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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
nausea and vomitting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ with h/o ankylosing spondilitis (on remicade
and prednisone) diabetes (from chronic steroid use)
gastroparesis (with 9 hospitalizations over the past ___ years for
vomitting) who p/w nausea and vomitting since this AM. Pt states
he awoke from sleep at 5a with sudden onset nausea. He took his
home Zofran dose but by then "it was too late" and he began
vomiting. Emesis non-bloody, currently bilious. Nausea/emesis
not relieved at home. Denies hematemesis, CP, dyspnea, diarrhea,
constipation. No recent change in PO intake from baseline, no
melena/hematochezia, change in BM consistency/color. (+) flatus.
Hx of frequent presentations to ED with identical Sx, resolved
with IVF, Zofran, Ativan, and +-Morphine. Extensive workup for
cause of cyclical vomitting but to this point, unknown. In ___,
he had an EGD that showed esophagitis with eosinophils and
neutrophils and per outpatient GI note eosinophilic gastritis
was thought to be a contributor to his condition. Etiology of
gastroparesis unknown though per some notes presumed diabetic
gastroparesis. Patient reports recent weight gain. He is a
smoker of 1.5ppd for ___, and occasionally drinks EtOH. He
denies any illicit drug use. He is currently not sexually active
but has been married to his wife for ___.
He was seen in the emergency department at ___ and admitted on
___, again ___, and ___. He saw Dr. ___ on ___ who
noted the increased frequency of episodes of nausea and
vomiting. She initiated Allegra and ranitidine for histamine
blockade, however, he , his amitriptyline was increased and
suggested a potential
trial of Gastrocrom. She is going to see him again in ___
and
is considering endoscopy and allergy testing. He saw Dr.
___ on ___ who recommended changing from Pradaxa to
aspirin
for PAF in the setting of nausea and vomiting and his risk for
bleeding outweighing the need for anticoagulation in a gentleman
with
a structurally normal heart.
In the ED, VS were 98.4 154/90 15 100 94% RA, patient received a
total of 16mg Zofran, 6mg Ativan in the ED and 10mg morphine.
Abdominal Xray showed no bowel obstruction. Labs showed no
change in LFTs, no elevation in his lipase, significant only for
a white count of 16.
At arrival on the floor, his vitals were 97.8, 181/118->158/94,
___, r20 93%RA. Patient received 8mg more of Zofran, 2.5mg
Ativan, and 2mg morphine with no response.
Past Medical History:
- ankylosing spondylitis diagnosed in ___
- corticosteroid-induced diabetes mellitus
- Multiple episodes of vomitting requiring hospitalization since
___
- s/p lumbar laminectomy ___
- s/p spondylolisthesis surgery ___
- s/p right inguinal hernia repair in ___
- esophageal ulcerations seen on EGD ___, h.pylori neg
Social History:
___
Family History:
Father: ankylosing spondylitis and ___ disease. He has had
peptic ulcer disease and has had a small-bowel obstruction.
Physical Exam:
Admission:
97.8, 181/118->158/94, ___, r20 93%RA
Gen: Patient uncomfortable, dry heaving
HEENT: no lymphadenopathy, OP clear
Card: Tachycardic. Regular rhythm. no m/r/g
Pulm: mild crackles at bases no wheezes
Abd: distended, nontender, bs+ all ___ strength throughout, trace ___: RRR, no murmurs
.
Discharge:
98.0/98.4, 129-151/76-113, p88-113, r20 98%RA
Gen: Patient comfortable, lying in bed
HEENT: no lymphadenopathy, OP clear
Cardiac: RRR no m/r/g
Pulm: CTA b/l no w/r/r
Abd: distended, nontender, bs+ all ___ strength throughout, trace ___: RRR, no murmurs
Pertinent Results:
___ 12:10PM BLOOD WBC-16.1*# RBC-4.33* Hgb-13.3* Hct-40.8
MCV-94 MCH-30.8 MCHC-32.6 RDW-15.3 Plt ___
___ 06:10AM BLOOD WBC-14.3* RBC-4.13* Hgb-13.0* Hct-39.3*
MCV-95 MCH-31.4 MCHC-33.0 RDW-15.2 Plt ___
___ 06:00AM BLOOD WBC-14.1* RBC-4.39* Hgb-13.9* Hct-41.7
MCV-95 MCH-31.7 MCHC-33.3 RDW-15.0 Plt ___
___ 09:30AM BLOOD WBC-15.9* RBC-4.24* Hgb-13.1* Hct-39.3*
MCV-93 MCH-31.0 MCHC-33.4 RDW-15.0 Plt ___
___ 05:15AM BLOOD WBC-13.0* RBC-4.05* Hgb-13.5* Hct-38.4*
MCV-95 MCH-33.3* MCHC-35.1* RDW-15.0 Plt ___
___ 12:10PM BLOOD Neuts-68.7 ___ Monos-7.2 Eos-0.4
Baso-0.4
___ 12:10PM BLOOD Glucose-176* UreaN-11 Creat-0.6 Na-142
K-4.6 Cl-100 HCO3-28 AnGap-19
___ 05:15AM BLOOD Glucose-124* UreaN-14 Creat-0.6 Na-138
K-3.8 Cl-100 HCO3-26 AnGap-16
___ 09:30AM BLOOD ALT-30 AST-28 AlkPhos-63 TotBili-0.6
___ 12:10PM BLOOD CK-MB-2 cTropnT-<0.01
___ 09:13PM BLOOD CK-MB-2 cTropnT-<0.01
___ 05:15AM BLOOD Calcium-9.4 Phos-4.2 Mg-2.1
___: CXR
IMPRESSION: Linear opacities at the bases, likely atelectasis.
Low lung
volumes. No focal consolidation.
___: Abdominal xray
IMPRESSION: No evidence of bowel obstruction
___: ECG
Sinus tachycardia. Borderline low voltage. Non-specific ST-T
wave
abnormalities. Compared to the previous tracing of ___ sinus
tachycardia
is new. However, no other significant changes are noted.
Medications on Admission:
. Information was obtained from .
1. Amitriptyline 60 mg PO HS
2. Clonazepam 0.5 mg PO BID anxiety
3. Cyclobenzaprine 10 mg PO HS:PRN muscle spasm
4. Docusate Sodium 100 mg PO DAILY Start: In am
5. Fluoxetine 40 mg PO DAILY Start: In am
6. Multivitamins 1 TAB PO DAILY Start: In am
7. Omeprazole 20 mg PO BID Start: In am
8. PredniSONE 5 mg PO QHS
9. PredniSONE 10 mg PO DAILY Start: In am
10. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN pain
11. FoLIC Acid 1 mg PO DAILY Start: In am
12. Calcium Carbonate 500 mg PO 1X Duration: 1 Doses Start: In
am
13. Diltiazem Extended-Release 120 mg PO DAILY Start: In am
14. MetFORMIN (Glucophage) 1000 mg PO BID
15. Metoprolol Succinate XL 100 mg PO DAILY Start: In am
16. Infliximab Dose is Unknown IV ONCE A MONTH
17. Ondansetron 4 mg PO Q8H:PRN nausea Start: In am
18. Aspirin 325 mg PO DAILY
19. Ranitidine 150 mg PO HS
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Clonazepam 0.5 mg PO BID anxiety
3. Diltiazem Extended-Release 120 mg PO DAILY
4. Docusate Sodium 100 mg PO DAILY
5. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN pain
6. PredniSONE 5 mg PO QHS
7. PredniSONE 10 mg PO DAILY
8. FoLIC Acid 1 mg PO DAILY
9. MetFORMIN (Glucophage) 1000 mg PO BID
10. Omeprazole 20 mg PO BID
11. Multivitamins 1 TAB PO DAILY
12. Fluoxetine 40 mg PO DAILY
13. Cyclobenzaprine 10 mg PO HS:PRN muscle spasm
14. Amitriptyline 60 mg PO HS
15. Metoprolol Succinate XL 100 mg PO DAILY
16. Infliximab 0 mg IV ONCE A MONTH
17. Ondansetron 4 mg PO Q8H:PRN nausea
18. Ranitidine 150 mg PO BID
19. Fexofenadine 180 mg PO BID
RX *Allegra 180 mg 1 tablet(s) by mouth twice a day Disp #*62
Tablet Refills:*5
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
emesis
SECONDARY
hypertension
diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
ABDOMINAL RADIOGRAPH PERFORMED ON ___
Comparison is made with a prior study from ___ as well as the CT of the
abdomen dated ___.
CLINICAL HISTORY: Gastroparesis history with bilious vomiting. Assess for
bowel obstruction.
FINDINGS: Supine and upright views of the abdomen and pelvis were provided.
No free air below the right hemidiaphragm. Bowel gas pattern is unremarkable
without signs of ileus or obstruction. There is likely a moderate fecal load.
Degenerative changes are noted at both hip joints.
IMPRESSION: No evidence of bowel obstruction.
Radiology Report
INDICATION: ___ male with sudden onset vomiting. Rule out
infiltrate.
COMPARISONS: Portable AP chest radiograph from ___.
FINDINGS: PA and lateral chest radiographs were provided. Lung volumes are
low. Bilateral patchy opacities at the bases are likely atelectasis. There
is no focal consolidation, pleural effusion or pneumothorax.
Cardiomediastinal silhouette is difficult to evaluate due to poor inspiration.
Osseous structures are intact. There is no free air under the hemidiaphragms.
IMPRESSION: Linear opacities at the bases, likely atelectasis. Low lung
volumes. No focal consolidation.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: VOMITING
Diagnosed with DIAB NEURO MANIF ADULT, GASTROPARESIS, NAUSEA WITH VOMITING
temperature: nan
heartrate: 124.0
resprate: 16.0
o2sat: 99.0
sbp: 163.0
dbp: 109.0
level of pain: 9
level of acuity: 2.0 | ___ with a hx of ankylosing spondylitis, diabetes, and
periodic episodes of nausea/vomiting responsive to Zofran,
Ativan and morphine who p/w nausea/vomiting since morning of
admission. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
antibiotic
Attending: ___.
Chief Complaint:
word-finding difficulty, stroke
Major Surgical or Invasive Procedure:
none
History of Present Illness:
per Dr. ___ admission note:
___ is a ___ ___-speaking female with a PMHx of
HTN, HLD, anxiety, hypothyroidism who presents with >24 hours of
word-finding difficulties. Ms. ___ arrived in the ___
___ this past ___ to visit with family; she and her
husband have been staying with her daughter. Her daughter states
that aside from being slightly jet-lagged, her mother has been
well.
On ___ at 3PM, Ms. ___ was on the phone with her sister
when suddenly (the sister later reports) she stopped speaking
and seemed to be unable to find the correct words. When Ms.
___ daughter came home later that day, Ms. ___ was
confusing names of family members and confusing the dates and
timing of her trip. If she could not produce a word, she was
able to describe it and "talk around it." Her daughter also
thinks that Ms. ___ was having difficulty hearing. She
thought that her mother was perhaps tired and got her into bed.
The next morning when Ms. ___ awoke, her deficits were still
present and largely stable. Her daughter called the PCP who
recommended that they take Ms. ___ to the hospital.
Ms. ___ was first taken to ___ where a ___,
laboratory work-up, and EKG were performed. NCHCT reported:
diminished attenuation of the L parietal lobe, likely evolving
infarct with 2-3mm of midline shift. Laboratory work-up was
remarkable only for a WBC of 12. EKG and troponins were
unremarkable. Following her ___ scan, Ms. ___ was
transferred to ___ ED for further care.
Upon arrival, Ms. ___ daughter states that she believes
her mother is basically stable - her deficits have not
substantially improved or worsened during the previous 48hrs.
Aside from her word-finding difficulties, Ms. ___ is
otherwise ___. She complains of some ringing in her
left ear, though her daughter states that this is a chronic
finding.
ROS is negative for N/V/D, SOB/cough, fevers/chills. She does
endorse "on and off" chest pain - though again this is a chronic
finding related to her anxiety. She denies any vision changes,
focal weakness, numbness, or parasthesias. She has had no bowel
or bladder incontinence or retention. No difficulties with gait,
no falls.
Past Medical History:
PMH:
- bronchitis
- hyperlipidemia
- hypertension
- diabetes
- anxiety
- seasonal allergies
- anginal pain
- hypothyroidism
- depression
PSHx:
- uterine dilation and curretage (distant)
Social History:
___
Family History:
- father with a stroke in old age
- anxiety in several family members
Physical Exam:
ADMISSION EXAM:
Vitals: T:98.2 P:91 R:18 BP:165/81 SaO2:94%RA
GEN - elderly F, cooperative, NAD
HEENT - NC/AT, MMM
NECK - Supple, no meningismus
RESP - Lungs CTA bilaterally without R/R/W
CV: RRR, no M/R/G noted
ABD: soft, NT/ND
Neurologic Exam:
MS - Awake, attends to examiner. Oriented to self, ___, says we are in a "room", unable to elaborate further,
when given choices able to say we are in a hospital. Able to
obey simple and two step commands. Able to read a simple
sentence in ___. Difficulty naming even relatively high
frequency objects ("thumb", "clasp", "hospital"). Unable to
repeat accurately ("It's a sunny day in ___ -> "It's a hot
day in ___, substituting "she's" for "he's". Normal
prosody. No dysarthria. No evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to finger counting.
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 voice.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline and has full ROM.
-Motor: Normal bulk, tone throughout. No pronator drift. No
tremor or asterixis noted. Full power throughout, but does
?orbit around RUE slightly.
-Sensory: No deficits to light touch, cold sensation. No
extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 0
R 2 2 2 2 0
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF bilaterally.
-Gait: Slow and careful, but narrow based. Daughter assists.
DISCHARGE EXAM:
Neurologic:
Mental status: Alert, speech is fluent in ___ per
daughter's translation. Intact repetition, reading a long
sentence in ___ with one word substitution, and naming
intact to high and low frequency objects. Comprehension intact
to appendicular and cross-body commands.
otherwise normal
Pertinent Results:
ADMISSION LABS (___):
8.6 > 13.3/39.0 < 343
Neuts-59.0 ___ Monos-5.7 Eos-10.1* Baso-0.5
___ PTT-30.0 ___
146 | 106 | 16
-----------------< 141
3.7 | 28 | 0.6
ALT-21 AST-19 CK(CPK)-81 AlkPhos-69 TotBili-0.3
Albumin-4.3 Calcium-9.6 Phos-3.5 Mg-2.2
___ 10:50PM BLOOD cTropnT-0.02*
___ 05:55AM BLOOD CK-MB-<1 cTropnT-0.02*
STROKE WORKUP (___):
%HbA1c-6.4* eAG-137*
Triglyc-150* HDL-46 CHOL/HD-2.8 LDLcalc-52
TSH-5.4*
IMAGING:
CTA Head/Neck ___
IMPRESSION:
1. Subacute left middle cerebral artery territory infarct
involving the left parietal lobe. No evidence of hemorrhagic
conversion.
2. No pathologic large vessel occlusion or hemodynamically
significant stenosis within the vasculature of the head and
neck.
3. Tiny 2 mm aneurysm versus infundibulum arising at the origin
of the right M1 segment.
MRI Head ___
IMPRESSION:
1. Slow diffusion in the left temporal lobe with corresponding
T2/FLAIR signal hyperintensity consistent with late acute/ early
subacute left MCA territory infarction.
2. Nonspecific T2/FLAIR signal hyperintensity in the
periventricular, deep, and subcortical white matter likely
secondary to chronic small vessel ischemic change.
Echocardiogram ___
Conclusions
The left atrium is mildly dilated. With maneuvers, there is
early appearance of agitated saline/microbubbles in the left
atrium/left ventricle most consistent with a patent foramen
ovale. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF = 70%). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. There are focal calcifications in the
aortic arch. 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. Trivial mitral regurgitation is seen. The left
ventricular inflow pattern suggests impaired relaxation. There
is borderline pulmonary artery systolic hypertension. There is
no pericardial effusion.
IMPRESSION: patent foramen ovale
Doppler Ultrasound ___
IMPRESSION: No evidence of deep venous thrombosis in the
bilateral lower extremity veins.
MRV Pelvis ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. fluticasone 250 mcg/actuation inhalation BID
2. Rosuvastatin Calcium 10 mg PO QPM
3. Losartan Potassium 100 mg PO DAILY
4. Hydrochlorothiazide 12.5 mg PO DAILY
5. MetFORMIN (Glucophage) 850 mg PO BID
6. desloratadine 5 mg oral daily
7. Levothyroxine Sodium 88 mcg PO DAILY
8. mirtazapine 15 mg oral QHS
9. Aspirin 150 mg PO DAILY
10. ALPRAZolam 0.5 mg PO QAM
11. ALPRAZolam 2 mg PO QHS
12. vastarel (trimetazidine, anti-anginal) 35mg, 2 tabs per day
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. desloratadine 5 mg oral daily
3. Levothyroxine Sodium 88 mcg PO DAILY
4. MetFORMIN (Glucophage) 850 mg PO BID
5. mirtazapine 15 mg oral QHS
6. Rosuvastatin Calcium 10 mg PO QPM
7. ALPRAZolam 0.5 mg PO QAM
8. ALPRAZolam 2 mg PO QHS
9. fluticasone 250 mcg/actuation inhalation BID
10. Outpatient Speech/Swallowing Therapy
Discharge Disposition:
Home
Discharge Diagnosis:
L temporal lobe infarct
Patent foramen ovale
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
INDICATION: ___ year old woman with stroke // stroke chronicity
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique.
COMPARISON: No prior MRI available. Prior head CTs dated ___.
FINDINGS:
There is a moderate sized region of slow diffusion in the left parietal lobe
with corresponding T2/FLAIR signal hyperintensity. Findings are consistent
with late acute/ early subacute left middle cerebral artery territory
infarction. The ventricles and sulci are normal in caliber and configuration.
There is periventricular, subcortical, and deep white matter T2/FLAIR signal
hyperintensity which is nonspecific but likely secondary to chronic small
vessel ischemic change. There is a small region of chronic infarction in the
left cerebellar hemisphere. The orbits are unremarkable. There is mucosal
thickening within the bilateral ethmoid and maxillary sinuses. The mastoid air
cells are clear. There is prominent flow void at the left carotid terminus
which may be due to a tortuous vessel but correlation with CTA is recommended.
IMPRESSION:
1. Slow diffusion in the left temporal lobe with corresponding T2/FLAIR signal
hyperintensity consistent with late acute/ early subacute left MCA territory
infarction.
2. Nonspecific T2/FLAIR signal hyperintensity in the periventricular, deep,
and subcortical white matter likely secondary to chronic small vessel ischemic
change.
Radiology Report
EXAMINATION: CHEST RADIOGRAPH ___
INDICATION: ___ year old woman with stroke // infection
TECHNIQUE: Chest PA and lateral
COMPARISON: None.
FINDINGS:
The lungs are well inflated and clear. The cardiomediastinal silhouette is
unremarkable. There is no pleural effusion, pulmonary edema, pneumothorax, or
focal airspace consolidation.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: ___ DUP EXTEXT BIL (MAP/DVT)
INDICATION: ___ year old woman with embolic stroke, recent plane trip.
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, superficial 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 bilateral lower extremity veins.
Radiology Report
EXAMINATION: MRV OF THE PELVIS
INDICATION: ___ year old woman with history of HTN, HLD, p/w L temporal stroke
which appears embolic. Echocardiogram shows PFO. // evaluate for thrombus
TECHNIQUE: Multiplanar T1 and T2 weighted images were obtained through the
pelvis on a 1.5 Tesla magnet including 3D dynamic imaging performed prior to,
during, and after the uneventful administration of 7 mm Ablavar intravenous
contrast material. 3D postprocessing was performed on an independent
workstation, including the creation of 3D maximum intensity projection images.
COMPARISON: ___ Doppler ultrasound of the bilateral lower
extremity veins.
FINDINGS:
No filling defect is identified in the IVC. The bilateral common iliac
arteries and pelvic branches opacify normally without evidence of thrombus or
occlusion. The abdominal aorta is non aneurysmal through the bifurcation.
Subcentimeter nonenhancing lesions within the liver are consistent with cysts
or biliary hamartomas (1102:64). The gallbladder, common bile duct, and
visualized portions of the spleen and pancreas are unremarkable. The kidneys
enhance and excrete contrast symmetrically. A 2.2 cm thin-walled cyst at the
right kidney upper pole looks benign. Visualized loops of small bowel in
colon are grossly unremarkable.
The urinary bladder is well-distended with normal appearance. A 2.1 cm
submucosal fibroid (12:108) and ___ intramural versus subserosal fibroids
measuring up to 2.8 cm (12:122) arise from the uterus. No adnexal mass is
identified. No free fluid is seen within the pelvis. Bone marrow is normal in
signal intensity.
3D maximum intensity projection images support these findings.
IMPRESSION:
1. No venous thrombosis in the infrahepatic IVC or pelvic veins.
2. Uterine fibroids.
Gender: F
Race: PORTUGUESE
Arrive by AMBULANCE
Chief complaint: Altered mental status
Diagnosed with ALTERED MENTAL STATUS , DIABETES UNCOMPL ADULT, HYPERTENSION NOS, HYPOTHYROIDISM NOS
temperature: 98.2
heartrate: 91.0
resprate: 18.0
o2sat: 94.0
sbp: 165.0
dbp: 81.0
level of pain: 13
level of acuity: 2.0 | ___ presented with anomia. MRI showed an acute left
temporal lobe stroke. Given that her symptoms started four days
after a long plane flight from Portugual, a thorough workup for
embolic etiology was performed. Her workup was notable for:
echocardiogram with patent foramen ovale and no evidence of
intraventricular thrombus; negative doppler ultrasound studies
of her lower extremities and MRV of the pelvis which was
negative for thrombus; HbA1C of 6.4%, LDL of 92 and TSH of 5.4.
Her stroke was thought to be most likely secondary to
thromboembolus with no residual thrombus. She was already taking
aspirin 150 mg and a high-potency statin. We recommended
increasing her dose to a full aspirin. No further adjustments
were made to her medications.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes [performed
and documented by admitting resident] () 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 =
92) - () No
5. Intensive statin therapy administered? () Yes - (x) No [if
LDL >= 100, reason not given: remains on home rosuvastatin 10 mg
]
(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 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
Iodinated Contrast Media - IV Dye
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
___ - Cardiac Catheterization
___ - Aortic valve replacement with a 21 mm ___
___ tissue valve, and coronary artery bypass grafting x2
with left internal mammary artery to left anterior descending
artery and reverse saphenous vein graft to the obtuse marginal
artery.
History of Present Illness:
Mr. ___ is an ___ year old man with a history atrial
fibrillation, cerebrovascular accident, chronic kidney disease,
hyperlipidemia, hypertension, and renal carcinoma status post
nephrectomy. He presented to ___ with chest pain and
elevated troponin. He reported sudden onset left sided chest
pain withradiation to his left neck and shoulder. He denied
associated shortness of breath, diaphoresis, or nausea. He was
treated with Aspirin, nitroglycerin x 3, and moprhine with
eventual resolution of his pain. An EKG revealed non-specific
T-wave inversions inferiorily. He was not heparinized due to
supratherapeutic INR. He was transferred to ___ for further
management.
Of note, h was admitted under neurology service in ___ for
cerebrovascular accident (CVA). MRI brain showed right thalamic,
right cerebellar, and left occipital lobe acute infarcts. MRA
demonstrated no abnormalities. An echocardigoram was signficant
for a patent foramen ovale (PFO). The etiology of his CVA was
thought to be embolic from cardiac thrombus versus paradoxical
embolism through PFO.
Past Medical History:
Chronic Back Pain
Chronic Kidney Disease
Essential Tremor, bilateral hands, R>L
Gout
Hyperlipidemia
Hypertension
Renal Cell Carcinoma
Rotator Cuff Injury, left
Surgical History:
Cataract surgery, left
Nephrectomy, left, ___
Social History:
___
Family History:
Father - history of tremor
Physical Exam:
Pulse:67 Resp:18 O2 sat:97/RA
B/P ___
Height:70" Weight:149.9 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [] Murmur [x] grade III/VI
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+
[]
Extremities: Warm [x], well-perfused [x] Edema [] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: sheath in place Left: p
DP Right: d Left: d
___ Right: d Left: p
Radial Right: compressive bracelet in place Left: p
Carotid Bruit cardiac murmur radiating to b/l carotid arteries,
no bruits
Pertinent Results:
___ 07:00AM BLOOD WBC-11.8* RBC-3.21* Hgb-10.3* Hct-29.3*
MCV-91 MCH-32.0 MCHC-35.1* RDW-16.3* Plt Ct-91*
___ 02:08AM BLOOD WBC-10.6 RBC-3.30* Hgb-10.5* Hct-29.1*
MCV-88 MCH-32.0 MCHC-36.2* RDW-16.7* Plt ___
___ 12:00PM BLOOD Hct-27.4*
___ 01:30AM BLOOD WBC-9.3 RBC-2.69* Hgb-8.7* Hct-24.4*
MCV-91 MCH-32.4* MCHC-35.8* RDW-15.7* Plt ___
___ 08:55PM BLOOD WBC-10.4 RBC-3.17* Hgb-10.1* Hct-29.4*
MCV-93 MCH-31.9 MCHC-34.4 RDW-15.4 Plt ___
___ 07:25PM BLOOD WBC-13.8*# RBC-2.66*# Hgb-8.3*#
Hct-25.1*# MCV-94 MCH-31.4 MCHC-33.3 RDW-15.2 Plt ___
___ 07:00AM BLOOD ___ PTT-29.2 ___
___ 02:08AM BLOOD ___ PTT-32.6 ___
___ 01:30AM BLOOD ___ PTT-42.8* ___
___ 08:55PM BLOOD ___ PTT-38.6* ___
___ 07:25PM BLOOD ___ PTT-39.7* ___
___ 07:00AM BLOOD Glucose-127* UreaN-30* Creat-2.4* Na-132*
K-4.2 Cl-95* HCO3-28 AnGap-13
___ 03:55PM BLOOD Glucose-156* UreaN-28* Creat-2.3* Na-132*
K-4.7 Cl-96 HCO3-26 AnGap-15
___ 02:08AM BLOOD Glucose-137* UreaN-26* Creat-2.1* Na-134
K-4.2 Cl-100 HCO3-27 AnGap-11
___ 05:05PM BLOOD Glucose-125* UreaN-28* Creat-2.1* Na-136
K-4.6 Cl-103 HCO3-26 AnGap-12
___ 01:30AM BLOOD Glucose-114* UreaN-28* Creat-1.7* Na-139
K-5.0 Cl-108 HCO3-24 AnGap-12
___ 08:55PM BLOOD UreaN-27* Creat-1.5* Na-139 K-4.7 Cl-110*
HCO3-21* AnGap-13
.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Metoprolol Succinate XL 100 mg PO DAILY
3. Pravastatin 80 mg PO QPM
4. Amlodipine 10 mg PO DAILY
5. Ranitidine 150 mg PO BID
6. Warfarin 2.5 mg PO DAILY16
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Amlodipine 10 mg PO DAILY
3. Warfarin 2.5 mg PO 2X/WEEK (MO,FR)
Goal INR 2.0-2.5
Take 2.5 mg 2X/WEEK (MON, FRI)
4. Ranitidine 150 mg PO BID
5. Acetaminophen 650 mg PO Q4H:PRN pain, fever
6. Warfarin 3.75 mg PO 5X/WEEK (___)
7. Furosemide 20 mg PO DAILY Duration: 7 Days
8. Aspirin EC 81 mg PO DAILY
9. Atorvastatin 80 mg PO DAILY
10. Clopidogrel 75 MG PO DAILY
11. Metoprolol Tartrate 37.5 mg PO TID
12. Potassium Chloride 20 mEq PO DAILY Duration: 7 Days
13. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp
#*60 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Aortic Stenosis s/p aortic valve replacement
Coronary Artery Disease s/p coronary revascularization
Non-ST Elevation Myocardial Infarction
Patent Foramen Ovale
Secondary diagnosis
ST Elevation Myocardial Infarction
Atrial Fibrillation
Chronic Back Pain
Chronic Kidney Disease
Essential Tremor, bilateral hands, R>L
Gout
Hyperlipidemia
Hypertension
Renal Cell Carcinoma
Rotator Cuff Injury, left
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema- trace
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema- trace
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema- trace
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with STEMI // preop preop
IMPRESSION:
In comparison with the study of ___, overlying wires somewhat obscure
detail. However, the cardiac silhouette is within normal limits and there is
no evidence of vascular congestion, pleural effusion, or acute focal
pneumonia. Mild atelectatic changes are seen at the left base.
Radiology Report
EXAMINATION: CAROTID DOPPLER ULTRASOUND
INDICATION: ___ year old man scheduled for CABG and aortic valve replacement
// please ___ carotids
TECHNIQUE: Real-time grayscale and color and spectral Doppler ultrasound
imaging of the carotid arteries was obtained.
COMPARISON: MRA head and neck ___.
FINDINGS:
RIGHT:
The right carotid vasculature has mild atherosclerotic plaque.
The right internal carotid artery has peak systolic/diastolic velocities of
69/11 cm/sec in its proximal portion, 73/19 cm/sec in its mid portion, and
78/23 cm/sec in its distal portion.
The right common carotid artery has peak systolic/diastolic velocities of
92/13 cm/sec.
The external carotid artery has peak systolic velocity of 114 cm/sec.
The vertebral artery has peak systolic velocity of 65 cm/sec with normal
antegrade flow.
The right ICA/CCA ratio is 0.84.
LEFT:
The left carotid vasculature has mild atherosclerotic plaque.
The left internal carotid artery has peak systolic/diastolic velocities of
105/15 cm/sec in its proximal portion, 106/22 cm/sec in its mid portion, and
63/17 cm/sec in its distal portion.
The left common carotid artery has peak systolic/diastolic velocities of
116/21 cm/sec.
The external carotid artery has peak systolic velocity of 125 cm/sec.
The vertebral artery has peak systolic velocity of 48 cm/sec with normal
antegrade flow.
The left ICA/CCA ratio is 0.91.
IMPRESSION:
Less than 40% stenoses of bilateral internal carotid arteries.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man s/p CABG // FAST TRACK EARLY EXTUBATION CARDIAC
SURGERY Contact name: ___, Phone: 1
TECHNIQUE: CHEST PORT. LINE PLACEMENT
COMPARISON: ___
IMPRESSION:
ET tube tip is 4 cm above the carinal. Swan-Ganz catheter tip is at the level
of right lower lobe pulmonary artery and should be pulled back at least 4-5
cm. Bilateral chest tubes are in place. Mediastinal drain inches in place.
Sternotomy wires are unremarkable. No appreciable pleural effusion or
pneumothorax is seen.
NOTIFICATION: These findings were discussed with Dr. ___ by Dr. ___
telephone at 12:18am on ___, 15 minutes after discovery.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with s/p cardiac surgery, mediastinal CTs d/c'd
// evaluate for pneumothorax evaluate for pneumothorax
TECHNIQUE: Portable AP radiograph of the chest was obtained.
COMPARISON: Frontal chest radiograph ___.
FINDINGS:
Mediastinal drains and nasogastric tube have been removed. The midline
sternotomy wires are intact. Bibasilar chest tubes are unchanged in
positioning. Bibasilar opacities are likely secondary to atelectasis from low
inspiratory volumes. There is no pneumothorax. Mild prominence of mediastinal
veins is consistent with mild congestion.
IMPRESSION:
1. No pneumothorax.
2. Air distended stomach status post nasogastric tube removal.
3. Postsurgical changes consistent with sternotomy.
NOTIFICATION: The findings were discussed by Dr. ___ with ___,
ordering provider, on the telephone on ___ at 6:41 ___, 30 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p CABG/AVR // eval effusions/gastric bubble
COMPARISON: ___.
IMPRESSION:
As compared to the previous radiograph, the left and right chest tube are in
unchanged position. No evidence of pneumothorax or larger pleural effusions.
Borderline size of the cardiac silhouette. The pre-existing gastric over
distension has decreased. The lung volumes are low and atelectasis are seen at
both the left and the right lung bases. No overt pulmonary edema. The
alignment of the sternal wires is unchanged.
Radiology Report
EXAMINATION: CR -ABDOMEN (SUPINE AND ERECT)
INDICATION: ___ year old man with s/p cabg and avr. Evaluate for ileus.
TECHNIQUE: Portable supine and upright views of the abdomen.
COMPARISON: Chest x-ray from ___.
FINDINGS:
Bilateral chest tubes are unchanged since the prior radiograph. The stomach is
distended, but air is present and multiple loops of nondilated large and small
bowel. No free intraperitoneal air or evidence of obstruction. Patient is
status post CABG with intact median sternotomy wires. Surgical clips overlying
the mid abdomen and left pelvis are present.
IMPRESSION:
1. Mild gastric distention without evidence of obstruction.
2. Intrathoracic findings from recent CABG are better evaluated on chest
radiographs from ___.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man // eval for pneumo s/p CT removal eval for
pneumo s/p CT removal
COMPARISON: Chest radiographs since ___, most recently ___.
IMPRESSION:
There is no pneumothorax or appreciable pleural effusion, following removal of
the pleural drainage tubes present earlier in the day. Consolidative
abnormalities at both lung bases could well be pneumonia probably with
contribution of some atelectasis. Mild cardiomegaly is stable. Moderate
distention of the stomach with air and fluid is unchanged since earlier in the
day, improved since ___.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man s/p cabg // eval for effusion eval for
effusion
COMPARISON: Chest radiographs since ___ most recently ___ through
___ at 1:44 p.m.
IMPRESSION:
Bibasilar consolidation persists, most commonly due to atelectasis alone
pneumonia is not excluded. The upper lungs are clear. Heart is normal size.
Mild widening of the upper mediastinum postoperatively is unchanged. No
pneumothorax.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain, Transfer
Diagnosed with CHEST PAIN NOS, ATRIAL FIBRILLATION, LONG TERM USE ANTIGOAGULANT
temperature: 97.6
heartrate: 62.0
resprate: 18.0
o2sat: 95.0
sbp: 124.0
dbp: 58.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ was transferred to ___ for further management of his
non-ST elevation myocardial infarction. He was initially managed
medically. He developed new-onset chest pain on ___ and was
found to have inferior ST elevation myocardial infarction on
EKG. He was taken emergently to the cardiac catheterization
laboratory where the right coronary artery was found to be 100%
occluded which was stented with a bare metal stent. Plavix was
initiated and he is to remain on this x 1 month. The
catheterization was also significant for left main coronary
artery disease. He was transferred to the CCU and the cardiac
surgery service was consulted for revascularization. He remained
hemodynamically stable and was taken to the operating room on
___. Preoperative transesophageal echocardiogram
demonstrated severe aortic stenosis with an aortic valve area of
0.8cm2. He subsequently underwent aortic valve replacement and
coronary artery bypass grafting x 2. Please see operative note
for full details. He tolerated the procedure well and was
transferred to the CVICU in stable condition for recovery and
invasive monitoring.
He weaned from sedation, awoke neurologically intact and was
extubated on POD 1. He was weaned from inotropic and vasopressor
support. He was transfused blood products for acute blood loss
anemia and to correct coagulopathy. Beta blocker was initiated
and he was diuresed toward his preoperative weight. Lasix was
changed to oral due to rising BUN/Creatine - baseline creatinine
was 2.0. He remained hemodynamically stable and was transferred
to the telemetry floor for further recovery. Coumadin was
resumed for AFib. Narcotics were stopped due to confusion. He
was evaluated by the physical therapy service for assistance
with strength and mobility. By the time of discharge on POD 4 he
was ambulating with assistance, the wound was healing, and pain
was controlled with oral analgesics. He was discharged to
___ at ___ in good condition with appropriate
follow up instructions. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bactrim / Sulfa (Sulfonamide Antibiotics) / Hayfever / Levaquin
Attending: ___.
Chief Complaint:
AV graft thrombosis
Major Surgical or Invasive Procedure:
___: ___ thrombectomy
History of Present Illness:
In brief, this patient is a ___ year-old man with PMH of GPA
(crescentic glomerulonephritis, pHTN, cutaneous necrosis and
scleritis), ESRD on HD (MWF, last received ___, anemia (on
darbepoeitin), and DM2 who presents for AV graft evaluation. His
last dialysis was ___, but they were unable to access
graft for scheduled dialysis yesterday ___. Denies other
associated symptoms. Labs notable for K 6.1 with normal EKG ___
at 1300 and patient was given IV insulin and dextrose. He was
seen by transplant surgery in ED, who recommended ___
thrombectomy. Renal aware of patient, did not think urgent need
for HD.
Pt otherwise asymptomatic.
.
ROS: 10 point ROS negative unless otherwise mentioned above in
HPI
Past Medical History:
1. Granulomatosis with polyangiitis (Wegener's
granulomatosis)diagnosed ___ when presented with acute renal
failure
2. Crecentic GMN secondary to Wegener's granulomatosis.
3. End-stage renal disease, from ANCA-positive crecentic
glomerulonephritis dx ___ on dialysis through left arm graft,
MWF
4. Depression
5. Mitral regurgitation.
6. Pulmonary hypertension.
7. Gastritis. Gastrointestinal bleed secondary to NSAID use
8. Chronic anemia.
9. Diabetes mellitus type 2.
10. Obesity.
11. Herpes zoster in ___.
12. Asthma.
13. Gastrointestinal bleed in ___ secondary to diverticulosis,
hemorrhoids, and angiodysplasia.
14. Gout
15. HTN
16. HLD
17. Glaucoma
18. Diverticulosis
19. h/o Septic thrombophlebitis
20. h/o Cellulitis of the right upper extremity
21. chronic anemia
Social History:
___
Family History:
(Per OMR)
Mother with diabetes, kidney disease, CAD. 3 brothers with heart
disease, one has had MI. Sister with diabetes. No family history
of cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals - afebrile, 120s/80s, 80s, 96% RA
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, MMM, nontender supple neck, no
LAD, no JVD
CARDIAC: RRR, S1/S2, loud holosystolic murmur throughout
precordium
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: moving all extremities well, no cyanosis, clubbing
or edema. left brachial AVF without thrill or bruit
PULSES: 2+ radial pulses bilaterally
NEURO: CN II-XII intact, gait normal
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISPO:
PHYSICAL EXAM:
Vitals: 97.6, 97.6, 95/40-139/63, 67, 16, 98%RA
Weight 88kg
GENERAL: Sleeping while on dialysis machine,NAD
HEENT: Sclera anicteric, MMM
CARDIAC: RRR, ___ systolic murmur at RUSB, no r/g
LUNG: CTAB no w/c/r
ABDOMEN: Obese abdomen, soft NTND, no rebound or guarding
EXTREMITIES: Warm and well perfused, 1+ pitting edema, L
brachial AV graft in use
SKIN: No rashes
NEURO: Non focal, CNII-XII grossly intact
Pertinent Results:
ADMISSION LABS:
___:06PM ___ PTT-25.2 ___
___ 01:00PM GLUCOSE-100 UREA N-100* CREAT-9.0*#
SODIUM-140 POTASSIUM-6.1* CHLORIDE-99 TOTAL CO2-23 ANION GAP-24*
___ 01:00PM CALCIUM-8.9 PHOSPHATE-4.4 MAGNESIUM-2.1
___ 01:00PM WBC-7.8 RBC-2.30* HGB-8.1* HCT-25.2* MCV-110*
MCH-35.2* MCHC-32.1 RDW-15.1
___ 01:00PM NEUTS-81.7* LYMPHS-13.1* MONOS-4.6 EOS-0.3
BASOS-0.2
___ 01:00PM PLT COUNT-196
DISCHARGE LABS:
___ 06:22AM BLOOD WBC-8.6 RBC-2.37* Hgb-8.4* Hct-25.8*
MCV-109* MCH-35.4* MCHC-32.5 RDW-15.2 Plt ___
___ 06:22AM BLOOD Glucose-129* UreaN-58* Creat-5.7*# Na-140
K-4.6 Cl-96 HCO3-28 AnGap-21*
___ 01:40PM BLOOD Glucose-150* UreaN-121* Creat-9.8* Na-138
K-7.0* Cl-99 HCO3-15* AnGap-31*
___ 06:22AM BLOOD Calcium-8.7 Phos-3.4# Mg-1.9
.
___ Imaging CHEST (PA & LAT)
IMPRESSION:
1. Pulmonary vascular engorgement consistent with mild
interstitial edema and small bilateral pleural effusions.
2. Mild cardiomegaly.
.
___ ___ ___ AVF/DUPLEX HEMO/D
IMPRESSION:
Occluded left upper extremity loop graft.
.
___ Imaging AV FISTULOGRAM ___
PROCEDURE:
1. Left upper extremity AV graft fistulagram.
2. Axillary, subclavian and super vena cava venography.
3. Chemical and mechanical thrombolysis of the thrombosed graft
and outflow vein using the Angiojet device.
4. Balloon angioplasty of the arterial inflow and outflow vein.
5. ___ balloon pull through of the arterial inflow.
.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 325 mg PO Q6H:PRN pain
2. Azathioprine 50 mg PO DAILY
3. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
4. Docusate Sodium 100 mg PO BID
5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
6. Gabapentin 100 mg PO HS
7. Labetalol 200 mg PO BID ON NON-DIALYSIS DAYS
8. Nephrocaps 1 CAP PO DAILY
9. NIFEdipine CR 60 mg PO DAILY
10. Omeprazole 40 mg PO BID
11. Paroxetine 20 mg PO DAILY
12. sevelamer CARBONATE 1600 mg PO TID W/MEALS
13. Simvastatin 20 mg PO DAILY
14. Travatan Z (travoprost) 0.004 % ___
15. Aranesp (polysorbate) (darbepoetin alfa in polysorbat) 40
mcg/0.4 mL Injection q 2 weeks
16. cyanocobalamin (vitamin B-12) 1000 mcg ORAL QDAILY
17. Loratadine 10 mg Oral qdaily:prn allergies
18. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES QID
19. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheeze
20. Atovaquone Suspension 1500 mg PO DAILY
21. PredniSONE 30 mg PO DAILY
Tapered dose - DOWN
Discharge Medications:
1. Acetaminophen 325 mg PO Q6H:PRN pain
2. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheeze
3. Atovaquone Suspension 1500 mg PO DAILY
4. Azathioprine 50 mg PO DAILY
5. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
6. cyanocobalamin (vitamin B-12) 1000 mcg ORAL QDAILY
7. Docusate Sodium 100 mg PO BID
8. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
9. Gabapentin 100 mg PO HS
10. Labetalol 200 mg PO BID ON NON-DIALYSIS DAYS
11. Nephrocaps 1 CAP PO DAILY
12. NIFEdipine CR 60 mg PO DAILY
13. Omeprazole 40 mg PO BID
14. Paroxetine 20 mg PO DAILY
15. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES QID
16. PredniSONE 30 mg PO DAILY
Tapered dose - DOWN
17. sevelamer CARBONATE 1600 mg PO TID W/MEALS
18. Simvastatin 20 mg PO DAILY
19. Aranesp (polysorbate) (darbepoetin alfa in polysorbat) 40
mcg/0.4 mL Injection q 2 weeks
20. Loratadine 10 mg Oral qdaily:prn allergies
21. Travatan Z (travoprost) 0.004 % ___
Discharge Disposition:
Home
Discharge Diagnosis:
AV graft thrombosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Arteriovenous graft ultrasound.
INDICATION: ___ year old man with inablity to access AV fistula LUE //
Thrombosis? Stenosis?
TECHNIQUE: Grayscale and Doppler ultrasound images of the left upper
extremity arteriovenous graft were obtained.
COMPARISON: No relevant comparisons are available.
FINDINGS:
There is complete occlusion of a left upper extremity loop graft anastomosing
from the brachial artery to the left axillary vein. No flow is seen. The
brachial artery is patent with a peak velocity of 93.7 centimeters/second.
IMPRESSION:
Occluded left upper extremity loop graft.
Radiology Report
HISTORY: End-stage renal disease with graft failure. Evaluate for pulmonary
edema.
COMPARISON: Multiple prior radiographs the chest dated ___ through
___.
FINDINGS:
PA and lateral radiographs of the chest demonstrate hyperexpanded lungs with
some cephalization of pulmonary vasculature and haziness about the hilum,
consistent with mild pulmonary vascular engorgement. There is mild
cardiomegaly. There are small bilateral pleural effusions. The aorta is
somewhat tortuous. There is no focal consolidation or pneumothorax.
IMPRESSION:
1. Pulmonary vascular engorgement consistent with mild interstitial edema and
small bilateral pleural effusions.
2. Mild cardiomegaly.
Radiology Report
INDICATION: ___ male with left AV fistula graft, clotted for 3 days.
COMPARISON: Thrombectomy report from ___. (AV Care)
TECHNIQUE: OPERATORS: Dr. ___ radiology fellow) and Dr.
___ radiology attending) performed the procedure. The
attending, Dr. ___ was present and supervising throughout the procedure.
ANESTHESIA: Mild sedation was provided by administrating divided doses of
75mcg of fentanyl throughout the total intra-service time of 135 min 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: 5000 units of heparin IV , 2 g of calcium gluconate for elevated
potassium , 20 mg of hydralazine, 10 mg of intragraft t-PA
CONTRAST: 221 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 32.9 min, 86 mGy
PROCEDURE: 1. Left upper extremity AV graft fistulagram.
2. Axillary, subclavian and super vena cava venography.
3. Chemical and mechanical thrombolysis of the thrombosed graft and outflow
vein using the Angiojet device.
4. Balloon angioplasty of the arterial inflow and outflow vein.
5. ___ balloon pull through of the arterial inflow.
PROCEDURE DETAILS:
Written informed consent was obtained from the patient outlining the risks,
benefits and alternatives to the procedure. The patient was then brought to
the angiography suite and placed supine on the image table with the left upper
extremity abducted and stabilized.
Clinical examination demonstrated a palpable, but completely thrombosed graft
in the left upper extremity. Further evaluation by targeted ultrasound
demonstrated a completely thrombosed graft extending into the outflow vein.
The graft is a loop graft with several areas of dilation in its more proximal
portions. The left upper extremity was prepped and draped in the usual sterile
fashion. A preprocedure timeout and huddle was performed as per ___
protocol.
Using ultrasound and fluoroscopy, the arterial inflow and outflow levels were
identified and the skin was marked with a skin marker. Following
administration of 1 cc of 1% lidocaine antegrade (directed towards the venous
outflow) access into the thrombosed graft was obtained under continuous
ultrasound guidance using a 21G micropuncture needle. Permanent ultrasound
images were saved. An 018wire was then advanced easily into the outflow vein
under fluoroscopic guidance. A 4.5F micropuncture sheath was advanced and used
to exchange for an 0.035 Glidewire. The glide wire was advance to the level of
the subclavian vein. A short 6 ___ sheath was placed over the wire. A ___
Kumpe catheter was then advanced over the wire and contrast was injected for a
central venogram. After confirming central patency, an exchange length ___
wire was placed through the catheter and into the vena cava for stability.
Retrograde access directed towards the arterial inflow was then obtained in a
similar fashion using continuous ultrasound and intermittent fluoroscopic
guidance. Permanent ultrasound images were saved. Care was taken not to
advance the wire into the inflow brachial artery prior to thrombolysis. At
this point 4000 IU of heparin was administered systemically.
Tissue plasminogen activator was administered along the entire length of the
thrombosed graft and outflow vein using the AngioJet pulsespray device in the
both antegrade and retrograde directions. A total of 10 mg was infused. The
tPA was allowed to dwell for approximately 10 minutes. The AngioJet device was
then switched to thrombectomy mode and mechanical thrombectomy was performed
from the antegrade and retrograde approaches. An 0.035 glidewire was directed
into the inflow brachial artery and advanced proximally. A 5.5 ___ ___
balloon was advanced beyond the arterial anastomosis, partially inflated and
pullback was performed through the arterial anastamosis into the graft. This
resulted in a faint pulse in the graft. Pulse spray thrombectomy with the
Angiojet device was again repeated towards the outflow tract. Following ___
passes, a faint thrill was restored. The antegrade sheath was then connected
to a side arm heparinized saline flush.
Subsequently, angioplasty was performed along the outflow vein using a 8-mm
balloon. A fistulagram was performed from the proximal brachial artery
demonstrating slightly sluggish flow through the graft. Repeat ___
embolectomy of the inflow was carried out, followed by 6 mm balloon
angioplasty of the arterial anastomosis. 8 mm balloon angioplasty of the
outflow was repeated. The final fistulogram was repeated demonstrating brisk
flow through the graft.
Clinical examination revealed a reasonable thrill along the length of the
graft.
The sheaths were removed and hemostasis was achieved with two ___
pursestring sutures. There were no immediate complications.
FINDINGS:
Left upper extremity brachial basilic loop graft. The arterial anastomosis is
a few cm peripheral (toward the antecubital fossa) to the venous anastomosis.
The inflow limb of the graft is lateral and has aneurysmal components. The
outflow limb is medial, with flow traveling toward the antecubital fossa
before connecting with the basilic vein.
1. Complete thrombosis of the left upper extremity AV graft to the level of
the outflow vein.
2. Outflow vein stenosis with improvement following angioplasty to 8 mm.
3. Moderate arterial inflow stenosis, persistent following dilation with a 6
mm balloon.
IMPRESSION:
Satisfactory restoration of flow following chemical and mechanical
thrombolysis with a satisfactory clinical result. The graft is degraded
however with marked irregularity and aneurysmal portions.
RECOMMENDATION: The last AV graft de clot procedure was on ___ (4 weeks
ago). If the graft clots again, placement of a temporary or tunneled HD
catheter on the right with surgical revision on the left would be favored.
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: AV FISTULA EVAL
Diagnosed with DUE TO RENAL DIALYSIS DEVICE,IMPLANT,GRAFT, ACCIDENT NOS, END STAGE RENAL DISEASE
temperature: 97.8
heartrate: 63.0
resprate: 16.0
o2sat: 96.0
sbp: 124.0
dbp: 59.0
level of pain: 0
level of acuity: 3.0 | ___ yo M with a past medical history significant for ESRD
secondary to GPA on HD, mitral regurgitation, pulmonary
hypertension and diet controlled Type 2 DM who presented after a
missed dialysis session on ___ due to with AV graft
thrombosis.
# ESRD on HD c/b AV Graft Thrombosis: The patient has a history
of ESRD secondary to GPA and undergoes dialysis on a MWF
schedule. The patient missed HD session ___ due to thrombosis
of his AV graft. He was hyperkalemic in the ED and received D50
and insulin. The patient went to ___ ___ with successful
thombolysis of clotted graft. Patient underwent successful
dialysis session on ___. Underwent repeat dialysis session on
___ which was also successful. Given likely limited life span
(possibly 1 month) on current graft AV care was contacted and
appointment was arranged for followup in AV care clinic, at
which time further plans for access can be made. Patient will
continue on current dialysis schedule of ___.
# Hyperkalemia: Initial potassium was 6.1, EKG unchanged,
patient received d50 and insulin on arrival to the ED. Serum
chemistries on ___ reveal elevaed K+ to 7.4, for which
calcium gluconate was given during thrombectomy. The patient
susbsequently received HD with normalization of potassium. The
patient remained on telemetry without events.
# Syncope: patient was noted to have <5min episode of eyes
closed/decreased responsiveness towards the end of his first HD
session on ___, this corresponded to a drop in his blood
pressure and resolved with giving back a small amount of fluid.
Telemetry was unremarkable. His neuro exam remained intact, had
no signs seizure activity, and he was without complaints after
resolution of this episode. Thought vasovagal due to volume
shifts and possibly discomfort from being prolonged NPO
throughout the day. Can consider adjusting antihypertensive
medications going forward if continues to happen during
dialysis.
# GPA (ANCA negative) presenting with crescentic GN, pHTN,
cutaneous necrotizing manifestations and nodular scleritis.
During a recent admission for a flare the patient received 2
infusions of rituximab and high dose steroids. The patient was
on a steroid taper and did not have active skin vasculitic or
eye maifestations.
# HTN: patient was continued on home labetalol (non HD days),
nifedipine and simvastatin. As above, can conisder adjusting
antihypertensives in the outpatient setting should patient
continue to suffer hypotensive episodes with HD.
TRANSITIONAL ISSUES
# to resume previous dialysis schedule
# f/u with AV care clinic to address needs for alternate HD
access
# consider adjusting antihypertensive medications if patient
continues to be hypotensive during dialysis
# Emergency Contact: daughter ___ ___ (she is
currently in Fla), son ___ ___
#Code Status: Full code |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Salicylates / Penicillins / aspirin
Attending: ___
Chief Complaint:
Rectal bleeding
Major Surgical or Invasive Procedure:
___ CT-guided drain placement of right abdominal/paracolic
gutter abscess.
___ partial staple removal from wound
___ Take-back for anastamosis/closure
___ Extended Right hemicolectomy
History of Present Illness:
___ with history of BRBPR s/p emergent ex-lap, bowel resection
___, OSH, details unknown) now presenting with significant
BRBPR. Patient states symptoms began this morning suddenly and
that he 'filled up the toilet bowl.' He notes mild lower
quadrant pain without clear exacerbating factors.
He denied LOC/dizziness or weakness. Per report he was seen at
an OSH, given 1 unit of blood and transferred here for further
management
Past Medical History:
CHF, TEG/perforated ulcer requiring surgical repair,
diverticulitis
Social History:
___
Family History:
Non contributory
Physical Exam:
PHYSICAL EXAMINATION: ___: upon admission
Temp: 97.2 BP: 135/83 Resp: 18
Constitutional: Elderly, and deconditioned appearing but not ___
acute distress
Chest: Normal
Cardiovascular: Normal
Abdominal: Soft, Nontender, obese
Rectal: Large-volume red blood with some clots
Skin: Stage I decubitus ulcers on the inner thighs proximal to
buttocks
Neuro: Speech fluent
Psych: Normal mentation
Physical Examination upon discharge:
VS: 98.0 72, 116/68, 18, 98/2L
Gen: Resting ___ bed, NAD
Heent: EOMI, MMM
Cardiac: Normal S1 s2
Pulm: Lungs diminshed at bases.
Abdomen: Obese S/NT/ND EC fistula draining ___ ostomy appliance
Pigtail gutter
Ext: + pedal pulses. Trace edema b/l
Neuro: AAOx3
Pertinent Results:
___ 06:17AM BLOOD WBC-6.9 RBC-3.27* Hgb-7.6* Hct-27.2*
MCV-83 MCH-23.2* MCHC-28.0* RDW-17.1* Plt ___
___ 06:38AM BLOOD WBC-7.1 RBC-3.21* Hgb-7.6* Hct-26.3*
MCV-82 MCH-23.6* MCHC-28.8* RDW-16.9* Plt ___
___ 03:35PM BLOOD WBC-8.4 RBC-3.00* Hgb-7.4* Hct-24.9*
MCV-83 MCH-24.5* MCHC-29.6* RDW-16.9* Plt ___
___ 06:00AM BLOOD WBC-10.0 RBC-3.09* Hgb-8.0* Hct-26.4*
MCV-85 MCH-25.9* MCHC-30.4* RDW-16.8* Plt ___
___ 10:24AM BLOOD WBC-13.7* RBC-3.93* Hgb-9.9* Hct-32.9*
MCV-84 MCH-25.1* MCHC-29.9* RDW-17.1* Plt ___
___ 02:24AM BLOOD Neuts-86.5* Lymphs-6.3* Monos-4.9 Eos-1.2
Baso-0.3
___ 06:17AM BLOOD Plt ___
___ 06:17AM BLOOD ___
___ 06:17AM BLOOD Glucose-87 UreaN-7 Creat-0.9 Na-140 K-4.6
Cl-105 HCO3-29 AnGap-11
___ 06:38AM BLOOD Glucose-97 UreaN-8 Creat-0.7 Na-139 K-4.2
Cl-104 HCO3-26 AnGap-13
___ 02:24AM BLOOD Glucose-124* UreaN-20 Creat-0.9 Na-146*
K-3.8 Cl-113* HCO3-27 AnGap-10
___ 03:47PM BLOOD Glucose-127* UreaN-23* Creat-0.8 Na-148*
K-3.5 Cl-116* HCO3-23 AnGap-13
___ 10:24AM BLOOD Glucose-103* UreaN-23* Creat-0.8 Na-149*
K-3.9 Cl-112* HCO3-26 AnGap-15
___ 01:30PM BLOOD CK(CPK)-90
___ 10:24AM BLOOD ALT-10 AST-13 AlkPhos-65 TotBili-0.4
___ 01:30PM BLOOD CK-MB-2 cTropnT-<0.01
___ 01:30PM BLOOD proBNP-5825*
___ 06:17AM BLOOD Calcium-8.0* Phos-3.3 Mg-1.8
___ 02:17AM BLOOD Type-ART pO2-136* pCO2-48* pH-7.46*
calTCO2-35* Base XS-9 Intubat-NOT INTUBA
___ 06:09AM BLOOD freeCa-1.04*
___ 02:02PM BLOOD freeCa-1.09*
___: EKG:
Atrial fibrillation with mean ventricular rate of 77 beats per
minute with ventricular premature depolarizations. Left axis
deviation. Left anterior fascicular block. Non-specific
repolarization abnormalities. No previous tracing available for
comparison.
___: CTA of abdomen and pelvis:
1. Focus of active arterial extravasation ___ the proximal
transverse colon
just distal to the hepatic flexure.
2. Fluid-filled, dilated appendix measuring up to 12-mm,
although no evidence
of active inflammation to include acute appendicitis.
3. Enhancing lesion ___ the left kidney, concerning for a cystic
neoplasm.
Multiple bilateral renal cysts including a slightly complex
right renal cyst, possibly reflecting hemorrhagic or
proteinaceous components. Recommend nonemergent
contrast-enhanced MRI.
4. Nodule ___ the right lower lobe measuring less than 4 mm.
For nodule of this size, followup imaging ___ 12 months is
recommended by the ___ criteria if the patient has known
risk factors for lung cancer or history of malignancy. ___ the
absence of risk factors or cancer history, no followup imaging
is recommended.
5. Enlarged adrenal glands, left greater than right, consistent
with adrenal hyperplasia.
6. Sigmoid diverticulosis without evidence of diverticulitis.
7. Fluid filled colon which can be seen with diarrhea.
8. Cholelithiasis.
___: EKG
Atrial fibrillation with a rapid ventricular response. Low
voltage complexes.
Left anterior hemiblock. Ventricular rate much faster compared
to the previous tracing of ___. Otherwise, no significant
change.
___: chest x-ray:
PORTABLE AP CHEST RADIOGRAPH: There is stable cardiomegaly and
persistent pulmonary vascular congestion accompanied by mild
edema. There is mild left basilar atelectasis. Right basilar
atelectasis is improved since the prior examination. Persistent
small bilateral pleural effusions are noted.
___: US right arm:
IMPRESSION:
1. Nonocclusive thrombus ___ the right cephalic vein, a
superficial vein.
2. No right upper extremity deep venous thrombosis.
___: x-ray of the abdomen:
Large gas and fluid collection ___ right lower quadrant ___ this
patient status post prior right hemicolectomy. Considering
recent surgery and lack of identifiable haustral markings or
continuity with adjacent loops of bowel, this raises the
possibility of a contained, extraluminal gas and fluid
collection such as an abscess.
This finding is not, however, fully localized or characterized
on these
conventional radiographs, and further evaluation by dedicated CT
scan is
recommended. This information was communicated by telephone to
Dr. ___
at 11 o'clock a.m. on ___ at the time of discovery.
___: cat scan of abdomen and pelvis:
IMPRESSION:
1. Status post right colectomy with a fistula to the skin as
well as a fluid collection extending from the anastamosis to the
right paracolic gutter and a ___ collection ___ the pelvis
suspicious for developing abscesses and anastomotic leak.
2. Foci of free intraperitoneal air, suggestive of anastomotic
leak/perforation
___: cat scan CT drainage:
CT-guided drain placement of right abdominal/paracolic gutter
abscess. Microbiology pending
___ 10:41 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
Culture workup discontinued. Further incubation showed
contamination
with mixed skin/genital flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION OF TWO COLONIAL
MORPHOLOGIES.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 4 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ 11:29 am SWAB Source: abdominal wound.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS, CHAINS, AND
CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): YEAST(S).
WOUND CULTURE (Final ___:
This culture contains mixed bacterial types (>=3) so an
abbreviated
workup is performed. Any growth of P.aeruginosa, S.aureus
and beta
hemolytic streptococci will be reported. IF THESE BACTERIA
ARE NOT
REPORTED BELOW, THEY ARE NOT PRESENT ___ this culture..
STAPH AUREUS COAG +. RARE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # ___ ___.
ANAEROBIC CULTURE (Preliminary): RESULTS PENDING.
___ 3:00 pm ABSCESS ABCESS FLUID.
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
2+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S).
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
FLUID CULTURE (Preliminary):
This culture contains mixed bacterial types (>=3) so an
abbreviated
workup is performed. Any growth of P.aeruginosa, S.aureus
and beta
hemolytic streptococci will be reported. IF THESE BACTERIA
ARE NOT
REPORTED BELOW, THEY ARE NOT PRESENT ___ this culture..
STAPH AUREUS COAG +. SPARSE GROWTH.
ANAEROBIC CULTURE (Preliminary): RESULTS PENDING.
Medications on Admission:
lorazepam 0.5', protonix 40', tramadol 50', benadryl 25 q6h prn,
carvedilol 12.5', imdur 30', aldactone 25', albuterol prn,
lisinopril 10', spiriva 18', MVI, tylenol prn
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN sob/wheeze
3. Bisacodyl 10 mg PR HS:PRN constipation
4. Calcium Carbonate 500 mg PO QID:PRN heartburn, acid reflux
5. Carvedilol 6.25 mg PO BID
6. Clotrimazole Cream 1 Appl TP BID
3 week course, started ___. Docusate Sodium 100 mg PO BID
8. Heparin 5000 UNIT SC TID
9. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN sob/wheeze
10. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
11. Lisinopril 10 mg PO DAILY
12. Pantoprazole 40 mg PO Q24H
13. Sarna Lotion 1 Appl TP DAILY
14. Senna 1 TAB PO BID
15. Spironolactone 25 mg PO DAILY
16. Tiotropium Bromide 1 CAP IH DAILY
17. traZODONE 25 mg PO HS:PRN insomnia
18. Lorazepam 0.5 mg IV HS:PRN insomnia
19. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
20. Quetiapine Fumarate 25 mg PO QHS insomnia
21. DiphenhydrAMINE 12.5 mg PO Q6H:PRN itchiness
22. Sulfameth/Trimethoprim DS 1 TAB PO BID
last dose ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
lower GI bleed
cutaneous abdominal fistula
Secondary:
phelibitis right arm
acute systolic congestive heart failure
balantitis
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: ___ male with massive lower GI bleed.
TECHNIQUE: CTA imaging of the abdomen and pelvis was performed after
administration of 150 mL of Omnipaque IV contrast. Multiplanar reformats were
prepared and reviewed.
COMPARISON: None.
FINDINGS:
CTA ABDOMEN/PELVIS: The aorta and iliac arteries are normal in caliber
without evidence of dissection or intramural hematoma. The major abdominal
vessels are patent, including the celiac axis, SMA, and ___. There is a focus
of active extravasation in the proximal transverse colon just distal to the
hepatic flexure. Moderate atherosclerotic calcifications are seen in the
aorta and the other major abdominal arteries.
CT ABDOMEN: There is a nodule in the right lower lobe that measures less than
4 mm. The visualized lung bases are otherwise clear. Cardiomegaly is mild.
There is a sub-cm hypodensity in segment 6 of the liver that is too small to
characterize, but which likely represents a cyst. The liver is otherwise
homogeneous in texture. There is no biliary ductal dilatation. Numerous
gallstones are seen in the gallbladder. The adrenal glands are nodular and
enlarged, left greater than right, consistent with adrenal hyperplasia. The
spleen and pancreas are normal. There is an enhancing lesion in the left
kidney which appears hyperdense on the non-contrast study, concerning for
complex cystic mass. Multiple cystic structures are seen in the bilateral
kidneys, with one of the cysts measuring 2.5-cm and being slightly complex in
appearance in the right interpolar region, and the rest having a simple
appearance.
The stomach, duodenum, and intra-abdominal loops of small bowel are normal in
caliber and unremarkable. The colon is fluid-filled. The appendix is dilated
to 12-mm and fluid-filled proximally, but does not demonstrate wall thickening
or stranding. There is no retroperitoneal or mesenteric lymphadenopathy.
CT PELVIS: Diverticula are seen in the sigmoid colon without evidence of
inflammation. The sigmoid colon and rectum containing fluid, but otherwise
are normal in appearance. The distal ureters and bladder are normal. The
prostate and seminal vesicles are unremarkable. Several prominent lymph nodes
are seen in the pelvis, which are likely reactive. There is no free fluid in
the pelvis.
BONE WINDOWS: No focal lytic or sclerotic osseous lesion suspicious for
infection or malignancy is seen. Degenerative changes are seen in the
bilateral hips.
IMPRESSION:
1. Focus of active arterial extravasation in the proximal transverse colon
just distal to the hepatic flexure.
2. Fluid-filled, dilated appendix measuring up to 12-mm, although no evidence
of active inflammation to include acute appendicitis.
3. Enhancing lesion in the left kidney, concerning for a cystic neoplasm.
Multiple bilateral renal cysts including a slightly complex right renal cyst,
possibly reflecting hemorrhagic or proteinaceous components. Recommend
nonemergent contrast-enhanced MRI.
4. Nodule in the right lower lobe measuring less than 4 mm. For nodule of
this size, followup imaging in 12 months is recommended by the ___
criteria if the patient has known risk factors for lung cancer or history of
malignancy. In the absence of risk factors or cancer history, no followup
imaging is recommended.
5. Enlarged adrenal glands, left greater than right, consistent with adrenal
hyperplasia.
6. Sigmoid diverticulosis without evidence of diverticulitis.
7. Fluid filled colon which can be seen with diarrhea.
8. Cholelithiasis.
Radiology Report
INDICATION: Bright red blood per rectum, status post emergent extended right
hemicolectomy. Assess position of endotracheal tube.
COMPARISON: None available.
TECHNIQUE: Portable frontal chest radiograph.
FINDINGS: Cardiac silhouette is enlarged with mild vascular congestion
without frank edema. Lungs are clear. There is no large pleural effusion or
pneumothorax. Endotracheal tube is in place, 4 cm cranial to the carina;
however, the endotracheal cuff is inflated to a greater diameter in the
trachea. A right internal jugular sheath is in place.
IMPRESSION: Endotracheal tube appropriately positioned but with overinflated
cuff. Mild vascular congestion without frank edema.
Results were discussed over the telephone with Dr. ___ by ___ at
4:27 p.m. on ___ at the time of initial review.
Radiology Report
HISTORY: Diverticular bleed, to assess for change.
FINDINGS: In comparison with the study of ___, the monitoring and support
devices are unchanged.
Radiology Report
INDICATION: Rule out retained items in OR. Open abdomen necessitates
radiography per protocol.
TECHNIQUE: Five supine radiographs of the abdomen and pelvis obtained in the
operating room.
FINDINGS: Five radiographs were obtained of the abdomen and pelvis to assess
for the possibility of a retained foreign body. A nasogastric tube is in
place with tip terminating near the gastric fundus. Multiple calcified
gallstones are seen in the right upper quadrant. No radiopaque foreign body
is identified in the abdomen or pelvis. Bowel gas pattern appears
unremarkable. Metallic skin staples are evident at the site of surgical
incision. Osseous structures show diffuse degenerative change of the imaged
portion of thoracic and lumbar spine. Pneumoperitoneum is in keeping with
postoperative state.
IMPRESSION:
1. No radiographic evidence of retained foreign body,
2. Cholelithiasis.
3. Postoperative pneumoperitoneum.
The results were discussed via telephone by Dr. ___ with Dr. ___
attending, at 3:51 p.m. on ___ and again at 4:12 p.m. after
obtaining additional radiographs for complete coverage.
Radiology Report
HISTORY: Intubated check interval change.
COMPARISON: ___.
FINDINGS:
Compared to the prior study the ET tube and NG tube are unchanged. There is a
right IJ Cordis with its tip in the proximal SVC. There is moderate
cardiomegaly and pulmonary vascular redistribution. There is volume loss at
both bases. Compared to the prior study the fluid overload and volume loss of
increased impression slightly worse.
IMPRESSION:
The appearance of the lungs is slightly worse
Radiology Report
PORTABLE CHEST OF ___
COMPARISON: ___ radiograph.
FINDINGS: Interval intubation and removal of right internal jugular vascular
sheath, with no evidence of pneumothorax. Stable cardiomegaly and persistent
pulmonary vascular congestion accompanied by mild edema. Persistent bibasilar
atelectasis, with slight worsening on the right. Persistent small bilateral
pleural effusions.
Radiology Report
INDICATION: ___ man with poor blood oxygen and variable mental
status, evaluate for pulmonary process, compared to prior films.
COMPARISON: Portable AP chest radiograph ___.
PORTABLE AP CHEST RADIOGRAPH: There is stable cardiomegaly and persistent
pulmonary vascular congestion accompanied by mild edema. There is mild left
basilar atelectasis. Right basilar atelectasis is improved since the prior
examination. Persistent small bilateral pleural effusions are noted.
Radiology Report
HISTORY: Thrombophlebitis with expanding pain in the right upper extremity.
COMPARISON: No relevant comparisons available.
FINDINGS: Gray scale and color Doppler sonograms with spectral analysis of the
bilateral subclavian veins and the right internal jugular, axillary, brachial,
basilic, and cephalic veins were performed. There is partially occlusive
echogenic thrombus in the mid right cephalic vein. The upper right cephalic
vein is patent. The remainder of the veins demonstrate normal
compressibility, flow, and augmentation.
IMPRESSION:
1. Nonocclusive thrombus in the right cephalic vein, a superficial vein.
2. No right upper extremity deep venous thrombosis.
Radiology Report
ABDOMINAL SERIES, ___
COMPARISON: ___ radiograph and CT abdomen of ___.
Review of the patient's previous imaging studies provides additional history
that there has been a recent extended right hemicolectomy approximately two
weeks earlier.
A large gas- and fluid-containing structure is identified in the right lower
quadrant extending superiorly to the infrahepatic region. It measures about
22.6 cm in greatest diameter. On the lateral decubitus view, a prominent
air-fluid level is present within the structure, which does not have
identifiable haustral markings. Exam is otherwise remarkable for multiple
calcified gallstones within the gallbladder and air within loops of
nondistended small and large bowel in the remaining portion of the abdomen.
IMPRESSION:
Large gas and fluid collection in right lower quadrant in this patient status
post prior right hemicolectomy. Considering recent surgery and lack of
identifiable haustral markings or continuity with adjacent loops of bowel,
this raises the possibility of a contained, extraluminal gas and fluid
collection such as an abscess.
This finding is not, however, fully localized or characterized on these
conventional radiographs, and further evaluation by dedicated CT scan is
recommended. This information was communicated by telephone to Dr. ___
at 11 o'clock a.m. on ___ at the time of discovery.
Radiology Report
INDICATION: ___ male with bright red blood per rectum, status post
extended right hemicolectomy, left in discontinuity, now status post
anastomosis closure, evaluate for fluid collection, abscess, fistula of the
skin.
COMPARISON: CT abdomen from ___.
TECHNIQUE: MDCT images from the lung bases to the pubic symphysis were
obtained following the administration of 130 cc of Omnipaque without
complication. Sagittal and coronal reformations were obtained.
FINDINGS:
The lung bases are clear. There is no pericardial effusion.
There is a 7 mm hypoattenuating lesion in the posterior right hepatic lobe,
which is too small to characterize. The remainder of the liver is
unremarkable. Multiple gallstones are identified within the gallbladder,
however there is no surrounding inflammatory change. The spleen and pancreas
are unremarkable.
The bilateral adrenal glands are enlarged and nodular, left greater than
right, stable from the ___ exam. There are multiple hypoattenuating
lesions in the bilateral kidneys, likely representing cyts. The bladder is
partially distended, without wall thickening. The prostate gland is
unremarkable.
There is a fluid collection in the pelvis measuring approximately 5.5 x 5.9 x
3.2 cm (TV x AP x CC)(2:69). Additionally, there is fluid along the inferior
aspect of the liver trailing into the right paracolic gutter, which
demonstrates peritoneal enhancement. The patient is status post right
hemicolectomy. There are foci of free intraperitoneal air along the anterior
abdominal wall near the anastomosis site (2:32-34) with air extending into the
subcutaneous tissues at the incision site, suggestive of a fistula to the
skin. The previously identified large fluid and air filled structure
visualized on the abdomen radiograph on ___ is not visualized on today's
exam, however the foci of free intraperitoneal air may be related to
decompression of this structure. The small bowel is normal in caliber.
Atherosclerotic calcifications are noted in the aorta and its branches. There
are mildly prominent external iliac nodes bilaterally measuring up to 2.1 x
1.5 cm. There is no retroperitoneal or mesenteric adenopathy.
Degenerative changes are noted in the spine. There is no suspicious lytic or
blastic lesion.
IMPRESSION:
1. Status post right colectomy with a fistula to the skin as well as a fluid
collection extending from the anastamosis to the right paracolic gutter and a
___ collection in the pelvis suspicious for developing abscesses and
anastomotic leak.
2. Foci of free intraperitoneal air, suggestive of anastomotic
leak/perforation.
3. Cholelithiasis, without inflammatory changes.
These results were discussed with Dr. ___ ACS team by phone by Dr.
___ at 16:45 on ___.
Radiology Report
CT INTERVENTIONAL PROCEDURE: CT-guided fluid collection drainage.
INDICATION: ___ male status post right hemicolectomy, status post
anastomosis, now with enterocutaneous fistula and fluid collection in the
right paracolic gutter. Please drain right paracolic gutter fluid collection.
PHYSICIANS: Dr. ___, abdominal imaging fellow, and Dr. ___
___, radiology attending.
TECHNIQUE: The procedure, risks, benefits, and alternatives were discussed
with the patient and written informed consent was obtained. A preprocedure
timeout was performed discussing the planned procedure, confirming the
patient's identity with three identifiers, and reviewing a checklist per ___
protocol.
Under ultrasound guidance, the patient was placed in supine position and
limited axial CT images were obtained through the mid abdomen demonstrating a
right paracolic gutter fluid collection. Under CT guidance, an entrance skin
site was selected and was prepped and draped in usual sterile fashion. 1%
lidocaine was instilled to the skin and deep soft tissues for local
anesthesia.
A 17-gauge ___ needle was advanced into the abscess under CT guidance.
Once adequate positioning was confirmed, a wire was placed in the collection.
Next, an 8 ___ ___ catheter was exchanged over the wire and secured in
pigtail fashion. Placement was confirmed with aspiration of purulent greenish
material, 10 cc of which was sent to microbiology for culture and Gram stain.
The ___ pigtail catheter was fastened to a JP bulb for continuous drainage
of the remainder of the collection.
Moderate sedation was provided by administering divided doses of Versed 4 mg
and fentanyl 100 mcg throughout the total intraservice time of 20 minutes
during which the patient's hemodynamic parameters were continuously monitored
by radiology nursing personnel.
The patient tolerated the procedure well with no immediate complications.
Estimated blood loss was minimal. Post-procedure instructions were written in
the ___ medical record. Dr. ___ attending radiologist, was
present throughout the entire procedure.
IMPRESSION: CT-guided drain placement of right abdominal/paracolic gutter
abscess. Microbiology pending.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: GI
Diagnosed with GASTROINTEST HEMORR NOS
temperature: 97.2
heartrate: 77.0
resprate: 18.0
o2sat: 97.0
sbp: 135.0
dbp: 83.0
level of pain: nan
level of acuity: nan | The patient was admitted to the hospital with rectal bleeding.
Upon admission, he was reported to be ___ hemorrhagic shock
responding to intravenous fluids. The patient was made NPO,
underwent placement of a ___ tube, and underwent
imaging. A cat scan angiogram of the abdomen was done which
showed a focus of active extravasation ___ the proximal
transverse colon just distal to the hepatic flexure. While
being resucitated, the patient was taken emergently to the
operating room where he underwent an extended right colectomy
and a liver biopsy. During the operative course, the patient
had a 50cc blood loss and required 2 liters of fluid and 1 unit
of packed red blood cells. Operative findings included a fluid
filled abdomen. The patient's hemodynamic status improved with
resusitative measures. A liver biospy was done because of the
nodular nature of the liver. At the close of the procedure, the
decision was made to leave the abdomen open because the exact
site of bleeding had not been determined. After the procedure,
the patient was transported to the intensive care unit for
hemodynamic monitoring.
On POD #1, the patient returned to the operating room for
re-opening of laparotomy with small bowel to colon anastomosis
and closure. Intra-op, no peritoneal bleeding was reported.
After the procedure, the patient returned to the intensive care
unit. The patient was weaned and extubated 24 hours later. The
___ tube was removed and the patient was started on
sips. After stabilization of vital signs, the patient was
transferred to the surgical floor. His intravenous analgesia
was converted to oral agents and the patient resumed a regular
diet. On POD # ___, the patient experienced recurrence of his
congestive heart failure and was given lasix with good effect.
His vital signs and urine output were closely monitored.
Electrolytes were monitored and repleted. The patient was
evaulated by physical therapy ___ anticipation for discharge.
On HD #16, the patient reported increased abdominal pain which
was unrelieved with analgesia. A urine culture was sent and the
patient was found to be growing E.Coli and was started on
ciprofloxacin. The patient underwent a cat scan of the abdomen
which showed large gas and fluid collection ___ right lower
quadrant and there was concern for an abscess collection. He
remained afebrile with a normal white blood cell count. To
further evaluate the fluid collection, the patient underwent a
cat scan of the abdomen which showed a fistula to the skin as
well as a fluid collection extending from the anastamosis to the
right paracolic gutter and a ___ collection ___ the pelvis.
These findings were suspicious for developing abscesses and an
anastomotic leak. The patient was then taken to ___ for
placement of a drain into the right abdominal/paracolic gutter
abscess. Purulent greenish material was drained and sent for
culture. The patient was found to be growning staph aureus
coag. + from the abscess which was sensitive to bactrim. A
seven day course of bactrim was ordered. A vac dressing was
placed over the mid-line open abdominal wound, but because of
excessive leakage, the vac dressing was removed and replaced
with a large fistula pouch to contain the draingage.
The patient was discharged to a rehabilitation facily on ___
with stable vital signs. He remained afebrile with a white
blood cell count of 8.9 and a hematocrit of 27. Appointments
for follow-up were made with the acute care service. After
discharge from the rehabilitation facility, he will need
follow-up with his primary care provider for further evaluation
of a lung and kidney lesion. He will also need an appointment
with a Urologist for circumcision. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right distal tibular-fibula fracture
Major Surgical or Invasive Procedure:
ORIF, right distal tibia and fibula fracture
History of Present Illness:
___ h/o HIV on ___ transferred from ___ with
Right distal tib-fib fracture after falling 6 feet from a fence.
The patient had a couple cocktails to celebrate his upcoming
marriage in 1 week and got up on a fence to check out what his
neighbors were doing when he fell. Immediate Right leg
deformity, pain and swelling with inability to ambulate. Taken
to ___ where x-rays showed Right distal tib-fib
fracture, splinted, transferred to ___, ortho consulted.
Denies numbness/tingling/weakness.
Past Medical History:
- HIV on HAART
- anxiety
- depression
Social History:
___
Family History:
non-contributory
Physical Exam:
Vitals: AVSS
General: NAD, A&Ox3
Psych: appropriate mood and affect
Musculoskeletal:
Right Lower Extremity:
Incision/Wound: dressing clean dry and intact, no induration, no
erythema Thigh and leg compartments soft and compressible
Fires ___
Sensation intact to light touch sural, saphenous, tibial,
superficial and deep peroneal nerve distributions
1+ dorsal pedis and posterior tibial pulses
Pertinent Results:
___ 09:57PM GLUCOSE-115* UREA N-15 CREAT-0.9 SODIUM-140
POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-22 ANION GAP-17
___ 09:57PM estGFR-Using this
___ 09:57PM WBC-6.8 RBC-4.50* HGB-15.4 HCT-44.3 MCV-98#
MCH-34.2*# MCHC-34.7 RDW-13.5
___ 09:57PM NEUTS-67.8 ___ MONOS-3.0 EOS-0.8
BASOS-0.6
___ 09:57PM PLT COUNT-227
___ 09:57PM ___ PTT-24.4* ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ClonazePAM 0.5 mg PO BID
2. Fluoxetine Dose is Unknown PO Frequency is Unknown
3. ATRIPLA (efavirenz-emtricitabin-tenofov) ___ mg oral
daily
Discharge Medications:
1. crutches
dx ankle fx
px good
___ 13 months
2. ATRIPLA (efavirenz-emtricitabin-tenofov) ___ mg oral
daily
3. ClonazePAM 0.5 mg PO BID
4. Fluoxetine 20 mg PO DAILY
5. Acetaminophen 650 mg PO Q6H
6. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
discontinue if more than 5 loose stools a day
RX *bisacodyl 5 mg 2 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*2
7. Docusate Sodium 100 mg PO BID
discontinue if more than 5 loose stools per day
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*2
8. Enoxaparin Sodium 40 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 1 injection sc daily Disp #*14
Syringe Refills:*0
9. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone [Oxecta] 5 mg 1 - 2 tablet(s) by mouth every four
(4) hours Disp #*80 Tablet Refills:*0
10. Senna 8.6 mg PO BID
discontinue if more than 5 loose stools
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*30 Capsule Refills:*2
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right distal tibia-fibula 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, LAT AND OBLIQUE) RIGHT
INDICATION: FX REPAIR
IMPRESSION:
Images from the operating suite show fixations of the previous fractures of
the distal tibia and fibula. Further information can be gathered from the
operative report.
Radiology Report
INDICATION: ___ with R tib-fib fx s/p reduction // eval interval change
COMPARISON: Multiple prior exams, most recently of ___.
TECHNIQUE: Frontal and lateral views of the tibia.
FINDINGS:
The patient is status post casting of distal right tibia and fibula fractures.
There is persistent apex anterior angulation of both the tibial and fibular
fractures with mild lateral and proximal displacement of the distal tibial
fragment. The cast slightly obscures fine bony detail, but bony alignment is
visible.
IMPRESSION:
Status post casting of distal right tibia and fibular fractures, the fragments
of which remain displaced and angulated.
Gender: M
Race: ASIAN
Arrive by AMBULANCE
Chief complaint: s/p Fall, R Ankle pain
Diagnosed with FX ANKLE NOS-CLOSED, FALL FROM OTHER SLIPPING,TRIPPING,STUMBLING, ASYMPTOMATIC HIV INFECTION
temperature: 98.3
heartrate: 84.0
resprate: 16.0
o2sat: 94.0
sbp: 110.0
dbp: 66.0
level of pain: 5
level of acuity: 3.0 | Mr. ___ was admitted to the orthopaedic surgery service on
___ with a Right distal tib-fib fracture after falling 6
feet from a fence. Patient was taken to the operating room and
underwent ORIF, right distal tibia and fibula fracture. 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 non weight
bearing. After procedure, patient's weight-bearing status was
transitioned to touch down weight bearing. Throughout the
hospitalization, patient worked with physical therapy.
Neuro: post-operatively, patient's pain was controlled by
morphine IV and was subsequently transitioned to oxycodone with
good effect and adequate pain control.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Hematology: The patient's hematocrit remained stable.
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. He was also continued on his at home antivirals
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 ___ the patient was doing
well, afebrile with stable vital signs, tolerating a regular
diet, ambulating as tolerated after working with physical
therapy, 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: MEDICINE
Allergies:
Doxycycline / Lipitor
Attending: ___.
Chief Complaint:
fatigue
Major Surgical or Invasive Procedure:
none this hospitalization.
History of Present Illness:
Ms. ___ is ___ woman with a history of anxiety,
sinus tachycardia, and CAD with recent NSTEMI (discharged ___
s/p DES to LCx) who is presenting with orthostatic hypotension
and exertional dyspnea.
Patient was discharged on ___ after NSTEMI with DES to LAD.
She was also treated with Keflex and Cipro for a klebsiella UTI.
Medication changes during admission included changing atenolol
to metoprolol, and adding atorvastatin, plavix, and aspirin.
Patient reports that her only medication change since discharge
has been increasing dose of atorvastatin to 20 mg daily. She has
not missed any doses of Plavix.
Since discharge, patient has continued to feel fatigued. Over
the past ___ days, she has also been having increasing SOB on
exertion. Associated with some cough, but not significantly
above baseline smoker's cough and no significant sputum
production. She has stopped smoking with patch since discharge.
No chest pain, chest pressure, palpitations, fevers, chills,
n/v/d, lower extermity edema, dysuria/frequency/urgency. Patient
has been constipated with no bowel movement x 1 week.
She was seen by her home ___ today, who found her to be
orthostatic, with BP sitting 95/60 and standing 80/50 (HR
unchanged at 120). She may have been mildly lightheaded- she is
unsure. She was referred to the ___ ED, where vitals were HR
112 BP 102/14 98% RA. She received 500 cc NS. Labs showed a
negative UA, a slightly elevated WBC, an elevated BNP ~1000, and
D-dimer 700. CXR was unremarkable. Because of elevated d-dimer,
patient underwent CTA, which was negative for PE but suggested
bronchitis vs. esophagitis.
She was admitted to the floor, where initial vitals were 98
132/69 --> 99/54 118 18 97 RA Wt 189.9 (from 184 on ___.
Patient is asymptomatic.
Past Medical History:
PMR on chronic steroids
Depression
Anxiety
IBS
Osteoarthritis
PUD, patient unsure
H/o Sinus tachycardia
Vertigo
HTN
Hyperlipidemia
Colonic polyps
Non alcoholic fatty liver disease
Lumbar radiculopathy
Right sided sacroiliitis
Right sided piriformis syndrome
S/p D&C in ___ for dysfunctional uterine bleeding
Social History:
___
Family History:
Cervical cancer in her mother.
Physical Exam:
===========================
ADMISSION PHYSICAL
===========================
VS: 98.1 99-107/54-57 104-108 93-97% RA
WEIGHT: 189.8lbs
GENERAL: NAD. A+Ox3.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple non-elevated JVD
CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: CTAB
ABDOMEN: Soft, NTND. No HSM or tenderness
EXTREMITIES: No c/c trace peripheral edema
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ ___ 2+
Left: Carotid 2+ DP 2+ ___ 2+
============================
DISCHARGE PHYSICAL
============================
VS: 97.9 101 (90-109) 120/69 96% RA RR 18, negative orthostatics
WEIGHT: (189.8lbs ___
I/O NR
GENERAL: NAD. A+Ox3.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple non-elevated JVD
CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: CTAB
ABDOMEN: Soft, NTND. No HSM or tenderness
EXTREMITIES: No c/c trace peripheral edema
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ ___ 2+
Left: Carotid 2+ DP 2+ ___ 2+
Pertinent Results:
============================
ADMISSION LABS
============================
___ 01:05PM BLOOD WBC-14.2* RBC-4.56 Hgb-14.3 Hct-44.5
MCV-98 MCH-31.3 MCHC-32.1 RDW-14.4 Plt ___
___ 01:05PM BLOOD Neuts-85.0* Lymphs-10.3* Monos-3.2
Eos-0.9 Baso-0.6
___ 01:05PM BLOOD ___ PTT-27.5 ___
___ 01:05PM BLOOD Glucose-160* UreaN-20 Creat-0.9 Na-136
K-4.3 Cl-98 HCO3-24 AnGap-18
___ 01:05PM BLOOD CK-MB-8 proBNP-1050*
___ 01:05PM BLOOD cTropnT-0.34*
___ 08:00AM BLOOD Calcium-10.1 Phos-2.9 Mg-1.3*
___ 04:06PM BLOOD D-Dimer-705*
=============================
Pertinent results
=============================
___ 01:05PM BLOOD cTropnT-0.34*
___ 08:00AM BLOOD CK-MB-9 cTropnT-0.29*
___ 08:00AM BLOOD Cortsol-2.0
=============================
DISCHARGE LABS
=============================
___ 07:25AM BLOOD WBC-10.1 RBC-4.10* Hgb-12.6 Hct-40.0
MCV-98 MCH-30.7 MCHC-31.5 RDW-14.4 Plt ___
___ 07:25AM BLOOD Glucose-121* UreaN-16 Creat-0.9 Na-143
K-4.0 Cl-107 HCO3-26 AnGap-14
=============================
IMAGING
=============================
___ ECHO:
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF = 60%). However, the posterior wall may be hypokinetic.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets are mildly thickened (?#). There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is a trivial/physiologic
pericardial effusion. There are no echocardiographic signs of
tamponade.
Compared with the prior study (images reviewed) of ___,
there is no obvious change, but the technically suboptimal
nature of both studies precludes definitive comparison.
___ CTA:
IMPRESSION:
1. No evidence of a pulmonary embolism or acute aortic injury.
2. Mild bronchial wall thickening, could relate to bronchitis.
3. Possible mild esophageal wall thickening which raises
suspicion for
esophagitis and could be further evaluated for on UGI or
endoscopy.
4. Bilateral thryoid nodules; recommend correlation with
dedicated thyroid
ultrasound.
5. Fatty deposition within the liver.
___ CXR:
FINDINGS: AP upright and lateral views of the chest were
provided. There is
linear density at the right lung base likely representing
subsegmental
atelectasis or scarring. There is no focal consolidation to
raise concern for
pneumonia. No effusion or pneumothorax is seen. The heart size
appears
grossly stable. Mediastinal contour is unremarkable. Bony
structures are
intact. No free air below the right hemidiaphragm.
IMPRESSION: No convincing signs of pneumonia.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
2. ALPRAZolam 0.5 mg PO QID:PRN anxiety
3. Cyclobenzaprine 10 mg PO HS back pain/stiffness
4. Ferrous Sulfate 325 mg PO DAILY
5. Gabapentin 600 mg PO HS
6. Lidocaine 5% Patch 1 PTCH TD DAILY
7. Meclizine 25 mg PO BID
8. PredniSONE 10 mg PO DAILY
9. Vitamin D 3000 UNIT PO DAILY
10. Aspirin 81 mg PO DAILY
11. Clopidogrel 75 mg PO DAILY
12. Lisinopril 2.5 mg PO DAILY
13. Metoprolol Succinate XL 75 mg PO DAILY
14. Nicotine Patch 14 mg TD DAILY
15. Acetaminophen 650 mg PO PRN pain
16. Alendronate Sodium 70 mg PO QWED
17. Calcium Carbonate 1500 mg PO BID
18. Cyanocobalamin 1000 mcg PO DAILY
19. glucosamine-chondroitin 500-400 mg Oral daily
20. Hydrocodone-Acetaminophen (5mg-500mg) 1 TAB PO DAILY:PRN
pain
21. Rosuvastatin Calcium 20 mg PO DAILY
22. Desipramine 10 mg PO 3 TABS AT NIGHT
Discharge Medications:
1. Acetaminophen 650 mg PO PRN pain
2. ALPRAZolam 0.5 mg PO QID:PRN anxiety
3. Aspirin 81 mg PO DAILY
4. Calcium Carbonate 1500 mg PO BID
5. Clopidogrel 75 mg PO DAILY
6. Cyanocobalamin 1000 mcg PO DAILY
7. Ferrous Sulfate 325 mg PO DAILY
8. Gabapentin 600 mg PO HS
9. Lidocaine 5% Patch 1 PTCH TD DAILY
10. Lisinopril 2.5 mg PO DAILY
11. Meclizine 25 mg PO BID
12. Nicotine Patch 14 mg TD DAILY
13. PredniSONE 30 mg PO DAILY
RX *prednisone 10 mg 3 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
14. Rosuvastatin Calcium 20 mg PO DAILY
15. Vitamin D 3000 UNIT PO DAILY
16. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet extended release 24
hr(s) by mouth daily Disp #*30 Tablet Refills:*0
17. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
18. Alendronate Sodium 70 mg PO QWED
19. Cyclobenzaprine 10 mg PO HS back pain/stiffness
20. Desipramine 10 mg PO 3 TABS AT NIGHT
21. glucosamine-chondroitin 500-400 mg Oral daily
22. Hydrocodone-Acetaminophen (5mg-500mg) 1 TAB PO DAILY:PRN
pain
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY
1. secondary, exogenous adrenal insufficiency
2. orthostatic hypotension
3. fatigue
4. coronary artery disease
5. sinus tachycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH PERFORMED ON ___
COMPARISON: Prior exam from ___.
CLINICAL HISTORY: Weakness, status post acute MI last week requiring
stenting, elevated WBC, question pneumonia.
FINDINGS: AP upright and lateral views of the chest were provided. There is
linear density at the right lung base likely representing subsegmental
atelectasis or scarring. There is no focal consolidation to raise concern for
pneumonia. No effusion or pneumothorax is seen. The heart size appears
grossly stable. Mediastinal contour is unremarkable. Bony structures are
intact. No free air below the right hemidiaphragm.
IMPRESSION: No convincing signs of pneumonia.
Radiology Report
HISTORY: Elevated D-dimer with shortness of breath.
COMPARISON: Chest radiograph from same day.
TECHIQUE: MDCT-acquired axial images were obtained through the chest after
the administration of IV contrast. Multiplanar reformatted images were
preapred and reviewed.
FINDINGS:
CHEST CTA: Opacification of the pulmonary vasculature demonstrates no filling
defects to suggest a pulmonary embolism. The aorta and great vessels appear
within normal limits. Bilateral hypodensities are noted throughout the
thyroid gland and suggestive of thyroid nodules with the greatest on the left
measuring up to 9 mm. There is no hilar, mediastinal or axial lymph
adenopathy by CT size criteria. The heart is normal in size without
pericardial effusion. The esophagus is not distended but may be mildly
thick-walled raising suspicion for underlying esophagitis.
The tracheobronchial tree is patent to subsegmental levels. There is mild
centrilobular emphysema. There is mild bronchial wall thickening which is
nonspecific but may be subtly seen in the setting of bronchitis. Mild
bibasilar atelectatic changes are noted but the lungs are without focal
opacity.
The study is not tailored for evaluation of subdiaphragmatic structures but
the visualized portions of the upper abdomen demonstrates a hypodense liver
consistent with fatty deposition.
There are no lytic or sclerotic osseous lesions suspicious for malignancy.
Mild degenerative changes are noted throughout the thoracolumbar spine.
IMPRESSION:
1. No evidence of a pulmonary embolism or acute aortic injury.
2. Mild bronchial wall thickening, could relate to bronchitis.
3. Possible mild esophageal wall thickening which raises suspicion for
esophagitis and could be further evaluated for on UGI or endoscopy.
4. Bilateral thryoid nodules; recommend correlation with dedicated thyroid
ultrasound.
5. Fatty deposition within the liver.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Weakness, Hypotension
Diagnosed with OTHER MALAISE AND FATIGUE, TACHYCARDIA NOS, RESPIRATORY ABNORM NEC
temperature: 97.6
heartrate: 120.0
resprate: 16.0
o2sat: 98.0
sbp: 112.0
dbp: 68.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is ___ woman with a history of anxiety,
sinus tachycardia, PMR on prednisone, and recent NSTEMI who
presents with hypotension and dyspnea on exertion.
# Hypotension
# Adrenal Insufficency
Patient met criteria for orthostatic hypotension at home and
during the early part of her hospitalization;Given recent DES to
LCx, she is at high risk of in-stent thrombosis; however, lack
of enzyme elevation and ischemic EKG changes argue against this
diagnosis. Other post-MI complications, including new
failure/valvular disease/aneurysm are also a consideration. BNP
is elevated and LVEF was 50% in setting of NSTEMI, but clinical
exam is not very impressive for volume overload. Other
etiologies include infection, though patient has no obvious
infectious source with negative UA and CXR. Polypharmacy was
also considered to be a potential etiology given her metoprolol
was increased on the day of discharge. She was found to have an
AM cortisol level of 2 consistent with adrenal insufficiency.
She was given stress dose steroids. The underlying etiology was
lack of stress dose steroids at the time of her NSTEMI. Her
symptoms improved and the patient felt better. She did not have
any evidence of orthostasis at the time of discharge. Her
metoprolol was decreased to 50mg PO daily. Her echo was
reassuring for no post-MI complications.
# Dyspnea on Exertion: As above, post-MI complications are a
major consideration, but in-stent thrombus seems unlikely at
this point. Enzymes trended down. CTA was negative for PE but
did suggest bronchitis, but findings may be c/w prior smoking
history. Echo was negative. Her dyspnea, which pre-dated her MI,
was also thought to be secondary to deconditioning. She did feel
somewhat improved at the time of discharge.
# CAD: Recent NSTEMI and s/p DES to LCX. Continued on
rosuvastatin, plavix, aspirin, and lisinopril.
# Sinus tachycardia: continued to be tachycardic despite
beta-blockage.
# PMR: Prednisone was increased to 30mg PO daily until the
patient follows-up with her PCP.
# HLD: Continued on rosuvastatin.
# Fibromyalgia/Anxiety: Continued on meclizine, alprazolam,
gabapentin
=====================================
TRANSITIONAL ISSUES
=====================================
# stress dose steroids needed in time of stress and illness,
will continue on higher dose until follows with PCP
# sinus tachycardia |
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:
___ year old male with history of severe esophagitis c/b anemia
requiring recent hospitalization in ___ for transfusion,
hiatal hernia, and history of alcohol use disorder,
anxiety/depression who presents to ED with dyspnea on exertion x
1 month.
He presented to ___ with chief complaint of fatigue and dyspnea
on exertion found to be tachycardic to 120 and was referred to
the ED. Over last month endorses DOE, fatigued and dyspneic
walking up stairs and while coaching his daughters ___
practices. Recent difficulty sleeping has he wakes up with
heartburn from reflux but also with some shortness of breath. He
does report difficulty breathing when flat and occasionally
waking up gasping, both new within the last couple months. He
also endorses occasionally having edematous legs, though not
worse recently. He believes his weight has increased by about 30
lbs in the past 6 months despite attempting to adhere to a good
diet. Additionally reports dry cough within the last two months,
which is worse at night and he had associated with his GERD. No
chest pain, palpitations, wheezing, hemoptysis. Denies
lightheadedness, dizziness, n/v, fevers/chills, recent
illnesses, diarrhea, melena, hematochezia.
In ___, patient found to have HGB 3.8 requiring admission and
4 U PRBC with appropriate response. Most recent EGD ___ showing
severe esophagitis and hiatal hernia on PO PPI BID and oral iron
with most recent HGB 7.3 in ___. Patient now with fatigue for
1 month, tachycardia, conjunctival pallor c/f acute blood loss
anemia.
In the ED:
- Initial vital signs were notable for: T 98.2 HR 116 BP 151/107
RR 16 SPO2 96% RA
- Exam notable for: conjunctival pallor c/f acute blood loss
anemia
- Labs were notable for:
WBC 7.5 HGB 10.5 PLT ___ 4
------------< 96 AGap=18
4.2 22 1.1
ALT: 110 AP: 198 Tbili: 0.6 Alb: 4.3
AST: 114
Trop-T: <0.01 x2
proBNP: 52
D-Dimer: 380
- Studies performed include:
CXR:
IMPRESSION: Borderline heart size. Substantial hiatal hernia.
- Patient was given: PO Pantoprazole 40 mg
Vitals on transfer: HR 87 BP 128/98 RR 19 SPO2 92% RA
Upon arrival to the floor, the patient confirms the story above.
Not currently short of breath, lying flat on the bed but with
head under two pillows.
REVIEW OF SYSTEMS: Complete ROS obtained and is otherwise
negative.
Past Medical History:
- Chronic post-traumatic headache with migraine
- Anxiety
- Depression
- EtOH abuse
- Opioid dependence
Social History:
___
Family History:
- Mother: HTN
- Father: MI, T2DM, CHF
- MGM: Lung CA
No hx of sudden cardiac death
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: ___ 0610 Temp: 98.0 PO BP: 145/101 HR: 85 RR: 16 O2
sat: 94% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___
GENERAL: Alert and interactive. In no acute distress.
EYES: EOMI. Sclera anicteric and without injection.
ENT: MMM. No cervical lymphadenopathy. JVP 7-8cm
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
RESP: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
MSK: No clubbing, cyanosis. trace ___ edema to lower shins.
Pulses
DP/Radial 2+ bilaterally.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. AOx3.
PSYCH: appropriate mood and affect
Pertinent Results:
============================
ADMISSION LABORATORY STUDIES
============================
___ 05:58PM BLOOD WBC-7.5 RBC-4.96 Hgb-10.5* Hct-37.3*
MCV-75* MCH-21.2* MCHC-28.2* RDW-22.5* RDWSD-58.0* Plt ___
___ 07:00AM BLOOD ___ PTT-27.1 ___
___ 10:46PM BLOOD D-Dimer-380
___ 05:58PM BLOOD Glucose-96 UreaN-4* Creat-1.1 Na-141
K-4.2 Cl-101 HCO3-22 AnGap-18
___ 08:30PM BLOOD ALT-110* AST-114* AlkPhos-198*
TotBili-0.6
___ 05:58PM BLOOD cTropnT-<0.01
___ 07:00AM BLOOD Calcium-9.6 Phos-3.6 Mg-2.0 Iron-108
==========================================
DISCHARGE AND PERTINENT LABORATORY STUDIES
==========================================
___ 08:30PM BLOOD proBNP-52
___ 05:58PM BLOOD cTropnT-<0.01
___ 07:00AM BLOOD calTIBC-625* Ferritn-20* TRF-481*
___ 06:18AM BLOOD Triglyc-269* HDL-30* CHOL/HD-6.0
LDLcalc-95
___ 07:00AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG HAV Ab-NEG
___ 06:18AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
___ 06:27AM BLOOD ___
___ 06:27AM BLOOD IgG-PND IgA-PND IgM-PND
___ 06:27AM BLOOD tTG-IgA-PND
___ 07:00AM BLOOD A1A PHENOTYPE-PND
===========================
REPORTS AND IMAGING STUDIES
===========================
___ CTA Chest
IMPRESSION:
- No evidence of pulmonary embolism or aortic abnormality.
- Right upper paratracheal 12 mm lymph node is nonspecific,
three-month follow-up is recommended for interval assessment.
- Right upper lobe 8 mm sub-solid nodule and two 3 and 6 mm
nodules in the right upper and middle lung. Please see
recommendations below
- Large hiatal hernia with intrathoracic stomach.
- Fatty liver.
RECOMMENDATION(S): 3 month follow-up chest CT is recommended to
assess interval change of the right upper paratracheal 12 mm
lymph node.
For an incidentally detected single ground-glass nodule bigger
than 6mm, CT follow-up in 6 to 12 months is recommended to
confirm persistence. If persistent, CT follow-up every ___ years
until ___ years after initial detection are recommended.
___ Stress TTE
CONCLUSION: Poor functional exercise capacity for age and
gender. No ischemic ECG changes with no symptoms to achieved
treadmill stress. No 2D echocardiographic evidence of inducible
ischemia to achieved workload. Mild mitral regurgitation at
rest. Normal pulmonary artery systolic pressure at rest. Resting
systolic and diastolic hypertension with a blunted blood
pressure response to achieved workload.
- Type of stress/symptoms: The patient exercised on a modified
___ treadmill (3 min stages) protocol for 9 min ___ METS)
representing a poor exercise capacity for age and gender. The
test was stopped due to fatigue and drop in systolic blood
pressure from Stage 2 to Stage 3 of exercise. The patient had no
symptoms at rest/prior to stress. In response to stress, the
patient had no symptoms.
- Hemodynamics: There was restingsystolic and diastolic
hypertension. At rest, the blood pressure was 160/100 mmHg and
the heart rate was 87 bpm. In response to stress, the heart rate
increased to 160 bpm (88 % APMHR) with a peak systolic blood
pressure of 170 mmHg (peak rate-pressure product = ___.
- ECG: The resting ECG showed sinus rhythm and no STT wave
changes. The stress ECG showed showed no ischemic changes with
stress or during recovery.
- Rest Echo: Resting echo images demonstrated mild symmetric
left ventricular hypertrophy with a normal cavity size. There is
normal regional left ventricular systolic function. Overall left
ventricular systolic function is normal. The visually estimated
resting left ventricular ejection fraction is 55-60%. Tissue
Doppler suggests a normal left ventricular filling pressure
(PCWP less than12mmHg). The right ventricular cavity size is
normal with normal free wall motion. There is no pericardial
effusion. Doppler demonstrates no aortic valve stenosis, no
aortic regurgitation, mild [1+] mitral regurgitation and no
resting left ventricular outflow tract gradient. The resting
estimated pulmonary artery systolic pressure is normal.
- Stress Echo: Echo images were acquired within 61 sec post
stress at heart rates of 155 to 127 bpm. These demonstrated
appropriate augmentation of all left ventricular segments. There
was appropriate augmentation of right ventricular free wall
motion.
___ RUQUS
1. Echogenic liver consistent with steatosis. Other forms of
liver disease including steatohepatitis, hepatic fibrosis, or
cirrhosis cannot be excluded on the basis of this examination.
2. Cholelithiasis without gallbladder wall thickening or ductal
dilatation
RECOMMENDATION(S): Radiological evidence of fatty liver does
not exclude cirrhosis or significant liver fibrosis which could
be further evaluated by ___. This can be requested via
the ___ (FibroScan), or the Radiology Department with
MR ___, in conjunction with a GI/Hepatology
consultation" *
============
MICROBIOLOGY
============
None
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pantoprazole 40 mg PO Q12H
2. Sucralfate 1 gm PO BID
3. Ferrous Sulfate 325 mg PO 3X/WEEK (___)
Discharge Medications:
1. Ferrous Sulfate 325 mg PO 3X/WEEK (___)
2. Pantoprazole 40 mg PO Q12H
3. Sucralfate 1 gm PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
=================
PRIMARY DIAGNOSIS
=================
Dyspnea
===================
SECONDARY DIAGNOSES
===================
Hepatitis
Non-alcoholic fatty liver disease
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) PORT
INDICATION: ___ year old man with hx EtOH use disorder who p/w transaminitis
// new transaminitis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
FINDINGS:
LIVER: The liver is diffusely echogenic with fat sparing around the
gallbladder. 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: 3 mm
GALLBLADDER: Cholelithiasis without 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: 10.4 cm
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Echogenic liver consistent with steatosis. Other forms of liver disease
including steatohepatitis, hepatic fibrosis, or cirrhosis cannot be excluded
on the basis of this examination.
2. Cholelithiasis without gallbladder wall thickening or ductal dilatation
RECOMMENDATION(S): Radiological evidence of fatty liver does not exclude
cirrhosis or significant liver fibrosis which could be further evaluated by
___. This can be requested via the ___ (FibroScan), or the
Radiology Department with MR ___, in conjunction with a GI/Hepatology
consultation" *
* Chalasani et al. The diagnosis and management of nonalcoholic fatty liver
disease: Practice guidance from the ___ Association for the Study of
Liver Diseases. Hepatology ___ 67(1):328-357
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ year old man with tachycardia and 1mo worsening dyspnea on
exertion with acute change over past 7d // Evaluate for PE. Also considering
pulmonary edema or interstitial disease.
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 2.3 s, 29.9 cm; CTDIvol = 21.7 mGy (Body) DLP = 648.9
mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7
mGy-cm.
3) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7
mGy-cm.
Total DLP (Body) = 652 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. The heart, pericardium, and great vessels are within
normal limits. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: Large hiatal hernia with intrathoracic stomach.
Esophagus is unremarkable. No axillary or hilar enlarged lymph nodes are
present. Right upper paratracheal 12 mm lymph node. No mediastinal mass.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Right upper lobe subsolid 8 mm nodule (301:48). Two additional
3 and 6 mm nodules in the right middle and upper lobes (301:59, 66). No focal
consolidation or evidence of interstitial disease. 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 upper abdomen show cholelithiasis without
evidence of cholecystitis, otherwise is unremarkable. Low liver density
suggests fatty deposition.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
IMPRESSION:
No evidence of pulmonary embolism or aortic abnormality.
Right upper paratracheal 12 mm lymph node is nonspecific, three-month
follow-up is recommended for interval assessment.
Right upper lobe 8 mm sub-solid nodule and two 3 and 6 mm nodules in the right
upper and middle lung. Please see recommendations below
Large hiatal hernia with intrathoracic stomach.
Fatty liver.
RECOMMENDATION(S): 3 month follow-up chest CT is recommended to assess
interval change of the right upper paratracheal 12 mm lymph node.
For an incidentally detected single ground-glass nodule bigger than 6mm, CT
follow-up in 6 to 12 months is recommended to confirm persistence. If
persistent, CT follow-up every ___ years until ___ years after initial detection
are recommended.
See the ___ ___ Society Guidelines for the Management of Pulmonary
Nodules Incidentally Detected on CT" for comments and reference:
___
Gender: M
Race: HISPANIC/LATINO - GUATEMALAN
Arrive by WALK IN
Chief complaint: Anemia, Dyspnea on exertion, Fatigue
Diagnosed with Anemia, unspecified
temperature: 98.2
heartrate: 116.0
resprate: 16.0
o2sat: 96.0
sbp: 151.0
dbp: 107.0
level of pain: 0
level of acuity: 2.0 | =================
SUMMARY STATEMENT
=================
Mr. ___ is a ___ year old male with history of severe
esophagitis c/b anemia requiring recent hospitalization in
___ for transfusion, hiatal hernia, and history of alcohol
use disorder, anxiety/depression who presented with subacute
dyspnea on exertion. A stress echo showed no ischemic changes
and normal biventricular function. A CTA showed no pulmonary
edema and no PE. Hepatology was consulted and felt his fatty
liver disease was unlikely to be related to his dyspnea.
Ultimately it was felt that his dyspnea could be attributed to
deconditioning, obesity hypoventilation syndrome, or his large
hiatal hernia. We recommended he lose weight, establish with a
hepatologist, and been seen in the bariatric surgery clinic for
weight loss options and consideration of hiatal hernia surgery.
===================
TRANSITIONAL ISSUES
===================
[ ] 8mm RUL nodule on CTA. Recommend CT follow-up in 6 to 12
months is recommended to confirm persistence. If persistent, CT
follow-up every ___ years until ___ years after initial detection
are recommended.
[ ] 12mm R upper paratraceal lymph node. 3 month follow-up chest
CT is recommended to assess interval change.
[ ] Please consider referral to bariatric surgery ___
consideration of weight loss options.
[ ] Patient should have surgical referral for correction of
hiatal hernia as this may be contributing to his symptoms. It is
possible this could be combined with referral to bariatric
surgery.
[ ] ___ consider PFTs or sleep study as an outpatient for
further workup of dyspnea
[ ] Several studies pending at discharge including: A1AT, tTG,
IgG, IgA, IgM and ___
[ ] Needs second hepatitis A vaccine in 6 months
====================
ACUTE MEDICAL ISSUES
====================
# Dyspnea on exertion
Presenting with chronic DOE x 1 month, orthopnea, early satiety
and abdominal distension. He has gained about 30 pounds over the
past several months and has noticed that his abdomen is greatly
distended, making it difficult to wear the same shirts. Stress
TTE with poor exercise capacity, no ischemic changes, and
preserved biventricular function. D-dimer negative. Notably, BNP
was normal and so were biventricular filling pressure on TTE.
DDX includes weight gain leading to deconditioning, obesity
hypoventilation, compression from hiatal hernia. We recommended
he lose weight, establish with a hepatologist, and been seen in
the bariatric surgery clinic for weight loss options and
consideration of hiatal hernia surgery.
# Transaminitis
Hepatocellular pattern with AST 114, ALT 110, AP 198, increased
from 3 months prior. Found to have hepatic steatosis on RUQUS,
likely driven in part by obesity. Prior EtOH use disorder also
likely contributing. Congestive hepatopathy less likely given
preserved biventricular function on TTE. Will establish with
hepatology as an outpatient in a non-urgent timeline. Several
studies pending at discharge for complete workup of hepatitis.
Hepatitis A vaccine administered prior to discharge due to
non-immunity.
#Sinus tachycardia:
Present on arrival to ED, possibly related to exertion as self
resolved. Also noted during prior admission though in setting of
severe anemia. ___ be related to deconditioning.
======================
CHRONIC MEDICAL ISSUES
======================
#Severe esophagitis
#GERD
#Hiatal hernia erosions:
Prior admission in ___ with acute blood loss anemia due to
severe esophagitis and erosions from hiatal hernia requiring 4
units pRBC. EGD ___ again notable for severe esophagitis and
large hiatal hernia, biopsy negative for malignancy. Continued
home high dose PPI (pantoprazole 40 mg bid) for planned 8 week
course. Received 1 dose ferric gluconate. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
UTI, nephrolithiasis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ PMHx recurrent drug resistant UTIs, chronic sacral decubitus
ulcer c/b osteomyelitis presents from orthopedic surgery clinic
with altered mental status. The pt was at the orthopedic
surgery clinic today for evaluation of bilateral foot pain and
was found to be confused and lethargic and was transferred to
the hospital for additional work up. Per the pt's son, she has
had difficulty with feeding herself and has been confused since
last night. She also smelled of urine today, which raised
concern for UTI.
Of note, she had a recent admission ___ when she
had a ___ growing pseudomonas and enterococcus (VRE). She was
treated with zosyn for 3 days. During an admission in early
___, ___ grew E. coli and proteus.
In the ED, initial vitals were: 97.7 | 78 | 124/86 | 14 | 96% RA
Exam notable for: confusion (pt does not know year and thinks
she is in ___ and then corrected herself to say
___)
Labs notable for a leukocytosis to 12.7 and a UA showing large
leuks, pos nit, 300 prot, many bacteria. BCx and ___ sent.
Patient was given 4.5 g piperacillin-tazobactam IV
Decision was made to admit for UTI
Vitals notable for
On the floor, the pt is confused and believes she is in ___
___, does not know the president of the ___, and in
unable to recall the year. She does know her name. She denies
any pain.
Past Medical History:
Dementia
Hypothyroidism
L hip fx s/p ORIF ___
Recurrent UTI while with chronic indwelling foley
Stage IV sacral decub ulcer c/b chronic osteomyelitis
Cervical stenosis
PE/DVT (previously on Coumadin/xarelto)
Hiatal hernia - should sit upright for meals
Grave's disease
Anemia
Surgical debridement of decubitus ulcer
Social History:
___
Family History:
Non Contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 99.3 (ax) 100 108/53 20 95%RA
Weight: 118.5 kg (standing)
Gen: NAD, A&Ox1, poor attention, responds when called, hard of
hearing
HEENT: no JVD, mucus membranes dry
CV: RRR, S1 and S2, no m/r/g
Pulm: CTAB, poor respiratory effort
Abd: BS+. soft, diffusely tender, ND, no HSM
Ext: Trace bilateral ___ pitting edema
Skin: No eruptions
Neuro: A&Ox1, rigid in upper extremities, plantar reflex
withdraw
DISCHARGE PHYSICAL EXAM:
VS: 98.5 ___ 100s-130s/50s-80s ___ 95-97%RA
GENERAL: NAD, alert and interactive
HEENT: MMM
LUNGS: CTAB anteriorly, poor inspiratory effort
HEART: RRR, crescendo-decrescendo murmur at LSB
ABDOMEN: BS+, soft, NT, ND.
EXTREMITIES: Trace bilateral ___ edema
NEURO: AOx2, interactive, moving extremities, following commands
Pertinent Results:
==ADMISSION LABS==
___ 01:25PM BLOOD WBC-12.7*# RBC-3.86* Hgb-11.5 Hct-36.0
MCV-93 MCH-29.8 MCHC-31.9* RDW-14.6 RDWSD-49.6* Plt ___
___ 01:25PM BLOOD Neuts-56.9 ___ Monos-9.7 Eos-1.3
Baso-0.6 Im ___ AbsNeut-7.23*# AbsLymp-3.96* AbsMono-1.23*
AbsEos-0.17 AbsBaso-0.07
___ 01:25PM BLOOD Glucose-109* UreaN-27* Creat-1.0 Na-137
K-4.7 Cl-99 HCO3-26 AnGap-17
___ 01:31PM BLOOD Lactate-1.5
___ 01:45PM URINE Color-Red Appear-Cloudy Sp ___
___ 01:45PM URINE Blood-SM Nitrite-POS Protein-300
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG
___ 01:45PM URINE RBC->182* WBC->182* Bacteri-MANY
Yeast-NONE Epi-0
___ 01:45PM URINE CastHy-80*
___ 01:45PM URINE WBC Clm-MANY Mucous-FEW
==DISCHARGE LABS==
___ 06:34AM BLOOD WBC-9.8 RBC-3.38* Hgb-10.2* Hct-31.4*
MCV-93 MCH-30.2 MCHC-32.5 RDW-14.6 RDWSD-49.1* Plt ___
___ 06:34AM BLOOD Glucose-100 UreaN-24* Creat-0.9 Na-137
K-5.1 Cl-104 HCO3-23 AnGap-15
___ 06:34AM BLOOD Calcium-9.0 Phos-3.4 Mg-2.0
==IMAGING==
GU US ___
1. Mild hydronephrosis with two renal stones visualized in the
left kidney as was seen on the abdomen CT of ___.
No hydronephrosis in the right kidney. Limited evaluation as the
patient is uncooperative.
2. No bladder abnormality identified.
CT Urogram ___
1. Bilateral hydronephrosis is improved on the current exam.
Multiple
nonobstructing stones are seen in the left kidney. Bladder is
partly
distended.
2. Left sacral ulcer with underlying sclerosis of the sacrum is
similar in appearance. This is again highly concerning for
osteomyelitis in this location.
3. Mild bibasilar atelectasis is improved.
4. Post cholecystectomy.
5. Large hiatal hernia
==MICROBIOLOGY==
___ 1:45 pm URINE
URINE CULTURE (Preliminary):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
WORK UP PER ___. ___ ___) ___.
INTERPRET RESULTS WITH CAUTION.
PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML..
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
GRAM NEGATIVE ROD(S). 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| ENTEROCOCCUS SP.
| |
AMPICILLIN------------ 8 S
CEFEPIME-------------- 16 I
CEFTAZIDIME----------- 16 I
CIPROFLOXACIN--------- 0.5 I
GENTAMICIN------------ <=1 S
MEROPENEM------------- 4 I
NITROFURANTOIN-------- 32 S
TETRACYCLINE---------- =>16 R
TOBRAMYCIN------------ <=1 S
VANCOMYCIN------------ <=0.5 S
==OTHER LABORATORY DATA==
ESR 77 (___) -> 59 (___) -> 36 (___) -> 60
(___)
CRP 6.6 (___) -> 29.9 (___) -> 29 (___) -> 28.1
(___)
==RECENT HISTORICAL DATA==
Summary of Recent Microbiological Data
___ ___ pseudomonas, enterococcus
___ ___ pseudomonas, enterococcus
___ ___ E coli, proteus mirabilis
___ ___ mixed gram + and gram - flora
___ ___
___ ___ proteus, E coli, alpha-hemolytic strep
___ ___ mixed bacteria
___ ___ enterococcus
___ ___
BCx from ___: proteus and beta-hemolytic strep (ICU
admission for septic shock)
Hospital Admissions*:
___ ___
___ ___
___ ___
___ ___
___ ___
___ not be complete list of recent hospital admissions
Radiology Report
EXAMINATION: COMPLETE GU U.S. (BLADDER AND RENAL)
INDICATION: ___ year old woman with h/o multiple recent UTIs // ?
hydronephrosis, ? bladder abnormality
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: Abdomen CT ___
FINDINGS:
Note is made that this is a limited ultrasound due to the patient's limited
ability to cooperate.
The right kidney measures 10.2 cm. The left kidney measures 9.8 cm. There is
no hydronephrosis in the right kidney. Mild hydronephrosis is again seen in
the left kidney as was seen on the abdomen CT of ___. A renal
stone measuring 1.0 cm is seen in the hilum of the left kidney. A
nonobstructing stone in the upper pole of the left kidney measures 5 mm. No
suspicious renal mass is visualized however visualization of the kidneys is
limited.
The bladder is moderately well distended. No gross bladder abnormality is
visualized.
IMPRESSION:
1. Mild hydronephrosis with two renal stones visualized in the left kidney as
was seen on the abdomen CT of ___. No hydronephrosis in the
right kidney. Limited evaluation as the patient is uncooperative.
2. No bladder abnormality identified.
Radiology Report
EXAMINATION: CT abdomen and pelvis without intravenous or oral contrast.
INDICATION: ___ PMHx recurrent UTI with drug resistant organisms, dementia,
sacral decubitus ulcer p/w altered mental status, leukocytosis, and positive
UA on linezolid and piperacillin-tazobactam. Of note, pt has hx of
hydronephrosis with persistent left sided stones (prior imaging ___. //
please evaluate nephrolithiasis and hydronephrosis
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) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Spiral Acquisition 4.7 s, 51.4 cm; CTDIvol = 15.1 mGy (Body) DLP = 777.8
mGy-cm.
Total DLP (Body) = 778 mGy-cm.
COMPARISON: CT abdomen pelvis from ___
FINDINGS:
LOWER CHEST: There are trace bilateral pleural effusions with adjacent
atelectasis. There is a large hiatal hernia containing a portion of the
stomach without obstruction. Coronary stents are noted.
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. The gallbladder is surgically absent.
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: 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 within the limitations of an unenhanced scan. There is
a 7 mm nonobstructing calculus in the upper pole of the left kidney. There is
a 9 mm nonobstructing calculus in the mid polar collecting system of the left
kidney. There is a 3.3 cm parapelvic cyst on the left. No hydroureter.
There is no perinephric abnormality.
GASTROINTESTINAL: There is no bowel obstruction. Moderate amount of stool
seen in the rectum with concentric wall thickening likely from chronic
constipation. The appendix is not visualized. Large hiatus hernia containing
nonobstructed stomach.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The reproductive organs are unremarkable.
LYMPH NODES: Somewhat limited evaluation given the lack of intravenous
contrast. No large lymph nodes seen in the retroperitoneum or pelvis.
VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic
disease is noted.
BONES: Again is visualized a sacral decubitus ulcer with erosion of the sacrum
and reactive changes in the remaining bone. Active osteomyelitis cannot be
excluded. Severe degenerative changes are seen in the spine and hip joints,
with a right total hip arthroplasty and dynamic femoral neck screw on the
left. There are bony fragments surrounding the left proximal femur, related
to prior trauma. T12 superior endplate compression is also seen.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No evidence of hydronephrosis. 2 left-sided nonobstructing renal calculi
are again visualized. Limited evaluation for pyelonephritis given the lack of
intravenous contrast.
2. Sacral decubitus ulcer with erosions and sclerosis of the underlying lower
half of the sacrum. Active osteomyelitis cannot be excluded. No drainable
abscess seen in this region.
3. Large hiatus hernia containing nonobstructed stomach.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Altered mental status
Diagnosed with Urinary tract infection, site not specified
temperature: 97.7
heartrate: 78.0
resprate: 14.0
o2sat: 96.0
sbp: 124.0
dbp: 86.0
level of pain: Unresponsive
level of acuity: 1.0 | Ms. ___ presented with altered mental status, a leukocytosis,
and a unialysis suggestive of infection. Given her prior urinary
tract infections and the resistance seen on prior
microbiological studies, she was started on linezolid and
piperacillin-tazobactam and was narrowed to
piperacillin-tazobactam alone on ___. She had imaging that
showed mild hydronephrosis and a renal stone. Her sacral wound
appeared noninfected and even though imaging was concerning for
sacral osteomyelitis, the clinical suspicion for osteomyelitis
was low. She is followed out patient for her sacral wound and
has an out patient MRI scheduled in the coming days.
# UTI: Pt admitted with altered mental status, leukocytosis, and
positive urinalysis. Given her recent history of multilpe
resistant UTIs, she was started on cefepime and linezolid on
___. Further review of recent microbiological data showed
that she had an infection resistant to cefepime and with ID
consultation she was started on piperacillin-tazobactam. She
continued on this regimen through ___ when she was narrowed
to piperacillin-tazobactam alone given the sensitivities of the
pseudmonas and enterococcus in her urine culture. She was on
piperacillin-tazobactam until ___ to complete a 7 day
antibiotic course. She will be discharged on fosfomycin 3 gm (1
packet) every 7 days and topical estrogen twice per week for UTI
prevention.
# Nephrolithiasis: Pt had imaging showing persistent
nephrolithiasis. Urology was consulited and the patient will
follow up with them in clinic to discuss managment of her renal
stone.
# Sacral Ulcer: On admission, pt had longstanding sacral ulcer.
She is followed closely as an outpatient for this. Despite the
fact that her ESR and CRP were elevated and imaging was
concerning for sacral osteomyelitis, the clinical appearance of
the wound was not consistent with osteomytelitis. Therefore,
the pt was not treated for osteomyelitis. She is scheduled for
an MRI in the days following discharge and will continue her
outpatient care of her sacral ulcer. She should be turned every
2 hours.
# Chronic Constipation: Continued home senna, dulcolax, miralax.
# History of DVTs: Completed 6 months of lovenox. Has been
followed by hematology. On admission was on ASA81 daily. She
continued ASA81 daily.
# Graves' Disease: Continued home levothyroxine 50 mcg daily.
# Hyperlipidemia: Continued Atorvastatin 20 mg daily. |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
aphasia, left sided weakness
Major Surgical or Invasive Procedure:
thrombectomy ___
History of Present Illness:
NEUROLOGY STROKE ADMISSION/CONSULT NOTE
Neurology at bedside after Code Stroke activation within: 2 mins
Time/Date the patient was last known well: 1800
I was present during the CT scanning and reviewed the images
within 20 minutes of their completion.
___ Stroke Scale Score: 18 --> 12 (within 1 hr, with ___
iPAD interpreter)
t-PA administered:
[x] Yes - Time given: ___
Thrombectomy performed:
[x] Yes, not successful for clot retrieval secondary to tortuous
vessels
NIHSS performed within 6 hours of presentation at: ___
NIHSS Total: 23 --> 13 within 1 hr
1a. Level of Consciousness: 2 --> 0
1b. LOC Question: 2
1c. LOC Commands: 2
2. Best gaze: 2 --> 0
3. Visual fields: 1 (left not blinking to threat)
4. Facial palsy: 0
5a. Motor arm, left: 3 -->2
5b. Motor arm, right: 1 -->0
6a. Motor leg, left: 4-->3
6b. Motor leg, right: 1
7. Limb Ataxia: U
8. Sensory: 0
9. Language: 4-->1
10. Dysarthria: U-->0
11. Extinction and Neglect: 1
REASON FOR CONSULTATION: Code stroke, aphasia, left paresis
HPI:
___ (EU CRITICAL ___ MRN ___ is a ___ year old
___ woman with history of hypertension and GERD
and remote right hip fracture s/p repair ___ with residual
dependence on walker for stability who presented from her
nursing
home ___ - ___, primary nurse is ___ after
she
acutely became aphasic with left-sided weakness. History
obtained
by her nurse at the nursing facility, ___, who witnessed the
event.
Per ___, the patient was in her usual state of health and
was
conversing with ___ normally and clearly in ___ over
dinner. She finished dinner at around 1800 and got up to walk
towards a different room. After a few steps, she suddenly fell
to
the left without clear head strike or loss of consciousness.
___, who is bilingual in ___, rushed to her side and
found that she was totally mute, unable to speak or respond or
understand. EMS was called and arrived within 15 minutes and she
was rushed to ___ where code stroke.
Regarding additional supplementary history, the patient has been
in a nursing facility since ___ when she suffered a mechanical
fall and fractured her right hip. She was recovering and is able
to walk by herself with the help of a walker. She is completely
lucid per ___ and is able to talk and converse in ___
without difficulty - ___ notes she is "quite a talker." She
is oriented to the year and date at baseline and could take all
of her medications by herself if she had to as she has no memory
deficits per ___. She requires 1-person assist with bathing
and it is unclear if she is able to do her own finances given
the
language barrier, per ___. She is not sure if she would be
able to write a check given the difference in culture (per
___ Her family lives nearby and visits often but they were
not immediately available for further information gathering.
On arrival to ED:
- ___ initially 23 even with iPAD interpreter --> corrected to
12 within ~60 minutes (as below)
(note that NCHCT, CTA head and neck obtained prior to ___
reassessment given difficulties loading iPAD interpreter in CT
suite but pre-interpreter assessment also estimated to be >20
based on aphasia, neglect, left hemiparesis, gaze deviation)
- CTA with right M1 thrombus
- tPA bolus ___ with ongoing infusion
- taken to angio suite for attempted Thrombectomy, unable to
retrieve clot secondary to vessel tortuosity
- admitted to neuro-ICU without further complications
ROS:
Was reportedly in her usual state of health leading up to this
without fevers, chills, sicknesses, HA, palpitations.
Past Medical History:
Hypertension
GERD
Surgical History:
Right hip fracture s/p repair (___)
Social History:
Former profession unknown at this time, unable to obtain
Unclear tobacco or alcohol exposure at this time
Has lived in nursing home since hip fracture recovery in ___.
Oriented and alert and without reported memory impairment. Able
to feed and walk with walker. Requires one person assist for
bathing. Unclear if could do finances (language, culture barrier
per her primary RN).
- Modified Rankin Scale:
[] 0: No symptoms
[] 1: No significant disability - able to carry out all usual
activities despite some symptoms
[] 2: Slight disability: able to look after own affairs without
assistance but unable to carry out all previous activities
[x] 3: Moderate disability: requires some help but able to walk
unassisted
[] 4: Moderately severe disability: unable to attend to own
bodily needs without assistance and unable to walk unassisted
[] 5: Severe disability: requires constant nursing care and
attention, bedridden, incontinent
[] 6: Dead
Family History:
Non-contributory
Physical Exam:
On Admission
PHYSICAL EXAMINATION:
Vitals: BP 150/90, HR 80, RR16 SaO2 100
General: Frail, appears stated age. Initially was lying in bed
with head deviated to right, neglecting left side.
HEENT: moist, no scleral icterus, bilateral cataracts
Neck: Supple
Pulmonary: Normal work of breathing.
Cardiac: irregular rhythm. warm, well-perfused.
Abdomen: Soft, non-distended.
Extremities: No ___ edema.
Skin: scattered echymoses.
Neurologic:
-Mental Status: Initially was unresponsive to her name or to
loud
yelling but would arouse to sternal rub. No speech output. No
following of commands. After ___, with maximum volume on
iPAD interpreter, patient responded only to me calling her name
with ___ head nod. She would not follow commands or answer
questions at that time and would not say her name. Just prior to
tPA ___ after last known well) she did spontaneously say "I
have to pee" and per the interpreter, this was in clear
___. No other spontaneous speech output.
-Cranial Nerves: Bilateral cataracts, right pupil ? NR?. Left
pupil 3>2. Right VF blinks to threat. Left VF does not blink to
threat. Slight weakness with left eye closure. Initially ?
slight
left NLFF but patient was in hard collar secondary to report of
fall and this was difficult to assess, grimace to noxious nasal
tickle appeared symmetric. When she said one sentence in
___, it was reportedly not Dysarthric per interpreter.
Tongue appears midline.
-Motor: Decreased bulk, normal tone. Right upper extremity
without drift. Left upper extremity initially was with NO
movement. Within ~45 minutes, she began to move it anti-gravity
at level of biceps/triceps (just before tPA) but could not
sustain anti-gravity at deltoid. No adventitious movements, such
as tremor or asterixis noted. Right lower extremity was with
spontaneous movement and at least anti-gravity at level of quad,
but patient would not follow commands to assess further. Left
lower extremity initially was with minimal withdrawal to
noxious.
After ~ 60 min, she withdrew anti-gravity at level of hamstring
to noxious.
-Sensory: Withdrew from noxious in all extremities, less on left
compared to right.
-Coordination: Unable to assess given aphasia
Pertinent Results:
On admission:
==============
___ 06:38PM BLOOD WBC-7.4 RBC-3.76 Hgb-11.7 Hct-35.9 MCV-96
MCH-31.1* MCHC-32.6 RDW-13.7 RDWSD-48.2* Plt ___
___ 06:38PM BLOOD Neuts-44 Bands-0 ___ Monos-9 Eos-3
Baso-0 ___ Myelos-0 AbsNeut-3.26 AbsLymp-3.26
AbsMono-0.67 AbsEos-0.22 AbsBaso-0.00*
___ 06:38PM BLOOD ___ PTT-27.1 ___
___ 06:38PM BLOOD Glucose-126* UreaN-30* Creat-1.1 Na-138
K-7.5* Cl-105 HCO3-21* AnGap-12
___ 01:09AM BLOOD ALT-32 AST-50* LD(LDH)-318* CK(CPK)-146
AlkPhos-85 TotBili-0.5
___ 01:09AM BLOOD GGT-15
___ 01:09AM BLOOD CK-MB-4 cTropnT-<0.01
___ 06:38PM BLOOD Albumin-4.0 Calcium-9.4 Phos-3.8 Mg-2.4
___ 01:09AM BLOOD %HbA1c-5.3 eAG-105
___ 01:09AM BLOOD Triglyc-122 HDL-76 CHOL/HD-2.6
LDLcalc-100
___ 01:09AM BLOOD TSH-1.4
___ 06:38PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 06:46PM BLOOD ___ pO2-114* pCO2-35 pH-7.44
calTCO2-25 Base XS-0 Comment-GREEN TOP
Imaging:
=========
Left hip XR ___:
IMPRESSION:
Diffuse osteopenia is noted. There is redemonstration of the
subcapital
fracture of the left femoral neck with foreshortening/proximal
migration. No additional acute fractures are identified. There
is no evidence of
dislocation. An intramedullary rod and two femoral neck screws
are noted
within the right femur. There is extensive heterotopic
ossification
surrounding the proximal right femur.
___ TTE:
LVEF 61%. No ASD seen. Normal left ventricular wall thickness
and
biventricular cavity sizes and regional/global systolic
function.
Mild aortic and mitral regurgitation. Moderate tricuspid
regurgitation. Moderate pulmonary hypertension.
CT Chest/Abd/Pelvis ___:
1. Acute, mildly displaced subcapital fracture of the left
femoral neck.
2. No other acute traumatic sequelae within the abdomen or
pelvis.
3. Endometrial thickening and 2.1 cm right adnexal cystic lesion
are nonspecific but should be further evaluated with non urgent
ultrasound.
4. 0.5 cm right thyroid lobe nodule does not require further
follow-up.
CT C-spine ___:
1. No acute fracture. No prevertebral swelling.
2. Minimal retrolisthesis of C3 on C4, and minimal
anterolisthesis of C7 on T1 and T1 on T2, are all of
indeterminate chronicity but likely degenerative. If
available, comparison with prior studies is recommended.
3. Moderate to severe cervical spondylosis with moderate central
canal narrowing and severe bilateral neural foraminal narrowing
at C3-4.
NCHCT ___: no intracranial hemorrhage, severe periventricular
and
subcortical white matter hypodensities consistent with
small-vessel ischemic disease. Generalized atrophy.
CTA head and neck ___: right M1 cutoff. tortuous vessels, no
aneurysm. Nearly matched prolonged MTT with reduced CBF
and CBV concerning for large infarct core.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 25 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Ranitidine 150 mg PO DAILY
4. Senna 8.6 mg PO BID:PRN Constipation - First Line
5. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
Discharge Medications:
1. Acetaminophen IV 1000 mg IV Q8H:PRN Pain - Mild Duration: 24
Hours
2. Atropine Sulfate 1% ___ DROP SL Q4H:PRN excess secretions
3. Glycopyrrolate 0.1-0.2 mg IV Q4H:PRN excess secretions
4. Haloperidol 0.5-2 mg PO Q4H:PRN delirium
5. Lidocaine 5% Patch 1 PTCH TD QPM over left hip
6. LORazepam 0.5-2 mg PO Q2H:PRN anxiety
7. Morphine Sulfate ___ mg IV Q4H:PRN Pain - Moderate
8. Senna 8.6 mg PO BID:PRN Constipation - First Line
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Ischemic infarct
Hip fracture
Hypertension
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND NECK WITH PERFUSION PQ149 CT HEADNECK
INDICATION: History: ___ with fall, trauma, right sided gaze preference and
RUE flaccid paralysis, LKWT 30mins ago*** WARNING *** Multiple patients with
same last name!// eval stroke vs. bleed
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of intravenous contrast material. Three-dimensional angiographic
volume rendered, curved reformatted and segmented images were generated on a
dedicated workstation. This report is based on interpretation of all of these
images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
2) Sequenced Acquisition 19.2 s, 8.0 cm; CTDIvol = 314.2 mGy (Head) DLP =
2,513.8 mGy-cm.
3) Stationary Acquisition 6.0 s, 0.5 cm; CTDIvol = 65.3 mGy (Head) DLP =
32.7 mGy-cm.
4) Spiral Acquisition 4.8 s, 37.9 cm; CTDIvol = 31.9 mGy (Head) DLP =
1,205.8 mGy-cm.
Total DLP (Head) = 4,555 mGy-cm.
COMPARISON: None.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is no evidence of hemorrhage, edema, masses, or mass effect. Right
frontal white matter hypodensity extending to the cortex is best seen on image
22 of series 2. This is worrisome for an area of acute infarction.
CT PERFUSION:
Tmax > 6.0 sec: 92 mL
CBF <30%: 0 mL
Mismatch volume: 92 mL
This is consistent with a penumbra involving the right MCA territory. However,
on review of the rCBV and rCBF, there is a focus of low perfusion involving
the right anterior temporal lobe suggestive of a core infarct. No hemorrhage
is seen.
The ventricles and sulci are prominent, consistent with global cerebral volume
loss. Patchy hypodensities in the periventricular white matter most
consistent with chronic microvascular ischemic disease.
The visualized portion of the paranasal sinuses, mastoid air cells,and middle
ear cavities are clear. The visualized portion of the orbits are unremarkable.
CTA HEAD:
There is abrupt cutoff of contrast flow within intraluminal filling defect in
the mid right M1 segment with trace flow in the distal M2 and M3 segments.
There appears to be a small amount of antegrade flow past the thrombus with
most of the M CA territory supplied by collaterals.
Atherosclerotic changes of the cavernous and supraclinoid segments of the
bilateral internal carotid arteries are seen without stenosis.
Otherwise, the vessels of the circle of ___ and their principal
intracranial branches appear normal without stenosis, occlusion, or aneurysm
formation. The dural venous sinuses are patent.
CTA NECK:
Atherosclerotic changes of the carotid bifurcations are seen without
narrowing of the internal carotid arteries, by NASCET criteria. The vertebral
arteries appear normal with no evidence of stenosis or occlusion.
OTHER:
The visualized portion of the lungs are clear. The visualized portion of the
thyroid gland is within normal limits. There is no lymphadenopathy by CT size
criteria. Degenerative changes of the cervical spine are seen including 3 mm
posterior subluxation of C3-C4 resulting in moderate spinal canal narrowing.
IMPRESSION:
1. Penumbra of the right MCA territory with possible right anterior temporal
lobe infarct.
2. Noncontrast CT demonstrates an apparent area of acute infarction in the
left frontal lobe, not included on the CT perfusion images peer
3. No evidence of hemorrhage.
4. Abrupt cutoff of contrast flow within intraluminal filling defect in the
mid right M1 segment with trace flow in the distal M2 and M3 segments.
5. Small amount of antegrade flow at the thrombus with the right MCA territory
predominantly filled by collaterals.
6. No stenosis or occlusion of the cervical vessels.
7. Degenerative changes of the cervical spine including 3 mm posterior
subluxation of C3-4 resulting in moderate spinal canal narrowing.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: ___ year old female with trauma, ams, concern for ich, fx, trauma
ich, fx, 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 5.3 s, 20.8 cm; CTDIvol = 22.6 mGy (Body) DLP = 470.4
mGy-cm.
Total DLP (Body) = 470 mGy-cm.
COMPARISON: None.
FINDINGS:
There is minimal retrolisthesis of C3 on C4, and minimal anterolisthesis of C7
on T1 and T1 on T2, all of indeterminate chronicity but likely degenerative in
etiology. Vertebral body heights are grossly maintained. No acute fractures
are identified.
The bones are diffusely demineralized. There are multilevel degenerative
changes throughout the cervical spine, worst and severe at the C3-4 level
where there is near bone-on-bone loss of intervertebral disc space. Spinal
canal narrowing is worst and moderate at this level due to retrolisthesis of
C3 on C4 and endplate osteophytosis. Additionally, neural foraminal narrowing
is worst and severe bilaterally at the same level due to uncovertebral and
facet hypertrophy. There is no prevertebral soft tissue swelling.
Imaged thyroid gland demonstrates an 8 mm mildly hypodense thyroid nodule.
Visualized lung apices appear clear.
IMPRESSION:
1. No acute fracture. No prevertebral swelling.
2. Minimal retrolisthesis of C3 on C4, and minimal anterolisthesis of C7 on T1
and T1 on T2, are all of indeterminate chronicity but likely degenerative. If
available, comparison with prior studies is recommended.
3. Moderate to severe cervical spondylosis with moderate central canal
narrowing and severe bilateral neural foraminal narrowing at C3-4.
Radiology Report
INDICATION: ___ year old female with trauma, ams, concern for ich, fx, 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 7.6 s, 60.1 cm; CTDIvol = 18.2 mGy (Body) DLP =
1,090.7 mGy-cm.
Total DLP (Body) = 1,091 mGy-cm.
COMPARISON: None.
FINDINGS:
CHEST:
HEART AND VASCULATURE: The thoracic aorta is tortuous but normal in caliber
without evidence of acute injury. The heart is moderately enlarged. There
are mild aortic valvular and mitral annular calcifications. Otherwise, the
heart, pericardium, and great vessels are within normal limits. No pericardial
effusion is seen.
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: There is mild bibasilar atelectasis. Lungs are otherwise clear
without masses or areas of parenchymal opacification. The airways are patent
to the level of the segmental bronchi bilaterally. There is mild
bronchiectasis in the left lower lobe.
BASE OF NECK: A 0.5 cm hypodense nodule is seen in the right thyroid lobe
(02:12).
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. A
0.4 cm hypodensity in the right hepatic lobe (2:96) is too small to
characterize but likely represents a cyst or biliary hamartoma. An ovoid
calcified lesion near the liver dome measuring 0.9 cm likely reflects
calcified granuloma (2:74). There is no evidence of focal lesion or
laceration. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder contains gallstones without wall thickening or
surrounding inflammation.
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. There is a small accessory spleen.
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.
Scattered subcentimeter hypodensities within the bilateral kidneys are too
small to characterize but likely represent cysts. There is no hydronephrosis.
There is no perinephric abnormality.
GASTROINTESTINAL: The esophagus is diffusely patulous which may suggest
esophageal dysmotility or reflux. There is a small hiatal hernia. 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:
Apparent bladder wall thickening is likely due to decompressed state. The
distal ureters are unremarkable. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The endometrium of the uterus is abnormally thickened to
12 mm and heterogeneous. The right adnexa contains a 2.1 cm cystic lesion
(2:168). The left adnexa is not seen.
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: There is an acute, mildly displaced subcapital fracture of the left
femoral neck. Patient is status post fixation of right femoral neck with
medullary rod and intertrochanteric nail. Cortical irregularity about the
proximal right femur likely represents heterotopic ossification. There is
minimal anterolisthesis of L1 on L2, likely degenerative.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Acute, mildly displaced subcapital fracture of the left femoral neck.
2. No other acute traumatic sequelae within the abdomen or pelvis.
3. Heterogeneous endometrial thickening to 12 mm may reflect endometrial
hyperplasia, polyp, or neoplasm. Consider further assessment with nonemergent
pelvic ultrasound and/or endometrial biopsy in this postmenopausal woman, if
clinically indicated.
4. 2.1 cm right adnexal cystic lesion can be further assessed with non urgent
pelvic ultrasound if clinically indicated.
5. Patulous esophagus with debris could reflect esophageal dysmotility or
reflux.
6. Cholelithiasis.
7. 0.5 cm right thyroid lobe nodule does not require further follow-up.
RECOMMENDATION(S): Consider further assessment of endometrial thickening with
nonemergent pelvic ultrasound and/or endometrial biopsy in this postmenopausal
woman, if clinically indicated. Right adnexal cyst can be also evaluated with
pelvic ultrasound.
Radiology Report
EXAMINATION: Cerebral angiogram for right M1 occlusion
The following vessels were selectively catheterized and angiography was
performed
Right common femoral
INDICATION: A ___ female with a history of hypertension who is living
in a nursing home after a fall and hip fracture in ___. She was reportedly
her usual self when she developed difficulty speaking fell and had left-sided
weakness. She was brought to the emergency department and she is found to
have a right M1 occlusion. She is brought to the Angiography suite for
mechanical thrombectomy
ANESTHESIA: Please see separate note dictated by anesthesia service
TECHNIQUE: Angiography
COMPARISON: CTA, ___
PROCEDURE: The patient was identified and brought to the neuro radiology
suite. Her was transferred to the fluoroscopic table supine. Sedation was
administered by anesthesia service is. Bilateral groins were prepped and
draped in standard sterile fashion. A time-out was performed. The right common
femoral artery was identified using anatomic and radiographic landmarks. The
right common femoral artery was accessed using standard micropuncture
technique after infiltration of local anesthetic. A long 8 ___ sheath was
introduced, connected to continuous heparinized saline flush, and secured.
___ 2 diagnostic catheter was introduced. Catheter was flushed and
at 0 3 glidewire was introduced. The catheter was advanced over the aortic
arch and selected into the left subclavian. The catheter was then changed to
the ___ hook and advanced over the arch in selected into the right
innominate artery. Multiple attempts were made to the select the wire into
the right common carotid artery however this failed on multiple occasions.
___ catheter was withdrawn and a VTK catheter was introduced. Again this
is selected into the right innominate and multiple attempts were made to
select the right common carotid artery without success. A soft ___ 2,
Berenstein, and a 90 degree Berenstein were also used with a 038 glidewire, a
038 shapeable glidewire, and other wire combinations. After approximately 45
minutes is felt that there would be unsafe to continue on with the procedure
as were unable to gain access the right common carotid artery. At this point
the diagnostic catheters were withdrawn a right common femoral angiogram was
performed via hand injection through the sheath. The sheath was removed and
the arteriotomy was closed using a 6 ___ Perclose. The patient was removed
from the fluoroscopy table and remained at her neurologic baseline without any
evidence of thromboembolic complications.
FINDINGS:
Right common femoral artery: Arteriotomy is above the bifurcation. There is
good distal runoff. There is no evidence of dissection. Vessel caliber
appropriate for closure device.
IMPRESSION:
Unsuccessful right M1 mechanical thrombectomy
RECOMMENDATION(S):
1.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with R MCA infarct s/p tpa// lethargic, eval
size of infarct, r/o hemorrhagic conversion
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: Head CT ___
FINDINGS:
Areas of low-density in the right putamen, probably internal capsule,
consistent with acute infarct. Inhomogeneous attenuation right temporal ___,
___ represent contrast staining within infarcted territory.. Probable small
area of infarct in the right insula.
No parenchymal hematoma.
No hydrocephalus, no midline shift. Moderate chronic small vessel ischemic
change.
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:
Acute/early subacute infarct right putamen and probably internal capsule.
Probable acute infarcts right temporal lobe, right insula.
No hemorrhage.
Radiology Report
EXAMINATION: HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) LEFT
INDICATION: ___ year old woman with L hip fx// L hip fx
TECHNIQUE: Frontal view radiograph of the pelvis with additional frontal and
frog-leg lateral views of the left hip.
COMPARISON: CT chest, abdomen and pelvis ___.
IMPRESSION:
Diffuse osteopenia is noted. There is redemonstration of the subcapital
fracture of the left femoral neck with foreshortening/proximal migration. No
additional acute fractures are identified. There is no evidence of
dislocation. An intramedullary rod and two femoral neck screws are noted
within the right femur. There is extensive heterotopic ossification
surrounding the proximal right femur.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with R MCA stroke s/p tPA and unsuccessful
thrombectomy// hemorrhagic conversion; TO BE DONE AT 7PM ___
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 performed earlier on same day on ___ at
13:41, CTA head and neck on ___
FINDINGS:
Compared with CT head performed earlier on same day, hypodensities in the
right basal ganglia and internal capsule appears slightly more prominent.
Subtle hypoattenuation of the right temporal lobe is similar to prior. There
is no evidence of hemorrhagic transformation or intracranial hemorrhage. No
significant mass-effect. There is prominence of the ventricles and sulci
suggestive of age-related involutional changes. Subcortical and
periventricular white matter hypodensities are nonspecific, but likely
represent sequela of chronic small vessel ischemic disease.
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:
Evolving infarct in the distribution of the right MCA territory. No evidence
of hemorrhagic transformation or significant mass effect.
Gender: F
Race: UNKNOWN
Arrive by AMBULANCE
Chief complaint: Altered mental status
Diagnosed with Cereb infrc d/t unsp occls or stenos of left mid cereb art
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: Critical
level of acuity: 1.0 | Ms. ___ is a ___ year old right handed(?) woman with a history
of
hypertension, GERD, prior right hip fracture s/p repair ___,
who
presented with acute aphasia and left sided weakness s/p fall
and found to have a right MCA occlusion. Course complicated by
left hip fracture noted during admission workup and bradycardia
down to the ___. Ultimately, on ___ the family opted to pursue
comfort measures only and the patient is being transferred back
to her nursing home.
#R MCA stroke s/p tPA (19:39 on ___ and unsuccessful
thrombectomy (19:45 on ___
Patient had a NIHSS of 23 on arrival and was found to have right
M1 thrombus. She received tPA ___ at 19:39 and take to
thrombectomy at 19:45 (___) but clot retrieval was unsuccessful
due to tortuous vasculature. She was admitted to the NeuroICU
for closer monitoring. 24 hour CT scan after tPA stable. Patient
has not yet been able to tolerate MRI from cardiac perspective.
SQH and ASA rectal were started 24 hours after tPA. She was
monitored on telemetry and noted to have intermittent afib. TTE
was w/out structural or cardioembolic source of infarct. LDL 100
and A1c 5.3. Etiology of stroke as such likely cardio-embolic
given atrial fibrillation and distribution of stroke. Goals of
care discussion are ongoing with family.
# Primary (essential) hypertension
Blood pressure was monitored and liberalized to 180 without the
use of PRN medication to achieve this goal. Home metoprolol held
given significant bradycardia.
# New onset atrial fibrillation, concern for conduction block
Atrial fibrillation was noted on telemetry upon admission and
while in the NICU. Unclear if this is a new condition. Also of
note is bradycardia as low as 27 with frequent ___ second pauses
concerning for heart block. Blood pressure has remained stable
during these episodes of bradycardia. Cardiology was consulted
and ****. Her home metoprolol was held. During goals of care
meeting, it was confirmed patient is DNR.
#Left subcapital femoral neck fracture
Patient fell prior to presentation and was found to have acute
left hip fracture on presentation. Orthopedics has been
consulted and depending on family decision, are recommending a
left hemiarthroplasty. Patient is receiving standing IV tylenol
every 8 hours for pain control.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No. If no, reason why:
2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not
(I.e. bleeding risk, hemorrhage, etc.)
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No. If not, why not? (I.e. bleeding risk,
hemorrhage, etc.)
4. LDL documented? (x) Yes (LDL = 100) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) (x) Yes - () No [if LDL
>70, reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given in written
form? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No. If no, why not? (I.e. patient at baseline
functional status)
9. Discharged on statin therapy? () Yes - (x) No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[x] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist ---
patient CMO
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? () Yes [Type: ()
Antiplatelet - () Anticoagulation] - (x) No -- patient CMO
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - (x) No - If no, why not (I.e.
bleeding risk, etc.) (x) N/A |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Depakote / yellow dye / blue dye
Attending: ___
Chief Complaint:
seizures
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ with hx of TBI in ___ from a gunshot
wound with large b/l frontoparietal encephalomalacia and post
traumatic seizure s/p hemicraniectomy with L cranioplasty c/b
multiple infections and VPS placement ___ with recent
admission to neurosurgery for serous drainage from chest wall
here with increased seizure frequency and persistent alteration
of mental status.
History is difficult to obtain because the patient cannot
provide, his group home did not have anyone there at the time of
call who knew his history/baseline seizure frequency, his rehab
did not have anyone there who witnessed the seizures. The rehab
denied any recent illness, fever/chills, diarrhea, etc. They
reported 100% med compliance including ___ AM meds. They
reported that his Dilantin level on ___ was low at
8.4
and as a result, his dose was increased from 200mg BID to
___. Per recent notes, baseline mental exam includes
nonfluent speech, following simple commands, no movement on the
right side, full strength on the left, R homonymous hemianopsia,
right greater than left anisocoria.
By report from the rehab, he had one seizure ___ evening,
another ___ AM, and another ___ ___ all of unclear duration
which prompted transfer to ___ where he received
an
unknown amount of Ativan. At ___, they obtained shunt
series
and NCHCT that reportedly showed shunt leak. Patient was
transferred for neurosurgical evaluation.
Per his most recent epilepsy clinic note in ___, his last
seizure at that time were three in one day on ___.
Neurosurgical evaluation revealed stable NCHCT and functioning
shunt with good recoil. Neurology consulted for seizure
management.
On my initial evaluation, his mental status was significant for
being alert with no speech production, fixing/following at times
but not consistently, nodding inappropriately to orientation
questions. However, he was responding briskly to noxious in his
right arm, localizing with his left arm which had spontaneous
antigravity movement. R arm did not withdraw to noxious. B/l
legs
did not spontaneously movement but with noxious, both had
antigravity withdrawal.
With the above assessment, there was some concern for worsened
mental status from systemic tox/met process, possible
subclinical
seizures. cvEEG and tox/met workup was recommended. Discussed
giving phenytoin as IV.
While in the ED, he had a convulsive seizure at 9:10pm <1min
with
resolution with 1mg IV Ativan. Recommended loading with 750mg IV
Phenytoin and 200mg Vimpat as pt was not able to take PO. Before
these could be given, he had another convulsive seizure at
9:20pm
and given IV 2mg Ativan. Convulsive movements appeared to
resolve
but several minutes later, reassessed with persistent stiffness
of right arm and leg as well as unresponsiveness to pain,
concern
for status. Mutual decision with ED to intubate patient.
Ultimately patient received Fosphenytoin 750mg x1, Vimpat 200mg
x1, and home evening AED meds via OG.
Past Medical History:
TBI (___)
Intractable epilepsy
Rt hemiparesis
Aphasia
Social History:
___
Family History:
His mother is alive and well. His father died of an unknown
illness. He has one sister and two brothers, no history of
seizures in the family.
Physical Exam:
Vitals: HR fluctuating from 110s-130s during initial evaluation,
up to 160s when having seizure. 99.4F Tmax in ED, 135/96, RR 24,
96% on RA prior to intubation, then 100% on vent.
General: Awake, NAD
HEENT: NC/AT, no scleral icterus noted, MMM, will
Neck: Supple, No nuchal rigidity
Pulmonary: Lungs CTA anteriorly
Cardiac: Tachycardic.
Abdomen: soft, no reaction with palpation.
Extremities: No ___ edema.
Neurologic:
-Mental Status: Alert, nonverbal - does not name, repeat, or
tell
me his name to command. Nods inappropriately to orientation
questions initially - nodded that he knew where he was but
nodded to each multiple choice answer. Unable to follow most
simple commands (show thumb, smile, open/close eyes). Focused on
my face and followed several times but not consistently.
-Cranial Nerves:
Able to look to right and look to the left - after intubated,
has
full VOR. Does not blink reliably to BTT. Does not activate face
for me on command - has mild R NLFF visible through his beard.
Does not follow commands for the rest of his cranial. R>L pupil
4 vs 3mm and both reactive to light.
-Motor: Increased tone in his right arm and leg compared to the
left.
No movement in R arm to noxious. L arm spontaneous and
antigravity. No spontaneous movements in b/l legs - withdraws to
noxious with antigravity movement in each leg to noxious.
-Sensory: Reacts to noxious in all four extremities.
-DTRs:
___, patellar, and Achilles all brisk - right brisker
than left.
Plantar response was mute bilaterally. No ankle clonus.
-Coordination: Unable to perform
-Gait: Unable to assess
Pertinent Results:
___ 10:29PM GLUCOSE-135* UREA N-9 CREAT-0.8 SODIUM-142
POTASSIUM-3.5 CHLORIDE-105 TOTAL CO2-25 ANION GAP-16
___ 10:29PM CALCIUM-8.6 PHOSPHATE-3.1 MAGNESIUM-2.7*
___ 10:29PM PHENYTOIN-8.8*
___ 11:35AM GLUCOSE-121* UREA N-14 CREAT-0.8 SODIUM-146*
POTASSIUM-2.8* CHLORIDE-111* TOTAL CO2-25 ANION GAP-13
___ 11:35AM CALCIUM-8.5 PHOSPHATE-2.6* MAGNESIUM-1.8
___ 11:35AM WBC-6.6 RBC-3.15* HGB-10.0* HCT-30.8* MCV-98
MCH-31.7 MCHC-32.5 RDW-12.4 RDWSD-44.5
___ 11:35AM PLT COUNT-118*
___ 11:35AM ___ PTT-31.9 ___
___ 06:47AM TYPE-ART PO2-216* PCO2-38 PH-7.47* TOTAL
CO2-28 BASE XS-4
___ 06:47AM LACTATE-1.0
___ 06:47AM O2 SAT-99
___ 04:10AM CEREBROSPINAL FLUID (CSF) PROTEIN-148*
GLUCOSE-78
___ 04:10AM CEREBROSPINAL FLUID (CSF) WBC-11 RBC-72*
POLYS-21 ___ MONOS-21 ___ MACROPHAG-1 OTHER-1
___ 03:00AM URINE HOURS-RANDOM
___ 03:00AM URINE bnzodzpn-POS* barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 03:00AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 03:00AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-300
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 03:00AM URINE RBC-1 WBC-6* BACTERIA-NONE YEAST-NONE
EPI-1
___ 03:00AM URINE HYALINE-3*
___ 03:00AM URINE MUCOUS-RARE
___ 01:12AM TYPE-ART TIDAL VOL-400 PO2-146* PCO2-31*
PH-7.52* TOTAL CO2-26 BASE XS-3 INTUBATED-INTUBATED
VENT-CONTROLLED
___ 03:00AM URINE MUCOUS-RARE
___ 01:12AM TYPE-ART TIDAL VOL-400 PO2-146* PCO2-31*
PH-7.52* TOTAL CO2-26 BASE XS-3 INTUBATED-INTUBATED
VENT-CONTROLLED
___ 01:12AM O2 SAT-98
___ 10:18PM TYPE-ART TEMP-37 PO2-308* PCO2-37 PH-7.38
TOTAL CO2-23 BASE XS--2
___ 09:00PM URINE HOURS-RANDOM
___ 09:00PM URINE bnzodzpn-POS* barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 09:00PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 09:00PM URINE BLOOD-SM NITRITE-NEG PROTEIN-300
GLUCOSE-TR KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG
___ 09:00PM URINE RBC-2 WBC-13* BACTERIA-FEW YEAST-NONE
EPI-2
___ 07:03PM LACTATE-1.4
___ 06:56PM GLUCOSE-122* UREA N-16 CREAT-0.8 SODIUM-145
POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-26 ANION GAP-19
___ 06:56PM estGFR-Using this
___ 06:56PM ALT(SGPT)-28 AST(SGOT)-22 ALK PHOS-110 TOT
BILI-0.3
___ 06:56PM LIPASE-158*
___ 06:56PM LIPASE-158*
___ 06:56PM cTropnT-<0.01
CT head
IMAGING:
Non-Contrast CT of Head: Baseline size of ventriculomegaly with
VPS in place. no midline shift. global atrophy and
encephalomalacia. Subgaleal fluid collection.
abdominal xray
IMPRESSION:
Single mildly dilated loop of small bowel left mid abdomen.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clobazam 20 mg PO BID
2. LORazepam 1 mg PO Q8H:PRN for seizure aura
3. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO QID:PRN acid
reflux
4. OXcarbazepine 900 mg PO BID
5. Pantoprazole 40 mg PO Q24H
6. Warfarin 2.5 mg PO DAILY
7. Simvastatin 20 mg PO QPM
8. Zonisamide 100 mg PO QHS
9. Phenytoin Sodium Extended 200 mg PO QAM
10. Phenytoin Sodium Extended 100 mg PO QPM
11. Phenytoin Sodium Extended 200 mg PO NOON
Discharge Medications:
1. Bisacodyl 10 mg PO DAILY:PRN constipation
2. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
3. Docusate Sodium 100 mg PO BID
4. Phenytoin Sodium Extended 250 mg PO BID
5. Senna 8.6 mg PO BID
6. Simethicone 40-80 mg PO QID:PRN abdominal pain, nausea,
flatus
7. Tizanidine 8 mg PO BID
8. Warfarin 1 mg PO DAILY16
9. Zonisamide 500 mg PO DAILY
10. Clobazam 20 mg PO BID
11. LORazepam 1 mg PO Q8H:PRN for seizure aura
12. OXcarbazepine 900 mg PO BID
13. Pantoprazole 40 mg PO Q24H
14. Simvastatin 20 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Seizures
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old man with picc // l dl picc 46cm iv ping ___
Contact name: ping, ___: ___ l dl picc 46cm iv ping ___
IMPRESSION:
Left PICC line is mild position continuing to warrant the right internal
jugular vein. Subsequent study demonstrated repositioning of the catheter but
with its tip being in the right atrium and with role has been recommended.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old man with recent PICC // PICC line placement
Contact name: merry, ___: ___
TECHNIQUE: Single frontal view of the chest.
COMPARISON: Same-day chest radiographs.
FINDINGS:
Compared to chest radiographs from 5 minutes earlier, left PICC line has been
repositioned and the tip now terminates in the right atrium and should be
withdrawn approximately 3 cm. Otherwise, no significant change. Endotracheal
tube remains in unchanged position, terminating approximately 6.9 cm above the
carina. VP shunt catheter in place overlying the left hemithorax.
IMPRESSION:
Repositioned left PICC line, which now terminates in the right atrium and
should be withdrawn approximately 3 cm.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with hx of TBI, seen to have szs // Evaluate
cardiopulmonary status in setting of sinus tachycardia
TECHNIQUE: Chest single view
COMPARISON: ___
FINDINGS:
Left PICC line tip in the low SVC. Additional catheter projected over left
chest, presumed VP shunt. Shallow inspiration. Left basilar opacities, new
since prior, may represent atelectasis, consider pneumonitis in the
appropriate clinical setting. Right lung is clear. Normal heart size,
pulmonary vascularity. No pneumothorax.
IMPRESSION:
Left basilar opacity, may represent atelectasis, consider pneumonitis if
clinically appropriate.
Radiology Report
EXAMINATION: PORTABLE ABDOMEN
INDICATION: ___ year old man with recurrent emesis. // eval for abdominal
obstruction or perforation
TECHNIQUE: Abdomen single view
COMPARISON: ___
FINDINGS:
The left hip arthroplasty. IVC filter in place. Left catheter with tip in
the pelvis, presumed VP shunt, similar. Single mildly distended loop of small
bowel in the left mid abdomen. Otherwise, bowel gas pattern is normal.
Normal caliber colon. Degenerative arthritis right hip.
IMPRESSION:
Single mildly dilated loop of small bowel left mid abdomen.
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: Seizure, Transfer
Diagnosed with Epilepsy, unsp, not intractable, with status epilepticus
temperature: 97.9
heartrate: 112.0
resprate: nan
o2sat: 96.0
sbp: 135.0
dbp: 96.0
level of pain: unable
level of acuity: 2.0 | ___ with hx of TBI in ___ from a gunshot wound with large b/l
frontoparietal encephalomalacia and post traumatic seizure s/p
hemicraniectomy with L cranioplasty c/b multiple infections and
VPS placement ___ with recent admission to neurosurgery for
serous drainage from chest wall admitted with increased seizure
frequency and persistent alteration of mental status with
concern
for status epilepticus in the ED s/p intubation. Initial exam
prior to intubation was significant for lack of speech
production,
inconsistent tracking, not following commands, as well as
baseline motor deficits. CT head did not show any acute
intracranial abnormality. Because no etiology for increased
seizure frequency was
identified, Neurosurgery was asked to tap his shunt for a
CSF sample to complete his infectious workup. CSF showed WBC of
11 and protein of 148, but was otherwise unremarkable. The
increased white count in his CSF was attributed to recent VPS
placement. EEG showed discharges but no seizures. He was also
noted to have sub-therapeutic Dilantin level. His seizures were
ultimately attributed to sub-therapeutic Dilantin level. His
Dilantin and zonisamide were increased and he improved
significantly.
He is currently on Coumadin for history of DVT. INR was
initially therapeutic, but increased to >4 with continuation of
home dose during admission. This was attributed to decreased PO
intake. His Warfarin was subsequently decreased to a lower dose
from 2.5 mg daily to 1mg daily. However, phenytoin is known to
decrease warfarin so he will need to have close monitoring of
his INR levels and possible up-titration of warfarin.
Of note, the night prior to discharge pt was noted to have an
episode of emesis, he underwent abdominal xray which showed
single mildly dilated loop of small bowel left mid abdomen, but
was otherwise unremarkable. His symptoms improved the following
day. He was discharged in stable condition back to his nursing
facility with outpatient neurology follow up. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Subacute diarrhea, NSTEMI
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
Ms. ___ is a ___ year old woman with a history of
constipation, hypertension, and osteoporosis who presents with
nausea, vomiting, and diarrhea and was found to have NSTEMI.
Of note, this patient was recently hospitalized at ___ (___) with N/V/diarrhea (non-bloody) also at
that time and was found to have NSTEMI as well. She received an
echo which showed no regional WMA and EF 56%. It also revealed
severe TR. The presentation was thought to be secondary to
demand
ischemia in the setting of dehydration and general GI illness.
The patient and family declined catheterization. The patient
went
home for 3 days and continued to have diarrhea and vomiting and
presents back with continued symptoms. She is still not
interested in cardiac catheterization.
The N/V and diarrhea started about 10 days ago now and was
preceded by constipation. On ___ the patient was constipated
and consumed warm prune juice as well as milk-of-magnesia and
since that time has had the N/V and diarrhea as mentioned. She
also started Duloxetine for "pain all over" on ___ (side
effects include N/V and diarrhea).
On ROS, the patient denies SOB, CP, fevers, chills, dysuria, and
urinary frequency.
In the ED, her initial vitals were HR 79, hypertension to
182/88,
saturating 91% on RA (up to 97% with 2L) and the patient was
afebrile. Her exam was notable for elevated JVP, mild abdominal
tenderness, cool extremities, and trace edema. Her labs were
notable for troponin 2.41 and 2.33 (recorded as drawn at the
same
time), WBC 11.7, and lactate 2.0. CXR showed bilateral pleural
effusions, increased vascularity, and retrocardiac atelectasis.
She was started on a heparin drip, given 20mg Lasix IV, and
otherwise started on her home medications.
On arrival to the floor patient denies CP, SOB, palpitations,
dizziness, n/v, abdominal pain. She does feel that her legs are
somewhat swollen.
Past Medical History:
1. CARDIAC RISK FACTORS
- Hypertension
2. CARDIAC HISTORY
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY
Anal prolapse followed by Dr. ___ loss, osteoporosis,
ptosis of the left eyelid for many years now, and right wrist
Fx,
cervical radiculitis, Recurrent UTIs
Social History:
___
Family History:
# Daughter: recent breast cancer
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
GENERAL: Thin older woman sitting in bed, NC in place
HEENT: NCAT, sclerae anicteric, normal conjunctivae
NECK: Supple, JVP elevated to midway up neck at 45 degrees
CARDIAC: RRR, normal S1/S2, no m/r/g
LUNGS: Bibasilar crackles (L>R), no increased work of breathing
ABDOMEN: Soft, non-tender, non-distended, normoactive BS
EXTREMITIES: Warm to knees, cool more distally, DP pulses 2+
bilaterally, 1+ pitting edema to ankles bilaterally
NEURO: A&Ox3, mentating well, CN grossly intact, spontaneously
moving all extremities
DISCHARGE PHYSICAL EXAM
=======================
GENERAL: Thin older woman sitting in chair
HEENT: NCAT, sclerae anicteric, normal conjunctivae
NECK: Supple, JVP elevated to midway up neck at 45 degrees
CARDIAC: RRR, normal S1/S2, no m/r/g
LUNGS: Bibasilar crackles (L>R), but improved. No increased work
of breathing
ABDOMEN: Soft, non-tender, non-distended, normoactive BS
EXTREMITIES: Warm to knees, cool more distally, DP pulses 2+
bilaterally, trace pitting edema to ankles bilaterally
NEURO: A&Ox3, mentating well, CN grossly intact, spontaneously
moving all extremities
Pertinent Results:
ADMISSION LABS
==============
___ 11:00AM BLOOD WBC-11.7* RBC-4.39 Hgb-13.4 Hct-42.4
MCV-97 MCH-30.5 MCHC-31.6* RDW-13.6 RDWSD-47.8* Plt ___
___ 11:00AM BLOOD Glucose-96 UreaN-37* Creat-1.1 Na-140
K-5.3 Cl-106 HCO3-20* AnGap-14
___ 11:00AM BLOOD Calcium-9.5 Phos-4.0 Mg-2.0
DISCHARGE LABS
==============
___ 06:10AM BLOOD WBC-12.8* RBC-3.91 Hgb-12.1 Hct-38.2
MCV-98 MCH-30.9 MCHC-31.7* RDW-13.7 RDWSD-48.2* Plt ___
___ 06:10AM BLOOD Glucose-88 UreaN-26* Creat-0.8 Na-143
K-4.3 Cl-102 HCO3-29 AnGap-12
___ 06:10AM BLOOD Calcium-9.2 Phos-3.4 Mg-2.1
RELEVANT IMAGING
================
CXR ___
IMPRESSION:
Comparison to ___. On today's radiograph the patient
shows moderate
bilateral pleural effusions, better visualized on the lateral
than on the
frontal view. In addition, there are signs of mild pulmonary
edema as well as
a newly appeared retrocardiac atelectasis. Borderline size of
the cardiac
silhouette. No pneumothorax.
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 and global left ventricular systolic function.
Quantitative 3D volumetric left ventricular ejection fraction is
64 %. Left ventricular cardiac index is low normal (2.0-2.5
L/min/m2). There is no resting left ventricular outflow tract
gradient. Tissue Doppler suggests an increased left ventricular
filling pressure (PCWP greater than 18 mmHg). Normal right
ventricular cavity size with normal free wall motion. Intrinsic
right ventricular systolic function is likely lower due to the
severity of tricuspid regurgitation. There is abnormal
interventricular septal motion c/w right ventricular pressure
overload. The aortic sinus diameter is normal for gender with
normal ascending aorta diameter for gender. The aortic valve
leaflets (?#) are mildly thickened. There is no aortic valve
stenosis. There is mild [1+] aortic regurgitation. The mitral
valve leaflets appear structurally normal with no mitral valve
prolapse. There is moderate [2+] mitral regurgitation. The
tricuspid valve leaflets appear structurally normal. There is
moderate [2+] tricuspid regurgitation. There is SEVERE pulmonary
artery systolic hypertension. There is no pericardial effusion.
A left pleural effusion is present.
IMPRESSION: Severe pulmonary artery systolic hypertension.
Moderate mitral regurgitation. Moderate tricuspid regurgitation.
Normal left ventricular wall thickness and biventricular cavity
sizes and regional/global systolic function. Mild aortic
regurgitation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. TraMADol 25 mg PO TID
2. DULoxetine 20 mg PO DAILY
3. Gabapentin 300 mg PO TID
4. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever
5. felodipine 10 mg oral DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Clopidogrel 75 mg PO DAILY
4. Lisinopril 5 mg PO DAILY
5. Torsemide 20 mg PO DAILY
6. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever
7. felodipine 10 mg oral DAILY
8. Gabapentin 300 mg PO TID
9. TraMADol 25 mg PO TID
10.Outpatient Lab Work
Please collect labs within the next week (___):
ICD-9 code: ___
Name/Contact: ___, Phone: ___,
Fax: ___
Labs: CBC, Chem 10, LFTs
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY
=======
HFpEF Exacerbation
NSTEMI
SECONDARY
=========
Subacute diarrhea
Chronic 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
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with diarrhea/vomiting// admission CXR, r/o
infection admission CXR, r/o infection
IMPRESSION:
Comparison to ___. On today's radiograph the patient shows moderate
bilateral pleural effusions, better visualized on the lateral than on the
frontal view. In addition, there are signs of mild pulmonary edema as well as
a newly appeared retrocardiac atelectasis. Borderline size of the cardiac
silhouette. No pneumothorax.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Diarrhea
Diagnosed with Non-ST elevation (NSTEMI) myocardial infarction, Diarrhea, unspecified
temperature: 97.1
heartrate: 57.0
resprate: 24.0
o2sat: 92.0
sbp: 151.0
dbp: 59.0
level of pain: 0
level of acuity: 3.0 | Ms. ___ is a ___ year old woman with a history of
constipation, hypertension, and osteoporosis who presents with
nausea, vomiting, and diarrhea and was found to have NSTEMI in
the setting of HFpEF decompensation.
TRANSITIONAL ISSUES
===================
[ ] Patient have repeat labs to monitor her electrolytes and
LFTs at PCP appt in 1 week from discharge.
[ ] Patient was started on Lisinopril 5mg while inpatient.
Please titrate this medication for appropriate blood pressure
control.
[ ] Patient is being discharged on torsemide for better control
of her volume status. Please evaluate patient's volume status
controlled on this medication outpatient.
[ ] Given patient's desire to avoid further invasive
interventions, and declining functional status, it may be of
benefit to refer patient to palliative care for further
discussions regarding her goals of care.
[ ] Patient should follow-up with her gastroenterologist for
further discussion regarding her episodes of diarrhea and
constipation given the unclear etiology. Duloxetine was
discontinued as this was thought to possibly be contributing to
her symptoms.
ACUTE ISSUES
============
# HFpEF exacerbation
Patient admitted w/hypoxia, lower extremity edema, bibasilar
crackles consistent heart failure exacerbation. Hemodynamically
stable, exam not suggestive of cardiogenic shock. Etiology
concerning for ischemic event in setting of EKG changes and
significantly elevated trops, likely exacerbated in setting of
fluid resuscitation for diarrhea. Repeat TTE ___ similar to
previous, but indicated elevated pulmonary artery pressure and
increased PCWP. Patient was actively diuresed with IV Lasix
until she was thought to be euvolemic, and at that point
transitioned to p.o. torsemide. Patient was started on
lisinopril for better blood pressure control.
Preload: Torsemide 20mg
- Afterload: Felodipine 10mg daily, Lisinopril 5mg
# Elevated Troponin
# NSTEMI
EKG notable for 1st degree AV block, lateral TWI in V4-V6, and
no STE. Normal CK-MB on arrival to ___, and troponin peaked at
2.33. It was thought patient had type I NSTEMI, however she
declined further evaluation with a cath, and thus was medically
treated. She completed a 48-hour course of heparin drip, was
started on Plavix. She was continued on her home aspirin and
atorvastatin.
# Subacute Diarrhea
# IBS primarily constipation
Diarrhea originally began ~10 days prior to presentation per
patient, but resolved around hospitalization. Also reports hx of
IBS primarily constipation. Labs and imaging at ___ were
mostly unremarkable. There was suspicion that her diarrhea was
likely secondary to a viral gastroenteritis given its acute
onset spontaneous resolution. However there is also concern for
this being a side effect of initiation of duloxetine given she
started around the same time, versus worsening edema secondary
to severe tricuspid regurgitation and heart failure. Stool
evaluation here was unremarkable, and given patient no longer
had diarrhea, further inpatient evaluation was deferred and
patient was referred to her gastroenterologist for further
outpatient workup.
# Elevated INR
Likely secondary to poor PO intake lately due to N/V which makes
vitamin K deficiency a possibility. Received K IV for 3 days.
CHRONIC/RESOLVED ISSUES
=======================
# Chronic Pain
Held duloxetine given c/f adverse reaction w/ diarrhea.
Continued gabapentin 300 TID, tramadol 25 TID.
# CODE: DNR/DNI
# CONTACT: HCP: ___ (daughter) ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bcg (Bacillus ___) / Influenza Virus Vaccine /
Tylenol
Attending: ___.
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with chronic systolic heart failure, nocturnal leg cramps,
and transfusion dependent poratl hypertensive gastropathy is
admitted after 2 falls at ___ with acute mental status change.
She was in her usual state of health yesterday at her
hematologist's office where she received blood transfusion. She
went ___, and took her usual medications for HTN. She also
took one ativan, and a vicodin because of leg cramps. She awoke
in the night with a leg cramp and then fell out of bed. She was
unable to get up fully, and fell again. Her family found her
confused this morning and she was brought to the ER.
Orhtostatic vital signs were not done in the ER. There were no
signs of acute stroke, and a head CT showed no IC bleeding. She
began to mentally clear somewhat and is admitted for
observation.
ROS: chronic nocturnal leg cramps, anxiety from same. No HA,
CP, SOB, abd pain, melena, hematemesis, hematochezia. Other 13
point detail ROS is negative
Past Medical History:
1. Chronic GIB multiple possible sources including esophageal
varices, GAVE, portal hypertensive gastropathy, AVMs, rectal
varices
2. Anemia transfusion dependent, ___ PRBC about every 3
weeks, baseline Hct ___.
3. Clinical/biochemical features of cirrhosis with
esophageal/rectal varices thought to be ___ PBC
4. CAD w/h/o MI s/p CABG ___ and LCX stents ___, in-stent
restenosis s/p cutting balloon ___
5. 4+ mitral regurgitation, also at least mild aortic stenosis
6. CHF (systolic) w/ EF 25% w/ LV aneurysm (last echo ___
7. Pulmonary hypertension
8. HTN
9. Hyperlipidemia
10. Hypothyroidism
11. Ventral hernia s/p cholecystectomy, asymptomatic
12. Liposarcoma - L thigh
13. h/o TB exposure
14. Depression
15. chronic epistaxis
16. Peripheral arterial disease s/p vascular intervention LLEx
___. Chronic nocturnal leg cramps
Social History:
___
Family History:
She has 2 daughters, 1-step son, and several grandchildren who
are all healthy. No known family history of IBD,
gastrointestinal, or liver disease.
Physical Exam:
Alert & oriented, able to provide history
VS: 97.6, 113/52, 72, 18, 99RA Pain ___
ORTHOSTATIC VS: lying 122/51, 70 --> 117/52, 72 --> 85/51, 81
standing
HEENT: non-traumatic, OP dry, neck supples, anicteric
LUNGS: CTA bilat
COR: RRR, ___ apical murmur, no S3/S4
ABD: soft, NT/ND, no HSM or masses. Abd scars noted with
psicatrical hernia RUQ
EXT: no edema, C/C
SKIN: (+) R Stage III pressure ulcer medial glut, (+) ecchymosis
over L hip and bilateral anterior knees
NEURO: A&O x 3, fluent speech and cognition, moves all fours,
and stands without problem
Pertinent Results:
___ 09:30AM WBC-4.7 RBC-2.52* HGB-7.6* HCT-24.0* MCV-95
MCH-30.1 MCHC-31.6 RDW-17.6*
___ 09:30AM PLT COUNT-120*
___ 01:00PM UREA N-61* CREAT-1.3* SODIUM-139
POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-26 ANION GAP-13
___ 01:00PM ALBUMIN-3.0* CALCIUM-7.9* PHOSPHATE-4.1
MAGNESIUM-2.7*
___ 10:20AM WBC-6.8 RBC-2.86* HGB-8.7* HCT-27.3* MCV-96
MCH-30.4 MCHC-31.8 RDW-17.3*
___ 10:20AM PLT COUNT-114*
___ 10:20AM ___ PTT-30.1 ___
___ 10:20AM GLUCOSE-142* UREA N-63* CREAT-0.9 SODIUM-142
POTASSIUM-4.3 CHLORIDE-107 TOTAL CO2-26 ANION GAP-13
___ 10:20AM ALT(SGPT)-23 AST(SGOT)-32 ALK PHOS-128* TOT
BILI-0.7
___ 10:20AM cTropnT-<0.01
___ 10:20AM ALBUMIN-3.1*
___ 10:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 03:22PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 10:20AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
EKG ___ 10:13 - NSR w/ ___ AVB, unchanged STD and TWI v2-v6,
2,3,F vs ___ Read: DZRT SAT ___ 11:16 AM
No acute intracranial hemorrhage. No fracture. Well defined
hypodensity in the right frontal lobe with mild ex vacuo
dilatation of the frontal horn of the right lateral ventricle
likely sequela from a prior stroke.
CXR ___: 1. No evidence of acute cardiopulmonary process.
2. Scarring in the right lower lobe, pleural calcifications,
chronic pleural effusion/bluting of the right costophrenic angle
appear to be a chronic process.
___ 07:45AM BLOOD WBC-3.4* RBC-2.35* Hgb-7.1* Hct-22.1*
MCV-94 MCH-30.1 MCHC-32.0 RDW-17.2* Plt ___
___ 10:00AM BLOOD WBC-4.0 RBC-2.54* Hgb-7.6* Hct-24.1*
MCV-95 MCH-30.1 MCHC-31.6 RDW-17.4* Plt ___
___ 10:00AM BLOOD Plt ___
___ 10:20AM BLOOD Glucose-142* UreaN-63* Creat-0.9 Na-142
K-4.3 Cl-107 HCO3-26 AnGap-13
___ 07:45AM BLOOD Glucose-114* UreaN-45* Creat-1.1 Na-140
K-4.4 Cl-108 HCO3-27 AnGap-9
___ 07:45AM BLOOD Calcium-7.9* Phos-3.2 Mg-3.0*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Digoxin 0.125 mg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Hydrocodone-Acetaminophen (5mg-500mg) 1 TAB PO BID:PRN leg
cramp
5. Lisinopril 5 mg PO DAILY
6. Lorazepam 0.5 mg PO BID:PRN leg cramps
7. Levothyroxine Sodium 150 mcg PO DAILY
8. Metoprolol Succinate XL 25 mg PO HS
9. Nitroglycerin SL 0.3 mg SL PRN chest pain
10. Pantoprazole 40 mg PO Q24H
11. Potassium Chloride 10 mEq PO DAILY
extended release
12. Sertraline 50 mg PO DAILY
13. Spironolactone 25 mg PO DAILY
14. Sucralfate 1 gm PO TID
15. Torsemide 40 mg PO DAILY
16. Ursodiol 500 mg PO BID
17. Aspirin 81 mg PO DAILY
18. Docusate Sodium 100 mg PO BID
19. Magnesium Oxide 500 mg PO ONCE
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Digoxin 0.125 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. FoLIC Acid 1 mg PO DAILY
6. Levothyroxine Sodium 150 mcg PO DAILY
7. Lisinopril 5 mg PO DAILY
8. Metoprolol Succinate XL 12.5 mg PO HS
Take ___ of your normal tablet daily
9. Pantoprazole 40 mg PO Q24H
10. Potassium Chloride 10 mEq PO DAILY
11. Sertraline 50 mg PO DAILY
12. Spironolactone 25 mg PO DAILY
13. Sucralfate 1 gm PO TID
14. Torsemide 20 mg PO DAYS (___)
on ___
15. Torsemide 40 mg PO DAYS (___)
on ___
16. Ursodiol 500 mg PO BID
17. Magnesium Oxide 500 mg PO ONCE Duration: 1 Doses
18. Nitroglycerin SL 0.3 mg SL PRN chest pain
Discharge Disposition:
___ With Service
Facility:
___
Discharge Diagnosis:
Syncope
Orthostatic hypotension - resolved
Chronic heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ woman with altered mental status. Evaluate for
pneumonia.
COMPARISON: Chest radiograph from ___.
FINDINGS:
PA and lateral radiographs of the chest demonstrate right lower lobe scarring
and pleural calcifications. Blunting of the right costophrenic angle may be
due to scarring or small persistent chronic effusion. There is no focal
airspace opacity. There is stable mild cardiomegaly. Median sternotomy
cerclage wires are intact and there are multiple surgical clips in the
anterior mediastinum. There is no pneumothorax or left pleural effusion.
Pulmonary vascularity is normal.
IMPRESSION:
1. No evidence of acute cardiopulmonary process.
2. Scarring in the right lower lobe, pleural calcifications, chronic pleural
effusion/bluting of the right costophrenic angle appear to be a chronic
process.
Radiology Report
INDICATION: Acute mental status and lethargy upon waking.
COMPARISON: None.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of IV contrast. Coronal, sagittal and thin section
bone algorithm reconstructed images were acquired.
There is no evidence of hemorrhage, edema, mass effect, or recent infarction.
A well defined hypodensity in the right frontal lobe with mild resultant ex
vacuo dilatation of the frontal horn of the right lateral ventricle is likely
a sequela from a prior infarct. Prominence of the ventricles and sulci
suggests age-related atrophy. The basal cisterns appear patent, and there is
preservation of gray-white matter differentiation.
No fracture is identified. Extensive calcification of the carotid siphons is
noted. The paranasal sinuses, mastoid air cells, and middle ear cavities are
clear.
IMPRESSION: No acute intracranial process. Right frontal lobe hypodensity is
likely a sequela from prior stroke.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: LETHARGIC UPON AWAKENING
Diagnosed with SEMICOMA/STUPOR
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: 1.0 | ___ (ch sys HF EF<20%), ch anemia, chronic recurrent GI bleed
that is transfusion dependent) presents with syncope, acute
mental status change that is clearing, and orthostasis in the
setting opiate/benzo combination for leg cramps in the face of
an intensive BP and diuretic regimen. I think the fall/syncope
is iatrogenic.
.
# Syncope: (Iatrogenic). Opiate and Benzo was discontinued.
SHe was mildly orthostatic. Torsemide was reduced to 20mg
___ and 40mg ___, and Metoprolol XL was cut to
12.5mg daily in response to her orthostasis. The changes were
reviewed with patient and her HCP daughter. Daughter will make
follow-up with PCP this coming week.
.
# HTN: See above. Orthostasis resolved prior to dishcarge
without need for IVF. Medications were adjusted. She will f/u
with PCP this coming week.
# Stage III ulcer, R medial glut: about 1-2 cm, clean. Wound
care, nutrition consult. ___ RN should follow.
.
# Chr systolic HF: stabe, Continued ___ regimen of Lisinopril,
Spironolactone, but cut torsemide to 20mg/40mg alternating
every other day, and cut Metoprolol XL to 12.5mg. The latter
was held night of admission, and she will restart night of
dishcarge.
# Chr anemia: stable, from ch GI bleed.
# CKD III: stable.
.
# CAD: stable, continue ___ regimen
.
# Cirrhosis: stable. Torsemide dose changed as per above.
.
# CODE: DNR/DNI
Plan discussed with ___ RN, patient, and her daughter.
PCP notified of admission and will be sent copy of this
discharge. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Penicillins / Erythromycin Base / Tetracycline / olanzapine
Attending: ___
Chief Complaint:
Recurrence of drooling and dysarthria
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Neurology at bedside for evaluation after code stroke activation
within: 7 minutes
The patient was last known well: 20:00 on ___
___ Stroke Scale Score: 1
t-PA given:No Reason t-PA was not given or considered: Recent
admission with stroke 2 days prior, NIHSS-1 with improving
deficits
I was present during the CT scanning and reviewed the images
instantly within 20 minutes of their completion.
___ Stroke Scale score was 0:
1a. Level of Consciousness: 0
1b. LOC Question: 0
1c. LOC Commands: 0
2. Best gaze: 0
3. Visual fields: 0
4. Facial palsy: 0
5a. Motor arm, left: 0
5b. Motor arm, right: 0
6a. Motor leg, left: 0
6b. Motor leg, right: 0
7. Limb Ataxia: 0
8. Sensory: 0
9. Language: 0
10. Dysarthria: 1
11. Extinction and Neglect: 0
NEUROLOGY RESIDENT CONSULT NOTE
Reason for Consult: acute dysarthria
HPI:
___ is a ___ year-old right-handed pack-per-day smoker
with schizophrenia, history of left occipital stroke (dx ___,
with residual right visual field cut) and recent Neurology
admission ___ for drooling and left hand clumsiness during which
he was found with parietal hypodensity but left AMA prior to
MRI,
returns now with recurrence of dysarthria, drooling at home.
He was admitted on ___ after he woke up at 4:30am with new onset
drooling and left facial droop. He had no associated extremity
weakness or problem understanding or producing language but was
dysarthric. He also reported some tingling in his left>right
hand. When he came to the ED, exam was notable for slight his
left arm drift, left droop with drooling, and dysarthria.
Neurology was consulted and CT Head showed an area of
hypodensity
in the right parietal concerning for possible acute on chronic
ischemia. He had a normal CTA and echo, no Afib was seen on
tele, and had a normal LDL and A1c, but left AMA before further
evaluation with MRI. An outpatient MRI was arranged and the
patient went home on the evening of ___ on plavix 75mg daily,
which he had been on previously. He tells me he left AMA
because
"he didn't want to wait around for an MRI".
Since discharge he noted that his left hand was still clumsy and
he continued to have intermittent tingling in his hands but the
facial droop and drooling were better from ___ until tonight.
He
was apparently at home around 8PM, smoking a cigarette when he
noted the sudden onset of slurred speech and drooling, possible
with left facial droop. There was no weakness or worsening
paresthesias and again he had no dizziness, vision changes, or
problems with his speech.
He alerted EMS and was brought to the ED around 9:15 at which
time a Code Stroke was called. NIHSS-1 (with 1- for mild
dysarthria) done by the ED resident confirmed by Neurology.
There was not an overt facial droop. CT head showed a similar
region of hypodensity in the right parietal lobe which did not
appear to have a significant acute on chronic component. tPA was
deferred due to minimal, improving deficits and the presumed
recent stroke from ___.
On neuro ROS today, he continues to endorse tingling in the
bilateral finger tips, but no sensory loss. He endorses
dysarthria. He feels clumsy in the left hand, unchanged since
discharge ___. He also has baseline right field cut and hearing
loss on the left. He denies headache, loss of vision,
diplopia,lightheadedness, vertigo. Denies difficulties
comprehending speech. Denies focal weakness, numbness. No bowel
or bladder incontinence or retention. Denies difficulty with
gait.
On general review of systems, the pt denies recent fever or
chills. 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:
- Left occipital stroke ___ years ago with residual right field
cut
- Recent Neuro admit for left hand clumsiness and left facial
droop found with subacute right parietal hypodensity on CT head,
left AMA prior to MRI. Normal CTA, no PFO on echo. Discharged
on plavix.
-Says he has TIAs multiple times in the past few years but
cannot
elaborate on the symptoms.
-Schizophrenia
-Depression
-Ulcerative colitis
- pancreatitis
Denies h/o MI, HTN, DM, HLD, A fib
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Exam:
Vitals: T- 100 110/52 18 98% RA Glucose 139
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:
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history.
Inattentive at times, refuses ___ backward without difficulty.
Speech is mildly dysarthric. 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 on the NIHSS card. Speech was not dysarthric.
Able to follow both midline and appendicular commands. There was
no evidence of apraxia or neglect.
-Cranial Nerves:
II: PERRL 2.5 to 2mm and brisk. Right superior quadranopia.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: subtle L NLF flattening without overt left face droop
VIII: Hearing decreased to finger-rub (chronic)
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. Very slight left hand
cupping with prolonged testing of drift (>10 seconds). Orbiting
symmetric. Slowness of rapid alternative hand movement on left
(noted on prior exam)
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
-Sensory: No deficits to light touch, pinprick, proprioception
throughout. No extinction to DSS. impaired graphesthesia on the
left.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response was upgoing on left.
-Coordination: No dysmetria on FNF or HKS bilaterally.
-Gait: Gait is with normal stride and base.
Discharge Exam:
Alert, oriented, dysarthric, language fluent, slight R NLF
flattening with slow R face activation, chronic superior right
quadrantanopsia. R FEx 4+, all other muscle strength ___. No
drift. Sensation intact to fine touch.
Pertinent Results:
___
CT Head
No acute intracranial abnormality.
___
MR ___
1. Small, peripheral subacute infarct within the right temporal
lobe.
2. Chronic infarcts of left occipital right parietal lobe.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clopidogrel 75 mg PO DAILY
2. Omeprazole 40 mg PO BID
3. QUEtiapine Fumarate 200-400 mg PO 200 MG TID, 400 MG QHS
4. ClonazePAM 1 mg PO QID
5. Creon 12 2 CAP PO TID W/MEALS
6. codeine-butalbital-ASA-caff ___ mg oral Q4-6H PRN HA
7. Loxapine Succinate 25 mg ORAL BID
8. Mirtazapine 30 mg PO HS
9. Tamsulosin 0.4 mg PO DAILY
10. Trihexyphenidyl 2 mg PO TID
Discharge Medications:
1. ClonazePAM 1 mg PO QID
2. Clopidogrel 75 mg PO DAILY
3. Loxapine Succinate 25 mg ORAL BID
4. Mirtazapine 30 mg PO HS
5. Omeprazole 40 mg PO BID
6. QUEtiapine Fumarate 200-400 mg PO 200 MG TID, 400 MG QHS
7. Tamsulosin 0.4 mg PO DAILY
8. Trihexyphenidyl 2 mg PO TID
9. codeine-butalbital-ASA-caff ___ mg oral Q4-6H PRN HA
10. Creon 12 2 CAP PO TID W/MEALS
Discharge Disposition:
Home
Discharge Diagnosis:
Acute 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 W/O CONTRAST
INDICATION: ___ with hx of cva with slurred speech // eval ich, cva
TECHNIQUE: Contiguous axial images were obtained through the head without the
administration of intravenous contrast. Coronal and sagittal reformatted
images were generated and reviewed.
DOSE: DLP: 1494.26 mGy-cm; CTDI: 35.45 mGy
COMPARISON: NECT of the head, ___.
FINDINGS:
Again noted are areas of encephalomalacia in the right parietal and left
occipital lobes. There is also ex vacuo dilatation of the occipital horn of
left lateral ventricle. The ventricles and sulci are prominent, consistent
with global atrophy. There is no acute hemorrhage, edema, mass effect or
shift of normally midline structures. The basal cisterns appear patent. The
orbits and globes are unremarkable. The imaged paranasal sinuses, mastoid air
cells, and middle ear cavities are clear.
IMPRESSION:
No acute intracranial abnormality.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST
INDICATION: ___ year old man with left face/arm weakness // stroke eval
TECHNIQUE: MRI of the brain without contrast.
COMPARISON: CT head ___.
FINDINGS:
There is no evidence of acute intracranial hemorrhage or mass effect.
There is slow diffusion with T2/FLAIR signal abnormality within the right
temporal lobe compatible with a subacute infarct. There is focal volume loss
within the left occipital and right parietal lobes compatible with chronic
infarcts. There is moderate brain parenchymal volume loss. There are normal
vascular flow voids.
The orbits, skull base, and paranasal sinuses appear unremarkable.
IMPRESSION:
1. Small, peripheral subacute infarct within the right temporal lobe.
2. Chronic infarcts of left occipital right parietal lobe.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Slurred speech
Diagnosed with CEREBRAL ART OCCLUS W/INFARCT, APHASIA
temperature: nan
heartrate: 100.0
resprate: 18.0
o2sat: 98.0
sbp: 110.0
dbp: 52.0
level of pain: 0
level of acuity: 1.0 | Mr. ___ is a ___ year old man with history of prior strokes (L
occipital and right parietal) who returned to the ED with
dysarthria, subtle left facial weakness, mild left hand
clumsiness - all symptoms consistent with those noted during his
recent Neurology admission on ___ for presumed ischemic
stroke. MRI confirmed stroke in the R temporal lobe. Patient
left AMA prior to full workup and Attending evaluation, having
understood the risks of doing so. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ y/o F with no PMH who was sent to the ED from
her PCP's office with c/o abdominal pain. Found to have
pyelonephritis on CT. Admitted to the ICU due to hypotension
with SBPs in the 80-90s in the ED.
The patient was in her USOH until ___ days prior to admission
when she began to experience worsening abdominal pain,
fever/chills. Endorsed mild dysuria. Went to see her PCP who
sent her to the ED for further evaluation. A urine at the PCP's
office was (+) for minimal WBCs and proteinuria.
In the ED, the patient's initial VS were 100.4 86 110/61 20 98%.
Initials labs revealed a leukocytosis to 13.6 with a left shift
to 91.6. Elevated alk-phos. Normal lactate. A UA showed trace
leukocytes and few bacteria. A pelvic exam was unremarkable. The
patient underwent CT abd w/ which revealed b/l pyelonephritis.
The patient was given pain control with morphine and NSAIDs.
Started on ceftriaxone. While in the ED her SBP dipped into the
___ systolic and she received 4L IVF with minimal response.
Admitted to the ICU for mgmt of pyelonephritis with hypotension.
Past Medical History:
- C-section ___ years ago
Social History:
___
Family History:
No h/o kidney disease
Physical Exam:
Admission exam:
Vitals: 98.1 64 95/64 15 100%RA
General: Alert, oriented, no acute distress
HEENT: Sclera 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: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, moderately tender to deep palpation,
non-distended, bowel sounds present, no organomegaly
GU: no foley
Back: (+) CVAT b/l
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission labs:
___ 01:00PM BLOOD WBC-13.6*# RBC-4.64 Hgb-11.3* Hct-36.4
MCV-79*# MCH-24.4*# MCHC-31.1 RDW-19.4* Plt ___
___ 01:00PM BLOOD Glucose-128* UreaN-8 Creat-0.7 Na-133
K-3.3 Cl-101 HCO3-22 AnGap-13
___ 01:00PM BLOOD ALT-28 AST-34 AlkPhos-106* TotBili-0.6
___ 01:00PM BLOOD Lipase-18
___ 04:57AM BLOOD Calcium-7.5* Phos-2.9 Mg-1.9
___ 01:00PM BLOOD Albumin-3.9
___ 02:46PM BLOOD Lactate-1.5
CT abdomen/Pelvis ___
1. Heterogeneous enhancement of bilateral kidneys with
surrounding fat
stranding and periaortic lymphadenopathy worrisome for
pyelonephritis.
2. Mild bilateral hydronephrosis without obstructing lesion.
Recommend follow up renal ultrasound after this acute episode to
ensure resolution.
3. Severe distention of the bladder.
CHEST X RAY
IMPRESSION:
1. Bibasilar airspace opacities, concerning for aspiration
pneumonia in the appropriate clinical setting.
2. Bilateral pleural effusions, right greater than left.
3. Mild pulmonary vascular congestion.
Renal US ___
IMPRESSION:
Resolution of bilateral hydronephrosis with residual mild
bilateral fullness of the collecting system.
Slight heterogeneous appearance of the upper pole of the left
kidney, likely corresponding to the hypoenhancing areas of
pyelonephritis on the CT, however, with no evidence of abscess.
Mild overall increased echogenicity of both kidneys, likely
related to
resolving parenchymal inflammation/edema.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Omeprazole 40 mg PO BID Duration: 12 Days
RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*24
Capsule Refills:*0
2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp
#*14 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
acute pyelonephritis
moderate bilateral hydronephrosis - resolved
iron deficiency anemia
GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Fever with lower abdominal pain and tenderness.
TECHNIQUE: Axial helical MDCT images were obtained of the abdomen and pelvis
after the administration of oral and IV contrast. Multiple multiplanar
reformatted images were generated in the coronal and sagittal planes.
DLP: 344.12 mGy-cm.
COMPARISON: None available.
FINDINGS:
The heart size is normal. The imaged lung bases are clear.
CT abdomen: The liver enhances homogeneously without focal lesions or
intrahepatic biliary duct dilatation. The portal vein is patent. The
gallbladder is thin-walled and unremarkable. The spleen, pancreas and adrenal
glands are unremarkable in appearance. There is heterogeneous enhancement of
bilateral kidneys with delayed excretion of contrast and mild surrounding fat
stranding worrisome for pyelonephritis. Mild bilateral hydronephrosis is
noted without distal obstruction. There is prominence of bilateral ureters
without frank hydroureter. There are no focal solid or cystic renal lesions.
The stomach, duodenum, small and large bowel are unremarkable in appearance
without focal wall thickening or evidence of obstruction. A normal appendix
is visualized in the right lower quadrant (601b:27).
The abdominal aorta is of normal caliber with patent celiac axis, SMA,
bilateral renal arteries and ___. Periaortic lymphadenopathy is noted, likely
reactive in nature. There is no ascites, no pneumoperitoneum or hernia is
noted.
CT pelvis: The bladder is massively distended. A punctate calcification in
the left hemipelvis is too low in position to be in the distal ureter and is
compatible with a phlebolith. An IUD is seen within a normal uterus. The
ovaries and rectum are unremarkable in appearance. There is no free pelvic
fluid or air. There are no enlarged inguinal or pelvic wall lymph nodes by CT
size criteria.
Osseous structures: There are no focal blastic or lytic lesions in the
visualized osseous structures concerning for malignancy.
IMPRESSION:
1. Heterogeneous enhancement of bilateral kidneys with surrounding fat
stranding and periaortic lymphadenopathy worrisome for pyelonephritis.
2. Mild bilateral hydronephrosis without obstructing lesion. Recommend follow
up renal ultrasound after this acute episode to ensure resolution.
2. Severe distention of the bladder.
Radiology Report
PA AND LATERAL CHEST OF ___
No prior studies for comparison.
FINDINGS: Heart is upper limits of normal in size, and is accompanied by mild
pulmonary vascular congestion. Bibasilar areas of airspace consolidation are
present, predominantly in the retrocardiac regions, and affecting the right
lower lobe to a greater degree than the left. Small-to-moderate pleural
effusions are also present.
IMPRESSION:
1. Bibasilar airspace opacities, concerning for aspiration pneumonia in the
appropriate clinical setting.
2. Bilateral pleural effusions, right greater than left.
3. Mild pulmonary vascular congestion.
Radiology Report
TYPE OF THE EXAM: History of bilateral pyelonephritis and hydronephrosis on
admission.
REASON FOR THE EXAM: Evaluate for resolution of hydro or any developing
abscess.
COMPARISON EXAM: Prior CT of the abdomen and pelvis, dated ___.
TECHNIQUE:
Multiple grayscale and Doppler images through bilateral kidneys were obtained
with a multifrequency transducer. Several images through the urinary bladder
were also obtained.
The right kidney measures 13.8 cm. There is minimal pelvic fullness with near
complete resolution of previously seen hydronephrosis. The right upper pole
hypoenhancing areas are not clearly appreciated. There is no abscess.
Apparent hypoechoic region in the uppr pole showed in the images represents a
medullary pyramid.
Left kidney measures 13.3 cm. There is mild heterogeneity of the upper pole,
likely corresponding to the area of pyelonephritis seen on a CT without
evidence of abscess. There is minimal pelvic fullness.
Bilateral kidneys demonstrate overall mild increased echogenicity.
Evaluation of the urinary bladder demonstrates no mural masses.
IMPRESSION:
Resolution of bilateral hydronephrosis with residual mild bilateral fullness
of the collecting system.
Slight heterogeneous appearance of the upper pole of the left kidney, likely
corresponding to the hypoenhancing areas of pyelonephritis on the CT, however,
with no evidence of abscess.
Mild overall increased echogenicity of both kidneys, likely related to
resolving parenchymal inflammation/edema.
Gender: F
Race: ASIAN - CHINESE
Arrive by WALK IN
Chief complaint: ABD PAIN
Diagnosed with PYELONEPHRITIS NOS
temperature: 100.4
heartrate: 86.0
resprate: 20.0
o2sat: 98.0
sbp: 110.0
dbp: 61.0
level of pain: 8
level of acuity: 3.0 | Ms. ___ is a ___ y/o ___ female with iron
deficiency anemia admitted with pyelonephritis and hypotension.
#. Sepsis, due to pyelonephritis.
Admitted initially to the ICU where her pressure quickly
improved with fluid rescuscitation.
THe patient had symptoms of pyelonephritis with clear evidence
of pyelonephritis on imaging and exam is c/w that diagnosis,
though atypical pyelo is unusual. Additional history revealed
patient has had recurrent UTIs for past ___ years, treated at
home with "fever" medication and a penicillin-like antibiotic;
this home treatment likely explains why her UA was unimpressive
and urine culture was negative. Treated initially with
ceftriaxone x 48 hours however remained febrile without much
clinical improvement. ANtibiotics changes to ciprofloxacin with
prompt defervesence and clinical recovery. She will complete a
full course of cipro as an outpatient.
The development of bilateral hydronephrosis as seen on CT raises
concern for vesicoureteral reflux for which outpatient urology
follow up should be considered. The bilateral hydronephrosis
resolved however on repeat imaging.
She was encouraged to see her doctor for any recurrent symptoms
rather than self treating at home.
# Abnormal chest xray: CHest xray showed 1. Bibasilar airspace
opacities, concerning for aspiration pneumonia in the
appropriate clinical setting. 2. Bilateral pleural effusions,
right greater than left.
THis was likely due to capillary leak in the setting of sepsis,
the patient did not have respiratory symptoms. Recommend
outpatient chest X ray to ensure resolution / normalization.
# Dyspepsia / epigastric pain- does have h/o iron deficiency
anemia, has never had endoscopy. H. pylori serology sent and
was equivocal. Started empiric high dose PPI x 2 week course.
Recommend outpatient EGD to evaluate for PUD. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Roxicet / tramadol / Iodinated Contrast Media - IV Dye /
valacyclovir
Attending: ___.
Major Surgical or Invasive Procedure:
Left Chest tube ___ (___)
attach
Pertinent Results:
ADMISSION LABS:
===============
___ 12:35PM BLOOD WBC-13.4* RBC-3.06* Hgb-9.2* Hct-30.2*
MCV-99* MCH-30.1 MCHC-30.5* RDW-16.7* RDWSD-60.0* Plt ___
___ 12:35PM BLOOD Neuts-81.9* Lymphs-8.5* Monos-6.8 Eos-1.0
Baso-0.4 Im ___ AbsNeut-10.95* AbsLymp-1.14* AbsMono-0.91*
AbsEos-0.13 AbsBaso-0.05
___ 12:35PM BLOOD ___ PTT-34.5 ___
___ 12:35PM BLOOD Glucose-173* UreaN-32* Creat-2.0* Na-136
K-5.4 Cl-96 HCO3-21* AnGap-19*
___ 12:35PM BLOOD ___
___ 06:13AM BLOOD CRP-87.4*
___ 09:25PM BLOOD cTropnT-0.04*
___ 12:35PM BLOOD cTropnT-0.05*
___ 02:43PM BLOOD Lactate-1.9
DISCHARGE LABS:
===============
___ 06:25AM BLOOD WBC-10.3* RBC-2.80* Hgb-8.4* Hct-28.0*
MCV-100* MCH-30.0 MCHC-30.0* RDW-17.2* RDWSD-62.4* Plt ___
___ 06:25AM BLOOD Glucose-159* UreaN-43* Creat-2.3* Na-136
K-5.5* Cl-96 HCO3-26 AnGap-14
___ 06:17AM BLOOD LD(LDH)-170
___ 06:25AM BLOOD Calcium-8.8 Phos-3.3 Mg-2.3
___ 01:00PM BLOOD K-4.8
IMAGING:
============
CT Chest
IMPRESSION:
___:
1. Interval placement of a left thoracostomy tube, with
near-resolution of a left pleural effusion. Mild edema,
atelectasis, and/or tiny consolidations along the lingula and
left lower lobe are similar in comparison to the ___ examination.
2. Interval near-resolution of a right pleural effusion, now
trace, with mild peripheral edema along the right lower lobe
with tiny consolidations.
3. No pneumothorax.
CT Chest
___
IMPRESSION:
1. Recurrent small left pleural effusion, with left basilar
chest tube in
place. Trace right pleural effusion, minimally increased.
2. Moderate atelectasis and increased peribronchial
consolidations in the
left lower lobe. Scattered linear atelectasis in the left upper
lobe and
lingula. Small peribronchial consolidations in the right lower
lobe are
unchanged.
CT chest ___:
PLEURA: There is a moderate loculated left pleural effusion with
associated pleural thickening, slightly more prominent than on
the prior study. There is no right-sided pleural effusion.
Left-sided pacer leads project to the pleura.
LUNG: Stable subsegmental atelectasis in the right lung base.
There is stable subsegmental atelectasis in the left lung base.
Consolidative opacity in the left lower lobe could represent
round atelectasis.
BONES AND CHEST WALL : Review of bones shows degenerative
changes involving the thoracic spine.
UPPER ABDOMEN: Limited sections through the upper abdomen are
unremarkable.
IMPRESSION:
Small loculated left pleural effusion has slightly increased in
volume since the prior study. Adjacent atelectasis is
unchanged.
Moderate cardiomegaly. Left-sided pacemaker.
CXR ___
IMPRESSION:
Left-sided tube in situ with mild interval decrease in size of
the known
left-sided empyema. No pneumothorax.
TTE ___
The left atrial volume index is normal. No thrombus/mass is seen
on the right atrial/ventricular pacing leads/ catheter. The
estimated right atrial pressure is ___ mmHg. There is mild
symmetric left ventricular hypertrophy with a normal cavity
size. There is mild global left ventricular hypokinesis.
Quantitative biplane left ventricular ejection fraction is 46 %
(normal 54-73%). There is no resting left ventricular outflow
tract gradient. Normal right ventricular cavity size with normal
free wall motion. There is abnormal septal motion c/w conduction
abnormality/paced rhythm. The aortic sinus is mildly dilated
with normal ascending aorta diameter for gender. There is a
normal descending aorta diameter. 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 mild
[1+] mitral regurgitation. The pulmonic valve leaflets are
normal. The tricuspid valve leaflets appear structurally normal.
There is physiologic tricuspid regurgitation. Due to acoustic
shadowing, the severity of tricuspid regurgitation may be
UNDERestimated. The estimated pulmonary artery systolic pressure
is normal. There is no pericardial effusion.
IMPRESSION: No definite lead or valvular vegetations identified.
Mild symmetric left ventricular hypertrophy with normal cavity
size and mild global systolic dysfunction int he setting of
arrhythmia and conduction delay. Mild mitral regurgitation.
Normal estimated pulmonary artery systolic pressure.
RECOMMEND: If clinically indicated, and the suspicion for lead
vegetation or endocarditis is moderate or high, a TEE is
suggested for further evaluation.
Barium Swallow ___
In this limited esophagram, there is esophageal dyskinesia and
delay in
esophageal emptying into the stomach. There was no aspiration
or
extravasation of contrast. Otherwise no overt abnormalities.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
2. aspirin-dipyridamole ___ mg oral Q12H
3. Calcitriol 0.25 mcg PO 3X/WEEK (___) MWF
4. CARVedilol 50 mg PO BID
5. Vitamin D ___ UNIT PO DAILY
6. Gabapentin 300 mg PO DAILY
7. Glargine 5 Units Bedtime
8. Levothyroxine Sodium 100 mcg PO DAILY
9. melatonin 1 mg oral QHS
10. ___ ___ UNIT PO QID
11. Pravastatin 10 mg PO QPM
12. Saccharomyces boulardii 250 mg oral BID
13. Torsemide 60 mg PO DAILY
14. PredniSONE 5 mg PO DAILY
15. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
16. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN sob
17. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
18. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
Discharge Medications:
1. amLODIPine 10 mg PO DAILY
2. Ampicillin-Sulbactam 1.5 g IV Q12H
3. Dipyridamole-Aspirin 1 CAP PO BID
4. Fluconazole 200 mg PO Q24H
5. Lidocaine 5% Patch 1 PTCH TD QAM
6. LOPERamide 4 mg PO QID:PRN diarrhea
7. Pantoprazole 40 mg PO Q24H
8. CARVedilol 25 mg PO BID
9. Glargine 15 Units Bedtime
Humalog 3 Units Breakfast
Humalog 5 Units Lunch
Humalog 5 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
10. Calcitriol 0.25 mcg PO 3X/WEEK (___) MWF
11. Gabapentin 300 mg PO DAILY
12. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN sob
13. Levothyroxine Sodium 100 mcg PO DAILY
14. melatonin 1 mg oral QHS
15. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
16. Pravastatin 10 mg PO QPM
17. PredniSONE 5 mg PO DAILY
18. Saccharomyces boulardii 250 mg oral BID
19. Torsemide 60 mg PO DAILY
20. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Acute Hypoxemic Respiratory Failure
Exudative pleural effusion
Heart failure with preserved EF, exacerbation
Type II Diabetes
Vesicular Rash
Shingles
Elevated INR
Delirium
Dizziness
Diarrhea
Dysphagia
SECONDARY DIAGNOSES:
Hypertension
Coronary artery disease
Hyperlipidemia
History of transient ischemic attack
Chronic Kidney Disease, STAGE IV
Normocytic anemia
Rheumatoid arthritis
Sacral Ulcer stage 2
Hx of oral candidiasis
Hypothyroidism
Obstructive sleep apnea
Spinal stenosis, neuropathy
Insomnia
Lipoma
Secondary Hyperparathyroidism
Vitamin D deficiency
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: History: ___ with recent PNA and effusions// Change in
PNA/effusions;
TECHNIQUE: Upright AP and lateral views of the chest
COMPARISON: Chest radiograph ___ and CT chest ___
FINDINGS:
Left-sided AICD device is noted with leads in unchanged positions in the right
atrium and right ventricle as well as epicardial leads overlying the left
ventricle. Heart size is borderline enlarged. Central mediastinal venous
distension and mild pulmonary edema is present with perihilar haziness and
vascular indistinctness. Patchy opacities are seen in the lung bases. A
small left hydropneumothorax is present with fluid again noted to be partially
loculated laterally. Small right pleural effusion is likely without interval
change. No pneumothorax is seen. There are no acute osseous abnormalities.
IMPRESSION:
Interval development of mild pulmonary edema. Unchanged small left
hydropneumothorax, with some fluid again seen to be partially laterally
loculated. Probable unchanged trace right pleural effusion. Bibasilar patchy
opacities may reflect atelectasis, though infection is difficult to exclude in
the correct clinical setting.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: History: ___ with recent left PNA and paraneumonic effusions
presenting with worsening cough and fatigue; ? new aspiration event//
Evaluation of PNA/effusions.
TECHNIQUE: Contiguous axial images were obtained through the chest without
intravenous contrast. Coronal and sagittal reformats were obtained.
COMPARISON: CT chest ___.
FINDINGS:
HEART AND VASCULATURE: The thoracic aorta measures up to 4.1 cm in the
ascending portion, unchanged and top-normal in size for patient's age.
Descending thoracic aorta is normal caliber. There is heavy calcification of
the aortic arch and descending thoracic aorta. Left chest wall pacemaker
defibrillator device is noted which causes substantial streak artifact
limiting evaluation of the left hemithorax and mediastinum. Leads are noted
terminating in the right atrium and coronary sinus. Epicardial pacing wires
are noted overlying the lateral wall of the left ventricle. Main pulmonary
artery is enlarged measuring 3.4 cm in axial diameter. There are coronary
artery calcifications. No pericardial effusion.
AXILLA, HILA, AND MEDIASTINUM: No axillary lymphadenopathy. Conspicuous
mediastinal nodes measuring up to 10 mm are unchanged and likely reactive in
etiology (4:85).
PLEURAL SPACES: There has been interval removal of a chest tube from a left
hydropneumothorax. There has been interval reaccumulation of fluid in the left
basilar pleural space now a moderate to large amount. Small amount of fluid
is also loculated laterally, similar to prior. The air component of this
hydropneumothorax is likely similar from prior although the morphology makes
comparison difficult. A small right pleural effusion is slightly larger from
prior.
LUNGS/AIRWAYS: Evaluation of the lung parenchyma is limited by a substantial
respiratory motion artifact. Ground-glass opacification within the left
greater than right lung fields lung with smooth septal thickening is
consistent with asymmetric mild pulmonary edema. Mild atelectasis is
demonstrated in the lower lobes. Secretions are noted within the trachea. The
central airways are otherwise patent.
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.
Unchanged compression deformity of T12 is partially visualized. There is a
least moderate body wall anasarca.
IMPRESSION:
1. Interval removal of a chest tube from a left hydropneumothorax. In
comparison to prior there has been re-accumulation of fluid in this
hydropneumothorax, now moderate in degree, with continued partial loculation
of fluid laterally. The air component is likely similar.
2. A small right pleural effusion is slightly larger.
3. Asymmetric mild pulmonary edema, more pronounced on the left.
4. Minimal secretions are noted within the trachea but there is no evidence of
aspiration.
5. Main pulmonary artery is enlarged which can be seen in setting of pulmonary
arterial hypertension.
6. The thoracic aorta measures 4.1 cm, top normal for patient age, unchanged.
Radiology Report
EXAMINATION: CT-guided Procedure
INDICATION: ___ year old man with parapneumonic effusion// L chest tube
placement
COMPARISON: Prior chest CT from ___.
PROCEDURE: CT-guided drainage of loculated left pleural collection.
OPERATORS: Dr. ___, radiology trainee 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 supine 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. An Amplatz 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 clear yellow fluid was aspirated with a sample sent
for microbiology evaluation. The cavity was collapsed. The catheter was
secured by a StatLock. The catheter was attached to suction. Sterile dressing
was applied.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
DOSE: Acquisition sequence:
1) Spiral Acquisition 7.2 s, 22.2 cm; CTDIvol = 7.9 mGy (Body) DLP = 164.2
mGy-cm.
2) Stationary Acquisition 8.5 s, 1.4 cm; CTDIvol = 64.7 mGy (Body) DLP =
93.1 mGy-cm.
Total DLP (Body) = 267 mGy-cm.
SEDATION: Moderate sedation was provided by administering divided doses of
0.5 mg Versed and 25 mcg fentanyl throughout the total intra-service time of
20 minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
Limited images of the lower chest show small bilateral pleural effusions.
Mild linear atelectasis in the posterior aspect of both lower lobes.
Redemonstration of a loculated effusion in the left pleural space with an
air-fluid level and none hemorrhagic appearing fluid with low-attenuation.
The heart is top normal in size. No pericardial effusion. Pacemaker leads
are seen terminating in the right atrium and right ventricle. An external
pacemaker lead appears to terminate in the coronary sinus, exiting the wall
through a low left lateral intercostal space. A stent is noted in the LAD.
The esophagus, stomach and visualized segments of duodenum, small and large
bowel are unremarkable and undistended.
Liver, gall bladder, spleen and adrenal glands are unremarkable.
Pancreas is again noted to have severe fatty atrophy, with no solid a shin of
the pancreatic duct.
The visualized right kidney shows mild atrophy, in keeping with known chronic
kidney disease, with an unchanged, partially visualized cortical cyst.
IMPRESSION:
Successful CT-guided placement of a ___ pigtail catheter into the left
pleural collection. Samples were sent for microbiology evaluation.
RECOMMENDATION(S): See POE for pleural drain care recommendations.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with left chest tube placed ___ and lytic
therapy yesterday// eval for change
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Left-sided pacemaker is unchanged. Left-sided pigtail catheter is also
unchanged. There is a moderate Left pleural effusion. Small right pleural
effusions unchanged. Pulmonary edema is stable. Cardiomediastinal silhouette
is stable. No pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with empyema, s/p chest tube // eval interval
change
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Lungs are low volume with bibasilar atelectasis. Left-sided pacemaker is
unchanged. Left-sided pigtail catheter is also unchanged. Cardiomediastinal
silhouette is stable. There are degenerative changes involving the right
shoulder joint. No pneumothorax. Small left pleural effusion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with empyema s/p chest tube // eval interval change, please
perform at 0700
TECHNIQUE: AP chest radiograph
COMPARISON: Prior chest radiograph done ___
FINDINGS:
Cardiac support device in situ. Left-sided chest tube in situ. Interval
decrease in size of the known left-sided empyema. Improved lung volumes.
Bilateral lower lung zone opacities (left more than right) slightly improved
compared to prior. Calcific atherosclerotic changes of the aorta.
IMPRESSION:
Left-sided tube in situ with mild interval decrease in size of the known
left-sided empyema. No pneumothorax.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old man with empyema s/p chest tube, also CHF
exacerbation // eval interval change
TECHNIQUE: Axial CT images of the chest were acquired without the use of IV
contrast.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.5 s, 39.7 cm; CTDIvol = 8.7 mGy (Body) DLP = 343.2
mGy-cm.
Total DLP (Body) = 343 mGy-cm.
COMPARISON: CT examinations from ___ and ___.
FINDINGS:
Since the ___ examination there has been interval placement of a
left-sided chest tube, with near-resolution of a left pleural effusion.
Mild-to-moderate left lower and lingular edema, atelectasis, and tiny
consolidations have improved since ___ examination.
There has been interval near resolution of a small right pleural effusion, now
trace, with small peripheral consolidations/edema along the right lower lobe
(series 302, image 159).
There is no pneumothorax or lobar consolidation.
The heart is mildly enlarged. Pacer wires are unchanged in configuration.
There is no pericardial effusion.
The thoracic aorta measures up to 4.2 cm collection from prior. Enlargement
of the main pulmonary artery is again seen.
There are moderate atherosclerotic calcifications throughout the thoracic
aorta and coronary vasculature.
There are no osseous lesions concerning for malignancy or infection.
IMPRESSION:
1. Interval placement of a left thoracostomy tube, with near-resolution of a
left pleural effusion. Mild edema, atelectasis, and/or tiny consolidations
along the lingula and left lower lobe are similar in comparison to the ___ examination.
2. Interval near-resolution of a right pleural effusion, now trace, with mild
peripheral edema along the right lower lobe with tiny consolidations.
3. No pneumothorax.
Radiology Report
EXAMINATION: Esophagram
INDICATION: ___ year old man with dysphagia // esophageal abnormalities?
TECHNIQUE: Limited barium esophagram, multiple spot fluoroscopic images
obtained in a semi upright position.
DOSE: Acc air kerma: 6 mGy; Accum DAP: 80.77 uGym2; Fluoro time: 44 seconds.
COMPARISON: There are no prior barium falls available for comparison, however
there are multiple chest radiographs and CTs of the chest, most recently with
chest CT obtained yesterday and chest radiograph obtained this morning.
FINDINGS:
The study was severely limited due to the patient's inability to stand upright
or place pressure on his feet, so the images were obtained by obtaining semi
upright views.
The esophagus was not dilated. There was no stricture within the esophagus.
There was no esophageal mass. The esophageal mucosa appear normal.
The primary peristaltic wave was normal, however there were tertiary
contractions with a to and fro movement of the column. There is a mild delay
in esophageal emptying into the stomach.
There was no gastroesophageal reflux. There was no hiatal hernia.
No overt abnormality in the stomach on limited evaluation.
IMPRESSION:
In this limited esophagram, there is esophageal dyskinesia and delay in
esophageal emptying into the stomach. There was no aspiration or
extravasation of contrast. Otherwise no overt abnormalities.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with L. chest tube. Pleural effusion
resolutions?
TECHNIQUE: Chest PA and lateral
COMPARISON: Multiple radiographs of the chest dating back to ___. Most recent radiograph performed ___ 07:00. CT chest ___.
FINDINGS:
Pacemaker/ICD in situ.
There remains a pigtail catheter in the left basal pleural space.
Stable appearance of the left pleural space with stable circumferential
thickening of the pleura along the left chest wall. No definite right pleural
fluid. No pneumothorax.
Re-demonstrated bibasilar opacities, left more than right. The degree of
opacification in the left mid to lower lung zone has increased from prior.
This may be on a background of atelectasis.
There is stable volume loss in the left hemithorax. No pneumothorax.
Partially visualized contrast in the left upper abdomen, relating to barium
swallow performed earlier today.
Stable degenerative changes acromioclavicular and glenohumeral joints.
IMPRESSION:
Stable pleural thickening on the left. No pneumothorax.
Increased opacity in the left mid to lower lung zone when compared to the
radiograph performed earlier today. This may be on the background of
atelectasis. Attention on follow-up recommended.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with cough // Aspiration?
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Loculated left pleural effusions unchanged. Left-sided pacemaker is also
unchanged. Lungs are low volume with mild pulmonary vascular congestion.
There is bibasilar atelectasis. Pulmonary edema has improved. No
pneumothorax is seen.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old man with recurrent pleural effusions // Pleural
effusion reaccumulation?
TECHNIQUE: Contiguous axial images were obtained through the chest without
intravenous contrast. Coronal and sagittal reformats were obtained.
COMPARISON: CT chest ___
FINDINGS:
Evaluation is limited due to technique. The most inferior left costophrenic
recess is not within the field of view despite repeat imaging.
HEART AND VASCULATURE: There is a left-sided pacemaker device with leads in
the right atrium and right ventricle. The thoracic aorta is normal in
caliber. There is triple-vessel atherosclerotic calcification of the coronary
arteries with stents in place. Heart size is enlarged. There is no
pericardial effusion.
AXILLA, HILA, AND MEDIASTINUM: No axillary or mediastinal lymphadenopathy is
present. No mediastinal mass or hematoma.
PLEURAL SPACES: There remains a left-sided chest tube at the base of the left
hemithorax which is unchanged in position. There is a recurrent small left
pleural effusion compared to CT from ___, with associated
pleural thickening. A few tiny locules of gas are noted within the pleural
space. There is trace right pleural effusion, minimally increased.
LUNGS/AIRWAYS: There is moderate atelectasis and increased peribronchial
consolidations in the left lower lobe. There is scattered linear atelectasis
in the left upper lobe and lingula. Small peribronchial consolidations in the
right lower lobe are unchanged. The patient was scanned in expiration,
limiting evaluation of the airways. There trace secretions in the trachea.
BASE OF NECK: Visualized portions of the base of the neck are unremarkable.
ABDOMEN: Included portion of the visualized unenhanced upper abdomen is
unremarkable.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
IMPRESSION:
1. Recurrent small left pleural effusion, with left basilar chest tube in
place. Trace right pleural effusion, minimally increased.
2. Moderate atelectasis and increased peribronchial consolidations in the
left lower lobe. Scattered linear atelectasis in the left upper lobe and
lingula. Small peribronchial consolidations in the right lower lobe are
unchanged.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT ___
INDICATION: ___ year old man with new line // new right PICC 42 ___ ___
Contact name: ___ , ___: ___ new right PICC 42 ___ ___
IMPRESSION:
Compared to chest radiographs ___ through ___.
Mild pulmonary edema has worsened. Circumferential left pleural thickening
and left basal atelectasis unchanged. Heart size normal. No pneumothorax.
Trans vascular right atrial right ventricular pacer defibrillator leads and
epicardial leads unchanged in their respective positions.
New right PIC linem passes into the upper SVC where it is obscured by pacer
leads.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with new PICC // need lateral view right PICC
obscured behind pacer wires thanks ___ ___
TECHNIQUE: Chest PA and lateral
COMPARISON: Multiple chest x-rays dating back to ___, most
recently ___, CT chest ___.
FINDINGS:
Right-sided PICC line tip terminates in the cavoatrial junction. Right-sided
pacemaker transvenous leads in the right atrium and right ventricle;
transthoracic leads in the epicardium are unchanged. Mild pulmonary edema,
similar to prior study. Small left pleural effusion and basilar atelectasis
is unchanged. Normal heart size. No pneumothorax.
IMPRESSION:
Right-sided PICC line tip terminates in the cavoatrial junction. No
pneumothorax.
NOTIFICATION: The findings were discussed with ___, N.P. by ___
___, M.D. on the telephone on ___ at 1:53 pm, 1 minutes after discovery
of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with RLL pna // ?aspiration, new consolidation,
desatting
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiographs from ___ to most recent ___. Chest CT from ___.
FINDINGS:
In comparison with the prior study the left lower lobe pleural effusion and
atelectasis are unchanged, a superimposed consolidation cannot be excluded.
Unchanged mild pulmonary edema. There is no new focal consolidation in the
remaining parenchyma. Cardiomediastinal silhouette is stable. No
pneumothorax. Monitoring and support devices are in stable position.
IMPRESSION:
Unchanged appearance of the left lower lobe volume loss with associated
pleural effusion, superimposed consolidation cannot be excluded. No new focal
consolidations in the remaining lung parenchyma.
Radiology Report
EXAMINATION: Video oropharyngeal swallow study
INDICATION: ___ year old man with parapneumonic effusion // ?aspiration
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the Speech-Language Pathologist from the Voice, Speech &
Swallowing Service. Multiple consistencies of barium were administered.
DOSE: Fluoro time: 5 minutes 2 seconds
COMPARISON: Comparisons made to prior video swallow study from ___ as well as barium swallow study from ___.
FINDINGS:
There is penetration with thin and nectar thick, as well as 2 instances of
trace silent aspiration with thin liquids.
IMPRESSION:
There is penetration with thin and nectar thick liquids, as well as 2 episodes
of trace silent aspirations with thin liquids.
Please note that a detailed description of dynamic swallowing as well as a
summative assessment and recommendations are reported separately in a
standalone note by the Speech-Language Pathologist (OMR, Notes, Rehabilitation
Services).
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old man with parapneumonic effusion // resolution of
parapneumonic effusion resolution of parapneumonic effusion
TECHNIQUE: Volumetric CT acquisitions over the entire thorax in inspiration,
no administration of intravenous contrast material, multiplanar
reconstructions. The technical details of the protocol are consistent with the
___ of Radiology (___) requirements for low-dose CT lung cancer
screening*
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.3 s, 36.2 cm; CTDIvol = 10.3 mGy (Body) DLP = 373.1
mGy-cm.
Total DLP (Body) = 373 mGy-cm.
COMPARISON: The to a prior study done on ___
FINDINGS:
THORACIC INLET: The thyroid is unremarkable. There is a right-sided PICC line
with its tip in the right atrium. There is a left-sided pacemaker.
BREAST AND AXILLA : No enlarged axillary lymph nodes.
MEDIASTINUM: There are stable small mediastinal lymph nodes which are most
likely reactive. There is atherosclerotic calcification involving the
descending thoracic aorta. There is severe coronary artery calcification.
The aorta and pulmonary arteries are normal in caliber. There is no
pericardial effusion
PLEURA: There is a moderate loculated left pleural effusion with associated
pleural thickening, slightly more prominent than on the prior study. There is
no right-sided pleural effusion. Left-sided pacer leads project to the
pleura.
LUNG: Stable subsegmental atelectasis in the right lung base. There is stable
subsegmental atelectasis in the left lung base. Consolidative opacity in the
left lower lobe could represent round atelectasis.
BONES AND CHEST WALL : Review of bones shows degenerative changes involving
the thoracic spine.
UPPER ABDOMEN: Limited sections through the upper abdomen are unremarkable.
IMPRESSION:
Small loculated left pleural effusion has slightly increased in volume since
the prior study. Adjacent atelectasis is unchanged.
Moderate cardiomegaly. Left-sided pacemaker.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Cough, Dyspnea, Weakness
Diagnosed with Cough
temperature: 97.9
heartrate: 85.0
resprate: 18.0
o2sat: 99.0
sbp: 160.0
dbp: 86.0
level of pain: 0
level of acuity: 2.0 | PATIENT SUMMARY:
================
___ with PMH non-ischemic cardiomyopathy s/p PPM/AICD, RA on low
dose prednisone, IDDM2, asthma/ILD, CKDIV, CAD, HTN, HLD,
hypothyroidism, OSA, recent hospitalization ___ for
complicated parapneumonic pleural effusion requiring chest tube
(removed ___, who re-presented from rehab with worsening
respiratory status, weakness, and mental status, now on RA and
s/p ___ chest tube placement ___ and removal ___.
====================
TRANSITIONAL ISSUES:
====================
FOR PCP:
[ ] Patient discharged on Torsemide 60 daily
[ ] Empirically decreased home Coreg from 50mg BID to 25mg BID
in the setting of persistent lightheadedness although this
occurred in the setting of normotension with normal HR
[ ] Patient did have persistent diarrhea, C. diff negative,
likely antibiotic induced.
[ ] Initiateed on 14 days of fluconazole (___) for
esophageal candidiasis
[ ] Consider switching to high intensity statin as patient has
hx of CAD
[ ] Sacral ulcer, stage 2. Please do mepilex dressing q3H.
FOR IP:
[ ] Continued on unasyn for at least 2 weeks, extending to
office visit on ___. Please adjust course of Unasyn as you see
fit after 2 week appointment on ___ (continue Unasyn at least
until this time)
[ ] CT chest done on the day of discharge to see if pleural
effusion persisted; if it had not, would have canceled IP appt
per inpatient team recs. However, effusion does persist and so
will be followed up in clinic as scheduled.
[ ] If surgical decortication is ultimately advised and
desired, then may be worth giving a 1-time dose of IV Vitamin K
10mg prior to surgery for maximal repletion/correction given
slightly elevated INR
Discharge Cr: 2.3
Discharge weight: Bed weight, patient unable to stand on own.
ACUTE/ACTIVE PROBLEMS:
#Acute Hypoxemic Respirator Failure, resolved
#Exudative pleural effusion
Recent hospitalization ___ for pneumonia with empyema,
re-admitted from rehab ___ with acute hypoxic respiratory
failure and metabolic encephalopathy. Reaccumulated pleural
effusion seen on repeat ___ chest CT now s/p chest tube and
removal. During this hospitalization, patient was placed on
broad spectrum IV antibiotics for ~4 days before chest tube was
placed, thus pleural studies may be obscured. Pleural studies
with no growth, pH 7.42, and LDH was ___. Blood cultures had
no growth. It was discussed amongst medicine, pulmonary, and ID
whether this was Augmentin failure versus inadequate source
control from previous admission vs pleural effusion accumulation
___ heart failure exacerbation as below. Of note, patient has
PPM leads at site of pleural effusion likely causing nidus of
infection. IP has discussed with many services in the past
(including cardiologist at ___ who placed pacemaker),
however patient is high risk surgical candidate so surgical
removal is risky. On his prior hospitalization there was
discussion about doing VATS, however at that time it did not
align within patient and family's goals of care. VATS was not
discussed during this hospitalization, however palliative care
was still consulted given the complexity of medical issues and
further discussion of goals of care. On discharge, patient
satting well on room air. It was ultimately decided to continue
patient on Unasyn until 2 week follow up with IP at which point
abx duration may be finalized. Because he ended up being
discharged so close to his IP appointment, we obtained CT chest
on the day of discharge per IP recs with the plan to cancel appt
if pleural effusion was persistently reduced; however, this
still persisted and he will need f/u w IP.
# Dysphagia
#Aspiration PNA
Patient complaining of food getting stuck in throat. Overt
aspiration with trigger for hypoxemia occurred during hospital
stay. Esophagram ___ showing esophageal dyskinesia and delay in
esophageal emptying into the stomach. No strictures. There was
no aspiration or extravasation of contrast. Repeat SLP Eval
Video Swallow showed oropharyngeal dysphagia, and he was placed
on a diet of regular solids and nectar thick liquids. Per GI,
there was concern for esophageal candidiasis, and he was
empirically treated with 14 days of fluconazole (___),
with no need to follow up outpatient unless having persistent
dysphagia (have PCP refer to GI).
#Heart failure with preserved EF, exacerbation, resolved.
#ICD and PPM
Last TTE on ___ showed EF46%, global systolic dysfunction in
setting of arrhythmia and conduction delay. BNP on this
admission 43K, ___ CT chest with mild pulmonary edema. Could be
due to decreased torsemide dosing on last admission (from 80mg
qAM/40mg qPM to 60mg daily) vs infection as above. He was
discharged on a regimen of Torsemide 60 daily, daily weights at
rehab and adjust as appropriate.
#Lightheadedness:
Patient continued to endorse persistent lightheadedness (he is
clear that this is not dizziness -- nothing appears to be
spinning). VSS, normotensive with normal HR. Unclear etiology,
as VSS, patient is not hypoglycemic. Diarrhea is unlikely
etiology, as he is not hypotensive. Potential medication effect.
AM cortisol 3.6. Per Endocrine, this is unlikely to be AI given
the appropriate increase in cortisol after stim, 5mg Prednisone
daily is physiologic, and no abnormalities seen in potassium
levels w/ varying levels of sodium. Could potentially be related
to Coreg, and so empirically decreased home dose from 50mg BID
to 25mg BID.
# Nutrition:
# GOC:
Seen by nutrition this admission, who recommended tube feeds in
the setting of malnutrition. However, after discussion with
patient and his wife, decision was made to forego Dobhoff and
tube feeds at this time. Patient would like to continue with
diet with supplemental augmentation.
#Hyponatremia
Experiencing fluctuations during stay as initially hypovolemic
due to diarrhea as below however then developed hypervolemic in
setting of discontinuing diuretic from excessive diarrhea. He
was actively diuresed with intravenous Lasix for several days.
Home diuretic was restarted and Na at discharge was 136.
#Elevated INR
Stable INR at 1.5 from 1.4 on discharge at last admission. Did
not respond to PO vitamin K x 3 days this admission; normal
liver on recent CT scan; no known liver disease. Not on a DOAC.
Heme/onc consulted ___ and states borderline mixing study
likely due to decreased Factor VII level from vitamin K
deficiency. No further workup recommended however if surgical
decortication is ultimately advised and desired, then may be
worth giving a 1-time dose of IV Vitamin K 10mg prior to surgery
for maximal repletion/correction.
#T2DM
Home glargine 5u qHS with linagliptin 5mg daily [Tradjenta] and
ISS. Adjusted patient's insulin regimen while inpatient.
Discharge insulin regimen: Glargine 15 qpm, Humalog ___
mealtime doses. He was also on an insulin sliding scale while in
the hospital.
#Vesicular Rash
#Shingles
Tender vesicles noted on Right thigh on ___. Per wife, shingles
vaccine on ___. Also with history of
herpes. He was started on valacyclovir however developed
delirium and once discontinued, delirium resolved. Vesicles
eventually unroofed and patient was not started on further
treatment.
#Diarrhea
C.diff negative on ___ and ___. Diarrhea may be secondary to
unasyn. Placed on Imodium QID, Continue PRN
Diphenoxylate-Atropine
CHRONIC/STABLE PROBLEMS:
# HTN: Carvedilol 25mg BID per above, started amlodipine 10 mg
this admission
# CAD: Continue ASA-dipyridamole, continue home SL NTG prn
# HLD: continue home pravastatin 10mg qhs, consider switching to
high intensity as outpatient.
# Hx of transient ischemic attack: Continue ASA-dipyridamole
# Chronic Kidney Disease, STAGE IV: Baseline Cr in mid-3s per
review of OMR. Discharged last admission with Cr 2.0, stable
this admission around ~2.0-2.4
# Normocytic anemia: Has h/o chronic anemia likely in part ___
CKDIV. Improved Hb to 9.2 on this admission from discharge Hb
7.1.
# Rheumatoid arthritis: Did not appear to be in flare during
admission. MTX stopped several hospitalizations ago due to
worsened Cr, continues to be held. PLAN: continue home
prednisone 5mg daily
# Sacral Ulcer: Known on previous admission and evaluated by
Wound Care, per RN is stage 2. PLAN: mepilex changes q3d
# Hx of oral candidiasis: s/p nystatin ___. No oral
lesions noted at discharge.
# Hypothyroidism: continue home levothyroxine 100mcg daily
# OSA: Continue CPAP
# Spinal stenosis, neuropathy: continue home gabapentin 300mg
daily
# Insomnia: home melatonin 1mg qHS
# Lipoma: Noted on ___. Mobile, nontender, located on L. lower
shin. PLAN: f/u as outpatient
# Secondary Hyperparathyroidism
# Vitamin D deficiency: continue home calcitriol, vit D |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Cephalosporins
Attending: ___.
Chief Complaint:
Presenting CC: ___ speech ___ ___
Admission CC: COPD ___ +/- PNA
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male with a history of COPD, HTN, DMII, hx of
cocaine
use disorder, presents today via EMS for hypoglycemia.
About 3 to 4 days ago, patient noticed worsening shortness of
breath wheezing and nonproductive cough. Patient has been using
his 2 inhalers as prescribed. Today, patient checked his blood
sugar noted to be 200. Patient took his metformin and Lantus but
forgot to eat. Patient was found by family altered with slurred
speech. EMS was called, and patient had a blood sugar noted of
38. Patient received oral glucose (25grams x2) with resolution
of
his symptoms. Patient now currently complaining of just
wheezing.
Denies any fevers, chest pain, shortness of breath, belly pain,
urinary bowel symptoms, numbness or weakness.
Of note, was recently hospitalized here in ___ for COPD
exacerbation requiring intuation (___) and ICU stay.
Received prednisone/levofloxacin/azithromycin during this
hospitalization with slow steroid taper.
- In the ED, initial vitals were: afebrile, HR 68, BP 131/91,
99%
RA
- Exam was notable for: NAD, Breathing comfortably, diffuse
wheezing throughout, no focal rales/rhonchi. A&Ox3
- Labs were notable for: Influenza negative. Cr 1.3, WBC 8.9
- Studies were notable for:
Peak Flow (Pre) 173
Peak Flow (Post) 200
CXR: Linear lingular opacity. This could potentially represent
atelectasis, infection is not excluded.
- The patient was given:
Predisone 60mg, Duoneb, Levofloxacin IV, 1L NS
- No consults.
On arrival to the floor, patient endorses HPI as listed above.
States he is feeling better than when he first arrived to the
ED.
Notably endorsed few days of increased dyspnea, cough, and
sputum
production. Says it feels somewhat similar to prior COPD
exacerbations but that this is much milder. Denies any recent
f/c, night sweats, chest pain, palpitations, abd pain, N/V/D/C,
dysuria. Says he last used cocaine about one week ago, does not
think that this triggered his exacerbation. Said he had a clinic
visit about two weeks ago d/t worsening seasonal allergies,
further endorsed mild post-nasal drip, intermittent itchy watery
eyes. Was put on 5 days of prednisone at that time which
relieved
his sx.
In addition to the above, patient notes he has had chronic L
ankle pain x ___ years. States he uses cocaine to help ease the
pain since he was taken off Percocets in the past. Had
discussion
with patient about the risks of cocaine use, as well as the
risks
of concomitant metoprolol/cocaine use as well.
Past Medical History:
COPD
HTN
T2DM
substance use disorder (incl cocaine)
HCV
Social History:
___
Family History:
DMII Father, maternal grandmother
Physical Exam:
ADMISSION EXAM:
===============
VITALS: 98.4 | 156 / 76 | 77 | 18 | 94%, RA
GENERAL: AOx3, resting comfortably sitting up in bed, speaking
in
full sentences, no increased WOB, NAD.
HEENT: Likely lipoma in posterior cervical neck. PERRL, EOMI.
Sclera anicteric and without injection. MMM.
CARDIAC: RRR. Audible S1 and S2. No murmurs/rubs/gallops.
LUNGS: Wheezing noted bilaterally, primarily in bases. No
crackles. No increased work of breathing.
ABDOMEN: S, NT, ND, BS+.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: AOx3. CN2-12 grossly intact. Moving all 4 limbs
spontaneously.
DISCHARGE EXAM:
===============
24 HR Data (last updated ___ @ 2350)
Temp: 97.4 (Tm 98.5), BP: 141/89 (134-164/78-113), HR: 94
(73-108), RR: 19 (___), O2 sat: 100% (92-100), O2 delivery: Ra
GENERAL: Lying comfortably in bed, in no acute distress
HEENT: Sclera anicteric and without injection. MMM.
CARDIAC: Regular rate and rhythm. No murmurs, rubs, or gallops.
LUNGS: Faint inspiratory crackles in bilateral bases. No wheezes
or rhonchi. No increased work of breathing.
ABDOMEN: Soft, nontender, nondistended.
EXTREMITIES: No clubbing, cyanosis, or edema.
NEUROLOGIC: AAOx3. Motor and sensory function intact throughout.
Pertinent Results:
ADMISSION LABS:
===============
___ 01:41PM WBC-8.9 RBC-4.98 HGB-14.9 HCT-47.7 MCV-96
MCH-29.9 MCHC-31.2* RDW-14.7 RDWSD-51.5*
___ 01:41PM PLT COUNT-205
___ 01:41PM NEUTS-77.2* LYMPHS-16.3* MONOS-4.2* EOS-1.4
BASOS-0.6 IM ___ AbsNeut-6.86* AbsLymp-1.45 AbsMono-0.37
AbsEos-0.12 AbsBaso-0.05
___ 01:41PM GLUCOSE-226* UREA N-14 CREAT-1.3* SODIUM-138
POTASSIUM-4.9 CHLORIDE-99 TOTAL CO2-25 ANION GAP-14
RELEVANT LABS:
==============
___ 05:14PM FluAPCR-NEGATIVE FluBPCR-NEGATIVE
___ 01:08PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-POS* amphetmn-NEG oxycodn-NEG mthdone-NEG
DISCHARGE LABS:
===============
___ 05:16AM BLOOD WBC-14.4* RBC-5.00 Hgb-15.0 Hct-46.8
MCV-94 MCH-30.0 MCHC-32.1 RDW-14.6 RDWSD-50.2* Plt ___
___ 05:16AM BLOOD Glucose-267* UreaN-26* Creat-1.3* Na-138
K-4.5 Cl-99 HCO3-26 AnGap-13
IMAGING:
========
CHEST (PA & LAT)Study Date of ___
IMPRESSION:
Linear lingular opacity. This could potentially represent
atelectasis,
infection is not excluded.
MICROBIOLOGY:
=============
__________________________________________________________
___ 1:08 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB/Wheezing
2. MetFORMIN (Glucophage) 1000 mg PO DAILY
3. Glargine 56 Units Breakfast
4. Aspirin 81 mg PO DAILY
5. Hydrochlorothiazide 25 mg PO DAILY
6. amLODIPine 10 mg PO DAILY
7. Trelegy Ellipta (fluticasone-umeclidin-vilanter) 100-62.5-25
mcg inhalation DAILY
8. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN SOB
9. Nicotine Patch 21 mg/day TD DAILY
10. Metoprolol Succinate XL 100 mg PO DAILY
11. Cetirizine 10 mg PO DAILY
Discharge Medications:
1. CARVedilol 6.25 mg PO BID
RX *carvedilol 6.25 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
2. Glargine 45 Units Breakfast
Insulin SC Sliding Scale using REG Insulin
3. amLODIPine 10 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Cetirizine 10 mg PO DAILY
6. Hydrochlorothiazide 25 mg PO DAILY
7. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB/Wheezing
8. MetFORMIN (Glucophage) 1000 mg PO DAILY
9. Nicotine Patch 21 mg/day TD DAILY
10. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN SOB
11. Trelegy Ellipta (fluticasone-umeclidin-vilanter)
100-62.5-25 mcg inhalation DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
-Acute COPD exacerbation
-Symptomatic hypoglycemia
SECONDARY DIAGNOSES:
-Cocaine use disorder
-Type 2 Diabetes Mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with wheezing// ?PNA
TECHNIQUE: PA and lateral views the chest.
COMPARISON: Chest x-ray from ___.
FINDINGS:
Opacity seen at the left cardiophrenic angle is noted, also visualized on the
lateral view. Elsewhere, lungs are clear. Cardiac silhouette is within
normal limits. No acute osseous abnormalities.
IMPRESSION:
Linear lingular opacity. This could potentially represent atelectasis,
infection is not excluded.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Hypoglycemia
Diagnosed with Pneumonia, unspecified organism
temperature: 97.4
heartrate: 68.0
resprate: 14.0
o2sat: 99.0
sbp: 131.0
dbp: 91.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ is a ___ male with history of COPD and
diabetes who initially presented with slurred speech in setting
of hypoglycemia, also with dyspnea and wheezing consistent with
COPD exacerbation. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / ampicillin / ceftazidime (anhydrous) /
Cephalosporins / sulbactam sodium
Attending: ___.
Chief Complaint:
Chest Pain/L arm Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms ___ is a ___ female with a history of
hypertrophic cardiomyopathy, congestive heart failure with
preserved EF, atypical chest pain who presents for the
evaluation of 1 day of waxing and waning, constant, sharp
left-sided chest pain radiating to her neck and her left
shoulder.
Pain began on the morning of presentation, waking her from
sleep around 4am. She had ___ episodes of this sharp
left-sided pain throughout the day. Pain crescendos over several
minutes and then subsides on its own. There is no exertional or
pleuritic component. She denies any shortness of breath, cough,
fevers, orthopnea, lower extremity edema.
She thinks that her blood pressure was high over the ___ days
leading up to this admission; home readings were around 160s
systolic. She notes 2 days of bifrontal headache without blurry
vision or altered mental status or other neurological symptom.
In the ___ ED initial vitals were: 98 BP 163/100, HR 62, RR
18 98RA
EKG: Terminal T-wave inversion V2, 2mm STD V3 new from prior,
persistent STD V4-V6, inferior leads; STE aVR consistent with
prior
Labs/studies notable for: normal CBC, chemistry panel, Troponin
negative x1, UA negative, CXR with No acute cardiopulmonary
process.
Patient was given: PO 1g Acetaminophen, 10 mg IV
metoclopramide, PO aspirin 243, carvedilol 3.25mg PO
Cardiology was consulted, recommended admission to ___ for BP
medication titration. She has had many similar admissions, in
past also with SOB with asthma exacerbation along with diastolic
dysfunction.
REVIEW OF SYSTEMS:
Positive per HPI
+mild frontal headache
Cardiac review of systems is notable for absence dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope, or presyncope.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS
-Hypertension
-Obesity with BMI of 46
2. CARDIAC HISTORY
-Left ventricular hypertrophy, possibly hypertrophic
cardiomyopathy. (Cardiac MRI in ___ showed moderate left
ventricular hypertrophy with localized thickening of the basal
and mid anteroseptal area up to 1.7 cm. There was no late
gadolinium enhancement. There was mild-to-moderate mitral
regurgitation. Normal right ventricular cavity size and function
with moderate left atrial enlargement. Echocardiogram in ___ showed asymmetric left ventricular hypertrophy (LV septal
wall thickness 1.9cm), no resting LVOT gradient, ___ MR, 1+ TR
)
-Diastolic heart failure, right heart catheterization in
___ as described above with a mean PCWP of 22 mmHg.
Normal cardiac index, no evidence of intracardiac shunt.
-Intramyocardial bridge noted in the mid LAD, creating a 30%
stenosis with near lack of flow during systole. A dip and
plateau pattern was noted as well suggestive of marked RV
diastolic dysfunction.
3. OTHER PAST MEDICAL HISTORY
-Asthma triggered by URIs.
-Possible obstructive sleep apnea.
-Hypothyroidism.
-Carpal tunnel syndrome, requiring surgery.
-Nephrolithiasis.
- Hysterectomy.
-Upper extremity paresthesias and numbness.
-Retropubic mid urethral sling procedure (___)
Social History:
___
Family History:
Father: Died "young" ___ years ago from a brain aneurysm
Mother: Had "fluid in her lungs"
Physical Exam:
PHYSICAL EXAMINATION AT ADMISSION:
VS: T 97.5, bp 158/89, HR 68, RR 18, SPO2 94% on 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. JVP of 7 cm.
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-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
PHYSICAL EXAM AT DISCHARGE
VS: 98.3 136/84 69 18 94 Ra
wt 115.3 kg
I 220/O x1 not saved
GENERAL: Well developed, well nourished woman in NAD. Oriented
x3. Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. EOMI grossly
CARDIAC: systolic ejection murmur noted at R and LUSB, heart
sounds soft
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: no ___ edema, WWP
Pertinent Results:
PERTINENT LABS
=================
___ 04:45PM BLOOD WBC-7.6 RBC-5.03 Hgb-13.8 Hct-42.9 MCV-85
MCH-27.4 MCHC-32.2 RDW-13.1 RDWSD-40.3 Plt ___
___ 04:45PM BLOOD Neuts-54.8 ___ Monos-5.0 Eos-2.1
Baso-0.7 Im ___ AbsNeut-4.14 AbsLymp-2.80 AbsMono-0.38
AbsEos-0.16 AbsBaso-0.05
___ 04:45PM BLOOD Glucose-91 UreaN-12 Creat-0.8 Na-142
K-3.9 Cl-104 HCO3-25 AnGap-17
___ 04:45PM BLOOD cTropnT-<0.01
___ 10:50PM BLOOD cTropnT-<0.01
PERTINENT IMAGING
==================
none
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN SOB, wheezing
2. Docusate Sodium 100 mg PO BID:PRN Constipation
3. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
4. Levothyroxine Sodium 50 mcg PO DAILY
5. Pravastatin 40 mg PO QPM
6. Sertraline 50 mg PO DAILY
7. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
8. MetFORMIN (Glucophage) 500 mg PO BID
9. Aspirin 81 mg PO DAILY
10. Lisinopril 20 mg PO BID
11. amLODIPine 5 mg PO DAILY
12. Metoprolol Succinate XL 12.5 mg PO BID
Discharge Medications:
1. Metoprolol Succinate XL 37.5 mg PO DAILY
RX *metoprolol succinate 25 mg 1 and ___ tablet(s) by mouth
twice a day Disp #*90 Tablet Refills:*1
2. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN SOB, wheezing
3. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
4. amLODIPine 5 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Docusate Sodium 100 mg PO BID:PRN Constipation
7. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
8. Levothyroxine Sodium 50 mcg PO DAILY
9. Lisinopril 20 mg PO BID
10. MetFORMIN (Glucophage) 500 mg PO BID
11. Pravastatin 40 mg PO QPM
12. Sertraline 50 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Hypertrophic Cardiomyopathy
Chest Pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with cp// eval chf vs pneumonia
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___ and ___ and ___
FINDINGS:
The lungs are clear without focal consolidation. No pleural effusion or
pneumothorax is seen. The cardiac and mediastinal silhouettes are stable
compared to priors. Linq device projects over the subcutaneous tissue of the
left lower chest. No pulmonary edema is seen. Surgical clips noted in the
upper quadrant.
IMPRESSION:
No acute cardiopulmonary process.
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by WALK IN
Chief complaint: Chest pain, L Arm pain, Neck pain
Diagnosed with Chest pain, unspecified
temperature: 98.0
heartrate: 62.0
resprate: 18.0
o2sat: 98.0
sbp: 163.0
dbp: 100.0
level of pain: 6
level of acuity: 2.0 | Mrs ___ is a ___ year old woman with a history of
HCM and HFpEF who was admitted for chest pain. EKG and troponin
were negative for MI. Patient was started on higher dose
metoprolol for her HCM with improvement of her symptoms. She was
discharged home with intent to follow-up with her PCP and
cardiologist to further evaluate her symptoms. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / Coumadin
Attending: ___.
Chief Complaint:
respiratory failure, hypotension
Major Surgical or Invasive Procedure:
Intubation ___
History of Present Illness:
___ with CAD, HFrEF (EF 26%), Afib, HLD, hx of MCA/ICA stroke,
non-verbal and R side hemiplegia, presenting with tachycardia,
tachypnea, and hypotension consistent with septic shock
At baseline, he is non-verbal and on 2L O2 at his nursing home.
Earlier today, he was noted to have an O2 sat in the mid 80%,
along with dyspnea, tachypnea, fevers, tachycardia,and
hypotension to SBP ___. EMS was called and she was taken to the
___ ED. Of note, he was recently treated for a UTI with cipro.
In the ED, initial vitals were T 104, HR ___, SBPs ___ improved
to 110/74, RR 16, O2 98% Intubated. On exam, he was obtunded but
responded to painful stimuli. Initial labs showed WBC 29.5 (9%
bands), Hgb 11.1, Na 152, K 8.0 (hemolyzed), Cr 1.9, AG 20,
Lactate 3.5, VBG pH 7.35/46, AST/ALT 103/39 (hemolyzed), Albumin
2.5, INR 1.5, Trop 0.46, Fibrinogen 677, SvO2 77%, UA >182RBC,
111 WBC, Many bacteria, Mod leuks.
Bedside ultrasound showed hyperdynamic LV without pericardial
effusion.
Imaging:
- CXR: Moderate pulmonary vascular congestion.
- CXR: No pneumothorax or pleural effusion
- EKG: HR 143 with IVCD and PVCs
He was intubated and placed on CMV: Vt: 500, rr: 14, FiO2: 100,
Peep: 5. A left IJ was obtained for access. Foley placed.
He was given Vanc/Zosyn, 2L NS IVF, and started on levophed 0.3
mcg/kg/min, neo at 1 mcg/kg/min.
On arrival to the FICU, he was intubated and sedated. Initial
vitals were: HR 104, BP 97/65, RR 28, O2 99% Intubated on CMV
14x500, FiO2 100%, PEEP 5. He was not responding to commands. He
was on levophed 0.4 mcg/kg/min and neo 1 mcg/kg/min, along with
fentanyl 100 and versed (stopped).
Past Medical History:
-CAD s/p DES to mRCA ___ s/p DES x3 to pRCA followed by acute
thrombosis s/p PTCA and thrombectomy ___
-Ischemic CM s/p BiV ICD (EF ___
-Paroxysmal AF w/ anticoagulation declined ___ attributing
development of fatigue to Coumadin
-Paroxysomal atrial tachycardia
-HLD, refusing statin
-BPH
-PE ___
-DVT ___ years ago
outpatient cardiologist Dr ___ at ___
Social History:
___
Family History:
FH:
no family history of neurologic disease
No premature history of CAD or SCD.
Physical Exam:
ADMISSION PHYISCAL EXAM
==================================
VITALS: HR 104 (v-paced), BP 97/65, RR 28, O2 99% Intubated on
CMV 14x500, FiO2 100%, PEEP 5
GENERAL: Older male, lying in bed, not following commands, eyes
closed
HEENT: AT/NC, EOMI, pupils minimally reactive to light
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, no murmurs, gallops, or rubs
LUNG: Clear anteriorly, no wheezing
ABDOMEN: Obese, nondistended, nontender to palpation, PEG tube
in place
EXTREMITIES: no cyanosis, clubbing or edema, foley in place
PULSES: 2+ DP pulses bilaterally
NEURO: Intubated
DISCHARGE
VS - 97.4 AdultAxillary 91/60 L Lying 76 20 98 Ra 65.6kg
Gen - supine in bed
Eyes - EOMI, anicteric, EOMI
ENT - OP clear, MMM
Heart - RRR no mrg
Lungs - upper airway noises bilaterally; bases clear without
crackles;
Abd - soft nontender, normoactive bowel sounds; PEG c/d/i
Ext - no edema
Skin - excoriated skin around buttocks and genitals;
Vasc - 2+ DP/radial pulses
Neuro - aphasic; spontaneously moving L side;
Psych - unable to assess given aphasia
Pertinent Results:
ADMISSION
___ 12:00PM BLOOD WBC-29.5* RBC-3.32* Hgb-11.1* Hct-38.4*
MCV-116* MCH-33.4* MCHC-28.9* RDW-16.6* RDWSD-67.2* Plt ___
___ 12:00PM BLOOD ___ PTT-35.5 ___
___ 12:00PM BLOOD Glucose-163* UreaN-66* Creat-1.9* Na-152*
K-8.0* Cl-113* HCO3-19* AnGap-30*
___ 01:02PM BLOOD Lactate-3.5*
DISCHARGE
___ 11:25AM BLOOD WBC-5.9# RBC-2.77* Hgb-9.1* Hct-28.3*
MCV-102*# MCH-32.9* MCHC-32.2 RDW-16.9* RDWSD-62.1* Plt ___
___ 07:12AM BLOOD Glucose-115* UreaN-36* Creat-1.0 Na-138
K-4.0 Cl-100 HCO3-22 AnGap-20
MICROBIOLOGY
___ 1:00 pm URINE SOURCE: CATHETER.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. >100,000 CFU/mL.
ENTEROCOCCUS SP.. >100,000 CFU/mL. ___ STRAIN.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
| ENTEROCOCCUS SP.
| |
AMPICILLIN------------ 8 S 8 S
NITROFURANTOIN-------- 128 R 128 R
TETRACYCLINE---------- =>16 R =>16 R
VANCOMYCIN------------ <=0.5 S <=0.5 S
IMAGING
=================================
CXR ___ IMPRESSION:
1. Appropriate position of endotracheal and enteric tubes.
2. Mild pulmonary vascular congestion.
TTE ___ IMPRESSION:
Mild symmetric left ventricular hypertrophy with regional
systolic dysfunction most c/w CAD. Mild-moderate mitral
regurgitation most likely due to papillary muscle dysfunction.
Right ventriuclar cavity dilation with mild free wall
hypokinesis. Mildly dilated aortic root.
CT ABDOMEN/PELVIS ___ IMPRESSION:
1. Decompressed urinary bladder around a Foley's catheter. No
hydronephrosis.
2. Old splenic infarcts. There is new peripheral wedge-shaped
areas of
hypoenhancement peripherally from prior CT in ___, new since CT
chest ___ most compatible with splenic infarct, likely
subacute.
3. Large amount of fecal loading in the rectum and distal
sigmoid colon
without proximal bowel obstruction.
CT CHEST ___ IMPRESSION:
Bilateral lower lobe consolidations, with volume loss, largely
atelectasis. Extensive centrilobular, ___ nodules
bilateral posterior lungs, consistent with infection or
aspiration. There are extensive areas of mucous plugging, and
bronchial secretions.
There are small partially loculated pleural effusions, improved
since prior, superimposed infection cannot be excluded.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. GuaiFENesin ER 400 mg PO DAILY
2. Acetylcysteine 20% ___ mL NEB Q8H
3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea
4. TraZODone 25 mg PO Q6H:PRN agitation
5. Metoprolol Tartrate 12.5 mg PO BID
6. Omeprazole 20 mg PO BID
7. Senna 8.6 mg PO BID:PRN constipation
8. Bisacodyl 10 mg PR QHS:PRN constipation
9. Acetaminophen 1000 mg PO Q8H
10. Atorvastatin 10 mg PO QPM
11. Aspirin 81 mg PO DAILY
12. BusPIRone 10 mg PO TID
13. Divalproex (EXTended Release) 250 mg PO QHS
Discharge Medications:
1. Amiodarone 400 mg PO BID
2. Furosemide 20 mg PO DAILY
3. Pravastatin 20 mg PO QPM
4. Metoprolol Tartrate 6.25 mg PO BID
5. Acetaminophen 1000 mg PO Q8H
6. Acetylcysteine 20% ___ mL NEB Q8H
7. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea
8. Aspirin 81 mg PO DAILY
9. Bisacodyl 10 mg PR QHS:PRN constipation
10. BusPIRone 10 mg PO TID
11. Divalproex (EXTended Release) 250 mg PO QHS
12. GuaiFENesin ER 400 mg PO DAILY
13. Omeprazole 20 mg PO BID
14. Senna 8.6 mg PO BID:PRN constipation
15. TraZODone 25 mg PO Q6H:PRN agitation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
# Septic Shock
# Acute bacterial Pneumonia
# Bacterial UTI
# Acute on chronic systolic CHF
# Diarrhea, non-infectious
# Buttock Wounds
# Dysphagia
# Ventricular Tachycardia
# Type 2 NSTEMI
# Anxiety
# History of MCA Stroke with residual R hemiparesis
# Paroxysmal Atrial fibrillation
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
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with septic shock ___ UTI vs. PNA, intubated//
r/o interval change r/o interval change
IMPRESSION:
Comparison to ___. Status post re-intubation. The endotracheal tube
is in correct position. However, the tip of the left internal jugular vein
catheter now points upwards into the superior vena cava. Moderate
cardiomegaly, small bilateral pleural effusions are unchanged. Mild
retrocardiac atelectasis.
Radiology Report
EXAMINATION: Chest single view
INDICATION: ___ year old man with sepsis ___ bilateral PNA/UTI// r/o interval
change
TECHNIQUE: Chest portable AP
COMPARISON: ___
FINDINGS:
No interval change. Bilateral symmetrical opacity seen compatible with
pulmonary edema. Multilead pacemaker as previously. Jugular line ends in
right NG in right innominate vein.
IMPRESSION:
No interval change, bilateral pulmonary edema.
Radiology Report
INDICATION: ___ year old man with sepsis/PNA// r/o any interval change
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
A left chest wall biventricular AICD is present. The tip of a left internal
jugular central venous catheter is unchanged, projecting upward into the SVC.
The endotracheal and enteric tubes have been removed.
Low bilateral lung volumes. Unchanged pulmonary edema and bibasilar
atelectasis/consolidation. Small bilateral pleural effusions are again
present. No pneumothorax.
IMPRESSION:
Interval extubation.
Grossly unchanged pulmonary edema and mid to lower lung zone
atelectasis/consolidation.
Radiology Report
EXAMINATION: PORTABLE ABDOMEN
INDICATION: ___ year old man with bilious emesis// evaluation for obstruction
TECHNIQUE: Portable supine and sitting upright abdominal radiographs.
COMPARISON: CT abdomen/pelvis ___.
FINDINGS:
A percutaneous gastrostomy catheter is noted with the balloon tip projecting
in the epigastric region. No significant air-fluid levels or bowel dilatation
is seen to suggest obstruction. Stool is noted within the colon and rectum.
No pneumoperitoneum is seen.
Two small calculi are seen within the right renal hilum, similar to prior CT.
Partially evaluated biventricular AICD leads are present.
IMPRESSION:
No evidence of bowel obstruction or pneumoperitoneum. A substantial amount of
stool projects over the left colon.
Radiology Report
INDICATION: History: ___ with respiratory distress//eval tube placement
TECHNIQUE: Portable upright chest radiograph
COMPARISON: None
FINDINGS:
The tip of the endotracheal tube terminates approximately 6.5 cm above the
carina. An enteric tube terminates beyond the field of view, likely at least
in the stomach. Heart size is mildly enlarged. The lungs demonstrate mild
pulmonary vascular congestion and retrocardiac opacification which likely
represents atelectasis. There is no pneumothorax. No subdiaphragmatic free
air.
Left-sided AICD/pacemaker device is noted with leads terminating in the
regions of the right atrium, right ventricle and coronary sinus.
IMPRESSION:
1. Appropriate position of endotracheal and enteric tubes.
2. Mild pulmonary vascular congestion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with LIJ line placement
TECHNIQUE: Supine AP view of the chest
COMPARISON: Chest radiograph ___ at 12:34
FINDINGS:
There has been interval placement of a left internal jugular central venous
catheter with tip at the confluence of the brachiocephalic veins. No large
pneumothorax is detected on this supine exam. Endotracheal and enteric tubes
remain in unchanged positions. AICD/pacing leads are re-demonstrated. Mild
cardiomegaly is again noted. The mediastinal and hilar contours are similar.
Mild pulmonary vascular congestion appears slightly worse in the interval.
Persistent bibasilar opacities may reflect atelectasis. No large pleural
effusion is noted.
IMPRESSION:
Left internal jugular central venous catheter tip at the confluence of the
brachiocephalic veins. No pneumothorax or pleural effusion identified on this
supine exam.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with septic shock, respiratory failure now
intubated// r/o interval change r/o interval change
IMPRESSION:
In comparison with the study of ___, the monitoring and support devices
are essentially unchanged. Continued enlargement of the cardiac silhouette
with pulmonary vascular congestion bilateral pleural effusions with
compressive atelectasis at the bases. In view of the extensive changes, it
would be very difficult to unequivocally exclude superimposed pneumonia in the
appropriate clinical setting, especially in the absence of a lateral view.
Radiology Report
EXAMINATION: CT abdomen/pelvis
INDICATION: ___ with CAD, HFrEF (EF 26%), Afib, HLD, hx of MCA/ICA stroke,
non-verbal and R side hemiplegia, presenting with tachycardia, tachypnea, and
hypotension consistent with septic shock concerning for UTI as source, but
still hypotensive on two pressors and vanc/zosyn// eval for 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.
No 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 12.6 s, 0.2 cm; CTDIvol = 214.9 mGy (Body) DLP =
43.0 mGy-cm.
3) Spiral Acquisition 11.6 s, 75.4 cm; CTDIvol = 9.1 mGy (Body) DLP = 676.8
mGy-cm.
Total DLP (Body) = 722 mGy-cm.
COMPARISON: Compared to prior CT dated ___.
FINDINGS:
LOWER CHEST: Please refer to separate report of CT chest performed on the same
day for description of the thoracic findings.
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 distended, however its
walls are thin without evidence of acute cholecystitis. There is mild
periportal edema likely related to IV fluid hydration.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: Few peripheral wedge-shaped areas of hypoenhancement at the periphery
of the spleen appear unchanged from prior compatible with old splenic
infarcts, however there is new peripheral wedge-shaped area of hypoenhancement
(series 5, image 62 and 56) most compatible with splenic infarcts of
indeterminate age. There is mild associated capsular retraction, favoring
subacute infarct. Multiple splenic hypodensities of indeterminate etiology
are again visualized, grossly stable in size when compared to prior.
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.
Bilateral renal hypodensities, the largest at the interpolar region of the
left kidney measuring 20 mm, grossly stable in size when compared to prior
most compatible with simple renal cysts. No suspicious renal masses or
hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: The feeding tube is noted coiled in the stomach with its tip
at the pylorus. A PEG tube is also noted. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. There is large
amount of fecal loading within the rectum and distal sigmoid without proximal
colonic obstruction.
PELVIS: The urinary bladder is decompressed around a Foley's catheter. Small
amount of air is identified related to catheterization. There is no free
fluid in the pelvis.
REPRODUCTIVE ORGANS: Prostate is enlarged measuring 6.5 cm in transverse
dimension.
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.
There is benign bone island in the posterior left acetabular column, stable
since prior.
SOFT TISSUES: Diffuse anasarca in the soft tissues.
IMPRESSION:
1. Decompressed urinary bladder around a Foley's catheter. No hydronephrosis.
2. Old splenic infarcts. There is new peripheral wedge-shaped areas of
hypoenhancement peripherally from prior CT in ___, new since CT chest ___ most compatible with splenic infarct, likely subacute.
3. Large amount of fecal loading in the rectum and distal sigmoid colon
without proximal bowel obstruction.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: Rule out infectious source.
TECHNIQUE: Multiple contiguous axial images through the chest were performed
after the administration of intravenous contrast. Coronal sagittal reformats
were then performed and sent to 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 12.6 s, 0.2 cm; CTDIvol = 214.9 mGy (Body) DLP =
43.0 mGy-cm.
3) Spiral Acquisition 11.6 s, 75.4 cm; CTDIvol = 9.1 mGy (Body) DLP = 676.8
mGy-cm.
Total DLP (Body) = 722 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS WITH CONTRAST)
COMPARISON: ___.
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: Base of the neck is normal.
Thyroid gland is unremarkable. No supraclavicular lymphadenopathy. No
axillary lymphadenopathy. No suspicious chest wall mass. A left-sided chest
wall pacemaker is noted with leads at the right atrium, right ventricle and
coronary sinus, unchanged from prior.
UPPER ABDOMEN: Please refer to report of the abdomen and pelvis performed same
day for further details.
MEDIASTINUM: No mediastinal lymphadenopathy. No mediastinal hematoma or mass.
HILA: No hilar lymphadenopathy.
HEART and PERICARDIUM: Mild cardiomegaly. Left ventricle is prominent. No
pericardial effusion. Moderate coronary calcifications.
PLEURA: Bilateral small pleural effusions,, partially loculated, slightly
improved from prior.
LUNG:
1. PARENCHYMA: Bilateral lower lobe consolidations with volume loss left
greater than right as well as extensive ___, centrilobular nodules
within the lower lobes posterior segments of the upper lobes. Findings are
concerning for aspiration pneumonia. No lung masses.
2. AIRWAYS: Patient is intubated with the distal tip of the endotracheal tube
approximately 2.5 cm from the carina. There is extensive secretions layering
within bilateral mainstem bronchi and lower lobes bilaterally.
3. VESSELS: Thoracic aorta is normal in size. Main pulmonary artery is not
dilated.
CHEST CAGE: No suspicious osteoblastic or osteolytic mass lesions. No acute
fractures. There is 9.7 cm x 4 cm subcutaneous lipoma medial to the upper
edge of the right scapula.
IMPRESSION:
Bilateral lower lobe consolidations, with volume loss, largely atelectasis.
Extensive centrilobular, ___ nodules bilateral posterior lungs,
consistent with infection or aspiration. There are extensive areas of mucous
plugging, and bronchial secretions.
There are small partially loculated pleural effusions, improved since prior,
superimposed infection cannot be excluded.
Gender: M
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: Hypotension, Respiratory distress
Diagnosed with Sepsis, unspecified organism
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: Critical
level of acuity: 1.0 | This is an ___ year old male with past medical history of CAD,
systolic CHF, atrial fibrillation complicated by prior MCA
stroke with residual aphasia and R side hemiplegia admitted
___ with acute hypoxic respiratory failure and sepsis
secondary to acute bacterial pneumonia and urinary tract
infection, course complicated by acute systolic CHF, ventricular
tachycardia, now medically optimized and discharged back to
nursing home
# Septic shock
# Bacterial UTI
# Acute bacterial pneumonia
# Acute hypoxic respiratory failure
Patient presented with tachycardia, fever, tachypnea,
hypotension, leukocytosis with bandemia, elevated lactate, with
UA concerning for UTI and chest xray concerning for multifocal
pnuemonia. Intubated in setting of hypoxia. Patient initially
hypotensive despite fluid resuscitation requiring levophed and
phenylephrine initiation, with SvO2 77%, consistent with septic
shock. Patient started on empiric broad spectrum antibiotics.
Remainder of workup negative. Urine culture grew 2 species of
Enterococcus. Completed a 7 day course of vancomycin and zosyn
from ___ until ___, and also with stress dose steroids
hydrocortisone from ___. Patient improved over course of
this time, able to be weaned from pressors and vent.
# Acute on chronic systolic CHF
# NSTEMI
Patient with known history of ischemic cardiomyopathy (EF 24%),
with ICD in place, whose course was complicated by acute
systolic CHF and NSTEMI with associated hypotension, thought to
not be attributable to septic physiology. Patient seen by
cardiology, TTE without new focal wall motion abnormalities, was
started on IV heparin drip, Lasix drip, and restarted medically
optimizing therapy (metoprolol had been held in setting of
sepsis). Atorvastatin changed to pravastatin in setting of
initiation of amiodarone. Discharge weight 65.6kg. Newly
started on low dose Lasix. Would follow weights and repeat Cr
___ days post-discharge to guide if ongoing diuretic therapy
will be needed. Would have him follow-up with cardiologist Dr.
___ 2 months post-discharge.
# Ventricular tachycardia:
In setting of above processes, patient noted to have significant
ventricular tachycardia burden on telemetry, and prompting ICD
shock activation. He was started on amiodarone with
improvement. See goals discussion regarding ICD discussions.
# ___:
Patient with baseline creatinine 0.9, admitted with creatinine
1.9 in setting of sepsis. Improved with treatment of above, and
volume resuscitation. Cr at discharge was 1.0. Could not
tolerate ACE-I due to hypotension.
# Hypernatremia: Admission Na 152, thought to be likely
hypovolemic hypernatremia. Course complicated by diarrhea as
below, requiring aggressive free water deficit repletion.
Resolved once diarrhea resolved.
# Noninfectious diarrhea - Developed diarrhea in setting of
antibiotics and new tube feed formulation (started due to renal
failure). Once antibiotics stopped and renal failure resolved
(and he was transitioned back to home tube feed formulation)
diarrhea resolved. Cdiff negative.
# Buttock Wounds - In setting of diarrhea and critical illness,
developed friction/shearing wounds of posterior legs, and
excoriations over buttock from frequent stooling. See attached
wound care recommendations.
# Dysphagia - continued aspiration precautions.
# Anxiety - Continued BusPIRone
# History of MCA Stroke with residual R hemiparesis - continued
ASA, Divalproex
# Paroxysmal Atrial fibrillation - chronically not
anticoagulated due to prior bleed; on decreased metoprolol dose
due to relative hypotension;
# ___ of Care
Sons had not completed guardianship paperwork since patient's
stroke this past ___. On admission, 2 prior ___ forms were
located: 1 completed by patient in ___, stating DNR/DNI; the
___ completed by daughter-in-law in ___ stating full code.
Reviewed paperwork and found that daughter-in-law was not a
valid proxy, invalidating this ___ ___ forms. Family meetings
had with sons who reported initial MOSLST indicating DNR/DNI was
what patient would have wanted. Per further discussions, given
the discomfort caused by ICD shocks, they requested the
ICD-function be turned off--this was done by cardiology. While
here, the inpatient team and the sons completed the guardianship
paperwork, which ___ legal will be submitting for
consideration. Until then, the sons requested a hospice
consultation once the patient returned to his nursing home to
help further guide symptom-focused care. They agreed with
continuing all the above medical interventions for now. Would
continue to address with them, especially once guardianship is
approved.
# Abnormal CT Spleen -
Admission CT scan showed " Old splenic infarcts. There is new
peripheral wedge-shaped areas of hypoenhancement peripherally
from prior CT in ___, new since CT chest ___ most
compatible with splenic infarct, likely subacute." As above, he
has not been anticoagulated chronically for his atrial
fibrillation--could readdress this if felt to be within his
goals of care.
Transitional Issues
- Discharged back to nursing home
- Sons and inpatient team completed guardianship paperwork,
legal team is submitting
- Patient DNR/DNI per his prior completed ___ form from ___
___ from ___ is not valid as it was not completed by a valid
health care proxy)
- Admission CT scan showed " Old splenic infarcts. There is new
peripheral wedge-shaped areas of hypoenhancement peripherally
from prior CT in ___, new since CT chest ___ most
compatible with splenic infarct, likely subacute." As above, he
has not been anticoagulated chronically for his atrial
fibrillation--could readdress this if felt to be within his
goals of care.
> 30 minutes spent on this discharge |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Aspirin / monosodium glutamate
Attending: ___.
Chief Complaint:
Lower GI bleed
Major Surgical or Invasive Procedure:
___. Rectal exam under anesthesia.
2. Sigmoidoscopy
___ Colonoscopy (with polypectomy and thermal therapy)
___ Upper endoscopy, small bowel capsule endoscopy
History of Present Illness:
___ with h/o internal hemorrhoids s/p banding in ___
presents after painless, large volume BRBPR with bowl movement
this am ar 0630. Pt syncopal in bathroom with no traumatic fall.
Pt presented to the ED at 7am normotensive at 131/90 with HR 80.
However he became hypotensive to 84/62 HR 82 with passage of
more
bright red blood. Initial HCT 30.3, pt given 3 Units of PRBC and
2 liters of IVF with good response to HR 62, 120/75. Transiently
hypotensive again to the 80's in the ED with good response to 2
more units PRBC.
Perianal nerve block done in ED with 40cc of Lidocaine with
epinephrine and anus packed with surgicell.
Past Medical History:
PMH: Internal Hemorrhoids (Grade II on C-scope ___, otherwise
normal to cecum), HTN, NASH, L5 nerve root compression causing
peripheral neuropathy, Erectile dysfunction
PSH: Banding of internal hemorrhoids ___ (___)
Social History:
___
Family History:
mom - living. HTN
dad - deceased, HTN. died from MVC
MGF - heart disease, maternal uncle heart disease. sister with
thyroid cancer
Physical Exam:
On admission:
Pain ___, 62 120/75 16 100%
Gen: Anxious, lying supine, A&Ox3, cooperative with exam
CV: RRR, No R/G/M
RESP: Clear
ABD: Soft, NT, ND. NGT lavage with 500cc NS returned non-bilious
clear output. 500cc retrieved.
Ext: WWP
Rectal: No external hemorrhoids. Normal tone. Large right-sided
internal hemorrhoid. Rectal vault filled with bright red blood.
Anoscopy performed but limited view secondary to blood.
Visualized rectal mucosa pink.
On discharge:
VS 98.8, 71, 150/80, 14, 97% on room air
Pertinent Results:
___ 07:50AM ___ PTT-32.6 ___
___ 07:50AM PLT COUNT-155
___ 07:50AM NEUTS-48.9* ___ MONOS-6.8 EOS-1.9
BASOS-0.9
___ 07:50AM WBC-4.5 RBC-3.35*# HGB-10.5*# HCT-30.3*#
MCV-90 MCH-31.5 MCHC-34.8 RDW-13.5
___ 07:50AM ALT(SGPT)-16 AST(SGOT)-19 ALK PHOS-31* TOT
BILI-0.3
___ 07:50AM GLUCOSE-192* UREA N-17 CREAT-1.0 SODIUM-142
POTASSIUM-3.9 CHLORIDE-114* TOTAL CO2-24 ANION GAP-8
___ 07:56AM HGB-10.4* calcHCT-31
___ 07:56AM LACTATE-1.9
___ 01:25PM ___ PTT-31.1 ___
___ 02:30AM BLOOD Glucose-115* UreaN-10 Creat-0.9 Na-143
K-3.6 Cl-108 HCO3-26 AnGap-13
___: CTA
Linear area of enhancement on arterial phase at the level of the
rectum,
with slight pooling and expansion on delayed phase of imaging,
likely
represent active contrast extravasation. Hyperdense material is
seen within the rectal lumen on delayed phase, likely reflecting
hemorrhagic contents.
Subtle peripancreatic hypoattenuating ___ represent
sequala of
chronic inflammation or IgG 4 related autoimmune pancreatitis.
Clinical
correlation is recommended. Prior imaging, if available, will
be helpful. Renal cysts.
___ Colonoscopy
Grade 3 internal hemorrhoids
Ulcer in the distal rectum
Normal mucosa in the whole visualized colon without evidence of
blood or recent bleeding. Complete visualization of mucosa was
limited by fair prep.
Polyp in the proximal rectum (polypectomy, thermal therapy)
Otherwise normal colonoscopy to cecum
___ Upper endoscopy
Normal mucosa in the whole esophagus
Normal mucosa in the whole stomach
Normal mucosa in the whole duodenum
Otherwise normal EGD to third part of the duodenum
___ Capsule study: RESULTS PENDING
Medications on Admission:
Atenolol 25mg po qd
Gemfibrozil 600mg po qd
Oxycodone ___ q ___ hrs prn pain
Tramadol prn
Niacin
Melatonin
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Atenolol 25 mg PO DAILY
3. Gemfibrozil 600 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Lower gastrointestinal bleed
Internal hemorrhoids
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Patient with bright red blood per rectum. Assess for potential
source of bleeding.
COMPARISONS: None available.
TECHNIQUE: MDCT-acquired contiguous images through the abdomen and pelvis
were obtained without and with intravenous contrast at 5-mm slice thickness.
Coronally and sagittally reformatted images are provided.
FINDINGS:
Bibasilar areas of dependent atelectasis are noted. No pleural effusion is
seen. Heart is normal in size without pericardial effusion. A small hiatal
hernia is present.
The liver enhances homogeneously without suspicious focal lesions. There is
no intrahepatic biliary ductal dilatation. The hepatic vasculature is patent.
The gallbladder is incompletely distended. There is no gallbladder wall edema
or pericholecystic fluid collection to suggest acute inflammation. No
calcified gallstones are seen within its lumen. The spleen is unremarkable.
The pancreas enhances homogeneously without ductal dilatation. There is
subtle peripancreatic hypoattanuating halo. The adrenal glands are normal.
The kidneys enhance and excrete contrast symmetrically without evidence of
hydronephrosis or renal masses. There are multiple bilateral focal
hypodensities, which are too small to characterize and are likely cysts. The
largest left renal hypodense lesion arising from its upper pole measures 2.1 x
2.6 cm with 4 Hounsfield units in attenuation, compatible with a simple cyst
(4A:526).
Small and large bowel loops are normal in caliber without evidence of bowel
wall thickening or obstruction. There is no mesenteric or retroperitoneal
lymphadenopathy. Abdominal aorta and its branches are normal in caliber and
appear patent. Mild calcified atherosclerotic disease of the aorta is noted
without associated aneurysmal changes. There is no free air or free fluid
within the abdomen.
CT OF THE PELVIS: The bladder and distal ureters are unremarkable. Linear
hyper-enhancement at the level of the rectum (4A:163) likely reflects
patient's known hemorrhage. It demonstrates pooling and expansion on delayed
imaging. Hyperdense material within the rectum likely represents hemorrhagic
contents. Small locules of gas in perianal region (4A:185)is noted, which
may related to patient's reported history of injections. There is no free air
or free fluid within the pelvis. There is no pelvic or inguinal
lymphadenopathy.
OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesion is seen.
Dextroscoliosis and degenerative joint changes of the lumbar spine are noted.
IMPRESSION:
1. Linear area of enhancement on arterial phase at the level of the rectum,
with slight pooling and expansion on delayed phase of imaging, likely
represent active contrast extravasation. Hyperdense material is seen within
the rectal lumen on delayed phase, likely reflecting hemorrhagic contents.
2. Subtle peripancreatic hypoattenuating ___ represent sequala of
chronic inflammation or IgG 4 related autoimmune pancreatitis. Clinical
correlation is recommended. Prior imaging, if available, will be helpful.
2. Renal cysts.
Findings discussed with Dr. ___ at 12:30pm ___ by phone.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: BPR
Diagnosed with GASTROINTEST HEMORR NOS, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA
temperature: 96.9
heartrate: 80.0
resprate: 16.0
o2sat: 100.0
sbp: 131.0
dbp: 90.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ was admitted to the ___ service at ___ on
___ with a massive lower gastrointestinal bleeding. CTA
failed to show an obvious site of bleeding so he was taken to
the OR where an EUA and flexible sigmoidoscopy were performed.
By this point the bleeding had stopped and he had received five
units of packed red blood cells and three units of FFP. He
stabilized postoperatively and he was kept in the ICU for 24
hours to ensure his hematocrit levels were stable. He was
transferred to the floor on POD 2.
While on the inpatient ward, he underwent both an endoscopy and
colonoscopy, both of which showed no sites of bleeding. During
this time, his hematocrit levels were stable, ranging from 30 -
33. On the day of discharge, Mr. ___ also underwent a
capsule study. He gradually increased his oral intake per
guidelines set forth by ___ clinic. He was directed to
follow up with Dr. ___ regarding the results of
this examination.
At the time of discharge, Mr. ___ was hemodynamically
stable, afebrile and in no acute distress. Discharge
instructions were primarily provided by the GI motility
service/clinic post- capsule study. The patient was directed to
contact his PCP if he continues to have GI bleeding issues. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
fall, confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr ___ is a ___ year old man with a history of recurrent falls
who presents to the ED as a transfer from ___
with findings of an intraparenchymal hemorrhage. History is
obtained primarily from his daughter ___.
She reports that he sustained a fall at home about two weeks
ago.
This fall was not witnessed by anyone, but his son (who lives
with him) heard a thud in the room next door, and came in to
find
him on the floor. His son believes that he was trying to get
from
the bed to the bathroom, lost his balance, and fell backwards,
striking his head. He did not lose consciousness, and they did
not notice any facial droop, slurred speech, weakness, or
discoordination. Of note, he has a history of chronic gait
unsteadiness and recurrent falls, so this was not very atypical
for him. He typically ambulates by holding on to objects as he
makes his way around the house. They did not seek any medical
attention at the time.
After the fall he generally returned to his baseline for the
next
___ days or so. However, about ___ days ago his daughter (who
visits daily) noted him to be more lethargic and confused than
usual. He is usually able to make himself a bowl of oatmeal in
the morning, but yesterday she found him staring at the
microwave, apparently unsure what to do. He also seemed to be
confused about some of their routine activities, like going to
his daughter's house for dinner every ___. At this dinner, he
was repeatedly falling asleep at the table, which is unusual for
him. Again, there was no obvious facial droop, slurred speech,
weakness, sensory change, or discoordination.
Due to the ongoing confusion, his children brought him to ___. Initial blood pressure on arrival was 100/54.
A
head CT was performed and showed a small left intraparenchymal
hemorrhage. He was therefore transferred to ___ for further
evaluation.
On arrival to ___, he is unable to provide any further
history.
Past Medical History:
Benign Prostatic Hyperplasia
B Cell Lymphoma- currently in remission
Low back pain
Recurrent falls
Social History:
___
Family History:
Brother died of a stroke at age ___.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vitals: T: 98.1 BP: 135/70 HR: 64 RR: 22 SaO2: 98% room air
General: In bed, with covers in place, resists attempts to
interview/examine.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx.
Neck: Supple.
Pulmonary: Normal work of breathing.
Cardiac: RRR, warm, well-perfused.
Abdomen: Soft, non-distended.
Extremities: No ___ edema.
Skin: No rashes or lesions noted.
Neurologic:
-Mental Status: Awake and alert. Tracks and regards examiner.
Upon my entering the room, he concealed himself below the
blankets and resisted attempts to remove them. He was able to
tell me his name was ___, but otherwise refused to
answer
questions and would only say "Why should I?" or "Get out of
here". When attempts were made to examine him, he became very
agitated and attempted to punch or kick.
-Cranial Nerves: PERRL 4 to 2mm and brisk. EOMI without
nystagmus. Blink to threat present bilaterally. Slight left
nasolabial fold flattening, activates well. Very hard of
hearing.
Tongue midline.
-Motor: There is a fine tremor of the jaw. Otherwise unable to
assess bulk, tone, or power, though he does vigorously move all
extremities against gravity when agitate.
-Sensory: Unable to test.
-Reflexes: Unable to test.
-Coordination: Unable to test.
-Gait: Unable to test.
DISCHARGE PHYSICAL EXAM
=======================
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx.
Neck: Supple.
Pulmonary: Normal work of breathing.
Cardiac: RRR, warm, well-perfused.
Abdomen: Soft, non-distended.
Extremities: No ___ edema. All extremities without fluctuance,
erythema, or tenderness
Skin: No rashes or lesions noted.
Neurologic:
-Mental status: awake, oriented to name, hospital. follows
simple
commands. +palmonetal +grasp reflex. Inattentive.
-Cranial Nerves: PERRL 4 to 2mm and brisk. EOMI without
nystagmus. Mild L NLFF, improves with smile. Very hard of
hearing. Tongue midline.
-Motor: All extremities antigravity, needs encouragement. LLE
exam limited by mild pain with flexion.
-Sensory: intact to light touch throughout
-Reflexes: Deferred
-Coordination: Deferred
-Gait: Deferred
Pertinent Results:
ADMISSION LABS
==============
___ 08:15PM BLOOD WBC-5.7 RBC-4.93 Hgb-14.3 Hct-43.7 MCV-89
MCH-29.0 MCHC-32.7 RDW-12.8 RDWSD-41.7 Plt ___
___ 08:15PM BLOOD Neuts-70.9 Lymphs-14.1* Monos-11.1
Eos-2.6 Baso-0.9 Im ___ AbsNeut-4.03 AbsLymp-0.80*
AbsMono-0.63 AbsEos-0.15 AbsBaso-0.05
___ 08:15PM BLOOD Plt ___
___ 08:15PM BLOOD ___ PTT-29.1 ___
___ 08:15PM BLOOD Glucose-113* UreaN-23* Creat-1.2 Na-140
K-4.7 Cl-104 HCO3-20* AnGap-16
___ 08:15PM BLOOD ALT-10 AST-19 CK(CPK)-87 AlkPhos-133*
TotBili-0.7
___ 08:15PM BLOOD Albumin-4.0 Cholest-180
___ 08:15PM BLOOD %HbA1c-6.0 eAG-126
___ 08:15PM BLOOD Triglyc-85 HDL-55 CHOL/HD-3.3 LDLcalc-108
LDLmeas-110
___ 08:15PM BLOOD TSH-1.3
___ 08:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-7*
Tricycl-NEG
DISCHARGE LABS
==============
___ 07:40AM BLOOD WBC-6.0 RBC-4.82 Hgb-14.2 Hct-43.1 MCV-89
MCH-29.5 MCHC-32.9 RDW-12.9 RDWSD-42.4 Plt ___
___ 07:40AM BLOOD Plt ___
___ 07:40AM BLOOD ___ PTT-29.7 ___
___ 07:40AM BLOOD Glucose-101* UreaN-16 Creat-1.0 Na-141
K-4.3 Cl-106 HCO3-23 AnGap-12
___ 07:40AM BLOOD Calcium-8.8 Phos-3.1 Mg-2.0
IMAGING
========
MRI
IMPRESSION:
1. Single left temporal and 2 right cerebellar tiny early
subacute infarcts.
2. Early subacute parenchymal hematoma left basal ganglia,
stable, no abnormal enhancement.
3. Findings consistent with amyloid angiopathy.
4. Chronic superficial siderosis.
5. Chronic infarcts, as above, some are in watershed area.
6. Advanced brain parenchymal atrophy. Findings consistent with
severe chronic small vessel ischemic changes.
CTA HEAD W&W/O C & RECONS Study Date of ___
IMPRESSION:
1. A left globus pallidus hematoma has increased in size and
measures up to 1.7 x 1.0 cm, previously 1.2 x 0.8 cm. Minimal
adjacent vasogenic edema and effacement of the adjacent left
lateral ventricle anterior horn.
2. Occluded right V4 segment, likely caused by a calcified
atherosclerotic
plaque immediately proximal to the V4 segment origin. The right
posterior-inferior cerebellar artery originates from the basilar
arteryand is patent.
TTE
No LV thrombus seen. Mild symmetric left ventricular hypertrophy
with normal cavity size and regional/global biventricular
systolic function. Mild pulmonary hypertension.
Xray left knee ___:
IMPRESSION:
Chondrocalcinosis and multiple joint bodies in left knee without
definite
acute osseous abnormality seen. If there is continued clinical
concern for occult fracture, consider cross-sectional imaging
for further evaluation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Finasteride 5 mg PO QHS
2. Cyanocobalamin Dose is Unknown IM/SC MONTHLY
Discharge Medications:
1. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
2. Cefpodoxime Proxetil 100 mg PO/NG Q12H Duration: 5 Days
3. QUEtiapine Fumarate 25 mg PO QHS agitation
4. QUEtiapine Fumarate 12.5 mg PO QAM
5. Cyanocobalamin 100 mcg IM/SC MONTHLY
6. Finasteride 5 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
#cerebral intraparenchymal hemorrhage
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: CHEST (PORTABLE AP)
INDICATION: ___ year old man with stroke// Screening x-ray for admission
INTERVAL CHANGE
IMPRESSION:
No prior chest radiographs available.
Heterogeneous bibasilar opacification could be dependent edema but there are
no findings in the upper lungs or mediastinum to suggest vascular engorgement
and the heart is normal size, nor is there any pleural effusion. Alternative
explanation could be aspiration or pre-existing diffuse lung disease,
including UIP.
No pneumothorax.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old man with stroke// Eval for stroke
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of intravenous contrast, axial imaging was performed with
gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was
performed and re-formatted in axial and coronal orientations.
COMPARISON: CTA head, neck ___, head CT ___
FINDINGS:
Small focus of restricted diffusion abutting ventricle the posterior left
temporal lobe. 2 tiny punctate early subacute right cerebellar infarcts.
These findings are too small to see on priors.
1.4 cm x 0.9 cm early subacute hematoma centered on the very anterior left
caudate head, para terminal gyrus, similar compared with ___
allowing for differences in technique. No definite associated enhancement.
Mild surrounding edema, expected finding.
Multiple punctate foci of superficial distribution chronic microhemorrhage,
consistent with amyloid angiopathy. Areas of superficial siderosis are seen,
consistent with prior episodes of subarachnoid hemorrhage.
There is no evidence of mass effect, midline shift or infarction. Advanced
brain parenchymal atrophy. Findings consistent with severe chronic small
vessel ischemic changes. Few small chronic deep white matter infarcts right
frontal lobe. Small chronic cortical infarct left superior frontal gyrus. A
has a small focal cortical infarcts involving paramedian bilateral parietal,
occipital lobes, in watershed area. Possible additional area of small chronic
cortical infarct anterior right frontal lobe. 2 tiny chronic right single
left cerebellar infarcts. Vascular flow voids are preserved. Dominant left
vertebral artery, with hypoplastic right. Minimal mucosal thickening
paranasal sinuses. Clear mastoids.
IMPRESSION:
1. Single left temporal and 2 right cerebellar tiny early subacute infarcts.
2. Early subacute parenchymal hematoma left basal ganglia, stable, no abnormal
enhancement.
3. Findings consistent with amyloid angiopathy.
4. Chronic superficial siderosis.
5. Chronic infarcts, as above, some are in watershed area.
6. Advanced brain parenchymal atrophy. Findings consistent with severe
chronic small vessel ischemic changes.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with stroke, aspiration, new fever// evidence of
consolidation
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
There persisting opacities in the lower lungs bilaterally, right greater than
left. No pleural effusion or pneumothorax. The size of the cardiomediastinal
silhouette is within normal limits.
IMPRESSION:
No significant interval change since prior. Bibasilar opacities could reflect
atelectasis, pneumonia or chronic lung disease. Pulmonary edema is thought
less likely.
Radiology Report
EXAMINATION: KNEE (2 VIEWS) LEFT PORT
INDICATION: ___ year old man with new L knee pain// r/o fracture
TECHNIQUE: Two views of the left knee.
COMPARISON: None available.
FINDINGS:
No acute fractures or dislocations are seen.There is severe degenerative
changes of the medial compartment, mild of the patellofemoral and lateral
compartments. There is extensive chondrocalcinosis as well as multiple joint
bodies. There is a probable joint effusion, however this is obscured by the
overlying calcifications. Small superior pole patellar enthesophyte.
Prominent vascular calcifications.There is generalized osteopenia.
IMPRESSION:
Chondrocalcinosis and multiple joint bodies in left knee without definite
acute osseous abnormality seen. If there is continued clinical concern for
occult fracture, consider cross-sectional imaging for further evaluation.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: ___ with known bleed and AMS.
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of intravenous contrast material. Three-dimensional angiographic
volume rendered, curved reformatted and segmented images were generated on a
dedicated workstation. This report is based on interpretation of all of these
images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 18.0 s, 18.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
903.1 mGy-cm.
2) Stationary Acquisition 5.5 s, 0.5 cm; CTDIvol = 27.4 mGy (Body) DLP =
13.7 mGy-cm.
3) Spiral Acquisition 5.2 s, 40.7 cm; CTDIvol = 15.2 mGy (Body) DLP = 620.1
mGy-cm.
Total DLP (Body) = 634 mGy-cm.
Total DLP (Head) = 903 mGy-cm.
COMPARISON: Outside hospital noncontrast head and C-spine CT
FINDINGS:
CT HEAD WITHOUT CONTRAST:
A left globus pallidus hematoma has increased in size and measures 1.7 x 1.0
cm, previously 1.2 x 0.8 cm (series 2, image 15). There is minimal adjacent
edema with effacement of the frontal horn of the left lateral ventricle.
There is no other evidence of hemorrhage. No evidence ofinfarction.
Periventricular and subcortical white matter hypodensities are nonspecific but
likely sequelae of chronic small vessel ischemic disease. There is extensive
dural calcification as well as linearly oriented parietal corona radiata
calcification, basal ganglia calcification, and cerebellar calcification in
the location of the dentate nuclei extending toward the cerebellar peduncles.
The ventricles and sulci are prominent, consistent with involutional change.
CTA HEAD:
The right V4 segment is occluded at the location of a calcified plaque at the
point the vessel becomes intradural. The right posterior inferior cerebellar
artery is patent and arises from the basilar artery. An apparent focal
outpouching of the right C7 internal carotid artery segment reflects a
posterior communicating artery infundibulum. The left A1 segment is
hypoplastic. The remaining vessels of the circle of ___ and their
principal intracranial branches appear unremarkable without stenosis,
occlusion, or aneurysm formation. The dural venous sinuses are patent.
CTA NECK:
Mild bilateral carotid bifurcation atherosclerosis without significant
stenosis by NASCET criteria. The right vertebral artery is severely
hypoplastic throughout its course with focal atherosclerotic calcification at
the point the vessel becomes intradural. The carotidandvertebral arteries and
their major branches otherwise appear unremarkable with no evidence of
stenosis or occlusion.
OTHER:
Severe centrilobular emphysema at the lung apices. The visualized portion of
the thyroid gland is within normal limits. There is no lymphadenopathy by CT
size criteria.
IMPRESSION:
1. A left globus pallidus hematoma has increased in size and measures up to
1.7 x 1.0 cm, previously 1.2 x 0.8 cm. Minimal adjacent vasogenic edema and
effacement of the adjacent left lateral ventricle anterior horn.
2. Occluded right V4 segment, likely caused by a calcified atherosclerotic
plaque immediately proximal to the V4 segment origin. The right
posterior-inferior cerebellar artery originates from the basilar artery and is
patent.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ICH, Transfer
Diagnosed with Nontraumatic intracranial hemorrhage, unspecified
temperature: 97.2
heartrate: 62.0
resprate: 18.0
o2sat: 94.0
sbp: 131.0
dbp: 72.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ year old man with a history of recurrent falls
who presented to the ___ ED as a transfer from ___
___ after he was found to have a left sided
intraparenchymal hemorrhage. Notably had fall approximately 2
weeks prior to presentation, with worsening confusion ___ days
prior to presentation. Initial NIHSS 4, GCS Score at the scene
15, ICH Volume by ABC/2. Initial exam limited by agitation,
improved without focality. CTA with left frontal/BG IPH slightly
larger in size than prior (1.7 x 1 cm previously 1 x 1 cm). MRI
with stable hematoma and additional small subacute left
temporal, right cerebellar infarcts, as well as amyloid.
Etiology of bleed and infarcts suspicious for mixed
vasculopathy, with small vessel disease and amyloid. Family
preference to defer ASA or any form of anticoagulation. Deferred
___ monitor as results would not change management.
Risk factors notable for HgA1C 6, LDL 108. Initiated
atorvastatin 80 mg daily. Course was complicated by UTI,
sundowning in the setting of known dementia. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Advil / tetracycline / ampicillin
Attending: ___.
Chief Complaint:
Right proximal humerus fracture
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ is a ___ year-old right hand-dominant female who
presents to the ED as a transfer from ___ in
___ for orthopedic consultation of the right proximal
humerus fracture status post fall from standing. Ms. ___
denies any other injuries. She reports she was walking into her
house after drinking some wine and slipped on the entry step.
Because her fall and landed on her right shoulder resulting in
immediate pain. She denies striking her head has been able to
ambulate since the fall. She denies having any tingling or
numbness. Denies history of injury to her right upper
extremity.
Past Medical History:
Wegener's granulomatosisin remission.
Hypertension
Social History:
___
Family History:
N/C
Physical Exam:
Gen: Resting comfortably, NAD
CV: RRR
Pulm: Non labored respirations
RUE: Coaptation splint c/d/i
-Fires AIN, PIN, IO
-Sensory intact in ax/m/r/u
-Radial pulse 2+, digits WWP
Pertinent Results:
___ 03:32AM GLUCOSE-101* UREA N-8 CREAT-0.5 SODIUM-136
POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-19* ANION GAP-15
___ 03:32AM WBC-11.8* RBC-3.28* HGB-12.9 HCT-36.7
MCV-112* MCH-39.3* MCHC-35.1 RDW-12.0 RDWSD-49.9*
Medications on Admission:
Atenolol 25 mg daily
Prilosec
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 1 to 2 tablet(s) by mouth every eight
(8) hours Disp #*30 Tablet Refills:*1
2. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Give 5mg
for moderate pain or 10 mg for severe pain.
RX *oxycodone 5 mg 1 (One) tablet(s) by mouth every four (4)
hours Disp #*20 Tablet Refills:*0
3. Atenolol 25 mg PO DAILY
4.Outpatient Occupational Therapy
NWB RUE. Evaluate and treat.
Discharge Disposition:
Home
Discharge Diagnosis:
Right proximal humerus fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Right humerus fracture. Preoperative imaging.
TECHNIQUE: CT scan of the right shoulder.
COMPARISON: X-ray ___.
FINDINGS:
Bones: There is a comminuted fracture of the right proximal humerus with a
component of the fracture line extending into the greater tuberosity. There
is overall apex lateral angulation with lateral posterior displacement of the
fracture fragments and the distal humerus.
No fracture of the humeral head. The glenohumeral joint appears preserved.
No AC joint arthropathy.
Soft tissues: Mild-to-moderate hematoma is seen surrounding the fracture.
Likely small amount of blood products seen within the glenohumeral joint.
Rotator cuff is not well evaluated by CT. Rotator cuff musculature appears
preserved.
Miscellaneous: Linear opacity of the right middle lobe and lower lobe may
represent mild atelectasis. There is linear and solid mass like opacity
across the greater fissure of the partially visualized lung measuring
approximately 20 x 6 mm (image 2:73 and 400:71)).
IMPRESSION:
Markedly comminuted and displaced right proximal humerus shaft fracture with
extension into the greater tuberosity. The fracture does not appear to the
involve the humeral head.
Linear and solid mass like opacity across the greater fissure of the partially
visualized lung. This could represent scarring if patient has a prior
procedure, mass cannot be excluded. Correlation with any previous thoracic
chest CT is recommended. If this finding is new or no prior chest CT is
available, a nonemergent chest CT is recommended for further evaluation of
this lesion and to evaluate for any mass.
NOTIFICATION: The findings were discussed with Dr. ___ M.D. by ___
___, M.D. on the telephone on ___ at 2:36 pm.
Radiology Report
INDICATION: ___ year old woman with proximal humerus fracture s/p splinting//
Please assess alignment
TECHNIQUE: AP and lateral views of the right humerus were obtained
COMPARISON: CT scan of the right humerus from earlier today
FINDINGS:
There is been interval placement of a splint over the right shoulder and arm.
Re-demonstrated is a severely comminuted fracture of the proximal humeral
diaphysis with a large the fracture line again seen to extend to the greater
tuberosity. Apex lateral angulation is again seen. The degree of overriding
and displacement has however decreased since prior.
IMPRESSION:
Interval placement of a splint and reduction of a comminuted right humeral
fracture. The degree of displacement and overriding has decreased since
yesterday's radiograph.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R Humerus fracture, s/p Fall, Transfer
Diagnosed with Unsp fracture of upper end of right humerus, init, Fall on same level, unspecified, initial encounter
temperature: 98.3
heartrate: 82.0
resprate: 18.0
o2sat: 100.0
sbp: 130.0
dbp: 82.0
level of pain: 6
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 a right proximal humerus fracture and was admitted to
the orthopedic surgery service. The patient was treated
nonoperatively in a coaptation splint and worked with
occupational therapy who determined that discharge to home with
home OT was appropriate. The patient was given anticoagulation
per routine, and 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, and the patient was voiding/moving bowels
spontaneously. The patient is non weight bearing in the right
upper extremity, and will not require DVT prophylaxis on
discharge. 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:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
Endoscopy ___
History of Present Illness:
Patient is a ___ yo male with PMH of CAD s/p CABG ___, CHF w/ EF
55%, AFib (off coumadin for ___ yr), CKD, and long-standing iron
deficiency anemia, gastritis and chronic GI bleed presented to
his PCP's office today after he was seen in the at___ infusion
unit for iron infusion. When he presented to the infusion unit,
he was pale and short of breath with minimal ambulation. Of
note, he was recently hospitalized at ___ for 1
week in early ___ with CHF exacerbation where he was
diuresed down to a weight of 232 pounds. He was discharged on
lasix 40 mg po qAM, 20 mg po qPM. In the infusion unit, he was
noted to have a weight gain of ~25 pounds (232->258). He reports
shortness of breath and dyspnea on exertion x 1 month. He denies
PND but occasionally has difficulty using his CPAP unit. He
denies chest pain. He has occasioanal palpitations with climbing
stairs. He has been trying to diet recently and was drinking
more water and diet sodas to curb his appetite. He does not
follow a fluid restriction and has not been weighing himself at
home. He says a nurse prepares his medications and he does not
know how much lasix he has been taking.
Yesterday he also began to have abdominal cramping pains with
black diarrhea over past 3 days. He had ___ bowel movements per
day. He reports this is now resolved. He denies nausea,
vomiting, chest pain, BRBPR. His hgb was found to be 6.2 at the
___ clinic and he was referred to the ED for further
evaluation.
In the ED, initial VS were: 98.0 82 99/54 20 90% 12L. EKG showed
afib @ 76, new TWI v2-v5. Labs were significant for hct 23.3
(baseline ~28), creat 1.7 (at baseline), trop 0.02. Rectal exam
showed black-green heme positive stool. NG lavage showed clear
return, no blood. He was given pantoprazole 80 mg iv x 1. CXR
showed pulmonary edema. He was given 1 u blood + 20mg Lasix IV.
VS on transfer were: 80 104/42 18 94% RA
Past Medical History:
atrial fibrillation on coumadin, highest INR recently 3 in
___
T2DM A1c 5.5 ___
CRI, baseline ___
CAD s/p CABG ___, LIMA to LAD, vein graft to PDA, sequential
vein graft to D1 and OM
MI ___
___: cath with patent grafts and high grade OM1 treated with
stent
___: EF50%, cath with patent grafts except PDA which was
angioplasted
___: cardioversion for afib
___: EF unchanged
.
OA s/p THR
obesity
chronic pain
AVN femoral head and neck
PMR
colonic polyps
insomnia
gastritis/duodenitis
HLD
HTN
Social History:
___
Family History:
sister had breast cancer. No family hx of other cancers,
specifically GI malignancies.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 98.1, P: 69, BP: 154/75, RR: 18, 98% on 2l NC, Weight =
117.0KG
GENERAL: chronically ill-appearing male in NAD
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
NECK: supple, obese, unable to assess JVP
LUNGS: mild crackles at bases, otherwise CTA bilat, no r/rh/wh,
good air movement, resp unlabored, no accessory muscle use
HEART: irreg rhythm, no MRG, nl S1-S2
ABDOMEN: obese, NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES: WWP, 1+ pitting edema over shins b/l, 1+ ___
pulses
NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength
and sensation grossly intact throughout
DISCHARGE PHYSICAL EXAM:
VS: 97.9, 145/100, 65, 18, 98%RA, Weight = 107.8kg
GENERAL: chronically ill-appearing male in NAD
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
NECK: supple, obese, unable to assess JVP
LUNGS: CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
HEART: irreg rhythm, no MRG, nl S1-S2
ABDOMEN: obese, NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES: WWP, mild edema over shins b/l, 1+ ___ pulses
NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength
and sensation grossly intact throughout
Pertinent Results:
ADMISSION LABS:
___ 06:15PM BLOOD WBC-5.3 RBC-2.82* Hgb-6.8*# Hct-23.3*#
MCV-83# MCH-24.1*# MCHC-29.2* RDW-21.1* Plt ___
___ 06:15PM BLOOD Neuts-66 Bands-2 Lymphs-14* Monos-13*
Eos-3 Baso-0 Atyps-2* ___ Myelos-0
___ 06:15PM BLOOD ___ PTT-33.3 ___
___ 06:15PM BLOOD Glucose-103* UreaN-43* Creat-1.7* Na-137
K-4.6 Cl-99 HCO3-24 AnGap-19
___ 06:15PM BLOOD CK(CPK)-131
___ 06:15PM BLOOD CK-MB-3 cTropnT-0.02*
___ 06:00AM BLOOD Albumin-3.7 Calcium-9.2 Phos-4.6* Mg-2.2
___ 06:00AM BLOOD %HbA1c-5.7 eAG-117
___ 06:42PM BLOOD Lactate-2.2*
___ 06:42PM BLOOD Hgb-7.1* calcHCT-21
DISCHARGE LABS:
___ 06:45AM BLOOD WBC-6.4 RBC-3.47* Hgb-9.2* Hct-31.0*
MCV-89 MCH-26.6* MCHC-29.8*# RDW-22.6* Plt ___
___ 06:45AM BLOOD Glucose-130* UreaN-31* Creat-1.7* Na-137
K-3.9 Cl-96 HCO3-30 AnGap-15
___ 06:00AM BLOOD Calcium-8.6 Phos-3.9 Mg-2.0
MICROBIOLOGY:
HELICOBACTER PYLORI ANTIBODY TEST (Final ___:
NEGATIVE BY EIA.
(Reference Range-Negative).
IMAGING:
CXR - ___
FINDINGS: PA and lateral views of the chest were provided.
Midline
sternotomy wires are noted. There is a nasogastric tube
terminating in the
left upper quadrant. The heart is mildly enlarged. The lungs
appear clear.
Bony structures are intact.
IMPRESSION: Appropriately positioned nasogastric tube. Mild
cardiomegaly.
Otherwise, normal.
ECHO ___
Conclusions
The left atrium is moderately dilated. No left atrial
mass/thrombus seen (best excluded by transesophageal
echocardiography). There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). The right ventricular cavity is moderately
dilated with mild global free wall hypokinesis. [Intrinsic right
ventricular systolic function is likely more depressed given the
severity of tricuspid regurgitation.] There is abnormal systolic
septal motion/position consistent with right ventricular
pressure overload. The aortic root is mildly dilated at the
sinus level. The ascending aorta is mildly dilated. 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 to moderate (___) mitral regurgitation is seen.
There is severe pulmonary artery systolic hypertension. There is
no pericardial effusion.
IMPRESSION: Right ventricular cavity dilation with free wall
hypokinesis. Severe pulmonary artery hypertension. Mild-moderate
mitral regurgitation. Mild symmetric left ventricular
hypertrophy with preserved regional and global biventricular
systolic function. Dilated ascending aorta.
Compared with the prior study (images reviewed) of ___,
the estimated PA systolic pressure is higher and mild right
ventricular systolic dysfunction is now seen.. These findings
are suggestive of a chronic or acute on chronic pulmonary
process. Is there a history of sleep apnea, bronchospasm or
chronic pulmonary embolism, etc.?
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Feraheme *NF* (ferumoxytol) 510 mg/17 mL (30 mg/mL) Injection
every 2 weeks
2. Vytorin ___ *NF* (ezetimibe-simvastatin) ___ mg Oral at
night
3. Tamsulosin 0.4 mg PO HS
4. Mirtazapine 7.5 mg PO HS:PRN insomnia
5. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Furosemide Dose is Unknown PO BID
8. Omeprazole 40 mg PO DAILY
9. Pravastatin 80 mg PO DAILY
10. Allopurinol ___ mg PO DAILY
11. Colchicine 0.6 mg PO DAILY
12. Digoxin 0.125 mg PO DAILY
13. Citalopram 20 mg PO DAILY
14. Gabapentin 300 mg PO BID
15. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Mirtazapine 7.5 mg PO HS:PRN insomnia
3. Aspirin 81 mg PO DAILY
4. Citalopram 20 mg PO DAILY
5. Digoxin 0.125 mg PO DAILY
6. Gabapentin 300 mg PO BID
7. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
8. Tamsulosin 0.4 mg PO HS
9. Colchicine 0.6 mg PO DAILY
10. Feraheme *NF* (ferumoxytol) 510 mg/17 mL (30 mg/mL)
Injection every 2 weeks
11. Metoprolol Succinate XL 25 mg PO DAILY
12. Omeprazole 40 mg PO DAILY
13. Pravastatin 80 mg PO DAILY
14. Vytorin ___ *NF* (ezetimibe-simvastatin) ___ mg Oral at
night
15. Furosemide 40 mg PO BID
RX *furosemide 40 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
16. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
- Anemia secondary to upper gastrointestinal bleed (GAVE
disease)
- Acute on chronic diastolic congestive heart failure
exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH PERFORMED ON ___
COMPARISON: Chest radiograph from ___.
CLINICAL HISTORY: Shortness of breath.
FINDINGS: PA and lateral views of the chest were provided. Midline
sternotomy wires are noted. There is a nasogastric tube terminating in the
left upper quadrant. The heart is mildly enlarged. The lungs appear clear.
Bony structures are intact.
IMPRESSION: Appropriately positioned nasogastric tube. Mild cardiomegaly.
Otherwise, normal.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: GI BLEED
Diagnosed with GASTROINTEST HEMORR NOS, ANEMIA NOS
temperature: 98.0
heartrate: 82.0
resprate: 20.0
o2sat: 90.0
sbp: 99.0
dbp: 54.0
level of pain: 0
level of acuity: 2.0 | Patient is a ___ year old male with a history of coronary artery
disease with a CABG in ___, congestive heart failure with a
ejection fraction of 55%, atrial fibrillation (off coumadin for
___ yr), chronic kidney disease, and long-standing iron deficiency
anemia, gastritis and chronic gastrointestinal bleed who
presented with weakness, shortness of breath, 25 pound weight
gain, diarrhea with guaic positive stools found to have
hemaglobin 6.
# Acute on chronic anemia: Multifactorial from acute blood loss
and iron deficiency. He also has chronic iron deficiency anemia
and receives iron infusions. He received 2 units of blood along
with lasix. Gastroenterolgy perfromed a endoscopy and found
gastroanteral vascular ectasia (GAVE) which was treated with
thermal cauterization. He will need a repeat endoscopy in ___
weeks. His hematocrit remained stabe as did his vital signs. He
was treated with pantoprazole.
# Acute on chronic diastolic congestive heart failure
exacerbation: Findings of pulmonary edema on chest xray. Patient
was treated with lasix diueresis. On admission he was 25 pounds
up in weight. His weight trended down ward through his admission
with diuresis.
# Atrial fibrillation: Rate controlled with metoprolol. Was on
coumadin in the past (~ ___ year ag) but this has been
discontinued given gastric bleeding. He was continued on 81mg
asprin.
# Coronary artery diseas: Chronic stable issue. He was continued
on asprin, metoprolol, simvastatin.
# Diabetes ___ 2: stable chronic issue. He was placed on a
insulin sliding scale while inpatient.
# Chronic pain: Chronic stable issue. We continued his home
oxycodone.
# Gout: Chronic stable issue. We continued his home allopurinol.
# Neuropathy: Chronic stable issue. We continued his home
gabapentin. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ Y M with a history of CLL/SLL s/p C1D3 Bendamustine and
Rituxan on ___ presents to the ER with abdominal pain.
He first experienced abdominal pain 2 days prior to admission;
he describes it as constant, ___ in intensity, unchanged by
position and associated with nausea and mild anorexia. He
presented to ___ clinic today where abdominal exam warranted CT
which showed diverticulitis with microperforation. He received
1 unit PRBCs, platelets, and Cefepime before being transferred
to the ER. Vitals in the ER: 100.4 74 122/66 16 98% RA. Pt
received Dilaudid 1mg IV x2 and 1.5L IVF. On arrival to the
floor, he states that he is able to pass gas and has normal
bowel movements. His pain improved with the IV dilaudid.
REVIEW OF SYSTEMS:
(+) Per HPI; 12 lb weight loss over 1 week; fatigue and anorexia
after starting chemotherapy.
(-) Denies fever, Denies headache, cough, shortness of breath,
or wheezing. Denies chest pain, chest pressure, palpitations,
vomiting, diarrhea, constipation. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes. All other ROS negative
Past Medical History:
PAST ONCOLOGIC HISTORY:
Chronic Lymphocytic Leukemia dx ___
PAST MEDICAL HISTORY:
Chronic Lymphocytic Leukemia dx ___
Hypertension
Hyperlipidemia
Angina / New CAD: Per D/C summary ___: "His exertional chest
discomfort is likely due to his anemia. Stress test ___
showed marked ischemic
EKG changes in the presence of anginal type symptoms at a high
cardiac demand and average functional capacity. ECG changes
___ with 2D echocardiographic evidence of inducible ischemia
at achieved workload in the territory of the left anterior
descending artery. Echo ___ showed EF 50% to 55% and mild
MR."
Social History:
___
Family History:
--Mother ___ ___ MYOCARDIAL INFARCTION
--Father ___ ___ MYOCARDIAL INFARCTION ___ MIs in his early
___, prompted early retirement; died of glioblastoma
--Brother ___ ___ MYOCARDIAL INFARCTION Thought likely to
be MI; but very precipitous
Physical Exam:
Vitals: T 98.8 bp 114/74 HR 71 RR 18 SaO2 95 RA Wt 185.4
lbs
GEN: NAD, awake, alert
HEENT: supple neck, dry mucous membranes, no oropharyngeal
lesions
PULM: normal effort, CTAB
CV: RRR, no r/m/g/heaves
ABD: soft, tender in the LLQ with rebound tenderness but no
guarding ND, bowel sounds present
EXT: normal perfusion
SKIN: warm, dry
NEURO: AOx3, no focal sensory or motor deficits
PSYCH: calm, cooperative
VSS
Abdominal exam was greatly improved, without any pain,
tenderness. + BS. soft and nondistended
OTher aspecs of exam were unchanged
Pertinent Results:
___ 08:05PM LACTATE-0.4*
___ 07:10PM LACTATE-0.6
___ 07:10PM HGB-8.4* calcHCT-25
___ 07:00PM GLUCOSE-109* UREA N-23* CREAT-1.0 SODIUM-135
POTASSIUM-3.8 CHLORIDE-97 TOTAL CO2-26 ANION GAP-16
___ 07:00PM ALT(SGPT)-58* AST(SGOT)-30 ALK PHOS-68 TOT
BILI-2.1*
___ 07:00PM LIPASE-69*
___ 04:55PM PLT COUNT-29*#
___ 07:30AM WBC-9.1 RBC-2.92* HGB-8.8* HCT-23.8* MCV-82
MCH-30.0 MCHC-36.8* RDW-12.8
___ 07:30AM NEUTS-20* BANDS-1 LYMPHS-78* MONOS-0 EOS-1
BASOS-0 ___ MYELOS-0
___ 07:30AM PLT SMR-RARE PLT COUNT-18*
___ 09:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 09:50AM URINE RBC-0 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 08:10AM estGFR-Using this
___ 08:10AM ALT(SGPT)-36 AST(SGOT)-11 LD(LDH)-204 ALK
PHOS-65 TOT BILI-1.1
___ 08:10AM WBC-13.3*# RBC-3.19* HGB-9.6* HCT-26.5*
MCV-83 MCH-30.1 MCHC-36.3* RDW-13.2
___ 08:10AM NEUTS-12* BANDS-0 LYMPHS-87* MONOS-1* EOS-0
BASOS-0 ___ MYELOS-0
___ 08:10AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-OCCASIONAL POLYCHROM-NORMAL OVALOCYT-1+
TEARDROP-OCCASIONAL
___ 08:10AM PLT SMR-VERY LOW PLT COUNT-27*
.
___
3:21p CT Abd & Pelvis With Contrast -- Preliminary Result
1. Acute sigmoid diverticulitis with focal microperforation and
air with pericolonic stranding (2: 70) but no focal fluid
collection or evidence of abscess. 2. Prominent loops of small
bowel containing enteric contrast which are not pathologically
dilated to the level of the ileocecal valve without transition
point to suggest obstruction. 3. Extensive bulky lymphadenopathy
throughout the abdomen and pelvis with marked splenomegaly
measuring 17 cm
compatible with patient's known lymphoma. 4. Enlarged prostate
with
hypodensity in the hypertrophied median lobe and bulky seminal
vesicles may represent local inflammatory changes. Correlate
with clinical exam to exclude prostatitis. Wetread called to Dr.
___ at 17:00 on ___ who plans to admit patient currently
receiving blood transfusion in heme/onc.
DISCHARGE LABS:
------------------
___ 08:00AM BLOOD WBC-3.7* RBC-3.49* Hgb-10.3* Hct-29.0*
MCV-83 MCH-29.6 MCHC-35.6* RDW-13.7 Plt Ct-40*
___ 08:00AM BLOOD Neuts-44.8* Lymphs-51.6* Monos-2.8
Eos-0.6 Baso-0.1
___ 08:00AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 08:00AM BLOOD Plt Smr-VERY LOW Plt Ct-40*
___ 08:00AM BLOOD Glucose-118* UreaN-14 Creat-0.8 Na-140
K-3.8 Cl-103 HCO3-26 AnGap-15
___ 08:00AM BLOOD ALT-38 AST-23 LD(LDH)-213 AlkPhos-97
TotBili-1.3
___ 08:00AM BLOOD Calcium-9.1 Phos-3.3 Mg-2.0
___ 05:50AM BLOOD IgM-58
___ 06:30AM BLOOD IgG-215* IgA-26*
Micro:
------------
BCx negative
UCx negative
C diff negative
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 10 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Hydrochlorothiazide 25 mg PO DAILY
4. Triamterene 37.5 mg PO DAILY
5. Loratadine *NF* 10 mg Oral daily
6. Multivitamins 1 TAB PO DAILY
7. Allopurinol ___ mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Atorvastatin 10 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Multivitamins 1 TAB PO DAILY
5. Hydrochlorothiazide 25 mg PO DAILY
6. Loratadine *NF* 10 mg Oral daily
7. Triamterene 37.5 mg PO DAILY
8. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp
#*20 Tablet Refills:*0
9. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every 8 hours Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Diverticulitis
CLL
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ year old man with SLL and new LLQ pain REASON FOR THIS
EXAMINATION: Patient with known bulky small cell lymphoma s/p chemo now with
significant LLQ pain r/o tics obstruction
COMPARISON: CT torso ___
TECHNIQUE: Standard departmental protocol CT of the abdomen pelvis was
performed with intravenous contrast administration. Coronal sagittal
reformats were obtained. Total exam DLP 1036 mGy-cm.
FINDINGS:
Abdomen: minimal dependent subsegmental atelectasis left lung base. Again
visualized is splenomegaly measuring 17.3 cm in length, consistent with
patient's known lymphoma, slightly decreased in size since prior.
Normal-appearing pancreas, bilateral adrenal glands and left kidney. Simple
appearing right renal cortical cyst appears unchanged. Normal-appearing
gallbladder. Normal caliber abdominal aorta. Again noted is significant
bulky periportal, mesenteric, and retroperitoneal lymphadenopathy, including
an enlarged prehepatic lymph node and low axillary nodes, overall these lymph
nodes appear decreased in size compared to the prior exam, consistent with
treatment response. For example, the largest node is a periportal lymph node
measuring 2.7 cm in short axis, previously 3.5 cm. Normal-appearing small
bowel. No evidence of ascites or intraperitoneal free air.
Pelvis: Normal-appearing urinary bladder. Enlarged heterogeneous prostate
containing coarse calcifications. Normal-appearing seminal vesicles. No
evidence of pelvic free fluid. Interval decrease in size of bilateral
inguinal and pelvic sidewall lymphadenopathy. Sigmoid diverticulosis. A new
short segment circumferential thickening of the mid sigmoid colonic bowel wall
is seen, with significant surrounding inflammatory stranding, and a few foci
of air just outside the medial wall which likely represents micro perforation
associated with acute sigmoid diverticulitis. No evidence of significant
fluid collection or abscess. Visualized osseous structures unremarkable.
IMPRESSION:
1. Acute sigmoid diverticulitis with focal medial wall microperforation. No
evidence of fluid collection or abscess.
2. Interval decrease in splenomegaly and bulky lymphadenopathy throughout the
abdomen and pelvis, consistent with treatment response of patient's known
lymphoma.
3. Other chronic findings as above.
Radiology Report
HISTORY: ___ man with CLL presenting with microperforated
diverticulitis, low hematocrit not increased after 2 units of PRBCs. Study
requested for evaluation of bleeding in the abdomen.
COMPARISON: Prior abdominal/pelvic CT from ___.
TECHNIQUE: 64 row MDCT images were obtained through the abdomen and pelvis
without oral or IV contrast, as per clinical team's request. Coronal and
sagittal reformats were performed.
Total exam DLP: 965.75 mGy-cm.
FINDINGS:
Lung bases are clear. Visualized portions of the heart and pericardium are
unremarkable.
CT OF THE ABDOMEN: Examination of solid viscera is limited by lack of IV
contrast. The liver does not demonstrate focal lesions or intrahepatic
biliary duct dilatation. There is redemonstration of splenomegaly measuring
17.7 cm in length, consistent with patient's known lymphoma. The gallbladder,
pancreas, and adrenal glands are unremarkable. There is a 4.2 x 3.7 cm
hypodense lesion in the lower pole of the right kidney, likely a cyst.
Otherwise, kidneys do not demonstrate hydronephrosis or mass.
The stomach, duodenum and small bowel are grossly unremarkable. Residual
contrast is seen within large bowel. There is ongoing sigmoid diverticulitis
with a segment of circumferential thickening in the mid sigmoid colonic bowel
and surrounding inflammatory stranding. This has not progressed. There is no
evidence of fluid collections or abscess formation. No hematoma or sentinel
clot is identified. Given lack of IV contrast, active extravasation however
can not be ruled out, although there is no imaging finidngs to suggest it.
Again noted is significant bulky periportal, mesenteric and retroperitoneal
lymphadenopathy, not significantly changed from prior examination. The
intra-abdominal aorta and its branches demonstrate atherosclerotic
calcifications. No ascites, free air or abdominal wall hernias are noted.
CT OF THE PELVIS: The bladder demonstrates increased attenuation presumably
from retained contrast from prior examination, however clinical correlation is
recommended. No vesicoenteric fistula is seen. There is an enlarged
heterogeneous prostate with coarse calcifications. There is no pelvic free
fluid. Bilateral inguinal and pelvic lymphadenopathy is again noted.
OSSESOUS STRUCTURES: No blastic or lytic lesions suspicious for malignancy is
present.
IMPRESSION:
1. No evidence of hematoma or sentinel clot in this limited study. Active
extravasation can not be ruled out, although there are no imaging findings to
suggest it.
2. Ongoing sigmoid diverticulitis with no evidence of fluid collection or
abscess formation.
3. Stable splenomegaly and lymphadenopathy.
4. Increased attenuation within the bladder, presumably from retained
contrast from prior examination, however clinical correlation is recommended.
These findings were discussed with ___ by Dr. ___
telephone on ___ at 2:55 ___ time of discovery.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: DIVERTICULAR PERFORATION
Diagnosed with DIVERTICULITIS OF COLON
temperature: 100.4
heartrate: 74.0
resprate: 16.0
o2sat: 98.0
sbp: 122.0
dbp: 66.0
level of pain: 2
level of acuity: 2.0 | #Diverticulitis with microperforation but no radiographic
abscess: Pt was managed conservatively, NPO with cefepeim/flagyl
and IVF until pain resolved. When pt was pain free, pts diet was
advanced successfully.
.
#CLL/SLL: Pt is s/p C1D3 Bendamustine Rituxan ___ Dr.
___ is his outpatient oncologist. He did not receive chemo
during this hospitalization.
.
#Pancytopenia secondary to chemotherapy: Pt was transfused plts
and RBCs on admission. Neupogen was started on admission as when
bc of neutropenia. Pt was also given IVIG once stabilized for
hypogammaglobulinemia.
#CAD - Pt was not aspirin given thrombocytopenia; cont statin.
.
#? prostatitis on CT - UA was negative.
#HTN - Initially held antihypertensives with concern for
hypotension given perforation, but they were resumed on
discharge.
.
#Hyperlipidemia - Cont statin
.
TRANSITION ISSUES
# ongoing plan for chemotherapy |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Haldol / lorazepam
Attending: ___.
Chief Complaint:
Fall, gluteal hematoma
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ year-old gentleman with history of Alzheimer's
dementia as well as mitral mechanical valve for which he is on
coumadin, transferred from nursing home facility after being
found down earlier today. Unknown mechanism of fall, head strike
or loss of consciousness. Of note, patient was seen on ___nd increased confusion. He was discharged from
the ED after being found to have no injuries. Since then, he has
reportedly been more confused. Surgical team was consulted on
this occasion for trauma evaluation. At the time of this
examination, patient denied any discomfort.
Past Medical History:
Alzheimer's dementia
mitral mechanical valve on warfarin
seizure disorder
hypertension
hyperlipidemia
patent foramen ovale
benign colon neoplasm
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vital signs - 97.4 73 87/58 17 96% RA
Constitutional - Well appearing, in no acute distress
Cardiopulmonary - Well-healed midline thoracotomy. RRR,
prosthetic heart sounds. No murmurs, rubs or gallops. Lungs
clear
to auscultation bilaterally
Abdominal - Soft, non-tender, non-distended
Extremities - Warm and well-perfused. Right gluteal swelling and
tenderness. Distal pulses intact
Neurologic - Awake and alert, not oriented. No motor or sensory
deficits. Follows commands
DISCHARGE EXAM:
97.9 135/76 72 20 99RA
GEN: awake, sitting up in chair, AAOx1, pleasant
HEENT: NCAT. PERRL. MMM.
CARD: RRR, nml S1 and mechanical S2, no appreciable murmur
LUNGS: CTAB
ABD: Soft, nontender, nondistended.
EXT: No ___ edema; stable R gluteal hematoma with echymoses over
R hip and flank
GU: No Foley, has diaper
NEURO: Moving all extremities
Pertinent Results:
ADMISSION LABS
==============
13.3 145 | 108 | 19 |-8.4
6.7 >----< 114 -----------------< 101 |-2.2
40.7 4.2 | 29 | 1.3 |-3.1
___: 53.9 PTT: 50.5 INR: 4.8 Lactate: 1.8
Urinalysis: Negative
DISCHARGE LABS
==============
___ 05:47AM BLOOD Calcium-8.5 Phos-3.0 Mg-1.9
___ 05:47AM BLOOD Glucose-95 UreaN-16 Creat-0.9 Na-143
K-4.1 Cl-106 HCO3-28 AnGap-13
___ 06:04AM BLOOD ___ PTT-41.5* ___
___ 05:47AM BLOOD WBC-6.5 RBC-3.55* Hgb-10.9* Hct-34.8*
MCV-98 MCH-30.7 MCHC-31.2 RDW-18.5* Plt ___
STUDIES:
===============
EKG ___:
Atrial paced rhythm is suggested. Left bundle-branch block.
Occasional
ventricular premature beats. Compared to the previous tracing of
___
ventricular ectopy is seen.
CT head ___:
1. No evidence for acute intracranial abnormalities.
2. Mild soft tissue swelling in the left frontal scalp. No
evidence for a
fracture.
3. Mucosal thickening in the maxillary and sphenoid sinuses with
osseous
remodeling suggesting sequela of chronic sinusitis. In addition
to mucosal thickening, there may be fluid in the anterior
ethmoid air cells. Please correlate clinically whether the
patient has symptoms of acute sinusitis.
CT cervical spine ___:
Demineralized bones without evidence for an acute displaced
fracture. No acute subluxation.
CXR PA & Lat ___:
Dual lead left-sided pacer device is stable in position. The
cardiac and mediastinal silhouettes are stable. Low lung volumes
persist. Bibasilar atelectasis again seen. Slight blunting of
the costophrenic angles may be due to low lung volumes, however
trace pleural effusion not excluded. No pulmonary edema or
pneumothorax. The patient is status post median sternotomy.
Pelvic xray ___:
No fracture identified. Posttraumatic change at the right
acetabulum at the insertion of the rectus femoris muscle.
CT chest/abd/pelvis ___:
1. There is a large hematoma within the right gluteal muscles.
There is linear high density material seen adjacent to the right
ischium (2:123), which can be traced back to the right inferior
gluteal artery, and may represent a focus of active
extravasation.
2. Large anteriorly located region of ossification in continuity
with the right acetabulum may be related to prior trauma, or may
be degenerative in nature. There is no fracture identified.
3. Diverticulosis without diverticulitis.
CXR ___:
In comparison with the study of ___, there are again low
lung volumes. Cardiomediastinal silhouette is stable, as is the
dual-channel pacer device. Mild atelectatic changes are seen at
both bases without evidence of acute focal pneumonia. Blunting
of the costophrenic angles is again seen.
R knee xray ___:
No evidence of fracture. Mild tricompartmental degenerative
changes. Soft tissue swelling inferior to the patella.
CT head w/o contrast ___:
No acute intracranial abnormalities are identified. No change
from previous study.
MICROBIOLOGY:
============================
Blood cx ___ and ___ negative
Urine cx ___ and ___ negative
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Propranolol 10 mg PO BID
2. Warfarin 5 mg PO 5X/WEEK (___)
3. Warfarin 6 mg PO 2X/WEEK (MO,FR)
4. Simvastatin 80 mg PO QPM
5. TraZODone 50 mg PO QHS
6. Docusate Sodium 100 mg PO BID
7. Milk of Magnesia 30 mL PO DAILY:PRN constipation
8. QUEtiapine Fumarate 25 mg PO Q4H:PRN agitation
9. TraZODone 25 mg PO QHS:PRN insomnia
10. Aspirin 81 mg PO DAILY
11. Lorazepam 0.5 mg PO BID
12. Cyanocobalamin 1000 mcg PO DAILY
13. BuPROPion (Sustained Release) 100 mg PO QAM
14. FoLIC Acid 1 mg PO DAILY
15. Multivitamins 1 TAB PO DAILY
16. QUEtiapine Fumarate 50 mg PO BID
17. QUEtiapine Fumarate 75 mg PO QHS
18. Divalproex Sod. Sprinkles 250 mg PO BID
19. LaMOTrigine 100 mg PO BID
20. Memantine 10 mg PO BID
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. FoLIC Acid 1 mg PO DAILY
3. Warfarin 3 mg PO DAILY16
4. Aspirin 81 mg PO DAILY
5. Cyanocobalamin 1000 mcg PO DAILY
6. Milk of Magnesia 30 mL PO DAILY:PRN constipation
7. Multivitamins 1 TAB PO DAILY
8. Senna 8.6 mg PO BID
9. Polyethylene Glycol 17 g PO DAILY
10. OLANZapine (Disintegrating Tablet) 2.5 mg PO BID:PRN
agitation
11. OLANZapine (Disintegrating Tablet) 5 mg PO QHS agitation
12. Metoprolol Succinate XL 25 mg PO DAILY
13. Enoxaparin Sodium 80 mg SC BID
Start: Today - ___, First Dose: Next Routine Administration
Time
14. Atorvastatin 40 mg PO QPM
15. Acetaminophen 650 mg PO Q6H:PRN fever, pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
- Unwitnessed fall
- Right gluteal hematoma
- Toxic/metabolic encephalopathy
- Urinary tract infection
Secondary:
- Dementia
- Mechanical heart valve
- Dual chamber PPM
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ s/p unwitnessed fall // s/p fall with hip pain ?
pelvic bleed
TECHNIQUE: TECHNIQUE: MDCT images were obtained from the thoracic inlet to
the pubic symphysis. IV Omnipaque contrast was administered. Oral contrast
was not administered. Axial images were interpreted in conjunction with
sagittal and coronal reformats.
DLP: 800.98 mGy-cm
COMPARISON: Radiographs of the pelvis dated ___.
FINDINGS:
CHEST:
The thyroid is normal. Axillary, supraclavicular, mediastinal, and hilar
lymph nodes are not pathologically enlarged. The great vessels are
unremarkable. The heart and mediastinum are normal. The pericardium is intact
without effusion. Note is made of partial calcification of the pericardium. A
pacemaker device is present.
The airways are patent to the subsegmental levels. There is mild bibasilar
atelectasis. Streaky bibasilar opacities are consistent with aspiration. The
pleura is intact without effusion. No pneumothorax or pneumomediastinum.
The esophagus is unremarkable.
ABDOMEN:
The liver is normal without focal or diffuse abnormality. The gallbladder,
intra- and extra-hepatic bile ducts, pancreas, and bilateral adrenal glands
are normal.
A rounded focus of high-density material is seen within the spleen (2:49,
601b:65), measuring 0.8 x 0.7 x 0.6 cm. This may represent a hemangioma or
less likely a pseudo-aneurysm. The remainder of the spleen is unremarkable,
suggesting that this finding is unrelated to trauma.
The kidneys enhance symmetrically and excrete contrast promptly. The ureters
are normal in course and caliber.
The stomach is normal. The small and large bowel enhance homogeneously and
have a normal course and caliber. There is diverticulosis without
diverticulitis. The appendix is well seen and normal appearing.
No retroperitoneal or mesenteric lymphadenopathy. The portal and
intra-abdominal systemic vasculature are normal. No abdominal wall hernia,
pneumoperitoneum, or free abdominal fluid.
PELVIS:
The bladder and terminal ureters are normal. The prostate gland is
unremarkable. No pelvic side-wall or inguinal lymphadenopathy. No free pelvic
fluid or inguinal hernia.
There is a large hematoma within the right gluteal muscles. There is linear
high density material seen adjacent to the right ischium (2:123), which can be
traced back to the inferior gluteal artery, and likely represents a compressed
vessel adjacent to the hematoma, rather than active extravasation.
OSSEOUS STRUCTURES: Large anteriorly located region of ossification in
continuity with the right acetabulum may be related to prior trauma, or may be
degenerative in nature. There is no fracture identified. No focal lytic or
sclerotic lesion concerning for malignancy.
IMPRESSION:
1. There is a large hematoma within the right gluteal muscles. There is
linear high density material seen adjacent to the right ischium (2:123), which
can be traced back to the right inferior gluteal artery, likely represents a
compressed vessel adjacent to the hematoma rather than active extravasation.
2. Large anteriorly located region of ossification in continuity with the
right acetabulum may be related to prior trauma, or may be degenerative in
nature. There is no fracture identified.
3. Diverticulosis without diverticulitis.
4. Streaky bibasilar opacities are consistent with aspiration.
5. A rounded focus of high-density material is seen within the spleen,
measuring 0.8 x 0.7 x 0.6 cm. This may represent a hemangioma or less likely
a pseudo-aneurysm. The remainder of the spleen is unremarkable, suggesting
that this finding is unrelated to trauma. Recommend followup ultrasound of
the spleen for additional evaluation.
NOTIFICATION: Impression point 1 was discussed with Dr. ___ by Dr. ___
___ telephone at 4:50am on ___, approximately 2 hours after discovery.
Impression point 5 was discussed with Dr. ___ by Dr. ___ telephone at
9:22am on ___, approximately 5 minutes after discovery.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with Alzheimer's and acute delirium, with
leukocytosis yesterday and fever. // ?PNA ?PNA
IMPRESSION:
In comparison with the study of ___, there are again low lung volumes.
Cardiomediastinal silhouette is stable, as is the dual-channel pacer device.
Mild atelectatic changes are seen at both bases without evidence of acute
focal pneumonia. Blunting of the costophrenic angles is again seen.
Radiology Report
EXAMINATION: KNEE (2 VIEWS) RIGHT
INDICATION: ___ year old man with Alzheimer's/dementia, presenting s/p fall
with R gluteal hematoma and severe delirium, noted to have R knee effusion.
// ?R knee effusion ?R knee effusion
TECHNIQUE: Two views of the knee
COMPARISON: None.
FINDINGS:
There is no evidence of fracture, dislocation, osteoblastic or osteolytic
osseous lesions. There are mild tricompartmental degenerative changes with
small osteophytes and decrease in the joint space. There is soft tissue
swelling inferior to the patella. No large joint effusion is identified
IMPRESSION:
No evidence of fracture
Mild tricompartmental degenerative changes
Soft tissue swelling inferior to the patella.
Radiology Report
EXAMINATION: CT HEAD WITHOUT CONTRAST
INDICATION: ___ year old man with fall // please eval for hemorrhage
TECHNIQUE: Axial images of the head were obtained without contrast with
sagittal and coronal reformats.
DOSE: DLP:1345 MGy-cm
CTDI: 59 mGy
COMPARISON: ___.
FINDINGS:
There is no evidence of acute hemorrhage mass effect midline shift or
hydrocephalus. Gray-white matter differentiation is maintained.
There is no change from prior study. Previously seen chronic changes are
again identified.
IMPRESSION:
No acute intracranial abnormalities are identified. No change from previous
study.
Radiology Report
EXAMINATION: SPLEEN ULTRASOUND
INDICATION: ___ year old man with a rounded focus of high-density material
seen within the spleen on CT scan earlier this month // Please evaluate
lesion--hemangioma vs pseudo-aneurysm?
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Chest CTA ___
FINDINGS:
SPLEEN: Transverse and sagittal images were obtained of the spleen in the
right lateral decubitus position. The spleen is normal in size measuring 12.3
cm. There is no evidence of a pseudoaneurysm identified. No lesion is
visualized.
IMPRESSION:
1. No evidence of pseudoaneurysm in the spleen.
2. No lesion identified. The area of high density on prior CT is not
identified.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: s/p Fall
Diagnosed with BUTTOCK CONTUSION, UNSPECIFIED FALL, CARDIAC PACEMAKER STATUS, LONG TERM USE ANTIGOAGULANT, ABNORMAL COAGULATION PROFILE, SENILE DEGENERAT BRAIN, DEMENTIA IN CONDITIONS CLASSIFIED ELSEWHERE WITHOUT BEHAVIROAL DISTURBANCE
temperature: 98.0
heartrate: 63.0
resprate: 14.0
o2sat: 95.0
sbp: 122.0
dbp: 80.0
level of pain: 0
level of acuity: 3.0 | ___ with hx of Alzheimer's disease, aortic stenosis, mechanical
valve (reportedly mitral, but old records from ___ and clinical
exam suggest it is aortic) on warfarin and seizure disorder
presented with unwitnessed fall and R gluteal hematoma with
hosptial course complicated by UTI, aspiration, and delirium. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization (___)
History of Present Illness:
Ms. ___ is a ___ year old F with a sig PMHx of obesity s/p
laparscopic gastric bypass c/b bowel/badder injury ___ and B12
deficency, cholecystectomy c/b retained instrument & removal
___, h/o PID and chronic pain, who presents with worsening
chest
pain and dyspnea.
The patient was in her usual state of health until 3 days prior
to admission, when she experienced significant substernal chest
pain. She described the sensation as a heavy weight on her
chest.
Initially, the symptoms were non radiating, however the
following
day, she began experiencing radiation to her R arm. The episodes
would last approximately ___ hour. It was exertional in
nature
and relieved with rest. She also had associated lightheadedness
and dyspnea. At baseline, the patient can walk more than 1
flight
of stairs. Currently, she states she cannot take more than a few
steps without feeling dyspneic and with chest pain. She also
states she has been feeling mildly orthopneic, requiring 2
pillows to sleep at night.
The patient continued to monitor her symptoms until ___, when
she was at work, and a colleague noticed that she had increased
WOB. She was found to be tachycardic and was recommended to go
the ED. She called her PCP, who evaluated her. He was concerned
about ACS, and gave her aspirin 325mg, nitro X1, and checked an
EKG which showed T wave flattening in V3-V6 which was new
compared to baseline. She was transferred to ___ for further
work up.
Of note, the patient states that she has had epistaxis requiring
2 visits to an ENT for cauterization. Her last nose bleed was on
___. She also has lightheadedness. In the past, the patient
notes that she has had anemia which resulted in dyspnea but
never
chest pain.
Past Medical History:
OB: P1 ltcs twins
Gyn:
- STI: denies
- Abnl Pap: denies
___: recurrent ___ in ___, s/p ___ drainage
Medical Problems:
1. History of colitis, GI bleed, status post transfusion.
2. GERD.
3. Obesity, s/p LSC gastric bypass c/b bowel/bladder injury
(___) requiring reop. Current BMI 33.1
4. Vitamin B12 deficiency.
5. Abnormal uterine bleeding requiring recent transfusion.
6. Chronic endometritis, under current treatment.
7. h/o PID/bilateral hydrosalpinges (___) with ___ drainage.
Past Surgical History:
1. ___, cesarean delivery for twins.
2. ___, laparoscopic gastric bypass surgery at ___,
complicated by bowel and bladder injury.
3. ___, POD#1 reoperation via midline vertical laparotomy
for bowel and bladder injury.
4. ___, attempted LSC chole --> to xlap RUQ inc
cholecystectomy. surg c/b retained instrument.
5. ___, re-op (via same RUQ inc) for retained instrument.
6. ___, ___ drainage of bilateral ___. ___
Social History:
___
Family History:
FAMILY HISTORY:
5 sisters with chronic pain
Father: bladder cancer
Mother: lung cancer
Sister: breast cancer (___)
Sister: adrenal cancer
Physical Exam:
Admission:
VITALS: 98.5 137 / 82 97 18 95 RA
General: anxious appearing, sitting at the edge of the bed. nad.
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP 8cm at 45 deg, no LAD
CV: Regular rate and rhythm, +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, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Warm, chronic non pitting edema with dry scaling skin.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally.
Discharge:
___ 0425 Temp: 97.5 PO BP: 145/50 HR: 72 RR: 18 O2 sat: 99%
O2 delivery: Ra
GEN: Well appearing, in no acute distress. Overweight
HEENT: Conjunctiva clear, PERRL, MMM
NECK: No JVD. No cervical LA.
LUNGS: CTAB
HEART: RRR, nl S1, S2. No m/r/g.
ABD: NT/ND, normal bowel sounds.
EXTREMITIES: No edema or cyanosis.
SKIN: No rashes.
NEURO: AOx3.
Pertinent Results:
Admission Labs:
___ 02:20PM BLOOD WBC-5.7 RBC-4.16 Hgb-10.7* Hct-35.5
MCV-85 MCH-25.7* MCHC-30.1* RDW-13.3 RDWSD-42.1 Plt ___
___ 02:20PM BLOOD Glucose-91 UreaN-11 Creat-0.6 Na-140
K-4.2 Cl-104 HCO3-24 AnGap-12
___ 02:20PM BLOOD Calcium-9.5 Phos-3.5 Mg-2.1
Discharge Labs:
___ 06:18AM BLOOD WBC-6.3 RBC-4.06 Hgb-10.5* Hct-33.5*
MCV-83 MCH-25.9* MCHC-31.3* RDW-13.3 RDWSD-39.9 Plt ___
___ 06:18AM BLOOD Glucose-97 UreaN-11 Creat-0.5 Na-141
K-4.0 Cl-105 HCO3-24 AnGap-12
___ 05:00AM BLOOD VitB12-<150* Ferritn-8.9*
___ 09:45AM BLOOD %HbA1c-5.4 eAG-108
___ 06:18AM BLOOD Triglyc-119 HDL-32* CHOL/HD-4.3
LDLcalc-81
___ 05:00AM BLOOD TSH-0.86
Studies:
___ CXR
No acute cardiopulmonary process.
___ CT Head
The exam is limited secondary to patient motion. Within
limitation of the
study, there is no acute intracranial process.
___ ECHO
The left atrium is mildly dilated. The right atrium is mildly
enlarged. There is no evidence for an atrial septal
defect by 2D/color Doppler. The estimated right atrial pressure
is ___ mmHg. There is normal left ventricular
wall thickness with a normal cavity size. There is normal
regional and global left ventricular systolic function.
Quantitative biplane left ventricular ejection fraction is 65 %.
There is no resting left ventricular
outflow tract gradient. Tissue Doppler suggests a normal left
ventricular filling pressure (PCWP less than
12mmHg). 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 valve
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 a trivial
pericardial effusion.
IMPRESSION: Normal left ventricular wall thickness, cavity size,
and regional/global systolic
function. No valvular pathology or pathologic flow identified.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tizanidine 4 mg PO TID
2. TraZODone 150 mg PO QHS:PRN insomnia
3. Gabapentin 300 mg PO TID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. amLODIPine 2.5 mg PO DAILY
RX *amlodipine 2.5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Gabapentin 300 mg PO TID
4. Tizanidine 4 mg PO TID
RX *tizanidine 4 mg 1 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*0
5. TraZODone 150 mg PO QHS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Chest pain
Anemia
Iron deficiency
B 12 deficiency
Secondary:
S/p gastric bypass
Abnormal uterine bleeding
Chronic pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with CP and DOE// r/o acute process
TECHNIQUE: AP and lateral views the chest.
COMPARISON: Chest x-ray from ___.
FINDINGS:
The lungs are clear. There is no consolidation, effusion, or edema.
Cardiomediastinal silhouette is within normal limits. No acute osseous
abnormalities. Surgical clips noted in the right upper quadrant.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with altered mental status// rule out bleed
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, 16.8 cm; CTDIvol = 47.9 mGy (Head) DLP =
802.7 mGy-cm.
2) Sequenced Acquisition 3.0 s, 6.3 cm; CTDIvol = 47.9 mGy (Head) DLP =
301.0 mGy-cm.
Total DLP (Head) = 1,104 mGy-cm.
COMPARISON: Non-contrast CT head from outside facility dated ___.
FINDINGS:
Exam is limited secondary to patient motion. Within the limitation of the
study there is no evidence of acute large territory infarction, intracranial
hemorrhage,edema,or mass. The ventricles and sulci are normal in size and
configuration. A 4 mm posterior paramedian rounded extra-axial calcification
may represent a small calcified meningioma (02:24).
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:
The exam is limited secondary to patient motion. Within limitation of the
study, there is no acute intracranial process.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain, Dyspnea
Diagnosed with Chest pain, unspecified, Dyspnea, unspecified
temperature: 98.0
heartrate: 67.0
resprate: 20.0
o2sat: 100.0
sbp: 118.0
dbp: 60.0
level of pain: 10
level of acuity: 2.0 | Ms. ___ is a ___ year old F with PMH significant for obesity
s/p laparscopic gastric bypass (c/b bowel/badder injury, Fe
anemia, and B12 deficiency), cholecystectomy (c/b retained
instrument), chronic pain, who presents with acute onset chest
pain. She underwent coronary catheterization which was normal.
It is believed that her chest pain is musculoskeletal in nature. |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Protonix / Protopic /
Cephalexin
Attending: ___.
Chief Complaint:
Fall, failure to thrive, lower extremity swelling
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ with CAD, ___ edema, chronic bronchiectasis, untreated OSA
who
presented to ___ from PCP's office after fall at home.
On ___ patient fell out of her chair when she lost balance
while leaning to the left. She was able to fall on her back and
denies loss of consciousness or head strike. She denies any
pre-syncopal symptoms including dizziness, lightheadedness, or
confusion. She also describes worsening ___ edema over the last
weeks to month which has prohibited her mobility. She has not
been taking her prescribed Lasix over the last month, and was
taking it intermittently since her current dose was prescribed
___ as it causes her worsening urinary incontinence. She
had
difficulty getting back up because her legs were very swollen
and
required help from the staff at her senior living facility. She
refused to go to the ED after the event, and went to her PCP's
office instead. At the episodic visit, she was found to have ___
edema and was sent to ___ ED for further evaluation.
Throughout the course of these events she denies experiencing
SOB, N/V, abdominal pain, or new chest pains.
She was evaluated at ___ ED and found to have edematous ___ and
___ complaint of substernal chest pain. EKG was unchanged from
prior, troponins were elevated but within her baseline, and her
pain was similar to prior atypical chest pain worked up before
without concern for progressive ischemia. She had complaints of
L. knee pain and Xrays of the hip and knee were negative for
acute fracture. CT Head and Neck negative for intracranial
pathology or fractures. She was given 80 IV Lasix ON then an
additional 60 IV this AM. She has had a foley for monitoring as
she is fairly incontinent at baseline.
In the ED, initial vitals:
___ 15:55
Pain: 4, 96.8F, 80, 109/56, 16, 100% RA
- Exam notable for:
Normocephalic atraumatic
No midline cervical tenderness
Regular rate and rhythm clear to auscultation bilaterally
Soft nontender nondistended
Pelvis is stable moving all extremities with no gross
deformities
Ecchymosis over the lateral left knee
- Labs notable for:
___ 04:55PM BLOOD Hgb: 9.1*
___ 04:55PM BLOOD cTropnT: 0.05*
___ 10:43PM BLOOD cTropnT: 0.04*
___ 06:26AM BLOOD cTropnT: 0.05*
- Imaging notable for:
___ CT CHEST W/O CONTRAST
1. No acute traumatic injury identified within the chest. No
fracture.
2. Bronchiectasis within the right middle lobe and lingula along
with bronchiolitis in the right middle lobe and partial
atelectasis of the lingual suggest chronic ___ infection.
3. Trace left pleural effusion.
___ CT C-SPINE W/O CONTRAST
1. No acute fracture or malalignment.
2. Mild cervical spondylosis.
3. Several hypodense thyroid nodules measuring up to 10 mm.
No follow up recommended per ACR guidelines, please see
recommendations
section below.
___ CT HEAD W/O CONTRAST
No acute intracranial abnormality.
___ L. Hip XRAY
No acute fracture or dislocation of the left hip.
___ L. knee XRAY
Status post left knee arthroplasty with prosthesis in anatomic
alignment without evidence of hardware complication. No acute
fracture or dislocation.
Small suprapatellar joint effusion.
- Pt given:
___ 22:18 IV Furosemide 60 mg ___
___ 12:16 PO/NG Aspirin 325 mg ___
- Vitals prior to transfer:
___ 15:43
97.8F, 70, 118/54, 14, 97% RA
On the floor, patient verified the above history. Of note she
was often tangential in her history and would require
redirection
often to obtain pertinent details. In addition to the above,
she
notes that she had issues of L. sided vaginal bumps over the
last
week which have now improved/gone away since initiation of foley
catheterization. She was less mobile in this past week. She
confirmed that she has not had any symptoms of PND, orthopnea,
or
productive cough. Her chest pain is no different than normal,
and she no longer takes the imdur she was prescribed at her last
admission in ___.
Past Medical History:
-venous stasis from venous insufficiency; previously was on
furosemide but stopped ___ it being ineffective and it causing
polyuria
-kyphoscoliosis
-GERD
-atypical chest pain
-osteoporosis
-depression
-bronchiectasis
-LVH, mild pHTN
-heart murmur
-recent troponin elevation on previous admission
-questions of mild memory issues brought up when at recent rehab
Social History:
___
Family History:
Both parents died ___ years old from heart failure
Physical Exam:
ADMISSION EXAM:
==============
VITALS: 97.3F, 77, 114/61, 18, 99% on RA
GENERAL: AOx3, NAD, eating her dinner
HEENT: PERRLA, non-erythematous oropharynx.
NECK: No JVD, no cervical LAD.
CARDIAC: ___ SEM appreciated across precordium, regular rate and
rhythm.
LUNGS: Crackles ___ at bases.
BACK: No spinous process tenderness. no CVA tenderness.
EXTREMITIES: ___ 3+ non-pitting edema from thigh to foot. 1+ DP
pulses ___. Room temperature to the touch.
SKIN: Venous stasis ___, dry scaling on ___ ankle/shins, no
excoriations, purulence, or ulceration.
NEUROLOGIC: AAOx3, moving UE spontaneously, not following
commands consistently to evaluate ___ strength.
DISCHARGE EXAM:
==============
Temp: 97.5 (Tm 98.1), BP: 106/55 (96-111/41-63), HR: 82
(80-89), RR: 18, O2 sat: 96% (93-98), O2 delivery: Ra, Wt: 132.5
lb/60.1 kg
GENERAL: AOx3, NAD, upright in bed
HEENT: PERRLA, non-erythematous oropharynx.
CARDIAC: ___ SEM appreciated across precordium, regular rate and
rhythm.
LUNGS: CTAB
BACK: No spinous process tenderness. no CVA tenderness. 1+
sacral
edema.
GU: Deferred, would prefer female doctor
EXTREMITIES: Erythematous ___ 1 + pitting edema from thigh to
foot. 1+ DP pulses ___.
SKIN: Venous stasis ___, dry scaling on ___ ankle/shins with
erythema, no excoriations, purulence, or ulceration.
NEUROLOGIC: AAOx3, strength preserved in the ___ upper
extremities.
Pertinent Results:
ADMISSION LABS:
==============
___ 07:50PM GLUCOSE-125* UREA N-25* CREAT-0.8 SODIUM-141
POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-31 ANION GAP-9*
___ 07:50PM CALCIUM-8.8 PHOSPHATE-3.5 MAGNESIUM-1.7
___ 07:50PM WBC-6.4 RBC-2.83* HGB-8.3* HCT-26.9* MCV-95
MCH-29.3 MCHC-30.9* RDW-14.1 RDWSD-49.3*
___ 07:50PM PLT COUNT-137*
___ 02:00PM GLUCOSE-187* UREA N-23* CREAT-0.7 SODIUM-139
POTASSIUM-3.9 CHLORIDE-98 TOTAL CO2-27 ANION GAP-14
___ 02:00PM CALCIUM-8.8 PHOSPHATE-3.5 MAGNESIUM-1.8
___ 06:26AM cTropnT-0.05*
___ 10:43PM cTropnT-0.04*
___ 10:14PM URINE HOURS-RANDOM
___ 10:14PM URINE UHOLD-HOLD
___ 10:14PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 10:14PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.0
LEUK-NEG
___ 10:14PM URINE RBC-6* WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
___ 10:14PM URINE MUCOUS-RARE*
___ 05:13PM LACTATE-1.6 K+-3.8
___ 04:55PM GLUCOSE-140* UREA N-26* CREAT-0.8 SODIUM-139
POTASSIUM-5.7* CHLORIDE-103 TOTAL CO2-29 ANION GAP-7*
___ 04:55PM estGFR-Using this
___ 04:55PM cTropnT-0.05*
___ 04:55PM proBNP-223
___ 04:55PM CALCIUM-8.9 PHOSPHATE-3.4 MAGNESIUM-2.1
___ 04:55PM WBC-6.5 RBC-2.98* HGB-9.1* HCT-28.4* MCV-95
MCH-30.5 MCHC-32.0 RDW-14.2 RDWSD-48.6*
___ 04:55PM PLT COUNT-139*
DISCHARGE LABS:
==============
___ 05:00AM BLOOD WBC-9.1 RBC-2.94* Hgb-8.8* Hct-28.1*
MCV-96 MCH-29.9 MCHC-31.3* RDW-14.6 RDWSD-50.5* Plt ___
___ 05:00AM BLOOD Glucose-105* UreaN-31* Creat-0.8 Na-141
K-3.8 Cl-98 HCO3-32 AnGap-11
___ 05:00AM BLOOD Calcium-8.4 Phos-3.2 Mg-2.0
IMAGING:
=======
Hip X-ray ___
FINDINGS:
No evidence of acute fracture or dislocation is seen. The pubic
symphysis is intact. Degenerative changes are seen along the
partially imaged lower lumbar spine. There may be a
transitional vertebra at the lumbosacral junction. Vascular
calcifications are seen.
IMPRESSION:
No acute fracture or dislocation of the left hip.
Left knee X-ray ___
FINDINGS:
Patient is status post left knee arthroplasty with prosthesis in
anatomic alignment without evidence of hardware complication.
No acute fracture or dislocation is seen. There is a small
suprapatellar joint effusion. Vascular calcifications are seen.
IMPRESSION:
Status post left knee arthroplasty with prosthesis in anatomic
alignment without evidence of hardware complication. No acute
fracture or dislocation.
Small suprapatellar joint effusion.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Anti-Diarrhea (loperamide) 2 mg oral Q2H:PRN Diarrhea
2. Centrum Silver
(multivit-min-FA-lycopen-lutein;<br>mv-min-folic acid-lutein)
400-250 mcg oral DAILY
3. Aspirin 81 mg PO DAILY
4. Hydrocerin 1 Appl TP QHS
5. Lactaid (lactase) 9000 unit oral TID
6. Reclast (zoledronic acid-mannitol-water) 5 mg/100 mL
injection Yearly
7. Systane (PF) (peg 400-propylene glycol (PF)) 0.4-0.3 %
ophthalmic (eye) QAM
8. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral
DAILY
9. Atorvastatin 40 mg PO QPM
10. Famotidine 20 mg PO BID:PRN Heartburn
11. Furosemide 80 mg PO DAILY
Discharge Medications:
1. Acyclovir 400 mg PO Q8H
2. Bisacodyl 10 mg PO BID:PRN Contipation
3. Clindamycin 300 mg PO Q6H
4. Anti-Diarrhea (loperamide) 2 mg oral Q2H:PRN Diarrhea
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. Centrum Silver
(multivit-min-FA-lycopen-lutein;<br>mv-min-folic acid-lutein)
400-250 mcg oral DAILY
8. Famotidine 20 mg PO BID:PRN Heartburn
9. Furosemide 80 mg PO DAILY
10. Hydrocerin 1 Appl TP QHS
11. Lactaid (lactase) 9000 unit oral TID
12. Systane (PF) (peg 400-propylene glycol (PF)) 0.4-0.3 %
ophthalmic (eye) QAM
13. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral
DAILY
14. Zoledronic Acid (Reclast) (zoledronic acid-mannitol-water)
5 mg/100 mL injection YEARLY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
=======
Venous insufficiency
Lower extremity edema
Failure to thrive
Labial abscess
SECONDARY:
==========
Chronic bronchiectasis
Anemia
Osteoporosis
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
INDICATION: History: ___ with L knee pain s/p fall// please eval for knee
injury
TECHNIQUE: Three views of the left knee
COMPARISON: ___
FINDINGS:
Patient is status post left knee arthroplasty with prosthesis in anatomic
alignment without evidence of hardware complication. No acute fracture or
dislocation is seen. There is a small suprapatellar joint effusion. Vascular
calcifications are seen.
IMPRESSION:
Status post left knee arthroplasty with prosthesis in anatomic alignment
without evidence of hardware complication. No acute fracture or dislocation.
Small suprapatellar joint effusion.
Radiology Report
EXAMINATION: HIP UNILAT MIN 2 VIEWS LEFT
INDICATION: History: ___ with L hip pain s/p fall// please eval for hip
injury
TECHNIQUE: AP view of the pelvis and AP and lateral views of the left hip.
COMPARISON: None.
FINDINGS:
No evidence of acute fracture or dislocation is seen. The pubic symphysis is
intact. Degenerative changes are seen along the partially imaged lower lumbar
spine. There may be a transitional vertebra at the lumbosacral junction.
Vascular calcifications are seen.
IMPRESSION:
No acute fracture or dislocation of the left hip.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dizziness, L Chest pain, s/p Fall
Diagnosed with Heart failure, unspecified
temperature: 96.8
heartrate: 80.0
resprate: 16.0
o2sat: 100.0
sbp: 109.0
dbp: 56.0
level of pain: 4
level of acuity: 2.0 | PATIENT SUMMARY:
===============
___ with CAD, ___ edema, chronic bronchiectasis, untreated OSA
who presented to ___ from ___'s office after fall at home
found to have severe ___ edema and failure to thrive as well as
labial abscesses. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Keflex / aspirin / salicylates / methyl salicylate
Attending: ___
Chief Complaint:
Large parastomal hernia with colostomy.
Major Surgical or Invasive Procedure:
Single site laparoscopic takedown of colostomy,primary
colorectal anastomosis in an end-to-end fashion, repair of large
parastomal hernia with mesh.
History of Present Illness:
This is a ___ male patient with a metastatic melanoma
that underwent an end colostomy with a ___ procedure for
a colovesicular fistula when he was on immunotherapy. Now, the
patient is presenting with a large parastomal hernia that is
causing significant change in quality of life, skin breakdown
around the ostomy. The patient has undergone a pouchogram that
demonstrates that the rectum is intact. The patient is
proceeding with closure of his colostomy and repair of his
parastomal hernia.
Past Medical History:
PMH:
metastatic melanoma
prostate hyperplasiA
diverticulitis
HTN
PSH: ___ Wide excision of left upper arm melanoma with
complex
layered closure, Left axillary sentinel lymph node biopsy, Wide
excision of right chest basal cell carcinoma witH complex
layered closure
___: Completion axillary lymphadenectomy
___: Hand-assisted laparoscopic converted to open sigmoid
colectomy, end colostomy, mobilization of the splenic flexure,
drainage of intra-abdominal abscess, small bowel resection with
side-to-side enteroenteric anastomosis and takedown of
enterocolonic fistula
Bilateral Inguinal hernia repair
Social History:
___
Family History:
Father- colon cancer at age ___
Brother- lung cancer
Physical Exam:
On Discharge:
OBJECTIVE:
24 HR Data (last updated ___ @ 753)
Temperature: 98.6 (Maximum 98.7), Blood Pressure: 113/74
(94-125/59-76), Heart rate: 88 (71-88), Respiratory rate: 18,
Oxygen saturation: 92% (85%-90%-94), O2 delivery: RA, Weight:
202.2 lb/91.72 kg
Physical exam:
GEN: NAD
HEENT: NCAT, EOMI, anicteric
CV: RRR, No JVD
PULM: normal excursion, no respiratory distress
ABD: soft, NT, ND, no mass, no hernia, mild erythema surrounding
previous ostomy site, Incisions C/D/I
EXT: WWP, no CCE, 2+ B/L radial
NEURO: A&Ox3, no focal neurologic deficits
PSYCH: normal judgment/insight, normal memory, normal
mood/affect
Pertinent Results:
___ 07:25AM BLOOD WBC-6.9 RBC-3.39* Hgb-10.0* Hct-31.8*
MCV-94 MCH-29.5 MCHC-31.4* RDW-13.9 RDWSD-47.8* Plt ___
___ 09:42AM BLOOD WBC-7.7 RBC-3.28* Hgb-10.0* Hct-30.8*
MCV-94 MCH-30.5 MCHC-32.5 RDW-14.0 RDWSD-48.1* Plt ___
___ 06:11AM BLOOD WBC-6.0 RBC-3.36* Hgb-10.3* Hct-32.1*
MCV-96 MCH-30.7 MCHC-32.1 RDW-13.5 RDWSD-47.5* Plt ___
___ 06:17AM BLOOD WBC-5.9 RBC-3.56* Hgb-10.9* Hct-34.4*
MCV-97 MCH-30.6 MCHC-31.7* RDW-13.7 RDWSD-48.8* Plt ___
___ 07:25AM BLOOD Glucose-126* UreaN-12 Creat-0.9 Na-141
K-4.5 Cl-103 HCO3-29 AnGap-9*
___ 09:42AM BLOOD Glucose-88 UreaN-8 Creat-0.9 Na-138 K-4.7
Cl-99 HCO3-26 AnGap-13
___ 09:50PM BLOOD Glucose-91 UreaN-18 Creat-1.0 Na-142
K-4.2 Cl-105 HCO3-23 AnGap-14
___ 07:25AM BLOOD Calcium-8.9 Phos-4.3 Mg-2.0
___ 06:17AM BLOOD Calcium-9.1 Phos-5.1* Mg-1.7
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. benazepril 20 mg oral daily
3. Metoprolol Succinate XL 12.5 mg PO DAILY
4. Omeprazole 20 mg PO DAILY AS NEEDED heartburn
5. QUEtiapine Fumarate 100 mg PO QHS
6. Sertraline 50 mg PO DAILY
7. QUEtiapine Fumarate 50 mg PO BID
8. TraZODone 100 mg PO QHS:PRN sleep aid
9. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
Discharge Medications:
1. Acetaminophen 500 mg PO Q4H
RX *acetaminophen 500 mg 1 tablet(s) by mouth every four (4)
hours Disp #*30 Tablet Refills:*0
2. Amoxicillin-Clavulanic Acid ___ mg PO BID
RX *amoxicillin-pot clavulanate [Augmentin] 875 mg-125 mg 1
tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0
3. Nicotine Patch 21 mg/day TD DAILY smoking cessation
RX *nicotine [Nicoderm CQ] 21 mg/24 hour apply a patch daily
once a day Disp #*30 Patch Refills:*2
4. Nicotine Polacrilex 2 mg PO Q1H:PRN Nicotine craving
RX *nicotine (polacrilex) 2 mg Please chew 1 gum as needed Q1H
Disp #*100 Gum Refills:*0
5. Nitrofurantoin Monohyd (MacroBID) 100 mg PO BID UTI
RX *nitrofurantoin monohyd/m-cryst [Macrobid] 100 mg 1
capsule(s) by mouth twice a day Disp #*4 Capsule Refills:*0
6. TraMADol 50-100 mg PO Q4H:PRN Pain - Moderate
RX *tramadol 50 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
7. Gabapentin 600 mg PO QHS
RX *gabapentin 300 mg 2 capsule(s) by mouth as directed Disp
#*60 Capsule Refills:*3
8. Gabapentin 600 mg PO NOON
9. Gabapentin 600 mg PO QAM
10. amLODIPine 10 mg PO DAILY
11. benazepril 20 mg oral daily
12. Lidocaine 5% Patch 2 PTCH TD QAM
13. Metoprolol Succinate XL 12.5 mg PO DAILY
14. Omeprazole 20 mg PO DAILY AS NEEDED heartburn
15. QUEtiapine Fumarate 100 mg PO QHS
16. QUEtiapine Fumarate 50 mg PO BID
17. Sertraline 50 mg PO DAILY
18. Tamsulosin 0.4 mg PO QHS
19. TraZODone 100 mg PO QHS:PRN sleep aid
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Large parastomal hernia with colostomy.
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: +PO contrast; History: ___ with hx of colostomy, with abdominal
pain, hernia and wound redness. +PO contrast// Intra-abdominal abscess?
Anastomatic leak?
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 7.5 s, 0.5 cm; CTDIvol = 36.1 mGy (Body) DLP =
18.1 mGy-cm.
2) Spiral Acquisition 6.2 s, 48.6 cm; CTDIvol = 25.3 mGy (Body) DLP =
1,228.1 mGy-cm.
Total DLP (Body) = 1,246 mGy-cm.
COMPARISON: CT of the and pelvis from ___.
FINDINGS:
LOWER CHEST: 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 contains gallstones without
wall thickening or surrounding inflammation.
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 solid renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: Patient is status post Left lower quadrant diverting
colostomy and sigmoid resection. The stomach is unremarkable. Small bowel
loops demonstrate normal caliber, wall thickness, and enhancement throughout.
Oral contrast extends to the transverse colon. The appendix is normal.
There is no evidence of new Fluid collection or extraluminal extravasation of
oral contrast.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The visualized 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. Moderate atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Severe degenerative changes to left hip
SOFT TISSUES: An umbilical hernia containing fat is noted. Re-demonstrated is
a peristomal hernia measuring 14.0 cm at its largest transverse dimension with
a 4.5 cm neck. Mesh anchors are noted along the inferior abdominal wall.
Focus of hypodensity in the left lower quadrant wall is consistent with
postsurgical changes and is stable from prior.
IMPRESSION:
1. No evidence of acute abnormality in the abdomen is pelvis to explain the
patient's symptoms. No evidence of extraluminal oral contrast.
2. No evidence of new intra-abdominal Fluid collections.
3. Interval increase in size of fat containing parastomal hernia in the Left
lower quadrant
4. Cholelithiasis without evidence of cholecystitis.
Radiology Report
EXAMINATION: Fluoroscopic pouchogram
INDICATION: ___ with history metastatic melanoma s/p immunotherapy s/p lap
converted to open sigmoid colectomy, takedown of fistulas with creation of end
colostomy (___) for enterocolonic fistula presents with parastomal hernia//
would like to assess transit/leak to his ostomy before operative plan
TECHNIQUE: Fluoroscopy guided pouchogram as described below
DOSE: Acc air kerma: 62.95 mGy; Accum DAP: 747.61 uGym2; Fluoro time: 2
minutes, 7 seconds
COMPARISON: CT abdomen and pelvis performed ___
FINDINGS:
After scout images were obtained, a ___ Foley catheter was inserted into
the
rectum. 200 cc of water soluble contrast was gently instilled by gravity.
Contrast is seen filling the pouch with appropriate distention and no evidence
of leak.
IMPRESSION:
No extraluminal contrast to suggest a leak.
Radiology Report
INDICATION: ___ year old man with hx of COPD and long hx of smoking, s/p
colostomy reversal and parastomal hernia repair. Now POD3, desatted to 89% on
RA this morning, now 94% on 2L NC.// pneumonia? atelectasis? pulmonary edema?
COMPARISON: CT scan from ___
IMPRESSION:
Cardiomediastinal silhouette is within normal limits. There are patchy
opacities at the lung bases compatible with subsegmental atelectasis. There
are low lung volumes without overt pulmonary edema, pleural effusions, or
pneumothoraces. There are no pneumothoraces.
Radiology Report
EXAMINATION: CT ABD AND PELVIS W/O CONTRAST
INDICATION: colostomy reversal, parastomal hernia repair biologic mesh
overlay, now w/abdominal erythema// evaluate for intrabdominal process
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:
Total DLP (Body) = 1,185 mGy-cm.
COMPARISON: CT abdomen pelvis ___.
FINDINGS:
LOWER CHEST: There is a dense wedge-shaped correlation with air bronchograms
in the right lower lobe which may represent atelectasis or pneumonia in
appropriate clinical setting. 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. The gallbladder contains gallstones without wall thickening or
evidence of inflammation.
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: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size. There is no suspicious
renal lesions within the limitations of an unenhanced scan. There is no
hydronephrosis. There is no nephrolithiasis. There is no perinephric
abnormality.
GASTROINTESTINAL: The stomach is unremarkable.
There is an intact right lower quadrant anastomosis. Patient status post
colostomy takedown with a rectosigmoid anastomosis. However, there is small
amount of fluid intermixed with fat stranding superior to the anastomotic site
which is concerning for anastomotic leak (03:57, 05:35).
The remaining small bowel loops demonstrate normal caliber and wall thickness
throughout. The remaining colon and rectum are within normal limits. The
appendix is normal.
PELVIS: The urinary bladder is decompressed and therefore suboptimally
assessed. 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. Moderate atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: Patient status post left lower quadrant hernial repair with
overlying mesh and a subcutaneous drain in place. There are postsurgical
changes. There is thickening and edema of the underlying left rectus
abdominus musculature. No evidence of drainable fluid collections. There is
overlying subcutaneous edema. There are postsurgical changes in the anterior
pelvic wall/abdominal pannus from prior hernial repair.
IMPRESSION:
1. Fluid and fat stranding superior to the sigmoid-colonic anastomosis is
concerning for a small anastomotic leak.
2. Status post left lower quadrant ventral hernial repair with postsurgical
changes. Thickening of underlying edematous left rectus abdominus
musculature.
3. No evidence of drainable fluid collections.
4. Right lower lobe consolidation may represent atelectasis and/or pneumonia.
NOTIFICATION: The findings in the impression were discussed with ___,
M.D. by ___, M.D. on the telephone on ___ at 2:35 pm, 5
minutes after discovery of the findings.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Wound eval
Diagnosed with Parastomal hernia without obstruction or gangrene, Epigastric pain
temperature: 98.1
heartrate: 95.0
resprate: 16.0
o2sat: 96.0
sbp: 130.0
dbp: 84.0
level of pain: 7
level of acuity: 3.0 | Mr. ___ is a ___ yo male with hx of bipolar II disorder,
anxiety, ETOH use disorder living in sober house, metastatic
melanoma s/p immunotherapy with end colostomy (___) who
presented to ER with stomal pain and skin breakdown and
parastomal hernia. Patient was admitted to colorectal service
for further pain control and wound management. Subsequently
taken to operating room, s/p single site laparoscopic takedown
of colostomy reversal, parastomal hernia repair biologic mesh
overlay. He tolerated the procedure well without complications
and admitted for routine postoperative care.
Postoperatively,noted to have abdominal cellulitis and started
on empiric antibiotics. CT scan A/P showed inflammation, no
drainable fluid collections. Remainder of hospital course as
follows:
Neuro: Chronic pain service was consulted for medical management
of his chronic pains and recommended to continue current pain
regimen of tramadol, gabapentin. Patient seen by psychiatry and
home psych meds were continued.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulm: The patient remained stable from a pulmonary standpoint;
oxygen saturation was routinely monitored. He had good pulmonary
toileting, as early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI: The patient was advanced to and tolerated a regular diet.
Patient's intake and output were closely monitored.
GU: The patient voided spontaneously following surgery. Urine
output was monitored as indicated. Patient diuresed with Lasix
for fluid volume overload. Of note, preoperatively started on
macrobid for UTI.
ID: The patient was closely monitored for signs and symptoms of
infection and fever, of which there was none. ___, developed
abdominal cellulitis and started on antibiotics, (vancomycin x1
and changed to Augmentin).MRSA screen negative.
Heme: The patient received subcutaneous heparin and ___ dyne
boots during this stay. He was encouraged to get up and ambulate
as early as possible.
On ___, the patient was discharged to sober house. At
discharge, he was tolerating a regular diet, passing flatus,
voiding, and ambulating independently. He will follow-up in the
clinic in 2 weeks. This information was communicated to the
patient directly prior to discharge. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Motrin
Attending: ___.
Chief Complaint:
Celiac artery dissection, SMA pseudoaneurysm, as well as
bilateral external iliac dissection in setting of abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ PMHx for bilateral carotid/vertebral artery dissection,
negative genetic testing in ___ for who presents with ___ days
of abdominal pain.
On ___ night, the patient first noticed mild abdominal pain
in
her LLQ, but attributed it to simple gas pains of a stomach
ache.
Her symptoms worsened on the following day, and she noted
significant LLQ pain, with some radiation to her RLQ as well as
her back. She did not take anything for her pain, and while her
son urged her to go to the doctor, she thought that she did not
need to. She had no associated diarrhea, blood in her stool, or
vomiting, but did note some nausea on ___ and ___ which
she attributed to the pain. On ___, her eldest son visited
the
house and noticed how much discomfort she was in, she at that
point she presented to the ___ ED. Notably, the patient
reports feeling somewhat ill for the last 2 weeks, including
cough, sinus congestion, and general malaise. Otherwise, she
denies any other preceding symptoms.
Regarding her prior carotid and vertebral artery dissections, we
will need records from her outside workup, however per the
patient's history, in ___ she had ___ weeks of multiple
neurologic deficits including left hand weakness, and temporary
vision loss in her left eye. At this time, she presented to ___
where she was found to have bilateral carotid and vertebral
artery dissections. She was put on Aspirin and warfarin at that
time, and she followed up with a doctor at ___. After approximately one year, she was taken off of
coumadin. Her doctor at ___ referred her to ___
where
she had genetic testing which was reportedly negative for any
connective tissue disorder. She then had repeat testing at ___
in
___ which she also reports was negative.
In the ED, the patient had a CTA which demonstrated a celiac
artery dissection, SMA either pseudoaneurysm or ulcerating
plaque
with surrounding hematoma, as well as bilateral external iliac
artery and right common iliac artery dissections.
Past Medical History:
-Bilateral carotid/vertebral artery dissection ___ (Dr.
___ at ___, Dr. ___ at ___
-Anterior basement membrane dystrophy
-Liver hemangiomas
-Ovarian cyst
-Pituitary macroadenoma
-Shingles
-Venous stasis disease
Physical Exam:
Vitals: 24 HR Data
Temp: 92.9 (Tm 98.0), BP: 123/77 (111-142/62-87), HR: 61
(54-83), RR: 16 (___), O2 sat: 95% (95-100), O2 delivery: Ra
GENERAL: []NAD []A/O x 3 []intubated/sedated []abnormal
GENERAL: [X]NAD [X]A/O x 3 []intubated/sedated []abnormal
CV: HDS
PULM: []CTA b/l [X]no respiratory distress []abnormal
ABD: no epigastric or LUQ tenderness this morning; belly soft,
nondistended EXTREMITIES: [X]no CCE []abnormal
PULSES: R: P/P/P/P; L: P/P/P/P
Pertinent Results:
___ 05:21AM BLOOD WBC-9.9 RBC-4.45 Hgb-13.9 Hct-41.1 MCV-92
MCH-31.2 MCHC-33.8 RDW-12.7 RDWSD-43.1 Plt ___
___ 05:21AM BLOOD Glucose-96 UreaN-11 Creat-0.7 Na-142
K-4.2 Cl-106 HCO3-23 AnGap-13
___ 06:04PM BLOOD ALT-24 AST-22 AlkPhos-113* TotBili-0.3
___ 03:25AM BLOOD HDL-62 CHOL/HD-2.5
___ 01:00PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 01:00PM BLOOD ANCA-NEGATIVE B
___ 01:00PM BLOOD RheuFac-20* ___
___ 05:32AM BLOOD CRP-9.9*
___ 01:00PM BLOOD C3-82* C4-15
___ 01:00PM BLOOD HCV Ab-POS*
___ 01:20PM BLOOD HCV VL-5.6*
___ 07:22PM BLOOD Lactate-0.9
___ 10:32AM BLOOD CRYOGLOBULIN-PND
___ 01:00PM BLOOD SED RATE-Test
___ 01:00PM BLOOD QUANTIFERON-TB GOLD-Test
CTA ABD & PELVIS ___
IMPRESSION:
1. Focal triangular contrast outpouching arising from the
inferior aspect of
the superior mesenteric artery with surrounding hyperdense soft
tissue
stranding; findings most consistent with either a pseudoaneurysm
or ulcerating
plaque with surrounding hematoma.
2. Focal ectasia of the celiac trunk with a
fenestrated-appearing intimal flap
located just distally within the celiac trunk.
3. Small dissection flaps noted within the bilateral external
iliac arteries
and at the takeoff of the right common iliac artery.
4. No imaging findings to suggest bowel wall ischemia.
CTA ABD & PELVIS ___
IMPRESSION:
1. Slight decrease in caliber of the distal SMA and its
branches with several
new areas of moderate to severe stenosis in the distal SMA
branches. No
specific evidence of ischemic bowel.
2. Unchanged ectasia and intimal flap in the distal celiac
trunk.
3. Unchanged dissection flaps in the bilateral external iliac
arteries and
chronic calcified dissection flap in the right common iliac
artery.
4. Slight thickening of the left adrenal gland is nonspecific.
5. Extensive colonic diverticulosis without evidence of acute
diverticulitis.
CTA H&N ___
IMPRESSION:
1. No acute intracranial findings.
2. Findings consistent with left upper neck segment ICA
fibromuscular
dysplasia.
3. Short-segment dissection high right neck segment ICA, of
indeterminate age.
No significant vessel narrowing.
4. Moderate luminal narrowing left cavernous ICA. Otherwise,
normal
intracranial CTA.
5. Moderate left maxillary mucosal thickening
Radiology Report
EXAMINATION: DUPLEX DOPP ABD/PEL
INDICATION: mesenteric duplex
TECHNIQUE: Gray scale, color, and spectral Doppler evaluation of the abdomen
was performed.
COMPARISON: Abdomen pelvis CTA ___
FINDINGS:
The celiac artery is widely patent on color Doppler with wall-to-wall flow and
a normal arterial spectral Doppler waveform with a peak systolic velocity of
197 centimeters/second. The known dissection visualized on prior CTA is not
as well appreciated on this study. The major branches of the celiac artery,
including the splenic artery and common hepatic artery are widely patent with
wall-to-wall flow on color Doppler imaging and appropriate spectral Doppler
waveforms with velocities of 137 centimeters/second and 132 centimeters/second
respectively. Calcified atherosclerosis is identified within the splenic
artery.
The findings within the superior mesenteric artery are compatible with known
dissection. Two lumens are identified within the SMA extending from its
origin at the aorta extending to its distal branches where it can no longer be
identified by ultrasound. The anterior lumen is occluded and filled with
echogenic debris demonstrating no flow on color Doppler imaging. The
posterior lumen is widely patent on color Doppler imaging and remains patent
to its distal branches as far as can be seen with ultrasound showing normal
Doppler waveform and velocity of up to 225 centimeters/second.
The inferior mesenteric artery is visualized and is widely patent on color
Doppler imaging with an appropriate arterial waveform and peak systolic
velocity 134 centimeters/second.
The abdominal aorta is visualized and is widely patent on color and spectral
Doppler imaging with appropriate waveforms. Calcified and noncalcified plaque
is identified throughout the aorta. A small amount of soft plaque is
identified within the posterior wall of the mid aorta. Moderate calcified
plaque is identified within the distal aorta extending into the iliac
arteries.
An echogenic hepatic lesion is incidentally noted within the caudate lobe
measuring 1 cm and is likely compatible with a hemangioma.
IMPRESSION:
1. The celiac artery and its major branches are widely patent with appropriate
waveforms.
2. Sonographic findings within the superior mesenteric artery are compatible
with known dissection demonstrating multiple lumens with the anterior lumen
completely occluded and the posterior lumen widely patent.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: ___ female with history of bilateral carotid/vertebral
artery dissection now with abdominal pain with CTA demonstrating celiac
artery/SMA dissection, bilateral EIA dissection. Assessing for dissection,
aneurysms. Please extend imaging through the aortic arch.
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of intravenous contrast material. Three-dimensional angiographic
volume rendered, curved reformatted and segmented images were generated on a
dedicated workstation. This report is based on interpretation of all of these
images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.3 mGy-cm.
2) Spiral Acquisition 4.7 s, 37.1 cm; CTDIvol = 13.3 mGy (Body) DLP = 492.1
mGy-cm.
3) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 3.0 mGy (Body) DLP = 1.5
mGy-cm.
4) Stationary Acquisition 4.5 s, 0.5 cm; CTDIvol = 26.7 mGy (Body) DLP =
13.4 mGy-cm.
Total DLP (Body) = 507 mGy-cm.
Total DLP (Head) = 747 mGy-cm.
COMPARISON: None available.
FINDINGS:
Streak artifact from dental amalgam limits assessment.
CT HEAD WITHOUT CONTRAST:
No loss of gray-white matter differentiation to suggest acute infarction. No
evidence of intracranial hemorrhage. Ventricles and sulci are
age-appropriate. No mass effect or midline shift.
Calvarium is intact. Moderate mucosal thickening of the left maxillary sinus
with aerosolized secretions. Mild mucosal thickening of the ethmoid sinuses.
Mild opacification of the inferior right mastoid air cells. Unremarkable
intraorbital contents.
CTA HEAD:
Moderate narrowing proximal cavernous left ICA, no associated atherosclerotic
plaque.. Otherwise normal contrast opacification of the intracranial internal
carotid arteries. Adequate contrast opacification of the bilateral M1 and M2
segments. Slightly hypoplastic left A1 segment. Adequate opacification of
bilateral A2 segments.
Normal opacification of the bilateral vertebrobasilar system and both
posterior cerebral arteries. No occlusion or aneurysm formation.
The dural venous sinuses are patent.
CTA NECK:
Standard 3 vessel aortic arch anatomy.
Mild luminal narrowing and somewhat beaded appearance of the left internal
carotid artery, consistent with fibromuscular dysplasia (images 180-195 of
series 3).
Focal linear filling defect in the right internal carotid artery consistent
with dissection, age-indeterminate, but possibly chronic given clinical
history (images 186-187 of series 3).
No evidence of right internal carotid artery stenosis by NASCET criteria.
Vertebral arteries demonstrate normal opacification without evidence of focal
narrowing or dissection.
OTHER:
No suspicious pulmonary nodules. Mild bronchial wall thickening, likely
inflammatory. Few well-defined lucencies in the lungs, may represent
intrapulmonary cysts or emphysema.
Heterogeneous appearance of the thyroid gland, possibly due to underlying
nodules.
No lymphadenopathy by CT size criteria. No suspicious osteolytic or
osteoblastic lesions. Moderate mucosal thickening left maxillary sinus
IMPRESSION:
1. No acute intracranial findings.
2. Findings consistent with left upper neck segment ICA fibromuscular
dysplasia.
3. Short-segment dissection high right neck segment ICA, of indeterminate age.
No significant vessel narrowing.
4. Moderate luminal narrowing left cavernous ICA. Otherwise, normal
intracranial CTA.
5. Moderate left maxillary mucosal thickening
Radiology Report
INDICATION: ___ PMHx bilateral carotid/vertebral artery dissection now with
abdominal pain with CTA demonstrating celiac artery/SMA dissection, bilateral
EIA dissection. Now w/nausea and no BM for several days// Ileus vs SBO vs
fecal matter in loops
TECHNIQUE: Portable supine abdominal radiograph.
COMPARISON: CTA abdomen and pelvis ___.
IMPRESSION:
The stomach is mildly distended with air. There are no abnormally dilated
loops of large or small bowel. There is no free intraperitoneal air, although
evaluation is limited by supine technique. Contrast is seen within the
bilateral renal collecting systems and the bladder from recent prior CT. There
are no unexplained soft tissue calcifications or radiopaque foreign bodies.
Radiology Report
EXAMINATION: DUPLEX DOPP ABD/PEL
INDICATION: ___ PMHx bilateral carotid/vertebral artery dissection now with
abdominal pain with CTA demonstrating celiac artery/SMA dissection, bilateral
EIA dissection. Now with recurrent abdominal pain overnight.// Known
dissection of aorta/branches, abdominal pain, assessing stability
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Duplex Doppler abdominal ultrasound ultrasound dated ___.
FINDINGS:
The celiac artery is widely patent on color Doppler with wall to wall flow and
normal arterial spectral Doppler waveform with a peak systolic velocity of 188
centimeters/second previously 197 cm per sec. The known dissection visualized
on prior CT is not fully appreciated on study.
The major branches of the celiac artery including the splenic artery and
common hepatic artery are widely patent with wall to wall color flow on
Doppler imaging and appropriate spectral Doppler waveforms and velocities of
137 cm per second and 135 cm per second respectively and previously 137 cm per
second and 132 centimeters/second respectively.
Redemonstrated are 2 lumens identified within the superior mesenteric artery
extending to the origin of the aorta and its distal branches. In the anterior
lumen, there is echogenic material consistent with clot, and which
demonstrates no flow on color Doppler imaging. The posterior lumen again
demonstrates full patency on color Doppler imaging and remains patent to its
distal branches. The patent posterior lumen of the superior mesenteric artery
demonstrates appropriate Doppler waveform and velocities up to peak systolic
velocity of the superior mesenteric artery is 176 cm per second, previously
225 centimeters/second.
The inferior mesenteric artery is visualized and widely patent with wall to
wall color flow and appropriate arterial waveform and peak systolic velocity
of 164 centimeters/seconds, and previously 134 centimeters/seconds.
Moderate calcified plaque is again identified within the distal aorta.
IMPRESSION:
1. No interval change from prior examination dated ___.
2. The celiac artery and its major branches are widely patent with appropriate
waveforms.
3. Sonographic findings within the superior mesenteric artery are compatible
with known dissection redemonstrating two lumens with anterior lumen
completely occluded and posterior lumen widely patent.
Radiology Report
EXAMINATION: CTA ABD AND PELVIS
INDICATION: ___ PMHx bilateral carotid/vertebral artery dissection now with
abdominal pain with CTA demonstrating celiac artery/SMA dissection, bilateral
EIA dissection. Now with increasing LUQ pain radiating to the back and
nausea.// Progression of dissection/pseudoaneurysm
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 3.8 s, 49.9 cm; CTDIvol = 6.1 mGy (Body) DLP = 305.6
mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 2.1 mGy (Body) DLP = 1.1
mGy-cm.
3) Stationary Acquisition 5.4 s, 0.5 cm; CTDIvol = 19.0 mGy (Body) DLP =
9.5 mGy-cm.
Total DLP (Body) = 316 mGy-cm.
COMPARISON: CTA abdomen and pelvis ___
FINDINGS:
VASCULAR:
The intimal flap in the distal celiac trunk is unchanged (2:38). Ectasia of
the celiac trunk is also unchanged. The distal branches remain patent.
Slight contour irregularity and surrounding soft tissue density is again
appreciated in the SMA 1.7 cm from the origin (2:45). Distal to this point,
the caliber of the SMA and its distal branches are decreased compared to prior
study. Several of the branches also appear to have moderate severe areas of
narrowing (series 2, images 73-83).
The ___ is patent.
There is mild calcium burden in the abdominal aorta and great abdominal
arteries. There is no abdominal aortic aneurysm. The left gastric artery
arises directly from the aorta. An accessory left renal artery is again
noted.
Small dissection flaps in the bilateral external iliac arteries are unchanged.
A calcified chronic dissection flap at origin of the right common iliac artery
is also unchanged.
LOWER CHEST: Minimal atelectasis is noted in the lung bases. There is no
pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. A
1.6 cm hypoattenuating lesion in the hepatic dome with peripheral nodular
enhancement is unchanged, and likely represents a hemangioma (02:16). A 0.6
cm hyperattenuating lesion in hepatic segment II is unchanged, and likely
represents a hemangioma (02:30). Additional subcentimeter hypoattenuating
lesions scattered throughout the liver are too small to characterize, but
statistically likely represent cysts. 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 left adrenal gland is mildly thickened. The right adrenal gland
is 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
is no perinephric abnormality.
GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall thickness
and enhancement throughout. There is extensive colonic diverticulosis without
evidence of acute diverticulitis. There is no evidence of mesenteric
lymphadenopathy.
RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy.
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 visualized reproductive organs are unremarkable.
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. Slight decrease in caliber of the distal SMA and its branches with several
new areas of moderate to severe stenosis in the distal SMA branches. No
specific evidence of ischemic bowel.
2. Unchanged ectasia and intimal flap in the distal celiac trunk.
3. Unchanged dissection flaps in the bilateral external iliac arteries and
chronic calcified dissection flap in the right common iliac artery.
4. Slight thickening of the left adrenal gland is nonspecific.
5. Extensive colonic diverticulosis without evidence of acute diverticulitis.
Radiology Report
EXAMINATION: Carotid Doppler Ultrasound
INDICATION: ___ PMHx bilateral carotid/vertebral artery dissection now with
abdominal pain with CTA demonstrating celiac artery/SMA dissection, bilateral
EIA dissection.// carotid artery patency, dissection, stenosis
TECHNIQUE: Real-time grayscale, color, and spectral Doppler ultrasound
imaging of the carotid arteries was obtained.
COMPARISON: None
FINDINGS:
RIGHT:
The right carotid vasculature has no atherosclerotic plaque.
The peak systolic velocity in the right common carotid artery is 99 cm/s.
The peak systolic velocities in the proximal, mid, and distal right internal
carotid artery are 84 cm/s, 93 cm/s, and 88 cm/s respectively. The peak end
diastolic velocity in the right internal carotid artery is 40 cm/sec.
The ICA/CCA ratio is 09.
The external carotid artery has peak systolic velocity of61 cm/s.
The vertebral artery is patent with antegrade flow.
LEFT:
The left carotid vasculature has mild atherosclerotic plaque.
The peak systolic velocity in the left common carotid artery is 100 cm/s.
The peak systolic velocities in the proximal, mid, and distal left internal
carotid artery are 73 cm/s, 76 cm/s, and 96 cm/s respectively. The peak end
diastolic velocity in the left internal carotid artery is 43 cm/sec.
The ICA/CCA ratio is 1.0.
The external carotid artery has peak systolic velocity of 110 cm/s.
The vertebral artery is patent with antegrade flow.
IMPRESSION:
Less than 40% stenosis in the left internal carotid artery.
No significant stenosis in the right internal carotid artery.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with Aneurysm of other specified arteries
temperature: 96.2
heartrate: 80.0
resprate: 18.0
o2sat: 100.0
sbp: 166.0
dbp: 100.0
level of pain: 8
level of acuity: 3.0 | The patient was admitted to the CVICU overnight on ___. She
was started on an esmolol and nicardipine drip for SBP 151/111,
however these she was able to be weaned off of these as of 0900
on the day of admission with blood pressures <120/80 since that
time with heart rates remaining in the low ___. Her diet was
gradually advanced, and she was transitioned to the vascular
surgery step-down.
Vascular medicine was consulted for assistance, who recommended
aggressive blood pressure control of <120 SBP. After trialing
several anti-hypertensives, a regimen of metoprolol XR 37.5,
nifedipine 30 mg, and lisinopril 30 mg proved able to manage her
blood pressure adequately, and she tolerated a heart rate in the
low ___ well. Prior to determining the accurate blood pressure
regimen, she required multiple prn IV antihypertensive pushes;
it was noted that her hypertensive episodes corresponded to
reports of increased epigastric and LUQ pain. It was unclear
whether the pain caused the hypertension or hypertension
elicited the pain; however, the pain approved moderately better
controlled with increased blood pressure.
Due to repeated instances of nausea and pain, during which she
made NPO, a repeat CTA abdomen/pelvis was obtained that revealed
narrowing of her dissected end arteries but stability in the
suspected pseudoaneurysm. Hence, she was also started on a
heparin drip with a goal 40-60. Following this initiation, she
appeared moderately symptomatically improved, and so she was
planned to be continued on an anticoagulant in addition to
aspirin and atorvastatin.
GI was consulted in light of her persistent nausea and abdominal
pain, who observed that her symptoms of intermittent abdominal
pain of pressure-like and burning nature, localizing to LUQ and
without relation to meals were highly atypical for intestinal
ischemia and more consistent with gastritis or peptic ulcer
disease; hence, she was trialed on high dose BID PPI, Zofran,
and her constipation rigorously managed with standing bowel
regimen.
Rheumatology was consulted regarding the possibility of systemic
vasculitis, who believed that the clinical picture was not
consistent with systemic vasculitis due to the negative ___
and low ESR/CRP, and they recommended no immunosuppression but
continued medical management of the blood pressure.
During rheumatologic workup, she was noted have a positive
hepatitis C viral load (cryoglobulins pending), likely due to a
transfusion as a child or when taking care of her husband, who
had also underwent transfusions. She was informed of her
diagnosis and arranged for hepatology outpatient follow-up with
appropriate guidance regarding transmission risks. An inpatient
CTA H&N confirmed the reported carotid/vertebral dissections.
At the time of discharge, she was able to tolerate a regular
diet, get out of bed and ambulate without assistance, void
without issues, and pain was controlled on oral medications
alone. She was deemed ready for discharge, and was given the
appropriate discharge and follow-up instructions. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending: ___.
Chief Complaint:
Fever s/p ERCP
Major Surgical or Invasive Procedure:
ERCP with metal stent placement
PICC placement
History of Present Illness:
___ with DM, HTN who has been recently diagnosed with
pancreatic mass with ERCP results + for adenoCA (probable
metastases also found in the liver)found to have non-occlusive
proximal portal and distal superior mesenteric vein thrombosis.
He initially presented with abdominal pain and bloating x 5
weeks. He had an ERCP on ___ with biliary stenting and
sphincterotomy. He was discharged on ___. He had been feeling
okay, however over the last one to 2 days he has developed
fevers to 102.3, and diffuse bilateral lower quadrant abdominal
and epigastric pain which he rates as a ___. No clear
inciting or alleviating factors. He describes his pain as
constant. He denies nausea, vomiting, diarrhea, chest pain. in
the ED he was rigoring and then experienced shortness of breath.
He reports constipation.
In ER:
Triage Vitals: T 100, P ___, BP 132/60, RR 18, O2 99% on RA
Meds Given:
Today 16:58 HYDROmorphone (Dilaudid) 1mg/1mL Syringe [class 2] 1
___
___ 17:19 Acetaminophen 500mg Tablet 2 ___
___ 17:19 &&Piperacillin-Tazob (Mini Bag +) [___] 1
___
___ 18:41 Tetanus-DiphTox-Acellular Pertuss (Adacel) 0.5 mL
Syringe 1 ___
___ 18:49 Vancomycin 1g Frozen Bag 1 ___
___ 18:59 Readi-Cat 2 (Barium Sulfate 2% Suspension) 450 mL
Bottle 2 ___
___ 19:14 HYDROmorphone (Dilaudid) 1mg/1mL Syringe [class 2] 1
___
___ 19:26 Tetanus-DiphTox-Acellular Pertuss (Adacel) 0.5 mL
Syringe Return 1 ___
___ 22:24 Acetaminophen 500mg Tablet
Fluids given: 1L NS
Radiology Studies: RUQ US and abdominal CT
consults called: ERCP
.
PAIN SCALE: ___
________________________________________________________________
REVIEW OF SYSTEMS: 10 or 2 with "all otherwise negative"
CONSTITUTIONAL: [] All Normal
[ +] Fever [ ] Chills [ ] Sweats [ ] Fatigue [ ] Malaise
[ ]Anorexia [ ]Night sweats
[+ ] _12____ lbs. weight loss over ___1__ months
Eyes
[x] All Normal
[ ] Blurred vision [ ] Loss of vision [] Diplopia [ ]
Photophobia
ENT
[ ] Dry mouth [ ] Oral ulcers [ ] Bleeding gums [ ] Sore throat
[] Sinus pain [ ] Epistaxis [ ] Tinnitus
[ ] Decreased hearing [ x] Other: Rhinorrhea when he goes out
in the cold
RESPIRATORY: [] All Normal
[ X] Shortness of breath [X ] Dyspnea on exertion [ ] Can't
walk 2 flights [ ] Cough [ ] Wheeze [ ] Purulent sputum
[ ] Hemoptysis [ ]Pleuritic pain
[ ] Other:
CARDIAC: [x] All Normal
[ ] Palpitations [ ] Edema [ ] PND [ ] Orthopnea [ ]
Chest Pain [ ] Dyspnea on exertion [ ] Other:
GI: [] All Normal
[ -] Nausea [-] Vomiting [+] Abd pain [] Abdominal swelling
[ ] Diarrhea [+ ] Constipation [ ] Hematemesis
[ ] Blood in stool [ ] Melena [ ] Dysphagia: [ ] Solids
[ ] Liquids [ ] Odynophagia [ ] Anorexia [ ] Reflux
[ ] Other:
GU: [] All Normal
[ +] Dysuria - mild over the last few days [ ] Incontinence
or retention [ ] Frequency [ ] Hematuria []Discharge
[]Menorrhagia
SKIN: [X] All Normal
[ ] Rash [ ] Pruritus
MS: [] All Normal
[ ] Joint pain [ ] Jt swelling [ ] Back pain [ ] Bony pain
L calf pain with standing
NEURO: [x] All Normal
[ ] Headache [ ] Visual changes [ ] Sensory change [
]Confusion [ ]Numbness of extremities
[ ] Seizures [ ] Weakness [ ] Dizziness/Lightheaded [ ]Vertigo
[ ] Headache
ENDOCRINE: [X] All Normal
[ ] Skin changes [ ] Hair changes [ ] Heat or cold
intolerance [ ] loss of energy
HEME/LYMPH: [x] All Normal
[ ] Easy bruising [ ] Easy bleeding [ ] Adenopathy
PSYCH: [x] All Normal
[ ] Mood change []Suicidal Ideation [ ] Other:
ALLERGY:
[ x]Medication allergies- NKDA [ ] Seasonal allergies
[X]all other systems negative except as noted above
Past Medical History:
PMH:
-- Diagnosed with advanced pancreatic cancer in ___ when he
presented with abdominal pain
--- s/p ERCP with stent placement for biliary obstruction on
___
-- non-occlusive proximal portal and distal superior mesenteric
vein thrombosis.
--SVT, afib w/ RVR s/p ___. Pt with sx a fib
--diabetes - last A1C in ___ = 10 up from baseline of
___
--hypercholesterolemia
--EtOH and drug abuse, sober for 37 months
--h/o depression
PSHx
Ablation ___
thumb surgery
R shoulder surgery
Appendectomy
L inguinal hernia repair
Basal cell Ca removed.
Social History:
___
Family History:
mother has hypertension and smoking-related lung cancer. Father
died of MI at age ___nd CABG, had skin cancer.One
older brother has HTN.
Physical Exam:
ON Admission:
1. VS Tm 104 .4 P ___ BP 118/56RR O2Sat on _____ %RA_,
GENERAL: Middle aged male who is sweating in bed
Nourishment: OK
Grooming: good
Mentation: alert, speaking in full sentences
2. Eyes: [X] ? mild icterus
EOMI without nystagmus, Conjunctiva:
clear/injection/exudates/icteric Ears/Nose/Mouth/Throat: MMM, no
lesions noted in OP
3. ENT [X] WNL
[] Moist [] Endentulous [] Ulcers [] Erythema [] JVD ____ cm
[] Dry [] Poor dentition [] Thrush [] Swelling [] Exudate
4. Cardiovascular [] WNL
[X] Regular [X] Tachy [] S1 [] S2 [] Systolic Murmur /6,
Location:
[] Irregular []Brady []S3 [] S4 [] Diastolic Murmur /6,
Location:
[] Edema RLE None [] Bruit(s), Location:
[] Edema ___ None [] PMI
[] Vascular access [X] Peripheral [] Central site:
5. Respiratory [ ]
[] CTA bilaterally [ ] Rales [ ?] Diminshed BS at bases
bilaterally
[] Comfortable [ ] Rhonchi [ ] Dullness
[ ] Percussion WNL [ ] Wheeze [] Egophony
6. Gastrointestinal [ ] WNL
[X] Soft [-] Rebound [] No hepatomegaly [X] Non-tender []
Tender [] No splenomegaly
[X] Slightly distended [] distended [X] hyperactive bowel
sounds [] guiac: positive/negative
7. Musculoskeletal-Extremities [X] WNL
[ ] Tone WNL [ ]Upper extremity strength ___ and symmetrical [
]Other:
[ ] Bulk WNL [] Lower extremity strength ___ and symmetrica [
] Other:
[X] Normal gait []No cyanosis [ ] No clubbing [] No joint
swelling
8. Neurological [X] WNL
[ ] Alert and Oriented x 3 [ ] Romberg: Positive/Negative [ ]
CN II-XII intact [ ] Normal attention [ ] FNF/HTS WNL []
Sensation WNL [ ] Delirious/confused [ ] Asterixis
Present/Absent [ ] Position sense WNL
[ ] Demented [ ] No pronator drift [] Fluent speech
9. Integument [] WNL
[X] Warm [] Dry [] Cyanotic [] Rash:
none/diffuse/face/trunk/back/limbs
[ ] Cool [X] Moist [] Mottled [] Ulcer:
None/decubitus/sacral/heel: Right/Left
10. Psychiatric [X] WNL
[X] Appropriate [] Flat affect [] Anxious [] Manic []
Intoxicated [] Pleasant [] Depressed [] Agitated [] Psychotic
[] Combative
11. Hematologic/Lymphatic [X]WNL
[X] No cervical ___
12. Genitourinary [X] WNL
[ ] Catheter present [] Normal genitalia [ ] Other:
On Discharge:
Pertinent Results:
====================
LABORATORY RESULTS
====================
On Admission:
WBC-5.0 RBC-4.18* Hgb-12.4* Hct-37.8* MCV-90 RDW-12.9 Plt ___
--- Neuts-82.8* Lymphs-9.5* Monos-6.0 Eos-1.2 Baso-0.5
___ PTT-48.1* ___
Glucose-302* UreaN-11 Creat-0.8 Na-131* K-4.1 Cl-91* HCO3-29
AnGap-15
Calcium-9.6 Phos-2.6* Mg-2.0
calTIBC-302 VitB12-GREATER TH Folate-GREATER TH Ferritn-85
TRF-232
On Discharge:
=============
MICROBIOLOGY
=============
Blood Culture ___ bottles)
Blood Culture, Routine (Final ___:
KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES.
Piperacillin/Tazobactam sensitivity testing performed
by ___
___.
Ertapenem Susceptibility testing requested by ___. ___
___
(___) ON ___.
Ertapenem = SENSITIVE, TEST PERFORMED BY ___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- 8 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Aerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___ ___ ___ @
8:10 AM.
GRAM NEGATIVE ROD(S).
Anaerobic Bottle Gram Stain (Final ___: GRAM
NEGATIVE ROD(S).
Other blood cultures*10: No growth to date
Urine culture*2: No growth
Stool culture: no organisms, Negative for C diff
=============
OTHER STUDIES
=============
ECG ___:
Sinus tachycardia. Delayed precordial R wave transition.
Non-specific
inferolateral ST-T wave changes. Compared to the previous
tracing of ___ the rate has increased and there are
non-specific ST-T wave changes. Otherwise, no diagnostic interim
change.
Liver/GB U/S ___:
IMPRESSION:
1. Multiple liver lesions better assessed on recent CT and MRI.
2. Patent hepatic vasculature with normal waveforms. The
thrombus at the
main portal vein/SMV confluence seen on CT ___ is not seen
on this
study.
CXR AP and lateral ___:
IMPRESSION: No acute findings including no signs of free air
below the right hemidiaphragm.
CT Abdomen ___:
IMPRESSION:
1. No drainable fluid collection, as clinically queried.
2. Pancreatic head mass with multiple liver metastases,
unchanged from
___. Trace peripancreatic fluid is also unchanged.
3. Stable nonocclusive thrombus in the proximal main portal
vein/distal SMV
at the confluence.
___ ___:
CONCLUSION: No evidence for DVT.
CT T and L spine w/o contrast ___:
IMPRESSION: Minimal lumbosacral joint degenerative change. No
evidence of
metastases, fracture or infection.
TTE ___:
MPRESSION: Normal biventricular systolic function. No
significant valvular disease. No masses or vegetations
visualized on transthoracic echocardiography. However, the
absence of a vegetation by 2D echocardiography does not exclude
endocarditis. If clinically indicated, a transesophageal
echocardiographic examination is recommended.
Liver/GB Ultrasound ___:
IMPRESSION:
1. No evidence of interval change in liver lesions to suggest
abscess or
necrosis, as questioned.
2. Redemonstration of known pancreatic mass.
3. Gallbladder wall edema, unchanged from ___, is likely
related to third spacing. However, if there is high clinical
suspicion for acalculous
cholecystitis, this could not be excluded and HIDA would be
recommended.
CT Torso W/ Contrast ___:
IMPRESSION:
1. New small pleural effusions bilaterally as well as small
volume ascites
and mesenteric edema.
2. New small amount of pericholecystic fat stranding. In the
setting of
ascites this finding is nonspecific and must be interpreted in
the context of the patient's clinical examination.
3. Otherwise no change from the recent comparison examinations
re-demonstrating a pancreatic lesion, with numerous hepatic
metastases, an
enlarged portacaval lymph node and portal vein thrombosis.
Medications on Admission:
Metformin 850 mg bid
lisnopril 5 mg held
Tamsulosin 0.___ mg held
Omeprazole never took it
Bupropion 150 mg xr
Oxycodone and morphine
Lovenox 80 mg bid
Discharge Medications:
1. bupropion HCl 150 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO QAM (once a day (in the morning)).
2. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for pain fever.
3. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12 hrs
on and off.
Disp:*10 Adhesive Patch, Medicated(s)* Refills:*2*
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*2*
5. metformin 850 mg Tablet Sig: One (1) Tablet PO twice a day.
6. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*1*
7. hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q4H (every 4
hours) as needed for pain: do not drive or operate heavy
machinery after using this medication as it can make you sleepy.
Disp:*60 Tablet(s)* Refills:*0*
8. ertapenem 1 gram Recon Soln Sig: One (1) gram Intravenous
once a day for 16 days: Last day ___.
Disp:*16 gm* Refills:*0*
9. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous twice a day.
Disp:*60 syringes* Refills:*2*
10. Dressing Changes
___ line dressing changes Q7 days and PRN
11. Outpatient Lab Work
OK to draw labs through ___. Please check weakly CBC, Chem 10,
ALT, AST, ALK P, and TBili and fax results to Infectious
disease R.Ns. at ___ All questions regarding
outpatient antibiotics should be directed
to the infectious disease R.Ns. at ___
or to on call MD in when clinic is closed
12. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. gabapentin 100 mg Capsule Sig: ___ Capsules PO three times a
day: Take two tabs in the morning, two tabs in the afternoon,
and four tabs at night.
Disp:*240 Capsule(s)* Refills:*0*
15. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
16. senna 8.6 mg Tablet Sig: ___ Tablets PO BID (2 times a day):
hold if stools loose.
17. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) gm PO DAILY (Daily): hold for loose stools.
Disp:*510 gm* Refills:*0*
18. morphine 15 mg Tablet Sig: Three (3) Tablet Extended Release
PO Q12H (every 12 hours): do not drive or operate heavy
machinery after taking this medication as it can make you
sleepy.
Disp:*180 Tablet Extended Release(s)* Refills:*0*
19. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
20. insulin glargine 100 unit/mL (3 mL) Insulin Pen Sig: Fifteen
(15) units Subcutaneous QPM.
Disp:*2 pens* Refills:*1*
21. Lancets,Ultra Thin Misc Sig: One (1) lancet
Miscellaneous twice a day: use lancets for BID glood glucose
checks.
Disp:*60 lancets* Refills:*2*
22. Glucose meter
Please dispense fingerstick blood glucose meter (Free Style
lyte)
Quantity: 1
Refills: 0
23. Test strips
Glucose testing strips and lancet. Freestyle Light
Dispense 60
Refills: 1
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Sepsis due to Cholangitis
Klebsiella bacteremia
Pancreatic adenocarcinoma
Liver masses
Atrial fibrillation
Type 2 diabetes
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH
Comparison is made with a prior study from ___.
CLINICAL HISTORY: Fever and abdominal pain status post ERCP, question free
air.
FINDINGS: PA and lateral views of the chest were obtained. There is no free
air below the right hemidiaphragm. The lungs are clear bilaterally without
focal consolidation, effusion, or pneumothorax. The heart size is normal.
Mediastinal and hilar configuration is normal. The bony structures are
intact.
IMPRESSION: No acute findings including no signs of free air below the right
hemidiaphragm.
Radiology Report
CLINICAL HISTORY: ___ male with portal vein thrombus. Evaluate for
enlargement of clot.
COMPARISON: CT ___ and MRI ___.
FINDINGS: The liver shows no textural abnormality. Multiple focal liver
lesions in the right hepatic lobe are better assessed on recent CT and MRI.
There is mild gallbladder wall thickening and edema as seen on CT, but no
gallstone is identified. The common duct is not dilated measuring 6 mm. The
known CBD stent is not seen. The spleen is enlarged to 14.4 cm. A single
view of the right kidney is normal.
COLOR DOPPLER: Color Doppler assessment and spectral analysis of the hepatic
vasculature was performed. The main portal vein, right posterior portal vein,
right anterior portal vein, and left portal vein are patent with normal
waveforms. The middle, left and right hepatic veins are patent. The main,
right and left hepatic arteries are patent with normal waveforms and RIs of
0.47, 0.51 and 0.66 respectively. The thrombus at the portal confluence seen
on the CT is not visualized on this study. The splenic vein is patent at the
hilum.
IMPRESSION:
1. Multiple liver lesions better assessed on recent CT and MRI.
2. Patent hepatic vasculature with normal waveforms. The thrombus at the
main portal vein/SMV confluence seen on CT ___ is not seen on this
study.
Radiology Report
CLINICAL HISTORY: ___ man with pancreatic cancer with known hepatic
metastases. The patient presents with fever. Evaluate for abscess.
COMPARISON: MRI ___ and multiphasic CT ___.
TECHNIQUE: MDCT-acquired axial images from the lung bases to the pubic
symphysis were displayed with 5-mm slice thickness with oral and 130 mL
Omnipaque intravenous contrast. Coronal and sagittal reformats were obtained
for evaluation.
CT ABDOMEN: The visualized lung bases demonstrate mild dependent bibasilar
atelectasis. There is mild bibasilar pleural thickening. No pleural or
pericardial effusion.
Numerous hypodensities are again seen throughout the liver compatible with
hepatic metastases, similar in size and extent compared to CT from three days
prior. The gallbladder is decompressed without radiopaque stones with mild
gallbladder wall edema and thickening, unchanged from the prior study.
Pneumobilia is compatible with a patent CBD stent. The spleen is normal.
Again seen is a hypodensity within the pancreatic head, corresponding to the
known mass measuring approximately 3.6 x 4.0 cm, previously 3.7 x 4.0 cm in
the axial plane, unchanged from the prior study. There is trace peripancreatic
fluid, unchanged.
The bilateral adrenal glands are normal. The kidneys enhance symmetrically
and excrete contrast promptly without hydronephrosis. Multiple hypodensities
within the kidneys bilaterally are too small to characterize and likely
represent simple cysts, unchanged from the prior study.
The small and large bowel are normal in course and caliber without
obstruction. There is no free fluid and no free air. No drainable fluid
collection is seen to suggest abscess. The aorta is of normal caliber
throughout with mild atherosclerotic calcifications. Again seen is an
enlarged porta hepatic lymph node measuring 1.5 cm. No new lymphadenopathy is
seen. Thrombus in the proximal main portal vein/distal SMV confluence is
redemonstrated, similar to three days prior. The splenic vein is chronically
thrombosed at the confluence with multiple perisplenic collaterals. The
splenic vein is patent at the hilum.
CT PELVIS: The rectum is filled with stool. The sigmoid colon, bladder,
prostate, and seminal vesicles are normal. Bilateral ureteral jets are
demonstrated. There is no free fluid and no pelvic or inguinal
lymphadenopathy. A small fat-containing hernia is noted in the left groin with
linear areas of hyperdensity, possibly reflecting prior surgical repair.
BONE WINDOWS: No bone finding suspicious for infection or malignancy is seen.
A benign-appearing sclerotic focus in the left iliac wing is a bone island.
There is mild degenerative change in the thoracolumbar spine, worse at L5-S1.
IMPRESSION:
1. No drainable fluid collection, as clinically queried.
2. Pancreatic head mass with multiple liver metastases, unchanged from
___. Trace peripancreatic fluid is also unchanged.
3. Stable nonocclusive thrombus in the proximal main portal vein/distal SMV
at the confluence.
Radiology Report
LEFT LOWER EXTREMITY ULTRASOUND AND DOPPLER STUDIES
HISTORY: Advanced pancreatic CA, left calf pain. Assess for DVT.
FINDINGS: The left common femoral, superficial femoral, popliteal and deep
veins of the left calf show normal ultrasound appearance, compressibility and
Doppler flow.
CONCLUSION: No evidence for DVT.
Radiology Report
INDICATION: Thoracolumbar back pain in setting of cholangitis, pancreatic
cancer.
Look for evidence of infection, fracture or metastasis.
COMPARISON: No prior study for comparison.
FINDINGS: No fracture or malalignment identified. Minimal degenerative
change identified with anterior osteophyte formation in the upper thoracic
spine. A bone island is evident within the vertebral body of T1. No
suspicious lytic or blastic lesions are evident. Minimal scarring identified
within the bilateral apices. There are bilateral pleural effusions with
adjacent compressive atelectasis, right greater than left.
Multiple calcified nodes are identified in the mediastinum and hila, the
largest of which is in the precarinal space measuring 1.3 cm in the short
axis. Additional non-calcified prominent mediastinal lymph nodes are
identified and not fully evaluated on this study, particularly within the
paratracheal and precarinal spaces. None of the latter appear to meet CT
criteria for pathological enlargement.
IMPRESSION:
1. No fracture, dislocation or evidence of osteomyelitis.
2. Multiple enlarged mediastinal and hilar calcified lymph nodes are
identified likely reflecting prior granulomatous disease.
3. Other noncalcified lymph nodes are prominent though not pathologically
enlarged.
4. Bilateral pleural effusions, right greater than left, both
small-to-moderate in size.
ATTENDING NOTE: Although no lytic or sclerotic process seen, marrow
infilterative process can be better assessed with MRI if clinically indicated
(and if there are no contraindications for MRI).
Radiology Report
INDICATION: Lower mid thoracolumbar back pain in setting of cholangitis
pancreas cancer. Assess for infection or fracture metastases.
COMPARISON: No prior studies available for comparison.
FINDINGS: There is no evidence of fracture or malalignment. Minimal
degenerative change identified at the lumbosacral joint with mild disc space
narrowing and small posterior disc bulge. CT cannot provide intrathecal
detail comparable to MRI, though it demonstrated thecal sac is unremarkable.
No lytic or blastic lesions evident. The demonstrated portions of the knee
and inferior vena cava and aorta are unremarkable.
IMPRESSION: Minimal lumbosacral joint degenerative change. No evidence of
metastases, fracture or infection.
ATTENDING NOTE: Although no lytic or sclerotic process seen, marrow
infilterative process can be better assessed with MRI if clinically indicated
(and if there are no contraindications for MRI).
Radiology Report
PA AND LATERAL CHEST
HISTORY: ___ man with a persistent fever, cholangitis and bacteremia.
Possible pneumonia.
IMPRESSION: PA and lateral chest compared to ___.
Lung volumes are lower, small bilateral pleural effusions are new, and the
only focal pulmonary abnormalities or regions of bibasilar atelectasis. Lungs
are otherwise clear. Heart size is normal.
Radiology Report
REASON FOR THE EXAMINATION: This is a ___ man with known pancreatic
adenocarcinoma with metastases to the liver. The patient presents with
persistent fevers. The request is to rule out necrosis of the metastases or
developing abscesses.
COMPARISON: Prior CT examination from ___ and US from
___.
TECHNIQUE: Right upper quadrant ultrasound.
FINDINGS: Few hypoechoic lesions are seen throughout the liver that are
better assessed with prior CT examinations. These lesions are compatible with
the patient's known pancreatic metastases. No abscesses or necrosis of the
metastases are identified.
Re-identified is a hyperechoic nodule in segment VII that is most compatible
with hemangioma (1, 17).
No intrahepatic biliary duct dilatation is seen.
The common bile duct measures 0.7 cm.
The gallbladder wall is mildly thickened measuring 0.4 cm, and edematous,
grossly unchanged from prior examination from ___. ___ sign is
negative. No gallstones identified.
Ascites and right pleural effusion are identified. These findings were not
seen on prior CT examinations.
A heterogeneous mass is seen again in the head of the pancreas. The main
pancreatic duct is not dilated.
The portal vein is patent showing hepatopetal flow.
IMPRESSION:
1. No evidence of interval change in liver lesions to suggest abscess or
necrosis, as questioned.
2. Redemonstration of known pancreatic mass.
3. Gallbladder wall edema, unchanged from ___, is likely related to third
spacing. However, if there is high clinical suspicion for acalculous
cholecystitis, this could not be excluded and HIDA would be recommended.
Radiology Report
INDICATION: Persistent fevers of unclear origin in a patient with a history
notable for pancreatic cancer and recent cholangitis.
COMPARISON: CT from ___
TECHNIQUE: Axial CT images were acquired through the torso following the
uneventful intravenous administration of 130 cc of intravenous Omnipaque
contrast. Coronal and sagittal reformatted images were also reviewed.
CT CHEST WITH CONTRAST: The heart and great vessels are notable for
atherosclerotic calcifications. Note is again made of extensive mediastinal
and bilateral hilar lymphadenopathy, with some nodes demonstrating internal
calcifications overall the extent of which is unchanged from that seen on
___. There is no axillary lymphadenopathy. There is no pericardial
effusion. Bilateral small, right greater than left, pleural effusions are new
from ___. Biapical scarring is unchanged. The lungs are notable for
bibasilar subsegmental atelectasis dependently.
CT ABDOMEN WITH CONTRAST: There is a small hiatal hernia and the stomach and
duodenum are otherwise unremarkable. The adrenal glands, spleen are normal.
The kidneys enhance and excrete contrast in a symmetric fashion and contain
bilateral small hypodensities which are too small to characterize, and
unchanged. A metallic stent in the common bile duct is new. A large
predominantly hypodense mass at the pancreatic neck is unchanged. The
gallbladder is non-collapsed, and moderate pericholecystic fat stranding is
increased. There is no radiodense cholelithiasis. A small degree of
pneumobilia is unchanged. The size and number of extensive hepatic
hypodensities is unchanged, consistent with widespread hepatic metastatic
disease. A small thrombus within the medial aspect of the portal vein, near
the confluence of the superior mesenteric and splenic veins (2:61) is
unchanged. There is no free gas in the upper abdomen. A small amount of
ascites is new. A small amount of stranding throughout the mesentery has also
increased. An enlarged portacaval lymph node is unchanged.
CT PELVIS WITH CONTRAST: The urinary bladder, distal ureters, prostate,
seminal vesicles are normal. The rectum and colon are also normal. A small
amount of ascites settles dependently in the pelvis. There is no free gas in
the pelvis.
OSSEOUS FINDINGS: There is a small bone island in the left iliac bone.
Degenerative change at the lumbosacral junction is present, including vacuum
disc phenomenon.
IMPRESSION:
1. New small pleural effusions bilaterally as well as small volume ascites
and mesenteric edema.
2. New small amount of pericholecystic fat stranding. In the setting of
ascites this finding is nonspecific and must be interpreted in the context of
the patient's clinical examination.
3. Otherwise no change from the recent comparison examinations
re-demonstrating a pancreatic lesion, with numerous hepatic metastases, an
enlarged portacaval lymph node and portal vein thrombosis.
Radiology Report
CHEST ON ___
HISTORY: New PICC line.
FINDINGS: There is left-sided PICC line with tip in the SVC. The lungs are
clear without infiltrate. There is no pneumothorax.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: FEVER/S/P ERCP
Diagnosed with ABDOMINAL PAIN GENERALIZED, FEVER, UNSPECIFIED, ATRIAL FIBRILLATION, HYPERTENSION NOS, DIABETES UNCOMPL ADULT
temperature: 100.0
heartrate: 102.0
resprate: 18.0
o2sat: 99.0
sbp: 132.0
dbp: 60.0
level of pain: 3
level of acuity: 3.0 | ___ year old man with history of hypertension and new diagnosis
of pancreatic cancer presenting with cholangitis.
1) Sepsis due to Cholangitis with Klebsiella Bacteremia: High
fevers and rigors on admission. Started on Vanco/Zosyn and
Cipro was added. Blood cultures returned positive for GNR.
underwent ERCP with metal stent placement. He tolerated the
procedure well with improvement in his LFTs. He had persistent
fever and low blood pressures. His GNR returned as MDR
Klebsiella. He was thus changed to Tobramycin initially the
meropenem with final sensitivities. Transitioned on Meropenem
on ___, and Flagyl was started on ___ to cover for potential
anaerobes. Despite this, his fever persisted and ID was
consulted. They recommended discontinuing metronidazole but
after benign CT abdomen and other tests thought peristent fevers
likely due to small source of infection near metastases. All
subsequent cultures after day of admission benign. No abscess
seen on imaging. Given prolonged fefvers plan is for 4 wks of
abx as opposed to the two initially planned. Last day is ___.
2) Pancreatic cancer with likely liver metastases: The patient
had known pancreatic mass as well as numerous hypodensities in
the liver thought most likely to be metastases. As he missed
his primary oncology visit during his hospitalization he was
seen by Dr. ___ while in house. There has been some
question of biopsying his liver masses to confirm metastatic
disease prior to making a therapeutic decision. Nevertheless,
given very high suspicion that these do represent metastases, a
decision was made to not immediately postpone chemotherapy for
this procedure. Therefore, plan is to initiate chemotherapy
after he was completed a significant portion of this therapy for
klebsiella bacteremia (likely 2 wks). Further discussion of
liver biospy if these fail to respond to chemotherapy
(particularly if the primary mass does) in order to find out if
they could be something else and thus he could be resectable
will go on as an outpatient.
3) Abdominal and Back Pain: Patient with persistent epigastric
as well as subacute lower thoracic/upper lumbar back pain with
some point tenderness. CT failed to reveal a large metastases
or any ___ pathology in his back. Back pain responded well to
lidocaine patch. He was also started on gabapentin as an
adjunct for both pains with some benefit. Due to persistent
abdominal pain, thought likely to disease, he was started on
hydromorphone for breakthrough pain and eventually morphine SR
given patient was having some difficulty with frequency and
requesting short acting med. These provided reasonable control
of his pain. His pain medicine regimen will likely continue to
need titration as an outpatient with hope pain will improve with
therapy and hopefully response of his disease.
4) Diabetes Mellitus Type 2, uncontrolled, without complication:
Initially oral hypoglycemics were held but he had persistently
high sugars even after reinitiation of metformin therapy.
Presumed etiology of worse control is pancreatic disease and
increased islet cell dysfunction. Given importance of nutrition
in diagnosis patient and providers chose to focus on intake with
acceptance of insulin therapy being necessary to retain
reasonable control. Therefore, he was started on insulin
glargine once a day as well as his metformin to offer increased
glucose control.
***Prior to discharge blood glucose values stable between
100-250**
5) Portal Vein Thrombosis: He was initially placed on heparin
gtt for anticoagulation surrounding his ERCP but then
transitioned back to LMWH, which he had used previously, before
discharge.
6) Atrial fibrilation, s/p ablation: He continues to be in sinus
rhythm and not on anticoagulation.
7)HTN, benign: Held antihypertensives while septic. BP stable.
Continued to hold as remained normotensive.
8) Hyperlipidemia: held statin given elevated LFTs and unclear
future benefit given new diagnosis of pancreatic cancer.
Restarted at discharge as LFTs largely normalized
Transitional Issues:
-He will have follow up with ID and following of weekly safety
labs while on IV ertapenem.
-He will follow up with his oncologist regarding treatment of
his pancreatic cancer.
-He will require further titration of his analgesia and insulin
regimens as an outpatient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
crustaceans / Paraphenylenediamine (PPD) - ingredient in hair
dye
Attending: ___.
Chief Complaint:
Fatigue, pre-syncope, severe hyponatremia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ F with PMH of hypothyroidism and pituitary mass with
compression of optic chiasm and with invasion of cavernous
sinuses and s/p transphenoidal resection on ___, who
presented with presyncope and fatigue and was found to have
hyponatremia with a sodium level of 111.
She reported she was doing overall well after her recent
discharge, besides a headache that was well controlled with
acetaminophen. She started feeling "fuzzy" with generalized
weakness around 4 days prior to presentation. On the day of
presentation, she was extremely lightheaded, she vomited and was
very anxious. The fall was witnessed and she did not hit her
head and did not lose consciousness. She was then brought to the
emergency department for further evaluation where she was
triggered for hypotension and presyncope. She reported blurry
vision but denied diplopia. She felt generally weak. She denied
chest pain, shortness of breath, abdominal pain, nausea,
vomiting, dysuria/urinary frequency, bowel changes.
In the ED, initial vitals: 96.0 59 94/47 22 100% RA
Neuro exam was stable.
Labs were notable for Na 111 Cl 77 K 4.2 bicarb 19
creatinine 0.7 AGap=19, WBC 8.1 H/H 11.7/31.5 platelets 399.
Urine chemistry was notable for urine Na of 38 and urine osm of
169.
CT head without contrast showed 1. Postsurgical changes
following transsphenoidal resection of a pituitary adenoma with
fat packing. 2. No new hemorrhage or edema.
She was seen by neurosurgery and her symptoms were thought to be
likely due to hypocortisol. There were no acute neurosurgical
needs.
She was given Hydrocortisone Na Succ. 100 mg, IV LORazepam .5 mg
x2, IV Ondansetron 4 mg, IVF 1000 mL NS
On transfer, vitals were: 56 133/79 14 98% RA
On arrival to the MICU, she was comfortable and in no acute
distress. She confirmed the history detailed above.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies sinus tenderness, rhinorrhea or congestion. Denies
cough, shortness of breath, or wheezing. Denies chest pain,
chest pressure, palpitations, or weakness. Denies nausea,
diarrhea, constipation, abdominal pain, or changes in bowel
habits. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
Hypothyroidism
Hypercholesterolemia
Pituitary tumor s/p transphenoidal resection
Social History:
___
Family History:
Positive for hypothyroidism in one sister and two cousins and
hyperthyroidism in another sister. Her twin sister has
psoriasis. Mother had lung cancer; however, she smoked. No
family history of pituitary disease, hypercalcemia,
adrenal disease or any other endocrine disorders.
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
==================================
Vitals: T: afebrile BP: 115/57 P: 60 R: 18 O2: 100%RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, PERRLA
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
ABD: 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
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full with exception of the
left
nasal which is her baseline.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch., propioception, pinprick and
vibration bilaterally.
PHYSICAL EXAMINATION ON DISCHARGE:
==================================
Vitals: T 98.2, HR 68, BP 119/60, RR 18, 99% RA
General: Well-appearing, well-nourished woman sitting up in bed
in NAD.
HEENT: PERRL, L nasal visual field deficit stable since recent
pituitary surgery, sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB, no wheezes, rales, ronchi
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, obese, no rebound tenderness or
guarding, no organomegaly
Ext: WWP, 2+ pulses, no edema or rash
Neuro: CNII-XII intact, motor function grossly normal, A&Ox3.
Pertinent Results:
LABS ON ADMISSION:
==================
___ 08:20AM BLOOD WBC-8.1 RBC-3.95 Hgb-11.7 Hct-31.5*
MCV-80*# MCH-29.6 MCHC-37.1*# RDW-12.4 RDWSD-35.7 Plt ___
___ 08:20AM BLOOD Neuts-58.2 ___ Monos-14.5*
Eos-2.0 Baso-0.4 Im ___ AbsNeut-4.71 AbsLymp-1.92
AbsMono-1.17* AbsEos-0.16 AbsBaso-0.03
___ 08:20AM BLOOD Glucose-132* UreaN-7 Creat-0.7 Na-111*
K-4.2 Cl-77* HCO3-19* AnGap-19
___ 08:20AM BLOOD Calcium-10.4* Phos-3.1# Mg-1.6
___ 08:20AM BLOOD Osmolal-235*
___ 08:31AM BLOOD Lactate-2.0
LABS ON DISCHARGE:
==================
___ 06:32AM BLOOD WBC-10.1* RBC-3.77* Hgb-11.1* Hct-33.9*
MCV-90 MCH-29.4 MCHC-32.7 RDW-14.3 RDWSD-46.8* Plt ___
___ 06:32AM BLOOD Plt ___
___ 06:32AM BLOOD ___
___ 06:32AM BLOOD Glucose-87 UreaN-13 Creat-0.6 Na-136
K-4.8 Cl-101 HCO3-23 AnGap-17
___ 06:32AM BLOOD Calcium-9.5 Phos-4.8* Mg-2.3
MICRO:
======
___ 5:20 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING:
========
___ CXR:
No acute cardio-pulmonary process
___ CT WITHOUT CONTRAST:
1. Postsurgical changes following transsphenoidal resection of a
pituitary
adenoma with fat packing.
2. No new hemorrhage or edema.
___ CT HEAD I-:
1. Postsurgical changes related to prior transsphenoidal
pituitary adenoma
resection with fat packing are again seen, with residual
hemorrhagic products within the resection bed spanning
approximately 2.0 x 2.1 cm (3:9). This appearance is entirely
unchanged compared to the prior noncontrast head CT from ___.
2. No new intracranial hemorrhage or other acute findings are
identified
elsewhere.
3. Polypoid mucous retention cyst in the posterior right
maxillary sinus,
scattered ethmoid air cell opacification, and inferior right
mastoid effusion.
___ CTA HEAD AND NECK:
1. There is no evidence of dissection, occlusion, or significant
stenosis of the principal arteries of the head and neck.
2. There is mild mass effect on the A1 segment of the left
anterior cerebral artery by the above-mentioned postsurgical
changes, without focal stenosis.
3. No intracranial vascular malformation or aneurysm greater
than 3 mm.
Final read pending 3D reconstructions.
___ MRI HEAD w/o contrast
FINDINGS:
The sella is expanded and demonstrates postsurgical changes from
recent
macroadenoma resection extending into the suprasellar cistern,
including fat packing and small amount of blood products, as
seen on the recent posterior CTs. The sella, suprasellar
cistern, and optic chiasm are not evaluated in detail on this
noncontrast MRI without dedicated high-resolution images.
The brain parenchyma demonstrates no acute infarction, edema,
mass effect,
evidence for blood products, or other signal abnormalities.
Ventricles and sulci are normal in size. Basal cisterns are
also normal in size. Cerebellar tonsils are normally
positioned. Major intravascular flow voids appear grossly
preserved. The intracranial vasculature is better assessed on
the preceding CTA.
A small mucous retention cyst is noted in the posterior right
maxillary sinus. There is mild mucosal thickening of left
greater than right ethmoid air cells. There is an effusion in
the right mastoid air cells.
IMPRESSION:
1. No acute infarction. No evidence for other acute
intracranial
abnormalities.
2. Postsurgical changes in the sella and suprasellar cistern,
similar to
recent postsurgical CTs.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325 mg PO Q6H:PRN Pain
2. Atorvastatin 20 mg PO QPM
3. Levothyroxine Sodium 100 mcg PO DAILY
Discharge Medications:
1. Atorvastatin 20 mg PO QPM
2. Levothyroxine Sodium 100 mcg PO DAILY
3. Acetaminophen 325 mg PO Q6H:PRN Pain
4. Aspirin 81 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. Hyponatremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/ CONTRAST Q1211 CT HEAD
INDICATION: History: ___ with syncope, recent pituitary surgery // evidence
of bleed or pneumonia
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, 18.2 cm; CTDIvol = 49.7 mGy (Head) DLP =
903.1 mGy-cm.
Total DLP (Head) = 903 mGy-cm.
COMPARISON: Noncontrast head CT ___.
FINDINGS:
Patient is status post transsphenoidal resection of a pituitary adenoma with
fat packing. Interval evolution of residual blood products surrounding the
resection bed. There is otherwise no new hemorrhage. No evidence of acute
major vascular territorial infarction. Ventricles and sulci are normal in
size and configuration.
Other than postsurgical changes, there is no acute fracture. There are
secretions in the bilateral ethmoid air cells and right maxillary mucocele.
Left maxillary and frontal sinuses are clear. Mastoid air cells and middle
ear cavities are clear. The visualized portion of the orbits are
unremarkable.
IMPRESSION:
1. Postsurgical changes following transsphenoidal resection of a pituitary
adenoma with fat packing.
2. No new hemorrhage or edema.
Radiology Report
INDICATION: History: ___ with syncope, recent pituitary surgery // evidence
of bleed or pneumonia
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
Stable top-normal heart size. Normal mediastinal and hilar contours. No
focal consolidation, pleural effusion or pneumothorax.
IMPRESSION:
No acute intrathoracic process. Unchanged top-normal heart size.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK PQ147 CT HEADNECK
INDICATION: ___ year old woman with hx of pituitary adenoma s/p resection, now
w/ new word-finding difficulty ?stroke // please eval for acute bleed/stroke
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of 70 mL of Omnipaque intravenous contrast material.
Three-dimensional angiographic volume rendered, curved reformatted and
segmented images were generated on a dedicated workstation. This report is
based on interpretation of all of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 5.6 s, 14.0 cm; CTDIvol = 56.1 mGy (Head) DLP =
785.0 mGy-cm.
2) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 43.6 mGy (Head) DLP =
21.8 mGy-cm.
3) Spiral Acquisition 4.8 s, 37.9 cm; CTDIvol = 31.9 mGy (Head) DLP =
1,209.1 mGy-cm.
Total DLP (Head) = 2,016 mGy-cm.
COMPARISON: CT head ___
MRI pituitary ___
MRI head ___
FINDINGS:
CT HEAD WITHOUT CONTRAST:
The patient is status post trans-sphenoidal partial resection of a pituitary
mass with unchanged fat packing and blood products within the postoperative
bed. There is no evidence of no evidence of infarction, edema, or midline
shift. The ventricles and sulci are normal in size and configuration.
There is mild mucosal thickening in the bilateral ethmoid sinuses. The right
maxillary sinus contains a small mucous retention cyst. The right mastoid tip
is opacified. The visualized portion of the orbits are unremarkable.
CTA HEAD:
A 2 mm focal outpouching projects laterally from the left cavernous internal
carotid artery on 5:227. The vessels of the circle of ___ and their
principal intracranial branches are patent without stenosis,stenosis or
occlusion. The dural venous sinuses are patent.
CTA NECK:
There is a normal 3 vessel branching pattern of the aortic arch. The carotid
and vertebral arteries and their major branches appear normal with no evidence
of stenosis or occlusion. There is no evidence of internal carotid stenosis by
NASCET criteria.
OTHER:
The visualized portion of the lungs are clear. The visualized portion of the
thyroid gland is within normal limits. There is no lymphadenopathy by CT size
criteria.
IMPRESSION:
1. There is a 2 mm focal outpouching of the left cavernous internal carotid
artery, which may represent an aneurysm or infundibulum. Otherwise patent
circle of ___.
2. Normal CTA of the neck.
3. Status post trans-sphenoidal resection of a pituitary mass with unchanged
fat packing and blood products within the postoperative bed. No new
hemorrhage.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD
INDICATION: ___ woman s/p pituitary macroadenoma resection on ___
who presents with severe hyponatremia (111), gradually correcting, had episode
of unresponsiveness and word-finding difficulty overnight. Noncontrast head
CT and CT unremarkable. Evaluate for stroke.
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON Pituitary MRI, ___.
Limited surgical planning brain MRI, ___.
Noncontrast head CT, ___
CTA head/neck, ___.
FINDINGS:
The sella is expanded and demonstrates postsurgical changes from recent
macroadenoma resection extending into the suprasellar cistern, including fat
packing and small amount of blood products, as seen on the recent posterior
CTs. The sella, suprasellar cistern, and optic chiasm are not evaluated in
detail on this noncontrast MRI without dedicated high-resolution images.
The brain parenchyma demonstrates no acute infarction, edema, mass effect,
evidence for blood products, or other signal abnormalities. Ventricles and
sulci are normal in size. Basal cisterns are also normal in size. Cerebellar
tonsils are normally positioned. Major intravascular flow voids appear
grossly preserved. The intracranial vasculature is better assessed on the
preceding CTA.
A small mucous retention cyst is noted in the posterior right maxillary sinus.
There is mild mucosal thickening of left greater than right ethmoid air cells.
There is an effusion in the right mastoid air cells.
IMPRESSION:
1. No acute infarction. No evidence for other acute intracranial
abnormalities.
2. Postsurgical changes in the sella and suprasellar cistern, similar to
recent postsurgical CTs.
Gender: F
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: Syncope
Diagnosed with Abn lev hormones in specimens from female genital organs, Syncope and collapse
temperature: 96.0
heartrate: 59.0
resprate: 22.0
o2sat: 100.0
sbp: 94.0
dbp: 47.0
level of pain: 4
level of acuity: 2.0 | ___ F with PMH of hypothyroidism and pituitary mass with
compression of optic chiasm and with invasion of cavernous
sinuses and s/p transphenoidal resection on ___, primary
hypothyroidism, who presented with presyncope and was found to
have a sodium level of 111.
>> ACTIVE ISSUES:
#Hyponatremia: Patient has a baseline Na of high 130s/140s. At
admission to the ED, her sodium was 111. Given the close
proximity in time of the transphenoidal surgery, the
hyponatremia was thought to be secondary to a central cause,
with a component from hypovolemia given that the patient
endorsed poor PO. The patient had DI requiring DDAVP during
previous course after adenoma resection. In the ED, the patient
was given 1L NS. Neurosurgery saw patient in the ED and thought
the presentation to be consistent with adrenal insufficiency, so
stress-dose steroid at ___ hydrocortisone Q6H was started.
However, AM cortisol came back as 36, so steroids were reduced
to 20qAM and 10qPM. Free T4 was within normal limits, and T3 was
mildly low at 60, which was thought to not be consistent with
hypothyroidism causing hyponatremia. Renal and Endocrine saw the
patient and thought the presentation to be consistent with
DI/SIADH/DI, a triphasic response sometimes seen after
transphenoidal surgery for nonfunctional pituitary masses. The
patient's Na was initially difficult to treat, requiring DDAVP
then hypertonic saline to maintain a goal Na increase of
___. The patient's only complaint was headache stable
from several days prior to this admission and well-controlled on
acetaminophen. She did not have any neurologic deficits. Upon
transfer to the Medicine floor, her Na had been stable at
120-122 for 6+ hours, and Na checks had been spaced to Q6H. She
had an episode of ??unresponsiveness (was awake but did not
respond to questioning initially, then appeared to have
expressive aphasia) overnight ___, for which CT Head
non-contrast, CTA Head, and MRI Head non-contrast were obtained
and showed no signs of acute stroke or intracranial pathology.
She also had extended EEG monitoring on ___ which by
preliminary read showed no signs of epileptiform changes.
Patient's serum Na normalized to 135 on discharge, and she
exhibited normal mental status with no neurological deficits.
>> RESOLVED ISSUES:
#Pre-syncope: Patient was found to be hypotensive with SBP in
___ upon arrival to ED. Hypotension is the likely etiology of
presyncope. The hypotension was thought secondary to
hypovolemia. Upon transfer to the floor, the patient no longer
had any complaints related to pre-syncope and was not
orthostatic on exam.
>> STABLE ISSUES:
#Hypothyroidism: the patient carries a diagnosis of primary
hypothyroidism. At admission, her TSH was low (0.14), thought
secondary to her recent pituitary surgery. Her free T4 was
normal (1.1-1.2) and T3 was mildly low at 60. The patient
continued taking her home levothyroxine 100mcg daily.
#Hyperlipidemia: Patient continued taking her home Atorvastatin
20mg nightly.
>> TRANSITIONAL ISSUES:
[ ] ___ serum sodium check with ___ clinic
[ ] ASA 81mg was started on this admission in the setting of
episode of unresponsiveness and concern for acute stroke. No
signs of stroke on CT/MRI, can decide with PCP whether to
continue ASA.
[ ] Patient has left nasal visual field deficit stable since
pituitary surgery, would recommend follow-up with Ophthalmology. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ SLE c/b class IV lupus nephritis, AIHA, and
thrombocytopenia p/w SOB. Pt reports episodic SOB ("feels like I
can't breathe") precipitated by exertion and meals, and recently
also triggered by rolling over in bed, which wakes her up at
night. She states that her SXs never fully resolved since her
last admission in ___, but episodes of SOB have become more
frequent in the past 2 weeks. In particular, she thinks that her
SXs may have worsened about ___ days after her prednisone was
decreased from 60 mg to 50 mg daily. Pt currently experiences
___ self-resolving episodes of SOB per day. She also endorses
wheezing and a congested but non-productive cough. She does not
feel that her SOB is related to anxiety as it also occurs at
rest, such as when she is sitting down watching TV. Pt has
regular cold sweats, which is her baseline. Otherwise, she
denies fever, nausea/vomiting, diarrhea, calf
swelling/tenderness, sick contacts, and recent travel.
Pt was recently admitted to ___ for SOB from ___ to
___ and found to have pneumococcal PNA and bacteremia. She
has subsequently had multiple admissions for SOB, most recently
from ___ to ___, during which she was treated w/ broad
spectrum abx for consolidation of the RML w/ loss of distinction
of the R heart border c/f PNA v atelectasis. Per pt, her
outpatient rheumatologist (Dr. ___, ___ was
concerned about a rise in her ESR from 14 on ___ to 44 on ___
and admission to r/o infection was advised to permit cytoxan v
IVIG infusion.
Pt also has L sided pleuritic chest pain, which has been present
for about 9 months, stable in intensity since her previous
admission. She states that she has just filled her prescription
for colchichine, which was started by her rheumatologist at her
last outpatient appointment.
Past Medical History:
SLE, class IV lupus nephritis
Warm autoimmune hemolytic anemia
Thrombocytopenia ___ Syndrome)
ADHD, combined type
Depression
Hypertension
PTSD
Anxiety
Social History:
___
Family History:
Paternal uncle and aunt with SLE
Physical Exam:
ADMISSION EXAM:
=================
Vital Signs: 97.6 136 / 90 98 20 100 RA
General: Alert, oriented, no acute distress; pleasant
HEENT: Sclerae anicteric, MMM, oropharynx clear, supple, JVP not
elevated. Bilateral mydriasis, about 8mm in dim light. PERRLA
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops. NO RUBS.
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 edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait deferred.
Skin: No rashes.
DISCHARGE EXAM:
================
Vitals: 98.5 | BP 108/77 | HR 94 | RR 20 | O2 sat 100% RA
General: Alert, oriented, NAD
HEENT: PERRL, bilateral mydriasis, EOMI, sclerae anicteric, MMM,
oropharynx clear
Neck: Supple, JVP not elevated
Cardiac: RRR, S1/S2 normal, no M/R/G
Lungs: Adventitious breath sounds, scattered wheezes, no
appreciable crackles, no increased WOB
Abdomen: Soft, NT, ND, bowel sounds present, no organomegaly, no
rebound tenderness or guarding
GU: No foley
Extremities: WWP, no pedal edema
Neuro: CNs ___ intact, ___ strength BUE/BLE, SILT
Skin: No rashes
Pertinent Results:
ADMISSION LABS:
================
___ 10:10PM BLOOD WBC-5.3 RBC-3.20* Hgb-10.4* Hct-31.8*
MCV-99* MCH-32.5* MCHC-32.7 RDW-14.2 RDWSD-50.2* Plt ___
___ 10:10PM BLOOD Neuts-87* Bands-0 Lymphs-10* Monos-2*
Eos-0 Baso-0 ___ Myelos-1* AbsNeut-4.61
AbsLymp-0.53* AbsMono-0.11* AbsEos-0.00* AbsBaso-0.00*
___ 10:10PM BLOOD Plt Smr-LOW Plt ___
___ 10:10PM BLOOD Glucose-106* UreaN-25* Creat-0.6 Na-138
K-4.3 Cl-99 HCO3-25 AnGap-18
___ 10:10PM BLOOD ALT-25 AST-18 AlkPhos-57 TotBili-0.3
___ 10:10PM BLOOD Albumin-4.0
___ 10:10PM BLOOD D-Dimer-392
___ 10:10PM BLOOD CRP-10.8*
___ 10:23PM BLOOD Lactate-1.8
OTHER PERTINENT LABS:
=====================
___ 07:15AM BLOOD Ret Aut-6.3* Abs Ret-0.19*
___ 06:55AM BLOOD LD(LDH)-299* TotBili-0.3 DirBili-<0.2
IndBili-0.3
___ 07:15AM BLOOD VitB12-___
___ 06:55AM BLOOD Hapto-77
___ 10:00AM BLOOD ___ * Titer-1:1280
dsDNA-POSITIVE *
___ 10:00AM BLOOD C3-97 C4-7*
DISCHARGE LABS:
=================
___ 06:55AM BLOOD WBC-7.5 RBC-3.02* Hgb-9.8* Hct-30.4*
MCV-101* MCH-32.5* MCHC-32.2 RDW-14.5 RDWSD-52.5* Plt Ct-91*
___ 06:55AM BLOOD Plt Ct-91*
___ 06:55AM BLOOD Glucose-80 UreaN-24* Creat-0.6 Na-139
K-4.0 Cl-101 HCO3-28 AnGap-14
___ 06:55AM BLOOD LD(LDH)-299* TotBili-0.3 DirBili-<0.2
IndBili-0.3
___ 06:55AM BLOOD Calcium-9.0 Phos-5.0* Mg-2.0
___ 06:55AM BLOOD Hapto-77
URINE STUDIES:
===============
___ 09:19AM URINE Color-Yellow Appear-Clear Sp ___
___ 09:19AM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 09:19AM URINE RBC-3* WBC-2 Bacteri-NONE Yeast-NONE
Epi-5
MICROBIOLOGY:
===============
URINE CULTURE (Final ___:
PROTEUS MIRABILIS. 10,000-100,000 CFU/mL.
SENSITIVITIES: MIC expressed in MCG/ML
PROTEUS MIRABILIS
|
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- 8 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 8 I
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
Legionella Urinary Antigen (Final ___: NEGATIVE FOR
LEGIONELLA SEROGROUP 1 ANTIGEN.
___ 10:10 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 10:15 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING/STUDIES:
=================
CHEST (PA & LAT) (___)
IMPRESSION:
The previously noted right upper extremity PICC line has been
removed. Persistent opacity at the right medial lung base could
represent pneumonia versus prominent fat pad. Heart appears
top-normal in size. No large effusion or pneumothorax.
Mediastinal contour is normal. Bony structures are intact.
CTA CHEST (___)
IMPRESSION:
1. No evidence of pulmonary embolism through the segmental
level.
2. Diffuse ground-glass opacities in both lungs, compatible with
mild
pulmonary edema.
3. Small right and trace left pleural effusions.
4. Dilated pulmonary artery, measuring 3.6 cm, suggestive of
underlying
pulmonary hypertension, improved compared to CT of the chest
from ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. DULoxetine 60 mg PO DAILY
2. Citalopram 20 mg PO DAILY
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
4. Atovaquone Suspension 1500 mg PO DAILY
5. Calcium Carbonate 1250 mg PO DAILY
6. CloNIDine 0.1 mg PO TID
7. FoLIC Acid 1 mg PO DAILY
8. Hydroxychloroquine Sulfate 200 mg PO BID
9. Mycophenolate Mofetil 1500 mg PO BID
10. Omeprazole 20 mg PO DAILY
11. PredniSONE 50 mg PO DAILY
12. Topiramate (Topamax) 25 mg PO BID
13. Vitamin D 1000 UNIT PO DAILY
14. Cyanocobalamin ___ mcg PO DAILY
15. Zolpidem Tartrate 10 mg PO QHS
16. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath
17. ValACYclovir 500 mg PO Q24H
18. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Severe
19. Voltaren (diclofenac sodium) 1 % topical DAILY
20. Colchicine 0.6 mg PO BID
Discharge Medications:
1. DULoxetine 60 mg PO DAILY
2. Citalopram 10 mg PO DAILY Duration: 7 Days
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
4. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath
5. Atovaquone Suspension 1500 mg PO DAILY
6. Calcium Carbonate 1250 mg PO DAILY
7. CloNIDine 0.1 mg PO TID
8. Colchicine 0.6 mg PO BID
9. Cyanocobalamin ___ mcg PO DAILY
10. FoLIC Acid 1 mg PO DAILY
11. Hydroxychloroquine Sulfate 200 mg PO BID
12. Mycophenolate Mofetil 1500 mg PO BID
13. Omeprazole 20 mg PO DAILY
14. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Severe
15. PredniSONE 50 mg PO DAILY
16. Topiramate (Topamax) 25 mg PO BID
17. ValACYclovir 500 mg PO Q24H
18. Vitamin D 1000 UNIT PO DAILY
19. Voltaren (diclofenac sodium) 1 % topical DAILY
20. Zolpidem Tartrate 10 mg PO QHS
21.Outpatient Physical Therapy
Diagnosis: ___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY: Shortness of breath, systemic lupus erythematosus,
autoimmune hemolytic anemia, thrombocytopenia
SECONDARY: Lupus nephritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA chest
INDICATION: ___ w/ shortness of breath c/f PE or pulmonary arterial
hypertension// Please assess for PE and pulmonary arterial hypertension
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 1.6 s, 25.2 cm; CTDIvol = 20.4 mGy (Body) DLP = 513.2
mGy-cm.
2) Spiral Acquisition 1.6 s, 25.2 cm; CTDIvol = 12.7 mGy (Body) DLP = 318.3
mGy-cm.
3) Stationary Acquisition 5.1 s, 0.5 cm; CTDIvol = 17.2 mGy (Body) DLP =
8.6 mGy-cm.
Total DLP (Body) = 840 mGy-cm.
COMPARISON: CT of the chest from ___
FINDINGS:
The pulmonary arteries are well opacified to the segmental level, with no
evidence of filling defect within the main, right, left, lobar, segmental
pulmonary arteries. The main pulmonary artery is dilated, measuring 3.6 cm,
suggestive of underlying pulmonary hypertension, improved compared to CT of
the chest from ___, at which time it measured 4.4 cm. There is
no evidence of right heart strain.
The aorta is normal in caliber. There is no evidence of dissection or
intramural hematoma.
There is no supraclavicular, axillary, mediastinal, or hilar lymphadenopathy.
The thyroid gland appears unremarkable.
The heart is normal in size. There is no pericardial effusion.
There are small right and trace left pleural effusions.
There are diffuse ground-glass opacities in both lungs, compatible with mild
pulmonary edema.
The airways are patent to the subsegmental level.
Limited images of the upper abdomen are unremarkable.
No suspicious osseous lesion is identified.
IMPRESSION:
1. No evidence of pulmonary embolism through the segmental level.
2. Diffuse ground-glass opacities in both lungs, compatible with mild
pulmonary edema.
3. Small right and trace left pleural effusions.
4. Dilated pulmonary artery, measuring 3.6 cm, suggestive of underlying
pulmonary hypertension, improved compared to CT of the chest from ___.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with Pneumonia, unspecified organism
temperature: 96.0
heartrate: 118.0
resprate: 18.0
o2sat: 100.0
sbp: 147.0
dbp: 105.0
level of pain: 8
level of acuity: 3.0 | Ms. ___ is a ___ with SLE complicated by class IV lupus
nephritis on prednisone taper, who presented with at least 2
months of episodic shortness of breath. Patient was admitted due
to concern for pneumonia versus lupus flare; however, on further
evaluation her shortness of breath was felt to be most likely
multifactorial secondary to deconditioning, weight gain on
prednisone, anxiety, and possible OSA and/or reactive airway
disease. Patient was also seen by Rheumatology who were
concerned about active SLE due to anemia, thrombocytopenia,
+dsDNA, and low complement. Per nephrology consultant, repeat
renal biopsy was not indicated given stable renal function and
proteinuria. She was discharged with plan for close follow up
with her outpatient rheumatologist and nephrologist and will
likely require initiation of rituximab.
ACTIVE ISSUES:
===============
#SOB: Pt was admitted with symptoms of intermittent shortness of
breath due to c/f PNA given persistent opacity at the right
medial lung base on CXR versus lupus flare. She was initially
started on PO levofloxacin, which was discontinued after CTA of
the chest showed diffuse ground glass opacities compatible w/
mild pulmonary edema, small pleural effusions, and improved
pulmonary artery dilatation w/o e/o PNA. Infectious workup was
also negative for pneumococcal and Legionella urinary antigens.
Rheumatologic workup was notable for ESR 22, CRP 10.8, C3 97, C4
7, ___ positive, Hgb 31.8, plts 102, LDH 280, haptoglobin 72,
BUN 25, Cr 0.6, and urine protein/creatinine 0.4, largely
improved from prior admissions. D-dimer was 392 and chart review
was notable for prior lung scan from ___ w/ low likelihood of
chronic PE. Pt was seen by Pulmonology and her SOB was felt to
be most likely multifactorial ___ deconditioning, weight gain on
prednisone, anxiety, and possible OSA and/or reactive airway
disease. Pulmonology felt that the GGOs on imaging may have been
artifact. Outpatient PFTs, polysomnography, physical therapy,
incentive spirometry, prednisone taper, and optimization of
anxiety regimen w/ PRNs were recommended. Pt received
ipratropium bromide nebs and her home albuterol inhaler PRN w/
inpatient teaching by pharmacy prior to d/c.
#SLE/lupus nephritis/AIHA/thrombocytopenia: Pt w/ Hgb 9.7, plts
91, +dsDNA, and low complement. Rheumatology was c/f active SLE.
Anemia and thrombocytopenia were about at her baseline.
Nephrology was consulted for concern for nephritis, although
they were not c/f active nephritis requiring further inpatient
evaluation or intervention. Pt received her home
hydroxychloroquine, MMF, and prednisone 50 mg QD as well as
atovaquone and valacyclovir for prophylaxis. For her joint pain,
pt received tramadol 50 mg PO Q6H PRN as she was concerned that
her home oxycodone was making her sleepy. Pt was discharged w/
close outpatient follow-up w/ her rheumatologist for likely
initiation of rituximab.
CHRONIC ISSUES:
================
# Pleuritic chest pain/shoulder pain: Chronic, stable in
intensity, likely pericarditis v pleuritis i/s/o SLE. Pt states
that she just picked up Rx for colchicine prescribed by her
rheumatologist, however had not yet initiated. She was therefore
started on colchicine 0.6 mg BID during admission.
# Depression/anxiety: Pt was hospitalized within the past year
at ___ w/ suicidal ideation but reports that her
mood has been stable for several months. Continued on home
clonidine, zoplidem, and duloxetine. Her home citalopram was
tapered as outlined by her outpatient physicians as follows: 20
mg QD until ___, then 10 mg QD until ___, at this time
trazodone may be restarted and zolpidem stopped.
***TRANSITIONAL ISSUES***
==========================
#Follow-up with her outpatient rheumatologist, Dr. ___, for
likely initiation of rituximab for active lupus and weaning of
prednisone as her recent weight gain is likely contributing to
her poor exercise tolerance and shortness of breath.
#Follow-up with her outpatient nephrologist, Dr. ___, to
ensure stability of her stage IV lupus nephritis given concern
for currently active lupus.
#Follow-up with her Primary Care Physician for consideration of
pulmonary function testing and polysomnography to assess for
possible reactive airway disease and/or obstructive sleep apnea.
Further optimization of medications to address her anxiety
should also be considered.
#Citalopram was tapered, dose was reduced from 20 mg to 10 mg;
patient should continue taking citalopram 10 mg for 7 more days.
#Outpatient physical therapy to address her deconditioning, poor
exercise tolerance, and shortness of breath; she was provided
with a script.
#CODE: Full (presumed)
#CONTACT: ___ (mother) ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Splenic Bleed
Major Surgical or Invasive Procedure:
___: Successful coil embolization of at 3splenic arterial
pseudoaneurysms and active extravasation in the mid region of
the spleen
History of Present Illness:
___ s/p mechanical fall down stairs yesterday with positive LOC
and repeat fall associated with dizziness. Iniitally presented
to OSH with splenic lac and hypotensive and was transferred to
___ (received 2 units PRBC prior to arrival) for further
evaluation and management
Past Medical History:
recent R toe surgery, let inguinal hernia repair, ADHD,
tonsillitis,
Social History:
___
Family History:
Colon Cancer
Physical Exam:
General: patient lying comfortably in no acute distress
CV: Regular rate and rhythm
Lungs: breathing comfortably without any evidence of distress
Abdomen: soft, non-tender, non-distended
Extremeties: warm and pink
Pertinent Results:
HEAD AND CERVICAL SPINE CT SCAN ___ ___
IMPRESSION: No acute intracranial abnormality and no cervical
spine
fracture
CT/CHEST/ABD/PELVIS W CONTRAST ___ 1424 (time of note)
IMPRESSION:
1. Fractured spleen the chest anterior to the splenic artery
pedicle
with the hypo would enhancement to the anterior half of the
spleen
and significant hemorrhage surrounding the spleen. Vascular
blush at
the site of the fracture and around the splenic capsule is
consistent
with some active bleeding (grade 3 laceration).
2. Free fluid in the right upper abdomen, pericolic gutters and
pelvis, with some hyperdense blood in the left lower quadrant
fluid.
3. No acute finding in the chest.
4. Renal cysts. 1.5 cm round density in the right kidney has CT
numbers higher than fluid although cyst is favored. Ultrasound
correlation is recommended.
CT CHEST W/CONTRAST Study Date of ___ 3:33 ___ (outside
films second read)
IMPRESSION:
1. Shattered spleen with large sentinel clot and hemoperitoneum.
Multiple
areas of active bleeding noted with bleeding directly into the
peritoneal
cavity. No CT signs of shock.
2. Acute fractures of the right L2 and L3 transverse processes.
Radiology Report
EXAMINATION: CT TORSO performed at an outside hospital. This is a second
opinion interpretation.
INDICATION: ___ with fall from stairs now with splenic laceration.
TECHNIQUE: CT of the torso performed at an outside hospital with IV contrast
with multiplanar reformations provided. DLP: ___ MGy-cm
COMPARISON: None available.
FINDINGS:
CHEST: Imaged portion of the thyroid gland appears normal. The mediastinal
great vessels are intact. No mediastinal hematoma. No lymphadenopathy. The
heart is enlarged. There is no pericardial effusion. The airways are patent
and normal to the subsegmental level. The lungs are grossly clear without
focal consolidation. There is trace bilateral pleural effusions. There is no
pneumothorax or pneumomediastinum. There is a punctate calcified granuloma in
the left upper lobe. The esophagus is unremarkable.
ABDOMEN: Severe injury to the spleen is noted with multiple sites of
laceration and contusion involving greater than 50% of the spleen. Large
surrounding hematoma is noted with active intraperitoneal bleeding.
Extravasated contrast surrounds the upper pole of the spleen. Central areas of
splenic hyperdensity likely indicate additional areas of active bleeding.
There are no CT signs of shock.
The liver, gallbladder, spleen, adrenal glands appear intact. The kidneys
enhance symmetrically with numerous hypodensities likely represent simple
cysts. No retroperitoneal hematoma. The abdominal aorta and major branches
appear widely patent.
There is a small hiatal hernia. Stomach and duodenum appear normal.
PELVIS: Loops of small and large bowel demonstrate no signs of injury. No
mesenteric contusion. Hemoperitoneum extends into the pelvis.
The bladder is moderately distended and normal. There is no pelvic sidewall
or inguinal adenopathy.
OSSEOUS STRUCTURES/SOFT TISSUES: There is no soft tissue abnormality. There
are acute fractures through the right transverse process of L2 and L3.
IMPRESSION:
1. Shattered spleen with large sentinel clot and hemoperitoneum. Multiple
areas of active bleeding noted with bleeding directly into the peritoneal
cavity. No CT signs of shock.
2. Acute fractures of the right L2 and L3 transverse processes.
Radiology Report
INDICATION: ___ year old man with splenic laceration after mechanical fall
from stairs yesterday. Please perform splenic embolization.
COMPARISON: Outside hospital CT torso ___ 13:20.
TECHNIQUE: OPERATORS: Dr. ___ resident) and Dr. ___
___ radiology attending) performed the procedure. The attending,
Dr. ___ was present and supervising throughout the procedure. Dr.
___ radiologist, personally supervised the trainee during the
key components of the procedure and reviewed and agreed with the trainee's
findings.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
300mcg of fentanyl and 6 mg of midazolam throughout the total intra-service
time of 105 min 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: 2 g cefazolin IV, 4 mg of Zofran IV x2, 0.5 mg Dilaudid IV
x1.Intra-arterial nitroglycerine 200mcg.
CONTRAST: 80 ml of Optiray contrast and 100 mL of Visipaque.
FLUOROSCOPY TIME AND DOSE: 57.7 min, 1528 mGy
PROCEDURE:
1. Right common femoral artery access.
2. Splenic arteriogram.
3. Coil embolization of the distal splenic artery (x8), followed by post
embolization arteriogram.
4. Common femoral arteriogram.
PROCEDURE DETAILS:
Following a discussion 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. Right groin was
prepped and draped in the usual sterile fashion.
Using palpatory and fluoroscopic guidance, the right common femoral artery was
punctured using a 19 gauge single wall needle at the level of the mid femoral
head. A ___ wire was advanced easily under fluoroscopy into the aorta. A
small skin incision was made over the needle and the needle was exchanged for
a 5 ___ sheath which was attached to a continuous heparinized saline side
arm flush.
A C2 cobra catheter was advanced the level of the celiac axis and the splenic
artery was selected. Given the tortuosity of the splenic artery, stability
could not be obtained with this catheter alone. Therefore, the 5 ___ sheath
was switched for a 6 ___ ___ sheath, which was placed in the ostium of
the celiac axis. The Cobra catheter was advanced into the proximal celiac
artery and an angiogram was performed.
With an STC microcatheter and 0.018 fathom and 0.018 transcend wires, the
distal splenic arterial branches were subselected. We first superselected the
pseudoaneurysm in the mid spleen and placed three 3 mm x 4 cm Hilal coils with
a good angiographic result. Next, our attention was turned to the upper
splenic pole, however, we could not be selected distally and, therefore, four
Hilal coils were placed in the proximal aspect of this artery. Finally, we
were able to select the lower polar artery, but again could not get distal
enough for super selective embolization. At this point, three 3 mm x 2 cm
Hilal coils were placed. A final angiogram was performed from the main
proximal splenic artery.
A right common femoral arteriogram showed a high bifurcation of the CFA, and
thus, a Angioseal was deemed inappropriate. After removing all catheters and
___ compression was held for 25 min until hemostasis was achieved. A
sterile dressing was applied. The patient tolerated the procedure well and
there were no immediate complications.
FINDINGS:
1. 1 upper, 1 mid and 1 lower splenic pseudoaneurysms. The mid splenic
pseudoaneurysm was associated with active extravasation.
2. Superselection of the mid spleen with successful coil embolization
producing a satisfactory angiographic result.
3. Selection of the upper and lower splenic poles with successful coil
embolization. Post angiogram demonstrates large areas of splenic
hypoperfusion, as expected.
IMPRESSION:
Successful coil embolization of at 3splenic arterial pseudoaneurysms and
active extravasation in the mid region of the spleen.
RECOMMENDATION: Given the large area of ischemia/infarction, the patient is
at high risk for abscess formation. Two weeks of prophylactic antibiotics are
recommended.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: S/P FALL FROM HEIGHT
Diagnosed with SPLEEN INJURY NEC-CLOSED, TRAUMATIC SHOCK, FALL ON STAIR/STEP NEC
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | The patient presented Emergency Department on ___. Given
findings, the patient was taken to the operating room by
Interventional Radiology for Splenic Embolization. There were no
adverse events in the operating room; please see the operative
note for details. Pt was monitored until stable, then
transferred to the ICU for observation. Patient remained stable
and was transferred to the floor on ___.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with a IV narcotics
and then transitioned to oral pain regimen once tolerating a
diet.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored. He ws
Pulmonary: The patient 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: Following embolization the diet was advanced
sequentially to a Regular diet, which was well tolerated.
Patient's intake and output were closely monitored. The patient
initially had a Foley placed for close urine monitoring which
was removed on ___.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding with serial hematocrits. The patient received on
1unit of PRBCs on ___ with an appropriate increase in
hematocrit. His hematocrit remained stable thereafter.
Prophylaxis: The patient received subcutaneous heparin once
there were no signs of bleeding 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
(importantly regarding follow up for his incidental findings of
likely kidney cysts) 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: NEUROLOGY
Allergies:
Penicillins / Codeine / hydrocortisone acet-aloe ___ /
Cephalosporins
Attending: ___
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
Lumbar Puncture
History of Present Illness:
The pt is a ___ y/o LHW with a history of MS, Autoimmune
hepatitis (stable), HTN and urge incontinence presented as a
transfer from ___ for ___ time Sz.
History gathered from pt herself. States that she has been
battling a cold for the past several days, perhaps worse the
past
two days, with feeling hot/cold, malaise, headache, myalgia and
arthralgia. She reports poor sleep for the past two days. Went
to
sleep around 7 pm yesterday and around 5 am was noted by her
husband to be having a "seizure" with which she states was her
being tight all over. The time is not known as her husband is
not
here yet. She was confused afterward and it took her several
minutes to start to know where she was at and who was around
her.
She had bite her tongue and had urinary incontinence. This is a
first time event, denies any LOC before. As she was sleeping
does
not remember any type of aura. Denies Febrile seizures as a kid.
Notes no new medications other then the Copaxone 2 months ago.
Other then feeling sleepy now reports that she is back to
baseline, no weakness, no changes to vision but did note some
intermittent blurry vision over the past several days. Stated
had
not taken the lyrica x 2 days.
Husband arrived: States woke up to grunting noises. saw her with
arms tonically flexed, eyes open and rolled back, not
responsive,
no head turn. Lasted <5 min, confused for ___ min afterwards
then an hour later another event. This time found on floor,
lasted again < 5 min and again confused for about 20 min
afterward.
On neuro ROS, the pt denies loss of vision, dysarthria,
dysphagia, lightheadedness, vertigo, hearing difficulty. Denies
difficulties producing or comprehending speech. Denies focal
weakness, numbness, parasthesiae. No bowel incontinence.
On general review of systems, the pt supports fever, chills,
night sweats, cough, diarrhea.
No shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, constipation or
abdominal
pain. No dysuria. Denies rash.
Past Medical History:
Autoimmune hepatitis
Anxiety
Obesity
HTN
MS with ___
Social History:
___
Family History:
No seizures
Physical Exam:
Vitals: 98.2 86 131/79 16 99% 2L
General: Awake, cooperative, NAD.
HEENT: NC/AT, MMM. + Tongue bite
Neck: No nuchal rigidity
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2
Abdomen: soft, NT/ND.
Extremities: No edema or deformities.
Skin: no rashes.
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. There were no paraphasic errors. Pt. was able
to name fingers. Speech was not dysarthric. Able to follow both
midline and appendicular commands. Pt. was able to register 3
objects and recall ___ at 5 minutes. Current knowledge
demonstrated with knowledge of the president and republican
nominee . There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: Left pupil 4mm right 3mm. L- RAPD VFF to confrontation.
III, IV, VI: EOMI with endgaze nystagmus 4 beats b/l. 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 increased in ___. No pronator drift
bilaterally.
No tremor, asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
-Sensory: No deficits to light touch, cold sensation, vibratory
sense, proprioception (at the toes).
-DTRs: grade 3 throughout.
Plantar response was flexor bilaterally.
-Coordination: Dysmetria on FNF with the left hand..
Pertinent Results:
___ 12:55PM URINE HOURS-RANDOM
___ 12:55PM URINE UCG-NEGATIVE
___ 12:55PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 12:55PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 12:55PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 12:55PM URINE RBC-2 WBC-2 BACTERIA-FEW YEAST-NONE
EPI-3
___ 12:55PM URINE MUCOUS-RARE
___ 12:00PM GLUCOSE-93 UREA N-6 CREAT-0.6 SODIUM-140
POTASSIUM-3.5 CHLORIDE-105 TOTAL CO2-24 ANION GAP-15
___ 12:00PM estGFR-Using this
___ 12:00PM ALT(SGPT)-21 AST(SGOT)-25 ALK PHOS-58 TOT
BILI-0.2
___ 12:00PM ALBUMIN-4.3 CALCIUM-9.1 PHOSPHATE-2.4*
MAGNESIUM-2.1
___ 12:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 12:00PM WBC-11.1*# RBC-4.92 HGB-13.1 HCT-39.0 MCV-79*
MCH-26.6* MCHC-33.5 RDW-13.6
___ 12:00PM NEUTS-81.9* LYMPHS-11.2* MONOS-6.3 EOS-0.3
BASOS-0.3
___ 12:00PM PLT COUNT-262
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST CULTURE (Preliminary):
The sensitivity of an AFB smear on CSF is very low..
If present, AFB may take ___ weeks to grow..
VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED.
CSF totprot 31 glucose 64 WBC 16 RBC 3
HSV-neg enterovirus-neg EBV- neg toxoplasma-neg
Urine culture-neg
Cryptococcal antigen-neg
CMV-neg
MRI brain ___:
There are new nonenhancing signal abnormalities in bilateral
cerebellum without significant mass effect on the fourth
ventricle.
Additionally, there are supratentorial nonenhancing white matter
lesions which
are unchanged from the prior examination and most likely
represent sequela of
demyelinating disease. There is no hydrocephalus or acute
ischemia. There is
a mucosal thickening in the left maxillary sinus. There are
air-fluid levels
in the sphenoid sinus.
No evidence for acute ischemia is noted. There is an
inflammatory cyst in the
nasopharynx.
IMPRESSION:
1. Nonenhancing signal abnormalities in the cerebellum could
represent
sequela of viral infection, listeria or ADEM.
2. Unchanged supratentorial scattered white matter lesion.
MRI cervical spine:
The previously noted multifocal cord lesions have resolved to a
large extent and no enhancing lesions are noted. There are mild
degenerative
changes including disc osteophyte complexes at C6-C7 effacing
the anterior
thecal sac, which is unchanged. No enhancement is seen.
There is no suspect marrow lesion.
IMPRESSION:
Resolution of previously noted multifocal cord lesions, no
enhancement.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. ALPRAZolam 0.5 mg PO DAILY:PRN anxiety
2. Sertraline 150 mg PO DAILY
3. Pregabalin 100 mg PO BID
4. Copaxone *NF* (glatiramer) unknown Subcutaneous daily
5. Propranolol 20 mg PO BID
Discharge Medications:
1. Sertraline 150 mg PO DAILY
2. Propranolol 20 mg PO BID
3. Pregabalin 100 mg PO BID
4. LeVETiracetam 750 mg PO BID
RX *levetiracetam [___] 750 mg 1 tablet(s) by mouth twice
daily Disp #*60 Tablet Refills:*3
5. Clonazepam 0.5 mg PO BID
RX *clonazepam 0.5 mg 1 tablet(s) by mouth twice daily Disp #*60
Tablet Refills:*0
6. Copaxone *NF* (glatiramer) 0 mg SUBCUTANEOUS DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Seizure
Multiple Sclerosis
Aseptic Meningitis
Discharge Condition:
A&Ox3. Neck FROM. Neg kernig and ___. EOMI. VFF, PERRL.
RAPD. Face symmetric. No pronator drift. Strength: full in ___.
4+ deltoid b/l. 4+ L tricep and 5 R tricep. Decreased
proprioception on the left arm. DTR: ___ 3+, brisk b/l. toes
downgoing.
Followup Instructions:
___
Radiology Report
INDICATION: Productive cough for the past two to three days, now with new
onset seizure. Assess for pneumonia.
COMPARISON: None.
FINDINGS: The lungs are clear. The heart size is normal. The mediastinal
contours are normal. There are no pleural effusions. No pneumothorax is
seen. There is 1.6 cm density overlying the posterior aspect of a mid
thoracic vertebral body, possibly related to the osseous structures.
IMPRESSION:
1. No acute cardiac or pulmonary process.
2. 1.6 cm density overlying the posterior aspect of a mid thoracic vertebral
body on the lateral view, possibly related to the osseous structures.
Recommend follow-up radiographs in 3 months.
Radiology Report
TECHNIQUE: MRI of the brain without and with gad.
HISTORY: MS with first seizure.
COMPARISON: ___.
FINDINGS: There are new nonenhancing signal abnormalities in bilateral
cerebellum without significant mass effect on the fourth ventricle.
Additionally, there are supratentorial nonenhancing white matter lesions which
are unchanged from the prior examination and most likely represent sequela of
demyelinating disease. There is no hydrocephalus or acute ischemia. There is
a mucosal thickening in the left maxillary sinus. There are air-fluid levels
in the sphenoid sinus.
No evidence for acute ischemia is noted. There is an inflammatory cyst in the
nasopharynx.
IMPRESSION:
1. Nonenhancing signal abnormalities in the cerebellum could represent
sequela of viral infection, listeria or ADEM.
2. Unchanged supratentorial scattered white matter lesion.
Radiology Report
TECHNIQUE: MRI of the cervical spine without and with gad.
HISTORY: Multiple sclerosis.
___.
FINDINGS: The previously noted multifocal cord lesions have resolved to a
large extent and no enhancing lesions are noted. There are mild degenerative
changes including disc osteophyte complexes at C6-C7 effacing the anterior
thecal sac, which is unchanged. No enhancement is seen.
There is no suspect marrow lesion.
IMPRESSION:
Resolution of previously noted multifocal cord lesions, no enhancement.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: SEIZURE
Diagnosed with OTHER CONVULSIONS, MULTIPLE SCLEROSIS
temperature: 98.2
heartrate: 86.0
resprate: 16.0
o2sat: 99.0
sbp: 131.0
dbp: 79.0
level of pain: 7
level of acuity: 2.0 | This is a ___ y/o LHW with hx of autoimmune hepatitis and
Multiple sclerosis who presents with first time seizure x 2 in
the context of a gastrointestinal illness and poor sleep over
the prior week.
Neuro: Patient was admitted to the general neurology service.
She was monitored on telemetry. She had a routine EEG which
showed no activity suggestive of seizure. She had an MRI which
showed abnormal patchy signal intensity in the cerebellum. It
was unclear whether this was a progression of her MS or an
infectious process. Given her history of headache, neck pain and
photophobia the evening prior to her seizure we were concerned
for meningitis so covered her broadly with antibiotics. She has
multiple antibiotic allergies so the coverage included
acyclovir, IV bactrim (for listeria), vancomycin and
moxifloxacin. She had a lumbar puncture which showed mildly
elevated white blood cell count. This could have been due to her
recent seizure or a viral meningitis. Because of the lymphocyte
predominant CSF her antibiotics were stopped. She was continued
on acyclovir until the HSV PCR returned negative.
The patient was started n Keppra for seizure prevention. She had
no further seizures. Our current thinking is that she had a
seizure in the setting of underlying MS lesions combined with a
viral meningitis. We also changed her xanax to clonazepam
because of the increased seizure risk with xanax.
Transition issues: She will follow up with Dr. ___ week
___ studies: arbovirus, ___ virus, Listeria antibody, lyme
serology |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / shellfish derived / tape
Attending: ___
Chief Complaint:
Hypotensions/Altered Mental Status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old AA female with morbid obesity, HTN, HLD, DM II,
transferred from ___ after presyncopal episode.
Pt stated that about 2 weeks ago, she had ___ appointment with
her ___ doctor, and was asked to increase her metoprolol
tartrate 50 mg bid to ___ mg daily and irbesartan from 150 mg to
300 mg daily. She believed that she was instructed to take the
three of her old metoprolol tablets all at once and irbesartan
300 mg both in the morning. In the past 10 days, pt had
experienced intermittent lightheadedness, and blurry vision,
described as dark vision. Her symptoms typically goes away after
lying down, and happened more frequently during the day than at
night. She has attributed that to hypoglycemia, although her
sugar had been fine. Yesterday, pt was with her sister at ___
___, and again felt lightheadedness and black vision.
She experienced a near syncope, and collapsed on a bench. There
were questions whether pt had LOC, although pt appeared to
remember events fairly well. ___ MD from ___ clinic in that club
was notified, and reportedly found that her SBP was in ___ with
FSBS ~140. EMS was called, and pt was subsequently transferred
to ___. During the entire event, pt denied any chest
pain, SOB, N/V, arm/leg weakness or jerking.
While at ___, pt's heart rate was in ___, and SBP was
70-80s. EKG showed <1mm ST elevation in II. Lab showed baseline
CBC, CHEM7, negative TnI, and lactate at 2.2. CXR and CT head
were both normal. Pt was given 2 Liter NS, with temporary
unsustained BP increase to 100s. At that time, chronic beta
blocker toxicity was suspected, and pt was given 5 mg glucagon
with improvement of BP to 100-110s and HR to ___. Pt was given
another 5 mg glucagon, and transferred to ___, as there were
only 5 mg more glucagon left in the entire ___.
While at the ___ here, initial VS were 93 108/61 16 98% RA.
Workup showed similar findings as at ___. Toxicology were
consulted in the ___. No additional glucagon was given.
Past Medical History:
diabetes mellitus type II
hypertension
hypercholesterolemia
obesity
asthma
anxiety
depression
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - Temp 97.9F, BP 137/82, HR 93, R 20, O2-sat 97% RA
GENERAL - well-appearing obese female in NAD, comfortable,
appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, JVD not appreciated secondary to
body habbitus, 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 - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
DISCHARGE PHYSICAL EXAM:
VS - Temp 97.9F, 97.7, BP 137/82, 139/83, HR 93-98, R 20, O2-sat
97% RA
GENERAL - obese female, A+O x 1, lethargic with slurred speech
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, JVD not appreciated secondary to
body habbitus, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - RRR, ___ SEM
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
Pertinent Results:
ADMISSION LABS:
___ 08:25PM BLOOD WBC-9.7 RBC-3.89* Hgb-10.2* Hct-32.1*
MCV-82 MCH-26.2* MCHC-31.7 RDW-15.6* Plt ___
___ 08:25PM BLOOD Glucose-202* UreaN-20 Creat-0.9 Na-136
K-4.5 Cl-100 HCO3-24 AnGap-17
___ 08:25PM BLOOD Albumin-4.0 Calcium-9.0 Phos-4.7* Mg-1.6
___ 06:55AM BLOOD Free T4-1.2
___ 06:55AM BLOOD TSH-0.59
___ 09:51AM BLOOD Type-ART pO2-75* pCO2-43 pH-7.44
calTCO2-30 Base XS-4
___ 09:07PM BLOOD Lactate-1.7
___ 07:40PM URINE Color-Straw Appear-Clear Sp ___
___ 07:40PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR
___ 07:40PM URINE RBC-0 WBC-1 Bacteri-NONE Yeast-NONE Epi-1
RenalEp-<1
___ 09:07PM BLOOD Lactate-1.7
DISCHARGE LABS:
___ 06:55AM BLOOD WBC-7.6 RBC-3.99* Hgb-10.4* Hct-33.2*
MCV-83 MCH-26.1* MCHC-31.3 RDW-15.8* Plt ___
___ 06:55AM BLOOD Glucose-221* UreaN-13 Creat-0.8 Na-137
K-4.6 Cl-101 HCO3-27 AnGap-14
___ 06:55AM BLOOD Calcium-9.1 Phos-3.7 Mg-1.6
___ 09:51AM BLOOD Type-ART pO2-75* pCO2-43 pH-7.44
calTCO2-30 Base XS-4
IMAGING:
CXR ___:
IMPRESSION:
No acute cardiopulmonary abnormality.
EKG ___:
Sinus rhythm. Non-specific ST-T wave flattening. Otherwise,
within normal
limits and no significant change compared to previous tracing of
___
MICRO:
BLOOD CULTURES ___: NEGATIVE
URINE CULTURES ___: NEGATIVE
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Vitamin D ___ UNIT PO DAILY
2. Omeprazole 20 mg PO DAILY
3. Gabapentin 300 mg PO BID
4. Metoprolol Tartrate 50 mg PO TID
5. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
Do Not Crush
6. Lorazepam 1 mg PO HS:PRN insomnia
7. Levemir 60 Units Breakfast
Levemir 60 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
8. irbesartan *NF* 300 mg Oral qd
9. Oxycodone-Acetaminophen (5mg-325mg) 2 TAB PO Frequency is
Unknown
10. Fluticasone Propionate NASAL 1 SPRY NU DAILY
11. Cyclobenzaprine 10 mg PO DAILY:PRN muscle spasm
12. Escitalopram Oxalate 40 mg PO QHS
13. Rosuvastatin Calcium 40 mg PO DAILY
14. Multivitamins 1 TAB PO DAILY
15. Aspirin 81 mg PO DAILY
16. Amitriptyline 50 mg PO HS
17. ALPRAZolam 0.5 mg PO TID:PRN anxiety
18. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB, wheeze
19. Byetta *NF* (exenatide) 10 mcg/0.04 mL Subcutaneous bid
subcu injection before breakfast and dinner
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB, wheeze
2. Aspirin 81 mg PO DAILY
3. Byetta *NF* (exenatide) 10 mcg/0.04 mL Subcutaneous bid
subcu injection before breakfast and dinner
4. Fluticasone Propionate NASAL 1 SPRY NU DAILY
5. Multivitamins 1 TAB PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Rosuvastatin Calcium 40 mg PO DAILY
8. Vitamin D ___ UNIT PO DAILY
9. Amitriptyline 50 mg PO HS
10. Cyclobenzaprine 10 mg PO DAILY:PRN muscle spasm
do NOT take if confused, doing heavy activity as this can cause
sedation
11. Escitalopram Oxalate 40 mg PO QHS
12. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
Do Not Crush
13. Oxycodone-Acetaminophen (5mg-325mg) 2 TAB PO Q6H:PRN pain
14. Metoprolol Tartrate 25 mg PO TID
RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth three times a
day Disp #*90 Tablet Refills:*0
15. Levemir 60 Units Breakfast
Levemir 60 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
16. irbesartan *NF* 150 mg Oral daily
RX *irbesartan 150 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
17. Blood pressure cuff
Diagnosis: Hypertension
ICD-9: 401
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
iatrogenic hypotension
Secondary:
___, prerenal
Diabetes mellitus type iI
Hypertension
depression
anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Dizziness, lightheadedness, fatigue.
TECHNIQUE: Upright AP view of the chest.
COMPARISON: Reference chest radiograph from ___ at 13:45.
FINDINGS:
The heart size is normal. Mediastinal and hilar contours are unremarkable,
and the lungs are clear. No pleural effusion or pneumothorax is present. The
pulmonary vascularity is normal. No acute osseous abnormalities are present.
IMPRESSION:
No acute cardiopulmonary abnormality.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: WEAKNESS SYNCOPE
Diagnosed with HYPOTENSION NOS
temperature: 97.6
heartrate: 93.0
resprate: 16.0
o2sat: 98.0
sbp: 108.0
dbp: 61.0
level of pain: 0
level of acuity: 2.0 | ___ year old AA female with morbid obesity, HTN, HLD, IDDM,
transferred from ___ after presyncopal episode throught
to be ___ orthostasis from hypovolemia/BB toxicity, with AMS in
AM. AMS resolved with time and was likely ___ use of multiple
sedating/sleep aid medications given at ___ innapropriate time.
# AMS
Pt was A+O x 0, confused and lethargic when awoken in the
morning of her first hospital day. This episode resolved. There
were no focal neurologic signs. ABG was wnl, serum tox screen
was negative, TFTs wnl. CTH at OSH was also wnl. This likely
occurred in the setting of multiple sedating meds given
overnight instead of her usual 9pm, including gabapentin,
ativan, amitryptiline, and escitalopram. Alprazolam, lorazopam
and gabapentin were held at discharge and patient was encouraged
to follow up with her pcp prior to ___ these meds.
# Hypotension:
Given the history and time course, most likely iatrogenic in the
setting of recent uptitration of irbesartan and metoprolol. Pt
has been inappropriately taking metoprolol tartrate 150 mg qAM
for two weeks. The lack of tachycardia in the setting of
hypotension and response to glucagon at ___ were
consistent with beta blocker effect. DDx includes autonomic
neuropathy from DM (although no prior hx of such events), volume
depletion of other etiology (poor inake, etc.). VSS and no
events on tele. EKG was wnl. TnT negative. Metoprolol and
irebsartan were changed to original doses and patient was
discharged with ___ ambulatory blood pressure cuff/encouraged to
return if BP elevated or low.
# ___:
Pt's baseline cr was 0.7 in ___. She presented with Cr 1.3 at
___ and trended to baseline (0.8). ___ was likely in the
setting of hypotension.
# DM II:
Pt has poorly controlled DM2 (A1c in ___ was 9.8) and has
been followed by ___. Patient was continued on her home DM
regimen (with exception of metformin, which was re-started on
discharge).
# Hyperlipidemia: Continued rosuvastatin.
# CAD: Continued ASA 81 for primary prevention
# Vitamin D deficiency: Continued vitamin D 2000U
# GERD: Continued Omeprazole 20 mg qd |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Cough, diarrhea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with PMHx of COPD ___ FEV1 40% predicted FEV1/FVC
0.4), HLD, HTN, essential tremor, h/o possible seizure (vs.
syncope), h/o probable CVA (pontine lacunar), glaucoma, moderate
pHTN, 1+TR, who presents with cough and dyspnea.
Pt reports that for the past 3 weeks, she has had progressively
worsening generalized weakness, cough productive for yellow
sputum, SOB and chills. In the setting of cough, pt developed
some stress incontinence. She also reports
unsteadiness/pre-syncope and thus presented to the ED.
On ROS, pt denies fever, n/v, chest pain, abdominal pain, ___
edema, falls, syncope, dysuria, diarrhea, h/o DVT or PE. 10
point ROS otherwise negative.
In the ED, initial VS: T 98.2, P ___ (-> 82), BP 126/59, R 18,
O2 Sat 93% RA. Labs were notable for pCO2 49 on VBG, HCT 45.7,
WBC 13.7. Flu PCR was negative. CXR showed emphysema and RLL
opacity concerning for atelectasis or PNA. Pt received
Azithromycin 500mg, Prednisone 60mg, duonebs and 1L NS.
Currently, pt reports feeling better than she did prior to
arrival
Past Medical History:
COPD ___ FEV1 40% predicted FEV1/FVC 0.4), HLD, HTN,
essential tremor, h/o possible seizure (vs. syncope), h/o
probable CVA (pontine lacunar), glaucoma, moderate pHTN, 1+TR,
sp bl cateract surgery
Social History:
___
Family History:
Per record:
Mother - history of tremor, gastric ca
Father - died of CAD
Physical Exam:
ADMISSION EXAM:
VS: 98.5, 113/60, 95, 18, 95%3L
Gen: Thin female with resting tremor, NAD, coughing occasionally
HEENT: PERRL, EOMI, +nontender anterior R cervical LAD
Lungs: Trace RLL wheeze, diminished air movement throughout; no
crackles
Heart: RRR, no MRG, nl s1 and s2
Abd: Soft, NTND, no HSM
Ext: FROM, no c/e/e
Skin: Erythema/chronic stasis changes and scaling in ___
Neuro: CNII-XII intact; strength ___ in UE and ___ bl
97.4 114/44 74
attentive and not confused
slight inc breath sounds at her R base which were quite over the
weekend
no focal wheezes
no peripheral edema
Pertinent Results:
ADMISSION LABS:
======================
___ 11:11AM BLOOD WBC-13.7*# RBC-4.69 Hgb-14.5 Hct-45.7*
MCV-97 MCH-30.9 MCHC-31.7* RDW-15.0 RDWSD-53.7* Plt ___
___ 11:11AM BLOOD Neuts-85.6* Lymphs-4.4* Monos-8.3
Eos-0.0* Baso-0.2 Im ___ AbsNeut-11.74*# AbsLymp-0.60*
AbsMono-1.14* AbsEos-0.00* AbsBaso-0.03
___ 11:11AM BLOOD Glucose-134* UreaN-40* Creat-0.9 Na-145
K-4.6 Cl-101 HCO3-27 AnGap-22*
___ 11:21AM BLOOD ___ pO2-21* pCO2-49* pH-7.37
calTCO2-29 Base XS-0
___ 11:21AM BLOOD O2 Sat-23
___ 11:21AM BLOOD Lactate-2.0
MICRO:
======================
___ BLOOD CULTURES:
___ VIRAL PANEL: negative
IMAGING:
======================
CXR ___:
FINDINGS:
AP upright and lateral views of the chest provided. Lungs
appear
hyperinflated and lucent consistent with emphysema. There is
subtle
predominately linear opacity in the right lower lung which may
represent atelectasis and/or pneumonia. No large effusion or
pneumothorax. No overt evidence for pneumonia.
Cardiomediastinal silhouette is stable. Bony structures appear
intact.
IMPRESSION:
Emphysema with subtle right lower lung opacity which could
represent
atelectasis and/or pneumonia.
___ TTE:
The left atrium and right atrium are normal in cavity size. No
left atrial mass/thrombus seen (best excluded by transesophageal
echocardiography). No atrial septal defect is seen by 2D or
color Doppler. The estimated right atrial pressure is ___ mmHg.
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). The estimated cardiac
index is normal (>=2.5L/min/m2). 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
masses or vegetations are seen on the aortic valve, but cannot
be fully excluded due to suboptimal image quality. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. No masses or
vegetations are seen on the mitral valve, but cannot be fully
excluded due to suboptimal image quality. Moderate (2+) mitral
regurgitation is seen (clips 32, 35). There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Suboptimal image quality. Normal biventricular
cavity sizes with preserved regional and global biventricular
systolic function. Moderate mitral regurgitation with thickened
leaflets, but no discrete vegetation. Moderate pulmonary artery
systolic hypertension. The rhythm appears to be atrial
fibrillation with a rapid ventricular response.
Compared with the prior study (images reviewed) of ___,
the severity of mitral regurgitation is increased and the rhythm
now appears to be atrial fibrillation with a rapid ventricular
response.
If clinically indicated, a TEE would be better able to assess
the mitral valve for endocarditis and/or for a left atrial
appendage thrombus due to atrial fibrillation.
sputum
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
STREPTOCOCCUS PNEUMONIAE
|
CEFTRIAXONE----------- 0.5 S
ERYTHROMYCIN---------- =>1 R
LEVOFLOXACIN---------- <=0.5 S
PENICILLIN G---------- 2 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
___ 07:00AM BLOOD WBC-8.4 RBC-3.56* Hgb-11.2 Hct-34.0
MCV-96 MCH-31.5 MCHC-32.9 RDW-14.9 RDWSD-52.2* Plt ___
___ 07:00AM BLOOD Glucose-78 UreaN-23* Creat-0.9 Na-140
K-4.3 Cl-102 HCO3-33* AnGap-9
___ 07:00AM BLOOD ___
___ 07:05AM BLOOD cTropnT-0.01
___ 11:11AM BLOOD proBNP-50___
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: ___ with cough // eval for pneumonia
COMPARISON: ___
FINDINGS:
AP upright and lateral views of the chest provided. Lungs appear
hyperinflated and lucent consistent with emphysema. There is subtle
predominately linear opacity in the right lower lung which may represent
atelectasis and/or pneumonia. No large effusion or pneumothorax. No overt
evidence for pneumonia. Cardiomediastinal silhouette is stable. Bony
structures appear intact.
IMPRESSION:
Emphysema with subtle right lower lung opacity which could represent
atelectasis and/or pneumonia.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with COPD exacerbation, prior xray w concern
for concurrent PNA vs atelectasis // repeat assessment to attempt better
characterization if PNA is present repeat assessment to attempt better
characterization if PNA is present
IMPRESSION:
Comparison to ___. Better visualized than on the previous
examination are bilateral basal parenchymal opacities with air bronchograms,
likely reflecting pneumonia in the appropriate clinical setting. The lateral
radiograph also shows mild pleural effusions. No pneumonia, no pulmonary
edema. Signs of overinflation persists.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Cough, Diarrhea
Diagnosed with Chronic obstructive pulmonary disease w (acute) exacerbation, Hypoxemia
temperature: 98.2
heartrate: 120.0
resprate: 18.0
o2sat: 93.0
sbp: 126.0
dbp: 59.0
level of pain: 0
level of acuity: 2.0 | This is a ___ year old female with past medical history of severe
COPD, essential tremor, prior CVA, admitted ___ and
requiring urgent transfer to the ICU for respiratory distress
and new atrial fibrillation, now on steroids, this morning
triggering for tachypnea
# Acute Hypoxic Respiratory Failure / Acute COPD Exacerbation /
Acute Bacterial Pneumonia - patient presented with 3 weeks of a
productive cough. On admission patient triggered for hypoxia and
atrial fibrillation prompting ICU transfer. She was treated for
acute COPD exacerbation with Prednisone, azithromycin and nebs,
and continued on Advair, Flonase, and Loratadine. Following
transfer back to the floor, she triggered for worsening
respiratory symptoms and hypoxia--repeat workup showed CXR with
worsening opacities concerning for pneumonia. Patient also
reporting feeling like she was unable expectorate secretions.
She was started on broad spectrum antibiotics, underwent deep
suctioning and taught how to use flutter value, with slow
subsequent improvement over multiple days. Sputum culture grew
strep pneumaniae. She was transitioned from cefepime to IV
ceftriaxone on ___. She will continue for 2 additional days of
IV ceftriaxone on discharge to complete her last dose on ___
--continue antibiotic
--continue prednisone taper 40mg daily for 1 more week
--nebs
# AFIB WITH RVR - Patient found to be in new onset atrial
fibrillation with RVR, rates in the 130s-140bpms. TTE showed
2+MR, and she should discuss whether her afib is valve related
and warrants cardiology follow up with her PCP. Anticoagulation
indications and risks including bleeding were discussed w
patient and family and PCP participated in decision to
anticoagulate. She was started on Coumadin. Given history of
chronic stroke was started on heparin gtt but however given the
fact that stroke was chronic and her PTT remain elevated the
heparin drip was stopped before she was therapeutic with INR <2.
On day of discharge her INR was 1.7 and she had been on
Coumadin for several days at that point. . Rate control was
obtained with diltiazem. Dose of aspirin reduced to 81mg daily
# HISTORY OF PRIOR CVA: Continued home ASA, statin (simvastatin
changed to atrova)
# HTN: continued chronic home anti-HTN at time of discharge
# ESSENTIAL TREMOR - Continued primodine
# Glaucoma - continued dorzolamide, Latanoprost drops
TRANSITIONAL
[]REMOVE PIV WHEN DONE W IV ABX
[]ANTICOAGULATE MANAGEMENT, REFER TO ___ CLINIC
[]F/U WITH CARDS VS. PCP FOR AFIB |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Phenergan / Compazine / erythromycin / Sulfa (Sulfonamide
Antibiotics) / Penicillins / aspirin / carbamazepine /
meperidine / divalproex sodium / phenobarbital / iodine /
rifampin / Phenothiazines / phenytoin / Eszopiclone / daptomycin
/ Codeine / linezolid / azithromycin / hydrocodone / Dilantin /
Trileptal / vancomycin / Seroquel / Iodinated Contrast Media -
IV Dye
Attending: ___
Chief Complaint:
subjective fevers, dyspnea, headaches, losing blocks of time.
Major Surgical or Invasive Procedure:
General anesthesia for MRI
History of Present Illness:
___ y/o M with hx HIV/AIDS (most recent CD4 163 on ___ on
HAART, GERD, multiple joint replacements with prior L prosthetic
knee infection who presents with fever to 100.3 and dyspnea.
He was recently discharged from ___ on ___ for a similar
presentation with increasing dyspnea. CT chest during that
admission was suggestive of small viral airway process. Per ID,
his presentation was felt to be consistent with a viral versus
PJP PNA. He was therefore started on empiric treatment fo PJP
with atovaquone 750 mg BID x 21 days (completed). Bronchoscopy
was deferred during that admission due to concern for risks of
anesthesia. He had a negative b-d-glucan from ___.
He represents today with similar symptoms as fever to 100.3 as
noted above. In the ED, initial vitals were 97.0 76 123/82 20
97% on RA; with ambulation his O2 sats dropped to 91% on RA.
Initial labs notable for wnl Chem7, WBC 1.6 (53.9% neuts, at
baseline), H/H 10.3/35.1 (at baseline), Plt 75 (baseline
80-90s). The patient did receive a dose of ceftriaxone as well
as atovaquone. However, there was no evidence of a PNA on CXR so
the patient was felt to need any further ceftriaxone. Repeat
b-d-glucan was sent.
The patient states that he is feeling nauseous and requesting IV
Ativan. He had one episode of bilious emesis prior to arrival.
He endorses cough and states he had "tasted blood" but does not
think he can producie sputum. He denies abdominal pain, chest
pain. He endorses lightheadedness and headache. He is concerned
because he says he has had episodes of "blacking out" where he
loses track of time. No bowel or bladder incontinence.
Past Medical History:
ADHD
HIV INFECTION
HIV-RELATED NEUROPATHY
ADHD
DIVERTICULITIS
CHRONIC HBV
CRYPTOSPORIDIUM DIARRHEA
GASTROESOPHAGEAL REFLUX
BACK PAIN
KNEE PAIN
DIFFUSE BODY ACHES AND PAINS
SINUSITIS
IGA DEFICIENCY
DEPRESSION
ASTHMA
MORBID OBESITY
PAST SURGICAL HISTORY:
- Bilateral knee replacements
- Hemiarthroplasty of the left shoulder
- Bilateral hemiarthroplasty of the hips
- Total knee replacements
Social History:
___
Family History:
The patient has no relevant past medical history.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98 138/85 69 18 96% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, soft II/VI SEM across precordium
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, obese, non-tender, non-distended, bowel sounds
present, no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, scars from prior knee
surgery but no joint swelling/redness
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation
DISCHARGE PHYSICAL EXAM:
VS -98.4, 122/74, 67, 18, 97% on RA
General: morbidly obese man laying comfortably in bed in NAD,
breathing comfortably, tearful
HEENT: No cervical lymphadenopathy appreciated. no
oropharyngeal lesions, no thrush seen.
Neck: supple, no JVD appreciated.
CV: Normal S1, S2. No r/m/g.
Lungs: CTAB.
Abdomen: BS+, soft, non-distended, NTTP.
Ext: 1+ DP pulses b/l. skin changes consistent with chronic
venostasis on b/l LEs. one erythematous patch with scale on L
arm.
Neuro: CN II-XII grossly intact. AAOX3
Pertinent Results:
ADMISSION LABS:
___ 09:53PM BLOOD Lactate-2.0
___ 09:33PM BLOOD Albumin-4.3
___ 09:33PM BLOOD ALT-18 AST-31 LD(LDH)-269* AlkPhos-92
TotBili-0.3
___ 09:33PM BLOOD Glucose-146* UreaN-18 Creat-1.0 Na-140
K-4.4 Cl-103 HCO3-25 AnGap-16
___ 09:33PM BLOOD WBC-1.6* RBC-4.46* Hgb-10.3* Hct-35.1*
MCV-79* MCH-23.1* MCHC-29.3* RDW-18.3* RDWSD-50.2* Plt Ct-75*
DISCHARGE LABS:
___ 05:55AM BLOOD WBC-1.2* RBC-4.15* Hgb-9.7* Hct-32.5*
MCV-78* MCH-23.4* MCHC-29.8* RDW-18.5* RDWSD-51.6* Plt Ct-70*
___ 05:55AM BLOOD Glucose-183* UreaN-12 Creat-0.9 Na-140
K-4.3 Cl-104 HCO3-24 AnGap-16
___ 05:55AM BLOOD Calcium-8.7 Phos-4.3 Mg-2.3
IMAGING:
MRI head with contrast: 1. No evidence for intracranial
abnormalities.
2. Apparent swelling of bilateral nasal turbinates, atypical for
the expected
nasal cycle. Please correlate with any associated clinical
symptoms.
MRI Shoulder: Severe fatty atrophy of the sub scapularis muscle.
Evaluation limited by
susceptibility artifact from the shoulder hemiarthroplasty, but
no acute
process identified. The proximal extent of the humeral
prosthesis is not
visualized.
CT Chest w/o contrast: 1. Minimal scattered peribronchiolar
nodularity is persistent, but no longer
confluent and significantly improved compared to ___.
Mediastinal lymph
nodes remain minimally enlarged, but decreased compared to ___ and again
likely reactive.
2. Incidentally noted and partially imaged are a cirrhotic
morphology of the
liver and splenomegaly.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Adderall (dextroamphetamine-amphetamine) 15 mg ORAL DAILY
2. Adderall XR (dextroamphetamine-amphetamine) 30 mg ORAL DAILY
3. ARIPiprazole 5 mg PO DAILY
4. Cetirizine 5 mg PO DAILY
5. ClonazePAM 1 mg PO QHS:PRN insomnia
6. Duloxetine 60 mg PO BID
7. Famvir (famciclovir) 500 mg oral BID HSV prophylaxis
8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
9. FoLIC Acid 1 mg PO DAILY
10. LaMOTrigine 150 mg PO TID
11. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
12. Albuterol 0.083% Neb Soln 1 NEB IH PRN wheezing
13. Vitamin D ___ UNIT PO DAILY
14. Sonata (zaleplon) 10 mg ORAL QHS PRN insomnia
15. Simethicone 180 mg PO BID:PRN gas
16. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB, wheezing
17. Lidocaine 5% Patch 1 PTCH TD PRN muscle pain
18. Tamsulosin 0.4 mg PO HS
19. Senna 17.2 mg PO BID
20. Sucralfate 1 gm PO BID
21. Ropinirole 1 mg PO QHS
22. Oxybutynin 5 mg PO DAILY
23. Prazosin 2 mg PO QHS
24. Pregabalin 300 mg PO BID
25. Raltegravir 400 mg PO BID
26. Nystatin Cream 1 Appl TP BID apply to affected area
27. Levofloxacin 500 mg PO Q24H
28. Dronabinol 10 mg PO Q8H
29. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
30. Ranitidine 150 mg PO HS
31. Methadone 60 mg PO Q8H
32. Morphine Sulfate (Oral Soln.) 20 mg PO Q8H:PRN breakthrough
pain
33. Baclofen 10 mg PO TID
Discharge Medications:
1. Adderall (dextroamphetamine-amphetamine) 15 mg ORAL DAILY
2. Adderall XR (dextroamphetamine-amphetamine) 30 mg ORAL DAILY
3. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB, wheezing
4. ARIPiprazole 5 mg PO DAILY
5. Baclofen 10 mg PO TID
6. ClonazePAM 1 mg PO QHS:PRN insomnia
7. Dronabinol 10 mg PO Q8H
8. Duloxetine 60 mg PO BID
9. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
10. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
11. LaMOTrigine 150 mg PO TID
12. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
13. Levofloxacin 500 mg PO Q24H
14. Lidocaine 5% Patch 1 PTCH TD PRN muscle pain
15. Methadone 60 mg PO Q8H
16. Morphine Sulfate (Oral Soln.) 20 mg PO Q8H:PRN breakthrough
pain
17. Nystatin Cream 1 Appl TP BID apply to affected area
18. Oxybutynin 5 mg PO DAILY
19. Prazosin 2 mg PO QHS
20. Pregabalin 300 mg PO BID
21. Raltegravir 400 mg PO BID
22. Ranitidine 150 mg PO HS
23. Ropinirole 1 mg PO QHS
24. Senna 17.2 mg PO BID
25. Simethicone 180 mg PO BID:PRN gas
26. Sucralfate 1 gm PO BID
27. Tamsulosin 0.4 mg PO HS
28. Vitamin D ___ UNIT PO DAILY
29. Atovaquone Suspension 1500 mg PO Q24H
30. Albuterol 0.083% Neb Soln 1 NEB IH PRN wheezing
31. Famvir (famciclovir) 500 mg oral BID HSV prophylaxis
32. FoLIC Acid 1 mg PO DAILY
33. Sonata (zaleplon) 10 mg ORAL QHS PRN insomnia
34. Cetirizine 5 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
- Unknown
Secondary Diagnosis:
- HIV/AIDS on HAART
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: Evaluate for resolution of airways disease status post treatment
for PCP ___.
TECHNIQUE: Multidetector helical scanning 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.
DOSE: DLP: 721 mGy cm.
COMPARISON: CT chest from ___.
FINDINGS:
The airways are patent. There is been interval improvement/near resolution of
previously noted peribronchiolar nodularity with areas of confluence in the
right lower lobe. Minimal scattered peribronchiolar nodularity is persistent
(for example, 05:231), but no longer confluent and significantly improved
compared to ___. There is no pleural effusion or pneumothorax.
The thyroid gland is somewhat obscured by beam hardening artifact from the
left humeral prosthesis, but the imaged portion appears unremarkable. Mildly
enlarged mediastinal lymph nodes, measuring up to 10 mm in the right superior
paratracheal station and 11 mm in the subcarinal station are slightly
decreased in size compared to ___, and are again likely reactive. There
is no pathologic axillary lymph node enlargement by CT size criteria. The
heart is normal in size, without appreciable coronary artery calcification.
Great vessels are normal in caliber.
There is a left humeral prosthesis, resulting in beam hardening artifact,
which obscures the left axilla and supraclavicular regions. There is no acute
fracture or focal lytic or sclerotic lesion to suggest neoplasm or infection.
Multiple healed anterior left-sided rib fractures are unchanged.
Although this exam is not optimized for the evaluation of infra diaphragmatic
structures, the visualized upper abdomen demonstrates a nodular contour of the
liver compatible with a cirrhotic morphology. The spleen is enlarged.
IMPRESSION:
1. Minimal scattered peribronchiolar nodularity is persistent, but no longer
confluent and significantly improved compared to ___. Mediastinal lymph
nodes remain minimally enlarged, but decreased compared to ___ and again
likely reactive.
2. Incidentally noted and partially imaged are a cirrhotic morphology of the
liver and splenomegaly.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST
INDICATION: ___ year old man with HIV/AIDS CD4 163 presenting with subjective
fevers and headaches.
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 15 mL of Gadavist intravenous contrast, axial imaging was
performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal
MPRAGE imaging was performed and re-formatted in axial and coronal
orientations.
COMPARISON: None.
FINDINGS:
There is no evidence of an intracranial mass, and no pathologic parenchymal,
leptomeningeal, or pachymeningeal contrast enhancement. There is no evidence
for edema, abnormal diffusion, blood products, white matter lesions, or other
signal abnormalities in the brain parenchyma. The ventricles and sulci are
slightly prominent for age. Major arterial flow voids are grossly preserved.
Major dural venous sinuses appear patent on postcontrast MP RAGE images.
There is minimal mucosal thickening in the ethmoid air cells and mastoid air
cells. Swelling of bilateral nasal turbinates is noted. There is a small
amount of fluid layering in the nasopharynx.
IMPRESSION:
1. No evidence for intracranial abnormalities.
2. Apparent swelling of bilateral nasal turbinates, atypical for the expected
nasal cycle. Please correlate with any associated clinical symptoms.
Radiology Report
EXAMINATION: MR SHOULDER ___ CONTRAST LEFT
INDICATION: ___ year old man with shoulder pain // eval for shoulder pain.
needs anesthesia.
TECHNIQUE: Imaging performed at 1.5 test using the shoulder coil. Sequences
include axial T2, coronal proton density and STIR, sagittal T2 and sagittal T1
weighted sequences. Metal artifact reduction protocol was used in view of the
patient's left shoulder hemiarthroplasty.
COMPARISON: CT chest ___
FINDINGS:
Despite use of the metal artifact suppression technique, there is nonetheless
susceptibility related to the left shoulder prosthesis. The inferior extent
of the humeral prosthesis is not visualized on this study. Within these
limitations, no joint effusion is appreciated.
There is severe fatty atrophy of the sub scapularis muscle (03:19). Mild
fatty atrophy of infra spinatus (6:20). The distal portions of the rotator
cuff tendons could not be visualized due to susceptibility related to the
hardware. No tear seen in the visualized portions of the rotator cuff
tendons. Visualized portions of the deltoid muscle are unremarkable in
appearance. No axillary lymphadenopathy seen. No masses are seen along the
course of the suprascapular nerve, within the spinoglenoid notch or
quadrilateral space.
IMPRESSION:
Severe fatty atrophy of the sub scapularis muscle. Evaluation limited by
susceptibility artifact from the shoulder hemiarthroplasty, but no acute
process identified. The proximal extent of the humeral prosthesis is not
visualized.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED
temperature: 97.0
heartrate: 76.0
resprate: 20.0
o2sat: 97.0
sbp: 123.0
dbp: 82.0
level of pain: 8
level of acuity: 3.0 | ___ y/o M with hx HIV/AIDS (most recent CD4 163 on ___ on
HAART, GERD, multiple joint replacements with prior L prosthetic
knee infection on suppressive levofloxacin and atovaquone who
presented with subjective fevers, headaches, and DOE, and
"losing blocks of time." Brain MRI brain and CT chest were both
normal. Patient remained afebrile with normal SpO2 on room air
while in the hospital. Concern that blanking out episodes may be
related to seizures given h/o seizures and recommended
outpatient follow up. DOE possibly related to OSA or underlying
pulmonary disease.
#Fevers and DOE: The patient reported that he had fevers at home
to maximum 99.9. He could not correlate a time of day that
these occurred. He also felt that he could not walk from one
end of his house to the other like he used to, without shortness
of breath. ID was consulted and suggested a CT scan of the
chest to determine if the lung findings had improved with
treatment. The CT showed improvement in the nodularities
originally seen in the lungs. He was placed on prophylactic
doses of atovaquone. He otherwise remained afebrile in the
hospital and had regular O2Sats. On discharge, he was
instructed to follow up with Pulmonary Function Tests to
evaluate the source of his dyspnea.
#Losing blocks of time: Patient's partner said that he has
moments where he stares ahead and doesn't respond. Brain MRI
showed no intracranial lesions that could be contributing. Due
to the patient's history of seizures, he was instructed to
follow up with neurology.
#Headaches: The patient stated that along with his fevers he had
headaches throughout the day. An MRI brain with contrast was
negative for any intracranial lesions. Tylenol was used to help
treat his headaches. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Recurrent right breast abscess
Major Surgical or Invasive Procedure:
___ - I&D of recurrent R breast abscess
History of Present Illness:
___, 18 weeks pregnant, with history of recurrent right breast
abscess who presented with 3 days of painful, swollen right
breast with associated nausea and subjective fevers/chills. Pain
was ___. Pt reports stopping her abx two weeks ago. Of note,
she was recently hospitalized from ___ to ___ for the same
reason. During this admission, she underwent US-guided
aspiration of the
breast abscess with placement of pigtail drain catheter. Pt was
discharged with ___ in good condition on ___.
Past Medical History:
PNC: benign per pt; ___ ___ by early U/S
ObHx: none
GynHx: benign
MedHx: bipolar disorder
SurgHx: none
Social History:
___
Family History:
NC
Physical Exam:
Upon Discharge:
afebrile,VSS
GEN: NAD. Alert, oriented
HEENT: No scleral icterus. Mucous membranes mois.
Cardiac:RRR
Pulmonary:clear
Incision:R breast,no erythema, no drainage,dsg c/d/i
Abdomen: Soft, obese, nondistended, nontender
EXT: Warm without ___ edema/c/c
Pertinent Results:
RIGHT BREAST ULTRASOUND ___
Large fluid collection with debris in the retroareolar region
with a second adjacent superficial collection. These are highly
concerning for abscesses given the history.
RIGHT BREAST ULTRASOUND ___
Decreased size of retroareolar fluid collection compared to
recent ultrasound from ___. No drainable fluid
collection on today's study. Persistent edema of breast tissues
consistent with mastitis.
FETAL ULTRASOUND ___
single live intrauterine pregnancy, normal full fetal survey
___ 07:55AM BLOOD WBC-9.6 RBC-3.50* Hgb-9.4* Hct-29.6*
MCV-85 MCH-26.9* MCHC-31.8 RDW-14.5 Plt ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ferrous Sulfate 325 mg PO DAILY
2. Prenatal Vitamins 1 TAB PO DAILY
Discharge Medications:
1. Prenatal Vitamins 1 TAB PO DAILY
2. Ferrous Sulfate 325 mg PO DAILY
3. Acetaminophen 325-650 mg PO Q6H:PRN pain
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
5. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate [Augmentin] 875 mg-125 mg 1
tablet(s) by mouth every twelve (12) hours Disp #*60 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Recurrent right breast abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Recurrent right breast pain. History of recurrent breast
abscesses.
COMPARISONS: Right breast ultrasound from ___.
TECHNIQUE: Gray-scale and Doppler ultrasound images were acquired through the
right breast in a targeted fashion from 12 to 6 o'clock in the area of
concern.
FINDINGS: In the retroareolar region, there is a 6 x 5 x 2.5 cm fluid
collection with abnormal internal debris. Additionally, there is a second
more superficial fluid collection which is medial to the dominant collection.
This measures approximately 2.8 x 1 cm. It is unclear whether these two
collections are connected or separate. There is increased vascularity and
evidence of edema within the breast tissue. The subcutaneous tissue is
thickened.
IMPRESSION:
Large fluid collection with debris in the retroareolar region with a second
adjacent superficial collection. These are highly concerning for abscesses
given the history.
Radiology Report
INDICATION: Right breast abscess, status post incision and drainage. Please
evaluate for drainable collection
COMPARISON: Right breast ultrasound from ___.
RIGHT BREAST ULTRASOUND: Ultrasound evaluation was performed of the
retroareolar right breast in the area of erythema and firmness as indicated by
the patient. There is marked edema of the subcutaneous and breast tissues
induration consistent with ongoing inflammation. There is a small
retroareolar fluid collection which connects with the incision and drainage
site along the areola. This collection has overall decreased in size when
compared to the recent ultrasound from ___. At present, there is no
drainable collection.
IMPRESSION: Decreased size of retroareolar fluid collection compared to
recent ultrasound from ___. No drainable fluid collection on
today's study. Persistent edema of breast tissues consistent with mastitis.
Findings were discussed with the patient in person by Dr. ___ at the
conclusion of the study.
BI-RADS 2 - benign findings.
Radiology Report
HISTORY: Full fetal survey.
COMPARISON: ___.
LMP: ___.
FINDINGS:
There is a single live intrauterine gestation in breech presentation. The
placenta is posterior. There is no evidence of placenta previa. There is
normal amount of amniotic fluid. No fetal morphological abnormalities are
detected. Views of the head, face, heart, outflow tracts, stomach, kidneys,
cord insertion site, bladder, spine, three-vessel cord and extremities were
normal. The uterus is normal. No adnexal abnormalities were seen.
The following biometric data were obtained.
BPD is 19 weeks and 1 day.
HC is 19 weeks and 0 days.
AC is 19 weeks and 5 days.
FL is 19 weeks and 1 day.
Age by ultrasound is 19 weeks and 2 days.
Age by dates is 19 weeks and 2 days.
Compared to the prior study there has been appropriate interval growth.
IMPRESSION:
Single live intrauterine pregnancy with size equal dates with normal full
fetal survey, with limited views of nose and lips.
Gender: F
Race: OTHER
Arrive by AMBULANCE
Chief complaint: RIGHT BREAST ABSCESS
Diagnosed with BREAST ABSCESS-ANTEPART
temperature: 98.5
heartrate: 99.0
resprate: 16.0
o2sat: 99.0
sbp: 147.0
dbp: 57.0
level of pain: 8
level of acuity: 3.0 | Ms. ___ underwent I&D of her recurrent right breast abscess on
___. Reader is referred to the Operative Note for details.
Thereafter, she was admitted to the surgical floor for further
care.
Neuro: She was given appropriate pain control, and expressed
good control with oral medications.
CV: Stable throughout, no issues
Resp: Stable throughout, no issues
GI/FEN: She was given a regular diet after her procedure, which
she tolerated well, with no issues. She did note some nausea on
POD#1, which she attributed to pregnancy-related physiological
changes.
ID: She was maintained on a course of IV Unasyn while in-house.
Prior to discharge, she was transitioned to oral Augmentin, and
given a prescription for this. Her WBC count was monitored and
noted to normalize by POD#1. She had no fevers/chills
post-operatively. Her wound dressing was changed daily, and her
wound was monitored closely for any signs of worsening - none
were noted.
Other: OB/Gyn was consulted for appropriate recommendations in
the context of her pregnancy. Fetal HR monitoring was performed
by them pre-operatively and post-operatively. They provided
detailed recommendations on appropriate antibiotics and pain
control in pregnancy, which were followed. She was also
continued on her home prenatal vitamin. She was explained the
urgency and importance of establishing and continuing pre-natal
care with an OB/Gyn physician once discharged from the hospital.
At the time of discharge, she expressed feeling prepared to
complete her recovery outside the hospital. She was explained
and expressed agreement with the discharge plan, key elements
including: the importance of completing her full course of
antibiotics, monitoring the wound site closely with daily
dressing changes, and establishing Ob/Gyn care. She was then
discharged home in good condition. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lipitor / Zoloft / hydroxylitic acid / Captopril / Propulsid /
Nifedipine / BuSpar / Paxil / Nortriptyline
Attending: ___.
Chief Complaint:
Diarrhea, fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr ___ is a ___ male with pancreatic adenocarcinoma on
gemcitabine c/b biliary obstruction, and a recent c. difficile
infection who presents with recurrent diarrhea and fevers. He
was admitted ___ to ___ with fevers and was found to have
c.diff, for which he was treated with 14 days of PO
metronidazole. He started cycle 2 of gemcitabine ___, at which
point his diarrhea had improved to 2 soft BM's daily.
He saw his primary oncologist ___, who held his gemcitabine
dose because of recurrent diarrhea and prescribed PO vancomycin.
The patient was unfortunately unable to obtain the medication
and continues to have diarrhea. The plan at that point was ID
consultation for recurrent Cdiff. Yesterday and today, he began
having soaking fevers with associated rigors. He was having ___
BMs per day, though he was able to continue drinking fluids and
was urinating. He denies dizziness or lightheadedness, though he
has been weak and unstable while walking. His BMs have become
more pale, like previously when he had cholestasis.
In ED/Clinic, initial vitals were: 99.8 124 103/69 18 98%
Exam was significant for a benign abdominal exam
Labs were significant for WBC 28, creatinine 1.7 from baseline
1.2 to 1.5, sodium 131 and elevated LFTs
Patient was given PO vancomycin, as well as morphine
Final vitals prior to transfer were 98.6 °F (37 °C), Pulse: 103,
RR: 18, BP: 110/51, O2Sat: 98
Access PIV
IVF: 2L NS given
On arrival to the floor, patient anxious, but reports feeling
fairly well. Denies pain, and is not sure why he was given
Morphine in the ED.
Past Medical History:
PAST ONCOLOGIC HISTORY: ___ initially presented in
___ with epigastric pain and was diagnosed with gallstone
pancreatitis. He presented again in ___ with painless
jaundice and on ___ underwent ERCP at which time biopsy
was nondiagnostic. MRI ___ showed narrowing of the
common bile duct and pancreatic duct without evidence of a
discrete mass. He was hospitalized at ___ ___ and
underwent ERCP, which showed a 1.2 cm stricture at the common
bile duct with postobstructive dilation. A metal biliary stent
was placed. On ___ he underwent endoscopic ultrasound,
and cytology from biopsy of a 2.0 x 1.5 cm pancreatic head mass
showed adenocarcinoma. CT angiogram and MRI showed the mass in
close proximity to and invading the portal vein and was thus
deemed unresectable. He was then hospitalized with acute
cholangitis and underwent percutaneous biliary drain placement.
Mr. ___ began gemcitabine chemotherapy ___.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
2. History of gallstone pancreatitis.
3. Cholelithiasis.
4. Chronic kidney disease.
5. Hypercholesterolemia.
6. Hypertension.
7. Anxiety.
8. GERD.
Social History:
___
Family History:
The patient's sister has a history of gallbladder carcinoma
diagnosed at ___ years. His daughter was diagnosed with a
pilocytic astrocytoma at ___ years. His son had a benign tumor
of the skull base, treated with radiation.
Physical Exam:
Vitals - T: 99.5 BP: 122/53 HR: 111 RR: 16 02 sat: 97% RA
GENERAL: NAD, diaphoretic
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition. Slight jaundice under the
tongue. Nontender supple neck, no LAD, no JVD
CARDIAC: RRR with frequent PVCs, S1/S2, II/VI systolic murmur
loudest at the base. No 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
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema, no obvious deformities
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:
___ 03:55PM WBC-28.1*# RBC-4.27* HGB-12.4* HCT-36.8*
MCV-86 MCH-29.1 MCHC-33.8 RDW-15.2
___ 03:55PM NEUTS-84.0* LYMPHS-6.7* MONOS-9.2 EOS-0
BASOS-0.1
___ 03:55PM PLT COUNT-291
___ 03:55PM GLUCOSE-104* UREA N-30* CREAT-1.7*
SODIUM-131* POTASSIUM-3.9 CHLORIDE-94* TOTAL CO2-21* ANION
GAP-20
___ 03:55PM ALT(SGPT)-93* AST(SGOT)-132* ALK PHOS-205*
TOT BILI-0.6
___ 03:55PM LIPASE-10
___ 03:55PM ALBUMIN-4.0
___ 05:55PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 05:55PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 05:55PM URINE RBC-1 WBC-4 BACTERIA-FEW YEAST-NONE
EPI-1
___ 05:55PM URINE GRANULAR-17* HYALINE-4*
CXR: No acute cardiopulmonary process.
Medications on Admission:
LIPASE-PROTEASE-AMYLASE [ZENPEP] - 15,000 unit-51,000
unit-82,000 unit Capsule, Delayed Release(E.C.) - ___ Capsule(s)
by mouth three times a day with meals
LORAZEPAM - (Prescribed by Other Provider) - 1 mg Tablet - 1
Tablet(s) by mouth once a day
METOPROLOL SUCCINATE - (Prescribed by Other Provider) - 50 mg
Tablet Extended Release 24 hr - 1 Tablet(s) by mouth twice a day
MIRTAZAPINE - (Prescribed by Other Provider) - 30 mg Tablet - 1
Tablet(s) by mouth once a day
OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule,
Delayed Release(E.C.) - 1 Capsule(s) by mouth once a day
OXYCODONE - 5 mg Tablet - ___ Tablet(s) by mouth every six (6)
hours
PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth
q6 hour as needed for nausea/vomiting
SIMVASTATIN - (Prescribed by Other Provider; Dose adjustment -
no new Rx) - 40 mg Tablet - 1 Tablet(s) by mouth once a day
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet,
Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day
Discharge Medications:
1. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 3 weeks.
Disp:*84 Capsule(s)* Refills:*0*
2. mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. lipase-protease-amylase 5,000-17,000 -27,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. cholestyramine (with sugar) 4 gram Packet Sig: One (1) Packet
PO BID (2 times a day) for 1 weeks: **** IMPORTANT ****
Please take this medication 3 hours after and 3 hours before the
vancomycin medication (Never at the same time).
Disp:*14 Packet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
- recurrrent c. dificile colitis
Secondary Diagnosis
- cholelithiasis
- pancreatic CA s/p CBD stent
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ male with chills, with pancreatic cancer, evaluate
for pneumonia.
COMPARISONS: Chest radiograph ___.
PA AND LATERAL VIEWS OF THE CHEST: The lungs are clear. The lung volumes are
low resulting in slight vascular crowding. There is no pleural effusion or
pneumothorax. No focal airspace consolidation to suggest pneumonia. The
heart size is top normal but unchanged. The mediastinal contours are
unremarkable. A metallic common bile duct stent is noted.
IMPRESSION: No acute cardiopulmonary process.
Radiology Report
PA AND LATERAL CHEST OF, ___
COMPARISON: Chest radiograph ___.
FINDINGS: Patchy opacity in the right infrahilar region is new compared to
the prior radiograph, and projects over the lower thoracic spine on the
lateral view. Lungs are otherwise clear, and cardiomediastinal contours are
stable in appearance.
IMPRESSION: Patchy right basilar opacity, which may reflect focal
atelectasis, aspiration, or early pneumonia. Followup radiographs may be
helpful in this regard.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Pancreatic adenocarcinoma, fevers, rule out pneumonia.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the pre-existing
parenchymal opacities that have been described have completely resolved. On
the current image, there is no evidence of pneumonia or other acute lung
disease. Borderline size of the cardiac silhouette with mild tortuosity of
the thoracic aorta but no evidence of pleural effusion. No pneumothorax.
Radiology Report
INDICATION: History of pancreatic cancer with recent diagnosis of C. diff,
refractory to treatment. Has persistent large volume diarrhea and abdominal
pain. Assess for colitis and rule out megacolon.
COMPARISON: Abdominal CT from ___ and ___.
TECHNIQUE: MDCT axial images were acquired through the abdomen and pelvis
following the administration of both oral and intravenous contrast material.
Multiplanar reformats were performed.
ABDOMEN CT: A 2-mm right middle lobe nodule is not significantly changed in
size compared to CT from ___. There is subsegmental bilateral lower
lobe atelectasis. A small right pleural effusion is not significantly changed
in size. Coronary artery calcifications are again seen.
No focal liver lesions are seen. Focal thrombus is again noted at the
confluence of the SMV and splenic vein, unchanged in appearance. The main
portal vein and its branches are patent. The degree of pneumobilia is not
significantly changed, not unexpected given the presence of a biliary stent,
unchanged in position. The gallbladder is contracted, limiting its
evaluation. There is irregularity and thickening of the gallbladder fundal
wall, possibly secondary to scarring in the setting of prior cholecystostomy
tube removal. Note is again made of gallstones within the gallbladder body/and
neck.
The spleen is normal in size. The pancreatic body and tail are atrophic and
there is mild dilation of the main pancreatic duct, not significantly changed,
in keeping with the known diagnosis of pancreatic carcinoma, although no
discrete pancreatic head mass is identified. The adrenal glands are
unremarkable. The left kidney is slightly atrophic. Small bilateral renal
hypodensities are too small to characterize, not significantly changed. The
stomach and small bowel are grossly unremarkable.
There is new diffuse colonic wall thickening, mild mucosal enhancement, and
pericolonic vascular injection/fat stranding, most prominent along the cecum
and ascending colon (2:37-62). The colon is normal in caliber. There is no
evidence of obstruction or pneumatosis. There is a small volume of ascites in
the perihepatic regions as well as in the bilateral paracolic gutters. Small
mesenteric lymph nodes do not meet CT size criteria. The abdominal aorta is
normal in caliber. Scattered aortic calcifications and regions of mural
thrombus are identified, not significantly changed. There are also bilateral
iliac artery calcifications. There is no free air in the abdomen.
PELVIS CT: The bladder is unremarkable. The prostate is enlarged. There is
no free fluid in the pelvis. No pathologically enlarged pelvic lymph nodes
are seen.
Non-occlusive thrombus is seen within the left greater saphenous vein, at the
level of its insertion on the left common femoral vein. The degree of clot
burden is decreased compared to prior CT from ___.
BONE WINDOW: No suspicious lytic or blastic lesions are identified.
Multilevel degenerative changes of the thoracolumbar spine are noted, most
severe at L5-S1.
IMPRESSION:
1. Findings consistent with pancolitis, most severe in the cecum and
ascending segment, in keeping with the patient's diagnosis of C. difficile
infection. No evidence of pneumatosis or megacolon.
2. Small volume ascites.
3. Small right pleural effusion.
4. Non-occlusive thrombus in the left greater saphenous vein, decreased in
size compared to the prior CT from ___.
Pertitent findings were discussed with Dr. ___ by Dr. ___ at 10:18 p.m.
via telephone on the day of the study.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: WEAK/FEVERISH/DIARRHEA
Diagnosed with CLOSTRIDIUM DIFFICILE, DEHYDRATION, MALIG NEO PANCREAS NOS
temperature: 99.8
heartrate: 124.0
resprate: 18.0
o2sat: 98.0
sbp: 103.0
dbp: 69.0
level of pain: 0
level of acuity: 2.0 | ___ male with pancreatic adenocarcinoma on gemcitabine c/b
biliary obstruction, and a recent c. difficile infection who
presents with recurrent diarrhea.
#. C.diff infection: Given severe leukocytosis and
comorbidities, the patient was intially treated with PO
vancomycin. He continued to spike fevers and IV metronidazole
was added to the patients regimen. This was narrowed to PO
Vancomycin eventually, but he continued to have persistent
diarrhea. To ensure that no other etiology was contibuting to
the diarrhea, an Abd CT scan was obtained. It revealed
pancolitis, but no evidence of pneumatosis or megacolon. This
was all consistent with C.diff.
To improve his overall treatment, cholestyramine was added to
the vancomycin regimen. With this over the next 3 days, his
stool output decreased significantly to the point where he had
only 2 bowel movements during the day and was able to sleep 6
hours straight without a BM. Given the extent of the colitis
and the recurrence of the C.diff, we will give at total of at
least 1 month of PO vancomycin. Cholestyramine will be given
for only one additional week.
.
#. Elevated LFTs:
Most likely cholestasis in the setting of his cancer. He does
not have pain or a clinical picture suggesting ascending
colangitis. He has a metallic stent within his CBD. He has
evidence of cholelithiasis in the head of the GB, but no
clinical evidence of cholecystitis.
#. Fever and leukocytosis: The above was presumed to be due to
recurrent c. difficile and remained stable in the ___ level
(down from 28 on admission).
#. Hyponatremia: likely hypovolemic. Will continue IV fluids.
- Given iv fluids.
#. Acute kidney injury:
He was admitted with a Cr of 1.7. This was presumed to be
pre-renal due to dehydration. After hydration, it improved to
his baseline of 1.1. He was able to maintain PO to match his
total output.
.
#. Depression/anxiety: will continue home mirtzapine and
lorazepam. Per niece, has difficult situation with his wife also
hospitalized.
- SW consult
#. Pancreatic adenocarcinoma:
-non-resectable. Holding gemcitabine in setting of acute
infection.
- continue Zenpep pancreatic replacement
- continue PRN oxycodone for pain
#. CAD: holding metoprolol with infection. Can continue
simvastatin
.
# Contact: Both the daughter (___) and the Niece (___)
have been in close contact throughout the hospital stay and
updated on his overall improvement. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aspirin / Sudafed / Toradol / Levaquin / iv contrast /
Amitriptyline / Motrin / Ultram / acetaminophen / latex tape
Attending: ___.
Chief Complaint:
Shortness of breath, chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y.o M->F transgender (Preferred name ___ currently on
estradiol,history of bilateral lower extremity paralysis
following a MVA, wheelchair bound, with ileo conduit/urostomy
(known neurogenic bladder), COPD (2L home O2), prior concern
for
CAD with normal stress test in ___, and remote PE not on
anticoagulation who presents with constant left sided chest
pain
with radiation to axilla, back, neck. Pain is pleuritic in
nature
and not reproducible. Patient also endorses dyspnea on exertion
with the inability to fully dress herself. Also endorses right
paraspinal pain with anterior radiation. Near her urostomy site,
she feels significant abdominal fullness/swelling. Patient was
recently admitted for COPD exacerbation at ___ in ___.
Denies antecedent illness, fevers, lower extremity edema.
Endorses N/V.
VS of 98 82 147/86 20 92% RA.
EXam showed distended abdomen, TTP over urostomy site, slight
erythema around urostomy site, involuntary guarding throughout,
no rebound tenderness
BMP WNL. CBC with WBC of 13.4, otherwise normal CBC. Lipase 62.
Pro BNP 185. Troponin negative x 1.
UA was grossly positive.
She received duonebs, IV methylpred 40 mg, IV Benadryl, IV
dilaudid 1 mg x 3 doses, IV ceftriaxone.
Upon arrival to the floor, the patient confirms the story as
above. She reports "I feel I can not take care of myself at home
anymore." She reports that since her discharge from ___, she felt worse and worse and worse. She reports she
was supposed to stay at ___ for two weeks, but a new
doctor came on and discharged early. She was being treated there
for a COPD exacerbation and was discharged on a prednisone
taper,
which she finished. She reports significant worsening in her
shortness of breath which occurs with exertion. She reports she
is unable to exert herself, to dress herself, to shower, or to
clean due to significant shortness of breath. She reports this
has been significantly worse in the last two weeks. She is on
home O2 and has not noticed an increase in her oxygen
requirement. She reports chest pressure, which she reports is
"COPD chest pain" not "cardiac chest pain" but that it feels
like
an elephant is sitting on her chest. She reports that the chest
pain began on the day of discharge from ___ and that
it has been constant, without change in character. It is
aggravated by deep inhalation. She denies recent viral illness.
She denies change in her cough, but does report that the mucinex
has not improved her cough. She endorses nausea. She otherwise
reports that in her RLQ abdomen, she feels significant swelling
near the site of her ostomy. She endorses kidney pain, which she
describes as sharp pain in her left > right kidney, which is
intermittent and sharp. She does endorse an episode of syncope,
which occurred in her wheelchair, when she was struggling to
breath, causing her to slump forward and hit her lip and right
ear on the bathroom counter.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
- COPD: on home O2 at night, still smoking, multiple
exacerbations yearly, never intubated.
- possible tracheobronchomalacia
- h/o pulmonary embolism, no longer on anticoagulation
- ___
- medical attention-seeking personality traits, possible
factitious disorder per psychiatry
- opiate abuse
- Neurogenic Bladder - s/p ileal conduit ___
- insomnia
- ? h/o of SBO in ___
- Diverticulitis
- gastroparesis
- L Lung nodule followed q6 months
-chronic pain from spinal cord injury
Social History:
___
Family History:
mother died at ___ from Lung CA, emphysema
father died at ___ from CAD, chronic EtOH
Physical Exam:
EXAM
VITALS: 98.0 PO 121 / 82 87 18 98 2___
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
Mucous membranes moist
CV: Heart regular, no murmur
RESP: Lungs with significant expiratory wheezes in all lung
fields, occasional rales
GI: +Urostomy bag in RLQ, some fullness appreciated in RLQ with
tenderness, rest of the abdomen is soft
Back: + significant tenderness in R paraspinal area athough much
lower than typical CVA tenderness, + tenderness on L side
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: multiple bruises on anterior forearms reportedly from
recent hospitalization
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, ___ strength in upper extremities bilaterally, no
strength in lower extremities
EXT: no edema
PSYCH: Initially pleasant
On Discharge
VSS
Pox 96% on rA
He appeared very well, spoke very rapidly, had no signs of
respiratory distress whatsoever
Lung: CTA B with somewhat decreased bs throughout
Psych: Agitated when discussing discharge planning.
Pertinent Results:
___ 01:05PM BLOOD WBC-13.4* RBC-4.83 Hgb-15.0 Hct-44.6
MCV-92 MCH-31.1 MCHC-33.6 RDW-15.3 RDWSD-51.1* Plt ___
___ 01:05PM BLOOD Glucose-76 UreaN-20 Creat-0.7 Na-137
K-5.0 Cl-100 HCO3-24 AnGap-13
___ 01:05PM BLOOD ALT-46* AST-28 AlkPhos-46 TotBili-0.4
___ 01:05PM BLOOD Lipase-62*
___ 01:05PM BLOOD cTropnT-<0.01
___ 01:05PM BLOOD Albumin-3.5 Calcium-8.7 Phos-3.8 Mg-2.1
Blood cultures: NGTD
Urine culture: 100,000 CFU
CTA
1. No evidence of pulmonary embolism or acute aortic pathology.
2. Severe, upper lobe predominant emphysema. Mild bronchitis.
3. No acute intra-abdominal abnormality.
4. Status post cystectomy with right lower quadrant ileal
conduit, which
appears unremarkable. Mild fullness of the left renal
collecting system and
ureter, but no frank evidence of hydronephrosis
Bilateral ___
No evidence of deep venous thrombosis in the right or left lower
extremity veins.
I personally reviewed the EKG and my interpretation is sinus
rhythm, normal intervals, normal r wave progression, no acute ST
changes.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. TraZODone 100 mg PO QHS
2. Spironolactone 50 mg PO BID
3. Montelukast 10 mg PO DAILY
4. Cetirizine 10 mg PO DAILY
5. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
6. GuaiFENesin ER 1200 mg PO Q12H
7. Tiotropium Bromide 1 CAP IH DAILY
8. Estradiol Transdermal Patch (estradiol) 0.1 mg/24 hr
transdermal Apply two patches q 72 hours
Discharge Medications:
1. Azithromycin 250 mg PO DAILY Duration: 4 Doses
2. Ipratropium-Albuterol Neb 1 NEB NEB Q8H
for four days, and then every 8 hours as needed
3. PredniSONE 40 mg PO DAILY
4. Cetirizine 10 mg PO DAILY
5. Estradiol Transdermal Patch (estradiol) 0.1 mg/24 hr
transdermal Apply two patches q 72 hours
6. GuaiFENesin ER 1200 mg PO Q12H
7. Montelukast 10 mg PO DAILY
8. Spironolactone 50 mg PO BID
9. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
10. Tiotropium Bromide 1 CAP IH DAILY
11. TraZODone 100 mg PO QHS
Discharge Disposition:
Home with Service
Discharge Diagnosis:
COPD exacerbation
Anxiety
Transgender m-->f
Discharge Condition:
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Followup Instructions:
___
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ with hx/o estradiol p/w progressively worsening left-sided
CP.// DVT?
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: Bilateral 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: CT torso.
INDICATION: ___ year old MF transgender pt wheel chair bound at baseline with
chest pain, dyspnea, history urostomy. Signs/sx concerning for PE as well as
intra-abdominal processes vs hydronephrosis.// CT PE protocol for PE concern.
Also has significant PSH with concern for intraabdominal pathology.
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.
DOSE: Acquisition sequence:
1) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 9.1 mGy (Body) DLP = 4.6
mGy-cm.
2) Spiral Acquisition 4.1 s, 32.4 cm; CTDIvol = 11.7 mGy (Body) DLP = 377.2
mGy-cm.
3) Spiral Acquisition 6.4 s, 50.6 cm; CTDIvol = 17.1 mGy (Body) DLP = 862.0
mGy-cm.
Total DLP (Body) = 1,244 mGy-cm.
COMPARISON: Chest CT ___. CT abdomen and pelvis ___.
FINDINGS:
CHEST:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
segmental 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. No pericardial effusion is seen. Mild atherosclerotic
calcifications of the great vessels and thoracic aorta. Moderate coronary
artery calcifications.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Severe, upper lobe predominant centrilobular and paraseptal
emphysema is again seen. Mild bibasilar and lingular atelectasis. Otherwise,
the lungs are clear without masses or areas of parenchymal opacification.
Bilateral mild bronchial wall thickening is again seen suggestive of mild
bronchitis. 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.
BONES: A rib deformity of the right anterolateral sixth rib appears chronic.
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: A subcentimeter splenic hypodensity is too small to characterize
(05:15). The spleen shows normal size and attenuation throughout.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: Multifocal areas of renal cortical scarring within the left kidney
are re-demonstrated. The kidneys is a bit symmetric and normal nephrograms.
Surgical clips are again seen within the interpolar left kidney. Mild
fullness of the left renal collecting system and ureter appears similar
without frank 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 not definitively identified,
but there are no secondary signs of acute appendicitis. There is no free
intraperitoneal fluid or free air.
PELVIS:
The patient is status post cystectomy. The right lower quadrant ileal conduit
appears unremarkable. There is no free fluid in the pelvis. Multiple
surgical clips are seen within the pelvis and retroperitoneum, unchanged.
REPRODUCTIVE ORGANS: The prostate appears 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: Bilateral lucent lesions of the iliac bones measure up
to 1.0 cm (5:959), and appear stable from prior. There is no evidence of
acute fracture. Postsurgical changes of the anterior abdominal wall.
Subcutaneous edema within the soft tissues overlying the paraspinal muscles
adjacent to the lumbar spine, as well as the bilateral gluteus muscles.
Calcified granuloma within the soft tissue overlying the left gluteal muscles.
IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic pathology.
2. Severe, upper lobe predominant emphysema. Mild bronchitis.
3. No acute intra-abdominal abnormality.
4. Status post cystectomy with right lower quadrant ileal conduit, which
appears unremarkable. Mild fullness of the left renal collecting system and
ureter, but no frank evidence of hydronephrosis.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Chest pain, Dyspnea
Diagnosed with Chronic obstructive pulmonary disease w (acute) exacerbation
temperature: 98.0
heartrate: 82.0
resprate: 20.0
o2sat: 92.0
sbp: 147.0
dbp: 86.0
level of pain: 10
level of acuity: 2.0 | SUMMARY/ASSESSMENT: ___ y.o M->F transgender (Preferred name
___ currently on estradiol,history of bilateral lower
extremity paralysis following a MVA, wheelchair bound, with ileo
conduit/urostomy (known neurogenic bladder), COPD (2L home O2),
prior concern for CAD with normal stress test in ___,
and
remote PE not on anticoagulation who presents with constant
left
sided chest pain with radiation to axilla, back, neck, found to
have acute COPD exacerbation and UTI.
She left AMA on ___
# Acute COPD exacerbation: CT A without evidence of pulmonary
embolus or significant parenchymal infiltrate. Physical exam
consistent with COPD exacerbation.
He improved dramatically with prednisone 60 mg, standing
bronchodilators, montelukast and azithromycin.She acknowledged
her improvement, but stated that She "always gets worse at
night" and that he had recently been diagnosed with pneumonia.
I discussed that her CT scan was negative and that he should
have close outpatient f/u with pulmonary. She stated that he no
longer had a pulmonologist. I scheduled f/u with pulmonary but
he left AMA.
I had faxed prescriptions for four additional days of prednisone
and azithromycin and for albuterol nebulizer solution to her
pharmacy.
She continues to smoke 5 cigarettes a day.
# Chest Pain: Patient presenting with chest pain, which is
difficult for her to characterize, occasionally reporting it to
be sharp, and at other times, like a chest heaviness. The pain
is
pleuritic. It is not positional. CTA negative. Lower extremity
ultrasound negative. The duration of her pain (several days)
with
negative troponin is reassuring against cardiac pain.
Improved by the day of discharge, he did receive some doses of
oxycodone during his hospital stay.
# Urinary Tract Infection: Patient with with ileo
conduit/urostomy (known neurogenic bladder) with worsening pain
in the RLQ. CT A/P without acute pathology or abnormalities of
the ideal conduit. Prior Urine cultures have grown pansensitive
Klebsiella and ecoli as well as a single episode of MDR
enterobacter. Blood cultures remain negative, but his urine
culture grew out ___ CFU the day following his departure AMA.
I called his phone and he did not pick up. I asked him to call
the medical floor and ask for me to discuss further.
# Paraplegia: Patient reports she is unable to care for herself
safely and wonders if she needs to be in long term care.
Discussed with his community case manager who has been working
on getting him more assistance at home and he also met with our
CM. Our ___ felt that he was at functional baseline in terms of
being able to use her wheelchair and therefore could not be
discharged to rehab. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left hip pain
Major Surgical or Invasive Procedure:
left hip hemiarthroplasty
History of Present Illness:
___ yo male with DM2 presents s/p mechanical fall at 430pm (trip
steps with fall backward down two steps onto left hip, no other
injuries) and taken to ___. Xrays there confirmed
left femoral neck fracture and sent to ___ as per patient
request. Patient presents neurovasc intact with pain in hip.
Xrays demonstrates GARDEN III fracture
Past Medical History:
Diabetes
HTN
Social History:
___
Family History:
nc
Physical Exam:
left lower extremity
Incision CDI, no erythema, no brusing
Fires ___, SILT SP/P/S/S WWP
COMPARTMENTS SOFT
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Finasteride 5 mg PO DAILY
3. GlipiZIDE XL 10 mg PO BID
4. Lisinopril 2.5 mg PO DAILY
5. MetFORMIN (Glucophage) 500 mg PO BID
6. Simvastatin 40 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Finasteride 5 mg PO DAILY
3. GlipiZIDE XL 10 mg PO BID
4. Lisinopril 2.5 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Simvastatin 40 mg PO DAILY
7. Acetaminophen 650 mg PO Q6H
8. Enoxaparin Sodium 40 mg SC DAILY
9. OxycoDONE (Immediate Release) 2.5 mg PO Q3H:PRN pain
10. MetFORMIN (Glucophage) 500 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
left hip fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ male with left hip fracture.
COMPARISON: Outside plain films from earlier the same day performed at
___ Hospital.
FINDINGS:
AP view of the pelvis. Frontal and cross-table lateral views of the left hip.
Frontal view of the distal femur.
There is an acute fracture through the left femoral neck. Cross-table lateral
view demonstrates some degree of dorsal angulation and displacement of the
femoral head with respect to the neck. There is mild foreshortening. No
other fractures visualized. Atherosclerotic calcifications are noted.
IMPRESSION:
Left femoral neck fracture.
Radiology Report
HISTORY: Left THR.
TECHNIQUE: 2 frontal views of the left hip obtained portably in the OR.
COMPARISON: Preoperative radiographs dated ___.
FINDINGS:
The patient is status post placement of a left hemiarthroplasty in overall
anatomic alignment on these views. Skin staples present. No periarticular
fracture detected on these views.
IMPRESSION:
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: HIP FRACTURE
Diagnosed with FX NECK OF FEMUR NOS-CL, UNSPECIFIED FALL
temperature: 99.2
heartrate: 100.0
resprate: 18.0
o2sat: 98.0
sbp: 180.0
dbp: 77.0
level of pain: 7
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 femoral neck factor 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 please see the
separately dictated operative report). 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
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient had trouble urinating and urology was consulted given
his extensive prostatic and urinary history. He will keep the
foley on DC and follow up with them 1 week from discharge.
The patient was given perioperative antibiotics and
anticoagulation per routine. The patients 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 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. The patient is WBAT in the LLE extremity, and
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: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a ___ w/vascular risk
factors (HTN, HLD, CAD w/2 prior MIs), vascular disease (type B
ascending thoracic aorta and ___ rupture s/p emergent
repair with hemiarch replacement and aortic valve resuspension
___, descending aortic dissection likely due to a
penetrating aortic ulcer, aorta magna, ileal artery ectasia), a
history of transient AFib complicating the aneurysm repair
operation with no recurrence on metoprolol, and recently
diagnosed RCC. He now presents with 1 day of mild confusion and
difficulty performing complex activities. At baseline, Mr.
___ is a highly functioning divorce attorney, although he
has had to slow down in his practice over the last few months,
and recently needs to write down everything his clients say, so
that he doesn't forget it later.
On retelling of recent events, Mr. ___ occasionally gets
help from his wife, as he gets a few of the details wrong.
Yesterday, Mr. ___ and his wife went to their farm in ___
___. He stayed up late tending to the fires, and at one
point around 3 am, he dropped his utensils into the fire; it was
unclear if this was a pure accident, or due to clumsiness. This
morning, he noticed that he had difficulty making himself
coffee, but after a while figured out how to do that. He then
drove to the ___ store to get the morning newspaper, and had
no difficulty with that. However, he then realized that he had a
workman coming to the house but could not remember any of the
chores that man was supposed to do. Over the course of the day,
he and his wife noticed several other instances of forgetfulness
and inattentiveness. However, he was able to drive to ___
without difficulty. He still felt a little foggy in the waiting
room at ___, and was felt to be a little perseverative by the ED
resident, but this also had resolved by the time I saw him.
Per pt and wife, this presentation is similar to but less bad
than the one on ___, when he also presented with confusion,
with inability to perform simple tasks such as making coffee. At
that time, he also additionally had ___ difficulties,
an unsteady gait and headache. On examination, he was only
partially oriented to time and was very inattentive with poor
recall and a slight anomia. He was admitted to the stroke
service, where MRI revealed a shower of ___ acute
infarcts in the territory of the inferior division of the L MCA.
It also showed a few scattered cortical and cerebellar
microbleeds. On CTA, he had enlarged intracranial vessels; also,
the L proximal MCA was found to have some irregularity. There
were anatomical variants with a hypoplastic right vertebral
artery which ends in ___ and a ___ right PCA. He was
also found to have a PFO but no DVT was discovered, and he was
deemed to have had embolic strokes of unclear origin, more
likely thromboembolic. His A1c and LDL levels returned at goal
(HbA1C 5.3, LDL<100). He was switched from ASA 325 mg daily to
clopidogrel 75 mg daily.
In ___, Mr. ___ was admitted to the medicine service
here for a rash. He presented with 4 discrete erythematous
macules in his axilla with superimposed vesicles concerning for
zoster, which may have been triggered by ileitis. The patient
has a known history of chicken pox, did not receive the
varicella vaccine, and was complaining of associated headache
and fever, and so was given valacyclovir po x 1 in the ED, IV
acyclovir x 1 on the floor due to initial concerns for
disseminated disease, and was then transitioned back to
valacyclovir po to complete a 7d course at the time of
discharge, with Tzanck smear and DFA not performed due to
inadequate submitted specimen. He had no facial or eye
involvement during that admission. Given the possibility of
bacterial superinfection (pustular rather than vesicular
lesions), he was also started on a 7d course of bactrim/keflex.
He was also found to have ileitis and underwent a CT scan of his
abdomen, which showed enhancing mass in the upper pole of the
left kidney suspicious for renal cell carcinoma. He is
scheduled to see Dr. ___ at the end of next month for this.
On ___, Mr. ___ saw Dr. ___ in stroke clinic, who notes
the discovery of the renal mass, suspicious for renal cell
carcinoma, raising the possibility of ___
coagulopathy. He mentions considering switching him from
clopidogrel to enoxaparin or warfarin until his workup is
completed but defers this to the judgment of his other
physicians.
Past Medical History:
- HTN
- HLD
- CAD Prior MI ___ and ___ s/p distal LAD stent in ___ and
further stents in ___ and to LAD and D2 in ___.
- h/o type B ascending thoracic aorta and hemi arch rupture and
emergent repair with hemiarch replacement and aortic valve
resuspension ___. Also with a descending aortic dissection
in
the distal chest potentially related to a previously noted
penetrating aortic ulcer which is stable.
- Arteria magna with bilateral iliac artery ectasia
- h/o transient AF complicating aneurysm repair operation no
recurrence and on metoprolol
- h/o recurrent pleural effision s/p thoracocentesis s/p talc
pleurodesis ___
- h/o primary aldosteronism and edrenal adenoma s/p RF ablation
___ now resolved
- h/o babesiosis ___ after time in ___
- h/o Q fever as a young man after slaughtering a pig
- h.o multiple renal cysts which have been stable
- h/o squamous cell ca
- h/o herniated lumbar disc
- h/o mild Restrictive Lung Disease(on PFT's)
- Hard of Hearing with hearing aids
- Rosacea
PSurgHx:
- s/p Right rotator cuff repair ___
- s/p Left rotator cuff repair ___
- s/p Umbilical hernia repair with mesh ___
- s/p Adrenal cyst RF ablation ___
- s/p stents ___, and ___ x2
Social History:
___
Family History:
Mother - died ___ of CHF
Father - died ___ MI
Sibs - 3 dued 1 after an accident another after choking on her
vomit and another of unclear cause. Other ___hildren - 4 all well.
There is no history of seizures, developmental disability,
learning disorders, migraine headaches, strokes less than 50,
neuromuscular disorders, dementia or movement disorders
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS T:97.8 HR:63 BP:137/93 RR:18 SaO2:97%ra
General: NAD, lying in bed comfortably.
- Head: NC/AT, no conjunctival pallor or icterus, no
oropharyngeal lesions, + transverse earlobe creases
- Neck: Supple, no nuchal rigidity. No lymphadenopathy or
thyromegaly.
- Neurovascular: No carotid, vertebral or subclavian bruits; ABC
(angle of jaw, brow, cheek) pulses equal on both sides
- Cardiovascular: carotids with normal volume & upstroke; quiet
precordim; RRR, soft SEM at RUSB; sternotomy scar
- Respiratory: Nonlabored, clear to auscultation with good air
movement bilaterally
- Abdomen: obese but nondistended, normal bowel sounds, no
tenderness/rigidity/guarding, no hepatosplenomegaly to palpation
and percussion
- Extremities: Warm, no cyanosis/clubbing/edema, palpable
dorsalis pedis pulses.
- Skin was without rash, induration or neurocutaneous stigmata.
Nails show striking longitudinal beading
Neurologic Examination:
Mental Status:
Awake, alert, oriented x 3 grossly, but misplaces recent events
by one day. Oriented to recent world events.
Attention: Recalls a mostly coherent history but is fuzzy on a
few details (e.g., confuses the workman's chores for his own);
thought process coherent and linear without circumstantiality
and tangentiality. Digit span forward 6, reverse 3.
Affect: euthymic
Language: fluent without dysarthria and with intact repetition
and verbal comprehension. I heard one semantic paraphasia,
replacing the wrist watch's clasp with "hasp". High- and
___ naming otherwise intact. Follows ___
commands, midline and appendicular and crossing the midline.
Normal reading. Normal prosody.
Memory: Registration ___ and recall ___, improving to ___ with
category cueing and ___ with multiple choice.
Praxis: No neglect; slight ideomotor apraxia (e.g., not opening
mouth when pretending to brush his teeth). Had some difficulty
copying unfamiliar hand configurations. Initially had some
difficulty copying a cube but ___ on the second
attempt.
Executive function tests:
Luria hand sequencing learned after several attempts and with
verbal reinforcement but was then performed well.
Clock draw ("10 after 11") showed an intact contour but with
some embellishments such as an extension cord. Number placement
was somewhat crowded in the ___ quadrant. Initially was unable
to place hands correctly but then corrected himself by drawing a
second clock.
On word generation tasks: number of words starting with letter
"B" in 1 minute: 10, with one repetition; number of animals in 1
minute: 11, with one repetition.
Cranial Nerves:
[II] Pupils: equal in size and briskly reactive to light and
accommodation. No RAPD.
VF full to finger counting/finger motion
Fundoscopy: discs flat with crisp disc margins (no papilledema)
[III, IV, VI] EOM intact, no nystagmus
[V] ___ with symmetrical sensation to light touch. Pterygoids
contract normally.
[VII] No facial asymmetry at rest and with voluntary activation.
[VIII] Hard of hearing, chronic.
[IX, X] Palate elevation symmetric.
[XI] SCM strength ___. Trapezii ___.
[XII] Tongue shows no atrophy, emerges in midline and moves
easily.
Motor: Normal bulk and tone. No pronation or drift. No tremor or
asterixis.
[ Direct Confrontational Strength Testing ]
Arm
Deltoids [R 5] [L 5]
Biceps [R 5] [L 5]
Triceps [R 5] [L 5]
Extensor Carpi Radialis [R 5] [L 5]
Finger Extensors [R 5] [L 5]
Finger Flexors [R 5] [L 5]
Interossei [R 5] [L 5]
Abductor Digiti Minimi [R 5] [L 5]
Leg
Iliopsoas [R 5] [L 5]
Quadriceps [R 5] [L 5]
Hamstrings [R 5] [L 5]
Tibialis Anterior [R 5] [L 5]
Gastrocnemius [R 5] [L 5]
Extensor Hallucis Longus [R 5] [L 5]
Sensory:
Intact warm/cold temperature discrimination.
Intact proprioception at halluces bilaterally.
Cortical sensation: No extinction to double simultaneous
stimulation. Graphesthesia intact.
Reflexes
[Bic] [Tri] [___] [Quad] [Ankle]
L ___ 2 1
R ___ 2 1
Plantar response flexor bilaterally.
Coordination: No rebound. No ___ when touching own
nose with finger, with eyes closed. No dysmetria and only mild R
intention tremor on ___ normal ___
testing. No dysdiadochokinesia. Forearm orbiting symmetric.
Finger tapping on crease of thumb, and sequential finger tapping
symmetric.
Gait& station:
Stable stance without sway. No Romberg.
Normal initiation. Narrow base. Normal stride length and arm
swing. Intact heel, toe, gait. Some swaying on tandem.
DISCHARGE PHYSICAL EXAM: Mental status improved, the patient was
able to recall the things he had forgotten previously (named
several chores that he had previously forgotten to do). The
patient felt back to himself overall. Neurological examination
without any focal defecits on cranial nerves, strength,
reflexes, or sensation. Gait normal.
Pertinent Results:
ADMISSION LABS
___ 09:10PM URINE ___
___ 09:10PM URINE ___
___ 09:10PM URINE ___
___ 09:10PM URINE GR ___
___ 09:10PM URINE ___ SP ___
___ 09:10PM URINE ___
___
___
___ 09:10PM URINE ___
___
___ 09:10PM URINE ___
___ 06:20PM ___ UREA ___
___ TOTAL ___ ANION ___
___ 06:20PM ___ this
___ 06:20PM ALT(SGPT)-18 AST(SGOT)-21 ALK ___ TOT
___
___ 06:20PM cTropnT-<0.01
___ 06:20PM ___
___ 06:20PM ___
___
___ 06:20PM ___
___
___ 06:20PM PLT ___
___ 06:20PM ___ ___
___ 06:20PM ___
___ 07:00AM BLOOD ___
CT Head ___
No acute intracranial process.
CXR ___
No acute cardiopulmonary abnormality.
CTA head and neck ___
Atherosclerotic disease without evidence of significant stenosis
by NASCET
criteria or occlusion.
LENIs ___
No evidence of deep vein thrombosis in the right or left lower
extremity.
MRI head ___
Acute infarcts in the left parietal and left occipital lobes.
No acute intracranial hemorrhage.
Chronic microhemorrhages, ___ ischemic disease and a
multiple chronic infarcts.
Echo ___
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is ___ mmHg. Left ventricular wall thickness, cavity size, and
global systolic function are normal (LVEF>55%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. The estimated cardiac index is normal
(>=2.5L/min/m2). Doppler parameters are indeterminate for left
ventricular diastolic function. Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets are
mildly thickened (?#). Mild (1+) aortic regurgitation is seen.
The left ventricular inflow pattern suggests impaired
relaxation. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. No color flow seen across
the interatrial septum at rest. Normal biventricular cavity
sizes with preserved global biventricular systolic function.
Impaired LV relaxation. Mild aortic regurgitation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Furosemide 40 mg PO ONCE
4. Metoprolol Tartrate 100 mg PO BID
5. Omeprazole 20 mg PO DAILY
6. Clopidogrel 75 mg PO DAILY
Discharge Medications:
1. Atorvastatin 60 mg PO DAILY
RX *atorvastatin 40 mg 1.5 tablet(s) by mouth daily Disp #*45
Tablet Refills:*0
2. Metoprolol Tartrate 100 mg PO BID
3. Omeprazole 20 mg PO DAILY
4. Amlodipine 10 mg PO DAILY
5. Furosemide 40 mg PO ONCE
6. Enoxaparin Sodium 80 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 80 mg/0.8 mL 80 mg subQ BID (q12h) Disp #*60
Syringe Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
1. embolic stroke
Secondary diagnosis
1. renal cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Confusion. History of stroke.
TECHNIQUE: Multi detector CT scan through the head without the administration
of IV contrast. Coronal, sagittal and thin section coronal reconstructed
images were obtained.
COMPARISON: CTA head and neck ___.
FINDINGS: There is no acute hemorrhage, edema, mass, mass effect or acute
large vascular territorial infarction. Prominence of the ventricles and sulci
suggests age-related involutional changes. White matter periventricular
hypodensities are likely the sequela of chronic small vessel ischemic disease.
The basilar cisterns are patent and there is preservation of gray-white
differentiation.
There is no fracture. There is mucosal thickening in the ethmoid air cells
and opacification of the left maxillary sinus compatible with ongoing
inflammation. The right maxillary sinus, sphenoid sinuses and mastoid air
cells are clear. There are calcifications in the cavernous portion of the
internal carotid arteries.
IMPRESSION:
No acute intracranial process.
Radiology Report
HISTORY: Confusion.
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: ___.
FINDINGS:
The patient is status post median sternotomy and ascending aortic repair. The
cardiac silhouette size remains moderately enlarged. The aorta is remains
mildly enlarged and tortuous but this is unchanged. The mediastinal and hilar
contours are otherwise unchanged. The pulmonary vasculature is normal. No
focal consolidation, pleural effusion or pneumothorax is visualized.
Multilevel degenerative changes within the imaged thoracic spine are noted
with ossification of the anterior longitudinal ligament.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
HISTORY: ___ male with 1 day of confusion similar to prior stroke.
TECHNIQUE: Multi detector axial CT images were performed from the aortic arch
through the circle of ___ during the administration of intravenous
contrast. Coronal and sagittal images were reformatted from the source data.
At a separate workstation, curved reformats and 3D volume reconstructed images
were obtained.
COMPARISON: CT head without contrast ___ and CTA head and neck ___.
FINDINGS:
CTA head: Atherosclerotic calcifications are present at the cavernous
portions of both internal carotid arteries without significant stenosis.
Again seen is beading of the inferior M2 divisions similar to the prior
examinations, most consistent with atherosclerotic disease. A small calcified
plaque with associated narrowing is seen at the distal left M1 segment. The
anterior cerebral arteries and middle cerebral arteries are patent. There is
a normal anterior communicating artery complex.
The vertebral arteries, basilar artery and posterior cerebral arteries are
patent. The right posterior communicating artery is prominent, and there is a
hypoplastic right P1 segment. The left posterior communicating artery is not
well seen.
CTA neck: Mild calcified and noncalcified plaque is present at both carotid
bifurcations, left greater than right, without evidence of significant
stenosis by NASCET criteria. The common carotid arteries, internal carotid
arteries and external carotid arteries are patent. Both vertebral arteries
are patent along their courses. The left vertebral artery is dominant. The
right vertebral artery effectively terminates as ___.
A 1 cm hypodense left thyroid lesion is unchanged. Calcified right maxillary
sinus disease is present which may be fungal in etiology.
IMPRESSION:
Atherosclerotic disease without evidence of significant stenosis by NASCET
criteria or occlusion.
Radiology Report
HISTORY: ___ man with recent however embolic stroke and micro bleeds
on recent L5 now with acute onset of confusion.
COMPARISON: MRI brain ___.
FINDINGS:
There are new confluent and patchy regions of restricted diffusion within the
left parietal and occipital lobes compatible with acute infarct; the location
is similar to the patient's previous infrarts. No acute intracranial
hemorrhage is present. There are a few punctate foci of GRE hypointensity as
seen on the previous exam consistent with chronic microhemorrhages. Multiple
foci of T2 and FLAIR prolongation are present within the periventricular and
subcortical white matter, consistent chronic microvascular ischemic disease.
There is complete opacification of the left maxillary sinus with central T2
hyperintensity which may be related to chronic fungus ball .
IMPRESSION:
Acute infarcts in the left parietal and left occipital lobes. No acute
intracranial hemorrhage.
Chronic microhemorrhages, small-vessel ischemic disease and a multiple chronic
infarcts.
Radiology Report
HISTORY: History of stroke and PFO.
COMPARISON: None.
TECHNIQUE: Grayscale color and spectral Doppler evaluation was performed of
the bilateral lower extremity veins.
FINDINGS:
There is normal compressibility, flow, and augmentation of the bilateral
common femoral, proximal femoral, mid femoral, distal femoral, and popliteal
veins. The calf veins show normal color flow. There is normal respiratory
variation of the common femoral veins bilaterally.
IMPRESSION:
No evidence of deep vein thrombosis in the right or left lower extremity.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Confusion
Diagnosed with CEREBRAL ART OCCLUS W/INFARCT
temperature: 97.8
heartrate: 63.0
resprate: 18.0
o2sat: 97.0
sbp: 137.0
dbp: 93.0
level of pain: 0
level of acuity: 2.0 | AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented? (x) Yes (LDL = 51) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) (x) Yes - () No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) ___ - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
() Yes - (x) No: no rehab needs, cognitive symptoms resolved,
and no motor defeicts
9. Discharged on statin therapy? (x) Yes - () No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: ()
Antiplatelet - (x) Anticoagulation: lovenox due to systemic
hypercoag] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A
___ w/vascular risk factors (HTN, HLD,
CAD w/2 prior MIs), vascular disease (type B ascending thoracic
aorta and ___ rupture s/p emergent repair with hemiarch
replacement and aortic valve resuspension ___, descending
aortic dissection likely due to a penetrating aortic ulcer,
aorta magna, ileal artery ectasia), a history of transient AFib
complicating the aneurysm repair operation with no recurrence on
metoprolol, and recently diagnosed likely RCC. He now presents
with 1 day of mild confusion and difficulty performing everyday
activities. MRI shows a new acute infarcts in the left parietal
lobe. He has a prior known PFO. On imaging strokes have an
embolic appearance. Given that he has a hypercoaguable state
with likely renal cell carcinoma, and has a known PFO, he could
be showering paradoxical emboli. Alternatively, strokes could be
from intracerebral atherosclerosis. Given that the patient has
failed plavix treatment, and concern for cardioembolic phenomon,
ideal situation is to transition to anticoaguation to prevent
recurrent future strokes. Dr. ___ cardiothoracic surgery
was contacted feels it is safe to anticoagulate given his prior
aortic arch surgery and ongoing aortic dissection. Outpatient
cardiologist also on board with the plan. PCP also feels
comfortable with this plan. Would favor lovenox for now given
likely upcoming renal biopsy. After biopsy is complete, the
patient could be transitioned to coumadin for long term
anticoagualtion, or maintained on lovenox (lovenox may be
preferable since it has better efficacy in systemic
hypercoaguability states, but is more expensive in the long term
than coumadin).
TRANSITIONAL ISSUES
- ___ with stroke neurology
- ___ with PCP
- ___ with oncology
- continue lovenox, could consider transitioning to coumadin in
the future after renal biopsy. lovenox may be preferable in a
hypercoaguable state |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
Oxacillin / Penicillins / Gadolinium-Containing Contrast Media
Attending: ___
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
___ - Aortic valve replacement with 23 ___
Ease
tissue valve. Mitral valve replacement using a 31 mm ___
___ tissue valve.
___: Redo coil embolization of recurrent R MCA aneurysm
___: Coil embolization of R MCA aneurysm
History of Present Illness:
Ms. ___ is a ___ year old woman with a history of severe
mitral regurgitation, prior IVDU with multiple complications
including several episodes of prior endocarditis (now on
methadone with negative tox screen on
admission), untreated HCV, and cervical cancer s/p chemotherapy
who was admitted with GPC bacteremia found to have moderate
sized aortic valve vegetation with a least moderate aortic
regurgitation. During last admit, she was evaluated by Dr.
___ to multiple comorbidities and recent IVDU,
she was declined as a surgical candidate and was discharged home
on ___. She presented ___ with mental status changes and
dyspnea and was subsequently intubated. Further work up showed
new 4mm R MCA aneurysm, felt to be mycotic. Cardiac surgery
reevaluation for possible AVR/MVR has been requested.
Past Medical History:
Anxiety
Asthma
Cervical Cancer s/p chemotherapy
Depression
Hepatitis C
Intrauterine Fetal Demise X 3, therapeutic abortion X ___
Mitral Regurgitation
Polysubstance Abuse (heroin, cocaine) on methadone
Recurrent Endocarditis (MRSA, Enterobacter)
Septic Arthritis s/p open arthrotomy w/synovectomy and drainage
Surgical History:
Cholecystectomy
Social History:
___
Family History:
+Lung cancer (mother), +uterine cancer (aunts),
+CVAs, +Type 2 DM (father, brother).
Physical Exam:
Admission Exam:
========================
VITALS: Reviewed in ___
GENERAL: Intubated and sedated, difficult to arouse
HEENT: Sclera anicteric, pupils pinpoint, reactive to light b/l
NECK: supple, JVP not elevated
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, harsh II/VI systolic murmur and
diastolic murmur best appreciated at ___, rubs, gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, no clubbing, cyanosis or edema
SKIN: Petechiae of right palm and fingers; scattered petechiae
of b/l soles
NEURO: patient currently intubated and sedated; increased tone
of RUE; unable to assess for focal neurological deficits
Discharge Exam:
==========================
VITALS: Reviewed in ___
GENERAL: mood subdued and cooperative
HEENT: PERRL
NECK: supple
LUNGS: Clear to auscultation bilaterally, no wheezes
CV: Regular rate and rhythm
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, no clubbing, cyanosis or edema
SKIN: Petechiae of right palm and fingers; scattered petechiae
of b/l soles.
Sternal incision healed. Sternum stable. CT sites w/ intact
scabs. Right groin site w/ dry dressing. No hematoma.
NEURO: Grossly intact.
Pertinent Results:
ADMISSION LABS:
=============
___ 10:15PM BLOOD WBC-10.6* RBC-3.49* Hgb-8.3* Hct-26.7*
MCV-77* MCH-23.8* MCHC-31.1* RDW-16.7* RDWSD-43.1 Plt ___
___ 10:15PM BLOOD Neuts-53.5 ___ Monos-7.4 Eos-1.6
Baso-0.5 Im ___ AbsNeut-5.67 AbsLymp-3.87* AbsMono-0.78
AbsEos-0.17 AbsBaso-0.05
___ 10:15PM BLOOD Plt ___
___ 10:15PM BLOOD Glucose-91 UreaN-17 Creat-1.1 Na-141
K-4.0 Cl-104 HCO3-22 AnGap-15
___ 10:15PM BLOOD ALT-17 AST-14 AlkPhos-111* TotBili-0.3
___ 10:15PM BLOOD Lipase-31
___ 11:57PM BLOOD cTropnT-<0.01 proBNP-1135*
___ 10:15PM BLOOD Albumin-3.8 Calcium-9.2 Phos-4.3 Mg-2.2
___ 10:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 08:47PM BLOOD Type-ART Temp-37 ___ PEEP-5
FiO2-30 pO2-111* pCO2-33* pH-7.39 calTCO2-21 Base XS--3
Intubat-INTUBATED Vent-SPONTANEOU
___ 05:10PM URINE RBC-<1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-1
___ 05:10PM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 05:10PM URINE Color-Straw Appear-Clear Sp ___
___ 05:10PM URINE UCG-NEGATIVE
___ 05:10PM URINE bnzodzp-POS* barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-POS*
PERTINENT LABS:
=============
___ 03:15AM BLOOD HIV Ab-NEG
MICROBIOLOGY:
===========
None pertinent, all blood cultures negative.
STUDIES/REPORTS:
==============
CT Head Non Con (___)
1. Large right MCA territory infarction, new since ___.
Effacement of the adjacent sulci, but no significant mass
effect.
2. Small foci of hyperdensity overlying the right temporal and
parietal lobes, likely a combination of subarachnoid and
intraparenchymal hemorrhage. This can be confirmed with an MRI.
CTA Head and Neck (___)
1. Increased definition of an evolving subacute right temporal
parietal infarct.
2. Slight interval decrease in trace right temporal parietal
petechial hemorrhage.
3. Evidence of a right MCA M2 segment 4 mm aneurysm, likely
mycotic given history of endocarditis.
4. Normal CTA neck without evidence carotid stenosis by NASCET
criteria.
5. Left upper lobe 4 mm pulmonary nodule. Per the ___
___ criteria no follow-up imaging is recommended in low
risk patients. High-risk patients may receive a follow-up chest
CT in 12 months.
TTE (___)
IMPRESSION: Moderate sized aortic valve vegetation with moderate
to severe (based on holodiastolic flow reversal) aortic
regurgitation. Severe mitral regurgitation without vegetation.
No aortic root abscess seen (better evaluated with TEE).
Moderate pulmonary hypertension. Compared with the prior study
(images reviewed) of ___ there is more aortic
regurgitation. The aortic valve vegetation is similar. The
mitral valve vegetation seen on the TEE from ___ is not
seen. Pulmonary pressures are higher.
CT Head Non Con (___)
Unchanged extent of the right temporoparietal infarction. Two
tiny ___ foci of hyperintensity likely represent
petechial hemorrhage. The more inferior focus in the right
temporal lobe is mildly increased or new from the prior
examination and measures 4 mm. The previously seen tiny focus
of petechial hemorrhage is unchanged.
TTE (___)
There is mild regional left ventricular systolic dysfunction
with mild hypokinesis of the mid inferolateral wall. The
remaining segments contract normally (LVEF >= 55 %). The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. There is a moderate-sized vegetation on the aortic
valve attached to the non-coronary cusp measuring 1.27x0.38cm.
No aortic valve abscess is seen. Severe (4+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. The mitral valve leaflets do not fully coapt along
the A1/P1 commisure (see clip ___ . Severe (4+) mitral
regurgitation is seen. No vegetation/mass is seen on the
pulmonic valve. There is a trivial/physiologic pericardial
effusion. There are no echocardiographic signs of tamponade.
IMPRESSION: Moderate sized aortic valve vegetation with severe
aortic regurgitation. Severe mitral regurgitation due to
malcoaptation at P1/A1 which may in part be due tethering from
mild mid inferolateral wall dysfunction. A left pleural effusion
is present. Compared with the prior study (images reviewed) of
___ the vegetation measures 1.27cm in major axis versus
0.96cm, but image quality is better on current study. Aortic and
mitral regurgitation are frankly severe.
CTA HEAD & NECK (___)
1. The known right saccular m 2 aneurysm appears larger in size
and more lobulated than in the prior study and now measures
approximately 6.5 x 6 mm.
2. There is increased subtle hyperdensity in the right temporal
lobe, and hyperdensities in the right temporal lobe and
operculum, suggesting petechial changes and rib perfusion
phenomenon in the prior infarct.
EMBOLIZATION (___)
Uncomplicated coil embolization of right superior division M 2
aneurysm measuring 5 x 5 mm, unruptured, mycotic with evidence
of rapid growth on noninvasive imaging.
___: Redo coil embolization of recurrent R MCA aneurysm
Transthoracic Echocardiogram (___)
The left ventricular cavity size is top normal/borderline
dilated. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion. Moderate to severe (3+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. The mitral valve leaflets do not fully coapt.
No mass or vegetation is seen on the mitral valve. There is
small vegetation on the mitral valve measuring 0.53cm in the
major axis. Severe (4+) mitral regurgitation is seen. The
estimated pulmonary artery systolic pressure is normal. No
vegetation/mass is seen on the pulmonic valve. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Severe mitral regurgitation due to malcoaptation of
the leaflets. Probably moderate to severe aortic regurgitation
(aortic arch doppler not done limiting complete evaluation).
Aortic regurgitation can be quantified with Cardiac MR if
clinically indicated. Small vegetation on the aortic valve.
Compared with the prior study (images reviewed) of ___ the
aortic valve vegetation is smaller. Color doppler signal of the
aortic regurgitation is less prominent, but there likley has not
been a major change.
MRA BRAIN (___)
Motion artifact limits evaluation. Right M1 and proximal right
M2 segments remain smaller than the left. Other major
intracranial arteries appear patent without evidence for
high-grade stenosis but evaluation for subtle stenosis is
limited. There is artifact from the coil pack in the treated
right M2 aneurysm. There is 1.5 mm round focus of apparent flow
at the aneurysm neck, image 2:93.
Cardiac Catheterization ___
Dominance: Right
LMCA: normal.
LAD: normal.
LCX: normal.
RCA: normal.
___ 9:20 am TISSUE MITRAL VALVE LEAFLETS.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
NO FUNGAL ELEMENTS SEEN.
___ 9:10 am TISSUE AORTIC VALVE LEAFLETS.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
___
PROCEDURE: Coiling of a recurrent right MCA bifurcation
infectious aneurysm.
FINDINGS:
Right internal carotid artery: There is no gross change in the
angio
architecture of the right ICA angiogram with the exception of
recurrence at
the base and the ___ the right MCA bifurcation aneurysm
that measures
around 4.5 x 3.7 mm. Post primary coiling, successful complete
obliteration
of the aneurysm compatible with ___ grade 1.
Right common femoral artery: Well-visualized with a good caliber
size for
closure device.
IMPRESSION:
There is no gross change in the angio architecture of the right
ICA angiogram
with the exception of recurrence at the base and the ___
the right MCA
bifurcation aneurysm that measures around 4.5 x 3.7 mm. Post
primary coiling,
successful complete obliteration of the aneurysm compatible with
___
___ grade 1.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Linezolid ___ mg PO Q12H
2. Methadone 33 mg PO DAILY
3. Lidocaine 5% Patch 1 PTCH TD QPM R thigh pain
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H
RX *acetaminophen 325 mg 2 tablet(s) by mouth every 6 hours Disp
#*120 Tablet Refills:*1
2. ARIPiprazole 10 mg PO DAILY
RX *aripiprazole 10 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
3. Aspirin EC 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
5. Haloperidol 2.5 mg PO BID:PRN anxiety/agitation
RX *haloperidol 5 mg 0.5 (One half) tablet(s) by mouth twice a
day Disp #*10 Tablet Refills:*0
6. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain - Moderate
RX *hydromorphone 2 mg ___ tablet(s) by mouth every 3 hours Disp
#*40 Tablet Refills:*0
RX *hydromorphone 2 mg ___ tablet(s) by mouth every 3 hours Disp
#*40 Tablet Refills:*0
7. Metoprolol Tartrate 25 mg PO BID
RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
8. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every 8 hours Disp
#*45 Tablet Refills:*0
9. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram 1 packet by mouth daily
Disp #*30 Packet Refills:*0
10. Senna 17.2 mg PO QHS
RX *sennosides [senna] 8.6 mg 1 tab by mouth at bedtime Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Endocarditis
Subacute MCA stroke
Secondary:
Subarachnoid hemorrhage and intraparenchymal hemorrhage
R MCA mycotic aneurysm, subacute MCA stroke
Atrial valve endocarditis
IVDU
Anemia
Discharge Condition:
Alert and oriented x3, non-focal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema: none
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: History: ___ with headache and hx of endocarditis// ?mycotic
aneurysm, dissection
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of Omnipaque intravenous contrast material. Three-dimensional
angiographic volume rendered, curved reformatted and segmented images were
generated on a dedicated workstation. This report is based on interpretation
of all of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
2) Stationary Acquisition 6.0 s, 0.5 cm; CTDIvol = 65.3 mGy (Head) DLP =
32.7 mGy-cm.
3) Spiral Acquisition 5.1 s, 40.2 cm; CTDIvol = 31.0 mGy (Head) DLP =
1,246.3 mGy-cm.
Total DLP (Head) = 2,082 mGy-cm.
COMPARISON: CT head without contrast ___.
FINDINGS:
TUBES AND LINES:
Patient is intubated and there is an enteric tube in place. Retained
nasopharyngeal secretions likely relate to intubation.
CT HEAD WITHOUT CONTRAST:
Redemonstrated is hypoattenuation and gray-white differentiation loss in the
right temporal parietal region slightly more defined since ___.
There is persistent effacement of the adjacent cerebral sulci but no evidence
of midline shift. Slight interval decrease in the trace amount petechial
hemorrhage along the anterior margin of the infarct (02:15) and within the
right temporal lobe (02:11). Prominent right cortical vessels likely relate
to slow flow.
No evidence of a new infarct or new hemorrhage. The ventricles and sulci are
normal in size and configuration.
The visualized portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. The visualized portion of the orbits are unremarkable.
CTA HEAD:
There is a 4 mm aneurysm arising from the right MCA M2 segment. There is a
persistent fetal origin of the left PCA. The remaining vessels of the circle
___ and their principal intracranial branches appear normal without
stenosis, occlusion, or aneurysm formation. The dural venous sinuses are
patent.
CTA NECK:
The right vertebral artery V4 segment likely terminates into right ___. The
carotid and vertebral arteries and their major branches appear otherwise
normal with no evidence of stenosis or occlusion. There is no evidence of
internal carotid stenosis by NASCET criteria.
OTHER:
There is a 4 mm left upper lobe subpleural pulmonary nodule (03:51). The
visualized portion of the thyroid gland is within normal limits. There is no
lymphadenopathy by CT size criteria.
IMPRESSION:
1. Increased definition of an evolving subacute right temporal parietal
infarct.
2. Slight interval decrease in trace right temporal parietal petechial
hemorrhage.
3. Evidence of a right MCA M2 segment 4 mm aneurysm, likely mycotic given
history of endocarditis.
4. Normal CTA neck without evidence carotid stenosis by NASCET criteria.
5. Left upper lobe 4 mm pulmonary nodule. Per the ___ ___ criteria no
follow-up imaging is recommended in low risk patients. High-risk patients may
receive a follow-up chest CT in 12 months.
RECOMMENDATION(S): For incidentally detected single solid pulmonary nodule
smaller than 6 mm, no CT follow-up is recommended in a low-risk patient, and
an optional CT in 12 months is recommended in a high-risk patient.
See the ___ ___ Guidelines for the Management of Pulmonary
Nodules Incidentally Detected on CT" for comments and reference:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with ?stroke// verify tube placement post intubation
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
FINDINGS:
Endotracheal tube terminates approximately 6.3 cm above the carina. Enteric
tube courses below the diaphragm, out of the field of view. The patient is
rotated somewhat to the right. Subtle bibasilar opacities most likely due to
overlapping vasculature and mild atelectasis, but underlying aspiration is not
excluded. No large pleural effusion or pneumothorax. Cardiac silhouette size
remains mildly enlarged. Mediastinal contours are grossly unremarkable given
patient rotation. No overt pulmonary edema.
IMPRESSION:
Endotracheal tube terminates 6.3 cm above the carina.
Enteric tube courses below the diaphragm, out of the field of view.
Patient rotated somewhat to the right. Subtle bibasilar opacities most likely
represent overlying vascular structures and mild atelectasis, but underlying
aspiration is not excluded.
Cardiomegaly.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with respiratory failure// pulmonary edema
pulmonary edema
IMPRESSION:
Compared to chest radiographs since ___ most recently ___.
Moderate cardiac enlargement has increased despite tracheal intubation,
compared to ___. ET tube has been advanced, since ___, now
less than 2 cm from the carina an should be withdrawn 2 cm for appropriate
positioning.
There is relatively symmetric opacification of both lung bases new on the
right and increased on the left compared to ___. Findings are
consistent with either extensive pneumonia or dependent pulmonary edema.
There is no clear vascular engorgement in either the lungs or mediastinum.
Pleural effusions small if any. No pneumothorax.
Esophageal drainage tube passes into the stomach and out of view.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with hemorrhagic stroke ___ mycotic aneurysm or
hemorrhagic conversion.// please evaluate hemorrhage for progression or
stability
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 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 ___
FINDINGS:
In comparison to the study from 1 day prior, right temporoparietal
hypointensity with loss of gray-white differentiation, compatible with
infarction is unchanged. Persistent effacement of the adjacent sulci is also
unchanged. Two small hyperintense foci, measuring up to 4 mm, in the right
temporal lobe, involved by infarct likely represent petechial hemorrhage. The
more inferior of these lesions measures 4 mm in the (series 2, image 11)
appears increased from prior examination, while the more superior lesion
measures approximately 2 mm and appears unchanged (series 2, image 15).
No new infarction. No midline shift.
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. Unchanged extent of the right temporoparietal infarction. Two tiny
___ foci of hyperintensity likely represent petechial hemorrhage.
The more inferior focus in the right temporal lobe is mildly increased or new
from the prior examination and measures 4 mm. The previously seen tiny focus
of petechial hemorrhage is unchanged.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old woman with new R PICC// R DL Power PICC 38cm ___
___ Contact name: ___: ___
TECHNIQUE: Portable.
COMPARISON: ___.
FINDINGS:
Right PICC ends in the upper right atrium.
Endotracheal tube tip approximately 4 cm from carina. NG tube extends into
the stomach and out of view, side hole in good position.
Pleural surfaces with no abnormalities.
Right lower lung field has improved, likely improved edema, as reflected by
the mild decrease in size of the heart.
Left lower lobe retrocardiac opacity is due to atelectasis or possibly
pneumonia, unchanged.
IMPRESSION:
-Right PICC ends in the upper right atrium
-Prior mild pulmonary edema has resolved.
-Left lower lobe atelectasis versus pneumonia is unchanged.
Radiology Report
EXAMINATION: US EXTREMITY LIMITED SOFT TISSUE
INDICATION: ___ year old woman with recurrent endocarditis including septic
arthritis L knee, admitted for HA from hemorrhage and mycotic aneurysm// no
trauma to R ankle but tender, mildly swollen and warm to touch, R ankle
pathology?
TECHNIQUE: Grayscale ultrasound images were obtained of the superficial
tissues of the lateral right ankle.
COMPARISON: None
FINDINGS:
Transverse and sagittal images were obtained of the superficial tissues of the
lateral right ankle at the site of the patient's swelling. There is no
evidence of fluid collection or focal mass.
IMPRESSION:
No evidence of fluid collection over the lateral right ankle.
Radiology Report
EXAMINATION: Chest radiograph.
INDICATION: ___ year old woman with endocarditis and severe AR, TR. Evaluate
for evidence of fluid overload or new infiltrate.
TECHNIQUE: Portable chest AP radiograph. l
COMPARISON: Chest radiographs from ___, and ___.
FINDINGS:
In comparison to the studies from ___ there are opacities with
ill-defined borders involving the middle and lower lungs bilaterally, with
partial extension to the upper lung on the right. The cardiac silhouette is
enlarged, similar to prior exam. The right and left hemidiaphragms are
partially obscured and there is opacification of the costophrenic angles. In
comparison to the prior study these findings are suggestive of worsening
pulmonary edema. There is no pneumothorax. Tip of the right subclavian
central venous line projects over the cavoatrial junction.
IMPRESSION:
In comparison to the prior study there is interval increase of bilateral
pulmonary edema, worse on the right.
Radiology Report
EXAMINATION: Carotid Doppler Ultrasound
INDICATION: ___ year old woman with severe MR, IVDU on methadone, recurrent
endocarditis p/w AV endocarditis, ICH, subacute MCA stroke, now w/ e/o HF.
Plan for c-surg ___// pre-op eval per c-surg
TECHNIQUE: Real-time grayscale, color, and spectral Doppler ultrasound
imaging of the carotid arteries was obtained.
COMPARISON: None available.
FINDINGS:
RIGHT:
The right carotid vasculature has no atherosclerotic plaque.
The peak systolic velocity in the right common carotid artery is 103 cm/sec.
The peak systolic velocities in the proximal, mid, and distal right internal
carotid artery are 101, 99, and 97 cm/sec, respectively. The peak end
diastolic velocity in the right internal carotid artery is 35 cm/sec.
The ICA/CCA ratio is 1.
The external carotid artery has peak systolic velocity of 110 cm/sec.
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 99 cm/sec.
The peak systolic velocities in the proximal, mid, and distal left internal
carotid artery are 102, 93, and 90 cm/sec, respectively. The peak end
diastolic velocity in the left internal carotid artery is 35 cm/sec.
The ICA/CCA ratio is 1.
The external carotid artery has peak systolic velocity of 86 cm/sec.
The vertebral artery is patent with antegrade flow.
IMPRESSION:
There is no evidence of significant stenosis in the internal carotid arteries
bilaterally.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: ___ year old woman with endocarditis, mycotic aneurysm and SAH,
planned for AVR/MVR// evaluate progression of SAH and aneurysm
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of intravenous contrast material. Three-dimensional angiographic
volume rendered, curved reformatted and segmented images were generated on a
dedicated workstation. This report is based on interpretation of all of these
images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
934.2 mGy-cm.
2) Spiral Acquisition 4.8 s, 38.1 cm; CTDIvol = 13.3 mGy (Body) DLP = 505.4
mGy-cm.
3) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 3.0 mGy (Body) DLP = 1.5
mGy-cm.
4) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 3.0 mGy (Body) DLP = 1.5
mGy-cm.
5) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 17.8 mGy (Body) DLP =
8.9 mGy-cm.
Total DLP (Body) = 517 mGy-cm.
Total DLP (Head) = 934 mGy-cm.
COMPARISON: CT head from ___, ___, ___. x-ray from ___.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
Mild, subtle diffuse hyperdensity in the right temporal lobe in the area of
the known right M2 infarct/aneurysm is more conspicuous in the current study.
The distribution appears to be cortical, and does not follow the sulci, likely
not SAH.
Right temporal lobe and operculum gray-white matter differentiation loss
consistent with infarction, with areas of higher density, concerning for
petechial hemorrhagic changes or reperfusion phenomenon in the prior area of
infarction.
The ventricles and sulci are normal in size and configuration.
The visualized portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. The visualized portion of the orbits are unremarkable.
CTA HEAD:
Interval rapid increase in size of the known saccular right M2 aneurysm,
currently measuring 6.5 x 6 mm, was 3 x 3.6 mm on ___. In the current
study it appears more lobulated. Decrease in vascularity of the territory of
the MCA seen on the vascular 3D reconstructions, consistent with area of
infarction.
The vessels of the circle of ___ and their principal intracranial branches
appear normal without stenosis, occlusion, or aneurysm formation. The dural
venous sinuses are patent.
CTA NECK:
The carotid and vertebral arteries and their major branches appear normal with
no evidence of stenosis or occlusion. There is no evidence of internal carotid
stenosis by NASCET criteria.
OTHER:
Interval appearance of bilateral central ground-glass opacities in the right
upper lobe and left upper lobe and bilateral pleural effusion, larger on the
right, consistent pulmonary edema.
The visualized portion of the thyroid gland is within normal limits. There is
no lymphadenopathy by CT size criteria.
IMPRESSION:
1. The known right saccular m 2 aneurysm appears larger in size and more
lobulated than in the prior study and now measures approximately 6.5 x 6 mm.
2. There is increased subtle hyperdensity in the right temporal lobe, and
hyperdensities in the right temporal lobe and operculum, suggesting petechial
changes and rib perfusion phenomenon in the prior infarct.
Radiology Report
EXAMINATION: Diagnostic cerebral angiogram and coil embolization of right MCA
aneurysm, mycotic
During the procedure the following vessels were selectively catheterized
angiograms were performed:
Left internal carotid artery
Left vertebral artery
Right internal carotid artery
Three-dimensional rotational angiography of the right internal carotid artery
circulation requiring post processing on an independent workstation and
concurrent attending physician interpretation and review
Right internal carotid artery after coil embolization
Right common femoral artery
INDICATION: Is a ___ female with a long history of IV drug use and
endocarditis. She presented in mid ___ with symptoms of a right MCA
stroke. She was found to have a stroke on imaging. Additional imaging
revealed a right MCA aneurysm. On follow-up imaging several weeks later prior
to plans for anticoagulation for her cardiac surgery there was dramatic
increase in size by approximately 25% of the aneurysm. She also has an MRI
that dates ___ that shows no aneurysm. Due to the rapid growth of
aneurysm it was felt best to treat it emergently. Due the patient's poor
cardiac status with severe aortic and mitral regurgitation it was felt that
coiling procedure would be quickest and most easily tolerated by this patient.
ANESTHESIA: General endotracheal anesthesia was maintained throughout the
entirety of the procedure by a certified anesthesia provider. Please see
separately dictated anesthesia documentation. The patient's hemodynamic and
respiratory parameters were monitored continuously throughout the entirety of
the case by a trained and independent observer.
TECHNIQUE: Diagnostic cerebral angiogram and coiling of right MCA aneurysm
COMPARISON: CTA ___
CTA ___
___ MRI
PROCEDURE: The patient was identified and brought to the neuro radiology
suite. She was transferred to the fluoroscopic table supine. After smooth
induction of general endotracheal anesthesia, bilateral groins were prepped
and draped in standard sterile fashion. A time-out was performed. The right
common femoral artery was identified using anatomic and radiographic
landmarks. The right common femoral artery was accessed using standard
micropuncture technique after infiltration of local anesthetic. A long 8
___ sheath was introduced, connected to continuous heparinized saline
flush, and secured.
Next a ___ diagnostic catheter was introduced. It was connected
continuous heparinized saline flush as well as the power injector. It was
advanced over 038 glidewire through the aorta into the aortic arch. The wire
was used to select left internal carotid artery. The catheter was positioned
over the wire into the left internal carotid artery. The wire was removed.
Vessel patency was confirmed via hand injection. Standard AP and lateral as
well as high magnification oblique views were obtained.
The catheter was withdrawn to the aortic arch. The wire was introduced and
used to select the left vertebral artery. The catheter was advanced into the
left vertebral artery over the wire. The wire was removed. Vessel patency
was confirmed via hand injection. Standard AP and lateral views were
obtained.
The catheter was withdrawn the aortic arch. The wire was introduced and used
to select the right internal carotid artery. The catheter was advanced over
the wire to the right internal carotid artery. The wire was removed. Vessel
patency was confirmed via hand injection. Three-dimensional rotational as
well as AP and lateral views were obtained.
The diagnostic portion of the procedure was necessary to rule out other
aneurysms as well as to understand collateral flow. The images were also used
in device selection and procedure planning for the procedure the followed.
The preoperative images were also used as a baseline to compare to the
postoperative images to rule out thromboembolic complications. The
preoperative images were also used to obtain ideal working angles for the
intervention portion of the procedure.
The patient was loaded with 5000 units of heparin. Serial aCTs were obtained
the patient was re-loaded as necessary to obtain a target close to 200.
A roadmap was performed. Exchange length Glidewire was advanced into the
right internal carotid artery. The diagnostic catheter was exchanged off and
a flushed and prepared neuron max catheter was positioned into the right
internal carotid artery. The exchange length wire and dilator were removed.
The catheter was ___ flushed and then connected to continuous heparinized
saline flush as well as the power injector. Fresh roadmap was performed with
special working views that were obtained via manipulation of the
three-dimensional image. Fresh roadmap was performed. An SL 10 microcatheter
loaded with a synchro 2 standard micro wire was advanced into the distal
superior M2. The catheter was positioned over the wire. The wire was then
positioned within the aneurysm which arises from the superior division of the
M2. The catheter was positioned over the wire into the aneurysm and the micro
wire was removed. The microcatheter was connected to continuous heparinized
saline flush a microsphere coil was chosen. It was loaded into the
microcatheter and then slowly deployed. It was detached. 2 additional coils
were placed. Hand injection was performed at the end of the third coil
placement that showed good occlusion of the aneurysm. The microcatheter was
removed. A standard AP and lateral view was obtained in order to rule out
thromboembolic complications.
Next the guide catheter was removed. Right common femoral angiogram was
performed via hand injection through the sheath. The sheath was removed and
the arteriotomy was closed using a 6 ___ Perclose. After waking from
general anesthesia, the patient was removed from the fluoroscopy table
remained at her neurologic baseline without any evidence of thromboembolic
complications.
OPERATORS: Dr. ___ Dr. ___ physician performed the
procedure. Dr. ___ supervised the trainee during the key
components of the procedure and has reviewed and agrees with the trainee's
findings.
Device inventory
Guidant ___ Rotating Valve
Cook ___ Connecting Tubing
Baxter ___ 3-way Stopcock
Terumo ___ .038" 150cm Angled Glidewire
___ ___ x 150cm ___ Wire
___ ___ x 150cm ___ Wire
Terumo RS___ ___ x 25cm Terumo Sheath Set
___ Medical ___ ___ ___ 2 Cath. 100cm
___ 45-754 ___ Micropuncture Set
___ Medical ___ Injector tubing 72"
Medrad ART 700 SYR Syringe, 150cc Mark 7 Arterion
Terumo ___ 0 Silk Suture
___ ___ Excelsior SL-10 150cm ___
___ ___ ___
Terumo ___ .038 Angled Glidewire Exchange
Penumbra Inc. ___ ___ .088 90cm Straight Neuron MAX Cath.
___ 2641 Synchro2 Standard 14
200cm Wire
___ ___ 5mm/9.7cm Micrusphere 10 Coil
___ ___ Connecting Cable
___ ___ Target 360 Ultra 3mm/8cm Coil
___ ___ InZone Detachment System
___ ___ Target XL 360 Soft 3mm /9cm Coil
___ ___ Perclose ProGlide Closure Device lot#
FINDINGS:
Left internal carotid artery: Vessel caliber smooth and regular. There is
opacification the anterior middle cerebral arteries no distal territories.
There is a fetal configuration the PCOM. There is no evidence of aneurysm or
AVM. The venous phase is unremarkable. On the high magnification AP oblique
view there is a small area that is concerning at the MCA bifurcation but it is
a turn of the artery is of as confirmed on the other views.
Left vertebral artery: Vessel caliber smooth and regular. There is
opacification of the basilar artery as well as the right posterior cerebral
artery and bilateral superior cerebellar arteries. The superior cerebellar
artery appears to be duplicated on the left. There is a fetal configuration
the PCOM on the left which accounts for the decreased opacification of the
left PCA from the posterior injection. There is no evidence of aneurysm or
AVM. The venous phase is unremarkable.
Right internal carotid artery: Vessel caliber smooth and regular. There is
opacification the anterior and middle cerebral arteries and their distal
territories. There is an irregular 5 x 5 mm aneurysm arising from the
superior division of the MCA just distal to the bifurcation. The inferior
division of the MCA ends in a stump. This is consistent with her previous
stroke and her previous noninvasive imaging. This is confirmed on
three-dimensional rotational imaging. There is no evidence of additional
aneurysm or AVM. The venous phase is unremarkable.
Right internal carotid artery after aneurysm coiling: There is no residual
filling of the previous right M2 aneurysm. There is no new vessel dropout.
There is no evidence of thromboembolic complications or vasospasm.
Right common femoral artery: Arteriotomy is above the bifurcation. There is
good distal runoff. There is no evidence of dissection. Vessel caliber
appropriate for closure device.
IMPRESSION:
Uncomplicated coil embolization of right superior division M 2 aneurysm
measuring 5 x 5 mm, unruptured, mycotic with evidence of rapid growth on
noninvasive imaging.
RECOMMENDATION(S):
1. Patient will require close follow-up for the possibility of growth or
recanalization. Patient may be treated with a pipeline device prior to
discharge. She is currently secured from an aneurysm prospective and is
appropriate for cardiac surgery and anticoagulation as needed.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with severe MR/AR with dyspnea// eval for flash
pulmonary edema
IMPRESSION:
In comparison with the study of ___, there again is enlargement of the
cardiac silhouette. Continued pulmonary edema, though less prominent than on
the prior study, especially on the right. Bilateral pleural effusions with
compressive basilar atelectasis. Central catheter is unchanged.
Radiology Report
EXAMINATION: MRA BRAIN W/O CONTRAST T9___ MR HEAD
INDICATION: ___ year old woman with history prior intravenous drug use,
recurrent bacteremia/endocarditis with enlarging right MCA aneurysm s/p
coiling ___. Assess stability of coiled aneurysm.
TECHNIQUE: 3 dimensional time-of-flight MRA was performed through the brain.
No contrast was administered. Three dimensional maximum intensity projection
and segmented images were generated. This report is based on interpretation of
all of these images. No contrast was administered.
COMPARISON: CTA head from ___ and subsequent conventional
cerebral angiogram from ___
FINDINGS:
Motion artifact limits evaluation. Right M1 and proximal right M2 segments
remain smaller than the left. Other major intracranial arteries appear patent
without evidence for high-grade stenosis but evaluation for subtle stenosis is
limited. There is artifact from the coil pack in the treated right M2
aneurysm. There is 1.5 mm round focus of apparent flow at the aneurysm neck,
image 2:93.
IMPRESSION:
1. Motion limited exam.
2. 1.5 mm round focus of apparent flow at the neck of the coiled right M2
aneurysm.
3. Right M1 and proximal right M2 segments remains smaller than the left.
Radiology Report
EXAMINATION: CHEST (PRE-OP PA AND LAT)
INDICATION: ___ year old woman with endocarditis, needs pre-op eval// x Surg:
___ (AVR/MVR) ENDOCARDITIS
IMPRESSION:
Comparison to ___. The bilateral pleural effusions have completely
cleared. Minimal atelectasis persists at the right lung basis. Moderate
cardiomegaly persists no pleural effusions.
Radiology Report
INDICATION: ___ year old woman s/p AVR/MVR// fast track early extubation
cardiac surgery Contact name: ___: ___
TECHNIQUE: AP portable
COMPARISON: ___
IMPRESSION:
ETT 1.5 cm above the carina, 1-2 cm below optimal. NG tube with the tip in
the distal stomach. Right PICC line with the tip in the right atrium. New
median sternotomy wire since prior. Temporary pacemaker projecting over the
upper abdomen. Chest tube on the left hemithorax. Chest tube also projecting
over the mediastinum. Interval placement of aortic and mitral valve.
Asymmetric ill-defined opacities in the left lung and markedly enlarged left
pulmonary artery suggest the possibility of left pulmonary artery thrombus.
Possible small pneumomediastinum. Cardiac size remains stable. There is no
pneumothorax.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 3:19 pm, 20 minutes after
discovery of the findings.
Radiology Report
INDICATION: ___ year old woman s/p tiss MVR/AVR// please do at 8am on
___ eval for pneumothorax with CT on waterseal
COMPARISON: ___
IMPRESSION:
Swan-Ganz catheter has been removed. Mediastinal drains and bilateral chest
tubes are again seen. There are bilateral small pneumothoraces, left side
larger than right. There are bilateral pleural effusions and a left
retrocardiac opacity. There is mild cardiomegaly.
Radiology Report
INDICATION: ___ year old woman POD 3 from AVR with chest tubes placed to water
seal yesterday. Developed Bilat pnuemo. To suction overnight.// Interval
change
COMPARISON: Radiographs from ___
IMPRESSION:
Support lines and tubes are unchanged. Cardiomediastinal silhouette is within
normal limits. The small bilateral apical pneumothoraces have improved on are
very tiny bilaterally. There are bilateral pleural effusions, right slightly
greater than left. There is mild cardiomegaly.
Radiology Report
EXAMINATION: Chest x-ray
INDICATION: ___ year old woman with SOB// ___ year old woman with SOB
TECHNIQUE: Portable chest x-ray
COMPARISON: Chest x-ray ___ approximately 11 hours previous
FINDINGS:
Support lines and tubes appear stable in position. The heart is mildly
enlarged. There is a small right pleural effusion, unchanged, with adjacent
atelectasis.
Subsegmental atelectasis is seen at the left lung base. A developing
pneumonia cannot be completely excluded in this region.
Sternal wires appear intact. The patient is status post valve replacement.
IMPRESSION:
As above
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with s/p AVR/MVR// eval ptx eval ptx
IMPRESSION:
Compared to preoperative chest radiographs before ___ and postoperative
chest radiographs through ___ one.
Pulmonary edema has resolved. Moderate left basal atelectasis and bilateral
pleural effusions, moderate on the right small on the left are unchanged. No
pneumothorax. Mild enlargement cardiac silhouette has improved
postoperatively.
Right PIC line, midline and bilateral pleural drains still in place.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with s/p AVR/MVR// eval ptx-pt SOB on H2O seal,
now on suction
IMPRESSION:
In comparison with the earlier study of this date, the monitoring and support
devices are unchanged. Little overall change in the appearance of the heart
and lungs.
With the left chest tube on water seal. There may be a tiny apical
pneumothorax.
Radiology Report
INDICATION: ___ year old woman with s/p AVR/MVR// eval ptx-post pull, *Please
do at 1600, thx
TECHNIQUE: AP portable
COMPARISON: ___ at 13:59
FINDINGS:
Interval removal of a mediastinal drain. Right chest tube, left chest tube,
left-sided PICC line are in expected and unchanged position. Patient is status
post mitral and aortic valve replacement. Median sternotomy wires from prior
cardiac surgery.
Overall the current radiograph appears unchanged since prior. Right small
pleural effusion appears unchanged since prior. Cardiomediastinal and hilar
silhouettes are unchanged. Bibasilar atelectasis are again seen. There is no
significant pneumothorax or pneumomediastinum.
IMPRESSION:
Interval removal of the mediastinal drain without pneumothorax or
pneumomediastinum.
Overall unchanged cardiomediastinal and lung findings as described above.
Radiology Report
INDICATION: ___ year old woman POD 5 AVR/MVR// Clamp trial/Pneumo*****Take at
1330 please****
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Right-sided PICC line is unchanged. Bilateral chest tubes are also unchanged.
Bilateral effusions right greater than left are unchanged. Cardiomediastinal
silhouette is stable. No obvious pneumothorax is seen. The oxygen mask
overlies the left apex, limiting evaluation.
Radiology Report
EXAMINATION: Right internal carotid artery angiogram.
Right common femoral artery angiogram.
INDICATION: ___ year old woman with known cerebral aneurysm.// Pipeline
embolization of cerebral aneurysm. *Dr. ___ Anes sched 7:30am, case
___
ANESTHESIA: General endotracheal anesthesia was maintained by separate
anesthesia provider throughout the entirety of the case. The anesthesia
provider also monitored the patient's hemodynamic and respiratory parameters.
TECHNIQUE: Patient was brought into the angio suite, ID was confirmed via
wrist band.The patient was placed supine on fluoroscopy table and bilateral
groins were prepped and draped in the usual sterile manner. Time-out procedure
was performed per institutional guidelines. The location of the right mid
femoral head was located using anatomic and radiographic landmarks. 10 +10 cc
of subcutaneous lidocaine was infused into the tissue. Micropuncture kit was
used to gain access to the right femoral artery, serial dilation was
undertaken until a long 8 ___ groin sheath connected to a continuous
heparinized saline flush could be inserted. ___ catheter was
connected to the power injector and also to a continuous heparinized saline
flush. This was advanced over the 0.038 glidewire brought up the aorta used to
select the right internal carotid artery. AP, oblique and lateral views of the
anterior cerebral circulation were obtained. Subsequently, 3D rotational
images were performed requiring post processing on an independent workstation
under concurrent physician supervision and used in the interpretation and
reporting of the procedure.
Some vasospasm was noted at the cervical internal carotid which was treated
with 5 mg of verapamil, the artery responded very well.
In collaboration with our colleagues anesthesia, 5000 units of heparin were
given to target ACT between 250 and 300 subsequent doses were given as needed
to achieve this target.
Under constant fluoroscopy, using an angled Glidewire exchange, the diagnostic
catheter was exchanged to ___ .088 90cm Straight Neuron MAX catheter, which was
advanced to satisfactory position in the proximal cervical internal carotid
artery. The Glidewire was removed, a new AP and lateral road maps were
obtained, then ___ ___ was mounted over Phenom microcatheter catheter was
advanced carefully and slowly over a synchro 2 wire until the ___ ___ was
positioned in the petrous/cavernous portion of the ICA.
New magnified road maps were obtained, then the Phenom microcatheter was
advanced over synchro 2 wire into the distal M1, multiple attempts to
cannulate the superior division failed as the wire has the tendency to go
inside the aneurysm and the size of the Phenom microcatheter was larger than
the M2 division.
Due to that we decided not to execute the primary plan which was flow
diversion of this aneurysm. The Phenom microcatheter was removed and an SL 10
microcatheter was mounted over synchro 2 wire and was advanced slowly and
carefully until it was positioned halfway into the recurrent portion of the
aneurysm.
Target XL 360 Soft 3mm/9cm was the only coil that was used and was advanced
slowly and carefully until it was fully deployed inside the recurrent portion
of the aneurysm , before final detachment an angio run was done that showed no
filling of the distal M1. Due to that we decided to detached the coil and
take the microcatheter out, another angio run was obtained and showed patency
of the MCA tree.
then we obtained final AP and lateral views, which confirmed the patency of
all involved arteries and complete obliteration of the aneurysm.
The catheter was then pulled back in the aorta fully removed from the body. A
common femoral arteriogram was performed prior to use of a closure device,
subsequently 6 ___ Perclose was put in. At the conclusion of the procedure,
there is no evidence of thromboembolic complication and the patient was at his
neurologic baseline.
All angio runs were medically necessary for baseline assessment, collateral
was assessment, aneurysm regrowth measurements and for future comparison.
Devices inventory:
.038" 150cm Angled Glidewire
035 x 150cm ___ Wire
038 Angled Glidewire Exchange
Synchro2 Standard 14 200cm Wire x2
___ Micropuncture Set
___ Berenstein ___ 100cm Cath.
___ x 25cm Terumo Sheath Set
___ .088 90cm Straight Neuron MAX Cath. $395.00 ___
Synchro2 Standard 14 200cm Wire
Phenom Microcatheter 15cm tip, 150cm $1,265.00 EV3
___ ___ ___ 115 Intracranial Support Catheter
Excelsior SL-10 150cm Microcatheter
InZone Detachment System
Target XL 360 Soft 3mm/9cm Coil ___
___ PERCLOSE CLOSURE DEVICE ___
COMPARISON: ___
PROCEDURE: Coiling of a recurrent right MCA bifurcation infectious aneurysm.
FINDINGS:
Right internal carotid artery: There is no gross change in the angio
architecture of the right ICA angiogram with the exception of recurrence at
the base and the ___ the right MCA bifurcation aneurysm that measures
around 4.5 x 3.7 mm. Post primary coiling, successful complete obliteration
of the aneurysm compatible with ___ grade 1.
Right common femoral artery: Well-visualized with a good caliber size for
closure device.
I, ___, participated in the procedure. I, ___, was
present for the entirety of the procedure and supervised all critical steps.
I, ___, have reviewed the report and agree with the fellow's
findings.
IMPRESSION:
There is no gross change in the angio architecture of the right ICA angiogram
with the exception of recurrence at the base and the ___ the right MCA
bifurcation aneurysm that measures around 4.5 x 3.7 mm. Post primary coiling,
successful complete obliteration of the aneurysm compatible with ___ and
___ grade 1.
RECOMMENDATION(S): MRA in 1 month, continue on baby aspirin.
Radiology Report
INDICATION: ___ year old woman POD5 from AVR/MVR with left chest tube
currently clamped.// RE-evaluate apex for pneumo
TECHNIQUE: Chest AP view
COMPARISON: ___
IMPRESSION:
Bilateral effusions right greater than left are unchanged. There is bibasilar
atelectasis. Right-sided PICC line projects to the cavoatrial junction.
Multiple bilateral chest tubes are unchanged. Cardiomediastinal silhouette is
stable. No pneumothorax is seen.
Radiology Report
EXAMINATION: Chest x-ray
INDICATION: ___ year old woman POD 5 AVR/MVR.// Pnuemo post left CT removal.
TECHNIQUE: Portable chest x-ray
COMPARISON: Chest x-ray ___ approximately 1 hours previous
FINDINGS:
There are stable bilateral pleural effusions with adjacent basilar
atelectasis. The right PICC tip is in the region of the cavoatrial junction.
The left chest tube is been removed. The right chest tube appears stable in
position. There is a small left apical pneumothorax.
IMPRESSION:
Small left apical pneumothorax. Stable pleural effusions.
Radiology Report
INDICATION: ___ ___ s/p avr/mvr air leak post-op now on water seal// r/o ptx
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
IMPRESSION:
Pulmonary edema has improved. Bilateral effusions are stable. Right-sided
PICC line projects to the cavoatrial junction. Right-sided chest tube is
unchanged. Cardiomediastinal silhouette is stable. No pneumothorax is seen
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman s/p ct removal// r/o ptx r/o ptx
IMPRESSION:
Comparison to ___. The the right-sided chest tube was removed.
There is no evidence for the presence of a pneumothorax. Stable alignment of
the sternal wires. Stable appearance of the slightly enlarged cardiac
silhouette. Improved retrocardiac atelectasis. Otherwise normal appearance
of the left lung.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Headache
Diagnosed with Headache
temperature: 98.3
heartrate: 70.0
resprate: 18.0
o2sat: 100.0
sbp: 104.0
dbp: 64.0
level of pain: 10
level of acuity: 3.0 | Ms. ___ is a ___ F with PMHx notable for prior IVDU,
recurrent bacteremia/endocarditis most recently admitted for
AV/MV recurrent endocarditis and strep mitis bacteremia
(___) discharged on linezolid who was a/w headache, found to
have 4mm right MCA aneurysm in setting of new right MCA
territory stroke. Her hospital course has been complicated by
heart failure symptoms and enlarging mycotic aneurysm s/p
embolization on ___. She completed a 6 week course of
vanc/ceftriaxone for endocarditis while inpatient (end date
___. She underwent AVR/MVR with cardiac surgery on ___.
Please see operative note for full details. Her immediate post
op ICU course was without complications and she was transferred
to the stepdown floor on POD 1. Her chest tubes remained in due
to air leak and small pneumothorax. She continued to have
periods of agitation and anxiety. Psychiatry continued to follow
her and quetiapine was stopped and started aripiprazole 10mg po
daily, continue methadone 30mg po daily and offer haloperidol
2.5mg BID PRN anxiety/agitation. Her pain was controlled with
methadone and dilaudid. Neurosurgery evaluated her
postoperatively and decided that she would benefit from a
pipeline procedure this admission which was scheduled for
___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lopressor / Apomorphine / morphine / Coconut / Stadol / fentanyl
/ pain meds / muscle relaxant / Erythromycin Base / Codeine /
metal / surgical skin staples
Attending: ___
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with osteoporosis and several known compression fractures
and recent vertebroplasty L1 and L5, CAD s/p CABG ___ presents
with worsening back pain. Pt with chronic back pain with acute
excerb starting last night. She went to the restroom and
developed sharp pain around R rib. Pain comes and goes and made
worse with movement.
___ notes that the R side of her back feels like more of a
cramp while the L side is a severe pain. This has been coming
and going for last several months. Over the last couple of
months, she has intermittently walked with a walker because she
feels unsteady on her feet. She denies any associated fevers,
bowel or bladder incontinence.
The patient initially began experiencing severe back pain in
___. It had not improved by the following month,
and she was seen by Dr. ___ at ___, and MRI at that
time revealed L1, L5 compression fractures, for which she
underwent kyphoplasty. Her pain was not relieved
post-procedurally however, and she had significant pain in a
band-like distribution around her hips. She was re-hospitalized
in ___ at ___, and imaging done at that time
showed L2 compression fracture, which was presumed to be new.
They were reluctant to perform another kyphoplasty at that time,
given her minimal improvement. She had been gradually improving
since that time, even though bone density scanning done in ___
showed previously-unseen T11, T12 compression fractures in
addition. She then began aquatherapy in ___, and after
the third session, began experiencing worsened, acute pain in
her middle/low back, which was sudden in onset.
In the ED initial vitals were: 98.0 ___ 16 100% ra
- Labs were significant for Na 131. Otherwise unremarkable.
- Patient was given IV morphine 15mg, diazepam, and ondansetron.
CT Abdomen/Pelvis showed 1. No evidence of aortic dissection. 2.
Multiple thoracolumbar compression
deformities, similar to the recent MRI thoracolumbar spine from
___.
She was evaluated by Ortho Spine, who recommended TLSO brace and
admission to Medicine for further management.
Vitals prior to transfer were: 97 150/77 18 99% RA
On the floor, patient is complaining of cramping throughout her
back which is not new, but worse than before. She is also
feeling lightheaded and nauseous from all the pain medication
she received in the ER. She says she always has these reactions
to all pain medications and muscle relaxants.
Past Medical History:
-Osteoporosis
-Coronary artery disease s/p CABG ___
-Hypertension
-Hyperlipidemia
-Hypothryoidism
-Vertebral compression fractures as above
-RLE Melanoma: Biopsy ___ at least 1.75 mm thick,
___ Level IV, nonulcerated melanoma, extended to deep margin
with 4 mitoses/mm2. s/p wide local excision and right inguinal
sentinel lymph node biopsy ___.
Pathology revealed no residual melanoma at the primary site, and
no melanoma in 1 inguinal sentinel lymph node
Past Surgical History:
2-vessel CABG
Right calf melanoma excision
Social History:
___
Family History:
No family history of early fractures
Physical Exam:
Admission Physical
===================
Vitals - T:97.3 BP:150/81 HR:86 RR:16 02 sat:97RA
GENERAL: Patient laying on her L side, intermittently dry
heaving, tearful, in moiderate distress
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition, nontender supple neck, no
LAD, no JVD
CARDIAC: midline scar, RRR, S1/S2, no murmurs, 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
EXTREMITIES: unable to assess strength completely due to
discomofort, 4+plantar flexion and dorsiflexion b/l, ___ UE
strength b/l
BACK: no midline spinal tenderness on initial evalaution but
patient reported pain in her spine shortly after palpation.
patient had L sided lumbar paraspinal tenderness
PULSES: 1+ DP pulses bilaterally
NEURO: CN II-XII intact, downgoing toes b/l, 1+ patellar
reflexes b/l
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Discharge Physical
====================
Vitals- 98.3 98 104-133/48-60 56-70 ___ 98% RA
GENERAL: Resting comfortably in bed
CARDIAC: midline scar, RRR, S1/S2, no murmurs, 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
EXTREMITIES: unable to assess strength completely due to
discomfort, moving all extremities
BACK: no midline spinal tenderness, patient had L sided lumbar
paraspinal tenderness, R side with medicated patches
PULSES: 1+ DP pulses bilaterally
NEURO: CN II-XII intact, downgoing toes b/l, 1+ patellar
reflexes b/l
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
Admission Labs
==============
___ 03:15PM BLOOD WBC-8.9 RBC-4.41 Hgb-14.4 Hct-44.1
MCV-100* MCH-32.6* MCHC-32.6 RDW-13.3 Plt ___
___ 03:15PM BLOOD Neuts-73.4* ___ Monos-4.5 Eos-0.7
Baso-0.5
___ 07:00AM BLOOD Glucose-85 UreaN-13 Creat-0.9 Na-137
K-4.4 Cl-97 HCO3-30 AnGap-14
___ 07:00AM BLOOD Albumin-4.3 Calcium-10.0 Phos-4.8* Mg-2.2
Urinalysis
============
___ 06:20PM URINE Color-Straw Appear-Clear Sp ___
___ 06:20PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 06:20PM URINE Hours-RANDOM UreaN-193 Creat-23 Na-56
K-21 Cl-60
___ 06:20PM URINE Hours-RANDOM
___ 06:20PM URINE Osmolal-260
Discharge Labs
==============
___ 07:00AM BLOOD WBC-4.0 RBC-3.71* Hgb-12.3 Hct-36.3
MCV-98 MCH-33.1* MCHC-33.8 RDW-13.1 Plt ___
___ 07:00AM BLOOD ___ PTT-38.6* ___
___ 07:30AM BLOOD Glucose-127* UreaN-10 Creat-0.7 Na-135
K-4.8 Cl-98 HCO3-28 AnGap-14
___ 07:00AM BLOOD Calcium-10.2 Phos-3.2 Mg-2.0
Imaging
=============
Scoliosis Series ___
FINDINGS: No previous images. There are kyphoplasties at what
appear to be T12 and L4. Some loss of height is seen at L1,
T12, T11, and T9. Generalized osteopenia is seen. There is
minimal scoliosis convexed to the right and centered at about
T9. Slightly more scoliosis convexed to the left centered at
L1.
The intervertebral disc spaces in the lumbar spine appear to be
quite well
maintained.
Bilateral Hip Xray ___
IMPRESSION: Bony demineralization. No fracture or bone
destruction
identified.
Rib Xray ___
FINDINGS: Frontal and oblique views show no evidence of
fracture or
pneumothorax. Several vertebroplasties are seen in the
thoracolumbar spine.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amitriptyline 25 mg PO HS
2. Estrogens Conjugated 0.625 gm VG 2X/WEEK (MO,FR)
3. fesoterodine 8 mg oral Daily
4. Gabapentin 300 mg PO HS
5. Levothyroxine Sodium 75 mcg PO DAILY
6. Losartan Potassium 25 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Calcium Carbonate 1250 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Atorvastatin 10 mg PO DAILY
11. NIFEdipine 10 mg PO QHS
12. Zolpidem Tartrate 10 mg PO HS
13. Omeprazole 20 mg PO DAILY
14. black cohosh 40 mg oral Daily
15. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Amitriptyline 25 mg PO HS
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 10 mg PO DAILY
4. Calcium Carbonate 1250 mg PO DAILY
5. fesoterodine 8 mg oral Daily
6. Levothyroxine Sodium 75 mcg PO DAILY
7. Losartan Potassium 25 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. NIFEdipine 10 mg PO QHS
10. Omeprazole 20 mg PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
12. Zolpidem Tartrate 10 mg PO HS
13. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
14. Polyethylene Glycol 17 g PO BID
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by
mouth twice a day Disp #*20 Packet Refills:*0
15. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*60 Tablet Refills:*0
16. Tizanidine 4 mg PO TID
RX *tizanidine 4 mg 1 tablet(s) by mouth three times a day Disp
#*30 Tablet Refills:*0
17. black cohosh 40 mg oral Daily
18. Estrogens Conjugated 0.625 gm VG 2X/WEEK (MO,FR)
19. Baclofen 10 mg PO Q8H:PRN back pain
RX *baclofen 10 mg 1 tablet(s) by mouth three times a day Disp
#*20 Tablet Refills:*0
20. Methadone 2.5 mg PO BID
RX *methadone 5 mg 0.5 (One half) tablet by mouth twice a day
Disp #*15 Tablet Refills:*0
21. Gabapentin 400 mg PO BID
22. Gabapentin 600 mg PO HS
23. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth three times a day Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
-Chronic Vertebral Compression Fractures
-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
INDICATION: ___ woman with severe back pain, evaluate for compression
fracture and evaluate the aorta.
TECHNIQUE: Axial multidetector CT images were obtained through the chest,
abdomen and pelvis during rapid administration of intravenous contrast.
Multiplanar reformats.
DLP: 826 mGy-cm.
COMPARISON: MRI of the thoracic and lumbar spine dated ___.
FINDINGS:
CTA: Moderate atherosclerotic calcifications are noted along the infrarenal
abdominal aorta and iliac arteries without aneurysmal dilatation. There is no
evidence of aortic dissection.
CT CHEST: There is no axillary, mediastinal or hilar lymphadenopathy by CT
criteria. Heart is normal in size and there is no pericardial effusion.
Trachea is midline and airways are patent to subsegmental level. Background
lung parenchyma is notable for mild bibasilar atelectasis. There are no
concerning nodules, focal consolidation or pleural effusion. No pneumothorax.
Sternotomy wires are noted.
CT ABDOMEN: Liver enhances homogeneously without concerning lesions or
biliary dilatation. Cholecystectomy clips are noted. Prominent CBD likely
relates to post cholecystectomy state. Spleen, pancreas and adrenal glands are
unremarkable. Kidneys enhance and excrete symmetrically without concerning
lesions or hydronephrosis.
Stomach is partially decompressed. A diverticulum is incidentally noted
arising from the posterior gastric fundus. Nondilated loops of small bowel
are normal in course and caliber. There is no obstruction or bowel wall
thickening. There is no intra-abdominal free air or fluid. There is no
mesenteric or retroperitoneal lymphadenopathy.
CT PELVIS: The bladder is well distended and within normal limits. Uterus is
not visualized. There is no pelvic free fluid or lymphadenopathy.
BONE WINDOWS: Transitional anatomy with lumbarization of S1 is again noted.
There is evidence of prior vertebroplasty in the L1 and L5 vertebral bodies.
Multiple compression deformities in the thoracolumbar spine including T9, T11,
T12, L1, and L5 are better evaluated on recent MRI examination of ___ and appear relatively unchanged. No new fracture is identified.
IMPRESSION:
1. No evidence of acute aortic abnormality.
2. Multiple compression deformities in the thoracolumbar spine and evidence
of prior vertebroplasty, not significantly changed and better evaluated on MRI
from three days prior.
Radiology Report
HISTORY: Compression fractures.
FINDINGS: No previous images. There are kyphoplasties at what appear to be
T12 and L4. Some loss of height is seen at L1, T12, T11, and T9. Generalized
osteopenia is seen. There is minimal scoliosis convexed to the right and
centered at about T9. Slightly more scoliosis convexed to the left centered
at L1.
The intervertebral disc spaces in the lumbar spine appear to be quite well
maintained.
Radiology Report
BILATERAL HIP AND PELVIS RADIOGRAPHS
HISTORY: Question lytic lesion, fracture or dislocation; osteoporosis,
multiple spine fractures, and bilateral hip pain.
COMPARISONS: Recent prior CT dated ___.
TECHNIQUE: Bilateral hips, two views of each side, and AP pelvis.
FINDINGS: The patient is status post vertebroplasty of the L4 vertebral body,
which is visible on the pelvis views, but not completely characterized. The
hip joint spaces appear preserved. On the right, there is a small ossicle
superolateral to the acetabulum consistent with an os acetabulum, considered a
normal variant. There is no evidence for fracture, dislocation or bone
destruction. The bones appear demineralized.
IMPRESSION: Bony demineralization. No fracture or bone destruction
identified.
Radiology Report
HISTORY: Back pain and rib pain.
FINDINGS: Frontal and oblique views show no evidence of fracture or
pneumothorax. Several vertebroplasties are seen in the thoracolumbar spine.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Back pain
Diagnosed with FX DORSAL VERTEBRA-CLOSE, OVEREXERTION FROM SUDDEN STRENUOUS MOVEMENT
temperature: 98.0
heartrate: 111.0
resprate: 16.0
o2sat: 100.0
sbp: 153.0
dbp: 100.0
level of pain: 10
level of acuity: 3.0 | ___ with osteoporosis and several known compression fractures
and recent vertebroplasty L1 and L5, CAD s/p CABG ___ presents
with severe back pain.
#Back Pain with Vertebral Fractures - Patient has known
compression fractures at T11, T12, L1, L2 and L5 with history of
kyphoplasty at L1 and L5 prior to this admision. She was seen
throughout her stay by orthopedics and pain management. THere
was also extensive discussion with Interventional Radiology. She
unforunately after her kyphoplasty had extrusion of cement that
was in the spinal canal but not compressing the cord. Throughout
her stay she had very difficult to control left sided mid-back
pain. One reason was her intolerance of many medications. She
had nausea, vomiting, flushing, and fatigue to opiates and
muscle relaxants. She was attempted to be treated with
anti-emetics, however her QTc was prolonged which made treatment
difficult. She initially was treated with topical medications
including capsaicin and lidocaine patch but developed marked
skin irritation. Her pain was attempted to be controlled with
oral medications as well including tizanidine, baclofen, and
dilaudid but while these imprved her pain, she still had pain
that limited her to the point where she could not lie on her
back, sit in a chair, or move from sit to stand. She did improve
after spinal injection with steroids. There was discussion of
repeate kyphoplasty, but there was concern of spinal procedures
destabilizing her other vertebrae and putting her at more risk
of addtional fractures. Orthopedics was asked about the
possibility of removal of the cement, but they thought that any
procedure on her spine was dangerous given how soft her bones
were. They did recommend she be in TLSO brace at all times. She
was evaluated by ___ who noted that she still retained enough
functional strength that she did not need inpatient ___. She was
discharged with a new pain regimen, home ___, recommendation to
continually wear the TLSO brace, and close follow up with her
outpatient pain team to continue management and to decide if she
needed further surgical intervention.
#Osteoporosis - Patient had presented with a diagnosis of
osteoporosis with confirmation previously with DEXA scan based
on outpatient records. In hospital she had multiple images
consistent with osteoporotic bones. She had a family history of
osteoporosis. Initially there was concern that her symptoms
could be related to a malignancy, however, upon contacting the
neurosurgeon who had treated her previously, she had a negative
bone biopsy during her previous kyphoplasty. Her SPEP/UPEP were
not consistent with multiple myeloma. Her recent MRI of her
spine and her xrays of hips and ribs did not show any
destructive lesions consistent with malignancy. Additionally her
calcium remained normal during her stay. Her rheumatologist had
planned to start Prolia for her osteoporosis, which should be
continued after she was discharged from the hospital. She was
continued on her calcium and vitamin D.
#Hypovolemic Hyponatremia - She was initially hyponatremic in
setting of decreased PO intake. She was dry on exam, and this
resolved with fluids making the most likely reason a prerenal
etiology.
#Hypothyrodism - She appeared euthyroid and was continued on her
levothyroxine
#CAD s/p CABG - She remained asymptomatic and was continued on
her statin and aspirin.
#Hypertension - She remained normotensive and was continued on
losartan and nifedipine. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
___
Major Surgical or Invasive Procedure:
EGD:
Esophageal varices
No blood or source of bleeding identified.
No AVMs
Otherwise normal EGD to third part of the duodenum
History of Present Illness:
Ms. ___ is a ___ year old woman with alocholic cirrhosis
Child B and MELD 10 that has been complicated by stage 2 varices
and multiple variceal bleeds, history of ascites and hepatic
encephalopathy who presents following 2 days of melena.
Patient reports melena that is well formed beginning yesterday
___. She reports ___ episodes per day, with last episode being
this morning. She also reports 2 days of cold sweats, no
fevers, worsening abdominal pain and back pain (described as
pressure), nausea, tiredness, lightheadedness, palpitations, and
worsening shortness of breath. Denies any dysuria or change in
urinary frequency, urgency, color, or odor. No increased leg
swelling.
She also reports baseline waxing and waning mental status though
believes that her confusion has been worse over the last two
days.
She reports 2 recent hospitalizations for GI bleeding at ___
___ and ___. She reports her last variceal
bleed was "months ago." She reports four episodes of variceal
bleeding in the past. Also had recent admission for UTI. She
could not remember the exact time course of these admissions.
In the ED, initial vitals: 98.0 HR: 90 BP: 135/85 Resp: 18
O(2)Sat: 100
- RUQ US performed demonstrating patent portal vein and
coarsened hepatic echotexture without focal hepatic lesion.
- Also evaluated with bedside US in ED, however not enough
ascites to tap
- Chest X-ray without acute cardiopulmonary process
- Labs notable for WBC 14.7, H/H 12.3/40.4, Tbili 0.3, INR 1.4,
plts 228 and positive UA
- Pt received Ceftriaxone and Morphine
Vitals prior to transfer: 98.1 78 122/76 19 100%RA
Vitals on arrival to the floor: 97.9 124/70 75 14 100% RA
Currently, she is complaining of worsening back and abdominal
pain and pressure that feels like a "band." She denies chest
pain and endorses mild SOB.
ROS:
No changes in vision or hearing, no changes in balance. No
cough. No chest pain. No vomiting. No dysuria or hematuria.
Intermittent numbness and tingling of right arm and leg.
Past Medical History:
EtOH Cirrhosis with HE, ascites and EV grade 2 in ___
Anxiety
Pneumonia (frequent)
UTI a week ago
UGIB from an ulcer a month ago (pt reported)
Migraines
Chronic pain
Social History:
___
Family History:
No family history of liver disease or GI malignancy. DM and HTN
in family.
Physical Exam:
ON ADMISSION:
Vitals- 97.9 124/70 75 14 100% RA
General- A+Ox3, no acute distress, speech mildly slurred and
some word finding difficulties
HEENT- 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- BS+, tight, distended, dull to percussion, liver span
15cm, splenomegaly, no fluid wave
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Contracture of left ___ distal metacarpal joint.
Neuro- CNs2-12 intact, motor function grossly normal, no
asterixis, mild resting tremor bilaterally, more pronounced in
right hand
Skin - mildly jaundiced. No spider angiomas, no caput medusae,
no palmar erythema
ON DISCHARGE:
Vitals 98.1 81/47 76 16 98% RA
General- A+Ox3, no acute distress, speech mildly slurred and
some word finding difficulties
HEENT- 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- BS+, tight, distended, dull to percussion, liver span
15cm, splenomegaly, no fluid wave
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Contracture of left ___ distal metacarpal joint.
Neuro- CNs2-12 intact, motor function grossly normal, no
asterixis, mild resting tremor bilaterally, more pronounced in
right hand
Skin - mildly jaundiced. No spider angiomas, no caput medusae,
no palmar erythema
Pertinent Results:
ON ADMISSION:
___ 03:30PM GLUCOSE-92 UREA N-10 CREAT-0.8 SODIUM-139
POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-22 ANION GAP-18
___ 03:30PM ALT(SGPT)-20 AST(SGOT)-28 ALK PHOS-157* TOT
BILI-0.3
___ 03:30PM LIPASE-41
___ 03:30PM ALBUMIN-4.6
___ 03:30PM WBC-14.7* RBC-4.85 HGB-12.3 HCT-40.4 MCV-83
MCH-25.4* MCHC-30.4* RDW-17.2*
___ 03:30PM NEUTS-57.5 ___ MONOS-4.8 EOS-2.1
BASOS-0.8
___ 03:30PM PLT COUNT-228
___ 04:10PM ___ PTT-42.9* ___
___ 05:44PM URINE RBC-0 WBC-36* BACTERIA-FEW YEAST-NONE
EPI-9
___ 05:44PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG
___ 05:44PM URINE COLOR-Yellow APPEAR-Hazy SP ___
ON DISCHARGE:
___ 07:19AM BLOOD WBC-8.1 RBC-3.88* Hgb-9.2* Hct-31.8*
MCV-82 MCH-23.6* MCHC-28.8* RDW-17.2* Plt ___
___ 07:19AM BLOOD ___ PTT-41.7* ___
___ 07:19AM BLOOD Glucose-81 UreaN-9 Creat-0.7 Na-137 K-4.1
Cl-106 HCO3-22 AnGap-13
___ 07:19AM BLOOD ALT-17 AST-25 LD(LDH)-119 AlkPhos-123*
TotBili-0.3
___ 07:19AM BLOOD Albumin-3.8 Calcium-8.5 Phos-4.3 Mg-2.4
Radiology Report
INDICATION: ___ with altered mental status. // PNA?
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: None.
FINDINGS:
The lungs are clear. The cardiomediastinal silhouette is normal. No acute
osseous abnormalities identified.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
INDICATION: ___ with worsening chronic abdominal pain in the setting of
alcoholic cirrhosis. // Evaluate for portal venous thrombosis
TECHNIQUE: Grayscale, color, and spectral Doppler ultrasound was performed of
the right upper quadrant.
COMPARISON: None.
FINDINGS:
The liver has a coarsened echotexture but no focal hepatic lesion is
identified. The gallbladder is normal without wall thickening or gallstone.
The common duct measures 5 mm and there is no intra- or extra-hepatic bile
duct dilatation. The visualized portion of the pancreas is unremarkable. The
spleen is enlarged, measuring 11.3 cm.
Color flow and spectral Doppler waveform analysis were obtained. The main
portal vein is patent with hepatopetal flow.
IMPRESSION:
Patent portal vasculature. Coarsened hepatic echotexture without focal hepatic
lesion. The left portal vein is patent with hepatopetal flow.
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by WALK IN
Chief complaint: Melena
Diagnosed with HEPATIC ENCEPHALOPATHY, ALCOHOL CIRRHOSIS LIVER, RECTAL & ANAL HEMORRHAGE
temperature: 98.0
heartrate: 90.0
resprate: 18.0
o2sat: 100.0
sbp: 135.0
dbp: 85.0
level of pain: 9
level of acuity: 3.0 | Ms. ___ is a ___ year old woman with alcoholic cirrhosis
Child B and MELD 10 c/b stage 2 varices s/p multiple variceal
bleeds, and a history of ascites and hepatic encephalopathy who
presents following 2 days of melena and found to have hepatic
encephalopathy and UTI on infectious workup.
ACTIVE MEDICAL ISSUES
#Melena: Patient reported dark tarry stools starting the day
before admission. She has a known history of varices and past
admission for GI bleed 2 weeks ago at ___,
though of note her last endoscopy showed no varices. On arrival,
she did not appear to be actively bleeding, given that she was
hemodynamically stable and her Hemoglobin and hematocrit were
stable from priors. She did have a drop in her hematocrit
overnight on first night of admission, however, and underwent
upper endoscopy in the morning given concern for continued GI
bleeding. Endoscopy showed stage 1 varices but no active
bleeding. She was watched overnight and remained hemodynamically
stable, though relatively hypotensive near her baseline. Her
blood pressure and orthostatics improved significantly once she
began eating again (had been NPO before procedure).
#Hepatic encephalopathy: Pt has personal history of hepatic
encephalopathy and reports that even at baseline at home she has
waxing and waning mental status. She reported being confused on
admission, which improved back to baseline by the time of
discharge. Notably, she is alert and oriented, she had asterixis
on exam, no portal vein thrombosis on right upper quadrant
ultrasound, CXR negative, and no SBP detected though there was
not enough ascites for diagnostic paracentesis. Patient was
continued on home Lactulose 30mL and Rifaximin 550 BID.
#UTI: On admission, patient had a positive urinalysis, elevated
white count elevated, and was started on ceftriaxone. She
remained afebrile throughout her course. Urine cultures came
back negative, though of note the culture sample was taken
following first dose of ceftriaxone. She was discharged home on
cefpoxime for four additional days (last dose ___, for a total
of a ___tOH Cirrhosis: Pt was diagnosed ___ years ago. Child B and
MELD score 10. She is not currently on transplant list. Past
history of varices grade 2 with ?banding, not on nadolol and
more recent EGD from ___ showed no varices. She has had
ascites in the past and is on lasix and spironolactone. She has
no history of spontaneous bacterial peritonitis. Diuretics were
held during this admission for kidney protection, though kidney
function is current good with Creatinines <1. These will be held
for three more days after discharge and can be restarted on
___. |
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:
History of Present Illness:
___ with PMH of dCHF, reactive airway disease per OMR, OSA,
HTN presenting acutely with dyspnea and cough. Says she was in
her normal state of health just a few days ago. Reports she's
had a mildly productive cough for about a week and then had
labored breathing yesterday when walking around with her walker
which is unusual for her. She then states last night acutely she
developed much worse shortness of breath. No chest pain, no
hemoptysis. No leg swelling, no travel. She denies fevers, says
she has night sweats, but that this is chronic. She denies chest
pain, nausea, vomiting, diarrhea and abdominal pain. She called
her PCP this morning when the symptoms didn't resolve who
recommended she present to the ED for evaluation. She denies any
recent weight loss or gain. No asthma, no COPD. She says she
does at baseline require three pillows when she sleeps. She has
not noted worsening dyspnea on exertion. Per OMR, she stated
last month that she had not been taking her anti-hypertensive
medications consistently.
In the ED initial vitals 97.7 140 139/75 36 86% RA. Her oxygen
saturation improved to 98-99% with nebulizer treatment and 100%
oxygen via NRB mask. Her initial WBC was 13.2, lactate of 8.6,
D-dimer at 8882, BNP at 12915. Her lactate trended down to 3.5
with fluids. She received 40mg lasix IV, ceftriaxone, levoquin.
There was concern for PE; however her creatinine was elevated to
1.8 from baseline of 0.8 so CTA was not performed. She had a
head CT showed no acute intracranial abnormality and no mass was
identified. She was then started on a heparin drip because of
concern for PE. Because of the risk of PE and the elevated
d-dimer without a clear explanation for her lactic acidosis she
was admitted to the MICU for further management.
On arrival to the MICU, patient was afebrile, tachycaric to
120s, tachypneic to ___, sat mid ___ on 4L, and BP 120s/70s
Past Medical History:
1. Papillary Thyroid Cancer - Stage III (T3, Nx, MO)
2. Hypertension
3. Stroke ___ likely due to small vessel disease, residual
dysarthria
4. Hypercholesterolemia
5. Morbid obesity
6. Osteoarthritis
7. Sleep disordered breathing - does not use CPAP
8. "Reactive airway disease" documented in clinic note dated
___
9. Diastolic heart failure
Social History:
___
Family History:
Sister with PE and heart problems. Mother w/ DM and CVA
Physical Exam:
Physical Exam:
General- AAOx3
HEENT- Sclera anicteric, Dry MM, oropharynx clear
Neck- supple, +abdominojugular reflux, no LAD
Lungs- Bilateral wheezes, decreased breath sounds, increased
SOB, desat to high ___, and tachypnea when layed flat, no 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
GU- foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
___ 07:02PM LACTATE-2.6*
___ 06:34PM GLUCOSE-168* UREA N-25* CREAT-1.4* SODIUM-142
POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-24 ANION GAP-19
___ 06:34PM CK(CPK)-172
___ 06:34PM CK-MB-9 cTropnT-0.23*
___ 06:34PM CALCIUM-8.4 PHOSPHATE-3.8 MAGNESIUM-2.1
___ 06:34PM WBC-10.2 RBC-4.55 HGB-12.3 HCT-39.4 MCV-87
MCH-27.0 MCHC-31.2 RDW-13.3
___ 06:34PM PLT COUNT-189
___ 12:25PM D-DIMER-8882*
___ 11:55AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 11:55AM URINE HYALINE-43*
___ 09:34AM LACTATE-8.6*
___ 09:25AM estGFR-Using this
___ 09:25AM WBC-13.2*# RBC-4.75 HGB-12.9 HCT-43.3 MCV-91
MCH-27.1 MCHC-29.7* RDW-13.1
___ 09:25AM NEUTS-70.8* ___ MONOS-4.5 EOS-0.4
BASOS-0.7
___ 09:25AM estGFR-Using this
CT chest ___
FINDINGS: Large bilateral pulmonary emboli extend from the
central left and
right pulmonary arteries into the lobar and segmental arteries.
The right
ventricle and right atrium are markedly dilated, with flattening
and mild
bowing of the intraventricular septum, though this is not a
gated study
(2:65).
The lungs are fully expanded and clear with the exception of
mild atelectasis
in the right middle and lower lobes. There is no pleural
effusion. The
airways are patent to the subsegmental level. According to CT
size criteria,
there are no pathologically enlarged axillary, mediastinal, or
hilar lymph
nodes. Surgical clips anterior in the neck are from prior
thyroidectomy.
Three-vessel aortic arch is remarkable only for a few
atherosclerotic
calcifications.
Though not tailored for subdiaphragmatic evaluation, the imaged
portions of
the upper abdomen are normal.
OSSEOUS STRUCTURES: There is no lytic or blastic lesion
worrisome for
malignancy.
IMPRESSION: Large central bilateral pulmonary emboli with
findings suggesting
right heart strain as described above.
echocardiogram ___
Suboptimal image quality. The left atrium is normal in size. The
estimated right atrial pressure is at least 15 mmHg. There is
mild symmetric left ventricular hypertrophy. 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>50%). There is no ventricular septal defect. The right
ventricular free wall is hypertrophied. The right ventricular
cavity is dilated with mild global free wall hypokinesis. There
is abnormal septal motion/position. 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. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. Moderate [2+] tricuspid regurgitation is seen.
There is severe pulmonary artery systolic hypertension. There is
no pericardial effusion.
Compared with the prior study (images reviewed) of ___, RV
dilation/dysfunction and severe pulmonary hypertension are now
detected.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Lisinopril 40 mg PO DAILY
3. Metoprolol Succinate XL 200 mg PO BID
4. CloniDINE 0.3 mg PO BID
5. Amlodipine 10 mg PO DAILY
6. HydrALAzine 50 mg PO TID
7. Atorvastatin 20 mg PO DAILY
8. Aspirin 325 mg PO DAILY
9. Chlorthalidone 25 mg PO DAILY
10. Levothyroxine Sodium 300 mcg PO DAILY
11. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Amlodipine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 20 mg PO DAILY
5. Chlorthalidone 25 mg PO DAILY
6. CloniDINE 0.3 mg PO BID
7. Levothyroxine Sodium 300 mcg PO DAILY
8. Lisinopril 40 mg PO DAILY
9. Metoprolol Succinate XL 25 mg PO DAILY
10. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
11. Miconazole 2% Cream 1 Appl TP BID
12. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
13. Warfarin 5 mg PO DAILY16
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Pulmonary embolus
Secondary:
Obstructive sleep apnea
morbid obesity
diastolic heart failure
Discharge Condition:
alert, ambulatory
Followup Instructions:
___
Radiology Report
HISTORY: Thyroid cancer with shortness of breath.
TECHNIQUE: AP view of the chest.
COMPARISON: Chest radiograph ___.
FINDINGS:
The study is somewhat limited as the patient's chin projects over and obscures
the lung apices. Lung volumes are slightly reduced. The heart size remains
mildly enlarged. The aorta is unfolded. The mediastinal and hilar contours
are otherwise unchanged. There is no pulmonary vascular congestion. Minimal
patchy opacity in the left lung base likely reflects atelectasis. No pleural
effusion, focal consolidation or large pneumothorax is identified. Clips from
prior thyroidectomy are noted within the neck.
IMPRESSION:
Slightly limited exam. Left basilar atelectasis. No evidence for pulmonary
edema.
Radiology Report
HISTORY: History of thyroid cancer, planning fatigue and heparin with.
Evaluate from metastatic disease.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without administration of IV contrast. Reformatted coronal and sagittal and
thin section bone algorithm-reconstructed images were acquired.
COMPARISON: CTA head from ___.
FINDINGS:
There is no acute hemorrhage, edema, mass or mass effect, or large territorial
infarct. The ventricles and sulci are prominent, consistent with suggestive
of age-related volume loss. Periventricular white matter hypodensities and a
right corona radiata lacunar is consistent with chronic small vessel ischemic
disease. The basal cisterns are patent and there is preservation of
gray-white matter differentiation.
No fracture is identified. There is minimal mucosal thickening within the
right maxillary sinus. The other visualized paranasal sinuses, mastoid air
cells, and middle ear cavities are clear.
IMPRESSION:
No acute intracranial abnormality. No mass identified. Please note that MRI
with gadolinium is a more sensitive exam for the detection of small masses.
Radiology Report
AP CHEST, 5:38 A.M., ___
HISTORY: ___ woman with acute dyspnea, elevated white count. Is
there any pneumonia.
IMPRESSION: AP chest compared to ___:
There has been a slight increase in opacification in the infrahilar right
lower lobe, but whether this is pneumonia or atelectasis is radiographically
indeterminate. The lungs are otherwise clear. Mild cardiomegaly and mild
mediastinal vascular engorgement are stable. Pleural effusions are small if
any. No pneumothorax.
Radiology Report
HISTORY: Acute kidney injury.
TECHNIQUE: Transabdominal ultrasound utilizing grayscale and Doppler imaging
COMPARISON: ___
FINDINGS:
Visualization of both kidneys is limited by reduced acoustic penetration.
RIGHT KIDNEY: 10.8 cm without evidence of hydronephrosis, solid renal masses
or stones.
LEFT KIDNEY: 10.4 cm without evidence of hydronephrosis, solid renal masses
or stones.
BLADDER: Decompressed with a Foley catheter.
IMPRESSION:
Limited study demonstrating no evidence of obstruction.
Radiology Report
INDICATION: Right heart strain on EKG and concern for pulmonary embolism in
the setting of dyspnea.
TECHNIQUE: MDCT images were obtained through the chest per CTPA protocol.
Coronal and sagittal reformations as well as oblique MIPs were prepared.
COMPARISON: CTA chest, ___.
FINDINGS: Large bilateral pulmonary emboli extend from the central left and
right pulmonary arteries into the lobar and segmental arteries. The right
ventricle and right atrium are markedly dilated, with flattening and mild
bowing of the intraventricular septum, though this is not a gated study
(2:65).
The lungs are fully expanded and clear with the exception of mild atelectasis
in the right middle and lower lobes. There is no pleural effusion. The
airways are patent to the subsegmental level. According to CT size criteria,
there are no pathologically enlarged axillary, mediastinal, or hilar lymph
nodes. Surgical clips anterior in the neck are from prior thyroidectomy.
Three-vessel aortic arch is remarkable only for a few atherosclerotic
calcifications.
Though not tailored for subdiaphragmatic evaluation, the imaged portions of
the upper abdomen are normal.
OSSEOUS STRUCTURES: There is no lytic or blastic lesion worrisome for
malignancy.
IMPRESSION: Large central bilateral pulmonary emboli with findings suggesting
right heart strain as described above.
Findings were discussed by Dr. ___ with Dr. ___ by phone
at 11:52 a.m. (four minutes after discovery) on ___.
Radiology Report
INDICATION: Pulmonary embolism, lower extremity lymphedema. Evaluate for
clot.
COMPARISON: None available.
FINDINGS: There is normal phasicity in the common femoral veins bilaterally.
RIGHT: There is normal compression and flow in the right common femoral vein
and proximal superficial femoral vein. The mid and distal superficial femoral
veins and popliteal veins cannot be seen in gray-scale but compressed on color
images and demonstrate flow. Flow is seen in the posterior tibial veins. The
peroneal veins are not well seen. There is normal augmentation of the
popliteal, superficial femoral and common femoral veins.
LEFT: There is normal compression and flow in the common femoral and proximal
and mid superficial femoral veins. The distal superficial femoral veins can
only be seen with color images which demonstrate compression. The left
popliteal vein has normal compression, flow, and augmentation. One of the
posterior tibial veins is seen with color. The other posterior tibial vein
and peroneal veins are not well seen. There is normal augmentation of the
superficial femoral and the common femoral vein.
IMPRESSION: Limited study due to extensive edema. No definite DVT is seen in
the right or left legs.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with OTHER PULMONARY INSUFF, ACIDOSIS
temperature: nan
heartrate: 133.0
resprate: nan
o2sat: 87.0
sbp: nan
dbp: nan
level of pain: nan
level of acuity: 1.0 | Pulmonary embolism: Imaging demonstrated bilateral large PEs,
submassive without hemodynamic compromise (although her blood
pressure was low on admission, it was was not truly
hypotensive), but with significant right heart strain. Her
troponin peaked at 0.25, BNP ~12000. TTE showed RV dilation and
severe pulmonary HTN that is new from ___.
.
The precipitant of the PE was unclear as the patient was
without recent surgery or immobility, and no recent travel.
However, at baseline, she is morbidly obese and has limited
activity. Her sister died of a PE many years prior, but
otherwise no family history of PE and no personal history of
thrombophilia. In regards to cancer screening, she is up to
date on her mammography. Her last colonoscopy was in ___ with a
polyp without ___ year follow-up. Repeat ___ is likely warranted
as an outpatient. Due to morbid obesity endometrial carcinoma
is possibility but she has no c/o vaginal bleeding. She does
have a known history of thyroid cancer but TSH is adequately
suppressed and her latest thyroid ultrasound ___ shows no
evidence of local recurrance. She was placed on a heparin drip
___ as a bridge to Coumadin. She became theraputic on
warfarin, heparin drip was stopped.
.
dHF with preserved EF: The patient's chlorthalidone and
ace-inhibitor were added back. The pt's metoprolol XL was
restarted and increased to 50mg daily. Hr at this dose was in
the high ___ to low ___ at rest.
.
# Hypertension - Her hypertension appears to be uncontrolled as
an outpatient. Her medications were restarted and BPs were
controlled here.
.
# Hypothyroid s/p papillary thyroid cancer s/p thyroidectomy:
She was continued on synthroid
The patient did well on warfarin and her oxygen was weaned down.
She reamined on 2L and was short of breath with activity. She
was transferred to rehab for further ___. She was enrolled in
PACT to help with outpt follow up. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
bacitracin
Attending: ___.
Chief Complaint:
Epigastric pain
Major Surgical or Invasive Procedure:
___: Ultrasound-guided percutaneous cholecystostomy tube
placement
History of Present Illness:
A ___ male with history of pancreatitis (thought to be
secondary to alcoholism or gallstones) and pancreatic
pseudocysts, followed by Dr. ___ a potential interval
cholecystectomy, presenting with cramping epigastric abdominal
pain since ___. He had one episode of pain on
___ followed by another ___ night, ___ afternoon
all brought on by food, followed by an episode ___ night into
___ associated with nausea and emesis x1. He then saw his PCP
___ and ___, where he had an ultrasound that showed
diffuse thickening of the gallbladder with no stones and small
pericholecystic fluid (notably sonographic ___ was
negative) and he was referred to the ___ for a CT scan
and surgical evaluation. There he was admitted for one day and
discharged once his symptoms resolved. He presents today after
being discharged yesterday with recurrence of these symptoms.
He had been doing well since being hospitalized in the ICU for
pancreatitis in ___. He has had no further
episodes of abdominal pain and Dr. ___ has deferred
performing a cholecystectomy for that reason. He last saw Dr.
___ on ___. He last ate on ___ night, and
currently reports epigastric pain and nausea. He denies fever or
jaundice, has had normal bowel movements, denies dysuria.
Past Medical History:
PAST MEDICAL HISTORY:
1. Former alcoholic.
2. Hypertension.
3. GERD.
4. Hyperlipidemia.
5. Diverticulosis.
6. Cataracts.
PAST SURGICAL HISTORY:
Left eye lacrimal surgery.
Social History:
___
Family History:
Father had prostate cancer, mother emphysema
Physical ___:
T 97.5 P 89 BP 121/53 RR 18 O2 99%RA
Gen: no acute distress,
Cardiac: regular rate and rhythm, no murmurs appreciated
Resp: clear to auscultation, bilaterally
Abdomen: soft, non-tender, non-distended without rebound
tenderness or guarding; 8 ___ pigtail drain in right upper
abdomen; insertion site intact without erythema or drainage
Ext: no edema
Pertinent Results:
LABS:
___ 04:35AM BLOOD WBC-9.0 RBC-3.87* Hgb-11.0* Hct-33.6*
MCV-87 MCH-28.4 MCHC-32.7 RDW-14.5 RDWSD-46.0 Plt ___
___ 04:21PM BLOOD WBC-17.1* RBC-5.12# Hgb-14.2# Hct-43.6#
MCV-85 MCH-27.7 MCHC-32.6 RDW-14.6 RDWSD-45.3 Plt ___
Neuts-84.5* Lymphs-7.2* Monos-6.5 Eos-1.0 Baso-0.2 Im ___
AbsNeut-14.40* AbsLymp-1.22 AbsMono-1.11* AbsEos-0.17
AbsBaso-0.04 Lipase-22 ___ 06:05PM BLOOD Lactate-2.0
___ 10:05AM BLOOD Lipase-24
___ 04:40AM BLOOD Lipase-18
IMAGING:
___ CT ABD & PELVIS WITH CONTRAST: 1. Persistent
gallbladder luminal distension and pericholecystic fat stranding
since ___. While these findings may all be reactive,
the possibility of acute cholecystitis could be considered in
the proper clinical setting. 2. Extensive lobulated
peripancreatic fluid collections surrounding nearly the entire
pancreas have remained stable over the past 2 days. 3.
Diverticulosis.
___ GALLBLADDER SCAN: Abnormal hepatobiliary scan
consistent with acute cholecystitis.
___ GB DRAINAGE,INTRO PERC TRANHEP BIL US: Successful
ultrasound-guided placement of ___ pigtail catheter into
the gallbladder. Samples were sent for microbiology evaluation.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Docusate Sodium 100 mg PO BID
2. amLODIPine 10 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. Multivitamins 1 TAB PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth q 4 hours
Disp #*20 Tablet Refills:*0
3. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*20 Tablet Refills:*0
4. amLODIPine 10 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 10 mg PO QPM
7. Docusate Sodium 100 mg PO BID
8. Multivitamins 1 TAB PO DAILY
9. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute cholecystitis
Pancreatic pseudocyst, chronic
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: ___ male with a history of pancreatitis, now presenting
with epigastric pain x1 week, worsened over the past 2 days since recent
discharge from ___. WBC 17.
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following administration of 130 cc of Omnipaque
with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 675 mGy-cm.
COMPARISON: CT abdomen and pelvis ___.
FINDINGS:
LOWER CHEST: There is minimal bibasilar dependent atelectasis. No pleural
effusion. Heart size is normal. Coronary artery calcifications are diffuse.
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. Main portal and superior mesenteric veins
are patent. Splenic vein is chronically obliterated. In comparison to the
prior CT performed 2 days earlier, the appearance of the gallbladder is
similar noting some distension and chronic wall thickening. Pericholecystic
fat stranding also appears similar (02:20).
PANCREAS: Extensive lobulated peripancreatic fluid collections appear
unchanged from ___. The collections surround nearly the entire
gland, and are difficult to measure. Extension anteriorly on the right into
the mesenteries again noted. There are no locules of air within the fluid
collections. No evidence of pancreatic ductal dilation.
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.
A 6 mm hypodensity in the lower pole of the left kidney is too small to
characterize, but statistically likely represents a cyst. No hydronephrosis.
There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable besides a small hiatal hernia.
Small bowel loops demonstrate normal caliber, wall thickness, and enhancement
throughout. Duodenum diverticulum is noted. There is scattered
diverticulosis, without evidence of acute diverticulitis. Colon and rectum
are otherwise unremarkable in appearance. Normal appendix. No
pneumoperitoneum.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: Prostate gland is enlarged. The seminal vesicles are
unremarkable in appearance.
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.
Degenerative changes throughout the thoracolumbar spine are mild.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits besides a
fat containing left inguinal hernia. .
IMPRESSION:
1. Persistent gallbladder luminal distension and pericholecystic fat stranding
since ___. While these findings may all be reactive, the possibility
of acute cholecystitis could be considered in the proper clinical setting.
2. Extensive lobulated peripancreatic fluid collections surrounding nearly the
entire pancreas have remained stable over the past 2 days.
3. Diverticulosis.
Radiology Report
EXAMINATION: Ultrasound-guided percutaneous cholecystostomy tube placement.
INDICATION: ___ year old man with cholecystitis // Perc chole
COMPARISON: CT abdomen and pelvis ___ and nuclear medicine
gallbladder scan ___.
PROCEDURE: Ultrasound-guided percutaneous cholecystostomy.
OPERATORS: Dr. ___, radiology trainee 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 supine position on the ultrasound table. Limited
preprocedure imaging was performed to localize the gallbladder. An
appropriate skin entry site was chosen and the site marked. Local anesthesia
was administered with 1% Lidocaine solution.
Using continuous sonographic guidance, an ___ drainage catheter was
advanced via trocar technique into the gallbladder. A sample of fluid was
aspirated, confirming catheter position within the gallbladder. The plastic
stiffener was removed. The pigtail was deployed. The position of the pigtail
was confirmed within the collection via ultrasound. Ultrasound images were
stored on PACS.
Approximately 20cc of cloudy bilious fluid was drained with a sample sent for
microbiology evaluation. The catheter was secured by a StatLock. The catheter
was attached to gravity bag. Sterile dressing was applied.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
SEDATION: Moderate sedation was provided by administering divided doses of 2
mg Versed and 100 mcg fentanyl throughout the total intra-service time of 30
minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
The gallbladder was incompletely distended. After aspiration of 20 cc of
cloudy bilious fluid, the gallbladder was completely collapsed.
IMPRESSION:
Successful ultrasound-guided placement of ___ pigtail catheter into the
gallbladder. Samples were sent for microbiology evaluation.
RECOMMENDATION(S): The drain should be left in place for ___ weeks.
Monitoring of drain output should be performed.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with Unspecified abdominal pain
temperature: 97.5
heartrate: 75.0
resprate: 18.0
o2sat: 100.0
sbp: 132.0
dbp: 65.0
level of pain: 8
level of acuity: 3.0 | Mr. ___ was admitted on ___ under the Acute Care Surgery
service for management of cute cholecystitis on chronic
post-pancreatitis inflammatory changes. He was kept NPO with
maintenance IVF and analgesic medication. His symptoms and
hemodynamic status were monitored.
The next day after hospitalization he received a HIDA scan that
was consistent with acute cholecystitis. On ___ he went to
___ and underwent an ultrasound-guided percutaneous
cholecystostomy. A ___ drainage catheter was placed in the
gallbladder bilious fluid was drained with a sample sent for
microbiology evaluation. The catheter was attached to gravity
bag. Sterile dressing was applied. After aspiration of 20 cc of
cloudy bilious fluid, the gallbladder was completely collapsed.
The procedure was tolerated well, and there were no
complications.
The next day the patient was advanced to a regular diet. His
pain level was routinely assessed and well controlled at
discharge with an oral regimen as needed. On ___, he was
discharged home with scheduled follow up in ___ clinic on
___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percocet
Attending: ___.
Chief Complaint:
Hypoglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/PMH of advanced Alzheimer dementia, CAD s/p remote CABG,
severe AS, HFrEF (EF 31%), PAF, and DM2 presenting with AMS in
setting of hypoglycemia.
Patient recently hospitalized at ___ from ___ to ___ for
decompensated HF. At time of discharge, patient volume
overloaded per documentation, but breathing comfortably on room
air; further diuresis limited by ___, assessed to require
elevated LVEDP in setting of severe AS to maintain CO and renal
perfusion. Discharge weight 136 lbs. Discharged to rehab, but
family dissatisfied with rehab and checked her out after several
days. Per family, she has continued to take meds, although she
sometimes refuses to take them. Since she left rehab, she has
had a dry cough, and was prescribed an unspecified antibiotic
for a ___y an unspecified provider last ___ (last
dose morning of ___. Family reports weight have been
fluctuating at home, but have ranged from low 100s to 140s
(lbs). They do not feel that her level of swelling has changed
significantly since discharge, and report adherence to Lasix.
Evening prior to admission, patient received evening insulin but
did not eat dinner. Unclear if this was lantus or Humalog. In
morning, patient found sitting on edge of bed, unresponsive. ___
in ___. Patient given frosting by mouth, family called ___.
Initial fs 41 on EMS check. Patient given 25g of D10 with
improvement of fs to ___, brought in by ambulance to ___.
Family reports that patient's mental status improved to baseline
with improvement of sugars.
In the ED, patient given IV dextrose, started on D5W ___ NS
@75cc per hour. Labs notable for K 3.3 (repleted with 40mEq PO),
BNP ~13K (decreased from prior), renal function at baseline. CXR
with mild venous congestion, no focal consolidation or opacity,
no pulmonary edema. Patient admitted to medicine for further
management of hypoglycemia.
On arrival to the floor, patient breathing comfortably on room
air, mentating at baseline per family. Denies any pain or
discomfort, but unable to obtain further history on current or
recent symptoms from patient. Above history obtained from family
and review of prior documentation.
Past Medical History:
- Diabetes
- Hypertension
- CABG: 6x CABG in ___
- Severe AS
- CKD
- Dementia
- Glaucoma
- Osteoporosis
Social History:
___
Family History:
Reviewed and not pertinent to this admission.
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
___ 1607 Temp: 97.6 PO BP: 115/77 HR: 108 RR: 20 O2 sat:
99%
O2 delivery: RA FSBG: 103
GENERAL: Pleasant, lying in bed comfortably
HEENT: NCAT, sclerae anicteric, PERRL, oropharynx clear, MMM
NECK: Difficult to assess secondary to patient neck movement,
but
appears mid-neck at 90 degrees
CARDIAC: RRR, no audible S1/S2, II/VI crescendo-decrescendo
murmur loudest at RUSB
LUNG: Poor air movement, diffuse expiratory wheezes
ABD: Soft, non-tender, non-distended, normoactive BS
EXT: Warm, DP pulses 2+ bilaterally, 2+ pitting edema extending
to thighs bilaterally
NEURO: A&Ox2 (self, hospital), verbal, responding to questions
but generally not coherently, intermittently able to follow
simple commands, neuro exam limited by participation
DISCHARGE PHYSICAL EXAM
========================
24 HR Data (last updated ___ @ 456)
Temp: 98.4 (Tm 98.4), BP: 100/63 (98-108/50-71), HR: 91
(91-109), RR: 18 (___), O2 sat: 97% (82-100), O2 delivery: RA,
Wt: 140 lb/63.5 kg (135.58-140)
GENERAL: lying in bed
CARDIOVASCULAR: crescendo-decrescendo murmur heard throughout
precordium, radiating to carotids, no audible S1 or S2.
RESPIRATORY: on room air, breathing comfortably. CTAB.
EXT: b/l LLE
NEURO: Uncooperative w/ exam but moving all extremities
Pertinent Results:
ADMISSION LABS
===============
___ 08:41AM BLOOD WBC-5.9 RBC-3.62* Hgb-8.6* Hct-31.2*
MCV-86 MCH-23.8* MCHC-27.6* RDW-18.8* RDWSD-58.5* Plt ___
___ 08:41AM BLOOD Neuts-76.3* Lymphs-15.4* Monos-7.5
Eos-0.0* Baso-0.3 Im ___ AbsNeut-4.46 AbsLymp-0.90*
AbsMono-0.44 AbsEos-0.00* AbsBaso-0.02
___ 08:41AM BLOOD ___ PTT-34.6 ___
___ 08:41AM BLOOD Glucose-48* UreaN-18 Creat-1.4* Na-141
K-3.3* Cl-105 HCO3-26 AnGap-10
___ 08:41AM BLOOD ___
___ 08:41AM BLOOD Calcium-8.4 Phos-2.1* Mg-2.0
___ 08:55AM BLOOD Lactate-1.3
INTERVAL LABS
===============
___ 09:20AM BLOOD %HbA1c-7.0* eAG-154*
___ 09:20AM BLOOD TSH-17*
___ 09:20AM BLOOD T4-2.9* T3-60* Free T4-0.5*
DISCHARGE LABS
================
___ 12:50PM BLOOD WBC-5.4 RBC-3.15* Hgb-7.5* Hct-27.1*
MCV-86 MCH-23.8* MCHC-27.7* RDW-20.9* RDWSD-62.8* Plt ___
___ 08:30AM BLOOD Glucose-63* UreaN-33* Creat-1.6* Na-144
K-5.3 Cl-104 HCO3-27 AnGap-13
___ 08:30AM BLOOD Calcium-8.9 Phos-3.6 Mg-2.5
IMAGING/STUDIES
================
CXR ___
FINDINGS:
AP upright and lateral views of the chest provided. Midline
sternotomy wires and mediastinal clips are again noted.
Cardiomegaly is unchanged with pulmonary vascular congestion and
likely pulmonary edema. Tiny pleural effusions persist. There
is no pneumothorax. There are no overt signs of pneumonia.
Imaged osseous structures are intact.
IMPRESSION:
Stable cardiomegaly with mild pulmonary edema and tiny residual
pleural effusions.
CXR ___
IMPRESSION:
Compared to chest radiographs since ___ most recently
___ and ___.
Lower lung volumes exaggerate pulmonary vascular congestion, but
there has been an increase in small right pleural effusion
suggesting cardiac decompensation. Severe cardiomegaly and
hilar arterial enlargement are chronic. No pneumothorax.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Apixaban 2.5 mg PO BID
2. Aspirin 81 mg PO DAILY
3. Bisacodyl 10 mg PR QHS:PRN Constipation - Third Line
4. Furosemide 40 mg PO DAILY
5. Methimazole 2.5 mg PO DAILY
6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second
Line
7. Mirtazapine 30 mg PO QHS
8. Multivitamins W/minerals 1 TAB PO DAILY
9. Ranitidine 300 mg PO DAILY
10. Rosuvastatin Calcium 40 mg PO QPM
11. Senna 17.2 mg PO BID:PRN Constipation - First Line
12. Glargine 10 Units Bedtime
Humalog 4 Units Breakfast
Humalog 4 Units Lunch
Humalog 4 Units Dinner
13. Lisinopril Dose is Unknown PO DAILY
Discharge Medications:
1. linaGLIPtin 5 mg oral DAILY
RX *linagliptin [Tradjenta] 5 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
2. Repaglinide 2 mg PO TIDAC
RX *repaglinide 2 mg 1 tablet(s) by mouth TIDAC Disp #*120
Tablet Refills:*0
3. Simethicone 40-80 mg PO QID:PRN Gas pain
RX *simethicone 80 mg 1 tablet(s) by mouth QID:PRN Disp #*120
Tablet Refills:*0
4. Torsemide 80 mg PO DAILY
RX *torsemide 20 mg 4 tablet(s) by mouth once a day Disp #*120
Tablet Refills:*0
5. NPH 8 Units Breakfast
RX *insulin NPH isoph U-100 human [Humulin N NPH Insulin
KwikPen] 100 unit/mL (3 mL) AS DIR 8 SC 8 Units before BKFT;
Disp #*1 Syringe Refills:*3
6. Apixaban 2.5 mg PO BID
7. Aspirin 81 mg PO DAILY
8. Bisacodyl 10 mg PR QHS:PRN Constipation - Third Line
9. Mirtazapine 30 mg PO QHS
10. Multivitamins W/minerals 1 TAB PO DAILY
11. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second
Line
12. Ranitidine 300 mg PO DAILY
13. Rosuvastatin Calcium 40 mg PO QPM
14. Senna 17.2 mg PO BID:PRN Constipation - First Line
15. HELD- Methimazole 2.5 mg PO DAILY This medication was held.
Do not restart Methimazole until you see your endocrinologist
(if within goals of care)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
==================
Hypoglycemia
Dysphagia leading to aspiration
SECONDARY DIAGNOSES
====================
Heart failure with reduced ejection fraction
Severe aortic stenosis
Type two diabetes mellitus
Hypothyroidism
Dementia
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
EXAMINATION: CHEST (AP AND LAT)
INDICATION: ___ with hypoglycemia// ?infiltrate, pna
COMPARISON: Chest radiograph from ___
FINDINGS:
AP upright and lateral views of the chest provided. Midline sternotomy wires
and mediastinal clips are again noted. Cardiomegaly is unchanged with
pulmonary vascular congestion and likely pulmonary edema. Tiny pleural
effusions persist. There is no pneumothorax. There are no overt signs of
pneumonia. Imaged osseous structures are intact.
IMPRESSION:
Stable cardiomegaly with mild pulmonary edema and tiny residual pleural
effusions.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with HFrEF and new cough// Evidence of
pneumonia or fluid overload? Evidence of pneumonia or fluid overload?
IMPRESSION:
Compared to chest radiographs since ___ most recently ___ and
___.
Lower lung volumes exaggerate pulmonary vascular congestion, but there has
been an increase in small right pleural effusion suggesting cardiac
decompensation. Severe cardiomegaly and hilar arterial enlargement are
chronic. No pneumothorax.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Hypoglycemia
Diagnosed with Heart failure, unspecified
temperature: 97.6
heartrate: 100.0
resprate: 20.0
o2sat: 100.0
sbp: 110.0
dbp: 79.0
level of pain: 0
level of acuity: 2.0 | PATIENT SUMMARY
==================
___ w/PMH of advanced Alzheimer dementia, CAD s/p remote CABG,
severe AS, CMP (EF 31%), PAF, and DM2 presents due to
hypoglycemia from insulin administration with poor PO intake,
found to have acute on chronic systolic CHF exacerbation and
hospital course complicated by recurrent aspiration. After
goals of care discussions with family, patient was discharged
with home hospice.
ACUTE ISSUES:
=============
#Hypoglycemia (resolved)
#DM2
Patient became hypoglycemic in setting of receiving evening
insulin (unclear if Humalog, lantus, or both) with no dinner.
Improved with D5W. Currently mentating at baseline with fs >100,
intermittently refusing fingersticks. A1c checked on admission
was 7. Given patient's presentation with hypoglycemia, age, and
other comorbidities, it was decided she would benefit from
alternate form of glucose control other than insulin. For help
in deciding medications with goals of care in mind, ___ was
consulted ___. She was ultimately discharged on sitagliptin
(tradjenta), prandin and 8u NPH daily.
#HFrEF (EF 31% ___
Baseline ACC/AHA C, NYHA II-III. Able to walk ~60 feet with
assistance with mild dyspnea but no hypoxia on recent date of
discharge (___). Multifactorial etiology including ischemia
(multivessel CAD s/p CABG) and valvular disease (severe AS).
Beta blockade, ___ not tolerated due to low blood
pressures. She was volume overloaded on exam, but breathing
comfortably on room air, BNP decreased from prior. History and
data not suggestive of acute decompensation. Despite her severe
AS, she was warm, mentating at baseline, and did not appear in
low-flow state; given clinical status and hx of hypotension with
limited ability to tolerate anti-hypertensives, she was not
started on any agents for afterload at this time such as an ACE,
___, or beta blocker.
She was still up from her previous dry weight with significant
pitting ___ edema, so she was diuresed with boluses of 20 IV
Lasix, but transitioned to PO because of difficult IV access and
patient delirium/dementia making placement difficult. She was
initially stable on 40 PO Lasix BID, however her weight again
began to increase, so she was started on Torsemide 10 mg PO with
uptitration to torsemide 80 mg PO daily at the time of discharge
(she intermittently received 80 mg PO BID for additional
diuresis).
On day of discharge, her standing weight was 63.5 kg (139.99
lb), her diuretic dose was torsemide 80 mg PO daily and her
creatinine was 1.6.
#Severe AS
Low-flow, low-gradient, valve area 1 cm. Not a candidate for
SAVR based on age, co-morbidities. Initiated discussion of TAVR
work-up during recent hospitalization with ultimate decision not
to pursue given high procedural risk and improvement of
functional status with medical management of HFrEF.
#Cough
# Aspiration
Likely secondary to repeat aspirations due to progressive
dementia. Intermittent wet-sounding cough, but no apparent
sputum production (family also reports has been dry cough),
otherwise breathing comfortably on room air. Mild venous
congestion on CXR, no evidence of pneumonia on imaging. Mild
wheezes on exam, no crackles or focal decreased breath sounds.
Speech and swallow evaluated her and recommended puréed solids,
and nectar thick liquids.
#Paroxysmal AFib
CHADS2-Vasc 6. Per documentation from recent hospitalization
"Apixaban is not as well studied as warfarin in valvular AF, but
we felt that INR monitoring would be an additional quality of
life setback for this patient with severe dementia &
intermittent agitation." Dose-reduced based on age>___,
creatinine. Currently only meets 1 criterion for dose reduction
(age), but given fluctuating renal function and volume status
with borderline creatinine will continue apixaban 2.5 BID. No
current RVR, previously had metoprolol held for bradycardia and
hypotension; will continue to hold.
#History of Graves' Disease
#Hyperthyroidism
Methimazole decreased during recent hospitalization per
endocrinology recommendation based on elevated TSH. Per recent
discharge summary, planned for repeat thyroid function labs on
___ for titration of methimazole, which do not appear to have
been checked yet. Per previous records, patient has missed
repeated follow-ups over the last year with endocrinology. Her
TSH is elevated to 17 this admission, up from ___ during last
admission. T3-T4 and free T4 all low. Communicated with her
outpatient endocrinologist Dr. ___ recommended stopping
methimazole for now, and stressing with the family that she
should follow-up with her PCP to have thyroid tests again in 4
weeks after stopping methimazole.
#CKD
Fluctuating renal function in recent months. Prior baseline 1.7,
ranging 1.5-2.1 during ___ hospitalization. On day of
discharge, creatinine was 1.6.
#Goals of care
Patient with heart failure with reduced ejection fraction,
severe AS, and underlying dementia. Now with difficulty
swallowing solid foods, likely due to progressive dementia.
Family meeting ___ with palliative care revealed that family
goal is to get their mother home. They now understand that her
swallowing will not get better, and that this poses a great risk
to her life. They are open to having extra services provided by
hospice care, including VNAs and hospital bed, to enable them to
best care for their mother at home and keep her out of the
hospital as much as possible. However it is important to them
that she still be able to receive medications like Lasix,
glucose management, and antibiotics, and that she is able to
come in to the hospital if very sick. They articulate that if
their mother has died, they do not want chest compressions,
shocks, or intubation to bring her back while she is in the
hospital, and switched her code status to DNR/DNI. She has a
signed MOLST in the chart. However they do note that if she had
no pulse while at home, they would likely start CPR at home.
Family originally wanted home hospice services, then thought
hospice house would be better. However due to cost, have now
agreed again on home hospice services, with consideration of
hospice house in the future.
CHRONIC ISSUES:
===============
#Dementia
Baseline A&Ox2, verbal but not always able to coherently
verbalize symptoms or respond appropriately to questions.
Continuing to limit delirium causing medications, such as
scopolamine. Also halved home dose of ranitidine to limit
medications with potential anticholinergic properties.
#CAD:
#HLD
CAD s/p 6-vessel CABG in ___. EKG unchanged from prior, no
current ischemic symptoms (although patient ability to verbalize
symptoms unclear). She was continue on ASA 81MG daily,
rosuvastatin 40MG QHS.
#GERD:
Decreased dose of ranitidine 250 mg daily due to potential
off-target anticholinergic effects.
#Depression:
Continued Mirtazapine 30 QHS
#Nutrition
Continued MVI w/minerals
TRANSITIONAL ISSUES:
===============
[]Patient to be discharged home on hospice services but with
understanding that she could be taken to the hospital if her
family was worried she needed advanced medical care
[]Patient newly DNR/DNI after a family meeting during this
admission
[]Patient discharged on torsemide 80 mg PO daily. She should be
weighed daily and could have additional diuretic given should
she gain more than 3 pounds in any ___ period
[]Discharged on insulin regimen consisting of 8u NPH, Prandin
2.0mg preprandial, Linagliptin 5 mg daily. Goal BG < 250. Adjust
this regimen as needed.
# Code Status: DNR/DNI
# Emergency Contact: Name of health care proxy: ___
Phone number: ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
L Leg pain
Major Surgical or Invasive Procedure:
___ - Left quadriceps tendon repair
History of Present Illness:
___ female presents with the above injury in the setting of
rapid firing of left quadriceps muscle. Patient went to the
___ yesterday, where there is a large step to get in to the
business. She felt a brief pain in her left thigh, and then
immediately fell to the ground. She sat for a while, and try to
walk again, and her leg once again gave out. At no point did
she
strike her head or lose consciousness. No headaches, no nausea
or vomiting, no confusion. She has no persistent pain in her
left leg, but has not been able to extend her knee since this
episode. She was brought to the hospital by EMS for further
evaluation and management.
Past Medical History:
Anemia
Osteoporosis
IBS
Glaucoma
Insomnia
Hypertension
Hyperlipidemia
Social History:
___
Family History:
Non-contributory
Physical Exam:
Vitals:
___ 0500 Temp: 98.4 PO BP: 128/72 HR: 97 RR: 18 O2 sat: 96%
O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___
General: Well-appearing
Cardio: regular rate and rhythm by palpation at time of
examination
Pulm: no increased work of breathing
MSK:
LLE:
Cast c/d/i
Fires ___, FHL
SILT sp/dp/t distributions
Toes warm and well perfused
Pertinent Results:
___ 05:00AM BLOOD ___
___ 05:40AM BLOOD WBC-14.5* RBC-3.54* Hgb-9.8* Hct-30.2*
MCV-85 MCH-27.7 MCHC-32.5 RDW-13.8 RDWSD-43.1 Plt ___
___ 05:03AM BLOOD Glucose-99 UreaN-25* Creat-1.5* Na-142
K-3.5 Cl-105 HCO3-25 AnGap-12
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
2. ALPRAZolam 1 mg PO QHS:PRN insomnia
3. azelastine 137 mcg (0.1 %) nasal BID PRN
4. Losartan Potassium 50 mg PO DAILY
5. diclofenac sodium 1 % topical unknown
6. Fluticasone Propionate NASAL 1 SPRY NU BID
7. Omeprazole 40 mg PO Q12H
8. Polyethylene Glycol 17 g PO DAILY
9. Torsemide 20 mg PO DAILY
10. TraMADol 25 mg PO Q6H:PRN Pain - Moderate
11. umeclidinium-vilanterol 62.5-25 mcg/actuation inhalation qd
Discharge Medications:
1. Acetaminophen 650 mg PO 5X/DAY
Do not take more than 3000mg of acetaminophen (Tylenol) total,
daily.
2. Docusate Sodium 100 mg PO BID
Please take while using narcotic pain medications.
3. HYDROmorphone (Dilaudid) 1 mg PO Q4H:PRN Pain - Moderate
Do not drink or drive on this medication. Beware sedation
4. Warfarin 3 mg PO DAILY16 Duration: 3 Weeks
INR Goal 1.8-2.3. End date ___
5. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
6. ALPRAZolam 1 mg PO QHS:PRN insomnia
7. azelastine 137 mcg (0.1 %) nasal BID PRN
8. diclofenac sodium 1 % topical Frequency is Unknown
9. Fluticasone Propionate NASAL 1 SPRY NU BID
10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
11. Losartan Potassium 50 mg PO DAILY
12. Omeprazole 40 mg PO Q12H
13. Polyethylene Glycol 17 g PO DAILY
14. Tiotropium Bromide 1 CAP IH DAILY
15. Torsemide 20 mg PO DAILY
16. TraZODone 50 mg PO QHS:PRN insomnia/agitation
17. umeclidinium-vilanterol 62.5-25 mcg/actuation inhalation qd
18. HELD- TraMADol 25 mg PO Q6H:PRN Pain - Moderate This
medication was held. Do not restart TraMADol until you have
stopped taking the dilaudid given to you after your operation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left quadriceps tendon rupture
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: History: ___ with left knee pain s/p fall unable to WB/ambulate//
?fracture ?fracture
TECHNIQUE: Frontal, oblique, and lateral view radiographs of the left knee.
COMPARISON: Radiographs of the bilateral knees ___. MRI left
knee ___.
FINDINGS:
There is diffuse osteopenia. No fracture or dislocation is seen. There are no
significant degenerative changes. There is enthesopathic changes at the
insertion of the quadriceps tendon. There is a small suprapatellar joint
effusion.
IMPRESSION:
1. No acute fracture. If there is high clinical concern for an occult
fracture or the patient is nonweightbearing, further evaluation may be
performed with CT or MRI.
2. Small suprapatellar joint effusion.
Radiology Report
EXAMINATION: CT left lower extremity without contrast.
INDICATION: ___ year old woman with knee pain// eval for fracture
TECHNIQUE: MDCT axial images were acquired through the left lower extremity
at the level of the distal femur through the proximal tibia without the
administration of intravenous contrast. Coronal and sagittal reformations
were obtained and uploaded to PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 9.2 s, 19.5 cm; CTDIvol = 20.2 mGy (Body) DLP = 393.3
mGy-cm.
Total DLP (Body) = 393 mGy-cm.
COMPARISON: Prior radiograph dated ___.
FINDINGS:
There is a complete or near-complete tear of the distal quadriceps tendon
(401:42). There is an approximately 1.5 cm gap between the distal margin of
the quadriceps tendon and the superior margin of the patella. There is
surrounding edema and a small suprapatellar joint effusion. Ossific density
superior to the patella may represent degenerative change or a small avulsion
fragment (401:47). Patellar enthesophytes are noted. There is no evidence of
fracture in the distal femur, tibial plateau or fibula. There are varicose
veins. Vascular calcifications are noted in the popliteal artery. While the
current exam is not tailored for its evaluation, the ACL and PCL appear
intact.
IMPRESSION:
Complete or near-complete tear of the distal quadriceps tendon. Surrounding
edema and a small suprapatellar joint effusion. Ossific density superior to
the patella may represent degenerative change or small avulsion fragment. No
evidence of fracture in the visualized femur, tibia or fibula.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with L quad tendon rupture// pre op Surg:
___ (quad tendon repair) pre op
IMPRESSION:
Comparison to ___. The lung volumes are normal. Normal size of
the cardiac silhouette. Normal hilar and mediastinal contours. Minimal
atelectasis at the right lung basis. No pulmonary edema. No pneumonia, no
pleural effusions.
Gender: F
Race: PORTUGUESE
Arrive by WALK IN
Chief complaint: L Knee pain, s/p Fall
Diagnosed with Strain of left quadriceps muscle, fascia and tendon, init, Fall (on) (from) other stairs and steps, initial encounter
temperature: 98.2
heartrate: 89.0
resprate: 17.0
o2sat: 100.0
sbp: 208.0
dbp: 93.0
level of pain: 6
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 a L quadriceps tendon rupture and was admitted to the
orthopedic surgery service. Given the patient's age and
comorbidities, consultation with the internal medicine service
regarding her perioperative risk was sought. Once clearance was
received, she was taken to the operating room on ___
for left quadriceps tendon repair, 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
restarted appropriately throughout the course of her stay. By
the time that she was nearing discharge, all of her home
medications had been restarted. The patient worked with ___,
which was to some degree limited by the long leg cast on her
left leg. Given her diminished functional mobility status, it
was determined that discharge to rehab was appropriate. The
___ hospital course was otherwise unremarkable, she
remained hemodynamically stable at all points during her
hospitalization.
At the time of discharge the patient's pain was well controlled
with oral medications, the cast was well-fitting and without
concerns. The patient was voiding/moving bowels spontaneously.
The patient is weight bearing as tolerated in the left lower
extremity, and will be discharged on warfarin (3mg) for DVT
prophylaxis. The goal for her INR is 1.8-2.3. She will be on
this medication for three weeks total from the time of her
operation, therefore the warfarin should stop on ___. She should have daily INR checks with manipulations of her
warfarin dosing accordingly until she is stably at her INR goal.
Because she is to be discharged to a rehabilitation facility,
her warfarin is to be managed by the physician at her facility.
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:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever, confusion
Major Surgical or Invasive Procedure:
- Right internal jugular HD line removed (___)
- Left internal jugular HD line placement (___)
- L ___ metatarsal resection and debridement by podiatry
(___)
- L foot debridement and closure (___)
- R wrist aspiration (___)
- R wrist irrigation and debridement, medial dorsal arthrotomy
of the wrist joint (___)
- TEE (___)
History of Present Illness:
___ with ESRD on HD MWF, DM, CAD, who was noted to have
hypotension (SBP ___, fever to 101.3, and confusion at HD
today. Per report, he became acutely confused and agitated in HD
and became very combative, trying to remove his HD catheter. He
initially was brought on OSH where he was noted to have lactic
acid 3.3, right pleural effusion, and necrotic toe. He was given
levo, vancomycin/ceftriaxone, 500cc IV, peripheral neo for low
BP, and transferred to ___. En route, he vomited, became more
confused, and aspirated.
Of note, he was recently admitted to ___ for confusion
and discharged on ___
In the ED, initial vs were: 98.4 94 89/49 18 98% 4L Nasal
Cannula
-Exam was notable for pain and erythema over R fistula, R
subclavian dialysis access. BP drops to 60-70s when neo was
weaned.
-Labs were notable for: wbc 12.2, troponin 0.21, Cr 2.5,
lactate 2.5
- CXR showed right sided infiltrates with pleural effusion
-Femoral line was placed, and he was started on levophed, neo,
and given 1.5L IVF (total of 2L between OSH and here), then
admitted to the MICU.
- Vital signs on transfer were 83 112/55 19 100% Nasal Cannula
Upon arrival to the ICU the patient is awake and alert. Main
complaint is severe pain in his right wrist. Quite irritated
and dislikes answering questions. Cannot supply much of the
HPI.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency.
Past Medical History:
- ESRD on HD MWF - currently dialyzing through tunneled cath
- Diabetes mellitus
- Coronary artery disease
- Hyperlipidemia
- Peripheral neuropathy s/p L toe amputation
- Right pleural effusion - path from ___ pending
- Failure to thrive
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL:
General: elderly man lying in bed in NAD, irritable
HEENT: Sclera anicteric, dry MM, poor dentition
Neck: supple, JVP not elevated
Lungs: Diminished breath sounds with rales throughout the right
lung, left lung sounds clear
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Chest: tunneled HD catheter with minimal erythema at insertion,
no warmth or purulence
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
GU: no foley
Ext: left ___ toe stump with black eschar, no purulent
discharge, no surrounding erythema. Right wrist with effusion
and warmth at joint, severe pain with passive ROM (will not do
active ROM). Multiple areas of chronic wounds on feet.
Neuro: Alert, thinks he is at ___, guesses the date at
___. No focal CN deficits noted, strength not
formally tested
DISCHARGE PHYSICAL:
Vitals- 97.9 144/65 62 18 100%RA
General: elderly man lying in bed, in NAD
HEENT: Sclera anicteric, MMM, poor dentition
CV: regular rate and rhythm, systolic murmur loudest at apex
Lungs: Faint cracles at L base, otherwise CTA bl
Chest: + L tunneled HD catheter
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
Ext: + RUE fistula, Left foot bandaged over surgical site; R
wrist wrapped and splinted, non- tender to palpation
Neuro: Alert, oriented to ___ but not BI, date ___ no
sporadic muscle movements
Pertinent Results:
========================
Labs:
========================
ADMISSION LABS:
-------------------
___ 01:55AM BLOOD WBC-12.2* RBC-3.00* Hgb-10.1* Hct-31.9*
MCV-106* MCH-33.5* MCHC-31.6 RDW-16.4* Plt ___
___ 01:55AM BLOOD Neuts-70 Bands-9* Lymphs-9* Monos-10
Eos-0 Baso-0 Atyps-1* Metas-1* Myelos-0
___ 01:55AM BLOOD ___ PTT-39.5* ___
___ 01:55AM BLOOD Glucose-250* UreaN-32* Creat-2.5* Na-135
K-4.0 Cl-97 HCO3-25 AnGap-17
___ 01:55AM BLOOD ALT-20 AST-29 CK(CPK)-64 AlkPhos-297*
TotBili-1.8*
___ 01:55AM BLOOD CK-MB-3 cTropnT-0.22*
___ 01:55AM BLOOD Albumin-2.0* Calcium-7.6* Phos-1.4*
Mg-1.8
___ 05:59AM BLOOD Type-CENTRAL VE Temp-36.7 pO2-36*
pCO2-46* pH-7.39 calTCO2-29 Base XS-1 Intubat-NOT INTUBA
___ 02:05AM BLOOD Lactate-2.5*
PERTINENT LABS:
___ 05:01AM BLOOD ESR-100*
___ 01:55AM BLOOD cTropnT-0.21*
___ 05:01AM BLOOD CRP-126.0*
___ 05:59AM BLOOD Lactate-1.7
LABS AT TIME OF TRANSFER from MICU to FLOOR
___ 05:01AM BLOOD WBC-7.2 RBC-3.39* Hgb-11.0* Hct-35.5*
MCV-105* MCH-32.5* MCHC-31.0 RDW-16.8* Plt ___
___ 05:01AM BLOOD Glucose-273* UreaN-62* Creat-4.0* Na-135
K-4.5 Cl-103 HCO3-22 AnGap-15
___ 05:01AM BLOOD Calcium-7.5* Phos-2.6* Mg-2.1 UricAcd-5.8
R wrist aspiration:
___ 04:20PM JOINT FLUID ___ ___ Polys-76*
Bands-1* ___ Monos-11 Eos-2*
___ 04:20PM JOINT FLUID Crystal-NONE
DISCHARGE LABS:
___ 07:40AM BLOOD WBC-10.2 RBC-2.68* Hgb-9.1* Hct-29.6*
MCV-111* MCH-34.0* MCHC-30.7* RDW-19.7* Plt ___
___ 07:40AM BLOOD Glucose-354* UreaN-28* Creat-2.7* Na-134
K-4.1 Cl-98 HCO3-27 AnGap-13
___ 07:40AM BLOOD Calcium-7.7* Phos-3.4 Mg-2.0
___ 07:36AM BLOOD ___ PTT-32.6 ___
========================
Micro:
========================
Blood cultures ___ x2, ___ x2, ___ x2,
___: no growth
___ 5:35 pm CATHETER TIP-IV Source: temporary HD line.
**FINAL REPORT ___
WOUND CULTURE (Final ___: No significant growth.
___ 4:15 pm JOINT FLUID Source: R wrist.
CLOTTED SPECIMEN RECEIVED.
SPECIMEN IDENTIFIED AND TESTING AUTHORIZED BY ___
___ @1639,
___.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___:
Reported to and read back by ___. ___ ___
@ 12:31
___.
STAPH AUREUS COAG +. RARE GROWTH.
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.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
___ 4:27 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
___ 7:24 am SWAB Source: L ___ met ulcer.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Final ___:
STAPH AUREUS COAG +. MODERATE GROWTH OF TWO COLONIAL
MORPHOLOGIES.
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.
STAPH AUREUS COAG +. MODERATE GROWTH. THIRD
MORPHOLOGY.
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.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
| STAPH AUREUS COAG +
| |
CLINDAMYCIN-----------<=0.25 S <=0.25 S
ERYTHROMYCIN----------<=0.25 S <=0.25 S
GENTAMICIN------------ <=0.5 S <=0.5 S
LEVOFLOXACIN---------- 0.25 S 0.25 S
OXACILLIN------------- 0.5 S 0.5 S
TETRACYCLINE---------- <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S <=0.5 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
___ 2:12 pm SWAB RIGHT WRIST.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___:
STAPH AUREUS COAG +. SPARSE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # ___ ___.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
___ 1:15 pm TISSUE ___ METATARSAL HEAD.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
STAPH AUREUS COAG +. SPARSE GROWTH OF TWO COLONIAL
MORPHOLOGIES.
SENSITIVITIES PERFORMED ON CULTURE # ___ ___.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
___ 2:12 pm TISSUE RIGHT WRIST.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
STAPH AUREUS COAG +. SPARSE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # ___ ___.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
========================
Imaging:
========================
CHEST (PORTABLE AP) Study Date of ___ 1:32 AM
PORTABLE UPRIGHT FRONTAL VIEW OF THE CHEST: A right-sided line
ends in the mid superior vena cava. There is mild cardiomegaly.
The aortic knob is calcified. There is a moderate right
pleural effusion. There is right lower lobe compressive
atelectasis and possible airspace opacities. The left lung is
clear. There is no pneumothorax. There is no free air beneath
the hemidiaphragms.
IMPRESSION: moderate right pleural effusion and right lower
lobe airspace opacities which could represent aspiration in the
correct clinical setting.
LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of ___
8:25 AM
IMPRESSION:
1. Complex appearing right-sided pleural effusion with multiple
septations and heterogeneous areas.
2. Mild gallbladder wall edema without evidence of
cholelithiasis or
pericholecystic fluid. Negative sonographic ___ sign.
Gallbladder wall edema is often seen in the setting of ___
spacing secondary to hypoalbuminemia cannot be used as a sign of
cholecystitis.
CHEST (PORTABLE AP) Study Date of ___ 1:36 AM
FINDINGS:
Compared to the study from the prior day there is no significant
interval
change.
WRIST(3 + VIEWS) RIGHT PORT Study Date of ___ 7:19 AM
IMPRESSION:
Worrisome for osteomyelitis superimposed on degenerative changes
FOOT AP,LAT & OBL LEFT PORT Study Date of ___ 2:44 ___
FINDINGS: No previous images. There is severe degenerative
change involving the first MTP joint with multiple hammertoes
with apparent subluxations of several of the metatarsophalangeal
joints. Degenerative change is also seen at the
tarso-metatarsal level. A metallic device of uncertain etiology
is seen adjacent to the medial aspect of the distal portion of
the first metatarsal.
There is poor definition of the head of the fifth metatarsal and
the base of the proximal phalanx of the fifth digit. Since this
is close to an area of apparent ulceration, the possibility of
osteomyelitis should be considered. If the clinical findings
are unclear, MRI could be considered.
ART EXT (REST ONLY) Study Date of ___ 9:51 AM
FINDINGS:
RIGHT SIDE: Triphasic waveforms are identified at the right
femoral and
popliteal levels. Waveforms of the posterior tibial and
dorsalis pedis
regions, however, are monophasic. The ankle-brachial index at
the level of the ankle at the dorsalis pedis is reduced,
measuring 0.67.
Findings are in keeping with significant tibial disease.
LEFT SIDE: Again waveforms in the left femoral and popliteal
levels are
triphasic and normal in morphology. Waveforms in the posterior
tibial and dorsalis pedis arteries, however, are monophasic,
with a significantly reduced left digital brachial index of 0.47
recorded. The pulse volume recordings at level of the ankle and
metatarsal are attenuated.
IMPRESSION: Bilateral tibial disease with amarkedly reduced
left DBI.
FOOT AP,LAT & OBL LEFT PORT Study Date of ___ 2:42 ___
Compared with the prior study, there appears to have been
resection of the fifth toe and the distal portion of the fifth
metatarsal bone. Again seen is severe diffuse osteopenia,
degenerative changes, hallux valgus of the first ray, and a
metallic density, question foreign body, adjacent to the first
metatarsal medially. There is subcutaneous emphysema near the
surgical site. No new fracture is detected.
Portable TTE (Complete) Done ___ at 9:05:05 AM FINAL
Conclusions
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
and cavity size are normal. Due to suboptimal technical quality,
a focal wall motion abnormality cannot be fully excluded.
Overall left ventricular systolic function is mildly depressed
(LVEF= 45 %). Right ventricular chamber size is normal with mild
to moderate global free wall hypokinesis. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No masses or vegetations are seen on the aortic valve,
but cannot be fully excluded due to suboptimal image quality. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. No masses or vegetations are seen on the
mitral valve, but cannot be fully excluded due to suboptimal
image quality. Moderate (2+) mitral regurgitation is seen. There
is mild pulmonary artery systolic hypertension. No
vegetation/mass is seen on the pulmonic valve. There is no
pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size and mold global systolic dysfunction. Normal
right ventricular cavity size with mild to moderate global
systolic dysfunction. No definitive 2D echocardiographic
evidence of endocarditis, but given moderate mitral
regurgitation and poor overall image quality, this cannot be
excluded and TEE is recommmended if there is a high clinical
suspicion for endocarditis.
___ TUNNELED W/O PORT Study Date of ___ 2:46 ___
IMPRESSION:
1. Placement of 15.5F tunneled access catheter through a left
internal jugular vein approach. The tip is located in the right
atrium and the catheter is ready for use.
TEE (Complete) Done ___ at 11:34:25 AM
Conclusions
The left atrium is dilated. No atrial septal defect is seen by
2D or color Doppler. LV systolic function appears mildly
depressed. Right ventricular chamber size is normal. with
depressed free wall contractility. There are simple atheroma in
the aortic arch. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) are mildly
thickened. No masses or vegetations are seen on the aortic
valve. No aortic valve abscess is seen. No aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. No mass
or vegetation is seen on the mitral valve. Moderate (2+) mitral
regurgitation is seen. No masses or vegetations are seen on the
pulmonic valve, but cannot be fully excluded due to suboptimal
image quality.
IMPRESSION: No vegetations or abscess. Moderate degenerative
mitral regurgitation.
========================
Pathology:
========================
PATHOLOGIC DIAGNOSIS:
Date of Procedure: ___
1. Left foot fifth metatarsal head (1A):
Acute osteomyelitis.
2. Clearing margin fifth metatarsal (2A):
1. Dense fibrous tissue with necrosis and focal acute
inflammation.
2. Bone with focal intramedullary acute inflammation and
necrotic
debris.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluoxetine 30 mg PO DAILY
2. Pravastatin 40 mg PO DAILY
3. Ascorbic Acid ___ mg PO DAILY
4. Furosemide 40 mg PO 4X/WEEK (___)
5. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
6. Triphrocaps (B complex-vitamin C-folic acid) 1 mg oral daily
7. Carvedilol 12.5 mg PO BID
8. Ondansetron 4 mg PO Q8H:PRN nausea
9. Megestrol Acetate 800 mg PO DAILY
10. Glargine 6 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
11. Psyllium 1 PKT PO DAILY
12. Aspirin 81 mg PO DAILY
13. Multivitamins 1 TAB PO DAILY
14. sevelamer CARBONATE 2400 mg PO TID W/MEALS
15. Acetaminophen 650 mg PO Q4H:PRN pain
16. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN pain
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Ascorbic Acid ___ mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Fluoxetine 30 mg PO DAILY
5. Glargine 10 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
6. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
7. Megestrol Acetate 800 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Pravastatin 40 mg PO DAILY
10. Psyllium 1 PKT PO DAILY
11. CefazoLIN 2 g IV POST HD
Please give with HD on ___
RX *cefazolin in dextrose (iso-os) 2 gram/50 mL 2 g IV Once
weekly post-HD on ___ Disp #*12 Gram Refills:*0
12. CefazoLIN 2 g IV POST HD
Please give with HD on ___
RX *cefazolin in dextrose (iso-os) 2 gram/50 mL 2 g IV Once
weekly post-HD on ___ Disp #*12 Gram Refills:*0
13. CefazoLIN 3 g IV POST HD
Please give with HD on ___
RX *cefazolin in dextrose (iso-os) 1 gram/50 mL 3 g IV Once
weekly post-HD on ___ Disp #*18 Gram Refills:*0
14. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
RX *tramadol 50 mg 25 mg by mouth every twelve (12) hours Disp
#*15 Tablet Refills:*0
15. Senna 8.6 mg PO BID:PRN Constipation
hold for loose stools
RX *sennosides [senna] 8.6 mg 1 capsule by mouth twice daily
Disp #*60 Capsule Refills:*0
16. Docusate Sodium (Liquid) 100 mg PO BID
RX *docusate sodium 100 mg 100 mg by mouth twice daily Disp #*60
Capsule Refills:*0
17. Triphrocaps (B complex-vitamin C-folic acid) 1 mg oral daily
18. Ondansetron 4 mg PO Q8H:PRN nausea
Discharge Disposition:
Extended Care
Facility:
___
___)
Discharge Diagnosis:
Primary:
-MSSA bacteremia
-R wrist septic arthritis
-L foot osteomyelitis
Secondary:
-ESRD on HD
-DM
-CAD
-HTN
-Hyperlipidemia
-Depression
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
CLINICAL INDICATION: Possible aspiration. Evaluation for pneumonia.
COMPARISON: None.
PORTABLE UPRIGHT FRONTAL VIEW OF THE CHEST: A right-sided line ends in the
mid superior vena cava. There is mild cardiomegaly. The aortic knob is
calcified. There is a moderate right pleural effusion. There is right lower
lobe compressive atelectasis and possible airspace opacities. The left lung
is clear. There is no pneumothorax. There is no free air beneath the
hemidiaphragms.
IMPRESSION: moderate right pleural effusion and right lower lobe airspace
opacities which could represent aspiration in the correct clinical setting.
Radiology Report
HISTORY: Septic shock of unclear origin, vomiting and elevated alk phos.
Evaluate for biliary process
COMPARISON: None available
TECHNIQUE: Gray scale and Doppler ultrasound images of the abdomen were
obtained.
FINDINGS:
The liver shows no evidence of focal lesions or textural abnormality. There
is no evidence of intra or extrahepatic biliary dilatation and the common bile
duct measures 7 mm. There is mild gallbladder wall edema with no evidence of
stones or pericholecystic fluid. Sonographic ___ sign was negative. The
pancreas is unremarkable. The spleen was not examined as the patient could
not tolerate completing the exam.
IMPRESSION:
1. Complex appearing right-sided pleural effusion with multiple septations
and heterogeneous areas.
2. Mild gallbladder wall edema without evidence of cholelithiasis or
pericholecystic fluid. Negative sonographic ___ sign. Gallbladder wall
edema is often seen in the setting of ___ spacing secondary to hypoalbuminemia
cannot be used as a sign of cholecystitis.
Telephone notification to Dr. ___ by Dr. ___ at 11:30 on in ___, 25 min after review of study
Radiology Report
HISTORY: Septic shock and aspiration.
___.
FINDINGS:
Compared to the study from the prior day there is no significant interval
change.
Radiology Report
HISTORY: Septic shock source unknown.
COMPARISON: None.
FINDINGS:
3 views of the right wrist demonstrate degenerative changes involving the
carpal bones, radiocarpal joint, ___ carpometacarpal joint, and ___ proxminal
interphalangeal joint predominantly. of particular concern however is ill
definition of the cortical margin of the ulnar styloid and scapholunate joints
with associated soft tissue swelling. Osteomyelitis and is of concern in
these regions given the ill definition. Recommend clinical correlation. This
finding was called to Dr. ___ at the time of discovery by Dr. ___ at
9:10 on ___.
IMPRESSION:
Worrisome for osteomyelitis superimposed on degenerative changes.
Radiology Report
HISTORY: Diabetic foot, to assess for osteomyelitis.
FINDINGS: No previous images. There is severe degenerative change involving
the first MTP joint with multiple hammertoes with apparent subluxations of
several of the metatarsophalangeal joints. Degenerative change is also seen
at the tarso-metatarsal level. A metallic device of uncertain etiology is
seen adjacent to the medial aspect of the distal portion of the first
metatarsal.
There is poor definition of the head of the fifth metatarsal and the base of
the proximal phalanx of the fifth digit. Since this is close to an area of
apparent ulceration, the possibility of osteomyelitis should be considered.
If the clinical findings are unclear, MRI could be considered.
This information was conveyed to Dr. ___ for Dr.
___.
Radiology Report
EXAMINATION: Non-invasive Doppler evaluation of the arterial inflow to both
lower extremities at rest.
TECHNIQUE: Segmental blood pressures and pulse volume recordings were
obtained as well as ankle brachial indices.
Of note, patient was unable to hold his foot still to obtain a right toe
recording.
FINDINGS:
RIGHT SIDE: Triphasic waveforms are identified at the right femoral and
popliteal levels. Waveforms of the posterior tibial and dorsalis pedis
regions, however, are monophasic. The ankle-brachial index at the level of
the ankle at the dorsalis pedis is reduced, measuring 0.67.
Findings are in keeping with significant tibial disease.
LEFT SIDE: Again waveforms in the left femoral and popliteal levels are
triphasic and normal in morphology. Waveforms in the posterior tibial and
dorsalis pedis arteries, however, are monophasic, with a significantly reduced
left digital brachial index of 0.47 recorded. The pulse volume recordings at
level of the ankle and metatarsal are attenuated.
IMPRESSION: Bilateral tibial disease with amarkedly reduced left DBI.
Radiology Report
HISTORY: Chronic lateral left foot ulcer. Postop evaluation.
LEFT FOOT, THREE PORTABLE VIEWS
COMPARISON: Left foot radiographs dated ___.
Compared with the prior study, there appears to have been resection of the
fifth toe and the distal portion of the fifth metatarsal bone. Again seen is
severe diffuse osteopenia, degenerative changes, hallux valgus of the first
ray, and a metallic density, question foreign body, adjacent to the first
metatarsal medially. There is subcutaneous emphysema near the surgical site.
No new fracture is detected.
Radiology Report
INDICATION: ESRD. Tunneled HD line requested.
PHYSICIANS: Dr. ___ (attending, present and supervising throughout)
and Dr. ___ (fellow).
ANESTHESIA: Local anesthesia was provided by 1% lidocaine to the dermis and
1% lidocaine with epinephrine into the subcutaneous tissues.
RADIATION: 3 mGy, 1 min 3 sec
PROCEDURES:
1. Placement of a ___ tunneled hemodialysis catheter via the left internal
jugular approach.
PROCEDURE DETAILS: After explanation of the risks, benefits and alternatives
to the procedure, written informed consent was obtained. The patient was
transported to the angiography suite and placed supine on the imaging table.
The left neck and upper chest wall were prepped and draped in usual sterile
fashion. A preprocedure timeout and huddle was performed as per ___
protocol.
After anesthetizing the skin and subcutaneous tissues a 21G micropuncture
needle was inserted into the patent and compressible left internal jugular
vein under ultrasound guidance. Ultrasound images were saved for reference.
An 0.018 nitinol wire was advanced into the superior vena cava. After
additional anesthesia, a small ___ was made in the skin. The micropuncture
needle was exchanged with micropuncture sheath. The inner cannula and nitinol
wire were removed. A 0.035 J-wire was advanced into the right atrium.
Appropriate measurements were made for skin incision four fingerbreadths below
the venotomy site. The wire was then advanced into the IVC.
Attention was now turned to creation of subcutaneous tunnel. After additional
local anesthesia 1-cm skin incision was made. A 15.5 ___ tunneled catheter
was passed from the incision to the venotomy site with aid of metal tunneling
device. The venotomy tract was dilated with 10, 12 and 14 ___ dilators. A
___ peel-away sheath was passed over the wire.
The wire and inner cannula were removed and the catheter was passed through
the peel-away sheath. The peel-away sheath was removed while the catheter was
pushed into the right atrium. This was confirmed with fluoroscopy
demonstrating the catheter tip in the right atrium. Both lumens withdrew
blood and flushed easily. The catheter was secured to the skin with ___ silk
sutures. The venotomy site was closed with a ___ Vicryl subcuticular suture.
Dry sterile dressings were applied. The patient tolerated the procedure well
without immediate complication.
IMPRESSION:
1. Placement of 15.5F tunneled access catheter through a left internal jugular
vein approach. The tip is located in the right atrium and the catheter is
ready for use.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: HYPOTENSION
Diagnosed with SEPTICEMIA NOS, SEVERE SEPSIS , SEPTIC SHOCK, END STAGE RENAL DISEASE, ACCIDENT NOS
temperature: 98.4
heartrate: 94.0
resprate: 18.0
o2sat: 98.0
sbp: 89.0
dbp: 49.0
level of pain: 0
level of acuity: 1.0 | ___ with ESRD on HD MWF, DM, CAD, who was noted to have
hypotension (SBP ___, fever to 101.3, and confusion at HD,
found to have septic shock and MSSA bacteremia.
# Septic Shock, MSSA bacteremia:
On initial presentation the patient met ___ SIRS criteria and
had evidence of end-organ perfusion with confusion and a lactate
of 2.5. He was started on vancomycin, cefepime, and flagyl
empircally and put on levophed for pressure support. The source
of his sepsis was initially unclear, with potential sources
being the tunneled dialysis catheter vs. right wrist
osteomyelitis vs. left ___ metatarsal soft tissue infection and
osteomyelitis vs. aspiration pneumonia. With antibiotics and
fluid, the patient became hemodynamically stable, and he was
weaned off of levophed at 6 AM on ___. His blood cultures at
___ (___) ___ grew out MSSA, as did swabs from
his left foot wound. As his HD catheter was a potential source,
he had dialysis on ___ and the line was pulled; culture of tip
was negative. HD line was replaced on L side on ___, and HD was
resumed ___. It was felt most likely source of infection was
ulceration at base of LLE ___ digit (s/p prior amputation), with
growth of staph aureus at OSH (see below). Bacteremia may have
seeded R wrist, which also had staph aureus on culture (see
below). Antibiotics were changed from vanc back to cefazolin
___ given confirmation of MSSA on OSH blood cultures. TTE and
TEE did not show evidence of endocarditis. Pt to continue on
cefazolin dosed 3 times weekly with HD for 6 weeks (start date
___.
# L ___ metatarsal osteomyeltis:
Pt had ulcer at base of L foot ___ digit (s/p amputation) with
underlying exposed bone. Wound culture grew MSSA at OSH. X-ray
was concerning for osteomyelitis. Non-invasive vascular studies
showed evidence of poor perfusion. S/p L ___ metatarsal
resection by podiatry on ___ and closure ___, with staph
aureus on tissue culture. Vascular evaluated pt but did not
recommend further intervention. Was treated with antibiotics per
above.
# Septic arthritis of R wrist:
On presentation patient had extreme tenderness and effusion at
right wrist. He had no active ROM and extreme pain with passive
ROM. Plastic surgery was consulted and his wrist was tapped that
showed 1.2 million RBCs and only ___ WBC with no bacteria. MSSA
grew from joint culture. S/p wrist washout ___ by ortho, with
staph aureus on culture. Pt was treated with antibiotics per
above. Pain was treated with tylenol and tramadol.
# ESRD on HD:
Pt was on MWF via tunneled cath. Has R upper extremity fistula
which per report is not yet mature. HD line removed ___ HD; no
growth on culture of tip. Was given a line holiday, with HD line
replaced ___. Uremia may have contributed to myoclonus (see
below), which improved after HD was resumed ___. Sevelamer was
held given normal-low phosphate values. Cefazolin was dosed with
HD per above.
# Sporadic contractions of extremities, likely
myoclonus/asterixis:
Pt had sporadic contractins of extremities over ___ days, with
no loss of consciousness. Evaluated by neuro. Likely
myoclonus/asterixis due to infection/possible component of
uremia, not c/w seizure as contractions not rhythmic and no LOC
which would occur with generalized seizure affecting all
extremities. Lytes (including corrected ca) within normal
limits. Resolved after continued antibiotic treatment and
reinitiation of HD.
# Aspiration, ? pneumonia, moderate R pleural effusion:
Has diffuse hazy infiltrates in the right lung fields after
witnessed aspiration in the ambulance; was unclear yet if this
was a pneumonitis or developing pneumonia. CXR with stable
effusion, ultrasound shows complex loculation. S/p thoracentesis
at OSH, without growth on culture and negative cytology. Was
exudative at OSH based on pleural protein 4.8 (blood 7.4).
Etiology unclear. Pt declined thoracentesis when it was
discussed during admission. Given improvement with narrow
treatment of MSSA, pt was not treated for HCAP. Respiratory
status remained stable on the floor.
# DM type II:
The patients home lantus was held initially; however he had
elevated blood sugars, so it was restarted and he was put on an
insulin sliding scale. His blood sugars remained elevated in
250s-300s so his home lantus was increased from 6 to 10 units
daily.
# H/O HYPERTENSION:
Patients home carvediolol and lasix on non-HD days were held in
setting of septic shock. Pt BP remained normal to mildly
hypertensive prior to discharge. Following discharge,
consideration should be given to restarting outpt
anti-hypertensives.
# DEPRESSION:
Patient was continued on home fluoxetine.
# FAILURE TO THRIVE:
The patient has had ongoing weight loss and poor health, per
recent discharge summary. He was continued on home megestrol.
# CAD:
Continued on aspirin.
# Hyperlipidemia:
Continued on pravastatin.
======================= |
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:
___ Thoracentesis
History of Present Illness:
___ yo M with PMH recently dx HCC, cirrhosis, HCV, and CHF
presenting for evaluation of dyspnea. States he has "water in
his lungs" and had "surgery" one week ago to remove the fluid At
___. 2L taken from right lung and 1L from left.
He was discharged 1 week ago and felt better until 3 days after
discharge when he began feeling dyspneic again. Admits to
non-prod cough and worse SOB when lying flat. Not worse with
exertion. He is here for further evaluation and to establish
care with a hepatologist at his PCPs urging.
He was diagnosed with liver disease 3 months ago. He has never
had GI bleeding and has never had an EGD to eval for varices. He
has never has abd swelling or had fluid taken from his stomach.
ROS neg for f/c/s, N/V, CP, abd pain, diarrhea, constipation,
hematochezia, melena, dysuria, change in color of urine, leg
swelling.
In the ED, initial vs were: 97.0, 134/80, 64, 20, 94% RA. Labs
significant for CHEM-7 WNL, AST/ALT 312/177, AP 132, lipase 96,
Tbili 3.2, alb 2.7, CBC WNL except plats 107, INR 1.9.
Ultrasound of liver c/w known HCC and patent portal vein.
On the floor, vs were: 98.7, 149/84, 70, 18, 99% 1.5L. He has no
complaints.
Past Medical History:
___
HCV
Cirrhosis
DM
Hernia repair
EtOH abuse
Tobacco dependence
HTN
Thrombocytopenia and coagulopathy d/t EtOH disease.
Social History:
___
Family History:
no ___ liver or heart disease
Physical Exam:
ON ADMISSION:
Vitals: 98.7, 149/84, 70, 18, 99% 1.5L
General: appears older than stated age, ___ hospital but doesnt
know hospital name and appropriate date
HEENT: MM dry, sclera icteric
Lungs: decreased BS at right base. otherwise CTAB
CV: RRR no m/r/g
Abdomen: soft, nt, nd, nabs
Ext: 2+ pulses no edema
Skin: no rahses
Neuro: no asterixis
ON DISCHARGE:
Vitals: 98.2 | BP 132/71 | RR 18 | SpO2 93% RA
General: Alert, oriented.
HEENT: Sclera anicteric, PERRL, EOMI. Oropharynx without
erythema or edema.
Neck: Supple, NO JVD.
Lungs: Decreased breath sounds bilaterally, R>L. Crackles at the
right base.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: +BS, soft, distended, nontender. + Hepatomegaly.
Ext: Warm, well perfused, 2+ pulses. 2+ edema in ___ bilaterally.
No spider nevi, ___ erythema, clubbing.
Neuro: CNII-XII grossly intact.
Pertinent Results:
___ 05:30AM BLOOD WBC-7.8 RBC-3.99* Hgb-13.9* Hct-40.7
MCV-102* MCH-34.9* MCHC-34.2 RDW-15.3 Plt Ct-94*
___ 05:30AM BLOOD ___ PTT-62.9* ___
___ 05:30AM BLOOD Glucose-108* UreaN-11 Creat-0.5 Na-135
K-4.1 Cl-106 HCO3-22 AnGap-11
___ 05:30AM BLOOD ALT-161* AST-281* LD(LDH)-307*
AlkPhos-116 TotBili-3.2*
___ 06:25PM BLOOD Lipase-96*
___ 05:35AM BLOOD proBNP-336*
___ 05:30AM BLOOD Calcium-8.8 Phos-4.0 Mg-1.6
___ 10:30AM BLOOD calTIBC-189* ___ Folate-13.3
Ferritn-696* TRF-145*
___ 05:30AM BLOOD IgG-1627*
PENDING:
___ 10:30AM BLOOD HBsAb-PND HAV Ab-PND
___ 10:30AM BLOOD Smooth-PND
___ 10:30AM BLOOD ___
___ 10:30AM BLOOD HEPATITIS C VIRAL RNA, GENOTYPE-PND
IMAGING:
___: CT Chest and Abdomen w/ Contrast (preliminary)
1. 5.2cm arterially enhancing lesion in segment ___ of liver
which demonstrates washout on delayed phase imaging consistent
with HCC. Further small arterially enhancing foci within
remainder of the liver, suspicious for but not diagnostic of
HCC.
2. Cirrhosis. Borderline splenomegaly.
3. Moderate sized right sided pleural effusion with associated
compressive atelectasis of the right lower lobe. No pulmonary
metastases.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Neomycin Sulfate 1000 mg PO BID
2. Thiamine 100 mg PO DAILY
3. Spironolactone 50 mg PO DAILY
4. Lactulose 30 mL PO TID
titrate to 3BM daily
5. Nadolol 40 mg PO DAILY
6. Lisinopril 10 mg PO DAILY
Discharge Medications:
1. Lactulose 30 mL PO TID
2. Lisinopril 10 mg PO DAILY
3. Nadolol 40 mg PO DAILY
4. Thiamine 100 mg PO DAILY
5. Neomycin Sulfate 1000 mg PO BID
6. Spironolactone 100 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Hepatocellular carcinoma
Cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Known HCC and right pleural effusion, evaluate portal vein.
COMPARISON: None available.
TECHNIQUE: Grayscale and color Doppler ultrasound examination of the right
upper quadrant was performed.
FINDINGS: The liver demonstrates coarsened nodular echotexture. A large
heterogeneous predominantly hypoechoic mass is seen at the dome measuring 5.6
x 4.7 x 5.6 cm. Also, a second rounded hyperechoic lesion is seen within the
left lobe measuring 1.1 x 1.4 x 1.4 cm. The portal vein is patent with
hepatopetal flow. The gallbladder is relatively decompressed but does
demonstrate circumferential wall thickening up to 6 mm, likely from cirrhosis.
A right-sided pleural effusion is noted. The spleen demonstrates homogeneous
echogenicity and measures 11.7 cm.
IMPRESSION:
1. Large heterogenous lesion at the dome, likely patient's known HCC, a second
hyperechoic lesion in the left lobe may represent a second focus of HCC.
Please correlate with presumed previously performed imaging.
2. Portal vein is patent.
Radiology Report
PA AND LATERAL CHEST, ___
COMPARISON: ___ radiograph.
FINDINGS: Persistent large right pleural effusion with adjacent atelectasis
in the right middle and right lower lobe. Pulmonary vascular congestion is
accompanied by diffuse interstitial edema, similar to the recent radiograph.
There is no evidence of left pleural effusion. Nonspecific pleural and
parenchymal scarring at right apex are again demonstrated.
IMPRESSION: Large right pleural effusion with adjacent atelectasis. Diffuse
interstitial opacities most likely due to interstitial edema, but followup
radiographs would be helpful after diuresis to ensure resolution and to
exclude other causes of diffuse lung disease.
Radiology Report
HISTORY: ___ male with liver disease and recurrent pleural effusions,
evaluate pleural effusion
TECHNIQUE: PA and lateral radiographs were obtained of the patient in the
upright position.
COMPARISON: Chest radiograph from ___.
FINDINGS:
Large right pleural effusion is unchanged in size, with adjaent atelectasis of
the right middle and lower lobe. The previously seen pulmonary venous
congestion and interstitial edema has improved. Nonspecific right apical
scarring is again seen.
IMPRESSION:
No change in large right pleural effusion. Improved interstitial edema.
Radiology Report
CT CHEST AND ABDOMEN, ___
INDICATION: Recently diagnosed with HCC, cirrhosis, HCV. Presents here with
dyspnea and to establish care with hepatologist. Please evaluate lungs for
metastatic HCC. Please also evaluate liver and abdomen for HCC and local
invasion, metastasis.
TECHNIQUE: MDCT images of the thorax and abdomen were obtained following
administration of 100 cc of Omnipaque contrast. Non-contrast, arterial,
portal venous and delayed phase imaging of the liver was performed.
COMPARISON: Ultrasound ___.
FINDINGS: There is a large right-sided pleural effusion with associated
compressive atelectasis of the right lower lobe. There are background
emphysematous changes with bullous formation, most prominent at the right
apex. There is a 6 mm enhancing partially calcified nodule in the collapsed
right lower lobe (3b, 148), which may represent a hamartoma/granuloma. No
suspicious pulmonary lesions or nodules.
ABDOMEN: The liver has a nodular contour with hypertrophy of the caudate lobe
and a posterior right hepatic notch, compatible with cirrhosis. There is a
5.2 x 5.1 cm lesion straddling segments VII/VIII. This demonstrates
hyperenhancement on arterial phase imaging with washout on delayed phase
imaging and is consistent with a hepatocellular carcinoma. There is a 1 cm
focus of arterial enhancement within segment VIII (3a, 10) which also
demonstrates washout on delayed phase imaging (6, 8) which may represent a
further focus of hepatocellular carcinoma; however, does not meet the size or
imaging characteristics for definitive diagnosis of HCC. Multiple further sub
1 cm foci of arterial enhancement are seen within the liver (Series 3a, Images
14, 17, 52and 63) which also do not have definitive washout and are
indeterminant in nature.
No intra- or extra-hepatic biliary dilatation. The gallbladder is
unremarkable. There is conventional hepatic arterial anatomy. The portal and
hepatic venous systems are patent. There is borderline splenic enlargement
measuring 13.8 cm. No significant intra-abdominal varices. There is a small
amount of ascites adjacent to the liver.
The pancreas is normal in appearance. No pancreatic duct dilatation or focal
pancreatic lesion.
No adrenal lesion. The kidneys enhance and excrete contrast symmetrically.
No hydronephrosis. There are multiple nonenhancing lesions within both
kidneys which likely represent simple cysts.
There are borderline enlarged portacaval and celiac axis nodes, the largest is
a 1.5 cm short axis node adjacent to the common hepatic artery (3b, 194).
The visualized small and large bowel are unremarkable. Bilateral gynecomastia
noted.
There is anterior wedging of L1 with slight retropulsion of L1 on L2 into the
thecal sac. There is surrounding osteophyte formation indicating this is
likely non-acute. No destructive bone lesion.
IMPRESSION:
1. 5.2 cm lesion straddling segments VII and VIII of the liver demonstrates
arterial enhancement and washout on delayed phase imaging and is consistent
with a hepatocellular carcinoma.
2. Several small enhancing lesions within the liver, which do not meet the
definitive size and imaging criteria for hepatocellular carcinoma.
3. Features of cirrhosis and borderline enlargement of the spleen.
4. Moderate-sized right-sided pleural effusion with associated compressive
atelectasis of the right lower lobe.
5. 6 mm enhancing nodule within the right lower lobe which is partially
calcified, consistent with a granuloma/hamartoma.
6. Wedging of L1 with retropulsion of L1 on L2 indenting the thecal sac.
There is adjacent osteophyte formation indicating this is likely non-acute and
clinical correlation is advised.
This result (including the addition from the wet read) was discussed with Dr
___ by telephone, at 7.15pm on ___.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Status post right-sided thoracocentesis, rule out pneumothorax.
COMPARISON: ___, 9:45 a.m.
FINDINGS: As compared to the previous radiograph, the patient has undergone
right thoracocentesis. The right hemithorax shows no evidence for the
presence of pneumothorax. The right pleural effusion has substantially
decreased, but relatively large amount of effusion is still present, occupying
approximately one-quarter of the right hemithorax. Subsequent atelectasis at
the right lung base. The size of the cardiac silhouette is moderately
enlarged. Normal appearance of the left lung.
Gender: M
Race: HISPANIC/LATINO - CUBAN
Arrive by AMBULANCE
Chief complaint: DYSPNEA
Diagnosed with MAL NEO LIVER, PRIMARY, CIRRHOSIS OF LIVER NOS, UNSPECIFIED VIRAL HEPATITIS C WITHOUT HEPATIC COMA, DIABETES UNCOMPL ADULT, HYPERTENSION NOS, LACK OF HOUSING
temperature: 97.0
heartrate: 64.0
resprate: 20.0
o2sat: 94.0
sbp: 134.0
dbp: 80.0
level of pain: 0
level of acuity: 3.0 | # Right sided pleural effusion.
Patient initially dyspneic on admission. His spironolactone was
increased to 100mg, and dyspnea resolved by day 2 of
hospitalization. Patient underwent thoracentesis on ___ to
drain the pleural fluid. The fluid was sent for cytology and the
results are pending at discharge.
# Cirrhosis/HCC/HCV.
Patient is ___ class C, MELD score 18. He did not show
any signs of encephalopathy or ascites during the admission.
Work up for other causes of Cirrhosis are still pending. He will
establish care with Liver Tumor Clinic at ___. He was
continued on Spironolactone 100mg, rifaximin, thiamine,
lactulose, and nadolol. He also underwent a CT chest and
abdominal triple phase study. The final results are still
pending.
# Macrocytic anemia.
B12 and folate levels were normal. His anemia is most likely due
to EtOH abuse. His H/H were stable during the admission.
# Thrombocytopenia.
Secondary to chronic EtOH abuse. His platelets were stable
during admission.
# Coagulopathy.
Secondary to EtOH abuse.
# DM:
Not on medication as outpatient. He was placed on insulin
sliding scale.
# HTN.
Continued his lisinopril.
# EtOH abuse.
Last drink was 1 month ago. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
Cough, dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
=======================================
MICU RESIDENT ADMISSION NOTE
DATE OF ADMISSION: ___
=======================================
PCP: : ___
CC: cough, dyspnea
REASON FOR MICU: Shock
HISTORY OF PRESENTING ILLNESS:
Mr. ___ is a ___ year old male with a history of CAD s/p CABG
with ICD in place, HFrEF EF 15% ___ MR, 3+ TR), DMII and HNT
admitted for respiratory failure and found to be influenza B
positive.
The patient says that he has had increased cough for the past
two days with associated fevers, nausea and decreased PO intake.
He says that starting 2 days ago he developed a severe cough
that would lead to emesis after coughing fits. He was also very
nauseas with this cough and unable to eat as much so he was
drinking mostly fluids. As the cough worsened he felt more short
of breath and became dizzy at which point he presented to the
___ clinic At the clinic he redirected to the ED.
He says that he recently about 1 month ago was told to increase
his home torsemide dose to 90mg BID by Dr. ___. He denies
running out of his medication.
He denies any chest pain or discomfort.
In the ED, initial vitals: Temp 101.2 HR 115 BP 125/68 -->
75/50 RR 16 94% RA
Exam notable for: tachycardia, tachypnea, diffuse crackles
throughout, abd soft non-tender non distended
Labs notable for: WBC 5.7 hgb 12.1 hct 37 plt 170
Na 139 K 6.0-> 5.0 HC03 21, cl 103, glucose
202
Flu positive
Trop .03-> .02
Imaging:
CXR ___
IMPRESSION:
Interval development of a moderate right pleural effusion and
mild pulmonary
edema. Right basilar opacity presumably some component of
atelectasis noting
that infection is not entirely excluded.
CXR ___
IMPRESSION:
1. Almost complete resolution of mild pulmonary edema
characterized on chest
radiograph ___.
2. Small right pleural effusion is decreased.
Patient received:
IV Levofloxacin
IVF NS 1000 mL
PO/NG OSELTAMivir 30 mg
Acetaminophen IV 1000 mg
IV Furosemide 20 mg ___
IV DRIP NORepinephrine (0.03-0.25 mcg/kg/min ordered)
Consults: Cardiology consulted in the ED
Vitals on transfer:
Upon arrival to ___, he confirms his story as above. He says
that he is feeling much better after his time in the ED. He says
that his breathing feels less labored.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Otherwise
Past Medical History:
# HTN
# CAD
- s/p CABG in ___ ___, SVG-RAM, SVG-OM1, SVG-OM2,
SVG-Diag
# HFrEF
- EF 15%
- s/p Biotronik Lumax ICD
- h/o MMVT
- Dry weight ~140lbs
# PAD
- s/p R ___ bypass in ___
- s/p R ___ toe amputation; s/p L hallux amputation
- 70% ___ stenosis, R vertebral occlusion
- s/p L ___ angioplasty
# IDDM
- Poorly-controlled; c/b retinopathy
# HLD
# DJD
# CKD
- Baseline Cr ~1.3
# Seizure
Social History:
___
Family History:
Per the notes the family history his Grandmother throat cancer.
Aunt ___ DM.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: Temp 98.2 HR 92 RR 17 BP 107/77 99% 1l
GENERAL: middle aged appearing male lying in bed with NC on
breathing with shallow breaths, and some abdominal breathing, in
no acute pain or distress.
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: JVP seen at about 6 cm above the right ventricle, no LAD
LUNGS: right lower lung crackles, left lower lung base decreased
breath sounds, otherwise clear throughout
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, right lower extremity with
2+ pitting edema greater than left leg
SKIN: warm, chest with vertical scar overlying mediastinum
NEURO: alert and oriented X3
ACCESS: PIVs
DISCHARGE PHYSICAL EXAM:
========================
GENERAL: Resting comfortably in bed in no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: JVP ~8
LUNGS: CTAB
CV: Regular rate and rhythm, normal S1 S2, no murmurs
ABD: Soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding
EXT: Warm, well perfused, 2+ pulses, right lower extremity with
1+ pitting edema greater than left leg (chronic), no edema in
LLE as well
SKIN: warm, chest with vertical scar overlying mediastinum
NEURO: alert and oriented X3
ACCESS: PIVs
Pertinent Results:
ADMISSION LABS:
============
___ 03:33PM BLOOD WBC-5.7 RBC-4.07* Hgb-12.1* Hct-37.0*
MCV-91 MCH-29.7 MCHC-32.7 RDW-16.1* RDWSD-53.6* Plt ___
___ 03:33PM BLOOD Neuts-84.3* Lymphs-6.0* Monos-8.6
Eos-0.2* Baso-0.5 Im ___ AbsNeut-4.81 AbsLymp-0.34*
AbsMono-0.49 AbsEos-0.01* AbsBaso-0.03
___ 03:33PM BLOOD Glucose-202* UreaN-27* Creat-1.3* Na-139
K-6.0* Cl-103 HCO3-21* AnGap-15
___ 08:00PM BLOOD CK(CPK)-457*
___ 08:00PM BLOOD CK-MB-3 ___
___ 08:00PM BLOOD cTropnT-0.03*
___ 01:53AM BLOOD cTropnT-0.02*
___ 03:33PM BLOOD Calcium-8.8 Phos-3.9 Mg-1.7
___ 03:04AM BLOOD ___ pO2-69* pCO2-36 pH-7.38
calTCO2-22 Base XS--2
___ 08:10PM BLOOD Lactate-2.1*
NOTABLE HOSPITAL COURSE LABS/TRENDS:
====================================
___ 08:00PM BLOOD CK(CPK)-457*
___ 01:53AM BLOOD CK(CPK)-602*
___ 08:00PM BLOOD cTropnT-0.03*
___ 01:53AM BLOOD cTropnT-0.02*
MICROBIOLOGY:
============
___ 03:15PM OTHER BODY FLUID FluAPCR-POSITIVE*
FluBPCR-NEGATIVE
DISCHARGE LABS:
===============
___ 08:07AM BLOOD WBC-8.8 RBC-3.93* Hgb-11.5* Hct-34.8*
MCV-89 MCH-29.3 MCHC-33.0 RDW-15.0 RDWSD-49.3* Plt ___
___ 08:07AM BLOOD ___ PTT-44.5* ___
___ 08:07AM BLOOD Glucose-138* UreaN-41* Creat-1.5* Na-137
K-4.5 Cl-96 HCO3-28 AnGap-13
___ 05:09AM BLOOD ALT-12 AST-34 LD(LDH)-238 AlkPhos-237*
TotBili-0.9
___ 05:09AM BLOOD ___
___ 08:07AM BLOOD Calcium-8.7 Phos-3.5 Mg-2.2
TTE ___:
The left atrial volume index is normal. The estimated right
atrial pressure is at least 15 mmHg. Left ventricular wall
thicknesses and cavity size are normal. Overall left ventricular
systolic function is severely depressed (LVEF= 15%) due to
severe hypokinesis to akinesis of the entire left ventricle and
dyskinesis of the apex. The basal to mid anterior, lateral and
inferolateral walls contract ___. The estimated cardiac index
is depressed (<2.0L/min/m2). No masses or thrombi are seen in
the left ventricle. Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size is normal with severe global free wall
hypokinesis. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. Trace aortic regurgitation
is seen. The mitral valve leaflets and chordae are mildly
thickened, and mobile echodensities possibly representing torn
chordae are seen in the LV cavity. Mild to moderate (___)
mitral regurgitation is seen. The left ventricular inflow
pattern suggests a restrictive filling abnormality, with
elevated left atrial pressure. Moderate to severe [3+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. [In the setting of at least moderate to
severe tricuspid regurgitation, the estimated pulmonary artery
systolic pressure may be underestimated due to a very high right
atrial pressure.] There is a small pericardial effusion.
IMPRESSION: A left pleural effusion is present. Severe
biventricular systolic dysfunction. Mild-moderate mitral
regurgitation. Moderate-severe tricuspid regurgitation with at
least moderate pulmonary artery systolic hypertension.
Compared with the prior study (images reviewed) of ___,
biventricular systolic dysfunction and degree of valvular
regurgitation are similar. Estimated PASP is lower.
CXR ___:
A left chest wall single lead AICD is present.
There are low bilateral lung volumes. There is persisting
pulmonary edema and small bilateral pleural effusions.
Bibasilar atelectasis is similar to prior.
No pneumothorax. The size of the cardiac silhouette is
unchanged.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. HydrALAZINE 25 mg PO Q8H
2. Sacubitril-Valsartan (97mg-103mg) 1 TAB PO BID
3. Torsemide 60 mg PO BID
4. Glargine 45 Units Breakfast
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. FreeStyle Freedom Lite (blood-glucose meter) 1 meter
miscellaneous DAILY
Check BG daily in AM
RX *blood-glucose meter [FreeStyle Freedom Lite] Check BG daily
in AM daily Disp #*1 Kit Refills:*0
4. FreeStyle Lancets (lancets) 28 gauge miscellaneous DAILY
100 lancets
RX *lancets [FreeStyle Lancets] 28 gauge Test BG in AM daily
Disp #*100 Each Refills:*0
5. FreeStyle Lite Strips (blood sugar diagnostic) 1 strip
miscellaneous DAILY
100 strips
RX *blood sugar diagnostic [FreeStyle Lite Strips] Check BG
daily in AM daily Disp #*100 Strip Refills:*0
6. Losartan Potassium 25 mg PO DAILY
RX *losartan [Cozaar] 25 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
7. MetFORMIN (Glucophage) 500 mg PO BID
RX *metformin [Glucophage] 500 mg 1 tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*0
8. Torsemide 80 mg PO DAILY
9. HELD- Glargine 45 Units Breakfast This medication was held.
Do not restart Insulin until your doctor tells you to
10.straight cane
Staright Cane I50.42
Dx: heart failure
PPx: good
___ 13 months
11.Outpatient Lab Work
Please obtain: Chem-7 on ___
Fax to:
(1) Attn: ___ ___
(2) Attn: ___ ___
ICD-10: I50.2
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
=================
Acute on chronic heart failure exacerbation
Acute respiratory failure
Influenza
Acute kidney injury
Secondary Diagnosis
===================
Hypertension
Hyperlipidemia
Type 2 diabetes
Chornic Kidney 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
EXAMINATION: Chest radiograph
INDICATION: ___ male with cough, dyspnea. Evaluate for pulmonary
edema.
TECHNIQUE: Frontal view radiograph of the chest
COMPARISON: Chest radiographs ___ and ___
FINDINGS:
Left pectoral pacemaker with single lead terminating overlying the right
ventricle is unchanged. Median sternotomy wires and surgical clips overlying
the mediastinum are again noted.
There is central vascular engorgement. There is significant improvement in
the pulmonary edema noted on chest radiograph ___. Small right
pleural effusion is decreased in size. Moderate cardiomegaly is unchanged.
The left pleural effusion is also decreased in volume
IMPRESSION:
1. Significant improvement in the pulmonary edema characterized on chest
radiograph ___.
Small bilateral pleural effusions have improved.
Radiology Report
INDICATION: ___ year old man with CHF exacerbation, influenza// Assess for
interval change, pulmonary edema, infection
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
A left chest wall single lead AICD is present.
There are low bilateral lung volumes. There is persisting pulmonary edema and
small bilateral pleural effusions. Bibasilar atelectasis is similar to prior.
No pneumothorax. The size of the cardiac silhouette is unchanged.
IMPRESSION:
No significant interval change since the prior chest radiograph.
Gender: M
Race: HISPANIC/LATINO - GUATEMALAN
Arrive by AMBULANCE
Chief complaint: Dyspnea, ILI
Diagnosed with Flu due to oth ident flu virus w unsp type of pneumonia
temperature: 101.2
heartrate: 115.0
resprate: 16.0
o2sat: 94.0
sbp: 125.0
dbp: 68.0
level of pain: 5
level of acuity: 2.0 | ___ year old male with HFrEF (EF 15%), CAD s/p CABG ___, with
PAD s/p ___ bypass in ___ who presented to the ED
initially with cough and dyspnea and was found to be hypotensive
secondary to influenza in the setting of acute on chronic heart
failure exacerbation with known biventricular failure. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Pineapple
Attending: ___.
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
ICD explantation (___)
History of Present Illness:
___ year old gentleman with PMHx of atrial fibrillation not on
anticoagulation (previously cardioverted ___, CAD (with
past STEMI secondary to cardioembolic source with thrombus- as
had multiple vessels involved- diagonal, LAD, circumflex),
dilated cardiomyopathy thought to be secondary to tachyarhythmia
with echo ___ showing LVEF 30%, ICD placement ___,
pulmonary embolus, presenting with one day history of pain and
pruritus at the pacemaker site. Patient notes that four days
prior to presentation he developed diffuse body pruritus. During
this time he was itching the site of his previous pacemaker at
the left upper chest. One day prior to presentation, he
developed acute onset itching/burning at the site. This was
associated with chills, night sweats, and shortness of breath.
Pain is an ___ in severity and radiates to the left shoulder.
He notes there is "bulging" at the site of the pacemaker. To
treat the pain he took an aspirin and nitroglycerin. This helped
improve the pain but did not resolve the night sweats or rigors.
Of note, two days prior to presentation, he notes syncopizing.
During that time he was walking when he developed
lightheadedness, palpitations, diaphoresis and collapsed. He hit
his head. Cannot recall how long he was on the ground for.
In the ED, initial vitals were 98.5, 80, 153/95, 16, 100% on RA.
Patient underwent CXR which was unremarkable. Troponins x 2
negative. Plan was to obtain a nuclear stress test but after
cardiology evaluation and concern for infection of the
pacemaker, nuclear stress test was discontinued. In ED he
received nitoglycerin SL 0.4 mg, metoprolol succinate XL 50 mg x
2, dabigatran etexilate 150 mg x 2, sulfameth/trimethorpim DS 2
tabs, cefazoline 1 gram, vancomycin 1000 mg,
oxycodone-acetaminophen 5 mg-325 mg 2 tabs. Patient also noted
lightheadedness and underwent CT scan of the head due to concern
of septic emboli. CT scan of head showed no acute intracranial
process.
On arrival to the floor, patient was resting comfortably. He did
have continued pruritus of pacer site. IP interrogated the
device showed 11 episodes of narrow complex tachycardia, likely
sinus tachycardia; no VT or VF, no therapies delivered- but
normal functioning pacemaker.
Review of sytems:
Positive for orthopnea, dyspnea on exertion, lightheadedness,
dizziness, and one episode of syncope. Currently denies chest
pressure or shortness of breath. Denies nausea, vomiting.
Minimal diarrhea.
Past Medical History:
___ - ___ - EtOH intoxication/withdrawal
___ - syncope, chest pain
___ - dizziness
___ - abdominal pain
___ withdrawal, left AMA.
___- ETOH withdrawal tfr to ICU for high benzo
requirement, left AMA
___- ETOH withdrawal
___- hypotension and etoh withdrawl. left AMA from ICU
___- hematemesis ___ gastritis on EGD left AMA
# HTN
# AFib (not on anticoagulation)
# history of SVT in ___ and ___ @ ___
# CAD
- STEMI s/p LHC ___ @ ___, thought to be ___ cardioembolic
source with thrombus, s/p aspiration thrombectomy and PTCA, no
stent, c/b ___, but left AMA on ___ (per ___
___ record).
- Cath report: LAD: d100%, thrombus at apex, D1 d100% thrombus.
Cx, OM2 99% thrombus TIMI1 flow. RCA: unable to engage.
- s/p ICD ___ (___ Fortify VR Single chamber, ___
by Dr. ___ after sustained monomorphic VT with rate
200-250, treated with amiodarone/lidocaine/magnesium in ___,
left AMA @ ___
- NSTEMI ___ & ___ @ ___ (medical management) ___ demand
# Dilated CM (noted even prior to his MI's, thought to be ___
tachyarhythmia)
- Echo (___): LVEF 30%
# PE (___) s/p 6 months of enoxaparin
# ETOH abuse, reported drinking since age ___, with h/o blackouts,
withdrawal, w/ withdrawal seizure. drinks 1 pint vodka daily
- h/o cocaine abuse
# chronic pain
- chest pain syndrome
- chronic back pain
- chronic abdominal pain ___ ETOH gastritis vs. pancreatitis
- chronic chest pain localized to his left chest around his ICD
pocket
# GERD, h/o GI bleed
# anemia
# h/o rib fracture- right ___ and ___, noted on ___ CXR
# h/o stab wounds by knife to left shoulder/upper arm
# history of leaving AMA
Social History:
___
Family History:
Family history of HTN, CAD with MI, diabetes. Mother and
grandmother both have history of hypertension and MI.
Grandmother is diabetic
Physical ___:
ADMISSION PHYSICAL EXAM
=======================
Vital Signs: 98.4, 148/82, 70, 18, 97% on RA.
General: NAD, comfortable, pleasant
HEENT: PERRL, EOMI, slcera anicteric. Moist mucous membranes.
Neck: supple, no JVD
Chest: Left upper chest at ___ site is erythematous, warm,
with fluctuance. Exquisetly tender to palpation.
CV: Regular rate and rhythm, S1 and S2 present, no murmurs rubs
or gallops. II/VI holosystolic murmur at apex.
Lungs: Clear to auscultation, no wheezes, rales or rhonchi.
Abdomen: soft, non-tender, non-distended, no rebound or
guarding.
Ext: warm and well perfused. 2+ pulses of DPs. No splinter
hemorrhages. No ___ nodes ___ lesions.
Neuro: moving all extremities grossly, CN II-XII intact.
DISCHARGE PHYSICAL EXAM
=======================
Vitals: 98.6 (99.0) 113/58 (110-130/50-60) 65 (50-60) 18 100%RA
Weight: 93.2 <- 93.5 <- 92.2 kg <- 93.7 kg <- 95.2 kg <- 93.4 <-
92.1 kg
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB, no wheezes, rales, rhonchi
CV: RRR, normal S1 + S2, no MRG
Chest: ICD site with mild erythema and tender to palpation.
stiches removed. no drainage with mild edema. erythema
improving. dressing no longer in place
Abdomen: soft, NT, ND, +bs
GU: no foley.
Ext: warm, well perfused, 2+ pulses, trace ___ edema. shackles in
placeRUE PICC line dressing c/d/i with out erythema, warmth,
slightly tender.
Neuro: CNs2-12 intact, motor function grossly normal
Skin: resolving erythematous dicrete punctate papules across
lower back bilaterally, volar aspect of arms, and ___ around
shackles (improving). Xerosis noted in ___. ICD site with
resolving erythema per above
Pertinent Results:
ADMISSION LABS
==============
___ 06:55PM BLOOD WBC-4.9 RBC-4.15* Hgb-12.4* Hct-35.9*
MCV-87 MCH-29.9 MCHC-34.5 RDW-16.8* Plt ___
___ 06:55PM BLOOD Neuts-50.4 ___ Monos-7.3 Eos-3.1
Baso-0.4
___ 06:55PM BLOOD ___ PTT-29.3 ___
___ 06:55PM BLOOD Glucose-84 UreaN-10 Creat-0.8 Na-141
K-3.9 Cl-105 HCO3-30 AnGap-10
___ 03:07PM BLOOD Calcium-8.8 Phos-4.2# Mg-2.1
DISCHARGE LABS
==============
___ 05:09AM BLOOD WBC-7.2 RBC-4.33* Hgb-12.4* Hct-36.6*
MCV-84 MCH-28.6 MCHC-33.8 RDW-15.6* Plt ___
___ 05:09AM BLOOD Glucose-98 UreaN-23* Creat-1.1 Na-140
K-4.5 Cl-103 HCO3-28 AnGap-14
___ 05:09AM BLOOD CK(CPK)-92
CARDIOLOGY LABS
===============
___ 06:55PM BLOOD cTropnT-<0.01
___ 01:23AM BLOOD cTropnT-<0.01
___ 01:49AM BLOOD CK-MB-2 cTropnT-<0.01
LIVER TESTS
===========
___ 06:00PM BLOOD ALT-20 AST-26 LD(LDH)-256* AlkPhos-57
TotBili-0.4
___ 01:49AM BLOOD CK(CPK)-227
___ 06:46AM BLOOD LD(___)-255*
___ 08:20AM BLOOD CK(CPK)-597*
___:21AM BLOOD CK(CPK)-77
___ 06:55AM BLOOD CK(CPK)-57
___ 05:11AM BLOOD CK(CPK)-88
___ 05:09AM BLOOD CK(CPK)-92
ENDOCRINOLOGY TESTS
===================
___ 10:59AM BLOOD TSH-1.6
INFLAMMATORY MARKERS
====================
___ 06:00PM BLOOD CRP-1.4
___ 18:00PM BLOOD ESR-6
INFECTIOUS DISEASE TESTS
========================
___ 06:05AM BLOOD HCV Ab-NEGATIVE
___ 06:25AM BLOOD HIV Ab-NEGATIVE
COMPLEMENTS
===========
___ 06:46AM BLOOD C3-149 C4-41*
URINE STUDIES
=============
___ 10:14AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 10:52AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 10:42PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
MICROBIOLOGY
============
___: BLOOD CULTURE: NO GROWTH
___: BLOOD CULTURE: NO GROWTH
___: CULTURE FROM TIP OF ICD LEAD: NO GROWTH.
___: URINE CULTURE: NO GROWTH
**FINAL REPORT ___
ASO Screen (Final ___:
POSITIVE by Latex Agglutination.
ASO TITER (Final ___: POSITIVE 200-400 IU/ml.
___: CHLAMYDIA TRACHOMATIS URINE STUDY: NEGATIVE.
___: NEISSERIA GONORRHOEAE URINE STUDY: NEGATIVE.
___: RAPID PLASMA REAGIN TEST: NONREACTIVE.
___: BLOOD CULTURE: NO GROWTH.
___: BLOOD CULTURE: NO GROWTH.
QUANTIFERON(R)-TB GOLD: NEGATIVE
IMAGING
=======
___: CHEST (PA AND LATERAL)
IMPRESSION:
No acute cardiopulmonary process. Stable mild to moderate
cardiomegaly.
___: CT HEAD WITHOUT CONTRAST
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. The paranasal sinuses, mastoid
air cells, and
middle ear cavities are clear. The orbits are unremarkable.
IMPRESSION:
No acute intracranial process.
___: TRANS-THORACIC ECHOCARDIOGRAM
The left atrium is mildly dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is severely dilated.
Overall left ventricular systolic function is severely depressed
(LVEF= 25 %) secondary to hypokinesis of the inferior and
lateral walls and apex, and akinesis of the posterior wall.
Right ventricular chamber size and free wall motion are normal.
The ascending aorta is mildly dilated. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis or aortic regurgitation. The mitral valve
leaflets are mildly thickened. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
IMPRESSION: no vegetations seen
Compared with the prior study (images reviewed) of ___
the findings are similar.
___: TRANS-ESOPHAGEAL ECHOCARDIOGRAM
The left atrium is normal in size. A mass/thrombus associated
with a catheter/pacing wire is seen in the right atrium,
specifcally proximal to the tricuspid. This is filamentous and
represented early clot rather than frank thrombus.. The left
ventricular cavity is mildly dilated. There is moderate to
severe regional left ventricular systolic dysfunction with EF of
30%. No masses or thrombi are seen in the left ventricle. Right
ventricular chamber size is normal. with borderline normal free
wall function. The ascending, transverse and descending thoracic
aorta are normal in diameter and free of atherosclerotic
plaques. 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 an anterior
space which most likely represents a prominent fat pad.
Upon close examination of all 4 four valves, as well as the
aorto-mitral curtain, the aortic root, there was no evidence of
vegetation/ abcess seen.
After wire removal there was no sign of pericardial effusion or
right sided heart damage.
___: CHEST (PA AND LATERAL)
IMPRESSION:
In comparison with the study of ___, the pacer device has
been removed.
Lower lung volumes accentuate the transverse diameter of the
heart. No
evidence of pneumothorax. Mild basilar atelectatic changes
without definite vascular congestion or acute focal pneumonia.
___: RENAL ULTRASOUND
FINDINGS:
The right kidney measures 10.5 cm. The left kidney measures 11.7
cm. There is no hydronephrosis, stones, or masses bilaterally.
Normal cortical echogenicity and corticomedullary
differentiation are seen bilaterally.
The bladder is normal in appearance.
IMPRESSION:
Normal kidney and bladder ultrasound.
___: ECG
Sinus rhythm with baseline artifact. Left axis deviation with
possible left anterior fascicular block. Findings are consistent
with inferolateral myocardial infarction/ischemia. Left atrial
abnormality. Possible left ventricular hypertrophy. QTc interval
prolongation. Compared to the previous tracing of ___ the
QTc interval is somewhat longer with other major abnormalities
as reported. Clinical correlation is suggested.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
62 ___
___: U/S Chest Wall
Space-occupying structure at the site of the patient's recent
left chest
pacemaker which may represent a hematoma however ultrasound
cannot fully
characterize and infection cannot be excluded. No drainable
fluid is seen
within this region.
___: U/S Chest Wall
Resolution of the previous space occupying structure (likely
hematoma) in the left upper chest. No fluid collection is
identified.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lidocaine 5% Patch 1 PTCH TD QPM
2. econazole 1 % topical BID
3. Multivitamins 1 TAB PO DAILY
4. Thiamine 100 mg PO DAILY
5. FoLIC Acid ___ mcg PO DAILY
6. Naproxen 500 mg PO Q12H:PRN pain
7. Sertraline 100 mg PO DAILY
8. Omeprazole 40 mg PO DAILY
9. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN CP
10. Aspirin 81 mg PO DAILY
11. Atorvastatin 80 mg PO QPM
12. Losartan Potassium 25 mg PO DAILY
13. Metoprolol Succinate XL 50 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Losartan Potassium 25 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain Duration: 3
Doses
7. Sertraline 100 mg PO DAILY
8. Thiamine 100 mg PO DAILY
9. Acetaminophen 650 mg PO Q6H
10. Amiodarone 400 mg PO DAILY
11. Docusate Sodium 100 mg PO BID
12. HydrOXYzine 25 mg PO Q6H:PRN pruritus
13. Polyethylene Glycol 17 g PO DAILY
14. Rivaroxaban 20 mg PO DINNER
15. Sarna Lotion 1 Appl TP QID:PRN pruritus
16. Senna 8.6 mg PO BID constipation.
17. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush
18. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
19. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
20. Lidocaine 5% Patch 1 PTCH TD QPM
21. Omeprazole 40 mg PO DAILY
22. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
23. Atorvastatin 80 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
-intracardiac device pocket infection
-acute kidney injury
Secondary Diagnosis:
-paroxysmal atrial fibrillation
-chronic compensated systolic CHF
-history of ventricular tachycardia
-cornary artery disease
-hypertension
-gastroesophageal reflux disease
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 chest pain // Eval for structural process
TECHNIQUE: PA and lateral radiographs of the chest.
COMPARISON: ___.
FINDINGS:
A left pectoral pacer device with single lead terminating in the right
ventricle is unchanged. The inspiratory lung volumes are appropriate. The
lungs are clear without focal consolidation, pleural effusion or pneumothorax.
The pulmonary vasculature is not engorged. The cardiomediastinal and hilar
contours are stable with mild to moderate cardiomegaly. No acute osseous
abnormality is detected.
IMPRESSION:
No acute cardiopulmonary process. Stable mild to moderate cardiomegaly.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with an ICD, presenting for evaluation of dizziness// ?
brain abscess
TECHNIQUE: Contiguous axial images images of the brain were obtained without
contrast. Coronal and sagittal as well as thin bone-algorithm reconstructed
images were obtained.
DOSE: DLP: 1003 mGy-cm
CTDI: 54 mGy
COMPARISON: None.
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. The paranasal sinuses, mastoid air cells, and
middle ear cavities are clear. The orbits are unremarkable.
IMPRESSION:
No acute intracranial process.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with recent removal of ICD (left upper chest) on
___ due to ICD pocket infection. // Please evaluate for chest pathology s/p
removal of ICD. Please evaluate for chest pathology s/p removal of ICD.
IMPRESSION:
In comparison with the study of ___, the pacer device has been removed.
Lower lung volumes accentuate the transverse diameter of the heart. No
evidence of pneumothorax. Mild basilar atelectatic changes without definite
vascular congestion or acute focal pneumonia.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old man with acute kidney injury status post ICD removal.
Please evaluate for parenchymal process.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: None.
FINDINGS:
The right kidney measures 10.5 cm. The left kidney measures 11.7 cm. There is
no hydronephrosis, stones, or masses bilaterally. Normal cortical echogenicity
and corticomedullary differentiation are seen bilaterally.
The bladder is normal in appearance.
IMPRESSION:
Normal kidney and bladder ultrasound.
Radiology Report
INDICATION: ___ year old man with new picc // 52cm right picc. ___ ___
Contact name: ___: ___
EXAMINATION: CHEST PORT. LINE PLACEMENT
TECHNIQUE: Portable Chest radiograph, frontal view
COMPARISON: Chest radiograph ___
FINDINGS:
Right PICC terminates in the atrium. It can be pulled by 2 cm to reposition
at the low SVC. Mild right base atelectasis is similar to ___. There is
no pneumothorax or pleural effusion. Moderately enlarged cardiac silhouette is
unchanged.
IMPRESSION:
Right PICC terminates in the atrium. It can be pulled by 2 cm to reposition
at the low SVC.
Radiology Report
EXAMINATION: US CHEST WALL SOFT TISSUE
INDICATION: ___ year old man s/p PPM removal with continued pain and
tenderness at the site. // abscess at site of pacemaker removal
TECHNIQUE: Grayscale ultrasound images were obtained of the superficial
tissues of the left upper chest.
COMPARISON: None
FINDINGS:
Transverse and sagittal images were obtained of the superficial tissues of the
left upper chest. There is an echogenic tissue structure within the vacated
site of the implant in the left upper chest. This region measures 1.1 x 3.1 x
3.9 cm. Minimal peripheral vascularity is seen on color Doppler imaging. There
is no drainable fluid within this area.
IMPRESSION:
Space-occupying structure at the site of the patient's recent left chest
pacemaker which may represent a hematoma however ultrasound cannot fully
characterize and infection cannot be excluded. No drainable fluid is seen
within this region.
Radiology Report
EXAMINATION: US CHEST WALL SOFT TISSUE
INDICATION: ___ year old man with ppm removed and pain at site // please
assess drainable fluid collection in former PPM site
TECHNIQUE: Grayscale ultrasound images were obtained of the superficial
tissues of the left upper chest.
COMPARISON: Ultrasound chest wall ___
FINDINGS:
Transverse and sagittal images were obtained of the superficial tissues of the
left upper chest. There is no superficial fluid identified. The space
occupying structure seen on the prior ultrasound appears to be resolved. No
suspicious mass is visualized.
IMPRESSION:
Resolution of the previous space occupying structure ( likely hematoma) in the
left upper chest. No fluid collection is identified.
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by OTHER
Chief complaint: Chest pain
Diagnosed with CHEST PAIN NOS, CAD UNSPEC VESSEL, NATIVE OR GRAFT
temperature: 98.5
heartrate: 80.0
resprate: 16.0
o2sat: 100.0
sbp: 153.0
dbp: 95.0
level of pain: 5
level of acuity: 2.0 | ___ year old gentleman with HFrEF (30% ___, CAD, previous
STEMI requiring ICD placement ___ due to sustained ventricular
tachycardia, afib/aflutter s/p cardioversion, history of PE,
presenting with warmth, erythema, and fluctuance at site of ICD.
#Intracardiac Defibrillator (ICD)/Pocket Infection: Mr. ___
presented to ___ with erythema, warmth and fluctuance
of the left upper chest of the ICD placement. This was tender to
touch with excoriations. Patient notes he had been scratching at
the site over the past three days due to pruritus. Given concern
for ICD/pocket infection, he underwent a trans-thoracic
echocardiogram which did not reveal evidence of endocarditis. As
patient noted lightheadedness and dizziness a CT Head without
contrast was performed due to concern of ICD tip clot with
subsequent embolus to the brain. The CT head was negative for
any acute intracranial process. Electropysiology was consulted
who, due to concern for ICD infection, explanted the device on
___. A follow-up trans-esophageal echocardiogram did
not reveal evidence of endocarditis. The tip of the ICD lead was
sent for culture and showed no growth. Blood cultures were also
taken which showed no growth. CRP was 1.4 and ESR was 6.
Infectious Disease was also consulted due to concern of ICD
infection. They started Mr. ___ on vancomycin, however due
to changing renal function (please see below), they recommended
adjusting antibiotic to daptomycin (6 mg/kg/dose daily). Patient
received daptomycin from ___. A PICC line was placed
during hospitalization due to prolonged course of intravenous
antibiotic therapy and removed prior to discharge.
As part of Infectious Disease workup, an HIV, Quantiferon-Gold
and Hepatitis C antibody were obtained. Both of the results were
negative.
Per Electrophysiology, Mr. ___ does not require a life-vest
now that ICD has been removed. He was started on amiodarone 400
mg PO BID from ___ to ___ with subsequent transition to
amiodarone 400 mg PO daily. He had LFT's and TSH obtained during
hospitalization which were normal. He will require pulmonary
function tests as an outpatient given that he will be on
amiodarone. Per electrophysiology he should also be scheduled to
follow-up with Device Clinic (Dr. ___ to discuss need for
re-implantation.
#Acute Kidney Injury: Mr. ___ developed acute kidney injury
following explant of the ICD. Creatinine on admission to
hospital was 0.8. Creatinine rose from 1.1 on day of explant to
1.6 on day following explant. This continued to rise to a peak
of 2.2. Given acute rise in creatinine, Renal was consulted.
Renal ultrasound showed normal kidney and bladder.
Anti-streptolysin antibody but C3 (149) and C4 (41) were normal,
decreasing likelihood of post-streptococcal glomerulonephritis
(this was considered as the infection of the ICD was likely
related to either staphylococcus or streptococcus). When urine
was spun, white blood cell casts were noted. It was noted that
patient was given cefazolin in the Emergency Department, which
given patient's history of allergies to penicillin, may have led
to acute interstitial nephritis. Patient was then transitioned
to daptomycin with resolutiong of ___. Creatinine at the time of
discharge was 1.1 at patient's baseline.
#chronic, compensated systolic congestive heart failure: Patient
has history of dilated cardiomyopathy thought to be secondary to
tachyarrhythmia and STEMI in ___. Trans-thoracic echocardiogram
obtained ___ showed left atrium mildly dilated, left
ventricular cavity is severely dilated, overall left ventricular
systolic function is severely depressed (LVEF=25%) secondary to
hypokinesis of the inferior and lateral walls and apex, and
akinesis of the posterior wall. No evidence of vegetations. The
trans-esophageal echocardiogram obtained during explantation
showed an LVEF of 30% without evidence of vegetations. Given the
findings of dilated cardiomyopathy, Mr. ___ was on aspirin
81 mg PO daily, atorvastatin 40 mg PO daily, metoprolol
succinate 50 mg PO daily. He was also started on losartan 25 mg
PO daily and spironolactone 12.5 mg PO daily, however, given the
___ noted above, the losartan and spironolactone were
discontinued. With improval of renal function, his losartan was
continued, however spironolactone continued to be held given
___ Class 1 heart failure symptoms. Of note, the atorvastatin
was reduced from 80 mg PO daily to 40 mg PO daily given that
patient will be on daptomycin and increased risk of developing
rhabdomyolysis, however resumed to 80 mg upon completion of
daptomycin.
#Rash/Pruritus: Patient had pruritic rash during
hospitalization, near wrists, ankles, and waist. The location of
the rash coincided with the handcuffs, ankle cuffs, and waist
chain. This appeared to be related to contact dermatitis to
metal. He was started on triamcinolone during hospitalization
with resolution of rash. He also was given Sarna lotion with
improvement of pruritis.
#History of Ventricular Tachycardia: Patient had history of
sustained ventricular tachycardia resulting in need for ICD
device. Per electrophysiology, he does not need a life-vest at
the current time. As prophylaxis for ventricular tachycardia, he
was started on amiodarone as noted above, with follow-up in
Device Clinic to further discuss need for life vest vs ICD.
#Paroxysmal Atrial Fibrillation: Previously cardioverted in past
and remained in sinus rhythm on telemetry. Given past history of
atrial fibrillation and elevated CHADS score, patient was
started on systmeic anticoagulation with rivoroxaban. Patient
remained rate controlled in sinus on metoprolol succinate.
#Coronary Artery Disease: Patient has history of STEMI ___,
likely from thrombus. Per patient, it is unsure as to whether a
stent was placed in the past. During hospitalization he was
continued on aspirin, atorvastatin, metoprolol. As noted above,
losartan and spironolactone were discontinued in the setting of
___ with losartan continued upon discharge and spironolactone
held as above.
#History of Pulmonary Embolus: Patient has history of PE which
reportedly treated for 6 months in in ___ with enoxoparin.
Given his history of paroxysmal atrial fibrillation, a
discussion took place regarding need for anticoagulation. After
discussion decision was made to initiate rivoroxaban as above.
#Hypertension: Blood pressure well controlled. Continued
metoprolol, losartan as above and held spironolactone.
#Gastroesophageal Reflux Disease: Continued on omeprazole 40 mg
PO daily.
#Mood: Continued on sertraline 100 mg PO daily.
#Alcohol Use: Patient has a history significant for alcohol use.
He did not score on CIWA during hospitalization. He was
continued on thiamine and folic acid.
TRANSITIONAL ISSUES
===================
-will need outpatient PFTs given on amiodarone
-will need f/u with device clinic to determine need for
re-implantation of ICD vs life vest
-spironolactone held given stable BPs and NYHA Class 1 symptoms.
Can discuss with cardiology re: restarting medication.
-code status: full
-contact: ___, on ___. ___
___Brother): ___ (Lives in ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Perforated diverticulitis
Major Surgical or Invasive Procedure:
___: 1. Exploratory laparotomy.
2. Sigmoid colectomy with end colostomy.
History of Present Illness:
___ with small cell lung cancer of the right lung with an
endobronchial lesion of the right bronchus intermedius currently
undergoing chemo/rads (just completed second cycle of
chemotherapy) who presented to an OSH with a single day of
abdominal pain. CT scan was concerning for perforated
diverticulitis with free air. She was transferred to ___ for
further care. She has had no episodes like this in the past.
Last colonoscopy was ___ years ago and was normal.
Past Medical History:
- Hypertension
- Hyperlipidemia
- COPD
- GERD
- Melanoma s/p resection ___ years ago
- Anxiety and depression
Social History:
___
Family History:
- Father with prostate cancer
- Mother with cirrhosis
- Brother with CAD and MI
Physical Exam:
Admission Physical Exam:
Vitals: 98.1 86 121/59 17 92 RA
GEN: A&Ox3, NAD
HEENT: No scleral icterus, mucus membranes moist
PULM: no respiratory distress
ABD: Soft, nondistended, diffusely tender with rebound
tenderness
and guarding
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 10:24PM HCT-34.5
___ 03:23PM ___ PTT-20.4* ___
___ 02:02PM LACTATE-3.4*
___ 01:33PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 01:33PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 01:33PM URINE RBC-0 WBC-2 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 01:33PM URINE MUCOUS-FEW
___ 01:21PM GLUCOSE-121* UREA N-17 CREAT-0.6 SODIUM-130*
POTASSIUM-3.2* CHLORIDE-97 TOTAL CO2-21* ANION GAP-15
___ 01:21PM WBC-8.1 RBC-4.19 HGB-11.2 HCT-34.8 MCV-83
MCH-26.7 MCHC-32.2 RDW-14.4 RDWSD-43.2
___ 01:21PM NEUTS-96* BANDS-1 LYMPHS-3* MONOS-0 EOS-0
BASOS-0 ___ MYELOS-0 AbsNeut-7.86* AbsLymp-0.24*
AbsMono-0.00* AbsEos-0.00* AbsBaso-0.00*
___ 01:21PM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+
___ 01:21PM PLT SMR-HIGH PLT COUNT-502*
___: Tissue/Colon Partial Resection:
Procedure:Sigmoid colon, sigmoid colectomy:
1. Diverticular disease with peridiverticular acute and chronic
inflammation, granulation tissue, abscess formation and focally
transmural inflammation with acute purulent serositis;
consistent with perforation.
2. Six (6) reactive lymph nodes.
3. No malignancy is identified
Imaging:
___: CXR:
NG tube termination in the esophagus.
RECOMMENDATION(S): Re-position NG tube.
Medications on Admission:
Tudorza Pressair 400'', albuterol 90 2 puffs Q6hrs PRN,
alprazolam 0.25''' PRN, atorvastatin 20', Symbicort 80 mcg-4.5
mcg/actuation HFA aerosol inhaler 2 puffs'', Cardizem CD 180',
lorazepam 0.5 Q6 PRN, omeprazole 20''', ondansetron HCl 8'''
PRN,
prochlorperazine maleate 10 Q6 PRN, Evista 60', venlafaxine ER
75'
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
2. Atorvastatin 20 mg PO QPM
3. Diltiazem Extended-Release 180 mg PO DAILY
4. Filgrastim 480 mcg IV Q24H
5. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation QAM:PRN asthma/wheezing
6. Venlafaxine XR 75 mg PO DAILY
7. raloxifene 60 mg oral DAILY
8. Prochlorperazine 10 mg PO Q6H:PRN nausea
9. Omeprazole 20 mg PO TID
10. Lorazepam 0.5 mg PO QPM sleep
11. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheeze
12. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
do NOT drive while taking this medication
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every four
(4) hours Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Perforated diverticulitis
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: ___ year old woman with small cell lung cancer and diverticulitis
status post colectomy with end colostomy. Evaluate NG tube placement.
TECHNIQUE: Portable AP chest radiograph
COMPARISON: Multiple prior chest radiographs, most recent from ___.
FINDINGS:
NG tube terminates in the esophagus. Normal mediastinal and hilar contours.
No cardiomegaly. Interval improvement in right basilar opacity.
IMPRESSION:
NG tube termination in the esophagus.
RECOMMENDATION(S): Re-position NG tube.
NOTIFICATION: Findings were communicated to ___ at 15:13.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 1 EXAM
INDICATION: ___ w/ SCLC w/ diverticulitis and free air s/p sigmoid colectomy
and end colostomy // NGT placement NGT placement
IMPRESSION:
In comparison with the earlier study of this date, the nasogastric tube
extends only to the esophagogastric junction. It must be advanced at least
7-10 cm for good position.
No change in the appearance of the heart and lungs.
Gender: F
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: Transfer
Diagnosed with DIVERTICULITIS OF COLON
temperature: 98.1
heartrate: 86.0
resprate: 16.0
o2sat: 94.0
sbp: 92.0
dbp: 55.0
level of pain: 5
level of acuity: 2.0 | ___ year-old female with a history of right small cell lung
cancer and radiation therapy, presenting to ___ on ___
from an outside hospital with concerns for diverticulitis with
free air on CT scan. She was transferred to ___ for further
care. She was admitted to the Acute Care Surgery team for
further medical management.
On ___, she was taken to the OR and underwent exploratory
laparotomy and sigmoid colectomy with end colostomy. She also
had a #19 ___ drain placed during the operation. The patient
tolerated this procedure well and, after an uneventful stay in
the PACU, was transferred to the step-down surgery floor for
pain control and to await return of bowel function.
The patient was kept NPO and placed on IV fluids. She had a NGT
placed on ___ for nausea and abdominal distention. This
tube was later removed and the patient was advanced to a regular
diet and oral pain medicine which she tolerated. She was seen
and evaluated by the ___ Ostomy nurse for colostomy teaching.
She was also taught how to care for her abdominal JP drain.
The patient was alert and oriented throughout hospitalization.
The patient remained stable from a cardiovascular standpoint;
vital signs were routinely monitored.
The patient remained stable from a pulmonary standpoint. Good
pulmonary toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
The patient's intake and output were closely monitored. The
patient's fever curves were closely watched for signs of
infection. 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: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right nondisplaced tibial plateau fracture, C7 transverse
process fracture, right occipital bone fracture
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female presents with R tibial plateau fracture and C7 TP
fracture s/p mechanical
fall down 14 stairs. States she was rushing to leave the house
this morning and tripped falling on stairs. Endorses head
strike no loss of consciousness. Endorses pain in the right
knee and in the posterior neck.
Denies any numbness or paresthesias. Denies any pelvic pain.
Denies any other extremity injuries. Denies history of injuries
to the right knee.
Of note had a recent injury in ___ of this year to the right
hip, underwent a DHS. Cannot recall the details of the
procedure but believes it was done here at the ___
___.
Past Medical History:
Gastric bypass
hypertension
diabetes
Hx of ETOH abuse
Social History:
___
Family History:
noncontributory
Physical Exam:
Temp: 98.2 PO BP: 156/79 R Lying HR: 82 RR: 18 O2
sat: 97% O2 delivery: RA
VS: Refer to flowsheet
GEN: AOx3 WN, WD in NAD
HEENT: NCAT, EOMI, anicteric
CV: RRR
PULM: unlabored breathing with symmetric chest rise, no
respiratory distress
EXT:
Right lower extremity:
- Right lower extremity in hinged knee brace
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- foot warm and well-perfused
Pertinent Results:
See OMR
Medications on Admission:
Lisinopril 20mg daily
Trazodone 50mg qhs
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
2. Diazepam - CIWA protocol 10 mg PO Q2H:PRN CIWA > or = 10
3. Docusate Sodium 100 mg PO BID
4. Enoxaparin Sodium 40 mg SC QHS
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*36 Tablet Refills:*0
6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
7. Senna 8.6 mg PO BID:PRN Constipation - First Line
8. FoLIC Acid 1 mg PO DAILY
9. Thiamine 100 mg PO DAILY
10. TraZODone 25 mg PO QHS:PRN insomnia
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right nondisplaced tibial plateau fracture
C7 transverse process fracture and a right
occipital bone 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: DX FEMUR AND KNEE
INDICATION: History: ___ with s/p fall down 14-steps // s/p fall s/p
fall
s/p fall
IMPRESSION:
No comparison. 6 selected views of the right hip and right femur are
provided. Status post right femur neck fixation. The screws and the fixation
devices are in correct position. Extensive peritrochanteric calcifications.
Mild degenerative hip disease. Severe degenerative knee changes. No evidence
of cortical disruptions indicative of fracture.
Radiology Report
EXAMINATION: FOREARM (AP AND LAT) RIGHT
INDICATION: History: ___ with s/p fall down 14-steps // s/p fall s/p
fall
IMPRESSION:
No comparison. Two views of the right forearm are provided. No periarticular
soft tissue swelling. No pathologic calcifications. No dislocation. No
fracture.
Radiology Report
EXAMINATION: DX SHOULDER AND HUMERUS
INDICATION: History: ___ with s/p fall down 14-steps // s/p fall s/p
fall
s/p fall
IMPRESSION:
Five views of the left shoulder and the left humerus are provided. There is
no comparison. Minimal degenerative changes at the level of the humeral
glenoid joint. No luxation. No evidence of fracture. No pathologic soft
tissue calcifications.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD.
INDICATION: History: ___ with s/p fall down 14-steps // s/p fall.
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, 16.7 cm; CTDIvol = 48.1 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: No prior imaging studies are available at the time of this
dictation.
FINDINGS:
There is a minimally displaced right occipital bone fracture (03:11), with a
trace amount of adjacent subgaleal hematoma, consistent with the patient's
known history of skull fracture. There is no underlying intracranial
hemorrhage. The adjacent transverse dural venous sinus is normal in appearance
within the limits of this exam without contrast. There is no evidence of
acute large territory infarction,edema,or mass. The ventricles and sulci are
normal in size and configuration. Periventricular and subcortical white
matter hypodensities are nonspecific but likely represent sequelae of chronic
microangiopathic ischemic disease.
The visualized portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. The visualized portion of the orbits are normal.
IMPRESSION:
1. Minimally displaced right occipital bone fracture as described above.
2. There is no evidence of acute intracranial hemorrhage.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST.
INDICATION: History: ___ with s/p fall down 14-steps // s/p fall.
TECHNIQUE: Contiguous axial images obtained through the cervical spine
without intravenous contrast. Coronal and sagittal reformats were reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.7 s, 22.3 cm; CTDIvol = 23.0 mGy (Body) DLP = 511.8
mGy-cm.
Total DLP (Body) = 512 mGy-cm.
COMPARISON: None available.
FINDINGS:
The cervical spine alignment appears maintained. There is an obliquely
oriented fracture of the C7 transverse process with approximately 3 mm of
posterior displacement (602:35). A right occipital bone fracture is better
evaluated on same-day CT head. Articular joint facet hypertrophy with
sclerotic changes is noted at C4-C5 level on the right. Uncovertebral
hypertrophy results in mild left-sided neural foraminal stenosis at C5-C6. A
posterior osteophyte results in mild effacement of the CSF space at C7-T1.
Otherwise, there is is no significant spinal canal or foraminal
narrowing.There is no prevertebral edema.
The thyroid and included lung apices are better evaluated on same-day chest
CT.
IMPRESSION:
1. Mildly displaced fracture of the C7 transverse process.
2. Right occipital bone fracture is better evaluated on same-day head CT.
Radiology Report
EXAMINATION: CT CHEST/ABD/PELVIS W/ CONTRAST
INDICATION: History: ___ with s/p fall down 14-steps // s/p fall
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 9.1 s, 71.6 cm; CTDIvol = 20.7 mGy (Body) DLP =
1,484.0 mGy-cm.
Total DLP (Body) = 1,484 mGy-cm.
COMPARISON: None.
FINDINGS:
CHEST:
HEART AND VASCULATURE: The thoracic aorta is normal in caliber without
evidence of acute injury. The heart is mildly enlarged in size. The
pericardium, and great vessels are within normal limits. No pericardial
effusion is seen.
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: There is minimal dependent atelectasis. Otherwise, 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. There is no evidence of
intrahepatic or extrahepatic biliary dilatation. The gallbladder contains
gallstones without wall thickening or surrounding inflammation.
PANCREAS: There is fatty atrophy of the pancreas, 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: There is mild thickening of the bilateral adrenal glands with no
focal nodularity. There is a 2.0 x 2.6 cm rounded fat density lesion in the
right adrenal gland, consistent with a myelolipoma.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no hydronephrosis bilaterally. A few subcentimeter hypodense lesions
in the left kidney are too small to characterize but likely represent renal
cysts. There is no perinephric abnormality.
GASTROINTESTINAL: Postsurgical changes are seen in the stomach. 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: The uterus and bilateral adnexa 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.
Mild atherosclerotic disease is noted.
BONES: There is a partial compression deformity of the L1 vertebral body.
There is suggestion of a mildly impacted sacral fracture of at approximately
the level of S4. There is a minimally displaced transverse process fracture
at L2. These fractures are most likely chronic.
SOFT TISSUES: Small and flat simple fluid collection is seen in the left
gluteal area superficial fat (02:171).
IMPRESSION:
1. No acute abdominopelvic abnormality.
2. Chronic appearing spinal fractures as above.
3. Small layering collection in the left gluteal soft tissues may be
posttraumatic.
4. 2.6 cm right adrenal myelolipoma. Cholelithiasis.
Radiology Report
EXAMINATION: CT LOW EXT W/O C RIGHT Q61R
INDICATION: ___ year old woman with s/p fall down 14 stairs // Please
evaluate right knee for tibial plateau fracture
TECHNIQUE: CT right lower extremity
DOSE: Acquisition sequence:
1) Spiral Acquisition 7.4 s, 57.9 cm; CTDIvol = 11.9 mGy (Body) DLP = 688.3
mGy-cm.
Total DLP (Body) = 688 mGy-cm.
COMPARISON: None
FINDINGS:
There is an transversely oriented fracture of the anterior tibial plateau with
approximately 4 mm anterior displacement (02:37). In addition, there is an
obliquely oriented nondisplaced fracture through the posterior tibial plateau
originating just medial to the intratrochanteric eminence. There is a
moderate knee joint effusion. No additional fractures are seen. The ankle
mortise is congruent.
IMPRESSION:
1. Mildly displaced transverse fracture of the anteromedial tibial plateau.
2. Nondisplaced oblique fracture of the posterolateral tibial plateau
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Neck pain, R Knee pain, s/p Fall
Diagnosed with Displaced bicondylar fracture of right tibia, init, Fall (on) (from) other stairs and steps, initial encounter
temperature: 97.0
heartrate: 76.0
resprate: 17.0
o2sat: 97.0
sbp: 131.0
dbp: 91.0
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 a nondisplaced right tibial plateau fracture, C7
transverse process fracture, right occipital bone fracture, and
was admitted to the orthopedic surgery service. All of her
injuries can be managed nonoperatively. Her C-spine fracture is
being managed in a hard cervical collar at all times, and her
tibial plateau fracture is managed with an unlocked hinged knee
brace, touchdown weightbearing. The patient's pain was
well-controlled with p.o. pain medication. 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. The patient is touchdown weightbearing in
the right lower extremity, and will be discharged on Lovenox for
DVT prophylaxis while in rehab, to be transition to aspirin 325
mg daily after discharge home. The patient will follow up in the
orthopedic trauma clinic in the orthopedic spine clinic 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: NEUROLOGY
Allergies:
Penicillins
Attending: ___
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is is a ___ year-old Right-handed woman, pmh of
stroke and partial seizures, who presents with a cluster of 7
seisures today. She describes her spells as left face "pulling"
with eye twitching, with each episode lasting 3 mins. She is
conscious for each episode, but notes some difficultly breathing
during the seizure. They started on ___ at 2:30 am. She also
notes occasional numbness in her tongue lasting seconds. She
denies any recent triggers: no recent illness, no change in
sleep
patterns (she has broken sleep every night), but does note
stress
over the last few years since her stroke as she and her husband
both lost their jobs and then had to move 3 times; she's been
living in her current location for less than 1 month. She called
her PCP who recommended she com in for evaluation. She went to
an
OSH, was "given some benzo" and transferred to ___.
She has had seizures only once before, and it was a similar
presentation of cluster. ___ months prior, she was evaluated at
___. She says she had an MRI and an outpatient EEG. She was
given
___ in the hospital but she never heard results of EEG so she
did not take ___ and she was never contacted to followup with
an epilepsy physician. She says her PCP has been trying to
contact ___ re: records without success.
Of note, she has had a headache all day, which she describes as
pressure like vice around her forehead. They usually get better
with tylenol. She says that the headaches are associated with
her
seizures.
Of note, she had two strokes in ___. She describes one as ___
her atrial fibrillation and a second due to a bleed in her head
-
which she states was so severe "it changed the midline of her
brain", required intubation and rehab so she could learn to
speak
again. She describes residual deficits as lack of awareness on
the left side, left sided weakness, and anxiety.
Past Medical History:
2 Strokes (? ischemic and ?hemorrhagic). followed by Dr.
___ at ___
Diagnosed with MS at ___ and went into remission
Atrial Fibrillaiton
Social History:
___
Family History:
heart disease, sister with PD, ___, TIAs, no
seizures in the family.
Physical Exam:
On admission:
Vitals: 97.5 HR 58 BP 142/64 18 95% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits.
Pulmonary: CTABL. No R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G
Abdomen: soft, NT/ND, +BS, no masses or organomegaly noted.
Extremities: nonpitting pedal edema b/l
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.
Speech
was not dysarthric. Able to follow both midline and appendicular
commands. Pt was able to register 3 objects. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: L NLFF
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
-Sensory: No deficits to light touch or proprioception. Endorses
decreased cold in RUE and RLE, decreased pp in RLE and increased
pp in RUE. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor right, upgoing left toe .
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. unsteady with several steps, veers to right. Romberg
absent.
On discharge: exam unchanged from admission
Pertinent Results:
___ 03:30AM GLUCOSE-103* UREA N-15 CREAT-0.6 SODIUM-140
POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-25 ANION GAP-14
___ 03:30AM cTropnT-<0.01
___ 03:30AM CALCIUM-9.3 PHOSPHATE-3.3 MAGNESIUM-2.1
___ 03:30AM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
___ 03:30AM WBC-8.1 RBC-4.10 HGB-12.8 HCT-39.1 MCV-95
MCH-31.2 MCHC-32.7 RDW-13.0 RDWSD-44.8
___ 03:30AM NEUTS-54.5 ___ MONOS-7.8 EOS-2.1
BASOS-0.6 IM ___ AbsNeut-4.40 AbsLymp-2.81 AbsMono-0.63
AbsEos-0.17 AbsBaso-0.05
___ 01:50AM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 01:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-TR
___ 01:50AM URINE RBC-1 WBC-2 BACTERIA-NONE YEAST-NONE
EPI-1
CTA head/neck:
1. No evidence of acute intracranial hemorrhage.
2. No evidence of aneurysm greater than 3 mm, dissection or
vascular
malformation, or significant luminal narrowing.
3. Ascending aorta enlargement, measuring 4.2 cm
EEG: Mildly abnormal portable EEG due to the occasional mixed
frequency
slowing in the right temporal region. This suggests a focal
subcortical
dysfunction in that area but is nonspecific with regard to
etiology. Vascular
disease is one possible cause. There were no epileptiform
features in the
recording.
Medications on Admission:
Metoprolol
Furosemide 40 BID
Warfarin
Potassium 20 mg 4xd
Hydrocodone (?)
Discharge Medications:
1. Diltiazem Extended-Release 120 mg PO DAILY
RX *diltiazem HCl 120 mg 1 capsule(s) by mouth once a day Disp
#*30 Capsule Refills:*3
2. LeVETiracetam 1000 mg PO BID
RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*3
3. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*3
4. Warfarin 4 mg PO DAILY16
5. Furosemide 40 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Epilepsy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neuro: non-focal
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: History: ___ with seizure // eval for pna
TECHNIQUE: Chest PA and lateral
COMPARISON: No prior relevant imaging is available on PACS at the time of
this dictation.
FINDINGS:
The lungs are well-expanded and clear. No focal consolidation, effusion,
edema, or pneumothorax. The heart size is normal. The ascending and
descending thoracic aorta are tortuous and/or ectatic. No acute osseous
abnormality.
IMPRESSION:
1. No pneumonia.
2. Tortuous and/or ectatic thoracic aorta.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK
INDICATION: ___ with seizure // eval for acute process
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of Omnipaque intravenous contrast material. Three-dimensional
angiographic volume rendered, curved reformatted and segmented images were
generated on a dedicated workstation. This report is based on interpretation
of all of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 6.4 s, 16.0 cm; CTDIvol = 56.1 mGy (Head) DLP =
897.1 mGy-cm.
2) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 43.6 mGy (Head) DLP =
21.8 mGy-cm.
3) Spiral Acquisition 5.3 s, 41.7 cm; CTDIvol = 32.0 mGy (Head) DLP =
1,335.9 mGy-cm.
Total DLP (Head) = 2,255 mGy-cm.
COMPARISON: None.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is encephalomalacia of the right frontoparietal and temporal lobes,
secondary to a prior right MCA infarction. Asymmetric decrease in size of the
right thalamus, cerebral peduncle and midbrain is seen, secondary to wallerian
degeneration. There is mild ex vacuo dilatation of the right lateral
ventricle.
There is no evidence of no evidence of acute infarction, hemorrhage, edema, or
mass.
The visualized portion of the mastoid air cells, and middle ear cavities are
clear. Bilateral cataract extractions are seen. There is mucosal thickening
of the left maxillary and ethmoid sinuses.
CTA HEAD:
The vessels of the circle of ___ and their principal intracranial branches
appear normal without stenosis, occlusion or aneurysm formation. The dural
venous sinuses are patent.
CTA NECK: The ascending thoracic aorta measures 4.2 cm. There is mild
atherosclerotic calcification of the aortic arch and branch vessels. Mild
atherosclerotic calcification of the carotid bulbs is also seen. Otherwise,
the carotid and vertebral arteries and their major branches appear normal with
no evidence of stenosis or occlusion. There is no evidence of internal carotid
stenosis by NASCET criteria.
OTHER:
The visualized portion of the lungs are clear. The visualized portion of the
thyroid gland is within normal limits. There is no lymphadenopathy by CT size
criteria. Debris is noted in the bilateral external auditory canals with no
associated osseous erosions, likely representing cerumen. Degenerative
changes are noted throughout the visualized spine.
IMPRESSION:
1. No evidence of acute intracranial hemorrhage.
2. No evidence of aneurysm greater than 3 mm, dissection or vascular
malformation, or significant luminal narrowing.
3. Ascending aorta enlargement, measuring 4.2 cm.
Radiology Report
EXAMINATION: Chest radiograph.
INDICATION: ___ year old woman with seizure and afib on Coumadin //
?infection
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___
FINDINGS:
The aorta is ectatic and/or tortuous. Heart size is within normal limits.
The lung fields are clear. Soft tissues are unremarkable.
IMPRESSION:
No acute cardiopulmonary abnormality.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Seizure, Transfer
Diagnosed with Epilepsy, unsp, not intractable, without status epilepticus
temperature: 97.5
heartrate: 58.0
resprate: 20.0
o2sat: 95.0
sbp: 124.0
dbp: 65.0
level of pain: 0
level of acuity: 3.0 | ___ is a ___ woman with ischemic strokes ___ afib
on warfarin, hemorrhagic stroke, and partial seizures likely ___
prior strokes who presents with increased seizure frequency. Was
previously started on ___ when she had this before but did
not fill the prescription as she did not know what it was for.
Exam nonfocal. Triggered for afib with tachycardia to 120s-130s,
which is baseline for her and happens often at night, can wake
her out of sleep as it did ___. Sees a cardiologist for
management, too much metoprolol makes her hypotensive so unable
to titrate up. Diltiazem 30mg started, pt came out of afib. CTA
head/neck negative for acute intracranial abnormality/aneurysm,
did see incidental ascending aorta enlargement measuring 4.2 cm.
Started on ___ 1000mg BID, no side effects. Discharged home
with neurology follow up.
1. Epilepsy
- continue ___ 1000mg po BID
- counseled patient on taking her seizure medications, also
explained to her the diagnosis of epilepsy in the setting of
prior strokes.
2. Atrial fibrillation
- continue metoprolol succinate 25mg qd
- continue diltiazem ER 120mg po qd
- metoprolol 5mg IV q6h prn for HR>130
- continue warfarin
3. Fluid overload that can lead to SOB, ?CHF, no echo on record
here
- holding home Lasix 40mg po BID
- f/u cardiology as outpatient |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / bee sting / Zosyn / vitamin K2
Attending: ___
Chief Complaint:
Abnormal Labs
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ M h/o ETOH cirrhosis c/b HE listed for transplant, DVT/PE on
Coumadin, and bilateral lower extremity venous insufficiency,
presenting because of lab abnormalities at transplant clinic.
Pt went to transplant clinic on the day prior to admission
where routine labs revealed ___ to Cr 1.5, hypoNa 131, and rise
in bilirubin from 12 to 16. He is being admitted to the
hepatology service for repeat labs and an infectious workup.
Of note, the patient recently was discharged after prolonged
hospitalization (___) for hepatic encephalopathy, ___
initially admitted to the ICU, course c/b by fevers and proximal
weakness. He initially presented to ___ because of
generalized body pain and fatigue. No infectious cause was found
despite extensive workup, so he may have had a viral illness.
The weakness was evaluated by neurology and felt to be related
to his hepatic encephalopathy. He was discharged home with ___
because his insurance wouldn't cover rehab. He had fever after
IV vitamin K infusion and ?anaphylactic reaction to Zosyn during
his admission. His ___ was successfully treated with albumin and
he was discharged with Cr 1.1 on ___. He was on a stable
regimen of spironolactone 150 and furosemide 80 several days
prior to discharge. His nadolol was dose reduced to 20mg daily
given soft blood pressures and the ___.
Since his discharge on ___, the patient has felt well. He has
been taking his medications as prescribed, including the lower
dose of nadolol 20mg daily. He has been eating and drinking
normally. He does not have a fluid restriction. He notes about
___ BMs per day with only one dose of lactulose daily (plus
rifaximin). He has not been confused or disoriented but does
note difficulty sleeping through the night, which has been
ongoing for ___ year. He denies fever, chills, abdominal pain, abd
distension, worsening ___ edema, hematochezia, melena, hematuria,
chest pain, shortness of breath. Of note, his warfarin was
stopped during the last admission and he has NOT restarted it at
home.
In the ED, initial vital signs were: 0 97.2 69 121/62 18 99% RA
- Exam was notable for: scleral icterus, bibasilar crackles, 2+
___ edema, nontender abdomen, guiaiac positive stool.
- Labs were notable for: Anemia of ___ which was stable on
re-check, Na 129, Cr 1.4, Tbili 14.9, INR 2.9
- Imaging: RUQ ultrasound showed coarsened hepatic echotexture
in keeping with cirrhosis. Splenomegaly and portosystemic
collaterals are consistent with portal hypertension. No focal
liver lesion.
No ascites.
Patent main portal vein appropriate in directional flow.
CXR showed no significant interval change. No pulmonary edema.
- The patient was given: 1L NS at 125cc/hr when BP dropped to
85/40.
- Consults: Hepatology recommended admission to hepatology
Vitals prior to transfer were: 0 76 100/54 18 97% RA
Upon arrival to the floor, the NS at 125cc/hr that had been
started in the ED was stopped. The patient felt well.
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,
constipation, BRBPR, melena, hematochezia, dysuria, hematuri
Past Medical History:
Past Medical History: As HPI. ETOH cirrhosis with prior episodes
of encephalopathy; diverticulitis, GERD, bilateral lower
extremity edema and venous ulcerations, depression, HTN, history
of DVT/PE on coumadin, C difficile, history ___
Past Surgical History: R knee surgery, skin grafting LLE, EGD hx
of GE varix banding
Social History:
___
Family History:
Negative for liver disease. No major alcohol history in the
family. No cancer in the family. Does have family history of
blood clots.
Physical Exam:
ADMISSION PHYSICAL EXAM:
===========================
VS: 98.3F BP 115-121/76-80 HR ___ RR 18 98% RA
General: Sitting up in bed in NAD
HEENT: MMM, icteric sclera, EOMI, visible spider angiomata on
face.
Neck: Soft, supple, full ROM, no rashes noted. + spider
angiomata on chest.
CV: Normal rate, regular rhythm, soft systolic murmur loudest at
the base.
Lungs: clear to auscultation but with decreased breath sounds at
bases with trace crackles
Abdomen: Soft, nontender, active bowel sounds, domed abdomen. No
rebound or guarding.
Ext: 1+ edema to below knee with chronic venous stasis changes,
minimally tender over shins , no other rashes
Neuro: Ax0 x3, no asterixis
DISCHARGE PHYSICAL EXAM:
==========================
VS: Tc ___ BP 115-121/64 RR18 HR ___ 96-100% RA
___ BMs
112kg (246 lbs), last clinic weight 260 lbs
General: sitting up in bed, in NAD
HEENT: MMM, icteric sclera, EOMI, visible spider angiomata on
face.
Chest: right small ecchymosis, demarcated non tender, no
expansion
Neck: Soft, supple, full ROM, no + spider angiomata
CV: Normal rate, regular rhythm, soft systolic murmur loudest at
the base
Lungs: CTAB, breathing air to bases, no wheezes or crackles
Abdomen: Soft, nontender, active bowel sounds, No rebound
Ext: minimal edema to below knee with chronic venous stasis
changes, no asymmetry, non tender
Neuro: Ax0 x3, no asterixis
Pertinent Results:
ADMISSION LABS:
================
___ 12:52PM BLOOD WBC-6.6 RBC-2.62* Hgb-9.2* Hct-28.6*
MCV-109* MCH-35.1* MCHC-32.2 RDW-20.5* RDWSD-81.9* Plt Ct-54*
___ 12:52PM BLOOD Neuts-68.8 Lymphs-11.8* Monos-13.0
Eos-4.4 Baso-1.1* Im ___ AbsNeut-4.51 AbsLymp-0.77*
AbsMono-0.85* AbsEos-0.29 AbsBaso-0.07
___ 12:52PM BLOOD ___
___ 12:52PM BLOOD UreaN-33* Creat-1.5* Na-131* K-4.7 Cl-96
HCO3-25 AnGap-15
___ 12:52PM BLOOD ALT-18 AST-48* AlkPhos-58 TotBili-16.2*
___ 04:00PM BLOOD Albumin-3.4* Calcium-10.4* Phos-3.5
Mg-1.7
Other Labs
=============
___ 05:05AM BLOOD calTIBC-118* Hapto-<5* Ferritn-304
TRF-91*
___ 05:05AM BLOOD PTH-12*
___ 05:05AM BLOOD 25VitD-31
___ 12:52PM BLOOD AFP-3.2
___ 12:52PM BLOOD Ethanol-NEG
Discharge Labs
================
___ 06:31AM BLOOD WBC-3.6* RBC-2.33* Hgb-8.2* Hct-25.1*
MCV-108* MCH-35.2* MCHC-32.7 RDW-20.6* RDWSD-81.1* Plt Ct-31*
___ 06:31AM BLOOD ___ PTT-49.9* ___
___ 06:31AM BLOOD Glucose-96 UreaN-14 Creat-0.9 Na-131*
K-4.3 Cl-98 HCO3-24 AnGap-13
___ 06:31AM BLOOD ALT-19 AST-51* LD(LDH)-188 AlkPhos-57
TotBili-13.4*
___ 11:06PM URINE Color-Amber Appear-Hazy Sp ___
___ 11:06PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-NEG pH-5.5 Leuks-NEG
___ 11:06PM URINE Hours-RANDOM UreaN-686 Creat-138 Na-21
K-44 Cl-13
Micro
=======
___ 2:30 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
___ 11:06 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: <10,000 organisms/ml.
___ 4:00 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Imaging
================
Chest Xray ___
Heart size normal. Lungs clear. No pleural abnormality.
Liver ultrasound ___
IMPRESSION:
Coarsened hepatic echotexture in keeping with cirrhosis.
Splenomegaly and
portosystemic collaterals are consistent with portal
hypertension. No focal liver lesion. No ascites. Patent main
portal vein with appropriate directional flow.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325 mg PO Q6H:PRN pain
2. Furosemide 80 mg PO DAILY
3. Lactulose 30 mL PO TID
4. Pantoprazole 40 mg PO Q24H
5. Rifaximin 550 mg PO BID
6. Spironolactone 150 mg PO DAILY
7. Vitamin D ___ UNIT PO DAILY
8. FoLIC Acid 1 mg PO DAILY
9. Thiamine 100 mg PO DAILY
10. Nadolol 20 mg PO DAILY
11. Magnesium Oxide 400 mg PO TID
Discharge Medications:
1. Acetaminophen 325 mg PO Q6H:PRN pain
2. FoLIC Acid 1 mg PO DAILY
3. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Lactulose 30 mL PO TID
5. Nadolol 10 mg PO DAILY
RX *nadolol 20 mg 0.5 (One half) tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
6. Pantoprazole 40 mg PO Q24H
7. Rifaximin 550 mg PO BID
8. Spironolactone 100 mg PO DAILY
RX *spironolactone 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
9. Thiamine 100 mg PO DAILY
10. Vitamin D ___ UNIT PO DAILY
11. Magnesium Oxide 400 mg PO TID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
-Acute Renal failure
-Hyponatremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with renal failure, cirrhosis, recent 2wk admission
// assess for fluid in lungs
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
No new focal consolidation is seen. No pleural effusion or pneumothorax is
seen. The cardiac and mediastinal silhouettes are stable. No pulmonary edema
is seen.
IMPRESSION:
No significant interval change. No pulmonary edema.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ with etOH cirrhosis, transplant list, abdominal distension.
// ? portal vein thrombosis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Ultrasound dated ___
FINDINGS:
Limited ultrasound examination of the right upper quadrant was performed.
Overlying bowel gas obscures the pancreas and a majority of the left hepatic
lobe. The right hepatic lobe appears coarsened and nodular in keeping with
history of cirrhosis. There is no intrahepatic duct dilation. No focal
lesion is identified. The common bile duct measures 3 mm. The spleen is
enlarged measuring 18 cm without a focal lesion. Limited images of the right
kidney demonstrate no hydronephrosis. Portosystemic collaterals are present
with recannulized umbilical vein. Findings are in keeping with portal
hypertension. The main portal vein appears patent and hepatopetal in flow.
There is no ascites.
IMPRESSION:
Coarsened hepatic echotexture in keeping with cirrhosis. Splenomegaly and
portosystemic collaterals are consistent with portal hypertension. No focal
liver lesion.
No ascites.
Patent main portal vein with appropriate directional flow.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with alcoholic cirrhosis on transplant list,
admitted for ___, now with worsening cough // eval for pulm edema vs
pneumonia eval for pulm edema vs pneumonia
IMPRESSION:
Compared to chest radiographs since ___, most recently ___.
Heart size normal. Lungs clear. No pleural abnormality.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by WALK IN
Chief complaint: Abnormal labs
Diagnosed with Abn lev hormones in specimens from female genital organs, Acute kidney failure, unspecified
temperature: 97.2
heartrate: 69.0
resprate: 18.0
o2sat: 99.0
sbp: 121.0
dbp: 62.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ is a ___ year old gentleman with a past medical
history significant for EtOH cirrhosis complicated by hepatic
encephalopathy and esophageal varices/portal HTN, DVT/PE on
coumadin with MELD of 34 on presentation currently listed for
liver transplant who presented because of lab abnormalities
including acute kidney injury, rising bilirubin, and
hyponatremia.
# Hyponatremia: Low initially, then became normal after albumin.
Once diuretics were started sodium decreased slightly on day of
discharge to 131. Because of this diuretics were significantly
decreased to lasix 40mg and aldactone 50mg from admission of
80/150 respectively.
# Acute kidney injury: This was likely was related to
overdiuresis, as he had no evidence of bleed vs. infection vs.
HRS. He denied any infectious symptoms, and had no obvious
bleeding. His hemoglobin was higher than his previous discharge.
Overdiuresis was likely given his resolved edema. He received
two days of albumin with improved creatinine. His diuretics were
adjusted per above.
# Indirect Bilirubinemia: He presented with increasing
bilirubin, concerning for infection vs hemolysis, as he had
primarily an indirect component. Indirect bilirubinemia may be
sign of worsening hepatic uptake and conjugation. His labs were
consistent with hemolysis, his peripheral smear was not
concerning for a hematologic process and had only rare
abnormalities. His bilirubin downtrended by day of discharge.
# PE/DVT/COAGULOPATHY: His INR on admission 3.0 off warfarin.
His INR goal was 3 given his VTE history. He was found to have
spontaneous ecchymosis. He was given no Coumadin, given his
bleeding. He was not reversed given his history of VTE. His
discharge INR was 3.2.
# Hypercalcemia: PTH slightly low at 12, vitamin D level pending
at discharge. The differential was thought to be malignancy
related, thyroid disease, adrenal disease (normal cortisol in
past). He should have vitamin D level followed. Further workup
should be considered as an outpatient.
# HEPATIC ENCEPHALOPATHY: Patient has had history of recent
admission with encephalopathy, required NG tube and lactulose,
since then he has been alert and oriented, having multiple bowel
movements. He had no issues with this during this
hospitalization and was continued on lactulose and rifaxamin.
# GIB/VARICES: Has had banding in the past as well as a history
of GAVE. He was resumed on nadolol though at a lower dose of
10mg daily.
# CIRRHOSIS: Secondary to ETOH. MELD 34 on admission. On
transplant list.
# Chronic Macrocytic anemia: Likely from chronic hemolysis, he
did not require transfusions.
Transitional
===============
-Discharge creatinine: 0.9
-Discharge sodium: 131
-Given hyponatremia, aldactone dose decreased to 50 mg from 100
mg to avoid over diuresis, furosemide decreased to 40 from 80 mg
-Nadolol decreased given admission with ___ to 10mg daily from
20mg daily
-Patient's warfarin was held due to therapeutic INR associated
with worsening liver disease. However, it is important for his
INR to be measured consistently, given history of DVT and PE and
need to be within INR of ___. Please resume as clinically
indicated.
-Had high calcium intermittently, with low PTH, and vitamin D
pending at discharge. He should have further workup as deemed
necessary for his calcium levels if the continue to be elevated.
-Will email Liver transplant coordinators to setup follow up
with Dr. ___ in one week. At this visit he should have full
set of labs repeated including CBC, Chemistry panel, INR, and
liver function panel |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
traumatic left subdural hematoma
Major Surgical or Invasive Procedure:
___: Left craniotomy for subdural hematoma evacuation
___: Tracheostomy and percutaneous endoscopic gastrostomy
History of Present Illness:
This is a ___ man with a history of alcohol use disorder
with recent admission to ___ for frequent falls, R SDH,
alcohol withdrawal requiring ICU stay and thrombocytopenia
requiring platelet transfusion who presents with L SDH with
midline shift.
History obtained from OSH records and patient's wife as patient
is unable to provide any history. By report, he has been having
multiple falls in the last few weeks and in fact local fire
rescue went to his house on the day of admission to help him up
and he had some mild abrasions but he refused transfer to the
hospital. He was reportedly awake and oriented and appeared
normal. When wife returned home from the grocery store, she
arrived to find EMS in the house. She thinks her husband must
have pressed his life alert button to call them. He was
reportedly seizing and was unresponsive on arrival to ___,
with multiple abrasions on his left elbow and chest, presumably
from another fall. He had a second brief generalized
tonic-clonic seizure and CT scan that lasted less than 60
seconds and self terminated. He was treated with unknown dose of
Ativan and intubated for airway protection. CT scan revealed
large left acute SDH with midline shift. He received Mannitol
25g and was transferred to ___ for further management.
On arrival to ___, he was evaluated by neurosurgery, who made
the decision to take him to the OR for immediate left
craniotomy. Exam prior to OR was notable for asymmetric pupil
and flexor posturing of bilateral upper extremities. He was
given additional mannitol 50g and 1 unit of platelets. Platelets
287 on arrival.
Of note, he was recently admitted to the ICU at ___ from
___ with alcohol withdrawal symptoms after stopping
drinking a few days prior.
Past Medical History:
- ETOH disorder c/b anemia, esophageal varices and pancytopenia
- Opioid use disorder
- Frequent falls
- Colon polyp in ___
- Lumbar radiculopathy
- Anxiety
- Actinic keratosis
- Basal cell carcinoma
- S/p left total hip replacement complicated by postop DVT
Social History:
___
Family History:
Noncontributory.
Physical Exam:
On Admission:
-------------
Physical Exam:
O: T: 97.1 BP: 140/90 HR: 90 RR: 20 O2 Sat:
100%intubated
GCS at the scene: unknown
GCS upon Neurosurgery Evaluation: 7t Time of evaluation: ___
Airway: [x]Intubated [ ]Not intubated
Eye Opening:
[x]1 Does not open eyes
[ ]2 Opens eyes to painful stimuli
[ ]3 Opens eyes to voice
[ ]4 Opens eyes spontaneously
Verbal:
[x]1 Makes no sounds
[ ]2 Incomprehensible sounds
[ ]3 Inappropriate words
[ ]4 Confused, disoriented
[ ]5 Oriented
Motor:
[ ]1 No movement
[ ]2 Extension to painful stimuli (decerebrate response)
[ ]3 Abnormal flexion to painful stimuli (decorticate response)
[ ___ Flexion/ withdrawal to painful stimuli
[x]5 Localizes to painful stimuli
[ ]6 Obeys commands
Exam:
Gen: WD/WN, comfortable, NAD.
HEENT: Significant facial trauma, bilateral periorbital
ecchymosis & edema
Neck: Cervical collar
Extrem: Scattered abrasions and skin tears
Neuro: No eye opening. R pupil 2mm, nonreactive. Right corneal
absent. L pupil 2mm reactive, corneal present. +cough/gag.
localizing uppers, withdrawing lowers. not overbreathing vent.
On Discharge:
-------------
General: chronically ill-appearing man, thin
HEENT: normocephalic, left craniotomy, +Trach
CV: Regular rate and rhythm
Lungs: diminished in bases
Abdomen: soft, nontender, nondistended. +PEG
GU: deferred
Ext: contractures of the hands
Skin: multiple scattered bruises and abrasions
Neuro:
MS- Briefly EO to voice or noxious, will regard when eyes open.
follows commands in all extremities (weakest in RUE)
CN- Pupils 3->2 mm, + corneals, + cough, impaired gag
Sensory/Motor-
RUE: withdraws to noxious or moves plane of bed to command
LUE: shows thumbs up
RLE: wiggles toes to command, bends up knees to command
LLE: wiggles toes to command, bends up knees to command
Pertinent Results:
Please see OMR for relevant laboratory and imaging results.
___ 12:36AM BLOOD WBC-7.2 RBC-2.52* Hgb-7.8* Hct-24.1*
MCV-96 MCH-31.0 MCHC-32.4 RDW-13.7 RDWSD-48.5* Plt ___
___ 08:10PM BLOOD WBC-11.6* RBC-2.39* Hgb-7.6* Hct-23.1*
MCV-97 MCH-31.8 MCHC-32.9 RDW-14.8 RDWSD-52.1* Plt ___
___ 12:36AM BLOOD ___ PTT-40.5* ___
___ 08:10PM BLOOD ___ PTT-35.6 ___
___ 12:36AM BLOOD Glucose-127* UreaN-18 Creat-0.6 Na-139
K-4.1 Cl-108 HCO3-21* AnGap-10
___ 12:36AM BLOOD ALT-6 AST-14 LD(LDH)-194 AlkPhos-120
TotBili-0.2
___ 12:36AM BLOOD Albumin-2.6* Calcium-8.0* Phos-4.8*
Mg-1.8
___ 09:14AM BLOOD Vanco-23.2*
CT Chest:
An oblong thick-walled fluid filled cavity is noted in the left
lung. It is unclear whether this is a loculated empyema in the
left major
fissure or an intraparenchymal cavity given that this is in
close proximity to a mostly collapsed left lower lobe.
These appear to be in the same location as a previous pigtail
catheter.
Please note that after removal or the prior left-sided pigtail
catheter, there is still a small residual ipsilateral
pneumothorax.
Ground-glass opacities in the posterior segment and a small
cavity in the anterior segment of the left upper lobe are
indeterminate at this moment and could represent re-expansion
edema, contusion in the setting of prior trauma or concurrent
infection
Medications on Admission:
Acetaminophen PRN
Trazodone 25mg QHS PRN
Sucralfate 1g QID
Naltrexone 50mg BID
Pantoprazole 40mg BID
Folic acid 1mg daily
Thiamine 100mg daily
Guaifenisin 600mg BID
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever
2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN Shortness of
breath, wheezing
3. Docusate Sodium 100 mg PO BID
4. Ertapenem Sodium 1 g IV 1X Duration: 1 Dose
1g every 24 hours. Projected End Date: ___
5. FoLIC Acid 1 mg PO DAILY
6. Heparin 2500 UNIT SC DAILY
7. HydrALAZINE ___ mg IV Q6H:PRN SBP > 160
8. LevETIRAcetam Oral Solution 1000 mg PO BID
9. Metoprolol Tartrate 25 mg PO Q6H
10. Multivitamins W/minerals 15 mL PO DAILY
11. Pantoprazole (Granules for ___ ___ 40 mg PO DAILY
12. Senna 8.6 mg PO BID:PRN Constipation - First Line
13. Sodium Chloride 0.9% Flush ___ mL IV Q8H and PRN, line
flush
14. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
15. Thiamine 100 mg PO DAILY
16. Vancomycin 1000 mg IV Q 24H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
- Traumatic brain injury, traumatic left subdural hematoma
- Respiratory failure requiring tracheostomy
- left sided lung abscess/necrotizing pneumonia
- bacteremia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CR - CHEST PORTABLE AP
INDICATION: History: ___ intubated, OG tube placement
TECHNIQUE: AP radiograph of the chest.
COMPARISON: None.
IMPRESSION:
The endotracheal tube terminates 4.6 cm above the carina. The orogastric tube
terminates in the body of the stomach.
There is no focal consolidation, pleural effusion or pneumothorax. The
cardiomediastinal silhouette is within normal limits. No acute osseous
abnormalities are identified.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with left SDH s/p evacuation, intubated// eval
for interval change
IMPRESSION:
In comparison with the study of ___, the monitoring and support devices
are unchanged. Cardiomediastinal silhouette is within normal limits and there
is no vascular congestion, pleural effusion, or acute focal pneumonia.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with acute left subdural hematoma s/p craniotomy
and evacuation. Evaluate post op changes.
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 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.3 mGy-cm.
Total DLP (Head) = 747 mGy-cm.
COMPARISON: Outside reference CT head from ___.
FINDINGS:
Patient is status post left frontal craniotomy for large subdural hematoma
evacuation, with expected postoperative changes including moderate volume
pneumocephalus. There is a minimal step-off along the posterior aspect of the
craniotomy, image 301:36.
Residual left extra-axial collection of air, fluid, and small amount of blood
measures 16 mm at the level of the left frontal lobe on image 2:17, 13 mm at
the level of the left temporal lobe on image 2:8. There is also trace
residual subdural blood along the falx and tentorium.
There has been substantial improvement in previously seen rightward shift of
midline structures, now measuring 4 mm, previously 19 mm. There is
significantly decreased effacement of the left lateral and third ventricles,
and left hemispheric sulci. Left uncal herniation has substantially improved
and nearly resolved.
There is a 5 x 6 mm focus of blood in the left posterior cingulate gyrus,
images 2:18 and 602:47, with minimal surrounding edema and no significant mass
effect, not clearly seen on the prior study, though this area was compressed
and not well evaluated on the prior study.
No evidence for an acute major vascular territorial infarction.
There is mild mucosal thickening in the ethmoid air cells, sphenoid sinuses
and maxillary sinuses. There is trace fluid in the left sphenoid sinus and
partially imaged right maxillary sinus. There is mild-to-moderate mucosal
thickening in the partially imaged left maxillary sinus, and mild mucosal
thickening in the bilateral sphenoid sinuses, ethmoid sinuses, and
frontoethmoidal recesses. Mastoid air cells appear grossly clear. The orbits
appear grossly unremarkable.
IMPRESSION:
1. Status post left frontal craniotomy with minimal step-off along the
posterior aspect of the craniotomy flap.
2. Status post evacuation of left subdural hematoma with a residual left
extra-axial collection of air, fluid, and small amount of blood.
Substantially improved mass effect with significantly decreased left uncal
herniation, decreased shift of midline structures, decreased effacement of the
left lateral and third ventricles, and of the hemispheric sulci
3. 6 mm oval focus of blood in the left posterior cingulate gyrus with minimal
surrounding edema and no significant mass effect, not clearly seen on the
prior CT, though this area was compressed and not well evaluated on the prior
CT.
NOTIFICATION: The additional finding in impression items 3, not included in
the electronic preliminary report provided by Dr. ___ on ___ at
02:46, were discussed with ___, M.D. by ___, M.D.
on the telephone on ___ at 2:22 pm, 2 minutes after discovery of the
findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with SDH, intubated// Eval for new consolidation,
edema Eval for new consolidation, edema
IMPRESSION:
Compared to chest radiographs ___.
Lungs clear. Heart size normal. Normal hilar and mediastinal contours and
pleural surfaces.
ET tube and nasogastric drainage tube in standard placements.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with SDH// Eval for reaccumulation of SDH. Please
perform 4pm ___
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 11.0 s, 19.3 cm; CTDIvol = 47.6 mGy (Head) DLP =
917.0 mGy-cm.
Total DLP (Head) = 930 mGy-cm.
COMPARISON: CT head without contrast performed earlier on the same day at
02:19 a.m. on ___ under MRN ___.
FINDINGS:
Again, patient is status post left frontal craniotomy for evacuation of
subdural hemorrhage. There is interval decrease in left frontal
pneumocephalus, measuring 1.0 cm in greatest thickness, previously 1.6 cm (3;
20). Trace hyperdense fluid in the left frontal extra-axial space is again
demonstrated (3; 34). Interval decrease in right frontal pneumocephalus with
stable hypodense 5 mm right frontal extra-axial fluid collection similar to
prior. A hypodense extra-axial right parietal fluid collection measuring 1.2
cm in greatest thickness is similar to prior. There is also interval decrease
in rightward midline shift, measuring 2 mm, previously 4 mm (3; 21).
Re-demonstration of left occipital 6 mm intraparenchymal hemorrhage, similar
to prior (3; 26). 4 mm hyperdensity, likely hemorrhage, in the right corpus
callosum (3; 26) is similar to prior. No new foci of hemorrhage.
No evidence of large vascular territory infarction. There is interval
significant improvement in effacement of the left lateral ventricle. Basal
cisterns appear patent. There is improvement effacement of the left
hemispheric sulci.
Postsurgical changes are again noted in the left frontoparietal soft tissues
skin staples, subcutaneous edema, and subcutaneous gas, similar to slightly
improved compared to prior. Mild mucosal thickening of the left maxillary
sinus is noted. 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:
1. Status post left frontal craniotomy with interval improvement in bilateral
frontal pneumocephalus and decrease in left frontal extra-axial fluid
collection with residual hyperdense blood products, similar to prior.
Hypodense extra-axial fluid collections in the right frontal and right
parietal regions are similar to prior. Subcentimeter hyperdense foci in the
right corpus callosum and left occipital lobe are similar to prior, likely
representing intraparenchymal hemorrhage. No new foci of hemorrhage.
2. Substantial interval improvement and rightward midline shift, now minimal,
measuring 2 mm.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: ___ year old man with fall// Eval for fracture/misalignment
Eval for fracture/misalignment
re-eval SDH for evolution, eval for cspine 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: Total DLP 527.5 mGy-cm.
COMPARISON: CT C-spine ___.
FINDINGS:
Grade 1 retrolisthesis of C4 on C5 is similar to prior. No traumatic
malalignment.No fractures are identified.There is no prevertebral soft tissue
swelling.
Mild-to-moderate degenerative changes are noted, most notable from C4-C5
through C7-T1 with disc space narrowing, end plate osteophyte formation, and
ossification of the posterior longitudinal ligament. There is osseous fusion
of the left C3-C4 facet joint, similar to prior.
At C2-C3, there is mild spinal canal narrowing. At C5-C6, there is mild to
moderate spinal canal narrowing. There is moderate left C3-C4 neural
foraminal narrowing, moderate right C4-C5 neural foraminal narrowing, and
bilateral moderate C5-C6 neural foraminal narrowing.
ET tube and enteric tube are partially visualized. Visualized thyroid and
bilateral lung apices appear unremarkable. Multiple severe dental caries are
noted in both the maxillary and mandibular teeth.
IMPRESSION:
1. No evidence of cervical spine fracture or traumatic malalignment.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with SDH// Assess ETT position and for any
pulmonary congestion or edema
TECHNIQUE: Portable AP semi-erect
COMPARISON: Multiple prior chest radiographs dating back to ___
through ___
FINDINGS:
Endotracheal tube tip terminates 5 cm above the carina, similar to prior.
Gastric tube terminates in the stomach.
Lungs are well aerated. No focal consolidations or pulmonary edema.
Cardiomediastinal silhouette is normal. There is no pleural effusion or
pneumothorax.
IMPRESSION:
Endotracheal tube terminating 5 cm above the carina, should not be withdrawal
any further. No pulmonary edema.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with ___ man with a history of alcohol
use disorder p/w L SDH with mildline shift s/p craniotomy for SDH evacuation
in setting of multiple falls.// assess for PNA assess for PNA
IMPRESSION:
Compared to chest radiographs since ___, most recently ___.
ET tube in standard placement. Nasogastric tube passes below the diaphragm
and out of view.
Healed fractures lateral aspect left middle ribs. Lungs clear. Heart size
normal.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with SDH// NGT placement Contact name: ___
___, NP, ___: ___
TECHNIQUE: Single frontal view of the chest
COMPARISON: Chest radiograph ___
FINDINGS:
The endotracheal tube terminates approximately 5 cm above the carina. An
enteric tube extends beyond the GE junction with tip terminating in the
proximal stomach the left upper quadrant. Cardiac size is normal. The lungs
are clear. There is no pneumothorax or pleural effusion.
IMPRESSION:
The enteric tube terminates in the proximal stomach.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with SDH// assess for pulmonary edema or
congestion, was extubated at 1600 today. assess for pulmonary edema or
congestion, was extubated at 1600 today.
IMPRESSION:
Comparison to ___. The course of the feeding tube is
unremarkable. No pulmonary edema, no pleural effusions, no pneumonia. No
pneumothorax. Normal size of the heart.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with possible pneumonia, recently extubated//
interval changes
TECHNIQUE: Chest PA and lateral
COMPARISON: ___ and CT chest ___.
FINDINGS:
NG tube terminates in the stomach.
Lungs are well expanded. Increased peribronchovascular opacities in the right
lower lobe and probably in the right lower lobe. No pulmonary edema, pleural
effusions or pneumothorax. Cardiomediastinal silhouette is normal.
IMPRESSION:
Probable early pneumonia or recent aspiration, right lower lobe worse than
left.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with possible aspiration PNA// evaluation of
interval change evaluation of interval change
IMPRESSION:
Compared to chest radiographs ___ through ___ one.
Opacification at the left lung base developed on ___ one and has not
cleared. This could be atelectasis alone but pneumonia is certainly a
possibility.
Moderate left pneumothorax is new, without obvious explanation.
Right lung is clear. Heart size is normal. ET tube tip only 2.5 cm from the
carina should not be advanced further. Nasogastric drainage tube passes into
the stomach and out of view.
Electronic device projecting over the left upper chest is not from earlier
may, nor is the lead extending from at over the left shoulder.
NOTIFICATION: The findings were discussed with ___, M.D. by ___,
M.D. on the telephone on ___ at 12:23 pm, 1 minutes after discovery of
the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with SDH s/p evac. Was reintubated at 9AM// tube
placement tube placement
IMPRESSION:
Compared to chest radiographs ___.
New heterogeneous opacification and mild volume loss left lower lobe suggest
atelectasis due to aspiration.
Tip of the endotracheal tube is at the carina and should be withdrawn 3.5 cm.
Heart size normal. No pleural abnormality.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 11:49 am, 1 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with SDH// ETT pulled back 2cm
IMPRESSION:
In comparison with the earlier study of this date, the tip of the endotracheal
tube now measures approximately 2.2 cm above the carina. Since the position
of the chin cannot be determined on this study, it would probably be safe to
pull the endotracheal tube back another 1-1.5 cm.
Otherwise, little change.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with SDH// evl ETT evl ETT
IMPRESSION:
ET tube tip is 2 cm above the carinal. NG tube tip is in the stomach. Left
pigtail catheter is in place. There is interval substantial improvement in
the aeration of the left lower lobe with only minimal atelectasis still
present. No appreciable pneumothorax is seen but there are outside devise is
projecting over the left apex. No right apical pneumothorax is present.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with SDH, intubated// eval ETT, ro pna
IMPRESSION:
In Comparison with the study of ___, there again is an area of lucency
medially in the left hemithorax sharply outlining the cardiac silhouette and
hemidiaphragm. This is consistent with a medial and basilar pneumothorax,
which could well be loculated. Although there is no lateral view, the pigtail
catheter does not appear to be positioned so as to drain this region.
Otherwise, little change.
NOTIFICATION: The neuro resident covering for Dr. ___ has all other
day repeat a frontal radiograph with lateral view.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with SDH req intubation ___ now w new
pneumothorax s/p chest tube placement// baseline after chest tube placement
baseline after chest tube placement
IMPRESSION:
Compared to chest radiographs ___ through ___.
Left pneumothorax has been evacuated with insertion of a new, lateral entry,
mid level left pigtail pleural drainage catheter. Left lower lobe atelectasis
or consolidation persists. Right lung clear. Heart size normal. Tip of the
endotracheal tube isd 2.5 cm above the carina. It could be withdrawn another
2.5 cm to avoid unilateral intubation.
Radiology Report
EXAMINATION: CR - CHEST PORTABLE AP
INDICATION: ___ year old man with pigtail cath s/p on water seal 1100AM//
Check after placed to water seal in 4 hrs. 3PM
TECHNIQUE: AP radiograph of the chest.
COMPARISON: Chest radiograph ___ at 05:20.
IMPRESSION:
The support lines and tubes are in stable position. No pneumothorax is
identified although evaluation is limited by overlying devices. There is an
unchanged opacity in the left midlung, which most likely represents
atelectasis. The right lung is clear. The cardiomediastinal silhouette is
stable in appearance. No acute osseous abnormalities are identified.
Radiology Report
EXAMINATION: CR - CHEST PORTABLE AP
INDICATION: ___ year old man with increasing secretions// eval pleural
effusion
TECHNIQUE: AP radiograph of the chest.
COMPARISON: Chest radiograph ___ at 15:18.
FINDINGS:
No significant interval change compared to most recent prior study from
earlier today. The endotracheal tube and left pigtail catheter are in stable
position. An enteric tube crosses the diaphragm and terminates outside of the
field of view. There is no pneumothorax or large pleural effusion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with SDH, intubated. Chest tube for pneumo//
interval changes interval changes
IMPRESSION:
Comparison to ___. The left-sided pigtail catheter is in stable
position. There is no recurrent left pleural effusion. A small predominantly
basal and medial pneumothorax on the left continues to be present. Left lung
bases appears minimally better ventilated than on the previous image. The
endotracheal tube tip is within 1 cm of the carinal, the device should be
pulled back by approximately 3 cm.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with SDH// Chest tube remains on water seal,
evaluate pneumothorax
IMPRESSION:
In comparison with the earlier study of this date, there is now only a thin
area of lucency along the left lateral chest wall an outer aspect of the left
hemidiaphragm. This is consistent with a small residual area of pneumothorax.
On this image, the pigtail catheter a appears to be in the region of the
previous larger area of lucency.
Otherwise, little change.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with left SDH s/p evac. with new left hemiparesis
this AM// interval changes
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 =
934.1 mGy-cm.
Total DLP (Head) = 934 mGy-cm.
COMPARISON: Noncontrast head CTs between ___ and ___
FINDINGS:
Status-post left frontal/parietal/temporal craniotomy and subdural hematoma
evacuation. There is a new left frontotemporal subgaleal fluid collection
measuring up to 8.6 x 1.4 cm. The subacute chronic left hemispheric subdural
hematoma has decreased in attenuation. The mount of extra-axial fluid is
slightly increased in pneumocephalus is decreased since 7 days prior.
Allowing for differences in measurement technique, 3 mm rightward midline
shift is unchanged. The basal cisterns are patent.
A right frontoparietal subdural fluid collection is decreased in size,
measuring up to approximately 6 mm from the inner table, previously 1.3 cm.
Interval decrease in hyperattenuation in conspicuity of 2 small parenchymal
hematomas involving the corpus callosum and another small parenchymal hematoma
involving the left occipital lobe adjacent to the corpus callosum (series 2,
images 19 and 21).
Interval progression of focal hypoattenuation left temporal lobe, perhaps an
evolving temporal lobe infarct (series 2, image 12). There is no other
evidence of infarction. The ventricles and sulci are normal in configuration.
Mild paranasal sinus mucosal thickening. Small air-fluid levels in the
sphenoid sinus are new. Increased nonspecific partial opacification of
dependent mastoid air cells. The middle ear cavities are clear. A
nasoenteric catheter is partially imaged.
IMPRESSION:
1. There is a new 8.6 cm left frontotemporal subgaleal fluid collection
suggesting a CSF leak.
2. The evaluated left hemispheric subdural hematoma is decreased in size and
attenuation. 3 mm of rightward midline shift is unchanged.
3. Other intracranial hemorrhages have continued to decrease in size and
attenuation.
4. Continued focal decrease in attenuation in the left temporal lobe, perhaps
an evolving infarct.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with SDH, intubated.// Interval changes, concern
for PNA Interval changes, concern for PNA
IMPRESSION:
Compared to chest radiographs, ___ through ___.
Deepening of the left anterior basal pleural sulcus and some increase in
unusual air collections at the medial and basal aspect of the right lung
suggest loculated pneumothorax has increased since ___ on ___
following removal of the left pigtail pleural drainage catheter early in the
day. Consolidation in the left lung is consistent with pneumonia. Right lung
is clear. Heart size is normal and there is no pleural effusion.
Tip of the endotracheal tube is no more than 15 mm from the carina, 2 cm below
optimal placement. Nasogastric drainage tube ends in the midportion of a
nondistended stomach.
Radiology Report
EXAMINATION: CR - CHEST PORTABLE AP
INDICATION: ___ year old man with SDH, intubated. **Please do CXR at 18:30**//
CXR 4 hours s/p chest tube removed. **Please do CXR at 18:30**
TECHNIQUE: AP radiograph of the chest.
COMPARISON: Chest radiograph ___ at 03:47
IMPRESSION:
The endotracheal tube continues to be just above the carina. Retraction by 3
cm is recommended.
The left chest tube is been removed. The nasogastric tube terminates in the
body of the stomach.
The small pneumothorax along the medial and basilar aspects of the left
hemithorax is unchanged. The right lung remains clear. The cardiomediastinal
silhouette is within normal limits. No acute osseous abnormalities are
identified.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with SDH. Intubated, pneumothorax// interval
changes
TECHNIQUE: Chest AP view
COMPARISON: ___
IMPRESSION:
Patchy parenchymal opacity in the left lower lobe is unchanged and could
represent a pneumonia. Cardiomediastinal silhouette is stable. There are no
pleural effusions. No pneumothorax is seen.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with SDH, intubated// interval changes
interval changes
IMPRESSION:
ET tube tip is 4 cm above the carina. NG tube tip is in the stomach. Heart
size and mediastinum are stable. No abnormality demonstrated within the
cardiomediastinal silhouette.
Left basal consolidation and cavitary lesion are better appreciated on the
chest CT obtained on ___. Left pneumothorax is represented on
the chest radiograph as a deep sulcus sign.
Overall there is minimal progression of left lung opacities compared to chest
radiograph from the day prior.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ year old man with SDH, fevers, pneumothorax, aspiration.//
pneumothorax s/p pigtail. eval for left sided loculated fluid collection,
abscess
TECHNIQUE: Multi detector helical scanning of the chest was coordinated with
intravenous infusion of nonionic iodinated contrast agent and reconstructed as
5 and 1.25 mm thick axial, 2.5 mm thick coronal and parasagittal, and 8 mm MIP
axial images. All images were reviewed.
COMPARISON: Prior torso CT dated ___. Multiple prior chest
radiographs.
FINDINGS:
NECK, THORACIC INLET, AXILLAE AND CHEST WALL:
The thyroid is unremarkable. No enlarged lymph nodes in either axilla or
thoracic inlet. No abnormalities on the chest wall. Mild atherosclerotic
calcifications in the head and neck arteries.
HEART AND VASCULATURE:
The heart is normal size and shape. No pericardial effusion. Mild
atherosclerotic calcifications in the coronary arteries, aorta and aortic
valve. The pulmonary artery is enlarged measuring 3.8 cm. The aorta is
normal in caliber throughout.
MEDIASTINUM AND HILA:
Enteric tube passing through the esophagus which is otherwise unremarkable.
Small mediastinal lymph nodes, none pathologically enlarged by CT size
criteria. No hilar lymphadenopathy.
PLEURA:
Small left pneumothorax. No apical scarring bilaterally.
LUNGS:
The patient is intubated with an appropriately placed ETT. Please note there
are secretions cranially to the endotracheal tube cuff. Mild ground-glass
opacities are noted in the right lower lobe. Ground-glass opacities are noted
in the posterior segment of the left upper lobe. Near complete atelectasis of
the left lower lobe is noted. A small cavity noted in the anterior segment of
the left upper lobe (302:82).
Thick-walled fluid filled cavities in the left lung (302:169) none oblique
lung distribution.
CHEST CAGE:
Old healed fracture in the right posterior tenth and eleventh and in the left
anterior for through ninth ribs. Mild dorsal spondylosis. No acute
fractures. No suspicious lytic or.
UPPER ABDOMEN:
The limited sections of the upper abdomen show no significant abnormal
findings.
IMPRESSION:
An oblong thick-walled fluid filled cavity is noted in the left lung. It is
unclear whether this is a loculated empyema in the left major fissure or an
intraparenchymal cavity given that this is in close proximity to a mostly
collapsed left lower lobe.
These appear to be in the same location as a previous pigtail catheter.
Please note that after removal or the prior left-sided pigtail catheter, there
is still a small residual ipsilateral pneumothorax.
Ground-glass opacities in the posterior segment and a small cavity in the
anterior segment of the left upper lobe are indeterminate at this moment and
could represent re-expansion edema, contusion in the setting of prior trauma
or concurrent infection.
Recommend CT-guided drainage of this fluid filled cavity to exclude possible
empyema or intrapulmonary abscess.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 4:37 pm.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ yo M w/SDH, intubated. Pneumothorax// interval changes
interval changes
COMPARISON: Chest x-ray ___ and CT chest ___
FINDINGS:
The patient remains intubated the endotracheal tube tip approximately 3 cm
above the carina. Distal tip of the nasogastric tube is below the diaphragm
but collimated out of the field of view. The heart is normal in size. Left
basilar consolidation and cavitary lesion are better seen on the CT chest from
___. Left pneumothorax is still present but there is no
mediastinal shift.
IMPRESSION:
Stable left pneumothorax without mediastinal shift.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old man with new R PICC// R DL Power PICC 40cm ___
___ Contact name: ___: ___
IMPRESSION:
Comparison with the study of ___, there has been placement of a right
subclavian PICC line that extends to about the level of the cavoatrial
junction. Other monitoring and support devices are unchanged.
The area of increased opacification consistent with consolidation and cavitary
lesion at the left base was better seen on the CT chest study of ___.
No definite pneumothorax and no evidence of mediastinal shift.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with new trach// ptx,
IMPRESSION:
In comparison with the earlier study of this date, the endotracheal tube is
been removed and replaced with a tracheostomy tube, which is well seated
without evidence of pneumothorax or pneumomediastinum. The nasogastric tube
has been removed. Right subclavian PICC line again extends to the lower SVC.
Cardiomediastinal silhouette is unchanged. Areas of increased opacification
at the left base are consistent with the consolidation and cavitary lesions
seen on the previous CT study. The right lung is clear.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with SDH// Remains on vent, please evaluate lung
fields
TECHNIQUE: Portable AP radiograph of the chest.
COMPARISON: Radiograph the chest performed 16 hours prior.
FINDINGS:
Heart size is normal. Hilar and mediastinal contours are normal. The right
lung is relatively clear. PICC line terminates at the cavoatrial junction.
The opacities at the left lung base appear slightly improved compared to the
prior exam. There is no large pleural effusion or pneumothorax. Visualized
osseous structures are grossly unremarkable.
IMPRESSION:
Slight interval improvement of the opacities at the left lung base.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with trach/PEG// ?pna ?pna
IMPRESSION:
Compared to chest radiographs ___ through ___, read in
conjunction with chest CT ___.
Air in fluid collection, medial left hemithorax is mostly air. No layering
pleural effusion. No free pneumothorax. Right lung and right pleural space
normal. Cardiomediastinal silhouette unremarkable.
Tracheostomy tube midline. Right PIC line ends in the head mid SVC.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with trach// ?pna ?pna
IMPRESSION:
Compared to chest radiographs ___ through ___.
The unusual multi loculated left pleuroparenchymal air and fluid collection in
the left lower chest has probably not changed per week. There is no layering
pleural effusion or pneumothorax. Right lung is clear. Heart size normal.
Right PIC line ends in the low SVC.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with SDH// Assess for pulmonary congestion or
pneumonia
TECHNIQUE: Frontal chest radiograph.
COMPARISON: Multiple chest radiographs dating back to ___, most
recent dated ___.
FINDINGS:
Stable cardiomediastinal hilar contours. Stable heterogeneous opacification
over the left hemithorax. The right hemithorax remains clear interval
development of retrocardiac opacification. Stable position of right-sided
indwelling PICC line. Visualized osseous structures are unremarkable. No
evidence of pulmonary edema. No evidence of pleural effusion or pneumothorax.
IMPRESSION:
1. Stable heterogenous opacification in the left hemithorax likely represent
multifocal pneumonia.
2. No evidence of pulmonary edema.
RECOMMENDATION(S): Follow-up chest radiograph is recommended after completion
of antibiotic course.
Radiology Report
INDICATION: ___ man with a history of alcohol use disorder p/w L SDH
with mildline shift s/p craniotomy for SDH evacuation in setting of multiple
falls.// ? interval change
COMPARISON: Radiographs from ___
IMPRESSION:
The right-sided PICC line is unchanged in position. PEG tube is seen. Heart
size is within normal limits. There are again seen patchy opacities at the
lung bases which may represent atelectasis or early infiltrate. There are no
pneumothoraces.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ s/p fall, EtOH w/ thrombocytopenia with a large L SDH w/
MLS// ? interim change
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: Head CT noncontrast ___
FINDINGS:
Status post left frontal, parietal, temporal craniotomy. There is been
significant interval decrease in size of left frontal subgaleal fluid
collection. There is been slight decrease in previously seen left frontal
subdural collection with resolution of previously seen air within the subdural
space. Interval decrease in right parietal subdural fluid collection,
measuring 2 mm from the inner table on current exam, previously 6 mm.
The previously described hypodense region within the left temporal lobe is not
visualized on current exam. Additionally, there has been interval evolution
and decrease in attenuation of 2 small parenchymal areas of blood products
within the left occipital lobe adjacent to the corpus callosum and the body of
the corpus callosum.
There is no evidence of new large territory infarction,new hemorrhageedema,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. Interval significant decrease in size of left frontal subgaleal fluid
collection.
2. Interval decrease in size of the left frontal subdural collection and
resolution of air within the subdural space
3. There is been interval resolution of minimal rightward midline shift.
4. Interval decrease in size of right parietal subdural fluid collection.
5. No acute hemorrhage identified.
6. The previously-seen left temporal lobe focus of hypoattenuation is not
visualized on current exam.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: SDH, Seizure
Diagnosed with Epilepsy, unsp, not intractable, without status epilepticus
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: unable
level of acuity: 2.0 | ___ year old male status post fall with traumatic left subdural
hematoma.
#Traumatic brain injury status post left craniotomy for subdural
hematoma evacuation
The patient was taken to the OR emergently on ___ for a
left craniotomy for subdural hematoma evacuation. The operation
was uncomplicated. The patient remained intubated
postoperatively and was transferred to the Neuro ICU for close
neurologic monitoring. He continued on Keppra for seizure
prophylaxis which will continue for now since patient had a
seizure prior to arrival. Postoperative imaging was stable. The
patient was placed on cEEG postoperatively, which showed diffuse
slowing but was negative for seizures and was thus discontinued
on ___. On ___, he was noted to have new left sided
weakness, so a stat NCHCT was ordered, which was negative for
new infarcts or SDH. Exam has slowly improved throughout his
stay.
#Acute ventilator dependent respiratory failure now s/p trach
Patient remained intubated ___ to ___. He was extubated on ___,
with tenuous respiratory status post-extubation requiring high
flow O2 via nasal cannula. He had to be reintubated on ___,
after which he was found to have a left pneumothorax, for which
a chest tube was put in place. His chest tube was removed on
___. He was unable to be weaned from mechanical ventilation, and
ACS was consulted for trach placement on ___. On ___, the
Trach was placed. On ___, a trach collar was attempted. He has
been on trach collar for multiple days. He has copious
secretions from his trach requiring frequent suctioning. Trach
sutures can be removed 14 days from placement.
# Lung abscess/necrotizing pneumonia
The patient was febrile to 101.2 on ___, and was pancultured.
He was again febrile overnight ___, and was started on
vanc/zosyn for concern for respiratory source given concern for
aspiration when he was trial extubated. On ___, his antibiotics
were changed to Cefepime only. He spiked a fever of 103 on ___.
Flagyl was added on for anaerobic coverage. Blood cultures grew
out coag negative staph therefore vancomycin was started (see
"Bacteremia" below). ID was consulted and recommended CT of the
chest and continuing vanco, cefepime, and Flagyl. CT chest
showed loculated empyema in the left major fissure or an
intraparenchymal cavity given that this is in close proximity to
a mostly collapsed left lower lobe. These appear to be in the
same location as a previous pigtail catheter. IP and ___ were
consulted who reviewed CT and believed that there was a large
parenchymal component therefore attempting to drain could cause
more issues like a fistula. The decision was made to medically
manage with IV flagyl, cefepime, vanco for at least ___ weeks.
We could not narrow antibiotics given no specific culture data
from this source. His fever curve, respiratory status, and
leukocytosis have responded to IV antibiotics. At this time plan
is to check vanco trough at least twice a week, weekly CBC with
diff, weekly BUN and Cr. He will need to follow up CT chest
during the first week in ___ and a follow up with ID
at this time to determine final duration of antibiotics. On
discharge, we will change IV cefepime and flagyl to ertapenem
only for easier administration of antibiotics, and will continue
IV vancomycin (Day 1 antibiotics ___, projected end date
___.
# STAPHYLOCOCCUS CAPITIS Bacteremia, unclear if lung is the
source
For fever work up, patient had multiple blood cultures drawn.
One culture from ___ grew out STAPHYLOCOCCUS CAPITIS. Two blood
cultures from ___ grew out STAPHYLOCOCCUS CAPITIS. This organism
was sensitive to vancomycin. He will continue on vanco for a
total of at least ___ weeks to cover his lung infection, which
will also cover the blood. Vanco trough ___ at 0900 23, decr
dose to 1g IV q24h: (goal ___
# Nutrition
NG tube was placed and tube feeds were started. ACS was
consulted for PEG placement on ___. The PEG was placed on ___.
# History alcohol abuse
Patient was put on a CIWA scale, as well as given Thiamine,
Folate and Vitamin K for history of alcohol abuse.
# ETOH disorder c/b anemia, esophageal varices and pancytopenia
Patient required transfusions of PRBC periodically throughout
his stay. (___) to keep hemoglobin above 7. He
has history of pancytopenia. He did have some bloody respiratory
secretions at times during his stay thought to be due from
necrotizing pneumonia. The bloody secretions have resolved by
discharge. Hemoglobin on admit 7.6; hemoglobin on discharge 7.8
#Coagulopathy
Patient's INR ranged from 1.3-1.6 throughout his stay. He was
given multiple doses of vitamin K without much change in INR.
His coagulopathy is thought to be due to underlying liver
disease given extensive Etoh history. No signs of active
bleeding at this time.
# Sinus Tachycardia & Hypertension
On ___, the patient was started on Metoprolol for rate control
and BP control. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Headaches
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male with no significant past medical history
presents to the ED for evaluation after 3 days of intermittent
headaches. Patient reports headaches over the past few days were
relieved with ibuprofen. Today he reports a headache that began
around lunch and he began feeling dizzy. He went to an urgent
care at his PCP's office. A CT head was obtained which reveals a
small R temporal hyperdensity. Patient denies any recent falls,
head strikes and does not take any anticoagulation. Upon
examination patient reports resolution of headache, denies
double
vision, blurry vision, weakness in extremities.
Past Medical History:
PMHx:None
Social History:
___
Family History:
NC
Physical Exam:
O: T:98.4 BP: 116/56 HR:80 R14 O2Sats 100%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 5-3mm bilaterally EOMs intact
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 5 to 3
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch, proprioception, pinprick and
vibration bilaterally.
Toes downgoing bilaterally
Pertinent Results:
___ CTA head:
1. Unchanged hyperdense focus within the right temporal lobe
without evidence of significant enhancement or aneurysm, most
consistent with a cavernous malformation. MRI head with and
without contrast may be performed for further evaluation.
2. CTA of the head demonstrates no evidence of stenosis,
occlusion or
aneurysm.
3. CTA of the neck shows no evidence of stenosis, dissection or
occlusion.
There is no internal carotid artery stenosis by NASCET criteria.
___ MRI/MRA:
There are findings in the right temporal lobe that appear
typical of an occult vascular malformation. The area of high
density on the CT scan is shown to contain multiple foci of
hyperintensity surrounded by hypointense rings. The lesion
blooms on the gradient echo images. There is no abnormal
enhancement after contrast administration.
The gradient echo images demonstrate a tiny hypodensity in the
medial left
cerebellar hemisphere suggesting a second focus of chronic
hemorrhage. This is too small to further characterize, but it
may represent a second occult vascular malformation. There is no
evidence of edema, masses, mass effect, or infarction. The
ventricles and sulci are normal in caliber and configuration.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen-Caff-Butalbital ___ TAB PO Q4H:PRN headache
Do not exceed 4grams of Acetaminophen (Tylenol) daily
RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg ___
tablet(s) by mouth every 6 hours Disp #*90 Tablet Refills:*1
2. Docusate Sodium 100 mg PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Right Parietal and left cerebellar cavernous malformation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK
INDICATION: History: ___ with temporal IPH. // eval for vascular malformation
TECHNIQUE: Using a CT scanner, contrast-enhanced volumetric data was acquired
through the head and neck following the uncomplicated administration of
intravenous contrast and reconstructed at 1.25 mm slice thickness. Sagittal,
coronal and axial maximum intensity projections were also generated. Images
were processed on a separate workstation with display 3D volume rendered
images, and maximum intensity projection images.
DOSE: DLP: 1544.26 mGy-cm
COMPARISON: CT head without contrast ___.
FINDINGS:
Technique is limited secondary to inadequate timing of the contrast bolus.
Within the confines of this limitation:
Again noted is a pericentimeter hyperdense focus within the right temporal
lobe without evidence of significant enhancement. There are several small
vessels in the periphery of this focus but no evidence of aneurysm. This
finding is most consistent with a cavernous malformation.
CTA Head: There is adequate opacification of the internal carotid, anterior
cerebral, middle cerebral, vertebral, basilar and posterior cerebral arteries.
There is no significant atherosclerotic disease. The anterior communicating
artery is well visualized. The left vertebral artery is dominant. The
posterior communicating arteries are not identified. There is no evidence of
aneurysm formation, stenosis, occlusion, dissection or vascular malformation.
CTA Neck: There is a left-sided aortic arch with conventional origin of the
major branch vessels. There is adequate opacification of the bilateral common
carotid, internal carotid and vertebral arteries, without stenosis. There is
moderate diffuse atherosclerotic calcifications, particularly at the carotid
bulbs. The left vertebral artery is dominant. There is no evidence of
high-grade stenosis at the origins or throughout the courses of these vessels.
Right internal carotid artery (minimal dimension in mm):
Proximal: 8.5
Distal: 4.5
Left internal carotid artery (minimal dimension in mm):
Proximal: 8.0
Distal: 4.5
Additional findings: There is mild mucosal thickening of the maxillary
sinuses. Otherwise, the paranasal sinuses and mastoid air cells are clear. The
nasopharynx, oropharynx, hypopharynx and larynx are unremarkable. The thyroid
gland demonstrates homogeneous density. There is no evidence of enlarged lymph
nodes by CT criteria. The visualized lung apices are clear. There the are no
suspicious osseous lesions.
IMPRESSION:
Technique is limited secondary to inadequate timing of the contrast bolus.
Within the confines of this limitation:
1. Unchanged hyperdense focus within the right temporal lobe without evidence
of significant enhancement or aneurysm, most consistent with a cavernous
malformation. MRI head with and without contrast may be performed for further
evaluation.
2. CTA of the head demonstrates no evidence of stenosis, occlusion or
aneurysm.
3. CTA of the neck shows no evidence of stenosis, dissection or occlusion.
There is no internal carotid artery stenosis by NASCET criteria.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST
INDICATION: ___ year old man with R temporal hyperdensity // ?cavernoma
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 8cc of Gadavist intravenous contrast, axial imaging was
performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal
MPRAGE imaging was performed and re-formatted in axial and coronal
orientations.
COMPARISON: Head CT and CTA ___.
FINDINGS:
There are findings in the right temporal lobe that appear typical of an occult
vascular malformation. The area of high density on the CT scan is shown to
contain multiple foci of hyperintensity surrounded by hypointense rings. The
lesion blooms on the gradient echo images. There is no abnormal enhancement
after contrast administration.
The gradient echo images demonstrate a tiny hypodensity in the medial left
cerebellar hemisphere suggesting a second focus of chronic hemorrhage. This is
too small to further characterize, but it may represent a second occult
vascular malformation. There is no evidence of edema, masses, mass effect, or
infarction. The ventricles and sulci are normal in caliber and configuration.
IMPRESSION:
The right temporal lesion typical of a cold vascular malformation.
Small focus of hemorrhage in the medial left cerebellar hemisphere. This is
too small to characterize, but may represent a second occult malformation.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: HEAD BLEED
Diagnosed with INTRACEREBRAL HEMORRHAGE
temperature: 98.4
heartrate: 80.0
resprate: 14.0
o2sat: 100.0
sbp: 116.0
dbp: 56.0
level of pain: 5
level of acuity: 2.0 | Mr. ___ was seen in the ED, results of his CTA were reviewed
and he was admitted to the floor. He remained neurologically
intact. MRI was performed the following day that showed a right
parietal cavernous malformation as well as a left cerebellar
cavernous malformation.
The patient and family were updated with the plan for followup
with Dr. ___ the cavernous malformations.
At the time of discharge he was tolerating a regular diet,
ambulating without difficulty, afebrile with stable vital signs. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Celebrex
Attending: ___.
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ year old female with a PMHx of CAD s/p PCI,
AFib on apixaban, dCHF, and CKD who presents for worsening back
pain.
She states that her back pain has been going on for several
weeks but became acutely worse today. It is located in her
middle lower back. The pain shoots down her right leg. She
denies any weakness or bowel/bladder incontinence. She does get
numbness down the back of her right leg. She denies fevers or
chills. No particular injury or trauma.
While in the ED, she developed chest pain which improved with
sitting up and getting a GI cocktail.
In the ED, initial vitals were: 98.8 59 138/54 16 96% RA
Exam notable for: intact rectal tone. Normal strength.
Labs notable for: Hgb 10.5 (baseline ___, Cr 2.1 (baseline
1.8), Trop-T < 0.01 x 1.
Imaging notable for:
CXR
No acute cardiopulmonary process.
CT L-Spine W/O Contrast
1. New minimally displaced fracture of the inferior L1
endplate, with mild adjacent paravertebral tissue swelling. No
traumatic malalignment.
2. Unchanged superior endplate compression deformities of the
T12, L3, and L4 vertebral bodies since ___.
Patient was given:
___ 19:37 IV Morphine Sulfate 2 mg
___ 20:18 IV Morphine Sulfate 2 mg
___ 21:25 IV Morphine Sulfate 2 mg
___ 21:25 PO Aluminum-Magnesium Hydrox.-Simethicone 30
mL
___ 21:25 PO Donnatal 5 mL
___ 21:25 PO Lidocaine Viscous 2% 10 mL
Spine consulted and recommended:
Patient seen and examined. Imaging reviewed. Discussed with Dr.
___. No neurosurgical intervention. Neurosurgery plan is as
follows:
-Flat bedrest, spine precauations
-Plan for brace in AM
-Agree with admission to medicine for pain control
On the floor, she has ___ out of 10 back pain.
Past Medical History:
1. Single vessel CAD (p.w. burning chest discomfort) DES-->PRCA
in ___, residual disease: LAD ___, LCx 30%.
2. Hypertension:
3. Dyslipidemia
4. Obesity. BMI 35.4.
5. Moderate pulmonary artery systolic hypertension.
6. Diastolic heart failure(RHC 10.09).
7. Atrial fibrillation on dabigatran.
8. Severe OSA (CPAP).
9. TIA ___.
10. Hx of prior tobacco use.
11. Rheumatoid arthritis.
12. GERD.
13. Mild COPD
14. Hypothyrodism
15. s/p right total hip replacement.
16. T8/9 compression fracture ___.
Social History:
___
Family History:
Mother died at ___ with heart disease. Father lived until ___.
Physical Exam:
ON ADMISSION:
Vital Signs: 97.6, 129/87, HR 64, RR 18, O2 99/RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic
murmur heard throughout
Lungs: Clear to auscultation anteriorly, 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: sensation to light touch intact in b/l ___, strength ___
in ankle flexion/extension, able to lift both legs off bed
against resistance
ON DISCHARGE:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic
murmur heard throughout
Lungs: Clear to auscultation anteriorly, 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, ___ ___ edema with
erythema and evidence of chronic venous stasis
Neuro: sensation to light touch intact in b/l ___, strength ___
in ankle flexion/extension, able to lift both legs off bed
against resistance
Pertinent Results:
LABS UPON ADMISSION:
___ 05:22PM BLOOD WBC-6.7# RBC-4.34 Hgb-10.5* Hct-34.6
MCV-80* MCH-24.2* MCHC-30.3* RDW-21.7* RDWSD-62.5* Plt ___
___ 05:22PM BLOOD Neuts-68.4 Lymphs-18.4* Monos-11.6
Eos-1.0 Baso-0.3 Im ___ AbsNeut-4.58 AbsLymp-1.23
AbsMono-0.78 AbsEos-0.07 AbsBaso-0.02
___ 05:22PM BLOOD Glucose-95 UreaN-59* Creat-2.1* Na-140
K-4.7 Cl-96 HCO3-31 AnGap-18
___ 10:50PM BLOOD cTropnT-<0.01
___ 06:30AM BLOOD CK-MB-2 cTropnT-<0.01
LABS UPON DISCHARGE:
___ 06:35AM BLOOD WBC-5.1 RBC-4.13 Hgb-9.9* Hct-33.4*
MCV-81* MCH-24.0* MCHC-29.6* RDW-21.7* RDWSD-62.9* Plt ___
___ 06:35AM BLOOD Plt ___
___ 06:35AM BLOOD Glucose-98 UreaN-50* Creat-1.8* Na-143
K-4.1 Cl-97 HCO3-36* AnGap-14
IMAGING:
CT L SPINE W/O CONTRAST ___
IMPRESSION:
1. New minimally displaced fracture of the inferior L1
endplate, with mild adjacent paravertebral tissue swelling. No
traumatic malalignment.
2. Unchanged superior endplate compression deformities of the
T12, L3, and L4 vertebral bodies since ___.
CXR ___
IMPRESSION:
No acute cardiopulmonary process.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath,
wheezing
2. Amiodarone 200 mg PO DAILY
3. Apixaban 2.5 mg PO BID
4. Atorvastatin 80 mg PO QPM
5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
6. Gabapentin 300 mg PO BID
7. Levothyroxine Sodium 88 mcg PO DAILY
8. Losartan Potassium 25 mg PO DAILY
9. Metoprolol Succinate XL 100 mg PO DAILY
10. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
11. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN back
pain
12. Pantoprazole 40 mg PO Q12H
13. PredniSONE 5 mg PO DAILY
14. Torsemide 60 mg PO DAILY
15. Aspirin 81 mg PO DAILY
16. Enbrel (etanercept) 25 mg (1 mL) subcutaneous 1X/WEEK
17. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath,
wheezing
2. Amiodarone 200 mg PO DAILY
3. Apixaban 2.5 mg PO BID
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
7. Gabapentin 300 mg PO BID
8. Levothyroxine Sodium 88 mcg PO DAILY
9. Losartan Potassium 25 mg PO DAILY
10. Metoprolol Succinate XL 100 mg PO DAILY
11. Pantoprazole 40 mg PO Q12H
12. PredniSONE 5 mg PO DAILY
13. Torsemide 60 mg PO DAILY
14. Enbrel (etanercept) 25 mg (1 mL) subcutaneous 1X/WEEK
15. Multivitamins 1 TAB PO DAILY
16. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
17. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN back
pain
18. TraMADol 50 mg PO Q6H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every six hours Disp #*8
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Acute back pain
Lumbar compression fractures
Thoracic compression fractures
Secondary diagnoses:
CKD
Atrial fibrillation
GERD
COPD
Hypertension
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: CT L-SPINE W/O CONTRAST
INDICATION: ___ with pmh hemilaminectomy p/w severe back pain x 3 weeks. L
spine ttp. Evaluate for fracture.
TECHNIQUE: Non-contrast helical multidetector CT of the lumbar spine was
performed. Soft tissue and bone algorithm images were generated. Coronal and
sagittal reformations were then constructed.
DOSE: Total DLP (Body) = 866 mGy-cm.
COMPARISON: Lumbar spine CT of ___.
FINDINGS:
There is new cortical irregularity at the inferior endplate of L1 the midline
and right aspect (___). There is mild paravertebral soft tissue swelling
at this level (3:25). Findings are concerning for new minimally displaced
fracture. Superior endplate deformities of the T12, L3, and L4 vertebral
bodies are similar in appearance since ___, although the T12
vertebral body was not fully imaged at that time.
Right L3 and L4 hemi laminectomies are noted. Right L3 spondylolysis is
noted. Mild dextroscoliosis centered at L1-L2 and levoscoliosis centered at
L4-L5 is unchanged. No critical spinal canal or neuroforaminal narrowing. No
paravertebral soft tissue swelling or hematoma detected.
The previous 10 mm hyperdense lesion in the right kidney is less conspicuous
on the current study, but appears unchanged in size (3:24). Patient is post
cholecystectomy. Moderate to severe atherosclerotic calcification of the
abdominal aorta is again seen. There is a small hiatal hernia. Colonic
diverticulosis is noted. Left basilar atelectasis is also seen.
IMPRESSION:
1. New minimally displaced fracture of the inferior L1 endplate, with mild
adjacent paravertebral tissue swelling. No traumatic malalignment.
2. Unchanged superior endplate compression deformities of the T12, L3, and L4
vertebral bodies since ___.
NOTIFICATION: The updated impression was communicated via telephone by Dr.
___ to Dr. ___ at 23:09 on ___, 3 min after discovery.
Radiology Report
INDICATION: ___ with chest pain. here in ed for 3 weeks of back pain.
developed chest pain in ed // acute cardiopulmonary process
TECHNIQUE: Single AP view of the chest.
COMPARISON: ___ chest x-ray and chest CT from ___.
FINDINGS:
The lungs are clear without consolidation. Mild left basilar atelectasis is
again noted. Moderate cardiomegaly and atherosclerotic calcifications at the
aortic arch are noted. Focal opacity just below the right clavicular head is
compatible with tortuosity of the great vessels as seen on prior CT. No acute
osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Back pain, R Leg pain
Diagnosed with Low back pain, Other chest pain
temperature: 98.8
heartrate: 59.0
resprate: 16.0
o2sat: 96.0
sbp: 138.0
dbp: 54.0
level of pain: 8
level of acuity: 3.0 | ___ year old female with a PMHx of CAD, dCHF, AFib, CKD who
presents for evaluation of back pain with CT demonstrating
possible minimally displaced L1 endplate fracture as well as
several old compression fractures.
#LOW BACK PAIN
Pt reported worsening pain upon admission. CT L spine without
contrast was performed and revealed L1 endplate fracture. Pt
endorsed radiating numbness and tingling down her right leg but
there were no neurologic deficits on exam. Pain improved during
hospitalization. Neurosurgery was consulted and did not believe
the L1 findings were consistent with an acute fracture which
required intervention. Pt was treated with Tylenol and PRN
oxycodone for pain; however, she found oxycodone too sedating,
so she was switched to tramadol. All of her at-home medications
were continued. There are no restrictions on her activity.
# Chest Pain: Reported CP upon admission. Low concern for
cardiac etiology given improvement with GI cocktail and position
change while in the ED. Trop x2 negative. Patient with cardiac
cath in ___ with no intervene-able disease at that time.
===Chronic Issues====
# CAD
- Continued metoprolol, atorvastatin, ASA
# dCHF: Compensated
- Continued torsemide
# AFib
- Continued amiodarone, metoprolol
- Continued apixaban 2.5 mg BID
# RA: Patient takes Enbrel injections ___
- Continued prednisone 5 mg daily
# CKD: Cr 2.1 (stable per recent documentation)
- Continued to monitor
# COPD
- Continued home albuterol prn, fluticasone-salmeterol
# GERD
- Continued home pantoprazole
# HTN
- Continued home losartan; hold if worsening Cr
# Hypothyroidism
- Continued home levothyroxine
**Transitional issues**
-Please ensure uptodate malignancy screening given compression
fractures
-Patient was discharged home with ___ services
-Patient also expressed question regarding code status while in
the hospital. She remained full code, but did consider DNR/DNI.
Please f/u this discussion if appropriate.
-Patient has appointment with Neurosurgery for follow-up. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
RUQ pain
Major Surgical or Invasive Procedure:
___ ERCP
History of Present Illness:
Ms. ___ is a ___ woman with a history of anxiety
and derpression who is presenting with acute worsening of RUQ
abodominal pain, which has been present for several months.
Symptoms have been associated with a 20 lb weight loss, nausea,
and intermittent "orange urine," though no dysuria. Exacerbated
by eating. Of note, patient has also been drinking heavily in
the setting of psychosocial stressors (e.g financial and marital
difficulties) during this time, last drink 3 days ago, no
history of withdrawal seizures or DT's. Patient ultimately
presented to OSH, where RUQ US shows CBD 4mm, GB w/ mobile 2.5mm
stone, pericholecystic fluid, GB wall thickness 3.7mm, +
sonographic ___ sign. No evidence of choledocholithiasis.
OSH labs: Lipase 175, Alk Phos 417, AST/ALT 362/159, Tbili 6.8,
Dbili 5.3, INR 1.1. Patient was transferred to the ___ ED,
where she was started on Unasyn and Dilaudid for pain control.
This morning, patient reports slight improvement in pain with
Dilaudid, but she remains nauseous (no vomiting). She denies
tremulousness, hallucinations, anxiety (above baseline and what
she generally experiences in the hospital). She is very tearful
when talking about her worsening depression, alcohol use, and
marital difficulties. She reported to MS3 that she feels safe at
home, though was not directly asked about a history of domestic
violence. She reports she was tested for hepatitis at the OSH.
She thinks her husband has not had other partners in spite of
the frequent separations and does not want to be HIV tested.
Past Medical History:
- Anxiety
- Depression
Social History:
___
Family History:
Grandmother, aunt, and cousin all had ___ in the past. No HTN,
HLD, cancer in the family
Physical Exam:
ADMISSION EXAM
Vitals: T: 98.7, BP: 120/76 P: 81 R: 16 O2: 100% RA
General: Pleasant
HEENT: EOMI, sclera anicteric, conjunctiva pink
Neck: No LAD
CV: RRR, no m/r/g
Lungs: CTAB bilaterally
Abdomen: +BS, non-distended, soft, tender throughout, but most
significant in RUQ, with gaurding and positive ___ sign
Ext: 2+ radial and DP pulses, no edema
Neuro: CN II-XII intact
Skin: Tattoos on left shin, left forearm and right scapular
area.
DISCHARGE EXAM
VS - 98.0 127/85 88 18 99RA
GEN - Pleasant woman in NAD
PULM - CTAB
CV - RRR, no m/r/g
ABD- +BS, soft, nondistended, tenderness without rebound or
guarding in the RUQ
EXT - 2+ DP pulses, no edema
Pertinent Results:
ADMISSION LABS
___ 06:20PM BLOOD WBC-5.2 RBC-3.38* Hgb-11.9* Hct-35.8*
MCV-106* MCH-35.2* MCHC-33.2 RDW-13.1 Plt ___
___ 06:20PM BLOOD Neuts-65.8 ___ Monos-4.1 Eos-1.7
Baso-1.4
___ 06:20PM BLOOD ___ PTT-33.4 ___
___ 06:20PM BLOOD Glucose-90 UreaN-4* Creat-0.7 Na-141
K-3.4 Cl-100 HCO3-28 AnGap-16
___ 06:20PM BLOOD ALT-131* AST-303* AlkPhos-329*
TotBili-7.5* DirBili-5.2* IndBili-2.3
___ 06:20PM BLOOD Albumin-3.3*
___ 07:54AM BLOOD Calcium-8.2* Phos-2.7 Mg-1.7
IMAGING & STUDIES
___ Liver/Gallbladder Ultrasound
1. Distended gallbladder containing a 2.6 cm mobile gallstone.
The wall of the gallbladder is equivocally thickened but there
is no definite wall edema. Please correlate with clinical
symptoms of cholecystitis. HIDA scan can be performed if
clinically warranted.
2. Diffuse extrahepatic bile duct dilatation, measuring up to 7
mm, without intraductal stone or mass visualized.
3. Echogenic liver consistent with fatty infiltration. Other
forms of liver disease and more advanced liver disease including
significant hepatic fibrosis/cirrhosis cannot be excluded on
this study.
___ MRCP
1. There is hepatomegaly. 2. The intra and extrahepatic biliary
tree are
nondilated. The CBD is of normal caliber. 3. There is a
gallstone seen
within the gallbladder. The gallbladder is elongated however it
is narrow in appearance. There is mild periholecystic fluid and
edema within the wall near the fundus.
___ ERCP
Findings:
Esophagus: Limited exam of the esophagus was normal
Stomach: Limited exam of the stomach was normal
Duodenum: Limited exam of the duodenum was normal
Major Papilla: Normal major papilla
Cannulation: Cannulation of the biliary duct was successful and
deep with a sphincterotome using a free-hand technique. Contrast
medium was injected resulting in complete opacification.
Biliary Tree: There was a filling defect that appeared like
sludge in the lower third of the common bile duct. The bile duct
dilated to 8 mm. Intrahepatic ducts were normal. The cystic duct
was patent. Filling of the gallbladder was noted.
Procedures:
A sphincterotomy was performed in the 12 o'clock position using
a sphincterotome over an existing guidewire.
Sludge was extracted successfully using a balloon.
Impression:
There was sludge in the lower third of the common bile duct. The
bile duct dilated to 8 mm. The cystic duct was patent. Filling
of the gallbladder was noted. A sphincterotomy was performed.
Sludge was extracted successfully using a balloon.
(sphincterotomy, stone extraction)
Otherwise normal ercp to third part of the duodenum
DISCHARGE LABS
___ 08:00AM BLOOD WBC-3.2* RBC-3.10* Hgb-11.0* Hct-32.7*
MCV-105* MCH-35.3* MCHC-33.5 RDW-13.4 Plt ___
___ 08:00AM BLOOD ___ PTT-32.8 ___
___ 08:00AM BLOOD Glucose-101* UreaN-3* Creat-0.5 Na-141
K-3.8 Cl-104 HCO3-28 AnGap-13
___ 08:00AM BLOOD ALT-73* AST-116* LD(LDH)-209 AlkPhos-232*
TotBili-3.6*
___ 08:00AM BLOOD Albumin-3.2* Calcium-9.0 Phos-3.5 Mg-1.8
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ALPRAZolam 0.5 mg PO TID:PRN anxiety
2. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. ALPRAZolam 0.5 mg PO TID:PRN anxiety
2. Multivitamins 1 TAB PO DAILY
3. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule,delayed ___ by
mouth Daily Disp #*30 Capsule Refills:*0
4. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 11 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth Every 12 hours Disp #*20 Tablet Refills:*0
5. Ibuprofen 800 mg PO Q8H:PRN Pain
You can buy this over the counter.
Discharge Disposition:
Home
Discharge Diagnosis:
Acute cholecystitis
Alcohol abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ female with jaundice and epigastric pain.
COMPARISON: None.
FINDINGS:
Grayscale and Doppler ultrasound images of the abdomen were obtained.
The liver is diffusely echogenic. No focal hepatic lesion is identified. The
main portal vein is patent with hepatopetal flow.
The gallbladder is distended and contains a 2.6 cm mobile calcified stone.
The wall of the gallbladder appears equivocally thickened but there is no
definite wall edema. No reported sonographic ___ sign. The common bile
duct is diffusely dilated and measures up to 7 mm. The common duct is
visualized to the head of the pancreas without intraductal stone or mass.
Intrahepatic bile ducts are not dilated.
The visualized portion of the pancreas is unremarkable. The pancreatic tail
is obscured by overlying bowel gas. The spleen is normal and measures 10.3
cm.
IMPRESSION:
1. Distended gallbladder containing a 2.6 cm mobile gallstone. The wall of
the gallbladder is equivocally thickened but there is no definite wall edema.
Please correlate with clinical symptoms of cholecystitis. HIDA scan can be
performed if clinically warranted.
2. Diffuse extrahepatic bile duct dilatation, measuring up to 7 mm, without
intraductal stone or mass visualized.
3. Echogenic liver consistent with fatty infiltration. Other forms of liver
disease and more advanced liver disease including significant hepatic fibrosis
/ cirrhosis cannot be excluded on this study.
Radiology Report
HISTORY: ___ year old woman with acute cholecystitis, heavy EtOH use. RUQ U/S
at outside hospital with CBD dilation
COMPARISON: Ultrasound ___
TECHNIQUE: Multiplanar T1 and T2 weighted images were acquired on a 1.5 T
magnet, including dynamic 3D imaging, obtained prior to and during and after
the uneventful intravenous administration of 5 mL of Gadavist.
FINDINGS:
There is significant hepatic steatosis and hepatomegaly. The spleen is normal
in size. The pancreas is normal in signal intensity. The main pancreatic
duct is not dilated. Bilaterally the kidneys demonstrate normal signal
intensity. The is no hydronephrosis. The adrenals appear normal.
The gallbladder is elongated however it is not significantly distended. There
is mild pericholecystic fluid as well as edema within the gallbladder wall
near the fundus (image 129: series 1,502). There is a gallstone within the
gallbladder. There is no dilatation of the intra or extrahepatic biliary
tree.
There is no ascites. The aorta is of normal caliber. The visualized loops of
small and large bowel appear within normal limits.
Thyroid is no bone marrow signal abnormality.
IMPRESSION:
1. Findings reflect some mild edema within the gallbladder fundus and trace
pericholecystic fluid. The gallbladder is elongated but no distended. There is
a gallstone. This is an atypical appearance for acute cholecystitis. There is
no intra or extrahepatic biliary dilatation.
2. Hepatomegaly and significant hepatic steatosis. Steatohepatitis cannot be
excluded based on imaging.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: CHOLECYSTITIS
Diagnosed with ACUTE CHOLECYSTITIS
temperature: 97.8
heartrate: 108.0
resprate: 18.0
o2sat: 99.0
sbp: 116.0
dbp: 82.0
level of pain: 7
level of acuity: 3.0 | Ms. ___ is a ___ woman with a history of anxiety
and depression presents with worsening RUQ pain and was found to
have gallstones and CBD dilation consistent with acute
cholecystitis. Initial evaluation also notable for fatty
infiltration of liver.
ACTIVE ISSUES
# RUQ Pain/Cholecystitis: HPI, exam, labs and imaging were all
consistent with acute cholecystitis. Alcoholic hepatitis was
also a consideration in setting of recent heavy drinking and
fatty infiltration of liver, but Discriminant Function of 2
ruled out any significant component of alcoholic hepatitis.
Hepatitis antibodies were negative at OSH. Patient was treated
with Unasyn and ketorolac and dilaudid for pain control. She was
seen by surgery and ERCP, who recommended MRCP followed by ERCP.
ERCP was performed on ___ with sphincterotomy and sludge
extraction. She was seen by surgery who elected to defer surgery
until the inflamation had been reduced. She will follow up with
surgery in outpatient clinic for scheduling of the procedure
# Transaminitis: Likely secondary to acute cholecystitis. As
above, alcoholic hepatitis was unlikely. HCV, HAV IgM, HbsAg
were negative at OSH.
# Anemia: Patient has a macrocytic anemia. She has had poor PO
intake over the last 6 months with 20 lb weight loss in the
setting of heavy drinking, suggesting nutritional deficiency,
though B12 and folate were WNL.
# Thrombocytopenia: Patient was thrombocytopenic, which may have
been due to acute inflammation/sequestration, underlying liver
disease, or direct toxic effects of alcohol on marrow. Platelets
trended up by time of discharge to 130s from a nadir in the ___.
# Pancytopenia: Likely due to direct bone marrow toxicity from
alcohol, poor nutritional status, and dilution.
# Hepatic Steatosis: Patient found to have fatty infiltration of
the liver. She is not obese and has significant alcohol history,
suggesting alcoholic fatty liver disease. Initial AST/ALT ratio
was almost 3:1. As her acute process resolves, she will need to
have LFT's trended. Patient stopped drinking alcohol 3 days
prior to admission and was encouraged to enroll in AA and to
resestablish with a psychiatrist for ongoing alcohol cessation
support.
# Alcohol Abuse: Patient reported nearly daily heavy drinking,
which she attributed to difficulty managing her anxiety. She
says she stopped drinking 3 days ago and intends to quit for
good. She has no history of withdrawal and had no withdrawal
symptoms. She was seen by SW currently. She was encouraged to
enroll in AA. She received multivitamin and thiamine.
CHRONIC ISSUES
# Anxiety: Continued alprazolam.
# Depression: Transitioning between psychiatrists, not currently
on medications. Seen by SW.
TRANSITIONAL ISSUES
- Encourage enrollment in AA or another support group
- Help patient establish with new psychiatrist
- She will follow up with surgery as an outpatient to have a lap
chole. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ man with history of congenital
cardiac disease (s/p pulmonic valve repair in ___ now with PR
and TR and ___ cardiomyopathy with preserved EF),
cardiogenic cirrhosis with refractory ascites requiring frequent
LVP, CKD, atrial fibrillation on Coumadin, CLL who p/w
confusion. The patient is unable to provide a cogent history,
but reports coming in because "he was sick." Notably, in OMR
notes indicate that the patient has been becoming more confused
with multiple behavioral outbursts and a recent ___ for
encephalopathy.
In the ED, initial vitals were: 98.6 73 110/68 20 100% RA
- Exam notable for: AOx2 (does not know month/year), Abdomen
distended and ___, + asterixis
- Labs notable for: BUN 86, Cr 2.4, ALT 21, AST 19, AP 196, Alb
3.4, WBC 42, Hb 8.8, Hct 31.0, INR 1.5, lactate 3.2, urine with
neg leuks, neg nitrates, neg blood, serum tox negative
- Imaging was notable for: RUQ US with 1. Cirrhosis with
splenomegaly and moderate ascites, 2. Patent main, left, and
right portal veins. CT head w/o acute intracranial hemorrhage or
mass effect. CXR
- Hepatology was consulted and recommended: infectious work up
including diagnostic paracentesisi, lactulose and admission to
___ under Dr. ___
- Patient was given: lactulose and NS
- Vitals prior to transfer:
Diagnostic paracentesis was performed in the ED and showed 2191
WBCs, 3965 RBCs, 6% polys.
Of note, pt was recently admitted on from ___ to ___ of this
year for BRBPR. On ___ he underwent EGD without source of
bleeding, colonoscopy with large polyp as potential source.
Coumadin was held on discharge, to be discussed with his primary
care doctor. He was also treated with ciprofloxacin for GI
bleeding, SBP prophylaxis.
REVIEW OF SYSTEMS:
Unable to obtain with certainty given AMS, but patient denies
HA, neck stiffness, SOB, cough, CP, rashes, ___ swelling, abd
pain.
Past Medical History:
- Cardiac cirrhosis
- Atrial Fibrillation on coumadin
- Seizure disorder
- Pulmonic regurgitation
- Systolic CHF
- CLL
- MGUS
- Congenital heart disease s/p pulm valve replacement as a
child
- mild cognitive decline
- Seizure disorder
Social History:
___
Family History:
Denies history of liver disease. 4 healthy kids
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vital Signs: 97.7 118/70 99 20 100 Ra
General: AOx2, NAD
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL.
Neck: Supple. JVP not elevated. no LAD
CV: Irregularly irregular, tachycardic. Normal S1+S2, ___
systolic murmur at LUSB
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Severely distended, no ttp, soft, unable to appreciate
HSM given distention
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: AOx2, face symmetric, unable to cooperate with full
neurologic exam, MAE purposefully, +asterixis
Skin: multiple well circumscribed, erythematous macules with
excoriation in multiple stages, on arms chest and back, but
predominantly on L side
DISCHARGE PHYSICAL EXAM:
========================
Vital Signs: 97.9, 116/76, 117, 18, 99% RA
General: lying in bed comfortably, A&Ox2 (person, place), NAD.
HEENT: Sclerae anicteric, MMM, oropharynx clear
Neck: Supple. JVD not appreciated. no LAD
CV: Irregularly irregular, tachycardic, nl S1, S2
Lungs: CTAB, no crackles, wheezes, rhonchi
Abdomen: Moderately distended and tight, ___, +BS sounds,
no rebound or guarding
Ext: WWP, 2+ pulses, trace edema, no clubbing or cyanosis
Neuro: AOx2, face symmetric, unable to cooperate with full
neurologic exam, no asterixis, ___ grossly intact, moving
all extremities
Skin: multiple well circumscribed, erythematous macules with
excoriation in multiple stages
Pertinent Results:
ADMISSION LABS:
===============
___ 05:00PM BLOOD ___
___ Plt ___
___ 05:00PM BLOOD ___
___
___
___ 05:00PM BLOOD ___
___ Tear
___
___ 05:00PM BLOOD Plt ___ Plt ___
___ 05:00PM BLOOD ___ ___
___ 05:00PM BLOOD ___
___
___ 05:00PM BLOOD ___
___ 05:00PM BLOOD ___
___ 05:00PM BLOOD ___
___
___ 05:17PM BLOOD ___
___ 06:45PM URINE ___ Sp ___
___ 06:45PM URINE ___
___
___ 07:45PM ASCITES ___
___
___ 07:45PM ASCITES ___
PERTINENT FINDINGS:
URINE CULTURE (Final ___: < 10,000 CFU/mL.
URINE CULTURE (Final ___: NO GROWTH.
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Cepheid nucleic
acid
amplification assay..
(Reference ___.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
___ Blood Culture, Routine (Pending):
CXR ___:
IMPRESSION:
1. Severe cardiomegaly with mild pulmonary edema.
2. Continued enlargement of the main pulmonary artery suggestive
of pulmonary
arterial hypertension
3. Bibasilar atelectasis.
CT Head w/o contrast ___:
IMPRESSION:
No acute intracranial hemorrhage or mass effect.
Duplex Doppler Abd/Pelv ___:
IMPRESSION:
1. Cirrhosis with splenomegaly and moderate ascites.
2. Patent main, left, and right portal veins.
CXR ___:
IMPRESSION:
No significant interval change since the prior chest radiograph.
DISCHARGE LABS:
===============
___ 06:58AM BLOOD ___
___ Plt ___
___ 06:58AM BLOOD Plt ___
___ 06:58AM BLOOD ___
___
___ 06:58AM BLOOD ___ LD(LDH)-213 ___
___
___ 06:58AM BLOOD ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Digoxin 0.125 mg PO DAILY
2. Lactulose 30 mL PO BID
3. LevETIRAcetam 750 mg PO BID
4. Spironolactone 25 mg PO DAILY
5. Torsemide 40 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. ___ % topical daily
8. Metoprolol Succinate XL 50 mg PO DAILY
Discharge Medications:
1. Rifaximin 550 mg PO BID
2. Torsemide 20 mg PO DAILY
3. Digoxin 0.0625 mg PO DAILY
4. Lactulose 30 mL PO TID
5. Aspirin 81 mg PO DAILY
6. ___ % topical daily
7. LevETIRAcetam 750 mg PO BID
8. Metoprolol Succinate XL 50 mg PO DAILY
9. Spironolactone 25 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
hepatic encephalopathy
Secondary Diagnosis:
Cirrhosis
Heart failure
Chronic kidney disease
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
INDICATION: ___ year old man with cough// any e/o pna
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
Bibasilar opacities likely reflect atelectasis. There is mild persisting
pulmonary edema. No pleural effusion or pneumothorax is identified. The size
of the cardiomediastinal silhouette is enlarged but unchanged, including
enlargement of the main pulmonary arteries.
IMPRESSION:
No significant interval change since the prior chest radiograph.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Lethargy, Weakness
Diagnosed with Altered mental status, unspecified
temperature: 98.6
heartrate: 73.0
resprate: 20.0
o2sat: 100.0
sbp: 110.0
dbp: 68.0
level of pain: 2
level of acuity: 3.0 | Mr. ___ is a ___ man with history of congenital
cardiac disease (s/p pulmonic valve repair in ___ now with PR
and TR and ___ cardiomyopathy with preserved EF),
cardiogenic cirrhosis with refractory ascites requiring frequent
LVP, CKD, atrial fibrillation on Coumadin, CLL who presented
with confusion, likely from combination of hepatic
encephalopathy and dehydration.
#Altered Mental Status: Patient with history of AMS from hepatic
encephalopathy presented with increased confusion and agitation,
likely from hepatic encephalopathy and dehydration. He initially
had asterixis which resolved after lactulose, though he did not
return to baseline MS after frequent lactulose dosing with good
response. Significant elevation in BUN and clinical exam
suggested that he was also dehydrated. Other contributions to
AMS unlikely, as infectious workup was negative, with no recent
history of infection, changes in medications, changes in taking
lactulose with consistent bowel movement frequency, nor evidence
of portal vein thrombosis on RUQ US. He was continued on
frequent lactulose dosing, and started on rifaximin, and was
given albumin and fluids with improvement in his mental status.
He was discharged on his home dose of lactulose (with
instructions to tirate to 4BMs) and rifaximin.
#Lymphocytic ascites: This patient has cirrhosis requiring
frequent paracentesis for ascites, with recent large volume
paracentesis (6.8L) para on ___ at ___ and
diagnostic paracentesis during this admission. Fluid analysis
was negative for SBP, though concerning for increase in
nucleated cell count compared to prior, with lymphocytic
predominance consistent from prior paracenteses. As patient has
CLL, may need further workup to determine whether unusual fluid
cytology reflects progression of malignancy, recommend
outpatient ___.
#Decompensated cardiogenic cirrhosis ___ 22, ___ B,
not transplant candidate): This patient has history of cirrhosis
with previous presentations for hepatic encephalopathy and
ascites, currently on lactulose, spironolactone, and torsemide
at home. He did not have SBP nor portal vein thrombosis on this
admission and has no history of this. He has had a recent EGD
with Grade I varices of lower esophagus (___). He initially
received prophylactic ciprofloxacin in the ED but was stopped as
he does not have current indications for it. He was continued on
lactulose with multiple bowel movements and started on
rifaximin. His home spironolactone and torsemide were briefly
held during his admission and restarted prior to discharge. His
torsemide dose was decreased to 20mg PO daily given he presented
slightly dehydrated.
CHRONIC ISSUES:
# Atrial fibrillation: AC held post last admission for bleeding,
at this time hasn't made it to PCP ___ for discussion. Continued
metoprolol, and digoxin was briefly held and restarted at
0.0625mg PO daily prior to discharge given tachycardia to 150s
on ___.
#Gastric antral vascular ectasia on EGD: continued home
pantoprazole
#Chronic kidney disease stage 4: Cr at baseline. Renally dosed
medications.
#Seizure disorder: continued home keppra
TRANSITIONAL ISSUES |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
CC: ___ pain
Major Surgical or Invasive Procedure:
ERCP ___
History of Present Illness:
This is a ___ year old male with past medical history of
alcoholic cirrhosis (without ascites, encephalopathy, varices;
previously followed at ___, but not since ___, history of
gallstone pancreatitis s/p cholecystectomy in ___ complicated
by infected pancreatic pseudocyst (cx with Prevotella) with
complicated history requiring prolonged outpatient course of IV
antibiotics stopped ___, presenting with 10 days of
intermittent progressive abdominal pain and nausea. Patient
reports 10 day prior he noticed some abdominal pain he
associates with prior pancreatitis; periumbilical, band-like and
radiating to his back; associated with nausea; modified his diet
to bland, but symptoms persisted; nausea progressed to
intermittent vomitting, described as yellow and "bilious". He
denies any skin color changes, diarrhea, constipation, stool
color changes. He does report some darkening of his urine. He
may have had subjective fevers during this time as well. Given
symptom progression he presented to ___ ED and was
transferred to ___ ED for further management.
In ___ ED, VS were ___ 16 96%. Labs notable for
WBC 6.8, Hgb 12.6, Plt 56, K 3.0, ALT 222, AST 251, AP 216,
Tbili 3.0, Lip 865, INR 1.3, Lactate 1.3, UA few bact, 0 WBCs;
CT showed "Peripancreatic stranding and loss of pancreatic
acinar architecture consistent with mild acute interstitial
pancreatitis. Previously identified pancreatic pseudocysts are
again identified at the pancreatic tail, one of which markedly
decreased in size. The argest measures 2.3 x 3.4 cm is without
internal foci of air to suggest acute infection. No new fluid
collections." ERCP was consulted and patient was admitted to
the medicine service. He received dose of unasyn, and dilaudid
for pain.
On arrival he reported the above story. He also revealed that
over the last few months he has resumed drinking, has 2
"generous" mixed drinks per night. Denies any binges.
Full 10 point review of systems positive as above. Otherwise
negative.
Past Medical History:
-Gallstone pancreatitis c/b infected pancreatic pseudocysts,
status post ERCP for stone extraction, lap CCY, and ___ guided
psuedocyst drainage
- Alcoholic Cirrhosis (dx ___ - thrombocytopenia
- Type 2 NIDDM
- HTN
-Popliteal aneurysms s/p bilateral bypass
- GERD
- Gout
Social History:
___
Family History:
Brother and father with alcoholism and cirrhosis.
Physical Exam:
VS: 98.7 143/84 75 16 98%RA
___: 183
Gen: sitting up in bed, jaundiced, comfortable
Eyes - EOMI, +icterus
ENT - OP clear, MMM
Heart - RRR no mrg
Lungs - CTA bilaterally
Abd - soft tender to deep palpation at umbilicus, no
rebound/guarding; hypoactive bowel sounds
Ext - trace edema to ankles
Skin - +jaundice; no rashes
Vasc - 2+ DP/radial pulses
Neuro - AOx3, moving all extremities
Psych - appropriate
Pertinent Results:
Labs - WBC 6.8, Hgb 12.6, Plt 56, K 3.0, ALT 222, AST 251, AP
216, Tbili 3.0, Lip 865, INR 1.3, Lactate 1.3, UA few bact, 0
WBCs
Micro
___ - Bcx PENDING
___ - Ucx PENDING
CT Abd w Contrast
1. Peripancreatic stranding and loss of pancreatic acinar
architecture consistent with mild acute interstitial
pancreatitis. Previously identified pancreatic pseudocysts are
again identified at the pancreatic tail, one of which markedly
decreased in size. The largest measures 2.3 x 3.4 cm is without
internal foci of air to suggest acute infection. No new fluid
collections.
2. Moderate diverticulosis without evidence of diverticulitis.
3. Unchanged periportal, peripancreatic, mesenteric adenopathy,
thought reactive.
4. Extensive atherosclerotic calcifications within the
abdominal aorta which becomes ectatic at the level of the
inferior mesenteric artery, measuring 2.9cm.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. GlipiZIDE 5 mg PO BID
4. MetFORMIN (Glucophage) 1000 mg PO BID
5. Omeprazole 20 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Vitamin D 800 UNIT PO DAILY
8. Ferrous Sulfate 325 mg PO DAILY
9. Magnesium Oxide 500 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atenolol 50 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Tamsulosin 0.4 mg PO QHS
6. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice
a day Disp #*8 Tablet Refills:*0
7. Atorvastatin 40 mg PO QPM
8. Ferrous Sulfate 325 mg PO DAILY
9. GlipiZIDE 5 mg PO BID
10. Magnesium Oxide 500 mg PO DAILY
11. MetFORMIN (Glucophage) 1000 mg PO BID
12. Multivitamins 1 TAB PO DAILY
13. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
14. Vitamin D 800 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Gallstones
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ male with abdominal pain and elevated lipase.
TECHNIQUE: Multi detector CT images through the abdomen and pelvis were
obtained after the administration of intravenous contrast. No oral contrast
was administered. Coronal and sagittal reformations were generated and
reviewed.
DOSE: 961 mGy-cm.
COMPARISON: CT dated ___.
FINDINGS:
Chest: The bases of the lungs are clear bilaterally. Coronary artery
calcifications are mild. There is no pericardial effusion.
Abdomen: The liver is slightly nodular in contour or as previously noted.
There is no intra hepatic biliary ductal dilatation. The portal vein is
patent. The gallbladder is surgically absent.
Adjacent to the pancreatic tail is a 2.3 x 3.4 cm cystic structure with a thin
rind, not significantly changed in appearance relative to prior study dated ___, in keeping with known pseudocyst. A 1.1 x 1.6 cm collection
appears to be the remnant of a prior 3.8 x 3.5 cm pseudocyst at the tip of the
pancreatic tail adjacent to the spleen. There is no pancreatic ductal
dilatation. Relative to prior examination, mild peripancreatic stranding
about the pancreatic head and neck is more conspicuous, suggestive of
superimposed mild acute pancreatitis (series 2, image 29).
The spleen is unremarkable. Splenic vein is thrombosed with multiple
collaterals, not significantly changed. Bilateral adrenal glands are without
nodularity. Kidneys present symmetric nephrograms and excretion of contrast.
There is no hydronephrosis.
The stomach, duodenum, and loops of small bowel are grossly unremarkable. No
evidence of obstruction. The appendix visualized, air-filled and normal.
Scattered diverticula are noted throughout the colon without evidence of acute
diverticulitis.
Extensive atherosclerotic calcification within the abdominal aorta is noted.
At the level of the inferior mesenteric artery, the aorta becomes ectatic and
measures 2.9 cm in axial dimension (02:50). Prominent mesenteric,
peripancreatic, and periportal nodes are not significantly changed relative to
prior study. Retroperitoneal nodes are not pathologically enlarged. No
abdominal free fluid or air is present.
Pelvis: The bladder is moderately well distended and grossly unremarkable.
Prostate gland and seminal vesicles are within normal limits. There is no
pelvic free fluid. There is no inguinal or pelvic sidewall adenopathy. Small
fat containing bilateral inguinal hernias are noted, left greater than right.
Osseous structures: No suspicious lytic or blastic lesions are identified.
Degenerative changes at the left sacroiliac joint are moderate.
IMPRESSION:
1. Peripancreatic stranding and loss of pancreatic acinar architecture
consistent with mild acute interstitial pancreatitis. Previously identified
pancreatic pseudocysts are again identified at the pancreatic tail, one of
which markedly decreased in size. The largest measures 2.3 x 3.4 cm is
without internal foci of air to suggest acute infection. No new fluid
collections.
2. Moderate diverticulosis without evidence of diverticulitis.
3. Unchanged periportal, peripancreatic, mesenteric adenopathy, thought
reactive.
4. Extensive atherosclerotic calcifications within the abdominal aorta which
becomes ectatic at the level of the inferior mesenteric artery, measuring 2.9
cm.
NOTIFICATION: Discussed with Dr. ___ by ___ via telephone at 4:38
on ___.
Radiology Report
EXAMINATION: MRCP (MR ___
INDICATION: ___ year old man with alcoholic cirrhosis, prior gallstone
pancreatitis status post cholecystectomy presenting with LFT abnormalities and
pancreatitis // identify if choledocholithiasis with obstruction or other
obstructive etiology to explain elevated LFTs and acute pacnreatitis
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 11 mL Gadavist gadolinium based contrast. 1
mL Gadavist mixed with 50 mL water was also administered for oral contrast.
COMPARISON: Multiple prior CT scans, the last is from ___.
FINDINGS:
The lung bases are grossly clear. There is no pleural or pericardial effusion.
The liver has nodular border and widened preportal space, consistent with
cirrhosis. There is heterogeneous drop of signal on T1 out of phase images
compared to in phase images, consistent with steatosis. On arterial phase the
enhancement of the liver parenchyma is heterogeneous, becoming homogeneous on
later phases, consistent with perfusional abnormality. No arterial
hyperenhancing or suspicious focal lesions are seen. There is variant arterial
hepatic anatomy, with a replaced right hepatic artery from the SMA (1201:101)
and the replaced left hepatic artery from the left gastric artery (1201:56).
The portal and hepatic veins are patent.
The patient is status post cholecystectomy. The CBD is mildly dilated,
measuring 7 mm. Filling defect is seen in the distal CBD, with hyperintense
signal on T1WI, consistent with choledocholithiasis (7:5, 09:114). Thickening
and hyperenhancement of the distal CBD wall around the region of the
obstructing calculus is probably reactive inflammation (1202:114). There is
mild dilatation of the intrahepatic biliary ducts, more prominent in the left
lobe (1202:53).
The pancreas is normal in size. There is mildly decreased signal of the
pancreatic parenchyma in the head and neck on the precontrast T1 weighted
images (09:111), likely reflective of pancreatitis. Anterior to the pancreatic
tail there is a T2 hyperintense rim enhancing fluid collection 3 x 2.4 cm in
size (04:28), extending anteriorly and possibly communicating with an
intramural fluid collection within the posterior gastric wall 2.2 x 1.6 cm in
size (04:26 to 29). T2 hypointense debris are seen in the pancreatic tail
collection (04:29). The main pancreatic duct is normal in caliber.
There is fat stranding involving the anterior left para renal fascia, likely
related to acute pancreatitis (04:28).
The spleen is enlarged, measuring 15.5 cm in craniocaudal dimension. Small
lower esophageal varices are seen. Splenic vein remains patent.
The kidneys and adrenals are normal, aside from subcentimeter simple cortical
renal cysts.
There is diverticulosis throughout the colon, without diverticulitis.
Prominent periportal lymph nodes measuring up to 1 cm are seen, in keeping
with underlying liver disease.
Mild atherosclerosis of the abdominal aorta is noted without aneurysm.
There is no free fluid in the abdomen.
The bone marrow signal is normal.
IMPRESSION:
1. Choledocholithiasis in the distal CBD with mild upstream intra and
extrahepatic biliary dilatation.
2. Mild acute pancreatitis. No dilatation of the pancreatic duct.
3. 3 x 2.4 cm fluid collection anterior to the pancreatic tail, possibly
communicating with an intramural posterior gastric wall collection, decreased
in size compared to prior CT from ___, and likely reflective of
pseudocyst.
4. Cirrhosis with portal hypertension and splenomegaly.
5. Heterogeneous hepatic steatosis.
6. Heterogeneous arterial liver enhancement, without focal lesions.
7. Diverticulosis.
8. Mild atherosclerosis of the abdominal aorta.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with ACUTE PANCREATITIS, PANCREAT CYST/PSEUDOCYST
temperature: 102.0
heartrate: 103.0
resprate: 16.0
o2sat: 96.0
sbp: 146.0
dbp: 89.0
level of pain: 2
level of acuity: 2.0 | This is a ___ year old male with past medical history of
alcoholic cirrhosis, history of gallstone pancreatitis s/p
cholecystectomy complicated by infected pancreatic pseudocyst in
___, being admitted with 10 days of progressive abdominal pain,
found to have LFT abnormalities and elevated lipase. MRCP was
performed which revealed a small stone in the common bile duct.
ERCP was performed without complication and stone was removed.
Thereafter, he was able to tolerate an oral diet, however he had
persistent elevations in alkaline phosphatase with downtrending
total bilirubin (4.6 -> 3.1). His PCP ___ be following up
his labs.
He was also noted to have thrombocytopenia and was seen by
hepatology for underlying alcoholic cirrhosis. Dr ___
___ will be calling him after discharge to schedule a follow
up.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / codeine
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ PMH significant for severe obstructive asthma/COPD (FEV1
0.9, 39% predicted, FEV1/FVC 66%), tracheomalacia, and multiple
admissions for exacerbation of COPD (most recently ___
who presents with shortness of breath x 1 week concerning for
COPD exacerbation.
Patient reports for the past week that she gradually has felt
more short of breath at rest. She initially though she had a
cold with cough and runny nose. She has a cough prodcutive of
yellow sputum which is unusual for her. She has some chest
discomfort with the cough. Also notes feeling hot and sweating
at home. No sick contacts. Has been taking home inhalers as
prescribed. Has recieved 3 rounds of nebulizers prior to
arrival.
On arrival to the ED, initial vitals were:98.5 103 141/84 20 98.
Labs were notable for WBC 11.5 with PMNs 74.2. Chem 7 was
unremarkable. Blood cultures were obtained. EKG showed
tachycardia with what appears to be sinus arrhythmia. The
patient received albuterol, ipratroprium, methylprednisolone
125mg IVx1, azithromcyin.
Vital Signs prior to transfer: 97.3 110 125/80 20 99% RA
Currently, patient reports continued cough, wheeze and SOB. Her
chest wall is painful from coughing. Denies fever, chill,
orthopnea, nausea, vomiting, dysuria. Had 1 episode of loose
stools today.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
Severe obstructive asthma/COPD
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:
Non-contributory for Pulmonary disease.
Physical Exam:
ADMISSION EXAM:
VS - Temp ___, BP 114/53, HR 107, R 25, O2-sat 99% 2.5L NC
General: Obese female, NAD
HEENT: no scleral icterus, OP clear, MMM
Neck: supple, no cervical ___
CV: RRR, nl S1 S2, no r/m/g appreciated.
Lungs: Diffuse wheezes, no crackles
Abdomen: soft, NT/ND. No organomegaly. +BS.
GU: no Foley.
Ext: WWP, +2 pulses. No pedal edema.
Neuro: A+Ox3, attentive. Memory intact. CN II-XII intact. Motor
and sensory function grossly intact.
Skin: no rashes.
DISCHARGE PHYSICAL EXAM:
VS - 98.2 124/80 92 18 98RA
General: Obese female laying in bed, NAD
HEENT: no scleral icterus, OP clear, MMM
Neck: supple
CV: RRR, nl S1 S2, no r/m/g
Lungs: Diffuse wheezes, improved air movement compared to prior
Abdomen: soft, NT/ND. NABS
GU: no Foley.
Ext: WWP, +2 pulses. No pedal edema.
Pertinent Results:
ADMISSION LABS:
=================
___ 06:03PM BLOOD WBC-11.5* RBC-4.96 Hgb-12.7 Hct-42.3
MCV-85 MCH-25.5* MCHC-29.9* RDW-16.2* Plt ___
___ 06:03PM BLOOD Neuts-74.2* ___ Monos-2.2 Eos-0.7
Baso-0.5
___ 06:03PM BLOOD Glucose-115* UreaN-12 Creat-0.6 Na-139
K-4.1 Cl-102 HCO3-25 AnGap-16
___ 07:44AM BLOOD Calcium-9.3 Phos-3.0 Mg-1.7
IMAGING:
==============
___ CXR:IMPRESSION: No acute cardiopulmonary process.
DISCHARGE LABS:
===================
___ 07:45AM BLOOD WBC-15.2* RBC-4.52 Hgb-11.8* Hct-39.2
MCV-87 MCH-26.1* MCHC-30.0* RDW-16.0* Plt ___
___ 07:45AM BLOOD Glucose-72 UreaN-22* Creat-0.5 Na-139
K-4.3 Cl-103 HCO3-26 AnGap-14
___ 07:45AM BLOOD Calcium-8.8 Phos-4.2 Mg-2.0
MICRO:
================
___ 10:46 pm Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
**FINAL REPORT ___
Respiratory Viral Culture (Final ___:
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
___
within 1 week if additional testing is needed.
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 for further
information.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
2. ALPRAZolam 1 mg PO DAILY:PRN anxiety
3. Cyclobenzaprine 5 mg PO TID:PRN back pain
4. Docusate Sodium 100 mg PO BID
5. Furosemide 20 mg PO DAILY
6. Montelukast Sodium 10 mg PO DAILY
7. Omeprazole 40 mg PO DAILY
8. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain
9. TraMADOL (Ultram) 25 mg PO DAILY
10. Aspirin 81 mg PO DAILY
11. Diltiazem Extended-Release 180 mg PO DAILY
12. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION BID
13. Tiotropium Bromide 1 CAP IH DAILY
14. TraZODone 50 mg PO HS:PRN insomnia
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
2. ALPRAZolam 1 mg PO DAILY:PRN anxiety
RX *alprazolam 1 mg 1 (One) tablet(s) by mouth once a day Disp
#*5 Tablet Refills:*0
3. Aspirin 81 mg PO DAILY
4. Cyclobenzaprine 5 mg PO TID:PRN back pain
5. Diltiazem Extended-Release 180 mg PO DAILY
RX *diltiazem HCl 180 mg 1 (One) capsule,extended release
24hr(s) by mouth once a day Disp #*30 Capsule Refills:*0
6. Docusate Sodium 100 mg PO BID
7. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 (One) tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*0
8. Montelukast Sodium 10 mg PO DAILY
RX *montelukast 10 mg 1 (One) tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*0
9. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 (One) capsule,delayed ___
by mouth once a day Disp #*30 Capsule Refills:*0
10. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain
RX *oxycodone-acetaminophen 5 mg-325 mg 1 to 2 tablet(s) by
mouth every four (4) hours Disp #*20 Tablet Refills:*0
11. TraMADOL (Ultram) 25 mg PO DAILY
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth once a day
Disp #*10 Tablet Refills:*0
12. TraZODone 50 mg PO HS:PRN insomnia
RX *trazodone 50 mg 1 (One) tablet(s) by mouth at bedtime Disp
#*10 Tablet Refills:*0
13. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION BID
14. Tiotropium Bromide 1 CAP IH DAILY
15. Cepastat (Phenol) Lozenge 1 LOZ PO Q4H:PRN cough
16. PredniSONE 30 mg PO DAILY Duration: 4 Days
Start: ___ - First Routine Administration Time
___
Tapered dose - DOWN
RX *prednisone 10 mg as directed tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
17. PredniSONE 20 mg PO DAILY
Start: After 30 mg tapered dose
___
Tapered dose - DOWN
18. Albuterol Inhaler 1 PUFF IH Q6H Duration: 5 Days
RX *albuterol sulfate 90 mcg 1 (One) puff inhaled every six (6)
hours Disp #*1 Each Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: COPD exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST, TWO VIEWS: ___.
HISTORY: ___ female with COPD and worsening cough and wheezing.
COMPARISON: ___.
FINDINGS: Frontal and lateral views of the chest. The lungs are clear of
focal consolidation, effusion, or pulmonary vascular congestion. The
cardiomediastinal silhouette is within normal limits. No acute osseous
abnormality is identified. Degenerative changes seen at the acromioclavicular
joints.
IMPRESSION: No acute cardiopulmonary process.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Asthma exacerbation, Dyspnea
Diagnosed with OBSTRUCTIVE CHR. BRONCHITIS,WITH ACUTE EXACERBATION
temperature: 98.5
heartrate: 103.0
resprate: 20.0
o2sat: 98.0
sbp: 141.0
dbp: 84.0
level of pain: 13
level of acuity: 2.0 | ___ PMH significant for severe obstructive asthma/COPD (FEV1
0.9, 39% predicted, FEV1/FVC 66%), tracheomalacia, and multiple
admissions for exacerbation of COPD (most recently ___
who presented with shortness of breath c/w COPD exacerbation. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
blurry vision, left hand tingling, dizziness and headache
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a ___ yo F with a history of STEMI in ___,
HTN, HL, and remote history of migraines who presents with a
headache, change in vision, and transient L hand numbness.
History is obtained via ___ interpreter from patient and her
2 daughters, though the history is somewhat limited and very
difficult to obtain.
She reports that she had onset of headache at 2PM yesterday. She
was sitting at home, without any change from baseline (no change
in sleep, medications, or eating). She described it as a frontal
headache, ___ in intensity, and associated nausea/dizziness.
She
felt that her vision was blurry, without loss of vision or
blacking out of vision. She denies photophobia/phonophobia. She
says the head pain may have been worse with lying down, though
she inconsistently reported this during the evaluation. She
denies any neck pain, fevers or recent illness. She felt
generally weak, but no focal weakness. At 3PM, she had 2 minutes
of L wrist burning and L palmar numbness where she felt she
could
not feel anything on her hand up to the level of her wrist that
resolved within 2 minutes; she denies leaning on the hand that
she recalls. She reports that the headache was typical of her
prior migraines, though the last was ___ years ago. She has never
had any focal neurologic symptoms previously however.
She reports ___ seconds of chest pain yesterday around 11AM, not
related to her other symptoms and she denies any ongoing chest
pain.
She was scheduled to see stroke neurology in ___,
though did not show for the appointment. I called her PCP's
office and spoke with the doctor on call who reported that the
PCP ordered ___ brain MRI for persistent dizziness despite good BP
control; however, she was unable to tolerate the MRI due to
claustrophobia and it was therefore aborted. The patient reports
this MRI was "to look for lumps on her head". She did not know
she had a neurology appointment scheduled.
Currently, she reports no dizziness and that her headache has
essentially resolved. She said she took one pill for the pain,
though doesn't know the name of the medication.
On neurologic review of systems, the patient denies confusion.
Denies difficulty with producing or comprehending speech. Denies
loss of vision, diplopia, vertigo, tinnitus, hearing difficulty,
dysarthria, or dysphagia. Denies focal muscle weakness,
parasthesia.Denies bowel or bladder incontinence or retention.
Denies difficulty with gait.
On general review of systems, the patient denies fevers, rigors,
night sweats, or noticeable weight loss. Denies chest pain
though
reported 2 minutes of chest pain yesterday to another provided;
she has felt more of out breath recently. Denies vomiting,
diarrhea, constipation, or abdominal pain. No recent change in
bowel or bladder habits. Denies dysuria or hematuria. Denies
myalgias, arthralgias, or rash.
Past Medical History:
HTN
HLD
s/p STEMI and stent placement
colonoscopy ___ w/ diverticulosis (c/b GIB ___
Hernia repair
Appendectomy years ago
?tubal ligation
Social History:
___
Family History:
Her sister had some sort of cancer, unclear what kind. She has
12 children, 10 living. Many brothers and sisters. No family
history of GI cancer of any kind
Physical Exam:
Admission ___
PHYSICAL EXAMINATION
Vitals: 98.2 61 144/74 18 100% RA
General: NAD
HEENT: NCAT, some slight limitation in lateral neck movements
___: No cyanosis
Pulmonary: Breathing comfortably on RA
Extremities: Warm, no edema
Neurologic Examination:
MS: Awake, alert, oriented to her name, location and month but
not year or day of the month. Able to relate history, though
often changes her answers to the same question. Speech is fluent
with full sentences in ___. She appears to be able to repeat
a sentence in ___. Naming intact to high frequency objects
but difficulty with low frequency objects. No paraphasias. No
dysarthria. Normal prosody. No evidence of hemineglect. No
left-right confusion. Able to follow both midline and
appendicular commands.
Cranial Nerves - PERRL 3->2 brisk. Optic disc margins crisp
bilaterally. 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. Tongue midline.
Motor - Normal bulk and tone. No drift.
[Delt] [Bic] [Tri] [ECR] [IP] [Quad] [Ham] [TA] [Gas]
[C5] [C5] [C7] [C6] [L2] [L3] [L5] [L4] [S1]
L 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5
Sensory - No deficits to light touch, pin, or proprioception
bilaterally.
DTRs:
[Bic] [___] [Quad] [Achilles]
L 3+ 2+ 2+ 1+
R 3+ 2+ 2+ 1+
Plantar response flexor bilaterally.
Coordination - No dysmetria with finger to nose testing or HTS
bilaterally.
Gait - Normal initiation. Slightly wide-based and takes slow,
cautious steps because "she is tired".
_
________________________________________________________________
Discharge Exam ___
PHYSICAL EXAMINATION
Vitals: T: 98.5 BP: 149-192/77-86 HR: 60s RR:18 O2sat: 95%RA
General: NAD
Extremities: Warm, no edema
Neurologic Examination:
MS: Awake, ___. Able to recall history over recent days.
Speech is fluent with full sentences in ___. She appears to
be able to repeat a sentence in ___. No dysarthria. Able
to follow both midline and appendicular commands.
Cranial Nerves - PERRL 3->2 brisk. EOMI, no nystagmus. V1-V3
without deficits to light touch bilaterally. No facial movement
asymmetry. Hearing intact to finger rub bilaterally.
Motor - Normal bulk and tone. No drift.
[Delt] [Bic] [Tri] [ECR] [IP] [Quad] [Ham] [TA] [Gas]
[C5] [C5] [C7] [C6] [L2] [L3] [L5] [L4] [S1]
L 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5
Sensory - No deficits to light touch in upper and lower
extremities. Neg Phallen and ___ sign. Negative ___
maneuver
DTRs:
[Bic] [___] [Quad] [Achilles]
L 2+ 2+ 2+ 2+
R 2+ 2+ 2+ 2+
Coordination - No dysmetria with finger to nose testing or HTS
bilaterally.
Gait - slightly wide based, but able to ambulate without falling
Pertinent Results:
___ 04:44PM BLOOD WBC-5.2 RBC-4.78 Hgb-12.7 Hct-41.0 MCV-86
MCH-26.6 MCHC-31.0* RDW-13.7 RDWSD-43.3 Plt ___
___ 12:59AM BLOOD WBC-6.1 RBC-4.39 Hgb-11.6 Hct-37.0 MCV-84
MCH-26.4 MCHC-31.4* RDW-13.8 RDWSD-42.6 Plt ___
___ 04:44PM BLOOD ___ PTT-32.0 ___
___ 12:59AM BLOOD ___ PTT-30.3 ___
___ 04:44PM BLOOD Glucose-110* UreaN-16 Creat-1.0 Na-140
K-4.2 Cl-99 HCO3-28 AnGap-17
___ 12:59AM BLOOD Glucose-87 UreaN-15 Creat-0.9 Na-139
K-3.8 Cl-101 HCO3-26 AnGap-16
___ 12:59AM BLOOD ALT-12 AST-16 LD(LDH)-174 CK(CPK)-56
AlkPhos-52 TotBili-0.7
___ 04:44PM BLOOD cTropnT-<0.01
___ 12:59AM BLOOD CK-MB-1 cTropnT-<0.01
___ 04:44PM BLOOD Calcium-9.9 Phos-3.2 Mg-2.3 Cholest-131
___ 12:59AM BLOOD TotProt-6.6 Albumin-4.0 Globuln-2.6
Cholest-117
___ 08:29PM BLOOD %HbA1c-6.2* eAG-131*
___ 12:59AM BLOOD %HbA1c-5.8 eAG-120
___ 04:44PM BLOOD Triglyc-163* HDL-44 CHOL/HD-3.0
LDLcalc-54
___ 12:59AM BLOOD Triglyc-156* HDL-41 CHOL/HD-2.9
LDLcalc-45
___ 04:44PM BLOOD TSH-0.71
___ 12:59AM BLOOD TSH-1.2
___ 12:59AM BLOOD CRP-1.2
IMAGING:
CXR ___: AP upright and lateral views of the chest provided.
Lung volumes are low limiting assessment. Allowing for this,
there is no focal consolidation, large effusion or pneumothorax.
The heart is mildly enlarged. The overall hilar and
mediastinal configuration is unchanged. No acute bony
abnormalities.
NCHCT ___: There is no intra-axial or extra-axial hemorrhage,
edema, shift of normally midline structures, or evidence of
acute major vascular territorial infarction. Areas of
periventricular white matter hypodensity appears similar in
overall size pattern and extent from prior most likely
reflecting chronic microvascular ischemic disease. Ventricles
and sulci are normal in overall size and configuration. The
imaged paranasal sinuses are clear. Mastoid air cells and middle
ear cavities are well aerated. The bony calvarium is intact.
Bilateral TMJ arthritis is again noted.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin EC 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Carvedilol 12.5 mg PO DAILY
4. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
5. Losartan Potassium 50 mg PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Outpatient Physical Therapy
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Carvedilol 12.5 mg PO BID
5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
6. Losartan Potassium 50 mg PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
8.Outpatient Physical Therapy
Discharge Disposition:
Home
Discharge Diagnosis:
Vestibular migraine
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: ___ with neuro symptoms// assess for pna or ICH
COMPARISON: ___
FINDINGS:
AP upright and lateral views of the chest provided. Lung volumes are low
limiting assessment. Allowing for this, there is no focal consolidation,
large effusion or pneumothorax. The heart is mildly enlarged. The overall
hilar and mediastinal configuration is unchanged. No acute bony
abnormalities.
IMPRESSION:
As above.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with neuro symptoms
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) = 702 mGy-cm.
COMPARISON: Comparison with ___
FINDINGS:
There is no intra-axial or extra-axial hemorrhage, edema, shift of normally
midline structures, or evidence of acute major vascular territorial
infarction. Areas of periventricular white matter hypodensity appears similar
in overall size pattern and extent from prior most likely reflecting chronic
microvascular ischemic disease. Ventricles and sulci are normal in overall
size and configuration. The imaged paranasal sinuses are clear. Mastoid air
cells and middle ear cavities are well aerated. The bony calvarium is intact.
Bilateral TMJ arthritis is again noted.
IMPRESSION:
No acute intracranial process. Chronic microvascular ischemic disease.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Headache, Visual changes
Diagnosed with Chest pain, unspecified
temperature: 98.2
heartrate: 61.0
resprate: 18.0
o2sat: 100.0
sbp: 144.0
dbp: 74.0
level of pain: unable
level of acuity: 2.0 | Ms. ___ is a ___ yo F, ___, with a history of
STEMI in ___, HTN on 4 agents, HL, and remote history of
migraines who presented on ___ with an episode of headache,
change in vision, and transient L hand numbness concerning for
ACS vs. stroke vs. peripheral neuropathy. Admitted to neurology
for further work-up and evaluation. Upon arrival to the
hospital, she did not exhibit any additional episodes. Her
cardiac work-up in the ED was negative and NCHCT showed no signs
of acute infarct.
Neurology: She reported 2 min episode of left hand
tingling/numbness on ___ that self resolved, following by a 24
hour HA. The sensory episode followed a brief period of
non-radiating chest pain. The patient stated that the HA she ahd
is similar to the migraines that she used to have years ago.
#numbness/tingling: There were no sensory or motor deficits
noted on neurological exam during her admission. The tingling
sensation that she reported followed a median nerve distribution
on the left hand. Given the negative Head CT, and the median
nerve pattern of sensory changes, it was determined that the
episoded was unlikely to be related to a stroke. More likely,
the sensory changes are related to a peripheral nerve issue
given the median nerve distribution. Of note, she had a negative
phalen sign on exam. Can consider nerve conduction studies as
outpatient if episodes persist. Her stroke labs were notable for
an elevated triglyceride level (150s), but were otherwise
unremarkable.
#HA: 24 hour HA without neck pain that self-resolved and was
accompanied by blurry vision. Given her description of this HA
as similar to previous migraines, and no findings on CT, this
was determined to be a migraine. She had no further episodes.
Cardiac: Patient has a history of STEMI in ___, and presented
with brief episode of non-exertional substernal CP without
radiation that self-resolved. No additional episodes on
admission. Of note, her most recent EKG stress test done in ___
and was unremarkable. Cardiac work-up (EKG, CXR, trop) was
negative during this admission. There is no concern for ACS, but
should follow-up with PCP.
#HTN: Given concern for stroke, home HTN meds were held as
inpatient and restarted on discharge.
_
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________________________________________________________________ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Codeine / Streptokinase / Iodine / Bee Pollens
Attending: ___.
Chief Complaint:
shortness of breath and hypoxia
Major Surgical or Invasive Procedure:
PICC line in right arm
History of Present Illness:
___ y/o male with a history of COPD on 6L at home, DM2, afib on
coumadin, SLE, chronic pain on narcotics who presented to his
PCP's office with shortness of breath and hypoxia. He was
recenlty admitted to ___ at the beginning of ___
with fever, SOB, hypoxia. Had been taking levofloxacin before
this and received a few days of IV ceftriaxone as well as
Azithro. He was discharged on home oxygen to wear during day
which he has been since as well as oral antibiotics to complete
___ day course which he completed ___ days ago. A couple days
after finishing he started feeling worse with increased SOB,
decreased appetitie, fatigue. He then started taking
levofloxacin 750mg daily again (has standing script at home) and
has been on this the last 5 days. However has continued to
worsen, SOB with any movement. Home oxygen sat in mid 80%
despite 4L NC. This AM with fever to 101 orally and had episode
of nausea and vomiting. Also coughed up some brown sputum today
(otherwise not coughing much). Wife wanted him to go to ER but
decided to wait for his clinic visit this afternoon. In clinic
the day of his presentation initial O2 sat was 87% on 4L oxygen.
Repeat was 95% x 2 after patient sitting still for 20 min.
.
Initial VS in the ED: 97.2 80 124/78 100% 2L. Patient was give
CTX and azithrmycin. chest X-ray showed extensive new
opacification, particularly in the right middle and lower lobes,
most suggestive of pneumonia with pleural effusions. He was
admitted for pneumonia and possible HCAP.
.
On the floor, the patient stated that he was doing well. He
noted that he was feeling slightly better. He noted that all of
his symptoms are primarily from his lungs.
.
Review of systems:
(+) Per HPI
(-) Denies chills, night sweats, recent weight loss or gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denied cough, shortness of breath. Denied chest pain or
tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
Type II Diabetes on oral agents
Systemic Lupus Erythematosus
Coronary Artery Disease s/p MI in ___
Hepatitis C
COPD with emphysema and asthmatic component (FEV1 60% predicted
___
Diastolic Congestive Heart Failure EF 55% in ___
Seizure disorder
TIA 199
Colon Cancer s/p resection in ___ without chemotherapy
s/p abdominal trauma with subsequent splenectomy and amputation
of digits of his left hand
Hyperlipidemia
Hypertension
h/o cocaine abuse
Neuropathy and chronic pain on methadone
Chronic Atrial Fibrillation on Coumadin
Obstructive Sleep Apnea on home CPAP
Left Total Knee Replacement ___
Social History:
___
Family History:
Adopted so unknown
Physical Exam:
Admission Physical Exam
Vitals: T: 97.6 BP: 149/87 P: 76 O2: 96 6L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: coarse breath sounds bilaterally R>L, no wheezes noted,
descreased breath sounds on the right
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
Discharge Physical Exam
Vitals: Temp: 98.7 BP: (122/76-140/87) (84-96) 98% 6L
General: patient was alert and oriented
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: improved breath sounds, crackles noted that the bases,
wheezing noted bilaterally
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
Pertinent Results:
Admission Labs
___ 05:00PM BLOOD WBC-10.3 RBC-3.58* Hgb-9.7* Hct-32.3*
MCV-90 MCH-27.0 MCHC-29.9* RDW-15.6* Plt ___
___ 05:00PM BLOOD Plt ___
___ 06:30AM BLOOD ___ PTT-42.7* ___
___ 05:00PM BLOOD Glucose-126* UreaN-12 Creat-0.9 Na-138
K-3.4 Cl-97 HCO3-34* AnGap-10
___ 06:30AM BLOOD Calcium-8.5 Phos-3.4 Mg-2.0
Imaging
Chest X-Ray ___:
IMPRESSION: Extensive new opacification, particularly in the
right middle and lower lobes, most suggestive of pneumonia with
pleural effusions, although reticulation in the mid lung zones
may be due to coinciding fluid overload or sequelae of the
inflammatory process.
Chest X-Ray ___:
IMPRESSION:
1. Right PICC line with the tip in the upper SVC.
2. Development of opacities at the right base which may
represent
atelectasis, however infectious process cannot be excluded.
3. Slight improvement in retrocardiac and left middle lung zone
opacities.
Micro Data
Urine Legionalla ___: negative
Urine Culture ___: negative
Blood Culture ___: NGTD (final culure pending upon discharge)
Discharge Labs
___ 04:55AM BLOOD WBC-11.7* RBC-3.41* Hgb-9.2* Hct-31.4*
MCV-92 MCH-27.1 MCHC-29.4* RDW-15.7* Plt ___
___ 04:55AM BLOOD ___ PTT-34.2 ___
___ 04:55AM BLOOD Glucose-101* UreaN-23* Creat-1.1 Na-136
K-3.7 Cl-94* HCO3-37* AnGap-9
___ 04:55AM BLOOD Calcium-8.4 Phos-3.2 Mg-2.1
___ 05:09PM BLOOD Vanco-32.7*
Medications on Admission:
1. Captopril 100 mg PO TID
Hold is SBP<90
2. Gabapentin 600 mg PO QID
3. Prochlorperazine 10 mg PO Q6H:PRN Nausea
4. Hydroxychloroquine Sulfate 200 mg PO BID
5. Nicotine Patch 21 mg TD DAILY
6. Oxazepam 30 mg PO HS:PRN Insomnia
7. Metoprolol Tartrate 50 mg PO BID
Hold if SBP<90, HR<50
8. Docusate Sodium 100 mg PO TID
9. Senna 1 TAB PO BID Constipation
10. CloniDINE 0.1 mg PO BID
Hold for SBP<90
11. Tizanidine 4 mg PO QHS
12. Warfarin 7.5 mg PO DAILY16
13. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB/Wheezing
14. Fluoxetine 60 mg PO DAILY
15. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
16. Nitroglycerin SL 0.3 mg SL PRN Chest Pain
17. Simvastatin 40 mg PO DAILY
18. Methadone 10 mg PO QID
iin AM, 1 at noon, 2 tabs at 6pm, 2 tabs qhs as needed for for
pain
19. HydrALAzine 25 mg PO Q6H
Hold if SBP<90
20. Omeprazole 20 mg PO BID
21. Spironolactone 25 mg PO DAILY
Hold if SBP<90
22. Torsemide 50 mg PO DAILY
Hold if SBP<90
23. Aspirin 325 mg PO DAILY
24. Heparin 5000 UNIT SC TID
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Captopril 100 mg PO TID
Hold is SBP<90
3. CloniDINE 0.1 mg PO BID
Hold for SBP<90
4. Docusate Sodium 100 mg PO TID
5. Fluoxetine 60 mg PO DAILY
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
7. Gabapentin 600 mg PO QID
8. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
9. HydrALAzine 25 mg PO Q6H
Hold if SBP<90
10. Hydroxychloroquine Sulfate 200 mg PO BID
11. Methadone 10 mg PO QID
1 in AM, 1 at noon, 2 tabs at 6pm, 2 tabs qhs as needed for for
pain
RX *methadone 10 mg four times a day Disp #*18 Tablet Refills:*0
12. Metoprolol Tartrate 50 mg PO BID
Hold if SBP<90, HR<50
13. Nicotine Patch 21 mg TD DAILY
14. Nitroglycerin SL 0.3 mg SL PRN Chest Pain
15. Omeprazole 20 mg PO BID
16. Oxazepam 30 mg PO HS:PRN Insomnia
17. Senna 1 TAB PO BID Constipation
18. Simvastatin 40 mg PO DAILY
19. Spironolactone 25 mg PO DAILY
Hold if SBP<90
20. Tizanidine 4 mg PO QHS
21. Torsemide 50 mg PO DAILY
Hold if SBP<90
22. Warfarin 5 mg PO DAILY16
23. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB/Wheezing
24. CefePIME 2 g IV Q12H
End Date of ___. Prochlorperazine 10 mg PO Q6H:PRN Nausea
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
- HCAP
- Acute Renal Failure
Secondary
- Chronic Pain
- Atrial Fibrillation
- Diastolic Congestive Heart Failure
- Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPHS
HISTORY: Dyspnea.
COMPARISONS: ___.
Chest CT is also available from ___.
TECHNIQUE: Chest, PA and lateral.
FINDINGS: The heart is mildly enlarged. The aorta is again mildly tortuous.
There is patchy regional opacification of the right middle and lower lobes
suggesting pneumonia with fluid along the major and minor fissures as well as
a suspected small pleural effusion. A small pleural effusion is also
suspected on the left. Hazy opacification and reticulation involving each mid
lung zone may be associated with superimposed mild vascular congestion or
fluid overload, but also could be secondary to widespread inflammatory
process. There is no pneumothorax. The cardiac, mediastinal and hilar
contours appear unchanged. Bony structures are unremarkable.
IMPRESSION: Extensive new opacification, particularly in the right middle and
lower lobes, most suggestive of pneumonia with pleural effusions, although
reticulation in the mid lung zones may be due to coinciding fluid overload or
sequelae of the inflammatory process.
Radiology Report
STUDY: AP chest ___.
CLINICAL HISTORY: ___ man with COPD and low saturations. Evaluate
for mucus plug.
FINDINGS: Comparison is made to previous study from ___.
There is globular cardiomegaly. There is improved aeration at the right lung
base; however, there remains a pleural effusion. No pneumothoraces are seen.
There is a new fluid seen marginating in the minor fissure on the right side.
Radiology Report
INDICATION: ___ man with new right PICC 46cm.
COMPARISON: Prior radiographs from ___.
FINDINGS: There is a new right PICC catheter with the tip in the upper SVC.
There is no pneumothorax. Since the prior radiograph, there has been slight
increase in opacities at the right base which may represent atelectasis, but
infectious process cannot be excluded. Small right pleural effusion with
fluid in the minor fissure are stable. Retrocardiac and right middle lung
zone opacities are slightly improved. Again seen is globular cardiomegaly
mostly unchanged.
IMPRESSION:
1. Right PICC line with the tip in the upper SVC.
2. Development of opacities at the right base which may represent
atelectasis, however infectious process cannot be excluded.
3. Slight improvement in retrocardiac and left middle lung zone opacities.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: SOB
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, HYPERTENSION NOS, SYST LUPUS ERYTHEMATOSUS, UNSPECIFIED VIRAL HEPATITIS C WITHOUT HEPATIC COMA, HX OF COLONIC MALIGNANCY
temperature: 98.8
heartrate: 84.0
resprate: 22.0
o2sat: 95.0
sbp: 151.0
dbp: 93.0
level of pain: 0
level of acuity: 2.0 | ___ y/o male with a history of COPD on 6L at home, DM2, afib on
coumadin, SLE, chronic pain on narcotics who presented to his
PCP's off with shortness of breath and hypoxia.
# Health Care Associated Pneumonia: Patient has significant COPD
at baseline however with cough, fever and chest x-ray findings,
symptoms likely due to pneumonia. Due to him being in a hospital
setting recently and not responding to levaquin, he likely
developed an health care associated pneumonia with considerable
concern about resistant organisms. The differential also
included a COPD exacerbation and heart failure however these
were felt to be less likely given recent history. He was started
on vancomycin and cefepime on ___ with almost immediate
improvement in his symptoms. Plan is to complete an eight day
course of antibiotics. Unfortunately, he was unable to produce
an adequate sputum sample for sputum culture although blood
cultures remained negative. Plan is to complete an eight day
course of antibiotics.
# Leukocytosis: Patient was noted to have elevated an WBC to 14
on ___. Unclear etiology however came down to normal limits.
This developed in the midst of treatment for a pneumonia leading
to concern for C diff though he never had diarrhea or other
symptoms. This resolved without particular intervention. All
cultures remained negative.
# Acute Renal Failure: Patient's creatinine was noted to be up
this to 1.3 on ___. Improved to 1.1 prior to discharge. FeUrea
was noted to be 56%. A Vanco trough was checked given this
change in renal function and was noted to be 32 and he was
redosed per pharmacy recommendations.
# Methadone Overdose: Patient developed increased somnolence and
near unresponsiveness on the morning of ___. Given use of
methadone and apparent intoxication was dosed with naloxone *1
with rapid improvement in mental status. He later endorsed
having taken additional methadone that he had found among his
belongings. After this episode he was continued on his home
methadone with strong admonishments not to take additional
doses.
# Atrial fibrillation: He was well controlled on his usual
anticoagulation and nodal regimen after initially having an
elevated INR. He was restarted on his coumadin 5mg daily prior
to discharge.
# Hypertension: He appears to have difficult to control
hypertension and is on multiple antihypertensive. He was
continued on his home regimen.
# Depression: He was continued on her home fluoxetine.
# Congestive Heart Failure: He appeared to be euvolemic on exam.
He was continued on his torsemide. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aspirin / Penicillins / Morphine / IV Dye, Iodine Containing
Contrast Media
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old lady with a PMH chronic
pancreatitis, s/p CCY and TAH, referred in by outpatient GI
physician (___) for acute on chronic severe abdominal
pain, anorexia and vomiting.
Per patient and review of chart has a long history of abdominal
pain which started s/p ERCP in ___.
Typical pain is located in epigastrium, described as a gnaw/ache
constant in duration. Reports food and drink aggravate pain.
Pain medications help alleviate pain. Per patient reports
gradual worsening of pain over the last 2 months necessiating
uptitration of pain meds. She recently saw Dr ___ on ___ who
was concerned pain represented an acute flare and he ordered
abdominal imaging to better assess. In the interim patient
reported acute worsening of pain with associated episodes of
NBNB vomiting, with inability to tolerate anything PO, even
liquids. Worsening of pain prompted presentation to the ED.
In the ED, initial VS were: 97.2 140/93 76 16 99%. Labs were
notable for normal LFT's, AG of 13, CBC wnl, lactate 1.3, UA
negative, and PTT elevated 67.8, but normal ___. She was
given several doses of ondansetron, droperidol and Dilaudid. VS
prior to transfer were: 98.2 120/81 68 18 99%.
On arrival to the floor, patient reported epigastric pain, she
was placed on IVF, IV pain medications as well as prn
anti-emetics
This morning she reports persistent epigastric pain with
incomplete relief with 1mg dilaudid. Additionally complains of
thirst, and mild nausea with vomiting. Last BM one day prior.
Denies signs of pancreatic insufficiency.
Of note, over the 2months, patient endorses 28 pounds weight
loss. She has required TPN 6x in the last; longest duration of
TPN lasted 2mths.
REVIEW OF SYSTEMS:
(+) positive as noted in the HPI, weight loss over 2 months.
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, diarrhea, constipation, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
#. s/p CCY at age ___
#. ERCP with sphincterotomy and removal of bile duct stone in
___, question of pancreatic injury
#. Chronic Abddminal pain since ___ after ERCP. Extensive w/u
with repeat CT and ___ (with secretin) show NO evidence of
pancreatitis as previously believed. no ERCP given anatomy after
gastric bypass. Seen by Dr. ___. Recently started on TPN ___
#. History of recurrent "clots", ___ patient with multiple UE
DVT in setting of PICC placements. Recent US ___ with chronic
recanalized cephalic DVT
#. s/p TAH-unilateral oophorectomy at age ___
#/ Obesity s/p Roux-en-Y gastrojejunal bypass with gastric
stapling at ___ in ___
- Lost 136lbs from surgery.
#. arthorscopies in knees on several occasions, last one in ___
#. Depression/anxiety, recent loss of father ___
#. Ventral hernias, not thought to be causing abdominal symptoms
Social History:
___
Family History:
Father: Died age ___ from stroke, CAD
Mother: Alive age ___ - CAD, DM2
Physical Exam:
VS - 98.0 106/58 65 16 98%RA 104.0kg
GENERAL - well-appearing woman in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, dry MM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
CHEST - port-a-cath on right side of chest without erythema, TTP
or fluctuance
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/ND, very TTP in upper epigastrium, no
tender in other quadrant, no masses or HSM, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical LAD
NEURO - non-focal
Discharge exam:
VS - 98.0 116/58 66 16 98%RA
GENERAL - well-appearing woman in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
CHEST - port-a-cath on right side of chest without erythema, TTP
or fluctuance
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/ND, improved tenderness to palpation in
upper epigastrium, non-tender in other quadrant, no masses or
HSM, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical LAD
NEURO - non-focal
Pertinent Results:
___ 05:00PM BLOOD WBC-7.6# RBC-4.23 Hgb-13.7 Hct-40.2
MCV-95 MCH-32.5* MCHC-34.2 RDW-12.4 Plt ___
___ 02:59AM BLOOD WBC-5.2 RBC-3.89* Hgb-12.3 Hct-37.4
MCV-96 MCH-31.5 MCHC-32.8 RDW-12.8 Plt ___
___ 08:20AM BLOOD WBC-5.8 RBC-4.05* Hgb-12.9 Hct-39.0
MCV-96 MCH-31.9 MCHC-33.2 RDW-12.6 Plt ___
___ 05:00PM BLOOD ___ PTT-67.8* ___
___ 05:00PM BLOOD Glucose-86 UreaN-7 Creat-0.8 Na-138 K-3.8
Cl-104 HCO3-21* AnGap-17
___ 02:59AM BLOOD Glucose-87 UreaN-7 Creat-0.7 Na-140 K-4.0
Cl-108 HCO3-26 AnGap-10
___ 08:20AM BLOOD Glucose-82 UreaN-6 Creat-0.7 Na-139 K-4.1
Cl-106 HCO3-27 AnGap-10
___ 05:00PM BLOOD ALT-8 AST-14 AlkPhos-71 TotBili-0.2
___ 02:59AM BLOOD ALT-6 AST-11 AlkPhos-59 Amylase-39
TotBili-0.4
___ 05:00PM BLOOD Lipase-22
___ 02:59AM BLOOD Lipase-30
___ 05:00PM BLOOD Albumin-4.1 Calcium-8.8 Phos-3.4 Mg-2.2
___ 02:59AM BLOOD Albumin-3.4* Calcium-8.3* Phos-3.7 Mg-2.2
___ 08:20AM BLOOD Calcium-8.6 Phos-3.4 Mg-1.9
___ 08:11AM BLOOD Calcium-9.1 Phos-3.6 Mg-1.8
___ 05:37PM BLOOD Lactate-1.3
___ 02:59AM BLOOD Triglyc-108
CXR:
There is no radiopaque/metal density material in the port. The
port tip is at the mid SVC. Cardiomediastinal contours are
normal. The lungs are clear. There is no pneumothorax or
pleural effusion.
___
The liver is of diffusely low signal on T2 weighted imaging
indicating iron overload however concurrent fatty deposition
cannot be excluded. The spleenis also of diffusely low signal
consistent with hemosiderosis. No focal hepatic lesion. The
portal and hepatic veins are patent. There is
conventional hepatic arterial anatomy. There is dilatation of
the intra and extrahepatic bile ducts, the common hepatic duct
measures 18 mm and the common bile duct measures 9 mm tapering
to normal within the pancreatic head, no intraductal filling
defect. The patient is status post cholecystectomy and the
findings are unchanged from the prior study.
The pancreas is diffusely atrophic in nature, unchanged. The
pancreatic duct is slightly prominent measuring 3 mm. There is
minimal exocrine pancreatic response following administration of
secretin. No pancreatic duct stricture. No peripancreatic fluid.
No adrenal lesion. Visualized portions of the kidneys are
unremarkable. No
focal renal lesion or hydronephrosis. There is a small amount of
fluid
adjacent to the caudate lobe of the liver, this was also the
prior study and is of uncertain significance. There has been a
prior Roux-en-Y gastric
bypass.
No upper abdominal or retroperitoneal lymphadenopathy. The
visualized small and large bowel are unremarkable. No
abnormality identified at the lung bases.
IMPRESSION:
1. Atrophy of the pancreas with minimal exocrine pancreatic
function post
administration of secretin. Mildly prominent pancreatic duct
however no focal dilatation or stricture.
2. Intra and extrahepatic biliary dilatation, unchanged from
previously. The common bile duct tapers to normal within the
pancreatic head with no
intraductal filling defect. The patient is status post
cholecystectomy.
3. Previous Roux-en-Y gastric bypass.
4. Diffuse low T2 signal within the liver and spleen consistent
with
hemosiderosis.
5. Small amount of fluid adjacent to the caudate lobe of the
liver, of
uncertain significance but likely present on the prior study,
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Promethazine 25 mg PO Q6H:PRN nausea
2. Prochlorperazine 10 mg PO Q6H:PRN nausea
3. Oxycodone SR (OxyconTIN) 20 mg PO Q12H
hold for RR < 12, AMS or somnolence
4. Tolterodine 1 mg PO DAILY Start: In am
5. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
6. Venlafaxine XR 75 mg PO DAILY Start: In am
7. Cyanocobalamin 1000 mcg IM/SC 2X PER MONTH
8. Vitamin D2 *NF* (ergocalciferol (vitamin D2)) 50,000 unit
Oral 1x per week
9. Soma *NF* (carisoprodol) 350 mg Oral TID PRN: skeletal muscle
spasm
10. Clonazepam 1 mg PO BID
Discharge Medications:
1. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
2. Oxycodone SR (OxyconTIN) 20 mg PO Q12H
hold for RR < 12, AMS or somnolence
3. Prochlorperazine 10 mg PO Q6H:PRN nausea
4. Promethazine 25 mg PO Q6H:PRN nausea
5. Tolterodine 1 mg PO DAILY
6. Venlafaxine XR 75 mg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Clonazepam 1 mg PO BID
9. Cyanocobalamin 1000 mcg IM/SC 2X PER MONTH
10. Soma *NF* (carisoprodol) 350 mg Oral TID PRN: skeletal
muscle spasm
11. Vitamin D2 *NF* (ergocalciferol (vitamin D2)) 50,000 unit
Oral 1x per week
Discharge Disposition:
Home
Discharge Diagnosis:
Chronic Abdominal pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
PA AND LATERAL VIEWS OF THE CHEST
REASON FOR EXAM: Assess for metal in the port.
There is no radiopaque/metal density material in the port. The port tip is at
the mid SVC. Cardiomediastinal contours are normal. The lungs are clear.
There is no pneumothorax or pleural effusion.
Radiology Report
HISTORY: Chronic abdominal pain and presented with acute flare-up. ?
pancreatic insufficiency.
TECHNIQUE: Multiplanar T1 and T2 weighted imaging was obtained on a 1.5 T
magnet, including dynamic 3D imaging obtained prior to, during and subsequent
to the intravenous administration of 0.1 mmol/kg of Gadavist (10 ml). Oral
GastroMARK and ReadiCAT was administered for enteric marking. 16 mcg of
secretin was administered IV.
COMPARISON: MRCP ___.
FINDINGS:
The liver is of now diffusely low signal on T2 weighted imaging and dropping
signal on gradient echo images, indicating iron overload however concurrent
fatty deposition cannot be excluded. The spleen is also of diffusely low
signal consistent with hemosiderosis. No focal hepatic lesion. The portal
and hepatic veins are patent. There is conventional hepatic arterial anatomy.
There is dilatation of the intra and extrahepatic bile ducts, the common
hepatic duct measures 18 mm and the common bile duct measures 9 mm tapering to
normal within the pancreatic head, no intraductal filling defect. The patient
is status post cholecystectomy and the findings are unchanged from the prior
study.
The pancreas is diffusely atrophic in nature, unchanged. The pancreatic duct
is slightly prominent measuring 3 mm. There is relatively minimal pancreatic
juice production in response to the administration of secretin. No
significant ductal dilation results. Although some pancreatic juices are
produced, it is less than typically seen. No evidence of pancreatic duct
stricture. No peripancreatic fluid.
No adrenal lesion. Visualized portions of the kidneys are unremarkable. No
focal renal lesion or hydronephrosis. There is a small amount of fluid
adjacent to the caudate lobe of the liver of uncertain significance. There
has been a prior Roux-en-Y gastric bypass.
No upper abdominal or retroperitoneal lymphadenopathy. The visualized small
and large bowel are unremarkable. No abnormality identified at the lung
bases.
IMPRESSION:
1. Atrophy of the pancreas with minimal pancreatic juice producation post
administration of secretin. Mildly prominent pancreatic duct however no focal
dilatation or stricture. The degree of parenchymal atrophy appears worse than
in ___.
2. Intra and extrahepatic biliary dilatation, unchanged from previously. The
common bile duct tapers to normal within the pancreatic head with no
intraductal filling defect. The patient is status post cholecystectomy.
3. Previous Roux-en-Y gastric bypass.
4. Diffuse low T2 signal within the liver and spleen consistent with
hemosiderosis. This is new since the prior examination. The possibility of
concurrent fatty liver cannot be excluded given the degree of iron deposition.
5. Small amount of fluid adjacent to the caudate lobe of the liver, of
uncertain significance.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: ABDOMINAL PAIN
Diagnosed with ABDOMINAL PAIN GENERALIZED
temperature: 97.2
heartrate: 76.0
resprate: 16.0
o2sat: 99.0
sbp: 140.0
dbp: 93.0
level of pain: 8
level of acuity: 3.0 | Ms. ___ is a ___ year old lady with a diagnosis of chronic
pancreatitis, s/p CCY and TAH presenting with acute on chronic
abdominal pain.
# Abdominal pain. On admission patient reported persistent
gnawing epigastric pain that radiates to the back with
associated nausea/vomiting over the last several weeks with
concomittant weight loss. Per record, patient carries diagnosis
of chronic pancreatitis. Admission labs within normal limits
including an albumin of 3.4. Patient was placed on bowel rest,
IVF, IV pain meds and antiemetics. After discussion with
outpatient GI physician, ___ with secretin study was ordered to
assess pancreatic function. Before ___ could be finalized by an
attending radiologist patient reported that she was tolerating
PO and requesting discharge. Encouraged patient to remain in
house for at least additional 24hr while diet advanced and PO
medication tolerated however patient insisted on leaving. As she
was normotensive and tolerating PO decision made to allow
discharge with plan to follow-up with primary care as well as
primary GI. She was discharged on home pain medication regimen. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
Ciprofloxacin / Cephalosporins / clindamycin / vancomycin
Attending: ___.
Chief Complaint:
___ y/o M with long history of chronic right sided pelvic
osteomyelitis, sciatic palsy, b/l foot drop s/p fall from the
___
floor (___) admitted with fever and pain in r hip/pelvis
Major Surgical or Invasive Procedure:
1. Irrigation and Debridement, application of wound vac x8
2. Surgical prep, site 25 x 35 cm.
3. External oblique muscle flap.
4. Rectus femoris muscle flap.
5. Tensor fascia ___ muscle flap.
6. Vastus lateralis muscle flap.
History of Present Illness:
HPI: ___ w/hx aortic disruption and multiple pelvic femoral
fractures i/s/o fall from ___ floor (___) resulting in
paraplegia subsequently managed with ORIF c/b multiple
infections including pseudomonal osteomyelitis requiring
hemipelvectomy now admitted with dehiscence of his R
hemipelvectomy wound site s/p multiple I and D's.
Past Medical History:
Right pelvic, acetabular fracture
Chronic pelvic osteomeylitis
Right girdlestone procedure
Hyperlipidemia
Hypertension
Chronic pain
Social History:
___
Family History:
Non-Contributory
Physical Exam:
GEN: pleasant, NAD, sitting up in bed
HEENT: PERRL, EOMI, sclerae anicteric, moist mucous membranes,
no
ulcers, lesions or thrush
NECK: supple
CARD: RRR, normal S1, S2, no murmurs, rubs or gallops
PULM: clear to auscultation bilaterally w/o wheezes, rhonchi,
rales
BACK: no focal tenderness, no costovertebral angle tenderness
ABDM: large surgical incision extending from R lower quadrant/
previous ASIS inferiorly to inguinal fold and onto anterior
thigh. Surgical wound adherent, well appearing except for 5cm
defect in groin lateral to the scrotum. Area with surrounding
mild erythema. Wound circumference with fibrinous white/yellow
tissue, no tenderness or purulence. Dressing with serous
drainage
NEURO: No motor or sensory function below knee at baseline
bilaterally. Otherwise intact sensation in UEs.
EXT: no ___ edema, warm
Pertinent Results:
on discharge: wbc 9.1 hg 7.1 crp 106
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
2. Amlodipine 10 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Senna 8.6 mg PO BID:PRN constipation
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
6. Budesonide Nasal Inhaler 1 INH Other BID
7. Tizanidine 4 mg PO QHS
8. Warfarin 5 mg PO DAILY16
9. ALPRAZolam 0.5 mg PO TID:PRN anxiety
10. Aspirin 81 mg PO DAILY
11. Lovastatin 20 mg oral DAILY
12. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
Discharge Medications:
1. Daptomycin 500 mg IV Q24H
RX *daptomycin [Cubicin] 500 mg 500 mg IV every 24 hourrs Disp
#*21 Vial Refills:*0
2. ALPRAZolam 0.5 mg PO TID:PRN anxiety
3. Amlodipine 10 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
6. Senna 8.6 mg PO BID:PRN constipation
7. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
8. Tizanidine 4 mg PO QHS
9. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
only take as needed
RX *bisacodyl 10 mg 1 suppository(s) rectally per day Disp #*30
Suppository Refills:*0
10. Ketoconazole 2% 1 Appl TP BID
apply to groin area
RX *ketoconazole 2 % apply thin layer to area twice per day
Refills:*0
11. Nystatin Cream 1 Appl TP BID:PRN rash, itchiness
RX *nystatin 100,000 unit/gram apply thin layer twice per day
Refills:*0
12. Pulmicort Flexhaler (budesonide) 180 mcg/actuation
inhalation BID
13. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
14. Budesonide Nasal Inhaler 1 INH Other BID
15. Lovastatin 20 mg ORAL DAILY
16. Aspirin 81 mg PO DAILY
17. Enoxaparin Sodium 40 mg SC Q24H Duration: 4 Weeks
RX *enoxaparin 40 mg/0.4 mL 1 syringe sc daily Disp #*28 Syringe
Refills:*0
18. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN severe
pain
RX *oxycodone 30 mg 1 tablet(s) by mouth every 4 hours Disp #*60
Tablet Refills:*0
19. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain not relieved
by oxycodone or tylenol
RX *hydromorphone 2 mg ___ tablet(s) by mouth every 3 hours Disp
#*240 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
right hemipelvectomy wound healing problems
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: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old man with PICC line // ?picc placement ?picc
placement
IMPRESSION:
In comparison with the study of ___, there has been placement of a
right subclavian catheter that extends to the lower portion of the SVC.
Little change in the appearance of the cardiac silhouette. There is increased
opacification in the retrocardiac region, suggesting volume loss in the left
lower lobe. No evidence of vascular congestion.
Radiology Report
INDICATION: ___ year old man I D, vac change for R hip. preop CXR // preop
CXR Surg: ___ (vac change, I D)
FINDINGS:
Right-sided PICC line with the tip in the low SVC. Previously seen left
retrocardiac opacity has improved. The lungs are mildly hyperinflated with
emphysema. No pulmonary edema. No pleural effusions or pneumothorax.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CTA AORTA/BIFEM/ILIAC RUNOFF W/WANDWO C AND RECONS
INDICATION: ___ year old man with pelvic osteo, abscesses sp I D, needs flap
// vessel flow/patency, eval for future flap
TECHNIQUE: Run off CTA: Non-contrast images and arterial phase images were
acquired from diaphragm through toes. Delayed images were obtained from the
knees to the toes.
IV Contrast: 100mL of Omnipaque
Oral contrast was not administered.
MIP reconstructions were performed on independent workstation and reviewed on
PACS.
DOSE: Total DLP (Body) = 2,690 mGy-cm.
COMPARISON: CT of the pelvis dated ___.
FINDINGS:
VASCULAR:
There is no abdominal aortic aneurysm. An infrarenal IVC filter is present,
with multiple filter prongs and the tip of the filter seen external to the
inferior vena cava lumen. There is minimal calcium burden in the abdominal
aorta and great abdominal arteries. A focus of calcium at the origin of the
celiac trunk results in mild narrowing. The SMA, bilateral single renal
arteries, and ___ all appear patent.
RIGHT LOWER EXTREMITY: Minimal calcified plaque is seen within the common
iliac artery, without evidence of flow-limiting stenosis. The internal and
external iliac arteries are widely patent. The lateral circumflex femoral
artery is patent. The superficial femoral artery and popliteal artery appear
patent. There is normal three-vessel runoff in the lower extremity. Note is
made of marked fatty atrophy of the muscles of the right lower extremity and
right foot, with skin thickening and subcutaneous edema seen throughout the
lower extremity and foot as well. The right leg is foreshortened due to prior
surgery.
LEFT LOWER EXTREMITY: Mild calcified plaque is present within the left common
iliac artery, without evidence of flow-limiting stenosis. The internal and
external iliac arteries are patent. The common femoral, superficial femoral,
and the lateral circumflex femoral arteries are patent. The popliteal artery
is patent. There is normal three-vessel runoff in the left lower extremity.
A plate with screws is seen along the healed fracture through the midshaft of
the left femur.
LOWER CHEST: Minimal atelectasis is noted in the lung bases. A right-sided
fat containing Bochdalek's hernia is present. There is no pleural or
pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The imaged portion of 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 imaged portion of 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.
A 1.4 x 1.7 cm partially exophytic cyst arises from the upper pole of the left
kidney. There is no evidence of stones, 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. Colon and rectum are within normal limits.
Dilatation of the appendix 1.3 cm appears grossly unchanged. No surrounding
fat stranding.
LYMPH NODES: There is no evidence of retroperitoneal lymphadenopathy.
PELVIS: Asymmetrical thickening of the right side of the bladder is stable.
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: Patient is status post right hemipelvectomy and
resection of the proximal right femur. A wound VAC is present over the
surgical site in the right groin. There are multiple areas of calcification,
with marked soft tissue distortion, thickening and fat stranding seen within
the resection bed. There has been interval drainage of multiple previously
seen rim enhancing collections within the surgical bed. A 9.1 x 7 cm cavity
containing debris and gas with a tract to the skin (___:48), is located
superior and medial to the surgical margin of the femur, in a place where a
fluid collection previously existed. A circumscribed fluid collection is seen
within the lower portion of the psoas muscle (3a:85).
The right femoral resection margin appears stable, without evidence of active
osteomyelitis. Exuberant heterotopic ossification is seen surrounding this
margin.
IMPRESSION:
1. Status post right hemipelvectomy and resection of the proximal right femur.
There has been interval drainage of multiple previously seen rim enhancing
fluid collections within the surgical bed. A 9.1 x 7 cm cavity containing
debris and gas with a tract to the skin is located superior and medial to the
surgical margin of the femur, in a place where a fluid collection previously
existed.
2. Patent bilateral lateral circumflex femoral arteries. No flow-limiting
stenoses seen within the lower extremity arterial structures. Normal 3 vessel
runoff seen within the bilateral lower legs.
3. Persistent thickening of the appendix without surrounding fat stranding.
4. Unchanged thickening of the right wall of the bladder.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___
___ on the telephoneon ___ at 6:26 ___, 90 minutes after discovery of
the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with flaps for pelvic osteo // edema, PE, pna,
atelectasis edema, PE, pna, atelectasis
IMPRESSION:
In comparison with the study of ___, accounting for differences in the
degree of obliquity, there is little overall change. No evidence of acute
focal pneumonia, vascular congestion, or pleural effusion. Right subclavian
PICC line extends to the mid portion of the SVC.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: R Hip pain, Wound eval, Fever
Diagnosed with Peritoneal abscess
temperature: 97.0
heartrate: 125.0
resprate: 20.0
o2sat: 100.0
sbp: 141.0
dbp: 75.0
level of pain: 7
level of acuity: 2.0 | Patient had significant lower extremity trauma after a fall ___
years ago. He underwent multiple surgeries for this issue and
developed chronic osteomyelitis that failed repeated
debridements. He had R hemipielvectomy on previous admission and
was admitted for dehiscence of his wound. He had been treated in
rehab with wound vac but the wound was producing more drainage
and required admission. During his stay he was treated with
multiple debridements in the operating room by both Dr ___
___ Dr. ___. Infectious disease was consulted regarding
Pseudomonas infection and recommended continuing aztreonam.
Plastic surgery was consulted for assistance in wound closure
and muscle flaps for wound coverage which was performed on
___. He required multiple transfusions during his stay for
anemia. Antibiotics were switched to long term daptomycin. His
wound was significantly improved on discharge but did have
persistent drainage in the area near the groin. His CRP
continued to trend down indicating that his infection was being
adequately treated. This was felt to be stable and he was
discharged with wet to dry dressings to home. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
atorvastatin
Attending: ___.
Chief Complaint:
TIA and abnormal MRI
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ male who had a syncopal episode and
LOC at the gym one week ago with associated RUE weakness and
transient paralysis lasting about one minute. He has never had
similar sypmtoms and has been asypmtomatic since. He had an
outpatient MRI done yesterday which demonstrated tight left
carotid stenosis and small cortical infarcts in the left
frontal, parietal, and occipital lobes suggestive of recurrent
embolic events. He was contacted by his PCP and told to present
to the ED for evaluation by vascular surgery. He is currently
asymptomatic.
Past Medical History:
PMH: hyperlipidemia, HTN, CAD s/p cardiac cath with stenting x2,
GERD, SCC, CHF (EF 45%)
PSH: left shoulder surgery
Social History:
___
Family History:
FH: Negative for any CAD. Positive for history of colon cancer
Physical Exam:
On admission:
PE: 98.6 60 116/67 18 99% RA
NAD, AAOx3
Neuro intact with no cranial nerve defects or weakeness
RRR
CTA b/l
soft, ND, NT abdomen
no peripheral edema, extremities warm and well-perfused
Fem Pop DP ___
R p p p p
L p p p p
Examination of discharge is unchanged.
Pertinent Results:
Duplex carotid US ___ - wet read):
1. Occluded left internal carotid artery.
2. 70-79% occlusion of the right internal carotid artery.
CTA neck ___ - wet read):
1. Complete occlusion of the left internal carotid artery with
intermittent trickle flow in the distal and petrous left ICA
with reconstitution at the cavernous left intracranial ICA.
2. Approximately 60% stenosis of the right internal carotid
artery.
3. Stenosis at the origin of the right vertebral artery, but the
remainder of the vessel is patent.
4. 4 mm right apical pulmonary nodule. Per the ___
guidelines, if the patient has risk factors for lung malignancy,
followup with dedicated chest CT is recommended in ___ year.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 50 mg PO DAILY
2. Ezetimibe 10 mg PO DAILY
3. Lisinopril 5 mg PO DAILY
4. Pantoprazole 40 mg PO Q24H
5. Nitroglycerin SL 0.4 mg SL PRN chest pain
6. Viagra (sildenafil) 50 mg oral as needed
7. Aspirin 81 mg PO DAILY
8. Simvastatin 40 mg PO DAILY
Discharge Medications:
1. Atenolol 50 mg PO DAILY
2. Nitroglycerin SL 0.4 mg SL PRN chest pain
3. Viagra (sildenafil) 50 mg ORAL AS NEEDED
4. Simvastatin 40 mg PO DAILY
5. Pantoprazole 40 mg PO Q24H
6. Lisinopril 5 mg PO DAILY
7. Ezetimibe 10 mg PO DAILY
8. Aspirin 325 mg PO DAILY
Please increase your aspirin dose from 81mg to 325mg.
Discharge Disposition:
Home
Discharge Diagnosis:
Occlusive left-sided carotid stenosis
60-79% right-sided carotid stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA NECK WANDW/OC AND RECONS
INDICATION: ___ year old man with ? carotid disease. please include carotids
and arch // ___ year old man with ? carotid disease. please include carotids
and arch
TECHNIQUE: Rapid axial imaging was performed from the aortic arch through the
neck during infusion of Omnipaque intravenous contrast material. Images were
processed on a separate workstation with display of curved reformats, 3D
volume redendered images, and maximum intensity projection images.
DOSE: DLP: 1144.22 mGy-cm
COMPARISON: Carotid ultrasound ___
FINDINGS:
Neck CTA: There is a four vessel takeoff from the aortic arch with the left
vertebral artery originating from the arch, normal variant.
The right common carotid artery is patent. Hard and soft atherosclerotic
plaque is seen at the bifurcation of the right carotid artery with narrowing
of the right internal carotid artery to 4 x 2 mm at the site of maximal
stenosis (2:161). The distal right ICA is 5 mm.
Soft atherosclerotic plaque is seen at the left common carotid artery without
significant stenosis. The left internal carotid artery is occluded from the
bifurcation to the intracranial petrous portion with reconstitution at the
cavernous left intracranial ICA. There may be intermittent trickle flow
within the distal cervical ICA through the petrous portion.
Atherosclerotic calcifications are seen at the origin of the right vertebral
artery with stenosis at the origin, but the remainder of the right vertebral
artery is patent. The left vertebral artery is patent. There is no significant
stenosis, occlusion, or evidence of dissection.
A 4 mm right apical nodule is noted (2:47). Prominent mediastinal lymph nodes
are not enlarged by CT size criteria ranging up to 9 mm in the left hilum. The
visualized paranasal sinuses are clear. Sclerosis in the left mastoid air
cells may be related to chronic inflammation. A disc osteophyte complex is
noted at C6-C7.
IMPRESSION:
1. Complete occlusion of the left internal carotid artery with intermittent
trickle flow in the distal and petrous left ICA with reconstitution at the
cavernous left intracranial ICA.
2. Approximately 50% stenosis of the right proximal internal carotid artery.
3. Stenosis at the origin of the right vertebral artery, but the remainder of
the vessel is patent.
4. 4 mm right apical pulmonary nodule. Per the ___ guidelines, if the
patient has risk factors for lung malignancy, followup with dedicated chest CT
is recommended in ___ year.
NOTIFICATION: The preliminary findings were discussed by Dr. ___
with Dr. ___ in person on ___ at 3:50 ___.
Radiology Report
EXAMINATION: CAROTID DOPPLER ULTRASOUND
INDICATION: ___ year old man with TIA, left carotid stenosis on MRI // carotid
stenosis
TECHNIQUE: Real-time grayscale and color and spectral Doppler ultrasound
imaging of carotid arteries was obtained.
COMPARISON: CTA of the neck ___
FINDINGS:
RIGHT:
Heterogeneous plaque in the right internal carotid artery.
The right common carotid artery had peak systolic/diastolic velocities of
76/33 cm/sec.
The right internal carotid artery had peak systolic/diastolic velocities of
82/36 cm/sec in its proximal portion, 250 / 95 cm/sec in its mid portion and
102/27 cm/sec in its distal portion.
The external carotid artery has peak systolic velocity of 140cm/sec.
The vertebral artery has peak systolic velocity of 63 cm/sec with normal
antegrade flow.
The right ICA/CCA ratio is 3.2..
LEFT:
The left internal carotid artery is completely occluded.
The left common carotid artery had peak systolic/diastolic velocities of 55/14
cm/sec.
The external carotid artery has peak systolic velocity of 96cm/sec.
The vertebral artery has peak systolic velocity of 48 cm/sec with normal
antegrade flow.
IMPRESSION:
1. Occluded left internal carotid artery.
2. 70-79% occlusion of the right internal carotid artery.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: ABNORMAL MRI
Diagnosed with OCCLUS CAROTID ART NO INFARCT
temperature: 98.6
heartrate: 60.0
resprate: 18.0
o2sat: 99.0
sbp: 116.0
dbp: 67.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ was admitted to the hospital for further workup of his
TIA and left sided carotid stenosis visualized on outpatient
MRI. Duplex US was performed and failed to demonstrated any
flow through the left carotid artery. CTA of the neck was also
performed and though the radiology wet read commented on a
possible trick flow through the carotid, on review of the study
by the vascular team this did not seem convincing. Neurology
was consulted and saw the patient. They recommended either
angio or maitenance on coumadin if we were convinced of flow
through the artery, or discharge and observation on just aspirin
if we felt the left carotid to be occluded. When all three
studies (MRI, CTA and duplex) were taken into consideration we
felt that the artery was most likely occluded and opted to
discharge the patient on aspirin therapy, with follow-up for the
right sided carotid stenosis. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
pedestrian hit by car
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This patient is a ___ year old male who complains of ETOH.
This is an ___ male who arrived to the ED from EMS
after he was struck by a car at extremely low speed and fell
to his right knee. There was no reported head trauma per
bystanders. The patient is heavily intoxicated and admits to
drinking alcohol tonight. Only complaint is pain on his
right ribs and difficulty breathing.
Past Medical History:
no ___
Social History:
___
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION ___
Temp: 97.0 HR: 60 BP: 110/50 Resp: 16 O(2)Sat: 95 Normal
Constitutional: pale, appears intoxicated
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light
Chest: Clear to auscultation, chest wall tenderness
palpation in the right lower lateral ribs but no crepitus
appreciated
Cardiovascular: Normal
Abdominal: Normal
Extr/Back: abrasion right knee, no crepitus, able to range,
pelvis stable x3
Neuro: Normal
PHYSICAL EXAM ON DISCHARGE ___
Vitals: 98.1, 121/74, 65, 18, 99%ra
General: A&Ox3
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, mucous membranes moist
Chest: Diminished lung sounds in RLL, chest wall tenderness to
palpation in the right lower lateral ribs but no crepitus
appreciated
Cardiovascular: HRR, normal S1/S2
Abdominal: Soft, NT/ND
Extr/Back: abrasion right knee
Neuro: Intact
Pertinent Results:
___ 02:20AM BLOOD WBC-7.9 RBC-4.91 Hgb-15.3 Hct-43.9 MCV-89
MCH-31.1 MCHC-34.8 RDW-12.9 Plt ___
___ 02:20AM BLOOD Neuts-50 Bands-1 ___ Monos-5 Eos-1
Baso-0 Atyps-8* ___ Myelos-0
___ 02:20AM BLOOD Glucose-124* UreaN-14 Creat-0.9 Na-145
K-3.5 Cl-107 HCO3-23 AnGap-19
___ 02:20AM BLOOD ALT-75* AST-93* AlkPhos-125 TotBili-0.3
___ 02:20AM BLOOD Lipase-36
___ 02:20AM BLOOD Albumin-4.7
IMAGING
___- CHEST XRAY: Right rib fractures with subtle increased
opacity of the adjacent right lung.
___- CT C-SPINE W/O CONTRAST: No evidence for acute
cervical spine fracture. Right pneumothorax.
___- CT HEAD W/O CONTRAST: No acute findings.
___- CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST: 1.
Right rib fractures with underlying lung laceration, contusion,
and small
pneumothorax. 2. Right adrenal hyperdense nodule, which likely
represents acute hemorrhage. Followup MRI is recommended to
exclude underlying mass.
___- CXR: In comparison with the earlier study of this date,
there is a moderate right pneumothorax. An area of increased
opacification at the right base posteriorly could represent
pulmonary contusion or even superimposed consolidation.
___- CXR: 1. Decreased but persistent right apical
pneumothorax.
2. Increased right mid and lower lung opacities, which
correspond with
pulmonary contusions seen on recent CT.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain
do not exceed 3000mg/day
2. Docusate Sodium 100 mg PO BID
3. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
Narcotics may cause dizziness and drowsiness. do not drive or
drink while taking this
Discharge Disposition:
Home
Discharge Diagnosis:
1. Right ___ non-displaced right rib fractures
2. Right lung laceration,
contusion, and tiny pneumothorax
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ male pedestrian struck.
COMPARISON: None available.
TECHNIQUE: Frontal chest radiograph was obtained portably with the patient in
a supine position.
FINDINGS:
No pleural effusion, pneumothorax, or pulmonary edema is evident on this
single supine view. Heart and mediastinal contours are within normal limits.
Multiple minimally and non-displaced right rib fractures are seen, better
evaluated on concomitant CT; there is subtle increased opacity of the adjacent
right lung.
IMPRESSION:
Right rib fractures with subtle increased opacity of the adjacent right lung.
Radiology Report
HISTORY: ___ male pedestrian struck.
COMPARISON: None available.
TECHNIQUE: Head CT was performed without intravenous contrast. Multiplanar
reformatted images were reviewed.
FINDINGS:
There is no CT evidence for acute intracranial hemorrhage, large mass, mass
effect, edema, or hydrocephalus. There is preservation of gray-white matter
differentiation. The basal cisterns appear patent. The ventricles and sulci
are normal in caliber and configuration. No acute bony abnormality is
detected. The visualized portions of the paranasal sinuses and mastoid air
cells appear well aerated. No acute extracranial soft tissue abnormality is
detected.
IMPRESSION:
No acute findings.
Discussed with Dr. ___ by Dr. ___ in person at the time of image
acquisition.
Radiology Report
HISTORY: ___ male pedestrian struck.
COMPARISON: None available.
TECHNIQUE: CT of the cervical spine was performed without intravenous
contrast. Multiplanar reformatted images were reviewed.
FINDINGS:
2 corticated ossific fragments posterior to the posterior arch of C1 on the
left (2:20) are likely chronic. The ring of C1 is intact and the C1-2
articulation is preserved. There is no CT evidence for acute cervical spine
fracture. Cervical spine alignment is preserved. There is no prevertebral
soft tissue swelling. Several small foci of pleural air are seen along the
right lung apex, more thoroughly evaluated on concomitant chest CT.
IMPRESSION:
No CT evidence for acute cervical spine fracture.
Right pneumothorax, better evaluated on concomitant chest CT.
Discussed with Dr. ___ by Dr. ___ in person at the time of image
acquisition.
Radiology Report
HISTORY: ___ male pedestrian struck.
COMPARISON: None available.
TECHNIQUE: CT of the chest, abdomen, and pelvis was acquired after
administration of intravenous contrast. Multiplanar reformatted images were
reviewed.
FINDINGS:
Chest: A lung laceration is seen in the right lower lobe with surrounding
ground-glass opacity, consistent with hemorrhage. An additional small focus
of contusion is seen in the right upper lobe. Small foci of air are seen in
the right pleural space along the right apex as well as along the right lower
lobe adjacent to the liver and along the right middle lobe medially,
consistent with small pneumothorax. No left lung abnormality is detected. No
pleural effusion is seen. The central airways are patent with a small amount
of secretions layering in the proximal trachea.
The heart and mediastinum and great vessels are within normal limits. The
thyroid is homogeneous in attenuation. No lymphadenopathy is detected in the
chest.
Abdomen: Mild periportal edema is is seen without other acute abnormalities
of the liver. The gallbladder, spleen, pancreas, left adrenal gland, kidneys,
stomach, small bowel, colon, and appendix are within normal limits. There is
no free intraperitoneal air or ascites. The abdominal aorta is normal in
caliber with patent branch vessels. The portal vein, splenic vein, and
superior mesenteric vein appear patent.
A hyperdense nodule (65 hounsfield units) in the right adrenal gland measures
3.2 x 2.2 cm.
Pelvis: The urinary bladder, seminal vesicles, prostate, and rectum are
unremarkable. No free fluid is seen in the pelvis.
Bones: Minimally and nondisplaced posterior rib fractures are seen of the
right ___ through 11th ribs. A small corticated fragment is seen along the
left sacrum and therefore is likely chronic. Rudimentary 13th ribs are seen.
Subsequently, there are 5 non-rib-bearing lumbar vertebral bodies. There is
sacralization of L5, which is denoted by the iliolumbar ligaments.
IMPRESSION:
1. Multiple contiguous right rib fractures with underlying lung laceration,
contusion, and tiny pneumothorax.
2. Right adrenal hyperdense nodule, which likely represents acute hemorrhage.
Follow-up MRI is recommended to exclude underlying mass.
Findings and recommendations were discussed with Dr. ___ by Dr. ___ in
person at the time of image acquisition at approximately 3 a.m. on ___.
Radiology Report
HISTORY: Rib fractures and pulmonary laceration, to assess for pneumothorax.
FINDINGS: In comparison with the earlier study of this date, there is a
moderate right pneumothorax. An area of increased opacification at the right
base posteriorly could represent pulmonary contusion or even superimposed
consolidation.
This information was conveyed to Dr. ___.
Radiology Report
HISTORY: Status post trauma with right rib fractures and a right lung
laceration. Evaluate for interval change.
COMPARISON: Chest radiographs and CT torso from ___.
FINDINGS:
Frontal and lateral chest radiographs again demonstrate a normal
cardiomediastinal silhouette. Right mid and lower lung opacities are
increased from prior radiographs, and correspond with the pulmonary contusions
seen on recent CT. The right apical pneumothorax is decreased but still
present. There is no pleural effusion. Multiple right rib fractures are
again seen.
IMPRESSION:
1. Decreased but persistent right apical pneumothorax.
2. Increased right mid and lower lung opacities, which correspond with
pulmonary contusions seen on recent CT.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: ETOH
Diagnosed with FX MULT RIBS NOS-CLOSED, MV COLL W PEDEST-PEDEST, ALCOHOL ABUSE-UNSPEC
temperature: 97.0
heartrate: 60.0
resprate: 16.0
o2sat: 95.0
sbp: 110.0
dbp: 50.0
level of pain: 0
level of acuity: 3.0 | Mr ___ is a ___ year old male who was brought to ___
emergency department by EMS after being struck by a slow-moving
vehicle. Per patient and witnesses, there was no head strike and
no LOC. The patient was intoxicated and admitted to using
alcohol that night; he was hemodynamicall stable and complaining
of right-sided chest pain and difficulty breathing. CT imaging
showed ___ right rib fractures with underlying lung laceration,
contusion, and small pneumothorax. The patient was admitted to
the ___ service and watched closely on telemetry and continuous
O2 saturation monitoring. His pain was managed with IV morphine
and he was given supplemental oxygen via nasal cannula. Serial
standing expiratory chest x-rays (CXR) were taken to evaluate
the progression of his pneumothorax. On HD2 his CXR showed the
apical pneumothorax was decreased and the patient had remained
stable over night. His pain regimen was transitioned over to
oral analgesia with good effect. He was tolerating a regular
diet, voiding, and out of bed ambulating ad lib without any
issues. He was using his incentive spirometer as instructed. The
patient was discharged home on the afternoon of HD2 in stable
condition. His parents were at the bedside and planned on taking
him home to ___ to aide in his recovery. During the
initial work up of his injuries, there was an incidental finding
of a right adrenal hyperdense nodule, which likely represented
an acute hemorrhage, however, followup with MRI was recommended
to exclude underlying mass. The patient and his family were
aware of this incidental finding and had already scheduled an
appointment with the patient's PCP in ___ to have it
addressed. At the time of discharge, thorough instructions were
given to the patient and his family about activity restrictions,
danger signs and follow-up. There was a follow-up appointment
scheduled for 2 weeks in the ___ clinic. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Back and leg pain
Major Surgical or Invasive Procedure:
Anterior/posterior lumbar fusion L3-S1
L4-5 discectomy
History of Present Illness:
___ with PMH s/p L3-S1 laminectomy/discectomy for cauda equina
___ by Dr. ___ p/w left low back pain since yesterday.
Bent over to pick up his computer bag and twisted somehow and
had immediate severe pain in left low back radiating down to L
knee. Throughout day pain progressed and also feels slightly
weaker in LLE although has some baseline LLE weakness, as well
as R foot drop at baseline. At baseline has some mild saddle
anesthesia and decreased rectal tone (does self rectal
stimulation as needed) this has not changed recently. No
urinary/bowel incontinence but some evidence for retention. No
hx IVDU, other trauma, fevers/chills, headache, pain elsewhere.
Today pain was so bad was unable to ambulate so came to ED.
Past Medical History:
- Cauda equina s/p L3-S1 laminectomy with L3-4 discectomy
- Seasonal allergies
Social History:
___
Family History:
Grandmother with colon ___
Mother with liver ___
Father with esophageal ___
Grandfather with renal ___
Physical Exam:
GEN: Well appearing, pleasant middle aged man in NAD
VS 98.0 80 144/85 16 100% RA
Motor
Delt EF EE WF WE Grip IO
R ___ 5
L ___ 5
Sensation grossly intact in all UE dermatomes
Add Quad HS TA ___
R ___
L ___ 4+ 4+ 4+
Sensation grossly intact in all ___ dermatomes
Reflexes
R/L
Biceps 1+
Triceps 1+
BR 1+
Patella 1+
Achilles 1+
Babinski: downgoing
Clonus: none
Perianal sensation: intact
Rectal tone: minimally diminished
Pertinent Results:
___ 06:15AM BLOOD WBC-6.7 RBC-3.01* Hgb-8.7* Hct-26.3*
MCV-87 MCH-28.8 MCHC-33.0 RDW-12.9 Plt ___
___ 05:55AM BLOOD WBC-11.8* RBC-3.74* Hgb-10.7* Hct-32.6*
MCV-87 MCH-28.6 MCHC-32.9 RDW-12.9 Plt ___
___ 09:00PM BLOOD WBC-15.5* RBC-4.08* Hgb-11.7*# Hct-35.7*#
MCV-87 MCH-28.7 MCHC-32.8 RDW-12.9 Plt ___
___ 10:24AM BLOOD WBC-15.7*# RBC-5.35 Hgb-15.4 Hct-46.8
MCV-88 MCH-28.8 MCHC-32.9 RDW-13.0 Plt ___
___ 05:55AM BLOOD Glucose-113* UreaN-16 Creat-0.8 Na-137
K-4.5 Cl-101 HCO3-28 AnGap-13
___ 09:00PM BLOOD Glucose-111* UreaN-19 Creat-0.9 Na-140
K-4.4 Cl-104 HCO3-27 AnGap-13
___ 10:24AM BLOOD Glucose-115* UreaN-13 Creat-1.2 Na-140
K-4.7 Cl-101 HCO3-29 AnGap-15
___ 06:30AM BLOOD Glucose-98 UreaN-13 Creat-0.7 Na-140
K-4.4 Cl-103 HCO3-30 AnGap-11
___ 05:55AM BLOOD Calcium-7.7* Phos-3.2 Mg-1.7
___ 09:00PM BLOOD Calcium-7.6* Phos-3.3 Mg-1.6
Medications on Admission:
Dilaudid
Discharge Medications:
1. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Q3H Disp #*200 Tablet
Refills:*0
2. Morphine SR (MS ___ 30 mg PO Q12H
RX *morphine [MS ___ 30 mg 1 tablet extended release(s) by
mouth twice a day Disp #*60 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
4. Diazepam ___ mg PO Q8H:PRN spasm
RX *diazepam 5 mg ___ tablets by mouth every eight (8) hours
Disp #*90 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Lumbar stenosis and disc herniation
Discharge Condition:
Good
Followup Instructions:
___
Radiology Report
INTRAOPERATIVE RADIOGRAPHS OF THE LUMBAR SPINE
CLINICAL INDICATION: ___ male status post lumbar spinal fusion.
TECHNIQUE: Four intraoperative radiographs of the lumbar spine were obtained.
___.
FINDINGS:
A marker was placed between the L4 through L5 intervertebral disc space.
There has previously been laminectomy from L2 through L5. There is presumed
anterior fusion from L3 to S1. Please refer to the intraoperative report for
further details.
IMPRESSION: A marker placed between the L4 through L5 intervertebral disc
space. Please refer to the intraoperative report for further details.
Radiology Report
INTRAOPERATIVE RADIOGRAPHS OF THE LUMBAR SPINE:
CLINICAL INDICATION: Status post fusion of L3 through S1.
TECHNIQUE: Six intraoperative radiographs of the lumbar spine were obtained.
___.
FINDINGS:
There has been laminectomy at at least L2 through L5. Markers were placed
posterior to the lower lumbar vertebral bodies. There has been interval
posterior fusion of L3 through S1. No overt hardware complication is seen.
Mild degenerative change is present through the lower lumbar spine with
spurring about the vertebral bodies. Please refer to the intraoperative
report for further details.
IMPRESSION: Status post posterior fusion of L3 through S1, without overt
hardware complication. Please refer to the intraoperative report for further
details.
Radiology Report
HISTORY: Patient with lumbar stenosis, evaluate for residual disc.
COMPARISON: MR ___ from ___.
TECHNIQUE: Multiplanar, multi sequence MR images of the lumbar spine were
obtained without the administration of IV contrast.
FINDINGS:
At the T12-L1 level, there is mild midline disc protrusion without spinal
stenosis. At the L1-L2 level, there is a mild disc bulge and tiny protrusion
with minimal encroachment on the spinal canal.
At the L2 -L3 level, there is a disc protrusion and annular tear left of the
midline without significant spinal canal stenosis. There is evidence of a
prior laminectomy.
At the L3-L4 level, there is limited view at this level, but no apparent
abnormalitY is identified. There has also been previous laminectomy.
At the L4-L5 level, there has been slight interval improvement in the right
sided annular tear and disc protrusion. However, a large residual disc
fragment remains on the left with protrusion into ventral thecal sac. This
fragment extends superiorly into the posterior margin of the L4 vertebral
body, unchanged in appearance since preop study. There is mild to moderate
right neuroforaminal narrowing due to facet osteophytes and ligamentum flavum
thickening.
At the L5-S1 level, there has been a laminectomy with pedicle screws without
significant disc bulge.
There is expected postoperative edema in the spinal erector muscles. High
signal intensity is seen in L3 and L4 vertebral bodies on STIR sequence
consistent with postsurgical marrow edema. The distal spinal cord
demonstrates normal signal characteristics.
IMPRESSION:
1. Slight improvement in L4-L5 right sided disc bulge. However, there is a
large left-sided residual disc herniation fragment extending superiorly to the
posterior margin of the L4 vertebral body.
2. Multilevel degenerative changes as described above.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: BACK PAIN
Diagnosed with LUMBAR DISC DISPLACEMENT, BACKACHE NOS
temperature: 98.8
heartrate: 80.0
resprate: 16.0
o2sat: 98.0
sbp: 158.0
dbp: 82.0
level of pain: 10
level of acuity: 3.0 | Mr. ___ was admitted to the ___ Spine Surgery Service on
___ and taken to the Operating Room for L3-S1 interbody
fusion through an anterior approach. Please refer to the
dictated operative note for further details. The surgery was
without complication and the patient was transferred to the PACU
in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
given per standard protocol. Initial postop pain was controlled
with a PCA. On HD#2 he returned to the operating room for a
scheduled L3-S1 decompression with PSIF as part of a staged
2-part procedure. Please refer to the dictated operative note
for further details. The second surgery was also without
complication and the patient was transferred to the PACU in a
stable condition. Postoperative HCT was stable. A bupivicaine
epidural pain catheter placed at the time of the posterior
surgery remained in place until postop day one. Post-op he
continued to have considerable sciatica and a new MRI was
obtained which showed a large disc fragment behind the L4
vertebral body. He was taken to the OR for a L4-5 discectomy
and tolerated the procedure well. He was kept NPO until bowel
function returned then diet was advanced as tolerated. The
patient was transitioned to oral pain medication when tolerating
PO diet. Foley was removed on POD#2 from the second procedure.
He was fitted with a lumbar warm-n-form brace for comfort.
Physical therapy was consulted for mobilization OOB to ambulate.
Hospital course was otherwise unremarkable. On the day of
discharge the patient was afebrile with stable vital signs,
comfortable on oral pain control and tolerating a regular diet. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fluid overload during EGD
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ female with a history of cirrhosis likely attributed
to hepatitis C and alcohol, history of HIV, on Atripla, history
of pulmonary hypertension, on Sildenafil and bosentan, and
history of heroin abuse, currently on methadone who presents
with dyspnea.
Patient was scheduled for EGD today to evaluate varices, last
EGD from OSH on ___ showed mild gastric varices, but no
evidence of esophageal varices. Reportedly, the procedure was
aborted secondary to fluid overload and an inability to lay
flat. She has never had issues with gastrointestinal bleeding or
abdominal fluid, requiring paracentesis. The patient reported
that for the past ___ weeks she has been having increasing
dyspnea on exertion such that she can no longer walk up a half a
flight of stairs. She reports for the past year she has had 4
pillow orthopnea that is unchanged from previously. She reports
that her legs have been intermittently edematous, but currently
her ___ edema is the best that it has been. She has noted
increasing abdominal girth, but denies any early satiety or
decreased appetite. Typically has ___ soft nonbloody,
non-melenic BMs daily. Denies any fevers, chills, cough, CP,
PND, platypnea, melena, N/V, abdominal pain.
In the ED, initial vital signs were:98.5 54 118/57 12 97%. The
patient's labs were notable for Chem 7 WNL (Cr 0.9), WBC 4.0,
H&H 10.4/32.7, platelets 80. INR 1.2. lactate 0.8. LFTs with ALt
33, AST 75, albumin 3.0, Tbili 1.2. alk phos 164. BNP 298. Trop
<0.01. The patient did not receive any medications. Blood
cultures were obtained. RUQ US showed cirrhosis with patent
portal veins. CXR showed potentially mild edema. Hepatology was
consulted in the ED, and based RUQ images it does not appear
that there is a substantial amount of ascites that would be
amendable to paracentesis. Vital Signs prior to transfer:98.4 52
115/57 16 96% RA
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
1. Cirrhosis in the setting of hepatitis C and alcohol: She is
genotype 1A and is naive to treatment, IL28 CC, previously
decompensated with hepatic encephalopathy. MELD of 14. Her
___ status was ___ B. She previously did have an
endoscopy in ___ that was reportedly notable for mild
gastric varices.
2. History of HIV, currently stable on Atripla, last CD4 count
665 with undetectable viral load.
3. History of pulmonary hypertension: Prior echocardiogram
notable for PA systolic pressures in the ___ as well as some
right heart dysfunction. It is unclear where or when her prior
right heart catheterization was done; however, she remains on
sildenafil as well as bosentan.
4. History of IV drug use, currently on methadone.
5. Hyperthyroidism on methimazole with a history of Graves'
disease in the past.
6. History of hypercalcemia attributed to hyperthyroidism.
7. Remote history of pulmonary embolism in the past.
8. Iron deficiency anemia.
9. Hyperlipidemia.
10. Depression.
Social History:
___
Family History:
No family history of liver diseases
Physical Exam:
Admission exam:
VS:98.4 133/64 93 94%RA Wt 79.6
General: Awake watching tv when entered room Well-appearing,
NAD, AOx3
HEENT: Sclera anicteric, PERRL, EOMI
Neck: Supple, difficult to determine JVD, but EJ is distended,
thyroid fullness
CV: Nl S1, loud S2, III/VI SEM loudest at LLSB
Lungs: rhonchi throughout with some fine expiratory crackles at
bases
Abdomen: Softly distended, tympanic to percussion, no shifting
dullness to percussion
GU: No foley
Ext: +clubbing, difficult to determine if cyanosis given nail
___, No asterixis, 1+ Edema to knees, 2+ pulses
Neuro: CNII-XII grossly intact
Skin: + spider angiomata,
Discharge exam:
VS: 98.2 145/65 59 20 97% RA
General: Alert, NAD
HEENT: Sclera anicteric, PERRL, EOMI
Neck: Supple, EJ is distended up to 4cm at 30 degrees with (+)
hepatojugular reflex, thyroid fullness
CV: Nl S1, loud S2, III/VI SEM loudest at ___ and increases
with expiration
Lungs: rhonchi throughout with some fine expiratory crackles at
bases
Abdomen: Softly distended, tympanic to percussion,
Ext: +clubbing, trace edema at ankles bilaterally, 2+ pulses
Neuro: oriented x3, CNII-XII grossly intact, no asterixis
Pertinent Results:
Admission:
___ 05:02PM BLOOD WBC-4.0 RBC-2.97* Hgb-10.4* Hct-32.7*
MCV-110* MCH-35.2* MCHC-31.9 RDW-14.5 Plt Ct-80*
___ 05:02PM BLOOD ___ PTT-47.2* ___
___ 05:02PM BLOOD Glucose-103* UreaN-14 Creat-0.9 Na-142
K-3.6 Cl-113* HCO3-25 AnGap-8
___ 05:02PM BLOOD ALT-33 AST-75* AlkPhos-164* TotBili-1.2
___ 05:02PM BLOOD Albumin-3.0*
___ 08:50AM BLOOD Calcium-8.4 Phos-3.2 Mg-2.0
Discharge:
___ 06:45AM BLOOD WBC-4.5 RBC-2.98* Hgb-10.6* Hct-32.9*
MCV-111* MCH-35.4* MCHC-32.0 RDW-14.4 Plt Ct-81*
___ 06:45AM BLOOD ___ PTT-42.8* ___
___ 06:45AM BLOOD Glucose-132* UreaN-17 Creat-1.0 Na-137
K-3.3 Cl-106 HCO3-23 AnGap-11
___ 06:45AM BLOOD ALT-25 AST-65* AlkPhos-148* TotBili-1.2
___ 06:45AM BLOOD Albumin-2.8* Calcium-8.3* Phos-3.5 Mg-1.9
Imaging:
CXR ___:
IMPRESSION:
Mildly increased diffuse interstitial markings are nonspecific
but could
represent mild edema.
RUQ u/s ___:
IMPRESSION:
1. Cirrhosis with splenomegaly.
2. Patent portal veins.
Echo ___:
Conclusions
The left atrium is mildly dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). There is no ventricular septal defect. The
right ventricular cavity is mildly dilated with normal free wall
contractility. There is abnormal systolic septal motion/position
consistent with right ventricular pressure overload. 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 leaflets are structurally
normal. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional left ventricular systolic
function. Dilated right ventricle with evidence of mild pressure
overload and mild pulmonary hypertension. Early appearance of
agitated saline bubbles in the left atrium/ventricle at rest.
This finding is most consistent with an ASD or stretched patent
foramen ovale - however a relatively proximal ___
shunt could also cause early bubbles.
Compared with the prior study (images reviewed) of ___,
estimated pulmonary pressures are lower. Bubbles were given on
the current study. The other findings are similar.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
2. bosentan 62.5 mg oral BID
3. ATRIPLA (efavirenz-emtricitabin-tenofov) ___ mg oral
daily
4. Furosemide 20 mg PO TID
5. Lactulose 30 mL PO BID
6. Methimazole 7.5 mg PO DAILY
7. Methadone 70 mg PO DAILY
8. Mirtazapine 15 mg PO HS
9. Propranolol 30 mg PO BID
10. Sildenafil 20 mg PO TID
11. Spironolactone 25 mg PO DAILY
12. Pantoprazole 40 mg PO Q24H
13. Rifaximin 550 mg PO BID
14. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
2. Lactulose 30 mL PO TID
3. Methimazole 7.5 mg PO DAILY
4. Pantoprazole 40 mg PO Q24H
5. Rifaximin 550 mg PO BID
6. Sildenafil 20 mg PO TID
RX *sildenafil 20 mg 1 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*0
7. ATRIPLA (efavirenz-emtricitabin-tenofov) ___ mg oral
daily
8. bosentan 62.5 mg oral BID
RX *bosentan [Tracleer] 62.5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
9. Ferrous Sulfate 325 mg PO DAILY
10. Furosemide 60 mg PO DAILY
RX *furosemide 20 mg 3 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*1
11. Methadone 60 mg PO DAILY
12. Propranolol 20 mg PO BID
RX *propranolol 20 mg 1 tablet(s) by mouth twice a day Disp #*14
Capsule Refills:*0
13. Spironolactone 150 mg PO DAILY
RX *spironolactone 50 mg 3 tablet(s) by mouth daily Disp #*90
Tablet Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: hepatic encephalopathy
Secondary diagnosis: cirrhosis, hepatitis C, human
immunodeficiency virus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Chest pain and shortness of breath.
COMPARISON: None.
FINDINGS: Frontal and lateral views of the chest. Heart size is top normal.
Mediastinal contours are unremarkable. Interstitial markings appear diffusely
mildly increased without focal consolidation. No pleural effusion or
pneumothorax. Chronic right-sided rib fractures are appreciated.
IMPRESSION:
Mildly increased diffuse interstitial markings are nonspecific but could
represent mild edema.
Radiology Report
HISTORY: HCV cirrhosis with worsening abdominal distention.
COMPARISON: ___.
FINDINGS:
The liver is mildly echogenic with a coarsened echotexture, consistent with
known cirrhosis. No focal hepatic lesion is identified. The gallbladder is
decompressed, limiting evaluation. The common duct measures 5 mm and there is
no intra- or extra-hepatic bile duct dilatation. The visualized portion of
the pancreas is unremarkable. The pancreatic tail obscured by overlying bowel
gas. The spleen is enlarged, measuring 13.0 cm. There is no ascites. The
left kidney measures 11.1 cm and the right kidney measures 11.2 cm. A 1.4 cm
simple cyst is present in the right kidney.
Color flow and spectral Doppler waveform analysis were obtained. The main,
left, right anterior, and right posterior portal veins are patent with
hepatopetal flow. The IVC is prominent.
IMPRESSION:
1. Cirrhosis with splenomegaly.
2. Patent portal veins.
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by WALK IN
Chief complaint: Abdominal distention
Diagnosed with FLATUL/ERUCTAT/GAS PAIN, SHORTNESS OF BREATH
temperature: 98.5
heartrate: 54.0
resprate: 12.0
o2sat: 97.0
sbp: 118.0
dbp: 57.0
level of pain: 5
level of acuity: 3.0 | Impression: Ms. ___ is a ___ female with a history
of cirrhosis likely attributed to hepatitis C and alcohol,
history of HIV, on Atripla, history of pulmonary hypertension,
on Sildenafil and bosentan, and history of heroin abuse,
currently on methadone who presents with worsening dyspnea and
an inability to lay flat during EGD.
**ACUTE ISSUES**
# Orthopnea: Likely ___ fluid overload and pulmonary edema. Echo
showed possible ASD or stretched PFO vs ___
shunt, dilated RV with evidence of mild pressure overload and
mild pulmonary hypertension. TR gradient was ___ mmHg.
Patient's home lasix increased to 80mg initially and then
decreased to home dose of 60mg daily as potassium was down to
3.1. Spironolactone increased to 150mg daily. Patient
symptomatically improved with diuresis.
# Encephalopathy: Patient presented with lethargy, confusion,
and asterixis, noted during EGD and on admission as well.
Initial differential included hepatic encephalopathy vs lethargy
from sedating medications such as mirtazepine or methadone,
given her worsening liver function may decrease metabolism.
Lethargy resolved with lactulose and multiple bowel movements.
Methadone decreased to 60mg daily and mirtazepine was held.
**CHRONIC ISSUES**
# Pulmonary HTN: Initial work-up for pulmonary htn is currently
unknown. Records were requested from Dr. ___
___ It is unknown whether she
has had a right heart cath, but she has been on sildenafil and
bosentan, which were continued.
# GIB/VARICES: OSH EGD in ___ showed no esophageal
varices, but did show gastric varices. Patient's propanolol was
titrated down to 20mg daily as propanolol can worsen pulmonary
hypertension. Patient will need repeat EGD when she becomes
euvolemic.
# CIRRHOSIS ___ Hep C, Etoh: Hepatitis C is genotype 1A and is
naive to treatment, IL28 CC, previously decompensated with
hepatic encephalopathy. MELD on admission 9. Her ___
status was class B. Asictes and varices were managed as above.
# h/o Heroin abuse: Previously used heroin, on methadone
maintenance, confirmed with ___ clinic, Habit Opco, on ___. in ___ (telephone: ___. Methadone
decreased to 60mg daily as above.
# Hyperthyroidism: Patient states her methimazole was recently
increased to 1.5mg daily. Repeat TSH/free T4 showed TSH <0.02
and free T4 of 1.1. Methimazole dose was thus continued.
# HIV: Currently stable on Atripla, last CD4 count reportedly
665 with undetectable viral load. Continued home atripla.
**TRANSITIONAL ISSUES**
- Methadone was decreased to 60mg daily from 70mg daily given
altered mental status, can consider further tapering as an
outpatient now that liver function is worse
- Propranolol decreased to 20mg daily from 30mg daily in order
to not diminish cardiac filling time. This can be continued to
taper off as an outpatient and dirrected by liver clinic.
- Home diuretics increased to lasix 60mg daily and
spironolactone 150mg daily. Would recommend checking chemistires
at next PCP visit to ensure creatinine, potassium, and other
electrolytes are within normal limits. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hypoxemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ yo female w/ history of COPD, asthma,
hypertension presenting with hypoxemia after a reported fall.
Per EMS, the patient was originally ambulatory but became
"hypoxic in the ___. EMS found her to be satting in the high
___ on room air, placed the patient on nasal cannula and brought
her to the ED.
On arrival to the ED, initial vitals were: 99.3 97 172/65 30
100% on 15L non-rebreather. The patient was given prednisone,
lasix, and azithromycin and her oxygen requirement improved
until she was satting 93% on RA. CT head and C-spine were
benign. CXR consistent with pulmonary congestion. The patient
was subsequently admitted to SIRS3 for further management.
Currently, the patient is somewhat confused but reports that she
does not recall any fall or loss of consciousness or know why
she is in the hospital. She endorses using supplemental O2 at
night when sleeping and reports being able to ambulate
independently at baseline. She additionally states that she
feels well overall and denies any recent cough, fevers, chills,
diarrhea, dysuria, hematuria, abdominal pain or chest pain.
Past Medical History:
1.) COPD
2.) Asthma
3.) HTN
4.) Type 2 Diabetes
5.) Depression: Referred to Psychiatry. ___
6.) Cervical stenosis
7.) Cerebral aneurysms
8.) Emergency Room ___ ___: Pneumonia/UTI/hyponatremia 9.)
Smoker
10.) Microvascular changes on MRI of brain ___ ___
11.) Cerebral aneurysm, stable, in followup n Eurology ___
Social History:
___
Family History:
(per chart): DM, asthma. No history of colon, breast, or ovarian
cancer.
Physical Exam:
Admission Physical Exam:
VS - 97.3 F, 126/59 BP , 98 HR , 20 R , 97% on 2___
General: Obese woman lying in bed. Responsive to questions,
confused, repeatedly asking for her underwear and socks in
___, but in NAD.
CV: RRR. No m/r/g appreciated. Elevated JVP appreciated
Lungs: Poor inspiratory effort and difficult to discern breathe
sounds secondary to poor effort.
Abdomen: Obese, soft, NTND. +BS
Ext: WWP. 1+ pitting edema bilaterally.
LABS: See below
Discharge Physical Exam:
Wt No weight ___ yesterday, 81 @ admission)
VS - Tm/c99.1 BP 165/44 HR 81 RR 20 98% on RA
General: Comfortable NAD. Responsive to questions
CV: RRR. No m/r/g appreciated.
Lungs: Slight expiratory wheezes b/l, no crackles
Abdomen: Obese, soft, NTND. +BS
Ext: WWP. Trace edema bilaterally, continues to decrease.
Pertinent Results:
ADMISSION LABS:
___ 05:50AM BLOOD WBC-12.9* RBC-3.89* Hgb-10.5* Hct-34.0*
MCV-87 MCH-27.0 MCHC-30.9* RDW-17.1* Plt ___
___ 05:50AM BLOOD Neuts-90.4* Lymphs-4.5* Monos-4.1 Eos-0.7
Baso-0.2
___ 05:50AM BLOOD ___ PTT-22.2* ___
___ 05:50AM BLOOD Glucose-321* UreaN-25* Creat-1.0 Na-135
K-6.1* Cl-96 HCO3-30 AnGap-15
___ 06:40AM BLOOD Calcium-8.9 Phos-3.4 Mg-2.2
DISCHARGE LABS:
___ 07:00AM BLOOD WBC-7.4 RBC-3.86* Hgb-10.4* Hct-32.8*
MCV-85 MCH-26.9* MCHC-31.7 RDW-17.6* Plt ___
___ 07:40AM BLOOD Glucose-127* UreaN-28* Creat-1.0 Na-140
K-4.1 Cl-95* HCO3-37* AnGap-12
___ 07:40AM BLOOD Calcium-8.8 Phos-4.9* Mg-2.7*
MISC LABS:
___ 07:05AM BLOOD CK-MB-3 cTropnT-<0.01 proBNP-1823*
___ 02:14PM BLOOD CK-MB-2 cTropnT-<0.01
___ 03:50PM BLOOD Cholest-191
___ 03:50PM BLOOD Triglyc-52 HDL-89 CHOL/HD-2.1 LDLcalc-92
IMAGING:
# CT HEAD W/O CONTRAST Study Date of ___
IMPRESSION:
1. No evidence of an acute intracranial process.
2. Partial opacification of right greater than left mastoid air
cells. Fluid in a left middle ethmoidal air cell. Please
correlate clinically with any acute infectious symptoms.
# CT C-SPINE W/O CONTRAST Study Date of ___
IMPRESSION:
1. No fracture or malalignment.
2. ACDF at C4-5 without evidence hardware related
complications.
3. Moderate spinal canal narrowing at C4-5 due to posterior
osteophytes, and milder narrowing at C5-6 and c6-7.
# CHEST (PORTABLE AP) Study Date of ___
IMPRESSION:
1. Pulmonary vascular congestion with possible small bilateral
pleural
effusions.
2. Bibasilar opacities, likely atelectasis.
# Portable TTE (Complete) Done ___
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. Regional left
ventricular wall motion is normal. Left ventricular systolic
function is hyperdynamic (EF>75%). There is a mild resting left
ventricular outflow tract obstruction. Right ventricular chamber
size is normal. with normal free wall contractility. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. There is mild aortic valve stenosis (valve area
1.2-1.9cm2). The mitral valve leaflets are mildly thickened.
There is no mitral valve prolapse. There is mild pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Hyperdynamic left ventricular systolic function.
Mild aortic stenosis. Mild pulmonary artery systolic
hypertension. Preserved right ventricular systolic function.
# CHEST (PORTABLE AP) Study Date of ___
Mild-to-moderate cardiomegaly is stable. Vascular congestion is
mild and
improved from prior study. Bibasilar opacities larger on the
left side have markedly improved, consistent with improving
atelectasis. If any, there are small bilateral pleural
effusions. There is no pneumothorax. There are no new lung
abnormalities.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q4H:PRN pain, temp >101
2. Milk of Magnesia 30 mL PO EVERY OTHER DAY:PRN constipation
3. Bisacodyl 10 mg PR HS:PRN constipation if MOM not effective
4. ___ Enema ___AILY:PRN if bisacodyl PR uneffective
5. OLANZapine 2.5 mg PO BID
6. MetFORMIN XR (Glucophage XR) 500 mg PO BID
7. Aspirin 81 mg PO DAILY
8. Acetaminophen 1000 mg PO BID
9. Amlodipine 10 mg PO DAILY
10. ClonazePAM 1 mg PO TID
11. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing,
shortness of breath
12. Fluticasone Propionate 110mcg 4 PUFF IH BID
13. Tiotropium Bromide 1 CAP IH DAILY
14. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing, shortness of
breath
15. LOPERamide 2 mg PO QID:PRN diarrhea
16. Lantus (insulin glargine) 100 unit/mL Subcutaneous qAM
17. HumaLOG (insulin lispro) 100 unit/mL Subcutaneous TID
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing,
shortness of breath
2. Amlodipine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. ClonazePAM 1 mg PO TID
5. Fluticasone Propionate 110mcg 4 PUFF IH BID
6. OLANZapine 2.5 mg PO BID
7. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing, shortness of
breath
8. Bisacodyl 10 mg PR HS:PRN constipation if MOM not effective
9. ___ Enema ___AILY:PRN if bisacodyl PR uneffective
10. HumaLOG (insulin lispro) 100 unit/mL Subcutaneous TID
Please follow sliding insulin scale. Adjust as necessary.
11. Lantus (insulin glargine) 100 unit/mL Subcutaneous qAM
15 units q AM
12. LOPERamide 2 mg PO QID:PRN diarrhea
13. MetFORMIN XR (Glucophage XR) 500 mg PO BID
14. Milk of Magnesia 30 mL PO EVERY OTHER DAY:PRN constipation
15. Tiotropium Bromide 1 CAP IH DAILY
16. Acetaminophen 650 mg PO Q4H:PRN pain, temp >101
17. Furosemide 40 mg PO DAILY
18. PredniSONE 30 mg PO DAILY Duration: 3 Days
___
Tapered dose - DOWN
19. Vitamin D 1000 UNIT PO DAILY
20. PredniSONE 20 mg PO DAILY Duration: 2 Days
___
Tapered dose - DOWN
21. PredniSONE 10 mg PO DAILY Duration: 2 Days
___
Tapered dose - DOWN
22. PredniSONE 5 mg PO DAILY Duration: 2 Days
___
Tapered dose - DOWN
23. Acetaminophen 1000 mg PO BID
24. Outpatient Lab Work
Labs ___: Chem 7
25. home oxygen
Please provide patient with oxygen for ambulatory oxygen
saturations <89%.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: COPD Exacerbation, congestive heart failure
Secondary Diagnosis: Diabetes, Dementia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: S/p fall. Evaluate for hemorrhage.
COMPARISON: CT head without contrast from ___.
TECHNIQUE: MDCT axial imaging was obtained through the brain without the
administration of intravenous contrast material. Coronal and sagittal
reformats were completed.
DLP: 1025.7 mGy-cm.
CTDIvol: 60.4 mGy.
FINDINGS: There is no acute hemorrhage, edema, mass effect or CT evidence for
a large vascular territorial infarction. Again seen is a linear hypodensity in
the left frontal corona radiata, likely a chronic infarct, 2:20. The
ventricles, basal cisterns and sulci are normal in size and configuration.
There is no fracture.
Bilateral maxillary sinus walls are thickened, indicating sequela of chronic
sinusitis. Currently, only minimal mucosal thickening is present in the floor
of the right maxillary sinus. There is a fluid level in a left middle
ethmoidal air cell. There is partial opacification of the right greater than
left mastoid air cells.
IMPRESSION:
1. No evidence of an acute intracranial process.
2. Partial opacification of right greater than left mastoid air cells. Fluid
in a left middle ethmoidal air cell. Please correlate clinically with any
acute infectious symptoms.
Radiology Report
INDICATION: History of fall. Evaluate for cervical spine fracture.
___ radiographs.
TECHNIQUE: MDCT axial imaging was obtained through the cervical spine without
the administration of intravenous contrast material. Coronal and sagittal
reformats were completed.
DLP: 632.25 mGy-cm.
CTDIvol: 32.3 mGy.
FINDINGS: There is no acute fracture, traumatic malalignment or prevertebral
soft tissue swelling. There is instrumented anterior fusion of C4 and C5
with a well-incorporated intervertebral graft, and well-positioned anterior
plate with paired screws at C4 and C5. No evidence of hardware related
complications. There is moderate spinal canal narrowing at C4-5 due to
posterior osteophytes, and milder narrowing at C5-6 and c6-7. There is neural
foraminal narrowing at C4-5 and C5-6 due to facet and uncovertebral
osteophytes.
Evaluation of lung apices is limited by respiratory motion; no definite focal
abnormalities are seen. Concurrent head CT is reported separately.
IMPRESSION:
1. No fracture or malalignment.
2. ACDF at C4-5 without evidence hardware related complications.
3. Moderate spinal canal narrowing at C4-5 due to posterior osteophytes, and
milder narrowing at C5-6 and c6-7.
Radiology Report
INDICATION: ___ with dyspnea, question acute cardiopulmonary process.
COMPARISONS: Chest radiograph from ___.
TECHNIQUE: Single portable chest radiograph was provided.
FINDINGS: There is prominence of the pulmonary vasculature, consistent with
pulmonary congestion. Bibasilar opacities most likely represent atelectasis.
There may be small pleural effusions. There is no pneumothorax. The
cardiomediastinal silhouette is normal. The bones are intact.
IMPRESSION:
1. Pulmonary vascular congestion with possible small bilateral pleural
effusions.
2. Bibasilar opacities, likely atelectasis.
Radiology Report
SINGLE FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: Hypoxia. The patient with history of COPD, asthma and
hypertension.
Comparison is made with prior study, ___.
Mild-to-moderate cardiomegaly is stable. Vascular congestion is mild and
improved from prior study. Bibasilar opacities larger on the left side have
markedly improved, consistent with improving atelectasis. If any, there are
small bilateral pleural effusions. There is no pneumothorax. There are no
new lung abnormalities.
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by WALK IN
Chief complaint: S/P FALL
Diagnosed with OBSTRUCTIVE CHR. BRONCHITIS,WITH ACUTE EXACERBATION, CONGESTIVE HEART FAILURE, UNSPEC
temperature: 99.3
heartrate: 97.0
resprate: 30.0
o2sat: 100.0
sbp: 172.0
dbp: 65.0
level of pain: 13
level of acuity: 1.0 | ___ yo female w/ history of COPD, asthma, hypertension presenting
with hypoxemia after a reported fall |
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, nausea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a ___ previously high-functioning woman with
h/o AFib on Coumadin, bradycardia, dementia, HTN, CHF, and
hypothyroidism who presented with one day of dyspnea and nausea,
found to have an inferoposterior STEMI.
For the past day, pt has complaining of dyspnea and nausea. She
has episodes of dyspnea at baseline, which have been worsening
over the past 6 months. Today she had more frequent dyspneic
episodes with escalating severity. These evening when her
dyspnea continued, EMS was called. EMS reports that when they
arrived she was initially asymptomatic. However, while in the
ambulance en route to the ED, patient had an episode of
cyanosis, bradycardia to ___, and unresponsiveness with "muscle
spasm" that lasted ~40 seconds and resolved on its own with
complete return to normal consciousness immediately afterward.
12-lead EKG showed ST changes. She was given ASA 325mg en route.
In the ED, initial vitals were: 94 115/66 96% 3L. Pt complaining
of nausea and dyspnea. EKG showed Afib with frequent PVCs, ST
elevations in III and aVF with discordant T waves, and RBBB in
V1-V3 with 2-3mm ST depressions with upright T waves. Overall
concerning for infero-posterior MI (RV infarct). Troponin
markedly elevated at 1.17, Cr 1.5 (baseline 1.1), BNP 5072, INR
2.2 (on Coumadin), anion gap 18
Past Medical History:
Thyroidectomy in ___ with resultant hypothyroidism
Left nipple lesion
Hip fracture ___ - medically treated
Hysterectomy in ___ for excessive bleeding
Social History:
___
Family History:
Father died at age ___ of liver cancer
Mother died at age ___ of heart/GI problems
Physical Exam:
===============================
ADMISSION PHYSICAL
===============================
VS: ___ 22 98% 2L NC
General: NAD, comfortable, pleasant
HEENT: NCAT, PERRL, EOMI
Neck: supple, JVP elevated to jaw,
CV: irregularly irregular rhythm, ___ SM heard best @ LUSB
Lungs: + rales bilaterally half way up lung fields
Abdomen: soft, NT/ND, BS+
GU: foley in place, minimal amounts of urine
Ext: warm upper extremities, cool lower extremities, 1+ distal
pulses bilaterally
================================
DISCHARGE PHYSICAL
================================
expired
Pertinent Results:
===============================
ADMISSION LABS
===============================
___ 10:00PM BLOOD WBC-11.5*# RBC-4.78 Hgb-14.3 Hct-44.3
MCV-93 MCH-30.0 MCHC-32.4 RDW-13.5 Plt ___
___ 10:00PM BLOOD ___ PTT-41.5* ___
___ 10:00PM BLOOD Glucose-252* UreaN-29* Creat-1.5* Na-138
K-5.0 Cl-101 HCO3-19* AnGap-23*
___ 10:00PM BLOOD ALT-36 AST-98* AlkPhos-100 TotBili-0.6
___ 05:55AM BLOOD CK(CPK)-1585*
___ 10:00PM BLOOD proBNP-5072*
___ 10:00PM BLOOD cTropnT-1.17*
___ 05:55AM BLOOD CK-MB-320* MB Indx-20.2* cTropnT-2.76*
___ 05:55AM BLOOD Calcium-9.8 Phos-7.9*# Mg-2.5
___ 10:00PM BLOOD Albumin-4.0
================================
PERTINENT LABS
================================
___ 05:55AM BLOOD Glucose-283* UreaN-36* Creat-2.2* Na-139
K-5.5* Cl-103 HCO3-13* AnGap-29*
===============================
EKG
===============================
___: Atrial fibrillation with a controlled ventricular
response. Right
bundle-branch block. Marked right axis deviation. Frequent
ventricular
ectopy. ST segment changes in leads III and aVF which may be
related to
ischemia
================================
IMAGING
================================
___ CXR:
Single frontal view of the chest. Again seen is mild pulmonary
vascular
congestion. Blunting of the right costophrenic angle likely due
to an
effusion. More dense left basilar opacity is likely in part due
to known
large hiatal hernia and effusion. Bibasilar opacities may also
be from
superimposed atelectasis noting infection cannot be excluded.
Cardiac
silhouette is enlarged but stable in configuration. No acute
osseous
abnormalities detected
Medications on Admission:
- Coumadin
- Synthroid
- Aldactone (switched to this from Lasix on ___ due to rash)
- Cyanocobalamin
- High potency calcium
- Acetaminophen
(did not verify doses because pt expired_
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
inferior posterior myocardial infarction with ST elevations
atrial fibrillation
Secondary:
HTN
Discharge Condition:
expired
Followup Instructions:
___
Radiology Report
HISTORY: ___ year old female with shortness of breath. Question pulmonary
edema or pneumonia.
COMPARISON: Chest x-ray from ___ and chest CT from ___.
FINDINGS:
Single frontal view of the chest. Again seen is mild pulmonary vascular
congestion. Blunting of the right costophrenic angle likely due to an
effusion. More dense left basilar opacity is likely in part due to known
large hiatal hernia and effusion. Bibasilar opacities may also be from
superimposed atelectasis noting infection cannot be excluded. Cardiac
silhouette is enlarged but stable in configuration. No acute osseous
abnormalities detected.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC
temperature: nan
heartrate: 94.0
resprate: nan
o2sat: 96.0
sbp: 115.0
dbp: 66.0
level of pain: 0
level of acuity: 2.0 | ___ is a ___ previously high-functioning woman with
h/o AFib on Coumadin, bradycardia, dementia, HTN, CHF, and
hypothyroidism who presented with one day of dyspnea and nausea,
found to have an inferoposterior STEMI.
# GOALS OF CARE: Pt and her HCP clearly confirmed her DNR/DNI
status and pt refused cardiac cath after discussion with
cardiology fellow. Spoke again with HCP when pt arrived on floor
and clarified that we will also not escalate care (no ICU,
DNR/DNI, focus on staying comfortable) as this would not be
concordant with patient's wishes. She was transitioned to
comfort care and her symptoms were controlled with morphine and
lorazepam as needed. PCP was notified.
# CORONARIES: EKG is difficult to interpret given overlying AFib
with frequent PVCs which obscure the native QRS morphologies.
However, it does clearly show ST elevations in III and aVF with
discordant T waves and RBBB with 2-3mm ST depressions (with
upright T waves) in leads V1-V3. Overall this is concerning for
an infero-posterior STEMI (though right-sided and posterior EKGs
are unrevealing). These infarcts are very preload dependent, so
should use caution with meds that negatively impact preload
(opioids and nitrates) or heart rate and contractility (beta
blockers and CCBs). Would ideally increase preload by giving IV
fluids, but pt also has significant crackles on exam and
evolving pulm edema on CXR, cannot do this. She was transitioned
to comfort measures and her heart attack was not treated.
# PUMP: Evidence of both right and left heart failure on
physical exam. RV failure likely precipitating LV failure. There
was no management based on the pts wishes to be DNR/DNI and with
no invasive procedures.
# RHYTHM: AFib on Coumadin, not on any beta blockade at home.
Not in RVR in hospital. She was transitioned to comfort
measures.
# HYPOTHYROIDISM - synthroid was stopped when she was
transitioned to comfort measures. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
fever, cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with Eagle ___ with ESRD, s/p status post
living unrelated renal transplant in ___ on immunosupressive
therapy with hypertension, asthma, and anxiety who was lost to
follow-up for the last year and presents today with cough,
wheezing, and poor appetite for 4 days and fever today. Pt
states that he last saw the transplant team in ___, and given
the distant and difficult to get here he miss his appointments.
He has continued to take his tacro at 4mg and Mycophenalate at
1000mg BID. He has not have any medication level for the last
year. He developed cough, wheezing and decrease in appetite. He
has been feeling week and felt febrile with tmax 101. His
girlfriend's daughter was sick a few days ago with "bacterial
infection" thought to be Mono but test was negative. She had
sinus infection and cough. He then felt ill a few days after. He
denies having any changes in his urinary frequency or amount
(has been trying to drink fluids), no dysuria, no hematuria, no
change in odor or color.
In the emergency department, initial vitals: 97.9 ___ 20
100% on RA. Pt was given a L of NS and given Levofloxacin for
possible respiratory infection. His labs were notable for creat
of 2.5, BUN of 24, K 5.5, and phos of 1.8. His WBC 5.1 (N:77.2
L:12.8 M:9.4 E:0.4 Bas:0.3). Renal transplant was called and
recommended having renal US which showed normal ultrasound of
the right lower quadrant transplant kidney with normal main
renal artery and intrarenal resistive indices. He was then
admitted for further evaluation and possible renal biopsy.
.
Review of systems:
(+) Per HPI
(-) Denies chills, night sweats, recent weight loss or gain.
Denied shortness of breath, chest pain or tightness,
palpitations. Denied vomiting, diarrhea, constipation or
abdominal pain. No edema.
.
Past Medical History:
- Prune Belly Syndrome (___ s/p "kidney
reconstruction" as an infant and abdominal wall reconstruction.
- PE (___) in ___ on coumadin
- Exudative pleural effusions in setting of PE
- ESRD sinc ___ on HD ___
- Asthma
- HTN
- History of seizure- this was prior to having transplant,
setting of dialysis
- s/p status post living unrelated renal transplant in ___
Social History:
___
Family History:
Mother with HTN. Father healthy. Family hx of cancer (cousin
with lymphoma, aunt with breast ca). No bleeding or clotting
d/os.
Physical Exam:
Admission physical exam
VS: 98.3, 184/95 (repeated manually 160/100), 82, 20, 98% on RA
GENERAL: NAD, very pleasant male.
HEENT: No scleral icterus. PERRLA/EOMI. MMM. OP clear.
Neck: Supple, No LAD.
CARDIAC: RR. Normal S1, S2. No murmur
CHEST: CTA Bil post, ant there is exp wheezing, good air
movement bilaterally, no use of accessory muscles
ABDOMEN: Abnormal abdominal musculature c/w diagnosis of Prune
belly. NABS. Soft, NT, ND. No HSM appreciated.
EXTREMITIES: No c/c/e, 2+ dorsalis pedis/ posterior tibial
pulses.
NEURO: A&Ox3.
.
DISCHARGE EXAM:
unchanged
Pertinent Results:
ADMISSION LABS:
___ 07:04PM BLOOD WBC-8.0 RBC-5.60 Hgb-15.2 Hct-48.7
MCV-87# MCH-27.0 MCHC-31.2 RDW-12.4 Plt ___
___ 07:04PM BLOOD Neuts-81.7* Lymphs-10.7* Monos-7.0
Eos-0.3 Baso-0.3
___ 07:04PM BLOOD Glucose-113* UreaN-24* Creat-2.5* Na-138
K-5.5* Cl-101 HCO3-23 AnGap-20
___ 07:04PM BLOOD Calcium-9.8 Phos-1.8* Mg-2.0
___ 07:15PM BLOOD Lactate-1.1
.
DISCHARGE LABS:
___ 01:51AM BLOOD WBC-5.1 RBC-5.11 Hgb-13.7* Hct-44.9
MCV-88 MCH-26.8* MCHC-30.4* RDW-12.6 Plt ___
___ 01:51AM BLOOD Neuts-77.2* Lymphs-12.8* Monos-9.4
Eos-0.4 Baso-0.3
___ 01:51AM BLOOD ___ PTT-38.0* ___
___ 01:51AM BLOOD Glucose-100 UreaN-22* Creat-2.2* Na-137
K-4.9 Cl-101 HCO3-23 AnGap-18
___ 01:51AM BLOOD Calcium-9.2 Phos-3.6# Mg-1.8
___ 01:51AM BLOOD PTH-165*
___ 01:51AM BLOOD 25VitD-8*
.
IMMUNOSUPPRESSANT MONITORING:
___ 08:27PM BLOOD tacroFK-10.8
___ 10:45AM BLOOD tacroFK-10.1
.
IMAGING:
# RENAL TRANSPLANT ___. Study Date of ___
FINDINGS: The right lower quadrant transplant kidney measures
11.4 cm. No hydronephrosis, stones, or large masses are seen.
Appearance is unchanged
from ___. The urinary bladder is partially distended and
therefore incompletely evaluated, but no gross abnormalities are
detected.
The main renal vein appears patent with normal waveform. The
main renal
artery is patent with normal waveform and normal resistive index
measuring
0.59. Within the transplant kidney, resistive indices range from
0.55 to
0.59.
IMPRESSION: Normal ultrasound examination of the transplant
kidney. Normal
resistive indices within the main renal artery and intrarenal
arteries of the transplant kidney.
.
# CHEST (PA & LAT) Study Date of ___
FINDINGS: PA and lateral views of the chest were obtained. There
is stable
irregular opacity in the lower lungs compatible with known areas
of scarring as assessed on prior CT. No definite signs of
pneumonia or CHF.
Cardiomediastinal silhouette appears stable with top normal
heart size
redemonstrated. No pleural effusion or pneumothorax. Bony
structures appear intact.
IMPRESSION: No signs of pneumonia or CHF. Stable areas of
scarring in the
lower lungs.
Medications on Admission:
Tacrolimus 3 mg PO Q12H (dosing noon and midnight)
Mycophenolate Mofetil 1000 mg PO BID
Discharge Medications:
1. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
___ puffs Inhalation every ___ hours as needed for shortness of
breath or wheezing.
Disp:*1 inhaler* Refills:*0*
2. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
3. tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H (every
12 hours).
4. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
5. Outpatient Lab Work
Please have blood work checked weekly:
CBC, chem 10, BUN/Cr, tacrolimus.
Please have results faxed to Dr. ___ at the ___
___: phone: ___ fax: ___
ICD-9-CM Diagnosis Code V42.0
6. Outpatient Lab Work
Outpatient Lab Work
Please have blood work checked on ___: BK virus pcr. Please
have results faxed to Dr. ___ at the ___ transplant
center: phone: ___ fax: ___ ICD-9-CM
Diagnosis Code V42.0
Discharge Disposition:
Home
Discharge Diagnosis:
Renal insufficiency (primary)
s/p renal transplant (secondary)
Hypertension (secondary)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH PERFORMED ON ___
Comparison is made with a prior chest radiograph dated ___ as well as a CT
torso dated ___.
CLINICAL HISTORY: Cough, malaise, assess for pneumonia.
FINDINGS: PA and lateral views of the chest were obtained. There is stable
irregular opacity in the lower lungs compatible with known areas of scarring
as assessed on prior CT. No definite signs of pneumonia or CHF.
Cardiomediastinal silhouette appears stable with top normal heart size
redemonstrated. No pleural effusion or pneumothorax. Bony structures appear
intact.
IMPRESSION: No signs of pneumonia or CHF. Stable areas of scarring in the
lower lungs.
Radiology Report
INDICATION: ___ male with history of renal transplant, now with
fever.
COMPARISON: ___.
TECHNIQUE: Gray-scale and duplex Doppler ultrasound examination of the right
lower quadrant transplant kidney was performed.
FINDINGS: The right lower quadrant transplant kidney measures 11.4 cm. No
hydronephrosis, stones, or large masses are seen. Appearance is unchanged
from ___. The urinary bladder is partially distended and therefore
incompletely evaluated, but no gross abnormalities are detected.
The main renal vein appears patent with normal waveform. The main renal
artery is patent with normal waveform and normal resistive index measuring
0.59. Within the transplant kidney, resistive indices range from 0.55 to
0.59.
IMPRESSION: Normal ultrasound examination of the transplant kidney. Normal
resistive indices within the main renal artery and intrarenal arteries of the
transplant kidney.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: FEVER
Diagnosed with FEVER, UNSPECIFIED, KIDNEY TRANSPLANT STATUS
temperature: 97.9
heartrate: 102.0
resprate: 20.0
o2sat: 100.0
sbp: 157.0
dbp: 102.0
level of pain: 0
level of acuity: 3.0 | ___ with Eagle ___ with ESRD, s/p status post
living unrelated renal transplant in ___ on immunosuppressive
therapy with hypertension, asthma, and anxiety who was lost to
follow-up for the last year and presents with cough, wheezing,
fever and poor appetite for 4 days. His imaging was unrevealing
and he remained afebrile so he was discharged with close follow
up.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / Chantix
Attending: ___.
Chief Complaint:
BLE pain and Left leg numbness
Major Surgical or Invasive Procedure:
Microdiscectomy L5-S1
History of Present Illness:
Pt started having left leg pain starting ___- tried meds
and has had two injections. Second injection helped for a few
hours. Pain worsened over last week and started having right leg
pain and numbess in left leg. MRI revealed a large extruded disc
at L5/S1, worse on left than right
Past Medical History:
GI ulcer
Gastric bypass ___
Anxiety
Depression
Controlled Substance Use
Social History:
Worked in ___ and going to school for CRNA. Not currently
working or going to school.
Physical Exam:
Admission Physical ___
Motor-
Delt Bic Tri WrE FFl FE IO IP glut Quad Ham TA ___
L 5 ___ ___ 5 5 5 ___ 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory:
Sensory UE
C5 (Ax) R nl, L nl
C6 (MC) R nl, L nl
C7 (Mid finger) R nl, L nl
C8 (MACN) R nl, L nl
T1 (MBCN) R nl, L nl
T2-L2 Trunk R nl, L nl
Sensory ___
L2 (Groin): R nl, L nl
L3 (Leg) R nl, L nl
L4 (Knee) R nl, L ___
L5 (Grt Toe): R nl, L ___
S1 (Sm toe): R nl, L ___
S2 (Post Thigh): R nl, L ___
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 3 1
R 2 2 2 2 1
___: neg
Babinski: downgoing
Clonus: none
Perianal sensation: intact
Rectal tone: intact
Physical Exam ___-
General:Well appearing, sitting up in bed
Heart:RRR
Lungs:CTAB
Abd:soft,ntnd,+bs
Extremities:2+rad,2+dp pulses
___ throughout BLE ___
+SILT, LLE L4-S1 distribution diminished sensation
Pertinent Results:
___ 07:48AM BLOOD WBC-9.0 RBC-3.67* Hgb-8.8* Hct-30.7*
MCV-84 MCH-23.9* MCHC-28.6* RDW-17.8* Plt ___
___ 07:48AM BLOOD Plt ___
___ 07:48AM BLOOD ___ PTT-23.8* ___
___ 07:48AM BLOOD Glucose-76 UreaN-10 Creat-0.7 Na-138
K-4.6 Cl-102 HCO3-28 AnGap-13
Medications on Admission:
Diazepam
Gabapentin
Omeprazole
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H pain
may be taken over the counter
RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6)
hours Disp #*50 Tablet Refills:*0
2. Omeprazole 40 mg PO DAILY
3. Gabapentin 600 mg PO TID
RX *gabapentin 600 mg 1 tablet(s) by mouth three times a day
Disp #*42 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Lumbar Disc Herniation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: lumbar microdiscectomy.
COMPARISON: MR examination from ___.
TECHNIQUE: Intraoperative radiographs.
IMPRESSION:
2 intraoperative radiographs were obtained without the presence of a
radiologist, demonstrating spinal hardware posterior to the L5/S1 disc space.
Please see operative notes for further details.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Back pain, Urinary retention
Diagnosed with LUMBAR DISC DISPLACEMENT, BARIATRIC SURGERY STATUS
temperature: 98.3
heartrate: 72.0
resprate: 16.0
o2sat: 98.0
sbp: 110.0
dbp: 62.0
level of pain: 6
level of acuity: 2.0 | Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure. Refer to
the dictated operative note for further details. The surgery was
without complication and the patient was transferred to the PACU
in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
continued for 24hrs postop per standard protocol. Initial postop
pain was controlled with a PCA. Diet was advanced as tolerated.
The patient was transitioned to oral pain medication when
tolerating PO diet. The patient ambulated initially with nursing
and then independently for mobilization oob. Hospital course was
complicated by pain and urinary retention. Chronic pain,
Psychiatry, and Social Work were consulted in management of her
care. Chronic pain strongly advised not to discharge the patient
home with narcotics given her narcotic history and multiple
scripts being filled at multiple pharmacies. The patient also
admitted opioid misuse to psychiatry. Psychiatry agrees with no
narcotic scripts at discharge. Social work has been available
for support to the patient and has been in contact with the
patients father for d/c coordination of anticipated needs
relative to her ___ misuse and behavioral health. The patient
is connected with outpt behavioral health and it is strongly
recommended to follow up. The patient was not able to void after
a ___ void trial and a foley was re-placed on ___. She was
educated on foley care and offered ___ services for help with
foley care and accepted services. The patient is scheduled with
urology for follow up as an outpatient for management of her
foley. On the day of discharge the patient was afebrile with
stable vital signs, tolerating a regular diet, and ambulating
independently. She was discharged only with Tylenol and
Gabapentin under the advisement by chronic pain to not discharge
the patient with narcotics given her history of misuse. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
prochlorperazine
Attending: ___.
Chief Complaint:
Left hemiplegia, found to have right MCA stroke
Major Surgical or Invasive Procedure:
___: Right internal carotid artery stenting and right M1
segment of the MCA thrombectomy compatible with TICI 2b.
History of Present Illness:
___ is a ___ year old left handed male with history of
splenium anaplastic oligodendroglioma who presents with
___ weakness, found to have right ICA thrombus with
distal reconstitution of MCA. He was last seen normal at 1:30 on
___ and at 5:30pm his son found him to be weak on left-side,
arm and leg. His NIHSS score was found to be 18. On exam, he
was found to be mute, no blink to threat on left side, and could
withdraw to pain on arm and leg on left-side, but not moving
against gravity with a left sided facial droop. He went to ___
for neuro intervention and underwent a clot retrieval with grade
IIb revascularization and a right carotid stent for complete
occlusion. He was transferred to the NSICU for further
neurological monitoring.
Past Medical History:
1. Splenium anaplastic oligodendroglioma
2. Testicular cancer, right orchiectomy, mediastinal LN
dissection, ___
3. Hypertension
4. Dyslipidemia
5. Left hernia repair x3, recently ___
Social History:
___
Family History:
He has one healthy son. He has a healthy brother and a sister.
His mother is alive in her ___ and his father died at ___.
Physical Exam:
Admission Physical Exam:
Vitals: T: -- P: 70 R: 16 BP: 173/90 SaO2: 100% NC
General: Mildly sleepy but arouses easily
HEENT: NC/AT, no scleral icterus noted, dry MM, no lesions noted
in oropharynx
Pulmonary: Normal work of breathing
Cardiac: RRR
Abdomen: soft, NT/ND
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Mildly sleepy but arouses to voice, will track
and regard. Unable to form any words or sounds. Can follow
simple
commands such as close, open eyes, stick out tongue, lift arms.
-Cranial Nerves:
PERRL 3 to 2mm and brisk. Right gaze preference, but will look
all the way to left with encouragement. No blink to threat on
the
left. Moderate left lower facial droop, mouth hangs open.
Appears
to have difficulty managing secretions with possible impaired
palate elevation (unable to open mouth wide enough). Tongue does
not protrude fully.
-SensoriMotor: Right side full. Left arm and leg withdraw in the
plane of the bed, not antigravity.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor on the right, mute on the left.
-Coordination and gait: Deferred
__________________________________
Discharge Physical Exam:
MS: Awake, alert, following commands to open/close his eyes and
raise his right arm
Cranial Nerves: left facial droop; EOM grossly full, tongue
midline. PERRLA 3 -->2
Motor: Left sided ___ strength, Right sided ___ in upper and
lower extremities.
Reflexes: RUE 2+ bilateral (bi/brachio). LUE 3+ bi/brachio; B/l
patellar 3, +crossed adductors
+finger flexors on left, no ___
R toe down, left toe mute
Pertinent Results:
Labs:
Imaging:
___ CTA Head & Neck:
1. Hypodensity involving the right corona radiata, with
extension to the right basal ganglia and sub insular cortex is
concerning for an acute infarction in the right MCA territory
distribution. No acute intracranial hemorrhage is identified.
2. Filling defect within the M1 segment of the right middle
cerebral artery, as well as asymmetrically diminutive flow along
the distal segments of the right middle cerebral artery, is
concerning for an occlusive thrombus.
3. Complete occlusion of the right internal carotid artery is
seen from its origin with minimally reconstituted, yet
diminutive flow within the cavernous segment.
4. Debris and secretions within the upper trachea, is likely
secondary to aspiration.
5. Degenerative changes are seen within the upper cervical
spine.
___ TTE:
Normal biventricular systolic function. Mild aortic
regurgitation. No ASD (only rest saline injection performed as
patient could not cooperate with maneuvers).
___ NCHCT:
1. Dental amalgam streak artifact and mild motion limits study.
2. Evolving right internal capsule, putamen, and globus pallidus
infarcts as described.
3. Grossly stable putamen hyperdensity again suggestive of
contrast staining, with differential consideration of stable
blood products.
4. Within limits of study, no definite new hemorrhage.
5. Mild interval increased edema resulting in mass effect upon
right lateral ventricle and leftward shift of normally midline
structures up to 5 mm, previously measuring 3 mm.
MRI brain with and without contrast from ___:
IMPRESSION:
1. Subacute right MCA territory infarction with involvement of
the basal
ganglia, insula, and precentral gyrus with associated edema and
hemorrhagic
transformation, as described. Areas of associated enhancement
are likely
secondary to the infarct itself.
2. Overall no significant change in size of a pericallosal left
frontoparietal
parasagittal lobulated mainly T2 hyperintense mass, though there
has been
interval increase of enhancing nodular component, as described,
concerning for
progression.
3. New area of white matter T2/FLAIR hyperintensity without
associated slowed
diffusion in the medial temporal lobe, which appears to be
distinct from the
areas of infarct, and is concerning for new neoplastic focus.
However, these
also may reflect changes from the ongoing infarct, and continued
attention on
followup examination is advised.
4. Overall unchanged background confluent white matter T2/FLAIR
hyperintensity, likely reflecting post radiation change.
___ 07:00PM URINE HOURS-RANDOM
___ 07:00PM URINE HOURS-RANDOM
___ 07:00PM URINE GR HOLD-HOLD
___ 07:00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 07:00PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 07:00PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 07:00PM URINE RBC-7* WBC-2 BACTERIA-FEW YEAST-NONE
EPI-0
___ 07:00PM URINE HYALINE-1*
___ 07:00PM URINE MUCOUS-RARE
___ 06:53PM CREAT-0.7
___ 06:53PM estGFR-Using this
___ 06:46PM GLUCOSE-123* NA+-136 K+-3.9 CL--99 TCO2-25
___ 06:34PM UREA N-12
___ 06:34PM WBC-9.3 RBC-4.90 HGB-14.6 HCT-43.0 MCV-88
MCH-29.8 MCHC-34.0 RDW-11.9 RDWSD-38.1
___ 06:34PM ___ PTT-27.4 ___
___ 06:34PM PLT COUNT-165
___ 05:00AM BLOOD WBC-8.1 RBC-3.87* Hgb-11.5* Hct-34.5*
MCV-89 MCH-29.7 MCHC-33.3 RDW-11.9 RDWSD-38.0 Plt ___
___ 05:00AM BLOOD Glucose-119* UreaN-21* Creat-0.7 Na-141
K-3.9 Cl-103 HCO3-26 AnGap-16
___ 05:00AM BLOOD Calcium-8.4 Phos-3.2 Mg-2.1
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 4 mg PO DAILY
2. OxyCODONE (Immediate Release) 5 mg PO BID:PRN Pain
3. Tamsulosin 0.4 mg PO DAILY
4. temozolomide 300 mg oral DAILY
5. Tizanidine ___ mg PO QHS:PRN Pain
6. Acetaminophen 1000 mg PO Q6H:PRN Pain
7. Ibuprofen 400 mg PO DAILY:PRN Pain
8. Vitamin D ___ UNIT PO DAILY
9. Clindamycin 1% Solution 1 Appl TP DAILY
10. Hydrocortisone Cream 2.5% 1 Appl TP BID:PRN Scaling red skin
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Docusate Sodium 100 mg PO BID constipation
4. Nystatin Oral Suspension 5 mL PO QID
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
6. Senna 8.6 mg PO BID:PRN constipation
7. Sodium Chloride 3% Inhalation Soln 15 mL NEB Q6H
8. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
9. Clindamycin 1% Solution 1 Appl TP DAILY
10. Hydrocortisone Cream 2.5% 1 Appl TP BID:PRN Scaling red
skin
11. Ondansetron 4 mg PO DAILY
12. OxyCODONE (Immediate Release) 5 mg PO BID:PRN Pain
13. Tamsulosin 0.4 mg PO DAILY
14. Tizanidine ___ mg PO QHS:PRN Pain
15. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
right MCA stroke
right ICA thrombus
PEG placement
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK PQ147 CT HEADNECK
INDICATION: History: ___ with facial droop and aphasia // ?ICH
TECHNIQUE: Noncontrast head CT was initially performed. Subsequently, rapid
axial imaging was performed from the aortic arch through the head during
infusion of 70 mL of Omnipaque intravenous contrast material.
Three-dimensional angiographic volume rendered, curved reformatted and
segmented images were generated. This report is based on interpretation of all
of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 7.2 s, 18.0 cm; CTDIvol = 56.1 mGy (Head) DLP =
1,009.3 mGy-cm.
2) Stationary Acquisition 4.5 s, 0.5 cm; CTDIvol = 49.0 mGy (Head) DLP =
24.5 mGy-cm.
3) Spiral Acquisition 5.4 s, 42.1 cm; CTDIvol = 32.0 mGy (Head) DLP =
1,347.9 mGy-cm.
Total DLP (Head) = 2,382 mGy-cm.
COMPARISON: None.
FINDINGS:
Noncontrast head CT: A hypodensity is seen involving the right corona
radiata, with extension to the right basal ganglia and subinsular cortex,
concerning for an acute infarction, with mild mass effect on the right lateral
ventricle. There is no evidence of intracranial hemorrhage. Additional
hypodensities of the right medial prefrontal gyrus may also represent areas of
acute infarct. Encephalomalacia with cortical calcifications are seen along
the bilateral ACA territories near the vertex suggestive of cortical laminar
necrosis, sequelae of prior chronic infarction.
Mild mucosal sinus thickening is seen involving the left maxillary sinus. The
remainder the visualized paranasal sinuses are clear. The mastoid air cells,
and middle ear cavities are clear. A small calvarial defect overlying the
posterior left parietal bone measuring up to 1 cm, may be secondary to prior
surgical intervention. No acute fracture is identified.
CTA neck: The left internal carotid artery demonstrates mild atherosclerotic
calcifications at the left internal carotid artery bulb, however there is no
evidence of significant stenosis by NASCET criteria. The right internal
carotid artery is completely occluded from its origin with minimally
reconstituted yet diminutive flow within the cavernous segment. The right
common carotid artery is unremarkable. The vertebral arteries bilaterally are
normal.
CTA head: The cavernous segment of the right internal carotid artery
demonstrates extremely diminished flow, likely secondary to reconstitution
from the left across the anterior communicating artery. The M1 segment of the
right middle cerebral artery demonstrates a tubular filling defect, series 5,
image 269, concerning for an occlusive thrombus. Severely asymmetrically
attenuated flow is seen along the distal branches of the right middle cerebral
artery. The left internal carotid artery is unremarkable, although the
cavernous segment demonstrates moderate atherosclerotic disease. Remainder of
the left middle cerebral artery and bilateral anterior cerebral arteries
demonstrate robust flow. Mild narrowing of the right P1 segment likely
represents atherosclerotic disease. Otherwise, the posterior circulation is
also well preserved. The posterior communicating arteries are not visualized.
The thyroid is normal. Debris and secretions are seen within the upper
trachea, likely secondary to aspiration. There is no cervical
lymphadenopathy. Degenerative changes are seen along the upper cervical
spine, with anterior posterior osteophytosis. The visualized lung apices are
clear.
IMPRESSION:
1. Hypodensity involving the right corona radiata, with extension to the right
basal ganglia and sub insular cortex is concerning for an acute infarction in
the right MCA territory distribution. Additional foci of questionable
hypodensity along the right medial frontal lobe, potentially representing an
additional region of infarct. No acute intracranial hemorrhage is identified.
2. Filling defect within the M1 segment of the right middle cerebral artery,
as well as asymmetrically diminutive flow along the distal segments of the
right middle cerebral artery, is concerning for an occlusive thrombus.
3. Complete occlusion of the right internal carotid artery is seen from its
origin with minimally reconstituted, yet diminutive flow within the cavernous
segment.
4. Debris and secretions within the upper trachea, is likely secondary to
aspiration.
5. Degenerative changes are seen within the upper cervical spine.
Radiology Report
EXAMINATION: Left common carotid artery angiogram.
Right internal carotid artery angiogram.
Right common femoral artery angiogram.
INDICATION: ___ year old man with Lt hemiplegia, NIHHS18 // Rt ICA
embolictomy +/- stenting
TECHNIQUE:
Anesthesia: local analgesia, please see separate sheets for medications and
Um vital signs.
Patient was brought into the angio suite, ID was confirmed via wrist band.The
patient was placed supine on fluoroscopy table and bilateral groins were
prepped and draped in the usual sterile manner. Time-out procedure was
performed per institutional guidelines. The location of the right mid femoral
head was located using anatomic and radiographic landmarks. 10 cc of
subcutaneous lidocaine was infused into the tissue. Micropuncture kit was
used to gain access to the right femoral artery, serial dilation was
undertaken until a long 10 ___ groin sheath connected to a continuous
heparinized saline flush could be inserted. ___ catheter was
connected to the power injector and also to a continuous heparinized saline
flush. This was advanced over the 0.038 glidewire brought up the aorta used to
select the left common carotid artery. AP and lateral views of the anterior
cerebral circulation were obtained .
Catheter was then pulled back in the aorta and used to select the right common
carotid artery. AP, lateral views of the anterior cerebral circulation were
obtained. That confirmed the occlusion of the internal carotid artery.
Subsequently, ___ 2 catheter was exchanged to 7 ___ shuttle sheath under
direct fluoro guidance, shuttle sheath was positioned in the common carotid,
new road maps were obtained.
An exchange length synchro 2 wire was used to advance XT 27 micro catheter
beyond the critical stenosis in the internal carotid artery, position was
verified with a micro angio injection. The synchro 2 wire was then positioned
close to the carotid terminus in the micro catheter was pulled out and a 3.0mm
x 20mm Sprinter Legend balloon was advanced until it was positioned at the
proximal internal carotid artery and an angioplasty was done. Then, ___ X
40mm Tapered Protégé RX Stent was mounted and was deployed slowly and steadily
into the internal carotid, new angio runs were obtained after that confirmed
re-establishment of the flow into the internal carotid however there was an
InStent narrowing that was managed by an angioplasty using 5.0mm x 20mm
___ balloon.
New angio runs were obtained after that that confirmed re-establishment of the
flow with improvement of the InStent narrowing but however there was no flow
at the MCA. This led us to Mount an ACE catheter over the XT 27 micro
catheter over the synchro wire. XT 27 was over the synchro wire and
positioned at the distal M1 segment, the ACE Catheter was advanced slowly
until it was positioned in the paraclinioid segment of the internal carotid
artery. The synchro wire was withdrawn on micro angio run confirmed position
then a Trevo ProVue System 4MM X ___ was advanced and started deployment
across the M1 segment down to the carotid terminus, was kept deployed 5 min.
The Ace catheter was connected to the penumbra suction system then the Trevo
stent and the micro catheter were pulled out keeping the Ace Catheter in
position, once the micro system is out we applied hand suction to the Ace
Catheter, there were clots on the stent and clots in the see range, nice back
flow was established through the base catheter. The Ace catheter was removed
and a new angio runs were obtained that confirmed re-establishment of the flow
in the M1 and both M2s with stenosis at the takeoff of one of the M2 that we
decided not to pursue as it is already 8 hr since time of symptoms on set.
The shuttle sheath was then pulled back in the aorta fully removed from the
body. A common femoral arteriogram was performed prior to use of a closure
device, subsequently 8 ___ Angio-Seal was put in but did not see of the
hole in the artery properly, due to that we applied manual compression for 50
min until complete hemostasis was obtained. At the conclusion of the
procedure, there is no evidence of thromboembolic complication.
Devices inventory:
038" 150cm Angled Glidewire
035 x 150cm ___ Wire
___ Berenstein ___ 100cm Cath.
___ ___ 2 Cath. 100cm
___ Micropuncture Set
___ x 25cm Terumo Sheath Set
___ x 25cm Terumo Sheath Set
Synchro2 Standard 14 300cm Wire
___ x155cm Rapid Transit (2 Tip) Microcath
035 x 260cm Amplatz Straight Exchange
___ x 90cm Shuttle Sheath Set
3.0mm x 20mm Sprinter Legend RX
INFLATOR
___ X 40mm Tapered Protégé RX Stent LOT#___
5.0mm x 20mm ___
Excelsior XT-27 150cm Microcatheter
5.75F/132CM ACE 64 Reperfersion
Trevo ProVue System 4MM X ___ MC & Retriever
Aspiration Tubing (Sterile)
___ Angio Seal Evolution Closure
COMPARISON: None
FINDINGS:
Left common carotid artery: Carotid bifurcations well-visualized. There is
no significant atherosclerosis or carotid stenosis.
Left internal carotid artery: Distal left ICA, proximal and distal MCA and
ACA branches are well-visualized. Cross-filling of the contralateral ACA via
a via the A-comm with some perfusion of the contralateral MCA. Vessel caliber
smooth and tapering. Normal arterial, capillary, and venous phase . No
vascular abnormalities identified .
Right common carotid artery: Carotid bifurcations well-visualized. Abrupt
complete interruption of the flow in the internal carotid artery immediately
after the takeoff.
Right internal carotid artery: No flow before intervention. After carotid
stenting and thrombectomy of the M1, the distal right ICA, proximal and distal
MCA and ACA branches are well-visualized. With critical stenosis at the
superior division of the MCA but satisfactory flow beyond stenosis point. .
Right common femoral artery: Well-visualized with a good caliber size for
closure device.
I, ___, participated in the procedure. I, ___, was
present for the entirety of the procedure and supervised all critical steps.
I, ___, have reviewed the report and agree with the fellow's
findings.
IMPRESSION:
Successful right internal carotid artery stenting and right M1 segment of the
MCA thrombectomy compatible with TICI 2b.
RECOMMENDATION(S): Start aspirin after 24 hr and follow the Stroke Neurology
team recommendations.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with stroke, c/f aspiration // eval for
aspiration eval for aspiration
IMPRESSION:
No comparison. Moderate elevation of the right hemidiaphragm. Borderline
size of the cardiac silhouette. No parenchymal opacities suggesting
pneumonia. No pleural effusions. No pulmonary edema. No pneumothorax.
Radiology Report
EXAMINATION: ANKLE (AP, MORTISE AND LAT) LEFT PORT
INDICATION: ___ year old man with ankle swelling // fracture s/p fall
TECHNIQUE: Two portable views of the left ankle.
COMPARISON: None.
FINDINGS:
There is mild soft tissue swelling overlying the lateral malleolus. There is
slight asymmetric widening of the lateral ankle mortise, which may reflect
underlying ligamentous injury. Lucency along the lateral tailor dome may also
represent osteochondral lesion. No displaced fracture is seen. Moderate
narrowing and osteophyte formation along the anterior tibiotalar joint space
is noted.
IMPRESSION:
1. Widening of the lateral ankle mortise which may reflect underlying
ligamentous injury.
2. Questionable lateral talar dome osteochondral lesion.
3. Tibiotalar degenerative change.
Radiology Report
EXAMINATION: PORTABLE HEAD CT W/O CONTRAST Q151 CT HEAD
INDICATION: ___ year old man with right ica occlusion and left sided weakness.
Please do during am rounds // interval change
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence: 1) CTDIvol = 70.7 mGy (Phantom type N/A) DLP =
1,131.7 mGy-cm.
COMPARISON: CTA head and neck from ___ neurointerventional
angiography from ___.
FINDINGS:
There is hypodensity within the caudate head, putamen, globus pallidus, and
internal capsule consistent with infarction. Higher density in the putamen is
worrisome for hemorrhagic conversion, but may also represent contrast from
recent angiogram. Effacement of the right lateral ventricle is noted causing
ventricular asymmetry. Ventricles and sulci are prominent, consistent with
mild cerebral atrophy. Also demonstrated are multiple cerebral calcifications
of uncertain etiology, unchanged from prior exams. Also noted are multiple
periventricular, subcortical, and deep white matter hypodensities,
nonspecific, but likely represent chronic microvascular ischemic disease.
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. Hypodensity within the caudate head, putamen, globus pallidus, and internal
capsule consistent with infarction. Increased density in the putamen is
worrisome for hemorrhagic conversion, but may represent contrast from recent
angiogram.
2. Effacement of the right lateral ventricle and causing ventricular
asymmetry.
3. Mild cerebral atrophy and chronic microvascular ischemic disease.
4. Multiple cerebral calcifications of uncertain etiology, unchanged from
prior exam.
Radiology Report
EXAMINATION: AP chest.
INDICATION: ___ year old man with r mca stroke // dobhoff placement
DOBHOFF PLACEMENT FOLLOWED BY 4 ADJUSTMENTS, 5 IMAGES TOTAL
IMPRESSION:
Compared to chest radiograph 00:25 today.
5 sequential chest radiographs show advancement of the transesophageal feeding
tube, wire stylet in place, first into the right main bronchus, next withdrawn
to the carina and slightly above, ___ advanced into the right lower lobe
bronchus, then removed. Final radiograph shows a large transesophageal
drainage tube folded in the esophagus and returning to the neck out of view.
Lungs are clear. Heart size normal. No pneumothorax. ,
NOTIFICATION: Findings were discussed by telephone with the physician caring
for this patient at 17:00, 5 min after the findings were discovered. The
clinical care team was aware of these findings and had already repositioned
the esophageal drainage tube in the upper stomach.
Radiology Report
INDICATION: ___ year old man with r mca/ica stroke
TECHNIQUE: Portable AP chest radiograph
COMPARISON: Multiple prior chest radiographs performed same date.
FINDINGS:
Single AP portable chest radiograph demonstrates low lung volumes. Heart size
is upper limits of normal. There is no left pleural effusion. The right
hemidiaphragm is partially obscured. No evidence of pneumothorax. An enteric
tube descends the thorax in an uncomplicated course, its tip which terminates
in the anticipated location of the gastric lumen. Several clips project over
the midline in the upper abdomen.
IMPRESSION:
Enteric tube appropriately positioned within the gastric lumen.
Radiology Report
EXAMINATION: PORTABLE HEAD CT W/O CONTRAST Q151 CT HEAD
INDICATION: ___ man with a history of oligodendroglioma, who
presented with left-sided weakness and a right internal carotid artery
thrombus, now status post right carotid stenting and right M1 segment
thrombectomy with grade TICI 2b revascularization, postprocedural day 2.
Evaluate for postoperative changes and for evolving infarct.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) CTDIvol = 70.7 mGy (Phantom type N/A) DLP = 1,273.1 mGy-cm.
2) CTDIvol = 70.7 mGy (Phantom type N/A) DLP = 353.6 mGy-cm.
COMPARISON: ___ NEURO INTERVENTIONAL ANGIOGRAM.
___ NONCONTRAST HEAD CT.
___ CONTRAST HEAD CT.
___ HEAD AND NECK CTA.
___ HEAD CTA.
___, ___ CONTRAST BRAIN MRI.
FINDINGS:
Dental amalgam streak artifact and mild motion limits study.
As on prior exam, there is hypodensity involving the right internal capsule,
putamen, and globus pallidus.
Hyperdensity roughly conforming to the shape of the putamen is new compared to
___, but similar compared to ___.
There is no new hyperdensity to suggest interval hemorrhage.
There is slightly increased edema and resulting in slightly increased mass
effect upon the right lateral ventricle and leftward shift of normally midline
structures (now measuring 5 mm, previously 3 mm). The basal cisterns remain
patent.
There is no definite evidence of mass.
There is no evidence of fracture. Left parietal burr hole is again noted.
Mucous retention cysts are noted within the left maxillary sinus. The
visualized portion of the mastoid air cells, and middle ear cavities and
orbits are preserved.
IMPRESSION:
1. Dental amalgam streak artifact and mild motion limits study.
2. Evolving right internal capsule, putamen, and globus pallidus infarcts as
described.
3. Grossly stable putamen hyperdensity again suggestive of contrast staining,
with differential consideration of stable blood products.
4. Within limits of study, no definite new hemorrhage.
5. Mild interval increased edema resulting in mass effect upon right lateral
ventricle and leftward shift of normally midline structures up to 5 mm,
previously measuring 3 mm.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with R MCA territory infarct s/p mechanical
thrombectomy failing speech and swallow, more lethargic // ? aspiration ?
aspiration
IMPRESSION:
Heart size and mediastinum are stable. NG tube tip is in the stomach. Right
basal atelectasis is minimal. There is no focal consolidation otherwise to
suggest infectious process but the right basal area of atelectasis is new. No
pleural effusion. No pneumothorax.
Radiology Report
INDICATION: ___ year old man with R MCA territory infarct with successful
thrombectomy // Portable KUB, evaluate for hardware for MRI
TECHNIQUE: Portable supine abdominal radiograph.
COMPARISON: Chest radiograph from ___.
FINDINGS:
Multiple surgical clips project over the lumbar spine. Evidence of a prior
left inguinal hernia repair. There is no free intraperitoneal air. No
dilated air-filled loops of small or large bowel. Air is noted in the rectum.
Osseous structures are unremarkable.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
Surgical clips and hernia repair clips within the abdomen and pelvis. No
evidence of obstruction.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with left hemiplegia secondary to stroke being
evaluated for PEG tube // pre-op pre-op
IMPRESSION:
NG tube tip is in the stomach. Heart size and mediastinum are stable.
Bibasal areas of atelectasis are moderate, similar to previous study. There is
no pneumothorax.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: History of oligodendroglioma and new right MCA stroke. Evaluate
oligodendroglioma.
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 8 mL of Gadavist intravenous contrast, axial imaging was
performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal
MPRAGE imaging was performed and re-formatted in axial and coronal
orientations.
COMPARISON: Multiple prior MR head examinations dating from ___
through ___. CT head examinations dating from ___ through
___.
FINDINGS:
There are areas of slow diffusion with some degree of pseudo normalization
with associated FLAIR hyperintensity and enhancement within the right caudate,
globus pallidus, putamen, internal and external capsule with associated areas
of intrinsic T1 hyperintensity, with surrounding enhancement compatible with
subacute hemorrhagic infarct. There is a punctate area of slow diffusion with
associated FLAIR hyperintensity in the right precentral gyrus (06:26).
Additional areas of subacute infarct are noted in the right insular cortex.
There is associated mass effect with effacement of the right lateral
ventricle.
A lobulated, predominantly T2 hyperintense lesion centered superior to the
body of the corpus callosum extending through the left frontal and parietal
lobes with involvement of the genu of the corpus callosum is essentially
unchanged in size, though there has been mild interval increase of enhancing
nodular component within the posterior and medial aspect the lesion (13:17).
This 12 x 8 mm focus of nodular enhancement is in an area were there was a
previous soft tissue, though there was not much enhancement at that time.
There is minimal slowed diffusion corresponding to the areas of nodular
enhancement. There are prominent areas of associated susceptibility artifact,
reflecting a combination of hemosiderin staining and calcification
There is no evidence of midline shift. There is mild background prominence of
the ventricles and sulci suggestive of involutional changes. Areas of
background confluent white matter T2/FLAIR hyperintensity likely reflect the
sequela of chronic small vessel ischemic disease or treatment effect. These
have progressed compared the prior examination and may reflect evolution of
posttreatment change, with likely increased involvement from the infarct.
However, there is a new distinct focus of white matter T2/FLAIR hyperintensity
extending from the periventricular white matter of the occipital horn of the
right lateral ventricle, extending inferiorly into the medial temporal lobe,
along the lateral aspect of the temporal horn of the right lateral ventricle
(11:10). There is no associated slowed diffusion. The principal intracranial
vascular flow voids are preserved.
There are small mucous retention cysts in the bilateral maxillary sinuses.
The remainder of the visualized paranasal sinuses are grossly clear. The
orbits are grossly unremarkable.
IMPRESSION:
1. Subacute right MCA territory infarction with involvement of the basal
ganglia, insula, and precentral gyrus with associated edema and hemorrhagic
transformation, as described. Areas of associated enhancement are likely
secondary to the infarct itself.
2. Overall no significant change in size of a pericallosal left frontoparietal
parasagittal lobulated mainly T2 hyperintense mass, though there has been
interval increase of enhancing nodular component, as described, concerning for
progression.
3. New area of white matter T2/FLAIR hyperintensity without associated slowed
diffusion in the medial temporal lobe, which appears to be distinct from the
areas of infarct, and is concerning for new neoplastic focus. However, these
also may reflect changes from the ongoing infarct, and continued attention on
followup examination is advised.
4. Overall unchanged background confluent white matter T2/FLAIR
hyperintensity, likely reflecting post radiation change.
RECOMMENDATION(S): Continued attention on follow-up MR examination of a new
focus of right temporal white matter T2/FLAIR hyperintensity.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with decreased mental status // ?infiltrate
?infiltrate
IMPRESSION:
In comparison with study of ___, the patient has taken a better
inspiration. Continued elevation of the right hemidiaphragmatic contour.
Basilar opacifications are consistent with residual atelectatic changes. The
descending aorta is not well seen on this study, suggesting some increasing
volume loss in the left lower lobe. Blunting of the costophrenic angles could
reflect small pleural effusions.
The nasogastric
Gender: M
Race: WHITE
Arrive by UNKNOWN
Chief complaint: L Weakness
Diagnosed with Cerebral infarction, unspecified
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: Critical
level of acuity: 1.0 | Mr. ___ is a ___ year old male with splenium anaplastic
oligodendroglioma, hypertension, and dyslipidemia who presented
with ___ weakness found to have right ICA thrombus s/p
right carotid stenting and right MCA M1 thrombectomy with grade
TICI 2B revascularization.
#Acute Ischemic Stroke
Mr. ___ presented with ___ weakness. On physical exam in
the ED he was additionally noted to have ___ facial
droop, aphasia, and no blink to threat on the left. His NIHSS
score was 18. CT showed hypodensity concerning for an acute
infarction in the right MCA territory distribution and CTA
showed complete occlusion of the right internal carotid artery
and filling defect within the M1 segment of the right MCA.
Mechanism of stroke likely artery-to-artery embolism from
atherosclerotic disease. He went to ___ for neuro intervention
and underwent a clot retrieval with grade IIb revascularization
and a right carotid stent for complete occlusion. He was
transferred to the neuro ICU for further monitoring and
management. He was started on Aspirin and atorvastatin. He had
a lot of thick upper airway secretions requiring frequent
suctioning and saline nebulizers. He remained afebrile, with a
normal WBC count, and with a benign pulmonary exam. He also had
soft blood pressures, SBP 90-100, and received 500 cc NS boluses
PRN with good effect. He did not require pressors. Repeat CT on
___ and ___ showed stable putamen hyperdensity suggestive of
contrast extravasation, but we monitored for signs of
hemorrhagic conversion on neuro exam. Stroke labs showed HbA1c
of 5.2%, LDL 111, and TSH 0.62. He was transferred from the NICU
to ___ on ___.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented? (x) Yes (LDL = 111) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) (x) Yes - () No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - (x) No - () N/A
Pt was transferred to the Neurology Step Down Floor 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:
confusion
Major Surgical or Invasive Procedure:
Lumbar puncture
History of Present Illness:
___ yo M with well controlled HIV last CD4 >999 undetectable vl
on HAART, NHL s/p treatment many years ago, who presents with
acute confusional state. History is gathered mainly from
records. He recently returned from a trip to ___ and
was found to be lying in bed and confused by his partner. He
was conscious but non-verbal.
PER PARTNER:
Went to ___ last week, was fine for the entire trip.
Returned on ___. Started having sore throat and cough four days
ago. Fevers yesterday but did not take temperature. This AM,
patient feverish, shaking, and very weak. He states since
patient came home he has been altered, unresponsive, and was
soaked in his own urine. As far as partner can tell, patient
without nausea/vomiting, chest pain, SOB, diarrhea.
At baseline patient is alert and oriented x3 and high
functioning, working as a ___. Patient is compliant with his
HIV regimen. As far as his partner knows, he his HIV has been
well controlled for years. Also takes Gabapentin for a
neuropathy as a result of chemotherapy in the 1990s. Patient had
an episode similar to this a year and a half ago and was treated
with Tamiflu and got better.
This AM he complains of R arm pain but is otherwise unable to
give much history. He is coughing during our interview. he
denies any HA, vision change, CP, SOB, n/v/d, abd pain, leg or
joint pain or swelling.
10 point review of systems reviewed and otherwise negative
except as listed above
Past Medical History:
1. HIV CD4 ct ___, undetectable vl
2. Non-Hodgkin's lymphoma. Status post chemotherapy as well as
intrathecal chemotherapy for CNS involvement. Also with whole
brain radiation. treated with Cytoxan, Methotrexate,
Adriamycin,
and Vincristine as well as whole brain radiation
3. History of pancreatitis, medication related.
4. Status post left cataract surgery.
5. History of left ruptured eardrum.
6. Lactose intolerance.
7. Dry eye.
8. Vision impairment as a complication from radiation therapy
(legally blind in left eye).
9. Status post mid back spinal process fracture from boating
accident
Social History:
___
Family History:
Per report.
Father is deceased secondary to squamous cell lung cancer
Mother - colon cancer
Physical Exam:
VS: 98.9 PO 118 / 67 68 18 97 Ra
GEN: sitting up in bed in NAD
HEENT: NC/AT, MMM, OP clear, EOMI with crust around eyes,
anicteric sclera
NECK: supple no LAD full ROM no meningismus
CV: RRR no mrg
PULM: CTAB no wheezes or crackles
GI: soft NT/ND +BS no rebound or guarding
EXT: warm well perfused no pitting edema, no swollen joints
SKIN: no rashes appreciated
NEURO: tired appearing and inattentive, unable to do MOYB.
Awake, knows place and month. Follows basic commants.
CNII-XIII intact with fluent speech
Discharge exam:
T 98 PO BP: 127/69 HR: 60 RR: 18 O2 sat: 97% O2 delivery: RA
GEN: sitting up in bed, in NAD
HEENT: anicteric sclera, MMM, OP clear, temporal wasting
NECK: supple full ROM, no LAD appreciated
CV: RRR no m/r/g
PULM: CTAB no wheezes, rales, or crackles.
GI: soft NT/ND +BS no rebound or guarding
EXT: warm well perfused, no pitting edema.
MSK: no pain with passive ROM of R shoulder, strength ___
bilaterally in UE and no TTP/warmth over right shoulder
appreciated
SKIN: no rashes or lesions noted, no ecchymoses or petechiae
NEURO: awake and alert, oriented x 3 and making jokes
Pertinent Results:
___ 09:17PM BLOOD WBC-7.8 RBC-3.92* Hgb-13.1* Hct-37.5*
MCV-96 MCH-33.4* MCHC-34.9 RDW-13.1 RDWSD-46.1 Plt ___
___ 09:17PM BLOOD Neuts-55.6 ___ Monos-13.5*
Eos-1.7 Baso-0.3 Im ___ AbsNeut-4.36 AbsLymp-2.26
AbsMono-1.06* AbsEos-0.13 AbsBaso-0.02
___ 09:17PM BLOOD Calcium-8.1* Phos-1.8* Mg-2.0
___ 10:25 pm BLOOD CULTURE + MRSA
Crypto neg
Milaria neg
Flu neg
Collection Date Tests Result FROM ___
___ 19:10 Varicella-Zoster Virus DNA, PCR NEGATIVE
___ 19:10 Enterovirus RNA, Qualitative, RT-PCR PND
___ 15:56 Cytomegalovirus Dna, Qualitative, Pcr
NEGATIVE
___ 15:56 ___ Virus DNA, PCR NEGATIVE
___ 05:36 Herpes Simplex Virus PCR NEGATIVE
SHOULDER XRAY: neg fx
CT HEAD:
IMPRESSION:
1. No acute intracranial abnormalities on noncontrast head CT.
2. Stable numerous calcifications in the pons, bilateral frontal
lobes and
left occipital lobe dating back to ___, thought to represent
sequela of prior
infection/inflammation.
3. Stable focus of white matter hypodensity in the right frontal
lobe since
___.
CXR IMPRESSION:
Bibasilar opacities most likely atelectasis in setting of low
lung volumes. Otherwise clear lungs.
MRI BRAIN:
IMPRESSION:
No new intracranial abnormality noted. No infarct or
hemorrhage.
Fairly extensive periventricular, deep and subcortical white
matter T2 and
FLAIR hyperintense lesions are unchanged. There is no abnormal
enhancement
postcontrast. Calcifications are also unchanged.
These lesions are nonspecific and may be related to previously
treated
lymphoma or HIV with possible superimposed microangiopathic
changes.
MRI NECK:
IMPRESSION:
1. No CT evidence of abnormal signal within the spinal cord,
abnormal
enhancement or significant extrinsic spinal cord compression.
Disc bulging
mildly contact the spinal cord at multiple levels.
2. Changes of cervical spondylosis predominantly foraminal
narrowing as
described above with mild spinal stenosis at C3-4 and C4-___. Small right shoulder joint effusion with thin rim
enhancement with a small
amount of fluid distending the subscapular bursa.
2. No evidence of intramuscular abscess or myositis.
TTE: The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF = 60%). 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 mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
IMPRESSION: no vegetation seen (best excluded by transesophageal
echocardiography)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 800 mg PO DAILY
2. Triumeq (abacavir-dolutegravir-lamivud) 600-50-300 mg oral
DAILY
3. Prezcobix (darunavir-cobicistat) 800-150 mg-mg oral DAILY
4. Gabapentin 600 mg PO TID
5. TraZODone 150 mg PO QHS insomnia
Discharge Medications:
1. Vancomycin 1250 mg IV Q 12H Duration: 22 Days
You need to continue this medication through ___
RX *vancomycin 1 gram 1250 mg IV twice daily Disp #*42 Vial
Refills:*0
2. Acyclovir 800 mg PO DAILY
3. Gabapentin 600 mg PO TID
4. Prezcobix (darunavir-cobicistat) 800-150 mg-mg oral DAILY
5. TraZODone 150 mg PO QHS insomnia
6. Triumeq (abacavir-dolutegravir-lamivud) 600-50-300 mg oral
DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Staph aureus bloodstream infection
Aseptic meningoencephalitis
Encephalopathy
Right arm pain/weakness, resolving
HIV
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 AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old man with HIV, prior NHL s/p curative treatment,
admitted with altered mental status, recent travel, and concern for CNS
infection vs. seizure.// eval for etiology of altered mental status with
concern for CNS infection vs. seizure vs. recurrent ___
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of of Gadavist intravenous contrast, axial imaging was
performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal
MPRAGE imaging was performed and re-formatted in axial and coronal
orientations.
COMPARISON: Prior brain MR done ___ and prior CT head done ___
FINDINGS:
The study is markedly degraded by motion artifact. There is no acute
intracranial infarct. No mass. T2 and FLAIR hyperintense changes in the
periventricular, deep and subcortical white matter most marked in the right
frontal lobe appear similar compared to prior imaging. No abnormal
enhancement. Generalized cerebral atrophy with ex vacuo dilatation of the
ventricular system similar compared to prior. Suspected prior left lens
extraction. Partially empty sella. The craniocervical junction appears
normal. Hypointense signal change on T1 imaging in the central clivus is
unchanged compared to prior. Bilateral frontal lobe, basal ganglia and
pontine calcification is better seen on CT and is unchanged compared to prior
imaging. Air-fluid level present in the left maxillary sinus with associated
moderate mucosal thickening. Mild mucosal thickening involving the ethmoid
air cells.
IMPRESSION:
No new intracranial abnormality noted. No infarct or hemorrhage.
Fairly extensive periventricular, deep and subcortical white matter T2 and
FLAIR hyperintense lesions are unchanged. There is no abnormal enhancement
postcontrast. Calcifications are also unchanged.
These lesions are nonspecific and may be related to previously treated
lymphoma or HIV with possible superimposed microangiopathic changes.
Mild moderate paranasal sinus disease.
Radiology Report
EXAMINATION:
MRI OF THE CERVICAL SPINE WITH AND WITHOUT GADOLINIUM
INDICATION: ___ year old man with meningoencephalitis and ? R arm weakness//
eval for acute central process of infection
TECHNIQUE: T1, T2 and inversion recovery sagittal and gradient sequence T2
axial images of cervical spine obtained. T1 sagittal and axial images
obtained following gadolinium.
COMPARISON: No prior similar examinations for comparison.
FINDINGS:
The examination is limited by motion. There is no abnormal signal seen within
the spinal cord. Disc bulging contacts the spinal cord at multiple levels but
there is no evidence of high-grade spinal cord deformity or compression.
At the craniocervical junction and C2-3 mild degenerative change seen. At
C3-4 disc bulging results in mild spinal stenosis with moderate-to-severe left
and mild-to-moderate right foraminal narrowing.
At C4-5 level, disc bulging and posterior osteophyte result in mild spinal
stenosis with moderate-to-severe right as well as left foraminal narrowing.
At C5-6 disc and uncovertebral degenerative changes seen with moderate
bilateral foraminal narrowing.
At C6-7 disc bulging with mild narrowing of the foramina seen without spinal
stenosis.
From C7-T1 to T3-4 mild degenerative change seen.
No abnormal intraspinal enhancement is seen following gadolinium
administration. No evidence of discitis or osteomyelitis. No evidence of
bone marrow edema or ligamentous disruption.
IMPRESSION:
1. No CT evidence of abnormal signal within the spinal cord, abnormal
enhancement or significant extrinsic spinal cord compression. Disc bulging
mildly contact the spinal cord at multiple levels.
2. Changes of cervical spondylosis predominantly foraminal narrowing as
described above with mild spinal stenosis at C3-4 and C4-5 levels.
Radiology Report
EXAMINATION: CT UP EXT W/C RIGHT
INDICATION: ___ year old man with staph BSI, meningoencephalitis with
indistinct R arm pain localized around bicep, ? underlying infection// assess
for abscess, inflammation, myositis in upper R arm
TECHNIQUE: Helical Axial MDCT images from the right shoulder through elbow
with IV contrast. Bone and soft tissue algorithms reconstructions and coronal
and sagittal reformations were provided.
DOSE: Acquisition sequence:
1) Spiral Acquisition 10.5 s, 45.3 cm; CTDIvol = 30.6 mGy (Body) DLP =
1,364.3 mGy-cm.
Total DLP (Body) = 1,364 mGy-cm.
COMPARISON: Right shoulder radiographs on ___
FINDINGS:
There is a small right shoulder joint effusion with a small amount of fluid
distending the subscapular bursa. No intramuscular fluid collection. There is
no muscular edema or soft tissue stranding. No bony erosion. Mild
degenerative changes in the shoulder with spurring and subchondral cysts. No
fracture or dislocation.
There is mild atelectasis in the right lung. The visualized portions of the
chest and upper abdomen are otherwise within normal limits.
IMPRESSION:
1. Small right shoulder joint effusion with thin rim enhancement with a small
amount of fluid distending the subscapular bursa.
2. No evidence of intramuscular abscess or myositis.
Radiology Report
EXAMINATION: INJ/ASP MAJOR JT W/FLUORO
INDICATION: ___ year old man with Staph BSI and R shoulder pain and effusion
on CT// ARTHROCENTESIS RIGHT SHOULDER TO EVAL FOR INFECTION
COMPARISON: Right shoulder CT dated ___. Right shoulder
radiographs dated ___.
PROCEDURE: The risks, benefits, and alternatives were explained to the
patient and written informed consent obtained.
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.
2 cc of 1% Lidocaine was used to achieve local anesthesia. Under intermittent
fluoroscopic guidance, an 18-gauge spinal needle was advanced into the right
glenohumeral joint. As no fluid was aspirated, additional positions were
attempted including a more inferior and a more superior position. No fluid
was obtained. At that point, the patient refused to continue the procedure
due to pain and did not want any more attempted aspirations or lavage. We had
a discussion with the patient about the possibility of septic arthritis and
the consequences of having an undiagnosed septic arthritis, including sepsis
and joint destruction. The patient acknowledged the potential consequences
and insisted that the procedure be terminated.
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.
FINDINGS:
Needle tip overlying the right glenohumeral joint.
IMPRESSION:
1. Imaging Findings- as above.
2. Procedure- unsuccessful aspiration of the right glenohumeral joint. The
procedure was terminated at the request of the patient before a joint lavage
could be attended.
This was discussed with the ___ Dr. ___ at 16:30 on ___.
I Dr. ___ supervised the Resident/Fellow during the key
components of the above procedure and I have reviewed and agree with the
Resident/Fellow findings/dictation.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old man with new L PICC. Evaluation for left PICC
placement.
TECHNIQUE: Chest portable AP
COMPARISON: Chest radiograph from ___.
FINDINGS:
Interval placement of left-sided PICC line, which ends at the low SVC.
Cardiomediastinal silhouette is stable and within normal limits. The
pulmonary vasculature is normal. Lung volumes have shown interval
improvement. Lungs are clear. No pleural effusion or pneumothorax is seen.
There are no acute osseous abnormalities.
IMPRESSION:
Left-sided PICC line with tip terminating at the low SVC. No evidence of
pneumothorax.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Altered mental status, Weakness
Diagnosed with Altered mental status, unspecified
temperature: 97.6
heartrate: 73.0
resprate: 16.0
o2sat: 98.0
sbp: 118.0
dbp: 63.0
level of pain: ua
level of acuity: 2.0 | Mr. ___ is a ___ yo M with well controlled HIV on HAART and
past h/o NHL s/p treatment, who presented with acute
encephalopathy and fever concerning for acute CNS infection,
found to have staph aureus bloodstream infection.
Acute toxic metabolic encephalopathy, aseptic
meningoencephalitis:
Sepsis secondary to acute MRSA bloodstream infection, possible
right shoulder septic arthritis:
Pt underwent LP on admission that had significant prbcs and CSF
with lymphocytic pleocytosis (48 WBCs on tube 4). Pt was
started empirically on Vanc, CTX, Ampicillin and Acyclovir while
awaiting CSF cultures. Initial blood cx from the ED returned
positive for MRSA though all subsequent blood Cx were negative
for growth. MRI head without any acute findings (chronic
findings likely ___ previously treated NHL). Pt improved with
regards to mental status but reported right shoulder pain with
limited motion. CT RUE concerning for joint fluid and pt
underwent attempted ___ guided aspiration that was unsuccessful.
Ortho felt his exam was not consistent with septic arthritis and
the right shoulder symptoms resolved while inpatient. Abx were
de-escalated as CSF cultures returned negative for growth.
Viral CSF studies all returned negative (except enterovirus
while was pending at the time of d/c) and Acyclovir was
discontinued. Source of the MRSA bacteremia remained unclear
and TTE was negative for vegetations. Right shoulder symptoms
resolved entirely and mental status was back to baseline. ID
team felt this may all have been consistent with early right
shoulder septic arthritis from MRSA bacteremia and recommended 4
wks of Vancomycin ending on ___. Pt had a LUE PICC Placed and
was discharged on Vanc 1250mg BID for a 4 wk course with plan
for weekly OPAT labs and PCP follow up next week.
HIV, chronic: well controlled with CD4 999 and undetectable
viral load
Pt was continued on Triumeq and Prezcobix.
NHL: s/p treatment many years ago and apparently in remission.
No evidence of recurrence on imaging. Final CSF cytology was
pending at the time of discharge though given negative MRI, this
was felt unlikely.
Neuropathy: resumed Gabapentin, Trazodone after mental status
returned to baseline |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Vomiting and hematemasis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old man with HTN, type I diabetes complicated by
gastroparesis, and PUD presents with nausea, vomiting, diarrhea,
and hematemesis. Patient had recent ___ hospitalization on
___ for hyperglycemia, nausea, and vomiting thought to be due
to gastroparesis flare. The patient was managed with IV fluids,
insulin, and anti-emetics with improvement in his symptoms. The
patient also had hematemesis during his previous admission which
resolved with PPI. On ___, the patient left against medical
advice.
The patient called EMS earlier today because he was concerned
he was in DKA. He has been vomiting all day. He has been unable
to tolerate any PO and is also now having diarrhea. He denies
fevers but endorses chills. He has no pain complaints. He states
he is never experienced symptoms like this in the past. He has
been taking his medications as directed. Prior to arrival he
took 6 units of Humalog and 32 units of Lantus.
-In the ED, initial vitals were: T 96.8 HR 109 BP 179/119 RR 26
SpO2 98% RA
- Exam in ED was unremarkable
- Labs notable for: WBC 9.8, H/H 13.4/38.8 (was 14.9/42 on
___, Cr 1.0, no anion gap, FSG 74
- CXR with no free air under diaphragm
- Patient was given:
___ 22:25 IV Ondansetron 4 mg ___
___ 22:25 IVF NS ( 1000 mL ordered) ___ Started
Stop
___ 22:25 IV Dextrose 50% 25 gm ___
___ 22:45 IV Ondansetron 4 mg ___
___ 22:56 IV Pantoprazole 40 mg ___
___ 23:25 IV Lorazepam 1 mg ___
___ 00:08 IV Lorazepam 1 mg ___
___ 00:12 IVF D5NS + 40 mEq Potassium Chloride
___ Started 250 mL/hr
___ 01:01 IV Metoclopramide 10 mg ___
-Vitals prior to transfer: T 97.9 HR 89 BP 158/99 RR 16 SpO2
100% RA
Upon arrival to the floor, patient was very irritable and was
uncooperative with exam. He endorsed ongoing nausea/vomiting and
hematemesis (coffee ground emesis was noted in emesis basin with
black clots). He was given more IV fluids, IV reglan, and
continued on IV Pantoprazole. He otherwise remained
hemodynamically stable.
Past Medical History:
-Type 1 diabetes, since age ___
*c/b gastroparesis
-History of peptic ulcers requiring EGD
-Hypertension
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 98.7 BP 164/106 HR 82 RR 18 SpO2 100% RA
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL.
Neck: Supple. JVP not elevated. no LAD
CV: RRR. 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
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Moving all extremities with purpose, no facial
assymetry, gait deferred.
DISCHARGE PHYSICAL EXAM:
VS: 98.1, 152-171/97-111, HR 90, RR 18, 99% RA
GENERAL: In no acute distress, cooperative and comfortable in
bed
HEENT: AT/NC, anicteric sclera, pink conjunctiva, MMM
HEART: denied
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, normal bowel sounds present, TTP in
epigastric region, no guarding or rebound tenderness
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
NEURO: Cranial nerves grossly intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION/IMPORTANT LABS
___ 10:15PM BLOOD WBC-9.8 RBC-4.17* Hgb-13.4* Hct-38.8*
MCV-93 MCH-32.1* MCHC-34.5 RDW-13.2 RDWSD-45.1 Plt ___
___ 10:15PM BLOOD Neuts-63.7 ___ Monos-5.3 Eos-0.7*
Baso-0.8 Im ___ AbsNeut-6.21* AbsLymp-2.85 AbsMono-0.52
AbsEos-0.07 AbsBaso-0.08
___ 02:09PM BLOOD ___ PTT-27.8 ___
___ 10:15PM BLOOD Glucose-74 UreaN-11 Creat-1.0 Na-145
K-4.3 Cl-103 HCO3-25 AnGap-21*
___ 10:15PM BLOOD ALT-28 AST-38 CK(CPK)-364* AlkPhos-72
TotBili-0.2
___ 10:15PM BLOOD CK-MB-2
___ 10:15PM BLOOD cTropnT-<0.01
___ 10:15PM BLOOD Albumin-4.1 Calcium-10.2 Phos-4.1 Mg-1.9
___ 10:35PM BLOOD Glucose-74 Lactate-2.4* Na-146* K-3.6
Cl-99 calHCO3-32*
___ 02:41PM BLOOD Lactate-1.3
DISCHARGE LABS
___ 10:38AM BLOOD WBC-11.1* RBC-3.99* Hgb-12.8* Hct-37.1*
MCV-93 MCH-32.1* MCHC-34.5 RDW-13.2 RDWSD-45.2 Plt ___
___ 10:38AM BLOOD Glucose-135* UreaN-9 Creat-0.8 Na-142
K-3.9 Cl-101 HCO3-29 AnGap-16
___ 10:38AM BLOOD Calcium-8.9 Phos-3.0 Mg-2.2
MICROBIOLOGY
------------------
___ 10:18 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING/STUDIES
CXR ___: Normal chest radiographs.
KUB ___: Normal bowel gas pattern without evidence of
obstruction.
Medications on Admission:
1. Omeprazole 20 mg PO DAILY
2. Ondansetron ODT 4 mg PO Q8H:PRN nausea
3. Lisinopril 5 mg PO DAILY
4. Glargine 32 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Glargine 32 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
2. Lisinopril 5 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Ondansetron ODT 4 mg PO Q8H:PRN nausea
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Gastroparesis, gastroenteritis
Secondary: IDDM, HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with cough and chills// pna?
TECHNIQUE: Chest PA and lateral
COMPARISON: ___.
FINDINGS:
The lungs are clear. Heart size and mediastinal contours are normal. No
pleural effusion or pneumothorax. Osseous structures are intact.
IMPRESSION:
Normal chest radiographs.
Radiology Report
INDICATION: ___ year old man with hx gastroporesis, now with severe abdominal
pain and nausea.// Eval for SBO.
TECHNIQUE: Supine and upright abdominal radiographs were obtained.
COMPARISON: CT abdomen pelvis from ___
FINDINGS:
There are no abnormally dilated loops of large or small bowel.
There is no free intraperitoneal air. Osseous structures are unremarkable.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
Normal bowel gas pattern without evidence of obstruction.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Dizziness, Hypoglycemia, Vomiting
Diagnosed with Type 1 diabetes w diabetic autonomic (poly)neuropathy, Long term (current) use of insulin
temperature: 96.8
heartrate: 109.0
resprate: 26.0
o2sat: 98.0
sbp: 179.0
dbp: 119.0
level of pain: 0
level of acuity: 2.0 | ___ with history of HTN, type I diabetes complicated by
gastroparesis and PUD presenting with nausea, vomiting, and
diarrhea, likely ___ gastroporesis flare as well as hematemesis
likely ___ ___ tear. He improved with conservative
care and was discharged home in good condition.
#Nausea/Vomiting: Patient presented with nausea, vomiting, and
diarrhea, likely secondary to gastroparesis. Patient has a
recent admission on ___ for gastroparesis flare that
presented in the same manner, including the atypical feature of
diarrhea. Likely hypovolemic on admission given mildly elevated
Cr from baseline (1.0 from 0.7), lactate, and borderline
hypernatremia, but all normalized with IVF. He was treated with
acetaminophen, IV Reglan PRN, IV Zofran and IV lorazepam for
nausea, Lidocaine patch for abdominal pain with muscle tension
and Capsaicin cream for nausea. Diet was advanced and he was
able to tolerate PO on the morning of discharge. His pain was
not resolved, but was improved and tolerable at the time of
discharge.
#Hematemesis: Patient presented with nausea and coffee ground
emesis, with some red streaks and some clots. Hgb relatively
stable at 13.4, with mild drop at 12.7. Given hematemesis began
after ongoing severe vomiting, most concerning for ___
tear. Patient has known PUD and on omeprazole at home. He
remained hemodynamically stable during admission and was
discharged on home PPI. His hematemesis did not recur.
#Diabetes Mellitus, Type 1: Patient presenting with hypoglycemia
FSG ___ in the setting of using insulin while not taking PO, now
improved. No evidence of DKA. Continued home insulin regimen.
#Hypertension: Continued home Lisinopril 5 mg PO QDaily
======================================
TRANSITIONAL ISSUES
======================================
[ ] Will follow with PCP for ongoing DM care. Could consider
referral to GI if he continues to have flares of gastroparesis.
# CODE: Full (confirmed)
# CONTACT: Name of health care proxy: ___
Phone number: ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Avelox / amitriptyline / Penicillins
Attending: ___.
Chief Complaint:
SAH, new O2 requirement
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ COPD (on 2L home O2), CAD (s/p stent ___, HTN, HLD, DM,
transferred following a fall and found to have SAH, being
admitted for new oxygen requirement.
She resides in a nursing home and reports a fall from her chair
while leaning over to pick up an item off the floor. She fell
out of the chair and struck her head; she denies LOC. She was
brought to an OSH by ambulance where ___ showed small right
frontal tSAH. She was transferred to ___ for further
evaluation. Pt denies any vision changes, numbness, tingling or
weakness. Not on blood thinners. Otherwise feels well. Per
family is at baseline.
In the ED, initial vitals were: 97.4 112/57 12 93%NC. Remained
tachycardic ___. Oxygen saturation remained high ___ on NC.
- Exam notable for: not documented
- Labs notable for: H/H 8.4/28.4 (b/l Hgb ***), nl CHEM7, UA
negative, lactate 1.6. D-Dimer 2488
- Imaging was notable for: CTA w/o PE but limited study,
diffuse chronic lung disease, moderately severe aspiration. CT
head interval evolution of subarachnoid blood in right frontal
and temporal lobes, no new hemorrhage, moderate left parietal
subgaleal hematoma
- Patient was given: furosemide 40mg PO, losartan, tiotropium,
glimepride, spironolactone, sertraline, docusate, 500cc NS,
acetaminophen, olanzapine, albuterol neb
- Seen by NSGY, no role for neurosurgical intervention and no
follow up necessary
- Pt admitted for worsening O2 requirement
Upon arrival to the floor, VS: 97.9 116/56 110 18 95%
Pt currently denies difficulty breathing. Has had new cough. No
fevers or chills. Has had yellowish sputum production, unchanged
from baseline. No wheezing. No chest pain. No headache. Has had
chronic blurred vision. No new numbness or tingling.
Past Medical History:
COPD
Diabetes
Hyperlipidemia
Hypertension
Myocardial Infarction
CAD with stents ___
Macular degeneration
Legal blindness
Demetia
Anxiety
Surgery:
R fallopian tube removal
Knee Surgery
Foot surgery
Social History:
___
Family History:
- mother esophageal cancer
- family history of diabetes
Physical Exam:
ADMISSION PHYSICAL EXAM
======================
Vitals: 97.9 116/56 110 18 95%
General: alert, oriented, no acute distress, no use of
accessory muscles of respiration
HEENT: sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated
Lungs: pan-inspiratory wheezes diffusely, no rales or ronchi
CV: tachycardic, regular, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing or cyanosis,
trace edema
Neuro: CNs2-12 intact, moving all four extremities
DISCHARGE PHYSICAL EXAM
======================
VS: T 98.2 BP 114 / 58 HR 96 RR 16 O2 89% 3L
GENERAL: NAD, alert and oriented x1-3 and does not recall
yesterday's events.
HEENT: AT/NC, EOMI, PERRL, MMM
NECK: Supple, no LAD, no JVD
HEART: Tachy, regular rhythm, S1/S2, no murmurs, gallops, or
rubs
LUNGS: LLL rales, right lower lobe rhonchi. Apices bilaterally
are CTA.
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
Pertinent Results:
ADMISSION LAB RESULTS
====================
___ 09:50PM BLOOD WBC-8.5 RBC-3.54* Hgb-8.4* Hct-28.4*
MCV-80* MCH-23.7* MCHC-29.6* RDW-19.8* RDWSD-56.1* Plt ___
___ 09:50PM BLOOD ___ PTT-30.2 ___
___ 09:50PM BLOOD Glucose-159* UreaN-23* Creat-0.7 Na-139
K-4.4 Cl-98 HCO3-27 AnGap-18
___ 09:50PM BLOOD ALT-19 AST-19 LD(LDH)-254* AlkPhos-88
TotBili-<0.2
___ 09:50PM BLOOD Calcium-9.7 Phos-4.0 Mg-1.4*
___ 03:50PM BLOOD D-Dimer-2488*
MICROBIOLOGY
============
___ Blood culture:
___ Urine culture:
___ C diff:
IMAGING/STUDIES:
==============
___ CT Head without Contrast:
1. Interval evolution of subarachnoid blood in the right
frontal and temporal lobes. No new hemorrhage.
2. Moderate left parietal subgaleal hematoma.
3. Extensive paranasal sinus disease with likely an acute
component.
___ CTA Chest:
1. Severely limited study due to respiratory motion artifact,
but no central or lobar pulmonary embolism.
2. Diffuse chronic lung disease and moderately severe
emphysema.
3. Moderately severe aspiration involving the bronchus
intermedius, right middle, and right lower lobes.
DISCHARGE LAB RESULTS
====================
___ 04:45AM BLOOD WBC-13.0*# RBC-3.01* Hgb-7.2* Hct-24.0*
MCV-80* MCH-23.9* MCHC-30.0* RDW-20.1* RDWSD-57.8* Plt ___
___ 04:45AM BLOOD Glucose-124* UreaN-17 Creat-0.7 Na-137
K-4.0 Cl-100 HCO3-23 AnGap-18
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Multivitamins 1 TAB PO DAILY
2. Sertraline 50 mg PO DAILY
3. Tiotropium Bromide 1 CAP IH DAILY
4. OLANZapine 2.5 mg PO DAILY
5. OLANZapine 5 mg PO QHS
6. OLANZapine 5 mg PO BID:PRN agitation
7. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
8. Tessalon Perles (benzonatate) 100 mg oral TID:PRN
9. OxyCODONE (Immediate Release) 10 mg PO BID
10. LORazepam 0.5 mg PO BID
11. Gabapentin 100 mg PO BID
12. Calcium Carbonate 500 mg PO DAILY
13. Vitamin D 400 UNIT PO DAILY
14. Daliresp (roflumilast) 500 mcg oral DAILY
15. Furosemide 40 mg PO DAILY
16. Losartan Potassium 25 mg PO DAILY
17. Omeprazole 20 mg PO DAILY
18. Spironolactone 12.5 mg PO DAILY
19. melatonin 3 mg oral QHS
20. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
21. Atenolol 25 mg PO BID
22. Docusate Sodium 100 mg PO BID
23. Senna 8.6 mg PO BID
24. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
25. Fentanyl Patch 25 mcg/h TD Q72H
26. Ferrous Sulfate 325 mg PO 3X/WEEK (___)
27. Lidocaine 5% Patch 1 PTCH TD QPM
Discharge Medications:
1. Azithromycin 250 mg PO Q24H Duration: 4 Doses
2. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
3. LORazepam 0.5 mg PO DAILY Duration: 4 Doses
4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
5. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
6. Atenolol 25 mg PO BID
7. Calcium Carbonate 500 mg PO DAILY
8. Daliresp (roflumilast) 500 mcg oral DAILY
9. Docusate Sodium 100 mg PO BID
10. Ferrous Sulfate 325 mg PO 3X/WEEK (___)
11. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
12. Gabapentin 100 mg PO BID
13. Lidocaine 5% Patch 1 PTCH TD QPM
14. Losartan Potassium 25 mg PO DAILY
15. melatonin 3 mg oral QHS
16. Multivitamins 1 TAB PO DAILY
17. OLANZapine 5 mg PO BID:PRN agitation
18. OLANZapine 2.5 mg PO DAILY
19. OLANZapine 5 mg PO QHS
20. Omeprazole 20 mg PO DAILY
21. OxyCODONE (Immediate Release) 10 mg PO BID
22. Senna 8.6 mg PO BID
23. Sertraline 50 mg PO DAILY
24. Tessalon Perles (benzonatate) 100 mg oral TID:PRN
25. Tiotropium Bromide 1 CAP IH DAILY
26. Vitamin D 400 UNIT PO DAILY
27. HELD- Furosemide 40 mg PO DAILY This medication was held.
Do not restart Furosemide until the patient's blood pressure is
higher.
28. HELD- Spironolactone 12.5 mg PO DAILY This medication was
held. Do not restart Spironolactone until the patient's blood
pressure is higher.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: COPD exacerbation, subarachnoid hemorrhage
Secondary: Anemia, chronic pain
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: ___ year old woman with traumatic subarachnoid hematoma. Evaluate
for interval change.
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, 16.4 cm; CTDIvol
= 48.9 mGy (Head) DLP = 802.7 mGy-cm. Total DLP (Head) = 803 mGy-cm.
COMPARISON: Outside CT head from ___
FINDINGS:
Previously identified subarachnoid hemorrhage along the right frontal
convexities is slightly less conspicuous compared to the prior study (02:20).
There may be also in anterior frontal subarachnoid (02:17) although this area
is limited due to streak artifact. Subarachnoid blood is also present in the
right temporal lobe convexities. There is no new hemorrhage. Ventricles and
sulci are normal in size and configuration for patient's age. Periventricular
and subcortical white matter hypodensities are nonspecific but likely reflect
sequelae of chronic small vessel ischemic disease.
There is no evidence of fracture. There is a moderate-sized left parietal
subgaleal hematoma not significantly changed in size compared to the prior
study. There are aerosolized secretions within the right maxillary sinus and
air-fluid levels in the bilateral maxillary sinuses. There is also paranasal
sinus disease in the right ethmoid air cells as well as the frontal and
bilateral sphenoid sinuses. The visualized portion of the mastoid air cells,
and middle ear cavities are clear. Bilateral lens replacements are
identified. Carotid siphon calcifications are also present.
IMPRESSION:
1. Interval evolution of subarachnoid blood in the right frontal and temporal
lobes. No new hemorrhage.
2. Moderate left parietal subgaleal hematoma.
3. Extensive paranasal sinus disease with likely an acute component.
Radiology Report
INDICATION: ___ w/ hypoxia, tachycardia, eval for pna// ___ w/ hypoxia,
tachycardia, eval for pna
TECHNIQUE: Chest PA and lateral
COMPARISON: None
FINDINGS:
The lungs are hyperinflated and there are increased interstitial markings
bilaterally, indicative of interstitial edema. The patient is slightly
rotated, and thus the cardiomediastinal silhouette is off midline, but appears
normal in size. No focal consolidation or pleural effusion. No pneumothorax.
IMPRESSION:
Moderate interstitial edema with no cardiomegaly or pleural effusions.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ w/ dyspnea, hypoxia, tachycardia, +Ddimer 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) = 192 mGy-cm.
COMPARISON: None
FINDINGS:
HEART AND VASCULATURE: Evaluation of the pulmonary vasculature is severely
limited by extreme respiratory motion artifact. Within this limitation, there
is no central or lobar pulmonary embolism. The thoracic aorta is normal in
caliber without evidence of dissection or intramural hematoma. There is
extensive atherosclerotic calcification of the thoracic aorta. The heart,
pericardium, and great vessels are within normal limits. No pericardial
effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Evaluation of the lungs is limited by extreme respiratory
motion artifact. There is moderate to severe centrilobular emphysema and
diffuse increased thickness of the interstitium, compatible with chronic
underlying lung disease. There is extensive endobronchial secretions in the
bronchus intermedius, right middle and lower lobe airways, compatible with
aspiration. There is resultant moderate atelectasis at the right lung base.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: Included portion of the upper abdomen is unremarkable.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
IMPRESSION:
1. Severely limited study due to respiratory motion artifact, but no central
or lobar pulmonary embolism.
2. Diffuse chronic lung disease and moderately severe emphysema.
3. Moderately severe aspiration involving the bronchus intermedius, right
middle, and right lower lobes.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, SAH, Transfer
Diagnosed with Traum subrac hem w/o loss of consciousness, init, Fall on same level, unspecified, initial encounter
temperature: 97.4
heartrate: 115.0
resprate: 12.0
o2sat: 93.0
sbp: 112.0
dbp: 57.0
level of pain: 0
level of acuity: 2.0 | ___ is an ___ year old woman with a history of COPD,
chronic arthritis pain, dementia, who presented to ___
___ after falling out of her chair with a head strike.
Non-contrast CTH at ___ revealed small right frontal
subarachnoid hemorrhage. When she had a repeat at ___ 3 days
later the hemorrhage had evolved but there was no new
hemorrhage. Her mental status was at baseline per the family.
She also was found to have evidence of aspiration in the right
lobe and increased oxygen requirement and was given treatment
for a COPD exacerbation. Oral steroids were avoided due to
recent incident of steroid induced psychosis at ___
___ the previous week. She had a leukocytosis on her day of
discharge but otherwise appeared clinically very well and was on
her home O2 requirement of 3L (home O2 req: confirmed with her
HCP), and so she was discharged with instructions for close
follow up.
Her individual issues were assessed, diagnosed, and treated as
follows:
ACTIVE ISSUES:
====================================
#HYPOXEMIA:
Likely secondary to COPD exacerbation as patient has had
worsening productive cough with wheezes appreciated on exam with
also a component of aspiration. Imaging notable for no pulmonary
embolism with moderately severe aspiration involving the
bronchus intermedius, right middle, and right lower lobe
airways. Patient does have evidence of aspiration on imaging but
has not had fevers or leukocytosis, so it was not evident if
patient has developed pneumonia. Treated for COPD exacerbation
with azithromycin. Patient declined steroids given recent
steroid induced psychosis. She did have leukocytosis on her last
day but she appeared well clinically and was actually improving
overall.
- Azithromycin (___)
- S&S eval said OK for soft solids with thin liquids, no e/o
aspiration
- Standing ipratropium nebulizer, albuterol INH prn
- Standing fluticasone INH
#RIGHT SUBARACHNOID HEMORRHAGE:
Pt developed traumatic right subarachnoid hemorrhage. Repeat
NCHCT was stable. No neurosurgical intervention was needed and
DVT ppx was held.
#ANEMIA:
Hemoglobin 8.4 on admission. Unknown baseline. Denies bloody or
melenic stools. Low iron, low transferrin/TIBC, high ferritin
indicating mixed picture of iron deficiency/chronic
inflammation. Continued home PO iron and gave 1x dose of IV
iron.
#CHRONIC OSTEOARTHRITIS PAIN:
Mainly the right hip and back, through the knee, per the
daughter. Now the left knee is bothering her. Kept oxycodone and
added lidocaine patch, but discontinued Fentanyl because there
was concern she was on too many narcotics and benzos and that
this was contributing to an altered mental state. She was much
more alert by discharge.
TRANSITIONAL ISSUES:
====================================
CODE STATUS: Full code, confirmed
CONTACT: Proxy name: ___
Phone: ___
_________________________
FYI:
- Psych at ___ wanted to taper benzos, decrease
dose of oxy, and increase gabapentin. We continued this plan
here at ___.
o Ativan 0.5 mg DAILY ___, then STOP **** NOTE: BENZO
TAPER ****
o Oxycodone decreased to 10 mg BID
o Gabapentin increased to 100 mg BID, may increase weekly
o Zyprexa 2.5 mg QAM, 5.0 mg QPM, and 5 mg BID PRN
- Pulmonologist Dr. ___, MD
Address: ___
Phone: ___
- Neurosurgery did not feel any intervention was necessary for
the ___. DVT ppx was held this admission.
- Speech and swallow evaluated the patient and did not see overt
signs of aspiration and recommended a soft solid diet with thin
liquids.
- FENTANYL was DISCONTINUED this admission due to concern for
polypharmacy. Maintained on oxycodone PRN and lidocaine patch.
_________________________
TO DO:
[ ] Patient to complete azithromycin course for COPD flare (last
day ___.
[ ] Please follow up on the patient's diabetes regimen. She only
required a small amount of Humalog here.
[ ] When patient was discharged she had a minor leukocytosis
(13k) but her respiratory symptoms and clinic picture were
stable (on home O2 of 3L, afebrile). No antibiotics started as
this was attributable to uncomplicated aspiration pneumonitis
without superimposed infection. However, if she develops fever,
worsening respiratory status or increased O2 requirement, we
would recommend considering a repeat Chest X-Ray, CBC, and PO
clindamycin therapy for possible aspiration pneumonia (she is
allergic to quinolones and penicillins).
[ ] At PCP follow up, please re-evaluate volume status, recheck
Chem-10 panel and BP, and consider restarting Lasix and
Spironolactone (pre-admission medications held during this
admission and at discharge).
_________________________
MEDICATIONS:
- Azithromycin (___) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Erythromycin Base / CT dye Omnipaque 130
Attending: ___.
Chief Complaint:
Lethargy, Hyderocephalus
Major Surgical or Invasive Procedure:
___: VP shunt revision (Delta 1.0)
___: VP shunt revision to unkink catheter
___: Shunt removal, Left EVD placement
History of Present Illness:
___ known to Neurosurgery with history of lung adenocarcinoma
and breast cancer with brain mets s/p L VP Shunt placement in
___ who was admitted to the oncology service after
presenting with witnessed seizure. During her admission, she
underwent MRI brain which revealed worsened hydrocephalus with
increased dilatation of the third and lateral ventricles when
compared with imaging from ___. Neurosurgery was
consulted for a VP shunt will plans to revise
her shunt on ___ but patient's mother had passed and services
were scheduled and per patient request she was discharged with
plans to return ___ to clinic to plan revision. She
returns to the ER tonight, her husband reports she is more
lethargic, confused, and could not ambulate.
Past Medical History:
Left Frontal VPS ___, Delta 1.5 valve (nonprogrammable)
placed for hydrocephalus in the setting of cerebellar
metastasis;
KRAS mutated Adenocarcinoma of the Lung, Stage II (Dx ___
- KRAS G12V and SMAD4 intronic variant.
Metastatic lung cancer to bones and brain
Breast Cancer, T1bN0, grade 2, ER+/PR-/HER2 equivocal, on
anastrozole, diagnosed ___, s/p breast conserving therapy,
radiation therapy and continued on Arimidex (discontinued
___
High Cholesterol, HTN, CHF, chronic back ___, High Cholesterol,
Heparin dependent portacath
Social History:
___
Family History:
Father died of CAD at age ___. Mother is ___ y of age, has RCC and
was recently diagnosed with Alzheimer. One sister with breast
cancer and CLL. Another sister with breast cancer. Brother with
melanoma. Maternal aunt with pancreatic cancer.
Physical Exam:
ON DISCHARGE:
General: appears comfortable.
Pulm: breathing nonlabored
CV: pallor
Neuro: EO to voice, attempts to speak ___ words. Denies ___.
Pertinent Results:
___ SHUNT SERIES AP & LAT SKULL, AP CHEST, AP ABDOMEN:
There is a left neck VP shunt which crosses into the left upper
quadrant
before terminating in the right lower quadrant. The tubing
appears intact.
___ CT HEAD W/O CONTRAST:
1. Allowing for differences in technique, grossly stable
extensive lateral and third ventricle ventriculomegaly with near
complete effacement of the fourth ventricle compared to ___ prior.
2. Stable left frontal approach ventriculostomy catheter which
terminates in the third ventricle.
3. Partially visualized right cerebellar metastatic lesion with
adjacent
edema, better seen on ___ brain MRI.
___ CT HEAD W/O CONTRAST:
1. Grossly stable, moderate to severe ventriculomegaly with
sulcal effacement, now with new layering blood products and air
within the left and right lateral ventricles.
2. Hyperdense right cerebellar mass with associated surrounding
edema causing local mass effect and compressing the prepontine
cistern and fourth ventricle.
3. Interval repositioning of left frontal approach
ventriculostomy catheter, now with tip in region of right
lateral ventricle foramen of ___.
___ SHUNT SERIES AP & LAT SKULL, AP CHEST, AP ABDOMEN:
VP shunt as described above appears intact without evidence of
kinking.
___ SHUNT SERIES AP & LAT SKULL, AP CHEST, AP ABDOMEN:
Shunt series documents correct course of the shunt with
placement in the right sided peritoneum.
___ CT HEAD W/O CONTRAST:
1. No significant interval change from CT head ___
14:30.
2. Ventriculomegaly involving the lateral and third ventricles
is unchanged.
3. Intraventricular hemorrhage is unchanged.
4. Right cerebellar mass with surrounding edema and effacement
of the
prepontine cistern and fourth ventricle is unchanged.
5. Stable left frontal approach ventriculostomy catheter.
6. Please note MRI of the brain is more sensitive for the
detection of acute infarct.
___ CT HEAD W/O CONTRAST:
1. No change in the appearance of a left frontal ventricular
catheter.
2. Ventriculomegaly involving the lateral and third ventricles
has increased since the prior study.
3. Intraventricular hemorrhage is unchanged.
4. Right cerebellar mass with surrounding edema and effacement
the pre
pontine cistern and fourth ventricle is unchanged.
___ CT ABD & PELVIS W/O CONTRAST:
No abnormality identified along the tract of a previously seen
VP shunt to
explain its malfunction.
___ CT HEAD W/O CONTRAST:
IMPRESSION:
1. Unchanged left frontal ventriculoperitoneal shunt with
improved
postoperative pneumocephalus.
2. Mild interval improvement ventriculomegaly.
3. Unchanged intraventricular hemorrhage.
4. No new intracranial hemorrhage.
5. Unchanged right cerebellar mass with surrounding edema and
effacement of the pre pontine cistern and fourth ventricle.
Medications on Admission:
albuterol sulfate [ProAir HFA]
ProAir HFA 90 mcg/actuation aerosol inhaler
2 puffs inhaled Every 6 hours ___
Renewed ___,
___ Inhaler 6 ___ ___ Reprint Modify
nr dronabinol
dronabinol 2.5 mg capsule
1 capsule(s) by mouth twice a day ___
Modified ___,
___ 30 Capsule 3 Inactivate Renew Reprint Modify
furosemide
furosemide 20 mg tablet
1 tablet(s) by mouth daily ___
Renewed ___,
___. 30 Tablet 8 ___ Inactivate Renew Reprint Modify
gabapentin
gabapentin 300 mg capsule
1 capsule(s) by mouth three times a day Start 1 cap ___
x3days;then 1 cap @AM and 1 cap ___ x3days; then 1 cap three
times a day ___
New ___,
___ 90 Capsule 2 ___ MD
(___) Inactivate Renew Reprint Modify
ibuprofen
ibuprofen 800 mg tablet
1 tablet(s) by mouth ___ daily as needed for ___ (Prescribed by
Other Provider) ___
Recorded Only ___,
___ ___ Renew Modify
metoprolol succinate
metoprolol succinate ER 25 mg tablet,extended release 24 hr
1 tablet(s) by mouth daily ___
Renewed ___,
___. 30 Tablet 5 ___ Inactivate Renew Reprint Modify
omeprazole
omeprazole 40 mg capsule,delayed release
1 capsule(s) by mouth daily ___
Modified ___,
___. 30 Capsule 11 ___ Inactivate Renew Reprint Modify
ondansetron HCl
ondansetron HCl 8 mg tablet
1 tablet(s) by mouth every eight (8) hours ___
Modified ___,
___ 21 Tablet 3 ___ MD
(___) Inactivate Renew Reprint Modify
potassium chloride
potassium chloride ER 20 mEq tablet,extended release
1 tablet(s) by mouth qday please take 1 tablet daily for the
next 2 days or as further instructed by MD. ___
New ___,
___ 14 Tablet 3 ___ MD
(___) Inactivate Renew Reprint Modify
prednisone
prednisone 50 mg tablet
1 tablet(s) by mouth ___ hours before CT and ___lso take Benadryl 25mg ___
Renewed ___,
___ 3 Tablet 6 ___ MD
(___) Inactivate Renew Reprint Modify
sertraline
sertraline 100 mg tablet
2 tablet(s) by mouth once a day ___
New ___,
___ 60 Tablet 5 ___ MD
___ ___ Reprint Modify
topiramate
topiramate 100 mg tablet
1 tablet(s) by mouth twice daily
Discharge Medications:
1. Dexamethasone 6 mg IV Q8H
RX *dexamethasone in 0.9 % sod chl 20 mg/50 mL 6 mg IV every 8
hours Disp #*1 Intravenous Bag Refills:*3
2. Glycopyrrolate 0.2 mg IV Q6H:PRN increased secretions
RX *glycopyrrolate 0.2 mg/mL 0.2 mg IV every 6 hours as needed
Disp #*7 Vial Refills:*10
3. LevETIRAcetam 1000 mg IV BID
RX *levetiracetam 500 mg/5 mL 1000 mg IV every 12 hours Disp
#*12 Vial Refills:*7
4. LORazepam 0.5-2 mg IV Q4H:PRN anxiety or seizure
RX *lorazepam 4 mg/mL 0.5 (One half) mg IV every 1 hours prn
Disp #*7 Vial Refills:*5
5. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL ___
mg PO Q1H:PRN ___ - Mild
RX *morphine concentrate 100 mg/5 mL (20 mg/mL) ___ mg by mouth
every hour as needed Refills:*5
6. Morphine Sulfate ___ mg IV Q1H:PRN ___ - Mild
RX *morphine (PF) in dextrose 5 % 100 mg/100 mL (1 mg/mL) ___ mg
IV/SC every hour as needed Disp #*1 Bag Refills:*3
7. Ondansetron 4 mg IV Q8H:PRN nausea
RX *ondansetron HCl 2 mg/mL 4 mg IV every 8 hours Disp #*12 Vial
Refills:*7
8. Valproate Sodium 500 mg IV Q8H
RX *valproate sodium 500 mg/5 mL (100 mg/mL) 500 mg IV every 8
hours Disp #*21 Vial Refills:*7
Discharge Disposition:
Expired
Discharge Diagnosis:
Ventriculoperitoneal Shunt Malfunction
Obstructive hydrocephalus
Cerebellar metastasis
Cerebellar tonsillar herniation
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
EXAMINATION: Shunt series (AP and lateral skull, AP chest, AP abdomen)
INDICATION: ___ year old woman with lung CA with CNS mets, hydrocephalus s/p
VP shutn, p/w worsening dizziness and inability to ambulate // eval shunt
TECHNIQUE: AP and lateral skull, AP chest, AP abdomen radiographs
COMPARISON: ___
FINDINGS:
Compared to ___, again seen is a left neck VP shunt which crosses
into the left upper quadrant before terminating in the right lower quadrant.
The tubing appears intact.
There is a right port catheter with tip in the right atrium. Multiple
surgical clips overlie the right lung.
The patient is status post right hilar surgery and lumbosacral spinal surgery.
There are multiple gas filled loops of bowel.
IMPRESSION:
There is a left neck VP shunt which crosses into the left upper quadrant
before terminating in the right lower quadrant. The tubing appears intact.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with lung CA with known CNS mets and hydrocephalus s/p VP
shunt, now with dizziness, inability to ambulate. Evaluate for progression of
mets, ventriculomegaly, and shunt position.
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, 16.1 cm; CTDIvol = 49.9 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: ___ contrast brain MRI.
___ outside noncontrast head CT.
FINDINGS:
Compared ___, unchanged left frontal approach ventriculostomy
catheter which terminates in the right lateral ventricle near the foramen of
___. Again seen is a right cerebellar hyperdense mass with adjacent edema
(see 2:8). There is associated unchanged edema. As before, this has caused
effacement of the prepontine cistern and causes near complete effacement of
the fourth ventricle. Grossly stable extensive bilateral lateral and third
ventricle ventriculomegaly with complete effacement of the fourth ventricle
and noted.
No acute hemorrhage or infarct.
No osseous abnormalities seen. There is layering fluid in the right maxillary
sinus. The visualized portion of the mastoid air cells, and middle ear
cavities are clear. The orbits are unremarkable.
IMPRESSION:
1. Allowing for differences in technique, grossly stable extensive lateral and
third ventricle ventriculomegaly with near complete effacement of the fourth
ventricle compared to ___ prior.
2. Stable left frontal approach ventriculostomy catheter which terminates in
the third ventricle.
3. Partially visualized right cerebellar metastatic lesion with adjacent
edema, better seen on ___ brain MRI.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with posterior fossa metastatic lesion adjacent
edema with effacement of fourth ventricle and shunt malfunction, now status
post VP shunt revision. Evaluate ventricular size.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 9.0 s, 15.3 cm; CTDIvol = 48.8 mGy (Head) DLP =
746.1 mGy-cm.
Total DLP (Head) = 759 mGy-cm.
COMPARISON: ___ noncontrast head CT.
FINDINGS:
There is been interval adjustment of position of the previously noted left
frontal approach ventriculostomy catheter, with its tip now in the region of
the right lateral ventricle foramen ___ (see 03:15 on current study and
02:13 on prior exam). Although the extent of ventriculomegaly appears largely
unchanged from the prior examination, there is new layering hyperdense
material and air within the left and right lateral ventricles. Otherwise, no
additional sites of acute intracranial hemorrhage are seen. Bilateral sulcal
effacement is also similar.
A hyperdense right cerebellar mass with surrounding edema is again noted,
causing mass effect and effacement involving the prepontine cistern and near
complete collapse of the fourth ventricle.
There is no evidence of fracture. The right maxillary sinus again
demonstrates an air-fluid level. The visualized portion of the mastoid air
cells, and middle ear cavities are clear. The visualized portion of the
orbits are unremarkable.
IMPRESSION:
1. Grossly stable, moderate to severe ventriculomegaly with sulcal effacement,
now with new layering blood products and air within the left and right lateral
ventricles.
2. Hyperdense right cerebellar mass with associated surrounding edema causing
local mass effect and compressing the prepontine cistern and fourth ventricle.
3. Interval repositioning of left frontal approach ventriculostomy catheter,
now with tip in region of right lateral ventricle foramen of ___.
Radiology Report
INDICATION: ___ year old woman with shunt malfunction now S/P shunt revision
// evaluate shunt for kinks
TECHNIQUE: Frontal and lateral views of the skull, an AP view of the chest
and AP supine view of the abdomen radiographs were obtained
COMPARISON: ___ from earlier in the day
FINDINGS:
A left frontal approach VP shunt courses along the left neck, left chest and
within the upper abdomen crosses midline and terminates of the the right lower
quadrant. The tubing appears intact without evidence of any kinks.
A right chest wall power injectable Port-A-Cath tip extends to the right
atrium. Again noted are multiple surgical clips over the right lung and
evidence of prior right lung surgery.
The abdominal radiograph demonstrates wall thickening of the visualized colon.
No abnormally dilated loops of bowel are identified. Lumbosacral spinal
hardware is again noted and overall unchanged.
IMPRESSION:
VP shunt as described above appears intact without evidence of kinking.
Colonic wall thickening may be secondary to colitis. Correlate clinically.
Radiology Report
EXAMINATION: SHUNT SERIES AP AND LAT SKULL, AP CHEST, AP ABDOMEN
INDICATION: ___ year old woman with hydrocephalus s/p second VP shunt
revision// Evaluate for patency of revised VP shunt previously kinked just
distal to valve. Evaluate for patency of revised VP shunt previously
kinked just distal to valve.
IMPRESSION:
Shunt series documents correct course of the shunt with placement in the right
sided peritoneum.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old woman status post VP shunt, now with increased
lethargy evaluate for intracranial hemorrhage or ventriculomegaly.
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 11.0 s, 19.3 cm; CTDIvol = 47.4 mGy (Head) DLP =
911.9 mGy-cm.
Total DLP (Head) = 925 mGy-cm.
COMPARISON: ___ 14:30 and 03:34 noncontrast head CT.
___ contrast brain MRI.
FINDINGS:
Left frontal approach intraventricular drainage catheter terminates in the
right lateral ventricle and foramen of ___, and again demonstrates minimal
adjacent hypodensity (see 03:32 on current study and 03:24 on ___
1230 exam). Pneumocephalus along the bilateral lateral ventricles is noted
and expected. There is intraventricular hemorrhage in the occipital horns of
the both lateral ventricles, minimally changed from most recent head CT.
There is no new or worsening intracranial hemorrhage degree of
ventriculomegaly involving the lateral and third ventricles is unchanged.
Again noted is a hyperdense mass in the right cerebellum with surrounding
edema and effacement of the pre pontine cistern and fourth ventricle,
minimally changed in appearance since most recent head CT.
There is partial opacification of left maxillary sinus and air-fluid level in
the right maxillary sinus. Mastoid air cells and middle ear cavities are well
aerated. The bony calvarium is intact.
IMPRESSION:
1. No significant interval change from CT head ___ 14:30.
2. Ventriculomegaly involving the lateral and third ventricles is unchanged.
3. Intraventricular hemorrhage is unchanged.
4. Right cerebellar mass with surrounding edema and effacement of the
prepontine cistern and fourth ventricle is unchanged.
5. Stable left frontal approach ventriculostomy catheter.
6. Please note MRI of the brain is more sensitive for the detection of acute
infarct.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old woman with shunt removal, EVD placement// drain
placement
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 6.4 s, 16.5 cm; CTDIvol = 54.5 mGy (Head) DLP =
897.1 mGy-cm.
Total DLP (Head) = 897 mGy-cm.
COMPARISON: Head CTs ___ 12:58
CT head ___ and 3:374
FINDINGS:
There there is a left frontal approach ventricular catheter that terminates in
the medial aspect of the left frontal horn at the foramen of ___. The
degree of ventriculomegaly involving the lateral and third ventricles has
increased since the most recent head CT. Layering intraventricular hemorrhage
in the bilateral occipital horns of the lateral ventricle is is unchanged.
There is no new or worsening \ hemorrhage. Again noted is a hyperdense right
cerebellar mass with surrounding edema and effacement of the pre pontine
cistern and fourth ventricle, grossly unchanged from most recent head CT.
There is an air-fluid level in the right maxillary sinus. Mastoid air cells
and middle ear cavities are well aerated. There is no fracture.
IMPRESSION:
1. No change in the appearance of a left frontal ventricular catheter.
2. Ventriculomegaly involving the lateral and third ventricles has increased
since the prior study.
3. Intraventricular hemorrhage is unchanged.
4. Right cerebellar mass with surrounding edema and effacement the pre
pontine cistern and fourth ventricle is unchanged.
Radiology Report
EXAMINATION: CT abdomen and pelvis without contrast
INDICATION: ___ year old woman s/p VP shunt replacement with subsequent
removal for malfunction, going to OR for replacement, rule out abdominal
collection for cause of malfunction// rule out abdominal collection, going to
OR for VP shunt
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 4.9 s, 53.5 cm; CTDIvol = 10.2 mGy (Body) DLP = 545.8
mGy-cm.
Total DLP (Body) = 546 mGy-cm.
COMPARISON: CT abdomen and pelvis on ___
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. Pleural
thickening at the right lung base is not significantly changed. There is no
evidence of 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. The gallbladder contains gallstones without wall thickening or
evidence of inflammation.
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: A 1.5 cm fat containing left adrenal lesion is not significantly
changed, again consistent with a myelolipoma. The right adrenal is normal in
size and shape.
URINARY: The kidneys are of normal and symmetric size. There is no evidence
of focal renal lesions within the limitations of an unenhanced scan. There is
no hydronephrosis. There is no nephrolithiasis. There is no perinephric
abnormality.
GASTROINTESTINAL: The stomach is unremarkable. 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 not visualized. Compared with ___, patient has undergone
interval removal of a VP shunt, previously terminating in the right
hemipelvis. There is no abnormality along the tract of the previous catheter
to explain malfunction.
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: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: Again seen is a posterior lumbosacral fusion device. Metastatic
involvement in the left hemipelvis is not significantly changed from prior. A
left iliac wing fracture is chronic. No acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
No abnormality identified along the tract of a previously seen VP shunt to
explain its malfunction.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ women post left VP shunt placement presenting with
worsening neuro status. Evaluate for ventricular size and catheter position.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 6.4 s, 17.0 cm; CTDIvol = 52.7 mGy (Head) DLP =
897.1 mGy-cm.
Total DLP (Head) = 897 mGy-cm.
COMPARISON: ___ 0334, ___ 1430, ___
noncontrast head CT.
___ contrast brain MRI.
FINDINGS:
Overlying hardware streak artifact limits examination.
Patient status post left frontal approach ventriculoperitoneal shunt with its
tip terminating at the foramen of ___.
New left occipital, suboccipital and left frontal subcutaneous emphysema is
noted (see 04: ___. Interval new pneumocephalus tracking from the left
frontal catheter entrance point into the left frontal lobe is noted (see 4:
___.
There is minimal interval decrease in size of the ventricles compared to ___ prior exam. Intraventricular blood is unchanged. There is no
new hemorrhage or large territorial infarction. Hyperdense right cerebellar
mass with surrounding edema is unchanged. Effacement of the pre pontine
cistern and fourth ventricle are grossly similar to prior. Global sulcal
effacement is unchanged.
There is no evidence of fracture. Air-fluid level in the right maxillary
sinus is unchanged. The visualized portion of the mastoid air cells, and
middle ear cavities are clear. The visualized portion of the orbits are
unremarkable.
IMPRESSION:
1. Overlying hardware streak artifact limits examination.
2. Nonspecific new left occipital, suboccipital and left frontal soft tissue
subcutaneous emphysema, with new pneumocephalus tracking along left frontal
approach ventriculostomy catheter.
3. Grossly stable position of left frontal approach ventriculostomy catheter.
4. Allowing for difference in technique, grossly stable right sellar
metastatic lesion, which is better demonstrated on ___ contrast
brain MRI.
5. Mild interval improvement of ventriculomegaly.
6. Stable intraventricular hemorrhage.
7. No definite new intracranial hemorrhage.
8. Unchanged right cerebellar mass with surrounding edema and effacement of
the prepontine cistern and fourth ventricle.
9. Please note MRI of the brain is more sensitive for the detection of acute
infarct and intracranial metastatic disease.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 4:38 pm, 10 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman s/p VP shunt revision// Evaluate ETT and OGT
position and assess for pulmonary congestion
TECHNIQUE: Portable AP chest
COMPARISON: ___ outside reference chest radiograph. CT chest
from ___.
FINDINGS:
Endotracheal tube tip is positioned approximately 3 cm above the carina. An
orogastric tube is seen with its tip in the stomach. There is a right
Port-A-Cath with its tip positioned within the right atrium. A VP shunt is
seen with its distal tip terminating in the right upper quadrant.
Re-demonstration of ovoid mass at the right lung apex, better characterized on
prior CT chest from ___. There is moderate cardiomegaly. The
mediastinal and hilar contours are within normal limits. No pulmonary edema,
pleural effusion, or pneumothorax.
IMPRESSION:
1. Endotracheal tube and orogastric tube in appropriate position. Right
Port-A-Cath with its tip positioned within the right atrium. VP shunt with
distal tip terminating in the right upper quadrant.
2. Redemonstration of ovoid mass at the right lung apex, better characterized
on prior CT from ___.
3. No pulmonary edema or pleural effusion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with lung carcinoma and brain mets presenting
with hydrocephalus s/p VPS replacement// Please assess for interval change
Please assess for interval change
IMPRESSION:
In Comparison with the study of ___, the nasogastric tube has been on
coiled and the tip extends to the distal stomach. Other monitoring and
support devices are unchanged. No change in the appearance of the mass in the
right lung apex. No acute pneumonia or vascular congestion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with brain metastasis s/p vp shunt, intubated//
Intubated Intubated
IMPRESSION:
In comparison with the study of ___, the monitoring and support
devices are unchanged. The mass in the right apical region is stable.
Otherwise little change in the appearance of the heart and lungs.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with metastatic lung to brain cancer// Please
assess for changes s/p VP shunt setting changes at 1400
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 10.0 s, 17.0 cm; CTDIvol = 48.8 mGy (Head) DLP =
829.0 mGy-cm.
2) Sequenced Acquisition 3.0 s, 5.1 cm; CTDIvol = 48.8 mGy (Head) DLP =
248.7 mGy-cm.
Total DLP (Head) = 1,091 mGy-cm.
COMPARISON: ___ noncontrast head CT, MR head ___.
FINDINGS:
There has been resolution of in hydrocephalus since the study of ___. Are now small bilateral subdural hypodense fluid collections, likely
hygromas. The ventricles are collapsed. There is a small amount of air in
the frontal horn of the left lateral ventricle, presumably related to catheter
manipulation.
Again seen is extensive right cerebellar hemispheric swelling with posterior
fossa mass effect and obliteration of the fourth ventricle. Again seen is a
left frontal approach ventricular shunt with tip terminating in the region of
the foramen third ventricle. There is no evidence of infarction. There is a
small amount of intraventricular hemorrhage in the occipital horns of the
lateral ventricles, as on ___. The sulci appear similar in size
and configuration compared to ___.
There is no evidence of fracture. There is mild mucosal thickening in the
left maxillary sinus. Air-fluid level in the right maxillary sinus is similar
to ___. The visualized portion of the paranasal sinuses, mastoid
air cells, and middle ear cavities are otherwise clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
Resolution of hydrocephalus since ___, now with collapsed
ventricles.
Bilateral hypodense subdural fluid collections collections measuring
approximately 4 mm on the left and 2 mm on the right, new since ___, likely hygromas.
NOTIFICATION: The impression above was discussed with ___,
M.D. by ___, M.D. on the telephone on ___ at approximately 14:30,
at the time of discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with metastatic brain cancer, intubated// eval
for interval change eval for interval change
IMPRESSION:
In comparison with the study of ___, the monitoring and support
devices are unchanged. The right apical mass is stable and the remainder of
the heart and lungs is essentially clear.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: Right cerebellar mass. Assess for interval change.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 10.0 s, 17.0 cm; CTDIvol = 48.8 mGy (Head) DLP =
829.0 mGy-cm.
Total DLP (Head) = 842 mGy-cm.
COMPARISON: ___ head CT
FINDINGS:
Again seen is a hemorrhagic right cerebellar mass measuring 2.7 x 1.9 cm with
surrounding edema exerting mass effect on the adjacent fourth ventricle and
the brainstem, similar to the prior study.
There is unchanged positioning of a left frontal approach shunt catheter
terminating at the foramen of ___. The ventricles are unchanged in size
with similar appearance of a decompressed left lateral ventricle, without
midline shift. There is slight reduction in intraventricular pneumocephalus
within the frontal horn of the left lateral ventricle.
Intraventricular hemorrhage is again seen layering within bilateral occipital
horns of the lateral ventricle, unchanged. There is similar size of bilateral
hypodense subdural fluid collections, likely hygromas. Again seen is right
maxillary sinus mucosal opacification with air-fluid level, similar. There is
partial left sphenoid septa is opacification.
IMPRESSION:
1. Again seen is a hemorrhagic right cerebellar mass with surrounding edema
exerting mass effect on the fourth ventricle and the brainstem, similar to the
prior study.
2. Unchanged positioning of the ventriculostomy shunt catheter, with
decompressed left lateral ventricle, similar to the prior study.
3. Stable trace intraventricular hemorrhage and probable bilateral subdural
hygromas.
4. No evidence of new hemorrhage or infarction.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with hydrocephalus s/t cerebellar metastasis
and edema s/p shunt revision remains intubated// assess ETT placement,
infiltrate assess ETT placement, infiltrate
IMPRESSION:
In comparison with the study of ___, the monitoring and support
devices are stable. Cardiac silhouette is within normal limits and there is
no vascular congestion or pleural effusion or acute focal pneumonia. No
change in the right apical mass.
Gender: F
Race: WHITE
Arrive by UNKNOWN
Chief complaint: Dizziness
Diagnosed with Dizziness and giddiness, Syncope and collapse
temperature: 96.5
heartrate: 80.0
resprate: 16.0
o2sat: 94.0
sbp: 105.0
dbp: 65.0
level of pain: 0
level of acuity: 3.0 | ___ year old female admitted to the Neurosurgery service from the
___ ED with increased lethargy in setting of hydrocephalus.
# HYDROCEPHALUS
The patient underwent three surgeries. On ___, she first
underwent a VP shunt revision with placement of a Delta 1.0. She
then returned to the OR that night for a VP shunt revision to
unkink the catheter that was found to be blocked on her
post-operative shunt series. On ___ the patient underwent
a VP shunt removal and Left EVD placement. EVD was opened at 5.
Exam improved with drainage at 5. On ___, a CT of the
abdomen was obtained prior to placement of the new left VP shunt
to ensure there was no loculated fluid collections. The patient
was taken to OR on ___ for replacement of a low-profile
left-sided VP shunt. Postoperatively, she experienced
___ respirations, was very somnolent, and was
therefore intubated and brought to the Neuro ICU. She remained
off of sedation with persistent obtundation. In multiple family
meetings, her family voiced that she had said she would not want
tracheostomy or prolonged intubation. She was started on
steroids with the hope to reduce edema around the metastasis.
This resulted in some minimal improvement in mental status. She
was terminally extubated with family present on ___. Per
family, we subsequently pursued Comfort Measures Only. AED were
switched to IV formulations, glycopyrrolate and prn morphine
were started. She was discharged to hospice.
# URINARY TRACT INFECTION
On admission, the patient was found to have a UTI. She was
started on ceftriaxone for broad coverage. A urine culture was
sent and revealed Escherichia coli. Sensitivities showed that
the E. coli was sensitive to the ceftriaxone, therefore it was
continued to complete course.
#DYSPHAGIA
Secondary to altered mental status SLP was asked to evaluate
swallowing. Diet advanced to puree/nectar thin on ___.
=============================
Transitional Issues:
[ ] Remove scalp sutures on ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Percocet
Attending: ___.
Chief Complaint:
fall, shortness of breath, chest tightness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo M h/o prostate CA (s/p prostatectomy and LN dissection
___, mets to hips ___, mets to R hip ___ s/p palliative
external beam radiation) and prior PE ___ ago, previously
treated with Coumadin and recently stopped in ___, T2DM, HTN,
HLD, presented to ___ ___ after a fall, found to have
elevated trop with lateral ST depressions, transferred to ___
for further evaluation.
Per patient and family, he was walking inside the house on the
day of presentation, when he had a reportedly mechanical trip
while walking with his cane through a doorway. Patient denies
any preceding symptoms, such as CP, SOB, lightheadedness,
dizziness, nausea or diaphoresis. His wife helped him down to
the ground; no LOC or head strike. She did note that he appeared
to be SOB and that he reported chest tightness at that time.
Patient does not clearly recall this, aside from the trip/fall.
Patient and family report that he has otherwise been in good
health, without recent illness, surgery, travel or
immobilization. He has, however, had increased ___ edema,
without pain, for the past few months, for which he saw his PCP.
___ ___ did not show DVT, and was prescribed Lasix 3
months ago. ___ edema has improved with Lasix, and wife notes
that he has had a ___ pound weight loss since starting Lasix.
At ___, vitals were: 98.5, 113, 169/90, 15, 92% room air.
Trop T 0.09 elevated, EKG reportedly with sinus tach 112,
lateral lead ST depressions. Patient without chest pain. He was
given ASA 325, started on heparin gtt, given 1L NS. He was
transferred to ___ for concern of ACS.
At ___, VSS with initial vitals: 99, 187/105, 16, 94% RA. EKG
notable for S1Q3T3. Trop elevated at 0.08, proBNP elevated at
4602. Bedside U/S in ED was notable for ___ sign and
dilated RV. CTA showed saddle PE and widespread emboli
bilaterally, as well as flattening of ___ septum. He
was therapeutic on hepearin. MASCOT team consulted, did not opt
for TPA or EKOS at that time, given his hemodynamic stability
and limited saddle embolus (primarily appears to be in bl main
PA).
ED labs/studies notable for:
- trop 0.08
- proBNP: 4602
- creatinine 1.5 ___ 1.4)
- K 6.8, from 4.2
- WBC 12.8
- VBG 7.4/32
Vitals on transfer: 98.2, ___, 94% RA
On arrival to the CCU: Patient feels well. Family does note
that he is SOB with movement, such as in transferring beds.
Denies CP. Overnight, was initially hypertensive as above, which
resolved to SBP 140s after home labetalol (had missed it
earlier).
Past Medical History:
1. CARDIAC RISK FACTORS
+ Diabetes
+ Hypertension
+ Dyslipidemia
2. CARDIAC HISTORY
no known cardiac disease
3. OTHER PAST MEDICAL HISTORY
prostate cancer (diagnosed ___ years ago)
Note: had colonoscopy last year that was normal. Follows with a
doctor for his h/o prostate cancer regularly ___ months,
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Per chart: His brother had pancreas cancer, another brother
had stomach cancer, and another brother died of leukemia. His
sister had breast and stomach cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 99, 187/105, 16, 94% RA
GENERAL: Well developed, well nourished 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. Did not appreciate JVP at 90 deg.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Borderline tachycardic. Normal S1, S2. No murmurs, rubs,
or gallops.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, obese, +BS, ___.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis. ___
pitting edema of BLE, R>L
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE PHYSICAL EXAM:
T 98.3 PO BP 139 / 78 R Lying HR 75 RR 20 O2 96% RA
GENERAL: Well developed, well nourished in NAD. Oriented x3.
Sitting comfortably in bedside chair after returning from walk
with physical therapy.
HEENT: Normocephalic atraumatic. PERRL. EOMI.
NECK: Supple. No JVD.
CARDIAC: Regular rate and rhythm. Normal S1, S2. No murmurs,
rubs
or gallops.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, obese, +BS, ___.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis. No
edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
Pertinent Results:
ADMISSION LABS:
___ 10:10PM BLOOD ___
___ Plt ___
___ 10:10PM BLOOD ___
___ Im ___
___
___ 10:10PM BLOOD ___ ___
___ 10:10PM BLOOD ___
___
___ 10:10PM BLOOD ___
___ 10:10PM BLOOD ___
___ 03:36AM BLOOD ___
___ 10:27PM BLOOD ___
___ Base XS--3
INTERVAL LABS:
___ 03:36AM BLOOD ___
___ Plt ___
___ 07:40AM BLOOD ___
___ Plt ___
___ 02:45AM BLOOD ___
___ Plt ___
___ 03:36AM BLOOD ___
___
___ 07:40AM BLOOD ___
___
___ 02:45AM BLOOD ___
___
___ 10:10PM BLOOD ___
___ 03:36AM BLOOD ___
DISCHARGE LABS:
___ 07:50AM BLOOD ___
___ Plt ___
___ 07:50AM BLOOD Plt ___
___ 07:50AM BLOOD ___ ___
___ 07:50AM BLOOD ___
___
___ 07:50AM BLOOD ___
PERTINENT STUDIES:
CTA ___
IMPRESSION:
-Saddle pulmonary embolism, and widespread pulmonary emboli and
the bilateral
upper and lower lobe lobar, segmental and subsegmental arteries.
-Flattening of the ___ septum, concerning for right
heart failure.
-___ areas of ___ in the right upper lobe,
consistent with
pulmonary infarction.
-Single right lower lobe micronodule, for which no ___ CT
chest is
recommended in a patient at low risk for primary lung neoplasm,
and optional
CT chest is recommended in 12 months in a patient at high risk.
-Circumferential esophageal wall thickening, may represent
esophagitis,
however not well evaluated on CT.
RECOMMENDATION(S): For incidentally detected single solid
pulmonary nodule smaller than 6 mm, no CT ___ is
recommended in a ___ patient, and an optional CT in 12
months is recommend in a ___ patient.
TTE ___
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. Left ventricular
systolic function is hyperdynamic (EF>75%). The right
ventricular cavity is mildly dilated with moderate global free
wall hypokinesis. There is abnormal septal motion/position
consistent with right ventricular pressure/volume overload. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Mild (1+) aortic regurgitation is seen.
The pulmonary artery systolic pressure could not be determined.
There is a trivial/physiologic pericardial effusion.
IMPRESSION: Right ventricular cavity dilation with moderate
free wall hypokinesis. Normal left ventricular cavity size with
normal/hyperdynamic global systolic function. Mild aortic
regurgitation.
___ DOPPLER ___
-Nonocclusive deep vein thrombosis in the right common femoral
vein, proximal
femoral vein, and popliteal vein.
-Limited views of the left calf veins. Otherwise no deep vein
thrombosis in the left lower extremity.
TTE ___
The left atrial volume index is normal. There is mild symmetric
left ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). The right
ventricular cavity is moderately dilated with moderate global
free wall hypokinesis. 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 mildly thickened. The pulmonary artery systolic pressure
could not be determined. The ___ pulmonic
regurgitation velocity is increased suggesting pulmonary artery
diastolic hypertension. There is an anterior space which most
likely represents a prominent fat pad.
IMPRESSION: Right ventricular cavity dilation with free wall
hypokinesis. Normal left ventricular cavity size with preserved
regional and global systolic function.
Compared with the prior study (images reviewed) of ___,
the findings are similar.
CLINICAL IMPLICATIONS:
Based on ___ AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data. A right pleural effusion is
present.
Radiology Report
EXAMINATION: ___ DUP EXTEXT BIL (MAP/DVT)
INDICATION: ___ year old man with saddle PE// eval for DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
The right common femoral vein is noncompressible with echogenic material in
the lumen, and some residual flow seen, consistent with nonocclusive thrombus.
There is additional nonocclusive thrombus in the proximal right femoral vein.
The mid to distal femoral vein are compressible. The right popliteal vein is
noncompressible, with some residual flow seen, consistent with nonocclusive
thrombus. Normal color flow is demonstrated in the right posterior tibial
veins. The right peroneal veins are not well visualized.
There is normal compressibility, flow, and augmentation of the left common
femoral, femoral, and popliteal veins. Normal color flow and compressibility
are demonstrated in the left posterior tibial veins. The left peroneal veins
are not well visualized.
There is normal respiratory variation in the common femoral veins bilaterally.
IMPRESSION:
-Nonocclusive deep vein thrombosis in the right common femoral vein, proximal
femoral vein, and popliteal vein.
-Limited views of the left calf veins. Otherwise no deep vein thrombosis in
the left lower extremity.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Chest pain, Elevated troponin, Transfer
Diagnosed with Other pulmonary embolism without acute cor pulmonale
temperature: 99.0
heartrate: 99.0
resprate: 16.0
o2sat: 94.0
sbp: 187.0
dbp: 105.0
level of pain: 0
level of acuity: 2.0 | The patient is an ___ yo M with a history of metastatic prostate
cancer, prior PE, type 2 DM, HTN, HLD, who presented initially
to ___ on ___ after a fall with SOB and chest tightness,
transferred to ___ and found to have submassive saddle PE.
Below please find a detailed list of all of the problems
addressed during this hospitalization.
# CORONARIES: Unknown
# PUMP: LVEF>75%
# RHYTHM: Sinus, RBBB
ACTIVE ISSUES:
#Submassive PE
#DVT
PE occurred in the setting of metastatic prostate cancer. Of
note that he had a prior PE ___ years ago, for which he had been
on Coumadin until ___. During admission, the patient remained
hemodynamically stable with good oxygen saturations. ECHO showed
right ventricular dilatation and hypokinesis, with abnormal
septal motion consistent with right ventricular pressure/volume
overload. Per the PE team, the patient did not require
fibrinolysis or EKOS. He was started on a heparin drip. Lower
extremity ultrasounds displayed DVTs in his R common femoral
vein, proximal femoral vein and popliteal veins. IVC filter was
not indicated. He was restarted on warfarin at 5mg daily with
Lovenox 90 q12H for bridging. INR at discharge was 1.5.
#HTN
The patient was continued on his home labetalol 200 BID. His
systolic blood pressures remained elevated from the 160s to the
180s, and his Lisinopril was increased to 30mg PO daily from
10mg PO daily.
#Urinary retention
Patient was noted to retain urine; he was straight cathed
multiple times. His doxazosin was increased to 8mg BID. He was
discharged on a foley with urology follow up.
CHRONIC ISSUES:
# CKD: Baseline creatinine appears to be 1.5, on chart review.
Creatinine was stable from baseline this admission.
# Prostate cancer: Continued on home bicalutamide 50 daily
# HLD: Continued atorvastatin 40mg PO daily
# T2DM: Held home glipizide ER 5 - restarted on discharge. |
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:
Vaginal bleeding
Major Surgical or Invasive Procedure:
Dilation and curettage
History of Present Illness:
___ POD ___ s/p primary LTCS at 34w6d for twins, mild
preeclampsia, and cholestasis presents with heavy vaginal
bleeding since ___ this morning. Has been feeling slightly
dizzy
with a mild headache. Passed one clot in bathroom prior to
ultrasound, otherwise has been saturating over 1 pad/hr x 12
hrs.
Denies vision changes, chest pain, SOB, RUQ pain. Does report
nasal congestion that has been present since arrival to
hospital.
Was followed for cholestasis during the later part of her
pregnancy. Developed hypertension and had a 24-hr urine
performed, which returned at >500mg. Given a new diagnosis of
preeclampsia as well as a mild headache, she was delivered at
34w6d. She did not receive magnesium or antihypertensives
postpartum. She was discharged home in good condtion on POD#4.
She did have notable ___ swelling and had ___ U/S today which
was
negative for DVT. Her swelling has improved considerably since
delivery. She was seen today in the office for her bleeding and
her BP was elevated. A script for labetalol had been routed to
her pharmacy but she did not take any yet.
Past Medical History:
POBHx: ___ s/p LTCS ___
PGynHx: denies known fibroids
PMHx: right breast cancer in ___, s/p right lumpectomy, chemo
and XRT, as well as ___ years of tamoxifen with currently ___.
hypothyroidism.
PSHx: right breast lumpectomy as noted, gum surgery, LTCS
Social History:
married, denies t/e/d, trial court judge
Physical Exam:
On admission:
VS on admission to ED:
97.9 93 169/97 16 100%
Repeat BP 185/87
NAD, breathing through mouth as has stuffy nose
Heart RRR
Lungs CTAB
Abdomen soft, + BS, uterine fundus palpated ___ FB above
umbilicus,
tender to palpation at fundus and lower uterus.
___ mildly tender, 2+ pitting edema
Pelvic: dark blood pooled in vault. Cervix unable to be
visualized due to pt's discomfort and redundant vaginal walls.
On BME cervix very posterior, external os feels dilated ~1cm but
unable to palpate higher due to discomfort/posterior cervix
Pertinent Results:
LABS:
___ 12:55AM BLOOD WBC-6.6 RBC-2.64* Hgb-8.3* Hct-24.7*
MCV-93 MCH-31.5 MCHC-33.7 RDW-16.5* Plt ___
___ 12:29PM BLOOD WBC-8.4 RBC-2.86*# Hgb-9.6*# Hct-26.4*#
MCV-93 MCH-33.7* MCHC-36.4* RDW-16.5* Plt ___
___ 04:23AM BLOOD WBC-10.1 RBC-2.17* Hgb-6.9* Hct-20.3*
MCV-94 MCH-31.9 MCHC-34.1 RDW-16.1* Plt ___
___ 09:51PM BLOOD WBC-10.5 RBC-2.62* Hgb-8.6* Hct-24.5*
MCV-94# MCH-32.9* MCHC-35.1* RDW-15.7* Plt ___
___ 06:07PM BLOOD WBC-10.8 RBC-2.66* Hgb-8.8* Hct-27.1*
MCV-102* MCH-33.1* MCHC-32.5 RDW-13.4 Plt ___
___ 01:40PM BLOOD WBC-11.0# RBC-2.70* Hgb-8.8* Hct-28.1*
MCV-104* MCH-32.6* MCHC-31.3 RDW-13.2 Plt ___
___ 05:30AM BLOOD Neuts-70 Bands-0 Lymphs-15* Monos-8
Eos-6* Baso-1 ___ Myelos-0
___ 12:29PM BLOOD Neuts-80* Bands-0 Lymphs-13* Monos-3
Eos-0 Baso-1 ___ Metas-1* Myelos-2*
___ 08:00PM BLOOD ___ PTT-24.2* ___
___ 04:23AM BLOOD ___ PTT-26.7 ___
___ 09:51PM BLOOD ___ PTT-26.9 ___
___ 01:40PM BLOOD ___ PTT-31.3 ___
___ 05:30AM BLOOD Glucose-105* UreaN-9 Creat-0.5 Na-141
K-4.2 Cl-110* HCO3-23 AnGap-12
___ 12:29PM BLOOD Glucose-93 UreaN-8 Creat-0.6 Na-138 K-4.3
Cl-108 HCO3-22 AnGap-12
___ 04:23AM BLOOD Glucose-110* UreaN-8 Creat-0.7 Na-140
K-4.1 Cl-108 HCO3-24 AnGap-12
___ 06:07PM BLOOD Glucose-95 UreaN-11 Creat-0.6 Na-140
K-3.9 Cl-105 HCO3-23 AnGap-16
___ 01:40PM BLOOD Glucose-86 UreaN-13 Creat-0.6 Na-137
K-4.6 Cl-104 HCO3-21* AnGap-17
___ 04:23AM BLOOD ALT-25 AST-23 LD(LDH)-298* AlkPhos-157*
TotBili-0.4
___ 01:40PM BLOOD ALT-38 AST-46* LD(LDH)-544* AlkPhos-287*
TotBili-0.3
IMAGING:
Pelvic US ___:
1. Large bulky uterus containing a large amount of echogenic,
non-vascularized
products, likely blood and clot.
2. Ovaries not visualized. Fluid containing right pelvic
structure may
reprsent the bladder. Attention at follow-up pelvic ultrasound
in 6 weeks.
Radiology Report
___ ___ ___
Depart of Radiology
Standard Report - Normal Venous/US Report
Study: Bilateral Lower Extremity Venous Duplex
___ year old woman s/p C section on ___, with bilateral lower
extremity swelling.
Findings: Duplex evaluation was performed on the bilateral lower extremity
veins.
There is normal compression and augmentation of the common femoral, proximal
femoral, mid femoral, distal femoral, popliteal, posterior tibial and peroneal
veins. There is normal phasicity of the common femoral veins bilaterally.
Impression: No evidence of deep vein thrombosis either right or left lower
extremity. Bilateral calf edema is seen.
Radiology Report
INDICATION: Post C-section on ___ and increased vaginal bleeding.
No comparison studies available.
TECHNIQUE: Transabdominal and transvaginal ultrasonography of the pelvis were
performed, the latter to better assess the uterus and adnexa.
FINDINGS: The uterus is markedly enlarged, and cannot be measured within one
image. The endometrial cavity contains a large volume of echogenic material
that is non-vascularized, likely representing blood and clot. The ovaries are
not visualized. There is no free fluid. A fluid-filled structure right of the
uterus may represent the bladder.
IMPRESSION:
1. Large bulky uterus containing a large amount of echogenic, non-vascularized
products, likely blood and clot.
2. Ovaries not visualized. Fluid containing right pelvic structure may
reprsent the bladder. Attention at follow-up pelvic ultrasound in 6 weeks.
Radiology Report
PORTABLE AP CHEST FILM, ___ AT 12:09 A.M.
CLINICAL INDICATION: ___ with fever, question infiltrate.
No comparison studies. Please note that comparison to old films can be
helpful to detect subtle interval change.
A single portable AP upright chest film, ___ at 12:09 a.m. is submitted.
IMPRESSION:
1. Lungs appear well inflated without evidence of focal airspace
consolidation, pleural effusions, or pneumothorax. No evidence of pulmonary
edema. Overall cardiac and mediastinal contours are within normal limits. No
acute bony abnormality appreciated.
Gender: F
Race: OTHER
Arrive by WALK IN
Chief complaint: POSTPARTUM BLEEDING
Diagnosed with OTH CURR COND-POSTPARTUM, HEMATOMETRA
temperature: 97.9
heartrate: 93.0
resprate: 16.0
o2sat: 100.0
sbp: 169.0
dbp: 97.0
level of pain: nan
level of acuity: 2.0 | Given concern for hematometra and a diagnosis of delayed
postpartum hemorrhage, the decision was made to proceed to the
OR for a dilation and curettage. Please see operative report for
further details regarding the procedure. Total EBL for the case
was 1700cc. A bakri balloon was placed at the end of the case.
Ms ___ was transferred to the FICU for immediate post
operative monitoring. She received a total of 4units PRBCs, 1
FFP, and 2u cryo. She remained hemodynamically stable. Her
hematocrit was carefully trended and was stable 25 prior to
transfer to the postpartum floor. Her bleeding after the
procedure was minimal and the Bakri balloon was removed by
POD#1.
Ms. ___ was noted to have febrile (temp 100.6) prior to the OR
and was therefore started on gentamicin and clindamycin for
treatment of endometritis. This was continued until she was
afebrile for >24 hours.
Ms. ___ was noted to have persistently elevated BPs. On
arrival to the ED, her preeclampsia labs were notable for a
mildly elevated AST although the specimen was thought to be
hemolyzed. Magnesium was held as there was no evidence of severe
preeclampsia. She was treated with IV labetalol intraoperatively
and in the FICU. After transfer to the postpartum floor she was
started on labetalol PO 200 BID after having a BP of 160/90. Her
blood pressures remained well controlled on this regimen. |
Name: ___ ___ 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:
Splenic artery embolization
History of Present Illness:
___ year old male was recently admitted to our service after
a toolbox fell onto him. His injuries included C4-6 spinous
process fractures and C5 ligamentous injury now s/p C5-6 ACDF,
T7
burst fracture, R patella fracture s/p ORIF in ___ brace,
and
grade II splenic laceration. He returns now 2 days after
discharge with LUQ abdominal pain. The pain started one day
after
returning home. He states that it is much worse than the pain
from his leg. He denies fevers, nausea, vomiting, dizziness, or
headache. He is mildly constipated, but is having bowel
movements
since discharge.
Past Medical History:
Diabetes Mellitus Type II
Left inguinal hernia repair
Social History:
___
Family History:
Noncontributory
Physical Exam:
Physical Exam: upon admission: ___
Vitals: 98.7, 84, 164/85, 16, 98% RA
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 in LUQ, no rebound or guarding
Ext: No ___ edema, ___ warm and well perfused, RLE in ACE wrap and
___ brace
Physical examination upon discharge: ___:
vital signs: 98.2 78bp 157/91, rr= 18, 99% room air
CV: ns1, s2, no murmurs
LUNGS: clear
ABDOMEN: hypoactive BS, soft, non-tender, localized macular
rash abdomen, right groin soft, ecchymotic, non-tender, no
swelling
EXT: Bledoe brace right leg, stockinette under brace, + dp
bil.,ecchymosis upper shoulders post. aspect
NEURO: alert and oriented x 3, speech clear, no tremors
Pertinent Results:
___ 07:05AM BLOOD WBC-9.9 RBC-3.12* Hgb-10.6* Hct-31.4*
MCV-101* MCH-34.0* MCHC-33.8 RDW-12.8 RDWSD-46.3 Plt ___
___ 08:30AM BLOOD WBC-8.8 RBC-3.14* Hgb-10.6* Hct-31.8*
MCV-101* MCH-33.8* MCHC-33.3 RDW-12.9 RDWSD-47.7* Plt ___
___ 08:03AM BLOOD WBC-11.9* RBC-2.99* Hgb-10.0* Hct-29.8*
MCV-100* MCH-33.4* MCHC-33.6 RDW-12.7 RDWSD-45.9 Plt ___
___ 09:45AM BLOOD WBC-13.2* RBC-2.89* Hgb-9.7* Hct-29.2*
MCV-101* MCH-33.6* MCHC-33.2 RDW-12.7 RDWSD-47.1* Plt ___
___ 04:28AM BLOOD Neuts-68.6 Lymphs-16.3* Monos-13.0
Eos-1.0 Baso-0.2 Im ___ AbsNeut-5.50# AbsLymp-1.31
AbsMono-1.04* AbsEos-0.08 AbsBaso-0.02
___ 07:05AM BLOOD Plt ___
___ 04:28AM BLOOD ___ PTT-30.2 ___
___ 07:05AM BLOOD Glucose-116* UreaN-15 Creat-0.7 Na-132*
K-4.9 Cl-96 HCO3-23 AnGap-18
___ 08:30AM BLOOD Glucose-138* UreaN-17 Creat-0.7 Na-136
K-4.6 Cl-98 HCO3-24 AnGap-19
___ 09:45AM BLOOD Glucose-130* UreaN-21* Creat-0.8 Na-131*
K-4.6 Cl-94* HCO3-23 AnGap-19
___ 04:28AM BLOOD ALT-21 AST-45* AlkPhos-126 TotBili-1.3
___ 07:05AM BLOOD Calcium-9.4 Phos-4.3 Mg-2.3
___: cat scan abd and pelvis:
Splenic pseudoaneurysm formation within the known splenic
laceration spanning approximately 1.3 x 0.7 cm. No perisplenic
hematoma. Probable focal splenic infarction superior and
lateral to the known laceration
___: arteriogram:
Uncomplicated proximal embolization of the splenic artery with
an Amplatzer 2 occlusion device.
right fem. US:
Normal sonographic appearance of the groin, without evidence of
hematoma,
pseudo-aneurysm, or AV fistula.
___: CTA abd. and pelvis:
. Unchanged appearance of a splenic laceration. No ___
hematoma.
2. New infarct along the superior aspect of the spleen.
3. Moderate-sized right groin hematoma overlying a previous
vascular access site. There is a 10 mm focus of hyper
enhancement along the superficial soft tissues which could
represent a tiny pseudo-aneurysm vs bleed from a small
perforator. No femoral pseudo-aneurysm. No organized hematoma.
4. Hepatic steatosis.
5. Mucous plugging of multiple right lower lobe sub-segmental
bronchi.
6. Partially visualized right varicocele.
7. 2.4 cm segment VII/VIII hepatic hemangioma.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H
2. Bisacodyl 10 mg PO/PR DAILY
3. Calcium Carbonate 500 mg PO QID:PRN indigestion
4. Diazepam 5 mg PO BID:PRN pain
5. Docusate Sodium 100 mg PO BID
6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
7. Polyethylene Glycol 17 g PO DAILY
8. Sodium Chloride 1 gm PO TID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Calcium Carbonate 500 mg PO QID:PRN indigestion
3. Diazepam 5 mg PO BID:PRN pain
4. Docusate Sodium 100 mg PO BID
5. Enoxaparin Sodium 40 mg SC DAILY
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 40 mg/0.4 mL 1 syringe IM DAILY Disp #*20 Syringe
Refills:*0
6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth q4h:prn Disp #*15 Tablet
Refills:*0
7. Polyethylene Glycol 17 g PO DAILY
8. Senna 8.6 mg PO BID constipation
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Splenic pseudoaneurysm
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: ___ with L flank/abd pain. recent splenic laceration.
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: Acquisition sequence:
1) Stationary Acquisition 7.0 s, 0.5 cm; CTDIvol = 33.7 mGy (Body) DLP =
16.9 mGy-cm.
2) Spiral Acquisition 4.8 s, 52.9 cm; CTDIvol = 10.5 mGy (Body) DLP = 554.8
mGy-cm.
3) Spiral Acquisition 1.4 s, 15.5 cm; CTDIvol = 9.2 mGy (Body) DLP = 142.6
mGy-cm.
Total DLP (Body) = 714 mGy-cm.
COMPARISON: None. ___ CT abdomen/pelvis
FINDINGS:
LOWER CHEST: Mild bibasilar atelectasis. No pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: A 2.5 cm lesion in hepatic segment VII demonstrates peripheral
nodular enhancement, unchanged and consistent with a hemangioma. The
remaining liver parenchyma enhances homogeneously. 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 is normal in size. Within the dominant portion of a known
splenic laceration, there is pseudoaneurysm formation measuring approximately
1.3 x 0.7 cm. No perisplenic hematoma. New focal hypoenhancement lateral to
the laceration could reflect a small amount of focal infarction.
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. Diverticulosis of
the sigmoid colon is noted, without evidence of wall thickening and fat
stranding. The appendix is not visualized.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate is not enlarged.
LYMPH NODES: Prominent periportal lymph nodes measure up to 1 cm. Otherwise,
no retroperitoneal, mesenteric, 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: Small fat containing right inguinal hernia.
IMPRESSION:
Splenic pseudoaneurysm formation within the known splenic laceration spanning
approximately 1.3 x 0.7 cm. No perisplenic hematoma. Probable focal splenic
infarction superior and lateral to the known laceration.
Radiology Report
INDICATION: ___ year old man with traumatic injury causing grade II splenic
lac treated conservatively now presenting with LUQ pain. Imaging shows PSA in
area of splenic lac// Perform embo of splenic PSA.
COMPARISON: CT from ___
TECHNIQUE: OPERATORS: Drs. ___, attending radiologists
performed the procedure.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
125mcg of fentanyl and 1.5 mg of midazolam throughout the total intra-service
time of 114 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: Fentanyl and Versed
CONTRAST: 83 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 22.5 min, 421 mGy
PROCEDURE:
1. Right common femoral artery access.
2. Celiac arteriogram.
3. Splenic arteriogram.
4. Proximal embolization of splenic artery.
PROCEDURE DETAILS:
Following the discussion 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. Both groins were
prepped and draped in the usual sterile fashion.
Using palpatory and fluoroscopic guidance, the right common femoral artery was
punctured using a 19 gauge needle at the level of the mid-femoral head. A
___ wire was passed easily advanced under fluoroscopy into the aorta. The
needle was exchanged for a 5 ___ sheath which was attached to a continuous
heparinized saline side arm flush.
A C2 Cobra catheter was advanced over ___ wire into the aorta. The wire
was removed and the celiac artery was selectively cannulated and a small
contrast injection was made to confirm position. A celiac arteriogram was
performed. The catheter was then selectively advanced into the splenic artery
under fluoroscopic guidance. Arteriograms were then performed. A
microcatheter was then advanced over the wire into the distal splenic artery
and arteriograms were performed in different projections. Selective
catheterization of distal splenic artery branches were performed and selective
arteriograms were performed. At least 3 second order branches were
investigated with arteriograms.
The 5 ___ sheath was exchanged over wire for a 5.5 ___ ___ sheath
which was advanced into the proximal splenic artery under fluoroscopic
guidance. Embolization of the proximal splenic artery was performed with an
Amplatzer 2 occlusion device measuring 10 mm in diameter.
Post embolization arteriogram was performed through the sheath.
The sheath was removed. A external iliac arteriogram was performed to assess
for use of Angio-Seal closure device an Angioseal closure device was deployed
and manual pressure was held until hemostasis was achieved. Sterile dressings
were applied. The patient tolerated the procedure well.
FINDINGS:
Splenic arteriograms in different projections showed patent splenic artery and
distal branches with delayed filling of the pseudoaneurysm.
Selective distal splenic arteriograms did not demonstrate the origin of the
pseudoaneurysm clearly.
Post embolization arteriogram demonstrated significant reduction of flow
within the distal splenic artery.
IMPRESSION:
Uncomplicated proximal embolization of the splenic artery with an Amplatzer 2
occlusion device.
Radiology Report
EXAMINATION: FEMORAL VASCULAR US RIGHT
INDICATION: ___ year old man with s/p right groin puncture for splenic artery
embolization c/b small hematoma vs. possible pseudoaneurysm, here for further
evaluation.
TECHNIQUE: Grayscale, color, and spectral Doppler evaluation of the groin.
COMPARISON: None available.
FINDINGS:
Normal color flow and spectral Doppler waveforms are present in the common
femoral artery and vein. There is no evidence of hematoma, pseudoaneurysm, or
arteriovenous fistula.
IMPRESSION:
Normal sonographic appearance of the groin, without evidence of hematoma,
pseudoaneurysm, or AV fistula.
Radiology Report
EXAMINATION: CTA ABD/PEL WANDW/O C W/REONS
INDICATION: ___ year old man s/p blunt torso trauma with splenic lac c/b
pseudoaneurysm s/p splenic artery embolization with persistent LUQ pain// Eval
for interval change/worsening splenic infarcttion
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 3.2 s, 51.2 cm; CTDIvol = 2.8 mGy (Body) DLP = 142.0
mGy-cm.
2) Spiral Acquisition 3.3 s, 51.7 cm; CTDIvol = 11.5 mGy (Body) DLP = 591.5
mGy-cm.
3) Spiral Acquisition 3.3 s, 51.7 cm; CTDIvol = 11.4 mGy (Body) DLP = 591.4
mGy-cm.
4) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 10.3 mGy (Body) DLP =
5.2 mGy-cm.
Total DLP (Body) = 1,330 mGy-cm.
COMPARISON: CT from ___ procedure from ___.
FINDINGS:
There is mucous plugging at the right lower lobe subsegmental bronchi (series
3, image 4). There is no pericardial pleural effusion. The heart size is
normal.
The liver density is decreased, suggestive of cirrhosis. Along the superior
aspect of segment VII/VIII is a 2.4 x 2.1 cm lesion demonstrating peripheral
nodular enhancement, which on the delayed phase demonstrates centripetal
fill-in, compatible with a hemangioma. No concerning hepatic lesion is
detected. There is no intra or extrahepatic bile duct dilation. The
gallbladder is normal. No radiopaque ductal stones are detected.
The pancreas demonstrates normal density and bulk, without duct dilation or
focal mass.
The spleen size is within normal limits. Punctate calcifications, likely
granulomas, are scattered throughout the splenic parenchyma. A hypodense
laceration along the central posterior aspect of the spleen is again
demonstrated (series 3, image 38, series 603, image 84). There is no new
hematoma. There is a new wedge slight hypo density along the superior aspect
of the spleen (series 603, image 62), likely a small infarct (series 3, image
33). A splenic artery embolization coil is present (series 3, image 46).
The adrenal glands are normal in size and shape.
The kidneys are normal in size and enhance symmetrically, without
hydronephrosis or concerning mass.
The stomach and intra-abdominal and intrapelvic loops of small and large bowel
are normal in caliber. No focal gastrointestinal lesion is detected.
The abdominal aorta, celiac trunk, SMA, renal arteries, ___, and iliac
branches are patent and normal in caliber. A replaced left hepatic artery
arises from the left gastric (series 3, image 37). The portal and hepatic
veins are patent. There is a moderate-sized hematoma at the right groin
(series 3, image 342). A 10 mm focus of hyper enhance is seen within the
subcutaneous soft tissues of the right groin, which increases in density but
not size on the delayed phase (series 3 image ___, possibly representing a
tiny pseudoaneurysm of a superficial perforator (series 3, image 346). There
is no aneurysm or pseudoaneurysm of the iliac or femoral arteries.. No
organized collection is detected. There is mild compression of the common
femoral vein, without thrombosis (series 3, image 341).
The bladder is mildly distended, and appears normal. The prostate is normal
in size. A right varicocele partially visualized (series 3, image 366).
IMPRESSION:
1. Unchanged appearance of a splenic laceration. No perisplenic hematoma.
2. New infarct along the superior aspect of the spleen.
3. Moderate-sized right groin hematoma overlying a previous vascular access
site. There is a 10 mm focus of hyper enhancement along the superficial soft
tissues which could represent a tiny pseudoaneurysm vs bleed from a small
perforator. No femoral pseudoaneurysm. No organized hematoma.
4. Hepatic steatosis.
5. Mucous plugging of multiple right lower lobe subsegmental bronchi.
6. Partially visualized right varicocele.
7. 2.4 cm segment VII/VIII hepatic hemangioma.
NOTIFICATION: The findings were discussed with ___. ___. by ___,
M.D. on the telephone on ___ at 3:49 pm, 10 minutes after discovery of
the findings.
Gender: M
Race: OTHER
Arrive by AMBULANCE
Chief complaint: Abd pain, Transfer
Diagnosed with Aneurysm of other specified arteries, Essential (primary) hypertension
temperature: 98.9
heartrate: 94.0
resprate: 16.0
o2sat: 98.0
sbp: 172.0
dbp: 97.0
level of pain: 3
level of acuity: 2.0 | ___ year old male was recently admitted after a toolbox fell onto
him.
His injuries included c4-6 spinous process fractures and C5
ligamentous injury now s/p C5-6 ACDF, T7 burst fracture, R
patella fracture s/p ORIF in ___ brace, and grade II splenic
laceration. He was discharged home on ___.
The patient returned to the hospital on ___ reporting left
upper quadrant pain. Upon admission, the patient was made NPO,
given intravenous fluids, and underwent imaging. The patient
was reported to have a splenic pseudo-aneurysm and underwent
embolization of the splenic artery. Post-procedure, he was noted
to have a right groin hematoma noted after ambulating and
additional pressure was applied. The groin site was inspected
and serial hematocrits remained stable.
After clearance from interventional radiology and Orthopedics,
the patient was started on a 3 week course of lovenox related to
the recent ORIF right patella. Lovenox instruction was reviewed
and the patient demonstrated the ability for
self-administration. The patient was discharged on HD #5. His
vital signs were stable and he was afebrile. He was tolerating
a regular diet and voiding without difficulty. He was
ambulatory with the assistance of the walker. Discharge
instructions were reviewed and questions answered. Appointments
for follow-up were made with the Acute care, orthopedic, and
___ clinic. ___ services were provided for home safety
assessment and groin check.
***** Of note, the patient reported a non-pruritic localized
rash on his abdomen. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ woman with a history of ___ disease,
hypertension who presents for evaluation of chest pain. Of note,
patient lives with her daughter at home who is a nurse, she is
fairly independent and blind at baseline.
Pt was in her USH until ___ morning when she woke up at 7am
with chest pain and shortness of breath. Pt called her daughter
in the room who checked her BP and BP measured 200s/100. Pts
daughter pressed pts life line and patient was sent to ___. There she received a stress test which was negative and
cardiac enzymes were negative as well. She was sent home on
___.
___ - ___ no event.
___ morning at 3am, pt woke up with the same chest pain and
shortness of breath. BP at this time were 200/100 again and she
went back to ___. Pt was started on hep gtt and on
___ when for a cardiac cath which reportedly showed 40%
stenosis in an artery. CTA negative No intervention was done and
patient was discharged on ___ with imdur and Isordil.
___ morning, patient woke up again with chest pain, this time
BP 220/100. She was initially sent to ___ and then per
daughters request, transferred here for further care.
Chest pain: Subsernal, crushing, elephant sitting on her chest.
Pt has never had this pain. Radiates to left lateral chest and
left upper quadrant.
ROS: no nausea, vomiting, diarrhea, diaphoresis, abdominal pain,
diarrhea, constipation.
In the ED...
- Initial vitals: T 98, BP 155/77, HR 74, RR 16, 96% RA
- EKG: LBBB, ST changes that do not meet Scarbossa criteria
- Labs/studies notable for:
CBC WNL
BMP WNL
Trop <0.01 x 1
CXR: No acute cardiopulmonary process
- Patient was given:
Nitro gtt
Morphine 2 mg IV
- Vitals on transfer: BP 168/81, HR 71, RR 21, 93% RA
Past Medical History:
___ Disease
Social History:
___
Family History:
Non contributory
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
=====================
VITALS: 100s/60s, HR ___, RR 18 on room air
GENERAL: Sitting up, NAD, smiling, conversant
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no
pallor or cyanosis of the oral mucosa.
NECK: Supple and euvolemic with no JVD
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RRR, normal S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: low hum when patient takes a deep breath in diffusely,
otherwise no crackles
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
DISCHARGE:
==========
Pertinent Results:
ADMISSION LABS
==============
___ 12:31PM BLOOD WBC-4.3 RBC-3.80* Hgb-11.5 Hct-33.5*
MCV-88 MCH-30.3 MCHC-34.3 RDW-12.5 RDWSD-40.0 Plt ___
___ 12:31PM BLOOD Neuts-59.3 ___ Monos-7.0 Eos-1.2
Baso-1.2* Im ___ AbsNeut-2.53 AbsLymp-1.33 AbsMono-0.30
AbsEos-0.05 AbsBaso-0.05
___ 12:31PM BLOOD Plt ___
___ 02:50PM BLOOD ___ PTT-26.3 ___
___ 12:31PM BLOOD Glucose-109* UreaN-16 Creat-0.7 Na-144
K-4.0 Cl-110* HCO3-20* AnGap-14
___ 12:31PM BLOOD proBNP-720*
___ 12:31PM BLOOD cTropnT-<0.01
___ 12:31PM BLOOD Calcium-8.5 Phos-2.8 Mg-1.7
PERTINENT LABS
=============
DISCHARGE LABS
=============
IMAGING
=======
CHEST X RAY (___)
FINDINGS:
The lungs are clear. There is no consolidation, effusion, or
edema. The
cardiomediastinal silhouette is within normal limits. No acute
osseous
abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
RENAL US WITH DUPLEX (___)
FINDINGS:
There is no hydronephrosis, stones, or masses bilaterally.
Normal cortical
echogenicity and corticomedullary differentiation are seen
bilaterally.
Right kidney: 9.3 cm
Left kidney: 10.4 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 0.71-0.77. The resistive
indices on the
left range from 0.7-0.77. Bilaterally, the main renal arteries
are patent
with normal waveforms. The peak systolic velocity on the right
is 49
centimeters/second. The peak systolic velocity on the left is
37.6
centimeters/second. Main renal veins are patent bilaterally with
normal
waveforms.
The bladder is moderately well distended and normal in
appearance.
IMPRESSION:
Both kidneys are symmetric in size with no hydronephrosis. No
evidence of
renal artery stenosis.
TTE (___)
The left atrial volume index is normal. There is no evidence for
an atrial septal defect by 2D/color Doppler.
The estimated right atrial pressure is ___ mmHg. There is
normal left ventricular wall thickness with a normal
cavity size. There is mild-moderate left ventricular regional
systolic dysfunction with akinesis of the inferior
wall, and hypokinesis of the basal to mid inferolateral wall,
distal septum, and true apex (see schematic) and
preserved/normal contractility of the remaining segments. The
visually estimated left ventricular
ejection fraction is 35-40%. There is no resting left
ventricular outflow tract gradient. Diastolic function
could not be assessed. Normal right ventricular cavity size with
normal free wall motion. There is abnormal
septal motion c/w conduction abnormality/paced rhythm. 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) are
mildly thickened. There is no aortic valve stenosis.
There is no aortic regurgitation. The mitral valve leaflets are
moderately thickened with no mitral valve
prolapse. There is mild [1+] mitral regurgitation. The tricuspid
valve leaflets are mildly thickened. There is
physiologic tricuspid regurgitation. The estimated pulmonary
artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild to moderate left
ventricular regional dysfunction
most c/w multivessel CAD. Normal right ventricular cavity size
and systolic function. Mild mitral
regurgitation.
___ RUQUS:
1. Cholelithiasis, with no evidence of cholecystitis.
2. Pancreatic cystic structures are seen measuring up to 2.2 cm,
likely
representing side-branch intraductal papillary mucinous
neoplasms. This can
be followed up with ultrasound as clinically indicated.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carbidopa-Levodopa (___) 2 TAB PO TID
2. TraMADol 50 mg PO DAILY:PRN Pain - Moderate
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. amLODIPine 7.5 mg PO DAILY
RX *amlodipine 5 mg 1.5 tablet(s) by mouth daily Disp #*45
Tablet Refills:*0
3. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
5. CARVedilol 6.25 mg PO BID
RX *carvedilol 6.25 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
6. LORazepam 0.25 mg PO DAILY:PRN abdominal pain/anxiety
Duration: 5 Doses
RX *lorazepam 0.5 mg 0.5 (One half) tablet by mouth daily prn
Disp #*3 Tablet Refills:*0
7. Maalox/Diphenhydramine/Lidocaine ___ mL PO TID:PRN chest
pain
8. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
9. Simethicone 40-80 mg PO QID:PRN gas pain
10. Carbidopa-Levodopa (___) 2 TAB PO TID
11. TraMADol 50 mg PO DAILY:PRN Pain - Moderate
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary
Atypical Chest Pain
Gastric Ulcer
Secondary:
___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with CP// r/o PNA
TECHNIQUE: AP and lateral views the chest.
COMPARISON: None.
FINDINGS:
The lungs are clear. There is no consolidation, effusion, or edema. The
cardiomediastinal silhouette is within normal limits. No acute osseous
abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old woman with ___ disease presenting with chest
pain and hypertensive urgency// WITH DUPLEX please; looking for renal artery
stenosis, please comment on velocity
TECHNIQUE: Grey scale, color and spectral Doppler ultrasound images of the
kidneys were obtained.
COMPARISON: None available.
FINDINGS:
There is no hydronephrosis, stones, or masses bilaterally. Normal cortical
echogenicity and corticomedullary differentiation are seen bilaterally.
Right kidney: 9.3 cm
Left kidney: 10.4 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 0.71-0.77. The resistive indices on the
left range from 0.7-0.77. Bilaterally, the main renal arteries are patent
with normal waveforms. The peak systolic velocity on the right is 49
centimeters/second. The peak systolic velocity on the left is 37.6
centimeters/second. Main renal veins are patent bilaterally with normal
waveforms.
The bladder is moderately well distended and normal in appearance.
IMPRESSION:
Both kidneys are symmetric in size with no hydronephrosis. No evidence of
renal artery stenosis.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old woman with intermittent abdominal pain//
cholelithiasis?
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: 8 mm, prominent, but could be age-related.
GALLBLADDER: A few gallstones are seen measuring up to 1.7 cm. There is no
gallbladder wall thickening or distention. No pericholecystic fluid.
PANCREAS: At least 2 cystic structures are seen in the pancreatic body,
measuring up to 1.8 cm x 2.2 cm x 1.4 cm. The smaller one is seen adjacent to
it, measuring 1.4 cm 1.2 cm x 1.1 cm and contains a few echogenic foci, likely
septations. These are likely to represent side-branch intraductal papillary
mucinous neoplasms.
SPLEEN: Normal echogenicity.
Spleen length: 9.6 cm
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
Right kidney: 10.6 cm
Left kidney: 10.8 cm
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Cholelithiasis, with no evidence of cholecystitis.
2. Pancreatic cystic structures are seen measuring up to 2.2 cm, likely
representing side-branch intraductal papillary mucinous neoplasms. This can
be followed up with ultrasound as clinically indicated.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain, Transfer
Diagnosed with Chest pain, unspecified, Hypertensive heart disease without heart failure
temperature: 98.0
heartrate: 74.0
resprate: 16.0
o2sat: 96.0
sbp: 155.0
dbp: 77.0
level of pain: 0
level of acuity: 3.0 | ASSESSMENT AND PLAN
====================
___ yo F with hx of ___ disease and HTN who presented to
___ from ___ with substernal crushing chest
pain that had been ongoing since last week with negative stress
and negative coronary angiogram.
ACTIVE ISSUES
==============
#Chest pain
#PUD
On transfer, initial suspicion for hypertensive emergency given
BP>200,
secondary HTN work-up sent. BP subsequently improved, further
episodes CP
not correlating with BP elevations. Differential on admission
also included ACS, microvascular coronary disease, Prinzmetal's
angina, GI cause such as GERD or esophageal spasm, or medication
effect of carbidopa-levodopa. Troponins negative x4. TTE read as
mild to moderate regional
LV dysfunction suggestive of multi-vessel CAD, however no
significant lesions seen on angiogram from ___ (only
<50%
LAD lesion). Some delayed flow noted on angiogram, although not
in distribution consistent with TTE findings. On review of TTE,
EF appeared
greater than documented in report. Based on clinical
presentation
and review of OSH angiogram, low suspicion for cardiac etiology
of chest pain.
While on cardiology service, noted to have intermittent CP in
two locations likely ___ to dyspepsia (given improvement of
central upper chest discomfort
with GI cocktail) and musculoskeletal (given reproducibility on
chest wall palpation and improvement of band-like lower chest
discomfort with lorazepam). Symptoms markedly improved with GI
cocktail (maalox/diphenhydramine/lidocaine) and application of
lidocaine patch to chest wall. Also started on pantoprazole
daily and simethicone. Given negative cardiac work-up, patient
transferred to medicine for further evaluation and management of
non-cardiac chest pain. She underwent upper endoscopy and was
found to have multiple 1-2mm non bleeding ulcers. RUQUS showed
cholelithiasis without cholelithiasis. She was discharged with
plan for 8 weeks of high dose PPI. If pain recurs, colic from
cholelithiasis could be considered as etiology and surgical
referral could be considered.
#CAD
OSH angiogram suggestive of non-obstructive CAD: <50% LAD
lesion,
some slow flow that may be c/w microvascular disease. Chest
pain, shortness of breath unlikely secondary to ischemia as
discussed above. Given non-obstructive coronary disease,
continued aspirin and atorvastatin for prevention.
#Reported HF
OSH TTE read as EF 35-40% with inferior akinesis, baseline
unclear. Regional wall motion abnormality suggestive of
ischemia, however only non-obstructive CAD on angiogram, not in
distribution consistent with regional WMA, as discussed above.
On review of TTE, as discussed above, EF appeared greater than
reported, no evidence of HF on physical exam. NT-proBNP on
admission of 720 not clearly suggestive of decompensated heart
failure given patient age. While admitted to cardiology, patient
euvolemic, not on diuretics at home or in-hospital, no apparent
history of decompensated HF. Ongoing dyspnea did not appear to
be secondary to HF, as primarily correlated with non-cardiac
chest discomfort discussed above. Weights and I/O remained
stable without diuresis. Continued patient on carvedilol 6.25 mg
BID. Would consider repeat TTE after discharge to re-assess
ventricular function, ejection fraction.
#HTN
Patient presented with BP intermittently elevated to SBP in
200s. Started on carvedilol, amlodipine, isosorbide dinitrate
for BP control with subsequent improvement, sent secondary HTN
work-up. Subsequently discontinued isosorbide given improvement
of BP and further work-up indicating that severe hypertension
likely unrelated to chest pain. Renal US negative for renal
artery stenosis. Urine metanephrins were pending at discharge.
CHRONIC ISSUES
===============
___ disease
Continued carbidopa-levodopa.
TRANSITIONAL ISSUES
=================
[] Given significant anxiety/panic resulting from abdominal pain
and improvement with Ativan 0.25, a short course was prescribed
until primary care follow up. This should not be continued,
rather management of anxiety with SSRIs should be considered.
[] Underwent secondary hypertension work up, of which urine
metaneprhines are pending and require follow up
[] Patient discharge with planned 8 week course high dose
pantoprazole for findings of ulcer. Determine need to continue
medication
[] Incidental finding of Pancreatic cystic structures are seen
measuring up to 2.2 cm, likely representing side-branch
intraductal papillary mucinous neoplasms. Consider MR imaging.
[] Consider surgical management of cholelithiasis if repeated
episodes of pain after ulcer treated with PPI, consideration of
HIDA scan and surgical referral for cholecystectomy if her pain
does not improve with PPI therapy
[ ] Consider repeat TTE to re-assess ventricular function, EF
given no clinical evidence of heart failure this admission.
[ ]Code status - Mentioned briefly in one of the notes from ___
___ ED that patient stated she wanted to be DNR, but patient
and daughter here said full code; would re-assess what patient
would prefer.
.
.
.
.
.
.
.
Attending addendum
Greater than 30 minutes were spent providing and coordinating
care for this patient on day of discharge.
___ MD |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Dysuria and genital pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with pmhx of T2DM, lichen sclerosis, schizophrenia and
multiple recent admissions for her dysuria and genital pain
treated as UTI but stopped antibiotics when cultures came back
negative. This patient presents with acute exacerbation of
dysuria in the setting of chronic dysuria. Was admitted to the
hospital recently on IV antibiotics for presumed UTI and
discharged approximately 3 days ago on no antibiotics because
the urinalysis was actually negative and she was thought to have
atrophic vaginitis and possible yeast overgrowth in local
irritation as the source of her dysuria. She presents now with
worsening dysuria symptoms. No fevers or chills. No nausea or
vomiting. She also describes multiple episodes of watery
diarrhea up to approximately 10 per day. Nonbloody. No lethargy
or confusion or syncope. No incontinence or retention of urine.
No back pain or neck pain or injury. No chest pain or shortness
of breath or cough.
Past Medical History:
ANEMIA OF CHRONIC DISEASE
ARTHRITIS
SCHIZOPHRENIA
HYPERLIPIDEMIA
HYPERTENSION
OBESITY
BREAST MASS
DIABETES MELLITUS, type II on metformin
RIGHT THUMB FUSION
bladder cyst and recurrent dysuria
Social History:
___
Family History:
mother with HTN and HL
Physical Exam:
ADMISSION PHYSICAL EXAM:
Temp: 99.9 HR: 99 BP: 175/86 Resp: 18 O(2)Sat: 95 Normal
Constitutional: NAD
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nondistended, NABS, bladder tender to
palpation.
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash, Warm and dry
Neuro: Speech fluent, AAO x 3, CN ___ intact, nonfocal MS
exam
___: Normal mood, Normal mentation
___: No petechiae
DISCHARGE PHYSICAL EXAM:
PHYSICAL EXAM:
Vitals: 97.9, 103/59, 80, 16 96%RA
General: Obese woman sitting up in bed in NAD
HEENT: PERRL, EOMI, MMM.
CV: RRR, S1, S2 normal, soft S3 heard best at apex, no murmurs
or rubs.
Lungs: CTAB, no wheezing, no increased effort of breathing.
Abdomen: soft, distended, non-tender, hypoactive BS
GU: Healing candidal infection of the genital area and inguinal
folds.
Ext: WWP, no edema.
Neuro: AAOx3, CN II-XII grossly intact, moving all extremities
Pertinent Results:
ADMISSION LABS:
___ 07:45AM BLOOD WBC-17.4*# RBC-3.75* Hgb-11.5 Hct-36.1
MCV-96 MCH-30.7 MCHC-31.9* RDW-13.7 RDWSD-48.5* Plt ___
___ 07:45AM BLOOD Neuts-82.9* Lymphs-8.6* Monos-6.7
Eos-0.6* Baso-0.4 Im ___ AbsNeut-14.42*# AbsLymp-1.50
AbsMono-1.16* AbsEos-0.10 AbsBaso-0.07
___ 06:30AM BLOOD ___ PTT-28.1 ___
___ 07:45AM BLOOD Glucose-187* UreaN-25* Creat-1.0 Na-130*
K-5.1 Cl-96 HCO3-18* AnGap-21*
___ 08:07AM BLOOD Lactate-2.3*
IMAGING / STUDIES:
CT ABD/PELV ___
IMPRESSION:
1. Bladder wall thickening and ___ stranding raises
concern for
cystitis. Correlate with urinalysis.
2. Normal appendix.
CXR ___:
FINDINGS:
LOWER CHEST: Left lower lobe nodule measures 7 mm (2:2),
previously measuring
7 mm in ___. Right lower lobe 5 mm nodule is grossly
unchanged (2:5).
Scarring or atelectasis is seen in the right lower lobe.
ABDOMEN:
HEPATOBILIARY: Liver hypodensities, too small to characterize in
the right and
left lobes are unchanged from ___. There is no
evidence of
intrahepatic or extrahepatic biliary dilatation. The
gallbladder has been
surgically removed.
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 renal hypodensities, the largest in
the left
upper pole measuring 1.2 cm (02:17) similar to the prior study.
No
hydronephrosis.
GASTROINTESTINAL: There is a small hiatal hernia. 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 bladder is moderately well distended with wall
thickening and mild
___ fat stranding. 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: Chronic right inferior pubic rami fracture and anterior
compression
deformity of L1 are unchanged since ___.
SOFT TISSUES: There is a small abdominal fat containing ventral
hernia. There
is a small umbilical hernia containing small bowel, without
evidence of
obstruction.
FINDINGS:
As compared to the prior examination dated ___, there
has been no
relevant interval change. Streaky bibasilar atelectasis is
again noted.
There is no lobar consolidation, pleural effusion, pneumothorax,
or pulmonary
edema. The cardiomediastinal silhouette is unchanged. Stable
appearance of a
compression deformity involving a vertebral body at the
thoracolumbar
junction.
IMPRESSION:
No acute cardiopulmonary process.
DISCHARGE LABS:
___ 06:30AM BLOOD WBC-7.9# RBC-3.38* Hgb-10.4* Hct-32.9*
MCV-97 MCH-30.8 MCHC-31.6* RDW-13.7 RDWSD-49.1* Plt ___
___ 06:30AM BLOOD Glucose-143* UreaN-18 Creat-0.9 Na-137
K-4.4 Cl-104 HCO3-23 AnGap-14
___ 03:39PM BLOOD Lactate-1.8
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q8H:PRN pain
2. Lisinopril 20 mg PO DAILY
3. Metoprolol Tartrate 50 mg PO BID
4. Nystatin-Triamcinolone Ointment 1 Appl TP BID:PRN candidiasis
5. OLANZapine (Disintegrating Tablet) 20 mg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Phenazopyridine 200 mg PO TID
8. Simvastatin 40 mg PO QPM
9. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
10. Estrace (estradiol) 0.01 % (0.1 mg/gram) vaginal 2X/WEEK
11. MetFORMIN (Glucophage) 1000 mg PO BID
Discharge Medications:
1. Acetaminophen 500 mg PO Q8H:PRN pain
2. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
3. Lisinopril 20 mg PO DAILY
4. Metoprolol Tartrate 50 mg PO BID
5. Nystatin-Triamcinolone Ointment 1 Appl TP BID:PRN candidiasis
6. OLANZapine (Disintegrating Tablet) 20 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Phenazopyridine 200 mg PO TID
9. Simvastatin 40 mg PO QPM
10. MetFORMIN (Glucophage) 1000 mg PO BID
11. Estrace (estradiol) 0.01 % (0.1 mg/gram) vaginal 2X/WEEK
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
PRIMARY DIAGNOSIS:
Genital pain, unspecified
SECONDARY DIAGNOSES:
Lichen sclerosis
Schizophrenia
Hypertension
Type 2 diabetes
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 recurrent dysuria, tender abdomen, diarrhea, fever,
leukocytosis, question evidence of colitis.
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique. IV Contrast: 130 mL Omnipaque.
Coronal and sagittal reformations were performed and reviewed on PACS.
Oral contrast was not administered.
DOSE: Total DLP (Body) = 557 mGy-cm.
COMPARISON: CT abdomen pelvis dated ___.
FINDINGS:
LOWER CHEST: Left lower lobe nodule measures 7 mm (2:2), previously measuring
7 mm in ___. Right lower lobe 5 mm nodule is grossly unchanged (2:5).
Scarring or atelectasis is seen in the right lower lobe.
ABDOMEN:
HEPATOBILIARY: Liver hypodensities, too small to characterize in the right and
left lobes are unchanged from ___. There is no evidence of
intrahepatic or extrahepatic biliary dilatation. The gallbladder has been
surgically removed.
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 renal hypodensities, the largest in the left
upper pole measuring 1.2 cm (02:17) similar to the prior study. No
hydronephrosis.
GASTROINTESTINAL: There is a small hiatal hernia. 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 bladder is moderately well distended with wall thickening and mild
___ fat stranding. 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: Chronic right inferior pubic rami fracture and anterior compression
deformity of L1 are unchanged since ___.
SOFT TISSUES: There is a small abdominal fat containing ventral hernia. There
is a small umbilical hernia containing small bowel, without evidence of
obstruction.
IMPRESSION:
1. Bladder wall thickening and ___ stranding raises concern for
cystitis. Correlate with urinalysis.
2. Normal appendix.
Radiology Report
EXAMINATION: Chest radiographs.
INDICATION: History: ___ with elevated wbc, slightly elevated lactate 2.3.
Rule out for infection. // evidence of pneumonia
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiographs dated ___.
FINDINGS:
As compared to the prior examination dated ___, there has been no
relevant interval change. Streaky bibasilar atelectasis is again noted.
There is no lobar consolidation, pleural effusion, pneumothorax, or pulmonary
edema. The cardiomediastinal silhouette is unchanged. Stable appearance of a
compression deformity involving a vertebral body at the thoracolumbar
junction.
IMPRESSION:
No acute cardiopulmonary process.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dysuria
Diagnosed with Urinary tract infection, site not specified
temperature: 99.9
heartrate: 99.0
resprate: 18.0
o2sat: 95.0
sbp: 175.0
dbp: 86.0
level of pain: 10
level of acuity: 3.0 | Mrs ___ is a ___ year old female with a history of DM,
schizophrenia, lichen sclerosis, recurrent dysuria who presents
with genital pain worse with urination and diffuse abdominal
pain. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
cefazolin / Penicillins / Motrin / ciprofloxacin / omeprazole
Attending: ___.
Chief Complaint:
anemia, hypotension
Major Surgical or Invasive Procedure:
Upper endoscopy (___)
L subclavian line (removed ___
History of Present Illness:
___ yo M with hx of CAD s/p multiple RCA PCIs, ESRD s/p failed
renal transplant and back on HD (MWF), chronic anemia,
presenting with shortness of breath. Patient had dialysis today
and was told that his blood level was low and that if he
developed shortness of breath he should present to the emergency
department. This evening he felt SOB and came to the ED.
Of note, pt had recent admission to medicine for similar
complaints, found to have anemia and SOB. EGD was done during
the admission and was notable for esophagitis and ulcer. He was
started on PPI and is scheduled to see GI in ___.
In the ED, initial vitals: 98.4, 90/99, 52, 16. His guiac was
positive. An EJ was placed. Labs notable for Cr 5 and H&H
7.8/25.8. He was ordered for 2 U.
On arrival to the MICU, pt mentating well and comfortable. No CP
or SOB. IVF bolus given as blood products not yet at bedside. He
was started on PPI and octreotride drip.
Past Medical History:
- ESRD ___ glomerulonephritis s/p DDRT in ___, now back on
dialysis as of ___ uses LUE AVF
- CAD s/p multiple RCA PCIs, cath ___ s/p RCA ___ mid RCA for 90% ISRS. ___ ___ RCA 3.5
Promus with POBA to distal RCA., ___ rotational aterectomy
and ___ RCA/MID RCA stenting, instent restenosis
distal RCA ___ ___ placed.
- CVA (left periventricular subcortical infarct) with RUE
weakness after ___ cath
- Subdural Hematoma (___)
- ILD: ?chronic eosinophilic pneumonia
- PUD: Duodenal ulcers with UGIB ___ (H.pylori +)
- Chronic anemia
- Hypertension
- Bronchospasm
- Hx PPD positive
- Diverticulitis ___
- Aortic stenosis
- Mitral regurgitation
- Hyperparathyroidism
- Gout
- Hyperlipidemia
- Hypogonadism
Social History:
___
Family History:
Son and sister with kidney disease.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
VS: per metavision
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, moist mucus membranes, no blood
visible in oropharynx
CV: Regular rate and rhythm, S1, S2, S4 with II/VI systolic
murmur
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound or guarding
Ext: Warm, well perfused, 2+ pulses, no cyanosis or edema
Neuro: CNII-XII grossly intact, moves all extremities
PHYSICAL EXAM ON DISCHARGE:
Vital Signs: T 98-98.5 BP 98-152/72-85 HR ___ RR 20 O2 95-98%
on RA
General: Alert, oriented gentleman sitting up in bed, in no
acute distress
HEENT: Sclerae anicteric
Lungs: RLL crackles, otherwise clear
CV: RRR, normal S1/S2, III/VI wheezing systolic murmur best
heard at the ___. ?soft diastolic murmur throughout.
Torso: L subclavian line removed ___.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: 1+ radial pulses bilaterally. LUE with functional dialysis
fistula and overlying bandages. Mildly edematous LUE compared
to R, not pitting. LUE slightly cooler to touch, with intact
sensation and ___ strength bilaterally.
Skin: Without rashes or lesions
Neuro: A&O x3. Moves all four extremities spontaneously.
Pertinent Results:
LABS ON ADMISSION
==================
___ 04:05AM BLOOD WBC-11.0* RBC-2.78*# Hgb-7.8* Hct-25.8*
MCV-93 MCH-28.1 MCHC-30.2* RDW-18.2* RDWSD-61.1* Plt ___
___ 04:05AM BLOOD Neuts-56.8 ___ Monos-9.8 Eos-5.5
Baso-0.9 Im ___ AbsNeut-6.25* AbsLymp-2.91 AbsMono-1.08*
AbsEos-0.61* AbsBaso-0.10*
___ 04:05AM BLOOD ___ PTT-26.0 ___
___ 04:05AM BLOOD Glucose-142* UreaN-49* Creat-5.0* Na-138
K-4.2 Cl-95* HCO3-26 AnGap-21*
___ 04:05AM BLOOD ALT-9 AST-17 AlkPhos-93 TotBili-0.3
___ 04:05AM BLOOD Albumin-3.6 Calcium-7.6* Phos-3.5 Mg-1.9
IMAGING
=======
TRANSTHORACIC ECHOCARDIOGRAM (___):
Suboptimal image quality. Mild aortic stenosis. Mild aortic
regurgitation. Normal global biventricular systolic function.
Technically suboptimal to exclude focal wall motion abnormality.
Elevated PCWP.
Compared with the prior study (images reviewed) of ___,
mitral regurgitation is not present. Estimated pulmonary artery
pressure is lower (but image quality is markedly inferior so may
be technical difference).
DOPPLER L UPPER EXTREMITY (___):
1. No evidence of deep vein thrombosis in the left upper
extremity.
2. Patent AV fistula
MICRO
======
BCx x2 (___): Pending
DISCHARGE LABS
===============
___ 06:34AM BLOOD WBC-6.9 RBC-2.90* Hgb-8.5* Hct-26.6*
MCV-92 MCH-29.3 MCHC-32.0 RDW-16.9* RDWSD-55.8* Plt ___
___ 06:34AM BLOOD Plt ___
___ 06:34AM BLOOD Glucose-124* UreaN-37* Creat-6.1*# Na-138
K-4.4 Cl-94* HCO3-26 AnGap-22*
___ 06:34AM BLOOD Calcium-8.2* Phos-4.9* Mg-2.1
___ 02:15AM BLOOD calTIBC-142* ___ Ferritn-1047*
TRF-109*
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Clopidogrel 75 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Fluticasone Propionate 110mcg 2 PUFF IH BID
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Nephrocaps 1 CAP PO DAILY
9. Pantoprazole 40 mg PO Q12H
10. Senna 8.6 mg PO BID:PRN constipation
11. sevelamer CARBONATE 800 mg PO TID W/MEALS
12. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
13. Tetracaine 0.5% Ophth Soln 1 DROP BOTH EYES QID:PRN eye
redness
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Clopidogrel 75 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Fluticasone Propionate 110mcg 2 PUFF IH BID
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Nephrocaps 1 CAP PO DAILY
9. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
10. Pantoprazole 40 mg PO Q12H
11. Senna 8.6 mg PO BID:PRN constipation
12. sevelamer CARBONATE 800 mg PO TID W/MEALS
13. Tetracaine 0.5% Ophth Soln 1 DROP BOTH EYES QID:PRN eye
redness
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
Acute blood loss anemia
Upper GI bleed
Secondary
ESRD on hemodialysis
CAD s/p stents
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: ___ man with shortness of breath. Evaluate for
pneumonia.
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph of ___, and ___
FINDINGS:
Compared with the prior study, lung volumes are lower, causing bronchovascular
crowding. Mild cardiomegaly is unchanged. Increased interstitial lung
markings are likely due to chronic interstitial lung disease. No focal
consolidation, pleural effusion, or pneumothorax. Incidental note is made of
a heavily calcified left anterior descending artery.
IMPRESSION:
No focal consolidation concerning for pneumonia. Persistent findings related
to chronic interstitial lung disease.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with ett placement
COMPARISON: Prior exam from ___
FINDINGS:
AP portable upright view of the chest. There has been placement of an
endotracheal tube which is positioned with its tip 1.4 cm above the carina.
Severe levoscoliosis of the thoracic spine and low lung volumes limits
assessment.
IMPRESSION:
ET tube tip positioned 1.4 cm above the carina. Consider retraction by
approximately 1 cm for more optimal positioning.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with L subclavian placement // L subclavian
placement L subclavian placement
IMPRESSION:
Comparison to ___, 11:55. The patient has received a new left
subclavian line. The course of the line is unremarkable, the tip of the line
projects over the mid to lower SVC. No complications, notably no
pneumothorax. Otherwise, the radiograph is unchanged.
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US
INDICATION: ___ year old man with ESRD on HD with LUE swelling after dialysis.
Fistula with audible bruit but no palpable thrill. // Evaluate for LUE DVT,
?fistula thrombosis.
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 right subclavian vein.
The left subclavian vein is not visualized due to overlying Band-Aid.
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.
An AV fistula is identified from the brachial artery to the left basilic vein.
There is no thrombosis. Normal flow is seen throughout the fistula. There is
no evidence for stenosis.
IMPRESSION:
1. No evidence of deep vein thrombosis in the left upper extremity.
2. Patent AV fistula
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with Gastrointestinal hemorrhage, unspecified
temperature: 98.4
heartrate: 90.0
resprate: 16.0
o2sat: 100.0
sbp: 99.0
dbp: 52.0
level of pain: 4
level of acuity: 3.0 | ___ man with ___ notable for CAD s/p multiple RCA PCIs,
ESRD s/p failed renal transplant and back on HD (MWF), and
chronic anemia, who presented with shortness of breath and
reports of melenic stools for several days prior to arrival. He
was found to be anemic at a dialysis appointment on ___, and
subsequently developed SOB. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Heparin Agents / linezolid / chlorhexidine /
vancomycin
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Midline IV placement ___
bronchoscopy
History of Present Illness:
___ yo M with a complicated history including AAA repair c/b
thoracic cord infarction with resultant paraplegia, bowel
perforation resulting in colectomy/colostomy, complete heart
block s/p pacemaker, COPD and recurrent HCAP-LLL PNA,
tracheostomy, chronic indwelling foley catheter with ESBL E.Coli
and Proteus colonization as well as prior MRSA and Pseudomonas
UTI presents with ___ day history of increased shortness of
breath. Patient noticed yesterday that he had increased
shortness of breath. Patient normally is on 2 L nasal cannula to
3. Patient denies any cough, chest pain, abdominal pain, fevers,
chills, congestion, sore throat or headache.
Of note, patient was recently discharged from ___ on ___. At
that time was treated for multifocal pna with IV cefepime
(completed 14-day course on ___. BAL during that admission
grew pseudomonas sensitive to cefepime and stenotrophomonas
(sensitive to bactrim). In addition, UCx during that admission
grew E.coli and Proteus (both sensitive to cefepime), thought to
be most likely represent chronic colonization versus acute
infection.
He was seen by his PCP ___ ___ for follow-up of his
hospitalization, reported one week of increased cough, sputum
production and a low-grade fever (99.7), chest x-ray on ___
showed continued multi-focal pneumonia (worse in LLL), and worse
than CXR on ___. He was started on 2 week course of PO bactrim
at that time.
This past ___, 2 days prior to admission, he noted
increased shortness of breath like he "couldn't take a deep
breath, felt like hitting the bottom". This was made worse lying
down or lying on his left side. This SOB was episodic throughout
the day and worsened with exertion when he tried to
move/reposition himself. He describes feeling more short of
breath on ___ and which then stablized today.
In the ED, initial vs were: 98.9 103 ___ 93% 3L NC.
Labs were remarkable for WBC 17.0, H/H 7.5/26.1, Plt 498, Na/K
128/6.5, ___, BUN/Cr 41/0.6, Lactate 1.4. Repeat K was
6.1. CXR showed diffuse patchy opacities throughout the left
lung, but improved compared with CXR from ___. Patient
was given 2g IV cefepime.
On the floor, vs were: T98.8, P90, BP134/58, RR 20, O2 sat 91%
on 4L. Patient was sitting up, resting comfortably, in NAD.
Past Medical History:
- GI AVMs with chonic iron deficiency anemia
- Thoraco-AAA s/p repair ___ c/b T8 infarction resulting in
paraplegia
- Aortic graft infection, needs lifelong abx (Cipro/Flagyl)
suppression per ID
- Bowel perforation with colectomy and colostomy
- Recurrent pneumonia c/b respiratory failure s/p tracheostomy.
Previous PNAs caused by pseudomonas and MRSA.
- Bronchiectasis
- Neurogenic bladder -> indwelling foley
- s/p PEG placement (removed ___, replaced ___
- s/p pacemaker for complete heart block
- h/o hypertension - off BP meds
- Hyperlipidemia
- COPD
- Osteoarthritis
- Perihepatic fluid collection (s/p ___ drainage growing
Clostridium)
- Sacral ulcers
- Recurrent decubitus with L ischial osteomyelitis ___
- R fibular osteomyelitis (pseudomonas and MRSA) ___
Social History:
___
Family History:
- Mother: ovarian cancer (___)
- Father: hypertension, ___ aneurysm (deceased- ___
- Paternal uncle 1:Abdominal aneurysm (deceased - ___
- Paternal uncle 2: ___ aneurysm (deceased- ___
- Patenral uncle 3: Abdominal aneurysm (alive)
Physical Exam:
MICU ADMISSION:
---------------
General: Alert, oriented x 3, no acute distress, cachectic
appearing
HEENT: Sclera anicteric, Lips dry, oropharynx clear
Neck: Tracheostomy in place
Lungs: Decreased breath sounds at bases L>>R, bibasilar crackles
CV: Distant heart sounds, Regular rate and rhythm, normal S1 +
S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender (paraplegia), non-distended, bowel
sounds present, no organomegaly, osteomy intact filled w dark
brown liquid stool, PEG intact, chronic ulcer on RLQ with no
erthyema or exudate
GU: Foley in place filled with clear yellow urine
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Echymoses on arms bilaterally, LLE with ulcer on heel
Neuro: Ox3, CN II-XII assessed and intact, Biceps, Triceps,
brachioradialis ___ stength bilaterally, Sensation intact
through T8
DISCHARGE:
----------
Vital: 98.4, 65, 120/51, 20, 98% capped, RA
General: Alert, oriented x 3, no acute distress, cachectic
appearing
HEENT: Sclera anicteric, Lips dry, oropharynx clear
Neck: Tracheostomy in place, capped
Lungs: Decreased breath sounds at bases L>>R, otherwise
relatively clear
CV: Distant heart sounds, Regular rate and rhythm, normal S1 +
S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender (paraplegia), non-distended, bowel
sounds present, no organomegaly, osteomy intact filled w dark
brown liquid stool, PEG intact, chronic ulcer on RLQ with no
erthyema or exudate
GU: Foley in place filled with clear yellow urine
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Echymoses on arms bilaterally, LLE with ulcer on heel
Pertinent Results:
Admission:
----------
___ 07:55AM BLOOD WBC-11.9* RBC-2.91* Hgb-7.6* Hct-25.9*
MCV-89 MCH-26.0* MCHC-29.2* RDW-18.5* Plt ___
___ 02:55PM BLOOD Neuts-85.6* Lymphs-5.9* Monos-5.9 Eos-2.2
Baso-0.5
___ 01:02AM BLOOD Glucose-157* UreaN-36* Creat-0.6 Na-132*
K-5.1 Cl-96 HCO3-29 AnGap-12
___ 07:55AM BLOOD Calcium-10.1 Phos-2.7 Mg-1.6
___ 03:01PM BLOOD Lactate-1.1 Na-134 K-5.1
imaging:
--------
___ CTCHEST:
1. Longstanding left lower lobe collapse with bronchiectasis
and mucus filled subsegmental distal left lower lobe bronchi
likely due to chronic aspiration could be chronically infected.
There is no necrosis to suggest invasive aspergillosis or
mycetoma, but aspergillus could be colonizing the inflamed and
peripherally impacted airways in the chronically collapsed left
lower lobe.
2. Previous multifocal pnuemonia has improved.
3. New small right pleural effusion, small left pleural
effusion, and mild interstital pulmonary edema.
___ CXR:
Tracheostomy tube remains in standard position, and
cardiomediastinal contours are stable. Slight improvement in
left
retrocardiac opacity likely due to improving atelectasis with or
without
adjacent infectious consolidation. More heterogeneous opacities
in the
periphery of the left mid and lower lung appear slightly
worsened and may be due to provided history of pseudomonas
infection. Poorly defined opacity at the right lung base is
also slightly worsened, but adjacent area of pleuroparenchymal
scarring at the lateral costophrenic angle is unchanged
___ CXR:
Worsening left retrocardiac opacity with associated inferior
displacement of left hilum favors worsening left lower lobe
atelectasis, but coexisting pneumonia is possible, particularly
in the setting of poorly defined adjacent opacities in the mid
and lower lung regions. Additionally, in the right lung, a
worsening patchy and linear opacity is present with associated
volume loss. Small pleural effusions are similar to the prior
study.
___ CXR:
Frontal and lateral views of the chest were obtained. Left
costophrenic angle is not fully included on the image.
Single-lead
right-sided pacemaker is again seen, unchanged in position.
Tracheostomy is also unchanged. Patchy opacities projecting
over the left lung are grossly stable since the prior study, but
improved as compared to ___. There is also persistent
scarring/atelectasis at the right costophrenic angle. Trace
bilateral pleural effusions are difficult to exclude and may be
present. The cardiac and mediastinal silhouettes are stable, as
are the hilar contours.
microbiology:
-------------
___ 2:50 pm BRONCHOALVEOLAR LAVAGE
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final ___:
10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora.
UNABLE TO R/O OTHER PATHOGENS DUE TO OVERGROWTH OF
SWARMING PROTEUS
SPP..
PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML..
Piperacillin/Tazobactam sensitivity testing performed
by ___
___.
PROTEUS MIRABILIS. UNABLE TO QUANTITATE.
IDENTIFICATION AND SUSCEPTIBILITY REQUESTED BY ___ ___
___
(___).
PSEUDOMONAS AERUGINOSA. ~5000/ML. ___ MORPHOLOGY.
Piperacillin/Tazobactam sensitivity testing performed
by ___
___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| PROTEUS MIRABILIS
| | PSEUDOMONAS
AERUGINOSA
| | |
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- 8 R
CEFEPIME-------------- 8 S <=1 S 4 S
CEFTAZIDIME----------- 32 R <=1 S 8 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R =>4 R =>4 R
GENTAMICIN------------ 4 S 4 S 2 S
MEROPENEM------------- 4 I <=0.25 S 4 I
PIPERACILLIN/TAZO----- I <=4 S S
TOBRAMYCIN------------ <=1 S 4 S <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
___: NEGATIVE for Pneumocystis jirovecii
(carinii)..
FUNGAL CULTURE (Preliminary):
YEAST.
ASPERGILLUS SPECIES.
___ 3:22 pm BRONCHIAL WASHINGS
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final ___:
10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora.
PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML..
OF TWO COLONIAL MORPHOLOGIES.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___
ON ___.
FUNGAL CULTURE (Preliminary):
YEAST.
___ 1:21 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. >100,000 ORGANISMS/ML..
Discharge:
----------
___ 01:57AM BLOOD WBC-7.3 RBC-2.71* Hgb-7.0* Hct-24.7*
MCV-91 MCH-25.9* MCHC-28.3* RDW-18.5* Plt ___
___ 01:57AM BLOOD Plt ___
___ 01:57AM BLOOD Glucose-118* UreaN-37* Creat-0.6 Na-139
K-3.4 Cl-104 HCO3-28 AnGap-10
___ 01:57AM BLOOD Calcium-9.0 Phos-2.5* Mg-1.8
pertinent:
----------
___ 06:07AM BLOOD Hapto-221*
___ 06:06PM BLOOD Type-ART Temp-36.6 pO2-57* pCO2-28*
pH-7.64* calTCO2-31* Base XS-8
___ 10:23AM URINE Hours-RANDOM UreaN-708 Creat-48 Na-13
K-33 Cl-26
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ferrous Sulfate 325 mg PO TID
2. Fluconazole 200 mg PO Q24H
3. FoLIC Acid 1 mg PO DAILY
4. Gabapentin 300 mg PO BID
5. MetRONIDAZOLE (FLagyl) 500 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO DAILY:PRN pain
8. Paroxetine 20 mg PO DAILY
9. Sodium Chloride 3% Inhalation Soln 15 mL NEB TID:PRN cough
10. Brovana (arformoterol) 15 mcg/2 mL inhalation BID
11. Budesonide 0.5 mg/2 mL INHALATION BID
12. esomeprazole magnesium 40 mg oral daily
Discharge Medications:
1. Ferrous Sulfate 325 mg PO TID
2. Fluconazole 200 mg PO Q24H
3. FoLIC Acid 1 mg PO DAILY
4. Gabapentin 300 mg PO BID
5. Multivitamins 1 TAB PO DAILY
6. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO DAILY:PRN pain
7. Paroxetine 20 mg PO DAILY
8. Sodium Chloride 3% Inhalation Soln 15 mL NEB TID:PRN cough
9. Acetaminophen 650 mg PO Q6H:PRN pain/fever
10. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN SOB
11. Albuterol Inhaler 4 PUFF IH Q6H
12. CefePIME 2 g IV Q8H
13. Fluticasone Propionate 110mcg 2 PUFF IH BID
14. Ipratropium Bromide MDI 2 PUFF IH QID
15. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
16. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
17. Tobramycin 400 mg IV Q48H
18. TraZODone 50 mg PO HS:PRN insomnia
19. Zinc Sulfate 220 mg PO DAILY
20. MetRONIDAZOLE (FLagyl) 500 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
PRIMARY DIAGNOSIS:
1. Pseudomonal Pneumonia
2. Anemia
3. acute on chronic hypercarbic respiratory failure
4. chronic obstructive pulmonary disease
5. Malnutrition
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
EXAM: Chest frontal and lateral views.
CLINICAL INFORMATION: Altered mental status, dyspnea.
___.
FINDINGS: Frontal and lateral views of the chest were obtained. Left
costophrenic angle is not fully included on the image. Single-lead
right-sided pacemaker is again seen, unchanged in position. Tracheostomy is
also unchanged. Patchy opacities projecting over the left lung are grossly
stable since the prior study, but improved as compared to ___. There is
also persistent scarring/atelectasis at the right costophrenic angle. Trace
bilateral pleural effusions are difficult to exclude and may be present. The
cardiac and mediastinal silhouettes are stable, as are the hilar contours.
Radiology Report
PORTABLE CHEST RADIOGRAPH, ___
COMPARISON: Study of ___.
FINDINGS: Worsening left retrocardiac opacity with associated inferior
displacement of left hilum favors worsening left lower lobe atelectasis, but
coexisting pneumonia is possible, particularly in the setting of poorly
defined adjacent opacities in the mid and lower lung regions. Additionally,
in the right lung, a worsening patchy and linear opacity is present with
associated volume loss. Small pleural effusions are similar to the prior
study.
Radiology Report
REASON FOR EXAM: ___ years old man with tracheostomy, desaturation to ___,
assess for mucus plug.
COMPARISON: Exam is compared to chest x-ray of ___.
FINDINGS: AP portable semi-erect chest x-ray shows stable position of
tracheostomy tube; unnchanged right pectoral pacemaker with single lead
following the expected course and ending in the right ventricle. Compared to
prior chest x-ray, there are little changes with stable left lung base opacity
due to the left lower lobe atelectasis. Linear opacities at the right lung
base are minimally increased, likely due to linear atelectasis.
Cardiomediastinal silhouette is stable. There is no pneumothorax. Small
bilateral pleural effusion is unchanged.
Radiology Report
PORTABLE CHEST, ___
COMPARISON: Radiograph of one day earlier.
FINDINGS: Tracheostomy tube remains in standard position, and
cardiomediastinal contours are stable. Slight improvement in left
retrocardiac opacity likely due to improving atelectasis with or without
adjacent infectious consolidation. More heterogeneous opacities in the
periphery of the left mid and lower lung appear slightly worsened and may be
due to provided history of pseudomonas infection. Poorly defined opacity at
the right lung base is also slightly worsened, but adjacent area of
pleuroparenchymal scarring at the lateral costophrenic angle is unchanged.
Radiology Report
AP CHEST, 1:07 P.M., ___
HISTORY: A ___ man with thoracic spinal infarction after tracheostomy
and gastrostomy, recurrent pneumonia. Hypercarbia after bronchoscopy.
IMPRESSION: AP chest compared to ___ through ___:
Compared to ___ when there was extensive consolidation in the left lung,
the current appearance of the left lung could be due to scarring or a slowly
resolving residual of infection, but it is more clear today and has grown
progressively so since the end of ___. Small bilateral pleural effusions
may be present, but pulmonary vasculature is not sufficient to raise concern
for heart failure, and the heart is normal size. Transvenous pacer lead
passes to the apex of right ventricle. Tracheostomy tube is in standard
position.
If despite the slow improvement in appearance of the left lung patient has
symptoms of recurrent aspiration, the possibility of tracheoesophageal fistula
should be investigated.
Radiology Report
PORTABLE CHEST ___
COMPARISON: Radiograph of ___.
FINDINGS: Since the prior study, there has been little overall change in the
appearance of the chest except for slight improved aeration in the left
retrocardiac region.
Radiology Report
INDICATION: Chronic tracheostomy, pneumonia, new Aspergillus in sputum,
evaluate for evidence of Aspergillosis.
COMPARISON: ___, ___, and ___.
FINDINGS: There is no axillary, supraclavicular, mediastinal, or hilar
lymphadenopathy. The thyroid is normal. Tracheostomy is in place, slightly
high in position. Pacer wire courses are standard. The heart size is normal.
There is no pericardial effusion. Dilation of the aortic root to 4.4 cm is
stable. The esophagus is normal.
Moderate centrilobular emphysema is chronic. Peripheral ground glass opacities
are no longer apparent. The right lung and left upper lobe bronchi are patent
to subsegmental levels. The entire left lower lobe is collapsed around
widespread bronchiectasis even though the serving bronchi are patent to
segmental divisions, but more distal branches of the left lower lobe are
filled with secretions. The left lower lobe consolidation spared the
superior segment on ___, however, but progressed to its current
extent by ___. A small right pleural effusion has increased from
___ and there is a small left pleural effusion.
Limited evaluation of the intra-abdominal organs demonstrates bilateral renal
cysts.
BONES: No bone lesions concerning for malignancy.
IMPRESSION:
1. Longstanding left lower lobe collapse with bronchiectasis and mucus filled
subsegmental distal left lower lobe bronchi likely due to chronic aspiration
could be chronically infected. There is no necrosis to suggest invasive
aspergillosis or mycetoma, but aspergillus could be colonizing the inflamed
and peripherally impacted airways in the chronically collapsed left lower
lobe.
2. Previous multifocal pnuemonia has improved.
3. New small right pleural effusion, small left pleural effusion, and mild
interstital pulmonary edema.
Radiology Report
INDICATION: Dysphagia and oropharyngeal dysfunction per speech and swallow
department.
COMPARISON: Comparison is made to video oropharyngeal study performed ___.
TECHNIQUE: Oropharyngeal swallowing video fluoroscopy 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, though penetration was
noted with thin liquids. Patient was able to successfully clear vallecula and
piriform sinus residue.
IMPRESSION: Penetration with thin liquids. No aspiration.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Confusion
Diagnosed with PSYCHOSIS NOS
temperature: 98.8
heartrate: 86.0
resprate: 22.0
o2sat: 97.0
sbp: 132.0
dbp: 67.0
level of pain: 0
level of acuity: 3.0 | MICU COURSE ___ - ___:
reason for transfer: acute hypoxia
On the morning of ___, Mr ___ suffered another acute drop
in his O2 sats to 70%. After deep suctioning of a large amout
of secretions his sats only improved to the ___. ABG was
7.37/65/62. He was ambu bagged for about 5 minutes and deep
suctioning was repeated and his sats improved to the ___ where
he remained. He was then placed back on 40% trach mask. Due to
increased work of breathing, he has intermittently been required
to go back on the ventilator.
# Hypoxia: Likely ___ mucous plugging in the setting of
increased secretions that patient cannot clear given paraplegia
and underlying pneumonia. Patient's prior BALs showed
Pseudomonas ___ to cefepime and most recently stenotrophamonas.
He is s/p 7 days Bactrim Tx for steno, stopped due to ___.
Underlying etiology for presentation thought to be ___ Bactrim
toxicity. Cefepime and Tobramycin was started for double
coverage for pseudomonal infection. Vancomycin was started for
empiric MRSA coverage but later pulled back. Bronchoscopy ___
showed thick white secretions throughout the L lobe. He
continued to have hypercarbia and vent requirements, likely
secondary to underlying PNA and reaccumulating secretions in his
LLL. BAL cultures came back showing pseudomonas sensitive to
tobramycin. Pt refused arterial line or PICC for access. Patient
continued Flagyl and Fluconazole prophylaxis for his arterial
graft per ID. He continued to require pressure support
intermittently during admission because of CO2 retention,
however this improved with antibiotics. He was seen by case
management for placement to vent rehab.
# Access: Patient needed consistent blood draws for ABGs/VBGs.
Other types of access were considered but patient actively
refused arterial line or PICC.
# Anemia: Hct was 27.3 on ___ AM but dropped to 20.8 on ___ AM.
1 U pRBC was given. Iron supplementation was started. No other
decreases of WBC or PLT to suggest dilution were found. The
cause of rapid Hct drop was likely related to chronic GI losses.
Hct remained stable throughout the rest of her hospitalization.
# Hyponatremia: Na was 131 on ___. Tought to be related
to hypovolemic hyponatremia, he was given IVF with improvement
of Na+ to 134. FeNa 0.08 suggesting hypovolemic hyponatremia. Na
stabilized for the rest of his hospitalization.
# COPD: patient w/ ___ pack-year smoking h/o (quit in ___. CO2
elevated on afternoon of admission. Patient didnot appear to be
having COPD exacerbation as he is not wheezing on exam, but he
did have increased sputum production. We continued serial
ABGs/VBGs and the patient received standing duonebs and prn
hypertonic saline.
# Malnutrition: Patient had evidence of chronic malnutrition
with muscle wasting and bony prominences. Last known albumin of
2.2 in ___. We started Nepro tube feeds per home
regimen (60cc/hr,18hrs per day) and supplemented with ascorbic
acid, zinc, folic acid, MVI.
# AV block w/pacemaker: We continued to monitor him on
telemetry. He intermittently went into paced rhythm but self
converted and remained stable. His rhythm at discharge was not
paced.
# Paraplegia: We continued home gabapentin for neuropathic pain
TRANSITIONAL ISSUES:
--------------------
* will complete a 2 week course of tobramycin and cefepime to
end ___.
* re-start ciprofloxacin 500mg PO daily on ___.
* mechanical ventilation was initiate based on mental status,
tachypnea, and per patients wishes. Please wean as tolerated.
*Tubefeeding: Two Cal HN Full strength;
Starting rate:65 ml/hr; Do not advance rate
Residual Check:q4h Hold feeding for residual >= :200 ml
Flush w/ 200 ml water q4h
Other instructions: 18 hours per day
*Regular ___ gm sodium /Heart healthy ; Thin liquids
*Continue waffle boots bilaterally
*Alternate Air mattress for moisture management and limited
turning surfaces - needs bed extender
Pressure redistribution per pressure ulcer guidelines, turn side
to side off sacrum as tolerated.
If OOB,limit sit time to 1 hour and sit on a ROHO cushion.
*Topical Therapy:
Cleanse all wounds with wound cleanser then pat dry
Apply barrier ointment to all periwound tissue
*For Left heel -
Apply a small amount of DuoDerm Gel to the partial thickness
wounds; none on the black necrotic cap, cover all areas with
Adaptic to then ABD pad
Secure with Kerlix
change daily
*B/L Ischium and Sacrum:
Apply barrier ointment to the periwound tissue
Apply Aquacel to each wound
Cover with Sofsorb sponge
Change daily.
*Moisturize all intact dry skin BID with Sooth and ___
*Colostomy: Pouch was changed ___ and is intact.
Coloplast ___ ___, ___ # ___
Adapt Barrier ring # ___, ___ # ___
Change pouch every ___ days or prn. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
___
Attending: ___
Chief Complaint:
Weakness, ataxia, facial droop
Major Surgical or Invasive Procedure:
Right frontal meningeal biopsy
History of Present Illness:
___ yo RH man with history of prostate CA and recent prolonged
admission for ?AIDP (significant sensory ataxia and peripheral L
___ CN palsy) who present with an episode of aspiration.
Per discharge summary, he had worsening exam after admission to
the hospital with "dysautonomia, fluctuating mental status,
weakness of both upper extremities and proprioceptive loss but
also a new lower motor neuron left ___ cranial neuropathy" which
improved slowly over the hospitalization with treatment with 5
days of IVIg. He had episodes of fever, tacycardia and urinary
retention which was treated with clonidine and metoprolol. Also
complicated by orthostatic hypotension which improved with
decreased doses of clonidine.
He was discharged from the hospital yesterday. The wife reports
that even in the hospital he had some episodes of coughing with
liquids, especially when he was drinking thin liquids. However,
while he was hospitalized, she was able to watch him eat and
slow
him down as needed. This morning, she was not able to see him
during breakfast due to visiting hours at the rehab, and by the
time she arrived, she saw that he had coughed up some breakfast
in the basin next to him. He reports that he was eating/drinking
and began coughing after, thinks that he was choking a little
bit. He developed fevers and hypoxia, so was transferred to
___ and then transferred here.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, lightheadedness, vertigo, tinnitus
or hearing difficulty. Denies difficulties producing or
comprehending speech.
+stable urinary retention (foley still in place), weakness,
sensory loss and gait difficulty as noted during the last
hospitalization.
On general review of systems, the pt denies night sweats or
recent weight loss or gain. Denies 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:
Prostate CA s/p brady and beam therapy
Vitamin D deficiency
ED
Alcoholism: recovered ___ years ago
?AIDP vs. autoimmune brainstem encephalitis, hospitalized on
neurology service from ___
Social History:
___
Family History:
Parents both died in their ___ of CHF. Sister had multiple
myeloma (deceased). Other sister with rheumatoid arthritis.
Physical Exam:
ADMISSION:
- Mental Status: Alert, oriented to person, place and ___.
Attentive, able to name ___ forward and backward without
difficulty. Language is fluent with intact repetition and
comprehension, but pt has nasal voice (stable from discharge per
wife). Normal prosody. There were no paraphasic errors. Speech
was not dysarthric. Able to follow both midline and appendicular
commands. There was no evidence of neglect. There was no
evidence
of left-right confusion as the patient was able to accurately
follow the instruction to touch left ear with right hand.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2 to 1.5 mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: L facial droop involving lower face and eyelid.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically. +intact gag bilaterally.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. Drift without pronation
bilaterally. No adventitious movements, such as tremor, noted.
No
asterixis noted.
Delt Bic Tri WrE FFl FE IP Quad Ham TA ___
L 5 5 4+ ___ 5 5 5 5 5 5
R 5 ___ ___ 5 * 5 5 5
Some give away weakness in legs bilaterally, most notably in R
hamstring.
-Sensory: No deficits to light touch, cold sensation throughout.
Decreased vibration to the ankles bilaterally; proprioception
diminished in toes and fingers bilaterally.
-DTRs: ___ throughout; toes mute.
-Coordination: sensory ataxia bilaterally on FNF.
-Gait: deferred.
Pertinent Results:
1.) SERUM LABS
INFLAMMATORY MARKERS AND IMMUNOLOGY:
___:
ESR 20
CRP 64.8
___:
ANCA neg
dsDNA Ab neg
anti-Tg neg
anti-TPO neg
___ pos (1:160)
SM ANTIBODY <1.0 NEG
RO & ___ ANTIBODY (SS-A) <1.0 NEG
___ ANTIBODY (SS-B) <1.0 NEG
RNP ANTIBODY <1.0 NEG
PARANEOPLASTIC AUTOANTIBODY EVALUATION:
CRMP-5-IgG Western Blot,S POSITIVE
___, S Negative
___, S Negative
___, S Negative
AGNA-1, S Negative
PCA-1, S Negative
PCA-2, S Negative
PCA-Tr, S Negative
Amphiphysin Ab, S Negative
CRMP-5-IgG, S Negative
*(Note: western blot analysis sent for abnormal ___ pattern)
Striational (Striated Muscle) Ab, S Negative
P/Q-Type Calcium Channel Ab 0.00 nmol/L
N-Type Calcium Channel Ab 0.00 nmol/L
ACh Receptor (Muscle) Binding Ab 0.00 nmol/L
AChR Ganglionic Neuronal Ab, S 0.00 nmol/L
Neuronal (V-G) K+ Channel Ab, S 0.00 nmol/L
___:
GQ1B AB (IGG) <1:100
ACE, SERUM 29
___:
ANAPLASMA PHAGOCYTOPHILUM AND EHRLICHIA CHAFFEENSIS ANTIBODY
PANEL (IGM AND IGG) <1:64
___:
IgG 1778
IMMUNOGLOBULIN G SUBCLASS 1 1020 H
IMMUNOGLOBULIN G SUBCLASS 2 639
IMMUNOGLOBULIN G SUBCLASS 3 49
IMMUNOGLOBULIN G SUBCLASS 4 43.8
IMMUNOGLOBULIN G, SERUM 1768 H
IGE IMMUNOGLOBULIN E 82
INFECTION LABS:
___: LYME SERUM: NO ANTIBODY DETECTED BY EIA.
___: HIV Viral Load undetectable
___: RABIES ANTIBODY RABIES VACCINE RESPONSE END POINT
TITER <0.1
___: RPR nonreactive
___: LYME SERUM: NO ANTIBODY DETECTED BY EIA.
___: LYME SERUM: NO ANTIBODY DETECTED BY EIA.
___: FTA-ABS nonreactive
2.) ___ LABS
___:
Tube #1: WBC 32 RBC 2 Polys 1 Lymphs ___ Monos 25
Tube #2: Prot 121 Gluc 63
Tube #4: WBC 34 RBC 4 Polys 1 Lymphs ___ Monos 14
GRAM STAIN Neg
FLUID CULTURE Neg
CRYPTOCOCCAL ANTIGEN Neg
FUNGAL CULTURE Neg
VIRAL CULTURE Neg
HSV 1, PCR Negative
HSV 2, PCR Negative
EBV DNA, QL PCR Not Detected
CMV DNA, QL PCR NOT DETECTED
VZV QL RT PCR Not detected
Eastern Equine Encephalitis EIA-IgM Negative
___ Virus EIA-IgM Negative
LYME DISEASE AB INDEX 1.2 (EQUIVOCAL)
CYTOLOGY REPORT:
Numerous polymorphous lymphocytes and monocytes (see note).
Note: A few large, reactive-appearing lymphoid cells are
present.
In the ThinPrep monolayer preparation, several lymphoid cells
appear to form clusters, the significance of which is uncertain.
The overall cytologic findings are favored to represent a
reactive lymphocytic pleocytosis.
___:
Tube #1: WBC 20 RBC 21 Polys 1 Lymphs ___ Monos 4
Tube #2: Prot 194 Gluc 56
Tube #4: WBC 22 RBC 9 Polys 0 Lymphs ___ Monos 1
GRAM STAIN Neg
FLUID CULTURE Neg
CRYPTOCOCCAL ANTIGEN Neg
FUNGAL CULTURE Neg
VIRAL CULTURE Neg
LYME DISEASE AB INDEX 3.4 H
MTB Complex, PCR Not Detected
Lyme Disease AB (IgG) IBL No Bands Detected
Lyme Disease AB (IgM) IBL No Bands Detected
CYTOLOGY REPORT: NEGATIVE FOR MALIGNANT CELLS. Numerous
lymphocytes and monocytes.
___:
Tube #1: WBC 6 RBC 1 Polys 0 Lymphs ___ Monos 2
Tube #2: Prot 155 Gluc 65
Tube #4: WBC 12 RBC 1 Polys 1 Lymphs ___ Monos 2
GRAM STAIN Neg
Cryptococcus Ab Neg
3.) IMAGING
___:
CT ___:
No evidence of acute intracranial process.
MR ___:
1. Motion-limited brain MRI demonstrates no evidence for
cerebellar infarction or abnormal cerebellar enhancement.
Evaluation for subtle cerebellitis on T2-weighted and FLAIR
images is technically limited. No mass effect is seen.
2. Brain MRA is motion limited, and visualization of posterior
inferior cerebellar arteries is poor. Otherwise, no arterial
occlusion is seen, but evaluation for subtle stenoses and for
intracranial aneurysms is limited.
MR Spine:
1. At C6-7, there is a left paracentral disc herniation
extending primarily below the disc space, but also slightly
above
the disc space. It abuts the left ventrolateral surface of the
spinal cord without evidence for cord deformation or abnormal
cord signal. The portion of the herniation below the
disc space may represent a free fragment.
2. The remainder of the spinal cord appears normal.
3. 7 mm sclerotic lesion in the T5 vertebral body with
apparent mild surrounding edema, concerning for a prostate
cancer
metastasis. Recommend a bone scan for further evaluation.
___:
Renal U/S: normal
___:
MR ___ w and w/o contrast:
Markedly motion-degraded examination (despite the measures taken
by the MR technologist). While there is no significant change
since the slightly more satisfactory study of ___, there
is
onvincing evidence of pachymeningeal enhancement, diffusely,
also
present previously. While this finding may simply relate to
recent lumbar puncture, apparently performed on admission, it
should be closely correlated clinically.
CT Abdomen and Pelvis:
1. No CT evidence of new malignancy in the abdomen or pelvis.
2. Decreased size of previously noted enlarged right external
iliac lymph nodes.
3. New mild urothelial thickening of the left renal pelvis, new
from ___ CT. Correlate with urine cytology.
4. T5 sclerotic lesion. Correlate with PSA.
CT Chest:
1. The examination is limited by significant respiratory motion
artifact.
2. Small bilateral pleural effusions and associated atelectasis
which is new.
3. Please see report of outside hospital study for comment on
right hilar lymphadenopathy and subpleural right middle lobe
nodule better assessed on that CT.
___:
MR ___:
1. Diffuse pachymeningeal enhancement, which is new since the
prior examination dated ___, this finding is
nonspecific and probably is related with the recent lumbar
puncture.
2. Mild to moderate pattern of enhancement along the seventh
cranial nerves, more significant on the left as described in
detail above, suggesting inflammatory changes.
MR Spine:
Assisted previous MRI examination of ___, but is not
and enhancement of the cauda equina nerve roots identified
extending from the conus to the lower lumbar region. These
findings are indicative of inflammatory polyneuritis. No
abnormal
signal seen within the spinal cord or cord compression seen.
Otherwise the MRI of the cervical thoracic and lumbar spine is
stable in appearance.
___:
CT ___:
Expected post-operative changes with pneumocephalus and a small
amount of hemorrhage within the surgical bed.
___:
Bone Scan:
No definite metastatic lesions identified. Limited evaluation of
the pubic symphyses given a moderate amount of urine within the
bladder, however there has been no significant interval change.
___:
FDG-PET:
1. FDG-avid 9 mm right level III cervical lymph node. This may
be amenable to biopsy via ultrasound if clinically indicated.
2. Low-level FDG-avidity in the right hilum, without associated
enlarged lymph node. A sub 4 mm right middle lobe nodule is too
small to assess for FDG-avidity. No other concerning pulmonary
mass.
3. 9 mm portocaval lymph node is FDG-avid.
4. Previously enlarged right external iliac chain lymph nodes
have decreased in size and are not FDG-avid.
4.) PATHOLOGY
___:
1. Dura, right frontal, biopsy (1A): Dura mater with no
pathologic change.
2. Arachnoid, right, biopsy (2A): Minute fragments of
unremarkable cerebral cortex and small fragment of meninges with
no pathologic changes. No definite pathologic change identified
in multiple levels examined.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Doxazosin 8 mg PO HS
2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
3. Captopril 3.125 mg PO TID:PRN sBP > 170
4. CloniDINE 0.1 mg PO BID
5. Heparin 5000 UNIT SC BID
6. Thiamine 100 mg PO DAILY
7. Metoprolol Tartrate 25 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
CNS inflammation, possible lyme
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Neuro: Mild left facial weakness, proprioceptive/joint
positional sense loss (legs worse than arms, L worse than R),
mild weakness (L worse than R).
Followup Instructions:
___
Radiology Report
CHEST, TWO VIEWS: ___
HISTORY: ___ male with fever, cough, and hypoxia.
COMPARISON: Chest x-ray from ___ and chest CT from ___.
FINDINGS: Frontal and lateral views of the chest. There are increased
opacities in the lungs at the bases and most conspicuous in the right mid
lung. Blunting of the posterior costophrenic angle on the right is compatible
with a small effusion. Cardiomediastinal silhouette is within normal limits.
Osseous structures demonstrate no acute osseous abnormality.
IMPRESSION: Small right effusion and hazy opacities in the lungs at the bases
and the right mid lung could be due to atelectasis, infection, or aspiration
Radiology Report
EXAMINATION: Brain MRI.
INDICATION: ___ year old previously healthy man with flu-like symptoms, gait
imbalance, limb weakness concerning for brainstem encephalitis // ?brainstem
encephalitis. please do thin cuts through the brainstem
TECHNIQUE: Patient unable to tolerate the MRI study. Only localizer images
obtained.
COMPARISON: Brain MRI dated ___.
FINDINGS:
The limited localizer images are grossly unremarkable.
IMPRESSION:
Incomplete study as the patient could not tolerate further imaging. Recommend
repeat MRI under anesthesia.
Radiology Report
EXAMINATION: Cervical thoracic and lumbar spine
INDICATION: ___ year old previously healthy man with flu-like symptoms, gait
imbalance, limb weakness concerning for brainstem encephalitis //
?inflammatory myelopathy or radiculopathy. Please do it with and without
constrast.
TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 axial images of the
cervical, thoracic and lumbar spine were obtained. Following gadolinium T1
sagittal and axial images were obtained.
COMPARISON: Previous total spine MRI of ___.
FINDINGS:
In the cervical and thoracic region mild scoliosis seen. Mild multilevel
degenerative changes identified. No evidence of spinal stenosis. Cord
compression or abnormal signal seen within the spinal cord. No evidence of
abnormal intraspinal enhancement grade collection discitis or osteomyelitis.
Small areas of signal abnormalities within the T5 vertebral body again noted
unchanged. A perineural cyst within the right neural foramina at the T8-9
level also unchanged.
In the lumbar region no evidence of disk bulge or disk herniation identified.
Post gadolinium images demonstrate diffuse enhancement of the cauda equina
nerve roots extending from the level of the conus medullaris. This finding is
new since the prior study. These findings may suggest inflammatory bulging
neuritis. There is no intraspinal fluid collection or abscess seen. No
evidence of discitis or osteomyelitis. No disc bulge or herniation seen.
Mild increased soft tissue signal within the posterior subcutaneous fat in the
lumbar region may be due to soft tissue edema a nonspecific finding.
IMPRESSION:
Assisted previous MRI examination of ___, but is not and enhancement
of the cauda equina nerve roots identified extending from the conus to the
lower lumbar region. These findings are indicative of inflammatory
polyneuritis. No abnormal signal seen within the spinal cord or cord
compression seen. Otherwise the MRI of the cervical thoracic and lumbar spine
is stable in appearance.
Radiology Report
Indication: ___ year old male with dysphagia.
Swallowing video fluoroscopy: Oropharyngeal swallowing video fluoroscopy was
performed in conjunction with the speech and swallow division. Multiple
consistencies of barium were administered. Barium passed freely through the
oropharynx without evidence of obstruction. There was no gross aspiration or
penetration seen.
Impression: No gross aspiration or penetration seen. For details, please refer
to speech and swallow note in OMR.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST
INDICATION: ___ year old man with gait ataxia following febrile illness found
to have joint-position sense loss, facial nerve palsy, and left facial
weakness for two weeks. // Reassess for pachymeningitis, brainstem or
cerebellar lesions; If possible, with thin cuts through the crainial nerves
and brainstem. To be done under general anesthesia or MAC
TECHNIQUE: MRI of the brain is performed and includes the following
sequences: sagittal T1-weighted, axial fast spin echo T2-weighted,axial FLAIR,
axial diffusion weighted and axial gradient echo images. The T1 weighted
images were repeated after the administration of intravenous gadolinium
contrast. High-resolution images through the posterior fossa with FIESTA
technique
COMPARISON: Prior MRI of the brain dated ___ and ___.
FINDINGS:
In comparison with the prior examinations, there is evidence of diffuse
pachymeningeal enhancement with no evidence of narrowing of the foramen magnum
or low lying of the cerebellar tonsil, the splenium of the corpus callosum
appears in adequate position. No diffusion abnormalities are detected. The
ventricles are normal in size and configuration for the patient's age and
unchanged since the prior studies. The images with high-resolution through the
posterior fossa demonstrates patency of the internal auditory canals and
normal appearance in the cerebellar pontine cisterns, the distribution of the
major vascular structures is normal. Note is made of mild to moderate pattern
of enhancement along the seventh cranial nerves, more significant on the left
(image number 37, series 3301b) including the mastoid segment (image 72,
series 3300 b, and sagittal image number ___ series 33), this finding is
nonspecific and more obvious in the MP-RAGE sequences. The orbits are
unremarkable, the paranasal sinuses and mastoid air cells are clear.
IMPRESSION:
1. Diffuse pachymeningeal enhancement, which is new since the prior
examination dated ___, this finding is nonspecific and probably is
related with the recent lumbar puncture.
2. Mild to moderate pattern of enhancement along the seventh cranial nerves,
more significant on the left as described in detail above, suggesting
inflammatory changes.
NOTIFICATION: These findings were discovered and communicated via phone call
to Dr. ___ by Dr. ___ on ___ at 17:50 hrs.
Radiology Report
HISTORY: Preop operative evaluation the patient prior to brain biopsy.
COMPARISON: Chest radiograph from ___.
FINDINGS:
Previously visualized increased opacities at bilateral bases and in the right
mid lung have decreased. The lungs are without focal opacity suggestive of
infection. Cardiac and mediastinal silhouettes are within normal limits. No
acute fractures are identified.
IMPRESSION:
Previously visualized bilateral hazy opacities have decreased. No acute
cardiopulmonary process identified.
Radiology Report
INDICATION: History of meningeal biopsy. Please evaluate for bleeding.
COMPARISONS: Head CT from ___.
TECHNIQUE: ___ MDCT images were obtained through the brain without the
administration of IV contrast. Multiplanar reformatted images in coronal and
sagittal axes were generated and reviewed.
FINDINGS: The patient is status post meningeal biopsy of a right frontal lobe
with adjacent pneumocephalus and hyperdense products consistent with
hemorrhage within the resection bed; all of which are expected findings.
There is no evidence of midline shift to the left. The basilar cisterns are
patent and there is otherwise good preservation of gray-white matter
differentiation. The ventricles and sulci are normal in size and
configuration.
No acute fracture is identified. The visualized paranasal sinuses, mastoid
air cells and middle ear cavities are clear. Globes are unremarkable.
IMPRESSION: Expected post-operative changes with pneumocephalus and a small
amount of hemorrhage within the surgical bed.
Radiology Report
EXAMINATION: VIDEO OROPHARYNGEAL SWALLOW
INDICATION: Dysphagia. Evaluate for aspiration.
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the speech and swallow division. Multiple consistencies of
barium were administered.
COMPARISON: None available.
FINDINGS:
Barium passes freely through the oropharynx and esophagus without evidence of
obstruction. There is no penetration or gross aspiration. Please refer to the
speech and swallow division note in OMR for full details, assessment, and
recommendations.
IMPRESSION:
Normal oropharyngeal video fluoroscopy.
Radiology Report
HISTORY: Dysphagia, to assess for aspiration.
FINDINGS: In comparison with study of ___, there is no convincing
evidence of acute focal pneumonia. There is, however, an area at the right
base that could represent an area of early coalescence and, in the appropriate
clinical setting, be a manifestation of early pneumonia.
Radiology Report
EXAMINATION: Ultrasound guided right cervical lymph node fine needle
aspiration.
INDICATION: Cervical lymphadenopathy, FDG avid. Rule out neoplasm.
TECHNIQUE: Ultrasound guided right cervical lymph node fine needle
aspiration.
COMPARISON: Compared with prior PET/CT from ___.
FINDINGS:
Limited grayscale ultrasound imaging of the right cervical neck demonstrated
several lymph nodes including a round level III/IV lymph node measuring up to
8 mm, which was targeted for fine needle aspiration.
PROCEDURE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained from the patient. A pre-procedure timeout using three
patient identifiers was performed as per ___ protocol.
The patient was placed in a supine position on the US scan table. Limited
pre-procedure ultrasound of the right neck was performed. Based on the
ultrasound findings an appropriate position for the fine needle aspiration was
chosen. The site was marked.
The site was prepped in the usual aseptic fashion. 2 cc of 1% lidocaine were
administered to the subcutaneous and deep tissues for local anesthetic effect.
Under continuous ultrasound guidance, a 25 gauge needle was used for fine
needle aspiration x 2 passes. The specimen was evaluated by an onsite
cytologist and deemed adequate.
The procedure was well tolerated and there were no immediate post-procedural
complications.
Dr. ___, the attending radiologist, was present throughout the
entire procedure.
IMPRESSION:
Technically successful fine needle aspiration of right level III/IV cervical
lymph node. No immediate post-procedural complications. Pathology is pending.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ASPIRATION PNEUMONIA
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED
temperature: 101.5
heartrate: 106.0
resprate: 20.0
o2sat: 96.0
sbp: 155.0
dbp: 94.0
level of pain: 0
level of acuity: 2.0 | ___ h/o prostate ca who was recently admitted for predominantly
cerebellar symptoms which were initially thought due to a
partially treated meningitis (was on azithro for CAP). Mild
pleocytosis (30s) and positive ___ was thought to be suggestive
of autoimmune process, either central ___ spectrum) or
peripheral (GBS spectrum). His hospital course was c/b
hyper-sympathetic tone - tachy (up to 140s - now on metop),
hypertensive, retaining urine (causing post-renal ___ which has
resolved) which has improved drastically on clonidine.
Autoimmune workup showed ___ 1:160 speckled. CRP up but C3/4 nl,
ANCA neg. Lumbar puncture which showed 34 WBC and elevated
protein 121. HIV, RPR, Lyme, thyroglobuin, TPO, Anti-Tg nl. EEG
unremarkable. Empiric IVIG was trialed starting ___ with
improvement in symptoms. He was discharged to rehab on ___.
He was readmitted on ___ for persistent symptoms and an
aspiration event at his rehab. Briefly, he had a multifocal
involvement of the neuraxis that started on the background of a
febrile illness, involved mentation, left facial nerve, and the
posterior columns. A repeat CSF was inflammatory, but glucose is
normal. Further studies revealed equivocal Lyme antibody index
(and curiously, he had negative serum Lyme Ab). He completed 3
weeks of IV ceftriaxone for presumed CNS lyme. A meningeal
biopsy was also done, but was unrevealing for any pathology.
CSF lyme western blot was sent but returned negative (thought
there may be insufficient sample and hence we are concenred
about a false negative result). Clinically, he is improved
(left ___ nerve palsy much improved, as are proprioception and
L>R weakness) while on CTX though one may wonder: 1) Is he
improved because the lyme is being treated assuming he has lyme?
2) Can it be some other infectious cause that responds to CTX?
3) ___ be it's not infectious and whatever inflammatory process
has just improved over time? We repeated a LP the day after the
last dose of CTX (which was given on ___. Both the
wbc count and the protein improved, suggesting improved CNS
inflammation. Notably, he also had a positive anti-CRMP5
antibody, which prompted a neoplasm workup. CT torso shows right
hilar lymphadenopathy and right middle lobe nodule, mild
urothelial thickening of the left renal pelvis, T5 sclerotic
lesion. Bone scan was unrevealing. FDG PET shows a 9 mm right
level III cervical lymph node which we are planning to do
___ biopsy (see PET report for the rest of the details).
Biopsy was done on ___ without complication, pathology result
pending at the time of discharge. Oncology consulted and
recommended oncology outpatient follow up. Oncology appointment
has been scheduled prior to discharge.
# OTHER ISSUES LISTED BELOW:
# Aspiration
There has been concern about aspiration given his palatal
weakness. He did pass formal speech and swallow eval. His
palatal weakness continues to improve throughout hospital
course. His current diet is: Regular ___ gm sodium /Heart
healthy. Supplement: Ensure breakfast, lunch, dinner. Crush meds
and mix in apple sauce. He has remained afebrile for over 2
weeks prior to discharge.
# GI
He had some mild abdominal distension and loose stool. C diff
PCR negative on ___
# CV:
Earlier in his course, his blood pressure was somewhat labile
and required clonidine. It was slowly weaned off as his blood
pressure improved.
# GU:
DEcreased urge to void requiring Foley. Please continue clamp
trial. Clamp for 8 hours, ask patient if he has urinary urge.
Once he develop bladder sensation, may move on to voiding trial.
# TRANSITIONAL ISSUES:
- recheck LFTs in 3 days. Recheck as needed
- follow up cervical lymph node biopsy pathology result
- follow up pending studies (CSF lyme Western Blot, lyme index,
VDRL, paraneoplastic panel)
- f/u testosterone level (PSA down trending)
- Continue clamp trial at rehab.
- f/u with Dr. ___ at the ___ Clinic
- f/u at ___ as scheduled |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Vasotec
Attending: ___.
Chief Complaint:
ANGINA
Major Surgical or Invasive Procedure:
Cardiac catheterization ___
History of Present Illness:
Ms. ___ is a ___ lady with a history of CAD (prior MI ___
s/p
PCI x 2), afib on xarelto, sarcoidosis (not currently on
immunosuppression), HTN, HLD and who presented to the ED with
increasing left jaw pain over the past few months.
Of note the patient has been experiencing jaw pain for some
time.
she is followed by Dr. ___ last saw her on ___.
Per review of the last office note, she has been having jaw pain
for about ___ year. She states that this jaw pain is the same jaw
pain she experienced on a recent stress test. however she has
noticed this pain more often at rest of when climbing stairs.
Per Dr. ___ jaw pain is felt to be her angina equivalent.
At that visit, Dr. ___ the possibility of repeat
cardiac cath to evaluate her coronary anatomy but the patient
opted to hold off on this.
The presents now to the ED after having an episode of jaw pain
that woke her up from sleep yesterday and resolved with
sublingual nitroglycerin. She d enies worsening of pain with
chewing. No headaches or changes in her vision, although she is
followed for uveitis iso sarcoid.
In regards to her history of CAD:
the patient initially presented to ___ in ___ with bilateral jaw and upper back discomfort
without chest pain The patient went into ventricular
fibrillation
and was shocked and place on the amiodarone briefly. The patient
underwent cardiac cath and was found 100% occluded left
circumflex in which drug-eluting stents was placed.
She then was transferred to ___ for the second stage of the
procedure where she had a Promus drug-eluting stent placed into
the proximal LAD which had a 70-80% lesion. Beyond the LAD,
there
is no significant disease.
At the time of this second procedure, the LCX stent was patent.
The right coronary artery had just mild nonobstructive disease.
She has not had a cardiac cathertization procedure since.
In the ED...
- Initial vitals:
T97.8 RR66 BP166/76 RR18 O2 99% RA
- EKG: NSR
- Labs/studies notable for:
Trop-T: <0.01 X1
BMP, CBC unremarkable.
CXR: IMPRESSION:
No acute cardiopulmonary abnormality
- Patient was given:
___ 17:01 PO Aspirin 243 mg ___
___ 18:51 PO/NG Rivaroxaban 20 mg ___
- Vitals on transfer:
T 98.3 HR67 BP136/70 RR18 o297% RA
Past Medical History:
- Hypertension
- Dyslipidemia
- CAD s/p 3 stents as above.
- GERD
- Sarcoidosis
Social History:
___
Family History:
Grandmother died of MI when she was ___, otherwise no cardiac
history.
Physical Exam:
======================
ADMISSION PHYSICAL EXAM:
======================
___ Temp: 97.6 PO BP: 158/90 L Sitting HR: 64
RR: 16 O2 sat: 95% O2 delivery: RA
GENERAL: NAD.
CARDIAC:RRR, normal S1, S2. No murmurs
LUNGS: CTAB, 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.
PULSES: Distal pulses palpable and symmetric
=======================
DISCHARGE PHYSICAL EXAM:
=======================
VITALS: ___ 1113 Temp: 97.5 PO BP: 169/87 L Sitting HR: 60
RR: 17 O2 sat: 96% O2 delivery: RA
GENERAL: NAD.
CARDIAC:RRR, normal S1, S2. No murmurs
LUNGS: CTAB, 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.
PULSES: Distal pulses palpable and symmetric
Pertinent Results:
===============
ADMISSION LABS:
===============
___ 02:00PM BLOOD WBC-6.8 RBC-3.64* Hgb-11.6 Hct-33.8*
MCV-93 MCH-31.9 MCHC-34.3 RDW-12.2 RDWSD-41.4 Plt ___
___ 02:00PM BLOOD Neuts-69.3 ___ Monos-7.8 Eos-0.1*
Baso-0.6 Im ___ AbsNeut-4.72 AbsLymp-1.49 AbsMono-0.53
AbsEos-0.01* AbsBaso-0.04
___ 02:00PM BLOOD Glucose-92 UreaN-17 Creat-0.7 Na-145
K-3.7 Cl-104 HCO3-26 AnGap-15
___ 02:00PM BLOOD cTropnT-<0.01
___ 08:00PM BLOOD cTropnT-<0.01
===============
DISCHARGE LABS:
===============
___ 08:00AM BLOOD WBC-5.0 RBC-3.50* Hgb-11.1* Hct-32.9*
MCV-94 MCH-31.7 MCHC-33.7 RDW-12.6 RDWSD-43.0 Plt ___
___ 08:00AM BLOOD ___ PTT-32.6 ___
___ 08:00AM BLOOD Glucose-113* UreaN-18 Creat-0.7 Na-143
K-4.1 Cl-104 HCO3-26 AnGap-13
___ 08:00AM BLOOD Calcium-9.2 Phos-2.6* Mg-2.1
===========
KEY STUDIES:
===========
CHEST X-RAY ___ 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.
Mild degenerative changes are noted in the thoracic spine.
IMPRESSION: No acute cardiopulmonary abnormality.
CARDIAC CATHETERIZATION (___):
Coronary Anatomy Dominance: Right
Heavily calcified coronary arteries.
* Left Main Coronary Artery: The LMCA is normal.
* Left Anterior Descending: The LAD has 30% ___ stenosis and
widely patent stent in the mid segment. The ___ Diagonal is a
large vessel jailed by the LAD stent but is widely patent.
* Circumflex: The Circumflex has widely patent stent in the
proximal segment extending into large OM1. Mid LCX is jailed by
the stent and has 70% ostial stenosis but is small and supplies
small territory.
* Right Coronary Artery: The RCA has 40% ostial stenosis and
mild luminal irregularities.
Intra-procedural Complications: None
Impressions: One vessel CAD and widely patent stents. Mid LCX is
small vessel with very small territory and unlikely to be cause
of her symptoms.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 25 mg PO DAILY
2. irbesartan 300 mg oral DAILY
3. Rivaroxaban 20 mg PO DAILY
4. Hydrochlorothiazide 12.5 mg PO DAILY
5. Atorvastatin 20 mg PO QPM
6. Nitroglycerin SL 0.4 mg SL TAKE 1 TABUNDER TONGUE Q5 MIN X 3
FOR CHEST PAIN IF NO RESOLUTION CALL ___. Fluticasone Propionate NASAL 1 SPRY NU DAILY
8. Aspirin 81 mg PO DAILY
9. calcium carbonate-vit D3-min 600 mg (1,500 mg)-200 unit oral
daily
Discharge Medications:
1. Atorvastatin 40 mg PO DAILY
RX *atorvastatin 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
2. 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:*1
3. Aspirin 81 mg PO DAILY
4. calcium carbonate-vit D3-min 600 mg (1,500 mg)-200 unit oral
daily
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY
6. Hydrochlorothiazide 12.5 mg PO DAILY
7. irbesartan 300 mg oral DAILY
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Nitroglycerin SL 0.4 mg SL TAKE 1 TABUNDER TONGUE Q5 MIN X 3
FOR CHEST PAIN IF NO RESOLUTION CALL ___. Rivaroxaban 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Angina
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 h/o MI and sarcoid presents with worsening jaw
pain//evaluate for evidence of new masses
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. Mild
degenerative changes are noted in the thoracic spine.
IMPRESSION:
No acute cardiopulmonary abnormality.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Jaw pain
Diagnosed with Unstable angina
temperature: 97.8
heartrate: 66.0
resprate: 18.0
o2sat: 99.0
sbp: 166.0
dbp: 76.0
level of pain: 5
level of acuity: 2.0 | Ms. ___ is a ___ yo lady with a history of CAD s/p PCI X2 and
___ X3 who presents with jaw pain that woke her up
from sleep and resolved with sublingual nitroglycerin. Admitted
for cardiac catheterization. Cardiac cath on ___ showed widely
patient stents with modest additional disease and no clear
culprit lesions. No interventions were made and medical therapy
was optimized.
# CORONARIES: Single vessel CAD with patent DES
# PUMP: Unkonwn
# RHYTHM: NSR , history of paroxysmal Atrial fibrillation
============== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Dicloxacillin / amoxicillin
Attending: ___.
Chief Complaint:
R Shoulder Pain, R Leg Redness
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
Mr ___ is a ___ w/hx of HTN, anxiety, pAfib, recent ED visit
for cellulitis, p/w worsening ___ cellulitis and Rt shoulder
pain.
Per pt, he recently came to ED with ___ pain/erythema, had
prior F/C. Was found to have cellulitis, started on Doxycycline
100mg BID on ___. The pain has not resolved, also with
increased warmth, ttp, swelling, erythema. Also with new onset
scaling over infected area. Pt had banged leg in door which may
have been original source for infection, area had previous
purulent drainage that has resolved.
Of note, pt recent started working at ___
___, had to restrain someone there and banged his Rt
shoulder into wall, now with worsening Rt shoulder pain,
decreased ROM.
In the ED, initial vitals: T97.1 90 153/92 18 99% RA
Labs were significant for WBC 5.8, Cr 1.0
Imaging showed: Rt ___ neg, shoulder/leg xrays neg for Fx
In the ED, he received: oxycodone 5mg x2, morphine 4mg IV x2, IV
Vanc 1g
Vitals prior to transfer: T97.5 79 131/88 16 97% RA
On admission the patient complained of worsened pain, pain
control was only minorly effective. However, on ___, the
patient was pain medication was increased and his pain was
adequately controlled.
Denies chest pain, mild dyspnea at baseline. no abd pain
n/v/d/c, dysuria, cough.
ROS: 10 point ROS otherwise neg apart from listed above
Past Medical History:
MORBID OBESITY
PAROXYSMAL ATRIAL FIBRILLATION ___ s/p cardioversion
HYPOGONADISM
? RENAL STONES ___
ABNORMAL LIVER FUNCTION TESTS (presumed fatty liver dz)
ATYPICAL CHEST PAIN
HEADACHE
POSITIVE PPD ___
VENOUS STASIS ___
LOW BACK PAIN ___
KNEE PAIN ___
ANXIETY
HYPERTENSION
Social History:
___
Family History:
+ early CAD (Father died from MI at age ___, Grandmother with
CAD)
+HTN, DM
Physical Exam:
ADMIT EXAM
============
VS: 97.7 147/71 88 18 98 RA
GEN: Alert, lying in bed, no acute distress, very pleasant
gentleman
HEENT: Moist MM, anicteric sclerae, NCAT, PERRL, EOMI
NECK: Supple without LAD, diff to assess JVP ___ obesity though
possible +JVD
PULM: CTABL no w/c/r
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-tender, non-distended, +BS, obese
EXTREM: Warm, well-perfused. ___ ___ pitting edema b/l. Rt ___
large erythema below knee to heel, +scaling, +non-draining
lesion on Rt mid calf. ttp b/l ___. no clear area of fluctuance.
2+ DPP b/l.
Rt shoulder with +speed test/painful arc test, decreased ROM
NEURO: CN II-XII grossly intact, motor function grossly normal,
sensation grossly intact
DISCHARGE EXAM
================
97.7 ___ 84 20 97 RA
GEN: Alert, lying in bed, no acute distress, very pleasant
gentleman
HEENT: Moist MM, anicteric sclerae, NCAT, PERRL, EOMI
NECK: Supple without LAD, diff to assess JVP ___ obesity though
possible +JVD
PULM: CTAB
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-tender, non-distended, +BS, obese
EXTREM: Warm, well-perfused. ___ ___ pitting edema b/l. Rt ___
large erythema below knee to heel, +scaling, +non-draining
lesion on Rt mid calf. non-tender to palpation. no clear area of
fluctuance. 2+ DPP b/l.
Right shoulder w/difficulty in painful arc test, able to pass 90
degrees with pain. Patient is able to extend his arm forward,
empty can test positive.
Pertinent Results:
ADMIT LABS
=========
___ 04:30AM BLOOD WBC-5.8 RBC-4.50* Hgb-13.2* Hct-41.0
MCV-91 MCH-29.3 MCHC-32.2 RDW-14.3 RDWSD-47.8* Plt ___
___ 04:30AM BLOOD Neuts-67.0 ___ Monos-8.8 Eos-2.3
Baso-0.5 Im ___ AbsNeut-3.87 AbsLymp-1.18* AbsMono-0.51
AbsEos-0.13 AbsBaso-0.03
___ 04:30AM BLOOD Glucose-105* UreaN-14 Creat-1.0 Na-140
K-3.6 Cl-100 HCO3-28 AnGap-16
___ 05:30AM BLOOD Calcium-9.1 Phos-3.7 Mg-2.1
___ 03:23PM BLOOD Vanco-12.3
___ 05:45AM BLOOD Lactate-1.0
IMAGING
======
TIB/FIB (AP & LAT) RIGHTStudy Date of ___
No fracture.
GLENO-HUMERAL SHOULDER (W/ Y VIEW) RIGHTStudy Date of
___
No fracture dislocation is identified.
UNILAT LOWER EXT VEINS RIGHTStudy Date of ___
No evidence of deep venous thrombosis in the right lower
extremity veins.
US EXTREMITY LIMITED SOFT TISSUE RIGHTStudy Date of ___
Subcutaneous edema with no organized fluid collection identified
in the right calf.
MICRO
=====
___ blood cultures pending
DISCHARGE LABS
===============
___ 05:45AM BLOOD WBC-3.7* RBC-4.12* Hgb-12.4* Hct-37.6*
MCV-91 MCH-30.1 MCHC-33.0 RDW-14.0 RDWSD-47.1* Plt ___
___ 05:45AM BLOOD Glucose-76 UreaN-14 Creat-0.9 Na-138
K-4.0 Cl-100 HCO3-28 AnGap-14
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Testosterone Cypionate 2.5 g TD AS DIRECTED
2. ClonazePAM ___ mg PO QHS:PRN panic attack
3. tadalafil 10 mg oral ASDIR
4. Chlorthalidone 25 mg PO DAILY
5. Doxycycline Hyclate 100 mg PO Q12H
6. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours Disp
#*30 Tablet Refills:*0
2. Clindamycin 300 mg PO Q6H
RX *clindamycin HCl 300 mg 1 capsule(s) by mouth every 6 hours
Disp #*27 Capsule Refills:*0
3. Torsemide 20 mg PO DAILY
RX *torsemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Aspirin 81 mg PO DAILY
5. Chlorthalidone 25 mg PO DAILY
6. ClonazePAM ___ mg PO QHS:PRN panic attack
7. tadalafil 10 mg oral ASDIR
8. Testosterone Cypionate 2.5 g TD AS DIRECTED
9.Outpatient Physical Therapy
Shoulder tendinitis
ICD-9 726.10
Physical therapy ongoing
Discharge Disposition:
Home
Discharge Diagnosis:
Right Lower Extremity Cellulitis
Venous Stasis
Right Shoulder tendonitis
Secondary:
============
HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: GLENO-HUMERAL SHOULDER (W/ Y VIEW) RIGHT
INDICATION: History: ___ with right shoulder pain after hitting a hard
object. // To evaluate for fracture or dislocation
TECHNIQUE: AP in internal rotation, Grashey in external rotation, and
axillary view radiographs of right shoulder
COMPARISON: Chest radiograph ___
FINDINGS:
There is no fracture or dislocation involving the glenohumeral or AC joint.
No suspicious lytic or sclerotic lesion is identified. No periarticular
calcification or radio-opaque foreign body is seen.
IMPRESSION:
No fracture dislocation is identified.
Radiology Report
EXAMINATION: TIB/FIB (AP AND LAT) RIGHT
INDICATION: History: ___ with right lower leg swelling, erythema, pain //
evaluate for free air or osteomyelitis evaluate for free air or
osteomyelitis
TECHNIQUE: Frontal and lateral view radiographs of right tibia and fibula
COMPARISON: Left knee radiograph ___
FINDINGS:
No fracture is detected in the tibia or fibula. No suspicious lytic lesion,
sclerotic lesion, or periosteal new bone formation is detected. No soft tissue
calcification or radio-opaque foreign body is detected. Limited assessment of
the knee and ankle joint is unremarkable.
IMPRESSION:
No fracture.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS RIGHT
INDICATION: ___ year old man with RLE swelling and pain // evaluate for DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the right lower extremity veins.
COMPARISON: Right lower extremity vein ultrasound ___
FINDINGS:
There is normal compressibility, flow, and augmentation of the right 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 lower extremity veins.
Radiology Report
EXAMINATION: US EXTREMITY LIMITED SOFT TISSUE RIGHT
INDICATION: ___ year old man with RLE cellulitis. Please assess for
abscess/fluid collection. // r/o purulent cellulitis
TECHNIQUE: Grayscale and color Doppler ultrasound images were obtained of the
superficial tissues of the right calf in the area of swelling
COMPARISON: None
FINDINGS:
Transverse and sagittal images were obtained of the superficial tissues of the
right calf where an area of swelling and skin discoloration is seen. There is
subcutaneous edema and subcutaneous superficial vessels showing color flow.
No organized fluid collection is identified.
IMPRESSION:
Subcutaneous edema with no organized fluid collection identified in the right
calf.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: R Shoulder pain, R Leg Redness
Diagnosed with Cellulitis of right lower limb
temperature: 97.1
heartrate: 90.0
resprate: 18.0
o2sat: 99.0
sbp: 153.0
dbp: 92.0
level of pain: 9
level of acuity: 3.0 | Mr. ___ is a ___ w/hx of HTN, anxiety, pAfib, recent
ED visit for cellulitis, p/w worsening cellulitis on ___. He
was trialed on doxycycline with no effect and was subsequently
transitioned to IV vancomycin with good effect and transitioned
to oral clindamycin with improvement of cellulitis.
# Right lower extremity Cellulitis
Patient presented with cellulitis after failed outpatient
doxycycline treatment. He was transitioned to IV vancomycin with
improvement and subsequently transitioned to PO clindamycin
prior to discharge. Patient was discharged with 300 mg Q6 hours
to continue to complete total 10 day course to be completed on
___.
# Bilateral leg edema
Patient was initially diuresed with IV Lasix and transitioned to
torsemide 20 mg daily prior to discharge. Outpatient
echocardiogram should be obtained to evaluate ejection fraction.
Electrolytes and renal function should also be checked at time
of follow up.
# Right shoulder tendinitis
Patient's right shoulder pain thought to be most consistent with
tendinitis. X-ray of the shoulder did not show any acute
abnormality. Should pain not resolve further imaging including
MRI could be considered. Conservative management with Tylenol
and outpatient physical therapy were recommended.
CHRONIC ISSUES
==============
# Anxiety: continued klonopin prn
# HTN: continued chlorthalidone
# pAF: continued 81 mg aspirin daily
TRANSITIONAL ISSUES
=============
-Pt started on 300 mg Q6 hours for doxycycline resistant
cellulitis to continue until ___
-Would recommend repeat outpatient TTE to ensure no early onset
CHF
-please check chem-10 at time of follow up on ___ to ensure
electrolytes and renal function are normal
-Torsemide 20 mg daily started this hospitalization
-follow up shoulder pain and consider further imaging of such as
MRI if not improving
# CODE STATUS: Full (confirmed)
# CONTACT: ___
___ number: ___
Date on form: ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
None Performed
History of Present Illness:
___ male past medical history significant for 2
packs/day
smoking, NIDDM, hypertension, A. fib on Coumadin, COPD
presenting
to the emergency department with shortness of breath.
Patient states that he was in his USH until approx. 1 week ago
when he started having worsening SOBOE. His sx progressed over
the next several day to the point where he was symptomatic even
with minimal activity. Also has more difficulty breathing at
night. Endorses associated productive cough. Notes that he has
always had minimal cough in the morning which he has been
attributing to his smoking hx. However, sx over the last several
days were markedly more severe.
No CP / palpitations / lightheadedness / syncope. No n/v.
No f/c or other infectious s/s.
Patient was seen at outside hospital where he received nebs with
improvement in his sx. Of note, he also had two 9 second pauses
of non-conducting AF on tele.
Patient has not had a diagnosis of heart failure in the past. No
cardiac hx other than chronic AF on Coumadin and atenolol.
In the ED:
- Vitals: af, P 78-92, BP 143/72 - 163/83, 99% 2L NC -> 95% RA
- Crackles at bilateral lung bases, no peripheral edema
- EKG w/ AF, 90BPM, bifascicular block (unchanged from prior)
- WBC 10.3, plt / hgb nl, inr 3.4, Cr 1.1, LFTs nl, trop neg x1
- CXR: ill-defined parenchymal opacity with air bronchograms,
predominating in the right lower lobe, suggestive of PNA; no
cardiomegaly / pulmonary edema / pleural effusion
- bedside TTE w/ diminished EF
- Pt was given: Lasix 40 IV x1, azithro 500 mg, prednisone 50
mg,
nebs
On the floor, the patient states that his breathing has
significantly improved since getting the medications in the ED.
10 point ROS performed and otherwise negative.
Past Medical History:
atrial fibrillation on coumadin
mild COPD (never hospitilized, very rare exacerbations)
Multiple left knee arthroscopies and left TKR
Multiple right ankle surgeries and right ankle fusion
Eczema
Hypertension
Hyperlipidemia
DM II
Prostate hypertrophy, prostate biopsy in ___ showed prostate
adenocarcinoma in 1 biopsy with ___ score of 7, follows with
urology and has declined surgery.
Social History:
___
Family History:
Father died of colon cancer in ___, mother died of MI and DM in
___, sisters with DM, brother died of stroke. Denies FH of
other cancers or rheumatologic disease.
Physical Exam:
ADMISSION EXAM:
================
VS: 98.6 PO 146 / 71 L ___ room air
GENERAL: Well developed, well nourished male 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: JVP of 10 cm.
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: Normal effort. Crackles at both bases R>L, also with
rhonchi at R base. No wheezing.
ABDOMEN: Distended, but soft, non-tender. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. 1+ peripheral edema R>L
(asymmetry per pt at baseline).
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE EXAM:
===============
___ 0728 Temp: 97.6 PO BP: 125/69 L Lying HR: 76 RR: 18 O2
sat: 95% O2 delivery: RA FSBG: 129
General appearance: NAD, conversant
Neck: FROM, supple
Lungs: Clear to auscultation
CV: Irregular, SM LUSB; normal carotid upstroke and amplitude
without bruits. His JVD is elevated
Abdomen: Soft, non-tender; no masses or HSM
Extremities: 1+ edema or digital cyanosis
Skin: no rash, lesions or ulcers
Psych: Alert and oriented to person, place and time
Pertinent Results:
ADMISSION LABS:
===============
___ 08:43AM BLOOD WBC-10.3* RBC-3.32* Hgb-9.4* Hct-32.5*
MCV-98 MCH-28.3 MCHC-28.9* RDW-20.5* RDWSD-71.9* Plt ___
___ 08:43AM BLOOD Neuts-69.9 Lymphs-17.5* Monos-10.9
Eos-0.5* Baso-0.5 Im ___ AbsNeut-7.17* AbsLymp-1.79
AbsMono-1.12* AbsEos-0.05 AbsBaso-0.05
___ 08:43AM BLOOD Plt ___
___ 03:10PM BLOOD ___ PTT-41.0* ___
___ 08:43AM BLOOD Glucose-111* UreaN-23* Creat-1.1 Na-144
K-4.7 Cl-108 HCO3-19* AnGap-17
___ 03:10PM BLOOD ALT-6 AST-25 LD(LDH)-199 AlkPhos-57
TotBili-1.1
___ 08:43AM BLOOD cTropnT-<0.01
___ 03:10PM BLOOD cTropnT-<0.01 proBNP-3741*
___ 08:43AM BLOOD Calcium-9.2 Phos-2.9 Mg-1.7
DISCHARGE LABS:
===============
___ 07:01AM BLOOD WBC-7.7 RBC-3.08* Hgb-8.7* Hct-29.4*
MCV-96 MCH-28.2 MCHC-29.6* RDW-20.7* RDWSD-71.4* Plt ___
___ 07:01AM BLOOD Plt ___
___ 07:01AM BLOOD ___ PTT-36.1 ___
___ 07:01AM BLOOD Glucose-139* UreaN-29* Creat-1.0 Na-141
K-3.9 Cl-105 HCO3-23 AnGap-13
___ 07:01AM BLOOD Calcium-8.9 Phos-3.5 Mg-2.0
___ 06:30AM BLOOD calTIBC-365 Ferritn-76 TRF-281
IMAGING/STUDIES:
=================
___ CXR
IMPRESSION:
Comparison to ___. The patient shows a relatively large
ill-defined parenchymal opacity with air bronchograms,
predominating in the right lower lobe. In the appropriate
clinical setting the findings are highly suggestive of a right
lower lobe pneumonia. Mild cardiomegaly. No pulmonary edema.
No pleural effusions.
___ TTE
CONCLUSION:
The left atrial volume index is SEVERELY increased. No
thrombus/mass is seen in the body of the left atrium (best
excluded by TEE). The right atrium is markedly enlarged. There
is no evidence for an atrial septal defect by 2D/color Doppler.
The estimated right atrial pressure is ___ mmHg. There is mild
symmetric left ventricular hypertrophy with a mildly
increased/dilated cavity. There is mild regional left
ventricular systolic dysfunction with focal basal inferior
hypokinesis (see schematic) and preserved/normal contractility
of the remaining segments. There is beat-to-beat variability in
the left ventricular contractility due to the irregular rhythm.
Quantitative biplane left ventricular ejection fraction is 47 %
(normal 54-73%). There is no resting left ventricular outflow
tract gradient. Mildly dilated right ventricular cavity with
normal free wall motion. The aortic sinus diameter is normal for
gender with normal ascending aorta diameter for gender. There is
a normal descending aorta diameter. The aortic valve leaflets
(3) are moderately thickened. There is mild aortic valve
stenosis (valve area 1.5-1.9 cm2). There is mild [1+] aortic
regurgitation. The mitral valve leaflets are mildly thickened
with no mitral valve prolapse. There is mild [1+] mitral
regurgitation. The pulmonic valve leaflets are normal. The
tricuspid valve leaflets appear structurally normal. There is
mild to moderate [___] tricuspid regurgitation. The estimated
pulmonary artery systolic pressure is high normal. There is no
pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
mild regional systolic dysfunction most consistent with single
vessel coronary artery disease (PDA distribution). Mild aortic
valve stenosis with moderately thickened leaflets and mild
aortic regurgitation. Mild-moderate mitral
regurgitation with normal valve morphology. Mild-moderate
tricuspid regurgitation. Biatrial enlargement.
MICROBIOLOGY:
===============
___ 12:11 pm SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
<10 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.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ferrous Sulfate (Liquid) 325 mg PO TID
2. MetFORMIN XR (Glucophage XR) 500 mg PO BID
3. GlipiZIDE XL 2.5 mg PO BID
4. SITagliptin-metformin 50-500 mg oral BID
5. Fenofibrate 200 mg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Warfarin 7.5 mg PO 4X/WEEK (___)
8. Pravastatin 40 mg PO QPM
9. Tamsulosin 0.4 mg PO QHS
10. Finasteride 5 mg PO DAILY
11. Lisinopril 10 mg PO DAILY
12. Atenolol 100 mg PO DAILY
13. Warfarin 5 mg PO 3X/WEEK (___)
Discharge Medications:
1. Cefpodoxime Proxetil 400 mg PO BID Duration: 3 Days
RX *cefpodoxime 200 mg 2 tablet(s) by mouth twice a day Disp
#*10 Tablet Refills:*0
2. Doxycycline Hyclate 100 mg PO BID Duration: 4 Days
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth twice a day
Disp #*5 Tablet Refills:*0
3. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
4. Nicotine Patch 21 mg/day TD DAILY
RX *nicotine 21 mg/24 hour apply 1 patch to skin once a day Disp
#*28 Patch Refills:*0
5. Spironolactone 25 mg PO 3X/WEEK (___)
RX *spironolactone 25 mg 1 tablet(s) by mouth three times a week
on ___ Disp #*15 Tablet Refills:*0
6. Torsemide 20 mg PO DAILY
RX *torsemide 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
7. Warfarin 5 mg PO DAILY16
8. Fenofibrate 200 mg PO DAILY
9. Ferrous Sulfate (Liquid) 325 mg PO TID
10. Finasteride 5 mg PO DAILY
11. FoLIC Acid 1 mg PO DAILY
12. GlipiZIDE XL 2.5 mg PO BID
13. Lisinopril 10 mg PO DAILY
14. MetFORMIN XR (Glucophage XR) 500 mg PO BID
15. Pravastatin 40 mg PO QPM
16. SITagliptin-metformin 50-500 mg oral BID
17. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
==================
Community Acquired Pneumonia
Atrial Fibrillation
Acute Diastolic Heart Failure
Bifascicular block
Secondary Diagnosis:
====================
Hypertension
Hyperlipidemia
Type 2 Diabetes
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// ?pna, chf ?pna, chf
IMPRESSION:
Comparison to ___. The patient shows a relatively large ill-defined
parenchymal opacity with air bronchograms, predominating in the right lower
lobe. In the appropriate clinical setting the findings are highly suggestive
of a right lower lobe pneumonia. Mild cardiomegaly. No pulmonary edema. No
pleural effusions.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, Transfer
Diagnosed with Heart failure, unspecified
temperature: 97.0
heartrate: 80.0
resprate: 20.0
o2sat: 95.0
sbp: 158.0
dbp: 92.0
level of pain: 0
level of acuity: 2.0 | Brief Summary for Admission:
============================
___ male past medical history significant for active
tobacco use, NIDDM, hypertension, A. fib on Coumadin, COPD who
presented with shortness of breath, found to have PNA and heart
failure. |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ANESTHESIOLOGY
Allergies:
Percocet / atorvastatin / rosuvastatin
Attending: ___
Chief Complaint:
Unresponsiveness, right-sided weakness
Major Surgical or Invasive Procedure:
___ ___ lumbar puncture
History of Present Illness:
EU Critical ___ is an ___ year old woman with
unknown handedness with past medical history notable for
hypertension, hyperlipidemia, who presents as a transfer from
outside hospital for unresponsiveness and possible right-sided
weakness.
History is obtained from the transfer summary as well as the
family at bedside. According to the family, she had been
entirely normal from the evening of the ___ into the night,
when she was out with her friends, watching a movie in the city,
sleeping over at their house. The last time she was seen
totally
normal was by staff at the residence, more than 24 hours ago.
She was found down on the ground of her independent living
facility this morning, which led to her being transferred to an
outside hospital. There, she was initially afebrile but the
inability to protect her airway led to her being intubated.
Notably, she reportedly had left upper extremity jerking, with
unclear eye deviation or other features indicative of seizures.
She was found to have a white count of 13.7, and normal urine
tox
screen and UA, elevated lactate to 3, elevated CK to 1100, and
elevated troponin without known EKG changes. CTA head and neck
were unremarkable, without evidence of acute intracranial
process.
In the emergency department here, she was noted to have a
low-grade temperature to 100.8. She had been started on
vancomycin and ceftriaxone. At neurology request, she was
started as well on acyclovir and ampicillin. Midazolam was
switched to propofol infusion. An LP was performed in the ED,
which was not successful due to significant skeletal issues.
Past Medical History:
Hypertension
Hyperlipidemia
CAD
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: Intubated and sedated. No spontaneous eye opening to
voice. No spontaneous movement, but does localize to noxious.
No verbal commands.
HEENT: NCAT, no oropharyngeal lesions, neck supple without
evidence of meningismus
___: RRR, no M/R/G
Pulmonary: Intubated, initiating spontaneous breaths
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Eyes closed, grimaces to deep sternal rub. She
does not follow commands.
- Cranial Nerves: PERRL 2-1.5 mm bilaterally. Corneals brisk on
the left versus the right. She does have intact
vestibulo-ocular
reflex. She has an intact cough and gag.
- Sensorimotor:
To deep nailbed noxious, she briskly localizes with the left
upper extremity. Right upper extremity weakly withdraws in the
plane of the bed. Left lower extremity withdraws somewhat
antigravity with nailbed pressure. Right lower extremity
withdraws minimally in the plane of the bed.
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 2+ 2+ 2+ 2+ 1
R 2+ 2+ 2+ 2+ 1
Plantar response flexor bilaterally, no clonus
DISCHARGE PHYSICAL EXAM:
General: sitting up in bed with glasses on doing a crossword
puzzle
HEENT: NC/NT
Neck: supple
CV: RRR
Lungs: CTA
Abdomen: soft, NT, ND
Ext: No cyanosis, clubbing or edema bilaterally
Skin: no rashes or lesions noted.
Neuro:
MS- Awake, alert, interactive, oriented to person, place and
time, attentive to MOYF and backwards. Speech fluent,
comprehension intact.
CN- R pupil 3->2, L pupil 3->2, subtle L NLFF with symmetric
activation, tongue midline.
Motor- no drift in BUE, no asterixis. Arms and legs spontaneous
and antigravity.
Coordination intact.
Pertinent Results:
ADMISSION LABS:
___ 05:15PM BLOOD WBC-12.4* RBC-4.84 Hgb-14.2 Hct-41.9
MCV-87 MCH-29.3 MCHC-33.9 RDW-12.8 RDWSD-40.1 Plt ___
___ 05:15PM BLOOD Neuts-74.3* Lymphs-13.8* Monos-11.5
Eos-0.0* Baso-0.1 Im ___ AbsNeut-9.23* AbsLymp-1.71
AbsMono-1.43* AbsEos-0.00* AbsBaso-0.01
___ 05:15PM BLOOD ___ PTT-22.5* ___
___ 05:15PM BLOOD Glucose-105* UreaN-24* Creat-0.7 Na-137
K-3.3* Cl-102 HCO3-23 AnGap-12
___ 08:32AM BLOOD ALT-20 AST-44* LD(LDH)-356* CK(CPK)-1297*
AlkPhos-82 TotBili-0.3
___ 01:35AM BLOOD CK-MB-15* MB Indx-0.8 cTropnT-<0.01
___ 05:15PM BLOOD Calcium-8.3* Phos-2.3* Mg-1.8
___ 12:11AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
LP:
Tube 1: 5 wbc, 90 rbcs (86% lymphs)
Tube 4: 3 wbc, 423 rbcs (92% lymphs)
Protein 102, Glucose 62
CSF HSV PCR NEGATIVE
___ 1:09 pm CSF;SPINAL FLUID Source: LP.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Preliminary): NO GROWTH.
IMAGING:
___ 1:14 ___ LUMBAR PUNCTURE (W/ FLUORO)
1. Lumbar puncture at L3-4 without complication.
___ 12:53 AM MR HEAD W/O CONTRAST
1. Moderately motion degraded noncontrast examination.
2. Mild, equivocal restricted diffusion within the left greater
right occipital lobes involving the cortex. If non-artifactual
in nature, these nonspecific findings can be seen in the setting
of ischemia, PRES, hypoglycemia, or CJD. Further evaluation by
follow-up contrast enhanced MRI could be considered if
clinically
indicated.
3. Otherwise no additional candidate sites for infarction. No
acute intracranial hemorrhage.
4. Background global parenchymal volume loss and evidence of
chronic small vessel ischemic disease.
EEG ___:
This telemetry captured no pushbutton activations. It showed a
moderately low voltage slow background throughout, with
occasional bursts of generalized slowing, all indicative of a
widespread encephalopathy. This finding is nonspecific with
regard to etiology but can be seen in the setting of
toxic/metabolic derangement, anoxia, or medication effect. The
low-voltage background over the left hemisphere suggests the
possibility of additional cortical dysfunction on that side.
There were no definite epileptiform features and no
electrographic seizures.
CT HEAD ___:
No acute intracranial hemorrhage. Nonspecific white matter
hypodensity along the right frontal and parietal regions, may
relate to chronic small vessel ischemic disease, but findings
are nonspecific. MRI would further assess.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 162 mg PO DAILY
2. Atenolol 50 mg PO DAILY
3. amLODIPine 5 mg PO BID
4. Doxazosin 2 mg PO HS
5. Isordil (isosorbide dinitrate) 20 mg oral DAILY
6. Losartan Potassium 100 mg PO DAILY
7. Pravastatin 20 mg PO QPM
8. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. LevETIRAcetam 500 mg PO Q12H
2. amLODIPine 5 mg PO BID
3. Aspirin 162 mg PO DAILY
4. Atenolol 50 mg PO DAILY
5. Doxazosin 2 mg PO HS
6. Isordil (isosorbide dinitrate) 20 mg oral DAILY
7. Losartan Potassium 100 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Pravastatin 20 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Seizure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with ?stroke vs seizure. Evaluation for interval
change.
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, 18.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
903.1 mGy-cm.
Total DLP (Head) = 903 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of acute intracranial hemorrhage, midline shift, or mass
effect. The ventricles and sulci are normal in size and configuration.
Periventricular and subcortical hypodensities are nonspecific, and likely
reflect sequela of chronic small vessel ischemic disease. The white-matter
hypodensities more prominent on the right than the left, which could relate to
chronic small vessel disease, but is nonspecific and could be further assessed
on MRI.
There is no evidence of acute fracture. There is mild mucosal thickening of
the ethmoid air cells. Minimal fluid layering dependently within the left
maxillary sinus. The visualized portion of the remaining paranasal sinuses,
mastoid air cells, and middle ear cavities are clear. Endotracheal tube is
noted in place.
IMPRESSION:
No acute intracranial hemorrhage. Nonspecific white matter hypodensity along
the right frontal and parietal regions, may relate to chronic small vessel
ischemic disease, but findings are nonspecific. MRI would further assess.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with fever and right hemiparesis// ETT tube
placement
COMPARISON: None
FINDINGS:
Portable AP view of the chest provided.
Endotracheal tube terminates 2.5 cm above the level of carina. Enteric tube
passes into the expected location stomach beyond the field of view of the
image. There is no focal consolidation. No pleural effusion or pneumothorax.
Cardiomediastinal silhouette is within normal limits.
IMPRESSION:
Endotracheal tube is appropriately positioned.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD.
INDICATION: ___ year old woman with suspected meningoencephalitis// etiology
of encephalopathy.
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON CT head ___.
FINDINGS:
The examination is moderately motion degraded, allowing for this:
Subtle areas of cortically based restricted diffusion are seen within the left
greater than right occipital lobes (for example 4:12, 3:12). Minimal FLAIR
related hyperintensity is seen in these regions.
There is no additional site of restricted diffusion. No acute intracranial
hemorrhage. Ventricles and sulci are diffusely prominent compatible with
global parenchymal volume loss.
Periventricular and subcortical white matter FLAIR hyperintensities are noted,
a nonspecific finding that most likely represents the sequelae of chronic
small vessel ischemic disease. There is gross preservation of the principal
intracranial vascular flow voids.
The visualized paranasal sinuses, middle ear cavities, and mastoid air cells
are well aerated and clear. The orbits are within normal limits bilaterally.
IMPRESSION:
1. Moderately motion degraded noncontrast examination.
2. Mild, equivocal restricted diffusion within the left greater right
occipital lobes involving the cortex. If non-artifactual in nature, these
nonspecific findings can be seen in the setting of ischemia, PRES,
hypoglycemia, or CJD. Further evaluation by follow-up contrast enhanced MRI
could be considered if clinically indicated.
3. Otherwise no additional candidate sites for infarction. No acute
intracranial hemorrhage.
4. Background global parenchymal volume loss and evidence of chronic small
vessel ischemic disease.
Radiology Report
EXAMINATION: LUMBAR PUNCTURE (W/ FLUORO) N8 RF SPINE
INDICATION: ___ year old woman with left upper extremity shaking and right
sided hemiparesis// meningitis/encephalitis
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, 6 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.
COMPARISON: None.
FINDINGS:
16 mls of CSF were collected in 4 tubes.
IMPRESSION:
1. Lumbar puncture at L3-4 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.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old woman with AMS, found unresponsive, low grade temp on
admission, elevated protein in CSF pending culture data, concern for viral
meningitis vs. seizure// ___ year old woman with AMS, found unresponsive, low
grade temp on admission, elevated protein in CSF pending culture data, concern
for viral meningitis vs. seizure
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of intravenous contrast, axial imaging was performed with
gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was
performed and re-formatted in axial and coronal orientations.
COMPARISON: MRI brain ___
FINDINGS:
Patient motion slightly limits evaluation.
5-6 mm nodular enhancement in the right internal auditory canal (series 15,
image 59) is felt to most likely represent a vestibular schwannoma.
Otherwise, no other regions of abnormal enhancement is identified. A single
punctate focus of diffusion-weighted hyperintense signal of the left superior
parietal lobule (series 6, image 26) is felt to be artifactual as there is no
associated FLAIR or T2 signal abnormality. No evidence for acute infarct. No
intracranial hemorrhage. There are periventricular and subcortical T2/FLAIR
white matter hyperintensities, which are nonspecific, but commonly seen in
setting chronic microangiopathy in a patient of this age. The major
intracranial flow voids are preserved. The dural venous sinuses are patent.
There is mild mucosal thickening of the paranasal sinuses. The orbits are
unremarkable, noting bilateral lens replacements. Mild fluid signal is seen
in the mastoid air cells.
IMPRESSION:
1. 5-6 mm nodular enhancement in the right internal auditory canal is felt to
be most likely a vestibular schwannoma. No other abnormal enhancement.
2. Single punctate focus of left superior parietal lobule diffusion-weighted
hyperintense signal without correlated of abnormality on FLAIR or T2 sequence,
felt to be artifactual. There is no evidence for acute infarct or other
diffusion weighted signal abnormality.
3. Additional findings as described above.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Unresponsive, Transfer
Diagnosed with Altered mental status, unspecified
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | Ms. ___ is an ___ right-handed woman with
history notable for HTN, HLD, CAD, and lumbar stenosis s/p
fusion transferred from OSH after presenting with
unresponsiveness and right-sided weakness. In light of her prior
lumbar orthopedic procedures, Ms. ___ underwent lumbar
puncture under fluoroscopy following admission to the
Neurosciences ICU, which was notable for elevated protein (102),
normal glucose, and slight elevation of CSF WBC count (5) with
lymphocytic predominance. Accordingly, suspicion for a bacterial
meningoencephalitis was reduced, and empiric antibiotics were
discontinued. Acyclovir was later discontinued with negative CSF
HSV PCR. Following extubation, Ms. ___ mental status
continued to improve, demonstrating reasonably intact
registration and recall despite residual inattention and
disorientation, reducing suspicion for an autoimmune or
paraneoplastic encephalitis; in the absence of significant
exposures, testing for arthropod-borne encephalitides was also
deferred. MRI with and without contrast was reassuringly
unremarkable and did not show any contrast enhancement.
Overall, Ms. ___ reported prodrome of subtle cognitive
disturbance the day prior to admission, as well as episode of
unresponsiveness followed by encephalopathy and temporary
right-sided weakness, were suggestive of a seizure of left
hemispheric onset as the precipitant of her current
presentation. Notably, however, EEG monitoring over ___s MRI with and without contrast did not reveal a culpable
focal lesion. Etiology of the seizure likely secondary to small
vessel ischemic changes noted on MRI. Keppra 500mg BID was
started as seizure prophylaxis, which she should continue for
now. She should follow-up with neurology for continued
management. She will be discharged to acute rehab.
Transitional issues:
-Continue Keppra 500mg BID
-Driving restrictions x 6 months |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Motor Vehicle Crash.
Major Surgical or Invasive Procedure:
___ - C3-7 posterior fusion; C3-6 decompression.
History of Present Illness:
___ ___ only unrestrained MVC, unknown LOC,
initial loss of motor/sensory below T10, possible central cord
syndrome. He presented to ___ ED with b/l ___ paraparesis and
absent sensation below the umbilicus with diminished rectal tone
on admission. ___ showed L parieto-occipital lenticular
homogenously hyperdense mass that appears extra-axial. CT CSpine
at this time was notable for C6 L transverse process, and C5
spinous process fracture with extension into the spinal canal.
NSGY recommended code cord.
Pt complained only of neck pain but no pain elsewhere. He said
he was having trouble moving all parts of his body but that he
thinks his sense of touch had improved.
Other injuries include C5 spinous process frx, C6 transverse
process frx, R acetabular frx, hemangioma/meningioma.
Past Medical History:
PMH: None.
PSH: None.
Social History:
___
Family History:
N/A
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
General: incoherent even in Portugese, responds to questioning
but
very tangential
Neuro: EOMI, pupils 4->3 ___, AAOx1, ___ biceps, ___ triceps ___,
no hand grip bilaterally, dull sensation in ___ UE, reports no
sensation in ___ ___, moving RLE very little, cannot hold ___ up
against gravity. Pt is ___ strength in ___ ___. Is not
hyperreflexive. Reports tenderness over sacrum. Some loss of
tone
on DRE.
CV: RRR
PULM: CTAB
ABD: soft, NT/ND
EXT: no c/c/e
PHYSICAL EXAMINATION ON DISCHARGE:
___. Examined with translator.
Alert and oriented x3.
Delt Bi Tri Grip IP Quad Ham AT ___ ___
R 4+ 5- 3 o 4 5 5 5 5 5
L 5 5- 3 2 4 5 5 5 5 5
Incision is clean, dry and intact and well-healed.
Pertinent Results:
___ - CT Cervical Spine:
Fractures involving the anterior and posterior tubercle of the
left transverse process at C6 as well as the spinous process of
C5 with extension into the spinal canal. No evidence of
traumatic malalignment. Consider MRI for further evaluation of
possible spinal cord injury.
___ - CT Head:
3.9 cm high-density lesion centered in the left
parieto-occipital extra-axial space is suggestive of a
meningioma. Recommend serial neurologic exam this as well as MRI
of for further characterization of this lesion if clinically
indicated. Short interval CT of the head could also be obtained
for continued evaluation.
Extensive sinus disease as described above.
___ - CT Chest:
1. An exostosis arises from the right iliac bone just superior
to the
acetabulum which appears fractured at its base. Bilateral pars
defects at L5.
2. No free air or free fluid in the abdomen or pelvis. No
evidence of solid organ injury.
___ - MRI Cervical/Thoracic Spine:
Fracture of C5 lamina with adjacent focal ligamentum flava
disruption and cord edema. No evidence of intraspinal hematoma.
Small prevertebral hematoma and posterior soft tissue increase
signal secondary secondary to injury. Multilevel degenerative
changes in the cervical thoracic and lumbar region. Bilateral
severe foraminal narrowing at L5-S1 level with bilateral
spondylolysis of L5 and mild spondylolisthesis of L5 over S1.
___ - MRI/A Brain:
Left parietotemporal extra-axial mass consistent with meningioma
with mild surrounding underlying edema. No midline shift or
hydrocephalus. No acute infarcts. Chronic sinus changes
including suspicion of a polyp in the left maxillary sinus.
Clinical correlation recommended. No significant abnormalities
are seen on MRA of the head.
___ - LENIs:
No evidence of deep venous thrombosis in the bilateral lower
extremity veins.
HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) LEFT Study Date of
___ 11:30 AM
No acute fractures or dislocations are seen. The left hip
demonstrates mild joint space narrowing and prominent
superolateral osteophytic spurring. There are mild degenerative
changes of the inferior sacroiliac joints, left greater than
right.Arising from the right iliac bone just above the hip
joint, there is a linear ossification which has a fracture near
its base. Findings are most compatible with heterotopic
ossification related to prior trauma. Similarly, there are
calcifications adjacent to the right pubic symphysis, unchanged
since the prior CT scan.
BILAT LOWER EXT VEINS Study Date of ___ 9:07 AM
1. No evidence of deep venous thrombosis in the either leg.
2. Rouleaux formation seen bilaterally in the femoral and
popliteal veins
indicating slow velocity flow.
Shoulder X-Ray: ___
No fracture. Probable degenerative changes AC joint.
Medications on Admission:
None.
Discharge Medications:
1. Senna 8.6 mg PO BID:PRN constipation
2. Polyethylene Glycol 17 g PO DAILY:PRN constipation
3. Milk of Magnesia 30 mL PO Q6H:PRN constipation
4. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 10 Days
5. Heparin 5000 UNIT SC TID
6. Baclofen 10 mg PO TID
7. Midodrine 10 mg PO TID
8. Famotidine 20 mg PO BID
9. Docusate Sodium 100 mg PO BID
10. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
11. Acetaminophen 325-650 mg PO Q6H:PRN pain
Do not exceed greater than 4g Acetaminophen in a 24-hour period.
12. Artificial Tears ___ DROP BOTH EYES Q8H:PRN dryness
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Central Cord Syndrome.
C5 lamina fracture.
Ligamentous disruption.
Phimosis.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ unrestrained MVC*** WARNING *** Multiple patients
with same last name! // eval for acute traumatic injury
TECHNIQUE: Single AP view of the chest
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.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ unrestrained MVC, hypotensive, no motor or sensory in ___ ___.
*** WARNING *** Multiple patients with same last name! // eval of acute
traumatic injuries
TECHNIQUE: Contiguous axial images images of the brain were obtained without
contrast. Coronal and sagittal as well as thin bone-algorithm reconstructed
images were obtained.
DOSE: DLP: 1891 mGy-cm
CTDI: 53 mGy
COMPARISON: None.
FINDINGS:
There is a 3.9 x 2.1 cm high density lesion centered in the left
parieto-occipital lobe (series 5, image 13) the with the adjacent parenchymal
low-density suggesting edema. The lesion is most likely extra-axial and exerts
mass effect upon the adjacent brain parenchyma. There is no evidence of acute
territorial infarction. The ventricles are normal in size. There is mild
compression of the occipital horn of the left lateral ventricle by the high
density lesion.
No fractures are identified. There is extensive sinus disease involving
opacification of the ethmoid air cells, mucosal thickening of the right
maxillary sinus, complete opacification of the left maxillary sinus and
mucosal thickening of the frontal sinuses. The orbits are unremarkable.
IMPRESSION:
3.9 cm high-density lesion centered in the left parieto-occipital extra-axial
space is suggestive of a meningioma. Recommend serial neurologic exam this as
well as MRI of for further characterization of this lesion if clinically
indicated. Short interval CT of the head could also be obtained for continued
evaluation.
Extensive sinus disease as described above.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: History: ___ unrestrained MVC, hypotensive, no motor or sensory
in ___ ___. *** WARNING *** Multiple patients with same last name! // eval of
acute traumatic injuries eval of acute traumatic injuries
TECHNIQUE: Contiguous axial images were obtained. Sagittal and coronal
reformatted images were generated. No contrast was administered.
CTDIvol: 36 mGy
DLP: 798 mGy-cm
COMPARISON: None
FINDINGS:
Alignment is normal. There are fractures of the a anterior and posterior
tubercle of the left transverse process at C6. There is also a fracture of the
C5 spinous process with extension into the spinal canal. There is no evidence
of traumatic malalignment. A ossific density at the anterior superior endplate
of C5 is most likely degenerative. There is no evidence of spinal canal or
neural foraminal narrowing. There is no evidence of infection or neoplasm.
IMPRESSION:
Fractures involving the anterior and posterior tubercle of the left transverse
process at C6 as well as the spinous process of C5 with extension into the
spinal canal. No evidence of traumatic malalignment. Consider MRI for further
evaluation of possible spinal cord injury.
Radiology Report
EXAMINATION: CT TORSO W/CONTRAST
INDICATION: History: ___ unrestrained MVC, hypotensive, no motor or sensory
in ___ ___. *** WARNING *** Multiple patients with same last name! // eval of
acute traumatic injuries
TECHNIQUE: MDCT images were obtained of the chest abdomen and pelvis. Coronal
and sagittal reformations were prepared.
DOSE: DLP: 680 MGy-cm
COMPARISON: None
FINDINGS:
CT Chest:
Thyroid: The thyroid is normal.
Lymph Nodes: Axillary, supraclavicular, mediastinal, and hilar lymph nodes are
not pathologically enlarged.
Vessels: The great vessels are normal caliber.
Heart and pericardium: The heart size is normal. No pericardial effusion.
Airways: The airways are patent to subsegmental levels.
Lungs: The lungs are clear. No focal consolidation, pleural effusion, or
pneumothorax.
CT Abdomen:
Liver, Gallbladder: The liver is normal in size and attenuation. No focal
hepatic lesions are identified. The hepatic and portal veins are patent. There
is no intra or extrahepatic biliary duct dilatation. The gallbladder is
normal-appearing.
Spleen: The spleen is normal in size and enhancement.
Pancreas: The pancreas shows normal enhancement. There is no pancreatic duct
dilatation or peripancreatic fat stranding.
Kidneys, Adrenals: The kidneys display symmetric nephrograms with no evidence
of hydronephrosis or mass lesion in either kidney. The ureters are
symmetrical in their course to the bladder. The adrenal glands are
unremarkable bilaterally.
Stomach, Bowel: The distal esophagus, stomach and small bowel are normal
appearing. The large bowel is seen filled with stool and is normal. There is
no free air or free fluid in the abdomen or pelvis.
Vessels: There is no aneurysmal dilatation of the abdominal aorta. The aorta
and its major branches are patent.
Lymph Nodes: There are no pathologically enlarged retroperitoneal or
mesenteric lymph nodes by CT size criteria.
CT Pelvis: The bladder is unremarkable. The sigmoid colon and rectum are
normal appearing. There is no pelvic sidewall lymphadenopathy
Osseous Structures: No acute rib fractures are identified. There is an
exostosis which arises from the right iliac bone, which appears fractured at
its base. An additional 3.3 cm calcific density is seen adjacent to the pubic
symphysis on the right extending downward. There is no evidence of acute
fracture or traumatic malalignment in the thoracolumbar spine. Note is made of
bilateral pars defects at L5.
IMPRESSION:
1. An exostosis arises from the right iliac bone just superior to the
acetabulum which appears fractured at its base. Bilateral pars defects at L5.
2. No free air or free fluid in the abdomen or pelvis. No evidence of solid
organ injury.
Radiology Report
EXAMINATION: LUMBAR SP,SINGLE FILM
INDICATION: Trauma and inability to move legs.
TECHNIQUE: Lumbosacral spine, lateral view only
COMPARISON: None
FINDINGS:
There are 5 non-rib-bearing vertebral bodies. Lumbar lordosis is preserved.
There is mild loss of height at the L1 and L2 vertebral bodies, which may be
related to degenerative change. No fracture, or subluxation detected. No focal
lytic or sclerotic lesion is identified. Prominent anterior osteophytes are
noted.
IMPRESSION:
No evidence of acute fracture or traumatic malalignment. Mild degenerative
changes with prominent anterior osteophytes particularly at L1-L2.
Radiology Report
EXAMINATION: MRI OF THE THORACIC SPINE WITHOUT CONTRAST
INDICATION: History: ___ s/p MVCIV contrast to be given at radiologist
discretion as clinically needed*** WARNING *** Multiple patients with same
last name! // ?spinal cord injury
TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 axial images of the
cervical, thoracic and lumbar spine were acquired.
COMPARISON: Cervical spine CT of the same day.
FINDINGS:
Cervical spine: There is increased signal within the left lamina of C5 at the
fracture was identified on the cervical spine CT. There is also focal
discontinuity of the ligamentum flavum in this region. The anterior and
posterior longitudinal ligaments appear intact. There is increased signal
within the spinal cord at C5 level indicative of cord edema. There is mild
increase posterior soft tissue signal likely secondary to trauma seen. There
is increased signal within the prevertebral region from craniocervical
junction to upper thoracic region indicative of a small prevertebral edema or
hematoma. There is no intraspinal hematoma. Degenerative changes with disc
bulging seen from C3-4 to C6-7 levels with mild spinal canal narrowing.
Moderate-to-severe left foraminal narrowing is seen at C5-6 level.
Thoracic spine: There is no cord compression or intraspinal hematoma. No
evidence of fracture seen. No ligamentous disruption seen. No abnormal signal
within the spinal cord. Mild multilevel degenerative changes.
Lumbar spine:
Multilevel degenerative changes identified. Bilateral spondylolysis of L5 seen
with severe bilateral foraminal narrowing with compression of exiting nerve
roots. Mild degenerative changes seen at other levels. No evidence of
high-grade spinal stenosis. No evidence of bony or ligamentous injury.
IMPRESSION:
Fracture of C5 lamina with adjacent focal ligamentum flava disruption and cord
edema. No evidence of intraspinal hematoma. Small prevertebral hematoma and
posterior soft tissue increase signal secondary secondary to injury.
Multilevel degenerative changes in the cervical thoracic and lumbar region.
Bilateral severe foraminal narrowing at L5-S1 level with bilateral
spondylolysis of L5 and mild spondylolisthesis of L5 over S1.
Radiology Report
EXAMINATION: MRI AND MRA BRAIN
INDICATION: ___ ___ only unrestrained MVC, unknown LOC,
initial loss of motor/sensory below T10, possible central cord syndrome, C5
spinous process frx, C6 TP frx, R acetabular frx, hemangioma/meningioma //
characterize left parieto-occipital lesion
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of cc of Gadavist intravenous contrast, axial imaging was
performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal
MPRAGE imaging was performed and re-formatted in axial and coronal
orientations. 3D time-of-flight MRA of the circle of ___ was obtained.
COMPARISON: Head CT of the same day.
FINDINGS:
There is no acute infarct identified. There is a 3.8 x 2.2 cm mass
extra-axial mass in the left parietal temporal region with surrounding dural
enhancement and edema in the underlying brain consistent with a meningioma.
There is no midline shift or hydrocephalus. No other areas of abnormal
enhancement seen. Mucosal changes are seen within the sphenoid and maxillary
as were the less frontal and ethmoid sinuses. Inspissated secretions and
slight expansion of the left maxillary sinus seen which may be secondary to a
polyp. Clinical correlation recommended.
MRA of the head shows normal signal in the arteries of the anterior and
posterior circulation. No evidence of vascular occlusion stenosis or an
aneurysm greater than 3 mm in size seen.
IMPRESSION:
Left parietotemporal extra-axial mass consistent with meningioma with mild
surrounding underlying edema. No midline shift or hydrocephalus. No acute
infarcts. Chronic sinus changes including suspicion of a polyp in the left
maxillary sinus. Clinical correlation recommended. . No significant
abnormalities are seen on MRA of the head.
Radiology Report
INDICATION: Aspiration
TECHNIQUE: A single frontal radiograph of the chest was acquired.
COMPARISON: Chest radiograph from ___.
FINDINGS:
A right PICC ends near the superior cavoatrial junction. The lungs are clear.
The heart size is normal. There are no pleural abnormalities. Spinal fusion
hardware is partially imaged. There is a presumed surgical drain projecting
over the cervical region with adjacent skin staples.
IMPRESSION:
No radiographic evidence of pneumonia or aspiration pneumonitis.
Radiology Report
INDICATION: ___ year old man with new right CVL // plz confirm correct
position, r/o complications Contact name: ___: ___
IMPRESSION:
As compared to the previous study of earlier the same date, a right subclavian
vascular catheter is been placed, terminating in the lower superior vena cava,
with no definite pneumothorax.
Radiology Report
EXAMINATION:
C-SPINE, TRAUMA IN O.R.
INDICATION:
FUSION/LAMINECTOMY
TECHNIQUE: 4 intraoperative lateral projections of the cervical spine were
obtained without the radiologist present.
COMPARISON: CT cervical spine CT ___.
FINDINGS:
C1 through C5 are visualized. Localizer devices are noted posterior to C2 and
C4. Subsequent images demonstrate interval placement of posterior fusion
hardware spanning C3 -C6. There is no evidence of hardware complication. The
previously demonstrated fractures are not well seen on the current exam. There
is no significant vertebral body subluxation.
IMPRESSION:
Interval posterior fusion spanning C3-C6. Please see the operative report for
further details.
Previously demonstrated fractures within the cervical spine are more fully
characterized on the concurrent CT.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with productive cough and fever // ? cause of
cough
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
FINDINGS:
Cardiac size is normal. The lungs are clear. There is no pneumothorax or
pleural effusion. Right subclavian catheter tip is in the lower SVC. Skin
staples and spinal cervical hardware are partially imaged
IMPRESSION:
No acute cardiopulmonary abnormality
Radiology Report
EXAMINATION: ___ DUP EXTEXT BIL (MAP/DVT)
INDICATION:
___ year old man with spinal cord injury, HD 11 bedbound, evaluate for deep
vein thrombosis.
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, superficial 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 bilateral lower extremity veins.
Radiology Report
INDICATION: ___ year old man with s/p C3-7 post- fusion; C3-6 decompression
// please assess for fracture hip pain.
COMPARISON: Compared to the CT scan from ___
IMPRESSION:
No acute fractures or dislocations are seen. The left hip demonstrates mild
joint space narrowing and prominent superolateral osteophytic spurring. There
are mild degenerative changes of the inferior sacroiliac joints, left greater
than right.Arising from the right iliac bone just above the hip joint, there
is a linear ossification which has a fracture near its base. Findings are
most compatible with heterotopic ossification related to prior trauma.
Similarly, there are calcifications adjacent to the right pubic symphysis,
unchanged since the prior CT scan.
Radiology Report
EXAMINATION: ___ DUP EXTEXT BIL (MAP/DVT)
INDICATION: ___ year old man with central cord sydndrome- very limited
mobility // prolonged bedrest-? dvt
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
of the lower extremity veins bilaterally.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow and augmentation of bilateral common
femoral, femoral, and popliteal veins. Normal color flow and compressibility
are demonstrated in the posterior tibial and peroneal veins bilaterally.
There is normal respiratory variation in the common femoral veins bilaterally.
Rouleaux formation is incidentally noted in the femoral and popliteal veins
bilaterally indicating slow flow bilaterally.
IMPRESSION:
1. No evidence of deep venous thrombosis in the either leg.
2. Rouleaux formation seen bilaterally in the femoral and popliteal veins
indicating slow velocity flow.
Radiology Report
INDICATION: Pain right shoulder. It is unclear to me if this patient has had
trauma.
TECHNIQUE: 4 views of the right shoulder.
FINDINGS:
The poorly visualized AC joint suggest minor degenerative changes. No
fracture, dislocation, diminution in the acromial humeral soft tissues,
periarticular soft tissue calcifications or abnormality in the ipsilateral
lung or ribs. There is poorly visualized posterior fusion hardware in the
cervical spine
IMPRESSION:
No fracture. Probable degenerative changes AC joint.
Gender: M
Race: UNKNOWN
Arrive by AMBULANCE
Chief complaint: MVC
Diagnosed with C5-C7 FX-CL/CORD INJ NOS, MV COLL W OTH OBJ-DRIVER
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | The patient was admitted to the ___ under the ACS service
after initial resuscitation in the ED. An MRI of the C/T/L spine
showed a C5 lamina fx associated w/ edema and disruption of the
ligamentum flavum and bilateral severe foraminal narrowing at
L5-S1. He was thus taken to the OR by the neurosurg/spine
service for a C3-7 posterior fusion and C3-6 decompression.
Please see the dictated operative report for further details. A
JP bulb was placed intraop and the patient's c-collar was
removed by the neurosurg team. HSQ was held for 48 hours postop.
Neurology evaluated the patient and felt that the L
parietotemporal mass was likely a meningioma, which could be a
potential seizure focus, but they felt no further intervention
or treatment was indicated at that time. Postoperatively, the
patient was placed on levophed (intermittently on neosynephrine
and vasopressin as well) to keep his MAPS >85 per neurosurgery
recommendations. He was allowed to have a diet as tolerated. His
UOP was noted to be extremely high (>5L/day) so urine lytes were
checked, which were within normal limits. On POD2, HSQ was
resumed and the patinet's drain was dc'd. He spiked a fever to
101.5 later that day and was pan-cultured. His urinalysis was
borderline positive and he was started on bactrim
prophylactically for a UTI. On ___, he was started on midodrine
to help him wean off his pressors. He was then transferred to
the neurosurgery team.
On ___, the patient's care was transferred to the neurosurgery
team. He was working with ___ and OT. His neurologic examination
remained stable. He was attempting to wean off of levophed and
vasopressin.
On ___, the patient was no longer requiring pressors. He was
transferred to the floor. He was started on Nystatin for oral
thrush.
On ___, the patient's neurologic examination remained stable. He
was started on standing Baclofen for spasm.
On ___, the patient's neurologic examination remained stable.
His BUN was 18. His incision remained clean, dry and intact with
staples in place. He was experiencing right orbital drainage and
eye pain. Ophtalmology was consulted and recommended continuing
natural tear eyedrops.
On ___, the patient's neurologic examination was stable. His
wound remained clean, dry and intact and was closed with
staples. A drain stitch was left in place. He continues to
undergo rehabilitation at ___.
On ___ he remained unchanged and continued to work with ___. He
underwent lower extremity non-invasive ultrasounds which were
negative.
On ___, the patient's neurologic examination remained stable. He
continued to work with physical therapy. His staples and drain
stitch were removed and his wound was clean, dry and intact.
On ___, the patient remained stable. He is awaiting insurance
approval in preparation for discharge to a rehabilitation
facility.
On ___ - ___, The remained stable and continued physical
therapy. On ___ his foley catheter was clamped and unclamped
for bladder training. He remained stable on ___ awaiting for
rehab. Bladder training was continued and ___ were evaluating
him on an almost daily basis.
___, The motor exam was improved. The patient was mobilized oob
to chair.
___: Sitting in wheelchair, had mechanical fall when tried to
reposition himself. No LOC, no headstrike, no injury. Found to
have pus around foley. Afebrile. Foley removed, DTV at 1 AM. Has
been failing foley clamping trials, still no bladder sensation.
___: + UTI, started on ceftriaxone x 7 days
___: Stable. Urine culture + for enterococcus.
Mr. ___ remained stable between ___ and ___. During this
time, he began to regain some movement and strength in his left
hand and bilateral triceps.
On ___, a meeting was held between physical therapy, case
management, nursing and neurosurgery to discuss patient care
needs in preparation for discharge home. A potential meeting
with the family was set for ___.
On ___, The patient had left hip pain and was found to have
pain on range of motion. A left hip xray was performed and
consistent with no acute fractures or dislocations are seen left
hip.
On ___, The patient was neurologically stable.
On ___, The patient was neurologically stable. A urine
analysis was performed and consistent with a UTI. A urethra
swab was sent as the patient was having discharge from his penis
tip. A Fleets enema was ordered.
On ___, The patients exam was stable. The patients green card
was delivered to case management.
On ___, Infectious disease was curbsided for a urinary tract
infection. It was recommended taht teh ceftriaxone be
discontinued and to start augmentin 875 mg BID for ___ days.
LENIS were perfromed routine and were negative for deep venous
thrombosis. Physical therapy noted slightly limited range of
motion and pain of the right shoulder and a right shoulder xray
was ordered and was negative.
On ___, the patient's neurologic examination remained stable.
He was evaluated by the Urology team for penile discharge. He
denies any pain associated with the penile discharge. It was
determined he has a phimosis. Per urology recommendations, Mr.
___ will likely need an elective circumcision and will
follow-up with ___ Urology in 4-weeks. He will see Dr.
___ in 4-weeks with AP/Lateral X-rays of the cervical
spine. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
L Hip Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is an ___ year old gentleman with history of
pAF/aflutter, hypothyroidism, compression fractures who presents
with left hip pain.
Patient reports he was in his usual state of health, bent down 3
days ago putting his pants on, heard a pop and had subsequently
had left groin pain. His pain in the groin has improved but he
now has pain over the greater trochanter radiating down left leg
which prompted him to present to the ED for further evaluation.
He also notes he has had intermittent headaches which is
chronic, has taken aspirin 325mg q5h and ___ ibuprofen over the
past week.
In the ED, initial vitals:
97.3 116 105/66 20 100% RA
Exam notable for:
Tender over greater trochanter. 2+ DP bilaterally.
Labs were significant for no leukocytosis, normocytic anemia
with H/H 12.2/36.3, normal platelets, hyponatremia Na 131, Cr
1.1 (baseline =) glucose 115.
CT A/P showed: Intramuscular hematoma expanding the left iliacus
muscle up to 5.1 cm with extension to the left iliopsoas muscle.
-No acute fracture.
Left Femur X ray showed:
No fracture or dislocation.
Patient received:
___ 13:13 PO Acetaminophen 1000 mg
___ 13:13 PO OxycoDONE (Immediate Release)
___ 16:13 IV Morphine Sulfate 2 mg
___ 16:14 IV Morphine Sulfate 2 mg
Initial plan for ED obs for left iliopsoas hematoma with repeat
CBC and ___ management for potential rehab. While patient
was working with ___ he walked up and down a flight of stairs, at
the bottom of the stairs he felt dizzy. ___ got a chair, noted
patient became gray and pulseless. As patient put on floor for
CPR he moaned and "pinked up". He was put on stretcher in
___ with return to baseline within minutes. EKG showed
sinus bradycardia with a rate of 53. Patient did not have chest
pain during this episode. Patient reports he has had ___
presyncopal or syncopal episodes over last year.
ED paged Dr. ___ cardiologist) who was
concerned for bradyarrythmia, NSVT on exertion, unlikely ACS
unlikely.
Patient was then admitted for workup of syncope.
Vitals prior to transfer:
97.4 59 112/57 16 100% RA
On the floor, patient is feeling well. Laying still he has no
pain. With movement of L leg he has ___ pain in left hip and
buttock. He has not had any falls since the one that brought him
into the hospital in ___. He thinks his episode in the ED was
related to getting morphine and oxycodone and then working with
___. He does not take narcotics regularly at home. During the
episode he did not have chest pain, palpitations, shortness of
breath. He has not had any recent travel. He denies any fevers
or chills. No recent medication changes.
ROS:
As above per HPI, otherwise no fevers, chills, night sweats, or
weight changes. No changes in vision or hearing, no changes in
balance. No cough, no shortness of breath, no dyspnea on
exertion. No chest pain or palpitations. No nausea or vomiting.
No diarrhea or constipation. No dysuria or hematuria. No
hematochezia, no melena. No numbness or weakness, no focal
deficits.
Past Medical History:
ATRIAL FLUTTER/ paroxysmal atrial fibrillation
(previously on eliquis, stopped over year ago for
major bleed ___ traumatic fall)
HYPOTHYROIDISM
HEADACHE (migraine)
PROSTATE CANCER ___ years ago)
COMPRESSION FRACTURES
INSOMNIA
Bilateral glaucoma, limited vision in L eye
Social History:
___
Family History:
Non contributory
Physical Exam:
ADMISSION:
VS: 74.3 kg 97.2 131/64 58 18 100% on RA
GEN: Alert, oriented, very pleasant older gentleman, lying in
bed, no acute distress
HEENT: MMM, anicteric sclera, no conjunctival pallor
NECK: Supple without LAD
PULM: Clear, no wheeze, rales, or rhonchi
COR: RRR, normal S1/S2, no murmurs
ABD: Soft, NT ND, normal BS; old abdominal surgical scar
EXTREM: Warm, no edema; venous stasis changes up to mid shins;
unable to lift left leg ___ pain, greater range of motion with
passive movement but causes exquisite pain
NEURO: CN II-XII grossly intact, motor function grossly normal
DISCHARGE:
VS: T 98 BP 127/64 HR 97 RR 18 ___
GEN: Alert, oriented, very pleasant older gentleman, lying in
bed, no acute distress
HEENT: MMM, anicteric sclera, no conjunctival pallor
NECK: Supple without LAD
PULM: Clear to auscultation B/L anterior and posterior chest
COR: RRR, normal S1/S2, no murmurs
ABD: Soft, NT ND, normal BS; + old abdominal surgical scar
EXTREM: Warm, no edema; venous stasis changes up to mid shins;
unable to lift left leg ___ pain, greater range of motion with
passive movement but causes exquisite pain
NEURO: CN II-XII grossly intact, motor function grossly normal
Pertinent Results:
ADMISSION:
___ 12:05PM BLOOD WBC-6.6 RBC-4.08* Hgb-12.2* Hct-36.3*
MCV-89 MCH-29.9 MCHC-33.6 RDW-13.2 RDWSD-42.8 Plt ___
___ 12:05PM BLOOD Neuts-76.9* Lymphs-11.4* Monos-9.9
Eos-0.8* Baso-0.5 Im ___ AbsNeut-5.08 AbsLymp-0.75*
AbsMono-0.65 AbsEos-0.05 AbsBaso-0.03
___ 12:05PM BLOOD Plt ___
___ 12:05PM BLOOD Glucose-115* UreaN-42* Creat-1.1 Na-131*
K-4.9 Cl-97 HCO3-23 AnGap-16
___ 09:00PM BLOOD ALT-22 AST-30 LD(LDH)-181 AlkPhos-59
TotBili-0.6
___ 09:00PM BLOOD Albumin-3.5 Calcium-8.6 Phos-2.3* Mg-2.2
PERTINENT:
___ 01:17PM BLOOD ___
___ 05:41AM BLOOD Ret Aut-1.2 Abs Ret-0.04
___ 05:41AM BLOOD Hapto-184
DISCHARGE:
___ 06:23AM BLOOD WBC-6.0 RBC-3.80* Hgb-11.2* Hct-33.9*
MCV-89 MCH-29.5 MCHC-33.0 RDW-13.2 RDWSD-43.5 Plt ___
___ 06:23AM BLOOD Plt ___
___ 06:25AM BLOOD Glucose-88 UreaN-24* Creat-0.9 Na-134
K-4.6 Cl-102 HCO3-23 AnGap-14
EKG:
Sinus bradycardia. Leftward axis. One atrial premature complex.
Early
precordial R wave transition. Compared to the previous tracing
of ___
there is no significant change.
Intervals Axes
Rate PR QRS QT QTc (___) P QRS T
52 ___ 439/422 60 -19 66
IMAGING:
L Pelvis X ray:
___:
No fracture or dislocation. Moderate degenerative changes are
seen at the
left femoroacetabular joint and left knee. No knee joint
effusion. Vascular
calcifications are present. Multiple clips project over the
pelvis.
IMPRESSION:
No fracture or dislocation.
CT Pelvis ___:
GASTROINTESTINAL: The visualized small bowel loops demonstrate
normal caliber
and wall thickness throughout. Large amount of stool is seen
throughout the
colon. The colon and rectum are otherwise within normal limits.
The appendix
is not visualized however no secondary signs of acute
appendicitis.
PELVIS: Limited evaluation due to beam hardening artifact from
multiple
surgical clips within the pelvis in a patient who is status post
prostatectomy. The urinary bladder is largely distended. There
is no free
fluid in the pelvis.
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.
Well corticated lucency along the right anterior acetabulum is
stable since ___ and consistent with a nutrient foramen.
SOFT TISSUES: A heterogeneous intramuscular hematoma measuring
5.1 cm in
maximal thickness within the left iliacus with extension to the
left iliopsoas
muscle is seen.
IMPRESSION:
1. Intramuscular hematoma expanding the left iliacus muscle up
to 5.1 cm with extension to the left iliopsoas muscle.
2. No acute fracture.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ClonazePAM 0.5 mg PO QHS:PRN insomnia
2. Levothyroxine Sodium 137 mcg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES DAILY
5. Pindolol 5 mg PO DAILY
6. Centrum Silver
(multivit-min-FA-lycopen-lutein;<br>mv-min-folic acid-lutein) 1
tablet oral DAILY
7. Cyanocobalamin 500 mcg PO DAILY
8. Fleet Bisacodyl (bisacodyl) 10 mg/30 mL rectal ___
constipation
9. magnesium 250 mg oral DAILY
10. melatonin ___ mg oral QHS:PRN insomnia
11. Vitamin D 1000 UNIT PO DAILY
12. Calcium Carbonate 500 mg PO DAILY
13. Alendronate Sodium 70 mg PO QFRI
14. Aspirin 325 mg PO Q4-5H:PRN pain
15. Ibuprofen 600 mg PO DAILY:PRN pain
16. Acetaminophen 500 mg PO PRN pain
17. Acetaminophen w/Codeine 1 TAB PO Q8H:PRN pain
Discharge Medications:
1. Acetaminophen 500 mg PO PRN pain
2. Alendronate Sodium 70 mg PO QFRI
3. Calcium Carbonate 500 mg PO DAILY
4. ClonazePAM 0.5 mg PO QHS:PRN insomnia
5. Cyanocobalamin 500 mcg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Levothyroxine Sodium 137 mcg PO DAILY
8. Pindolol 5 mg PO DAILY
9. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. Centrum Silver
(multivit-min-FA-lycopen-lutein;<br>mv-min-folic acid-lutein) 1
tablet oral DAILY
12. Fleet Bisacodyl (bisacodyl) 10 mg/30 mL rectal ___
constipation
13. magnesium 250 mg oral DAILY
14. melatonin ___ mg oral QHS:PRN insomnia
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute Blood Loss Anemia
Iliacus Hematoma
Syncope
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: FEMUR (AP AND LAT) LEFT
INDICATION: History: ___ with hx osteoporosis presenting with left hip pain
and inability to walk. // fracture? fracture?
TECHNIQUE: Left femur, frontal and lateral views.
COMPARISON: None.
FINDINGS:
No fracture or dislocation. Moderate degenerative changes are seen at the
left femoroacetabular joint and left knee. No knee joint effusion. Vascular
calcifications are present. Multiple clips project over the pelvis.
IMPRESSION:
No fracture or dislocation.
Radiology Report
EXAMINATION: CT pelvis ortho without contrast.
INDICATION: ___ with hx osteoporosis presenting with left hip pain, negative
xray and H/H drop. Assess for hematoma or hip fracture.
TECHNIQUE: Multidetector CT images of the 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) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Spiral Acquisition 6.4 s, 31.4 cm; CTDIvol = 25.0 mGy (Body) DLP = 782.3
mGy-cm.
Total DLP (Body) = 782 mGy-cm.
COMPARISON: Left femur radiograph ___, CT abdomen/ pelvis ___.
FINDINGS:
GASTROINTESTINAL: The visualized small bowel loops demonstrate normal caliber
and wall thickness throughout. Large amount of stool is seen throughout the
colon. The colon and rectum are otherwise within normal limits. The appendix
is not visualized however no secondary signs of acute appendicitis.
PELVIS: Limited evaluation due to beam hardening artifact from multiple
surgical clips within the pelvis in a patient who is status post
prostatectomy. The urinary bladder is largely distended. There is no free
fluid in the pelvis.
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.
Well corticated lucency along the right anterior acetabulum is stable since ___ and consistent with a nutrient foramen.
SOFT TISSUES: A heterogeneous intramuscular hematoma measuring 5.1 cm in
maximal thickness within the left iliacus with extension to the left iliopsoas
muscle is seen.
IMPRESSION:
1. Intramuscular hematoma expanding the left iliacus muscle up to 5.1 cm with
extension to the left iliopsoas muscle.
2. No acute fracture.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: L Hip pain
Diagnosed with Pain in left hip, Syncope and collapse
temperature: 97.3
heartrate: 116.0
resprate: 20.0
o2sat: 100.0
sbp: 105.0
dbp: 66.0
level of pain: 9
level of acuity: 3.0 | Mr. ___ is an ___ year old gentleman with history of
pAF/aflutter (not on A/C ___ major bleed from prior fall),
compression fractures, hypothyroidism who presents with left hip
pain, found to have iliacus muscle hematoma and subsequent
episode of syncope. Patient's acute bleed secondary to recent
significant aspirin and ibuprofen use. Resolved without specific
intervention. Patient's syncope secondary to medication effect
with morphine and oxycodone administration. Patient was
evaluated by physical therapy who recommended acute
rehabilitation.
#Iliacus Hematoma, Acute Blood Loss Anemia:
Patient recently took increasing amounts of aspirin 325mg PO q5h
and iburpofin 600mg PO q8h for headache which lead to poor
platelet function. He subsequently bent over to put on his pants
and felt pain in his left hip. He was found to have no fracture
but a 5cm iliacus hematoma expanding into the iliopsoas. He was
monitored closely with TID hemoglobin/hematocrit checks. There
was no evidence of DIC or hemolysis. He did not require blood
transfusions and hematocrit stabilized without intervention.
Given hematoma patient had significant pain, started on standing
acetaminophen 1G PO q8h and low dose oxycodone 2.5mg PO q4h as
needed. He was instructed not to use high dose aspirin for pain.
He was evaluated by physical therapy who recommended acute
rehabilitation on discharge.
#Syncope:
Patient with history of syncope. Recently admitted ___ with
compression fractures and vasovagal episodes in setting of pain
and bowel movements treated with theophylline and subsequent
pindolol. During ED course patient received morphine and
oxycodone for pain, subsequently worked with physical therapy
and went up and down stairs, felt dizzy with apparent pulseless
event. He did not require CPR and recovered without specific
intervention. EKG remained at baseline with sinus bradycardia,
normal intervals. He was monitored on telemetry without
arrhythmia x 48 hours. His recent TTE was without significant
valvular disease. His last TSH was checked this fall and within
normal limits. He did not receive further morphine and received
pain control as above without subsequent episodes. He will
follow up with his outpatient cardiologist, Dr. ___, on
discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Suprapubic pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ male with with hx of high volume G3+4
prostate cancer s/p EBRT/cyber knife boost ___ and adjuvant
hormonal therapy, c/b urinary retention with occasional straight
cath at home and previous history of UTIs s/p TURP. He has not
had to catherize himself for weeks, and recent treatment for a
urinary tract infection, (strep throat, and thrush as well per
ED) in ___, who presents with persistent lower abdominal
pain
and fevers. Patient reports that over the last 2 weeks he was
treated with 2 different courses of oral antibiotics
pivmecillinam/selexid (extended-spectrum penicillin antibiotic)
/dihydrocodeine 40 mg T tid after a UA in ___ showed
evidence
of a UTI. He had intermittent fevers and lower abdominal pain at
that time. He has now had significant pain across the lower
abdomen for the past 2 days. He has had fevers, nausea and
vomiting. No diarrhea or blood in the stool. No chest pain,
shortness of breath, cough. No history of abdominal surgeries.
He
returned from ___ a week ago and his abdominal pain returned.
His supra-pubic pain was so bad that he is unable to stand up
straight. He had to crawl up and down stairs. His L hip pain is
also flaring because of how he has to walk bent over to avoid
pulling his supra-pubic region. He also had intermittent
dysuria.
He has been wearing pull ups because he has been having
accidents. His urine has turned brown and is very malodorous.
+nausea and non-bloody/non bilious emesis. He has not had chest
pain or shortness of breath. He has lost 12 lbs with all this.
He
has not been constipated. No change in his bowel habits.
.
On exam, he is awake and alert, diaphoretic and feels warm.
Abdomen is obese, soft, with significant tenderness to palpation
across the lower abdomen. No prostate tenderness.
.
In ER: (Triage Vitals: 4|102 |108 |142/64 |18 |94% RA
Meds Given: Morphine 4 mg IV| Ceftriaxone 1 gm
Fluids given: NS x 2L|
Radiology Studies:None
consults called: None
.
PAIN SCALE: ___ supra-pubic pain worse with movement.
Past Medical History:
PAST MEDICAL HISTORY (per chart, confirmed with pt):
ATRIAL FIBRILLATION
HYPERTENSION
ARTHRITIS
MALE ERECTILE DISORDER
HYPERGLYCEMIA
COLONIC POLYPS
PROSTATE CANCER
GOUT
Social History:
___
Family History:
(per chart, confirmed with pt):
Mother with cardiac aneurysm, father with arthritis, twin
brother with prostate CA
Physical Exam:
ADMISSION
Vitals: 99.3, P= 85, 110 / 62, 93% on RA
CONS: NAD, comfortable appearing, he is constantly making jokes
HEENT: ncat anicteric MMM
CV: s1s2 rrr with occasional PACs, ? soft SEM at LLSB
RESP: b/l ae no w/c/r
GI: +bs, soft, + supra-pubic tenderness, + obesely distended, no
guarding or rebound
GU: No foley catheter
RECTAL: Body habitus and ? TURP made it difficult to reach the
prostate but pressing in the location of the prostate did not
elicit pain. Small amount of soft brown stool
MSK:no c/c/e 2+pulses
SKIN: no rash
NEURO: face symmetric speech fluent
PSYCH: calm, cooperative
LAD- No cervical LAD
Psychiatric [] WNL
[X] Appropriate [] Flat affect [] Anxious [] Manic []
Intoxicated
[X] Pleasant [] Depressed [] Agitated [+] Funny
DISCHARGE
98.0 PO 144 / 78 R Lying 88 18 95 Ra
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally
GI: Abdomen soft, non-distended, non-tender
GU: Very mild suprapubic pain to palpation. Foley in place
MSK: Neck supple, moves all extremities
PSYCH: pleasant, appropriate affect
NEUROLOGIC: alert and cooperative. Oriented to person and place
and time.
Pertinent Results:
ADMISSION
___ 06:40AM BLOOD WBC-7.5 RBC-3.33* Hgb-9.9* Hct-30.2*
MCV-91 MCH-29.7 MCHC-32.8 RDW-13.6 RDWSD-45.1 Plt ___
___ 05:27PM BLOOD Neuts-90.5* Lymphs-2.9* Monos-6.1
Eos-0.0* Baso-0.1 Im ___ AbsNeut-12.39* AbsLymp-0.40*
AbsMono-0.83* AbsEos-0.00* AbsBaso-0.01
___ 07:05AM BLOOD ___ PTT-35.3 ___
___ 06:40AM BLOOD Glucose-136* UreaN-12 Creat-0.9 Na-139
K-3.8 Cl-95* HCO3-25 AnGap-19*
___ 05:27PM BLOOD ALT-13 AST-18 AlkPhos-65 TotBili-0.5
___ 07:05AM BLOOD Calcium-8.9 Phos-3.0 Mg-1.6
___ 05:33PM BLOOD Lactate-1.2
DISCHARGE
___ 05:15AM BLOOD WBC-7.3 RBC-2.77* Hgb-8.2* Hct-24.6*
MCV-89 MCH-29.6 MCHC-33.3 RDW-13.7 RDWSD-44.7 Plt ___
___ 05:15AM BLOOD Plt ___
___ 05:15AM BLOOD Glucose-112* UreaN-12 Creat-0.8 Na-138
K-3.9 Cl-96 HCO3-28 AnGap-14
___ 05:15AM BLOOD Calcium-8.2* Phos-3.7 Mg-1.9
___ 07:15AM BLOOD CRP-269.7*
MRI pelvis ___
1. Findings consistent with septic arthritis of the symphysis
pubis with associated osteomyelitis of the bilateral superior
inferior pubic rami. This is contiguous with the inflammatory
changes detailed below.
2. Findings suspicious for a defect in the anterior wall of the
prostatic urethra. There is a small amount of fluid and more
extensive phlegmon and inflammatory change involving the
adjacent
soft tissues at the space of Retzius, obturator internus and
adductor musculature. No drainable fluid
collection seen.
3. Bladder wall thickening, edema and hyper enhancement may
reflect cystitis or postradiation change.
4. Fat containing left inguinal hernia.
5. Severe degenerative changes in the left hip.
Cystoscopy ___
1. Contrast outlining the urinary bladder and urethra without
evidence of rupture or fistulous tract connection to the
unchanged collection of air and fluid anterior to the urinary
bladder and posterior to the pubic symphysis.
2. Redemonstration of imaging findings of radiation cystitis.
CTU ___
IMPRESSION:
1. No findings of metastatic disease.
2. Redemonstration of imaging findings compatible with cystitis.
Extraluminal pocket of fluid and gas anterior to the urinary
bladder likely a developing abscess or a small contained urinary
bladder rupture. The pocket of gas may be also secondary to
degenerative changes in the symphysis pubis as there is a pocket
of gas within the joint, however the finding is not fully
explained by degenerative changes given the presence of fluid.
Urine culture ___
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ 2 S
NITROFURANTOIN-------- S
TETRACYCLINE---------- =>32 R
VANCOMYCIN------------ 2 S
Urine culture ___
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 2 S
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. amLODIPine 10 mg PO DAILY
3. Apixaban 5 mg PO BID
4. Lisinopril 2.5 mg PO DAILY
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Tamsulosin 0.8 mg PO QHS
Discharge Medications:
1. Ampicillin 2 g IV Q4H
2. Docusate Sodium 100 mg PO BID
3. Gabapentin 100 mg PO NOON
4. Gabapentin 100 mg PO DAILY
5. Gabapentin 300 mg PO QHS
6. Ondansetron 4 mg IV Q8H:PRN nausea
7. OxyCODONE (Immediate Release) 5 mg PO Q3H:PRN BREAKTHROUGH
PAIN
8. OxyCODONE (Immediate Release) 5 mg PO Q6H
9. Senna 8.6 mg PO BID:PRN Constipation - First Line
10. Allopurinol ___ mg PO DAILY
11. amLODIPine 10 mg PO DAILY
12. Apixaban 5 mg PO BID
13. Lisinopril 2.5 mg PO DAILY
14. Metoprolol Succinate XL 50 mg PO DAILY
15. Tamsulosin 0.8 mg PO QHS
16.Rolling Walker
Dx: suprapubic pain, UTI, deconditioning
Px: good
___ 13 months
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Primary:
Septic arthritis of symphysis pubis
Osteomyelitis of bilateral superior inferior pubic rami
Acute cystitis
Secondary:
History of prostate cancer s/p radiation
History of benign prostatic hypertrophy s/p TURP
Atrial fibrillation
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 urogram of the abdomen and pelvis
INDICATION: ___ year old man with UTI, hx radiation cystitis// severe flank
pain and recurrent UTI. ?pyelonephritis
TECHNIQUE: CTU: Multidetector CT of the abdomen and pelvis were acquired
prior to and after intravenous contrast administration with the patient in
prone position. The non-contrast scan was done with low radiation dose
technique. The contrast scan was performed 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 8.0 s, 52.0 cm; CTDIvol = 4.6 mGy (Body) DLP = 237.2
mGy-cm.
2) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 7.2 mGy (Body) DLP = 1.4
mGy-cm.
3) Stationary Acquisition 2.4 s, 0.2 cm; CTDIvol = 39.9 mGy (Body) DLP =
8.0 mGy-cm.
4) Spiral Acquisition 7.7 s, 49.9 cm; CTDIvol = 17.0 mGy (Body) DLP = 837.7
mGy-cm.
5) Spiral Acquisition 6.8 s, 44.2 cm; CTDIvol = 4.8 mGy (Body) DLP = 210.8
mGy-cm.
Total DLP (Body) = 1,295 mGy-cm.
COMPARISON: Multiple prior examinations, most recent CT abdomen pelvis from
___
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: There is a 4.2 cm hepatic cyst adjacent to the gallbladder
(series 14; image 38). An additional small hepatic is noted in the right
lobe, measuring 1.5 cm (series 14; image 29). Multiple additional
hypodensities are too small to characterize on CT and were previously
consistent with cysts prior MRI. Gallbladder is unremarkable.
PANCREAS: Pancreas is mildly atrophic.
SPLEEN: Unremarkable.
ADRENALS: Unremarkable.
URINARY: Multiple bilateral renal hypodensities, consistent with cysts on
prior MRI, measure up to 1.9 cm in the interpolar left kidney (series 7; image
52). No hydronephrosis. There is mild cortical thinning. There is no regional
hypodensity or perinephric stranding suggestive of pyelonephritis.
GASTROINTESTINAL: There is no small bowel obstruction.
PELVIS: Again seen are fiducials in the prostate.
There is circumferential bladder wall thickening with surrounding stranding,
similar in extent to ___, consistent with known radiation cystitis. There is
intraluminal gas noted at the bladder dome, presumably related to
instrumentation (series 14; image 66). A TURP defect is again noted.
There is a small extraluminal 1.2 cm pocket of fluid and gas anterior to the
urinary bladder, posterior to the inferior aspect of the symphysis pubis on
series 7, image 132. Please note there is a diminutive pocket of gas within
the symphysis pubis which can be seen with degenerative changes.
LYMPH NODES: No enlarged abdominal or pelvic lymph nodes. A few prominent
subcentimeter external iliac lymph nodes a (series 7, image 105) are likely
reactive.
VASCULAR: There is no abdominal aortic aneurysm.
BONES: There is moderate to severe degenerative change with endplate sclerosis
most notable in the inferior endplate of L3, the inferior endplate of L4, in
the inferior endplate of L2. No concerning sclerotic or lytic lesions.
SOFT TISSUES: Bilateral fat containing inguinal hernias are seen. Again seen
is
IMPRESSION:
1. No findings of metastatic disease.
2. Redemonstration of imaging findings compatible with cystitis. Extraluminal
pocket of fluid and gas anterior to the urinary bladder likely a developing
abscess or a small contained urinary bladder rupture. The pocket of gas may
be also secondary to degenerative changes in the symphysis pubis as there is a
pocket of gas within the joint, however the finding is not fully explained by
degenerative changes given the presence of fluid.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 12:13 pm, 5 minutes after
discovery of the findings.
Radiology Report
INDICATION: ___ hx atrial fibrillation on apixaban, prostate cancer s/p
radiation with cystitis and intermittent self cath (in the past, not
currently), BPH s/p TURP, HTN who presents with severe suprapubic pain.//
PLEASE CLAMP FOLEY to assess for GU fistula
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.
Approximately 200-250 cc of the intravesical contrast is administered via
Foley.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.8 s, 31.4 cm; CTDIvol = 21.9 mGy (Body) DLP = 672.4
mGy-cm.
2) Spiral Acquisition 3.3 s, 21.4 cm; CTDIvol = 21.2 mGy (Body) DLP = 438.8
mGy-cm.
3) Spiral Acquisition 5.5 s, 35.4 cm; CTDIvol = 18.0 mGy (Body) DLP = 626.6
mGy-cm.
Total DLP (Body) = 1,738 mGy-cm.
COMPARISON: CT U dated ___.
FINDINGS:
PELVIS: The partially visualized small and large bowel are unremarkable
except for sigmoid diverticulosis without diverticulitis. Again seen is
circumferential wall thickening of the urinary bladder with surrounding
stranding, unchanged compared to ___, in keeping with known history of
radiation cystitis. Foci of air within the bladder are likely related to
instrumentation. A Foley is seen within the bladder. Foci of extraluminal
fluid and gas anterior to the urinary bladder and posterior to the inferior
aspect of the pubic symphysis are again noted. After administration of
contrast via the Foley, the urinary bladder is filled with contrast without
evidence of rupture. After the balloon is deflated and patient spontaneously
voids, contrast outlines the urethra without communication to the extraluminal
fluid and gas anterior to the urinary bladder (series 8, image 29 and series
11, image 43).
REPRODUCTIVE ORGANS: Post TURP defect is again noted. Fiducial markers are
seen in the prostate.
LYMPH NODES: There is no pelvic or inguinal lymphadenopathy.
VASCULAR: Mild atherosclerotic disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Foci of air within the pubic symphysis can be seen with degenerative changes.
SOFT TISSUES: There are bilateral fat containing inguinal hernias.
IMPRESSION:
1. Contrast outlining the urinary bladder and urethra without evidence of
rupture or fistulous tract connection to the unchanged collection of air and
fluid anterior to the urinary bladder and posterior to the pubic symphysis.
2. Redemonstration of imaging findings of radiation cystitis.
Radiology Report
EXAMINATION: MR PELVIS WANDW/O CONTRAST
INDICATION: ___ year old man with history of atrial fibrillation on apixaban,
prostate cancer s/p radiation, BPH s/p TURP, HTN who presents with suprapubic
pain, treating for cystitis but with persistent unchanged collection of air
and fluid anterior to the urinary bladder and posterior to the pubic
symphysis.// ?pubic symphysis osteo or other pathology related to air/fluid
collection
TECHNIQUE: Imaging performed at 1.5 tesla using the body array coil.
Sequences include axial T1 and STIR, coronal T1 and STIR, axial T1 fat sat pre
and post-contrast, coronal T1 fat sat post contrast weighted sequences. The
patient received 10 mL Gadavist for intravenous contrast..
COMPARISON: CT cystogram ___ and CT urogram ___
FINDINGS:
There is a Foley catheter in-situ, the balloon is positioned relatively
inferiorly in the region of the prostatic urethra (11:34). At this level,
there is an apparent defect in the anterior urethral wall (11:33) which is
contiguous with a trace fluid and more extensive phlegmon and inflammatory
change involving the adjacent obturator internus muscles, the space of Retzius
and the bilateral superior and inferior pubic rami. Fluid tracks in a
contiguous fashion into the symphysis pubis consistent with septic arthritis.
Replacement of the normal T1 marrow signal intensity in the parasymphyseal
regions bilaterally is consistent with osteomyelitis.
As well as involvement of the obturator internus muscles, there is edema and
hyper enhancement seen in the bilateral adductor longus and brevis muscles
(11:35).
This study is not tailored for evaluation of the pelvic parenchymal structures
including the bladder and urethra, nonetheless the bladder demonstrates
irregular wall thickening is seen on the prior studies, consistent with
provided history of cystitis.
There is a fat containing left inguinal hernia. No pelvic lymphadenopathy
seen.
There are severe degenerative changes in the left hip, mild degenerative
changes in the right hip.
IMPRESSION:
1. Findings consistent with septic arthritis of the symphysis pubis with
associated osteomyelitis of the bilateral superior inferior pubic rami. This
is contiguous with the inflammatory changes detailed below.
2. Findings suspicious for a defect in the anterior wall of the prostatic
urethra. There is a small amount of fluid and more extensive phlegmon and
inflammatory change involving the adjacent soft tissues at the space of
Retzius, obturator internus and adductor musculature. No drainable fluid
collection seen.
3. Bladder wall thickening, edema and hyper enhancement may reflect cystitis
or postradiation change.
4. Fat containing left inguinal hernia.
5. Severe degenerative changes in the left hip.
Radiology Report
INDICATION: ___ year old man with Right PICC// Right PICC 50cm, ___ ___
Contact name: ___: ___
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The tip of a right PICC line projects over the cavoatrial junction. There is
pulmonary vascular congestion without overt pulmonary edema. No focal
consolidation, pneumothorax or large pleural effusion. The size of the
cardiac silhouette is within normal limits.
IMPRESSION:
The tip of the right PICC line projects over the cavoatrial junction.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Lower abdominal pain, Urinary frequency
Diagnosed with Urinary tract infection, site not specified
temperature: 102.0
heartrate: 108.0
resprate: 18.0
o2sat: 94.0
sbp: 142.0
dbp: 64.0
level of pain: 4
level of acuity: 3.0 | #Septic arthritis of symphysis pubis
#Osteomyelitis of bilateral superior inferior pubic rami
#Suprapubic pain
#Acute cystitis
#History of prostate cancer s/p radiation
#History of BPH s/p TURP
On admission, labs remarkable for WBC 13.7, UA with >182 WBC &
___. Pt started on cefepime and admitted to general medicine.
UCx with growth of Amp-S enterococcus and pt narrowed to
ampicillin. While leukocytosis resolved and pt remained
afebrile, he continued to have significant suprapubic pain. CTU
obtained to help identify
potential pyelonephritis or abscess given severe pain and
recurrent UTIs. While no evidence of pyelo noted, imaging with
evidence of radiation cystitis and revealed a 1.2 cm pocket of
fluid and gas anterior to the urinary bladder thought to be
either degenerative changes vs. ?Pubic septic arthritis.
Follow-up CT cystogram showed no fistulous tract between urinary
bladder and pocket of air. Pt evaluated by urology, no urgent GU
intervention thought to be necessary and reccomended 4 week
course of PO abx. ID consulted for assistance with abx
management and any further work-up of fluid/air pocket adjacent
to pubic symphysis. MRI was obtained which showed septic
arthritis of the symphysis pubis with associated osteomyelitis
of the bilateral superior inferior pubic rami. His antibiotic
regimen was changed back to IV ampicillin for a planned 6 week
course.
- repeat Ucx growing enterococcus with same sensitivities as
prior
-IV CTX -> ___ IV ampicillin for enterococcus in urine culture
-> PO ___ -> back to IV ampicillin ___ for planned 6 week
course (has PICC)
-For pain (also seen by chronic pain team):
--- ___ increased oxycodone to 10 mg qh6 -> 5 mg q6h standing
given patient was sleeping all day on higher dose.
--- oxycodone 5 mg q4h prn
--- gabapentin 100 mg twice daily + 300 mg qHS
-continuous foley catheter drainage (discussed suprapubic
catheter as alternative if more comfortable for patient but he
prefers to keep his current foley catheter)
-urology f/u scheduled
-ID consult will contact him for f/u appointment
-ID follow up with weekly CBC with differential, BUN, Cr, CRP
-Continued home tamsulosin
-___ evaluated patient and initially recommended home with home
___ but patient felt uncomfortable going home given his ongoing
difficulty ambulating and lack of sufficient support at home and
preferred rehab stay.
#Atrial fibrillation
-Continued home apixaban
-Continued home Metoprolol
#Hypertension
Home lisinopril 2.5 mg daily and amlodipine 10 mg daily were
initially held, then resumed when BPs became elevated in the
140-60s/70-80s. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
aspirin
Attending: ___.
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
Right post crani for mass resection ___
History of Present Illness:
Ms. ___ is a ___ yo F with a hx of Lung CA s/p resection
x 2 and chemo. Patient presented to ___ with c/o of severe
headaches over the last month. Patient also reports frequent pre
syncopal events often resulting in falls occurring the last
month. She also reports decreased peripheral vision. She states
she had gotten in a few minor car accidents secondary to her
decreased vision. She also endorses nausea and vomiting. She
states she has been vomiting every few days for the past month.
She denies any feeling of weakness, numbness or tingling. A CT
head was done at ___ which revealed a R parietal mass. She was
transferred to ___ ___ for further management
Past Medical History:
Lung CA
-Resection of ___ R lung ___
-resection of ___ remaining R lung in ___ + chemotherapy
HTN
HLD
Depression GERD
Social History:
___
Family History:
NC
Physical Exam:
O: T:97.7 BP: 138/67 HR:72 R18 O2Sats 99%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: ___ EOMs intact with beats of horizontal
nystagmus
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: ___ objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally. Decreased vision in bilateral peripheral fields
(difficult to assess in ___
III, IV, VI: Extraocular movements intact bilaterally with
horizontal nystagmus on both left and right gaze
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch, proprioception, pinprick and
vibration bilaterally.
ON THE DAY OF DISCHARGE:
Patient is awake, alert, oriented. MAE full, incision C/D/I
Pertinent Results:
CT: large right parietal mass with vasogenic edema
Radiology Report CT chest ABD & PELVIS W & W/O CONTRAST, ADDL
SECTIONS Study Date of ___ 9:10 AM
IMPRESSION:
1. Centrally necrotic subcarinal lymph node concerning for
disease recurrence/ metastasis which results in extrinsic
compression and narrowing of the right mainstem bronchus. Right
hilar and mediastinal lymphadenopathy also compatible with
metastatic disease.
2. Patient is status post right upper lobectomy and wedge
resection of the right lower lobe. There is diffuse
centrilobular emphysema.
3. Liver hemangioma is noted in segment 6. No evidence of
metastasis in the abdomen or pelvis.
Radiology Report MR HEAD W & W/O CONTRAST Study Date of
___ 10:45 AM
IMPRESSION:
Approximately 3.5 cm enhancing mass with a broad dural
attachment to the right occipital dura. This mass is highly
suspicious for a dural based metastasis. A meningioma was
considered given the signal intensity and enhancement
characteristics, however, it is felt to be less likely as there
is a 4 mm enhancing satellite leptomeningeal lesion in the right
parietal region superior to the mass (series 15, image 15).
If further radiographic characterization is needed, MR
spectroscopy with the voxel placed in the extensive surrounding
FLAIR signal abnormality could help distinguish between edema
surrounding a malignancy and edema surrounding a meningioma.
Edema is noted to cross the corpus callosum.
___ ___ F ___ ___
Pathology Report Tissue: BRAIN/MENINGES FOR TUMOR Procedure Date
of ___
Report not finalized.
Logged in only.
PATHOLOGY # ___
BRAIN/MENINGES FOR TUMOR
Cardiovascular Report ECG Study Date of ___ 8:32:24 AM
Normal sinus rhythm. Normal ECG. No previous tracing available
for
comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
77 124 88 ___ 56 36 48
Radiology Report CHEST (PRE-OP PA & LAT) Study Date of
___ 12:00 AM IMPRESSION:
The patient is after right lung surgery, most likely a right
upper lobectomy. In addition there is also evidence of the
___ wedge resection. The lungs are clear. No pleural
effusion or pneumothorax demonstrated. Mass in the sub- carinal
location that is obstructing right upper lobe and right lower
lobe bronchi is present in, better appreciated on the CT towards
the from ___. It is also can be seen on the
radiograph especially on the lateral view.
Radiology Report MR HEAD W/ CONTRAST Study Date of ___
9:30 AM
IMPRESSION:
Right occipital lobe lesion with surrounding satellite lesion
again identified for surgical planning. No significant change
since the previous study.
Radiology Report CT HEAD W/O CONTRAST Study Date of ___
7:59 ___
IMPRESSION:
Expected postoperative changes status post recent right
occipital craniotomy and resection of a right occipital lobe
lesion with no evidence of hemorrhage or territorial infarction.
Radiology Report MR HEAD W & W/O CONTRAST Study Date of
___ 9:20 AM
IMPRESSION:
1. Right occipital craniotomy an interval resection of the right
occipital-region mass seen on prior MRI. Thin curvilinear
enhancement in the operative bed (series 13, image 11) is seen
at the upper margin of the surgical cavity. Attention on
follow-up imaging suggested.
2. Unchanged 3 mm enhancing satellite lesion in the right
parietal lobe.
3. Expected postsurgical changes with a thin 1.5 cm parafalcine
subdural
hematoma.
Medications on Admission:
lisinopril 10mg, HCTZ 12.5, paroxetine 20 mg, lansoprazole
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN pain/fever
2. Paroxetine 20 mg PO DAILY
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*80 Tablet Refills:*0
4. Lisinopril 10 mg PO DAILY
5. Hydrochlorothiazide 12.5 mg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Dexamethasone 2 mg PO Q8H Duration: 3 Doses
RX *dexamethasone 2 mg 1 tablet(s) by mouth every eight (8)
hours for 3 doses Disp #*60 Tablet Refills:*0
8. Dexamethasone 2 mg PO Q12H Duration: 9999 Doses
9. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
10. LeVETiracetam 500 mg PO BID
RX *levetiracetam [Keppra] 500 mg 1 tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*1
11. Senna 8.6 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Right parietal brain mass
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 AND W/O CONTRAST
INDICATION: History: ___ with new brain mass // eval mass
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 5cc of Gadavist intravenous contrast, axial imaging was
performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal
MPRAGE imaging was performed and re-formatted in axial and coronal
orientations
COMPARISON: Noncontrast CT head ___
FINDINGS:
There is a 3.0 x 3.5 x 2.4 cm (AP x TV x SI) T1 isointense to gray matter, T2
heterogeneously hyperintense to gray matter, mass peripherally within the
right occipital region. This mass appears to have a broad dural attachment to
the right occipital dura (best appreciated axial series 15 image 11, sagittal
series 14 image 99). There is a suggestion of a CSF cleft between the mass and
the right occipital lobe (series 13, image 10). These features suggest that
the mass is extra-axial in location. The mass enhances rather homogeneously in
its peripheral portions and is relatively hypoenhancing within its central
portion. There is slowed diffusion within the solidly enhancing portions of
the mass. There is no hemorrhage in the mass. There is extensive surrounding
abnormal FLAIR signal in the right occipital, temporal, and frontoparietal
lobes. This abnormal FLAIR signal extends into the splenium of the corpus
callosum. Superior to the mass, there is a 4 mm homogeneously enhancing focus
within the right parietal region (axial series 15 image 15, sagittal series 14
image 101). This enhancing lesion appears to be leptomeningeal in location.
Major intravascular flow voids are preserved. There is normal enhancement of
the major intracranial arteries and dural venous sinuses following contrast
administration.
No osseous lesions are identified. The paranasal sinuses and mastoid air cells
are clear. The orbits are normal.
IMPRESSION:
Approximately 3.5 cm enhancing mass with a broad dural attachment to the right
occipital dura. This mass is highly suspicious for a dural based metastasis. A
meningioma was considered given the signal intensity and enhancement
characteristics, however, it is felt to be less likely as there is a 4 mm
enhancing satellite leptomeningeal lesion in the right parietal region
superior to the mass (series 15, image 15).
If further radiographic characterization is needed, MR spectroscopy with the
voxel placed in the extensive surrounding FLAIR signal abnormality could help
distinguish between edema surrounding a malignancy and edema surrounding a
meningioma. Edema is noted to cross the corpus callosum.
Radiology Report
EXAMINATION: CT TORSO W/CONTRAST
INDICATION: History: ___ with history of lung cancer status post right upper
lobectomy and right lower lobe wedge resections with new brain mass
TECHNIQUE: Multidetector CT of the torso was done as part of CT torso without
and with IV Contrast. Initially the abdomen was scanned without IV contrast.
Subsequently a single bolus of IV contrast was injected and the torso was
scanned in the portal venous phase, followed by scan of the abdomen in
equilibrium (3-min delay) phase.
Coronal and sagittal reformations were performed and submitted to PACS for
review.
IV contrast: 100ml Omnipaque
DOSE: DLP: 751 mGy-cm .
COMPARISON: None available.
FINDINGS:
CHEST:
There is a centrally necrotic lymph node measuring 5.0 x 2.9 x 3.2 cm in the
subcarinal region causing extrinsic compression and narrowing of the right
mainstem bronchus (601b:28). Secretions are noted within the narrowed
bronchus as well as proximal to the area of narrowing. Right hilar (3:28),
right upper paratracheal, (3:15), and left lower paratracheal lymph nodes
(3:20), are also enlarged.
Patient is status post right upper lobectomy and wedge resection of the right
lower lobe with right-sided volume loss and subsequent mediastinal shift to
the right. There is diffuse centrilobular emphysema. Lungs are clear without
focal consolidation or suspicious nodule.
The pleura is intact without effusion. No pneumothorax or pneumomediastinum.
The thoracic aorta is normal caliber. The pulmonary arteries are well
opacified without filling defect.
The thyroid is unremarkable. The heart is unremarkable. The pericardium is
intact without effusion.
The esophagus is unremarkable.
ABDOMEN:
GENERAL: There is no intra-abdominal free air or free fluid.
HEPATOBILIARY: There is a 1.2 cm hypodense lesion in the liver segment 6 with
nodular peripheral enhancement on portal venous phase that fills in on delayed
phase, consistent with a hemangioma. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is unremarkable, without
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. There is no evidence
of focal renal lesions or hydronephrosis. There are no urothelial lesions in
the kidneys or ureters. There is no perinephric abnormality.
GASTROINTESTINAL: Colon and small bowel loops demonstrate normal caliber and
wall thickness. . Appendix contains air, has normal caliber without evidence
of fat stranding.
RETROPERITONEUM: There is no evidence of retroperitoneal and mesenteric
lymphadenopathy.
VASCULAR: There is moderate calcium burden in the abdominal aorta.
PELVIS:
The bladder and uterus are unremarkable. There is no evidence of pelvic or
inguinal lymphadenopathy. There is no free fluid in the pelvis.
BONES AND SOFT TISSUES:
There is no evidence of worrisome lesions. Abdominal and pelvic wall is within
normal limits.
IMPRESSION:
1. Centrally necrotic subcarinal lymph node concerning for disease recurrence/
metastasis which results in extrinsic compression and narrowing of the right
mainstem bronchus. Right hilar and mediastinal lymphadenopathy also compatible
with metastatic disease.
2. Patient is status post right upper lobectomy and wedge resection of the
right lower lobe. There is diffuse centrilobular emphysema.
3. Liver hemangioma is noted in segment 6. No evidence of metastasis in the
abdomen or pelvis.
Radiology Report
EXAMINATION: MR HEAD W/ CONTRAST
INDICATION: ___ year old woman with brain mass, OR ___ ___ // OR scheduled
for afternoon ___ please perform by noon
TECHNIQUE: Axial T1 and MPRAGE post gadolinium images were obtained with
surface markers for surgical planning.
COMPARISON: ___.
FINDINGS:
Again an enhancing lesion lesion with surrounding edema identified in the
right occipital region. A small satellite lesion is identified. Surrounding
edema and mass effect are noted. There is no midline shift.
IMPRESSION:
Right occipital lobe lesion with surrounding satellite lesion again identified
for surgical planning. No significant change since the previous study.
Radiology Report
EXAMINATION: CHEST (PRE-OP PA AND LAT)
INDICATION: ___ year old woman pre-op for craniotomy // any acute issues?
Surg: ___ (craniotomy)
TECHNIQUE: CHEST (PRE-OP PA AND LAT)
COMPARISON: ___
IMPRESSION:
The patient is after right lung surgery, most likely a right upper lobectomy.
In addition there is also evidence of the ___ wedge resection. The lungs
are clear. No pleural effusion or pneumothorax demonstrated. Mass in the sub-
carinal location that is obstructing right upper lobe and right lower lobe
bronchi is present in, better appreciated on the CT towards the from ___. It is also can be seen on the radiograph especially on the
lateral view.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old woman with s/p right crani // post op by 8 pm
TECHNIQUE: Contiguous axial CT images were obtained through the brain without
the administration of IV contrast. Reformatted coronal, sagittal and thin
section bone algorithm-reconstructed images were then generated.
DOSE: DLP: 1003 mGy-cm
CTDI: 50
COMPARISON: Reference head CT on ___ and MR head on ___ at 09:50
FINDINGS:
The patient is status post right occipital craniotomy with resection of a
right occipital lobe lesion, as characterized on recent MRI. Expected
postoperative changes including pneumocephalus are seen adjacent to the
surgical bed, along the right convexity and bilateral frontal lobes. Edema and
mass effect in the right occipital lobe are similar in extent to the prior CT.
There is persistent compression of the right lateral ventricle with 7 mm of
leftward midline shift. There is no evidence of acute hemorrhage or
territorial infarction.
The basal cisterns appear patent and there is preservation of gray-white
matter differentiation.
The paranasal sinuses, mastoid air cells, and middle ear cavities are clear.
The globes are unremarkable.
IMPRESSION:
Expected postoperative changes status post recent right occipital craniotomy
and resection of a right occipital lobe lesion with no evidence of hemorrhage
or territorial infarction.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST
INDICATION: ___ year old woman with s/p right crani for mass resection //
post op must be performed on ___
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 5cc of Gadavist intravenous contrast, axial imaging was
performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal
MPRAGE imaging was performed and re-formatted in axial and coronal
orientations
COMPARISON: MRI head ___, MRI head ___
FINDINGS:
There has been a right occipital craniotomy and resection of a right occipital
region mass. There are areas of slowed diffusion with corresponding ADC
weighted hypointensity and blood products within the operative bed, consistent
with postoperative change. There is a 1.5 cm thick subdural hemorrhage along
the falx, new from preoperative MRI. There is postsurgical frontal
pneumocephalus. There is thin curvilinear enhancement in the operative bed
(series 13, image 11). The 3 mm enhancing satellite lesion in the right
parietal lobe superior to the resected mass remains present (series 13, image
14). Extensive vasogenic edema throughout the right occipital, parietal, and
temporal lobes is not significantly changed from preoperative MRI. Abnormal
FLAIR signal is again noted to extend across the splenium of the corpus
callosum.
Major intracranial flow voids are preserved. There is normal enhancement of
the major intracranial arteries and dural venous sinuses following contrast
administration.
The paranasal sinuses and mastoid air cells appear clear. The orbits are
normal.
IMPRESSION:
1. Right occipital craniotomy an interval resection of the right
occipital-region mass seen on prior MRI. Thin curvilinear enhancement in the
operative bed (series 13, image 11) is seen at the upper margin of the
surgical cavity. Attention on follow-up imaging suggested.
2. Unchanged 3 mm enhancing satellite lesion in the right parietal lobe.
3. Expected postsurgical changes with a thin 1.5 cm parafalcine subdural
hematoma.
*********reviewed with Dr. ___
Gender: F
Race: OTHER
Arrive by AMBULANCE
Chief complaint: Headache
Diagnosed with SWELLING IN HEAD & NECK
temperature: 97.7
heartrate: 72.0
resprate: 18.0
o2sat: 99.0
sbp: 138.0
dbp: 67.0
level of pain: 2
level of acuity: 2.0 | On ___ the patient was transferred to ___ after presenting to
an outside hospital for complaints of headaches and a non
contrast head CT showed a large right parietal mass with
vasogenic edema. The patient was admitted to the neurosurgery
service. The patient was alert and oriented to person place and
time. The patient was moving all of her extremities with full
strength. The patients extraocular movements were intact her
pupils were equal round and reactive to light, and the patient
had a left peripehral visual field cut. The patient was admitted
to the floor.
On ___ the patient remained neurologically intact, and alert
and oriented to perosn place and time. The patients pupils were
equal round and reactive to light, 2.5-2 mm bilaterally, and the
patient continues to have a left peripheral visual field cut.
The patient was NPO, and taken to the operating room for a
craniotomy for mass resection.
On ___, The patient was in the intensive care unit and was
neurologically ___. The patient diet was advanced and the
patient was transferred to the floor. A post operative MRI was
performed.
On ___, The patients serum potassium was repleated and the
surgical dressing was removed. The patient was mobilized and
tolerating a regular diet well. physical and occupational
therapy consults were placed.
On ___, The patient complained of dizziness with position
changes. The patient was given a 500 cc bolus and orthostaic
signs were ordered. Physical therapy evaluated the patient and
determined that there was no need for ___ or OT. The patient
would like to change oncology care from ___ to here so
that all oncology care in the same place. On ___ the patient
was stable on exam and cleared for discharge home. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
DVT
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ hx of mild Alzheimer disease, hypertension, history of
kidney stones, Crohn disease with colostomy, solitary kidney,
history of multiple DVTs w/ IVC filter. She woke up this morning
and reported painful, red and swollen right leg to her husband.
She was unable to walk on it because of the pain but has been
ambulatory at home. Five week ago she fell against her bed and
broke her pelvis, she was admitted to ___ for 3
days, no surgery, went to ___ for 2 weeks, and has
been followed by ___ and ___ since and has been doing well at
home. She has had multiple DVTs in the past and was on Coumadin
5mg for a DVT earlier in the year but was stopped by her PCP
with the last dose on ___. She denies CP or SOB. Her husband
reports that her appetite has been less since rehab and she is
not drinking as much as he would like but has not noticed weight
loss (113lbs at home). No history of malignacy, but it has been
"at least ___ years" since she had a colonoscopy or been seen by
a gynecologist.
Past Medical History:
Alzheimer disease
Hypertension
History of kidney stones
Crohn diseases with colostomy (?partial colectomy)
Solitary kidney (from surgery complication)
History of multiple DVTs
Gout
DJD of shoulder
Social History:
___
Family History:
non-contributory
Physical Exam:
Admission Physical Exam:
Vitals: T:97.4 BP:100/60 P:66 R:16 O2:96%RA
General: Alert, oriented, no acute distress. Pleasantly
demented.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, 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. Colostomy
stoma, pink and putuberent, yellow-brown stool.
Ext: Warm, well perfused, 2+ pulses, no clubbing, edema and
cellulitis in both legs, worse on the left, redness on the left
calf, negative ___ sign
Neuro: CNII-XII grossly intact. EOMI, PERRLA, visual fields
intact. Strength 2+ in both ___, strength 2+ in UE except right
shoulder limited by pain
MSE: AAOx1 to person, spelled WORLD backwards
External Pelvic: No lesions noted, no gross blood
DRE: No lesions or masses. Red brown stool. Guiac positive.
Discharge Physical Exam:
Vitals - 97.3 145/50 93 20 96%RA
General: Alert, oriented, no acute distress. Pleasantly
demented.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, 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. Colostomy
stoma, pink and putuberent, yellow-brown stool.
Ext: Warm, well perfused, 2+ pulses, no clubbing, edema and
cellulitis in both legs, worse on the left, redness on the left
calf, negative ___ sign
Neuro: CNII-XII grossly intact. EOMI, PERRLA, visual fields
intact. Strength 2+ in both ___, strength 2+ in UE except right
shoulder limited by pain
MSE: AAOx1 to person, spelled WORLD backwards
Pertinent Results:
Labs on Admission
___ 11:15AM BLOOD WBC-8.6 RBC-3.79* Hgb-11.7* Hct-35.7*
MCV-94 MCH-30.8 MCHC-32.7 RDW-13.8 Plt ___
___ 11:15AM BLOOD Neuts-71.5* ___ Monos-5.0 Eos-2.1
Baso-0.5
___ 11:54AM BLOOD ___ PTT-29.7 ___
___ 11:15AM BLOOD Plt ___
___ 11:15AM BLOOD Glucose-113* UreaN-21* Creat-3.1* Na-141
K-5.9* Cl-104 HCO3-28 AnGap-15
Labs on Discharge
___ 07:15AM BLOOD WBC-5.7 RBC-3.50* Hgb-10.7* Hct-33.2*
MCV-95 MCH-30.4 MCHC-32.1 RDW-13.9 Plt ___
___ 07:15AM BLOOD Plt ___
___ 07:15AM BLOOD ___ PTT-37.0* ___
___ 06:40AM BLOOD Ret Aut-1.6
___ 07:15AM BLOOD Glucose-94 UreaN-15 Creat-2.1* Na-140
K-4.2 Cl-107 HCO3-25 AnGap-12
___ 07:15AM BLOOD Calcium-8.8 Phos-3.4 Mg-2.1
Imaging:
CT HEAD W/O CONTRAST Study Date of ___ 8:15 AM
FINDINGS: There is no evidence of hemorrhage, edema, mass
effect or
infarction. The ventricles and sulci are normal in size and
configuration. The basal cisterns appear patent and there is
preservation of gray-white differentiation. Of note, there is
presence of a cavum septum pellucidum and verge.
No fracture is identified. There is evidence of a chronically
inflamed left maxillary sinus, otherwise mastoid air cells, and
middle ear cavities are clear. The globes are unremarkable.
CONCLUSION:
1. No evidence of hemorrhage, infarction, or mass effect.
2. Chronically inflamed left maxillary sinus.
Neurophysiology Report EEG Study Date of ___
FINDINGS:
ABNORMALITY #1: There were occasional bursts of generalized
slowing in the theta range and occasional, brief focal theta
slowing in the right temporal region.
BACKGROUND: Included a 9 Hz alpha rhythm posteriorly which
attenuated
symmetrically with eye opening.
HYPERVENTILATION: Could not be performed.
INTERMITTENT PHOTIC STIMULATION: Produced no activation of the
record.
SLEEP: The patient remained awake during the study.
CARDIAC MONITOR: Showed a regular rhythm with an average rate of
100 bpm.
IMPRESSION: Mildly abnormal EEG due to the occasional bursts of
generalized slowing and right temporal slowing in theta range.
This suggests multifocal subcortical dysfunction. Vascular
disease is one of the most common causes at this age. No
epileptiform discharges were seen.
MRA BRAIN W/O CONTRAST Study Date of ___ 3:15 ___
FINDINGS: There is no evidence of perfusion abnormality or
hemorrhage.
Ventricles and sulci are normal in size and configuration.
Basal cisterns are patent. Again noted is a cavum septum
pellucidum. FLAIR hyperintensities in the periventricular white
matter consistent with the sequelae of chronic small
vessel ischemic disease.
The left and right carotids appear widely patent. Apparent
patulous
appearance of the bifurcation of the left MCA is likely just of
bulbous
division. There is no evidence of aneurysm in this area.
There is however irregularity in the inferior division of the M1
as well as an apparent abrupt occlusion in the distal M1
superior division branches (12:20 and 101:6). Atherosclerotic
plaque is likely responsible for irregularities in A2 and left
M2.
IMPRESSION:
1. Apparent occlusion of the distal M1 superior branches as
well as
irregularity in the inferior branches of M1 are likely due to
emboli. There are no diffusion abnormalities seen in this area.
2. Patulous appearance of the bifurcation of the left MCA
without any
evidence of aneurysm.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Family/Caregiver.
1. Verapamil 120 mg PO DAILY
2. Atenolol 25 mg PO BID
3. Donepezil 5 mg PO HS
Discharge Medications:
1. Donepezil 5 mg PO HS
2. Warfarin 2 mg PO DAILY16
hold if INR >3.0, increase if INR <2.0
RX *warfarin [Coumadin] 2 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
3. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth Daily Disp
#*30 Tablet Refills:*0
4. Outpatient Lab Work
PLEASE check INR on ___ and fax results to Dr.
___ at ___
1. Donepezil 5 mg PO HS
2. Warfarin 2 mg PO DAILY16
hold if INR >3.0, increase if INR <2.0
RX *warfarin [Coumadin] 2 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
3. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth Daily Disp
#*30 Tablet Refills:*0
4. Outpatient Lab Work
PLEASE check INR on ___ and fax results to Dr.
___ at ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
primary diagnosis: Deep venous thrombosis, urinary tract
infection
secondary diagnosis: Alzheimer's Disease, hypertension
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with left lower extremity swelling and
erythema. Evaluate for evidence of DVT.
COMPARISON: None available.
TECHNIQUE: Gray-scale, color Doppler, spectral analysis of the venous system
of the left lower extremity was performed followed by examination of the right
lower extremity after findings of DVT in the left lower extremity.
FINDINGS: There is no compression or color flow in the common femoral,
superficial femoral, or popliteal veins in the left lower extremity. The calf
veins were not clearly visualized in the left lower extremity. The left
greater saphenous vein did not show compression, suggesting probable thrombus
burden at this level (1:6). In the right lower extremity, there is normal
compression and augmentation of the common femoral, superficial femoral,
popliteal, posterior tibial, and peroneal veins.
IMPRESSION:
1. Occlusive deep vein thrombosis in the left lower extremity extending from
the popliteal vein to the common femoral vein, with probably thrombus burden
in the greater saphenous vein as well.
2. No evidence of DVT in the right lower extremity.
A wet read was entered at 11:05 a.m. after discovery of the findings at
approximately 11:03 a.m and Dr. ___ is aware of the findings.
Radiology Report
INDICATION: Acute kidney injury. Evaluate for obstructive process.
TECHNIQUE: Renal ultrasound.
COMPARISON: None.
FINDINGS:
The right kidney measures 8.3 cm.
The left kidney measures 7.9 cm.
The study is technically limited. However, there is no obvious evidence of
hydronephrosis, stone, or mass. The bladder was empty at the time of the
examination and cannot be evaluated. The renal parenchyma may be mildy
echogenic.
IMPRESSION: Limited renal ultrasound. No hydronephrosis. Mildly echogenic
renal parenchyma suggestive of renal parenchymal disease.
Radiology Report
INDICATION: ___ woman with DVT and Alzheimer's on a heparin drip who
presents with new expressive aphasia.
COMPARISONS: None.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without administration of IV contrast.
FINDINGS: There is no evidence of hemorrhage, edema, mass effect or
infarction. The ventricles and sulci are normal in size and configuration.
The basal cisterns appear patent and there is preservation of gray-white
differentiation. Of note, there is presence of a cavum septum pellucidum and
verge.
No fracture is identified. There is evidence of a chronically inflamed left
maxillary sinus, otherwise mastoid air cells, and middle ear cavities are
clear. The globes are unremarkable.
CONCLUSION:
1. No evidence of hemorrhage, infarction, or mass effect.
2. Chronically inflamed left maxillary sinus.
Radiology Report
HISTORY: ___ woman with Alzheimer's, history of DVT, now with
expressive aphasia.
COMPARISON: CT of the head without contrast from ___.
TECHNIQUE: MRI and MRA of the brain and neck.
FINDINGS: There is no evidence of perfusion abnormality or hemorrhage.
Ventricles and sulci are normal in size and configuration. Basal cisterns are
patent. Again noted is a cavum septum pellucidum. FLAIR hyperintensities in
the periventricular white matter consistent with the sequelae of chronic small
vessel ischemic disease.
The left and right carotids appear widely patent. Apparent patulous
appearance of the bifurcation of the left MCA is likely just of bulbous
division. There is no evidence of aneurysm in this area.
There is however irregularity in the inferior division of the M1 as well as an
apparent abrupt occlusion in the distal M1 superior division branches (12:20
and 101:6). Atherosclerotic plaque is likely responsible for irregularities in
A2 and left M2.
IMPRESSION:
1. Apparent occlusion of the distal M1 superior branches as well as
irregularity in the inferior branches of M1 are likely due to emboli. There
are no diffusion abnormalities seen in this area.
2. Patulous appearance of the bifurcation of the left MCA without any
evidence of aneurysm.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: BIL FEET/NUMBNESS TO TOES/CELLULITIS
Diagnosed with ACUTE VENOUS EMBOLISM AND THROMBOSIS OF UNSPECIFIED DEEP VESSELS OF LOWER EXTREMITY, ALZHEIMER'S DISEASE, DEMENTIA IN CONDITIONS CLASSIFIED ELSEWHERE WITHOUT BEHAVIROAL DISTURBANCE
temperature: 98.6
heartrate: 80.0
resprate: 18.0
o2sat: 98.0
sbp: 122.0
dbp: 64.0
level of pain: 13
level of acuity: 3.0 | ___ with a hx of mild Alzheimer disease, hypertension, history
of kidney stones, Crohn disease with colostomy, solitary kidney,
history of DVT w/ IVC filter with completed Coumadin treatment
___ who presented with a swollen lower left leg.
# DVT: Patient presented with a swollen left lower extremity.
She had ___ which revealed an occlusive thrombosis in the
left lower extremity extending from the popliteal vein to the
common femoral vein with probable thrombus burden in the greater
saphenous vein as well. She has a history of DVT and possible
causes of recurrent DVT include hypercoagulable states such as
malignancy or Crohns disease. She also had a recent hip fracture
putting her at higher risk. The primary team spoke with PCP who
confirmed that there was no absolute contraindication to
anticoagulation and therefore, the patient was started on a
heparin drip to bridge to coumadin. Initially her PTTs were
elevated on the heparin drip requiring her drip to be
intermittently stopped. Her INR eventually trended up as high as
6.5 but was within therapeutic range (2.1) at time of discharge.
She was discharged on 2 mg of warfarin daily with plans to have
close PCP follow up and frequent INR checks.
# Acute toxic metabolic encephalopathy: Mental status at
baseline on admission. Continued donepazil 5mg QHS. However on
___, she was noted to have a non focal neuro exam, but exhibited
expressive aphasia significantly different than baseline. A code
stroke was called and neurology evaluated the patient. She had a
head CT followed by an MRI/MRA and EEG which were all
unrevealing for an acute cause of her altered mental status. It
was felt that her confusion and agitation were most likely
related to delirium from her UTI and Cipro use. Her mental
status improved to baseline after completion of UTI treatment
and cessation of antibiotics.
# Acute on chronic kidney disease: Cr was 3.1 on admission,
baseline Cr around 2.0. Solitary kidney from surgical
complication. Renal U/S showed no hydronephrosis. Urine lytes
were suggestive of prerenal etiology. She was give intravenous
fluids with improvement in her creatinine to baseline.
# UTI - UA showed WBC >187 and pos leukocyte esterase. She
denied urinary symptoms, however due to her confusion, she was
treated for a total of 3 days.
# Hypertension: Well controlled at home with SBPs in the
100s-120s. D/Ced verapamil due to concern of polypharmacy and
switched her atenolol to metoprolol tartrate given her renal
function. She developed tachycardia to 120s and hypertension up
to SBP 170 on ___ so we increased her metoprolol to 50mg with
blood pressure controlled down to SBP of 140s and HR of ___ by
discharge. We switched to metoprolol succinate XL 100mg for
outpatient therapy.
Transitional Issues:
- INR will need to be closely followed and warfarin dose may
need further titration to remain in therapeutic range.
- her blood pressure and heart rate will need to be monitored
and her antihypertensive regimen may need further adjustment
- code during admission: full |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old ___ speaking woman with PMHx significant for
Alzhemier's and vascular dementia, HTN, HLD, DM, & cirrhosis who
presents with chest pain lasting several hours. Per family, she
was having chest pain this morning when she woke up that
radiated to her L arm, back, and shoulder. She was given ASA
81mg x2 and 2 SL nitroglycerin prior to arrival. Upon arrival,
she denies any pain. Pt has had chest pain previously and was
seen in the ED for chest pain on ___ at which time she
had a workup including enzymes and CXR, and cardiac enzymes that
was negative.A stress test was recommended, however, patient
refused this at the time as was being discharged against medical
advice. Per her daughter pt continues to have chest pain since
the ED evaluation in ___. She continues to have chest pain
on a regular basis a couple times per week for which she takes
nitroglycerin. Chest pain is worse when she is nervous.
Of note on ___ pt had a pharmacologic stress test with no
EKG changes and a persantine MIBI both which was had normal
myocardial perfusion scan.
In the ED, initial VS were 97.4, 50, 119/55, 18, 96% RA. EKG
showed sinus bradycardia, prolonged QT, LAD, and LVH. Exam
showed well appearing woman in no acute distress, RRR with nml
S1S2, lungs CTA, abd SNTND, no pedal edema. Labs notable for
negative troponin, BUN 28, Cr 1.3. CXR neg for acute process.
Patient was given ASA 81mg x2 (for total 325mg) and quetiapine
25mg. She was initially placed in ED observation for ___ with 2
sets and a stress, but was observed trying to hang herself with
telemetry wires, therefore she is being admitted for ___ and
psychiatry eval. Psychiatry saw her in the ED and do not feel
that she is depressed or suicidal, however given her dementia
they recommended 1:1 observation for now.
.
On arrival to the floor, patient reports that she does not
currently have chest pain. However she does have some chest
discomfort with deep breathing.
.
REVIEW OF SYSTEMS:
+chest pain, anxiety
Denies 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.
All other 10-system review negative in detail.
Past Medical History:
- dementia (Alzhemier's and vascular)
- diabetes type 2
- hypertension
- hyperlipidemia
- hypothyroidism
- cirrhosis
- gastritis seen on EGD ___
- pancreatitis
- diverticulosis
- gastritis
- benign colonic polyp s/p polypectomy ___
- right rotator cuff arthropathy
- TAH
- cholecystectomy
Social History:
___
Family History:
Mother: deceased no known medical problems
Father: deceased no known medical problems
Sister: T2DM, CAD
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T:98 BP: 157/65 P:50 RR:18 Pox:94% RA
GEN Alert, oriented x2 (person, place), no acute distress lying
comfortably in bed
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD, no bruit
PULM normal respirtory effort, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no r/g
MSK: TTP of anterior chest wall
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions
DISCHARGE EXAM
VS: T:97.8 BP: 104/60 P:50 RR:18 Pox:98% RA
GEN Alert, oriented x2 (person, place), no acute distress lying
comfortably in bed
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD, no bruit
PULM normal respirtory effort, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no r/g
MSK: TTP of anterior chest wall
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions
Pertinent Results:
ADMISSION LABS:
___ 03:00PM cTropnT-<0.01
___ 11:06AM ___ PTT-32.5 ___
___ 10:40AM GLUCOSE-126* UREA N-28* CREAT-1.3* SODIUM-138
POTASSIUM-5.0 CHLORIDE-103 TOTAL CO2-25 ANION GAP-15
___ 10:40AM estGFR-Using this
___ 10:40AM cTropnT-<0.01
___ 10:40AM WBC-7.1 RBC-4.37 HGB-12.9 HCT-38.0 MCV-87
MCH-29.4 MCHC-33.9 RDW-13.8
___ 10:40AM NEUTS-73.0* ___ MONOS-5.5 EOS-2.0
BASOS-0.9
___ 10:40AM PLT COUNT-204
DISCHARGE LABS:
___ 08:40AM BLOOD WBC-5.6 RBC-4.59 Hgb-13.7 Hct-39.3 MCV-86
MCH-29.9 MCHC-34.9 RDW-13.7 Plt ___
___ 08:40AM BLOOD ___ PTT-32.4 ___
___ 08:40AM BLOOD Glucose-142* UreaN-25* Creat-1.3* Na-139
K-4.7 Cl-102 HCO3-29 AnGap-13
___ 08:40AM BLOOD ALT-13 AST-18 LD(LDH)-160 AlkPhos-139*
TotBili-0.5
___ 08:40AM BLOOD Albumin-3.9 Calcium-9.2 Phos-3.4 Mg-2.0
EKG: (___): sinus bradycardia, prolonged QT interval, LAD,
LVH
(___) sinus bradycardia, LAD
IMAGING:
CXR (___): There is mild cardiomegaly. The aorta is
tortuous. There is no evidence of pneumonia, CHF, pneumothorax
or pleural effusion. The main pulmonary arteries are enlarged
as before.
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from
Family/CaregiverwebOMR.
1. Citalopram 40 mg PO DAILY
2. Donepezil 10 mg PO HS
3. Enalapril Maleate 20 mg PO DAILY
4. GlipiZIDE XL 2.5 mg PO DAILY
5. Isosorbide Mononitrate (Extended Release) 60 mg PO PRN chest
pain
6. Levothyroxine Sodium 100 mcg PO DAILY
7. Metoprolol Succinate XL 100 mg PO DAILY
8. Omeprazole 20 mg PO BID
9. Quetiapine Fumarate 12.5 mg PO QAM
10. Quetiapine Fumarate 25 mg PO QHS
11. Aspirin 81 mg PO DAILY
12. MEMAntine *NF* 10 mg Oral ___
13. meloxicam *NF* 15 mg Oral Daily
14. Spironolactone 25 mg PO DAILY
15. Hydrochlorothiazide 25 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Citalopram 20 mg PO DAILY
3. Donepezil 10 mg PO HS
4. Enalapril Maleate 20 mg PO DAILY
5. Hydrochlorothiazide 12.5 mg PO DAILY
hold for SBP<100
6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
hold for SBP<100
7. Levothyroxine Sodium 100 mcg PO DAILY
8. MEMAntine *NF* 10 mg Oral ___
9. Omeprazole 20 mg PO BID
10. Quetiapine Fumarate 12.5 mg PO QAM
11. Quetiapine Fumarate 25 mg PO QHS
12. Spironolactone 25 mg PO DAILY
13. Docusate Sodium 100 mg PO BID
RX *Col-Rite 100 mg 1 capsule(s) by mouth twice a day Disp #*30
Capsule Refills:*0
14. Metoprolol Succinate XL 100 mg PO DAILY
15. Senna 1 TAB PO BID:PRN constipation
RX *senna 8.6 mg 1 capsule by mouth BID: PRN for constipation
Disp #*60 Capsule Refills:*0
16. Simvastatin 20 mg PO DAILY
RX *simvastatin 20 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
17. meloxicam *NF* 15 mg ORAL DAILY
18. GlipiZIDE XL 2.5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Chest pain (stable vs unstable angina)
dementia
HTN
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
PA AND LATERAL VIEWS OF THE CHEST
REASON FOR EXAM: Chest pain.
There is mild cardiomegaly. The aorta is tortuous. There is no evidence of
pneumonia, CHF, pneumothorax or pleural effusion. The main pulmonary arteries
are enlarged as before.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: CHEST PAIN
Diagnosed with CHEST PAIN NOS
temperature: 97.4
heartrate: 50.0
resprate: 18.0
o2sat: 96.0
sbp: 119.0
dbp: 55.0
level of pain: 0
level of acuity: 2.0 | ___ year old ___ speaking woman with PMHx significant for
Alzhemier's and vascular dementia, HTN, HLD, DM, & cirrhosis who
presents with chest pain.
#Chest Pain: Differential of chest pain in this ___ yo F includes
acute MI, stable or unstable angina, pericarditis, myocarditis,
aortic dissection, GERD, PUD, pancreatitis, PNA, pneumothorax,
PE, musculoskeletal chest pain, or anxiety. CXR rules out PNA,
PTX, no evidence of widened mediastinum so aortic dissection
less likely. Pt has history of pancreatitis but symptoms are
not consistent with pancreatitis. Pt has also had episodes of
chest pain before so this is likely angina. Of note pt had a
negative pharmacologic stress test in ___. Other possiblities
include anxiety and costochondritis. Pt chest pain work up
included cardiac enzymes which were negative and an ECG was
revealed some QT prolongation. Pt was continue apirin, beta
blocker, and ACEI. Pt was started on simvastatin 20mg. We also
started isosorbide mononitrate xr at 30mg for her chest pain and
decreased her hydrochlorothiazide to 12.5mg to reduce the risk
of hypotension with the nitrate. A cardiac stress test was
recommended but pt and family are opting not to do stress test
given that pt would not want cardiac catheterization procedure
if the test were positive. So pt was optimal medical management
on ASA, beta-blocker, aceI, and statin.
#Hypertension: Initially pt BP was not well controlled but pt
likely did not get her normal anti-hypertensive meds day of
admission. Once pt received appropriate meds her SBP was in
range of 100-140. Her goal BP is <130/80. We continued pt on
home anti-hypertensive medications with the following changes.
We continued SPIRONOLACTONE 25mg daily, decreased
HYDROCHLOROTHIAZIDE to 12.5 mg daily, continued ENALAPRIL
MALEATE 20mg daily, continued METOPROLOL SUCCINATE 100mg Daily.
If pt remains hypertensive consider increasing the enalapril.
#Depression/SI: Pt has a history of depression although there
was concern for pt safety she was not acutely suicidal. She has
never had SI/HI in the past. Pt has dementia and her episode of
wrapping tele wires around neck is thought to be dementia
related. Pt has a long history of severe depression but refuses
to see a pyschiatrist although is on anti-depressants. We
continued her citalopram but reduced the dose to 20mg daily (pt
was on 40mg but the higher dose causes QT prolongation and pt
came in with a long QTc). Pt was put on 1:1 monitoring
throughout her hospitalization since telemetry was continued and
the wires present a danger given her dementia (could potentially
put wires around neck again). Psych evaluated her and also think
suicide attempt was dementia related since pt is in new
environment and upset about being in hospital. Pt had no plan
for suicide. Pt does have severe depression, but unwilling to
have psych care. Pt was scheduled with pyschiatric and cognitive
neurology follow up care.
#Dementia: Pt has combination of vascular and alzhiemers
dementia that has been progressively worsening. Per recent
neurology note pt has continued to show a slow, but steady
decline in her cognitive abilities. She now needs at least some
help with dressing and she does have episodes of urinary
incontinence, two or three times a week. Pt was continued on
donepezil 10mg daily, quetiapine 12.5mg QAM and 25mg QPM, and
memantine 10mg daily.
#Hyperlipidemia: Pt has not had recent cholesterol check. We
restarted simvastatin 20mg to optimize CAD management. Recommend
outpatient follow up of lipids in 6 weeks with a goal LDL<100.
#Diabetes: Well controlled with hemoglobin A1C 5.7% which is at
goal of <7% so pt was continued on GLIPIZIDE 2.5 mg daily
#GERD: no acute symptoms. Continue omeprazole 20mg BID
#Cirrhosis: Unknown cause, diagnosed in ___. Pt is Hep A
postive, hep C negative. No significant transaminitis was
found. We recommend outpatient follow-up for etiology and
consider screening for Hep B.
#Gastritis: Pt reports no new symptoms. Has been stable.
Continued omeprazole 20mg BID
#Hypothyroidism: We did not check a TSH level. Pt was not
complaining of new endocrine symptoms so we continued
levothyroxine 100mcg daily. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ace Inhibitors / Aspirin / Rifaximin / Tramadol /
Plavix / morphine / Statins-Hmg-Coa Reductase Inhibitors
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ F former psychoanalyst with h/o HTN, atrial
fibrillation on Coumadin, remote breast CA, GERD, CAD, MDD with
psychotic features, who presents status post fall. The patient
states she took Ambien and Zyprexa to sleep, which she has
reportedly taken every night for a long time. She got up and
went to the bathroom soon after taking these meds and felt
woozy, needed to use the wall to support herself, then she fell
on her bottom and struck the back of her head. She denies any
loss of consciousness prior to or as a result of the fall. She
denies any palpitations, excessive perspiration, or other
preceding symptoms. She reports pain in her coccyx, minimal pain
in neck and head. She also reports right hip pain. She denies
headache. She has a history of osteoporosis. She states she does
not fall frequently, last fall was a couple of years ago on ice.
She has had some nausea in the days preceding the fall without
any vomiting, but admits to reduced PO intake. She also reports
a 10lb weight loss over the last year, which she thinks is due
to her dietary restriction of being lactose intolerant. She
reports a recent change to a psych medication but is unsure of
the drug. Of note, patient was in ED on ___ for anxiety and HTN
to 200s which improved without intervention. She lives at
___, walks with a cane at baseline. She denies any
recent flu-like illnesses. Denies any chest pain, shortness of
breath, abdominal pain, back pain, numbness, weakness, urinary
symptoms.
In the ED, initial VS were 98.9 66 111/60 20 98% RA
Labs showed Hb 11.6, Na 126-> 134, K 4.1, BUN 23, Cr 0.9, AG
11, INR 4.6, ___ 50.5, PTT 43.2, UA negative, FENa 0.2%
Received pantoprazole 40, irbesartan 150, Bupropion 200mg,
___ consulted
REVIEW OF SYSTEMS:
(+)PER HPI
Past Medical History:
HYPONATREMIA
ATRIAL FIBRILLATION on Coumadin
BREAST CANCER TWICE IN RIGHT BREAST
lumpectomy and xrt s/p mastectomy ___
CORONARY ARTERY DISEASE
s/p ramus stent ___, negative exercise echo ___
CORONARY ARTERY DISEASE
___ cath 3-v disease with PCTA ramus of circ
DEPRESSION
GASTROESOPHAGEAL REFLUX
HYPERTENSION
OSTEOARTHRITIS
OSTEOPOROSIS
ANXIETY
MDD WITH PSYCHOTIC FEATURES
GAD
CATARACT
AORTIC SCLEROSIS
Social History:
___
Family History:
FAMILY PSYCHIATRIC HISTORY: brother with ___ (in ___
Mother died of AD at age ___
Father died of MI age ___.
Physical Exam:
Admission physical exam:
VS: 97.6PO 160 / 77 70 18 96 RA
GENERAL: NAD, flat affect
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: systolic ejection murmur, RRR
LUNGS: Diffusely reduced but audible breath sounds in left
compared to right lung fields. no wheezes, rales, rhonchi,
breathing comfortably without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema. has ulnar
deviation bilaterally.
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, can count months of the year backwards without
issue, moving all 4 extremities with purpose
SKIN: warm and well perfused. two small white raised lesions on
right hand which patient reports as "precancerous lesions", no
rashes
Discharge physical exam:
T98.0 BP 132 / 77 Lying HR 60 RR 18 O2 98 Ra
GENERAL: NAD, flat affect, A/Ox3, sitting up in chair
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
HEART: RRR, systolic ejection murmur with radiation to carotids,
delayed carotid upstroke, no rubs, 2+ DP and radial pulses
LUNGS: 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, moving all extremities with purpose.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS
==========================
___ 09:56AM BLOOD WBC-5.7 RBC-4.01 Hgb-11.6 Hct-35.2 MCV-88
MCH-28.9 MCHC-33.0 RDW-14.4 RDWSD-46.3 Plt ___
___ 09:56AM BLOOD Neuts-68.3 Lymphs-16.7* Monos-13.2*
Eos-0.7* Baso-0.7 Im ___ AbsNeut-3.90# AbsLymp-0.95*
AbsMono-0.75 AbsEos-0.04 AbsBaso-0.04
___ 10:35AM BLOOD ___ PTT-43.2* ___
___:56AM BLOOD Glucose-86 UreaN-23* Creat-0.9 Na-126*
K-9.3* Cl-93* HCO3-22 AnGap-11
___ 11:54AM BLOOD K-3.6
INTERVAL LABS
=========================
Hyponatremia trend:
___ 08:00AM BLOOD Glucose-76 UreaN-22* Creat-0.7 Na-138
K-3.9 Cl-100 HCO3-21* AnGap-17*
___ 06:45AM BLOOD Glucose-84 UreaN-17 Creat-0.7 Na-137
K-3.9 Cl-100 HCO3-24 AnGap-13
___ 08:22AM BLOOD Glucose-86 UreaN-18 Creat-0.8 Na-136
K-4.1 Cl-99 HCO3-25 AnGap-12
___ 08:00AM BLOOD Glucose-76 UreaN-18 Creat-0.7 Na-134
K-4.1 Cl-97 HCO3-25 AnGap-12
Coag labs:
___ 08:00AM BLOOD ___ PTT-47.8* ___
___ 04:45PM BLOOD ___ PTT-39.4* ___
___ 11:10AM BLOOD ___ PTT-36.4 ___
___ 08:00AM BLOOD ___ PTT-34.2 ___
DISCHARGE LABS
=========================
___ 09:52AM BLOOD ___ PTT-34.9 ___
RELEVANT STUDIES
=========================
CT Head ___
No acute intracranial process.
CT Spine ___
1. No traumatic malalignment or acute fracture of the cervical
spine.
2. Chronic multilevel retrolisthesis.
CT Pelvis
1. No acute pelvic fracture.
2. Irregularity of the superomedial aspect of the right femoral
head with minimal subchondral lucency and patchy sclerosis.
While these findings are unchanged from prior CT from ___,
avascular necrosis cannot be completely excluded. This can be
further assessed with MR of the right hip.
CXR ___
No acute cardiopulmonary abnormality.
Hip X-ray ___
No definite acute fracture or dislocation.
TTE ___
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. The estimated right atrial pressure is ___
mmHg. There is mild symmetric left ventricular hypertrophy with
normal cavity size and regional/global systolic function
(LVEF>55%). The estimated cardiac index is normal
(>=2.5L/min/m2). Diastolic function could not be assessed. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. There are three aortic valve leaflets. The aortic valve
leaflets are moderately thickened. There is moderate aortic
valve stenosis (valve area 1.0-1.2cm2). Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
The left ventricular inflow pattern suggests impaired
relaxation. The tricuspid valve leaflets are mildly thickened.
The estimated pulmonary artery systolic pressure is normal.
There is a very small circumferential pericardial effusion.
There are no echocardiographic signs of tamponade.
IMPRESSION: Moderate calcific aortic stenosis. Mild aortic
regurgitation. Mild mitral regurgitation. Mild symmetric left
ventricular hypertrophy with preserved global and regional
biventricular systolic function. Very small circumferential
pericardial effusion without echocardiographic signs of
hemodynamic compromise.
Compared with the prior study (limited resting stress echo
images reviewed) of ___, the gradient across the aortic
valve is slightly higher. A very small pericardial effusion is
seen.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Azopt (brinzolamide) 1 % ophthalmic TID
2. Docusate Sodium 100 mg PO BID
3. Famotidine 20 mg PO BID
4. irbesartan 150 mg oral QAM
5. irbesartan 75 mg oral QPM
6. Polyethylene Glycol 17 g PO DAILY
7. Mirtazapine 7.5 mg PO QHS
8. OLANZapine 2.5 mg PO QHS
9. Pantoprazole 40 mg PO Q12H
10. Vitamin D 400 UNIT PO DAILY
11. Warfarin 6 mg PO DAILY16
12. Zolpidem Tartrate 5 mg PO QHS
13. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
14. Calcium Carbonate 500 mg PO QID:PRN Heartburn
15. Meclizine 12.5 mg PO Q8H:PRN Vertigo
16. Mylanta 10 mL oral Q8H:PRN
17. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN Chest pain
18. Ondansetron 4 mg PO Q8H:PRN nausea
19. Sucralfate 1 gm PO QID:PRN heartburn
20. Multivitamins 1 TAB PO DAILY
21. Sodium Chloride Nasal ___ SPRY NU TID:PRN nasal congestion
22. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID:PRN rash
23. olopatadine 0.1 % ophthalmic TID:PRN
24. Loratadine 10 mg PO DAILY:PRN congestion
25. Simethicone 40-80 mg PO QID:PRN gas
26. Benzonatate 100 mg PO TID:PRN cough
27. DULoxetine 30 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
2. Azopt (brinzolamide) 1 % ophthalmic TID
3. Benzonatate 100 mg PO TID:PRN cough
4. Calcium Carbonate 500 mg PO QID:PRN Heartburn
5. Docusate Sodium 100 mg PO BID
6. Famotidine 20 mg PO BID
7. irbesartan 150 mg oral QAM
8. irbesartan 75 mg oral QPM
9. Mirtazapine 7.5 mg PO QHS
10. Multivitamins 1 TAB PO DAILY
11. Mylanta 10 mL oral Q8H:PRN
12. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN Chest pain
13. OLANZapine 2.5 mg PO QHS
14. olopatadine 0.1 % ophthalmic TID:PRN
15. Ondansetron 4 mg PO Q8H:PRN nausea
16. Pantoprazole 40 mg PO Q12H
17. Polyethylene Glycol 17 g PO DAILY
18. Simethicone 40-80 mg PO QID:PRN gas
19. Sodium Chloride Nasal ___ SPRY NU TID:PRN nasal congestion
20. Sucralfate 1 gm PO QID:PRN heartburn
21. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID:PRN rash
22. Vitamin D 400 UNIT PO DAILY
23. Warfarin 6 mg PO DAILY16
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
Fall secondary to polypharmacy
SECONDARY:
Atrial fibrillation on warfarin
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
INDICATION: History: ___ with righ hip pain// ? fracture
TECHNIQUE: AP view of the pelvis, two views of the right hip
COMPARISON: Right hip radiographs ___
FINDINGS:
No acute fracture or dislocation is identified. Minimal lateral acetabular
spurring is seen involving both femoroacetabular joints with subchondral
sclerosis. No diastases of the pubic symphysis or sacroiliac joints is
present. The osseous structures are diffusely demineralized. There are no
concerning lytic or sclerotic osseous abnormalities. Diffuse vascular
calcifications are noted. Degenerative changes within the lumbar spine are
incompletely assessed.
IMPRESSION:
No definite acute fracture or dislocation.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with fall with headstrike on coumadin ? acute process
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 2.0 s, 2.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
100.3 mGy-cm.
2) Sequenced Acquisition 14.0 s, 14.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
702.4 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: None.
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 prominent, consistent with
age-appropriate atrophy. There are periventricular, subcortical, and deep
white matter hypodensities, which may represent chronic small vessel ischemic
changes.
The imaged paranasal sinuses are clear. The right mastoid air cells are
partially opacified suggestive of ongoing inflammation. The left mastoid air
cells and bilateral middle ear cavities are well aerated. The bony calvarium
is intact. Patient is status post bilateral lens resections. Moderate
atherosclerotic calcifications of the cavernous carotid arteries are seen and
mild atherosclerotic calcifications of the distal vertebral arteries are
noted.
IMPRESSION:
No acute intracranial process.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ with fall with headstrike on coumadin//? 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 5.5 s, 21.8 cm; CTDIvol = 22.7 mGy (Body) DLP = 494.1
mGy-cm.
Total DLP (Body) = 494 mGy-cm.
COMPARISON: Cervical spine radiograph dated ___.
FINDINGS:
There is retrolisthesis C4 relative to C3, and of C5 relative to C4, similar
in appearance when compared to radiograph from ___. No fractures are
identified.Multilevel moderate to severe degenerative changes are seen, most
extensive at C4 through C7 and notable for intervertebral disc space
narrowing, endplate irregularity, anterior and posterior osteophyte formation,
and fusion of C6-7. No high-grade central canal stenosis is present. Facet
joint arthropathy causes mild to moderate neural foraminal narrowing
bilaterally, most pronounced at C3-4 and C4-5. There is no prevertebral
edema.
The thyroid and included lung apices are unremarkable. There are extensive
bilateral carotid artery calcifications.
Partial opacification of the right mastoid air cells is again seen.
IMPRESSION:
1. No acute fracture or change in alignment of the cervical spine.
2. Moderate to severe cervical spondylosis with chronic multilevel
retrolisthesis.
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: History: ___ with hyponatremia// ? pneumonia
TECHNIQUE: Upright AP and lateral views of the chest
COMPARISON: Chest radiograph ___
FINDINGS:
Cardiac silhouette size remains mildly enlarged. The aorta is tortuous and
diffusely calcified, as is the right brachiocephalic and subclavian arteries..
Pulmonary vasculature is not engorged. The mediastinal and hilar contours are
unremarkable. Lungs appear hyperinflated without focal consolidation. No
pneumothorax or pleural effusion is seen. The osseous structures are
diffusely demineralized. S shaped scoliosis of the thoracolumbar spine is
noted. Right axillary clips are re-demonstrated.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: CT pelvis without contrast.
INDICATION: ___ with right hip pain, ? pelvic fracture
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 6.1 s, 30.1 cm; CTDIvol = 24.8 mGy (Body) DLP = 747.4
mGy-cm.
Total DLP (Body) = 747 mGy-cm.
COMPARISON: CT dated ___
FINDINGS:
PELVIS: Scattered colonic diverticula are noted. The partially visualized
small and large bowel are otherwise unremarkable. The partially visualized
kidneys are unremarkable. The partially visualized liver is unremarkable.
The urinary bladder and distal ureters are unremarkable. There is no free
fluid in the pelvis.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: There is no pelvic or inguinal lymphadenopathy.
VASCULAR: Extensive atherosclerotic disease is noted.
BONES: There is no evidence of acute fracture. There is diffuse osteopenia.
Mild-to-moderate degenerative changes of both hips with joint space narrowing,
osteophyte formation, and subchondral sclerosis are re-demonstrated, right
worse than left. Irregularity at the superomedial aspect of the right femoral
head with minimal subchondral lucency is unchanged from prior from ___.
There is grade 1 anterolisthesis of L4 on L5 with disc space narrowing,
unchanged.
SOFT TISSUES: The low abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No acute pelvic fracture.
2. Irregularity of the superomedial aspect of the right femoral head with
minimal subchondral lucency and patchy sclerosis. While these findings are
unchanged from prior CT from ___, avascular necrosis cannot be
completely excluded. This can be further assessed with MR of the right hip.
RECOMMENDATION(S): MR of the right hip.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall
Diagnosed with Contusion of right hip, initial encounter, Fall on same level, unspecified, initial encounter, Abnormal coagulation profile, Hypo-osmolality and hyponatremia
temperature: 98.9
heartrate: 66.0
resprate: 20.0
o2sat: 98.0
sbp: 111.0
dbp: 60.0
level of pain: 7
level of acuity: 2.0 | Ms. ___ is an ___ yo F w/ PMH HTN, atrial fibrillation
on warfarin, aortic stenosis, remote breast cancer, CAD, and MDD
w/ psychotic features who presented s/p fall after taking
nightly zolpidem and olanzapine.
ACUTE ISSUES:
===============================
#Fall: Attributed to polypharmacy with no loss of consciousness.
CT Head was negative for bleed. Since she takes zolpidem and
olanzapine every evening for sleep, this could have led to
over-sedation. EKG and TTE were unremarkable, and patient was
ruled out for infection. Orthostatics were also ruled out due to
concern for hypovolemia with decreased PO intake. Patient was
evaluated by physical therapy while ___ and was determined
appropriate for rehab. On discharge, her zolpidem and duloxetine
were held due to concern for fall risk and will be re-assessed
as outpatient. She was continued on home olanzapine and
mirtazapine as patient has been on these medications long term
with only one reported fall. Two other medications that were
held during this hospital stay are loratadine and meclizine,
since they can worsen sedation and confusion. She tolerated this
change well.
#AFib on Warfarin: Patient was admitted with supratherapeutic
INR 4.6 upon
admission with no signs of active bleeding, CT head negative.
Her home dose of warfarin, 6 mg daily, was held briefly until
INR trended down, and then she was slowly uptitrated back to her
home regimen. She was discharged on her home regimen but will
require close INR follow-up at rehab. Additionally, there was
concern that warfarin would increase her risk of bleeding in the
setting of falls, so it will be important to discuss risks and
benefits of warfarin for atrial fibrillation in the setting of
outpatient.
#Hyponatremia: Recently seen by PCP for hyponatremia. Etiology
is unclear but psych does not believe this is related to her
psych medications. Her Initial Na in ED was 126, which improved
to within normal limits on discharge.
#Aortic Stenosis: While working up etiology for fall, patient
underwent a TTE on this admission, which showed stable moderate
aortic valve stenosis (valve area 1.0-1.2cm2). This was deemed
not related to patient's history of fall.
CHRONIC/STABLE ISSUES:
===============================
#MDD with psychotic features:
#Anxiety:
#Insomnia: Patient recently saw Psych in ___. At this time,
buproprion was discontinued, and she was continued on
mirtazapine 7.5 mg, Olanzapine 2.5 mg, and zolpidem. Duloxetine
30 mg was started then. On this admission, duloxetine and
zolpidem were stopped due to concern for polypharmacy and risk
of oversedation. Please follow up and consider restarting
duloxetine if indicated.
#CAD: Intolerant to ASA, Plavix, and statins. Continued on home
irbesartan
#GERD: Continued home pantoprazole, famotidine, PRN sucralfate
#HTN: Continued home irbesartan
#OA: PRN APAP for pain
#Osteoporosis: Continued vitamin D |