinued, patient continued on HCTZ
- DECREASED insulin regimen to: 17 units NPH (Humalin N) in the
morning, 6 units NPH (Humalin N) at dinner, sliding scale of
regular insulin at breakfast lunch and dinner but NOT at bedtime |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Low back ___
Major Surgical or Invasive Procedure:
- None.
History of Present Illness:
___ w/ PmHx of chronic back ___ sciatica (followed
by ___ service), depression/GAD (followed by psych), chronic
migraines, alcohol use, now presenting with acute on chronic
exacerbation after mechanical fall earlier this morning.
She says she was in her usual state of health with chronic back
___ and intermittent sciatic-type shooting pains when she
tripped on her way to work this morning. She reports tripping on
a hangar. She fell and struck her right hip without head/neck
strike. She was able to walk to her workplace afterward although
her ___ was worsened over baseline. She says her chronic limp
on the right side was worse. She felt limited by the ___ but
denies having new focal weakness or numbness. By the time she
reached her workplace she was not able to stand the ___ so she
called ___ reporting ___ ___. She was tearful and crying on
phone. When told no Epi spots available in the next hour, she
called EMS to be taken to the hospital.
On arrival to ER, she is reported to have been in tremendous
___ and underwent XR of her hip. Perhaps 2 hours later she had
an episode of urinary incontinence while waiting in the ED bed.
She reports never having had episodes of incontinence prior to
this. She denies saddle anesthesia or stool incontinence or new
lower extremity numbness. Denies abdominal ___, nausea,
vomiting. No headache.
Of note, patient with stressful social situations related to
divorce proceedings, difficulties at work, caring for daughters.
Was seeing Dr. ___ in psychiatry and ___ in ___ this
fall for this. Appears to not have followed-up.
Also has history at ___ of calling in regarding back ___ and
requesting tyelnol #3 but refusing to come in and be seen as
well as some scattered ER presentations, both here and
elsewhere, for low back ___ for which she has at times been
given narcotics. There often seems to be a preceeding fall
accompanying most her ED presentations in the past.
In the ED, initial VS were: 10 98.4 70 137/88 18 98% RA. Code
cord was called due to concern about urinary incontinence report
and back ___. Neuro and ___ saw patient, imaging not
consistent with cord compression or acute change. ___
recommended f/u in clinic in 1 week. Neurology recommended ___
control. Patient was given percocet + diazepam and then when
___ not controlled multiple doses of IV morphine (5mg x 5) over
the span of 9 hours. Still reporting significnat ___ so
decision made to admit for ___ control as patient reporting
that she is unable to ambulate.
VS on transfer: 97.9 65 126/76 18 100%.
Past Medical History:
CHRONIC BACK ___ - managed by ___ management service in past,
has gotten steroid injections, history of ED presentations for
back ___ and ___ medications
DEPRESSION
GENERALIZED ANXIETY DISORDER
MIGRAINES
ALCOHOL USE
OBESITY
H/O ANALGESIC OVERUSE HEADACHE
H/O CERVICAL CANCER s/p TAH
Social History:
___
Family History:
Non contributory
Physical Exam:
ADMISSION EXAM:
VS: 97.2, BP 140/99, HR 63, RR 18, Sats 98% on RA
GENERAL: lying flat in bed, appears comfortable when MD enters
the room, anxious and exclaiming with ___ during certian exam
maneuvers
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
NECK: supple, obese
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: normal bowel sounds, soft, non-tender, non-distended
EXTREMITIES: WWP, no edema, 2+ pulses radial and dp
BACK: patient wincing in ___ when moving from sitting to
standing, needs examiner's help for this movement, jumping with
___ to lightest of touches to lumbar ___, generally tender to
light touch over lower back, but worst over ___, no
significant muscle spasm felt, mild tenderness wrapping around
to R hip
NEURO: awake, A&Ox3, moving toes, winces with ___ when moving
legs, moving upper ext without issue, sensation intact to light
touch over lower extremities
DISCHARGE EXAM:
BACK: Mild TTP over lumbar ___.
Rest of exam unchanged.
Pertinent Results:
ADMISSION LABS:
___ 12:30PM BLOOD WBC-6.3 RBC-5.17 Hgb-14.6 Hct-45.4 MCV-88
MCH-28.2 MCHC-32.2 RDW-13.3 Plt ___
___ 12:30PM BLOOD Neuts-65.0 ___ Monos-4.0 Eos-2.4
Baso-1.0
___ 12:30PM BLOOD Glucose-101* UreaN-10 Creat-0.8 Na-142
K-4.7 Cl-105 HCO3-23 AnGap-19
DISCHARGE LABS:
___ 07:20AM BLOOD Glucose-91 UreaN-10 Creat-0.8 Na-144
K-4.2 Cl-106 HCO3-28 AnGap-14
RELEVANT STUDIES:
MR ___:
IMPRESSION:
1. No significant spinal canal stenosis.
2. Degenerative findings in the lower lumbar ___, including
narrowing of
the subarticular zones bilaterally at L4-L5 with disk and facet
material
combining to contact the traversing L5 nerve roots bilaterally.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluoxetine 80 mg PO DAILY
2. Gabapentin 1600 mg PO BID
3. traZODONE 100 mg PO HS:PRN insomnia
4. HydrOXYzine ___ mg PO QHS:PRN insomnia
5. Naproxen 1500 mg PO QAM
6. Naproxen 1000 mg PO QPM
Discharge Medications:
1. Fluoxetine 80 mg PO DAILY
2. traZODONE 100 mg PO HS:PRN insomnia
3. Acetaminophen 1000 mg PO Q8H
4. Diazepam 5 mg PO Q8H:PRN ___, muscle spasm
RX *diazepam 5 mg 1 by mouth every eight (8) hours Disp #*15
Tablet Refills:*0
5. HydrOXYzine ___ mg PO QHS:PRN insomnia
6. Naproxen 1500 mg PO QAM
7. Naproxen 1000 mg PO QPM
8. Gabapentin 800 mg PO TID
RX *gabapentin 800 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
- Back ___
SECONDARY DIAGNOSES:
- Sciatica
- Degenerative Joint Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: Fall, landed on right side with right hip and pelvic pain.
TECHNIQUE: AP view of the pelvis, 2 views of the right femur and 2 views of
the right hip.
COMPARISON: None.
FINDINGS:
No acute fracture or dislocation is seen. Sacroiliac joints and pubic
symphysis are not diastatic. Hips are preserved. No focal lytic or sclerotic
osseous abnormalities are visualized. There are no soft tissue
calcifications. Within the imaged aspect of the right knee, there are mild
degenerative changes with osteophytic spurring in the medial and
patellofemoral compartments. No sizable knee effusion is present.
IMPRESSION:
No acute fracture or dislocation.
Radiology Report
HISTORY: Fall, landed on right side with low back pain.
TECHNIQUE: 2 views of the lumbar spine.
COMPARISON: Report from MRI of the lumbar spine ___. Images are not
available for direct comparison at this time.
FINDINGS:
No fracture or malalignment is identified. Vertebral body heights are
maintained. There are mild degenerative changes most pronounced at L1-2 with
anterior osteophyte formation and mild intervertebral disc space narrowing.
Sacroiliac joints are preserved. No suspicious lytic or sclerotic osseous
abnormalities are visualized.
IMPRESSION:
No acute fracture or malalignment.
Radiology Report
HISTORY: Incontinence and low back pain following a fall
COMPARISON: None available
Technique:
Multi planar MR images were acquired through the total spine without
intravenous contrast.
FINDINGS:
MRI CERVICAL SPINE:
Vertebral body heights and alignment are normal. Bone marrow signal reveals
no focal concerning abnormality. Spinal cord signal is normal. Note is made
of a circumferential disc bulge with shallow right paracentral disk protrusion
at C5-C6 as well as a disc bulge with shallow left paracentral protrusion at
C6-C7. These result in minimal spinal canal narrowing, with no evidence of
spinal cord compression or deformity.
MRI THORACIC SPINE:
Vertebral body heights and alignment are normal. There is no significant
spinal canal or neural foraminal stenosis. There is no disk herniation.
Spinal cord signal is normal.
MRI LUMBAR SPINE:
Vertebral body heights and alignment are normal. Bone marrow signal reveals
no focal concerning abnormalities. The conus medullaris terminates posterior
to the L1 vertebral body.
L1-L2: There is mild spinal canal narrowing, and no neural foraminal
narrowing. Note is made of a circumferential disk bulge and mild bilateral
facet arthropathy.
L2-L3: There is mild spinal canal narrowing and no neural foraminal
narrowing. Note is made of a small circumferential disc bulge. There is mild
bilateral facet arthropathy.
L3-L4: There is mild spinal canal narrowing, related to a circumferential
disk bulge, thickening of the ligamentum flavum bilaterally and mild bilateral
facet arthropathy. There is no neural foraminal stenosis.
L4-L5: There is mild spinal canal narrowing, and no neural foraminal
narrowing. Note is made of a circumferential disc bulge, moderate bilateral
facet arthropathy and thickening of the ligamentum flavum bilaterally. Disc
and ligamentum interior combine to narrow the subarticular zones bilaterally,
affecting the traversing L5 nerve roots.
L5-S1: There is no spinal canal or neural foraminal stenosis. Note is made
of a small circumferential disc bulge and mild bilateral facet arthropathy.
IMPRESSION:
1. No significant spinal canal stenosis.
2. Degenerative findings in the lower lumbar spine, including narrowing of
the subarticular zones bilaterally at L4-L5 with disk and facet material
combining to contact the traversing L5 nerve roots bilaterally.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: S/P FALL
Diagnosed with BACKACHE NOS, JOINT PAIN-PELVIS
temperature: 98.4
heartrate: 70.0
resprate: 18.0
o2sat: 98.0
sbp: 137.0
dbp: 88.0
level of pain: 10
level of acuity: 3.0 | ___ F w chronic back ___ sciatica (followed by ___
service), depression/GAD (followed by psych), chronic migraines,
alcohol use, now presenting with acute on chronic exacerbation
after mechanical fall.
# ACUTE ON CHRONIC BACK ___: MRI ___ showed degenerative
disk disease particularly in the L4-5 zones bilaterally with
disk and facet material combining to contact the traversing L5
nerve roots bilaterally, correlating with exam but there was no
spinal cord involvement. She was seen by ortho & neuro in ED.
Episode of ___ felt to be due to spasm after fall. ___
managed with Toradol, tylenol, & valium. Seen by ___ in AM; felt
to have sufficient mobility to be discharged home w ___. Given
BZD & increased dose of gabapentin at time of discharge. Pt
instructed to make follow up appointments with ___ & ___
center after discharge (numbers provided). |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
ALS assessment - dysphagia, dysarthria and weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year-old right-handed man with a history of HTN and HLD who
presents with 3 months of progressively worsening dysarthria,
dysphagia and generalized weakness. He reports that on ___ he woke up with difficulty speaking. He and his family
note that his voice used to be a very 'deep ___ voice' but
since that time is has been soft and hoarse, and he has to speak
slowly to avoid slurring his words. He was taken to the
hospital at that time, and underwent an MRI of the brain, which
showed no sign of a stroke, and was then referred for outpatient
neurology follow-up. Since that time he and his wife report
that his speech has been getting progressively worse. He
initially was somewhat better first thing in the morning, but
would be unintelligible by ~5pm, though now he notes that he has
difficulty speaking even first thing in the morning. Around the
same time he began to develop difficulty swallowing. He notes
this both with solids and with liquids, noting that things will
get stuck in his throat, and he will sometimes choke on them.
If he takes large drinks of water it will actually spit out of
his mouth. He also notes that he had to go from swallowing his
pills all at once, to taking them one at a time, or else he will
choke on them. He also feels as though he is occasionally
choking on his saliva.
During this time he also notes that he has been getting
progressively weaker, losing ~75% of his prior strength. He
reports that he used to walk or run up to 6 miles every other
day, climb mountains and work out with his Wii on a daily basis.
However, since ___ he has difficulty even getting up from
his couch unassisted, and can barely make it down to the end of
his driveway. He has difficulty going up stairs, though feels
as though this is a combination both of muscle weakness and
shortness of breath. He will also occasionally get cramps in
his legs, initially on the left side, now occurring on the right
leg as well. He feels as though his respiratory status is
getting slowly worse, feeling as though it is difficult to take
a deep breath in at times, though this has been gradual, and has
not acutely worsened.
After his initial hospitalization he was seen in follow-up,
where he initially underwent an EMG of his legs, as well as
extensive laboratory testing detailed below, including AChR
testing, all of which were negative. As his symptoms continued
to progress, he was then referred to ___. There
he underwent an EMG of all 4 extremities and the face, which
showed evidence of active denervation in 3 extremities. He and
his family report he was told at that time that he had ALS, and
that there was nothing to do for him 'and was sent home to die.'
___ notes the plan had been to obtain baseline pulmonary
function tests and arrange for him to follow-up in the ___
clinic, however it is unclear what happened after that. In an
attempt to find a second opinion, given his reports of
progressive weakness and respiratory distress, he was told to
come to the emergency department for further evaluation.
On neuro ROS, the pt denies headache, loss of vision, diplopia,
lightheadedness, vertigo, tinnitus or hearing difficulty. No
bowel or bladder incontinence or retention.
On general review of systems, the pt denies recent fever or
chills. No night sweats. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or abdominal pain. No recent change in bowel or bladder habits.
No dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
- HTN
- HLD
- Barrett's esophagitis
Social History:
___
Family History:
Mother died at age ___ of a aneurysm. Father died in his ___ of
alcoholism. He has 13 siblings, one with neuropathy and one
with a stroke, and a few with EtOH abuse, otherwise healthy.
Physical Exam:
Physical Exam:
Vitals: T: 99.2 P: 78 R: 16 BP: 156/85 SaO2: 98% on RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward
without difficulty. Language is fluent with intact repetition
and comprehension. Normal prosody. There were no paraphasic
errors. Pt. was able to name both high and low frequency
objects. Able to read without difficulty. Speech was soft and
nasal with mild dysarthria. Can count to 31 in one breath.
Able to follow both midline and appendicular commands. Pt. was
able to register 3 objects and recall ___ at 5 minutes. The pt.
had good knowledge of current events. There was no evidence of
apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades. Slight
right ptosis that worsens with sustained upgaze.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric, but weak
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline, but with slight atrophy and
decreased strength on the left.
-Motor: Atrophy of bilateral deltoids and left leg. Increased
tone on the right. Pronounced fasciculations of the left thigh.
No pronator drift bilaterally. No asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5- ___ ___ 5 5 5 5 5 5 5-
R 5- ___ ___ 5 5 5 5 5 5 4+
No fatiguable weakness.
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 3 3 3 2 1
R 2 2 2 2 1
Plantar response was extensor bilaterally. Increased jaw jerk.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Romberg absent.
.
.
Discharge examination:
Soft nasal speech. Bifacial weakness with slight right ptosis.
L tongue atrophy and weakness. L leg atrophy with
fasciculations in L thigh. 3+ reflexes with increased jaw jerk.
can count tp 40 in 1 breath
Pertinent Results:
Admission labs:
___ 12:40PM BLOOD WBC-7.1 RBC-4.79 Hgb-15.6 Hct-44.5 MCV-93
MCH-32.6* MCHC-35.1* RDW-12.4 Plt ___
___ 12:40PM BLOOD Neuts-60.9 ___ Monos-7.1 Eos-3.5
Baso-0.5
___ 05:10AM BLOOD ___ PTT-24.6 ___
___ 12:40PM BLOOD Glucose-188* UreaN-16 Creat-0.9 Na-138
K-6.3* Cl-103 HCO3-25 AnGap-16
___ 12:40PM BLOOD Calcium-9.3 Phos-3.1 Mg-2.4
.
Other pertinent labs:
___ 05:10 PREALBUMIN 27 ___ mg/dL
___ 12:40PM BLOOD CRP-2.8
___ 05:10AM BLOOD TSH-4.0
___ 05:10AM BLOOD %HbA1c-6.3* eAG-134*
___ 05:10AM BLOOD VitB12-___
___ 12:40PM BLOOD ALT-26 AST-52* CK(CPK)-199 AlkPhos-77
TotBili-0.3
___ 12:40PM BLOOD ESR-11
.
Discharge labs:
___ 07:40AM BLOOD WBC-5.7 RBC-4.70 Hgb-15.3 Hct-43.6 MCV-93
MCH-32.5* MCHC-35.0 RDW-12.9 Plt ___
___ 07:40AM BLOOD Glucose-116* UreaN-21* Creat-0.9 Na-139
K-4.4 Cl-103 HCO3-27 AnGap-13
___ 07:40AM BLOOD Calcium-9.0 Phos-3.1 Mg-2.2
.
.
Urine:
___ 07:26PM URINE Color-Straw Appear-Clear Sp ___
___ 07:26PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-150 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 07:56PM URINE Color-Yellow Appear-Clear Sp ___
___ 07:56PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 07:56PM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-0
___ 07:56PM URINE CastHy-3*
___ 07:56PM URINE Mucous-MOD
.
.
Microbiology:
___ 7:26 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
.
.
Cardiology:
ECG Study Date of ___ 12:43:08 ___
Sinus rhythm. Otherwise, normal tracing. No previous tracing
available for
comparison.
Read by: ___
Intervals Axes
Rate PR QRS QT/QTc P QRS T
67 122 98 ___ 37 -5 21
.
.
Radiology:
CHEST (PA & LAT) Study Date of ___ 2:58 ___
FINDINGS: No focal consolidation to suggest pneumonia is seen.
Linear
opacities at the bases likely reflect subsegmental atelectasis.
No
pneumothorax or pleural effusion is seen. No pulmonary edema is
present. The
heart, mediastinal and pleural surface contours are normal.
IMPRESSION: No radiographic evidence of pneumonia
.
MR CERVICAL SPINE W/O CONTRAST Study Date of ___ 8:05 ___
FINDINGS:
The cervical spine has normal lordotic curvature, vertebral body
height and
alignment. Discrete ___ type 2 endplate changes are seen
involving the
C2/C3 and C3/C4 segments. The intervertebral discs demonstrate
loss of T2
signal as a manifestation of degenerative disc disease.
At level C2/C3, there is an annular tear with central disc
protrusion which is
mildly impinging on the anterior thecal sac.
At level C3/C4, there is central disc protrusion that impinges
on the anterior
thecal sac and causes mild cord remodeling without T2 signal
abnormality. The
bilateral neural foramina are mildly narrowed by facet and
uncovertebral joint
arthropathy.
At level C4/C5, a median disc protrusion is impinging on the
anterior thecal
sac and is associated with mild flattening of the anterior cord.
The left
neural foramen is moderately narrowed by uncovertebral and facet
joint
osteophytes.
At C5/C6, the combination of median disc protrusion and
thickening of the
flavum ligament is associated with mild spinal canal narrowing
and minimal
flattening of the anterior spinal cord. The left neural foramen
is minimally
narrowed by uncovertebral osteophytes.
At level C6/C7, thickening of the flavum ligament and central
disc protrusion
are mildly impinging on the thecal sac.
The craniocervical junction is normal. The cervical cord
demonstrates a
normal intrinsic T2 signal. The posterior elements and
paraspinal soft
tissues are unremarkable.
IMPRESSION:
Multilevel, multifactorial degenerative changes of the cervical
spine with
multilevel cord remodelling and mild to moderate neural
foraminal stenosis as
detailed above.
.
VIDEO OROPHARYNGEAL SWALLOW Study Date of ___ 9:26 AM
FINDINGS: No gross aspiration or penetration. Pre-spill was
noted with
multiple consistencies of barium. Swallowing delay accompanied
by tongue
pumping also seen. There is mild prominence of the upper
esophageal
sphincter. For details, please refer to speech and swallow
division note in
OMR.
IMPRESSION: Mild pre-spill with swallowing delay and slight
prominence of
upper esophageal sphincter. No aspiration or penetration.
.
.
OSH results:
CK: 106
A1C: 6.5%
ESR: 10
Lyme: negative
___ virus: negative
Intrinsic factor: negative
TSH: 3.74
B12: 297
Folate: 11.0
Vitamin D: 22.8
___, Anti-Yo, Anti-Ri: negative
AChR binding, blocking and modulating: negative
Anti-striated: negative
___: negative
RPR: negative
Hypercoag panel: negative
.
.
*****************
Pending results:
.
Neurophysiology:
EMG ___
Report pending
.
Pending labs:
___ 02:15PM BLOOD MUSK ANTIBODY-PND
Medications on Admission:
- Atenolol 50mg daily
- Pravastatin 40mg daily
- Nifedipine 60mg daily
- Prilosec
- Vitamin D
- B12
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. nifedipine 60 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO DAILY (Daily).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: 0.5 Tablet
PO DAILY (Daily).
9. Outpatient Lab Work
Please check LFTs in 1 week post discharge and fax to Dr ___
___ at ___.
10. riluzole 50 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours.
Disp:*60 Tablet(s)* Refills:*5*
Discharge Disposition:
Home
Discharge Diagnosis:
Likely motor neurone disease (ALS)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neurological: atrophy in proximal muscles, fascuculations in all
4 limbs predominantly the thighs and upper arms. Nasal speech.
Slow tongue movements and fascuculations on right side of
tongue. Can count to 30 in 1 breath.
Followup Instructions:
___
Radiology Report
INDICATION: Worsening dyspnea. History of ALS.
TECHNIQUE: Two views of the chest.
COMPARISON: None available.
FINDINGS: No focal consolidation to suggest pneumonia is seen. Linear
opacities at the bases likely reflect subsegmental atelectasis. No
pneumothorax or pleural effusion is seen. No pulmonary edema is present. The
heart, mediastinal and pleural surface contours are normal.
IMPRESSION: No radiographic evidence of pneumonia.
Radiology Report
INDICATION: ___ man with weakness and spasticity. Assess for
cervical spondylosis.
COMPARISON: None available for comparison.
TECHNIQUE: Sagittal T1 and T2 as well as axial T2 gradient echo sequences of
the cervical spine were obtained without contrast.
FINDINGS:
The cervical spine has normal lordotic curvature, vertebral body height and
alignment. Discrete ___ type 2 endplate changes are seen involving the
C2/C3 and C3/C4 segments. The intervertebral discs demonstrate loss of T2
signal as a manifestation of degenerative disc disease.
At level C2/C3, there is an annular tear with central disc protrusion which is
mildly impinging on the anterior thecal sac.
At level C3/C4, there is central disc protrusion that impinges on the anterior
thecal sac and causes mild cord remodeling without T2 signal abnormality. The
bilateral neural foramina are mildly narrowed by facet and uncovertebral joint
arthropathy.
At level C4/C5, a median disc protrusion is impinging on the anterior thecal
sac and is associated with mild flattening of the anterior cord. The left
neural foramen is moderately narrowed by uncovertebral and facet joint
osteophytes.
At C5/C6, the combination of median disc protrusion and thickening of the
flavum ligament is associated with mild spinal canal narrowing and minimal
flattening of the anterior spinal cord. The left neural foramen is minimally
narrowed by uncovertebral osteophytes.
At level C6/C7, thickening of the flavum ligament and central disc protrusion
are mildly impinging on the thecal sac.
The craniocervical junction is normal. The cervical cord demonstrates a
normal intrinsic T2 signal. The posterior elements and paraspinal soft
tissues are unremarkable.
IMPRESSION:
Multilevel, multifactorial degenerative changes of the cervical spine with
multilevel cord remodelling and mild to moderate neural foraminal stenosis as
detailed above.
Radiology Report
HISTORY: ___ man with possible dysphagia.
COMPARISONS: None.
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the speech and swallow division. Multiple consistencies of
barium were administered.
FINDINGS: No gross aspiration or penetration. Pre-spill was noted with
multiple consistencies of barium. Swallowing delay accompanied by tongue
pumping also seen. There is mild prominence of the upper esophageal
sphincter. For details, please refer to speech and swallow division note in
OMR.
IMPRESSION: Mild pre-spill with swallowing delay and slight prominence of
upper esophageal sphincter. No aspiration or penetration.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: NEURO DISORDER
Diagnosed with AMYOTROPHIC SCLEROSIS, OTHER MALAISE AND FATIGUE
temperature: 99.2
heartrate: 78.0
resprate: 14.0
o2sat: 98.0
sbp: 156.0
dbp: 85.0
level of pain: 0
level of acuity: 3.0 | ___ year-old right-handed man with a history of HTN and HLD who
was transferred from OSH for assessment of possible ALS after
presenting with 3 months of worsening dysarthria, dysphagia and
weakness. Patient had an extensive work-up at
___ including an EMG which was
compatible with ALS. Examination at ___ was notable for
dysarthria, mild bifacial weakness, left sided tongue atrophy
and fasciculations, fasciculations in both thighs and proximal
upper limb, and brisk reflexes throughout, including increased
jaw jerk. Overall, the brisk reflexes in conjunction with
fasciculations as well as signs of cranial nerve involvement
with bifacial weakness and nasal speech, in conjunction with an
EMG with diffuse denervation suggested likely motor neurone
disease. CXR showed no evidence of infection and UA/UCx were
unremarkable. He had an MRI C-spine on ___ which showed
multilevel degenerative changes of the cervical spine with
multilevel cord remodelling and mild to moderate neural
foraminal stenosis but were not causing myelopathy and were
deemed not clinically significant. He was assessed by speech and
swallow who passed him for regular solids and thin liquids and
proceeded to a video swallow on ___ which showed mild/moderate
oral dysphagia and mild pharyngeal dysphagia and they
recommended a repeat swallow study in ___ months. He was
assessed by ___ and OT and deemed independent without requiring
services. His NIFs remained good at -40 and FVC 2.55L and in
addition, he was able to count to 30 in 1 breath. Unfortunately,
he did not have continuous O2 saturations measured during this
admission. He was independently mobilising on the ward and not
in distress. He maintained good oral intake. He was reviewed by
the neuromuscular team and proceeded to an EMG on ___ which
was strongly suggestive of ALS thus they felt it not necessary
to proceed to single fiber testing. Neuromuscular recommended
possible repeat EMG in ___ months time. Anti-MuSK Ab was sent
___ and is pending at time of writing. After his EMG, he was
started on riluzole 50mg bid and was discharged on this
medication. He should have his LFTs checked by his PCP ___ 1 week
and he was given a script for this. Patient was discharged home
___ and he will be contacted by the ___ clinic to arrange
follow-up. We made no changes to his other home medications. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath, cough, fever
Major Surgical or Invasive Procedure:
NG tube placed and advanced to post-pyloric position ___
Bronchoscopy ___
Right and left heart catheterization ___
History of Present Illness:
___ with PMH of relapsed Hodgkin's Disease s/p allo tx in ___
with multiple complications including GVHD, skin Ca, facial/Jaw
CA, ESRD on nightly PD, who presents with fevers, cough, and
shortness of breath after evaluation by his PCP.
Mr. ___ developed shortness of breath and a dry cough ___
weeks ago. He gets short of breath after walking 0.25 miles or
one flight of stairs. He also new onset orthopnea, but denies
PND. Also denies any weight gain ___ edema.
Two nights ago, he had a fever to 101 degrees. He also felt some
chest discomfort characterized as an achey pain worse with
cough. He has no pleuritic chest pain and is currently chest
pain free. His cough is only mildly productive of sputum.
His last PD was two nights ago. He still makes urine at baseline
(1500 cc/day), and denies dysuria or changes in urinary
frequency. He denies abdominal pain. No recent travel or sick
contacts.
Patient has cancer history, bone marrow transplant in the past
but is not on any immunosuppression. The patient spoke to his
doctor who sent him to the emergency department for evaluation.
Recent admission over the ___ for L facial cellulitis
and transudative pleural effusions. He underwent thoracentesis
which showed a transudative process, with negative cytology.
In the ED, initial vital signs were: 98.2 89 140/85 16 100%RA
- Labs were notable for WBC 12.9 (81.5% PMNs, no bands), H/H
8.5/27.7, BUN/SCr 40/8.3, trop 0.10/ MB 2, d-dimer 1828, UA
negative for infection
- Studies performed include CXR which showed "Increasing pleural
effusions, small in volume with lower lobe ground-glass opacity
concerning for pneumonia. Probable loculated pleural effusion
along
the right lung apex and periphery of the right mid lung.
Possible additional focus of pneumonia in the right upper lobe."
- Patient was started on a heparin gtt, given CTX/azithro for
CAP, and 1gm APAP
- Vitals on transfer: 98.1 106 157/93 28 98%RA
Upon arrival to the floor, the patient is alert and oriented and
in good spirits. He thinks he has a pneumonia due to his cough
and chest discomfort. Currently no chest pain. Vitals on
arrival: 98.1, BP 145/96, 100, 16, 96% 3L
Review of Systems:
(+) per HPI, (-) otherwise
Past Medical History:
- Hodgkin's lymphoma dx ___
- status post allogenic bone marrow transplant ___
- asplenic
- basal cell carcinoma (most recent is currently on acral
segment nose ___ with plan for MOHs)
- squamous cell carcinoma
- hyperlipidemia
- history of orthostatic hypotension especially for several
months following the radical neck dissection (___)
- chronic renal failure now requiring peritoneal dialysis
- chronic graft-versus-host disease
Past Surgical History:
- squamous cell carcinoma status post radical neck dissection
(___)
- bilateral hip replacement due to chronic osteonecrosis
secondary to long-term prednisone use
- splenectomy in ___
- numerous skin biopsies and resections for basal cell carcinoma
- the placement of peritoneal dialysis catheter in ___.
Social History:
___
Family History:
His mother passed away at ___ from cervical
cancer. His father is alive at ___ with dementia and prostate
cancer. He has three sisters at ___, ___, ___ with ovarian cancer,
arthritis, COPD. He has two brothers at ___ and ___ with
hypertension and heart disease. He has three adopted children.
A ___ daughter who is healthy, a ___ son with
mental health issues and a son who passed away ___ from an
overdose.
Physical Exam:
Admission exam:
Vitals- 98.1, BP 145/96, 100, 16, 96% 3L
___: AOx3, NAD, cachectic male
HEENT: PERRL, EOMI, MMM
NECK: Thyroid normal, no cervical lymphadenopathy.
CARDIAC: RRR, no m/r/g
LUNGS: Clear to auscultation in upper lung fields, diminished
lung sounds in the bases
BACK: Cachectic, no tenderness
ABDOMEN: Soft, nontender, nondistended, normal BS
EXTREMITIES: No clubbing, cyanosis, or edema, mild muscular
atrophy of ___, skin appears shiny
NEUROLOGIC: CN2-12 intact. ___ strength througout. Normal
sensation.
Discharge exam:
Vitals: 97.6 (98.2) BP 100-155/70s HR 67-8s RR 18 O2 100 on RA
___: Awakens easily, comfortable cachectic, chronically ill
appearing.
HEENT: Speech is muffled d/t lack of tongue musculature after
radiation/surgery, dobhoff tube in place
CARDIAC: RRR, murmurs/rubs/gallops
LUNGS: Clear to auscultation, but decreased breath sounds at
bases.
ABDOMEN: Thin, PD catheter in place. +BS. PD port c/d/I. Sacral
edema present.
BACK: sacral edema improved
EXTREMITIES: extremities warm and dry. Edema in b/l distal upper
extremities improved. Feet diffusely erythematous
NEUROLOGIC: Alert, oriented, appropriate. Strength is full and
symmetric. Dysarthric speech (baseline)
Pertinent Results:
Admission labs:
___ 04:30PM BLOOD WBC-12.9* RBC-2.92* Hgb-8.5* Hct-27.7*
MCV-95 MCH-29.1 MCHC-30.7* RDW-18.4* RDWSD-63.4* Plt ___
___ 04:30PM BLOOD Neuts-81.5* Lymphs-9.4* Monos-7.8
Eos-0.5* Baso-0.3 NRBC-0.2* Im ___ AbsNeut-10.48*#
AbsLymp-1.21 AbsMono-1.01* AbsEos-0.06 AbsBaso-0.04
___ 07:45PM BLOOD ___ PTT-35.3 ___
___ 04:30PM BLOOD Glucose-87 UreaN-40* Creat-8.3* Na-139
K-3.8 Cl-99 HCO3-27 AnGap-17
___ 06:00AM BLOOD ALT-8 AST-11 LD(LDH)-231 CK(CPK)-60
AlkPhos-199* TotBili-<0.2
___ 04:30PM BLOOD CK-MB-2 proBNP->70000*
___ 06:00AM BLOOD Calcium-8.3* Phos-8.1* Mg-1.6
___ 04:30PM BLOOD D-Dimer-1828*
___ 04:30PM BLOOD calTIBC-261 Ferritn-389 TRF-201
Discharge labs:
___ 06:00AM BLOOD WBC-8.2 RBC-2.93* Hgb-8.4* Hct-26.8*
MCV-92 MCH-28.7 MCHC-31.3* RDW-18.2* RDWSD-60.7* Plt ___
___ 06:00AM BLOOD ___ PTT-29.2 ___
___ 06:00AM BLOOD Glucose-59* UreaN-30* Creat-9.4* Na-141
K-3.6 Cl-100 HCO3-27 AnGap-18
___ 06:00AM BLOOD Calcium-8.4 Phos-6.4* Mg-2.6
Imaging:
CTA Chest w/ contrast (___): Moderate free peritoneal air
has worsened since prior exam, maybe consistent with use of
peritoneal dialysis catheter. There are no pulmonary emboli.
There are moderate pleural effusions. Patchy mild ground-glass
nodular
opacities, consider infection, edema. Stable left basilar
infiltrates with nodular components, consider infectious
process, aspiration. Stable right paratracheal lymph nodes.
CT chest w/o contrast (___): 1. Small bilateral pleural
effusions, improved since prior study with
interval improvement in bibasilar compressive atelectasis. 2.
New infiltrate in the left lung base, with nodular components,
and
scattered bilateral lower lobe ill-defined ground-glass nodular
opacities, favoring infectious process, possibly aspiration.
Stable right paratracheal lymph node. 3. New free peritoneal
air in the abdomen. This should be correlated with any recent
interventions and CT of the abdomen as clinically warranted for
further evaluation.
Video swallow (___): Significantly impaired bolus
propulsion, with silent aspiration after swallowing due to
residue, which cough is only partially effective in clearing.
Cardiac catheterization (___): 1. Diffuse calcific
atherosclerosis and diffuse slow flow consistent with
microvascular dysfunction, with two
vessel complex quintification lesion in the mid LAD and at the
origin of a RCA right ventricular/acute
marginal branch.
2. Normal left ventricular diastolic pressure with normal PA and
mean PCW pressures and very low RA
pressure, arguing against restrictive physiology under the
current loading conditions.
3. No oxymetric evidence of significant right-to-left or
left-to-right shunting.
ECHOCARDIOGRAM ___:
The left atrial volume index is normal. No atrial septal defect
is seen by 2D or color Doppler. The estimated right atrial
pressure is ___ mmHg. Left ventricular wall thicknesses and
cavity size are normal. Overall left ventricular systolic
function is moderately-to-severely depressed (LVEF= 30%)
secondary to akinesis of the inferior wall amd hypokinesis of
the rest of the left ventricle. Tissue Doppler imaging suggests
an increased left ventricular filling pressure (PCWP>18mmHg).
There is no ventricular septal defect. Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Moderate (2+) mitral regurgitation is seen.
The left ventricular inflow pattern suggests a restrictive
filling abnormality, with elevated left atrial pressure. The
tricuspid valve leaflets are mildly thickened. The estimated
pulmonary artery systolic pressure is normal. There is a small
pericardial effusion.
Compared with the prior study (images reviewed) of ___,
the left ventricular ejection fraction is further reduced.
LOWER EXTREMITY ULTRASOUND ___:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
CT chest (___):
There are moderate bilateral pleural effusions, with significant
bilateral subpulmonic components. Significant bilateral lower
lobe atelectasis, more prominent on the left.
There is small area of clustered nodules in the anterior basal
segment left lower lobe, favoring infectious etiology. Left
lung apex zone of ground-glass opacities, may represent
infection, with possible component of edema. Left ventricle is
dilated.
Multiple bilateral pulmonary nodules, few have mildly increased
in size, largest measures 1.1 cm, indeterminate. Continued
follow-up recommended.
VQ SCAN ___:
IMPRESSION: Indeterminate V/Q study due to the inadequate
ventilation study in which most of the tracer activity remains
in the mouth as well as a large left pleural effusion limiting
evaluation of the left lower lung.
OTHER RELEVANT STUDIES:
___
Test Result Reference
Range/Units
FUNGITELL(R) (___) B D >500 H pg/mL
B-GLUCAN
HISTOPLASMA GALACTOMANNAN <0.5 ng/mL
ANTIGEN, URINE
Test Result Reference
Range/Units
INDEX VALUE 7.42 H <0.50
ASPERGILLUS AG, EIA, BAL Detected A Not Detected
___ 1:45 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE,
LLL.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___:
___ CFU/mL Commensal Respiratory Flora.
LEGIONELLA CULTURE (Final ___: NO LEGIONELLA
ISOLATED.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
___: NEGATIVE for Pneumocystis jirovecii
(carinii).
FUNGAL CULTURE (Final ___:
YEAST.
NOCARDIA CULTURE (Final ___: NO NOCARDIA ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old man PMH of relapsed Hodgkin's Lymphoma s/p allogenic
stem cell transplant c/b GVHD, basal and squamous cell CA of the neck s/p
radial neck dissection and radiation, ESRD on nightly PD who presents with SOB
and chest discomfort which is likely multifactorial in etiology. // please
evaluate multifocal PNA (c/f viral based on exam), pulmonary edema, please
evaluate pleural effusions (previously noted to be transudative, possibly
loculated). Of note pt with remote history of radiation of head and neck and
unknown chemotherapy
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
without intravenous contrast. Reformatted coronal, sagittal, thin slice axial
images images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.8 s, 38.0 cm; CTDIvol = 8.0 mGy (Body) DLP = 303.1
mGy-cm.
2) Spiral Acquisition 1.2 s, 9.1 cm; CTDIvol = 7.5 mGy (Body) DLP = 68.3
mGy-cm.
Total DLP (Body) = 371 mGy-cm.
COMPARISON: CT chest ___
FINDINGS:
Lungs:
Parenchyma and Airways: There is volume loss, bronchiectasis in the right
upper lobe, apex, stable since prior, likely treatment related. Less
prominent mild fibrosis left lung apex, with mild volume loss, stable. There
is no mucous plugging. Right posterolateral tracheal diverticulum is mildly
more prominent since prior.
Moderate bilateral pleural effusions are present, more prominent since prior.
There is significant bilateral pleural effusion subpulmonic components.
There are bilateral lower lobe dependent atelectasis, more prominent since
prior, with significant volume loss in the left lower lobe. Punctate
calcifications in the right lower lobe are similar, may be sequela of prior
inspiration or chronic atelectasis. Subpleural scarring, nodular thickening
right lung laterally. , similar since prior. There is small volume of
loculated pleural fluid in the right lung apex medially.
1.0 cm nodule right upper lobe series 4, image 580 is stable. 0.6 cm nodule
right upper lobe image 89 is similar. 0.7 cm nodule right lower lobe image 91
is stable. 0.6 cm nodule left upper lobe image 101, stable. Surgical
scarring in the lingula. 1.1 cm subpleural nodule right middle lobe image 123
compared to 1.0 cm on prior.
Small cluster of ill-defined nodular opacities in the left lower lobe anterior
basal segments suggest infection. Zone of ground-glass opacity in the left
lung apex involving apical posterior segment, may be infectious with possible
component of edema.
Vessels: Normal caliber main pulmonary artery, aorta.
Mediastinum and Hila: No lymphadenopathy
Heart and Pericardium: There is trace pericardial effusion. Suggestion of
anemia. Mitral annular calcifications. Normal heart size with mildly dilated
left ventricle.
Pleura: Moderate bilateral pleural effusions have worsened since prior, with
significant subpulmonic components.
Neck, Thoracic Inlet, Axillae, Chest Wall: Stable 1.2 cm left thyroid nodule.
No lymphadenopathy.
Upper Abdomen: Surgical clips left upper quadrant, spleen is not seen, is
presumed surgically absent. No other abnormalities in the visualized upper
abdomen.
Chest Cage: There is mild chronic compression fracture T5 vertebral body,
stable.
IMPRESSION:
There are moderate bilateral pleural effusions, with significant bilateral
subpulmonic components. Significant bilateral lower lobe atelectasis, more
prominent on the left.
There is small area of clustered nodules in the anterior basal segment left
lower lobe, favoring infectious etiology. Left lung apex zone of ground-glass
opacities, may represent infection, with possible component of edema. Left
ventricle is dilated.
Multiple bilateral pulmonary nodules, few have mildly increased in size,
largest measures 1.1 cm, indeterminate. Continued follow-up recommended.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ with PMH of relapsed Hodgkin's Lymphoma s/p allogenic stem
cell transplant c/b GVHD, basal and squamous cell CA of the neck s/p radial
neck dissection and radiation, ESRD on nightly PD who presents with SOB and
chest discomfort concerning for PE // eval for DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: Duplex lower extremity ultrasound ___.
FINDINGS:
There is normal compressibility, flow, and augmentation of the bilateral
common femoral, femoral, and popliteal veins. Normal color flow is
demonstrated in the posterior tibial and peroneal veins. There is normal
respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with increasing O2 requirement, PNA // PNA,
worsening edema
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___ chest x-ray are CT from ___
IMPRESSION:
large bilateral pleural effusions left greater than right with associated
adjacent consolidations, bilateral lung nodules, lymphadenopathy, chronic
biapical opacities right greater than left and to nodular pleural thickening
in the right apex are better evaluated on prior CT.
Radiology Report
EXAMINATION: Fluoroscopic video oro pharyngeal swallow
INDICATION: ___ with PMH of relapsed Hodgkin's Lymphoma s/p allogenic stem
cell transplant c/b GVHD, basal and squamous cell CA of the neck s/p radial
neck dissection and radiation, ESRD on nightly PD who presents with SOB and
chest discomfort which is likely multifactorial in etiology. // eval for
swallow function
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the speech and swallow division. Multiple consistencies of
barium were administered.
DOSE: Fluoro time: 04:43 min.
COMPARISON: ___
FINDINGS:
Barium passes freely through the oropharynx and esophagus without evidence of
obstruction. There was significant bolus propulsion impairment. There was
nasopharyngeal regurgitation. There was silent aspiration after swallowing
due to residue. Cough was only partially effective in clearing.
IMPRESSION:
Significantly impaired bolus propulsion, with silent aspiration after
swallowing due to residue, which cough is only partially effective in
clearing.
Please refer to the speech and swallow division note in OMR for full details,
assessment, and recommendations.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ with PMH of relapsed Hodgkin's Disease s/p allo tx in ___
with multiple complications including GVHD, facial/Jaw CA, ESRD on nightly PD,
who presents with fevers, cough, and shortness of breath after evaluation by
his PCP, being treated for pneumonia with Vanc/Cef/Flagyl s/p azithro and HF
exacerbation with diuresis, now with elevated b-glucan concerning for fungal
infection, planning for bronch // evaluate for fungal infection and nodules,
planning for bronch
TECHNIQUE: Contiguous axial CT cuts of the thorax were performed without the
administration of intravenous contrast. Coronal sagittal reformats were then
performed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.2 s, 41.0 cm; CTDIvol = 6.7 mGy (Body) DLP = 273.4
mGy-cm.
Total DLP (Body) = 273 mGy-cm.
COMPARISON: Compared to prior dated ___.
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: Stable a 1.2 cm left thyroid
nodule. No axillary lymphadenopathy.
UPPER ABDOMEN: The spleen is not visualized, likely surgically absent. A
feeding tube is noted with its distal tip in the gastric body. There is
however new small amount of free peritoneal air in the upper abdomen. No
other abnormalities of the visualized solid abdominal organs in the upper
abdomen.
MEDIASTINUM: There is stable 1.3 cm right peritracheal thoracic inlet lymph
node.
HILA: No hilar lymphadenopathy.
HEART and PERICARDIUM: Trace pericardial effusion, not significantly changed
from prior. Suggestion of anemia. Mitral annular calcifications. Normal
heart size. Coronary artery calcifications.
PLEURA: There are bilateral small pleural effusions, significantly improved
since prior CT dated ___.
LUNG:
-PARENCHYMA: There has been interval improvement in bibasilar atelectasis
when compared to prior. There is however new linear atelectasis within the
anterior basal segment of the left lower lobe, with surrounding nodular
peribronchial opacities, with additional small, ill-defined centrilobular
opacities in the left lower lobe, and 2 smaller degree in the right lower
lobe, favoring infectious process, possibly aspiration. This is in an area of
previously at atelectatic lung. There is stable subpleural scarring and
nodular thickening of the right lung laterally. Stable mild volume loss in
the right lung apex. Surgical scarring in the lingula. A 6 mm nodule in the
right upper lobe (series 4, image 75) is stable from prior. A 8 mm nodule
within the superior segment of the right lower lobe (series 4, image 88) is
also stable from prior. 5 mm nodule left upper lobe, stable. Multiple stable
punctate calcifications in the right lower ___ represent sequela of
chronic calcified granulomas, chronic aspiration, sequela of chronic
atelectasis. Ground-glass opacities previously seen in the left lung apex
have resolved. Postoperative change the lingula.
-AIRWAYS: Bronchiectasis in the right upper lobe, stable from prior, likely
treatment related. Right posterolateral tracheal diverticulum, stable from
prior. There is minimal mucosal plugging of subsegmental bronchi within the
left lower lobe. Remainder airways are patent.
-VESSELS: Normal caliber main pulmonary artery and aorta.
CHEST CAGE: No suspicious osseous lesions. Mild chronic compression fracture
of T5 vertebral body, stable.
IMPRESSION:
1. Small bilateral pleural effusions, improved since prior study with
interval improvement in bibasilar compressive atelectasis.
2. New infiltrate in the left lung base, with nodular components, and
scattered bilateral lower lobe ill-defined ground-glass nodular opacities,
favoring infectious process, possibly aspiration. Stable right paratracheal
lymph node.
3. New free peritoneal air in the abdomen. This should be correlated with
any recent interventions and CT of the abdomen as clinically warranted for
further evaluation.
RECOMMENDATION(S): CT of the abdomen as clinically warranted for further
evaluation of small amount of free air in the upper abdomen.
NOTIFICATION: The findings were discussed with ___, M.D.
by ___, M.D. on the telephone on ___ at 7:33 ___, 5 minutes
after discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with dobhoff // interval placement
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___.
IMPRESSION:
Dobhoff tube tip isin the stomach. Evaluation of the lungs is limited.
Bilateral pleural effusions, adjacent consolidations have improved.
Cardiomegaly cannot be assessed. The apices of the lungs were not totally
included on the exam. Patient has known volume loss bronchiectasis and
fibrosis in the apices.
Radiology Report
INDICATION: ___ year old man with NG tube, came out through nose, pushed back
in by patient // evaluate NG tube placement
COMPARISON: Radiographs from ___.
IMPRESSION:
The enteric tube has been advanced and the distal tip is within the body of
the stomach. There is again seen bilateral pleural effusions and basilar
consolidations, unchanged. There is again seen areas of volume loss and
increased density at the apices, right greater than left consistent with known
bronchiectasis and fibrosis.
Radiology Report
EXAMINATION: Post pyloric advancement of NG tube
INDICATION: ___ with PMH of relapsed Hodgkin's Disease ___ allo tx in ___
with multiple complications including GVHD, facial/Jaw CA, ESRD on nightly PD,
who presents with fevers, cough, and shortness of breath after evaluation by
his PCP, ___ treatment for pneumonia with Vanc/Cef/Flagyl/azithro and HF
exacerbation with diuresis ___ RHC/LHC ___ w/PCWP 8, resuscitated with 1U
pRBC, crystalloids, albumin, ___ dobhoff TFs for poor PO intake. //
Advancement of NG tube post-pyloric
DOSE: Acc air kerma: 7 mGy; Accum DAP: 165.9 uGym2; Fluoro time: 01:28
COMPARISON: None.
FINDINGS:
The left nare was anesthetized with lidocaine jelly. Under intermittent
fluoroscopic guidance, the existing Dobhoff feeding tube was advanced
post-pylorically using a guidewire.
10 cc of Optiray contrast were used to confirm post pyloric placement. Final
fluoroscopic spot images demonstrated the tip of the feeding tube in the
proximal third portion of the duodenum.
The feeding tube was affixed to the patient's nose and cheek using tape.
IMPRESSION:
Successful post-pyloric advancement of a Dobhoff feeding tube. The tube is
ready to use.
Radiology Report
EXAMINATION: CTA CHEST
INDICATION: ___ with PMH of relapsed Hodgkin's Disease ___ allo tx in ___
with multiple complications including GVHD, facial/Jaw CA, ESRD on nightly PD,
who presents with fevers, cough, and shortness of breath after evaluation by
his PCP, ___ treatment for pneumonia with Vanc/Cef/Flagyl/azithro and HF
exacerbation with diuresis now with NG tube, concern for PE // eval for PE
TECHNIQUE: Axial multidetector CT images of the chest were obtained during
intravenous administration of cc of Omnipaque 350 with sagittal and coronal
reformatted images. Oblique angiographic maximal intensity projection
reformatted images were obtained. This report is based upon review of all of
the above images.
DLP mGy cm.
DOSE: Acquisition sequence:
1) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 4.9 mGy (Body) DLP = 2.4
mGy-cm.
2) Spiral Acquisition 4.6 s, 36.3 cm; CTDIvol = 5.9 mGy (Body) DLP = 213.0
mGy-cm.
Total DLP (Body) = 215 mGy-cm.
COMPARISON:
CT chest ___
FINDINGS:
Lungs:
Parenchyma and Airways: There are new mild proximal tracheal secretions.
Bilateral lower lungs small ill-defined ground-glass nodular opacities,
similar compared with yesterday, consider infection, aspiration, possible
component of edema. There is stable left basilar consolidation with nodular
components, predominantly involving anterior basilar segment. There is no
interlobular septal thickening. No new areas of consolidation. Posttreatment
changes in the right lung apex are stable, with bronchiectasis. Stable lung
nodules as noted on yesterday's exam. Postoperative changes left lower chest.
Vessels: No pulmonary emboli. Aorta and great vessels are normal.
Mediastinum and Hila: Stable few right paratracheal thoracic inlet lymph
nodes, largest 1.3 cm. . No hilar adenopathy.
Heart and Pericardium: Left ventricle is enlarged, stable. Coronary artery
calcifications
Pleura: There are moderate bilateral pleural effusions, similar.
Neck, Thoracic Inlet, Axillae, Chest Wall: No mass or adenopathy.
Upper Abdomen: Free peritoneal air has increased. Enteric tube tip terminates
in the mid stomach.
Chest Cage: No new findings.
IMPRESSION:
Moderate free peritoneal air has worsened since prior exam, maybe consistent
with use of peritoneal dialysis catheter.
There are no pulmonary emboli.
There are moderate pleural effusions. Patchy mild ground-glass nodular
opacities, consider infection, edema. Stable left basilar infiltrates with
nodular components, consider infectious process, aspiration.
Stable right paratracheal lymph nodes.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 9:35 ___, 5 minutes
after discovery of the findings.
Radiology Report
INDICATION: ___ year old man with NG tube re-adjustment, checking placement.
// ___ year old man with NG tube re-adjustment, checking placement.
COMPARISON: ___.
IMPRESSION:
Findings are stable. The feeding tube is unchanged position. Heart size is
within normal limits. There are small bilateral effusions. There is an
unchanged left retrocardiac opacity. There is again seen areas of volume loss
and increased density at the lung apices, right greater than left, consistent
with known bronchiectasis and pulmonary fibrosis.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea, Chest pain
Diagnosed with Dyspnea, unspecified, Precordial pain, Pneumonia, unspecified organism
temperature: 98.2
heartrate: 89.0
resprate: 16.0
o2sat: 100.0
sbp: 140.0
dbp: 85.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ is a ___ gentleman with PMH of relapsed Hodgkin's
Disease s/p allo transplant in ___ with multiple complications
including GVHD, facial/Jaw CA, ESRD on nightly PD, who presented
with fevers, cough, and shortness of breath after evaluation by
his PCP, was treated for pneumonia with Vanc/Cef/Flagyl/azithro
and HF exacerbation found to have elevated fungal markers
(beta-glucan), concerning for fungal infection.
# Pneumonia with suspected aspiration, sepsis on admission: He
presented with chest discomfort, fever, and dyspnea on exertion.
He met criteria for sepsis on admission. MRSA screen was
positive and influenza PCR was negative. He was treated with
vanc/cefepime/flagyl/azithro (Day 1= ___, 7 day course, last
day = ___, and his symptoms improved. Additionally, there was
concern for possible fungal infection, which is discussed
separately below. He underwent bronchoscopy with BAL, the
results of which were pending upon discharge.
-Will need repeat CT in 3 months (about ___
#Fungal infection:
Patient had an elevated b-glucan (>500), which was concerning in
setting of past allo transplant and findings on chest CT for a
fungal infection. Unusual given that on prophylactic fluconazole
as outpatient weekly. q48h (renal dose) here. Cyptococcal
antigen was found to be negative. He was evaluated by infectious
disease and pulmonary specialists while inpatient, who
recommended outpatient follow-up, as he was asymptomatic and the
preliminary results were inconclusive.
He underwent bronchoscopy w/ BAL on ___, and appropriate
studies were sent subsequently and are pending on discharge. At
the time this discharge summary was finalized, the repeat
B-glucan returned persistently elevated > 500, Aspergillus Ag
elevated, and Histoplastma Ag negative. He was seen in
infectious disease clinic to discuss treatment.
# Acute exacerbation of HFrEF (30%): He presented with ___ weeks
of dyspnea, fatigue, and orthopnea, without weight gain or
peripheral edema. He initially required O2 supplement with 4L by
NC and BNP was > 70,000. Likely exacerbated by PNA given above
(c/b pleural effusion b/l). He was treated with IV diuretics and
peritoneal dialysis to achieve euvolemia, which improved his
respiratory status.
A subsequent TTE (___) showed new EF of 30% and diffuse
hypokinesis. After diuresis, his respiratory status improved
greatly. On LHC, there was no evidence of reversible coronary
obstructions. On RHC, there were low filling pressures.
According to cardiology, new worsening in EF is likely
chemotherapy related (Adriamycin cardiomyopathy). He will see
Dr. ___ in ___ clinic on discharge, where lisinopril 2.5
and beta-blocker may be started.
-f/u initiation of appropriate HFrEF treatment, unable to start
ACE inhibitor while inpatient due to hypotension
#Pleural effusions: CXR showed concern for right lung apex and
mid-lung pleural effusions, maybe loculated. IP was consulted
and commented that these are unchanged from ___, at which
time they were drained and transudative. Etiology may be from
dialysate extravasation vs CHF, however IP does not feel that
thoracentesis is warranted at this time given that collections
are unchanged from last time and respiratory status is stable.
#Severe protein-calorie malnutrition:
Patient had a low albumin (2.1 on admission) and he was
cachectic with a BMI around 17. Due to increasing dysphagia and
poor PO intake, Dobhoff and tube feeds were initiated (goal of
50 mL/hr (1800 kcals, 77 g protein)). NG tube advanced to be
post-pyloric on ___ and it was subsequently bridled. Tube
feeds will be continued on discharge.
#Dysphagia: Patient has long-standing trouble swallowing
secondary to surgery/radiation for facial/jaw cancer. Has had
many swallow studies in past. On most recent video swallow
study,
he was evaluated to have an aspiration risk so pureed food was
recommended. But in conversation, patient and wife wanted to
advance his diet to regular diet with no restrictions and to
take
meds whole (not crushed). Patient is able to recite and
comprehend the risks of this, which include aspiration,
pneumonia, hypoxia, and possible clinical worsening. Despite
this, patient thinks he can increase his PO intake more if the
dietary restrictions are removed. Tube feeds initiated to
further improve his nutritional status, after conversation with
nephrology team. Patient to supplement TF with regular diet
without restrictions.
-f/u if patient wishes to pursue swallow therapy.
# Hypotension: Triggered on ___ for BP ___. He was
asymptomatic aside from light-headedness. The etiology is likely
secondary to hypovolemia given low PCWP on cath and poor PO
intake. He was resuscitated with crystalloids and albumin, and
his BP improved.
# End stage renal disease on PD secondary to FSGS during
Hodgkin's: On home PD, but still has renal function and makes
urine (100 cc/day). Patient to continue PD and calcitriol 0.25
mcg daily. He was started on sevelamer and lanthanum was
discontinued.
# Anemia: Etiology likely related to ACD and CKD. Gets epo
injection every 2 weeks, but Epo will be less effective in
setting of an infection so he received 1U of pRBC for
symptomatic anemia. His hgb remained stable thereafter. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Azithromycin /
lisinopril / ACE Inhibitors / ___ Receptor
Antagonist / Imdur
Attending: ___
Chief Complaint:
Chest pain, diaphoresis
Major Surgical or Invasive Procedure:
___ - 1. Coronary artery bypass graft x 3, Total arterial
revascularization.
2. Skeletonized left internal mammary artery grafting to second
obtuse marginal artery.
3. Skeletonized in situ right internal mammary grafting to left
anterior descending artery.
4. Left radial artery grafting to first obtuse marginal artery.
5. Endoscopic harvesting of the left radial artery.
History of Present Illness:
Ms. ___ is a ___ year old ___ year old woman with a history of
aortic insufficiency, coronary artery disease, hyperlipidemia,
and hypertension. She presented to ___ with exertional chest
pain and diaphoresis. She has had several weeks of exertional
chest pain with activity level steadily decreasing. She had an
abnormal stress test 2 weeks ago, with plan for medical
management given her age, however her exertional ability keeps
decreasing. She underwent a cardiac catheterization which
revealed coronary artery disease and she was referred for a
coronary artery bypass graft evaluation.
Past Medical History:
Actinic Keratosis
Aortic Regurgitation
Coronary Artery Disease
Hyperlipidemia
Hypertension
Hypothyroidism
Osteoarthritis
Osteoporosis
Past Surgical History:
Total Knee Replacement
Social History:
___
Family History:
Older sister with 'heart problem' (onset after age ___
Mother died in ___
Father died of prostate cancer in ___
Physical Exam:
==============
ADMISSION EXAM
==============
VS: 97.6 155/74 71 18 95 RA
GENERAL: NAD, pleasant in conversation, speaking in full
sentences.
HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM.
NECK: JVP elevated 3cm above the clavicle with bed at 45
degrees.
HEART: RRR, S1/S2, soft systolic murmur at the RUSB, no
rubs/gallops.
LUNGS: Bibasilar crackles, otherwise CTABL.
ABDOMEN: Nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly.
EXTREMITIES: WWP. No cyanosis, clubbing, or edema.
PULSES: 2+ radial pulses bilaterally.
NEURO: A&Ox3, moving all 4 extremities with purpose.
SKIN: Warm and well perfused, scattered ecchymoses.
==============
DISCHARGE EXAM
==============
General/Neuro: NAD [x] A/O x2 [x]
non-focal [x]
Cardiac: RRR [x] Irregular [] Nl S1 S2 [x]
Lungs: slightly decreased bases [x], no respiratory distress [x]
Abd: normoactive BS [x]Soft [x] ND [x] NT [x] healing LLQ
bruise[x]
Extremities: trace edema, palpable pulses, 1+ [x]
Wounds: Sternal: CDI [x] no erythema or drainage [x]
Sternum stable [x] Prevena []
Right UE [x] Left[] CDI [x] no erythema or drainage [x]
very ecchymotic
Pertinent Results:
Cardiac Catheterization ___
Dominance: Right
LMCA: no flow limiting stenosis.
LAD: proximal calcified 90-95% stenosis at its origin and then a
tubular long 70% up to the mid LAD. D1 is a small vessel and D2
is a moderate size vessel with a 95% stenosis at its origin.
Vessel is severely calcified.
LCX: mid 80% stenosis and distal 99% stenoss with TIMI 2 flow
distally into a moderate size very distal branch.
RCA: subtotally occluded with diffuse disease.
Chest CT ___
No adenopathy. No pleural effusions. No suspicious pulmonary
nodules or
masses. Non characteristic bilateral parenchymal scarring.
Borderline
diameter of the main pulmonary artery. Severe coronary
calcifications.
Vein Mapping ___
Patent bilateral great saphenous and small saphenous veins.
Carotid Ultrasound ___
Bilateral less than 40% carotid stenosis.
Transthoracic Echocardiogram ___
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. There is mild symmetric left ventricular
hypertrophy with normal cavity size and global systolic function
(LVEF>55%). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). The ascending aorta
is mildly dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion. There is an anterior space which most
likely represents a prominent fat pad.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global biventricular systolic function. Increased left
ventricular filling pressure. Mildly dilated ascending aorta.
Mild mitral regurgitation.
Compared with the prior study (stress echocardiogram - images
reviewed) of ___, the severity of aortic insufficiency has
decreased.
Upper Extremity Ultrasound ___
No evidence of deep vein thrombosis in the left upper extremity.
Extensive
hematoma in the left forearm.
Transesophageal Echocardiogram ___ small patent foramen ovale is present. A
left-to-right shunt across the interatrial septum is seen at
rest. Left ventricular wall thicknesses and cavity size are
normal. Right ventricular chamber size and free wall motion are
normal. There are simple atheroma in the ascending aorta. There
are complex (>4mm) atheroma in the aortic arch. There are
complex (>4mm) atheroma in the descending thoracic aorta. There
is borderline mild aortic stenosis by continuity, but the valve
plainemeters at with low gradients at a normal cardiac output.
Moderate (2+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen.
Post Bypass: Patient is A paced on phenylepherine infusion.
There is preserved biventricular function, LVEF >55%. Aortic
insufficiency remains moderate. Mitral regurgitation is
unchanged. Aortic contours intact after cannula removal.
Remaining exam is unchanged. All findings discussed with
surgeons at the time of the exam.
___
The right IJ line has been removed. Mediastinal clips and
sternal wires are
re-demonstrated. There are small bilateral pleural effusions,
similar to
previous. The cardiomediastinal silhouette appears similar to
previous.
Atelectasis at the lung bases has decreased in severity. The
aorta is
tortuous. The bones are diffusely osteopenic.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Isosorbide Dinitrate 10 mg PO BID
3. Levothyroxine Sodium 25 mcg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. amLODIPine 5 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Furosemide 20 mg PO DAILY Duration: 7 Days
5. Heparin 5000 UNIT SC BID
6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
Duration: 3 Months
7. Metoprolol Tartrate 50 mg PO TID
8. Ramelteon 8 mg PO QHS
9. Aspirin 81 mg PO DAILY
10. Atorvastatin 40 mg PO QPM
11. Levothyroxine Sodium 25 mcg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Coronary Artery Disease
Aortic Regurgitation
Hypertension
Hypothyroidism
Osteoarthritis
Osteoporosis
Actinic Keratosis
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. No Edema
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PRE-OP PA AND LAT)
INDICATION: ___ year old woman with multi-vessel disease, undergoing eval for
CABG// r/o pneumonia, volume overload Surg: ___ (possible CABG)
IMPRESSION:
In comparison with the study ___ the, there is little change and no
evidence of acute pneumonia, vascular congestion, or pleural effusion.
Blunting of the left costophrenic angle could represent pleural thickening.
Mild scoliosis of the thoracic spine convex to the right is again seen.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old woman with multivessel heart disease, undergoing
workup for CABG// please evaluate for abnormalities
TECHNIQUE: Volumetric CT acquisitions over the entire thorax in inspiration,
no administration of intravenous contrast material, multiplanar
reconstructions.
DOSE: DLP: 266 mGy-cm
COMPARISON: No comparison.
FINDINGS:
No incidental thyroid findings. No supraclavicular, infraclavicular or
axillary lymphadenopathy. All visible lymph nodes in the chest wall (2, 9)
Are normal in size. Moderate calcifications of the aortic arch. Moderate
calcifications of the descending aorta. Borderline diameter of the main
pulmonary artery. Severe coronary calcifications. Punctate aortic valve
calcifications (2, 35) mild elongation of the descending aorta. No
pericardial effusion. The upper abdomen shows a renal collecting system
calcifications (2, 53). No osteolytic lesions at the level of the ribs, the
sternum, or the vertebral bodies. Moderate degenerative vertebral disease.
No vertebral compression fractures. Mild bilateral apical scarring. Minimal
non characteristic right dorsal pleural thickening. Mild thickening any
irregularities of the airway walls. Several scattered nonsuspicious
micronodules, mostly in subpleural location. No suspicious pulmonary nodules
or masses. Non characteristic scarring at the level of the lower lobes is
only partially imaged, given respiratory motion. No pleural effusions. No
diffuse lung disease.
IMPRESSION:
No adenopathy. No pleural effusions. No suspicious pulmonary nodules or
masses. Non characteristic bilateral parenchymal scarring. Borderline
diameter of the main pulmonary artery. Severe coronary calcifications.
Radiology Report
EXAMINATION: ___ DUP EXTEXT BIL (MAP/DVT)
CLINICAL HISTORY ___ year old woman with multivessel heart disease, undergoing
work up for CABG// vein mapping for eval for CABG vein mapping for eval
for CABG
FINDINGS:
Duplex was performed of bilateral lower extremity veins. Great saphenous
veins are patent from the groin to the ankle bilaterally and a small saphenous
veins are patent throughout bilaterally as well. Right great saphenous
diameters range from 4-6 mm while the left great saphenous diameters range
from 3-9 mm. The right small saphenous diameters range from 2-3 mm as do the
left small saphenous diameters. See the scanned worksheet for detailed
diameter locations.
IMPRESSION:
Patent bilateral great saphenous and small saphenous veins.
Radiology Report
EXAMINATION: CAROTID SERIES COMPLETE
CLINICAL HISTORY ___ year old woman with multivessel heart disease, undergoing
work up for CABG// r/o stenosis r/o stenosis
FINDINGS:
Duplex was performed of bilateral carotid arteries. Mild heterogeneous plaque
is seen in the proximal ICA bilaterally.
Right: Peak velocities are 68, 72 and 94 cm/sec in the ICA, CCA and ECA
respectively. This is consistent with less than 40% right ICA stenosis.
Left: Peak velocities are 79, 69 and 89 cm/sec in the ICA, CCA and ECA
respectively. This is consistent with less than 40% left ICA stenosis.
Vertebral flow is antegrade bilaterally.
IMPRESSION:
Bilateral less than 40% carotid stenosis.
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US
INDICATION: ___ year old woman with large hematoma at left elbow with edema
and pain.// Left arm DVT and evaluate hematoma at Left elbow.
TECHNIQUE: Grey scale and Doppler evaluation was performed on the left upper
extremity veins.
COMPARISON: None.
FINDINGS:
There is normal flow with respiratory variation in the left subclavian vein.
The left internal jugular and axillary veins are patent, show normal color
flow and compressibility. The left brachial, basilic, and cephalic veins are
patent, compressible and show normal color flow and augmentation.
There is an extensive hypoechoic mass in the left forearm corresponding with
the area of concern, corresponding to a hematoma. There is no thrombus seen
within the cephalic vein.
IMPRESSION:
No evidence of deep vein thrombosis in the left upper extremity. Extensive
hematoma in the left forearm.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old woman with S/P CABG// Fast track extubation,
effusion, pneumothx Contact name: ___, Phone: 1 Fast track
extubation, effusion, pneumothx
IMPRESSION:
Comparison to ___. The patient has undergone cardiac surgery.
All monitoring and support devices, including the bilateral chest tubes and
the endotracheal tube, are in correct position. Expected postoperative
appearance of the cardiac silhouette. Minimal left pleural effusion with left
basilar atelectasis. No pneumothorax. No pulmonary edema. The alignment of
the sternal wires is unremarkable.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman s/p ct removal// r/o ptx
IMPRESSION:
In comparison with the study of ___, the right chest tube is been
removed and there is no evidence of pneumothorax. Left chest tube remains in
place with no evidence of pneumothorax.
Endotracheal and nasogastric tubes have been removed. Right IJ catheter tip
now is in the lower SVC.
Continued small pleural effusions with basilar atelectatic changes.
Radiology Report
INDICATION: ___ year old woman with s/p CABG// eval ptx-post pull
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The tip of a right internal jugular central venous catheter projects over the
cavoatrial junction. The left chest tube has been removed. There is no
pneumothorax identified. Small bilateral pleural effusions are present with
subjacent atelectasis. The size and appearance of the cardiomediastinal
silhouette is unchanged.
IMPRESSION:
No pneumothorax post removal of the left chest tube.
Radiology Report
INDICATION: ___ year old woman with SOB// ___ year old woman with SOB
TECHNIQUE: Chest AP view
COMPARISON: ___
IMPRESSION:
The right IJ line is unchanged in position with its tip projecting over the
lower SVC. Bilateral effusions right greater than left with bibasilar
atelectasis is unchanged. Cardiomediastinal silhouette is stable. There is
mild pulmonary vascular congestion. No pneumothorax is seen.
Radiology Report
INDICATION: ___ year old woman s/p CABG// predischarge evaluation. Follow up
effusions
TECHNIQUE: Chest PA and lateral
COMPARISON: Portable chest x-ray ___
FINDINGS:
The right IJ line has been removed. Mediastinal clips and sternal wires are
re-demonstrated. There are small bilateral pleural effusions, similar to
previous. The cardiomediastinal silhouette appears similar to previous.
Atelectasis at the lung bases has decreased in severity. The aorta is
tortuous. The bones are diffusely osteopenic.
IMPRESSION:
Stable small bilateral pleural effusions.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abnormal EKG, Chest pain
Diagnosed with Unstable angina
temperature: 98.2
heartrate: 74.0
resprate: 15.0
o2sat: 95.0
sbp: 132.0
dbp: 74.0
level of pain: 0
level of acuity: 2.0 | She was admitted to ___ on ___ and underwent routine
preoperative testing and evaluation. She remained
hemodynamically stable and was taken to the operating room on
___. She underwent coronary artery bypass grafting X 3.
Please see operative note for full details. She tolerated the
procedure well and was transferred to the CVICU in stable
condition for recovery and invasive monitoring.
She was weaned from sedation, awoke neurologically intact, and
was extubated on POD 1. She was weaned from inotropic and
vasopressor support. She had delirium post-operatively and
narcotic pain medicine was discontinued. An initial urinalysis
was positive and she was started on cefepime. The urine culture
showed fecal contamination and a UA was repeated. The repeat UA
was negative and antibiotics were stopped. She was transfused 1
unit of PRBCs for acute blood loss anemia. Beta blocker was
initiated and she was diuresed toward her preoperative weight.
She remained hemodynamically stable and was transferred to the
telemetry floor for further recovery.
The patient developed mild post operative dysphagia and was
followed by the speech pathology team. She will be discharged on
a Ground (dysphagia) and Nectar prethickened liquids. She will
be followed at rehab for further management. She was evaluated
by the physical therapy service for assistance with their
strength and mobility. By the time of discharge on POD 10 pt was
deconditioned, ambulating with assist, all wounds were healing,
and pain was controlled with oral analgesics. She was discharged
to ___ in good condition with appropriate follow up
instructions. Of note, PCP requested that her synthroid be
increased from 25 to 50 mcgs, which was done. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
morphine
Attending: ___.
Chief Complaint:
right groin pain
Major Surgical or Invasive Procedure:
___: revision femoral component and head and liner
History of Present Illness:
___ male with history of hypertension, CVA complicated by
seizures about ___ years ago, right total hip arthroplasty done in
___ who presents to the ED with right groin pain and was
found to have a right hip femoral component hardware failure.
He was doing well with his right total hip replacement. He
denies any issues with infection, dislocations, antecedent pain.
He was doing well until this morning while at work and on all
of a sudden developed an inability to bear weight. He is unable
to recall specific event. He denies any trauma or falls.
Past Medical History:
HTN
Hyperlipidemia
Small MI in ___
question of a TIA ___
Social History:
___
Family History:
-mother: heart attack and stroke. ___ with heart attack
-father: passed away after heart attack ___. No CA, no
migraines; no epilepsy.
Physical Exam:
AVSS
NAD, A&Ox3
Neuro: A&Ox2-3.
RLE: Incision well approximated, clean/dry/intact to air.
Right lower extremity noted to have ___ edema as compared to
left side. This has been stable and ___ performed on ___ and
___ were not significant for DVT.
Fires FHL, ___, TA, GCS. SILT ___ in distributions.
palp DP pulse, wwp distally.
Pertinent Results:
See OMR for pertinent results
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
2. Divalproex (DELayed Release) 250 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO 5X/DAY
2. Aspirin 81 mg PO BID
RX *aspirin 81 mg 1 tablet(s) by mouth twice a day Disp #*30
Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
4. Multivitamins 1 TAB PO DAILY
5. Senna 17.2 mg PO HS
6. Divalproex (DELayed Release) 250 mg PO DAILY
7. Lisinopril 10 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
right hip femoral component failure with fracture at component
neck
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: INJ/ASP MAJOR JT W/FLUORO
INDICATION: ___ year old man with R hip hardware failure. Requesting aspirate
prior to surgery to rule out infection// Please obtain R hip aspirate d/t
concern for infection. Please send cell count, crystals, gram stain, culture
COMPARISON: None
PROCEDURE: The risks, benefits, and alternatives were explained to the
patient and written informed consent obtained by the healthcare proxy.
A pre-procedure timeout confirmed three patient identifiers.
Under fluoroscopic guidance, an appropriate spot was marked. The area was
prepared and draped in standard sterile fashion.
18 cc of 1% Lidocaine was used to achieve local anesthesia. Under intermittent
fluoroscopic guidance, a -gauge spinal needle was advanced into the right
femoroacetabular joint. Approximately 5 cc of black fluid was aspirated.
The needle was removed, hemostasis achieved, and a sterile bandage applied.
The patient tolerated the procedure well and left the department in good
condition. There were no immediate complications or complaints.
FINDINGS:
There is fracture of the right hip prosthesis in the prosthetic neck/head
junction.
IMPRESSION:
1. Imaging Findings- fracture of the right hip prosthesis at the prosthetic
neck/head junction.
2. Procedure - Technically successful aspiration of right hip joint. Samples
were sent for laboratory analysis as requested.
Radiology Report
INDICATION: Total right hip arthroplasty
TECHNIQUE: Two views of the right proximal femur intraoperatively.
COMPARISON: CT ___
FINDINGS:
To intraoperative images were acquired without a radiologist present.
Images show the distal portion of a right major prosthesis femoral component..
IMPRESSION:
Intraoperative images were obtained during right hip arthroplasty.. Please
refer to the operative note for details of the procedure.
Radiology Report
EXAMINATION: PELVIS (AP ONLY)
INDICATION: ___ year old man s/p revision THA// s/p revision THA
TECHNIQUE: Frontal view radiograph of the pelvis and single view of the
proximal right femur
COMPARISON: ___ CT scan
FINDINGS:
The patient is status post revision total hip arthroplasty. The alignment is
near anatomic and there is no evidence of acute periprostatic fracture or
immediate complication. Severe degenerative changes of the left hip are again
noted.
IMPRESSION:
Post right revision total hip arthroplasty in near anatomic alignment.
Radiology Report
EXAMINATION: HIP 1 VIEW
INDICATION: ___ year old man s/p revision THA// PLEASE OBTAIN CROSS TABLE
LATERAL s/p revision THA PLEASE OBTAIN CROSS TABLE LATERAL s/p revision
THA
TECHNIQUE: Cross-table lateral view of the right hip
COMPARISON: Pelvic radiograph from earlier in the evening
IMPRESSION:
Single cross-table lateral view demonstrates a right total hip arthroplasty.
Suboptimal evaluation for alignment or periprostatic fractures.
Radiology Report
EXAMINATION: VENOUS DUP EXT UNI (MAP/DVT) RIGHT
INDICATION: ___ year old man with new right lower extremity swelling// rule
out DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the right lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the right common
femoral, femoral, and popliteal veins. Normal color flow is demonstrated in
the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
There is mild subcutaneous edema in the right lower extremity.
IMPRESSION:
No evidence of deep venous thrombosis in the right lower extremity veins.
Mild subcutaneous edema seen in the right lower extremity.
Radiology Report
EXAMINATION: HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW)
INDICATION: ___ year old man with revision hip// s/p Surgery
TECHNIQUE: AP pelvis and two views right hip.
COMPARISON: Portable postoperative AP view of right hip from ___.
FINDINGS:
Uppermost iliac crests excluded from film as is the lateral most edge of the
left greater trochanter.
Radiographs obtained on trauma board.
Again seen is the right THR with noncemented long femoral stem,, in overall
anatomic alignment. No periprosthetic fracture is detected. No periprosthetic
lucency to suggest loosening and no focal osteolysis identified. Spurring and
some small ossific fragments adjacent to the greater tuberosity are again
noted. There is overlying soft tissue swelling. Subcutaneous emphysema has
resolved.
Again noted is severe left hip osteoarthritis, bone-on-bone. The pelvic
girdle is congruent. The sacrum is obscured by overlying bowel gas, but,
where visible, is grossly unremarkable. Scattered vascular calcifications
again noted.
IMPRESSION:
Status post right THR with noncemented along femoral stem, in overall anatomic
alignment. No periprosthetic fracture, evidence of loosening, or aggressive
osteolysis is identified.
Severe left hip osteoarthritis again noted.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R Hip pain
Diagnosed with Oth fracture of head and neck of right femur, init, Overexertion from strenuous movement or load, init, Periprosth fracture around internal prosth r hip jt, init
temperature: 98.8
heartrate: 62.0
resprate: 18.0
o2sat: 100.0
sbp: 145.0
dbp: 99.0
level of pain: 5
level of acuity: 3.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have ___ and was admitted to the orthopedic surgery
service. The patient was observed over the week and medically
optimized prior to surgery. Operative reports from original THA
at ___ were obtained for pre-operative planning The patient was
taken to the operating room on ___ ___ of
the arthroplasty surgeons at ___ for revision right total hip
with exchange of liner, femoral head and component, which the
patient tolerated well. For full details of the procedure please
see the separately dictated operative report. The patient was
taken from the OR to the PACU where he was monitored overnight.
The patient was noted to be hypotensive and anemic, requiring
multiple units of blood and neosynephrine for blood pressure
support. On POD1 the patient was weaned off of pressors and his
hematocrit stabilized. He was in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#2. The patient did not require any additional
units of pRBCs while on the floor. The patient was given
___ antibiotics and anticoagulation per Dr. ___
___. The patient's home medications were continued
throughout this hospitalization except for lisinopril which was
held while patient's blood pressures normalized. The patient
worked with ___ who determined that discharge to rehab was
appropriate. The ___ hospital course was otherwise
unremarkable.
Of note, the patient was noted to be intermittently confused and
verbally inappropriate by multiple staff (___) so
geriatrics was consulted for management of possible delirium
given recent risk factors. In discussion with family, it was
noted that patient had experienced a cognitive decline and
bizarre behavior of the past two months, frequently speaking
inappropriately or illogically. Given concern for ongoing
cognitive disorder, an appointment was made for patient to
follow up with our Cognitive Neurologist on ___. As an
update, appears as though patient was not able to make
appointment while remaining in house and should have follow-up
rescheduled. The patient and family were agreeable and thought
this would be beneficial.
Patient was noted to have right lower extremity swelling and
edema during his post-operative course. This was stable and
LENIs done on ___ and ___ failed to show any evidence of
blood clot.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weightbearing as tolerated with posterior hip precautions in the
right lower extremity, and will be discharged on 81 ASA BID for
DVT prophylaxis. The patient will follow up with Dr. ___
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course
including reasons to call the office or return to the hospital,
and all questions were answered. The patient was also given
written instructions concerning precautionary instructions and
the appropriate follow-up care. The patient expressed readiness
for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Sulfa(Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year-old female well-known to the pancreaticobiliary surgery
service. Briefly, she is a ___ year old female with h/o HCV who
initially underwent an ERCP for RUQ pain and abnormal LFTs,
complicated by duodenal perforation s/p ___, washout of
retroperitoneum, and gastrojejunostomy on ___. She
had multiple ___ drain placements for fluid collections without a
good result and eventually required a washout. Had a recent
episode of seizure versus cardiac arrest at home, for which she
was intubated, hospitalized in ___ and was discharged on
___. Of note her JP Drain fell out on ___ with no
replacement of drain and patient finished a a 2-week course of
IV ceftazidime on
___. She did have a residual rim-enhancing fluid collection in
the right posterior perirenal on her last CT on ___, but
patient refused to get another ___ drain.
Patient presents today with acute abdominal pain starting last
night at midnight, initially in the whole right side of the
abdomen, then localized to the RUQ. Denies any nausea, vomiting,
fevers or chills. Her last bowel movement was this morning and
has been passing flatus.
Past Medical History:
Perforated bowel
Heroin Abuse
ERCP on ___
HCV
migraines
Chronic LBP
Anxiety/Depression
CBD stones
Cholilithiasis
History of sphincterotmy complicated by duodenal perforation
Social History:
___
Family History:
Mother and sister with symptomatic cholelithiasis requiring CCY.
Father died in ___ from MI, mother, alive, with alcoholic
cirrhoisis.
Physical Exam:
On Admission:
Vitals: 97.8 84 128/80 18 100%
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, tender to palpation on RUQ, no rebound
or guarding, normoactive bowel sounds, no palpable masses
Ext: No ___ edema, ___ warm and well perfused
On Discharge:
VS: 98.4, 66, 96/60, 12, 98% RA
GEN: NAD
CV: RRR, no m/r/g
RESP: CTAB
ABD: Soft, nondistended, tender to palpation on RUQ, no rebound
or guarding, normoactive bowel sounds, no palpable masses
EXTR: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 06:45AM BLOOD WBC-7.5 RBC-3.83* Hgb-11.5* Hct-35.3*
MCV-92 MCH-29.9 MCHC-32.5 RDW-15.0 Plt ___
___ 06:47AM BLOOD Glucose-100 UreaN-7 Creat-0.4 Na-139
K-3.8 Cl-107 HCO3-23 AnGap-13
___ 06:47AM BLOOD ALT-14 AST-12 AlkPhos-93 TotBili-0.1
___ 06:47AM BLOOD Albumin-3.7
___ ABD CT:
IMPRESSION:
1. Distended gallbladder with edematous wall, pericholecystic
soft tissue
stranding, and gallbladder fossa hyperemia, compatible with
acute
cholecystitis. Hyperdensity near the gallbladder neck,
potentially a stone vs due to adjacent traversing vasculature.
2. Two CBD stents with slight interval increase in pneumobilia,
attesting to patency of stents.
3. Near-complete resolution of right pararenal collection.
Medications on Admission:
Xanax 1 tid, Fioricet 50 mg-325 mg-40 mg' prn, Zoloft 25 mg',
Keppra 500 mg bid, phenytoin sodium extended 100 mg tid
Discharge Medications:
1. Acetaminophen-Caff-Butalbital 1 TAB PO DAILY:PRN headache
2. ALPRAZolam 1 mg PO TID:PRN anxiety
3. Amoxicillin-Clavulanic Acid ___ mg PO Q8H
RX *amoxicillin-pot clavulanate 500 mg-125 mg 1 Tablet(s) by
mouth every eight (8) hours Disp #*30 Tablet Refills:*0
4. Calcium Carbonate 1000 mg PO QID:PRN indigestion
5. LeVETiracetam 500 mg PO BID
6. Nicotine Patch 7 mg TD DAILY
7. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 Tablet(s) by mouth once a day Disp #*30
Capsule Refills:*0
8. Phenytoin Sodium Extended 100 mg PO TID
9. Sertraline 25 mg PO DAILY
10. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 Tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Acute cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with history of duodenal perforation and
obstruction, presenting with abdominal pain.
COMPARISONS: Multiple prior CT abdomen and pelvis, most recently of ___.
TECHNIQUE: MDCT images were obtained from the lung bases to the pubic
symphysis. Oral and 130 cc of IV Omnipaque contrast were administered. Axial
images were interpreted in conjunction with coronal and sagittal reformats.
DLP: 381 mGy-cm.
FINDINGS:
ABDOMEN:
The visualized heart is unremarkable. The lung bases are clear. No pleural
or pericardial effusion is seen.
The gallbladder is distended and has an edematous wall measuring up to 5 mm,
with slight surrounding pericholecystic fat stranding. A hyperdensity
adjacent to the gallbladder neck (2a:24) may represent vasculature or
potentially a dense stone in the neck. The liver parenchyma adjacent to the
gallbladder fossa is hyperemic. The liver parenchyma is otherwise normal
without focal or diffuse abnormality. Pneumobilia is seen, slightly increased
from prior, demonstrating patency of two CBD stents.
The pancreas, spleen, and bilateral adrenal glands are normal. Bilateral
kidneys enhance symmetrically and excrete contrast promptly. The ureters are
normal in course and caliber.
The previously identified posterior pararenal fluid collection has nearly
completely resolved since the prior exam. There is now mild residual
thickening and stranding of the paraspinal musculature posterior to the right
kidney.
The stomach is unremarkable. Small and large bowel are normal in course and
caliber. The appendix is normal.
No retroperitoneal or mesenteric lymphadenopathy. The portal and
intra-abdominal systemic vasculature is unremarkable. Scarring in the
anterior abdominal wall is likely due to prior surgery. No abdominal wall
hernia, free abdominal fluid, or pneumoperitoneum.
PELVIS: Bladder and terminal ureters are normal. The uterus contains an IUD.
Bilateral tubal ligation clips are also seen. The adnexa are otherwise
unremarkable. No inguinal or pelvic lymphadenopathy. No inguinal hernia or
free pelvic fluid.
OSSEOUS STRUCTURES: No focal lytic or sclerotic lesion concerning for
malignancy.
IMPRESSION:
1. Distended gallbladder with edematous wall, pericholecystic soft tissue
stranding, and gallbladder fossa hyperemia, compatible with acute
cholecystitis. Hyperdensity near the gallbladder neck, potentially a stone vs
due to adjacent traversing vasculature.
2. Two CBD stents with slight interval increase in pneumobilia, attesting to
patency of stents.
3. Near-complete resolution of right pararenal collection.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ABD PAIN
Diagnosed with ABDOMINAL PAIN OTHER SPECIED
temperature: 97.8
heartrate: 84.0
resprate: 18.0
o2sat: 100.0
sbp: 128.0
dbp: 80.0
level of pain: 10
level of acuity: 3.0 | The patient well known to Dr. ___ was admitted to the
General Surgical Service for evaluation of the acute abdominal
pain. On ___, the patient underwent abdominal CT scan,
which demonstrated distended gallbladder with edematous wall
compatible with acute cholecystitis. The patient was made NPO
with IV fluids and started on IV Unasyn. On HD # 2, patient's
WBC was within normal limits, she was afebrile and her abdominal
pain started to improve. The patient's diet was advanced to
clears and was well tolerated. On HD # 3, patient's pain was
well controlled, her diet was advanced to regular and her
antibiotic was changed to oral. The patient was discharged home
on 10 days course of antibiotics in stable condition.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
L pathologic femoral neck fracture
Major Surgical or Invasive Procedure:
___ - L hip girdlestone
___ - L hip completion hemiarthroplasty, long stem (Krod)
History of Present Illness:
Ms. ___ is a ___ who presents with left hip pain after
sustaining a ground level fall onto her left side earlier today.
She has been having persistent lower back pain with radiation
into her left buttocks and leg for the past ___ months, and she
actually saw a pain medicine doctor (___) at ___
before her incident earlier today. On ___, she had MRI L
spine which showed disc bulges at L4-5 and L5-S1 without root
displacement or compression. She recently began using a single
crutch in her right hand to help her balance and alleviate her
back pain with ambulation.
Today, she was using a cane instead of a crutch, and she lost
her
balance and fell onto her left side after walking down a flight
of stairs in her home. She had immediate severe pain in her
left
hip and inability to bear weight. Her mother was home with her
and called EMS, who brought the patient to the ED for
evaluation.
She denies HS/LOC, other injuries sustained in the fall, or pain
in other areas. She also denies numbness/tingling in her
extremities and change in sensory/motor function or
bowel/bladder
incontinence. She has no other complaints currently.
Past Medical History:
*SUSCEPTIBILITY TO MALIGNANT HYPERTHERMIA* (Her brother
reportedly had malignant hyperthermia after anesthesia; she has
never experienced problems with anesthesia herself, and her only
reported surgery was a cystoscopy for kidney stone removal).
Nephrolithiasis
Lower back pain radiating to left leg with known lumbar disc
bulges
Cystoscopy for kidney stone removal
Obstetric/Gynecologic history:
Age at ___: ___ years old
G0P0
Age at men___: has had periods on/off for past year with
occasional spotting
Hormone history: never on hormone replacement or OCPs
Cancer screening:
Pap smear: Last approx. ___ years ago, does not recall ever being
abnormal
Colonoscopy: never
Mammogram: never
Social History:
___
Family History:
*Brother with history of malignant hyperthermia with anesthesia*
No family history of breast or ovarian cancer
Father with colon cancer diagnosed in ___
Multiple family members with kidney stones
Brother and mother with thyroid problems
Multiple family members with CAD, HTN and heart failure
Maternal cancer with brain tumor
Physical Exam:
Gen: NAD
LLE: incision c/d/i, SILT s/s/sp/dp/t, Fires ___, FHL, G/S, TA,
1+ DP
Medications on Admission:
GABAPENTIN - 300mg TID
Ibuprofen PRN
Discharge Medications:
1. Senna 17.2 mg PO BID
2. Gabapentin 300 mg PO TID
3. Enoxaparin Sodium 40 mg SC QPM Duration: 2 Weeks
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 40 mg/0.4 mL 40 mg sc qpm Disp #*14 Syringe
Refills:*0
4. Docusate Sodium 100 mg PO BID
5. Acetaminophen 650 mg PO Q4H
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
7. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*85 Tablet Refills:*0
8. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
RX *oxycodone 20 mg 1 tablet(s) by mouth every twelve (12) hours
Disp #*28 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
L pathologic femoral neck fracture
Discharge Condition:
Stable
Followup Instructions:
___
Radiology Report
EXAMINATION: MRI AND MRA BRAIN PT12 MR HEAD
INDICATION: ___ year old woman with left displaced pathologic femoral neck
fracture. Likely R breast primary due to lump lateral side. ___
Girdlestone // ?metastatic disease, recent vision changes R eye
TECHNIQUE: 3 dimensional time-of-flight MRA was performed through the brain.
Sagittal and axial T1 weighted imaging were performed along with diffusion
imaging.
After administration of 7 mL of Gadavist intravenous contrast, axial imaging
was performed with gradient echo, FLAIR, T2, and T1 technique. Sagittal MPRAGE
imaging was performed and re-formatted in axial and coronal orientations.
Three dimensional maximum intensity projection and segmented images were
generated. This report is based on interpretation of all of these images.
COMPARISON: None.
FINDINGS:
MRI BRAIN:
There is no evidence of hemorrhage, edema, masses, mass effect, midline shift
or infarction. The ventricles and sulci are normal in caliber and
configuration. There is no abnormal enhancement after contrast
administration.
MRA brain: The intracranial vertebral and internal carotid arteries and their
major branches appear normal without evidence of stenosis, occlusion, or
aneurysm formation.
IMPRESSION:
1. Normal study. No evidence of metastatic disease.
Radiology Report
EXAMINATION: RIGHT BREAST ULTRASOUND
INDICATION: Inpatient presenting with left pathologic hip fracture. Right
breast mass seen on CT. Patient with limited mobility due to fracture.
Referred for targeted ultrasound and core biopsy for tissue diagnosis. She
cannot tolerate mammography at this time.
COMPARISON: No prior mammograms or ultrasounds are available. Comparison is
made to chest CT of ___ which shows a right breast mass.
TECHNIQUE: Targeted breast ultrasound was performed. Selected images were
obtained.
FINDINGS:
Targeted sonographic examination the right lateral breast was performed with
attention to the area of abnormality seen on CT scan. At 10 o'clock, 5 cm
from the nipple, there is a heterogeneous hypoechoic mass measuring 2.6 x 2.6
x 2.2 cm. This has internal and peripheral vascularity on Doppler exam. This
is palpable to my clinical exam.
Ultrasound evaluation of the right axilla shows some lymph nodes which appear
to have cortical thickening or partial obliteration of the fatty hila although
are not enlarged.
IMPRESSION:
1. Suspicious right breast mass at 10 o'clock.
2. Slightly suspicious right axillary lymph nodes on ultrasound, in this
patient with presumed pathologic left hip fracture.
RECOMMENDATION(S): Ultrasound-guided core biopsy of this right breast mass
was performed later today, reported separately.
NOTIFICATION: Findings reviewed with the patient at the completion of the
study.
BI-RADS: 5 Highly Suggestive of Malignancy.
Radiology Report
EXAMINATION: HIP 1 VIEW
INDICATION: Left hemiarthroplasty
TECHNIQUE: One view left hip
COMPARISON: ___
FINDINGS:
The patient is status post left hip hemiarthroplasty, in overall anatomic
alignment on this single view. Expected soft tissue postoperative changes are
noted. When the patient is able, dedicated images of the left hip in multiple
views are recommended.
Radiology Report
EXAMINATION: SHOULDER ___ VIEWS NON TRAUMA RIGHT
INDICATION: ___ year old woman with R proximal humerus lesion on bone scan //
assess for pathologic fracture assess for pathologic fracture
TECHNIQUE: AP in internal rotation, Grashey in external rotation, and
axillary view radiographs of the right shoulder
COMPARISON: Bone scan ___
FINDINGS:
No acute fracture or dislocation. There are moderate to severe degenerative
changes at the acromioclavicular joint. The glenohumeral joint space is
preserved. There is no well defined lesion within the humeral head.
Visualized lung is clear.
IMPRESSION:
1. No fracture or dislocation.
2. Moderate to severe degenerative changes at the acromioclavicular joint.
3. No definite lesion seen within the humeral head. If there is high
clinical concern, would recommend MRI.
Radiology Report
EXAMINATION: FEMUR (AP AND LAT) LEFT
INDICATION: History of known left femoral neck fracture. Please evaluate.
TECHNIQUE: Left hip, two views. Left femur, two views
COMPARISON: None.
FINDINGS:
There is an impacted, mildly displaced subcapital femoral neck fracture, with
the neck foreshortened by approximately 1.6 cm superiorly. Moderate
degenerative changes are seen within the left hip, with evidence of
subchondral sclerosis and joint space narrowing. The visualized left femur is
unremarkable. There is no evidence of dislocation. Limited assessment of the
left knee appears to be unremarkable.
IMPRESSION:
Impacted, mildly displaced subcapital femoral neck fracture, with
foreshortening of the left femur by approximately 1.6 cm superiorly. No
evidence of dislocation.
Moderate degenerative changes seen within the left hip.
Radiology Report
INDICATION: ___ year old woman with L femoral neck fx. // L femoral neck
pathologic fracture, please image the L thigh in entirety.
TECHNIQUE: MDCT axial images were obtained through the left femur without IV
contrast. Coronal and sagittal reformats were obtained.
DOSE: Please refer to the report for CT torso obtained at the same time.
COMPARISON: None
FINDINGS:
Patient is status post left femoral head and neck resection. Postsurgical
changes are identified surrounding the resection bed. Heterogeneous density
at the resection bed likely reflects hematoma, however soft tissue mass cannot
be excluded.
There is elongated areas of hypodensity surrounding the femoral diaphysis and
tracking along the surrounding muscles to the level of mid femoral diaphysis
(14b:153, 15b:78). The finding may reflect hematoma, myositis, or
infiltrative process. A 1.9 x 2.2 cm lucent lesion is noted in the right
sacral ala, as seen on the CT torso obtained at the same time.
IMPRESSION:
1. Patient is status post left femoral head and neck resection. Heterogeneous
density at the resection bed likely reflect hematoma, however soft tissue mass
cannot be excluded.
2. Areas of hypodensities tracking along the length of the muscles surrounding
the left femur may reflect hematoma, myositis, or infiltrative process.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST; CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ year old woman with L pathologic hip fx // ? primary
TECHNIQUE: Multidetector helical scanning of the torso was coordinated with
intravenous infusion of nonionic iodinated contrast agent. Axial images of
the chest was reconstructed as contiguous 5- and 1.25-mm thick axial, 2.5-mm
thick coronal and parasagittal, and 8 x 8 mm MIPs axial images. Axial images
of the abdomen and pelvis was reconstructed in coronal and sagittal images.
DOSE: Acquisition sequence:
1) Stationary Acquisition 0.5 s, 1.0 cm; CTDIvol = 1.2 mGy (Body) DLP = 1.2
mGy-cm.
2) Stationary Acquisition 3.0 s, 1.0 cm; CTDIvol = 6.9 mGy (Body) DLP = 6.9
mGy-cm.
3) Spiral Acquisition 28.0 s, 107.7 cm; CTDIvol = 9.9 mGy (Body) DLP =
1,052.3 mGy-cm.
Total DLP (Body) = 1,115 mGy-cm.
COMPARISON: None prior
FINDINGS:
CHEST:
Partially imaged nodule in the right thyroid lobe measures 1.3 cm.
Supraclavicular, axillary, mediastinal and hilar lymph nodes are not enlarged.
Aorta and pulmonary arteries are normal size. Cardiac configuration is normal
and there is no appreciable coronary calcification.
A 2.2 cm enhancing mass in the right breast is concerning for malignancy
(series 7, image 28).
Discoid atelectasis is seen at the left lung base and linear atelectasis seen
at the right lung base. Central airways are patent to the segmental levels
bilaterally.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
Multiple hypodense lesions measuring up to 2.8 cm are identified in the liver.
The larger lesions are compatible with hepatic cysts or biliary MR ___.
Many subcentimeter lesions are too small to be fully characterized. The
ill-defined geographic area of hypodensity adjacent to the falciform ligament
likely reflects focal fatty deposition or perfusional anomaly. There is
prominence of intrahepatic and extrahepatic biliary ducts. Common bile duct
measures 11 mm in diameter. A 9 mm polyp is identified in the gallbladder
fundus.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
Multiple left parapelvic cysts are identified. Several sub cm hypodensities
in bilateral kidneys are too small to be characterized. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. Colonic
diverticulosis is noted. The appendix is not visualized.
PELVIS: Bladder contains a Foley catheter. There is no free fluid in the
pelvis.
REPRODUCTIVE ORGANS: Uterus is enlarged due to the presence of multiple large
masses consistent with fibroids. The largest fibroid at the uterine fundus
which is largely exophytic measures 11.6 x 9.3 x 11.7 cm.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: Left femoral head and neck has been resected. A 1.6 x 1.9 cm lucent
lesion is identified at the right sacral ala. A small defect at the superior
endplate of L3 vertebral body is likely a Schmorl's node.
SOFT TISSUES: A 1.9 x 2.2 cm enhancing mass is identified in the right lateral
posterior breast, abutting the right pectoralis muscle (07:28). A 0.4 cm
lesion is identified in the superior left breast (___:18), likely representing
a lymph node.
IMPRESSION:
1. A 2.2 cm enhancing mass in the right breast is concerning for malignancy.
A 0.4 cm density in the left upper breast is likely a lymph node.
2. 1.9 cm lucent lesion in the right sacral ala is suspicious for metastatic
lesion. Left femoral head and neck has been resected.
3. A 1.3 cm right thyroid nodule is partially imaged. If clinically
indicated, consider nonemergent ultrasound for further evaluation.
4. A 0.9 cm gallbladder lesion is identified.
5. Prominent intrahepatic and extrahepatic bile ducts are nonspecific.
RECOMMENDATION(S): Abdominal ultrasound for possible gallbladder polyp.
Consider non urgent ultrasound for thyroid nodule.
Radiology Report
EXAMINATION: RIGHT BREAST ULTRASOUND GUIDED CORE BIOPSY WITH CLIP PLACEMENT
INDICATION: Suspicious breast mass in the right breast, referred for tissue
biopsy for diagnosis.
COMPARISON: The relevant imaging was available for this procedure.
FINDINGS:
In the right breast at 10 o'clock 5 cm from the nipple is an irregular
hypoechoic mass measuring 2.7 cm. This was targeted for biopsy.
PROCEDURE: The procedure, risks, benefits and alternatives were discussed
with the patient and written informed consent was obtained.
Time-out certification: Performed using three patient identifiers.
Allergies and/or Medications: Reviewed prior to the procedure.
Clinicians: N. ___, N.P.. The procedure was supervised by T. ___,
M.D.(Attending).
Description: Using ultrasound guidance, aseptic technique and 1% lidocaine for
local anesthesia, a 13-gaugecoaxial needle was placed adjacent to the lesion
and using a 14-gauge Bard spring-loaded biopsy device, 5 cores were obtained.
Next, a percutaneous ribbon clip was deployed under ultrasound guidance. The
needle was removed and hemostasis was achieved.
Estimated blood loss: < 1 cc.
Specimens: Sent to pathology.
Anesthesia: ___ cc 1% lidocaine.
Complications: No immediate complications.
Post procedure diagnosis: Same.
POST-PROCEDURE MAMMOGRAM: The patient has a pathologic hip fracture. The
clip was well seen on ultrasound. Mammography was deferred.
IMPRESSION:
Technically successful US-guided core biopsy of suspicious right breast mass.
Pathology is pending.
The patient expects to hear the pathology results from the referring provider,
Dr. ___. Standard post care instructions were provided to the patient.
Gender: F
Race: OTHER
Arrive by AMBULANCE
Chief complaint: Transfer, L Hip fracture
Diagnosed with Unsp intracapsular fracture of left femur, init for clos fx, Fall on same level, unspecified, initial encounter
temperature: 98.4
heartrate: 98.0
resprate: 24.0
o2sat: 97.0
sbp: 197.0
dbp: 97.0
level of pain: 8
level of acuity: 3.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have L femoral neck fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for planned L hip girdlestone, which
the patient tolerated well.
She was initially planned for a THA but intraop it was noted
that her bone quality was peculiar. A frozen section was sent
for pathology and came back + for malignancy. The THA was
aborted. After the case she was noted to have a R breast lump.
For full details of the procedure please see the separately
dictated operative report. The patient was taken from the OR to
the PACU in stable condition and after satisfactory recovery
from anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given ___ antibiotics and anticoagulation
per routine.
Heme/onc and ___ Surgery were consulted and her onc w/u
was begun. She underwent a mammogram, ultrasound with possible
breast biopsy, bone
scan, spep/upep, CT C/A/P, a bone scan and MRI brain. At this
time her pathology form her breast u/s came back as invasive
ductal carcinoma, stains pending. She will follow up with these
heme/onc as an outpatient for further w/u and treatment.
The patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to rehab was appropriate. The ___ hospital
course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
WBAT in the LLE, and will be discharged on lovenox for DVT
prophylaxis. The patient will follow up with Dr. ___
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course
including reasons to call the office or return to the hospital,
and all questions were answered. The patient was also given
written instructions concerning precautionary instructions and
the appropriate follow-up care. The patient expressed readiness
for discharge. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___: Laparoscopic cholecystectomy
History of Present Illness:
Ms ___ is a ___, PMH significant for Left ovarian cyst
rupture
(without needing subsequent intervention), presents today with
complaint of epigastric pain x 1 day. She reports acute onset of
colicky, sharp pain localized to the epigastric area with
occasional radiation to the back. She notes no association with
po intake. No nausea, vomiting, fevers, chills, urinary
symptoms,
change in bowel habits or bowel movement characteristics. At the
time of interview, her symptoms has largely subsided. Notably,
she professes a history of severe cramps with menstruation for
which she takes NSAIDs. However, this episode feels different
and
is earlier than her normal periods. Furthermore, she also says
that she is scheduled for ablation as management of menorrhagia
in the near future.
Past Medical History:
PAST MEDICAL HISTORY:
Left ovarian cyst - ruptured
Menorrhagia - planned endometrial ablation
PAST SURGICAL HISTORY:
C-section x 2
Dermoid tumor + L oophorectomy
Tubal ligation
Social History:
___
Family History:
noncontributory
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
VITAL SIGNS: 99.1 84 127/70 16 100% RA
GENERAL: AAOx3 NAD
HEENT: NCAT, EOMI, PERRLA, No scleral icterus, mucosa moist, no
LAD
CARDIOVASCULAR: R/R/R, S1/S2, NO M/R/G
CAROTIDS: 2+, No bruits or JVD
PULSES: L/R radial: P/P LLE: P/P/P/P RLE: P/P/P/P
PULMONARY: CTA ___, No crackles or rhonchi
GASTROINTESTINAL: S/NT/ND. No guarding, rebound, or peritoneal
signs. +BSx4
INCISION/WOUNDS: C/D/I. Soft, no hematoma or ecchymosis
EXT/MS/SKIN: No C/C/E; Feet warm. Good perfusion.
NEUROLOGICAL: Reflexes, strength, and sensation grossly intact
CNII-XII: WNL
Discharge Physical Exam:
VS: 98.3, 83, 102/54, 16, 97%ra
GEN: AA&O x 3, NAD, calm, cooperative.
HEENT: (-)LAD, mucous membranes moist, trachea midline, EOMI,
PERRL.
CHEST: Clear to auscultation bilaterally, (-) cyanosis.
ABDOMEN: soft, mildly tender to palpation incisionally,
non-distended. Incisions: clean, dry and intact, dressed and
closed with steristrips.
EXTREMITIES: Warm, well perfused, pulses palpable, (-) edema
================================================
Pertinent Results:
___ 08:30AM BLOOD WBC-7.6 RBC-5.13 Hgb-12.1 Hct-41.0
MCV-80* MCH-23.6* MCHC-29.5* RDW-16.3* RDWSD-47.0* Plt ___
___ 01:10PM BLOOD WBC-6.4 RBC-4.86 Hgb-11.6 Hct-38.5
MCV-79* MCH-23.9* MCHC-30.1* RDW-16.4* RDWSD-47.0* Plt ___
___ 12:50PM BLOOD WBC-9.0 RBC-4.86 Hgb-11.6 Hct-37.3
MCV-77* MCH-23.9*# MCHC-31.1* RDW-16.2* RDWSD-45.0 Plt ___
___ 08:30AM BLOOD Glucose-115* UreaN-6 Creat-0.8 Na-140
K-4.4 Cl-103 HCO3-26 AnGap-15
___ 01:10PM BLOOD Glucose-113* UreaN-7 Creat-0.7 Na-139
K-4.4 Cl-106 HCO3-26 AnGap-11
___ 12:50PM BLOOD Glucose-106* UreaN-9 Creat-0.8 Na-139
K-4.1 Cl-107 HCO3-24 AnGap-12
___ 08:30AM BLOOD ALT-70* AST-29 AlkPhos-112* TotBili-0.2
___ 01:10PM BLOOD ALT-96* AST-56* AlkPhos-112* TotBili-0.3
___ 12:50PM BLOOD ALT-124* AST-235* AlkPhos-118*
TotBili-0.3
___ 08:30AM BLOOD Calcium-9.3 Phos-3.0 Mg-2.1
___ 01:10PM BLOOD Calcium-8.7 Phos-2.8 Mg-2.2
IMAGING:
___ Gallbladder US:
1. Cholelithiasis without evidence of acute cholecystitis.
2. Otherwise normal abdominal ultrasound.
___ MRCP:
1. Layering dense bile or sludge in the gallbladder without
discrete stones.
No evidence of acute cholecystitis. No biliary ductal
dilatation or
choledocholithiasis.
2. Approximately 7 cm segment of probable transient
jejunojejunal
intussusception in the left abdomen, with other short segments
of
jejunojejunal intussusception identified on the most inferior
images. No
bowel dilatation proximally to indicate obstruction. No lesion
identified.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BuPROPion (Sustained Release) 150 mg PO BID
2. Citalopram 40 mg PO QHS
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6)
hours Disp #*40 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*20 Capsule Refills:*0
3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*25 Tablet Refills:*0
4. Senna 8.6 mg PO BID:PRN constipation
5. BuPROPion (Sustained Release) 150 mg PO BID
6. Citalopram 40 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Cholelithiasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MRCP
INDICATION: ___ year old woman with poss choledocholithiasis // biliary
anatomy ? stones in ducts
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
Intravenous contrast: 10 mL Gadavist.
Oral contrast: 1 cc of Gadavist mixed with 50 cc of water was administered
for oral contrast.
COMPARISON: Right upper quadrant ultrasound dated ___.
FINDINGS:
Lower Thorax: There is no pleural or pericardial effusion.
Liver: The liver is normal in size and smooth in contour. There is no
evidence of hepatic steatosis. No hepatic lesions are identified.
Biliary: There is layering dense bile or sludge in the gallbladder without
discrete stones. There is no evidence of choledocholithiasis. There is no
intra or extrahepatic biliary ductal dilatation.
Pancreas: The pancreas is within normal limits. There is no pancreatic ductal
dilatation.
Spleen: The spleen is within normal limits.
Adrenal Glands: The adrenal glands are within normal limits.
Kidneys: The kidneys are within normal limits.
Gastrointestinal Tract: There is an approximately 7 cm segment of probable
transient jejunojejunal intussusception in the left abdomen, with other short
segments of jejunojejunal intussusception identified on the most inferior
images (series 17, images 57-82). There is no bowel dilatation proximally to
indicate obstruction. No lead point is identified.
Lymph Nodes: There is no mesenteric or retroperitoneal lymphadenopathy.
Vasculature: The abdominal aorta and major mesenteric branches are patent and
normal in caliber.
Osseous and Soft Tissue Structures: The bone marrow is normal in signal. The
abdominal wall is within normal limits.
IMPRESSION:
1. Layering dense bile or sludge in the gallbladder without discrete stones.
No evidence of acute cholecystitis. No biliary ductal dilatation or
choledocholithiasis.
2. Approximately 7 cm segment of probable transient jejunojejunal
intussusception in the left abdomen, with other short segments of
jejunojejunal intussusception identified on the most inferior images. No
bowel dilatation proximally to indicate obstruction. No lesion identified.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 12:17 ___, 15 minutes after
discovery of the findings.
Radiology Report
INDICATION: ___ year old woman with cholelithiasis // pre op
TECHNIQUE: Chest PA and lateral
COMPARISON: ___ chest radiograph
FINDINGS:
In comparison to ___ chest radiograph, there are no changes noted.
The lungs are well inflated. There are no consolidations, opacities, masses,
pneumothorax, or pleural effusion appreciated. The cardiomediastinal
silhouette and hilar silhouettes are normal size. The heart size is normal.
There is no acute bony abnormality nor evidence of acute fracture.
IMPRESSION:
1. No change since ___. Normal chest radiograph.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain
Diagnosed with Right upper quadrant pain
temperature: 98.0
heartrate: 95.0
resprate: 18.0
o2sat: 99.0
sbp: 121.0
dbp: 63.0
level of pain: 8
level of acuity: 3.0 | ___ relatively unremarkable PMH p/w acute abdominal pain. There
is radiographic evidence of GB stones without inflammation,
accompanied by slight biliary obstructive pattern on labs. She
has cholelithiasis and probably choledocholithiasis.
The patient was admitted to the General Surgical Service on ___
for evaluation and treatment of abdominal pain. Admission
abdominal ultra-sound revealed evidence of GB stones without
inflammation, accompanied by slight biliary obstructive pattern
on labs. The patient had an MRCP which was negative for CBD
stones. The patient then underwent laparoscopic cholecystectomy,
which went well without complication (reader referred to the
Operative Note for details). After a brief, uneventful stay in
the PACU, the patient arrived on the floor tolerating sips, on
IV fluids, and oral narcotics for pain control. The patient was
hemodynamically stable.
.
Pain was well controlled. Diet was progressively advanced as
tolerated to a regular diet with good tolerability. The patient
had to be straight catheterized once post op but then was able
to void without a problem. During this hospitalization, the
patient ambulated early and frequently, was adherent with
respiratory toilet and incentive spirometry, and actively
participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
.. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Heparin Agents / Iodine-Iodine Containing / ACE Inhibitors /
prednisone / contrast dye
Attending: ___.
Chief Complaint:
SOB, Chest Pressure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms ___ is a ___ year old woman with PMHx notable for
___, PE on coumadin since 1990s, pericardial effusion (___),
and HIT who presents with chest tightness and sob for the last 3
days. SHe reports that she stopped her coumadin 7 days ago as
she had a steroid injection for cervical pain. She reports that
she does not know what her dry weight is. She weighs herself
occasionally. In the setting of not feeling well for the last
couple of days she has not taken her torsemide. She reports that
the symtpoms are worse with exertion. Reports non productive
cough, no fevers or chills. She does feel like she has had a
couple of "hot flashes". Pt reports ___ edema at baseline and
denies change in weight. No n/v/d or recent falls. SHe does
report that he daughter and grandson were sick ___ weeks ago.
In the ED intial vitals were: 6 98.9 72 150/pap 24 99%
Patient was given:
___ Fondaparinux 10 mg SC DAILY Start: Today - ___, First
Dose: Next Routine Administration Time new
___ Furosemide 40 mg IV ONCE
Labs were notable for:
D-Dimer: 1596
___: 16.2 PTT: 34.3 INR: 1.5
proBNP: 401
Vitals on transfer: 85 158/78 16 98% Nasal Cannula
On the floor the patient reports that her breathing has mildy
improved since she got the lasix.
ROS: On review of systems, s/he denies any prior history of
stroke, TIA, deep venous thrombosis, pulmonary embolism,
bleeding at the time of surgery, myalgias, joint pains, cough,
hemoptysis, black stools or red stools. S/he denies recent
fevers, chills or rigors. S/he denies exertional buttock or calf
pain. All of the other review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. Obesity.
2. Chronic diastolic CHF.
3. Pulmonary hypertension, reportedly mild.
4. Sleep apnea/obesity hypoventilation syndrome
5. History of positive PPD.
6. Paroxysmal atrial fibrillation/flutter with RVR.
7. Mitral regurgitation.
8. PE in ___, on Coumadin.
9. COPD/asthma.
10. Hypertension.
11. Hypothyroidism.
12. Chronic dyspnea on exertion and hypoxia with need for home
O2. She uses four liters with exercise and currently three
liters with sleep (overnight oximetry performed on two liters in
___, revealed 22 minutes less than 88%, for which her
nocturnal O2 was increased to 3 liters). DME is ___.
13. Anemia.
14. Tension headaches.
15. History of pericarditis with hemorrhagic pericardial
effusion status post pericardiocentesis in ___.
16. Sacroiliitis.
17. Cervical radiculopathy, with shoulder, back and neck pain.
18. Scoliosis.
19. Status post cataract surgery.
20. History of dysfunctional uterine bleeding status post
vaginal hysterectomy and left salpingo-oophorectomy in ___.
21. Vitamin D deficiency.
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Initial Physical Exam
==========================
VS: T=98.1 BP=152/78 HR=77 RR=22 O2 sat=100% on 5LNC
GENERAL: NAD, laying in bed. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple. Unable to appreciate JVP due to body habitus
CARDIAC: RRr, normal S1, S2. No m/r/g.
LUNGS: Resp were unlabored, no accessory muscle use. Difficult
to auscultate. Distant breath sounds anteriorly, not ablt to
asucultate posteriorly.
ABDOMEN: Soft, NTND. Obese
EXTREMITIES: 1+ lower extermity edema
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Discharge Physical Exam
===========================
VS: T=98.3 BP=103-121/48-63 HR=56-62 RR=18 O2 sat=96% on 4L
GENERAL: NAD, . Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. EOMI, right ocular exotropia. no
pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple. Unable to appreciate JVP due to body habitus
CARDIAC: RRr, normal S1, S2. No m/r/g.
LUNGS: Resp were unlabored, no accessory muscle use. Difficult
to auscultate. Distant breath sounds posteriorly.
ABDOMEN: Soft, NTND. Obese
EXTREMITIES: 1+ lower extermity edema
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
Initial Lab Results
========================
___ 02:05PM BLOOD WBC-8.8 RBC-4.55# Hgb-13.6# Hct-43.9#
MCV-97 MCH-30.0 MCHC-31.1 RDW-16.2* Plt ___
___ 03:00PM BLOOD Glucose-94 UreaN-16 Creat-1.0 Na-139
K-4.7 Cl-102 HCO3-25 AnGap-17
___ 02:05PM BLOOD cTropnT-<0.01
___ 06:00AM BLOOD CK-MB-1 cTropnT-<0.01
___ 03:00PM BLOOD proBNP-401*
___ 06:00AM BLOOD Calcium-8.9 Phos-4.0 Mg-2.2
___ 02:51PM BLOOD D-Dimer-1596*
___ 02:49PM BLOOD Lactate-1.4
Imaging
===========================
___ CXR
FINDINGS: There is cardiomegaly as well as diffuse alveolar
opacities and
septal thickening consistent with mild pulmonary edema. The
cardiomediastinal
silhouette and hilar contours are normal. The pleural surfaces
are normal
without effusion or pneumothorax.
IMPRESSION: Mild pulmonary edema and cardiomegaly
Discharge Labs
============================
___ 07:00AM BLOOD WBC-9.1 RBC-4.53 Hgb-13.6 Hct-44.8
MCV-99* MCH-30.0 MCHC-30.4* RDW-14.6 Plt ___
___ 07:00AM BLOOD Glucose-117* UreaN-24* Creat-1.0 Na-142
K-4.4 Cl-96 HCO3-31 AnGap-19
___ 07:00AM BLOOD Calcium-9.2 Phos-4.5 Mg-2.0
___ 07:00AM BLOOD ___ PTT-41.5* ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pravastatin 10 mg PO DAILY
2. Vitamin D ___ UNIT PO DAILY
3. Warfarin 7.5 mg PO DAILY16
4. DuoNeb (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg base)/3 mL
inhalation QID:PRN SOB
5. TraMADOL (Ultram) 100 mg PO Q6H:PRN Pain
6. Torsemide 40 mg PO DAILY
7. Lidocaine 5% Patch 1 PTCH TD QAM
8. Levothyroxine Sodium 75 mcg PO DAILY
9. Metoprolol Tartrate 37.5 mg PO BID
10. Omeprazole 20 mg PO BID
11. Loratadine 10 mg PO DAILY
12. Fluticasone Propionate 110mcg 2 PUFF IH BID
Discharge Medications:
1. Fluticasone Propionate 110mcg 2 PUFF IH BID
2. Levothyroxine Sodium 75 mcg PO DAILY
3. Lidocaine 5% Patch 1 PTCH TD QAM
4. Loratadine 10 mg PO DAILY
5. Metoprolol Tartrate 37.5 mg PO BID
6. Omeprazole 20 mg PO BID
7. Pravastatin 10 mg PO DAILY
8. Torsemide 30 mg PO DAILY
9. TraMADOL (Ultram) 50 mg PO Q6H:PRN Pain
10. Vitamin D ___ UNIT PO DAILY
11. DuoNeb (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg base)/3 mL
inhalation QID:PRN SOB
12. Warfarin 5 mg PO DAILY16
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
1. Diastolic Cardiac Heart Failure
2. Paroxysmal Atrial Fibrillation
SECONDARY DIAGNOSIS
1. Chronic Obstructive Pulmonary Disease
2. Obstructive Sleep Apnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: Shortness of breath with history of CHF and PE.
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: Chest radiograph on ___.
FINDINGS: There is cardiomegaly as well as diffuse alveolar opacities and
septal thickening consistent with mild pulmonary edema. The cardiomediastinal
silhouette and hilar contours are normal. The pleural surfaces are normal
without effusion or pneumothorax.
IMPRESSION: Mild pulmonary edema and cardiomegaly.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Chest pain
Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC
temperature: 98.9
heartrate: 72.0
resprate: 24.0
o2sat: 99.0
sbp: 150.0
dbp: nan
level of pain: 6
level of acuity: 2.0 | ___ year old woman with PMHx notable for dCHF, PE on coumadin
since ___, pericardial effusion, and HIT who presents with
chest tightness and sob for the last 3 days.
ACUTE ISSUES
# Acute on chronic diastolic CHF:
Patient presented with shortness of breath with mildly elevated
BNP in the setting of obesity, CXR with mild pulmonary edema.
She also reported not taking torsemide for the last 2 days as
she did not feel well. She was diuresed initially with IV Lasix
and then transitioned to Torsemide. On day 2 of admission she
reported feeling significantly better and was net negative 2.6 L
s/p diuresis.
# Chest Pressure/left axillary pain
Low likelihood of cardiac ischemia given negative Tn, and relief
of left axillary pain with tylenol and lidocaine patch. On
morning of arrival her chest pressure had resolved. There was
low likelihood of PE given the patient is on warfarin at home.
CHRONIC ISSUES
# COPD:
The patient has a history of COPD and is on fluticasone inhaler
and duonebs at home. She did not endorse any worsening of her
symptoms. She was managed with duonebulizers, albuterol
nebulizers, and continuation of her home fluticasone regimen.
# OSA:
The patient has a known history of OSA and uses a BiPAP at home.
She was provided a BiPAP during admission.
# Hx PE:
Patient has a distant history of PE. She had an elevated d-dimer
on admission however given her allergy to contrast, a CTA was
not performed. She is on warfarin at home due to her history of
PE, and thus her home regimen of anti-coagulation would be
treatment for a PE if she was presenting with one. She had not
taken some of her home warfarin for a week due to a cervical
injection, and thus her INR was sub-therapeutic on admission.
Therefore she was bridged with Fondaparinux 10mg SC daily and
received Coumadin. On day of discharge her INR was therapeutic
at 2.5.
# Paroxysmal Atrial Fibrillation:
The patient was continued on coumadin with bridge of
Fondaparinux as above, and her INR was therapeutic on day of
discharge. She was also rate contolled with her home metoprolol
regimen.
# Back Pain:
-Continue home tramadol.
# Hypothyroidism:
-Continue home Levothyroxine Sodium 75 mcg
TRANSITIONAL ISSUES
******Patient DESATURATES at night due to her history of OSA and
she is non-compliant with her home BiPAP
**Pls monitor patient's INR. Goal INR of ___
**Pls monitor patient's weight and BP in rehab to ensure weight
is not increasing and she is not hypotensive
**Discharge Weight: 170.6 kg |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
metronidazole / Zosyn
Attending: ___.
Chief Complaint:
abd pain
Major Surgical or Invasive Procedure:
-
none
History of Present Illness:
___ female with hx of IBS here with abd pain. Pt reports that
about 1 month ago she had an episode of IBS that was quite
severe with abd cramping, esp in the epigastric region. 4 days
ago she began to have another episode. Characterized by
epigrastric and ruq abdominal pain. It has been nearly
continuous since then and increasing in severity. She at times
hasbeen doubled over in pain. Further, she has been having
severe nausea, abd distention and a decrease in po intake. no
diarrhea or bloody stools. She thinks that she had fevers
yesterday.
she reports hx of hives with flagyl a few years ago when she was
given it for horrible diarrhea.
In the ED pt was given only zosyn and developed B hives,
redness, arm swelling and epigastric discomfort. no sob or
wheeze.
Past Medical History:
IBS
gastritis & duodenal ulcers ___ yrs ago
Seasonal allergies
plantar fascitis
Rotater cuff tear
C-section ___ yrs ago
Ex-lap ___ yrs ago, due to suspected bowel perf during IVF
procedure ___ yrs ago. No bowel perf found.
Social History:
___
Family History:
sister and mother with diverticulitis, both needed surgery
Physical Exam:
temp 99. VSS
Cons: NAD, lying in bed , well appearing
Eyes: EOMI, no scleral icterus
ENT: MMM
Cardiovasc: rrr, no murmur, no edema
Resp: CTA B
GI: +hypoactive bs,soft, mild distention, mild R ttp
MSK: no significant kyphosis
Skin: no rashes
Neuro: no facial droop
Psych: full range of affect
Discharge exam:
afebrile, normal VS
Abdomen: soft, mildly tender in epigastrium/RUQ, no rebound or
guarding
otherwise exam as above
Pertinent Results:
___ 09:51PM LACTATE-1.0
___ 09:39PM GLUCOSE-96 UREA N-9 CREAT-0.7 SODIUM-140
POTASSIUM-3.4 CHLORIDE-104 TOTAL CO2-26 ANION GAP-13
___ 09:39PM ALT(SGPT)-13 AST(SGOT)-11 ALK PHOS-51
AMYLASE-37 TOT BILI-0.8
___ 09:39PM ALT(SGPT)-13 AST(SGOT)-11 ALK PHOS-51
AMYLASE-37 TOT BILI-0.8
___ 09:39PM ALBUMIN-4.1 CALCIUM-8.6 PHOSPHATE-3.5
MAGNESIUM-2.0
___ 09:39PM WBC-12.0* RBC-4.15* HGB-12.7 HCT-38.1 MCV-92
MCH-30.6 MCHC-33.4 RDW-13.4
___ 09:39PM NEUTS-74.0* ___ MONOS-5.2 EOS-1.2
BASOS-0.2
___ 09:39PM PLT COUNT-175
___ 09:39PM ___ PTT-28.6 ___
CTA ABD W&W/O C & RECONS
1. Complex, fluid density lesion interposed between the second
portion of the duodenum and the pancreatic head containing
locules of air measuring approximately 2.6 cm. Inflammation of
the second and third portions the duodenum. The appearance is
most suggestive of duodenal diverticulitis. There are several
other duodenum diverticula (605b:58, 3b:169). The size and
complexity of this lesion is suspicious for an accompanying
abscess. Duodenal ulcer with an abscess or focal pancreatitis
are
also possible, but atypical. Malignancy is less likely (no
pancreatic or biliary ductal dilatation). MRCP or EUS would be
helpful for further characterization.
2. 7 mm hypodensity in the head of the pancreas, separate from
the above process. This is most likely a side branch IPMN and
further characterization with MRCP is recommended
MRCP:
1. Complex, fluid-filled lesion posterior to the second portion
the duodenum and improving inflammation throughout the anterior
pararenal space. The constellation of findings and appearance
suggests an inflamed duodenum diverticulum with
microperforation. Perforated duodenal ulcer is also possible,
though the location is atypical.
2. 6 mm pancreatic cyst is most likely side branch IPMN.
Follow-up MRCP is recommended in ___ year.
Discharge labs:
___ Ct
___
GlucoseUreaNCreatNaKClHCO3AnGap
___
blood culture pending
H. pylori IgG pending
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ibuprofen 400 mg PO Q8H:PRN pain
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth Q12 Disp
#*14 Tablet Refills:*0
2. Clindamycin 300 mg PO Q8H
RX *clindamycin HCl [Cleocin] 300 mg 1 capsule(s) by mouth every
eight (8) hours Disp #*21 Capsule Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
4. Pantoprazole 40 mg PO Q12H
RX *pantoprazole [Protonix] 40 mg 1 tablet(s) by mouth every
twelve (12) hours Disp #*60 Tablet Refills:*1
5. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 cap by mouth twice a day Disp
#*30 Capsule Refills:*0
6. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron HCl [Zofran (as hydrochloride)] 4 mg 1 tablet(s)
by mouth every eight (8) hours Disp #*21 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
duodenal ulcer vs. duodenal diverticulum with contained
perforation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MRCP (MR ___
INDICATION: ___ year old woman with pancreatic/duodenal/renal mass or abscess.
please obtain MRI to better characterize. // ?etiology of mass or abscess in
abdomen on CT
TECHNIQUE: Multiplanar T1 and T2 weighted MR images of the abdomen were
obtained on a 1.5 Tesla magnet including dynamic 3D imaging prior to, during,
and after the administration of 7 mL Gadavist gadolinium based contrast. 1 mL
Gadavist mixed with 50 mL water was also administered for oral contrast.
COMPARISON: CTA abdomen, ___.
FINDINGS:
Similar to the recent CTA of the abdomen, there is a cluster of tubular
fluid-filled lesions posterior to the second and third portions of the
duodenum, measuring approximately 3.4 x 1.2 cm (1202:129). There are
surrounding inflammatory changes in the anterior pararenal space. Allowing for
differences in technique, this appears improved from ___. The second and
third portions of the duodenum are thickened and no definite diverticulum is
visualized. There is no intra or extrahepatic biliary ductal dilatation and
the common bile duct measures 6 mm in diameter. The pancreas is normal in
signal and there is no ductal dilatation. However, there is a 6 mm cystic
lesion in the head, corresponding to the abnormality on CT (4:37).
There are trace bilateral pleural effusions with secondary atelectasis. The
liver enhances homogeneously and there is no focal liver lesion. The hepatic
and portal veins are patent. Hepatic arterial anatomy is conventional. There
are bilateral breast cysts. The kidneys are normal with the exception of a 2.7
x 2.5 cm parapelvic cyst on the right (04:42). The spleen, and adrenal glands
are normal. The stomach and visualized bowel are unremarkable. Bone marrow
signal is normal.
IMPRESSION:
1. Complex, fluid-filled lesion posterior to the second portion the duodenum
and improving inflammation throughout the anterior pararenal space. The
constellation of findings and appearance suggests an inflamed duodenum
diverticulum with microperforation. Perforated duodenal ulcer is also
possible, though the location is atypical.
2. 6 mm pancreatic cyst is most likely side branch IPMN. Follow-up MRCP is
recommended in ___ year.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, NEW MASSES
Diagnosed with ABDOMINAL PAIN GENERALIZED, PANCREATIC DISEASE NOS
temperature: 99.0
heartrate: 80.0
resprate: 16.0
o2sat: 95.0
sbp: 111.0
dbp: 67.0
level of pain: 0
level of acuity: 2.0 | ___ year old female with history of IBS and duodenal ulcer
presenting with abdominal pain, fevers, chills and leukocytosis.
1. GI: CT scan showing likely perforated duodenal ulcer that is
contained, less likely duodenal diverticulitis with abscess.
General surgery and GI were consulted. She appeared non-toxic
and had a benign abdominal examination. She has an allergy to
flagyl causing hives and received Zosyn in the emergency
department and developed diffuse rash treated with solumedrol,
benadryl and pepcid. Started on meropenem on admission to floor
and protonix 40 mg IV BID. MRCP showed duodenal diverticulum
vs. duodenal ulcer with small, contained perforation.
Antibiotics de-escalated to ciprofloxacin and clindamycin. H.
Pylori serology was sent. Endoscopy deferred given risk of
perforation with insufflation; she will need an endoscopy in one
month to evaluate the area. Until then, will continue on high
dose PPI, avoid NSAIDs/alcohol, and complete a 10 day course of
cipro/clinda. H. pylori was pending at time of discharge and
will be followed up. She will need a repeat MRCP in one year to
evaluate the above noted pancreatic cyst. She was tolerating a
regular diet upon discharge, and has close PCP follow up in one
week.
Full code |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Gantrisin
Attending: ___
Chief Complaint:
Abnormal labs
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ w/chronic kidney disease (baseline 1.3-1.6),
insulin-dependent diabetes, diastolic heart failure (EF >55%),
and dementia who was sent in from her nursing home with abnormal
labs drawn today. The pt was recently discharged 6d prior after
admission for UTI, ___ in setting of changes to her lasix, on
meropenem via PICC. She was dc/ed on etrapenam back to rehab but
is now presenting back with elevated Cr and na on labs.
.
In the ED, initial VS were (unable) 98.2 68 103/68 16 98% 4L nc.
Pt has severe dementia and is unable to give history but denies
pain. Had neg CXR at ___ prior to transfer. She was given 1L NS.
.
Currently, is AOX1, remains non-verbal. Foley shows gross
hematuria.
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
.
Past Medical History:
DM (HbA1C 8.3% ___
Congestive Heart Failure, TTE in ___: EF >55%, mild-to-mod
aortic regurgitation, mild-to-mod mitral regurgitation
Paranoid schizophrenia
Urinary incontinence
Chronic cystitis
Dementia
HTN
Osteoporosis
Chronic renal failure, baseline Cr 1.5 (stage III)
Anemia, has refused colonoscopy in the past.
Hypercholesterolemia
Multiple GI bleeds managed conservatively, last in ___
requiring 3u pRBCs
ORIF left hip fracture ___ complicated by blood loss (Hct
25.9 1u pRBC, 1u FFP)
Social History:
___
Family History:
Per OMR, Unknown.
Physical Exam:
admission:
VS - Temp 97.5F, BP 100/35, HR 80, R 20, O2-sat 100% 6L
GENERAL - non-verbal elderly female
HEENT - sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, nl S1-S2, ___ systolic murmur
consistent with MR
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding, ventral hernia
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox1, unable to assess as pt not consistently
responding to verbal commands.
discharge:
GENERAL - verbal but non-sensical elderly female, who appears to
be comfortable at rest
HEENT - sclerae anicteric, PERRL
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - bilateral crackles
HEART - PMI non-displaced, RRR, nl S1-S2, ___ systolic murmur
consistent with MR
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding, ventral hernia
NEURO - speaking more fluently today; moving all 4 extremities.
Pertinent Results:
admission labs:
___ 02:50PM BLOOD WBC-5.7 RBC-3.80* Hgb-9.9* Hct-33.4*
MCV-88 MCH-26.1* MCHC-29.6* RDW-16.0* Plt ___
___ 02:50PM BLOOD Neuts-69.2 ___ Monos-4.2 Eos-0.2
Baso-0.1
___ 07:45AM BLOOD ___ PTT-30.1 ___
___ 02:50PM BLOOD Glucose-159* UreaN-51* Creat-2.4* Na-150*
K-5.3* Cl-118* HCO3-25 AnGap-12
___ 07:45AM BLOOD Calcium-8.3* Phos-3.9# Mg-2.2
___ 05:10PM URINE Color-AMBER Appear-Cloudy Sp ___
___ 05:10PM URINE Blood-LG Nitrite-NEG Protein-100
Glucose-70 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG
___ 05:10PM URINE RBC->182* WBC->182* Bacteri-FEW
Yeast-NONE Epi-0
___ 05:10PM URINE CastHy-33*
___ 05:10PM URINE WBC Clm-MANY Mucous-OCC
___ 02:24PM URINE Hours-RANDOM Creat-47 Na-89 K-42 Cl-75
URINE CULTURE (Final ___: NO GROWTH.
ct abd pelvis w/o contrast ___:
IMPRESSION: 1. Bronchial calcification and opacification within
the left lower lobe, raising the possibility of aspiration.
2. 2.1 cm stable hypodensity of the left kidney, previously
characterized as a cyst. Small amount of residual fat stranding
around the left kidney. No evidence of hydronephrosis.
3. Non-obstructive 2-mm left renal calculus. Please note the
bladder is not completely evaluated on this CT.
4. Scattered colonic diverticulosis without evidence of acute
diverticulitis.
5. Stable compression fracture of L3.
cxr ___:
IMPRESSION: Since ___, left lung consolidation and
left lower lung volume loss is unchanged; minimal right lower
lung consolidation has worsened
Medications on Admission:
1. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week:
Every ___. x
2. atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. x
3. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day. x
4. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO three
times weekly, on ___. x
5. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. x
6. Lantus 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous twice a day. x
7. lactulose 10 gram/15 mL Solution Sig: Fifteen (15) mL PO once
a day as needed for constipation.
8. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO QHS (once a day (at bedtime)). x
9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every four
(4) hours as needed for pain.
10. calcium carbonate 500 mg calcium (1,250 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO once a day. x
11. Vitamin D3 400 unit Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO once a day. x
12. docusate sodium 50 mg/5 mL Liquid Sig: One (1) Tablet PO BID
(2 times a day). x
13. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day). x
14. Dulcolax 10 mg Suppository Sig: One (1) Suppository Rectal
once a day as needed for constipation: If senna ineffective.
15. Fleet Enema ___ gram/118 mL Enema Sig: One (1) Enema Rectal
once a day as needed for constipation: If dulcolax suppository
ineffective.
16. Regular Insulin Sliding Scale x
BS ___ = 0 units sub-q
BS 201-250 = 2 units sub-q
BS 251-300 = 4 units sub-q
BS 301-350 = 6 units sub-q
BS 351-400 = 8 units sub-q
BS > 400 = CALL MD
17. ertapenem 1 gram Recon Soln Sig: One (1) gram Intravenous
once a day for 11 days. Last dose on ___.
18. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
Mid-line, heparin dependent: Flush with 10 mL Normal Saline
followed by Heparin as above, daily and PRN per lumen.
Discharge Medications:
1. morphine 10 mg/5 mL Solution Sig: 2 - 5 mg PO every ___ hours
as needed for pain, distress: Please give 2 - 5 mg as needed for
pain, distress. .
2. Maalox/Diphenhydramine/Lidocaine Sig: Fifteen (15) mL
every four (4) hours as needed for oral pain.
3. acetaminophen 325 mg Tablet Sig: ___ Tablets PO every six (6)
hours as needed for pain.
4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
5. senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
6. bisacodyl 10 mg Suppository Sig: One (1) suppository Rectal
once a day as needed for constipation: If senna not effective. .
7. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO at bedtime.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
- END STAGE DEMENTIA
- URINARY TRACT INFECTION
- ASPIRATION PNEUMONIA
Discharge Condition:
Mental Status: Confused - always.
Activity Status: Bedbound.
Level of Consciousness: Lethargic but arousable.
Followup Instructions:
___
Radiology Report
INDICATION: ___ woman with hematuria, soft tissue bladder mass and
left kidney hydronephrosis on ultrasound. Assess left kidney hydronephrosis
and bladder mass.
COMPARISON: Comparison is made to previous CT dated ___, and renal
ultrasound dated ___.
TECHNIQUE: Axial MDCT images were acquired through the abdomen and pelvis
without oral or IV contrast. Coronal and sagittal reformats were obtained.
DLP: 596.3 mGy-cm.
FINDINGS:
Stable 5-mm nodule within the right middle lobe (3:6). A 4-mm nodule within
the lateral segment of the right middle lobe was not previously imaged (3:3).
No other pulmonary nodules are identified. There is bronchial calcification
and left lower lobe opacification, which may be due to aspiration. There is
severe coronary artery calcification. There is a small paraesophageal hernia
(3:17).
Allowing for the lack of IV contrast, the liver is normal in attenuation. No
definite focal liver lesions are identified on this non-contrast CT. No
intra- or extra-hepatic duct dilation. The gallbladder is normal in
appearance. The spleen and both adrenal glands are normal in appearance.
There is a left interpolar renal cyst measuring 2.1 cm, previously
characterized as a cyst on ultrasound. Non-obstructive 2-mm calculus within
the upper pole of the left kidney (400B:40). No evidence of hydronephrosis
bilaterally. There is a small amount of fat stranding surrounding the left
kidney. There is fatty atrophy of the pancreas.
There is moderate atherosclerotic calcification of the aorta which is of
normal caliber. There are subcentimeter retroperitoneal lymph nodes (3:37).
No pathologically enlarged lymph nodes.
There is scattered colonic diverticulosis without evidence of acute
diverticulitis.
Allowing for the lack of oral contrast, the visualized small bowel is normal
in appearance.
CT PELVIS: There is a Foley catheter within an almost completely collapsed
bladder. Air present within the bladder is likely due to recent
instrumentation. The rectum is normal in appearance. There is sigmoid
diverticulosis without evidence of acute diverticulitis. There is no free
fluid or pathologically enlarged pelvic or inguinal lymph nodes. There is a
ventral hernia containing loops of transverse colon (3:65). No evidence of
obstruction.
OSSEOUS STRUCTURES: No suspicious osseous, sclerotic or lucent lesions
identified. The patient is status post left ORIF.
There is a stable compression fracture of L3 vertebral body.
IMPRESSION:
1. Bronchial calcification and opacification within the left lower lobe,
raising the possibility of aspiration.
2. 2.1 cm stable hypodensity of the left kidney, previously characterized as
a cyst. Small amount of residual fat stranding around the left kidney. No
evidence of hydronephrosis.
3. Non-obstructive 2-mm left renal calculus. Please note the bladder is not
completely evaluated on this CT.
4. Scattered colonic diverticulosis without evidence of acute diverticulitis.
5. Stable compression fracture of L3.
WET READ by ___ on MON ___ 10:29 ___
Radiology Report
INDICATION: End-stage dementia, concern for aspiration pneumonia.
COMPARISON: ___.
FINDINGS: Portable AP chest radiograph demonstrates left lower lobe collapse
with mild leftward shift of the cardiomediastinum. There are left perihilar
opacities that may represent consolidation. There is mild hyperexpansion of
the right lung.
IMPRESSION:
1. New Left lower lobe collapse most likely due to mucus plugging.
2. Left perihilar opacity could represent a pneumonia.
Findings were discussed by Dr. ___ with Dr. ___ by
phone at 11:40 a.m. on ___.
Radiology Report
CHEST RADIOGRAPH
INDICATION: ___ woman with UTI, aspiration pneumonia, congestive
heart failure.
TECHNIQUE: Single supine portable chest view was reviewed in comparison with
prior chest radiograph from ___.
FINDINGS: Left lung consolidation and left retrocardiac density likely from
consolidation and associated left lower lung volume loss is unchanged since
___. Mild right lower lung consolidation has worsened. No pleural
effusion on the right side. Mediastinal shift to the left side is attributed
to left lower lung volume loss. Mediastinal silhouette is otherwise stable.
Tip of the left PIC line still lies in the left axillary region, unchanged
since ___.
IMPRESSION: Since ___, left lung consolidation and left lower lung
volume loss is unchanged; minimal right lower lung consolidation has worsened.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ABNORMAL LABS
Diagnosed with DEHYDRATION, ACUTE KIDNEY FAILURE, UNSPECIFIED, HYPEROSMOLALITY
temperature: 98.2
heartrate: 68.0
resprate: 16.0
o2sat: 98.0
sbp: 103.0
dbp: 68.0
level of pain: 13
level of acuity: 2.0 | HOSPITAL COURSE: ___ w/chronic kidney disease (baseline
1.3-1.6), insulin-dependent diabetes, diastolic heart failure
(EF >55%), and dementia who presented with elevated Cr and Na
from SNF. Made CMO after discussion with legal guardian.
Goals of Care: Patient was rapidly deteriorating in functional
status. On ___, patient became hypotensive after
receiving a small dose of morphine and lasix. Patient received
IVF with minimal response. An ICU consult was initiated. The
primary team discussed the worsening clinical condition with the
patient's guardian Ms ___. Given the worsening clinical
condition, decision was made to make patient DNR/DNI/CMO.
Patient's guardian Ms. ___ signed and faxed in the
DNR/DNI/CMO form. Patient was transitioned to focus on comfort
measures. She was written for PRN morphine and tylenol. She
was allowed to eat for comfort.
Patient was very comfortable without complaints during the
remainder of admission. She is being discharged to ___
___ with PRN morphine, tylenol, and a bowel regimen.
At the time of transfer, she appears to have stabilized and is
interactive, able to respond to staff (though some of her
responses are not intelligible), and reports she is comfortable. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Cholecystitis
Major Surgical or Invasive Procedure:
___: Laparoscopic cholecystectomy
History of Present Illness:
___ hx of biliary colic now presents with abdominal pain.
Patient had one episode of biliary colic in ___ and was
referred for surgical evaluation at that time, however, declined
surgery given social circumstances. Since then she had one
additional episode of colic that resolved until ___ night
when she describes increasing crampy right upper quadrant and
epigastric pain radiating to back. Patient reports that she was
seen in ___ and discharged twice since then with pain and
anti-nausea medications with recommendation to follow up with a
surgeon. Last night after discharge from ___ had tortolleni
with cheese and then pain came back accompanied by nausea. She
also felt weak. Denies fevers or chills. No jaundice. No weight
loss. Social situation still insecure but agrees to have surgery
at this time as pain is making her miserable.
Past Medical History:
PMH: thyroid ca s/p thyroidectomy, prior SBOs managed
conservatively, htn, GERD, osteoporosis, h.pylori, anxiety,
dementia, nephrolithiasis, gallstones, hematuria, incidentally
noticed side branch IPMN, benign right hepatic duct stricture
PSH: total thyroidectomy, total hysterectomy, ex-lap for bowel
obstruction following hysterectomy in ___
Social History:
___
Family History:
NC
Physical Exam:
VS: 24 HR Data (last updated ___ @ 818)
Temp: 98.1 (Tm 98.4), BP: 138/76 (106-150/65-88), HR: 87
(71-87), RR: 18, O2 sat: 96% (93-96), O2 delivery: Ra
GEN: NAD, resting comfortably
HEENT: NCAT, EOMI, anicteric
CV: RRR
PULM: no respiratory distress
ABD: soft, mildly tenderness throughout abdomen, Non-distended,
no rebound or guarding
WOUND: incision c/d/i
EXT: warm, well-perfused, no edema
NEURO: A&Ox3, no focal neurologic deficits
PSYCH: normal insight, memory, mood/affect
Fluid Balance (last updated ___ @ 900)
Last 8 hours Total cumulative 442ml
IN: Total 742ml, IV Amt Infused 742ml
OUT: Total 300ml, Urine Amt 300ml
Last 24 hours Total cumulative 2553ml
IN: Total 3528ml, PO Amt 620ml, IV Amt Infused 2908ml
OUT: Total 975ml, Urine Amt 975ml
Pertinent Results:
Lab results:
___ 05:28AM BLOOD WBC-9.9 RBC-3.73* Hgb-10.5* Hct-32.5*
MCV-87 MCH-28.2 MCHC-32.3 RDW-14.2 RDWSD-45.2 Plt ___
___ 05:28AM BLOOD Glucose-106* UreaN-14 Creat-0.8 Na-143
K-4.3 Cl-107 HCO3-25 AnGap-11
___ 05:28AM BLOOD ALT-31 AST-42* AlkPhos-48 TotBili-0.5
___ 05:28AM BLOOD Calcium-7.1* Phos-3.0 Mg-1.9
ABDOMINAL US ___:
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The
contour of the liver is smooth. There is a hyperechoic lesion in
segment 8 of the liver compatible with known hemangioma. The
main portal vein is patent with hepatopetal flow. There is no
ascites.
BILE DUCTS: There is mild intrahepatic biliary dilation. The CHD
measures 3 mm.
GALLBLADDER: The gallbladder is markedly distended and contains
sludge and
stones. There is a stone at the gallbladder neck that is
difficult to assess for mobility. ___ sign difficult to
assess given premedication of the patient. The gallbladder wall
appears slightly thickened.
PANCREAS: The imaged portion of the pancreas appears within
normal limits,
without masses or pancreatic ductal dilation, with portions of
the pancreatic tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 7.9 cm.
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are
within normal limits.
IMPRESSION:
1. Findings concerning for early acute cholecystitis.
2. Stable focal biliary dilatation of the right hepatic lobe
better characterized on MRCP of ___.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Lisinopril 5 mg PO DAILY
2. Metoprolol Tartrate 50 mg PO BID
3. Omeprazole 20 mg PO DAILY
4. Citalopram 10 mg PO DAILY
5. Levothyroxine Sodium 125 mcg PO DAILY
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
do not exceed more then 3000 mg/day
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
3. Docusate Sodium 100 mg PO BID
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain
5. Citalopram 10 mg PO DAILY
6. Levothyroxine Sodium 125 mcg PO DAILY
7. Lisinopril 5 mg PO DAILY
8. Metoprolol Tartrate 50 mg PO BID
9. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ with upper abdominal pain, known h/o gallstones//
?gallstones, ?cholecystitis, ?biliary ductal dilation
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: MRCP from ___
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is a hyperechoic lesion in segment 8 of the liver
compatible with known hemangioma. The main portal vein is patent with
hepatopetal flow. There is no ascites.
BILE DUCTS: There is mild intrahepatic biliary dilation. The CHD measures 3
mm.
GALLBLADDER: The gallbladder is markedly distended and contains sludge and
stones. There is a stone at the gallbladder neck that is difficult to assess
for mobility. ___ sign difficult to assess given premedication of the
patient. The gallbladder wall appears slightly thickened.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 7.9 cm.
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Findings concerning for early acute cholecystitis.
2. Stable focal biliary dilatation of the right hepatic lobe better
characterized on MRCP of ___.
NOTIFICATION:
1.
Gender: F
Race: WHITE - OTHER EUROPEAN
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with Acute cholecystitis
temperature: 98.5
heartrate: 85.0
resprate: 18.0
o2sat: 100.0
sbp: 165.0
dbp: 108.0
level of pain: 8
level of acuity: 3.0 | ___ is a ___ year-old woman with a history of history of
biliary colic who presented to the ___ on ___ with recurrent
symptoms and evaluation consistent with cholecystitis. She was
admitted for IV antibiotics, IV fluids and was brought to the
operating room on ___ where she underwent a laparoscopic
cholecystectomy with Dr. ___. The patient tolerated the
procedure well and a small amount of drainage from the inflamed
gallbladder was noted. On POD#1, the was advanced to a regular
diet, IV fluids were discontinued and the patient was
transitioned to PO pain medications, including oxycodone and
Tylenol. On POD#2 the patient was tolerating a regular diet,
pain was well controlled on an oral pain regimen, and they had
regular flatus/BMs. She was transitioned to oral antibiotics
with a plan to complete a 4 day course of Augmentin. The patient
was discharged from the hospital in stable condition to home on
POD#1 with follow up in clinic in ___ weeks. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Ciprofloxacin /
Mavik / Diovan / ___ DM / adhesive tape / aspirin /
Nifedipine / Cyclobenzaprine / chlorthalidone /
pseudocholesteine deficiency / simvastatin / Iodinated Contrast
Media - IV Dye / Zofran / ceftriaxone / Crestor / Decadron /
Solu-Cortef / gabapentin / Benadryl / latex / Gadavist
Attending: ___
Chief Complaint:
Malaise
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ PMH of Metastatic Neuro-endocrine (carcinoid) tumor, T2DM
c/b
recent toe ulcer/cellulitis, multiple drug allergies, presented
to ED with malaise
Pt reports that she recently had a relative pass away which was
very upsetting. However, she was able to continue her ADLs and
take her medications as prescribed. Several days ___ she felt
extremely fatigued w/ malaise and had a hard time getting out of
bed. She noted that she wasn't eating much. Endorsed some loose
stools that self resolved. Noted that she was without headache,
neck stiffness, cough, vomiting, abdominal pain, dysuria. She
reported that her left ___ toe looked stable to her.
She visited her outpatient allergist who noted her fatigue and
found her to be hypotensive, so referred her to the ED. In the
ED
she was hypotensive but given IVF and remained normotensive so
was discharged. Malaise/Fatigue continued so son brought her
back
to the ED.
In the ED this visit, initial vitals: 98.1 115 110/62 10 95% RA.
T max 102.6. WBC 11.6, Hgb 11.5, plt 231, AST 55, Lipase 87,
other LFTs wn, CK 118, CHEM w/ Cr of 1.1, lactate 1.0, Mg 1.5.
UA
negative for infection. Trop <0.01
CXR: No acute process
CT Head:
1. No acute intracranial process.
2. Partially visualized right parietal mass with surrounding
edema is not substantially changed compared to prior MR from ___, given differences in technique.
3. Previously seen enhancing right hypothalamic lesion is again
noted.
EKG:
Sinus rhythm, Low voltage, precordial leads, Anteroseptal
infarct, old. Compared with previous ECG, no significant change
During time in ED, TMax increased to 102, patient became
encephalopathic at the time. ED staff consented son for LP and
attempted but failed. She was broadened to bacterial meningitis
dosing, and admitted for further care. During time that she was
febrile, was hypoxic to 88%RA, but CXR unchanged.
REVIEW OF SYSTEMS:
A complete 10-point review of systems was performed and was
negative unless otherwise noted in the HPI.
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
-___ transbronchial needle aspiration of left hilarity
mass shows well-differentiated neuroendocrine tumor (carcinoid
tumor)
-___ MRI brain confirms suspicion of brain mets. Most
notable are a 2.3cm well-defined enhancing lesion with
surrounding edema in the right posterior parietooccipital region
and a 1.3 cm enhancing lesion in the region of tuber sign area
indicative of a hypothalamic
metastasis
-___ C1D1 of octreotide and initiation of daily
everolimus
-___: Radiation complete for 4 brain metastases with SRS
and cyber knife
- ___ C2D1 of octreotide LAR 30mg with continued daily
everolimus
-___ C3D1 of octreotide with continued daily
everolimuseverolimus
-___ C4D1 of octreotide with continued daily everolimus
-___ C5D1 of octreotide with continued daily everolimus
-___ C6D1 of octreotide with continued daily everolimus
-___ C7D1 of octreotide with continued daily everolimus
-___ C8D1 of octreotide
PAST MEDICAL HISTORY (per OMR):
NEUROENDOCRINE TUMOR
ADVANCED DIRECTIVES
ARTHRITIS
BELL'S PALSY
CIGARETTE SMOKING
DIABETES TYPE II
GASTROINTESTINAL
HYPERTENSION
MULTIPLE MEDICATION ALLERGIES
RIGHT AXILLARY LYMPHADENOPATHY
S/P CARPAL TUNNEL SURGERY
S/P CHOLECYSTECTOMY
S/P HYSTERECTOMY
S/P ULNAR NERVE RECONSTRUCTION
THYROID NODULE
PERIPHERAL VASCULAR DISEASE
BACK PAIN
DERMATOFIBROMA
MOLE
LEG PAIN
RASH
PERIPHERAL VASCULAR DISEASE
DRUG ALLERGY
90 DAY PRESCRIPTIONS
GYNECOLOGIC
BACK PAIN
KNEE PAIN
BRAIN METASTASES
H/O CHICKENPOX
Surgical History (Last Verified ___ by ___,
MD, PHD):
ULNAR NERVE RECONSTRUCTION
avoid bps on right arm!
MULTIPLE EAR SURGERY
TONSILLECTOMY
HYSTERECTOMY
partial, only ovaries left, also cervix removed prior
CARPAL TUNNEL SYNDROME
x2
GANGLION REMOVAL
x2
CHOLECYSTECTOMY
late ___ ___, per patient
Social History:
___
Family History:
FAMILY HISTORY (per OMR):
Relative Status Age Problem Onset Comments
Mother ___ ___ HEART heart disease
TRANSIENT ISCHEMIC
ATTACK
EYE loss eye sight
___ DM;
___ had eye
___
DIABETES TYPE I
Father ___ ___ MYOCARDIAL
INFARCTION
Sister Living ___ VALVE valve prolapse,
unspecified
HEARING LOSS
Other Deceased SUDDEN CARDIAC DEATH
Daughter Living ___ PNEUMONIA She was given
steroids that
___ DM II.
___ steroids
d/c, DM
resolved.
OBESITY over 300 pounds
Son Living ___ BLOOD PRESSURE fluctuates
___ bit
GOUT
Other Living 21 CROHN'S DISEASE grand-daughter
Other Living 17 HEARING PROBLEMS grand-daughter
Other ___ 3 MYOCARDIAL
weekINFARCTION
s
old
Other Living 23 PTSD grand-daughter
DEPRESSION
OBESITY
STRESS
Aunt Living ___ STROKE
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals: ___ 2223 Temp: 99.7 PO BP: 147/63 HR: 98 RR: 20 O2
sat: 100% O2 delivery: 4L NC
GENERAL: laying in bed, appears tired, but answering questions
appropriately, NAD, pleasant, calm
EYES: PERRLA, anicteric
HEENT: OP clear, MMM
NECK: supple, normal ROM
LUNGS: CTA b/l, no nasal cannula, normal resp rate, no
increased
WOB
CV: RRR no m/r/g, normal distal perfusion, no peripheral edema
ABD: soft, NT, ND, normoactive BS, no rebound or guarding
GENITOURINARY: no foley or suprapubic tenderness
EXT: warm, left ___ toe is absent, left ___ toe with
onychomycosis, and erythema extending 1 inch proximal from nail
bed which is warm to touch
SKIN: erythema of left ___ toe as above, has erythema
surrounding
neck with superifical desquamation at right/lower margin which
patient notes is chronic
NEURO: AOx3, fluent speech, moving all extremities
spontaneously
ACCESS:PIV
DISCHARGE PHYSICAL EXAM:
========================
VITALS: 24 HR Data (last updated ___ @ 347)
Temp: 98.3 (Tm 98.8), BP: 135/73 (123-168/70-88), HR: 94
(88-106), RR: 20 (___), O2 sat: 93% (93-97), O2 delivery: RA
GENERAL: pleasant, alert, appropriately answering questions,
NAD,
pleasant, calm
EYES: anicteric
HEENT: OP clear, MMM
NECK: supple, normal ROM
LUNGS: CTAB, no increased WOB
CV: RRR NMRG
ABD: soft, NT, ND, normoactive BS, no rebound or guarding
GENITOURINARY: no suprapubic tenderness
EXT: warm, left ___ toe is s/p amputation and well-healed, no
ulcer; left ___ toe with onychomycosis, and erythema extending 1
inch proximal from nail bed which is warm to touch, there's an
ulceration noted to the distal tip of the left second toe but
w/o
purulent discharge.
MSK: Area overlying left scapula tender to palpation. Skin
overlying left scapula is intact and absent of lesions, rashes,
masses.
SKIN: erythema of left ___ toe as above. Erythema around neck
(chronic per patient).
NEURO: moving all extremities spontaneously
ACCESS:PIV
Pertinent Results:
ADMISSION LABS:
===============
___ 11:26AM ___ PTT-28.7 ___
___ 11:26AM PLT COUNT-231
___ 11:26AM NEUTS-70.3 LYMPHS-17.2* MONOS-9.8 EOS-0.5*
BASOS-0.6 NUC RBCS-0.3* IM ___ AbsNeut-7.97* AbsLymp-1.95
AbsMono-1.11* AbsEos-0.06 AbsBaso-0.07
___ 11:26AM WBC-11.3* RBC-4.37 HGB-11.5 HCT-34.9 MCV-80*
MCH-26.3 MCHC-33.0 RDW-16.0* RDWSD-41.5
___ 11:26AM ALBUMIN-3.9
___ 11:26AM cTropnT-<0.01
___ 11:26AM LIPASE-87*
___ 11:26AM ALT(SGPT)-25 AST(SGOT)-55* CK(CPK)-118 ALK
PHOS-80 TOT BILI-0.7
___ 11:26AM GLUCOSE-134* UREA N-14 CREAT-1.1 SODIUM-135
POTASSIUM-4.3 CHLORIDE-95* TOTAL CO2-25 ANION GAP-15
___ 11:42AM LACTATE-2.1*
___ 03:05PM URINE RBC-<1 WBC-2 BACTERIA-FEW* YEAST-NONE
EPI-5 TRANS EPI-<1
___ 03:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-MOD*
INTERVAL LABS:
==============
___ 05:59AM BLOOD WBC-8.8 RBC-3.53* Hgb-9.2* Hct-29.5*
MCV-84 MCH-26.1 MCHC-31.2* RDW-15.8* RDWSD-45.4 Plt ___
___ 05:59AM BLOOD Neuts-78.5* Lymphs-10.5* Monos-8.5
Eos-0.7* Baso-0.7 Im ___ AbsNeut-6.93* AbsLymp-0.93*
AbsMono-0.75 AbsEos-0.06 AbsBaso-0.06
___ 05:59AM BLOOD ___ PTT-33.6 ___
___ 05:59AM BLOOD Glucose-194* UreaN-9 Creat-1.1 Na-140
K-3.4* Cl-99 HCO3-23 AnGap-18
___ 05:59AM BLOOD ALT-14 AST-25 AlkPhos-66 TotBili-0.5
___ 05:59AM BLOOD Calcium-8.0* Phos-2.0* Mg-2.3
DISCHARGE LABS:
===============
___ 08:50AM BLOOD WBC-12.5* RBC-3.52* Hgb-9.2* Hct-28.5*
MCV-81* MCH-26.1 MCHC-32.3 RDW-16.5* RDWSD-44.6 Plt ___
___ 08:50AM BLOOD ___ PTT-25.5 ___
___ 08:50AM BLOOD Glucose-231* UreaN-7 Creat-0.9 Na-146
K-3.5 Cl-102 HCO3-28 AnGap-16
___ 08:50AM BLOOD Calcium-8.2* Phos-1.3* Mg-2.0
IMAGING:
========
___ CT HEAD W/O CONTRAST
1. No acute intracranial process.
2. Partially visualized right parietal mass with surrounding
edema is not
substantially changed compared to prior MR from ___, given
differences in technique.
3. Previously seen enhancing right hypothalamic lesion is again
noted.
___ CHEST X-RAY
No acute cardiopulmonary process.
___ CT CHEST W/O CONTRAST
1. Mild interval improvement in mediastinal and left hilar
lymphadenopathy.
2. Numerous pulmonary nodules which demonstrate varying response
with some
nodules demonstrating interval increase in size, some
demonstrating decrease
in size, and some appear unchanged.
3. Diffuse patchy sclerosis throughout the vertebral bodies,
similar to prior.
4. Stable nodular focus along the left pericardium which
demonstrated
increased dotatate uptake concerning for metastatic disease.
5. No evidence of pneumonia.
6. Stable upper abdominal adenopathy.
___ MR FOOT ___ CONTRAST
Exam is severely limited ___ motion artifact. However, within
these
limitations:
1. Mild distal second toe phalangeal bone marrow edema with mild
surrounding soft tissue edema. No definite cortical involvement.
Indistinct margin of the distal phalanx likely secondary to
motion artifact.
2. Status post left great toe distal amputation with expected
postsurgical
changes.
3. Small plantar distal second toe skin ulceration without
definite
involvement of the adjacent osseous structures.
___ ULTRASOUND, SOFT TISSUE
Likely benign 5.5 x 3.4 x 0.9 cm hypoechoic well-circumscribed
lesion without
evidence of vascularity. This may represent fibrous tissue or
myoclonic
muscle. Needle biopsy may be performed if clinically indicated.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with ?meningitis, new O2 requirement following
resuscitation // eval for pulmonary edema
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph dated ___.
FINDINGS:
The lung volume is low, exaggerating bronchovascular markings. No focal
consolidation or pulmonary edema. No pleural effusion or pneumothorax. The
cardiomediastinal silhouette is within normal limits given supine technique.
No acute osseous abnormalities.
IMPRESSION:
Low lung volume. No pulmonary edema.
Radiology Report
EXAMINATION: FOOT AP,LAT AND OBL LEFT
INDICATION: ___ year old woman with diabetic ulcer on distal left ___ toe with
cellulitis, please assess for e/o deeper infection, osteo // ___ year old
woman with diabetic ulcer on distal left ___ toe with cellulitis, please
assess for e/o deeper infection, osteo
TECHNIQUE: Three views of the left foot
COMPARISON: ___
FINDINGS:
Status post amputation of the big toe at the level of the distal first
metatarsal with no interval change compared to the prior radiograph.
No acute cortical destruction is seen to suggest acute osteomyelitis
radiographically.
There is a small bony plantar calcaneal spur.
IMPRESSION:
No definite evidence of osteomyelitis on these radiographs, status post
amputation of the great toe at the level of the distal first metatarsal.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old woman with carcinoid tumor, metastatic. Here with
fever, source unclear. // assess for disease burden, evidence infection
TECHNIQUE: MDCT axial images were acquired through the chestwithout the
administration of intravenous contrast. Coronal, sagittal, and MIP
reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.9 s, 31.9 cm; CTDIvol = 8.1 mGy (Body) DLP = 253.6
mGy-cm.
Total DLP (Body) = 254 mGy-cm.
COMPARISON: CT chest ___, dotatate scan from ___
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: The thyroid gland is unremarkable.
There is no supraclavicular or axillary adenopathy. A 1.3 cm soft tissue
density lesion is seen along the left anterior chest wall abutting the skin
surface, likely representing a epidermoid cyst.
UPPER ABDOMEN: Limited views of the upper abdomen show diverticulosis without
evidence of acute diverticulitis. Enlarged upper abdominal lymph nodes are
seen including a 1.5 cm porta hepatis lymph node and a 1.7 cm peripancreatic
lymph node. Additionally, there is a 1.2 x 1.3 cm paraesophageal lymph node,
previously measuring 1.2 x 1.0 cm from ___ however in ___,
this measured 1.6 x 2.0 cm.
MEDIASTINUM: There is increased lymphoid tissue in the mediastinum. A 1.9 x
1.6 cm right paratracheal node is seen which previously measured 2.1 x 1.7 cm
(5:63), a subcarinal lymph node when measured in a similar plane measures 1.8
x 1.4 cm, previously 2.2 x 1.6 cm (03:24). Increase in lymphoid tissues also
seen along the aortic arch/periaortic region extending into the hilum
measuring 4 x 4.1 cm, previously 4.7 x 3.7 cm.
HILA: Evaluation of the hila is limited without intravenous contrast, however
the left hilum appears prominent suggestive of adenopathy. There is soft
tissue in the left hilum measuring 2.0 x 1.5 cm (5:111), previously measuring
1.9 x 1.6 cm.
HEART and PERICARDIUM: Heart size is normal. Moderate coronary artery and
mild aortic annular calcifications are noted. Trace pericardial fluid is
likely within physiologic limits. The 1.2 cm nodule is again seen along the
left pericardium concerning for metastatic disease, similar to prior.
PLEURA: No pleural effusion or pneumothorax.
LUNG:
1. PARENCHYMA: There is mosaic attenuation of the lungs suggestive of air
trapping in addition to the exam being performed in expiration. There is no
focal consolidation. There are numerous bilateral pulmonary nodules.
Representative examples as follows:
-A 9 mm right upper lobe nodule, which previously measured 10 mm (5:90)
-7 mm left upper lobe nodule which previously measured 6 mm (5:76)
-7 mm right lower lobe nodule, similar to prior (5:137)
-5 mm left lower lobe nodule, similar to prior (5:75)
-6 mm right upper lobe nodule, previously measuring 5 mm (5:93).
1. AIRWAYS: The airways are patent to the subsegmental level bilaterally.
2. VESSELS: The thoracic aorta, main, right, lobar arteries are within normal
limits.
CHEST CAGE: Again noted is diffuse patchy sclerosis throughout the vertebral
bodies concerning for metastatic disease.
IMPRESSION:
1. Mild interval improvement in mediastinal and left hilar lymphadenopathy.
2. Numerous pulmonary nodules which demonstrate varying response with some
nodules demonstrating interval increase in size, some demonstrating decrease
in size, and some appear unchanged.
3. Diffuse patchy sclerosis throughout the vertebral bodies, similar to prior.
4. Stable nodular focus along the left pericardium which demonstrated
increased dotatate uptake concerning for metastatic disease.
5. No evidence of pneumonia.
6. Stable upper abdominal adenopathy.
Radiology Report
EXAMINATION: assess for osteomyelitis of second toe
INDICATION: ___ year old woman with carcinoid tumor, DM, history of left toe
osteomyelitis s/p great toe amputation, now with fevers and redness of the
left second toe. ID recommend MRI. // assess for osteomyelitis of second toe
TECHNIQUE: Coronal and sagittal images of the left foot were obtained with
and without the use of intravenous contrast. 7 mL of Gadavist was
administered.
COMPARISON: Foot radiograph ___. Foot radiograph ___.
FINDINGS:
Exam is markedly limited due to motion artifact. However, within these
limitations:
Patient status post right great toe phalangeal amputation with expected
postsurgical changes. No significant edema, abnormal enhancement or T1
hypointensity or fatty bone marrow replacement within the first metatarsal to
suggest an active process.
There is edema involving the second middle and distal phalanges along the
undersurface with mild associated surrounding plantar soft tissue edema (5:9,
9:8). T1 marrow signal is grossly preserved. The majority of the middle and
distal phalanges cortex appears intact, however the distal phalanx cortical
tip margin is not well visualized likely secondary to motion and surrounding
inflammatory changes (5:9).
In addition, there is a small low signal, hypoenhancing plantar
subcutaneous/skin defect of the distal second toe, consistent with a small
ulceration. However, this ulceration does not appear to involve the adjacent
osseous structures.
The remaining metatarsals and phalanges demonstrate normal bone marrow signal,
without evidence of cortical destruction or abnormal enhancement. Otherwise,
there is mild nonspecific soft tissue edema of the forefoot.
Exam is not tailored for ligamentous or tendinous evaluation, however where
visualized appear grossly intact without evidence of severe tenosynovitis.
IMPRESSION:
Exam is severely limited due to motion artifact. However, within these
limitations:
1. Mild distal second toe phalangeal bone marrow edema with mild surrounding
soft tissue edema. No definite evidence of osteomyelitis within the
limitations of the study. Indistinct margin of the distal phalanx likely
secondary to motion artifact.
2. Status post left great toe distal amputation with expected postsurgical
changes.
3. Small plantar distal second toe skin ulceration without definite
involvement of the adjacent osseous structures.
Radiology Report
EXAMINATION: US, OTHER SOFT TISSUE AREA
INDICATION: ___ year old woman with left posterior shoulder pain with TTP, and
erythema on the left upper back. Pt has a hx of being abused by husband. //
Evaluate for abscess.
TECHNIQUE: Grayscale ultrasound images were obtained of the superficial
tissues of the posterior left back.
COMPARISON: None
FINDINGS:
Transverse and sagittal images were obtained of the superficial tissues of the
left posterior back. Overlying the left scapula there is a hypoechoic
well-circumscribed lesion that measures approximately 5.5 x 3.4 x 0.9 cm.
There is no evidence of vascularity.
IMPRESSION:
Indeterminate palpable lesion in the left shoulder musculature without
worrisome features. Needle biopsy could be performed if clinically indicated.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Weakness
Diagnosed with Fever, unspecified, Disorientation, unspecified, Weakness
temperature: 98.1
heartrate: 115.0
resprate: 10.0
o2sat: 95.0
sbp: 110.0
dbp: 62.0
level of pain: 0
level of acuity: 2.0 | PATIENT SUMMARY:
===============
___ PMH of Metastatic Neuro-endocrine (carcinoid) tumor on
octreotide depot injections (qMonthly), T2DM with recent toe
ulcer/cellulitis who presented with fever, infectious workup
negative, evaluated by podiatry, and discharged off of
antibiotics with outpatient follow up. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
IV Dye, Iodine Containing
Attending: ___.
Chief Complaint:
Shortness of breath, fever
Major Surgical or Invasive Procedure:
Direct Flexible Laryngoscopy
History of Present Illness:
HPI: Ms. ___ is a ___ MDS ___ allo-HSCT ___, in
remission, gets care at ___, c/b GVHD on prednisone 2.5 and
tacro 0.5 bid, Bactrim/acyclovir ppx) who presents with fever.
About a week ago she developed URI symptoms, fatigue, shortness
of breath, and productive cough. She also noted some tingling in
her hands and feet that came on around the same time. On
___ she measured a temperature of 102 at home and so
presented to Urgent Care at ___. When they saw her they
directed
her to the ___ given fever and history of BMT. At ___:
Labs showed WBC 8.04, mild LFT abnormalities that are chronic,
Flu PCR negative, ___ NGTD
CXR initially read as streaky RLL opacity, but final read in
chart notes "No acute cardiopulmonary process seen"
Given concern for PNA in ___ patient, she was given vancomycin
and cefepime and sent to ___ ___ for further evaluation and
admission.
She spent ~24 hours in our Emergency room and continued to
receive vancomycin/cefepime. Her last documented fever was on
___ and on admission this evening she reports her symptoms
are improving. She still feels somewhat short of breath, but URI
symptoms are somewhat improved, paresthesias are gone, and
energy
is a bit better.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
MDS ___ BMT
GVHD eyes, liver
Hypothyroidism
Social History:
___
Family History:
Reviewed and found to be not relevant to this illness/reason for
hospitalization.
Physical Exam:
Discharge exam:
T 98.7 BP 139/84 P 86 RR 18 Spo2 97 Ra
GENERAL: Fatigued appearing woman in no distress
EYES: Anicteric, PERRL, +erythema around eyelids (chronic per
patient)
ENT: MMM. No OP lesion, erythema or exudate. Ears and nose
without visible erythema, masses, or trauma. No cerumen
impaction. NO stridor noted.
CV: Heart regular, no m/g. JVP 6cm
RESP: Lungs CTAB no w/r/r. Breathing comfortably
GI: Abdomen soft, NTND. Bowel sounds present.
GU: No suprapubic ttp or fullness
MSK: Extremities warm without edema. Moves all extremities
SKIN: No rashes or ulcerations noted on examined skin
NEURO: Alert, oriented, face symmetric, speech fluent sensation
to light touch grossly intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
___ 07:10AM BLOOD WBC-5.7 RBC-3.98 Hgb-13.6 Hct-41.7
MCV-105* MCH-34.2* MCHC-32.6 RDW-12.2 RDWSD-47.7* Plt ___
___ 07:10AM BLOOD Glucose-87 UreaN-14 Creat-1.1 Na-141
K-4.4 Cl-103 HCO3-27 AnGap-11
Interval labs:
___ 06:29AM BLOOD Calcium-8.3* Phos-3.0 Mg-2.3
No labs on the day of discharge
Micro:
___ 11:50 am Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal aspirate.
Respiratory Viral Culture (Preliminary):
Respiratory Viral Antigen Screen (Final ___:
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture and/or Influenza PCR
(results
listed under "OTHER" tab) for further information.
Imaging:
b/l rib films ___
Multiple views of the left and right ribs show no fracture or
dislocation.
IMPRESSION:
No fracture or dislocation.
CXR ___
IMPRESSION:
1. No radiographic evidence of pneumonia or aspiration.
2. Limited study secondary to overlying bra material.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 50 mcg PO DAILY *AST Approval Required*
2. Omeprazole 20 mg PO DAILY *AST Approval Required*
3. PredniSONE 2.5 mg PO DAILY
4. Tacrolimus 0.5 mg PO Q12H
5. FLUoxetine 20 mg PO DAILY
6. Magnesium Oxide 400 mg PO TID
7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
8. Acyclovir 400 mg PO Q8H
9. FoLIC Acid 1 mg PO DAILY
10. Fluticasone Propionate NASAL 2 SPRY NU DAILY
11. Multivitamins 1 TAB PO DAILY
12. LORazepam 1 mg PO QHS:PRN insomnia
Discharge Medications:
1. GuaiFENesin-Dextromethorphan 5 mL PO Q6H:PRN Cough
RX *dextromethorphan-guaifenesin 100 mg-10 mg/5 mL 5 ml by mouth
every six (6) hours Refills:*0
2. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
3. Acyclovir 400 mg PO Q8H *AST Approval Required*
4. FLUoxetine 20 mg PO DAILY *AST Approval Required*
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Levothyroxine Sodium 50 mcg PO DAILY
8. LORazepam 1 mg PO QHS:PRN insomnia
9. Magnesium Oxide 400 mg PO TID
10. Multivitamins 1 TAB PO DAILY
11. PredniSONE 2.5 mg PO DAILY
12. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
13. Tacrolimus 0.5 mg PO Q12H
Discharge Disposition:
Home
Discharge Diagnosis:
Viral infection
Acid reflux
Possible aspiration event
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with likely recent viral infection, now with
acute sob, ?stridor.// eval for aspiration
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
No new focal consolidations. No pneumothorax or pleural effusion.
The cardiomediastinal silhouette is normal.
The study was obtained with the bra in place which limits assessment of some
ribs. No acute displaced rib fractures are demonstrated within the limits of
the study.
IMPRESSION:
1. No radiographic evidence of pneumonia or aspiration.
2. Limited study secondary to overlying bra material.
Radiology Report
EXAMINATION: RIB BILAT, W/AP CHEST
INDICATION: ___ with rib pain post heimlich// eval for fracture eval for
fracture
COMPARISON: Chest x-ray ___
FINDINGS:
Multiple views of the left and right ribs show no fracture or dislocation.
IMPRESSION:
No fracture or dislocation.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Pneumonia, Transfer
Diagnosed with Pneumonia, unspecified organism
temperature: 98.6
heartrate: 82.0
resprate: 16.0
o2sat: 98.0
sbp: 138.0
dbp: 91.0
level of pain: 0
level of acuity: 3.0 | 30 ___ w/ MDS ___ allo-HSCT ___, in remission, gets care at
___,
c/b GVHD on prednisone 2.5 and tacro 0.5 bid, Bactrim/acyclovir
ppx) who presents with URI symptoms, SOB, cough, and fever most
consistent with viral syndrome, course c/b acute episode of
dyspnea/apnea - ?mucous plugging vs aspiration event and
OP dysphagia.
#Acute SOB
#?Aspiration episode vs mucous plugging
#OP dysphagia
#Poorly controlled acid reflux
Pt noted to be acutely dyspnic/apenic AM of ___ with some
initial c/f grossly audible stridor though none noted with
direct
auscultation. Empirically given Heimlich maneuver
No abnormalities on bedside fiberoptic ENT eval.
CXR stable without e/o pneumonitis/PNA. She was treated
conservatively with aspiration precautions, PPI was inc to BID
(omeprazole --> PPI d/t tacro interaction). No e/o hypoxia
acutely or with continuous 02 monitoring.
She was evaluated by ___ who recommended outpatient ENT and GI
follow-up, but pt did not require any dietary restrictions.
Her dysphagia improved prior to discharge with no acute
intervention.
#Rib pain: Noted after Heimlich maneuver.
CXR and dedicated rib films negative.
#Fever
#SOB/Cough
P/w fever to 102 at home, URI symptoms, productive cough.
Afebrile here.
No leukocytosis and final read of CXR from ___ with no
clear infiltrate and none on repeat here.
Initially given vancomycin/cefepime in the ___ for >24 hours.
Suspect presentation most c/w a viral process as opposed to
bacterial pneumonia. She was narrowed to Levaquin monotherapy
which was stopped prior to discharge as well. Respiratory viral
panel negative. ___ (NGTD)
Held off on sending glucan/galactomannan as appears clinically
well and improving
#MDS ___ SCT: ___, per last DFCI note in remission.
Outpatient oncologist is Dr. ___ at ___
___ prednisone 2.5mg QD; low threshold for stress dose
steroids if any hemodynamic concerns
Continued tacrolimus 0.5mg BID
Continue Bactrim/acyclovir ppx
#Elevated MCV:
MCV in low 100s
B12, Folate wnl |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
atorvastatin / Norvasc / enalapril / salicylates
Attending: ___.
Chief Complaint:
Right lower extremity hematoma
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ on Coumadin s/p mechanical fall 5 days ago, p/w
expanding right leg hematoma. Reports that she was walking to
her
car when she rolled her left foot and fell onto her right side.
No HS, no LOC. Was ambulatory immediately afterward. She felt
well and stayed home, but noticed continuing enlargement of her
right leg so went to her PCP's office. Her PCP referred her to
the ED for trauma evaluation. She has no other acute signs of
trauma and no other sites of pain.
Past Medical History:
PMH: HTN, MS, spinal stenosis s/p steroid injections, HLD,
psoriasis, OSA, gastritis, DM2 with neuropathy, h/o PE in ___,
started on coumadin
PSH: Open CCY in remote past
Social History:
___
Family History:
Father ___ Disease
Other Breast Cancer; Colon Cancer; Diabetes
Physical Exam:
VS: 98.9 70 130/90 18 98% RA
Gen: GCS 15, A&Ox3
HEENT: NCAT, OP wnl, PERRLA, EOMI
CV: RRR, no M/R/G
pulses: distal lower extremities +2 pulses palpable
Resp: BS equal b/l, no chest wall tenderness, no crepitus
Abd: soft, nontender, nondistended
MSK: L foot with bruising around toes, lateral edge. R leg with
bruising, swelling from knee extending up through thigh
Neuro: Motor ___ throughout, sensation intact throughout. No
midline spinal tenderness, step-offs
Pertinent Results:
___ 06:23PM ___ PTT-41.1* ___
___ 06:23PM PLT COUNT-358
___ 06:23PM NEUTS-55.7 ___ MONOS-7.3 EOS-2.5
BASOS-0.5 NUC RBCS-0.2* IM ___ AbsNeut-6.17* AbsLymp-3.71*
AbsMono-0.81* AbsEos-0.28 AbsBaso-0.06
___ 06:23PM WBC-11.1* RBC-3.26* HGB-8.1* HCT-27.0* MCV-83
MCH-24.8* MCHC-30.0* RDW-16.5* RDWSD-48.7*
___ 06:23PM CK(CPK)-174
___ 06:23PM estGFR-Using this
___ 06:23PM GLUCOSE-104* UREA N-16 CREAT-0.8 SODIUM-141
POTASSIUM-5.0 CHLORIDE-101 TOTAL CO2-26 ANION GAP-19
___ 06:39PM LACTATE-3.0*
___ 12:06AM BLOOD WBC-9.7 RBC-3.07* Hgb-7.6* Hct-25.2*
MCV-82 MCH-24.8* MCHC-30.2* RDW-16.4* RDWSD-46.9* Plt ___
___ 05:48AM BLOOD WBC-8.6 RBC-2.82* Hgb-7.2* Hct-23.4*
MCV-83 MCH-25.5* MCHC-30.8* RDW-16.5* RDWSD-47.9* Plt ___
___ 03:09PM BLOOD WBC-7.6 RBC-3.07* Hgb-7.7* Hct-25.2*
MCV-82 MCH-25.1* MCHC-30.6* RDW-16.9* RDWSD-47.5* Plt ___
___ 06:00AM BLOOD WBC-7.8 RBC-2.83* Hgb-7.2* Hct-23.7*
MCV-84 MCH-25.4* MCHC-30.4* RDW-16.9* RDWSD-48.9* Plt ___
___ 12:45PM BLOOD Hct-26.5*
___ 06:25AM BLOOD WBC-8.0 RBC-2.89* Hgb-7.3* Hct-24.9*
MCV-86 MCH-25.3* MCHC-29.3* RDW-17.5* RDWSD-51.5* Plt ___
Radiology Report
INDICATION: History ___ who fell 5 days ago and has had persistent pain and
___ edema since in Right leg and left foot // eval for fracture/dislocation
TECHNIQUE: Left foot, three views
COMPARISON: None.
FINDINGS:
Nondisplaced transverse fracture involving the base of the fifth metatarsal
bone does not extend to the articular surface. No dislocation is present.
Small plantar calcaneal spur is demonstrated. Mild degenerative spurring is
seen in the midfoot as well as within the anterior aspect of the tibiotalar
joint. No concerning lytic or sclerotic osseous abnormalities are detected.
There are no radiopaque foreign bodies or soft tissue calcifications.
IMPRESSION:
Nondisplaced extra-articular transverse fracture involving the base of the
fifth metatarsal bone.
Radiology Report
INDICATION: History ___ who fell 5 days ago and has had persistent pain and
___ edema since in Right leg and left foot
TECHNIQUE: Right femur, two views, right tibia and fibula, two views
COMPARISON: None.
FINDINGS:
No fracture or dislocation is identified. No concerning lytic or sclerotic
osseous abnormalities are detected. Within the right hip, mild degenerative
spurring is noted. The right knee demonstrates moderate tricompartmental
degenerative changes with joint space narrowing, subchondral sclerosis, and
osteophyte formation, most pronounced in the medial compartment. There is no
joint effusion identified. The ankle appears grossly unremarkable apart from
degenerative spurring in the anterior tibiotalar joint. There are scattered
vascular calcifications. Dorsal to the midfoot there appears to be either
heterotopic calcification or marked osteophyte formation noted.
IMPRESSION:
No fracture.
Radiology Report
EXAMINATION: CTA LOWER EXT W/ANDW/O C AND RECONS RIGHT
INDICATION: ___ year old woman who fell and has had increasing hematoma with
Hct drop, evaluate for extravasation.
TECHNIQUE: Abdomen and pelvis CTA: Non-contrast and multiphasic post-contrast
images were acquired through the abdomen and pelvis.
Oral contrast was not administered.
MIP reconstructions were performed on independent workstation and reviewed on
PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 13.4 s, 105.6 cm; CTDIvol = 4.7 mGy (Body) DLP =
499.2 mGy-cm.
2) Stationary Acquisition 3.5 s, 0.5 cm; CTDIvol = 16.9 mGy (Body) DLP =
8.4 mGy-cm.
3) Spiral Acquisition 13.4 s, 105.1 cm; CTDIvol = 14.2 mGy (Body) DLP =
1,495.2 mGy-cm.
4) Spiral Acquisition 8.2 s, 64.6 cm; CTDIvol = 6.3 mGy (Body) DLP = 404.4
mGy-cm.
Total DLP (Body) = 2,407 mGy-cm.
COMPARISON: None.
FINDINGS:
VASCULAR:
A hematoma overlying the distal lateral right femur measures up to 9.8 x 3.7
by 12.1 cm (AP by TR by CC ; 2:84, 606:30). On the early arterial images a
small arterial branch off the lateral superior geniculate artery is noted
entering into the hematoma (3a:171), which appears slightly more diffuse on
early delayed imaging (3b:636). This is suspicious for a focal area of active
extravasation. There is extensive associated fat stranding throughout the
right leg. Atherosclerotic disease is mild with patent right lower extremity
vasculature and a normal 3 vessel runoff into the calf.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in the
pelvis.
REPRODUCTIVE ORGANS: Multiple calcified fibroids are seen within the uterus.
A 4.8 x 3.3 cm left adnexal cyst warrants further evaluation with pelvic
ultrasound.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits. Multiple
intramuscular lipomas are incidentally noted (2: 45, 120, 125).
IMPRESSION:
1. 12.1 cm hematoma in the subcutaneous tissues of the distal right lateral
thigh with possible active extravasation from a branch of the lateral superior
geniculate artery.
2. 4.8 cm left adnexal cyst for which non-emergent pelvic ultrasound is
recommended.
RECOMMENDATION(S): Nonemergent pelvic ultrasound.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 3:43 AM, 25 minutes after
discovery of the findings.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, R Foot swelling, R Leg swelling
Diagnosed with Contusion of right thigh, initial encounter, Disp fx of fifth metatarsal bone, right foot, init, Other fall on same level, initial encounter, Acute posthemorrhagic anemia
temperature: 97.9
heartrate: 76.0
resprate: 18.0
o2sat: 97.0
sbp: 136.0
dbp: 94.0
level of pain: 0
level of acuity: 2.0 | Ms ___ is a ___ on Coumadin (h/o DVT/PE) who presented s/p
mechanical fall 5 days ago. She had an expanding right leg
hematoma, with possible active extravasation and Left foot
fracture. Her initial INR was 3.7 upon presentation. We
therefore, reversed her anticoagulation with FFP, and repeat INR
was 1.5. Furthermore, her hct was trended and was stable at
25.2. Tertiary exam was performed without additional findings
except for the above. Orthopedics were involved early in order
to rule out compartment syndrome. They deemed this to be a
non-operative injury, without compartment syndrome, and she did
not need to be drained or aspirated. Weight bearing is as
tolerated. Podiatry was consulted for her left foot fracture.
This was also deemed to be nonoperative. Finally, their
recommendations included weight bearing as tolerated while CAM
boots are on. She will follow up with podiatry in 2 weeks.
Coumadin was held upon discharge to be restarted at the
discretion of per PCP. Patient was deemed appropriate for
discharge on ___.
Upon d/c, pt was doing well, afebrile, and hemodynamically
stable wnl. pt received discharge instructions and teaching,
along with follow up instructions. pt verbalizes agreement and
understanding of discharge plans. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril
Attending: ___
Major Surgical or Invasive Procedure:
none
attach
Pertinent Results:
___ 03:45PM BLOOD WBC-5.9 RBC-3.77* Hgb-10.5* Hct-33.5*
MCV-89 MCH-27.9 MCHC-31.3* RDW-12.4 RDWSD-39.9 Plt ___
___ 06:56AM BLOOD Glucose-86 UreaN-22* Creat-0.7 Na-139
K-3.4* Cl-101 HCO3-26 AnGap-12
___ 03:45PM BLOOD ALT-19 AST-44* CK(CPK)-1145* AlkPhos-81
TotBili-0.4
___ 06:56AM BLOOD ALT-18 AST-32 LD(LDH)-184 CK(CPK)-568*
AlkPhos-75 TotBili-0.3
___ 06:56AM BLOOD Albumin-3.5 Calcium-9.4 Phos-3.5 Mg-2.0
___ 06:56AM BLOOD TSH-1.4
___ 03:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. Mirtazapine 7.5 mg PO QHS
2. Apixaban 2.5 mg PO BID
3. Hydrochlorothiazide 25 mg PO DAILY
4. Vitamin D ___ UNIT PO DAILY
5. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
6. Multivitamins 1 TAB PO DAILY
7. Metoprolol Tartrate 12.5 mg PO BID
Discharge Medications:
1. Sertraline 50 mg PO DAILY
2. Apixaban 2.5 mg PO BID
3. Metoprolol Tartrate 12.5 mg PO BID
4. Multivitamins 1 TAB PO DAILY
5. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
6. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with gradually worsening weakness of unclear cause,
recent fall with head strike, also reports right hip pain last night which is
now resolved // CT head and neck: Bleed or fracture?Chest x-ray:
Pneumonia?Pelvis x-ray: Fracture?
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: None.
FINDINGS:
The lungs are relatively hyperinflated. Ill-defined opacity at the lateral
right upper lung is seen on the frontal view. Right suprahilar chain sutures
are seen from a prior surgery. There is also rightward shift of the
mediastinum, most likely postsurgical. There is possible trace pleural
effusion. Cardiac silhouette size is mildly enlarged. Aortic knob is
calcified.
IMPRESSION:
Right suprahilar chain sutures from prior surgery. Rightward shift of the
mediastinum, most likely postsurgical.
Ill-defined opacity at the lateral right upper lung, unclear whether this
could represent consolidation from pneumonia, trauma, underlying neoplasm not
excluded.
Possible trace pleural effusion.
Radiology Report
EXAMINATION: PELVIS AP ___ VIEWS
INDICATION: History: ___ with gradually worsening weakness of unclear cause,
recent fall with head strike, also reports right hip pain last night which is
now resolved // CT head and neck: Bleed or fracture?Chest x-ray:
Pneumonia?Pelvis x-ray: Fracture?
TECHNIQUE: Single AP view of the pelvis.
COMPARISON:
Pelvis and right hip radiographs from ___.
FINDINGS:
There is no acute fracture or dislocation. The SI and pubic symphysis joints
are unremarkable. Mild degenerative changes of the bilateral femoroacetabular
joints.
IMPRESSION:
No evidence of acute pelvic fracture.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ with gradually worsening weakness of unclear cause, recent
fall with head strike, with neck pain.
TECHNIQUE: Noncontrast CT cervical spine with axial, coronal, sagittal
reformations.
DOSE: Total DLP (Body) = 553 mGy-cm.
COMPARISON: Prior exam is dated ___
FINDINGS:
There is no acute fracture. Multilevel degenerative changes are again noted
within the cervical spine most progressed at C4 through C7 and not
significantly changed from prior. There is subtle anterolisthesis of C3 on C4
which is also unchanged. Otherwise alignment is preserved. No prevertebral
edema. The aerodigestive tract appears patent. Several small nodules are
again seen involving the right thyroid lobe. Suture and scarring is again
seen at the right lung apex.
IMPRESSION:
Multilevel degenerative changes without acute fracture or change in alignment.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with gradually worsening weakness of unclear cause, recent
fall with head strike and pain.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Total DLP (Head) = 803 mGy-cm.
COMPARISON: CT of the head from ___.
FINDINGS:
There is no intra-axial or extra-axial hemorrhage, edema, shift of normally
midline structures, or evidence of acute major vascular territorial
infarction. Age related involutional changes are slightly progressed from
prior. Ventricular prominence is unchanged. Periventricular white matter
hypodensities are most suggestive of chronic microvascular ischemic disease.
The imaged paranasal sinuses appear well aerated as do the mastoid air cells
and middle ear cavities. The bony calvarium is intact.
IMPRESSION:
No acute intracranial process. Age related involutional changes and chronic
microvascular ischemic disease.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Fatigue
Diagnosed with Other pneumonia, unspecified organism, Weakness, Unspecified atrial fibrillation
temperature: 97.8
heartrate: 67.0
resprate: 20.0
o2sat: 97.0
sbp: 119.0
dbp: 77.0
level of pain: 0
level of acuity: 3.0 | Ms. ___ is an ___ year-old woman with HTN, A Fib, h/o
Lung
Cancer presenting with fatigue, difficulty walking, that have
been progressively worsening for past 6 months. She has had
significant stressors related to her son, and appears to be
having adjustment disorder/major depressive disorder. She was
started on sertraline, seen by social work, and evaluated by ___
and nutrition. She had no acute injuries on trauma scan. Her
HCTZ was held given her normotension and possible contribution
to weakness with her poor po intake. Mirtazapine was held due to
side effects. Continued on metoprolol and apixaban for afib.
# Health care proxy/emergency contact: ___
(daughter):
___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever, Diarrhea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ PMH of Stage IIa Pancreatic Adenocarcinoma (On cycle ___
FOLFIRINOX, w/ planned SRS prior to resection with curative
intent), who presents with persistent diarrhea and fever, was
admitted for further evaluation/treatment
As per review of notes, patient had been tolerating her
FOLFIRINOX regimen fairly well with some neuropathy and diarrhea
which were managed with anti-motility agents and intermittent
outpatient IVF. She had been managing fairly well and was last
seen on ___ when she received pegfilgrastim and 1L NS.
Pt reports that she has had persistent diarrhea for weeks that
has been worse since this last cycle of chemotherapy. She noted
that she has ___ bowel movements per day that are watery,
nonbloody, unchanged in color or consistency over the past few
weeks. She denied any association with abdominal pain or
vomiting but endorsed nausea and decreased appetite. She noted
that she eats toast and broth during the day but not much more
she does not tolerate ensures because she does not like the
taste. She denied any fever, chills, sore throat, headache,
shortness of breath, cough, redness at port site, dysuria, rash.
She noted that she tried Imodium but did not notice any
improvement in symptoms so then try Lomotil which helped
slightly
but not in a significant manner. She noted that she takes her
pancrelipase enzymes (2 tabs) with each meal and feels that it
worsens her diarrhea
In the ED initial vitals were 100.1 129 130/92 20 98% RA, Tmax
100.9 . Labs included CBC: WBC: 0.9*. HGB: 10.2*. Plt Count:
52*.
Neuts%: 20*. ANC 180, Chemistry: Na: 134*. K: 3.2*. Cl: 95*.
CO2:
25. BUN: 7. Creat: 0.5. Ca: 8.3*. Mg: 1.7. PO4: 1.9*, Lactate:
1.3, Coags: INR: 1.4*. PTT: 26.5, LFTs: ALT: 26. AST: 16. Alk
Phos: 117*. Total Bili: 1.5, CXR: No acute cardiopulmonary
abnormality, UA: WBC 4.
As per discussion between outpatient oncology team and ED staff,
she was given cefepime and flagyl for neutropenic fever and
coverage of possible GI infection, as well as IVF and Tylenol.
Past Medical History:
Pancreatic cancer stage IIA (T3N0M0)
- ___ Developed new onset heartburn and abdominal pain.
- ___ Presented to ___ with epigastric pain, which
worsened when lying down. She was found to have elevated LFTs.
MRCP which showed a 3.8 cm mass at the head of the pancreas
causing extrinsic obstruction of the CBD.
- ___ Referred ___ EUS/ERCP. ERCP demonstrated
significant post obstructive dilation of the CBD, CHD, and R and
L main heptic ducts, with the CBD mearsuring up to 1.3cm.
Sphincterotomy performed, CBD brushings sent to cytology, which
were negative for malignant cells, and plastic stent
successfully
placed. EUS showed a 3 cm ill defined mass in the HOP, borders
were irregular and poorly defined. ___ confirmed showed
adenocarcinoma.
- ___ CT chest ___
- ___ C1D1 FOLFIRINOX + Neulasta
- ___ C1D1 CATIQ ___ ___
- ___ C2D1 FOLFIRINOX + Neulasta
- ___ CTA torso shows reduction in disease burden
- ___ C3D1 FOLFIRINOX + Neulasta
Status post tubal ligation.
Social History:
___
Family History:
1. Mother: Died of lung cancer.
2. Father: ___ cancer.
3. Sister: Kidney cancer, uterine cancer, and ovarian cancer.
4. Paternal aunt: ___ cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.4
PO 135 / 84
L Lying 100 18 98 ra
GENERAL: Laying in bed, appears comfortable, chronically ill
appearing, no acute distress
EYES: Pupils equally round and reactive to light
HEENT: Oropharynx clear, no frank ulceration but has white
lesions under tongue, mostly on left side, MMM
NECK: supple
LUNGS: Clear to auscultation bilaterally without any wheezes
rales or rhonchi, normal respiratory rate
CV: Tachycardic, regular rhythm, no murmurs
ABD: Soft nondistended, nontender, normal bowel sounds, no
rebound or guarding
GENITOURINARY: No Foley in place
EXT: Warm, no deformity
SKIN: Warm dry/no rash
NEURO: Alert and oriented ×3, fluent speech
ACCESS: Port is accessed in right chest with dressing
clean/dry/intact, no erythema
DISCHARGE EXAM:
VITALS: 98.1, 145 / 88, 106, 18, 100 RA
GENERAL: Alert and in no apparent distress, cachectic
EYES: Anicteric, no conjunctival injection, pupils equally round
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-tender in all quadrants, non-distended.
No rebound or guarding.
EXT: Warm and well perfused. No ___ edema.
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI, speech fluent, moves all limbs
PSYCH: pleasant, appropriate mood and affect
Pertinent Results:
ADMISSION LABS:
___ 12:50PM BLOOD WBC-0.9*# RBC-3.21* Hgb-10.2* Hct-30.3*
MCV-94 MCH-31.8 MCHC-33.7 RDW-16.3* RDWSD-55.8* Plt Ct-52*#
___ 12:50PM BLOOD Neuts-20* Bands-0 Lymphs-65* Monos-15*
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-0.18*
AbsLymp-0.59* AbsMono-0.14* AbsEos-0.00* AbsBaso-0.00*
___ 12:50PM BLOOD ___ PTT-26.5 ___
___ 12:50PM BLOOD Glucose-125* UreaN-7 Creat-0.5 Na-134*
K-3.2* Cl-95* HCO3-25 AnGap-14
___ 12:50PM BLOOD ALT-26 AST-16 AlkPhos-117* TotBili-1.5
___ 12:50PM BLOOD Albumin-3.3* Calcium-8.3* Phos-1.9*
Mg-1.7
___ 06:04AM BLOOD calTIBC-190* ___ Folate-17
Ferritn-1484* TRF-146*
___ 01:04PM BLOOD Lactate-1.3
DISCHARGE LABS:
___ 12:42AM BLOOD WBC-21.0* RBC-2.82* Hgb-8.8* Hct-27.9*
MCV-99* MCH-31.2 MCHC-31.5* RDW-19.5* RDWSD-66.3* Plt ___
___ 12:42AM BLOOD Neuts-70 Bands-7* Lymphs-12* Monos-7
Eos-1 Baso-0 ___ Metas-3* Myelos-0 AbsNeut-16.17*
AbsLymp-2.52 AbsMono-1.47* AbsEos-0.21 AbsBaso-0.00*
___ 12:42AM BLOOD Glucose-91 UreaN-4* Creat-0.6 Na-142
K-3.6 Cl-106 HCO3-26 AnGap-10
___ 12:42AM BLOOD Calcium-8.5 Phos-3.2 Mg-1.8
MICROBIOLOGY:
___ 12:50 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
BETA STREPTOCOCCUS GROUP B. >100,000 CFU/mL.
Blood cultures x 2 negative (___).
Stool cultures NGTD.
C. diff negative.
STUDIES:
CXR ___
IMPRESSION:
No acute cardiopulmonary abnormality.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 8 mg PO Q8H:PRN nausea
2. Dexamethasone 4 mg PO DAILY for 3d post-chemo
3. Diphenoxylate-Atropine ___ mL PO Q6H:PRN after every stool
4. Prochlorperazine 10 mg PO BID:PRN nausea
5. Pegfilgrastim Onpro (On Body Injector) 6 mg SC PRN CHEMO
6. lipase-protease-amylase ___ CAP oral QIDWMHS
Discharge Medications:
1. Fluconazole 100 mg PO QPM Duration: 4 Days
RX *fluconazole [Diflucan] 100 mg 1 tablet(s) by mouth QPM Disp
#*3 Tablet Refills:*0
2. Opium Tincture (morphine 10 mg/mL) 6 mg PO QID:PRN diarrhea
RX *opium tincture 10 mg/mL (morphine) 6 mg by mouth four times
a day Refills:*0
3. Diphenoxylate-Atropine ___ mL PO Q6H:PRN after every stool
4. lipase-protease-amylase ___ CAP oral QIDWMHS
5. Ondansetron 8 mg PO Q8H:PRN nausea
6. Prochlorperazine 10 mg PO BID:PRN nausea
Discharge Disposition:
Home
Discharge Diagnosis:
# Neutropenic fever
# Group B Strep urinary tract infection
# Diarrhea
# Mucositis
# Pancreatic Adenocarcinoma
# Pancytopenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with fever,immunocompromsed//evaluate for pneumonia
TECHNIQUE: Chest PA and lateral
COMPARISON: CT chest ___
FINDINGS:
Right-sided Port-A-Cath tip terminates at the SVC/right atrial junction.
Heart size is normal. Mediastinal and hilar contours are within normal
limits. Pulmonary vasculature is not engorged. Scarring in the apices is
unchanged, more pronounced on the right. Pulmonary vasculature is normal.
Lungs appear clear without focal consolidation. No pleural effusion or
pneumothorax is present. Mild degenerative changes are seen in the thoracic
spine. A stent is seen within the common bile duct.
IMPRESSION:
No acute cardiopulmonary abnormality.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Diarrhea, Tachycardia
Diagnosed with Diarrhea, unspecified, Tachycardia, unspecified
temperature: 100.1
heartrate: 129.0
resprate: 20.0
o2sat: 98.0
sbp: 13.0
dbp: 92.0
level of pain: 0
level of acuity: 2.0 | Patient is a ___ female with a past medical history of
stage IIa pancreatic adenocarcinoma who presented with diarrhea
and neutropenic fever.
#Neutropenic fever
#GBS urinary tract infection
Patient was found to have a GBS urinary tract infection and was
treated initially with vancomycin/cefepime/Flagyl and narrowed
to Augmentin for a 7 day course (completed on ___. She was
given Neulasta and her white count improved. Her other cultures
were negative. She had no fevers after she was admitted.
#Diarrhea
Stool cultures have been negative. She has tried multiple
medications for this in the past and now has had good
improvement with opium tincture in the hospital. She will
continue the opium tincture on discharge.
#Mucositis/thrush
Started on 5 day course of p.o. fluconazole.
#Pancreatic adenocarcinoma
She has close follow-up with her outpatient oncologist.
Otherwise no changes were made to her home medications.
#CODE: Full Code, presumed
#EMERGENCY CONTACT / HCP: ___ / husband, has been d/w husband
at
bedside daily
Phone number: ___
Cell phone: ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
erythromycin base / gluten
Attending: ___.
Major Surgical or Invasive Procedure:
Cardiac catheterization with percutaneous coronary intervention
and placement of drug-eluting stent
attach
Pertinent Results:
ADMISSION LABS:
===============
___ 03:00PM BLOOD WBC-9.8 RBC-5.51 Hgb-15.9 Hct-49.2 MCV-89
MCH-28.9 MCHC-32.3 RDW-12.5 RDWSD-40.9 Plt ___
___ 03:00PM BLOOD ___ PTT-22.2* ___
___ 03:00PM BLOOD Glucose-99 UreaN-10 Creat-0.9 Na-142
K-4.4 Cl-103 HCO3-25 AnGap-14
___ 08:07AM BLOOD ALT-22 AST-73* AlkPhos-75 TotBili-1.0
___ 03:00PM BLOOD cTropnT-0.36*
___ 11:16AM BLOOD CK-MB-29* cTropnT-1.10*
___ 08:00PM BLOOD CK-MB-12* cTropnT-0.94*
___ 12:57AM BLOOD Calcium-8.8 Phos-3.4 Mg-1.8
___ 08:07AM BLOOD %HbA1c-5.5 eAG-111
___ 08:07AM BLOOD Triglyc-161* HDL-45 CHOL/HD-5.5
LDLcalc-171*
___ 06:15PM URINE Blood-TR* Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-TR* Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 06:15PM URINE RBC-1 WBC-0 Bacteri-NONE Yeast-NONE Epi-0
___ 06:15PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
___ 06:15PM URINE Color-Straw Appear-Clear Sp ___
DISCHARGE LABS:
================
___ 08:07AM BLOOD WBC-9.1 RBC-5.39 Hgb-15.8 Hct-48.1 MCV-89
MCH-29.3 MCHC-32.8 RDW-12.9 RDWSD-42.0 Plt ___
___ 08:07AM BLOOD ___ PTT-29.0 ___
___ 07:19AM BLOOD Glucose-100 UreaN-13 Creat-1.0 Na-140
K-4.4 Cl-104 HCO3-21* AnGap-15
___ 07:19AM BLOOD CK-MB-5 cTropnT-0.92*
MICROBIOLOGY:
=============
___ 6:15 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
2. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Aspirin Regimen] 81 mg 1 tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*0
2. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth nightly Disp #*30
Tablet Refills:*0
3. Lisinopril 2.5 mg PO DAILY
RX *lisinopril 2.5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
5. Prasugrel 10 mg PO DAILY
RX *prasugrel 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
6. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
7. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Non-ST elevation myocardial infarction
SECONDARY DIAGNOSIS:
====================
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with chest pain // Rule out pneumonia
TECHNIQUE: PA and lateral views the chest.
COMPARISON: None.
FINDINGS:
Lungs are clear. There is no consolidation, effusion, or edema.
Cardiomediastinal silhouette is within normal limits. No acute osseous
abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Chest pain
Diagnosed with Non-ST elevation (NSTEMI) myocardial infarction
temperature: 98.1
heartrate: 89.0
resprate: 16.0
o2sat: 100.0
sbp: 144.0
dbp: 105.0
level of pain: 7
level of acuity: 2.0 | Mr. ___ is a ___ yo M with PMH HLD, likely HTN who presents
with acute on subacute chest pain found to have ___ now s/p
DES to OM1.
CORONARIES: Single vessel disease (100% occluded culprit OM1
that fills distally via L-L collaterals) s/p PCI with ___: LVEF 55%
RHYTHM: Sinus rhythm
#CODE: Full Code
#CONTACT: No HCP designated |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
D&E under ultrasound guidance
History of Present Illness:
Ms. ___ is a ___ yo G1P0 @ ___+2 presents to ED ___ severe R
chest pain. History significant for thymoma s/p median
sternotomy, resection of involved R phrenic nerve and R middle
lobectomy on ___ with neoadjuvant chemotherapy and
radiation, who has had persistent R chest pain since the time of
her surgery. This pain has been worsening and she was recently
diagnosed with a large R chest mass measuring 15x11x7cm
suspicous for recurrence of thymic carcinoma. Patient was
scheduled to undergo US guided biopsy today however instead
presented to the ED ___ severe chest pain. Initially rated her
pain ___ and has had minimal improvement despite narcotics.
Also c/o DOE. These sx have been present for some time though
worse today.
- ___ ___ by 9wk US
- B+/Ab-,RPRnr, RI,HBsAg-, HIV neg
- integrated screen low risk
- FFS normal; marg post previa -> resolved (19 wk U/S)
- CF neg
- Hospitalized mid ___ for ?empyema after tx for presumed
pneumonia, subsequently dx with recurrent chest mass/? recurrent
thymic cancer.
Past Medical History:
OBhx:
- G1
GYNhx:
- h/o endometriosis
- h/o HSV
- no abnormal Paps
PMH:
- thymoma s/p median sternotomy, resection of mass + involved R
phrenic nerve and R middle lobectomy on ___ with neoadjuvant
chemotherapy (etoposide and cisplatin) and radiation. Likely
recurrence
- depression, hx suicide attempt by OD
- T2DM
PSH:
- sternotomy, resection of thymoma including involved R phrenic
nerve/ R middle lobe
- dx lsc
Social History:
___
Family History:
No cancer or cardiac problems in family. Mother has DM but
alive. Father without medical problems.
Physical Exam:
On admission:
98.2, HR 120's, BP's 120/70's, O2 sat 96-100%
Well appearing, slightly shortened sentences though appears to
be comfortable
tachycardic, regular
+ dullness to percussion R lower ___ lung, no BS over this area,
L lung clear
abd gravid, S=D
ext NT, NE
On discharge:
afebrile, HR 100s, remainder of VS normal
A&O, slightly shortened sentences but comfortable
Regular, tachycardic
Clear on left lung, breath sounds minimal on right
Abdomen soft, minimally appropriately tender postprocedure
Ext nontender
Pertinent Results:
___ 12:03PM BLOOD WBC-7.0 RBC-3.77* Hgb-11.5* Hct-34.8*
MCV-92# MCH-30.4# MCHC-32.9 RDW-14.4 Plt ___
___ 07:25AM BLOOD WBC-6.1 RBC-3.35* Hgb-10.3* Hct-30.2*
MCV-90 MCH-30.7 MCHC-34.0 RDW-14.4 Plt ___
___ 05:57AM BLOOD WBC-4.9 RBC-3.32* Hgb-10.5* Hct-30.5*
MCV-92 MCH-31.5 MCHC-34.2 RDW-14.4 Plt ___
___ 10:20AM BLOOD WBC-6.6 RBC-2.98* Hgb-9.1* Hct-27.4*
MCV-92 MCH-30.4 MCHC-33.2 RDW-15.1 Plt ___
___ 10:15PM BLOOD WBC-7.6 RBC-2.97* Hgb-9.1* Hct-27.5*
MCV-92 MCH-30.7 MCHC-33.2 RDW-14.9 Plt ___
___ 07:30AM BLOOD WBC-5.0 RBC-2.92* Hgb-8.7* Hct-27.2*
MCV-93 MCH-29.7 MCHC-31.9 RDW-14.3 Plt ___
___ 12:03PM BLOOD Neuts-83.7* Lymphs-10.8* Monos-5.0
Eos-0.2 Baso-0.2
___ 10:20AM BLOOD Neuts-82.5* Lymphs-13.3* Monos-4.0
Eos-0.1 Baso-0.2
___ 12:03PM BLOOD ___ PTT-30.1 ___
___ 07:25AM BLOOD ___ PTT-28.4 ___
___ 10:20AM BLOOD ___ PTT-77.4* ___
___ 10:15PM BLOOD ___ PTT-28.8 ___
___ 07:30AM BLOOD ___ PTT-29.3 ___
___ 10:15PM BLOOD ___
___ 07:30AM BLOOD ___
___ 12:03PM BLOOD Glucose-107* UreaN-7 Creat-0.7 Na-131*
K-4.4 Cl-99 HCO3-24 AnGap-12
___ 07:25AM BLOOD Glucose-109* UreaN-7 Creat-0.7 Na-133
K-4.0 Cl-100 HCO3-27 AnGap-10
___ 05:57AM BLOOD Glucose-119* UreaN-5* Creat-0.6 Na-134
K-3.7 Cl-102 HCO3-25 AnGap-11
___ 10:20AM BLOOD Glucose-95 UreaN-5* Creat-0.6 Na-137
K-4.0 Cl-103 HCO3-24 AnGap-14
___ 12:03PM BLOOD ALT-16 AST-21 AlkPhos-66 TotBili-0.3
___ 10:20AM BLOOD Calcium-8.5 Phos-2.8 Mg-1.8
___ 12:03PM BLOOD Lipase-24
___ 12:03PM BLOOD Albumin-4.0
___ 07:25AM BLOOD Calcium-9.3 Phos-3.3 Mg-1.6
___ 05:57AM BLOOD Calcium-8.4 Phos-2.8 Mg-1.6
___ 10:20AM BLOOD Calcium-8.5 Phos-2.8 Mg-1.8
___ 06:02PM BLOOD %HbA1c-5.6 eAG-114
___ 10:20AM BLOOD TSH-1.6
___ CXR
SINGLE AP ERECT PORTABLE VIEW OF THE CHEST: The patient is
status post median sternotomy. There is elevation of the right
hemidiaphragm with a right basilar opacity compatible with known
pleural mass and adjacent atelectasis with a small pleural
effusion. Right-sided Port-A-Cath terminates in the lower SVC.
Left lung is essentially clear with no pleural effusion. No
pneumothorax is noted. Bones are intact.
IMPRESSION: Right basilar opacification compatible with the
patient's known pleural based mass with adjacent atelectasis and
small pleural effusion.
___ CTA
FINDINGS: Study is limited by very poor contrast bolus. Within
the limitation of the suboptimal contrast bolus, no filling
defects are noted
within the main pulmonary arteries. The lobar, segmental, and
subsegmental
pulmonary arteries are poorly evaluated on this exam. The
thoracic aorta shows no evidence of acute aortic injury and is
normal in caliber. Trace pleural effusion is noted at the right
lung base with minimal increased fluid accumulated within the
minor fissure (2:41), new since the most recent MRI of ___. Atelectasis within the right middle and lower lung lobes
are again noted.
Mediastinal, axillary and hilar lymph nodes do not meet CT size
criteria for pathology. The patient is status post median
sternotomy.
Incompletely imaged is a right anterobasal pleural-based mass
measuring approximately 17.3 x 7.9 cm, similar in size and
better delineated on the MRI of ___. This mass has
increased in size compared to the most recent prior CT ___ previously measuring 12 x 4.2 cm at comparable levels.
This mass causes compressive effect on the liver. Elevation of
the right hemidiaphragm is again seen.
There is a 2.2 x 0.6 cm focal area of left anterolateral pleural
thickening within the mid lung (2:41) which was not clearly
visualized on the MRI of ___ tumor within this area
cannot be completely excluded.
The upper abdominal structures are obscured by presence of
barium in the stomach.
Visualized osseous structures show no definite focal lytic or
sclerotic lesions suspicious for malignancy.
IMPRESSION:
1. Suboptimal contrast bolus. No central pulmonary embolism.
Pulmonary embolism within the lobar, segmental, or subsegmental
pulmonary arteries cannot be excluded.
2. No acute aortic injury.
3. Incompletely visualized right anterobasal pleural based mass
better delineated on chest MRI of ___ likely
reflecting disease recurrence.
4. Focal thickening of the left anterolateral pleura. Tumor in
this area is not excluded. Attention to this region on follow up
imaging is recommended.
5. Slightly increased small right pleural effusion. Atelectasis
in right
middle and lower lung.
___ wks pregnant. Pt has portacath.
LEFT ATRIUM: Normal LA and RA cavity sizes.
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%). Transmitral
Doppler E>A and TDI E/e' <8 suggesting normal diastolic
function, and normal LV filling pressure (PCWP<12mmHg). No
resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
___ VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
Normal PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Transmitral and tissue
Doppler imaging suggests normal diastolic function, and a normal
left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. No pulmonary hypertension or clinically-significant
valvular disease seen.
___ BIOPSY
PROCEDURE: The risks and benefits of the procedure were
explained to the
patient, and written informed consent was obtained. A
preprocedure timeout was performed verifying three patient
identifiers and the nature of the procedure to be performed.
General anesthesia was given to the patient per request of
OB/GYN service. The skin of the right upper quadrant was
prepped and draped in standard sterile fashion.
Preprocedure ultrasound revealed a large cystic and
solid-appearing mass in the right upper quadrant superior to
liver dome. Under direct ultrasonographic guidance, an
18-gauge core biopsy needle was advanced into the complex mass
and multiple (6) core biopsy samples were obtained in various
locations of the mass. Of note, most samples contained fluid
and very little solid tissue was obtained. Aspiration of the
cystic portions of the mass yielded approximately 3 cc of
sanguineous fluid which was also sent for pathologic analysis,
flow cytometry and cytology. The patient tolerated the
procedure well, with no complications evident at the time of the
procedure. The attending radiologist, Dr. ___, was present
throughout the procedure. Samples were sent for pathologic and
cytologic analysis. Initial on-site cytology revealed mostly
lymphocytes, raising the possibility of a lymphangioma.
SEDATION: General endotracheal intubation and general
anesthesia was provided by the anesthesiology staff. Please see
anesthesiology note for further details. During the procedure,
the patient's hemodynamic parameters were continuously monitored
by radiology department nursing staff as well as anesthesiology
staff.
IMPRESSION: Ultrasound-guided targeted biopsy of large complex
right upper quadrant mass, found to be predominantly cystic.
___ CYTOLOGY, CORE BIOPSY, PRODUCTS OF CONCEPTION
Pathology all pending at time of discharge
Medications on Admission:
- wellbutrin 300qam
- lamictal 300 qhs
- seroquel 200 qhs
- seroquel Rx 400 @ 6pm
- PNV
- morphine, oxycodone
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain
RX *acetaminophen 325 mg ___ tablet(s) by mouth every 6 hours
Disp #*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID:PRN Constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
3. Doxycycline Hyclate 100 mg PO Q12H
Skip doses day of surgery
RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day
Disp #*12 Capsule Refills:*0
4. HYDROmorphone (Dilaudid) 2 mg PO Q4H pain
please offer to patient q4h; she may refuse. If requests pain
meds earlier may be taken as soon as q3h prn. page ___ with
questions.
RX *hydromorphone 2 mg ___ tablet(s) by mouth every 4 hours Disp
#*40 Tablet Refills:*0
5. LaMOTrigine 300 mg PO HS
6. Quetiapine Fumarate 300 mg PO HS
7. Wellbutrin XL *NF* (buPROPion HCl) 300 mg ORAL DAILY
pt may take own * Patient Taking Own Meds *
8. Ferrous Sulfate 325 mg PO DAILY
do not take with doxycycline
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
9. Methylergonovine Maleate 0.2 mg PO TID Duration: 3 Days
RX *methylergonovine 0.2 mg 1 tablet(s) by mouth three times
daily Disp #*9 Tablet Refills:*0
10. Ibuprofen 600 mg PO Q6H pain
___ give with sip of water while NPO for surgery
RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp
#*20 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
23 week pregnancy s/p D&E
History of thymic cancer
Right chest mass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CLINICAL HISTORY: ___ female status post median sternotomy. Now with
right-sided pain.
COMPARISON: ___ x-ray as well as CT from outside hospital from ___.
SINGLE AP ERECT PORTABLE VIEW OF THE CHEST: The patient is status post median
sternotomy. There is elevation of the right hemidiaphragm with a right
basilar opacity compatible with known pleural mass and adjacent atelectasis
with a small pleural effusion. Right-sided Port-A-Cath terminates in the
lower SVC. Left lung is essentially clear with no pleural effusion. No
pneumothorax is noted. Bones are intact.
IMPRESSION: Right basilar opacification compatible with the patient's known
pleural based mass with adjacent atelectasis and small pleural effusion.
Radiology Report
INDICATION: ___ female 22 weeks pregnant with past medical history of
thymic cancer, now presents with shortness of breath; evaluate for pulmonary
embolism.
COMPARISON: Multiple priors, most recent MR chest ___ reference CT
chest ___ CT chest ___.
TECHNIQUE: MDCT axial images were obtained through the chest with the
administration of IV contrast, per pregnancy protocol. Multiplanar reformats
were generated and reviewed.
FINDINGS: Study is limited by very poor contrast bolus. Within the
limitation of the suboptimal contrast bolus, no filling defects are noted
within the main pulmonary arteries. The lobar, segmental, and subsegmental
pulmonary arteries are poorly evaluated on this exam. The thoracic aorta
shows no evidence of acute aortic injury and is normal in caliber. Trace
pleural effusion is noted at the right lung base with minimal increased fluid
accumulated within the minor fissure (2:41), new since the most recent MRI of
___. Atelectasis within the right middle and lower lung lobes are
again noted.
Mediastinal, axillary and hilar lymph nodes do not meet CT size criteria for
pathology. The patient is status post median sternotomy.
Incompletely imaged is a right anterobasal pleural-based mass measuring
approximately 17.3 x 7.9 cm, similar in size and better delineated on the MRI
of ___. This mass has increased in size compared to the most recent
prior CT ___ previously measuring 12 x 4.2 cm at comparable
levels. This mass causes compressive effect on the liver. Elevation of the
right hemidiaphragm is again seen.
There is a 2.2 x 0.6 cm focal area of left anterolateral pleural thickening
within the mid lung (2:41) which was not clearly visualized on the MRI of ___ tumor within this area cannot be completely excluded.
The upper abdominal structures are obscured by presence of barium in the
stomach.
Visualized osseous structures show no definite focal lytic or sclerotic
lesions suspicious for malignancy.
IMPRESSION:
1. Suboptimal contrast bolus. No central pulmonary embolism. Pulmonary
embolism within the lobar, segmental, or subsegmental pulmonary arteries
cannot be excluded.
2. No acute aortic injury.
3. Incompletely visualized right anterobasal pleural based mass better
delineated on chest MRI of ___ likely reflecting disease recurrence.
4. Focal thickening of the left anterolateral pleura. Tumor in this area is
not excluded. Attention to this region on follow up imaging is recommended.
5. Slightly increased small right pleural effusion. Atelectasis in right
middle and lower lung.
Updated findings discussed with Dr. ___ at 12:20am on ___ via
telephone.
Radiology Report
ULTRASOUND INTERVENTIONAL PROCEDURE.
HISTORY: ___ female with thymic cancer, status post median sternotomy
and thymoma resection, right phrenic nerve section, en bloc right middle lobe
lobectomy ___. Continued right chest pain. 15 cm right chest/right
upper quadrant mass noted on MRI, please evaluate. Patient also 24 weeks
pregnant.
COMPARISON: CTA chest ___, MR chest ___.
PROCEDURE: The risks and benefits of the procedure were explained to the
patient, and written informed consent was obtained. A preprocedure timeout
was performed verifying three patient identifiers and the nature of the
procedure to be performed. General anesthesia was given to the patient per
request of OB/GYN service. The skin of the right upper quadrant was prepped
and draped in standard sterile fashion.
Preprocedure ultrasound revealed a large cystic and solid-appearing mass in
the right upper quadrant superior to liver dome. Under direct
ultrasonographic guidance, an 18-gauge core biopsy needle was advanced into
the complex mass and multiple (6) core biopsy samples were obtained in various
locations of the mass. Of note, most samples contained fluid and very little
solid tissue was obtained. Aspiration of the cystic portions of the mass
yielded approximately 3 cc of sanguineous fluid which was also sent for
pathologic analysis, flow cytometry and cytology. The patient tolerated the
procedure well, with no complications evident at the time of the procedure.
The attending radiologist, Dr. ___, was present throughout the procedure.
Samples were sent for pathologic and cytologic analysis. Initial on-site
cytology revealed mostly lymphocytes, raising the possibility of a
lymphangioma.
SEDATION: General endotracheal intubation and general anesthesia was provided
by the anesthesiology staff. Please see anesthesiology note for further
details. During the procedure, the patient's hemodynamic parameters were
continuously monitored by radiology department nursing staff as well as
anesthesiology staff.
IMPRESSION: Ultrasound-guided targeted biopsy of large complex right upper
quadrant mass, found to be predominantly cystic.
Radiology Report
HISTORY: Operative guidance requested for D&E.
COMPARISON: None.
FINDINGS:
Sonographic guidance was provided for D&E performed by Dr. ___.
Postprocedure demonstrates no evidence of retained products of conception.
IMPRESSION:
Successful guidence.
Gender: F
Race: HISPANIC OR LATINO
Arrive by WALK IN
Chief complaint: R SIDED ABD PAIN
Diagnosed with OTH CURR COND-ANTEPARTUM, CHEST PAIN NEC, PALPITATIONS, CHEST SWELLING/MASS/LUMP, HX-INTRATHORACIC MAL NEC
temperature: 98.2
heartrate: 127.0
resprate: 16.0
o2sat: 100.0
sbp: 121.0
dbp: 82.0
level of pain: 20
level of acuity: 2.0 | Because of her pregnancy, Ms ___ was admitted to the
antepartum service with RUQ chest pain, tachycardia, and
enlarging RUQ mass seen on imaging that was suspicious for
recurrence of her thymic cancer. Her hospital course is outlined
below.
*) Tachycardia / chest pain
EKG showed sinus tachycardia. CTA was suboptimal but negative
for large pulmonary embolus. She was placed on telemetry and had
one episode of HR in the 140s and received one dose of
metoprolol on hospital day #1. Her heart rate subsequently
remained stable in the 100s-120 for the remainder of her
hospitalization. She was started on prophylactic heparin. An
echo was normal. She received dilaudid as needed for pain. She
never had an oxygen requirement. Her tachycardia improved
slightly at the end of her hospitalization with a heart rate in
the ___ at discharge.
*) RUQ mass
She was followed by the thoracic surgery team. An
ultrasound-guided biopsy of the mass was performed on ___ and
the pathology report was not finalized at the time of discharge.
She will be followed as an outpatient with PET-CT and
medical/surgical oncology appointments.
*) Pregnancy
She was admitted to the antepartum service. She underwent
multiple discussions with all her care providers reviewing the
imaging findings, potential prognosis under various scenarios,
and diagnosis and treatment options with and without pregnancy.
After extensive discussion she ultimately opted for pregnancy
termination. She underwent uncomplicated ultrasound-guided D&E
following intraamniotic digoxin injection and two days of
laminaria; see operative report for details.
*) Anemia
On admission her hematocrit was 34% that decreased to 30% with
hydration. Following her biopsy her hematocrit trended to 27%
where it remained stable. She did not have any clinical evidence
of bleeding. She was discharged home on iron.
*) T2DM
Her A1c was 5.6% and she did not have any elevated blood glucose
on random fingerstick.
*) Social
She was followed by the Social Work department. She was
continued on her home medications.
She was discharged home in stable condition on hospital day #5
with close outpatient followup. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
___ Coronary Angiography with stent placement
History of Present Illness:
Mr. ___ is a ___ male with a PMH notable for CAD s/p
PCI to mid LAD in ___ and PCI to D1 in ___, HTN, HLD, DM2
who presents with chest pain.
The patient was transferred from ___ to
___ on ___ after presenting with an NSTEMI. He was found on
diagnostic cath to have a bifurcation lesion in the ___ diagonal
and was referred to ___ for intervention. He had PCI to bifur
intervention. He successfully had a PCI to the bifurcating
lesion of LAD. He was discharged on aspirin and Plavix with
plans
for outpatient cardiac rehab.
He did well with cardiac rehab and had been working on regular
exercise, walking consistently >12,000 steps a day and working
out on the elliptical machine for at least 30 minutes, 3 times
per week. About 1 week ago, he started having burning chest pain
that is located in the middle of the chest with no radiation
whenever he walked any moderate distance. The pain would come on
reliably with activity and go away with rest. The morning of
presentation, he woke up at 3AM and started to have sharper
burning chest pain. He lied down for 5 minutes with no relief,
so
he got up and talk a dose of nitro, with resolution of pain in 5
minutes. He came in to work (near ___ though he lives ___, and felt generally unwell with a headache, so he
called his cardiologist, who instructed him to go to the nearest
hospital.
In the ED, he reported no recurrent of chest pain or any recent
symptoms of dyspnea, palpitations, diaphoresis, fevers, chills,
cough, nausea, vomiting, abdominal pain. He reports taking
aspirin and clopidogrel daily without missed doses. He also
mentions that while lying down, he occasionally gets pain in the
lower sternal area that feels like burning as well.
- Initial vitals: 97.6 ___ 18 98% RA
- EKG: Normal sinus rhythm. Normal intervals. T-wave flattening
in inferior leads.
- Labs/studies notable for:
16.9
8.6 >----< 207
48.8
138|100|22
----------< 151
4.3|23|1.1
Trop < 0.01 x 2
- Patient was given:
Aspirin 243mg
Atorvastatin 40mg
Amlodipine 5mg
Clopidogrel 75mg
Lisinopril 40mg
+ Consults:
Cardiology was consulted who recommended stress test. Stress
test
was performed and showed LV dysfunction in the setting of
anginal
type symptoms without ST segment changes.
- Vitals on transfer: T 98 HR 75 BP 169/97 RR 20 SpO2 97% RA
(Transferred to the CCU)
Reason for CCU: Post-cath monitoring
In brief, Mr. ___ is a ___ with past medical history notable
for CAD s/p PCI to mid LAD in ___ and PCI to D1 in ___,
HTN, HLD, DM2 who initially presented with chest pain. In the
ED, cardiology was consulted and recommended further evaluation
with stress test, which showed LV dysfunction in the setting of
anginal type symptoms and no ST segment changes. He was
subsequently taken to the cath lab, where he was found to have
in-stent thrombosis of D1, s/p repeat DES complicated by
perforation with balloon angioplasty tamponade. Post-procedure
echo with no pericardial effusion and small hematoma that has
since stabilized.
Upon arrival to the CCU, patient is feeling well and has no
complaints. Denies chest pain, palpitations, or shortness of
breath. Has a good appetite.
Past Medical History:
- CAD s/p PCI to mid LAD in ___ and PCI to D1 in ___
- diabetes
- hypertension
- hyperlipidemia
Social History:
___
Family History:
Father had a history of heart disease and mother had kidney
disease.
Physical Exam:
VS: Reviewed in metavision
___: Well-appearing, well-nourished, in NAD
HEENT: NC/AT, EOMI, PERRL, anicteric sclera, MMM
NECK: Supple, no appreciable JVD
HEART: RRR, normal S1/S2, no m/r/g
LUNGS: CTAB, breathing comfortably on RA, no appreciable
crackles
or rhonci
ADBOMEN: Obese, soft, non-tender to palpation, non-distended,
active bowel sounds, no hepatomegaly
EXTREMITIES: No c/c/e
SKIN: Warm, well-perfused, no rashes
NEURO: Alert, oriented, moving all extremities with purpose, no
facial asymmetry
Discharge Physical Exam
VSS although slight hypertension
Obese, well appearing.
R- Radial Cath sight C/d/i.
Pertinent Results:
Admission labs:
--------------------
___ 03:29PM cTropnT-<0.01
___ 11:00AM cTropnT-<0.01
___ 11:00AM WBC-8.6 RBC-5.28 HGB-16.9 HCT-48.8 MCV-92
MCH-32.0 MCHC-34.6 RDW-12.6 RDWSD-42.6
IMPORTANT SUDIES:
-----------------
Anatomy:
R dominant
LM: The Left Main, arising from the left cusp, is a large
caliber vessel. This vessel bifurcates into the Left Anterior
Descending and Left Circumflex systems.
LAD: The Left Anterior Descending artery, which arises from the
LM, is a large caliber vessel. There is a stent in the proximal
and mid segments. There is a 30% in-stent restenosis in the mid
segment.
The Diagonal, arising from the proximal segment, is a medium
caliber vessel. There is a stent in the ostium extending to the
mid segment. There is a 90% in-stent restenosis in the proximal
segment beyond the ostium.
Cx: The Circumflex artery is free of signifcaint disease.
RCA: The Right Coronary Artery, arising from the right cusp, is
a large caliber vessel. There is moderate ectasia in the
proximal segment. There is a 30% stenosis in the mid segment.
There is moderate ectasia in the mid and distal segments.
We planned PCI of the diagonal in-stent restenosis. Heparin was
used for anti-coagulation and ACT confirmed >250. 6 ___ EBU
3.5 provided poor support and was changed for EBU 4.0. There was
difficulty crossing inton the diagonal and delivering balloon
suggesting under stent strut. Eventually with Guideliner support
and CPT XS wire we were able to deliver a 2.0 x 12 balloon -
inflated to 12 ATM with good expansion. A 2.5 x 8 Promus DES was
then delivered and deployed at 16 ATM with second inflation for
post-dilation. Angiography at this time showed a very distal dye
stain consistent with wire perforation. A 2.0 balloon was
inflateddistally x 2 for 2.5 minutes. There was no further
contrast leak and stain was stable. There was trivial
pericardial effusion and hemodynamics remained
stable. There was no residual stenosis, Flow was TIMI 3 and
there was no dissection.
DISCHARGE LABS:
___ 06:10AM BLOOD WBC-9.3 RBC-5.25 Hgb-17.2 Hct-50.4 MCV-96
MCH-32.8* MCHC-34.1 RDW-13.2 RDWSD-46.7* Plt ___
___ 06:10AM BLOOD Glucose-138* UreaN-22* Creat-1.2 Na-142
K-4.2 Cl-103 HCO3-24 AnGap-15
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clopidogrel 75 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. MetFORMIN (Glucophage) 500 mg PO DAILY
4. Lisinopril 40 mg PO DAILY
5. amLODIPine 5 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Metoprolol Succinate XL 150 mg PO DAILY
Discharge Medications:
1. amLODIPine 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Clopidogrel 75 mg PO DAILY
5. Lisinopril 40 mg PO DAILY
6. MetFORMIN (Glucophage) 500 mg PO DAILY
7. Metoprolol Succinate XL 150 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
- Unstable angina
- Coronary artery disease
Secondary diagnosis:
- Coronary artery perforation
- Hyperlipidemia
- Hypertension
- Type II diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with CP// ?CHF
TECHNIQUE: Chest PA and lateral
COMPARISON: None.
FINDINGS:
Heart size is normal. The mediastinal and hilar contours are normal. The
pulmonary vasculature is normal. Lungs are well inflated and clear. No
pleural effusion or pneumothorax is seen. There are no acute osseous
abnormalities. Mild degenerative changes are noted in the thoracic spine.
IMPRESSION:
No acute cardiopulmonary abnormality.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Chest pain, Dyspnea
Diagnosed with Chest pain, unspecified
temperature: 97.6
heartrate: 104.0
resprate: 18.0
o2sat: 98.0
sbp: 125.0
dbp: 106.0
level of pain: 5
level of acuity: 2.0 | Mr. ___ is a ___ male with a PMH notable for CAD s/p
PCI to mid LAD in ___ and PCI to D1 in ___, HTN, HLD, DM2
who presented with chest pain and an abnormal stress test. He
was taken to the cath lab and found to have in stent restenosis
of proximal diag and had DES placed, however, this was
complicated by mild perforation that resolved with balloon
angioplasty. He was admitted to the CCU for monitoring
post-procedure and did well. There was no pericardial effusion
on follow up TTE. He was discharged on his home medications and
told to follow up with his outpatient cardiologist.
TRANSITIONAL ISSUES
- Med changes: None
- DES (2.5 x 8 Promus) placed for in stent in proximal circ for
in-stent restenosis. Continue DAPT.
- Coronary artery perforation w/ no evidence of effusion on TTE. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Left displaced femoral neck fracture
Major Surgical or Invasive Procedure:
___ Left hip hemiarthoplasty
History of Present Illness:
Ms. ___ is an ___ lady with history of hypertension,
chronic clostridium difficile infection (on vancomycin), and
breast cancer (s/p lumpectomy & XRT) who sustained a mechanical
fall on ___ evening when tripping over her untied robe. She fell
on to her left side. She denies head strike and loss of
consciousness. She crawled down the stairs of her home this
morning and called her son for help, and she was subsequently
brought to the ___ ED for further management. She endorses
pain isolated to the left hip. She denies paresthesias. She
endorses some mild baseline bilateral hip pain.
Past Medical History:
#GLAUCOMA - Followed by Dr. ___
#HYPERTENSION
#BREAST CANCER ___ - Right Lumpectomy and radiation X 37. Dr.
___ at ___. annual mammograms
#HIATAL HERNIA
#BELL'S PALSY ___ - Left side,
#TREMOR
#DIVERTICULOSIS
Social History:
___
Family History:
mother having died due to ovarian cancer and the patient's
father died due to pneumonia.
Physical Exam:
Left Lower Extremity:
- Skin intact, inc cdi
- Sensation intact to light touch throughout
- Fires ___ FHL TA GSC
- Palpable dorsalis pedis pulse
Medications on Admission:
1. Amlodipine-benazepril 5 mg - 20 mg 1 capsule po qam
2. Betaxolol 0.25% 1 drop ___ bid
3. Vancomycin 250 mg po daily
4. Vitamin D3
5. Vitamin B12 500 mcg po daily
Discharge Medications:
1. Acetaminophen 650 mg PO 5X/DAY
2. Amlodipine 5 mg PO DAILY
3. Betaxolol Ophth Susp 0.25% 1 DROP BOTH EYES BID
4. Cyanocobalamin 500 mcg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Enoxaparin Sodium 40 mg SC QPM
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 40 mg SQ once a day Disp #*24
Syringe Refills:*0
7. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
8. Senna 17.2 mg PO BID
9. Vancomycin Oral Liquid ___ mg PO BID
10. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left displaced femoral neck fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: HIP 1 VIEW
INDICATION: Hemiarthroplasty.
TECHNIQUE: Single AP view of the left hip.
COMPARISON: None.
FINDINGS:
The patient is status post left hip pain hemiarthroplasty in overall anatomic
alignment on this single AP view. No periarticular fracture is detected.
Overlying subcutaneous emphysema is consistent with recent surgery.
Radiology Report
EXAMINATION: PELVIS (AP ONLY)
INDICATION: assess for fx
TECHNIQUE: Frontal view of the pelvis.
COMPARISON: Abdominal radiograph dated ___.
FINDINGS:
There is a transcervical fracture through the left femoral neck with impaction
and foreshortening. Degenerative changes are seen at the bilateral
femoroacetabular joints. No radiopaque foreign bodies or subcutaneous gas.
Possible rectal prolapse.
IMPRESSION:
Impacted transcervical fracture through the left femoral neck.
Radiology Report
INDICATION: History: ___ with likely hip fx // Eval pre-op
TECHNIQUE: Frontal chest radiograph.
COMPARISON: Chest x-ray dated ___.
FINDINGS:
The lungs appear hyperinflated. Re- demonstrated is asymmetrical thickening
of the bilateral apical margins, right greater than left. The heart is not
enlarged. Calcifications are again seen at the aortic knob. No pneumothorax,
pleural effusion, or consolidation.
IMPRESSION:
1. No acute cardiopulmonary process.
2. Asymmetrical thickening of apical margins, right greater than left.
3. Hyperinflated lungs consistent with COPD.
Radiology Report
EXAMINATION: FEMUR (AP AND LAT) LEFT
INDICATION: History: ___ with left hip pain after fall // assess for fx
assess for fx
TECHNIQUE: Frontal and lateral radiographs of the left femur.
COMPARISON: Radiographs of the pelvis dated ___
FINDINGS:
There is an impacted transcervical fracture of the left femoral neck. There
is associated foreshortening of the left femur. No additional fractures are
identified. Limited views of the left knee demonstrate mild tricompartmental
degenerative change. No knee joint effusion.
IMPRESSION:
Impacted transcervical fracture of the left femoral neck.
Radiology Report
EXAMINATION: CT L-SPINE W/O CONTRAST Q331 CT SPINE
INDICATION: ___ with back pain after a fall. Assess for fracture.
TECHNIQUE: Non-contrast helical multidetector CT was performed.Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Spiral Acquisition 6.6 s, 25.6 cm; CTDIvol = 32.0 mGy (Body) DLP = 818.2
mGy-cm.
Total DLP (Body) = 818 mGy-cm.
COMPARISON: Abdominal radiograph ___, pelvic radiograph ___.
FINDINGS:
Alignment is normal. No acute fractures are identified. Multiple
degenerative changes are seen throughout the lumbar spine with anterior
osteophytes, disc space narrowing and subchondral sclerosis. Multilevel
vacuum disc phenomenon is also noted. There is no prevertebral soft tissue
swelling. There is no evidence of infection or neoplasm.
T12-L1: Mild degenerative changes.
L1-L2: No significant spinal canal or neural foraminal narrowing.
L2-L3: Small posterior disc protrusion and intervertebral osteophytes results
in mild canal narrowing. There is mild bilateral neural foraminal narrowing.
L3-L4: Small posterior disc protrusion and intervertebral osteophytes with
bilateral ligamentum flavum thickening causing moderate canal narrowing and
mild left neural foraminal narrowing.
L4-L5: Moderate posterior disc osteophyte complex with mild ligamentum flavum
thickening causing moderate canal narrowing and moderate narrowing of the left
neural foramina and mild right neural foraminal.
L5-S1: A disc protrusion results in mild spinal canal narrowing. There is
mild bilateral neural foraminal narrowing.
Limited assessment of lung bases are notable for bilateral lower lobe
emphysematous changes. Prominent atherosclerotic calcification of the
abdominal aorta and iliac vessels are noted. There is long segment ectasia of
the infrarenal abdominal aorta measuring up to 2 cm in diameter. Focal
outpouchings of the abdominal aorta proximal to the iliac bifurcation is noted
(series 601b, image 34)
IMPRESSION:
1. Multilevel degenerative changes most notable at L3-L4 and L4-L5 causing
moderate canal narrowing and mild to moderate left neural foraminal narrowing.
2. No acute fracture or acute malalignment.
3. Ectasia of the infrarenal abdominal aorta measuring up to 2 cm with
prominent atherosclerotic calcifications are noted.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, L Hip pain
Diagnosed with Oth fracture of head and neck of left femur, init, Fall same lev from slip/trip w/o strike against object, init
temperature: 96.5
heartrate: 72.0
resprate: 20.0
o2sat: 100.0
sbp: 147.0
dbp: 51.0
level of pain: 10
level of acuity: 3.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have Left displaced femoral neck fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for Left hip hemiarthoplasty, which
the patient tolerated well. For full details of the procedure
please see the separately dictated operative report. The patient
was taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to rehab
was appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
WBAT in the LL extremity, and will be discharged on lovenox for
DVT prophylaxis. The patient will follow up with Dr.
___ trauma per routine. A thorough discussion was had
with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percocet
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a ___ with history significant for gastric bypass
(Roux en Y) ___ at ___ who presents to ___ with a several day
history of abdominal pain. She had been in her usual state of
health until ___ days ago when she began to have abdominal
discomfort in her upper abdominal area. Of note she had been
taking 1 tab of motrin qhs for 3 nights for knee pain about 5
days ago. Her pain was not precipitated by anything in
particular
and she has had no nausea, vomiting, diarrhea or fever. It is
described as sharp, constant and severe, in the mid epigastric
area. Pain was exacerbated by eating yesterday but today did not
significantly change when she had clear liquids. Yesterday her
pain became so severe, rated ___, worse with any PO intake or
movement, prompting evaluation in the ED.
She had a CT abdomen that showed findings possibly consistent
with diverticulitis. She was seen by the bariatric surgery team
given her prior hx of gastric bypass who felt that her scan did
not show any findings consistent with obstruction/hernia, and
therefore admitted to the medical team for further workup. In
the
ED she received Pepcid and had PO contrast for her CT scan, she
is not sure if either of these helped with her pain but her pain
is substantially better (___) at this time. Did not take any
meds at home for the pain.
ROS: positive for abdominal pain and discomfort, decreased PO
intake, chills
ROS: negative for fever, n/v, diarrhea, chest pain, SOB, or any
other complaints
Remainder ROS negative unless stated above
ED Course:
Tylenol 1g po x1
Pepcid 20mg iv x1
Cipro 400mg iv x1
Flagyl 500mg iv x1
Past Medical History:
Gastric bypass ___ at ___
Diabetes (now off meds since bypass surgery)
Hypertension
Thyroid nodules
OSA on CPAP
Hyperparathyroidism
Obesity
History of anemia
Social History:
___
Family History:
Father - hypertension
Mother - diabetes
Physical Exam:
ADMISSION PHYSICAL EXAM:
T 98.2, BP 132/83, HR 44, RR 18, O2 97% RA
Gen - no distress, sitting up in bed, appears a bit
uncomfortable
HEENT - nc/at, moist mucous membranes, no oropharyngeal lesion
or
erythema
Neck - supple, no LAD
___ - bradycardic, regular rhythm, s1/2, +soft ___ systolic
murmur best heard LUSB
Lungs - cta b/l, no w/r/r
Abd - soft, non distended, slightly tender in epigastric area,
no
rebound/guarding/rigidity, no palpable masses, +bowel sounds in
all quadrants
Ext - no peripheral edema or cyanosis
Skin - warm, dry, no rashes
Psych - calm, cooperative
DISCHARGE PHYSICAL EXAM:
VS: afebrile, HDS
Gen: no distress, sitting up in bed, appears a bit uncomfortable
HEENT: nc/at, moist mucous membranes, no oropharyngeal lesion or
erythema
Neck: supple, no LAD
___: bradycardic, regular rhythm, s1/2, +soft ___ systolic
murmur best heard LUSB
Lungs: cta b/l, no w/r/r
Abd: soft, non distended, slightly tender in lower mid abdomen,
no
rebound/guarding/rigidity, no palpable masses, +bowel sounds in
all quadrants
Ext: no peripheral edema or cyanosis
Skin: warm, dry, no rashes
Psych: calm, cooperative
Pertinent Results:
ADMISSION LABS:
___ 12:03AM BLOOD WBC-6.9 RBC-3.34* Hgb-10.5* Hct-31.4*
MCV-94 MCH-31.4 MCHC-33.4 RDW-12.3 RDWSD-42.5 Plt ___
___ 12:03AM BLOOD Plt ___
___ 12:03AM BLOOD Glucose-123* UreaN-17 Creat-0.7 Na-144
K-4.2 Cl-108 HCO3-27 AnGap-9*
___ 12:03AM BLOOD ALT-14 AST-15 AlkPhos-92 TotBili-0.7
___ 12:03AM BLOOD Lipase-17
___ 12:03AM BLOOD Albumin-4.0
___ 12:06AM BLOOD Lactate-0.9
DISCHARGE LABS:
___ 06:06AM BLOOD WBC-5.2 RBC-3.53* Hgb-11.1* Hct-33.0*
MCV-94 MCH-31.4 MCHC-33.6 RDW-12.3 RDWSD-42.3 Plt ___
___ 06:06AM BLOOD ___
___ 06:06AM BLOOD Glucose-98 UreaN-9 Creat-0.7 Na-145 K-3.8
Cl-105 HCO3-27 AnGap-13
___ 06:06AM BLOOD ALT-11 AST-13 AlkPhos-83 TotBili-0.8
___ 06:06AM BLOOD Calcium-8.6
MICRO:
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-Coag
Negative Staph
___ URINE URINE CULTURE-FINAL {ESCHERICHIA COLI}
CT A/P ___:
Relative increased fat stranding surrounding a segment of distal
descending colon with several diverticula and slightly thickened
walls, may represent early diverticulitis in the appropriate
clinical setting.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO QHS
2. Hydrochlorothiazide 25 mg PO QHS
3. Vitamin D2 (ergocalciferol (vitamin D2)) 50,000 unit oral
2X/WEEK
4. Magnesium Oxide Dose is Unknown PO Frequency is Unknown
5. Cyanocobalamin Dose is Unknown PO Frequency is Unknown
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain
RX *acetaminophen 325 mg 2 tablet(s) by mouth every 6 hours Disp
#*60 Tablet Refills:*0
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice
daily Disp #*14 Tablet Refills:*0
3. MetroNIDAZOLE 500 mg PO TID
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every 8
hours Disp #*21 Tablet Refills:*0
4. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
5. Cyanocobalamin 100 mcg PO DAILY
6. Hydrochlorothiazide 25 mg PO QHS
7. Lisinopril 40 mg PO QHS
8. Magnesium Oxide 400 mg PO DAILY
9. Vitamin D2 (ergocalciferol (vitamin D2)) 50,000 unit oral
2X/WEEK
Discharge Disposition:
Home
Discharge Diagnosis:
Diverticulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with gastric bypass now with 3 days of abdominal pain+PO
contrast// ? marginal ulcer ? SBo ? internal hernia
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were
acquired through the abdomen and pelvis following intravenous contrast
administration with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 1,481 mGy-cm.
COMPARISON: CT abdomen pelvis ___.
FINDINGS:
LOWER CHEST: There is mild bibasilar dependent atelectasis. 2 mm left lower
lobe subpleural nodule is unchanged since ___ (02:10). Otherwise, the
remaining visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: Patient is status post gastric bypass surgery Roux-en-Y with
postsurgical changes and intact anastomosis. Otherwise, stomach is
unremarkable. Small bowel loops demonstrate normal caliber, wall thickness,
and enhancement throughout. The appendix is normal.
There is mild diffuse mesenteric stranding throughout the abdomen. However,
there is an area of relatively increased fat stranding surrounding a segment
of distal descending colon with several diverticula and slightly thickened
walls which may represent early diverticulitis in the appropriate clinical
setting (02: 50, 51, 53).
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus and bilateral adnexae are within normal
limits.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: Again visualized, is prominence of the bilateral gonadal veins with
multiple calcified phleboliths. There is no abdominal aortic aneurysm. Mild
atherosclerotic disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Stable multilevel degenerative changes of the visualized thoracolumbar spine
are noted.
SOFT TISSUES: There is a small fat containing umbilical hernia. Otherwise,
the abdominal and pelvic wall is within normal limits.
IMPRESSION:
Relative increased fat stranding surrounding a segment of distal descending
colon with several diverticula and slightly thickened walls, may represent
early diverticulitis in the appropriate clinical setting.
NOTIFICATION: Changes to initial preliminary impression was discussed with
___, M.D. by ___, M.D. on the telephone on ___ at 9:09
am, 30 minutes after discovery of the findings.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with Dvtrcli of lg int w/o perforation or abscess w/o bleeding, Unspecified abdominal pain
temperature: 98.2
heartrate: 86.0
resprate: 18.0
o2sat: 100.0
sbp: 166.0
dbp: 82.0
level of pain: 10
level of acuity: 3.0 | ___ hx gastric bypass ___ at ___, diabetes now off meds, Htn,
hyperparathyroidism, thyroid nodules, OSA on CPAP, hx anemia now
presents with ___ days of abdominal pain, with CT findings
suggestive of diverticulitis.
#Abdominal pain, lower midabdomen
Pt presented with ___ days of constant abdominal pain in her
midabdomen. Not worsened with food or movement. Pt also denied
any melena/hematochezia, emesis or fevers/chills. Exam notable
for TTP in lower mid-abdomen. She underwent a CT a/p which
showed likely diverticulitis. Doubt marginal ulcer as location
of pain and tenderness was lower than that of epigastrum. She
was started on a PPI, and abx with improvement in pain. She
will be discharged with a PPI for a few weeks, and 7d days of
cipro/flagyl to complete course for uncomplicated
diverticulitis. She was tolerating a regular diet without
recurrence of pain on discharge. Also prescribe Simethicone for
chronic bloating/gas.
# Blood culture with coag negative staph
___ blood culture bottles from admission growing coag negative
staph. All subsequent blood cultures were NGTD on discharge.
Pt otherwise afebrile with no leukocytosis. Felt to be most
likely a contaminant.
# ?UTI
Pt had >100K e.coli growing in her urine. UA however, negative
and pt denied urinary symptoms. Will be treated either way with
abx for diverticulitis above.
Greater than 30 minutes spent on discharge counseling and
coordination of care. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
azathioprine / Bactrim
Attending: ___.
Chief Complaint:
___ edema
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w/ recently diagnosed autoimmune hepatitis, h/o breast CA
s/p surgery/radiation, p/w ___ edema.
Of note, pt was recently hospitalized at ___
___ from ___ through ___. EGD showed
clean based gastric ulcer w/ negative H. pylori, pt was treated
with PPI. with regards to jaundice, she had had a liver biopsy,
which showed moderate to focal severe portal, periportal and
central perivenular inflammation with focal bridging consisting
of lymphocytes, plasma cells and focally prominent eosinophils
and scattered neutrophils with significant necrosis and collapse
with grade III inflammation. There was also focal perivenulitis
with mild hemorrhage and glandular bile duct proliferation with
associated neutrophils with minimal steatosis and negative
stains for CMV and HSV. It was felt that this is due to
autoimmune hepatitis. There was no drug implicated and she was
started on prednisone 40 mg with improvement in her liver
chemistries.
She subsequently had her prednisone tapered to 30 mg on
___ and down to 20 mg on ___. Azathioprine was
started on the ___. She has continued to have
persistently improvement in her liver chemistries.
Unfortunately, she then developed a significant rash after
starting azathioprine on the ___, three days after
starting azathioprine, she noted an erythematous blanching rash
on her chest and back. It progressed to involve her face, arms
and legs. From the ___, her azathioprine was discontinued, but
she continued to have progression of her rash along with
significant itching. There were no fevers or chills. She had
also been on Bactrim for PCP prophylaxis in the setting of high
prednisone dosing and this was discontinued on the ___
___.
She saw her hepatologist on ___, At the visit, pt had
erythematous blanching lesions over her entire face, chest and
back. Her face also has been swollen. There have been no fevers
or chills, although she does feel thirsty. She also has a
blotchy rash over her arms and legs and says that it is
involving almost her entire body. There has been no obvious
mucosal involvement of the eyes, tongue or ropharynx. There has
been no difficulty with swallowing. No dysuria or hematuria. No
GI bleeding or diarrhea. No abdominal pain, nausea or vomiting.
In past few days, pt had gained ___ lbs (dry weight is 139
lbs). Significant lower extremity edema. Pt denies SOB, DOE, or
orthopnea.. Pt called her hepatologist, who was concerned for
high output heart failure in setting of erythroderma. Dr. ___
___ hepatologist) advised patient to come to ___ ER for
evaluation and admission for fluid management and further
evaluation of full body rash.
Of note, her hepatologist also increased prednisone back up to
40mg daily in the past 2 days. Her home omeprazole has also been
discontinued.
Past Medical History:
1. History of breast cancer, status post lumpectomy and
radiation in ___.
2. Autoimmune hepatitis.
Social History:
___
Family History:
Mother died of breast cancer in ___.
Father died of lymphosarcoma in ___.
No known liver disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.8 143/75 83 20 98RA
General: pleasant Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, no sloughing of
mucosal surfaces, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi; very trace crackles at base
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
SKIN: diffusely erythematous w/ drying.
Ext: Warm, well perfused, 2+ pulses, b/l edema
Neuro: non-focal
DISCHARGE PHYSICAL EXAM:
Vitals: T: 97.8 BP:143/75 P:83 R:20 O2:93RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, eyes not
erythematous
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Diffused, generalized, blanching erythematous rash that is
coalescent on face, neck, trunk and extremities with area of
fine desquamation.
Neuro: A&Ox3. CNII-XII intact. Strength ___ throughout.
Pertinent Results:
ADMISSION LABS:
---------------
___ 06:15PM BLOOD WBC-6.5 RBC-3.76* Hgb-11.9 Hct-36.0
MCV-96 MCH-31.6 MCHC-33.1 RDW-14.5 RDWSD-50.5* Plt ___
___ 06:15PM BLOOD Neuts-81.4* Lymphs-11.6* Monos-5.1
Eos-0.0* Baso-0.5 Im ___ AbsNeut-5.28 AbsLymp-0.75*
AbsMono-0.33 AbsEos-0.00* AbsBaso-0.03
___ 06:15PM BLOOD ___ PTT-26.6 ___
___ 06:15PM BLOOD Glucose-214* UreaN-18 Creat-0.6 Na-138
K-4.4 Cl-104 HCO3-23 AnGap-15
___ 06:15PM BLOOD ALT-32 AST-21 AlkPhos-95 TotBili-1.3
___ 06:15PM BLOOD Albumin-3.7
DISCHARGE LABS:
---------------
___ 06:30AM BLOOD WBC-5.2 RBC-3.21* Hgb-10.2* Hct-30.5*
MCV-95 MCH-31.8 MCHC-33.4 RDW-14.3 RDWSD-49.5* Plt ___
___ 06:30AM BLOOD Glucose-82 UreaN-14 Creat-0.6 Na-139
K-3.9 Cl-105 HCO3-26 AnGap-12
___ 06:30AM BLOOD ALT-23 AST-22 AlkPhos-81 TotBili-0.9
___ 06:30AM BLOOD Calcium-8.6 Phos-3.7 Mg-2.0
MICROBIOLOGY:
-------------
___ Urine culture - Negative
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 40 mg PO DAILY
2. TraZODone 50 mg PO QHS:PRN insomnia
Discharge Medications:
1. PredniSONE 30 mg PO DAILY
2. TraZODone 50 mg PO QHS:PRN insomnia
3. Ranitidine 150 mg PO BID
RX *ranitidine HCl 150 mg 1 tablet(s) by mouth Twice a day Disp
#*60 Tablet Refills:*0
4. Outpatient Lab Work
Please obtain a CHEM7 between ___ for the
diagnosis of hypokalemia (ICD10 ___.6)
Fax to ___ ATTN Dr. ___
5. Cetirizine 10 mg PO DAILY
RX *cetirizine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
6. Hydrochlorothiazide 25 mg PO DAILY
RX *hydrochlorothiazide 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
7. Hydrocortisone Cream 1% 1 Appl TP BID
RX *hydrocortisone 1 % Apply to face Twice daily Refills:*0
8. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID
RX *triamcinolone acetonide 0.1 % Apply to body twice a day
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
Edema
Secondary diagnosis:
Drug eruption, autoimmune hepatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with autoimmune hepatitis p/w ___ edema, shortness of breath.
Evaluate for pneumonia, pulmonary edema, or effusions.
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest x-ray from ___.
FINDINGS:
The lungs are well inflated and clear. The cardiomediastinal silhouette and
hilar contours are normal. There is no pleural effusion or pneumothorax.
Right axillary surgical clips are noted. Severe degenerative changes are
noted at the left glenohumeral joint with deformity of the humeral head.
IMPRESSION:
No acute cardiopulmonary process.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Leg swelling
Diagnosed with Edema, unspecified
temperature: 98.0
heartrate: 87.0
resprate: 18.0
o2sat: 100.0
sbp: 150.0
dbp: 72.0
level of pain: 0
level of acuity: 3.0 | ___ w/ recently diagnosed autoimmune hepatitis, h/o breast CA
s/p surgery/radiation, p/w ___ edema in the setting of ongoing
steroid use and drug eruption.
# Bilateral ___ edema: Pt had acute onset ___ edema w/7 lbs weight
gain. No signs of L sided heart failure. Albumin was >3, so
unlikely ___ low oncotic pressure. Most likely etiology is ___
steroid use vs. right heart etiology. Swelling improved with
diuresis with HCTZ. Furosemide was not used ___ sulfa moiety and
possible sulfa allergy causing rash. Derm consulted and do not
think that this edema is ___ inflammatory state and rash. Her
prednisone dose was reduced and she was sent home on ___ with
hepatology follow up.
# Drug rash/Erythroderma: Pt has had a diffuse edematous rash
with no mucoal involvement for weeks. It was suspected that this
is a drug eruption that was caused by either azathioprine
(started for immunosuppression in AI-hepatitis) or Bactrim
(started for PCP ___. Omeprazole had also been recently started
and is a possible contributor. All three meds were discontinued
prior to admission. Dermatology was consulted and agreed that
this is most consistent with a drug reaction. They recommended
regimen of Triamcinalone 0.1% ointment for body, hydrocortisone
cream for face. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Celebrex / Aspirin
Attending: ___.
Chief Complaint:
R hip pain
Major Surgical or Invasive Procedure:
ORIF R intertrochanteric hip fracture (Gamma nail)
History of Present Illness:
___ mechanical fall while walking to restroom this afternoon.
Had immediate right hip pain, denies head strike, (-)LOC,
reports pain at right ankle from recent fall where she suffered
minimally displaced bimalleolar ankle fracture (___)
treated in ankle stirrups. Brought to ED, orthopaedic surgery
consulted for evaluation and treatment of right hip pain. Of
note was briefly hypotensive in ED ___ brief vasovagal episode.
Past Medical History:
- Osteoarthritis
- Coronary artery disease, unstable angina, daily nitrates
- Osteoporosis
- Hypertension
- Hyperlipidemia, in the context of a fall stopped both
metoprolol and statin - unclear if proximal weakness and
orthostasis suspected
- Hearing loss, severe, uses hearing aids, right ear best
- Pseudogout
- B12 deficiency
- Urinary incontinence, four children, surgery improved
continence, but now completely incontinent of urine (for several
years)
- Cataracts
- Tonsillectomy
- Appendectomy
- Numerous basal cell carcinoma - due to stop ASA today for
biopsy of right eye lid
- Cystocele
- Sick sinus syndrome, daughter endorses atrial fibrillation,
never anticoagulated, antiplatelet only (prior ASA, then Plavix,
now ASA 81 mg three times per week)
- Chronic constipation
- Oophorectomy, ___
Social History:
___
Family History:
NC
Physical Exam:
VS: AVSS
Gen: NAD, AAO x 3
CV: RRR
Pulm: Non-labored breathing
MSK:
RLE skin clean and intact
Leg externally rotated and slightly shortened. Compartments soft
No pain with passive motion at knee
Pain with passive motion at ankle
Saph Sural DPN SPN MPN LPN ___ FHL ___ TA PP Fire
1+ ___ and DP pulses
Pertinent Results:
AP Pelvis/ R hip: 3 part intertrochanteric fracture of the right
hip with displacement of postero-medial cortex.
___ 07:20PM WBC-10.6# RBC-3.31* HGB-10.4* HCT-30.9*
MCV-93 MCH-31.6 MCHC-33.8 RDW-13.0
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 5 mg PO DAILY
2. Furosemide 20 mg PO EVERY OTHER DAY
3. Nitroglycerin Patch 0.2 mg/hr TD Q24H
1.5 patches once a day. Leave on for 12 hours
4. Pravastatin 20 mg PO DAILY
5. Tiotropium Bromide 1 CAP IH DAILY
6. Aspirin 81 mg PO MWF
7. Omeprazole 20 mg PO DAILY
8. Docusate Sodium 100 mg PO BID
9. Cyanocobalamin 100 mcg PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. Ascorbic Acid ___ mg PO DAILY
Discharge Medications:
1. Ascorbic Acid ___ mg PO DAILY
2. Aspirin 81 mg PO MWF
3. Cyanocobalamin 100 mcg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Furosemide 20 mg PO EVERY OTHER DAY
6. Lisinopril 5 mg PO DAILY
7. Nitroglycerin Patch 0.2 mg/hr TD Q24H
1.5 patches once a day. Leave on for 12 hours
8. Pravastatin 20 mg PO DAILY
9. Tiotropium Bromide 1 CAP IH DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. Acetaminophen 650 mg PO Q6H
12. Calcium Carbonate 500 mg PO TID
13. Enoxaparin Sodium 30 mg SC Q24H
14. Omeprazole 20 mg PO DAILY
15. Senna 1 TAB PO BID
16. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
R intertrochanteric hip fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY:
Right hip deformity after fall.
TECHNIQUE: AP view of the pelvis, 2 views of the right hip.
COMPARISON: ___.
FINDINGS:
Diffuse demineralization of the osseous structures is noted. Comminuted right
intertrochanteric femoral neck fracture is present with mild distraction of
the dominant distal fracture fragment and medial displacement of the fracture
fragment containing the lesser trochanter. There is slight varus angulation.
There is no dislocation identified. Degenerative changes within the hips are
mild to moderate with joint space narrowing and mild osteophyte formation.
There is no diastasis of the pubic symphysis or sacroiliac joints.
Calcifications within the right upper quadrant of the abdomen likely reflect
gallstones. There are scattered vascular calcifications.
IMPRESSION:
Comminuted right intertrochanteric femoral neck fracture.
Radiology Report
HISTORY: Fall.
TECHNIQUE: Supine AP view of the chest.
COMPARISON: Chest CTA ___ and chest radiograph ___.
FINDINGS:
Moderate cardiomegaly is re- demonstrated. Tortuosity of the thoracic aorta
with diffuse atherosclerotic calcifications is again noted. The hilar
contours are unchanged, and there is no pulmonary vascular congestion.
Streaky left basilar opacity likely reflects atelectasis, with an irregular
nodular opacity measuring 5 mm noted in the right lung base. There is no
focal consolidation, pleural effusion or pneumothorax. No displaced rib
fractures are identified.
IMPRESSION:
Streaky opacity in the left lung base likely reflective of atelectasis. 5 mm
irregular nodular opacity in the right lung base is nonspecific, and could be
further assessed with shallow obliques to determine if this is a true
pulmonary nodule or summation of shadows.
Radiology Report
HISTORY: ___ female with known fracture, assessment prior to traction
for femoral Fx.
COMPARISON: None available.
Three views of the right ankle were obtained. An oblique fracture is seen
through the right distal fibula with minimal displacement and extesioninto
ankle joint. The ankle mortise is congruent with talus. Prominent geralized
demineralization consistent with ___. Incidental degenerative changes in
several TMT joints.
Radiology Report
STUDY: Right femur, ___.
CLINICAL HISTORY: Patient with right hip ORIF.
FINDINGS: Single AP view of the right femur demonstrates a fracture of the
intertrochanteric region of the right proximal femur. There is a displaced
lesser trochanter fracture fragment. There is varus angulation at the
proximal femur due to the fracture. No additional fractures are seen. There
are severe degenerative changes of the knee joint with marked loss of joint
space and spurring. Vascular calcifications are also seen.
Radiology Report
STUDY: RIGHT HIP INTRAOPERATIVE STUDY, ___.
CLINICAL HISTORY: Patient with right dynamic hip screw placement.
FINDINGS: Comparison is made to the prior study from ___ at 4:24
p.m.
Several images of the right hip demonstrate interval placement of a short
intramedullary rod with proximal pin and distal interlocking screw. This is
fixating an intertrochanteric fracture of the right proximal femur. There is
improved anatomic alignment. There remains a displaced lesser trochanter
fracture fragment. The total intraservice fluoroscopic time was 92.8 seconds.
Radiology Report
HISTORY: ORIF.
FINDINGS: In comparison with study of ___, there has been placement of a
gamma nail and intramedullary rod across the previously described
intertrochanteric fracture. Separation of the lesser trochanter is again
seen.
Standard post-surgical changes in soft tissues.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: RIGHT HIP PAIN
Diagnosed with INTERTROCHANTERIC FX-CL, UNSPECIFIED FALL
temperature: 98.7
heartrate: 73.0
resprate: 16.0
o2sat: 97.0
sbp: 200.0
dbp: 69.0
level of pain: 6
level of acuity: 3.0 | The patient was admitted to the orthopaedic surgery service on
___ with R intertrochanteric hip fracture. Patient was taken
to the operating room and underwent ORIF R intertroch hip
fracture (short gamma nail). Patient tolerated the procedure
without difficulty and was transferred to the PACU, then the
floor in stable condition. Please see operative report for full
details.
Musculoskeletal: prior to operation, patient was NWB RLE.
After procedure, patient's weight-bearing status was
transitioned to WBAT RLE. Throughout the hospitalization,
patient worked with physical therapy.
Neuro: post-operatively, patient's pain was controlled by
oxycodone and morphine and was subsequently transitioned to
tylenol with good effect and adequate pain control.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Hematology: The patient was transfused 2 units of blood
intraoperatively and an additional 3 units post-operatively for
acute blood loss anemia.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
GI/GU: A po diet was tolerated well. Patient was also started
on a bowel regimen to encourage bowel movement. Intake and
output were closely monitored.
ID: The patient received perioperative antibiotics. The
patient's temperature was closely watched for signs of
infection.
Prophylaxis: The patient received enoxaparin during this stay,
and was encouraged to get up and ambulate as early as possible.
At the time of discharge on ***, POD #***, the patient was
doing well, afebrile with stable vital signs, tolerating a
regular diet, ambulating, voiding without assistance, and pain
was well controlled. The incision was clean, dry, and intact
without evidence of erythema or drainage; the extremity was NVI
distally throughout. The patient was given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient will be continued on chemical DVT
prophylaxis for 2 weeks post-operatively. All questions were
answered prior to discharge and the patient expressed readiness
for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / Iodine / Amoxicillin
Attending: ___
Chief Complaint:
left chest wall pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old female admitted as basic trauma. She was transferred
from ___ s/p MVC at approx. 15mph where patient was
restrained passenger.
Head/c-spine CT negative, c-spine cleared PTA. Chest CT with
left rib fractures x4. No pulmonary contusions appreciated. Pt
transferred for trauma eval.
Past Medical History:
PMH: R breast ca, HTN, hyperlipidemia, GERD
PSH: wisdom tooth extraction
Social History:
___
Family History:
Her family history is significant for paternal aunt
who had breast cancer at ___ and died at ___. There is no other
known family history of breast or ovarian cancer.
Physical Exam:
___
Physical examination:
General: Calm (No Distress), Alert, Well Developed, Well
Nourished. Psycho-Social: Eye Contact,
Normal Affect, Cooperative, Normal Speech, Lives with Family,
___, Normal Ideations. Respiratory:
left rib fx x4. No Resp Distress, Airway Intact.
Cardio-Vascular: Normal Rate, Rhythm is Regular,
Chest Pain, left chest TTP, No Pedal Edema. Neurological: Alert,
Oriented X3, No Gross Weakness,
Facial Symmetry. Skin: Warm, Dry, Pink. Gastro-Intestinal: Not
Tender, No Distension. Musculo-
Skeletal: ambulatory after MVC. No Deformity or Swelling Noted,
Full ROM in all Extremities. Behavior:
Appearance: clean/neat. Orientation: oriented to
person/place/time. Affect: calm.
Physical examination upon discharge: ___:
GENERAL: NAD
CV: ns1, s2
LUNGS: clear
ABDOMEN: soft, non-tender
EXT: no pedal edema bil, no calf tenderness bil
NEURO: alert and oriented x 3, speech clear
Pertinent Results:
___ 06:30AM BLOOD WBC-6.4 RBC-4.03 Hgb-12.7 Hct-39.2 MCV-97
MCH-31.5 MCHC-32.4 RDW-12.2 RDWSD-43.8 Plt ___
___ 03:20PM BLOOD WBC-7.2 RBC-3.92 Hgb-12.4 Hct-37.7 MCV-96
MCH-31.6 MCHC-32.9 RDW-12.3 RDWSD-43.6 Plt ___
___ 11:34PM BLOOD WBC-14.8* RBC-4.10 Hgb-13.0 Hct-38.3
MCV-93 MCH-31.7 MCHC-33.9 RDW-11.9 RDWSD-40.9 Plt ___
___ 06:30AM BLOOD Plt ___
___ 06:30AM BLOOD ___
___ 06:30AM BLOOD Glucose-102* UreaN-10 Creat-0.7 Na-141
K-4.9 Cl-101 HCO3-25 AnGap-15
___ 06:30AM BLOOD Calcium-9.7 Phos-3.8 Mg-2.2
___ 11:34PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-17
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 11:41PM BLOOD Glucose-97 Lactate-1.8 Na-135 K-4.1
Cl-100 calHCO3-24
___ 11:41PM BLOOD freeCa-1.08*
___: CXR:
No pneumothorax.
___: CXR:
Subtle haziness of the left costo-phrenic angle may be due to
overlying soft tissue versus atelectasis versus small pleural
effusion. If patient able, PA and lateral views of the chest
would be helpful for further assessment.
Known left-sided rib fractures were better seen on recent prior
CT, a more
sensitive study.
___: cxr
In comparison with the study of ___, there is little
interval change.
Cardio-mediastinal silhouette is within normal limits and there
is no evidence of acute pneumonia, vascular congestion, or
pleural effusion. In continued blunting of the costo-phrenic
angle on the frontal view most likely reflect pleural
thickening. In the known left rib fractures were much better
seen on recent prior CT. Multiple surgical clips are again seen
in the right breast.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clopidogrel 75 mg PO DAILY
2. Lisinopril 40 mg PO DAILY
3. amLODIPine 2.5 mg PO DAILY
4. Atorvastatin 20 mg PO QPM
5. Ranitidine 300 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Ranitidine 150 mg PO QHS:PRN GERD
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO BID
3. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine 5 % apply to left rib cage once a day Disp #*6
Patch Refills:*0
4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
do not drive while on this medication, may cause drowsiness
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*10 Tablet Refills:*0
5. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
6. Senna 8.6 mg PO BID:PRN Constipation - First Line
7. amLODIPine 2.5 mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Atorvastatin 20 mg PO QPM
10. Clopidogrel 75 mg PO DAILY
11. Lisinopril 40 mg PO DAILY
12. Ranitidine 300 mg PO DAILY
13. Ranitidine 150 mg PO QHS:PRN GERD
Discharge Disposition:
Home
Discharge Diagnosis:
MVC: left sided rib fractures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ s/p MVC w left sided rib fractures on Plavix.// ? interval
changes
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
FINDINGS:
Subtle haziness overlying the left costophrenic angle may be due to overlying
soft tissue versus atelectasis versus small pleural effusion. If patient
able, PA and lateral views of the chest would be helpful for further
assessment.
No focal consolidation is seen elsewhere. There is no evidence of
pneumothorax. The cardiac and mediastinal silhouettes are stable.
Known left-sided rib fractures were better seen on recent prior CT.
Multiple surgical clips are again seen overlying the right hemithorax.
IMPRESSION:
Subtle haziness of the left costophrenic angle may be due to overlying soft
tissue versus atelectasis versus small pleural effusion. If patient able, PA
and lateral views of the chest would be helpful for further assessment.
Known left-sided rib fractures were better seen on recent prior CT, a more
sensitive study.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ hx of TIA on Plavix presents after MVC with ___ L rib
fractures// ? interval change on upright PA/L CXR
IMPRESSION:
In comparison with the study of ___, there is little interval change.
Cardiomediastinal silhouette is within normal limits and there is no evidence
of acute pneumonia, vascular congestion, or pleural effusion. In continued
blunting of the costophrenic angle on the frontal view most likely reflect
pleural thickening. In the known left rib fractures were much better seen on
recent prior CT. Multiple surgical clips are again seen in the right breast.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: MVC, Transfer
Diagnosed with Multiple fractures of ribs, left side, init for clos fx, Car passenger injured in collision w car in traf, init, Long term (current) use of anticoagulants
temperature: 98.4
heartrate: 79.0
resprate: 16.0
o2sat: 100.0
sbp: 108.0
dbp: 69.0
level of pain: 0
level of acuity: 2.0 | ___ year old female who was a restrained passenger involved in an
MVC resulting in ___ left sided rib fractures. Initially
evaluated at an outside hospital and transferred here for
management. Imaging of the cervical spine and head were
negative. Chest cat scan showed left sided rib fractures.
Upon admission, the patient was made NPO, and given intravenous
fluids. Her rib pain was controlled with oral analgesia and she
underwent serial chest x-rays. She was instructed in the use
of the incentive spirometer.
The patient was discharged home on HD #3. Her vital signs were
stable and she was afebrile. She was tolerating a regular diet
and voiding without difficulty. Discharge instructions were
reviewed. An appointment for follow-up was made with her
primary care provider. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left leg pain
Major Surgical or Invasive Procedure:
___ placement
History of Present Illness:
Pt is a ___ with h/o CAD s/p CABG in ___, HTN,
hypercholesterolemia and COPD who presents for 1 week of LLE
erythema, edema, and pain. The patient notes he began
experiencing bilateral toe pain last ___ associated with
erythema and swelling. He applied some cream to his feet, but
his pain continued and he reports that some of his toes and
bottoms of both feet began to drain fluid and smell bad. On
___, patient reports that he vacuumed his home after some
flooding; the patient reports that he did not wear shoes as he
usually does, and afterwards on ___, noted that his LLE
swelling and pain had progressed. Since then, his LLE continued
to worsen, with swelling and pain extending to his knee and
medial groin. Over the past week, the patient also developed
fevers to 102 and chills with no improvement with Tylenol. He
has only been able to walk with crutches at home. The patient
monitors his HR and noticed an increase of his HR from a
baseline of 60-70s to 80-90s. He was seen by his PCP yesterday
am who referred the pt to the ED for concern of DVT and
cellulitis.
In the ED, initial vital signs were 99.2 81 93/66 18 98%. Exam
was notable for an erythematous hot L leg w/ extension to knee
and medial thigh. Labs were notable for WBC 15.2, lactate 2.2,
Na 130. Left ___ was done and negative for DVT. Patient was
given 1 mg IV vancomycin x1 and admitted to ED observation. He
received a second dose of vancomycin, morphine, tylenol,
ibuprofen, unasyn, and his home medications (asa, simvastatin,
metoprolol, ranitidine, tiotroprium). Given lack of improvement
patient was admitted to medicine for further management. VS on
transfer were: 99.2 73 113/69 16 100%.
On the floor, T 98.5, BP 115/66, HR 78, RR 18, O2sat 99% on RA.
The patient reports that his LLE pain has improved from ___ at
admission to ___. He denies any pruritis, bug bites, recent
trauma to his lower extremities, any prior skin/soft tissue
infections, and also denies any pleuritic pain, CP, SOB. He
does report some dyspnea and wheezing at baseline, attributed to
his COPD. He also reports some chronic intermittent swelling of
his R big toe which he believes to be gout. He currently has
some pain and swelling of his ___ MTP joint.
Review of Systems:
(+) fever, chills, sweats, SOB, wheezing
(-) headache, vision changes, rhinorrhea, congestion, sore
throat, cough, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
Hypertension
Mild Hyperlipidemia
Vitamin D deficiency
Coronary artery by-pass graft x2 in ___ (LIMA to LAD, SVG to
OM)
CAD
COPD
Hypercholesterolemia
BPH
GERD
Social History:
___
Family History:
Reviewed. No pertinent family history
Physical Exam:
ADMISSION
Vitals- 98.5 115/66 78 18 99% on RA
General: Pleasant, NAD, mildly dyspneic
HEENT: MMM, NCAT
Neck: supple
Chest: well-healed scars from CABG
CV: RRR, normal S1 S2, no m/r/g
Lungs: no accessory muscle use, mildly dyspneic, CTAB, decreased
breath sounds, symmetric expansion of chest
Abdomen: soft, NTND, no organomegaly, + bowel sounds
GU: deferred
Ext: Koilonychia of nails in BUE, 1+ DP of LLE, 2+ DP of RLE,
erythema and edema of LLE extending from toes to knee and
improved to upper inner thigh but not groin, mild erythema of
RLE toes, scabbed over sites along bottoms of feet bilaterally,
- ___ sign bilaterally with no palpable cords, tenderness to
palpation of LLE, no crepitus along erythematous region
Neuro: AOx3
Skin: see Ext exam
DISCHARGE
Physical exam:
Vitals: Tm 98.4 Tc98.4 109/71 (109-120/71-82) 73 18 99% on RA
General: lying in bed, improved dyspnea
HEENT: MMM, NCAT
Neck: supple
Chest: well-healed scars from CABG
CV: RRR, normal S1 S2, no m/r/g
Lungs: no accessory muscle use, mildly dyspneic, CTAB, decreased
breath sounds, symmetric expansion of chest
Abdomen: soft, NTND, no organomegaly, + bowel sounds
GU: deferred
Ext: Koilonychia of nails in BUE, 1+ DP of LLE, 1+ DP of RLE,
improvement of patient's erythema and increased edema of LLE
only @ foot; pustules extending along LLE from ankle to knee,
improved erythema of RLE toes, scabbed over sites along bottoms
of feet bilaterally, - ___ sign bilaterally with no palpable
cords, tenderness to palpation of LLE, no crepitus along
erythematous region
Neuro: AOx3
Skin: see Ext exam
Pertinent Results:
Admission Labs:
___ 01:50PM BLOOD WBC-15.2*# RBC-4.52* Hgb-14.3 Hct-42.3
MCV-93 MCH-31.6 MCHC-33.8 RDW-12.6 Plt ___
___ 01:50PM BLOOD Neuts-88.9* Lymphs-6.3* Monos-4.4 Eos-0.2
Baso-0.2
___ 01:50PM BLOOD Glucose-134* UreaN-13 Creat-1.1 Na-130*
K-3.6 Cl-92* HCO3-26 AnGap-16
___ 06:45AM BLOOD Calcium-8.5 Phos-4.0 Mg-2.3
___ 02:03PM BLOOD Lactate-2.2*
Pertinent Interval Labs:
___ 06:45AM BLOOD CK-MB-2 cTropnT-<0.01
___ 03:00PM BLOOD CK-MB-2 cTropnT-<0.01
Reports:
L ___ ___:
No evidence of deep venous thrombosis in the left lower
extremity.
___:
ECG-Sinus rhythm. Anteroseptal ST-T wave abnormalities. Compared
to the previous tracing of ___ segment elevation
has resolved.
___:
LEFT ANKLE X-ray (AP,LAT,OBLIQUE)
No prior studies for comparison.
FINDINGS: Diffuse soft tissue swelling is present about the
ankle. No acute fracture or dislocation is evident, and there
are no radiographic findings to suggest the presence of
osteomyelitis. However, if there is strong clinical suspicion
for this diagnosis, MRI or bone scan may be considered.
Incidental note is made of a plantar calcaneal spur.
___:
CXR
Left PIC catheter tip projects over mid SVC. No pneumothorax.
Lung volumes are normal. There is minimal blunting of the left
costophrenic angle. Trace pleural effusion is likely. No right
pleural effusion. Hilar and mediastinal silhouettes are
unchanged. Heart is mildly enlarged. Intrathoracic aorta is
tortuous. Patient is status post medial sternotomy and CABG.
Partially imaged upper abdomen is unremarkable.
IMPRESSION:
Left PICC catheter tip projects over mid SVC.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium Carbonate 600 mg PO QD
2. Vitamin D 600 mg PO DAILY
3. Tiotropium Bromide 1 CAP IH DAILY
4. albuterol sulfate *NF* 90 mcg/actuation Inhalation two puffs
QID
2 puffs four times a day 15 minutes prior to physical activity.
5. Aspirin 81 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Metoprolol Succinate XL 75 mg PO DAILY
Please hold for SBP < 100, HR < 60
8. Ranitidine (Liquid) 150 mg PO BID
9. Simvastatin 20 mg PO DAILY
10. Tamsulosin 0.4 mg PO HS
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Calcium Carbonate 600 mg PO QD
3. Docusate Sodium 100 mg PO BID
4. Metoprolol Succinate XL 75 mg PO DAILY
5. Ranitidine (Liquid) 150 mg PO BID
6. Simvastatin 20 mg PO DAILY
7. Tamsulosin 0.4 mg PO HS
8. Tiotropium Bromide 1 CAP IH DAILY
9. Vitamin D 600 mg PO DAILY
10. Acetaminophen 1000 mg PO TID
RX *acetaminophen 500 mg 2 tablet(s) by mouth three times a day
Disp #*60 Tablet Refills:*0
11. Ibuprofen 600 mg PO BID Duration: 7 Days
RX *ibuprofen 600 mg 1 tablet(s) by mouth twice a day Disp #*14
Tablet Refills:*0
12. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
Do not drive or drink alcohol while taking this medication.
RX *oxycodone 5 mg 1 tablet(s) by mouth three times a day Disp
#*21 Tablet Refills:*0
13. Vancomycin 1250 mg IV Q 12H
RX *vancomycin 1 gram 1250 mg IV q12 hours Disp #*18 Bag
Refills:*0
14. albuterol sulfate *NF* 90 mcg/actuation Inhalation two puffs
QID
15. Outpatient Lab Work
682.9 Cellulitis
Vancomycin Trough ___.
Please fax results to PCP ___ at ___.
Thank you.
16. PICC FLUSH
PICC LINE FLUSH
Per Home Infusion Protocol
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Cellulitis
Secondary:
Gout with tenosynovitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: Left lower extremity swelling, cellulitis, rule out DVT.
COMPARISON: None available
TECHNIQUE : Grayscale, color, and spectral Doppler evaluation of the left
lower extremity was performed.
FINDINGS:
Normal respiratory variation is seen in bilateral common femoral veins.
There is normal compressibility, flow, and augmentation in the left common
femoral and proximal, mid, and distal portions of the left superficial femoral
vein. Normal compressibility, flow, and augmentation is also seen in the left
popliteal vein. There is normal color flow in the left posterior tibial and
peroneal veins. Incidental note is made of a prominent left inguinal lymph
node measuring 3.0 x 2.0 x 0.6 cm, containing a fatty hilum.
IMPRESSION:
No evidence of deep venous thrombosis in the left lower extremity.
Radiology Report
LEFT ANKLE STUDY, DATED ___
No prior studies for comparison.
FINDINGS: Diffuse soft tissue swelling is present about the ankle. No acute
fracture or dislocation is evident, and there are no radiographic findings to
suggest the presence of osteomyelitis. However, if there is strong clinical
suspicion for this diagnosis, MRI or bone scan may be considered. Incidental
note is made of a plantar calcaneal spur.
Radiology Report
INDICATION: Assess for a left PIC catheter position.
COMPARISONS: ___.
FINDINGS:
Left PIC catheter tip projects over mid SVC. No pneumothorax. Lung volumes
are normal. There is minimal blunting of the left costophrenic angle. Trace
pleural effusion is likely. No right pleural effusion. Hilar and mediastinal
silhouettes are unchanged. Heart is mildly enlarged. Intrathoracic aorta is
tortuous. Patient is status post medial sternotomy and CABG. Partially
imaged upper abdomen is unremarkable.
IMPRESSION:
Left PIC catheter tip projects over mid SVC.
Gender: M
Race: ASIAN - CHINESE
Arrive by WALK IN
Chief complaint: L Leg swelling, LLE REDNESS
Diagnosed with CELLULITIS OF LEG
temperature: 99.2
heartrate: 81.0
resprate: 18.0
o2sat: 98.0
sbp: 93.0
dbp: 66.0
level of pain: 8
level of acuity: 3.0 | Plan and Assessment:
Pt is a ___ with h/o CAD s/p CABG in ___, HTN,
hypercholesterolemia and COPD who presents for 1 week of LLE
erythema, edema, and pain.
ACTIVE ISSUES
# LLE cellulitis: Pt's cellulitis, most likely incited by
athlete's foot as well as venous stasis s/p CABG in ___. Pt's
exam notable for pustular draining most consistent with a Staph
cellulitis and pt has had improvement with IV Vancomycin. Pt ha
leukocytosis at admission with WBC of 15.2 which has since
improved. Blood cultures showed no growth to date at discharge.
The patient reported prior surgical instrumentation at his L
ankle, and therefore had left ankle plain films which were only
notable for soft tissue swelling and no concerning bony changes.
The patient was encouraged to limit weight-bearing activity of
his LLE and to elevate it. His pain was managed with standing
Tylenol, standing Ibuprofen and oxycodone prn.
#Chest pressure/CAD/CABG. The patient experienced several
episodes of chest pressure, but was ruled out for ACS with
negative cardiac enzymes x 2 and negative EKGs. Pt reported
worsening SOB at admission, but since he was not tachycardic,
hypoxic, and LENIs were negative for DVTs bilaterally, PE did
not seem likely. The patient was monitored on telemetry which
showed no arrhythmias. Etiology of chest pressure is unclear,
but appeared to be anxiety-related.
# Dyspnea: H/o COPD. Pt's baseline dyspnea was worse at
admission but improved with standing albuterol.
# Acute Gout: On exam the patient's ___ MTP joint was swollen
and tender, consistent with gout. The patient also has had
long-standing bilateral tenosynovitis which can occur in gout.
The patient's symptoms were relieved with standing Ibuprofen
800mg TID. This was quickly weaned to 600mg BID given his
history of stable CAD, to complete a very short course ___ days
maximum).
CHRONIC ISSUES
# HTN: Stable. Patient was continued on home metoprolol
succinate ER 75 daily.
# Hypercholesterolemia/hyperlipidemia. Stable. Patient was
continued on home simvastatin 20 mg daily.
# CAD: s/p CABG in ___. Stable. Patient was continued on
home simvastatin and ASA 81.
# Vitamin D deficiency: Stable. Patient continued on home
calcium and Vit D supplementation.
# BPH: Recently started on Flomax by PCP. Stable. Continued on
home Flomax 0.4 mg.
# GERD: Stable. Patient continued on home ranitidine.
TRANSITIONAL ISSUES
--Code: Full (discussed with patient)
--Because the patient will be discharged with IV vancomycin
(last day on ___, he will require vancomycin trough check
as an outpatient on ___. Pt has f/u with PCP ___ on
___.
--Patient will require outpatient follow-up for further work-up
of intermittent episodes of chest pressure (cardiac ischemia
unlikely given in-hospital work-up).
--Patient had left inguinal lymph node noted on US at admission;
may require outpatient follow-up, but lymph node on physical
exam has been nontender. Patient has been asymptomatic. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Percocet
Attending: ___.
Chief Complaint:
Abdominal pain with intermittent nausea and vomiting
Major Surgical or Invasive Procedure:
Exploratory laparotomy, Small bowel resection, Small bowel
anastomosis (___)
History of Present Illness:
___ w/Crohn's disease s/p proctocolectomy and end-ileostomy in
___, c/b multiple ventral hernias and recurrent SBOs p/w a 3
day history of abdominal pain with intermittent emesis and
nausea. No stool from his ileostomy since the previous day, with
minimal gas on the day of presentation. No changes in his
hernia, but had a lot of pain overlying the hernia. Had
subjective fevers at home, decreased PO intake. Of note he was
last admitted ___ ___ SBO, which
was treated conservatively. Dr. ___ has offered him a
ventral hernia repair, which he deferred in the past. RIJ was
placed in ED as patient had no access. He had an NGT placed and
the stomach on the CT appears to be decompressed. VSS and he has
received 2L of fluid in the ED.
Past Medical History:
PMH:
-Crohns disease
-Chronic bronchitis
-Asthma
-Hyperlipidemia
-Anxiety
-GERD
PSH:
-___: proctocolectomy with end ileostomy
-___: Takedown ileostomy, multiple abdominal wall
fistulotomies, resection RLQ inflammatory mass and segmental
enterectomy x2
-___: Exploratory laparotomy with control of multiple small
bleeding points
-___: Exploratory laparotomy, control of multiple small
bleeding points
Social History:
___
Family History:
No family history if IBD. Father with lung cancer, was smoker.
Physical Exam:
Admission exam:
Vitals: 98.2 92 116/76 18 97% RA
GEN: A&O, NAD
CV: RRR
PULM: Clear to auscultation b/l
ABD: Soft, mildly distended, minimally tender, no rebound or
guarding, large reducible ventral hernia
Ext: No ___ edema, ___ warm and well perfused
Discharge exam:
Vitals: 98.8 88 114/65 18 95%RA
GEN: A&O, NAD
CV: RRR
PULM: CATB
ABD: +BS, soft, non-distended, appropriately tender to
palpation, no rebound or guarding. Staples on midline incision.
Incision without erythema or drainage. Ostomy LLQ with stool and
gas.
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
Admission Labs:
___ 05:45PM BLOOD WBC-16.1*# RBC-5.74 Hgb-16.8 Hct-49.0
MCV-85 MCH-29.3 MCHC-34.4 RDW-14.6 Plt ___
___ 05:45PM BLOOD Neuts-92.6* Lymphs-2.7* Monos-4.0 Eos-0.2
Baso-0.5
___ 05:45PM BLOOD ___ PTT-31.4 ___
___ 05:45PM BLOOD Plt ___
___ 05:45PM BLOOD Glucose-145* UreaN-30* Creat-2.2* Na-131*
K-4.3 Cl-94* HCO3-17* AnGap-24*
___ 11:29AM BLOOD ALT-17 AST-13 AlkPhos-69 TotBili-1.0
___ 03:08PM BLOOD CK(CPK)-67
___ 03:08PM BLOOD CK-MB-3 cTropnT-<0.01
___ 11:29AM BLOOD Albumin-3.9 Calcium-8.8 Phos-5.2*#
Mg-1.5*
___ 05:46PM BLOOD Lactate-2.9*
___ 02:42AM BLOOD Lactate-2.4*
___ 08:41AM BLOOD Lactate-1.7
___ 01:32PM BLOOD Lactate-4.9*
___ 07:56PM BLOOD Lactate-3.5* Na-137 K-4.2
___ 09:54PM BLOOD Lactate-2.3*
Discharge Labs:
___ 05:49AM BLOOD Glucose-126* UreaN-18 Creat-1.1 Na-133
K-4.5 Cl-98 HCO3-28 AnGap-12
___ 05:49AM BLOOD Calcium-8.8 Phos-3.2 Mg-1.9
Imaging:
CT abdomen/pelvis (___):
IMPRESSION: Multiple exterial and internal hernias are seen
with teathering
of multiple small bowel loops, primarily in the right upper
quadrant. There
is a new closed loop obstruction involving a loop of internally
herniated,
volvulized small bowel in the right upper quadrant. More
distally, there is
another point of small bowel obstruction. Distal to this, the
bowel is
decompressed to the end ileostomy.
CXR ___:
IMPRESSION:
Tip of the right PICC line is low in the SVC. Small bilateral
pleural
effusions unchanged. Heart size normal. Upper lungs clear.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN pain
2. Famotidine 20 mg PO Q12H
3. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
4. LOPERamide 4 mg PO QID
5. Opium Tincture 5 DROP PO Q6H
6. Psyllium Wafer 1 WAF PO TID
7. Sarna Lotion 1 Appl TP QID:PRN itching
8. Heparin 5000 UNIT SC TID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Small bowel volvulus with bowel ischemia, s/p ex-lap and small
bowel resection (___)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: History of Crohn's status post proctocolectomy with end ileostomy
with recent admission for small bowel obstruction, now with severe abdominal
pain, nausea, and vomiting.
TECHNIQUE: MDCT imaging of the abdomen and pelvis without intravenous
contrast was performed. Multiplanar reformats were prepared and reviewed.
COMPARISON: Comparison is made with CT abdomen and pelvis from ___.
FINDINGS:
ABDOMEN: The visualized lung bases are clear. Evaluation of the abdominal
organs is somewhat limited on this noncontrast exam. The liver is homogeneous
in texture with no focal lesions. There is no biliary ductal dilatation. The
gallbladder is normal. The spleen, pancreas, and adrenal glands are normal.
The kidneys are unremarkable with no contour irregularities, hydronephrosis,
or nephrolithiasis. The stomach is unremarkable.
Multiple exterial and internal hernias are seen with teathering of multiple
small bowel loops, primarily in the right upper quadrant. There is a new
closed loop obstruction involving a loop of internally herniated, volvulized
small bowel in the right upper quadrant (601b:35). More distally, there is
another point of small bowel obstruction (2:38, 602b:38). Distal to this, the
bowel is decompressed to the end ileostomy. No pneumatosis is seen. There is
no retroperitoneal or mesenteric lymphadenopathy. The intra-abdominal aorta
is normal in appearance.
PELVIS: The patient is status post proctocolectomy. The distal ureters and
bladder are normal. There is no pelvic or inguinal lymphadenopathy. There is
no free fluid in the pelvis.
BONE WINDOWS: No focal lytic or sclerotic osseous lesion suspicious for
infection or malignancy is seen.
In the right upper quadrant there is an area of sp mesenteric swirling again
seen, with a
IMPRESSION: Multiple exterial and internal hernias are seen with teathering
of multiple small bowel loops, primarily in the right upper quadrant. There
is a new closed loop obstruction involving a loop of internally herniated,
volvulized small bowel in the right upper quadrant. More distally, there is
another point of small bowel obstruction. Distal to this, the bowel is
decompressed to the end ileostomy.
Radiology Report
HISTORY: History of bowel obstructions, with NG tube in place. Please
evaluate position of NG tube.
COMPARISON: Abdominal radiographs dated back to ___. CT abdomen
from ___.
TECHNIQUE: Single AP view of the chest and upper abdomen.
FINDINGS:
The NG tube appears to be just distal to the GE junction. Suggest advancement
so that it is well within the stomach. The heart size is normal. The hilar
and mediastinal contours are normal. Please note that the right costophrenic
angle is not seen, however there is no large pleural effusion or pneumothorax.
No focal consolidations concerning for pneumonia are identified. Right
internal jugular central venous catheter terminates at the proximal to mid
SVC.
The high-grade bowel obstruction seen on the recent CT is not seen on this
exam, due to paucity of bowel gas and only the upper abdomen was imaged
limiting evaluation of the intra-abdominal bowel loops. There is no
pneumatosis or free air.
IMPRESSION:
1. NG tube terminates just beyond the GE junction. Suggest advancement so
that it is well within the stomach.
2. High-grade bowel obstruction seen on the recent CT is not seen on this
exam given the paucity of bowel gas and only the upper abdomen was imaged
limiting evaluation.
Findings were discussed with Dr. ___ by Dr. ___ by phone at 10AM
on the day of the exam
Radiology Report
INDICATION: History of NG tube. Please evaluate for position.
COMPARISONS: Multiple prior chest radiographs dated back to ___.
TECHNIQUE: AP portable radiograph of the chest.
FINDINGS: The heart size is normal. The hilar and mediastinal contours are
normal. The lungs are clear without evidence of focal consolidations
concerning for pneumonia. There is no pleural effusion or pneumothorax.
Right-sided IJ appears to terminate in the low SVC. Enteric tube appears to
extend below the diaphragm, with a coil at the junction. The tip of the tube
appears to be within the fundus of the stomach.
IMPRESSION: Although the NG tube is in the fundus of the stomach, it does
appear to coil at the GE junction. Straightening of the NG tube and further
advancement is suggested.
Radiology Report
AP CHEST, 7:54 P.M., ___
HISTORY: ___ man with endotracheal tube placed.
IMPRESSION: AP chest compared to ___:
Tip of the endotracheal tube above the upper margin of the clavicles, at least
6 cm from the carina, should be advanced 2 to 3 cm for more secured seating.
Lungs low in volume but clear. Heart size normal. No pleural abnormality.
Right jugular line ends low in the SVC.
Radiology Report
AP CHEST, 6:15 A.M., ___
HISTORY: ___ man intubated.
IMPRESSION: AP chest compared to ___, 7:54 p.m.:
There has been no interval change. Lung volumes are mildly diminished, but
lungs are clear of any focal abnormality. Heart size normal. Normal hilar
and mediastinal contours and pleural surfaces.
ET tube in standard placement, right jugular line ends low in the SVC and an
upper enteric drainage tube passes into the stomach and out of view.
Radiology Report
HISTORY: Status post PICC placement.
COMPARISON: Chest radiograph from ___.
FINDINGS:
There has been interval placement of a right-sided PICC, with the tip in the
mid to low SVC. A right internal jugular line also terminates in the mid to
low SVC. There is a new moderate right pleural effusion and small left
pleural effusion, both with associated atelectasis. The cardiomediastinal
silhouette is normal. There is no focal consolidation or pneumothorax.
IMPRESSION:
1. Right-sided PICC with the tip in the mid to low SVC.
2. New moderate right pleural effusion and small left pleural effusion, both
with associated atelectasis.
These findings were communicated via telephone by Dr. ___ to Dr.
___ at 1209 on ___, 5 minutes after discovery.
Radiology Report
AP CHEST, 2:29 P.M. ON ___
HISTORY: A ___ man with a central venous line removed. Did this
disturb the PICC line.
IMPRESSION: AP chest compared to ___, 10:06 a.m.:
Tip of the right PICC line is low in the SVC. Small bilateral pleural
effusions unchanged. Heart size normal. Upper lungs clear.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: HERNIA/ABD PAIN
Diagnosed with ABDOMINAL PAIN OTHER SPECIED
temperature: 97.4
heartrate: 115.0
resprate: 18.0
o2sat: 98.0
sbp: 115.0
dbp: 75.0
level of pain: 10
level of acuity: 3.0 | The patient was admitted to the General Surgical Service on
___ with abdominal pain, nausea, vomiting. CT scan showed
closed loop obstruction. Patient became tachycardic to 150s, WBC
increased from 16 to 24, and pt had increased abdominal pain. He
was taken to the operating room for exploratory laparatomy for
suspected closed loop obstruction with bowel ischemia. In the
OR, the surgeons found the pt had a small bowel volvulus with
bowel ischemia. They performed a small bowel resection and small
bowel anastomosis. The procedure went well without complication
(refer to the Operative Note by Dr. ___ details).
Following the OR, the patient was transferred to the surgical
ICU, intubated, for close observation.
Neuro: The patient arrived to the SICU post-operatively
intubated and sedated. He was extubated on POD1. He was given
dilaudid PCA for pain control with good effect and adequate pain
control. When tolerating oral intake, the patient was
transitioned to oral pain medications.
CV: Post-operatively, the patient required a phenylephrine drip
for a few hours to keep MAP > 60. He remained tachycardic to
120s post-operatively, which eventually improved on POD ___.
Vital signs were routinely monitored.
Pulmonary: The patient was taken to the SICU intubated
post-operatively. He was extubated on POD1. After extubation, he
remained stable from a pulmonary standpoint; vital signs were
routinely monitored. Good pulmonary toilet, early ambulation and
incentive spirometry were encouraged throughout hospitalization.
GI/GU/FEN: Post-operatively, the patient was made NPO with IV
fluids. NG tube was removed on POD3, and he was started on TPN
on POD3 for supplemental nutrition. PICC line was placed for TPN
on ___. Diet was advanced slowly when appropriate, which was
well tolerated. His ostomy output was initially very liquid
post-operatively, but became more formed after starting
loperamide, adding tincture of opium drops, and after starting a
regular diet. Patient's intake and output were closely
monitored, and IV fluid was adjusted when necessary.
Electrolytes were routinely followed, and repleted when
necessary. His potassium dropped to 3.0 given his liquid ostomy
output, but was repleted and improved. Pt was encouraged a high
potassium diet. Also, he was instructed to wear his abdominal
binder tightly at all times post-surgery.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. WBC initially increased
from 16 to 24, after which pt was taken to OR. Post-operatively,
WBC returned to normal. Pt was given zosyn perioperatively,
___. The wound dressings were changed daily.
Endocrine: The patient's blood sugar was monitored four times
per day while on TPN. He did not require insulin.
Hematology: The patient's complete blood count was examined
routinely. He was transfused 3upRBC for HCT of 21, which then
increased to 28. Heart rate improved post-transfusion from HR
120s->110s.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet in addition to receiving TPN, ambulating, voiding without
assistance, and pain was well controlled on oral medications. He
will be discharged to a long term care facility for further
care. The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. He will follow up in the general surgery
clinic in ___ weeks. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Unwitnessed fall
Major Surgical or Invasive Procedure:
ACDF ___
History of Present Illness:
___ year old male with HTN, HLD, and dementia presented to ED
after an unwitnessed fall at home. Of note, patient is a poor
historian given his dementia and repeatedly stated, "ask my
daughter" when questioned about his fall. The remainder of the
HPI is per report from his daughter, who was not there when the
patient had the fall.
Per ED notes, patient fell on the day of presentation around
5pm,
around which time he was reportedly feeling dizzy/lightheaded.
His family notes that lightheadedness/dizziness are not new
issues for him and frequently occur when he stands from a seated
position. He denies any chest pain. After his fall, patient
pushed his life-line button, at which point EMS was contacted
and
brought him to the ED. Per his daughter, when she arrived at his
house he was more confused and disoriented than baseline, and
she
noted a new right sided facial droop, slurred speech, swelling
of
the left jaw, and unfocused gaze on the right, all of which have
since resolved.
In the ED, CT head showed no indication of acute intracranial
bleeding. CT of the c-, t-, and l-spine were notable for
multilevel mild subluxation of C2-C3 and C5-C6 with findings
concerning for ligamentous injury. An MRI of the C-spine was
notable for injury to the anterior C6-C7 intervertebral disc
with
disruption of the anterior longitudinal ligament and
prevertebral
soft tissue swelling as well as moderate spinal stenosis at
C2-C3
C3-C4 and C6-C7 with slight deformity of the spinal cord without
high-grade spinal cord compression. The rest of the spine was
only notable for chronic degenerative changes.
Given the above findings, both trauma surgery and ortho spine
surgery were consulted. Ortho spine surgery is planning to
perform a ACDF of C6-C7. Admitted to medicine for optimization
prior to surgery.
Also of note, CT chest was notable for a previously known
3.2x1.7
cm mass in the left lower lobe that has increased in size since
___. Patient's family is aware of this mass and has
opted
for conservative management.
In the ED, initial vitals were:
- Exam notable for: VSS, SBP 170s-180s, cervical spine
tenderness, anterior chest wall tenderness
- Labs notable for:
WBC 11.0
Hgb 8.3
Cr 2.3
CK 425
Troponin ___
UA negative for nitrites, ___, and bacteria
- Imaging was notable for: As above
Upon arrival to the floor, patient reports no active pain. His
family is at bedside and have many questions about the plans for
surgery.
Past Medical History:
HYPERTENSION
HYPERLIPIDEMIA
ASTHMA
TRANSIENT ISCHEMIC ATTACK
ANEMIA
BENIGN PROSTATIC HYPERTROPHY
GLAUCOMA
RENAL INSUFFICIENCY
CONGESTIVE HEART FAILURE
ATRIAL FIBRILLATION
HYPOTHYROIDISM
ORCHITIS
HERPES ZOSTER
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITAL SIGNS: T 98.6 BP 158/65 HR 77 RR 20 SpO2 96% RA
GENERAL: Elderly male laying in bed with C-collar in place.
Sleeping when I entered but easily arousable. Polite and
cooperative with interview and exam. NAD.
HEENT: Normocephalic. Left eye with changes consistent with
glaucoma, eyelid mildly swollen and shut, although patient can
open it with prompting. Right pupil round and reactive to light.
NECK: C-collar
CARDIAC: RRR, systolic murmur. No rubs or gallops.
LUNGS: CTAB on anterior surface exam.
ABDOMEN: Soft, nontender, nondistended. NABS.
EXTREMITIES: 2+ pitting edema to the ankles bilaterally. Warm
and well perfused.
NEUROLOGIC: CNII-XII intact. ___ strength of hip flexion on
left, slightly weaker on right but still ___ strength in UE
bilaterally.
DISCHARGE PHYSICAL EXAM:
GENERAL: Elderly male laying in bed, NAD. Polite and
cooperative
with interview and exam.
HEENT: NGT in place. Normocephalic. Left eye with changes
consistent with glaucoma, eyelid mildly swollen and with thin
discharge, although patient can open it with prompting. Right
pupil round and reactive to light.
NECK: Bandage without strike through.
CARDIAC: RRR, no murmur, rubs, or gallops
LUNGS: CTAB on anterior surface exam.
ABDOMEN: Soft, nontender, nondistended. NABS.
EXTREMITIES: No ___ edema. Warm and well perfused.
NEUROLOGIC: CNII-XII grossly intact. No focal deficits. Moving
all 4 extremities.
Pertinent Results:
ADMISSION LABS
================
___ 07:25PM BLOOD WBC-11.0*# RBC-2.66* Hgb-8.3* Hct-25.4*
MCV-96 MCH-31.2 MCHC-32.7 RDW-14.8 RDWSD-52.2* Plt ___
___ 07:25PM BLOOD Neuts-86.1* Lymphs-6.3* Monos-6.1
Eos-0.7* Baso-0.3 Im ___ AbsNeut-9.43*# AbsLymp-0.69*
AbsMono-0.67 AbsEos-0.08 AbsBaso-0.03
___ 07:25PM BLOOD ___ PTT-30.8 ___
___ 07:25PM BLOOD Glucose-124* UreaN-70* Creat-2.3* Na-142
K-5.0 Cl-107 HCO3-18* AnGap-17
___ 07:25PM BLOOD CK(CPK)-425*
___ 06:05AM BLOOD CK(CPK)-494*
___ 07:25PM BLOOD CK-MB-10 MB Indx-2.4
___ 07:25PM BLOOD cTropnT-0.05*
___ 01:10AM BLOOD cTropnT-0.05*
___ 06:05AM BLOOD CK-MB-7 cTropnT-0.06*
___ 09:00AM BLOOD cTropnT-0.06*
___ 07:25PM BLOOD Calcium-8.6 Phos-4.1 Mg-2.3
DISCHARGE LABS
==================
___ 04:40AM BLOOD WBC-7.6 RBC-2.40* Hgb-7.5* Hct-22.8*
MCV-95 MCH-31.3 MCHC-32.9 RDW-14.8 RDWSD-51.9* Plt ___
___ 04:40AM BLOOD Glucose-107* UreaN-57* Creat-2.0* Na-145
K-3.8 Cl-109* HCO3-24 AnGap-12
___ 04:40AM BLOOD Calcium-8.4 Phos-4.5 Mg-2.1
IMAGING
===========
CT HEAD W/O CONTRAST ___
IMPRESSION:
1. No acute intracranial hemorrhage or mass effect. No fracture.
2. Age-appropriate atrophy with chronic small vessel ischemic
changes.
3. Prominence of the extra-axial spaces overlying the frontal
and parietal
lobes could reflect the presence of small and symmetric
bilateral subdural
hygromas or chronic subdural hematomas.
CT CHEST ___
IMPRESSION:
1. No acute traumatic injury identified within the chest or
thoracic spine.
Specifically, no acute fracture or malalignment of the thoracic
spine. No rib
fractures.
2. 3.2 x 1.7 cm mass in the left lower lobe has increased in
size compared to
___, concerning for a neoplasm. This can be further
assessed with
PET-CT or direct sampling, if clinically indicated.
3. Extensive atherosclerotic disease.
4. Severe degenerative changes of the bilateral glenohumeral
joints with
moderate bilateral joint effusions, larger on the right.
5. Cholelithiasis without cholecystitis.
6. Diffusely patulous esophagus suggestive of underlying
dysmotility
disorder.
7. Diffuse airway wall thickening and scattered areas of mucous
plugging
suggests chronic bronchitis.
CT C-SPINE W/O CONTRAST ___. Multilevel mild subluxation is of indeterminate chronicity,
though given
the presence of prevertebral soft tissue edema extending from
C2-C3 through
C5-C6, ligamentous injury may be present. MRI of the cervical
spine is
recommended to assess for ligamentous injury.
2. No evidence of acute fracture.
3. Moderate cervical spondylosis, most severe at C6-7.
CT T-SPINE W/O CONTRAST ___. No acute traumatic injury identified within the chest or
thoracic spine.
Specifically, no acute fracture or malalignment of the thoracic
spine. No rib
fractures.
2. 3.2 x 1.7 cm mass in the left lower lobe has increased in
size compared to
___, concerning for a neoplasm. This can be further
assessed with
PET-CT or direct sampling, if clinically indicated.
3. Extensive atherosclerotic disease.
4. Severe degenerative changes of the bilateral glenohumeral
joints with
moderate bilateral joint effusions, larger on the right.
5. Cholelithiasis without cholecystitis.
6. Diffusely patulous esophagus suggestive of underlying
dysmotility
disorder.
7. Diffuse airway wall thickening and scattered areas of mucous
plugging
suggests chronic bronchitis.
CT L-SPINE W/O CONTRAST ___. No acute fracture.
2. Severe lumbar spondylosis with multilevel subluxation.
3. Multilevel mild to moderate spinal canal and moderate to
severe neural
foraminal narrowing, most severe at L4-5 and L5-S1.
4. Cholelithiasis.
MRI C-SPINE W/O CONTRAST ___. Injury to the anterior C6-7 intervertebral disc with
disruption of the
anterior longitudinal ligament and prevertebral soft tissue
swelling.
2. Moderate spinal stenosis at C2-3 C3-4 and C6-7 levels with
slight deformity
of the spinal cord without high-grade spinal cord compression.
3. Although slightly limited evaluation secondary to motion no
evidence of
obvious increased signal within the spinal cord. No signs of
hemorrhage
contusion on gradient echo images.
ECHO ___
The left atrial volume index is moderately increased. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. Overall
left ventricular systolic function is normal (LVEF = 60%).
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). The right ventricular free wall
is hypertrophied. The right ventricular cavity is moderately
dilated with normal free wall contractility. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is no pericardial effusion.
C-SPINE ___
Expected postsurgical changes status post C6-C7 anterior fusion
MICROBIOLOGY
===============
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Valsartan 320 mg PO DAILY
2. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
3. Furosemide 40 mg PO DAILY
4. Labetalol 200 mg PO BID
5. Levothyroxine Sodium 50 mcg PO DAILY
6. NIFEdipine (Extended Release) 60 mg PO DAILY
7. Tamsulosin 0.4 mg PO QHS
8. Tiotropium Bromide 1 CAP IH DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Artificial Tears ___ DROP BOTH EYES PRN Dry eyes
3. Bisacodyl 10 mg PO DAILY
4. Diazepam 2 mg PO Q6H:PRN Muscle spasm in neck
RX *diazepam 2 mg 1 tablet by mouth every 6 hours as needed Disp
#*10 Tablet Refills:*0
5. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every 4
hours as needed Disp #*6 Tablet Refills:*0
6. Polyethylene Glycol 17 g PO DAILY
7. Senna 17.2 mg PO HS
8. Vitamin D 800 UNIT PO DAILY
9. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
10. Furosemide 40 mg PO DAILY
11. Labetalol 200 mg PO BID
12. Levothyroxine Sodium 50 mcg PO DAILY
13. NIFEdipine (Extended Release) 60 mg PO DAILY
14. Tamsulosin 0.4 mg PO QHS
15. Tiotropium Bromide 1 CAP IH DAILY
16. Valsartan 320 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
=================
Ligamentous injury of C6-C7 with disk disruption
Secondary Diagnoses
=================
HTN
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ status post fall with new back pain and altered
mental status.// Intracranial bleed? New fractures?
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.2 cm; CTDIvol = 49.6 mGy (Head) DLP =
802.7 mGy-cm.
2) Sequenced Acquisition 2.0 s, 2.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
100.3 mGy-cm.
Total DLP (Head) = 903 mGy-cm.
COMPARISON: None available.
FINDINGS:
Study is mildly limited by motion artifact. There is no evidence of large
territorial infarction,acute intracranial hemorrhage,edema,or mass. There is
prominence of the ventricles and sulci suggestive of involutional changes.
Prominence of the extra-axial spaces overlying the frontal and parietal lobes
could reflect the presence of small bilateral subdural hygromas or chronic
subdural hematomas. Periventricular and subcortical hypodensities are
nonspecific but most likely represent sequela of chronic small vessel ischemic
changes. Dense atherosclerotic calcifications of the cavernous carotid
arteries are noted with mild atherosclerotic calcifications of the distal left
vertebral artery seen.
There is no evidence of acute fracture. There is mild mucosal thickening of
the ethmoid air cells and bilateral maxillary sinuses. The remaining
paranasal sinuses, mastoid air cells, and middle ear cavities are clear.
Patient is status post bilateral lens replacement.
IMPRESSION:
1. No acute intracranial hemorrhage or mass effect. No fracture.
2. Age-appropriate atrophy with chronic small vessel ischemic changes.
3. Prominence of the extra-axial spaces overlying the frontal and parietal
lobes could reflect the presence of small and symmetric bilateral subdural
hygromas or chronic subdural hematomas.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: History: ___ status post fall with new back pain and altered
mental status.// Intracranial bleed? New fractures?
TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.3 s, 21.0 cm; CTDIvol = 22.6 mGy (Body) DLP = 474.7
mGy-cm.
Total DLP (Body) = 475 mGy-cm.
COMPARISON: None available.
FINDINGS:
There is mild (2 mm) anterolisthesis of C4 on C5 and mild (3 mm)
retrolistheses of C6 on C7.No acute fractures are identified.Moderate
multilevel degenerative changes with intervertebral disc space narrowing,
endplate sclerosis and cysts, and anterior and posterior osteophyte formation
are most pronounced at C5-6, C6-7, and C7-T1. There is asymmetric widening
anteriorly of the disc space at C6-7. Vertebral body heights are preserved.
Disc bulging and posterior osteophytes result in mild central canal stenosis,
worse C6-7. Uncovertebral and facet osteophytes cause moderate to severe
narrowing of multiple bilateral neural foramina, most pronounced at C6-7.Mild
prevertebral soft tissue edema is seen extending from C2-C3 through C5-C6
levels.
There is no evidence of infection or neoplasm. The thyroid and bilateral lung
apices are unremarkable. Visualized aspect of the proximal esophagus is
patulous.
IMPRESSION:
1. Multilevel mild subluxation is of indeterminate chronicity, though given
the presence of prevertebral soft tissue edema extending from C2-C3 through
C5-C6, ligamentous injury may be present. MRI of the cervical spine is
recommended to assess for ligamentous injury.
2. No evidence of acute fracture.
3. Moderate cervical spondylosis, most severe at C6-7.
RECOMMENDATION(S): MRI cervical spine without contrast.
Radiology Report
INDICATION: History: ___ status post fall with chest tenderness.//
Fractures?
TECHNIQUE: Contiguous axial images were obtained through the chest and
thoracic spine without intravenous contrast. Coronal and sagittal reformats
were obtained.
COMPARISON: Chest radiograph dated ___, CT chest dated ___.
FINDINGS:
HEART AND VASCULATURE: The thoracic aorta is normal in caliber with diffuse
atherosclerotic calcifications involving the thoracic aorta and arch vessels.
The heart, pericardium, and great vessels are otherwise within normal limits
based on an unenhanced scan. No pericardial effusion is seen. There are
diffuse coronary artery calcifications and aortic valve calcifications. There
is mild cardiomegaly. A 2.3 x 2.0 cm hypodense round structure in the right
infrahilar region may reflect a small amount of fluid within a pericardial
recess (02:38).
AXILLA, HILA, AND MEDIASTINUM: No axillary or mediastinal lymphadenopathy is
present. No mediastinal mass or hematoma.
PLEURAL SPACES: Trace bilateral pleural effusions are noted. No pneumothorax.
LUNGS/AIRWAYS: 3.2 x 1.7 cm soft tissue density mass in the left lower lobe
previously measured 1.8 x 1.8 cm from ___. Bronchial wall
thickening and mucus plugging in the bilateral lower lobes are consistent with
suggest chronic bronchitis. There is bilateral dependent atelectasis. No
focal consolidation to suggest pneumonia. The central airways are patent.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
The esophagus is diffusely patulous suggestive of underlying dysmotility
disorder.
ABDOMEN: Included portion of the unenhanced upper abdomen demonstrates
cholelithiasis without evidence of cholecystitis. Multiple hypoattenuating
lesions throughout the bilateral kidneys measuring up to 2.7 cm in the left
kidney are consistent with cysts. 1.8 x 1.7 cm hypodense lesion in the spleen
is not fully evaluated on this exam, possibly a cyst or hemangioma.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture
or subluxation. Thoracic vertebral bodies are preserved in height.
Multilevel moderate degenerative changes of the thoracic spine are noted with
intervertebral disc space narrowing, anterior osteophyte formation, and mild
intervertebral disc calcification. There are extensive degenerative changes
of the bilateral glenohumeral joints with moderate amount of joint effusions
bilaterally, right greater than left.
IMPRESSION:
1. No acute traumatic injury identified within the chest or thoracic spine.
Specifically, no acute fracture or malalignment of the thoracic spine. No rib
fractures.
2. 3.2 x 1.7 cm mass in the left lower lobe has increased in size compared to
___, concerning for a neoplasm. This can be further assessed with
PET-CT or direct sampling, if clinically indicated.
3. Extensive atherosclerotic disease.
4. Severe degenerative changes of the bilateral glenohumeral joints with
moderate bilateral joint effusions, larger on the right.
5. Cholelithiasis without cholecystitis.
6. Diffusely patulous esophagus suggestive of underlying dysmotility
disorder.
7. Diffuse airway wall thickening and scattered areas of mucous plugging
suggests chronic bronchitis.
Radiology Report
INDICATION: History: ___ status post fall with chest tenderness.//
Fractures?
TECHNIQUE: Contiguous axial images were obtained through the chest and
thoracic spine without intravenous contrast. Coronal and sagittal reformats
were obtained.
COMPARISON: Chest radiograph dated ___, CT chest dated ___.
FINDINGS:
HEART AND VASCULATURE: The thoracic aorta is normal in caliber with diffuse
atherosclerotic calcifications involving the thoracic aorta and arch vessels.
The heart, pericardium, and great vessels are otherwise within normal limits
based on an unenhanced scan. No pericardial effusion is seen. There are
diffuse coronary artery calcifications and aortic valve calcifications. There
is mild cardiomegaly. A 2.3 x 2.0 cm hypodense round structure in the right
infrahilar region may reflect a small amount of fluid within a pericardial
recess (02:38).
AXILLA, HILA, AND MEDIASTINUM: No axillary or mediastinal lymphadenopathy is
present. No mediastinal mass or hematoma.
PLEURAL SPACES: Trace bilateral pleural effusions are noted. No pneumothorax.
LUNGS/AIRWAYS: 3.2 x 1.7 cm soft tissue density mass in the left lower lobe
previously measured 1.8 x 1.8 cm from ___. Bronchial wall
thickening and mucus plugging in the bilateral lower lobes are consistent with
suggest chronic bronchitis. There is bilateral dependent atelectasis. No
focal consolidation to suggest pneumonia. The central airways are patent.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
The esophagus is diffusely patulous suggestive of underlying dysmotility
disorder.
ABDOMEN: Included portion of the unenhanced upper abdomen demonstrates
cholelithiasis without evidence of cholecystitis. Multiple hypoattenuating
lesions throughout the bilateral kidneys measuring up to 2.7 cm in the left
kidney are consistent with cysts. 1.8 x 1.7 cm hypodense lesion in the spleen
is not fully evaluated on this exam, possibly a cyst or hemangioma.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture
or subluxation. Thoracic vertebral bodies are preserved in height.
Multilevel moderate degenerative changes of the thoracic spine are noted with
intervertebral disc space narrowing, anterior osteophyte formation, and mild
intervertebral disc calcification. There are extensive degenerative changes
of the bilateral glenohumeral joints with moderate amount of joint effusions
bilaterally, right greater than left.
IMPRESSION:
1. No acute traumatic injury identified within the chest or thoracic spine.
Specifically, no acute fracture or malalignment of the thoracic spine. No rib
fractures.
2. 3.2 x 1.7 cm mass in the left lower lobe has increased in size compared to
___, concerning for a neoplasm. This can be further assessed with
PET-CT or direct sampling, if clinically indicated.
3. Extensive atherosclerotic disease.
4. Severe degenerative changes of the bilateral glenohumeral joints with
moderate bilateral joint effusions, larger on the right.
5. Cholelithiasis without cholecystitis.
6. Diffusely patulous esophagus suggestive of underlying dysmotility
disorder.
7. Diffuse airway wall thickening and scattered areas of mucous plugging
suggests chronic bronchitis.
Radiology Report
EXAMINATION: CT L-SPINE W/O CONTRAST Q331 CT SPINE
INDICATION: History: ___ status post fall with new back pain and altered
mental status.//new fractures?
TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 8.3 s, 32.5 cm; CTDIvol = 31.1 mGy (Body) DLP =
1,012.5 mGy-cm.
Total DLP (Body) = 1,013 mGy-cm.
COMPARISON: None available.
FINDINGS:
There is grade 1 retrolisthesis of L2 on L3, L3 on L4 and grade 1
anterolisthesis of L4 on L5 and L5 on S1.No fractures are identified.There are
severe multilevel degenerative changes of the lumbar spine including anterior
and posterior osteophytes, severe loss of disc heights with vacuum disc
phenomena, endplate sclerosis and subchondral cysts. There is multilevel
mild-to-moderate moderate spinal canal stenosis due to retrolisthesis,
posterior osteophyte formation, and ligamentum flavum hypertrophy, most
pronounced at L4-5 and L5-S1. There is moderate to severe bilateral neural
foraminal stenosis at L3-4 and L5-S1 due to facet hypertrophy.There is no
prevertebral soft tissue swelling.
There is no evidence of infection or neoplasm. The partially imaged abdomen
and pelvis again demonstrates multiple hypoattenuating lesions throughout the
kidneys likely representing cysts. There is extensive atherosclerotic
disease. There are gallstones in the gallbladder without evidence of
cholecystitis. The partially imaged pancreas, liver, bowel, and bladder are
unremarkable.
IMPRESSION:
1. No acute fracture.
2. Severe lumbar spondylosis with multilevel subluxation.
3. Multilevel mild to moderate spinal canal and moderate to severe neural
foraminal narrowing, most severe at L4-5 and L5-S1.
4. Cholelithiasis.
Radiology Report
EXAMINATION:
MRI OF THE CERVICAL SPINE
INDICATION: History: ___ with evidence of ligamentous injury of C-spine on
CTIV contrast to be given at radiologist discretion as clinically needed//
Ligamentous injury?
TECHNIQUE: T1, T2 and inversion recovery sagittal and gradient sequence T2
axial images of cervical spine obtained.
COMPARISON: CT of ___.
FINDINGS:
At C6-7 level there is increased signal within the anterior portion of the
intervertebral disc which appears slightly widened indicative of extension
injury and injury to the intervertebral disc. There is discontinued of the
anterior longitudinal ligament (3:8) indicative of disruption. The posterior
longitudinal ligament and ligamentum flavum appear intact. There is
prevertebral soft tissue swelling extending from C2-3 to upper thoracic region
which most pronounced changes at C3 and C4 level.
Multilevel degenerative changes are seen with moderate spinal stenosis at C2-3
C3-4 and see C6-7 levels with disc bulging contacting and minimally deforming
the spinal cord without spinal cord compression. There is no abnormal signal
seen within the spinal cord. Multilevel degenerative changes are seen at
other levels. At C2-3 C3-4 and C6-7 levels moderate-to-severe bilateral
foraminal narrowing seen most pronounced at C6-7 level.
IMPRESSION:
1. Injury to the anterior C6-7 intervertebral disc with disruption of the
anterior longitudinal ligament and prevertebral soft tissue swelling.
2. Moderate spinal stenosis at C2-3 C3-4 and C6-7 levels with slight deformity
of the spinal cord without high-grade spinal cord compression.
3. Although slightly limited evaluation secondary to motion no evidence of
obvious increased signal within the spinal cord. No signs of hemorrhage
contusion on gradient echo images.
Radiology Report
EXAMINATION: CERVICAL SINGLE VIEW IN OR
INDICATION: Intraoperative radiographs
COMPARISON: ___ cervical spine MRI
FINDINGS:
Intraoperative radiographs demonstrate surgical instrumentation and hardware
during anterior cervical fusion of C6-C7. Vertebral body heights and
alignment are maintained. The C7 vertebral body is not well visualized on
these radiographs. Multilevel degenerative disc disease, better assessed on
recent prior MRI.
IMPRESSION:
Intraoperative radiographs demonstrating anterior fusion of C6-C7.
Radiology Report
EXAMINATION: C-SPINE NON-TRAUMA ___ VIEWS
INDICATION: ___ year old man with acdf// post op ACDF post op ACDF
TECHNIQUE: Frontal and lateral radiographs of the cervical spine.
COMPARISON: CT ___.
FINDINGS:
C1 through C6 are seen on lateral view. Soft tissues partially obscure
anterior fusion hardware at C6-C7 on lateral view, however no definite
complication is identified. Anterolisthesis of C2 through C6 appears similar
to prior exam. Moderate degenerative change at C5-C6 appears similar. Mild
prevertebral soft tissue swelling. Drain is seen in place. Dense aortic
vascular calcifications.
IMPRESSION:
Expected postsurgical changes status post C6-C7 anterior fusion
Gender: M
Race: OTHER
Arrive by AMBULANCE
Chief complaint: s/p Fall
Diagnosed with Oth incmpl lesion at unsp level of cerv spinal cord, init, Fall on same level, unspecified, initial encounter, Altered mental status, unspecified
temperature: 97.6
heartrate: 86.0
resprate: 16.0
o2sat: 98.0
sbp: 150.0
dbp: 82.0
level of pain: 4
level of acuity: 2.0 | ___ year old male with HTN, asthma, TIA, chronic anemia, CKD,
atrial fibrillation, hypothyroidism, and HFpEF who presented to
___ after an unwitnessed fall at home. Spine imaging in ED
concerning for retrolithesis of C2-C6 with some evidence of
ligamentous injury.
# Cervical retrolithesis with ligamentous injury:
Imaging concerning for cervical retrolithesis of C6-C7 and
ligamentous injury. Patient underwent surgical anterior cervical
discectomy and fusion with orthopedics on ___. Surgery was
uncomplicated. Patient was given oxycodone for pain relief and
low dose diazepam for muscle spasm.
# Dysphagia:
Patient developed dysphagia following surgery on ___ with
nursing noting that he was coughing while taking PO. Speech and
swallow were consulted, who recommended patient be NPO and have
an NGT placed given the concern that edema would increase over
the ___ days post op. The patient and his family were notified
of this recommendation, and ultimately discussed it with the
patient who refused an NGT. The family felt that this was within
his goals of care and requested that he be able to eat. We
reached a compromise to allow him soft solids and nectar
thickened liquids with 1:1 supervision with feeding. Patient
continued to take PO diet with family present, reportedly
without any coughing or evidence of choking.
# Unwitnessed fall:
Patient presented following an unwitnessed fall at home. Per
family report, the patient was found at the bottom of the stairs
with some indication that he may have been upstairs even though
he shouldn't be while unsupervised. Exact etiology of his fall
was unclear, as patient could not provide an accurate history.
Work up was negative for acute coronary event as troponin were
negative, echocardiogram was unremarkable, and EKG was unchanged
from previous. There were no indications of seizure activity.
Infectious workup was unrevealing. Patient was on telemetry
without any signs of arrhythmia. Leading suspicion is that this
was a mechanical fall. Patient was seen by physical therapy
while inpatient who recommended for rehab facility. Patient will
then likely need to be transferred to a long term care facility,
as his family feels that he is unsafe to remain at home alone.
Chronic Medical Conditions
==============================
# HTN: Patient continued on his outpatient antihypertensive
regimen including nifedipine 60mg PO daily, valsartan 320mg PO
daily, and labetalol 200mg PO BID.
# HFpEF: Echocardiogram performed on ___ with EF 60%. He was
continued on home furosemide.
# Anemia: Patient with anemia at baseline. Per family, he was
previously Procrit but this was recently stopped. Hgb remained
stable while inpatient.
# Hypothyroidism - continued levothyroxine 50mcg PO daily
# BPH - continued tamsulosin 0.4mg PO qHS
# Glaucoma: patient with history of glaucoma, however per Dr.
___ (ophthalmologist) his glaucoma drops were all
recently discontinued. We continued artificial tears for
symptomatic relief of dry eyes.
Transitional Issues
=====================
[]Placement - patient is unsafe to return home where he lives
along and will likely need a long term care facility.
[]Surgical follow up - patient to be seen in orthopedic spine
clinic as detailed elsewhere for follow up of his surgery.
[]Dysphagia - as above, dysphagia may worsen over he ___ days
post op (surgical date ___. Patient and family refused NGT.
Swallowing should be monitored and NGT readdressed as necessary
if family requests.
HCP
Name of health care proxy: ___
Phone number: ___
Code Status
DNR, ok to intubate for short trials |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
dyspnea, wheezing
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ year old woman (patient of Dr. ___
___ with PMH of asthma, COPD, anxiety, hepatitis C, chronic
hip and low back pain who presented to ED with dyspnea.
She reports a 3 day history of chills, cough productive of clear
sputum, wheezing. She has been using her inhaler and albuterol
nebs ___ times a day without much improvement over the past
week. No recorded fevers, nausea, vomiting, abdominal pain but
did note chest tightness associated with wheezing. She feels
this is similar to her prior episodes of asthma exacerbations.
She went to her regularly scheduled PCP follow up today and was
noted to be mildly hypoxic with an oxygen saturation of 90%,
improved to 95% after albuterol nebulizer. Wheezing not
significantly improved with nebulizer. Peak flow 150 at best
attempt. Thus sent to ED.
Last asthma exacerbation was in ___. She takes ___ and
montelukast for maintenance and albuterol home nebs prn
exacerbation + rescue inhaler if outside. Was recently in
___ in ___, no respiratory difficulties at that time.
In ED, VS: Temp: 98.2 HR: 87 BP: 127/80 Resp: 22 O(2)Sat: 99
Normal. Exam notable for decreased air movement throughout,
expiratory wheezes. Labs showed WBC 6.8, H/H 9.7/31.5
(baseline), plt 158. CXR shows no evidence of infiltrates. She
was given a duoneb, azithro 500 and prednisone PO 60mg x1. Given
her peak flow was still 150 after nebs, she was admitted to
medicine for frequent nebs.
Past Medical History:
Moderate Persistent Asthma
Tracheobronchomalacia
Mild restrictive ventilatory defect (likely ___ obesity)
GERD
Hepatitis C genotype 1a (Dx ___, not on therapy)
HTN
Insomnia
Anxiety
Depression
Obesity
Chronic back/right thigh pain
History of alcohol and crack-cocaine abuse.
Likely adhesive capsulitis of right shoulder.
___ digit injury sp repair of PIP volar plate on ___
Social History:
___
Family History:
No family history of lung disease
Physical Exam:
ADMISSION
Gen: Obese, anxious, NAD
HEENT: NCAT, EOMI
Neck; JVD difficult to assess
CV: RRR, nl S1 S2
Lungs: diffuse expiratory wheezes, prolonged expiratory wheezes,
no egophony. No rales
Abd: Soft, non tender, non distended, +BS, no organomegaly
Ext: 2+ edema at midshins
Neuro: Moves all 4 extremities grossly
DISCHARGE
VS: 97.6 135/93 92 20 100%RA
Gen: sitting up on side of bed, comfortable
Eyes - EOMI
ENT - OP clear, MMM
Heart - RRR no mrg
Lungs - CTA bilaterally
Abd - soft nontender, normoactive bowel sounds
Ext - no edema
Skin - no rashes
Vasc - 2+ DP/radial pulses
Neuro - AOx3, moving all extremities; no tremor
Psych - appropriate
Pertinent Results:
ADMISSION
___ 06:03PM BLOOD WBC-6.8 RBC-3.46* Hgb-9.7* Hct-31.5*
MCV-91 MCH-28.0 MCHC-30.8* RDW-16.3* RDWSD-53.6* Plt ___
___ 06:03PM BLOOD Glucose-91 UreaN-12 Creat-0.7 Na-137
K-3.5 Cl-104 HCO3-25 AnGap-12
___ 07:40AM BLOOD ALT-32 AST-63* LD(LDH)-174 AlkPhos-96
TotBili-0.5
DISCHARGE
___ 10:55AM BLOOD WBC-6.5 RBC-3.34* Hgb-9.1* Hct-30.0*
MCV-90 MCH-27.2 MCHC-30.3* RDW-16.5* RDWSD-54.0* Plt ___
___ 10:55AM BLOOD Glucose-97 UreaN-41* Creat-0.8 Na-137
K-5.1 Cl-104 HCO3-23 AnGap-15
CXR - ___
No evidence of pneumonia.
RUQ U/S - ___
Coarsened and nodular appearance of the liver, sonographically
consistent with cirrhosis, with moderate splenomegaly. No
evidence of focal liver lesion or ascites.
Medications on Admission:
Medications:
ALBUTEROL SULFATE - albuterol sulfate 0.63 mg/3 mL solution for
nebulization. 1 nebulitazion inhaled once to three times a day
as
needed for wheezing, shortness of breath
ALBUTEROL SULFATE [PROAIR HFA] - ProAir HFA 90 mcg/actuation
aerosol inhaler. 2 puffs INH every four to six hours as needed
BUDESONIDE-FORMOTEROL [SYMBICORT] - Symbicort 160 mcg-4.5
mcg/actuation HFA aerosol inhaler. 2 puffs(s) IH twice a day
CYCLOBENZAPRINE - cyclobenzaprine 5 mg tablet. 1 tablet(s) by
mouth three times per day as needed for back pain
DIAZEPAM - diazepam 2 mg tablet. 1 tablet(s) by mouth at bedtime
DO NOT FILL UNTIL ___
FLUTICASONE - fluticasone 50 mcg/actuation nasal
spray,suspension. 1 spray both nares twice a day
FUROSEMIDE - furosemide 20 mg tablet. 1 tablet(s) by mouth daily
GABAPENTIN - gabapentin 600 mg tablet. 1 tablet(s) by mouth 3
times per daily standing three times a day
LIDOCAINE - lidocaine 5 % topical patch. 1 patch daily
MONTELUKAST - montelukast 10 mg tablet. 1 tablet(s) by mouth
once
a day
NORTRIPTYLINE - nortriptyline 25 mg capsule. 1 capsule(s) by
mouth twice a day
OXYCODONE - oxycodone 5 mg tablet. 1 tablet(s) by mouth every
___
hours as needed for pain. Do NOT drink or drive while on this
med
DO NOT FILL UNTIL ___
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - Spiriva with
HandiHaler 18 mcg and inhalation capsules. 1 puff inhaled Daily
TRAZODONE - trazodone 50 mg tablet. 1 tablet(s) by mouth every
night before sleep
WALKER WITH SEAT ATTACHMENT - walker with seat attachment . use
as directed Dx: chronic low back pain Wt: 224 lbs: 5ft
Lifetime
need
Medications - OTC
ASPIRIN [ASPIRIN LOW DOSE] - Aspirin Low Dose 81 mg
tablet,delayed release. one tablet,delayed release (___) by
mouth daily
CHOLECALCIFEROL (VITAMIN D3) - cholecalciferol (vitamin D3)
2,000
unit capsule. 1 capsule(s) by mouth once a day
LORATADINE [CLARITIN] - Claritin 10 mg tablet. 1 tablet(s) by
mouth once a day
OMEPRAZOLE - omeprazole 20 mg tablet,delayed release. 2
tablet,delayed release (___) by mouth once a day
Discharge Medications:
1. Azithromycin 250 mg PO Q24H Duration: 2 Days
last day = ___
RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*1
Tablet Refills:*0
2. PredniSONE 60 mg PO DAILY Duration: 2 Doses
Start: ___, First Dose: First Routine
Administration Time
This is dose # 1 of 3 tapered doses
RX *prednisone 20 mg AS DIR tablet(s) by mouth daily Disp #*15
Tablet Refills:*0
3. PredniSONE 40 mg PO DAILY Duration: 3 Doses
Start: After 60 mg DAILY tapered dose
This is dose # 2 of 3 tapered doses
4. PredniSONE 20 mg PO DAILY Duration: 3 Doses
Start: After 40 mg DAILY tapered dose
This is dose # 3 of 3 tapered doses
5. albuterol sulfate 0.63 mg / 3 mL INHALATION TID:PRN
wheezing, SOB
6. albuterol sulfate 90 mcg/actuation INHALATION Q4H:PRN
wheezing, SOB
7. Aspirin 81 mg PO DAILY
8. budesonide-formoterol 160-4.5 mcg/actuation INHALATION BID
9. Cyclobenzaprine 5 mg PO TID:PRN back pain
10. Diazepam 2 mg PO QHS
11. Fluticasone Propionate NASAL 1 SPRY NU DAILY
12. Furosemide 20 mg PO DAILY
13. Gabapentin 600 mg PO TID pain
14. Lidocaine 5% Patch 1 PTCH TD QAM
15. Montelukast 10 mg PO DAILY
16. Nortriptyline 25 mg PO BID
17. Omeprazole 20 mg PO DAILY
18. OxycoDONE (Immediate Release) 5 mg PO Q4-6HRS: PRN pain
19. Tiotropium Bromide 1 CAP IH DAILY
20. TraZODone 50 mg PO QHS:PRN insomnia
21. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
# Moderate Persistent Asthma with Acute Exacerbation
# Anxiety
# Chronic Pain Back and Leg Pain
# GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ woman with asthma presenting with worsening shortness
of breath, evaluate for pneumonia
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph and CT ___
FINDINGS:
Cardiomediastinal silhouette is normal. There is no pleural effusion or
pneumothorax. There is left basilar atelectasis, as demonstrated on prior CT.
There is no focal lung consolidation concerning for pneumonia.
IMPRESSION:
No evidence of pneumonia.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old woman (patient of Dr. ___ with PMH of
asthma, COPD, anxiety, hepatitis C, chronic hip and low back pain who
presented to ED with dyspnea c/w asthma exacerbation evaluate for cirrhosis,
___ screening
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The hepatic parenchyma appears coarsened. The contour of the liver is
nodular, consistent with cirrhosis. There is no focal liver mass. The main
portal vein is patent with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 2 mm.
GALLBLADDER: The gallbladder is contracted, somewhat limiting evaluation.
PANCREAS: The pancreas is not well visualized, largely obscured by overlying
bowel gas.
SPLEEN: Normal echogenicity, measuring 16.9 cm.
KIDNEYS: Limited views of the right kidney show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
Coarsened and nodular appearance of the liver, sonographically consistent with
cirrhosis, with moderate splenomegaly. No evidence of focal liver lesion or
ascites.
Radiology Report
INDICATION: ___ year old woman (patient of Dr. ___ with PMH of
asthma, COPD, anxiety, hepatitis C, chronic hip and low back pain who
presented to ED with dyspnea c/w asthma exacerbation. // eval for pulmonary
congestion, effusions
TECHNIQUE: Frontal view of the chest
COMPARISON: ___
FINDINGS:
Mild bibasilar opacities are consistent with atelectasis. Prominent perihilar
vessels are unchanged. There is no pulmonary edema or pneumothorax. There is
no large pleural effusions. Mildly enlarged cardiac silhouette is unchanged.
IMPRESSION:
Prominent pulmonary vessels are similar to ___. There is no pulmonary
edema large pleural effusion.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with asthma exacerbation, initially improving,
now with worsening wheezing // signs of new consolidation signs of new
consolidation
IMPRESSION:
In comparison with the study of ___, there again is enlargement of the
cardiac silhouette, but little if any vascular congestion. Atelectatic
changes are seen in the retrocardiac region. No acute focal pneumonia.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with Chronic obstructive pulmonary disease w (acute) exacerbation
temperature: 98.2
heartrate: 87.0
resprate: 22.0
o2sat: 99.0
sbp: 127.0
dbp: 80.0
level of pain: 0
level of acuity: 2.0 | This is a ___ year old female with past medical history of
moderate persistent asthma, anxiety, hepatitis C, admitted
___ with dyspnea and cough secondary to acute asthma
exacerbation, treated with steroids and azithromycin with
improvement, discharged home with services
# Moderate Persistent Asthma with Acute Exacerbation - Patient
admitted with cough and wheezing, as well as concerning upper
airway stridorous sounds. Chest xray was clear. Patient was
started on systemic steroids and nebulizers without initial
improvement, prompting pulmonary consultation who felt this was
likely an asthma exacerbation complicated by vocal cord
dysfunction, with possible contribution from bacterial
bronchitis. Started PO Azithromycin and continued above
interventions, as well as home montelukast and loratadine. She
slowly clinically improved, subsequently was ready for discharge
after several days of ongoing inpatient management. Ambulatory
saturation was 96-97% on room air. She was discharged to
completed 5 day course of azithromycin, last day = ___, and
total 2 week course of prednisone with a taper. Continued
tiotropium, budesonide-formoterol.
# Anxiety - continued valium
# Furosemide usage - based on review of her chart, we could find
no clear documentation regarding what lasix was being used for
(hypertension, diastolic CHF, lower extremity edema); would
consider addressing as outpatient.
# Chronic Pain Back and Leg Pain - continued nortriptyline,
gabapentin, cyclobenzaprine, oxycodone.
# GERD - continued PPI
# Primary prevention - continued aspirin
# Anxiety - continue valium
Transitional Issues
- RUQ ultrasound showed "Coarsened and nodular appearance of the
liver, sonographically consistent with cirrhosis, with moderate
splenomegaly. No evidence of focal liver lesion or ascites."
Would consider outpatient referral to hepatology
- Last day azithromycin = ___
- Last day prednisone taper = ___ (60mg daily x 2 days, 40mg
daily x 3 days, 20mg daily x 3 days) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This patient is a ___ year old female who complains of s/p Fall,
Transfer. The patient is transferred from ___. She
presented status post fall at 4 AM. She was diagnosed with right
9 through 12 rib fractures. There is a
question of syncope. She was hemodynamically stable. She had a
head CT and a neck CT that were negative. She has right hip pain
and right knee pain. She received fentanyl and Ativan. There is
question of hemothorax but no evidence of
pneumothorax.
Past Medical History:
PMH:
HLD, Osteoporosis, GERD, frequent falls, uterine cancer
PSH:
Hysterectomy, R hip pinning
Social History:
___
Family History:
Non-contributory
Physical Exam:
VS: Temp: 97.5 BP:130/72 HR:88 O2:18 O2%92
Constitutional: In pain with movement
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact
Chest: Clear to auscultation right chest wall tenderness
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender
Extr/Back: Right knee contusion with minimal tenderness.
There is minimal right hip tenderness. Right lower extremity
is neurovascular intact and there is no other evidence of
trauma Back: Nontender
Extremities: Nontender, no evidence of trauma. Neurovascular
intact. Normal pulses.
Pelvis: Stable.
Neuro: Speech fluent A/O X 3
CN ___
intact
Normal sensory, normal motor.
Normal cerebellar function, downgoing toes, DTRs normal
___ Results:
IMAGING:
___: CXR:
Portable AP upright view the chest provided. In this patient
with multiple known right rib fractures, there is no evidence of
right pleural effusion or pneumothorax. There is no focal
consolidation or signs of edema. Cardiomediastinal silhouette
appears grossly unremarkable. Known rib fractures better
assessed on CT. Degenerative changes at the right shoulder
noted.
___: KNEE (AP, LAT & OBLIQUE) RIGHT:
No acute fracture, dislocation or joint effusion. Mild
degenerative disease.
___: CXR:
Compared to chest radiographs since ___ most recently ___.
Small right pleural effusion or right basal atelectasis is new.
No
pneumothorax. Left lung clear. Heart size normal.
___: CXR:
Comparison to ___. New minimal parenchymal opacity at
the right
lung bases, combines to a minimal right pleural effusion. The
effusion is
better seen on the lateral than on the frontal view. There is
no evidence of pneumothorax. Stable appearance of the cardiac
silhouette and of the left lung.
LABS:
___ 06:39PM LACTATE-2.2*
___ 06:30PM GLUCOSE-164* UREA N-16 CREAT-0.7 SODIUM-136
POTASSIUM-4.4 CHLORIDE-96 TOTAL CO2-28 ANION GAP-12
___ 06:30PM CALCIUM-8.7 PHOSPHATE-4.0 MAGNESIUM-2.1
___ 06:30PM WBC-6.5 RBC-4.06 HGB-12.1 HCT-36.1 MCV-89
MCH-29.8 MCHC-33.5 RDW-14.8 RDWSD-48.2*
___ 06:30PM PLT COUNT-145*
___ 06:30PM ___ PTT-25.4 ___
___ 10:15AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 10:15AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Simvastatin 20 mg PO QPM
2. Levothyroxine Sodium 50 mcg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
3. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
Take lowest effective dose, wean as tolerated.
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
4. Polyethylene Glycol 17 g PO DAILY
5. Senna 8.6 mg PO BID:PRN Constipation
6. Levothyroxine Sodium 50 mcg PO DAILY
7. Simvastatin 20 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
-Fall
-Right ___ rib fractures
-Small right hemothorax
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
Followup Instructions:
___
Radiology Report
INDICATION: Trauma, fall
COMPARISON: Prior CT of the chest from outside hospital performed earlier
same day.
FINDINGS:
Portable AP upright view the chest provided. In this patient with multiple
known right rib fractures, there is no evidence of right pleural effusion or
pneumothorax. There is no focal consolidation or signs of edema.
Cardiomediastinal silhouette appears grossly unremarkable. Known rib
fractures better assessed on CT. Degenerative changes at the right shoulder
noted.
IMPRESSION:
As above.
Radiology Report
INDICATION: ___ with trauma// fracture/disloc
COMPARISON: None
FINDINGS:
Three views of the right knee provided. Bones are diffusely demineralized.
There is faint calcification in the tibiofemoral joint space likely due to
chondrocalcinosis. No acute fracture, dislocation or joint effusion. A
superior patellar enthesophytes is noted. Tiny dorsal patellar spurs are
present. Soft tissues are unremarkable.
IMPRESSION:
No acute fracture, dislocation or joint effusion. Mild degenerative disease.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with R rib fx, small effusion// interval change
interval change
IMPRESSION:
Compared to chest radiographs since ___ most recently ___.
Small right pleural effusion or right basal atelectasis is new. No
pneumothorax. Left lung clear. Heart size normal.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with R ___ Rib fx// R rib tx, with new O2
requirement R rib tx, with new O2 requirement
IMPRESSION:
Comparison to ___. New minimal parenchymal opacity at the right
lung bases, combines to a minimal right pleural effusion. The effusion is
better seen on the lateral than on the frontal view. There is no evidence of
pneumothorax. Stable appearance of the cardiac silhouette and of the left
lung.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, Transfer
Diagnosed with Multiple fractures of ribs, right side, init for clos fx, Unspecified fall, initial encounter
temperature: 96.9
heartrate: 75.0
resprate: 15.0
o2sat: 100.0
sbp: 118.0
dbp: 80.0
level of pain: 5
level of acuity: 1.0 | Ms. ___ is a ___ y/o F transferred from ___ s/p
unwitnessed fall. Per EMS report, pt had an unwitnessed fall
while at home, with a possible syncopal episode. CT showed R
rib ___ fx with small R hemothorax and was transferred to ___
for further work-up. At ___, she was HD stable and
maintaining O2sat >95% with adequate respirations. She was
admitted to ___ for closer resp monitoring. When appropriate
patient was transferred to the floor.
She initially received acetaminophen with IV morphine PRN and
then pain medication as later converted to oral oxycodone with
prn acetaminophen. The patient was alert and oriented throughout
hospitalization. She remained stable from a cardiovascular and
pulmonary standpoint; vital signs were routinely monitored. Good
pulmonary toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization. The patient tolerated a
regular diet and intake and output were closely monitored. The
patient's fever curves were closely watched for signs of
infection, of which there were none. The patient's blood counts
were closely watched for signs of bleeding, of which there were
none. The patient received subcutaneous heparin and ___ dyne
boots were used during this stay and was encouraged to get up
and ambulate as early as possible.
The patient received subcutaneous heparin and venodyne boots
were used during this stay; was encouraged to get up and
ambulate as early as possible.
The patient worked with Physical Therapy and it was recommended
she be discharged to rehab to continue her recovery.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
___ instructions with understanding verbalized and
agreement with the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
ibuprofen
Attending: ___
___ Complaint:
Tongue swelling
Major Surgical or Invasive Procedure:
Intubated for airway protection
History of Present Illness:
___ yo woman without significant past medical history who
presents with acute onset tongue swelling at about 3pm today.
She reports NKDA. She ate a lunch of fried chicken, fried
plantains and salad with dressing and acutely developed tongue
swelling and feeling unwell. She went to the ED.
In the ED, initial VS were T 96.8 P 90 BP 131/83 RR 18 O2 98% on
RA.
The patient complained of airway swelling and had impending
respiratory distress. She had a difficult awake intubation..
Labs were unremarkable. CXRay showed no acute abnl. Pt received
125 mg methylpred, famotidine, and diphenhydramine. Pt did not
receive epinephrine.
On arrival to the MICU, pt intubated. Per discussion with
sister, she had two previous episiode of brief tongue swelling
in the past, month that resolved without intervention. She has
no history of allergies to any foods or medications. She is
fairly healthy. She uses no illicits. She has no family history
of anything like this occurring. She has recently been taking
more NSAIDs for back pain.
Review of systems:
Unable to be obtained due to intubation.
Past Medical History:
hypothyroid
iron deficiency
Fibroids
Social History:
___
Family History:
Denies any history of allergies or anaphylaxis
Physical Exam:
On Admission
General: Intubated and sedated.
HEENT: Face swollen, tongue swollen
Neck: Thick, significant submandibular swelling
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Inspiratory rhonchi bilaterally without wheeze, good air
movement.
Abdomen: Distended
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Not assessed
Skin: No rash
On Discharge:
General:Awake, alert NAD.
HEENT: tongue swollen but much smaller in size than before
Neck: Thick, significant submandibular swelling
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Inspiratory rhonchi bilaterally without wheeze, good air
movement.
Abdomen: obese, soft, NT ND
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: non-focal exam
Skin: No rash
Pertinent Results:
IMPRESSION:
CXR: ___
1. Endotracheal tube likely has its tip approximately 2 cm
above the carina. Placement of nasogastric tube which courses
below the diaphragm and has its tip projecting over the expected
location of the stomach. Lung volumes remain low. The heart is
upper limits of normal in size given portable technique. There
is increasing prominence to the hilar soft tissues, which may
reflect prominent vascular structures. This can be better
assessed on followup imaging. Low lung volumes with patchy
opacity at the left base most likely reflecting atelectasis,
although superimposed pneumonia cannot be entirely excluded. No
large pneumothorax. No large pleural effusions. No evidence of
pulmonary edema
ON ADMISSION
___ 05:50PM GLUCOSE-97 UREA N-13 CREAT-0.9 SODIUM-138
POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-26 ANION GAP-11
___ 05:56PM LACTATE-1.0
___ 05:50PM ALT(SGPT)-17 AST(SGOT)-19 ALK PHOS-43 TOT
BILI-0.1
___ 05:50PM TSH-1.2
___ 05:50PM CRP-1.3
___ 05:50PM C3-148 C4-38
___ 05:50PM WBC-9.3# RBC-4.45 HGB-11.6* HCT-36.1 MCV-81*#
MCH-26.0*# MCHC-32.1 RDW-17.0*
___ 05:50PM SED RATE-11
___ 05:50PM ___ PTT-27.7 ___
___- positive 1:40
___ 03:20AM BLOOD PEP-PND
___ 03:20AM BLOOD C1 ESTERASE INHIBITOR, FUNCTIONAL
ASSAY-PND
___ 03:20AM BLOOD TRYPTASE-PND
___ 03:20AM BLOOD C1 INHIBITOR-PND
ON DISCHARGE
___ 03:38AM BLOOD WBC-15.0* RBC-3.88* Hgb-10.0* Hct-32.4*
MCV-83 MCH-25.8* MCHC-30.9* RDW-16.9* Plt ___
___ 03:38AM BLOOD Glucose-91 UreaN-20 Creat-0.7 Na-141
K-3.9 Cl-108 HCO3-24 AnGap-13
___ 03:38AM BLOOD Calcium-8.6 Phos-3.8 Mg-2.3
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. PredniSONE 40 mg PO DAILY
RX *prednisone 5 mg 8 tablets(s) by mouth daily Disp #*39 Tablet
Refills:*0
2. DiphenhydrAMINE 25 mg PO Q 8H
RX *diphenhydramine HCl [Antihistamine] 25 mg 1 capsule(s) by
mouth twice a day Disp #*4 Capsule Refills:*0
3. Ferrous Sulfate 325 mg PO DAILY
4. EpiPen *NF* (EPINEPHrine) 0.3 mg/0.3 mL (1:1,000) Injection
once as needed throat swelling
RX *epinephrine [EpiPen] 0.3 mg/0.3 mL (1:1,000) 1 injection IM
once as needed Disp #*1 Tube Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Angioedema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAM: Chest AP portable views.
CLINICAL INFORMATION: Intubation.
___.
FINDINGS: Endotracheal tube is seen, terminating approximately 3.5 cm above
the level of the carina on the semi-erect view and approximately 5.3 cm above
the level of the carina on the portable #1 view. No focal consolidation,
pleural effusion, or pneumothorax is seen. The cardiac silhouette is top
normal. The mediastinal contours are unremarkable. No displaced fracture is
seen.
Radiology Report
PORTABLE AP CHEST ON ___ AT 2202
CLINICAL INDICATION: ___ with angioedema, status post intubation,
evaluate for tube placement.
Comparison is made to the patient's previous study dated ___ at 1821.
Portable semi-supine chest film ___ at 2202 is submitted.
IMPRESSION:
1. Endotracheal tube likely has its tip approximately 2 cm above the carina.
Placement of nasogastric tube which courses below the diaphragm and has its
tip projecting over the expected location of the stomach. Lung volumes remain
low. The heart is upper limits of normal in size given portable technique.
There is increasing prominence to the hilar soft tissues, which may reflect
prominent vascular structures. This can be better assessed on followup
imaging. Low lung volumes with patchy opacity at the left base most likely
reflecting atelectasis, although superimposed pneumonia cannot be entirely
excluded. No large pneumothorax. No large pleural effusions. No evidence of
pulmonary edema.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: SWOLLEN TONGUE
Diagnosed with ANGIONEUROTIC EDEMA, ACCIDENT NOS
temperature: 96.8
heartrate: 90.0
resprate: 18.0
o2sat: 98.0
sbp: 131.0
dbp: 83.0
level of pain: 0
level of acuity: 1.0 | Ms ___ is a ___ yo woman with hypothyroidism presenting with
angioedema intubated for airway protection
# Angioedema: On presentation patient presenting with chief
complaint of throat tightness, but no other symptoms concerning
for mast-cell mediated angioedema, such as urticaria, flushing,
generalized pruritus. However, the time course with fairly rapid
onset over the period of hours with significant tongue/lip
swelling decision made to intubate for airway protection.
Patient was given benadryl, famotidine and methlypred 40mg IV
BID x48hr and then transitioned to prednisone for a planned
taper. Allergy was consulted and a work-up was sent: C4 and C1
inhibitor level,LFTs, CRP, ESR, and C4/C3 levels. ESR, CRP,
C4/C3, and LFT's were normal. ___ was positive. The thought was
that this episode of angioedema was idiopathic or caused by
NSAID use.
Patient was extubated AM of ___. She remained comfortable on
room air. She was able to ambulate and tolerate a full diet on
d/c. She was discharged with 8 days of prednisone for a total of
a 12 day course. She was also given an EPIPEN Rx and benadryl.
# Iron Deficiency
Patient sent home on home iron dose.
Transitional issues
-Patient will follow-up with allergist Dr ___
-C1 Inh, C1 esterase inhibitor, and tryptase level are pending |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Motrin / acetaminophen
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a history of GERD, previous heavy alcohol use (none
since ___, and recent dx of pancreatitis presents with several
days of diffuse, but mosly epigastric abdominal pain radiating
to the back.
Patient was diagnosed at ___ ___ with
pancreatitis confirmed with CT scan. He was subsequently
readmitted at the end of ___ for recurrent pancreatitis with a
lipase of 144. He had a lipase of 39 at discharge from ___ on
___.
Patient was pain free ___, but over last couple days
epigastric pain has returned. No as severe as first episode, but
it is associated with nausea and one episode of emesis. Patient
has been able to tolerate basic PO including soup broth and
simple vegetables. No recent fevers or chills. No constipation
or diarrhea. Abdominal pain radiates to back but also to L chest
recently, which is new.
In the ED initial vitals were: 98.9 76 134/76 18 99% ra
- Labs were significant for lipase 102. Other LFT's normal
- Patient was given 10mg IV morphine and 1mg IV dilaudid
Vitals prior to transfer were: 97.9 59 126/99 16 100% RA
On the floor, patient reports ___ abdominal pain with no
current nausea or vomiting.
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
-Recent Pancreatitis at ___
-Hepatitis C- Not on treatment
-GERD
-Polysubstance Abuse
Social History:
___
Family History:
Mother and father both died of cancer- unknown type
Physical Exam:
ADMISSION:
Vitals - T:97.9 BP:159/95 HR:59 RR:20 02 sat: 100RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition, nontender supple neck, no
LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, ? decreased breath sounds at L
base
ABDOMEN: nondistended, +BS, tender in epigastric area and LUQ.
tender in epigastrium when palpating in all quadrants. Negative
___ sign
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE:
VSS
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition, nontender supple neck, no
LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB
ABDOMEN: nondistended, +BS, slightly tender in epigastric area
and LUQ. tender in epigastrium when palpating in all quadrants.
Negative ___ sign
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
___ 03:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 03:15PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 03:15PM URINE UHOLD-HOLD
___ 03:15PM URINE HOURS-RANDOM
___ 03:20PM PLT COUNT-228
___ 03:20PM NEUTS-64.3 ___ MONOS-5.5 EOS-2.6
BASOS-0.6
___ 03:20PM WBC-7.7 RBC-4.66 HGB-15.6 HCT-49.1 MCV-105*
MCH-33.4* MCHC-31.7 RDW-12.6
___ 03:20PM ALBUMIN-4.4 CALCIUM-9.9 PHOSPHATE-2.2*
MAGNESIUM-2.0
___ 03:20PM LIPASE-102*
___ 03:20PM ALT(SGPT)-29 AST(SGOT)-27 ALK PHOS-66 TOT
BILI-0.4
___ 03:20PM estGFR-Using this
___ 03:20PM GLUCOSE-101* UREA N-12 CREAT-0.9 SODIUM-141
POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-31 ANION GAP-10
___ 03:32PM ___ PTT-32.5 ___
DISCHARGE LABS:
___ 06:08AM BLOOD WBC-5.6 RBC-3.90* Hgb-13.5* Hct-40.5
MCV-104* MCH-34.6* MCHC-33.3 RDW-11.9 Plt ___
___ 06:08AM BLOOD Glucose-87 UreaN-9 Creat-0.8 Na-141 K-3.9
Cl-106 HCO3-28 AnGap-11
___ 06:08AM BLOOD Calcium-8.5 Phos-3.7 Mg-1.9
___ 06:08AM BLOOD Triglyc-105
MICRO:
___ 3:15 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
IMAGING:
CXR ___: As compared to the previous radiograph, no relevant
change is seen. The lung
volumes are normal. Normal size of the cardiac silhouette.
Normal hilar and
mediastinal structures. No pleural effusions. No pneumonia, no
pulmonary
edema.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 40 mg PO DAILY
Discharge Medications:
1. Omeprazole 40 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Alcoholic pancreatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with pancreatitis and new L sided chest pain //
Eval for pleural effusion
COMPARISON: ___.
IMPRESSION:
As compared to the previous radiograph, no relevant change is seen. The lung
volumes are normal. Normal size of the cardiac silhouette. Normal hilar and
mediastinal structures. No pleural effusions. No pneumonia, no pulmonary
edema.
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with ACUTE PANCREATITIS
temperature: 98.9
heartrate: 76.0
resprate: 18.0
o2sat: 99.0
sbp: 134.0
dbp: 76.0
level of pain: 10
level of acuity: 3.0 | ___ yo M admitted with abdominal pain.
#Abdominal Pain/Alcoholic Pancreatitis:
Patient was diagnosed with pancreatitis in beginning of ___
with confirmed CT findings. Represented to ___ at end of
___ with similar complaints- no imaging was obtained at that
time. Lipase only 106 at this point, though pain very similar in
quality from last month. BISAP score zero. On further discussion
pt said that the main reason for presentation was to acquire
narcotics, that he had been taking family member's narcotic
medications, and that if he wouldnt be receiving narcotics then
he wanted to be discharged. It was recommended by social work
that he enter into substance abuse programs as an outpatient,
and that consideration be made for treating his depression. His
diet was quickly advanced without complication and was
comfortable. It was felt very unlikely that he had a
complication such as necrosis or pseudocyst and was subsequently
was discharged on a low fat diet.
#History of Hepatitis C:
LFT's normal. Never been treated. Outpatient follow-up.
#GERD: Continued home omeprazole
#Substance abuse: It was recommended by social work that he
enter into substance abuse programs as an outpatient, and that
consideration be made for initiation of antidepressant
medication.
Transitional issues:
- Liver f/u for untreated hep C
- Referred to substance abuse programs as an outpt
- Recommend assessment of level of depression and indications
for treatment
- Discharged with low fat diet |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Phenergan Plain / Compazine / Reglan / Haldol / citalopram
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
Colonoscopy
History of Present Illness:
Ms ___ is a ___ y/o F with PMH significant for type 1 DM,
complicated by gastroparesis (s/p gastric stimulator, with
recent
generator change on ___, HTN, HLD, Anxiety/Depression, and UE
DVT (on warfarin), who
is presenting with abdominal pain and distention.
Patient reports that, after having worsening nausea and
abdominal
pain, she had her gastric stimulator replaced on ___, with good
improvement in nausea and PO tolerance. However, she had the
stimulator turned off on ___ due to periodic abdominal cramps
that were possibly due to the stimulator (although the
stimulator
was confirmed via CT to be in proper place). After the
stimulator
was turned off, the patient notes that increased nausea and
decreased p.o. intake. She reports 1 small non-bilious
non-bloody
small volume vomitus after eating today.
She also reports increasing abdominal distention and lower
abdominal pain for the last few weeks. During this time, she
notes that her stool caliber has been decreasing over the last
few weeks. Normally she suffers constipation and passes large,
hard stools. Currently she is having daily soft stools that are
2-3 cm in diameter, and brown in color, which she considers
abnormal. Denies bloody stools.
On further ROS, the patient also reports a syncopal episode 3
days ago in the context of blood sugar is at 50 and denies
hitting her head. Paramedics arrived, patient refused to be
transported at that time. No syncopal episodes since.
ROS is also positive for diffuse headache, but is negative for
chest pain, SOB.
Initial vital signs were notable for:
99.0 98 160/93 18 99% RA
Exam notable for:
+ Port LUQ, non erythematous
+ Right eye subconjunctival hemorrhage 40% left side of eye
+ rRght lower quadrant stimulator without erythema or pain at
the
site, abdomen is mildly distended, normoactive bowel sounds,
diffusely mildly tender
Labs were notable for: Cr 1.2, Glucose 290, INR 4.6. Normal UA.
Studies performed include: None
Patient was given:
___ 19:06IVHYDROmorphone (Dilaudid) 1 mg
___ 19:06IVDiphenhydrAMINE 25 mg
___ 19:15IVFNS
___ 20:09IVFNS 1000 mL
Consults:
# Surgery: state gastric stimulator site well healing, no
intervention necessary
Vitals on transfer: 98.5 PO13___ L Lying 88 16 98RA
Upon arrival to the floor, the patient is stable, suffering from
diffuse abdominal pain, and asking for dilaudid.
Past Medical History:
Type 1 DM
diabetic retinopathy
gastroparesis
- recurrent inpatient admissions, mostly at ___
- history of G-tube when previously needed for nutrition
- s/p neuroenteric gastric stimulator ___, ___
- s/p pyloric Botox injections
chronic abdominal pain (on longstanding opiates)
colonic inertia (attributed to opiates)
anxiety (followed by psych at ___
depression
bulimia
iron deficiency anemia
AUB s/p D&C
upper extremity DVT (on Coumadin while she has a Port-A-Cath in
place)
Genital herpes
carpal tunnel syndrome
Hyperlipidemia
Hypertension
MRSA carrier
Social History:
___
Family History:
Father with DM 2. Mother with ___. Brother with
diabetes.
Sister with ___. Maternal uncle and maternal grandmother
died
of MI's at age ___.
Physical Exam:
ADMISSION EXAM:
VITALS: 98.5 PO135 / 83 L Lying 88 16 98RA
GENERAL: Alert, in no acute distress.
HEENT: PERRL MMM.
NECK: No JVD.
CARDIAC: RRR, nl s1/s2, no m/r/g
LUNGS: CTAB
ABDOMEN: Normal bowels sounds, minimally distended, mild
tenderness in epigastrum and lower abdomen without rebound or
guarding
EXTREMITIES: No edema
SKIN: Warm. No rash.
NEUROLOGIC: AOx3.
DISCHARGE EXAM:
___ ___ Temp: 98.7 PO BP: 135/77 L Lying HR: 85 RR: 16 O2
sat: 97% O2 delivery: Ra FSBG 223
GENERAL: Lying comfortably in bed
HEENT: NC/AT, PERRL, EOMI
NECK: supple, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales, or
rhonchi
CV: RRR, S1/S2, no murmurs, gallops, or rubs
Abd: Soft, nondistended. Normoactive bowel sounds. TTP ___
throughout, not peritoneal. No e/o organomegaly. LLQ insulin
pump in place RLQ gastric stimulator in place no overlying
erythema or TTP.
EXTREMITIES: 2+ peripheral pulses
Pertinent Results:
ADMISSION LABS:
___ 04:35PM URINE RBC-1 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-1
___ 04:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-1000* KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 04:35PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 04:35PM URINE UCG-NEGATIVE
___ 04:35PM URINE HOURS-RANDOM
___ 06:29PM PLT COUNT-274
___ 06:29PM ___ PTT-59.4* ___
___ 06:29PM NEUTS-66.9 ___ MONOS-8.8 EOS-1.2
BASOS-0.3 IM ___ AbsNeut-3.95 AbsLymp-1.33 AbsMono-0.52
AbsEos-0.07 AbsBaso-0.02
___ 06:29PM WBC-5.9 RBC-3.96 HGB-11.4 HCT-35.3 MCV-89
MCH-28.8 MCHC-32.3 RDW-14.5 RDWSD-46.5*
___ 06:29PM cTropnT-<0.01
___ 06:29PM estGFR-Using this
___ 06:29PM GLUCOSE-292* UREA N-15 CREAT-1.2* SODIUM-137
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-26 ANION GAP-7*
INTERVAL LABS:
___ 04:58AM BLOOD WBC-4.0 RBC-4.20 Hgb-12.0 Hct-37.5 MCV-89
MCH-28.6 MCHC-32.0 RDW-14.9 RDWSD-47.3* Plt ___
___ 06:20AM BLOOD WBC-6.5 RBC-4.23 Hgb-12.0 Hct-37.8 MCV-89
MCH-28.4 MCHC-31.7* RDW-14.6 RDWSD-46.6* Plt ___
___ 04:33AM BLOOD WBC-4.8 RBC-4.04 Hgb-11.8 Hct-36.3 MCV-90
MCH-29.2 MCHC-32.5 RDW-14.8 RDWSD-47.7* Plt ___
___ 07:19AM BLOOD WBC-4.3 RBC-4.12 Hgb-11.9 Hct-37.4 MCV-91
MCH-28.9 MCHC-31.8* RDW-14.6 RDWSD-48.3* Plt ___
___ 04:58AM BLOOD Plt ___
___ 04:58AM BLOOD ___ PTT-73.5* ___
___ 06:20AM BLOOD Plt ___
___ 06:20AM BLOOD ___ PTT-111.5* ___
___ 04:33AM BLOOD Plt ___
___ 04:33AM BLOOD ___ PTT-45.8* ___
___ 04:58AM BLOOD Glucose-117* UreaN-15 Creat-1.1 Na-138
K-4.5 Cl-103 HCO3-27 AnGap-8*
___ 06:20AM BLOOD Glucose-153* UreaN-10 Creat-1.0 Na-139
K-3.9 Cl-102 HCO3-24 AnGap-13
___ 04:33AM BLOOD Glucose-84 UreaN-14 Creat-0.9 Na-142
K-4.1 Cl-105 HCO3-27 AnGap-10
___ 04:58AM BLOOD Calcium-9.2 Phos-3.6 Mg-2.1
___ 06:20AM BLOOD Calcium-8.5 Phos-2.7 Mg-1.9
___ 04:33AM BLOOD Calcium-8.7 Phos-3.9 Mg-1.9
DISCHARGE LABS:
___ 06:00AM BLOOD WBC-5.5 RBC-4.34 Hgb-12.6 Hct-38.7 MCV-89
MCH-29.0 MCHC-32.6 RDW-14.9 RDWSD-47.8* Plt ___
___ 06:00AM BLOOD Plt ___
___ 06:00AM BLOOD ___ PTT-150* ___
___ 06:00AM BLOOD Glucose-166* UreaN-27* Creat-1.1 Na-137
K-4.5 Cl-100 HCO3-24 AnGap-13
___ 06:00AM BLOOD Calcium-9.9 Phos-3.4 Mg-2.0
MICRO
URINE CULTURE (Final ___: < 10,000 CFU/mL.
IMAGING:
Portable Abdomen ___:
IMPRESSION:
Nonspecific, nonobstructive bowel gas pattern.
Radiology Report
INDICATION: ___ year old woman with DM c/b gastroporesis with gastric
stimulator, HTN, HLD, and DVT (upper extremity) on Coumadin who presented with
progressively worsening abdominal pain and distention. N/V, small caliber
stools. Abdominal pain ___ in the lower abdomen/pelvic region. Tolerating
PO.// Question of possible bowel distention and partial obstruction in the
setting of abdominal distention and abdominal pain.
TECHNIQUE: Portable supine abdominal radiograph was obtained.
COMPARISON: CT scan of the abdomen and pelvis dated ___
FINDINGS:
There are no abnormally dilated loops of large or small bowel. Stool and gas
is seen throughout the colon, particularly within the ascending colon and
transverse colon. A right abdominal gastric stimulator is present with the
leads projecting over the location of stomach. Another 2 battery packs are
seen; 1 projecting over the right iliac crest in the other overlying the soft
tissues of the left abdomen.
There is no free intraperitoneal air.
Osseous structures are unremarkable.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
Nonspecific, nonobstructive bowel gas pattern.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Vomiting
Diagnosed with Unspecified abdominal pain
temperature: 99.0
heartrate: 98.0
resprate: 18.0
o2sat: 99.0
sbp: 160.0
dbp: 93.0
level of pain: 8
level of acuity: 3.0 | Ms. ___ is a ___ year old female with history significant for
type 1 DM, complicated by gastroparesis (s/p gastric stimulator,
with recent battery change on ___, HTN, HLD,
Anxiety/Depression, and UE DVT (on warfarin), who initially had
worsening abdominal rhythmic contractions with stimulator
subsequently turned off ___ prior to presentation. She
subsequently presented with worsening abdominal pain, nausea,
and vomiting. She was seen by her outpatient GI Dr. ___
the GI team here. Her gastric stimulator was evaluated and
decision was made to keep on as it was thought her pain was less
likely gastroparesis like pain. Given her decreased stool
caliber, she also underwent inpatient colonoscopy which was
normal, although with poor prep. She will follow up in 1 week
with GI for re-evaluation of the stimulator. Her pain was
managed by her PCP ___ developed pain care plan
and was transitioned back to PO pain regimen prior to discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Small bowel obstruction
Major Surgical or Invasive Procedure:
None
History of Present Illness:
From ED Admission Note ___:
Mr ___ is a ___, PMH significant for ulcerative colitis status
post open total colectomy with J-pouch construction and
diverting
ileostomy ___ years ago / Dr. ___ / ___, status post
ileostomy reversal complicated by enterocutaneous fistula,
presents with complaints of nausea, vomiting, and po
intolerance.
He has been in his normal state of health with not other
complications related to his surgery since resolution of his
enterocutaneous fistula describes onset of nausea, vomiting, and
po intolerance for 24 hours. He also endorses distension that
had
worsen over this time course. For this reason, he presented to
___. Workup included a KUB which shows distended
bowels. He was referred to ___ ED. Subsequent imaging was
concerning for SBO with transition point in the RLQ at the
anastamosis site. His symptoms, by his testimony, has largely
improved since onset. Furthermore, he endorses having passed
flatus and bowel movement several times earlier today. No
fevers,
chills, chest pain, shortness of breath. Last endoscopic study
was over ___ years ago.
Past Medical History:
Ulcerative colitis
PAST SURGICAL HISTORY
Open total colectomy, J-pouch formation, diverting ileostomy and
subsequent reversal ___ years ago)
Social History:
___
Family History:
Diverticular disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITAL SIGNS: 97.9 82 141/93 16 97% R
GENERAL: AAOx3 NAD
HEENT: NCAT, EOMI, PERRLA, No scleral icterus, mucosa moist, no
LAD
CARDIOVASCULAR: R/R/R, S1/S2, NO M/R/G
PULMONARY: CTA ___, No crackles or rhonchi
GASTROINTESTINAL: S/NT/Distended. No guarding, rebound, or
peritoneal signs. +BSx4
INCISION/WOUNDS: C/D/I. Soft, no hematoma or ecchymosis
EXT/MS/SKIN: No C/C/E; Feet warm. Good perfusion.
NEUROLOGICAL: Reflexes, strength, and sensation grossly intact
CNII-XII: WNL
Discharge Physical Exam:
Gen: well appearing male, NAD
HEENT: no lymphadenopathy, moist mucous membranes
Lungs: CTAB
Heart: rrr
Abd: soft, nt, nd
Extremities: wwp
Pertinent Results:
___ 07:40PM URINE HOURS-RANDOM
___ 07:40PM URINE UHOLD-HOLD
___ 07:40PM URINE COLOR-Amber APPEAR-Clear SP ___
___ 07:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-5.5
LEUK-NEG
___ 07:40PM URINE RBC-2 WBC-2 BACTERIA-NONE YEAST-NONE
EPI-0
___ 07:40PM URINE MUCOUS-RARE
___ 03:02PM GLUCOSE-127* UREA N-13 CREAT-1.0 SODIUM-134
POTASSIUM-4.2 CHLORIDE-97 TOTAL CO2-26 ANION GAP-15
___ 03:02PM estGFR-Using this
___ 03:02PM ALT(SGPT)-20 AST(SGOT)-15 ALK PHOS-92 TOT
BILI-0.9
___ 03:02PM ALBUMIN-4.0
___ 03:02PM HBsAg-Negative
___ 03:02PM HCV Ab-Negative
___ 03:02PM WBC-9.1 RBC-5.79 HGB-14.9 HCT-46.2 MCV-80*
MCH-25.7* MCHC-32.3 RDW-14.6 RDWSD-41.3
___ 03:02PM NEUTS-80.9* LYMPHS-12.2* MONOS-6.2 EOS-0.3*
BASOS-0.1 IM ___ AbsNeut-7.35* AbsLymp-1.11* AbsMono-0.56
AbsEos-0.03* AbsBaso-0.01
___ 03:02PM PLT COUNT-338
___ 09:10AM HIV Ab-Negative
Medications on Admission:
None
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction, self-resolved
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with abdominal pain, history of total colectomy, for
ulcerative colitis. Evaluate for bowel obstruction.
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 937 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: There are multiple lung nodules at the bases bilaterally, the
largest measuring 7 mm at the right lung base (2:3). Other lung nodules (2:3,
4, 5, 6, 7, 8, 9, 10, 11, 12) warrant comparison with prior imaging or short
interval followup. There is no consolidation at the lung bases. There is no
pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: There liver is diffusely low in attenuation, compared to the
spleen, concerning for hepatic steatosis. There is a mild amount of
perihepatic ascites. There is no evidence of focal lesions. There is no
evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder
is nondistended, with no radiopaque stones. Focal hyperdensity at the fundus
of the gallbladder and may indicate focal adenomyomatosis (02:32).
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions. There is trace perisplenic ascites.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is an intermediate density, 8 mm lesion at the interpolar region of the
right kidney (02:40). No hydronephrosis.
GASTROINTESTINAL: The stomach and proximal small bowel are normal. The
patient is status post total colectomy with ileoanal anastomosis. Beginning
in the mid jejunum, there are dilated, fluid-filled loops of bowel leading up
to a transition point in the right lower quadrant (2:69), in the apparent
location of an end-to-side surgical anastomosis. Beyond this, the distal
bowel is decompressed, although still containing some air and stool. There is
mural stratification of the bowel indicative of chronic inflammation, with
wall thickening representing acute inflammatory change. Reactive mesenteric
edema and fluid is as expected.
PELVIS: The urinary bladder and distal ureters are unremarkable.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: Central mesenteric lymphadenopathy is reactive. There is no
pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted.
BONES: Bilateral sacroiliac joint sclerosis is indicative of sacroiliitis. No
concerning osseous lesions.
IMPRESSION:
1. Small bowel obstruction with a transition point in the right lower
quadrant, in the region of a surgical anastomosis. No evidence of
perforation.
2. Multiple bilateral lower lobe lung nodules. Comparison with prior imaging
is recommended, otherwise three-month follow-up chest CT is recommended for
evaluation of interval change.
3. Indeterminate 8 mm right renal lesion, for which nonemergent renal
ultrasound is recommended.
4. Hepatic steatosis.
RECOMMENDATION(S):
1. Correlation with prior imaging to evaluate for change in bilateral lower
lobe lung nodules, otherwise three-month follow-up chest CT to evaluate for
interval change.
2. Nonemergent renal ultrasound to evaluate the indeterminate right renal
lesion.
NOTIFICATION: The findings were discussed with Dr. ___. by ___
___, M.D. on the telephone on ___ at 6:01 ___, 5 minutes after
discovery of the findings.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, N/V, SBO
Diagnosed with Unspecified intestinal obstruction
temperature: 97.8
heartrate: 76.0
resprate: 16.0
o2sat: 97.0
sbp: 126.0
dbp: 76.0
level of pain: middle
level of acuity: 3.0 | Mr. ___ presented to the ED at ___ on ___ with
nausea, vomiting, and PO intolerance. A CT Abdomen and Pelvis
demonstrated a small bowel obstruction likely from an adhesion
vs. a stricture at his ileostomy site from his prior surgery. He
was treated conservatively and was made NPO. He was given fluids
while NPO and once passing flatus his diet was advanced as
tolerated. On day of discharge (___), the patient was
discharged to home. At discharge, he was tolerating a regular
diet, passing flatus, stooling, voiding, and ambulating
independently. He will follow-up in the clinic in ___ weeks. He
was given warning signs of repeat SBO at time of discharge and
asked to monitor his stool output and take Imodium/psyllium
wafers or laxatives as necessary to titrate his stool output.
This information was communicated to the patient directly prior
to discharge. |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
abdominal pain, fever
Major Surgical or Invasive Procedure:
___ abdominal wound debridement
___ vac dressing placed
History of Present Illness:
HPI: Ms. ___ is a patient who is well known to the
ACS service after undergoing ventral hernia repair using
component separation with a polypropylene mesh inlay on ___
with Dr. ___. The surgery was complicated by wound
dehiscence
requiring a takeback to the operating room on ___ for wound
debridement and VAC placement. Since discharge, the patient has
been undergoing routine VAC changes 3 times per week. She was
seen in clinic twice last week for malodorous drainage noticed
during VAC changes. Additionally her VAC output is quite high,
approximately 300cc per day. She represents to the ED now with
increasing pain, drainage and erythema, as well as intermittent
fevers and chills at home.
Past Medical History:
HTN
anxiety/depression
Migraines
Recurrent UTI's
RnY gastric bypass in ___
s/p appendectomy in ___
s/p C-section
Social History:
___
Family History:
Mother with pancreatic CA. Father with vascular disease.
Physical Exam:
PE: 98.2 109 122/76 18 96% RA
GEN: NAD, AAOx3
CV: RRR
RESP: CTA b/l
ABD: SNDNT, VAC in place with brownish ouput, extremely
foul-smelling, left sided subcutaneous tissue is black and
necrotic, healthy pink granulation tissue deep
EXT: no peripheral edema or cyanosis
Upon discharge, the patient's vitals were stable. She had a
wound VAC in place with minimal surrounding erythema. Her exam
was otherwise unchaged from admission.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. BusPIRone 30 mg PO BID
3. Chlorthalidone 25 mg PO DAILY
4. Duloxetine 40 mg PO DAILY
5. Potassium Chloride 40 mEq PO DAILY
6. Acetaminophen 650 mg PO Q6H:PRN pain
7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN fevers/pain
2. BusPIRone 30 mg PO BID
3. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
4. Duloxetine 60 mg PO DAILY
5. OxycoDONE (Immediate Release) 15 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 3 tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
6. Amlodipine 10 mg PO DAILY
7. Chlorthalidone 25 mg PO DAILY
8. Potassium Chloride 40 mEq PO DAILY
9. Gabapentin 200 mg PO TID
RX *gabapentin 100 mg 2 capsule(s) by mouth three times a day
Disp #*90 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
abdominal wound infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: NO_PO contrast; History: ___ with ventral abdominal hernia repair
with mesh, wound vac with malodorous outputNO_PO contrast // Eval for
abscess, deep infection
TECHNIQUE: MDCT axial images were acquired through abdomen and pelvis
following intravenous contrast administration with split bolus technique.
Coronal and sagittal reformations were performed and submitted to PACS for
review.
No oral contrast was administered.
DOSE: DLP: 956.2 mGy-cm (abdomen and pelvis.
COMPARISON: Comparison is made to CT of the abdomen and pelvis from ___.
FINDINGS:
LOWER CHEST:
Bibasilar atelectasis is present. There is no pleural or pericardial effusion.
There is a small hiatal hernia (601b:40).
ABDOMEN:
GENERAL: There is no intra-abdominal free air or free fluid.
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is within normal limits,
without stones or gallbladder wall thickening.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of stones, focal renal lesions or hydronephrosis. There
are no urothelial lesions in the kidneys or ureters. There is no perinephric
abnormality.
GASTROINTESTINAL: Postsurgical changes related to gastric bypass are noted.
There is no evidence of bowel obstruction. The colon is unremarkable. The
appendix is not visualized.
RETROPERITONEUM: There is no evidence of retroperitoneal and mesenteric
lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. There is mild calcium
burden in the abdominal aorta and great abdominal arteries.
PELVIS:
The urinary bladder and distal ureters are unremarkable. There is no evidence
of pelvic or inguinal lymphadenopathy. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: Reproductive organs are within normal limits
BONES AND SOFT TISSUES:
A large abdominal wound is noted, with abdominal wall mesh repair of ventral
hernia. Along the superior aspect of the mesh repair, there is a 6.2 x 1.4 x
4.1 cm fluid collection with rim thickening and enhancement. No osseous lesion
worrisome for malignancy is identified. Multi level degenerative changes are
noted throughout the lumbar spine.
IMPRESSION:
1. Large anterior abdominal soft tissue defect with 6.2 x 1.4 x 4.1 cm fluid
collection along the superior aspect of mesh repair, compatible with abscess.
No evidence of intra-abdominal fistulous connection.
2. No intra-abdominal free fluid or abscess is identified.
3. Postoperative changes related to sleeve gastrectomy.
4. Small hiatal hernia.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Wound eval, LLQ abdominal pain
Diagnosed with ABDOMINAL PAIN LLQ, ABN REACT-PROCEDURE NOS
temperature: 98.2
heartrate: 109.0
resprate: 18.0
o2sat: 96.0
sbp: 122.0
dbp: 76.0
level of pain: 8
level of acuity: 3.0 | The patient was admitted for further management of her abdominal
wound. Due to persistnat foul smelling discharge and necrotic
fat, she was taken to the OR for debridement. She was also
started on antibiotics. A wet-to-dry dressing was placed. After
a day of wet-to-dry dressing changes, a wound VAC was placed. 3
days later, her VAC was removed. The wound had healthy
granulation tissue throughout without evidence of infection. The
wound VAC was replaced and her antibiotics were discontinued.
The following day, she was discharged home with ___ for VAC
changes and close follow-up in ___ clinic. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Primary Prevention ICD Placement ___
R heart cath ___
History of Present Illness:
Mr. ___ is a ___ with PMHx retinoschisis and dilated
cardiomyopathy (with a strong family history on his father's
side) who presents with a chief complaint of intermittent chest
pain and progressive shortness of breath/dyspnea on exertion for
the past 3 weeks.
Briefly, patient has been diagnosed with a dilated
cardiomyopathy
at some point in his childhood. He had an echocardiogram at
___ in ___ that demonstrated LV dilation and
reduced EF (unclear quantification), and he followed with Dr.
___ as a pediatric patient. He reports that he has
not been started on medications until recently; this ___ the patient began starting on heart failure medications
shortly after an echocardiogram demonstrated EF ___ at the
Atrius system. This year he was working on transitioning to an
adult cardiologist and adult internist as he turned ___.
Over the past 3 weeks, patient has been having intermittent
episodes of shortness of breath that are reliably provoked by
exertion. He has chest pain that accompanies this shortness of
breath. One pain is constant, "dull," and ___ the other is
"sharp," intermittent, and is ___ at maximal intensity. Both
pains are located in the substernum and are nonradiating. They
both resolve after several minutes of rest. The patient has had
escalating frequency of dyspnea on exertion over the past 3
weeks; he has had to prop himself up on more of an incline to
sleep, has become dyspneic with less physical activity, and has
had perhaps some worsening leg swelling. He does not weigh
himself regularly, so he is not sure if he has a lot of extra
weight on board.
Prior to his arrival, the patient tried increasing his home
furosemide from 10mg daily to 40mg BID to help with his
symptoms.
This alleviated his symptoms somewhat, but not completely. He
ultimately presented to the ___ ED due to progressive
shortness
of breath and an episode of nausea/vomiting that was flecked
with
blood the night of arrival.
In the ED initial vitals were: T 97 BP 113/73 HR 98 RR 16 O2
98%
on RA
EKG:
Sinus tachycardia at a rate of 109 bpm. Normal axis. Left
atrial enlargement. Borderline criteria for LVH. There are
submillimeter ST elevations in V2 and V3, with TWI in V4-V5 and
TW flattening in V6.
Compared to most recent prior dated ___, nonspecific ST and
TW changes as above are new.
Labs notable for:
-Cr 1.2
-Trop < 0.01
-ProBNP 1714
-INR 1.5
-WBC 11.3, Hb 14.9
Imaging notable for:
CXR PA AND LATERAL (___):
No prior available for comparison. There is cardiomegaly with
mild pulmonary vascular congestion.
Per radiology read, cannot exclude pericardial effusion.
POCUS:
Per ED resident report, no pericardial effusion. Likely reduced
EF.
Patient was given: 20mg IV furosemide. Per ED report Pt had
good urine output from same.
Vitals on transfer: T 98.1 BP 112/76 HR 101 RR 18 O2 98% on RA
On the floor, the patient reports the above history. He feels
somewhat better after the 20mg IV furosemide and reports that he
urinated somewhat.
He denies any dizziness, lightheadedness, or palpitations. He
has not had infectious symptoms such as fevers, chills, muscle
aches/joint aches prior to his arrival here. He has taken no
other medications to help with his symptoms, and does not
believe
anything besides light exertion makes them worse.
Past Medical History:
1. CARDIAC RISK FACTORS
- Overweight without dyslipidemia
2. CARDIAC HISTORY
- Per cardiology note from Atrius ___, "The last time he was
seen in the ___ he was noted to have a marked
reduction in his LVEF to about 28%. He had a cardiac MRI done
at
___ last ___ but I can't seem to find results...he
says
nothing new was found."
- Per above note, he had a Holter monitor at one point for 24hrs
which was apparently unremarkable.
- Reportedly had a genetic workup for cardiomyopathies that was
negative.
3. OTHER PAST MEDICAL HISTORY
- Seasonal allergies
Social History:
___
Family History:
Per cardiology note from ___ ___, "Strong family history
of
familial cardiomyopathy...his father has been a patient of mine
and had a heart transplant." Pt with siblings that are well,
but
there is an uncle and paternal grandfather who had
cardiomyopathy
as well. Other family history notable for a grandmother with
diabetes ___, and an uncle with colon cancer in his ___.
Mother also has retinoschisis.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VS: T 97.9 BP 111/76 HR 112 RR 18 O2 92% on RA
GENERAL: Obese black male, appears stated age, sitting up in bed
at approximately 45 degrees. Pleasant, tired appearing. In no
acute distress.
HEENT: Sclerae anicteric, MMM.
NECK: Difficult to appreciate JVP given habitus; appears to be
10-11cm H2O while lying at 30 degrees. Pt is able to lie at 30
degrees without much dyspnea, though I sit him up quickly after
the exam.
CARDIAC: PMI is inferiorly displaced to the ___ intercostal
space, midclavicular line; minimally laterally displaced. RRR,
normal S1, S2. Faint ___ early-peaking systolic ejection murmur
only heard at the RUSB. No gallops or rubs.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: Trace to 1+ lower extremity edema to the mid-shin
bilaterally.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
DISCHARGE PHYSICAL EXAM
=======================
Pertinent Results:
ADMISSION LABS
==============
___ 03:55AM BLOOD WBC-11.3* RBC-4.87 Hgb-14.9 Hct-45.3
MCV-93 MCH-30.6 MCHC-32.9 RDW-13.4 RDWSD-45.1 Plt ___
___ 03:55AM BLOOD Neuts-73.0* ___ Monos-5.0
Eos-0.4* Baso-0.3 Im ___ AbsNeut-8.23* AbsLymp-2.35
AbsMono-0.56 AbsEos-0.05 AbsBaso-0.03
___ 03:55AM BLOOD ___ PTT-27.2 ___
___ 03:55AM BLOOD Glucose-135* UreaN-23* Creat-1.2 Na-138
K-5.0 Cl-106 HCO3-22 AnGap-10
___ 03:55AM BLOOD cTropnT-<0.01 proBNP-1714*
___ 10:05AM BLOOD CK-MB-3 cTropnT-<0.01
___ 10:05AM BLOOD Calcium-9.2 Phos-4.3 Mg-2.0
DISCHARGE LABS
==============
___ 08:07AM BLOOD WBC-11.7* RBC-5.20 Hgb-15.6 Hct-47.7
MCV-92 MCH-30.0 MCHC-32.7 RDW-13.2 RDWSD-44.6 Plt ___
___ 08:07AM BLOOD Glucose-104* UreaN-24* Creat-1.3* Na-139
K-4.1 Cl-100 HCO3-26 AnGap-13
___ 08:07AM BLOOD ALT-52* AST-28 LD(LDH)-232 AlkPhos-55
TotBili-1.5
___ 08:07AM BLOOD Calcium-9.4 Phos-4.3 Mg-2.0
IMAGING
=======
___ CXR
Moderate cardiomegaly with mild central pulmonary vascular
congestion. Given the lack of priors, change in cardiac size
cannot be assessed. The presence of pericardial effusion cannot
be excluded on the basis of this film.
___ CXR
Pacer defibrillator lead tip, right ventricular apex anteriorly.
No
complications.Moderate severe cardiomegaly unchanged. Previous
pulmonary vascular congestion has improved. No evidence of
acute cardiac decompensation.
___ CT CHEST
HEART AND VASCULATURE: The thoracic aorta is normal in caliber.
The heart is enlarged. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary or mediastinal
lymphadenopathy is present. No mediastinal mass or hematoma.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Lungs are clear without masses or areas of
parenchymal
opacification. The airways are patent to the level of the
segmental bronchi bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show
no abnormality.
ABDOMEN: Included portion of the unenhanced upper abdomen is
unremarkable.
BONES: No suspicious osseous abnormality is seen.? There is no
acute fracture.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Enalapril Maleate 5 mg PO DAILY
2. Eplerenone 25 mg PO DAILY
3. Furosemide 40 mg PO DAILY
4. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Cephalexin 500 mg PO/NG Q6H Duration: 2 Days
2. Metoprolol Succinate XL 12.5 mg PO DAILY
3. OxyCODONE (Immediate Release) 5 mg PO Q12H:PRN BREAKTHROUGH
PAIN
RX *oxycodone 5 mg 1 tablet(s) by mouth as needed Disp #*2
Tablet Refills:*0
4. Sacubitril-Valsartan (49mg-51mg) 1 TAB PO BID
5. Spironolactone 25 mg PO DAILY
6. Torsemide 80 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses
=================
Familial Cardiomyopathy
Acute Heart Failure with Reduced Ejection Fraction Exacerbation
Secondary Diagnoses
===================
Iron Deficiency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with cardiomegaly with worsening fatigue sob//
sob, known cardiomegaly
COMPARISON: None
FINDINGS:
PA and lateral views of the chest provided.
There is no focal consolidation, effusion, or pneumothorax.
Moderate cardiomegaly is noted. Mild central pulmonary vascular congestion
demonstrated by cephalization of the pulmonary vasculature. No pulmonary
edema.
IMPRESSION:
Moderate cardiomegaly with mild central pulmonary vascular congestion. Given
the lack of priors, change in cardiac size cannot be assessed. The presence
of pericardial effusion cannot be excluded on the basis of this film.
Radiology Report
EXAMINATION: ABDOMEN US (COMPLETE STUDY)
INDICATION: ___ with PMHx familial dilated cardiomyopathy who presents with 3
weeks of DOE found to have likely HFrEF exacerbation and EF<20%.// pre-cardiac
transplant eval r/o gallbladder pathology, ascites, AAA
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of
the liver is smooth. There is no focal liver mass. The main portal vein is
patent with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 4 mm
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity.
Spleen length: 11.0 cm
KIDNEYS: Normal cortical echogenicity and corticomedullary differentiation is
seen bilaterally. There is no evidence of masses, stones, or hydronephrosis
in the kidneys.
Right kidney: 10.8 cm
Left kidney: 11.8 cm
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
Normal abdominal ultrasound.
Radiology Report
EXAMINATION: Carotid Doppler Ultrasound
INDICATION: ___ man with familial cardiomyopathy whopresented with
decompensated heart failure and new EF of 12%, now indergoing pre-heart
transplantation workup// pre-transplant evaluation
TECHNIQUE: Real-time grayscale, color, and spectral Doppler ultrasound
imaging of the carotid arteries was obtained.
FINDINGS:
RIGHT:
The right carotid vasculature has no atherosclerotic plaque.
The peak systolic velocity in the right common carotid artery is 55.
The peak systolic velocities in the proximal, mid, and distal right internal
carotid artery are 59, 61, and 57 respectively. The peak end diastolic
velocity in the right internal carotid artery is 26 cm/sec.
The ICA/CCA ratio is 1.1.
The external carotid artery has peak systolic velocity of92.
The vertebral artery is patent with antegrade flow.
LEFT:
The left carotid vasculature has no atherosclerotic plaque.
The peak systolic velocity in the left common carotid artery is 57.
The peak systolic velocities in the proximal, mid, and distal left internal
carotid artery are 64, 53, and 54 respectively. The peak end diastolic
velocity in the left internal carotid artery is 25 cm/sec.
The ICA/CCA ratio is 1.1.
The external carotid artery has peak systolic velocity of 65.
The vertebral artery is patent with antegrade flow.
IMPRESSION:
No atherosclerosis or hemodynamically significant stenosis of the bilateral
carotid arteries.
Radiology Report
EXAMINATION: ART EXT (REST ONLY)
INDICATION: ___ man with familial cardiomyopathy whopresented with
decompensated heart failure and new EF of 12%, now indergoing pre-heart
transplantation workup// pre-transplant eval
TECHNIQUE: Noninvasive evaluation of the arterial system of the lower
extremities was performed with Doppler signal recordings, pulse volume
recordings and segmental limb the pressure measurements at rest.
COMPARISON: None
FINDINGS:
On the right-side, triphasic Doppler waveforms were seen at the right femoral,
popliteal, posterior tibial, and dorsalis pedis arteries. The right ABI was
1.14 at rest with a toe pressure of 96 mm Hg and a TBI of 0.98. Pulse volume
recordings demonstrate blunted upstroke bilaterally which could be consistent
with the low cardiac output state.
On the left-side, triphasic Doppler waveforms were seen at the right femoral,
popliteal, posterior tibial, and dorsalis pedis arteries. The left ABI was
1.07 at rest with a toe pressure of 96 mm Hg in a TBI of 0.98. Pulse volume
recordings demonstrate slightly blunted upstroke throughout consistent with
low cardiac output state.
IMPRESSION:
Normal ABIs at rest bilaterally.
Radiology Report
INDICATION: ___ year old man with new EF of 12%, needs non con CT chest for
cardiac transplant// pre cardiac transplant work up
TECHNIQUE: Contiguous axial images were obtained through the chest without
intravenous contrast. Coronal and sagittal reformats were obtained.
COMPARISON: None
FINDINGS:
HEART AND VASCULATURE: The thoracic aorta is normal in caliber. The heart is
enlarged. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary or mediastinal lymphadenopathy is
present. No mediastinal mass or hematoma.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Lungs are clear without masses or areas of parenchymal
opacification. The airways are patent to the level of the segmental bronchi
bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: Included portion of the unenhanced upper abdomen is unremarkable.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
IMPRESSION:
Enlarged heart. No additional abnormality in the chest.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ is a ___ man with familial cardiomyopathy who
presented with decompensated heart failure and new EF of 12%, now undergoing
precardiac transplantation workup.// location of swan, pulm edema location
of swan, pulm edema
IMPRESSION:
Comparison to ___. The patient has received a Swan-Ganz catheter.
The tip of the catheter is at the outflow tract of the right ventricle. No
complications, notably no pneumothorax. Stable moderate cardiomegaly without
pulmonary edema. No pleural effusions. No pulmonary edema.
Radiology Report
EXAMINATION: Chest radiograph, portable AP upright.
INDICATION: Familial cardiomyopathy. Heart failure with Swan, now
reposition.
COMPARISON: Prior radiographs from ___.
FINDINGS:
Pulmonary artery catheter has been advanced into the distal intralobar
pulmonary artery. Otherwise, no significant change.
IMPRESSION:
Catheter tip is been advanced into the distal intralobar pulmonary artery.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with non-ischemic cardiomyopathy now s/p single
chamber ICD// pneumothorax ?
TECHNIQUE: AP portable chest radiograph
COMPARISON: CT chest dated ___
FINDINGS:
A left chest wall single lead pacing device is present. There is no focal
consolidation, pleural effusion or pneumothorax. The size of the cardiac
silhouette is markedly enlarged.
IMPRESSION:
Interval placement of a left chest wall single lead ICD. No pneumothorax.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with non-ischemic cardiomyopathy now s/p single
chamber ICD// lead position ?
TECHNIQUE: Chest PA and lateral
COMPARISON: Multiple prior radiographs, most recently dated ___.
Chest CT ___.
FINDINGS:
Trans subclavian defibrillator device continuous from the left pectoral
generator ends along the anterior wall of the right ventricular apex.
Heart is moderately to severely enlarged, but unchanged. Upper mediastinum
is normal. No pulmonary edema. Pulmonary vascular engorgement is minimal,
improved since ___. Pleural surfaces are normal. Lungs are fully
expanded and clear.
IMPRESSION:
Pacer defibrillator lead tip, right ventricular apex anteriorly. No
complications.
Moderate severe cardiomegaly unchanged. Previous pulmonary vascular
congestion has improved. No evidence of acute cardiac decompensation.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Chest pain
Diagnosed with Heart failure, unspecified, Chest pain, unspecified
temperature: 97.0
heartrate: 98.0
resprate: 16.0
o2sat: 98.0
sbp: 113.0
dbp: 73.0
level of pain: 5
level of acuity: 2.0 | TRANSITIONAL ISSUES
===================
[ ] Monitor for gynecomastia or other adverse events whie on
spironolactone, unclear if patient trialed in past or if he was
just started on eplerenone
[ ] Patient asked to repeat labs (CBC, Chem-10) on ___
with results to be forwarded to Dr. ___ at ___.
Patient plans to have labs drawn at ___
[ ] Consider uptitration of Entresto to 97/103 as tolerated,
patient newly started during this hospitalization and tolerated
moderate dose, PA obtained prior to discharge
[ ] Recommend repeat genetic testing of patient, father and
cousin given recent genomic advances and identification of new
genes/alleles as the patient underwent genetic testing at ___ a
few years ago
[ ] Ensure up to date with all preventative vaccinations (PPSV
23, Tdap, Flu)
[ ] Continue to complete transplant/LVAD evaluation (see blow
for already completed workup)
TRANSPLANT WORKLIST
==================
Please see below for status of transplant workup that was
performed during this hospitalization:
Transplant Worklist |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aspirin / Lipitor / Enviromental
Attending: ___.
Chief Complaint:
hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female sent in from clinic with chief complaint of
dyspnea and hypoxia for the past 6 months. DOE for about 6
months then found to have O2 sats in the low ___ with ambulation
while at ___ yesterday. No localizing sxs - no CP, palpitations,
lightheadedness, ___ edema, orthopnea, cough. No fevers, sweats,
chills. No black/bloody stools. Energy level has been normal. No
personal or second hand smoking history. Stress TTE in ___ was
nml and CXR ___ nml. No h/o PFTs. Lives at home alone,
independent in ADLs/iADLs, husband passed away recently in
___. Reports that she is normally able to do the 3 flights
of stairs in her house with only mild SOB at the end; this
hasn't changed recently. She does report needing to stop halfway
up the hill to her house due to SOB, but never has associated CP
or tightness. Given concern for PE, she was referred to ER for
expedited work-up of hypoxia.
In the ED, initial vital signs were: 97.4 80 137/78 20 97% RA.
Labs were notable for CBC WNL, Lytes WNL, BUN/Cr normal, D-dimer
610, proBNP 48, UA w/ 10 WBCs, few bacteria, Lactate 1.0, Trop
<0.01. EKG without evidence of ischemia, CXR showed large hiatal
hernia with adjacent opacity concerning for infection vs.
atelectasis. CTA showed no PE but showed an intrathoracic
stomach with adjacent compressive atelectasis. Vitals prior to
transfer were: 98.0 90 135/74 20 95% RA. In the ED, there was
one O2 sat of 85% RA documented that resolved without
intervention.
Upon arrival to the floor, she reports feeling well and has no
complaints. She adds that she has not had reflux symptoms
recently (had a Schatzky's ring dilated several years ago
without symptoms since), no recent fever/chills, no cough, she
has not been told she snores, she has restorative sleep, and she
has working carbon monoxide detectors at home. She has no
occupational exposures to asbestos or silica.
REVIEW OF SYSTEMS: Per HPI. Denies headache, visual changes,
pharyngitis, rhinorrhea, nasal congestion, cough, fevers,
chills, sweats, weight loss, dyspnea, chest pain, abdominal
pain, nausea, vomiting, diarrhea, constipation, hematochezia,
dysuria, rash, paresthesias, and weakness.
Past Medical History:
-migraines
-borderline hypertension
-exertional dyspnea
-HLD
-GERD
-chronic low back pain
Social History:
___
Family History:
Mother: AAA.
Father: MI/CAD
Physical Exam:
ADMISSION:
VITALS: 64.2 kg 98.1 125/59 84 16 95% RA
GENERAL: NAD, breathing comfortably.
HEENT: No head or neck lymphadenopathy. Sclerae are anicteric.
No conjunctival pallor. Oropharynx is clear without erythema or
exudate.
NECK: JVD not appreciated.
HEART: Regular rate and rhythm. No murmurs. Physiologically
split S2 with P2 of normal intensity. No thrill.
LUNGS: Coarse crackles at the R lung base. No wheezes
ABDOMEN: Soft, nontender, normoactive bowel sounds.
EXTREMITIES: Warm and well perfused, no edema.
DISCHARGE:
VITALS: 98.1 123/61 93 18 96RA (87-88% on RA with exertion)
GENERAL: NAD, breathing comfortably.
HEENT: No head or neck lymphadenopathy. Sclerae are anicteric.
No conjunctival pallor. Oropharynx is clear without erythema or
exudate.
NECK: JVD not appreciated.
HEART: Regular rate and rhythm. No murmurs. Physiologically
split S2 with P2 of normal intensity. No thrill.
LUNGS: Coarse crackles at the R lung base. No wheezes
ABDOMEN: Soft, nontender, normoactive bowel sounds.
EXTREMITIES: Warm and well perfused, no edema.
Pertinent Results:
ADMISSION LABs:
___ 02:12PM BLOOD WBC-6.3 RBC-4.67 Hgb-13.6 Hct-41.8 MCV-90
MCH-29.1 MCHC-32.5 RDW-14.0 RDWSD-45.3 Plt ___
___ 02:12PM BLOOD Neuts-54.9 ___ Monos-9.6 Eos-2.8
Baso-0.3 Im ___ AbsNeut-3.47 AbsLymp-2.02 AbsMono-0.61
AbsEos-0.18 AbsBaso-0.02
___ 02:12PM BLOOD Glucose-88 UreaN-20 Creat-0.7 Na-137
K-5.0 Cl-100 HCO3-28 AnGap-14
___ 02:12PM BLOOD proBNP-48
___ 02:12PM BLOOD cTropnT-<0.01
___ 02:12PM BLOOD D-Dimer-610*
___ 02:26PM BLOOD Lactate-1.0
DISCHARGE LABS:
___ 07:29AM BLOOD Glucose-90 UreaN-18 Creat-0.7 Na-138
K-4.2 Cl-99 HCO3-31 AnGap-12
___ 07:29AM BLOOD Calcium-10.4* Phos-3.6 Mg-2.1
STUDIES:
CXR ___:
IMPRESSION:
1. Moderate to large hiatal hernia and adjacent pulmonary
opacity which may reflect compressive atelectasis or infection.
2. Persistently elevated right hemidiaphragm. No pneumothorax.
EKG: ___: LVH with secondary repolarization abnormality
CTA Chest ___:
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Elevation of the right hemidiaphragm and large hiatal hernia
with
intrathoracic stomach and associated bibasilar atelectasis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ezetimibe 10 mg PO DAILY
2. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob
2. Ezetimibe 10 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Hypoxia on ambulation
Hiatal hernia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: History: ___ with dyspnea on exertion worsening over 6 months //
Assess for infiltrate, effusion, lesion, and assess volume status
TECHNIQUE: Chest PA and lateral
COMPARISON: Prior chest radiographs the most recent on ___
FINDINGS:
The hilar contours are within normal limits. The cardiac silhouette is
somewhat obscured by a moderate to large fluid-filled hiatal hernia. There is
elevation of the right hemidiaphragm which is largely stable from the prior
examination. Lung volumes are somewhat low. Opacity at the base of the left
lung is likely compressive atelectasis related to the patient's hernia however
underlying infection should be considered. No pneumothorax.There is marked
levoscliosis of the thoracic spine.
IMPRESSION:
1. Moderate to large hiatal hernia and adjacent pulmonary opacity which may
reflect compressive atelectasis or infection.
2. Persistently elevated right hemidiaphragm. No pneumothorax.
Radiology Report
INDICATION: History: ___ with 6 months of stuttering progressive dyspnea on
exertion
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Stationary Acquisition 1.5 s, 0.5 cm; CTDIvol = 4.6 mGy (Body) DLP = 2.3
mGy-cm.
2) Spiral Acquisition 3.4 s, 26.4 cm; CTDIvol = 13.1 mGy (Body) DLP = 344.8
mGy-cm.
Total DLP (Body) = 347 mGy-cm.
COMPARISON: CT colonoscopy ___
FINDINGS:
The aorta and its major branch vessels are patent, with no evidence of
stenosis, occlusion, dissection, or aneurysmal formation. There is no
evidence of penetrating atherosclerotic ulcer. Mild calcified atherosclerotic
disease is noted within the aortic arch and descending thoracic aorta.
The pulmonary arteries are well opacified to the subsegmental level, with no
evidence of filling defect within the main, right, left, lobar, segmental or
subsegmental pulmonary arteries. The main and right pulmonary arteries are
normal in caliber, and there is no evidence of right heart strain.
There is no supraclavicular, axillary, mediastinal, or hilar lymphadenopathy.
The thyroid gland appears unremarkable.
There is no evidence of pericardial effusion. There is no pleural effusion.
There is mild atelectasis of both lung bases. The airways are patent to the
subsegmental level.
Limited images of the upper abdomen is notable for elevated right
hemidiaphragm and a large hiatal hernia with an intra thoracic stomach. No
evidence for gastric outlet obstruction. Large right renal cyst is partially
imaged.
No lytic or blastic osseous lesion suspicious for malignancy is identified.
Fluid about the left shoulder may represent bursitis.
There is S shaped scoliosis of thoracic spine. No suspicious bony lesion is
identified.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Elevation of the right hemidiaphragm and large hiatal hernia with
intrathoracic stomach and associated bibasilar atelectasis.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with Dyspnea, unspecified, Hypoxemia
temperature: 97.4
heartrate: 80.0
resprate: 20.0
o2sat: 97.0
sbp: 137.0
dbp: 78.0
level of pain: 0
level of acuity: 3.0 | Ms. ___ is an ___ w/ PMH of HLD, HTN, GERD, and DOE for the
past 6 months who was sent in to the ED from clinic after she
was found to be hypoxemic to mid ___ on room air while
ambulating.
#HYPOXIA: Uncertain etiology. Initial workup with a large hiatal
hernia / intrathoracic stomach and bilateral compressive
atelectasis. CTPA was negative for pulmonary embolus/pneumonia.
Troponins x2 were negative. She was seen by thoracic surgery who
gave her contact information re:surgery if she desires. There is
a question if the compressive atelectasis is contributing to her
hypoxia with exertion. On day of discharge, she was 96% on room
air at rest. O2 saturation decreased to 87-88% with ambulation,
but quickly increased to normal after rest. She was recommended
transthoracic echocardiogram with bubble study and home oxygen,
however, as it was the holiday weekend and these could no be
obtained until ___, she opted to go home. She was counseled
to avoid strenuous exercise and to rest when she feels
lightheaded. She expressed understanding.
Note, it is unclear if her compressive atelectasis is the main
contributor. She may have pulmonary HTN or pulmonary vs
intracardiac shunt as well. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Amoxicillin
Attending: ___.
Chief Complaint:
cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with h/o subglottic tracheal stenosis s/p
endoscopic intervention in ___, asthma who presents
productive cough. Pt states for the last 1.5 weeks she has had
cough occ productive of ___ sputum and dyspnea. No
fevers. She saw her PCP 3 days ago and had CXR which showed RML
pneumonia and was treated with azithromycin (z-pack). Today she
is on day 4 of this antibiotic but sx have not improved. She
called PCP who referred her to the emergency department.
In the ED, initial VS were 97.3 67 ___ 100%. She was given
a dose of Levofloxacin. CXR showed persistent RML opacity c/w
pna. She was admitted to the floor for treatment of pneumonia.
On transfer to the floor, vitals were 98.2,68,14,140/82,100%.
She c/o persistent cough, also rhinorrhea/sore throat which are
improving. Feels her breathing is comfortable at rest, becomes
slightly dyspneic with exertion. Denies chest pain, abdominal
pain, N/V, diarrhea.
ROS: per HPI, denies fever, night sweats, headache, vision
changes, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
Idiopathy subglottic stenosis
Hypothyroidism
Asthma
Vertigo
Social History:
___
Family History:
NC
Physical Exam:
VS - Temp 97.6F, BP 135/80, HR 71, R 20, O2-sat 100% RA
GENERAL - well-appearing female in NAD, occ dry cough,
comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no cervical LAD
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, strength and
sensation grossly intact and symmetric
Pertinent Results:
Admission Labs:
___ 10:30AM BLOOD WBC-6.7# RBC-4.04* Hgb-11.7* Hct-34.6*
MCV-86 MCH-28.9 MCHC-33.7 RDW-13.1 Plt ___
___ 10:30AM BLOOD Glucose-72 UreaN-13 Creat-0.7 Na-138
K-4.8 Cl-101 HCO3-28 AnGap-14
___ 07:46AM BLOOD Calcium-9.1 Phos-4.2 Mg-2.0
___ 10:53AM BLOOD Lactate-1.3
Discharge Labs:
___ 07:46AM BLOOD WBC-4.7 RBC-3.68* Hgb-10.7* Hct-31.5*
MCV-86 MCH-29.2 MCHC-34.1 RDW-12.6 Plt ___
___ 07:46AM BLOOD Glucose-86 UreaN-14 Creat-0.8 Na-136
K-4.6 Cl-99 HCO3-27 AnGap-15
Imaging:
CXR PA&LAT ___:
COMPARISON: ___, radiograph from only three days
prior.
PA AND LATERAL VIEWS OF THE CHEST: There is persistent subtle
opacity in the lateral segment of the RML, consistent with
pneumonia. Otherwise, lungs are clear. Heart size is normal.
There is no pleural effusion or evidence of central lymph node
enlargement. The bones are intact.
IMPRESSION: Persistent opacity in the lateral segment of the
RML, consistent with pneumonia.
Medications on Admission:
Azithromycin 250mg PO daily, started ___
Codein-Guaifenesin 100mg-10mg/5mL 1tsp q3h prn cough
Vitamin D 50,000units PO qweek
Fluticasone-Salmeterol 100mcg-50mcg 1puff BID
Levothyroxine 50mcg PO daily
Discharge Medications:
1. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
2. dextromethorphan-guaifenesin ___ mg/5 mL Syrup Sig: Five
(5) ML PO every ___ hours as needed for cough: ___ cause
drowsiness.
Disp:*100 mL* Refills:*0*
3. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO QSUN (every ___.
4. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig:
One (1) inhalation Inhalation BID (2 times a day).
5. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Bacterial pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CLINICAL HISTORY: ___ woman with shortness of breath and report of
right middle lobe pneumonia.
COMPARISON: ___, radiograph from only three days prior.
PA AND LATERAL VIEWS OF THE CHEST: There is persistent subtle opacity in the
lateral segment of the RML, consistent with pneumonia. Otherwise, lungs are
clear. Heart size is normal. There is no pleural effusion or evidence of
central lymph node enlargement. The bones are intact.
IMPRESSION: Persistent opacity in the lateral segment of the RML, consistent
with pneumonia.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: DYSPNEA/+ PNA
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED
temperature: 97.3
heartrate: 67.0
resprate: 18.0
o2sat: 100.0
sbp: 106.0
dbp: 74.0
level of pain: 0
level of acuity: 3.0 | Primary reason for hospitalization:
___ with h/o subglottic stenosis s/p endoscopic intervention
in ___, asthma who presents with cough x10 days and RML
infiltrate, c/w pneumonia. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Failure to thrive
Major Surgical or Invasive Procedure:
IVC filter placement
History of Present Illness:
PCP: Name: ___
___: ___
Address: ___
Phone: ___
Fax: ___
CC: ___ of breath and failure to thrive.
___ with h/o pancreatic CA recently discharged for PE on Lovenox
60 sc daily complains of decreased PO intake, lethargy, nausea.
Since being home, appetite has been worse. Continues to have
abdominal pain which she has had since her surgery. She was
undergoing chemo which was put on hold last week when she
developed PEs. Denies fevers/chills, CP, vomiting, dysuria, HA.
Takes zofran and compazine at home for nausea but it doesn't
help. In the ED, she was tachycardic to 116. CT scan was
ordered, report came back after patient hit the floor.
On the floor, patient endorses SOB, but saturating well on 3 L
NC at this time. Endorses nausea, but controlled after Zofran IV
in the ED. Mild diffuse abdominal pain unchanged from before.
ROS as above. + for nausea. She has chronic loose stools. She
has lost 25 lbs since her diagnosis. Denies fever, chills, night
sweats, headache, vision changes, rhinorrhea, congestion, sore
throat, cough, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Patient is DNR/DNI
ONCOLOGIC HISTORY:
___ MRI abdomen in order to follow up the previously
diagnosed neurofibroma at T10 revealed a new hypoenhancing
pancreatic head mass measuring 1.8 x 2.7 cm, associated with
mild
intrahepatic and extrahepatic bile duct dilation. ___ EUS
confirmed biopsy c/w pancreatic adenocarcinoma.
___ abdomen and pelvic CT revealed pancreatic head mass
and
no evidence of involvement of surrounding vasculature, lymph
nodes in the liver or omentum.
___ on planned ___ procedure, tumor was found to be
involving the portal vein to an extent that was felt to be
unresectable without significant morbidity, gastric and biliary
bypass performed with a Roux-en-Y hepaticojejunostomy.
___, cycle 1, day 1 gemcitabine.
___ CT torso, no concerning liver lesions, pancreatic
hypoattenuating lesion measures 2.2 cm, unchanged
___, CyberKnife
___ CT torso, hypoattenuating lesion in the pancreatic
head measures 2.6 x 1.9, mildly increased from prior; new
hypodense lesion, 1.6 cm in the pancreatic body concerning for
metastatic disease; two liver lesions that are new or
significantly increased in size from prior examination are
concerning for metastatic foci measuring 1.6 cm and 1.2 cm
respectively.
ALLERGY: NKDA
Past Medical History:
Neurofibromatosis
GERD
SVT
UGIB
Social History:
___
Family History:
Two children with NF.
Physical Exam:
98.3 141/96, 103, 18, 98% 3L
GENERAL: NAD
HEENT: PERRLA, sclera anicteric, MM dry
NECK: no JVP, no LAD, supple
LUNGS: Decreased breath sounds b/l at bases. Scattered rales
B/L.
HEART: RRR, normal S1, loud and split S2, no MRG
ABDOMEN: Soft, mild tenderness diffuse, NABS, no organomegaly
EXTREMITIES: No c/c/e
NEUROLOGIC: alert and oriented times 3. Cranial nerves ___
grossly intact. Intact sensory and motor exams.
BACK: spinal deformity; kyphoscoliotic
Pertinent Results:
___ 02:30PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 02:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 02:30PM URINE RBC-6* WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 02:30PM URINE HYALINE-1*
___ 02:30PM URINE MUCOUS-RARE
___ 01:30PM GLUCOSE-147* UREA N-10 CREAT-0.3* SODIUM-137
POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-24 ANION GAP-14
___ 01:30PM estGFR-Using this
___ 01:30PM WBC-5.6 RBC-3.66* HGB-11.1* HCT-34.2* MCV-93
MCH-30.3 MCHC-32.4 RDW-18.5*
___ 01:30PM NEUTS-78.3* LYMPHS-12.6* MONOS-8.8 EOS-0.2
BASOS-0.1
___ 01:30PM PLT COUNT-265
CXR: IMPRESSION: New bilateral left greater than right pleural
effusions and mild pulmonary edema when compared to ___.
CTA thorax: IMPRESSION:
1. Interval progression of the pulmonary embolic burden in the
left lung now affecting the distal left main and upper lobe
pulmonary arteries. Partial retraction of the right-sided clot
burden as detailed above.
2. Diffuse ground-glass opacities and enlargement of the
bilateral pleural effusions, which are moderate in size.
Findings are suggestive of pulmonary edema. 3. Bibasilar
atelectasis with more confluent consolidation at the left lung
base abutting the fissure, raising concern for superimposed
infection. 4. Previously characterized liver metastases as
previously detailed.
Lower extremity venous dopplers: IMPRESSION:
1. Right proximal and mid SFV occlusive and nearly occlusive
thrombus. Right peroneal vein thrombus also nearly occlusive.
2. Minimal peripheral non-occlusive chronic-appearing thrombus
in the left common femoral vein.
Medications on Admission:
1. Dronabinol 2.5 mg PO BID
2. Lorazepam 0.5 mg PO Q4H:PRN anxiety, nausea
3. Pantoprazole 40 mg PO Q24H
4. Verapamil SR 180 mg PO Q24H
hold for HR < 60 or SBP < 100
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Capecitabine 1000 mg PO BID
Twice daily for 14 days, then break for 7 days
8. Prochlorperazine 10 mg PO Q6H:PRN nausea
9. Ascorbic Acid ___ mg PO BID
10. Vitamin D 0 UNIT PO Frequency is Unknown
11. oxygen
2 liters oxygen by nasal cannula, continuous
diagnosis: bilateral pulmonary emboli
patient desaturates to 88%
12. Ondansetron 8 mg PO Q 8H
13. Enoxaparin Sodium 60 mg SC DAILY
RX *enoxaparin 60 mg/0.6 mL Inject one syringe into skin daily
Disp #*30 Syringe Refills:*3
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
hold for loose stools
2. Enoxaparin Sodium 40 mg SC BID
3. Lorazepam 0.5 mg PO Q4H:PRN anxiety
hold for sedation
RX *lorazepam 0.5 mg 0.5 (One half) mg by mouth every four (4)
hours Disp #*30 Tablet Refills:*0
4. Metoprolol Succinate XL 25 mg PO DAILY
hold for sbp less than 90, HR less than 60
5. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain,
while awake
hold for significant somnolence/sedation
RX *oxycodone 5 mg 0.5 - 1 tablet(s) by mouth every four (4)
hours Disp #*30 Tablet Refills:*0
6. Pantoprazole 40 mg PO Q24H
7. Verapamil SR 180 mg PO Q24H
hold for sbp less than 90, HR less than 60
8. Haloperidol 0.5 mg PO HS
Discharge Disposition:
Home with Service
Facility:
___
Discharge Diagnosis:
Advanced metastatic pancreatic cancer
Pulmonary emboli (multiple) and deep vein thrombosis
Inferior vena cava filter placement
Bacterial pneumonia
Delirium
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST, TWO VIEWS: ___.
HISTORY: ___ female with shortness of breath.
FINDINGS: Frontal and lateral views of the chest are compared to previous
exam from ___. Left chest wall port is again seen with catheter tip
in the region of the mid SVC. There is severe thoracolumbar scoliosis similar
to prior. New from prior however is blunting of the lateral costophrenic
angles, suggestive of pleural effusions, larger on the left than on the right.
Instinct pulmonary vascular markings are seen throughout potentially in part
due to crowding from position however a component of mild edema is suspected.
The mediastinal silhouette which is difficult to assess based on patient's
scoliosis and positioning has not significantly changed. Surgical clips noted
in the abdomen.
IMPRESSION: New bilateral left greater than right pleural effusions and mild
pulmonary edema when compared to ___.
Radiology Report
CTA CHEST WITHOUT AND WITH CONTRAST: ___.
HISTORY: ___ female with pulmonary emboli, worsening shortness of
breath and hypoxia. History of pancreatic cancer.
TECHNIQUE: Contiguous axial images were obtained from the thoracic inlet
through the diaphragms without intravenous contrast. After the administration
of intravenous contrast in the arterial phase, repeat exam was performed.
Coronal and sagittal reformats were reviewed.
COMPARISON: CT angiogram of the chest from ___.
FINDINGS: When compared to prior, again seen are multiple bilateral pulmonary
emboli. On the right, there is a similar distribution of non-occlusive clot
within the distal right main pulmonary artery extending to the lower lobe
pulmonary artery, which demonstrates some interval retraction. On the left,
however, the clot is seen more proximally now. An occlusive thrombus at the
origin of the left upper lobe pulmonary artery extending into the lower lobe
artery, which is new. Configuration of the heart has not changed without
definite evidence of right heart strain.
New diffuse bilateral ground-glass opacities have progressed since prior.
Bilateral pleural effusions, slightly larger on the left, have also enlarged.
Extensive atelectasis, primarily involving the left lower lobe is again noted.
Degree of right basilar atelectasis has also progressed. Component of
infection at the left lung base is also possible.
A 10-mm prevascular node is again seen. There is also a 1.3-cm precarinal
node. Included portion of the upper abdomen again notable for pneumobilia,
presumably from prior sphincterotomy or stent. Area of heterogeneous
enhancement within the right lobe of the liver is again seen, noting less
well-circumscribed peripheral regions of enhancement seen in segment VII when
compared to prior, potentially from different phase of contrast.
Severe thoracolumbar scoliosis is again seen. Left lateral mid thoracic
lateral meningocele is again seen in addition to dural ectasia. No new focal
suspicious osseous lesions are detected.
IMPRESSION:
1. Interval progression of the pulmonary embolic burden in the left lung now
affecting the distal left main and upper lobe pulmonary arteries. Partial
retraction of the right-sided clot burden as detailed above.
2. Diffuse ground-glass opacities and enlargement of the bilateral pleural
effusions, which are moderate in size. Findings are suggestive of pulmonary
edema.
3. Bibasilar atelectasis with more confluent consolidation at the left lung
base abutting the fissure, raising concern for superimposed infection.
4. Previously characterized liver metastases as previously detailed.
Radiology Report
CLINICAL HISTORY: Recurrent pulmonary embolism, on therapy. Please assess
clot burden before IVC filter.
STUDY: Bilateral lower extremity venous ultrasound with color Doppler and
spectral analysis.
FINDINGS:
Within the left common femoral vein, there was slight anterior
hypoechogenicity and incomplete compression, consistent with a small amount of
residual peripheral non-occlusive thrombus. This appeared chronic in nature.
The remainder of the left lower extremity veins have normal appearance
including the superficial femoral, popliteal, posterior tibial and peroneal
veins with normal 2D grayscale appearance, compression, color Doppler
appearance and normal waveforms on spectral analysis.
The right common femoral vein has a normal appearance with normal compression,
augmentation, color Doppler flow and waveform by spectral analysis. The
proximal and mid right superficial femoral vein segments have echogenic
material within them consistent with occlusive thrombus. The more peripheral
superficial femoral vein, however, is patent and has normal compression and
color flow. The popliteal vein is also patent and demonstrates
compressibility and normal color Doppler flow as well as the posterior tibial
veins. The right peroneal veins, however, are distended with hypoechogenic
material with only a tiny amount of flow peripherally consistent with nearly
occlusive thrombus.
IMPRESSION:
1. Right proximal and mid SFV occlusive and nearly occlusive thrombus. Right
peroneal vein thrombus also nearly occlusive.
2. Minimal peripheral non-occlusive chronic-appearing thrombus in the left
common femoral vein.
Radiology Report
INDICATION: ___ woman with marked kyphoscoliosis, DVT and PE, for IVC
filter placement.
PHYSICIANS: Dr. ___ (radiology fellow), Dr. ___
___ (radiology attending) and Dr. ___ (radiology attending) were
present and supervised throughout.
MEDICATIONS: Patient received 150 mcg of fentanyl and 3 mg of Versed in
divided doses for a total intraservice time of 2 hours.
PROCEDURES:
1. Inferior venacavogram.
2. Option IVC filter deployment via a left common femoral venous access.
3. IVC filter repositioning via left internal jugular access.
PROCEDURE DETAILS:
Following discussion of the risks, benefits and alternatives to the procedure,
informed written patient consent was obtained. The patient was brought to the
angiographic suite and placed supine on the table. A preprocedure timeout was
performed using three patient identifiers. The skin in the left groin was
prepped and draped in usual sterile fashion. Using ultrasound guidance, the
left common femoral vein was targeted. Approximately 3 cc of 1% lidocaine
were infiltrated into the skin and subcutaneous tissues for local anesthesia.
Again, using ultrasound guidance, a micropuncture needle was advanced into the
left common femoral vein. Once this had been achieved, a nitinol wire was
advanced via the needle, a 2mm skin incision was made and the needle was
removed and exchanged for micropuncture sheath. At this point, the introducer
and nitinol wire were removed and ___ wire was advanced via the sheath
into the IVC. The patient has severe scoliosis and the IVC was markedly
tortuous, therefore, we removed the micropuncture sheath, advanced an
Omniflush catheter directly over the wire into the inferior IVC, removed the
wire and performed an inferior venacavogram.
This demonstrated multiple surgical clips in the abdomen, a very tortuous IVC
and demonstrated the location of the bilateral renal veins. No caval thrombus
was identified with a normal caval diameter of 18mm. We elected to place the
IVC filter in an infrarenal position. An Option vena cava filter was selected
and loaded onto its sheath. This was advanced into the IVC to approximately
the anticipated location; however, following unsheathing of the filter, this
displaced somewhat inferiorly and a further contrast injection demonstrated
that the filter was very close to and possibly even covering part of the
insertion of the right common iliac vein. Since its position was suboptimal,
we therefore proceeded to try and reposition the filter from above.
Using ultrasound guidance, a further 3 cc of 1% lidocaine were infiltrated
into the skin and subcutaneous tissues overlying the left internal jugular
vein. Under ultrasound guidance, a micropuncture needle was advanced into the
left internal jugular, followed by a nitinol wire which passed with minimal
difficulty down to the central veins. A 2mm skin incision was made and the
needle was removed and exchanged for a micropuncture sheath. The inner
portion of the sheath and the wire removed and exchanged for ___ wire,
which advanced into the central veins, to the right atrium down into the IVC.
Having achieved this, we passed a 6 ___ 45 cm sheath down over the wire to
approximate the hook on the superior aspect of the IVC filter. Using a
combination of a 6 ___ RDC guide catheter and a 10mm snare devive, we
manipulated the snare over the hook in the IVC filter and resheathed this into
our ___ sheath. Having achieved this, the IVC filter was repositioned into a
more optimal superior location and the sheath was removed. Completion
cavography follwing filter repositiong demonstrated appropriate positioning of
the infrarenal IVC filter with the filter apex at the renal vein inflow. Both
sheaths were removed and firm manual compression was applied for 5 minutes.
There were no immediate post-procedure complications.
IMPRESSION:
1. Marked caval tortuosity given spinal anatomy but normal caval diameter
with no thrombus identified.
2. Successful placement of an Option retreivable infrarenal IVC filter via
the left common femoral vein access with succesful repositioning via a left
internal jugular access.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ?DEHYDRATION
Diagnosed with NAUSEA WITH VOMITING, DEHYDRATION, SHORTNESS OF BREATH
temperature: 97.3
heartrate: 120.0
resprate: 16.0
o2sat: 97.0
sbp: 145.0
dbp: 95.0
level of pain: 0
level of acuity: 2.0 | This is a ___ y/o F with advanced metastatic pancreatic CA and a
history of neurofibromatosis with severe advanced kyphoscoliosis
who was discharged early this month by Dr. ___ oncology
after a hospitalization for a new PE, represents with SOB and
recurrent increased PE clot burden despite therapeutic LMWH
(1.5mg/kg daily) at home. Also has increasing moderate and
bilateral pleural effusions which may also be adding to
dyspnea/O2 need (4L NC), as well as a possible LLL consolidation
c/w a pneumonia (healthcare associated). Is 'DNR/DNI' but not
'comfort measures only' on presentation. Was treated with IV
heparin initially and with vancomycin and cefepime for possible
HCAP. ___ performed showing ongoing DVTs, so IVC filter was
placed by ___. Heparin then transitioned to enoxaparin at bid
dosing intervals. Dr. ___ am and discussed
with me and her - pt. now will transition to Hospice care at
home as no real treatment options remain and she is failing
quickly. Treatment for possible pneumonia was completed
however, with a course of 7 days of IV vancomycin and cefepime.
She was needing more pain medication(oxycodone increased from
2.5 mg prn to 5 mg prn) but became intermittently delirious and
agitated. Labs were stable without new fevers to suggest a new
or worsening infection. I suspect the delirium is
multifactorial and due to advanced cancer, pain, infection,
opiates. She is tachypneic for the multiple reasons above (PEs,
effusions, severe kyphoscoliosis, pneumonia), but when resting
appears comfortable. Maintains sats with ___ LPM NC. Given the
agitation with delirium, she was given a low dose anti-psychotic
(olanzapine didn't seem to help, so changed to haloperidol) to
help her sleep at night and to treat her agitated delirious
state. Lorazepam did seem to help with her agitation. Around
the time of discharge, the patient's daughter developed concerns
about her ability to provide the level of care the patient would
require at home, and so the decision was made to discharge the
patient to a skilled nursing facility ___) to
receive hospice care. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
keflex, / Flagyl
Attending: ___.
Chief Complaint:
abdominal pain, nausea, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old woman w/ DM that has been c/b
retinopathy, neuropathy, and gastroparesis, anxiety depression,
constipation, and recent D&C for fetal anomaly, who presented to
the ED with recurrent nausea, vomiting, and abdominal pain,
similar to prior exacerbations of her gastroparesis symptoms.
She has been admitted frequently in recent months with similar
presentations. The trigger for these episodes is not entirely
clear, although they have been felt to potentially result from
worsening of her glycemic control. She states that the current
episode began yesterday and has been similar in nature to prior
episodes, characterized by nausea, vomiting, and abdominal pain
with minimal other symptoms. She describes her vomit as dark in
color but nonbloody. She states that her constipation has been
well controlled with her bowel meds. She does endorse worsening
glycemic control in recent days, more often in 200s-300s
compared to 100s-200s, which it has been previously. However she
does endorse compliance with her home medication regimen. She
also endorses stocking/glove distribution paresthesias, which
are not new. She denies dysuria, cough, dyspnea, URI symptoms,
CP, f/c, or any other new symptoms.
In the ED she was noted to be hyperglycemic at 423 and was given
her home dose of 34 units insulin. She also had ___ with cre
1.4 and received 2 L IVFs. For her pain and nausea she received
zofran 4mg x3 and morphine 4 mg x 3. She was tachy in 100s-110s
and had mostly stable BPs.
ROS:
Comprehensive 10 pt ROS negative except as per HPI
Past Medical History:
- DM2 with with DM1 features. Last HbA1C 10.8 ___
- Hypertension
- Diabetic retinopathy
- Diabetic neuropathy
- Gastroparesis
- Chronic constipation
- History of necrotizing fasciitis of lower abdomen in ___
- Anxiety and depression
- Lipoma
- HSV
- ___ D&C for fetal anomaly
Social History:
___
Family History:
Significant for HTN, DM2, CAD, and cancer.
Physical Exam:
Admission Physical Exam:
VS: 98.1 156 / 97 106 20 98 RA
gen: pt appears in mild discomfort
HEENT: NC/AT, sclera anicteric, conjunctiva noninjected, PER,
EOMI, MMMs
CV: RRR no m/r/g
Pulm: CTAB no c/r/w
Abd: S ND moderate TTP greatest in epigastric area
Extr: wwp no edema, distal pulses intact
Neuro: grossly intact/nonfocal
Skin: no lesions noted on limited exam
Psych: somewhat restricted range of affect
Pertinent Results:
========================================
Admission labs/diagnostic studies:
CBC: 10.7>11.4<367
BMP: ___
LFTs wnl
UA w. tr pro 1000 glu tr ket 1 RBC 4 WBC few act
UCG neg
Lactate 1.8
CXR No acute cardiopulmonary process.
========================================
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
2. Citalopram 10 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Metoclopramide 10 mg PO QIDACHS
5. Polyethylene Glycol 17 g PO DAILY
6. Senna 8.6 mg PO BID
7. MetFORMIN (Glucophage) 500 mg PO BID
8. Lantus (insulin glargine) 34 U subcutaneous QHS
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Calcium Carbonate 500 mg PO QID:PRN heart burn
3. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth once a day Disp #*30
Capsule Refills:*0
4. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
5. Citalopram 40 mg PO DAILY
RX *citalopram 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
6. Docusate Sodium 100 mg PO BID
7. Lantus (insulin glargine) 34 U subcutaneous QHS
8. MetFORMIN (Glucophage) 500 mg PO BID
9. Metoclopramide 10 mg PO QIDACHS
10. Polyethylene Glycol 17 g PO DAILY
11. Senna 8.6 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old woman with gastroparesis with abdominal pain and
nausea
TECHNIQUE: Supine and upright abdominal radiographs were obtained.
COMPARISON: ___
FINDINGS:
There are no abnormally dilated loops of large or small bowel. Assessment of
intraperitoneal free air is limited as the upper abdomen is not included
within the imaged field. Osseous structures are unremarkable. Note is made
of mild vascular calcifications in the pelvis.
IMPRESSION:
Unremarkable bowel gas pattern.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Abd pain, Hyperglycemia, N/V
Diagnosed with Unspecified abdominal pain, Vomiting, unspecified
temperature: 98.9
heartrate: 110.0
resprate: 18.0
o2sat: 100.0
sbp: 96.0
dbp: 61.0
level of pain: 10
level of acuity: 2.0 | #Gastroparesis exacerbation:
No obvious trigger, except possibly d/t hyperglycemia (no clear
cause of worsening glycemic control). We treated her with pain
control and reglan. Her KUB showed non-specific bowel gas
pattern. She was initially treated with IV Morphine, then
transitioned to oxycodone and discharged with Tylenol. She
improved quickly and was tolerating oral intake on discharge.
She also found that walking the hallways helped her pain. She
will need close outpatient follow up as she has had several
admissions over recent time. She was also started on omeprazole
as she noted some symptoms of abdominal pain. Her erythromcyin
was discontinued. She was discharged on Reglan and bowel
regimen.
#DM:
Stable glycemic control on her home regimen. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Magnesium / calcium carbonate-vitamin D3
Attending: ___.
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
TEE ___
History of Present Illness:
Mr. ___ is a ___ y/o M with PMH CAD (s/p NSTEMI with drug
eluting stent to mid-LAD in ___, HTN, HLD, DM II (dietary
controlled), CKD (Cr baseline 1.2-1.4), who presented to BI with
chest pain, and found to be in AF-RVR. Via ___ interpreter
in
ED, patient awoke with chest pain and weakness. With a ___
interpreter, he complains cough and chills that woke him in the
middle of the night. Upon awakening in the morning he had chest
pain that he describes as a constant ache as well as weakness.
Denies fevers. Endorses mild cough for a few days without
dyspnea. No nausea.
In the ED, he was found to be in AFRVR 160s, and received dilt
with good reduction of HR into ___ AF with SBPs in ___.
Per most recent cards note:
ABI ___: Right 1.07 rest/exercise, left 0.92 rest/exercise.
Cath ___ (___): pLAD 95% --> DES, LCx T.O., ramus 70%, RPDA TO
Echo ___: nl LV/LV function, 2+ AR, indeterminate PA pressure
- Initial vitals:
99.1 145 114/72 18 92% RA
- EKG: Rapid AFib, anterolateral ST depression
- Labs/studies notable for: WBC 15.5, TnI of .07 at
admission->.22->.5
CTA chest with:
1. No evidence of pulmonary embolism.
2. Severe atherosclerotic disease with penetrating
atherosclerotic ulcers within the aortic arch.
3. Aspiration pneumonia in the left upper lobe, lingula, right
middle lobe and right lower lobe.
4. Moderate cardiomegaly, mild pulmonary edema, and
moderate-sized bilateral pleural effusions.
5. Mediastinal and hilar lymphadenopathy as described above,
likely reactive.
- Patient was given:
___ 08:55 PO Aspirin 324 mg
___ 08:58 IV Adenosine 6 mg
___ 09:03 IV Adenosine 12 mg
___ 09:10 IVF NS
___ 09:12 IV Diltiazem 10 mg
___ 10:39 PO Diltiazem 15 mg
___ 10:40 IVF NS 1000 mL
___ 14:56 IV Heparin 4000 UNIT
___ 14:56 IV Heparin Started 850 units/hr
___ 18:01 IV Furosemide 20 mg
___ 19:31 IV Piperacillin-Tazobactam
___ 19:31 IV Metoprolol Tartrate 5 mg
___ 19:33 IV Furosemide 20 mg
___ 20:33 TP Lidocaine Jelly 2% (Glydo)
___ 21:10 IV Piperacillin-Tazobactam 2.25 g
___ 21:13 IV Furosemide 40 mg
___ 21:13 IV Furosemide 20 mg
- Vitals on transfer: HR 112 BP 137/63 RR 21 O2 sat 93% HFNC
On arrival to the CCU: Patient states that his chest pain has
resolved, breathing feels labored but better than it was in the
ED.
REVIEW OF SYSTEMS:
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope, or presyncope.
On further review of systems, denies any prior history of
stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. Denies exertional buttock or calf pain.
Denies recent fevers, chills or rigors. All of the other review
of systems were negative.
Past Medical History:
- HTN - checks daily at home
- Diabetes melitus, diet controlled, recent ___ ___ - 100s.
- L. cataract removal in ___
- Cholecystectomy
- Shrapnel injury in the R. lower back/buttock and R. leg
- R. lower back pain onset within the last few years, gradually
progressive without acute exacerbation.
Social History:
___
Family History:
Pt denies relevant family history
Physical Exam:
ADMISSION
VITALS: HR 108 BP 136/64 RR 23 O2 sat: 94% HFNC
GENERAL: Well appearing, NAD
HEENT: PERRL, MMM
NECK: JVP elevated
CARDIAC: Irregular rhythm, borderline tachycardia, normal S1,
S2. II/VI SEM.
LUNGS: Bilateral lower lung rales
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No ___ edema
PULSES: Distal pulses palpable and symmetric
DISCHARGE
VS: reviewed in OMR
GENERAL: Well appearing, NAD
HEENT: PERRL, MMM
NECK: JVP not elevated
CARDIAC: regular rhythm, borderline tachycardia, normal S1,
S2. II/VI SEM.
LUNGS: Bilateral lower lung rales
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: Trace pitting edema up to bilateral knees
PULSES: Distal pulses palpable and symmetric
Pertinent Results:
ADMISSION LABS:
___ 08:54AM BLOOD WBC-15.5* RBC-3.75* Hgb-12.2* Hct-38.4*
MCV-102* MCH-32.5* MCHC-31.8* RDW-16.6* RDWSD-62.4* Plt ___
___ 08:54AM BLOOD ___ PTT-25.7 ___
___ 08:54AM BLOOD Glucose-166* UreaN-25* Creat-1.3* Na-138
K-4.4 Cl-103 HCO3-15* AnGap-20*
___ 09:36AM BLOOD CK(CPK)-240
___ 08:54AM BLOOD cTropnT-0.07*
___ 08:54AM BLOOD Calcium-9.4 Phos-3.7 Mg-1.9
___ 09:28PM BLOOD ___ pO2-28* pCO2-45 pH-7.23*
calTCO2-20* Base XS--9
MICRO/OTHER PERTINENT LABS:
___ 5:50 pm SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final ___:
TEST CANCELLED, PATIENT CREDITED.
___ 08:04AM BLOOD ALT-56* AST-49* AlkPhos-82 TotBili-1.4
___ 08:54AM BLOOD cTropnT-0.07*
___ 09:36AM BLOOD CK-MB-8
___ 10:50AM BLOOD CK-MB-11* MB Indx-3.5 cTropnT-0.22*
proBNP-7291*
___ 01:20PM BLOOD CK-MB-23* MB Indx-6.9*
___ 01:20PM BLOOD cTropnT-0.52*
___ 12:47AM BLOOD CK-MB-22* cTropnT-1.60*
___ 05:33AM BLOOD CK-MB-21* cTropnT-1.50*
___ 11:34AM BLOOD D-Dimer-1008*
___ 11:35AM BLOOD %HbA1c-5.9 eAG-123
___ 12:47AM BLOOD TSH-2.3
IMAGING:
___ CTA:
1. No evidence of pulmonary embolism.
2. Severe atherosclerotic disease with penetrating
atherosclerotic ulcers
within the aortic arch.
3. Aspiration pneumonia in the left upper lobe, lingula, right
middle lobe and right lower lobe.
4. Moderate cardiomegaly, mild pulmonary edema, and
moderate-sized bilateral pleural effusions.
5. Mediastinal and hilar lymphadenopathy as described above,
likely reactive.
___ TTE
Compared with the prior TTE of ___, left ventricular
systolic function is slightly more vigorous due to synchronous
septal contraction (lack of conduction abnormality and
flattening due to pressure/volume overload). The right ventricle
is mildly dilated. The degree of mitral
regurgitaiton is greater. Significant pulmonary hypertension is
now detected.
___ TEE:
Moderate to severe ___ spontaneous echo contrast without
thrombus. Mild RAA
spontaneous echo contrast without thrombus. Depressed
biventricular systolic function. Moderate central aortic
regurgitation. Aortic stenosis present. Mild to moderate mitral
regurgitation. Mild tricuspid regurgitation.
___ CXR
Increased interstitial markings likely reflect pulmonary edema.
Opacities
along the periphery of the left hemithorax are similar to ___ and
could reflect areas of aspiration/pneumonia. There is a small
left pleural effusion, unchanged. No pneumothorax. The size of
the cardiac silhouette is at the upper limits of normal.
___ CT CHEST
1. Multi-focal consolidations and ground-glass opacities in both
lungs likely representing multifocal pneumonia.
2. There is mediastinal and probable hilar lymphadenopathy,
likely reactive.
3. Moderate left and small right nonhemorrhagic pleural
effusions.
DISCHARGE LABS:
___ 08:25AM BLOOD WBC-14.0* RBC-3.55* Hgb-11.6* Hct-35.2*
MCV-99* MCH-32.7* MCHC-33.0 RDW-16.8* RDWSD-59.7* Plt ___
___ 08:25AM BLOOD ___ PTT-33.4 ___
___ 08:25AM BLOOD Glucose-94 UreaN-34* Creat-1.6* Na-142
K-4.4 Cl-105 HCO3-21* AnGap-16
___ 08:25AM BLOOD Calcium-8.6 Phos-3.1 Mg-2.2
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with AFRVR, cough// PNA?
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___
FINDINGS:
Mild cardiac enlargement is re-demonstrated. The aorta remains tortuous with
atherosclerotic calcifications at the aortic knob. A new focal peripheral
ill-defined opacity seen within the left midlung field. As seen previously,
there is mild pulmonary edema with pulmonary vascular congestion and central
mediastinal venous distension. Small left pleural effusion appears slightly
increased in size. Patchy opacities in lung bases may reflect atelectasis.
No pneumothorax. Mild deformity of the left eighth posterior rib suggests a
remote fracture. No acute osseous abnormalities detected.
IMPRESSION:
1. Peripheral ill-defined focal opacity in the left midlung field, new in the
interval. While this could reflect pneumonia, pulmonary infarction is not
excluded in the correct clinical setting, and if there is concern for
pulmonary embolism, this would be best assessed with chest CTA with
intravenous contrast.
2. Mild pulmonary edema with bibasilar atelectasis and small left pleural
effusion.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: History: ___ with palpitations. Evaluation for pulmonary
embolus.
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast. Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal intensity
projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Stationary Acquisition 2.5 s, 0.5 cm; CTDIvol = 15.2 mGy (Body) DLP =
7.6 mGy-cm.
2) Spiral Acquisition 3.5 s, 27.8 cm; CTDIvol = 15.9 mGy (Body) DLP = 441.9
mGy-cm.
Total DLP (Body) = 450 mGy-cm.
COMPARISON: None
FINDINGS:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
subsegmental level without filling defect to indicate a pulmonary embolus. The
thoracic aorta is normal in caliber without evidence of dissection or
intramural hematoma. Marked atherosclerotic calcification is noted along the
aortic arch and descending thoracic aorta with focal penetrating ulcers
(03:51) with a neck measuring approximately 5 mm and the ulcer measuring up to
1.3 x 0.6 cm. Moderate cardiomegaly is seen. The pericardium and great
vessels are otherwise unremarkable. No pericardial effusion is seen.
Moderate atherosclerotic calcifications of the coronary arteries.
AXILLA, HILA, AND MEDIASTINUM: No axillary lymphadenopathy is present. There
are multiple enlarged mediastinal and hilar lymph nodes, including a
pretracheal lymph node measuring 1.1 cm (03:59), a right paratracheal lymph
node measuring 1.3 cm (3:75), a right hilar lymph node measuring 1.2 cm
(3:86), and a subcarinal lymph node measuring 1.3 cm (3:93). No mediastinal
mass.
PLEURAL SPACES: There are moderate sized nonhemorrhagic bilateral pleural
effusions. No pneumothorax.
LUNGS/AIRWAYS: Diffuse septal thickening with ground-glass opacification is
likely compatible with pulmonary edema. More focal nodular ill-defined
opacities, most notably within the left upper lobe, lingula, right middle
lobe, and right lower lobe likely compatible likely reflect aspiration
pneumonia. There is diffuse airway wall thickening with scattered mucous
plugging.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: Included portion of the upper abdomen is unremarkable. The
esophagus appears mildly patulous which may suggest and esophageal motility
disorder.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Severe atherosclerotic disease with penetrating atherosclerotic ulcers
within the aortic arch.
3. Aspiration pneumonia in the left upper lobe, lingula, right middle lobe and
right lower lobe.
4. Moderate cardiomegaly, mild pulmonary edema, and moderate-sized bilateral
pleural effusions.
5. Mediastinal and hilar lymphadenopathy as described above, likely reactive.
Radiology Report
INDICATION: History: ___ with dyspnea// eval for pulmonary edema
TECHNIQUE: AP and lateral chest radiograph
COMPARISON: CT chest from earlier today
IMPRESSION:
Increased pulmonary edema and opacities along the periphery of the left lung
and right perihilar region. Bilateral pleural effusions are present. There is
no pneumothorax identified. The size of the cardiac silhouette is enlarged but
unchanged.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: Mr. ___ is a ___ y/o M with PMH CAD (s/p NSTEMI with drug
eluting stent to mid-LAD in ___, HTN, HLD, DM II (dietary controlled), CKD
(Cr baseline 1.2-1.4), who presented to BI with chest pain, and found to be in
AF- RVR, with troponin elevation due to likely demand ischemia, with new onset
shortness of breath.// ?decrease in pulmonary edema?
IMPRESSION:
In comparison with the study of ___, there again is enlargement of the
cardiac silhouette with bilateral pulmonary opacifications that are
decreasing. Blunting of the left costophrenic angle is unchanged.
Radiology Report
INDICATION: ___ y/o M with PMH CAD (s/p NSTEMI with drug eluting stent to
mid-LAD in ___, HTN, HLD, DM II (dietary controlled), CKD (Cr baseline
1.2-1.4), who presented to BI with chest pain, and found to be in AF- RVR,
with troponin elevation due to likely demand ischemia. Persistetn hypoxia//
edema? infection?
TECHNIQUE: Chest AP view
IMPRESSION:
Pulmonary edema has improved. Cardiomediastinal silhouette is stable. No
pneumothorax is seen. There is a small left pleural effusion with left
basilar atelectasis
Radiology Report
INDICATION: ___ year old man who presented with chest pain, found to have
demand NSTEMI ___ afib w/ RVR s/p cardioversion, now with coughing/sputum
production c/f pneumonia// pneumonia
TECHNIQUE: AP portable chest radiograph
COMPARISON: Multiple prior radiographs most recently dated ___
IMPRESSION:
Increased interstitial markings likely reflect pulmonary edema. Opacities
along the periphery of the left hemithorax are similar to ___ and
could reflect areas of aspiration/pneumonia. There is a small left pleural
effusion, unchanged. No pneumothorax. The size of the cardiac silhouette is
at the upper limits of normal.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ y/o M with PMH CAD (s/p NSTEMI with drugeluting stent to
mid-LAD in ___, HTN, HLD, DM II, CKD (Crbaseline 1.2-1.4), who presented
with chest pain, found to be inAF-RVR, with troponin elevation, acute
hypoxemic respiratoryfailure, and PNA.// assess pleural effusion? evidence of
PNA?
TECHNIQUE: Multi detector multisequence images of the chest were obtained
with reconstructed axial images. Coronal, sagittal, and axial maximum
intensity projection reformatted images were obtained. No intravenous
contrast was given.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.3 s, 36.2 cm; CTDIvol = 11.2 mGy (Body) DLP = 404.4
mGy-cm.
Total DLP (Body) = 404 mGy-cm.
COMPARISON: Chest radiographs ___ and ___
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: There is no axillary or
supraclavicular lymphadenopathy.
UPPER ABDOMEN: Both adrenal glands are unremarkable. Patient is status post
cholecystectomy.
MEDIASTINUM: There are enlarged mediastinal lymph nodes measuring up to 1.6 cm
in the subcarinal station (02:27) and 1.1 cm in the right upper paratracheal
station (02:19).
HILA: Within the limitations of a CT scan without intravenous contrast, there
is soft tissue density in the bilateral hilar regions likely representing high
lymphadenopathy.
HEART and PERICARDIUM: The heart is not enlarged. Aortic valvular
calcification and coronary arterial calcifications are severe. There is no
pericardial effusion.
PLEURA: There are nonhemorrhagic partially loculated moderate left and small
right pleural effusions.
LUNG:
1. PARENCHYMA: There is multifocal consolidation in surrounding ground-glass
opacity in the right upper, right lower, left upper, and left lower lobes.
There is dependent atelectasis in the bilateral lower lobes.
2. AIRWAYS: The tracheobronchial tree is patent to the subsegmental levels.
3. VESSELS: The main pulmonary artery is not enlarged.
CHEST CAGE: There is no acute osseous abnormality.
IMPRESSION:
1. Multi-focal consolidations and ground-glass opacities in both lungs likely
representing multifocal pneumonia.
2. There is mediastinal and probable hilar lymphadenopathy, likely reactive.
3. Moderate left and small right nonhemorrhagic pleural effusions.
Gender: M
Race: WHITE - RUSSIAN
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with Chest pain, unspecified
temperature: 99.1
heartrate: 145.0
resprate: 18.0
o2sat: 92.0
sbp: 114.0
dbp: 72.0
level of pain: 5
level of acuity: 1.0 | Mr. ___ is a ___ y/o M with PMH CAD (s/p NSTEMI with drug
eluting stent to mid-LAD in ___, HTN, HLD, DM II, CKD (Cr
baseline 1.2-1.4), who presented with chest pain, found to be in
AF-RVR, with troponin elevation, acute hypoxemic respiratory
failure, and PNA.
ACTIVE ISSUES
=============
# New productive cough, leukocytosis in the setting of
pneumonia:
Patient with productive cough, leukocytosis, and evidence of
multifocal PNA on imaging, s/p 1 day Piperacillin-Tazobactam and
1 day CTX and flagyl. Narrowed to levofloxacin ___. S/p 5 day
course of levaquin. DDx includes PNA, aspiration pneumonitis,
parapneumonic effusion. CT Chest ___ showed multifocal PNA with
possible residual treated PNA. IP believed effusion on left side
is most likely related to recent pulmonary edema and not
concerning for infection. Discharged to rehab with
recommendation to monitor sputum production and respiratory
symptoms, and to recheck a CBC to watch his leukocytosis; if
concerning, can consider treating for a CAP (5 days cefpodoxime;
careful with levaquin given QTc prolongation on amiodarone).
# Acute diastolic heart failure:
Likely secondary to tachyarrhythmia induced cardiomyopathy vs.
ischemic heart disease. TTE ___ showed EF 54%, LVH, mild-mod
AR, mod MR, mild TR, RVSP >60. PAH is new and likely has an
element of precapillary pulmonary hypertension.
- Preload: Lasix 20mg PO daily
- Afterload: Held afterload agents including Lisinopril
- NHBK: Metop tartrate 25 BID
- PAH: Outpatient follow up. Not clearly causing symptoms
currently, but may benefit from RHC+pulmonary vasodilators.
# Afib with RVR:
No known history of afib, likely precipitated in the setting of
PNA. CHADS2VASC: 5. Rates in 100s-150s, not sustained. s/p
TEE/DCCV with conversion to sinus. Started amiodarone load.
- RC: Metoprolol tartrate 25 BID
- AC: Apixaban 2.5 BID
# ___ on CKD
Scr baseline 1.2-1.4. Stable on discharge at 1.6.
# NSTEMI:
___ be demand ischemia in the setting of AFib with RVR, though
TnT peaked at 1.6. s/p heparin drip 48 hours. Continued ASA 81
mg daily, atorvastatin 40 mg, metoprolol.
RESOLVED ISSUES
==============
# Acute Hypoxemic Respiratory Failure:
Patient initially presented without oxygen requirement,
subsequently became hypoxemic requiring BiPAP and HFNC. Likely a
combination of acute pulmonary edema in setting of AF RVR/fluid
administration, and PNA. Currently on ___ NC. Diuresed w/IV
Lasix, back on home regimen Lasix 20mg po daily.
CHRONIC ISSUES
==============
# HTN:
Continued metoprolol as above, held home Lisinopril.
# HLD:
Continued home atorvastatin 40 mg daily.
# Type II DM:
Diet controlled, A1C 5.9%
# Gout:
Continued allopurinol ___ mg daily.
TRANSITIONAL ISSUES
===================
DISCHARGE WT: 67.4 kg (148.59 lb)
DRY WEIGHT: 149 lbs
DISCHARGE CR: 1.6
DISCHARGE HGB: 11.6
DISCHARGE WBC: 14
NEW MEDICATIONS:
Amiodorone
Apixaban 2.5mg BID
Lasix 20mg daily
Metoprolol 25mg BID
STOPPED MEDICATIONS:
Lisinopril
[ ] PAH: Outpatient follow up. Not clearly causing symptoms
currently, but may benefit from RHC+pulmonary vasodilators.
[ ] Amiodarone taper
---[] amiodarone 200mg TID x1 day (___)
---[] amiodarone 200mg BID x5 days (___)
---[] amiodarone 200mg daily (___-)
[ ] Follow-up electrolytes and WBC in 1 week (prescription
provided)- ensure Cr stable on maintenance diuretic, and
leukocytosis is stable/downtrending
[ ] Consider re-starting lisinopril once Cr improves
[ ] Monitor sputum production, if WBC count still elevated and
patient with significant respiratory symptoms, consider starting
treatment for pneumonia (consider cefpodoxime x5d)
[ ] ___ clinic to repeat CXR in 1 month. If persistent and
would benefit from sampling, would be ok to hold AC at this
point for a couple days once he is over 1 month out from ___
[ ] follow up volume status on maintenance Lasix
# ADVANCE CARE PLANNING: ___
Relationship: step-daughter Phone: ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
bcp / Penicillins / morphine
Attending: ___
___ Complaint:
Motor Vehicle Crash
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ who presents w/ pain in her shoulder s/p MVC. Per EMS,
the patient was a restrained driver who lost control of her
car while trying to change lanes. The car flipped onto the
roof with considerable intrusion to the passenger side and
roof. The airbags did deploy, and the patient was held in
her seat by her seatbelt. She required assistance
extricating. She states she did not lose consciousness. The
patient endorses pain in her chest and left shoulder. A full
HPI and ROS could not be obtained due to patient's acuity.
Past Medical History:
___ who presents w/ pain in her shoulder s/p MVC. Per EMS,
the patient was a restrained driver who lost control of her
car while trying to change lanes. The car flipped onto the
roof with considerable intrusion to the passenger side and
roof. The airbags did deploy, and the patient was held in
her seat by her seatbelt. She required assistance
extricating. She states she did not lose consciousness. The
patient endorses pain in her chest and left shoulder. A full
HPI and ROS could not be obtained due to patient's acuity.
Social History:
___
Family History:
non-contributory
Physical Exam:
Admission Physical exam
DISCHARGE PHYSICAL EXAM:
VS:
GEN: awake, alert, pleasant and interactive.
CV: RRR
PULM: diminished in the bases. mild inspiratory wheeze diffuse.
Tender to palpation midchest/sternum.
ABD: Soft, non-tender, non-distended. Active bowel sounds.
EXT: Warm and dry. No edema.
NERUO: A&Ox3. Follows commands and moves all extremities equal
and strong. Speech is clear and fluent.
Pertinent Results:
___ 06:08AM BLOOD WBC-6.6 RBC-3.49* Hgb-10.3* Hct-31.9*
MCV-91 MCH-29.5 MCHC-32.3 RDW-14.5 RDWSD-48.3* Plt ___
___ 01:32AM BLOOD WBC-9.2 RBC-4.02 Hgb-11.7 Hct-36.1 MCV-90
MCH-29.1 MCHC-32.4 RDW-13.9 RDWSD-45.4 Plt ___
___ 01:32AM BLOOD ___ PTT-25.9 ___
___ 06:08AM BLOOD Glucose-102* UreaN-18 Creat-0.9 Na-143
K-4.0 Cl-105 HCO3-21* AnGap-17
___ 06:08AM BLOOD Calcium-9.3 Phos-3.9 Mg-1.9
___ 01:31AM BLOOD Glucose-139* Lactate-1.9 Creat-0.8 Na-140
K-3.7 Cl-109* calHCO3-24
Radiology:
___ HAND RIGHT: No acute fracture or dislocation.
___ CT C-Spine: No acute cervical spine fracture or traumatic
malalignment.
___ CT HEAD:
1. No evidence of acute fracture or acute intracranial process
or hemorrhage.
2. Mucosal thickening identified in the left maxillary sinus
and
ethmoidal air cells, suggesting an ongoing inflammatory process.
___ CT Chest: Minimally displaced fracture involving the upper
body of the sternum.
___ DX BILATERAL WRISTS: No acute fracture or dislocation.
Degenerative changes of both first CMC joints.
___ Hand:
1. No fracture or dislocation.
2. 5 mm lucent lesion in the proximal end of the middle finger
proximal phalanx is nonspecific but unlikely to be of clinical
significance. If there is further specific concern, evaluation
with MRI may be performed.
___ GLENO-HUMERAL SHOULDER Left: No acute fracture or
dislocation.
Medications on Admission:
Mucinex prn
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild
Take with food.
3. Lidocaine 5% Patch 1 PTCH TD QAM
___ use over the counter 4% strength if not covered by
insurance.
RX *lidocaine 5 % Apply to painful area 12 hours on, then 12
hours off Disp #*14 Patch Refills:*0
4. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
5. GuaiFENesin ER 600 mg PO Q12H
6. Montelukast 10 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
sternal fracture
trace pericardial effusion
Right anterior ___ rib fractures
Left anterior ___ rib fractures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: TRAUMA #2 (AP CXR AND PELVIS PORT)
INDICATION: History: ___ with chest pain, hemotympanium, seatbelt sign***
WARNING *** Multiple patients with same last name!// MVC; acute process
TECHNIQUE: Portable chest and pelvis AP.
COMPARISON: None
FINDINGS:
Low lung volumes. There is no focal consolidation, pleural effusion, or
pneumothorax. Cardiomediastinal silhouette is within normal limits.
No acute fractures identified in the chest or pelvis.
IMPRESSION:
No pneumothorax or consolidation
No acute chest or pelvic fracture identified.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST.
INDICATION: History: ___ with chest pain, hemotympanium, seatbelt sign***
WARNING *** Multiple patients with same last name!// MVC; acute process.
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformations and bone
algorithms reconstructions were also performed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 17.9 cm; CTDIvol = 44.9 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: None available.
FINDINGS:
There is no evidence of infarction, intracranial hemorrhage, edema, or mass.
The ventricles and sulci are normal in size and configuration.
No acute fracture seen. The paranasal sinuses are notable for mucosal
thickening in the left maxillary sinus with narrowing of the left
infundibulum, there is mucosal thickening in the ethmoidal air cells, no
air-fluid levels are seen. The mastoid air cells, and middle ear cavities are
grossly clear. The orbits are unremarkable.
IMPRESSION:
1. No evidence of acute fracture or acute intracranial process or hemorrhage.
2. Mucosal thickening identified in the left maxillary sinus and ethmoidal
air cells, suggesting an ongoing inflammatory process.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST.
INDICATION: History: ___ with chest pain, hemotympanium, seatbelt sign***
WARNING *** Multiple patients with same last name!// MVC; acute process.
TECHNIQUE: Contiguous axial images obtained through the cervical spine
without intravenous contrast. Coronal and sagittal reformats were reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.0 s, 19.8 cm; CTDIvol = 22.8 mGy (Body) DLP = 451.2
mGy-cm.
Total DLP (Body) = 451 mGy-cm.
COMPARISON: None available.
FINDINGS:
The cervical spine alignment is normal. No acute cervical spine fractures are
identified.There is no significant canal or foraminal narrowing.There is no
prevertebral edema.
The thyroid and included lung apices are unremarkable.
IMPRESSION:
No acute cervical spine fracture or traumatic malalignment.
Radiology Report
EXAMINATION: CT CHEST/ABD/PELVIS W/ CONTRAST
INDICATION: ___ with chest pain, hemotympanium, seatbelt sign// MVC; acute
process
TECHNIQUE: MDCT axial images were acquired through the chest, abdomen and
pelvis following intravenous contrast administration with split bolus
technique.
Oral contrast was not administered.Coronal and sagittal reformations were
performed and reviewed on PACS.
DOSE: Total DLP (Body) = 1,678 mGy-cm.
COMPARISON: None.
FINDINGS:
CHEST:
HEART AND VASCULATURE: The thoracic aorta is normal in caliber without
evidence of acute injury. The heart, pericardium, and great vessels are
within normal limits. No pericardial effusion is seen. Trace fluid is seen
within a high pericardial recess. Subtle amount of residual thymic tissue
noted on series 2, image 40 in the anterior mediastinal space.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass or hematoma.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Lungs are clear without masses or areas of parenchymal
opacification. The airways are patent to the level of the segmental bronchi
bilaterally.
BASE OF NECK: A 2 mm right thyroid nodule is noted.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesion or laceration. There is no evidence of
intrahepatic or extrahepatic biliary dilatation. The gallbladder is within
normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesion or laceration.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: Bilateral renal cortical hypodensities likely cysts seen measuring up
to 1.0 cm on the right. 2 punctate hyperdense foci within the right kidney as
seen on series 2, image 145 and 137 likely representing nonobstructing stones.
The kidneys are of normal and symmetric size with normal nephrogram. There is
no evidence of focal renal lesions or hydronephrosis. There is no perinephric
abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is normal. There is no
evidence of mesenteric injury.
There is no free fluid or free air in the abdomen.
PELVIS:The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: Several uterine fibroids are noted. There is a 4 cm left
adnexal cyst (series 2, image 208).
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm or retroperitoneal hematoma.
Mild atherosclerotic disease is noted.
BONES AND SOFT TISSUES: A minimally displaced fracture through the mid upper
body of the sternum is noted without significant retrosternal hematoma.
Minimal anterior chest wall contusion is related extending leftward
superolaterally along the expected course of the seatbelt. No other acute
fractures are seen. Degenerative changes at L5-S1 are moderate to severe.
Small fat containing umbilical hernia is noted.
IMPRESSION:
Minimally displaced fracture involving the upper body of the sternum.
Additional nontraumatic findings as above.
NOTIFICATION:
Findings discussed in real-time with ACS team.
Radiology Report
EXAMINATION: DX BILATERAL WRISTS
INDICATION: History: ___ with trauma*** WARNING *** Multiple patients with
same last name!// trauma
TECHNIQUE: Frontal, oblique, and lateral view radiographs of bilateral
wrists.
COMPARISON: None
FINDINGS:
No acute fractures or dislocation are seen. There are moderate to severe
degenerative changes of the first carpometacarpal joints bilaterally. Carpal
bones are well aligned.
IMPRESSION:
No acute fracture or dislocation. Degenerative changes of both first CMC
joints.
Radiology Report
EXAMINATION: HAND (PA,LAT AND OBLIQUE) LEFT
INDICATION: History: ___ with trauma*** WARNING *** Multiple patients with
same last name!// trauma
TECHNIQUE: Frontal, oblique, and lateral view radiographs of the left hand.
COMPARISON: None.
FINDINGS:
No fracture or dislocation is seen. There are no significant degenerative
changes. There is an oval 5 mm lucent lesion with a sclerotic rim in the
proximal end of the middle finger proximal phalanx. No soft tissue
calcification or radio-opaque foreign bodies are detected.
IMPRESSION:
1. No fracture or dislocation.
2. 5 mm lucent lesion in the proximal end of the middle finger proximal
phalanx is nonspecific but unlikely to be of clinical significance. If there
is further specific concern, evaluation with MRI may be performed.
Radiology Report
EXAMINATION: GLENO-HUMERAL SHOULDER (W/ Y VIEW) LEFT
INDICATION: History: ___ with trauma*** WARNING *** Multiple patients with
same last name!// trauma
TECHNIQUE: AP, Grashey, and Y-views of the left shoulder.
COMPARISON: None
FINDINGS:
There is no acute fracture or dislocation involving the glenohumeral or AC
joint. There are no significant degenerative changes. No periarticular
calcification or radio-opaque foreign body is seen.
IMPRESSION:
No acute fracture or dislocation.
Radiology Report
EXAMINATION: HAND (PA,LAT AND OBLIQUE) RIGHT
INDICATION: ___ year old woman with right hand pain s/p mvc// fractre/
dislocation
TECHNIQUE: Frontal, oblique, and lateral view radiographs of the left hand.
COMPARISON: None
FINDINGS:
No acute fracture or dislocation is seen. Moderate degenerative changes of
the first carpometacarpal joint are noted. No radio-opaque foreign bodies are
detected.
IMPRESSION:
No acute fracture or dislocation.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ s/p rollover MVC w/ sternal fx, mediastinal hematoma, trace
pericardial effusion, aortic stranding now with increased back pain.
Evaluation for aortic injury/dissection.
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast. Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal intensity
projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.2 s, 28.9 cm; CTDIvol = 15.2 mGy (Body) DLP = 437.9
mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7
mGy-cm.
3) Stationary Acquisition 2.4 s, 0.5 cm; CTDIvol = 13.3 mGy (Body) DLP =
6.6 mGy-cm.
Total DLP (Body) = 446 mGy-cm.
COMPARISON: No prior imaging available for comparison.
FINDINGS:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
subsegmental level without filling defect to indicate a pulmonary embolus. The
thoracic aorta is normal in caliber without evidence of dissection or
intramural hematoma. The heart, pericardium, and great vessels are within
normal limits. Small pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. Few mildly prominent mediastinal lymph nodes are
not pathologically enlarged by CT size criteria.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Lungs are clear without masses or areas of parenchymal
opacification. Mild dependent bibasilar atelectasis. There is a 1.4 cm
air-filled cystic space in the right lower lobe (301:123), likely representing
a bulla or pneumatocele. The airways are patent to the level of the segmental
bronchi bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: Please note that the current study is not tailored for
subdiaphragmatic evaluation, however the included portion of the upper abdomen
appears unremarkable.
BONES: No suspicious osseous abnormality is seen.? Multiple nondisplaced
fractures involving the anterior aspect of the right ribs 2 through 6. Subtle
nondisplaced fractures involving anterior aspect of the left second and third
ribs. Small mildly displaced fracture involving the anterior aspect of the
upper sternal body, with small amount of adjacent chest wall edema.
IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic abnormality.
2. Mildly displaced fracture involving the anterior aspect of the upper
sternal body. No retrosternal hematoma.
3. Multiple subtle nondisplaced fractures involving the anterior ribs,
including the right ribs 2 through 6 and left ribs 2 and 3.
4. Small pericardial effusion. No evidence of active hemorrhage.
Gender: F
Race: WHITE
Arrive by UNKNOWN
Chief complaint: MVC
Diagnosed with Fracture of body of sternum, init encntr for closed fracture, Car occupant (driver) injured in oth transport acc, init
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: uta
level of acuity: 1.0 | Ms. ___ is a ___ yo F who presented to the emergency
department on ___ after a rollover motor vehicle crash
without loss of consciousness. Pan scan was notable for sternal
fracture with possible hamatoma, trace pericardial effusion, and
aortic stranding. Extremity imaging was negative for further
fractures or dislocations. She was admitted to the ___ for
cardiac monitoring and pain control.
She remained alert and oriented throughout hospitalizations. She
was monitored continuous telemetry and had no abnormal EKG
findings. TTE was unremarkable. Respiratory status was monitored
on continuous O2 and she was given albuterol nebs as needed.
Pulmonary toileting and incentive spirometery were encouraged.
She was initially given IV fluids which were stopped once
tolerating a regular diet. Intake and output were closely
monitored and remained adequate. On HD2 she has worsening
back/flank pain that was persistent and therefore underwent CTA
to better evaluate aorta given possible stranding on initial
imaging. CTA was negative for acute aortic injury. The patient's
fever curves were closely watched for signs of infection, of
which there were none.The patient's blood counts were closely
watched for signs of bleeding, of which there were none. The
patient received subcutaneous heparin and ___ dyne boots were
used during this stay and was encouraged to get up and ambulate
as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Cardiac arrest
Major Surgical or Invasive Procedure:
ICD Placement ___
Device brand/name: ___ AF MRI VR DVFB1D4
Model Number: ___
Lead Model ___ Sprint ___ MRI, MR ___ Yes, Lead
Position RV, Lead Length 62 cm, Manufacturer ___, Serial
Number ___, Implant Date ___
History of Present Illness:
___ is a ___ male with no significant past
medical history who presented (initially to ___ after
witnessed cardiac arrest around midnight. The patient was at a
bar and reportedly collapsed suddenly while showing ID. Per
report, CPR was started immediately and an AED was applied. This
initial AED did not recommend defibrillation. When ACLS arrived
approximately 6 minutes after and attached their defibrillator,
rhythm was reported as VF. In this setting, the patient was
defibrillated twice and received 4 mg epinephrine. Patient also
received naloxone, which reportedly did not improve his mental
status. He was down for approximately ___ minutes. He was
intubated in the field. There was also concern for ___
activity in the field as well as at ___ and the patient
received 1gm Levitiracetam and also needed vasopressor support
transiently. He was then transferred for further ___
management. On arrival to ___, the patient was hemodynamically
stable and was not on any vasopressors. In the ED, focused
bedside echo did not demonstrate any large wall motion
abnormalities and showed preserved LV function, normal RV and no
pericardial effusion. His ECG was without ST elevations, but was
noted to have lateral ST depressions.
In the ED,
- Initial vitals were: BP: 140/70 (only recorded vital in ED
Dash)
- Exam notable for: biting ETT, overbreathing vent, ?myoclonus
- Labs notable for:
26.0> 17.0/50.1 <249
___ 10.9, PTT 22.4, INR 1.0
Fibrinogen 187
BUN 15, Cr 1.1
ALT: 359 AP: 79 Tbili: 0.3 Alb: 4.3
AST: 292
pH:7.20, pCO2:36, pO2:76, HCO3:15
Urine Tox: Negative
Serum Tox: Positive for Ethanol 54
Lactate: 6.4
O2Sat: 91
- Studies notable for:
CT Head: No acute intracranial abnormality
CT Neck: No fracture
- Patient was given:
Amiodarone 150mg IV
Amiodarone 1mg/min
- ___ Team was consulted:
1) Would recommend TTM at 35 degrees for 24 hours and then
2) Check ABG with lactate
3) Wean the Fio2 as rapidly as possible to keep sat > 94%
4) Goal pCO2 between ___
5) Seek underlying etiology as you are doing
6) EEG in the ICU
7) Head of bed up 30 degrees
On arrival to the CCU, the patient is intubated and sedated.
Past Medical History:
GERD
Social History:
___
Family History:
Grandmother: CHF
Uncle: ?mitral valve disease
No FHx of sudden death, drowning, car accidents
Physical Exam:
ADMISSION PHYSICAL
==================
GENERAL: Well developed, well nourished in NAD.
HEENT: NC/AT. Sclera anicteric. PERRL. EOMI.
NECK: Supple. No JVP at 30 degrees.
CARDIAC: Normal rate, regular rhythm. No murmurs, rubs, or
gallops.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No adventitious breath
sounds.
ABDOMEN: Soft, NTND. +BS.
EXTREMITIES: Cool, no edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE PHYSICAL
==================
VS: ___ ___ Temp: 97.9 PO BP: 106/65 R Lying HR: 90 RR: 16
O2 sat: 94% O2 delivery: Ra
GENERAL: Well developed, well nourished young man.
HEENT: NC/AT. No icterus or injection. MMM.
NECK: Supple. JVP not visible at 30 degrees.
CARDIAC: regular rate, regular rhythm. No murmurs.
LUNGS: CTAB.
ABDOMEN: Soft, NTND.
EXTREMITIES: Warm, no edema.
SKIN: No rashes or lesions. +Tattoo.
NEURO: AAOx3. PERRL, EOMI, CN ___ intact. Strength ___ and
symmetric throughout.
Pertinent Results:
ADMISSION LABS
==============
___ 01:53AM BLOOD ___
___ Plt ___
___ 05:39AM BLOOD ___
___ Im ___
___
___ 05:39AM BLOOD ___
___
___ 01:53AM BLOOD ___ ___
___ 01:53AM BLOOD ___ 01:53AM BLOOD ___
___ 01:53AM BLOOD ___
___ 01:53AM BLOOD ___
___ 05:39AM BLOOD ___ MB ___
___ 01:53AM BLOOD ___
___ 05:39AM BLOOD ___
___ 11:56AM BLOOD ___
___ 05:39AM BLOOD ___
___ 11:56AM BLOOD ___
___ 01:53AM BLOOD ___
___
___ 02:00AM BLOOD ___
___ Base XS--14
___ 02:00AM BLOOD ___
___
___ 02:00AM BLOOD ___ O2 ___
___
___ 02:00AM BLOOD ___
___ 02:01AM URINE ___
___
PERTINENT LABS
==============
___ 06:01AM BLOOD HIV ___
___ 05:39AM BLOOD ___ MB ___
___ 11:56AM BLOOD ___ MB ___
___ 06:07PM BLOOD ___
___ 11:57PM BLOOD ___
___ 08:38PM URINE ___ Sp ___
___ 08:38PM URINE ___
___
___ 08:38PM URINE ___
Epi-<1 TransE-<1
___ 08:38PM URINE ___
___ 08:38PM URINE ___
MICRO
=====
_________________________________________________________
___ 11:28 pm BLOOD CULTURE Source: ___.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 8:46 pm BLOOD CULTURE Source: Venipuncture 1 OF 2.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 8:38 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 9:09 am BLOOD CULTURE Source: Venipuncture X2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 9:08 am BLOOD CULTURE Source: ___.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 8:13 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
__________________________________________________________
___ 8:13 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
STUDIES
=======
CXR ___
The left cardiac device lead terminates in the right ventricle
without
appreciable pneumothorax. Better lung aeration with improved
basilar consolidations. However, new right midlung consolidation
concerning for pneumonia.
Cardiac MRI ___
The left atrial AP dimension is normal with mild left atrial
elongation.
The right atrium is mildly dilated. There is asymmetric septal
hypertrophy with maximal wall thickness of the basal anterior
septum with mildly increased mass and mildly increased mass
index. The left ventricular ___ dimension was normal
with normal ___ dimension index and mildly increased
left ventricular ___ volume with normal ___
volume index.There is mild global left ventricular hypokinesis
with mildly depressed ejection fraction. There is papillary
muscle hypertrophy with relative apical displacement. There is
regional variation in T2 with increased signal of the mid and
basal anterolateral wall.
Early gadolinium enhancement images showed diffuse
subendocardial enhancement (see schematic). There is diffuse
subendocardial based late gadolinium enhancement in a slightly
less extensive pattern than that seen on the early gadolinium
enhancement images (see schematic). Normal right ventricular
cavity size with normal regional/global free wall motion. Normal
origin of the right and left main coronary arteries. Normal
ascending aorta diameter with normal aortic arch diameter and
normal descending thoracic aorta diameter. Normal abdominal
aorta diameter. Normal pulmonary artery diameter. The aortic
valve has 3 leaflets. Leaflet thickness is normal. There is no
aortic valve stenosis. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no valvular
systolic anterior motion (___) or evidence for a resting LVOT
gradient. There is mild mitral regurgitation. There is mild
tricuspid regurgitation. There is a small pericardial effusion.
Pericardial thickness is normal.
IMPRESSION:
Asymmetric septal hypertrophy with maximal wall thickness of the
basal anterior septum (maximal thickness 1.6 cm) with mildly
increased mass index. Papillary muscle hypertrophy and apical
displacement. Normal left ventricular cavity size with mild
global left ventricular systolic dysfunction. Diffuse
subendocardial early and late gadolinium enhancement as
described above, consistent with inflammation and/or fibrosis.
Increased T2 signal involving the mid and basal anterolateral
wall, consistent with inflammation and/or edema. Normal right
ventricular cavity size and free wall motion. Small pericardial
effusion. In the correct clinical context, the increased left
ventricular wall thickness, increased left ventricular mass, and
papillary muscle hypertrophy with apical displacement are
consistent with hypertrophic cardiomyopathy. Diffuse early and
late gadolinium enhancement with focal increased T2 signal is
most likely related to his known recent cardiac arrest.
MRI Head w/o Contrast ___
Essentially normal brain MRI, with no evidence of acute/subacute
intracranial process.
TTE ___
The left atrium is not well seen. There is normal left
ventricular wall thickness with a normal cavity size. There is
normal regional left ventricular systolic function. Quantitative
biplane left ventricular ejection fraction is 62 %. There is no
resting left ventricular outflow tract gradient. Normal right
ventricular cavity size with normal free wall motion. The aortic
valve leaflets (3) appear structurally normal. Aortic
valve stenosis cannot be excluded. There is no aortic
regurgitation. The mitral leaflets appear structurally normal
with no mitral valve prolapse. There is mitral regurgitation
(cannot be qualified). The tricuspid valve leaflets appear
structurally normal. There is triuspid regurgitation present
(could not be qualified). The pulmonary artery systolic pressure
could not be estimated. There is a trivial pericardial effusion.
IMPRESSION:
Adequate image quality. Focused study to evaluate left
ventricular function. Normal left ventricular wall thickness,
cavity size, and regional/global systolic function.
CXR ___
There are low bilateral lung volumes. Increased bilateral lower
lobe
opacities may reflect pulmonary edema however superimposed
pneumonia would be hard to exclude in the proper clinical
context. There is a left pleural
effusion, new since prior. No pneumothorax. The size of the
cardiac
silhouette is mildly enlarged however may be exaggerated by low
lung volumes and AP portable technique.
EEG ___
This is an abnormal continuous ___ study because of
generalized slowing, consistent with moderate to severe
encephalopathy. This finding is nonspecific as to etiology but
may be due to ___ disturbances, infection or
medications. As the study progresses there is some improvement
seen in the background after 17:00. Superimposed frontally
predominant faster frequency activity is often seen as an effect
of sedating medications. There are no epileptiform discharges or
electrographic seizures.
TTE ___
The left atrial volume index is normal. A prominent Chiari
network is present (normal variant). There is no evidence for an
atrial septal defect by 2D/color Doppler . The right atrial
pressure could not be estimated. There is normal left
ventricular wall thickness with a normal cavity size. Global
left ventricular systolic function is severely depressed with
severe hypokinesis of the distal ventricle and akinesis of the
apex. The remaining segments are also hypokinetic. Quantitative
biplane left ventricular ejection fraction is 26 %. Left
ventricular cardiac index is low normal ___ L/min/m2).
There is no resting left ventricular outflow tract gradient. No
ventricular septal defect is seen. Sludge is seen in the left
ventricular apex. At this point a defined thrombus has not
formed, but anticoagulation should be continued. Normal right
ventricular cavity size with focal hypokinesis of the apical
free wall. The aortic sinus diameter is normal for gender with
normal ascending aorta diameter for gender. The aortic valve
leaflets (3) appear structurally normal. There is no aortic
valve stenosis. There is no aortic regurgitation. The mitral
leaflets appear structurally normal with no mitral valve
prolapse. There is mild [1+] mitral regurgitation. The
___ PR velocity is elevated suggesting pulmonary
artery diastolic hypertension. The tricuspid valve leaflets
appear structurally normal. There is physiologic tricuspid
regurgitation. The estimated pulmonary artery systolic pressure
is normal. There is no pericardial effusion.
IMPRESSION:
Good image quality. Severe global left ventricular systolic
dysfunction with normal cavity size and more prominent
dysfunction of apical segments. Sludge in the left ventriuclar
apex (see above and attached photo). Prominent apical right
ventricular systolic dysfunction. No significant
valvular disease.
RUQUS ___
Splenomegaly. Otherwise, unremarkable abdominal ultrasound.
CT ___ w/o Contrast ___. No fracture or traumatic malalignment.
2. Prominent lymph nodes in adenoids, likely reactive.
3. Additional findings described above
CT Head w/o Contrast ___. No acute intracranial abnormality on noncontrast head CT.
Specifically no large territorial infarct or intracranial
hemorrhage. The ___
differentiation appear preserved.
2. No acute displaced calvarial fracture.
ECG ___
Sinus tachycardia. ___ wave changes. There is PR
segment
depression which may represent pericardial disease in the
appropriate clinical context. Compared to the previous tracing
of the same date, there is no significant change.
DISCHARGE LABS
==============
15.7
11.0>------< 233
43.6
142 | 105 | 20
---------------<94 AGap=16
4.8 | 21 | 0.9
Ca: 9.6 Mg: 2.1 P: 4.9
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium Carbonate 500 mg PO QID:PRN GERD
Discharge Medications:
1. Cephalexin 500 mg PO/NG Q6H Duration: 3 Days
RX *cephalexin 500 mg 1 capsule(s) by mouth four times a day
Disp #*11 Capsule Refills:*0
2. Diltiazem ___ 120 mg PO DAILY
RX *diltiazem HCl 120 mg 1 capsule(s) by mouth once a day Disp
#*30 Capsule Refills:*0
3. OxyCODONE (Immediate Release) 5 mg PO ONCE MR1 Duration: 1
Dose
RX *oxycodone 5 mg 1 tablet(s) by mouth ___ pain
Disp #*2 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses
=================
Hypertrophic nonobstructive cardiomyopathy
Sudden cardiac arrest
___ pneumonia
Aspiration pneumonitis
Transaminitis
Secondary Diagnoses
===================
GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: History: ___ with cardiac arrest, intubated*** WARNING ***
Multiple patients with same last name!// ett inplace? og inplace?
TECHNIQUE: Single AP view of the chest
COMPARISON: CT C-spine ___.
FINDINGS:
An enteric tube courses below the level the diaphragm and tip projects over
left upper quadrant in the expected location stomach. An endotracheal tube
ends in the mid thoracic trachea. Allowing for low lung volumes the
cardiomediastinal silhouette is likely within normal limits. There are
bilateral airspace opacities most conspicuous in the left upper lobe, also
seen on CT C-spine from the same date.
IMPRESSION:
An enteric tube is seen with tip projecting over left upper quadrant in the
expected location of the stomach. Bilateral airspace opacities, also seen on
CT C-spine from the same date, concerning for pneumonia possibly due to
aspiration given the history.
ET tube terminates approximately 3 cm from the carina.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with fall, cardiac arrest, c/f seizure*** WARNING
*** Multiple patients with same last name!// cva? fx?
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 18.0 s, 19.1 cm; CTDIvol = 47.3 mGy (Head) DLP =
903.1 mGy-cm.
Total DLP (Head) = 903 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass effect. The
ventricles and sulci are normal in size and configuration. Incidental note is
made ___ cisterna magna.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
1. No acute intracranial abnormality on noncontrast head CT. Specifically no
large territorial infarct or intracranial hemorrhage. The gray-white
differentiation appear preserved.
2. No acute displaced calvarial fracture.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: History: ___ with fall, cardiac arrest, c/f seizure*** WARNING
*** Multiple patients with same last name!// cva? fx? cva? fx?
TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.0 s, 23.8 cm; CTDIvol = 22.8 mGy (Body) DLP = 542.1
mGy-cm.
Total DLP (Body) = 542 mGy-cm.
COMPARISON: None.
FINDINGS:
Alignment is anatomic.No acute displaced fractures are identified. There is no
evidence of spinal canal or neural foraminal stenosis. There is no
prevertebral soft tissue swelling.The adenoids are prominent and the cervical
lymph nodes are slightly enlarged, the largest measuring up to 1.9 cm in long
axis in level 2A, likely reactive in a patient of this age.
There is extensive consolidation at the lung apices, bilaterally. An
endotracheal tube is partially visualized.
IMPRESSION:
1. No fracture or traumatic malalignment.
2. Prominent lymph nodes in adenoids, likely reactive.
3. Additional findings described above
Radiology Report
INDICATION: ___ year old man s/p post cardiac arrest, right femoral line,
intubated// interval line check
TECHNIQUE: Frontal radiograph of the chest.
COMPARISON: ___
IMPRESSION:
ET tube is seen with tip projecting 5 cm from the carina. Enteric tube is
seen with tip projecting over left upper quadrant in the expected location of
the stomach, similar positions.
Opacities of the upper lung field bilateral lungs, left greater than right,
appears similar prior exam. Mildly prominent cardiac silhouette appears
similar to prior exam and may be exacerbated by low lung volumes.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ who presented with sudden cardiac arrest, admitted to the CCU
for post VF arrest care and targeted temperature management, remains intubated
and sedated.// Eval interval change, lines and tubes Eval interval change,
lines and tubes
IMPRESSION:
Compared to chest radiographs ___.
Previous mild to moderate, upper lobe predominant pulmonary edema is
improving. Some residual consolidation persists on the right. Follow-up
advised to exclude development of concurrent aspiration pneumonia.
Low lung volumes exaggerate mild cardiomegaly. No pneumothorax or pleural
effusion.
ET tube in standard placement. Nasogastric tube ends in the stomach.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ with no significant past medical history who presented with
sudden cardiac arrest, admitted to the CCU for post VF arrest care and
targeted temperature management, initially with GI prodome symptoms and with
abnormal LFTs// Eval etiology abnormal LFTs
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 2 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
head obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 14.8 cm.
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
Splenomegaly. Otherwise, unremarkable abdominal ultrasound.
Radiology Report
INDICATION: ___ year old man admitted for cardiac arrest, extubated early
today, now with worsening hypoxemia and work of breathing// eval for edema,
PNA, aspiration
TECHNIQUE: AP portable chest radiographs
COMPARISON: ___ from earlier in the day
IMPRESSION:
There are low bilateral lung volumes. Increased bilateral lower lobe
opacities may reflect pulmonary edema however superimposed pneumonia would be
hard to exclude in the proper clinical context. There is a left pleural
effusion, new since prior. No pneumothorax. The size of the cardiac
silhouette is mildly enlarged however may be exaggerated by low lung volumes
and AP portable technique.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD
INDICATION: ___ with no medical history admitted after witnessed sudden
cardiac arrest with 15 minutes of down-time. Unclear etiology. Likely primary
arrhythmia. Now with memory issues and persistent nausea and vomiting.// Any
hypoperfusion/ischemic changes following cardiac arrest to explain persistent
N/V and memory issues.
TECHNIQUE: Sagittal T1, axial T2, axial FLAIR, axial magnetic susceptibility
and axial diffusion-weighted images were obtained through the brain.
COMPARISON Prior head CT dated ___.
FINDINGS:
There is no evidence of intracranial hemorrhage, mass, mass effect or shifting
of the normally midline structures, there is no evidence of territorial
infarction. There is slightly prominent cisterna magna in the posterior fossa
consistent with anatomical variation, otherwise, the ventricles and sulci are
normal in caliber and configuration. The pituitary appears normal. The
craniocervical junction appears normal. The intracranial arteries demonstrate
normal T2 flow void signal. The orbits appear normal. The middle ear
cavities and mastoid air cells are clear
IMPRESSION:
Essentially normal brain MRI, with no evidence of acute/subacute intracranial
process.
Radiology Report
INDICATION: ___ with no medical history admitted after witnessed
cardiacarrest with 15eval structural cause of cardiac arrest
TECHNIQUE: Cardiac MRI was performed by the Department of Cardiology.
COMPARISON: Chest x-ray dated ___.
IMPRESSION:
Please note that this report only pertains to extracardiac findings.
Splenomegaly, measuring 14.9 cm. Multifocal areas of heterogeneous signal are
seen within the lung parenchyma bilaterally likely reflecting aspiration or
atelectasis.
The entirety of this Cardiac MRI is reported separately in the Electronic
Medical Record (OMR) - Cardiovascular Reports.
Radiology Report
INDICATION: ___ year old man s/p ICD implant// check lead location and pnx
TECHNIQUE: Chest PA and lateral
COMPARISON: Multiple prior chest radiographs, most recently dated ___.
FINDINGS:
Left chest wall cardiac device lead terminates in right ventricle.
The lungs are better aerated bilaterally. The cardiomediastinal silhouette is
within normal limits. There is improved consolidation of the lung bases
bilaterally. However, there is a new consolidation projecting over the right
lateral midlung which may represent pneumonia. The pleural surfaces are
normal.
IMPRESSION:
The left cardiac device lead terminates in the right ventricle without
appreciable pneumothorax.
Better lung aeration with improved basilar consolidations.
However, new right midlung consolidation concerning for pneumonia.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 10:43 am, 5 minutes after
discovery of the findings.
Gender: M
Race: UNKNOWN
Arrive by HELICOPTER
Chief complaint: Cardiac arrest, Transfer
Diagnosed with Cardiac arrest, cause unspecified
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: 140.0
dbp: 70.0
level of pain: unable
level of acuity: 1.0 | Mr. ___ is a ___ male with no medical history who
initially presented after witnessed VF cardiac arrest, down for
15 minutes in the field, transferred to ___ from ___
s/p cooling protocol. TTE with no overt abnormality but
subsequent cardiac MRI showed hypertrophic ___
cardiomyopathy. He underwent ICD placement prior to discharge on
___.
Device brand/name: ___ AF MRI VR DV___
Model Number: ___
Lead Model ___ Sprint ___ MRI, MR ___ Yes, Lead
Position RV, Lead Length 62 cm, Manufacturer ___, Serial
Number ___, Implant Date ___
ACUTE ISSUES
============
#Sudden Cardiac Arrest
#Hypertrophic ___ Cardiomyopathy
The patient initially presented after sudden cardiac arrest
(mono- and polymorphic VT, VF, PEA and NSVT on EMS strips)
lasting approximately 15 minutes s/p defibrillation ×2, 4 mg
epinephrine, and 10mg naloxone (no effect). Intubated in the
field prior to arrival. Was initiated on targeted temperature
management on arrival at ___ on ___. On initiation of
rewarming, patient regained all neurocognitive function, without
deficit and was subsequently extubated. Initial TTE showed
reduced EF 26%, however on repeat, 60% on repeat echo on ___.
He underwent cardiac MRI showing asymmetric septal hypertrophy
with maximal thickness of the basal anterior septum measuring
1.6 cm, consistent with hypertrophic obstructive cardiomyopathy.
He subsequently underwent ICD placement prior to discharge on
___. Patient was discharged on Cephalexin 500mg QID prophylaxis
s/p ICD placement for 3 days course (___).
#Community Acquired Pneumonia Vs Aspiration Pneumonitis
#Leukocytosis
The patient initially presented with leukocytosis of 26.0.
Suspected aspiration pneumonitis in the setting of cardiac
arrest and intubation. Was initially started on cefepime,
however was descalated to ceftriaxone and completed a ___
course of ceftriaxone. CXR on ___ demonstrated possible right
lobe pneumonia. Patient was asymptomatic, afebrile, and without
white count. He was discharged without further treatment given
recent completion of CAP treatment. CXR findings were thought to
be radiographic delay. Patient was given strict instructions in
case he began to develop infectious signs/symptoms.
#Transaminitis
#Acute Liver Injury
The patient initially presented with transaminitis, ALT 359, AST
292, likely in the setting of cardiac arrest and poor forward
flow. Liver enzymes down trended to normal at time of discharge.
Likely due to hypoperfusion during cardiac arrest, now resolved.
TRANSITIONAL ISSUES
===================
[] Pneumonia/CXR: Recommend repeat CXR and evaluation for
pneumonia as last CXR prior to discharge showed possible
consolidation, recommend treating for HAP if patient develops
symptoms
[] LFTs: Recommend repeating LFTs in ___ weeks to ensure that
they remain normalized
[] Heart Rate: Recommend titrating Diltiazam as needed to
achieve adequate heart rates
[] HoCM Screening: Recommend cardiac MRI for family members and
siblings (HoCM was not evident on TTE)
[] ICD Followup: Device clinic ___ will be scheduled for
patient within one week
[] Cephalexin 500mg QID for prevention of infection after ICD
placement for 3 days (___)
#CODE: Full (presumed)
#CNOTACT: ___ (Mother), ___ |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Bradycardia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a background history of CAD, status post CABG in ___
(LIMA-LAD, SVG-OM, SVG-RCA), permanent atrial
fibrillation/flutter (status post ablation in ___, CKD, HTN,
HLD and type II diabetes mellitus, who presented from his PCP
office, where he was found to be bradycardic ___, now
transferred to ICU given hyperkalemia >6.5 with new ___.
Over the past several weeks, patient has noticed he has been
experiencing more fatigue than usual. He spends ___ in
___, and considers himself an active walker, walking daily
up to two miles with his wife. However, in the last few weeks
prior to returning to ___, he was unable to walk more than
___ yards without having to stop, secondary to fatigue. Denied
shortness of breath, chest tightness, palpitations,
light-headedness, or dizziness during these episodes. However,
over the last ___ weeks, patient reports increasing "leg
weakness" when ambulating.
About two weeks ago, patient had a mechanical fall when
attempting to climb into a SUV. No prodromal symptoms, including
light-headedness, dizziness, palpitations, chest pressure or
nausea/vomiting. Suffered a laceration to his right anterior
shin, but otherwise did not lose consciousness or hit his head.
No post-ictal symptoms. Given increasing redness at site of
laceration, patient presented to urgent care on ___, and was
given a course of Bactrim (two DS tablets BID) and Keflex ___
QID) for cellulitis, for seven days.
Today, patient was seen by his PCP for ___, both of his
weakness and cellulitis. HR was noted to be in ___, prompting
referral to ___.
In the ED, initial VS were notable for;
Temp 98.6 HR 29 BP 166/56 RR 19 SaO2 95% RA
Examination was notable for clear lungs bilaterally, S1 and S2
normal with no murmurs/rubs/gallops, and no lower extremity
edema.
Labs were notable for;
WBC 9.1 Hgb 10.6 Plt 211
___ 14.1 PTT 32.5 INR 1.3
Na 129 K >10 (hemolyzed) Cl 100 HCO3 18 BUN 67 Cr 2.9
ALT <5 AST 93 ALP 140 Tbili 0.3 Alb 3.4
Ca 8.9 Mg 2.3 P 5.5
Troponin <0.01
Trend for potassium;
>10 -> 7.3 -> 7.2 -> 6.3 -> 6.9 (whole blood 6.5) -> 6.5 (whole
blood)
Urine studies were notable for negative leuks, negative
nitrites, 300 protein and no bacteria
CXR was notable for patchy opacities in the lung bases in the
setting of low lung volumes, likely reflecting atelectasis, and
probable mild pulmonary vascular engorgement.
Initial EKG; rate 38, atrial fibrillation, RBBB, no ischemic
changes.
EP were consulted for bradycardia on presentation. Although
unlikely, they felt presenting symptoms with ___ may signify
hypoperfusion in the setting of bradycardia. No acute indication
for temporary pacing wire. Recommended discontinuing sotolol and
plan to walk the patient when off sotolol >24hrs to assess for
chronotropic incompetence to determine need for future PPM
implantation.
Renal were also consulted for hyperkalemia and ___. Recommended
temporizing with insulin/dex, calcium gluconate and IV
furosemide. No urgent need for dialysis, but if patient remained
bradycardic with significant hyperkalemia, could consider
dialysis.
Patient received;
- Insulin regular 10 units x2 and 25g D50 x3
- Sodium bicarbonate 50mcg x2
- Calcium gluconate 1g x2
- 1.5L NS
- IV furosemide 80mg x2
- Albuterol neb
Transfer vital signs were notable for;
Temp 98.4 HR 53 BP 153/38 RR 20 SaO2 95% 2L NC
On arrival to the MICU, patient repeats the above story.
Currently he is reporting no symptoms. Denies chest pain,
shortness of breath, light-headedness, dizziness, or lower
extremity edema. Notes significant improvement in area of
erythema on right lower extremity over antibiotic course. With
regards to urine output, patient reports no changes in frequency
or volume recently. Good PO intake.
Past Medical History:
- Atrial flutter, status post ablation ___
- Atrial fibrillation
- CAD status post CABG ___ (LIMA-LAD, SVG-OM, SVG-RCA)
- Hypertension
- Hyperlipidemia
- Mild bilateral ICA stenoses
- Type II DM
- CKD
- COPD/Asthma
- GERD
- Gallbladder surgery, complicated by sepsis
Social History:
___
Family History:
History of diabetes mellitus on maternal and paternal side. Both
parents passed away in late ___, father secondary to CVA.
Otherwise non-contributory.
Physical Exam:
===============================
ADMISSION PHYSICAL EXAMINATION:
===============================
VS: Reviewed in Metavision
GENERAL: lying comfortably in bed, no acute distress
HEENT: AT/NC, EOMI, PERRL, no conjunctival pallor, anicteric
sclera, MMM
NECK: supple, non-tender, JVP below clavicle at 90 degrees
CV: irregular rhythm, S1 and S2 normal, no murmurs/rubs/gallops
RESP: CTAB, no wheezes/crackles, breathing comfortably
___: soft, non-tender, no distention, BS normoactive
EXTREMITIES: warm, well perfused, trace ankle edema bilaterally
SKIN: multiple ecchymoses, laceration on right anterior shin
healing with mild erythema surrounding, well within demarcated
line
NEURO: A/O x3, strength ___ in all extremities, CN II-XII intact
===============================
DISCHARGE PHYSICAL EXAMINATION:
===============================
24 HR Data (last updated ___ @ 1116)
Temp: 97.9 (Tm 98.2), BP: 155/81 (127-157/59-81), HR: 68
(68-84), RR: 18 (___), O2 sat: 96% (90-96), O2 delivery: Ra
GENERAL: Laying in bed, in NAD
HEENT: AT/NC
CV: RRR, S1 and S2 normal, no murmurs/rubs/gallops
RESP: CTAB, no wheezes/crackles, breathing comfortably
___: Soft, non-tender, no distention, BS normoactive
EXTREMITIES: Warm, well perfused, trace ankle edema bilaterally
SKIN: Multiple ecchymoses, laceration on right anterior shin
healing with mild erythema surrounding, well within demarcated
line
NEURO: AOx3
Pertinent Results:
===============
ADMISSION LABS:
===============
___ 03:14PM BLOOD WBC-9.1 RBC-3.34* Hgb-10.6* Hct-33.9*
MCV-102* MCH-31.7 MCHC-31.3* RDW-13.9 RDWSD-51.5* Plt ___
___ 03:14PM BLOOD Neuts-75.1* Lymphs-15.5* Monos-8.1
Eos-0.4* Baso-0.5 Im ___ AbsNeut-6.85* AbsLymp-1.42
AbsMono-0.74 AbsEos-0.04 AbsBaso-0.05
___ 03:14PM BLOOD ___ PTT-32.5 ___
___ 03:14PM BLOOD Glucose-184* UreaN-67* Creat-2.9*#
Na-129* K->10.0* Cl-100 HCO3-18* AnGap-11
___ 03:14PM BLOOD ALT-<5 AST-93* AlkPhos-140* TotBili-0.3
___ 03:14PM BLOOD Lipase-31
___ 03:18PM BLOOD cTropnT-<0.01
___ 03:14PM BLOOD Albumin-3.4* Calcium-8.9 Phos-5.5* Mg-2.3
=====================
OTHER PERTINENT LABS:
=====================
___ 04:36PM BLOOD K-7.2*
___ 07:55PM BLOOD K-6.0*
___ 08:07PM BLOOD K-6.5*
======
MICRO:
======
___ Urine culture negative.
================
IMAGING/REPORTS:
================
___ CXR
Patchy opacities in the lung bases in the setting of low lung
volumes likely reflect atelectasis. Early infection however
cannot be fully excluded in the correct clinical setting.
Probable mild pulmonary vascular engorgement.
___ Renal US
No hydronephrosis. Tiny right renal cysts.
___ CT head
1. No acute intracranial process.
===============
DISCHARGE LABS:
===============
___ 07:10AM BLOOD WBC-8.0 RBC-3.50* Hgb-10.9* Hct-33.6*
MCV-96 MCH-31.1 MCHC-32.4 RDW-13.0 RDWSD-44.9 Plt ___
___ 07:10AM BLOOD Plt ___
___ 01:00PM BLOOD Glucose-234* UreaN-57* Creat-2.2* Na-139
K-5.2 Cl-97 HCO3-25 AnGap-17
___ 01:00PM BLOOD Calcium-8.9 Phos-3.7 Mg-2.0
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB, wheeze
2. Apixaban 5 mg PO BID
3. Atorvastatin 40 mg PO QPM
4. Fluticasone Propionate NASAL 2 SPRY NU Q6H:PRN congestion
5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH PRN SOB,
wheeze
6. Losartan Potassium 25 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Pantoprazole 40 mg PO Q24H
9. Sotalol 40 mg PO BID
10. Januvia (sitaGLIPtin) 50 mg oral DAILY
11. Repaglinide 4 mg PO TID
12. Sulfameth/Trimethoprim DS 2 TAB PO BID Last day ___. Cephalexin 500 mg PO Q6H Last day ___. Aspirin 81 mg PO EVERY OTHER DAY
Discharge Medications:
1. Apixaban 2.5 mg PO BID
RX *apixaban [Eliquis] 2.5 mg 1 tablet(s) by mouth Twice a day
Disp #*60 Tablet Refills:*0
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB, wheeze
3. Aspirin 81 mg PO EVERY OTHER DAY
4. Atorvastatin 40 mg PO QPM
5. Fluticasone Propionate NASAL 2 SPRY NU Q6H:PRN congestion
6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH PRN SOB,
wheeze
7. Januvia (sitaGLIPtin) 50 mg oral DAILY
8. Multivitamins 1 TAB PO DAILY
9. Pantoprazole 40 mg PO Q24H
10. Repaglinide 4 mg PO TID
11. HELD- Losartan Potassium 25 mg PO DAILY This medication was
held. Do not restart Losartan Potassium until hyperkalemia
stabilizes
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
=========
Bradycardia
___
Hyperkalemia
SECONDARY
==========
Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with cough and hypoxia// eval for pulmonary edema
TECHNIQUE: Upright AP view of the chest
COMPARISON: Chest radiograph ___
FINDINGS:
Lung volumes are low. Patient is status post median sternotomy and CABG.
Mild cardiac enlargement is similar to the previous exam. The mediastinal and
hilar contours are unchanged. Crowding of bronchovascular structures is
present with possible mild pulmonary vascular congestion, but no frank
pulmonary edema. Minimal patchy opacities in the lung bases likely reflect
atelectasis, without focal consolidation. No pleural effusion or pneumothorax
is identified. There are no acute osseous abnormalities.
IMPRESSION:
Patchy opacities in the lung bases in the setting of low lung volumes likely
reflect atelectasis. Early infection however cannot be fully excluded in the
correct clinical setting. Probable mild pulmonary vascular engorgement.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ with a background history of CAD, status post CABG in ___
(LIMA-LAD, SVG-OM, SVG-RCA), permanent atrial fibrillation/flutter (status
post ablation in ___, CKD, HTN, HLD and type II diabetes mellitus, who
presented from his PCP office, where he was found to be bradycardic ___,
now transferred to ICU given hyperkalemia >6.5 with new ___// Evaluate for
hydronephrosis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: CT of the abdomen and pelvis dated ___
FINDINGS:
Right kidney measures 10.2 cm in length. The left kidney measures 10.3 cm in
length. 2 tiny anechoic cysts are noted in the left kidney, 1 in the midpole
and 1 in the lower pole, both measuring up to 9 mm. No hydronephrosis or
worrisome renal lesion. There is normal bilateral renal echogenicity with
normal corticomedullary differentiation. The urinary bladder appears
unremarkable. There is an adjacent fluid-filled structure representing a
penile pump reservoir.
IMPRESSION:
No hydronephrosis. Tiny right renal cysts.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with multiple falls, AMS, ? bleed/hematoma// ___
year old man with multiple falls, AMS, ? bleed/hematoma
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
934.2 mGy-cm.
Total DLP (Head) = 934 mGy-cm.
COMPARISON: ___ head CT
FINDINGS:
There is no evidence of acute large territory infarction,hemorrhage,edema, or
mass. There is prominence of the ventricles and sulci suggestive of
involutional changes.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
1. No acute intracranial process.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Bradycardia, Weakness
Diagnosed with Hyperkalemia
temperature: 98.6
heartrate: 29.0
resprate: 19.0
o2sat: 95.0
sbp: 166.0
dbp: 56.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ with a background history of CAD, status
post CABG in ___ (LIMA-LAD, SVG-OM, SVG-RCA), permanent atrial
fibrillation/flutter. CKD, HTN, HLD and type II diabetes
mellitus, who presented from his PCP office, where he was found
to be bradycardic to HR ___, with hyperkalemia and new ___.
His bradycardia improved with discontinuing of home sotolol and
his Cr trended towards baseline without further intervention. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
Lumbar puncture ___
History of Present Illness:
Mrs. ___ is a ___ woman who presents as OSH transfer
for headache.
Briefly, pt was recently admitted for intermittent headache and
neurological symptoms over many days and was found to have a
right a-comm aneurysm status post coiling on ___ with
discharge from the neurosurgery service on ___. She then
returned to the ED on ___ with complaints of a left orbital and
temporal headache with associated numbness and was found to have
a new left precentral cSAH with RCVS as a possible etiology. MRI
Brain w and wo contrast was performed showing changes secondary
to the blood as well as left subacute/chronic small white matter
ischemic changes. The etiology of these changes was not entirely
clear, but thought to be possibly due to periprocedural from her
aneurysm coiling vs sequelae of RCVS. CTA during this admission,
which was done during her headache had no evidence of vasospasm.
She was started on verapamil 120mg daily and nortryptiline 10mg
qhs.
Two weeks after discharge she again started complaining of
headaches. Describes them as low-grade constant nagging
headaches. Mostly located on the left side associated with some
nausea photophobia and phonophobia and some intermittent left
sided facial numbness. She called Dr. ___ recommended
to
increase the nortriptyline to 20 mg nightly and instructed her
to
go back to the ED should she again experience a thunderclap
headache. This morning around 1 AM patient reports she woke up
of severe headache 8 out of 10 associated with mild nausea, and
may be subtle photo and phonophobia, no other neurological
symptoms associated with the headache. It was located centrally
on her forehead and she describes it as throbbing. She went back
to bed and at 7 AM again woke up with severe headache ___ out of
10. This time the headache was located on her right side. This
worried her since her headache is usually on the left side so
she
decided to go to the emergency room of an outside hospital.
There CT head was performed and did not show any new bleed. She
was given 8 mg of morphine which for short time relieved her
symptoms but then the headache restarted. She was subsequently
transferred back to ___ for
further management.
On neuro ROS, the pt denies loss of vision, blurred vision,
diplopia, dysarthria, dysphagia, lightheadedness, vertigo,
tinnitus or hearing difficulty. Denies difficulties producing or
comprehending speech. No bowel or bladder incontinence or
retention. Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
PMHx:
Sciatica
Lumbar laminectomy ___
Social History:
___
Family History:
Negative for migraine, SAH or aneurysm.
Physical Exam:
Admission Physical Exam:
General: Awake, cooperative, NAD.
- HEENT: NC/AT
- Neck: Supple
- Pulmonary: no increased WOB
- Cardiac: well perfused
- Abdomen: soft, nontender, nondistended
- Extremities: no edema, pulses palpated
- Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Able
to
read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. The pt had good
knowledge of current events. There was no evidence of apraxia or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-DTRs:
[Bic] [Tri] [___] [Quad]
L 2+ 2+ 2+ 2+
R 2+ 2+ 2+ 2+
Plantar response flexor bilaterally.
-Sensory: mild deficits to LT in LLE which is chronic.
-Coordination: No intention tremor. No dysmetria on FNF or HKS
bilaterally.
-Gait: deferred
Discharge Physical Exam:
General: Awake, cooperative, NAD, appears upset
HEENT: No pain on palpation of occipital, no scalp tenderness,
no pain with neck flexion
Neck: Supple
Pulmonary: Breathing comfortable on room air
Cardiac: well perfused
Abdomen: soft, nontender, nondistended
Extremities: no edema
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to self, place, and date. Able
to relate history without difficulty. Language is fluent with
intact repetition and comprehension. Normal prosody. There were
no paraphasic errors. Pt was able to name both high and low
frequency objects. Speech was not dysarthric. Able to follow
both midline and appendicular commands. There was no evidence of
apraxia or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. No
papilledema on funduscopic examination.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Decreased sensation around lateral left eye to pinprick.
Corneal reflex present bilaterally.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 4+ 5
R 5 ___ ___ 5 5 5 5 5 5 5
-DTRs:
[Bic] [Tri] [___] [Quad] [Ankle]
L 2+ 2+ 2+ 2+ 1+
R 2+ 2+ 2+ 2+ 1+
Plantar response flexor bilaterally.
-Sensory: Intact sensation to light touch, pinprick throughout
b/l arms and legs
-Coordination: No intention tremor. No dysmetria on FNF
bilaterally
Pertinent Results:
___ 05:15AM BLOOD WBC-21.0*# RBC-3.88* Hgb-12.2 Hct-36.4
MCV-94 MCH-31.4 MCHC-33.5 RDW-11.9 RDWSD-40.9 Plt ___
___ 05:15AM BLOOD Plt ___
___ 05:15AM BLOOD ___ PTT-25.6 ___
___ 05:20AM BLOOD Sickle-NEG
___ 01:20PM BLOOD Lupus-NEG
___ 05:15AM BLOOD Glucose-121* UreaN-28* Creat-0.7 Na-145
K-4.1 Cl-106 HCO3-22 AnGap-17*
___ 05:15AM BLOOD Calcium-9.3 Phos-4.5 Mg-2.0
___ 05:20AM BLOOD Cryoglb-NO CRYOGLO
___ 05:25AM BLOOD %HbA1c-5.1 eAG-100
___ 05:25AM BLOOD Triglyc-42 HDL-72 CHOL/HD-2.5 LDLcalc-100
___ 05:25AM BLOOD TSH-0.64
___ 05:20AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 01:20PM BLOOD RheuFac-<10 ___ CRP-1.2
dsDNA-NEGATIVE
___ 01:20PM BLOOD ANCA-NEGATIVE B
___ 10:25AM BLOOD HIV Ab-NEG
___ 01:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-5*
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 05:20AM BLOOD HCV Ab-NEG
___ 05:30AM BLOOD WBC-9.2 RBC-3.87* Hgb-12.3 Hct-36.6
MCV-95 MCH-31.8 MCHC-33.6 RDW-11.9 RDWSD-40.8 Plt ___
___ 06:16AM BLOOD Neuts-53.7 ___ Monos-7.0 Eos-4.0
Baso-0.9 Im ___ AbsNeut-4.13# AbsLymp-2.59 AbsMono-0.54
AbsEos-0.31 AbsBaso-0.07
___ 05:30AM BLOOD Plt ___
___ 01:20PM BLOOD Lupus-NEG
___ 05:30AM BLOOD Glucose-84 UreaN-17 Creat-0.7 Na-145
K-4.4 Cl-102 HCO3-28 AnGap-15
___ 05:30AM BLOOD Calcium-8.9 Phos-4.1 Mg-2.2
MRI ___
FINDINGS:
The patient is status post coil embolization of anterior
communicating artery
aneurysm with associated blooming artifact on gradient echo
sequences.
Again seen are T2/FLAIR deep white matter hyperintensities in
the left frontal
and right parietal lobes with corresponding hyperintensity on
isotropic
diffusion-weighted imaging without evidence of signal dropout on
ADC mapping,
new since ___ and unchanged since ___. These
findings are
consistent with evolving subacute infarcts. Signal dropout in
the left
parietal lobe in a gyriform pattern is consistent with
superficial siderosis
in the area of previously noted subarachnoid hemorrhage. Within
the
limitations of this study, without specific MR imaging, no
evidence of
residual lumen within the previous anterior communicating artery
aneurysm.
There is no evidence of acute hemorrhage, edema, masses, mass
effect, midline
shift or acute infarction. The ventricles and sulci are normal
in caliber and
configuration.
IMPRESSION:
1. Patient is status post coil embolization of anterior
communicating artery
aneurysm without evidence of residual lumen within the
limitations of this low
sensitivity study.
2. T2/FLAIR deep white matter hyperintensities in the left
frontal and right
parietal lobes are unchanged and likely represent evolving
subacute infarcts.
3. Signal dropout in left parietal lobe in gyriform pattern is
consistent with
superficial siderosis in area of previously noted subarachnoid
hemorrhage.
ECHO ___
Conclusions
The left atrial volume index is normal. No atrial septal defect
is seen on color flow Doppler, but there is early appearance of
agitated saline/microbubbles in the left atrium/ventricle at
rest most consistent with an atrial septal defect or stretched
patent foramen ovale (though a very proximal intrapulmonary
shunt cannot be fully excluded). Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis or aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
IMPRESSION: Patent foramen ovale. Normal global and regional
biventricular systolic function.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Nortriptyline 10 mg PO QHS
2. Verapamil SR 120 mg PO Q24H
3. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Valproic Acid ___ mg PO BID
RX *valproic acid (as sodium salt) 500 mg/10 mL (10 mL) 500 mg
by mouth twice daily Disp #*480 Box Refills:*2
3. Verapamil SR 180 mg PO Q24H
RX *verapamil 180 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*2
4.Outpatient Lab Work
Chem 8, CBC, LFTs
ICD 784, 966.3
Fax to PCP ___ at ___
Discharge Disposition:
Home
Discharge Diagnosis:
Headache
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old woman with history of a-com aneurysm s/p coiling and
SAH presents with headache// Eval for interval change
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON MRI brain from ___ intracranial coiling from ___ CT head from ___ MRI head from ___ reference CT head
from ___
FINDINGS:
The patient is status post coil embolization of anterior communicating artery
aneurysm with associated blooming artifact on gradient echo sequences.
Again seen are T2/FLAIR deep white matter hyperintensities in the left frontal
and right parietal lobes with corresponding hyperintensity on isotropic
diffusion-weighted imaging without evidence of signal dropout on ADC mapping,
new since ___ and unchanged since ___. These findings are
consistent with evolving subacute infarcts. Signal dropout in the left
parietal lobe in a gyriform pattern is consistent with superficial siderosis
in the area of previously noted subarachnoid hemorrhage. Within the
limitations of this study, without specific MR imaging, no evidence of
residual lumen within the previous anterior communicating artery aneurysm.
There is no evidence of acute hemorrhage, edema, masses, mass effect, midline
shift or acute infarction. The ventricles and sulci are normal in caliber and
configuration.
IMPRESSION:
1. Patient is status post coil embolization of anterior communicating artery
aneurysm without evidence of residual lumen within the limitations of this low
sensitivity study.
2. T2/FLAIR deep white matter hyperintensities in the left frontal and right
parietal lobes are unchanged and likely represent evolving subacute infarcts.
3. Signal dropout in left parietal lobe in gyriform pattern is consistent with
superficial siderosis in area of previously noted subarachnoid hemorrhage.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old woman with PFO and subacute infarcts// Evaluate for
DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the bilateral
common femoral, femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
Incidentally noted is thickening of the anterior wall of the right common
femoral vein, likely of doubtful clinical significance and may represent prior
resolved thrombophlebitis.
IMPRESSION:
1. No evidence of deep venous thrombosis in the right or left lower extremity
veins.
2. Incidentally noted right common femoral vein anterior wall thickening,
likely of doubtful clinical significance, may represent prior resolved
thrombophlebitis.
Radiology Report
EXAMINATION: LUMBAR PUNCTURE (W/ FLUORO) N8 RF SPINE.
INDICATION: ___ year old woman with chronic headache, SAH ___ ?RCVS. Attempted
LP unsuccessfully// ___ guided LP with opening pressure.
TECHNIQUE: After informed consent was obtained from the patient explaining
the risks, benefits, and alternatives to the procedure, the patient was laid
in prone position on the fluoroscopic table. A pre-procedure time-out was
performed confirming the patient's identity, relevant history, procedure to be
performed and labs.
Puncture was performed at L3-4.
Approximately 5 cc of 1% lidocaine was administered for local anesthesia.
Under fluoroscopic guidance, a 20 gauge, 7 cm spinal needle was inserted into
the thecal sac. There was good return of clear CSF. 16 mls of CSF were
collected in 4 tubes and sent for requested analysis. An opening pressure of
12 cm H20.
COMPARISON: None.
FINDINGS:
16 mls of clear CSF were collected in 4 tubes. An opening pressure of 12 cm
H2O was obtained.
IMPRESSION:
Lumbar puncture at L3-L4 level without complication.
I, Dr. ___ supervised the trainee during the key components of
the above procedure and I reviewed and agree with the trainee's findings and
dictation.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Headache, Transfer
Diagnosed with Headache
temperature: 98.4
heartrate: 66.0
resprate: 16.0
o2sat: 99.0
sbp: 130.0
dbp: 88.0
level of pain: 8
level of acuity: 2.0 | Mrs. ___ is a ___ woman with a 1.5 month intermittent
headache and neurological symptoms who was found to have a right
a-comm aneurysm s/p coiling on ___, followed by left orbital
and temporal headache with associated numbness which was found
to
be a new left precentral cSAH ___ which was thought to be
secondary to RCVS and started on verapamil and nortryptiline.
This admission, she presented with persistent headache, newly
right-sided that has subsequently shifted back to the left.
The right a-comm aneurysm incidentally found at the first
admission was 3mm and unlikely to account for her headache, due
to its small size. We are now looking to determine the etiology
of her persistent headache, which did not respond to verapamil
and nortryptiline, as would be expected in ___. We wanted to
ensure that there was no other cause for her headache such as
systemic or CNS vasculitis. NCHCT showed no acute hemorrhage.
MRI showed resolving SAH. Systemic vasculitis workup sent, which
was all negative. LP was performed to assess for inflammatory or
infectious etiology, results were normal. We saw no evidence of
CNS vasculitis as cause of headache, and she previously had a
normal conventional angiogram in ___, which makes this
diagnosis less likely. As echo demonstrates a PFO,
hypercoaguability workup sent, which was negative (although the
full workup cannot be sent in the hospital and will need to be
done as an outpatient). LENIs showed no acute DVT.
Her headache improved with standing toradol, and toradol was
decreased to BID. Discussion with patient regarding cerebral
angiogram repeat for diagnosis, patient opted to pursue medical
management as she already had a normal angio ___. She was
started on IV steroids, and after 6 doses her headache
persisted, so she was switched to IV Depakote. Her headache
improved, and she was switched to PO Depakote. She remained
headache free for >48 hours, and was amenable to discharge with
outpatient follow up ___.
#Headache - unclear etiology
-Improved with IV toradol to ___, and was resolved with
Depakote.
- on discharge patient's pain well controlled on Depakote 500mg
Q12H
- Plan to continue Depakote for 1 month, then titrate down at
follow up appointment with neurology in ___. Also has
headache follow up in ___ scheduled.
#SAH
-Resolving as seen on MRI on admission
#Hypercoaguable workup
- Initially was sent because small infarct seen around the area
of SAH. Per discussion with radiology, the likely etiology of
these infarcts are secondary to the ___ itself, and likely not a
hypercoaguable state.
- Beta 2 macroglobulin negative, Cardiolipin IgG negative, IgM
13 (indeterminant ___
- Outpatient labs studies to be sent to complete hypercoaguable
workup: Factor V leiden, prothrombin gene mutation, antithrombin
gene mutation. Protein C and Protein S pending. Determine
necessity at follow up appointment with stroke. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
codeine
Attending: ___.
Chief Complaint:
right ankle fracture
Major Surgical or Invasive Procedure:
___ ORIF of right ankle fracture
History of Present Illness:
Patient was on a boat with friends this past evening when he
jumped off onto the dock. His foot landed on the cleat and he
immediately twisted his ankle. He was unable to ambulate and
taken to ___ and found to have a pronation
external rotation ankle fracture. He was reduced and splinted
there and then trannsferred here. He reports no other injuries,
no head strike, no LOC. He is having some numbness in his little
toe on arrival.
Past Medical History:
HTN, GERD, HLD
Social History:
___
Family History:
noncontributory
Physical Exam:
Right lower extremity:
- Skin intact, incisions well approximated
- Able to flex and extend toes
- SILT SPN/DPN/TN/saphenous/sural distributions
- Foot warm and well-perfused
Pertinent Results:
___ 04:00AM BLOOD WBC-11.5* RBC-4.20* Hgb-13.6* Hct-39.3*
MCV-94 MCH-32.4* MCHC-34.6 RDW-12.0 RDWSD-41.3 Plt ___
___ 06:50PM BLOOD Glucose-138* UreaN-15 Creat-1.1 Na-138
K-4.1 Cl-100 HCO3-25 AnGap-17
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 40 mg PO DAILY
2. Fenofibrate 600 mg PO DAILY
3. Lisinopril 20 mg PO DAILY
Discharge Medications:
1. crutches
dx: right trimalleolar ankle fracture
Px: good
duration: 13 months
2. Enoxaparin Sodium 40 mg SC DAILY Duration: 4 Weeks
RX *enoxaparin 40 mg/0.4 mL 40 mg SC daily Disp #*28 Syringe
Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice daily Disp
#*20 Tablet Refills:*0
4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth every 4 hours Disp
#*80 Tablet Refills:*0
5. Omeprazole 40 mg PO DAILY
6. Lisinopril 20 mg PO DAILY
7. Fenofibrate 600 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
right trimalleolar ankle fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: ANKLE (AP, MORTISE AND LAT) RIGHT
INDICATION: RT ANKLE FX.ORFI
TECHNIQUE: 32 fluoroscopic images were obtained.
COMPARISON: Right ankle radiographs on ___.
FINDINGS:
2 screws are placed in a medial malleolus and 2 syndesmotic screws were
placed. Alignment is improved. Please see operative note for further
details.
IMPRESSION:
Please see operative note for further details.
Radiology Report
EXAMINATION: TIB/FIB (AP AND LAT) RIGHT
INDICATION: ___ man with right ankle fracture. Status post
reduction.
TECHNIQUE: Two views of the right tibia and fibula.
COMPARISON: Outside hospital right tibia and fibula radiographs ___.
FINDINGS:
An overlying cast obscures the fine bony detail. There is a fracture through
the medial malleolus with separation of the distal fragment by 9 mm. The
talus is medially displaced relative to the tibia, improved relative to the
prior radiographs but persistently dislocated. There is a comminuted fracture
of the mid fibula. A vertical fracture of the posterior malleolus is
minimally displaced. There are degenerative changes in the patellofemoral
joint.
IMPRESSION:
1. Comminuted fracture of the mid fibula and transverse fracture of the medial
malleolus.
2. Dislocation of the talar dome laterally relative to the tibia with somewhat
improved alignment compared to the prior radiographs.
3. A vertical fracture of the posterior malleolus is minimally displaced.
Radiology Report
INDICATION: ___ man with an ankle fracture. Preoperative evaluation.
TECHNIQUE: Frontal and lateral views of the chest.
COMPARISON: None.
FINDINGS:
Normal heart, lungs, pleura and mediastinal surfaces. Cervical spine hardware
is noted.
IMPRESSION:
No acute cardiopulmonary process seen.
Radiology Report
EXAMINATION: CT right extremity without contrast
INDICATION: ___ year old man with right ankle fracture // fracture
TECHNIQUE: 1.25 mm axial images were obtained through the right lower
extremity soft tissue bone algorithms without intravenous contrast. Coronal
and sagittal reformats.
DOSE: Total DLP 902.62 mGy-cm
COMPARISON: Right tibia/fibula and ankle radiographs ___.
FINDINGS:
There is a comminuted displaced fracture thorough the mid and distal fibular
diaphysis with a large butterfly fragment displaced laterally.There is a
fracture dislocation of the distal tibia with a comminuted fracture of the
posterior malleolus with a dominant vertically oriented fracture plane. There
is a transverse fracture through the medial malleolus with displacement of the
distal fracture fragment. The tibial plafond is dislocated at the tibiotalar
joint with medial displacement and mild anterior angulation with resultant
widening of the syndesmosis. Multiple tiny osseous fragments are seen within
the syndesmosis at the site of fracture. No talar dome fracture. There is a
small tibiotalar joint effusion.
The posterior tibiofibular ligament is intact and attached to the posterior
malleolar fracture fragment. The anterior tibiofibular and the talofibular
ligaments are not seen well and may be torn.
There is soft tissue edema overlying the medial aspect of the lower extremity
centered at the tibiotalar joint. There is a more focal hematoma adjacent to
the tibiotalar joint.
The anterior extensor tendons, peroneus tendons, and medial flexor tendons are
grossly intact. The Achilles tendon is intact. There are enthesopathic
changes at the Achilles insertion on the calcaneus.
IMPRESSION:
1. Comminuted displaced fracture of the distal fibular diaphysis with a large
butterfly fragment.
2. Fracture dislocation of the distal tibia with medial displacement and
angulation of the tibial plafond with disruption of the syndesmosis. There is
a comminuted fracture involving the posterior malleolus with displacement of
the fracture fragment and a transverse fracture through the medial malleolus.
Radiology Report
EXAMINATION: DX TIB/FIB AND ANKLE/FOOT
INDICATION: ___ year old man with bimall fx // post reduction post
reduction
TECHNIQUE: 9 views of right tibia, fibula, ankle, and foot.
COMPARISON: Tibia/ fibula radiograph ___ 05:36
FINDINGS:
Medially displaced talus with respect to the tibia is persistent but improved.
Fracture through the medial malleolus and the separation of distal fragment is
also persistent but less.
Comminuted fracture of the mid fibula similar to before.
Vertical fracture at the posterior malleolus is stable. Cast is noted
overlying the right calf and foot.
IMPRESSION:
1. Lateral dislocation of talardome with respect to the tibia is persistent
but improved. Displacement of fracture fragment at the medial malleolus is
also a persistent but improved.
2. Comminuted fracture of the mid fibula and vertical fracture of posterior
malleolus appear similar to before.
Radiology Report
EXAMINATION: ANKLE (AP, MORTISE AND LAT) RIGHT
INDICATION: ___ man with an ankle fracture status post reduction,
assess reduction.
TECHNIQUE: Three views of the right ankle.
COMPARISON: Tib-fib and ankle radiographs ___ at 11:21.
FINDINGS:
In comparison to prior radiograph from same-day, again seen is the spiral
fracture of the mid distal fibular shaft, unchanged in appearance. There is a
horizontally oriented fracture through the medial malleolus, with
approximately 8 mm of medial displacement of the distal fracture fragment,
somewhat improved in comparison to prior radiograph (previously with 10 mm of
displacement and more angulation of the distal fracture fragment). Again seen
is widening of the ankle mortise consistent with tibiofibular syndesmotic
disruption, possibly minimally improved. The tailor dome is intact. No
fracture of the posterior malleolus is not as well seen on the current
radiograph, better assessed on prior CT.
IMPRESSION:
1. Minimal interval improvement in the alignment of the distal fracture
fragment at the site of the known medial malleolus fracture, now with 8 mm of
medial displacement (versus 10 mm previously), and approved angulation.
2. Stable appearance of known spiral fracture of the fibular diaphysis.
3. Unchanged widening of the ankle mortise, compatible with tibiofibular
syndesmotic disruption.
4. Known posterior malleolar fracture is not as well seen on the current
radiograph.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R Ankle injury
Diagnosed with FX BIMALLEOLAR-CLOSED, FX SHAFT FIBULA-CLOSED, OTHER OVEREXERTION AND STRENUOUS AND REPETIVE MOVEMENTS OR LOADS
temperature: 98.3
heartrate: 88.0
resprate: 20.0
o2sat: 99.0
sbp: 129.0
dbp: 69.0
level of pain: 7
level of acuity: 4.0 | Hospitalization Summary
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have right ankle fracture and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for ORIF of right trimalleolar ankle fracture, which the
patient tolerated well. For full details of the procedure please
see the separately dictated operative report. The patient was
taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
TDWB in the right lower extremity, and will be discharged on
Lovenox for DVT prophylaxis. The patient will follow up with Dr.
___ routine. A thorough discussion was had with the
patient regarding the diagnosis and expected post-discharge
course including reasons to call the office or return to the
hospital, and all questions were answered. The patient was also
given written instructions concerning precautionary instructions
and the appropriate follow-up care. The patient expressed
readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Called by Emergency Department to evaluate for seizures.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is very lethargic and was not able to provide any
history; history obtained from review of OMR.
Ms. ___ is a ___ year-old right-handed woman with PMH
significant for temporal lobe epilepsy (followed by Dr. ___ in
epilepsy clinic) and comorbid psychiatric disorder (depression
with psychotic component) who was recently discharged from
Neurology Epilepsy service on ___ and who was sent to the ED
from epilepsy clinic today for increased seizure frequency in
the
setting of medication noncompliance (expressed fear of med side
effects in past). During her recent hospitalization, Depakote
was
d/c due to weight gain and Vimpat was started. She did not take
her new AEDs regularly upon discharge. While home, she had
trouble sleeping and became irritable. She was actually seen in
the ___ ED on ___ for a manic episode, which was described as
running around and being difficult to control. While in ED, she
was noted to have a partial seizure and was loaded with
Dilantin,
but was then discharged on her regular AEDs, which she continues
to not take as prescribed. Her father reported that she had 4
seizures since last night- 1 last night with staring and
lipsmacking that lasted 1 minute, w/o any postictal symptoms,
then one this morning that was more severe, staring,
lipsmacking,
tremors of legs, drooling lasting 2 minutes, then took at least
2
minutes to come back to normal. After leaving epilepsy clinic
this morning and going home, she had a small seizure with
staring, followed by another seizure. At that point, she was
brought to the ___ ED. Upon arrival to the ED, she had another
seizure and was given Ativan 1 mg.
Her prior work-up for seizures included MRI, which showed
right
mesial temporal sclerosis and EEGs, which showed seizures
arising
from both temporal lobes. Regarding her seizure semiology; per
OMR notes, she has 1 seizure type as all her seizures have the
same clinical onset, but some of them evolve into GTCs.
Typically, she feels a pressure like sensation in her forehead
followed by her staring, and she becomes unresponsive. Her eyes
remain open, she can walk around, but does not talk or follow
commands. This is always accompanied by lip smacking and hand
automatisms (both hands). Sometimes, this is followed by a fall
to the floor, then she has a full body shaking; this lasts for
about ___ seconds but the longest has been 3 minutes. It is
followed by a period of right sided weakness that gradually
resolves, as well as sleepiness. She returns to her baseline
within ___ minutes. She has the "big seizures" ___ times per
month and they cluster around her period. She has the "small
seizures" about ___ times per month. She has been tried on
multiple medications which were stopped either due to side
effects or to failure to control her seizures, this list
includes Lamictal
oxcarbazepine, carbamazepine, neurontin, phenytoin and now,
depakote.
ROS: She was not cooperating with ROS questions so unable to
obtain.
Past Medical History:
- h/o positive PPD positive
- No h/o head trauma.
- Seizure d/o: the patient began having seizures in ___. Has
had abnormal EEGs (left temporal region and later bitemporal
spikes) and abnormal MRIs (right mesiotemporal lobe lesion,
right
hippocampal abnormality, mild ventricular dilatation). In ___,
she was diagnosed with complex partial seizures. Followed by
Dr. ___ her last sz was ~2 mos ago
- Obstructive sleep apnea per sleep study, has CPAP but rarely
uses
Social History:
___
Family History:
Father denies.
Per OMR: Aunt and great-aunt with unclear psychiatric illness.
Physical Exam:
General: laying in bed with blanket over her head, lethrgic, NAD
HEENT: NC/AT, sclera nonicteric, MMM, no lesions noted in
oropharynx
Neck: Supple
Pulmonary: lcta b/l
Cardiac: RRR, S1S2, no murmurs appreciated
Abdomen: soft, NT/ND, +BS
Extremities: warm, well perfused
Neurologic:
Mental Status: Alert, oriented, following all commands.
Cranial Nerves: PERRL 4-->2 mm. No clear visual field cuts. EOMI
with no nystagmus noted. Palate elevated symmetrically. Face is
symmetric.
Motor: Normal bulk, tone throughout. She moves all extremities
symmetrically when asked, but would not participate in formal
strength testing.
Sensory: No obvious deficits to light touch, though
participation
limited.
DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
Coordination: no dysmetria on finger-nose b/l.
Gait: can tandem mormally.
Pertinent Results:
___ 01:49PM GLUCOSE-134* UREA N-11 CREAT-0.9 SODIUM-144
POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-12* ANION GAP-31*
___ 01:49PM CALCIUM-9.4 PHOSPHATE-3.6 MAGNESIUM-2.2
___ 01:49PM WBC-16.2*# RBC-3.94* HGB-12.1 HCT-39.3
MCV-100* MCH-30.6 MCHC-30.7* RDW-14.4
___ 01:49PM NEUTS-75.3* ___ MONOS-3.4 EOS-0.2
BASOS-0.4
___ 01:49PM PLT COUNT-350
___ 09:15AM PHENYTOIN-< 0.6
Medications on Admission:
-Vimpat 200 mg bid
-Zonisamide 300 mg qhs
-Ativan prn seizure
-risperidone 0.5 mg qAM
-Calcium carbonate-Vitamin D3 500mg-200 units bid
-Cholecalciferol 1000 units daily
-multivitamin daily
Discharge Medications:
1. clobazam *NF* 10 mg Oral BID Reason for Ordering: intractable
epilepsy
please start tonight.
RX *Onfi 5 mg twice a day Disp #*120 Tablet Refills:*2 (Two)
2. Calcium Carbonate 500 mg PO BID
3. Multivitamins 1 TAB PO DAILY
4. Risperidone 0.5 mg PO QAM
5. Vitamin D 1000 UNIT PO DAILY
6. Zonisamide 400 mg PO HS
RX *zonisamide 100 mg at bedtime Disp #*120 Capsule Refills:*5
(Five)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Intractable epilepsy
Discharge Condition:
Condition: Good
Mental status: Alert, oriented, following commands, intact
speech.
Ambulatory: normal gait, independent unassisted.
Followup Instructions:
___
Radiology Report
INDICATION: ___ woman with temporal lobe epilepsy,and seizures,
evaluate for pneumonia.
COMPARISONS: PA and lateral chest radiographs from ___ and ___.
FINDINGS: There is no focal consolidation, pleural effusion, or pneumothorax.
The cardiomediastinal silhouette is normal. There is no pulmonary vascular
congestion. The osseous structures are unremarkable.
IMPRESSION: No acute cardiopulmonary process.
Gender: F
Race: BLACK/CARIBBEAN ISLAND
Arrive by WALK IN
Chief complaint: SZ
Diagnosed with OTHER FORMS OF EPILEPSY AND RECURRENT SEIZURES, WITHOUT MENTION OF INTRACTABLE EPILEPSY
temperature: 99.0
heartrate: 76.0
resprate: 20.0
o2sat: 99.0
sbp: 112.0
dbp: 68.0
level of pain: 0
level of acuity: 2.0 | ___ was placed on scheduled ativan 1mg q8 which was weaned
then stopped over 3 days after her admission.
She was started on clobazam 5mg BID, increased to 10mg BID, and
her vimpat was discontinued.
Her zonegran dose was increased to 400mg QHS.
She did not report any side effects from the medication changes.
She did not have any further seizures during her admission.
She was seen by the psychiatry team and no new recommendations
were given.
She was also evaluted by social work, and we decided she should
receive ___ services twice daily at home, so that her
medications could be administered on time without missing any
doses. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / aspirin
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
n/a
History of Present Illness:
Ms. ___ is a ___ yo woman with with PMHx laparoscopic RYGB in
___ (c/b post-gastric bypass hypoglycemia requiring G-tube
placement for tube feeds in ___
and ___, marginal ulcers) s/p open gastric bypass reversal
___, chronic abdominal pain/n/v, anxiety/depression, c diff,
with multiple recent admissions for acute on chronic abdominal
pain who presents with abdominal pain, nausea, vomiting.
Of note she has had three recent admissions. The first
___ for abdominal pain and was found to have c diff. She
was again admitted ___ for abdominal pain and was found
to have recurrent c diff. She was discharged on a longer taper
of oral vancomycin. She represented ___ again with
abdominal pain. Her c diff at that time was negative. She was
treated with IVF, pain meds, antiemetics and returned home.
Since discharge she states she was doing well and was starting
to return to normal. She stopped taking her oral vancomycin on
___, per her discharge summary she was suppose to be taking it
q3days until ___. Over the last week she had sudden onset of
severe ___ midepigastric pain which was worse with food. She
continued to take her oxycodone which did not help. She states
this is very different that her chronic abdominal pain. She
describes the pain as exactly the same as her ulcer in ___. ON
review of records she did have multiple ulcers seen on EGD in
___ although multiple subsequent EGDs were negative. She states
she recently stopped all her GERD medications as she felt they
were no longer needed.
Shortly after the pain began she began to have diarrhea about
___ times a day. In the last day she began to have NBNB vomiting
and could not hold down any food prompting her to come to the
ED.
In the Ed vitals were T 96.1, HR 68, BP 113/65, RR16, O2Sat 100%
RA. Labs were unremarkable. She underwent a CT scan which was
unremarkable. Surgery was consulted and did not feel she needed
any surgical intervention but were concerned about ulcers. She
was given morphine x3, pantoprazole 40mg, 1L NS, and Zofran and
admitted to medicine.
On arrival to the floor she is still feeling nauseous and feels
unable to swallow pills. She is asking for her keppra IV. She
feels shaky and weak. As far as her chronic pain it is also in
the midepigastric area. She thinks it is ___ scar tissue and is
currently seeking a second surgical opinion in hopes she can
have the scar tissue removed.
14 point ROS evaluated with patient and remarkable per HPI
otherwise negative. No fevers, chills, chest pain, SOB, sick
contacts.
Past Medical History:
Per OMR:
- Laparoscopic RYGB in ___ (c/b post-gastric bypass
hypoglycemia requiring G-tube placement for tube feeds in ___
and ___, marginal ulcers) s/p open gastric bypass reversal
___
- Chronic abdominal pain
___: hypoglycemia. s/p reversal of gastric bypass
___: nausea. rx'd w/ IVF, symptom management, diet advanced
to bariatric stage 3 diet
___: abd pain. rx'd w/ bowel rest, G tube exchange, diet
advanced to bariatric stage 5 diet
___: PO intolerance. changed tube feeds to Jevity 1.5 @ 45
___: epigastric pain. added ranitidine to home PPI. EGD
showed anastomotic ulcers. dc'd on pantoprzole 40bid and
ranitidine 150 qd
___: abd pain. rx'd w/ IV PPI
___: epigastric pain. changed back to oral PPI
___: abd pain. trialed on erythromycin and rifaximin.
___: abd pain. bowel rest, diet advanced. gabapentin
increased to 600gm tid.
___: abd pain. bowel rest, diet advanced. started on marinol
due to poor po.
___: abd pain, n/v. NPO, IVF, Zofran/Compazine
___: abd pain. norovirus gastroenteritis. symptomatic therapy
___: nausea, vomiting, diarrhea. viral gastroenteritis.
___: n/v/d. IV morphine --> PO oxycodone. npo, diet advanced.
___: abd pain. KUB obtained showed fecal loading, rx'd w/
bowel regimen. EGD with no marginal ulcers
___: abd pain. resumed home PPI/H2 blocker/Carafate (has been
dc'd recently).
___: Abd pain. treated with Tylenol 1 gram TID standing,
resumption of pantoprazole/ranitidine/Carafate, bowel regimen,
home pain medications. C. diff negative. Pyridostigmine d/ced as
can contribute to GI upset. Referred to Dr. ___ ___ for
chronic pain management
___: abd pain, N/V/D. C. diff positive, ___ recurrence,
previously treated with metronidazole. Prescribed PO vancomycin
(day 1 ___ for ___bd pain managed with home
medications and oxycodone prn.
- Obstructive sleep apnea, resolved.
- Gastroesophageal reflux, resolved.
- History of polycystic ovary disease.
- History of fatty liver.
- History of gastrojejunal anastomotic ulcer.
- History of C. difficile colitis, ___, recurrence ___.
- Depression and anxiety.
- Breath test positivity for bacterial overgrowth, ___.
- Seizure
Past Surgical History:
1. Right carpal tunnel surgery in ___.
2. Right shoulder surgery in ___.
3. Tubal ligation in ___.
4. Laparoscopic Roux-en-Y gastric bypass in ___.
5. Right internal jugular Hickman placed ___, status
post removal.
6. Appendectomy.
7. Laparoscopic gastrostomy tube in ___, status post removal.
8. Interventional placed gastrostomy tube inadvertently placed
in the Roux limb in ___, status post removal.
9. Laparoscopic converted to open gastrostomy tube placement in
___. Currently, tube is ___ MIC
gastrostomy
tube, 20 ___ with a ___ mL balloon.
10. Wound drainage and removal of foreign body (suture) from
abdominal wall incision in ___.
11. Open gastric bypass reversal ___
Social History:
___
Family History:
Family history of obesity.
Mother - ___ disease and elevated liver enzymes.
No other known family history of gut, liver, or pancreatic
disorders.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: T 98.4, BP 109/61, HR 91, RR18, O2Sat 94 % RA
BS= 70
Constitutional: Alert, oriented, resting, does not appear in
acute distress
EYES: Sclera anicteric, EOMI, PERRL
ENT: Slightly dry mucous membranes, oropharynx clear,
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Respiratory: Clear to auscultation bilaterally, no wheezes,
rales, rhonchi
GI: Soft, tender throughout epigastrium, no rebound or guarding,
non-distended, bowel sounds present, no organomegaly
GU: No foley
EXT: Warm, well perfused, no CCE
NEURO: aaox3 CNII-XII and strength ___ in upper and lower
extremities, gait deferred
SKIN: no rashes or lesions
============================================================
DISCHARGE PHYSICAL EXAM
Vitals: 98.5
PO 115 / 76 59 16 96 RA
Constitutional: comfortable appearing, watching TV with empty
breakfast tray next to her, eating mints. Alert and conversant.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Respiratory: Clear to auscultation bilaterally, no wheezes,
rales, rhonchi
GI: Soft, tender throughout epigastrium, no rebound or guarding,
non-distended, bowel sounds present, no organomegaly
NEURO: aaox3, calm
SKIN: no rashes or lesions
Pertinent Results:
___ 10:16AM PLT COUNT-319
___ 10:16AM NEUTS-69.0 ___ MONOS-8.5 EOS-0.6*
BASOS-0.3 IM ___ AbsNeut-4.74# AbsLymp-1.46 AbsMono-0.58
AbsEos-0.04 AbsBaso-0.02
___ 10:16AM WBC-6.9# RBC-4.35 HGB-12.8 HCT-40.4 MCV-93
MCH-29.4 MCHC-31.7* RDW-14.6 RDWSD-49.5*
___ 10:16AM ALBUMIN-4.3
___ 10:16AM LIPASE-31
___ 10:16AM ALT(SGPT)-40 AST(SGOT)-29 ALK PHOS-137* TOT
BILI-0.4
___ 10:16AM estGFR-Using this
___ 10:16AM GLUCOSE-82 UREA N-9 CREAT-1.0 SODIUM-137
POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-20* ANION GAP-20
___ 12:46PM URINE MUCOUS-RARE
___ 12:46PM URINE HYALINE-4*
___ 12:46PM URINE RBC-5* WBC-5 BACTERIA-FEW YEAST-NONE
EPI-2
___ 12:46PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-TR
___ 12:46PM URINE COLOR-Straw APPEAR-Clear SP ___
CT Abdomen/Pelvis
IMPRESSION:
1. No small bowel obstruction or evidence of complication with
the patient's
gastric bypass status post reversal.
2. Duplicated renal collecting system, bilaterally. New, mild
hydronephrosis
of the lower moiety of the right kidney without evidence of
focal obstruction
and likely due to reflux. If there is concern for obstruction,
MRU or CTU
could be performed for further evaluation.
========================================================
___ 09:00AM BLOOD WBC-4.6 RBC-3.86* Hgb-11.3 Hct-36.0
MCV-93# MCH-29.3 MCHC-31.4* RDW-14.7 RDWSD-50.3* Plt ___
___ 09:00AM BLOOD Glucose-87 UreaN-3* Creat-0.9 Na-143
K-4.4 Cl-107 HCO3-24 AnGap-16
___ 06:25AM BLOOD ALT-35 AST-27 LD(LDH)-201 AlkPhos-112*
TotBili-0.4
___ 09:00AM BLOOD Calcium-8.8 Phos-3.1 Mg-2.3
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
2. ARIPiprazole 10 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. FLUoxetine 80 mg PO DAILY
5. Gabapentin 900 mg PO TID
6. LevETIRAcetam 500 mg PO BID
7. LORazepam 1 mg PO TID
8. Multivitamins 1 TAB PO DAILY
9. Ondansetron ODT 4 mg PO Q8H:PRN nausea
10. Pantoprazole 40 mg PO Q12H
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
12. Ranitidine 150 mg PO BID
13. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
14. Propranolol 10 mg PO TID
Discharge Medications:
1. Sucralfate 1 gm PO QID
RX *sucralfate [Carafate] 1 gram 1 tablet(s) by mouth four times
a day Disp #*30 Tablet Refills:*0
2. TraMADol 100 mg PO Q6H:PRN Pain - Moderate
RX *tramadol 50 mg ___ tablet(s) by mouth up to every 6 hours
Disp #*30 Tablet Refills:*0
3. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
4. ARIPiprazole 10 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. FLUoxetine 80 mg PO DAILY
7. Gabapentin 900 mg PO TID
8. LevETIRAcetam 500 mg PO BID
9. LORazepam 1 mg PO TID
10. Multivitamins 1 TAB PO DAILY
11. Ondansetron ODT 4 mg PO Q8H:PRN nausea
12. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth every 12 hours Disp
#*60 Tablet Refills:*0
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
14. Propranolol 10 mg PO TID
15. Ranitidine 150 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
bile gastritis
abdominal pain
complication of gastric bypass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT abdomen pelvis
INDICATION: +PO contrast; History: ___ with history gastric bypass surgery,
h/o SBO, ulcers presenting complaining of abdominal pain, vomiting and
diarrhea. Recent d.diff+PO contrast // ?obstruction or other process causing
pain
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 6.0 s, 0.5 cm; CTDIvol = 28.9 mGy (Body) DLP =
14.4 mGy-cm.
2) Spiral Acquisition 4.6 s, 50.0 cm; CTDIvol = 15.9 mGy (Body) DLP = 794.0
mGy-cm.
Total DLP (Body) = 808 mGy-cm.
COMPARISON: CT abdomen pelvis ___
FINDINGS:
LOWER CHEST: There is minimal atelectasis at the lung bases, bilaterally.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: There are bilateral duplicated renal collecting systems. There is
mild hydronephrosis involving the lower moiety of the right kidney, new from
prior.
GASTROINTESTINAL: The patient is status post Roux-en-Y gastric bypass status
post reversal without evidence complication. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No small bowel obstruction or evidence of complication with the patient's
gastric bypass status post reversal.
2. Duplicated renal collecting system, bilaterally. New, mild hydronephrosis
of the lower moiety of the right kidney without evidence of focal obstruction
and likely due to reflux. If there is concern for obstruction, MRU or CTU
could be performed for further evaluation.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: n/v/d
Diagnosed with Epigastric pain, Left upper quadrant pain, Diarrhea, unspecified
temperature: 96.1
heartrate: 68.0
resprate: 16.0
o2sat: 100.0
sbp: 113.0
dbp: 65.0
level of pain: 8
level of acuity: 3.0 | Ms. ___ is a ___ yo woman with history of laparoscopic Roux en
Y Gastric Bypass in ___ (c/b post-gastric bypass hypoglycemia
requiring G-tube placement for tube feeds in ___ and ___,
marginal ulcers) s/p open gastric bypass reversal ___, which
was further c/b chronic abdominal pain/n/v, anxiety/depression,
c diff, with multiple admissions for acute on chronic abdominal
pain who presented again with abdominal pain, nausea, vomiting.
GI consulted and feel this is likely bile reflux relating to her
post surgical anatomy, recommending IV PPI and bowel rest.
Deferred EGD, recommending bowel rest, advancing diet, and
smaller, more frequent meals to avoid bile reflux in the future.
She triggered ___ for hypotension (chronically low BP), which
improved s/p IV fluid, and after we discontinued IV morphine.
Her diet was slowly advanced. Her ab pain did improve very
slowly but was still present, near her baseline levels of
chronic abdominal pain.
Today, she noted having a normal BM yesterday but none yet
today. Her pain is the same in quality and location as it has
been "for many months now" and unchanged. She was frustrated
that we haven't "figured out what's going on in my stomach" and
initially did not want to go home before an EGD is done. I told
her I would speak again with her GI team regarding the EGD but
informed her that an EGD would not fix her pain. the patient
called her outpatient gastroenterologists office of Dr. ___.
Throughout the morning, she continued eating small meals as
instructed, without significant nausea or vomiting. She has been
seen ambulating the hallways without issues. I communicated with
her outpatient gastroenterologist and inpatient GI fellow and
they reiterated that she would not benefit from EGD at this time
and continuing with planned outpatient EGD. No further inpatient
recommendations were made.
I came back in the afternoon and her ab pain was still present
but she felt like she could manage the pain on her current po
medication regimen. She agreed with GI follow up plan with Dr.
___.
Rest of hospital course and plan are outlined below by issue:
#Acute on Chronic Abdominal Pain
#Nausea
#Vomiting
Discussed with gastroenterology fellow and felt this was likely
gastritis due to bile reflux and EGD would be of limited utility
because we would simply increase her PPI anyway. She has had
ulcers in the past near the anastomotic site and she did
recently stop her PPI and ranitidine, making this very possible.
She was also seen by surgery who did not feel she needed any
further intervention. Also, we considered viral
gastroenteritis, which is also possible but she denied any sick
contacts and diarrhea had stopped upon arrival to the ED. After
speaking with GI team again later during her hospital course in
light of ongoing pain, we considered adding a TCA for likely
component of functional abdominal pain however given her
multiple QT prolonging agents (tramadol, psych medciations) this
was ultimately not done.
-continued symptomatic management with Zofran
-discontinued narcotics.
-Pain managed currently with Tylenol PRN, increased tramadol PO
to maxium dose 100mg q6h PRN
-Protonix IV BID later converted to PO PPI BID
-Carafate
-Ranitidine
#Recent Cdiff Infection: She did not finish the prolonged oral
vancomycin as it was prescribed (stopped ___ because she says
she ran out of pills). Did not have a BM for >24 since
admission, she has not had significant diarrhea since admission.
Stool studies were discontinued.
#Hypoglycemia
Recurrent issue for her likely worse in the setting of poor PO
intake. Unlikely to be "true" hypoglycemia (< 50 documented on
BMP) as lowest blood sugar reading has been 70. Regardless,
relatively low normal blood sugars likely related to poor PO
intake and she stated she was feeling shaky, which is now
resolved. She was placed on D51/2 NS and monitored finger
sticks. D5 was later discontinued and her blood sugars have
remained stable since she has been eating.
#Seizure Disorder
Stated could not swallow pills d/t nausea so temporarily placed
on IV keppra, which was later changed back to PO after nausea
resolved she began tolerating a diet.
#Depression: Continued home medications as below.
- ARIPiprazole 10 mg PO DAILY
- FLUoxetine 80 mg PO DAILY
- Gabapentin 900 mg PO TID
#S/p RYGB reversal: Continued home MVI, iron, and nutritional
supplements.
#HLD: continued home statin
#ANXIETY
-continued home propranolol PRN, Lorazepam
#CONTACTS:
-___: I communicated with her outpatient gastroenterologist and
inpatient Gi fellow and confirmed plan for outpatient endoscopy
which is scheduled for her.
#Transitional Issues:
-resumed BID PPI and added Carafate to outpatient medication
regimen
-advised to eat small meals (to minimize bile reflux) per GI
recommendations
-GI f/u with Dr. ___ for ___
#CONSULTS: surgery, GI
#DISPO; was at home with husband without services prior to
admission. d/c today home without services.
spent > 30 minutes seeing the patient and organizing her
discharge.
___
___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: PODIATRY
Allergies:
Ceftin / Sulfa (Sulfonamide Antibiotics) / Reglan / Compazine
Attending: ___
Chief Complaint:
fevers; L foot pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old female with PMH significant for diabetes, left foot
charcot reconstruction with external fixation for Charcot ___
with frame removal ___ presenting to the ED with fevers and
worsening left foot pain. Patient states that she was seen
recently by Dr. ___ slightly debrided a callus to the
plantar aspect of her foot. Over the course of the past weekend
she has had increased pain in the left foot as well as fevers
/chills. She had just recently started to put weight on the
left foot. She notes that she has had decreased appetite over
the past few days as well. She adjusted her insulin because she
was not eating
Past Medical History:
DM
Depression
Social History:
___
Family History:
Positive for heart disease and lung disease and rheumatoid
arthritis.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
Vitals: 100.2 101 145/65 19 98% RA
GENERAL: Examination shows a well-developed,
well-nourished female who is in no acute distress.
Heart: Regular rate and rhythm peripherally
Lungs: Breathing comfortably on room air.
Lower Extremity Exam: Examination revealed palpable pedal
pulses. Gross sensation diminished. Left plantar foot with
callused area to the midfoot with surrounding erythema. After
debridement there is an ulceration down to subcutaneous tissue
with extension of the ulceration laterally. Serous drainage
noted to the area. Mild pain to the left foot with palpation. No
noted fluctuance to the L foot. No open lesions to the Right
foot. No pain with compression of the calf b/l.
DISCHARGE PHYSICAL EXAMINATION:
Vitals:AVSS
GENERAL: Examination shows a well-developed,
well-nourished female who is in no acute distress.
Heart: Regular rate and rhythm peripherally
Lungs: Breathing comfortably on room air.
Lower Extremity Exam: Examination revealed palpable pedal
pulses. Gross sensation diminished. Dry sterile dressing in
place
Pertinent Results:
Admission labs:
___ 07:15PM BLOOD WBC-10.3*# RBC-3.28* Hgb-10.3* Hct-30.7*
MCV-94 MCH-31.4 MCHC-33.6 RDW-13.1 RDWSD-44.6 Plt ___
___ 07:15PM BLOOD Neuts-78.2* Lymphs-9.5* Monos-10.6
Eos-0.4* Baso-0.5 Im ___ AbsNeut-8.09*# AbsLymp-0.98*
AbsMono-1.09* AbsEos-0.04 AbsBaso-0.05
___ 07:15PM BLOOD Plt ___
___ 07:15PM BLOOD ___ PTT-20.9* ___
___ 07:15PM BLOOD Glucose-233* UreaN-13 Creat-1.0 Na-131*
K-4.7 Cl-93* HCO3-27 AnGap-16
___ 07:46PM BLOOD Lactate-0.9
Imaging:
Left Foot Xray ___:
No radiographic evidence of osteomyelitis. Diffuse soft tissue
swelling with plantar ulceration, but no subcutaneous gas. No
significant changes from prior Xrays ___.
Discharge labs:
___ 06:30AM BLOOD WBC-7.4 RBC-3.06* Hgb-9.5* Hct-29.0*
MCV-95 MCH-31.0 MCHC-32.8 RDW-13.0 RDWSD-44.7 Plt ___
___ 06:30AM BLOOD Plt ___
___ 06:30AM BLOOD Glucose-280* UreaN-10 Creat-1.0 Na-139
K-4.8 Cl-100 HCO3-27 AnGap-17
___ 06:30AM BLOOD Calcium-9.3 Phos-2.9 Mg-1.9
Medications on Admission:
. Docusate Sodium 100 mg PO BID
. Pseudoephedrine 30 mg PO Q8H:PRN sinus congestion
. Glargine 13 Units Breakfast Glargine 13 Units Dinner
Insulin SC Sliding Scale using Novolog Insulin
. Acetaminophen-Caff-Butalbital ___ TAB PO ONCE:PRN Headache
. Acetaminophen 650 mg PO Q6H
. Acyclovir 400 mg PO Q12H
. Align (Bifidobacterium infantis) 4 mg oral DAILY
. Lisinopril 5 mg PO DAILY
. Movantik (naloxegol) 25 mg oral DAILY
. Omeprazole 20 mg PO BID
. Ondansetron 4 mg PO Q8H:PRN Nausea
. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
. Senna 8.6 mg PO BID:PRN Constipation
. Venlafaxine XR 225 mg PO DAILY
. Voltaren (diclofenac sodium) 1 % topical DAILY:PRN
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Docusate Sodium 100 mg PO BID:PRN constipation
3. Doxycycline Hyclate 100 mg PO Q12H
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth twice a day
Disp #*20 Tablet Refills:*0
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*20 Tablet Refills:*0
5. Senna 8.6 mg PO BID:PRN Constipation
6. Acyclovir 400 mg PO Q12H
7. Aspirin 81 mg PO DAILY
8. Glargine 8 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
9. Lisinopril 5 mg PO DAILY
10. naloxegol 25 mg oral DAILY
11. Omeprazole 20 mg PO BID
12. Venlafaxine XR 225 mg PO DAILY
13. Voltaren (diclofenac sodium) 1 % topical DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
fevers; L foot pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: FOOT AP,LAT AND OBL LEFT
INDICATION: History: ___ with left foot infection// cellulitis? air?
TECHNIQUE: Left foot, three views
COMPARISON: Left foot radiographs ___
FINDINGS:
Overlying bandage material slightly limits assessment of the toes. The
osseous structures are diffusely demineralized. Patient is status post
arthrodesis of the posterior facet of the subtalar joint and first, second and
fourth TMT joints. No hardware complications are identified. Unchanged
osseous deformity and collapse of the midfoot is re-demonstrated. No new
cortical destruction or periosteal new bone formation is identified. Diffuse
soft tissue swelling is seen about the foot with ulceration along the plantar
aspect of the foot at the level of the midfoot. Prominent dorsal spurring
within the midfoot is unchanged. Mild degenerative changes of the first and
second MTP joints are re-demonstrated. No subcutaneous emphysema is
identified.
IMPRESSION:
No radiographic evidence of osteomyelitis. Diffuse soft tissue swelling with
plantar ulceration, but no subcutaneous gas. Please note that MRI would be
more sensitive for detection of osteomyelitis.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Fever, L Foot pain
Diagnosed with Fever, unspecified
temperature: 100.2
heartrate: 101.0
resprate: 19.0
o2sat: 98.0
sbp: 145.0
dbp: 65.0
level of pain: 5
level of acuity: 3.0 | The patient was admitted to the podiatric surgery service from
the ED on ___ for a L foot infection. On admission, he was
started on broad spectrum antibiotics. And
transferred to the ward for observation.
The patient remained afebrile with stable vital signs; pain was
well controlled oral pain medication on a PRN basis. The
patient remained stable from both a
cardiovascular and pulmonary standpoint. He was placed on
vancomycin, ciprofloxacin, and flagyl while hospitalized and
discharged with oral antibiotics. His intake and output were
closely monitored and noted to be adequate. The patient received
subcutaneous heparin throughout admission; early and frequent
ambulation were strongly encouraged. ___ was consulted and
recommended home with home ___ was consulted to help get
you glucose levels under better control.
The patient was subsequently discharged to home on HOD 4 with PO
abx, home ___ and home ___. The patient received discharge
teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
acute onset right upper quadrant pain
Major Surgical or Invasive Procedure:
___ drainage
History of Present Illness:
___ with hypertrophic cardiomyopathy with obstructive
symptoms and ICD placement presents with acute onset right upper
quadrant pain. The patient reports pain starting at 4PM
yesterday
that has been persistent. He reports pain is worse with deep
inspiration. He has had chills the last two days as well as a
dry
cough and nausea. He denies emesis, diarrhea, urinary symptoms.
He denies chest pain or shortness of breath. He has been
tolerating a regular diet. He feels somewhat constipated.
Work-up in the ED was notable for a WBC of 18.8 and imaging
showing a large intraperitoneal fluid collection in the right
upper quadrant. Surgery was consulted for management
recommendations.
Past Medical History:
Past Medical History:
hypertrophic obstructive cardiomyopathy
HLA-B27, sacroilitis
Past Surgical History: AICD implantation
Social History:
___
Family History:
His maternal grandmother had heart failure
(unclear if HCM), his maternal uncle has definite HCM (no ICD),
and his mother died in her sleep (reportedly no HCM on autopsy).
He has 3 sisters(reports negative echo). Notably, his half
brother (from his father's side) was recently diagnosed with
HCM.
NKDA.
Physical Exam:
Admission:
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: regular rate, regular rhythm
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, tender to palpation in right upper
quadrant with +rebound, other quadrants non-tender, no palpable
masses
Ext: No ___ edema, ___ warm and well perfused
Discharge:
Gen: NAD, AxOx3
Card: RRR, no m/r/g
Pulm: CTAB, no respiratory distress
Abd: Soft, tender on R abdomen/flank around drain,
non-distended,
normal bs. JP drain serous
Ext: No edema, warm well-perfused
Pertinent Results:
___ 01:13PM ___ PTT-31.0 ___
___ 01:09PM GLUCOSE-111* UREA N-9 CREAT-1.0 SODIUM-140
POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-23 ANION GAP-12
___ 01:09PM estGFR-Using this
___ 01:09PM ALT(SGPT)-13 AST(SGOT)-18 ALK PHOS-50 TOT
BILI-1.2
___ 01:09PM LIPASE-12
___ 01:09PM ALBUMIN-4.6
___ 01:09PM CRP-46.3*
___ 01:09PM WBC-18.8* RBC-5.47 HGB-15.5 HCT-43.7 MCV-80*
MCH-28.3 MCHC-35.5 RDW-14.3 RDWSD-41.1
___ 01:09PM NEUTS-87.0* LYMPHS-4.7* MONOS-7.0 EOS-0.1*
BASOS-0.6 IM ___ AbsNeut-16.40* AbsLymp-0.89* AbsMono-1.32*
AbsEos-0.01* AbsBaso-0.11*
___ 01:09PM PLT COUNT-229
Medications on Admission:
verapamil 180XR
meloxicam 15mg'
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild/Fever
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*14 Tablet Refills:*0
3. meloxicam 15 mg oral DAILY
4. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*21 Tablet Refills:*0
5. Verapamil SR 180 mg PO Q24H
Discharge Disposition:
Home
Discharge Diagnosis:
intraperitoneal fluid collection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ with RLQ PainNO_PO contrast// ?appendicitis
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was not administered.Coronal and sagittal reformations were
performed and reviewed on PACS.
DOSE: Total DLP (Body) = 1,044 mGy-cm.
COMPARISON: Cardiac MRI ___.
FINDINGS:
LOWER CHEST: Mild basal dependent atelectasis. The imaged portion the heart
appears top-normal in size. Percutaneous ICD seen in the anterior lower chest
wall.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: Duplicated right collecting system, otherwise unremarkable. Normal
left kidney. Both kidneys present normal renal nephrogram. There is no
evidence of focal renal lesions or hydronephrosis. There is no perinephric
abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. Colon appears
unremarkable. The appendix is normal.
A 9 x 5 x 5 cm hypodense collection is seen in the right paracolic gutter,
below the tip of the liver, lateral to the second portion of the duodenum and
above the right kidney. There is subtle irregularity of this collection along
the inferior margin, best seen on series 601, image 27. There is associated
minimal fat stranding. There is no enhancing rim. No gas within this
collection. When compared with a prior cardiac MRI from ___, this lesion was
not definitively visualized. These cystic structure was not seen on the scout
images of prior cardiac MRI from ___.
PELVIS: The urinary bladder is normal. Duplicated right ureters appear
unremarkable proximally in nonexcretory phase, the distal portion cannot be
evaluated in this phase. Left urinary is otherwise unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: Prostate and seminal glands are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Hypodense collection in the right mid abdomen adjacent to the liver,
duodenum, and ascending colon measuring 9 x 5 x 5 cm. The etiology of this
collection is unknown though the possibility of an duplication cyst or
sequelae of perforated duodenal ulcer are considered. Given associated pain,
leukocytosis, percutaneous drainage may be considered.
2. Normal appendix.
3. Duplicated right renal collecting system.
Radiology Report
EXAMINATION: CT-GUIDED DRAINAGE
INDICATION: ___ year old man with intraperitoneal fluid collection of unclear
etiology// intraperitoneal fluid collection
COMPARISON: CT abdomen and pelvis ___
PROCEDURE: CT-guided drainage of a right abdominal fluid collection
OPERATORS: Dr. ___, radiology fellow and Dr. ___, attending
radiologist. Dr. ___ supervised the trainee during the key
components of the procedure and reviewed and agrees with the trainee's
findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a left lateral position on the CT scan table.
Limited preprocedure CT scan was performed to localize the collection. Based
on the CT findings an appropriate skin entry site for the drain placement was
chosen. The site was marked. Local anesthesia was administered with 1%
Lidocaine solution.
Using intermittent CT fluoroscopic guidance, an 18-G ___ needle was
inserted into the collection. A sample of fluid was aspirated, confirming
needle position within the collection. 0.038 ___ wire was placed through
the needle and needle was removed. This was followed by placement of ___
Exodus pigtail catheter into the collection. The plastic stiffener and the
wire were removed. The pigtail was deployed. The position of the pigtail was
confirmed within the collection via CT fluoroscopy.
Approximately 100 cc of purulent fluid was aspirated with a sample sent for
microbiology evaluation. The catheter was secured by a StatLock. The catheter
was attached to suction bulb. Sterile dressing was applied.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
DOSE: Acquisition sequence:
1) Spiral Acquisition 7.6 s, 23.1 cm; CTDIvol = 7.3 mGy (Body) DLP = 158.8
mGy-cm.
2) Stationary Acquisition 11.2 s, 1.4 cm; CTDIvol = 116.7 mGy (Body) DLP =
168.0 mGy-cm.
Total DLP (Body) = 338 mGy-cm.
SEDATION: Sedation was provided by the anesthesiology team, during which time
the patient's hemodynamic parameters were continuously monitored.
FINDINGS:
1. Limited preprocedure CT of the abdomen again shows an approximately 9 cm
collection in the right anterior pararenal space, surrounded by the lower pole
of the right kidney, inferior margin of the liver, and hepatic flexure. This
was targeted for CT-guided drainage, yielding 100 cc of slightly purulent
fluid.
2. Postprocedure imaging shows appropriate drainage catheter placement, with
complete collapse of the collection.
IMPRESSION:
Successful CT-guided placement of an ___ pigtail catheter into the
collection. Samples were sent for microbiology evaluation.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: RLQ abdominal pain
Diagnosed with Right upper quadrant rebound abdominal tenderness, Right lower quadrant rebound abdominal tenderness
temperature: 97.7
heartrate: 103.0
resprate: 16.0
o2sat: 100.0
sbp: 121.0
dbp: 80.0
level of pain: 9
level of acuity: 3.0 | Mr. ___ is a ___ male who presented to the ED
with acute-onset right upper quadrant abdominal pain. Imaging
showed a large intraperitoneal fluid collection in the right
upper quadrant. On ___ he underwent ___ drainage which
yielded 100cc of slightly purulent fluid. On ___, the patient
was out of bed and ambulating. He continued to experience right
buttock pain and mild abdominal distention. JP drained 27cc
straw colored fluid with sediment. WBC 15.4, T-98.6. He was
advanced to regular diet and ID had us switch his antibiotics
from vancomycin and zosyn to ceftriaxone and flagyl. On ___,
his JP continued to drain straw colored fluid with mild
sediment. 37cc that day. We switched him to PO cipro and flagyl.
On ___, he was medically cleared for discharge and sent home
with PO antibiotics and his drain still in place. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lipitor / levofloxacin in D5W / Bactrim
Attending: ___.
Chief Complaint:
dysuria and fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a ___ with history of multiple myeloma s/p allogenic
stetm cell (d+186) and hypertension who presents with dysuria
and fevers. Dysuria and increased frequency began on ___
which then progressed to gross hematuria on ___. Later that
today, after lunch, patient felt tired and spike a fever to
103.5. Endorsed chills but no rigors, SOB, CP, URI symptoms,
nasuea, vomiting, diarrhea, or joint aches. He also mentioned
that while having this fever, he felt disoriented. Given his
symptoms he presented to an OSH ED for evaluation.
At OSH, patient received CTX and was then transferred to ___
for evaluation.
In ED initial VS were 98.8 63 106/55 14 98% RA. Evaluation was
significant for bloody UA and pancytopenia. CXR was
unremarkable. Patient was then admitted to ___ for further
management. VS prior to transfer were Temp: 99.1 °F (Oral),
Pulse: 62, RR: 16, BP: 106/65, O2Sat: 98, O2Flow: (Room Air).
On arrival to floor, patient stated that he was feeling better
however continued to feel tried. Patient also complained of
itchiness skin and dry skin around eyes.
Past Medical History:
PAST ONCOLOGIC HISTORY:
___, diagnosed with multiple myeloma, stage III by
ISS
___, s/p anterior T3 corpectomy with anterior and
posterior spinal fusion T1 thru T5 for a T3 myelomatous lesion
along with thoracic decompression laminectomy T1 to T2, T2 to
T3,
T3 to T4, and T4 to T5
___, pulse dexamethasone
___, completed XRT ___ (3000 cGy) and ___ (3000 cGy)
___, 3 cycles of Velcade/dexamethasone, stopped due to
neuropathy
___, completed 4 cycles of Revlimd/dexamethasone
___, autologous stem cell transplant, in PR after
transplant
___, completed 3 vaccinations per protocol ___
___, sacral mass causing inability to bear weight on right
lower extremity and was radiated, total dose 3500 cGy
___ through ___, multiple combinations of Revlimid,
Velcade and dexamethasone
___, completed XRT to right superior pubic ramus (3500
cGy)
and left hip/proximal femur (3000 cGy)
___, admitted for non ablative sibling allogeneic stem cell
transplant per protocol ___ (TLI, ATG, clofarabine)
___, diagnosed with PTLD and began treatment with Velcade
and Rituxan per protocol ___, d/c'd after 4 cycles due to
neuropathy.
___: DLI
PAST MEDICAL HISTORY:
- Hypertension
- Hypercholesterolemia
- Degenerative joint disease
- Osteoporosis, ___ multiple myeloma
- Obstructive sleep apnea requiring CPAP at night
- Episodic vertigo
- Ocular migraines
- s/p appendectomy
- s/p bilateral knee arthroscopies, right ___, left ___
- s/p hernia repair as a child
Social History:
___
Family History:
No family history of hematologic malignancies.
Physical Exam:
Admission Physical Exam:
Vitals - 99.1 111/59 68 16 98% RA
GENERAL: NAD, well appearing
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, dry MM, good dentition, nontender supple neck, no
LAD, no JVD
CARDIAC: RRR, S1/S2, no murmers, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
Back: no CVAT
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: CN ___ intact
SKIN: very dry periorbital skin
DISCHARGE PHYSICAL EXAM:
Pertinent Results:
Admission Labs:
___ 02:00AM BLOOD ___
___ Plt ___
___ 02:00AM BLOOD ___
___
___ 02:00AM BLOOD ___
___ Tear ___
___ 02:00AM BLOOD Plt ___
___ 02:00AM BLOOD ___
___
___ 01:45AM URINE ___
___
PERTINENT MICRO:
___ 9:17 am URINE VIRAL CULTURE (Final ___:
ADENOVIRUS. CONFIRMED BY MONOCLONAL FLUORESCENT ANTIBODY..
___ Blood Adenovirus DNA, Qn ___ H, RR <500
Copies/mL
___ Adenovirus DNA, Qn PCR 6573 H <500 Copies/mL
---------
___ URINE BK Virus, QN ___ H, RR <500 copies/mL
___ BK Virus, QN PCR 630 H <500 copies/mL
___ 10:30AM URINE BK VIRUS BY PCR, ___
----------
___ Blood HHV6, EBV, CMV negative
___ EBV DNA- negative
PERTINENT PATH:
___ Bone marrow final ___ HYPOCELLULAR MARROW WITH
___ MYELOPOIESIS.NO MORPHOLOGIC EVIDENCE OF ABNORMAL
LYMPHOCYTIC ___ hybridization is positive in
scattered cells, some of which are ___. This finding
is interpreted as persistent EBV infection. While morphological
evidence of ___ lymphoproliferative disorder is not
seen, the persistence of EBV infection is suggestive, but not
diagnostic of minimal residual PTLD. Clinical correlation is
suggested
___ BM immunophenotyping: ___ T cell dominant
lymphoid profile; diagnostic immunophenotypic features of
involvement by ___ lymphoma are not seen in
specimen.
PERTINENT IMAGING:
___ RENAL ULTRASOUND: IMPRESSION: Cannot exclude
pyelonephritis on ultrasound. Bilateral mild hydronephrosis. No
obstructing stones or abscess identified.
___ CT ABD/PEL w/o contrast: IMPRESSION:
1. Findings suggestive of cystitis with pyelitis. Assessment
of pyelonephritis is limited without intravenous contrast. Mild
bilateral
hydronephrosis.
2. In this patient with lymphoma, there is no evidence of
recurrent disease. The findings including bilateral femoral
avascular necrosis, and additional lucent pelvic lesions, are
stable. No new bone lesion is seen.
___ PET CT
IMPRESSION: 1. New focus of mild ___ within the left
iliac crest, but no correlate lesion is seen on the CT portion.
2. No new ___ lymphadenopathy detected. 3. Thickened
bladder wall and ___ stranding, compatible with
infection, overall slightly improved since ___. 4.
Unchanged sclerosis of the left femoral head.
___ CT Torso w/o contrast
IMPRESSION:
1. New, relatively focal ___ opacities within the left
lower lobe
which may represent aspiration versus developing infection. No
large
consolidation is noted. Minimal right pleural effusion.
2. Edematous kidneys with increasing perinephric stranding and
mild
hydroureteronephrosis, increased in severity compared to the
prior study. This may be secondary to an underlying infection
or aggressive volume overload.
3. No evidence of abscess within the abdomen or pelvis. There
is no small bowel or colonic obstruction.
4. Small amount of fluid within the pelvis and in perirectal
region. This may related to overall fluid overload, adjacent
inflammatory changes remain a possibily.
5.Stable osseous lesions.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver.
1. Acyclovir 400 mg PO Q8H
2. Carvedilol 3.125 mg PO BID
hold for sbp < 100 and HR< 60
3. FoLIC Acid 1 mg PO DAILY
4. Albuterol Inhaler ___ PUFF IH QMONTHLY PRIOR TO PENTAMINIDINE
DOSE
5. Omeprazole 20 mg PO DAILY
6. Ondansetron 8 mg PO BID:PRN nausea
7. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
8. Oxycodone SR (OxyconTIN) 30 mg PO Q12H
hold for rr < 10 and somnolence
9. ___ 300 mg IH MONTHLY
FOR INHALATION ONLY
*Admin/Prep Precautions*
10. Pregabalin 100 mg PO TID
11. Vitamin B Complex 1 CAP PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Vitamin D ___ UNIT PO DAILY
14. Lorazepam ___ mg PO Q6H:PRN nausea or anxiety
15. Prochlorperazine 10 mg PO Q8H:PRN nausea
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. Lorazepam ___ mg PO Q6H:PRN nausea or anxiety
3. Multivitamins 1 TAB PO DAILY
4. Omeprazole 20 mg PO DAILY
5. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
6. Oxycodone SR (OxyconTIN) 30 mg PO Q12H
hold for rr < 10 and somnolence
7. Pregabalin 100 mg PO TID
8. Vitamin B Complex 1 CAP PO DAILY
9. Vitamin D ___ UNIT PO DAILY
10. Sodium Bicarbonate 650 mg PO BID
RX *sodium bicarbonate 650 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
11. Potassium Chloride 40 mEq PO DAILY Duration: 24 Hours
Hold for K >5.3
RX *potassium chloride 10 mEq 40 meq by mouth daily Disp #*100
Tablet Refills:*0
12. Albuterol Inhaler ___ PUFF IH QMONTHLY PRIOR TO
PENTAMINIDINE DOSE
13. Ondansetron 8 mg PO BID:PRN nausea
14. ___ 300 mg IH MONTHLY
FOR INHALATION ONLY
*Admin/Prep Precautions*
15. Prochlorperazine 10 mg PO Q8H:PRN nausea
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Systemic adenovirus
BK cystitis
Cidofovir induced RTA
Secondary: multiple myeloma
gastroesophageal reflux disease
hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ post-stem cell transplant with fevers.
TECHNIQUE: Frontal and lateral radiographs of the chest were obtained.
COMPARISON: Chest radiograph from ___.
FINDINGS:
Upper thoracic spinal hardware is intact. The lungs are clear, and the
cardiomediastinal silhouette and hila are normal. There is no pleural
effusion and no pneumothorax.
IMPRESSION: No acute cardiothoracic process.
Radiology Report
INDICATION: ___ man day 188 after bone transplant. Presents with
fevers and dysuria not improved 48 hours. Evaluate for pyelo or abscess.
COMPARISON: Comparison is made to CT abdomen and pelvis performed ___.
FINDINGS:
The right kidney measures 11.8 cm. The left kidney measures 10.5 cm.
Mild hydronephrosis present bilaterally. No hydroureter definitively
identified. In the left upper pole, there is a 0.8 cm cystic lesion with
linear echogenicity possibly representing a partially calcified cyst versus
crystals in a calyceal diverticulum. No suspicious mass is identified. No
obstructing stones noted. The bladder is minimally distended but demonstrates
mild symmetric wall thickening, greater than expected with collapse.
IMPRESSION: Cannot exclude pyelonephritis on ultrasound. Bilateral mild
hydronephrosis. No obstructing stones or abscess identified.
Radiology Report
INDICATION: ___ male, day ___ status post allogenic bone marrow
transplant, now with high fevers.
COMPARISON: FDG PET-CT of ___.
TECHNIQUE: Multidetector CT imaging of the chest, abdomen and pelvis was
obtained without intravenous contrast, given the patient's renal
insufficiency. Oral contrast was administered for this study. Sagittal and
coronal reformations were performed.
FINDINGS:
CT CHEST WITHOUT CONTRAST: The lungs are clear, without pulmonary nodules,
masses, consolidation or pleural effusion. The airways are patent to
subsegmental levels. No significant axillary, mediastinal or hilar adenopathy
is seen. The heart is normal in size. Moderate-to-severe coronary arterial
calcification is present. The aorta and pulmonary arteries are unremarkable
in this non-contrast exam.
CT ABDOMEN WITHOUT INTRAVENOUS CONTRAST: The liver, gallbladder, adrenal
glands, spleen and pancreas are unremarkable in this non-contrast examination.
There is mild fullness of both renal collecting systems with extensive fat
stranding around the entire course of both ureters, consistent with acute
pyeloureteritis. Extension of infection to the kidney cannot be excluded in
this non-contrast study. The stomach, small and large bowel loops are normal.
No significant retroperitoneal or mesenteric lymphadenopathy is seen.
CT PELVIS WITHOUT INTRAVENOUS CONTRAST: The urinary bladder is decompressed
with a Foley catheter in place. There is significant wall thickening and
perivesical fat stranding, consistent with acute cystitis. The rectum,
sigmoid colon and prostate are unremarkable. Bilateral small fat-containing
inguinal hernias are noted. No significant pelvic lymphadenopathy is seen.
BONES AND SOFT TISSUES: Old healed right lateral third and fourth rib
fractures are noted. The patient is status post T3 corpectomy and posterior
spinal fusion from T1 through T5 levels with paired pedicle screws and rods.
The fixation hardware is in stable alignment. Severe compression deformity of
L2 and S1 vertebral bodies, are stable since the earlier study of ___.
No new compression fracture is seen. There is diffuse osteopenia of the
imaged spine and the pelvic bones. Bilateral femoral head avascular necrosis
is unchanged. Lucent lesions in the right sacral ala, left iliac bone
(300B:44), and both proximal femurs (300B:37 and 300B:40) are all unchanged.
Sclerotic appearance of the sacrum relates to old healed sacral fractures. No
new bone lesion is identified.
IMPRESSION:
1. Findings suggestive of cystitis with pyelitis. Assessment of
pyelonephritis is limited without intravenous contrast. Mild bilateral
hydronephrosis.
2. In this patient with lymphoma, there is no evidence of recurrent disease.
The findings including bilateral femoral avascular necrosis, and additional
lucent pelvic lesions, are stable. No new bone lesion is seen.
Findings discussed with Dr. ___ at 11:20 p.m. on ___.
Radiology Report
INDICATION: ___ male with new PICC line.
COMPARISON: Comparison is made to chest radiograph from ___.
FINDINGS: Single frontal image of the chest demonstrates right-sided PICC
line with the tip overlying the right atrium. Catheter will need to be pulled
back 2-3 cm to be in appropriate position. There is no pneumothorax or other
complication seen. The lungs are clear bilaterally. There are no pleural
effusions or infiltrate. There is no evidence of heart failure.
Cardiomediastinal silhouette is unchanged. ___ rods are again seen,
unchanged.
IMPRESSION: Right-sided PICC line with the tip in the right atrium. Line
will need to be pulsed back 2-3 cm to be in appropriate position.
These findings were communicated to Sal with the IV nursing team at 2:05 p.m.
by telephone.
Radiology Report
INDICATION: ___ man with acute kidney injury, history of bilateral
hydronephrosis. Question interval progression of hydronephrosis.
COMPARISON: CT Torso with contrast from ___, renal ultrasound from
___.
FINDINGS: The right kidney measures 12.3 cm and the left kidney measures 12.5
cm. There is mild bilateral hydronephrosis and proximal hydroureter,
unchanged from the prior ultrasound. The distal ureter is not clearly
identified. No obstructing stones are seen. There is no suspicious mass.
Within the upper pole of the left kidney is a linear echogenic foci with
cystic area which may represent a partially calcified cyst versus crystals in
a caliceal diverticulum as seen on prior ultrasound. The bladder is
nondistended but the thickened appearance of the wall is similar to prior
studies and a foley catheter is noted.
IMPRESSION:
Stable mild bilateral hydronephrosis and proximal hydroureter without source
of obstruction identified.
Radiology Report
TYPE OF THE EXAM: CT torso without intravenous contrast.
REASON FOR THE EXAM: ___ man with history of multiple myeloma status
post allogenic stem cell with adenoviremia, persistent fevers. Please assess
for PTLD versus evidence of viral pneumonia or other infectious source.
TECHNIQUE: Multiple axial CT images of the chest, abdomen and pelvis were
obtained after ingestion of oral contrast only. Coronal and sagittal
reconstructions were obtained.
COMPARISON EXAMS: Multiple prior exams, including a CT torso without
contrast, dated ___. Comparison was also made with an MR of the
L-spine, dated ___ PET-CT, dated ___ and CT torso
dated on ___.
FINDINGS:
CHEST: There is no evidence of axillary, supraclavicular, or mediastinal
lymphadenopathy. Again is seen a right-sided central venous catheter, which
terminates at the cavoatrial junction. Coronary calcifications and valvular
calcifications are seen. Heart is normal size. There is no pericardial
effusion. There might be a trace right pleural effusion.
On the lung windows, there are new ground-glass opacities within the left
lower lobe which may represent aspiration versus developing infectious
process.
ABDOMEN: Limited assessment of parenchymatous organs is obtained, secondary
to lack of intravenous contrast. Liver demonstrates no focal lesions. Spleen
is normal in size. The bilateral adrenal glands are normal with no evidence
of focal masses. Pancreas demonstrates no evidence of focal masses.
Bilateral kidneys demonstrate presence of mild hydroureteronephrosis. There
is apparant increase in kidneys size and perinephric strnading, compared to
the prior CT of ___. No obstructing mass is seen. There is no
significant mesenteric or retroperitoneal lymphadenopathy. The visualized
small and colonic loops of bowel within the upper abdomen are normal in
appearance without evidence of obstruction or wall thickening.
PELVIS: Minimal free fluid in the pelvis with some stranding in the presacral
area and perirectal area. Urinary bladder is collapsed and contains a Foley
catheter. Colonic loops of bowel are opacified with oral contrast and
demonstrate no evidence of abnormal wall thickening or dilatation. There are
surgical clips within the right lower quadrant, likely represent status post
appendectomy. There was no lymphadenopathy within the pelvis. Bilateral
small fat-containing inguinal hernias are again seen.
Vascular structures. Abdominal aorta demonstrates presence of mild
atherosclerotic plaques, which extend into bilateral iliac arteries.
OSSEOUS STRUCTURES: Diffuse osteopenia with bilateral sacral lesions, right
greater than left. There is again seen a compression deformity of S1 and L2,
not significantly changed from the prior study. Stable expansile lesion
within the left seventh rib is noted, not significantly changed from the prior
study. Again seen right sided rib fractures and thoracic posterior fusion
hardware.
IMPRESSION:
1. New, relatively focal round-glass opacities within the left lower lobe
which may represent aspiration versus developing infection. No large
consolidation is noted. Minimal right pleural effusion.
2. Edematous kidneys with increasing perinephric stranding and mild
hydroureteronephrosis, increased in severity compared to the prior study.
This may be secondary to an underlying infection or aggressive volume
overload.
3. No evidence of abscess within the abdomen or pelvis. There is no small
bowel or colonic obstruction.
4 Small amount of fluid within the pelvis and in perirectal region. This
may related to overall fluid overload, adjacent inflammatory changes remain a
possibily.
5. Stable osseous lesions.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: FEVER
Diagnosed with URIN TRACT INFECTION NOS, HYPERTENSION NOS, MULTIPLE MYELOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
temperature: 98.8
heartrate: 63.0
resprate: 14.0
o2sat: 98.0
sbp: 106.0
dbp: 55.0
level of pain: 5
level of acuity: 3.0 | ___ with history of multiple myeloma s/p MRD allogenic stem
cell (D+187 on admission) and hypertension who presented with
dysuria, hematuria and fevers, found to have BK virus UTI and
disseminated adenovirus infection.
# Systemic adenovirus: Patient presented with high fevers,
dysuria, hematuria mostly likley due to disseminated adenovirus
found in blood and urine from admission. ID was consulted,
patient was treated with weekly IV cidofovir with pre- and
___ hydration and probenecid, and serum adenovirus was
followed weekly. Treatement was complicated by ___
renal injury as discussed below. He will need weekly serum
adenovirus levels prior to Cidofovir every ___ until complete
suppression of the adenovirus. The patient will also have follow
up in transplant ___ clinic
# BK virus cystitis: Patient's presenting symptoms were most
likely caused by BK virus in combination with adenovirus
infection as discussed above. Urine BK virus was positive on
admission, serum BK virus was negative. ID was consulted,
patient received three doses of intravesicular cidofovir before
adenovirus infection was identified and treated as above.
Patient received ceftriaxone empirically from ___
before viral source of infection was identified. Urine bacterial
cultures had no growth. His urine BK virus continued to trend
down,with resolution of his hematuria. Urine BK from ___ is
pending on discharge.
# Fevers: Patient had high fevers (up to 103.2F) daily for the
first 10 days of admission and intermittently during his
hospital course . Most likely from disseminated adenovirus
infection. Was treated empirically with broad spectrum
antibiotics when patient was neutropenic, but these were
discontinued when counts came back up and alternative source for
fevers (adenovirus) was identified. Blood cultures throughout
admission were negative, ___ lymphoblastic disease
work up was negative, including PET/CT and bone marrow biopsy.
# Acute kidney injury: The patient's initial kidney injury on
admission was most likley ___. The patient was
passing large clots in urine and had significant edema of
bilateral ureters and bilateral hydronephrosis on imaging.
Urology was consulted, and did not recommend continuous bladder
irrigation due to concern for friable bladder mucosa. Foley was
placed, dysuria improved and patient was no longer passing
clots, and his creatinine initially improved. The patient
suffered a second renal insult following initiation of cidofovir
for adenovirus as discussed above, despite careful pre/post
hydration and probenecid. Renal was ___ and concluded
the patient had Cidofovir induced RTA. He was started on
continuous NaBicarb IVFs with agressive electrolyte repletion.
His second dose of Cidofovir was dose adjusted from
5mg/kg-->3mg/kg, with less renal injury. The patient will need
follow up in ___ clinic.
# Pancytopenia: Most likely due to adenoviremia. Patient was
treated with neupogen and responded well. He was supported with
pRBC transfusions to maintain hematocrit of >21.
# Multiple Myeloma s/p MRD allo transplant: Admitted on D+187
(___), had DLI ___. Not on any immunosupressive
medications. ___ course has been complicated by
PTLD, treated with Velcade and Rituxan (Cycle 2 was ___.
Continued to have painful lytic lesions in hip, as well as
___ neuropathy, treated with pregabalin. Patient was
monitored carefully for GVHD in setting of recent DLI. Patient
was continued on pentamidine ( last dose ___, acyclovir
prophylaxis, though acyclovir was held during adenovirus
treatment because of the patient poor renal function. Will
defer to primary oncologist when to resume acyclovir.
-Will continue to follow up with Dr. ___ in ___ clinic
# Xeroderma: Patient presented with dry, flaking skin over face
and erythematous patches over forearms. Most likley result of
revlimid rash two weeks prior to admission vs drug rash. Seen by
dermatology, low suspicion for GVHD, though could have
potentially been mild GVHD, too early for biopsy per
dermatology. Patient with dry flaking skin over face x1wk,
started a day or two before DLI on ___. One week
before that he reports facial swelling with revlimid that
resolved prior to dryness started. Dryness and erythema resolved
quickly with moisturizing lotions and sarna. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / vancomycin / CHG / amlodipine
Attending: ___.
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ M PMHx STEMI (___) notable for RCA occlusions, LAD
occlusion s/p DES x2 complicated by cardiogenic shock requiring
LVAD placement (now with destination Heartware, undergoing
work-up for transplant) c/b GIB and midbrain stroke who
presenting with fall concerning for syncope. Pt stated he was
lying in bed, then stood up, and syncopized, hitting his head.
He denied pre-syncopal symptoms (light headedness, dizziness,
vision changes, diaphoresis) and denies CP, palpitations, or
SOB. He denied diarrhea, vomiting, or recent illness. His
appetite has been good. He noted that he had not worn his ___
stockings for the last few days. He also noted that when he
takes his AM meds (two BP meds), he gets "loopy" and a somewhat
lightheaded and that this improves throughout the day.
Of note, he was admitted ___ for low flow states and
increased SOB. During that admission it was felt that his high
afterload was the culprit of the low flow alarms and he was
discharged on hydralazine 75mg q8h, lisinopril 20mg BID, and
torsemide 10mg as needed for ___ lbs weight gain. He was
continued on digoxin, amiodarone, and mexiletine. His fluorinef
was discontinued at discharge. Discharge weight of: Wt: 68.1
In the ED, initial vitals were RR 18 99%RA. He had a non con
head CT that was negative. Dr. ___ orthostatics by
Doppler which were positive: 114/93 supine > 104/77 sitting up >
94/64 standing.
1L of IVF started in the ED. H&H ___, INR 3.2, LFTs normal,
Chem 7 normal, Lactate 1.5, UA normal.
On arrival to the floor, he felt fine without complaints. His
cardiac ROS was negative.
Past Medical History:
1. CARDIAC RISK FACTORS:
- Hypertension
2. CARDIAC HISTORY:
- CABG/PCI: 2 DES to RCA and LAD
- PUMP FUNCTION: <20%
- PACING/ICD: ___ Inogen ICD
-Ischemic cardiomyopathy s/p LVAD (Heartware): LVAD in place
after large STEMI (___) c/b cardiogenic shock. Patient
currently has destination LVAD, undergoing evaluation for
transplant. Surgery c/b right hemothorax and GI bleeding.
- STEMI (had 100% RCA occlusion, 100% LAD occlusion), now s/p
2x DES to LAD, with cardiogenic shock requiring Heartware VAD
Placement in ___
3. OTHER PAST MEDICAL HISTORY:
- Prostate Cancer ___ 3+3 from biopsy in ___ s/p
radical minimally invasive prostatectomy (___)
- Midbrain stroke with residual vision changes (___)
Social History:
___
Family History:
Mother: Had "fluid in her lungs", died of MI
Brother: stomach cancer
Physical Exam:
ADMISSION PE:
============
VS: 98.5 114/92 75 18 99RA 66.4KG
General: NAD, comfortable, pleasant
HEENT: NCAT, PERRL, EOMI
Neck: supple, no JVD
CV: LVAD
Lungs: CTAB, no w/r/r
Abdomen: soft, NT/ND, BS+
Ext: WWP, no c/c/e, 2+ distal pulses bilaterally
Neuro: moving all extremities grossly
DISHCARGE PE:
============
VS: 98, 98-100/75-79, 69-77, ___, 99-100 RA
Weight: 66.4 < 67.3 < 67.1 < 67.1 (last d/c wt: 68.1)
I/O: 8H: ___
LVAD settings:
Dop: ___ (91 at night prior to hydral 50mg)
Flow: ___
Power: ___
Speed: 2680
PHYSICAL EXAMINATION:
General: NAD, lying comfortably at 30 deg.
HEENT: Bilateral orbital ecchymoses and abrasion on nasal bone,
no signs of displacement. Air movement at both nares.
Neck: no JVD
CV: LVAD hum
Lungs: CTAB, no w/r/r
Abdomen: soft, NT/ND, BS
Ext: WWP, no c/c/e, no palpable pulse
Neuro: moving all extremities grossly
Pertinent Results:
___ 06:30PM URINE HOURS-RANDOM
___ 06:30PM URINE HOURS-RANDOM
___ 06:30PM URINE UHOLD-HOLD
___ 06:30PM URINE GR HOLD-HOLD
___ 06:30PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 06:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 06:00PM COMMENTS-GREEN TOP
___ 06:00PM LACTATE-1.5
___ 05:45PM GLUCOSE-86 UREA N-27* CREAT-1.1 SODIUM-135
POTASSIUM-4.8 CHLORIDE-99 TOTAL CO2-26 ANION GAP-15
___ 05:45PM estGFR-Using this
___ 05:45PM ALT(SGPT)-24 AST(SGOT)-20 LD(LDH)-190 ALK
PHOS-87 TOT BILI-0.4
___ 05:45PM ALBUMIN-4.4 CALCIUM-9.4 PHOSPHATE-3.2
MAGNESIUM-2.2
___ 05:45PM WBC-11.4* RBC-4.55* HGB-13.6* HCT-41.9 MCV-92
MCH-29.9 MCHC-32.5 RDW-14.6 RDWSD-49.1*
___ 05:45PM NEUTS-76.8* LYMPHS-11.0* MONOS-10.3 EOS-1.1
BASOS-0.4 IM ___ AbsNeut-8.77* AbsLymp-1.25 AbsMono-1.17*
AbsEos-0.12 AbsBaso-0.04
___ 05:45PM PLT COUNT-161
___ 05:45PM ___ PTT-35.6 ___
___ 08:50AM BLOOD WBC-7.4 RBC-3.83* Hgb-11.4* Hct-35.3*
MCV-92 MCH-29.8 MCHC-32.3 RDW-14.3 RDWSD-47.5* Plt ___
___ 08:50AM BLOOD Plt ___
___ 08:50AM BLOOD ___ PTT-35.1 ___
___ 09:00AM BLOOD Plt ___
___ 09:00AM BLOOD ___ PTT-33.8 ___
___ 08:50AM BLOOD Ret Aut-0.9 Abs Ret-0.03
___ 08:50AM BLOOD Glucose-115* UreaN-11 Creat-1.0 Na-139
K-4.1 Cl-102 HCO3-27 AnGap-14
___ 08:50AM BLOOD LD(LDH)-132
___ 08:50AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.1 Iron-60
___ 08:50AM BLOOD calTIBC-272 Ferritn-96 TRF-209
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 200 mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Digoxin 0.125 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Ferrous Sulfate 325 mg PO BID
7. Lisinopril 20 mg PO Q12H
8. Magnesium Oxide 400 mg PO BID
9. Mexiletine 250 mg PO Q12H
10. Pantoprazole 40 mg PO Q12H
11. Warfarin 2.5 mg PO DAILY16
12. HydrALAZINE 75 mg PO Q8H
13. Torsemide 10 mg PO DAILY:PRN Weight gain
Discharge Medications:
1. Fludrocortisone Acetate 0.1 mg PO 3X/WEEK (___)
take on ___, and ___
RX *fludrocortisone 0.1 mg 1 tablet(s) by mouth three times per
week Disp #*12 Tablet Refills:*0
2. HydrALAZINE 50 mg PO QHS
RX *hydralazine 50 mg 1 tablet(s) by mouth twice per day Disp
#*60 Tablet Refills:*0
3. HydrALAZINE 25 mg PO QAM
take this dose in morning
RX *hydralazine 25 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
4. HydrALAZINE 50 mg PO DAILY
take this as second dose of day
5. Amiodarone 200 mg PO DAILY
6. Aspirin 325 mg PO DAILY
7. Atorvastatin 40 mg PO QPM
8. Digoxin 0.125 mg PO DAILY
9. Docusate Sodium 100 mg PO BID
10. Ferrous Sulfate 325 mg PO BID
11. Lisinopril 20 mg PO Q12H
12. Magnesium Oxide 400 mg PO BID
13. Mexiletine 250 mg PO Q12H
14. Pantoprazole 40 mg PO Q12H
15. Torsemide 10 mg PO DAILY:PRN Weight gain
16. Warfarin 2.5 mg PO DAILY16
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: syncope secondary to hypovolemia in setting of LVAD
Discharge Condition:
Alert and oriented x2
Ambulatory without restrictions
Independent in ADLs
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with LVAD and syncope.
COMPARISON: ___
FINDINGS:
PA and lateral views of the chest provided. Midline sternotomy wires and
AICD again noted with LVAD again noted projecting over the cardiac apex. The
lungs appear clear without focal consolidation, large effusion or
pneumothorax. Cardiomediastinal silhouette is stable. Bony structures are
intact.
IMPRESSION:
No signs of pneumonia.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ man with fall on Coumadin. Evaluate for acute
intracranial hemorrhage.
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed.
DOSE: Total DLP (Head) = 903 mGy-cm.
COMPARISON: Head CT of ___.
FINDINGS:
There is no intra-axial or extra-axial hemorrhage, edema, shift of normally
midline structures, or evidence of acute major vascular territorial
infarction. Ventricles and sulci are normal in overall size and configuration.
Small area of right frontal encephalomalacia unchanged. Bilateral white
matter hypodensities are unchanged, right greater than left, and are likely
sequela of chronic small vessel ischemic disease. There is right maxillary
sinus mucosal thickening. The imaged remaining paranasal sinuses are clear.
Mastoid air cells and middle ear cavities are well aerated. The bony calvarium
is intact.
IMPRESSION:
No acute intracranial process. Specifically, no acute intracranial
hemorrhage.
Gender: M
Race: WHITE
Arrive by UNKNOWN
Chief complaint: Syncope, Epistaxis
Diagnosed with Syncope and collapse
temperature: 98.1
heartrate: nan
resprate: 18.0
o2sat: 99.0
sbp: nan
dbp: nan
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ M with a PMHx of STEMI (___) notable
for RCA occlusions, LAD occlusion s/p DES x2 complicated by
cardiogenic shock requiring LVAD placement (now with destination
Heartware, undergoing
work-up for transplant), c/b GIB and midbrain stroke who
presented with syncope likely ___ to hypovolemic state in
setting of d/c'd fludrocortisone at last admission vs
dysrhythmia, with the former more likely given observed low flow
rates with multiple suction events during this admission.
#Ischemic cardiomyopathy s/p LVAD (Heartware): LVAD in place
after large STEMI (___) undergoing work-up for transplant.
Recently admitted ___ for low flow states and increased
SOB, thought ___ high afterload and discharged on hydralazine
75mg q8h, lisinopril 20mg BID, and torsemide 10mg as needed for
___ lbs weight gain. Fluorinef was discontinued at that time.
Presented following syncopal episode in which he sustained
trauma to his nose and orbits bilaterally. CT head neg for
fracture. Concern for hypotension and low volume as etiology for
syncope so hydral was reduced to 25mg TID. However, MAPs were
variable on this dose with some excursions into the low ___ so
hydral was increased to 50mg for the second 2 doses of the day.
AM dose held at 25mg as the AM doses are when he feels most
lightheaded. This regimen smoothed out his MAPs to some degree
and the pt was asymptomatic throughout the admission. He was
discharged on lisinopril 20 BID, hydralazine 25 for AM dose and
50mg for the ___ and QHS doses. Goal MAP of ___ to ___.
# Syncope - Orthostatic here with elevated BUN with no chest
pain, palpitations, or shortness of breath, likely represented
dehydration and excess afterload reduction in setting of
increased BP meds on last discharge. Simultaneously stopping
fludrocortisone likely contributed. On this admission,
lisinopril was increased from 10 to 20 BID fpr afterload
reduction, hydral was adjusted per above, and fluodrocortisone
was restarted at 0.1mg 3x per week, ___. Pacemaker
interrogation was non-contributory. He received a total of 2L
IVF and PO intake was encouraged. The patient remained largely
asymptomatic.
#LVAD Thrombus: continued ASA 325, continued Warfarin on the
following schedule: INR was 2.9 on day of discharge so given
only 2 mg on ___. 3mg after admission on ___ and the usual
2.5 mg on ___ and ___. Further titration likely necessary as
outpatient to maintain goal of ___.
# History of VT: continued on amiodarone and mexilitine.
# Prior CVA - Continue aspirin and statin.
# Prostate cancer: s/p prostatectomy. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
DC Cardioversion
History of Present Illness:
___ with a history of atrial fibrillation s/p cardiversion
___, uprovoked PE on rivaroxaban, and OSA on CPAP,
presenting with dyspnea and fatigue.
The patient reports that for several months, he has been having
increased dyspnea and fatigue, and noted increasing HRs on a
monitor he has at home. First saw Dr. ___ on ___ for
evaluation of persistent atrial fibrillation, and underwent
successful DC cardioversion on ___ to sinus rhythm, after which
his verapamil was stopped and he was started on propefone. Was
also started on furosemide 20 mg after post-DCCV TTE showed an
EF
of 42%. Symptoms of dyspnea and fatigue resolved for 2 days, but
recurred on ___, and patient presented to ED due to worsening
of
these symptoms.
In the ED initial vitals were: T 97.8 HR 119 BP 102/77 RR 18 O2
sat 99% RA. Patient triggered for HRs in 130s, which eventually
responded to IV metop. EKG showed atrial fibrillation with rapid
ventricular response, normal axis, TWI in V5-V6. Labs/studies
notable for: Hgb 10.2 MCV 73, BNP 10267, Cr 1.3, HCOR 21,
Lactate
1.4, Troponin 0.01, BNP 10267. Cardiology was consulted and
recommended admission for possible repeat cardioversion.
Patient was given: IV metop 5 x4, metop 50 PO, home propefone
and
rivaroxaban prior to transfer to floor.
On the floor, patient reports feeling somewhat better after
receiving medicines to control his HR in the ED. He endorses
dyspnea and orthopnea, along with occasional dry cough, but
denies chest pain, palpitations, lower extremity edema,
fevers/chills, melena, BRBPr, or other recent changes in his
health prior to presentation.
Past Medical History:
1. CARDIAC RISK FACTORS
- Dyslipidemia
2. CARDIAC HISTORY
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY
Unprovoked saddle PE ___
OSA on CPAP
Social History:
___
Family History:
FAMILY HISTORY:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM
======================
VS: T 98.1 BP 112/76 HR 120 RR 22 O2 sat 98%RA
GENERAL: Well-appearing male, alert and responsive, not in
distress
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Moist mucus
membranes.
NECK: Supple, no elevated JVD
CARDIAC: Tachycardic, irregular rhythm, no murmurs
LUNGS: Clear bilaterally to auscultation without rales, wheezes,
rhonchi
ABDOMEN: Soft, non-tender, non-distended
EXTREMITIES: Warm, well-perfused, no lower extremity edema
PULSES: Distal pulses palpable and symmetric
DISCHARGE PHYSICAL EXAM
======================
VITALS: T 98.1 PO BP 95/65 L Sitting HR 72 RR 18 97 RA
I/Os: 1.88 L/ 2.08 L
WEIGHT: 97 kg
PHYSICAL EXAM:
GENERAL: Well-appearing male, alert and responsive, not in
distress
HEENT: NCAT. Sclera anicteric. EOMI. Moist mucus membranes.
NECK: Supple, JVP < 10 at 90 degrees
CARDIAC: RRR, no murmurs/rubs/gallops
LUNGS: Clear bilaterally to auscultation without rales, wheezes,
rhonchi
ABDOMEN: Soft, non-tender, non-distended
EXTREMITIES: Warm, well-perfused, no lower extremity edema
PULSES: Distal pulses palpable and symmetric
Pertinent Results:
ADMISSION LABS:
==============
___ 06:10PM BLOOD WBC-9.3 RBC-5.37 Hgb-10.2* Hct-39.0*
MCV-73* MCH-19.0* MCHC-26.2* RDW-18.0* RDWSD-45.8 Plt ___
___ 06:10PM BLOOD Neuts-64.3 ___ Monos-9.0 Eos-2.9
Baso-1.1* Im ___ AbsNeut-5.96 AbsLymp-2.07 AbsMono-0.83*
AbsEos-0.27 AbsBaso-0.10*
___ 06:10PM BLOOD ___ PTT-35.2 ___
___ 06:10PM BLOOD Glucose-125* UreaN-26* Creat-1.3* Na-145
K-4.6 Cl-109* HCO3-21* AnGap-15
___ 06:10PM BLOOD ___
___ 01:34PM BLOOD Calcium-9.4 Phos-4.3 Mg-2.3
___ 06:10PM BLOOD calTIBC-434 Ferritn-8.3* TRF-334
___ 06:17PM BLOOD Lactate-1.4
DISCHARGE LABS:
==============
___ 06:05AM BLOOD WBC-7.6 RBC-4.91 Hgb-9.3* Hct-34.8*
MCV-71* MCH-18.9* MCHC-26.7* RDW-17.8* RDWSD-44.2 Plt ___
___ 06:05AM BLOOD ___ PTT-34.8 ___
___ 06:05AM BLOOD Glucose-108* UreaN-38* Creat-1.4* Na-148*
K-4.1 Cl-110* HCO3-21* AnGap-17*
___ 06:05AM BLOOD Calcium-9.0 Phos-4.7* Mg-2.2
IMAGING RESULTS:
==============
___ CHEST AP:
FINDINGS:
Exam is limited by motion. There is no confluent consolidation
or large
effusion. Calcific density projects over the anterior left
third rib,
potentially bone island versus parenchymal calcification. There
is moderate
cardiomegaly. There is no evidence of pulmonary edema. There
is no acute
fracture.
IMPRESSION:
Cardiomegaly without definite acute cardiopulmonary process
based on this
limited exam.
___ ECHOCARDIOGRAM:
The left atrium is moderately dilated. The right atrium is
moderately dilated. Left ventricular wall thicknesses and cavity
size are normal. There is mild global left ventricular
hypokinesis. Quantitative (biplane) LVEF = 42 %. Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size is normal with
mild global free wall hypokinesis. The aortic root is mildly
dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic arch is mildly dilated. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Trace aortic regurgitation is seen. The mitral leaflets
are mildly thickened. Mild to moderate (___) mitral
regurgitation is seen. There is at least moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with mild global
biventricular hypokinesis. Mildly dilated thoracic aorta. Mild
to moderate mitral and tricuspid regurgitation. At least
moderate pulmonary hypertension.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Furosemide 20 mg PO DAILY
3. Ipratropium-Albuterol Inhalation Spray 1 INH ___ Q6H:PRN
dyspnea
4. Metoprolol Succinate XL 200 mg PO DAILY
5. Potassium Chloride 20 mEq PO DAILY
6. Propafenone HCl 150 mg PO TID
7. Rivaroxaban 20 mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Magnesium Oxide 400 mg PO DAILY
Discharge Medications:
1. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Furosemide 20 mg PO DAILY
5. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN
dyspnea
6. Magnesium Oxide 400 mg PO DAILY
7. Potassium Chloride 20 mEq PO DAILY
8. Propafenone HCl 150 mg PO TID
9. Rivaroxaban 20 mg PO DAILY
10.Outpatient Lab Work
ICD ___
Please check:
Chem 7 (Na, K, Cl, Bicarbonate, BUN, Cr)
CBC (hemoglobin)
Contact information:
___ MD, PHD
Fax #: ___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
ATRIAL FIBRILLATION WITH RAPID VENTRICULAR RATE (STATUS POST
CARDIOVERSION)
HEART FAILURE WITH REDUCED SYSTOLIC FUNCTION
SECONDARY DIAGNOSIS
===================
ACUTE KIDNEY INJURY
IRON DEFICIENCY ANEMIA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ with dyspnea// ?pulmonary edema or pneumonia
TECHNIQUE: Portable frontal view radiograph of the chest.
COMPARISON: None available.
FINDINGS:
Exam is limited by motion. There is no confluent consolidation or large
effusion. Calcific density projects over the anterior left third rib,
potentially bone island versus parenchymal calcification. There is moderate
cardiomegaly. There is no evidence of pulmonary edema. There is no acute
fracture.
IMPRESSION:
Cardiomegaly without definite acute cardiopulmonary process based on this
limited exam.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with Unspecified atrial fibrillation
temperature: 97.8
heartrate: 119.0
resprate: 18.0
o2sat: 99.0
sbp: 102.0
dbp: 77.0
level of pain: 0
level of acuity: 2.0 | ___ with a history of atrial fibrillation s/p cardiversion
___, unprovoked PE on rivaroxaban, and OSA on CPAP,
presenting with dyspnea and fatigue, found to have persistent
atrial fibrillation after cardioversion, now s/p repeat DC CV
___ with successful conversion to NSR.
#PUMP: EF 42%
#RHYTHM: NSR
#CORONARIES: Unknown |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMHx CAD c/b V Fib arrest ___ s/p stents with known
ostial RCA stenosis and ICD placement, permanent A Fib on
warfarin who presents with chest pain.
He reports 2 days of intermittent substernal nonradiating
"discomfort" that he cannot describe. There is no pleuritic pain
or back pain. He has no associated shortness of breath,
dizziness, nausea or sweating. The pain is intermittent and can
last as long as 2 hours. Is not associated with activity but he
has avoided exercise the last few days. The pain improved last
night with one nitroglycerin. The pain feels different from when
he had his heart attack in the past which was a stabbing pain.
In the ED initial vitals were: 98.8 90 151/86 18 98% RA
- Labs were significant for negative troponin
- Patient was given ASA and metoprolol
Vitals prior to transfer were: 98.4 91 114/82 18 95% RA
On the floor, patient is chest pain free and gives above
history.
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
Past Medical History:
1. CAD s/p MI in ___ c/b VF arrest (___). Catheterization
revealing an 80% RCA that was stented, 80% PLVB, s/p PTCA. s/p
ICD implantation, ICD replaced ___
2. ___: PAF, started on Coumadin
3. Hyperlipidemia
4. Hypertension
5. Prediabetes
6. COPD
7. Osteoarthritis s/p total knee replacement bilaterally
8. Prostate cancer s/p radiation
9. Hx of colonic adenomas
10. Lumbar disc disease
11. Obesity
12. Hx of tinnitus
13. Mild hearing loss
14. Obesity
15. Resection of salivary gland for stones
Social History:
___
Family History:
Brother with a history of CVA
Physical Exam:
Admission physical exam:
Vitals - T:98 BP:174/109 HR:96 irregular RR:16 02 sat:100RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: irregular, S1/S2, no murmurs, gallops, or rubs, ICD in
place c/d/i
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Discharge physical exam:
VS T98.1 ___ 66-150 (currently 80) 18 97%RA
GENERAL: NAD
HEENT: AT/NC, EOMI, anicteric sclera, MMM, good dentition
NECK: no JVD
CARDIAC: irregular, S1/S2, no murmurs, gallops, or rubs, ICD in
place
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: WWP, no cyanosis, clubbing or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, CN II-XII intact
Pertinent Results:
Admission labs:
___ 06:25PM BLOOD WBC-6.1 RBC-4.42* Hgb-14.3 Hct-41.7
MCV-94 MCH-32.4* MCHC-34.4 RDW-13.9 Plt ___
___ 06:25PM BLOOD ___ PTT-38.9* ___
___ 06:25PM BLOOD Glucose-99 UreaN-19 Creat-1.0 Na-138
K-4.4 Cl-102 HCO3-25 AnGap-15
___ 08:55AM BLOOD Calcium-9.3 Phos-2.9 Mg-2.1
Discharge labs:
___ 06:10AM BLOOD WBC-5.5 RBC-4.34* Hgb-14.3 Hct-41.5
MCV-96 MCH-32.9* MCHC-34.5 RDW-14.5 Plt ___
___ 06:10AM BLOOD Glucose-110* UreaN-18 Creat-1.0 Na-136
K-4.4 Cl-101 HCO3-27 AnGap-12
___ 06:10AM BLOOD Calcium-9.2 Phos-3.3 Mg-2.0
Pertinent labs:
___ 06:25PM BLOOD cTropnT-<0.01
___ 02:23AM BLOOD cTropnT-<0.01
___ 04:50PM BLOOD cTropnT-<0.01
Studies:
Exercise stress test ___:
This ___ year old man with h/o HTN and HLD; s/p IMI,
V. fib arrest, RCA stent, and ICD placement in ___ with known
CAD was
referred to the lab for evaluation of chest pain. The patient
exercised
for 9.0 minutes of a Modified ___ protocol (~ ___ METS),
representing an
average exercise tolerance for his age. The test was stopped due
to
fatigue. No chest, neck, back, or arm discomforts were reported
by the
patient throughout the study. At peak exercise, there was 0.5-1
mm of
upsloping/horizontal ST segment depression in the inferolateral
leads,
resolving by minute 7 of recovery. The rhythm was atrial
fibrillation
with rare/occasional, isolated VPBs during exercise. Blunted
blood
pressure response to exercise. Appropriate heart rate response
to
exercise.
IMPRESSION: Average functional exercise capacity. Non-specific
EKG
changes in the absence of anginal type symptoms to achieved
workload.
Blunted blood pressure response to exercise.
Nuclear stress test ___:
___ yo man with HTN and HL, h/o atrial fibrillation,
s/p MI and VF arrest with ICD placement in ___, RCA stent and
cardiac
catheterization in ___ revealing 3-vessel CAD was referred to
evaluate
an atypical chest discomfort. The patient completed 8 minutes
and 0
seconds of a modified ___ protocol representing an average
exercise
tolerance; ~ ___ METS. The exercise test was stopped due to
fatigue. No
chest, back, neck or arm discomforts were reported by the
patient during
the procedure. At peak exercise, and in the presence of atrial
fibrillation with RVR, 1-1.5 mm horizontal/slow upsloping ST
segment
depression was noted inferiorly and in leads V4-V6. These ST
segment
changes resolved quickly and were absent 2 minutes
post-exercise. The
rhythm was atrial fibrillation with rapid ventricular response
noted
with exercise. The blood pressure increased with exercise,
however the
response was blunted; < 30 mmHg increase from baseline.
IMPRESSION: Average exercise tolerance. No anginal symptoms with
ischemic ST segment changes noted in the presence of atrial
fibrillation
with RVR. Blunted blood pressure response to exercise. Nuclear
report
sent separately.
Nuclear imaging ___:
FINDINGS:
Left ventricular cavity size is normal.
Resting and stress perfusion images reveal uniform tracer uptake
throughout the
left ventricular myocardium.
Gated images reveal normal wall motion.
The calculated left ventricular ejection fraction is 57%.
Compared with the study of ___, there has been no
significant change.
IMPRESSION: Normal myocardial perfusion, EF 57%.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Metoprolol Tartrate 50 mg PO QAM
4. Diltiazem Extended-Release 90 mg PO DAILY
5. Fish Oil 120-180 mg Oral Daily
6. Warfarin 5 mg PO DAILY16
7. Metoprolol Tartrate 25 mg PO QPM
8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
9. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Warfarin 5 mg PO DAILY16
5. Fish Oil 120-180 mg Oral Daily
6. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
8. Metoprolol Tartrate 62.5 mg PO BID
RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth
twice a day Disp #*30 Tablet Refills:*0
RX *metoprolol tartrate 50 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
9. Diltiazem Extended-Release 90 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Chest pain
Coronary artery disease
Secondary diagnoses:
Atrial fibrillation
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: Chest pain.
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
Left-sided AICD is unchanged. Heart size is top-normal with mild unfolding of
the thoracic aortic arch. Hilar contours are normal. Lungs are clear. Upper
lobes are lucent, suggestive of emphysema. Pleural surfaces are clear without
effusion or pneumothorax.
IMPRESSION:
No acute cardiopulmonary abnormality.Emphysema.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Chest pain
Diagnosed with CHEST PAIN NOS, AICD STATUS, CAD UNSPEC VESSEL, NATIVE OR GRAFT, LONG TERM USE ANTIGOAGULANT
temperature: 98.8
heartrate: 90.0
resprate: 18.0
o2sat: 98.0
sbp: 151.0
dbp: 86.0
level of pain: 3
level of acuity: 3.0 | ___ with PMHx CAD c/b V Fib arrest ___ s/p stents with known
ostial RCA stenosis and ICD placement, permanent A Fib on
warfarin who presented with 2 days of intermittent substernal
nonradiating "discomfort."
#Chest pain: Troponin was negative x3. EKG showed afib with T
wave flattening in inferior leads, unchanged from prior. Due to
pt being high risk, exercise stress test was performed ___,
but was inconclusive (average exercise capacity for age but
nonspecific EKG changes and blunted BP response). Nuclear
exercise stress test was then done and was normal, showing EF
57% with no perfusion defects. Although stress tests normal and
no invasive procedure indicated, given pt's risk factors/history
of CAD, metoprolol was increased, as below, to provide better
rate control.
#Permanent A Fib on Warfarin
Coumadin was held in the event an invasive procedure was
necessary, but INR remained therapeutic (goal ___ throughout
the hospital stay. Pt continued on metop and dilt for rate
control.
#Hypertension
Pt continued on home diltiazem and home isosorbide mononitrate.
For better rate control (pt's heart rate noted to be mainly in
___ metoprolol was uptitrated from home dose (50mg am, 25mg
qhs) to 62.5 mg bid, and pt discharged on this new higher dose.
#Hyperlipidemia
Pt continued on home statin.
#COPD
Pt continued on home albuterol. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Right MCA infarct
Major Surgical or Invasive Procedure:
-Mechanical right MCA clot retrieval with Solitaire device
-Endotracheal intubation
History of Present Illness:
___ yo RH M with no significant PMH who presents with sudden
onset L sided weakness and dizziness at 10:45 pm, found to have
a R MCA infarct. He was given tPA at ___
at 1 am with NIHSS of 13 when the non-contrast CT showed no
hemorrhage and dense R MCA sign. His exam did not improve
significantly post tPA so he was transferred to ___ for
consideration of neurointervention.
History obtained from the family: Pt does not have significant
medical history, ?asthma which occurs when he has a cold. He
does have history of frequent headaches, unclear whether it is
migrainous in nature. He confines himself to his room when he
does get headaches and sleeps all day. He has been complaining
of stuffy nose and headaches, treated with tylenol and motrin
prn.
Today he went to his cousin's work and helped her out with
things, and then saw his friends. In the evening, he and his
cousin went to ___ for grocery shopping and had dinner at
___, and he was normal at that time. They were driving back
when his cousin noticed that the patient's face had twisted in a
weird way and he was slurring his words, he thought he was
joking and drove home. However, he noted that pt was unable to
get out of car so took him to ED. Pt vomited on the way to the
hospital.
He was given NIHSS score of 14 for L hemiplegia, neurology was
consulted and tPA was given at 1 AM. As his examination did not
improve after tPA, he was transferred to ___ for evaluation
for neurointervention. CTA/CT perfusion was performed at ___
ED and showed proximal R M1 clot with collaterals, hypodensity
in R basal ganglia (caudate and putamen) and some gray/white
matter
differentiation loss in the R insula. He was taken to the angio
suite where Solitaire stent was placed and then removed with
return of flow in R MCA.
On brief ROS: no complain of headache, +weakness/numbness on
left side. Feeling cold.
Past Medical History:
asthma (uses his aunt's inhaler occasionally)
headaches, ?migraine
?history of broken R leg long time ago
Social History:
___
Family History:
Unclear what his father passed away from, but his mother passed
away from a "mass." On the maternal side, about ___ aunts has
history of miscarriage (about 1 miscarriage each) out of 6
aunts. ?one aunt with "blood clot."
Physical Exam:
========================
ADMISSION PHYSICAL EXAM:
========================
Vitals: 61 130/70 12 96% RA
___: somnolent, opens eyes to voice NAD.
HEENT: NC/AT
Neck: No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: somnolent, opens eyes to shaking and noxious
stimuli but able to maintain some attention. Oriented to self,
place and time. Speaking ___, fluent per his cousin at the
bedside. Follows simple commands.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2.5 to 2mm and brisk. counts fingers in all visual
fields.
III, IV, VI: right gaze deviation initially, roving eye
movements noted afterwards. Full horizontal eye movements.
V: Facial sensation decreased on L to light touch
VII: L facial droop
VIII: Hearing intact to voice
IX, X: Palate elevates symmetrically
XI: not tested
XII: Tongue protrudes in midline
- Motor: Normal bulk, mildly increased tone on LUE. Unable to
test pronator drift due to LUE weakness. No adventitious
movements, such as tremor, noted. No asterixis noted.
LUE with extensor posturing to noxious stimuli. RUE at least
antigravity in deltoid, biceps. Able to hold RUE up against
gravity for 10 seconds. Some spontaneous movement in LLE and
withdrawal against gravity at IP with noxious stimuli. RLE with
good spontaneous movements.
-Sensory: Decreased light touch to L side. R side intact to
light touch.
-DTRs:
Bi Tri ___ Pat Ach
L 2+ 2+ 2+ 2+ 1
R 2 2 2 2 1
Plantar response was flexor on R and mute on L.
-Coordination: On R hand, no dysmetria to FNF.
-Gait: Unable to test.
Pertinent Results:
ADMISSION LABS:
___ 03:01AM BLOOD WBC-14.8* RBC-5.34 Hgb-14.8 Hct-45.9
MCV-86 MCH-27.7 MCHC-32.2 RDW-13.4 Plt ___
___ 03:01AM BLOOD ___ PTT-25.4 ___
___ 03:07AM BLOOD Glucose-115* Na-140 K-4.0 Cl-103
calHCO3-22
___ 04:35AM BLOOD Type-ART pO2-287* pCO2-37 pH-7.40
calTCO2-24 Base XS-0 Intubat-INTUBATED
___ 08:28AM BLOOD CK-MB-3 cTropnT-<0.01
___ 01:49AM BLOOD CK-MB-2 cTropnT-<0.01
___ 08:28AM BLOOD ALT-31 AST-28 LD(LDH)-169 CK(CPK)-278
AlkPhos-72 TotBili-0.8
MODIFIABLE STROKE RISK FACTOR LABS:
- %HbA1c-5.6 eAG-114
-Triglyc-59 HDL-39 CHOL/HD-5.2 LDLcalc-152*
HYPERCOAGULABILITY PANEL: ***
ANGIOGRAM (___): ***
NCHCT/CTA/CTP (___):
- CT HEAD: Note is made of a hyperdense right M1 segment (series
2, image 10). There is no intracranial hemorrhage. Note is
made of asymmetric hypodensity involving the head of the caudate
nucleus on the right, as well as the right lentiform nucleus and
insular ribbon. These findings appear new from the comparison
examination 3 hr earlier. There is no space-occupying mass.
Ventricles and sulci are normal in size and configuration.
Incidental note is made of moderate mucosal thickening
throughout the ethmoid air cells bilaterally, as well as
moderate mucosal thickening in the right maxillary sinus.
- CT ANGIOGRAM NECK: The aorta demonstrates a normal 3 vessel
branching pattern. The origins and courses of the vertebral
arteries, common carotid arteries and internal carotid arteries
are normal. Overall there are no luminal caliber irregularities
to suggest thromboembolic filling defects, dissection or
pseudoaneurysm. Imaged portions of the lung apices are clear as
are image soft tissue structures of the neck. Bony structures
reveal no suspicious sclerotic or lytic lesion.
- CT ANGIOGRAM HEAD: Primary intracranial arterial structures
demonstrate an abrupt filling defect in the proximal right M1
segment. Otherwise, there is appropriate contrast
opacification, with evidence of collateral filling of the middle
cerebral artery territory. Anatomy is conventional in
orientation. There are no luminal caliber irregularities to
suggest dissection or aneurysm.
- CT PERFUSION HEAD: Relative cerebral blood volume maps
demonstrate a small area of decreased relative cerebral blood
volume relative to the contralateral side surrounding the right
basal ganglia. Mean transit time maps demonstrate a larger area
of asymmetrically minimally prolonged mean transit time in the
right middle cerebral artery distribution.
IMPRESSION:
1. Occlusive filling defect in the right M1 segment, with new
hypodensity in the right caudate nucleus head, lentiform nucleus
and insular ribbon.
2. Mild abnormalities on relative cerebral blood volume and mean
transit time maps, with a mismatch in the area of involvement.
3. No acute intracranial hemorrhage.
MRI HEAD (___): Infarction of the right caudate head,
anterior limb of the internal capsule, putamen and globus
pallidus, insular cortex, and scattered right MCA distribution
cortical locations. The distribution appears similar to the
prior CT scans. There is hemorrhage in the putamen.
NCHCT ___, 6:37 AM): Patient with known right MCA thrombus,
status post neuro intervention earlier this morning.
Hyperdensity centered in the right lentiform nucleus is new
since pre-intervention exam of the same date, which may
represent hemorrhage and/or contrast extravasation due to
compromise blood brain barrier. Continued followup is
recommended.
NCHCT ___, 10:58 AM):
1. Nearly complete resolution of large focus of hyperdensity in
the right lentiform nucleus/corona radiata suggests that this
hyperdensity was likely the result of a combination of
extravasation of contrast and some hemorrhage. The remaining
focus of hyperattenuation may represent blood products versus
remaining contrast material.
2. Large hypodensity in the area of the right lentiform nucleus,
internal
capsule and head of the caudate nucleus is compatible with
evolving
infarction. Infarct related edema is causing mild mass effect
with effacement of the ipsilateral sulci and frontal horn of the
lateral ventricle.
3. No evidence of new hemorrhage or intracranial herniation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acyclovir Ointment 5% 1 Appl TP ASDIR cold sore
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
3. Atorvastatin 40 mg PO DAILY
4. Warfarin 5 mg PO DAILY16
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right MCA infarct
Deep vein thrombosis of the right peroneal vein
Patent foremen ovale
hyperlipidemia
Pneumonia
UTI
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Awake, alert, oriented x3. Speech fluent, mild dysarthria.
Repetition/comprehension intact. Follows midline/appendicular
commands. No neglect. L lower facial droop. Motor: ___ L delt,
___ L FE, ___ L FFl, ___ L IP, ___ L ham, ___ L quad. Full
strength on right.
Followup Instructions:
___
Radiology Report
INDICATION: Recent cerebrovascular accident, in need for MRI. Assessment for
evidence of foreign body precluding MRI.
TECHNIQUE: Single frontal radiograph of the abdomen and pelvis.
COMPARISON: None available.
FINDINGS: No metallic foreign body to preclude MRI is seen though the upper
most portion of the hepatic dome is excluded from the field of view. There is
a right femoral sheath in place which should not affect MRI. The bowel gas
pattern is unremarkable.
Radiology Report
INDICATION: Patient with known right MCA infarct, assess for interval change.
COMPARISONS: ___.
TECHNIQUE: MDCT-acquired contiguous images through the head were obtained
without intravenous contrast at 5-mm slice thickness. Coronally and
sagittally reformatted images are provided.
FINDINGS:
The study is slightly limited due to motion artifact. Within this limitation,
the infarction of the right caudate head, globus pallidus, anterior limb of
internal capsule, putamen and adjacent insular cortex is largely unchanged
since study obtained 14 hours prior. The right putaminal hemorrhage measures
12.9 mm, and is also unchanged (2:13). There is persistent surrounding edema,
effacement of sulci and slight mass effect as seen by effacement of the right
lateral ventricle. There is no shift of normally midline structures. No new
hemorrhage is detected. Otherwise, gray-white matter differentiation in an
unaffected brain parenchyma is preserved. There is no hydrocephalus. The
basal cisterns are patent.
Visualized paranasal sinuses and mastoid air cells are well aerated. Orbits
are unremarkable in appearance. No acute fracture is seen.
IMPRESSION:
In comparison to study obtained 14 hours prior, there is no significant
interval change in the partially hemorrhagic right sided infarction.
Radiology Report
PORTABLE AP CHEST FILM ___ AT ___
CLINICAL INDICATION: ___ with MCA infarct, now status post extubation
and recent fever, question consolidation.
Comparison is made to the patient's prior study of ___ at 1506.
A portable AP upright chest film ___ at ___ is submitted.
IMPRESSION:
1. Interval extubation. Relatively well inflated lungs. Subtle patchy
opacity in the right mid to lower lung could reflect an area of atelectasis,
although an early infectious process should also be considered. Followup
imaging would be advised. No pleural effusions, pulmonary edema, or
pneumothorax. No acute bony abnormality. Overall, cardiac and mediastinal
contours are unchanged.
Radiology Report
PORTABLE AP CHEST FILM ___ AT 2153
CLINICAL INDICATION: ___ with nasogastric tube placement.
Comparison to prior study dated ___ at ___.
A series of three portable AP sequential images of the chest, the first at
2154, the second at 2158 and the third at 2201, are submitted.
IMPRESSION:
There has been interval attempted placement of a nasogastric tube which
courses into the stomach but the tip ends up in the mid esophagus on all three
images. Overall, cardiac and mediastinal contours are stable. Lungs are
relatively well inflated. The subtle opacity in the right mid lung on the
previous study does not persist and therefore is felt to correspond to an area
of patchy atelectasis. No focal airspace consolidation is seen to suggest
pneumonia. No pleural effusions or pneumothorax.
Radiology Report
PORTABLE AP CHEST FILM ___ AT 2226
CLINICAL INDICATION: ___ with stroke status post Dobbhoff tube
placement.
Comparison is made to the patient's prior study of ___ at 2153.
A portable chest film dated ___ at 2226 is submitted.
IMPRESSION:
1. A portion of a feeding tube is seen coiled in the upper neck. No feeding
tube is seen to extend into the esophagus or stomach. Lungs remain relatively
well inflated without evidence of focal airspace consolidation to suggest
pneumonia. The left costophrenic angle is not entirely included. No pleural
effusions or pneumothorax. Overall, cardiac and mediastinal contours are
unchanged given patient rotation on the current examination. Results were
communicated to ___, the patient's nurse, by phone on ___ at 9:30 a.m.
at the time of discovery.
Radiology Report
HISTORY: Right MCA stroke.
TECHNIQUE: Noncontrast head CT.
COMPARISON: Multiple prior studies most recently ___ at 6:15.
FINDINGS:
The infarction of the right caudate head, globus pallidus, internal capsule
and adjacent insular cortex is largely unchanged from the prior study. The
surrounding edema exerts mass effect particularly on the right lateral
ventricle, also unchanged. Hyperdense content located centrally compatible
with hemorrhage is not a larger than it was on the prior study. There is no
shift of the normal in midline structures. No new hemorrhage is noted. There
is no hydrocephalus. The basal cisterns remain patent.
IMPRESSION:
No significant interval change in the partially hemorrhagic right-sided
infarction status post MCA recannulization.
Radiology Report
INDICATION: ___ man with a history of a right MCA stroke, who
presents for evaluation.
COMPARISONS: None.
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the speech and swallow division. Multiple consistencies of
barium were administered.
FINDINGS: Barium passes freely through the oropharynx and esophagus without
evidence of obstruction. There is no gross aspiration. There is evidence of
slight penetration in the vallecula. For further details, please refer to the
speech and swallow division note in OMR.
IMPRESSION: Slight penetration in the vallecula. For further details, please
refer to the speech and swallow division note in OMR.
Radiology Report
HISTORY: Left-sided neurologic deficits.
COMPARISON: Head CT from ___
TECHNIQUE: Axial CT images were acquired through the head without intravenous
contrast. Thereafter, images were acquired through the head and neck
following the uneventful intravenous administration of iodine based contrast.
Multiplanar reformatted images including maximum intensity projection images
and dedicated 3 dimensional angiographic reconstructions were created. CT
perfusion imaging of the head is also performed.
FINDINGS:
CT HEAD:
Note is made of a hyperdense right M1 segment (series 2, image 10). There is
no intracranial hemorrhage. Note is made of asymmetric hypodensity involving
the head of the caudate nucleus on the right, as well as the right lentiform
nucleus and insular ribbon. These findings appear new from the comparison
examination 3 hr earlier. There is no space-occupying mass. Ventricles and
sulci are normal in size and configuration. Incidental note is made of
moderate mucosal thickening throughout the ethmoid air cells bilaterally, as
well as moderate mucosal thickening in the right maxillary sinus.
CT ANGIOGRAM NECK:
The aorta demonstrates a normal 3 vessel branching pattern. The origins and
courses of the vertebral arteries, common carotid arteries and internal
carotid arteries are normal. Overall there are no luminal caliber
irregularities to suggest thromboembolic filling defects, dissection or
pseudoaneurysm.
Imaged portions of the lung apices are clear as are image soft tissue
structures of the neck. Bony structures reveal no suspicious sclerotic or
lytic lesion.
CT ANGIOGRAM HEAD:
Primary intracranial arterial structures demonstrate an abrupt filling defect
in the proximal right M1 segment. Otherwise, there is appropriate contrast
opacification, with evidence of collateral filling of the middle cerebral
artery territory. Anatomy is conventional in orientation. There are no
luminal caliber irregularities to suggest dissection or aneurysm.
CT PERFUSION HEAD:
Relative cerebral blood volume maps demonstrate a small area of decreased
relative cerebral blood volume relative to the contralateral side surrounding
the right basal ganglia. Mean transit time maps demonstrate a larger area of
asymmetrically minimally prolonged mean transit time in the right middle
cerebral artery distribution.
IMPRESSION:
1. Occlusive filling defect in the right M1 segment, with new hypodensity in
the right caudate nucleus head, lentiform nucleus and insular ribbon.
2. Mild abnormalities on relative cerebral blood volume and mean transit time
maps, with a mismatch in the area of involvement.
3. No acute intracranial hemorrhage.
Radiology Report
INDICATION: Patient with known history of right MCA thrombosis, status post
TPA and neuro intervention earlier this morning.
COMPARISONS: CTA head and neck of the same date.
TECHNIQUE: MDCT-acquired contiguous images through the head were obtained
without intravenous contrast at 5-mm slice thickness. Coronally and
sagittally reformatted images are provided.
FINDINGS:
Cerebral vessels are opacified, which relate to contrast administration during
neuro interventional procedure earlier this morning slightly limiting
evaluation. Diminished flow is seen in distal right middle cerebral artery.
There is a 3.5 x 1.2 cm hyperdensity centered in the right lentiform nucleus
(2:15), which appears slightly more hyperdense posteriorly. There is
surrounding edema, and mild mass effect and effacement of the frontal horn of
the right lateral ventricle. There is no shift of normally midline
structures. The sulci and ventricles are otherwise normal in size and
configuration. Basal cisterns remain patent. There is no hydrocephalus.
Imaged paranasal sinuses and mastoid air cells are well aerated. Orbits are
normal in appearance. No acute fracture is seen.
IMPRESSION:
Patient with known right MCA thrombus, status post neuro intervention earlier
this morning. Hyperdensity centered in the right lentiform nucleus is new
since pre-intervention exam of the same date, which may represent hemorrhage
and/or contrast extravasation due to compromise blood brain barrier.
Continued followup is recommended.
Radiology Report
HISTORY: Right MCA stroke, evaluate for DVTs.
TECHNIQUE: Grayscale, color, and spectral Doppler ultrasound images of the
bilateral lower extremity veins.
COMPARISON: None
FINDINGS:
There is normal compressibility, flow, and augmentation of the bilateral
common femoral, proximal femoral, mid femoral, distal femoral, and popliteal
veins. Normal color flow and compressibility is demonstrated in the left
posterior tibial and peroneal veins. Normal color flow and compressibility is
demonstrated in the right posterior tibial veins.
One of the two right peroneal veins demonstrates normal color flow and
compressibility. The other right peroneal vein demonstrates a short segment
with echogenic contents not compressible with transducer pressure and only
peripheral flow.
There is normal respiratory variation of the common femoral veins bilaterally.
IMPRESSION:
1. Nonocclusive DVT in one of the two right peroneal veins.
2. No evidence of DVT in the left lower extremity.
The above results were telephoned to Dr. ___ by Dr. ___ at 13:00 on ___, 20 minutes after discovery.
Radiology Report
HEAD CT WITHOUT CONTRAST
INDICATION: ___ male with right MCA territory infarct with mechanical
thrombolysis and recanalization of the right MCA, with hyperdense material
seen in the right lentiform nucleus after recanalization. Evaluate for
interval change.
COMPARISON: Head CT performed 10 hours prior to this exam.
TECHNIQUE: Axial contiguous MDCT images were obtained through the brain
without administration of IV contrast.
DLP: 891.83 mGy-cm.
CTDI: 55.57 mGy.
FINDINGS: The hyperdense material seen in the lentiform nucleus immediately
after thrombolysis has almost completely resolved, with a remaining focus of
relative ___ in the posterior portion of the right lentiform nucleus
and corona radiata measuring 1.6 x 1.1 cm (AP,TR). An area of hypodensity
extends from this region anteriorly spanning the lentiform nucleus, the
internal capsule, and the head of the caudate nucleus, with effacement of the
frontal horn of the right lateral ventricle as well as mild effacement of the
ipsilateral sulci. No shift of midline structures is noted.
No new hemorrhage or infarction is noted. There is preservation of gray-white
matter differentiation in the non-affected areas of the brain. The basal
cisterns are patent and the foramen magnum is not crowded.
No fracture is identified. The right maxillary sinus is partially opacified
and with a defect in the medial wall, unchanged from prior and compatible with
prior antrectomy. The remaining paranasal sinuses, mastoid air cells and
middle ear cavities are clear. Retained aerosolized secretions in the
nasopharynx are usually seen in intubated patients.
IMPRESSION:
1. Nearly complete resolution of large focus of ___ in the right
lentiform nucleus/corona radiata suggests that this ___ was likely
the result of a combination of extravasation of contrast and some hemorrhage.
The remaining focus of hyperattenuation may represent blood products versus
remaining contrast material.
2. Large hypodensity in the area of the right lentiform nucleus, internal
capsule and head of the caudate nucleus is compatible with evolving
infarction. Infarct related edema is causing mild mass effect with effacement
of the ipsilateral sulci and frontal horn of the lateral ventricle.
3. No evidence of new hemorrhage or intracranial herniation.
Radiology Report
MR HEAD WITHOUT CONTRAST, ___
HISTORY: Right middle cerebral artery stroke, status post TPA.
Sagittal short TR, short TE spin echo imaging was performed through the brain
followed by axial imaging with long TR, long TE fast spin echo, FLAIR,
gradient echo, and diffusion methods. No contrast was administered.
COMPARISON: Multiple head CTs and a CT arteriogram, and a catheter
arteriogram of ___.
FINDINGS: The MR examination demonstrates infarction corresponding to the
distribution noted on the CT studies. This involves the right caudate head,
anterior limb of the internal capsule, globus pallidus, putamen, and scattered
right middle cerebral artery distribution cortical regions. There is a focus
of hemorrhage in the putamen, corresponding to that observed on the CT scan.
The overall distribution of infarction appears similar to the CT, and no new
areas of infarction are detected. Note that the small cortical regions may be
difficult to detect on CT scanning, with the exception of the relatively
sizeable insular component.
CONCLUSION: Infarction of the right caudate head, anterior limb of the
internal capsule, putamen and globus pallidus, insular cortex, and scattered
right MCA distribution cortical locations. The distribution appears similar
to the prior CT scans. There is hemorrhage in the putamen.
Radiology Report
HISTORY: Motor vehicle accident. Please evaluate for metal prior to MRI.
COMPARISON: None.
FINDINGS: Single portable view of the chest demonstrates endotracheal tube
terminates approximately 3 cm above the carina. Cardiac size is normal. No
evidence of pneumonia. No pleural effusion or pneumothorax.
IMPRESSION: No evidence of radiopaque foreign body.
Gender: M
Race: UNKNOWN
Arrive by HELICOPTER
Chief complaint: CVA
Diagnosed with CEREBRAL ART OCCLUS W/INFARCT
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: 1.0 | This is a ___ yo RH man with history of headaches and strong
family history of hypercoagulability presenting with acute onset
of L sided weakness. He was found to have a proximal R MCA
thrombus. He was given tPA at ___ at 1AM
and then transferred for possible neurointervention.
NEURO: As the patient's CTA/CTP showed clear proximal R MCA
thrombus, he was taken to the angio suite on arrival and had a
solitaire stent placed and then removed with return of flow
through the R MCA. Subsequent MRI showed infarct of the entire
M1 region (but sparing of M2 inferior/superior divisions), also
some blooming artifact on GRE indicating mild post-tPA
hemorrhagic conversion. He subsequently was found to have a PFO
and nonocclusive right popliteal DVT, which is likely the
etiology of his stroke. We also checked stroke risk factors. His
cholesterol was somewhat elevated with an LDL of 152.
Atorvastatin was started for this. We also checked an A1C which
was normal at 5.6%. The patient was started on heparin drip as a
bridge to coumadin. Heparin drip was stopped on ___ when INR
was 2.8.
The patient's exam began to improve the day after admission and
continued to improve very well during the remainder of his stay.
ID: The patient had fevers in the ICU and had thick yellow
sputum. His sputum grew strep pneumo and heamophilus. He had
citrobacter in the urine and 1 bottle of blood cultures which
initially grew gram positive cocci. Because of this he was
started on empiric vancomycin and zosyn. This was narrowed to
Levaquin for pneumonia and UTI when the above speciation
returned and blood culture resulted as coag negative staph with
following blood cultures negative. This was likely a
contaminant.
HEME: The patient has a family history of hypercoagulability so
hypercoagulability workup was started. Fibrinogen, Factor XIII,
lupus, antithombin, protein C, protein S were all normal.
Anticardiolipin antibody IgM and IgG are pending at this time.
GI: The patient initially was not able to manage his secretions
and was not safe to take PO. An NG tube was not able to be
passed after many attempts while in the ICU. He was seen by
speech and swallow and his dysphagia gradually improved over
several days. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Benzodiazepines / Augmentin / Clavulanic Acid / Amoxicillin /
latex / Keflex
Attending: ___.
Chief Complaint:
Lost IV access
Major Surgical or Invasive Procedure:
___ Tunneled Line Placement
History of Present Illness:
___ w/ end-stage MS ___ quadriplegia s/p tracheostomy, gj-tube,
nephrostomy, who was recently admitted for septic shock due to
proteus mirabilis UTI as well as pseudomonal pneumonia. He was
discharged to rehab on ___ and now returns after midline IV was
lost. He has not received his ceftazidime for PNA/UTI for the
past 2 doses. He has received his cipro.
In the ED, initial VS were T 97.7, P 76, BP 108/50, RR 20, O2
100% Trach Mask
Labs showed WBC 9.5, BUN/Cr ___
CXR showed:
1. Persistent but markedly improved pneumonia.
2. Small right pleural effusion and atelectasis.
3. Improved edema and bronchovascular engorgement, now minimal
in more symmetric.
Received ceftazidime, tramadol.
Transfer VS were T 98.6, P 88, BP 112/67, RR 22,O2sat 97% RA
On arrival to the floor, history was obtained from patient with
assistance from son. Patient noticed midline was missing 1 day
prior to admission. He postponed returning to ED until the
morning because he felt well and was not keen to wait for a long
time in triage on a ___ night. Overall, the patient feels
his health has been stable since discharge last ___. No fever
or chills. No pain around the former midline site. No dyspnea on
room air or chest pain. He has chronic, with no recent changes.
No nausea or vomiting. He has chronic loose stools but no
abdominal pain or tenesmus. He has chronic pain around his
sacrum, unchanged from baseline.
Past Medical History:
1. MS, endstage, secondary progressive type.
2. History of lung aspiration and lung abscess.
3. Hypertension.
4. Gastroesophageal reflux.
7. H/o Afib
8. H/o Olgilvie's syndrome
9. Hypothyroidism
10. Hyperlipidemia
11. OSA on CPAP (8cm H20)
12. Chronic constipation
13. Decubitus ulcer (healing)
14. Nephrolithiasis
Social History:
___
Family History:
No family history MS. ___ non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM:
==========================
VS - 97.4 Axillary 134/59 85 20 97 ra
GENERAL: Alert, oriented, NAD.
HEENT: EOMI. Poor dentition. Mouth moist.
NECK: Trach collar. Erythema around left collar.
CARDIAC: RRR, no murmurs.
RESP: Shallow breathing but non-labored. Diminished breath
sounds.
ABDOMEN: Soft, mild tenderness to palpation in left flank, no
rebound or guarding. +BS.
G-tube site erythematous, no induration or pus.
J-tube site C/D/I.
GU: Nephrostomy tube draining clear urine. No suprapubic
tenderness.
EXTREMITIES: Atrophied, cool. Pneumatic boots.
NEURO: Alert, oriented, speech very quiet but coherent.
DISCHARGE PHYSICAL EXAM:
=========================
VS - T 97.6-98.1, BP 92-112/48-60, P 79-97, RR 20, O2sat 96-99%
on 35% trach mask
GENERAL: Alert, oriented, NAD.
HEENT: EOMI. Poor dentition. Mouth moist.
NECK: Trach collar with minimal erythema.
CARDIAC: RRR, no murmurs.
RESP: Shallow breathing but non-labored. Diminished breath
sounds.
ABDOMEN: Soft, mild tenderness to palpation in left flank, no
rebound or guarding. +BS.
GU: Nephrostomy tube draining clear urine. No suprapubic
tenderness.
EXTREMITIES: Atrophied, cool. Pneumatic boots.
NEURO: Alert, oriented, speech very quiet but coherent.
Quadriplegic. Upper extremities contracted.
Pertinent Results:
ADMISSION LABS:
==============
___ 07:50AM BLOOD WBC-12.9* RBC-3.31* Hgb-9.1* Hct-31.0*
MCV-94 MCH-27.5 MCHC-29.4* RDW-19.2* RDWSD-63.3* Plt ___
___ 07:50AM BLOOD Glucose-137* UreaN-23* Creat-0.3* Na-137
K-4.9 Cl-97 HCO3-28 AnGap-17
DISCHARGE LABS:
===================
___ 07:15AM BLOOD WBC-10.3* RBC-3.00* Hgb-8.3* Hct-28.1*
MCV-94 MCH-27.7 MCHC-29.5* RDW-19.3* RDWSD-62.5* Plt ___
___ 07:15AM BLOOD ___ PTT-31.3 ___
___ 07:15AM BLOOD Glucose-95 UreaN-20 Creat-0.3* Na-137
K-4.9 Cl-96 HCO3-26 AnGap-20
IMAGING:
==============
CXR (___):
IMPRESSION:
1. Persistent but markedly improved pneumonia.
2. Small right pleural effusion and atelectasis.
3. Improved edema and bronchovascular engorgement, now minimal
in more
symmetric.
Line placement ___:
Successful placement of a 27cm tip-to-cuff length tunneled
single lumen
catheter. The tip of the catheter terminates in the right
atrium. The
catheter is ready for use.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Baclofen 15 mg PO TID
3. Bisacodyl 10 mg PR QHS:PRN constipation
4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
5. Docusate Sodium 100 mg PO DAILY
6. Finasteride 5 mg PO DAILY
7. Heparin 5000 UNIT SC TID
8. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN Wheeze
9. Metoprolol Tartrate 12.5 mg PO Q6H
10. Metoclopramide 2.5 mg PO QID
11. TraMADol 50 mg PO Q8H:PRN Pain - Severe
12. Lidocaine 5% Patch 1 PTCH TD QAM
13. Modafinil 200 mg PO DAILY
14. Polyethylene Glycol 17 g PO DAILY:PRN constipation
15. Senna 8.6 mg PO DAILY:PRN constipation
16. Aspirin 81 mg PO DAILY
17. Ascorbic Acid ___ mg PO BID
18. Clotrimazole Cream 1 Appl TP BID
19. Fenofibrate 145 mg PO DAILY
20. Multiple Vitamins Liq. 15 mL PO DAILY
21. polyvinyl alcohol 1.4 % ophthalmic Q4H:PRN
22. Scopolamine Patch 1 PTCH TD Q72H
23. Vitamin D ___ UNIT PO DAILY
24. Zinc Sulfate 220 mg PO BID
25. CefTAZidime 2 g IV Q12H
26. Ciprofloxacin HCl 500 mg PO Q12H
27. Glargine 12 Units Breakfast
Insulin SC Sliding Scale using Novolog Insulin
Discharge Medications:
1. CefTAZidime 2 g IV Q8H Duration: 7 Days
2. Glargine 12 Units Breakfast
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
4. Ascorbic Acid ___ mg PO BID
5. Aspirin 81 mg PO DAILY
6. Baclofen 15 mg PO TID
7. Bisacodyl 10 mg PR QHS:PRN constipation
8. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
9. Ciprofloxacin HCl 500 mg PO Q12H
10. Clotrimazole Cream 1 Appl TP BID
11. Docusate Sodium 100 mg PO DAILY
12. Fenofibrate 145 mg PO DAILY
13. Finasteride 5 mg PO DAILY
14. Heparin 5000 UNIT SC TID
15. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN Wheeze
16. Lidocaine 5% Patch 1 PTCH TD QAM
17. Metoclopramide 2.5 mg PO QID
18. Metoprolol Tartrate 12.5 mg PO Q6H
19. Modafinil 200 mg PO DAILY
20. Multiple Vitamins Liq. 15 mL PO DAILY
21. Polyethylene Glycol 17 g PO DAILY:PRN constipation
22. polyvinyl alcohol 1.4 % ophthalmic Q4H:PRN
23. Scopolamine Patch 1 PTCH TD Q72H
24. Senna 8.6 mg PO DAILY:PRN constipation
25. TraMADol 50 mg PO Q8H:PRN Pain - Severe
26. Vitamin D ___ UNIT PO DAILY
27. Zinc Sulfate 220 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
-IV access replacement
-Pseudomonal Pneumonia/Proteus UTI
Secondary:
Anemia
Multiple Sclerosis
Paroxysmal Atrial Fibrillation
Type 2 Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: History: ___ with PNA diagnosis who has missed some doses of abx.
// ? worsening pneumonia
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph dated ___.
FINDINGS:
The patient is rotated distorting the appearance of the right thoracic cage.
Tracheostomy tube is in standard position. Right lower hemithorax opacity
with silhouetting of the right heart border is consistent with a combination
of a small pleural effusion, atelectasis, and residual but improved
consolidation from infection. No pneumothorax. Asymmetric edema and
pulmonary vascular engorgement on the prior exam in the right lung has
markedly improved. No frank pulmonary edema. Pulmonary vascular engorgement
is now more symmetric and minimal.
IMPRESSION:
1. Persistent but markedly improved pneumonia.
2. Small right pleural effusion and atelectasis.
3. Improved edema and bronchovascular engorgement, now minimal in more
symmetric.
Radiology Report
INDICATION: ___ with end-stage MS ___ quadriplegia s/p tracheostomy,
gj-tube, L nephrostomy tube), admitted recently for septic shock due to
pseudomonas PNA and proteus UTI, discharged on IV ceftaz and PO cipro,
readmitted for lost midline access // please place non power single lumen
tunneled access line, ___ aware
COMPARISON: Chest radiograph ___
TECHNIQUE: OPERATORS: Dr. ___ resident Dr. ___
___ and Dr. ___ radiologist performed the procedure.
Dr. ___ supervised the trainee during the key components of the
procedure and has reviewed and agrees with the trainee's findings.
ANESTHESIA: Patient's hemodynamic parameters were continuously monitored by
an independent trained radiology nurse. 1% lidocaine was injected in the skin
and subcutaneous tissues overlying the access site.
MEDICATIONS: None recorded.
CONTRAST: 0 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 4 min, 5 mGy
PROCEDURE: PROCEDURE DETAILS: Following the explanation of the risks,
benefits and alternatives to the procedure, written informed consent was
obtained from the patient. The patient was then brought to the angiography
suite and placed supine on the exam table. A pre-procedure time-out was
performed per ___ protocol. The left upper chest was prepped and draped in
the usual sterile fashion.
Under continuous ultrasound guidance, several needle passes were made at the
patent left internal jugular vein, which could not be successfully accessed
due to the presence of tracheostomy collar and the collapsed state of the
vein.
Under continuous ultrasound guidance, the patent left external jugular vein
was compressible and accessed using a micropuncture needle. Permanent
ultrasound images were obtained before and after intravenous access, which
confirmed vein patency. Subsequently a Nitinol wire was passed into the right
atrium using fluoroscopic guidance. The needle was exchanged for a
micropuncture sheath. The Nitinol wire was removed and a short ___ wire was
advanced to make appropriate measurements for catheter length. The ___ wire
was then passed distally into the IVC.
Next, attention was turned towards creation of a tunnel over the upper
anterior chest wall. After instilling superficial and deeper local anesthesia
using lidocaine mixed with epinephrine, a small skin incision was made at the
tunnel entry site. A tunneled single lumen catheter was selected. The catheter
was tunneled from the entry site towards the venotomy site from where it was
brought out using a tunneling device. The venotomy tract was dilated using
the introducer of the peel-away sheath supplied. Following this, the peel-away
sheath was placed over the ___ wire through which the catheter was threaded
into the right side of the heart with the tip in the right atrium. The sheath
was then peeled away. The catheter was sutured in place with 0 silk sutures.
___ subcuticular Vicryl sutures were also used to close the venotomy incision
site. Final spot fluoroscopic image demonstrating good alignment of the
catheter and no kinking. The tip is in the right atrium. The catheter was
flushed and both lumens were capped. Sterile dressings were applied. The
patient tolerated the procedure well.
FINDINGS:
Patent left external jugular vein. Final fluoroscopic image showing tunneled
single lumen catheter with tip terminating in the right atrium.
IMPRESSION:
Successful placement of a tunneled single lumen catheter. The tip of the
catheter terminates in the right atrium. The catheter is ready for use.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: PICC line eval
Diagnosed with Pneumonia, unspecified organism
temperature: 97.7
heartrate: 76.0
resprate: 20.0
o2sat: 100.0
sbp: 108.0
dbp: 50.0
level of pain: uta
level of acuity: 3.0 | ___ M w/ end-stage MS ___ quadriplegia s/p
tracheostomy/gj-tube who re-presented from his nursing home
after losing his midline access, which was placed in ___ for
IV antibiotics for pseudomonal pneumonia and proteus UTI, prior
course requiring ICU stay for initial sepsis/septic shock. He
represented to ___ 2 days after discharge, as he lost his
midline access. He appeared well, with no new localizing
symptoms and His repeat urine testing has improved, thus his
antibiotic course was unchanged, with planned Ceftazidime 2g q12
___ Ciprofloxacin 500 mg q12, (day ___.
Given multiple losses of peripherally placed catheters, the IV
team decided that he would benefit from placement of tunneled
central venous catheter for more durable access, patient
agreeable.
FROM PRIOR HOSPITAL COURSE: ___
=================================================
#Pseudomonal and Serratia Pneumonia- During last
hospitalization, patient was found unresponsive and hypoxic at
nursing home, and required ventilator support. At baseline,
patient is on trach mask. CXR showed RLL opacification. He was
able to be weaned to trach collar as is his baseline. He was
continued on his antibiotics from his previous hospitalization.
He should continue ceftazidime 2g q12h (___) and
ciprofloxacin 500 mg q12h (___).
#Urosepsis: During last admission, patient presented with
leukocytosis, hypoxia, hypotension, fever. Infectious source
secondary to urinary tract infection (chronic suprapubic
catheter, +proteus) and pneumonia (+pseudomonas on BAL).
Urosepsis also complicated by obstructing stones seen on imaging
(now s/p suprapubic cath ___ and he received a Percutaneous
nephrostomy tube placement over left side on ___. Initially
treated with meropenem but narrowed ultimately to ceftazidime
and ciprofloxacin, for urinary proteus and pulmonary pseudomonas
which will require a 2 week course. (Ciprofloxacin Day ___-
___, ceftazidime ___.
#Labile Blood Pressures: Patient initially presented at last
admission with BP in ___, in setting of presumed septic shock,
required pressor support briefly and then was treated with broad
spectrum antibiotics. In looking into his chart further, he used
to be on amlodipine 5 in ___, which was discontinued
Metoprolol tartrate was restarted for rate control of A-fib (see
below). Dose was eventually increased to 12.5 mg BID given
persistent tachycardia during admission. However given low
baseline pressures and stable heart rate, he received fluid
resuscitation and metoprolol decreased to 6.25 BID. This dose
was continued during this hospitalization.
CHRONIC ISSUES
=====================
#NSTEMI: likely type II, demand in the setting of hypotension
and acute infection. EKG with new TWI in V4, otherwise largely
unchanged from prior. Peaked at ___. ASA and atorvastatin
were continued. Patient continued to be tachycardic, so
metoprolol tartrate dose was increased to 12.5 mg BID
#AMS: Likely in setting of sepsis as above, improved with
antibiotic treatment and nephrostomy placement.
___ (resolved): Cr 0.3, during last admission, patient
presented with Cr 1.9.
Resolved after suprapubic catherter insertion s/p exchange on
___ and shock management.
#ANEMIA: near baseline of Hgb ___. No signs of active bleeding.
Fe studies within normal limits. Consider additional work-up in
outpatient setting.
#MULTIPLE SCLEROSIS: s/p trach, GJ tube. Baclofen,
metoclopramide, scopolamine, and modafinil were continued.
#HX AFIB: CHADS score of 3, not on anticoagulation, continues on
aspirin 81 mg daily. In sinus rhythm on admission and remained
to do so. Of note, patient is not on systemic anticoagulation.
Please discuss risks vs benefits.
# DMII: Continue home medications as prescribed. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
R foot pain
Major Surgical or Invasive Procedure:
Amputation R hallux
History of Present Illness:
Mr. ___ is a ___ man with history of DMI
complicated by neuropathy and food ulcers who presents for
fevers
and right foot redness.
The patient was seen in ___ clinic on ___ and his chronic
foot wounds appeared uninfected at that time. On ___, he called
his podiatrist to report fevers, chills, and right foot swelling
and erythema. He denies significant pain. He also reported
nausea
without vomiting. He was prescribed clindamycin. However, his
foot continued to worsen despite antibiotics so he presented to
the ED for further evaluation.
In the ED, vitals: 100.1 89 120/74 16 100% RA
Labs notable for: WBC 19.7, Hb 11, BUN/Cr 34/2.0
Imaging: Right foot plain film with osteomyelitis
Patient given: Clindamycin 600 mg IV, Zofran 4 mg IV, Tylenol
___
mg, Vancomycin 1 gm, Zosyn 4.5 gm IV
Consults: Podiatry
The patient was taken from the ED to the OR and underwent right
hallux amputation.
On arrival to the floor, the patient reports that he feels very
well and has no complaints. He denies any pain. No nausea. No
other complaints.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
PMH:
-Diabetes mellitus type 1
-Peripheral neuropathy
PSH:
-Appendectomy
-Right foot debridement
Social History:
___
Family History:
Father has HTN
Physical Exam:
VITALS: 97.8 103/55 77 18 97 Ra
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs; right foot with dressing
c/d/i
SKIN: No rashes or ulcerations noted; right foot dressed
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: Very pleasant, appropriate affect
Discharge paperwork;
0722 T 98.3 BP 138/78 P 61 RR 18 Sp02 95 RA
GEN: Well appearing in NAD. Speaking in full sentences
HEENT/Neck: NC/AT, external ear intact, anicteric sclera, MMM,
OP
clear
CV: RRR no m/r/g, no carotid bruits appreciated.
PULM: CTAB no wheezes, rales, or crackles. Symmetric expansion
GI: soft NT/ND +BS no rebound or guarding
EXT: Warm well perfused, no pitting edema. R foot bandaged
cleanly which was not removed
SKIN: No rashes or lesions noted, no ecchymoses or petechiae
NEURO: alert and oriented. Fluent speech. CN II-XII intact.
No
focal deficits on strength testing
Lines: LUE PICC c/d/i.
Pertinent Results:
Admission labs:
___ 03:30PM BLOOD WBC-19.7* RBC-3.51* Hgb-11.1* Hct-33.1*
MCV-94 MCH-31.6 MCHC-33.5 RDW-14.1 RDWSD-48.2* Plt ___
___ 03:30PM BLOOD Glucose-236* UreaN-34* Creat-2.0*# Na-136
K-4.3 Cl-90* HCO3-25 AnGap-21*
___ 07:20AM BLOOD Calcium-8.4 Phos-2.7 Mg-2.4
___ 08:19AM BLOOD %HbA1c-8.0* eAG-183*
Discharge labs:
___ 06:00AM BLOOD WBC-11.8* RBC-3.65* Hgb-11.2* Hct-33.5*
MCV-92 MCH-30.7 MCHC-33.4 RDW-13.7 RDWSD-46.6* Plt ___
___ 06:00AM BLOOD Glucose-97 UreaN-8 Creat-0.7 Na-143 K-4.2
Cl-100 HCO3-27 AnGap-16
___ 06:00AM BLOOD Calcium-9.1 Phos-3.6 Mg-1.7
___ 08:19AM BLOOD %HbA1c-8.0* eAG-183*
___ 03:52PM BLOOD Lactate-1.0
FOOT XRAY:
IMPRESSION:
Findings consistent with acute osteomyelitis with bony loss of
the distal tuft
of the big toe and extensive subcutaneous gas. Overlying
bandage obscures
fine bony detail.
Foot XR s/p AMP: ___
Post right hallux amputation at the level of the MTP. The first
metatarsal head is unremarkable
Foot XR s/p closure: ___
New subtle erosion along the first metatarsal head concerning
for
osteomyelitis.
CXR (post line placement); ___
IMPRESSION:
Tip of left upper extremity PICC projects over the right atrium,
5-7 cm
inferior to the cavoatrial junction.
******
Micro:
------
- Blood cultures (___): NGTD
- Wound culture (___): NGTD
Wound swab ___:
WOUND CULTURE (Preliminary): MIXED BACTERIAL FLORA.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
ACID FAST SMEAR (Final ___: None detected
Tissue gram stain/cx ___
TISSUE (Preliminary): MIXED BACTERIAL FLORA.
ANAEROBIC CULTURE (Preliminary): RESULTS PENDING.
ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON
DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary):
POTASSIUM HYDROXIDE PREPARATION (Final ___:
NO FUNGAL ELEMENTS SEEN.
"Foot" culture ___: MIXED BACTERIAL FLORA.
BETA STREPTOCOCCUS GROUP A. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Pathology: Hallux, proximal phalanx margin: Acute osteomyelitis
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Citalopram 40 mg PO DAILY
3. Tresiba 16 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
4. Clindamycin 300 mg PO Q6H
5. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
6. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Ertapenem Sodium 1 g IV 1X Daily Duration: 1 Dose
To be taken once daily
3. Sodium Chloride 0.9% Flush ___ mL IV Q8H and PRN, line
flush
4. Humalog 3 Units Breakfast
Humalog 3 Units Lunch
Humalog 3 Units Dinner
Tresiba 11 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
5. Atorvastatin 40 mg PO QPM
6. Citalopram 40 mg PO DAILY
7. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
8. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute osteomyelitis R hallux
Type 1 diabetes mellitus with neuropathy
Acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Heel weight bearing in surgical shoe.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with R great toe infection// eval for osteo
TECHNIQUE: Three views of the right foot
COMPARISON: ___
FINDINGS:
A bandage overlies big toe. There is extensive soft tissue gas involving the
big toe distally. Additional foci of soft tissue gas are seen adjacent to the
level of the proximal phalanx. Evidence of bony loss of the distal tuft is
seen even though overlying bandage partially obscures the view. There is
extensive soft tissue swelling.
Re-demonstrated postsurgical changes involving the head of the second proximal
phalanx, as well as erosion at the lateral head of the second metatarsal.
IMPRESSION:
Findings consistent with acute osteomyelitis with bony loss of the distal tuft
of the big toe and extensive subcutaneous gas. Overlying bandage obscures
fine bony detail.
Radiology Report
EXAMINATION: FOOT AP,LAT AND OBL RIGHT
INDICATION: ___ year old man s/p R hallux amp// eval s/p right hallux amp
TECHNIQUE: Three views of the right foot were obtained
COMPARISON: ___
FINDINGS:
The patient is post amputation of the right first digit at the level of the
MTP. The first metatarsal head is unremarkable. Postsurgical changes are
seen overlying the soft tissues of the first digit. Re-demonstrated are
postsurgical changes involving the second proximal interphalangeal joint and
an erosion along the lateral head of the second metatarsal.
IMPRESSION:
Post right hallux amputation at the level of the MTP. The first metatarsal
head is unremarkable.
Radiology Report
EXAMINATION: FOOT AP,LAT AND OBL RIGHT
INDICATION: ___ year old man s/p R foot debridement w primary closure// post
op eval
TECHNIQUE: Three views of the right foot
COMPARISON: Right foot radiograph from ___
FINDINGS:
The patient is status post right foot debridement and amputation of the right
first digit at the level of the MTP. Along the lateral head of the first
metatarsal there is a new subtle area of erosion concerning for osteomyelitis.
Postsurgical changes are again seen involving the head of the second proximal
phalanx. Vascular calcifications are noted.
IMPRESSION:
New subtle erosion along the first metatarsal head concerning for
osteomyelitis.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 12:02 pm, 10
minutes after discovery of the findings.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with picc// s/p left 50cm picc Contact name:
___: ___
TECHNIQUE: Portable chest AP.
COMPARISON: Chest radiograph from ___.
FINDINGS:
Tip of left upper extremity PICC projects over the right atrium. Lungs are
expanded. There is no focal consolidation, pleural effusion, or pneumothorax.
Cardiomediastinal silhouette is within normal limits.
IMPRESSION:
Tip of left upper extremity PICC projects over the right atrium, 5-7 cm
inferior to the cavoatrial junction.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Fever, Wound eval
Diagnosed with Type 1 diabetes w diabetic peripheral angiopathy w gangrene, Gas gangrene, Long term (current) use of insulin
temperature: 100.1
heartrate: 89.0
resprate: 16.0
o2sat: 100.0
sbp: 120.0
dbp: 74.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ is a ___ man with history of DMI complicated
by neuropathy and food ulcers who presented for fevers and right
foot redness, found to have acute osteomyelitis s/p right hallux
amputation and subsequent closure ___ with concern for ongoing
radiographic evidence of osteomyelitis, recommended to complete
a ___cute osteomyelitis, R hallux:
# MSSA positive wound culture
Patient with history of DMI complicated by neuropathy and foot
ulcers who presented with fever and foot erythema, found to have
osteomyelitis of right first toe now s/p right hallux amputation
___ and s/p closure on ___.
He was treated initially with vanco, ceftaz, flagyl.
Though he clinically improved post amputation and per Podiatry
they
think they removed all of the affected bone, repeat radiographs
suggested persistent osteomyelitis so it was recommended by ID
that a PICC be placed to complete 6 weeks of IV ertapenem from
the date of closure ___, end date ___.
Per Podiatry, pt to remain heel weight bearing in surgical shoe
with plan for next dressing change at Podiatry f/u on ___ or
___ of next week.
Enrolled in OPAT, pt to be called for ___ and ___ labs to be
faxed to their department.
# Acute kidney injury:
Suspect pre-renal azotemia in setting of acute infection as
above. S/p IVF with resolution. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
food impaction
Major Surgical or Invasive Procedure:
___ EGD
History of Present Illness:
Mr. ___ is a ___ man with COPD and prior esophageal
strictures and food impactions, who presented with sensation of
food being stuck in his throat, and is being admitted after EGD
showing food impaction.
He ate a peanut butter sandwich at 5am on ___ before Church,
and
subsequently had a worsening feeling of food stuck in his
throat.
He was tolerating his secretions and breathing well. No cough or
shortness of breath. He presented to the ED. Of note, last EGD
in
___ with food impaction and strictures
He was taken to the Endoscopy suite, where GI successfully
performed EGD. He had a possible aspiration event during the
procedure- he was successfully extubated after, but was
requiring
3L nasal cannula. His esophagus was also bloody. GI recommended
admission to medicine for overnight monitoring.
On arrival to the floor, patient feels great. His breathing is
comfortable and he has no chest pain. He has a little discomfort
in his upper abdomen, but much improved from prior. No dizziness
or lightheadedness. Of note, he had a prior pneumonia after a
food impaction.
Past Medical History:
-COPD
-Hypertension
-Hyperlipidemia
-C. diff colitis after knee replacement
-Bilateral knee replacement
-Hard of Hearing
-Melanoma
-Choledocholithiasis s/p ERCP
Social History:
___
Family History:
No family history of GI disease or malignancy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.3 PO 136 / 58 R Sitting 84 20 85 RA
GENERAL: sitting comfortably in bed, NAD
HEENT: AT/NC, EOMI, anicteric sclera, pink conjunctiva, dry MM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, junky upper respiratory sounds, no wheezes or
crackles
ABDOMEN: nondistended, mild epigastric ttp, no r/g, normal bowel
sounds
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
vitals: 96.3, 122/70, 88, 20, 91% 70%OFM
Sitting in bed, NAD
Shallow breathing but per patient is baseline and feels
comfortable, RRR, no murmurs, crackles in LLL, no wheezes or
rhonchi.
Abd soft, TTP in LLQ, tympanic. No clubbing cyanosis or edema
Warm and well perfused
Pertinent Results:
Admission Labs
==============
___ 08:10AM BLOOD WBC-16.8* RBC-5.13 Hgb-15.6 Hct-49.4
MCV-96 MCH-30.4 MCHC-31.6* RDW-15.6* RDWSD-55.5* Plt ___
Abdominal X-ray:
No radiographic evidence of mechanical obstruction or
pneumoperitoneum.
Evaluation of the small bowel somewhat limited by paucity of
intraluminal gas.
CXR:
There has removal of the endotracheal tube and enteric tube.
Cardiomediastinal silhouette is within normal limits. There has
been
improvement of the bilateral pleural effusions. There remains
bilateral
perihilar and basilar opacities, stable.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tiotropium Bromide 1 CAP IH DAILY
2. Ranitidine 300 mg PO DAILY
3. Simvastatin 40 mg PO QPM
4. Levothyroxine Sodium 150 mcg PO DAILY
5. Sertraline 25 mg PO DAILY
6. Pantoprazole 40 mg PO Q24H
Discharge Medications:
1. Levofloxacin 500 mg PO Q24H
RX *levofloxacin 500 mg 1 tablet(s) by mouth q24h Disp #*5
Tablet Refills:*0
2. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*120 Tablet Refills:*0
3. Levothyroxine Sodium 150 mcg PO DAILY
4. Ranitidine 300 mg PO DAILY
5. Sertraline 25 mg PO DAILY
6. Simvastatin 40 mg PO QPM
7. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Final Diagnosis
================
Food impaction
Esophageal stricture
Secondary Diagnosis
====================
COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old man with COPD p/w food impaction, concern for
aspiration in EGD// assess for aspiration pneumonitis/pneumonia
COMPARISON: Radiographs from ___
IMPRESSION:
There has removal of the endotracheal tube and enteric tube.
Cardiomediastinal silhouette is within normal limits. There has been
improvement of the bilateral pleural effusions. There remains bilateral
perihilar and basilar opacities, stable.
Radiology Report
INDICATION: ___ year old man with distended abdomen, tympanic TTP// evidence
of obstruction, free air
TECHNIQUE: Supine and upright abdominal radiographs were obtained.
COMPARISON: Chest radiograph dated same day.
FINDINGS:
There are no abnormally dilated loops of large or small bowel. Evaluation of
the small bowel is limited by relative paucity of intraluminal gas. No
air-fluid levels are identified on the upright radiograph. There is moderate
fecal loading of the distal transverse and descending colon.
There is no free intraperitoneal air.
Degenerative changes of the thoracolumbar spine with bulky bridging
osteophytes. Cholecystectomy clips are noted projected over the right upper
quadrant. Atherosclerotic calcification of the splenic artery is noted.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
No radiographic evidence of mechanical obstruction or pneumoperitoneum.
Evaluation of the small bowel somewhat limited by paucity of intraluminal gas.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Food bolus
Diagnosed with Food in esophagus causing other injury, initial encounter, Exposure to other specified factors, initial encounter
temperature: 97.5
heartrate: 82.0
resprate: 22.0
o2sat: 94.0
sbp: 113.0
dbp: 69.0
level of pain: 3
level of acuity: 2.0 | Mr. ___ is a ___ man with COPD and prior esophageal
strictures and food impactions, who presented with food
impaction, and is admitted for overnight monitoring of
respiratory status & H/H after endoscopy. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
anemia identified in clinic
Major Surgical or Invasive Procedure:
port-a-cath removal ___
History of Present Illness:
___ with hx of tobacco use, metastatic colon cancer on
palliative chemotherapy (s/p XRT ___, FLOX, Irinotecan, with
plans to start capecitabine) sent to ___ ED for Hb 6.2 in
routine oncology visit. History obtained from chart review and
from patient, although he appears to have limited understanding
of his oncologic history. Briefly, pt was diagnosed with colon
cancer in ___ when he developed symptoms of cord
compression, and was found to have metastatic disease. He
received XRT ___, and FLOX begininning ___. He has
had numerous complications related to his various chemotherapy
regimens, necessitating delays in treatment. Most recently, he
has received Irinotecan alone (C3D1 ___. CEA has continued
to rise and most recent imaging (CT ___ shows progression
of disease. He received XRT to sternal mass ___, and was
seen in ___ clinic on ___ for f/u and plans to start
capecitabine. Routine blood work revealed H/H 6.2/19.9. Pt was
directed to ED for further evaluation. Baseline H/H ___.
Pt denies recent chest pain, SOB, lightheadedness, abd pain,
hematochezia, melena, hematuria, dysuria, fevers, chills,
nausea, vomiting.
10 pt ROS reviewed in detail and negative except as noted above.
In the ___ ED:
98.7 68 96/65 16 98% RA
Guaiac positive
Admitted for transfusion and eval of GIB
Past Medical History:
Past Medical History:
Metastatic colon cancer
Pathologic L4 compression fracture
Fracture of left wrist at 14
?sickle cell trait and alpha thalassemia diagnosed by Hb
electropheresis at ___ in setting of diagnosis of colon cancer
.
Pertinent Oncologic history (include past therapies, surgeries,
etc):
___, he woke up with the inability to walk and
difficulty with bowel and bladder continence. He presented to
the emergency room at ___ and at that time,
underwent imaging study that demonstrated a pathologic L4
compression fracture. The patient was given a TLSO brace by
Neurosurgery and underwent 10 sessions of radiation therapy that
started on ___ and was to be completed by ___. workup showed multiple liver and lung nodules that were
concerning for malignancy. colonoscopy on ___ that
demonstrated a 5-cm mass that was biopsied from the hepatic
flexure.
See OMR for detailed onc hx
Social History:
___
Family History:
Family History (per OMR): The patient reports that he has one
brother who lives in ___. He does have adult children. His
mother died secondary to cirrhosis of the liver. She was a
heavy drinker. His father died with stomach ulcers and a massive
bleed. The patient is unaware of any family members that have
cancer.
Physical Exam:
ADMISSION EXAM:
98.5 94/50 73 18 100% RA
General: Lying in bed with sheet pulled over head, arouses
easily to voice, NAD. Thin ___ male.
HEENT: Cushingoid, +conjunctival pallor, moist mucosal
membranes. No
oropharyngeal lesions. Poor dentition.
NECK: Supple, no cervical or supraclavicular adenopathy.
CHEST: sternal mass protruding, firm, nontender to palpation
without overlying erythema. Port in place at R chest, Tegaderm
on place, CTAB, no drainage or erythema, nontender. XRT markings
in place over sternal mass.
Lungs: CTAB in posterior lung fields, no use of accessory
muscles, speaking in full sentences
CARDIOVASCULAR: Regular rate and rhythm. Normal S1 and S2. No
murmurs, rubs or gallops.
ABDOMEN: Soft, non-tender. +bowel sounds. No rebound or
guarding.
RECTAL: No gross blood or melena visible. Small nonerythematous
skin tag at anterior anal verge.
NEUROLOGIC: A+O to person, "rehab," ___ Answers are
delayed.
EXTREMITIES: 2+ pitting edema of LLE, trace pitting edema of
RLE. No clubbing or cyanosis.
DISCHARGE EXAM:
T 98.5 BP 128/64 HR 92
GEN: Alert, oriented to name, place and situation. appears
chronically ill, fatigued but pleasant
HEENT: NCAT, Pupils equal and reactive, sclerae non-icteric,
MMM.
Neck: 3-4cm mass protruding over manubrium but no skin breakdown
CV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops.
bandage over site of right upper chest where port was removed,
nontender, no erythema
RESP: Good air movement bilaterally, no rhonchi or wheezing.
normal work of breathing, mild crackles at the bases bilaterally
GI: Soft, non-tender, non-distended, no hepatosplenomegaly
EXTR: no edema, no back tenderness to spinal palpation
Neuro: weakness in lower extremities, essentially bedbound at
this point (though pt refusing to get up for meals) though
babinskis downgoing bilaterally. able to bend both legs at the
knee on his own and has a little more than ___ strength of the
quadriceps, calf muscles ___
PSYCH: withdrawn. Condom cath in place with concentrated
appearing urine, almost tea-colored
Pertinent Results:
IMAGING:
EKG: NSR at 67 BPM, borderline LAD, normal intervals, QTc 420,
TWI in III, V1, no ST segment changes, no Q waves.
TTE ___:
The left atrium is mildly dilated. The right atrium is
moderately dilated. Left ventricular wall thickness, cavity
size, and global systolic function are normal (LVEF = 65%).
Right ventricular chamber size and free wall motion are normal.
The aortic root is mildly dilated at the sinus level. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. No obvious vegetations
seen (best excluded by TEE)
CT abd ___:
IMPRESSION:
1. No fluid collection or other evidence of infection.
2. Worsening metastatic disease with prominent increase in size
of numerous
calcified and noncalcified hepatic lesions along with interval
appearance of
new smaller lesions throughout the liver.
3. Similar appearance of diffuse bony metastatic disease along
with 3
demonstration of chronic vertebra plana of the L4 vertebral
body. Note is
made of mainly lytic appearance of the T12 vertebral body which
is at risk for
pathologic fracture.
4. Re-demonstration of concentric wall thickening of the colon
within the
hepatic flexure corresponding to known adenocarcinoma.
CT chest ___:
IMPRESSION:
1. Acute segmental pulmonary embolus in the anterior basal
segment of the left
lower lobe.
2. No fluid collection or evidence of infection in the chest.
3. Interval disease progression with interval increase in size
of a large
right middle lobe mass along with new adjacent satellite nodules
and
additional increase in size of a right upper lobe nodule.
4. No significant interval change in a soft tissue mass of the
low anterior
neck with invasion of the manubrium and anterior mediastinum,
sitting adjacent
to the left brachiocephalic vein.
CT head ___
IMPRESSION:
No evidence of acute intracranial process. Of note, MRI is more
sensitive for
detection of metastatic lesions.
LABS:
CBC:
___ 10:00AM BLOOD WBC-4.7 RBC-1.95*# Hgb-6.2*# Hct-19.9*#
MCV-102* MCH-31.7 MCHC-30.9* RDW-25.5* Plt Ct-76*
___ 05:14AM BLOOD WBC-4.0 RBC-3.49*# Hgb-10.7*# Hct-33.0*
MCV-95 MCH-30.7 MCHC-32.5 RDW-23.4* Plt Ct-60*
___ 06:06AM BLOOD WBC-3.4* RBC-2.91* Hgb-9.0* Hct-27.5*
MCV-95 MCH-31.0 MCHC-32.7 RDW-21.4* Plt Ct-51*
___ 05:23AM BLOOD WBC-2.7* RBC-2.77* Hgb-8.5* Hct-26.4*
MCV-95 MCH-30.5 MCHC-32.1 RDW-21.8* Plt Ct-71*
___ 05:14AM BLOOD WBC-3.8* RBC-2.68* Hgb-8.1* Hct-25.5*
MCV-95 MCH-30.2 MCHC-31.7 RDW-20.9* Plt ___
___ 04:05AM BLOOD WBC-3.8* RBC-2.20* Hgb-6.6* Hct-21.1*
MCV-96 MCH-29.8 MCHC-31.0 RDW-20.6* Plt ___
___ 04:15PM BLOOD WBC-4.8 RBC-2.99*# Hgb-9.2*# Hct-28.3*#
MCV-95 MCH-30.8 MCHC-32.6 RDW-18.9* Plt ___
___ 06:16AM BLOOD WBC-4.5 RBC-2.95* Hgb-9.0* Hct-27.9*
MCV-94 MCH-30.5 MCHC-32.3 RDW-19.0* Plt ___
___ 06:00AM BLOOD WBC-4.9 RBC-3.06* Hgb-9.4* Hct-28.8*
MCV-94 MCH-30.8 MCHC-32.7 RDW-20.0* Plt ___
CHEM/LFTS/HEMOLYSIS LABS: (note LDH has been up to 7000 in the
past)
___ 10:00AM BLOOD UreaN-14 Creat-0.5 Na-137 K-3.6 Cl-101
HCO3-25 AnGap-15
___ 06:16AM BLOOD Glucose-74 UreaN-10 Creat-0.5 Na-141
K-3.4 Cl-108 HCO3-26 AnGap-10
___ 10:00AM BLOOD ALT-300* AST-184* AlkPhos-259*
TotBili-0.4
___ 05:14AM BLOOD ALT-122* AST-156* LD(LDH)-1474*
AlkPhos-747* TotBili-0.6
___ 09:00AM BLOOD ___ TotBili-0.7
___ 05:56AM BLOOD ALT-366* AST-220* LD(___)-1609*
AlkPhos-263* TotBili-0.4
___ 09:00AM BLOOD Hapto-231*
___ 07:04PM BLOOD Hapto-163
MICRO:
___ 4:06 am BLOOD CULTURE Source: Line-POC.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STREPTOCOCCUS BOVIS GROUP. UNABLE TO SPECIATE.
Sensitivity testing performed by Sensititre.
CLINDAMYCIN = SENSITIVE ( <=0.12 MCG/ML ). FINAL
SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STREPTOCOCCUS BOVIS GROUP
|
CLINDAMYCIN----------- S
ERYTHROMYCIN----------<=0.25 S
PENICILLIN G----------<=0.06 S
VANCOMYCIN------------ <=1 S
Anaerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___ @ 1710 ON ___
- ___.
GRAM POSITIVE COCCI.
IN PAIRS.
Medications on Admission:
Medication list from ___ clinic note dated ___. Will
need to be confirmed in am.
1. Acetaminophen 650 mg PO Q4H:PRN pain/fever
2. Docusate Sodium 100 mg PO BID:PRN constipation
3. Ferrous Sulfate 325 mg PO DAILY
4. Lactulose 30 mL PO DAILY
5. Morphine SR (MS ___ 15 mg PO Q12H
6. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
7. Prochlorperazine 10 mg PO Q6H:PRN nausea
8. Senna 8.6 mg PO DAILY:PRN constipation
9. Cetirizine 10 mg oral daily
10. Pyridoxine 50 mg PO DAILY
11. Lidocaine 5% Patch 1 PTCH TD QAM back
12. Omeprazole 40 mg PO DAILY
13. Dexamethasone 4 mg PO Q12H
Discharge Medications:
1. CeftriaXONE 2 gm IV Q24H
RX *ceftriaxone 2 gram 2 grams IV daily Disp #*42 Gram
Refills:*0
2. Outpatient Lab Work
Please do weekly CBC with diff, BUN/creatinine, and AST/ALT,
Tbili, Alk phos and fax to ___ clinic at ___
Attn: Dr. ___
3. Acetaminophen 650 mg PO Q4H:PRN pain/fever
4. Cetirizine 10 mg oral daily
5. Dexamethasone 4 mg PO DAILY
6. Docusate Sodium 100 mg PO BID:PRN constipation
7. Enoxaparin Sodium 70 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
8. Ferrous Sulfate 325 mg PO DAILY
9. Gabapentin 300 mg PO TID
10. Lidocaine 5% Patch 1 PTCH TD QAM back
11. Morphine SR (MS ___ 30 mg PO QAM
12. Morphine SR (MS ___ 15 mg PO QPM
13. Omeprazole 40 mg PO DAILY
14. Ondansetron 4 mg PO Q8H:PRN nausea
15. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
16. Prochlorperazine 10 mg PO BID:PRN nausea
17. Pyridoxine 50 mg PO DAILY
18. Senna 8.6 mg PO DAILY:PRN constipation
19. Citalopram 20 mg PO DAILY
20. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line
flush
21. Polyethylene Glycol 17 g PO DAILY:PRN constipation
22. melatonin 6 mg oral qHS
23. Lorazepam 0.5-1 mg PO Q8H:PRN anxiety/insomnia
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
metastatic colon cancer
SECONDARY:
S.bovis bacteremia
anemia of underproduction (bone marrow involvement)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS LEFT
INDICATION: ___ year old man with metastatic colon ca with ___ asymmetry, LLE
edema. // Eval for DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow and augmentation of the left common
femoral, superficial femoral, and popliteal veins. Normal color flow is
demonstrated in the posterior tibial veins. The peroneal veins were not
visualized.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the left lower extremity veins.
Radiology Report
EXAMINATION: CT abdomen pelvis with contrast
INDICATION: Metastatic colon cancer with S. bovis bacteremia. Evaluate for
abscess.
TECHNIQUE: Axial helical multi detector CT images were acquired of the chest,
abdomen and pelvis after the administration of IV and oral contrast. Chest
images were separated to a different clip. Multiplanar reformatted images were
generated in the coronal and sagittal planes.
DOSE: DLP: 512.6 mGy-cm
COMPARISON: CT abdomen pelvis ___
FINDINGS:
ABDOMEN:
HEPATOBILIARY: There has been interval metastatic disease progression within
the liver with the largest heterogeneous mass being mostly hyperdense with
areas of partial calcification located in the right lobe mainly in segments 8
and 4 measuring roughly 9.9 x 7.4 cm, previously measuring collectively 7.2 x
3.8 cm. A more heavily calcified mass in segment 7 and 8 has also mildly
increased in size measuring 6.9 x 4.9 cm, previously measuring 6.6 x 4.5 cm.
Additional scattered hypodense and calcified lesions are seen throughout the
liver, some larger than the previous examination and is some new. The portal
vein appears patent. There is no intra or extrahepatic biliary ductal
dilatation. The gallbladder appears unremarkable.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: There is re- demonstration of a millimetric hypodensity in the right
interpolar kidney, too small to fully characterize but likely a cyst. The
kidneys are of normal and symmetric size with normal nephrogram. There is no
evidence of stones, focal solid renal lesions or hydronephrosis. There are no
urothelial lesions in the kidneys or ureters. There is no perinephric
abnormality.
GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall thickness
and enhancement throughout. There is again a roughly 4 cm length of concentric
wall thickening in the colon at the hepatic flexure, similar to the prior
examination compatible with known colonic adenocarcinoma. This lesion is
nonobstructing. Additionally, there is prominent fecal loading.
RETROPERITONEUM: There is no evidence of retroperitoneal and mesenteric
lymphadenopathy. There is no fluid collection to suggest infection.
VASCULAR: There is no abdominal aortic aneurysm. There is mild calcium burden
in the abdominal aorta and great abdominal arteries.
PELVIS:
The urinary bladder and distal ureters are unremarkable. There is no evidence
of pelvic or inguinal lymphadenopathy. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: Reproductive organs are within normal limits
BONES AND SOFT TISSUES:
There is re- demonstration of a vertebra plana of the L4 vertebral body with
roughly 9 mm of retropulsion at this level. Again there is diffuse mottled
appearance of the visualized osseous structures with areas of heterogeneous
sclerosis and hypodensity compatible with metastatic disease appearing similar
to prior study. Note is made of mainly lytic involvement of the T12 vertebral
body.
IMPRESSION:
1. No fluid collection or other evidence of infection.
2. Worsening metastatic disease with prominent increase in size of numerous
calcified and noncalcified hepatic lesions along with interval appearance of
new smaller lesions throughout the liver.
3. Similar appearance of diffuse bony metastatic disease along with 3
demonstration of chronic vertebra plana of the L4 vertebral body. Note is
made of mainly lytic appearance of the T12 vertebral body which is at risk for
pathologic fracture.
4. Re-demonstration of concentric wall thickening of the colon within the
hepatic flexure corresponding to known adenocarcinoma.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: History of metastatic colon cancer with S. bovis bacteremia.
Evaluate for abscess.
TECHNIQUE: Axial helical multi detector CT images were obtained of the chest,
abdomen and pelvis after the administration of oral and IV contrast.
Abdomen/pelvis images were separated to a different clip. Multiplanar
reformats were generated in the coronal and sagittal planes.
DOSE: DLP: Reported on the separate abdomen/ pelvis dictation.
COMPARISON: CT chest ___.
FINDINGS:
The imaged portion of the thyroid is unremarkable. There is re- demonstration
of a large destructive mass in the soft tissues of the anterior lower neck
with invasion of the manubrium, the superior most portion of which is not
imaged however measures roughly 6.9 x 4.1 x 6.9 cm, similar to the prior exam.
The mass appears to invade into the anterior mediastinum and is adjacent to
but does not yet compress the left brachiocephalic vein.
Heart size is top normal without significant pericardial effusion. The aortic
arch and main pulmonary artery are normal in caliber. There is new acute
pulmonary embolus in the anterior basal segmental branch of the left lower
lobe pulmonary artery. There is no supraclavicular, axillary or hilar
lymphadenopathy. A high right paratracheal prominent lymph node is re-
demonstrated measuring 1.6 by 0.9 cm, unchanged from prior exam (05:10).
Large mass in the right middle lobe measures 3.5 x 3.4 x 4.1 cm, slightly
increased compared to the prior examination where it measured 3.4 x 3.3 cm.
There at least 5 surrounding satellite nodules measuring between 3-8 mm in
size (6:150) that are new compared to the prior examination. 6 mm nodule in
the right upper lobe (6:118). Has increased in size from 3 mm. There is
moderate bilateral dependent atelectasis. There is no pleural effusion or
pneumothorax. There is moderate bibasilar dependent atelectasis.
There is no fluid collection or evidence of infection.
Osseous structures: Again there is diffuse, heterogeneous mixed lytic and
sclerotic appearance of the vertebral bodies suggestive of additional
metastatic disease involvement without readily measurable lesion.
IMPRESSION:
1. Acute segmental pulmonary embolus in the anterior basal segment of the left
lower lobe.
2. No fluid collection or evidence of infection in the chest.
3. Interval disease progression with interval increase in size of a large
right middle lobe mass along with new adjacent satellite nodules and
additional increase in size of a right upper lobe nodule.
4. No significant interval change in a soft tissue mass of the low anterior
neck with invasion of the manubrium and anterior mediastinum, sitting adjacent
to the left brachiocephalic vein.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr.
___ on the telephone on ___ at 9:34 ___, 5 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man with metastatic colon Ca // eval for brain mets,
hemorrhage prior to starting anticoagulation
TECHNIQUE: Axial helical MDCT images were obtained through the brain without
administration of IV contrast. Multiplanar reformatted images in coronal and
sagittal axes and thin section bone algorithm reconstructed images were
acquired.
DOSE: DLP: 961 mGy-cm
CTDI: Compatible with the patient's age mGy
COMPARISON: Nonenhanced head CT dated ___
FINDINGS:
There is no evidence of hemorrhage, edema, mass effect or infarction. The
ventricles and sulci are prominent. The basal cisterns appear patent and there
is preservation of gray-white matter differentiation.
No fracture is identified. There is mucosal thickening of the left maxillary
sinus and near opacification of the left sphenoid sinus with surrounding
osseous sclerosis consistent with chronic sinus disease. There is partial
opacification of the bilateral anterior ethmoid air cells. The remaining
visualized paranasal sinuses, mastoid air cells and middle ear cavities are
clear. The globes are unremarkable.
IMPRESSION:
No evidence of acute intracranial process. Of note, MRI is more sensitive for
detection of metastatic lesions.
Radiology Report
EXAMINATION:
CHEST PORT. LINE PLACEMENT
INDICATION:
___ year old man with new picc // R picc 43cm sal ___ Contact name: sal,
___: ___
TECHNIQUE: Chest single view
COMPARISON: ___
IMPRESSION:
There is not new PICC line with tip at the cavoatrial junction. There is a 4
cm mass in the right lower lung the slightly larger than on the study from 16
months prior. There is volume loss in both lower lobes
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Anemia
Diagnosed with GASTROINTEST HEMORR NOS
temperature: 98.7
heartrate: 68.0
resprate: 16.0
o2sat: 98.0
sbp: 96.0
dbp: 65.0
level of pain: 0
level of acuity: 2.0 | ___ with hx of metastatic colon ca (liver, lung, spine) on
palliative chemotherapy presenting with drop in hgb and guaiac
positive stool, ultimately with stable Hct but found to have
fever, strep bovis bacteremia, and PE.
# Fever/S. Bovis bacteremia: fevers resolved. No localizing
signs or symptoms but blood culture turned positive for pan
sensitive S. Bovis in ___ bottles ___, started on vanc ___ and
changed to CTX ___ per ID recs. No subsequent positive
cultures. Port removed ___, though suspect unresected primary
colon cancer likely portal of entry. TTE negative, CT a/p
without e/o abscess. it was decided not to pursue TEE at this
time but plan for 4 week total course of IV antibiotics (CTX
till ___. PICC in ___. Pt has OPAT Infectious disease
follow up scheduled. He needs weekly CBC, bun/creat, and LFTs
faxed to them while on ceftriaxone, see transitional issues
below.
# Relative hypotension/tachycardia - resolved. intermittent
throughout his hospital course, likely from poor PO intake in
setting of loss of appetite and depression. We had been holding
steroids in setting of infection on admission but pt stable on
CTX and per rad onc the steroids may be benefiting his bony mets
particularly in the spine so restarted dex prior to discharge
(relative hypotension may have involved component of adrenal
insufficiency). No evidence of significant bleeding throughout
his stay. BP was in the 110s when Hct was higher also. More over
prior clinc notes suggest baseline BP in ___.
# Acute PE: no symptoms, found on CT scans to look for S.bovis
related abscesses. Had been off ppx heparin here initially due
to low platelets and concern for GI bleeding. Hgb was stable and
thrombocytopenia improved ___, so benefit of
anticoagulation outweighed risks. Heparin gtt started ___, Hct
stable and plts uptrending so changed to lovenox on ___. Pt on
omeprazole given anticoagulation and dex use.
# Anemia/ GI bleed: Hct stable. No signs of melena and Hct
stable at this point. Likely myelosuppression given no
significant clinical GI bleed. Bone marrow underproduction may
be from chemo, more likely it is from his malignancy however
given extensive bone marrow involvement. Hemolysis labs not
suggestive of hemolysis process and his retic index was low
suggesting inadequate bone marrow response. Note that pt also
reportedly has sickle trait and/or thalassemia per Hb
electropheresis at ___ in ___. GI saw pt and recommended
simply monitoring for now given it was not ever apparent that
the GI bleed was a dominant problem. He tolerated a regular
diet. His LDH was quite elevated, but lower than it had been in
the past and Tbili low so nothing to suggest active hemolysis.
Iron supplementation was continued though not clear pt was iron
deficient but this could be helpful. Holding bactrim prophylaxis
with his steroids for now given its marrow suppression effects.
Pt will need weekly CBC checks every ___ for the time being
and will need a red blood cell transfusion for Hct <21.
# LLE edema: Resolved. LLE u/s with doppler negative for DVT
# Thrombocytopenia: improved. Has been attributed to irinotecan
but last chemo almost 2 months ago. other concerns as above,
bone marrow involvement, radiation effect. PLTs improved and pt
was switched from heparin gtt to therapeutic lovenox as above.
# Lower extremity weakness - pt reports inability to walk at
times and has h/o spinal mets s/p XRT to lumbar and thoracic
spine. Declined surgical intervention for impending cord
compression earlier this year. Per radiation oncologist exam
prior to discharge is stable compared to his prior exam and pt
is very much averse to surgical intervention or further XRT.
Restarted dex as per surgery there may be some benefit ongoing
for spinal mets. Holding bactrim prophylaxis with his steroids
for now given its marrow suppression effects. (Unfortuantely due
to liver disease, did not start at___). Pt will be off PCP
ppx for now. Can consider steroid taper.
# Peripheral neuropathy: ___ chemotherapy, chronic. Continued
home gabapentin
# Metastatic colon cancer: s/p 11 cycles full dose FLOX with
cycle 2 c/b neutropenic enteroclitis and SBO, s/p progression in
___ so switched to irinotecan alone but not able to
tolerate therapy and changed to lower dose. Thrombocytopenia has
required multiple treatment delays. Last chemo ___. He has
also undergone sternal XRT in ___. Had planned to
initiate capecitabine, on hold for now. if he remains
pancytopenic that may limit our ability to start a new
chemotherapy regimen. Due to his extensive bony disease, the
pthas also been receiving zoledronic acid injections every 3
months. He will be due for next injection in ___. S/P
XRT to T and L spine as well as sternum.
# Pain control: Back pain ___ known osseous disease. Stable on
home regimen.
Continued home MScontin 30 mg qAM, 15 mg qPM with oxycodone 10
mg prn for breakthrough and gabapentin as above
# Code: DNR/DNI. Pt discussed hospice and wishes to pursue this.
He understands there is no further treatment for his cancer and
wishes to be as comfortable as possible.
# Contact: ___
Relationship: brother
Phone number: ___
Cell phone: ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ibuprofen / Trazodone / ceftriaxone
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ woman with a h/o CAD S/P PCI, mild
aortic stenosis, prior left breast cancer, ESRD on HD,
hypertension, hyperlipidemia, pulmonary hypertension, ___
who presents with left sided chest pain in a band-like
distribution for several days. She reported intermittent chest
pain over the preceding days that would worsen with movement and
would not improve with rest. She reported the pain is pleuritic
and worsens with deep inspiration and when standing up and
bending over. She could not otherwise identify the quality of
pain. No alleviating factors or shortness of breath. She went to
hemodialysis today and then came to the ED after returning home
still having chest pain. No similar prior chest pain. No cough,
fevers. Left lower extremity swelling but usually asymmetric. No
recent travel.
In the ED, initial vitals were: T 98.2 HR 72 BP 143/44 RR 15
SaO2 96% on RA. Labs notable for troponin-T 0.02, Hgb 8.8, plt
140, WBC 10 (74% N), BUN/Cr ___, CK-MB 1. EKG was NSR, no
STEMI. Patient refused CTA (does not want contrast), so d-dimer
sent and returned at 2211. No rib fracture on CXR, but point
tenderness over L rib. She was admitted for evaluation of acute
coronary syndrome vs. pulmonary embolism. She was not
empirically heparinized as she was hemodynamically stable.
Vitals prior to transfer: HR 67 BP 126/57 RR 16 SaO2 97% on RA.
On arrival to the cardiology floor, patient reported ___ chest
pain, with no shortness of breath. She endorsed anxiety.
ROS: + per HPI, otherwise negative.
Past Medical History:
-Type 2 diabetes mellitus requiring insulin complicated by
nephropathy and neuropathy
-Chronic kidney disease
-Dyslipidemia
-Hypertension
-CAD with H/O Myocardial infarction S/P PCI x4 in ___ (unknown
anatomy)
-Diastolic heart failure
-Severe pulmonary hypertension
-Mild aortic stenosis (1.2-1.9 cm2)
-Patent foramen ovale
-Hypothyroidism
-Rheumatoid arthritis
-History of breast cancer S/P left mastectomy in ___
-Obstructive sleep apnea on CPAP
-Osteoporosis
-Osteoarthritis S/P bilateral knee replacements
-Depression/anxiety
-Recurrent urinary tract infections
-Atrophic vaginitis
Social History:
___
Family History:
Father, mother, sister, and brother with heart disease. Dad died
of MI. Mom died of metastatic CRC.
Physical Exam:
On admission
General: elderly white woman, sitting up in recliner, in NAD
Vitals: T 98, BP 136/37, HR 68, RR 20, SaO2 91% on RA
HEENT: mucous membranes moist
Neck: supple, no JVD
CV: RRR, systolic murmur
Lungs: CTAB, breathing comfortably
Chest: tender to palpation over Left mid-anterior chest
Abdomen: soft, non-tender, obese
Extr: 1+ ___ bilaterally with Left > Right asymmetry, mild Left
calf tenderness to palpation
Neuro: alert, attentive and appropriate
At discharge
General: in NAD, conversant, pleasant
Vitals: T 98, BP 135/41, HR 64, RR 18, SaO2 96% on RA
HEENT: mucous membranes moist, NCAT
Neck: supple, no JVD
CV: RRR, II/VI SEM @ LUSB
Lungs: CTAB, breathing comfortably
Chest: tender to palpation over Left mid-anterior chest, no
overlying skin changes
Abdomen: soft, non-tender, obese, BS+
Extr: Trace edema BLE with Left > Right asymmetry, neuropathy in
legs
Neuro: alert, attentive and appropriate
Pertinent Results:
___ 09:50PM BLOOD WBC-10.0 RBC-2.92* Hgb-8.8* Hct-27.6*
MCV-95 MCH-30.1 MCHC-31.9* RDW-17.9* RDWSD-58.1* Plt ___
___ 09:50PM BLOOD Neuts-74.8* Lymphs-15.5* Monos-7.0
Eos-1.4 Baso-0.5 Im ___ AbsNeut-7.44* AbsLymp-1.54
AbsMono-0.70 AbsEos-0.14 AbsBaso-0.05
___ 09:50PM BLOOD Glucose-181* UreaN-17 Creat-3.4* Na-137
K-3.9 Cl-94* HCO3-29 AnGap-18
___ 09:50PM BLOOD Calcium-8.4 Phos-2.7 Mg-2.2
___ 10:48PM BLOOD K-3.7
___ 09:50PM BLOOD CK(CPK)-43
___ 09:50PM BLOOD cTropnT-0.02*
___ 09:50PM BLOOD D-Dimer-2211*
___ 01:30PM BLOOD CK-MB-1 cTropnT-0.02*
___ 03:50AM BLOOD CK-MB-1 cTropnT-0.02*
___ 07:13AM BLOOD WBC-7.5 RBC-2.82* Hgb-8.3* Hct-26.7*
MCV-95 MCH-29.4 MCHC-31.1* RDW-18.2* RDWSD-61.1* Plt ___
___ 07:13AM BLOOD Glucose-181* UreaN-31* Creat-5.1*# Na-135
K-4.0 Cl-97 HCO3-27 AnGap-15
___ 07:13AM BLOOD Calcium-8.6 Phos-4.6* ___
11:45AM BLOOD UreaN-8
ECG ___ 9:40:28 ___
Sinus rhythm. Borderline P-R interval prolongation. ST-T wave
abnormalities. Compared to the previous tracing of ___ the
rate is now faster. Axis is more leftward. QTc interval is
shorter. ST-T wave abnormalities may be more prominent. Clinical
correlation is suggested.
CHEST (PA & LAT) ___ 11:05 ___
Lung volumes are low leading to crowding of the bronchovascular
structures. Mild prominence to the central pulmonary vasculature
is similar as compared to ___. No focal
consolidation, large pleural effusion, or pneumothorax is
identified. The patient is status post left mastectomy, and
surgical clips overlie the left lung base. The cardiomediastinal
silhouette is unchanged from the prior examination. A large
hiatal hernia is noted.
IMPRESSION: Low lung volumes and mild pulmonary vascular
congestion. Large hiatal hernia. No discrete consolidation or
pleural effusion.
CT CHEST W/O CONTRAST ___ 12:41 AM
The thyroid gland is not discretely visualized.
Supraclavicular, axillary, mediastinal and hilar lymph nodes are
not enlarged. Aorta and pulmonary arteries are normal size.
Moderate cardiomegaly is noted. There are extensive coronary
artery and aortic calcifications.
Airways are patent the subsegmental level. Mild bibasilar
atelectasis is noted. There is no large consolidation, pleural
effusion, or pneumothorax identified. Mild centrilobular
emphysematous changes are noted. A 5 mm perivascular nodule is
seen at the right lung base (4:148). Multiple additional, sub-3
mm pulmonary nodules are seen within the left upper lobe (04:27,
32, 38, 81), right upper lobe (4: 25, 37), and right middle lobe
(4:93).
OSSEOUS STRUCTURES: No acute fracture is identified. A small
sclerotic focus within the right lateral ninth rib likely
represents a bone island. Multilevel degenerative changes are
noted within the mid thoracic spine.
The patient is status post left mastectomy with surgical clips
noted overlying the anterior left thorax. Included portions of
the upper abdomen demonstrated a moderate hiatal hernia.
IMPRESSION:
1. No evidence of acute intrathoracic process or fracture.
2. Multiple bilateral pulmonary nodules, as above, measuring up
to 5 mm in the right lower lobe.
RECOMMENDATION(S): Given the patient's risk history of
malignancy, recommend follow-up chest CT in ___ months.
BILAT LOWER EXT VEINS ___ 7:51 AM
There is normal compressibility, flow and augmentation of the
left common femoral, superficial femoral, and popliteal veins.
Normal color flow and compressibility are demonstrated in the
posterior tibial and peroneal veins.
There is normal compressibility, flow, and augmentation in the
right common femoral and proximal superficial femoral veins. The
patient was unable to tolerate compression of the remainder of
the right lower extremity veins. There is normal color flow and
augmentation in the mid and distal superficial femoral and
popliteal veins. Normal color flow is demonstrated in the
posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral
veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
1. No evidence of deep venous thrombosis in the left lower
extremity veins.
2. The patient was unable to tolerate compression of the right
lower extremity veins, but normal color flow seen in the right
lower extremity veins without evidence of deep venous
thrombosis.
LUNG SCAN ___
Ventilation images demonstrate homogeneous radiotracer
distribution without focal photopenic defect.
Perfusion images demonstrate homogeneous radiotracer
distribution without areas of perfusion defect.
Chest x-ray shows low lung volumes without focal
consolidation.
IMPRESSION: No evidence of pulmonary embolism.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q8H:PRN SOB
2. Amlodipine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
6. Carvedilol 25 mg PO BID
7. Citalopram 30 mg PO DAILY
8. Docusate Sodium 200 mg PO QAM
9. FoLIC Acid 1 mg PO DAILY
10. Gabapentin 300 mg PO QHS
11. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
12. Levothyroxine Sodium 112 mcg PO DAILY
13. Omeprazole 40 mg PO DAILY
14. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
15. PredniSONE 5 mg PO DAILY
16. Senna 17.2 mg PO HS
17. Nephrocaps 1 CAP PO DAILY
18. Ascorbic Acid ___ mg PO DAILY
19. coenzyme Q10 200 mg oral daily
20. Cyanocobalamin 500 mcg PO DAILY
21. Estradiol 2 mg VAGINAL REPLACE Q3MONTHS
22. Florastor (saccharomyces boulardii) 250 mg oral BID
23. melatonin 5 mg oral HS:PRN insomnia
24. Glargine 6 Units Bedtime
25. sevelamer CARBONATE 800 mg PO TID W/MEALS
26. Acetaminophen 650 mg PO Q4H:PRN pain
27. Lidocaine-Prilocaine 1 Appl TP PRN to AVF fistula site
28. Fish Oil (Omega 3) 1000 mg PO 2 CAPSULES DAILY
29. d-mannose ___ mg oral DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth three times per
day Disp #*90 Tablet Refills:*0
2. Albuterol Inhaler 2 PUFF IH Q8H:PRN SOB
3. Amlodipine 10 mg PO DAILY
4. Ascorbic Acid ___ mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
7. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
8. Carvedilol 25 mg PO BID
9. Citalopram 30 mg PO DAILY
10. Cyanocobalamin 500 mcg PO DAILY
11. Docusate Sodium 200 mg PO QAM
12. FoLIC Acid 1 mg PO DAILY
13. Gabapentin 300 mg PO QHS
14. Glargine 6 Units Bedtime
15. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
16. Levothyroxine Sodium 112 mcg PO DAILY
17. Nephrocaps 1 CAP PO DAILY
18. Omeprazole 40 mg PO DAILY
19. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
20. PredniSONE 5 mg PO DAILY
21. Senna 17.2 mg PO HS
22. sevelamer CARBONATE 800 mg PO TID W/MEALS
23. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine 5 % (700 mg/patch) Apply one patch to area of
greatest pain every morning Disp #*30 Patch Refills:*0
24. coenzyme Q10 200 mg oral daily
25. d-mannose ___ mg oral DAILY
26. Estradiol 2 mg VAGINAL REPLACE Q3MONTHS
27. Fish Oil (Omega 3) 1000 mg PO 2 CAPSULES DAILY
28. Florastor (saccharomyces boulardii) 250 mg oral BID
29. Lidocaine-Prilocaine 1 Appl TP PRN to AVF fistula site
30. melatonin 5 mg oral HS:PRN insomnia
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
-Musculoskeletal chest pain
-Shoulder arthritis
-Cervical arthritis
-Rheumatoid arthritis
-Diabetes mellitus, on insulin
-End stage renal disease on hemodialysis
-Pulmonary nodules
-Pulmonary hypertension
-Coronary artery disease
-Orthostatic hypotension
-Hypertension
-Hyperlipidemia
-Hypothyroidism
-Mild aortic stenosis
-Chronic left ventricular diastolic heart failure
-Chronic anemia
-Gastroesophageal reflux disease
-Anxiety
-Depression
-Obstructive sleep apnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: History: ___ with L rib pain, breast ca on that side pls eval
for rib fx // History: ___ with L rib pain, breast ca on that side pls eval
for rib fx
TECHNIQUE: Multidetector helical scanning of the chest was performed without
intravenous contrast agent reconstructed as contiguous 5- and 1.25-mm thick
axial, 2.5-mm thick coronal and parasagittal, and 8 x 8 mm MIPs axial images.
DOSE: DLP: 644 mGy cm
COMPARISON: Multiple prior chest radiographs most recently ___, CT
chest dated ___.
FINDINGS:
The thyroid gland is not discretely visualized. Supraclavicular, axillary,
mediastinal and hilar lymph nodes are not enlarged. Aorta and pulmonary
arteries are normal size. Moderate cardiomegaly is noted. There are extensive
coronary artery and aortic calcifications.
Airways are patent the subsegmental level. Mild bibasilar atelectasis is
noted. There is no large consolidation, pleural effusion, or pneumothorax
identified. Mild centrilobular emphysematous changes are noted. A 5 mm
perivascular nodule is seen at the right lung base (4:148). Multiple
additional, sub-3 mm pulmonary nodules are seen within the left upper lobe
(04:27, 32, 38, 81), right upper lobe (4: 25, 37), and right middle lobe
(4:93).
OSSEOUS STRUCTURES: No acute fracture is identified. A small sclerotic focus
within the right lateral ninth rib likely represents a bone island.
Multilevel degenerative changes are noted within the mid thoracic spine.
The patient is status post left mastectomy with surgical clips noted overlying
the anterior left thorax. Included portions of the upper abdomen demonstrated
a moderate hiatal hernia.
IMPRESSION:
1. No evidence of acute intrathoracic process or fracture.
2. Multiple bilateral pulmonary nodules, as above, measuring up to 5 mm in
the right lower lobe.
RECOMMENDATION(S): Given the patient's risk history of malignancy, recommend
follow-up chest CT in ___ months.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old woman with L-sided pleuritic chest pain, L calf edema
and mild pain // r/o DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower extremity veins.
COMPARISON: ___.
FINDINGS:
There is normal compressibility, flow and augmentation of the left common
femoral, superficial femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
There is normal compressibility, flow, and augmentation in the right common
femoral and proximal superficial femoral veins. The patient was unable to
tolerate compression of the remainder of the right lower extremity veins.
There is normal color flow and augmentation in the mid and distal superficial
femoral and popliteal veins. Normal color flow is demonstrated in the
posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
1. No evidence of deep venous thrombosis in the left lower extremity veins.
2. The patient was unable to tolerate compression of the right lower
extremity veins, but normal color flow seen in the right lower extremity veins
without evidence of deep venous thrombosis.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with CHEST PAIN NOS
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: 2.0 | Ms. ___ is an ___ woman with a h/o CAD, ESRD on HD,
hyeprtension, hyperlipidemia, mild aortic stenosis, pulmonary
hypertension, prior left breast cnacer, and ___ presenting
with left sided chest pain during hemodialysis.
# Chest pain: Patient has a history of extensive CAD with
angiographically documented 2-vessel disease in ___, so her
chest pain was initially concerning for unstable
angina/crescendo angina. There were no significant EKG changes
and troponins were only mildly elevated and stable in the
setting of renal insufficiency. Given her history of malignancy
and immobilization secondary to knee pain/rheumatoid arthritis,
pulmonary embolism was another possibility. Her D-dimer was
elevated to 2211, so LENIs and a V/Q scan were obtained, both of
which were normal without evidence of venous thrombobembolism. A
chest CT did not show rib fracture of evidence of trauma. There
was no rash to suggest zoster. Chest pain is left-sided in a
band-like distribution and is most likely musculoskeletal in
etiology as pain is non-exertional and is reproducible on
palpation, making ischemia unlikely. She was treated with a
lidocaine patch as well as high dose acetaminophen, in addition
to home dose oxycodone. She was evaluated by physical therapy
who cleared her for home with ___ services.
# Chronic dCHF without exacerbation: Patient asymptomatic
without exertional dyspnea. Mild ___ edema, lungs clear. CXR with
mild vascular prominence. We continued her home medications
including isosorbide mononitrate, amlodipine and carvedilol and
held her hydralazine given orthostatic hypotension.
# ___: last HbA1C 7.7% in ___, complicated by
nephropathy and neuropathy. We continued Lantus and gabapentin
and had her on an insulin sliding scale.
# CAD s/p PCI: Continued atorvastatin, ASA, carvedilol,
amlodipine and long acting nitrate.
# Chronic anemia: Her hematocrit remained close to baseline in
the ___ range, so we monitored her Hct. She remained symptomatic
throughout the admission.
# ESRD on HD: On admission, patient underwent hemodialysis on
___, last dialyzed ___. While inpatient, patient was
dialyzed on ___. No fluid was removed since the patient was
orthostatic the evening prior. We continued to trend her
electrolytes, and repleted her with nephrocaps and sevelemer.
# Left Shoulder Pain: Exacerbated by neck movement, perhaps
consistent with cervical arthritis. Also tender to palpation
laterally at humeral head. Recommend follow up with PCP for
further evaluation.
CHRONIC ISSUES:
# Hypertension: continued statin
# Hypertension: continued amlodipine and carvedilol
# GERD: continued PPI
# Severe Pulmonary hypertension: asymptomatic currently
# Hypothyroidism: continued levothyroxine
# Rheumatoid arthritis: continued prednisone
# Obstructive sleep apnea: on CPAP
# Depression/anxiety: continued citalopram |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aspirin / lisinopril / Penicillins / Compazine
Attending: ___.
Chief Complaint:
headache, nausea, chest pain, and abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ woman with a history of CAD status post CABG ___
(LIMA-LAD, rSVG-RCA, rSVG-OM, rSVG-diagonal), HFrEF (20%), DM2,
HTN, migraine, reported history of chronic pancreatitis, and
GERD who presents with headache, nausea, chest pain, and
abdominal pain.
My interview with the patient today was performed with the
assistance of a ___ interpreter.
Patient was just hospitalized from ___ with very similar
symptoms. She did undergo nuclear stress testing which showed a
mild reversible defect in the distal anterior wall and apex. It
was ultimately felt that the patient's symptoms were primarily
the result of volume overload and she was therefore diuresed.
Coronary angiography was deferred. Her epigastric tenderness was
evaluated with an abdominal CT that showed no evidence of acute
pancreatitis. Prior to discharge, she states her symptoms had
improved. Of note, she was started on ASA which she has a chart
history of an allergy involving GI upset.
Patient states that she was doing well at home until yesterday
when she had the relatively acute onset of abdominal and chest
discomfort as well as a headache while lying down "a little
while" after eating. She says the symptom started with belly
pain, and then progressed to involve chest and her head. When
asked if these symptoms are similar to past episodes of
pancreatitis, she says yes. She says the symptoms have been
constant since they came on. She has not been eating as much
since the symptoms started but has been able to eat a little,
thinks it might make the pain a little worse.
She notes that it is sometimes pleuritic and sometimes worse
with palpation. She states that she has intermittently had lower
extremity edema at home but denies orthopnea or PND. She states
she has been taking her medications. She states that
intermittently she has dark stools.
In the ED initial vitals were: T-98.0 BP-128/67 P-88 RR-17
SpO2-97% RA
EKG: NSR, LBBB with PVC, no changes from prior
Labs/studies notable for:
Na-142 K-3.9 Cl-106 HCO3-24 BUN-19 Cr- 0.9 Glucose-138
Troponin <0.01
WBC- 7 Hct- 32.7 Hb-9.8 Plt-189
Patient was given: acetaminophen 1000 mg PO
On the floor, she reports ongoing abdominal, chest, and head
pain. She is most bothered by the abdominal pain.
REVIEW OF SYSTEMS:
Positive per HPI.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations,
syncope, or presyncope.
On further review of systems, denies fevers or chills. Denies
any prior history of stroke, TIA, deep venous thrombosis,
pulmonary embolism, bleeding at the time of surgery, myalgias,
joint pains, cough, hemoptysis, black stools or red stools. All
of the other review of systems were negative.
Past Medical History:
- CAD status post CABG ___ (___-LAD, rSVG-RCA, rSVG-OM,
rSVG-diagonal)
- HFrEF (EF 20% ___
- HTN
- HLD
- Type ___ DM
- Depression
- Migraine
- Chronic pancreatitis
- GERD
Social History:
___
Family History:
Father with type ___ diabetes mellitus and CAD. Son with colon
cancer. No history of premature CAD, sudden cardiac death or
arrhythmias.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
=======================
VS: 97.6F, BP 99/55, HR 70, RR 17, 97% RA
GENERAL: Well developed, well nourished woman in NAD. Oriented
x3. Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma.
NECK: Supple. No JVD.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Regular rate and rhythm. Normal S1, S2. No murmurs, rubs,
or gallops. No thrills or lifts.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, non-distended. Mildly tender to palpation in
epigastrium and LLQ.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE PHYSICAL EXAMINATION:
========================
Vitals: 97.9F, BP 118/68, HR 77, RR 16, 100 RA
GENERAL: Well developed, well nourished woman in NAD. Lying on
bed.
HEENT: Conjunctiva were pink. No pallor or cyanosis of the oral
mucosa.
NECK: JVP 6-8cm.
CARDIAC: RRR, normal S1/S2, no R/M/G. Sternum nontender.
LUNGS: LLL crackles, no wheezes/rhonchi
ABDOMEN: Soft. LLQ mildly tender to palpation without rebound.
Epigastrium mildly tender to palpation.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis. Trace
BLE edema.
SKIN: No significant skin lesions or rashes.
Pertinent Results:
ADMISSION LABS
========================
___ 05:41PM BLOOD WBC-7.0 RBC-3.77* Hgb-9.8* Hct-32.7*
MCV-87 MCH-26.0 MCHC-30.0* RDW-18.8* RDWSD-56.4* Plt ___
___ 05:41PM BLOOD Neuts-59.9 ___ Monos-10.3 Eos-2.9
Baso-0.6 Im ___ AbsNeut-4.18 AbsLymp-1.81 AbsMono-0.72
AbsEos-0.20 AbsBaso-0.04
___ 05:41PM BLOOD Glucose-138* UreaN-19 Creat-0.9 Na-142
K-3.9 Cl-106 HCO3-24 AnGap-12
___ 05:41PM BLOOD ALT-11 AST-17 AlkPhos-80 TotBili-0.3
___ 05:41PM BLOOD Lipase-145*
___ 05:41PM BLOOD cTropnT-<0.01 proBNP-3731*
___ 09:10PM BLOOD cTropnT-<0.01
___ 05:41PM BLOOD Albumin-3.9
___ 08:15AM BLOOD Calcium-9.5 Phos-3.8 Mg-2.1
___ 05:46PM BLOOD Lactate-1.9
RELEVANT IMAGING
=========================
___ CXR PA/LAB
Re-demonstrated mild prominence of the interstitial markings
could be due to mild interstitial edema versus chronic changes.
No focal consolidation to suggest pneumonia.
DISCHARGE LABS
=========================
___ 08:26AM BLOOD WBC-5.4 RBC-3.63* Hgb-9.7* Hct-32.0*
MCV-88 MCH-26.7 MCHC-30.3* RDW-19.4* RDWSD-59.7* Plt ___
___ 08:26AM BLOOD Glucose-277* UreaN-17 Creat-0.9 Na-141
K-4.3 Cl-102 HCO3-26 AnGap-13
___ 08:26AM BLOOD ALT-11 AST-16 LD(LDH)-170 AlkPhos-78
TotBili-0.2
___ 08:15AM BLOOD Lipase-52
___ 08:26AM BLOOD Calcium-9.0 Phos-3.3 Mg-2.0
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Atorvastatin 80 mg PO QPM
3. Clopidogrel 75 mg PO DAILY
4. Cyanocobalamin 1000 mcg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY
7. Gabapentin 100 mg PO TID
8. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN SOB,
wheezing
9. Loratadine 10 mg PO DAILY
10. Losartan Potassium 25 mg PO DAILY
11. Metoprolol Succinate XL 100 mg PO DAILY
12. Montelukast 10 mg PO DAILY
13. Pantoprazole 40 mg PO Q24H
14. PARoxetine 30 mg PO DAILY
15. Ramelteon 8 mg PO QHS
16. Simethicone 40-80 mg PO QID:PRN gas
17. Topiramate (Topamax) 50 mg PO BID
18. Vitamin D 1000 UNIT PO DAILY
19. Aspirin 81 mg PO DAILY
20. Furosemide 40 mg PO DAILY
21. HydrOXYzine 25 mg PO DAILY:PRN itching
22. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB
23. Januvia (SITagliptin) 100 mg oral DAILY
24. Meclizine 25 mg PO Q8H:PRN dizziness
25. MetFORMIN (Glucophage) 1000 mg PO BID
26. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation Q12H
27. Ferrous GLUCONATE 324 mg PO DAILY
Discharge Medications:
1. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
RX *isosorbide mononitrate 30 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Clopidogrel 75 mg PO DAILY
6. Cyanocobalamin 1000 mcg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Ferrous GLUCONATE 324 mg PO DAILY
9. Fluticasone Propionate NASAL 2 SPRY NU DAILY
10. Furosemide 40 mg PO DAILY
11. Gabapentin 100 mg PO TID
12. HydrOXYzine 25 mg PO DAILY:PRN itching
13. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN
SOB, wheezing
14. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB
15. Januvia (SITagliptin) 100 mg oral DAILY
16. Loratadine 10 mg PO DAILY
17. Losartan Potassium 25 mg PO DAILY
18. Meclizine 25 mg PO Q8H:PRN dizziness
19. MetFORMIN (Glucophage) 1000 mg PO BID
20. Metoprolol Succinate XL 100 mg PO DAILY
21. Montelukast 10 mg PO DAILY
22. Pantoprazole 40 mg PO Q24H
23. PARoxetine 30 mg PO DAILY
24. Ramelteon 8 mg PO QHS
25. Simethicone 40-80 mg PO QID:PRN gas
26. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation Q12H
27. Topiramate (Topamax) 50 mg PO BID
28. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
==================
PRIMARY DIAGNOSES:
==================
Left lower quadrant and epigastric abdominal pain
Coronary artery disease status post coronary artery bypass
grafting
Chest pain
====================
SECONDARY DIAGNOSES:
====================
Heart failure with reduced ejection fraction
Anemia
Hypertension
Type ___ diabetes mellitus
Depression
Allergic rhinitis
Peripheral neuropathy
Asthma
Gastroesophageal reflux disease
Vitamin D deficiency
Migraine
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with CHF and recent admission presenting with chest
pain and diarrhea// Pulmonary edema compared to prior?
COMPARISON: Chest radiograph ___
FINDINGS:
PA and lateral views of the chest provided.
Median sternotomy wires are intact. Mediastinal surgical clips are noted. No
focal consolidation. Re-demonstrated slight prominence of the interstitial
markings could be due to mild interstitial pulmonary edema. No pleural
effusion or pneumothorax. Heart size is mildly enlarged, unchanged.
IMPRESSION:
Re-demonstrated mild prominence of the interstitial markings could be due to
mild interstitial edema versus chronic changes. No focal consolidation to
suggest pneumonia.
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: Hyperglycemia, Nausea
Diagnosed with Epigastric pain
temperature: 98.0
heartrate: 88.0
resprate: 17.0
o2sat: 97.0
sbp: 128.0
dbp: 67.0
level of pain: 0
level of acuity: 3.0 | ___ is a ___ woman with a history of CAD
status post CABG ___ (LIMA-LAD, rSVG-RCA, rSVG-OM,
rSVG-diagonal), HFrEF (20%), DM2, HTN, migraine, reported
history of chronic pancreatitis, and GERD who presented with
headache, nausea, chest pain, and abdominal pain.
Of note, patient was hospitalized from ___ with similar
symptoms. She did undergo nuclear stress testing which showed a
mild reversible defect in the distal anterior wall and apex. It
was ultimately felt that the patient's symptoms were primarily
the result of volume overload and she was therefore diuresed.
Coronary angiography was deferred. Her epigastric tenderness was
evaluated with an abdominal CT that showed no evidence of acute
pancreatitis. Prior to discharge, she states her symptoms had
improved.
During this hospitalization, trops were negative, and EKG was
without ischemic changes. Her abdominal pain, chest pain,
headache, and nausea self-improved such that at discharge, they
were minimal. She was also started on Imdur, as her chest pain
was felt to have a possible anginal component.
==================== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
atenolol
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___ Laparoscopic cholecystectomy
History of Present Illness:
HPI: Mr. ___ is a ___ male with history of CVA in
___
without residual deficit, afib on Coumadin, known PFO, HTN, HLD,
GERD, anxiety who presents with gallstone pancreatitis as a
transfer from BID-P on ___.
Patient reports heartburn in the past but this abdominal pain
that started abruptly yesterday was different; sharp, stabbing
RUQ nonradiating. No associated fever, jaundice, SOB, or chest
pain. He had a bout of nausea with vomiting with meal yesterday.
He then presented to BID-P and had nothing to eat since.
THe patient denies ever having RUQ pain like this in the past.
No
prior gallstone or gallbladder issues known to him. Had EGD
before for GERD but no prior ERCP. He reports a normal BM
yesterday morning.
At BID-P, he reportedly had transaminitis, elevated lipase, with
right upper quadrant ultrasound with CBD of 6 mm that was unable
to visualize the gallbladder. CT abdomen pelvis there showed a
gallbladder with gallstones inside. Also noted to have
pancreatitis with peripancreatic fluid.
Here in our ED, he had lipase of 858, ALT 215, AST 161, ALP 57,
Tbili 1.1. WBC 10.2 without bands.
ED: given 1L NS
History obtained from patient.
Past Medical History:
CVA in ___ without residual deficit,
afib on Coumadin,
known PFO,
HTN,
HLD,
GERD,
anxiety
PAST SURGICAL HISTORY:
varicose vein stripping
Social History:
___
Family History:
Negative for parents with biliary disease. Sister did have
gallbladder removed though.
Physical Exam:
Admission Physical Exam:
Vitals: 98.3 | 98.3 | 87 140/78 | 18 | 95 Ra
GEN: A&O, NAD
HEENT: No scleral icterus or jaundice, , mucus membranes moist,
OP clear
CV: Irregular rhythm, regular rate, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, mild epigastric tenderness, no rebound
or guarding, no palpable masses
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam:
VS: 98.1 PO 156 / 95 77 18 98 RA
Gen: Appears well, AAOx3
CV: RRR
Resp: Normal effort, no distress
Abdomen: Soft, nondistended, mildly tender to palpation as
anticipated, no rebound or guarding. Abdominal Incisions C/D/I.
Ext: Warm, well perfused, no edema.
Pertinent Results:
___ Imaging MRCP (MR ABD ___
IMPRESSION:
1. Cholelithiasis without evidence of choledocholithiasis. No
intra or
extrahepatic biliary dilatation.
2. Focal acute pancreatitis involving the distal pancreatic
body and tail. No peripancreatic collection is seen. Small
amount of free intraabdominal fluid.
PATHOLOGY:
1. Gallbladder, cholecystectomy:
- Chronic cholecystitis and cholelithiasis.
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
___ 07:33 36 15 44 0.9
___ 06:50 45* 16 46 1.0
___ 07:10 46* 17 40 1.1
___ 07:35 65* 23 47 1.6*
___ 07:50 104* 33 55 1.7*
___ 02:35 215*1 161*1 57 1.1
OTHER ENZYMES & BILIRUBINS Lipase
___ 09:15 70*
___ 02:35 858*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO DAILY
2. Lisinopril 10 mg PO DAILY
3. LORazepam 0.5 mg PO QHS:PRN Anxiety
4. Pravastatin 10 mg PO QPM
5. Warfarin 2.5 mg PO DAILY16
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO BID
3. Enoxaparin Sodium 98 mg SC BID Duration: 2 Weeks
talk to your cardiologist about when to stop lovenox injections.
RX *enoxaparin 100 mg/mL 0.98 mL SQ twice a day Disp #*28
Syringe Refills:*0
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation
5. Lisinopril 10 mg PO DAILY
6. LORazepam 0.5 mg PO QHS:PRN Anxiety
7. Omeprazole 20 mg PO DAILY
8. Pravastatin 10 mg PO QPM
9. Warfarin 2.5 mg PO DAILY16
please follow up with ___ clinic for dosing.
Discharge Disposition:
Home
Discharge Diagnosis:
Gallstone pancreatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MRCP
INDICATION: ___ year old man with gallstone pancreatitis, went to outside
hospital and found to have transaminitis, elevated lipase. Right upper
quadrant ultrasound with CBD of 6 mm. Unable to visualize the gallbladder. CT
abdomen pelvis shows a gallbladder with gallstones inside. Also noted
pancreatitis with peripancreatic fluid.// eval choledocholithiasis
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
Intravenous contrast: 10 mL Gadavist.
Oral contrast: 1 cc of Gadavist mixed with 50 cc of water was administered
for oral contrast.
COMPARISON: CT torso from ___
FINDINGS:
Lower Thorax: Bibasilar atelectasis worse on the right
Liver: No significant hepatic steatosis seen. Multiple tiny T2 hyperintense
thin-walled nonenhancing cysts are seen throughout the hepatic parenchyma,
largest cluster of cysts is seen in segment 2 measuring 2.9 x 1.8 cm. No
suspicious solid mass identified. The portal and hepatic veins are patent.
Biliary: There is no evidence of intra or extrahepatic biliary dilatation. No
evidence of bile duct wall enhancement. Gallbladder is non distended and
shows multiple intraluminal calculi. No calculus or filling defect seen
within the CBD.
Pancreas: There is mild enlargement of the distal pancreatic body and tail
with mild surrounding stranding and minimal fluid extending into the left
anterior para renal space. No peripancreatic collection seen. The remaining
pancreas shows homogeneous signal intensity and enhancement without focal
mass. No pancreatic ductal dilatation seen.
Spleen: Homogeneous parenchymal enhancement and normal size
Adrenal Glands: Symmetric in shape and sized. No focal mass is seen.
Kidneys: Both kidneys show normal parenchymal enhancement. No hydronephrosis
seen. No focal mass identified.
Gastrointestinal Tract: Visualized bowel loops are normal in caliber and wall
thickness.
Lymph Nodes: No significant lymphadenopathy in the retroperitoneum and
visualized mesentery.
Small amount of abdominal free fluid.
Vasculature: Aorta and IVC are within normal limits of sized.
Osseous and Soft Tissue Structures: No abnormal marrow signal seen.
IMPRESSION:
1. Cholelithiasis without evidence of choledocholithiasis. No intra or
extrahepatic biliary dilatation.
2. Focal acute pancreatitis involving the distal pancreatic body and tail.
No peripancreatic collection is seen. Small amount of free intraabdominal
fluid.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abnormal labs, Upper abdominal pain
Diagnosed with Biliary acute pancreatitis without necrosis or infection
temperature: 98.5
heartrate: 90.0
resprate: 16.0
o2sat: 94.0
sbp: 128.0
dbp: 94.0
level of pain: 3
level of acuity: 3.0 | TRANSITIONAL ISSUES:
-Patient will need INR level drawn on ___ (being bridged
from lovenox to Coumadin).
-On MRCP, there were multiple tiny T2 hyperintense thin-walled
nonenhancing cysts are seen throughout the hepatic parenchyma,
largest cluster of cysts is seen in segment 2 measuring 2.9 x
1.8 cm. No suspicious solid mass identified. This is likely a
benign incidental finding. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right leg and arm pain
Major Surgical or Invasive Procedure:
___: Right leg fasciotomies
___: Right leg irrigation and debridement, medial closure,
lateral wound vac placement
___: Right leg incision and draingae, lateral closure
History of Present Illness:
___ who presents with right leg and arm pain. Pt recently
discharged from rehab facility for heroin abuse. Pt recently
relapsed and did heroin yesterday and subsequently passed out
for unclear amount of time. Now complains of pain to right leg
and rash to right leg. Also reports tingling in RUE and
inability to extend wrist since waking up on the floor. Pt
reports she injects in her upper extremities, never her lower
extremities.
Past Medical History:
None
Social History:
___
Family History:
NC
Physical Exam:
RUE:
SILT in m/r/u/ax distributions
Full strength (___) in deltoid, biceps, and triceps. Able to
extend wrist against resistance. Unable to fire EPL. Unable to
appreciably extend ___ or ___ fingers, extends ___ and ___
fingers, able to clench fist tightly, weakly abduct/adduct
fingers.
Digits all WWP, radial pulse 2+
RLE:
Medial/lateral leg incisions c/d/i with sutures in place. No
excessive
erythema, induration, or drainage
Minimal swelling
SILT in DP/SP/Saph/Sural/Tib distributions
-___, ___
2+ DP pulse
Pertinent Results:
___ 07:40AM BLOOD WBC-7.0 RBC-3.81* Hgb-11.6* Hct-36.5
MCV-96 MCH-30.5 MCHC-31.8 RDW-13.4 Plt ___
___ 09:21AM BLOOD Glucose-93 UreaN-6 Creat-0.6 Na-143 K-4.0
Cl-106 HCO3-34* AnGap-7*
___ 01:00PM BLOOD ALT-68* AST-82* LD(___)-404* CK(CPK)-551*
___ 08:43AM BLOOD ALT-138* AST-273* LD(___)-561*
CK(CPK)-4472* AlkPhos-57 TotBili-0.5
___ 08:00AM BLOOD ALT-181* AST-498* LD(___)-696*
___ AlkPhos-59 TotBili-0.5
___ 04:08PM BLOOD ___
___ Right hand and forearm films:
The alignment is normal without fracture or dislocation. No
foreign bodies are visualized.
Medications on Admission:
Gabapentin
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Lithium Carbonate 150 mg PO DAILY
3. Multivitamins 1 CAP PO DAILY
4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every
four (4) hours Disp #*80 Tablet Refills:*0
5. Gabapentin 800 mg PO Q8H
6. Enoxaparin Sodium 40 mg SC QPM
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 40 mg SC nightly Disp #*14 Syringe
Refills:*0
7. Docusate Sodium 100 mg PO BID
Please take while taking prescription pain medication
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*50 Capsule Refills:*0
8. Calcium Carbonate 500 mg PO QID:PRN indigestion
9. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right leg compartment syndrome
Right hand PIN and ulnar neurapraxias
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
(crutches).
Followup Instructions:
___
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS RIGHT
INDICATION: ___ with unilateral swelling and pain // evidence of DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the right lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow and augmentation of the right common
femoral, superficial femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial veins. The peroneal
veins are not well seen.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right lower extremity veins.
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US RIGHT
INDICATION: ___ with unilateral swelling and pain // evidence of DVT
TECHNIQUE: Grey scale and Doppler evaluation was performed on the right upper
extremity veins.
COMPARISON: None.
FINDINGS:
There is normal flow with respiratory variation in the bilateral subclavian
veins.
The right internal jugular and axillary veins are patent and compressible with
transducer pressure.
The right brachial, basilic, and cephalic veins are patent, compressible with
transducer pressure and show normal color flow and augmentation.
IMPRESSION:
No evidence of deep vein thrombosis in the right upper extremity.
Radiology Report
EXAMINATION:
FOREARM (AP AND LAT) RIGHT
INDICATION:
___ y/o woman with right forearm swelling, sensory disturbance, and pain //
Evaluate for bony injury or foreign body R forearm
TECHNIQUE: Two views of the right 4R
COMPARISON: None.
IMPRESSION:
The alignment is normal without fracture or dislocation. No foreign bodies are
visualized.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Tachycardia
Diagnosed with NONTRAUMATIC COMPARTMENT SYNDROME OF LOWER EXTREMITY, RHABDOMYOLYSIS, HYPOKALEMIA
temperature: 100.6
heartrate: 148.0
resprate: 18.0
o2sat: 100.0
sbp: 130.0
dbp: 80.0
level of pain: 10
level of acuity: 1.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have right leg compartment syndrome and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for right leg fasciotomies, ___
for right leg irrigation and debridement, medial closure,
lateral wound vac placement, and
___ for right leg incision and draingae, lateral closure,
all of which the patient tolerated well (for full details please
see the separately dictated operative reports).
Following all operations, the patient was taken from the OR to
the PACU in stable condition and after recovery from anesthesia
was transferred to the floor. The patient was given
perioperative antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization.
The patient was also found to have right hand motor dysfunction
likely secondary to neurapraxic injury of the PIN and ulnar
nerves. Right forearm and hand films were taken and found to be
normal. The patient was given a volar resting splint with
fingers in extension to be worn at night only. She will
follow-up in hand clinic in ___ weeks.
Of note, there were two instances when the patient was found to
have needles on her possession. After the second time she was
found with a needle, she was restricted to no visitors. These
incidences were documented in the medical record.
The patient worked with ___ who determined that discharge to home
was appropriate.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. She was tolerating a regular diet. The patient is
weight bearing as tolerated in the right upper extremity and
right lower extremity. She will be discharged on lovenox for DVT
prophylaxis. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / tenofovir
Attending: ___
Chief Complaint:
referred for acute on chronic renal failure
Major Surgical or Invasive Procedure:
S/p right ureteral stent placement ___
History of Present Illness:
___ is a ___ year old man with well controlled HIV (on
Biktarvy), CKD (etiology unclear, perhaps related to ATN that
never recovered after a cholecystectomy in ___, suboptimally
controlled hypertension, nephrolithiasis s/p lithotripsy with
ureter stenting ___, and prior right MCA ischemic stroke on
aspirin/plavix who is presenting to the ED for evaluation of
acute on chronic renal failure.
Referred to ED by PCP ___, ID) after a discussion
with the renal fellow ___) for rising
creatinine of unclear etiology.
Of note, patient recently had his lisinopril increased from 30mg
to 40mg at the end of ___ given ongoing hypertension. His
creatinine was stable on ___ at 1.7 (baseline 1.5-1.8). His
labs were then re-checked on ___, and since that time his
creatinine has been in 3.5-3.8 range. He was told to stop taking
the lisinopril for the last couple days but the SCr elevation
persisted and thus was referred to the ED.
In the ED he has been hypertensive with BPs ranging 200s/100s
without fevers. His exam was otherwise unremarkable per the ED
documentation. His labs other than the BUN/SCr are stable and
the urine has trace blood and protein. His renal ultrasound
showed interval development of moderate-severe right-sided
hydronephrosis.
On arrival to floor, patient states he overall feels well. He
does note that he has had some R sided flank pain that was
intense for one day last week but improved after sleeping it
off. He has had occasional flank pain since then.
Past Medical History:
- HIV on HAART
- Fanconis
- Obesity
- OSA on CPAP (recently CPAP machine broke and he has not been
able to get it fixed)
- Smoking
- Hypertension
- Hyperlipidemia
- Chronic kidney disease (baseline 1.5-1.8)
Social History:
___
Family History:
History of hypertension in mother and father. No history of
kidney disease.
Physical Exam:
ADMISSION EXAM:
VITALS: ___ 0420 Temp: 97.7 PO BP: 168/90 HR: 63 RR: 18 O2
sat: 99% O2 delivery: Ra Dyspnea: 0 RASS: 0 Pain Score: ___
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. ___ strength throughout. Normal sensation.
DISCHARGE EXAM:
VITALS: Afebrile, HR ___, BP 120-130s/70-80s, SaO2 95-99% RA
GENERAL: Alert and interactive.
HEENT: PERRL. MMM.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
GU: Normal exam, no tenderness to palpation, no erythema or
swelling noted.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+ bilaterally.
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: AOx3.
Pertinent Results:
ADMISSION LABS:
___ 09:50PM BLOOD WBC-7.7 RBC-5.14 Hgb-14.9 Hct-45.9 MCV-89
MCH-29.0 MCHC-32.5 RDW-13.2 RDWSD-43.1 Plt ___
___ 09:50PM BLOOD Neuts-58.7 ___ Monos-8.1 Eos-3.3
Baso-0.8 Im ___ AbsNeut-4.49 AbsLymp-2.22 AbsMono-0.62
AbsEos-0.25 AbsBaso-0.06
___ 09:15AM BLOOD ___ PTT-37.8* ___
___ 09:50PM BLOOD Glucose-79 UreaN-46* Creat-3.7* Na-141
K-4.5 Cl-105 HCO3-24 AnGap-12
PERTINENT REPORTS:
RENAL ULTRASOUND ___:
Interval development of moderate-severe right-sided
hydronephrosis. No stones in the right kidney or obstructing
stones are definitively visualized. No suspicious renal masses
on the right. Multiple simple cysts including a large anechoic
right renal cyst which measures 9.7 x 7.2 x 8.4 cm off of the
lower pole, previously 9.1 x 7.9 x 8.8 cm.
There is no hydronephrosis, or suspicious masses in the left
kidney. Within the left kidney, there is a 2.0 cm simple cyst,
as well as multiple echogenic foci which may represent
nonobstructing collecting system stones or milk of calcium
within the collecting system, measuring up to 0.8 cm. Normal
cortical echogenicity and corticomedullary differentiation are
seen bilaterally.
Right kidney: 13.5 cm
Left kidney: 12.3 cm
The bladder is moderately well distended and normal in
appearance. Bilateral ureteral jets were demonstrated
CT A/P W/O CONTRAST ___:
1. Two adjacent obstructing calculi measuring 6 and 5 mm each
within the mid to distal right ureter causing obstruction with
moderate to severe
hydroureteronephrosis on the right. There is periureteric fat
stranding at the level of obstruction, without a surrounding
fluid collection.
2. Multiple additional bilateral nonobstructing renal collecting
system stones measuring up to 6 mm on the right and 9 mm on the
left.
3. Pneumobilia, similar to a prior CT from ___, likely
representative of
prior biliary procedure such as sphincterotomy.
4. Small hiatal hernia.
ABDOMINAL FLUORO ___:
13 intraoperative fluoroscopic images obtained at the time of
right ureteral stent placement have been provided for
interpretation. Serial images demonstrate a wire, contrast
within the ureter and collecting system and final placement of a
stent, only the proximal portion of which is visualized. Filling
defects within the ureter likely represent air bubbles.
DISCHARGE LAB:
___ 08:30AM BLOOD WBC-7.4 RBC-5.00 Hgb-14.6 Hct-45.1 MCV-90
MCH-29.2 MCHC-32.4 RDW-13.7 RDWSD-45.3 Plt ___
___ 08:30AM BLOOD Glucose-106* UreaN-44* Creat-3.9* Na-144
K-4.8 Cl-104 HCO3-26 AnGap-14
___ 08:30AM BLOOD Calcium-9.3 Phos-4.5 Mg-1.8
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Bictegrav-Emtricit-Tenofov Ala 1 TAB PO DAILY
2. Aspirin 81 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Rosuvastatin Calcium 40 mg PO QPM
5. Lisinopril 40 mg PO DAILY
6. Labetalol 800 mg PO BID
7. Klor-Con M20 (potassium chloride) 20 mEq oral DAILY
Discharge Medications:
1. Oxybutynin 5 mg PO TID:PRN bladder spasms
RX *oxybutynin chloride 5 mg 1 tablet(s) by mouth three times a
day Disp #*90 Tablet Refills:*0
2. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*30
Capsule Refills:*1
3. Aspirin 81 mg PO DAILY
4. Bictegrav-Emtricit-Tenofov Ala 1 TAB PO DAILY
5. Clopidogrel 75 mg PO DAILY
6. Labetalol 800 mg PO BID
7. Rosuvastatin Calcium 40 mg PO QPM
8. HELD- Klor-Con M20 (potassium chloride) 20 mEq oral DAILY
This medication was held. Do not restart Klor-Con M20 until your
creatinine improves and your doctor says it is ok to start.
9. HELD- Lisinopril 40 mg PO DAILY This medication was held. Do
not restart Lisinopril until your creatinine improves and your
doctor says it is ok to start.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Hydronephrosis ___ obstructive calculi in right ureter
Acute on chronic renal failure
Secondary diagnoses:
HIV
Hypertension
Right MCA Stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT ABD AND PELVIS W/O CONTRAST
INDICATION: NO_PO contrast; History: ___ with hydro, AKINO_PO contrast// CTU
noncom to assess for obstructive process causing hydro
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.8 s, 53.8 cm; CTDIvol = 27.6 mGy (Body) DLP =
1,486.8 mGy-cm.
Total DLP (Body) = 1,487 mGy-cm.
COMPARISON: CT U ___
FINDINGS:
Optimal evaluation of organ pathology and vasculature is limited without the
benefit of intravenous contrast.
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout.
There is no evidence of focal lesions within the limitations of an unenhanced
scan. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. Pneumobilia is again noted, and appears similar in extent to the
prior study from ___, suggestive of prior biliary procedure such as
sphincterotomy. The gallbladder is not present.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions within the limitations of an unenhanced scan. There is no
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: 1.0 cm fat density left renal lesion consistent with a myelolipoma.
Otherwise the bilateral adrenal glands are normal.
URINARY: The kidneys are of normal and symmetric size.
There is moderate to severe hydronephrosis on the right-new since ___, 2 discrete radiopaque calculi which appear impacted at the mid to distal
ureter measuring 6 mm superiorly and 5 mm inferiorly (series 601, image 66).
There is substantial periureteric stranding at the level of obstruction
(series 2, image 123).
No hydronephrosis on the left. There is a 6 mm nonobstructing stone within
the right renal collecting system and several nonobstructing stones within the
left renal collecting system measuring up to 9 mm (series 2 image 61, 80, 86,
90).
A 9.0 cm simple cyst exophytic off of the right lower renal pole is unchanged.
GASTROINTESTINAL: Tiny hiatal hernia. Small bowel loops demonstrate normal
caliber and wall thickness throughout. Diverticulosis of the sigmoid colon is
noted, without evidence of wall thickening and fat stranding. The appendix is
normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are grossly
unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Two adjacent obstructing calculi measuring 6 and 5 mm each within the mid
to distal right ureter causing obstruction with moderate to severe
hydroureteronephrosis on the right. There is periureteric fat stranding at
the level of obstruction, without a surrounding fluid collection.
2. Multiple additional bilateral nonobstructing renal collecting system stones
measuring up to 6 mm on the right and 9 mm on the left.
3. Pneumobilia, similar to a prior CT from ___, likely representative of
prior biliary procedure such as sphincterotomy.
4. Small hiatal hernia.
Radiology Report
TECHNIQUE: Intraoperative fluoroscopic images obtained at the time of right
ureteral stent placement
COMPARISON: CT abdomen from ___
FINDINGS:
13 intraoperative fluoroscopic images obtained at the time of right ureteral
stent placement have been provided for interpretation. Serial images
demonstrate a wire, contrast within the ureter and collecting system and final
placement of a stent, only the proximal portion of which is visualized.
Filling defects within the ureter likely represent air bubbles.
IMPRESSION:
Please refer to detailed procedural note for intraoperative findings.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abnormal labs
Diagnosed with Acute kidney failure, unspecified, Unspecified hydronephrosis
temperature: 98.1
heartrate: 66.0
resprate: 16.0
o2sat: 100.0
sbp: 205.0
dbp: 102.0
level of pain: 1
level of acuity: 3.0 | TRANSITIONAL ISSUES:
[ ] Creatinine should be checked within ___ days of discharge.
Discharge Cr 3.9. Results will be forwarded to the patient's
PCP.
[ ] Urology arranging time for surgery to treat calculi. Will
contact patient directly.
[ ] Lisinopril and potassium supplementation held on discharge.
Should be restarted once creatinine returns to baseline.
[ ] Follow-up blood pressure in outpatient setting, as
lisinopril was held during this hospitalization.
___ is a ___ year old man with well controlled HIV (on
Biktarvy), CKD (etiology unclear, Fanconi syndrome from
tenofovir use, also possibly related to ATN that never recovered
after a cholecystectomy in ___, baseline Cr ~1.7), suboptimally
controlled hypertension, nephrolithiasis s/p lithotripsy with
ureter stenting ___, and prior right MCA ischemic stroke on
aspirin/plavix who is presenting to the ED for evaluation of
acute on chronic renal failure.
#Acute on chronic renal failure
#New moderate-severe hydronephrosis
#Two obstructing calculi (6 and 5 mm) within right ureter
Baseline creatinine around 1.7, presented with a creatinine of
3.7-3.8 in the setting of new right hydronephrosis with
mid-to-distal right ureteral stones. S/p right ureteral stent
placement w/ urology. Post procedure, made 1.5L urine over next
___ hours. ___ secondary to obstructive uropathy and increased
lisinopril dose (increased from 30mg to 40mg at end of ___. Cr on discharge 3.9. Post discharge, patient will need Cr
checked within two days. Held lisinopril on discharge and it can
be restarted after his creatinine improves. Patient also
instructed to measure urine output and to increase oral
fluidintake to match losses. Advised to come back and if he
produces more than 3 L of urine in a 24-hour. will follow up
with urology as an outpatient.
#Hypertension
Held Lisinopril 40mg daily in setting of ___. Continued
Labetalol 800mg BID.
#HIV
Continued Biktarvy.
#Tenofovir-induced Fanconi's syndrome
Held Klor-Con 20mEq daily in setting of ___.
#Prior right MCA CVA
Continued Aspirin 81mg daily, Clopidogrel 75mg daily,
Rosuvastatin 40mg daily.
35 minutes spent on discharge preparation and coordination of
care |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril / Chlorhexidine
Attending: ___.
Chief Complaint:
Motor vehicle accident
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr ___ is a ___ yo M with non-ischemic cardiomyopathy resulting
in systolic heart failure (EF 15%) s/p Heartmate II LVAD
(___) as destination therapy due to morbid obesity, and h/o
pancreatitis who presents after a motor vehicle collision on
___.
Patient was restrained driver that was rear-ended at a stop and
hit the car in front of him. No head strike, airbags did not
deploy. He however hit his epigastrium against the steering
wheel and per LVAD team there were some episodes of low flow on
the monitoring. Also had an episode of vomiting on the ambulance
ride over.
On evaluation in the ED patient denies any chest pain or SoB, no
headache, vision changes, no facial numbness.
In the ED:
- Initial vitals were: 63 64/p 20 100% RA
- Labs/studies notable for:
+ CBC: WBC 5.8 H/H 12.4/37.4, Plt 222
+ Chem 10: Na 141, K 3.9, Cl 106, HCO3 24, BUN 18, Creat 1.2,
Glucose 101
+ Coags: ___ 27.8, PTT 41.1, INR 2.5
- Imaging showed:
+ CT Head: No acute intracranial process.
+ CT abdomen and pelvis: no evidence of acute intrathoracic or
intraabdominal injury within the limitation of an unenhanced
scan. LVAD and transvenous pacemaker are in appropriate
position. Severe cardiomegaly with LVAD and transvenous
pacemaker
- Patient was given: 1L NS
Vitals on transfer: 60 82 20 100% RA
On the floor, the patient states his epigastric has resolved.
Otherwise denies lightheadedness, dizziness, blurry vision,
nausea, vomiting, chest pain, shortness of breath, cough,
abdominal pain, diarrhea. States he feels well overall.
Past Medical History:
- Morbid Obesity
- H/o pancreatitis
- Non-insulin dependent Type 2 Diabetes Mellitus
- Hypertension
- Mixed Cardiomyopathy; Systolic Heart Failure with Reduced
Ejection Fraction s/p s/p Heartmate II LVAD ___ as
destination therapy
- Myocardial Infarction s/p DES to the LAD (___)
- H/o gout
Social History:
___
Family History:
Family history of ESRD in both his father and grandmother. No
known family history of cardiovascular disease.
Physical Exam:
ADMISSION EXAM
====================
Vitals: 97.8, 110/76, 61, 16, 100% RA
LVAD Settings: Flow 5.9 L/min, Speed: 9200 RPM, PI: 7.3,
Power/Watts: 6.0
Weight on admission: 172 kg
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, neck supple, JVP
unable to appreciate
Lungs: CTAB, no wheezing/crackles/rhonchi
CV: RRR, normal S1 and S2, + VAD hum
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present. Driveline c/d/i
Ext: Warm, well perfused, no pitting edema
Skin: Without rashes or lesions
Neuro: A&Ox3. Grossly intact.
DISCHARGE EXAM
======================
Vitals: 97.7, 116/68 MAP 70, 55-61, 16, 100 RA
Wt: 172 -> 173
LVAD Settings: Flow 5.6 L/min, Speed: 9200 RPM, PI: 7.1
(6.7-7.3), Power/Watts: 5.9
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, neck supple, JVP
unable to appreciate
Lungs: CTAB, no wheezing/crackles/rhonchi
CV: RRR, normal S1 and S2, + VAD hum
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present. Driveline c/d/i
Ext: Warm, well perfused, no pitting edema
Skin: Without rashes or lesions
Neuro: A&Ox3. Grossly intact.
Pertinent Results:
ADMISSION LABS
=================
___ 03:00PM BLOOD WBC-5.8 RBC-4.35* Hgb-12.4* Hct-37.8*
MCV-87 MCH-28.5 MCHC-32.8 RDW-14.5 RDWSD-46.1 Plt ___
___ 03:00PM BLOOD Neuts-54.4 ___ Monos-9.1 Eos-0.5*
Baso-0.9 Im ___ AbsNeut-3.18 AbsLymp-2.03 AbsMono-0.53
AbsEos-0.03* AbsBaso-0.05
___ 03:00PM BLOOD ___ PTT-41.1* ___
___ 03:00PM BLOOD Glucose-101* UreaN-18 Creat-1.2 Na-141
K-3.9 Cl-106 HCO3-24 AnGap-15
___ 03:00PM BLOOD LD(LDH)-356*
___ 03:15AM BLOOD proBNP-857*
___ 03:15AM BLOOD Albumin-3.5 Calcium-9.3 Mg-2.0
___ 03:00PM BLOOD Hapto-<10*
DISCHARGE LABS
==================
___ 03:15AM BLOOD WBC-5.3 RBC-4.30* Hgb-12.1* Hct-37.4*
MCV-87 MCH-28.1 MCHC-32.4 RDW-14.6 RDWSD-46.8* Plt ___
___ 03:15AM BLOOD Glucose-83 UreaN-14 Creat-1.2 Na-140
K-3.6 Cl-106 HCO3-24 AnGap-14
___ 03:15AM BLOOD ALT-21 AST-29 LD(LDH)-315* AlkPhos-89
TotBili-0.6
REPORTS
===================
CT head ___
IMPRESSION:
No acute intracranial process
CT torso ___
IMPRESSION:
1. No evidence of acute intrathoracic or intraabdominal injury
within the limitation of an unenhanced scan. No fracture.
2. LVAD and transvenous pacemaker are in appropriate position
and grossly intact.
3. Severe cardiomegaly with LVAD and transvenous pacemaker.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 50 mg PO BID
2. Pantoprazole 40 mg PO Q24H
3. Sildenafil 20 mg PO TID
4. Warfarin 7 mg PO 2X/WEEK (WE,SA)
5. Warfarin 6 mg PO 5X/WEEK (___)
6. Aspirin 325 mg PO DAILY
7. Calcium Carbonate 600 mg PO DAILY
8. Vitamin D 3000 UNIT PO BID
9. Multivitamins 1 TAB PO DAILY
10. Thiamine 100 mg PO DAILY
11. Allopurinol ___ mg PO DAILY
12. Amiodarone 200 mg PO DAILY
13. Carvedilol 6.25 mg PO BID
14. Colchicine 0.6 mg PO DAILY
15. Digoxin 0.0625 mg PO DAILY
16. Doxycycline Hyclate 100 mg PO Q12H
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Amiodarone 200 mg PO DAILY
3. Aspirin 325 mg PO DAILY
4. Calcium Carbonate 600 mg PO DAILY
5. Carvedilol 6.25 mg PO BID
6. Colchicine 0.6 mg PO DAILY
7. Digoxin 0.0625 mg PO DAILY
8. Doxycycline Hyclate 100 mg PO Q12H
9. Losartan Potassium 50 mg PO BID
10. Multivitamins 1 TAB PO DAILY
11. Pantoprazole 40 mg PO Q24H
12. Sildenafil 20 mg PO TID
13. Thiamine 100 mg PO DAILY
14. Vitamin D 3000 UNIT PO BID
15. Warfarin 7 mg PO 2X/WEEK (WE,SA)
16. Warfarin 6 mg PO 5X/WEEK (___)
Discharge Disposition:
Home
Discharge Diagnosis:
Motor Vehicle Accident
Cardiomyopathy with LVAD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION:
CT chest abdomen pelvis without contrast
INDICATION: History: ___ with LVAD and IVC for ischemic cardiomyopathy status
post MVC with his chest hit his steering wheel.// ? LVAD mechanical issues
TECHNIQUE: Contiguous axial images were obtained through the chest, abdomen
and pelvis without intravenous contrast. Coronal and sagittal reformats were
performed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 9.3 s, 73.3 cm; CTDIvol = 23.9 mGy (Body) DLP =
1,751.7 mGy-cm.
Total DLP (Body) = 1,752 mGy-cm.
COMPARISON: Noncontrast chest CT from ___.
FINDINGS:
CHEST:
HEART AND VASCULATURE: The thoracic aorta is normal in caliber without
evidence of acute injury based on an unenhanced scan. The heart is severely
enlarged. An LVAD appears grossly intact and is in standard and unchanged
position. Transvenous pacemaker wires terminate in the right atrium and right
ventricle. There is trace pericardial effusion.
AXILLA, HILA, AND MEDIASTINUM: No axillary or mediastinal lymphadenopathy is
present. No mediastinal mass or hematoma.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Lungs are clear without masses or areas of parenchymal
opacification. The airways are patent to the level of the segmental bronchi
bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesion or laceration within the limitation of an
unenhanced scan.There is no perihepatic free fluid. There is no evidence of
intrahepatic or extrahepatic biliary dilatation. The gallbladder is within
normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesion or laceration within the limitation of an unenhanced
scan.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size. There is no evidence
of focal renal lesions or hydronephrosis. There is no perinephric
abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber. The colon and rectum are within normal limits. The appendix
is normal. There is no evidence of mesenteric injury.
There is no free fluid or free air in the abdomen.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm or retroperitoneal hematoma.
No atherosclerotic disease is noted.
BONES: Status post median sternotomy with no evidence of sternal wire fracture
or sternal dehiscence. There is no acute fracture. No focal suspicious
osseous abnormality.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
Bilateral gynecomastia is incidentally noted.
IMPRESSION:
1. No evidence of acute intrathoracic or intraabdominal injury within the
limitation of an unenhanced scan. No fracture.
2. LVAD and transvenous pacemaker are in appropriate position and grossly
intact.
3. Severe cardiomegaly with LVAD and transvenous pacemaker.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with recent MVC on Coumadin.// ? intracranial
hemorrhage
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformations and bone
algorithms reconstructions were also performed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: Head CT dated ___.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. The ventricles
and sulci are normal in size and configuration.
No osseous abnormalities seen. There is a large mucous retention cyst in the
right maxillary sinus and a small mucous retention cyst in the left maxillary
sinus. The remaining paranasal sinuses, mastoid air cells and middle ear
cavities are otherwise clear. The orbits are unremarkable.
IMPRESSION:
No acute intracranial process.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: LVAD, MVC
Diagnosed with Epigastric pain
temperature: nan
heartrate: nan
resprate: 16.0
o2sat: 99.0
sbp: nan
dbp: nan
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ y/o M with a history of non-ischemic dilated
cardiomyopathy resulting in systolic heart failure, now with
LVAD in place, who presented after a motor vehicle accident on
___.
He was the restrained driver that was rear-ended at a stop, and
hit the car in front of him. He initially had abdominal pain,
and he vomited once immediately after the accident, but
otherwise he was asymptomatic. No head strike, and airbags did
not deploy. CT head revealed no acute intracranial process. CT
torso without evidence of acute intrathoracic or intraabdominal
injury, and no evidence of acute fracture. Hgb was monitored as
it was slightly below prior baseline, but it was stable and
there was no sign of bleeding. LDH downtrended as well. He
received 1L of NS on arrival but was subsequently
hemodynamically stable during the stay.
His pacemaker was interrogated, and there was no antecedent
cardiac event prior to the accident.
Otherwise, his home medications were left unchanged, he was
asymptomatic and hemodynamically stable, and he was discharged
to home
TRANSITIONAL ISSUES
=====================
- No medication changes made
- Free hemoglobin level pending at time of discharge
- Continue to follow-up with ___ clinic
- Continue to follow-up with ___ clinic |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Dilantin / Erythromycin Base
Attending: ___.
Chief Complaint:
Fever; hypoxemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ woman with a history of metastatic vaginal sarcoma s/p
posterior pelvic exenteration, colostomy, VRAM flap for
posterior vaginal and perineal repair, b/L ureteral stents, and
pelvic radiation referred to the ED from home by her oncologist
with several days of fever, cough, night sweats, weakness, and
reported altered mental status at home.
Of note, patient has an extremely complicated course with
multiple hospitalizations over the past 3 months. On ___,
underwent pelvic exenteration, VRAM flap/pelvic reconstruction,
colostomy, and b/L ureteral stents. On ___, admitted for
urosepsis and treated with antibiotics. On ___,
re-admitted with post-op fever, presumed to have UTI and treated
with Zosyn. On ___ admitted for neutropenic fever in the
setting of chemotherapy. She was found
to have new bilateral hydroureteronephrosis, a pelvic fluid
collection, and left-sided loculated pleural effusion. Despite
negative cultures, she was treated with vanc/zosyn for 5 days
and then treated with fluconazole and nystatin. Received
Neupogen for persistent neutropenia. for oral candidiasis. Most
recently, she was admitted from ___ for cycle 2 of
Doxorubicin/Ifosfamide during which she developed a UTI that was
treated with 7 days of ciprofloxacin.
In the few days prior to admission, patient developed fevers and
symptoms described above. ED chart notes husband's report of
"lethargy" and AMS. Called oncologist who referred patient to
___ ED.
In the ED, initial vitals notable for fever 102-103 with
tachycardia into low 100s but no hypotension. She was satting
well on room air.
- Exam notable for question of rales in the left upper lung
field, non-peritonitic abdomen with well-appearing stoma and
+RLQ tenderness.
- Labs were notable for: WBC=18.2 (85% PMNs, 2 bands),
H/H=6.8/22.2; Na=129.
- Imaging:
CXR with No definite acute cardiopulmonary process. Persistent
nodular left pleural thickening and suspected effusion.
CT Abdomen/Pelvis for focal abdominal tenderness:
1. Increased left pleural tumor burden with a small left pleural
effusion.
2. Similar to slightly increased size of the right pelvic mass
involving the distal right ureter.
3. Unchanged posterior pelvic fluid collection.
4. Interval right gonadal vein thrombus.
- Patient was given:
___ 18:15 IV HYDROmorphone (Dilaudid) 0.5 mg
___ 18:49 IV CefePIME 2 g
___ 19:30 IVF NS 1 mL
___ 20:37 IV Vancomycin 1 mg
___ 22:42 IV Acetaminophen IV 1000 mg
___ 23:14 IV HYDROmorphone (Dilaudid) 1 mg
Vitals on transfer: T 102.5, HR 106, BP 114/50, RR 19, O2 98% RA
On arrival to the MICU, patient is comfortable and breathing
easily on 4L nasal cannula. She is interactive and following
commands but very somnolent.
Past Medical History:
PAST MEDICAL & SURGICAL HISTORY:
PAST ONCOLOGIC HISTORY (per OMR):
- ___ - presented for daily vaginal bleeding
- ___ - PUS 3.9x3.7x2.7cm complex hypoechoic area along R
side of vaginal wall ?hematoma; 2cm L ovarian cyst likely
physiologic follicle, no free fluid
- ___ - laceration seen along R vaginal side wall, overlying
tender bulge 3-4cm in size, slow oozing from the area
- ___ - PUS vaginal hematoma 57mmx43mmx54mm w/ color flow; R
ovarian follicles, largest 25mm, L ovary unremarkable
- ___ - laceration along R vaginal sidewall proximally,
laceration overlies tender bulge now extended distally, 5 x
4.5cm in size, no active bleeding
- ___ - MRI - 7mm endometrium, areas borderline junctional
zone thickness, myometrial signal nl, majority of cervical
signal nl, large R sided mass not distinctly separable from the
R inferior most aspect of the cervix & R side of vagina; vaginal
canal displaced L anteriorly; mass predominantly hypointense T1
and heterogeneous T2 signal 5.5x6.5x7.5cm, demonstrates
heterogeneous postcontrast enhancement; b/l adnexa wnl, no
significant free fluid, nonspecific subcentimeter nodes, no
definite invasion into rectum or posterior bladder
- ___ - seen by Dr. ___, necrotic appearing
friable mass from R mid-vagina protruding into vaginal canal 6cm
x 3cm, firm, mostly fixed, tender to palpation, biopsy obtained;
rectovaginal septum w/o nodularity; final path undifferentiated
sarcoma
- ___ CT torso - thickening of broad ligament on the R, 3mm
pulm nodule, cyst in kidney & bone island in R iliac wing
- ___ PET/CT - no e/o metastatic disease
- ___ - completed radiation 5400 cGy
- ___ - f/u w/ smooth surface exophytic mass protruding into
vagina arising out of R mid-vagina 2-3cm from R vaginal fornix,
significantly smaller; intra-vaginal portion of mass 2x4cm;
palpates 4-5cm in greatest dimension
- ___ - MRI - 4.1x2.4x4.1cm enhancing mass arising from R
posterolateral aspect of the mid to upper vaginal wall w/
projections into the vaginal canal, now separate from cervix &
decreased in size; no adj organ invasion, no pelvic LAD
- ___ - PET/CT - interval decrease in size and FDG avidity
of R vaginal lesion; no FDG avid LAD or distant mets; R iliac
wing sclerotic focus no FDG avid, likely bone island
- ___ - posterior pelvic exenteration, colostomy, VRAM
flap for posterior vaginal and perineal repair, b/l ureteral
stents for vaginal sarcoma
- ___ - admission for urosepsis
- ___ CT A/P: small 1.5 cm x 1 cm extravasated contrast
adjacent to distal ureter c/f possible ureteral leak. Mild B/L
hydroureter R>L. 4.4 x 3.0 cm fluid collection b/w VRAM flap and
sacrum, likely seroma but cannot r/o abscess.
- ___ PET: several pulmonary nodules that are new/increased
in size c/w metastatic disease. Diffuse low-level FDG uptake
along scar likely post-surgical, cannot r/o recurrence.
- Admitted to Gyn/OMED ___ for post-operative
fever, treated with course of zosyn for presumed UTI and had ___
drainage of abdominal fluid collection. She began the first
cycle of ifosfamide and doxorubicin ___, completed ___.
- Admitted to OMED ___ for neutropenic fever. Found
to have new bilateral hydroureteronephrosis, pelvic fluid
collection, and left sided loculated pleural effusion with
nodular split pleura sign. Cultures were negative. Treated with
vanco/zosyn for 5 days and discontinued. Received Neupogen for
persistent neutropenia. Treated with fluconazole and nystatin
for oral candidiasis.
OTHER PAST MEDICAL HISTORY:
- Metastatic vaginal sarcoma as above
- Chronic Cervicalgia
- L5-S1 DJD demonstrated on MRI in ___
- Chronic opioid therapy for neck and back pain
- Possible history of post-partum seizure with documented
allergy to Dilantin (followed by Dr. ___ in Neurology)
PAST SURGICAL HISTORY:
- Lower Transverse C-Section
- C6-7 anterior cervical fusion ___ (Dr. ___ at ___
___) and laminectomy in ___. Previously had
implanted spinal cord stimulator in ___ c/b staph infection.
- Pelvic exenteration ___ as above
Social History:
___
Family History:
Aunt and sister with breast cancer diagnosed around the age of
___. No h/o colon, ovarian, uterine, or other cancers.
Physical Exam:
ADMISSION PHYSICAL EXAM:
==========================
GENERAL: Thin, chronically ill appearing woman. Somnolent, but
interactive. A+O x3.
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: Diminished breath sounds, especially at bases L>R. No
wheezes or rhonchi.
ABDOMEN: nondistended, Colostomy in place, stoma dark pink.
Brown stool, guaiac negative. Mild RUQ tenderness, no
rebound/guarding. No hepatosplenomegaly.
BACK: R CVAT.
EXTREMITIES: WWP. No cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN grossly intact. Moving all four extremities. Too
somnolent to participate in full neuro exam.
DISCHARGE PHYSICAL EXAM:
============================
VS: 98.2 110 / 55 88 18 97% RA
GEN: Middle aged female laying in bed, no acute distress
HEENT: PERRL. MMM.
Cards: RRR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: CTABL no crackles or wheezes
Abd: large midline scar present in the ___ the abdomen
w/ostomy in place, bowel sounds are present, soft, NT, no
rebound/guarding, no suprapubic tenderness, mild tender to
palpation of RLQ
Extremities: Warm, no ___ edema, no pain with palpation of the
legs
Skin: no rashes or bruising
Neuro: AOx3, CNs II-XII intact. ___ strength in U/L extremities.
DTRs 2+ ___.
Pertinent Results:
Admission labs:
___ 06:20PM BLOOD WBC-18.2*# RBC-2.59* Hgb-6.8* Hct-22.2*
MCV-86 MCH-26.3 MCHC-30.6* RDW-20.1* RDWSD-59.7* Plt ___
___ 06:20PM BLOOD Neuts-85* Bands-2 Lymphs-3* Monos-6 Eos-1
Baso-0 Atyps-1* Metas-1* Myelos-1* NRBC-2* AbsNeut-15.83*
AbsLymp-0.73* AbsMono-1.09* AbsEos-0.18 AbsBaso-0.00*
___ 01:53AM BLOOD ___ PTT-31.1 ___
___ 06:20PM BLOOD Glucose-94 UreaN-7 Creat-0.7 Na-129*
K-3.4 Cl-90* HCO3-25 AnGap-17
___ 06:20PM BLOOD ALT-12 AST-30 AlkPhos-111* TotBili-0.2
___ 06:20PM BLOOD Albumin-2.7* Calcium-8.1* Phos-3.0 Mg-1.8
___ 02:24AM BLOOD calTIBC-127* Ferritn-563* TRF-98*
___ 02:28AM BLOOD ___ pO2-38* pCO2-50* pH-7.36
calTCO2-29 Base XS-1
Pertinent results:
___ 06:20PM BLOOD Lipase-9
___ 02:28AM BLOOD Lactate-1.0
___ 08:21PM BLOOD Lactate-1.4
Microbiology:
___ 6:20 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). >100,000
CFU/mL.
Imaging:
CT A/P with contrast: ___
1. Increased left pleural tumor burden with a small left pleural
effusion.
2. Similar to slightly increased size of the right pelvic mass
involving the distal right ureter.
3. Unchanged posterior pelvic fluid collection.
4. Interval right gonadal vein thrombus.
Echo ___:
Left ventricular wall thickness, cavity size, and overall
systolic function are normal (LVEF = 70%). Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Right ventricular chamber size and free wall
motion are normal. There is no pericardial effusion.
LENIs ___:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
CXR ___:
Increasing bilateral diffuse airspace opacities are likely
reflective of
worsening pulmonary edema. Stable pleural effusions bilaterally
as well as a left basilar opacity.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ClonazePAM 0.5 mg PO QHS:PRN insomnia
2. Escitalopram Oxalate 10 mg PO DAILY
3. Gabapentin 800 mg PO TID
4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
5. Nystatin Oral Suspension ___ mL PO QID:PRN mouth pain
6. OxyCODONE SR (OxyconTIN) 60 mg PO Q8H
7. Ondansetron 4 mg PO Q8H:PRN nausea
8. Neulasta (pegfilgrastim) 6 mg/0.6mL subcutaneous ONCE
9. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
Discharge Medications:
1. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 14 Days
RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice daily Disp
#*20 Tablet Refills:*0
2. Neulasta (pegfilgrastim) 6 mg/0.6mL subcutaneous ONCE
3. ClonazePAM 0.5 mg PO QHS:PRN insomnia
RX *clonazepam 0.5 mg 1 tablet(s) by mouth qhs: prn Disp #*7
Tablet Refills:*0
4. Escitalopram Oxalate 10 mg PO DAILY
5. Gabapentin 800 mg PO TID
6. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
RX *hydromorphone 4 mg ___ tablet(s) by mouth q 4 hours Disp
#*24 Tablet Refills:*0
7. Nystatin Oral Suspension ___ mL PO QID:PRN mouth pain
8. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth q 8 hoursa Disp #*9
Tablet Refills:*0
9. OxyCODONE SR (OxyconTIN) 60 mg PO Q8H
RX *oxycodone [OxyContin] 60 mg 1 tablet(s) by mouth q 8 hours
Disp #*6 Tablet Refills:*0
10. HELD- Sulfameth/Trimethoprim DS 1 TAB PO DAILY This
medication was held. Do not restart Sulfameth/Trimethoprim DS
until you discuss this with your doctor and you complete the
course of cefpodoxime
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Fever
Sepsis
Right gonadal vein thrombosis
Hypoxemia
SECONDARY DIAGNOSES:
Hydronephrosis
Metastatic vaginal sarcoma
Depression
Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiograph.
INDICATION: ___ with neutropenic fever. Assess for pneumonia
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___. ___
FINDINGS:
Lungs are moderately well inflated. Unchanged left lower lobe opacity.
Interval resolution of right upper lobe opacity noted. Stable moderate sized
left pleural effusion with nodular pleural thickening. No right pleural
effusion. No pneumothorax. Heart size, mediastinal contour, and hila are
unremarkable. Cervical fixation hardware is noted.
IMPRESSION:
No definite acute cardiopulmonary process. Persistent nodular left pleural
thickening and suspected effusion.
Radiology Report
INDICATION: ___ with RLQ abdominal pain, fever, tachycardiaNO_PO contrast //
Please evaluate for acute surgical and/or infectious intra-abdominal process
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 497 mGy-cm.
COMPARISON: CT abdomen/pelvis from ___ and CT chest from ___.
FINDINGS:
LOWER CHEST: There is a small left pleural effusion with irregular pleural
thickening, which has increased since ___. This is concerning for
tumoral involvement of the pleura and malignant pleural effusion. Adjacent
atelectasis is noted. There is a small right pleural effusion which is new
since ___. No pericardial effusion is seen.
ABDOMEN:
HEPATOBILIARY: The liver is homogeneous in background attenuation without
focal lesion or intra or extrahepatic biliary duct dilation. The main portal
vein is patent. The gallbladder is within normal limits.
PANCREAS: The pancreas is normal in attenuation, without focal lesion, ductal
dilation, or peripancreatic stranding or fluid collection.
SPLEEN: The spleen is homogeneous and normal in size.
ADRENALS: The adrenal glands are normal in caliber and configuration
bilaterally.
URINARY: The kidneys are symmetric and normal in size. There are delayed
nephrograms bilaterally. Severe hydronephrosis bilaterally with a
nephroureteral stent on the right, are unchanged. No concerning focal renal
lesion is identified. Hypodensities in the interpolar region of the right
kidney are too small to characterize but likely represent simple renal cysts.
There is no perinephric abnormality.
GASTROINTESTINAL: There is a small hiatal hernia. The stomach is relatively
decompressed, but there is no obvious focal wall thickening or mass. Small
bowel loops are normal in caliber without wall thickening or evidence of
obstruction. The patient is status post distal colectomy, with a left lower
quadrant colostomy. The remainder of the large bowel was within normal
limits. A normal appendix is visualized.
PELVIS: The urinary bladder is within normal limits. Again seen is a soft
tissue mass involving the distal right ureter is similar to slightly increased
in size allowing for differences in planes of scanning, measuring 3.3 x 4.3 x
6.1 cm (2:73, 601b:30, previously 3.0 x 4.6 x 5.8 cm). Ill-defined hyper
enhancement of the distal left ureter is unchanged. The posterior pelvic
fluid collection is decreased in size, now measuring 1.1 x 3.9 cm (2:74,
previously 1.5 x 5.2 cm). No new fluid collection is identified.
REPRODUCTIVE ORGANS: The uterus is surgically absent.
LYMPH NODES: There is no retroperitoneal, mesenteric, pelvic, or inguinal
lymph node enlargement by CT size criteria.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted. There is filling defect within the right gonadal vein (02:50) which
is new since prior exam.
BONES: A 12 mm sclerotic lesion in the left iliac bone is unchanged. No new
focal lytic or sclerotic osseous lesion is identified. Fixation hardware at
the L5-S1 levels noted.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits besides
postoperative changes detailed above. .
IMPRESSION:
1. Increased left pleural tumor burden with a small left pleural effusion.
2. Similar to slightly increased size of the right pelvic mass involving the
distal right ureter.
3. Unchanged posterior pelvic fluid collection.
4. Interval right gonadal vein thrombus.
NOTIFICATION: The updated finding of impression point 4 was discussed with
___, M.D. by ___, M.D. on the telephone on ___ at
10:55 ___, 5 minutes after discovery of the findings.
Radiology Report
EXAMINATION: Chest radiograph.
INDICATION: ___ with tachycardia hypoxia fever. Assess for pulmonary edema
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___.
FINDINGS:
Lungs are moderately well inflated with new bilateral perihilar interstitial
opacities. Persistent left lower lobe opacity. Stable moderate-sized left
pleural effusion with nodular pleural thickening. New trace right pleural
effusion. No pneumothorax. Interval increase in mild cardiomegaly.
Mediastinal contour and hila are unremarkable.
IMPRESSION:
1. New mild pulmonary edema with mild cardiomegaly, new trace right pleural
effusion and stable moderate left pleural effusion.
2. Persistent left nodular pleural thickening.
Radiology Report
INDICATION: ___ year old woman with hypoxemia in the setting of metastatic
cancer to lungs, pleural effusion // interval change
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
Increased bilateral diffuse airspace opacities likely reflecting worsening
pulmonary edema. Small bilateral pleural effusions are unchanged as well as
the nodular thickening along the left pleural surface and left basilar
opacity. No pneumothorax is identified. The size of the cardiomediastinal
silhouette is enlarged but unchanged.
IMPRESSION:
Increasing bilateral diffuse airspace opacities are likely reflective of
worsening pulmonary edema. Stable pleural effusions bilaterally as well as a
left basilar opacity.
Radiology Report
EXAMINATION: ___ DUP EXTEXT BIL (MAP/DVT)
INDICATION: ___ woman with metastatic vaginal sarcoma s/p
exenteration, pelvic radiation, and chemotherapy p/w fevers, AMS, and
leukocytosis consistent with sepsis incidentally found to have gonadal vein
thrombus admitted to the ICU for hypoxemia. // ? DVTs
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the bilateral
common femoral, femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Fever, Cough, Dysuria
Diagnosed with Fever, unspecified
temperature: 101.0
heartrate: 109.0
resprate: 18.0
o2sat: 95.0
sbp: 114.0
dbp: 57.0
level of pain: 6
level of acuity: 3.0 | ___ woman with metastatic vaginal sarcoma s/p pelvic
exenteration and chemotherapy presenting with several days of
fevers and altered mental status with ED course complicated by
hypoxemia admitted to ICU for hypoxemia and management of
sepsis, incidentally noted to have right gonadal vein
thrombosis. Pt was briefly treated in ICU and then transferred
to the floor.
============== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
erythromycin base
Attending: ___
Chief Complaint:
CODE STROKE: facial droop
Major Surgical or Invasive Procedure:
none
History of Present Illness:
per Dr. ___ note:
The patient is a ___ year-old right-handed woman with hx of HTN
and recent laparoscopic gastric bypass surgery with 55 Lbs
Weight loss, presented to the hospital with difficulty in
writing, walking, hand numbness and facial droop with concern
for stroke.
She noted that about 2 days ago after 2 weeks of stay in ___,
she was back home by plane. She felt tired but did not have any
complaint. Today she woke up in the morning, around 1040 she
walked to her car, drove to the mall( 20 minutes of drive,
without any difficulty. It was 1100 when she parked and got off
her car, she wanted to walk to the mall when she noticed that
instead of walking straight, she is drifting toward the right.
Then she decided to test this with walking on a line, which she
could not. She thought "maybe this is because I am tired". She
picked up a gift and when she wanted to pay with her credit card
and wanted to sign the paper, she could not sign it, she also
felt numb in her right ___ fingers. She drove home
without difficulty, walked into her home. She was telling her
husband the story of her problems, when she felt her speech is
different and her voice is different, at the same time she felt
that her right face is heavy and when she checked it in the
mirror it was droopy. He daughter who was upstairs heard her and
recommended to go to the hospital with concern for stroke. By
the time that she arrived her numbness, speech and facial droop
improved but not to her baseline. Over the 2 hours of stay in
the ED the symptoms even improved more but still not to her
baseline.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysphagia, lightheadedness, vertigo, tinnitus
or hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness, paresthesia. No
bowel or bladder incontinence or retention.
On general review of systems, the pt denies recent fever or
chills. No night sweats. Denies cough, shortness of breath.
Denies chest pain or tightness, palpitations. Denies nausea,
vomiting, diarrhea, constipation or abdominal pain. No recent
change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias. Denies rash.
Past Medical History:
OSA resolved after Gastric bypass surgery which was done 6
months ago. She lost about 55 LBS after the surgery. HTN, which
was detected 6 months ago, now her BP is under control with diet
and lisinopril.
Social History:
___
Family History:
She is adopted and her daughter is healthy.
Physical Exam:
ADMISSION EXAM:
97.4 55 105/57 19 100% RA
General: Awake, cooperative, no apparent distress.
HEENT: Normocephalic, atraumatic, with no scleral icterus noted.
Mucus membranes moist, no lesions noted in oropharynx
Neck: Supple. No carotid bruits appreciated. No orbital bruits.
Cardiac: Regular rate, normal S1 and S2 no murmurs, rubs or
gallops.
Pulmonary: Lungs clear to auscultation bilaterally.
Abdomen: Soft and nontender with no hepatosplenomegaly and
normal bowel sounds.
Extremities: Warm, well-perfused. Calves soft and non-tender and
good peripheral pulses.
Skin: has a erythomatous maculopapular rash in her neck.
Skull & Spine: No spinal tenderness. Good range of motion of
head with no pain.
Neck flexion and extension are normal.
Neurological examination:
Mental Status:
The patient is alert, oriented x3, attentive to ___ backward.
The patient had good knowledge of current events. Language is
fluent with intact repetition and comprehension and normal
prosody. There is no evidence of aphasia and patient was able to
name both high and low frequency objects. There were no
paraphasic errors. Speech was not dysarthric, although she
thinks it is different from her baseline, her daughter and
husband did not notice any changes in her speech. Patient is
able to read without difficulty, writing is slow but she
reported that it improved significantly. Memory was intact:
register 3 objects and recall ___ at 5 minutes. No neglect, no
parietal lobe finding: she is able to recognize the letters
written on her palm. No agraphesthesia, no astereognosis There
is no left-right agnosia.
Cranial Nerves:
The sense of smell is not tested.
Visual acuity was intact with eye glasses. The visual fields are
full to confrontation. The pupils react normally to light
directly and consensually 3 to 2 mm bilaterally.
Eye movements are normal and saccades are smooth with no
saccadic intrusions.
Sensation on the face is decreased to pin on the right face: 95%
compare to 100 in the left.
Has droop in the right face UMN pattern: able to move the right
face but slower than the left side.
Hearing is intact to finger rub bilaterally.
The palate elevates in the midline.
Neck rotation, flexion and shoulder shrug are normal and
symmetric.
The tongue protrudes in the midline and is of normal appearance.
Good normal velocity tongue movements.
Motor System:
No pronator drift, slow finger tap on the right compare to the
left, she is not able to touch either her nose or her chin with
her right index finger.
There are no adventitious movements
D/T/B/WE/WF/FE/FF
R 5/5/5/5/5/5/5
L ___
___
R 5/5/5/5/5/5/5
L ___
Reflexes:
The tendon reflexes are present, symmetric , has hyper reflexia
at the level of knee, with positive cross adductor bilaterally.
Has 5 beats of clonus bilaterally, The plantar reflexes is
flexor on the right, equivocal on the left.
Sensory System:
Sensation is intact to pin prick, light touch, vibration sense,
and position sense in all extremities and trunk, except for mild
(95 % of the baseline)diminished pinprick sensation in the right
face and right upper extremities.
Coordination:
FNF: Has slower movement on the right side with mild dysmetria.
HNK: accurate and fast bilaterally.
She is able to sit and keep her upright position.
She is able to stand up without any help, Romberg is negative,
during her casual walking her body is tilting to the right and
her direction mildly drifted toward the right side. Tandem gait
could not be tested.
DISCHARGE EXAM:
R facial droop improved but did not completely resolve with
residual right nasolabial fold flattening.
Strength was full, sensation was intact, reflexes were
symmetric.
Subtle intention tremor on R FNF, rapid alternating movements
were slower and more irregular than the left.
Pertinent Results:
ADMISSION LABS:
8.3 > 13.4/36.9 < 222
___ PTT-31.8 ___
144 | 107 | 18
---------------< 76
4.3 | 28 | 0.7
Albumin-4.0 Calcium-9.4 Phos-4.8* Mg-2.3
ALT-31 AST-30 AlkPhos-130* TotBili-0.2
___ 01:10PM BLOOD cTropnT-<0.01
___ 06:19AM BLOOD CK-MB-2 cTropnT-<0.01
___ 01:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
STROKE WORKUP:
___ 06:19AM BLOOD Cholest-168
___ 06:19AM BLOOD %HbA1c-5.4 eAG-108
___ 06:19AM BLOOD Triglyc-126 HDL-40 CHOL/HD-4.2
LDLcalc-103
___ 06:19AM BLOOD TSH-1.3
IMAGING:
MRI/MRA Head/Neck ___
IMPRESSION:
1. Small late acute/ early subacute infarctions within the left
caudate tail and left insular cortex.
2. Hypoplastic Left A1 segment. Otherwise unremarkable MRA of
the head.
3. Apparent narrowing of the proximal left internal carotid
artery just distal to the bifurcation are reconstructed images.
This may be artifactual. Limited neck MRA without vascular
occlusion.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315-250
mg-unit oral daily
2. Celebrex ___ mg oral QAM
3. Cyanocobalamin 1000 mcg PO DAILY
4. Ferrous Sulfate 325 mg PO DAILY
5. lisinopril-hydrochlorothiazide ___ mg oral daily
6. Lorazepam 0.5-1 mg PO QHS:PRN insomnia
7. potassium citrate 5 mEq (540 mg) oral daily
8. Sertraline 50 mg PO DAILY
9. Ursodiol 300 mg PO BID
10. Hydrochlorothiazide 12.5 mg PO DAILY
Discharge Medications:
1. Cyanocobalamin 1000 mcg PO DAILY
2. CELECOXIB 200 mg oral QAM
3. Sertraline 50 mg PO DAILY
4. Ursodiol 300 mg PO BID
5. Ferrous Sulfate 325 mg PO DAILY
6. Lorazepam 0.5-1 mg PO QHS:PRN insomnia
7. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315-250
mg-unit oral daily
8. potassium citrate 5 mEq (540 mg) oral daily
9. lisinopril-hydrochlorothiazide ___ mg ORAL DAILY
10. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*3
11. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*6
Discharge Disposition:
Home
Discharge Diagnosis:
small vessel ischemic stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD WITHOUT CONTRAST
INDICATION: ___ with dizziness, tingling
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of IV contrast. Coronal, sagittal and thin bone
slice reformats were generated.
DOSE: DLP: 1003 mGy-cm
CTDI: 56 mGy
COMPARISON: None available
FINDINGS:
There is no hemorrhage, edema, mass, mass effect or large vascular territorial
infarction. The ventricles and sulci are normal in size and configuration.
There is preservation of grey-white matter differentiation and the basal
cisterns are patent.
No fracture or suspicious osseous lesion is identified. A small lucent focus
in the right posterior parietal bone series 3, image 49, can relate to
avascular focus suggest hemangioma.
Hyperostosis frontalis noted.
The paranasal sinuses, mastoid air cell and middle ear cavities are clear.
IMPRESSION:
No evidence of acute intracranial process. Of note, CT has low sensitivity
for detection of acute and hyperacute ischemic cerebrovascular accident and if
there is further clinical concern a brain MR should be obtained if not
contraindicated; MR cervical spine if needed given the history of tingling.
Radiology Report
EXAMINATION: CHEST RADIOGRAPHS
INDICATION: Weakness.
TECHNIQUE: Chest, PA and lateral.
COMPARISON: ___.
FINDINGS:
The heart is normal in size. The mediastinal and hilar contours appear within
normal limits. There is no pleural effusion or pneumothorax. The lungs
appear clear.
IMPRESSION:
No evidence of acute cardiopulmonary disease.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST
INDICATION: ___ year old woman with right facial droop and right hand
clumsiness // ischemic infarction
TECHNIQUE: Three dimensional time of flight MR arteriography was performed
through the brain with MIP reconstructions. Dynamic MRA of the neck was
performed during administration of Multihance intravenous contrast. Brain
imaging was performed with sagittal T1 and axial FLAIR, T2, gradient echo and
diffusion technique
COMPARISON: No prior MRI available for comparison. Prior CT scan of the brain
dated ___.
FINDINGS:
MRI Brain: There are small regions of slow diffusion in the left caudate tail
and left insular cortex with corresponding FLAIR signal abnormality consistent
with late acute/ early subacute infarction. There is no evidence of
hemorrhage, edema, masses or shift of midline. Ventricles and sulci are
normal in caliber and configuration. There are few additional scattered
nonspecific foci of T2/FLAIR signal hyperintensity in the periventricular and
subcortical white matter. Vascular flow voids are preserved. The orbits are
unremarkable. There is minimal mucosal thickening within the ethmoid air
cells. Remaining paranasal sinuses and mastoid air cells are clear.
Hyperostosis frontalis is again incidentally noted.
MRA brain: There is mild asymmetric narrowing of the left A1 artery. The
intracranial vertebral and internal carotid arteries and their major branches
otherwise appear normal without evidence of stenosis, occlusion, or aneurysm
formation. There are bilateral fetal type posterior cerebral arteries noted
with hypoplastic P1 segments bilaterally.
MRA neck: The contrast portion of the exam is somewhat limited by poor
contrast bolus timing. On reconstructed images, there is a apparent narrowing
of the proximal left internal carotid artery just distal to the bifurcation.
The degree of stenosis is difficult to quantify on source post-contrast as
well as noncontrast time-of-flight images. The common, right internal and
external carotid arteries appear normal. The origins of the great vessels,
subclavian and right vertebral artery appear normal bilaterally. The right
vertebral artery is dominant. The origin of the left vertebral artery is not
well visualized.
IMPRESSION:
1. Small late acute/ early subacute infarctions within the left caudate tail
and left insular cortex.
2. Hypoplastic Left A1 segment. Otherwise unremarkable MRA of the head.
3. Apparent narrowing of the proximal left internal carotid artery just distal
to the bifurcation are reconstructed images. This may be artifactual.
Limited neck MRA without vascular occlusion.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Slurred speech, Ataxia
Diagnosed with CEREBRAL ART OCCLUS W/INFARCT, OTHER SPEECH DISTURBANCE, HYPERTENSION NOS
temperature: nan
heartrate: 57.0
resprate: 16.0
o2sat: 100.0
sbp: nan
dbp: nan
level of pain: 0
level of acuity: 1.0 | Ms. ___ presented with a right facial droop and transient
clumsiness/weakness of the right hand clumsiness/weakness. By
discharge, only deficit was mild R nasolabial fold flattening.
MRI showed a small vessel L sided infarct. Patient was started
on plavix 75mg qd for stroke prevention (safter than aspirin
given prior gastric bypass). Also, started atorvastatin 40mg qd
given elevated cholesterol. She will have a TTE as an
outpatient-we felt that although helpful given her hypertension
and the fact that a fraction of presumed small vessel strokes
can still be embolic in origin, it did not necessitate inpatient
stay. She will follow up with Dr. ___ in stroke clinic.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? () Yes [performed
and documented by admitting resident] (x) No
2. DVT Prophylaxis administered by the end of hospital day 2?
(x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented (required for all patients)? (x) Yes (LDL =
pending ) - () No
5. Intensive statin therapy administered? (x) Yes - () No [if
LDL >= 100, reason not given: ____ ]
(intensive statin therapy = simvastatin 80mg, simvastatin
80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin
20mg or 40mg, for LDL >= 100)
6. Smoking cessation counseling given? () Yes - (x) No [if no,
reason: (x) non-smoker - () unable to participate]
7. Stroke education given (written form in the discharge
worksheet)? (x) Yes - () No
(stroke education = personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup)
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No [if no, reason not assessed: ____ ]
9. Discharged on statin therapy? (x) Yes - () No [if LDL >= 100
or on a statin prior to hospitalization, reason not discharged
on statin: ____ ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No [if no, reason not
discharge on anticoagulation: ____ ] - (x) N/A |