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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
___ BAL and EBUS of lung mass
___ colonoscopy
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
Mr. ___ is a ___ man with a history of HTN, HLD, and OSA who
presents with 10 weeks of nasal congestion and cough, now with 3
days of fevers, chills, and malaise.
10 weeks ago, he developed nasal congestion, post-nasal drip,
and
a cough productive of yellow sputum. This was not associated
with
any fevers, chills, malaise, or shortness of breath initially.
He
presented to his PCP, where he was diagnosed with a viral
bronchitis, and was started on an albuterol inhaler prn and
tessalon perles. His symptoms remained unchanged on these
medicines for the next 4 weeks. On ___, he re-presented to his
PCP, and CXR showed a pneumonia. He completed a 6-day course of
Levoquin, but unfortunately his symptoms remained unchanged. He
continued to have the same nasal congestion, a now dry cough,
and
post-nasal drip, and re-presented to an Urgent Care at ___ on ___. CXR showed a persistent pneumonia, so he was
given Augmentin & Azithromycin.
Over the past 3 days, his symptoms have worsened. On ___, he
developed fevers (Tm 103), chills, and malaise. He also had
diarrhea, but no abdominal cramping or pain, and no blood in his
stools. Throughout this, his cough has persisted. He denies any
chest pain (including with deep inspiration), orthopnea, PND,
lower extremity swelling, weight gain, or weight loss. He
presented to the ED because his symptoms were getting worse.
- In the ED, initial VS were: 101.2 128 156/66 20 95% RA
- Exam notable for: uncomfortable & diaphoretic man,
tachycardic,
decreased breath sounds over left side
- ECG: sinus tachycardia, HR 134
- Labs showed: K 3.1, Na 133, flu negative
- Imaging showed: CXR with Linear focus of atelectasis in the
left upper lobe alongside bibasilar atelectasis without focal
consolidation.
- Patient received:
___ 02:15IVFNS
___ 03:28IVCefTRIAXone
___ 03:32IVAzithromycin (500 mg ordered)
- Transfer VS were: 99.1 109 132/65 18 96% RA
On arrival to the floor, patient feels a little better. He still
has a dry cough, but denies any chest pain, shortness of breath,
dizziness, or lightheadedness.
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as
per HPI
Past Medical History:
- HTN
- HLD
- OSA
- GERD
- hypogonadism
Social History:
___
Family History:
Father with COPD
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.4 PO161 / 75 L Lying___
GENERAL: sitting comfortably in bed, sweaty, but nontoxic
HEENT: EOMI, no scleral icterus, mmm
NECK: supple, no LAD, no JVD
HEART: tachycardic, regular, no m/r/g
LUNGS: decreased lung sounds in bilateral bases, L>R, no
wheezes
or crackles
ABDOMEN: soft, NT/ND, normal bowel sounds, no HSM
EXTREMITIES: no cyanosis, clubbing, or edema. Warm
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
VS: ___ 1151 Temp: 98.5 PO BP: 164/77 L Sitting HR: 75 RR:
16 O2 sat: 95% O2 delivery: Ra
GENERAL: Sitting comfortably in chair in NAD.
HEENT: EOMI, no scleral icterus, MMM.
NECK: Supple
HEART: RRR, no M/R/G.
LUNGS: Mild inspiratory wheezing on left. No rhonchi, crackles.
ABDOMEN: Normoactive bowel sounds, obese, firm but non-tender
EXTREMITIES: WWP. No C/C/E.
PULSES: 2+ DP pulses b/l.
NEURO: A&Ox3. CN II-XII grossly intact. Moving all 4 extremities
with purpose.
Pertinent Results:
ADMISSION LABS:
===============
___ 12:27AM BLOOD WBC-4.8 RBC-4.74 Hgb-14.6 Hct-41.2 MCV-87
MCH-30.8 MCHC-35.4 RDW-13.0 RDWSD-41.2 Plt ___
___ 12:27AM BLOOD Neuts-87.4* Lymphs-6.3* Monos-4.6*
Eos-0.0* Baso-0.2 Im ___ AbsNeut-4.15 AbsLymp-0.30*
AbsMono-0.22 AbsEos-0.00* AbsBaso-0.01
___ 12:27AM BLOOD Plt ___
___ 12:27AM BLOOD Glucose-143* UreaN-18 Creat-1.1 Na-133*
K-3.1* Cl-95* HCO3-23 AnGap-15
___ 12:27AM BLOOD ALT-94* AST-134* LD(LDH)-567* AlkPhos-60
TotBili-1.2
___ 01:24PM BLOOD Calcium-8.8 Phos-2.4* Mg-2.1
PERTINENT LABS:
===============
___ 09:19AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 09:19AM BLOOD HCV Ab-NEG
Time Taken Not Noted Log-In Date/Time: ___ 2:59 am
URINE ADDED TO 66566D.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
___ 10:00 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Cepheid nucleic
acid
amplification assay..
(Reference Range-Negative).
___ BAL studies pending
RELEVANT STUDIES:
=================
___ colon polypectomy: Colonic mucosa, no diagnostic
abnormalities recognized, multiple levels
___, left upper lobe of lung: Poorly differentiated
adenocarcinoma with mucinous features,
___ present in submucosal lymphatic spaces,
see note.
Note: Multiple levels are examined. The carcinoma is strongly
positive for CK 7, and shows only
focal CK 20 positivity. It is negative for TTF-1, Napsin, p40,
and CDX-2. Multiple levels are
examined. The tumor morphology and immunoprofile is somewhat
non-specific. While this
malignancy may represent a poorly differentiated lung primary,
clinical and radiological correlation is indicated to exclude a
metastasis from another site, including the gastrointestinal
tract. Dr ___ has reviewed this case.
RELEVANT IMAGING:
================
___ CXR
IMPRESSION:
Possible obstructing left hilar mass should be evaluated with
contrast-enhanced chest CT.
___ CTA chest and CT abdomen
IMPRESSION:
1. Ill-defined left hilar mass with associated nodularity and
opacification
along the left major fissure and extension into the
superolateral left aspect
of the mediastinum. Mass encases the left main pulmonary
artery, as well as
the left lingular, lower lobar, and upper lobar pulmonary
arteries.
2. Notably, the mass also causes significant narrowing of the
left upper
lobar bronchus (see series 301, image 46).
3. Associated enlarged left para-aortic, right upper
paratracheal, and
subcarinal mediastinal lymph nodes.
4. Incidentally noted 3.5 x 3.2 cm hypodense mass involving the
appendix,
without adjacent fat stranding (see series 304, image 59). This
is worrisome
for a separate neoplasm. Less likely metastasis, but this
possibility is not
excluded.
5. No evidence of pulmonary embolism.
___ MRI Brain
IMPRESSION:
1. Unremarkable brain MRI without evidence of infarction or
hemorrhage.
Specifically, no abnormal enhancement or mass is identified.
DISCHARGE LABS
===========
___ 06:45AM BLOOD WBC-7.1 RBC-4.75 Hgb-14.5 Hct-42.5 MCV-90
MCH-30.5 MCHC-34.1 RDW-13.0 RDWSD-42.5 Plt ___
___ 06:45AM BLOOD ___ PTT-27.7 ___
___ 06:45AM BLOOD Glucose-106* UreaN-17 Creat-1.0 Na-141
K-4.5 Cl-102 HCO3-24 AnGap-15
___ 06:45AM BLOOD ALT-201* AST-140* LD(LDH)-519*
AlkPhos-195* TotBili-0.7
___ 06:45AM BLOOD Calcium-9.2 Phos-3.4 Mg-2.5
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. GuaiFENesin ER 600 mg PO Q12H
2. guaiFENesin AC (codeine-guaifenesin) ___ mg/5 mL oral
Q6H:PRN
3. Atorvastatin 40 mg PO QPM
4. Benzonatate 100 mg PO TID:PRN cough
5. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheeze
6. Lisinopril 30 mg PO DAILY
7. Glucosamine (glucosamine sulfate) 500 mg oral BID
8. Hydrochlorothiazide 25 mg PO DAILY
9. Metoprolol Succinate XL 50 mg PO DAILY
10. testosterone cypionate 200 mg/mL injection once weekly
11. Omeprazole 20 mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheeze
2. Atorvastatin 40 mg PO QPM
3. Benzonatate 100 mg PO TID:PRN cough
4. Glucosamine (glucosamine sulfate) 500 mg oral BID
5. guaiFENesin AC (codeine-guaifenesin) ___ mg/5 mL oral
Q6H:PRN
6. GuaiFENesin ER 600 mg PO Q12H
7. Hydrochlorothiazide 25 mg PO DAILY
8. Lisinopril 30 mg PO DAILY
9. Metoprolol Succinate XL 50 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Omeprazole 20 mg PO DAILY
12. testosterone cypionate 200 mg/mL injection once weekly
13.Outpatient Lab Work
ICD-10: R74.0
Please draw labs on ___
Please obtain LFTs (AST, ALT, ALP, LDH, total bilirubin)
ATTN: Dr. ___, fax #: ___
Discharge Disposition:
Home
Discharge Diagnosis:
Post obstructive pneumonia
Diarrhea
Poorly differentiated adenocarcinoma of unclear primary
Lung mass
Appendix mass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ with persistent SOB, cough// Please evaluate for pneumonia
or effusion
TECHNIQUE: Chest PA and lateral
COMPARISON: None.
FINDINGS:
Enlargement of the left hilus and combination of atelectasis and consolidation
in the left upper lobe raise concern for bronchial obstruction and secondary
infection. Right lung is clear. Heart size is normal. There is no
appreciable pleural effusion, but the left major fissure appears thickened on
the lateral view.
IMPRESSION:
Possible obstructing left hilar mass should be evaluated with
contrast-enhanced chest CT.
NOTIFICATION: The findings were discussed with ___, M.D. by ___,
M.D. on the telephone on ___ at 8:33 am, 2 minutes after discovery of
the findings.
Radiology Report
EXAMINATION: CTA CHEST AND CT ABDOMEN AND PELVIS
INDICATION: ___ year old man with HTN, HLD, and OSA who presents with 10 weeks
of nasal congestion and cough, now with 3 days of fevers, chills, and malaise
who has a left hilar mass.// new left hilar mass on CXR and elevated LDH
concern for cancer. Please pan scan (and eval for PE while at it as he is
tachycardic and hypoxic)
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) Spiral Acquisition 2.3 s, 30.9 cm; CTDIvol = 14.2 mGy (Body) DLP = 438.4
mGy-cm.
2) Spiral Acquisition 3.8 s, 49.7 cm; CTDIvol = 16.5 mGy (Body) DLP = 821.1
mGy-cm.
3) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7
mGy-cm.
4) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol = 27.3 mGy (Body) DLP =
13.7 mGy-cm.
Total DLP (Body) = 1,275 mGy-cm.
COMPARISON: Chest x-ray of ___.
FINDINGS:
CHEST:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
subsegmental level without filling defect to indicate a pulmonary embolus.
The thoracic aorta is normal in caliber without evidence of dissection or
intramural hematoma. There is no pericardial effusion. Aortic arch
calcifications are mild.
AXILLA, HILA, AND MEDIASTINUM: There is mediastinal invasion from the left
hilar and pulmonary parenchymal mass, which will be described below. Left
para-aortic heterogeneous lymph node conglomeration measures approximately 4.0
x 1.3 cm (301:29). An upper right paratracheal lymph node measures 2.5 x 1.7
cm (301:35) an enlarged subcarinal node measures 1.7 x 2.4 cm (301:49).
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Opacification mass lesion along the left major fissure,
predominantly involving the left hilus, is difficult to measure accurately,
but spans approximately 6.7 x 4.0 cm (AP by TRV) (301:46), with an associated
nodular component in the apical left upper lobe (301:26), measuring 2.9 x 2.1
cm. There is associated left major fissural thickening and nodularity
(602:57). There is associated encasement of the left main pulmonary artery,
as well as the left lingular, lower lobar, and upper lobar pulmonary arteries.
The mass extends into the left and superior aspect of the mediastinum. There
is associated narrowing of the left upper lobe bronchus (301:46).
BASE OF NECK: Subcentimeter left thyroid hypodensity is nonspecific, likely a
small nodule, but does not meet size criteria for thyroid ultrasound.
ABDOMEN:
HEPATOBILIARY: The liver is diffusely hypoattenuating, suggesting hepatic
steatosis. A subcentimeter hypodensity in segment VIII is incompletely
characterized, but likely a biliary hamartoma or hepatic cyst. 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 enlarged, measuring 13.7 cm.
ADRENALS: The right adrenal gland is unremarkable. The left adrenal gland is
thickened, without definite nodularity.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
A 4.9 x 3.3 cm left lower renal cyst is partially exophytic. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. There is partial
cecal thickening with a 3.5 x 3.2 cm hypodense mass involving the appendix
(607:26, 304:59). There is no adjacent fat stranding. There appear to be 2
tablets adjacent to the mass (304:53, 54). No evidence of bowel obstruction.
There is no free peritoneal air or fluid.
PELVIS:
The urinary bladder and distal ureters are unremarkable. There is no free
fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate is enlarged.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic
disease is noted.
BONES AND SOFT TISSUES: There is no evidence of worrisome osseous lesions or
acute fracture. Note is made of hyperdense mesh material along the anterior
abdominal wall, likely due to prior hernia repair.
IMPRESSION:
1. Ill-defined left hilar mass with associated nodularity and opacification
along the left major fissure and extension into the superolateral left aspect
of the mediastinum. Mass encases the left main pulmonary artery, as well as
the left lingular, lower lobar, and upper lobar pulmonary arteries.
2. Notably, the mass also causes significant narrowing of the left upper
lobar bronchus (see series 301, image 46).
3. Associated enlarged left para-aortic, right upper paratracheal, and
subcarinal mediastinal lymph nodes.
4. Incidentally noted 3.5 x 3.2 cm hypodense mass involving the appendix,
without adjacent fat stranding (see series 304, image 59). This is worrisome
for a separate neoplasm. Less likely metastasis, but this possibility is not
excluded.
5. No evidence of pulmonary embolism.
NOTIFICATION: The above findings were communicated via telephone by Dr.
___ to Dr. ___ at 13:40 on ___, 5 minutes after discovery.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD
INDICATION: ___ year old man with h/o HTN, HLD, OSA p/w 10 weeks of nasal
congestion and cough and 5 days of fevers and malaise, found to have left
hilar mass and appendeceal mass on CTA.// evaluate for brain metastases
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: None.
FINDINGS:
There is no evidence of infarction, hemorrhage, mass, mass effect, edema or
midline shift. There is no abnormal enhancement. The dural venous sinuses
appear patent.
The ventricles and sulci are normal, without evidence of hydrocephalus. There
is gross preservation of the principal intracranial vascular flow voids.
Mild mucosal thickening is seen throughout scattered ethmoid air cells
bilaterally. The remainder of 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. Unremarkable brain MRI without evidence of infarction or hemorrhage.
Specifically, no abnormal enhancement or mass is identified.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea on exertion, ILI
Diagnosed with Pneumonia, unspecified organism, Fever, unspecified, Diarrhea, unspecified, Dyspnea, unspecified
temperature: 101.2
heartrate: 128.0
resprate: 20.0
o2sat: 95.0
sbp: 156.0
dbp: 66.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ is a ___ man w/ h/o HTN, HLD, OSA, and esophageal
ulcer s/p cauterization who p/w 10 weeks of nasal congestion and
cough s/p several course of outpatient antibiotics for
pneumonia, now with fevers to 103, chills, and malaise who was
found to have a have LUL lung mass consistent with poorly
differentiated adenocarcinoma of unclear primary and appendiceal
mass.
# Left hilar mass
# Appendiceal/cecum mass/liver lesion
# Liver lesion
# Carcinoma
CTA torso demonstrated left hilar mass extending into
superolateral left mediastinum and encasing left main pulmonary
as well as lingular, lower lobar, and upper lobar pulmonary
arteries. Also noted is a mass in the appendix and liver lesion.
MRI brain negative. Patient does have a 20 pack year smoking
history (quit ___ years ago) and distant history of significant
alcohol use. Patient underwent EBUS with biopsy of left upper
lobe mass and colonoscopy that was unable to biopsy appendiceal
mass. Pathology of lung mass was consistent with poorly
differentiated adenocarcinoma of unclear primary. Atrius
oncology was consulted and patient was established with Dr.
___. Plan was made for outpatient PET scan and
completion of work up as an outpatient.
# Fever
# Post Obstructive Pneumonia.
Patient presented after 10 weeks of prolonged cough and nasal
congestion only, diagnosed with viral bronchitis then pneumonia
s/p several courses of antibiotics (levoflox, augmentin,
azithro) as an outpatient. Flu negative, MRSA negative. Likely
source of infection is post-obstructive PNA. He was treated
initially w/ vanco and ceftazidime (Vanco DC w/ neg MRSA).
Ceftaz continued for 7 day IV abx course (completed ___.
Patient defervesced after initiation of antibiotics. Supportive
treatments cough suppression and nebulizers provided.
# Transaminitis
Patient with liver lesion c/f metastasis and fatty liver
findings on CTA. Hep B and C serologies negative. Uptrended
during admission, with stabilization after discontinuation of
acetaminophen.
# Diarrhea
___ be secondary to antibiotic vs. viral gastroenteritis.
Improved during hospitalization. He underwent a colonoscopy that
showed single polyp, unable to biopsy appendiceal mass. Will
need screening colonoscopy within ___ year as an outpatient.
# HTN
Home HCTZ held w/ electrolyte abnormalities and colonoscopy
prep. Lisinopril was restarted as patient's blood pressures
increased during stay. His metoprolol Succinate XL 50 mg PO
DAILY was continued while inpatient.
# Hyponatremia, resolved
# SIADH
Mild hyponatremia to 133, improved with IVF. Likely initially
hypovolemic now with SIADH given most recent urine lytes.
Ulegionella negative. Home HCTZ held until after colonoscopy. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Likely focal seizure with left ___ paresis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPC:
___ with a PMH of HTN, HLD, metastatic lung ca with brain mets
s/p RUL resection and chemo/XRT in ___ apparently in remission,
new diagnosis of PD on Sinemet and ropinirole presents after an
episode of unresponsiveness and mutism with left-sided weakness
with nil acute on CT head which likely represents a focal
seizure
with Tod;s paresis and transferred to ___ for further
management.
Patient was in his usual state of health until this morning.
Patient notes that he felt well yesterday and had no recent
fevers or infection and had been sleeping well. He also recalls
that he was disoriented this morning and thought that he had
coffee and doughnuts ? if true. He was found by family members
unresponsive in his wheelchair and he was then taken to ___. Patient does not recall this morning events but does
recall talking to his son and daughter who said he had to go to
hospital. There, he was noted to be mute and had flaccid
weakness
arm>leg on the left side with an initial NIHSS of 19 with
patient
drowsy, not answering any questions, had profound left arm
weakness and less severe left leg weakness and was mute. Vitals
there revealed SBPs 130s-170s and labs were unrevealing. He was
given aspirin 300mg PR and IV Unasyn and went on to have a CT
head which was significantly motion degraded but showed no clear
stroke or mass. He improved and regarding his left weakness and
speech and was transferred to ___ for further management.
Here, he has no aphasia and has slight left-sided weakness
although patient feels that he is back to baseline. Patient
denies that this has ever happened before and that he has never
had a prior seizure or stroke. He denies headache. He denies any
previous significant head injuries or meningitis/encephalitis.
Patient was recently diagnosed with PD a few months ago by his
neurologist Dr ___ of spelling) at ___ but denies any slowness, tremor or freezing. He
was started on Sinemet and ropinirole which per the patient made
no difference. He states that his PCP Dr ___ he may
not have PD.
Patient has a current cough which is productive and is drowsy,
yawning.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Denies focal weakness,
numbness, parasthesiae. No bowel or bladder incontinence or
retention.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
PMH:
- HTN
- HLD
- h/o metastatic lung ca with per records possible left
occipital
met on MRI s/p RUL resection and chemo/XRT in ___ apparently in
remission
- PD on sinemet and ropinorole new diagnosis seemingly a few
months ago
- s/p left cataract operation
- No h/o HI/meningitis/encephalitis
Social History:
___
Family History:
Family Hx:
Mother - died during childbirth in her ___
Father - died ___ committed suicide
Sibs - 3 sisters ___hildren - 1 son 1 daughter
There is no history of seizures, developmental disability,
learning disorders, migraine headaches, strokes less than 50,
neuromuscular disorders, dementia or movement disorders.
Physical Exam:
Physical Exam on admission:
Vitals: T:98 P:63 R:16 BP:148/72 SaO2:99% RA
General: Somewaht drowsy, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid/vertebral bruits appreciated but
transmitted cardiac murmur. No nuchal rigidity. Full range of
motion.
Pulmonary: Bronchial breathing left UL and decreased BS right
UL.
Cardiac: RRR, nl. S1S2, with an ESM in teh aortic area radiating
to carotids
Abdomen: soft, NT/ND, normoactive bowel sounds.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally. Calves SNT bilaterally.
Skin: no rashes or lesions noted.
Neurological examination:
- Mental Status:
Slightly drowsy and ywaning frequently.
ORIENTATION - Alert, oriented x person place and ___ but
thoughtit was ___.
Knew president is ___.
SPEECH
Able to relate history with some difficulty.
Language is fluent with intact repetition and comprehension.
Normal prosody. There were no paraphasic errors.
Speech was not dysarthric.
NAMING Pt. was able to name both high and low frequency objects.
READING - Cannot see card to read.
ATTENTION - Attentive, able to name ___ backward with some
difficulty.
REGISTRATION and RECALL
Pt. was able to register 3 objects and recall ___ at 5 minutes
___ with category prompts.
COMPREHENSION
Able to follow both midline and appendicular commands
There was no evidence of apraxia or neglect
___ examination:
Slight hypophonia and hypomimia. Bilateral UE and ___ rigidity
perhaps right>left with slight right resting tremor and
cogwheeling. There is right>left bradykinesia and clumsy finger
tapping. Stooped posture but gait unstable and unable to assess.
Glabellar tap positive and slight snout-pout.
- Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2 to 1mm and brisk. ___ left ___ and > ___ on
right uncorrected - no glassess. VFF to confrontation.
Funduscopic exam reveals no papilledema, exudates, or
hemorrhages
on the left where there is a very pale disc and unable to see
the
right due to a dense cataract.
III, IV, VI: EOMI save a slight reduced upgaze without
nystagmus.
Slightly jerky pursuits and no abnormal vertical saccades.
V: Facial sensation intact to light touch. Good power in muscles
of mastication.
VII: No facial weakness, 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 with normal velocity movements.
- Motor: Normal bulk save bilateral EDB wasting, tone with
rigidity throughout more so on the right. Left pronator drift.
Bilateral postural tremor noted. No asterixis noted.
SAb SAdd ElF ElE WrE FFl FE IO HipF HipE KnF KnE AnkD ___
L 5 5 4+ 4+ ___ 4 5 5 4+ 5 4+ 5 4
R 5 5 ___ ___ 5 ___ ___
EDBs ___ bilaterally.
- Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout in UE and ___ save
slight decreased vibration at te right great toe. No extinction
to DSS.
- DTRs:
BJ SJ TJ KJ AJ
L 3* 3* 3* 3 1
R ___ 3 1
There was no evidence of clonus.
___ negative.
Plantar response was mute flexor on the right and extensor on
the
left.
- Coordination: Bilateral action tremor, clumsy finger tapping
right>left with bradykinesia and dysdiadochokinesia noted. No
clear ataxia on FNF or HKS bilaterally grossly but had great
difficulty seeing the finger and woudl try to point 6 inches
away. I initially thought this was bilateral optic ataxia but
his
vision is very poor and this likely accounts for this finding.
He
was better with a sound cue.
- Gait: Able to stand and is stooped but very unstable and did
not walk.
Exam on discharge:
VSS
NAD, comfortable
Resp nonlabored
RRR
MS: alert, oriented to being in hospital but not which one, not
oriented to date or even year, fluent & mostly conversing
appropriate
CN: VF improved to finger counting, L nasolabial fold flattening
Pertinent Results:
Laboratory Data:
Bloods:
Trop-T: <0.01
139 ___ AGap=14
------------<
4.2 24 1.3
Ca: 9.1 Mg: 2.2 P: 3.9
ALT: 9 AP: 170 Tbili: 0.2 Alb: 3.3
AST: 23 LDH: Dbili: TProt:
___: Lip:
Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Negative
UricA:5.1
Lactate:1.6
___: 11.0 PTT: 24.4 INR: 1.0
OSH labs:
Chol 126 TGCs 64 HDL 55.1 LDL ___
Fibr 731
WBCs 8.3 Hb 9.0 HCt 28.6 MCV 76.1* Plt 230
Urine:
Possibly positive UA with negative nitr small LeukE 2 RBCs 17
WBcs and few bacteria with 0 Epis
Urine Benzos, Barbs, Opiates, Cocaine, Amphet, Mthdne Negative
ECG: SR 68 QTc 406 normal axis and no acute changes.
Radiology:
OSH CT head ___
Neuro resident read:
Sigbnificantly motiobn degraded. No clear mass, loss of
grey-white matter differentiation or infarct although there is
significant focal atrophy in the right>left fronto-parietal
junction and ___ regaions.
OSH MRI head ___
Neuro resident read:
Predominantly right>left fronto-parietal junction and
___ atrophy and mild small vessel disease with focal
areas in the just subcortical right frontal lobe and left corona
radiata in addition to GRE features of amyloid angiopathy. Not
done with contrast.
___ CXR
FINDINGS:
There is evidence of right lung volume loss with tenting of the
right
hemidiaphragm and opacification in the right apex compatible
prior right upper
lobectomy. Ill-defined focal opacification within the right
upper lung field
appears progressed compared to the prior radiograph from ___ but
is unchanged compared to the radiograph performed earlier the
same day. The
cardiac silhouette is normal in size. The aorta is slightly
unfolded. There
is no pulmonary vascular congestion. Left lung is clear. No
pleural effusion
or pneumothorax is identified. Degenerative changes are seen
within the
thoracic spine.
IMPRESSION:
IStatus post right upper lobectomy with ill-defined
opacification within the
right upper lung field which could reflect post treatment
changes, though
infection or neoplasm is not excluded. Comparison with prior
cross sectional
imaging is recommended, and if none are available, a dedicated
chest CT is
suggested.
___ EKG
Sinus rhythm. Normal tracing. No previous tracing available for
comparison.
Rate PR QRS QT/QTc P QRS T
68 164 80 ___ 64
TTE ___:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 3.9 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *6.1 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *5.4 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.3 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 55% to 60% >= 55%
Left Ventricle - Stroke Volume: 95 ml/beat
Left Ventricle - Cardiac Output: 5.61 L/min
Left Ventricle - Cardiac Index: 3.22 >= 2.0 L/min/M2
Left Ventricle - Lateral Peak E': *0.08 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.07 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 11 < 15
Aorta - Sinus Level: 3.6 cm <= 3.6 cm
Aorta - Ascending: 3.2 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 0.9 m/sec <= 2.0 m/sec
Aortic Valve - LVOT VTI: 21
Aortic Valve - LVOT diam: 2.4 cm
Mitral Valve - E Wave: 0.8 m/sec
Mitral Valve - A Wave: 0.8 m/sec
Mitral Valve - E/A ratio: 1.00
Mitral Valve - E Wave deceleration time: 184 ms 140-250 ms
TR Gradient (+ RA = PASP): *28 mm Hg <= 25 mm Hg
Findings
Due to technical difficulties, images from bubble study were not
recorded and therefore, could not be interpreted.
LEFT ATRIUM: Elongated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
global systolic function (LVEF>55%). Suboptimal technical
quality, a focal LV wall motion abnormality cannot be fully
excluded. Doppler parameters are indeterminate for LV diastolic
function. No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Normal ascending aorta diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets. No AS. No
AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Physiologic MR ___ normal limits).
TRICUSPID VALVE: Tricuspid valve not well visualized. Mild [1+]
TR. Borderline PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
No PS. Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion. There is an anterior space
which most likely represents a fat pad, though a loculated
anterior pericardial effusion cannot be excluded.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. 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 (?#). There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Physiologic
mitral regurgitation is seen (within normal limits). There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion. There is an anterior space which most
likely represents a prominent fat pad.
IMPRESSION: Mild symmetric LVH with normal biventricular cavity
sizes and global systolic function. Aortic sclerosis without
stenosis. No structual cardiac cause of syncope identified.
Bubble study unable to be fully recorded due to technical
difficulties; cannot rule out ASD/PFO. If there is a high
clinical suspicion, a focused bubble study can be obtained.
CT Chest ___:
FINDINGS:
The patient had a right upper lobe lobectomy, chemo and
radiation therapy for
primary lung malignancy. There is an evolving mass at the right
apex
consistent with local recurrence measuring 6 x 5.2 cm in axial
plane and 3.6
cm in coronal, previously on the neck CT of ___, 3.6 x
3.7 x 3.7 cm.
The lesion invades the adjacent posterior first, second, third
ribs. There is
also periosteal reaction of the posterior fourth rib. Vertebral
bodies of T1
and T2 are also involved with destruction of the posterior wall
of the
vertebra. This exam is not tailored to assess involvement of
the central
canal. The lesion involves the right foramen of T1-T2, T2-T3.
There is
extension of the tumor above the chest wall at the apex, series
5, image 22.
There is no cleavage plane with the adjacent esophagus and the
subclavian
artery lies just anterior to the mass, remaining patent.
4-mm right lower lobe nodule, series 5, image 151, is
indeterminate and will
have to be followed up. A few bronchiolar nodules and opacities
in left lower
lobe are probably due to aspiration.
MEDIASTINUM:
Thyroid is unremarkable. There is a 9-mm right lower
paraesophageal lymph
node and a few subcentimeter right hilar lymph nodes of
indeterminate
significance. There is no pleural effusion. A trace of
pericardial effusion
is seen.
UPPER ABDOMEN: This study is not tailored for assessment for
intra-abdominal
organs. The adrenal glands are normal.
CONCLUSION:
1. Patient was treated with right upper lobe lobectomy,
radiation and
chemotherapy for primary lung malignancy. An enlarging right
apical mass
since neck CT of ___ is consistent with local
recurrence. This mass
invades the adjacent ribs and thoracic spine. There is
destruction of the
posterior wall of T1 and T2. This exam is not tailored to
assess the central
canal, so if the patient has any neurologic symptoms, a
dedicated MRI can be
done.
2. Minimal bronchiolar opacities in left lower lobe are
consistent with
aspiration.
3. Indeterminate right lower lobe 4-mm nodule.
EEG ___:
FINDINGS:
ABNORMALITY #1 : Throughout the recording, there were very
frequent bursts of
___ Hz slowing usually with a generalized distribution but
with some
rightsided emphasis.
BACKGROUND: Included a well-formed 9.5 Hz alpha frequency rhythm
posteriorly,
early in the record during wakefulness.
HYPERVENTILATION: Could not be performed.
INTERMITTENT PHOTIC STIMULATION: Could not be performed.
SLEEP: The patient progressed from wakefulness to sleep with no
additional
findings beyond the slowing.
CARDIAC MONITOR: Showed a generally regular rhythm.
IMPRESSION: Abnormal portable EEG due to frequent bursts of
theta and delta
slowing, usually with a generalized distribution but with some
rightsided
emphasis. These findings suggest a dysfunction and midline
structures, but
this is non-specific with regard to etiology. The background
rhythm was
normal at times, and there were no epileptiform features.
INTERPRETED BY: ___.
MRI brain ___:
FINDINGS: The image quality is moderately motion degraded.
Within the
confines of the study:
There are large areas of FLAIR-bright, DWI-bright and
ADC-isointense signal
abnormality involving the bilateral cerebella and the occipital
lobes,
compatible with acute-to-subacute infarctions. There are
punctate foci of
DWI-bright signal in the right insula and the left parietal lobe
(image 6:19
and 6:20), representing scattered focal embolic infarcts.
There are superimposed confluent periventricular and scattered
subcortical
white matter T2/FLAIR hyperintensities, compatible with chronic
microvascular
ischemic disease. There is no evidence of acute hemorrhage.
Multifocal small
supratentorial susceptibility artifacts represent old
microhemorrhages.
The ventricles and sulci are prominent, representing age-related
global
atrophy. There is no shift of normally midline structures.
There is no
abnormal post-contrast enhancement.
There is mild mucosal thickening in the visualized paranasal
sinuses. There
is a large mucus retention cyst with near-complete opacification
of the right
maxillary sinus. The left lens is surgically absent.
IMPRESSION:
1. Acute-to-subacute infarctions involving the bilateral
occipital lobes and
the bilateral cerebellum. No evidence of acute hemorrhagic
conversion.
2. Unchanged scattered supratentorial foci of old
microhemorrhages.
3. No abnormal post-contrast or evidence of a mass lesion.
4. Significant global atrophy with mild-to-moderate chronic
microvascular
ischemic disease.
5. Right maxillary sinus disease.
CTA head/neck w/ w/o contrast ___:
FINDINGS:
HEAD CT: There is no evidence of hemorrhage, edema, masses,
mass effect, or
infarction. The ventricles and sulci are normal in size and
configuration.
No fracture is identified.
HEAD AND NECK CTA: There is significant atherosclerotic
calcification in the
aorta and bilateral subclavian arteries. The right vertebral
artery is not
visualized proximally and is completely occluded, likely due to
the adjacent
lung mass. The right vertebral artery reappears distally,
reconstituted by
collateral vessels. The left vertebral artery arises from the
aorta, with
significant atherosclerotic disease at its origin. The left
vertebral artery
remainS patent throughout its course, without evidence of
occlusion,
dissection, or aneurysm. The basilar artery is patent and
normal in
appearance. The carotid arteries and their major branches are
patent with no
evidence of stenosis, occlusion, dissection, or aneurysm. There
is a fetal
type left PCA which arises from the left carotid artery.
The right lung apex demonstrates changes consistent with known
right lung
mass. Associated with the lung mass, there is erosion of the T1
and T2
vertebral bodies and erosion of the ribs, which are better
described on recent
chest CT.
IMPRESSION:
1. Occluded proximal right vertebral artery, likely due to
adjacent known
lung mass, with distal reconstitution by collateral vessels.
2. Patent left vertebral artery, bilateral carotid arteries,
and intracranial
vessels.
2. Right lung mass with associated erosion of the T1 and T2
vertebral bodies
and ribs, better characterized on recent chest CT.
MR ___ ___:
FINDINGS: There is a mass in the right lung apex which extends
from C7-T1 to
T4 level in the paraspinal region. There are signal changes
predominantly
affecting the T1 and T2 vertebrae on the right side, but also
minimally
involving the T3 and T4 vertebral bodies on the right side.
There is
extension of the mass to the right C7-T1, T1-T2 and T2-T3 as
well as T3-T4
intervertebral foramina predominantly at T1-T2 and T2-3 levels.
There is mild
epidural soft tissue extension to the right side of the thecal
sac with
minimal indentation on the thecal sac without cord compression.
There appears
to be involvement of the right transverse process of the T1 and
of the first
rib which can be further assessed with the chest CT.
There is no abnormal signal within the spinal cord. There are
no other focal
abnormalities within the vertebral bodies. Within the thoracic
vertebral
bodies except for increased T1 and T2 signal in the upper
thoracic region from
T3-T5 level which could be related to prior radiation. An
incidental
hemangioma is seen in T12 vertebral body. There is diffuse
ossification of
the anterior longitudinal ligament. This could be related to
diffuse
idiopathic skeletal hyperostosis. Mild multilevel degenerative
changes are
seen without high-grade spinal stenosis.
IMPRESSION:
Right upper lung mass with secondary bony infiltration of the
right side of
T1-T4 vertebral bodies, more predominantly involving the T1 and
T2 vertebrae.
Extension into the right neural foramina from C7-T1 to T3-T4,
level more
predominantly at T1-T2 and T2-T3 level with mild epidural soft
tissue
extension to the spinal canal but no evidence of compression of
the spinal
cord. Other findings as described above.
Medications on Admission:
Medications:
Allopurinl 200mg qd
Aspirin EC 81mg qd
Atenoll 25mg qd
Carbidopa/levodopa ___ 2 tabs tid
___ ___ u weekly
Ropinorole 0.25mg qd
Simvastatin 80mg qd
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Carbidopa-Levodopa (___) 1 TAB PO TID
4. Simvastatin 80 mg PO DAILY
5. Enoxaparin Sodium 40 mg SC Q12H
RX *enoxaparin 40 mg/0.4 mL 40 mg sc (under the skin) twice
daily Disp #*60 Syringe Refills:*0
6. Ropinirole 0.25 mg PO QAM
7. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
8. Outpatient Occupational Therapy
9. Outpatient Physical Therapy
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
- Multiple infarcts in the posterior circulation (bilateral
occipital and bilateral cerebellar strokes), likely due to
top-of-the-basilar syndrome with clot recanalization
- Recurrence of locally aggressive lung cancer with bone
invasion
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: ___ man, with likely focal seizures, with past history of
lung cancer and brain mets and evidence of amyloid angiopathy on prior exam.
Assess for brain mets or other cause of seizure.
COMPARISON: Outside MR head on ___.
TECHNIQUE: Multiplanar, multisequence T1- and T2-weighted images were
acquired through the head. Diffusion-weighted images and ADC maps were also
obtained for evaluation.
FINDINGS: The image quality is moderately motion degraded. Within the
confines of the study:
There are large areas of FLAIR-bright, DWI-bright and ADC-isointense signal
abnormality involving the bilateral cerebella and the occipital lobes,
compatible with acute-to-subacute infarctions. There are punctate foci of
DWI-bright signal in the right insula and the left parietal lobe (image 6:19
and 6:20), representing scattered focal embolic infarcts.
There are superimposed confluent periventricular and scattered subcortical
white matter T2/FLAIR hyperintensities, compatible with chronic microvascular
ischemic disease. There is no evidence of acute hemorrhage. Multifocal small
supratentorial susceptibility artifacts represent old microhemorrhages.
The ventricles and sulci are prominent, representing age-related global
atrophy. There is no shift of normally midline structures. There is no
abnormal post-contrast enhancement.
There is mild mucosal thickening in the visualized paranasal sinuses. There
is a large mucus retention cyst with near-complete opacification of the right
maxillary sinus. The left lens is surgically absent.
IMPRESSION:
1. Acute-to-subacute infarctions involving the bilateral occipital lobes and
the bilateral cerebellum. No evidence of acute hemorrhagic conversion.
2. Unchanged scattered supratentorial foci of old microhemorrhages.
3. No abnormal post-contrast or evidence of a mass lesion.
4. Significant global atrophy with mild-to-moderate chronic microvascular
ischemic disease.
5. Right maxillary sinus disease.
Dr. ___ discovered and discussed by phone the pertinent findings with
the neurology team Dr. ___ at 8:00 am on ___.
Radiology Report
HISTORY: ___ male with bilateral occipital and cerebellar strokes,
now requiring assessment of vasculature.
COMPARISON: Comparison is made with CT chest from ___ and CT head
from ___.
TECHNIQUE: Contiguous axial images were obtained through the brain without
contrast material. Subsequently helical acquired axial images were obtained
through the head and neck using a CTA protocol after the uneventful
administration of 70 cc of Omnipaque intravenous contrast. Curved reformats
and CTA maximum intensity projection images were generated on independent
workstation.
FINDINGS:
HEAD CT: There is no evidence of hemorrhage, edema, masses, mass effect, or
infarction. The ventricles and sulci are normal in size and configuration.
No fracture is identified.
HEAD AND NECK CTA: There is significant atherosclerotic calcification in the
aorta and bilateral subclavian arteries. The right vertebral artery is not
visualized proximally and is completely occluded, likely due to the adjacent
lung mass. The right vertebral artery reappears distally, reconstituted by
collateral vessels. The left vertebral artery arises from the aorta, with
significant atherosclerotic disease at its origin. The left vertebral artery
remainS patent throughout its course, without evidence of occlusion,
dissection, or aneurysm. The basilar artery is patent and normal in
appearance. The carotid arteries and their major branches are patent with no
evidence of stenosis, occlusion, dissection, or aneurysm. There is a fetal
type left PCA which arises from the left carotid artery.
The right lung apex demonstrates changes consistent with known right lung
mass. Associated with the lung mass, there is erosion of the T1 and T2
vertebral bodies and erosion of the ribs, which are better described on recent
chest CT.
IMPRESSION:
1. Occluded proximal right vertebral artery, likely due to adjacent known
lung mass, with distal reconstitution by collateral vessels.
2. Patent left vertebral artery, bilateral carotid arteries, and intracranial
vessels.
2. Right lung mass with associated erosion of the T1 and T2 vertebral bodies
and ribs, better characterized on recent chest CT.
Radiology Report
EXAM: MRI of the thoracic spine.
CLINICAL INFORMATION: Patient with diagnosis of lung mass for further
evaluation to exclude infiltration of the spine.
TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 axial images were
obtained before gadolinium. T1 sagittal and axial images were obtained
following gadolinium.
FINDINGS: There is a mass in the right lung apex which extends from C7-T1 to
T4 level in the paraspinal region. There are signal changes predominantly
affecting the T1 and T2 vertebrae on the right side, but also minimally
involving the T3 and T4 vertebral bodies on the right side. There is
extension of the mass to the right C7-T1, T1-T2 and T2-T3 as well as T3-T4
intervertebral foramina predominantly at T1-T2 and T2-3 levels. There is mild
epidural soft tissue extension to the right side of the thecal sac with
minimal indentation on the thecal sac without cord compression. There appears
to be involvement of the right transverse process of the T1 and of the first
rib which can be further assessed with the chest CT.
There is no abnormal signal within the spinal cord. There are no other focal
abnormalities within the vertebral bodies. Within the thoracic vertebral
bodies except for increased T1 and T2 signal in the upper thoracic region from
T3-T5 level which could be related to prior radiation. An incidental
hemangioma is seen in T12 vertebral body. There is diffuse ossification of
the anterior longitudinal ligament. This could be related to diffuse
idiopathic skeletal hyperostosis. Mild multilevel degenerative changes are
seen without high-grade spinal stenosis.
IMPRESSION:
Right upper lung mass with secondary bony infiltration of the right side of
T1-T4 vertebral bodies, more predominantly involving the T1 and T2 vertebrae.
Extension into the right neural foramina from C7-T1 to T3-T4, level more
predominantly at T1-T2 and T2-T3 level with mild epidural soft tissue
extension to the spinal canal but no evidence of compression of the spinal
cord. Other findings as described above.
Radiology Report
HISTORY: Altered mental status.
COMPARISON: Chest radiograph ___ at 11:01 from ___. Chest
radiograph ___ from ___.
TECHNIQUE: PA and lateral views of the chest.
FINDINGS:
There is evidence of right lung volume loss with tenting of the right
hemidiaphragm and opacification in the right apex compatible prior right upper
lobectomy. Ill-defined focal opacification within the right upper lung field
appears progressed compared to the prior radiograph from ___ but
is unchanged compared to the radiograph performed earlier the same day. The
cardiac silhouette is normal in size. The aorta is slightly unfolded. There
is no pulmonary vascular congestion. Left lung is clear. No pleural effusion
or pneumothorax is identified. Degenerative changes are seen within the
thoracic spine.
IMPRESSION:
IStatus post right upper lobectomy with ill-defined opacification within the
right upper lung field which could reflect post treatment changes, though
infection or neoplasm is not excluded. Comparison with prior cross sectional
imaging is recommended, and if none are available, a dedicated chest CT is
suggested.
Radiology Report
CHEST CT WITH CONTRAST
INDICATION: Patient with history of lung cancer, right upper lobe resection,
chemo and radiation therapy, now with 40-pound weight loss. Chest x-ray with
changes from resection versus neoplasm.
COMPARISON: Chest x-ray from outside hospital of ___. Neck CT of outside
hospital of ___. No prior chest CT. Chest x-ray of ___.
TECHNIQUE:
Axial helical MDCT images were obtained from the suprasternal notch to the
upper abdomen with administration of IV contrast. Multiplanar reformatted
images in coronal and sagittal axes were generated.
FINDINGS:
The patient had a right upper lobe lobectomy, chemo and radiation therapy for
primary lung malignancy. There is an evolving mass at the right apex
consistent with local recurrence measuring 6 x 5.2 cm in axial plane and 3.6
cm in coronal, previously on the neck CT of ___, 3.6 x 3.7 x 3.7 cm.
The lesion invades the adjacent posterior first, second, third ribs. There is
also periosteal reaction of the posterior fourth rib. Vertebral bodies of T1
and T2 are also involved with destruction of the posterior wall of the
vertebra. This exam is not tailored to assess involvement of the central
canal. The lesion involves the right foramen of T1-T2, T2-T3. There is
extension of the tumor above the chest wall at the apex, series 5, image 22.
There is no cleavage plane with the adjacent esophagus and the subclavian
artery lies just anterior to the mass, remaining patent.
4-mm right lower lobe nodule, series 5, image 151, is indeterminate and will
have to be followed up. A few bronchiolar nodules and opacities in left lower
lobe are probably due to aspiration.
MEDIASTINUM:
Thyroid is unremarkable. There is a 9-mm right lower paraesophageal lymph
node and a few subcentimeter right hilar lymph nodes of indeterminate
significance. There is no pleural effusion. A trace of pericardial effusion
is seen.
UPPER ABDOMEN: This study is not tailored for assessment for intra-abdominal
organs. The adrenal glands are normal.
CONCLUSION:
1. Patient was treated with right upper lobe lobectomy, radiation and
chemotherapy for primary lung malignancy. An enlarging right apical mass
since neck CT of ___ is consistent with local recurrence. This mass
invades the adjacent ribs and thoracic spine. There is destruction of the
posterior wall of T1 and T2. This exam is not tailored to assess the central
canal, so if the patient has any neurologic symptoms, a dedicated MRI can be
done.
2. Minimal bronchiolar opacities in left lower lobe are consistent with
aspiration.
3. Indeterminate right lower lobe 4-mm nodule.
The results have been discussed with Dr. ___ at 3:30 p.m.
Gender: M
Race: OTHER
Arrive by AMBULANCE
Chief complaint: S/P UNRESPONSIVE
Diagnosed with ALTERED MENTAL STATUS , URIN TRACT INFECTION NOS, SEC MAL NEO BRAIN/SPINE, HX-BRONCHOGENIC MALIGNAN, PARKINSON'S DISEASE, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA
temperature: 98.0
heartrate: 72.0
resprate: 16.0
o2sat: 98.0
sbp: 157.0
dbp: 80.0
level of pain: 0
level of acuity: 2.0 | ___ with a PMH of HTN, HLD, metastatic lung ca with
questionable history of brain mets (not apparent on recent MRI)
s/p RUL resection and chemo/XRT in ___ reportedly in remission,
new diagnosis of PD on Sinemet and ropinirole, who presented
after an episode of unresponsiveness and mutism with left-sided
weakness, which lasted several hours and appears to have mostly
resolved, with nil acute on CT head, initially thought to
represent a focal seizure with ___ paresis.
On examination, has some difficulty with orientation (does not
know the date or his own age, nor the hospital) and
low-frequency naming, perhaps compatible with early
dementia/MCI, also neglects visual field and initially appeared
to have some optic ataxia. He has very poor vision. On motor
exam left pronator drift and a mild left hemiparesis arm>leg and
slightly brisker reflexes on the left with a left extensor
plantar; however, these findings improved over the admission.
MRI shows new bilateral occipital lobe and cerebellar infarcts;
together with the HPI of an episode of loss of consciousness,
with a left hemiparesis that gradually resolved almost
completely. Initial diagnosis was of a seizure with left-sided
___ paralysis. However, in light of the bilateral infarcts in
posterior distribution, he most likely had a top of the basilar
syndrome with subsequent clot recanalization.
He was initially loaded with levetiracetam, and started a
standing dose. This was d/c'd after the ___.
On CXR and CT chest, he appears to have recurrence of his
previous lung cancer, perhaps contributing to
hypercoagulability. TTE w/o obvious embolic sources.
# Neuro: Collapse, likely secondary to top-of-the basilar
syndrome with subsequent recanalization
- Have started enoxaparin anticoagulation as there is evidence
that it provides superior anticoagulation in cancer-related
hypercoagulability
- Will stop LEV 500mg bid (initiated on admission)
- Stroke workup: lipid panel TChol 140 ___ 72 HDL 57 LDL 69 , A1C
5.6; as cholesterol values appear in good range, will not modify
statin therapy
- Continued levodopa/carbodopa but at reduced dose as susipicion
of ___ is low, continued ropinorole
- ___ recommended rehab but as pt is adamant about returning
home to be with his terminally ill wife, we agreed to discharge
home with outpt ___.
.
# ___
- ECG wnl
- No events on telemetry
- Continue home atenolol and simvastatin
- Continue aspirin
.
# Pulm:
- CT chest shows likely cancer recurrence. Have made appointment
with oncology for outpt w/u
#Endo: TSH elevated at 6.1, awaiting remainder of TFTs 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:
LLQ pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male with salivary gland carcinoma w/ metastases to lung,
adrenal glands and liver presents with abdominal pain and
malaise. Per the patient, the pain started abruptly last night
when he was getting ready to go to bed. The pain is located in
the LUQ radiating to the groin, described as a sharp ___ pain
that worsens with inspiration. Not associated with any nausea or
vomiting and it was not related to eating. The patient did
report some loose stool on the ___ prior to admission but
his wife gave him ___ and he did not have any recurrent
episodes. No blood noted in the stool.
Of note, the patient was recently discharged after admission for
AMS and ___ on ___. There was some concern for c dif and
the patient was treated with empiric vanc but this was dc'd
after test came back negative. Since discharge the patient had
noticed some progressive fatigue, weakness, and general malaise
that has gotten worse in the past few days. He also endorses a
decreased appetite and per his wife, an approximately 10 lb
weight loss during this time period. The patient denies any sick
contacts, no fevers, chills, or change in mental status. Denies
blood per rectum or melena. No dysuria or hematuria.
In the ED, initial vitals were: 98.0 120 119/57 16 94% ra. He
received 3L NS and HR prior to transfer to the floor was 90. In
the ED started on vancomycin, zosyn, flagyl, pantoprazole. Labs
were significant for wbc count of 17.6 and lactate 3.6 that are
new, and AST 68, ALT 63, Alk phos 488 which are decreased from
the previous admission. He had a CT abdomen and pelvis which
showed colitis concerning for ischemic etiology but cannot rule
out inflammatory or infectious etiology. He was seen by ACS in
the ED who felt that he was not an operative candidate and
recommended NPO, IVF, broad antibiotic coverage for cdif. Stools
in the ED guiac negative and stool studies ordered.
On the floor, the patient is complaining of ___ abdominal
pain that improved with morphine. He is a bit confused from the
morphine but his wife verified the above history given to the
ED. No other complaints or changes at this time.
Past Medical History:
ONCOLOGIC HISTORY:
- initially noted a mass in his left lower neck in ___.
He applied heat to it thinking it might be a salivary gland
stone; however, it did not resolve.
- MRI on ___, which showed a 3.6 x 2.3 x 2.8 cm
lesion with irregular borders and some mild edema as well as two
lymph nodes measuring 1.1 and 2 cm respectively.
- seen by Dr. ___ on ___, who sent him up
for surgical removal of his mass, which occurred on ___. At that time, he underwent a left modified radical neck
dissection with resection of submandibular infiltrate of tumor
with facial nerve monitoring. Pathology of this was an adenoid
cystic carcinoma T4N2b carcinoma.
- underwent a PET scan on ___, which showed
post-surgical changes and marked tracer uptake in the T9
vertebral body. He was initiated at radiation therapy on
___, was started on concurrent ___ on
___.
- biopsy of the spinal lesion, which was performed on ___, and pathology of which came back as metastatic
carcinoma, consistent with the patient's known adenoid cystic
carcinoma.
- completed his concurrent chemotherapy and radiation on
___.
- He underwent surgery for stabilization of his T9 lesion on
___.
- He then had radiation to this area which was completed on
___.
- Started C1 of navelbine ___ for metastatic disease
PAST MEDICAL HISTORY:
1. Metastatic adenoid cystic carcinoma of the salivary gland.
2. Hypertension.
3. Gastric ulcer status post gastrectomy.
4. High cholesterol.
5. Diabetes.
6. Hearing loss.
7. Prior renal stone.
Social History:
___
Family History:
There is no history of cancer. His father died of an accident.
His mother is reported as dying of old age
Physical Exam:
Admission Physical Exam:
========================
Vitals: T: 98.4 BP: 141/79 P: 82 R: 18 O2: 97%
General: NAD, AAO x3
HEENT: NCAT, pupils symmetrically constricted, scleral icterus,
MMM
Neck: Soft, supple, no LAD, no JVD
CV: RRR, normal S1S2, -m/r/g
Lungs: normal respiratory effort, CTAB, no w/r/r
Abdomen: NBS, soft, slightly distended, TTP over epigastrium and
LUQ, no rebound tenderness, guarding, no hepatosplenomegaly
Ext: WWP, moving all extremities equally, no c/c/e
Neuro: CNIII-XII grossly intact, no focal motor or sensory
deficits
Skin: slightly jaundiced, intact, no rashes or lesions
Discharge Physical Exam:
========================
Vitals: 98.6 134/87 74 (62-77) 18 99% RA
General: NAD, AAO x3
CV: RRR, normal S1S2, -m/r/g
Lungs: normal respiratory effort, CTAB, no w/r/r
Abdomen: NBS, soft, non-distended, non-tender to palpation
Ext: moving all extremities equally, no clubbing, cyanosis,
edema
Neuro: CNIII-XII grossly intact, no focal motor or sensory
deficits
Pertinent Results:
Admission Labs:
===============
___ 06:35AM BLOOD WBC-17.6*# RBC-3.66* Hgb-11.9* Hct-38.3*
MCV-105* MCH-32.6* MCHC-31.1 RDW-16.3* Plt ___
___ 06:35AM BLOOD Neuts-92.3* Lymphs-2.9* Monos-4.1 Eos-0.5
Baso-0.3
___ 06:35AM BLOOD Glucose-172* UreaN-41* Creat-1.9* Na-136
K-4.5 Cl-102 HCO3-17* AnGap-22*
___ 06:35AM BLOOD ALT-63* AST-68* AlkPhos-488* TotBili-1.5
___ 06:35AM BLOOD Albumin-3.5 Calcium-9.2 Phos-3.1 Mg-1.6
___ 06:26AM BLOOD Lactate-3.6*
=============================================
Pertinent Labs:
===============
___ 06:43AM BLOOD Lactate-1.5
=============================================
Microbiology:
===============
___ 9:50 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Reported to and read back by ___ AT 9:33AM
ON ___.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C. difficile by the Illumigene
DNA
amplification. (Reference Range-Negative).
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
___ 6:30 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 9:30 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
___. 10,000-100,000 ORGANISMS/ML..
GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML..
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
___
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 128 R
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
==================================================
Studies:
==========
___ CT Abdomen Pelvis with Contrast:
1. Focally thickened 13 cm segment of transverse colon is
concerning for
ischemic colitis. Other less favored differential considerations
include
infectious or inflammatory etiologies. No free fluid or free
air.
2. Progression in hepatic and pulmonary metastatic disease.
3. Stable left adrenal nodule dating back to ___.
4. Status post removal of percutaneous cholecystostomy tube with
small simple
fluid collection adjacent to the right inferior lobe of the
liver.
==================================================
Discharge Labs:
===============
___ 07:00AM BLOOD WBC-6.1 RBC-3.14* Hgb-10.3* Hct-32.5*
MCV-103* MCH-32.7* MCHC-31.6 RDW-16.0* Plt ___
___ 07:00AM BLOOD Glucose-107* UreaN-25* Creat-1.3* Na-138
K-3.9 Cl-106 HCO3-22 AnGap-14
___ 07:00AM BLOOD Calcium-8.3* Phos-2.9 Mg-1.8
Medications on Admission:
1. Acetaminophen 650 mg PO Q6H:PRN pain, fever
2. Levothyroxine Sodium 50 mcg PO DAILY
3. Ranitidine 150 mg PO DAILY
4. Ondansetron 8 mg PO Q6H:PRN n/v
5. Prochlorperazine 10 mg PO Q6H:PRN n/v
6. Tamsulosin 0.4 mg PO HS
7. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Levothyroxine Sodium 50 mcg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Ondansetron 8 mg PO Q6H:PRN n/v
4. Ranitidine 150 mg PO DAILY
5. Tamsulosin 0.4 mg PO HS
6. Acetaminophen 650 mg PO Q6H:PRN pain, fever
7. Prochlorperazine 10 mg PO Q6H:PRN n/v
8. Vancomycin Oral Liquid ___ mg PO Q6H Duration: 11 Days
RX *vancomycin 125 mg 5 mL by mouth Every 6 hours Disp #*220
Milliliter Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Clostridium Dificile Infection
Chronic Kidney Disease
Metastatic Salivary Gland Cancer
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: ___ with LLQ pain, TTP diffusely with invol guarding, metastatic
salivary gland cancer with known metastasis to liver and lung.
COMPARISON: Prior chest radiograph from ___, CT chest from ___. Prior CT abdomen pelvis from ___.
FINDINGS:
PA and lateral views of the chest provided. No free air below the right
hemidiaphragm is seen. Known pulmonary nodules poorly visualized. There is
mild left basilar atelectasis better assessed on subsequent CT of the abdomen
pelvis. The heart and mediastinal contour appear grossly unchanged. No
pneumothorax or large effusion. Bony structures appear grossly intact.
IMPRESSION:
No free air below the right hemidiaphragm. Mild bibasilar atelectasis. Known
pulmonary nodules poorly visualized. Please refer to subsequent CT abdomen
pelvis for further details.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ male with history salivary gland cancer with hepatic
metastic disease presenting with left lower quadrant pain.
TECHNIQUE: MDCT images were obtained from the lung bases to the pubic
symphysis after the administration of intravenous contrast. Axial images were
interpreted in conjunction with coronal and sagittal reformats. Oral contrast
was administered.
DLP: 952 mGy-cm
COMPARISON: CT abdomen and pelvis ___, CT abdomen and pelvis ___, CT chest ___
FINDINGS:
CHEST: Multiple lower lobe lung nodules are again seen. The majority of which
are unchanged in size. A left lower lobe lung nodule has mildly increased
since ___ and now measures 8 mm previously 7 mm (2:4). The heart is
normal in size and there is no evidence of pericardial effusion. There is
moderate coronary artery disease.
ABDOMEN:
There are innumerable hepatic metastases which have overall increased in both
size and number since ___. A lesion in segment 8 measures approximately
8.1 x 6.6 cm, previously 6.1 x 5.2 cm (02:20). The portal vein is patent.
Again seen, is mild intrahepatic biliary duct dilation.
Since prior CT, there has been removal of a percutaneous cholecystostomy tube.
The gallbladder is normal in appearance with multiple dependent gallstones.
New from prior is a small 1.1 x 3.9 x 1.6 cm fluid collection along the
inferior right lobe of the liver (02:39).
The spleen is unremarkable. Left adrenal nodule measures 1.4 cm and is
unchanged dating back to ___ (02:31). The pancreas enhances
homogenously and is without focal lesions.
The kidneys display symmetric nephrograms. The right kidney is atrophic.
Multiple bilateral simple renal cysts are unchanged from prior. The largest
renal lesion is located in the left lower pole, measures 5.3 cm, is mildly
hyperdense, and likely represents a hemorrhagic cyst (2:51). There is no
hydronephrosis. The ureters are normal in caliber and course to the bladder.
The patient is status post a gastrojejunostomy. The distal esophagus is
normal without a hiatal hernia. The small bowel is normal in caliber without
evidence of obstruction.
There is a 13.0 cm segment of mid-distal transverse colon which is abnormally
thickened with surrounding fat stranding. There are clearly defined margins
between normal and abnormal colon (2:42). The remainder of the large bowel is
unremarkable. The appendix is contrast filled and normal (2:67). There is
diverticulosis of the sigmoid colon without evidence of diverticulitis. There
is no free abdominal fluid or air.
There are dense calcifications of the abdominal aorta branching into the iliac
arteries. The abdominal aorta and its major branches do however appear
patent.. There is no retroperitoneal or mesenteric lymphadenopathy by CT size
criteria. Mesenteric panniculitis is noted, a non specific finding (2:60).
PELVIS: The bladder is well distended and normal. There is no pelvic
side-wall or inguinal lymphadenopathy by CT size criteria. No free pelvic
fluid is identified. A 0.5 cm hyperdense lesion in the median lobe of the
prostate which extends to the bladder is unchanged from ___.
OSSEOUS STRUCTURES: Multilevel, multifactorial degenerative changes are seen
within the visualized thoracolumbar spine. No focal lytic or sclerotic lesion
concerning for malignancy. Spinal fusion hardware in the lower thoracic spine
is unchanged as is a chronic T9 compression deformity. Transitional anatomy at
the lumbar sacral junction is noted.
IMPRESSION:
1. Focally thickened 13 cm segment of transverse colon is concerning for
ischemic colitis. Other less favored differential considerations include
infectious or inflammatory etiologies. No free fluid or free air.
2. Progression in hepatic and pulmonary metastatic disease.
3. Stable left adrenal nodule dating back to ___.
4. Status post removal of percutaneous cholecystostomy tube with small simple
fluid collection adjacent to the right inferior lobe of the liver.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Jaundice, Abd pain
Diagnosed with NONINF GASTROENTERIT NEC
temperature: 98.0
heartrate: 120.0
resprate: 16.0
o2sat: 94.0
sbp: 119.0
dbp: 57.0
level of pain: 5
level of acuity: 2.0 | Mr. ___ is an ___ year old male with salivary gland carcinoma
w/ mets to lung, adrenal glands and liver who presented with LLQ
pain and was found to have focal transverse colitis secondary to
C diff.
# Colitis: Stool PCR positive for C diff. He was started on PO
vancomycin 125mg q6h for severe C diff. His leukocytosis and
elevated lactate resolved. His abdominal pain also resolved and
he was able to tolerate PO intake.
# Lactic Acidosis with fluid-responsive tachycardia: likely d/t
colitis, blood cx, urine cx were ordered to r/o other source of
infection. CXR showed no signs of PNA. Lactate decreased to 1.5
on ___.
# Salivary gland carcinoma: pt had been planned for palliative
navelbine though this has been on hold given his multiple
hospitalizations. hold off on port placement for now. he will
readdress pros/cons of chemo with Dr. ___ he is
better.
# ___: likely prerenal in etiology as a result of infection and
diarrhea. Improved s/p fluids and antibiotics, with resolution
of diarrhea and improvement of colitis.
# HTN: BP stable. Antihypertensives held at previous discharge
d/t stability off medication. We continued to hold BP meds.
# HLD: Statin held at previous hospitalization d/t
transaminitis. We continued to hold.
# Diabetes: Patient has never been on medication. Last a1c
___ 6.4%. He was monitored with fingersticks qachs
# hypothyroidism: He was continued on levothyroxine
# Hx gastric ulcer: He was continued on ranitidine
# BPH: He was continued on tamsulosin |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ampicillin
Attending: ___.
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ MEDICINE ATTENDING ADMISSION NOTE .
.
Date: ___
Time: 1722
_
________________________________________________________________
PCP: Name: ___
___: ___
Address: ___
Phone: ___
Fax: ___
.
_
________________________________________________________________
HPI:
___ year old female with depression, family h/o colon cancer, h/o
recurrent polyps with yearly colonoscopies. She had a
colonoscopy in ___ which revealed a sessile polyp. She
returned on ___ to have the polyp removed. She is s/p
___ with polypectomy of a 10mm sessile polyp in the
ascending colon as well as a 7mm sessile polyp in the transverse
colon. Now p/w moderate to severe RLQ pain and passing large
blood clots per rectum. 3 clots last night, 7 this AM, some
dizziness. HCT on presentation 36.4/11.6, baseline per atrius
records: 40/13.6.
Immediately after the procedure she felt well but then developed
RLQ pain. She then had an explosion of maroon stool. She then
passed clots the following morning and this morning. Yesterday
am and this am she also passed maroon clots. +___ with standing.
No syncope. No cp, sob, n/v. Abdominal pain improved with
Tylenol. She currently experiences ___ RLQ pain. She developed
R groin pain and had a CT scan as an o/p which revealed a L
adnexal cyst. She will have an US next ___. Prior to the
colonoscopy she felt fine apart from this.
.
In ER: (Triage Vitals:
8 |98.1 |72 |155/69 | 18 |100% RA )
Meds Given: No medications or IVF given \
Radiology Studies: abdominal CT scan
consults called: GI through the ED dashbaord
.
===============================================
REVIEW OF SYSTEMS:
CONSTITUTIONAL: As per HPI
HEENT: [X] All normal
RESPIRATORY: [X] All normal
CARDIAC: [X] All normal
GI: As per HPI
GU: [X] All normal
SKIN: [X] All normal
MUSCULOSKELETAL: [X] All normal
NEURO: [X] All normal
ENDOCRINE: [X] All normal
HEME/LYMPH: [X] All normal
PSYCH: [X] All normal
All other systems negative except as noted above
Past Medical History:
Menopause
Family history of colon cancer
Condyloma acuminatum
fh of breast cancer in mother
History of basal cell carcinoma
Psoriasis
Depressive disorder
Vitamin D deficiency
Macrocytosis
Knee pain
Renal cyst, left
Social History:
___
Family History:
Brother CAD/PVD - Early; Hypertension
Father CAD/PVD; Cancer; Diabetes - Type II; Hypertension; Psych
- Depression
Mother CAD/PVD; Cancer - Breast; Cancer - Colon; Cancer -
Melanoma; Diabetes - Type II; Hypertension; Mother still alive
at ___.
Physical Exam:
Vitals: 97.4 PO 115 / 54 70 18 99 RA
CONS: NAD, comfortable appearing, very pleasant
HEENT: ncat anicteric MMM
CV: s1s2 rr no m/r/g
RESP: b/l ae no w/c/r
GI: +bs, soft, ND, mild tenderness in RLQ without no guarding or
rebound
RECTUM: one particle of melena/a speck otherwise her vault is
empty
MSK:no c/c/e 2+pulses
SKIN: no rash
NEURO: face symmetric speech fluent
Ambulated with pt who ambulates independently without
difficulty.
PSYCH: calm, cooperative
Pertinent Results:
___ 09:30AM GLUCOSE-97 UREA N-12 CREAT-0.7 SODIUM-138
POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-24 ANION GAP-17
___ 09:30AM estGFR-Using this
___ 09:30AM ALT(SGPT)-19 AST(SGOT)-25 ALK PHOS-71 TOT
BILI-0.3
___ 09:30AM LIPASE-26
___ 09:30AM ALBUMIN-4.2
___ 09:30AM WBC-5.2 RBC-3.45* HGB-11.6 HCT-36.4 MCV-106*#
MCH-33.6* MCHC-31.9* RDW-12.7 RDWSD-49.1*
___ 09:30AM NEUTS-58.9 ___ MONOS-9.6 EOS-3.8
BASOS-0.8 IM ___ AbsNeut-3.06 AbsLymp-1.39 AbsMono-0.50
AbsEos-0.20 AbsBaso-0.04
___ 09:30AM PLT COUNT-210
___ 09:30AM ___ PTT-32.6 ___
___ 09:10AM URINE HOURS-RANDOM
___ 09:10AM URINE HOURS-RANDOM
___ 09:10AM URINE UHOLD-HOLD
___ 09:10AM URINE GR HOLD-HOLD
___ 09:10AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 09:10AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-TR
___ 09:10AM URINE RBC-2 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 09:10AM URINE MUCOUS-RARE
====================================
Single sessile 10 mm polyp was found in the ascending colon
polyp. A single-piece polypectomy was performed using a hot
snare. The polyp was completely removed. A single sessile 7 mm
polyp was found in the transverse colon A single-piece
polypectomy was performed using a hot snare. The polyp was
completely removed. Small internal hemorrhoids were noted on
retroflexion. The hepatic flexure was carefully inspected. There
was no evidence of residual polyp tissue.
Impression: A single sessile 10 mm polyp was found in the
ascending colon polyp.
A single-piece polypectomy was performed using a hot snare. The
polyp was completely removed.
A single sessile 7 mm polyp was found in the transverse colon A
single-piece polypectomy was performed using a hot snare. The
polyp was completely removed.
Small internal hemorrhoids were noted on retroflexion
The hepatic flexure was carefully inspected. There was no
evidence of residual polyp tissue.
Otherwise normal colonoscopy to cecum
==========================
Recommendations: Clear liquid diet when awake, then advance
diet as tolerated.
If any fever, worsening abdominal pain, or post procedure
symptoms, please call the advanced endoscopy fellow on call
___/ pager ___.
Follow up with pathology reports. Please call Dr. ___
___ ___ in 7 days for the pathology results.
Repeat colonoscopy with Dr. ___ in ___ years
Restart ASA in 5 days
==============================
IMPRESSION:
1. No acute intraabdominal process.
2. 1.6 cm left adnexal cystic structure, which should be
followed up with a pelvic ultrasound in a postmenopausal female.
RECOMMENDATION(S): Pelvic ultrasound is recommended.
Medications on Admission:
PEG 3350-Electrolytes-Vit C 100-7.5-2.691 gram Powder in Packet
Use as directed.
EFFEXOR TABLET 75MG PO (VENLAFAXINE HCL)
She was taking ASA 81 mg up to 3 ___.
Discharge Medications:
1. Venlafaxine XR 75 mg PO DAILY
2.Outpatient Lab Work
Please have your Hgb/HCT check on ___. Results to Name:
___
Location: ___
Address: ___
Phone: ___
Fax: ___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
1. Post polypectomy bleed
SECONDARY DIAGNOSIS
1. Colonic polyps
2. Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT abdomen and pelvis with IV contrast.
INDICATION: ___ post-colonoscopy w/post-polypectomy bleed, RLQ pain, please
eval for colitis, post-surgical pathologyNO_PO contrast // ___
post-colonoscopy w/post-polypectomy bleed, RLQ pain, please eval for colitis,
post-surgical pathology
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 696 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Small amount of dependent atelectasis at the left base. No focal
consolidations. There is no evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: There is subcentimeter hypodensity in the dome of the liver
(series 2, image 7), which is too small to characterize, but likely represents
a cyst or biliary hamartoma. The geographic hypodensity adjacent to the
falciform ligament likely represents focal fatty deposition (series 2, image
24). Otherwise, the liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions. There is a small amount of perisplenic fluid.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: There is a slightly exophytic hypodensity arising from the left
kidney measuring approximately 1.6 x 1.5 cm (series 2, image 21), which is
likely a simple cyst. There are multiple additional subcentimeter
hypodensities within the kidneys bilaterally, which are too small to
characterize, but likely represent simple cysts. Otherwise, the kidneys are
of normal and symmetric size with normal nephrogram. There is no evidence of
hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Multiple duodenal diverticula
are noted. Small bowel loops demonstrate normal caliber, wall thickness, and
enhancement throughout. The colon and rectum are within normal limits. The
appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: There is a 1.6 cm left adnexal cystic structure (series
2, image 64), which should be followed up with a pelvic ultrasound in a
postmenopausal female.
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: The are degenerative changes within the lumbar spine, most prominent
at L4-5. There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: There is a small fat containing umbilical hernia. Otherwise,
the abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No acute intraabdominal process.
2. 1.6 cm left adnexal cystic structure, which should be followed up with a
pelvic ultrasound in a postmenopausal female.
RECOMMENDATION(S): Pelvic ultrasound is recommended.
NOTIFICATION: The final impression was discussed with ___,
M.D. by ___, M.D. on the telephone on ___ at 2:36 ___, 30
minutes after discovery of the findings.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: BRBPR, RLQ abdominal pain
Diagnosed with Right lower quadrant pain, Gastrointestinal hemorrhage, unspecified
temperature: 98.1
heartrate: 72.0
resprate: 18.0
o2sat: 100.0
sbp: 155.0
dbp: 69.0
level of pain: 8
level of acuity: 2.0 | MEDICAL DECISION MAKING/Assessment
The patient is a ___ year old female with depression, family h/o
colon cancer, h/o recurrent colon polyp who p/w post polypectomy
bleeding.
.
BRBPR
ABDOMINAL PAIN
The patient's presentation was most consistent with a post
polypectomy bleed. She was monitored for twelve hours and did
not have any more bleeding. She did not have any more light
headeadness. Her abdominal CT scan was reassuring. She ate two
meals. Her rectal vault was empty of stool x 2. Her Hgb remained
stable from 11.6 -> 11.___nough to drive home. He
husband will be at home. She had stopped taking a baby aspirin
3 days prior to the procedure and was asked to hold off on
resuming this before checking in with Dr. ___. She
was concerned about her co-pay as an observation admission. She
attempted to call her insurance company to find out but no one
was available. O/C CM was contacted and was not able to let us
know the cost. The author also attempted to verify that the
patient was observation but at that time CM had already left for
the day. Given her clinical stability, reassuring CT scan
results and stable Hgb as well as her close location to the
hospital and her reliability as a patient she was discharged
home. D/w ERCP team prior to discharge. Pt given a PPx for a HCT
check in her PCP's office on ___. She knows to contact Dr.
___ me with any concerns overnight. Her telemetry
demonstrated sinus rhythm wth HR = 60s without any alarms.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Leg pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ y/o man with hx of EtOH cirrhosis c/b ascites
with recent SBP, portal vein thrombosis (on lovenox), recurrent
pancreatitis, with recent tx for acute on chronic pancreatitis,
presenting with left leg pain and swelling.
Recently admitted ___ - ___ for abdominal pain felt ___
chronic pancreatitis. During that admission, he was empirically
treated 7 days for possible SBP, had therapeutic LVP, and was
transitioned from coumadin to lovenox for anticoagulation of
portal vein thrombus. Of note, he was transferred initially from
an OSH, where he reports receiving an IM injection to his left
thigh.
In past 2 days, has had progressive pain in left thigh; on day
of presentation had rapidly progressing swelling of thigh and
left knee. No fevers, vomiting/diarrhea. Denies
numbness/tingling in left foot; difficult to ambulate due to
pain.
In the ED, initial vital signs were: 98.6 95 117/92 20 99% RA
- Exam was notable for significant edema over left thigh/knee,
with ecchymoses of left knee, tautness on palpation over left
knee but retained ability to flex/extend foot/toes, with intact
distal perfusion.
- Labs were notable for: WBC of 12.4, Hgb of 10 (discharge hgb
13 on ___, normal coagulation studies, K 5.5 (hemolyzed
specimen), and Cr of 0.9 (baseline ~0.7).
- Imaging include:
___ L Hip and Knee X-ray: Suprapatellar soft tissue swelling
without fracture.
___ LLE U/S: 8.8 x 7.2 x 13.8 cm hematoma in the
subcutaneous tissues of the left lateral thigh.
___ LLE ___: No evidence of deep venous thrombosis in the
left lower extremity veins.
- The patient was given:
___ 14:29 IV Morphine Sulfate 4 mg
___ 16:06 IV HYDROmorphone (Dilaudid) .5 mg
___ 17:18 IV HYDROmorphone (Dilaudid) .5 mg
___ 19:20 IV HYDROmorphone (Dilaudid) .5 mg
___ 20:59 IV HYDROmorphone (Dilaudid) 2 mg
- Consults: Ortho : No concern for acute compartment syndrome
and no surgical intervention currently indicated.
Upon arrival to the floor, patient reports being in ___ pain
and does not want to speak with anyone until he gets dilaudid
pain medication.
Past Medical History:
MEDICAL HISTORY:
- Cirrhosis secondary to alcohol abuse (dx ___ c/b PVT (dx
___ and prior SBP
- Recurrent pancreatitis
- Hypertriglyceridemia
- Pancreatic pseudocyst vs underlying malignant mass (needs rpt
MRCP)
SURGICAL HISTORY:
- R Inguinal hernia repair
- ORIF of Right ankle
Social History:
___
Family History:
Remote history of "liver problems" in great grandparents.
Father: DM.
Physical Exam:
========================
ADMISSION PHYSICAL EXAM:
========================
VITALS: T 98.3 BP 144/95 HR 88 RR 18 Sats 98 RA
GENERAL: Yelling and shouting in distress
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP clear.
NECK: Supple, no LAD, no thyromegaly, JVP flat.
CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops.
PULMONARY: Clear to auscultation bilaterally, without wheezes or
rhonchi.
ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended,
no organomegaly. No asterixis
EXTREMITIES: significant edema over left thigh/knee, with
ecchymoses of left knee, tautness on palpation over left knee
but retained ability to flex/extend foot/toes, with intact
distal perfusion.
NEUROLOGIC: A&Ox3, CN II-XII grossly normal
========================
DISCHARGE PHYSICAL EXAM:
========================
VS: Tm/Tc 98.9 | HR 85-101 | BP 127/63-128/78 | RR 18 | 02 95%
RA
General: Well appearing. A+O x3. Some distress due to pain.
HEENT: MMM, EOMI. No jaundice or scleral icterus.
Neck: Supple, full ROM
CV: RRR. No M/R/G.
Lungs: CTAB, breathing comfortably
Abdomen: Soft. B/l lower adominal subcutaneous ecchymoses. Mild
RUQ tenderness, otherwise nontender. Minimal distention without
obvious ascites. Hard liver edge 4 cm below right costal margin.
No splenomegaly. No caput medusa.
GU: deferred
Extremities:
LLE: Skin intact, no open wounds with darkening from evolving
ecchymoses. Significant swelling and tense edema from proximal
thigh through distal knee, resolving by distal calf. Thigh tense
and tender to palpation, though less than prior exams.
Calf/lower leg/foot with sensation intact. Warm and well
perfused b/L. 1+ to 2+ DP pulses b/L.
Neuro: Grossly normal. No asterixis.
Pertinent Results:
===============
ADMISSION LABS:
===============
___ 02:10PM BLOOD WBC-12.8*# RBC-3.10* Hgb-10.0*#
Hct-29.5*# MCV-95# MCH-32.3* MCHC-33.9 RDW-13.2 RDWSD-45.6 Plt
___
___ 02:10PM BLOOD Neuts-75.3* Lymphs-13.3* Monos-9.7
Eos-0.6* Baso-0.4 Im ___ AbsNeut-9.66* AbsLymp-1.70
AbsMono-1.25* AbsEos-0.08 AbsBaso-0.05
___ 02:10PM BLOOD ___ PTT-35.5 ___
___ 02:10PM BLOOD Glucose-102* UreaN-13 Creat-0.9 Na-132*
K-5.5* Cl-93* HCO3-24 AnGap-21*
___ 02:10PM BLOOD Albumin-4.0 Calcium-9.5 Phos-3.6 Mg-2.1
___ 02:10PM BLOOD ALT-32 AST-84* AlkPhos-193* TotBili-1.6*
================
DISCHARGE LABS:
================
___ 06:45AM BLOOD WBC-7.1 RBC-2.67* Hgb-8.6* Hct-26.1*
MCV-98 MCH-32.2* MCHC-33.0 RDW-13.4 RDWSD-48.0* Plt ___
___ 06:45AM BLOOD ___ PTT-31.6 ___
___ 06:45AM BLOOD Glucose-162* UreaN-12 Creat-0.7 Na-134
K-3.7 Cl-96 HCO3-26 AnGap-16
___ 06:45AM BLOOD Calcium-8.4 Phos-3.7 Mg-2.1
___ 06:05AM BLOOD ALT-26 AST-47* CK(CPK)-222 AlkPhos-240*
TotBili-1.4
==============
MICROBIOLOGY:
==============
___ 12:51 am BLOOD CULTURE (Pending at discharge): NO
GROWTH TO DATE
===================
KEY IMAGING/STUDIES:
===================
___ KNEE XR AP/LAT/OBL: Suprapatellar soft tissue swelling
without fracture.
___ LEFT ___ U/S: No evidence of deep venous thrombosis in the
left lower extremity veins.
___ LEFT ___ SOFT TISSUE U/S: 8.8 x 7.2 x 13.8 cm hematoma in
the subcutaneous tissues of the left lateral thigh.
___ RUQ U/S WITH DOPPLER: 1. Persistent nonocclusive thrombus
in the left port portal vein. The main and right portal veins
are patent. This is improved compared to the outside
hospital CT obtained ___, which demonstrated complete
occlusion of the left portal vein and partial occlusion of the
main portal vein, right portal vein, superior mesenteric vein.
Of note, the SMV is not visualized on the current examination.
2. Coarsened and nodular liver with portosystemic
collateralization is consistent with known cirrhosis. No focal
lesions identified.
___ CT LEFT ___: Partially visualized lower pelvis
demonstrates fat containing left inguinal
hernia. Otherwise unremarkable pelvic organs.
There is a large predominantly hyperdense heterogeneous
collection centered in the left vastus lateralis muscle
measuring 9.7 x 5.5 x 17.2 cm. There is edema in the
surrounding musculature, particularly superior to the hematoma.
Small joint effusion is seen in the left knee. There is
subcutaneous edema of
the left lower extremity particularly laterally.
Tiny calcification is seen in between the left gluteus medius
and minimus muscles. No acute fracture or dislocation. No
significant degenerative changes.
IMPRESSION:
Large left thigh hematoma centered in the vastus lateralis
muscle as detailed above. Hyperdense hemorrhage is seen.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Enoxaparin Sodium 90 mg SC Q12H
2. FoLIC Acid 1 mg PO DAILY
3. Multivitamins W/minerals 1 TAB PO DAILY
4. QUEtiapine Fumarate 50 mg PO QHS
5. Thiamine 100 mg PO DAILY
6. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
7. Docusate Sodium 100 mg PO BID:PRN constipation
8. Gabapentin 300 mg PO QHS
9. Senna 8.6 mg PO BID:PRN constipation
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Lactulose 30 mL PO BID:PRN constipation
12. Furosemide 20 mg PO DAILY ascites
13. Spironolactone 50 mg PO DAILY ascites
14. Magnesium Oxide 400 mg PO DAILY
15. Morphine Sulfate ___ 7.5 mg PO QID:PRN breakthrough pain
16. Morphine SR (MS ___ 15 mg PO Q8H
Discharge Medications:
1. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
2. FoLIC Acid 1 mg PO DAILY
3. Furosemide 20 mg PO DAILY ascites
RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. Lactulose 30 mL PO BID:PRN constipation
5. Morphine SR (MS ___ 15 mg PO Q8H
RX *morphine [MS ___ 15 mg 1 tablet(s) by mouth three times
a day Disp #*21 Tablet Refills:*0
6. Morphine Sulfate ___ 7.5 mg PO QID:PRN breakthrough pain
RX *morphine 15 mg 0.5 (One half) tablet(s) by mouth four times
a day Disp #*14 Tablet Refills:*0
7. Multivitamins W/minerals 1 TAB PO DAILY
8. QUEtiapine Fumarate 50 mg PO QHS
RX *quetiapine 50 mg 1 tablet(s) by mouth at bedtime Disp #*7
Tablet Refills:*0
9. Spironolactone 50 mg PO DAILY ascites
RX *spironolactone 50 mg 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*0
10. Thiamine 100 mg PO DAILY
11. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4)
hours Disp #*56 Tablet Refills:*0
12. Docusate Sodium 100 mg PO BID:PRN constipation
13. Magnesium Oxide 400 mg PO DAILY
14. Polyethylene Glycol 17 g PO DAILY:PRN constipation
15. Senna 8.6 mg PO BID:PRN constipation
16. Gabapentin 300 mg PO QHS
RX *gabapentin 300 mg 1 capsule(s) by mouth at bedtime Disp #*7
Capsule Refills:*0
17. Cane
CANE (assistive device)
Dx: ___
Px: Good
Length of need: 13 months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
- Left Thigh hematoma
- Acute anemia from blood loss into thigh hematoma
SECONDARY DIAGNOSIS:
- Portal vein thrombosis
- Cirrhosis, secondary to ethanol
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: FEMUR (AP AND LAT) LEFT
INDICATION: ___ with progressive swelling of left thigh/knee in setting of
recent IM injection and anticoagulation // ?fracture or other abnormality.
TECHNIQUE: AP and lateral views of the proximal distal left femur.
COMPARISON: None available.
FINDINGS:
No fracture or dislocation detected. No suprapatellar effusion. No
radiopaque foreign body. There is suprapatellar soft tissue swelling without
evidence of subcutaneous gas. No suspicious lytic or sclerotic lesions are
present
IMPRESSION:
Suprapatellar soft tissue swelling without fracture.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS LEFT
INDICATION: History: ___ with history of portal vein thrombosis, presents
with left thigh and knee pain. // eval for DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower extremity veins.
COMPARISON: ___ left lower extremity ultrasound
FINDINGS:
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 posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
IMPRESSION:
No evidence of deep venous thrombosis in the left lower extremity veins.
Radiology Report
EXAMINATION: US EXTREMITY LIMITED SOFT TISSUE LEFT
INDICATION: History: ___ M with cirrhosis complicated by portal vein
thrombosis (on lovenox) now with swelling/edema of thigh, knee. // Please
evaluate for hematoma.
TECHNIQUE: Grayscale ultrasound images were obtained of the superficial
tissues of the left lateral thigh.
COMPARISON: None
FINDINGS:
Targeted transverse and sagittal images of the area of concern in the left
lateral thigh demonstrate an 8.8 x 7.2 x 13.8 cm heterogeneous lesion in the
subcutaneous tissues without internal vascular flow compatible with a
hematoma.
IMPRESSION:
8.8 x 7.2 x 13.8 cm hematoma in the subcutaneous tissues of the left lateral
thigh.
Radiology Report
EXAMINATION: DUPLEX DOPP ABD/PEL
INDICATION: Please eval for interval change in venous thrombosis with Do
TECHNIQUE: Gray scale, color and spectral Doppler evaluation of the abdomen
was performed.
COMPARISON: ___ CTA abdomen/pelvis
FINDINGS:
Liver: The hepatic parenchyma is coarsened and nodular.. Nofocal liver
lesions are identified. There is no ascites. Multiple portosystemic
collaterals are visualized in the midline abdomen.
Bile ducts: There is no intrahepatic biliary ductal dilation. The common
bile duct measures 2 mm.
Gallbladder: The gallbladder is contracted and not well evaluated.
Pancreas: Imaged portion of the pancreas appears within normal limits, with
portions of the pancreatic tail obscured by overlying bowel gas.
Spleen: The spleen demonstrates normal echotexture, and measures 14.6 cm.
Kidneys: No stones, masses or hydronephrosis are identified in either kidney.
Doppler evaluation:
The main portal vein is patent, with flow in the appropriate direction.
Main portal vein velocity is 20 a cm/sec.
Left portal vein demonstrates persist nonocclusive thrombus with flow in the
appropriate direction. The right portal vein is patent and demonstrates wall
to wall color flow with low in the appropriate direction.
The main hepatic artery is patent, with appropriate waveform.
Right, middle and left hepatic veins are patent, with appropriate waveforms.
IMPRESSION:
1. Persistent nonocclusive thrombus in the left port portal vein. The main
and right portal veins are patent. This is improved compared to the outside
hospital CT obtained ___, which demonstrated complete occlusion of the
left portal vein and partial occlusion of the main portal vein, right portal
vein, superior mesenteric vein. Of note, the SMV is not visualized on the
current examination.
2. Coarsened and nodular liver with portosystemic collateralization is
consistent with known cirrhosis. No focal lesions identified.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 11:47 AM, approximately
15 minutes after discovery of the findings.
Radiology Report
EXAMINATION: CT lower extremity without contrast
INDICATION: ___ year old man with cirrhosis c/b PVT on lovenox now with left
thigh hematoma // Please assess size and location of LEFT THIGH hematoma, hip
to knee
TECHNIQUE: Contiguous axial CT images were obtained of the left lower
extremity the hip to the knee. Coronal and sagittal reformats were performed.
No IV contrast was administered.
DOSE: Acquisition sequence: 1) Spiral Acquisition 11.7 s, 57.4 cm; CTDIvol =
25.4 mGy (Body) DLP = 1,454.6 mGy-cm. Total DLP (Body) = 1,455 mGy-cm.
COMPARISON: Ultrasound ___
FINDINGS:
Partially visualized lower pelvis demonstrates fat containing left inguinal
hernia. Otherwise unremarkable pelvic organs.
There is a large predominantly hyperdense heterogeneous collection centered in
the left vastus lateralis muscle measuring 9.7 x 5.5 x 17.2 cm. There is
edema in the surrounding musculature, particularly superior to the hematoma.
Small joint effusion is seen in the left knee. There is subcutaneous edema of
the left lower extremity particularly laterally.
Tiny calcification is seen in between the left gluteus medius and minimus
muscles. No acute fracture or dislocation. No significant degenerative
changes.
IMPRESSION:
Large left thigh hematoma centered in the vastus lateralis muscle as detailed
above. Hyperdensce hemorrhage is seen.
RECOMMENDATION(S): Follow up imaging if there is persistent abnormality to
exclude underlying lesion.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: L Leg pain
Diagnosed with Postproc hemor of skin, subcu fol a dermatologic procedure, Oth medical procedures cause abn react/compl, w/o misadvnt
temperature: 98.6
heartrate: 95.0
resprate: 20.0
o2sat: 99.0
sbp: 117.0
dbp: 92.0
level of pain: 10
level of acuity: 2.0 | ___ male with EtOH cirrhosis c/b portal vein thrombosis on
anticoagulation and recent SBP treatment, recurrent chronic
pancreatitis, who presented with worsening leg pain found to
have a large thigh hematoma after IM injection.
Patient's blood counts did drop significantly from baseline but
he was never hemodynamically unstable and never required
transfusion. His hemoglobin stabilized between 8.5 and 9 at the
time of discharge.
Patient's lovenox (enoxaparin) was held for the duration of
hospitalization and not restarted at discharge. RUQ ultrasound
demonstrated some improvement of his portal venous thrombosis
with residual nonocclusive thrombus in left portal vein. His
enoxaparin will need to be restarted in the near future at the
discretion of his primary hepatologist.
============= |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___
Attending: ___
Chief Complaint:
Abdominal distention, weakness
Major Surgical or Invasive Procedure:
EGD ___
History of Present Illness:
___ with hypertension and cirrhosis (likely EtOH) complicated by
ascites and currently undergoing evaluation for liver transplant
presents with worsening abdominal distention, weakness,
lethargy.
Patient has noted worsening abdominal distention and lower
extremity edema over the last several days. She notes bloating
as
well, though no abdominal pain. She had one episode of nausea
this morning, but otherwise denies fevers, chills, vomiting,
diarrhea. Of note, she recently stopped taking lactulose because
she was having ___ bowel movements daily without it, though she
does recognize her bowel movements were significantly smaller.
She has not noticed any confusion.
Otherwise she had not developed any new symptoms. She denies
cough, fevers, diarrhea, abdominal pain, chest pain, dyspnea,
blood in stool, blood in urine, dysuria, hematuria.
EMERGENCY DEPARTMENT COURSE
Initial vital signs were notable for:
T 98.6 HR 86 BP 117/45 RR 18 SpO2 100% RA
Exam notable for:
VSS
Gen: Chronically ill appearing female, fatigued appearing
HEENT: Scleral icterus. Normocephalic, atraumatic.
CV: RRR, normal S1/S2, ___ systolic murmur at RUSB
Resp: CTAB, no wheezes, rales, or rhonchi
Abd: Distended, soft, nontender
Ext: 2+ edema in the lower extremities bilaterally, right
greater
than left.
Neuro: Mild asterixis. AAOx3. No focal deficits.
Labs were notable for:
- Cr 1.0; BUN 28
- ALT 30; AST 73
- AP 274
- LDH 329
- TBili 5.5
- Alb 2.9
- CBC 7.3
- Platelets 84
Studies performed include:
- Peritoneal Fluid: 185 WBC, 3% poly
- RUQUS: Cirrhotic liver with splenomegaly and small volume
ascites. Patent main, left, and right portal veins.
- UA with 12 WBC, few bacteria; small leukocytes
Patient was given:
___ 15:55PO/NGLactulose 15 mL
40mg IV Lasix
Consults:
HEPATOLOGY:
Case discussed with ___ team:
Patient is a ___ y/o female w/ a PMHx of EtOH cirrhosis c/b
ascites and small EVs who presents with worsening abdominal
distension, weakness, and lethargy.
-Follow-up with diagnostic paracentesis labs. If c/f SBP, would
treated with ceftriaxone, albumin infusion, and check blood
cultures.
-Likely will need up-titration of diuretics and nutrition
consult
for counseling on low salt diet, this can be done by the
admitting team.
-Would treat asterixis with lactulose and monitor for signs of
HE
closely.
Admit to ___ under Dr. ___.
Vitals on transfer: T 98.0; HR 68; BP 110/68; RR 15; 100% RA
Upon arrival to the floor, the patient reports feeling slightly
better than earlier today. Her chief complaint is swelling in
her
ankles, which is stable from earlier in the day.
================
REVIEW OF SYSTEMS
================
Complete ROS obtained and is otherwise negative.
Past Medical History:
Alcoholic Cirrhosis c/b ascites, esophageal varices
Colonic adenoma
Essential hypertension
Melanocytic nevus
Low back pain
GERD
Anemia
Cholecystectomy
Social History:
___
Family History:
Mother: ___ kidney disease, deceased
Father: ___, deceased
Brother: CAD with stent
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: T:98.1; BP:133/55 HR79 RR16 O2100 Ra
GENERAL: Well appearing woman sitting up on the side of her bed
and speaking to me in no apparent distress.
HEENT: R pupil 5mm, L pupil 3mm, both reactive to like EOMI
intact. Poor hearing from R ear. Significant scleral icterus and
sublingual jaundice. Moist mucous membranes.
NECK: No or cervical. submandibular lymphadenopathy.
CARDIAC: S1/S2 regular. ___ systolic murmur best heard at ___.
Mild heave.
LUNGS: Clear bilaterally.
ABDOMEN: Distended abdomen. Shifting dullness. Small, reducible
umbilical hernia. No pain to deep palpation.
EXTREMITIES: Vericose veins on bilateral lower extremities. 1+
pitting edema up to mid shin. Warm extremities.
SKIN: 1 or 2 spider angiomata on chest. No palmar erythema.
Multiple cherry angiomata. Mild jaundice. Mild eccymoses on
extremities.
NEUROLOGIC: CN2-12 intact aside from pupils and hearing, as
noted
above. ___ strength throughout. Normal sensation. Mild
axterixis.
DISCHARGE PHYSICAL EXAM
=======================
98.1 105/67 7818 99 Ra
GENERAL: Well appearing woman sitting in bed, speaking to me in
no distress.
HEENT: R pupil 5mm, L pupil 3mm, both reactive to light. EOMI
intact. Poor hearing from R ear. Significant scleral icterus and
sublingual jaundice. Moist mucous membranes.
NECK: No cervical or submandibular lymphadenopathy.
CARDIAC: S1/S2 regular. ___ systolic murmur best heard at ___.
LUNGS: Clear bilaterally.
ABDOMEN: Distended abdomen. Shifting dullness. Small, reducible
umbilical hernia. No pain to deep palpation.
EXTREMITIES: Vericose veins on bilateral lower extremities. No
edema on lower extremities. Warm extremities.
SKIN: 1 or 2 spider angiomata on chest. No palmar erythema.
Multiple cherry angiomata. Mild jaundice. Mild ecchymoses on
extremities.
NEUROLOGIC: CN2-12 intact aside from pupils and hearing, as
noted
above. ___ strength throughout. Normal sensation. Mild
axterixis.
Pertinent Results:
ADMISSION LABS
==============
___ 01:39PM BLOOD WBC-4.0 RBC-2.63* Hgb-7.3* Hct-22.3*
MCV-85 MCH-27.8 MCHC-32.7 RDW-16.7* RDWSD-51.8* Plt Ct-84*
___ 01:39PM BLOOD Neuts-66.1 ___ Monos-10.4 Eos-1.8
Baso-0.5 Im ___ AbsNeut-2.62 AbsLymp-0.82* AbsMono-0.41
AbsEos-0.07 AbsBaso-0.02
___ 01:39PM BLOOD Glucose-104* UreaN-28* Creat-1.0 Na-135
K-4.5 Cl-99 HCO3-21* AnGap-15
___ 01:39PM BLOOD ALT-30 AST-73* LD(LDH)-329* AlkPhos-274*
TotBili-5.5*
___ 01:39PM BLOOD TotProt-6.0* Albumin-2.9* Globuln-3.1
DISCHARGE LABS
==============
___ 04:50AM BLOOD WBC-4.2 RBC-3.20* Hgb-8.9* Hct-26.8*
MCV-84 MCH-27.8 MCHC-33.2 RDW-16.4* RDWSD-49.5* Plt Ct-80*
___ 04:50AM BLOOD Glucose-110* UreaN-22* Creat-0.9 Na-132*
K-3.9 Cl-98 HCO3-23 AnGap-11
___ 04:50AM BLOOD ALT-19 AST-46* LD(___)-217 AlkPhos-216*
TotBili-7.8*
___ 04:50AM BLOOD Calcium-8.8 Phos-3.9 Mg-2.1
___ 04:52AM BLOOD calTIBC-317 ___ Ferritn-51 TRF-244
MICRO
=====
___ 10:09 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
___ 10:09 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Cepheid nucleic
acid
amplification assay..
(Reference Range-Negative).
___ 4:11 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 4 S
AMPICILLIN/SULBACTAM-- 4 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
___ 3:00 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
2+ ___ 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.
IMAGING
=======
CXR ___
IMPRESSION:
There has been interval development of a new small left-sided
pleural effusion with adjacent compressive atelectasis. Heart
size is top-normal. There is unfolding of the thoracic aorta
with vascular calcifications. There is borderline vascular
congestion with trace interstitial edema, appearing unchanged.
Otherwise no new consolidation is seen. There is no
pneumothorax. There is no right-sided effusion. Surgical clips
project over the right upper quadrant abdomen.
Abd US ___
IMPRESSION:
Cirrhotic liver with sequelae of portal hypertension including
splenomegaly and small volume ascites. Patent main, left, and
right portal veins.
EGD ___
one cord grade 1 varices
portal hypertensive gastropathy
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old woman with h/o ETOH cirrhosis, worsening
ascites/edema, encephalopathy// r/o PVT
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Ultrasound from ___
FINDINGS:
LIVER: The liver is coarsened and nodular in echotexture. The contour of the
liver is nodular, consistent with cirrhosis. There is no focal liver mass. The
main, left, and right portal veins are patent with hepatopetal flow. There is
a small volume of ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 7 mm.
GALLBLADDER: The patient is status post cholecystectomy.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 16.6 cm.
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
Cirrhotic liver with sequelae of portal hypertension including splenomegaly
and small volume ascites. Patent main, left, and right portal veins.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ with hypertension and cirrhosis (likely EtOH) complicated by
ascites and currently undergoing evaluation for liver transplant presents with
worsening abdominal distention, weakness, lethargy.// please evaluate for any
consolidation
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: ___.
IMPRESSION:
There has been interval development of a new small left-sided pleural effusion
with adjacent compressive atelectasis. Heart size is top-normal. There is
unfolding of the thoracic aorta with vascular calcifications. There is
borderline vascular congestion with trace interstitial edema, appearing
unchanged. Otherwise no new consolidation is seen. There is no pneumothorax.
There is no right-sided effusion. Surgical clips project over the right upper
quadrant abdomen.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abdominal distention, Weakness
Diagnosed with Hepatic failure, unspecified without coma
temperature: 98.6
heartrate: 86.0
resprate: 18.0
o2sat: 100.0
sbp: 117.0
dbp: 45.0
level of pain: 5
level of acuity: 3.0 | BRIEF HOSPITAL COURSE
==================
___ with hypertension and cirrhosis (likely EtOH) complicated by
ascites and currently undergoing evaluation for liver transplant
presented with worsening abdominal distention, weakness,
lethargy, no SBP on diagnostic tap and infectious studies were
negative, improved after titration of lactulose and started on
rifaximin. Course c/b acute anemia requiring 2 units of blood,
with EGD showing portal gastropathy.
===========
ACUTE ISSUES
===========
# Weakness/Abdominal ___ edema:
Likely due to decompensated cirrhosis, trigger is unclear but
possibly medication non-compliance (lactulose). No SBP on tap.
On Lasix 40mg daily and recently started on spironolactone 25mg
BID. RUQUS with patent portal vasculature and small volume
ascites. Rifaximin was added during this hospitalization.
Spironolactone was continued. Lasix was initially held and
restarted subsequently when the kidney function improved to
baseline.
#UTI: patient found to have UTI with UCx growing pan-sensitive
EColi. She was started on Ciprofloxacin for a 7 day course to
complete on ___.
#Acute on Chronic anemia:
Hb 6.6 from 7.1 overnight on ___. Patient reports last EGD and
colonoscopy was in ___ of this year and she has "small
varices" and had a colonic polyp biopsied that was benign. s/p
2u pRBC on ___. Drop in hemoglobin was most likely due to the
albumin she received the day prior. EGD on ___ showed once cord
of grade 1 varices and portal gastropathy with no concern for
active bleeding. Hgb 8.9 at discharge.
___: Cr 1.2 on arrival, improved with albumin resuscitation. Cr
0.9 at discharge.
#Asterixis
Patient reports not taking lactulose for at least several days.
She was having ___ very small bowel movements daily. Did not
report any recent confusion. Cdiff and stool cultures found to
be negative. Lactulose titrated to ___ bowel movements daily.
Urine culture found to grow pan sensitive Ecoli, for which
patient was initiated on treatment.
# ETOH cirrhosis:
In the process of being evaluated for transplant, has not been
cleared yet. Meld 22 on admission (based on INR from 2 weeks
ago). MELD 24 at discharge. ___ Class C. Will follow up
with Dr ___ on ___ and will have ENT clearance on ___.
#Nutrition
Severe malnutrition. Has previously discussed tube feeds with
her outpatient hepatologist. Recommended to be on high calorie,
low sodium, moderate-high protein. Patient reports drinking ___
shakes daily. Regular diet, 2g sodium, 2L fluid restrict while
inpatient.
=============== |
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
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI was performed in conjunction with pt's daughter, ___, who
was able to interpret. Language - ___.
HPI: Mr. ___ is an ___ year-old ___ man with smoking
history, and small cell lung cancer with nodal metastases s/p
cycle 2 cisplatin and etoposide (day 1 = ___, day 3 on ___,
also s/p 16 of 35 fractions of radiation, who presents with
fever. Daughter called in to report father had temperature of
___ yesterday, higher last evening (up to 100.5) and then 101
this morning. Pt has been having a sore throat since the last 6
days, since ___. He thinks it is about the same, if not
slightly worse. He has been taking Maalox, benadryl, Lidocaine
mixture in addition to Tylenol and one other medication (name
unknown) to help with the pain but without much relief. He has
had a cough, but this is chronic and not worse. He has minimal
white sputum production. He denies shortness of breath or chest
pain.
In ED/Clinic, initial vitals were: Pain 9 Temp 99 HR 84 BP
158/79 RR 16 O2 sat 98. Exam was significant for some throat
erythema, but no evidence of thrush. On HEENT exam, per d/w
resident, pt without evidence of erythema or pus. No meningismus
and no concerns for meningitis. Labs were significant for normal
electrolytes, WBC 1.0 with 47% PMN's, 21% mono's. Lactate was
1.8. CXR showed no acute process. UA showed RBC 3 WBC 1 Leuk and
nitrite negative. Blood cultures and urine cultures were sent.
Patient was given 1 dose of Cefepime at 1345. Also given 1L NS @
150cc/hour.
Final vitals prior to transfer were 100.2po 86 16 143/75 96 %
RA.
Access #20 PIV R forearm to saline lock.
Currently on the floors, he currently has ___ throat pain. He
denies chest pain or dysphagia. He just has pain with swallowing
water. Denies neck pain or stiffness. No sick contacts. His
daughter thinks he may have last ___ lbs since his last
chemotherapy. Denies diarrhea. He had his last BM formed and
dark brown this morning.
Review of Systems:
(+) Per HPI
(-) Denies chills, night sweats, recent weight loss or gain.
Denies blurry vision, diplopia, loss of vision, photophobia.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies chest pain or tightness, palpitations, lower extremity
edema. Denies shortness of breath, or wheezes. Denies nausea,
vomiting, diarrhea, constipation, abdominal pain, melena,
hematemesis, hematochezia. Denies dysuria, stool or urine
incontinence. Denies any rectal pain. Denies arthralgias or
myalgias. Denies rashes or skin breakdown. No numbness/tingling
in extremities. All other systems negative.
Past Medical History:
Small cell lung cancer with nodal metastases
-presented to medical care in ___ with an enlarging
right-sided neck/supraclavicular mass. An initial biopsy showed
a possible
neuroendocrine tumor. He was first seen by Thoracic Oncology on
___ and referred for a mediastinal node biopsy. The biopsy
occurred on ___ and it showed malignant cells with
morphology of a small cell carcinoma. The tumor cells were
immunoreactive for keratin CK7, TTF-1, and synaptophysin
-Status post 1 cycle of carboplatin 5 AUC D1 and etoposide 80
mg/m2 D1-D3 on ___
-Status post 1.8 Gy of planned 63 Gy given in 35 fractions;
started on ___.
-s/p 2 cycle cisplatin and etopside on ___, last day ___
PAST MEDICAL HISTORY:
1. Hypertension
2. Hypercholesterolemia
3. Prior duodenal ulcer
4. Prostatic enlargement
5. Prior hemorrhoids
6. Chronic obstructive pulmonary disease/emphysema
7. Elevated blood sugars per daughter - not on any medications
Social History:
___
Family History:
Denies family history of cancer, strokes, MI's
Physical Exam:
Admission Physical:
Vitals - T: 100.0 BP: 140/72 HR: 80 RR: 18 02 sat: 97% RA
GENERAL: pleasant gentleman, appears comfortable, NAD
HEENT: NCAT, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, mildly dry MM, poor dentition, throat erythema
though no thrush or ulcerations
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, distant heart sounds, S1/S2, no murmurs
LUNG: fair air exchange, decreased BS at RUL, though clear
without wheezes, rales, rhonchi, breathing comfortably without
use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: warm, dry moving all extremities well, no cyanosis,
clubbing or edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, ___ strength in upper and lower
extremities, 3+ patellar DTR's b/l symmetric, downgoing toes
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Discharge Physical:
Vitals - T: 99.2 BP: 128/64 HR: 65 RR: 16 02 sat: 96% RA
GENERAL: NAD, pleasant, comfortable
HEENT: NCAT, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, moist mucous membranes, poor dentition, no oral
lesions or thrush
NECK: supple, no lymphadenopathy, no JVD
CARDIAC: RRR, normal S1/S2, no murmurs
LUNG: CTAB without wheezes, rales, rhonchi, breathing
comfortably without use of accessory muscles
ABDOMEN: soft, nontender, nondistended, no rebound/guarding, no
hepatosplenomegaly, normoactive bowel sounds
EXTREMITIES: warm, dry moving all extremities well, no cyanosis,
clubbing or edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, ___ strength in upper and lower
extremities
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
Admission Labs:
___ 12:20PM BLOOD WBC-1.0*# RBC-3.63* Hgb-11.9* Hct-35.4*
MCV-98 MCH-33.0* MCHC-33.7 RDW-13.8 Plt ___
___ 12:20PM BLOOD Neuts-47* Bands-0 ___ Monos-21*
Eos-3 Baso-0 ___ Myelos-0
___ 12:20PM BLOOD ___ PTT-33.4 ___
___ 12:20PM BLOOD Glucose-171* UreaN-15 Creat-0.9 Na-137
K-4.2 Cl-101 HCO3-29 AnGap-11
___ 12:20PM BLOOD ALT-16 AST-14 AlkPhos-59 TotBili-0.5
___ 06:45AM BLOOD Calcium-8.6 Phos-3.2 Mg-2.1
Discharge Labs:
___ 06:15AM BLOOD WBC-2.5* RBC-3.24* Hgb-10.6* Hct-31.0*
MCV-96 MCH-32.7* MCHC-34.2 RDW-14.1 Plt ___
___ 06:15AM BLOOD Neuts-53 Bands-0 Lymphs-13* Monos-32*
Eos-2 Baso-0 ___ Myelos-0
___ 06:15AM BLOOD Glucose-101* UreaN-12 Creat-0.7 Na-141
K-4.2 Cl-102 HCO3-29 AnGap-14
___ 06:15AM BLOOD ALT-11 AST-14 AlkPhos-63 TotBili-0.2
___ 06:15AM BLOOD Calcium-8.6 Phos-3.7 Mg-2.1
Microbiology:
Blood Culture, Routine (Final ___: NO GROWTH.
Blood Culture, Routine (Final ___: NO GROWTH.
URINE CULTURE (Final ___: <10,000 organisms/ml.
Blood culture ___ x2 pending
URINE CULTURE (Final ___: NO GROWTH.
Imaging:
CXR ___:
IMPRESSION:
1. Previously noted mediastinal lymphadenopathy may be slightly
improved. Fullness of the right hilum is unchanged and
reflective of known lymphadenopathy.
2. Emphysema.
3. Known nodule within the right upper lobe is better seen on
the prior exams.
Medications on Admission:
HOME MEDICATIONS: reviewed with daughter and confirmed
------------- --------------- --------------- ---------------
Active Medication list as of ___:
Medications - Prescription
CARVEDILOL - (Prescribed by Other Provider) - 12.5 mg Tablet -
1
(One) Tablet(s) by mouth once a day
HYDROCHLOROTHIAZIDE - (Prescribed by Other Provider) - 25 mg
Tablet - 1 Tablet(s) by mouth daily
LORAZEPAM - 1 mg Tablet - 1 Tablet(s) by mouth every 12 hours as
needed for anxiety or nausea use as indicated by MD
LOSARTAN - (Prescribed by Other Provider) - 100 mg Tablet - 1
Tablet(s) by mouth daily
ONDANSETRON HCL - 8 mg Tablet - 1 Tablet(s) by mouth every 8
hours as needed for nausea or as indicated by MD ___ nausea
PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth 8
hours as needed for nausea or as directed by MD.
RANITIDINE HCL - (Prescribed by Other Provider) - 150 mg
Capsule
- 1 Capsule(s) by mouth once daily
SIMVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet - 1
(One) Tablet(s) by mouth once a day
Dilaudid 2mg po every 4 hours as needed
Medications - OTC
DOCUSATE SODIUM - (Prescribed by Other Provider) - 100 mg
Capsule - 1 (One) Capsule(s) by mouth three times a day as
needed
SENNOSIDES [SENOKOT] - (Prescribed by Other Provider) - 8.6 mg
Tablet - 1 to 2 Tablet(s) by mouth at bedtime; may repeat in
morning as needed
No longer taking Doxazosin
Discharge Medications:
1. carvedilol 12.5 mg tablet Sig: One (1) tablet PO DAILY
(Daily).
2. hydrochlorothiazide 25 mg tablet Sig: One (1) tablet PO once
a day.
3. lorazepam 1 mg tablet Sig: One (1) tablet PO twice a day as
needed for anxiety or nausea.
4. losartan 100 mg tablet Sig: One (1) tablet PO once a day.
5. ondansetron HCl 8 mg tablet Sig: One (1) tablet PO every
eight (8) hours as needed for nausea.
6. prochlorperazine maleate 10 mg tablet Sig: One (1) tablet PO
every eight (8) hours as needed for nausea.
7. simvastatin 40 mg tablet Sig: One (1) tablet PO once a day:
restart this AFTER you have finished the Fluconazole.
8. ranitidine HCl 150 mg tablet Sig: One (1) tablet PO once a
day.
9. docusate sodium 100 mg tablet Sig: One (1) tablet PO three
times a day as needed for constipation.
10. senna 8.6 mg tablet Sig: ___ tablets PO at bedtime as needed
for constipation.
11. fluconazole 200 mg tablet Sig: Two (2) tablet PO once a day
for 6 days: last day = ___.
Disp:*12 tablet(s)* Refills:*0*
12. fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72 hr(s)* Refills:*0*
13. oxycodone 5 mg tablet Sig: One (1) tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*30 tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Neutropenic fever
2. Esophageal candidiasis
Secondary:
1. Non-small cell lung cancer
2. Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Fever.
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: ___ chest radiograph. ___. PET-CT.
FINDINGS:
The cardiac silhouette size is normal. The aorta remains mildly tortuous.
Fullness of the right hilum is unchanged, compatible with underlying
lymphadenopathy. Previously noted enlargement of the right mediastinal
contour at the level of the azygos is less pronounced on the current study
suggesting somewhat improved lymphadenopathy. The lungs are hyperinflated.
The pulmonary vascularity is not engorged. Extensive emphysematous changes
are again noted, most pronounced within the lung apices. Nodular opacity
within the posterior aspect of the right upper lobe is not as clearly
visualized on the current study. There is no new focal consolidation. Linear
atelectasis or scarring is seen within the lung bases. There are multilevel
degenerative changes in the thoracic spine.
IMPRESSION:
1. Previously noted mediastinal lymphadenopathy may be slightly improved.
Fullness of the right hilum is unchanged and reflective of known
lymphadenopathy.
2. Emphysema.
3. Known nodule within the right upper lobe is better seen on the prior exams.
Gender: M
Race: ASIAN - CHINESE
Arrive by AMBULANCE
Chief complaint: FEVER
Diagnosed with NEUTROPENIA, UNSPECIFIED , FEVER PRESENTING WITH CONDITIONS CLASSIFIED ELSEWHERE, MAL NEO BRONCH/LUNG NOS
temperature: 99.0
heartrate: 84.0
resprate: 16.0
o2sat: 98.0
sbp: 158.0
dbp: 79.0
level of pain: 9
level of acuity: 3.0 | BRIEF COURSE:
Mr. ___ is an ___ year-old ___ man with smoking history,
and small cell lung cancer with nodal metastases s/p cycle 2
cisplatin and etoposide (day 1 = ___, day 3 on ___, also s/p
16 of 35 fractions of radiation, who presents with febrile
neutropenia. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / fish derived / tramadol / codeine
Attending: ___.
Major Surgical or Invasive Procedure:
Excisional debridement of sacral decubitus ulcer to bone
(___)
attach
Pertinent Results:
INITIAL LABS
============
___ 09:15PM BLOOD WBC-15.7* RBC-3.83* Hgb-11.0* Hct-34.8
MCV-91 MCH-28.7 MCHC-31.6* RDW-13.0 RDWSD-42.9 Plt ___
___ 09:15PM BLOOD Neuts-82.5* Lymphs-8.7* Monos-7.6
Eos-0.3* Baso-0.3 Im ___ AbsNeut-12.99* AbsLymp-1.37
AbsMono-1.20* AbsEos-0.04 AbsBaso-0.04
___ 02:09AM BLOOD ___ PTT-31.6 ___
___ 09:15PM BLOOD Glucose-102* UreaN-19 Creat-0.7 Na-133*
K-4.0 Cl-88* HCO3-32 AnGap-13
___ 09:18PM BLOOD Lactate-1.2
___ 01:10AM URINE Color-Straw Appear-HAZY* Sp ___
___ 01:10AM URINE Blood-NEG Nitrite-NEG Protein-20*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NORMAL pH-7.5
Leuks-LG*
___ 01:10AM URINE RBC-7* WBC-98* Bacteri-FEW* Yeast-NONE
Epi-<1
MICROBIOLOGY
============
___ 1:10 am URINE
URINE CULTURE (Preliminary):
PROTEUS MIRABILIS. PRESUMPTIVE IDENTIFICATION.
10,000-100,000 CFU/mL.
___ 8:49 am TISSUE SACRAL DECUBIUS BIOPSY CULTURE.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
TISSUE (Preliminary):
PROTEUS MIRABILIS. RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROF
IMAGING
=======
CTAP (___):
1. Distended urinary bladder with bilateral mild hydronephrosis
and hydroureter.
2. Urinary bladder wall thickening and enhancement concerning
for cystitis.
3. Large sacral wound with wound track extending 1.6 cm
superiorly, 3.9 cm inferiorly and 2.4 cm anteriorly to the soft
tissue. Destructive change of the distal sacrum. Osteomyelitis
could not be excluded.
4. Significant wall thickening of the rectum with extension to
the sigmoid colon consistent with proctosigmoiditis.
5. L5 compression deformity new from ___.
6. Left femur chronic nonunion fracture with distal fragment
dislocate posterolaterally.
7. Significant hepatomegaly.
8. Other chronic/incidental findings described as in above.
CXR (___):
1. New mild pulmonary edema.
2. Interval improvement of the left lower lobe collapse and
leftward
mediastinal shift.
OTHER RESULTS
=============
___ 02:09AM BLOOD ___ PTT-31.6 ___
___ 12:40AM BLOOD ALT-7 AST-11 AlkPhos-128* TotBili-<0.2
___ 12:40AM BLOOD CRP-216.1*
___ 12:45AM BLOOD ___ pO2-72* pCO2-51* pH-7.41
calTCO2-33* Base XS-5
DISCHARGE LABS
==============
___ 11:11PM BLOOD WBC-8.5 RBC-2.28* Hgb-6.5* Hct-21.3*
MCV-93 MCH-28.5 MCHC-30.5* RDW-13.2 RDWSD-45.1 Plt ___
___ 12:40AM BLOOD Glucose-117* UreaN-14 Creat-0.5 Na-131*
K-4.8 Cl-94* HCO3-28 AnGap-9*
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. Zolpidem Tartrate 10 mg PO QHS PRN insomnia
2. Promethazine 12.5 mg PO Q6H:PRN naseau
3. Betamethasone Dipro 0.05% Cream 1 Appl TP BID
4. Gabapentin 800 mg PO TID
5. Oxybutynin 5 mg PO BID
6. OxyCODONE (Immediate Release) 30 mg PO Q4H:PRN Pain -
Moderate
7. Rivaroxaban 10 mg PO DAILY
8. Diazepam 10 mg PO Q8H:PRN anxiety
9. Fentanyl Patch 75 mcg/h TD Q72H
10. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
11. Albuterol Inhaler 2 PUFF IH Q4H
12. Topiramate (Topamax) 50 mg PO BID
13. Vitamin D ___ UNIT PO DAILY
14. zinc oxide 20 % topical daily prn
15. Aspirin 81 mg PO DAILY
16. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild
17. Furosemide 40 mg PO BID
18. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
19. Senna 8.6 mg PO BID:PRN Constipation - First Line
20. ARIPiprazole 10 mg PO QHS
21. Docusate Sodium 100 mg PO BID
22. Doxepin HCl 150 mg PO HS
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 21 Doses
Last day ___
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*28 Tablet Refills:*0
2. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. MetroNIDAZOLE 500 mg PO Q8H Duration: 32 Doses
Last dose ___
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*42 Tablet Refills:*0
4. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
5. Albuterol Inhaler 2 PUFF IH Q4H
6. ARIPiprazole 10 mg PO QHS
7. Betamethasone Dipro 0.05% Cream 1 Appl TP BID
8. Diazepam 10 mg PO Q8H:PRN anxiety
9. Docusate Sodium 100 mg PO BID
10. Doxepin HCl 150 mg PO HS
11. Fentanyl Patch 75 mcg/h TD Q72H
12. Gabapentin 800 mg PO TID
13. Oxybutynin 5 mg PO BID
14. OxyCODONE (Immediate Release) 30 mg PO Q4H:PRN Pain -
Moderate
15. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
16. Promethazine 12.5 mg PO Q6H:PRN naseau
17. Senna 8.6 mg PO BID:PRN Constipation - First Line
18. Topiramate (Topamax) 50 mg PO BID
19. Vitamin D ___ UNIT PO DAILY
20. zinc oxide 20 % topical daily prn
21. Zolpidem Tartrate 10 mg PO QHS PRN insomnia
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
======================
- Sacral osteomyelitis
SECONDARY DIAGNOSIS
======================
- Anemia
- Bipolar disorder
- History of pulmonary embolism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with leukocytosis, fevers // pna?
TECHNIQUE: Portable chest x-ray AP view.
COMPARISON: Multiple priors, most recently dated ___.
FINDINGS:
Although lungs are hyperinflated, obscuration of the descending thoracic aorta
and leftward mediastinal shift indicate left lower lobe collapse. There is no
obvious left hilar mass. No other focal pulmonary abnormalities. No pleural
effusion or pneumothorax. Heart size normal.
IMPRESSION:
Left lower lobe collapse. Chest CT recommended for diagnosis.
Probable COPD.
No pneumonia.
RECOMMENDATION(S): ED physician, ___, paged at 9:20 a.m. to
discuss change in radiographic report. Dr. ___ will report these findings
to the operating room.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: NO_PO contrast; History: ___ with diarrhea, sacral woundNO_PO
contrast // ?colitis, abscess
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 19.3 mGy (Body) DLP =
9.6 mGy-cm.
2) Spiral Acquisition 5.7 s, 44.6 cm; CTDIvol = 10.5 mGy (Body) DLP = 466.4
mGy-cm.
Total DLP (Body) = 476 mGy-cm.
COMPARISON: CT abdomen pelvis dated ___. MRI spine dated ___.
FINDINGS:
LOWER CHEST: There is no pericardial effusion or pleural effusion. There is
left lung base partially visualized consolidation likely secondary to
atelectasis. However superimposed pneumonia can not be excluded.
ABDOMEN:
HEPATOBILIARY: The liver is significantly enlarged measuring 22.5 cm
craniocaudally. There is a 1.1 cm low-attenuation lesion in hepatic segment 8
grossly unchanged from ___. There are also subcentimeter low-attenuation
lesions in hepatic segment 6 and left hepatic lobe stable from previous study
and too small to characterized. There is mild intrahepatic biliary ductal
dilation. The common bile duct is also dilated measuring up to 1 cm. There
is no distal ductal stricture or stone. There is no ampullary region mass
visualized.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: There is mild bilateral hydronephrosis and hydroureter. There is a
Foley catheter visualized in the urinary bladder. However the urinary bladder
is due distended with significant wall thickening and enhancement suggestive
of mal functioning Foley catheter and cystitis. There is no evidence of solid
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. There is
significant thickening of the rectum with extension to the sigmoid colon which
may represent proctosigmoiditis. There is also thickening and enhancement of
the gluteal fold skin. The appendix is not visualized.
There is small free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus and bilateral ovaries are not visualized.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted.
BONES AND SOFT TISSUE: There are chronic deformity of the left anterolateral
sixth and seventh ribs. There is chronic nonunion fracture of the left femur
with posterolateral dislocation of the distal fragment. There is soft tissue
density surrounding the fracture with fragment. There is significant
compression deformity of the L5 vertebral body new from previous MRI study in
___. There is an open wound underneath the sacrum with air trapping anterior
to the distal sacrum. The wound track extending 1.6 cm superiorly, 3.9 cm
inferiorly and 2.4 cm anteriorly to the soft tissue. There is no discrete
fluid collection visualized. There is distal sacrum destructive change.
Osteomyelitis can not be excluded.
IMPRESSION:
1. Distended urinary bladder with bilateral mild hydronephrosis and
hydroureter.
2. Urinary bladder wall thickening and enhancement concerning for cystitis.
3. Large sacral wound with wound track extending 1.6 cm superiorly, 3.9 cm
inferiorly and 2.4 cm anteriorly to the soft tissue. Destructive change of
the distal sacrum. Osteomyelitis could not be excluded.
4. Significant wall thickening of the rectum with extension to the sigmoid
colon consistent with proctosigmoiditis.
5. L5 compression deformity new from ___.
6. Left femur chronic nonunion fracture with distal fragment dislocate
posterolaterally.
7. Significant hepatomegaly.
8. Other chronic/incidental findings described as in above.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman who presented with septic shock likely
secondary to infected sacral ulcer now with worsening hypoxemia. // Evaluate
for pulmonary edema.
TECHNIQUE: Portable chest AP
COMPARISON: Multiple prior chest radiographs, most recent dated ___ about 14 hours prior
FINDINGS:
Sternotomy wires appear intact and aligned. The cervical hardware appears
unchanged in position.
In comparison to the radiograph performed about 14 hours prior, there is
interval increase in the interstitial lung markings concerning for mild
pulmonary edema. No large pleural effusions. The retrocardiac opacification
has slightly improved and there is interval decrease in the degree of leftward
mediastinal shift, indicating interval improvement in the left lower lobe
collapse. No pneumothorax.
IMPRESSION:
1. New mild pulmonary edema.
2. Interval improvement of the left lower lobe collapse and leftward
mediastinal shift.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Wound eval
Diagnosed with Sepsis, unspecified organism
temperature: 99.4
heartrate: 99.0
resprate: 16.0
o2sat: 94.0
sbp: 126.0
dbp: 82.0
level of pain: 10
level of acuity: 3.0 | TRANSITIONAL ISSUES
===================
[ ] HEMODYNAMIC INSTABILITY - Ms. ___ is leaving against the
recommendation of her medical team and is at a high risk for
ongoing hemodynamic instability. We have instructed her to
follow-up as soon as possible with medical care.
[ ] OSTEOMYELITIS - please help facilitate for follow-up with
Infectious Disease clinic (infectious disease service working on
this as well). Please ensure patient continues to dress wound
with wet-to-dry dressing
[ ] ANTICOAGULATION - home rivaroxaban was discontinued upon
discharge given concern for ongoing bleeding. Recommend
reassessing need to resume as her PE ___ years ago appears to
have been provoked in the setting of surgery. She additionally
no longer has an IVC filter in place.
[ ] DIURESIS - home furosemide was discontinued upon discharge
given apparent euvolemia and hypotension, please reassess need
to resume
BRIEF HOSPITAL COURSE
=====================
Ms. ___ is a ___ year old woman with history of IV drug use
complicated by recurrent cervical epidural abscess (___)
treated with C7-T2 spinal fusion (___), complicated by C5
paraplegia, submassive pulmonary embolism with IVC filter, and
bipolar disorder who presented with septic shock due to
superinfected sacral ulcer / osteomyelitis. Her hospital course
was notable for surgical debridement (___) and hypotension in
the setting of a declining hemoglobin. Patient elected to leave
against the recommendation of her medical team after capacity
assessment by her primary team and psychiatry (___).
ACTIVE ISSUES
=============
# Necrotic sacral decubitus ulcer
# Osteomyelitis
# UTI
Ms. ___ presented in septic shock requiring admission to ICU
and administration of pressors. CTAP (___) demonstrated
extensive sacral wound with possible osteomyelitis. She
underwent surgical debridement and was empirically started on
vancomycin-cefepime. Site cultures grew pan-sensitive proteus
mirabilis. Blood cultures were NGTD at the time of discharge.
She was recommended for prolonged IV abx course, however,
patient elected to leave against medical advice and could not be
safely discharged with a PICC. Upon discharge, she was narrowed
to ciprofloxacin/flagyl to complete two week course
(___) for overlying skin and soft tissue
infection. Patient was recommended for wet-to-dry surgical site
dressing by ___ team for surgical site after discharge
# Anemia
# Hypotension
During her hospitalization, she had an acute drop in her
hemoglobin (11.0 on ___ to 6.5 on ___ with hemodynamic
instability including episodes of hypotension to 70/40,
concerning for hemorrhagic shock due to surgical site blood
loss, though patient had no obvious overt bleeding. Ms. ___
declined blood transfusion due to beliefs as a Jehovah's
Witness. Patient declined lab draws as well as recommendation to
remain in the hospital for further monitoring and supplemental
therapy with IV iron. Her home anticoagulation was discontinued
at the time of AMA discharge given concern for active bleed. Of
note, however, patient PE was noted to be provoked in setting of
surgery in ___ and clinical indication for indefinite
anti-coagulation should be re-assessed as an outpatient. Since
patient IVC filter appears to have been removed, it no longer
will serve as a nidus for potential clotting.
CHRONIC ISSUES
==============
# BPD - her home medications were resumed by the time of
discharge
# Chronic pain - her home medications were resumed by the time
of 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:
seizure like event
Major Surgical or Invasive Procedure:
Lumbar puncture
History of Present Illness:
HPI: ___ is a ___ RH AAM with h/o HIV/AIDS (last
CD4
483) and ?seizures who presents after an episode of right-leg
shaking and total-body stiffening with preserved consciousness
concerning for seizure.
History is obtained from pt and OMR, unable to reach his friend
___ phone ___ who witnessed event for
collateral. Apparently he was in his usual state of health
earlier today. This afternoon, while at home with his friend, he
had a sudden episode of stereotyped right leg shaking and
stiffening ("locking up") of his upper extremities bilaterally.
It lasted for ~1 minute. He insists that he was conscious and
alert throughout the episode. Reports it is exactly the same as
prior seizure episodes he's had for the past ___ years (see below
for more history). It was preceded by a feeling of
"lightheadedness" which always occurs prior to these events, and
afterward he immediately felt normal again. However, per EMS
notes, patient's friend ___ apparently witnessed "multiple"
episodes of generalized shaking over 30 minutes. Also, when EMS
arrived, he apparently "appeared post-ictal". FSBS 195. Patient
denies having generalized shaking or confusion. He says he's had
2 seizures in the past month, which is an increase from his
baseline seizure frequency. In terms of provoking factors, he
does admit to increased stress and worse sleep in past few
weeks.
Reports unintentional 10 lb weight loss in past 3 months.
Patient is followed in Dr. ___ clinic for these
shaking episodes. Please see detailed note from ___ for full
description of their findings. He has been having these episodes
for approximately ___ years. In their note, events always
consisted of LEFT leg shaking. Are preceded by "warning"
sensation, then stiffening and straightening of the left leg
followed by mild LLE shaking while his hands both grip tightly
or
"lock up". Per their notes, the episodes happen a few times per
month; always has rapid recovery immediately afterward. Drs.
___ felt that seizures (?focal motor +/- dystonic
features) were possible, so ordered extended routine EEG which
was unrevealing except for some fast beta activity. Also
obtained
MRI which showed progression of white matter atrophy and focus
of
old hemorrhage near corpus callosum on the RIGHT.
Epilepsy risk factors (per prior clinic note):
"- Denies any prior time lapses, behavioral/speech arrests, or
episodes of loss of consciousness.
- Denies any prior febrile seizures, meningitis or encephalitis,
or major head injury (with loss of consciousness).
- Denies any personal history of seizures or learning disorders.
- Denies any substance abuse.
- Denies any family history of seizures.
- With regards to temporal lobe auras, the patient endorses some
odd smells ("bleach" or "food") lasting a few seconds, but he
wonders if this is related to his recurrent sinusitis. He
otherwise denies olfactory hallucinations, gustatory
hallucinations, micropsia, macropsia, frequent ___ or
___, dream-like state, sudden unprovoked fear, or epigastric
rising sensation."
Neuro ROS: +Chronic difficulties with gait (since his HIV
diagnosis, he has limped with his right foot). Denies headache,
photophobia, neck pain or stiffness. Per prior note, does have
occasional frontal, periorbital and bitemporal pulsatile
headaches precipitated by sinus infections and sometimes
radiating to ears. Denies vertigo, lightheadedness, headache,
vision loss, blurred vision, double vision, difficulty hearing,
tinnitus, trouble swallowing, difficulty producing or
understanding speech, focal numbness, tingling, bowel
incontinence, urinary incontinence or retention.
- General ROS: +unintentional 10lb weight loss over past 3
months. Denies fevers, chills, night sweats, cough, sputum.
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:
PAST MEDICAL HISTORY:
- HIV with AIDS (diagnosed ___ years ago,complicated by ___'s
sarcoma, ___ on antiretroviral therapy, previously also
including Combivir-lamivudine/zidovudine and nelfinavir)
- Headaches
- Right ulnar nerve injury (right ___ contracture)
- Rhinitis and recurrent sinusitis
- Amblyopia (right eye, since youth)
Social History:
___
Family History:
FAMILY HISTORY: Stroke (maternal and paternal grandmothers, in
their ___. No seizures. No tremors or movement disorders. No
other known neurologic disease. Myocardial infarction (sister,
at
age ___. Cancer (mother, unknown type, died at age ___. Diabetes
mellitus (brother).
Physical Exam:
ADMISSION EXAM:
- Vitals: 97.0 84 100/64 16 100%
- General: thin AAM in NAD, talking comfortably with examiner.
- HEENT: NC/AT
- Neck: Supple, no meningismus.
- Pulmonary: CTABL
- Cardiac: RRR, no murmurs
- Abdomen: soft, nontender, nondistended
- Extremities: no edema, pulses palpated
- Skin: chronic KS lesions noted over shins bilaterally.
NEURO EXAM:
- Mental Status: Awake and alert. Oriented to self and date, but
only knows that it's ___. Relates a coherent history,
but
vague and obtuse about details. Inattentive on ___ backwards,
cannot get past ___. Language is fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Able to name both high and low frequency
objects. Speech was not dysarthric. Able to follow both midline
and appendicular commands, but some R-L confusion on cross-body
commands. Registration is ___ and requires 3 trials to get ___
registration. Recall is ___ at 5 minutes, ___ with choices.
Knows
current president is ___, thought prior president was ___.
Some ideomotor apraxia, uses hand as tool. No frontal signs. No
evidence of neglect.
- Cranial Nerves: PERRL 3 to 2mm and brisk. VFF to finger
counting. Funduscopic exam revealed no papilledema, exudates, or
hemorrhages. EOMS w mild R exotropia (chronic), no nystagmus. No
facial droop, facial musculature symmetric. Palate elevates
symmetrically. Tongue protrudes in midline.
- Motor: Decreased bulk throughout. +Cogwheeling at the left
wrist and elbow that doesn't increase with augmentation
maneuvers. +Mild left arm postural tremor. No pronator drift.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 4 5 5 5 5 5 5
- Sensory: No deficits to light touch, cold sensation, vibratory
sense throughout. No extinction to DSS.
- DTRs:
Bi Tri ___ Pat Ach
L 2+ 2+ 2+ 2+ 2
R 2+ 2+ 2+ 2+ 2
Plantar response was MUTE bilaterally.
- Coordination: mild dysmetria on FNF bilaterally (noted in
prior
neuro eval also). No DDK.
- Gait: not tested.
DISCHARGE EXAM:
General: Thin, well-appearing
HEENT: NCAT, MMM, OP clear
CV: RRR
Lungs: CTAB
Extremities: WWP
Skin: No rashes or lesions
Neuro:
MS: ___, speech fluent, DOWB w/o difficulty, unable to do
MOYB, follows simple and complex commands
CN: PERRL, EOMI, face symmetric, tongue midline
Motor: good tone and bulk, full strength throughout, no drift
Reflexes: intact
Sensation: intact
Gait: stable
Pertinent Results:
___ 11:48PM CEREBROSPINAL FLUID (CSF) PROTEIN-68*
GLUCOSE-67
___ 11:48PM CEREBROSPINAL FLUID (CSF) WBC-15 RBC-2*
POLYS-0 ___ MONOS-3 OTHER-4
___ 11:48PM CEREBROSPINAL FLUID (CSF) WBC-16 RBC-1675*
POLYS-4 ___ MONOS-7 OTHER-1
___ 06:57PM GLUCOSE-147* UREA N-9 CREAT-0.9 SODIUM-136
POTASSIUM-4.0 CHLORIDE-92* TOTAL CO2-22 ANION GAP-26*
___ 06:57PM CALCIUM-9.4 PHOSPHATE-2.7 MAGNESIUM-1.8
___ 06:57PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 06:57PM WBC-9.0# RBC-4.24* HGB-12.9* HCT-37.7* MCV-89
MCH-30.5 MCHC-34.2 RDW-13.1
___ 06:57PM NEUTS-90.3* LYMPHS-5.7* MONOS-3.3 EOS-0.4
BASOS-0.3
___ 06:57PM ___ PTT-27.4 ___
___ 06:57PM PLT COUNT-213
___ 06:19PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 06:19PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 06:19PM URINE BLOOD-SM NITRITE-NEG PROTEIN-100
GLUCOSE-TR KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG
___ 06:19PM URINE RBC-1 WBC-4 BACTERIA-FEW YEAST-NONE
EPI-0
___ 06:19PM URINE GRANULAR-7* HYALINE-22*
___ 06:19PM URINE MUCOUS-OCC
Non-contrast Head CT: No acute intracranial process.
Periventricular white matter hypodensities reflect HIV
encephalopathy.
MRI brain (___): Age-appropriate, central-predominant
atrophy and ventricular dilatation. Diffuse periventricular
white matter FLAIR hyperintensities, while can be seen with
small-vessel ischemic disease, likely indicates HIV
encephalopathy. No mass lesions or intracranial hemorrhage.
CTA Chest (___): IMPRESSION: No evidence of pulmonary
embolus. Scarring and atelectasis within the left lower lobe
with prominent pulmonary arterial branches within the basal
segments of the left lower lobe. Trace bilateral pleural
effusions with bibasal atelectasis. Marked peribronchial
thickening bilaterally, likely reflecting chronic inflammatory
change. Compression fracture of the inferior vertebral endplate
of T6. It is not possible to determine the age of this fracture
with CT. However, the fracture is stable and there is no
retropulsion of fracture fragments.
___ 11:48PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS
PCR-Test Name
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ATRIPLA (efavirenz-emtricitabin-tenofov) ___ mg oral
daily
Discharge Medications:
1. ATRIPLA (efavirenz-emtricitabin-tenofov) ___ mg oral
daily
Discharge Disposition:
Home
Discharge Diagnosis:
Non-epileptic events
HIV encephalopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Seizures and HIV. Evaluate for seizure focus.
TECHNIQUE: Routine enhanced ___ MRI brain protocol including axial T1, T2,
gradient echo, and FLAIR sequences as well as sagittal T1, MP-rage sequences.
Diffusion weighted imaging was performed.
COMPARISON: ___ and ___.
FINDINGS:
There is age-appropriate prominence of ventricles, indicative of central
atrophy. Diffuse periventricular white matter hyperintensities can be seen
with small-vessel ischemic disease, however may be due to HIV encephalopathy.
No acute infarction is identified. No evidence of cerebral hemorrhage. No
mass lesions are identified. Possible intracranial flow voids are preserved.
The brainstem, posterior fossa and cervical-medullary junction are preserved.
The calvarium is unremarkable. The periorbital and paracavernous spaces are
normal. Paranasal sinuses, mastoid air cells, and middle ear cavities are
clear.
IMPRESSION:
1. Age-appropriate, central-predominant atrophy and ventricular dilatation.
2. Diffuse periventricular white matter FLAIR hyperintensities, while can be
seen with small-vessel ischemic disease, likely indicates HIV encephalopathy.
3. No mass lesions or intracranial hemorrhage.
Radiology Report
HISTORY: HIV and left rib pain with coughing.
COMPARISON: Chest radiograph from ___.
FINDINGS:
Frontal and lateral chest radiographs demonstrate decreased lung volumes,
which likely explain an apparent increase in cardiomediastinal size. No rib
fracture is identified. Left base atelectasis may be due to splinting
secondary to pain. There is also possible left base consolidation, which can
be seen with a pulmonary embolus. Surgical material in the upper lung is
consistent with a wedge resection. There is no pleural effusion or
pneumothorax.
IMPRESSION:
1. Left base atelectasis may be due to splinting from pain, although no rib
fracture is identified. Possible superimposed left base consolidation can be
seen with a pulmonary embolus. If there is clinical concern, a CTA chest can
be performed.
2. Decreased lung volumes likely explain the apparent increase in
cardiomediastinal size.
These findings were communicated via telephone by Dr. ___ to Dr.
___ at 1304 on ___.
Radiology Report
HISTORY: Left lung consolidation and atelectasis concerning for pulmonary
embolus. Evaluate for pulmonary embolus.
COMPARISON: Chest radiograph dated ___ and CT dated ___.
TECHNIQUE: Multidetector CTA of the chest was performed after the uneventful
intravenous administration of 100 cc of Omnipaque. Coronal and sagittal
reformats were provided.
DLP: 269 mGy-cm.
FINDINGS:
CTA CHEST:
No filling defects are identified within the pulmonary arterial vasculature.
No CT evidence of right heart strain. There are multiple prominent pulmonary
arterial branches within the left lower lobe. Of note, the left intercostal
arteries are more prominent than the right and the left inferior phrenic
artery is larger than the right.
The thoracic aorta and aortic arch are within normal limits. The great
vessels of the aortic arch are widely patent. There is variant aortic arch
anatomy with a common origin of the brachiocephalic trunk and the left common
carotid artery. The heart and pericardium are unremarkable.
CHEST:
Scarring and atelectasis is identified within the left lower lobe. Note is
made of surgical clips within the apical segment of the left lower lobe.
There are trace bilateral pleural effusions with bibasal atelectasis noted.
No pulmonary nodules or masses are identified. There is marked peribronchial
thickening bilaterally, likely reflecting chronic inflammatory change.
No mediastinal, axillary or hilar adenopathy. The thyroid gland is
unremarkable. Limited evaluation of the upper abdominal viscera is
unremarkable.
There is compression of the inferior vertebral end plate of T6 with less than
25% loss of vertebral body height. The osseous structures of the chest are
otherwise unremarkable.
IMPRESSION:
1. No evidence of pulmonary embolus.
2. Scarring and atelectasis within the left lower lobe with prominent
pulmonary arterial branches within the basal segments of the left lower lobe.
3. Trace bilateral pleural effusions with bibasal atelectasis.
4. Marked peribronchial thickening bilaterally, likely reflecting chronic
inflammatory change.
5. Compression fracture of the inferior vertebral endplate of T6. It is not
possible to determine the age of this fracture with CT. However, the fracture
is stable and there is no retropulsion of fracture fragments.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Seizure
Diagnosed with OTHER CONVULSIONS, ASYMPTOMATIC HIV INFECTION
temperature: 97.0
heartrate: 84.0
resprate: 16.0
o2sat: 100.0
sbp: 100.0
dbp: 64.0
level of pain: 0
level of acuity: 3.0 | Patient is a ___ RH AAM with h/o HIV/AIDS (last CD4 483) and
?seizures who presents after an episode of right-leg shaking and
total-body stiffening with preserved consciousness concerning
for seizure. He states this is c/w his typical events, but a
witness apparently saw him have multiple generalized shaking
episodes over 30 minutes.
# NEURO: Non-contrast head CT done and no acute process, has PV
___ hypodensities c/w HIV encephalopathy. LP prelim studies show
WBCs of 15, 93% Lymphs. We initially continued ACYCLOVIR to
empirically cover HSV encephalitis until HSV PCR was negative.
MRI brain with/without gadolinium was done and showed atrophy
and periventricular white matter hypodensities consistent with
HIV encephalopathy. Extended routine EEG was also done and
showed no epileptiform activity.
# ID: We continued his home Atripla (Truvada + Efavirenz given
we don't have Atripla). His CD4 count returned at 345. Given
left costochondral pain on ___ and cough, we obtained a CXR to
evaluate for pneumonia. CXR showed left base atelectasis with
possible superimposed left base consolidation which raised
suspicion for pulomnary embolus. CTA chest was obtained which
confirmed the left base atelectasis, with some small bibasilar
effusions, but also incidentally found a compression fracture of
the inferior vertebral endplate of T6 of undetermined age.
# NSG: Given incidental finding of compression fracture of the
inferior vertebral endplate of T6 of undetermined age,
Neurosurgery was consulted and felt fracture appeared chronic
and did not require intervention. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Compazine / Thorazine / erythromycin base
Attending: ___.
Chief Complaint:
LOC from subacute R occipital stroke
Major Surgical or Invasive Procedure:
TEE.
History of Present Illness:
The patient is a ___ gentleman with past medical history
of coronary artery disease, diabetes, hypertension, and prior
stroke who presents to ___ ED after an episode of loss of
consciousness.
Briefly, spoke to RN at rehab facility who reports, the patient
has been residing at the rehab facility for the past 2 weeks
after recent fall. Today he was with his family at church, when
circa around 2:30 ___ the patient became diaphoretic and became
unconscious. Unfortunately, no further details about the event
are known. Unclear how long the patient was unconscious. When
he became conscious again patient complained of chest pain and
was subsequently brought to ___
by his family. In the ED his blood pressure was 107/57 and his
heart rate was 56. He was given 1 L NS IVF bolus. He had an
EKG
which showed T-wave inversions in V5 and V6 but was otherwise
unremarkable, troponins were negative ×2. CT head was obtained
and showed a right occipital infarct with effacement of the
posterior horn of the right ventricle.
Of note, per RN at the rehab facility, patient has been acting
a
little confused for the past few days.
On neuro ROS, the pt denies headache, loss of vision, diplopia,
dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or
hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness, numbness,
parasthesiae. No bowel or bladder incontinence or retention.
Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Denies rash.
Past Medical History:
Coronary artery disease
Stroke
Diabetes
Hypertension
Social History:
___
Family History:
Unknown
Physical Exam:
ADMISISON PHYSICAL EXAM
The patient is a ___ gentleman with past medical history
of coronary artery disease, diabetes, hypertension, and prior
stroke who presents to ___ ED after an episode of loss of
consciousness.
Briefly, spoke to RN at rehab facility who reports, the patient
has been residing at the rehab facility for the past 2 weeks
after recent fall. Today he was with his family at church, when
circa around 2:30 ___ the patient became diaphoretic and became
unconscious. Unfortunately, no further details about the event
are known. Unclear how long the patient was unconscious. When
he became conscious again patient complained of chest pain and
was subsequently brought to ___
by his family. In the ED his blood pressure was 107/57 and his
heart rate was 56. He was given 1 L NS IVF bolus. He had an
EKG
which showed T-wave inversions in V5 and V6 but was otherwise
unremarkable, troponins were negative ×2. CT head was obtained
and showed a right occipital infarct with effacement of the
posterior horn of the right ventricle.
Of note, per RN at the rehab facility, patient has been acting
a
little confused for the past few days.
On neuro ROS, the pt denies headache, loss of vision, diplopia,
dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or
hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness, numbness,
parasthesiae. No bowel or bladder incontinence or retention.
Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Denies rash.
******************
DISCHARGE EXAM
Tm 98.4F/Tc 97.9F, BP 125-151/67-81, HR 61-62, RR 18, O2 94-97%
RA
Very impaired vision globally, difficulty comprehending what he
sees -- prosopagnosia, inability to see faces.
General: sitting up in chair, calm and comfortable.
HEENT: MMM.
Neck: Supple
CV/R: Breathing comfortably on room air,
Extremities: Warm, no edema
Skin: No rashes or lesions
Neurologic Examination:
- Mental Status - Awake, alert, oriented to person, but not
date.
Fluent speech. When we discussed what was found on the CT scan
and used words like "mass," he was able to repeat back and
interpreted the news with the word "tumor," from his own words.
- Cranial Nerves - PERRL 3->2 brisk. VF -- difficulty seeing
left
side. Mildly restricted upward gaze. no nystagmus.
- Motor - Normal bulk and tone. Some drift on the right. No
tremor or asterixis.
- Sensory - No deficits to light touch or temperature sensation.
- Coordination - Dysmetria bilaterally, difficulty with rapid
alternating movements, difficulty seeing target.
Pertinent Results:
LABORATORY STUDIES
___ 11:10PM cTropnT-<0.01
___ 03:10PM cTropnT-<0.01
___ 03:10PM TRIGLYCER-186* HDL CHOL-31 CHOL/HDL-3.7
LDL(CALC)-46
___ 03:10PM GLUCOSE-112* UREA N-20 CREAT-1.3* SODIUM-139
POTASSIUM-3.7 CHLORIDE-98 TOTAL CO2-25 ANION GAP-20
___ 03:10PM TSH-1.6
___ 03:10PM ___ PTT-26.7 ___
___ 07:00AM BLOOD %HbA1c-5.0 eAG-97
******************
TEE ___
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. No atrial septal defect is seen
by 2D or color Doppler. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. There are simple atheroma in
the ascending aorta. The aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis. Trace 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 no
pericardial effusion.
IMPRESSION: No thrombi in the atria or atrial appendages. No
atrial septal defect seen with 2D or color Doppler. Normal
biventricular systolic function. Simple atheroma in the
descending aorta.
CT Chest w/ Contrast ___
No evidence of intrathoracic malignancy or infection.
CT abdomen/pelvis w/ contrast ___
IMPRESSION:
1. 2.0 cm right renal mass has a density which is highly
suggestive of a
enhancing lesion and is concerning for renal cell carcinoma.
Urologic
consultation is recommended and MRI may be considered for
further evaluation.
2. Diverticulosis without diverticulitis.
3. Mild splenomegaly.
4. Prostatomegaly likely secondary to benign prostatic
hypertrophy.
5. Please refer to separate report of CT chest performed on the
same day for description of the thoracic findings.
TTE ___
The left atrium and right atrium are normal in cavity size. No
atrial septal defect is seen by 2D or color Doppler. There is
mild symmetric left ventricular hypertrophy with normal cavity
size and regional/global systolic function (LVEF>55%). No masses
or thrombi are seen in the left ventricle. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Trace aortic regurgitation is seen. Trivial mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
IMPRESSION: No left ventricular thrombus seen. Normal global
and regional biventricular systolic function.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Atenolol 50 mg PO DAILY
3. Lisinopril 20 mg PO DAILY
4. MetFORMIN (Glucophage) 500 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Omeprazole 20 mg PO DAILY
7. DICYCLOMine 20 mg PO QID
8. Isosorbide Dinitrate ER 30 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*12
2. Clopidogrel 75 mg PO DAILY
3. Atenolol 50 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. DICYCLOMine 20 mg PO QID
6. Isosorbide Dinitrate ER 30 mg PO DAILY
7. Lisinopril 20 mg PO DAILY
8. MetFORMIN (Glucophage) 500 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute ischemic stroke
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with prior MI, prior stroke, episode of cp and
unresponsiveness PTA.// ?cpd, ?intracranial bleed ?cpd, ?intracranial
bleed
IMPRESSION:
No comparison. The lung volumes are low. Normal size of the cardiac
silhouette. Mild elongation of the descending aorta. No pneumonia, no
pulmonary edema.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with prior MI, prior stroke, episode of cp and
unresponsiveness PTA.// ?cpd, ?intracranial bleed
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 7.0 s, 14.9 cm; CTDIvol = 47.3 mGy (Head) DLP =
702.4 mGy-cm.
Total DLP (Head) = 702 mGy-cm.
COMPARISON: None.
FINDINGS:
There is loss of gray-white differentiation in the right occipital lobe with
mild effacement of the posterior horn of the right lateral ventricle, likely
due to infarct, which may be subacute to old. There is no significant shift
of the midline structures. The basilar cisterns remain patent. There is
prominence of the ventricles and sulci suggestive of involutional changes.
Periventricular and subcortical hypodensities are nonspecific, however likely
due to chronic small vessel ischemic disease in this age group. There is no
acute intracranial hemorrhage.
Projecting over the left occiput is a region of high density material
measuring approximately 4.2 x 1.5 cm in the scalp, which may represent a
hematoma. Correlate with direct visualization/clinical history and exam to
alternatively exclude soft tissue lesion. There is no evidence of acute
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. Dense calcifications at the bilateral carotid siphons are
noted.
IMPRESSION:
1. Loss of gray-white differentiation in the right occipital lobe with
effacement of the posterior horn of the right lateral ventricle, likely due to
cytotoxic edema secondary to infarct in the right PCA distribution, may be
subacute to old. No midline shift. Patent basal cisterns.
2. Projecting over the left occiput is a region of high density material in
the scalp measuring approximately 4.2 x 1.5 cm, which may represent a
hematoma. Correlate with direct visualization/clinical history and exam to
alternatively exclude soft tissue lesion.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: ___ man with altered mental status, evaluate for 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 6.4 s, 16.0 cm; CTDIvol = 56.1 mGy (Head) DLP =
897.1 mGy-cm.
2) Stationary Acquisition 6.0 s, 0.5 cm; CTDIvol = 65.3 mGy (Head) DLP =
32.7 mGy-cm.
3) Spiral Acquisition 5.2 s, 41.1 cm; CTDIvol = 31.9 mGy (Head) DLP =
1,312.1 mGy-cm.
Total DLP (Head) = 2,242 mGy-cm.
COMPARISON: None.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
Hypodensity in the right occipital lobe, is consistent with an evolving
infarct. There is no evidence of hemorrhage. Prominence of the ventricles
and sulci is unchanged in keeping with age related involutional changes.
There is no mass or shift of normally midline structures. The scattered
periventricular and subcortical white matter hypodensities are nonspecific but
likely sequelae of chronic small vessel ischemic disease.
There is enlargement of the sella turcica with thin bone at the sellar floor,
partially evaluated in this exam, and apparently apparently protruding
anteriorly as demonstrated on the image 31, series 603b, correlation with MRI
of the sella turcica and pituitary gland is recommended for further
characterization. The paranasal sinuses, mastoid air cells, middle ear
cavities are clear. The orbits are grossly unremarkable.
CTA HEAD:
There is mild multifocal atherosclerotic plaque along the cavernous and
paraclinoid segments of the internal carotid arteries bilaterally without
appreciable luminal narrowing.
Moderate focal narrowing of the mid basilar artery is likely related to
atherosclerotic disease. There is also moderate to severe focal narrowing of
the distal left posterior communicating artery and proximal left posterior
cerebral artery, in a fetal PCA configuration (series 5, image 274). Fetal
origin of the right posterior cerebral artery is also noted with high-grade
focal narrowing or cutoff of the proximal right P2 segment (series 5, image
271).
There are two areas of moderate to severe focal narrowing along the course of
the left posterior inferior cerebellar artery best appreciated on the volume
rendered images (series 565, image 9). The vessels of the circle of ___
and their principal intracranial branches otherwise 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:
The visualized portion of the lungs are clear. Bilateral subcentimeter
thyroid nodules do not require follow-up as per current ___ College of
Radiology guidelines. There is no lymphadenopathy by CT size criteria.
IMPRESSION:
1. Evolving right PCA territory infarct.
2. High-grade focal narrowing or cutoff of the P2 segment of the right
posterior cerebral artery. Multifocal moderate to high-grade stenosis of the
left posterior communicating/posterior cerebral arteries in a fetal
configuration.
3. Moderate focal narrowing of the mid basilar artery.
4. Unremarkable neck CTA without evidence of occlusion, stenosis, or
dissection.
5. Enlarged sella turcica, partially evaluated in this exam, the possibility
of underlying sellar adenoma is a consideration, correlation with dedicated
MRI of the sella turcica is recommended as clinically warranted.
RECOMMENDATION(S): Prominent sella turcica, partially evaluated in this exam,
if clinically warranted correlation with MRI of the sella turcica is
recommended.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD.
INDICATION: ___ year old man with right occipital hypodensity seen on CT
head// please further assess right occipital hypodensity seen on CT head.
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 9 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: Noncontrast CT of the head from ___.
CTA of the head and neck from ___.
FINDINGS:
Areas of slow diffusion in the right parietal, occipital, and inferior
temporal lobes are consistent with infarct (06:15, 06:12, 06:11) with
corresponding areas of abnormal high signal on FLAIR. Gyriform high signal on
T1 weighted images and hyperenhancement postcontrast administration in these
regions suggest laminar necrosis.
Another area of slowed diffusion in the left occipital lobe with corresponding
FLAIR high signal, ex vacuo dilatation of the occipital horn of the left
lateral ventricle, and susceptibility on gradient echo are suggestive of a
more chronic infarct with petechial hemorrhage or residual hemorrhagic blood
products (6:9, 11:11, 13:12).
Additional scattered punctate foci of susceptibility are seen on gradient echo
sequence since in the left cerebellum (10:4), posterior left frontal lobe
(10:18), right frontal lobe (10:21), bilateral parietal, and bilateral
occipital lobes (10:12, 10:8).
In the posterior parasagittal left frontal lobe near the vertex, an oval
region of hyperintense signal on T2 weighted sequences (image 21, series 12),
does not restrict diffusion and follows CSF signal on all sequences without
hyperenhancement postcontrast, which measures 2.6 x 1.8 cm, likely consistent
with a prominent subarachnoid space.
Asymmetric prominence of the left sella turcica measures approximately 1.1 x
0.7 cm with hyperintense signal on FLAIR and T2 and no central enhancement
with slight mass effect on the surrounding structures.
Scattered background hyperintense signal abnormalities on FLAIR are present in
a periventricular distribution are nonspecific but likely represent small
vessel ischemic changes.
The ventricles and sulci are prominent consistent with involutional changes.
The basal cisterns are patent.
The paranasal sinuses are clear. The orbits are unremarkable. No osseous
abnormality is appreciated.
IMPRESSION:
1. Right PCA territory subacute infarct with corresponding high FLAIR signal
and gyriform signal abnormalities suggestive of laminar necrosis.
2. Subacute/chronic left occipital infarct with chronic petechial hemorrhage.
3. Scattered diffuse peripheral hemorrhagic foci involving all lobes and the
left cerebellum may suggest amyloid deposits.
4. 1.1 cm asymmetric prominence of the left sella turcica suggests a pituitary
adenoma. Dedicated pituitary MRI is recommended for further characterization.
5. Mild global atrophy and nonspecific scattered white mattered changes which
likely represent chronic microvascular ischemic changes.
RECOMMENDATION(S): If clinically warranted dedicated pituitary MRI is
advised.
Radiology Report
INDICATION: ___ year old man with multiple strokes// eval for source of clots
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 1,242 mGy-cm.
COMPARISON: None.
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
biliary dilatation. There is prominence of the common bile duct as expected
post cholecystectomy. The gallbladder is surgically absent.
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 mildly enlarged measuring approximately 13.8 cm.
Otherwise, it shows normal attenuation throughout, without evidence of focal
lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: There are several cortical hypodensities in left kidney, some which
are too small to characterize, but likely represent cysts. The right kidney
contains a 2.0 x 2.0 cm well-circumscribed homogeneously enhancing masslike
lesion measuring an attenuation of 98 Hounsfield units arising from the
midpole (2:64, 601:44). Lateral to this lesion, is a mild indent of the renal
cortex with an adjacent partially calcified cystic lesion likely representing
an involuted cyst. There is no evidence of hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: There are surgical clips adjacent to the gastroesophageal
junction and anterior to the gastric cardia from a prior uncertain surgery.
Otherwise, the stomach is unremarkable. Small bowel loops demonstrate normal
caliber, wall thickness, and enhancement throughout. Diverticulosis of the
colon is noted, without evidence of wall thickening and fat stranding. The
appendix is not visualized, however, there are no secondary signs of acute
appendicitis.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate is enlarged and the seminal vesicles are
unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is incidental note of accessory right renal arteries. There
is no abdominal aortic aneurysm. Mild atherosclerotic disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Multilevel degenerative changes of the thoracolumbar spine are noted.
SOFT TISSUES: There is atrophy of the right abdominal rectus muscle.
Otherwise, the abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. 2.0 cm right renal mass has a density which is highly suggestive of a
enhancing lesion and is concerning for renal cell carcinoma. Urologic
consultation is recommended and MRI may be considered for further evaluation.
2. Diverticulosis without diverticulitis.
3. Mild splenomegaly.
4. Prostatomegaly likely secondary to benign prostatic hypertrophy.
5. Please refer to separate report of CT chest performed on the same day for
description of the thoracic findings.
RECOMMENDATION(S): Urology consultation and MRI are recommended for further
evaluation of an enhancing right renal mass.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 5:28 pm, 5 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: Multiple strokes.
TECHNIQUE: Volumetric CT acquisitions over the entire thorax in inspiration,
administration of intravenous contrast material, multiplanar reconstructions.
DOSE: DLP: Given in abdominal CT report.
COMPARISON: No comparison.
FINDINGS:
Multiple millimetric thyroid nodules (2, 5). The patient is asymmetrically
positioned in the scanner. No supraclavicular, infraclavicular or axillary
lymphadenopathy. No enlarged lymph nodes in the mediastinum or at the level
of the hilar structures. Mild dilatation of the main pulmonary artery.
Moderate coronary calcifications, no pericardial effusion. The posterior
mediastinum is unremarkable. The upper abdomen is reported in detail in the
dedicated abdominal CT report. No osteolytic lesions at the level of the
ribs, the sternum, or the vertebral bodies. Mild degenerative vertebral
disease. No vertebral compression fractures. The large airways are patent.
No pleural thickening, no pleural effusions. Mild respiratory motion at the
lung bases. No diffuse lung disease. No focal abnormalities, in particular
no evidence of morphological is suspicious nodular or masslike lesions.
IMPRESSION:
No evidence of intrathoracic malignancy or infection.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain, Unresponsive
Diagnosed with Syncope and collapse, Chest pain, unspecified
temperature: 95.9
heartrate: 58.0
resprate: 18.0
o2sat: 96.0
sbp: 120.0
dbp: 72.0
level of pain: 2
level of acuity: 2.0 | HOSPITAL COURSE:
Mr. ___ is an ___ year old gentleman with PMH of CAD, HTN, DM,
and prior hx of strokes who presented with loss-of-consciousness
and 6 weeks of visual problems consistent with L homonymous
hemianopsia.
On imaging, his MRI showed an old PCA stroke with superimposed
acute stroke in a similar area, likely explaining his symptoms.
He also had a diminutive right PCA with a P2-cutoff.
A work up of the etiology behind his stroke was conducted. His
labs showed an LDL of 46, A1C of 5, and a TSH of 1.6. A TEE
echo showed no thrombus or atrial septal defect, with normal
left ventricular systolic function further ruling out an
cardio-embolic etiology behind his stroke.
An occult malignancy work up was then conducted to look for a
hyper-coagulable state with a CT torso which showed a 2.0 cm
right renal mass concerning for renal cell carcinoma. The renal
mass is concerning for a renal cell carcinoma causing a
hyper-coagulable state, which could possibly be the cause of his
likely cardio-embolic strokes.
Additionally, with further review of his MRI, there are several
microhemorrhages intracranially concerning for CAA that may have
precipitated these recent, multiple strokes.
In terms of his plan, given his renal mass concerning for renal
cell carcinoma, we were worried about the oncologic process
causing both a hyper- coagulable state and increased risk of
bleed due to the tendency of RCC to hemorrhage. In addition, his
possible CAA further increases his risk of bleeding. As a
result, anticoagulation was considered but ultimately we did not
prescribe (apixaban or warfarin, for example) due to his
increased risk of bleeding. Instead, Mr. ___ was prescribed
aspirin and Plavix for secondary stroke prevention. He should
follow-up with urology to further-work-up the renal mass as an
outpatient and be followed for an oncologic work-up and plan.
Hospital course above written in collaboration with ___.
TRANSITIONAL ISSUES
1. Dual-anti-platelet therapy for 3 months, then consider
switching back to monotherapy after neurology follow-up.
2. Follow-up with urology re: workup of right renal mass.
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 = 46 ) - () 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 - () No - (x) N/A |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Aspirin / Sulfa (Sulfonamide Antibiotics) / Latex
/ banana / kiwi / peanut / clindamycin / salicylates
Attending: ___
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ F with h/o asthma, PCOS, HTN, G6PD, and
PTSD presenting with syncope. Awoke overnight to go to bathroom,
voided without issue and when leaving bathroom lost
consciousness. Awoke to son waking her on floor. Was face down
when regained consciousness. Initially felt weak, flushed w/
pain on R forehead. No preceding SOB, chest pain,
lightheadedness, palpitations. No ___, urinary or
fecal incontinence. ___ per run report was wnl on the scene.
Notably, this patient has had 2 episodes of syncope in the past.
Two wks PTA, she drove to ___ and back for a family
funeral. This included stretches of driving that were >10 hours
with few to no breaks. She said when she got "down south" she
was diffusely swollen, in the setting of missing
___ doses. On her return trip, ___, she was
driving her car when she had LOC for seconds. Children in back
seat witnessed and said head dropped, rear ended car in front of
her. There were no tonic clonic movements, no ___ period.
No preceding symptoms with that episode. Prior to that, reports
one episode of syncope in ___ which she attributes to receiving
nifedipine for postpartum HTN.
In the ED, initial vitals were: 98.4 88 142/79 18 96% RA
- Exam notable for: RRR, no murmur, 4 ext pulses brisk and
equal, no swelling; remainder of exam normal.
- Labs notable for: no anemia, K of 3.7, Cr of 1.2 versus
baseline of 0.5
- Imaging was notable for: EKG with ST elevations, ? lead
placement vs true pathology. Repeat EKG with similar changes
- Patient was given: 1L normal saline, 1g APAP
Upon arrival to the floor, patient reports feeling fatigued,
somewhat weak with positional change. She has pain over R
eyebrow. No F/C, vertigo, diplopia, HA, CP, dyspnea,
palpitations, wheezing, N/V/D/C, dysuria or hematuria. She did
not eat dinner last night. She did not take any of her morning
medications.
Past Medical History:
Asthma
Obstructive sleep apnea
PCOS (polycystic ovarian syndrome)
Psychosocial stressors, PTSD
Iron deficiency anemia
G6PD deficiency
Headaches/Migraines
Menorrhagia
Atypical squamous cells of undetermined significance (ASCUS) on
Papanicolaou smear of cervix
h/o STD, Herpes simplex vulvovaginitis
Social History:
___
Family History:
- Sister w/ arrhythmia on rhythm control - unable to specify
further
- brother with cardiomyopathy
- low potassium in family
- Hypertension
- Malignancy (sarcoma in mother, leukemia in father)
- Depression
- Obesity
- T2DM
- Keratoconus (multiple family members)
Physical Exam:
ADMISSION:
==========
Vitals: 98.1 PO 108 / 64 R Lying 77 16 98 Ra
General: AOx3, NAD
HEENT: SAI, MMM, OP without lesions, no lacerations on tongue,
hirsuite
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, ___, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: ___ intact, motor function grossly normal
DISCHARGE:
==========
Vitals: Temp 98.3; BP 154/100 R sitting, 147/98 R standing; HR
72, RR 18, O2sat 100 CPAP o/n
Ins/outs: outs not recorded but since admission, weight has
increased from 224.4 (___) to 228.9 (___)
General: AOx3
Neuro: ___ intact, peripheral strength and sensation intact
HEENT: no scleral icterus, no conjunctival injection
CV: rrr, no mrg, JVP not appreciated; b/l 2+ pulses in upper and
lower extremities
Pulm: CTAB
Abdomen: soft, nt, nd, no rebound or guarding
GU: no foley
Extremities: visibly swollen with indentations left by socks,
but no pitting edema
Pertinent Results:
ADMISSION:
==========
___ 05:15AM BLOOD ___
___ Plt ___
___ 05:15AM BLOOD ___
___ Im ___
___
___ 05:15AM BLOOD ___
___
___ 06:40PM BLOOD CK(CPK)-162
___ 11:30PM BLOOD CK(CPK)-150
___ 05:15AM BLOOD cTropnT-<0.01
___ 06:40PM BLOOD ___ cTropnT-<0.01 ___
___ 11:30PM BLOOD ___ cTropnT-<0.01
___ 05:15AM BLOOD ___
___ 06:40PM BLOOD ___
___ 05:15AM BLOOD ___
___
___ 05:15AM BLOOD ___
___ 06:40PM BLOOD ___
___ 07:41PM BLOOD ___
OTHER:
======
___ 06:40PM BLOOD ___
___
___ 06:30AM BLOOD ___
___
___ 08:55AM BLOOD ___
___
___ 03:16PM BLOOD ___
___
___ 07:40AM BLOOD ___
___
___ 09:40AM BLOOD ___
___
___ 07:32AM BLOOD ___
___
___ 12:50PM BLOOD ___
___
___ 06:30AM BLOOD ___
___ 08:55AM BLOOD ___
___ 03:16PM BLOOD ___
___ 07:40AM BLOOD ___
___ 09:40AM BLOOD ___
___ 07:32AM BLOOD ___
___ 12:50PM BLOOD ___
___ 03:16PM BLOOD ___
___ 07:32AM BLOOD ___
___ 08:55AM BLOOD ___
___ 06:30AM BLOOD ___
___ 06:59AM BLOOD ___ TOP
___ 10:04PM BLOOD ___
___ Base ___
___ 03:17AM BLOOD ___ TOP
___ 11:46PM BLOOD ___
___ 02:45AM BLOOD ___
___ 06:59AM BLOOD ___
___ 10:04PM BLOOD ___
___ 03:17AM BLOOD ___
___ 11:35PM BLOOD ___
___ 03:12PM BLOOD ___
___ 09:08PM BLOOD ___
___ 06:59AM BLOOD ___
___ 08:55AM BLOOD RENIN - ___
___ 06:52PM BLOOD ___
___ 05:35AM URINE ___ Sp ___
___ 05:35AM URINE ___
___
___ 05:35AM URINE ___
___ 04:00PM URINE ___
___ Calcium-<0.8 ___
___ 05:35AM URINE ___
___ 04:00PM URINE ___
___ 01:10PM URINE ___ Sp ___
___ 01:10PM URINE ___
___
___ 01:10PM URINE ___
___ 01:10PM URINE ___
Uric ___
___ 01:10PM URINE ___
MICRO:
======
___ 5:35 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING:
========
___ 4:56 AM
CHEST (PA & LAT)
IMPRESSION:
No acute cardiopulmonary process.
___ 3:16 ___
CT HEAD W/O CONTRAST
IMPRESSION:
1. No evidence of intracranial hemorrhage or large vascular
territory infarction.
2. No evidence of fracture.
___ 2:07 ___
RENAL U.S.; DUPLEX DOPP ABD/PEL
IMPRESSION:
Normal renal ultrasound. No evidence of renal artery stenosis.
Portable TTE (Complete) Done ___ at 9:38:03 AM FINAL
Conclusions
The left atrial volume index is normal. No atrial septal defect
is seen by 2D or color Doppler. The estimated right atrial
pressure is ___ mmHg. Normal left ventricular wall thickness,
cavity size, and global systolic function (3D LVEF = 59 %).
There is no left ventricular outflow obstruction at rest or with
Valsalva. Right ventricular chamber size and free wall motion
are normal. The diameters of aorta at the sinus, ascending and
arch levels are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
IMPRESSION: Normal study. Normal biventricular cavity sizes
with preserved regional and global biventricular systolic
function. No structural cardiac cause of syncope identified.
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.
___ 1:39 ___
CT HEAD W/O CONTRAST
IMPRESSION:
1. No evidence of acute intracranial abnormality. Specifically,
no evidence of intracranial hemorrhage.
DISCHARGE:
==========
___ 07:32AM BLOOD ___
___ Plt ___
___ 12:50PM BLOOD ___
___
___ 12:50PM BLOOD ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Prenatal Vitamins 1 TAB PO DAILY
2. Vitamin D ___ UNIT PO DAILY
3. ___ Diskus (250/50) 1 INH IH BID
4. ___ mg oral DAILY
5. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze
6. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN
7. etonogestrel 68 mg Other ONCE
Discharge Medications:
1. Potassium Chloride 40 mEq PO BID
RX *potassium chloride 20 mEq 2 tablet(s) by mouth twice a day
Disp #*28 Tablet Refills:*0
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze
3. etonogestrel 68 mg Other ONCE
4. ___ Diskus (250/50) 1 INH IH BID
5. Prenatal Vitamins 1 TAB PO DAILY
6. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN
7. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
=================
Syncope
Hypokalemia
Acute kidney injury
Prediabetes
SECONDARY DIAGNOSES:
====================
Hypertension
Polycystic ovarian syncrome
Severe persistent asthma
Obstructive sleep apnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiographs.
INDICATION: History: ___ with syncope// eval cardiomegaly
TECHNIQUE: Chest PA and lateral
COMPARISON: Radiographs ___.
FINDINGS:
The lungs are well expanded and clear without lobar consolidation, pleural
effusion, pneumothorax, or pulmonary edema. Heart is normal size. Hilar and
mediastinal contours are unremarkable.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD.
INDICATION: ___ year old woman w/ PCOS, HTN, presents after syncopal event and
reports head pain// Evidence of acute intracranial or skull pathology?.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Total DLP 749.92 mGy-cm.
COMPARISON: CTA head ___.
FINDINGS:
There is no evidence of territorial infarction,intracranial
hemorrhage,edema,or mass. The ventricles and sulci are normal in size and
configuration. Dural calcifications are noted along the falx.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
1. No evidence of intracranial hemorrhage or large vascular territory
infarction.
2. No evidence of fracture.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old woman with hypertension, syncope, ___ and
hypokalemia. Please evaluate with doppler// ?arterial stenosis
TECHNIQUE: Grey scale, color and spectral Doppler ultrasound images of the
kidneys were obtained.
COMPARISON: ___ torso CT
FINDINGS:
The right kidney measures 13.1 cm. The left kidney measures 12.0 cm. There is
no hydronephrosis, stones, or masses bilaterally. Normal cortical
echogenicity and corticomedullary differentiation are seen bilaterally.
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 0.60 to 0.70. The resistive indices on
the left range from 0.61 to 0.65. Bilaterally, the main renal arteries are
patent with normal waveforms. The peak systolic velocity on the right is 111
centimeters/second. The peak systolic velocity on the left is 74.1
centimeters/second. Main renal veins are patent bilaterally with normal
waveforms.
The bladder is moderately well distended and normal in appearance.
IMPRESSION:
Normal renal ultrasound. No evidence of renal artery stenosis.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with syncope and head strike, w/ worsening
memory, nonfocal exam// evaluate for slow 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 10.0 s, 17.5 cm; CTDIvol = 47.4 mGy (Head) DLP =
829.0 mGy-cm.
Total DLP (Head) = 844 mGy-cm.
COMPARISON: CT head without contrast from ___
FINDINGS:
There is no evidence of acute large territory infarct,hemorrhage,edema,or mass
effect. The ventricles and sulci are normal in size and configuration.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
1. No evidence of acute intracranial abnormality. Specifically, no evidence
of intracranial hemorrhage.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Syncope
Diagnosed with Syncope and collapse
temperature: 98.4
heartrate: 88.0
resprate: 18.0
o2sat: 96.0
sbp: 142.0
dbp: 79.0
level of pain: 10
level of acuity: 2.0 | Ms. ___ is a ___ F with h/o asthma, PCOS, HTN, G6PD, and
PTSD presenting with syncope c/b head trauma, c/f cardiac
etiology, also found to have ___, hypokalemia and prolonged QTc.
#SYNCOPE: Morning of presentation, awoke around 3AM, urinated,
washed hands, and upon exiting the bathroom, fell. No prodrome,
no seizures. Reportedly down for 15 min and confused for about
20 min afterwards. When she awoke she was diaphoretic with a
headache. She had no dinner. She had been taking her outpatient
medicines including ___, daily. She hit her
R forehead. Notably, she had an episode of syncope 10 days prior
while driving that lasted for seconds. She has also had other
episodes of syncope, one of which was documented in the medical
record from ___ - ___ orthostatic hypotension.
She also reports a more extensive family history of arrhythmia
(sister), cardiomyopathy (brother) and syncope (brother) than
previously noted. Admission also notable for hypokalemia and ___
which could either be consistent with an orthostatic syncope ___
hypovolemia in the setting of chlorthalidone, bradycardic
syncope in setting of atenolol toxicity, or hypokalemia causing
long QTc(>500msec on admission EKG) and triggering
tachycarrhythmia (with K repletion QTc returned to normal, 430).
What argues against atenolol toxicity is that the patient's
heart rate augmented with orthostatic vital signs taken on
admission. Patient was monitored on telemetry. Home
___ were held. Ruled out for PE with
___. IVF was given and K+ repleted. No further
arrhythmias or syncopal events occurred. On HD3, a TTE was
obtained which was a normal study. Atrius Cardiology was
consulted and patient will have f/u monitoring.
#R FOREHEAD TRAUMA: NCHCT of head was obtained and negative for
acute intracranial process or fractures.
#HYPOKALEMIA: Though initial value wnl, admit BMP was hemolyzed,
so wonder if she was hypokalemic on presentation (as above,
possibly leading to QTc prolongation and possibly PMVT).
Diuretic effect certainly possible, but given her hypertension
and FHx of such, wonder about renin or aldosterone effect or
___. Would expect that diuretic effect would have
worn off by 2 days inpatient. The patient was discharged with
40meq BID of potassium repletion and off of her diuretics. Can
carefully consider ___ of very low dose diuretics as
outpatient if felt appropriate.
#Severe Persistent Asthma: Per report, required steroids 2
months ago, has near nightly awakenings with dry mouth but
___ requires rescue inhaler. Reportedly ___ to
medications per chart. Currently not having an exacerbation at
this time. Continued home nebs, inhaler.
#Headache/Migraine: No migraines this hospitalization.
#PCOS: Nexplanon. HbA1c this admission 6.2%.
#OSA: Not using home CPAP ___ lack of "correct tubing". Please
consider connecting this patient w/ the equipment supplier. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
vancomycin / Erythromycin Base / lisinopril / nifedipine /
gabapentin / lorazepam / omeprazole
Attending: ___.
Chief Complaint:
abdominal pain, N/V
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F PMH of DM2, gastroparesis, HTN, GERD, depression,
recurrent UTIs who presents to the ED with nausea, vomiting,
abdominal pain x 3 days. Pt believes this to be similar to her
usual gastroparesis flares. She notes the pain is worst at
epigastrium when pressed, but really it is diffuse and feels
sharp, does not radiate to the back. Denies diarrhea, fevers,
chills, dysuria. Of note, she was discharged on ___, at which
time she reports she felt well. She had been hospitalized for
similar complaints; there was some concern about a possible
pyelonephritis although it was not clear that this was actually
an issue; she was to continue PO cipro until ___ which she
did, then discuss suppressive abx. She had an MRI at last
admission which showed a ureteral divertilus which could be
nidus of infection.
In the ED, initial vitals: 10 98.5 98 148/81 18 100% RA. Labs
were significant for WBC 20.1, lactate 2.2 w/normal pH 7.39, AP
164, BG 325, negative urine and serum tox, neg UA. She had
normal LFTs and lipase. No imaging done. ED course c/b
hypertension to 200s/100s. She rec'd PO labetalol 100mg,
lisinopril 40mg, nifedipine, and 10mg IV labetalol. She rec'd
several doses of IV narcotics in ED as well.
On arrival to the floor, she was very agitated and screaming in
pain; by the time of exam, she was calmer.
Past Medical History:
Hypertension
IDDM2
Asthma
GERD
Depression
Social History:
___
Family History:
pt not willing to discuss
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals- 98.1 132/67 93 20 100% RA
General- somnolent but arousable, flat affect, minimally willing
to engage in discussion
HEENT- Sclerae anicteric, MM dry,
Neck- difficult to appreciate JVP given body habitus
Lungs- CTAB no wheezes, rales, rhonchi anteriorly
CV- distant heart soudns, RRR, Nl S1, S2, No MRG
Abdomen- soft, mild tenderness diffusely w/o rebound or
guarding. bowel sounds present but infreq
GU- foley
Ext- warm, well perfused
DISCHARGE PHYSICAL EXAM
General- awake, alert, interactive. oriented x3
HEENT- Sclerae anicteric, MM dry,
Neck- difficult to appreciate JVP given body habitus
Lungs- CTAB no wheezes, rales, rhonchi anteriorly
CV- distant heart soudns, RRR, Nl S1, S2, No MRG
Abdomen- soft, nontender w/o rebound or guarding. NABS
GU- foley
Ext- warm, well perfused
Pertinent Results:
ADMISSION LABS
___ 01:20AM PLT COUNT-516*
___ 01:20AM WBC-20.1* RBC-4.21 HGB-10.0* HCT-32.3*
MCV-77* MCH-23.8* MCHC-31.0 RDW-18.9*
___ 01:20AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 01:20AM ALBUMIN-4.0
___ 01:20AM LIPASE-38
___ 01:20AM ALT(SGPT)-26 AST(SGOT)-18 ALK PHOS-164* TOT
BILI-0.3
___ 01:20AM GLUCOSE-325* UREA N-16 CREAT-1.0 SODIUM-135
POTASSIUM-4.0 CHLORIDE-96 TOTAL CO2-28 ANION GAP-15
___ 01:33AM LACTATE-2.2*
___ 01:33AM ___ PO2-66* PCO2-48* PH-7.39 TOTAL
CO2-30 BASE XS-2
___ 02:16AM URINE RBC-16* WBC-2 BACTERIA-NONE YEAST-NONE
EPI-3
___ 02:16AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100
GLUCOSE-1000 KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 02:16AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 02:16AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 02:16AM URINE UCG-NEGATIVE
___ 04:20PM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-1
___ 04:20PM URINE BLOOD-TR NITRITE-NEG PROTEIN-100
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 04:20PM URINE COLOR-Straw APPEAR-Clear SP ___
DISCHARGE LABS
___ 04:54AM BLOOD WBC-14.0* RBC-3.56* Hgb-8.6* Hct-27.1*
MCV-76* MCH-24.1* MCHC-31.5 RDW-18.4* Plt ___
___ 04:54AM BLOOD Glucose-179* UreaN-15 Creat-1.0 Na-138
K-3.8 Cl-101 HCO3-28 AnGap-13
___ 06:42AM BLOOD ALT-21 AST-17 AlkPhos-125* TotBili-0.3
IMAGING
CXR ___
IMPRESSION:
No acute cardiopulmonary process.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Ciprofloxacin HCl 500 mg PO Q12H
4. Docusate Sodium 100 mg PO BID
5. Ferrous Sulfate 325 mg PO TID
6. Gabapentin 600 mg PO TID
7. Lisinopril 40 mg PO DAILY
8. Metoclopramide 10 mg PO QIDACHS
9. NIFEdipine CR 60 mg PO DAILY
10. Pantoprazole 40 mg PO Q24H
11. Senna 8.6 mg PO BID:PRN constipation
12. Sertraline 150 mg PO DAILY
13. TraMADOL (Ultram) 50 mg PO DAILY PRN pain
14. Glargine 35 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Gabapentin 600 mg PO TID
5. Glargine 35 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
6. Lisinopril 40 mg PO DAILY
7. Metoclopramide 10 mg PO QIDACHS
8. NIFEdipine CR 60 mg PO DAILY
9. Pantoprazole 40 mg PO Q24H
10. Senna 8.6 mg PO BID:PRN constipation
11. Sertraline 150 mg PO DAILY
12. Ferrous Sulfate 325 mg PO TID
13. TraMADOL (Ultram) 50 mg PO DAILY PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Gastroparesis flare
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 leukocytosis // PNA?
TECHNIQUE: Portable upright chest radiograph
COMPARISON: ___
FINDINGS:
The lungs are clear and the cardiac and mediastinal contours are accentuated
by portable technique, but stable since ___. There is no pleural
effusion or pneumothorax.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old woman with lethargy, AMS, with BPs in 200s/100s
earlier in day, concern for bleed // r/o bleed
TECHNIQUE: Contiguous axial MDCT images were obtained from the skull base
through the vertex, without IV administration of contrast. Reformatted coronal
and sagittal and thin-section bone algorithm-reconstructed images were
acquired, and all images are viewed in brain and bone window on the
workstation.
DOSE: DLP (mGy-cm): 892
CTDIvol (mGy): 53
COMPARISON: CT head from ___
FINDINGS:
There is no evidence of hemorrhage, edema, mass effect, or acute vascular
territorial infarction. Periventricular white matter hypodensities are
nonspecific and unchanged from the prior examination. The ventricles and sulci
are stable in size and configuration. The basal cisterns are patent.
Gray-white matter differentiation is preserved.
No fracture is identified. The paranasal sinuses are notable for mild to
moderate mucosal thickening in bilateral maxillary sinuses, ethmoid air cells,
and sphenoid sinuses. Mastoid air cells, and middle ear cavities are clear.
The orbits are unremarkable.
IMPRESSION:
No acute intracranial abnormality.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: N/V, Abd pain
Diagnosed with DIAB NEURO MANIF IDDM, GASTROPARESIS, VOMITING
temperature: 98.5
heartrate: 98.0
resprate: 18.0
o2sat: 100.0
sbp: 148.0
dbp: 81.0
level of pain: 10
level of acuity: 3.0 | ___ yo F PMH of DM2, gastroparesis, HTN, GERD, depression who
presents with nausea, vomiting, abdominal pain c/w gastroparesis
flare.
ACTIVE ISSUES
#N/V/abd pain: Patient felt this was very similar to her prior
gastroparesis flares. Treated conservatively with NPO, IVF,
metoclopramide, acetaminophen (avoided narcotics); advanced diet
as tolerated. Symptoms quickly resolved the day after admission,
and she ate full meals. The patient also c/o some mild back
pain, and she has a history of questionable pyelonephritis on
prior admission, but UA was negative this admission. She had
finished her course of abx on ___ for the possible pyelo.
Will need to discuss outpatient whether she should be on
suppressive abx given her known urethral diverticulum.
# HTN: Very elevated BPs in ED requriing IV meds, but controlled
on arrival to the floor with home regimen of lisinopril 40mg and
nifedipine 60mg daily. Suspect some elevation in setting of
pain.
CHRONIC ISSUES
# DM: continued home regimen of insulin (35units lantus plus
mealtime 2,4, or9 untis based on meal size).
# GERD: continued PPI.
# Depression: continued sertraline.
TRANSITIONAL ISSUES
-Will need to discuss outpatient whether she should be on
suppressive abx given her known urethral diverticulum
-Close BP monitoring to ensure well controlled chronically |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Celexa / Iodine-Iodine Containing
Attending: ___.
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
cardiac cath, diagnostic
History of Present Illness:
The patient is a ___ with PMH HTN, Hep C, protein S deficiency
(no h/o clots), GERD, p/w intermittent SOB and chest pressure
assocaited with nausea. The SOB has been going on for years on
and off, but she feels it has been getting worse recently, and
in the past ___ months has become associated with a feeling of
chest pressure. The SOB can come on both at rest or on exertion,
and seems to get worse on exertion. The chest pressure occurs
with the SOB and is ___, and associated with L arm pain,
bilateral shoulder pain, and once with numbness in her face. For
the past 2 weeks, the chest pressure has been occuring every
day, multiple times a day, lasting ___ minutes each episode,
resolving on its own. She also complains of nausea associated
with the chest pain, and cough for 2 weeks.
The patient has had several stress tests in the past. In ___,
she had a negatie ETT in which she developed chest pain but no
diagnostic EKG changes. In ___, she had an ETT that caused an
increase in her baseline chest pain and 1-___epressions. Therefore, she was referred for stress-echo
performed ___ with similar symptoms and ekg changes, normal
baseline echo and no wall motion abnormalities post-stress. She
was seen again in ___ EW over the weekend with chest pain and
SOB, with normal troponin and no ekg abnormalities.
In the ED, initial vitals were T afebrile HR 57 BP 144/82 RR 13
O2sat 100%. D-dimer was elevated at 778, and the patinet got a
V/Q scan because of contrast allergy. A CXR was also done. She
recieved lorazepam in the ED.
ROS:
The patient denied fever, chills, vomiting, diarrhea, abdominal
pain, night sweats, leg swelling. She says she has 2 pillow
orthopnea, no PND.
Past Medical History:
--HTN
--Hep C, no treatment, says her VL has been "Stable"
--GERD
--protein S deficiency, detected on genetic testing after her
father had a blood clot
Social History:
___
Family History:
Father: HLD, CAD (hospitalized in ___ for a "heart problem",
unclear if MI), blood clot, lung Ca, died recently
Mother: HLD
Physical ___:
ADMISSION EXAM:
VS- T 97.6 HR 58 BP 150/95 RR 16 O2sat 99% ra
GENERAL- NAD
HEENT- MMM, EOMI
NECK- supple, no elevation in JVP
CARDIAC- S1S2, RRR, no MRG
LUNGS- CTABL, mild bibasilar wheezes
ABDOMEN- Soft, NTND. No HSM or tenderness.
EXTREMITIES- No c/c/e. + pulses b/l
DISCHARGE EXAM: unchanged
Pertinent Results:
IMAGING:
EKG -- NSR at 54 bpm. No significant ST segment chenages, no
significant Q waves, overall normal EKG
IMAGING-
CXR ___:
No acute cardiopulmonary process.
V/Q Scan ___:
Low likelihood ratio for acute pulmonary embolus given
ventilation and perfusion defects described above.
CT scan w/o contrast ___
No acute or chronic lung parenchymal changes. None of the
present
non-characteristic findings (small cysts, areas of atelectasis)
are explaining the clinical presentation of the patient.
Trop-T negative x2
Cardiac cath ___. Coronary angiography of this right dominant system
demonstrated no
angiographically apparent disease. The LMCA, LAD, LCx and RCA
had no
angiographically apparent disease.
2. Resting hemodynamics revealed normal central aortic pressure
(136/77
mm Hg, mean 85 mm Hg).
ADMISSION LABS
___ 12:20PM GLUCOSE-90 UREA N-9 CREAT-0.7 SODIUM-139
POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-30 ANION GAP-9
___ 12:20PM estGFR-Using this
___ 12:20PM cTropnT-<0.01
___ 12:20PM D-DIMER-778*
___ 12:20PM URINE HOURS-RANDOM
___ 12:20PM URINE UCG-NEGATIVE
___ 12:20PM WBC-5.6 RBC-4.26 HGB-13.0 HCT-38.0 MCV-89
MCH-30.5 MCHC-34.2 RDW-13.4
___ 12:20PM NEUTS-47.3* ___ MONOS-4.2 EOS-6.1*
BASOS-1.2
___ 12:20PM PLT COUNT-205
___ 12:20PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 12:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Lisinopril 10 mg PO DAILY
2. Metoprolol Succinate XL 25 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Aspirin 325 mg PO DAILY
5. Nicotine Patch 21 mg TD DAILY
6. Clonazepam 0.25-0.5 mg PO BID:PRN anxiety
7. Hydrochlorothiazide 25 mg PO DAILY
8. Nitroglycerin SL 0.3 mg SL PRN chest pain
Discharge Medications:
1. Clonazepam 0.5-1 mg PO BID:PRN anxiety
hold for sedation, please wait 1 hour after giving benadryl
RX *clonazepam 1 mg 1 tablet(s) by mouth up to twice a day as
needed for anxiety Disp #*10 Tablet Refills:*0
2. Hydrochlorothiazide 25 mg PO DAILY
3. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30
Tablet Refills:*5
4. Lisinopril 10 mg PO DAILY
5. Nicotine Patch 21 mg TD DAILY
6. Nitroglycerin SL 0.3 mg SL PRN chest pain
7. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
shortness of breath, ruled out for CAD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with chest pain, evaluate for cardiopulmonary
process.
COMPARISON: Scout radiograph from CT neck from ___.
TECHNIQUE: PA and lateral chest radiographs were provided.
FINDINGS: There is no focal consolidation, pleural effusion or pneumothorax.
The cardiomediastinal silhouette is normal. There may be a trace amount of
fluid in the right minor fissure. Deformity of the right shoulder is
unchanged from prior exams and may be due to prior trauma. No acute fractures.
IMPRESSION: No acute cardiopulmonary process.
Radiology Report
COMPUTED TOMOGRAPHY OF THE THORAX
INDICATION: Shortness of breath, contrast allergy, evaluation for parenchymal
abnormalities.
COMPARISON: No comparison available at the time of dictation.
TECHNIQUE: Volumetric CT acquisitions over the entire thorax in inspiration,
no administration of intravenous contrast material, multiplanar
reconstructions.
FINDINGS: No incidental thyroid findings. No supraclavicular,
infraclavicular, or axillary lymphadenopathy. No mediastinal lymph node
enlargement. The large mediastinal vessels are unremarkable. Normal size and
shape of the heart, no coronary calcifications. Normal appearance of the
posterior mediastinum, with, however, a small hiatal hernia (2, 44).
Status post cholecystectomy. One clip located between the dorsal aspect of
the liver and the ventral aspect of the right kidney. No other remarkable
findings in the upper abdomen.
The lung volumes are normal. 8-mm cyst in the apex of the left lower lobe (4,
77). Non-characteristic minimal band-like scar at the level of the apex of
the right lower lobe (4, 91).
5-mm subpleural cysts in the right lower lobe (4, 122).
Minimal band-like areas of atelectasis in the dependent lung regions (4, 185).
No other lung parenchymal abnormalities, in particular no abnormalities able
to explain the clinical presentation of the patient. In particular, there is
no evidence of fibrotic disease or infection. No lung nodules or masses. The
airways are patent, and the wall structure of the airways is unremarkable.
Even pleural surfaces without evidence of pleural effusion.
IMPRESSION:
No acute or chronic lung parenchymal changes. None of the present
non-characteristic findings (small cysts, areas of atelectasis) are explaining
the clinical presentation of the patient.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: CP
Diagnosed with CHEST PAIN NOS
temperature: 98.1
heartrate: 59.0
resprate: 18.0
o2sat: 100.0
sbp: 148.0
dbp: 93.0
level of pain: 4
level of acuity: 2.0 | ___ with PMH HTN, Hep C, protein S deficiency (no h/o clots),
GERD, p/w intermittent SOB and chest pressure assocaited with
nausea, which has been getting worse over the past month.
# SOB and chest pain: CE negative, 2 recent stress tests which
showed some EKG changes but did not show any wall motion
abnormalities. However, the patient has significant family
history of CAD (father), and several risk factors including
smoking and HTN. Troponins negative x2 and EKg wnl, Tele showed
no events. Cardiac cath was preformed after pretreatment for
contrast allergy, which showed no CAD. The patient was very
distressed that she had no explanation for her SOB with the
negative cath, so pulmonology consult was obtained to help the
patient transition to outpatient setting for further pulm
workup. Pulm consult recommended CT chest to reassure the
patient and assess for parechymal disease, CT lungs was
negative. The patient was strongly recommended towards smoking
cessation and weight loss.
# HTN: BP was slightly elevated during admission, mostly
systolic 130s. Continued home lisinopril, metoprolol, HCTZ,
ASA. Deferred further BP control decisions to PCP.
# GERD: the patient's dose of omeprazole was increased to 40
when her cardiac cath was negative, as GERD is the leading most
likely cause of her SOB at this time.
# Anxiety: The patient was very anxious on the floor, and
responded well to clonazepam. She was discharged with a short
perscription for clonazepam, further anxiolytic treatment
deferred to PCP.
# FEN- heart healthy diet/ replete lytes PRN
# ACCESS- PIV's
# PROPHYLAXIS-
-DVT ppx with SQ Heparin
-Pain management with tylenol prn
-Bowel regimen with docusate, senna
# CODE- Full (confirmed)
# EMERGENCY CONTACT- Mother ___ ___
TRANSITIONAL ISSUES
--Needs to follow up with pulm specialist for full set of PFTs
to eval for asthma vs COPD
--highly recommend smoking cessation, weight loss |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
heparin / Haldol
Attending: ___.
Chief Complaint:
Weakness
Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
PCP: ___
CC: ___ Pain
REASON FOR MICU: Hypotension
HISTORY OF PRESENTING ILLNESS:
___ with history of pAF not on AC, enterocutaneous fistula s/p
ostomy, hypothyroidism, hx of constipation who presents with
weakness and hypotension. Patient was at his assisted living
facility and has been feeling weak over the past few days.
Patient with decreased PO intake. Facility concern patient was
dehydrated. Found to be hypotensive with a systolic blood
pressure of 80. Noted that he had the contents of his colostomy
bag were increased from normal. He has been taking ___ Imodium
daily. Went to ___ and had CT a/p revealing rectal
fecal impaction with possible mild stercoral proctitis with
associated extensive fecal stasis/constipation. No evidence of
SBO. No fevers, chest pain, shortness of breath, vomiting.
Started on levofed at ___ and ___ IJ was placed. Got
Levaquin and Flagyl at OSH, and was transferred to ___.
___ labs ___
128 85 50
----------< 105
3.9 28 1.8
In the ED, initial vitals: 99.9 65 105/64 16 95% RA
Exam notable for: no abdominal tenderness. Hypotensive to the
___ off of Levophed. Clear lungs and normal heart sounds. Rectal
performed. Patient had a soft bowel movement immediately prior
to rectal. Soft, light brown stools with minimal stool in the
vault removed.
Labs notable for: WBC 8.9, Hgb 7.8, BUN/Cr: 46/1.4, normal
LFTs/lipase, lactate 1.3. VBG: ___
Imaging: CT a/p: Rectal fecal impaction with possible mild
stercoral proctitis. Associated extensive fecal
stasis/constipation. No evidence of SBO.
Patient received: norepinephrine. Given levaquin & flagyl, 4L
IVF at ___
Consults:
Surgery: Patient has no surgical needs. Would benefit from
disempaction by medical provider.
Vitals on transfer: 100.4 66 97/49 14 95% RA
Upon arrival to ___, patient feels well without any abdominal
pain. Confirms history as above. He is hard of hearing. Denies
any chest pain or shortness of breath. Per family at bedside,
has been taking Imodium as has large output from his ostomy. Was
severely constipated in the past hospitalized at ___
requiring multiple enemas and aggressive bowel regimen. No
perforation then.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Otherwise
Past Medical History:
BPH
Hyperlipidemia
Hx of diverticulitis
Umbilical hernia
Abdominal fistula with colostomy
Recurrent constipation
Psoriasis
Hx of fall with reported nasal fracture, possible subdural
hematoma
Paroxysmal Afib
Social History:
___
Family History:
Non-contributory
Physical Exam:
Discharge exam:
GENERAL: well appearing in no acute distress
HEENT: Sclera anicteric, MMM. PERRL oropharynx clear
NECK: JVP not elevated, no LAD
LUNGS: Crackles at L lung base. Good inspiratory effort
CV: Difficult to auscultate
ABD: Ostomy with light brown stool. +BS. Soft, nontender,
nondistended. no rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: Psoriasis plaques on abdomen
NEURO: moving all extremities. AO to self, hospital.
Pertinent Results:
___ 06:36AM BLOOD WBC-8.9 RBC-2.78* Hgb-7.8* Hct-24.5*
MCV-88 MCH-28.1 MCHC-31.8* RDW-15.8* RDWSD-51.0* Plt ___
___ 06:56AM BLOOD WBC-5.4 RBC-3.02* Hgb-8.6* Hct-26.7*
MCV-88 MCH-28.5 MCHC-32.2 RDW-16.1* RDWSD-52.3* Plt ___
___ 06:56AM BLOOD ___
___ 06:36AM BLOOD Glucose-84 UreaN-46* Creat-1.4* Na-138
K-3.4 Cl-100 HCO3-25 AnGap-13
___ 06:56AM BLOOD Glucose-96 UreaN-16 Creat-1.1 Na-142
K-4.2 Cl-103 HCO3-26 AnGap-13
___ 04:52AM BLOOD ALT-10 AST-13 AlkPhos-67 TotBili-0.3
___ 06:56AM BLOOD Calcium-8.4 Phos-3.2 Mg-1.7
___ 11:49AM BLOOD Hapto-184
___ 04:52AM BLOOD calTIBC-270 VitB12-1494* Folate->20
Ferritn-126 TRF-208
___ 06:36AM BLOOD TSH-2.0
___ 02:45PM BLOOD Lactate-1.6
C.diff neg
Guaiac neg
BCx (___): pending x 2
UCx (___): yeast
pCXR ___: Left IJ line terminates in the upper SVC. There
is no focal consolidation. There are probable small bilateral
pleural effusions. There is no large pneumothorax. Apparent
right
hilar fullness is stable from prior and previously evaluated on
recent chest CT. Mild cardiomegaly stable.
Mediastinal silhouette is otherwise within normal limits.
OSH CT A/P (___):
Subsegmental atelectasis/infiltrates noted in lung base. Chronic
aspiration cannot be excluded. Bilateral pleural thickening with
R pleural calcifications are seen. Large hiatal hernia seen
containing stomach. Contracted gallbladder with small gallstones
seen. Pancreas is atrophic. Bilateral renal cysts are seen.
Multiple small nonobstructing bilateral renal calculi are seen.
Nonspecific perinephric fat stranding is noted bilaterally. No
ureteric calculus or hydroureteronephrosis. Liver, spleen,
adrenal glands grossly unremarkable.
Mid abdominal ostomy is seen. Sigmoid anastomatic sutures are
seen. Large amount of stool is noted throughout colon reflecting
constipation. Rectum distended up to 10cm with abundant fecal
matter & mild perirectal fat stranding & wall thickening. No
evidence of bowel obstruction. Aorta demonstrates atheromatous
calcification w/o evidence of aneurysm. No free fluid.
A foley catheter seen in decompressed urinary bladder
demonstrating multiple diverticula & wall calcification/calculi.
Right retractile testis is seen in the right lower inguinal
canal.
Diffuse osteopenia w/ severe degenerative changes in spine.
Impression:
Rectal fecal impaction with possible mild stercoral proctitis.
Associated extensive fecal stasis/constipation. No evidence of
SBO.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 112 mcg PO DAILY
2. Venlafaxine XR 75 mg PO DAILY
3. Metoprolol Succinate XL 12.5 mg PO DAILY
4. dutasteride 0.5 mg oral DAILY
5. Vitamin D 400 UNIT PO DAILY
6. Sodium Bicarbonate 1300 mg PO BID
7. Aspirin 325 mg PO DAILY
8. Magnesium Oxide 400 mg PO DAILY
9. LOPERamide 2 mg PO QID:PRN diarrhea
10. Nexium 40 mg Other BID
11. Sodium Bicarbonate ___ mg PO QHS
Discharge Medications:
1. Bisacodyl 10 mg PO/PR DAILY Constipation
2. Polyethylene Glycol 17 g PO DAILY:PRN constipation
3. Senna 8.6 mg PO BID:PRN constipation
4. Aspirin 325 mg PO DAILY
5. dutasteride 0.5 mg oral DAILY
6. Levothyroxine Sodium 112 mcg PO DAILY
7. LOPERamide 2 mg PO QID:PRN diarrhea
8. Magnesium Oxide 400 mg PO DAILY
9. Metoprolol Succinate XL 12.5 mg PO DAILY
10. Nexium 40 mg Other BID
11. Sodium Bicarbonate ___ mg PO QHS
12. Sodium Bicarbonate 1300 mg PO BID
13. Venlafaxine XR 75 mg PO DAILY
14. Vitamin D 400 UNIT PO DAILY
Discharge Disposition:
Home with Service
Facility:
___
Discharge Diagnosis:
Hypovolemia
Stercoral proctitis
Constipation
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 (PORTABLE AP)
INDICATION: History: ___ with L IJ, please confirm placment*** WARNING ***
Multiple patients with same last name!// Confirm placement of L IJ
COMPARISON: Chest radiograph ___
Chest CT ___ apparent right hilar fullness is stable from prior and
was evaluated on prior chest CT. Mild cardiomegaly is stable. Mediastinal
silhouette is otherwise within normal limits.
FINDINGS:
Portable AP view of the chest provided.
Left IJ line terminates in the upper SVC. There is no focal consolidation.
There are probable small bilateral pleural effusions. There is no large
pneumothorax. Apparent right hilar fullness is stable from prior and
previously evaluated on recent chest CT. Mild cardiomegaly stable.
Mediastinal silhouette is otherwise within normal limits.
IMPRESSION:
Left IJ line terminates in the upper SVC.
Radiology Report
INDICATION: ___ year old man with enterocutaneous fistula p/w stercoral
colitis.// Please evaluate stool burden.
TECHNIQUE: Supine and left lateral decubitus abdominal radiographs
COMPARISON: CT abdomen and pelvis ___
FINDINGS:
There are no abnormally dilated loops of large or small bowel. A small amount
of stool is seen within the descending colon, although no large stool burden
is noted within the rectum.
There is no free intraperitoneal air.
There is severe disc space narrowing at the T12-L1, L1-2 L2, and L2-L3
vertebral levels as well as moderate disc space narrowing at the L3-L4
vertebral level. Moderate to severe degenerative changes with osteophytosis
of the lumbar spine are also seen. The axial skeleton is diffusely
osteopenic.
A metallic device projects over the right upper quadrant, presumably outside
the patient.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
1. Small stool burden within the descending colon without large stool burden
within the rectum.
2. Nonobstructive bowel gas pattern.
3. No free intraperitoneal air.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, Transfer
Diagnosed with Other specified noninfective gastroenteritis and colitis, Hypotension, unspecified
temperature: 99.9
heartrate: 65.0
resprate: 16.0
o2sat: nan
sbp: 105.0
dbp: 64.0
level of pain: 0
level of acuity: 2.0 | ___ male with history of constipation, diverticulitis
s/p partial sigmoidectomy with known enterocutaneous fistula who
was admitted to FICU on ___ with hypotension (likely
dehydration in setting of high-output fistula) and CT concerning
for mild stercoral proctitis, now with resolution of hypotension
and tx to floor ___.
#Hypotension:
The patient presented with hypotension, likely secondary to
dehydration in the setting of large EC fistula output resulting
from rectal fecal impaction (the result of uptitrating his home
imodium prior to admission). Briefly required levophed in the
ICU via L IJ, but was quickly weaned with 4L IVFs. He was
initiated on levofloxacin/flagyl, discontinued given low concern
for sepsis. Active bleeding was thought unlikely. Surgery was
consulted, but in the absence of evidence of intra-abdominal
perforation on imaging only disimpaction and medical management
of constipation were recommended (see below). Of note, baseline
blood pressures appear to be SBPs in the ___ to low 100s. He has
previously required intermittent IVF for similar presentations,
last about 5 months ago, and is reportedly in discussion with
his PCP about establishing ___ schedule for regular IVF infusions.
He will need to f/u with his PCP for further management of this
recurrent issue.
#Stercoral proctitis
#Constipation
#Chronic metabolic acidosis
Patient has chronic constipation, diverticulitis s/p
sigmoidectomy, and known enterocutaneous fistula with CT
concerning for stercoral proctitis. He is managed with
anti-diarrheals at his assisted living facility to control EC
fistula output, with resulting constipation that then
exacerbates fistula output. As above, his presentation was
thought secondary to rectal impaction resulting in high fistula
output and hypotension. C.diff was negative. There was no
evidence of intra-abdominal perforation on imaging. He had a
large bowel movement prior to transfer to ___ from ___
___ and underwent disimpaction in the ICU. On transfer to
the floor he was continued on an aggressive bowel regimen of
senna, bisacodyl, miralax, and enemas, with resolution of his
rectal impaction. He was discharged on his home imodium in
addition to senna, bisacodyl, and miralax PRN and will need to
work with his PCP to balance control of his fistula output with
management of constipation. His home sodium bicarbonate was
continued on discharge.
#Normocytic anemia: Hct 24.5 on admission from b/l 37 in ___.
Etiology of anemia was unclear. Guaiac negative with no e/o
active bleeding. Iron studies most consistent with anemia of
chronic disease. No e/o hemolysis. His anemia was stable, and
Hct was 26.7 at the time of discharge. He will need to f/u with
his PCP for ___ repeat CBC and further w/u as
appropriate.
#pAF not on anticoagulation: continued home metoprolol in
fractionated form
#GERD: continued home PPI
#Hypothyroidism: TSH WNL. continued home synthroid
#BPH: replaced home dutasteride with finasteride while
hospitalized (formulary issues)
#Depression: continued home Venlafaxine |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
hydrochlorothiazide
Attending: ___
Chief Complaint:
difficulty walking
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ old right-handed woman with a history of
hypertension, not on any medications, stress incontinence,
rheumatic aortic valve and osteoporosis who presents with sudden
onset difficulty walking and lower extremity weakness.
Patient was sitting down eating lunch and in her usual state of
health when she went to stand and her legs gave out from
underneath her but she did not fall. She started to walk and
noticed that she was unable to walk without assistance and was
stumbling to the right side. She was evaluated at her assisted
living facility where it was noted that she is waiting to the
right when walking and was sent to the emergency room for
evaluation of possible stroke.
There is also report of slurred speech lasting approximately 15
minutes which resolved by the time of presentation. She denies
any vertigo but does report lightheadedness symptoms.
Patient also notes that she had new onset urinary frequency
today.
Past Medical History:
Stress incontinence
UTI
IBS
Osteoarthritis
GERD
Rheumatic aortic valve
Status post bilateral cataract surgery ___
Anxiety
Depression
Hypertension
Osteoporosis
Ectopic pregnancy ___
Appendectomy
Social History:
___
Family History:
noncontributory
Physical Exam:
===ADMISSION EXAM===
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
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: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Able
to
read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. There was no
evidence of neglect.
-Cranial Nerves:
II, III, IV, VI: Left pupil is irregular and nonreactive. Right
pupil was 3 mm and sluggishly reactive. EOMI without nystagmus.
VFF to confrontation.
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 bilaterally.
XII: Tongue protrudes in midline with good excursions.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
She had give way weakness in the arms and legs and was 4+/5- in
all muscle groups tested in the upper and lower extremities.
There is no obvious asymmetry to her exam.
-Sensory: No deficits to light touch, pinprick, proprioception
throughout. No extinction to DSS. Romberg positive with eyes
open.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor. Slowed and clumsy finger
tap
on the right. Mild right upper extremity dysmetria on finger to
nose testing.
-Gait: Extremely hesitant. Narrow base but steps to the side
frequently and is a 1 person assist due to frequency of tending
to fall.
====DISCHARGE EXAM===
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Able
to
read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. There was no
evidence of neglect.
-Cranial Nerves:
II, III, IV, VI: Left and right pupils is sluggishly reactive
(Left slower to accomodate than right). Left pupil irregular,
stable from prior surgery. EOMI without nystagmus. VFF to
confrontation.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally. On Weber,
decreased on left compared to right. AC>BC bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No
asterixis noted. Upper extremity strength ___ bilaterally,
symmetric. There is asymmetric weakness in the legs on the right
side in upper motor neuron pattern, with IP/ham 4- vs 4+ on the
left.
-Sensory: No deficits to light touch, pinprick, proprioception
throughout. No extinction to DSS. Romberg deferred.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Babinski: Toes upgoing on right, downgoing on left
-Coordination: No intention tremor. Slowed and clumsy finger
tap
on the right. Mild right upper extremity dysmetria on finger to
nose testing.
-Gait: Extremely hesitant. wide based, requires 1 person assist
from chair to bed.
Pertinent Results:
===ADMISSION LABS===
___ 04:55PM BLOOD WBC-7.4 RBC-4.62 Hgb-13.6 Hct-42.8 MCV-93
MCH-29.4 MCHC-31.8* RDW-13.8 RDWSD-46.6* Plt ___
___ 05:05AM BLOOD Glucose-102* UreaN-22* Creat-0.9 Na-140
K-4.0 Cl-101 HCO3-27 AnGap-16
___ 04:55PM BLOOD ALT-10 AST-26 CK(CPK)-56 AlkPhos-72
TotBili-0.3
___ 04:55PM BLOOD CK-MB-3 cTropnT-<0.01
___ 05:05AM BLOOD Calcium-9.5 Phos-2.7 Mg-2.1 Cholest-215*
___ 05:05AM BLOOD %HbA1c-5.4 eAG-108
___ 05:05AM BLOOD Triglyc-140 HDL-57 CHOL/HD-3.8
LDLcalc-130*
___ 05:05AM BLOOD TSH-6.0*
___ 05:05AM BLOOD T4-6.8
___ 04:55PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
___ 07:00PM URINE Color-Straw Appear-Clear Sp ___
___ 07:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
___ 07:00PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
===RELEVANT IMAGING/DATA===
CTA ___
1. No evidence of acute territorial infarction or intracranial
hemorrhage. Acute infarct demonstrated in the left lateral
thalamus on subsequent MRI is not visualized on the current
exam.
2. Chronic infarction within the left lentiform nucleus.
3. Diffuse parenchymal volume loss with probable chronic small
vessel ischemic disease.
4. Inspissated secretions within the left sphenoid sinus, which
may be related to acute sinusitis.
5. Patency of the intracranial vasculature without stenosis,
occlusion, or
aneurysm.
6. Atherosclerotic disease at the carotid bifurcations without
internal
carotid artery stenosis by NASCET criteria.
7. Prominence of the pulmonary artery, which may be related to
pulmonary
hypertension.
MRI ___
1. Acute left thalamic infarction without associated hemorrhage.
2. Chronic infarction of the left caudate and putamen with prior
hemorrhage.
3. Moderate diffuse parenchymal volume loss with probable
chronic small vessel ischemic disease.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PreserVision AREDS (vitamins A,C,E-zinc-copper)
___ unit-mg-unit oral DAILY
2. Calcium Carbonate Dose is Unknown PO Frequency is Unknown
3. Multivitamins 1 TAB PO DAILY
4. cranberry extract ___ mg oral DAILY
5. Restasis 0.05 % ophthalmic DAILY:PRN
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Calcium Carbonate 500 mg PO BID
4. cranberry extract ___ mg oral DAILY
5. Multivitamins 1 TAB PO DAILY
6. PreserVision AREDS (vitamins A,C,E-zinc-copper)
___ unit-mg-unit oral DAILY
7. Restasis 0.05 % ophthalmic DAILY:PRN
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
left thalamic infarct
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: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: ___ patient with slurred speech and dizziness. Evaluate
for 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 18.0 s, 18.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
903.1 mGy-cm.
2) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 43.6 mGy (Head) DLP =
21.8 mGy-cm.
3) Spiral Acquisition 4.6 s, 36.2 cm; CTDIvol = 30.9 mGy (Head) DLP =
1,118.8 mGy-cm.
Total DLP (Head) = 2,044 mGy-cm.
COMPARISON: CT head ___, MRI head of ___
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is no evidence of acute large territory territorial infarction or
intracranial hemorrhage. There is chronic infarction within the left
lentiform nucleus. Acute infarct of the lateral thalamus visualized on
subsequent MRI head is not visualized on the current exam. There is diffuse
parenchymal volume loss with nonspecific white matter hypodensities, likely
related to chronic small vessel ischemic disease. There is moderate right
maxillary sinus mucosal retention cyst. There are inspissated secretions
within the left sphenoid sinus. The bilateral mastoid air cells appear clear.
CTA HEAD:
There are vascular calcifications of the cavernous and clinoid segments of
bilateral internal carotid arteries. There is no evidence of stenosis,
occlusion, or aneurysm. The dural venous sinuses appear patent.
CTA NECK:
There are vascular calcifications at the bilateral carotid bifurcations
without internal carotid artery stenosis by NASCET criteria. The bilateral
vertebral arteries appear patent. There is no evidence of a dissection.
There are vascular calcifications of the aortic arch and origins of the great
vessels.
OTHER:
The thyroid gland appears unremarkable. There is no lymphadenopathy per size
criteria. There is prominence of the pulmonary artery, which may be related
to pulmonary hypertension. There is dependent atelectasis. There is mild left
upper centrilobular emphysema. Streak artifact related to dental hardware
obscures visualization of adjacent structures.
IMPRESSION:
1. No evidence of acute territorial infarction or intracranial hemorrhage.
Acute infarct demonstrated in the left lateral thalamus on subsequent MRI is
not visualized on the current exam.
2. Chronic infarction within the left lentiform nucleus.
3. Diffuse parenchymal volume loss with probable chronic small vessel ischemic
disease.
4. Inspissated secretions within the left sphenoid sinus, which may be related
to acute sinusitis.
5. Patency of the intracranial vasculature without stenosis, occlusion, or
aneurysm.
6. Atherosclerotic disease at the carotid bifurcations without internal
carotid artery stenosis by NASCET criteria.
7. Prominence of the pulmonary artery, which may be related to pulmonary
hypertension.
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with slurred speech and weakness// eval for PNA
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: None.
FINDINGS:
There relatively low lung volumes. Mild lateral left base atelectasis is seen
without definite focal consolidation. No pleural effusion or pneumothorax is
seen. The cardiac and mediastinal silhouettes are unremarkable.
IMPRESSION:
Mild lateral left base atelectasis/scarring without definite focal
consolidation.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD
INDICATION: ___ patient with sudden onset of unsteady gait, lower
extremity weakness, right upper extremity ataxia on exam. 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 CTA head and neck ___
FINDINGS:
The left thalamus demonstrates a focus of slow diffusion without definite
FLAIR hyperintensity. There is prior infarction within the left caudate and
putamen, with associated focus of susceptibility artifact, likely related to
chronic hemorrhage. There is ex vacuo dilatation of the frontal horn of the
left lateral ventricle.
There is moderate diffuse parenchymal volume loss with nonspecific
periventricular and subcortical FLAIR hyperintensities, likely a sequela of
chronic small vessel ischemic disease. The major visualized arterial vascular
flow voids are preserved. There is a right maxillary sinus mucosal retention
cyst. There is mild mucosal thickening of bilateral ethmoid air cells. The
patient is status post bilateral lens replacement.
IMPRESSION:
1. Acute left thalamic infarction without associated hemorrhage.
2. Chronic infarction of the left caudate and putamen with prior hemorrhage.
3. Moderate diffuse parenchymal volume loss with probable chronic small vessel
ischemic disease.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 5:19 am, 2 minutes after
discovery of the findings.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Slurred speech, Unsteady gait
Diagnosed with Cerebral infarction, unspecified
temperature: 97.5
heartrate: 81.0
resprate: 18.0
o2sat: 96.0
sbp: 170.0
dbp: 80.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ was admitted for further work up of her gait
disturbance. MRI subsequently revealed a small left thalamic
stroke. There was concern of flow dependent exam changes, so
activity was initially restricted to bed rest to with liberal
blood pressure targets to promote perfusion. Mechanism was felt
to be small vessel disease; she was started on aspirin and
atorvastatin. TTE was unremarkable. No evidence of arrhythmia.
Patient screened for rehab with ___. Discharged on holter
monitoring.
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 = 130) - () 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? (X) Yes - () No [reason
() 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 >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
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 - (X) N/A |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fatigue
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with ESRD on HD (TThSa), CAD, severe spinal stenosis, DM2
c/o feeling unwell since ___. She has been very fatigued.
Patient describes rhinorrhea, sneezing, and malaise. No sore
throat, HA, F/C, coughing, CP, abdominal pain, vomiting. Also
complained of loose watery stool occuring ___ times daily x
5days.
He was seen by his PCP today, where he appeared very tired and
fatigued. Vital signs in office: 97.9 ___ and exam notable
for cool skin. Lungs were on auscultation.
ED Course: Initial Vitals 97.9 76 168/75 16 100%/RA. Rectal exam
- guiaiac negative. Exam otherwise notable for bibasilar rales
and distended but nontender abd. CT abd negative for significant
findings. Chest xray with b/l atelectasis.
Past Medical History:
-CAD s/p CABG ___ with LIMA to LAD, radial to ramus and distal
RCA
-ESRD: HD TuThSat Dialysis Center: ___
-gout
-HTN
-HLD
-spinal stenosis
-neuropathy
-PVD s/p aortobifemoral bypass
-s/p appendectomy, cholecystectomy
-CVA sans residual deficits
Social History:
___
Family History:
Non-contributory
Physical Exam:
On admission:
VS -97.9 76 168/75 16 100%/RA
General: Male appearing younger than stated age in NAD,
appropriate
HEENT: DMM, Sclera anicteric, no conjunctival pallor, oropharynx
clear
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, ___ SEM
Lungs: CTAB. no wheezes, rales, ronchi
Abdomen: soft, non-tender,well-healed surgical scar
Ext: well perfused, Right forarm AVG with 2cm thrill,
nonerythematous, nonpainful. 2+ pulses, no clubbing, cyanosis
or edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities
On discharge:
VS T98.4 112/70 62 20 95%RA
GENERAL - comfortable,eating breakfast
HEENT - NC/AT, PEERLA, EOMI, MMM
NECK - supple, no LAD
LUNGS - CTAB. No crackles or wheezes
HEART - RRR, ___ SEM
ABDOMEN - soft/NT/ND, no masses or HSM, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs). Right forarm AVG with palpable thrill, nonerythematous,
nonpainful.
Pertinent Results:
LABS:
On admission ___ 04:35PM)
WBC-12.6*# RBC-3.81* Hgb-11.4* Hct-33.7* MCV-88 MCH-29.9
MCHC-33.8 RDW-13.9 Plt ___ Neuts-82.2* Lymphs-13.2* Monos-3.3
Eos-0.8 Baso-0.4
Glucose-151* UreaN-19 Creat-2.7* Na-136 K-3.5 Cl-96 HCO3-28
AnGap-16
ALT-38 AST-35 LD(LDH)-203 AlkPhos-57 TotBili-0.3 Lipase-45
Lactate-1.1
.
On discharge ___ 11:00AM)
WBC-10.7 RBC-3.50* Hgb-10.5* Hct-30.7* MCV-88 MCH-30.0 MCHC-34.3
RDW-14.2 Plt ___
Glucose-138* UreaN-33* Creat-3.9*# Na-135 K-3.5 Cl-98 HCO3-27
AnGap-14
.
DIAGNOSTICS:
CT ABD & PELVIS W/O CONTRAST ___ IMPRESSION:
1. No acute intra-abdominal process, although complete
evaluation is limited by lack of IV contrast. No bowel
obstruction. Fluid within small and large bowel is non-specific
but could be seen with mild ileus or enteritis.
2. Aortobifemoral bypass, incompletely evaluated on this
noncontrast study.
3. Dense coronary artery calcifications.
.
CHEST (PA & LAT) ___ IMPRESSION: Findings suggesting minor
left basilar atelectasis without definite evidence for
pneumonia.
Medications on Admission:
AMLODIPINE
CARVEDILOL
CLOPIDOGREL
FLUNISOLIDE
FOLIC ACID
GABAPENTIN
ISOSORBIDE MONONITRATE
LACTULOSE
OMEPRAZOLE
ROSUVASTATIN
TEMAZEPAM
ASPIRIN
CALCIUM ACETATE
POLYETHYLENE GLYCOL
Discharge Medications:
1. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
2. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. flunisolide 25 mcg (0.025 %) Spray, Non-Aerosol Sig: Two (2)
sprays each nostril Nasal twice a day.
5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
7. gabapentin 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO at bedtime.
9. lactulose 10 gram/15 mL (15 mL) Solution Sig: Fifteen (15) mL
PO once a day.
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
11. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
12. temazepam 15 mg Capsule Sig: One (1) Capsule PO at bedtime.
13. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
14. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual every 5 min PRN as needed for chest pain.
15. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
16. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS). Capsule(s)
17. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed for pain.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Viral syndrome
Secondary diagnosis:
ESRD on HD
CAD
gout
hyper cholesterolemia
HTN
Spinal stenosis
PVD s/p aortobifemoral bypass
s/p appendectomy
s/p cholecystectomy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPHS
HISTORY: Prior pneumonia and feeling poorly.
COMPARISONS: ___.
TECHNIQUE: Chest, PA and lateral.
FINDINGS: The patient is status post coronary artery bypass graft surgery. A
dual-lead pacemaker/ICD device appears in a similar position. The cardiac,
mediastinal and hilar contours appear unchanged, allowing for differences in
technique. The lung volumes are very low. Particularly in that setting,
minimal left basilar opacities are probably associated with minor atelectasis.
The lungs appear otherwise clear. There is no pleural effusion or
pneumothorax. The bones are probably demineralized to some degree.
IMPRESSION: Findings suggesting minor left basilar atelectasis without
definite evidence for pneumonia.
Radiology Report
CLINICAL HISTORY: ___ man with distended abdomen and chest x-ray
evidence of dilated bowel. Evaluate for obstruction or other intra-abdominal
pathology. Patient has ESRD and is on hemodialysis.
COMPARISON: CT L-SPINE ___.
TECHNIQUE: MDCT-acquired axial images from the lung bases to the pubic
symphysis were displayed with 5-mm slice thickness without oral or intravenous
contrast. Intravenous contrast was not administered due to patient's
creatinine of 2.7.
CT ABDOMEN: The visualized lung bases demonstrate mild dependent bibasilar
atelectasis. There is a small fat-containing left Bochdalek hernia. There is
no pleural or pericardial effusion. Dense atherosclerotic calcifications are
seen in the coronary arteries. Pacemaker lead ends in the expected locations
of the right atrium and right ventricle.
CT ABDOMEN: Evaluation of the intra-abdominal organs is limited without
intravenous contrast. The liver, spleen and bilateral adrenal glands are
normal. The gallbladder is not visualized. The pancreas is atrophic but
otherwise normal. The kidneys are atrophic with renal artery calcifications
compatible with patient's known end stage renal disease. There is no
hydronephrosis or stone identified. A 3.2 x 3.0 cm hypodensity in the right
interpolar region is consistent with a simple cyst.
There is fluid within the mildly prominent small bowel and colon but without
bowel wall thickening or bowel obstruction. A 6 mm hypodensity in the third
part of the duodenum has fat attenuation consistent with small lipoma (2:39).
Dense atherosclerotic calcifications are seen in the normal caliber native
aorta with an aortobifemoral bypass, the patency of which cannot be assessed
without IV contrast. No pathologically enlarged mesenteric or retroperitoneal
lymph nodes are identified. There is no free fluid and no free air.
CT PELVIS: The rectum, sigmoid, bladder, prostate, and seminal vesicles are
normal. There is no free fluid and no pelvic or inguinal lymphadenopathy.
BONE WINDOWS: No bone finding suspicious for infection or malignancy is seen.
Degenerative changes in the lower lumbar facet joints are noted. Grade 1
anterolisthesis of L4 on L5 is unchanged from ___.
IMPRESSION:
1. No acute intra-abdominal process, although complete evaluation is limited
by lack of IV contrast. No bowel obstruction. Fluid within small and large
bowel is non-specific but could be seen with mild ileus or enteritis.
2. Aortobifemoral bypass, incompletely evaluated on this noncontrast study.
3. Dense coronary artery calcifications.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: HYPOTENSION
Diagnosed with OTHER MALAISE AND FATIGUE, SYNCOPE AND COLLAPSE, DIARRHEA, HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE, END STAGE RENAL DISEASE, DIABETES UNCOMPL ADULT, HYPERCHOLESTEROLEMIA
temperature: 97.9
heartrate: 76.0
resprate: 16.0
o2sat: 100.0
sbp: 168.0
dbp: 75.0
level of pain: 0
level of acuity: 2.0 | ___ M hx of ESRD on HD, HTN, CAD s/p CABG presenting with
fatigue in the setting of 1 week of loose stool.
.
# FATIGUE: During PCP evaluation patient blood pressure was
110/80 which was evaluated as a relative hypotension given
patient's baseline. There was concern for endovascular infection
given recent cannulation of AVG a week prior. However, cultures
from dialysis 4d before admission were neg. As patient had poor
PO intake and loose stools, it is likely the cause of the
relative hypotension was secondary to low intravascular volume.
Amlodipine was held overnight and patient received IVF. Blood
pressure was 130-160s during his admission. Patient measures
blood pressure at home as was instructed to hold amlodipine if
systolic pressure was below 120. Patient will see his primary
care doctor on the day after discharge. Patient's main complaint
of fatigue and poor appetite coincided with loose stools for 5
days. Patients white count was elevated on admission to 12.6.
Abdominal CT scan did not show any acute abnormalities. No
evidence of colitis. Guaiac negative. LFTs, lipase, and lactate
were within normal limits. Symptoms were likely due to a viral
syndrome. ___ normalized and patient tolerated a full breakfast
and felt much improved on the day of discharge. Patient will
receive physical therapy at home.
.
# ESRD: Patient HD scheduled is ___ at ___
___. Patient will return to HD on the day after discharge.
Will continue Calcium acetetate for phosphate binding.
.
#ANEMIA: Likely of chronic disease. Stable from prior. Will
follow-up with primary care doctor within ___ week of discharge.
.
# CAD: s/p CABG Aspirin and beta blocker and statin were
continued.
.
# PVD s/p AORTOBIFEMORAL BYPASS: Distal pulses were intact on
exam. Aspirin and plavix were continued.
.
# DM2: Diet controlled.
.
# Chronic pain/spinal stenosis: Gabapentin and tylenol were
continued.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Right hip pain
Major Surgical or Invasive Procedure:
Right hip CRPP ___ ___
History of Present Illness:
___ female with no pertinent PMH who presents status
post fall. Reports had taken a shower this morning and had
gotten out to use a towel. Reports fell onto her right side,
predominantly right elbow. Denies headstrike, LOC. Denies any
blood thinners. Patient recalls the entire event. Reports she
lives in independent living and does all her daily activities on
her own. Denies any presyncopal symptoms including headache,
lightheadedness. Denies any chest pain, shortness of breath,
palpitations, abdominal pain. Reports in last year had one other
fall one month ago that was minor with no injuries sustained or
any difficulties afterward. Reports an aching pain in her groin
only with movement or upon standing. Reports she has not walked
since then and when she tries to bear weight there is a strong
ache in her right groin. Reports difficulty lifting the right
leg. Denies any other pain in her RLE.
S/p Right hip CRPP by Dr. ___ on ___.
Past Medical History:
HTN, High Cholesterol
Social History:
___
Family History:
non-contributory
Physical Exam:
General: alert, oriented, responsive, intelligible speech
Chest/Resp: no chest pain, breathing unlabored
Abd:
Right lower extremity:
Incisional dressing c/d/I
SILT distally
Fires TA, ___, ___, FHL
Well-perfused
Pertinent Results:
___ 05:16AM BLOOD WBC-7.7 RBC-3.96 Hgb-10.9* Hct-33.9*
MCV-86 MCH-27.5 MCHC-32.2 RDW-14.0 RDWSD-43.1 Plt ___
___ 05:05AM BLOOD Hct-33.4*
___ 05:16AM BLOOD Glucose-148* UreaN-20 Creat-0.9 Na-143
K-4.4 Cl-102 ___ AnGap-___
Medications on Admission:
OTC miralax, not daily but prn
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
Take around the clock for baseline pain control.
RX *acetaminophen 325 mg 2 tablet(s) by mouth 5 times daily
while awake Disp #*150 Tablet Refills:*1
2. Docusate Sodium 100 mg PO BID
Take as directed to prevent constipation. Hold for diarrhea or
loose stools.
RX *docusate sodium 100 mg 2 capsule(s) by mouth twice daily
Disp #*56 Capsule Refills:*0
3. Enoxaparin Sodium 30 mg SC QPM
Use daily for 4 weeks post-operatively to prevent blood clots.
RX *enoxaparin 30 mg/0.3 mL 1 syringe subcutaneous every evening
Disp #*25 Syringe Refills:*0
4. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain
Don't take before or while driving, operating machinery, or with
alcohol, sedatives, or hypnotics.
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours as
needed Disp #*30 Tablet Refills:*0
5. Senna 8.6 mg PO DAILY
Take as directed to prevent constipation. Hold for diarrhea or
loose stools.
RX *sennosides 8.6 mg 2 tablets by mouth every evening Disp #*28
Tablet Refills:*0
6. Vitamin D 800 UNIT PO DAILY
Take as directed to improve bone health.
RX *ergocalciferol (vitamin D2) 400 unit 2 tablet(s) by mouth
daily Disp #*120 Tablet Refills:*1
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right femoral neck fracture
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: ___ s/p fall// r/o intracranial bleed, fracture
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 17.1 cm; CTDIvol = 47.0 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of acute hemorrhage,edema,or mass. There is prominence
of the ventricles and sulci suggestive of involutional changes. Confluent
periventricular and subcortical white matter hypodensities are nonspecific,
however likely due to chronic small vessel ischemic disease in this age group.
There is a discrete area of hypodensity and encephalomalacia with mild ex
vacuo dilatation of the occipital horn of the right ventricle in right
parieto-occipitaloccipital lobe, likely representing an old infarct.
Otherwise, there is no evidence of acute infarct.
There is no evidence of acute fracture. There is diffuse mucosal thickening
of the ethmoid air cells. The visualized portion of the remaining paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. Patient is
status post bilateral lens replacements. Otherwise, the visualized portion of
the orbits are unremarkable. Carotid siphon calcifications are moderate.
Degenerative changes of the left TMJ is severe with mild anterior and lateral
subluxation of the condylar head, which is in bone-on-bone contact with the
anterior glenoid fossa.
IMPRESSION:
1. No acute hemorrhage.
2. Evidence of an old infarct in the right parieto-occipital lobe. Otherwise,
no evidence of territorial infarct.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: History: ___ s/p fall// r/o intracranial bleed, fracture
r/o intracranial bleed, fracture
TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.2 s, 20.3 cm; CTDIvol = 22.6 mGy (Body) DLP = 457.6
mGy-cm.
Total DLP (Body) = 458 mGy-cm.
COMPARISON: None.
FINDINGS:
There is 2 mm anterolisthesis of C 2 on C3 and 2 mm retrolisthesis of C3 on C4
and 3 mm anterolisthesis of C7 on T1. There is no acute fracture, though
evaluation is mildly limited due to diffuse osteopenia. Multilevel
degenerative changes are noted throughout the cervical spine with loss of
vertebral body height and disc spaces, worst at C4 through C7. Large anterior
osteophyte is noted at C5-6. Neural foramina and spinal canal narrowing is
mild-to-moderate throughout the cervical spine, most notable at C3-4, C4-5,
C5-6 and C6-7 due to posterior osteophyte, loss of disc spaces and disc bulge,
resulting in moderate to moderate neural foraminal and spinal canal narrowing
at those levels. There is no prevertebral soft tissue swelling. There is
minimal periapical lucency around the right mandibular posterior molar. The
imaged lung apices are clear. The thyroid gland is grossly unremarkable.
IMPRESSION:
1. Mild anterolisthesis and retrolisthesis of the cervical spine as described
above. No prevertebral swelling. No acute fracture, though evaluation is
mildly limited due to diffuse osteopenia.
2. Moderate degenerative changes of the cervical spine, resulting in moderate
spinal canal and neural foraminal narrowing as described above.
Radiology Report
EXAMINATION: ELBOW (AP, LAT AND OBLIQUE) RIGHT
INDICATION: History: ___ s/p fall// r/o intracranial bleed, fracture
r/o intracranial bleed, fracture
TECHNIQUE: Three views of the right shoulder.
COMPARISON: Radiograph from ___
FINDINGS:
No acute fractures or dislocations are seen. Joint spaces are preserved
without significant degenerative changes. No joint effusion is seen. No soft
tissue calcifications or radiopaque foreign bodies are detected.
IMPRESSION:
No acute fracture or dislocation.
Radiology Report
EXAMINATION: HIP UNILAT MIN 2 VIEWS RIGHT
INDICATION: History: ___ s/p fall// r/o intracranial bleed, fracture
TECHNIQUE: Frontal view radiograph of the pelvis with additional frontal and
frog-leg lateral views of the right hip.
COMPARISON: None.
FINDINGS:
Evaluation for fine detail is markedly limited due to diffuse osteopenia.
Within these limits, there is no acute displaced fracture or dislocation.
Degenerative changes of the hip joints are severe on the right. There is
evidence of moderate degenerative changes on the left on the limited frontal
view. There is no suspicious lytic or sclerotic lesion. There is no soft
tissue calcification or radio-opaque foreign body. Evaluation of the sacrum
is limited due to overlying bowel gas. Large amount of stool is seen within
the rectum. There are vascular calcifications.
IMPRESSION:
Limited evaluation due to diffuse osteopenia. No displaced fractures or
dislocation.
Radiology Report
EXAMINATION: CT pelvis without contrast
INDICATION: History: ___ s/p fall with hip pain// R hip 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 5.6 s, 27.6 cm; CTDIvol = 24.7 mGy (Body) DLP = 682.2
mGy-cm.
Total DLP (Body) = 682 mGy-cm.
COMPARISON: Pelvic radiograph from ___.
FINDINGS:
BONES AND SOFT TISSUES: There is a minimally displaced subcapital right
femoral fracture. Degenerative changes of the bilateral hip joints are mild
with marginal spurring. A small right femoroacetabular joint effusion is
noted. There is soft tissues the ending super adjacent to the right greater
trochanter, posttraumatic. No drainable fluid collection. Left gluteal
calcified granuloma noted.
PELVIS: There is a large amount a fecal material in the rectum. No
significant fat stranding, however the wall of the rectum is mildly thickened.
There is no free fluid in the pelvis. Changes of partial right hemicolectomy
are noted.
REPRODUCTIVE ORGANS: Patient is status post hysterectomy.
LYMPH NODES: There is no pelvic lymphadenopathy.
VASCULAR: Extensive atherosclerotic disease is noted.
IMPRESSION:
Minimally displaced subcapital right femoral fracture and sequela of trauma as
above. No hip dislocation.
Large amount of fecal material in the rectum with mild wall thickening,
however without soft tissue stranding. Please correlate with clinical
findings of stercoral colitis.
NOTIFICATION: The findings were discussed with ___, M.D. by ___,
M.D. on the telephone on ___ at 12:18 pm, 2 minutes after discovery of
the findings.
Radiology Report
EXAMINATION: MR HIP ___ CONRAST RIGHT
INDICATION: ___ year old woman with right hip pain and CT c/f possible
fracture// fracture?
TECHNIQUE: Multiplanar multisequence MRI of the right hip was performed
without the IV administration of contrast material using routine hip MR
protocol.
COMPARISON: CT ___.
FINDINGS:
Bones: Curvilinear STIR hyperintensity and corresponding T1 hypointensity in
the subcapital region of the right proximal femur is consistent with a
nondisplaced, likely minimally impacted fracture. There is a small right hip
effusion.
Mild degenerative changes of the bilateral hips. There is slight leftward
curvature of the partially visualized lumbar spine. There are mild to
moderate degenerative changes of the partially visualized lower lumbar spine.
Soft tissues: Small amount of susceptibility artifact along the ventral lower
abdominal wall corresponds with metal seen on prior CT and likely is due to
prior hernia repair.
Moderate to large amount of stool is seen throughout the visualized colon,
particularly in the rectum. No definite surrounding stranding.
Mild-to-moderate amount of subcutaneous edema overlying the lateral aspect of
the right greater trochanter as well as mild amount of edema of the gluteus
maximus overlying the right greater trochanter is likely due to contusion.
IMPRESSION:
1. Nondisplaced, likely minimally impacted subcapital fracture of the right
femoral neck.
2. Soft tissue edema pattern along the right greater trochanter, consistent
with contusion.
3. Small right hip joint fluid, likely reactive to injury.
4. Moderate to large amount of stool is seen throughout the visualized colon,
particularly in the rectum. Diverticulosis without evidence of diverticulitis.
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: ___ with s/p fall.// preop
COMPARISON: Prior from ___
FINDINGS:
AP upright and lateral views of the chest provided.
Patient is leftward rotated limiting assessment. Allowing for this, the lungs
are clear. No large effusion or pneumothorax. Aortic calcification again
noted. A contour abnormality at the right heart border on prior exam is not
clearly seen on today's study likely due to patient rotation. Subtle
angulation of the right tenth rib along the posterolateral arch may reflect an
old injury though not definitively seen on prior. Please correlate for focal
pain.
IMPRESSION:
As above.
Radiology Report
EXAMINATION: HIP UNILAT MIN 2 VIEWS RIGHT
INDICATION: Right hip percutaneous pinning
TECHNIQUE: Fluoroscopic assistance provided to the clinician in the OR
without the radiologist present. 10 spot views obtained. Fluoro time
recorded as 67.6 seconds. Fluoro data sheet indicates right hip.
COMPARISON: Right hip radiographs from ___. Targeted review of
hip CT and hip MRI from ___
FINDINGS:
Views demonstrate steps related to percutaneous ORIF of a right femoral neck
fracture.
IMPRESSION:
Correlation with real-time findings and, when appropriate, conventional
radiographs is recommended for further assessment.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R Elbow pain, R Hip pain, s/p Fall
Diagnosed with Unsp intracapsular fracture of right femur, init for clos fx, Fall same lev from slip/trip w/o strike against object, init
temperature: 97.4
heartrate: 87.0
resprate: 18.0
o2sat: 97.0
sbp: 210.0
dbp: 78.0
level of pain: 1
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 Right femoral neck fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for Right hip CRPP, which the patient
tolerated well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications by POD#1.
The patient was given ___ antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to rehab was appropriate.
The ___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
WBAT in the Right lower extremity, and will be discharged on
Lovenox 30mg sc qpm for DVT prophylaxis. The patient will follow
up with Dr. ___ routine. A thorough discussion was had
with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ h/o advanced Alzheimer's dementia, hyperparathyroidism,
multinodular goiter, and HTN presents with fall.
History obtain from daughter, ___, and review of medical
record due to mental status.
Her daughter notes a decline over the past ___ weeks. She has
been weaker than usual. She is generally able to walk to the
restroom with her walker, but she has been having more
difficulty
with this. She has also been eating less than usual, though at
baseline she does not eat very much. Last night, her daughter
put
her to bed. A few hours later, she heard a "thump" and entered
her mother's bedroom finding her on the ground. She was
conscious
and noting pain in her head. EMS was called and she came to the
ED.
In the ED, BP initially 92/60 with HR: 60. Labs showed no
leukocytosis, BMP showed BUN: 30, Cr:1, Ca: 11.3 --> 10.2 with
fluids. Tox negative. UA showing moderate blood, 100 protein, 10
ketone, 20 RBC, >182 WBC, few bacteria. Exam showed scalp
hematoma. Imaging included head and neck CT as well as CXR
without acute abnormality. She received CTX, 1L NS, 1L LR.
When I saw her she was sleeping, but arousable. She did not
appear in distress.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
Dementia
Hyperparathyroidism
Osteoporosis
HTN
HLD
Social History:
___
Family History:
Reviewed and found to be not relevant to this
illness/reason for hospitalization.
Physical Exam:
HEENT: Anicteric, eyes conjugate, MMM, no JVD
Cardiovascular: RRR no MRG, nl. S1 and S2
Pulmonary: Lung fields clear to auscultation throughout
Gastroinestinal: Soft, non-tender, non-distended, bowel sounds
present, no HSM
MSK: No edema
Skin: No rashes or ulcerations evident
Neurological: Alert, interactive, speech fluent, face symmetric,
moving all extremities
Psychiatric: pleasant, appropriate affect
Pertinent Results:
Admission Labs
___ 01:31AM BLOOD WBC-8.5 RBC-4.81 Hgb-14.2 Hct-43.4 MCV-90
MCH-29.5 MCHC-32.7 RDW-15.3 RDWSD-50.0* Plt ___
___ 01:31AM BLOOD Glucose-101* UreaN-30* Creat-1.0 Na-142
K-4.7 Cl-105 HCO3-23 AnGap-14
___ 01:31AM BLOOD Albumin-3.1* Calcium-11.3* Phos-2.7
Mg-1.9
___ 02:05AM BLOOD Lactate-1.6
___ 2:40 am BLOOD CULTURE
Blood Culture, Routine (Preliminary):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
Reported to and read back by ___ (___)
@12:10
(___).
IMPRESSION:
No previous images. There is moderate degenerative change
symmetrically
involving the hip joints. No evidence of acute fracture.
However, if an
occult fracture is a serious clinical concern, MRI could be
obtained.
Of incidental note is a small calcified fibroid in the lower
pelvis.
IMPRESSION:
No previous images. There is moderate degenerative change
symmetrically
involving the hip joints. No evidence of acute fracture.
However, if an
occult fracture is a serious clinical concern, MRI could be
obtained.
Of incidental note is a small calcified fibroid in the lower
pelvis.
IMPRESSION:
1. No evidence for an acute intracranial abnormality or
displaced fracture.
2. Trace fluid versus mild dependent mucosal thickening in the
left sphenoid
sinus, and small focus of aerosolized secretions in the right
sphenoid sinus.
Please correlate with any associated inflammatory symptoms.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cyanocobalamin 1000 mcg PO DAILY
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
3. budesonide-formoterol 160-4.5 mcg/actuation inhalation BID
4. Sertraline 25 mg PO DAILY
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice
a day Disp #*10 Tablet Refills:*0
2. Neutra-Phos 2 PKT PO TID Duration: 6 Doses
RX *potassium, sodium phosphates [Phos-NaK] 280 mg-160 mg-250 mg
2 powder(s) by mouth twice a day Disp #*18 Packet Refills:*0
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
4. budesonide-formoterol 160-4.5 mcg/actuation inhalation BID
5. Cyanocobalamin 1000 mcg PO DAILY
6. Sertraline 25 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
#UTI
#Hypovolemia
#Hypernatremia
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 radiograph
INDICATION: History: ___ with fall with ams// CVA ? fracture ? acute process
? General
TECHNIQUE: Chest PA and lateral
COMPARISON: Multiple prior examinations, most recent from ___
FINDINGS:
Examination is moderately limited due to significant patient rotation.
Overall, density in the medial right hemithorax likely represents mediastinal
structures, which are unchanged compared to prior, although patient rotation
limits evaluation of this region. There is persistent tortuosity of the
descending aorta. Cardiac silhouette is unchanged in size. There is no
definite focal consolidation. Density overlying the right hilus likely
represents pulmonary vasculature. No pneumothorax or pleural effusion.
IMPRESSION:
Moderately limited examination due to patient rotation. No definite focal
consolidation identified. Evaluation of the mediastinum is limited. Density
along the medial aspect of the right hemithorax represents unchanged
mediastinal structures. Repeat chest radiograph can be considered if
clinically appropriate.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ status post fall with altered mental status.
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: MRI of the head from ___
FINDINGS:
Exam is mildly to moderate limited by motion artifact and patient head tilt.
There is no evidence acute hemorrhage, edema, or acute major vascular
territorial infarction. Ventricles and sulci are prominent consistent with
age-related global parenchymal loss. Periventricular, subcortical, and deep
white matter hypodensities are nonspecific, but likely represent sequela of
chronic microvascular ischemic disease in this age group.
No displaced fracture is seen allowing for motion artifact. The orbits appear
grossly unremarkable. There is mild mucosal thickening in the ethmoid air
cells. There is a small mucous retention cyst in the left maxillary sinus,
image 301:12. There is mild mucosal thickening and small mucous retention
cysts in the right maxillary sinus. Right maxillary sinus walls are mildly
thickened and sclerotic, indicating sequela of chronic inflammation. There is
trace fluid versus mild dependent mucosal thickening in the left sphenoid
sinus. There is a small focus of aerosolized secretions in the right sphenoid
sinus.
IMPRESSION:
1. No evidence for an acute intracranial abnormality or displaced fracture.
2. Trace fluid versus mild dependent mucosal thickening in the left sphenoid
sinus, and small focus of aerosolized secretions in the right sphenoid sinus.
Please correlate with any associated inflammatory symptoms.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: History: ___ status post fall with altered mental status.
Evaluate for cervical spine fracture.
TECHNIQUE: Non-contrast helical multidetector CT of the cervical spine was
performed. Soft tissue and bone algorithm images were generated. Coronal and
sagittal reformations were then constructed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.6 s, 18.2 cm; CTDIvol = 25.1 mGy (Body) DLP = 455.8
mGy-cm.
Total DLP (Body) = 456 mGy-cm.
COMPARISON: No relevant comparison is identified
FINDINGS:
Streak artifact from dental amalgam limits evaluation at the level of C2. The
bones are demineralized. No acute displaced fracture is seen. C3 through C7
vertebral bodies demonstrate mild diffuse loss of height, without evidence for
acute fracture lines. T2 vertebral body demonstrates mild to moderate loss of
height with sclerosis along the superior endplate, which may be secondary to
subacute or chronic fracture. No evidence for prevertebral soft tissue
swelling. Minimal anterolisthesis of C6 on C7 and of C7 on T1 is most likely
degenerative, with associated disc space narrowing. Mild dextroconvex
curvature of the cervical spine is also noted. Disc protrusions and endplate
osteophytes indent the thecal sac at multiple levels. There appears to be
mild to moderate spinal canal narrowing at C4-C5 and C5-C6, and milder spinal
canal narrowing elsewhere. There is also multilevel neural foraminal
narrowing by uncovertebral and facet osteophytes.
0.8 x 0.5 cm irregularly-shaped sclerotic focus in the left aspect of the C7
vertebral body, image 601:13, is nonspecific but compatible with a bone
island.
Concurrent head CT is reported separately. There are several circumscribed
right thyroid nodules versus cysts, up to 0.8 cm on image 301:51, superimposed
upon underlying heterogeneity of the right thyroid lobe. No concerning
abnormalities at the included lung apices.
IMPRESSION:
1. No evidence for an acute displaced fracture.
2. T2 vertebral body mild-to-moderate loss of height with sclerosis along the
superior endplate, which may be subacute or chronic.
3. Minimal anterolisthesis of C6 on C7 and of C7 on T1 is most certainly
degenerative, though there are no comparison exams to confirm chronicity.
4. Multilevel degenerative disease.
5. 0.8 cm sclerotic focus in the left C7 vertebral body is nonspecific but
compatible with a bone island. However, if there is a clinical concern for
sclerotic metastasis, then further evaluation may be performed by cervical
spine MRI with and without contrast versus nuclear medicine bone scan.
6. Heterogenous right thyroid lobe with nodules versus cysts measuring up to
0.8 cm. ACR guidelines do not recommend sonographic evaluation of nodules
smaller than 1.5 cm in this age group.
RECOMMENDATION(S): 0.8 cm sclerotic focus in the left C7 vertebral body is
nonspecific but compatible with a bone island. However, if there is a clinical
concern for sclerotic metastasis, then further evaluation may be performed by
cervical spine MRI with and without contrast versus nuclear medicine bone
scan.
Radiology Report
EXAMINATION: BILAT HIPS (AP, LAT, AND PELVIS) 5 OR MORE VIEWS
INDICATION: ___ year old woman with fall// hip fracture
IMPRESSION:
No previous images. There is moderate degenerative change symmetrically
involving the hip joints. No evidence of acute fracture. However, if an
occult fracture is a serious clinical concern, MRI could be obtained.
Of incidental note is a small calcified fibroid in the lower pelvis.
Gender: F
Race: WHITE - RUSSIAN
Arrive by AMBULANCE
Chief complaint: Altered mental status, s/p Fall
Diagnosed with Urinary tract infection, site not specified
temperature: 96.9
heartrate: 64.0
resprate: 16.0
o2sat: 100.0
sbp: 103.0
dbp: 64.0
level of pain: 0
level of acuity: 2.0 | ___ h/o Alzheimer's dementia, hyperparathyroidism, multinodular
goiter, HTN presents with fall.
#Fall
Suspect in the setting of UTI and hypovolemia. No evidence of
intracranial process. she had a CTA head and neck which were
negative for acute process. No current sequelae from her fall.
___ worked closely with her and recommended rehab.
#GPC Bacteremia
___ blood cultures grew coag negative staph. She was initially
treated with vancomycin until GPCs speciated. At this time very
likely a contaminate given she had already rapidly improved
prior to being treated with vancomycin. Subsequent blood
cultures were negative
#UTI
Presenting with positive UA. Was treated with ceftriaxone and
transitioned to ciprofloxacin to complete a 7 day course. Her
urine culture was contaminated.
#Hypovolemia
#Hypernatremia
completely resolved with IV fluids.
#Toxic Metabolic Encephalopathy
#Dementia
Initially altered. Head CT without acute abnormality. With
treatment of UTI and IVF rapidly improved to baseline.
#Incidental finding
0.8 cm sclerotic focus in the left C7 vertebral body is
nonspecific but compatible with a bone island. However, if there
is a clinical
concern for sclerotic metastasis, then further evaluation may be
performed by
cervical spine MRI with and without contrast versus nuclear
medicine bone
scan. Can discuss further with her PCP.
>30 minutes were spent on complex discharge |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Clindamycin
Attending: ___.
Chief Complaint:
dyspnea on exertion
Major Surgical or Invasive Procedure:
___ Catheterization for EKOS insertion
History of Present Illness:
This is a ___ w/hx of hypothyroidism and peripheral neuropathy,
presenting to ___ w/new onset SOB, found to have
extensive bilateral PEs and residual left lower extremity DVT.
Pt states that she has been in her USOH recently, though she
notes that on ___ she had several bouts of dyspnea and
diaphoresis w/exertion. Today, she went to the ___ for a
scheduled Ortho appt for hip arthritis, says she had extensive
SOB and diaphoresis just w/walking from her car to her appt.
First went straight to the ED, noted a long wait, went to her
Ortho appt and then returned to the ED as she was still very
SOB. In the ED, she had a CT-A that showed extensive bilateral
PEs, and was transferred to ___ for further management.
Pt normally has exercise tolerance of ___ mile and 3 flights of
stairs, though also w/concurrent hip arthritis which limits her
physical activity. Was at the gym earlier this week and did her
usual swimming and treadmill exercises. Pt denies any recent
long plane/bus trips though she does commute frequently from the
___, and was in the car for over an hour on ___. No hx of
bleeding/clotting problems.
Pt notes that she had some diarrhea on ___ which resolved
w/immodium, no recent Abx use. Denies F/C/NS, dysuria, URI Sx,
chest pain, LH/dizziness, orthopnea, N/V/C.
At ___, pt rec'd IV heparin and Ativan for anxiety. Was
found to have Troponin 0.08, Ddimer 3207, pBNP 5275, WBC 13.7,
Na 148, K 5.8, Cr 1.1, AG 32.
In the ___ ED, initial vitals were: 97.5 106 124/58 18 96% RA
Exam: dyspnea on exertion
Labs: WBC 11.5, therapeutic PTT, K 5.2, bicarb 16, AG 15, Trop
.07, BNP 4800, lactate 1.5
Imaging: ___ in the Lt femoral vein
Consults: MASCOT-c/w heparin IV, admit to CCU, vascular surgery
to be consulted
Patient was given: heparin IV
Decision was made to admit to CCU for close monitoring
Vitals on transfer were: 97.9 105 140/94 18 96% NC
On the floor, patient reports being mildly agitated w/dyspnea on
exertion, had a non-bloody loose BM in the ED before admission
Of note,
REVIEW OF SYSTEMS:
(+) per HPI
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Denies any prior history of stroke, TIA, deep venous thrombosis,
pulmonary embolism, bleeding at the time of surgery, myalgias,
joint pains, cough, hemoptysis, black stools or red stools.
Denies recent fevers, chills or rigors. Denies exertional
buttock or calf pain. All of the other review of systems were
negative.
Past Medical History:
HYPOTHYROIDISM
PERIPHERAL NEUROPATHY
RIGHT HIP OSTEOARTHRITIS
Social History:
___
Family History:
No hx of bleeding/clotting
Physical Exam:
ADMISSION EXAM:
===============
VS: T=97.8 BP=114/78 HR=119 RR=17 O2 sat=96% 2L NC
GEN: Pleasant, mildly irritable, overweight female
HEENT: No conjunctival pallor. No icterus. MMM. OP clear. PERRL.
EOMI.
NECK: Supple, No LAD. JVP wnl
CV: Tachycardic. normal S1,S2. No murmurs, rubs, clicks, or
gallops
LUNGS: CTABL. No wheezes, rales, or rhonchi.
ABD: +BS. Soft, NT/ND. No HSM.
EXT: WP, NO Clubbing/cyanosis. Full distal pulses bilaterally.
Mild 1+ ___ edema b/l. Lt post knee/thigh warm. Hands/feet mildly
cold.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. CN ___ grossly intact. Decreased light touch
sensation in ___. ___ strength throughout. Normal coordination.
Gait assessment deferred.
DISCHARGE EXAM:
===============
VS: Tm 98.6 BP 131/90 (129-143/81-96) HR 92-105, RR 20 92%RA
Tele: sinus tachycardia, rare pacs
GEN: Pleasant woman, NAD
HEENT: No conjunctival pallor. No icterus. MMM. OP clear. PERRL.
EOMI.
NECK: Supple, No LAD. JVP wnl
CV: Tachycardic. normal S1,S2. No murmurs, rubs, clicks, or
gallops
LUNGS: CTABL. No wheezes, rales, or rhonchi.
ABD: +BS, soft non tender
EXT: WP, NO Clubbing/cyanosis. Full distal pulses bilaterally.
Mild 1+ ___ edema b/l.
NEURO: A&Ox3. CN ___ grossly intact. Normal gait
Pertinent Results:
ADMISSION LABS:
===============
___ 06:10PM BLOOD WBC-11.5* RBC-4.30 Hgb-12.3 Hct-38.3
MCV-89 MCH-28.6 MCHC-32.1 RDW-13.8 RDWSD-45.1 Plt ___
___ 06:10PM BLOOD Neuts-62.5 ___ Monos-14.1*
Eos-1.8 Baso-0.7 Im ___ AbsNeut-7.17* AbsLymp-2.36
AbsMono-1.62* AbsEos-0.21 AbsBaso-0.08
___ 06:10PM BLOOD ___ PTT-78.7* ___
___ 06:10PM BLOOD Glucose-105* UreaN-15 Creat-1.0 Na-134
K-5.2* Cl-103 HCO3-16* AnGap-20
___ 06:10PM BLOOD cTropnT-0.07*
___ 06:10PM BLOOD proBNP-47___*
___ 01:00AM BLOOD Lactate-1.5
MICRO:
======
C Diff (___): Negative
MRSA Screen (___): Negative
IMAGING:
========
CT-PA (___):
Intraluminal thrombus in both main pulmonary arteries extending
into
bilateral lower, upper and middle lobe segmental pulmonary
arteries.
No saddle embolus identified. Thoracic aorta enhances
homogeneously
without evidence of aneurysm or dissection. Focal right middle
lobe
opacity, nonspecific may represent atelectasis and/or sequela of
pulmonary infarct. Minimal right lower lobe atelectasis
(superior
segment). Lungs are otherwise clear. No pleural effusions.
Normal
heart size. Trace pericardial effusion. Small hiatal hernia in
the
central lower chest.
Adrenal glands are normal. 4.5 cm area of low density in the
right
hepatic lobe, nonspecific. ? Hemangioma. No other lesion
identified in
the visualized liver.
Impression: Extensive bilateral PE.
___ (___)
1. Deep vein thrombosis involving the left femoral vein
extending into the left popliteal and into one of the left
posterior tibial veins.
2. No DVT in right lower extremity veins.
CT-Venogram (___)
1. Filling defect seen within the left superficial femoral vein
and popliteal vein compatible with known DVT. The IVC and iliac
veins appear patent.
2. Inflamed diverticulum in the sigmoid colon may reflect
resolving
diverticulitis in the setting of recent GI symptoms. No free
air or fluid
collection.
3. 9 mm hypodensity in the head of the pancreas, statistically
likely
represents a side-branch IPMN.
4. 4.9 cm hepatic hemangioma
5. Wedge-shaped peripheral ground-glass opacity in the right
middle lobe.
TTE (___)
The left atrium is elongated. The estimated right atrial
pressure is at least 15 mmHg. 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 depressed free wall contractility (RV apical
systolic function is spared suggestive of acute pulmonary
embolism). There is abnormal septal motion/position consistent
with right ventricular pressure/volume overload. The diameters
of aorta at the sinus, ascending and arch levels are normal.
There is no aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. The
tricuspid valve leaflets are mildly thickened. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
IMPRESSION: RV strain.
Cath (___)
U/S facilitated lysis x12 hours
CXR (___)
Comparison to ___. Placement of a device through
the right
internal jugular vein. The tips of the device projects over the
left and
right pulmonary artery is respectively. There is no evidence of
pneumothorax. Moderate cardiomegaly persists. No pleural
effusions. No pneumonia.
CXR (___)
Mild obscuration of the pulmonary vessels can be mild pulmonary
edema. Mild basilar atelectasis.
DISCHARGE LABS:
===============
___ 07:15AM BLOOD WBC-9.5 RBC-4.31 Hgb-12.3 Hct-37.7 MCV-88
MCH-28.5 MCHC-32.6 RDW-13.8 RDWSD-44.8 Plt ___
___ 07:15AM BLOOD ___ PTT-36.0 ___
___ 07:15AM BLOOD Glucose-98 UreaN-9 Creat-0.9 Na-137 K-4.4
Cl-104 HCO3-21* AnGap-16
___ 06:35AM BLOOD LD(LDH)-255*
___ 07:15AM BLOOD Calcium-9.1 Phos-3.9 Mg-1.9
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 150 mcg PO DAILY
2. Gabapentin 600 mg PO DAILY
3. Ibuprofen 400 mg PO Q8H:PRN pain
4. alpha lipoic acid ___ mg oral BID
5. Nortriptyline 20 mg PO QHS
Discharge Medications:
1. Gabapentin 600 mg PO DAILY
2. Levothyroxine Sodium 150 mcg PO DAILY
3. Nortriptyline 20 mg PO QHS
4. alpha lipoic acid ___ mg oral BID
5. Ibuprofen 400 mg PO Q8H:PRN pain
6. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
7. Amlodipine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
8. Warfarin 6 mg PO DAILY16
RX *warfarin 1 mg 6 tablet(s) by mouth daily Disp #*180 Tablet
Refills:*0
9. Outpatient Lab Work
___
ICD 10: ___
PROVIDER THAT WILL FOLLOW UP: ___.
Phone: ___
Fax: ___
10. Enoxaparin Sodium 120 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
-Bilateral Pulmonary Embolism
-Lower Extremity Deep Venous Thrombosis
-Hypertension
Secondary Diagnosis:
-Hypothyrodism
-Peripheral Neuropathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old woman with large bilateral PEs, +tnt and BNP on
heparin, evaluate for DVT.
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility and flow in the left common femoral vein.
There is deep vein thrombosis within the left femoral vein just after the take
off of the greater saphenous vein extending into the popliteal vein and likely
into one of the left posterior tibial veins. The left peroneal veins were not
clearly visualized.
There is normal compressibility, flow, and augmentation of the right common
femoral, femoral, and popliteal veins. Normal compressibility is demonstrated
in the right posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
1. Deep vein thrombosis involving the left femoral vein extending into the
left popliteal and into one of the left posterior tibial veins.
2. No DVT in right lower extremity veins.
Radiology Report
EXAMINATION: CTA ABD AND PELVIS
INDICATION: ___ w/extensive b/l PE and ___ DVT // CT Venogram of
chest/abdomen/pelvis with runoff through b/l extremities to evaluate for clot
burden
TECHNIQUE: Abdomen and pelvis CTA: Non-contrast and multiphasic post-contrast
images were acquired through the abdomen and pelvis.
IV Contrast: 150mL of Omnipaque
Oral contrast was not administered.
MIP reconstructions were performed on independent workstation and reviewed on
PACS.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Spiral Acquisition 25.1 s, 76.7 cm; CTDIvol = 9.6 mGy (Body) DLP = 726.5
mGy-cm.
4) Spiral Acquisition 28.6 s, 76.5 cm; CTDIvol = 22.0 mGy (Body) DLP =
1,657.0 mGy-cm.
Total DLP (Body) = 2,401 mGy-cm.
COMPARISON: Lower extremity ultrasound dated ___ and reference CT
chest dated ___
FINDINGS:
VASCULAR:
There is no abdominal aortic aneurysm. Filling defect is seen within the left
superficial femoral vein extending into the popliteal vein. The iliac veins
and IVC appear patent. There is minimal calcium burden in the abdominal aorta
and great abdominal arteries.
LOWER CHEST: There is a small right nonhemorrhagic pleural effusion which
appears new from 1 day prior. There is bibasilar atelectasis. Ground-glass
wedge-shaped peripheral opacity in the right middle lobe appears similar to
chest CT from 1 day prior likely reflecting evolving pulmonary infarct in the
setting of extensive pulmonary emboli. There is a small hiatal hernia.
ABDOMEN:
HEPATOBILIARY: In segment 7 of the liver there is a 4.9 cm hypodense lesion
demonstrating peripheral nodular discontinuous enhancement compatible with a
hemangioma. The gallbladder demonstrates focal wall thickening at the fundus
possibly representing adenomyomatosis (4:64).
PANCREAS: There is a 9 mm hypodense lesion in the head of the pancreas
(04:54). The pancreatic duct is normal in caliber.
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 are multiple cortical defects bilaterally likely related to old
infectious or ischemic insults. There is no evidence of stones, focal renal
lesions, or hydronephrosis. There are no urothelial lesions in the kidneys or
ureters. There is no perinephric abnormality.
GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall thickness
and enhancement throughout. There is mild inflammation centered around a
diverticulum on the sigmoid colon with thickening of the lateral Conal fascia.
There is no free air or drainable fluid collection. Appendix contains air,
has normal caliber without evidence of fat stranding. 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: Uterus and adnexal regions appear within normal limits.
BONES: Degenerative changes are seen in the lumbar spine.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Filling defect seen within the left superficial femoral vein and popliteal
vein compatible with known DVT. The IVC and iliac veins appear patent.
2. Inflamed diverticulum in the sigmoid colon may reflect resolving
diverticulitis in the setting of recent GI symptoms. No free air or fluid
collection.
3. 9 mm hypodensity in the head of the pancreas, statistically likely
represents a side-branch IPMN.
4. 4.9 cm hepatic hemangioma
5. Wedge-shaped peripheral ground-glass opacity in the right middle lobe.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on
the telephone on ___ at 3:00 ___, 15 minutes after discovery of the
findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with PE w/EKOS catheter placement // interval
changes, signs of pneumothorax interval changes, signs of pneumothorax
IMPRESSION:
Comparison to ___. Placement of a device through the right
internal jugular vein. The tips of the device projects over the left and
right pulmonary artery is respectively. There is no evidence of pneumothorax.
Moderate cardiomegaly persists. No pleural effusions. No pneumonia.
Radiology Report
INDICATION: ___ year old woman with PE w/EKOS catheter placement // s/p EKOS,
interval change, pneumothorax?
TECHNIQUE: Portable semi-upright AP chest
COMPARISON: Chest radiograph ___ and ___
FINDINGS:
Previous device in the right internal jugular vein has been removed. Previous
moderate cardiomegaly is improved now mild. There is no new focal airspace
opacity. Mild bibasilar atelectasis is not significantly changed. There is
no pneumothorax or large pleural effusion. The mediastinal and hilar contours
are normal.
Lobulated soft tissue obscuring the contour of the descending thoracic aorta
and paraspinal line is likely a hiatal hernia.
IMPRESSION:
1. Improved mild cardiomegaly. No pneumothorax.
2. Lobulated soft tissue obscuring the descending thoracic aorta and
paraspinal line is likely hiatal hernia. Recommend attention on followup.
Radiology Report
INDICATION: This is a ___ w/hx of hypothyroidism and peripheral neuropathy,
presenting to ___ ED w/new onset SOB, found to have extensive bilateral
PEs and residual left lower extremity DVT. // Interval change? pulmonary
edema?
FINDINGS:
As compared to chest radiograph from the same day, slight increase in left
basilar opacity, likely worsening atelectasis. Right lower lobe atelectasis
has not substantially changed. Mild obscuration of the pulmonary vessels can
be mild pulmonary edema. No large effusions. Mild moderate cardiomegaly
unchanged.
IMPRESSION:
Mild obscuration of the pulmonary vessels can be mild pulmonary edema. Mild
basilar atelectasis.
Gender: F
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: PE, Dyspnea on exertion, Transfer
Diagnosed with Acute embolism and thrombosis of left popliteal vein, Other pulmonary embolism without acute cor pulmonale
temperature: 97.5
heartrate: 106.0
resprate: 18.0
o2sat: 96.0
sbp: 124.0
dbp: 58.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ w/hx of hypothyroidism and peripheral
neuropathy, who presented to ___ w/new onset SOB,
found to have extensive bilateral PEs and residual left lower
extremity DVT, appeared to be unprovoked, started on an IV
heparin drip, s/p EKOS Catheter w/tPA w/improvement in dyspnea.
# SUBMASSIVE PULMONARY EMBOLISM: Patient was found to have
extensive b/l PE at ___, with mildly elevated Trops and
elevated BNP that have downtrended at ___. She was started on
heparin IV at OSH and continued at ___. The etiology of her
DVT/PEs was unclear and appeared to be unprovoked, though pt had
complained of NS, no large malignancies appeared to be
visualized on imaging. MASCOT team was consulted and the pt was
admitted to CCU for close monitoring. EKOS was initially delayed
as pt appeared to be stable w/o hypotension or large O2
requirement, though she had significant pain w/deep inspiration
and was consistently sinus tachycardic. Vascular Surgery was
consulted, recommended CT-Venogram, which did not show extensive
clot burden apart from the DVT, and recommended no surgical
interventions for DVT. Pt remained tachycardic and was dyspneic
w/only mild exertion, went for Cath on ___ for b/l EKOS
catheter placement w/local tPA administration for 24 hours.
Heparin IV was continued, with Lovenox injections started and pt
was bridged to Coumadin. Pt's dyspnea on exertion and exercise
tolerance were much improved, pt did not desat when walking with
___ and was only mildly tachycardic w/ambulation.
# LEUKOCYTOSIS:
Pt had recent diarrheal episode but no Abx use prior to
admission, no other infxn Sx. She was found to have elevated
WBCs at ___ to 13.7 which downtrended to normal levels at
___. Pt was c/o NS but was afebrile w/o chills. C Diff was
sent, which was negative. Leukocytosis was most likely ___ PE.
CT-V found inflamed sigmoid diverticulum which may have
reflected resolving diverticulitis.
# HTN:
Pt was not on any anti-HTN meds at home, but BPs were up to
160s/100, likely precipitated by acute PE and also anxiety, but
given high persistent BPs, she was started on Lisinopril 10mg
and Amlodipine 5mg with plan for outpatient PCP ___
# Night Sweats/Mild Monocytosis:
The patient presented w/an unprovoked DVT and severe PE, which
can have a paraneoplastic etiology, especially in tumors
w/larger mass/volume. However, there were no other findings
which raised the concern for malignancy. Hem/Onc was consulted
to r/o malignancy. Her recent imaging included CT chest and
abdomen/pelvis, as well as her last colonoscopy and mammography
in ___ which did not raise suspicion for (potential)
malignancy. Pt had elevated LDH to 861 on admission which was
most likely stress related and was close to normalizing to 251
on DC. Pt had pending chromogranin A (diarrhea, HTN, with
possible neuroendocrine etiology) on DC. Will have outpatient
f/u as well as mammogram.
CHRONIC
=======
# Peripheral Neuropathy: Pt's home gabapentin and nortyptiline
were held initially, though these were restarted w/improving
status
# Hypothyroidism: c/w Levothyroxine 150 mcg
====================
TRANSITIONAL:
====================
- Pt started on warfarin 6mg qD with lovenox bridge. Please
recheck INR on ___
- Pt started on amlodipine 5 mg and lisinopril 10 mg for HTN
(SBPs 160-180s) during hospitalization.
- Pt reports 4 month history of drenching night/day sweats. Inpt
heme-onc consulted and felt no acute concern for malignant
process. Please consider further workup as outpt. Please follow
up on chromogrannin A level (in setting of diarrhea, HTN to r/o
NET). CT revealed 9 mm hypodensity in the head of the pancreas
that statistically likely represents a side branch IPMN, please
continue to follow up with non-urgent MRI.
- CXR from ___ with lobulated soft tissue obscuring the
descending thoracic aorta and paraspinal line is likely hiatal
hernia. Please continue to monitor
- CT A/P with 4.9 mm hepatic hemangioma, inflamed diverticulum
in sigmoid colon that may reflect resolving diverticulitis in
setting of recent GI sx. No free air or fluid collection.
- Pt had a dry cough on admission, which continued throughout.
If this continues without improvement, consider changing new
lisinopril to losartan, though cough appeared to start before
ACE-Inhibitor was started.
# Discharge weight: 120.4 kg
# CODE: Full (confirmed)
# CONTACT: ___ (niece): ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
iodine / povidone / erythromycin base / ciprofloxacin /
azithromycin
Attending: ___
Chief Complaint:
Malaise, Shoulder Pain, Palpitations
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is ___ with hx Afib on digoxin and apixiban s/p DCCV
on ___, COPD, HFpEF w/ pulmonary HTN & OSA on 2LO2, DM2, CKD
(b/l Cr 1.2), chronic back pain and gout, who presented from
assisted living facility to ED on ___ with 2 days of
intermittent L shoulder pain and palpitations. The L shoulder
pain had previously been treated with colchicine without
improvement. She reported no increased dyspnea from baseline.
Denied fever/chills.
In the ED, initial vitals notable for HR 120, O2 sat 78% on 2L
NC, other vitals normal. ECG showed sinus tachycardia. On exam,
she was found to have abdominal tenderness and increased girth
from baseline similar to previous CHF exacerbations. She was
also
found to have bilateral ___ erythema with open wound on her L/R?
shin, which was being treated w/ levofloxacin (day4). The
patient
was placed on 6L NC, and O2 sat improved to >95%. She was
transferred to MICU on ___ d/t concern for sepsis and CHF
exacerbation.
In the MICU, wound swab culture from ED returned +Staph growth,
and she was started on IV Vanc and Cefepime on ___. The ___
erythema improved, and abx were switched to PO doxycycline and
cephalexin. Tachycardia resolved with oxycodone for pain. She
was
diuresed -2L with IV lasix, returned to ___ state, and
started on home torsemide. The patient was noted to have
sleepiness and mild strabismus, so home gabapentin and Carafate
were held. She was placed on a trilogy mask at night for
OSA/COPD, and transferred to the floor on ___.
Vitals prior to transfer: 98.1F, 121/78, HR 90, RR 16, 97% on 3L
Upon arrival to the floor, the patient says she has been on 3L
O2
at home since discharge from prior hospitalization on ___.
Currently her shortness of breath is similar to yesterday, and
is
a "little wheezy". She said she had not used albuterol since
admission. She reports a low fever last night (99-101 degF)
that
resolved with Tylenol. She does not think her lower extremity
cellulitis has improved from admission. Endorses continued joint
pain in fingers and left shoulder attributed to gout - rated
___ now compared to ___ on admission. Reports that oxycodone
helps with the pain temporarily. Left shoulder movement limited
due to pain. Currently, denies fever/chills, palpitations.
Past Medical History:
HFpEF (ECHO ___ showed EF 66%)likely secondary to untreated OSA
and COPD
COPD
OSA
Atrial fibrillation s/p cardioversion
Crohn's disease
DVT (deep venous thrombosis)
DM (diabetes mellitus), type 2 with neurological complications
Gout
Chronic low back pain
Obesity (BMI ___
Iron deficiency anemia
Hyperlipidemia
DJD (degenerative joint disease)
Lumbar spinal stenosis
Vitamin D deficiency
CKD (chronic kidney disease) stage 3, GFR ___ ml/min
pulmonary hypertension
Social History:
___
Family History:
PE, prostate cancer, Crohn's disease. No family history of early
MI, arrhythmia, cardiomyopathies, or sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: 99.2 136/80 117 20 95%4L
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP elevated to jawline at 40 degrees, no LAD
LUNGS: Clear to auscultation bilaterally, occasional late
expiratory wheezing, no rhonchi
CV: tachycardic rate and regular rhythm, normal S1 S2, no
murmurs, rubs, gallops
ABD: firm, non-tender, mildly distended, bowel sounds present,
no rebound tenderness or guarding
EXT: bilateral bright erythema, tender to palpation mid-shin to
thigh, frequent wounds as below, 1+ pitting edema
SKIN: frequent ecchymosis and cuts in various stages of healing
on bilateral upper and lower extremities
NEURO: A&Ox3, no sensation to light touch below mid-shin
bilaterally
DISCHARGE PHYSICAL EXAM
=======================
Vitals: 98.4 116/69 57 18 96 Ra
General: Alert, oriented, lying in bed visibly uncomfortable
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, no JVD, no LAD
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: CTAB, increased expiration to inspiration
Abdomen: Soft, NT, mildly distended, bowel sounds present, no
rebound or guarding,
Ext: B/L erythema and swelling up to shin with multiple ulcers
on
the left and right, with largest on right around 1 in diameter,
minimal purulence, evidence of chronic venous status b/l,
erythema within the skin markings, improved by the time of
discharge.
Gout tophi present on L and R indeces, on R more than L. L ring
finger swollen and painful, with ring cut off.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation
Pertinent Results:
ADMISSION LABS:
===============
___ 09:25PM BLOOD WBC-17.3* RBC-5.05 Hgb-11.3 Hct-40.3
MCV-80* MCH-22.4* MCHC-28.0* RDW-21.9* RDWSD-61.6* Plt ___
___ 09:25PM BLOOD Neuts-82.0* Lymphs-6.7* Monos-9.1 Eos-1.3
Baso-0.4 NRBC-0.1* Im ___ AbsNeut-14.17* AbsLymp-1.15*
AbsMono-1.57* AbsEos-0.23 AbsBaso-0.07
___ 09:25PM BLOOD ___ PTT-29.0 ___
___ 09:25PM BLOOD Glucose-233* UreaN-27* Creat-1.2* Na-136
K-4.8 Cl-93* HCO3-27 AnGap-16
___ 09:25PM BLOOD ALT-26 AST-30 AlkPhos-77 TotBili-0.4
___ 09:25PM BLOOD Lipase-22
___ 09:25PM BLOOD proBNP-4336*
___ 09:25PM BLOOD cTropnT-0.05*
___ 09:25PM BLOOD Albumin-3.7
___ 09:25PM BLOOD Digoxin-0.9
___ 09:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 09:33PM BLOOD ___ pO2-38* pCO2-58* pH-7.34*
calTCO2-33* Base XS-3
___ 09:33PM BLOOD Lactate-3.1*
Discharge Labs
==============
___ 06:14AM BLOOD WBC-15.0* RBC-4.30 Hgb-9.8* Hct-34.4
MCV-80* MCH-22.8* MCHC-28.5* RDW-20.6* RDWSD-58.1* Plt ___
___ 06:14AM BLOOD Glucose-183* UreaN-34* Creat-0.8 Na-141
K-3.5 Cl-97 HCO3-28 AnGap-16
___ 06:14AM BLOOD Calcium-8.0* Phos-3.3 Mg-1.5*
OTHER PERTINENT/DISCHARGE LABS:
===============================
___ 09:25PM BLOOD cTropnT-0.05*
___ 04:14AM BLOOD cTropnT-0.03*
IMAGING/STUDIES:
================
CXR (portable AP) ___: Low lung volumes accentuate the
bronchovascular markings. Given this, there may be slight
increase in opacity at the left lung base, which could be due to
atelectasis or vascular congestion, but developing consolidation
is not excluded. Dedicated PA and lateral views, when/if
patient able, would be helpful for further assessment.
Shoulder X-ray ___
No evidence of left shoulder fracture or dislocation.
RUQ US ___ No significant intra-abdominal ascites.
MICROBIOLOGY:
=============
___ CULTURENegative
___ CULTURENegative
___ Respiratory Viral Screen & CultureRespiratory
Viral Culture-Negative
___ CULTURE-Negative
___ CULTURE-FINAL {STAPH AUREUS COAG +,
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS)}
___ CULTURENegative
___ CULTURENegative
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Apixaban 5 mg PO BID
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Digoxin 0.125 mg PO DAILY
5. Gabapentin 300 mg PO TID
6. Loratadine 10 mg PO DAILY
7. Metoprolol Succinate XL 50 mg PO QHS
8. Metoprolol Succinate XL 100 mg PO QAM
9. Sertraline 100 mg PO DAILY
10. Sodium Chloride Nasal ___ SPRY NU BID:PRN nasal congestion
11. Sucralfate 1 gm PO TID
12. TraZODone 50 mg PO QHS
13. Venlafaxine XR 75 mg PO DAILY
14. Allopurinol ___ mg PO DAILY
15. Ferrous Sulfate 325 mg PO DAILY
16. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
17. Spironolactone 25 mg PO DAILY
18. Acidophilus (Lactobacillus acidophilus) 1 mg oral DAILY
19. Mirtazapine 7.5 mg PO QHS
20. Omeprazole 20 mg PO DAILY
21. Torsemide 40 mg PO BID
22. Humalog ___ 24 Units Breakfast
Humalog ___ 10 Units Bedtime
23. PredniSONE 7.5 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB/wheezing
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 2 puff every six (6)
hours Disp #*1 Vial Refills:*0
2. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
RX *fluticasone-salmeterol [Advair Diskus] 250 mcg-50 mcg/dose 2
puffs twice a day Disp #*1 Disk Refills:*0
3. HumaLOG (insulin lispro) 100 unit/mL subcutaneous QIDACHS
Per sliding scale
RX *insulin lispro [Humalog] 100 unit/mL X UNITS QACHS Disp #*3
Cartridge Refills:*1
4. Vancomycin 1000 mg IV Q 12H
RX *vancomycin 500 mg 2 bags q12 Disp #*22 Vial Refills:*0
5. Allopurinol ___ mg PO DAILY
6. Humalog ___ 24 Units Breakfast
Humalog ___ 10 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
7. PredniSONE 40 mg PO DAILY
40mg (___), 20mg (___), 10mg (___), 5mg (___)
Tapered dose - DOWN
RX *prednisone 5 mg ___ tablet(s) by mouth once a day Disp #*25
Tablet Refills:*0
8. Torsemide 60 mg PO DAILY
9. Acidophilus (Lactobacillus acidophilus) 1 mg oral DAILY
10. Apixaban 5 mg PO BID
11. Aspirin 81 mg PO DAILY
12. Atorvastatin 40 mg PO QPM
13. Digoxin 0.125 mg PO DAILY
14. Ferrous Sulfate 325 mg PO DAILY
15. Gabapentin 300 mg PO TID
16. Loratadine 10 mg PO DAILY
17. Metoprolol Succinate XL 100 mg PO QAM
18. Metoprolol Succinate XL 50 mg PO QHS
19. Mirtazapine 7.5 mg PO QHS
20. Omeprazole 20 mg PO DAILY
21. Sertraline 100 mg PO DAILY
22. Sodium Chloride Nasal ___ SPRY NU BID:PRN nasal congestion
23. Spironolactone 25 mg PO DAILY
24. Sucralfate 1 gm PO TID
25. TraZODone 50 mg PO QHS
26. Venlafaxine XR 75 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1) Hypoxic respiratory failure
#Acute on chronic right-sided heart failure with preserved
ejection fraction
#Lower extremity cellulitis
# Gout
# Diabetes, mellitus
# Atrial fibrillation
Secondary
Atrial fibrillation
Pulmonary hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with shortness of breath, hypoxia, eval for
pneumonia// shortness of breath, hypoxia, eval for pneumonia
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
FINDINGS:
Bilateral spinal hardware is re-demonstrated. There is a battery pack
projecting over the region of the left hilum, unclear whether external to the
patient. Low lung volumes accentuate the bronchovascular markings. Given
this, there may be slight increase in opacity at the left lung base, which
could be due to atelectasis or vascular congestion, but developing
consolidation is not excluded. Dedicated PA and lateral views, if/when
patient able, would be helpful for further assessment. No large pleural
effusion or pneumothorax is seen. Cardiac and mediastinal silhouettes are
stable.
IMPRESSION:
Low lung volumes accentuate the bronchovascular markings. Given this, there
may be slight increase in opacity at the left lung base, which could be due to
atelectasis or vascular congestion, but developing consolidation is not
excluded. Dedicated PA and lateral views, when/if patient able, would be
helpful for further assessment.
Radiology Report
EXAMINATION: SHOULDER (AP, NEUTRAL AND AXILLARY) TRAUMA LEFT
INDICATION: ?fracture
TECHNIQUE: Four views of the left shoulder.
COMPARISON: Chest Radiograph ___
FINDINGS:
There is no fracture or dislocation. No suspicious bony lesion is identified.
There are mild glenohumeral degenerative change. Acromioclavicular joint not
well evaluated. Partially image posterior spinal fusion hardware is present.
No radiopaque foreign body. Incompletely evaluated retrocardiac opacity,
better seen on dedicated chest radiograph.
IMPRESSION:
No evidence of left shoulder fracture or dislocation.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old woman with new R PICC// R SL Power PICC 45cm ___
___ Contact name: ___: ___ R SL Power PICC 45cm ___ ___
IMPRESSION:
Compared to chest radiographs ___.
Pulmonary vasculature is more engorged but there is no edema, and heart size
is smaller. No appreciable pleural effusion or indication of pneumothorax.
Tip of the new right PIC line is approximately 35 mm below the estimated
location of the superior cavoatrial junction
Radiology Report
EXAMINATION: US ABD LIMIT, SINGLE ORGAN
INDICATION: ___ year old woman with increasing abdominal distention// ascites
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
There is no ascites visualized in the right upper quadrant, right lower
quadrant, left lower quadrant, or left upper quadrant of the abdomen.
IMPRESSION:
No significant intra-abdominal ascites.
Gender: F
Race: WHITE
Arrive by UNKNOWN
Chief complaint: Palpitations, R Shoulder pain, Tachycardia
Diagnosed with Pain in right shoulder
temperature: 96.9
heartrate: 120.0
resprate: 17.0
o2sat: 97.0
sbp: 130.0
dbp: 62.0
level of pain: 0
level of acuity: 2.0 | ___ with PMHx of Afib on apixiban s/p DCCV on ___, COPD on
home O2, HFpEF, pulmonary HTN, DM2, CKD (bl Cr 1.2) who
presented 2 days of L shoulder pain and palpitations, found to
be hypoxic
on 6L NC O2 w/ volume overloaded and RLE purulent cellulitis (on
day 4 of levofloxacin treatment). The patient was originally
transferred to MICU on d/t concern for sepsis and CHF
exacerbation.
In the MICU, she quickly stabilized with IV diuresis. She was
also found to be hypercarbic and was set up for a trilogy mask
at night for OSA/COPD, and transferred to the floor on ___.
There she continued to be diuresed to her dry weight and started
on home torsemide, where she remained stable. Although she
remained in sinus throughout her hospitalization, there was
concern that her initial presentation was CHF ___ recurrent
Afib. She was wearing an event monitor at the time which should
be interrogated as an outpatient. Her discharge weight was 239.7
lbs (108.7 kg), and she was sent on torsemide 60 mg.
In terms of her cellulitis, wound swab culture from ED returned
MRSA and she was started on IV Vanc and Cefepime for 2 days. The
___ erythema improved, and abx were switched to PO doxycycline
and cephalexin. The erythema worsened over the next day and she
was transitioned back to IV vancomycin with plans to complete a
7 day course. She had a PICC line placed and was discharged with
home infusion therapy.
During hospitalization pt also had polyarticular arthritis (Lt
ankle, wrist, ___ PIP) c/f a severe gout flare. Rheumatology was
consulted, who recommended prednisone for treatment and increase
of allopurinol as outpatient. The patient had continued swelling
of her left ring finger, so her ring was cut off by othro. The
patient improved prior to discharge and was scheduled to
follow-up with rheumatology as an outpatient.
======================= |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Drainage from right laparoscopic port site
Major Surgical or Invasive Procedure:
None this admission
History of Present Illness:
___ s/p robotic cystoprostatectomy with Dr. ___ on ___
with drainage from his R lap site and an elevated potassium
being admitted for observation. Patient had been doing well at
home except for some leg and abdominal swelling. Two days ago
he reported clear fluid draining from his R lap site. He was
instructed to come to the emergency room at ___ for
evaluation.
At ___, his CT scan showed no drainable collection. The fluid
draining from his wound was sent for Cr and found to be 2. He
denies any fever, chills, chest pain, shortness of breath or
palpitations. His potassium on presentation was 7.1 and he was
given 10U insulin. On repeat check it was 7.2. The patient was
given kayexylate, insulin, albuterol, dextrose with decrease to
6.7.
Past Medical History:
PMH:
Type 2 diabetes ___ years; hepatitis C after IV drug use;
hypertension; ___ esophagus; GERD; macular degeneration;
penile prosthesis, malleable, ___ years ago.
All:
NKDA
Social History:
___
Family History:
Negative for bladder cancer.
Physical Exam:
Avss
NAD
Unlabored breathing
abd distended, nontender
no rebound or guarding
incisions c/d/i
urostomy pink patent and draining clear urine
extremities with 1+ edema
Pertinent Results:
___ 05:04AM BLOOD WBC-5.9 RBC-3.60* Hgb-10.5* Hct-31.5*
MCV-88 MCH-29.2 MCHC-33.3 RDW-13.9 Plt ___
___ 05:35AM BLOOD WBC-6.2 RBC-3.66* Hgb-10.4* Hct-32.4*
MCV-89 MCH-28.3 MCHC-32.0 RDW-14.0 Plt ___
___ 05:54AM BLOOD WBC-6.1 RBC-3.51* Hgb-10.1* Hct-31.2*
MCV-89 MCH-28.7 MCHC-32.3 RDW-14.1 Plt ___
___ 05:37AM BLOOD WBC-6.3 RBC-3.60* Hgb-10.3* Hct-32.0*
MCV-89 MCH-28.5 MCHC-32.0 RDW-14.2 Plt ___
___ 06:15AM BLOOD WBC-6.9 RBC-3.45* Hgb-10.4* Hct-31.0*
MCV-90 MCH-30.0 MCHC-33.4 RDW-14.4 Plt ___
___ 07:00PM BLOOD WBC-6.4 RBC-3.40* Hgb-10.0* Hct-30.4*
MCV-90 MCH-29.5 MCHC-32.9 RDW-14.9 Plt ___
___ 05:03AM BLOOD WBC-5.8 RBC-3.41* Hgb-10.0* Hct-30.2*
MCV-89 MCH-29.4 MCHC-33.1 RDW-14.9 Plt ___
___ 12:00PM BLOOD WBC-4.9# RBC-3.29* Hgb-9.8* Hct-30.0*
MCV-91 MCH-29.6 MCHC-32.5 RDW-13.9 Plt ___
___ 12:00PM BLOOD Neuts-77.2* Lymphs-16.9* Monos-5.0
Eos-0.6 Baso-0.3
___ 05:04AM BLOOD Glucose-94 UreaN-59* Creat-1.7* Na-134
K-5.3* Cl-102 HCO3-22 AnGap-15
___ 05:35AM BLOOD Glucose-76 UreaN-56* Creat-1.8* Na-137
K-5.8* Cl-107 HCO3-19* AnGap-17
___ 04:29PM BLOOD Glucose-71 UreaN-55* Creat-1.9* Na-134
K-6.0* Cl-103 HCO3-19* AnGap-18
___ 05:54AM BLOOD Glucose-65* UreaN-51* Creat-1.9* Na-133
K-5.7* Cl-105 HCO3-19* AnGap-15
___ 03:34PM BLOOD Glucose-64* UreaN-50* Creat-1.8* Na-135
K-5.8* Cl-106 HCO3-19* AnGap-16
___ 05:37AM BLOOD Glucose-79 UreaN-50* Creat-1.8* Na-137
K-5.3* Cl-107 HCO3-19* AnGap-16
___ 03:54PM BLOOD Glucose-72 UreaN-49* Creat-1.9* Na-134
K-5.6* Cl-106 HCO3-20* AnGap-14
___ 06:15AM BLOOD Glucose-83 UreaN-47* Creat-2.0* Na-133
K-5.2* Cl-105 HCO3-20* AnGap-13
___ 03:57PM BLOOD Glucose-91 UreaN-42* Creat-1.9* Na-133
K-5.5* Cl-107 HCO3-19* AnGap-13
___ 06:17AM BLOOD Glucose-193* UreaN-43* Creat-1.7* Na-130*
K-5.5* Cl-105 HCO3-20* AnGap-11
___ 06:17AM BLOOD Glucose-193* UreaN-43* Creat-1.7* Na-130*
K-5.5* Cl-105 HCO3-20* AnGap-11
___ 07:00PM BLOOD Glucose-151* UreaN-43* Creat-2.0* Na-134
K-6.2* Cl-108 HCO3-19* AnGap-13
___ 05:03AM BLOOD Glucose-108* UreaN-39* Creat-1.8* Na-135
K-5.9* Cl-108 HCO3-20* AnGap-13
___ 09:56PM BLOOD Glucose-154* UreaN-43* Creat-1.9* Na-133
K-7.1* Cl-107 HCO3-19* AnGap-14
___ 05:54AM BLOOD Calcium-8.8 Phos-4.3 Mg-1.7
___ 03:54PM BLOOD Calcium-8.2* Phos-4.7* Mg-1.7
___ 06:17AM BLOOD Calcium-8.6 Phos-4.1 Mg-1.7
___ 07:00PM BLOOD Calcium-8.3* Phos-4.5 Mg-1.5*
___ 05:03AM BLOOD Calcium-8.4 Phos-4.4 Mg-1.6
___ 09:56PM BLOOD Calcium-8.9 Phos-4.3 Mg-1.6
___ 07:03PM BLOOD K-6.7*
___ 04:54PM BLOOD K-7.2*
___ 12:00 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
___ 12:00 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 12:00 pm URINE Site: NOT SPECIFIED INCISIONAL.
**FINAL REPORT ___
URINE CULTURE (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE. 10,000-100,000
ORGANISMS/ML..
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
GENTAMICIN------------ =>16 R
LEVOFLOXACIN---------- =>8 R
NITROFURANTOIN-------- 32 S
OXACILLIN------------- =>4 R
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ 2 S
___ ___ 3:___BD & PELVIS W/O CONTRAST Clip # ___
Reason: abscess, fluid collection
UNDERLYING MEDICAL CONDITION:
History: ___ with recent bladder suregry with leakage from
wound
REASON FOR THIS EXAMINATION:
abscess, fluid collection
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read: MXAk SAT ___ 5:55 ___
1. The patient is staus post cystoprostatectomy with an ileal
conduit exiting
in the right lower quadrant. There is mild hydorureteronephrosis
bilaterally
but the conduit appears patent.
2. There is a small amount of free fluid and a 5.2 x 2.1 cm
focus of what may
be loculated fluid in the right retorperitoneum. These findings
may be
representative of normal postsurgical changes. However, seroma
or an urine
due to leakage cannot be excluded in this noncontrast study.
These can be
further assessed with a contrast enhanced study when possible.
3. Mild soft tissue stranding from post-surgery in the
mid-abdomen with no
drainable collections identified.
Wet Read Audit # ___ ___ SAT ___ 5:55 ___
1. The patient is staus post cystoprostatectomy with an ileal
conduit exiting
in the right lower quadrant. There is mild hydorureteronephrosis
bilaterally
but the conduit appears patent.
2. There is a small amount of free fluid and a 5.2 x 2.1 cm
focus of what may
be loculated fluid in the right retorperitoneum. These findings
may be
representative of normal postsurgical changes. However, seroma
or an urine
due to leakage cannot be excluded in this noncontrast study.
These can be
further assessed with a contrast enhanced study when possible.
Final Report
HISTORY: Evaluation of patient with history of metastatic
bladder cancer
status post cystoprostatectomy with an ileal diversion with
leakage from the
surgical wound.
COMPARISON: Multiple prior studies ranging from CTU from
___
to CT Torso from ___. Renal ultrasound ___.
TECHNIQUE: MDCT-acquired axial images were obtained from the
base of the
lungs to the pubic symphysis without the administration of IV
contrast.
Multiplanar reformatted images were prepared and reviewed.
FINDINGS:
CT ABDOMEN WITHOUT IV CONTRAST:
Evaluation of visceral organs is limited due to the lack of IV
contrast.
A 7 x 4 mm pleural based nodule is noted on the left (2:12) and
relatively
stable compared to prior study from ___ when it
was partially
visualized. A tiny granuloma is again noted at the right lung
base (2:4).
The patient is status post cystoprostatectomy with an ileal
conduit in the
right lower quadrant. Both kidneys demonstrate new mild
hydroureteronephrosis, with no calculi seen. Postsurgical
changes are noted
involving a loop of ileum (2:64) which then traverses to the
right lower
quadrant and exists the anterior abdominal wall (2: 52).
Inferior and
posterior to the anastomosis of the ureters to the ileal
conduit, there is a
small amount of free and partially loculated right
retroperitoneal simple
fluid measuring up to 5.2 x 2.1 cm (2:70). This fluid is likely
expected
post-surgical and may be reflective of a developing seroma; a
small urine leak
from the anastamosis, however, cannot be completely excluded on
this non
contrast study.
Otherwise, post ileal anastomosis changes are noted with no
evidence for
obstruction. Postsurgical changes are also noted mid anterior
abdomen with no
evidence of a drainable collection. Foci of air noted in
bilateral inguinal
regions also represent postsurgical changes.
The spleen is enlarged at 19.1 cm with unchanged coarse
calcifications. There
is trace perihepatic ascites. Otherwise, the liver, gallbladder,
pancreas,
stomach, and visualized loops of small and large bowel are
within normal
limits. Mild atherosclerotic calcifications of the distal
abdominal aorta are
present, but the aorta is normal in caliber and contour. A few
small
retroperitoneal and mesenteric lymph nodes are noted but there
is no
pathologic lymphadenopathy by CT size criteria.
CT PELVIS WITHOUT IV CONTRAST:
Evaluation of visceral organs is limited due to the lack of IV
contrast. The
patient is status post cystoprostatectomy with an ileal conduit.
There is
sigmoid diverticulosis without diverticulitis. A small amount
of free fluid
is noted in resection bed and extra-peritoneal pelvic tissues,
likely
post-operative. There is no pelvic or inguinal lymphadenopathy
by CT size
criteria. Penile prosthesis is partially imaged.
Osseous structures: There are no lytic sclerotic osseous
lesions suspicious
for malignancy.
IMPRESSION:
1. Status post cystoprostatectomy with an ileal conduit exiting
in the right
lower quadrant. Mild hydorureteronephrosis bilaterally is
noted, new from the
ultrasound of ___.
2. Small amount of free fluid within the right retroperitoneum
and pelvic
surgical bed, with a 5.2 x 2.1 cm partially loculated collection
in the right
retroperitoneum, near the ureteral anastamosis with the ileal
conduit. These
findings are likely reflective of expected postsurgical changes.
A small
urine leak cannot be completely excluded on this noncontrast
study, and if
this is a concern, further assessment can be performed with a
contrast
enhanced study.
3. Mild post-operative subcutaneous soft tissue stranding in the
mid-and right
abdomen with no drainable collections identified.
___ ___ 5:53 ___
RENAL U.S. Clip # ___
Reason: r/u hydronephrosis
UNDERLYING MEDICAL CONDITION:
___ year old man with bladder cancer s/p radical cystectomy
with ileal loop
urinary diversion and elevated kidney function tests
REASON FOR THIS EXAMINATION:
r/u hydronephrosis
Wet Read: ___ TUE ___ 11:10 ___
Mild bilateral hydronephrosis.
Final Report
HISTORY: Bladder cancer status post radical cystectomy with
ileal loop
urinary diversion. Question hydronephrosis.
COMPARISON: ___ and server ___.
FINDINGS:
Multiple sonographic grayscale images were obtained of the
kidneys
bilaterally.
The left kidney measures 13.5 cm and the right kidney measures
11.5 cm.
Neither kidney demonstrating evidence of stones or solid renal
masses.
Bilaterally, there is mild hydronephrosis without hydroureter.
The bladder
area demonstrates surgical changes status post cystectomy
without any evidence
of fluid collection.
IMPRESSION:
Mild bilateral hydronephrosis. Given ileal loop diversion, it
is unclear if
this may be related to ureteral reflux.
___ ___ 5:53 ___
RENAL U.S. Clip # ___
Reason: r/u hydronephrosis
UNDERLYING MEDICAL CONDITION:
___ year old man with bladder cancer s/p radical cystectomy
with ileal loop
urinary diversion and elevated kidney function tests
REASON FOR THIS EXAMINATION:
r/u hydronephrosis
Wet Read: ___ ___ 11:10 ___
Mild bilateral hydronephrosis.
Final Report
HISTORY: Bladder cancer status post radical cystectomy with
ileal loop
urinary diversion. Question hydronephrosis.
COMPARISON: ___ and server ___.
FINDINGS:
Multiple sonographic grayscale images were obtained of the
kidneys
bilaterally.
The left kidney measures 13.5 cm and the right kidney measures
11.5 cm.
Neither kidney demonstrating evidence of stones or solid renal
masses.
Bilaterally, there is mild hydronephrosis without hydroureter.
The bladder
area demonstrates surgical changes status post cystectomy
without any evidence
of fluid collection.
IMPRESSION:
Mild bilateral hydronephrosis. Given ileal loop diversion, it
is unclear if
this may be related to ureteral reflux.
___ 12R ___ 10:36 AM
LUMBO-SACRAL SPINE (AP & LAT) Clip # ___
Reason: r/o spine compression fracture
UNDERLYING MEDICAL CONDITION:
___ year old man with Bilateral lower back and leg pain.
REASON FOR THIS EXAMINATION:
r/o spine compression fracture
Final Report
STUDY: Lumbosacral spine, ___.
CLINICAL HISTORY: ___ male with bilateral lower leg and
back pain.
Evaluate for compression deformities.
FINDINGS: Comparison is made to the CT scan from ___. There
are no compression deformities. There are degenerative changes
with loss of
intervertebral disc height, worse at L4-L5 and L5-S1. No
abnormal ___- or
retrolisthesis is seen. There are abdominal aortic
calcifications anteriorly.
___ ___ 6:52 ___
MR ___ SPINE W/O CONTRAST Clip # ___
Reason: r/o nerve root compression or L-spine mass
UNDERLYING MEDICAL CONDITION:
___ year old man with Pt with Hx of bladder cancer, now with
lower back pain
radiating to legs requiring narcotic pain meds
REASON FOR THIS EXAMINATION:
r/o nerve root compression or L-spine mass
CONTRAINDICATIONS FOR IV CONTRAST:
Renal failure
Final Report
HISTORY: History of bladder cancer, now lower back pain
radiating to the legs
requiring narcotics pain. Evaluate for nerve root compression
or mass.
TECHNIQUE: Multiplanar multisequence MRI of the lumbar spine
was obtained
without IV gadolinium as per department protocol. Please note
that this
examination was initially protocoled with contrast, however the
patient had
difficulty tolerating the exam due to pain and urinary
incontinence and asked
to stop this examination. Contrast was not given.
COMPARISON: CT of the abdomen and pelvis of ___.
FINDINGS:
The bone marrow signal is unremarkable throughout the lumbar
spine with
exception of a hemangioma at L5 vertebral body. There is no
evidence of
abnormal STIR signal. The vertebral body heights are grossly
preserved. The
alignment is maintained. There are endplate changes with a
Schmorl's node at
the inferior endplate of L1 vertebral body and at the superior
endplate of L5
vertebral body.
The conus medullaris terminates at L1-L2 and has normal signal
and
configuration.
At L1-L2, there is narrowing of the disc space with decreased
signal within
the disc without spinal canal or neural foraminal narrowing.
At L4-L5, there is a central disc protrusion superimposed on a
diffuse disc
bulge flattening the anterior thecal sac and narrowing of the
subarticular
zones. There is ligamentum flavum thickening and facet joint
arthropathy.
These result in mild to moderate bilateral neural foraminal
narrowing.
At L5-S1, there is a diffuse disc bulge, facet joint
arthropathy, and
ligamentum flavum thickening resulting in mild to moderate
bilateral neural
foraminal narrowing.
The paraspinal and prevertebral soft tissues are unremarkable.
Note is made of 2.4 cm x 1.3 cm x 2.2 cm oval lesion immediately
beneath the
dermis of the posterior soft tissues likely representing a
sebaceous cyst.
IMPRESSION:
1. No evidence of abnormal STIR signal within the lumbar spine
or masses.
2. Mild degenerative changes of the lumbar spine.
___ ___
RENAL SCAN Clip # ___
Reason: S/P RADICAL CYSTECTOMY W/ ILEAL LOOP URINARY DIVERSION
Final Report
RADIOPHARMACEUTICAL DATA:
5.5 mCi Tc-99m MAG3 ___
RADIOPHARMACEUTICAL:
(___) 5.5 mCi Tc-99m MAG3
HISTORY: Status post radical cystectomy with ileal loop
diversion. Assess for
urinary leak.
INTERPRETATION:
Comparison was made with post-operative CT from ___.
Flow and dynamic images were obtained after intravenous
administration of
tracer.
Blood flow images show slight decreased in flow bilaterally when
compared with
the spleen suggesting decreased renal function but there is
appropriate peak of
flow compared to aortic flow.
Renogram images show appropriate tracer uptake in the left
kidney with normal
clearance of tracer. However, the right kidney shows constant
accumulation of
tracer without any clearance after 20 minutes of imaging. 40 mg
of lasix were
then administered and an appropriate clearance of tracer from
the right kidney
was observed - 42% residual after 20 minutes - precluding the
possibility of
obstruction.
The differential function obtained by analysis of tracer
concentration in the
parenchyma from 2 to 3 minutes post tracer injection shows the
left kidney to be
performing 54 % of the total renal function and the right
kidney performing 46
%.
Delayed imaging showed a circular morphology of tracer which
appears contained
and is similar to the CT appearance of diverting ileal loop.
Inferior to the
loop there is some tracer which might be associated with course
of diverting
loop through the abdominal wall and urinary catheter. However,
further
assessment with SPECT for accurate localization of tracer in the
pelvis could
not be performed due to the patient's inability to cooperate
secondary to pain.
IMPRESSION:
1. Delayed peak of flow bilaterally compatible with mild renal
insufficiency.
2. No evidence or obstruction.
3. No clear evidence of urinary leak in delayed images. However,
accurate
localization of pelvic tracer could not be performed owing to
patient inability
to cooperate with SPECT/CT secondary to pain. If there is
continued suspicion
of urinary leak, further imaging with SPECT/CT may be helpful.
Medications on Admission:
Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN
Gabapentin 300 mg PO QID
HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN
NPH 50 Units Breakfast
NPH 50 Units Bedtime
Regular 10 Units Lunch
Regular 10 Units Dinner
Omeprazole 20 mg PO DAILY
Simvastatin 20 mg PO DAILY
TraMADOL (Ultram) 50-100 mg PO Q6H:PRN
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath, wheeze
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
3. Gabapentin 300 mg PO QID
4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *hydromorphone 4 mg 1 tablet(s) by mouth every six (6) hours
Disp #*40 Tablet Refills:*0
5. NPH 50 Units Breakfast
NPH 50 Units Bedtime
Regular 10 Units Lunch
Regular 10 Units Dinner
6. Medium Chain Triglycerides 15 mL PO TID
RX *medium chain triglycerides [MCT Oil] 7.7 kcal/mL 15 ml by
mouth tid with food Disp #*1 Bottle Refills:*0
7. Omeprazole 20 mg PO DAILY
8. Simvastatin 20 mg PO DAILY
9. TraMADOL (Ultram) 50-100 mg PO Q6H:PRN pain
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 17 gram by
mouth daily Disp #*10 Pack Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Bladder Cancer
Discharge Condition:
Mental Status: Clear and coherent, intermittently confused
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: Evaluation of patient with history of metastatic bladder cancer
status post cystoprostatectomy with an ileal diversion with leakage from the
surgical wound.
COMPARISON: Multiple prior studies ranging from CTU from ___
to CT Torso from ___. Renal ultrasound ___.
TECHNIQUE: MDCT-acquired axial images were obtained from the base of the
lungs to the pubic symphysis without the administration of IV contrast.
Multiplanar reformatted images were prepared and reviewed.
FINDINGS:
CT ABDOMEN WITHOUT IV CONTRAST:
Evaluation of visceral organs is limited due to the lack of IV contrast.
A 7 x 4 mm pleural based nodule is noted on the left (2:12) and relatively
stable compared to prior study from ___ when it was partially
visualized. A tiny granuloma is again noted at the right lung base (2:4).
The patient is status post cystoprostatectomy with an ileal conduit in the
right lower quadrant. Both kidneys demonstrate new mild
hydroureteronephrosis, with no calculi seen. Postsurgical changes are noted
involving a loop of ileum (2:64) which then traverses to the right lower
quadrant and exists the anterior abdominal wall (2: 52). Inferior and
posterior to the anastomosis of the ureters to the ileal conduit, there is a
small amount of free and partially loculated right retroperitoneal simple
fluid measuring up to 5.2 x 2.1 cm (2:70). This fluid is likely expected
post-surgical and may be reflective of a developing seroma; a small urine leak
from the anastamosis, however, cannot be completely excluded on this non
contrast study.
Otherwise, post ileal anastomosis changes are noted with no evidence for
obstruction. Postsurgical changes are also noted mid anterior abdomen with no
evidence of a drainable collection. Foci of air noted in bilateral inguinal
regions also represent postsurgical changes.
The spleen is enlarged at 19.1 cm with unchanged coarse calcifications. There
is trace perihepatic ascites. Otherwise, the liver, gallbladder, pancreas,
stomach, and visualized loops of small and large bowel are within normal
limits. Mild atherosclerotic calcifications of the distal abdominal aorta are
present, but the aorta is normal in caliber and contour. A few small
retroperitoneal and mesenteric lymph nodes are noted but there is no
pathologic lymphadenopathy by CT size criteria.
CT PELVIS WITHOUT IV CONTRAST:
Evaluation of visceral organs is limited due to the lack of IV contrast. The
patient is status post cystoprostatectomy with an ileal conduit. There is
sigmoid diverticulosis without diverticulitis. A small amount of free fluid
is noted in resection bed and extra-peritoneal pelvic tissues, likely
post-operative. There is no pelvic or inguinal lymphadenopathy by CT size
criteria. Penile prosthesis is partially imaged.
Osseous structures: There are no lytic sclerotic osseous lesions suspicious
for malignancy.
IMPRESSION:
1. Status post cystoprostatectomy with an ileal conduit exiting in the right
lower quadrant. Mild hydorureteronephrosis bilaterally is noted, new from the
ultrasound of ___.
2. Small amount of free fluid within the right retroperitoneum and pelvic
surgical bed, with a 5.2 x 2.1 cm partially loculated collection in the right
retroperitoneum, near the ureteral anastamosis with the ileal conduit. These
findings are likely reflective of expected postsurgical changes. A small
urine leak cannot be completely excluded on this noncontrast study, and if
this is a concern, further assessment can be performed with a contrast
enhanced study.
3. Mild post-operative subcutaneous soft tissue stranding in the mid-and right
abdomen with no drainable collections identified.
Radiology Report
HISTORY: Bladder cancer status post radical cystectomy with ileal loop
urinary diversion. Question hydronephrosis.
COMPARISON: ___ and server 16 ___.
FINDINGS:
Multiple sonographic grayscale images were obtained of the kidneys
bilaterally.
The left kidney measures 13.5 cm and the right kidney measures 11.5 cm.
Neither kidney demonstrating evidence of stones or solid renal masses.
Bilaterally, there is mild hydronephrosis without hydroureter. The bladder
area demonstrates surgical changes status post cystectomy without any evidence
of fluid collection.
IMPRESSION:
Mild bilateral hydronephrosis. Given ileal loop diversion, it is unclear if
this may be related to ureteral reflux.
Radiology Report
STUDY: Lumbosacral spine, ___.
CLINICAL HISTORY: ___ male with bilateral lower leg and back pain.
Evaluate for compression deformities.
FINDINGS: Comparison is made to the CT scan from ___. There
are no compression deformities. There are degenerative changes with loss of
intervertebral disc height, worse at L4-L5 and L5-S1. No abnormal ___- or
retrolisthesis is seen. There are abdominal aortic calcifications anteriorly.
Radiology Report
HISTORY: History of bladder cancer, now lower back pain radiating to the legs
requiring narcotics pain. Evaluate for nerve root compression or mass.
TECHNIQUE: Multiplanar multisequence MRI of the lumbar spine was obtained
without IV gadolinium as per department protocol. Please note that this
examination was initially protocoled with contrast, however the patient had
difficulty tolerating the exam due to pain and urinary incontinence and asked
to stop this examination. Contrast was not given.
COMPARISON: CT of the abdomen and pelvis of ___.
FINDINGS:
The bone marrow signal is unremarkable throughout the lumbar spine with
exception of a hemangioma at L5 vertebral body. There is no evidence of
abnormal STIR signal. The vertebral body heights are grossly preserved. The
alignment is maintained. There are endplate changes with a Schmorl's node at
the inferior endplate of L1 vertebral body and at the superior endplate of L5
vertebral body.
The conus medullaris terminates at L1-L2 and has normal signal and
configuration.
At L1-L2, there is narrowing of the disc space with decreased signal within
the disc without spinal canal or neural foraminal narrowing.
At L4-L5, there is a central disc protrusion superimposed on a diffuse disc
bulge flattening the anterior thecal sac and narrowing of the subarticular
zones. There is ligamentum flavum thickening and facet joint arthropathy.
These result in mild to moderate bilateral neural foraminal narrowing.
At L5-S1, there is a diffuse disc bulge, facet joint arthropathy, and
ligamentum flavum thickening resulting in mild to moderate bilateral neural
foraminal narrowing.
The paraspinal and prevertebral soft tissues are unremarkable.
Note is made of 2.4 cm x 1.3 cm x 2.2 cm oval lesion immediately beneath the
dermis of the posterior soft tissues likely representing a sebaceous cyst.
IMPRESSION:
1. No evidence of abnormal STIR signal within the lumbar spine or masses.
2. Mild degenerative changes of the lumbar spine.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: WOUND CHECK
Diagnosed with SURG COMPL-URINARY TRACT, ABN REACT-ANASTOM/GRAFT, DIABETES UNCOMPL ADULT
temperature: 97.9
heartrate: 80.0
resprate: 14.0
o2sat: 100.0
sbp: 178.0
dbp: 52.0
level of pain: 7
level of acuity: 3.0 | The patient was admitted from the ED to the urology service. He
was found to have an elevated Cr and potassium. He was
monitored for hyperkalemia with serial EKGs and medical
management. CT did not show any drainable collection in his
abdomen, and thus he was observed and treated conservatively for
a suspected lymphatic leak. On HD #2, a renal US was obtained
which revealed mild hydronephrosis. On HD #3, a renal consult
was obtained to aid in the management of hyperkalemia and he was
treated with gentle diuresis. A repeat renal US was obtained as
recommended by renal consult and this was significant for no
change in hydronephrosis. A nutrition consult was obtained to
educate the patient on a low fat, medium chain fatty acid diet.
His abdominal leak had resolved on his own. A MAG3 lasix
renogram was performed to assess for the presence of obstruction
since the renal team suspected obstruction as a reason for his
hyperkalemia. On HD #5, an MRI and lumbar xray were obtained
secondary to chronic bilateral lower back pain with onset of
burning pain down bilateral ___. These were negative for any
acute process. Throughout his hospital course, his labs were
monitored at least daily. A foley catheter was placed into his
stoma and his labs were stable. He was discharged ___ on HD7
with services for home ___, stoma care, and for labs to be drawn
on ___. He was tolerating a regular diet that is low in
potassium, low fat and medium chain fatty acid. His pain was
controlled on oral medications. He was ambulating with a
walker. He was producing adequate amounts of urine. |
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:
___ who is DNR/DNI with ESRD on dialysis (TThS), cognitive
impairment, stroke/small vessel ischemic changes,
hypothyroidism,
microvascular hemorrhage, CAD, T2DM, HTN presents with hypoxic
respiratory distress. Yesterday evening, patient developed acute
respiratory distress while at nursing home. He pressed his alert
button for assistance and was found to be tripoding with an
initial O2 saturation in the 70's. He was subsequently placed on
6 L nasal cannula with improvement to 84%. Patietn was
transitioned to BiPAP by EMS with improved oxygenation to 94%.
Of note, patient was last dialyzed on ___ and is due for
repeat dialysis tomorrow morning
In the ED,
- Initial Vitals: HR: 126; BP: 126/67; RR: 35; PO2: 78
- Exam:Tachypnea, mild distress, on the BiPAP mask; Coarse
breath
sounds bilaterally
- Labs: VBG: 7.25/57/29. Cultures/CBC/BMP pending.
- Imaging: EKG nonischemic, potential some peaking of T waves.
Chest x-ray shows bilateral diffuse opacities, likely pulmonary
edema cannot rule out aspiration
- Consults: Renal: Volume overload, since stable on BiPAP will
defer HD until early AM, nitro gtt if decompensates
- Interventions: BiPAP: ___, initially 70%, weaned to 50%.
Given
Vanc/cefepime
History otherwise notable for recent admission to ___ on ___
after being found unresponsive at HD ___ to
posterior circulation hypoperfusion secondary to bilateral
vertebral artery stenosis and preload-dependent aortic stenosis.
Hospital course notable for hypoxia to 78% on RA that resolved
without intervention believed to be ___ to volume overload as
well as aspiration PNA treated w/ levoquin. GOC discussion held
with family at that time, agreed to avoid invasive procedures
and
maintain DNR/DNI code status.
Past Medical History:
- ESRD on HD TTS ___ ___. LUE AVF ___, RIJ tunnelled
line ___
- Stroke/small vessel ischemic changes, microvascular hemorrhage
(likely amyloid angiopathy by MRI), followed by Neurology
- Mild dementia
- CAD, anterior wall changes on EKG
- DM2, HbA1c 6.5% in ___
- Hypertension
- Asthma
- Anemia, likely due to CKD
- Gout
- BPH
- kidney stones
- S/P bilateral cataract surgery ___
Social History:
___
Family History:
No history of kidney disease or diabetes. Few family members
with hypertension.
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
VITALS: T: 98.7, HR: 105; BP: 144/78; O2: 100
GENERAL: Comfortable on BiPAP
HEENT: NCAT. PERRL, EOMI
CARDIAC: Regular rhythm, normal rate. IV/VII
crescendo/decrescendo systolic murmur loudest at base.
LUNGS: Mild bibasilar wheezing
BACK: No spinous process tenderness.
ABDOMEN: Non distended, non-tender to deep palpation in all four
quadrants. No organomegaly.
EXTREMITIES: WWP, LLE with non pitting edema through midcalf.
NEUROLOGIC: AAOx3
DISCHARGE PHYSICAL EXAM:
=======================
VITALS: 24 HR Data (last updated ___ @ 715)
Temp: 98.1 (Tm 98.5), BP: 132/62 (104-149/49-73), HR: 76
(57-84), RR: 16 (___), O2 sat: 97% (94-99), O2 delivery: 2 L,
Wt: 132.9 lb/60.28 kg
GENERAL: Alert and interactive. comfortably lying in bed
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM.
NECK: No cervical lymphadenopathy. no JVD
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. harsh
___ systolic ejection murmur throughout
LUNGS: CTAB. 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.
EXTREMITIES: No clubbing, cyanosis. Trace to mild dependent
edema
in the lower extremities L>R. RUE with AV fistula +thrill/bruit
SKIN: Warm. Cap refill wnl. No rash.
NEUROLOGIC: AOx3. Moving all extremities
Pertinent Results:
ADMISSION LABS:
==============
___ 10:16AM BLOOD WBC-9.7 RBC-2.35* Hgb-8.3* Hct-24.5*
MCV-104* MCH-35.3* MCHC-33.9 RDW-13.6 RDWSD-51.2* Plt ___
___ 04:01PM BLOOD Glucose-147* UreaN-22* Creat-4.3*# Na-136
K-4.9 Cl-93* HCO3-26 AnGap-17
___ 04:01PM BLOOD Calcium-8.5 Phos-2.4* Mg-2.0
___ 10:38AM BLOOD ___ Temp-36.8 Rates-/18 pO2-275*
pCO2-38 pH-7.47* calTCO2-28 Base XS-4 Intubat-NOT INTUBA
INTERVAL LABS:
================
___ 03:37AM BLOOD cTropnT-0.12*
___ 10:25AM BLOOD CK-MB-3 cTropnT-0.19*
___ 04:01PM BLOOD CK-MB-3 cTropnT-0.21*
___ 04:59AM BLOOD CK-MB-2 cTropnT-0.21*
___ 10:50AM BLOOD CK-MB-3 cTropnT-0.19*
IMAGING:
========
Video swallowing study (___)
ASPIRATION/PENETRATION:
Nectar Thick Liquids -
1. Intermittent trace-mild amount of penetration with nectar
thick liquids in isolation during the swallow ___ premature
spillage, delayed swallow initiation, and delayed laryngeal
vestibular closure. Penetration cleared at the height of the
swallow (PAS = 2)
2. Trace flash penetration with nectar thick liquids during the
swallow following pudding. Penetration cleared at the height of
the swallow (PAS = 2)
3. Deeper, moderate amount of penetration with nectar thick
liquids following ground solids. Penetration cleared at the
height of the swallow (PAS = 2)
Thin Liquids -
1. Trace-mild amount of penetration with thin liquids before the
swallow due to premature spillage, delayed swallow initiation,
and delayed laryngeal vestibular closure. Penetration cleared at
the height of the swallow (PAS = 2)
2. Moderate amount of penetration with thin liquids following
pudding during the swallow due to premature spillage, delayed
swallow initiation, and delayed laryngeal vestibular closure.
Penetration cleared at the height of the swallow (PAS = 2)
Pudding and Ground Solids - No penetration or aspiration of
solids observed during today's study
TREATMENT TECHNIQUES:
1. Chin tuck - A chin tuck was not effective in reducing
penetration of liquids
2. Repeat Swallow - A cued repeat dry swallow was largely
effective in clearing oral and pharyngeal residue. Pt was
intermittently sensate to residue.
1. Penetration of thin and nectar thick liquids with no evidence
for aspiration.
2. Proximal esophageal dysmotility, likely age related.
CXR (___)
Complete opacification of the left lower lung is likely
secondary to a
combination of pleural effusion and atelectasis however,
superimposed
infection would be difficult to exclude in the correct clinical
context.
2. Interval increase in right mid to lower lung opacification
concerning for
underlying infectious process or aspiration
Lower extremity US (___)
No evidence of deep venous thrombosis in the left lower
extremity veins
DISCHARGE LABS:
===============
___ 05:09AM BLOOD WBC-5.6 RBC-2.42* Hgb-8.2* Hct-25.4*
MCV-105* MCH-33.9* MCHC-32.3 RDW-15.6* RDWSD-59.9* Plt ___
___ 05:09AM BLOOD Glucose-133* UreaN-23* Creat-5.3*# Na-137
K-4.2 Cl-92* HCO3-30 AnGap-15
___ 10:50AM BLOOD VitB12-650 Folate->20
___ 04:59AM BLOOD calTIBC-186* Hapto-286* Ferritn-966*
TRF-143*
___ 06:45AM BLOOD Calcium-8.7 Phos-2.8 Mg-2.1
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ male with respiratory distress. Evaluate for edema
or pneumonia.
TECHNIQUE: Portable AP chest
COMPARISON: Chest radiograph performed ___.
FINDINGS:
There is complete opacification of the left lower lung and costophrenic angle,
likely secondary to a combination of pleural effusion and atelectasis. A
superimposed infection would be difficult to exclude. Additionally there is
now increased opacification of the right mid to lower lung also concerning for
an underlying infection. There is mild prominence of the pulmonary
vasculature and minimal interstitial edema. No large pneumothorax. The
cardiomediastinal silhouette is not adequately assessed, but likely unchanged.
IMPRESSION:
1. Complete opacification of the left lower lung is likely secondary to a
combination of pleural effusion and atelectasis however, superimposed
infection would be difficult to exclude in the correct clinical context.
2. Interval increase in right mid to lower lung opacification concerning for
an underlying infectious process or aspiration.
3. Mild interstitial pulmonary edema
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS LEFT
INDICATION: ___ year old man with asymmetric leg swelling concern for DVT//
R/O DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the left common
femoral, 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 left lower extremity veins.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with ESRD on HD, dyspnea, evaluate for volume
status.
TECHNIQUE: Chest AP
COMPARISON: Comparison to prior radiograph studies dated ___ and ___.
FINDINGS:
Cardiomediastinal silhouette is moderately enlarged and unchanged. Mildly
improved bilateral interstitial opacities. No acute focal consolidation.
Unchanged bilateral pleural effusions, moderate left and small right, with
associated basilar atelectasis. No pneumothorax.
IMPRESSION:
1. Moderate pulmonary edema, mildly improved from prior study.
2. Unchanged small right and moderate left pleural effusions.
Radiology Report
EXAMINATION: Oropharyngeal swallow study
INDICATION: ___ year old man with hx stroke admitted for acute hypoxic
respiratory failure, c/f silent aspiration.// ?silent 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: 4 minutes and 45 seconds
COMPARISON: Esophagram dated ___
FINDINGS:
Penetration of thin and nectar thick liquids with no evidence for aspiration.
There was retention of contrast material in the proximal esophagus with
retrograde flow, most likely reflecting age-related proximal escape.
IMPRESSION:
1. Penetration of thin and nectar thick liquids with no evidence for
aspiration.
2. Proximal esophageal dysmotility, likely age related.
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).
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with Pneumonia, unspecified organism
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: c
level of acuity: 1.0 | SUMMARY STATEMENT:
==================
Mr. ___ is a ___ with hx of ESRD on dialysis (TTS),
cognitive impairment, stroke/small vessel ischemic changes, CAD,
T2DM, and hypothyroidism presenting with acute hypoxia likely
___ to pulmonary edema from volume overload and possibly
exacerbated by and aspiration event, now s/p HD on ___ and
___ with
decreasing O2 requirement.
ACUTE ISSUES
===========
#Acute hypoxic respiratory failure - resolved
#Volume overload - resolving
#Leukocytosis - resolved
#Aspiration Risk
Presenting with acute hypoxic respiratory failure requiring
BiPAP in MICU on admission. On clarification of history with
patient's family at bedside, presented with subacute worsening
of dyspnea overnight with no reported events of an acute
aspiration like event. CXR on admission showing volume overload
with possible e/o
concurrent aspiration. O2 requirement now improving after
undergoing dialysis. Did have a leukocytosis on admission c/f
possible aspiration PNA/HAP (as lives in nursing home) and was
covered broadly on vanc/ceftaz/azithromycin and now narrowing.
Our suspicion for a true pulmonary infection decreased with his
rapid improvement after dialysis given he had no fever, no
symptoms of cough, and he had recently completed a course of
levaquin for HAP a month ago. We stopped all antibiotics on
___ with continuing resolution of his leukocytosis with no
fevers subsequently. Speech and swallow evaluated the patient
with a video swallowing study which showed no evidence of
aspiration, but some penetration with thin>thick liquids that
worsened as a meal progressed. He was noted to be at high risk
for postprandial reflux and aspiration - it may be possible that
he had an aspiration event while sleeping prior to admission
leading to his acute hypoxic respiratory failure. They
recommended continuing a pureed dysphagia diet and nectar thick
liquids as an outpatient. On discharge, his respiratory status
was stable O2>92% on 1L NC with no signs of increased work of
breathing.
The following are recommendations by speech and swallow to
reduce patient's aspiration risk:
1. Aggressive means to reduce prandial aspiration risk while
accepting post-prandial aspiration risk:
-Pt to continue on current diet of pureed solids and nectar
thick liquids.
2. Moderate means to reduce prandial aspiration risk while
accepting post-prandial aspiration risk:
- Pt to continue on current diet of pureed solids and nectar
thick liquids with initiation ___ Free Water protocol
- Pt permitted to drink thin liquid water between meals and at
least 30 minutes after meals following oral care
- Pt must continue to drink nectar-thick liquids during meals
3. Mild-moderate means to reduce prandial aspiration risk while
accepting post-prandial aspiration risk:
- Pt to consume a diet of thin liquids and pureed solids
4. Limited means to reduce risk for prandial aspiration and
asphyxiation:
- Pt to drink thin liquids and any solid consistency with
acknowledgement of risk for aspiration and/or asphyxiation
#ESRD: HD schedule of ___ maintained and
he received dialysis on ___ and ___. Continued on home
sevelamer, ___ caps, and cinacalcet
#Respiratory acidosis: Inadequate ventilation in setting of
ongoing pulmonary process described above.
#LLE Edema: New onset left lower extremity edema. US showed no
signs of DVT
#at risk for malnutrition: was provided with Ensure puddings TID
with meals
CHRONIC ISSUES
=============
# Hip pain - Imaging negative for acute pathology. Pain control
with Tylenol.
# Depression - Continue home sertraline
# Dementia/prior infarct - Continue ASA 325
# Poor mobility - Continue ___ at rehab, ___ c/s while inpatient
# CAD - Continue aspirin, metoprolol, atorvastatin
# DM2 - HISS
# Hypertension - Continue amlodipine
# Anemia - Stable, likely AOI ___ ESRD. Did not require
transfusion while inpatient.
# Gout - Continue home allopurinol
# GERD - Continue home omeprazole
# BPH - No intervention
# Hypothyroidism - Continue home levothyroxine |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
Lumbar puncture
History of Present Illness:
___ with pituitary tumor, CML presented to ED yesterday after HA
that woke him up at 9:30AM -- severe, sudden, maximum severity
at onset, in the occipital region radiating to right temporal
area, associated with N/V x6-7. There was no syncope, no visual
changes, and no positional component to the HA per ER records.
He endorsed photo and phono phobia, and transient blurry vision,
with improvement in HA when supine to neurology consult.
In the ER pain ___, T 97.5, HR 71, BP 139/90, RR 18 100% SpO2.
CT head showed no bleeding. A CTA showed no evidence of
aneurysm, carotid or vertebral artery stenosis. LP showed 1
WBC, 0RBC, nl protein/gluc. Other labs unremarkable.
He was treated medically for migraine with minimal improvement
in headache. Neurology team was consulted and recommended
further MRV imaging and admission for pain control.
Other 12 pt ROS negative including no loss of vision, diplopia,
dysarthria,
dysphagia, lightheadedness, vertigo, tinnitus or hearing
difficulty. Denies difficulties producing or comprehending
speech. Denies focal weakness, numbness, parasthesias. No bowel
or bladder incontinence or retention. Denies difficulty with
gait.
Past Medical History:
- Chronic phase CML (dx'd ___ BCR-ABL negative) on Sprycel
since ___
- Pituitary adenoma ___ (frontal HA) -- per ___ outpatient
OMR notes, sequentially followed with increase in size from 9mm
to 12mm in ___ followed at ___; mild
hyperporlactinemia ___
- Posterior migraine HA
- right shoulder injury from MVA ___ years ago
- s/p surgery for hammer toe ___ years ago
- s/p surgery for deviated septum ~ ___ years ago
Social History:
___
Family History:
- Sister had ___ lymphoma
- Mother died during open heart surgery
- Father died ___ (age ___
Physical Exam:
ADMISSION PHYSICAL
VS: 97.6, 140/77, 56, 18, 100%RA
Alert, oriented, in NAD
EOMI, PERRLA, OP clear, no ___, neck supple
LUNGS CTA bilat
COR RRR nl S1, S2, no MRG
ABD soft, NT/ND
EXT no C/C/E
SKIN no lesions
NEURO fluent, non-dysarthric speech, nl cognition, CN2-12 intact
bilat, moves all extremities equally and spontaneously with ___
strength in all groups proximally and distally, DTRs equal and
symmetric 2+ throughout bilaterally, no dysdiodokinesis with
FTN/HTS testing, gait is normal and not wide-based
DISCHARGE PSYSICAL
GEN: well-apparing man in NAD
HEENT - EOMI, pinpoint pupils after AM dilaudid
LUNGS - CTA bilat
COR - RRR no MRG
ABD - soft NT/ND no masses
EXT - no edema
NEURO - fluent speech, alert, cognition intact, CN ___ intact,
moves in bed unassisted, no focal weakness, no sensory deficits
Pertinent Results:
Admission labs (blood):
WBC-6.3 RBC-4.43* HGB-13.8 HCT-39.8* MCV-90 RDW-12.4 PLT
COUNT-213
NEUTS-66.8 ___ MONOS-9.7 EOS-0.8* BASOS-1.0
CRP-1.1
SODIUM-136 POTASSIUM-3.9 CHLORIDE-99 TOTAL CO2-18* UREA N-14
CREAT-1.0 GLUCOSE-115*
CALCIUM-10.0 PHOSPHATE-2.5* MAGNESIUM-2.0
PTT-30.8 ___
Lumbar puncture:
TNC-1 RBC-0 POLYS-0 ___ MONOS-14
PROTEIN-65* GLUCOSE-57 LD(LDH)-15
Endocrine labs:
TSH:0.58, free-T4:0.7, T3: 69
LH: 1.6
Prolact: 28
AM cortisol: 1.1 (increased to 20.2 on ___ stim)
Testost: 75
SHBG: 29
calcFT: 15
___ HEAD CT:
No acute intracranial process.
___ MRI/MRV:
1. 22 x 17 x 15 mm sellar mass with suprasellar extension has
increased in size compared to ___, with areas of central
T2 hyperintensity and hypoenhancement which may represent a
component of necrosis and areas of intrinsic T1 hyperintensity
likely representing intralesional hemorrhage.
2. Otherwise no acute hemorrhage, infarct, or new enhancing
mass.
3. No evidence of cerebral venous thrombosis. No evidence for
venous sinus thrombosis.
4. Mild paranasal sinus disease, as described.
5. Minimal areas of scattered white matter signal abnormality,
likely reflecting chronic small vessel ischemic disease in a
patient of this age.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. DASatinib 100 mg PO DAILY
2. LORazepam 0.5 mg PO QHS:PRN insomnia
3. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild
Discharge Medications:
1. Hydrocortisone 20 mg PO DAILY
RX *hydrocortisone 10 mg 3 tablet(s) by mouth Daily Disp #*100
Tablet Refills:*0
2. Hydrocortisone 10 mg PO QPM
3. Levothyroxine Sodium 88 mcg PO DAILY
RX *levothyroxine 88 mcg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Severe
Duration: 5 Days
RX *oxycodone 5 mg 1 capsule(s) by mouth q4h PRN Disp #*20
Capsule Refills:*0
5. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild
6. DASatinib 100 mg PO DAILY
7. LORazepam 0.5 mg PO QHS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
Headache
Pituitray adenoma
CML
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Q16
INDICATION: ___ w/worst headache of life, refusing LP, please eval for
aneursym// ___ w/worst headache of life, refusing LP, please eval for aneursym
TECHNIQUE: CT of the head was acquired. Following contrast administration and
departmental protocol CT angiography of the head and neck was obtained. 3D
and curved reformatted images were obtained on the independent workstation.
DOSE: Total DLP (Head) = 1,441 mGy-cm.
COMPARISON: Head CT of the same day.
FINDINGS:
CT angiography of the neck shows normal appearance of the carotid and
vertebral arteries without stenosis or occlusion or dissection. Early
vascular calcifications are seen at the right carotid bifurcation.
CT angiography of the head shows normal appearance of the arteries of the
anterior and posterior circulation without stenosis or occlusion or aneurysm
greater than 3 mm in size.
IMPRESSION:
No significant abnormalities on CT angiography of the head indent neck.
Radiology Report
EXAMINATION: MRI AND MRA BRAIN PT12 MR HEAD
INDICATION: History of pituitary adenoma, CML, migraines admitted with severe
acute onset headache with unremarkable CTA and lumbar puncture. Assess
pituitary adenoma and evaluate for cerebral venous thrombosis.
TECHNIQUE: Sagittal and coronal T1 weighted imaging were performed along with
coronal T2 imaging. Sagittal and coronal T1 weighted imaging were repeated
after the uneventful intravenous administration of 10 mL of Gadavist contrast.
Axial T2, FLAIR, T1 post, diffusion, as well as sagittal MP-RAGE images with
axial and coronal reformats.
3D phase-contrast MRV of the head was obtained. Sagittal T1 weighted imaging
was performed. Three dimensional maximum intensity projection and segmented
images of the MRV were then generated. This report is based on interpretation
of all of these images.
COMPARISON CTA head and neck ___. Noncontrast head CT ___. MR pituitary ___. MR head ___.
FINDINGS:
MR pituitary: There has been prominent interval increase in size of a
lobulated, intra sellar and suprasellar hypoenhancing, mainly T2 hyperintense
mass measuring up to 22 x 17 x 15 mm, previously 11 x 11 x 11 mm in ___. This lesion demonstrates areas of intrinsic T1 hyperintensity, likely
representing hemorrhage. There may be a thin rim of residual pituitary
tissue, flattening within the base of the sella. The mass encases a roughly
30% circumference of the right internal carotid artery, with preserved flow
void. The mass approaches the optic chiasm, without contact. There is
increased leftward deviation of the infundibulum secondary to mass effect
(series 12, image 8). The cavernous sinuses appear preserved.
MR brain: There is no acute edema, new mass, mass effect, or infarct. The
ventricles and sulci are normal in size and configuration for age. Mild
scattered areas of periventricular and subcortical white matter T2/FLAIR
hyperintensity most likely reflect the sequela of chronic small vessel
ischemic disease. There is no abnormal focus of slowed diffusion. The dural
venous sinuses are patent on MP-RAGE images. No extra-axial abnormal FLAIR/T2
signal. The principal intracranial vascular flow voids are preserved. No
other enhancing lesion is identified.
There is mild mucosal wall thickening in the floors of the maxillary sinuses
with a small mucous retention cyst on the left, mild mucosal wall thickening
of the sphenoid sinuses and bilateral anterior ethmoid air cells. The frontal
sinuses are clear. The orbits are grossly unremarkable. The mastoid air
cells are clear.
MRV: Normal flow signal is demonstrated within the superior sagittal sinus,
straight sinus, transverse sinuses, and sigmoid sinuses. The jugular bulbs and
proximal jugular veins are patent. Evaluation of the deep venous systems
reveals normal flow signal in the internal cerebral veins. The vein ___
is also unremarkable.
IMPRESSION:
1. 22 x 17 x 15 mm sellar mass with suprasellar extension has increased in
size compared to ___, with areas of central T2 hyperintensity and
hypoenhancement which may represent a component of necrosis and areas of
intrinsic T1 hyperintensity likely representing intralesional hemorrhage.
2. Otherwise no acute hemorrhage, infarct, or new enhancing mass.
3. No evidence of cerebral venous thrombosis. No evidence for venous sinus
thrombosis.
4. Mild paranasal sinus disease, as described.
5. Minimal areas of scattered white matter signal abnormality, likely
reflecting chronic small vessel ischemic disease in a patient of this age.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Headache, N/V
Diagnosed with Headache
temperature: 97.5
heartrate: 71.0
resprate: 18.0
o2sat: 100.0
sbp: 139.0
dbp: 90.0
level of pain: 9
level of acuity: 2.0 | ___ w/ pituitary tumor, CML (on Sprycel), and presumed OSA
presenting with severe headache. CT and LP were both
unremarkable for any evidence of acute bleed, but MRI showed
enlargement of known pituitary mass (>2cm) with hemorrhage.
He was seen by neurology who noted that his neurologic exam was
"unremarkable aside from symmetrically brisk reflexes." Visual
field was evaluated by opthalmology, who did not find evidence
of peripheral vision loss that would suggest any compression of
the optic chiasm. Per ophtho's note: "ophthalmology evaluation
revealed best corrected visual acuity of ___ bilaterally,
dilated fundus examination was normal, including
normal-appearing optic nerves without signs of edema (to suggest
acute compression) or pallor (to suggest chronic compression and
atrophy). Notably, automated visual field testing showed... no
detectable temporal field defects on visual fields to suggest
pituitary compression at the optic chiasm." Following this
workup, he was seen by neurosurgery who opined that there was no
acute neurosurgical issue and asked that he follow up in clinic.
Endocrine workup was notable for panhypopituitarism. Notably, AM
cortisol was 1.1 (and increased to 20.2 one hour after
cosyntropin); free T4 was 0.7 and T3 was 69. He was seen by
endocrinology, who suggested starting levothyroxine 88 mcg and
steroid replacement with hydrocortisone 20mg qam (9am) and 10mg
qpm (3pm) daily. The patient was much improved after starting
cortisol and reported that his fatigue, malaise and headache
were all much better.
He was instructed to double his dose of steroid replacement any
time he has an acute infection, and also to obtain a medical
alert bracelet stating that he has central adrenal insufficiency
and central hypothyroidism (in case he presents to an ER
unconconscious from adrenal crisis or myxedema coma
respectively). He will follow closely with his outpatient
endocrinologist Dr. ___.
It was not entirely clear whether the headache was related to
this hemorrhage, or whether it was unrelated, but it improved
steadily throughout his admission and he was discharged with
oxycodone for the residual pain. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Amoxicillin / simvastatin / morphine
Attending: ___.
Chief Complaint:
syncope, diarrhea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ PMHx T2DM, HTN, HLD admitted after syncopal event in setting
of recent diarrheal illness. Pt was feeling well until this
morning, when she felt "clammy." She later had an episode of
diarrhea. She denies any noticing any blood or mucous in her
stool. She also had associated nausea and abdominal crampy but
no emesis. As she was returning to bed, she had an unwitnessed
syncopal event. The pt thinks she may have hit her head. Her
husband found her on the ground next to her bed. The pt
reported lightheadedness prior to the event. No chest pain or
palpitations. She did not have bowel or bladder incontinence.
Her husband did not note any abnormal movements. The pt denied
any confusion following the event. Per EMS, her SBP was in the
___ upon arrival, finger stick was in the 200s.
In the ED, initial vitals were: 98.3 94/41 73 18 99%RA
Labs notable for mild leukocytosis (WBC 11.3) with neutrophil
predominance (73.3 % SNs), Hct 47.3, normal coags, BUN/Cr ___
(b/l Cr 0.7-0.9), lactate 2.5, AST 57, ALT 30, Alk Phs 171, nl
Tbili, nl lipase, neg trop x 1, UA negative for infection.
Urine and blood cultures sent.
Imaging notable for CXR without evidence of pneumonia
Patient was given 2L IVF
Decision was made to admit for further management of syncope and
diarrhea.
On the floor, vitals were: 98.7 121/62 82 20 100RA. The pt
reports that she feels fatigued. She denies any current
abdominal pain. She had one episode of diarrhea in the ED, that
reportedly had small amount of bright red blood, no mucous. She
denies any fevers or chills. No nausea or emesis. No chest
pain or palpitations. ROS otherwise negative. No recent travel
or sick contacts. No recent antibiotic use.
Review of systems:
(+) Per HPI, otherwise negative
Past Medical History:
- Hypertension
- Hyperlipidemia
- T2DM
- Sciatica
- s/p lap cholecystectomy
Social History:
___
Family History:
- sister with stroke at age ___ in context of drug use.
- Parents are alive with HTN and DM.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.7 121/62 82 20 100RA
General: Alert, oriented, no acute distress
HEENT: NCAT, no scalp tenderness, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non tender, normoactive BS, no organomegaly, no
rebound tenderness
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
DISCHARGE PHYSICAL EXAM:
VS: 98.4 109/61 69 18 100RA
General: Alert, oriented, no acute distress
HEENT: NCAT, no scalp tenderness, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non tender, normoactive BS, no organomegaly, no
rebound tenderness
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Pertinent Results:
LABORATORY STUDIES ON ADMISSION
====================================
___ 07:38AM BLOOD WBC-11.3* RBC-5.44*# Hgb-15.5# Hct-47.3*#
MCV-87 MCH-28.5 MCHC-32.8 RDW-14.0 RDWSD-44.0 Plt ___
___ 07:38AM BLOOD Neuts-73.3* ___ Monos-3.6*
Eos-0.6* Baso-0.4 Im ___ AbsNeut-8.26* AbsLymp-2.40
AbsMono-0.41 AbsEos-0.07 AbsBaso-0.04
___ 07:38AM BLOOD ___ PTT-28.9 ___
___ 07:38AM BLOOD Glucose-293* UreaN-24* Creat-1.2* Na-134
K-7.1* Cl-102 HCO3-27 AnGap-12
___ 07:38AM BLOOD ALT-30 AST-57* AlkPhos-171* TotBili-0.3
___ 07:38AM BLOOD Lipase-52
___ 07:38AM BLOOD cTropnT-<0.01
___ 07:38AM BLOOD Albumin-3.9 Calcium-9.8 Phos-4.3 Mg-2.1
___ 09:40AM BLOOD K-3.8
___ 07:48AM BLOOD Lactate-2.5* K-7.5*
___ 09:06AM URINE Color-AMBER Appear-Hazy Sp ___
___ 09:06AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-4* pH-5.5 Leuks-NEG
___ 09:06AM URINE RBC-2 WBC-1 Bacteri-FEW Yeast-NONE Epi-1
___ 09:06AM URINE CastHy-20*
___ 09:06AM URINE Mucous-RARE
LABORATORY STUDIES ON DISCHARGE
====================================
___ 09:45AM BLOOD WBC-10.0 RBC-4.23 Hgb-12.2# Hct-36.6#
MCV-87 MCH-28.8 MCHC-33.3 RDW-13.9 RDWSD-43.2 Plt ___
___ 09:45AM BLOOD Glucose-192* UreaN-14 Creat-0.6 Na-141
K-3.9 Cl-105 HCO3-25 AnGap-15
___ 09:45AM BLOOD Calcium-9.0 Phos-2.0*# Mg-1.8
MICROBIOLOGY
====================================
BLOOD CULTURE: PENDING
URINE CULTURE: PENDING
IMAGING
====================================
CXR (___): no radiographic evidence of pneumonia.
+ EKG: rate 67, NSR, left axis deviation, delayed R wave
progression old anteroseptal infarct
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ woman with hypotension evaluate for acute process
TECHNIQUE: Portable chest radiograph
COMPARISON: Chest radiograph ___ and ___
FINDINGS:
The cardiomediastinal silhouette is normal. There is no pleural effusion or
pneumothorax. There is no focal lung consolidation. The aortic knob is
calcified. Note is made of mild left acromioclavicular arthropathy.
IMPRESSION:
No radiographic evidence of pneumonia.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Diarrhea, Syncope
Diagnosed with Syncope and collapse
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: 5
level of acuity: 1.0 | ___ PMHx T2DM, HTN, HLD admitted after syncopal event likely ___
orthostasis in setting of recent diarrheal illness.
# Syncope, secondary to orthostasis
Pt presented after syncopal event likely secondary to
orthostasis in setting of diarrheal illness and poor oral
intake. Pt was found to have postural hypotension, for which
she was given IVF and her home anti-hypertensives were held.
She has no known structural heart disease, EKG was without
ischemic changes, and cardiac enzymes were negative. Pt was
monitored on telemetry overnight without events noted. On
discharge, pt was hemodynamicaly stable without orthostasis.
One of her anti-hypertensives was held on discharge, with plans
to follow-up with PCP for consideration of restarting
medications.
# Diarrhea
Pt presented with one day history of diarrhea and signs of
severe volume depletion. However, pt had no signs of systemic
toxicity with no documented fevers or leukocytosis. During
admission, pt had no further episodes of diarrhea, so stool
studies were not sent. She was given IVF with good response.
Tolerating PO on discharge.
# Acute kidney injury
Baseline Creatinine 0.7-0.9. On admission, pt noted to have
elevated creatinine to 1.2. Likely secondary to pre-renal
azotemia in setting of volume depletion from diarrheal illness.
Improved with IVF.
TRANSITIONAL ISSUES
==========================
1. Home dose lisinopril was held upon discharge. Pt to follow
up with PCP for consideration of restarting.
2. Pt needs follow-up with PCP within one week of discharge
3. Home dose potassium held upon discharge. Patient to clarify
with PCP dosing and indication.
# CODE: Full (confirmed)
# CONTACT: ___ (husband/HCP) ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Wide complex tachycardia
Major Surgical or Invasive Procedure:
Venricular tachycardia ablation
History of Present Illness:
Mr. ___ is an ___ y/o M with PMH of TIAs and prostate Ca
undegoing active Tx who presented to his PCP's office today with
new SOB. Patient described SOB as worst with exertion but
present even at rest. Does describe URI Sx recently. Reportedly
found to have afib w/ RVR @ rates of 180-200bpm at PCP's office
and sent to the ED.
The patient has been c/o SOB to his PCP for the past ___ years but
worsening recently. An ECG ordered to evaluate this new
complaint on ___ showed a new RBBB and new inferior Q waves. An
echo revealed normal LVEF and no wall motion abnormalities, mild
AI. A stress echo showed no wall motion abnormalities.
In addition to the above, the patient has been having
blood-tinged diarrhea since this past ___. This has
improved somewhat.
In the ED, the patient's initial VS were 98.4 190 94/61 20 97%.
An ECG revealed wide-complex tachycardia which was initially
thought to represent VT and started on amiodarone. Rate slowed
and was found to ahve afib w/ RVR, rate controlled with amio to
192-->124. Seen by at___ cardiology who recommended
transitioning to a dilt drip given unknown duration of afib.
Also found to be guiac (+) and given 1 unit PRBCs in the setting
of hypotension. Labs notable for WBC of 11.3, HCO3- of 16, and
lactate of 2.3. Admitted to the CCU for further management of
afib w/ RVR and hypotension.
On arrival to the floor, patient's VS were 124/82 124 16 98%RA.
Patient on monitor had multiple episodes of HR in the 190s. Wide
complex. Felt lightheaded at the time. Broke with lidocaine
push.
REVIEW OF SYSTEMS
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis. S/he
denies recent fevers, chills or rigors. S/he denies exertional
buttock or calf pain. All of the other review of systems were
negative.
Past Medical History:
- h/o TIAs ___ and more recently ___. Evaluated at ___. Work
up with negative MRI-MRA of head and neck, negative telemetry,
negative echo with bubble. Never had a holter or event
recorder.
- Prostate Cancer - s/p radiation and chemoRx. Now on Zoladex
every 3 months, last dose ___
- HTN
- HL
- Open angle glaucoma
- A. Fib with RVR and aberrance
- Ventricular Tachycardia
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL
VS: 124/82 124 16 98%RA
GENERAL: Lying in bed in NAD
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with no JVD
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, Irregularly irregular, S1, S2. No m/r/g. No thrills,
lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
.
DISCHARGE PHYSICAL
Vitals - Tmax 98.8/98.3, HR 57-60, RR ___, BP 91-117/72-79, O2
sat: 96% RA
I/O
24H:
8H;
Weight: 83.8 (83.3)
Tele: ___, SR
.
GENERAL: Pleasant in NAD. Alert and interactive.
NECK: supple without lymphadenopathy, unable to assess JVD ___
beard.
___: NSR. No S3 or S4 no rubs or gallops.
RESP: No accessory muscle use. Lungs with fine crackles at
bases, clear somewhat with deep breath.
ABD: soft, NT/ND, normoactive bowel sounds.
EXTR: no edema. Feet warm. Vascular access points bilat with
mild vbruising, no drainage or tenderness.
NEURO: Alert and oriented x 3. Denies pain. MAE
Pertinent Results:
ADMISSION LABS
___ 03:30PM BLOOD WBC-11.8*# RBC-4.72 Hgb-14.8 Hct-44.5
MCV-94 MCH-31.3 MCHC-33.2 RDW-13.9 Plt ___
___ 03:30PM BLOOD Neuts-71.7* ___ Monos-6.9 Eos-0.9
Baso-0.7
___ 03:30PM BLOOD ___ PTT-30.6 ___
___ 03:30PM BLOOD Glucose-98 UreaN-26* Creat-1.2 Na-139
K-3.7 Cl-104 HCO3-16* AnGap-23*
___ 03:30PM BLOOD Calcium-8.7 Phos-3.5 Mg-2.0
___ 03:39PM BLOOD Lactate-2.3*
.
IMAGING:
___ CXR
FINDINGS: The lung volumes are low. There is moderate blunting
of the
costophrenic sinus on the right, potentially reflecting a
minimal right
pleural effusion. Moderate cardiomegaly but no overt pulmonary
edema. No
pneumonia. Calcified lymph nodes in the mediastinum and the
right hilus.
___ ECHO
Conclusions
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. The right atrial appendage
ejection velocity is depressed (<0.2m/s). No atrial septal
defect is seen by 2D or color Doppler. There is symmetric left
ventricular hypertrophy. Overall left ventricular systolic
function is normal (LVEF>55%). The aortic valve leaflets (3) are
mildly thickened. Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild to moderate
(___) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. No thrombus seen in the
atria or atrial appendages. Mild-to-moderate mitral
regurgitation. Mild aortic regurgitation. Symmetric left
ventricular hypertrophy with preserved systolic function.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Goserelin Acetate 10.8 mg SC 1 IMPLANT EVERY 3 MONTHS
2. Pravastatin 20 mg PO DAILY
3. abiraterone *NF* 1000 mg Oral daily
take 1 hour prior to meals
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
7. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
8. Aspirin 81 mg PO DAILY
9. PredniSONE 5 mg PO BID
10. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. abiraterone *NF* 1000 mg Oral daily
2. Goserelin Acetate 10.8 mg SC 1 IMPLANT EVERY 3 MONTHS
3. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
4. Warfarin 3 mg PO DAILY16
5. Amiodarone 600 mg PO DAILY Duration: 2 Days
then decrease to 2 tablets a day
6. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
8. Pravastatin 20 mg PO DAILY
9. PredniSONE 5 mg PO BID
10. Vitamin D 1000 UNIT PO DAILY
11. brimonidine *NF* 1 DROP ___ BID
12. Omeprazole 20 mg PO DAILY
13. Enoxaparin Sodium 80 mg SC BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Ventricular tachycardia
Atrial fibrillation with rapid ventricular response
Acute blood loss anemia
Hyperlipidemia
Hypertension
Prostate Cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH
INDICATION: Prostate cancer, evaluation for pulmonary edema.
COMPARISON: No comparison available at the time of dictation.
FINDINGS: The lung volumes are low. There is moderate blunting of the
costophrenic sinus on the right, potentially reflecting a minimal right
pleural effusion. Moderate cardiomegaly but no overt pulmonary edema. No
pneumonia. Calcified lymph nodes in the mediastinum and the right hilus.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: RAPID AFIB
Diagnosed with PAROX VENTRIC TACHYCARD, GASTROINTEST HEMORR NOS, ATRIAL FIBRILLATION
temperature: 98.4
heartrate: 190.0
resprate: 20.0
o2sat: 97.0
sbp: 94.0
dbp: 61.0
level of pain: 0
level of acuity: 1.0 | ASSESSMENT AND PLAN: ___ y/o M with PMH of prostate CA and TIAs
who presented with wide complex tachycardia.
# Ventricular Tachycardia. Patient initially presented with wide
complex tachycardia. At the time difficult to determine if it
was VT or A. Fib with RVR. Cardioverted back to sinus rhythm, at
which time patient continued to have runs of VT. EP study found
inducible VT but could not localize the lesion due to the short
duration of the VTs. Ablated a large around around the suspected
lesion, but he continued to have episodes of NSVT. Amiodarone
started on ___. Plan to load with 600mg daily for 5 days then
400mg daily. Will follow up with Atrius cardiology as outpatient
to further titrate dose.
# A. Fib with RVR with aberrance. CHADS2 score of 4.
Cardioverted to sinus rhythm. During EP procedure above,
returned to A. Fib and transient heart block, but self converted
back to sinus rhythm. Maintained on Heparin gtt. Bridging with
Lovenox to coumadin. Amiodarone loaded as above.
# Prostate CA - Has Goserelin implant. Touched base with
patient's oncologist who is ok with warfarin.
# HL. Continued home statin.
# Glaucoma. Continued eye drops.
TRANSITIONAL ISSUES:
CODE STATUS: FULL
COMMUNICATION: Wife ___ ___
- f/u INR
- f/u Amiodarone dose |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Tetracycline Analogues / Bactrim / Egg / Sulfa (Sulfonamide
Antibiotics) / Avelox / Flexeril
Attending: ___.
Chief Complaint:
Worsening lower extremity weakness
Major Surgical or Invasive Procedure:
1. Laminectomy T12-L1, L1-L2, L2-L3.
2. Removal intraspinal abscess lumbar.
3. Open biopsy bone, lumbar.
4. Lateral extracavitary corpectomy, L1.
5. Posterior interbody fusion L1-L2.
6. Autograft, local, for fusion.
7. Posterior fusion L1-L2.
History of Present Illness:
___ with MRSA bacteremia, right foot and L2 vertebral osteo on
ceftaroline, who is admitted from rehab with subacute worsening
of weakness in his BLE.
Pt has had subacute worsening BLE weakness over the last 6
weeks, with inability to ambulate and now almost complete
inability to move either leg or participate in rehab. These
symptoms have been slowly worsening over this time though it is
unclear why he has not had any interval spinal assessment since
then. Per his family there was concern for urinary retention 2
days ago at rehab and had a foley placed, which was removed in
the ED. He has not voided since. No bowel incontinence. He has
baseline stocking/glove neuropathy to his bilateral mid shins
which is unchanged. He denies fevers. The physicians at rehab
were concerned about his worsening weakness and sent him to the
ED for evaluation.
Recent history notable for admission ___ for AMS in the
setting of flexeril initiation, where he had his pain medication
regimen adjusted, ___ requiring lasix downtitration, Cdiff s/p
PO vanc course. It was recommended that he have a wound VAC for
his foot ulcer but per his family he has not had this on. he has
a PICC which has been working well.
Of note, he is on ceftaroline bc ___ ___ vancomycin.
In the ED vitals were: 98.1, HR 80-90s, BP ___, RR
___, SpO2 96-100% on RA. Spinal MRI (which required IV
dilaudid and versed) revealed worsening osteomyelitis at
multiple vertebral levels. Spine surgery recommended admission
to medicine and decompressive laminectomy and washout tomorrow,
though they are not optimistic that he will regain function. His
CRP was down to 55 from 75 2 weeks ago.
On the floor, the pt is without acute complaints.
Review of Systems: +/- per HPI.
Past Medical History:
ADULT ONSET DIABETES MELLITUS
GOUT
HYPOKALEMIA
RENAL INSUFFICIENCY
SINUSITIS
WEGENERS GRANULOMATOSIS
LEFT CHARCOT FOOT, c/b right foot ulcer/osteomyelitis
PROGRESSIVE GLOMERULONEPHRITIS
MRSA bacteremia and vertebral osteomyelitis
Social History:
___
Family History:
Family history of diabetes in his mother and grandparents.
Physical Exam:
PHYSICAL EXAM:
ADMISSION PHYSICAL
Vitals - 98.1 91 105/55 100% RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, NECK: nontender supple neck, no JVD
CARDIAC: 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: no cyanosis, clubbing or edema. Punched out R
forefoot ulcer without signs of infection. Signs of chronic
venous stasis. PICC site with slight erythema without drainage
noted
NEURO: CN II-XII intact, full strength/sensation in bilateral
upper arms, bilateral lower extremities unable to be lifted off
the bed, can wiggle toes, all muscle groups will fire but
minimal movement and virtually no resistance to confrontation.
Globally hyporeflexic. Decreased sensation in a stocking glove
pattern up to the mid shin. No spinal tenderness on limited exam
but pt declines to be rolled for full posterior exam and rectal.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
PERTINENT INTERIM PHYSICAL EXAM
Extremities: R plantar foot ulcer 3x2cm approx 1cm deep, no
visible bone, no appearance of infection, surrounding erythema.
Three superficial pressure spots appear red, no evidence of
ulcer, located on ventral surface of foot. Signs of chronic
venous stasis. PICC site without erythema or drainage. Large
callous on bottom of left foot. Feet in waffle boots.
BACK- evidence of 2 open sacral pressure ulcer in between
gluteal fold roughly 2X2cm. Surrounding erythmea/appearance of
fungal infection. Lumbar region incision covered with dressing,
C/d/i, staples in place no pus or bleeding.
DISCHARGE PHYSICAL EXAM:
Vitals - Tm 98.3 62 ___ 97%RA
GENERAL: laying in bed
HEENT: AT/NC, EOMI,
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs, no pain with
palpation
LUNG: CTAB in anterior/lateral ___, no wheezes, rales,
rhonchi, breathing comfortably without use of accessory muscles
ABDOMEN: nondistended, +BS, tenderness to deep palpation in LLQ
with palapable soft tissue, no rebound/guarding, no
hepatosplenomegaly
EXTREMITIES: no edema. Waffle boots and dressing in place,
c/d/i.
NEURO: CN II-XII intact, bilateral lower extremities unable to
lift off the bed, can move toes, all muscle groups will fire
with increasing intesity, patient had improving dorsiflex and
plantarflex feet. New minimal flexion and extension of knee.
Able to slide legs side to side. Left greater than right.
Decreased sensation in a stocking glove pattern up to the mid
shin.
GU: foley catheter in place
Pertinent Results:
ADMISSION LABS:
___ 02:54PM BLOOD WBC-5.8 RBC-3.31* Hgb-10.1* Hct-30.7*
MCV-93 MCH-30.5 MCHC-33.0 RDW-17.2* Plt ___
___ 02:54PM BLOOD Neuts-75.0* Lymphs-15.4* Monos-6.4
Eos-2.7 Baso-0.5
___ 02:54PM BLOOD ___ PTT-32.2 ___
___ 02:54PM BLOOD Glucose-110* UreaN-58* Creat-2.2* Na-136
K-4.2 Cl-103 HCO3-21* AnGap-16
___ 02:54PM URINE Color-Yellow Appear-Hazy Sp ___
___ 02:54PM URINE Blood-TR Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 02:54PM URINE RBC-7* WBC-78* Bacteri-FEW Yeast-FEW
Epi-0
___ 02:54PM URINE CastHy-7*
PERTINENT LABS:
___ 06:40AM BLOOD WBC-4.6 RBC-2.51* Hgb-7.6* Hct-23.5*
MCV-94 MCH-30.5 MCHC-32.6 RDW-17.1* Plt ___
___ 05:50AM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-1+ Schisto-1+
___ 05:21AM BLOOD ___ PTT-73.9* ___
___ 05:10AM BLOOD ___ PTT-150* ___
___ 08:15PM BLOOD ___ PTT-101.7* ___
___ 07:02AM BLOOD ___ PTT-88.4* ___
___ 04:00PM BLOOD ___
___ 05:07AM BLOOD Ret Aut-1.9
___ 06:39AM BLOOD ALT-26 AST-18 CK(CPK)-41* AlkPhos-120
TotBili-0.5
___ 05:10AM BLOOD ALT-12 AST-16 CK(CPK)-23* AlkPhos-103
TotBili-0.2
___ 05:07AM BLOOD proBNP-1178*
___ 04:00PM BLOOD CK-MB-2 cTropnT-0.06*
___ 08:45PM BLOOD CK-MB-1 cTropnT-0.04*
___ 06:40AM BLOOD CK-MB-1 cTropnT-0.04*
___ 05:50AM BLOOD calTIBC-125* Hapto-366* Ferritn-475*
TRF-96*
___ 06:40AM BLOOD VitB12-813
___ 05:07AM BLOOD TSH-0.22*
___ 06:40AM BLOOD TSH-0.17*
___ 06:30AM BLOOD T4-2.9* T3-48*
___ 02:54PM BLOOD CRP-55.0*
DISCHARGE LABS:
___ 07:02AM BLOOD WBC-5.0 RBC-2.53* Hgb-7.8* Hct-24.4*
MCV-96 MCH-30.9 MCHC-32.1 RDW-18.7* Plt ___
___ 10:17AM BLOOD ___ PTT-142.5* ___
___ 07:02AM BLOOD Glucose-79 UreaN-14 Creat-1.4* Na-139
K-3.7 Cl-107 HCO3-21* AnGap-15
___ 05:10AM BLOOD ALT-12 AST-16 CK(CPK)-23* AlkPhos-103
TotBili-0.2
___ 07:02AM BLOOD Calcium-9.0 Phos-3.7# Mg-1.7
MICRO:
___ 12:41 am URINE Site: CATHETER
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. >100,000 ORGANISMS/ML..
___ 3:00 pm BLOOD CULTURE Source: Line-PICC.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 1:50 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 8:30 pm SWAB L1-L2 DISC FLUID.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___:
A swab is not the optimal specimen collection to evaluate
body
fluids.
NO GROWTH.
___ 8:30 pm TISSUE L1-L2 DISC.
*FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
___ 2:54 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. >100,000 ORGANISMS/ML..
___ 2:54 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING/REPORT:
___ Imaging MR ___ SPINE W/O CONTRAST
FINDINGS:
Alignment is normal.
There is increased T2/STIR signal in the L1-2 intervertebral
disc, L1
vertebra, and L2 vertebra, consistent with discitis
osteomyelitis. There is similar increased T2/STIR signal in the
L2-3 intervertebral disc and superior endplate of L3, also
consistent with discitis osteomyelitis. The amount of abnormal
signal within these discs and vertebrae has markedly increased
from MRI on ___, consistent with progressive
disease. Evaluation for epidural abscess is limited due to the
absence of intravenous contrast. Within this limitation, no
fluid collection is identified within the spinal canal. There is
inflammation of the left psoas muscle, new from prior MRI.
Spinal canal stenosis at L1-2 and L2-3 is due to degenerative
disc and joint disease and ligamentum flavum thickening. The
stenoses are unchanged from MRI on ___. There are
disc bulges and protrusions at L3-4, L4-5, and L5-S1, also
unchanged from prior MRI.
IMPRESSION:
1. Worsening discitis osteomyelitis at L1-2 and L2-3 compared to
prior MRI from ___. Evaluation for epidural abscess
is limited without intravenous contrast but no fluid collection
is identified within the spinal canal. New inflammation of the
left psoas muscle.
2. Degenerative disc and joint disease throughout the lumbar
spine, worst at L1-2 and L2-3 and causing spinal canal stenosis.
This is unchangedfrom MRI on ___.
___ Pathology Tissue: INTERVERTEBRAL DISC
PATHOLOGIC DIAGNOSIS:
Intervertebral disc, L1-L2, laminectomy (1A):
Acute and chronic inflammation with necrotic bone and
granulation tissue; bony reparative changes.
___ Imaging CHEST (PORTABLE AP)
As compared to the previous radiograph, no relevant change is
seen. The lung volumes are normal. Normal size of the cardiac
silhouette. Normal hilar and mediastinal structures.
Unremarkable course of the PICC line. No pleural effusions. No
pulmonary edema.
___ Imaging LUMBAR SINGLE VIEW
FINDINGS:
Localizing devices are noted posterior to the L2 vertebral body.
The bones are demineralized. Destructive changes are noted at
the inferior endplate of L1 and superior endplate of L2 with
associated intervertebral disk space narrowing consistent with
discitis osteomyelitis as seen on prior MRI. The remainder of
the vertebral body heights are grossly maintained without
evidence for a compression fracture. There is no vertebral body
subluxation. There is mild to moderate intervertebral disk space
narrowing with marginal osteophyte formation.
IMPRESSION:
Localizing devices noted posterior to the L2 vertebral body.
Please see the operative report for further details. Endplate
destructive changes and intervertebral disk space narrowing at
L1-L2 consistent with osteomyelitis as seen on the prior MRI.
Mild to moderate multilevel degenerative disc.
___ Imaging BILAT LOWER EXT VEINS
RIGHT LEG: The right common femoral vein contains partially
occlusive
thrombus that extends to the proximal portion of the right deep
femoral vein. The right superficial femoral veins, popliteal
and 1 of the paired posterior tibial vein are patent. The other
posterior tibial vein in the right upper calf appears
thrombosed. The right peroneal veins were not visualized.
LEFT LEG: Partially occlusive thrombus is noted within the left
common
femoral vein which extends throughout the left superficial
femoral vein and left popliteal vein. The left posterior tibial
veins are completely
thrombosed and no flow is seen in the peroneal veins. The left
deep femoral vein appears patent.
___ Cardiovascular 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. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). The right
ventricular cavity is mildly dilated 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. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion.
IMPRESSION: Symmetric LVH with normal global and regional
systolic function. Mild RV dilation. Mild mitral regurgitation.
___BD & PELVIS W/O CON
There is a stable 6 mm nodule in the right middle lobe (2:5), as
well as a stable 4 mm nodule inferiorly to this (2:9).
LIVER: Given the limits of evaluation without IV contrast, the
liver is
homogeneous and unremarkable. The non-distended gallbladder is
within normal limits, without wall thickening or pericholecystic
fluid.
SPLEEN: The spleen is homogeneous and at the upper limits of
normal in size, measuring 13.2 cm, unchanged from before.
PANCREAS: The pancreas is without focal lesion or peripancreatic
stranding or fluid collection.
ADRENALS: The adrenal glands are visualized and unremarkable.
KIDNEYS: Two simple cysts are again seen in the right kidney,
the largest of which measures 4.4 x 3.8 and simple cyst at the
upper pole, largely unchanged (601b:44 and 2:25). There is also
unchanged bilateral perinephric stranding.
GI:The stomach is notably distended without an intraluminal mass
or wall
thickening.The small and large bowel are within normal limits,
without wall thickening or evidence of obstruction. There is a
fat containing periumbilical hernia.
RETROPERITONEUM: The aorta and common iliac vessels are normal
in caliber, with mild atherosclerotic calcifications. There are
multiple prominent retroperitoneal and mesenteric lymph nodes,
however none of these meet CT size criteria for pathologic
enlargement. No evidence of retroperitoneal bleed.
CT PELVIS: The urinary bladder appears normal without wall
thickening. There is a Foley catheter within the bladder.No
pelvic wall or inguinal lymph node enlargement by CT size
criteria is seen. The previously described right external iliac
lymph node with a fatty hilum is unchanged (2:70).There is no
pelvic free fluid.There are no inguinal hernias.
SOFT TISSUES: Again seen is asymmetric induration of the soft
tissues above the umbilicus, left greater than right.
BONES: No focal lesion suspicious for malignancy.Patient is
status post
laminectomy from T12-L3. Bony destruction of the L1 and L2
vertebral bodies is consistent with the known history of
osteomyelitis.
IMPRESSION:
1. No evidence of retroperitoneal bleed or inguinal hernias.
2. Status post laminectomy from T12-L3 with bony destruction of
the L1 and L2 vertebral bodies, consistent with the known
history of osteomyelitis.
3. Stable findings from the prior CT, including 2 right
pulmonary nodules, a fat containing periumbilical hernia, and
multiple prominent retroperitoneal and mesenteric lymph nodes.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q4H:PRN pain
2. Allopurinol ___ mg PO DAILY
3. Bisacodyl 10 mg PR HS:PRN constipation
4. Calcium Carbonate 1000 mg PO TID:PRN Indigestion
5. Ceftaroline 400 mg IV Q12H
6. Docusate Sodium 100 mg PO BID
7. Furosemide 40 mg PO DAILY
8. Polyethylene Glycol 17 g PO BID constipation
9. Senna 17.2 mg PO BID:PRN constipation
10. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
11. Fentanyl Patch 25 mcg/h TD Q72H
12. Gabapentin 100 mg PO QHS
13. Heparin 5000 UNIT SC TID
14. Heparin Flush (10 units/ml) 2 mL IV PRN and PRN, line flush
15. HYDROmorphone (Dilaudid) 4 mg PO Q3H:PRN back pain/spasm
16. Lidocaine 5% Patch 1 PTCH TD QAM
17. Methocarbamol 750 mg PO Q4H
18. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
19. Vitamin D 400 UNIT PO BID
20. NPH 20 Units Breakfast
NPH 20 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Chronic Cauda Equina
Vertebral Osteomyelitis
Deep Vein Thrombosis
Presumed Pulmonary Embolism
SECONDARY DIAGNOSIS
Diabetic Neuropathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
EXAMINATION: MR ___ SPINE W/O CONTRAST
INDICATION: ___ year old man with increasing ___ weakness // Eval for L1
osteomyelitis / epidural abscess Eval for L1 osteomyelitis / epidural abscess
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial T2 weighted imaging was performed.
COMPARISON: MRI lumbar spine ___, CT abdomen and pelvis ___.
FINDINGS:
Alignment is normal.
There is increased T2/STIR signal in the L1-2 intervertebral disc, L1
vertebra, and L2 vertebra, consistent with discitis osteomyelitis. There is
similar increased T2/STIR signal in the L2-3 intervertebral disc and superior
endplate of L3, also consistent with discitis osteomyelitis. The amount of
abnormal signal within these discs and vertebrae has markedly increased from
MRI on ___, consistent with progressive disease. Evaluation for
epidural abscess is limited due to the absence of intravenous contrast. Within
this limitation, no fluid collection is identified within the spinal canal.
There is inflammation of the left psoas muscle, new from prior MRI.
Spinal canal stenosis at L1-2 and L2-3 is due to degenerative disc and joint
disease and ligamentum flavum thickening. The stenoses are unchanged from MRI
on ___. There are disc bulges and protrusions at L3-4, L4-5, and
L5-S1, also unchanged from prior MRI.
IMPRESSION:
1. Worsening discitis osteomyelitis at L1-2 and L2-3 compared to prior MRI
from ___. Evaluation for epidural abscess is limited without
intravenous contrast but no fluid collection is identified within the spinal
canal. New inflammation of the left psoas muscle.
2. Degenerative disc and joint disease throughout the lumbar spine, worst at
L1-2 and L2-3 and causing spinal canal stenosis. This is unchanged from MRI on
___.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with PICC on admission // ?appropriate position
COMPARISON: ___
IMPRESSION:
As compared to the previous radiograph, no relevant change is seen. The lung
volumes are normal. Normal size of the cardiac silhouette. Normal hilar and
mediastinal structures. Unremarkable course of the PICC line. No pleural
effusions. No pulmonary edema.
Radiology Report
EXAMINATION: LUMBAR SINGLE VIEW IN OR
INDICATION: POST. L1-2 LAMI
TECHNIQUE: 2 lateral projections of the lumbar spine were obtained
intraoperatively without a radiologist present.
COMPARISON: MRI of the lumbar spine pole ___.
FINDINGS:
Localizing devices are noted posterior to the L2 vertebral body. The bones are
demineralized. Destructive changes are noted at the inferior endplate of L1
and superior endplate of L2 with associated intervertebral disk space
narrowing consistent with discitis osteomyelitis as seen on prior MRI. The
remainder of the vertebral body heights are grossly maintained without
evidence for a compression fracture. There is no vertebral body subluxation.
There is mild to moderate intervertebral disk space narrowing with marginal
osteophyte formation.
IMPRESSION:
Localizing devices noted posterior to the L2 vertebral body. Please see the
operative report for further details.
Endplate destructive changes and intervertebral disk space narrowing at L1-L2
consistent with osteomyelitis as seen on the prior MRI.
Mild to moderate multilevel degenerative disc.
Radiology Report
EXAMINATION: BILATERAL LOWER EXTREMITY ULTRASOUND
INDICATION: Lower extremity edema
TECHNIQUE: Real-time grayscale and Doppler ultrasound imaging of both common
femoral veins, superficial femoral, popliteal and proximal calf veins were
obtained.
COMPARISON: None.
FINDINGS:
RIGHT LEG: The right common femoral vein contains partially occlusive
thrombus that extends to the proximal portion of the right deep femoral vein.
The right superficial femoral veins, popliteal and 1 of the paired posterior
tibial vein are patent. The other posterior tibial vein in the right upper
calf appears thrombosed. The right peroneal veins were not visualized.
LEFT LEG: Partially occlusive thrombus is noted within the left common
femoral vein which extends throughout the left superficial femoral vein and
left popliteal vein. The left posterior tibial veins are completely
thrombosed and no flow is seen in the peroneal veins. The left deep femoral
vein appears patent.
IMPRESSION:
Extensive DVT within the lower extremities, detailed above.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on
the telephone on ___ at 6:36 ___, 5 minutes after discovery of the
findings.
Radiology Report
EXAMINATION: CT ABD AND PELVIS W/O CONTRAST
INDICATION: ___ with MRSA bacteremia, right foot and L2 vertebral osteo on
ceftaroline, who is admitted from rehab with subacute worsening of weakness in
his BLE concerned for subacute cauda equina syndrome s/p laminectomy on ___
w/ new bilateral DVTs on heparin gtt with slowly dropping hemoglobin as well
as back pain/spasms. Evidence of RP bleed?
TECHNIQUE: MDCT images were obtained from the lung bases to the pubic
symphysis without the administration of IV contrast. Axial images were
interpreted in conjunction with coronal and sagittal reformats.
DLP: 897 mGy-cm
COMPARISON: CT abdomen and pelvis from ___ and ___.
FINDINGS:
There is a stable 6 mm nodule in the right middle lobe (2:5), as well as a
stable 4 mm nodule inferiorly to this (2:9).
LIVER: Given the limits of evaluation without IV contrast, the liver is
homogeneous and unremarkable. The non-distended gallbladder is within normal
limits, without wall thickening or pericholecystic fluid.
SPLEEN: The spleen is homogeneous and at the upper limits of normal in size,
measuring 13.2 cm, unchanged from before.
PANCREAS: The pancreas is without focal lesion or peripancreatic stranding or
fluid collection.
ADRENALS: The adrenal glands are visualized and unremarkable.
KIDNEYS: Two simple cysts are again seen in the right kidney, the largest of
which measures 4.4 x 3.8 and simple cyst at the upper pole, largely unchanged
(601b:44 and 2:25). There is also unchanged bilateral perinephric stranding.
GI:The stomach is notably distended without an intraluminal mass or wall
thickening.The small and large bowel are within normal limits, without wall
thickening or evidence of obstruction. There is a fat containing
periumbilical hernia.
RETROPERITONEUM: The aorta and common iliac vessels are normal in caliber,
with mild atherosclerotic calcifications. There are multiple prominent
retroperitoneal and mesenteric lymph nodes, however none of these meet CT size
criteria for pathologic enlargement. No evidence of retroperitoneal bleed.
CT PELVIS: The urinary bladder appears normal without wall thickening. There
is a Foley catheter within the bladder.No pelvic wall or inguinal lymph node
enlargement by CT size criteria is seen. The previously described right
external iliac lymph node with a fatty hilum is unchanged (2:70).There is no
pelvic free fluid.There are no inguinal hernias.
SOFT TISSUES: Again seen is asymmetric induration of the soft tissues above
the umbilicus, left greater than right.
BONES: No focal lesion suspicious for malignancy.Patient is status post
laminectomy from T12-L3. Bony destruction of the L1 and L2 vertebral bodies
is consistent with the known history of osteomyelitis.
IMPRESSION:
1. No evidence of retroperitoneal bleed or inguinal hernias.
2. Status post laminectomy from T12-L3 with bony destruction of the L1 and L2
vertebral bodies, consistent with the known history of osteomyelitis.
3. Stable findings from the prior CT, including 2 right pulmonary nodules, a
fat containing periumbilical hernia, and multiple prominent retroperitoneal
and mesenteric lymph nodes.
NOTIFICATION: The above findings were communicated via telephone by Dr.
___ to Dr. ___ at 14:58 on ___, 5 min
after discovery.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Back pain, Weakness
Diagnosed with OSTEOMYELIT NOS-OTH SITE, METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS IN CONDITIONS CLASSIFIED ELSEWHERE AND OF UNSPECIFIED SITE
temperature: 98.1
heartrate: 93.0
resprate: 18.0
o2sat: 98.0
sbp: 100.0
dbp: 50.0
level of pain: 10
level of acuity: 2.0 | ___ man with history of MRSA bacteremia, right foot and L2
vertebral osteomyelitis on ceftaroline, who was admitted from
rehab with subacute worsening of weakness in his bilateral lower
extermities concerned for chornic cauda equina syndrome
secondary to vertebral osteomyelitis. During hospital stay
patient underwent procedure by spine orthopetics and Laminectomy
T12-L3, abscess removal, biopsy and fusion of L1-L2 were
performed. Biopsy samples were negative. The patient had
improving movement of his lower extermities (able to slide them
side to side and improved plantar/dorsiflexion) Infectious
disease was consulted and the patient was started on daptomycin,
and the ceftaroline was continued. He will require treatment for
a total of 10 weeks given his symptoms. To be completed on
___. The patient was started on PO vancomycin for
prophylaxis given his history of c.diff. The patient will need
to continue this till 2 weeks after his IV antibiotics are
completed (___). The patient was diagnosed with bilateral
deep vein thrombosis and presumed to have a pulmonary embolism
(unable to do CT angio due to acute on chronic kidney injury).
Patient was started on heparin and bridged to warfarin, will
require treatment for a minimum of 3 months(goal INR ___. Acute
on chronic kidney injury likely pre-renal due to limited
hydration and poor PO intake. Patient was having gas pain and
back spasms which were medically controlled. The patient notably
had limited effort with physical therapy secondary to pain and
discomfort.
ACUTE ISSUES
# Cauda Equina Syndrome: Patient presented with increased low
back pain, in combination with immobility and urinary retention
(___ placed at rehab) raising concern for subacute cauda
equina syndrome secondary to discitis and osteomyelitis that has
been progressive over 6 weeks prior to admission. Patient
underwent decompressive laminectomy and washout on ___ with
orthopedics spine for infection source control and to prevent
further neurologic deterioration and loss of bowel/bladder
function. The patient had his drains pulled once output
decreased. Bilateral ___ motor exam was improving prior to
discharge, from ___ to ___ in bilateral lower extremity
muscle groups. He failed multiple voiding trials and had foley
replaced. Foley was pulled again on day of discharge. ___ be
replaced if required. For his neuropathic pain his gabapentin
was increased. Pain was controlled with oral diluadid.
#Vertebral Osteomyelitis- patient was admitted on treatment with
ceftaroline. Given that the patients symptoms had continued to
worsen, infectious disease was consulted and the patient was
started on daptomycin for increased coverage against his MRSA
osteomyelitis and bacteremia. The patient underwent
decompression/laminectomy as per orthopedic spine and the wound
cultures/biopsies were negative. The patient is set to be
treated for a total of 10 weeks with the current medical regimen
treatment of Ceftaroline 400mg IV q12 and daptomycin 500mg q24
hours.Start Date: ___ (date of laminecomy, abscess
evacuation, and
fusion) Projected End Date: ___ weeks). Patient will
require weekly blood tests including ESR/CRP, LFTs, CK, Cr.
(please see outlined transitional issues)
#Chest pain- Patient had acute onset ___ chest pain,
reproducible with palpation on left side of sternum, no
radiation. EKG unchanged- tachycardia to the ___. No shortness
of breath. No hypoxia. Normotensive. Unlikely to be cardiac
chest pain. Troponins were indeterminate. Patient unable to
undergo CT-A ___ ___. Diagnosed with DVT and presumed PE (see
below). Echo was performed and was grossly normal with no
evidence of right heart strain. Chest pain likely caused by
presumed PE. Chest pain resolved on discharge.
#Back spasms/Pain/ Limited mobility- Patient was having severe
pain and was admitted on a fentanyl patch and methocarbamol. The
patients pain regimen was adjusted during his hospital stay. He
was switched to tinazedine for muscle spasms. His fentanyl patch
was discontinued and he was started on PO regimen of dilaudid.
Patient was also started on simethecone.
#DVT/Presumed PE: Patient had substernal chest pain as well as
tachycardia on exam. Patient had lower extermity ultrasounds
that were positive bilaterally for significant DVTs (see
ultrasound report). Patient was treated for presumed PE. CTA
was contraindicated given patient's chronic kidney injury. V/Q
scan could not be performed given patients mobility. Patient was
started on a heparin drip and bridged to warfarin with goal INR
of ___. Echo showed no evidence of right heart strain. The
decision was made not to place retrivable fitler given that
patient was actively infected and it was not clearly indicated.
INR on discharge was 2.5.
#Anemia- Patient had an acute drop in his hemoglobin/hematocrit
___ to 7.3/22. Estimated blood loss in surgery was approx
400cc as per operative report. Drains did not have significant
output. No evidence of acute bleeding. Patient underwent CT
abdomen and had no signs of retroperitoneal bleeding. His work
up showed reticulocyte count 1.9. Iron studies concerning for
anemia of inflammation. His haptoglobin was elevated likely as
an acute phase reactant protein. Patient was stable and should
have his anemia followed up as an outpatient. Hgb on discharge
was 7.8.
#History of C.diff- patient was started on prophylaxis dose of
oral vancomycin 125mg PO q6 while on antibiotic therapy. Will
need to be continued for 2 weeks post completion of IV
antibiotics (___).
#Delirium- Patient had an acute changes in mental status. Likely
to be due to medications, muscle relaxants as well as pain
medications. Patient previously has had admissions for pain
medications causing confusion. Patients blood sugars were normal
and no new infectious sources were found. Patients pain regimen
was switched orals. Patient had TSH checked which was low, T3
and T4 low consistent with normal thyroidal illness. Patient
will need further evaluation when this resolves. Patients
delerium resolved during hospital stay.
# Acute on Chronic renal disease: Patient with known chronic
kidney disease, baseline from 1.3 to 1.5, presented with a Cr
2.2. Down trended throughout hospitalization. Likely to be
pre-renal as it resolved with increased fluid intake/IVF.
Patient was encouraged to continue hydration and all medications
were renally dosed. Cr on discharge was 1.4
# Foot ulcer/osteomyelitis: No overt signs of infection. Wound
care was consutled and recommended keeping wound clean and
dressed. Patient was continued on antibiotics as per above.
#Pressure Sacral Ulcers- patient was evaluated by wound care and
was found to have pressure ulcers on right leg as well as sacrum
(outlined in physical exam. Patient is to apply nystatin cream
to affected areas.
CHRONIC ISSUES
# Diabeties Mellitus: Patients evening dose was decreased to 10
units of NPH at night and his home dose and insulin sliding
scale was continued
# Gout: stable continued on home allopurinol
# Hypertension stable
- furosemide was held, can be restarted as an outpatient
- continued Dorzolamide
# Access: ___ right arm
# Code: Resuscitate (Full code) confirmed
# Emergency Contact: HCP / Contacts: ___
___: WIFE Phone: ___ and ___
Relationship: SON Phone: ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
ht hemibody sensory
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year-old left-handed ___ woman with a
history of right MCA/PCA ischemic stroke in ___ while
pregnant with PFO and common iliac vein thrombus, and recent
finding of possible new acute infarction while admitted to ___
___, who represents to the ED with new right hemibody
sensory deficit.
History is obtained from the patient and her mother and is
limited by the patient's speech deficit.
Ms. ___ neurological history began in ___
when she presented with nonfluent aphasia and mild left-sided
weakness to ___ and received IV tpa. She was
transferred here where MRI showed an inferior right MCA and
partial PCA stroke. The cause of her stroke was thought to be
thromboembolic related to hypercoagulability (she was found to
be 6 weeks pregnant at that time), non-occlusive thrombosis of
the common iliac veins and PFO seen on echo. She was bridged
from lovenox to coumadin. Despite rehab, she continued to have
a mild nonfluent aphasia with paraphasic errors with long
phrases, left homonymous hemianopsia, and left arm sensory
deficit. Her pregnancy was ultimately terminated because of the
stroke and severe hyperemesis gravidarum. MRV was repeated 1
month later and the illiac vein thrombis was resolved.
She was continuing rehab at home and continuing to improve until
___, when she developed dull headache, left eye
blurriness, left ear pressure and cramping in her left foot.
She presented to her PCP who referred her to ___ ED. She was
ultimately admitted for MRI/MRA brain and there was a finding of
a "small foci of acute infarction in the same location (as the
prior stroke) due to small patchy foci of restricted diffusion
and ADC map hypodensity." Her secondary stroke prevention
regimen was increased from therapeutic coumadin (INR 2.8 at ___)
to include ASA 81mg and atorvastatin 40 (LDL 102). Shortly
after the MRI was done she had a ___ hour episode of right arm
numbness and discomfort. She told the ___ physicians and she
was observed, but no repeat imaging was done. She was dischaged
on ___ and upon arriving home she had an additional episode or
right arm paresthesias and numbness that again spontaneously
resolved. On ___, she again had paresthesias of the arm and
developed facial numbness (primarily in the cheek) and
intermittent right leg numbness. Currently she has only right
arm paresthesias and mild numbness. She has not noticed new
weakness. Her mother does note that her speech has worsened in
the past ___ days and she is making more errors and talking
slower. She has been compliant with her Coumadin, and she tells
me that one dose was held at ___ because her level was slightly
high, but there have been no low INRs recently. Of note she
has not been ill recently and she has no current sick contacts.
On neurologic review of systems, the patient denies
lightheadedness, or confusion. Denies loss of vision, diplopia,
vertigo, tinnitus, dysarthria, or dysphagia. Denies focal muscle
weakness. 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,
palpitations, dyspnea, or cough. Denies nausea, 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:
Right MCA/PCA stroke in the setting of DVT (___)
- MRV with common iliac vein thrombosis
- Elective abortion, pregnancy detected after stroke in ___
Social History:
___
Family History:
Maternal aunt has migraines. There is no family history of
stroke, heart diseaes or blood clots
Physical Exam:
ADMISSION EXAM
==============
Vitals: 98.5 102 116/72 16 100%
General: ___ woman, slender, anxious, NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Feet cool to touch, no edema
Neurologic Examination:
Awake, alert, oriented to full name, DOB, ___. Speech is somewhat nonfluent. All verbal responses are
slow and deliberate, it seems she is trying to avoid phonemic
paraphasias which still occur. Her description of cookie theft
is telegraphic and slow: "Spilling over...in the tap...the
childrens going to fall...the eating..the cookie jar."
Attentive, but ___ backwards is confounded by speech difficulty.
Repetition slowed with paraphasias. Reading, slowed with
paraphasias. Verbal comprehension of simple commands intact,
but impaired for multistep commands. No dysarthria. Able to
register 3 objects and recall ___ at 5 minutes. No apraxia.
There is subtle left neglect of double sensory presentation in
visual and sensory modalities. Mild left-right confusion. At
times, question of right apraxia (hammering nail and cutting
breat), which is not seen on left hand. Prosody is somewhat
limited, but may be appropriate given she is quite nervous about
her medical condition.
- Cranial Nerves - Visual acuity: ___ bilaterally. PERRL 4->3
brisk. Left homonymous hemianopsia when checking finger
counting, but can see finger wiggle bilaterally. She does
extinguish left finger wiggle, when presented bilaterally, thus
there is visual neglect as well. EOMI, no nystagmus. V1-V3
without deficits to light touch bilaterally. No facial movement
asymmetry. Hearing intact to finger rub bilaterally, but she
reports decreased hearing from the left ear since the stroke.
Palate elevation symmetric. SCM/Trapezius strength ___
bilaterally. Tongue midline and strong.
- Motor - Normal bulk and tone. No drift. Question of
psueudoathetosis of the right hand when outstretched.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ ___ 5 5 5
R 5 5 4+ ___ ___ 5 5 5 5
- Sensory - Light touch is appreciated less on the left hemibody
(sparing the face) which she notes is related to stroke in ___.
Pinprick is felt less on the right hemibody (sparing the face).
Proprioception intact a great toes bilaterally.
-DTRs:
Bi Tri ___ Pat Ach
L 3 3 3 3 2
R 2 2 2 2 2
Plantar response flexor bilaterally. There is a pectoralis jerk
on the left side, not on the right. No clonus
- Coordination - No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating movements bilaterally. Toe-finger-toe is normal.
- Gait - Normal initiation. Narrow base. Normal stride length.
Stable without sway. Negative Romberg.
DISCHARGE EXAM
==============
GENERAL EXAM: slender ___ woman in NAD, sitting
upright in chair, talking comfortably with examiner. No carotid
bruits present. Cardiac exam is RRR.
NEURO EXAM:
- Mental Status: awake, alert, oriented x 3. Speech is slow and
mildly dysfluent, occasionally skipping conjunctive words but
overall grammatical and without paraphasias. No dysarthria.
Naming intact to high and low frequency objects. Repetition
intact. Some difficulty following crossed-body commands, and
intermittent R-L confusion. There is mild acalculia with more
complex calculations (cannot add 18 + 7). No evidence of
neglect.
- Cranial Nerves: PERRL 4 to 3mm and brisk. +Subtle L homomynous
hemianopia, also +extinction to DSS on left. EOMI without
nystagmus. Facial sensation slightly decreased in R face. Face
symmetric, no NLF flattening. Tongue protudes in midline. Palate
elevates symmetrically.
- Motor: Normal bulk and tone throughout. Strength ___ on formal
testing of all motor groups throughout.
- Sensory: There is subtle hypERalgesia to pinprick over the
left
hemibody. She is inconsistent when describing pinprick over R
hemibody but says it feels "different" (and is clear that the L
hemibody sensations are chronic). No extinction to sensory DSS.
- Reflexes: brisker in left hemibody. Toes downgoing
bilaterally.
- Coordination: No dysmetria on FNF or HKS bilaterally.
- Gait: Normal initiation. Narrow base. Normal stride length.
Stable without sway. Negative Romberg.
Pertinent Results:
LABS
====
___ 05:30AM BLOOD WBC-5.4 RBC-4.75 Hgb-11.4* Hct-34.9*
MCV-74* MCH-23.9* MCHC-32.6 RDW-14.4 Plt ___
___ 09:58AM BLOOD WBC-5.8 RBC-5.04 Hgb-12.4 Hct-37.3
MCV-74* MCH-24.6* MCHC-33.3 RDW-14.4 Plt ___
___ 05:30AM BLOOD ___ PTT-45.1* ___
___ 09:58AM BLOOD ___ PTT-44.7* ___
___ 05:30AM BLOOD Glucose-88 UreaN-15 Creat-0.8 Na-138
K-4.2 Cl-105 HCO3-23 AnGap-14
___ 09:58AM BLOOD Glucose-100 UreaN-14 Creat-0.8 Na-137
K-4.2 Cl-105 HCO3-21* AnGap-15
___ 09:58AM BLOOD AST-19 AlkPhos-88 TotBili-0.2
___ 09:15PM BLOOD CK-MB-<1 cTropnT-<0.01
___ 09:58AM BLOOD cTropnT-<0.01
___ 05:30AM BLOOD Calcium-9.6 Phos-3.3 Mg-2.0
___ 09:58AM BLOOD Albumin-4.5 Calcium-10.1 Phos-2.6* Mg-2.0
___ 09:58AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
PERTINENT STUDIES
=================
___ MR HEAD W/O CONTRAST:
Right occipital and temporal lobe encephalomalacia with ex vacuo
dilatation of the right lateral ventricle are noted, consistent
with the patient's ___ MCA PCA distribution infarct.
Additionally, parenchymal signal intensity abnormalities
consistent with patient's reported ___ right MCA and
PCA distribution infarct are also noted, with signal changes
suggestive of an evolving subacute infarct in the right frontal,
temporal, parietal and occipital lobes. Question small area of
superimposed acute infarct in the right parietal lobe (series 3,
images 17 and 21).
There is a focus of FLAIR hyperintensity in the left parietal
subcortical
white matter (series 10, image 15) .
There are no additional vascular territory acute infarcts. There
is no
hemorrhagic transformation. There is mass effect on the involved
sulci but no compression of the ventricular system or
herniation.
Major intravascular flow voids are preserved. Marrow signal is
within normal limits. The paranasal sinuses and mastoid air
cells appear clear. The orbits are normal.
IMPRESSION:
1. Findings consistent with patient's chronic ___ right MCA/
PCA distribution infarct with ex vacuo dilatation of the left
lateral ventricle posterior horn.
2. Large area of left temporal, parietal, occipital lobe
demonstrating
findings suggestive of subacute infarct, consistent with
patient's reported ___ right hemisphere recent acute
infarct.
3. Question small right parietal area of acute infarct versus
artifact.
4. Small left parietal parenchymal signal intensity abnormality
without
evidence of acute infarct. Differential considerations include
prior injury, ischemic event, infection, demyelinating process,
and migraine headaches.
___ CTA HEAD/NECK:
Head CT: There is hypodensity with loss of cerebral sulci in the
right
temporal, occipital, and parietal lobes. There is ex vacuo
dilatation of the right occipital and temporal horns, suggesting
that the majority of the infarct is chronic in nature. There is
additional hypodensity in the right caudate, external capsule,
and insula. Hypodensity is consistent with infarcts of the right
posterior cerebral and right middle cerebral artery territories.
It is difficult to determine what parts of the infarcts are
chronic and which are acute or subacute; correlation should be
made with subsequently performed MRI head. There is no
hemorrhage. There is no compression of the ventricles or
herniation.
The osseous structures are normal. The paranasal sinuses,
mastoid air cells, and tympanic cavities are clear. The orbits
are normal.
Head CTA: There are relatively decreased M3 and M4 branches of
the right
middle cerebral artery relative to the left middle cerebral
artery. No focal M2 or M3 level hyperdense thrombus is noted.
Otherwise, there is no
steno-occlusive disease of the major branches of the anterior
posterior
circulations. There is a right fetal type posterior cerebral
artery, a
developmental variant. There is no evidence of aneurysm or
vascular
malformation.
Dural venous sinuses are patent.
Neck CTA: There is two vessel aortic arch anatomy with a common
origin of the brachiocephalic and left common carotid arteries.
The carotid and vertebral arteries and their major branches are
patent with no evidence of stenoses. There is no evidence of
internal carotid stenosis by NASCET criteria.
There are hypodense nodules scattered in both lobes of the
thyroid gland. The largest is an 8 mm nodule in the upper pole
of the left lobe (series 5, image 69).
IMPRESSION:
1. Chronic infarcts of the right posterior and right middle
cerebral artery territories with acute to subacute ischemia
superimposed on these chronic infarcts, when compared with
subsequently performed MRI head.
2. Fetal type right posterior cerebral artery, a developmental
variant.
3. Paucity of right M3 and M4 middle cerebral artery branches
relative to the left middle cerebral artery.
4. Otherwise, no steno-occlusive disease of the major
intracranial anterior or posterior circulations.
5. No steno-occlusive disease of the cervical carotid and
vertebral arterial systems.
6. Scattered nodules in both thyroid lobes with the largest an 8
mm nodule in the left upper pole.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 10 mg PO DAILY16
2. Atorvastatin 40 mg PO QPM
3. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Nortriptyline 10 mg PO QHS
RX *nortriptyline 10 mg 1 tablet by mouth at bedtime Disp #*30
Capsule Refills:*0
2. Warfarin 10 mg PO DAILY16
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Central pain syndrome
Late effects of cerebrovascular disease
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neuro Exam on Discharge = mildly non-fluent speech but no frank
aphasia. +Acalculia with more difficult equations. Subtle L
hemianopia and L visual extinction to DSS. Left hemibody
HYPERalgesia, and decreased sensation in the left face. Reflexes
brisker on the left.
Followup Instructions:
___
Radiology Report
INDICATION:
___ year old woman with stroke in ___, recent stroke at ___, now
presenting with repeat right sided paresthesias, evaluate for infection.
COMPARISON: None Available.
TECHNIQUE
Frontal and lateral view of the chest.
FINDINGS:
The cardiomediastinal silhouette is normal. There is no pleural effusion or
pneumothorax. There is no focal lung consolidation. Views of the upper
abdomen are normal.
IMPRESSION:
No evidence of pneumonia.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK
INDICATION: ___ female with history of thromboembolic ischemic stroke
to right MCA/PCA distribution in ___, and ___ outside MRI
demonstrating acute right hemisphere stroke, now with 5 day history of
intermittent right sided sensory symptoms. Evaluate for steno-occlusive
disease.
TECHNIQUE: Contiguous axial images were obtained through the brain without
contrast material. Subsequently, rapid axial imaging was performed from the
aortic arch through the brain during infusion 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: DLP: 2302.19 mGy-cm; CTDI: 135.07 mGy
COMPARISON: MRI head ___.
FINDINGS:
Head CT: There is hypodensity with loss of cerebral sulci in the right
temporal, occipital, and parietal lobes. There is ex vacuo dilatation of the
right occipital and temporal horns, suggesting that the majority of the
infarct is chronic in nature. There is additional hypodensity in the right
caudate, external capsule, and insula. Hypodensity is consistent with infarcts
of the right posterior cerebral and right middle cerebral artery territories.
It is difficult to determine what parts of the infarcts are chronic and which
are acute or subacute; correlation should be made with subsequently performed
MRI head. There is no hemorrhage. There is no compression of the ventricles or
herniation.
The osseous structures are normal. The paranasal sinuses, mastoid air cells,
and tympanic cavities are clear. The orbits are normal.
Head CTA: There are relatively decreased M3 and M4 branches of the right
middle cerebral artery relative to the left middle cerebral artery. No focal
M2 or M3 level hyperdense thrombus is noted. Otherwise, there is no
steno-occlusive disease of the major branches of the anterior posterior
circulations. There is a right fetal type posterior cerebral artery, a
developmental variant. There is no evidence of aneurysm or vascular
malformation.
Dural venous sinuses are patent.
Neck CTA: There is two vessel aortic arch anatomy with a common origin of the
brachiocephalic and left common carotid arteries. The carotid and vertebral
arteries and their major branches are patent with no evidence of stenoses.
There is no evidence of internal carotid stenosis by NASCET criteria.
There are hypodense nodules scattered in both lobes of the thyroid gland. The
largest is an 8 mm nodule in the upper pole of the left lobe (series 5, image
69).
IMPRESSION:
1. Chronic infarcts of the right posterior and right middle cerebral artery
territories with acute to subacute ischemia superimposed on these chronic
infarcts, when compared with subsequently performed MRI head.
2. Fetal type right posterior cerebral artery, a developmental variant.
3. Paucity of right M3 and M4 middle cerebral artery branches relative to the
left middle cerebral artery.
4. Otherwise, no steno-occlusive disease of the major intracranial anterior or
posterior circulations.
5. No steno-occlusive disease of the cervical carotid and vertebral arterial
systems.
6. Scattered nodules in both thyroid lobes with the largest an 8 mm nodule in
the left upper pole.
RECOMMENDATION(S): Re 1: Please refer to MRI head for more detailed
evaluation of the brain.
Re 5: Clinical correlation recommended. Thyroid ultrasound can be considered
for further evaluation as clinically indicated.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST
INDICATION: ___ female with history of thromboembolic ischemic stroke
to right MCA/PCA distribution in ___, and ___ outside MRI
demonstrating acute right hemisphere stroke, now with 5 day history of
intermittent right sided sensory symptoms. Evaluate for acute infarct.
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique.
COMPARISON: CTA head and neck ___.
FINDINGS:
Right occipital and temporal lobe encephalomalacia with ex vacuo dilatation of
the right lateral ventricle are noted, consistent with the patient's ___ MCA
PCA distribution infarct. Additionally, parenchymal signal intensity
abnormalities consistent with patient's reported ___ right MCA and
PCA distribution infarct are also noted, with signal changes suggestive of an
evolving subacute infarct in the right frontal, temporal, parietal and
occipital lobes. Question small area of superimposed acute infarct in the
right parietal lobe (series 3, images 17 and 21).
There is a focus of FLAIR hyperintensity in the left parietal subcortical
white matter (series 10, image 15) .
There are no additional vascular territory acute infarcts. There is no
hemorrhagic transformation. There is mass effect on the involved sulci but no
compression of the ventricular system or herniation.
Major intravascular flow voids are preserved. Marrow signal is within normal
limits. The paranasal sinuses and mastoid air cells appear clear. The orbits
are normal.
IMPRESSION:
1. Findings consistent with patient's chronic ___ right MCA/ PCA distribution
infarct with ex vacuo dilatation of the left lateral ventricle posterior horn.
2. Large area of left temporal, parietal, occipital lobe demonstrating
findings suggestive of subacute infarct, consistent with patient's reported ___ right hemisphere recent acute infarct.
3. Question small right parietal area of acute infarct versus artifact.
4. Small left parietal parenchymal signal intensity abnormality without
evidence of acute infarct. Differential considerations include prior injury,
ischemic event, infection, demyelinating process, and migraine headaches.
RECOMMENDATION(S): RE 3, 4: Recommend clinical correlation and attention on
followup imaging.
Gender: F
Race: BLACK/AFRICAN
Arrive by WALK IN
Chief complaint: R SIDE PAIN, R Chest pain
Diagnosed with CEREBRAL ART OCCLUS W/INFARCT, SKIN SENSATION DISTURB, LONG TERM USE ANTIGOAGULANT
temperature: 98.5
heartrate: 102.0
resprate: 16.0
o2sat: 100.0
sbp: 116.0
dbp: 72.0
level of pain: 5
level of acuity: 2.0 | ___ year-old left-handed woman with a history of right MCA/PCA
ischemic stroke in ___ while pregnant thought to be due to
PFO and common iliac vein thrombus who presented with concern
for worsened speech deficit and new RUE paresthesia.
#POST STROKE PAIN SYNDROME
MRI at ___ showed concern for possible new acute infarction,
although her clinical exam did not correlate. A repeat MRI at
___ showed possible new small foci of acute infarcts in the
same temporal-occipital region as her prior ___s a possible new small area of acute infarct in the left
parietal region. Because of the uncertainty about these findings
and concomitant therapy with warfarin & therapeutic INR, we did
not change her anticoagulation regimen. Her speech deficit was
verified to be at baseline per pt's mother's bedside collateral.
Pt's RUE paresthesia was thought to be potentially due to
central pain syndrome and she was started on nortriptyline. She
was discharged in stable condition with neurology clinic
follow-up. We discussed her condition with Dr. ___
recommended repeating her brain MRI in a few weeks to assess for
the resolution of DWI abnormalities or appearance of new ones
since this may be indicative of an ongoing embolism in the
setting of oral anticoagulation and may require altering her
current treatment strategy (for example, considering closure of
PFO or lovenox).
TRANSITIONAL ISSUES
===================
-No changes to anticoagulation treatment. Discharged on warfarin
10mg daily. Please continue to monitor INR and titrate warfarin
prn.
-Started on nortriptyline 10mg qhs for RUE paresthesia thought
to be due to central thalamic pain syndrome. Please uptitrate
prn.
-CTA showed incidental finding of "Scattered nodules in both
thyroid lobes with the largest an 8 mm nodule in the left upper
pole". Follow-up with outpatient thyroid ultrasound has been
recommended by radiology. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Amoxicillin / levofloxacin
Attending: ___
Chief Complaint:
pneumonia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ no significant past medical history presenting with 4 days
of cough, malaise and subjective fevers. Patient did NOT have
objective fever either at home or in ED. Returned from ___
yesterday. Also reports travel to ___ in ___ and ___
in ___ and ___ in ___. While in ___ he was directly
interacting with patients but nobody with known TB. No sick
contacts recently. Cough has been productive of green sputum, no
blood.
In the ED, initial vitals were:
- Exam was notable for non-toxic appearance, RRR, CTAB, no ___
edema.
- Labs notable for WBC 6.5, Hgb 12.8, normal lytes
- Imaging: CXR showed a RUL lesion that appeared cavitary, but
subsequent Chest CT was NOT c/w cavitary lesion, rather just
showing multifocal GGOs in RUL c/f pneumonia with NO features of
TB.
- Patient was nevertheless admitted for TB rule out.
On the floor, patient endorses ongoing cough and would like a
cough suppressant. He has not had nightsweats or weight loss.
Review of systems:
(+) Per HPI
(-) Denies night sweats, recent weight loss or gain. Denies
chest pain or tightness, palpitations. Denies nausea, vomiting,
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria.
Past Medical History:
- ALLERGIC RHINITIS
- L SHOULDER INJURY
- VITILIGO
- ANEMIA
- IRRITABLE BOWEL SYNDROME
Social History:
___
Family History:
Mother - DM, HTN, HLD, depression
Father - HTN, HLD
Brother - HTN
Physical ___:
UPON ADMISSION:
Vital Signs: T 98.3, 124/80, 96, 18, 99%RA, Weight 86 kg
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Several small patches of vitiligo.
UPON DISCHARGE:
VS - 98.3 124/80 96 18 99 r/a
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear without erythema
or exudate
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Several small patches of vitiligo.
Pertinent Results:
___ 07:00PM BLOOD WBC-6.5# RBC-4.37* Hgb-12.8* Hct-37.9*
MCV-87 MCH-29.3 MCHC-33.8 RDW-13.6 RDWSD-43.0 Plt ___
___ 07:00PM BLOOD Neuts-71.4* Lymphs-15.3* Monos-8.9
Eos-3.8 Baso-0.3 Im ___ AbsNeut-4.65 AbsLymp-1.00*
AbsMono-0.58 AbsEos-0.25 AbsBaso-0.02
___ 07:00PM BLOOD Glucose-89 UreaN-14 Creat-1.0 Na-137
K-4.1 Cl-102 HCO3-25 AnGap-14
___ 07:00PM BLOOD Glucose-89 UreaN-14 Creat-1.0 Na-137
K-4.1 Cl-102 HCO3-25 AnGap-14
___ 07:00PM BLOOD Lactate-1.1
IMAGING:
___ CXR
IMPRESSION:
Apparent cavitary lesion in right suprahilar region, concerning
for an
infectious etiology (including fungal and mycobacterial
organisms as well asseptic emboli) in the setting of cough and
fever.
RECOMMENDATION(S): Chest CT for confirmation and further
characterization of cavitary lesion.
___ CHEST CT
IMPRESSION:
1. Multifocal ground-glass opacities within the right upper lobe
concerning
for pneumonia. No specific features of tuberculosis.
2. 2 discrete 4 mm nodules within the right lung for which
followup chest CT may be performed in 12 months if patient is at
elevated risk factors for lung cancer.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cetirizine 10 mg PO DAILY
2. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Cetirizine 10 mg PO DAILY
2. Omeprazole 20 mg PO DAILY
3. Cefpodoxime Proxetil 200 mg PO Q12H
RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice daily Disp
#*13 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Community acquired pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with cough and fever // ?infiltrate
TECHNIQUE: Chest PA and lateral
COMPARISON: ___.
FINDINGS:
Heart size is normal. The mediastinal and hilar contours are normal. The
pulmonary vasculature is normal. Lungs are remarkable for an apparent 2.8 x
2.0 cavitary lesion in the right suprahilar region, not definitively seen on
the prior chest radiograph. No pleural effusion or pneumothorax is seen.
There are no acute osseous abnormalities.
IMPRESSION:
Apparent cavitary lesion in right suprahilar region, concerning for an
infectious etiology (including fungal and mycobacterial organisms as well as
septic emboli) in the setting of cough and fever.
RECOMMENDATION(S): Chest CT for confirmation and further characterization of
cavitary lesion.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 3:56 ___, 5 minutes
after discovery of the findings.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ with cavitary lesion on x-ray concerning for TB
TECHNIQUE: Multidetector CT through the chest performed with IV contrast.
Reformatted coronal, sagittal, thin slice axial images, and axial maximal
intensity projection images were submitted to PACS and reviewed.
Dose: Total DLP (Body) = 594 mGy-cm.
COMPARISON: Same-day chest radiograph.
FINDINGS:
Imaged thyroid is unremarkable. The thoracic aorta is normal in course and
caliber without appreciable atherosclerosis. The main pulmonary artery is
normal in caliber. No adenopathy in the chest. An azygous fissure is noted.
The heart is normal in size and shape. No pleural or pericardial effusion is
seen.
There are ground-glass multifocal small opacities within the right upper lobe
concerning for early pneumonia. No cavitary component or specific features of
tuberculosis. There is a tiny right upper lobe nodule on series 4, image 56
measuring 4 mm. There is a nodule in the right middle lobe on series 4, image
139 measuring 4 mm
Within the imaged portion of the upper abdomen, no abnormalities are detected.
Bones: No worrisome lytic or blastic osseous lesion. No fracture. No
significant degenerative disease.
IMPRESSION:
1. Multifocal ground-glass opacities within the right upper lobe concerning
for pneumonia. No specific features of tuberculosis.
2. 2 discrete 4 mm nodules within the right lung for which followup chest CT
may be performed in 12 months if patient is at elevated risk factors for lung
cancer.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Cough
Diagnosed with Cough
temperature: 97.8
heartrate: 91.0
resprate: 18.0
o2sat: 99.0
sbp: 121.0
dbp: 84.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ is a healthy ___ yo M who presented with productive
cough and malaise. His CXR was concerning for a cavitary lesion
and he was admitted for TB rule out. CT chest demonstrated
evidence of multifocal ground-glass opacities within the right
upper lobe without features of TB. Given negative CT, he did not
require further work up for TB rule out. He was treated with IV
ceftriaxone (day ___ upon admission and was written for
cefpodoxime to be started on the evening of ___ upon discharge.
Pt will complete seven day course of antibiotics (end date ___. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
Penicillins
Attending: ___
Chief Complaint:
s/p fall, ___
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: This is a ___ year old man who was transferred from ___ on coumadin and aspirin for afib/pacer/and history of
TIAs who presented after a mechanical fall and head strike. The
patient denies loss of consciousness, numbness, tingling
sensation, weakness, bowel incontinence, vision or hearing
deficit. The patient reports longstanding urine incontinence
for
which he takes vesicare.
Past Medical History:
PMHx:afib, cardiac pacer, urine incontinence, prostate CA, with
prostatectomy ___, CABG x 5 vessels ___, HTN, DM type II,
colon
resection ___, root canal right ___, TIAs ___.
Physical Exam:
On admission:
PHYSICAL EXAM:
O: T:97.7 BP: 174/79 HR:50 R:18 O2Sats: 100% r/a
Gen: WD/WN, comfortable, NAD.
HEENT: ___ 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.
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. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial sensation intact and symmetric. Facil nasal
labial
fold flattening on right- that patient states is his baseline
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 bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger
Upon discharge:
Awake, alert, oriented x3, MAE full
Pertinent Results:
Head CT ___:
IMPRESSION: Apparently growing subdural hematoma along the
anterior right
falx comparison to the prior study. While on some images a small
component of this appears to be intraparenchymal, more likely
this is a slightly expanded subdural hematoma compared to the
prior day.
___ 05:00PM ___ PTT-34.7 ___
___ 05:00PM PLT COUNT-257#
___ 05:00PM WBC-6.1 RBC-4.12*# HGB-12.4*# HCT-38.0*#
MCV-92 MCH-30.0 MCHC-32.5 RDW-13.5
___ 05:00PM GLUCOSE-87 UREA N-19 CREAT-0.9 SODIUM-144
POTASSIUM-4.5 CHLORIDE-106 TOTAL CO2-30 ANION GAP-13
___ 12:00AM ___ PTT-32.1 ___
___ 12:00AM PLT COUNT-253
___ 12:00AM WBC-6.6 RBC-3.76* HGB-11.4* HCT-34.3* MCV-91
MCH-30.4 MCHC-33.4 RDW-13.6
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Quinapril 10 mg PO BID
2. MetFORMIN (Glucophage) 500 mg PO BID
3. Ascorbic Acid (Liquid) 250 mg PO DAILY
4. Ferrous Sulfate 162.5 mg PO DAILY
5. Tolterodine 2 mg PO BID
6. Simvastatin 20 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Ascorbic Acid ___ mg PO DAILY
2. Ferrous Sulfate 162.5 mg PO DAILY
3. MetFORMIN (Glucophage) 500 mg PO BID
4. Multivitamins 1 TAB PO DAILY
5. Quinapril 10 mg PO BID
6. Simvastatin 20 mg PO DAILY
7. Tolterodine 2 mg PO BID
8. Acetaminophen 325-650 mg PO Q6H:PRN pain/headache
Discharge Disposition:
Home
Discharge Diagnosis:
Subdural hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Status post fall, on Coumadin.
COMPARISON: ___, CT from outside hospital.
TECHNIQUE: Non-contrast head CT.
FINDINGS: A subdural hematoma along the right anterior falx appears to be
slightly larger compared to the prior study. Much of this may be
redistribution however there does appear to be a more circular part measuring
approximately 1 cm x 1 cm which was not clearly present on the prior study.
While on some images this appears to perhaps the intraparenchymal, the
location will be unusual and more likely this is extension of the subdural
component of the hemorrhage layering in an unuasal way. There is no shift of
the midline structures. There is no evidence of vascular territorial infarct.
Basal cisterns are patent and gray-white matter differentiation is preserved
throughout. Ventricles and sulci are mildly prominent consistent with
age-related global atrophy. Mastoid air cells and paranasal sinuses are well
aerated. A small mucus retention cyst is noted in the left maxillary sinus.
There is no evidence of fracture.
IMPRESSION: Apparently growing subdural hematoma along the anterior right
falx comparison to the prior study. While on some images a small component of
this appears to be intraparenchymal, more likely this is a expanding subdural
hematoma compared to the prior day.
___ d/w ___ at 6:46 am via telephone 5 mins after review of the
study.
NOTE ADDED AT ATTENDING REVIEW: The new focus of hemorrhage in the right
frontal region is intraparenchymal and apparently reflects an evolving
contusion. This revised interpretation was discussed with Dr. ___ by
Dr. ___ telephone at 10:15am, on ___, 3 minutes after noting it.
Dr. ___ was aware of the intraparenchymal nature of the hemorrhage.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: SDH
Diagnosed with SUBDURAL HEM W/O COMA, OPEN WOUND OF ELBOW, FALL RESULTING IN STRIKING AGAINST OTHER OBJECT, HYPERTENSION NOS, LONG TERM USE ANTIGOAGULANT, CARDIAC PACEMAKER STATUS
temperature: 97.7
heartrate: 50.0
resprate: 18.0
o2sat: 100.0
sbp: 174.0
dbp: 79.0
level of pain: 0
level of acuity: 2.0 | Mr ___ was admitted to the neurosurgery service on ___
after sustaining a fall and Subdural hematoma. He was given 2
units of FFP at the OSH and 10 mg of Vit K. No further FFP was
given at ___. The patient remained stable and a repeat head CT on
___ was stable. He was evaluated by ___ and cleared for home.
Patient may return to work in one week from our perspective.
Please continue to hold COumadin for one month. ___ restart
Aspirin in 3 days. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Gabapentin
Attending: ___.
Chief Complaint:
right lower extremity erythema and edema
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ year old gentleman with a PMH of IDDM,
previous diabetic foot infection, recurrent lower extremity
cellulitis, and HCV cirrhosis, who presents with right lower
extremity erythema and edema. His symptoms are acute on chronic.
.
The patient is followed closely by Infectious Disease and
Podiatry for his symptoms. He first developed a non-healing
plantar wound after stepping on some glass ___ the ___
___. This wound grew: MSSA ___ ___, and Proteus and beta
Streptococcus ___ ___. ___ ___, he noted worsening
of the ulceration ___ his right foot, ___ the context of
increasing bilateral lower extremity erythema and swelling. At
that time, he was treated with doxycyclne and Augmentin for 10
days with some improvement, but required an extra consecutive
10-day course of doxycycline/Augmentin, as his erythema and
swelling worsened. Following those courses, he developed a
blister on the left anterior shin; he self-drained this blister,
and took more doxycycline (this was his last course of
antibiotics).
.
However, as noted ___ note from ___ on ___, he continued
to have significant edema and erythema. He was seen ___ his
primary care clinic on ___, where diuresis was augmented by
increasing Lasix from 60 to 80 mg daily, and patient was
instructed to use ACE wraps on his legs and elevated them. His
lower extremity edema and erythema improved. On ___, he
underwent plantar ulcer debridement by Dr. ___ noted
moderate improvement and prescribed a pad for improved weight
distribution. ___ ___ clinic follow-up on ___, the patient
noted persistent drainage from the ulcer, as well as low-grade
fevers to 100 over the preceding few days. He noted a red spot
on the left medial lower leg that was warm with irregular
borders that were slightly raised. Since his debridement, his
wound swab has grown mixed bacteria, with moderate growth of
Pseudomonas (sensitive to cefepime, ceftaz, cipro, gent, ___,
pip-tazo, and tobra).
.
Three days ago, he noted increasing swelling, erythema and pain
___ his right foot. This extended from the dorsum of his foot, to
the medial malleolus, and up the medial calf. Pain initially
occured two times per day, the increased ___ frequency and
severity the day of admission. The pain was sharp/shooting, and
felt like it was deep inside the right ankle. Tylenol, elevation
and ACE wraps helped minimally. Pain was accompanied by fevers
measured to 100.7. He believes that this is consistent with
cellulitis, which he thinks may have been presented and
untreated/undertreated since ___. He has been vigilant with
wound care for his ulcer and legs; his wife and daughter, who
are nurses, help him with this.
.
___ the ED, initial VS were: 97.6 69 132/54 14 100%. Labs were
notable for X-ray of his foot was obtained; blood and urine
cultures were sent. He was given vancomycin 1g IV x1. On arrival
to the floor, the patient was comfortable, but reported mild
pain ___ his right leg.
.
Review of sytems:
(+) Per HPI. Also positive for elevated blood glucose to the
200s for the past 5 days (from baseline good control ___ the
100s).
(-) Denies chills, night sweats, recent weight loss or gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough, shortness of breath. Denies chest pain or
tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change ___ bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
1. Hepatitis C genotype 1 (s/p interferon plus ribavirin x at
least six months and relapsed)
-- Treated ___ the 2000s by Dr. ___ at ___.
He was treated with interferon plus ribavirin x at least six
months and was a relapser on nadolol.
-- Now followed by Dr. ___ at ___
2. HCV Cirrhosis with portal hypertension including grade 2
esophageal varices
-- EGD (___) - varices at the lower third of the
esophagus, friability and erythema ___ the antrum and pre-pyloric
area compatible with gastritis, erythema ___ the duodenal bulb
compatible with Duodenitis
3. Insulin dependent diabetes.
4. Hypertension.
5. Hyperlipidemia.
6. BPH.
7. History of HBV exposure (core antibody positive/surface
antigen negative.)
8. Overweight/obese state.
9. R foot drop
10. Chronic median neuropathy at the L wrist, as ___ carpal
tunnel syndrome, w/associated axonal loss ___ EMG), s/p
neurolysis and release (___)
11. s/p Colonic and rectal polypectomies (___)
12. GERD
13. Recurrent herpes simplex (on acyclovir)
14. Moderate to severe AS (valvearea 1.0-1.2cm2)
15. Low back pain ___ discitis
16. Right tib-fib fracture ___ with indwelling screws
Social History:
___
Family History:
Father with heart valve replacement. Mother with diabetes. Both
are deceased.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.6 130/70 75 18 99%RA
General: Very pleasant, comfortable
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no cerv LAD
Lungs: Minimal end-inspiratory rales at bases bilaterally.
CV: RRR, diminsed S1 and S2. III/VI systolic ejection murmur,
loudest at the RUSB, with radiation to carotids bilaterally and
apex.
Abdomen: Soft, discomfort with palpation of LLQ, non-distended,
normoactive bowel sounds, no rebound tenderness or guarding, no
organomegaly
Ext: Warm, well perfused, 2+ pulses, trace edema ___ LLE, 1+
edema ___ right foot and ankle. Calf 40.5 cm at top dot, 28 cm at
middle dot, 31 cm at third dot (ankle at the greatest
circumference).
Skin: Left anterior shin with scar from previous blister, as
well as venous stasis changes. Mild erythema with mild TTP over
right medial calf extending over dorsum of right foot, with one
extraneous patch on right foot (erythema outlined). Scar along
middle of right shin is mildly warmer than rest of skin. Venous
stasis changes over right shin. Scaling skin inter-digits. Ulcer
on plantar surface of right foot with off-white, dry border and
dark, dry eschar inside.
Neuro: A+O x3, alert and awake. ___ strength ___ upper and lower
extremities. CNs II-XII intact.
DISCHARGE PHYSICAL EXAM:
General: pleasant, comfortable
Lungs: CTAB
CV: RRR, diminsed S1 and S2. III/VI systolic ejection murmur,
loudest at the RUSB, with radiation to carotids bilaterally and
apex.
Abdomen: Soft, NT, ND, NABS
Ext: Warm, well perfused, mild erythema on RLE improved. trace
edema bilat.
Pertinent Results:
ADMISSION LABS:
___ 04:40PM BLOOD WBC-4.5 RBC-3.67* Hgb-10.9* Hct-34.5*
MCV-94 MCH-29.7 MCHC-31.6 RDW-15.8* Plt ___
___ 04:40PM BLOOD Neuts-64.3 ___ Monos-6.5 Eos-4.0
Baso-1.9
___ 04:40PM BLOOD Glucose-286* UreaN-17 Creat-1.0 Na-138
K-3.8 Cl-106 HCO3-22 AnGap-14
___ 05:04PM BLOOD Lactate-1.7
___ 05:00PM URINE Color-Yellow Appear-Clear Sp ___
___ 05:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
DISCHARGE LABS:
___ 05:45AM BLOOD WBC-3.1* RBC-3.57* Hgb-10.5* Hct-34.0*
MCV-95 MCH-29.4 MCHC-30.9* RDW-15.8* Plt ___
___ 05:45AM BLOOD Glucose-245* UreaN-13 Creat-1.0 Na-136
K-4.2 Cl-103 HCO3-27 AnGap-10
___ 05:45AM BLOOD Calcium-9.0 Phos-3.4 Mg-2.1
MICROBIOLOGY:
___ Blood cultures x2: NGTDx2
___ 5:00 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
NITROFURANTOIN-------- 128 R
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ =>32 R
___ 9:55 am SWAB Source: right foot ulceration.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
WOUND 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..
ANAEROBIC CULTURE (Final ___:
UNABLE TO R/O OTHER PATHOGENS DUE TO OVERGROWTH OF
SWARMING PROTEUS
SPP..
IMAGING:
___ Right foot AP/lat/obl: no evidence of osteomyelitis
Medications on Admission:
Acyclovir 400 mg PO TID x5 days for lesion recurrences
Clotrimazole 1% cream, apply BID to fungus on feet for one month
then stop and reuse as needed
Felodipine (ext rel) 2.5 mg PO daily
Finasteride 5 mg PO daily
Furosemide 80 mg PO daily
Glipizide (ext rel) 10 mg PO daily
Insulin glargine 80 units at bedtime
Insulin lispro (Humalog) per SSI before breakfast and lunch
Lactulose 30 mL QID until at least 3 BMs per day
Lidocaine 5% patch, apply once per 24 hours to affected area
(back), remove after 12 hours. Max 2 patches simultaneously.
Metformin (ext rel) 1000 mg PO daily
Nadolol 20 mg PO daily
Nortriptyline 25 mg PO qHS
Omeprazole (E.C., delayed release) 40 mg PO BID
Rifaxamin 550 mg PO BID
Simvastatin 20 mg PO qHS
Tamsulosin (ext rel) 0.4 mg PO daily
Calcium 500 mg PO BID
Cholecaliferol (Vit D3) 1000 units PO daily
Cranberry 1000 mg PO daily
Ferrous sulfate 325 mg PO TID
Glucosamine sulfate 750 mg PO BID
Multivitamin PO daily
Omega-3 Fatty Acids-Vitamin E (fish oil) ___ mg PO daily
Silver-hydrocolloid dressing (Aquacel-Ag) 1.2 %-2" X 2" Bandage,
apply to affected area every third day
Discharge Medications:
1. acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8
hours): for lesion recurrences.
2. clotrimazole 1 % Cream Sig: One (1) Appl Topical BID (2 times
a day) as needed for fungal infection.
3. felodipine 2.5 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO DAILY (Daily).
4. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. glipizide 10 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet
Extended Rel 24 hr PO DAILY (Daily).
7. Insulin glargine 80 units at bedtime
8. Insulin lispro (Humalog) per SSI before breakfast and lunch
9. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4
times a day): titrate to three BMs per day .
10. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for back pain: apply once per 24 hours to affected area
(back), remove after 12 hours. Max 2 patches simultaneously.
11. metformin 500 mg Tablet Extended Release 24 hr Sig: Two (2)
Tablet Extended Release 24 hr PO DAILY (Daily).
12. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. nortriptyline 25 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
14. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
15. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
16. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
17. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO DAILY (Daily).
18. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
19. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
20. cranberry 500 mg Capsule Sig: Two (2) Capsule PO once a day.
21. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO TID (3 times a day).
22. Glucosamine 750 mg Tablet Sig: One (1) Tablet PO twice a
day.
23. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
24. omega-3 fatty acids Capsule Sig: One (1) Capsule PO
DAILY (Daily).
25. Aquacel-AG ___ X 2 %- Bandage Sig: One (1) bandage
Topical once a day: apply to affected area every third day.
26. ciprofloxacin 750 mg Tablet Sig: One (1) Tablet PO twice a
day for 11 days.
Disp:*22 Tablet(s)* Refills:*0*
27. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a
day for 11 days.
Disp:*22 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
cellulitis
Secondary Diagnosis:
chronic non-healing plantar ulcer
diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
RIGHT FOOT
CLINICAL HISTORY: Plantar diabetic ulcer. Evaluate for osteomyelitis.
COMPARISON: ___.
FINDINGS: Three views of the right foot are provided. There is stable mild
plantar soft tissue swelling. Stable appearance of the partially resected
second metatarsal and deformity of the first metatarsal head, which may be
post-traumatic or degenerative. There are prominent degenerative changes of
the first MTP. There are multiple hammertoe deformities, unchanged.
Articular surfaces are otherwise unremarkable. There is an os naviculare.
There is no osseous destruction to suggest osteomyelitis. There is soft
tissue swelling over the dorsum of the foot.
IMPRESSION: No evidence of osteomyelitis. No interval change.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: R FOOT PAIN
Diagnosed with IDDM W SPEC MANIFESTATION, CELLULITIS OF FOOT
temperature: 97.6
heartrate: 69.0
resprate: 14.0
o2sat: 100.0
sbp: 132.0
dbp: 54.0
level of pain: 9
level of acuity: 3.0 | Mr. ___ is a ___ year old gentleman with a PMH of IDDM,
previous diabetic foot infection, recurrent lower extremity
cellulitis, and HCV cirrhosis, who presents with right lower
extremity erythema and edema. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
testicular pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of psoriatic arthritis on methotrexate and
Enbrel presents with urinary changes and right-sided testicular
pain. Patient had a past history of UTI four months ago and
began feeling similar symptoms today. However, this time he had
pain in the right testicle with associated swelling. This was
associated with dysuria and difficulty initiating stream. He
noticed his urine was cloudy with some blood. He had fever to
102 at home and some right flank pain that did not radiate.
In the ED, initial vital signs were ___ 141/67 16 94%. He
spiked a temperature to 100.1. Scrotal ultrasound demonstrated
epididymitis. CTU showed some nonobstructing stones, but no
hydronephrosis. WBC was elevated at 17 and he was given a dose
of 1g ceftriaxone IV.
On the floor, his vitals were 99 127/73 73 18 96% on RA
He appeared more comfortable with less scrotal pain and he no
longer had any right flank pain. denies abdominal pain, nausea
or vomiting
Review of Systems:
(+) as per HPI
(-) headache, vision changes, rhinorrhea, congestion, sore
throat, cough, shortness of breath, chest pain, abdominal pain,
nausea, vomiting, diarrhea, constipation
All other systems reviewed and were negative
Past Medical History:
- psoriatic arthritis
- GERD with evidence of ___ esophagus on EGD
- rotator cuff tendinopathy s/p joint injection ___
Social History:
___
Family History:
father died of CAD at age ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals- 99 127/73 73 18 96% on RA
General- Alert, oriented, no acute distress
HEENT- PERRL, EOMI, 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, no murmurs, rubs, gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Back: no CVA tenderness
GU- Right scrotum mildly tender, erythematous, mild swelling
Lymph - 1cm right inguinal LN
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
DISCHARGE PHYSICAL EXAM:
Vitals- 99.1 125/79 74 18 96% RA
General- Alert, oriented, no acute distress
HEENT- PERRL, EOMI, Sclera anicteric, MMM, oropharynx clear
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, no murmurs, rubs, gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
GU- Right scrotum mildly tender, non-erythematous, mild swelling
Ext- warm, well perfused, no clubbing, cyanosis or edema
Neuro- motor function grossly normal
Pertinent Results:
ADMISSION LAB:
___ 04:00PM BLOOD WBC-17.6*# RBC-4.57* Hgb-14.5 Hct-45.5
MCV-100* MCH-31.7 MCHC-31.9 RDW-14.4 Plt ___
___ 04:00PM BLOOD Neuts-88.4* Lymphs-5.6* Monos-5.3 Eos-0.2
Baso-0.5
___ 04:00PM BLOOD Glucose-142* UreaN-20 Creat-0.9 Na-137
K-4.2 Cl-101 HCO3-25 AnGap-15
___ 04:06PM BLOOD Lactate-1.6
DISCHARGE LAB:
___ 05:20AM BLOOD WBC-16.4* RBC-4.45* Hgb-13.9* Hct-44.5
MCV-100* MCH-31.2 MCHC-31.2 RDW-13.9 Plt ___
URINE
___ 03:53PM URINE Color-Red Appear-Cloudy Sp ___
___ 03:53PM URINE Blood-LG Nitrite-POS Protein-30
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 03:53PM URINE RBC->182* WBC->182* Bacteri-FEW
Yeast-NONE Epi-0
MICROBIOLOGY
__________________________________________________________
___ 7:50 pm URINE Source: ___.
Chlamydia trachomatis, Nucleic Acid Probe, with Amplification
(Pending):
NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH
AMPLIFICATION
(Pending):
__________________________________________________________
___ 4:10 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 4:00 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 3:53 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 4 S
AMPICILLIN/SULBACTAM-- 4 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
IMAGING
___ CT A&P W/O CONTRAST
IMPRESSION: Punctate nonobstructing left renal stones. No
hydronephrosis or hydroureter. Mild bilateral perinephric
stranding. Cannot exclude infecton.
Correlation with urinalysis is recommended. Chronic findings
including sigmoid diverticulosis.
___ Scrotal US
FINDINGS:
The right testicle measures 4.2 x 2.8 x 2 cm.
The left testicle measures 3.7 x 2.7 x 2.6 cm.
Right testicular echogenicity is somewhat heterogenous.
However, there is no focal abnormality. Normal arterial and
venous waveforms are detected in both testicles. The right
epididymis is enlarged and hyperemic. The left
epididymis is unremarkable. Small right and trace left
hydroceles are
present.
IMPRESSION:
1. Findings compatible with right epididymitis; early orchitis
is not
excluded.
2. Small right and trace left hydroceles.
3. The left testicle and epididymis are normal.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Enbrel (etanercept) 50 mg/mL (0.98 mL) subcutaneous weekly
2. Fluticasone Propionate NASAL 2 SPRY NU DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Methotrexate 20 mg SC 1X/WEEK (MO)
5. Hydrocortisone Cream 0.5% 1 Appl TP TID:PRN psoriasis
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. Hydrocortisone Cream 0.5% 1 Appl TP TID:PRN psoriasis
3. Ciprofloxacin HCl 500 mg PO/NG Q12H
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice daily Disp
#*15 Tablet Refills:*0
4. Ibuprofen 400 mg PO Q8H:PRN pain
5. Enbrel (etanercept) 50 mg/mL (0.98 mL) subcutaneous weekly
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY
7. Methotrexate 20 mg SC 1X/WEEK (MO)
Discharge Disposition:
Home
Discharge Diagnosis:
Epididymitis
Urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Right testicular pain. Evaluate for epididymitis versus torsion.
COMPARISON: None.
TECHNIQUE: Grayscale, color and spectral Doppler ultrasound of the scrotum
and contents.
FINDINGS:
The right testicle measures 4.2 x 2.8 x 2 cm.
The left testicle measures 3.7 x 2.7 x 2.6 cm.
Right testicular echogenicity is somewhat heterogenous. However, there is no
focal abnormality. Normal arterial and venous waveforms are detected in both
testicles. The right epididymis is enlarged and hyperemic. The left
epididymis is unremarkable. Small right and trace left hydroceles are
present.
IMPRESSION:
1. Findings compatible with right epididymitis; early orchitis is not
excluded.
2. Small right and trace left hydroceles.
3. The left testicle and epididymis are normal.
Radiology Report
HISTORY: Right flank pain.
TECHNIQUE: Multi detector CT scan of the abdomen and pelvis was performed
without IV contrast. The patient was scanned in the prone position. Coronal
and sagittal reformatted images were obtained.
COMPARISON: None.
FINDINGS: The lung bases are clear. There is no pericardial or pleural
effusion.
The liver, gallbladder, pancreas, spleen and adrenal glands appear normal.
There are punctate nonobstructing stones in the left kidney. There are no
stones in the ureters or within the right kidney. There is no hydronephrosis.
There is bilateral mild perinephric fat stranding. The appendix appears
normal. The small and large bowel are without wall thickening or obstruction.
There is sigmoid diverticulosis. The appendix is visualized in the right
lower quadrant and appears normal. The bladder appears normal. There are
brachytherapy seeds in the prostate. The aorta is normal in caliber and
contains scattered atherosclerotic calcifications. A focal athereosclerotic
calcification in the right internal iliac artery should not be confused for a
ureteral stone. There is no free fluid, free air or lymphadenopathy.
Osseous structures: There are no concerning osteoblastic or osteolytic
lesions.
IMPRESSION: Punctate nonobstructing left renal stones. No hydronephrosis or
hydroureter. Mild bilateral perinephric stranding. Cannot exclude infecton.
Correlation with urinalysis is recommended. Chronic findings including sigmoid
diverticulosis.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: FEVER
Diagnosed with PYELONEPHRITIS NOS
temperature: 99.0
heartrate: 99.0
resprate: 16.0
o2sat: 94.0
sbp: 141.0
dbp: 67.0
level of pain: 5
level of acuity: 3.0 | ___ year old man with psoriatic arthritis on methotrexate,
admitted for UTI and epididymitis.
# Testicular pain. Hir right testicular pain was secondary to
epididymitis and UTI. US showed no evidence of testicular
torsion and there was low concern for pyelonephritis on exam and
on CT A&P, and for prostatitis on rectal exam in the ED. He was
initially started on IV ceftriaxone in the ED on ___ and
transitioned to ciprofloxacin PO. His fevers subsided and
leukocytosis began to trend down, and his urinary symptoms of
hesitancy and dysuria as well as testicular pain improved. His
cultures returned with E coli sensitive to cipro and he was
discharged with 10-day full abx course to finish on ___. He
was seen by urology consult team while inpatient and will f/u
with Dr. ___ be scheduled) and PCP within the following
week.
# psoriatic arthritis
- continued Enbrel and methotrexate (dosed on ___
# macrocytosis - MCV 100 - ___ methotrexate
- encouraged compliance with folic acid
# GERD - not currently taking any medications at home
- ranitidine prn |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Benzoin / Penicillins
Attending: ___.
Chief Complaint:
dysesthesias of tongue and nose
Major Surgical or Invasive Procedure:
LP
History of Present Illness:
Mr ___ is a ___ right-handed man presenting with tongue
and perioral dysaesthesia on a background of pulmonary sarcoid,
and prior renal calculi.
About three weeks ago he noted that his tongue was tingly and
the
bottom felt 'puffy', but was not swollen. He then developed a
feeling of drooling out of both sides of his mouth about one
week
ago - this is persistent. He has a tingling feeling of the tip
of his nose that has come and gone since this time. Tongue
tingling is also essentially persistent. This is a burning and
tingling sensation that is not painful - he is anxious and
concerned, but no in pain or discomfort. He noted altered taste
(he would not have brought this up, he says), like 'blood in his
mouth' for a while - he thinks that this is not associated with
reflux. He felt 'for sure' that there was some infection or
nerve problem in the gum adjacent to his lower incisors, but his
dentist found nothing on clean, inspection and pan-orex on
___. He gave a major speech last ___ night, and this
went well. He is not sure whether his voice is changed, as he
told Dr. ___ thinks that this is subtle if
present
(a lisp).
No trips to the woods, no known ticks, no rash, no joint pain.
No HIV risks, no pulmonary symptoms, no headache. Felt really
tired with exercise with leg aching yesterday - had to stop -
this is atypical and he exercises frequently. Review of systems
negative except as above.
Past Medical History:
Past Medical History:
- Chronic benign prostatitis, ___ - on doxazosin
- Renal calculi, ___ (Dr. ___ at ___
- Pulmonary sarcoid, incidental finding on imaging, perhaps MRI,
at time of lithotripsy as above in ___, biopsy proven, has
never
been symptomatic
- Possible rectal fissure, nifedipine topical ___ months, MRI
planned
- GERD, on omeprazole
- Hypercholesterolemia, on Statin
Social History:
___
Family History:
Family Hx:
Sister with sarcoid, another sister won't get tested. Mother
has
osteoporosis. Father died ___, ___ disease with
prominent
autonomic failure, heart disease and AMI, 'benign brain tumor in
mid-___' ... 'successful surgery', unclear tumor type, but
visual
symptoms.
Physical Exam:
Vitals: 98.2 77 123/84 18 98% ra
General Appearance: Comfortable, no apparent distress.
HEENT: NC, OP clear, MMM.
Neck: Supple. No bruits.
Lungs: CTA bilaterally.
Cardiac: RRR. Normal S1/S2. No M/R/G.
Abdominal: Soft, NT, BS+
Extremities: Warm and well-perfused. Peripheral pulses 2+.
Neurologic:
Mental status:
Awake and alert, cooperative with exam, normal affect. Oriented
to person, place, date and context. Normal fluency,
comprehension, repetition, naming. No paraphasic errors.
Excellent memory and fund of knowledge for recent current events
___, DOMA, recent murder, etc.). Proverbial understanding is
abstract. Highly articulate; mildly anxious (had been more
anxious earlier in clinic).
Cranial Nerves:
I: Not tested.
II: Pupils equally round and reactive to light, 4 to 3 mm
bilaterally. Visual fields are full to confrontation. Normal
fundi with bilateral myopic crescent and refractive error of
about 8 diopters, venous pulsations appreciable on right.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation (temperature, pin, touch)
intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetric.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations, good rapid movements
and good strength on pressing into cheek.
Tone normal throughout. Normal bulk.
Power
D B T WE WF FF FAb | IP Q H AT G/S ___ TF
R ___ ___ 5 | ___ ___ 5
L ___ ___ 5 | ___ ___ 5
Reflexes: B T Br Pa Ac
Right ___ 2 1
Left ___ 2 1
Toes downgoing bilaterally
Sensation intact to light touch, vibration, joint position,
pinprick bilaterally. Romberg negative.
Normal finger nose, great toe finger, RAM's bilaterally.
Gait:
Normal initiation, cessation, turn, arm swing, base.
Pertinent Results:
___ 12:40PM BLOOD WBC-5.0 RBC-4.80 Hgb-13.7* Hct-41.7#
MCV-87 MCH-28.6 MCHC-32.9 RDW-13.3 Plt ___
___ 12:40PM BLOOD Neuts-66.0 ___ Monos-5.1 Eos-1.3
Baso-1.1
___ 04:25PM BLOOD ___ PTT-33.6 ___
___ 12:40PM BLOOD Glucose-88 UreaN-20 Creat-1.0 Na-143
K-4.0 Cl-104 HCO3-28 AnGap-15
___ 12:40PM BLOOD ALT-22 AST-26 LD(LDH)-166 AlkPhos-53
TotBili-1.4
___ 12:40PM BLOOD Albumin-5.2 Calcium-9.9 Phos-3.3 Mg-2.0
___ 01:15PM BLOOD CRP-1.2
Lyme serology: PND
Vit B12: PND
MMA: PND
___ 12:40PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
CXR:FINDINGS: In comparison with an outside image of ___,
there is little change and no evidence of acute cardiopulmonary
disease. Specifically, no evidence of hilar or mediastinal
lymph nodes or prominence of interstitial lung disease to
radiographically suggest sarcoidosis.
MRI brain with and without contrast w FIESTA sequences through
skull base: FINDINGS:
The ventricles, sulci, and subarachnoid spaces are normal in
size and
configuration. There is no evidence of acute infarct or
hemorrhage. Few
scattered T2/FLAIR hyperintense foci in the subcortical white
matter are
nonspecific. There is no abnormal intra or extra-axial fluid
collection, no shift of normally midline structures, and no mass
lesion or mass effect. There is no mass lesion or abnormal
enhancement in the expected location of the cranial nerves. The
brainstem appears normal. There is no abnormal enhancement.
There is mild mucosal thickening in the maxillary sinuses and
ethmoid air cells. The remaining visualized paranasal sinuses,
mastoids, and orbits are unremarkable.
IMPRESSION:
1. No acute intracranial abnormality. No evidence of mass,
infarct or
hemorrhage.
2. No abnormality related to the cranial nerves or brainstem.
Medications on Admission:
1. Aspirin 81 mg PO DAILY
2. Doxazosin 4 mg PO HS
3. Omeprazole 20 mg PO DAILY
4. Simvastatin 20 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Doxazosin 4 mg PO HS
3. Omeprazole 20 mg PO DAILY
4. Simvastatin 20 mg PO DAILY
5. Propranolol 10 mg PO BID:PRN anxiety
Take when tingling worsens, or when anxious
RX *propranolol 10 mg 1 tablet(s) by mouth twice a day Disp #*20
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
tongue and perioral paresthesias
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ male with bilateral lower facial and arm tingling.
COMPARISON: None.
TECHNIQUE: Multi sequence multi planar imaging of the brain and posterior
fossa/skull base was performed both prior to and following the intravenous
administration of 7 mL Gadavist as per standard department protocol.
FINDINGS:
The ventricles, sulci, and subarachnoid spaces are normal in size and
configuration. There is no evidence of acute infarct or hemorrhage. Few
scattered T2/FLAIR hyperintense foci in the subcortical white matter are
nonspecific. There is no abnormal intra or extra-axial fluid collection, no
shift of normally midline structures, and no mass lesion or mass effect.
There is no mass lesion or abnormal enhancement in the expected location of
the cranial nerves. The brainstem appears normal. There is no abnormal
enhancement.
There is mild mucosal thickening in the maxillary sinuses and ethmoid air
cells. The remaining visualized paranasal sinuses, mastoids, and orbits are
unremarkable.
IMPRESSION:
1. No acute intracranial abnormality. No evidence of mass, infarct or
hemorrhage.
2. No abnormality related to the cranial nerves or brainstem.
Radiology Report
HISTORY: Sarcoidosis, to compare with previous studies.
FINDINGS: In comparison with an outside image of ___, there is little
change and no evidence of acute cardiopulmonary disease. Specifically, no
evidence of hilar or mediastinal lymph nodes or prominence of interstitial
lung disease to radiographically suggest sarcoidosis.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: TONGUE TINGLING/SPEECH OFF
Diagnosed with SKIN SENSATION DISTURB, FACIAL WEAKNESS
temperature: 98.2
heartrate: 77.0
resprate: 18.0
o2sat: 98.0
sbp: 123.0
dbp: 84.0
level of pain: 5
level of acuity: 3.0 | Mr ___ was admitted for a three-week history of tingling in his
tongue, and intermittently in the tip of his nose, as well as a
subjective drooling sensation.
#Neuro
His MRI with and without contrast including FIESTA sequences of
the skull base was normal, suggesting no cranial involvement of
his sarcoid. His CXR showed imporved hilar findings. On exam he
had some findings suggestive of cervical spine disease (reduced
position sense of toes), which could possibly cause sensation
loss. He also reported to adhere to a very strict diet almost
without red meat.
We ordered Lyme serology which is negative, vitamin B12 which is
normal and methyl malonic acid is still pending.
He also reported increased dysesthesias upon hyperventilation,
suggesting a stress component.
We discharged him with Neurology follow up and a prescription
for propranolol PRN anxiety.
Dr. ___ call the patient after his discharge to give
him the results of the Lyme and B12 levels. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ h/o pericarditis, GERD presenting for evaluation of chest
pain. Pain started 2 days prior to presentation, mild and
worsens wtih deep breathing. No cough, no shortness of breath.
Reports occasionally has had similar pains twice per year in the
past which was felt to be related to reflux pain usually lasts
___ days and resolves on its own or with some ibuprofen. Denies
any pain or swelling in his legs, no recent travel or surgery or
other immbolization, no family history of blood clots, no cancer
history. Had low grade fever to 100.3 day prior to admission.
His fiance recently had a cold and he feels that he may be
coming down with the same thing, although has no cough.
Initially was seen in ___'s office, concern was for reflux vs
GERD vs pericarditis. CXR showed small pleural effusions on L
with LLL infiltrate, started on azithromycin for PNA. D-dimer
was done to r/o PE and was elevated so pt sent to ED for further
eval with CTA chest. Of note pt has h/o ?pericarditis dx at
___ ___ years ago and has presented to ___'s office
last in ___ for similar complaints. Prior episode that was
diagnosed as pericarditis was different; pt was unable to lie
flat and pain was much more severe and improved with ibuprofen.
.
In the ED, initial VS were 98.8 140 138/87 16 100%. CTA chest
was negative for PE but with trace pericardial effusion and
small pleural effusions. Noted to be tachycardic to 130s and
received some IV NS.
.
Currently pt denies any complaints. Chest pain resolved several
hours ago, lasting a total of a day and a half. Describes pain
as mostly in ___ chest substernal but radiating throughout
chest and worsening on any position change (ie worse when going
from layign to sitting, or sitting ot laying, or sitting to
standing) and then improves when not moving. Chest does not feel
tender to palpation. Worse with reathing, no associated
shortness of braeth except when going up stairs while chest pain
was happening. Took a few motrin over the last day, about 2
pills every 4 hours.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. he denies recent fevers, chills or rigors.
S/he denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, -Dyslipidemia, -Hypertension
2. CARDIAC HISTORY: ?pericarditis
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
alopecia
Social History:
___
Family History:
Grandfather with heart disease, unsure of details. No family
history of early MI, arrhythmia, cardiomyopathies, or sudden
cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 99 128/82 114 20 98% RA
GENERAL: WDWN M in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with no JVD.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
DISCHARGE PHYSICAL EXAMINATION:
98.5 (99.1) 112/72 (SBP 105-125) 98 (92-114) 18 99%RA
GENERAL: NAD
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: JVP 7cm H2O
CARDIAC: RRR, nl S1/S2, no m/r/g. No reproducible chest pain.
LUNGS: CTAB
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. Good peripheral pulses.
Pertinent Results:
PERTINENT LABORATORY RESULTS:
___ 06:40PM BLOOD WBC-9.6 RBC-4.57* Hgb-13.9* Hct-41.0
MCV-90 MCH-30.5 MCHC-33.9 RDW-11.9 Plt ___
___ 06:40PM BLOOD Neuts-67.2 ___ Monos-5.7 Eos-1.0
Baso-0.5
___ 06:40PM BLOOD ___ PTT-29.9 ___
___ 06:40PM BLOOD Glucose-98 UreaN-12 Creat-1.1 Na-140
K-3.5 Cl-100 HCO3-29 AnGap-15
___ 06:40PM BLOOD CK-MB-1 cTropnT-<0.01
___ 06:40PM BLOOD D-Dimer-2386*
STUDIES:
ECG (___):
Sinus tachycardia. Normal tracing except for rate. No previous
tracing
available for comparison.
CTA CHEST (___):
FINDINGS: Moderate left and small right pleural effusions are
present with
overlying atelectasis. No pulmonary embolism is present. No
acute aortic
syndrome There is a small pericardial effusion. No mediastinal,
hilar, or
axillary lymphadenopathy. Visualized portions of the upper
abdomen are
unremarkable. No acute fracture is seen.
IMPRESSION: Small pericardial effusion. Moderate right and small
left
pleural effusions. No evidence of pulmonary embolism.
ECHO (___):
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF 60%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Tissue Doppler
imaging suggests a normal left ventricular filling pressure
(PCWP<12mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic root is mildly dilated at the
sinus level. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis or
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no systolic
anterior motion of the mitral valve leaflets. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
Medications on Admission:
finasteride 5 mg daily
azithromycin (took first dose of 5 days course)
Discharge Medications:
1. azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days: Final day of antibiotic is ___.
2. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) for 10 days: Take every 8 hours, for a total of 10 days.
Take with meals. .
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnosis: pleurisy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ man with chest pain, elevated D-dimer.
TECHNIQUE: MDCT data were acquired through the chest after the administration
of intravenous contrast. Images were displayed in multiple planes including
oblique projections.
FINDINGS: Moderate left and small right pleural effusions are present with
overlying atelectasis. No pulmonary embolism is present. No acute aortic
syndrome There is a small pericardial effusion. No mediastinal, hilar, or
axillary lymphadenopathy. Visualized portions of the upper abdomen are
unremarkable. No acute fracture is seen.
IMPRESSION: Small pericardial effusion. Moderate right and small left
pleural effusions. No evidence of pulmonary embolism.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: ELEVATED D DIMER
Diagnosed with MYOCARDITIS NOS
temperature: 98.8
heartrate: 140.0
resprate: 16.0
o2sat: 100.0
sbp: 138.0
dbp: 87.0
level of pain: 3
level of acuity: 1.0 | ===============
BRIEF HOSPITAL SUMMARY
===============
___ h/o pericarditis, GERD presenting for evaluation of chest
pain. An echo demonstrated no significant pericardial effusion
or wall motion abnormalities or valvular abnormalities. The
patient's chest pain resolved with ibuprofen.
===============
ACTIVE ISSUES
===============
# Chest pain: pleurisy, unlikely to be of cardiac etiology as
cardiac enzymes negative, no changes in EKG, and echo was
unremarkable . Musculoskeletal possible given that pain is worse
with any movement. PE was ruled out with CTA. Most likely
pericarditis, as pain improved with ibuprofen. Will treat with
NSAID. L pleural effusion also was present on initial episode
of pericarditis years ago ( then resolved). There was no
comment re: any signs of pneumonia on CTA. Ordered autoimmune
labs to initiate evaluation for potential vasculitis ___, RF,
ESR, CRP, anti-CCP), yet patient was anxious to leave and the
labs were never drawn. ___ consider auto-immune w/u as outpt.
Prescribed 400mg ibuprofen standing TID for pericarditis x 10d.
continued azithromycin x 4 days
.
# CORONARIES: no ischemnic changes on EKG, neg enzymes
.
# PUMP: euvolemic on exam. no e/o heart failure on echo
.
# RHYTHM: tachycardic on admission, in setting of anxiety and
potential infection. no events while on tele
==================
TRANSITIONAL ISSUES
==================
1. Medication Changes:
ADD 3. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 10 days: Take every 8 hours, for a total of 10
days. Take with meals. .
2. Pt w/ moderate L sided pleural effusion. Consider f/u CXR in
___ weeks to evaluate evolution.
3. Consider drawing auto-immune labs (were ordered but never
drawn here) to consider potential vasculitis or rheumatic cause
of pleural effusions, as an outpatient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
1) Large left retroperitoneal fluid collection.
2) Infected left leg external-fixator pin sites
3) Left leg DVT
Major Surgical or Invasive Procedure:
___: Interventional Radiology - percutaneous drainage of
retroperitoneal fluid collection
___: Incision and debridement of left lower extremity
external fixator pin sites
History of Present Illness:
___. male s/p fall on ___ sustaining right calcaneus
fracture, left tibial plateau fracture, left pubic ramus fx, and
L4 burst fracture. He underwent multiple surgeries including
ex-fix and fasciotomy of left lower leg, ORIF of left tibial
plateau, and anterior and posterior fusion from L3-S1, with Dr.
___ (Vascular Surgery) assisting for anterior
exposure. He was recently readmitted ___ for
fevers and concerning for external fixator pin tract infection
as
well as retroperitoneal fluid collection. He underwent removal
of external fixator spanning the left knee with debridement of
the pin tract, from which tissue cultures grew rare coagulase
negative staphylococcus and sparse group B beta streptococcus.
For antibiotics, he only received perioperative cefazolin and
remained afebrile during the entire admission. He also
underwent
percutaneous drainage of the retroperitoneal fluid colelction,
which showed no microorganisms on gram stain and grew sparse
group B beta streptococcus. Blood cultures from that admission
show no growth to date.
Pt returns from rehab with R flank pain x 1 day. Denies fevers,
chills, sweats, n/v, wound problems, or other complaints.
Past Medical History:
Past Medical History:
schizophrenia, HTN
Past Surgical History:
Pacemaker placement ___ EXTERNAL FIXATION, FASCIOTOMIES LEFT LOWER EXTREMITY
___
___ ANTERIOR CORPECTOMY L4; L3-S1 FUSION; BMP;
ALLOGRAFT;AUTOGRAFT ___
___ INCISION AND DRAINAGE VAC CHANGE OF LEFT LEG;
PERCUTANEOUS IVC FILTER; POSTERIOR L3-S1 FUSION WITH
INSTRUMENTATION AND BONE GRAFT; REVISION ANTERIOR LUMBAR FUSION
L3-L5 ___
___ I&D LEFT LEG, ORIF tibia fracture, Closure of
fasciotomies ___
___ 1. REMOVAL OF LEFT EX-FIX LEFT LEG. I AND D LEFT
LEG.REMOVAL OF LEFT LEG STITCHES. MANIPULATION LEFT KNEE
___
___ History:
___
Family History:
NC
Physical Exam:
T: 98.4 P: 90s BP: 123/72 RR: 16 O2sat: 98% on RA
General: NAD, calm and comfortable, AAOx3
HEENT: NCAT, EOMI, anicteric
Heart: RRR
Lungs: CTAB, no respiratory distress
Abdomen: Soft, mild LLQ tenderness; non-distended; midline
incision c/d/i, small soft tissue swelling LLQ without
fluctuance
or erythema
Extremities: L lower leg fasciotomy incisions with wet-to-dry
dressings; ___ brace. R lower leg in short leg cast. BLE
neurovascularly intact distally.
Pertinent Results:
___ 11:10PM WBC-14.0*# RBC-3.73* HGB-11.0* HCT-33.1*
MCV-89 MCH-29.4 MCHC-33.1 RDW-14.9
___ 11:10PM NEUTS-89.1* LYMPHS-5.1* MONOS-3.4 EOS-2.0
BASOS-0.3
___ 11:10PM PLT COUNT-418
___ 11:10PM GLUCOSE-98 UREA N-9 CREAT-0.8 SODIUM-136
POTASSIUM-3.7 CHLORIDE-99 TOTAL CO2-27 ANION GAP-14
___ 03:54AM ___ PTT-35.5 ___
Medications on Admission:
Coumadin, lovenox, aspirin, plavix, vantin, amiodarone,
simvastatin, imipramine, benztropine, olanzipine,
cholecalciferol, calcium carbonate, senna, miralax, nicotine
patch, docusate sodium, bisacodyl, dulcolax suppository,
thiothixene, valium, vitamin D, acetaminophen, oxycodone
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO
Q4H (every 4 hours) as needed for pain.
4. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. imipramine HCl 25 mg Tablet Sig: Four (4) Tablet PO HS (at
bedtime).
7. thiothixene 5 mg Capsule Sig: Two (2) Capsule PO QAM (once a
day (in the morning)).
8. thiothixene 5 mg Capsule Sig: Four (4) Capsule PO QPM (once a
day (in the evening)).
9. benztropine 1 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
10. olanzapine 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
11. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
12. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
pack PO DAILY (Daily) as needed for constipation.
13. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
14. enoxaparin 100 mg/mL Syringe Sig: One (1) Injection
Subcutaneous Q12H (every 12 hours) for 1 days.
15. warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once):
Target INR ___. ___ and patient's PCP ___ monitor
patient's INR. .
16. ceftriaxone in dextrose,iso-os 1 gram/50 mL Piggyback Sig:
One (1) gram Intravenous Q24H (every 24 hours) for 6 weeks.
17. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO once a day:
Please start ___. Monitor for bleeding. .
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1) Large left retroperitoneal fluid collection.
2) Infected left leg external-fixator pin sites
3) Left leg DVT
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
INDICATION: ___ male with right knee pain.
___.
RIGHT KNEE, AP, OBLIQUE, AND CROSS-TABLE LATERAL: There are no acute
fractures. There is tricompartmental osteoarthritis, with mild joint space
narrowing, spurring of the medial and lateral tibial spines, and small
superior/inferior patellar enthesophytes. No joint effusion is present.
IMPRESSION: No fractures. Tricompartmental osteoarthritis.
Radiology Report
INDICATION: ___ male with right knee pain following surgical repair
of comminuted fractures.
No prior examinations for comparison.
RIGHT LOWER EXTREMITY ULTRASOUND: There is normal compressibility, flow, and
augmentation in the right common, superficial, and deep femoral and popliteal
veins. Left common femoral and right calf veins were not imaged, due to
overlying cast.
IMPRESSION: No right lower extremity DVT above the knee.
Radiology Report
INDICATION: ___ male with L4 burst fracture post L3-S1 anterior and
posterior fusion, complicated by large abdominal fluid collection.
Percutaneous drainage on ___, now reaccumulated.
COMPARISON: Ultrasound intervention from ___ and CT torso from ___.
TECHNIQUE: Helical MDCT images were acquired from the lung bases through the
greater trochanters without intravenous contrast, based on referring
physician's report of retroperitoneal hematoma. Oral contrast was not
administered. 5-mm axial, coronal, and sagittal multiplanar reformats were
generated.
FINDINGS: There is mild atelectasis at the lung bases. Trace left simple
pleural effusion has developed. Right atrial and ventricular pacemaker leads
course in expected position. Relative hypoattenuation of the blood pool is
compatible with anemia. There is physiologic pericardial fluid. A small
sliding hiatal hernia is present.
ABDOMEN: The liver is unremarkable on this non-contrast examination. The
gallbladder is partially distended, with hyperdense layering sludge, but no
wall edema or pericholecystic fluid. The pancreas is atrophic. No intra- or
extra-hepatic biliary dilation. Spleen is borderline enlarged at 14 cm, with
accessory splenule at the inferior pole.
The adrenals are normal. Left kidney remains enlarged and edematous, with
moderate hydroureteronephrosis secondary to distal compression. There is mild
perirenal fat stranding, but no free fluid to suggest forniceal rupture. The
right kidney is normal.
The stomach is normal. A small diverticulum arises from the first portion of
the duodenum. The distal small bowel is normal, though displaced to the right
by the abdominal fluid collection.
PELVIS: There has been interval reaccumulation of the predominantly simple
fluid collection in the left lower quadrant, abutting the spinal surgical site
anteriorly. Size is similar to pre-drainage CT at 18.5 cm AP x 13.7 cm TV x
21 cm SI. This has lobulated borders, multiple internal septatations, and
scattered peripheral areas of calcification. Interval development of a few
locules of internal air could be related to recent procedure.
There is severe mass effect on surrounding structures, including anterior
bowing of the left rectus abdominis, rightward displacement of the bladder and
small/large bowel loops, and kinking/obstruction of the distal left ureter.
There is edema in the subjacent iliopsoas muscle.
The appendix is normal. Single cecal diverticulum is present. Note is made
of fecal impaction. Bladder is distended and mildly thick-walled, possibly
due to reactive changes or third spacing. The prostate is enlarged, with
central coarse calcifications. A small right fat-containing inguinal hernia
is present. Mild free fluid in the pelvis.
Calcifications throughout the abdominal aorta and iliac arteries. Infrarenal
IVC filter is in place. Scattered prominent mesenteric and retroperitoneal
nodes.
There is asymmetric edema of the lower extremities, left greater than right,
likely reflecting central venous thrombosis or compression.
Again seen are changes of L4 corpectomy, L5-S1 anterior fusion screws and
interbody fusion, and L3-S1 posterior fusion with L3-L5 cage fixation. L3
vertebral screws abut the L3 superior endplate. Hardware is otherwise well
seated, without periprosthetic lucency or fracture. Comminuted, mildly
displaced fractures of the left inferior pubic ramus and ischial tuberosity
persist.
IMPRESSION:
1. Interval reaccumulation of left lower quadrant fluid collection, likely
postoperative seroma/lymphocele. New gas locules may reflect recent
intervention, though superinfection is not excluded.
2. L3-S1 surgical changes.
3. Asymmetric lower extremity edema, likely due to central venous
obstruction.
4. Moderate left hydronephrosis, secondary to distal ureteral obstruction.
Radiology Report
NONINVASIVE VENOUS STUDY OF THE LEFT LOWER EXTREMITY:
CLINICAL INDICATION: Multiple trauma with left lower extremity swelling,
recently postop.
FINDINGS: This is a very limited study as most of the left lower extremity is
inaccessible due to the recent surgical procedure.
However, the common femoral and proximal femoral veins were approachable and
scans demonstrate non-compressibility at both levels indicating deep venous
thrombosis. This appears to be acute with a relatively distended and largely
obstructed vein.
CONCLUSION: A limited scan demonstrating acute DVT in the common femoral and
proximal femoral veins.
The findings were called to Dr. ___ and relayed to ___ by
telephone at 10:27 a.m.
Radiology Report
ULTRASOUND-GUIDED DRAINAGE
INDICATION: ___ man with retroperitoneal collection status post
spinal fusion. Please drain.
PREPROCEDURE IMAGING AND FINDINGS: There is a large left retroperitoneal
fluid collection extending to the left anterior abdominal wall which is highly
complex containing innumerable septations and dependent echogenic debris,
likely blood clot. This is significantly more complex than on the prior
ultrasound for drainage. The complex fluid collection measures at least 13.8
x 15.0 x 18.7 cm.
PHYSICIANS: Dr. ___, Dr. ___.
PROCEDURE:
The procedure, risks, benefits and alternatives were discussed with the
patient's sister, ___ via the telephone, and informed consent was
obtained with a witness.
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, an entrance site was selected and the skin was
prepped and draped in the usual sterile fashion. Approximately 10 mL of 1%
lidocaine buffered with sodium bicarbonate was instilled for local anesthesia.
An ___ catheter was advanced into the complex left
retroperitoneal fluid collection with attempted disruption of septations. 900
mL of clear, serosanguineous fluid was removed. A sample was sent for Gram
stain and culture. The catheter was left in place to J/P bulb suction.
The patient tolerated the procedure well without immediate complication.
Estimated blood loss was less than 5 mL.
Dr. ___ attending radiologist, was present throughout the procedure.
Post-procedure orders were entered into the electronic medical record.
IMPRESSION:
Ultrasound-guided ___ drainage catheter placement into left
retroperitoneal complex fluid collection. Gram stain and culture pending.
Radiology Report
INDICATION: Evaluate PICC.
COMPARISONS: Chest radiograph ___.
FINDINGS: A new left PICC extends from the right brachiocephalic into the
left brachiocephalic vein. A defibrillator and its wires are in proper
position. Right basilar atelectasis is unchanged. There is no consolidation,
edema, pleural effusion, or pneumothorax. The cardiomediastinal silhouette is
normal.
IMPRESSION: Malposition of the PICC in the left brachiocephalic.
Radiology Report
INDICATION: PICC evaluation.
COMPARISON: Chest radiograph ___ at 8:53.
FINDINGS: A right PICC ends at or just beyond the superior atriocaval
junction. To ensure that the PICC would be in the low SVC or at the
atriocaval junction, could pull back approximately 2 cm. There has been no
significant change from the prior radiograph with mild right basilar
atelectasis and mild engorgement of the pulmonary vasculature. There is no
consolidation, edema, or pneumothorax. A defibrillator is unchanged in
position. The cardiomediastinal silhouette is normal.
IMPRESSION: PICC ends at or just beyond the superior atriocaval junction. To
ensure that the PICC is in the low SVC or at the atriocaval junction, could
pull back 2 cm.
Results were discussed with the IV team at 10:15 a.m. on ___
telephone and pager by Dr. ___.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: LEG PAIN
Diagnosed with SEROMA COMPLIC PROCEDURE, ABN REACT-SURG PROC NEC, JOINT PAIN-L/LEG, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA
temperature: 98.4
heartrate: 100.0
resprate: 16.0
o2sat: 98.0
sbp: 123.0
dbp: 72.0
level of pain: 10
level of acuity: 3.0 | Mr. ___ was admitted to the Orthopedic service on ___
for recurrence of a left-sided retroperitoneal fluid collection
after being evaluated and treated in the emergency room. There
was further questions regarding possible infection of his
external-fixator pin sites on his left femur. The vascular and
spine surgery teams responsible for his prior lumbar surgery
were also consulted, given the retroperitoneal location of the
fluid collection. Everyone was in agreement with repeat drainage
and he subsequently underwent percutaneous drainage of his
retroperitoneal fluid collection without complication on ___
by interventional radiology. 900cc of serosanguinous fluid was
removed. A pigtail drain was left in place, to continue drainage
of the fluid collection, which continued with a significant
amount of output. On ___, the pigtail drain was removed, per
the recommendation of the Vascular Surgery team.
On ___, he underwent incision and debridement of his left
leg external fixator pin sites. Please see operative report for
full details of both procedures. The retroperitonteal fluid gram
stain and culture, as well as the left leg pin site wound gram
stain and culture both revealed Beta Streptococcus, Group B.
Infectious disease was consulted and per their recommendations,
he was started on IV Ceftriaxone 1 gram daily. Given the
retroperitoneal location of the fluid collection and the
presence of hardware in his spine, it was recommended that he
remain on IV antibiotics for a prolonged period: at least 6
weeks.
During his hospital stay, he was noted to have edema in his left
lower extremity, so an ultrasound was ordered to evaluate for
the presence of a DVT. He was diagnosed with a right common,
superficial, and deep femoral and popliteal vein thrombosis on
___. Consequently, he was started on therapeutic Lovenox as
a bridge to Coumadin for treatment of his DVT, with a goal INR
of ___.
He had adequate pain management and worked with physical therapy
while in the hospital. The remainder of his hospital course was
uneventful and Mr. ___ is being discharged to rehab in
stable condition. |
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
Major Surgical or Invasive Procedure:
Esaphagogastroduodenoscopy
History of Present Illness:
History obtained through ___ interpreter on phone as well
as medical record and chart). This is a ___ year old man with
asthma who presented with nausea/vomiting for two days. He had
been dealing with approximately 10 days of cough for which he
has been seen twice in ___. During the first visit despite no
infiltrate on chest radiograph he was started on azithromycin
and fluticasone inhaler. His cough had gotten better and less
productive but he was still coughing. Over the last two days
prior to presentation he developed vomiting after every attempt
to eat solids. He has no anorexia or abdominal pain.
Apparently about 10 minutes after each attempt to eat he would
develop nausesa and vomit once and his symptoms would be
resolved. He had been drinking liquids without issue. Other
than cough and vomiting he has been well without chills, fever.
Pt presented to ED with T 98.3, P 67, BP 113/74, RR 18, O2 98%
on RA. Received combivent (for mild wheezing), EKG, 1.5 L NS,
and admitted to floor for further evaluation of vomiting. Vital
signs prior to admission T 97.8, P 63, BP 154/71, 100% on RA.
REVIEW:
(+) Per HPI
Otherwise limited review of systems reviewed and unremarkable.
Past Medical History:
-Insomnia
-BPH status post TURP
-Cervical spondylytic myopathy
-asthma
-elevated PSA
-history of squamous cell carcinoma in situ
Social History:
___
Family History:
Pt does not know.
Physical Exam:
On Admission:
VS: T 97.6, P 54, BP 174/83, RR 16, 100% on RA
Appearance: Well appearing elderly Asian man in NAD
Eyes: Conjunctiva Clear
ENT: Moist, no ulcers, erythema, pharyngeal irriation visible
CV: Regular, no systolic or diastolic murmur, no lower extremity
edema, PIV in place
Respiratory: Clear to auscultation bilaterally with good air
movement and no rales or wheezing noted, resps are unlabored.
GI: Soft, Nontender, Nondistended, bowel sounds positive, No
hepatomegaly, No splenomegaly
MSK: Bulk WNL; Upper and lower extremity Strength ___ and
symmetrical; No cyanosis, No clubbing, No joint swelling
Neuro: CNII-XII intact, Normal attention, Fluent speech (in
___
Integument: Warm, Dry, no apparent rash
Psychiatric: Appropriate, pleasant
On Discharge:
VS: T 98.1, BP 144/66, P 71, RR 18, O2 Sat 97% on RA
Appearance: Appears well in NAD
ENT: Mucous membranes moist, OP benign without erythema or
infiltrates
CV: RRR, no M/R/G
Pulm: Clear to auscultation bilaterally with no wheezes,
rhonchi, or rales
Abd: Soft, NT, ND, BS+
Otherwise exam unchanged from presentation and unremarkable.
Pertinent Results:
===================
LABORATORY RESULTS
===================
On Admission:
WBC-6.0 RBC-5.70 Hgb-11.9* Hct-36.8* MCV-65* RDW-16.2* Plt
___
---Neuts-79.6* Lymphs-14.5* Monos-4.1 Eos-1.6 Baso-0.2
___ PTT-28.2 ___
Glucose-123* UreaN-14 Creat-0.8 Na-136 K-3.3 Cl-101 HCO3-26
ALT-8 AST-18 AlkPhos-54 TotBili-0.7
Lipase-22
Lactate-1.1
On Discharge:
WBC-4.4 RBC-5.25 Hgb-11.1* Hct-33.5* MCV-64* RDW-16.6* Plt
___
Glucose-127* UreaN-4* Creat-0.7 Na-136 K-3.6 Cl-105 HCO3-24
==============
OTHER RESULTS
==============
ECG ___:
Sinus arrhythmia. Normal tracing. Compared to the previous
tracing of ___ no change.
Abdominal Radiograph ___:
IMPRESSION: No evidence of bowel obstruction or free
intraperitoneal gas.
Chest Radiograph ___:
IMPRESSION: Little change in comparison to prior study from
___, with no acute cardiopulmonary process.
CT Abdomen/Pelvis W/ Contrast ___
IMPRESSION:
1. No esophageal mass detected.
2. Focal thickening of the pylorus likely reflects physiological
contraction. There is no evidence of gastric outlet or bowel
obstruction. This was discussed by phone with Dr. ___ at about
7pm, ___.
3. 14-mm hypodense nodule within the posterior aspect of the
left thyroid
lobe warrants further evaluation with ultrasound on a
non-emergent basis or comparison with any outside hospital
studies.
Medications on Admission:
AMMONIUM LACTATE 12 % Lotion bid to dry skin on body
CODEINE-GUAIFENESIN 100 mg-10 mg/5 mL Liquid - 5 ml(s) by mouth
at night as needed for cough may make drowsy
DESONIDE - 0.05 % Ointment - apply to rash on neck twice a day
for two weeks per month.
FLUTICASONE - 50 mcg Spray, Suspension - ___ sprays(s) in each
nostril twice a day Use daily during allergy season or with
upper
respiratory infections
FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol - ___
puffs
twice daily Take for 3 weeks and then may reduce dose and stop
if
symptoms resolved
HYDROXYZINE HCL - 10 mg Tablet - 1 Tablet(s) by mouth at night
as
needed for itching if needed, f/u in derm in ___ months
IPRATROPIUM-ALBUTEROL [COMBIVENT] - 18 mcg-103 mcg (90
mcg)/Actuation Aerosol - ___ puffs inh every six (6) hours as
needed for shortness of breath
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth once a day
POLYETHYLENE GLYCOL 3350 - 17 gram/dose Powder - 17 g by mouth
daily as needed for constipation
SOLIFENACIN [VESICARE] - 10 mg Tablet - 1 (One) Tablet(s) by
mouth once a day
TERAZOSIN - 1 mg Capsule - 1 Capsule(s) by mouth at bedtime
TRIAMCINOLONE ACETONIDE - 0.1 % Ointment - apply to rash on arms
and legs twice a day for two weeks per month maximum. do not
apply elsewhere.
ZOLPIDEM - 10 mg Tablet - ___ Tablet(s) by mouth nightly as
needed for insomnia Do not take on the same night as lorazepam
DOCUSATE SODIUM - 100 mg Capsule - 1 Capsule(s) by mouth twice a
day as needed for constipation
LUTEIN - 10 mg Tablet - 1 Tablet(s) by mouth daily
MULTIVITAMIN [MEN'S MULTI-VITAMIN] - (OTC) - Tablet - 1
Tablet(s) by mouth daily
Discharge Medications:
1. ammonium lactate 12 % Lotion Sig: One (1) application Topical
twice a day: to dry skin on body as directed in ___
clinic.
2. desonide 0.05 % Ointment Sig: One (1) application Topical
twice a day as needed for rash: apply as needed for rash on neck
no more than two weeks/mo.
3. fluticasone 50 mcg/Actuation Spray, Suspension Sig: ___
Sprays Nasal BID (2 times a day).
4. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation BID (2 times a day).
5. hydroxyzine HCl 10 mg Tablet Sig: One (1) Tablet PO at
bedtime as needed for itching.
6. Combivent ___ mcg/Actuation Aerosol Sig: ___ puffs
Inhalation four times a day as needed for shortness of breath or
wheezing.
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
dose
dose PO once a day as needed for constipation.
9. solifenacin 10 mg Tablet Sig: One (1) Tablet PO once a day.
10. terazosin 1 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
11. triamcinolone acetonide 0.1 % Ointment Sig: One (1)
applciation Topical twice a day as needed for rash: apply to
arms and legs twice a day for no more than two weeks per month
(do not apply elsewhere).
12. zolpidem 5 mg Tablet Sig: ___ Tablets PO HS (at bedtime) as
needed for insomnia.
13. dextromethorphan-guaifenesin ___ mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours) as needed for cough.
14. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO twice a
day.
15. multivitamin Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Nausea/Vomiting
Secondary Diagnoses:
Benign prostatic hypertrophy
Asthma
Cervical spondylopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Evaluation of patient with cough.
COMPARISON: Chest radiograph from ___.
FINDINGS: Frontal and lateral chest radiographs were obtained. Except for
minima subsegmental atelectasis in the right lung base laterally, the lungs
are clear with no evidence of consolidation, effusion, or pneumothorax.
Cardiomediastinal silhouette remains stable with the heart size within normal
limits. Osseous structures remain grossly unremarkable.
IMPRESSION: Little change in comparison to prior study from ___, with no acute cardiopulmonary process.
Radiology Report
INDICATION: Evaluation of patient with vomiting.
COMPARISON: Chest radiograph from the same day at 12:50 p.m.
FINDINGS: Supine and upright abdominal radiographs were obtained. There is a
normal bowel gas pattern with no evidence of obstruction. No free air is
noted throughout the abdomen. There is moderate dextroscoliosis of the mid
lumbar spine. Mild degenerative changes are visualized at the bilateral hips.
Otherwise, no soft tissue calcifications or radiopaque foreign bodies are
noted.
IMPRESSION: No evidence of bowel obstruction or free intraperitoneal gas.
Radiology Report
INDICATION: Difficulty vomiting. Concern for esophageal mass.
COMPARISON: CT available from ___.
TECHNIQUE: MDCT-acquired 5-mm axial images of the chest and abdomen were
obtained following the uneventful administration of 100 cc of Optiray
intravenous contrast. Coronal and sagittal reformations were performed at
5-mm slice thickness.
CHEST: A 14-mm left posterior hypodense thyroid nodule is present (2:8).
There is no axillary or mediastinal lymphadenopathy. The great vessels are
patent and normal in caliber. Multiple calcified mediastinal lymph nodes are
present (2:24, 29) compatible with prior granulomatous disease. Oral contrast
distends the esophagus, and no esophageal mass or abnormal wall thickening is
seen. There is a small hiatal hernia (2:50). No pulmonary nodules or masses
are detected. Mild dependent atelectasis is slightly worse on the right
(2:45). Coronary artery calcifications are present (2:35).
ABDOMEN: Wall thickening at the pylorus (2:59) likley represents
physiological contraction. The proximal stomach is not dilated. The small
bowel and large bowel are normal. There is no mesenteric or retroperitoneal
lymphadenopathy, and no free air or free fluid. The pancreas, spleen, adrenal
glands, gallbladder, and liver are normal. A subcentimeter hypoenhancing
lesion within the interpolar region of the right kidney (2:60) is
statistically likely a cyst but remains too small for further characterization
on this single phase study. Abdominal aorta is normal in caliber.
OSSEOUS STRUCTURES: There are old traumatic deformities of the spinous
processes at T12 and L1. No acute fractures or concerning blastic or lytic
lesions are identified.
IMPRESSION:
1. No esophageal mass detected.
2. Focal thickening of the pylorus likely reflects physiological contraction.
There is no evidence of gastric outlet or bowel obstruction. This was
discussed by phone with Dr. ___ at about 7pm, ___.
3. 14-mm hypodense nodule within the posterior aspect of the left thyroid
lobe warrants further evaluation with ultrasound on a non-emergent basis or
comparison with any outside hospital studies.
Gender: M
Race: ASIAN - CHINESE
Arrive by WALK IN
Chief complaint: N/V
Diagnosed with VOMITING, COUGH
temperature: 98.3
heartrate: 67.0
resprate: 18.0
o2sat: 98.0
sbp: 113.0
dbp: 74.0
level of pain: 0
level of acuity: 3.0 | ___ year old man with history of BPH and asthma presenting with
two days of vomiting solids.
1) Vomiting/Nausea: Pt presented two days of vomiting with
solids thought tolerating liquids, which raised considerable
concern for mechanical obstruction. Despite this patient had
been tolerating liquids and appeared appropriately hydrated and
generally well. CT scan performed in ED was without a mass or
lesion and patient went on to have an EGD that was unremarkable
without esophageal web or stricture. Pt tolerated liquid diet
throughout hospitalization and had no nausea, abdominal pain, or
other concerning symptoms. Prior to discharge (after
esophageal stricture excluded) pt tolerated a regular diet
without nausea or vomiting. Most likely etiology of vomiting
thought to be post-emesis or possibly mild gastrointestinal
virus with atypical features that resolved without intervention.
He was continued on his home PPI throughout his hospitalization.
2) Cough/ Asthma with exacerbation: Pt presented reporting 10
days of cough that was progressively improving. He continued
treatment with fluticasone inhaler and combivent and though he
had mild wheezes on presentation he never had an oxygen
requirement or respiratory distress. He will continue these
inhalers until he follows up with his PCP.
3) Hyponatremia: The patient developed hyponatremia on hospital
day 2 in the context of having no solid food and receiving IVF
and taking in liquids. This was very mild and urine lytes
showed appropriately dilute urine suggesting appropriate
response. This was likely due to increased intake of hypotonic
drinks with minimal PO intake of solutes. This resolved by
discharge.
4) BPH: The patient continued his terazosin and was switched
from solifenacin to tamsulosin in house.
5) Microcytic Anemia: Patient has always had stable microcytic
anemia. Given age, chronicity, and ethnic background strongly
suspect thalassemia. This worsened slightly in the hospital but
then improved again likely in relation to dilution from volume.
He evidenced no signs of bleeding.
The patient tolerated a full diet prior to discharge. He
received subcutaneous heparin for DVT prophylaxis. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right hip and abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male with h/o brain aneurysms s/p clippings x3, CAD,
CEA, CVA, and recently diagnosed metastatic adenocarcinoma of
the lung in ___, s/p WBRT presenting with c/o R hip and
abdominal pain. According to his family, he was complaining of R
hip pain that did not improve with his home PO dilaudid. Over
the past few days, he had also been complaining of increased
belly soreness and "feeling tired."
Past Medical History:
metastatic adenocarcinoma of the lung with hemorrhagic brain and
liver mets diagnosed in ___
brain aneurysms s/p clippings x3
CEA
CVA
CAD
Social History:
___
Family History:
Denies family history of lung cancer.
Family history is significant for history of heart disease.
Reports that
his older brother has been diagnosed with multiple different
types of cancer, unclear which ones.
Physical Exam:
On admission:
Vital Signs: SBP ___
General: Alert, oriented to self and place, not time/date,
intermittently falling asleep during the exam
HEENT: Sclera anicteric, neck supple, JVP not elevated, no LAD
Lungs: Clear to auscultation although limited by pt positioning
CV: Tachycardic, regular rhythm
Abdomen: soft, diffusely tender especially in the RLQ, distended
and dull to percussion
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Without rashes or lesions
Neuro: alert, oriented x1, following commands but lethargic,
EOMI
On discharge:
Absent pulse. Absent breath sounds and heart sounds.
Pertinent Results:
___ 09:00PM BLOOD WBC-22.9*# RBC-4.31* Hgb-12.9* Hct-39.0*
MCV-91 MCH-29.9 MCHC-33.1 RDW-15.0 RDWSD-49.5* Plt ___
___ 09:00PM BLOOD Neuts-66 Bands-12* Lymphs-2* Monos-7
Eos-8* Baso-1 Atyps-1* Metas-2* Myelos-0 Promyel-1*
AbsNeut-17.86* AbsLymp-0.69* AbsMono-1.60* AbsEos-1.83*
AbsBaso-0.23*
___ 09:00PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
___ 09:00PM BLOOD Plt Smr-NORMAL Plt ___
___ 09:00PM BLOOD estGFR-Using this
___ 09:00PM BLOOD HoldBLu-HOLD
___ 09:12PM BLOOD Lactate-3.2*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
2. Citalopram 10 mg PO DAILY
3. Dexamethasone 2 mg PO DAILY
4. Metoprolol Succinate XL 75 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Acetaminophen 1000 mg PO Q6H
7. Cefpodoxime Proxetil 200 mg PO Q12H
8. FoLIC Acid 1 mg PO DAILY
9. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
10. Ibuprofen 800 mg PO Q8H
11. Docusate Sodium 100 mg PO BID
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
13. Senna 8.6 mg PO DAILY
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Perforated viscus
Small bowel obstruction
Metastatic adenocarcinoma of the lung
Discharge Condition:
n/a
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST RADIOGRAPH
INDICATION: History: ___ with new NG tube // NG tube placement? NG tube
placement?
TECHNIQUE: Frontal portable view of the chest.
COMPARISON: Chest radiograph from ___.
FINDINGS:
An orogastric tube courses below the diaphragm, the tip projects over the
gastric fundus. As compared to prior chest radiograph, lung volumes remain
decreased. Right lower lobe opacity has slightly improved with persistent
adjacent moderate right pleural effusion was subpulmonic component. However, a
right upper lobe opacity adjacent to the minor fissure has worsened. No
pneumothorax identified. Dilated loops of small bowel are seen in the upper
abdomen.
IMPRESSION:
Orogastric tube courses below the diaphragm, the tip projects over the gastric
fundus.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, Abdominal distention, Vomiting
Diagnosed with INTESTINAL OBSTRUCT NOS, ACUTE KIDNEY FAILURE, UNSPECIFIED, SHOCK NOS
temperature: 97.7
heartrate: 76.0
resprate: 18.0
o2sat: 99.0
sbp: 107.0
dbp: 73.0
level of pain: 10
level of acuity: 2.0 | ___ year old male with h/o brain aneurysms ___ s/p clippings, CEA,
CVA, recent diagnosis of metastatic lung adenocarcinoma with
brain and liver mets in ___ presenting with abdominal and right
hip pain.
ACTIVE ISSUES:
- Small bowel obstruction: In the ED CT abdomen showed
high-grade SBO with early signs of pneumatosis and impending
bowel perforation. He received Zofran, 1 L NS, and 5 mg IV
morphine with improvement in pain. General surgery was consulted
and rec'ed conservative tx. An NG tube was placed and drained
about 2 L of biliary fluid. His SBP dropped to the ___ and he
became less responsive. His brother ___ (healthcare proxy) was
called and decision was made to change pt's code status from
full to CMO. Per family discussion, the patient's NG tube was
removed and IV fluids were stopped. Lab draws were stopped.
- ___ focused care: The patient was made CMO in the ED. On
the floor, a family meeting was held between family members and
members of the healthcare team. His family was informed about
the small bowel obstruction and that imaging suggested an
impending bowel perforation. They were informed that given his
metastatic cancer and poor state of health, there was a strong
likelihood this kind of condition would recur. His healthcare
proxy and brother, ___, stated that his brother would not want
to be on long-term life support if there was no chance of
recovery and with the quality of life that he would likely have.
The family agreed that the patient should have comfort focused
care. To that end, only respiratory rate was checked on vital
signs, lab draws were stopped, and treatment for the SBO was
halted. The patient did not receive his home medications. The
patient and family received spiritual and social work care.
Patient expired at 2:45 ___ on ___. He appeared comfortable
throughout, with family at his bedside. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
right lower quadrant abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ female G6 P5 at 22 weeks presenting with right
lower quadrant abdominal pain from approximately Hospital.
Patient developed sharp right lower quadrant abdominal pain
yesterday evening. She was seen a ___
overnight where she had a pelvic ultrasound performed that
was unrevealing. She has a gallbladder ultrasound was
unrevealing. They are MRI machine that was not functioning
and she has been sent here for further evaluation of
possible appendicitis. She describes nausea and vomiting
without diarrhea. No vaginal bleeding or discharge. No
dysuria. She isn't anorexic at this time.
Timing: Sudden Onset
Quality: Sharp
Severity: Severe
Duration: Hours
Location: Right lower quadrant
Associated Signs/Symptoms: Nausea and vomiting
Past Medical History:
chronic anemia
Social History:
___
Family History:
unknown
Physical Exam:
PHYSICAL EXAMINATION: upon admission: ___
Temp: 98.2 HR: 90 BP: 113/64 Resp: 16 O(2)Sat: 96 Normal
Constitutional: Patient is in mild discomfort
HEENT: Pupils equal, round and reactive to light,
Extraocular muscles intact, Normocephalic, atraumatic
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nondistended, and to palpation in the
right lower quadrant
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema, 2+ radial and DP
pulses bilaterally, and digits are warm and well perfused
Skin: No rash, Warm and dry
Neuro: Speech fluent, moving all extremities
Psych: Normal mood, Normal mentation
Pertinent Results:
___ 06:00AM BLOOD WBC-9.7 RBC-3.74* Hgb-10.9* Hct-33.5*
MCV-90 MCH-29.2 MCHC-32.6 RDW-13.7 Plt ___
___ 05:00PM BLOOD WBC-13.2* RBC-3.62* Hgb-10.8* Hct-32.0*
MCV-88 MCH-29.8 MCHC-33.7 RDW-13.7 Plt ___
___ 05:00PM BLOOD Neuts-81.2* Lymphs-13.8* Monos-4.2
Eos-0.6 Baso-0.2
___ 05:00PM BLOOD Glucose-78 UreaN-5* Creat-0.5 Na-138
K-3.3 Cl-108 HCO3-22 AnGap-11
___ 05:00PM BLOOD Lipase-24
___ 05:00PM BLOOD Albumin-3.5
___ 05:00PM BLOOD ___
___: MRI pelvis:
Appendix is well visualized, with equivocal findings for
appendicitis as
detailed above. The appendix is located laterally at the level
of the
umbilicus, surrounded by peritoneal fat. Correlation with
directed physical exam and repeat targeted ultrasound sound
examination may be helpful in deciphering normal from early
inflamed appendix.
___: MRI of abdomen:
Appendix is well visualized, with equivocal findings for
appendicitis as
detailed above. The appendix is located laterally at the level
of the
umbilicus, surrounded by peritoneal fat. Correlation with
directed physical exam and repeat targeted ultrasound sound
examination may be helpful in deciphering normal from early
inflamed appendix.
___: US of appendix:
Appendix not visualized.
Medications on Admission:
: iron supplement
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain, fever
Discharge Disposition:
Home
Discharge Diagnosis:
abdominal pain, rule out appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MRI OF THE ABDOMEN AND PELVIS WITHOUT CONTRAST
INDICATION: ___ year old woman with RLQ pain with N/V, pregnant, seen at
___ could not visulaize appendix. MRI at OSH down // Please eval for
appendicitis
TECHNIQUE: Multiplanar MRI of the abdomen pelvis is obtained at 1.5 Tesla per
the pregnant appendicitis protocol. T1 and T2 weighted sequences are acquired
without contrast.
COMPARISON: Abdominal ultrasound dating ___.
FINDINGS:
The appendix is definitively visualized throughout its length, coursing
posterior laterally from the cecal tip at the level of the umbilicus,
surrounded by a peritoneal fat (03:16). The appendix has upper limits of
normal dimension and with total diameter of approximately 7 mm and wall
thickness of 2-3 mm. There is mild wall thickening, measuring up to 3 mm
(06:45). The there is fluid within the appendiceal lumen. Subtle haziness of
the surrounding fat is noted the, although not significantly different from
other and distant locations of peritoneal edema (9:3). There is no
extraluminal fluid or gas.
There is a gravid uterus with the fundus extending 5 cm above the umbilicus.
The placenta is positioned anteriorly towards the uterine fundus. Single fetus
is identified in breech presentation during the majority of the examination.
This study is not intended to be a full examination of the fetus, although no
gross morphologic abnormalities identified.
The cervix is closed. The ovaries are normal in appearance.
Limited evaluation of the solid abdominal viscera is reveals no additional
abnormality. No cholelithiasis or evidence of cholecystitis is identified.
The renal collecting systems are decompressed with an the medial fibrosis or
parenchymal renal abnormality.
IMPRESSION:
Appendix is well visualized, with equivocal findings for appendicitis as
detailed above. The appendix is located laterally at the level of the
umbilicus, surrounded by peritoneal fat. Correlation with directed physical
exam and repeat targeted ultrasound sound examination may be helpful in
deciphering normal from early inflamed appendix.
Radiology Report
EXAMINATION: US APPENDIX
INDICATION: ___ with RLQ pain, pregnant. Assess for acute appendicitis.
TECHNIQUE: Limited sonographic evaluation of the right lower quadrant at site
of patient's symptoms.
COMPARISON: MRI abdomen/pelvis ___.
FINDINGS:
Limited evaluation of the right lower quadrant demonstrated prominent vessels
at site of patient's symptoms. The appendix is not visualized despite scanning
by 2 different individuals. No focal fluid collection at site of patients
symptoms.
IMPRESSION:
Appendix not visualized.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: RLQ abdominal pain, Pregnant
Diagnosed with ABDOMINAL PAIN RLQ
temperature: 98.2
heartrate: 90.0
resprate: 16.0
o2sat: 96.0
sbp: 113.0
dbp: 64.0
level of pain: 7
level of acuity: 3.0 | ___ year old female, ___ weeks pregnant, was admitted to the
hospital with right lower quadrant abdominal pain. The patient
was seen at an outside hospital where she underwent abdominal
ultrasound which was reportedly negative for gallbladder
pathology. The appendix was not visualized. The patient was
transferred here for further evaluation. An MRI of the abdomen
and pelvis was obtained which was
equivocal for appendicitis. She had a mild elevation of the
white blood cell count to 13.
The OB service was consulted to evaluate for any obstetrical
indication for her abdominal pain. The patient's vital signs
remained stable and she was afebrile. She reported a decrease in
her abdominal pain and her white blood cell count had decreased
to 9.7. The patient resumed a regular diet with no further
recurrence of the abdominal pain.
On HD #3, the patient was deemed stable for discharge from the
surgical standpoint. US imaging in the ___ Maternal Fetal
Medicine was arranged by the OB service. The patient was
escorted to the ___ for additional imaging. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / ampicillin
Attending: ___.
Chief Complaint:
Palpitations
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with radiculopathy, HTN, HLD, recent NSTEMI with BMS placed
on ___ presents with tachycardia. Over the last several weeks
since the MI, she felt palpitations with exertion that resolved
after a few minute of rest. However, during the last few days,
she has also noticed palpitations even with rest. Tonight, after
a shower and drying her hair, she felt palpitations that lasted
for hours and did not resolve with rest. She also felt
dizziness, no syncope. No cp or
SOB during these episodes. During the last few weeks, she has
also experienced significant fatigue. Also endorses persistent
dry, nonproductive cough which was treated last week with 7 days
of levofloxacin which she completed on ___.
In the ED intial vitals were: 98.0 138 130/84 16 99% RA
Patient was given full dose aspirin
-patient was noted to be in afib/flutter on EKG, but self
converted back to sinus
-Labs showed elevated troponin 0.07, CKMB42, WBC 8.5, lactate
1.4
-UCG negative, urine with large leuks, 10 WBC
-CXR: no signs of pna
-EKG: 83bpm, sinus, Twave flattening in V4-V6 also present in
last EKG
-admitted for new afib and elevated troponins
Vitals on transfer: 98.2 77 101/62 18 98% RA
On the floor, patient complains of generalized fatigue and
persistent dry cough.
Past Medical History:
1. CARDIAC RISK FACTORS: (-)Diabetes, (+)Dyslipidemia,
(+)Hypertension
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: ___ - LAD: long 50%
___. 60% ostial in large D1, RCA: 99% ___. With TIMI 2 distal
flow. 40% mid. Proximal RCA stenosis pre-dilated using a 2.0 mm
balloon. 3.0 mm x 15 mm Integrity (bare metal) stent deployed at
14 atm.
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
- L4-L5 spondylolisthesis with disk bulge and protrusion
causing mild-to-moderate central stenosis and moderate
effacement of the lateral recesses.
- L5-S1 disk osteophyte complex with large extraforaminal
component contacting the traversing L5 nerve roots.
- L3-L4 broadbased disk protrusion and bilateral facet and
ligamentum hypertrophy.
- Right-sided greater than left-sided lumbar radicular symptoms
with calf atrophy.
- Cervical spinal stenosis/radiculopathy
- History of breast cancer status post mastectomy.
- Status post hysterectomy.
- History of pancreatitis.
- Osteopenia
- Vulvodynia
- Hx of BCC and SCC
- Osteoarthritis
- Blistering dermatitis NOS
Social History:
___
Family History:
- Mother: ___ dementia
- Father: CAD s/p CABG, melanoma
- Sister: ___ cancer
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: T=98.2 BP= 134/92 HR= 65 RR= 16 O2 sat= 97% RA
GENERAL: awake, alert, NAD
HEENT: EOMI, PERRLA, OMM no lesions, no JVD
CARDIAC: RRR, ___ systolic murmur LUSB, no r/g
LUNGS: CTABL
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO: CN II-XII intact, strength ___ in UE and ___ b/l
DISCHARGE PHYSICAL EXAM:
VSS
GENERAL: awake, alert, NAD
HEENT: EOMI, PERRLA, OMM no lesions, no JVD
CARDIAC: RRR, ___ systolic murmur LUSB, no r/g
LUNGS: CTABL
ABDOMEN: Soft, NTND.
EXTREMITIES: No edema
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO: grossly intact
Pertinent Results:
ADMISSION LABS:
___ 10:30PM BLOOD WBC-8.5 RBC-4.01* Hgb-12.6 Hct-38.8
MCV-97 MCH-31.3 MCHC-32.5 RDW-12.8 Plt ___
___ 10:30PM BLOOD ___ PTT-34.6 ___
___ 10:30PM BLOOD Glucose-117* UreaN-17 Creat-0.7 Na-138
K-5.0 Cl-102 HCO3-26 AnGap-15
___ 10:30PM BLOOD CK(CPK)-491*
___ 06:20AM BLOOD Calcium-9.0 Phos-3.4 Mg-2.2
___ 06:20AM BLOOD TSH-3.3
___ 11:24PM BLOOD Lactate-1.4
DISCHARGE LABS:
___ 06:10AM BLOOD WBC-4.9 RBC-3.72* Hgb-11.4* Hct-35.7*
MCV-96 MCH-30.5 MCHC-31.9 RDW-12.4 Plt ___
___ 06:10AM BLOOD ___ PTT-37.0* ___
___ 06:10AM BLOOD Glucose-95 UreaN-18 Creat-0.8 Na-140
K-4.3 Cl-109* HCO3-28 AnGap-7*
___ 06:10AM BLOOD Calcium-9.1 Phos-3.9 Mg-2.1
CARDIAC ENZYMES:
___ 10:30PM BLOOD CK-MB-42* MB Indx-8.6*
___ 10:30PM BLOOD cTropnT-0.07*
___ 06:20AM BLOOD CK-MB-28* cTropnT-0.07*
___ 06:10AM BLOOD CK-MB-16* cTropnT-0.05*
STUDIES:
EKG #1 ___:
Atrial fluter with 3:1 block and ventricular response of 136
beats per minute.
Delayed R wave progression in the precordial leads with ST-T
wave
abnormalities. Compared to the previous tracing of ___
atrial flutter is
new.
EKG #2 ___:
Sinus rhythm with extensive but non-specific ST-T wave
abnormalities. Compared
to tracing #1 patient has now reverted to sinus rhythm.
CXR ___:
No acute cardiopulmonary process.
Echocardiogram ___:
The left atrial volume index is normal. No atrial septal defect
is seen by 2D or color Doppler. The estimated right atrial
pressure is ___ mmHg. Mild symmetric left ventricular
hypertrophy with normal wall thickness, cavity size, and global
systolic function (biplane LVEF = 64 %). The estimated cardiac
index is normal (>=2.5L/min/m2). Tissue Doppler imaging suggests
an increased left ventricular filling pressure (PCWP>18mmHg).
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) are mildly thickened
but aortic stenosis is not present. Trace aortic regurgitation
is seen. The mitral valve leaflets are structurally normal.
There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is a very small circumferential
pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved regional and global biventricular systolic function.
Mild mitral regurgitation. Increased PCWP. Very small
circumferential pericardial effusion.
Is there a clinical history to suggest pericarditis?
Compared with the prior study (images reviewed) of ___, the
rhythm is now atrial fibrillation and mild mitral regurgitation
and a very small circumferential pericardial effusion are now
seen.
MICRO: None
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO HS
3. Clopidogrel 75 mg PO DAILY
4. Lisinopril 2.5 mg PO DAILY
5. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO HS
3. Clopidogrel 75 mg PO DAILY
4. Lisinopril 2.5 mg PO DAILY
5. Warfarin 5 mg PO DAILY16
Continue 5mg through ___.
RX *warfarin 1 mg 5 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
6. Atenolol 25 mg PO DAILY
RX *atenolol 25 mg one tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
7. Outpatient Lab Work
Please draw ___, PTT, and INR ___
ICD-9-CM diagnosis code ___, atrial flutter
Please fax results to Dr. ___, Fax#
___
8. Warfarin 3 mg PO DAILY16
Start taking this dose of warfarin ___.
Discharge Disposition:
Home
Discharge Diagnosis:
Atrial flutter
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Shortness of breath.
COMPARISON: Comparison is made with CTA chest from ___.
FINDINGS:
Lungs well expanded and clear. There is no pleural effusion or pneumothorax.
The cardiomediastinal silhouette is unremarkable.
IMPRESSION:
No acute cardiopulmonary process.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Palpitations
Diagnosed with ATRIAL FIBRILLATION
temperature: 98.0
heartrate: 138.0
resprate: 16.0
o2sat: 99.0
sbp: 130.0
dbp: 84.0
level of pain: 0
level of acuity: 1.0 | ___ with radiculopathy, HTN, HLD, recent NSTEMI with BMS placed
on ___ presents with tachycardia found to be in atrial
flutter and self converted back to sinus rhythm. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
syncope, altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ with PMHx of dementia, CAD/stable angina, HTN,
dyslipidemia, NIDDM, recently traveled to ___ from ___ about 1
week ago, who presents with recurrent syncope.
Patient has reportedly had ___ presyncopal/syncopal events over
the past ___. Much of the history is obtained from his family,
partially nebulous as they do not live with him (he travelled to
___ from ___ ~1wk ago). Prior events have occurred at church, it
seems always while sitting, no exertional component. Patient
describes no real prodrome, endorses momentary loss of vision
and consciousness. L temporal headaches, several times weekly,
have been increasing over the past 1mo. Patient has decreased
vision in the L eye, though this is chronic for years. No
palpitations or SOB. Patient does endorse chronic, mild
substernal chest discomfort when exerting himself. No CP
related to syncopal episodes.
Patient recently established care with Dr. ___ (APG)
___. Due to endorsement of exertional CP (chronic, stable
angina) and 2+ ___, patient was ordered for TTE ___. While in
the waiting room earlier today, he had a subsequent syncopal
episode, by report his most severe. His daughter reports that
while he was seated in a chair, his eyes rolled back and he
seemed to have shaking movements in his extremities for a few
seconds. He lost consciousness briefly (several seconds) and
slumped in the chair. There was no fall or head strike.
Patient's daughter says that he lost control of his bladder
(which has been a problem for him over the past several months),
and seemed somewhat confused, continuing to the present.
In the ED, initial vital signs were: 95.1 71 123/82 17 95% RA
- Exam notable for: nonfocal neuro exam
- Labs were notable for:
Negative trop x1
CBC: 8.7>13.2/41.1<280 (Metas, Myelos And Pros)
BMP: 139/5.0/102/25/___/.9
LFTs: ___
Albumin 3.7
Lactate: 2.7
UA: neg leuks, sm bld, neg nitr, tr prot, 22 RBC, 11 WBC
- Studies performed include:
CXR ___
FINDINGS:
AP and lateral views of the chest provided.
The lungs are somewhat hyperinflated. Right basilar opacity is
noted on the frontal view. Elsewhere, lungs are clear without
consolidation or effusion. There is no pulmonary edema. Cardiac
silhouette is mildly enlarged and there is tortuosity of the
thoracic aorta. Old healed left lateral rib fractures are noted.
IMPRESSION:
Right basilar opacity which may be atelectasis. Possibility of
infection is not excluded.
___ ___
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass.
Prominence of the ventricles and sulci is consistent with age
related involutional changes. Nonspecific subcortical and
periventricular white matter hypodensities are suggestive of
chronic small vessel ischemic disease. There is mucosal
thickening of the frontal sinuses, the ethmoidal air cells, and
bilateral maxillary sinuses. The mastoid air cells and middle
ear cavities are clear. The orbits are unremarkable.
IMPRESSION:
No acute intracranial process
CTA CHEST ___
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Bilateral pleural thickening and pleural plaques likely
represent sequelae
from prior asbestos exposure.
3. Mild right lower lobe atelectasis.
4. Mild bronchial wall thickening likely represents chronic
airway disease.
5. Mild to moderate centrilobular emphysema.
6. Mild-to-moderate cardiomegaly.
- Patient was given:
APAP 100mg
Azithromycin 500mg IV
- Vitals on transfer: 97.8 78 130/65 18 96% 2LNC
Upon arrival to the floor, the patient is accompanied by his
family. They recount the story as above. Patient denies any
acute complaints, AOx2.
10-point ROS POSITIVE as above, otherwise NEGATIVE.
Past Medical History:
CORONARY ARTERY DISEASE
DIABETES TYPE II
HYPERLIPIDEMIA
HYPERTENSION
OSTEOARTHRITIS
KNEE PAIN
PERIPHERAL VASCULAR DISEASE
Social History:
___
Family History:
N/C
Physical Exam:
ADMISSION EXAM
==============
Vitals- 97.8 78 130/65 18 96% on RA
GENERAL: AOx2 (self, 'hospital'), NAD
HEENT: PERRL. EOMI. No scleral icterus. Nasal aspect of L eye
with resolving conjunctival hemorrhage vs. pinguecula. OP clear
with MMM, poor dentition.
NECK: JVP elevated to 4cm above clavicle at 45degrees. No
carotid bruits.
CARDIAC: Regular rhythm, normal rate, ___ SEM at RUSB with
radiation to carotids, no rubs/gallops.
LUNGS: Poor airway movement bilaterally, scattered coarse
inspiratory crackles.
ABDOMEN: Normal bowels sounds, slightly distended, non-tender to
deep palpation in all four quadrants. Tympanic to percussion. No
organomegaly.
EXTREMITIES: WWP. Pulses DP/Radial 2+ bilaterally. Trace edema
in ankles b/l.
SKIN: No evidence of ulcers, rash or lesions suspicious for
malignancy
NEUROLOGIC: AOx2 (self, 'hospital'). CN2-12 grossly intact.
Strength/sensation intact throughout. Gait not assessed.
DISCHARGE EXAM
==============
Vitals- 98.2 ___ RA
I/O: -/500 // -/500
GENERAL: AOx3, NAD
HEENT: PERRL. EOMI. No scleral icterus. Nasal
aspect of L eye with resolving conjunctival hemorrhage vs.
pinguecula. OP clear with MMM, poor dentition.
NECK: JVP elevated to 4cm above clavicle at 45degrees (JVP to
mandible when lying flat). No carotid bruits.
CARDIAC: Regular rhythm, normal rate, ___ SEM at RUSB with
radiation to carotids, no rubs/gallops.
LUNGS: Clear to auscultation anteriorly.
ABDOMEN: Normal bowels sounds, non-distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: WWP. Pulses DP/Radial 2+ bilaterally. Trace edema
in ankles b/l.
SKIN: No evidence of ulcers, rash or lesions suspicious for
malignancy
NEUROLOGIC: AOx3. CN2-12 grossly intact. Strength/sensation
intact throughout. Gait not assessed.
Pertinent Results:
ADMISSION LABS
=============
___ 08:40AM BLOOD WBC-8.7 RBC-4.50* Hgb-13.2* Hct-41.1
MCV-91 MCH-29.3 MCHC-32.1 RDW-14.9 RDWSD-49.8* Plt ___
___ 08:40AM BLOOD Neuts-42.9 ___ Monos-10.5 Eos-2.1
Baso-0.5 Im ___ AbsNeut-3.73 AbsLymp-3.80* AbsMono-0.91*
AbsEos-0.18 AbsBaso-0.04
___ 08:40AM BLOOD ___ PTT-23.9* ___
___ 08:40AM BLOOD Plt ___
___ 08:40AM BLOOD Glucose-111* UreaN-16 Creat-0.9 Na-139
K-5.0 Cl-102 HCO3-25 AnGap-17
___ 08:40AM BLOOD ALT-10 AST-36 CK(CPK)-144 AlkPhos-50
TotBili-0.5
___ 08:40AM BLOOD Lipase-43
___ 08:40AM BLOOD cTropnT-<0.01
___ 08:40AM BLOOD Albumin-3.7 Calcium-8.9 Phos-3.1 Mg-1.8
___ 08:55AM BLOOD ___ Comment-GREEN TOP
___ 08:55AM BLOOD Lactate-2.7* K-4.1
___ 07:25AM URINE Color-Straw Appear-Clear Sp ___
___ 11:30AM URINE Color-Yellow Appear-Clear Sp ___
___ 07:25AM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 11:30AM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 07:25AM URINE RBC-6* WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1
___ 11:30AM URINE RBC-22* WBC-11* Bacteri-NONE Yeast-NONE
Epi-1
DISCHARGE LABS
=============
___ 07:00AM BLOOD WBC-5.8 RBC-4.54* Hgb-13.4* Hct-41.2
MCV-91 MCH-29.5 MCHC-32.5 RDW-15.0 RDWSD-50.1* Plt ___
___ 07:00AM BLOOD Plt ___
___ 07:00AM BLOOD Glucose-122* UreaN-11 Creat-0.8 Na-141
K-3.5 Cl-102 HCO3-29 AnGap-14
MICRO
=====
___ 8:40 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 11:30 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING/STUDIES
==============
CXR ___
FINDINGS:
AP and lateral views of the chest provided.
The lungs are somewhat hyperinflated. Right basilar opacity is
noted on the frontal view. Elsewhere, lungs are clear without
consolidation or effusion. There is no pulmonary edema. Cardiac
silhouette is mildly enlarged and there is tortuosity of the
thoracic aorta. Old healed left lateral rib fractures are noted.
IMPRESSION:
Right basilar opacity which may be atelectasis. Possibility of
infection is not excluded.
NCCTH ___
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass.
Prominence of the ventricles and sulci is consistent with age
related involutional changes. Nonspecific subcortical and
periventricular white matter hypodensities are suggestive of
chronic small vessel ischemic disease. There is mucosal
thickening of the frontal sinuses, the ethmoidal air cells, and
bilateral maxillary sinuses. The mastoid air cells and middle
ear cavities are clear. The orbits are unremarkable.
IMPRESSION:
No acute intracranial process.
CTA CHEST ___
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Bilateral pleural thickening and pleural plaques likely
represent sequelae
from prior asbestos exposure.
3. Mild right lower lobe atelectasis.
4. Mild bronchial wall thickening likely represents chronic
airway disease.
5. Mild to moderate centrilobular emphysema.
6. Mild-to-moderate cardiomegaly.
EKG ___: NSR, normal axis, normal intervals, isolated Qwave
III, J point elevation V3, submm STDs V4-V5
EEG ___
IMPRESSION: This was a normal continuous video EEG monitoring.
No pushbutton
activations were captured. There were no areas of prominent
focal slowing, and
there were no electrographic seizures or epileptiform
discharges.
TTE ___
The left atrial volume index is mildly increased. The estimated
right atrial pressure is ___ mmHg. Doppler parameters are most
consistent with Grade I (mild) left ventricular diastolic
dysfunction. 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. There is a minimally increased
gradient consistent with minimal aortic valve stenosis. Trace
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
IMPRESSION: No specific echocardiographic evidence of a
structural cardiac abnormality identified to explain patient's
syncope.
EEG ___
MPRESSION: This telemetry captured no pushbutton activations. It
showed a
mildly slow background, indicative of a mild, widespread
encephalopathy. There
were no areas of prominent focal slowing, and there were no
electrographic
seizures or epileptiform discharges.
MR CERVICAL SPINE ___
IMPRESSION:
1. Mild cervical spondylosis without high-grade spinal canal
stenosis, cord
edema, or cord compression.
2. Presumed ossification of the anterior longitudinal ligament,
possibly
related to diffuse idiopathic skeletal hyperostosis. If
clinically warranted,
further evaluation with radiograph or CT could be performed.
MR BRAIN ___
IMPRESSION:
1. No evidence of acute infarction or intracranial hemorrhage.
2. Diffuse parenchymal volume loss with probable chronic small
vessel ischemic
disease.
Radiology Report
EXAMINATION: MR CERVICAL SPINE W/O CONTRAST ___ MR ___ SPINE
INDICATION: ___ patient with early Alzheimer's, CAD, HTN,
dyslipidemia, NIDDM, recently moved to ___ from ___ about 1 week ago, who
presents with syncope concerning for seizure vs. primary cardiac etiology. Now
with hyperesthesia to pinprick on the left. Please assess for stenosis.
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial T2 and gradient echo imaging were next performed.
COMPARISON: None.
FINDINGS:
The alignment of the cervical spine is maintained. The vertebral body heights
and intervertebral disc space are preserved. There T1 and T2 intrinsically
hyperintense signal anterior to the C2 through C4 vertebral bodies which
suppresses on fat saturated sequences, compatible with marrow from large
anterior bridging osteophytes/ossification of the anterior longitudinal
ligament extending from C2 through C4 levels, with additional ossification
anterior to C5 and C6 levels, likely representing diffuse idiopathic skeletal
hyperostosis. The bone marrow signal otherwise appears unremarkable.
The spinal cord is normal in caliber and signal without evidence of cord edema
or cord compression. The craniocervical junction, prevertebral and paraspinal
soft tissues otherwise appear unremarkable.
C2-C3: There is no spinal canal stenosis or neural foraminal narrowing.
C3-C4: There is no spinal canal stenosis or neural foraminal narrowing.
C4-C5: There is a disc protrusion with bilateral facet and uncovertebral joint
arthropathy resulting in mild bilateral neural foraminal narrowing without
spinal canal stenosis or cord deformity.
C5-C6: There is a disc protrusion with bilateral facet and uncovertebral joint
arthropathy resulting in mild bilateral neural foraminal narrowing without
spinal canal stenosis or cord deformity.
C6-C7: There is a disc protrusion with facet and uncovertebral joint
arthropathy resulting in moderate right and mild left neural foraminal
narrowing, without spinal canal stenosis or cord deformity.
C7-T1: There is a disc protrusion with facet and uncovertebral joint
arthropathy resulting in mild bilateral neural foraminal narrowing without
spinal canal stenosis or cord deformity.
The visualized prevertebral and paraspinal soft tissues are otherwise
unremarkable.
IMPRESSION:
1. Mild cervical spondylosis without high-grade spinal canal stenosis, cord
edema, or cord compression.
2. Presumed ossification of the anterior longitudinal ligament, possibly
related to diffuse idiopathic skeletal hyperostosis. If clinically warranted,
further evaluation with radiograph or CT could be performed.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with AMS, ? syncope, cough, hypoxia// Please eval for
pneumonia
COMPARISON: None
FINDINGS:
AP and lateral views of the chest provided.
The lungs are somewhat hyperinflated. Right basilar opacity is noted on the
frontal view. Elsewhere, lungs are clear without consolidation or effusion.
There is no pulmonary edema. Cardiac silhouette is mildly enlarged and there
is tortuosity of the thoracic aorta. Old healed left lateral rib fractures
are noted.
IMPRESSION:
Right basilar opacity which may be atelectasis. Possibility of infection is
not excluded.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with syncope, ? head strike// eval for bleed
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, 16.3 cm; CTDIvol = 49.3 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. Prominence of
the ventricles and sulci is consistent with age related involutional changes.
Nonspecific subcortical and periventricular white matter hypodensities are
suggestive of chronic small vessel ischemic disease.
There is mucosal thickening of the frontal sinuses, the ethmoidal air cells,
and bilateral maxillary sinuses. The mastoid air cells and middle ear
cavities are clear. The orbits are unremarkable.
IMPRESSION:
No acute intracranial process.
Radiology Report
INDICATION: History: ___ with chest pain, recent travel// Eval for pulmonary
embolism
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) = 418 mGy-cm.
COMPARISON: Chest radiograph ___
FINDINGS:
The aorta and its major branch vessels are patent, with no evidence of
stenosis, occlusion, dissection, or aneurysmal formation. There is no
evidence of penetrating atherosclerotic ulcer or aortic arch atheroma present.
There is mild-to-moderate cardiomegaly with diffuse coronary artery
calcifications.
The pulmonary arteries are well opacified to the subsegmental level, with no
evidence of filling defect within the main, right, left, lobar, segmental or
subsegmental pulmonary arteries. The main and right pulmonary arteries are
normal in caliber, and there is no evidence of right heart strain.
There is no supraclavicular, axillary, mediastinal, or hilar lymphadenopathy.
The thyroid gland appears unremarkable.
There is no evidence of pericardial effusion. There is no pleural effusion.
There is bilateral pleural thickening and calcified plaques which likely
represent the sequelae of prior asbestos exposure.
There is mild right lower lobe atelectasis. There is mild to moderate
centrilobular emphysema. There are several calcific densities within
bilateral lung fields which represent calcified granulomas. Otherwise, no
evidence of other pulmonary parenchymal abnormality. The airways are patent
to the subsegmental level. However, there is mild bronchial wall thickening
which may represent chronic airway disease.
Limited images of the upper abdomen are unremarkable.
Multilevel degenerative changes and minimal retro scoliosis of the visualized
thoracic spine are noted. No lytic or blastic osseous lesion suspicious for
malignancy is identified.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Bilateral pleural thickening and pleural plaques likely represent sequelae
from prior asbestos exposure.
3. Mild right lower lobe atelectasis.
4. Mild bronchial wall thickening likely represents chronic airway disease.
5. Mild to moderate centrilobular emphysema.
6. Mild-to-moderate cardiomegaly.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST ___ MR HEAD
INDICATION: ___ year old man with HTN/dyslipidemia, dementia, now presenting
with recurrent syncope episodes concerning for possible stroke. Evaluate for
possible nidus 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 CT head ___
FINDINGS:
There is no evidence of acute infarction. There is susceptibility artifact
within the left parietal lobe near the vertex, obscuring visualization of the
adjacent structures. Within the confines, there is no evidence of
intracranial hemorrhage.
There is prominence of the ventricles and sulci related to involutional
changes. There are nonspecific confluent and scattered periventricular and
subcortical FLAIR hyperintensities, likely a sequela of chronic small vessel
ischemic disease.
The major visualized arterial vascular flow voids appear preserved, with
tortuous course of the cavernous segment of the left internal carotid artery.
There is moderate mucosal thickening of bilateral ethmoid and mild mucosal
thickening of the maxillary sinuses. The patient is status post bilateral
lens replacement. There is trace nonspecific fluid opacification of bilateral
mastoid air cells, likely reactive.
IMPRESSION:
1. No evidence of acute infarction or intracranial hemorrhage.
2. Diffuse parenchymal volume loss with probable chronic small vessel ischemic
disease.
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: N/V, Syncope
Diagnosed with Nausea with vomiting, unspecified
temperature: 95.1
heartrate: 71.0
resprate: 17.0
o2sat: 95.0
sbp: 123.0
dbp: 82.0
level of pain: 0
level of acuity: 2.0 | Patient is a ___ just recently moved to ___ from ___
with PMHx of dementia, CAD with likely stable angina, HTN,
dyslipidemia, and prediabetes who presented with recurrent
syncopal events. Patient was admitted after having episode in
waiting room prior to outpatient TTE, episode concerning for
possible seizure.
# Recurrent Syncope - Episode just prior to d/c notable for
having occurred at rest, patient's daughter described that while
he was seated in a chair, his eyes rolled back and he seemed to
have shaking movements in his extremities for a few seconds. He
lost consciousness briefly (several seconds) and slumped in the
chair. There was no fall or head strike. Patient's family
reported that he was confused after the episode, responsive
though somewhat inappropriate over the ensuing ~___. Etiologies
considered include seizure vs. stroke vs. primary cardiac
pathology (arrhythmia/mechanical) vs. orthostasis/autonomic
neuropathy iso dementia vs. donepezil side effect. Patient had
full work-up. Orthostatics were negative. Cardiac work-up was
all unremarkable (normal ECG, NEG trops, no arrhythmias on 24h
telemetry, TTE with normal LVEF and no significant valvular
pathology). Of note, patient's diltiazem was eventually d/c'd
(though he was not bradycardic) as he remained largely
normotensive and as per his PCP there was no reported history of
atrial fibrillation. Given greater concern that presentation was
consistent with seizure (description of event, bladder
incontinence, mild lactatemia, post-event confusion that
improved over ~___), neurology was consulted. NCCTH in ED showed
no acute intracranial process, though did show chronic small
vessel ischemic disease. Neurology recommended obtaining 24h EEG
and MRI brain (they also wanted MRI C-spine to assess for
cervical pathology unrelated to syncope given hyperasthesia to
pinprick over left upper extremity/left lower extremity/left
chest wall/left shoulder as well as bilateral upgoing toes).
They did mention the possibility of Zika infection given that
___ is an endemic area, did not suggest obtaining Zika
serologies. A paraneoplastic limbic encephalopathy seemed
unlikely as there was no evidence for malignancy, CT chest
lacked masses or lymphadenopathy on chest CT. MRI brain and C
spine revealed: no evidence of acute infarction or intracranial
hemorrhage; diffuse parenchymal volume loss with likely small
vessel ischemic disease; mild cervical spondylosis without
high-grade spinal canal stenosis or cord compression/edema. 24h
EEG was normal, results from ___ still pending. Neurology
ultimately recommended the following:
1) Seizure most likely etiology, will not start AEDs now given
isolated event, patient will ___ as outpatient with Dr.
___, should also have autonomics testing
2) Can consider weaning donepezil (given slight possibility of
syncope/dizziness and new onset seizure, also anticholinergic
bradycardia) in discussion with patient's family given that his
mental status is not consistent with advanced Alzheimer's
disease
# Dementia - Unknown etiology, was prescribed donepezil in
___. As mentioned above, Neurology recommended weaning
donepezil as patient's presentation/mental status is not
necessarily consistent with Alzheimer's.
# Lactatemia - Iso seizure as above vs. possible transient
hypotension during syncopal event vs. Metformin effect. Improved
s/p 500cc NS on admission.
# Concern for pneumonia - Patient was started on treatment for
CAP in ED given ?RLL opacity on CXR, most likely atelectasis
given CTA results. No clinical signs of pneumonia, d/c'd
antibiotics on admission (he received 1x dose azithromycin).
# CAD
# Stable angina - Unclear history, though by report patient has
had stable angina for many years, possibly previously on prn
NTG, now taking imdur. Trop NEG .01 x2 in ED. TTE as above was
unremarkable, normal EF and normal biV function, no valvular
dysfunction. Patient should have stress test as an outpatient
(likely pharm stress) given report of exertional chest
discomfort. Patient was continued on ASA 81mg qd and Simvastatin
40mg qHS. His imdur 30mg qd was fractionated while inpatient,
reconsolidated to once daily imdur at time of discharge.
# COPD - No known PFTs. Patient with signs of mild to moderate
emphysema on CTA chest in ED. Long smoking history. Not on home
O2. No metabolic compensation on BMP, no severe hypercarbia on
VBG (51). Patient did not desaturate while walking with physical
therapy. Patient was given duonebs while inpatient. Outpatient
PFTs may be obtained, though his respiratory status is
currently, no hypercarbia or limitation ___ hypoxia. Patient was
not started on any COPD treatment.
# Hypertension - HTN to 160s on arrival to floor, he likely
missed doses of antiHTNs in the ED. SBPs subsequently 115-150.
Home enalapril 2.5mg qd was continued. Imdur fractionated as
above while inapteint. Initially his diltiazem 30mg BID was
continued as any history of afib was unknown, ultimately it was
d/c'd prior to discharge given that PCP did not suspect any
history of afib. If hypertensive at next PCP visit, may consider
uptitrating enalapril.
# Microscopic Hematuria - 22RBCs on UA from ED. No clinical
concern for UTI or renal stone. Repeat UA with 6RBCs. Should
consider urinary tract malignancy given significant smoking
history. Patient will require outpatient CTU/cytology if
persistent hematuria.
# Dyslipidemia - Most recent lipids ___, tot chol 187, hdl 46,
ldlcalc 86. Continued simvastatin 40mg qHS.
# Prediabetes - Most recent A1C 6.1 ___ - Glipizide was d/c'd
at recent visit with PCP. Held metformin given lactatemia,
restarted at time of discharge.
TRANSITIONAL ISSUES
===================
- Most likely etiology seizure, though given isolated event,
neurology does not recommend starting AEDs at this time; he will
follow up with Dr. ___ for ___ and autonomics
testing
- EEG results from ___ are pending at time of discharge
- Can consider weaning donepezil (given slight possibility of
syncope/dizziness and new onset seizure, also anticholinergic
bradycardia) in discussion with patient's family given that his
mental status is not consistent with advanced Alzheimer's
disease
- MRI cervical spine revealed ossification of the anterior
longitudinal ligament, possibly related to diffuse idiopathic
skeletal hyperostosis. If clinically warranted, further
evaluation with radiograph or CT could be performed
- Patient and his family have been instructed that he should NOT
be driving a vehicle given dementia
- ___ consider uptitration of enalapril at next PCP visit if
hypertensive
- Patient with microscopic hematuria and long smoking history,
consider CTU/cytology if persistent hematuria. Please repeat UA
at follow up appointment.
- Mild to moderate COPD on CT chest, consider outpatient PFTs
- Patient describes long history of exertional chest discomfort,
consider outpatient stress test.
Medication changes
------------------
- Diltiazem 30mg BID was STOPPED given that he was largely
normotensive and does not have any reported hx of atrial
fibrillation
===================================
# Code status: Full code (confirmed)
# Contact: ___ ___ (daughter), ___ ___ (son in
law) |
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:
EGD ___
History of Present Illness:
___ w/hx of diabetes and active smoker with PVD s/p R SFA stent
___ and known L SFA occlusion, who presents with 3
weeks of intermittent abdominal
pain, nausea, diarrhea.
She was seen in her psychiatric outpatient appointment today for
Adderall refill and was found to be hypertensive (200s/110s),
and was therefore referred to the ___ for further
evaluation. Upon further questioning at ___, the patient
noted 3 weeks of intermittent abdominal cramping, nausea (no
vomiting), and diarrhea. She denies sick contacts. She also has
had poor
appetite for the past 3 days. No fevers, but occasional chills.
A CTA abdomen/pelvis was obtained which was read by the OSH
radiologist as "mild thickening of the wall of the distal
abdominal aorta, raising the question of aortitis." Given this
finding, she was transferred to ___ for further evaluation.
In the ED, initial vitals:
- Exam notable for: TTP in mid epigastrum
- Labs notable for: normal LFTs, lipase, CRP. Cr 1.2
- Consults: Vascular surgery: CTA reviewed with inhouse
radiologist. No significant findings to be conclusive of
aortitis. OSH read also uncertain if there is aortitis. Patient
has significant GI symptoms including diarrhea and generalized
abdominal pain. Please add on CRP and ESR. Admit to medicine for
further work-up and evaluation. Vascular surgery will follow.
- Pt given: morphine 4 mg IV
- Vitals prior to transfer: 85 128/64 15 100%RA
On the floor, patient endorses the above, she states that she
has had a labile BP in the past with anxiety/anger. She trys to
take all of her medications but knows that she is not as good
with them as she should be. She did take her medications
yesterday morning. She has had a right sided headache that
started around the same time as the abdominal pain and has
remained the same
since then. She is normally constipated, but had a loose bowel
movement 2 days ago. Some subjective fevers/chills and mild SOB
with anxiety, which has happened in the past. No chest pain,
vomiting, or new muscle/joint pains.
Past Medical History:
- DM type II c/b neuropathy
- HLD
- HTN
- PVD w/R and L SFA stents
- Anxiety
- PTSD
- Bipolar disorder
- ADHD
Social History:
___
Family History:
Mother: DM, CAD
Father: DM, CAD
States that she has some cousins with history of blood clots.
Physical Exam:
ADMISSION
=========
VITALS: ___ 0835 BP: 177/92 L Lying HR: 60 RR: 16 O2 sat:
99% O2 delivery: Ra
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-distended, moderately TTP in epigastrium and
midline abdomen, and RLQ. Bowel sounds present, no organomegaly,
no rebound or guarding
Ext: Warm, well perfused, 1+ pulses in BLEs, right greater than
left, no clubbing, cyanosis or edema
Skin: Warm, dry, no rashes or notable lesions.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation
DISCHARGE
=========
VITALS: ___ 0728 Temp: 98.4 PO BP: 158/89 L Lying HR: 59
RR:
18 O2 sat: 100% O2 delivery: Ra FSBG: 102
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL
CV: Regular rate and rhythm, normal S1 + S2
Lungs: CTAB
Abdomen: Soft, non-distended, moderately TTP in epigastrium and
midline abdomen, and R/L LQ. Bowel sounds present, no
organomegaly,no rebound or guarding
Ext: Warm, well perfused, 1+ pulses in BLEs, right greater than
left, no clubbing, cyanosis or edema
Skin: Warm, dry, no rashes or notable lesions.
Neuro: CNII-XII intact, ___ strength in biceps and triceps
bilaterally. Left grip strength now ___. Right grip strength
___.
Sensation to pressure and light touch normal in BLEs and LLEs.
Finger to nose testing normal.
Pertinent Results:
ADMISSION
=========
___ 02:12AM ___ PTT-27.9 ___
___ 02:12AM WBC-7.8 RBC-4.20 HGB-11.9 HCT-37.6 MCV-90
MCH-28.3 MCHC-31.6* RDW-13.7 RDWSD-44.4
___ 02:12AM NEUTS-47.6 ___ MONOS-11.5 EOS-1.5
BASOS-0.4 IM ___ AbsNeut-3.71 AbsLymp-3.02 AbsMono-0.90*
AbsEos-0.12 AbsBaso-0.03
___ 02:12AM CRP-2.2
___ 02:12AM ALBUMIN-3.0* CALCIUM-8.7 PHOSPHATE-3.3
MAGNESIUM-1.9
___ 02:12AM LIPASE-18
___ 02:12AM ALT(SGPT)-9 AST(SGOT)-14 ALK PHOS-90 TOT
BILI-0.2
___ 02:12AM GLUCOSE-156* UREA N-20 CREAT-1.2* SODIUM-136
POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-19* ANION GAP-12
INTERVAL
========
___ 06:35AM BLOOD CRP-0.7
___ 07:35AM BLOOD CRP-54.9*
___ 07:00AM BLOOD CRP-12.7*
___ 07:45AM BLOOD HIV Ab-NEG
___ 07:45AM BLOOD HCV Ab-NEG
IMMUNOGLOBULIN G SUBCLASS 1 1146 H 382-929 mg/dL
IMMUNOGLOBULIN G SUBCLASS 2 ___ mg/dL
IMMUNOGLOBULIN G SUBCLASS 3 73 ___ mg/dL
IMMUNOGLOBULIN G SUBCLASS 4 116 H ___ mg/dL
IMMUNOGLOBULIN G, SERUM 1815 H ___ mg/dL
DISCHARGE
=========
___ 06:58AM BLOOD WBC-4.9 RBC-3.93 Hgb-11.3 Hct-35.9 MCV-91
MCH-28.8 MCHC-31.5* RDW-13.6 RDWSD-45.7 Plt ___
___ 06:58AM BLOOD Glucose-91 UreaN-24* Creat-1.4* Na-139
K-5.0 Cl-105 HCO3-22 AnGap-12
___ 06:58AM BLOOD Calcium-9.1 Phos-3.6 Mg-2.1
IMAGING
=======
___ Opinion CT Torso:
1. Mild circumferential wall thickening involving the infrarenal
abdominal
aorta extending to the bifurcation into the common iliacs.
While this
appearance could reflect either aortitis or very early
retroperitoneal
fibrosis, there is a similar wall thickening involving the
superior mesenteric artery which suggests this is a vasculitic
process. The extent of involvement and degree of soft tissue
thickening is unchanged compared to the prior CT study.
2. Apparent 1.6 cm intraluminal gastric polyp in the gastric
antrum, recommend correlation with endoscopy.
___ Pelvic US:
Normal Pelvic Ultrasound
___ Renal US:
Normal renal ultrasound. No hydronephrosis.\
___ Carotid US:
Less than 40% stenosis bilaterally.
___ MRA Chest and Abdomen:
1. Nonspecific wall thickening and wall enhancement of the
infrarenal
abdominal aorta, which is compatible with vasculitis. Active
mild
retroperitoneal fibrosis can have a similar appearance.
2. Eccentric wall thickening of the SMA may also represent
vasculitis.
3. Unremarkable appearance of the great vessels of the chest
without evidence for intrathoracic vasculitis.
___ Venous Doppler UE:
No evidence of deep vein thrombosis in the left upper extremity.
___ EGD:
Diffuse erythema without erosions consistent with gastritis.
Pathology from Gastric Biopsy:
Antral mucosa with mucin depletion and foveolar hyperplasia,
consistent with chemical-type gastropathy or mucosa adjacent to
and erosion.
___ Arterial Doppler UE:
Patent left upper extremity arteries of mild calcifications. No
evidence of stenosis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO DAILY
2. amLODIPine 5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. lurasidone 80 mg oral DAILY
5. ClonazePAM 1 mg PO BID
6. CloNIDine 0.2 mg PO BID
7. Atorvastatin 80 mg PO QPM
8. Gabapentin 600 mg PO BID
9. Gabapentin 900 mg PO QHS
10. MetFORMIN XR (Glucophage XR) ___ mg PO DAILY
11. Chlorthalidone 12.5 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen [Acetaminophen Extra Strength] 500 mg 2
tablet(s) by mouth three times a day Disp #*180 Tablet
Refills:*0
2. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*20 Tablet Refills:*0
3. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
4. Polyethylene Glycol 17 g PO BID
RX *polyethylene glycol 3350 17 gram/dose 17 G by mouth Daily
Refills:*0
5. Senna 17.2 mg PO BID
RX *sennosides [senna] 8.6 mg 2 by mouth twice a day Disp #*120
Tablet Refills:*0
6. amLODIPine 10 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Atorvastatin 80 mg PO QPM
9. Chlorthalidone 12.5 mg PO DAILY
10. ClonazePAM 1 mg PO BID
11. CloNIDine 0.2 mg PO BID
12. Gabapentin 900 mg PO QHS
13. Lisinopril 40 mg PO DAILY
14. lurasidone 80 mg oral DAILY
15. MetFORMIN XR (Glucophage XR) ___ mg PO DAILY
16. HELD- Gabapentin 600 mg PO BID This medication was held. Do
not restart Gabapentin until your doctor says you need it
17. HELD- Gabapentin 600 mg PO BID This medication was held. Do
not restart Gabapentin until your doctor says you should resume
it
18. HELD- Gabapentin 600 mg PO BID This medication was held. Do
not restart Gabapentin until your doctor says to resume
19. HELD- Gabapentin 600 mg PO BID This medication was held. Do
not restart Gabapentin until your doctor says to resume it
20. HELD- Gabapentin 600 mg PO BID This medication was held. Do
not restart Gabapentin until your doctor says to resume it
21. HELD- Gabapentin 600 mg PO BID This medication was held. Do
not restart Gabapentin until your doctor says to resume it
22. HELD- Gabapentin 600 mg PO BID This medication was held. Do
not restart Gabapentin until your doctor says to resume it
23. HELD- Gabapentin 600 mg PO BID This medication was held. Do
not restart Gabapentin until your doctor says to resume it
24. HELD- Gabapentin 600 mg PO BID This medication was held. Do
not restart Gabapentin until your doctor says to resume it
25.Outpatient Lab Work
Please check Chem10 at primary care appointment to make sure
renal function stable. Fax results to Dr. ___ at ___
ICD10: I12.9
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
==================
Abdominal pain
Aortitis
Gastritis
SECONDARY DIAGNOSES
====================
Peripheral vascular disease
Diabetes
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: SECOND OPINION CT NEURO PSO1 CT
INDICATION: ___ year old woman with abdominal pain and outside CT with
findings possibly suggestive of aortitis.// Second opinion from CTA
chest/abd/pelvis ___ Second opinion from CTA chest/abd/pelvis ___
TECHNIQUE: Contiguous axial images of the brain were obtained after the
uneventful administration of Omnipaque intravenous contrast. Thin
bone-algorithm reconstructed images and coronal and sagittal reformatted
images were then produced.
DOSE: Found no primary dose record and no dose record stored with the sibling
of a split exam.
!If this Fluency report was activated before the completion of the dose
transmission, please reinsert the token called CT DLP Dose to load new data.
COMPARISON: None.
FINDINGS:
There is no evidence of fracture, infarction, hemorrhage, edema,or mass. The
ventricles and sulci are normal in size and configuration. A 1.2 x 1.2 x 2 cm
arachnoid cyst is seen in the posterior fossa. There is no abnormal
enhancement on post contrast images.
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. 1.2 x 1.2 x 2 cm posterior fossa arachnoid cyst.
2. No acute intracranial abnormality.
Radiology Report
EXAMINATION: SECOND OPINION CT TORSO
INDICATION: ___ year old woman with abdominal pain.// Please Review CTA
ABD/Pelvis from ___. Question aortitis versus constipation versus
diverticulitis
TECHNIQUE: MDCT axial images were acquired through the abdomen and pelvis
with intravenous contrast administration.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Found no primary dose record and no dose record stored with the sibling
of a split exam.
!If this Fluency report was activated before the completion of the dose
transmission, please reinsert the token called CT DLP Dose to load new data.
COMPARISON: CT abdomen from ___.
FINDINGS:
Lungs: The visualized lung bases demonstrate bibasilar atelectasis.
Liver: The liver is homogeneous with a smooth contour. There is a 5 mm
hypoenhancing lesion in segment 8 (02:17), too small to characterize but
statistically likely a cyst or hamartoma. No suspicious liver lesion.
The portal vein is patent. The hepatic veins are not well opacified due to
the timing of contrast bolus..
Biliary: There is no intrahepatic or extrahepatic bile duct dilatation. The
gallbladder is unremarkable.
Spleen: The spleen is not enlarged and is homogeneous.
Pancreas: Unremarkable. There is no pancreatic duct dilatation.
Adrenal glands: Unremarkable.
Urinary: The kidneys are unremarkable. There is no hydronephrosis.
Pelvis: The urinary bladder is unremarkable. The distal ureters are
unremarkable. There is no free fluid in the pelvis.
Reproductive organs: The visualized reproductive organs are unremarkable.
Gastrointestinal: Although assessment of the gastric mucosa is limited on CT
imaging, there does appear to be a 1 x 1.6 by 0.7 cm endophytic mucosal lesion
in the gastric antrum. The appendix is unremarkable in appearance in the
right lower quadrant (2:62). No dilation of the small or large bowel loops.
No mesenteric or pericolonic stranding seen..
Vascular: There are mild atherosclerotic calcifications of the abdominal
aorta. There is mild circumferential wall thickening involving the infrarenal
aorta and extending to the bifurcation into the bilateral common iliac
arteries for a length of approximately 5 cm. In addition there is near
circumferential wall thickening involving the superior mesenteric artery
(02:33). This appearance is unchanged compared to the prior CT study from ___ suggestive of aortitis/vasculitis. Early retroperitoneal fibrosis
is considered less likely given the involvement of the superior mesenteric
artery and the lack of displacement of the bilateral ureters.
Lymph nodes: There is no size significant lymph nodes.
Bone and soft tissues: There is no suspicious bone lesion. Mild degenerative
disc disease at L4-L5.
IMPRESSION:
1. Mild circumferential wall thickening involving the infrarenal abdominal
aorta extending to the bifurcation into the common iliacs. While this
appearance could reflect either aortitis or very early retroperitoneal
fibrosis, there is a similar wall thickening involving the superior mesenteric
artery which suggests this is a vasculitic process. The extent of involvement
and degree of soft tissue thickening is unchanged compared to the prior CT
study.
2. Apparent 1.6 cm intraluminal gastric polyp in the gastric antrum, recommend
correlation with endoscopy.
Radiology Report
EXAMINATION: Carotid Doppler Ultrasound
INDICATION: ___ year old woman with PVD present with abdominal pain pain
concern for atherosclerosis
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 mild homogeneous atherosclerotic plaque.
The peak systolic velocity in the right common carotid artery is 77 cm/sec.
The peak systolic velocities in the proximal, mid, and distal right internal
carotid artery are 79, 76, and 81 cm/sec, respectively. The peak end
diastolic velocity in the right internal carotid artery is 37 cm/sec.
The ICA/CCA ratio is 1.05.
The external carotid artery has peak systolic velocity of 143 cm/sec.
The vertebral artery is patent with antegrade flow.
LEFT:
The left carotid vasculature has mild homogeneous atherosclerotic plaque.
The peak systolic velocity in the left common carotid artery is 121 cm/sec.
The peak systolic velocities in the proximal, mid, and distal left internal
carotid artery are 73, 78, and 72 cm/sec, respectively. The peak end
diastolic velocity in the left internal carotid artery is 33 cm/sec.
The ICA/CCA ratio is 0.64.
The external carotid artery has peak systolic velocity of 170 cm/sec.
The vertebral artery is patent with antegrade flow.
IMPRESSION:
Less than 40% stenosis bilaterally.
Radiology Report
INDICATION: ___ year old woman with abdominal pain and CTA findings consistent
with possible infrarenal aortitis and SMA inflammation, evaluate for Aortitis
TECHNIQUE: T1 and T2 weighted MRI images through the chest, abdomen, and
pelvis were obtained before and after the uneventful administration of 15 cc
MultiHance IV contrast.
COMPARISON: Outside hospital CT of the abdomen and pelvis dated ___.
FINDINGS:
Vasculature: As seen previously, there is diffuse circumferential wall
thickening of the infrarenal abdominal aorta with surrounding fat stranding,
reactive adenopathy, and contrast enhancement. Findings are nonspecific and
can be seen in the setting of vasculitis or active retroperitoneal fibrosis.
Also unchanged is mild eccentric wall thickening of the midportion of the SMA,
likely also related to underlying vasculitis, although this may represent
early onset atherosclerotic disease as there is less surrounding reactive
change. The ascending aorta, aortic arch, and intrathoracic descending aorta
are unremarkable without evidence for vasculitis.
Chest: The lungs are clear. There is no pleural or pericardial effusion. The
there is no mediastinal, hilar, or axillary adenopathy.
Liver: Hepatic morphology is normal. There is no focal lesion. The portal
and hepatic veins are patent.
Biliary: There is no intrahepatic or extrahepatic biliary ductal dilatation.
The gallbladder is unremarkable.
Pancreas: The pancreas is normal in signal intensity and morphology without
focal lesion or ductal dilatation.
Spleen: Normal in size without focal lesion.
Adrenals: Unremarkable.
Kidneys: Small simple cysts are present bilaterally. There is no
hydronephrosis or suspicious renal lesion.
Gastrointestinal: There is moderate to large colonic fecal loading. The
visualized loops of large and small bowel are otherwise unremarkable.
Pelvis: The bladder and distal ureters are unremarkable. The uterus is
unremarkable. There is no adnexal abnormality. There is no free fluid in the
pelvis. There is no suspicious lymphadenopathy.
Lymph nodes: There is mild reactive retroperitoneal lymphadenopathy
surrounding the infrarenal abdominal aorta. There is no other suspicious
adenopathy.
Osseous structures: There is no suspicious osseous lesion.
IMPRESSION:
1. Nonspecific wall thickening and wall enhancement of the infrarenal
abdominal aorta, which is compatible with vasculitis. Active mild
retroperitoneal fibrosis can have a similar appearance.
2. Eccentric wall thickening of the SMA may also represent vasculitis.
3. Unremarkable appearance of the great vessels of the chest without evidence
for intrathoracic vasculitis.
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US
INDICATION: ___ year old woman with Left hand/arm swelling.// ? Left Upper
extremity DVT.
TECHNIQUE: Grey scale and Doppler evaluation was performed on the left upper
extremity veins.
COMPARISON: None.
FINDINGS:
There is normal flow with respiratory variation in the left subclavian vein.
The left internal jugular and axillary veins are patent, show normal color
flow and compressibility. The left brachial, basilic, and cephalic veins are
patent, compressible and show normal color flow.
IMPRESSION:
No evidence of deep vein thrombosis in the left upper extremity.
Radiology Report
EXAMINATION: Arterial duplex
INDICATION: ___ w/hx of diabetes and active smoker with PVD s/p R SFA stent
___ ___ and known L SFA occlusion, who presents with 3 weeks of
intermittent abdominal pain, nausea, diarrhea of unclear etiology. Had an
episode of LUE tingling and mild swelling with difficulty closing the hand,
concerning for possible vascular process. No DVT// vasculitis? arterial
insufficiency?
TECHNIQUE: Grayscale ultrasound, color Doppler, and spectral Doppler
waveforms of the left upper extremity were obtained.
COMPARISON: None
FINDINGS:
Mild calcifications are seen throughout the arteries.
The left subclavian artery is patent with triphasic waveforms and peak
systolic velocity range 119-140 cm/sec.
Left axillary artery is patent with triphasic waveform and peak systolic
velocity of 108 cm/second
The left brachial artery is patent with a triphasic waveform and peak systolic
velocity range of 63-107 cm/sec.
The left ulnar artery is patent has the triphasic waveform and a peak systolic
velocity 53.6 centimeters/second.
The left radial artery is patent with triphasic waveform and peak systolic
velocity of 73 cm/second.
IMPRESSION:
Patent left upper extremity arteries of mild calcifications. No evidence of
stenosis.
Radiology Report
EXAMINATION: PELVIS, NON-OBSTETRIC
INDICATION: ___ year old woman with 3 week history of suprapubic/ LLQ Pain and
increase in vaginal discharge.// ? Ovarian Cyst/ PID
TECHNIQUE: Grayscale ultrasound images of the pelvis were obtained with
transabdominal approach followed by transvaginal approach for further
delineation of uterine and ovarian anatomy.
COMPARISON: None available.
FINDINGS:
The uterus is retroverted and measures 9.3 x 4.1 x 4.3 cm. The endometrium is
homogenous and measures 7 mm.
The ovaries are normal. There is no free fluid.
IMPRESSION:
Normal pelvic ultrasound.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old woman with rising Creatinine and abdominal pain.//
Question Hydronephrosis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: None.
FINDINGS:
There is no hydronephrosis, stones, or masses bilaterally. Normal cortical
echogenicity is identified bilaterally. Normal corticomedullary
differentiation are seen bilaterally.
Right kidney: 11.9 cm
Left kidney: 11.4 cm
The bladder is moderately well distended and normal in appearance.
IMPRESSION:
Normal renal ultrasound. No hydronephrosis.
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: Abd pain, AORTITIS, Transfer
Diagnosed with Epigastric pain, Type 1 diabetes mellitus without complications, Long term (current) use of insulin
temperature: 97.4
heartrate: 64.0
resprate: 16.0
o2sat: 99.0
sbp: 168.0
dbp: 88.0
level of pain: 8
level of acuity: 2.0 | SUMMARY
=======
___ w/hx of diabetes and active smoker with PVD s/p R SFA stent
___ and known L SFA occlusion, who presents with 3
weeks of intermittent abdominal pain, nausea, diarrhea. She
underwent an extensive workup with a final diagnosis of aortitis
with a possible component of vasculitis and/or early
retroperitoneal fibrosis. After discussion with the vascular
medicine and rheumatology teams, the decision was made to have
close rheumatology follow up as an outpatient and defer the
decision for immunosuppressive treatment until the
signs/symptoms of her disease worsen.
ACUTE PROBLEMS
==============
# Abdominal pain:
Reports three weeks of intermittent abdominal pain, nausea, and
diarrhea. Aside from finding of possible aortitis/vasculitis on
MRA, CTA A/P without concerning acute intra-abdominal pathology.
Vascular inflammation should not cause this degree of abdominal
pain. Inflammatory markers downtrended on admission. LFTs,
lipase WNL. EKG without concerning ST changes to suggest ACS.
Could also be GERD, patient states that she has had GERD in the
past but hasn't taken medication in ___ years, EGD consistent
with gastritis this admission, and she was started on
omeprazole. Discharged with a 1 week prescription for 5MG
oxycodone Q6H PRN with the plan to wean down and stop. She will
follow up for treatment of her aortitis with rheumatology as
outpatient. She was encouraged to only take oxycodone if needed
to prevent constipation and related abdominal discomfort from
that. Some degree of her symptoms are exacerbated by anxiety for
which she will have close follow up with her outpatient
psychiatrist.
# Concern for aortitis:
CTA with findings of mild wall thickening of the distal
abdominal aorta at the iliac bifurcation, possibly suggestive of
aortitis per ___ read. Repeat imaging with MRA shows stable
findings of vascular inflammation along with ESR and CRP
elevations, but still unclear if these findings are contributing
to the abdominal pain. Follow up with rheumatology and vascular
medicine as above to determine treatment (likely steroids).
# ___:
Initially thought to be due to contrast from CTA, returned to
baseline of 1.3 and then bumped again to 1.7 this admission.
Mostly likely pre-renal on CKD in the setting of abdominal pain
/ reduced PO intake. Discharge Cr 1.4.
CHRONIC/STABLE/RESOLVED PROBLEMS
================================
# HTN Urgency:
Possibly due to medication non-complicance or anxiety. Continued
home Lisinopril 40MG Daily, and Clonidine 0.2MG BID. Increased
Amlodipine to 10 MG daily with improved BP control.
# PVD
# L SFA stent occlusion:
Follows with vascular surgery with recent visit in ___.
Continues to actively smoke for which smoking cessation is a
prerequisite for additional intervention. Of note, patient has
been without cigarettes or nicotine patch this admission.
Continued Atorvastatin 80MG QHS
# Bipolar Disorder/Anxiety:
Patient took her own lurasidone. Continued Clonazepam. Will have
outpatient psychiatry and therapist follow up.
# DM:
Held home metformin and glipizide while inpatient, resumed on
discharge
# ADHD:
Held Adderall given HTN. Follow up with psych outpatient to
restart this medication.
TRANSITIONAL ISSUES
===================
Discharge Cr: 1.4
[ ] Spoke with PCP and psychiatrist prior to discharge to make
sure everyone on the same page regarding plan. Should not have
opiates prescribed after short course from our discharge, with
plans to start therapy with rheumatology
[ ] Recheck creatinine at PCP follow up to ensure that it
remains at baseline
[ ] Follow up pain management, and attempt to wean/stop opiates.
Given 5 day course with agreement that she should not be
maintained on these medications. Pending rheumatology and
vascular medicine management
[ ] Patient has a level of anxiety, especially given new medical
issues this admission. Continue to monitor and encourage
especially non-pharmacologic anxiety reduction. Should be seeing
psychiatry/therapist regularly
[ ] Adderall held this admission, would be hesitant to restart
it due to patient's anxiety and intermittent chest
pain/palpitations due to anxiety this admission.
[ ] Continue to encourage smoking cessation, she has been
without a nicotine patch this admission and is planning on
quitting on discharge.
[ ] Increased amlodipine to 10mg daily. Please monitor blood
pressures on new regimen
[ ] Holding gabapentin 600mg BID as patient says she only
benefits from the gabapentin 900mg at night. Consider restarting
if pain not controlled
[ ] Gastritis on EGD, starting pantoprazole daily
[ ] Ensure having reguarl bowel movements as constipation could
contribute to her abdominal pain; discharged on senna BID and
polyethylene glycol prn
[ ] Follow up sugars back on oral regimen, have been controlled
inpatient
[ ] last CRP 54.9->12.7, last ESR 92->29, IgG subclasses with
subclass I, 4, and serum; ANCA negative
#CODE: Full (Presumed)
#CONTACT: None given
This patient was prescribed, or continued on, an opioid pain
medication at the time of discharge (please see the attached
medication list for details). As part of our safe opioid
prescribing process, all patients are provided with an opioid
risks and treatment resource education sheet and encouraged to
discuss this therapy with their outpatient providers to
determine if opioid pain medication is still indicated. |
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, Dizziness, Chest Pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ with PMH signficant for HTN, HLD,
obesity and depression who presents from his PCP's office where
he was seen for 4 days of progressive SOB. Patient was in his
usual state of health until 4 days prior to admission when he
developed dizziness, lightheadedness and fatigue while doing
yardwork. The day prior to admission he had an episode of near
syncope while going up a flight of stairs. He endorsed
lightheadedness and diaphoresis, no chest pain. He slumped to
the floor without headstrike or LOC. He was seen in his PCP's
office the day of admission for these complaints.
In the ED, initial vitals were: 97.6, 90, 147/92, 16, 92%RA.
Labs were notable for d-dimer of 7766. INR was 1.1, trop < 0.01.
CTA chest was done and showed a saddle pulmonary embolus with
evidence of right heart strain (leftward bowing of the
interventricular septum). He was placed on 2L NC for a
desaturation to 85% on room air. He was started on a heparin gtt
and admitted to the CCU for further management.
Of note, 2 weeks prior he developed a URI (sneezing, cough,
sinus congestion) which had nearly resolved. He has been feeling
more tired than usual for the past two weeks and attributed it
to his URI. He has also endorsed a 12 lb weight loss over the
past 6 months. He denies any recent travel. He reports having a
DVT in his right leg ___ years ago immediately after a hamstring
injury where he took Lovenox. No history of blood clotting
disorders.
Vitals prior to transfer were: 98.0, 89, 137/86, 13, 95% 2L NC
In the CCU, patient was placed on 1L O2 and saturated mid-90s.
When taken off nasal cannula he desaturated to 89%.
REVIEW OF SYSTEMS: Positive per HPI. Negative for chest pain,
SOB, fevers/chills, melena/hematochezia. He endorses a good
appetite.
Past Medical History:
HTN
HLD
obesity
depression
Social History:
___
Family History:
No known clotting disorders or issues with blood clots. Father
died of an MI at age ___. Mother with diabetes.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 98 BP 167/95 HR 81 RR 19 O2 sat 96%RA
Gen: Pleasant, calm, in NAD
HEENT: No conjunctival pallor. No icterus. MMM. OP clear.
NECK: Supple, No LAD. JVP low. Normal carotid upstroke without
bruits. No thyromegaly.
CV: PMI in ___ intercostal space, mid clavicular line. No RV
heave. RRR. normal S1,S2. No murmurs, rubs, clicks, or gallops
LUNGS: CTAB. No wheezes, rales, or rhonchi.
ABD: NABS. Soft, NT, ND. No HSM. Abdominal aorta was not
enlarged by palpation. No abdominal bruits.
EXT: WWP, NO CCE. Full distal pulses bilaterally. No femoral
bruits. Legs symmetrical, no calf tenderness.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. CN ___ grossly intact. Gait assessment deferred
DISCHARGE PHYSICAL EXAM:
Gen: Pleasant, calm, in NAD
HEENT: No conjunctival pallor. No icterus. MMM. OP clear.
NECK: Supple, No LAD. JVP low. Normal carotid upstroke without
bruits. No thyromegaly.
CV: PMI in ___ intercostal space, mid clavicular line. No RV
heave. RRR. normal S1,S2. No murmurs, rubs, clicks, or gallops
LUNGS: CTAB. No wheezes, rales, or rhonchi.
ABD: NABS. Soft, NT, ND. No HSM. Abdominal aorta was not
enlarged by palpation. No abdominal bruits.
EXT: WWP, NO CCE. Full distal pulses bilaterally. No femoral
bruits. Legs symmetrical, no calf tenderness.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. CN ___ grossly intact. Gait assessment deferred
Pertinent Results:
ADMISSION LABS:
___ 05:00PM BLOOD WBC-11.0 RBC-5.22 Hgb-16.5 Hct-48.6
MCV-93 MCH-31.7 MCHC-34.0 RDW-14.6 Plt ___
___ 05:00PM BLOOD Neuts-76.5* Lymphs-14.2* Monos-5.8
Eos-2.2 Baso-1.3
___ 05:00PM BLOOD ___ PTT-28.0 ___
___ 05:00PM BLOOD Glucose-117* UreaN-14 Creat-1.0 Na-141
K-5.0 Cl-102 HCO3-26 AnGap-18
PERTINENT LABS:
___ 07:04PM BLOOD D-Dimer-7766*
___ 05:00PM BLOOD proBNP-2899*
___ 05:00PM BLOOD cTropnT-<0.01
___ 10:30AM BLOOD cTropnT-<0.01
DISCHARGE LABS:
___ 06:30AM BLOOD WBC-8.2 RBC-4.86 Hgb-15.1 Hct-44.9 MCV-92
MCH-31.1 MCHC-33.6 RDW-14.5 Plt ___
___ 06:30AM BLOOD ___ PTT-34.1 ___
___ 06:30AM BLOOD Glucose-94 UreaN-13 Creat-0.9 Na-142
K-4.2 Cl-100 HCO3-28 AnGap-18
___ 06:30AM BLOOD Calcium-9.4 Phos-3.8 Mg-2.1
IMAGING/STUDIES:
EKG (___): NSR @ 90bpm, LAD, poor R wave progression, S1
and T3 indicative of right heart strain, delayed QRS
depolariztaion suggestive of RV enlargement, <1mm STE in aVR.
___ Imaging CHEST (PA & LAT)
IMPRESSION:
Apparent right hilar enlargement, potentially enlarged pulmonary
artery or adenopathy. Consider CT scan to further evaluate. No
acute cardiopulmonary process.
___ Imaging CTA CHEST W&W/O C&RECON
IMPRESSION:
Saddle pulmonary embolism extending into lobar and segmental
branches of all the lobes. There is evidence of right heart
strain with leftward bowing of the interventricular septum.
___ Imaging BILAT LOWER EXT VEINS
IMPRESSION:
1. Occlusive left popliteal deep venous thromboses with
extension to the
posterior tibial and peroneal veins.
2. No right deep venous thromboses
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Simvastatin 10 mg PO DAILY
Discharge Medications:
1. Simvastatin 10 mg PO DAILY
2. Enoxaparin Sodium 100 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 100 mg/mL one syringe SC twice a day Disp #*8
Syringe Refills:*2
3. Warfarin 5 mg PO DAILY16
RX *warfarin 5 mg one tablet(s) by mouth daily Disp #*30 Tablet
Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Pulmonary Embolus
Left popliteal deep vein thrombosis
Hypertension
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with sob and cp // eval pneumonia, chf
TECHNIQUE: Frontal and lateral views of the chest.
COMPARISON: None.
FINDINGS:
The lungs are clear of focal consolidation. Cardiomediastinal silhouette is
within normal limits. There is apparent enlargement of right hilum which could
be due to underlying enlargement of the pulmonary artery or underlying
adenopathy. No acute osseous abnormalities identified, hypertrophic changes
are noted spine and degenerative changes at the acromioclavicular joints.
IMPRESSION:
Apparent right hilar enlargement, potentially enlarged pulmonary artery or
adenopathy. Consider CT scan to further evaluate. No acute cardiopulmonary
process.
Radiology Report
EXAMINATION: CTA CHEST WANDW/O CANDRECONS, NON-CORONARY
INDICATION: ___ with 3 days of DOE, SpO2 92% // eval for PE
TECHNIQUE: Contiguous helical MDCT images were obtained through the chest
after administration of 100 cc of Omnipaque IV contrast. Multiplanar axial,
coronal, sagittal and maximum intensity projection oblique images were
generated.
DOSE: DLP: 638 mGy-cm
COMPARISON: None available
FINDINGS:
CT CHEST WITH CONTRAST: The partially visualized thyroid is unremarkable.
There is no supraclavicular, axillary, hilar or mediastinal lymphadenopathy.
The esophagus is grossly normal without hiatal hernia.
Heart size is normal without pericardial effusion. There is leftward bowing of
the intraventricular septum and relative enlargement of the right ventricle
with respect to the left ventricle. The aorta and main thoracic vessels are
normal in caliber and well opacified. The main pulmonary arteries are dilated
up to 3.2 cm. There is a moderate-size saddle embolism extending across right
and left main pulmonary arteries joining bulky emboli in the bilateral main
pulmonary arteries which extend into the lobar and subsegmental branches of
all the lobes.
There is no pleural effusion or pneumothorax. Lung volumes are low with
bibasilar dependent changes.
OSSEOUS STRUCTURES: There are no worrisome blastic or lytic lesions. There is
no acute fracture.
UPPER ABDOMEN: This study is not designed for evaluation of the
subdiaphragmatic structures however the partially visualized solid organs and
stomach are grossly normal.
IMPRESSION:
Saddle pulmonary embolism extending into lobar and segmental branches of all
the lobes. There is evidence of right heart strain with leftward bowing of the
interventricular septum.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old man with submassive pulmonary embolism. Assess for
deep venous thromboses.
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: CTA chest ___.
FINDINGS:
Occlusive expansile thrombus is seen within the left popliteal vein with
extension to the posterior tibial and peroneal veins. The left common femoral
vein and superficial femoral veins demonstrate normal compressibility and
flow.
There is normal compressibility, flow and augmentation of the right common
femoral, superficial femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
1. Occlusive left popliteal deep venous thromboses with extension to the
posterior tibial and peroneal veins.
2. No right deep venous thromboses.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr.
___ on the telephone on ___ at 1:47 AM, 5 minutes after discovery
of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)CHEST (PORTABLE AP)
INDICATION: ___ year old man with PE. // assess interval change
COMPARISON: Chest radiographs ___
IMPRESSION:
Lungs clear. Heart size normal. Left hilar pulmonary arteries may be slightly
smaller. No pleural abnormality. No evidence of left or right heart failure.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, Dizziness, Chest pain
Diagnosed with SADDLE EMBOLUS OF PULMONARY ARTERY, HYPERCHOLESTEROLEMIA
temperature: 97.6
heartrate: 90.0
resprate: 16.0
o2sat: 92.0
sbp: 147.0
dbp: 92.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ with PMH significant for HTN, HLD,
obesity and depression who presents from his PCP's office with 4
days of shortness of breath/ DOE and found to have a saddle
pulmonary embolism.
#Saddle pulmonary embolism: The patient was found to have a
submassive PE with evidence of right heart strain on CTA as well
as EKG. The etiology of PEs is unclear, as he has no history of
prolonged travel, no smoking history, no history of clotting
disorders. However he has endorsed a 12 lb weight loss in the
past 6 months so malignancy is a possibility. He also has a
prior history of DVT. He remained hemodynamically stable with
BPs 160s and HR ___ upon admission, although he continued to
have an oxygen requirement of 1L NC. He was started on a heparin
drip. LENIs showed occlusive left popliteal deep venous
thromboses with extension to the posterior tibial and peroneal
veins. He was started on enoxaparin to bridge to warfarin.
#HTN: Upon transfer, the patient's blood pressures were
160s/90s. He was not on antihypertensives at home. His blood
pressures stabilized to the 120s-140s.
#HLD: The patient was continued on home simvastatin 10 mg daily. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Tylenol / Sulfa (Sulfonamide Antibiotics) /
gabapentin
Attending: ___.
Chief Complaint:
fever, chills, myalgias
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ F with PMH of fibromyalgia and elective
L4-L5 synovial cyst removal on ___ who presents to the ED
with acute onset of fevers, chills and myalgias. Her surgery
last
week was without complications and immediately after she was
able
to ambulate in the PACU. She was discharged on ___ to finish
a week of prophylactic clindamycin. On ___, she started to
develop subjective fevers, chills, myalgias and rigors. She
initially had a temperature of 100.0. By ___, she felt no
better
and had a temperature of 101.4, which prompted her to come into
the ED. She endorses nausea and dry heaving, and has had no PO
intake since ___. She denies diarrhea. She states that her
incision has been improving every day. She was ambulating at
home
without any difficulty. She endorses a cough prior to surgery,
productive of surgery, but it had resolved by ___. She denies
sick contacts, shortness of breath, PND, orthopnea, or leg
swelling. She reports pain in her calves L>R when wearing SCDs.
In the ED, she has been afebrile since admission with a TMax of
98.4. HR ranged from 93-126, with a RR of ___. BPs stable, and
saturating in the upper ___ on room air. A chest x-ray was
obtained which showed: Lungs are clear. No focal consolidations.
CBC, BMP normal, ALT 61. CRP 82.4. Lactic acid was initially
2.8,
now 1.6. Flu A/B PCR negative. UA unremarkable. Urine and blood
cultures pending. CXR was unremarkable.
Given her recent spine surgery, an MRI was obtained which
showed:
1. Postoperative changes related to recent right subarticular
synovial cyst resection. No epidural fluid collection. Epidural
and surgical bed enhancement, is within the expected amount
following surgery, however this could obscure superimposed
infection.
A CT abdomen and pelvis were also obtained which showed:
1. No acute intra-abdominal or intrapelvic findings.
2. Postsurgical changes after L4/L5 procedure including soft
tissue stranding and fluid collection in the posterior
subcutaneous tissue, as well as the intraspinal findings are
better characterized on the same day MRI.
3. Findings suggestive of hepatic steatosis. Please see
recommendations below.
Bilateral LENIs: No evidence of DVT in the right or left lower
extremity veins.
The patient was given 3L LR, dilaudid 1mg IV x1, Zofran 4mg IV
x2, lorazepam 1mg IV x1, amitriptyline 75mg PO, clindamycin
300mg
PO x2, hydroxychloroquine 200 PO x2, amlodipine 5mg x1,
levothyroxine 150mcg PO x1, omeprazole 20mg x1, and metoprolol
50mg x1.
Neurosurgery was consulted and determined that MRI showed a
phlegmon; incision looked good with no evidence of infection and
recommended finishing a 14-day course of clindamycin, with
follow
up ___ days post-surgery.
Prior to transfer, vital signs were T 98.3, HR 97, BP 114/63, RR
18, O2 sat 97% on RA. On arrival to the floor, patient confirms
the above history. She reports she is overall feeling much
better
than prior to admission. She denies shortness of breath, nausea,
vomiting, diarrhea, cough (although had a productive cough with
some rhinorrhea prior to surgery ___.
REVIEW OF SYSTEMS:
==================
Pertinent positives and negatives as noted in the HPI. All other
systems were reviewed and are negative.
Past Medical History:
1. Chronic LBP
2. L4-5 disc bulge with R sciatic
3. Fibromyalgia
4. Arthritis (reportedly ___ on Hydroxychloroquine
5. Thyroid CA s/p thyroidectomy
6. HTN
7. s/p AVNRT ablation
8. C Diff infection
Social History:
___
Family History:
Adopted and does not know her family.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: reviewed in eflowsheets
GENERAL: Obese female, alert and in no apparent distress
HEENT: Anicteric, PERRL, OP clear with no erythema, MMM
CV: RRR, no murmur, no S3, no S4.
RESP: Lungs CTABL with good air movement bilaterally. Breathing
is non-labored on RA
GI: +BS. Abdomen soft, non-distended, non-tender to palpation.
No HSM.
MSK: No swelling or pain on palpation of bilateral calves.
SKIN: Lower back incision with staples in place, no drainage and
no surrounding erythema, mildly tender to palpation over wound.
NEURO: Strength is ___ in her hip flexion and leg
extension/flexion without any pain.
PSYCH: pleasant, appropriate affect
DISCHARGE PHYSICAL EXAM:
========================
24 HR Data (last updated ___ @ 555)
Temp: 98.2 (Tm 98.7), BP: 132/78 (117-142/77-89), HR: 87
(87-101), RR: 20 (___), O2 sat: 95% (94-100), O2 delivery: Ra
GENERAL: Obese female, alert and in no apparent distress.
Pleasant and cooperative.
HEENT: Sclerae anicteric, MMM.
CV: RRR, no murmur, no S3, no S4.
RESP: Lungs CTABL with good air movement bilaterally. Breathing
is non-labored on RA.
GI: +BS. Abdomen soft, non-distended, non-tender to palpation.
No HSM.
MSK: No swelling or pain on palpation of bilateral calves.
SKIN: Lower back incision with staples in place, no drainage and
no surrounding erythema, mildly tender to palpation over wound.
NEURO: Strength is ___ in her hip flexion, extension,
dorsi/plantarflexion bilaterally. SILT bilaterally.
PSYCH: pleasant, appropriate affect
Pertinent Results:
ADMISSION LABS:
===============
___ 09:30PM BLOOD WBC-8.5 RBC-4.72 Hgb-12.6 Hct-39.0 MCV-83
MCH-26.7 MCHC-32.3 RDW-13.9 RDWSD-41.4 Plt ___
___ 09:30PM BLOOD Neuts-61.2 ___ Monos-7.0 Eos-2.2
Baso-0.5 Im ___ AbsNeut-5.22 AbsLymp-2.41 AbsMono-0.60
AbsEos-0.19 AbsBaso-0.04
___ 09:30PM BLOOD Glucose-111* UreaN-9 Creat-0.9 Na-138
K-5.0 Cl-102 HCO3-23 AnGap-13
___ 09:30PM BLOOD ALT-61* AST-47* AlkPhos-85 TotBili-0.3
___ 09:30PM BLOOD Albumin-4.3
___ 09:30PM BLOOD CRP-82.4*
___ 09:32PM BLOOD Lactate-2.6*
___ 10:49PM BLOOD Lactate-2.8*
___ 02:30AM BLOOD Lactate-1.6
___ 10:50PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
___ 10:50PM URINE Color-Straw Appear-Clear Sp ___
DISCHARGE LABS:
===============
___ 05:47AM BLOOD WBC-6.7 RBC-4.38 Hgb-11.6 Hct-36.9 MCV-84
MCH-26.5 MCHC-31.4* RDW-14.2 RDWSD-43.4 Plt ___
___ 05:47AM BLOOD Glucose-98 UreaN-13 Creat-0.7 Na-143
K-4.3 Cl-105 HCO3-24 AnGap-14
___ 05:47AM BLOOD ALT-42* AST-23 AlkPhos-74 TotBili-<0.2
___ 05:47AM BLOOD Albumin-3.7 Calcium-8.7 Phos-4.5 Mg-2.0
MICRO:
======
___ urine culture
**FINAL REPORT ___
URINE CULTURE (Final ___:
PROTEUS MIRABILIS. 10,000-100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ blood cultures x3 - pending, no growth to date
IMAGING/STUDIES:
================
___ CXR
Lungs are clear. No focal consolidations.
___ MRI L spine w/ and w/o contrast
1. Postoperative changes related to recent right subarticular
synovial cyst resection.
2. No epidural fluid collection.
3. Epidural and surgical bed enhancement, is within the expected
amount
following surgery, however the appearance would be this same in
the setting of superimposed infection.
___ CT AP w/ contrast
1. No acute intra-abdominal or intrapelvic findings.
2. Postsurgical changes after L4/L5 procedure including soft
tissue stranding and fluid collection in the posterior
subcutaneous tissue, as well as the intraspinal findings are
better characterized on the same day MRI.
3. Findings suggestive of hepatic steatosis. Please see
recommendations
below.
___ ___
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate
2. Amitriptyline 75 mg PO QHS
3. amLODIPine 5 mg PO DAILY
4. Cyclobenzaprine 20 mg PO BID
5. Hydroxychloroquine Sulfate 200 mg PO BID
6. Levothyroxine Sodium 150 mcg PO DAILY
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Clindamycin 300 mg PO Q6H
10. Cyclobenzaprine 10 mg PO LUNCH
Discharge Medications:
1. Amitriptyline 75 mg PO QHS
2. amLODIPine 5 mg PO DAILY
3. Cyclobenzaprine 20 mg PO BID
4. Cyclobenzaprine 10 mg PO LUNCH
5. Hydroxychloroquine Sulfate 200 mg PO BID
6. Levothyroxine Sodium 150 mcg PO DAILY
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Recent L4-L5 synovial cyst removal
Secondary diagnoses:
Asymptomatic bacteriuria
Tachycardia
Elevated AST
Fibromyalgia
Low back pain
Hypertension
History of AVNRT s/p ablation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MR ___ AND W/O CONTRAST T___ MR SPINE
INDICATION: History: ___ with fever s/p spinal surgery, LLQ tendernessIV
contrast to be given at radiologist discretion as clinically needed//
?epidural abscess ?intrabdominal infection ?epidural abscess
?intrabdominal infection
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique,
followed by axial T2 imaging. This was followed by sagittal and axial T1
images obtained after the uneventful intravenous administration of Gadavist
contrast agent.
COMPARISON: Radiograph ___, MR ___
FINDINGS:
The cauda equina terminates at L1. Alignment is maintained. No marrow
replacing process. There has been interval resection of the previously seen
L4-5 right subarticular synovial cyst. Small amount of fluid and extensive
edema throughout the superficial soft tissues and interspinous ligament,
compatible with recent surgery. Fluid and a small amount of air within the
surgical bed, also compatible with recent surgery. Appearance of the
posterior epidural fat (series 3, image 10), is similar to ___.
There is no epidural collection. Epidural and surgical bed enhancement is
within the expected amount following surgery, however the appearance would be
this same in the setting of superimposed infection. No organized fluid
collection.
Multilevel degenerative changes are mild throughout the lower thoracic and
lumbar spine, worse at T11-T12 and L3-4, where mild disc bulges result in mild
bilateral neural foraminal narrowing. ___ type II endplate changes noted at
T11-T12.
Left renal simple cysts noted. Otherwise, limited assessment of the
intra-abdominal structures is grossly unremarkable.
IMPRESSION:
1. Postoperative changes related to recent right subarticular synovial cyst
resection.
2. No epidural fluid collection.
3. Epidural and surgical bed enhancement, is within the expected amount
following surgery, however the appearance would be this same in the setting of
superimposed infection.
NOTIFICATION: The updated findings were discussed by Dr. ___ Dr.
___ by telephone at 11:35 on ___, 10 minutes following the
discovery of the findings.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ with fever s/p spinal surgery, LLQ tenderness// ?epidural
abscess ?intrabdominal infection
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: Total DLP (Body) = 1,416 mGy-cm.
COMPARISON: MR ___ performed ___ at 00:51
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates hypotension relative to the spleen
throughout, suggestive of steatosis. There are focal areas of relative
increased enhancement within segment 4 B (series 2, image 26). This may be
due to focal fatty sparing or transient hepatic enhancement differences.
There is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. Several renal
hypodensities too small to characterize by CT are demonstrated and likely
represent benign entities. There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. Diverticulosis is
noted, particularly of the transverse colon, without evidence of wall
thickening and fat stranding.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: No uterus is visualized. Bilateral essure devices are
noted.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Minimal atherosclerotic
disease is noted.
BONES/SOFT TISSUES: No acute fractures. No traumatic subluxation.
Postsurgical changes seen at the L4/L5 vertebral body with a small focus of
air overlying the right L4 lamina. There is soft tissue stranding with a
small fluid collection noted in the soft tissue overlying the paraspinal
muscles, better characterized on the same day MRI performed earlier. The
spinal canal is better visualized on the prior MRI.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No acute intra-abdominal or intrapelvic findings.
2. Postsurgical changes after L4/L5 procedure including soft tissue stranding
and fluid collection in the posterior subcutaneous tissue, as well as the
intraspinal findings are better characterized on the same day MRI.
3. Findings suggestive of hepatic steatosis. Please see recommendations
below.
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 either MR ___ or US ___, 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: BILAT LOWER EXT VEINS
INDICATION: ___ year old woman with recent back surgery and post-op fever, leg
pain L>R// Evaluate for DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, color flow, and spectral doppler of the
bilateral common femoral, femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Fever, Palpitations
Diagnosed with Other dorsalgia, Fever, unspecified
temperature: 97.0
heartrate: 128.0
resprate: 26.0
o2sat: 100.0
sbp: 134.0
dbp: 94.0
level of pain: 10
level of acuity: 2.0 | Ms. ___ is a ___ female with fibromyalgia on
hydroxychloroquine, history of C Diff, with an excision of an
L4-L5 synovial cyst last ___, who presents with
fevers and chills. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
scallops
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ yo M w/ PMHx of COPD (FEV 1 26% ___ on
home 3L O2, HTN, AAA s/p endovascular repair in ___ c/b STEMI
with BMS to left main and RCA and left femoral endarterectomy.
Patient states she's had increased shortness of breath over the
last 2 days. He reports his sputum has become thicker than
prior, but denies any fevers, chills, or cough. He does endorse
worsening orthopnea and sleeps at a 45 degree angle. He also has
PND and moves to the chair to sit upright to relief the dyspnea.
He has had significant decline in physical capacity to the point
that now, he cannot make his bed without becoming short of
breath. He is followed closely by Dr. ___ and saw her
on ___ and he has been using his nebulizers and flutter
valve as directed. This morning, he woke up short of breath,
moved to the chair, had his nebulizer treatments and went back
to sleep. When he next woke up, he felt confused and SOB and
thus, called EMS. EMS found patient on oxygen saturations in the
___ that improved to mid ___ on a nonrebreather.
Of note, patient recently admitted in late ___ and
___ for COPD exacerbations, treated with IV lasix,
steroids and azithromycin. He required short MICU stays both
visits with non-invasive ventilation and non-rebreathers and was
quickly weaned to NC. CT scan during admission in ___ showed
no evidence of an obstructing lesion as the cause of the right
middle lobe abnormalities, but there was a 2.5 cm polygonal
shaped opacity adjacent to the minor fissure present since
___. They also noted ground-glass and septal thickening in the
right middle lobe inferior to this level, possibly a more
diffuse process.
In the ED, initial vitals: 97.2 92 151/78 24 92% Non-Rebreather.
- Labs notable for: WBC 8.1, chemistries HCO3 39, Cl 95, BUN 21.
- CXR: RLL opacity c/w pna
- He was given azithromycin and vancomycin, 80mg methylpred,
ipratropium and albuterol nebs.
Pleth did not improve on non-rebreather, so he was placed on
bipap with improvement in saturation.
On transfer, vitals were: 81 105/58 23 95% on BiPap.
On arrival to the MICU, he reports feeling much improved. His
breathing feels better than this morning. He was weaned quickly
to non-rebreather successfully. He denies any increased cough or
chest pain. He does feel a little frustrated that he has had so
many infections recently requiring hospitalizations.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. 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. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
- COPD- baseline home O2 3LCN
- CAD
- Morbid Obesity
- PVD
- HTN
- HLD
- AAA s/p endoluminal repair in ___ c/b STEMI and limb ischemia
- Pulm. nodule
- Edema
- S/P abd. hernia repair
Social History:
___
Family History:
CAD/PVD - father and mother, died in their ___
CVA - brother in ___. Brother diagnosed with ___ at age
___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals- T: 96.3 BP: 137/97 P:89 R: 18 O2: 92% non-rebreather
GENERAL: Alert, oriented, sitting up in chair
HEENT: Sclera anicteric, MMM, oropharynx clear,
NECK: supple, JVP unable to assess ___ body habitus, no LAD
LUNGS: uses accessory muscles to talk, diminished breath sounds
throughout all lung fields, faint bilateral crackles at bases,
no wheezing
CV: Regular rate and rhythm, blowing II/VI systolic murmur best
heard left sternal border
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pitting edema bilaterally
NEURO: AAOx3, CN II-XII grossly intact, moving all extremities
DISCHARGE PHYSICAL EXAM:
VSS
GENERAL: Alert, oriented, sitting up in chair
HEENT: Sclera anicteric, MMM, oropharynx clear,
NECK: supple, JVP unable to assess ___ body habitus, no LAD
LUNGS: speaking in full sentences, breath sounds throughout all
lung fields with tight air movement, few wheezes
CV: Regular rate and rhythm, distant heart sounds, soft systolic
murmur
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pitting edema bilaterally minimally
improved form day prior
NEURO: AAOx3, CN II-XII grossly intact, moving all extremities
Pertinent Results:
ADMISSION LABS:
=============================
___ 09:30AM BLOOD WBC-8.1 RBC-4.50* Hgb-13.1* Hct-43.6
MCV-97 MCH-29.1 MCHC-30.1* RDW-14.3 Plt ___
___ 09:30AM BLOOD Neuts-61.8 ___ Monos-7.5 Eos-1.5
Baso-0.4
___ 09:30AM BLOOD Glucose-90 UreaN-21* Creat-1.1 Na-143
K-5.2* Cl-95* HCO3-39* AnGap-14
___ 09:30AM BLOOD Calcium-8.9 Phos-4.5 Mg-2.5
___ 09:39AM BLOOD Lactate-1.5
MICRO:
=========
___ 6:12 pm SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
___ PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
IMAGING/STUDIES:
=============================
___
There is a new opacity at the right lung base
suggesting pneumonia with lesser but a new opacity along
the left mid lung, the latter obscuring the left heart
border and probably localizing to the lingula.
IMPRESSION: Findings concerning for pneumonia.
___ EKG:
sinus at rate of 78, normal axisQ waves in V1, V2, and V3
unchanged from prior
ECHO ___:
The left atrium is moderately dilated. 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
low normal (LVEF 50-55%). Right ventricular chamber size and
free wall motion are normal. The aortic root is mildly dilated
at the sinus level. The aortic valve is not well seen. The study
is inadequate to exclude significant aortic valve stenosis. The
mitral valve leaflets are not well seen. Trivial mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
Compared with the prior study (images reviewed) of ___,
findings are probably similar, although the very suboptimal
technical quality of both studies precludes definite comparison.
CTA ABDOMEN/PELVIS ___:
IMPRESSION:
1. Previously seen endoleak no longer apparent, which may be
due to
differences in technique. Decreased size of the abdominal
aortic aneurysm
sac. Otherwise, stable appearance of the aortic stent.
2. Patchy Right middle and lower lobe pulmonary consolidation,
partially
imaged, concerning for infection.
3. 6-mm left common femoral artery pseudoaneurysm.
4. 2.4 cm lobulated fluid density lesion inferior to the cecum.
MRI is
recommended for further evaluation.
5. Focus of air in the bladder. Clinical correlation for
recent
instrumentation is recommended. Otherwise, infection cannot be
excluded.
DISCHARGE LABS:
=============================
___ 06:02AM BLOOD WBC-8.2 RBC-4.02* Hgb-11.9* Hct-38.5*
MCV-96 MCH-29.6 MCHC-30.9* RDW-14.4 Plt ___
___ 06:02AM BLOOD Glucose-85 UreaN-32* Creat-1.0 Na-141
K-4.2 Cl-91* HCO3-44* AnGap-10
___ 06:02AM BLOOD Calcium-8.8 Phos-4.5 Mg-2.4
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q8H:PRN Wheezing
2. Aspirin 325 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Fluticasone Propionate 110mcg 2 PUFF IH BID
5. Furosemide ___ mg PO DAILY
6. Metoprolol Succinate XL 100 mg PO DAILY
7. Tiotropium Bromide 1 CAP IH DAILY
8. Enalapril Maleate 5 mg PO DAILY Hypertension
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q8H:PRN Wheezing
2. Aspirin 325 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Enalapril Maleate 5 mg PO DAILY Hypertension
5. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
6. Azithromycin 250 mg PO Q24H Duration: 8 Days
Please take through ___
RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*8
Tablet Refills:*0
7. Cefpodoxime Proxetil 400 mg PO Q12H Duration: 8 Days
Take through ___
RX *cefpodoxime 200 mg 2 tablet(s) by mouth every twelve (12)
hours Disp #*32 Tablet Refills:*0
8. PredniSONE 60 mg PO DAILY Duration: 1 Day
Take through ___
RX *prednisone 20 mg 3 tablet(s) by mouth daily Disp #*3 Tablet
Refills:*0
9. Fluticasone Propionate 110mcg 2 PUFF IH BID
10. Metoprolol Succinate XL 100 mg PO DAILY
11. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES: COPD exacerbation, pneumonia
SECONDARY DIAGNOSES: abdominal aortic aneurysm, coronary artery
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
CHEST RADIOGRAPH
HISTORY: Shortness of breath.
COMPARISONS: Radiographs from ___ and CT from ___.
TECHNIQUE: Chest, portable AP, two views.
FINDINGS: There is a new opacity at the right lung base suggesting pneumonia
with lesser but new opacity also projecting along the left mid lung, the
latter obscuring the left heart border and probably localizing to the lingula.
The cardiac, mediastinal and hilar contours appear unchanged. There is no
pleural effusion or pneumothorax.
IMPRESSION: Findings concerning for pneumonia.
Radiology Report
INDICATION: History of coronary artery disease, COPD with increasing oxygen
requirement. Please evaluate.
COMPARISONS: Chest radiograph from ___ dated back to ___.
TECHNIQUE: Single AP portable radiograph of the chest.
FINDINGS: Mild cardiomegaly has been persistent compared to exams dated back
to ___. Overall, there has been interval worsening of right
middle lobe atelectasis, and interval progression of left basilar
consolidation. Small bilateral pleural effusions are persistent. There is no
evidence of a pneumothorax. Mild bibasilar atelectasis is persistent.
IMPRESSION:
1. Interval progression of right middle lobe atelectasis.
2. Interval worsening of consolidation at the left lung base which may be
secondary to pneumonia.
Radiology Report
INDICATION: ___ male with history of abdominal aortic aneurysm status
post endovascular repair, query endoleak.
COMPARISON: ___.
TECHNIQUE: CT angiogram of the abdomen and pelvis was performed before and
after administration of intravenous contrast. Multiplanar reformatted images
were reviewed.
DLP: ___.59 mGy-cm.
FINDINGS: Patient is status post aortobifemoral stent placement with aneurysm
sac measuring 6.7 x 5.5 cm, which is decreased in size compared to prior. The
previously seen endoleak is no longer apparent, but this may be due to
differences in technique. A small amount of plaque within the aortic stent
posteriorly just above the bifurcation appears similar compared to prior
allowing for slight differences in imaging technique.
6 mm pseudoaneurysm arises from the left common femoral artery. Bilateral
renal arteries, the superior mesenteric artery, and the celiac axis appear
patent.
ABDOMEN: The lung bases demonstrate consolidation in the right middle lobe,
partially imaged, and dependent atelectasis at the bases, right greater than
left. Dense mitral annulus and coronary artery calcifications are seen. No
pericardial effusion is seen.
No acute abnormalities are detected of the liver, gallbladder, spleen,
pancreas, kidneys, adrenal glands, stomach, small bowel, or colon. 2.5 x 1.9
cm lobulated fluid density lesion is seen just inferior to the cecum. No free
intraperitoneal air or ascites is detected.
PELVIS: A focus of air is seen in the anterior urinary bladder. The prostate
contains coarse calcifications. The seminal vesicles are unremarkable. No
free fluid is seen in the pelvis. Stranding is seen adjacent to the common
femoral vessels, likely secondary to prior instrumentation.
BONES: A bone island in the right iliac is stable compared to ___. No
concerning osseous lesions are detected.
IMPRESSION:
1. Previously seen endoleak no longer apparent, which may be due to
differences in technique. Decreased size of the abdominal aortic aneurysm
sac. Otherwise, stable appearance of the aortic stent.
2. Patchy Right middle and lower lobe pulmonary consolidation, partially
imaged, concerning for infection.
3. 6-mm left common femoral artery pseudoaneurysm.
4. 2.4 cm lobulated fluid density lesion inferior to the cecum. MRI is
recommended for further evaluation.
5. Focus of air in the bladder. Clinical correlation for recent
instrumentation is recommended. Otherwise, infection cannot be excluded.
Findings and recommendations were discussed with Dr. ___ by Dr.
___ by telephone at 20:00 on ___ at the time of initial
review of the examination.
Gender: M
Race: WHITE - RUSSIAN
Arrive by UNKNOWN
Chief complaint: Dyspnea
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, HYPOXEMIA
temperature: 97.2
heartrate: 92.0
resprate: 24.0
o2sat: 92.0
sbp: 151.0
dbp: 78.0
level of pain: 0
level of acuity: 1.0 | Mr. ___ is a ___ man with h/o COPD (FEV 1 26% ___ on
home 3L O2, HTN, AAA s/p endovascular repair in ___ c/b STEMI
with BMS to left main and RCA and left femoral endarterectomy
who presents with DOE concerning for COPD exacerbation.
# Hypoxemic respiratory distress: COPD EXACERBATION AND
MULTIFOCAL PNEUMONIA
Multifactorial in setting of known severe COPD (GOLD stage IV)
and CAD. Patient has presented for 3 exacerbations within 4
months despite close outpatient monitoring and medication
compliance at home. Each incidence appears precipitated by
infectious process and CXR on admission was c/w new RLL PNA.
Most recent CT showed RML deformities of unclear significance
although cancer could not be ruled out. Not found to have an
obstructive process at last admission. Patient also had some
signs and symptoms of decompensated CHF including orthopnea, and
lower extremity edema. TTE ___ showed LVEF 50-55% similar to
prior. He was given ceftriaxone / azithromycin and will
complete a 10 day course. He also received a 5-day pulse of
prednisone 60mg, and was diuresed with IV lasix in the MICU. He
was placed on BiPAP and monitored in the ICU, but quickly weaned
to nasal cannula. During his stay on the medical floor, he was
continued on nebulizer treatments, prednisone, ceftriaxone and
azithromycin. He was transitioned to his home lasix 40 mg PO
daily. He was requiring ___ of oxygen and was weaned to his
home 3L by discharge. ___ evaluated patient and recommended home
with ___.
# Pneumonia: CXR shows new RLL opacity c/w PNA , CT chest with
opacities in RML and RLL and patient with changes in sputum
production that may be c/w PNA. Although patient meets criteria
for HCAP (hospital admission within last 90 days), he remains
afebrile, without any leukocytosis, or significant cough. Thus,
he likely has either viral process or atypical infection.
Treated with antibiotics as above. Sputum culture revealed
sparse commensal respiratory flora.
# CAD s/p RCA and left main stents: EKG was not significantly
changed compared to prior, and troponins were negative.
Continued home medications and diuresed as above.
# HTN: Continued home enalapril
# HLD: Continued home atorvastatin
# s/p AAA repair: Per vascular surgery, patient is due for
surveillance CTA abdomen. He had a CTA on ___ which showed
no apparent endoleak but did show a 2.4 cm lobulated fluid
collection below the cecum, the significance of which is unclear
and should be followed up with MRI.
# Emergency contact: Son ___ is HCP: ___
# Code: Full Code |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain, nausea
Major Surgical or Invasive Procedure:
___: Laparoscopic lysis of adhesions and small bowel
resection with primary anastomosis.
History of Present Illness:
___ hx Meckel's diverticulum s/p small bowel resection for SBO
in ___ who presents with 10h of severe cramping lower abdominal
pain that does not radiate associated with nausea, no vomiting.
Pt had a small BM this am, last normal BM was yesterday
afternoon. He has not eaten or drank since the pain began. Pt
reports dysuria at the end of urination, no hematuria. Pt denies
any fevers, diarrhea, constipation prior to today, blood in
stool.
Past Medical History:
PMH: reccurent SBO.
Incidental finding of right anterior portal vein to middle
hepatic vein shunt found on ___ liver/gallbladder
ultrasound
Past Surgical History:
___: Laparoscopic converted to open small bowel resection for a
small bowel obstruction and Meckel's diverticulum
Age ___: Laparoscopic appendectomy
Wisdom teeth extraction
Social History:
___
Family History:
Drinks ___ cocktails/day, denies EtOH within the past 3
weeks. Denies current/prior tobacco. Occasional marijuana,
denies
other illicits/IVDU. Lives with wife and 2 children. Works as a
___.
Physical Exam:
Admission Physical Exam:
VITALS: Afebrile, HD stable
GEN: A&Ox3, uncomfortable
HEENT: No scleral icterus, mucus membranes moist
PULM: no respiratory distress
ABD: Soft, mildly distended, tender to palpation bilateral lower
quadrants, no rebound or guarding
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical exam:
Vitals AVSS
GEN: A&Ox3, resting comfortably
HEENT: No scleral icterus or injection, EOMI, mucus membranes
moist
PULM: no respiratory distress, clear to auscultation
bilaterally, symmetric expansion, no adventitious sounds
ABD: Soft, nontender, nondistended, no rebound or guarding. Well
healing incision in midline abdomen with staples removed on port
incisions and midline. Small dry eschar at superior aspect of
incision line, pinhead size granulation tissue by prior staple
site with minimal serous output. No erythema, edema, cyanosis.
Ext: No ___ edema, ___ warm and well perfused. 2+ DP pulses. Right
upper extremity with mild superficial phlebitis, tender to
palpation at IV insertion site with palpable induration with
narrow fan shaped blanching erythema. No itching or pain at
rest.
Pertinent Results:
Imaging:
CT abdomen/pelvis ___:
Small bowel obstruction, with a transition point at the left
lower quadrant at patient's anastomotic site. Of note, this is
the same location of transition point as in ___. There is
a small amount of free fluid in the pelvis. There is no
abnormal bowel wall enhancement, pneumatosis, or free air.
___: Chest/Port Line Placement:
Enteric tube tip is positioned within the stomach. No acute
cardiopulmonary process.
___: Pathology:
Small bowel anastomosis, resection:
- Segment of small intestine including anastomotic site with
mucosal ischemic-type necrosis, submucosal congestion and edema,
and serosal adhesions consistent with clinical history of small
bowel obstruction.
Labs:
___ 11:19AM BLOOD Albumin-4.4 Calcium-9.7 Phos-3.3 Mg-2.0
___ 04:55AM BLOOD Calcium-8.6 Phos-2.1* Mg-1.6
___ 05:05AM BLOOD Calcium-8.7 Phos-3.8 Mg-1.7
___ 11:19AM BLOOD ALT-11 AST-15 AlkPhos-43 TotBili-0.4
___ 11:19AM BLOOD Glucose-107* UreaN-12 Creat-0.9 Na-141
K-4.9 Cl-103 HCO3-27 AnGap-16
___ 04:55AM BLOOD Glucose-111* UreaN-10 Creat-0.7 Na-140
K-3.3 Cl-104 HCO3-27 AnGap-12
___ 05:05AM BLOOD Glucose-96 UreaN-11 Creat-0.6 Na-137
K-3.6 Cl-102 HCO3-22 AnGap-17
___ 04:55AM BLOOD Plt ___
___ 05:05AM BLOOD Plt ___
___ 07:43AM BLOOD WBC-7.1 RBC-4.81 Hgb-14.6 Hct-45.7 MCV-95
MCH-30.4 MCHC-31.9* RDW-13.8 RDWSD-48.1* Plt ___
___ 04:55AM BLOOD WBC-4.6 RBC-3.68* Hgb-11.1* Hct-35.3*
MCV-96 MCH-30.2 MCHC-31.4* RDW-13.4 RDWSD-47.3* Plt ___
___ 05:05AM BLOOD WBC-4.9 RBC-3.80* Hgb-11.8* Hct-37.0*
MCV-97 MCH-31.1 MCHC-31.9* RDW-13.2 RDWSD-47.5* Plt ___
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID:PRN constipation
Take for any constipation caused by your pain medication. Hold
for loose stools.
3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Severe
4. Senna 8.6 mg PO BID:PRN constipation
Take for any constipation caused by your pain medication. Hold
for loose stools.
5. Simethicone 40-80 mg PO QID:PRN bloating
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT abdomen and pelvis with contrast
INDICATION: ___ with history of Meckel's diverticulum and small bowel
obstruction status post partial small bowel resection in ___, with abdominal
pain// ? bowel obstruction or other acute intraabdo pathology
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 1,116 mGy-cm.
COMPARISON: CT abdomen pelvis on ___
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. A
middle hepatic vein to portal vein fistula is unchanged (2:14). There is no
evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder
is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Patient is status post partial
small bowel resection. There are multiple dilated loops small bowel measuring
up to 4.2 cm in the lower abdomen and pelvis, with fecalized loops in the low
pelvis and a transition point in the left lower quadrant at the patient's
anastomotic site (601b:27). There is no abnormal bowel wall enhancement,
pneumatosis, or free air. The colon and rectum are within normal limits. The
appendix is surgically absent.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is a
small amount of free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are normal.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
Small bowel obstruction, with a transition point at the left lower quadrant at
patient's anastomotic site. Of note, this is the same location of transition
point as in ___. There is a small amount of free fluid in the pelvis.
There is no abnormal bowel wall enhancement, pneumatosis, or free air.
Radiology Report
INDICATION: History: ___ with abdominal pain and small-bowel obstruction//
?NG tube placement
TECHNIQUE: 2 sequential portable upright AP views of the chest
COMPARISON: Chest radiograph ___
FINDINGS:
Initial chest radiograph obtained at 16:21 demonstrates the enteric tube
distally to be coiled in the distal esophagus. Subsequent chest radiograph
obtained at 16:30 demonstrates the enteric tube tip is now within the stomach.
Is borderline enlarged. Mediastinal and hilar contours are normal. Pulmonary
vasculature is normal. Lungs are clear without focal consolidation. No
pleural effusion or pneumothorax is present. No acute osseous abnormality is
detected.
IMPRESSION:
Enteric tube tip is positioned within the stomach. No acute cardiopulmonary
process.
Radiology Report
INDICATION: ___ year old man with recurrent SBO s/p resection and
re-anastomosis, now with mild distension, emesis x4 // ?obstructive pattern
vs. ileus
TECHNIQUE: Portable AP supine abdomen
COMPARISON: CT scan from ___
FINDINGS:
There are dilated air-filled loops of small bowel.
A small amount of gas is seen within the right colon.
Supine assessment limits detection for free air; there is no gross
pneumoperitoneum.
Osseous structures are unremarkable.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
Findings are suggestive of adynamic ileus versus a partial small bowel
obstruction.
Reviewed with Dr. ___.
Radiology Report
EXAMINATION: CT of the abdomen and pelvis
INDICATION: ___ year old man withh/o SBO, s/p SBR with anastomosis // IV+ PO
contrast. Assess for collection/obstruction
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 984 mGy-cm.
COMPARISON: 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: The liver demonstrates homogenous attenuation throughout. A
middle hepatic vein to portal vein fistula is unchanged (2:11). There is no
evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder
is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. There are surgical sutures at
the midline lower abdomen at the anastomosis from a recent small bowel
resection. Several loops of small bowel are adherent to the anterior
abdominal wall, likely from adhesions. There is linear irregular enhancement
within this area suggestive of fibrotic changes. There is a transition point
in the left lower quadrant involving the bowel approaching the area of
tethering near the anastomotic sutures. Bowel loops are dilated from the area
of transition in the left lower quadrant all the way to the ligament of Treitz
No free air. Mild pelvic ascites, increased in amount from prior. No
organizing collection
The colon and rectum are within normal limits.
The appendix is surgically absent.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is a
moderate amount of free fluid in the pelvis, increased from prior.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are normal.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: Midline surgical changes with foci of air within the
subcutaneous right greater than left lower abdomen and within the right
anterior abdominal wall musculature between the external and internal oblique
muscles.
IMPRESSION:
1. Status post small bowel resection. Small bowel obstruction with a
transition point in the left lower quadrant and dilated loops of bowel
extending all the way to the ligament of Treitz. The obstruction is likely
due to adhesive disease just proximal to the anastomosis. No free air. No
organizing collection.
2. Mild pelvic ascites, increased in amount when compared to ___.
NOTIFICATION: Spoke with Dr. ___ on ___ at 16:10
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with s/p SBR for SBO with emesis despite NGT //
Assess NGT placement.
TECHNIQUE: Chest single view
COMPARISON: ___
FINDINGS:
Enteric tube tip in the distal stomach. Surgical staples upper abdomen. Few
dilated small bowel loops upper abdomen, partially seen. Shallow inspiration.
Lungs clear. Normal heart size.
IMPRESSION:
Enteric tube tip in the distal stomach.
Radiology Report
INDICATION: ___ y/o M ___ s/p ex lap, LOA, now w/ NGT reinserted for SBO vs
ileus. Evaluate for interval change.
TECHNIQUE: Supine and upright abdominal radiographs were obtained.
COMPARISON: Abdominal radiographs of ___ and ___. CT
abdomen pelvis of ___.
FINDINGS:
Multiple loops of air-filled small bowel are dilated up to 5.1 cm, with
several air-fluid levels on the upright view. The new nasogastric tube
projects in the region of the stomach. A small amount of air is identified in
the right colon. No evidence of free intraperitoneal air.
Osseous structures are unremarkable.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
1. Nasogastric tube terminates in the region of the stomach.
2. Findings suggestive of adynamic ileus versus a partial small bowel
obstruction, similarly to the study of ___.
Radiology Report
INDICATION: ___ year old man pod11 small bowel resection, loa high NGT output.
NGT placement and compare to prior study. Evaluate for ileus vs obstruction
TECHNIQUE: Supine abdominal radiograph was obtained.
COMPARISON: Abdominal radiographs dated ___
FINDINGS:
An enteric tube is seen projecting under the left hemidiaphragm and
terminating in the left upper quadrant, likely the fundus of the stomach. A
side-port is noted in the distal esophagus. Compared to ___, the
tube has been retracted. There are no abnormally dilated loops of large or
small bowel. Compared to ___, there is no longer a dilated loop of
small bowel with air-fluid level seen in the left upper quadrant.
There is no free intraperitoneal air.
Osseous structures are unremarkable.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
1. The enteric tube has been retracted since ___, and now
terminates 5 cm from the diaphragm, consistent with the the fundus of the
stomach. A a side port is located in the distal esophagus.
2. There has been interval resolution of a dilated loop of small bowel and
air-fluid levels.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with Unspecified intestinal obstruction
temperature: 97.8
heartrate: 65.0
resprate: 20.0
o2sat: 96.0
sbp: 123.0
dbp: 79.0
level of pain: 8
level of acuity: 3.0 | Mr. ___ is a ___ year-old male with a history of Meckel's
diverticulum s/p small bowel resection for SBO in ___, who
presented this admission to the pre-op/Emergency Department on
___ with cramping abdominal pain and nausea. CT imaging
showed a small bowel obstruction with transition point near his
prior anastomosis site. He was initially decompressed with
nasogastric tube placement and bowel rest x 1 day prior to
undergoing surgical revision of his anastomosis on hospital day
2. There were no adverse events in the operating room; please
see the operative note for details. The patient was extubated,
taken to the PACU until stable, then transferred to the ward for
observation. He did well post-operatively and started passing
flatus on POD1. His NGT was removed on POD2 and he was advanced
to clears starting on POD3, which he tolerated well with return
of bowel function. He was then advanced to regular diet on POD4,
which he tolerated well. His pain was adequately controlled with
morphine PCA, toradol, and IV Tylenol initially after surgery,
which were switched to oral agents once tolerating a clear diet.
The patient refused subcutaneous heparin ___ dyne boots were
used during this stay and the patient was encouraged to get up
and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
None
Major Surgical or Invasive Procedure:
Liver biopsy
History of Present Illness:
___ year old male with narcotic dependence who was doing well
until one week ago when he trauma to his hand requiring hand
surgery 4 days ago at ___. He presented to ED
today with reported anxiety seeking a dual diagnosis bed. On
routine labs he was noted to have AST/ALT of 2300/2800, tbili
3.6, dbili 2.7 and INR 1.2. The patient reports that he was
consuming ___ tabs of 325-500mg tylenol ___ times per day, as
well as Percocet which he had after his operation. LFTs on
___ were normal. Patient was started on N-acetylcysteine
and transferred to ___ for further evaluation and management.
In the ED, initial vitals were: 98.2 116 128/82 18 98%. Labs
notable for ALT of 3337, AST of 1770, T.bili of 4.3 and INR of
1.3. Lactate and creatinine normal. RUQ US was normal.
Toxicology was consulted who recommended continuing NAC and
close monitoring. Hepatology was consulted who recommended
admission to liver service for further evaluation and
management.
On the floor, he reports no other complaints.
Past Medical History:
? IVDU, chronic pain narcotic addiction
Typde 1 DM
Social History:
___
Family History:
Dad with crohn's disease
Physical Exam:
Admission PE:
VS : 97.9 137/91 97 98RA
GEN Alert, oriented, no acute distress
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no hsm
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions
Discharge PE:
Afebrile, BP 107/70 HR 70 RR 20 O2 98% RA
GEN: Alert & Ox3, in NAD
HEENT: PERRL, sclera icteric, OP clear
CV: RRR, no murmurs
PULM: CTAB, no wheezes, rales, ronchi
ABD: soft, NT, ND, normoactive bowel sounds
EXT: WWP, no ___ edema, R wrist wrapped with gauze
NEURO: motor function grossly normal, no asterixis
SKIN: jaundice, no ulcers or lesions
Pertinent Results:
Admission Labs:
___ 10:51PM K+-3.9
___ 09:42PM LACTATE-1.3
___ 09:20PM GLUCOSE-310* UREA N-21* CREAT-0.9 SODIUM-135
POTASSIUM-7.1* CHLORIDE-100 TOTAL CO2-25 ANION GAP-17
___ 09:20PM ALT(SGPT)-3337* AST(SGOT)-1770* ALK PHOS-272*
TOT BILI-4.3*
___ 09:20PM LIPASE-33
___ 09:20PM ALBUMIN-4.2
___ 09:20PM HBs Ab-POSITIVE HAV Ab-NEGATIVE
___ 09:20PM IgG-685*
___ 09:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 09:20PM WBC-9.0 RBC-5.28 HGB-15.4 HCT-46.2 MCV-87
MCH-29.2 MCHC-33.4 RDW-13.7
___ 09:20PM NEUTS-68.7 ___ MONOS-7.7 EOS-1.2
BASOS-0.7
___ 09:20PM PLT COUNT-296
___ 09:20PM ___ PTT-31.9 ___
RUQ U/S ___:
The pancreas is not visualized due to overlying bowel gas. The
liver demonstrates no focal lesion or intrahepatic biliary
dilatation. The portal vein is patent with directionally
appropriate flow. The CBD measures 4mm in caliber. The
gallbladder is decompressed. The patient exhibited no
sonographic ___ sign.
IMPRESSION: Patent portal vein.
RUQ U/S ___:
1. Doppler wave analysis shows patency of portal and hepatic
veins. No
evidence of hepatic vein thrombosis, as clinically questioned.
2. Left hepatic lobe hemangioma.
3. Borderline splenomegaly.
.
Pertinent results:
- ___ neg, HIV neg, anti-SM Ab neg, HAV Ab neg, HBsAb pos, HBcAb
neg, HBsAg neg, RPR neg
- HCV Ab positive
- HCV viral load: 20,321,454 IU/mL.
- CMV serologies negative
- HSV 1 IGG TYPE SPECIFIC AB >5.00 H index
- HSV 2 IGG TYPE SPECIFIC AB <0.90 index
- HIV VL undetectable
- HCV GENOTYPE, ___: 1a
- HAV IgM: neg
Liver biopsy ___
DIAGNOSIS: Liver, needle core biopsy:
1. Acute hepatitis with marked lobular regeneration, apoptoses,
and diffuse inflammatory infiltrate of the lobules that includes
lymphocytes, rare neutrophils, and Kupffer cells, with focal
hepatocytic dropout.
2. Frequent apoptotic hepatocytes but no zones of necrosis are
seen.
3. Mild portal mixed inflammation including lymphocytes,
occasional neutrophils, eosinophils, and plasma cells with
associated bile duct proliferation.
4. Trichrome shows increased portal fibrosis and foci of
sinusoidal fibrosis.
5. Iron shows no stainable iron.
Note: The findings in this biopsy are mainly that of an acute
hepatitis with mild portal mixed inflammation and moderate
lobular regeneration, frequent apoptotic hepatocytes, and foci
of hepatocellular dropout. Differential diagnosis includes
acute phase of viral hepatitis, drug induced injury, and less
likely, autoimmune hepatitis.
Discharge Labs:
___ 04:04PM BLOOD WBC-7.1 RBC-5.07 Hgb-14.9 Hct-45.7 MCV-90
MCH-29.4 MCHC-32.6 RDW-15.1 Plt ___
___ 09:15AM BLOOD ___
___ 04:04PM BLOOD Glucose-236* UreaN-15 Creat-0.4* Na-137
K-4.1 Cl-101 HCO3-25 AnGap-15
___ 09:15AM BLOOD ALT-3712* AST-2259* AlkPhos-231*
TotBili-17.2*
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Fentanyl Patch 75 mcg/h TP Q72H - called PCP to confirm that
should actually by 50mcg
2. Glargine 30 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Fentanyl Patch 50 mcg/h TP Q72H
2. Glargine 42 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Acute hepatitis
Hepatitis C
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ male status post Tylenol ingestion, now question of
liver failure.
STUDY: RIGHT UPPER QUADRANT ULTRASOUND.
COMPARISON: None.
FINDINGS: The pancreas is not visualized due to overlying bowel gas. The
liver demonstrates no focal lesion or intrahepatic biliary dilatation. The
portal vein is patent with directionally appropriate flow. The CBD measures 4
mm in caliber. The gallbladder is decompressed. The patient exhibited no
sonographic ___ sign.
IMPRESSION: Patent portal vein.
Radiology Report
PROCEDURE: Complete abdominal ultrasound.
INDICATION: ___ man with acute hepatitis, rule out hepatic vein
thrombosis.
COMPARISON: Liver/gallbladder ultrasound from ___.
TECHNIQUE: Sonographic Grayscale and Doppler images were obtained of the
abdomen.
FINDINGS: The liver demonstrates a normal contour. An echogenic area is noted
within the left hepatic lobe measuring 1.3 x 1.2 x 1.2 cm and represents a
hemangioma.
Color flow and Doppler waveform analysis was performed as requested. Main
portal vein is hepatopetal and patent. Left and right portal vein branches are
also patent and demonstrate full wall-to-wall blood flow. The left, middle
and right hepatic veins are patent. The main hepatic artery waveform is
normal.
No intrahepatic or extrahepatic biliary ductal dilatation is noted. The
common bile duct measures 0.43 cm. The gallbladder is identified without
cholelithiasis, gallbladder wall thickening, or pericholecystic fluid.
Visualized portions of the midline structures appear normal. Pancreatic head
and body are visualized. Pancreatic tail is obscured by overlying bowel gas;
however, no evidence of pancreatic ductal dilatation is noted. The visualized
portions of the aorta from the proximal region to the bifurcation are normal.
The spleen measures 13.4 cm, representing borderline splenomegaly.
The right kidney measures 12.3 cm in craniocaudal dimension. The left kidney
measures 12.2 cm in craniocaudal dimension. No evidence of hydronephrosis,
nephrolithiasis, or obvious mass in either kidney.
Both lower quadrants demonstrate no evidence of ascites.
IMPRESSION:
1. Doppler wave analysis shows patency of portal and hepatic veins. No
evidence of hepatic vein thrombosis, as clinically questioned.
2. Left hepatic lobe hemangioma.
3. Borderline splenomegaly.
Radiology Report
HISTORY: ___ man who is status post right hand surgery. Evaluation
for healing.
TECHNIQUE: Three views of the right hand.
COMPARISON: None available.
FINDINGS:
Two K-wires extend across a mildly displaced, volar angulated distal right
fifth metacarpal fracture. No prior studies available for comparison.
Remaining imaged osseous structures are intact and normal in appearance.
Right carpus is intact. Distal right radius and ulna are intact.
IMPRESSION:
Status post open reduction internal fixation of a minimally displaced, volar
angulated distal right fifth metacarpal fracture.
Radiology Report
PROCEDURE: Non-targeted liver biopsy.
CLINICAL INDICATION: ___ man with acute hepatitis secondary to
hepatitis C with climbing t-bili/LFTs.
PHYSICIANS: Dr. ___ Dr. ___.
Dr. ___ was present and supervising for the entire procedure.
MEDICATIONS: 150 mcg fentanyl IV, 2 mg Versed IV, 7 mL lidocaine
subcutaneous.
Moderate sedation was provided by administering divided doses of fentanyl and
Versed throughout the total intra-service time of 10 minutes during which the
patient's hemodynamic parameters were continuously monitored.
TECHNIQUE/FINDINGS: Informed consent was obtained. The patient was placed
supine on the ultrasound bed. Initial scanning was carried out and a spot
over the right lobe of the liver was marked. A final timeout was performed
using two patient identifiers and confirming the location to be the right lobe
of the liver. The skin over the planned tract was prepped and draped in
sterile fashion and anesthetized using 1% lidocaine. Ultrasound guidance and
using a 16-gauge core Monopty biopsy device, a single non-targeted biopsy was
obtained from the right liver. The needle was removed. The patient tolerated
the procedure well and was transferred to the Radiology Care Unit for
post-procedural monitoring.
COMPLICATIONS: None.
IMPRESSION: Successful core liver biopsy, non-targeted. No complications.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: LIVER FAILURE
Diagnosed with POIS-AROM ANALGESICS NEC, ACUTE & SUBACUTE NECROSIS OF LIVER, ACC POISON-AROM ANALGESC
temperature: 98.2
heartrate: 116.0
resprate: 18.0
o2sat: 98.0
sbp: 128.0
dbp: 82.0
level of pain: 10
level of acuity: 2.0 | ___ year old male with h/o narcotic dependence who presented to
OSH and noted to have severe transaminitis with elevated T.Bili
in setting of reported chronic supratherapeutic tylenol
ingestion.
# Acute hepatitis: Most likely related to hepatitis C infection.
Thought initially to be due to supratherapeutic tylenol
ingestion though acetaminophen level neg on serum tox and
history very questionable; NAC discontinued after approx 36hrs
when HCV serology returned positive. Given unclear time course
for hepatitis C infection and already positive HCV Ab, low
likelihood that this represents acute hepatitis C, but no clear
immunocompromised state to trigger acute hepatitis. HCV viral
load very high at 20million. Pt not encephalpathic. No acidosis
on ABG. No evidence of ___. INR stable. T bili uptrended to 20,
transaminases remained stable initially with uptrend to high
3000 - 4000s. RUQ U/S unremarkable and without signs of
cirrhosis, portal vein thrombosis or hepatic vein thrombosis. Pt
went for liver biopsy ___ which showed findings c/w acute
hepatitis. Pt's bili and transaminases started to downtrend.
# Multiple psychiatric issues: Patient reportedly pursuing
dual-diagnosis bed for anxiety on presentation to OSH ED.
Reported h/o anxiety, narcotic dependence, ?IVDU. Pt with
inconsistent behavior and interaction with staff. Fluctuating
history and stories provided. Affect odd and threatening to
leave AMA on multiple occasions. Poor insight into current
situation. SW and Psych consulted. Started mirtazapine per psych
recs with mild improvement and uptitrated to 15 QHS. Mirtazapine
discontinued in setting of continued uptrend in LFTs. Pt
continued to have odd behaviors and some difficult interactions
with staff, including situations re: pain control and his
fentanyl patch. Pt persistently denied h/o of drug use and
reported he had no idea how he could have gotten HCV.
# T1DM: bld glucose running high in 300s. Intensified HSSI and
went up on lantus (home dose of 30u QHS).
# Recent traumatic injury to R hand requiring surgery with pin
placement. In setting of prolonged hospitalization, R hand xray
done and spoke with hand surgery, who did not want to intervene
because of uncertainty regarding surgery done at OSH. Spoke with
OSH hand surgeon who recommended continuing dressings and close
f/u at discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Adhesive
Attending: ___.
Chief Complaint:
___
Major Surgical or Invasive Procedure:
Left foot bedside debridement ___
History of Present Illness:
Mr ___ is a ___ yo man with PMH significant for Alzheimer's
dementia, afib on aspirin, HTN, HLD, DM who presents from an OSH
with IPH. The patient was sitting on the toilet straining to
have
a bowel movement. She he tried to stand he tell backwards, Tried
again and fell to the left. When his family came in to help
there
were unable to get him up because his "legs just wouldn't hold
him". He was taken to an OSH where a R IPH was found on CT and
the patient was sent here.
The patient recently developed a diabetic foot ulcer on the
bottom of his left foot. he was told to keep his weight off of
it
and spent about 2 weeks in bed. thereafter he was very
deconditioned and started to fall. spent about 6 weeks in rehab
with some improvement until now.
The patient's daughter (who is at the bedside and providing most
of this information) reports that the patient's BP has been
running higher than usual lately.
He passed a swallow evaluation at the OSH and ate dinner without
incident.
On neuro ROS: the pt denies headache, loss of vision, blurred
vision, diplopia, oscilopsia, dysarthria, dysphagia,
lightheadedness, vertigo, tinnitus or hearing difficulty. Denies
difficulties comprehending speech. No bowel or bladder
incontinence or retention.
On general ROS: the pt denies recent fever or chills. No night
sweats or recent weight loss (he has had intentional weight loss
of 40lbs) or gain. Denies cough, shortness of breath. Denies
chest pain or tightness, palpitations. Denies nausea, vomiting,
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria. Denies arthralgias or
myalgias. Denies rash.
Past Medical History:
Alzheimer's dementia
afib on asa
squamous cell cancer of the lung (s/p R upper lobectomy)
type 1 DM
chronic back pain
Prior R CEA
chronic renal insufficiency
cholecystectomy
HTN
obesity
hyperlipidemia
Social History:
___
Family History:
non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
T: 97.5 HR: 70 BP: 118/68 RR: 18 Sat:96% on RA
GENERAL MEDICAL EXAMINATION:
General appearance: alert, in no apparent distress, obese
HEENT: Sclera are non-injected. Mucous membranes are moist.
CV: Heart rate is regular with rare premature beats
Lungs: breathing comfortably on RA
Abdomen: soft, non-tender, no organomegaly
Extremities: deep ulcer on dorsom of L foot
Skin: Warm and well perfused.
NEUROLOGICAL EXAMINATION:
Mental Status: Alert and oriented to person place and ___. unable to relate details of his history. Language is
fluent and appropriate with intact comprehension, repetition and
naming of both high frequency objects (trouble with low
frequency
objects). Normal prosody. There were no paraphasic errors.
Speech
was dysarthric, both edentulous and guttural dysarthria. Able to
follow both midline and appendicular commands. No neglect,
left/right confusion or finger agnosia.
Cranial Nerves:
I: not tested
II: visual fields full to confrontation
III-IV-VI: pupils equally round, reactive to light. Normal
conjugated, extra-ocular eye movements in all directions of
gaze.
No nystagmus or diplopia.
V: Symmetric perception of LT in V1-3
VII: left NLF attenuation. symmetric with activation
VIII: Hearing intact to finger rub bl
IX-X: Palate elevates symmetrically
XI: Shoulder shrug and head rotation ___ bl
XII: No tongue deviation or fasciculations
Motor: Normal muscle bulk and tone throughout. Left pronator
drift. action and postural tremor R>L.
Strength:
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 4- 5 4+ 4 5 4- 4-
R 5 ___ ___ 5 5 5 4+ 5 5 5
Reflexes:
Bi Tri ___ Pat Ach
L 2 2 2 1 0
R 2 2 2 1 0
Toes are down going bilaterally.
Sensory: decreased sensation to pin in the right arm and left
leg.
Coordination: ataxic with finger to nose on the left.
Gait: could not test
===================================================
DISCHARGE PHYSICAL EXAM:
T98.7 BP 122-151/48-88 HR 65-103 RR ___ O2 sat: 94 RA
Alert, interactive, speech fluent, no dysarthria
Left corner of the mouth slightly lower than right, symmetric
activation of smile
Motor: Deltoid ___ on left, ___ right. Bi/Tri/ECR ___
bilaterally. IP 4+/5 on left. ___ on right.
Right sided action tremor. No pronator drift.
Pertinent Results:
ADMISSION LABS:
___ 01:08PM BLOOD WBC-5.1 RBC-4.12* Hgb-11.9* Hct-37.9*#
MCV-92 MCH-28.9 MCHC-31.4* RDW-15.7* RDWSD-52.1* Plt ___
___ 01:08PM BLOOD ___ PTT-29.2 ___
___ 01:08PM BLOOD Glucose-194* UreaN-29* Creat-1.2 Na-137
K-4.1 Cl-101 HCO3-26 AnGap-14
___ 01:08PM BLOOD ALT-12 AST-14 AlkPhos-64 TotBili-1.2
___ 01:08PM BLOOD cTropnT-<0.01
___ 01:08PM BLOOD Albumin-3.3* Calcium-8.7 Phos-3.2 Mg-2.0
Cholest-99
___ 01:08PM BLOOD %HbA1c-7.0* eAG-154*
___ 01:08PM BLOOD Triglyc-133 HDL-33 CHOL/HD-3.0 LDLcalc-39
LDLmeas-54
___ 01:08PM BLOOD TSH-0.25*
___ 09:05PM BLOOD T3-77* Free T4-1.3
IMAGING:
CXR ___:
As compared to the previous radiograph, low lung volumes
persist. Borderline size of the cardiac silhouette. No
pulmonary edema. No pleural effusions. No pneumonia.
CT HEAD ___:
1. Re-demonstrated small hyperdensity in the right thalamus with
surrounding edema appears stable compared to prior imaging in
___. While this may be an intraparenchymal hematoma,
the possibility of an occult vascular malformation cannot be
excluded.
2. Prominent ventricles and sulci, likely representing
involutional changes, as well as evidence of chronic ischemic
small vessel changes.
3. There is no evidence of new bleed or infarct.
CT HEAD ___:
1. Redemonstrated intraparenchymal hemorrhage in the right
thalamus appears stable compared to previous imaging from ___ with similar amount of surrounding edema.
2. No new hemorrhages or infarcts.
DISCHARGE LABS:
NONE
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO DAILY
2. QUEtiapine Fumarate 25 mg PO QHS
3. PredniSONE 2 mg PO DAILY
4. Simvastatin 20 mg PO QPM
5. Aspirin 81 mg PO DAILY
6. Donepezil 10 mg PO QHS
7. Furosemide 40 mg PO DAILY
8. Cyanocobalamin 1000 mcg PO DAILY
9. Levothyroxine Sodium 125 mcg PO DAILY
10. Lantus 20 Units Breakfast
11. Bisacodyl 10 mg PO DAILY:PRN constipation
12. Vitamin D 400 UNIT PO DAILY
Discharge Medications:
1. Donepezil 10 mg PO QHS
2. Furosemide 40 mg PO DAILY
3. Lantus 20 Units Breakfast
4. Levothyroxine Sodium 125 mcg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. PredniSONE 2 mg PO DAILY
7. Amlodipine 2.5 mg PO DAILY
8. Bisacodyl 10 mg PO DAILY:PRN constipation
9. Cyanocobalamin 1000 mcg PO DAILY
10. QUEtiapine Fumarate 25 mg PO QHS
11. Simvastatin 20 mg PO QPM
12. Vitamin D 400 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Primary diagnosis:
Right intra-parenchymal hemorrhage
Secondary diagnosis:
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: CHEST (PORTABLE AP)
INDICATION: ___ year old man with IPH // r/o infection
COMPARISON: ___.
IMPRESSION:
As compared to the previous radiograph, low lung volumes persist. Borderline
size of the cardiac silhouette. No pulmonary edema. No pleural effusions.
No pneumonia.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man with IPH.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: This study involved 3 CT acquisition phases with dose indices as
follows: 1) CT Localizer Radiograph 2) CT Localizer Radiograph 3) Sequenced
Acquisition 6.4 s, 17.1 cm; CTDIvol = 52.5 mGy (Head) DLP = 897.1 mGy-cm.
Total DLP (Head) = 897 mGy-cm.
COMPARISON: Comparison is made with prior CT Head without contrast from
___.
FINDINGS:
Re- demonstrated is the small hyperdensity in the right thalamus extending
into the right cerebral peduncle and laterally into the posterior limb of the
internal capsule. There is surrounding edema, which appears to be slightly
increased in comparison to prior imaging from ___. This lesion may
be an intraparenchymal hematoma but a possible occult vascular malformation
cannot be excluded. There is no evidence of new bleed or infarct.
There is prominence of the ventricles and sulci suggestive involutional
changes. Periventricular hypodensities are visualized bilaterally, likely
representing a sequela of chronic ischemic small vessel 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. Re-demonstrated small hyperdensity in the right thalamus with surrounding
edema appears stable compared to prior imaging in ___. While this may
be an intraparenchymal hematoma, the possibility of an occult vascular
malformation cannot be excluded.
2. Prominent ventricles and sulci, likely representing involutional changes,
as well as evidence of chronic ischemic small vessel changes.
3. There is no evidence of new bleed or infarct.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old man with R IPH // eval for change in bleed size
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: This study involved 3 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 4.8 s, 16.2 cm; CTDIvol = 52.4 mGy (Head) DLP =
848.0 mGy-cm.
Total DLP (Head) = 848 mGy-cm.
COMPARISON: Comparison is made with prior head CT from ___.
FINDINGS:
Redemonstrated small intraparenchymal hemorrhage appears stable compared to
previous imaging from ___ with similar amount of surrounding edema.
There is no evidence of midline shift or mass effect. There are no new
hemorrhages or infarcts.
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. Redemonstrated intraparenchymal hemorrhage in the right thalamus appears
stable compared to previous imaging from ___ with similar amount of
surrounding edema.
2. No new hemorrhages or infarcts.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ICH, Transfer
Diagnosed with INTRACEREBRAL HEMORRHAGE, SINOATRIAL NODE DYSFUNCT
temperature: 97.5
heartrate: 70.0
resprate: 18.0
o2sat: 100.0
sbp: 118.0
dbp: 68.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ yo man with PMH significant for Alzheimer's
dementia, afib on aspirin, HLD, DM who presents from an OSH with
right IPH likely secondary to hypertension.
# Right intra-parenchymal hemorrhage: The etiology of the bleed
is likely hypertensive in the setting of the Valsalva manuever.
His exam is notable for mild left nasolabial fold flattening,
bilateral upper extremity intention tremors and clumsiness on
finger tapping. His blood pressures were closely monitored and
he was initiated on amlodipine 2.5mg daily. Aspirin, heparin and
nsaids were held. He had a follow-up CT after 24 hours which
showed a stable size of the bleed. He will restart aspirin in
___ days after the bleed.
# Atrial fibrillation: Per PCP, the patient is on aspirin alone
due to patient and family's choice to avoid INR checks. He is
not a novel anti-coagulant due to the prohibitive costs of these
agents. He remained in atrial fibrillation on telemetry.
# Left foot ulceration: Patient has had a chronic wound followed
by an outside wound clinic for a few months. He was evaluated by
the wound nurse who recommended podiatry consult for possible
debridement. Podiatry performed a bedside debridement and felt
the wound was clean without evidence of infection. They
recommended daily dressing changes with hydrogel and follow-up
with his outpatient wound center.
# Alzheimer's dementia: Patient was continued on Donepezil 10 mg
PO/NG QHS.
# Diabetes mellitus: Patient was continued on lantus 20 qam and
SSI. HbA1C was 7.
# Hyperlipidemia: Patient is not currently on treatment. His
lipid panel included LDL 54 HDL 33 triglycerides 133.
# Hypothyroidism: Patient continued on Levothyroxine Sodium 112
mcg PO/NG DAILY.
# CKD: Basline of 1.4. His Cr ranged around 1.4 while inpatient.
# OSA not on CPAP: Patient uses O2 at home nightly.
# Gout: Patient is on a prednisone taper.
Transitional issues:
- titrate up amlodipine as needed
- monitor left foot wound for signs of infection
- recheck thyroid studies as outpatient
- restart aspirin on ___
- HCP: ___ ___ daughter
- code status: confirmed FULL |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
metformin / HCTZ
Attending: ___
Chief Complaint:
LT facial palsy
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a ___ yo am with medical history of HTN and DM who
was transferred from an OSH for brain MRI and neurology
evaluation of LT facial weakness.
He reports was in his usual state of health until several months
ago when he started noticing intermittent blurry vision and
later
noted double vision when tilting his head to the LT. In the
beginning this was intermittent but he seems to think the blurry
vision is worse over the last couple of weeks, while the double
vision is occasional.
Yesterday he was watching a football game and felt unwell with
bifrontal dull achy headache and pain behind his eye. He noted
his LT eye was tearing. When he arrived home last night he woke
up his wife and told her he didn't feel well and thought he
needed to go to the hospital. She turned on the light and saw
his
LT face was droopy, she also noted his speech was slurred. She
was concerned for a stroke told him she would take him. However,
he wanted to try and "sleep it off". This morning when he woke
up
and brushed his teeth he noticed that his LT face felt "funny"
and he was having trouble with rinsing and swishing as he could
not keep the water from spilling from the left side of his mouth
but denies any issues with swallowing. He also thought his eye
looked swollen in the mirror. He then decided to go to the
hospital.
He makes note that he had the flu shot 2 weeks ago and has never
had it before. He also notes lives in a wooded area and recently
was outside cooking in the yard. They also have a dog but he has
not noted any tick bites. He does report always has skin
breakdown in his legs due to his diabetes.
On neurologic review of systems, he notes RT leg numbness which
is chronic. Otherwise, the patient denies lightheadedness, or
confusion. Denies difficulty with comprehending speech. Denies
vertigo, tinnitus, hearing difficulty, or dysphagia. Denies
focal
muscle weakness. 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,
palpitations, dyspnea, or cough. Denies nausea, 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:
DM
HTN
Herniated disc lower back
Social History:
___
Family History:
Sister: developmental delay
Father died at ___ with HTN, DM
Mother: died at ___ in her sleep unknown cause.
Physical Exam:
Vitals:
98.1
99
159/89
18
99% RA
General: NAD
HEENT: +hordeolum medial upper eyelid,NCAT, no oropharyngeal
lesions, neck supple
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
Awake, alert, oriented x 3. Able to relate history without
difficulty. Attentive, able to name ___ backward without
difficulty. Speech is dysarthric, worse with labial sounds.
Intact repetition, and intact verbal comprehension. Naming
intact. No dysarthria. Normal prosody. Able to register 3
objects
and recall ___ at 5 minutes. No evidence of hemineglect. No
left-right confusion. Able to follow both midline and
appendicular commands.
Cranial Nerves: PERRL 3->2 brisk. VF full red pin. EOMI, no
nystagmus. Unable to assess CN IV as patient finds holding head
rotated to the left intolerable because of the diplopia. V1-V3
without deficits to light touch or temperature
bilaterally. Prominent LT facial droop with hordeolum on LT
upper
eyelid. Hearing intact to finger rub bilaterally. Palate
elevation symmetric. SCM/Trapezius strength ___ bilaterally.
Tongue midline.
Motor: Normal bulk and tone. No drift. No tremor or asterixis.
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: distal sensory loss concerning for diabetic neuropathy.
No exinction to DSS.
DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response flexor bilaterally.
Coordination: No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating
movements.
Gait: Normal initiation. Narrow base. Normal stride length and
arm swing. Stable without sway. Negative Romberg.
Pertinent Results:
___ 05:10AM BLOOD WBC-5.1 RBC-4.32* Hgb-8.6* Hct-30.3*
MCV-70* MCH-19.9* MCHC-28.4* RDW-17.5* RDWSD-44.1 Plt ___
___ 04:03PM BLOOD Neuts-57.8 ___ Monos-12.7
Eos-7.7* Baso-1.1* Im ___ AbsNeut-3.22 AbsLymp-1.13*
AbsMono-0.71 AbsEos-0.43 AbsBaso-0.06
___ 05:10AM BLOOD Plt ___
___ 04:03PM BLOOD ___ PTT-28.6 ___
___ 05:10AM BLOOD Glucose-125* UreaN-9 Creat-0.7 Na-136
K-3.7 Cl-102 HCO3-24 AnGap-14
___ 05:10AM BLOOD ALT-79* AST-69* LD(LDH)-155 AlkPhos-80
TotBili-0.4
___ 04:03PM BLOOD cTropnT-<0.01
___ 04:03PM BLOOD Calcium-8.8 Phos-2.8 Mg-1.9 Cholest-139
___ 04:03PM BLOOD %HbA1c-8.3* eAG-192*
___ 04:03PM BLOOD Triglyc-124 HDL-35 CHOL/HD-4.0 LDLcalc-79
___ 05:10AM BLOOD TSH-1.9
___ 04:03PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 06:37PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-POS* amphetm-NEG oxycodn-NEG mthdone-NEG
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Glargine 72 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
2. Ibuprofen 800 mg PO Q8H:PRN Pain - Moderate
3. amLODIPine 5 mg PO DAILY
4. Viagra (sildenafil) 50 mg oral DAILY:PRN
5. Lisinopril 40 mg PO DAILY
Discharge Medications:
1. Artificial Tear Ointment 1 Appl LEFT EYE PRN dryness
2. PredniSONE 60 mg PO DAILY Duration: 5 Doses
This is dose # 1 of 6 tapered doses
3. PredniSONE 50 mg PO DAILY Duration: 1 Dose
This is dose # 2 of 6 tapered doses
4. PredniSONE 40 mg PO DAILY Duration: 1 Dose
This is dose # 3 of 6 tapered doses
5. PredniSONE 30 mg PO DAILY Duration: 1 Dose
This is dose # 4 of 6 tapered doses
6. PredniSONE 20 mg PO DAILY Duration: 1 Dose
This is dose # 5 of 6 tapered doses
7. PredniSONE 10 mg PO DAILY Duration: 1 Dose
This is dose # 6 of 6 tapered doses
8. Glargine 72 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
9. amLODIPine 5 mg PO DAILY
10. Ibuprofen 800 mg PO Q8H:PRN Pain - Moderate
11. Lisinopril 40 mg PO DAILY
12. Viagra (sildenafil) 50 mg oral DAILY:PRN
Discharge Disposition:
Home
Discharge Diagnosis:
Bell's palsy; ___ nerve palsy
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 T9113 MR HEAD
INDICATION: ___ man presenting with left facial paralysis. 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 Noncontrast head CT dated ___
FINDINGS:
There is no evidence of acute infarction, edema, mass effect, blood products.
The ventricles and sulci are normal in size. The cranial nerves are not
assessed in detail on this exam. Principal intracranial vascular flow voids
are preserved. There is moderate mucosal thickening in bilateral ethmoid air
cells, and mild mucosal thickening in the maxillary, frontal, and sphenoid
sinuses.
IMPRESSION:
1. No acute infarction and no evidence of other intracranial abnormalities.
2. Paranasal sinus disease.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with SOB // r/o PNA r/o PNA
IMPRESSION:
No previous images. Low lung volumes accentuates the prominence of the
transverse diameter of the heart. Mild tortuosity of the aorta. No evidence
of acute pneumonia, vascular congestion, or pleural effusion.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old man with LT bells palsy and subacute intermittent
visual symptoms // Please assess for underlying structural abnormality
TECHNIQUE: Axial FLAIR imaging was performed followed by axial diffusion and
T1 technique. 3 dimensional high-resolution T2 weighted imaging was performed.
After administration of 10 mL of Gadavist intravenous contrast,
high-resolution axial and coronal T1 weighted imaging were performed along
with sagittal MPRAGE images. The MPRAGE images were reformatted in axial and
coronal orientations.
COMPARISON: ___ noncontrast brain MRI
FINDINGS:
There is asymmetric enhancement of the seventh cranial nerve on the left, most
pronounced in the labyrinthine segment, geniculate ganglion and proximal
tympanic segment. Eighth cranial nerve complexes are symmetric. There is no
evidence of abnormal enhancement or mass lesion within the internal auditory
canals, cerebellopontine angles or membranous labyrinth. No other mass lesions
are seen within the posterior fossa.
Limited included imaging of the remainder of the brain demonstrates no
evidence of hemorrhage, edema, masses, mass effect, midline shift or
infarction. The ventricles and sulci are normal in caliber and configuration.
There are a few scattered intraparotid nodes bilaterally, measuring up to 6
mm. No mass lesions are identified within the imaged portions of the upper
parotid glands.
No osseous abnormalities are seen. There is mild mucosal thickening of the
right frontal sinus and bilateral ethmoid air cells. The mastoid air cells
and middle ear cavities are clear. The orbits are unremarkable. The
visualized portion of the principle vascular flow voids are preserved.
Evaluation of the soft tissues reveals a scalp defect along the left vertex
(series 1101, image 84), likely scarring.
IMPRESSION:
1. Asymmetric left facial nerve enhancement, consistent with known Bell's
palsy.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: L Facial droop, Transfer
Diagnosed with Facial weakness
temperature: 98.1
heartrate: 99.0
resprate: 18.0
o2sat: 99.0
sbp: 159.0
dbp: 89.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ was admitted for further evaluation of diplopia and
facial palsy. Diplopia thought to be secondary to chronic CN IV
palsy upon further history of and physical exam. MRI brain with
and without contrast demonstrated Bell's palsy. He was started
on a 5 day course of oral prednisone 60 mg with taper. Notable
labs were +urine cocaine and HbA1C 8.3%. HTN remains an issue
with BP ranging 145-154/65-73. He was otherwise stable
throughout this hospitalization. He was noted to have a
microcytic anemia for which anemia labs were sent and are
pending. He also had a mild elevation of his transaminases,
which he should follow up as an outpatient. He will be
discharged with neurology follow up and a prednisone taper. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ woman with HCV (genotype 1) and EtOH cirrohsis c/b ascites,
HE, and portal hypertensive gastropathy, with EtOH abuse and
current use, and depression on multiple psychiatric medications
with history of psych admissions and hx of SI, presenting with
AMS.
Her daughter, whom the patient lives with, noticed that her
mother was more confused yesterday, seeming more sleepy and
drowsy, and also noticed the patient could barely stand on her
own, which was new, and along with her AMS, this prompted her
daughter to send the patient to the hospital. She also had N/V,
which has been ongoing for many months, at least with an episode
of vomiting about every ___ days. Daughter believes this is from
her alcohol use lately, but patient would refuse lactulose from
daughter because she thought the lactulose made her nauseous. Of
note, per daughter has been vomiting up the lactulose recently.
Daughter also noted that her mother was recently prescribed
300mg Seroquel, in addition to the 150 qHS and 50 qAM that the
patient is already on, that was filled on ___, and had 5
pills missing yesterday. Also recently prescribed Welbutrin that
was filled ___ for a month, and was empty yesterday. Per
daughter, does not note her mother more depressed than usual nor
did patient mention any suicidal thoughts, daughter thinks her
mother is addicted to her prescription medications.
The patient was complaining of of some abdominal pain on arrival
to the ED. Says she had not taken lactulose today.
In the ED initial vitals were: 98.5 113 139/77 16 98% RA
- Labs were significant for INR 1.8, tox notable for postive
Tricyc, platelets 61, WBC 2.3.
- Patient was given lactulose 30mL x2 and zofran x1 while in the
ED.
- Toxicoloy and hepatology were consulted. Hepatology recomended
lactulose and infectious ___. Toxicology recomended EKG,
seizure precautions, benzodiazapines for worsening tachycardia,
agitation, or hyperthermia, with avoidance of antipsychotics,
and holding home psychiatric medications.
Vitals prior to transfer were: 98.4, 105, 181/99, 18, 99% RA
On the floor, the patient is somulant but arousable. She admits
to taking welbutrin twice a day because she thought that was
what they told her, but in reality she was only supposed to take
it once a day. She reports that she has not been taking her
lactulose all the time. Per patient she last had a drink 1.5
days ago (daughter said day of presentation, ___, it was a
nip. She reports that she has been drinking at least 1 nip a
day.
Past Medical History:
- Chronic HCV and Alcoholic Cirrhosis (genotype 1): complicated
by ascites, encephalopathy, portal hypertensive gastropathy
- Hx of ETOH abuse
- Major depressive disorder: multiple psychiatric
hospitalizations and prior suicide attempts
- Rheumatoid arthritis
- Type II Diabetes Mellitus
- Prolapsed uterus s/p pessary
- Rectocele/cystocele
- Lateral epicondylitis
Social History:
___
Family History:
Mother passed away from ETOH cirrhosis.
Father had lung ca with liver mets.
Daughter with depression.
Physical Exam:
ADMISSION PHYSICAL EXAM:
===================
Vitals - T:98.9 BP:190/106 HR:67 RR:16 02 sat:98%RA
GENERAL: Laying in bed, drowsy but arousable
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM
NECK: nontender supple neck, no LAD
CARDIAC: Tachycardic, S1/S2, no murmurs
LUNG: CTAB, no w/rh/r, breathing comfortably without use of
accessory muscles
ABDOMEN:mildly distended, +BS, tender to palpation in the
epigastic region. no r/g
EXTREMITIES: moving all extremities. No ___ edema
NEURO: Difficult to assess due to patient inattention. No gross
focal defecits
SKIN: warm and well perfused
DISCHARGE PHYSICAL EXAM:
===================
Vitals - Tm 98.5 Tc 98.2 HR 101 (___) BP 141/61
(___) RR 20 (___) O2sat 100%RA (___)
GENERAL: Lying in bed, alert and interactive, though tearful
throughout interview.
HEENT: AT/NC, EOMI, pupils round and reactive to light,
anicteric sclera, dry mm. Some tremor of her facial muscles
NECK: nontender supple neck, no LAD appreciated
CARDIAC: S1/S2, tachycardic, soft ___ systolic murmur in USBs
LUNG: CTAB, no w/rh/r, moderate air movement, breathing
comfortably without use of accessory muscles; poor inspiratory
effort/cooperation with exam, difficult to auscultate movement
in the bases
ABDOMEN: obese, +BS, nontender throughout, soft. no
rebound/guarding. No appreciable fluid wave.
EXTREMITIES: moving all extremities. No ___ edema, 2+ peripheral
pulses
NEURO: A&O to name, ___, aware it is ___
___. Some mild asterixis bilaterally, low frequency. Sensation
to light touch grossly intact in all extremities. Positional
tremor with hold arms up, mild low frequency, as well as resting
tremors
SKIN: warm and well perfused, no lesions noted.
PSYCH: Emotionally labile as has been last few days.
Pertinent Results:
ADMISSION LABS:
============
___ 01:10AM BLOOD ___
___ Plt ___
___ 01:10AM BLOOD ___
___
___ 03:57AM BLOOD ___ ___
___ 01:10AM BLOOD ___
___
___ 01:10AM BLOOD ___
___ 01:10AM BLOOD ___
___ 01:10AM BLOOD ___
___ 01:10AM BLOOD ___
___
___ 01:10AM URINE ___ Sp ___
___ 01:10AM URINE ___
___
___ 01:10AM URINE ___ WBC-<1 ___
___
___ 01:10AM URINE ___
___
DISCHARGE LABS:
============
___ 09:26AM BLOOD ___
___ Plt ___
___ 09:26AM BLOOD ___ ___
___ 09:26AM BLOOD ___
___
___ 09:26AM BLOOD ___ LD(LDH)-272* ___
___
___ 09:26AM BLOOD ___
MICRO:
============
___ URINE CULTURES: Mixed bacterial flora
___ BLOOD CULTURES (x4): no growth
___ VRE SWAB: VRE positive
___ URINE CULTURES: Mixed bacterial flora
REPORTS:
============
CT Abd/Pelvis ___:
1. Cirrhotic liver with portal hypertension. The portal vein
is patent.
2. Mild body wall and mesenteric edema may reflect fluid
status.
CT Head ___:
No acute intracranial hemorrhage or mass effect.
Correlate clinically for further workup/followup.
CXR ___: Cardiac size is normal. Bibasilar atelectasis are
unchanged. There are low lung volumes. There is no pneumothorax
or pleural effusion.
PENDING RESULTS:
============
None
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 4 mg PO BID:PRN nausea
2. Lactulose 60 mL PO TID
3. Prochlorperazine 5 mg PO Q8H:PRN nausea
4. HydrOXYzine 50 mg PO DAILY anxiety
5. Polyethylene Glycol 17 g PO BID
6. Spironolactone 25 mg PO DAILY
7. pramipexole 0.125 mg oral QHS
8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
9. Omeprazole 20 mg PO BID
10. Rifaximin 550 mg PO BID
11. TraZODone 100 mg PO HS
12. Nortriptyline 25 mg PO DAILY
13. QUEtiapine ___ 300 mg PO QHS
14. BuPROPion (Sustained Release) 150 mg PO DAILY
Discharge Medications:
1. Omeprazole 20 mg PO BID
2. Polyethylene Glycol 17 g PO BID
3. Rifaximin 550 mg PO BID
4. Spironolactone 25 mg PO DAILY
5. Ondansetron 4 mg PO BID:PRN nausea
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
7. FoLIC Acid 1 mg PO DAILY
This is a new medication to help treat the negative effects of
your alcohol use.
8. Multivitamins 1 TAB PO DAILY
This is a new medication to help treat the negative effects of
your alcohol use.
9. Thiamine 100 mg PO DAILY
This is a new medication to help treat the negative effects of
your alcohol use.
10. BuPROPion (Sustained Release) 150 mg PO DAILY
RX *bupropion HCl 150 mg 1 tablet(s) by mouth Once daily Disp
#*14 Tablet Refills:*0
11. Lactulose 60 mL PO TID
RX *lactulose 20 gram/30 mL 60 mL by mouth three times a day
Refills:*0
12. TraZODone 100 mg PO HS
RX *trazodone 150 mg 1 tablet(s) by mouth Once at night before
bedtime Disp #*14 Tablet Refills:*0
13. Cyanocobalamin 50 mcg PO DAILY
This is a new medication to treat the negative effects of
alcohol use, as a supplement.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Hepatic encephalopathy
Alcohol withdrawal
Polypharmacy
Secondary Diagnoses:
Alcohol abuse
HCV/EtOH cirrhosis
Anxiety
Major depressive disorder
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: History: ___ with altered mental status // acute process?
cirrhosis
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed.
DOSE: DLP: The 935 mGy-cm
CTDI: 53 mGy
COMPARISON: CT head ___
FINDINGS:
There is no acute intracranial hemorrhage, major acute infarction, mass effect
or shift of midline structures. There is no hydrocephalus. Visualized
paranasal sinuses and mastoid air cells are clear. Sphenoid sinus septation
inserts on right carotid groove.
There is no suspicious osseous lesion or fracture.
IMPRESSION:
No acute intracranial hemorrhage or mass effect.
Correlate clinically for further workup/followup.
Radiology Report
INDICATION: NO_PO contrast; History: ___ with cirrhosis, RUQ pain, LLQ
painNO_PO contrast // diverticulitis? biliary disease?
TECHNIQUE: Contiguous helical MDCT images were obtained through the abdomen
and pelvis after administration of 130 cc of Omnipaque IV contrast.
Multiplanar axial, coronal and sagittal images were generated.
DOSE: Total body DLP: 832 mGy-cm
COMPARISON: CT abdomen and pelvis ___
FINDINGS:
LOWER CHEST: Similar to the prior study there is platelike atelectasis at the
lung bases. 14 the heart is not enlarged and there is no pericardial effusion.
CT ABDOMEN WITH CONTRAST:
HEPATOBILIARY: The liver is shrunken and nodular. There is no intrahepatic
biliary duct dilation. The umbilical vein is recanalized. The portal vein is
patent. The gallbladder is absent. There is stable dilation of the CBD to 9
mm.
PANCREAS: The pancreas has normal attenuation without focal lesions, duct
dilation or peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation without focal lesions.
ADRENALS: Mild thickening of the left adrenal gland without nodularity. The
right adrenal gland is normal.
URINARY: The kidneys excrete contrast promptly and symmetrically without
hydronephrosis. Subcentimeter hypodense foci in the right kidney are too small
to characterize but are unchanged and are most likely simple cysts. The
ureters are normal throughout their visualized course.
GASTROINTESTINAL: The stomach, small and large bowel are normal in caliber
without wall thickening or obstruction. The appendix is gas-filled and
normal.
RETROPERITONEUM: There is no mesenteric or retroperitoneal lymphadenopathy.
VASCULAR: The abdominal aorta and iliac arteries are normal in caliber.
There is mild mesenteric edema and generalized body wall edema. There is no
free air or free fluid.
CT PELVIS WITH CONTRAST: The urinary bladder and rectum are normal. There is
no pelvic wall or inguinal lymphadenopathy and no free fluid. The uterus is
unremarkable.
BONES AND SOFT TISSUES: There are no worrisome blastic or lytic lesions. The
abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Cirrhotic liver with portal hypertension. The portal vein is patent.
2. Mild body wall and mesenteric edema may reflect fluid status.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with hepatic encephalopathy, vomiting. Concern
for aspiration. // Evaluate for infection
TECHNIQUE: Single frontal view of the chest
COMPARISON: CT abdomen performed the same day earlier in the morning.
IMPRESSION:
Cardiac size is normal. Bibasilar atelectasis are unchanged. There are low
lung volumes. . There is no pneumothorax or pleural effusion.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Altered mental status
Diagnosed with ALTERED MENTAL STATUS , CIRRHOSIS OF LIVER NOS, LONG TERM USE OTHER MED
temperature: 98.5
heartrate: 113.0
resprate: 16.0
o2sat: 98.0
sbp: 139.0
dbp: 77.0
level of pain: 0
level of acuity: 2.0 | ___ woman with HCV (genotype 1) and EtOH cirrohsis c/b ascites,
HE, and portal hypertensive gastropathy, with EtOH abuse and
current use, and depression on multiple psychiatric medications
with history of psych admissions and hx of SI, presenting with
AMS in the setting of likely medication overdose, alcohol use,
and decreased lactulose. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Worsening shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
Denies is a ___ yo woman with history of obesity and chronic COPD
who was just recently discharged 5 days prior from an admission
for COPD exacerbation who now represents to the ED with
worsening shortness of breath.
She indicates that following her discharge she was slowly
improving, she was more functional, walking around with O2 tank
and nasal cannula and continuing the steroids, however the day
of presentation she developed worsening shortness of breath and
non-productive cough which was not improving with nebulizer
treatments. She reports feeling unable to get a breath but
denies frank chest pain or pressure, no sputum production, no
fevers or chills. The only new symptom on this presentation was
cough which she reports was not present previously. She called
EMS as the symptoms continued to deteriorate and they found her
tachypneic to 35 with O2 sats of 82% on supplemental O2, she was
started on CPAP in the field and transferred to the ED.
In the ED, initial vitals were: 99.1 113 ___ 29 94% bipap.
While in the ED they were unable to wean from BiPAP and an ICU
bed was requested. With frequent nebulizer treatments eventually
she was weaned off BiPAP to 6L NC and bed switched from ICU to
floor. Her labs were notable for a leukocytosis and VBG with
respiratory acidosis.
On the floor, she continues to feel dyspneic, having trouble
completing full sentences. When walking to bathroom from her bed
her oxygen saturations dropped to 64% for which she was put on
6L NC and brought back to bed but it took 4 minutes to recover
back to >90% on ___ NC.
Past Medical History:
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
CHRONIC HYPOXIC RESPIRATORY FAILURE ON HOME O2
MORBID OBESITY
___ ESOPHAGUS
TRAUMA SURVIVOR
DEPRESSION
HISTORY OF SI
OSA on CPAP
SPINAL STENOSIS
Social History:
___
Family History:
HTN diffusely in family
Physical Exam:
PHYSICAL EXAM:
Vitals:97.5 PO 121 / 82 R Sitting 87 20 93 4L Nc Pain Scale:
___
General: awake, alert, breathing comfortably, able to speak in
full sentences
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, thick neck, no LAD appreciated
Lungs: decreased air movement throughout, diminished at bases,
no wheeze or rhonchi
CV: Regular rate and rhythm, S1 and S2 clear and of good
quality, no murmurs, rubs or gallops appreciated
Abdomen: Obese but soft, non-tender, non-distended, normoactive
bowel sounds throughout, no rebound or guarding
Ext: Warm, well perfused, full distal pulses, no clubbing,
cyanosis or edema
Neuro: CN2-12 grossly in tact, motor and sensory function
grossly intact in bilateral UE and ___, symmetric
Psych: calm mood, appropriate affect
Pertinent Results:
Admission Labs:
___ 02:25PM BLOOD WBC-14.8*# RBC-4.74 Hgb-12.9 Hct-42.5
MCV-90 MCH-27.2 MCHC-30.4* RDW-14.7 RDWSD-48.2* Plt ___
___ 02:25PM BLOOD Neuts-86.2* Lymphs-5.8* Monos-5.5
Eos-0.0* Baso-0.5 Im ___ AbsNeut-12.81*# AbsLymp-0.86*
AbsMono-0.81* AbsEos-0.00* AbsBaso-0.07
___ 02:25PM BLOOD Glucose-141* UreaN-22* Creat-0.8 Na-137
K-4.1 Cl-97 HCO3-22 AnGap-22*
___ 02:25PM BLOOD proBNP-320*
___ 02:25PM BLOOD cTropnT-<0.01
___ 02:25PM BLOOD Calcium-10.4* Phos-4.2 Mg-1.7
___ 02:48PM BLOOD ___ Temp-36.7 pO2-73* pCO2-52*
pH-7.33* calTCO2-29 Base XS-0
Imaging:
CXR: No acute cardiopulmonary abnormality.
CTPA: No evidence of pulmonary embolism or aortic abnormality.
Pulmonary nodules measure up to 1.7 cm in the right lower lobe,
stable at least through ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ClonazePAM 1 mg PO TID:PRN anxiety
2. Docusate Sodium 200 mg PO DAILY
3. Doxepin HCl 325 mg PO HS
4. Fexofenadine 180 mg PO QAM
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
7. Gabapentin 1200 mg PO QHS
8. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild
9. Ipratropium-Albuterol Neb 1 NEB NEB TID shortness of breath
10. Levothyroxine Sodium 25 mcg PO DAILY
11. Montelukast 10 mg PO DAILY
12. Oxybutynin 5 mg PO QHS
13. Pantoprazole 40 mg PO Q12H
14. Polyethylene Glycol 34 g PO DAILY
15. Ranitidine 300 mg PO QHS
16. RisperiDONE 6 mg PO QAM
17. Senna 17.2 mg PO QHS
18. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN dyspnea/wheezing
19. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
20. Ascorbic Acid ___ mg PO DAILY
21. Fish Oil (Omega 3) 1000 mg PO TID
22. Lactulose 15 mL PO Q8H:PRN constipation
23. Vitamin D ___ UNIT PO DAILY
24. Tiotropium Bromide 1 CAP IH DAILY
25. Multivitamins 1 TAB PO DAILY
26. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN wheezing
27. Fluticasone Propionate NASAL 2 SPRY NU BID
28. Ketoconazole 2% 1 Appl TP BID:PRN rash
Discharge Medications:
1. Doxepin HCl 325 mg PO HS
2. PredniSONE 50 mg PO DAILY
Taper by 10 mg every four days over 20 days
Tapered dose - DOWN
3. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN dyspnea/wheezing
4. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
5. Ascorbic Acid ___ mg PO DAILY
6. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3)
600 mg(1,500mg) -200 unit oral BID
7. ClonazePAM 1 mg PO TID:PRN anxiety
8. Docusate Sodium 200 mg PO DAILY
9. Fexofenadine 180 mg PO QAM
10. Fish Oil (Omega 3) 1000 mg PO TID
11. Fluticasone Propionate 110mcg 2 PUFF IH BID
12. Fluticasone Propionate NASAL 2 SPRY NU BID
13. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
14. Gabapentin 1200 mg PO QHS
15. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild
16. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN wheezing
17. Ipratropium-Albuterol Neb 1 NEB NEB TID shortness of breath
18. Ketoconazole 2% 1 Appl TP BID:PRN rash
19. Lactulose 15 mL PO Q8H:PRN constipation
20. Levothyroxine Sodium 25 mcg PO DAILY
21. Montelukast 10 mg PO DAILY
22. Multivitamins 1 TAB PO DAILY
23. Oxybutynin 5 mg PO QHS
24. Pantoprazole 40 mg PO Q12H
25. Polyethylene Glycol 34 g PO DAILY
26. Ranitidine 300 mg PO QHS
27. RisperiDONE 6 mg PO QAM
28. Senna 17.2 mg PO QHS
29. Tiotropium Bromide 1 CAP IH DAILY
30. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
acute COPD exacerbation
obstructive sleep apnea
acute on chronic hypoxic respiratory failure
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 (PORTABLE AP)
INDICATION: History: ___ with dyspnea, COPD, change in sputum// Edema,
infiltrate, effusion
TECHNIQUE: Single AP radiograph of the chest.
COMPARISON: Chest radiograph dated ___.
FINDINGS:
No focal consolidations to suggest pneumonia. No pulmonary edema. Stable
appearance of the cardiomediastinal silhouette. No pleural effusion. No
pneumothorax. Multiple healed rib fractures on the right.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
INDICATION: ___ year old woman with severe COPD and hypoxia not improving on
treatment.// Assess for PE (or other comorbid lung condition to explain
hypoxia)
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 7.0 s, 37.2 cm; CTDIvol = 21.5 mGy (Body) DLP = 807.3
mGy-cm.
Total DLP (Body) = 807 mGy-cm.
COMPARISON: CTA chest dated ___.
FINDINGS:
Patient is status post left hemithyroidectomy. No nodule within the right
thyroid gland is present which warrants further evaluation. There is no
axillary or supraclavicular adenopathy. Scattered central nodes are present
measuring up to 7 mm in short axis (03:43) located at the right upper
paratracheal station. This appears to have been present on examination dated
___, unchanged. There is no hilar adenopathy.
The ascending aorta is non aneurysmal. The main pulmonary artery is within
normal limits in caliber. The pulmonary arteries are opacified to the
subsegmental level without a filling defect to suggest pulmonary embolism.
Heart size is within normal limits. Coronary artery calcifications involve
predominantly the left anterior descending coronary artery. There is no
pericardial effusion.
Centrilobular emphysema is upper lobe predominant. Scarring or subsegmental
atelectasis involves the right middle lobe and lingula. Airways are patent to
the subsegmental level. Minimal secretions layer within the left mainstem
bronchus.
A right lower lobe 1.7 cm nodule (4:184) is stable. A 4 mm nodule within the
right lower lobe inferiorly (4:218) is unchanged. A 3 mm nodule previously
present in the left upper lobe anteriorly is no longer present. A small
calcified granuloma is present in the left lower lobe.
Although examination is not tailored for subdiaphragmatic evaluation, images
of the upper abdomen demonstrate no appreciable abnormality.
Multiple healed bilateral rib fractures are noted.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Pulmonary nodules measure up to 1.7 cm in the right lower lobe, stable at
least through ___. No new or growing pulmonary nodule.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with Chronic obstructive pulmonary disease w (acute) exacerbation
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: c
level of acuity: 1.0 | ___ w/ obesity, OSA on CPAP, and COPD (on home O2) readmitted
for COPD exacerbation.
# Acute COPD exacerbation
# Acute on chronic hypoxic respiratory failure
# Morbid obesity, potentially with component of obesity
hypoventilation syndrome
# OSA on home CPAP
Recurrent symptoms following completion of antibiotics and
steroids. She had worsening symptoms, increased sputum
production and increased O2 requirement all consistent with COPD
exacerbation. She reported rhinorrhea and dry cough, so an upper
respiratory virus was suspected as the inciting factor. CTPA
ruled out intercurrent acute pulmonary pathologies such as PE or
pneumonia. We attempted to manage her conservatively by simply
restarting PO steroids and giving frequent nebs, but she
decompensated further and was started on IV Solumedrol 125 mg
TID for two days. She was also restarted on doxycycline BID and
completed a seven day course. Her nocturnal CPAP was continued
and she was given increased nasal cannula oxygen as needed. The
patient was concerned that her breathing was too poor to allow
her to return home to her relatively independent living
situation. She elected to be discharged to pulmonary rehab. Her
O2 requirements steadily declined to 4L/min via NC, only
slightly up from her baseline of 3L/min. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril / Amoxicillin
Attending: ___.
Chief Complaint:
Abdominal pain and nausea
Major Surgical or Invasive Procedure:
___ Flexible sigmoidoscoy with decompression of sigmoid
volvulus
History of Present Illness:
Pt is a ___ with PMHx significant for AFib on coumadin, CAD s/p
CABG and recent stent to the LAD on plavix, who presents as a
transfer from OSH for abdominal pain and distention. Patient
reports 2 days of worsening abdominal pain, diffuse in nature.
Patient thought it was secondary to something he ate. Over the
two days he did not pass flatus or have bowel movements. He did
have some nausea but no emesis, also no fevers reported. Given
the worsening nature of pain which reached to ___ patient
presented to ___. At ___, his abdomen was noted to
be very distended. CT A/P there showed a severely dilated
sigmoid volvulus, and transfer to ___ was recommended by
surgery team there. Before transfer, patient received Dilaudid
1mg IV x2, zofran 4mg IV, Flagyl 500mg IVPB, Cipro 400mg IVPB.
In the ED initial vitals were: 97.7 56 130/78 16 99% 2L. Initial
labs showed a WBC 14.9, INR 3.5, lactate of 3.7. GI and surgery
were both consulted. GI placed a rectal tube for decompression
with clinical resolution. Surgery agreed no intervention at this
time given successful rectal tube decompression, but will follow
along. Post-compression KUB showed partial decompression of the
volvulus.
On the floor, patient states his pain has totally resolved s/p
decompression. He is asking for a sleeping pill. No other
complaints
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
HTN
HLD
CAD s/p stent to LAD in ___ and s/p CABG in ___
s/p hip surgery
Atrial fibrillation on warfarin
Gout
BCC (basal cell carcinoma)
Lumbar spinal stenosis
OA (osteoarthritis)
Gynecomastia
Chronic kidney disease, stage III (moderate)
Social History:
___
Family History:
Mother w/ unknown cancer (but does not think there is a fam hx
of GI malignancies)
Physical Exam:
Physical exam on admission:
Vitals - T: 97.8 139/71 66 20 98% RA
GENERAL: NAD
HEENT: AT/NC,
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: 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: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Physical exam at discharge
Vitals - 98.6 97.4 100-120s/60-80s 40-60s 16 >93% RA, No BM
GENERAL: NAD, well appearing, walked comfortably to the bathroom
and back to bed with no discomfort
HEENT: AT/NC, sclera anicteric, dry mucous membrane, no lesions
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: Irregularly irregular rhythm w/ bradycardia, S1/S2, no
murmurs, gallops, or rubs, occasional dropped beat
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Protruding abdomen (baseline), firm, increased tympany,
hyperactive BS, nontender in all quadrants, no rebound/guarding,
no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
Labs on admission
___ 03:53PM LACTATE-2.0
___ 08:38AM %HbA1c-6.2* eAG-131*
___ 08:01AM ___ COMMENTS-GREEN TOP
___ 08:01AM LACTATE-3.1*
___ 08:00AM GLUCOSE-97 UREA N-20 CREAT-1.1 SODIUM-136
POTASSIUM-3.5 CHLORIDE-96 TOTAL CO2-29 ANION GAP-15
___ 08:00AM CALCIUM-9.3 PHOSPHATE-3.7 MAGNESIUM-2.1
___ 08:00AM WBC-13.0* RBC-3.96* HGB-12.4* HCT-39.7*
MCV-100* MCH-31.4 MCHC-31.3 RDW-13.1
___ 08:00AM PLT COUNT-177
___ 08:00AM ___ PTT-32.4 ___
___ 10:52PM COMMENTS-GREEN TOP
___ 10:45PM GLUCOSE-219* UREA N-21* CREAT-1.2 SODIUM-134
POTASSIUM-3.4 CHLORIDE-93* TOTAL CO2-23 ANION GAP-21*
___ 10:45PM GLUCOSE-219* UREA N-21* CREAT-1.2 SODIUM-134
POTASSIUM-3.4 CHLORIDE-93* TOTAL CO2-23 ANION GAP-21*
___ 10:45PM estGFR-Using this
___ 10:45PM cTropnT-<0.01
___ 10:45PM WBC-14.9* RBC-4.59* HGB-14.5 HCT-46.3
MCV-101* MCH-31.6 MCHC-31.4 RDW-12.9
___ 10:45PM NEUTS-85.0* LYMPHS-9.6* MONOS-4.9 EOS-0.3
BASOS-0.1
___ 10:45PM PLT COUNT-214
___ 10:45PM ___ PTT-40.7* ___
Labs at discharge
___ 07:30AM BLOOD WBC-10.0 RBC-4.11* Hgb-13.0* Hct-41.6
MCV-101* MCH-31.7 MCHC-31.3 RDW-13.2 Plt ___
___ 07:30AM BLOOD Plt ___
___ 07:30AM BLOOD ___
___ 07:30AM BLOOD
___ 07:30AM BLOOD Glucose-91 UreaN-20 Creat-1.1 Na-142
K-3.5 Cl-103 HCO3-30 AnGap-13
___ 03:53PM BLOOD Lactate-2.0
ECG ___
Atrial fibrillation with slow ventricular response. Wandering
baseline and
baseline artifact. Q-T interval prolongation. Left ventricular
hypertrophy.
Compared to the previous tracing of ___ atrial fibrillation
has appeared.
The Q-T interval has prolonged. The rate has slowed. Otherwise,
no diagnostic
interim change.
Images
CT Abdomen/Pelvis: C/w sigmoid volvulus per ED reports.
Sigmoidoscopy ___
Impression: The endoscope was inserted and traversed across an
area of twisting at the sigmoid colon starting at ~15cm. The
colon proximal to this appeared dilated and mildly congested.
This was decompressed fully. A colonic decompression tube was
then placed over a wire. The wire was removed and the
decompression tube was left in place.
Otherwise normal sigmoidoscopy to descending colon
KUB ___ (after decompression):
IMPRESSION:
1. Interval placement of rectal tube with decompression of the
sigmoid
volvulus.
2. Left base atelectasis.
Echo ___
The left atrium is normal in size. No spontaneous echo contrast
or thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. Overall left ventricular systolic function is normal
(LVEF>55%). There are simple atheroma in the aortic arch and
descending thoracic aorta. The aortic valve leaflets (3) appear
mildly thickened. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild to moderate (___)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. There is no pericardial effusion.
ENDOSCOPY ___
Indications:Sigmoid volvulus
Procedure:The procedure, indications, preparation and potential
complications were explained to the patient, who indicated his
understanding and signed the corresponding consent forms. A
physical exam was performed. The patient was administered
moderate sedation. Supplemental oxygen was used. The patient was
placed in the left lateral decubitus position and the
colonoscope was introduced through the rectum and advanced under
direct visualization until the descending colon was reached. The
colonoscope was retroflexed within the rectum. Careful
visualization was performed as the instrument was withdrawn. The
procedure was not difficult. The quality of the preparation was
good. The patient tolerated the procedure well. There were no
complications.
Findings:
OtherThe endoscope was inserted and traversed across an area of
twisting at the sigmoid colon starting at ~15cm. The colon
proximal to this appeared dilated and mildly congested. This was
decompressed fully. A colonic decompression tube was then placed
over a wire. The wire was removed and the decompression tube was
left in place.
Impression:The endoscope was inserted and traversed across an
area of twisting at the sigmoid colon starting at ~15cm. The
colon proximal to this appeared dilated and mildly congested.
This was decompressed fully. A colonic decompression tube was
then placed over a wire. The wire was removed and the
decompression tube was left in place.
Otherwise normal sigmoidoscopy to descending colon
Recommendations:Check KUB
Colonic decompression tube to gravity
Follow up surgery recs
Additional notes:
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 2 mg PO 5X/WEEK (___)
2. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO BID
5. Atorvastatin 40 mg PO DAILY
6. TraZODone 50 mg PO HS:PRN insomnia
7. Digoxin 0.125 mg PO DAILY
8. Amlodipine 5 mg PO DAILY
9. Aspirin 81 mg PO DAILY
10. Omeprazole 20 mg PO BID
11. Lorazepam 0.5 mg PO BID:PRN Anxiety
12. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
13. FoLIC Acid 1 mg PO DAILY
14. Vitamin D 1000 UNIT PO DAILY
15. Ascorbic Acid ___ mg PO DAILY
16. Magnesium Oxide 500 mg PO DAILY
17. melatonin 5 mg oral 1-2/day PRN Insomnia
18. Cyanocobalamin 3000 mcg PO DAILY
19. Docusate Sodium 100 mg PO DAILY:PRN Constipation
20. Multivitamins 1 TAB PO DAILY
21. Ferrous Sulfate 325 mg PO DAILY
22. Warfarin 1 mg PO 1X/WEEK (FR)
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Digoxin 0.125 mg PO DAILY
6. Docusate Sodium 100 mg PO DAILY:PRN Constipation
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Omeprazole 20 mg PO BID
9. TraZODone 50 mg PO HS:PRN insomnia
10. Acetaminophen 325-650 mg PO Q6H:PRN Pain, fever
11. Ascorbic Acid ___ mg PO DAILY
12. Cyanocobalamin 3000 mcg PO DAILY
13. Ferrous Sulfate 325 mg PO DAILY
14. FoLIC Acid 1 mg PO DAILY
15. Lorazepam 0.5 mg PO BID:PRN Anxiety
16. Magnesium Oxide 500 mg PO DAILY
17. melatonin 5 mg oral 1-2/day PRN Insomnia
18. Multivitamins 1 TAB PO DAILY
19. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
20. Vitamin D 1000 UNIT PO DAILY
21. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
22. Warfarin 1 mg PO 1X/WEEK (FR)
23. Warfarin 2 mg PO 5X/WEEK (___)
Discharge Disposition:
Home
Discharge Diagnosis:
Primary disgnosis
Sigmoid volvulus
Secondary diagnosis
Atrial fibrillation
Dizziness
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with + sigmoid vulvulus on CT s/p rectal tube placement //
Eval for rectal tube placement and resolution of volvulus
TECHNIQUE: 4 total views of the abdomen.
COMPARISON: CT abdomen pelvis ___.
FINDINGS:
There is no pneumoperitoneum. There has interval placement of a rectal tube
whose tip terminates in the left upper quadrant near the midline. The
volvulized loop of sigmoid colon has undergone interval decompression.
Contrast is seen opacifying the bladder. The patient is status post CABG.
Opacification of the left lung base likely reflects atelectasis, as better
seen on the recent CT abdomen pelvis. Note is made of bilateral total hip
arthroplasties.
IMPRESSION:
1. Interval placement of rectal tube with decompression of the sigmoid
volvulus.
2. Left base atelectasis.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain
Diagnosed with VOLVULUS OF INTESTINE
temperature: 97.7
heartrate: 56.0
resprate: 16.0
o2sat: 99.0
sbp: 130.0
dbp: 78.0
level of pain: 0
level of acuity: 2.0 | Pt is a ___ y/o M with PMHx of HTN, AFib on coumadin, CAD s/p
stent to LAD in ___ who presents with sigmoid volvulus s/p flex
sig decompression with partial resolution of volvulus and
complete clinical resolution of symptoms
ACTIVE MEDICAL ISSUES
#Sigmoid Volvulus: He underwent decompression by flexible
sigmoidoscopy in the ED on ___ with colonic decompression tube
placed. General surgery consulted but no plan for surgery at
this time given complete resolution of symptoms and successful
decompression. Post-decompression KUB with partial decompression
so rectal tube left in place for ~24hours. Elevated lactate on
admission at 3.7 improved throughout course w/o any signs of
ischemia. Rectal tube d/c'ed on HD#2 prior to discharge with no
complications. Tolerating regular diet prior to discharge. Per
surgery team, if he has recurrence, options would be either
sigmoid resection and 1' anastomosis or primary resection and
end colostomy as desired according to the patient's ability to
control defecation and avoid impaction (done by very minimal
lap-assisted approach and is very safe even in an elderly, or
debilitated patient). However, ideally would be done on a
non-emergent basis after ___ when patient no longer on
clopidogrel. We discussed this with him; he will follow up with
Dr. ___.
# AFib on warfarin. Initially given FFP for potential surgical
intervention, but once clinically appropriate we continued home
warfarin. Given recent elevated INR, he will get labs checked
___ to be faxed to ___ clinic. This was
confirmed with ___ and patient. We also continued digoxin 125
mcg daily. We decreased his metoprolol succinate XL frequency to
50mg once daily ___ bradycardia.
# Coagulopathy: INR on admission was 3.5, received 3 units FFP
in the ED given possibility for surgical intervention. INR of
2.5 on day of discharge. See above.
#Bradycardia: Pt bradycardic to ___ on HD#1 and 52 on day of
discharge. Report feeling dizzy. Orthostatics reassuring. We
decreased home dose metoprolol to 50mg XL daily from BID. He
will check his pulses at home.
- Pt to follow-up with PCP for further management
# Pre-diabetes, hyperglycemia: Pt had glu of 219 on admission.
Repeat glu of 91 on day of discharge. A1C 6.2 on admission
making the diagnosis of pre-diabetes. Possibly may have
hyperglycemia in the setting of acute inflammation secondary to
his volvulus.
- Educated on healthy diet and behavioral changes
#CAD s/p stent and CABG: continued ASA, plavix, and statin.
Decreased metoprolol XL as above.
#HTN: held triamterine-HCTZ initially, restarted on discharge,
continued amlodipine, decreased metoprolol as above.
#GERD: continued home omeprazole BID
TRANSITIONAL ISSUES
===================
- Code status: Full code, confirmed.
- Studies pending on discharge: None.
- Emergency contact: ___ ___ or cell
___.
- Regarding volvulus, plan for conservative management for now;
patient will follow up with Dr. ___ in ___ once
clopidogrel is able to be discontinued.
- Pre-diabetes: Patient noted to have random glucose >200, Hba1c
6.2. Discussed with patient.
- Decreased metoprolol XL to 50mg daily from 50mg BID given
bradycardia while inpatient. Patient will monitor own pulse
rates; please f/u.
- Patient will have INR checked on ___, will be f/u by
___ clinic, and will be discharged on home
regimen. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Flagyl / Ertapenem / ciprofloxacin
Attending: ___
Chief Complaint:
Fall, R eye droop
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
Ms. ___ is an ___ with PMH of diverticulitis c/b multiple
abscesses, s/p colonoscopy c/b perforation c/b rectovaginal
fistula, recurrent C diff infection on PO vanc daily, permanent
AF on apixaban, carcinoid tumor and chronic diarrhea, h/o breast
cancer s/p lumpectomy, iron deficiency anemia who presents with
fall and weakness.
Patient reports poor sleep over the last 3 days for reasons
unclear to her. Her PCP prescribed mirtazapine, which patient
had
not yet started for symptomatic relief. She was walking to the
bathroom today, had an episode of diarrhea - she reports 2 loose
bowel movements. When she got up from the toilet, she fell to
the
ground, striking the L side of her head on vanity. She reports
feeling generally weak, but denied preceding chest pain,
palpitations, dyspnea, dizziness, change in vision. She denies
numbness/tingling. She did not lose consciousness. Ambulance was
called and she was brought to ___ ED for further evaluation.
In the ED, initial VS were: 97.9 84 119/70 18 97% RA
- Exam notable for: 0.5cm abrasion to occipital region on L
- Labs showed: WBC 23.6, INR 1.5, Hgb 9.6
- Imaging showed: CXR w/no focal consolidation, persistent
severe
compression of lower thoracic vertebral body, CT Head with no
acute process.
- Patient received: 500cc IVF
While in the ED, patient noted to develop dysarthria, facial
droop and decreased mentation with word finding difficulties.
Code Stroked was called. NCHCT negative for acute hemorrhage. On
neuro review, suspected low probability of TIA - though patient
with significant vascular risk factors. Patient already on
optimal treatment for secondary stroke prevention, so no further
medication recommendations. Though this may be more related to
systemic condition. CTA head and neck without vessel occlusion
or
cut-off, mild calcification in anterior circulation and narrowed
vertebral artery. Symptoms spontaneously improved.
Past Medical History:
(per chart, confirmed with pt):
Atrial Fibrillation, previously on Coumadin, now on eliquis
Diverticulitis c/b abscesses (___)
Hx bowel perforation during colonoscopy
Paraesophageal hernia s/p repair
Breast cancer s/p lumpectomy and radiation therapy, axillary
nodes were dissected and negative (___)
Hiatal hernia repair ___, ___
Left Hip Fracture s/p Left Hemiarthroplast c/b Hematoma
Social History:
___
Family History:
(per chart, confirmed with pt): Mother with gastric cancer,
father passed from old age. Brother suffered from liver cancer.
Another brother had ALS. Daughters with breast cancer and
stomach cancer, thyroid ca, melanoma.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 97.7 129/59 86 20 97 RA
GENERAL: NAD
HEENT: MMM
NECK: no JVD
HEART: RRR, nl S1 S2, II/VI systolic murmur RUS
LUNGS: CTAB, no wheezes, rales, rhonchi
ABDOMEN: soft, NT, ND, NABS
EXTREMITIES: no edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, normal strength and sensation, ?mild facial droop
on R
SKIN: WWP, no rash
Discharge physical exam:
PHYSICAL EXAM:
VITALS:
24 HR Data (last updated ___ @ 1129)
Temp: 97.7 (Tm 97.9), BP: 165/70 ___ manual), HR:
79 (57-91), RR: 18 (___), O2 sat: 97% (97-100), O2 delivery:
RA
General: Elderly woman with R sided facial droop, in no acute
distress.
HEENT: Normocephalic, atraumatic. Pupils are equal, round, and
reactive to light and accommodation constricting from 3.0 mm to
2.5 mm bilaterally. EOMI in all cardinal directions of gaze
without nystagmus. Unable to close R eye fully. Vision is
grossly
intact and full to confrontation in all quadrants. Hearing
grossly intact. Nares patent with no nasal discharge. Oral
cavity
and pharynx are without inflammation, swelling, exudate, or
lesions. Noted facial asymmetry with flattening of R nasolabial
fold. Teeth and gingiva in good general condition.
Neck: Neck supple, non-tender without lymphadenopathy, masses or
thyromegaly.
Cardiac: Irregular rhythm. II/VI systolic murmur at RUSB. There
is trace peripheral edema, no cyanosis or pallor. Extremities
are
warm and well perfused.
Pulmonary: Clear to auscultation without rales, rhonchi,
wheezing
or diminished breath sounds.
Abdomen: Normoactive bowel sounds. Soft, nondistended,
nontender. No guarding or rebound. No masses.
Musculoskeletal: No joint erythema. Tenderness of left knee
joint. Pain along L lumbar/paraspinal musculature.
Skin: Skin type III. No gross lesions or eruptions.
Mental Status: Alert and oriented x3.
Cranial Nerves:
Visual Fields: Full to confrontation in all quadrants
bilaterally
Visual Acuity: Vision grossly intact
Fundi: Not assessed
Eye Movements: Intact to all cardinal directions of gaze without
nystagmus
V: Sensation to soft touch intact in all distributions. Muscles
of mastication intact.
VII: Facial expression is limited and asymmetric with R sided
facial droop and flattening of nasolabial fold.
VIII: Hearing intact to soft finger rub bilaterally
IX, X: Uvula is midline
XI: Shoulder shrug and strength in sternocleidomastoid intact
XII: Tongue protrudes to midline
Pertinent Results:
ADMISSION LABS:
___ 05:10PM ___ PTT-29.0 ___
___ 05:10PM PLT COUNT-396
___ 05:10PM HOS-AVAILABLE
___ 05:10PM NEUTS-93.4* LYMPHS-2.2* MONOS-2.9* EOS-0.2*
BASOS-0.3 IM ___ AbsNeut-22.02* AbsLymp-0.53* AbsMono-0.69
AbsEos-0.05 AbsBaso-0.08
___ 05:10PM WBC-23.6* RBC-3.32* HGB-9.6* HCT-31.6* MCV-95
MCH-28.9 MCHC-30.4* RDW-16.6* RDWSD-56.3*
___ 05:10PM CK-MB-2
___ 05:10PM CK(CPK)-46
___ 05:10PM estGFR-Using this
___ 05:10PM GLUCOSE-103* UREA N-22* CREAT-1.1 SODIUM-137
POTASSIUM-4.6 CHLORIDE-103 TOTAL CO2-22 ANION GAP-12
___ 05:36PM GLUCOSE-92 NA+-136 K+-3.9 CL--102 TCO2-25
___ 05:41PM estGFR-Using this
___ 05:41PM CREAT-1.0
DISCHARGE LABS:
___ 04:20AM BLOOD WBC-9.4 RBC-2.89* Hgb-8.4* Hct-27.4*
MCV-95 MCH-29.1 MCHC-30.7* RDW-17.2* RDWSD-59.9* Plt ___
___ 04:20AM BLOOD Glucose-103* UreaN-21* Creat-0.8 Na-140
K-4.4 Cl-105 HCO3-23 AnGap-12
___ 04:00AM BLOOD GQ1B IGG ANTIBODIES-PND
___ MRI BRAIN
IMPRESSION:
1. No evidence of acute infarct, mass or intracranial
hemorrhage.
2. Mild to moderate generalized cerebral atrophy and chronic
microvascular
ischemic changes.
3. No abnormal enhancing lesions.
4. The visualized cisternal segment of the cranial nerves
appear normal.
5. Narrowing of the V4 segment of the right vertebral artery is
again
visualized, however was better characterized on most recent CTA
head neck done
___
___ CTA HEAD
The intracranial arteries are patent without marked stenosis,
occlusion or
aneurysm formation.
Mild calcific atherosclerotic changes at the carotid bulbs
bilateral, but
there is no evidence of internal carotid stenosis by NASCET
criteria.
Dominant left vertebral artery. The vertebral arteries are
patent bilateral.
Mild moderate narrowing of the V4 segment of the right vertebral
artery.
Bronchial wall thickening with retained secretions and a couple
of
nonsuspicious millimetric nodules which are most likely
secondary to
infection/inflammation.
A couple of small thyroid nodules as described above.
RECOMMENDATION(S): Thyroid nodule. No follow up recommended.
Absent suspicious imaging features, unless there is additional
clinical
concern, ___ College of Radiology guidelines do not
recommend further
evaluation for incidental thyroid nodules less than 1.0 cm in
patients under
age ___ or less than 1.5 cm in patients age ___ or ___.
Suspicious findings include: Abnormal lymph nodes (those
displaying
enlargement, calcification, cystic components and/or increased
enhancement) or
invasion of local tissues by the thyroid nodule.
___, et al, "Managing Incidental Thyroid Nodules Detected on
Imaging: White
Paper of the ACR Incidental Findings Committee". J ___
___ ___
12:143-150.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Apixaban 2.5 mg PO BID
2. Atorvastatin 20 mg PO QPM
3. Cyanocobalamin 1000 mcg IM/SC QMONTHLY
4. Diltiazem Extended-Release 120 mg PO DAILY
5. Mirtazapine 7.5 mg PO QHS
6. Vancomycin Oral Liquid ___ mg PO DAILY
7. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
8. Vitamin D ___ UNIT PO DAILY
9. lactobacillus combination ___ billion cell oral DAILY
10. Lotemax (loteprednol etabonate) 0.5 % ophthalmic (eye) DAILY
11. Neomycin-Polymyxin-Dexameth Ophth. Oint 1 Appl BOTH EYES QHS
Discharge Medications:
1. Artificial Tear Ointment 1 Appl RIGHT EYE BID
2. Artificial Tears ___ DROP BOTH EYES QID:PRN eye dryness
3. Lidocaine 5% Patch 1 PTCH TD QAM
4. PredniSONE 20 mg PO DAILY
5. Ranitidine 150 mg PO BID
6. ValACYclovir 500 mg PO BID
continue up to and including ___. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
8. Apixaban 2.5 mg PO BID
9. Atorvastatin 20 mg PO QPM
10. Cyanocobalamin 1000 mcg IM/SC QMONTHLY
___. Diltiazem Extended-Release 120 mg PO DAILY
12. lactobacillus combination ___ billion cell oral DAILY
13. Lotemax (loteprednol etabonate) 0.5 % ophthalmic (eye)
DAILY
14. Neomycin-Polymyxin-Dexameth Ophth. Oint 1 Appl BOTH EYES
QHS
15. Vancomycin Oral Liquid ___ mg PO DAILY
16. Vitamin D ___ UNIT PO DAILY
17. HELD- Mirtazapine 7.5 mg PO QHS This medication was held.
Do not restart Mirtazapine until discussing w/your pcp
___:
Extended Care
Facility:
___
___ Diagnosis:
Bell's Palsy
S/p Fall
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with acute onset slurred speech// eval for ICH
TECHNIQUE: Noncontrast enhanced MDCT images of the head were obtained.
Reformatted coronal and sagittal images were also obtained.
DOSE Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.5 cm; CTDIvol = 48.8 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: ___
FINDINGS:
There is no evidence of acute intracranial hemorrhage, midline shift, mass
effect, or acute large vascular territorial infarct. Prominence of the
ventricles and sulci is consistent with involutional changes. Periventricular
and subcortical white matter hypodensities are likely sequelae of chronic
small vessel disease. The visualized paranasal sinuses show very minimal
mucosal thickening in the anterior right ethmoid air cells and in the right
sphenoid sinus.. The mastoid air cells are clear. No acute fracture is seen.
IMPRESSION:
No acute intracranial process. Chronic changes. MRI is more sensitive in
detecting acute ischemia.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: History: ___ with acute slurred speech// eval for stroke
TECHNIQUE: 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) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 19.9 mGy (Body) DLP =
10.0 mGy-cm.
2) Spiral Acquisition 4.8 s, 37.9 cm; CTDIvol = 15.2 mGy (Body) DLP = 576.5
mGy-cm.
Total DLP (Body) = 586 mGy-cm.
COMPARISON: Prior CT head done ___
FINDINGS:
CTA HEAD:
The vessels of the circle of ___ and their principal intracranial branches
are patent without marked stenosis, occlusion, or aneurysm formation. Mild
hypoplasia of the right A1 segment. Fetal type origin of the right PCA. The
dural venous sinuses are patent.
CTA NECK:
Moderate calcific atherosclerotic changes of the aortic arch and proximal
great vessels. Mild calcific atherosclerotic changes at the carotid bulbs
bilateral, but there is no evidence of internal carotid stenosis by NASCET
criteria. Dominant left vertebral artery. The vertebral arteries are patent
bilateral. Mild moderate narrowing of the V4 segment of right vertebral
artery.
OTHER:
Mild moderate biapical pleural-parenchymal scarring. Couple of 2 mm
nonsuspicious pulmonary nodules as well as bronchial wall thickening with
retained secretions are most likely infective/inflammatory in nature. Couple
of thyroid nodules, the largest measuring 11 mm in the right lobe of thyroid.
There is no lymphadenopathy by CT size criteria.
IMPRESSION:
The intracranial arteries are patent without marked stenosis, occlusion or
aneurysm formation.
Mild calcific atherosclerotic changes at the carotid bulbs bilateral, but
there is no evidence of internal carotid stenosis by NASCET criteria.
Dominant left vertebral artery. The vertebral arteries are patent bilateral.
Mild moderate narrowing of the V4 segment of the right vertebral artery.
Bronchial wall thickening with retained secretions and a couple of
nonsuspicious millimetric nodules which are most likely secondary to
infection/inflammation.
A couple of small thyroid nodules as described above.
RECOMMENDATION(S): Thyroid nodule. No follow up recommended.
Absent suspicious imaging features, unless there is additional clinical
concern, ___ College of Radiology guidelines do not recommend further
evaluation for incidental thyroid nodules less than 1.0 cm in patients under
age ___ or less than 1.5 cm in patients age ___ or older.
Suspicious findings include: Abnormal lymph nodes (those displaying
enlargement, calcification, cystic components and/or increased enhancement) or
invasion of local tissues by the thyroid nodule.
___, et al, "Managing Incidental Thyroid Nodules Detected on Imaging: White
Paper of the ACR Incidental Findings Committee". J ___ ___
12:143-150.
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with fall// eval for PNA
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
No focal consolidation is seen. There is no pleural effusion or pneumothorax.
Cardiac silhouette size is mildly enlarged. There is severe compression of a
lower thoracic vertebral body, as also seen on the prior study. Surgical
clips again overlie the left axillary region. The bones are diffusely
osteopenic, limiting assessment for subtle fracture.
IMPRESSION:
No focal consolidation. Persistent severe compression of a lower thoracic
vertebral body. Mild cardiomegaly.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD.
INDICATION: ___ year old woman with acute facial droop and dysarthria with
negative NCHCT// Eval for stroke*Please perform with thin cuts through
brainstem to assess for CN and/or leptomeningeal enhancement.
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: Prior CTA head neck done ___.
FINDINGS:
There is no evidence of hemorrhage, edema, masses, mass effect, midline shift
or acute infarction. Mild moderate generalized cerebral atrophy with ex vacuo
dilatation of the ventricular system. The ventricular system is symmetrical.
Pontine, periventricular and deep white matter T2 and FLAIR hyperintense
changes are nonspecific, but most likely sequela of chronic small vessel
disease. There is no abnormal enhancement after contrast administration. No
diffusion abnormalities are detected. The pituitary appears normal. The
craniocervical junction appears normal. The intracranial arteries demonstrate
normal T2 flow void signal. Narrowing of the V4 segment of the right
vertebral artery is again visualized, however was better characterized on most
recent CTA head neck. The orbits appear normal. Evidence of previous left
lens surgery. Minimal mucosal thickening involving the paranasal sinuses.
The middle ear cavities and mastoid air cells are clear.
IMPRESSION:
1. No evidence of acute infarct, mass or intracranial hemorrhage.
2. Mild to moderate generalized cerebral atrophy and chronic microvascular
ischemic changes.
3. No abnormal enhancing lesions.
4. The visualized cisternal segment of the cranial nerves appear normal.
5. Narrowing of the V4 segment of the right vertebral artery is again
visualized, however was better characterized on most recent CTA head neck done
___
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, Weakness
Diagnosed with Weakness
temperature: 97.9
heartrate: 84.0
resprate: 18.0
o2sat: 97.0
sbp: 119.0
dbp: 70.0
level of pain: 0
level of acuity: 2.0 | Patient Summary:
================
Ms. ___ is an ___ year old woman with PMH of diverticulitis
c/b
multiple abscesses, s/p colonoscopy c/b perforation c/b
rectovaginal fistula, recurrent C diff infection on PO vanc
daily, permanent AF on apixaban, carcinoid tumor and chronic
diarrhea, h/o breast cancer s/p lumpectomy, iron deficiency
anemia who presents with fall and weakness and found to have R
facial droop.
# Right sided VII cranial nerve palsy: MRI was obtained given
patient has multiple vascular risk factors pre-disposing to CVA;
however CTA head and neck and MRI brain did NOT show any
evidence of stroke. Neurology was consulted. Exam was more
consistent with peripheral level of involvement, consistent with
Bell's palsy (idiopathic). Also in ddx was lyme associated CN
VII palsy or less likely ___ variant of GBS. Given her
multiple comorbidities, after discussion w/family and PCP, it
was decided to start a lower dose of prednisone (20 mg dialy)
with plans for a 7 day course (___). She was also started on
valacyclovir 500 mg PO BID. Started on artificial tear ointment
BID, white petrolatum ointment at night, and eye patch or eye
taping at night.
# S/P FALL
# GENERALIZED WEAKNESS
Patient with fall in the setting of generalized weakness.
Unclear
if this represents true syncope, as patient without LOC. ___
have represented vagal episode, given recent preceding bowel
movement,
though patient without other prodromal symptoms. Low suspicion
for cardiac etiology and cardiac enzymes negative. Negative
orthostatics, telemetry unrevealing.
#L sided back pain
Likely muscular spasm. Pain improved with heat pad. started on
lidocaine patch. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
falls
Major Surgical or Invasive Procedure:
none
History of Present Illness:
(obtained from wife as patient not able to state history)
___ right handed with PMH of bipolar disorder, epilepsy,
diabetes, HTN, HLD, and ?possible ___ disease who
presented to the ED s/p multiple falls and worsening mobility.
He has been a patient of Dr ___ ___. He was most
recently seen in clinic by Dr ___ on ___. At that visit
there was concern that some of his tremor may be due to
olanzapine and valproate. Exam was notable for tremor of ___
in
the fingers which was 'not as rhythmic as a typical Parkinsonian
tremor'. However, 'his arms were found to be quite rigid, with
increased tone with movement. Also, his eye
movements were somewhat saccadic to either side and quite
limited
in upgaze.' He also had occasional episodes of confusion which
were thought to be due to presyncopal events or hypoglycemia.
The
plan was to gradually increase lamotrigine to 300mg qd (150 bid)
with the intention of lowering valproate to 500mg qd (250 bid).
His psychiatrist was also requested to stop his home olanzapine
so that he could start Sinemet.
Since that clinic visit, wife states his symptoms have
significantly worsened. Prior to that visit, the patient was
able
to walk independently (albeit with shuffling gait). Since that
time, his symptoms have gotten progressively worse, with the
most
significant change over the last ___ weeks. He started having to
use a walker both at home and at the ___ he goes to 5
days a week. Additionally, he has had ___ falls since the
clinic visit, at least 2 with head strike (whereas previously,
he
would fall ~once/week). Per the wife, most of the falls occur
when he initiates walking or when he has just taken a few steps.
This occurs even though she has him stand still for a few
moments
before he starts to move. Per wife, he knows he is unbalanced,
but "just doesn't know how to fix it'. She denies seeing his
knees buckle, stating "he just falls, and falls hard". He does
not trip over objects. He has never complained of
lightheadedness
or dizziness, palpitations, SOB, or cough.
Wife states that she and the patient visited ___
(starting last ___ and returning ___ of presentation to
the
ED). She thinks that the unfamiliar setting may have exacerbated
some of his symptoms. He had to be wheelchaired to the plane,
and
after that she had to 'push' him into his seat. While in ___, their son had to carry him from place to place because
he just wouldn't walk. Wife thinks some of this reluctance may
be
fear of falling (patient would say "I'm going to fall" over and
over again). He even feels like he is about to fall when sitting
on the toilet. Per wife, his BP has not been an issue. However,
patient has also become incontinent of urine over the past week,
which may be partially due to him not being able to get to the
bathroom in time.
Other concerns include decreased food intake (patient's tremor
has gotten worse to the point where he has trouble feeding
himself). Short term memory has been a chronic issue as well,
although wife states his current mental status is his baseline.
Per wife, memory has been deteriorating over years; he keeps
asking the same questions over and over again.
He was hospitalized at ___ this ___ after an
episode of seeing purple dots and having clammy skin. Per wife,
he has had multiple episodes in the past of clamminess which was
initially attributed to presyncopal episodes and possible
hypoglycemia; however wife states she checked glucose during
these episodes and it was not low. At ___, he received a
brain MRI as they were concerned about stroke. Wife does not
remember what the results were.
Since his last clinic visit, per wife he now takes lamotrigine
150mg BID and valproic acid ___ BID (will switch to 250mg BID
this ___. He also stopped taking olanzapine a week ago. He
was supposed to start taking Sinemet, but ended up coming to the
ED. His wife is concerned about his worsening symptoms over the
past 2 weeks which is why she brought him to the ED. No other
medication changes than what was mentioned above.
Per outpatient clinic notes, he was first noted to have hand
tremor in ___. In ___, his wife noticed a slight shuffling
gait, balance problems, and hunched posture. He fell at least
once during this time. Later in ___ his wife noticed that he
was
drooling occasionally and his facial expressions looked more
flat. His psychiatrist tried prescribing propranolol, which did
not help his symptoms.
In late ___, the tremors became worse to the point where he
couldn't eat or drink properly. This may have been related to
his
lithium and AED medications as the symptoms improved when the
medication doses were decreased. However, he also had trouble
with short term memory and sleep. For example, he would wake up
confused at unusual hours of the night and then would be sleepy
during the day.
Regarding his epilepsy, he has had a history of seizures since
he
was a teenager. Per clinic note, his seizures may involve seeing
spots in front of his eyes, although wife is not really sure. He
may have had a GTC in ___ (wife found him lying in bed,
having urinated himself). No seizures since then.
In the ED, he received a CT C/T/L spine as well as head CT which
were unremarkable other than moderate DJD.
Past Medical History:
- Seizures (since teenager)
- Diabetes (A1c 6.5%)
- Hx bipolar disorder (___)
- Hypertension
- Hyperlipidemia
Social History:
___
Family History:
No seizures or ___. Father died in his ___. Mother died
from cancer. 2 sisters, one of whom is diabetic.
2 brothers.
Physical Exam:
Admission Exam:
General: Awake, elderly man lying in bed, no emotions on face
HEENT: no scleral icterus noted, MMM
Neck: kept in flexed position
Pulmonary: Normal work of breathing.
Cardiac: Warm, well-perfused.
Extremities: No ___ edema.
Skin: No rashes or lesions noted.
Neurologic:
-Mental Status: Alert, cooperative. Able to state full name,
___. States he is at ___". When asked why
he was at the hospital, he states "when people are sick they go
to the hospital". Able to name hand, knuckles, finger. Calls
collar 'blouse' and blanket 'towel'. Could repeat short phrases
but not longer sentences. Not able to relate history. When asked
to name ___ backwards, he says ___.
Registered 3 objects but recalled ___ at 5 minutes. When
reminded
of category, ___. When multiple choice, another ___.
-Cranial Nerves:
II, III, IV, VI: L>R pupil 4.5mm vs 4mm, both reactive. Patient
appeared to have difficulty with upgaze but also would not open
his eyes wide. No nystagmus. Normal saccades. VFF to finger
wiggling.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to conversation.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions.
-Motor: Limited by patient's ability to follow directions. All
extremities are at least antigravity, although patient does not
give good effort in strength exam. BUEs have cogwheel rigidity
at
both elbows and wrists. Both hands are held in flexed position
at
the wrist. Patient did not appear to be able to straighten R arm
at the elbow, and resisted when examiner attempted. Rigidity
appeared worse with faster movements.
At rest, no tremor was observed. When patient held arms outward,
a fine tremor could be seen in bilateral hands.
-Sensory: No deficits to light touch, pinprick. Extinction noted
in BUEs and BLEs to light touch (says 'right' even though
examiner touches both right and left).
-Reflexes:
Difficult to elicit given that patient does not relax when
instructed. Bilateral patellars 3+. Plantar response was
equivocal bilaterally; patient withdraws feet to stimulus. No
clonus.
-Coordination: Again, fine tremor noted during FNF. FNF grossly
intact bilaterally, although patient does not follow commands
reliably.
-Gait: deferred given fall risk. Per RN, required 2 person
assist
to go from wheelchair to bed; could not support his own weight
at
all.
===============
Discharge Exam
General: Awake, elderly man lying in bed, no emotions on face
HEENT: no scleral icterus noted, MMM
Neck: kept in flexed position
Pulmonary: Normal work of breathing.
Cardiac: Warm, well-perfused.
Extremities: No ___ edema.
Skin: No rashes or lesions noted.
Neurologic:
-Mental Status: Alert, cooperative. Able to state full name,
Year, Month, City.
-Cranial Nerves:
PERRL. conjugate gaze. Full horizontal eye movements. Limited
upgaze; full downgaze. No nystagmus. Normal saccades. No facial
droop, facial musculature symmetric. Hearing intact to
conversation. Palate elevates symmetrically. Tongue protrudes in
midline with good excursions.
-Motor:
Left sided UE weakness (4+) in upper motor neuron pattern. Right
UE full strength. B/l ___ weakness L>R quad, TA. Otherwise ___
were
___.
BUEs have cogwheel rigidity at both elbows and wrists. Rigidity
4+ in b/l UE but improved to 3+ with facilitation. Both hands
are
held in flexed position at the wrist L>R. Patient did appear to
able to straighten L arm at the elbow better today. Overall, did
seem looser on exam today.
Pt has a fine tremor in b/l hands. Kinetic > postural > rest
tremor.
-Sensory: No deficits to light touch, though pt is somewhat
unreliable.
-Reflexes:
Difficult to elicit given that patient does not relax when
instructed. B/l UE 2+ throughout. Bilateral patellars 3+ L>R.
Plantar response up on the right, equivocal on left; patient
withdraws feet to stimulus. few beats of clonus b/l.
-Coordination: Again, tremor noted during FNF. FNF grossly
intact
bilaterally.
Gait: deferred today
from ___: TLSO brace in place. Yesterday, ___ person assist
with
walking: Some instability upon standing requiring nursing
support
to prevent fall backwards. leaned heavily on walker. very short,
quick shuffling steps without raising knees. Hesitation, poor
initiation, freezing, and almost no elevation of the foot above
the floor. There was no ataxia and no circumduction. Heals
appeared raised off floor. Raised knees transiently upon verbal
suggestion. Unusual gait, perhaps combination of spastic
and magnetic.
Pertinent Results:
___ 10:10AM BLOOD WBC-4.9 RBC-4.69 Hgb-13.7 Hct-42.5 MCV-91
MCH-29.2 MCHC-32.2 RDW-13.2 RDWSD-43.2 Plt ___
___ 10:10AM BLOOD Glucose-202* UreaN-21* Creat-0.9 Na-137
K-4.7 Cl-100 HCO3-23 AnGap-14
___ 05:10AM BLOOD cTropnT-<0.01
___ 12:49AM BLOOD VitB12-485
___ 09:36AM BLOOD Ammonia-13
___ 12:49AM BLOOD TSH-0.91
___ 09:36AM BLOOD 25VitD-40
___ 12:49AM BLOOD Trep Ab-NEG
___ 09:36AM BLOOD Valproa-42*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Divalproex (DELayed Release) 500 mg PO BID
2. empagliflozin 10 mg oral DAILY
3. GlipiZIDE XL 10 mg PO DAILY
4. LamoTRIgine 150 mg PO BID
5. LORazepam 0.5 mg PO BID
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Simvastatin 10 mg PO QPM
8. SITagliptin 100 mg oral DAILY
9. Tamsulosin 0.4 mg PO BID
10. Calcium Carbonate Dose is Unknown PO DAILY
11. Multivitamins Dose is Unknown PO DAILY
Discharge Medications:
1. Carbidopa-Levodopa (___) 2 TAB PO TID
2. Docusate Sodium 100 mg PO BID
3. Lidocaine 5% Patch 1 PTCH TD QPM back
4. Polyethylene Glycol 17 g PO DAILY
5. Senna 8.6 mg PO BID
6. Calcium Carbonate 500 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. empagliflozin 10 mg oral DAILY
9. GlipiZIDE XL 10 mg PO DAILY
10. LamoTRIgine 150 mg PO BID
11. LORazepam 0.5 mg PO BID
12. MetFORMIN (Glucophage) 1000 mg PO BID
13. Simvastatin 10 mg PO QPM
14. SITagliptin 100 mg oral DAILY
15. Tamsulosin 0.4 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
___)
Discharge Diagnosis:
Vertebral compression fracture
cervical spinal stenosis
atypical ___
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 HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with history of ___ s/p multiple falls.
Evaluation for traumatic injury.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 18.0 s, 18.6 cm; CTDIvol = 48.7 mGy (Head) DLP =
903.1 mGy-cm.
Total DLP (Head) = 903 mGy-cm.
COMPARISON: Comparison to MRI brain from ___.
FINDINGS:
There is no evidence of intracranial hemorrhage, acute large territorial
infarction, edema,or mass. Brain parenchymal atrophy..
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
No acute findings.
Brain parenchymal atrophy.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: History: ___ with history of ___ s/p multiple falls.
Evaluation for traumatic injury, fracture.
TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.2 s, 24.5 cm; CTDIvol = 22.9 mGy (Body) DLP = 560.5
mGy-cm.
Total DLP (Body) = 561 mGy-cm.
COMPARISON: No relevant prior imaging for comparison.
FINDINGS:
Minimal anterolisthesis C7-T1, degenerative. No fracture. No prevertebral
edema.
Multilevel degenerative changes, disc space narrowing, disc osteophyte
complexes, diffuse disc bulges, posterior element hypertrophic changes.
Moderate to severe central canal narrowing C3-C4, C4-C5, C5-C6, C6-C7 levels.
Congenital narrowing spinal canal. Multilevel moderate to severe foraminal
narrowing.
5 mm pulmonary nodule at the left apex (3:78).
IMPRESSION:
1. No acute findings.
2. Advanced degenerative changes cervical spine.
3. Moderate to severe central canal narrowing C3-C4 through C6-C7 levels.
4. Few lung nodules, largest 5 mm, recommendations below.
RECOMMENDATION(S): For incidentally detected multiple solid pulmonary nodules
smaller than 6mm, no CT follow-up is recommended in a low-risk patient, and an
optional CT follow-up in 12 months is recommended in a high-risk patient.
See the ___ ___ Society Guidelines for the Management of Pulmonary
Nodules Incidentally Detected on CT" for comments and reference:
___
Radiology Report
EXAMINATION: CT T-SPINE W/O CONTRAST Q321 CT SPINE
INDICATION: History: ___ with midline TTP after fall and possible anterior
compression fracture on Xrays// eval for fracture eval for fracture
TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 11.2 s, 44.0 cm; CTDIvol = 31.6 mGy (Body) DLP =
1,389.5 mGy-cm.
Total DLP (Body) = 1,389 mGy-cm.
COMPARISON: Same day thoracic and lumbar spine radiographs.
FINDINGS:
Alignment is normal.Linear lucency anterior to mid superior T12 vertebral body
with prevertebral stranding is consistent with acute compression fracture.
There is less than 25% loss of vertebral body heights. No retropulsion.
There is minimally displaced L2 right transverse process fracture.The disc
heights are preserved. Anterior bridging osteophytes are seen throughout the
thoracic spine, most severe from T6-T12. Facet osteophytes cause mild spinal
canal narrowing at T10-11 and moderate to severe left neural foraminal
narrowing. Otherwise no high-grade spinal canal stenosis or neural foraminal
narrowing of the remaining thoracic spine. The visualized mediastinal
structure is unremarkable. No focal consolidation in the visualized lung.
There is bilateral dependent atelectasis. Few small lung nodules, largest 0.5
cm series 2, image 23. Basilar atelectasis.. Coronary artery calcifications.
There is a 3 mm left calcified granuloma. The visualized liver, gallbladder,
spleen, pancreas, bilateral adrenal glands, and bilateral kidneys are
unremarkable. No abdominal aortic aneurysm. Visualized retroperitoneal lymph
nodes are not enlarged.
IMPRESSION:
1. T12 acute compression fracture, with horizontal cleft, minimal height loss.
2. Minimally displaced right L2 transverse process fracture.
3. Degenerative changes thoracic spine..
4. Lung nodules, largest 0.5 cm.
RECOMMENDATION(S): For incidentally detected nodules smaller than 6mm in the
setting of an incomplete chest CT, no CT follow-up is recommended.
See the ___ ___ Society Guidelines for the Management of Pulmonary
Nodules Incidentally Detected on CT" for comments and reference:
___
Radiology Report
EXAMINATION: CT L-SPINE W/O CONTRAST Q331 CT SPINE
INDICATION: History: ___ with midline TTP after fall and possible anterior
compression fracture on Xrays// eval for fracture eval for fracture
TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 8.5 s, 33.3 cm; CTDIvol = 31.2 mGy (Body) DLP =
1,038.8 mGy-cm.
Total DLP (Body) = 1,039 mGy-cm.
COMPARISON: Same day thoracic and lumbar spine radiograph.
FINDINGS:
Alignment is normal.There is minimally displaced subacute. Benign subchondral
lesion left innominate bone near sacroiliac joint. Right L2 transverse
process fracture. Compression fracture of T12 as described on same day
thoracic spine CT report..
Disc bulge at L2-3 causes mild to moderate spinal canal stenosis indenting on
the thecal sac (Series 3, image 53). Small calcified central, inferior disc
extrusion L1-L2 level. Broad-based disc bulge L2-L3, probable central,
inferior small disc protrusion component. Multilevel disc space narrowing,
diffuse disc bulges, facet arthritis.
Probably moderate central canal narrowing L2-L3 level. Multilevel moderate
foraminal narrowing.
5 mm lucency very low-density L4 spinous process, likely benign in the absence
of history of malignancy. Chronic fracture right L1 transverse process
IMPRESSION:
1. Chronic right L1, subacute right L2 transverse process fractures.
2. T12 acute compression fracture, horizontal cleft, mild paraspinal edema.
3. Degenerative changes lumbar spine.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD
INDICATION: ___ year old man with worsening dementia and gait abnormalities. L
sided UMN weakness.// structural causes for decline
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: None.
FINDINGS:
There is no evidence of acute intracranial infarction, mass or hemorrhage.
Ventricles and sulci are age appropriate. Few periventricular deep
subcortical FLAIR white matter hyperintensities are likely sequelae of chronic
microangiopathy. Mild mucosal sinus thickening is seen involving the ethmoid
air cells. The remainder of the visualized paranasal sinuses, mastoid air
cells, and middle ear cavities are clear. The globes are unremarkable. The
principal vascular flow voids are well preserved.
IMPRESSION:
-No acute intracranial abnormalities identified. No concerning intracranial
enhancing lesions seen. Mild chronic microangiopathy.
Radiology Report
EXAMINATION: MR ___ WAND W/O CONTRAST ___ MR ___ SPINE
INDICATION: ___ year old man with PMH of bipolar disorder, epilepsy, diabetes,
HTN, HLD, atypical parkinsonianism, and and possible malnutrition who
presented to the ED with worsening weakness and multiple falls with a concern
for ___ plus etiology
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial T2 and gradient echo imaging were next performed. After administration
of Gadavist intravenous contrast, sagittal and axial T1 weighted imaging was
performed.
COMPARISON: CT from ___
FINDINGS:
The alignment is normal. No concerning bone marrow signal abnormalities are
identified. Possible subtle increased cord signal is seen at C4-C5. Diffuse
loss of the normal T2 signal seen throughout the intervertebral discs of the
cervical spine.
C2-C3: Mild disc bulge is seen resulting in mild spinal canal narrowing.
Facet joint and uncovertebral arthropathy results in mild left neural
foraminal narrowing. The right neuroforamen is patent.
C3-C4: Disc bulge with a focal central disc protrusion is seen resulting in
moderate spinal canal narrowing. Facet joint and uncovertebral arthropathy
results in moderate left and mild right neural foraminal narrowing.
C4-C5: Disc bulge along contributes to severe spinal canal stenosis. Facet
joint and uncovertebral arthropathy results in severe left and moderate right
neural foraminal narrowing.
C5-C6: Disc bulge with a focal central disc protrusion is seen resulting in
moderate to severe spinal canal stenosis. Facet joint and uncovertebral
arthropathy results in severe left and moderate right neural foraminal
narrowing.
C6-C7: Mild disc bulge is seen resulting in mild spinal canal narrowing.
Facet joint and uncovertebral arthropathy results in severe bilateral neural
foraminal narrowing, left greater than right.
C7-T1: There is no spinal canal or neural foraminal narrowing.
No paraspinal or paravertebral soft tissue abnormalities are identified.
IMPRESSION:
-Severe spinal canal stenosis is seen at C4-C5 secondary to disc bulge. At
this level, severe left and moderate right neural foraminal narrowing is seen.
-Moderate to severe spinal canal stenosis is seen at C5-C6 and C3-C4 secondary
to disc bulge with focal central disc protrusions. Moderate to severe left
neural foraminal narrowing is seen at these levels.
-Possible subtle increased cord signal abnormality at C4-C5 could be secondary
to myelomalacia although a small focus of cord edema cannot be excluded.
-No concerning enhancing lesions identified.
Radiology Report
EXAMINATION: CHEST (SINGLE VIEW)
INDICATION: History: ___ with weakness, multiple falls. Evaluation for
infiltrate, pna.
TECHNIQUE: Chest AP supine
COMPARISON: No prior imaging for comparison.
FINDINGS:
Mildly enlarged cardiac silhouette. The pulmonary vasculature is within
normal limits. Slightly diminished lung volumes with mild bibasilar
atelectasis, most notably at the left lung base. No focal consolidation
identified. No pleural effusion or pneumothorax.
IMPRESSION:
1. No focal consolidation identified.
2. Slightly diminished lung volumes with mild bibasilar atelectasis, left
greater than right.
Radiology Report
EXAMINATION: DX THORACIC AND LUMBAR SPINES
INDICATION: History: ___ with history of ___ and multiple falls w/
back pain. Evaluation for traumatic injury.
TECHNIQUE: Frontal and lateral view radiographs of the thoracic and lumbar
spine.
COMPARISON: No prior imaging for comparison.
FINDINGS:
Thoracic spine: There is anterior wedging of the T12 vertebral body of
uncertain age. This could represent an old compression fracture or acute
injury. Vertebral body and disc heights are otherwise preserved. No other
fracture or subluxation is detected. No suspicious lytic or sclerotic lesion
is identified. Visualized cardiomediastinal structures and lungs are within
normal limits.
Lumbar spine: 5 non-rib-bearing lumbar vertebral bodies are present. Vertebral
body and disc heights are preserved. No fracture, subluxation, or degenerative
change is detected. No suspicious lytic or sclerotic lesion is identified.
Mild fecal loading is noted within the colon. Few calcific densities within
the pelvis likely represent phleboliths.
IMPRESSION:
Anterior wedging of T12 vertebral body. Old compression fracture versus acute
injury. If the patient is symptomatic at this level CT scan of the thoracic
spine is suggested.
RECOMMENDATION(S): The changes in the report from pulmonary to final were
discussed with ___, M.D. by ___, M.D. on the telephone on
___ at 9:04 am.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Confusion, Lower back pain, s/p Fall
Diagnosed with Weakness
temperature: 97.1
heartrate: 102.0
resprate: 16.0
o2sat: 95.0
sbp: 120.0
dbp: 84.0
level of pain: 5
level of acuity: 2.0 | ___ right handed with PMH of bipolar disorder, epilepsy,
diabetes, HTN, and HLD who presented to the ED s/p multiple
falls
over the past 2 weeks and worsening mobility.
Exam notable for masked facies, cognitive impairment, limited
upgaze, cogwheel rigidity in BUEs, left sided UE weakness in UMN
pattern, tremor kinetic > postural> resting, and gait
abnormality.
CT spine imaging is notable for acute T12 compression fracture.
Neurosurgery spine was consulted and recommended conservative
management.
MR brain unremarkable.
MR ___ spine notable for severe cervical spinal stenosis.
His left UE weakness, urinary incontinence, ___ hyperreflexia,
and upgoing toe can be explained by cervical stenosis. However,
his gait is not clearly spastic and his neck rigidity and
cognitive impairment cannot be explained by this. Ortho spine
consulted and believe he is a surgical candidate. Plan to follow
up in spine clinic to discuss this option. Okay for patient to
participate in ___. Patient should continue to wear soft cervical
collar.
There was mild improvement in his symptoms after initiation
of Sinemet. Plan to continue this for at least 2 weeks to assess
response.
On ___, we did a trial of IV Lorazepam to determine whether
this could lead to improvement. It led to significant
improvement in his tone transiently, which supports spasticity
(which could be secondary to a stiff person syndrome) or
oppositional paratonia (gegenhalten), and less likely rigidity
secondary to a Parkinsonian syndrome.
His overall picture is somewhat unclear at this time. it is
likely that his symptoms are multifactorial and related to both
atypical ___ syndrome plus cervical spinal stenosis.
Also on the differential is stiff person syndrome. Although
typically cognition is not involved. GAD ab testing sent and
pending at time of discharge. Outpatient EMG ordered. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
worsening shortness of breath x 3 days
Major Surgical or Invasive Procedure:
none.
History of Present Illness:
___ yo M with hx of CHF (EF in ___ 55%), IDDM c/b retinopathy,
nephropathy, HTN, HLD, TIA in ___, CKD undergoing evaluation
for dialysis who was transfered from ___ for DOE &
elevated cardiac enzymes.
.
Patient reports for the last 3 days he has felt increasingly
short of breath and wheezing. Says that at baseline can walk 1
block but in the last few days becomes short of breath with
dressing himself or walking ___ feet. While in the ED, he stated
that he had substernal chest pain, epigastric and radiates
toward his sides and back and jaw, rated ___ in severity,
exertional/improves with 20 minutes of rest. However, upon my
asking, patient completely denies any chest pain, No n/v, no
diaphoresis, palpitations, diarrhea, constipation, or
bloody/melanotic stool. States that he has shortness of breath,
with worsening opthopnea, PND, and increased lower extremity
edema. Also states that he has a 18 lb weight gain in the last 1
month. Denies recent infection, missing medication doses, or any
dietary changes to me but apparently endorsed dietary
noncompliance in ED.
.
There he reportedly was found to have an elevated troponin (2.1)
and nonspecific ST changes on ECG. He was given ASA 325,
sublingual nitro, nitro paste, 300 mg plavix, and started on a
heparin gtt. He was given 40 mg IV lasix at 11 am.
.
ON THE FLOOR, VSS. Patient continues to be short of breath but
denies any chest pain/discomfort.
.
ROS as above, otherwise negative.
Past Medical History:
CAD: "a mild heart attack" in ___ at ___,
no PCI
CHF (last report here 55% EF in ___
IDDM
HTN
HLD
TIA ___
CKD ___ DM, followed at ___ with plans to initiate dialysis
in future)
diabetic retinopathy
Glaucoma
Social History:
___
Family History:
father with MI at ___, mother with MI at ___
Physical Exam:
Admission PEx:
VS: 98.2 158/73 68 20 100%RA
GENERAL: WDWN in NAD. obese ___ male, Alert &
Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple; JVD difficult to appreciate given body habitus and
discomfort with being more supine.
CARDIAC: RR, muffled heart sounds, No m/r/g.
LUNGS: CTAB, Respirations mildly unlabored.
ABDOMEN: Soft, NTND.
EXTREMITIES: ___ pitting edema to mid shins, No cyanosis,
clubbing.
SKIN: No stasis dermatitis, ulcers, scars.
NEURO: CN2-12 intact; moving 4 extremities spontaneously
.
.
Discharge PEx:
VS: 97.8 137/81 65 18 100%RA
Wt: 130.9 on admission --> 121.3kg
I/O: ___ (8hr); ___ (24hr)
GENERAL: WDWN in NAD. obese ___ male, Alert &
Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple; JVD difficult to appreciate given body habitus and
discomfort with being more supine.
CARDIAC: RR, muffled heart sounds, No m/r/g.
LUNGS: CTAB, Respirations mildly unlabored.
ABDOMEN: Soft, NTND.
EXTREMITIES: min edema, No cyanosis, clubbing.
SKIN: No stasis dermatitis, ulcers, scars.
NEURO: CN2-12 intact; moving 4 extremities spontaneously
Pertinent Results:
Labs on Admission:
___ 02:05PM BLOOD WBC-10.1 RBC-2.92* Hgb-8.3* Hct-26.0*
MCV-89 MCH-28.3 MCHC-31.8 RDW-15.0 Plt ___
___ 02:05PM BLOOD Neuts-89.0* Lymphs-6.9* Monos-3.6 Eos-0.3
Baso-0.3
___ 02:05PM BLOOD ___ PTT-47.5* ___
___ 02:05PM BLOOD Glucose-121* UreaN-63* Creat-3.7* Na-138
K-5.2* Cl-110* HCO3-15* AnGap-18
___ 02:05PM BLOOD Iron-23* Cholest-127
___ 07:46PM BLOOD Calcium-8.1* Phos-6.3* Mg-2.4
___ 02:05PM BLOOD calTIBC-208* Ferritn-543* TRF-160*
___ 07:05AM BLOOD %HbA1c-6.4* eAG-137*
ABG:
___ 08:36PM BLOOD Type-ART pO2-41* pCO2-41 pH-7.26*
calTCO2-19* Base XS--8 Intubat-NOT INTUBA
___ 08:42PM BLOOD Type-ART pO2-34* pCO2-43 pH-7.25*
calTCO2-20* Base XS--9
___ 08:59PM BLOOD Type-ART pO2-80* pCO2-36 pH-7.30*
calTCO2-18* Base XS--7 Intubat-NOT INTUBA
___ 08:36PM BLOOD Lactate-0.9
Urine:
___ 02:48PM URINE Color-Straw Appear-Hazy Sp ___
___ 02:48PM URINE Blood-TR Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
___ 02:48PM URINE RBC-<1 WBC-0 Bacteri-FEW Yeast-NONE Epi-0
___ 02:48PM URINE CastGr-3* CastHy-6*
___ 07:12PM URINE Hours-RANDOM UreaN-484 Creat-67 Na-48
K-29 Cl-56
Cardiac Markers:
___ 02:05PM BLOOD CK-MB-13* MB Indx-1.7 proBNP-6897*
___ 02:05PM BLOOD cTropnT-0.31*
___ 12:45AM BLOOD CK-MB-12* cTropnT-0.33*
___ 07:05AM BLOOD CK-MB-10 MB Indx-1.7 cTropnT-0.34*
Labs on Discharge:
___ 07:35AM BLOOD WBC-7.1 RBC-3.25* Hgb-9.3* Hct-28.1*
MCV-87 MCH-28.8 MCHC-33.2 RDW-14.2 Plt ___
___ 07:35AM BLOOD ___ PTT-29.0 ___
___ 07:35AM BLOOD Glucose-69* UreaN-104* Creat-5.0* Na-141
K-3.6 Cl-99 HCO3-30 AnGap-16
___ 07:35AM BLOOD Calcium-9.2 Phos-6.3* Mg-2.6
Imaging:
EKG:Sinus rhythm wiht atrial premature beats. Diffuse
non-specific ST-T wave abnormality. Compared to the previous
tracing of ___ the inferior and lateral T wave abnormality
is less prominent.
CXR: Heart size is enlarged. There is mild interstitial edema.
There
are small bilateral pleural effusions. No focal consolidation or
pneumothorax is detected on these views, although small
posterobasilar consolidation may be obscured by pleural
effusion. IMPRESSION: Mild congestive heart failure.
ECHO: The left atrium is moderately dilated. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Regional left ventricular wall motion is
normal. 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. There is no aortic valve
stenosis. Trace aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
The estimated pulmonary artery systolic pressure is normal.
There is a trivial/physiologic pericardial effusion. Compared
with the report of the prior study (images unavailable for
review) of ___, findings are similar. Trace aortic
regurgitation is now detected.
Upper extremity vein mapping: Patent subclavian veins. Normal
radial and brachial waveforms. The left arm veins and right
upper arm basilic are of appropriate diameter for conduit.
Medications on Admission:
atenolol 50 mg daily
Simvastatin 80 mg daily
lasix 40mg BID
amlodipine 5mg
methazolamide 50 mg BID
Lantus 40 Units qAM
Aspart
terazosin 4mg daily
prilosec 20 mg
citalopram 40 mg
calcitriol 0.25mg daily
Na HCO3 650mg BID
iron 325
temazepam
timilol
alphagan
Discharge Medications:
1. Toprol XL 100 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0*
2. pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
3. methazolamide 50 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. insulin glargine 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous every morning.
5. insulin aspart 100 unit/mL Solution Sig: as previously
directed units Subcutaneous as directed: please use sliding
scale as previously directed.
6. terazosin 2 mg Capsule Sig: Two (2) Capsule PO once a day.
7. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
9. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
10. sodium bicarbonate 650 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
12. temazepam 15 mg Capsule Sig: Two (2) Capsule PO qhs prn ()
as needed for anxiety .
13. hydralazine 50 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*0*
14. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*qs Tablet, Chewable(s)* Refills:*0*
15. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic BID (2
times a day).
16. dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic BID (2
times a day).
17. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*qs Tablet(s)* Refills:*0*
18. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
19. torsemide 20 mg Tablet Sig: Three (3) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
___
___:
CHF exacerbation
chronic kidney disease
hypertension
obstructive sleep apnea
secondary:
hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ male with history of diabetes, congestive heart
failure, hypertension, and hyperlipidemia, now with chest pain, dyspnea, and
elevated troponin.
COMPARISON: None available.
TECHNIQUE: Frontal and lateral chest radiographs were obtained.
FINDINGS: Heart size is enlarged. There is mild interstitial edema. There
are small bilateral pleural effusions. No focal consolidation or pneumothorax
is detected on these views, although small posterobasilar consolidation may be
obscured by pleural effusion.
IMPRESSION: Mild congestive heart failure.
Radiology Report
INDICATION: ___ male with renal failure.
Both right and left subclavian veins have phasic flow. The right subclavian
venous waveform is slightly less phasic than the right; this is of unclear
significance.
Brachial and radial waveforms are triphasic. On the right the brachial and
radial diameters are 6 and 2.4 mm respectively. On the left the brachial and
radial diameters are 3.4 and 3.4 respectively.
RIGHT ARM VEIN: The right arm cephalic vein is patent with diameters less
than 2 mm in the forearm. The upper arm cephalic is not visible. The right
upper arm basilic diameters are 3.2, 5.5, 6.6, 7.8 mm.
LEFT ARM VEIN: The left arm cephalic is patent with diameters from wrist to
anticubital of 3.4, 3.6, 3.7 mm. The upper arm cephalic diameters are 4.9,
4.0, 4.0 mm. The left upper arm basilic diameters are 2.8, 3.1, 3.3 mm.
IMPRESSION: Patent subclavian veins. Normal radial and brachial waveforms.
The left arm veins and right upper arm basilic are of appropriate diameter for
conduit.
Gender: M
Race: HISPANIC OR LATINO
Arrive by UNKNOWN
Chief complaint: TRANS. NSTEMI
Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE, END STAGE RENAL DISEASE, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN, HYPERLIPIDEMIA NEC/NOS
temperature: 98.8
heartrate: 78.0
resprate: 18.0
o2sat: 98.0
sbp: 151.0
dbp: 80.0
level of pain: 0
level of acuity: 2.0 | ___ yo M with hx of CHF (EF in ___ 55%), IDDM c/b retinopathy,
nephropathy, HTN, HLD, TIA in ___, CKD undergoing evaluation
for dialysis who was transfered from ___ for DOE &
elevated cardiac enzymes, admitted for CHF exacerbation likely w
trop leak ___ worsening CKD.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Seroquel / Penicillin G / Latex / Trazodone
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
Admission Labs:
___ 09:38PM BLOOD WBC-8.4 RBC-4.06 Hgb-11.9 Hct-36.7 MCV-90
MCH-29.3 MCHC-32.4 RDW-12.8 RDWSD-41.8 Plt ___
___ 09:38PM BLOOD Neuts-49.7 ___ Monos-10.2 Eos-1.9
Baso-0.4 Im ___ AbsNeut-4.20 AbsLymp-3.16 AbsMono-0.86*
AbsEos-0.16 AbsBaso-0.03
___ 09:38PM BLOOD Glucose-94 UreaN-15 Creat-0.5 Na-138
K-4.8 Cl-100 HCO3-29 AnGap-9*
___ 07:22PM BLOOD ALT-46* AST-43* AlkPhos-77 TotBili-<0.2
___ 07:22PM BLOOD Albumin-3.8 Calcium-9.4 Phos-2.5* Mg-2.0
___ 09:38PM BLOOD CRP-30.6*
Imaging:
1. Interval development of right C3-C4 facet joint effusion with
marrow edema
extending to the right lateral vertebral bodies. There is
prominent
surrounding enhancing paraspinal muscle edema pattern as well as
high signal
of the interspinous ligaments extending from the occiput to
C6-C7 levels. The
findings given the patient's clinical context is highly
suspicious for
infectious synovitis with associated osteomyelitis and possibly
myositis.
Differential consideration include sequela of trauma with
ligamentous injury
and capsular injury. Inflammatory degenerative changes is a
consideration,
but considered much lower on the differential of given the
degree of para
spinal muscle edema and enhancement. Motion degraded sagittal
T1 postcontrast
images demonstrates suggestion of dorsal and ventral epidural
enhancement
spanning the upper cervical spine, however this is likely
artifactual given
lack of corresponding signal abnormality on the remainder of the
sequences.
However, close attention on follow-up is recommended.
2. No drainable paraspinal abscesses or collections.
3. Cervical cord show normal signal intensity.
4. Additional findings described above.
CT:
1. The study is moderately limited by motion artifact and the
inability of the
patient to follow instructions during the acquisition of images.
Within the
limitation of the study, there is no acute abdominopelvic
pathology to explain
patient's symptoms. Normal appearance of the appendix.
2. Nonspecific mild intrahepatic and extrahepatic biliary ductal
dilatation,
unchanged.
CT Head
1. No evidence of large territory infarction or hemorrhage
noncontrast CT
head.
2. Meningitis cannot be excluded on the basis of this
examination.
Discharge Labs:
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OLANZapine 10 mg PO DAILY
2. Buprenorphine-Naloxone Film (8mg-2mg) 1 FILM SL TID
3. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*14 Tablet Refills:*0
2. Clindamycin 600 mg PO Q8H
RX *clindamycin HCl 300 mg 2 capsule(s) by mouth three times a
day Disp #*21 Capsule Refills:*0
3. Buprenorphine-Naloxone Film (8mg-2mg) 1 FILM SL TID
4. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
5. OLANZapine 10 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
C4 facet Joint Septic Arthritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MRI CERVICAL, THORACIC, AND LUMBAR PT22 MR SPINE
INDICATION: History: ___ with neck pain concerning for abscess IV contrast to
be given at radiologist discretion as clinically needed // r/o epidural
abscess r/o epidural abscess
r/o epidural abscess
r/o epidural abscess
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial T2 imaging was performed. Axial GRE images of the cervical spine were
performed. After the uneventful administration of Gadavist contrast agent,
additional axial and sagittal T1 images were obtained.
COMPARISON: MRI whole spine dated ___.
FINDINGS:
CERVICAL:
There is a pronounced fluid signal intensity centered at right C3-4 facet
joint with underlying cortical margin irregularities and with associated
locoregional paraspinal muscles T2 STIR hyperintense signal intensity with
corresponding postcontrast enhancement; described findings are highly
suspicious of facet joint septic arthritis with secondary opposing osseous
structures osteomyelitis and myositis given the patient's clinical history.
There is edema like signal intensity involving C3 and C4 ipsilateral posterior
elements extending to vertebral bodies with postcontrast enhancement raising
concern of inflammatory/infectious process extension. The left facet joint at
the same level and both C3 and C4 hemivertebra is relatively spared. The C3-C4
disc show normal signal intensity height and no abnormal postcontrast
enhancement.
Only sagittal T1 post-contrast were obtained with significantly degraded by
motion artifact. There is minimal circumferential epidural thickening with
corresponding postcontrast enhancement, however this is without corresponding
signal abnormality on the remaining axial T2, sagittal STIR or T2 sequences
and is felt to be likely artifactual. Close attention on follow-up is
recommended.
There is less than 2 mm prevertebral fluid signal intensity up to lower C4
endplate level; underlying postcontrast enhancement cannot be excluded.
Alignment of the cervical spine is maintained.
There are essentially unchanged multilevel disc degenerative disease evidenced
by endplate irregularities, disc desiccation, disc osteophytosis, facet
arthropathy and Schmorl's nodule formation.
There are multilevel spondylitic spinal canal stenosis most severe at level
C4-C5; unchanged since previous examination.
Cervical cord and cervicomedullary junction show normal signal intensity and
volume.
THORACIC:
Vertebral body height and alignment is preserved. The disc spaces are
maintained. There is no epidural collection. The thoracic cord appears
normal in caliber and configuration. Unchanged mild degenerative changes
affecting thoracic spine. Unchanged T2 STIR hyperintense signal intensity
with corresponding T1 hypointensity of anterior superior endplate of T12;
stable since previous examination; could represent ___ lesions.
Bilateral glenohumeral joint effusions are unchanged, partially visualized on
scout images.
LUMBAR:
Postsurgical changes after L4-L5 and L5-S1 laminectomies are noted. There is
no epidural collection.
Unchanged grade 1 retrolisthesis of L4 on L5. Vertebral body height and
alignment is otherwise preserved. There is mild degenerative disc disease
predominantly along the lower lumbar spine with grossly preserved disc space
heights; unchanged. Bone marrow signal intensity is within normal limits.
The conus medullaris and cauda equina fibers show normal signal intensity and
size.
At L1-L2 and L2-L3, there is no significant spinal canal stenosis or neural
foraminal narrowing.
At L3-L4, there is a disc bulge, bilateral facet joint arthropathy and
moderate ligamentum flavum thickening, mild spinal canal stenosis and moderate
right and mild left neural foraminal narrowing.
At L4-L5, there is a disc bulge, facet joint arthropathy with moderate
bilateral facet joint effusions and severe ligamentum flavum thickening,
moderate spinal canal stenosis. There are severe right and moderate left
neural foraminal narrowing. Findings are not significantly changed from the
prior exam.
At L5-S1, there is diffuse disc bulge with no significant spinal canal
stenosis. There are bilateral moderate neural foraminal narrowing; worse on
the right side.
IMPRESSION:
1. Interval development of right C3-C4 facet joint effusion with marrow edema
extending to the right lateral vertebral bodies. There is prominent
surrounding enhancing paraspinal muscle edema pattern as well as high signal
of the interspinous ligaments extending from the occiput to C6-C7 levels. The
findings given the patient's clinical context is highly suspicious for
infectious synovitis with associated osteomyelitis and possibly myositis.
Differential consideration include sequela of trauma with ligamentous injury
and capsular injury. Inflammatory degenerative changes is a consideration,
but considered much lower on the differential of given the degree of para
spinal muscle edema and enhancement. Motion degraded sagittal T1 postcontrast
images demonstrates suggestion of dorsal and ventral epidural enhancement
spanning the upper cervical spine, however this is likely artifactual given
lack of corresponding signal abnormality on the remainder of the sequences.
However, close attention on follow-up is recommended.
2. No drainable paraspinal abscesses or collections.
3. Cervical cord show normal signal intensity.
4. Additional findings described above.
PREVALENCE: Prevalence of lumbar degenerative disk disease in subjects
without low back pain:
Overall evidence of disk degeneration 91% (decreased T2 signal, height loss,
bulge)
T2 signal loss 83%
Disk height loss 58%
Disk protrusion 32%
Annular fissure 38%
Jarvik, et all. Spine ___ 26(10):___
Lumbar spinal stenosis prevalence- present in approximately 20% of
asymptomatic adults over ___ years old
___, et al, Spine Journal ___ 9 (7):545-550
These findings are so common in asymptomatic persons that they must be
interpreted with caution and in context of the clinical situation.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with history of polysubstance use disorder and neck
pain concerning for meningitis. Also abdominal pain // R/o acute intracranial
process r/o acute intraabdominal process
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, 17.7 cm; CTDIvol = 45.5 mGy (Head) DLP =
802.7 mGy-cm.
2) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 1,605 mGy-cm.
COMPARISON: CT head without contrast of ___.
FINDINGS:
There is no evidence of fracture, acute large territory
infarction,hemorrhage,edema,or mass. The ventricles and sulci are within
expected limits in size and configuration.
The visualized portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. Soft tissue density within the left external auditory
canal likely reflects cerumen. The visualized portion of the orbits are
normal.
IMPRESSION:
1. No evidence of large territory infarction or hemorrhage noncontrast CT
head.
2. Meningitis cannot be excluded on the basis of this examination.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: NO_PO contrast; History: ___ with history of polysubstance use
disorder and neck pain concerning for meningitis. Also abdominal pain NO_PO
contrast // R/o acute intracranial process r/o acute intraabdominal process
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol = 48.1 mGy (Body) DLP =
24.1 mGy-cm.
2) Spiral Acquisition 6.2 s, 49.1 cm; CTDIvol = 14.5 mGy (Body) DLP = 710.2
mGy-cm.
3) Stationary Acquisition 5.5 s, 0.5 cm; CTDIvol = 39.7 mGy (Body) DLP =
19.9 mGy-cm.
4) Spiral Acquisition 6.4 s, 50.6 cm; CTDIvol = 10.5 mGy (Body) DLP = 528.3
mGy-cm.
Total DLP (Body) = 1,282 mGy-cm.
COMPARISON: CT scan abdomen dated ___ and abdominal ultrasound
dated ___.
FINDINGS:
The study is moderately limited by motion artifact and inability of patient to
cooperate with instruction during the acquisition of images.
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 mild extrahepatic and
intrahepatic biliary duct dilatation with the CBD measuring up to 7 mm,
(series 601, image 21) unchanged. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: A punctate hypodensity within the left renal cortex is too small to
fully characterize on CT but statistically likely a renal cyst. 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: Evaluation of the gastrointestinal system is limited by
motion artifact. Within the limitation of the study there is no bowel
obstruction and the appendix is normal.
PELVIS: The urinary bladder is unremarkable. There is no free fluid in the
pelvis.
REPRODUCTIVE ORGANS: The uterus appears present however suboptimally
evaluated.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Grade 1 anterolisthesis of L4 on L5 without evidence of spondylolysis.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. The study is moderately limited by motion artifact and the inability of the
patient to follow instructions during the acquisition of images. Within the
limitation of the study, there is no acute abdominopelvic pathology to explain
patient's symptoms. Normal appearance of the appendix.
2. Nonspecific mild intrahepatic and extrahepatic biliary ductal dilatation,
unchanged.
NOTIFICATION: The findings were discussed with ___, M.D. By
___, M.D. on the telephone on ___ at 12:15 pm, 10minutes
after discovery of the findings.
Radiology Report
EXAMINATION: US NECK, SOFT TISSUE
INDICATION: ___ year old woman with likely right C3-C4 facet joint septic
arthiritis with plan for ___ guided aspiration requests ultrasound feasibility
study. // ultrasound feasibility study.
TECHNIQUE: Grayscale ultrasound images were obtained of the superficial
tissues of the cervical spine.
COMPARISON: None
FINDINGS:
Transverse and sagittal images were obtained of the posterior superficial
tissues of the cervical spine. There is no evidence of a drainable fluid
collection or abscess.
IMPRESSION:
No evidence of drainable fluid collection or abscess in the imaged portion of
the soft tissues of the neck.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Nausea, Neck pain
Diagnosed with Cervicalgia
temperature: 97.0
heartrate: 96.0
resprate: 17.0
o2sat: 98.0
sbp: 118.0
dbp: 71.0
level of pain: 10
level of acuity: 3.0 | ___ female with history of HCV, homelessness, substance
use disorder (IV methamphetamines and PO suboxone), previous
epidural abscess, and previous diagnoses of schizoaffective
disorder; bipolar type, bipolar disorder, ADHD and PTSD,
multiple inpatient and CSU/CCS hospitalizations (last at ___
___ in ___ who presents with one week history of neck
pain. Found to have Septic Facet Joint arthritis with
osteomyolytis |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hemoptysis
Major Surgical or Invasive Procedure:
Bronchoscopy ___
Bronchial Arteriography and Embolization ___
History of Present Illness:
___ year old man with history of papillary thyroid cancer with
known met to lung, s/p total thyroidectomy ___ and
radioablation, presenting with 2 days of hemoptysis of bright
red blood described as small amounts of blood (approx 15 times).
On arrival to ED, initial VS were 98.0 65 121/108 18 98%. Labs
normal including H/H ___ and normal coags. Patient's UA was
negative and blood cultures are pending. CTA demonstrated
innumerable bilateral pulmonary masses, largest measuring 2.7 cm
within the right hila with invasion and compression of right
superior lobar bronchus. No active extravasation of contrast. He
was seen by IP who recommended ICU monitoring and plan for
bronch in am.
Past Medical History:
# Papillary thyroid cancer - S/p total thyroidectomy ___,
and 140 mCi ___. Recurrence ___ with >30
pulmonary
nodules on CT, s/p ___ mCi I-131 on ___.
# Essential hypertension
# Obesity
# Vitamin D deficiency
# OSA
Social History:
___
Family History:
His mother has enlargement of one side of her
thyroid gland and he believes she has hyperthyroidism. She does
take a pill for her thyroid, but does not know the name of this.
She is ___ years old and lives in ___. She also has a history
of hypertension, which was present even before the patient was
born. His father is ___ years old and healthy. He has five
sisters
and four brothers, none of whom have thyroid disease.
Physical Exam:
Admission:
General: No acute distress, sleeping but easily arousable,
appropriate.
HEENT: PERRL, anicteric sclera, OP clear.
CV: S1S2 RRR w/o murmurs noted.
Lungs: CTA bilaterally without crackles or wheezing.
Ab: Positive BSs, NT/ND, no HSM noted.
Ext: No c/c/e.
Neuro: Alert, appropriately oriented, no focal motor deficits
noted.
Discharge:
Grossly unchanged.
Pertinent Results:
LABS:
===================
___ 05:02AM BLOOD WBC-7.3 RBC-4.37* Hgb-13.0* Hct-40.6
MCV-93 MCH-29.7 MCHC-32.0 RDW-13.7 Plt ___
___ 06:56PM BLOOD WBC-7.7 RBC-4.63 Hgb-14.1 Hct-43.6 MCV-94
MCH-30.5 MCHC-32.3 RDW-13.6 Plt ___
___ 05:02AM BLOOD ___ PTT-33.0 ___
___ 05:02AM BLOOD Glucose-98 UreaN-11 Creat-0.9 Na-140
K-3.4 Cl-100 HCO3-31 AnGap-12
___ 06:56PM BLOOD cTropnT-<0.01
___ 06:56PM BLOOD TSH-0.94
___ 06:56PM BLOOD T4-8.1 calcTBG-0.99 TUptake-1.01
T4Index-8.2 Free T4-1.4
___ 06:56PM BLOOD Anti-Tg-LESS THAN Thyrogl-22
___ 06:58PM BLOOD Lactate-1.6 K-4.1
STUDIES:
====================
___ CTA Chest: 1. No evidence of pulmonary embolism or aortic
dissection.
2. Many bilateral pulmonary masses which have slightly increased
since ___ and are consistent with known metastatic disease. Largest
measures 2.7 cm within the right hila. No active extravasation
of contrast.
3. Tree in ___ appearance in left lower lobe with patchy areas
in the right
middle and right lower lobe is most likely bronchopneumonia,
however may
represent sequelae of hemorrhage. Aerosolized secretions in the
trachea and
left mainstem bronchus may represent aspiration or sequelae of
hemorrhage in the appropriate clinical setting.
___ Bronchial embolization: IMPRESSION:
1. Embolization of a left upper bronchial artery and a right
bronchial artery.
2. A left lower bronchial artery arising from a common bronchial
trunk could not be catheterized.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
2. Atenolol 100 mg PO DAILY
3. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
4. Fluticasone Propionate 110mcg 1 PUFF IH DAILY
5. Levothyroxine Sodium 175 mcg PO DAILY
6. Sildenafil 100 mg PO DAILY:PRN need
7. Cialis (tadalafil) 20 mg oral QD PRN need
8. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
9. Calcium Carbonate 500 mg PO DAILY
Discharge Medications:
1. Atenolol 100 mg PO DAILY
2. Levothyroxine Sodium 200 mcg PO DAILY
RX *levothyroxine 200 mcg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
3. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
4. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
5. Calcium Carbonate 500 mg PO DAILY
6. Cialis (tadalafil) 20 mg oral QD PRN need
7. Fluticasone Propionate 110mcg 1 PUFF IH DAILY
8. Sildenafil 100 mg PO DAILY:PRN need
9. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
10. Lisinopril 40 mg PO DAILY
please make sure you have bloodwork done on ___
RX *lisinopril 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Hemoptysis
Secondary: Metastatic papillary thyroid cancer to the lung,
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH
HISTORY: Hemoptysis. Question pneumonia.
COMPARISONS: No prior dedicated chest radiography or CT imaging available.
I-131 scan from ___ included CT images of the chest obtained for
SPECT-CT imaging.
TECHNIQUE: Chest, portable AP upright.
FINDINGS: The heart is at the upper limits of normal size. The mediastinal
and hilar contours are unremarkable aside from vague fullness of the right
superior mediastinum which probably reflects a known right suprahilar nodule.
Throughout each lung, multiple nodules of medium size are noted that are
consistent with known metastatic disease. Streaky left basilar opacity
suggests minor atelectasis in the lingula. There is no pleural effusion or
pneumothorax.
IMPRESSION: Multiple nodules suggesting metastatic disease, difficult to
compare directly to the prior study, but compatible with prior findings.
Radiology Report
HISTORY: Large amount of hemoptysis. Assess for metastatic cancer in lungs
with active extravasation versus pulmonary embolism.
COMPARISON: Chest radiograph ___, ___ Scan ___.
TECHNIQUE: Axial helical MDCT images were obtained from the suprasternal
notch to the upper abdomen with early arterial phase scanning after the
administration of 100 cc of Omnipaque. Multiplanar reformatted images in
coronal and sagittal axes were generated. Oblique MIP's were prepared in an
independent workstation.
DLP: 612.27 mGy-cm
FINDINGS:
CT Thorax: Innumerable bilateral pulmonary masses are consistent with known
metastatic disease. Largest measuring 2.7 x 1.6 cm (3:76), which is
substantially increased. Multiple small to moderate bilateral hilar lymph
nodes noted, difficult to compare directly to the prior non-contrast CT
examination.
Tree in ___ appearance in left lower lobe with patchy areas in the right
middle and right lower lobe is most likely bronchopneumonia, however may
represent sequelae of hemorrhage. Aerosolized secretions in the trachea and
left mainstem bronchus may represent aspiration or sequelae of hemorrhage in
the appropriate clinical setting. Diffuse bronchial wall thickening is noted.
There is no mediastinal or axillary lymph node enlargement by CT size
criteria. The heart, pericardium, and great vessels are within normal limits.
A small hiatal hernia is seen. No pleural effusion or pneumothorax seen.
CTA Thorax: The aorta and main thoracic vessels are well opacified. The
aorta demonstrates normal caliber throughout the thorax without intramural
hematoma or dissection. The pulmonary arteries are opacified to the segmental
level. No filing defect to suggest pulmonary embolism. No arteriovenous
malformation seen. No active extravasation of contrast.
Osseous structures: No blastic or lytic lesions suspicious for malignancy.
Although this study is not designed for assessment of intra-abdominal
structures, the visualized solid organs and stomach are unremarkable.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic dissection.
2. Many bilateral pulmonary masses which have slightly increased since ___ and are consistent with known metastatic disease. Largest measures 2.7
cm within the right hila. No active extravasation of contrast.
3. Tree in ___ appearance in left lower lobe with patchy areas in the right
middle and right lower lobe is most likely bronchopneumonia, however may
represent sequelae of hemorrhage. Aerosolized secretions in the trachea and
left mainstem bronchus may represent aspiration or sequelae of hemorrhage in
the appropriate clinical setting.
Updated results were conveyed via telephone by ___ to Dr. ___,
___ on ___.
Radiology Report
INDICATION: ___ year-old man with metastatic papillary thyroid cancer (mets to
lung) p/w hemoptysis, s/p IP bronchoscopy ___ w/ LLL clot but no active
bleed, continuing to have hemoptysis overnight, requesting ___ evaluation and
management // please evaluate for L bronchial artery bleed and embolise if
appropriate.
COMPARISON: CTA chest from ___.
TECHNIQUE: OPERATORS: Dr. ___ ___ resident) and Dr. ___
___ radiology attending) performed the procedure. The attending,
Dr. ___ was present and supervising throughout the procedure.
ANESTHESIA: General anesthesia.
FLUOROSCOPY TIME AND DOSE: 97.3 minutes, ___ mGy.
PROCEDURE: 1. Right common femoral artery access.
2. Common bronchial trunk arteriogram.
3. Left bronchial artery arteriogram.
4. Right bronchial artery arteriogram.
5. Bilateral bronchial embolization using 300-500 micron Embosphere particles.
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
positioned supine on the exam table. A pre-procedure time-out was performed
per
___ protocol. Both groins was prepped and draped in the usual sterile
fashion.
Using ultrasound and fluoroscopic guidance, the right common femoral artery
was punctured using a micropuncture set at the level of the mid-femoral head.
A permanent ultrasound image of the patent and compressible right common
femoral artery was saved to the PACS. A 0.018 inch wire was passed into the
vessel lumen. A small skin incision was made over the needle. The inner
dilator and wire were removed, and ___ wire was advanced under
fluoroscopy into the aorta. The micropuncture sheath was exchanged for a 5
___ sheath which was attached to a continuous heparinized saline side arm
flush.
A 5 ___ Omniflush catheter was used to advance the wire over the aortic
bifurcation to form the 5 ___ ___. The ___ catheter was used
to selectively catheterize a left bronchial artery arising from the aorta. A
bronchial arteriogram was performed which demonstrated supply to bronchi in
the left mid and upper lung. A Renegade ___ catheter was advanced into the
left bronchial artery with a Transend microwire and embolization to stasis was
performed using 300-500 micron Embosphere particles. Subsequently, the
___ catheter was used to selectively catheterze a common bronchial
artery and an arteriogram was performed. The Renegade ___ catheter was
advanced into the right bronchial artery with the aid of a Transend wire and
embolization to stasis was performed using 300-500 micron Embosphere
particles. The left bronchial artery arising from the common artery could not
be selectively catheterized.
The catheter and sheath were removed. Manual pressure was held until
hemostasis was achieved. Sterile dressings were applied. The patient tolerated
the procedure well, and there were no immediate
post-procedure complications
FINDINGS:
1. Left bronchial artery demonstrating hypervascular supply to bronchi in the
left mid and upper lung. This vessel was embolized to stasis.
2. Common bronchial artery with single right and left branches.
3. The right bronchial branch of the common bronchial artery demonstrted two
areas of hypervascular supply. This vesselswas embolized to stasis.
4. The left bronchial artery arising just beyond the origin of the common
bronchial trunk demonstrated hypervascular supply to mid and lower bronchi.
This vessel could not be catheteriezed.
IMPRESSION:
1. Embolization of a left upper bronchial artery and a right bronchial artery.
2. A left lower bronchial artery arising from a common bronchial trunk could
not be catheterized.
RECOMMENDATION: A left lower bronchial artery arising from a common
bronchial trunk could not be catheterized. As this was the area in which blood
was seen on bronchoscopy, repeat attempt at catherization may be considered if
the patient's hemoptysis continues.
Gender: M
Race: BLACK/AFRICAN
Arrive by WALK IN
Chief complaint: Hemoptysis
Diagnosed with OTHER HEMOPTYSIS
temperature: 98.0
heartrate: 65.0
resprate: 18.0
o2sat: 98.0
sbp: 121.0
dbp: 108.0
level of pain: 6
level of acuity: 3.0 | Admitted to MICU ___ - ___ due to hemoptysis.
#Hemoptysis: Patient was evaluated by IP in the ED for his known
pulmonary masses without evidence of active extravasation. He
was put on BP control to SBP<150 and underwent scheduled
bronchoscopy with Interventional Pulmonology, which showed no
bleeding but did show a clot in the left lower lobe. He was
given 1 day of CTX and azithromycin for initial concern for CAP,
but these were d/c'd after further evaluation. He continued to
have hemoptysis, so he was taken for bronchial artery
embolization by interventional radiology, who embolized the
right bronchial and accessory left bronchial arteries. The left
bronchial artery could not be cannulated. After the procedure,
the patient had some upper back pain, likely from
post-embolization necrosis. His hemoptysis resolved. His
hematocrit never fell, he never had hypoxia, and he was never
hemodynamically unstable.
#Hypertension: Requires strict BP control in the setting of his
hemoptysis. Home atenolol and triamterene-HCTZ were continued
for hypertension. He was given labetalol PRN for SBP >150. His
triamterene-HCTZ was held on the day of embolization to avoid
contrast-induced nephropathy.
#Metastatic Thyroid Cancer: Patient with known thyroid cancer
s/p radioactive iodine with known mets to the lungs. TSH 0.94,
T4 8.1, fT4 1.4, anti-tg <20, thyroglobulin 22. Patient's
longstanding endocrinologist visited him. Inpatient
endocrinology was also consulted and increased his synthroid
from 175 mcg to 200 mcg for TSH suppression. Hematology/oncology
was also consulted and agreed with ___ evaluation as above, with
radiation oncology eval if hemoptysis recurs. He will follow up
with his outpatient endocrinology for further management of his
cancer. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / E-Mycin
Attending: ___
Chief Complaint:
fatigue, DOE
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old male with a history of CAD, CKD/ESRD
with LUE fistula in place (not yet on HD), anemia, diabetes,
hypertension who presents ___ day history of generalized fatigue
and dyspnea with exertion.
He has been feeling weak for the past ___ days with associated
chest burning and dyspnea with exertion. These symptoms are
similar to those he experienced when he was admitted with
multifocal pneumonia in ___, though currently not as
severe. Per PCP recommendations he went to ___ Urgent
Care for further evaluation. He was advised to be evaluated in
the ED given his symptoms and his daughter requested transfer to
___ ED.
Of note, he was admitted in ___ of this year with
recurrent syncope. He was found to have a slow atrial rate with
bigeminy. It was thought that his PVCs were not perfusing beats.
His metoprolol was reduced from 200mg to 25mg daily. He had a
LINQ recorder placed for further monitoring with no significant
arrhythmias noted as of ___ per cardiology note.
In the ED, initial vitals were: 98.8 HR 83 BP 162/69 RR 16 96%
RA. He subsequently was febrile to 101.6.
Labs were notable for WBC 6.5 Hgb 8.9 Hct 27.2 Plt 171.
Chemistry with Cr 5.2 (baseline)
Trop 0.06--> 0.05 MB flat INR 5.4
UA with 100 protein, but neg leuk est and neg nitrite
Imaging: CT head with no acute intracranial process. CXR with
concern for pneumonia.
He received: Ceftriaxone, azithromycin, and tylenol
On the floor he is feeling more comfortable. He continues to
feel mildly dyspneic at rest, worse with exertion. He denies
chest burning at rest. He notes that his current symptoms are
similar to those he experienced with prior pneumonia, though not
as severe.
Review of systems is negative for headache, vision changes. He
had an episode of emesis 2 days ago, but none since. He denies
constipation or diarrhea. He recently underwent a root canal for
which he continues to take ciprofloxacin (dose unknown). He had
a mechanical fall 3 weeks ago and 6 weeks ago complicated by
cellulitis of the leg, now resolved.
Past Medical History:
- COPD not on O2
- CKD (Off transplant list)
- Diabetes Mellitus (type 2)
- HTN
- HLD
- CAD
- OA
Social History:
___
Family History:
-No history of renal disease in his family
-Prostate CA in brother, father, nephew
-No ___ of seizures
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vital Signs: 98.3 147/56 87 95% 2L NC
General: Alert, oriented, no acute distress, breathing
comfortably
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and normal rhythm, ___ SEM at RUSB
Lungs: Crackles extending from the base to the mid right lung
Abdomen: Soft, mildly tender across the inferior abdomen
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Alert and oriented x3
DISCHARGE PHYSICAL EXAM:
Vital Signs: AF, 147/50, 92, 18, 98% on RA
General: Alert, oriented, no acute distress, breathing
comfortably
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and normal rhythm, ___ crescendo-decrescendo
at RUSB
Lungs: crackles b/l bases, worse on R, L crackles improved.
decrease breath sounds at b/l upper lung fields.
Abdomen: soft, NTND
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Alert and oriented x3
Pertinent Results:
ADMISSION LABS:
___ 02:35PM BLOOD WBC-6.5# RBC-3.04* Hgb-8.9* Hct-27.2*
MCV-90 MCH-29.3 MCHC-32.7 RDW-16.4* RDWSD-53.1* Plt ___
___ 02:35PM BLOOD Neuts-86.4* Lymphs-6.8* Monos-5.3
Eos-0.9* Baso-0.3 Im ___ AbsNeut-5.59# AbsLymp-0.44*
AbsMono-0.34 AbsEos-0.06 AbsBaso-0.02
___ 02:35PM BLOOD ___ PTT-58.4* ___
___ 02:35PM BLOOD Glucose-140* UreaN-82* Creat-5.2* Na-139
K-3.6 Cl-101 HCO3-22 AnGap-20
___ 02:35PM BLOOD Calcium-8.9 Phos-5.9* Mg-2.4
DISCHARGE LABS:
___ 07:07AM BLOOD Glucose-127* UreaN-77* Creat-4.5* Na-141
K-3.6 Cl-104 HCO3-23 AnGap-18
___ 12:53PM BLOOD ___ PTT-33.6 ___
___ 07:07AM BLOOD WBC-6.7 RBC-2.92* Hgb-8.2* Hct-26.3*
MCV-90 MCH-28.1 MCHC-31.2* RDW-16.1* RDWSD-52.9* Plt ___
IMAGING:
CXR ___: There is a patchy area of density in the right
lower lobe medially. There is
a small patchy area of density in the retrocardiac region of the
left lower
lobe.
There is cardiomegaly but there is no CHF, pneumothorax or
effusion.
Degenerative changes are present spine and both shoulders.
There is a small
electronic device projecting over the anterior left chest
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amitriptyline 25 mg PO QHS
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Doxazosin 3 mg PO HS
5. Doxazosin 3 mg PO QAM
6. Fenofibrate 48 mg PO DAILY
7. Fish Oil (Omega 3) ___ mg PO DAILY
8. Multivitamins W/minerals 1 TAB PO DAILY
9. Polyethylene Glycol 17 g PO DAILY
10. Tizanidine 8 mg PO QHS
11. TraZODone 100 mg PO QHS:PRN insomnia
12. Warfarin 5 mg PO DAILY16 pAF
13. Ranitidine 150 mg PO DAILY
14. alpha lipoic acid 50 mg oral DAILY
15. Furosemide 40 mg PO DAILY
16. glucosam-msm-chondr-vit C-hyal ___ mg oral DAILY
17. lutein 6 mg oral DAILY
18. lycopene 10 mg oral DAILY
19. Metoprolol Succinate XL 25 mg PO DAILY
20. Travatan Z (travoprost) 0.004 % ophthalmic 1 gtt OS QHS
21. Amlodipine 10 mg PO DAILY
22. ubiquinol (bulk) 300 mg miscellaneous DAILY
23. Calcitriol 0.5 mcg PO DAILY
24. Epoetin Alfa 1000 units SC Q7DAYS
25. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation
1 INH daily
26. NovoLIN N (insulin NPH human recomb) 100 unit/mL
subcutaneous ___ units SC QHS per sliding scale
27. NovoLIN R (insulin regular human) 100 unit/mL injection ___
units QHS per sliding scale
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Doxazosin 3 mg PO HS
5. Doxazosin 3 mg PO QAM
6. Fenofibrate 48 mg PO DAILY
7. Fish Oil (Omega 3) ___ mg PO DAILY
8. Furosemide 40 mg PO DAILY
9. Metoprolol Succinate XL 25 mg PO DAILY
10. Multivitamins W/minerals 1 TAB PO DAILY
11. Polyethylene Glycol 17 g PO DAILY
12. Ranitidine 150 mg PO DAILY
13. TraZODone 100 mg PO QHS:PRN insomnia
14. Warfarin 5 mg PO DAILY16 pAF
15. alpha lipoic acid 50 mg oral DAILY
16. Amitriptyline 25 mg PO QHS
17. Calcitriol 0.5 mcg PO DAILY
18. Epoetin Alfa 1000 units SC Q7DAYS
19. glucosam-msm-chondr-vit C-hyal ___ mg oral DAILY
20. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation
1 INH daily
21. lutein 6 mg oral DAILY
22. lycopene 10 mg oral DAILY
23. NovoLIN N (insulin NPH human recomb) 100 unit/mL
subcutaneous ___ units SC QHS per sliding scale
24. NovoLIN R (insulin regular human) 100 unit/mL injection ___
units QHS per sliding scale
25. Tizanidine 8 mg PO QHS
26. Travatan Z (travoprost) 0.004 % ophthalmic 1 gtt OS QHS
27. ubiquinol (bulk) 300 mg miscellaneous DAILY
28. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath
RX *albuterol sulfate [Ventolin HFA] 90 mcg ___ puffs Q4H PRN
shortness of breath Disp #*1 Inhaler Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
community-acquired pneumonia
Secondary
chronic kidney disease stage 4
coronary artery disease
chronic obstructive pulmonary disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old man with PNA with worsening hypoxia // evaluate for
volume overload/worsening PNA
TECHNIQUE: Portable upright AP chest radiograph
COMPARISON: Chest radiograph from ___ for ___.
CT chest from ___.
IMPRESSION:
Substantial right lower lung opacity is increased from ___ which may
represent focal asymmetric pulmonary edema, early ARDS, or pneumonia.
Substantial cardiomegaly is likely stable given differences in technique. No
pleural effusion. Metallic foreign body overlying the left chest is seen to
sit on the anterior chest wall on lateral radiograph from ___.
RECOMMENDATION(S): Repeat chest radiographs after diuresis is recommended to
evaluate for underlying consolidation.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 4:53 ___, 5 minutes after
discovery of the findings.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dizziness, Weakness
Diagnosed with Pneumonia, unspecified organism
temperature: 98.8
heartrate: 83.0
resprate: 16.0
o2sat: 96.0
sbp: 162.0
dbp: 69.0
level of pain: 0
level of acuity: 3.0 | ___ yo M w/ CAD, CKD/ESRD with LUE fistula in place (not yet on
HD), anemia, diabetes, hypertension, COPD not on home O2 who
presents ___ day history of generalized fatigue and dyspnea with
exertion, found to have radiographic and clinical evidence of
pneumonia.
# RLL pneumonia: CXR was concerning for pneumonia with new 02
requirement. On admission he had no evidence of CHF,
pneumothorax, or effusion. Troponin elevated in the setting of
CKD and EKG without acute ischemic changes. He did not have
evidence of COPD exacerbation on admission. He was continued on
IV ceftriaxone/PO azithromycin for CAP. He became more hypoxic
during hospitalization requiring 6L NC. Repeat CXR showed
worsening b/l opacities, concerning for pulmonary edema vs.
worsening pneumonia. He was given IV Lasix which improved his
respiratory status and oxygen requirement. He was transitioned
to his home Lasix before discharge. He was also transitioned to
PO levofloxacin for 5 day total course of antibiotics.
# CKD: H/O CKD likely due to type 2 diabetes, not yet on
dialysis. He was inactivated on the kidney transplant list
after
recent hospitalization with pneumonia, sepsis and fevers
(___). Creatinine was at baseline during admission. He was
given IV Lasix and transitioned to his PO home Lasix dose as
above.
# Atrial fibrillation on coumadin: INR was supratherapeutic,
likely in the setting of concurrent antibiotic use for recent
root canal . Warfarin was held until INR decreased. He was
continued on metoprolol.
# COPD: Not on home ___. Patient was given duonebs standing to
improve respiratory status during hypoxic event discussed above.
- Continued tiotropium daily
# Diabetes: Mr. ___ is listed as being on NPH 10 units
nightly, though takes 5 units QHS at home along with insulin
sliding scale
- Continued NPH 5 units QHS
- Placed on insulin sliding scale
# HTN: Continued amlodipine 10 mg daily, doxazosin
# HLD: Continued atorvastatin, held fish oil and fenofibrate
# CAD: Continued metoprolol, statin, aspirin
# Insomnia: Continued trazodone prn
# GERD: Continued home ranitidine
# Glaucoma: Travoprost nonformulary, switched to latanoprost
while patient was in-house
# Constipation: Continued daily miralax
# S/P root canal: Recent root canal requiring a course of
ciprofloxacin. The patient had one more day of his course left
on admission and he was covered by IV ceftriaxone/azithromycin
for pneumonia. No further ciprofloxacin was given. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril / oxaliplatin / Codeine
Attending: ___.
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
Paracentesis
History of Present Illness:
___ w/metastatic pancreatic cancer on chemotherapy, last
chemotherapy last week, presents with back pain, acute kidney
injury and worsening thrombocytopenia. Patient states 3 days ago
she noted weakness in her legs, 2 days ago she noted low back
pain, no fevers she has not had any falls. She reports that pain
started suddenly while sitting. No trauma. Worse with sitting
down, better standing and leaning forward. Located in ___
low back and radiates into her coccyx. Stable since onset.
+Paresthesias of legs, but unable to state where and unclear if
this is true sensory problem or RLS type symptom as she also
reports that her legs feel "jumpy". Weakness has gotten worse
since onset. She cannot walk upstairs, has difficulty rising
from a seated position, can only stand independently for short
amounts of time or walk short distances. Weakness in worse in
thighs. She denies any bladder incontinence. Had one episode of
bowel incontinence but this was prior to onset of pain and
weakness. Last BM 2 days ago was normal.
Today she was scheduled for an L spine MRI to evaluate weakness
as well as chemotherapy. Her MRI was completed, however her labs
are checked and she was noted to have new acute kidney injury to
2.2 from a baseline of 0.9, she is also noted to be from
thrombocytopenic to platelets of 21. Pt admitted for further
work up.
She denies any chest pain or dyspnea. Patient is currently on
Lovenox for bilateral DVTs, with left leg swelling worse than
right for the last month. She denies any urinary symptoms,
diarrhea or abdominal pain. She did have some nausea and
vomiting with her chemotherapy. No GU or GI bleeding noted.
Curently, pt reports pain is well controlled with home
oxycodone. No nausea. + Fatigue and anorexia.
ROS: + as above, 10 points reviewed and otherwise negative
Past Medical History:
POncHx: Presented with abdominal complaints and abnormal LFTs in
___
with ultrasound imaging of the abdomen on ___ to evaluate
the gallbladder, a 4 cm hypoechoic area in the region of the
pancreas was identified, a mass or lesion could not be excluded,
there were no obvious gallstones present.
-On ___, CT imaging of the abdomen and pelvis with and
without contrast was performed at ___.
This revealed a 1.8-cm lesion in the dome of the liver, with
ring enhancing portion, no other definitive lesions were seen.
An MRI was recommended. Evaluation of the pancreas identified a
4 cm mass, low attenuation involving the pancreatic head, small
amount of surrounding infiltration of the fat, no surrounding
lymphadenopathy was seen. There was dilatation of the pancreatic
duct distal to the mass. SMV and SMA were patent and SMV was
immediately adjacent to the mass and the fat planes between the
SMV and the mass were blurred. There were no other concerning
abnormalities detected. There was incidental note of a duplex
right kidney.
-The patient was referred to ___ for EUS and diagnostic biopsy
which was performed by Dr. ___ on ___. EUS
identified a mass measuring 4 cm at the head of the pancreas,
borders were irregular and hard to define, mass was adjacent to
the portal confluence, no obvious abutting of the portal vein,
but the SMV could not be well visualized. There was no evidence
of celiac or SMA involvement. There was one hypoechoic 7-mm
lymph node adjacent to the mass. There was no definitive biliary
obstruction. FNA was performed of the pancreatic mass at the
time of the procedure. Cytology positive for malignant cells
consistent with adenocarcinoma with a component of signet ring
cells.
-___: ERCP with stenting of CBD for obstructive jaundice
-Staging laparoscopy with liver biopsy on ___: negative for
peritoneal spread, liver biopsy was positive for metastatic well
differentiate adenocarcinoma.
-FOLFIRINOX started ___ received two doses complicated by
allergic reaction to oxaliplatin manifesting as tongue
dysmotility and slurred speech.
-Gemcitabine monotherapy ___
PMHx:
1. Hypertension.
2. Obesity.
3. Hyperlipidemia.
4. Depression.
5. Hypothyroidism.
6. Chronic venous stasis.
7. History of tick bite.
8. Seasonal allergies.
9. Borderline type 2 diabetes.
10. Pancreatic cancer as described above.
11. Transvaginal hysterectomy for uterine prolapse in ___.
12. Bilateral DVT
Social History:
___
Family History:
Father had aortic stenosis. Mother is deceased due to CVA in her
___. Family history of peptic ulcer disease. Otherwise, no
breast, pancreatic, colon, or ovarian malignancies.
Physical Exam:
Admission:
VITALS: 97.7 117/56 55 18 100%ra
Pain: 4
GENERAL: nad
HEENT: membranes dry
NECK: no adenopathy
CARDIAC: rrr ___ sem
LUNG: ctab
ABDOMEN: distended, bowel sounds present, nontender
EXTREMITIES: +2 pitting edema to knees, + pulses by doppler
BACK: spinous process tenderness ~L4
NEURO: CN ___ intact. +nystagmus w/right gaze. upper
extremities strength ___. lower extremities ___. able to stand
independently. unable to stand on one leg or on toes. gait wide
based with small steps. sensation to light touch intact
SKIN: no rashes or ulcerations
Pertinent Results:
Admission Labs:
___ 01:00PM WBC-7.7 RBC-2.81* HGB-9.7* HCT-28.3* MCV-101*
MCH-34.3* MCHC-34.1 RDW-22.2*
___ 01:00PM PLT SMR-VERY LOW PLT COUNT-21*#
___ 01:00PM ___ ___
___ 01:00PM RET AUT-0.2*
___ 01:00PM HAPTOGLOB-133
___ 01:00PM TOT PROT-5.3* ALBUMIN-2.2* GLOBULIN-3.1
CALCIUM-7.9* PHOSPHATE-2.1* MAGNESIUM-1.6
___ 01:00PM ___
___ 01:00PM ALT(SGPT)-19 AST(SGOT)-38 LD(LDH)-217 ALK
PHOS-113* TOT BILI-1.3 DIR BILI-0.8* INDIR BIL-0.5
___ 01:00PM GLUCOSE-174* UREA N-48* CREAT-2.2*
SODIUM-129* POTASSIUM-3.9 CHLORIDE-94* TOTAL CO2-25 ANION GAP-14
Discharge Labs ___
White Blood Cells 11.0 4.0 - 11.0 K/uL
Hemoglobin 9.1* 12.0 - 16.0 g/dL
Hematocrit 26.4* 36 - 48 %
Urea Nitrogen 34* 6 - 20 mg/dL
Creatinine 1.7* 0.4 - 1.1 mg/dL
Sodium ___ mEq/L
Potassium 4.0 3.3 - 5.1 mEq/L
Chloride ___ mEq/L
Bicarbonate 24 22 - 32 mEq/L
Bilirubin, Total 2.5* 0 - 1.5 mg/dL
Reports:
MRI L Spine ___:
1. Diffuse marrow replacement is non-specific and may related
to a generalized marrow process such as marrow reconversion.
Diffuse metastases are unlikely without associated fluid signal
abnormality.
2. Multilevel degenerative disease causes moderate to severe
spinal stenosis at L2-L3, L3-L4, and L4-L5
CXR ___: No pneumonia. Slight interval increase of pulmonary
vascular congestion with evidence of mild pulmonary edema.
Renal ultrasound ___: 1. No evidence of hydronephrosis,
nephrolithiasis or suspicious renal masses. Bilateral kidneys
demonstrate a duplex morphology. 2. Ascites.
MR abdomen ___: 1. Extremely limited study due to the lack of
intravenous contrast and motion
artifact. No biliary obstruction. 2. Multiple liver
metastases which have progressed since the previous CT dated
___. 3. Mass within the pancreatic head and neck
surrounding the distal common bile duct stent consistent with
the known primary pancreatic malignancy. 4. The portal vein
confluence and splenic vein are not clearly identified on this
non-contrast study. Should further evaluation be required,
ultrasound is recommended. 5. Large volume intraperitoneal
ascites. 6. Trace left pleural effusion with associated left
lower lobe atelectasis
US-guided paracentesis ___: Ultrasound-guided therapeutic and
diagnostic paracentesis with removal of approximately 3.65
liters of clear straw-colored fluid.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 50 mcg PO DAILY
2. Lorazepam 0.5 mg PO Q4H:PRN nausea, anxiety, insomnia
3. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
4. Sertraline 25 mg PO DAILY
5. Vitamin D ___ UNIT PO DAILY
6. Hydrochlorothiazide 25 mg PO DAILY
7. Metoprolol Tartrate 100 mg PO BID
8. Ondansetron 8 mg PO Q8H:PRN nausea
9. Prochlorperazine 10 mg PO Q8H:PRN nausea
10. Enoxaparin Sodium 80 mg SC Q24H
Discharge Medications:
1. Enoxaparin Sodium 80 mg SC Q24H
2. Levothyroxine Sodium 100 mcg PO DAILY
3. Lorazepam 0.5 mg PO Q4H:PRN nausea, anxiety, insomnia
4. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
5. Prochlorperazine 10 mg PO Q8H:PRN nausea
6. Sertraline 25 mg PO DAILY
7. Vitamin D ___ UNIT PO DAILY
8. Ondansetron 8 mg PO Q8H:PRN nausea
9. Ciprofloxacin HCl 250 mg PO Q12H Duration: 2 Days
last day ___
10. Docusate Sodium 100 mg PO BID
11. Lactulose 30 mL PO BID:PRN constipation
12. Ranitidine 150 mg PO BID
13. Senna 1 TAB PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute renal failure
Thrombocytopenia
Metastatic pancreatic cancer
Anemia, chemotherapy-induced
Hyperbilirubinemia
Hypothyroidism
Ileus
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
HISTORY: Known metastatic prostate cancer, stool incontinence, and lower
extremity weakness.
COMPARISON: CT abdomen pelvis ___.
TECHNIQUE: Multiplanar multisequence MRI data were acquired through the
lumbar spine without intravenous contrast.
FINDINGS:
There is diffuse loss of normal signal intensity throughout the marrow of the
vertebral bodies. Vertebral body height is preserved. The spinal cord ends
at L1. There are severe degenerative changes at multiple levels.
T12-L1: No significant canal or neural foraminal stenosis.
L1-L2: Mild broad-based disc bulge. No central canal or right neural
foraminal stenosis. Mild left neural foraminal stenosis. Moderate ligamentum
flavum hypertrophy.
L2-L3: Moderate broad-based disc bulge, ligamentum flavum thickening and
facet hypertrophy cause moderate central canal stenosis. There is mild
bilateral neural foraminal narrowing. The disc bulge appears to contact the
right dorsal root ganglion.
L3-L4: Moderate broad-based disc bulge, facet hypertrophy and ligamentum
flavum thickening cause moderate central canal stenosis. There is moderate
right and mild left neural foraminal narrowing.
L4-L5: Mild broad-based disc bulge, facet hypertrophy, and ligamentum flavum
hypertrophy cause moderate to severe central canal stenosis. There is
moderate right and severe left neural foraminal stenosis. There is mild
anterolisthesis of L4 over l5. There is a small left facet joint effusion.
L5-S1: Moderate broad-based disc bulge and mild ligamentum flavum hypertrophy
cause mild central canal narrowing. There is no right and mild left neural
foraminal stenosis. There is a focus of fluid signal at the left L4-L5 facet
articulation.
IMPRESSION:
1. Diffuse marrow replacement is non-specific and may related to a
generalized marrow process such as marrow reconversion. Diffuse metastases
are unlikely without associated fluid signal abnormality.
2. Multilevel degenerative disease causes moderate to severe spinal stenosis
at L2-L3, L3-L4, and L4-L5.
Radiology Report
INDICATION: History of weakness on chemotherapy. Please rule out infiltrate.
COMPARISON: Chest radiographs from ___ and ___.
TECHNIQUE: Upright AP and lateral exam of the chest.
FINDINGS: A left-sided Port-A-Cath terminates at the cavoatrial junction.
The cardiac and mediastinal silhouette appears stable. There appears to be a
slight interval increase in the amount of pulmonary vascular congestion, with
evidence of mild pulmonary edema. There is no acute focal consolidation
concerning for pneumonia. There is a small left pleural effusion. No
pneumothorax is identified.
IMPRESSION: No pneumonia. Slight interval increase of pulmonary vascular
congestion with evidence of mild pulmonary edema.
Radiology Report
TYPE OF THE EXAM: Renal ultrasound.
REASON FOR THE EXAM AND MEDICAL HISTORY: Pancreatic cancer admitted with
acute kidney insufficiency and urinary retention; evaluate for obstruction.
COMPARISON EXAM: The most recent CT of the abdomen and pelvis, dated ___.
TECHNIQUE:
Multiple grayscale and Doppler images through the kidneys and urinary bladder
were obtained with a multifrequency transducer.
The right kidney measures 11.8 cm. There is no hydronephrosis,
nephrolithiasis or suspicious masses. Kidney demonstrates a duplex
morphology.
Left kidney measures 11.3 cm without evidence of hydronephrosis,
nephrolithiasis, or suspicious masses. Left kidney demonstrates a duplex
morphology as well.
Visualization of the urinary bladder is limited, however, there is evidence of
ascites superior to the urinary bladder as well as surrounding the kidneys.
IMPRESSION:
1. No evidence of hydronephrosis, nephrolithiasis or suspicious renal masses.
Bilateral kidneys demonstrate a duplex morphology.
2. Ascites.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient with metastatic pancreatic
cancer, mild wheezing.
PA and lateral upright chest radiographs were reviewed in comparison to ___.
The Port-A-Cath catheter tip terminates at the level of cavoatrial junction.
Heart size and mediastinum are unremarkable. There is interval resolution of
interstitial pulmonary edema. Small bilateral pleural effusions are most
likely present. There is no overt evidence of consolidation or pneumothorax.
Radiology Report
HISTORY: Metastatic pancreatic cancer presenting with ___, now with rising
bilirubin. Please evaluate for biliary obstruction, progression of disease,
vein patency.
COMPARISON: CT dated ___.
TECHNIQUE: Multiplanar T1 and T2 weighted images were acquired on a 1.5 Tesla
magnet without intravenous contrast.
The study is technically very limited due to the lack of intravenous contrast
and due to motion artifact.
FINDINGS:
There is a mass involving the head and neck of the pancreas which is
surrounding the metallic stent within the common bile duct (13:37). The body
and tail of the pancreas appear atrophic.
There are multiple rounded T2 hyperintense lesions within the liver which
demonstrate restricted diffusion -the largest measures 2.5 cm in segment VI
(13:33). These have progressed significantly since the previous CT in ___ and are consistent with multiple liver metastases. No intra or
extrahepatic duct dilatation. Pneumobilia is noted with air within the left
hepatic duct and also within the gallbladder. No biliary dilatation is
present.
The portal vein confluence and splenic vein are not clearly identified on this
non-contrast study.
There is large volume intraperitoneal ascites. There is edema throughout the
subcutaneous tissues, consistent with widespread anasarca. Note is made of a
cystic lesion within the skin of the back measuring 1.9 cm and likely
representing a sebaceous cyst (6:39).
Note is made of duplex collecting systems within both kidneys. The kidneys
are otherwise unremarkable on this non-contrast study. No hydronephrosis.
The adrenals and spleen are unremarkable. There is a small sliding hiatus
hernia. The visualized small and large bowel is unremarkable. No
retroperitoneal or mesenteric adenopathy. There is a trace left pleural
effusion with associated left lower lobe atelectasis. Bone marrow signal is
normal. No destructive osseous lesions.
IMPRESSION:
1. Extremely limited study due to the lack of intravenous contrast and motion
artifact. No biliary obstruction.
2. Multiple liver metastases which have progressed since the previous CT
dated ___.
3. Mass within the pancreatic head and neck surrounding the distal common
bile duct stent consistent with the known primary pancreatic malignancy.
4. The portal vein confluence and splenic vein are not clearly identified on
this non-contrast study. Should further evaluation be required, ultrasound is
recommended.
5. Large volume intraperitoneal ascites.
6. Trace left pleural effusion with associated left lower lobe atelectasis.
Radiology Report
INDICATION: History of pancreatic cancer with new ascites, please do
paracentesis.
PREPROCEDURE IMAGING AND FINDINGS: There is a moderate-to-large amount of
ascites seen in the abdomen. The largest fluid pocket in the right lower
quadrant was targeted for paracentesis.
PHYSICIANS: Dr. ___ and Dr. ___.
PROCEDURE:
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 an entrance site was selected and the skin was
prepped and draped in the usual sterile fashion. 1% lidocaine was instilled
for local anesthesia.
A 5 ___ ___ catheter was advanced into the largest fluid pocket in the
right lower quadrant and 3.65 liters of clear straw-colored fluid was removed.
The patient tolerated the procedure well without immediate complication.
Estimated blood loss was minimal.
Dr. ___ attending radiologist, was present throughout the critical
portions of the procedure.
IMPRESSION:
Ultrasound-guided therapeutic and diagnostic paracentesis with removal of
approximately 3.65 liters of clear straw-colored fluid.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: LOWER BACK PAIN
Diagnosed with LUMBAGO, MALIG NEO PANCREAS NOS, SECOND MALIG NEO LIVER, HYPERTENSION NOS, HYPOTHYROIDISM NOS
temperature: 97.7
heartrate: 52.0
resprate: 16.0
o2sat: 100.0
sbp: 112.0
dbp: 53.0
level of pain: 1
level of acuity: 3.0 | ___ with metastatic pancreatic adenocarcinoma on
gemcitabine/capecitabine who presented with ___,
thrombocytopenia, and leg weakness, course complicated by
hyperbilirubinema, ileus, and hypothyroidism.
# Acute renal failure: She presented with elevated creatinine to
2.2 from a normal baseline. Urine lytes and history were
consistent with volume depletion. She was given IV fluids with
mild improvement in her creatinine. She became total body
volume overloaded with worsening ascites and peripheral edema
from the IV fluid. Urine lytes were consistently consistent
prerenal etiology. Urine output remained borderline oliguric
despite IV fluids and albumin. Renal was consulted and
recommended fluids as needed given her intravascular volume
depletion. Her creatinine slowly improved with these measures
and was 1.4-1.7 at discharge.
# Ileus: She had constipation and developed bilious vomiting
despite an aggressive bowel regimen. There were no signs of
obstruction on MR abdomen. It was felt that she likely had an
ileus from her ascites, volume overload and cancer. This
resolved with bowel regimen / relief of constipation and
paracentesis.
# Hyperbilirubinemia: T bili was 1.3 on admission and increased
to 2.9, mostly direct. She underwent MR abdomen to rule out
biliary obstruction which showed no obstruction. Cause of
elevated bilirubin felt to be due to liver ___ vs cholestasis
related to volume overload. Also could consider hemolysis as
haptoglobin trended down to undetectable although LDH was
normal. Total bili 2.5 at discahrge.
# Hypothyroidism: TSH>100 on admission, although free T4, T3
only mildly low. ___ explain some of her symptoms such as
constipation, weakness, slow mental status. Also mildly
bradycardic which could be related (or related to beta blocker).
AM cortisol was normal. Increased levothyroxine to 100mcg
daily and repeat TFTs were improving. She should have repeat
TFTs in 1 week and 4 weeks with further adjustment of her
levothyroxine dose as needed.
# Bilateral popliteal DVT: Lovenox started ___ as outpatient.
It was initially held due to thrombocytopenia and then restarted
when platelets >50K.
# Metastatic Pancreatic adenocarcinoma: On C2D9 of gemcitabine
and xeloda on admission which was held due to complications.
She had evidence of worsening disease with MR showing growing
liver ___. Oncology, Palliative care and SW was consulted.
In discussion with her primary oncologist, the patient decided
to pursue palliative care only from this point forward. She
remains a full code at discharge but recommend ongoing SW and
palliative care involvement for goals of care discussions and
end of life planning.
# ___ weakness: Lumbar MRI showed severe spinal stenosis but no
metastatic disease or cord compression. She had some mild back
pain which was controlled with oxycodone. She had generalized
weakness on exam felt to be most likely related to above medical
issues and deconditioning. ___ recommended rehab.
# Thrombocytopenia: Platelets 22K on admission felt related to
chemo. Improved daily, normal by discharge.
# Anemia: Overall remained stable during admission.
Multifactorial, low retic count. ___ be element of hemolysis
with low haptoglobin however LDH not elevated.
# Diabetes mellitus type II: Diet controlled
# UTI: Culture grew Klebsiella. Treated with 7 day course of
ciprofloxacin to end ___.
#Bradycardia: ___, asymptomatic. Metoprolol discontinued.
___ also have been contribution from hypothyroid. Normalized by
discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
codeine / Percocet
Attending: ___.
Chief Complaint:
Hematochezia, found to have AML
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with a history of
HTN and HLD presenting with acute leukemia.
Patient reports a 1 week history of sore throat and cough.
Denies
fevers. Also reported some dysuria. Overnight had sweats. Awoke
with urgency to defecate. Did not make it to bathroom and had a
large bloody BM. Had ___ more mostly blood BMs since this AM.
She initially presented to ___. There labs notable for: H/H
___. WBC 10. Diff on CBC notable for platelets of 43, neuts
of 1%. Manual smear read by pathologist at ___ and reportedly
c/f
leukemia. She received IV CTX for UTI. Received 40mg IV
protonix. She was transferred to ___ for further care.
In the ___ ED, initial VS: 98 123/77 88 20 96RA. Fever 100.8
at
1500. Hgb 10.2 w/ 93% blasts (repeat 9.7). Plts 35, nl coags,
unremarkable CHEM10, LFTs; uric acid 4.6; fibrinogen 508. She
received 1 bag of platelets (post-transfusion plt 84), 2g IV
cefepime.
Upon arrival to the floor, she feels well. No further large
BRBPR
since ___.
REVIEW OF SYSTEMS: A 10 point review of systems was performed in
detail and is negative exact as noted in the HPI
Past Medical History:
hypertension
hyperlipidemia
?Takutsubo's after death of a friend, elevated enzymes, sounds
like clean LHC, follows yearly with a cardiologist
-Prior UTIs
-Prior D&C for vaginal bleeding
Social History:
___
Family History:
Siblings: brother died of lung cancer (smoker) at age ___
Mother: died of pancreatic cancer at age ___
Father: died at ___, healthy
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
General: NAD
VITAL SIGNS: 100.8 94 138/54 18 95% RA
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary adenopathy, no thyromegaly
CV: RR, NL S1S2 no S3S4 MRG
PULM: CTAB
ABD: BS+, soft, NTND, no masses or hepatosplenomegaly
RECTAL: on visual exam, no external hemorrhoids
LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal
adenopathy
SKIN: No rashes or skin breakdown
NEURO: Cranial nerves II-XII are within normal limits excluding
visual acuity which was not assessed, no nystagmus; strength is
___ of the proximal and distal upper and lower extremities; gait
is normal, coordination is intact.
DISCHARGE PHYSICAL EXAM
========================
VITAL SIGNS: 97.7 (97.7-98.7) 90 (77-96) 120/76 (102-120/60-78)
18 96-98RA
General: Pleasant elderly women, alert and oriented in NAD
HEENT: MMM, clear OP , no cervical LAD.
CV: RRR. Normal S1, S2. No murmurs, rubs, or gallops
PULM: CTA b/l. No increase work of breathing. No wheezes,
crackles, rhonchi
ABD: +BS. nondistended, nontender. no masses or
hepatosplenomegaly
EXTREMITIES: WWP. No ___ edema. 2+ ___ pulses
SKIN: No rashes or skin breakdown; 3 cm erythematous, warm,
indurated, non-fluctuant, and slightly tender plaques, with
central hair, on left labia and directly below mons pubis, less
indurated on ___ (resolved on ___ re-emergence of
erythematous indurated plaque on left labia on ___.
NEURO: CN II-XII grossly intact. Steady gait
LINE: L Port c/d/i
Pertinent Results:
ADMISSION LABS
=============================
___ 11:25AM WBC-10.2* RBC-3.13* HGB-9.7* HCT-29.8* MCV-95
MCH-31.0 MCHC-32.6 RDW-12.3 RDWSD-42.6
___ 11:25AM NEUTS-2* BANDS-0 LYMPHS-5* MONOS-0 EOS-0
BASOS-0 ___ MYELOS-0 BLASTS-93* AbsNeut-0.20*
AbsLymp-0.51* AbsMono-0.00* AbsEos-0.00* AbsBaso-0.00*
___ 11:25AM PLT SMR-VERY LOW PLT COUNT-35*
___ 11:25AM ___ PTT-26.4 ___
___ 11:25AM ___
___ 11:25AM GLUCOSE-109* UREA N-16 CREAT-0.9 SODIUM-139
POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-26 ANION GAP-12
___ 11:25AM ALT(SGPT)-9 AST(SGOT)-13 LD(LDH)-187 ALK
PHOS-63 TOT BILI-0.4
___ 11:25AM ALBUMIN-3.9 CALCIUM-8.4 PHOSPHATE-2.8
MAGNESIUM-1.6 URIC ACID-4.6
MICROBIOLOGY
=============================
Bcx from ___ (___): No growth
Ucx from ___ (___): >100k E. coli sensitive to cefepime,
CTX, Keflex
Ucx (___): No growth
Bcx x2 (___): No growth
Ucx (___) < 10,000 CFU/mL.
BCx (___): NGTD (final)
UCx (___): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES),
CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION.
Influenza A/B PCR (___): negative
Nasopharyngeal swab (___):
Respiratory Viral Culture (Final ___: No respiratory
viruses isolated. Culture screened for Adenovirus, Influenza A &
B, Parainfluenza type 1,2 & 3, and Respiratory Syncytial Virus.
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.
PATHOLOGY
=============================
BM Biopsy (___):
ACUTE MYELOID LEUKEMIA, SEE NOTE.
NOTE: Blast including some with Auer rods noted. The concurrent
flow cytometry show amyeloid phenotype (CD34 (subset), HLA ___
(___), CD117, CD13, cMPO and aberrant CD7).
The corresponding cytogenetic analysis shows a normal female
karyotype without recurrent cytogenetic abnormalities (see
separate complete report ___-___). Molecular analysis is
underway.
MICROSCOPIC DESCRIPTION.
ASPIRATE SMEAR:
The aspirate material is for evaluation and consists of multiple
cellular spicules. Numerous blasts are seen that are large in
size with slightly irregular nuclear contours, one or more
prominent
nucleoli, and mild to moderate amount of cytoplasm. Few granules
present in the cytoplasm with rare Auer rods. Erythroid
precursors are seen and have normoblastic maturation. Rare
maturing myeloid precursors are seen. Rare megakaryocytes are
seen. A 300 cell differential shows 65% blasts, 1% myelocytes,
1% bands/neutrophils, 2% eosinophils, 30% erythroids, 1%
lymphocytes.
CLOT SECTION and BIOPSY SLIDES:
The core biopsy material is adequate for evaluation. Focal
aspiration artifact is present. It consists of a 1.5 cm long
core biopsy with skeletal muscle, periosteum and trabecular
marrow with a cellularity of 30%. There is an interstitial
infiltrate of mononuclear cells, consistent with blasts
occupying 90% of overall cellularity. The limited remaining
hematopoiesis is comprised of erythroid precursors, along with
rare maturing myeloid precursors and eosinophils. Megakaryocytes
are
deceased in number. Clot sections show similar findings.
SPECIAL STAINS:
Iron stain performed on aspirate material is adequate for
evaluation. Storage iron is present. Occasional sideroblasts are
seen and ringed sideroblasts are not present.
IMMUNOPHENOTYPING:
FLOW CYTOMETRY REPORT
The following tests (antibodies) were performed: ___, Kappa,
Lambda and CD antigens
2,3,4,5,7,8,10,11c,13,14,16,19,20,23,33,34,38,45,56,64,117,
nTdT, cMPO, cCD79a, cCD3, cCD22.
RESULTS:
10-color analysis with linear side scatter vs. CD45 gating is
used to evaluate for leukemia.
95% of total acquired events, are evaluable non-debris events.
The viability of the analyzed non-debris events, done by 7-AAD
is 99.6%.
CD45-bright, low side-scatter gated lymphocytes comprise 7% of
total analyzed events.
B cells comprise 14% of lymphoid gated events, are polyclonal,
and do not express aberrant antigens.
T cells comprise 51% of lymphoid gated events and express mature
lineage antigens CD3, CD5, CD2 and CD7.
CD56 positive, CD3 negative natural-killer cells represent 28%
of gated lymphocytes.
Cell marker analysis demonstrates that the majority (86%) of the
cells isolated from this peripheral blood are in the CD45
dim/low side-scatter "blast" region. They express immature
anitgens CD34 (subset), ___ (___), and CD117, along with
CD7, CD13 (minor subset dim), CD38 and cMPO, and are negative
for CD33, the remaining B and T cell associated surface antigens
evaluated and CD14, CD16, CD56, CD64, nTdT, cCD79a, cCD3, and
cCD22.
INTERPRETATION
Immunophenotypic findings consistent with involvement by acute
myeloid leukemia. Correlation with clinical and other ancillary
findings is recommended. Flow cytometry immunophenotyping may
not detect all abnormal populations due to topography, sampling
or artifacts of sample preparation.
CYTOGENETIC DIAGNOSIS: 46,XX[20] Normal female karyotype.
FISH: NEGATIVE MDS PANEL. No evidence of interphase bone marrow
cells with the common cytogenetic abnormalities observed in
myelodysplastic syndrome. These include deletion 5q31 and
monosomy 5, deletion 7q31 and monosomy 7, trisomy 8, and
deletion 20q12.
BM Biopsy (___):
PATHOLOGIC DIAGNOSIS:
SPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY
DIAGNOSIS:CELLULAR ERYTHROID DOMINANT BONE MARROW WITH
TRILINEAGE MATURING HEMATOPOIESIS AND INCREASED BLASTS IN THE
PERIPHERAL BLOOD ONLY, SEE NOTE.
NOTE: It is unusual in this case that a significant number of
blasts are seen in the peripheral blood but not in the bone
marrow. The latter was confirmed by immunostain for CD34. Still,
by WHO criteria, this represents persistent acute myeloid
leukemia.
MICROSCOPIC DESCRIPTION
Peripheral blood smear:
The smear is adequate for evaluation. Erythrocytes are decreased
and normocytic and had slight anisopoikilocytosis including
scattered elliptocytes. The white blood cell count is markedly
decreased and frequent myeloblasts are seen. Platelet count
appears markedly decreased. Large and giant platelets are not
seen. A 100 cell differential shows 39% myeloblasts, 5%
neutrophils, 5%
bands, 39% lymphocytes, 10% monocytes, 1% eosinophils, 0%
basophils.
Bone marrow aspirate:
The aspirate material is adequate and consists of multiple
cellular spicules. The M:E ratio is 0.28:1.
Erythroid precursors are relatively proportionately increased in
number and have normoblastic maturation. Myeloid precursors are
relatively proportionately decrased in number and show
left-shifted maturation with increased blasts . Megakaryocytes
are increased in number. Abnormal forms are seen including
occasional hypolobated cells, micromegakaryocytes with widely
spaced
and disjointed nuclei, large. A 300 cell differential shows 6%
blasts, 0% promyelocyts, 8% myelocytes, 1% metamyelocytes, 1%
bands/neutrophils, 3% eosinophils, 67% erythroids, 13%
lymphocytes, 1% plasma cells.
Clot section and biopsy slides:
The core biopsy material is suboptimal for evaluation due to
small size. It consists of a 0.5 cm long core biopsy of
trabecular marrow cortical bone and periosteum with a
cellularity of ___. The M:E
ratio estimate is decreased. Erythroid precursors are relatively
proportionately increased in number and have overall
normoblastic maturation. Myeloid precursors are relatively
proportionately
decreased in number with maturation. Megakaryocytes are present.
FLOW CYTOMETRY REPORT
FLOW CYTOMETRY IMMUNOPHENOTYPING
The following tests (antibodies) were performed: ___, nTdT,
cMPO, cCD79a, cCD3, cCD22, and CD antigens
7,11b,13,14,16,19,33,34,45,64, and 117.
RESULTS:
10-color analysis with linear side scatter vs. CD45 gating is
used to evaluate for leukemia.
A subset of the acquired events are in the low light scatter
cell debris/lysed cell region with nondebris cells comprising
81% of total acquired events. The viability of the analyzed
non-debris events, done by 7-AAD is 88%. A limited panel is
performed to look for residual disease.
CD45-bright, low side-scatter gated lymphocytes comprise 17% of
total analyzed events. Of these, CD19(+) B cells comprise 15% of
lymphoid gated events. Cell marker analysis demonstrates that a
significant subset (49%) of the cells isolated from this bone
marrow are in the CD45-dim/low side-scatter "blast" region. They
express immature antigens CD34 (subset; 34% of CD45dim gated
events, ~16% of total), ___ ___ ~50% of gated, 25% of
total), myeloid associated antigens CD117, CD33(dim, subset),
CD13 (minor subset), cMPO, as well as nTdT (subset) and lymphoid
associated antigens CD7 (subset). They lack other T cell
associated (cCD3), B-cell associated (cCD79, cCD22) antigens and
are negative for CD14 or CD11b. CD117(+), CD45dim, low
side-scatter blast cells comprise ~40% of total analyzed events.
CD34(+) blasts are 16%.
INTERPRETATION
Immunophenotypic findings consistent with patient's known acute
myeloid leukemia.
bone marrow biopsy (___): preliminary read shows no blasts
IMAGING
=============================
CXR (___):
FINDINGS:
Heart size is normal. The aorta The mediastinal and hilar
contours are
otherwise unremarkable. The pulmonary vasculature is normal. No
focal
consolidation, pleural effusion or pneumothorax is present.
Hypertrophic
changes are noted in the thoracic spine.
IMPRESSION:
No acute cardiopulmonary abnormality.
Chest CT w/o contrast (___):
IMPRESSION:
1. No pneumonia.
2. Sub 3-mm right middle and upper lobe pulmonary micronodules.
Follow-up chest CT in ___ year if the patient is high risk.
3. 5-mm right mid central and outer breast lesion could be a
cyst. Further evaluation with mammography non-emergently is
recommended if clinically indicated.
4. 1.3-cm thyroid nodule. Given the size <1.5 cm and the
patient's age, no specific follow-up is needed if the patient is
not deemed high risk. If the patient is high risk, further
evaluation non-emergently with ultrasound is recommended.
5. Anemia.
RECOMMENDATION(S):
1. Follow-up chest CT in ___ year for right lobe pulmonary
micronodules <4 mm if the patient is high risk. Otherwise, no
follow-up is needed.
2. Non-emergent thyroid ultrasound for thyroid nodule
evaluation is
recommended only if the patient is deemed high risk.
3. Consider non-emergent mammogram or comparison with prior
imaging if
available for a 5-mm right breast lesion.
CT A/P w/o contrast (___):
IMPRESSION:
1. No specific finding on CT in the abdomen or pelvis to explain
the patient's symptoms. No abnormal colonic stool burden or
bowel obstruction.
2. Cholelithiasis.
3. Non-specific mild fat-stranding near the celiac trunk and SMA
could be
related to the patient's known malignancy.
4. Fibroid uterus.
5. 5-mm left upper renal pole hemorrhagic or proteinaceous cyst.
This preliminary report was reviewed with Dr. ___,
___ radiologist.
CXR (___):
IMPRESSION: In comparison to study of ___, this and
placement of a right IJ catheter that extends to the lower SVC.
No evidence of post procedure pneumothorax. No acute pneumonia
or vascular congestion.
CXR (___):
FINDINGS:
Cardiac size is normal. The lungs are clear. There is no
pneumothorax or
pleural effusion. Unchanged position of right subclavian
central line.
IMPRESSION: No acute cardiopulmonary abnormality and no
significant changes since ___
CXR (___):
FINDINGS:
Patent left internal jugular vein. Final fluoroscopic image
showing port with catheter tip terminating in the right atrium.
IMPRESSION:
Successful placement of a single lumen chest power Port-a-cath
via the left internal jugular venous approach. The tip of the
catheter terminates in the right atrium. The catheter is ready
for use.
DISCHARGE AND PERTINENT LABS
=============================
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Simvastatin 20 mg PO QPM
2. losartan-hydrochlorothiazide 100-12.5 mg oral DAILY
3. Vitamin D Dose is Unknown PO DAILY
4. flaxseed unknown oral DAILY
5. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acyclovir 400 mg PO TID
RX *acyclovir 400 mg 1 tablet(s) by mouth three times a day Disp
#*42 Tablet Refills:*0
2. Bisacodyl 10 mg PO DAILY constipation
RX *bisacodyl [Laxative (bisacodyl)] 5 mg 2 tablet(s) by mouth
once a day Disp #*14 Tablet Refills:*0
3. Cephalexin 500 mg PO Q12H
RX *cephalexin 500 mg 1 capsule(s) by mouth every twelve (12)
hours Disp #*28 Capsule Refills:*0
4. Docusate Sodium 100 mg PO BID constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*28 Capsule Refills:*0
5. Fluconazole 400 mg PO Q24H
RX *fluconazole 200 mg 2 tablet(s) by mouth Q24H Disp #*28
Tablet Refills:*0
6. Losartan Potassium 100 mg PO DAILY
RX *losartan 100 mg 1 tablet(s) by mouth once a day Disp #*14
Tablet Refills:*0
7. Polyethylene Glycol 17 g PO DAILY constipation
RX *polyethylene glycol 3350 17 gram/dose 17g powder(s) by mouth
once a day Refills:*0
8. Senna 8.6 mg PO BID constipation
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*28 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
Acute Myeloid Leukemia
Hematochezia
Hypertension
Urinary Tract Infection
Folliculitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest CT
INDICATION: ___ woman with new acute leukemia presenting with an
acute cough. Evaluate for acute process.
TECHNIQUE: Contiguous axial images were obtained through the chest without
intravenous contrast. Coronal and sagittal reformats were obtained.
COMPARISON: No prior cross-sectional imaging of the chest is available on
PACS at the time of this dictation. Limited reference is made with the
conventional chest radiograph from ___.
FINDINGS:
Detailed evaluation of the solid organs, soft tissues, and vessels is limited
without the use of intravenous contrast. Within this limitation:
The thoracic aorta is normal in caliber. The main, left, and right pulmonary
arteries are normal in caliber. Mitral annulus calcifications are mild.
Coronary artery calcifications are present. Hypoattenuation of the cardiac
blood pool on this unenhanced scan suggests anemia. No evidence of a
pericardial effusion.
Several bilateral axillary lymph nodes are prominent but appear to maintain
their normal fatty hila. No pathologically enlarged axillary,
supraclavicular, mediastinal, or hilar lymph nodes. No mediastinal mass. A
fat-containing right posterior medial diaphragmatic hernia is small (series 6,
image 43; series 4, image 259; series 7, image 24).
Detailed evaluation of the lung parenchyma is limited secondary to respiratory
and cardiac motion artifact. Pulmonary micronodules in the right upper and
middle lobes measure under 3 mm (series 4, image 113, 161). No pulmonary
edema, focal consolidation concerning for infection, or suspicious pulmonary
mass. The airways are patent to at least the subsegmental level. No pleural
effusion or pneumothorax.
The thyroid is not enlarged but is heterogeneous with several hypodense
nodules, the largest measuring up to 1.3 cm in the left lobe (series 3, image
9).
This exam is not dedicated for imaging of the breasts for which mammography
would be required. However, there is a 5-mm soft tissue nodule in the right
mid central outer breast at mid depth (series 3, image 39; series 6, image
15). No osseous lesions concerning for malignancy or infection in the bony
thoracic cage. Multi-level degenerative changes are most prominent in a lower
thoracic spine with prominent anterior osteophytes. No fracture.
Please refer to the dedicated CT abdomen and pelvis report from the same day
for a description of sub-diaphragm findings.
IMPRESSION:
1. No pneumonia.
2. Sub 3-mm right middle and upper lobe pulmonary micronodules. Follow-up
chest CT in ___ year if the patient is high risk.
3. 5-mm right mid central and outer breast lesion could be a cyst. Further
evaluation with mammography non-emergently is recommended if clinically
indicated.
4. 1.3-cm thyroid nodule. Given the size <1.5 cm and the patient's age, no
specific follow-up is needed if the patient is not deemed high risk. If the
patient is high risk, further evaluation non-emergently with ultrasound is
recommended.
5. Anemia.
This preliminary report was reviewed with Dr. ___
radiologist.
RECOMMENDATION(S): 1. Follow-up chest CT in ___ year for right lobe pulmonary
micronodules <4 mm if the patient is high risk. Otherwise, no follow-up is
needed.
2. Non-emergent thyroid ultrasound for thyroid nodule evaluation is
recommended only if the patient is deemed high risk.
3. Consider non-emergent mammogram or comparison with prior imaging if
available for a 5-mm right breast lesion.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old woman with newly diagnosed leukemia, received CVL for
chemotherapy // Please evaluate line placement Contact name: ___ , ___:
___ Please evaluate line placement
IMPRESSION:
In comparison to study of ___, this and placement of a right IJ catheter
that extends to the lower SVC. No evidence of post procedure pneumothorax.
No acute pneumonia or vascular congestion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with newly diagnosed AML p/w worsening cough
// Please evaluate for any acute processes
TECHNIQUE: Single frontal view of the chest
COMPARISON: Chest radiograph ___
FINDINGS:
Cardiac size is normal. The lungs are clear. There is no pneumothorax or
pleural effusion. Unchanged position of right subclavian central line.
IMPRESSION:
No acute cardiopulmonary abnormality and no significant changes since ___
Radiology Report
INDICATION: ___ year old woman with AML on dicitabin and MUC1. will need
portacath for chemo // please place chest single leumon port for
chemotherapy. patient is in house please leave access. ___.
COMPARISON: None available.
TECHNIQUE: OPERATORS: Dr. ___, attending radiologist performed the
procedure.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
75 mcg of fentanyl and 1.5 mg of midazolam throughout the total intra-service
time of 30 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: Cefazolin 1 g.
CONTRAST: 0 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 1.9 min, 1 mGy
PROCEDURE
1. Left internal jugular approach chest single lumen Port-a-cath placement
PROCEDURE DETAILS: Following the explanation of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The upper chest was prepped and draped in the usual sterile fashion.
Under continuous ultrasound guidance, the patent left internal jugular vein
was compressible and accessed using a micropuncture needle. Permanent
ultrasound images were obtained before and after intravenous access, which
confirmed vein patency. Subsequently a Nitinol wire was passed into the right
atrium using fluoroscopic guidance. The needle was exchanged for a
micropuncture sheath. The Nitinol wire was removed and a short ___ wire was
advanced to make appropriate measurements for catheter length. The ___ wire
was then passed distally into the IVC.
Next, attention was turned towards creation of a subcutaneous pocket over the
upper anterior chest wall. After instilling superficial and deeper local
anesthesia using lidocaine mixed with epinephrine, a 2.5 cm transverse
incision was made and a subcutaneous pocket was created by using blunt
dissection. The single lumen port was then connected to the catheter. The
catheter was tunneled from the subcutaneous pocket towards the venotomy site
from where it was brought out using a tunneling device. The port was then
connected to the catheter and checks were made for any leakage by accessing
the diaphragm using a non-coring ___ needle. No leaks were found.
The port was then placed in the subcutaneous pocket and secured with ___
Prolene sutures on either side. The venotomy tract was dilated using the
introducer of the peel-away sheath supplied. Following this, the peel-away
sheath was placed over the ___ wire through which the port was threaded into
the right side of the heart with the tip in the right atrium. The sheath was
then peeled away.
The subcutaneous pocket was closed in layers with ___ interrupted and ___
subcuticular continuous Vicryl sutures. Vicryl sutures and Dermabond were
used to close the venotomy incision site. Final spot fluoroscopic image
demonstrating good alignment of the catheter and no kinking. The tip is in the
right atrium.
The port was accessed using a non coring ___ needle and could be aspirated
and flushed easily. Sterile dressings were applied. The patient tolerated the
procedure well without immediate complication. The port was left accessed as
requested.
FINDINGS:
Patent left internal jugular vein. Final fluoroscopic image showing port with
catheter tip terminating in the right atrium.
IMPRESSION:
Successful placement of a single lumen chest power Port-a-cath via the left
internal jugular venous approach. The tip of the catheter terminates in the
right atrium. The catheter is ready for use.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with cough
TECHNIQUE: Chest PA and lateral
COMPARISON: None.
FINDINGS:
Heart size is normal. The aorta The mediastinal and hilar contours are
otherwise unremarkable. The pulmonary vasculature is normal. No focal
consolidation, pleural effusion or pneumothorax is present. Hypertrophic
changes are noted in the thoracic spine.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: CT abdomen and pelvis
INDICATION: ___ woman with new acute leukemia presenting with acute
cough and hematochezia, found to have a distended abdomen on exam. Evaluate
for acute process or constipation. No IV contrast needed. Only PO
gastrograffin contrast.
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 administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 10.5 s, 67.9 cm; CTDIvol = 11.3 mGy (Body) DLP =
762.3 mGy-cm.
Total DLP (Body) = 762 mGy-cm.
COMPARISON: No prior relevant imaging is available on PACS at the time of
this dictation.
FINDINGS:
Detailed evaluation of the solid organs, soft tissues, and vessels is limited
without the use of intravenous contrast. Within this limitation:
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 homogeneous but mildly decreased
attenuation throughout, suggesting steatosis. No evidence of focal lesions
within the limitations of an unenhanced scan. No evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is collapsed with
gallstones. No evidence of gallbladder wall thickening or pericholecystic
fluid collection. No ascites.
PANCREAS: There is uneven lipomatosis of the pancreatic head and uncinate
process, a normal variant. No evidence of focal lesions within the
limitations of an unenhanced scan. No pancreatic ductal dilation or
peripancreatic fat stranding.
SPLEEN: The attenuation of the spleen is normal without evidence of a focal
lesion. No splenomegaly.
ADRENALS: The adrenal glands are normal in size and configuration.
URINARY: The kidneys are of normal and symmetric size. A 5-mm renal cortical
hyperdensity in the left upper renal pole measures 90 Hounsfield units, most
likely a hemorrhagic or proteinaceous cyst (series 3, image 66; series 7,
image 48). A 5.5 x 4.6-cm fluid density, thin-rimmed right upper to mid renal
pole lesion is consistent with a simple cyst (series 3, image 71; series 7,
image 20). No nephrolithiasis, hydronephrosis, or perinephric abnormality.
GASTROINTESTINAL: Ingested enteric contrast reaches the proximal large bowel.
The stomach is moderately distended with enteric contrast and ingested food
contents. Small bowel loops are normal in caliber and wall thickness
throughout. The terminal ileum is normal. Colonic diverticulosis is minimal.
The rectum is within normal limits. The appendix is normal. No significant
colonic stool burden. No bowel obstruction, intra-abdominal fluid collection,
pneumoperitoneum, or pneumatosis.
MESENTERY: There is non-specific mild fat-stranding and haziness near the
celiac trunk and SMA (e.g., series 3, image 61, 60).
PELVIS: The urinary bladder is underdistended, limiting evaluation but grossly
unremarkable. No free fluid in the pelvis.
REPRODUCTIVE ORGANS: Coarse calcifications in the uterus are consistent with
fibroids, the largest is exophytic from the anterior right uterus, measuring
up to 2.8 cm (series 3, image 109; series 7, image 26). The ovaries are
unremarkable.
LYMPH NODES: No retroperitoneal or mesenteric lymphadenopathy. No pelvic or
inguinal lymphadenopathy.
VASCULAR: No abdominal aortic aneurysm. Diffuse atherosclerotic
calcifications are mild-to-moderate.
BONES: No lytic or sclerotic osseous lesions concerning for malignancy or
infection. Multilevel degenerative changes throughout the lumbosacral spine
are mild-to-moderate. Degenerative changes in the hips are moderate.
SOFT TISSUES: A fat-containing umbilical hernia small (series 7, image 40).
IMPRESSION:
1. No specific finding on CT in the abdomen or pelvis to explain the patient's
symptoms. No abnormal colonic stool burden or bowel obstruction.
2. Cholelithiasis.
3. Non-specific mild fat-stranding near the celiac trunk and SMA could be
related to the patient's known malignancy.
4. Fibroid uterus.
5. 5-mm left upper renal pole hemorrhagic or proteinaceous cyst.
This preliminary report was reviewed with Dr. ___
radiologist.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: BRBPR, Transfer
Diagnosed with Hemorrhage of anus and rectum
temperature: 98.0
heartrate: 88.0
resprate: 20.0
o2sat: 96.0
sbp: 123.0
dbp: 77.0
level of pain: 0
level of acuity: 2.0 | ___ w/ HTN admitted w/ viral-like illness, acute BRBPR, and
febrile neutropenia ___ to UTI found to have AML (CEBPA
mutation). Patient was started on Decitabine/MUC1 trial
___ and ___ and tolerated chemotherapy without any
major complications besides a need to uptitrate her BP
medication.
#AML: Newly diagnosed. BmBx (___) consistent with AML (CEBPA
mutation). Patient started on Decitabine/MUC1 Trial ___,
___. Patient experienced elevated blood pressure in the
setting of MUC1 and her blood pressure regimen was adjusted
accordingly as below. She was started and maintained on
acyclovir and fluconazole for prophylaxis. She had a bone marrow
biopsy on ___ (C1D25) per trial protocol with immunophenotyping
notable for 16% blasts and aspirate w/6% blasts, down from 65%
blasts on bone marrow biopsy on ___ (prior to chemotherapy). A
port was placed on ___ to facilitate chemotherapy. On ___,
patient endorsed sore throat/URI sx, which resolved. Flu A/B PCR
neg, RSV, Paraflu, adeno antigen from nasopharyngeal swab
studies (___) and cultures were negative. Patient had repeat
C2D25 bone marrow biopsy on ___ (two days early) as part of the
trial protocol with preliminary read showing no blasts, but
final results pending at time of discharge. On ___, at time of
discharge, WBC 1.0, ANC 100, H&H 7.3/22.4, Plt 43, and blasts
4%. Plan is for patient to continue with C3D1 of Decitabine/MUC1
on ___.
#Hypertension: Patient had elevated BP's after infusion of MUC1.
Her home BP regimen included losartan 100mg, HCTZ 12.5mg. Her
meds were adjusted to losartan 100mg and amlodipine 10mg with
adequate control of her BPs, with SBPs ranging from 110s-130s.
Plan is to have patient continue on losartan 100mg as an
outpatient. She will likely need to restart amlodipine 5mg QD
once she restarts MUC1.
#Folliculitis: Patient developed 3 cm erythematous, warm,
indurated, non-fluctuant, and slightly tender plaques, with
central hair, on left labia and directly below mons pubis, first
noticed on ___. She received vancomycin (___), which was
discontinued on ___ given resolution of lesions. On ___, there
was re-emergence of erythematous, indurated plaque on left
labia. Vancomycin 1000 Q24H was started on ___ and d/c'ed on
___, and converted to Keflex PO 500mg Q12H on ___. Gynecology
was consulted to evaluate the lesions, and felt that they were
representative of folliculitis and recommended that patent apply
warm compresses to lesions. Patient will be discharged on
Keflex, to continue until resolution of lesions/count recovery.
#UTI: Patient presented with dysuria on admission. Ucx at ___
was positive for E. coli. Initially started on cefepime for
febrile neutropenia. E. coli was found to be sensitive to
cefepime, CTX, Keflex, but resistant to ciprofloxacin.
Subsequently, she was narrowed to cefpodoxime PO 400mg
___. Repeat urine cx negative. In the setting of
folliculitis as above, patient was switched to cephalexin PO
500mg Q12H (___), which she will continue until count recovery.
#Hematochezia: Patient presented with BRBPR on admission. Likely
diverticular vs AVM vs hemorrhoids in the setting of
thrombocytopenia. Hematochezia resolved without any recurrence
throughout admission. She was transfused with Hgb goal>7 and
platelet goal >10K, with irradiated restriction on all of blood
products.
#Transaminitis: Patient developed elevated transaminases into
the ___ on ___, uptrending from baseline in the ___. Alk phos
was not elevated. Transaminitis is likely ___ to fluconazole ppx
or MUC1 therapy as above. Patient's acetaminophen was held and
LFTs were monitored. ALT/AST ___ on ___ at time of discharge.
TRANSITIONAL ISSUES
=========================
- Patient will need to return to the ___,
___ floor, on ___, at 9:00 AM for an appointment
with her treatment team.
- At time of discharge, final pathology results from bone marrow
biopsy on ___ are pending.
- Patient required amlodipine 5mg QD in addition to losartan
100mg QD for BP control while receiving MUC1. When not on MUC1,
she only requires losartan 100mg QD. Please restart amlodipine
5mg QD when resuming MUC1 therapy.
- Patient should have colonoscopy as an outpatient to evaluate
for hematochezia.
- Patient has a 1.3cm thyroid nodule identified on CT chest.
Please consider thyroid ultrasound in outpatient setting if
patient is deemed to be high risk.
- Please follow-up chest CT in ___ year for right lobe pulmonary
micronodules <4 mm identified on CT chest if patient is deemed
to be high risk. Otherwise, no follow-up is needed. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Codeine / Latex / Sulfa (Sulfonamide Antibiotics) / Fluorescein
Sodium / Iodine / Hayfever / Fruit Extracts / Nifedipine
Attending: ___.
Chief Complaint:
left sided numbness and weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old right handed woman with history of HTN,
HLD, DM II, obesity who presents with left arm/face/leg numbness
and tingling since yesterday. At approximately 11:15pm
yesterday, patient noted that her left palm/fingers were
tingling
and numb. She has had tingling in her fingertips and toes
before
which usually resolves in less than a minute, but this time, the
sensation persisted so she was a little bit worried. She went
to
sleep. At 4am, she woke up and noted that she still had tingling
in the left palm/fingers, but now she had the same sensation at
the medial aspect of arm to the shoulder. Also, noticed
tingling/numbness from just below the knee to dorsum of foot and
toes. She first states that her left arm felt slightly heavy,
but on clarification, was more numb than heavy. She went back
to
sleep. This morning, she noted numbness/tingling in left face
and posterior left neck as well and the entire left leg. At
that
time, Ms. ___ was quite concerned and went to urgent care where
she was referred to the ED.
Currently, she still has numbness/tingling in the L
face/posterior neck, L palm/arm and L foot. She is slightly
improved, but not at baseline. Denies headaches, endorses mild
blurring of vision in left eye. Also endorses several episodes
of as mild heat sensation over left side of face and left
deltoid
region, was transient, has occurred ___ times since morning.
Today, left leg felt weak, so she brought a cane with her. No
clumsiness. Did drop gloves from her left hand today. Endorses
lightheadedness.
Ms. ___ has never had similar symptoms in the past. As above,
has had tingling in her fingertips and toes on one side or the
other lasting <1 a minute, but nothing like this.
On neuro ROS, the pt denies headache, loss of vision, diplopia,
dysarthria, dysphagia, vertigo, tinnitus or hearing difficulty.
Denies difficulties producing or comprehending speech. No bowel
or bladder incontinence or retention.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
Hypertension
Hyperlipidemia (LDL 156)
DM II, insulin dependent (HbA1c 8.8), renal + retinal
complications
GERD
Fibromyalgia
Rheumatic fever at age ___
Social History:
___
Family History:
Daughter - hypothyroidism
Mother-myocardial infarct, diabetes
Paternal grandmother-lung history
No history of strokes, seizures
Grandmother died in her ___ of lung ca, non-smoker. Maternal
uncle died in his ___ of lung ca, was a heavy smoker.
Physical Exam:
ADMISSION EXAM
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward
without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name both high and low frequency objects. Able
to read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt. was able to
register 3 objects and recall ___ at 5 minutes. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: Pupils are both surgical and irregular, but reactive. VFF
mildly restricted to confrontation in all quadrants, pt reports
this is her baseline. Testing inconsistent.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation decreased to light touch, pin prick,
vibration sense on left V1-V3.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted. Mildly orbits around L arm.
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
*has some pain limited weakness, but able to give almost full
strength with encouragement
-Sensory: Decreased sensation to light touch, cold, pin prick in
LUE to shoulder and LLE to below the knee. Decreased pin prick
is 100% on right, ~30% on left. Does have decreased sensation
distally in LEs to mid shin as well, L>R. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 1 0
R 2 2 2 1 0
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, mild dysdiadochokinesia
bilaterally. No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Takes small, cautious steps.
=
=
=
=
================================================================
DISCHARGE EXAM
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Language is fluent with intact repetition
and
comprehension. Normal prosody. Speech was not dysarthric.
Able to
follow both midline and appendicular commands.
-Cranial Nerves:
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation decreased to light touch, pin prick,
vibration sense on left V2-V3.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 4+ 5 4+ 4- ___ 4 5 4 5 5 5 5
R 5 ___ ___- 5 5 5 5 5 5 5
-Sensory: Decreased sensation to light touch, cold, pin prick in
LUE to shoulder and LLE to below the knee. No extinction to
DSS.
-Coordination: No dysmetria on FNF or HKS bilaterally.
-Gait: deferred
Pertinent Results:
LABS
___ 02:00PM BLOOD WBC-8.2 RBC-4.19* Hgb-11.8* Hct-35.2*
MCV-84 MCH-28.0 MCHC-33.4 RDW-13.6 Plt ___
___ 02:00PM BLOOD Neuts-57.5 ___ Monos-4.3 Eos-4.6*
Baso-0.9
___ 02:00PM BLOOD Glucose-142* UreaN-24* Creat-1.0 Na-136
K-4.4 Cl-100 HCO3-25 AnGap-15
___ 02:00PM BLOOD Albumin-4.1 Calcium-9.4 Phos-4.3# Mg-2.0
Cholest-157
___ 02:00PM BLOOD ALT-18 AST-21 AlkPhos-68 TotBili-0.3
___ 02:00PM BLOOD cTropnT-<0.01
___ 06:13PM BLOOD %HbA1c-9.6* eAG-229*
___ 02:00PM BLOOD Triglyc-204* HDL-48 CHOL/HD-3.3
LDLcalc-68
=
=
================================================================
DIAGNOSTIC STUDIES
___ HEAD ___:
No acute intracranial process.
MRI/ MRA BRAIN AND NECK ___:
Two small acute infarctions in the right thalamus and at the
junction of the right midbrain and pons.
Unremarkable MRA of the neck and brain.
TTE ___:
The left atrium is mildly dilated. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. 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%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: No ASD or PFO. Symmetric LVH with normal global and
regional biventricular systolic function.
Medications on Admission:
albuterol sulfate HFA 90 mcg inh prn, uses ___ times per year
carvedilol 25 mg qhs
Flonase 50 mcg/actuation nasal spray prn, uses in the ___
hydrochlorothiazide 25 mg qd
Novolog Flexpen 100 unit/mL, 25U with lunch and dinner
Lantus Solostar 100 unit/mL, 32U qhs
lisinopril 40 mg qhs
metformin 1,000 mg bid
ranitidine 150 mg bid prn heartburn (takes rarely)
simvastatin 40 mg qhs
Diovan 320 mg qd
Aspirin 81 mg qd
CALCIUM 600 + D - Dosage uncertain
cholecalciferol (vitamin D3) 1,000 U qd
Fish Oil 1,200 mg-144 mg-216 mg qhs
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Fish Oil (Omega 3) 1000 mg PO HS
4. Hydrochlorothiazide 25 mg PO DAILY
THIS MEDICATION WAS HELD WHILE INPATIENT IN THE SETTING OF ACUTE
STROKE. MAY BE RESUMED AS NEEDED.
5. Carvedilol 25 mg PO QHS
THIS MEDICATION WAS HELD INPATIENT IN THE SETTING OF ACUTE
STROKE AND MAY BE RESUMED AS NEEDED
6. Fluticasone Propionate NASAL 1 SPRY NU DAILY: PRN ALLERGIES
7. Lisinopril 40 mg PO HS
THIS MEDICATION WAS HELD WHILE INPATIENT IN THE ACUTE STROKE
SETTING, MAY BE RESUMED AS NEEDED
8. Valsartan 320 mg PO DAILY
THIS MEDICATION WAS HELD INPATIENT IN THE SETTING OF ACUTE
STROKE, MAY BE RESUMED AS NEEDED
9. Vitamin D 1000 UNIT PO DAILY
10. MetFORMIN (Glucophage) 1000 mg PO BID
THIS MEDICATION WAS HELD WHILE INPATIENT BECAUSE YOU WERE ON
INSULIN. MAY BE RESUMED ON DISCHARGE.
11. Glargine 35 Units Bedtime
aspart 5 Units Breakfast
aspart 12 Units Lunch
aspart 13 Units Dinner
Insulin SC Sliding Scale using aspart Insulin
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. Acute Ischemic Stroke: Right thalamus
2. Uncontrolled Diabetes
3. Dyslipidemia
Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: Patient with left-sided numbness and weakness. Assess for
intracranial hemorrhage.
COMPARISONS: ___ and ___.
TECHNIQUE: MDCT-acquired contiguous images through the head were obtained at
5 mm slice thickness. Coronally and sagittally reformatted images are
provided.
FINDINGS: There is no evidence of acute intracranial hemorrhage, mass effect,
or shift of normally midline structures. There is no cerebral edema or loss
of gray-white matter differentiation to suggest an acute ischemic event.
Sulci and ventricles are slightly prominent, likely age-related involutional
changes. The basal cisterns are patent. There is no evidence of herniation.
Mucous retention cyst in the left maxillary sinus is partially imaged.
Otherwise, imaged paranasal sinuses. Mild opacification of the left mastoid
air cells is noted. No acute fracture is seen.
IMPRESSION:
No acute intracranial process.
Radiology Report
INDICATION: Left-sided weakness and numbness. Assess for pneumonia.
COMPARISONS: ___.
FINDINGS: Frontal and lateral views of the chest demonstrate low lung volumes
without pleural effusion, focal consolidation or pneumothorax. Hilar and
mediastinal silhouettes are unremarkable. The heart is normal in size. There
is no pulmonary edema. Vascular calcifications involving the aortic arch and
the descending aorta are noted.
IMPRESSION: No acute cardiopulmonary process.
Radiology Report
EXAMINATION: MRI AND MRA BRAIN WITHOUT CONTRAST, AND MRA NECK WITH/WITHOUT
CONTRAST
INDICATION: ___ year old woman with hypertension, high cholesterol, diabetes,
who presents with left sided numbness.
TECHNIQUE: Sagittal T1 weighted, and axial T2 weighted, FLAIR, gradient echo,
and diffusion-weighted images of the brain were obtained. 3D time-of-flight
MRA of the brain was obtained with multiplanar maximum intensity projection
angiographic reformatted images. 2D time-of-flight MRA of the neck was
obtained with multiplanar maximal intensity projection angiographic
reformatted images. 3D coronal T1 weighted gradient echo imaging of the neck
was obtained before, during, and after intravenous gadolinium administration
with multiplanar maximum intensity projection angiographic reformatted images.
COMPARISON: Noncontrast head CT from earlier on ___. Brain MRI and
MRA without contrast from ___.
FINDINGS:
MRI BRAIN There is a small acute infarction in the right thalamus and a
small acute infarction at the junction of the right midbrain and pons, both of
which demonstrate seen high signal on T2 weighted and FLAIR images. There is
no evidence for associated blood products. An oval focus subcentimeter focus
of high signal on T2 weighted and FLAIR images in the left thalamus is
consistent with a chronic infarct, given the high signal on FLAIR images,
rather than a large Virchow ___ space. There are multiple small foci of high
T2 signal in the deep and periventricular white matter of the cerebral
hemispheres, as well as in the pons bilaterally, likely sequelae of chronic
small vessel ischemic disease in a patient with known cardiovascular risk
factors. The ventricles and sulci are normal in size for age.
There are large mucous retention cysts almost completely opacifying the left
maxillary sinus.
MRA NECK There is a 3 vessel aortic arch. Common carotid, cervical internal
carotid, and vertebral arteries appear patent without evidence of
hemodynamically significant stenoses.
MRA BRAIN The images are limited by motion artifact. The intracranial
internal carotid and vertebral arteries, and their major branches, appear
patent without evidence of hemodynamically significant stenoses or aneurysms.
There is an ___ complex on the right and a patent ___ on the left.
IMPRESSION:
Two small acute infarctions in the right thalamus and at the junction of the
right midbrain and pons.
Unremarkable MRA of the neck and brain.
Gender: F
Race: ASIAN
Arrive by WALK IN
Chief complaint: L Weakness, L Numbness
Diagnosed with MUSCSKEL SYMPT LIMB NEC
temperature: 97.8
heartrate: 63.0
resprate: 16.0
o2sat: 100.0
sbp: 134.0
dbp: 119.0
level of pain: 0
level of acuity: 2.0 | #STROKE
Ms. ___ is a ___ old right handed woman with history of HTN,
HLD, DM II, obesity who presented to ___ with left
arm/face/leg numbness and tingling. A CT scan was done in the
ER, which showed no acute intracranial abnormality. Her exam was
notable for decreased sensation to cold, pin prick, light touch
in the left face/arm/leg as well as some weakness on the left in
an upper motor neuron pattern. She was admitted to the stroke
service, where an MRI was performed and demonstrated two strokes
- in the right thalamus and in the brainstem. MRA brain and neck
did not show intracranial or extracranial atherosclerosis. Given
her uncontrolled DM as well as HTN and HLD as well as the
location of the strokes, the etiology was thought to be likely
small vessel disease. She was continued on ASA 81 ___s her
home simvastatin 40mg daily.
As part of risk factor screening, a TTE with bubbles was
performed which did not show a shunt or an intracardiac
thrombus. It did, however, show mild LVH. Telemetry showed sinus
rhythm. Her HbAIC was 9.6, her LDL was 204. In the setting of
acute stroke, her blood pressure was allowed to autoregulate
(goal SBP 120-200) and her home antihypertensives were held.
These can be resumed upon discharge from the stroke service as
needed to maintain normotension.
Family was given stroke education and stroke information packet.
#DM
Ms. ___ has a history of longstanding uncontrolled DM and is on
oral hypoglycemics as well as insulin at home. She was placed on
an ISS inpatient as well as her home lantus dose of 32. Her
HbA1C was noted to be 9.6 and ___ was consulted to optimize
her ISS and recommended increasing coverage at breakfast as well
as increasing her lantus dose to 35. Her fingersticks were in
200s with this regimen and Metformin home dose was added prior
to discharge. She will require outpatient optimization of her
home glycemic regimen given her uncontrolled DM.
#ID
Her urine showed some white cells but she was not symptomatic,
so no antibiotics were initiated. If she develops urinary
urgency or dysuria or symptoms of UTI, please consider UA and
UTI treatment.
#REHAB
Ms. ___ was evaluated by physical therapy who determined that
she is at high risk for deconditioning and would most benefit
from discharge to interdisciplinary
rehababiliation to maximize functional status.
She was discharged in stable condition and has follow up
appointments scheduled with Stroke neurology as well as her
primary care doctor.
============================================================
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 =68
) - () No
5. Intensive statin therapy administered? (x) Yes - () No [if
LDL >= 100, reason not given: ____ ]
(intensive statin therapy = simvastatin 80mg, simvastatin
80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin
20mg or 40mg, for LDL >= 100)
6. Smoking cessation counseling given? () Yes - () 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: ()
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - (x) No [if no, reason not
discharge on anticoagulation: ____ ] - () N/A |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Chief Complaint:
shaking episodes, falls
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
Mr. ___ is a ___ year old man with a PMHx notable for TBI ___ MVA with associated cognitive decline and questionable
seizure event in ___ on Keppra 1500mg BID daily now
presenting after shaking movements and multiple falls in the
past two weeks.
Patient had two witnessed episdoes of body shaking, in the
setting of ambulating. Several days ago, son saw pt walking up a
flight of stairs, he suddenly grabbed ahold of the bannister,
lower and upper extremities shaking (<~1 min), no fall. Also, on
morning of admission, wife states that pt was walking out to the
deck and called out to her. She saw him grab the railing, upper
extremities shaking (~45 sec). He returned to baseline w/o fall
within ___ sec. Wife reports that episodes are similar in
nature but less severe then seizure-like event in ___.
After the witnessed episode, she decided to bring him to the ED.
This occured in the setting of two weeks of documented
hypotension (BP's in the ___ as reported by physical
terapists) and poor fluid intake, with titration of metoprolol
to 25mg BID (switched from atenolol).
Of note: MVA ___, complicated by progressive cognitive decline,
anxiety, and depression. In ___, pt experiened ~20secs of upper
extremity shaking. No LOC, no fall, no urinary incontinence, no
tongue biting, no immediate postictal-like state. Later in the
evening took a nap, awoke very disoriented. Presented to OSH and
empirically started on Keppra 500mg BID for a suspected seizure,
no EEG obtained at the time.
Following ___ episode, pt reported as "chronically
encephalopathic"--inattentive, often staring off into space,
confusing his wife for his deceased mother, developed urinary
incontinence. Pt switched to brand-name levetiracetam at 1500mg
BID and phenytoin 300mg, improvement reported by family but
intermitent, widely-spaced hallucinations persisted. Started
being seen by ___ neuro in ___ diagnosis drawn
into question. Phenytoin stopped, levetiracetam 3000mg daily
contd. Hallucinations have become more pronounced and frequent
since ___, lasting ___ hours.
Patient performs basic ADLS -- bathes, dresses, feeds himself.
Puts plates in dishwasher. Does not perform IADLS. Recently got
lost in ___ for 3 hours. Police were called. Patient
eventually found without harm.
ED COURSE:
In the ED, initial vitals were 98.5 60 125/49 18 99%RA
- Labs significant for WBC 12.9, lactate 1.4
- CT head w/o contrast w/ no acute intracranial process
- PRELIM CXR read w/ possible RLL pneumonia
- Given 1g ceftriaxone and 500mg azithromycin
Vitals prior to transfer: 65 160/72 16 95%RA
Last night on the floor, pt himself provided additionaly
history. Reports that shaking episodes of the past 2 weeks only
occur when he is standing, never while sitting or laying. He is
awake throughout but feels that he does not remember everything
that happens during the episode. He reports that his vision
becomes narrowed but he never blacks out and he has never
fallen. Additionally he reports a dry cough over the past
3+weeks, not worse around eating. He denies fever, chills, SOB.
This morning on the floor, pt states that he is an undercover
police detctive who came in because his chief told him to. He
does not know why he is here but doesn't feel he needs to be
here. He does not endorse any pain, confusion, lightheadedness,
N/V, or other health complaints. He is resistant to answering
questions and cooperating with physical exam.
Shortly after morning rounds patient eloped from floor, found on
___ by security, brought back by ambulance.
Past Medical History:
- ?Seizure Disorder--refer to above
- Sleep apnea->on CPAP
- HTN
- HLD
- ?B12 deficiency
- prostatic hypertrophy s/p TURP
- Depression--Paroxetine 40mg PO daily
- "Cardiac Problems"--Wife reports that a stress test performed
at ___ resulted in an "incident." A cardiologist that
subseuqnetly saw the pt said there was something irregular with
an 'electrical bundle' and perscribed nitroglycerin prn chest
pain. Pt used the nitroglycerin for the first time 10 days aho
when his wife sensed he was having chest pain.
Social History:
___
Family History:
Mother Passed in her ___ (unclear cause)
Father Passed away from ___ in early ___
Physical Exam:
=====================================
ADMISSION PHYSICAL EXAM:
=====================================
Vitals - T:97.6 BP:148/70 HR:61 RR:20 02sat:97%RA
Orthostatics:
lying- 163/56 63
sitting- 165/79 62
standing- 139/67 60
GENERAL: NAD, well-appearing large elderly man sitting on chair
reading, seemingly gaurded
HEENT: AT/NC, EOM grossly intact, PERRL
NECK: nontender supple neck, no LAD
CARDIAC: 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: grossly moving all extremities well, no cyanosis or
clubbing. slightly edematous right ankle-pt refused to remove
shoes for further inspection
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII grossly intact
SKIN: warm and well perfused, not well assessed as pt fully
clothed and not cooperative with exam
================================
DISCHARGE PHYSICAL EXAM
================================
Vitals: T 97.8 BP 136/64 HR 69 RR 20 SPO2 93RA
General: Awake and alert, sitting in chair bedside. NAD.
Interactive and humerous.
HEENT: AT/NC, EOM grossly intact, PERRL
NECK: nontender supple neck, no LAD
CARDIAC: 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: Grossly moving all extremities well, no cyanosis or
clubbing. Slightly edematous right ankle ___ injury from
military service
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII grossly intact; A&Ox3, ___ register and ___
recall at 2 mins, 9 quarters in $2.25, difficulty with serial
7's (many miscalculations), DOWB
SKIN: Warm and well perfused. Areas of red, hypertrophied skin
t/o face and back noted.
Pertinent Results:
NOTABLE LABS:
___
- CBC: WBC 12.9, Plt Ct ___
- Lactate 1.4
___
- CBC: WBC 99, Plt Ct ___
- TSH 1.4
- UA: clear
___
- CBC: WBC 9.7, Plt Ct ___
- VitB12 and folate pending
MICRO:
- RPR pending
- Urine Culture: No growth
IMAGING STUDIES:
___ Chest (PA and LAT):
No evidence of acute cardiopulmonary disease.
___ CT head w/o contrast:
Vague areas of hypodensity in cerebral white matter bilaterally
are most often associated with chronic small vessel ischemic
disease.
No evidence of acute intracranial process.
___ MR head w/o contrast:
PENDING
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Keppra (levETIRAcetam) 1500 mg oral BID
2. Paroxetine 40 mg PO DAILY
3. Metoprolol Tartrate 25 mg PO BID
4. Probenecid ___ mg PO DAILY
5. Rosuvastatin Calcium 40 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Cyanocobalamin 500 mcg PO DAILY
8. ClonazePAM 0.5 mg PO QHS
9. Oxybutynin 15 mg PO QHS
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. ClonazePAM 0.25 mg PO QHS
3. Keppra (levETIRAcetam) 1500 mg oral BID
4. Paroxetine 40 mg PO DAILY
5. Probenecid ___ mg PO DAILY
6. Rosuvastatin Calcium 40 mg PO DAILY
7. Cyanocobalamin 500 mcg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
- DEMENTIA
- ORTHOSTATIC HYPOTENSION secondary to hypovolemia
SECONDARY DIAGNOSIS:
- questionable SEIZURE DISORDER
- HYPERLIPIDEMIA
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST RADIOGRAPHS
INDICATION: Seizure.
TECHNIQUE: Chest, PA and lateral.
COMPARISON: None.
FINDINGS:
The heart is borderline in size. Aside from dextropositioning, the mediastinal
and hilar contours are otherwise unremarkable. Incidental note is made of an
azygos fissure which is consistent with a normal variant. Mild biapical
pleural thickening is consistent with minor scarring at each lung apex. The
lungs appear otherwise clear. There is no pleural effusion or pneumothorax.
IMPRESSION:
No evidence of acute cardiopulmonary disease.
Radiology Report
EXAMINATION: HEAD CT
INDICATION: Recent fall and seizure.
TECHNIQUE: Non-contrast CT.
DOSE: DLP: 891.9 mGy-cm.
COMPARISON: None.
FINDINGS:
Vague areas of hypodensity in cerebral white matter bilaterally are most often
associated with chronic small vessel ischemic disease. Mild age-related
involutional changes are characterized by mild prominence of extra-axial
spaces, ventricles, and sulci. There is no mass effect, hydrocephalus or shift
of normally midline structures. There is no evidence of intracranial
hemorrhage. Over the right parietal region there is a small subgaleal
hematoma. Otherwise, surrounding soft tissue structures are unremarkable.
Vascular calcifications are particularly conspicuous along the vertebral and
cavernous carotid arteries. No fracture is identified. The visualized
paranasal sinuses and mastoid air cells appear clear.
IMPRESSION:
No evidence of acute intracranial process.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST
INDICATION: ___ yo M with rapidly progressive dementia, now presenting with
delirium.
TECHNIQUE: Sagittal T1 weighted, and axial T2 weighted, FLAIR, gradient echo,
and diffusion-weighted images of the brain were obtained.
COMPARISON: CT head ___.
FINDINGS:
There is no edema, acute infarction, mass effect, or evidence for blood
products in the brain parenchyma. There is moderate brain parenchymal volume
loss with associated prominence of the ventricles and sulci. All components of
the right lateral ventricle are slightly larger than the left, suggesting
developmental or congenital etiology. There are multiple foci of T2/FLAIR
hyperintensity within the subcortical, deep, and periventricular white matter
of the cerebral hemispheres, and in the pons, which are nonspecific though
likely sequelae of chronic small vessel ischemic disease the patient of this
age.
There is mild bilateral maxillary sinus mucosal thickening. Incidental note is
made of a nasopalatine duct cyst.
IMPRESSION:
1. No evidence of an acute intracranial abnormality.
2. Moderate parenchymal volume loss. Extensive signal abnormalities in the
supratentorial white matter and pons, likely sequelae of chronic small vessel
ischemic disease in a patient of this age.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Seizure
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, EPILEPSY, NOS WITHOUT INTRACTABLE EPILEPSY
temperature: 98.5
heartrate: 60.0
resprate: 18.0
o2sat: 99.0
sbp: 125.0
dbp: 49.0
level of pain: 0
level of acuity: 2.0 | ___ year old man w/ a hx of progressive cognitive decline ___ TBI
and questionable seizure diagnosis presenting now with episodes
of upper and lower extremity shaking on standing/walking x2
weeks, likely attributable to orthostatic hypotension. Review of
OMR documentation in light of altered mental status on floor
indicates underlying, undiagnosed dementia with overlying
delirium in the setting of hospitalization.
# Orthostatic Hypotension: Episodes of shaking upon
standing/walking in setting of poor PO intake and documented
hypotension, consistent with orthostatic hypotension.
Neurology evaluated, concurs that episodes are not consistent
with seizures. In hospital, increased oral intake. No episodes
of hypotension, falls, shaking. Recommend monitor blood
pressures as outpatient and encourage increased fluid intake at
home.
# Dementia: Pt's wife reports progressive cognitive decline,
memory difficulties, inattentiveness, hallucinations since MVA
in ___, worsening over past few months. Consistent with
dementia. Subtype ddx: alzheimers vs vascular ___ Body
dementia.
Neurology evaluated patient in the hospital. Neuropsychology
testing scheduled as an outpatient, will need to follow-up at
this appointment for further evaluation. As outpatient, needs
follow-up B12, folate, RPR as reversible dementia work-up. Needs
follow-up MRI results.
# DELIRIUM: Mental status waxing and waning, complicated by
hallucinations and delusions, during inpatient course. CXR
negative and urinalysis not consistent with infection. No
infectious etiology has been identified at this time.
Oxybutinin and Clonazepam stopped as have been known to cause
delirium. Possible that this is progression of dementia.
# ?SEIZURE DISORDER: Unclear diagnosis. Event leading to
hospitalization was not a seizure. Follow-up appointment with
outpatient neurologist for further analysis.
# Hypertension: Metoprolol stopped in setting of orthostatic
hypotension. Blood pressure stable and heart rate normal. No
need for antihypertensives at this point.
# Hyperlipidemia: Continue home Rosuvastatin Calcium 40 mg PO
daily.
------------ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Shortness of breath and pre-syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo ___ man w/ fully treated tuberculosis s/p
RIPE
from ___ (f/b Dr. ___ at ___, last + sputum cx
as ___ c/b NSTEMIs, NSVT, history of gastric cancer (s/p
resection f/b ___ and chronic low back pain recently
admitted ___ and ___ for invasive pulmonary aspergillosis
c/b parapneumonic effusion s/p R tunneled pleural catheter
(___) on voriconazole presenting with progressive shortness
of breath over one month and pre-syncope.
History obtained from ___ and from patient, who is ___
speaking, with his daughter ___ interpreting at her request
and given the lack of ___ interpreters.
Patient has a hx of TB for which he received 12 months of RIPE
___ via Dr. ___ at ___. He was admitted
___ for hemoptysis. During that admission he was
ruled out for TB. CT chest that admission compared to ___
showed
new R upper lobe cavitation and right middle lobe cavitation
with
a soft tissue nodule. Serum glucan and galactomannan negative.
Aspergillus ___ was isolated from sputum (___) and from
subsequent BAL, concerning for invasive pulmonary aspergillosis.
R-sided pleural fluid (collected before abx and anti-fungals)
were no growth. R-sided chest tube was placed ___, removed
___, and voriconazole was initiated per ID recommendations on
___ with plan for 12 week course. Patient declined surgical
intervention for presumed parapneumonic effusion.
He was subsequently re-hospitalized ___ for leukopenia
and bandemia, ultimately thought to be spurious. Given
persistent
R pleural effusion, Mr. ___ ultimately agreed to a R-sided
TPC, placed ___. Pleural fluid cultures no growth. He was
discharged on a lower dose of voriconazole (150mg BID) given
elevated troughs.
Mr. ___ was seen by IP (Drs. ___ on ___, at which
time R-sided effusion was stable and plan was to continue TPC
with reassessment in 2 months. On ___, Mr. ___ presented
to ___ clinic with Drs. ___. He reported progressive
dyspnea during that visit over the prior month and was found to
desaturate to mid ___ on RA after a walk to the bathroom.
Pleural fluid output was noted to be ___ twice a week.
Referral to the ED was advised, but patient adamantly declined
and was thought to have capacity. He declined repeat imaging as
well and requested home oxygen, which was arranged. It appears
that his PCP (Dr. ___ at ___) was working to arrange home
hospice at the request of the patient's daughter/HCP, ___.
___ reports that over the last few weeks Mr. ___ has been
increasingly dyspneic on exertion with a stable, minimally
productive cough without hemoptysis or associated F/C or chest
pain. PO intake for liquids has been poor, and he has been
losing
weight. Family has urged him to present to the hospital, but
patient has declined. Concerned that Mr. ___ needed
additional care at home, ___ requested hospice enrollment,
although she admits that patient was not consulted about this
decision and that she is not sure hospice is his goal. This
morning Mr. ___ got out of bed and walked - with his wife's
assistance - to the bathroom. As he was walking back from the
bathroom, his eyes rolled back into his head and he slumped
over.
His wife caught him and lowered him to the ground; unclear LOC
but no head strike. Family reports that Mr. ___ was confused
after the fall, unable to recall the event and unsure where he
was. Concerned, EMS was called and patient was brought to ___
ED.
Past Medical History:
-Invasive pulmonary aspergilloisis
-TB s/p 12 months RIPE therapy in ___
-CAD with silent MI
-NSVT
-Gastric cancer s/p resection (in remission)
-Chronic low back pain
Social History:
___
Family History:
Non-contributory.
Physical Exam:
24 HR Data (last updated ___ @ 1117)
Temp: 97.8 (Tm 98.6), BP: 117/71 (99-117/53-71), HR: 82
(70-105), RR: 18, O2 sat: 96% (90-96), O2 delivery: 2lnc (1L
NC-2L NC)
General: Appears cachectic and weak
EYES: PERRL, anicteric sclerae
ENT: Moist oral mucosa.
CV: Regular rate and rhythm. No murmur. Radial and DP pulses 2+.
RESP: Nonlabored breathing at rest. Diffuse crackles and
decreased air entry at the right base with associated "popping"
sounds, unchanged. Right-sided chest catheter in place with
dressing intact.
GI: Abdomen is soft, nontender, nondistended. Bowel sounds
present.
GU: No suprapubic tenderness
SKIN: No rashes or ulcerations noted
MSK: Lower extremities warm without edema. No spinal tenderness.
NEURO: Alert. Oriented to person, place, situation. Follows
basic commands.
PSYCH: pleasant
Pertinent Results:
___ 05:10AM BLOOD WBC-3.1* RBC-4.17* Hgb-10.0* Hct-33.5*
MCV-80* MCH-24.0* MCHC-29.9* RDW-17.9* RDWSD-52.0* Plt ___
___ 06:18AM BLOOD ___
___ 05:10AM BLOOD Glucose-84 UreaN-9 Creat-0.7 Na-144 K-3.6
Cl-97 HCO3-36* AnGap-11
___ 05:10AM BLOOD ALT-11 AST-33 AlkPhos-383* TotBili-0.3
___ 08:44AM BLOOD Lipase-18
___ 08:44AM BLOOD cTropnT-<0.01
___ 08:44AM BLOOD proBNP-398
___ 05:10AM BLOOD Mg-2.1
___ 08:44AM BLOOD Albumin-3.0* Calcium-9.0 Phos-3.8 Mg-2.1
___ 06:18AM BLOOD calTIBC-172* Ferritn-196 TRF-132*
___ 06:18AM BLOOD Calcium-8.3* Phos-3.0 Mg-1.9 Iron-14*
___ 02:40PM BLOOD ___ pO2-39* pCO2-43 pH-7.34*
calTCO2-24 Base XS--2
___ 08:54AM BLOOD ___ pO2-53* pCO2-67* pH-7.28*
calTCO2-33* Base XS-2 Intubat-NOT INTUBA
___ 08:54AM BLOOD Lactate-2.0
___ 07:30AM BLOOD VORICONAZOLE-PND
___ 06:18AM BLOOD VORICONAZOLE-Test Name
___ 06:18AM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-Test
___ 06:18AM BLOOD B-GLUCAN-Test
___ 01:47PM PLEURAL TNC-6928* RBC-6368* Polys-93* Lymphs-1*
Monos-5* Macro-1*
___ 02:13AM PLEURAL TNC-8398* ___ Polys-98*
Lymphs-1* Monos-1*
___ 01:47PM PLEURAL TotProt-3.6 Glucose-20 LD(LDH)-1309
Amylase-18 Albumin-1.4 Cholest-32 proBNP-934
___ 01:19PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 7:00 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
___ 5:10 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
___ 1:47 pm PLEURAL FLUID
GRAM STAIN (Final ___:
3+ ___ 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, if
applicable.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
___ 1:47 pm PLEURAL FLUID
GRAM STAIN (Final ___:
3+ ___ 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, if
applicable.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
___ 1:19 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 and/or Influenza PCR
(results
listed under "OTHER" tab) for further information..
___ 5:03 am SPUTUM Site: INDUCED Source: Induced.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Pending):
___ 4:59 pm SPUTUM Source: Induced.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Pending):
___ 8:51 am SPUTUM Source: Induced.
GRAM STAIN (Final ___:
___ PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final ___:
RARE GROWTH Commensal Respiratory Flora.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
MTB Direct Amplification (Final ___:
M. TUBERCULOSIS DNA NOT DETECTED BY NAAT: A negative NAAT
cannot rule
out TB or other mycobacterial infection.
.
NAAT results will be followed by confirmatory testing with
conventional culture and DST methods. This TB NAAT method
has not
been approved by FDA for clinical diagnostic purposes.
However, this
laboratory has established assay performance by in-house
validation
in accordance with ___ standards.
.
Test done at ___ Mycobacteriology
Laboratory.
___ 6:18 am BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
BLOOD/FUNGAL CULTURE (Pending): No growth to date.
BLOOD/AFB CULTURE (Pending): No growth to date.
___ 2:43 am URINE Source: ___.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
___ 2:13 am PLEURAL FLUID
GRAM STAIN (Final ___:
4+ (>10 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, if
applicable.
FLUID CULTURE (Preliminary):
Reported to and read back by ___ (___) 11AM
___.
PROBABLE MICROCOCCUS SPECIES. RARE GROWTH.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
___ 10:23 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
___ 9:32 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 8:44 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
Reported to and read back by ___ ___ X
___ 16:41.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. albuterol sulfate 90 mcg/actuation inhalation QID PRN
shortness of breath
2. Atorvastatin 20 mg PO QPM
3. diclofenac sodium 1 % topical QID
4. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
5. Metoprolol Succinate XL 50 mg PO DAILY
6. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Severe
7. Voriconazole 150 mg PO Q12H
8. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
RX *acetaminophen 650 mg 1 tablet(s) by mouth Q6H PRN Disp #*30
Tablet Refills:*0
2. Bisacodyl ___AILY:PRN Constipation - First Line
RX *bisacodyl 10 mg 1 Supp rectally Daily PRN Disp #*10
Suppository Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*14 Tablet Refills:*0
4. GuaiFENesin ER 1200 mg PO Q12H
RX *guaifenesin 1,200 mg 1 tablet(s) by mouth twice a day Disp
#*14 Tablet Refills:*0
5. Lidocaine 5% Patch 2 PTCH TD QAM back and neck pain
RX *lidocaine [Lidocaine Pain Relief] 4 % 2 PTCH QAM topical PRN
Disp #*20 Patch Refills:*0
6. albuterol sulfate 90 mcg/actuation inhalation QID PRN
shortness of breath
7. Atorvastatin 20 mg PO QPM
8. diclofenac sodium 1 % topical QID
9. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
10. Metoprolol Succinate XL 50 mg PO DAILY
11. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Severe
12. Vitamin D ___ UNIT PO DAILY
13. Voriconazole 150 mg PO Q12H
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
# Shortness of breath
# Acute hypoxemic respiratory failure
# Sepsis
# Pneumonia
# Invasive pulmonary aspergillosis
# Right-sided effusion s/p tunneled pleural catheter
# History of TB status post RIPE therapy
# Syncope: Vasovagal vs orthostatic
# Acute metabolic encephalopathy, likely delirium
# Hypovolemic Hypotension: resolved s/p 2L LR in ED
# Acute on chronic pain (Neck, back, knee)
# Alkaline phosphatase elevation
# Coronary artery disease
# Hyperlipidemia
# History of NSVT
# History of gastric cancer s/p resection
# Urinary urgency
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 (PORTABLE AP)
INDICATION: History: ___ with dyspnea// eval for effusion
TECHNIQUE: Chest PA and lateral
COMPARISON: Prior chest radiograph ___
FINDINGS:
Redemonstration of a chest tube at the right lung base which appears grossly
unchanged in position.
Slightly decreased lung volumes compared to the prior study. The previously
demonstrated air-fluid level within the right chest has resolved although
there is still residual pleural fluid at the base of the chest despite the
indwelling pleural drainage tube. There may also be new consolidation at the
base of the right lung projecting over middle lobe bronchiectasis.
Heterogeneous opacification of the left lung base is new, pneumonia until
proved otherwise.
The heart border is stable in size. Rightward deviation of the trachea is
unchanged.
IMPRESSION:
New pneumonia, left and possibly right lower lobes.
Persistent small to moderate right pleural effusion, despite indwelling
pleural drain. No pneumothorax
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ yo ___ man w/ fully treated tuberculosis s/p RIPE
from ___ (f/b Dr. ___ at ___, last + sputum cx as ___
c/b NSTEMIs, NSVT, history of gastric cancer (s/p resection f/b ___ and
chronic low back pain recently admitted ___ and ___ for invasive
pulmonary aspergillosis c/b parapneumonic effusion s/p R tunneled pleural
catheter (___) on voriconazole presenting with progressive shortness of
breath over one month and pre-syncope.// Please evaluate for PNA, abscess,
size of R-sided effusion
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 6.1 s, 39.4 cm; CTDIvol = 9.0 mGy (Body) DLP = 347.4
mGy-cm.
Total DLP (Body) = 347 mGy-cm.
COMPARISON: Chest CT from ___.
FINDINGS:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
segmental level without filling defect to indicate a pulmonary embolus.
Evaluation to the subsegmental level is limited. The diameter of the
ascending aorta is again in the upper limit of normal, measuring up to 4.0 cm
in diameter. There is no evidence of dissection or intramural hematoma.
Otherwise, the great vessels are within normal limits. The heart is within
normal limits. No substantial pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: Several prominent but not pathologically
enlarged paratracheal and subcarinal nodes are noted. No axillary,
mediastinal, or hilar lymphadenopathy is present. No mediastinal mass is
seen.
PLEURAL SPACES: A posterior approach thoracostomy catheter is present within a
moderately-sized loculated pleural effusion, associated with pleural
enhancement. Several air locules are seen within the effusion. A trace
effusion is present on the left.
LUNGS/AIRWAYS: Fibrosis with numerous destructive cavitations are again seen
involving the right middle lobe. Consolidations involving the right apex are
similar allowing for differences in inspiratory effort. Comparison with the
prior study there are multifocal airspace and patchy consolidations primarily
involving the lower lobes, but also seen in the left upper lobe, predominately
within the dependent portions of the lungs. The patulous trachea is 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 a prominent gallbladder and
multiple low attenuating liver lesions.
BONES: Multilevel degenerative changes of the thoracic spine without
suspicious osseous abnormality.? There is no acute fracture.
IMPRESSION:
1. Progressive bilateral multifocal consolidations in a background of
significant fibrosis and destructive changes in the right middle lobe,
suggestive of multifocal pneumonia most notable in the lower lobes. Given the
dependent location of these changes, this may be secondary to aspiration.
2. Persistent right loculated pleural effusion with catheter in place.
3. No evidence of pulmonary embolism to the segmental level.
Radiology Report
EXAMINATION: VIDEO OROPHARYNGEAL SWALLOW STUDY
INDICATION: ___ year old man with recurrent pneumonia and concern for
microaspiration. Evaluation for 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: 05:14 min.
COMPARISON: No relevant prior imaging for comparison.
FINDINGS:
Penetration with nectar thick liquids. Silent aspiration with thin liquids.
IMPRESSION:
1. Silent aspiration with thin liquids.
2. Penetration with nectar thick 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).
Gender: M
Race: ASIAN
Arrive by AMBULANCE
Chief complaint: Dyspnea, Lethargy
Diagnosed with Pneumonia, unspecified organism
temperature: 96.6
heartrate: 103.0
resprate: 24.0
o2sat: 98.0
sbp: 91.0
dbp: 53.0
level of pain: UTA
level of acuity: 1.0 | ___ years-old male with fully treated tuberculosis status post
RIPE from ___ (followed by Dr. ___ at ___, last + sputum cx as
___ complicated by NSTEMIs, NSVT, history of gastric
cancer (s/p resection f/b ___ and chronic low back pain
recently admitted ___ and ___ for invasive pulmonary
aspergillosis complicated by parapneumonic effusion s/p
right-tunneled pleural catheter placement (___) on
voriconazole presenting with shortness of breath, hypoxia, and
syncope. Patient was found to have sepsis likely due to
secondary pneumonia versus progression of invasive
aspergillosis.
# Shortness of breath, Acute hypoxemic respiratory failure, and
Sepsis
# Invasive pulmonary aspergillosi; Right-sided parapneumonic
effusion s/p tunneled; pleural catheter; history TB s/p RIPE:
- CXR suggestive of worsening bilateral PNA. CT chest confirms
progression and ongoing loculated effusion. Differential
diagnosis includes superimposed bacterial/viral PNA or recurrent
TB (much less likely) versus progression of known invasive
pulmonary aspergillosis. Repeat voriconazole level is pending at
time of discharge as is fungal cultures (may take weeks).
Pleural fluid not suggestive of empyema as culture negative and
lactate reassuring at 2.0; however, cytology is pending. No TPA
of effusion was recommended by IP given risk of bleeding to
necrotic
tissue. Sputum cultures including AFB not suggestive of
particular pathogen, thus antibiotics were narrowed
sequentially. Patient remained without clinical exacerbation off
antibiotics. Discontinued IV Vancomycin with MRSA screen
negative. Bronchoscopy not felt to add data and was not pursued.
ID and IP managed the patient. Patient was reportedly adamant on
admission that he would not want surgical intervention for
persistent R-sided effusion; will
not consult thoracic surgery. PleurX management to be continued
on discharge. Voriconazole to be continued on discharge 150mg
BID. ID will follow finalization of cultures and advise changes
to voriconazole course as an outpatient. Patient continued on
home albuterol PRN and home oxygen. Goals of care meeting was
performed with patient and family with the assistance of
palliative care, leading towards decision for Home with Hospice.
Ongoing code status discussions are needed as patient remains
DNR, but okay to intubate. Patient would be okay with some
escalation of care, but maintains ultimate goal of comfort focus
and staying at home for as long as possible - not a comfort
only/withdrawal of care path at this time.
# Syncope was likely vasovagal versus orthostatic in the setting
of infection,
dehydration, and hypoxia. Low suspicion for arrhythmia, ACS, or
PE. Recent TTE ___ without significant valvular disease.
Antihypertensive medications initially held, but restarted
effectively.
# Acute metabolic encephalopathy, likely delirium. Considered CT
head to exonerate CNS aspergillus involvement especially with
mild confusion, but given goals of care
discussion will no pursue and family agreeable.
# Hypotension related to poor intake resolved following 2L LR in
ED.
# Acute on chronic pain (Neck, back, knee). Neurologic exam
non-focal. No spinal tenderness. Paraspinal tenderness and
improvement with massage makes this likely arthritis with
deconditioning due to position/lying in bed. Home oxycodone ___
mg continued based on severity of symptoms. Tylenol prescribed
PRN. Initiated lidocaine patch as needed. Will not pursue spinal
imaging given goals of care discussion and nontender spine.
# Alkaline phosphatase elevation: Unclear etiology. Likely
medication related (? voriconazole) and/or inflammatory from
acute illness. Low suspicion for biliary
obstruction without hyperbilirubinemia. Low suspicion for bone
involvement of infection or cancer at this time. No spine
imaging pursued as as acute on chronic pain and no focal
tenderness on examination.
# CAD and HLD:
- Low suspicion for ACS in absence of chest pain, negative
troponin, and no significant ischemic EKG changes. Continue
statin, Metoprolol, isosorbide mononitrate.
# Hx NSVT: Monitored on telemetry without significant event. On
Metoprolol.
# Hx gastric cancer s/p resection. EGD in ___ with biopsies
without evidence of recurrence. Continue Outpatient follow up
with Dr. ___
# Urinary urgency. Concern for BPH. Unable to dose Flomax given
drug-drug
interaction with Voriconazole. Reconsider if voriconazole is
discontinued in a few weeks.
Hospital course, assessment, and discharge plans discussed with
patient and family who express understanding and agree with
discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Low blood sugars
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w/ hx DM II, HTN, HLD, CKD and recent pelvic frx after a
fall
who presents with hypoglycemia. States she has not been eating
much the past few days as appetite is down due to pain in her
lower back. Continued to take her oral hypoglycemic meds. Today
she felt funny, lightheaded, couldnt get words out. Denies any
HA, numbness, weakness or slurred speech. Says this felt similar
to episode of low BG she had a few yrs ago. her boyfriend called
EMS, she did not think to drink OJ or eat something sweet. Was
found to have FSBS of low ___. Mental status improved after 1
amp
of D50.
Regarding her low back pain states that she fell in ___ while
dancing at a ___. She was discharged from ___
___
TCU on ___. Per rehab d/c had plain films of her pelvis which
demonstrated a fracture of the superior ramus and bilateral
fractures of the inferior pubic rami of unknown chronicity
however actual reports not available. still has some pain over R
ant pelvis when moving RLE but overall improving. Was doing home
___ but in last few days developed new lower back pain. Describes
as throbbing, severe enough she was using left over oxycodone
from rehab. Ran out and was prescribed naproxen by PCP but not
getting enough relief. Still ambulating at home, no radiation of
pain, no numbness or weakness although cant lift R leg entirely
due to pelvic pain. No further falls or other injury to back.
No
other extremity or joint pain. Denies any recent fever/chills,
incontinence, urinary frequency or dysuria. Tends to have
constipation but relieved with docusate. NO bowel incontinence.
Also while in rehab she presented with increased BUN/Creat
(level
unknown) and hyperkalemia (K 5.9) so had chlorthalidone and
lisinopril dose reduced, received kayexelate 15gm po x1 and
advised on low potassium diet. She also had low blood sugars in
the 40-50___s requiring glucagon. Glyburide and metformin dose
reduced and was continued on actos. Subsequent blood sugars
ranging 72-287, patient advised on bedtime snack to avoid am
hypoglycemia. BPs were elevated up to 170s with decreased dose
of
chlorthalidone and lisinopril needing to increase labetalol from
200 to 300 BID.
On arrival to ED was alert and coherent. Initial VS 09:43 97.3
81 184/73 16 98%. BG 182 at 10:40, then dropped to 36 at 4pm.
was
given addnl amp D50. Was found to have pyuria even on cathd
specimen. given 2L NS and dose of ceftriaxone. Underwent CT L
spine for back pain, wet read showing L5 burst fracture with 6mm
cord narrowing but per spine read this is not accurate and frx
not acute.
Also of note, EMS, reported concerns regarding the patient's
home
safety due to evidence of unsanitary living conditions and is
planning to file a report to elder ___. Was admitted to
Medicine for UTI, hypoglycemia and inability to care for herself
at home.
Past Medical History:
DM II
CKD
HTN
HLD
Hypothyroid
Social History:
___
Family History:
parents died of natural causes, no CAD/CA/DM/HTN
Physical Exam:
ADMISSION:
General: NAD, smells of stale urine
VITAL SIGNS: 98.1 176/71 92 18 99%RA BG 127
HEENT: MMM, no OP lesions, 1cm raised hematoma L tongue not
purpuric
Neck: supple, no JVD
Lymph: no cervical, supraclavicular, axillary or inguinal
adenopathy
CV: RR, NL S1S2 no S3S4 or MRG
PULM: CTAB
ABD: BS+, soft, NTND
EXT: warm well perfused, no edema, nontender over entire spine,
tender to palpation over superior pelvis at bilateral bony
prominences just lateral to L5/S1
SKIN: No rashes or skin breakdown
NEURO: alert and oriented x 4, ___, EOMI, no nystagmus, face
symmetric, no tongue deviation, full hand grip, shoulder shrug
and bicep flexion, full toe dorsiflexion. Able flex hips against
resistance although R side limited by pain, sensation intact to
light touch, no clonus, babinski downgoing
DISCHARGE:
VS - 97.9 139/56 p68 rr18 95%RA
bs: ___ 167
General: Alert and oriented x 3. NAD
HEENT: NCAT, PERRL, EOMI
Neck: supple
CV: RRR
Lungs: CTAB
Abdomen: soft and nt
GU: no suprapubic tenderness
Ext: no edema or cyanosis
Neuro: ___ strength bilaterally lower and upper
extremities.Sensation intact
Pertinent Results:
___ 11:35AM BLOOD WBC-6.6 RBC-4.37 Hgb-12.2 Hct-37.5 MCV-86
MCH-28.0 MCHC-32.7 RDW-14.1 Plt ___
___ 07:35AM BLOOD WBC-4.0 RBC-3.82* Hgb-10.3* Hct-31.5*
MCV-83 MCH-26.9* MCHC-32.6 RDW-14.4 Plt ___
___ 07:25AM BLOOD WBC-5.0 RBC-3.88* Hgb-10.8* Hct-32.1*
MCV-83 MCH-27.8 MCHC-33.6 RDW-13.6 Plt ___
___ 11:35AM BLOOD Glucose-143* UreaN-38* Creat-1.3* Na-137
K-4.2 Cl-97 HCO3-27 AnGap-17
___ 05:10PM BLOOD Glucose-172* UreaN-20 Creat-0.9 Na-137
K-4.3 Cl-102 HCO3-26 AnGap-13
___ 07:35AM BLOOD Glucose-140* UreaN-20 Creat-1.1 Na-138
K-4.9 Cl-104 HCO3-26 AnGap-13
___ 07:25AM BLOOD Glucose-161* UreaN-18 Creat-1.0 Na-136
K-4.8 Cl-98 HCO3-27 AnGap-16
micro:
urine cx ___
SENSITIVITIES: MIC expressed in 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
___ 11:35 am BLOOD CULTURE
STAPHYLOCOCCUS, COAGULASE NEGATIVE. GRAM POSITIVE COCCI IN
CLUSTERS.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST.
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
IMAGING:
CT L spine ___
IMPRESSION:
1. Burst fracture of the L1 vertebral body with retropulsion,
causing 6 mm narrowing of the spinal canal.
2. Bilateral sacral alar fractures.
3. Bilateral transverse process fractures at the level of L5.
4. Partly visualized right acetabular fracture
PELVIS & SACRO-ILIAC ___
IMPRESSION:
There is diffuse osteopenia. There are minimally displaced right
superior and inferior pelvic rami fractures . While it is
unlikely that the fracture extends to the right acetabulum, the
medial aspect of the right acetabulum is poorly visualized and
would be better assessed by CT.
CT PELVIS ___
IMPRESSION:
1. Right superior pubic ramus fracture with extension into the
anterior
acetabular wall and likely anterior column.
2. Right inferior pubic ramus fracture.
3. Bilateral hemi sacral fractures with a longitudinally
oriented fracture through the left sacral alum paralleling the
left sacroiliac joint and a fracture through the right sacral
alum with longitudinal and transverse elements, with the
transverse element extending to the right sacroiliac joint.
4. Severe degenerative disc disease and facet arthropathy within
visualized portions of the lower lumbar spine.
CXR - FINDINGS:
The heart is mildly enlarged. The aortic arch is calcified.
The right upper mediastinum has a convex contour which is most
commonly due to tortuosity of the great vessels. The lungs
appear clear. There no pleural effusions or pneumothorax.
discharge labs:
___ 07:25AM BLOOD WBC-5.0 RBC-3.88* Hgb-10.8* Hct-32.1*
MCV-83 MCH-27.8 MCHC-33.6 RDW-13.6 Plt ___
___ 07:25AM BLOOD Glucose-161* UreaN-18 Creat-1.0 Na-136
K-4.8 Cl-98 HCO3-27 AnGap-16
___ 07:25AM BLOOD Calcium-10.3 Phos-3.2 Mg-1.8
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
2. Timolol Maleate 0.25% 1 DROP BOTH EYES DAILY
3. Docusate Sodium 100 mg PO BID
4. GlyBURIDE 5 mg PO BID
5. Lisinopril 20 mg PO DAILY
6. Chlorthalidone 12.5 mg PO DAILY
7. MetFORMIN XR (Glucophage XR) 500 mg PO QPM
8. Labetalol 300 mg PO BID
9. Calcium Carbonate 1500 mg PO DAILY
10. Vitamin D 400 UNIT PO DAILY
11. Senna 17.2 mg PO DAILY
12. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO BID:PRN pain
13. Pioglitazone 30 mg PO DAILY
14. Pravastatin 80 mg PO HS
Discharge Medications:
1. Calcium Carbonate 1500 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Labetalol 300 mg PO BID
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
5. Lisinopril 20 mg PO DAILY
6. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO BID:PRN pain
RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth
every six (6) hours Disp #*20 Tablet Refills:*0
7. Pravastatin 80 mg PO HS
8. Senna 17.2 mg PO DAILY
9. Timolol Maleate 0.25% 1 DROP BOTH EYES DAILY
10. Vitamin D 400 UNIT PO DAILY
11. Chlorthalidone 12.5 mg PO DAILY
12. GlyBURIDE 5 mg PO BID
13. MetFORMIN XR (Glucophage XR) 500 mg PO QAM
14. Pioglitazone 30 mg PO DAILY
15. Heparin 5000 UNIT SC BID
16. Levothyroxine Sodium 25 mcg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Diabetes Mellitus
Secondary:
Sacral fx
Fracture of the pubic rami
L1 burst fx
Acute cystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST RADIOGRAPHS
INDICATION: Hypoglycemia.
COMPARISON: None.
TECHNIQUE: Chest, AP and lateral.
FINDINGS:
The heart is mildly enlarged. The aortic arch is calcified. The right upper
mediastinum has a convex contour which is most commonly due to tortuosity of
the great vessels. The lungs appear clear. There no pleural effusions or
pneumothorax.
IMPRESSION:
No evidence of acute cardiopulmonary disease.
Radiology Report
EXAMINATION: CT L-SPINE W/O CONTRAST
INDICATION: ___ with point tenderness ___ s/p fall // Please eval for
l-spine fracture
TECHNIQUE: Contiguous axial images were obtained. Sagittal and coronal
reformatted images were generated. No contrast was administered.
DLP: 832.60 mGy-cm
COMPARISON: Pelvis and hip x-ray ___
FINDINGS:
There is an burst fracture of the L1 vertebral body with retropulsion of bony
fragments, causing a 6 mm narrowing of the spinal canal. Additionally, there
are bilateral fractures of the L5 transverse processes.
Multilevel degenerative changes are noted throughout the lumbar spine with
multilevel spondylosis and demineralized bone. Anterolisthesis of L4 on L5 is
noted. Bilateral facet arthropathy is noted at the level of L5 is worse on the
left than the right.
Bilateral sacral alar fractures are noted at the anterior tips. A
non-displaced fracture line is along noted along the incompletely imaged right
acetabulum.
Cholelithiasis is noted. There is a moderate calcium burden within the aorta
and its branches.
IMPRESSION:
1. Burst fracture of the L1 vertebral body with retropulsion, causing 6 mm
narrowing of the spinal canal.
2. Bilateral sacral alar fractures.
3. Bilateral transverse process fractures at the level of L5.
4. Partly visualized right acetabular fracture.
Given the patient's recent history of trauma several weeks ago, however, it is
unclear whether these fractures are acute or subacute based on the imaging
findings although there was already a medial right superior pubic ramus
fracture at that time.
Radiology Report
EXAMINATION:
PELVIS AND SACRO-ILIAC
INDICATION:
___ year old woman with superior iliac pelvic pain following fall // eval for
posterior pelvic fracture
TECHNIQUE: Frontal views of the pelvis
COMPARISON: None.
IMPRESSION:
There is diffuse osteopenia. There are minimally displaced right superior and
inferior pelvic rami fractures . While it is unlikely that the fracture
extends to the right acetabulum, the medial aspect of the right acetabulum is
poorly visualized and would be better assessed by CT.
NOTIFICATION: Findings were called to ___ by Dr. ___ at 11:20 at
the time of interpretation of this study
Radiology Report
EXAMINATION: NONCONTRAST CT SCAN OF THE PELVIS
INDICATION: ___ year old woman with recurrent falls and known pelvic fracture.
// ? involvement of acetabulum in pelvic fracture
TECHNIQUE: A noncontrast CT scan of the pelvis was performed utilizing 2 mm
thin contiguous axial sections from just above the iliac crests through the
pubic symphysis. Subsequent coronal sagittal reconstructed images were
obtained.
DOSE: Total exam DLP is 220.7 mGy-cm. None
COMPARISON: Radiographs of pelvis ___.
FINDINGS:
The bones are demineralized. There is redemonstration of a comminuted fracture
through the right superior pubic ramus with extension into the anterior wall
of the right acetabulum and likely the anterior column (series 3, images 74
-80 and series 6 images 56 -72). There is redemonstration of a fracture
through the inferior right pubic ramus. Both fractures demonstrate exuberant
surrounding callus formation without osseous bridging. There is a healed left
inferior pubic ramus fracture. There is are bilateral hemi sacral fractures
with a longitudinally oriented fracture through the left sacral alum
paralleling the sacroiliac joint (series 6, image 74) and a fracture with
longitudinal and horizontal components extending through the right sacral
alum, with the transverse component extending to the right sacroiliac joint
(series 6, image 74). No additional fracture is seen.
The femoral head contours are maintained without evidence for osteonecrosis.
No lytic or sclerotic lesion is seen.
There is no dislocation. There are mild degenerative changes at the femoral
acetabular joints bilaterally with mild joint space narrowing and marginal
spurring. There is severe degenerative disc disease within the visualized
portions of the lower lumbar spine with associated facet arthropathy. There
are mild sacroiliac joint degenerative changes bilaterally.
The visualized muscles and tendons are grossly unremarkable. No soft tissue
hematoma is seen.
Limited evaluation of the pelvic viscera demonstrates scattered colonic
diverticula without associated inflammatory changes. No free fluid is noted
within the pelvis. There is no significant pelvic or inguinal lymphadenopathy.
The subcutaneous soft tissues are unremarkable.
IMPRESSION:
1. Right superior pubic ramus fracture with extension into the anterior
acetabular wall and likely anterior column.
2. Right inferior pubic ramus fracture.
3. Bilateral hemi sacral fractures with a longitudinally oriented fracture
through the left sacral alum paralleling the left sacroiliac joint and a
fracture through the right sacral alum with longitudinal and transverse
elements, with the transverse element extending to the right sacroiliac joint.
4. Severe degenerative disc disease and facet arthropathy within visualized
portions of the lower lumbar spine.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___ on the
telephone on ___ at 1:06 ___, 25 minutes after discovery of the
findings.
Gender: F
Race: ASIAN - ASIAN INDIAN
Arrive by AMBULANCE
Chief complaint: Hypoglycemia
Diagnosed with DIAB W MANIF NEC ADULT, URIN TRACT INFECTION NOS
temperature: 97.3
heartrate: 81.0
resprate: 16.0
o2sat: 98.0
sbp: 184.0
dbp: 73.0
level of pain: 0
level of acuity: 2.0 | Ms ___ is a ___ yr old female with hx of DM II and related
CKD, HTN, HLD and recent pelvic rami frx who is admitted with
hypoglycemia.
#DM II w/ hypoglycemia - Due to poor PO intake in the setting of
immobility. Hypoglycemia improved with dextrose. hgbA1C 6.___
___ and improving over past ___ yrs per ___ labs. Most recently
on reduced dose glyburide/pm metformin and longstanding dose am
actos. Was placed on SSI and blood sugars improved with no
recurrent hypoglycemic event.
#Lower back pain w/ L1 burst frx - nontender over L1 but tender
just lateral to L5/S1. Pt eval'd by spine service and impression
of non-acute L1 frx and no cord compromise, no further
intervention recommended; no surgery, no brace. Did not require
frequent doses of oxycodone for pain control. ___ was
advised.
# CKD w/ mild ___ - pt ___ during recent rehab stay but peak Cr
unknown, per d/c did improve to 1 and baseline Cr per ___ is
0.9- 1.1. Cr elevated to 1.3 on admission, likely prerenal from
recent poor PO as well as NSAID use. Resolved after hydration
#R superior and inferiot rami frx, older left ramus fx and
sacral fx : Orthopedics was consulted. Radiographs/imaging was
reviewed and recommendations to continue physical therapy and
pain control.
#UTI - Urine Cx grew E. coli. She was treated with antibiotics x
3 days. Ceftriaxone initially, the Ciprofloxacin (both
sensitive)
# positive blood culture x 1: likely contaminant. coag negative
staph, was afebrile and non-toxic.
# HTN - BP elevated on admission. Continued home labetalol and
lisinopril with reasonable BP control. Chlorthalidone resumed
upon discharge.
# Hypothyroid - continued levothyroxine
# HLD - continued statin |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
MEDICINE ATTENDING ADMISSION NOTE
Time of Initial Eval: ___ 00:15
CC: SOB
Major ___ or Invasive Procedure:
None
History of Present Illness:
The patinet is an ___ y/o F with PMHx of stage IV lung CA
currently on C21 of pemetrexed, as well as multiple prior PEs
with IVC filter in place, who presented to the ED with worsened
SOB and productive cough.
Of note, pt reports that she has had fairly poor functional
capacity at home ever since a hospitalization earlier this year.
She endorses baseline weakness and shortness of breath that
limit her ability to move about her house. She has 2 sons that
are very involved and help her out, however.
Over the 2 days prior to presentation, however the patient noted
significant worsening of her shortness of breath. She also had
nausea and vomiting. Emesis was productive of large amounts of
clear mucus. Shortness of breath was constant, not positional.
She does report prior similar episodes, however of less
intensity. No fevers, chills. No chest pain. No other symptoms.
ED Course:
Initial VS: 98.9 120 116/45 36 96% 2L Pain ___
Labs largely unremarkable.
Imaging: CXR with no acute changes. CTA with no new PE.
Meds given: albuterol/ipratropium nebs, metoprolol, lovenox
VS prior to transfer: 98.8 88 117/51 21 97% RA
On arrival to the floor, the patient reports that her breathing
is much improved after getting multiple nebs by EMS and in the
ED. Her current respiratory status is similar to how it has been
for the past few months.
ROS: As above. Denies headache, lightheadedness, dizziness, sore
throat, sinus congestion, chest pain, heart palpitations,
diarrhea, constipation, urinary symptoms, muscle or joint pains,
focal numbness or tingling, skin rash. The remainder of the ROS
was negative.
Past Medical History:
ONCOLOGIC HISTORY:
**Stage IV non-small cell lung cancer:
- Diagnosed in early ___
- ___: CT scan showed evidence of progression and she
was complaining of producing pink-tinged sputum in the morning.
Her disease had slowly progressed over the last few years.
- Due to progressive dyspnea, Pemetrexed started ___. Due to
lack of symptomatic or radiographic findings, chemotherapy held
in ___ and she returned to surveillance.
- Received prophylactic radiation to the large paravertebral
soft tissue mass involving the T11-T12 neural foramina and
extending in to the paravertebral region and the pedicle of T11.
She completed radiation on ___.
- She started pemetrexed again on ___ because of substantial
progression of intrathoracic malignancy.
- She was from ___ to ___ with bilateral PE and DVT after
stopping anticoagulation due to frequent falls. Lovenox was
restarted and IVC filter was placed.
- Chemotherapy resumed on ___. Received B12 on ___.
- Had facial flushing after cycle ___; thus, dexamethasone
discontinued
- Current on C21 of maintenance pemetrexed
Past Medical History/Past Surgical:
- h/o tuberculosis exposure as a child s/p multiple PPDs, all of
which have been negative, most recently several years ago
- Breast cancer; ___ years ago status post right mastectomy with
reconstructive surgery (Negative mammogram in ___
- Right ankle fracture ___ years ago.
- TAH
- PE (reportedly x 3 in past) and DVT after her ankle fracture
in ___.
- Hypertension
- AVNRT s/p ablation ___
- Frequent falls/syncope for over ___ years
- Multifocal atrial tachycardia found on on ___ admission
(deemed unlikely to be causing her syncope/falls)
Social History:
___
Family History:
Mother - died at ___ from metastatic cancer of unknown primary,
also had tuberculosis. Father - died at 53 from a staph
infection. Maternal aunt - died from lung cancer. Brother with
colon CA, in remission. Two sons - healthy.
Physical Exam:
Admission Exam
VS - 98.4 124/86 89 28 98%RA Pain ___
GEN - Alert, NAD
HEENT - NC/AT, OP clear
NECK - Supple, no JVD noted
CV - RRR, no m/r/g
RESP - mildly labored respirations with scattered wheeze;
otherwise clear
ABD - S/NT/ND, BS present
EXT - no ___ edema, no calf tenderness
SKIN - no apparent rashes
NEURO - non-focal
PSYCH - calm, appropriate
Discharge Exam, remained unremarkable and her pulmonary exam was
improved with good airmovement and no wheezes.
Pertinent Results:
Admission Labs:
___ 02:07PM BLOOD WBC-4.8 RBC-3.28* Hgb-12.7 Hct-35.8*
MCV-109* MCH-38.8* MCHC-35.5* RDW-15.0 Plt ___
___ 02:07PM BLOOD Neuts-78.5* ___ Monos-1.2*
Eos-1.0 Baso-0.2
___ 02:20PM BLOOD ___ PTT-37.3* ___
___ 02:07PM BLOOD Glucose-111* UreaN-16 Creat-0.9 Na-139
K-5.3* Cl-102 HCO3-23 AnGap-19
___ 02:07PM BLOOD cTropnT-<0.01
___ 02:07PM BLOOD proBNP-481
___ 06:26PM BLOOD K-4.5
___ 07:39PM URINE Color-Yellow Appear-Clear Sp ___
___ 07:39PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD
___ 07:39PM URINE RBC-0 WBC-25* Bacteri-NONE Yeast-NONE
Epi-1
Discharge Labs:
___ 07:05AM BLOOD WBC-1.8* RBC-2.82* Hgb-10.6* Hct-32.7*
MCV-116* MCH-37.6* MCHC-32.4 RDW-15.5 Plt ___
___ 07:05AM BLOOD Glucose-104* UreaN-13 Creat-0.9 Na-137
K-4.1 Cl-101 HCO3-28 AnGap-12
___ 07:05AM BLOOD ALT-50* AST-51*
___ 07:05AM BLOOD Calcium-9.4 Phos-4.1 Mg-1.8
CXR - FINDINGS: The lungs are well expanded. Multiple patchy
opacities throughout the right lung are compatible with known
pleural metastasis. Chain sutures in the right upper lung are
re-demonstrated, consistent with prior wedge resection. A focal
nodularity seen in the left apex was compared with prior CT and
corresponds to a focus of fibrosis/scarring. No focal opacities
are seen in the right lung concerning for pneumonia. Cardiac
size is normal. There is a tortuous aorta with atherosclerotic
calcifications of the aortic wall, unchanged. There is no
pleural effusion or pneumothorax. An IVC filter is partially
imaged.
IMPRESSION: Findings compatible with pleural-based right lung
metastasis have not significantly changed compared with prior
exam. No new focal opacities suggestive of pneumonia.
CTA - Web-like chronic thrombus in a segmental artery of the
right lower lobe, with significantly decreased thrombus burden
compared to ___. No new PE. Multiple pulmonary and right
pleural lesions are not significantly changed from prior. Post
wedge resection changes in the right upper lobe are also stable.
ECG (my read) - sinus tach, left axis, no significant changes
from prior
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Prochlorperazine 10 mg PO Q6H:PRN nausea
2. Metoprolol Tartrate 25 mg PO TID
3. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit Oral BID
4. albuterol sulfate 90 mcg/actuation Inhalation 2 puffs q 4
hours PRN shortness of breath or wheezing
5. FoLIC Acid 1 mg PO DAILY
6. Enoxaparin Sodium 70 mg SC Q12H Start: ___, First Dose:
Next Routine Administration Time
Discharge Medications:
1. albuterol sulfate 90 mcg/actuation Inhalation 2 puffs q 4
hours PRN shortness of breath or wheezing
2. Enoxaparin Sodium 70 mg SC Q12H Start: ___, First Dose:
Next Routine Administration Time
3. FoLIC Acid 1 mg PO DAILY
4. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit Oral BID
5. Prochlorperazine 10 mg PO Q6H:PRN nausea
6. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet extended release 24
hr(s) by mouth once a day Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Lung cancer, deconditioning, PE, DOE
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with lung cancer and respiratory distress.
Evaluate for pneumonia.
COMPARISON: Multiple prior chest radiographs, most recent on ___.
Chest CT from ___.
TECHNIQUE: Portable upright chest radiograph.
FINDINGS: The lungs are well expanded. Multiple patchy opacities throughout
the right lung are compatible with known pleural metastasis. Chain sutures in
the right upper lung are re-demonstrated, consistent with prior wedge
resection. A focal nodularity seen in the left apex was compared with prior CT
and corresponds to a focus of fibrosis/scarring. No focal opacities are seen
in the right lung concerning for pneumonia. Cardiac size is normal. There is
a tortuous aorta with atherosclerotic calcifications of the aortic wall,
unchanged. There is no pleural effusion or pneumothorax. An IVC filter is
partially imaged.
IMPRESSION: Findings compatible with pleural-based right lung metastasis have
not significantly changed compared with prior exam. No new focal opacities
suggestive of pneumonia.
Radiology Report
INDICATION: ___ female with history of pulmonary embolism, presenting
with acute shortness of breath and hypoxia. Evaluate for pulmonary embolism.
COMPARISON: Multiple prior chest CTs, most recent on ___ and ___.
TECHNIQUE: Axial helical MDCT images were obtained from the suprasternal
notch to the upper abdomen at an early arterial phase after the administration
of 80 cc of Omnipaque following a chest CTA protocol. Coronal and sagittal
reformations were generated. Oblique MIP reformats were prepared on an
independent workstation.
DLP: 382.47 mGy-cm.
CHEST CTA: The main thoracic vessels are well opacified. The aorta is normal
in caliber throughout, without evidence of dissection or mural hematoma.
Atherosclerotic calcifications of the thoracic aorta are present. The
pulmonary arteries are well opacified to the segmental level. No filling
defect is noted in the left pulmonary arterial tree. In the segmental branch
to the posterobasal segment of the right lower lobe (2:73) there is a central
web-like filling defect which has significantly decreased in size compared
with ___, and represents a residual chronic thrombus. No new filling
defect concerning for pulmonary embolism in the right lung is identified.
CHEST CT: A right thyroid lobe nodule measuring 1.8 x 1.7 cm (2:14) has also
not significantly changed since at least ___. There is stable
appearance of the post-surgical changes status post right upper lobe wedge
resection. The soft tissue mass encasing the right hilus is unchanged in size
or appearance, with stable bilateral solid and ground-glass pulmonary nodules
and diffuse irregular nodular pleural thickening on the right compatible with
pleural metastasis. No new lesions are identified in the lungs. The heart is
normal in size without significant pericardial effusion. Mild coronary artery
calcifications are again seen. Again seen is complete occlusion of the right
upper lobe bronchi. The remaining tracheobronchial tree is grossly patent.
OSSEOUS STRUCTURES: There is unchanged appearance of paraspinal soft tissue
mass centered in the right T11-T12 neural foramina with extension into the
paravertebral soft tissues (2:101). Additional areas of sclerosis along the
inner margins of the right posterior ___ and 12th ribs are stable. Sclerotic
lesions in the lateral right fifth and seventh ribs are also unchanged. No
new osseous lesions are identified.
Although this study is not tailored for assessment of subdiaphragmatic
structures, the liver and spleen are grossly unremarkable. No celiac axis
lymphadenopathy is present. Multiple exophytic lesions in the upper pole of
both kidneys are incompletely imaged. Thickening of the left adrenal gland
remains unchanged.
IMPRESSION:
1. No new pulmonary embolism identified. Significant interval decrease
since ___ of clot burden in the right lower lobe pulmonary artery
with residual web-like thrombus compatible with chronic pulmonary thrombus.
2. Stable disease burden with unchanged extent of right pleural metastasis,
right hilar mass, bilateral solid and ground-glass pulmonary nodules, as well
as stable appearance of paraspinal soft tissue mass at the T11-T12 level. No
new lesions are identified.
3. Stable post-surgical appearance status post right upper lobe wedge
resection.
4. Unchanged right thyroid lobe nodule.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: DYSPNEA
Diagnosed with SHORTNESS OF BREATH, MAL NEO BRONCH/LUNG NOS, HYPERTENSION NOS
temperature: 98.9
heartrate: 120.0
resprate: 36.0
o2sat: 96.0
sbp: 116.0
dbp: 45.0
level of pain: 0
level of acuity: 1.0 | Ms. ___ is an ___ y.o with stage IV lung CA on pemetrexed
(last given ___, multiple prior PEs with IVC filter, MFAT,
frequent falls/syncope (for which AC was transiently held but
resumed with recurrent PE - now on lovenox) who presented with
sob, productive cough.
#SOB in the setting of lung cancer with recent treatment: In the
ED She was found to be tachycardic, but otherwise stable. CXR
and CTA without pna, new lesions, all findings were
old/unchanged with reference to masses/thrombus (latter
organized/reduced). She responded mostly to nebs in the ED with
return of sob to baseline per patient prior to reaching the
floor. No antibiotics given. Given her improvement with nebs,
there is question of a component of COPD vs. bronchospasm. She
was at baseline at discharge. The other likely scenario appears
that this is a result of side effects of chemo given myositis
type symptoms, as well as n/v for a few days prior to admission
and no po intake.
# Neutropenia: She reached a nadir while admitted with a WBC of
1.7 and 29% neutrophils. It was discussed with her outpatient
oncologists, and though she was neutropenic she remained
afebrile. Her culture data was negative, and no evidence of
pneumonia on imaging. She was discharged with instructions to
return to the ED for evaluation and treatment if she were to
develop a fever of 100.4.
# Atach and HTN: She was admitted on metoprolol tartrate TID
with bursts of tachycardia when out of bed. She was changed to
50mg of metoprolol succinate BID which gave her relief of
symptoms (anxiety, fatigue) so this was continued on discharge.
She remained normotensive, and her HR was WNL for multiple days
after this change.
#Mult PE/IVC filter: She was continued on Lovenox 70mg BID
#Disposition: She worked with ___ on back to back days and showed
good motivation and improvement and discharge home with ___ was
recommended. Her son ___ was on board with the plan and she
was discharged home.
DNR/DNI |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
diarrhea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
History of Present Illness: ___ w/ PMH ruptured aneurysm and
hemorrhagic stroke s/p clipping, HTN, peripheral vascular
disease, and recent L lower ext cellulitis (has been on
antibiotics since ___, now coming in w/ ___ month of
diarrhea. Per Atrius records, he has been on 5 different courses
of antibiotics: amox/clav (only took a few doses), clindamycin,
cephalexin, clindamycin, then cephalexin. Most recent course
stopped middle ___. Pt reports having watery diarrhea that
started 2 months ago, it was mild and felt to be related to the
antibiotics and over the past month it has been getting worse, 3
weeks ago had 2 episdoes of diarrhea a day and now more recently
___. No fevers, no chills, no lightheadedness, but reports
thirst. No black tarry stool or blood. No abdominal pain, still
passing gas. Reporst that he is living with his brother, who
helps with his medications. No travel, no exotic exposures, no
sick contacts. He reports occasional vomitting ___ times a day.
.
In the ED, initial vital signs were 99.4 96 132/50 18 98% RA
labs notable for WBC 13 Cr 1.7 (baseline 1.2-1.3) K 2.9. Patient
was given flagyl and KCl 1L NS bolus
.
Review of Systems:
(+)
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
STROKE, UNSPEC
HYPERTENSION - ESSENTIAL, UNSPEC
SCREENING FOR COLON CANCER - 2-days' prep
HISTORY CEREBRAL ANEURYSM REPAIR
HYPERCHOLESTEROLEMIA
Advanced directives, counseling/discussion
PVD (peripheral vascular disease)
Chronic venous insufficiency
Proteinuria
Left leg cellulitis
Leg wound, left
Left leg pain
Normocytic anemia
Antibiotic long-term use
LBBB
Social History:
___
Family History:
father with CAD
Physical Exam:
Admission:
Vitals- 137/52 96 72
General: WD WN AAOx3 comfortable in NAD. Speech with slowing and
dysarthria, but is understandable.
CV: RRR, normal S1/S2, no murmers
Lungs: clear breath sounds b/l
Abdomen: pos bowel sounds, slightly distended, non tender
Ext: chronic venous stasis changes in lower extremities, no
evidence of cellulitis
Neuro: weakness on R, contracted R arm, slurred speech, R facial
droop. Left legs postured in extension. Tongue weakness.
Skin: venous stasis b/l and severe dry cracking skin without
erythema or warmth
on d/c
97.7 149/66 79 18 99%RA had 5Bm yest and 2 overnight
.
Discharge:
GENERAL: WD WN AAOx3 comfortable in NAD. Speech with slowing and
dysarthria, but is understandable.
HEENT: NC/AT PERRL EOMI, sclera anicteric, slightly dry MM OP
clear
NECK: supple, no LAD, no JVD, no thyromegaly
CARDIAC: RRR, S1, S2, no m/r/g
LUNG: CTAB no w/r/r
ABDOMEN: soft NT ND +BS no organomegally
GU: no foley
EXT: WWP no c/c 2+ radial ___, 1+ lower extremity edema,
chronic venous stasis changes in lower extremities, with
moisturized skin (under dry cracked), no erythema or warmth
NEURO: AAOX 3, dysarthria noted. Baseline weakness on R
(face&body)+ contracted R arm, R facial droop, R sided weakness
in upper and lower extremities. Unchanged from admission exam
Sensory: nml to light touch and vibratory sense throughout
SKIN: dry cracking skin lower ext
Pertinent Results:
Admission labs:
___ 09:28AM BLOOD WBC-12.3*# RBC-4.01* Hgb-11.6* Hct-35.0*
MCV-87 MCH-28.9 MCHC-33.1 RDW-16.2* Plt ___
___ 09:28AM BLOOD Neuts-78.3* Lymphs-10.7* Monos-10.7 Eos-0
Baso-0.2
___ 09:28AM BLOOD Glucose-92 UreaN-31* Creat-1.7* Na-141
K-2.9* Cl-102 HCO3-28 AnGap-14
___ 09:28AM BLOOD ALT-26 AST-49* AlkPhos-67 TotBili-1.2
___ 09:28AM BLOOD Albumin-3.2* Calcium-8.6 Phos-2.9 Mg-1.9
___ 09:40AM BLOOD Lactate-1.4
Discharge labs:
___ 06:45PM BLOOD WBC-11.8* RBC-4.34* Hgb-12.2* Hct-38.4*
MCV-88 MCH-28.2 MCHC-31.9 RDW-16.5* Plt ___
___ 05:40AM BLOOD Glucose-105* UreaN-17 Creat-1.2 Na-148*
K-3.3 Cl-116* HCO3-28 AnGap-7*
___ 09:28AM BLOOD ALT-26 AST-49* AlkPhos-67 TotBili-1.2
___ 05:40AM BLOOD Calcium-7.9* Phos-1.8* Mg-2.3
Microbiology:
___ Stool culture-
C. difficile DNA amplification assay (Final ___:
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C. difficile by the Illumigene
DNA
amplification. (Reference Range-Negative).
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
___ Blood culture- pending with NGTD
Imaging:
___ Video swallow- Multiple consistencies of barium were
administered with the speech and swallow division. There is
evidence of penetration of thins and nectars and aspiration of
thins. For further details, please refer to the speech and
swallow division note in OMR.
___ CT head, noncontrast- There is no acute intracranial
hemorrhage, edema, mass effect or major vascular territorial
infarct. Left thalamic volume loss with ex vacuo dilatation of
the left lateral ventricle is unchanged since ___.
Wallerian degeneration of the left cerebral peduncle is also
similar. The patient is status post aneurysmal clipping in the
left cavernous sinus region and left frontotemporal craniotomy.
There is no shift of normally midline structures. Basal cisterns
are preserved. Gray-white matter differentiation is preserved.
The visualized paranasal sinuses, mastoid air cells and middle
ear cavities are clear.
IMPRESSION: No acute intracranial abnormality. No change from
___. MRI is more sensitive to detect stroke, but depending
on when and where the aneurysmal clip was placed, MRI may be
contraindicated.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydrochlorothiazide 25 mg PO DAILY
2. Losartan Potassium 100 mg PO DAILY
3. Amlodipine 10 mg PO DAILY
4. Vitamin D ___ UNIT PO DAILY
5. Aspirin 325 mg PO DAILY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. Vitamin D ___ UNIT PO DAILY
5. Losartan Potassium 100 mg PO DAILY
6. Vancomycin Oral Liquid ___ mg PO Q6H
day 1: ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
primary: C diff, ___
secondary: HTN, h/o stroke
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
INDICATION: History of recent choking. Please evaluate.
COMPARISONS: None.
Multiple consistencies of barium were administered with the speech and swallow
division. There is evidence of penetration of thins and nectars and
aspiration of thins. For further details, please refer to the speech and
swallow division note in OMR.
Radiology Report
HISTORY: History of stroke with difficulty swallowing.
TECHNIQUE: Noncontrast MDCT axial images were acquired through the head.
Bone reconstructions and coronal and sagittal reformations were provided for
review.
COMPARISON: CT Head ___.
FINDINGS: There is no acute intracranial hemorrhage, edema, mass effect or
major vascular territorial infarct. Left thalamic and posterior limb of
internal capsule volume loss with ex vacuo dilatation of the left lateral
ventricle is unchanged since ___. Wallerian degeneration of the left
cerebral peduncle is also similar. The patient is status post aneurysmal
clipping in the left cavernous sinus region and left frontotemporal
craniotomy. There is no shift of normally midline structures. Basal cisterns
are preserved. Gray-white matter differentiation is preserved. The
visualized paranasal sinuses, mastoid air cells and middle ear cavities are
clear.
IMPRESSION: No acute intracranial abnormality. No change from ___. MRI
is more sensitive to detect stroke, but depending on when and where the
aneurysmal clip was placed, MRI may be contraindicated.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: DIARRHEA
Diagnosed with HYPOKALEMIA, DIARRHEA, RENAL & URETERAL DIS NOS
temperature: 99.4
heartrate: 96.0
resprate: 18.0
o2sat: 98.0
sbp: 132.0
dbp: 50.0
level of pain: 0
level of acuity: 3.0 | ___ h/o cellulitis which he has been on antibiotics or 2 months
is here with diarrhea concerning for C dif in setting of
antibiotic use.
# Diarrhea / C. diff colitis: h/o antibiotic use for 2 months
prior to onset of symptoms with stool culture C diff positive.
Patient was started on oral vancomcyin 125mg q6h and given IVF.
He had a decrease in frequency and volume of bowel movements at
the time of discharge (5 day prior). He will be treated for 14
days, day 1: ___, end date ___.
# Acute kidney injury: per Atrius records baseline Cr is 1.2-1.3
and on admission creatinine was 1.7 consistent with hypovolemia.
Creatinine improved with fluids and was 1.2 (baseline) on the
day of discharge. Losartan was held initially, restarted once
creatinine returned to baseline.
# Hypokalemia: Attributed to severe diarrhea. K was repleted
daily as needed.
# Hypernatremia: Patient developed mild hypernatremia to max 149
acutely related to normal saline infusions. He had no change in
mental status and in addition to encouraging oral free water
intake, patient was given IV D5W. Will need sodium rechecked in
2 days.
# Choking/worsening weakness: Patient has h/o stroke (slow
speech and R facial droop) but noted more difficulty with eating
and swallowing pills during this hospital stay. Patient and
brother noted this difficulty began approximately 3 d prior to
admission. Speech/Swallow was consulted and performed video
swallow which noted good pharyngeal swallowing, but weakness in
the tongue. Given concern for acute/subacute intracranial event,
a CT head without contrast was performed which showed no
changes. MRI could not be performed due to pre-existing
aneurysmal clips, and patient was out of window for treatment.
Tongue weakness may not represent acute cerebral event, and may
represent recrudescence from prior stroke. Patient did well
with thin liquids; medications were made liquid where possible,
and pills were crushed and dissolved in fluids. He will need
Ensure TID to ensure appropriate nutrition. Foods will need to
be pureed and nursing notes that when food is placed in back of
mouth, patient has an easier time with swallowing. He will need
ongoing speech/swallow rehabilitation to assist in regaining
tongue strength.
# Debilitation: Patient was independent in most ADLs at home. He
has been in a motorized wheelchair for the last ___ years but
also uses a cane. Likely from deconditioning, patient was unable
to return to his prior baseline when working with physical
therapy and rehab was recommended.
# Hypertension: Home amlodipine and HCTZ was continued. Losartan
was initially held due to acute kidney injury, restarted prior
to discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Mechanical fall
Major Surgical or Invasive Procedure:
Right sided Chest tube placement
History of Present Illness:
___ y/o Male s/p mechanical fall in his bathtub 2 days ago while
drunk. He did not seek immediate medical attention and stayed at
home until ___ when he experienced intense right sided pain
that prompted him to seek medical attention at ___.
The pain was not associated with shortness of breath. At ___
CT chest showed contiguous right rib fractures ___ c/b
hemothorax, pulmonary contution and possible splenic hematoma. A
chest tube was placed and the patient was transferred to ___
for further management. He remained hemodynamically stable at
the ED but desating to 90% at RA and required 3L.
Past Medical History:
PMH: none
PSH: none
Social History:
___
Family History:
Non-contributory
Physical Exam:
PHYSICAL EXAM ON ADMISSION
Vitals:98.2 96 130/88 22 96% 3L NC
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Chest tube on R. chest, no crepitus, tender to palpation.
ABD: mildy tender RUQ and guarding, normoactive bowel sounds, no
palpable masses
Ext: No ___ edema, ___ warm and well perfused
PHYSICAL EXAM ON DISCHARGE
Vitals:97.9 82 134/76 18 94% 2L NC
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: CTA b/l, chest tube incision C/D/I with pressure dressing
in place
ABD: mildy tender RUQ and guarding, normoactive bowel sounds, no
palpable masses
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___
137 ___ AGap=14
-------------<
4.0 22 0.8
7.8 \ 12.3 / 209
/ 35.9 \
N:92.3 L:4.1 M:3.0 E:0.4 Bas:0.2
___: 11.6 PTT: Pnd INR: 1.1
Imaging:
CT Chest (___): No images sent. Per report: Right rib
fractures
___, hemothorax, and pulmonary contusion, possible liver
hematoma.
CT Abdomen (___): R chest tube with small residual
pneumothorax, basilar
atelectasis, and subcutaneous emphysema. A small right chest
wall
hematoma surrounds the chest tube. In addition, there is a very
small subcapsular liver hematoma extending from chest tube along
the right lateral surface of liver. It is unclear if liver
hematoma is due to initial trauma of tube insertion which is
ultimately intra-pleural or if the course of the tube is
partially intra-peritoneal,though the latter is felt less likely
significantly distended bladder
Medications on Admission:
None
Discharge Medications:
1. Hydrocodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain
Duration: 10 Days
2. Docusate Sodium 100 mg PO BID Duration: 10 Days
Discharge Disposition:
Home
Discharge Diagnosis:
Mechanical Fall; Right sided ___ rib fractures hemothorax and
pulmonary contusion and small subcapsular liver hematoma.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
PORTABLE CHEST FILM ___ AT 1032
CLINICAL INDICATION: ___ status post fall, assess for interval
changes.
Comparison is made to patient's prior study of ___ at 238.
Portable semi-erect chest film ___ at 1032 is submitted.
IMPRESSION:
1. Right basilar chest tube remains in place with some right lateral chest
wall subcutaneous emphysema. Suggestion of small right apical pneumothorax.
Stable patchy opacity at the right base. No evidence of pulmonary edema.
Overall cardiac and mediastinal contours are unchanged. Possible tiny left
effusion. Bibasilar opacities likely reflect areas of atelectasis, although
aspiration or pneumonia should also be considered. Results of this
examination were conveyed to the patient's nurse, ___, by phone on ___
at 12:20 p.m. at the time of discovery.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ y/o M s/p mech fall seen 2 days later ___, R rib fx ___,
hemothorax and pulm contusion and small subcapsular liver hematoma //
?interval changes
TECHNIQUE: Portable chest
COMPARISON: ___.
FINDINGS:
Compared to the prior study there is no significant interval change.
IMPRESSION:
No change.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient after mechanical fall, rib
fractures and hemothorax and pulmonary contusion ,chest tube discontinued.
PA and lateral upright chest radiographs were reviewed in comparison to ___.
There is small right apical pneumothorax present. Right pleural effusion
appears to be unchanged. Associated atelectasis is unchanged. Left lung is
essentially clear. Left basal atelectasis is unchanged.
Radiology Report
INDICATION: Right-sided chest tube, hemothorax. Please evaluate and chest
tube placement.
COMPARISON: No prior studies available for comparison.
FINDINGS: Frontal and lateral chest radiographs demonstrate cardiomegaly with
mild central vessel congestion. Right lower lung opacification likely
represents a combination of elevated hemidiaphragm, atelectasis and reported
hemothorax. Minimal blunting of the left costophrenic angle may reflect small
pleural effusion versus scarring. No pneumothorax identified, though there is
subcutaneous gas within the right chest wall surrounding a right chest tube.
IMPRESSION: Right lower lung opacification, likely combination of elevated
right hemidiaphragm, atelectasis, and reported hemothorax. No pneumothorax.
Possible small left pleural effusion.
Radiology Report
INDICATION: Report of subcapsular hematoma on outside hospital chest CT.
COMPARISON: Comparison is made to chest radiograph performed ___.
FINDINGS: The patient has a notably elevated right hemidiaphragm, possibly
reflecting incompletely assessed right lung base collapse. There is a right
approach chest tube which given the presence a small adjacent subcapsular
liver hematoma may be at least partially intraperitoneal. Other possibilities
include hematoma due to initial contact with the liver on tube insertion
though tube remains intrapleural. The liver parenchyma enhances homogeneously
without concerning liver lesions. A 27 mm simple cyst is evident within the
hepatic segment IVb. There is no intra- or extra-hepatic biliary ductal
dilatation. The gallbladder, pancreas, spleen, adrenal glands, kidneys and
ureters are unremarkable. The bladder is significantly distended.
The stomach, small and large bowel are normal in appearance. The appendix is
visualized and normal. No free air or fluid identified. No lymphadenopathy
present.
No suspicious lytic or blastic lesions present. No fractures identified.
IMPRESSION: Right-sided chest tube with small residual right pneumothorax and
collapse of the right lung base. Associated with chest tube insertion is a
small chest wall hematoma as well as small subcapsular liver hematoma. It is
unclear if hematoma was sustained with initial contact of the liver on chest
tube insertion or reflects a partially intraperitoneal course of the tube. No
other evidence of trauma.
Gender: M
Race: WHITE - BRAZILIAN
Arrive by AMBULANCE
Chief complaint: R Rib pain, HEMOTHORAX
Diagnosed with LIVER HEMATOMA/CONTUSION, FRACTURE THREE RIBS-CLOS, TRAUM PNEUMOHEMOTHOR-CL, UNSPECIFIED FALL
temperature: 97.0
heartrate: 82.0
resprate: 16.0
o2sat: 97.0
sbp: 131.0
dbp: 89.0
level of pain: 5
level of acuity: 2.0 | The patient presented as detailed above and was admitted to the
Acute Care Surgery service for management of his rib fractures,
hemothorax and subcapsular hematoma. The plan was to ensure good
pain control to ensure good ventilation, follow chest tube
output and perform serial abdominal exams for the subcapsular
hematoma. The patient remained hemodynamically stable on the
floor and his chest tube output was low so his chest tube, which
was initially kept to wall suction, was switched to waterseal on
HD2. Follow-up CXR demonstrated good lung volumes and no
pneumothorax so his chest tube was removed. A post-pull CXR was
obtained to rule out any residual pneumothorax. By end of HD2
the patient was maintaining his oxygen saturations on room air
after being weaned off oxygen and his pain was under control on
PO pain medications so he was discharged home with a scheduled
follow up visit in the ___ clinic in 2 weeks. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Code Cord
Major Surgical or Invasive Procedure:
EMG/NCS
Lumbar puncture
History of Present Illness:
This is a very pleasant ___ man with a medical history notable
for rectal adenocarcinoma s/p local resection and adjuvant
chemoradiation who was referred to the ED by Dr. ___ to
rule out a possible cauda equina syndrome. He provides an
excellent history.
He explains that he has had problems with lower extremity
symptoms for at least a couple of months. His last dose of
radiation to the groin was back in ___, and following those
sessions of radiation, he had a lot of local problems with skin
peeling. These all resolved, and he had essentially normal
urinary and bowel function for the next several months. He
started to notice bilateral hip pain in ___ or so. It was
first
thought to be a case of trochanteric bursitis. He received a
local joint injection to the left hip with plans to do the right
hip next, but the left joint injection did not help. During this
time, he was symptomatically managed with low dose opiate
narcotics. Then, he started to have midline lower back pain in
conjunction with this bilateral hip pain, which he describes as
radiating down the side of his legs down to his lateral
malleolus.
He was hospitalized for this in late ___ and received an MRI
of
his L-spine - this study has now been uploaded to our system
(was
done at ___ "___ in an open Shield's MRI). This
identified a few protruding discs and at least one significant
posterolateral L5-S1 disc herniation resulting in partial disc
extrusion compressing the left S1 nerve root. For this new back
pain, he received a local ESI which partially helped relieve his
symptoms.
Over the past two-three weeks, he explains that his pain has
gotten worse. He has been prescribed morphine sulfate (10mg BID)
and this together with other opiates has caused him to become
more confused. The pain is so bad that it causes him to wake up
in the middle of the night. It is not necessarily worse on lying
flat, and he reports that physical activity does tend to make it
worse. He has noticed his legs giving out and a resulting fall
on
at least four occasions. His gait has become very clumsy. He
explains that producing urine has become somewhat more difficult
now, in that he has to strain at times and feels like "there is
still some left after I have gone". He has also had a few
episodes of frank stool incontinence, one episode of which was
associated with a fall.
Review of systems is positive for an extremity rash that he has
had for a few years now and has been stable. He has not been
able
to maintain an erection for the past six months; thought to be a
side effect of surgery. He has not had any groin anesthesia, for
example when he wipes himself. He has not had any weight loss.
No
change to his appetite. No belly pain or chest pain. He has not
had any drooling. He has not had any episodes of LOC.
Past Medical History:
Past medical history includes GERD, hypertension and a remote
history of tobacco abuse. He was seen by a dermatologist a few
years ago for this arm and leg rash that he has now ("they
described it with a really long name"). He takes some topical
treatment at this time that is available over the counter which
he did not know the name of.
Regarding his oncologic history, he was was found to have a
polpyoid lesion in his rectum in ___ which was
incompletely
resected. He had a full thickness of this cancerous lesion in
___, following which a portacath was placed and he
started chemotherapy with ___. Concurrently, he received
chemotherapy. The radiation and chemotherapy resulted in what he
describes a miserable few months consisting of significant
peeling and "burns" in his groin, "ass" and his feet. His last
dose of radiation was in ___. He also reports a
previous history of "stroke" in ___ that resulted in some
slurring of his speech. Further details are not available.
Social History:
___
Family History:
Family history is negative for neuromuscular disease. He did
have
a father who died of prostate cancer at ___.
Physical Exam:
EXAM ON ADMISSION:
V/s: 97.1, HR 68, BP 166/77, R 18, 97% RA.
This is a large obese gentleman who was lying supine in his
stretcher. He was pleasant and cooperative and in no apparent
distress. Head was NCAT with moist mucous membranes. OP was
clear
of lesions. Heart and lung sounds were distant. Belly was obese
but without focal tenderness or organomegaly. Lower extremities
were without edema or cyanosis. He has a rash on his arms and
legs that consisted of scattered 1cm diameter red macules in the
background of generally dry skin. He had a subcutaneous port
over
his left chest area. Rectal tone was normal.
Neurologically, he was awake, alert and oriented. He could
recall
the ___ backwards. His comprehension and fluency was full. He
could read simple phrases. He had mildly slurred speech which he
says was his baseline. Pupils were round, small (1mm) and not
reactive to light. Eye movements were full. Visual fields were
full. Face was asymmetric with a relative flattening of the left
NLF (although it appeared that the right face was also slightly
distorted for unclear reasons). Tongue was full and midline.
Facial sensation intact to pinprick. Hearing was grossly intact.
Strength examination showed normal bulk, tone throughout. No
pronator drift 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+ 4 5 5 4
R 5 5 ___ ___ 4+ 4- 5 4 4
The sensory examination revealed no deficits to light touch,
pinprick, cold sensation, proprioception throughout. Pinprick
was
normal in the sacral dermatomes. Vibration at great toes was
absent, but present at the knees.
The reflex examination revealed ..
Bi Tri ___ Pat Ach
L 0 0 0 3 0
R 0 0 0 3 0
Plantar response: Down
Bedside tests of cerebellar function revealed no intention
tremor, or dysmetria. Gait examination revealed a wide based,
generally steady gait with small strides.
Exam on discharge:
T 98.2 BP 165/78 HR 54 RR 18 O2sat 99%RA
Gen: NAD, comfortable
Resp: nonlabored
MS: alert, oriented, conversing appropriately & following
instructions
Sensory: Decreased sensation to pinprick over dorsa of both feet
Motor: strength in the ___ as follows: R/L IP ___,
quads5/5, hams 4+/5-, ankle DF ___, ___ ___, PF ___.
Patellar reflex is 2+, ankle jerks are absent as earlier.
Gait: waddling with bilateral foot drop
Pertinent Results:
___ 09:50PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 09:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-7.0
LEUK-NEG
___ 03:20PM GLUCOSE-109* UREA N-24* CREAT-1.1 SODIUM-137
POTASSIUM-4.5 CHLORIDE-98 TOTAL CO2-28 ANION GAP-16
___ 03:20PM WBC-5.2 RBC-3.50* HGB-11.1* HCT-33.3* MCV-95
MCH-31.8 MCHC-33.4 RDW-13.0
___ 03:20PM NEUTS-72.4* LYMPHS-15.7* MONOS-9.4 EOS-2.0
BASOS-0.4
___ 03:20PM PLT COUNT-203
MRI spine ___:
FINDINGS:
Cervical spine: The vertebral bodies are normal in height and
alignment.
Degenerative marrow endplate signal changes are ntoed at C5-6.
There is disc
desiccation and loss of disc height throughout the cervical
spine. The spinal
cord and the craniocervical junction are normal. The paraspinal
soft tissues
are unremarkable. There is no abnormal enhancement.
At C2-C3, there is a broad-based disc protrusion with endplate,
uncovertebral
joint, facet osteophytes resulting in mild narrowing of the
right neural
foramen.
At C3-C4, there is a broad-based disc protrusion as well as
uncovertebral and
facet joint degenerative changes resulting in mild to moderate
bilateral
neural foraminal narrowing.
At C4-5, there is a broad-based disc protrusion with facet and
uncovertebral
joint osteophytes with no significant spinal canal or neural
foraminal
narrowing.
At C5-6, there is a broad-based disc protrusion with facet and
uncovertebral
joint osteophytes resulting in mild spinal canal narrowing,
moderate right
neural foraminal narrowing, and mild left neural foraminal
narrowing.
At C6-7, there are facet and uncovertebral joint osteophytes
resulting in mild
left neural foraminal narrowing.
At C7-T1, there is a broad-based disc protrusion without
significant spinal
canal or neural foraminal narrowing.
Thoracic spine: The vertebral bodies normal in height and
alignment. There
is a focal area of fatty deposition in the T7 vertebral body.
Otherwise, the
bone marrow signal is normal. The spinal cord is normal signal
intensity and
morphology. There is disc desiccation loss of intervertebral
disc height at
multiple levels, with a small protrusion at T9-T10 level, but
there is no
significant spinal canal or neural foraminal narrowing. There
is no abnormal
enhancement.
Lumbar spine: Vertebral bodies are normal in height, signal
intensity, and
alignment. The distal spinal cord and conus medullaris are
normal in
appearance, with the conus medullaris terminating at L1-2.
There is diffuse
disc desiccation and loss of intervertebral disc height, most
prominent at
L3-L4 through the L5-S1. The paraspinal soft tissues are
unremarkable.
At L3-4, there is a diffuse disc bulge, ligamentum flavum
thickening, facet
degenerative change without significant narrowing of the spinal
canal or
neural foramina.
At L4-5, there is a diffuse disc bulge with a superimposed
central protrusion,
ligamentum flavum thickening, and facet degenerative change
resulting in mild
bilateral neural foraminal narrowing without significant
narrowing of the
spinal canal.
At L5-S1, there is a diffuse disc bulge eccentric to the left
with facet
degenerative changes resulting in mild bilateral neural
foraminal narrowing
and no significant narrowing of the spinal canal.
Paraspinal soft tissues are unremarkable. There is no abnormal
enhancement.
IMPRESSION:
1. No evidence of spinal cord or cauda equina compression.
2. Mild degenerative changes of the cervical, thoracic, and
lumbar spine,
with lumbar spine degenerative changes similar to prior MRI from
___.
Cerebrospinal fluid (LP) ___:
NEGATIVE FOR MALIGNANT CELLS.
Lymphocytes, monocytes, and neutrophils.
CT abdomen/pelvis w/contrast ___:
FINDINGS:
Abdomen: Mild dependent subsegmental atelectasis bilateral lung
bases. Small
bilateral peripheral pulmonary nodules appear unchanged, the
largest measuring
3-4 mm. Liver, gallbladder, spleen, pancreas, bilateral adrenal
glands and
kidneys appear unremarkable. Minimal calcific atherosclerosis
of a normal
caliber abdominal aorta. No evidence of significant
lymphadenopathy.
Normal-appearing small bowel. No evidence of ascites.
Pelvis: Normal-appearing partially full urinary bladder.
Normal-appearing
prostate and seminal vesicles. No evidence of pelvic free
fluid. No evidence
of significant inguinal or pelvic sidewall lymphadenopathy. A
few left-sided
colonic diverticula. Normal-appearing appendix. Visualized
portions of the
bilateral sciatic nerves appear unremarkable. Visualized
osseous structures
appear unremarkable.
IMPRESSION:
No acute pathology identified. No evidence of recurrent or
metastatic
disease.
EMG/NCS ___:
FINDINGS:
Motor nerve conduction studies (NCSs) of the right deep peroneal
nerve
revealed mild prolongation of distal latency, markedly reduced
response
amplitudes, severely slowed conduction velocity in the foreleg,
and normal
conduction velocity across the fibular neck.
Motor NCSs of the right tibial nerve were normal, including
F-responses.
Motor NCSs of the left deep peroneal nerve revealed normal
distal latency,
markedly reduced response amplitudes, and moderately slowed
conduction
velocities. There was no abnormal facilitation of response
amplitude after 10
seconds of maximal voluntary exercise.
Motor NCSs of the left common peroneal revealed normal distal
latency,
markedly reduced response amplitudes, and normal conduction
velocities.
Motor NCSs of the left tibial nerve were normal; F-minimum
latency was
moderately prolonged.
Motor NCSs of the left ulnar nerve were normal.
Sensory NCS of the right sural nerve revealed borderline normal
response
amplitude and moderately slowed conduction velocity.
Sensory NCS of the right superficial peroneal revealed mildly
reduced response
amplitude and mildly slowed conduction velocity.
Responses of the left sural and superficial peroneal sensory
responses were
absent.
Sensory NCS of the left radial nerve was normal.
Concentric needle electromyography (EMG) of selected muscles
representing the
left L2-S1 myotomes was performed. EMG of vastus lateralis
revealed mild
ongoing denervation, mild chronic reinnervation, and slightly
reduced
recruitment. EMG of gluteus medius, tibialis anterior, medial
gastrocnemius,
and exetensor hallucis longis revealed severe ongoing
denervation in the form
of fibrillation potentials, mild chronic reinnervation, and
slightly-
moderately reduced recruitment. EMG of L4 paraspinal muscles
revealed
occasional fibrillation potentials. EMG of L5 paraspinal muscles
was normal.
Concentric needle EMG of left mid-thoracic paraspinal muscles
was normal.
Concentric needle EMG of right tibialis anterior and medial
gastrocnemius
revealed severe ongoing denervation in the form of fibrillation
potentials,
mild chronic reinnervation, and slightly reduced recruitment.
Further
evaluation was deferred in the setting of patient discomfort.
IMPRESSION:
Abnormal study. There is electrophysiologic for a severe,
ongoing and chronic
left lumbosacral plexopathy, characterized by prominent axon
loss. Limited
examination of the right lower extremity demonstrates evidence
of a similar
process. The severity and extent of the abnormalities suggest an
infiltrative/inflammatory etiology.
FELLOW: ___.
INTERPRETED BY: ___.
Cerebrospinal fluid (lumbar puncture) ___:
NEGATIVE FOR MALIGNANT CELLS.
Lymphocytes and monocytes.
MRI pelvis w/ w/o contrast ___:
FINDINGS:
The sacral plexus is normal in signal intensity bilaterally
without evidence
of swelling or edema. No evidence of abnormal masses or nerve
impingement.
L3-S5 nerve roots bilaterally are normal in signal intensity and
no abnormal
enhancement is identified post-contrast.
The rectum is unremarkable. No features to suggest disease
recurrence.
Note is again made of a subcentimeter focus of high signal
within the right
seminal vesicle (9:47) which does not enhance post-contrast and
is unchanged
since previous - this most likely represents a small calculus.
The prostate
gland is unremarkable. The bladder is within normal limits. No
pelvic
adenopathy. No free fluid within the pelvis. Bone marrow
signal is normal.
No destructive osseous lesions.
IMPRESSION:
Normal MRI of the sacral plexus
Bone scan ___:
INTERPRETATION: Whole body images of the skeleton obtained in
anterior and
posterior projections show increased tracer uptake in cervical
region laterally,
bilateral knees and right first MTP joint, likely degenerative
in nature.
The kidneys and urinary bladder are visualized, the normal route
of tracer
excretion.
IMPRESSION: No evidence of osseous metastatic disease.
Increased tracer uptake
in cervical region, bilateral knees and right MTP joint, most
likely
degenerative in nature.
Medications on Admission:
omeprazole, HCTZ 25mg daily, metop ER
25mg daily, amitryptilline 50mg nightly (for sleep), cozaar
100mg
___, morphine sulfate 10mg BID, PRN hydrocodone/acetaminophen,
amlodipine. He has no known medication allergies.
Discharge Medications:
1. Escitalopram Oxalate 20 mg PO DAILY
2. Hydrochlorothiazide 25 mg PO DAILY
3. Losartan Potassium 100 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Amitriptyline 50 mg PO HS sleeping difficulties
6. Gabapentin 600 mg PO Q8H
7. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Sever Pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth no more often than
every 3 hours Disp #*200 Tablet Refills:*0
8. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
RX *oxycodone [OxyContin] 20 mg 1 tablet extended release 12
hr(s) by mouth twice a day Disp #*60 Tablet Refills:*0
9. PredniSONE 60 mg PO DAILY
60mg qd x 2d, 50mg qd x2d, 40mg qd x2d, 30 mg qd x2d, 20 mg qd
x2d, then continue 10 mg qd
10. Metoprolol Succinate XL 50 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Bilateral lumbosacral plexopathy of unclear etiology
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 question of spinal cord compression or cauda
equina compression.
COMPARISON: MRI lumbar spine, ___.
TECHNIQUE: Multisequence multiplanar imaging of the cervical, thoracic, and
lumbar spine was performed both prior to and following the intravenous
administration of 11 mL Gadavist.
FINDINGS:
Cervical spine: The vertebral bodies are normal in height and alignment.
Degenerative marrow endplate signal changes are ntoed at C5-6. There is disc
desiccation and loss of disc height throughout the cervical spine. The spinal
cord and the craniocervical junction are normal. The paraspinal soft tissues
are unremarkable. There is no abnormal enhancement.
At C2-C3, there is a broad-based disc protrusion with endplate, uncovertebral
joint, facet osteophytes resulting in mild narrowing of the right neural
foramen.
At C3-C4, there is a broad-based disc protrusion as well as uncovertebral and
facet joint degenerative changes resulting in mild to moderate bilateral
neural foraminal narrowing.
At C4-5, there is a broad-based disc protrusion with facet and uncovertebral
joint osteophytes with no significant spinal canal or neural foraminal
narrowing.
At C5-6, there is a broad-based disc protrusion with facet and uncovertebral
joint osteophytes resulting in mild spinal canal narrowing, moderate right
neural foraminal narrowing, and mild left neural foraminal narrowing.
At C6-7, there are facet and uncovertebral joint osteophytes resulting in mild
left neural foraminal narrowing.
At C7-T1, there is a broad-based disc protrusion without significant spinal
canal or neural foraminal narrowing.
Thoracic spine: The vertebral bodies normal in height and alignment. There
is a focal area of fatty deposition in the T7 vertebral body. Otherwise, the
bone marrow signal is normal. The spinal cord is normal signal intensity and
morphology. There is disc desiccation loss of intervertebral disc height at
multiple levels, with a small protrusion at T9-T10 level, but there is no
significant spinal canal or neural foraminal narrowing. There is no abnormal
enhancement.
Lumbar spine: Vertebral bodies are normal in height, signal intensity, and
alignment. The distal spinal cord and conus medullaris are normal in
appearance, with the conus medullaris terminating at L1-2. There is diffuse
disc desiccation and loss of intervertebral disc height, most prominent at
L3-L4 through the L5-S1. The paraspinal soft tissues are unremarkable.
At L3-4, there is a diffuse disc bulge, ligamentum flavum thickening, facet
degenerative change without significant narrowing of the spinal canal or
neural foramina.
At L4-5, there is a diffuse disc bulge with a superimposed central protrusion,
ligamentum flavum thickening, and facet degenerative change resulting in mild
bilateral neural foraminal narrowing without significant narrowing of the
spinal canal.
At L5-S1, there is a diffuse disc bulge eccentric to the left with facet
degenerative changes resulting in mild bilateral neural foraminal narrowing
and no significant narrowing of the spinal canal.
Paraspinal soft tissues are unremarkable. There is no abnormal enhancement.
IMPRESSION:
1. No evidence of spinal cord or cauda equina compression.
2. Mild degenerative changes of the cervical, thoracic, and lumbar spine,
with lumbar spine degenerative changes similar to prior MRI from ___.
Radiology Report
HISTORY: ___ year old man with hx of rectal cancer, now with unrelenting
neuropathic lumbosacral pain and proximal leg weakness REASON FOR THIS
EXAMINATION: Query recurrence of malignancy, nerve root infiltration
COMPARISON: MRI spine ___, CTA chest ___, CT torso ___
TECHNIQUE: Standard departmental protocol CT of the abdomen pelvis was
performed with intravenous contrast administration. 3 min delayed imaging of
the abdomen was also performed. Coronal and sagittal reformats were obtained.
Total exam DLP 1533 mGy-cm.
FINDINGS:
Abdomen: Mild dependent subsegmental atelectasis bilateral lung bases. Small
bilateral peripheral pulmonary nodules appear unchanged, the largest measuring
3-4 mm. Liver, gallbladder, spleen, pancreas, bilateral adrenal glands and
kidneys appear unremarkable. Minimal calcific atherosclerosis of a normal
caliber abdominal aorta. No evidence of significant lymphadenopathy.
Normal-appearing small bowel. No evidence of ascites.
Pelvis: Normal-appearing partially full urinary bladder. Normal-appearing
prostate and seminal vesicles. No evidence of pelvic free fluid. No evidence
of significant inguinal or pelvic sidewall lymphadenopathy. A few left-sided
colonic diverticula. Normal-appearing appendix. Visualized portions of the
bilateral sciatic nerves appear unremarkable. Visualized osseous structures
appear unremarkable.
IMPRESSION:
No acute pathology identified. No evidence of recurrent or metastatic
disease.
Radiology Report
HISTORY: Past medical history of rectal cancer, now with leg weakness. Rule
out inflammation or neoplastic infiltration.
COMPARISON: MRI pelvis dated ___.
TECHNIQUE: Multiplanar T1 and T2 weighted images were acquired on a 1.5 Tesla
magnet including dynamic 3D imaging obtained prior to, during and after the
uneventful intravenous administration of 12 mL of Gadavist.
FINDINGS:
The sacral plexus is normal in signal intensity bilaterally without evidence
of swelling or edema. No evidence of abnormal masses or nerve impingement.
L3-S5 nerve roots bilaterally are normal in signal intensity and no abnormal
enhancement is identified post-contrast.
The rectum is unremarkable. No features to suggest disease recurrence.
Note is again made of a subcentimeter focus of high signal within the right
seminal vesicle (9:47) which does not enhance post-contrast and is unchanged
since previous - this most likely represents a small calculus. The prostate
gland is unremarkable. The bladder is within normal limits. No pelvic
adenopathy. No free fluid within the pelvis. Bone marrow signal is normal.
No destructive osseous lesions.
IMPRESSION:
Normal MRI of the sacral plexus.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: LEG WEAKNESS
Diagnosed with LUMBAGO, OTHER MALAISE AND FATIGUE
temperature: 97.1
heartrate: 68.0
resprate: 18.0
o2sat: 97.0
sbp: 166.0
dbp: 77.0
level of pain: 7
level of acuity: 2.0 | ___ M with rectal adenocarcinoma, s/p local resection with
chemoradiation, abdominal obesity, HTN, and lumbar spondylosis,
who was referred from the ED for ___ pain and weakness.
He finished chemoradiation 5 months ago (6 wks ___ with 5000
cGy), complicated by hand and foot syndrome (erythema, peeling
of palms and soles), bloody diarrhea, mucositis, and urinary
incontience, all of which resolved after treatment was finished.
He has, however, remained impotent with no response to
sildenafil, and continues to have occasional problems with stool
continence.
Two months ago, he started experiencing shooting pain
bilaterally, when lifting heavy luggage. The pain has become
increasingly
severe, now unrelenting pulsating bilateral hip & thigh pain,
worsening with activity and needing to rest after a few steps,
sciatica to ankles, and midline lower back pain that has
required escalating doses of opiate narcotics. The pain has now
been associated with frank weakness in the past ___ weeks
resulting in significant falls, associated with urinary
hesitancy & incomplete evacuation as well as episodic stool
incontinence.
On examination, upper extremities are strong but with diminished
reflexes. Lower extremities show significant weakness in
multiple muscle groups, but especially b/l hamstrings, glutei
medii, TAs, EHLs, EDBs; knee reflexes are normal but S1 reflexes
is lost with diminished vibration sense. There is no sensory
level along the trunk or back. Gait is broad based, waddling,
with impaired dorsiflexion and inability to toe & heel walk.
Rectal tone was normal. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
adhesive tape / Bactrim
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with history of
multiple medical problems (thyroid ca ___ thyroidectomy/XRT,
G6PD, MV repair) and initially stage IIIB follicular lymphoma
c/b
CVID (on monthly IVIG), ___ R-CHOP ___, relapsed ___ w/ DLBCL,
___ salvage w/ R-ICE and auto-HSCT (D0: ___, second relapse
(___) ___ 2 cycles R-GemOx with significant cytopenias and
persistence of circulating ymphoma and now ___ MRD allogentic
SCT (D0: ___ who is admitted for high fevers in setting
of cough for one week.
Patient initially called her oncologist's office regarding fever
to 102.7 at 4:30 am, in the setting of cough for 1 week
productive of white sputum and associated with shortness of
breath. No hemoptysis, orthopnea or lower extremity swelling.
She
did not take Tylenol or anything for her fever. On ___
night,
Ms. ___ had noted chills, nausea with one episode of
non-bloody
vomiting; nausea has persisted since then. No other focal
symptoms. She denies diarrhea. Patient denies sick contacts. She
recently traveled to ___ for 10 days and returned home
yesterday. She also reports decreased fluid intake. She was
instructed to present to the emergency room for further
evaluation.
On arrival to the ED, initial vitals were 104.6 107 123/52 18
98%
RA. Exam was notable for bibasilar crackles. Labs were notable
for WBC 9.0 (PMNs 76%, lymphs 17%), H/H 9.6/29.4, Plt 159, Na
135, K 3.8, BUN/Cr ___, Mg 1.5, Phos 1.6, ALT/AST 55/52, ALP
221, BNP 2094, INR 1.0, lactate 1.5, UA bland, and influenza PCR
negative. Imaging was notable for bibasilar airspace opacities
concerning for multifocal pneumonia or aspiration. CT chest w/o
contrast showed bilateral airspace consolidations worst in the
lingula and left lower lobe and multifocal ground-glass
opacities
are concerning for multifocal pneumonia. Patient was given
tylenol 1g PO, cefepime 2g IV, vancomycin 1.5g IV, tamiflu 75mg
PO, solumedrol 125mg IV, and 1L NS. Vitals prior to transfer
were
97.6 63 99/54 15 95% RA.
On arrival to the floor, patient reports feeling much better.
She
denies pain. She also reports dizziness for the past few days.
She denies headache, vision changes, weakness/numbness, nasal
congestion, sinus pain, sore throat, myalgias, chest pain,
palpitations, abdominal pain, diarrhea, hematochezia/melena,
dysuria, hematuria, and new rashes.
REVIEW OF SYSTEMS: A complete 10-point review of systems was
performed and was negative unless otherwise noted in the HPI.
Past Medical History:
PAST ONCOLOGIC HISTORY:
* Diagnosed in ___ with grade IIIB follicular lymphoma.
* Treated with R-CHOP from ___ through ___.
* Noted for persistent diffuse parotid gland swelling, dry mouth
and weight loss with increased splenomegaly.
* ___, splenectomy for diagnostic purposes showed
probable
lymphoproliferative disorder.
* Started on maintenance rituximab from ___ through
___.
* Also noted for CVID and getting IVIG until ___.
* ___, CT scan halfway through Rituxan maintenance showed
some
new hilar lymphadenopathy and left lower lobe opacities with
enhancing structures within the retroperitoneum. Short interim
follow up CT scan showed interval growth in the left lower lobe
mass with concern for recurrent or transformed lymphoma versus
granulomatous disease related to her CVID.
* ___, Bronchoscopy and biopsy of left lower lobe mass
revealed a monoclonal population of B cells.
* ___, PET scan showed interval growth and increase in
FDG
avidity.
* ___, Excisional biopsy of one of her abdominal nodes
revealed diffuse large B-cell lymphoma likely relapsed or
transformed from her initial grade IIIB follicular lymphoma.
* Started aggressive therapy with Rituxan and ICE with Cycle 1
on
___ and Cycle 2 on ___.
* ___, PET scan showed overall interval improvement of
disease, with decrease in size and FDG avidity of the left lower
lobe pulmonary consolidation and pelvic adenopathy, although
residual FDG uptake was seen in some of the lesions. Also noted
a
foci of FDG avidity in right pelvis which was difficult to
separate from ureter but concerning for residual disease.
* Received Cycle 3 of R-IE on ___ (carboplatin removed to
help with planned stem cell mobilization).
* Stem cell collections over 3 days from ___ to ___ for
total collection of 4.64 x 10e6 CD34/kg. Did not feel well
following collections with persistent nausea, fatigue and night
terrors.
* ___, CT imaging showed continued response and no
evidence for recurrent lymphoma except note was made of new
hypoattenuating lesions involving the periphery of the left
kidney with differential diagnosis including lymphomatous
involvement of the left kidney or pyelonephritis.
* Blood cultures and urinalysis and urine cultures were
negative.
* ___, MRI imaging of the kidney showed no
lymphadenopathy
with note of multifocal scarring of the upper left kidney, with
cortical volume loss, likely representing sequela of prior
infection or infarction in the interim between ___
and ___. No renal mass or evidence of renal
lymphoma.
* ___, Admission for autologous stem cell transplant with
BEAM conditioning. D 0 = ___. Post-transplant course was
complicated by persistent FN, aspiration PNA, dilated
esophagus/esophagitis(retained food in esophagus), mucositis,
persistent diarrhea, hypoxia, and possible DAH/inflammatory
reconstitution. Noted to have RLL infiltrates as part of work up
for fever in immediate post transplant period. Developed
significant respiratory distress requiring ICU transfer and
eventually was electively intubated for bronchoscopy on ___ and
___. Bronch consistent with DAH, cultures negative, and
she
was started on high dose steroids. These were quickly weaned
after a galactomannin from serum on ___ returned elevated
and she was started on antifungals (BAL galactoma was negative).
She clinically improved from respiratory standpoint, but a
repeat
CT scan on ___ noted for increase in multinodular
peribronchial infiltration and consolidations. Underwent lung
biopsy ___ to evaluate for organizing pneumonia vs fungal
infection as noted for elevated beta glucan to 81 on ___.
Aspergillus galactomannin from serum on ___
and
___ have been negative (only positive on ___.
Pathology showed organizing pneumonitis with no bacteria or
fungi
seen on special staining. She recovered slowly from prolonged
hospitalization and finally discharged to own home on ___.
She was discharged on voriconazole in the setting of the
elevated
B-glucan.
* ___: DLCO on day +43 75% CT chest showed extensive multi
focal pulmonary abnormality, mildly improved in nearly all areas
compared to ___, though not as significantly improved as
the
earlier change between ___ and ___. No new lung
lesions to suggest a second pathogen or second, non infectious,
inflammatory condition.
___: Admitted for elevated transaminases, RUQ
unrevealing. CT torso with no ___ or evidence of lymphoma. Most
likely secondary to drug effect (voriconazole). Received
pentamidine prior to d/c. Given 3 days of cipro for Proteus UTI.
* ___: Presented with diarrhea and noted for C.
difficile
infection. Fever workup with CT imaging showing a multifocal
bronchocentric pulmonary inflammation that appeared to be more
likely infectious. Given concern for pulmonary aspergillosis
during her transplant admission, she went on to have a
bronchoscopy and BAL on ___. Cytology was negative for
malignant cells. Gram stain showed 1+ gram-negative rods.
However, the culture only grew ___ commensal respiratory
flora. No CMV was noted. ___ prep was negative. PCP was
negative.
Galactomannan was sent off the BAL and was negative. In her
serum, beta-glucan was slightly positive on ___ at 85
pg/mL. Galactomannan was also slightly positive at 0.52. Repeat
serum beta-glucan and galactomannan showed Beta-glucan was
positive at 150 and the galactomannan was again negative. She
had
received 10 g of IVIG on ___. Completed a course of IV
vancomycin, cefepime, and Flagyl, which was ultimately narrowed
to cefepime for total of seven days. Discharged on voriconazole
given potential concern for fungal infection.
* CT ___ Chest, abdomen and pelvis: While consolidation
and
more nodular lesions in the right middle and both lower lobes
have improved slightly since ___, extensive adenopathy
both axillary and mediastinal and hilar has not receded and some
lymph nodes are slightly larger. Mesenteric, pelvic, and
inguinal lymphadenopathy is more significant since prior CT.
* ___ PB cytogenetics: Complex abnormal karyotype with a
duplication of the long arm of chromosome 3 resulting in partial
trisomy 3 and rearrangement of the BCL6 gene, trisomy 7, partial
trisomy 12, and several other chromosome aberrations. These
findings are consistent with a B cell lymphoma.
* ___: Presented to ED with dysuria and fever and was
found
to have UTI with associated E. coli bacteremia. Initially
treated
with IV antibiotics and then transitioned to oral Cipro and
completed two weeks of vancomycin past the completion of the
Cipro given recent history of C. diff.
* ___: PET scan showed extensive cervical, axillary,
subdiaphragmatic, retrosternal, mediastinal,
retroperitoneal,inguinal and pelvic side wall lymphadenopathy
that was FDG avid.
* ___: Excisional lymph node biopsy done with pathology
consistent with recurrent diffuse large B-cell lymphoma with a
complex karyotype including BCL6 rearrangement. Immunophenotypic
findings consistent with involvement by a kappa restricted B
cell
lymphoma
* ___: C1D1 R-GemOx (20% dose reduction)
* ___: C2D1 R-GemOx (40% dose reduction for cytopenias)
* ___: Rituximab
* ___: day 1 lenalidomide (10mg on days ___
* ___: Presented to ED with UTI, started on cipro
* ___: Admitted with facial swelling, diarrhea. Found to
be C diff +. Swelling most likely lenalidomide flare, responded
to pulse of dexamethasone. CT chest showed 2 new peripheral
nodules in the left lower lobe and the persistent consolidation
in the right middle lobe. Plan was to switch from voriconazole
to
posaconazole, although cost initially prohibitive. Of note,
serum
galactomannan < 0.5.
* ___: Rituximab
* ___: Rituximab (lenalidomide increased to 15mg)
* ___: Admitted with fever of 102. Chest x-ray showed
persistent opacities without any new obvious focal area of
consolidation. Her presentation was most consistent with a
flu-like illness. CT torso showed new peribronchial opacities
and
mild consolidation in the left lower lobe concerning for
infection. Lymph nodes had decreased in size. Discharged on a
course of levofloxacin to cover any bacterial pneumonia.
Increased to a treatment dose of Clostridium difficile while on
this. Discharged to complete a course of Tamiflu.
* ___: LLL VATS - Non-necrotizing granulomas and no
evidence
of active infection.
* ___: Rituximab
* ___: Admission for MRD reduced intensity allogeneic
transplant with Flu/Bu conditioning.
* ___: Day 0
PAST MEDICAL HISTORY:
- Non-Hodgkin's lymphoma, as above
- Sjogren's
- Depression
- GERD
- CVID. IgA, IgG deficiency
- Thyroid neoplasm: Hurthle cell cancer status post total
thyroidectomy on ___ and radioiodine remnant ablation with
100 mCi of I-131 on ___.
- Migraines
- MR ___ MV repair with ring annuloplasty ___
- Vitamin D deficiency
- C. diff colitis
- Urinary incontinence
- G6PD deficiency + Heinz body prep in ___
- Aspergillosis
- Parotitis
- Splenectomy
- ___ VATS to r/o fungal infection prior to allo transplant,
___
Social History:
___
Family History:
Several family members with diabetes.
Father with heart disease.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
===========================
VS: Temp 97.8, BP 127/67, HR 80, RR 18, O2 sat 95% RA.
GENERAL: Pleasant woman, in no distress, lying in bed
comfortably.
HEENT: Anicteric, PERLL, OP clear.
CARDIAC: RRR, normal s1/s2, no m/r/g.
LUNG: Appears in no respiratory distress, bibasilar inspiratory
crackles.
ABD: Normal bowel sounds, soft, nontender, nondistended, no
hepatomegaly, no splenomegaly.
EXT: Warm, well perfused, no lower extremity edema, erythema or
tenderness.
NEURO: Alert, oriented, good attention and linear thought,
CNII-XII intact. Strength full throughout.
SKIN: No significant rashes.
ACCESS: Right chest wall port without erythema.
PHYSICAL EXAM ON DISCHARGE:
===========================
VS: 97.8 105/70 76 19 97% RA, ambulatory SpO2 88-93%
GENERAL: Pleasant woman, in NAD, sitting up in bed comfortably
HEENT: Anicteric, PERRLA, OP clear.
CARDIAC: RRR, normal s1/s2, no m/r/g.
LUNG: No respiratory distress, CTAB.
ABD: NABS, soft, nontender, nondistended, no HSM
EXT: WWP, no lower extremity edema, erythema or tenderness.
NEURO: Alert, oriented, good attention and linear thought,
CNII-XII intact. Strength full throughout.
SKIN: No significant rashes.
Pertinent Results:
LAB RESULTS ON ADMISSION:
=========================
___ 08:25AM BLOOD WBC-9.0# RBC-3.41* Hgb-9.6* Hct-29.4*
MCV-86 MCH-28.2 MCHC-32.7 RDW-16.8* RDWSD-53.1* Plt ___
___ 08:25AM BLOOD Neuts-76* Bands-0 Lymphs-17* Monos-5
Eos-1 Baso-0 Atyps-1* ___ Myelos-0 AbsNeut-6.84*
AbsLymp-1.62 AbsMono-0.45 AbsEos-0.09 AbsBaso-0.00*
___ 08:25AM BLOOD ___ PTT-26.9 ___
___ 08:25AM BLOOD Glucose-138* UreaN-24* Creat-1.6* Na-135
K-3.8 Cl-98 HCO3-18* AnGap-23*
___ 08:25AM BLOOD ALT-55* AST-52* AlkPhos-221* TotBili-1.0
___ 08:25AM BLOOD Albumin-3.9 Calcium-8.9 Phos-1.6* Mg-1.5*
___ 05:20AM BLOOD ___ Folate->20
___ 08:25AM BLOOD IgG-518*
___ 08:38AM BLOOD Lactate-1.5
PERTINENT INTERVAL LABS:
========================
___ 08:25AM BLOOD IgG-518*
___ 11:00 am Immunology (CMV)
**FINAL REPORT ___
CMV Viral Load (Final ___:
CMV DNA not detected.
Performed by Cobas Ampliprep / Cobas Taqman CMV Test.
Linear range of quantification: 137 IU/mL - 9,100,000
IU/mL.
Limit of detection 91 IU/mL.
This test has been verified for use in the ___ patient
population.
___ 6:52 am URINE Source: ___.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
___ 12:23 am 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 and/or Influenza PCR
(results
listed under "OTHER" tab) for further information.
Blood Culture, Routine (Final ___: NO GROWTH.
Blood Culture, Routine (Final ___: NO GROWTH.
URINE CULTURE (Final ___: < 10,000 CFU/mL.
RESPIRATORY VIRAL PANEL, PCR
Test Result Reference
Range/Units
ADENOVIRUS NOT DETECTED NOT DETECTED
RHINOVIRUS DETECTED A NOT DETECTED
INFLUENZA A NOT DETECTED NOT DETECTED
INFLUENZA A SUBTYPE H1 NOT DETECTED NOT DETECTED
INFLUENZA A SUBTYPE H3 NOT DETECTED NOT DETECTED
INFLUENZA B NOT DETECTED NOT DETECTED
HUMAN METAPNEUMOVIRUS NOT DETECTED NOT DETECTED
HUMAN RSV A NOT DETECTED NOT DETECTED
HUMAN RSV B NOT DETECTED NOT DETECTED
HUMAN PARAINFLU VIRUS 1 NOT DETECTED NOT DETECTED
HUMAN PARAINFLU VIRUS 2 NOT DETECTED NOT DETECTED
HUMAN PARAINFLU VIRUS 3 NOT DETECTED NOT DETECTED
COMMENT See Below
This test is performed using the xTAG
Luminex Technology.
Limitations: A negative result does not rule out
respiratory viral infection if the viral nucleic acid in
the specimen is at a concentration below the sensitivity
limit of the assay. The sensitivity of the Luminex assay
varies depending on virus and sample type.
This assay cannot distinguish between Rhinovirus and Enterovirus
due
to PCR primer cross-reactivity. If clinically warranted,
additional
testing may be used to distinguish between these two viruses.
Interpretation of this test may be affected by the
presence of rare viral variants. The xTAG RVP Detection
test (IVD) is approved by the ___. Food and Drug
Administration (FDA).
REPORT COMMENT:
SOURCE: NASOPHARYNGEAL
THIS TEST WAS PERFORMED AT:
___ LLC
___ ___
___
Comment: RESPIRATORY VIRAL PANEL, PCR
___ 08:15AM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
LAB RESULTS ON DISCHARGE:
=========================
___ 06:34AM BLOOD WBC-4.1 RBC-3.30* Hgb-9.1* Hct-28.8*
MCV-87 MCH-27.6 MCHC-31.6* RDW-17.6* RDWSD-55.0* Plt ___
___ 06:34AM BLOOD Neuts-35 Bands-0 ___ Monos-12
Eos-13* Baso-0 ___ Myelos-0 AbsNeut-1.44*
AbsLymp-1.64 AbsMono-0.49 AbsEos-0.53 AbsBaso-0.00*
___ 06:34AM BLOOD ___ PTT-35.7 ___
___ 06:34AM BLOOD Glucose-88 UreaN-18 Creat-1.1 Na-139
K-4.2 Cl-104 HCO3-25 AnGap-14
___ 06:34AM BLOOD ALT-31 AST-32 LD(LDH)-263* AlkPhos-158*
TotBili-0.3
___ 06:34AM BLOOD Albumin-3.4* Calcium-9.0 Phos-3.6 Mg-1.7
IMAGING:
========
___ CT CHEST WITHOUT CONTRAST
1. Multifocal pneumonia, worse in the lingula and left lower
lobe, but also
the right upper and lower lobes.
2. Mild bronchiectasis and atelectasis in the right middle lobe,
as seen
previously, with increased opacification suggestive of
superimposed pneumonia.
3. Status post left lower lobe wedge resection.
4. Mild bilateral lower lobe bronchiectasis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q12H
2. FoLIC Acid 1 mg PO DAILY
3. LORazepam 0.5-1 mg PO Q8H:PRN nausea/anxiety
4. Posaconazole Delayed Release Tablet 200 mg PO DAILY
5. Sertraline 75 mg PO DAILY
6. Vancomycin Oral Liquid ___ mg PO BID
7. Atovaquone Suspension 1500 mg PO DAILY
8. CycloSPORINE (Neoral) MODIFIED 50 mg PO QAM
9. CycloSPORINE (Neoral) MODIFIED 25 mg PO QPM
10. Artificial Tears ___ DROP BOTH EYES PRN itchy eyes
11. Loratadine 10 mg PO DAILY
12. Unithroid (levothyroxine) 112 mcg oral 6X/WEEK
13. Omeprazole 40 mg PO DAILY
14. Fluticasone Propionate NASAL 1 SPRY NU BID
15. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
16. Multivitamins 1 TAB PO DAILY
17. Unithroid (levothyroxine) 56 mcg oral 1X/WEEK
18. PredniSONE 5 mg PO DAILY
19. Potassium Chloride 20 mEq PO DAILY
20. Vitamin D 1000 UNIT PO DAILY
21. magnesium oxide-Mg AA chelate 133 mg oral TID
Discharge Medications:
1. Levofloxacin 500 mg PO DAILY Duration: 6 Days
2. Vancomycin Oral Liquid ___ mg PO/NG Q6H
Take 4x daily until 2 weeks after you finish your antibiotics
(end ___
3. Acyclovir 400 mg PO Q12H
4. Artificial Tears ___ DROP BOTH EYES PRN itchy eyes
5. Atovaquone Suspension 1500 mg PO DAILY
6. CycloSPORINE (Neoral) MODIFIED 50 mg PO QAM
7. CycloSPORINE (Neoral) MODIFIED 25 mg PO QPM
8. Fluticasone Propionate NASAL 1 SPRY NU BID
9. FoLIC Acid 1 mg PO DAILY
10. Loratadine 10 mg PO DAILY
11. LORazepam 0.5-1 mg PO Q8H:PRN nausea/anxiety
12. magnesium oxide-Mg AA chelate 133 mg oral TID
13. Multivitamins 1 TAB PO DAILY
14. Omeprazole 40 mg PO DAILY
15. Posaconazole Delayed Release Tablet 200 mg PO DAILY
16. Potassium Chloride 20 mEq PO DAILY
17. PredniSONE 5 mg PO DAILY
18. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
19. Sertraline 75 mg PO DAILY
20. Unithroid (levothyroxine) 112 mcg oral 6X/WEEK
21. Unithroid (levothyroxine) 56 mcg oral 1X/WEEK
22. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Multifocal pneumonia, +rhinovirus
Diffuse large B cell lymphoma ___ reduced-intensity allogeneic
transplant (___)
Acute kidney injury, pre-renal
Common variable immume deficiency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with fever, infection workup // pneumonia?
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___
FINDINGS:
Patient is status post median sternotomy and mitral valve replacement.
Right-sided Port-A-Cath tip terminates in the low SVC. Mild cardiomegaly is
unchanged. The mediastinal and hilar contours are per similar. There is no
pulmonary edema. Patchy airspace opacities are noted in the lung bases, new
from the previous study, worrisome for multifocal pneumonia or aspiration. No
pleural effusion or pneumothorax is present. There are no acute osseous
abnormalities.
IMPRESSION:
Bibasilar airspace opacities concerning for multifocal pneumonia or
aspiration.
Radiology Report
EXAMINATION: Chest CT without contrast
INDICATION: ___ with hypoxia cough, hx of bmt. Assess for ILD or pneumonia.
TECHNIQUE: Contiguous axial images were obtained through the chest without
intravenous contrast. Coronal and sagittal reformats were obtained.
COMPARISON: Noncontrast chest CT ___
FINDINGS:
HEART AND VASCULATURE: The thoracic aorta is normal in caliber. A
right-sided subclavian Port-A-Cath is seen terminating at the SVC/ right
atrial junction. The patient is status post mitral valve replacement. There
is mild calcification of the aortic arch. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: Previously seen calcified mediastinal lymph
nodes appear similar to decreased in size from prior. No hilar or axillary
lymphadenopathy is detected. No mediastinal mass or hematoma.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: There are dense consolidative opacities that track along the
airways in the lingula and left lower lobe with air bronchograms. The right
middle lobe again demonstrates mild cylindrical bronchiectasis with adjacent
atelectasis, but there is worsening opacification which may suggest a
superimposed pneumonia. Additionally, there are nodular bronchocentric
ground-glass opacities within the right upper and right lower lobes concerning
for airways infection. These findings are concerning for multifocal
pneumonia. There is evidence of the patient's prior left lower lobe wedge
resection. Mild cylindrical bronchiectasis is re- demonstrated in both lower
lobes.
BASE OF NECK: Surgical clips are noted in the thyroid bed.
ABDOMEN: Included portion of the unenhanced upper abdomen is unremarkable.
Patient is status post splenectomy.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
Patient status post median sternotomy.
IMPRESSION:
1. Multifocal pneumonia, worse in the lingula and left lower lobe, but also
the right upper and lower lobes.
2. Mild bronchiectasis and atelectasis in the right middle lobe, as seen
previously, with increased opacification suggestive of superimposed pneumonia.
3. Status post left lower lobe wedge resection.
4. Mild bilateral lower lobe bronchiectasis.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Fever
Diagnosed with Fever, unspecified
temperature: 104.6
heartrate: 107.0
resprate: 18.0
o2sat: 98.0
sbp: 123.0
dbp: 52.0
level of pain: 3
level of acuity: 2.0 | Ms. ___ is a ___ grandmother with history of
multiple medical problems (thyroid ca ___ thyroidectomy/XRT,
G6PD, MV repair) and initially stage IIIB
follicular lymphoma c/b CVID (on monthly IVIG), ___ R-CHOP ___,
relapsed ___ w/ DLBCL, ___ salvage w/ R-ICE and auto-HSCT (D0:
___, second relapse (___) ___ 2 cycles R-GemOx with
significant cytopenias and persistence of circulating lymphoma
and now ___ MRD allogentic SCT (D0: ___ who is admitted
for high fevers in setting of cough for one week; found to have
evidence of multifocal pneumonia on CT chest.
# Multifocal pneumonia: On CT chest, patient with evidence of
multifocal pneumonia worse in the lingula and left lower lobe,
but also the right upper and lower lobe. She also had documented
fever to 104.6 while in the emergency department in setting of
productive cough for one week. She was started on broad spectrum
antibiotics (vancomycin (___), cefepime (___),
levofloxacin (___) and empiric oseltamivir
(___) upon admission on ___ given immunocompromised
state. These were slowly discontinued as patient improved and
infectious studies returned as negative. Ultimately, she was
found to have +rhinovirus on viral PCR. She was given a dose of
30 g IVIG on ___ as she is immunocompromised from HSCT, CVID,
and was due for a dose during this admission. Other infectious
studies, including flu antigen/culture, respiratory viral
panel/culture, urine culture, urine legionella, S. pneumo,
aspergillus antigen, CMV/EBV viral load, MRSA swab, blood
cultures were all negative. We did incidentally note +beta
glucan >500 (114 pg/mL in ___ this was drawn prior to
cefepime dosing and prior to IVIG administration), briefly
discussed with ID, and the conclusion was that this was
difficult to interpret and that given her clinical improvement
would not pursue at this time. Were she to get sicker, the next
step would have been bronchoscopy for sampling. She will
continue a 14 day course of levofloxacin, ending ___ given
immunocompromise.
# Acute Kidney Injury: Patient initially had ___ with Cr 1.6 of
from baseline of 1.0 in setting of poor PO intake. Resolved with
IVF, Cr 1.1 on discharge.
# Lymphoma: She is ___ reduced intensity allogenic SCT with
sibling donor, D0 = ___. On chronic posaconazole for prior
history of aspergillus, elevated G/G. We continued prophylaxis
with atovaquone, acyclovir, and posaconazole. She has follow up
appointment ___.
# GVHD: Continued home cyclosporine and prednisone. We note that
she had increasing eosinophilia, wonder if related. #eos pending
at time of discharge. LFT on discharge ALT 31 AST 32 AP 128
Tbili 0.3.
# Recurrent C. Diff Infection: H/O recurrent C. diff infections
and remains on suppressive twice daily vancomycin. She was
increase to QID PO vancomycin while on antibiotics (for 2 weeks
after finishing levofloxacin course, ending ___.
# Anemia: On discharge Hgb 9.1.
# CVID: IgG low at 518. She received 30 g IVIG on ___. Given
history of prior reactions (reported as chest pain and fever),
we went at a low rate not exceeding 75 mL/hr with
pre-medication. Administration of IVIG was uneventful.
# Hypothyroidism: Continued home levothyroxine
# Depression: Continued home sertraline |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
PCI with ___.
History of Present Illness:
___ year old man with h/o CAD s/p PCI to RCA (___) and balloon
PTCA to mid LAD (no stent) with 30% residual on ___, stroke
with L hemiparesis presents with crescendo angina with rest pain
and minimal exercise. Pt was recently admitted from ___ to
___. Pt describes two episodes of chest pain since discharge.
One was on ___ after rolling over in bed at night he
developed intense pressure-like pain that last 10 minutes. He
had not filled his nitro at that time; however, his daughter
filled the prescription the following day. The second episode
was the morning of ___ when the pt was in the shower, also
pressure like on the right side of his chest and moving down his
right arm. No diaphoresis or palpitations. Pt then took a total
of 2 nitros that releived his pain completely. He denies
shortness of breath on lying flat. Grand daughter states SOB on
exertion and pt states he can walk ___ feet before having to
stop d/t SOB but denies chest pain. Patient also reports new dry
cough which began after hospitalization.
He states his headache has resolved. Pt states he has had poor
PO
intake since discharge and there is no chest pain in
relatiobnship to food.
Patient was seen by Dr. ___ morning who referred patient
in for cath with likely stent placement to LAD.
In the ED intial vitals were: 97.8 68 124/61 18 100%; TnT to
0.07. BUN/Cr ___ (baseline of 1.1). H&H 9.5/___.
ECG was significant for lateral T wave inversions.
Past Medical History:
PAST MEDICAL HISTORY:
- stroke in ___ while in ___
- Hypertension
- Hyperlipidemia
- diabetes mellitus, type 2
- left inguinal hernia repair in ___
- Glaucoma
- Coronary Artery Disease
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
PHYSICAL EXAMINATION:
VS: 97.7 128/53 68 16 100RA FSG 115 Weight 83.6kg
GENERAL: in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with .
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Admission:
PHYSICAL EXAMINATION:
VS: 98.2 114/53 58 18 100% on RA
GENERAL: in NAD
HEENT: NCAT
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND
EXTREMITIES: No c/c/e
R femoral site: c/d/i, nontender, no hematoma
___: warm, well perfused, 2+ DP pulses bilaterally
Pertinent Results:
___ 06:00PM CK-MB-2 cTropnT-0.07*
___ 11:30AM GLUCOSE-205* UREA N-25* CREAT-1.3*
SODIUM-131* POTASSIUM-5.0 CHLORIDE-97 TOTAL CO2-22 ANION GAP-17
___ 11:30AM estGFR-Using this
___ 11:30AM cTropnT-0.07*
___ 11:30AM WBC-11.2* RBC-2.98* HGB-9.5* HCT-30.1*
MCV-101* MCH-31.8 MCHC-31.5 RDW-14.6
___ 11:30AM PLT COUNT-322
___ 11:30AM PLT COUNT-322
___ 11:30AM ___ PTT-27.5 ___
Cardiac Cath
BRIEF HISTORY: ___ yo with known CAD s/p PCI to RCA on ___
and PCI
(with rotational atherectomy and POBA) to LAD on ___ with
continued
intermittent angina, referred for further coronary
revascularization.
INDICATIONS FOR CATHETERIZATION:
unstable angina, coronary artery disease
PROCEDURE:
R femoral arterial access with a ___ Fr sheath was obtained under
ultrasound guidance, using micropuncture and Seldinger
technique. The
___ was engaged with a ___ XB 3.5 guide.
Conscious Sedation: was provided with appropriate monitoring
performed by
a member of the nursing staff.
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 1 hour 35 minutes.
Arterial time = 0 hour 44 minutes.
Fluoro time = 18.9 minutes.
Effective Equivalent Dose Index (mGy) = 2397 mGy.
Contrast injected:
Non-ionic low osmolar (isovue, optiray...), vol ml,
Indications - Renal
Premedications:
Midazolam 0.5 mg IV
Fentanyl 50 mcg IV
Anesthesia:
1% Lidocaine subq.
Anticoagulation:
Heparin 5000 units IV
Other medication:
Bivalirudin
COMMENTS: Multiple attempts to cross the OM1 (2mm vessel)
ostial
stenosis were unsuccessful despite mtuliple wires. Then the
mid-LCx
lesion was crossed with a Prowater wire and predilated with a
2.5 x 12
balloon. Then a 3.0 x 28 mm Promus drug-eluting stent was placed
in the
mid-LCx. There was 0% residual stenosis and normal flow. Patient
remained stable during the procedure. Of note, deployment of the
LCx
stent and the predilation reproduced patient's angina.
FINAL DIAGNOSIS:
1. Successful PCI to mid-LC with drug-eluting stent.
2. Cont ASA and clopidogrel.
___ ATTENDING OF RECORD: ___.
REFERRING PHYSICIAN: ___.
FELLOW: ___
INVASIVE ATTENDING STAFF: ___.
(___)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin EC 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Acetaminophen 325-650 mg PO Q6H:PRN pain/temp
4. Alphagan P (brimonidine) 0.1 % ophthalmic bid
5. Artificial Tears Preserv. Free ___ DROP LEFT EYE PRN dry eye
6. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
7. Clopidogrel 75 mg PO DAILY
8. Dorzolamide 2% Ophth. Soln. 1 DROP LEFT EYE BID
9. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
10. Metoprolol Succinate XL 100 mg PO DAILY
11. Pantoprazole 40 mg PO Q24H
12. MetFORMIN (Glucophage) 1000 mg PO BID
13. Lisinopril 20 mg PO DAILY
14. ___ 30 Units Breakfast
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain/temp
2. Alphagan P (brimonidine) 0.1 % ophthalmic bid
3. Artificial Tears Preserv. Free ___ DROP LEFT EYE PRN dry eye
4. Aspirin EC 81 mg PO DAILY
5. Atorvastatin 80 mg PO DAILY
6. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
7. Clopidogrel 75 mg PO DAILY
8. Dorzolamide 2% Ophth. Soln. 1 DROP LEFT EYE BID
9. ___ 30 Units Breakfast
10. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
11. Metoprolol Succinate XL 100 mg PO DAILY
12. Pantoprazole 40 mg PO Q24H
13. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
call you doctor if having to use.
RX *nitroglycerin [Nitrostat] 0.3 mg 1 tablet(s) sublingually
every 5 minutes Disp #*30 Tablet Refills:*0
14. MetFORMIN (Glucophage) 1000 mg PO BID
15. Amlodipine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
Unstable Angina
Coronary Artery Disease
SECONDARY
Hypertension
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with chest pain
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
Lung volumes are low. The cardiac, mediastinal and hilar contours are
unremarkable. Atherosclerotic calcifications are again noted at the aortic
knob. There is no pulmonary edema. There is slightly improved aeration at
the left lung base with residual patchy bibasilar opacities possibly
reflecting atelectasis. No pleural effusion, new focal consolidation or
pneumothorax is present.
IMPRESSION:
Interval improvement in aeration of the left lung base with residual patchy
bibasilar opacities, possibly atelectasis but infection or aspiration cannot
be excluded.
Gender: M
Race: BLACK/CAPE VERDEAN
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with INTERMED CORONARY SYND, DIABETES UNCOMPL ADULT
temperature: 97.8
heartrate: 68.0
resprate: 18.0
o2sat: 100.0
sbp: 124.0
dbp: 61.0
level of pain: 0
level of acuity: 2.0 | ASSESSMENT AND PLAN ___ year old man with h/o CAD s/p 2 DES
to RCA and PCI of mid LAD without stenting and 30% residual;
also with history of TIIDM, HTN, HPLD presenting from clinic
with unstable angina.
# CORONARIES: Unstable angina/ACS - Tnt to 0.07 and EKG showing
new t wave inversions in lateral leads. During last admission
the LAD was not stented d/t length of procedure and dye load.
The lesion causing his unstable angina (The Circ) was intervened
upon via PCI and stented
We Continued CAD medical magnagement with:
- Atorvastatin 80 mg
- Aspirin EC 81 mg
- Clopidogrel 75 mg
# Hypertension--we continued pt's home regimen:
- Pt was discharged at last admission on Lisinopril for kidney
protection given his h/o of TIIDM; however, he developed a dry
cough.
- Started Amlodipine 5 mg mg (also for angina).
- Imdur 30 mg.
- Metoprolol Succinate XL 100 mg PO DAILY
-Upon discharge, a change from amlodipine to ___ could be
considered balancing renal protective effects of the ___ in
context of DM2 versus anti-anginal effects of CCB>
# Hyponatremia - Pt with persistently low yet stable Na and
multiple urine lytes on last admission consistent with SIADH.
-fluid restriction to 1500 ml.
#A Anemia - Hb of 9.5 on this admission (11 on presentation
during last admision with slow decline). MCV to 101 with normal
RDW. B12 low normal. Fe studies not conclusive of Fe def or ACD
given normal ferritin, but low TIBC. Pt had CRP >50 at OSH on
prior admission. Given these mixed findings, the most likely
etiology is mixed Fe deficiency and ACD. However, elevated MCV
could represent MDS.
-___ level, as B12 level inconclusive.
-ACD best addressed by treating his underlying chronic
conditions.
# ___ - Cr of 1.3 on admission (baseline 1.1). Likely pre-renal
as granddaughter states low PO intake over the last week.
-Urine lytes
-500 cc NS fluid folus
# Glaucoma/Eye Pain - Headache and eye pain greatly resolved.
Has follow up appointment with Optho on ___
- Alphagan P *NF* (brimonidine) 0.1 % ophthalmic bid
- Artificial Tears Preserv. Free ___ DROP LEFT EYE PRN dry eye
- Dorzolamide 2% Ophth. Soln. 1 DROP LEFT EYE BID
# Diabetes
- Continue home insulin and ISS while in house
- ___ 30 Units Breakfast
TRANSTIONAL ISSUES
1) The ___ of 60 - 69% with left hemiplegia should be addressed
after the patient is revascularized since he is symptomatic and
has moderate ICA stenosis.
2) Follow up MMA levels for B12 def.
3) Consider CCB to ___ change |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
cool LLE
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is an ___ with (per chart) PMH of HFrEF (EF 35%),
s/p PPM, ?Cirrhosis, HTN, AF on warfarin, obstructive uropathy
s/p ureteral stent placement and s/p foley, GERD, h/o CVA in
___, and dementia, who presents as a transfer from OSH with
cool
LLE.
Per limited records sent with patient, he was recently admitted
to ___ on ___, with obstructive uropathy, treated with stent
placement. He may have also been treated for UTI with
cefpodoxime. He was discharged home and re-presented to ___ on
___ after his ___ found him to be altered and tachypneic. He
was
initially hypotensive on that admission, SBP 60-70, suspected to
be related to UTI and CXR unremarkable. It is unclear what he
was
treated with. He was discharged to ___ for 1 day
(___). On the day prior to presentation, he was noted to
have a cool LLE > RLE, limb appearing cool and mottled. There
was
concern for acute limb ischemia as pulses not palpable on L DP,
so he was transferred back to ___ for further evaluation.
At ___, patient found to have weak dopplerable pulse on ___ on
LLE. BP measuring on left calf 79/62, R calf 96/68, L upper arm
101/58. Discussed with vascular surgery at OSH, who recommended
heparin gtt (which was started) and CTA, but ultimately
determined that they did not have OR availability in case urgent
intervention needed so he was transferred to ___ for further
care.
In the ED, initial VS were: 97.9 60 119/79 16 98% RA
- Exam notable for: RLE cool the touch with good cap refill, no
TTP, normal ROM; dopplerable ___ LLE cool the touch with good
cap refill, no TTP, normal ROM; dopplerable ___
- Labs showed: Cr 1.5, K 5.5, HCO3 19, lactate 2.2, INR 1.9
- Imaging showed: N/A
- Consults: Vascular surgery who recommended first admission to
medicine given medical complexity, with q4hr pulse exams and
bilateral ___ with toe pressures to be done ___.
- Patient received: heparin gtt
Transfer VS were: 97.8 60 103/68 20 100% RA
On arrival to the floor, patient denies pain in LLE or
otherwise.
He denies chest pain or dyspnea. He knows that he lives at home
with his daughter, but cannot provide further history. He
believes his family was going to take him to church.
Past Medical History:
- hyperparathyroidism
- Cirrhosis
- hepatitis A
- CHF EF 35%
- HTN
- AF
- s/p CVA ___
- s/p PPM ___
- obstructive uropathy s/p ureteral stents, s/p foley with plan
for TURP as outpatient?
Social History:
___
Family History:
unable to obtain
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 97.3 130/84 60 22 100 RA
___: NAD
HEENT: MMM, sclera anicteric
NECK: JVD not visualized
HEART: RRR, nl S1 S2, systolic murmur LUSB/RUBS
LUNGS: CTAB anteriorly, no wheezes, rales, rhonchi
ABDOMEN: soft, NT, ND, NABS
EXTREMITIES: no edema, LLE cooler than RLE, decreased hair
growth
on bilateral lower extremities
PULSES: DP dopplerable bilaterally
NEURO: oriented to person, not place or time (___).
EOMI. Moving all extremities
SKIN: no rash
DISCHARGE PHYSICAL EXAM
VS: 97.6 PO 128 / 76 64 18 94 RA
___: pleasant, intermittently dyspneic, in no acute distress
HEENT: MMM, sclera anicteric
HEART: RRR, nl S1 S2, ___ systolic murmur LUSB/RUSB
LUNGS: CTAB, no wheezes, rales, rhonchi
ABDOMEN: soft, NT, ND, NABS
EXTREMITIES: no edema, bilateral lower extremities mildly cool,
but equal, decreased hair growth on bilateral lower extremities
PULSES: DP dopplerable bilaterally
NEURO: oriented to person, EOMI. Moving all extremities with
purpose.
SKIN: ecchymosis on R arm
Pertinent Results:
ADMISSION LABS
___ 10:05PM WBC-5.5 RBC-4.37* HGB-12.7* HCT-40.2 MCV-92
MCH-29.1 MCHC-31.6* RDW-14.6 RDWSD-49.5*
___ 10:05PM NEUTS-70.5 LYMPHS-15.9* MONOS-10.3 EOS-2.5
BASOS-0.4 IM ___ AbsNeut-3.90 AbsLymp-0.88* AbsMono-0.57
AbsEos-0.14 AbsBaso-0.02
___ 10:05PM ___ PTT-150* ___
___ 10:05PM CK-MB-3 cTropnT-<0.01 proBNP-2440*
___ 10:12PM LACTATE-2.2*
___ 10:05PM GLUCOSE-102* UREA N-25* CREAT-1.5* SODIUM-137
POTASSIUM-5.5* CHLORIDE-105 TOTAL CO2-19* ANION GAP-13
___ 10:05PM ALT(SGPT)-46* AST(SGOT)-82* CK(CPK)-55 ALK
PHOS-290* TOT BILI-0.9
___ 10:05PM CALCIUM-10.3 PHOSPHATE-3.4 MAGNESIUM-2.2
PERTINENT/DISCHARGE LABS
___ 08:55AM BLOOD WBC-5.2 RBC-4.10* Hgb-11.9* Hct-37.9*
MCV-92 MCH-29.0 MCHC-31.4* RDW-14.7 RDWSD-49.6* Plt ___
___ 08:55AM BLOOD ___ PTT-81.9* ___
___ 08:55AM BLOOD Glucose-100 UreaN-25* Creat-1.4* Na-139
K-4.8 Cl-105 HCO3-21* AnGap-13
___ 08:55AM BLOOD ALT-39 AST-42* AlkPhos-269* TotBili-1.0
___ 08:55AM BLOOD Calcium-10.2 Phos-2.5* Mg-2.2
___ 09:38AM BLOOD Lactate-2.2*
IMAGING/STUDIES
CXR ___- No previous images. There is mild enlargement of
the cardiac silhouette with
indistinctness of pulmonary vessels consistent with some
elevation of pulmonary venous pressure. 3 pacer leads extend to
the right atrium, right ventricle, and coronary sinus
distribution. No evidence of acute pneumonia or pneumothorax.
ABI ___- Mild to moderately decreased resting ankle-brachial
index on the left (ABI 0.71), and normal resting ankle-brachial
index on the right (ABI 1.05). Presence of monophasic waveforms
distally may represent mild peripheral vascular disease on the
right and mild to moderate peripheral vascular disease on the
left.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with CHF// please eval for infection vs. edema
IMPRESSION:
No previous images. There is mild enlargement of the cardiac silhouette with
indistinctness of pulmonary vessels consistent with some elevation of
pulmonary venous pressure. 3 pacer leads extend to the right atrium, right
ventricle, and coronary sinus distribution. No evidence of acute pneumonia or
pneumothorax.
Radiology Report
INDICATION: ___ year old man with dementia, AF, CHF, kidney injury of unclear
duration, referred for cool left extremity with dopplerable pulse.// Evaluate
for arterial insufficiency/blockage
TECHNIQUE: Non-invasive evaluation of the arterial system in the
lower extremities was performed with Doppler signal recording, pulse volume
recordings and segmental limb pressure measurements.
COMPARISON: None
FINDINGS:
On the right side, triphasic Doppler waveforms are seen in the right femoral
and superficial femoral arteries. Monophasic waveforms are seen within the
popliteal, posterior tibial and dorsalis pedis arteries.
The right ABI was 1.05.
On the left side, triphasic Doppler waveforms are seen at the left femoral and
superficial femoral arteries. Monophasic waveforms are seen within the
popliteal, posterior tibial and dorsalis pedis arteries.
The left ABI was 0.71.
The pulse volume recordings are significantly dampened in amplitude on the
left from the calf down to the digit.
IMPRESSION:
Mild to moderately decreased resting ankle-brachial index on the left (ABI
0.71), and normal resting ankle-brachial index on the right (ABI 1.05).
Presence of monophasic waveforms distally may represent mild peripheral
vascular disease on the right and mild to moderate peripheral vascular disease
on the left.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: L Pulseless foot, Transfer
Diagnosed with Peripheral vascular disease, unspecified
temperature: 97.9
heartrate: 60.0
resprate: 16.0
o2sat: 98.0
sbp: 119.0
dbp: 79.0
level of pain: unable
level of acuity: 2.0 | SUMMARY STATEMENT
Mr. ___ is an ___ year-old man with a history of HFrEF (EF
35%), s/p PPM, ?Cirrhosis, HTN, AF on warfarin, obstructive
uropathy s/p ureteral stent placement and s/p foley, GERD, h/o
CVA in ___, and dementia, who presented as a transfer from OSH
with concern for a cool LLE.
ACUTE ISSUES
# Cool LLE:
# Peripheral Vascular Disease
Patient presented to OSH with cool LLE more so than right,
concerning for vascular compromise, also with decreased BP on
LLE > RLE. On transfer, it was noted that his pulses remained
Dopplerable throughout his hospitalization. He was evaluated by
vascular surgery in the ED, who recommended non-emergent ABI/PVR
with toe pressures bilaterally. Deferred CTA as no concern for
critical limb ischemia and patient also with decreased renal
function of unknown chronicity (see below). Patient was notably
anti-coagulated with warfarin, INR 1.9 on
admission. Given his sub-therapeutic INR he was briefly placed
on a heparin drip. The patient underwent ABI/PVR with toe
pressures bilaterally on ___. As per vascular surgery, there
was little concern for an acute process and the patient can
continue to get worked up as an outpatient.
# Elevated transaminases:
Mildly elevated with an unknown baseline, as patient with h/o
?cirrhosis. It was initially felt that the increase may also be
in the setting of hepatic congestion. They ultimately
downtrended without intervention.
# Elevated lactate
Elevated to 2.2 on admission. This may have represented mild
hypoperfusion in the
setting of limb ischemia. However, this remained stable without
intervention.
CHRONIC ISSUES
# Chronic Systolic CHF:
EF reportedly 35% per OSH paperwork. BNP 2000s on admission,
though unclear how high previously or if this represents at
change. Some documentation of BNP 3000s at OSH and perhaps even
as high as 4000s. Patient did not appear grossly volume
overloaded on exam and remained on his home carvedilol and
furosemide.
# ANEMIA
Hgb 12.7 on admission, unknown baseline. Downtrended slightly to
11.9.
# AF ON WARFARIN
# S/PPM
Unknown indication for PPM. INR slightly subtherapeutic on
presentation. He was on a heparin drip briefly, before being
transitioned back to warfarin.
# H/O URETERAL STENT
# S/P FOLEY
Reported h/o obstructive uropathy s/p stent placement, also with
Foley in place with reported plan for TURP as outpatient. CT A/P
from OSH records with no residual hydronephrosis (unclear when
examined).
# DEMENTIA:
AAOx2 on admission, unclear baseline. Family stated patient is
AOx3 at home. His mention status showed no fluctuation in house,
and he was oriented to person and place. He knew the names of
his family members. We felt this was his baseline.
# ?HYPERLIPIDEMIA:
Unclear if statin prescribed for CAD or for HLD. Continued home
atorvastatin.
# ?CIRRHOSIS:
Unknown etiology. LFTs elevated on admission, unknown baseline.
INR most likely elevated due to warfarin use. LFTs downtrended
without intervention.
# ?CKD:
Unknown Cr baseline, may be related to obstructive uropathy as
above. Cr on admission 1.5. Cr on discharge 1.4.
# ? HYPERPARATHYROIDISM
# HYPERCALCEMIA
Ca elevated to 10.2 at OSH. Reported history of
hyperparathyroidism at OSH. Held home vitamin D.
#CODE STATUS: OSH records mentioned DNR/DNI, but we could find
no formal documentation of this. When discussed with the family,
___ mentioned this is something that they have been thinking
about but no formal decision had been made. Ordered for full
code here in hospital.
TRANSITIONAL ISSUES
[]We scheduled follow up with vascular surgery here; if patient
prefers, he can follow up with vascular surgery at ___
___ for likely LLE angiogram and further workup of
chronic peripheral arterial disease
[]can consider starting patient on aspirin given history of CVA
[]can consider further hepatology evaluation of cirrhosis given
elevated LFTs on admission
#CODE: Full (presumed); see above for details
#CONTACT: ___ ___ (per ___
Facility), also phone number ___ listed for ___ in
___ paperwork, other daughter, ___ ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Aspirin / Levofloxacin /
NSAIDS (Non-Steroidal Anti-Inflammatory Drug)
Attending: ___.
Chief Complaint:
Altered mental status.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is an ___ year-old man with h/o NSTEMI s/p PCI,
abdominal mass on CT in ___ (family does not want work-up)
recent UTI, IDDM, CKD, HTN who presents with altered mental
status and poor PO intake x several days. Patient had an
unwitnessed fall three weeks ago at home and was admitted to
rehab on ___ following stay at ___ for the
fall.
In the ED initial vitals, 98 118 157/82 22 97% ra. EKG was sinus
rhythm at 92 BPM, LAD, no ischemic changes. He ha a head CT
showing no acute intracranial process. Labs were consistent for
a WBC of 16 and an UA consistent with UTI. Pt received 2L NS and
ceftriaxone 1 g. Vitals on transfer were 98.1 °F (36.7 °C)
(Oral), Pulse: 96, RR: 21, BP: 129/59 (Laying Down), O2Sat: 95,
O2Flow: (Room Air).
On the floor, patient complains of being tired and "worn down."
She said that he came to the hospital becasue one of his heel
ulcers is bothering him. He denies any pain. He endorses some
dysuria. Denies headache, visual changes, chest pain, shortness
of breath.
Review of systems:
(+) Per HPI
(-) Denies fever, 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,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria.
Past Medical History:
Diabetes Mellitus Type 2 - insulin dependent - ?secondary to
prednisone (per pt. son)
CAD s/p stent
Congestive Heart Failure
Polymyalgia rheumatica - on chronic prednisone
Essential Tremor - manifest as frequent spasm-like activity
?Factor 11 and 13 deficiency
Hyperlipidemia
h/o rheumatic fever
HTN
Diabetic Neuropathy
Diverticulosis
BPH s/p TURP
PUD s/p partial gastrectomy
s/p hiatal hernia repair
s/p appendectomy
s/p cholecystectomy
s/p rectal surgery - secondary to bleeding
Social History:
___
Family History:
Mother- ___ disease. Sister - bilateral hand tremor.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 97.8 BP: 120/75 P: 103 R: 22 O2: 100% on RA, weight
72.5
General: Alert, oriented to self, but thinks year is "13", not
oriented to place, does not know his birthday. Comfortable, in
no acute distress. (Baseline is A&Ox3 as per last discharge
summary)
HEENT: Sclera anicteric, slightly dry mucus membranes,
oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Few bibasilar rales, no wheezes, no rhonchi
CV: Slightly tachy, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: erythema and warmth on RLE extending from his anlke to ___
way up the calf, b/l pressure ulcers on heels, s/p amputation of
left great toe.
Neuro: A&Ox1, follows simple commands, inattentive, cannot name
months backwards, CN II - XII grossly intact
DISCHARGE PHYSICAL EXAM:
Vitals: T: 98.8 BP: 110/61 P: 85 R: 20 O2: 97% on RA
General: Alert, oriente to person, place, time, somewhat
confused upon awakening but quickly clears. At baseline per
family. Comfortable, in no acute distress.
HEENT: Sclera anicteric, moist mucus membranes, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB, no wheezes, no rhonchi
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: Scrotum mildly tender, improving erythema laterally
Ext: small erythema surrounding midcalf posterior RLE wound,
much improved compared to extent of erythema marked by line on
HOD1. pressure ulcers on bilateral heels.
Neuro: CN II - XII grossly intact, oriented x3, moving all
extremities, strength grossly intact
Pertinent Results:
___ 06:30AM BLOOD WBC-8.4 RBC-3.03* Hgb-9.7* Hct-29.8*
MCV-98 MCH-32.0 MCHC-32.6 RDW-15.0 Plt ___
___ 04:13PM BLOOD WBC-16.0*# RBC-3.91*# Hgb-12.7*#
Hct-38.0*# MCV-97 MCH-32.4* MCHC-33.3 RDW-15.2 Plt ___
___ 06:30AM BLOOD Glucose-84 UreaN-26* Creat-1.3* Na-141
K-3.6 Cl-108 HCO3-24 AnGap-13
___ 04:13PM BLOOD Glucose-161* UreaN-45* Creat-2.1* Na-138
K-4.2 Cl-100 HCO3-27 AnGap-15
___ 04:00PM BLOOD CK-MB-2 cTropnT-0.06*
___ 08:55AM BLOOD CK-MB-2 cTropnT-0.07*
___ 06:20PM URINE RBC-50* WBC->182* Bacteri-MANY Yeast-MANY
Epi-0
URINE CULTURE (Final ___:
YEAST. >100,000 ORGANISMS/ML..
Scrotal U/S (___):
1. Acute right-sided epididymitis.
2. Normal testicle vascular waveforms bilaterally.
3. Large bilateral hydroceles, similar to prior.
NCHCT: No acute intracranial process. Unchanged ventricular
dilatation,
somewhat disproportionate to the degree of sulcal prominence,
which may
reflect central atrophy but normal pressure hydrocephalus is not
excluded.
CXR: Minimal left basilar atelectasis.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Clopidogrel 75 mg PO DAILY
2. Metoprolol Tartrate 50 mg PO BID
HOLD for SBP < 100, HR < 60
3. Simvastatin 40 mg PO DAILY
4. Pantoprazole 40 mg PO Q12H
5. Furosemide 20 mg PO DAILY
6. Allopurinol ___ mg PO DAILY
7. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
8. Nitroglycerin Patch 0.4 mg/hr TD Q24H
12h on/___ off
9. Ferrous Sulfate 325 mg PO BID
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Metoprolol Tartrate 50 mg PO BID
HOLD for SBP < 100, HR < 60
4. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
5. Pantoprazole 40 mg PO Q12H
6. Simvastatin 40 mg PO DAILY
7. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 19 Doses
Last dose ___. Doxycycline Hyclate 100 mg PO Q12H Duration: 19 Doses
Last dose ___. Nitroglycerin Patch 0.4 mg/hr TD Q24H
12h on/___ off
10. Ferrous Sulfate 325 mg PO BID
11. Furosemide 40 mg PO DAILY
12. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Delirium
Acute epididymitis
Right lower extremity cellulitis
Acute renal failure
Angina
Urinary retention
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: ___ male with fall three weeks ago presenting with
altered mental status, evaluate for intracerebral hemorrhage.
COMPARISONS: Head CT, ___.
TECHNIQUE: Continuous sections through the brain were obtained without the
administration of IV contrast. Coronal and sagittal reformations were
provided and reviewed. Reconstruction was performed using a bone algorithm.
FINDINGS: There is no acute hemorrhage, edema or shift of the normally
midline structures. The gray-white matter differentiation has been preserved.
There is no evidence for acute large territorial vascular infarction. Sulcal
and ventricular prominence is likely due to age-related involutional changes,
however, given the degree of ventricular enlargment which is somewhat out of
proportion to the degree of sulcal prominence, normal pressure hydrocephalus
cannot be excluded. Nevertheless, ventricular dilatation is unchanged compared
to the prior exam. In addition, periventricular white matter hypodensities,
although nonspecific, likely related to sequela of chronic small vessel
ischemic disease. The mastoid air cells and imaged paranasal sinuses are well
aerated. There is no fracture. A small right occipital subgaleal hematoma is
noted.
IMPRESSION: No acute intracranial process. Unchanged ventricular dilatation,
somewhat disproportionate to the degree of sulcal prominence, which may
reflect central atrophy but normal pressure hydrocephalus is not excluded.
Radiology Report
HISTORY: Altered mental status.
TECHNIQUE: Upright AP and lateral views of the chest.
COMPARISON: ___.
FINDINGS:
The heart size is top normal. The aorta is mildly tortuous and diffusely
calcified. The mediastinal and hilar contours are otherwise within normal
limits. The pulmonary vascularity is not engorged. Minimal blunting of the
costophrenic angles posteriorly on the lateral view may reflect chronic
pleural thickening. There is no large pleural effusion or pneumothorax. Mild
atelectatic changes are noted within the left lung base. No acute osseous
abnormalities are seen. There are multilevel degenerative changes in the
thoracic spine.
IMPRESSION:
Minimal left basilar atelectasis.
Radiology Report
INDICATION: ___ male with tender scrotum. Evaluate for epididymitis
or testicular torsion.
COMPARISONS: Multiple prior scrotal ultrasounds, most recently of ___.
FINDINGS: The right testicle measures 2.8 x 2.5 x 4.5 cm and the left
testicle measures 2.8 x 3.2 x 4.1 cm. The right epididymis is enlarged,
heterogeneous, and hypervascular, compatible with acute right-sided
epididymitis. Both testicles are homogeneous in echotexture and have normal
vascular waveforms. Large bilateral hydroceles are similar to prior. A
calcification along the upper pole of the right testicle may represent a
chronically torsed epididymal appendix. Two small pearls are present in the
right scrotum. Bilateral epidydimal cysts are similar to prior.
IMPRESSION:
1. Acute right-sided epididymitis.
2. Normal testicle vascular waveforms bilaterally.
3. Large bilateral hydroceles, similar to prior.
Findings were communicated via phone call by ___ to Dr. ___
___ on ___ at 10:37 p.m.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: HALLUCINATING/ NOT EATING
Diagnosed with URIN TRACT INFECTION NOS
temperature: 98.0
heartrate: 118.0
resprate: 22.0
o2sat: 97.0
sbp: 157.0
dbp: 82.0
level of pain: 13
level of acuity: 2.0 | ___ h/o CAD s/p NSTEMI and PCI ___ admitted after short rehab
stay due to altered mental status and found to have acute
epididymitis, lower extremity cellulitis, and pre-renal ARF, all
now improved.
#Delirium: On admission to the hospital, the patient was
oriented only to person. Per report from the patient's son and
from previous notes, this was significantly off his baseline.
The patient was also intattentive and unable to carry on a
simple conversation. He had evidence of infection and
hypovolemia. We treated these with antibiotics and fluids. He
had been taking morphine XR at rehab. We stopped the morphine,
as we thought this may be contributing to his delirium. We kept
him on oxycodone for pain. As he became more hydrated and his
infections were treated, his mental status improved. He is now
alert oriented to person, place, and time. He is able to hold a
simple conversation and remember caregiver names. ___ son
indicates that he is at his baseline mental status. He is
sometimes confused upon awakening but should quickly orient.
#Acute renal failure: On admission, the patient had a creatinine
of 2.1 from a baseline of 1.2. His BUN on admission was 45 with
a BUN/Cr>20, suggesting a pre-renal etiology to the ARF. On
exam, his mucus membranes were dry, suggesting hypovolemia. He
was given IV fluids until he was taking a good amount of oral
intake. His creatinine improved to 1.3 on the day prior to
discharge. Diuretics initially held and restarted at discharge.
#Acute epididymitis: On admission the patient had an
erythematous, swollen, tender scrotum. His U/A was positive for
infection with many WBCs in the urine. His WBC count was 16.0 on
admission. Scrotal U/S was consistent w/ acute epididymitis.
There was no evidence of torsion. He was initially treated with
ceftriaxone IV and transitioned to oral cefpodoxime for total
14day course to end ___. His WBC count on the day prior to
discharge was 8.4. UCx grew yeast, felt to be colonization and
not treated.
#RLE cellulitis: On admission, the patient had about 5cm of
tenderness, erythema of medial right calf around a laceration
extending to the anterior calf. He was treated for cellulitis
with vancomycin IV for MRSA coverage as he has been in the
hospital and rehab. His cellulitis improved on this regimen. He
was transitioned to oral doxycycline for a planned 14 day course
to end ___. Bactrim would have been the preferred oral
antibiotic for this, but he is allergic to sulfa.
#Angina: The patient has a significant CAD history. On HOD2, the
patient developed ___ chest pain radiating to the left
shoulder. His systolic blood pressure dropped only from 120 to
100. His SpO2 remained steady at >95%RA. Am EKG prior to the
nitro showed nonspecific changes from prior but negative for ST
elevations. He was given nitroglycerin which improved his chest
pain. Troponins were elevated but stable at 0.07 and 0.06. Since
that event has had no chest pain. EKG unremarkable ___.
#Abdominal masses: There is a history of abdominal masses found
on a CT scan. We had a discussion with the patient and his
family. They confirmed they do not want this to be worked up
further. He had no abdominal pain during this hospitalization.
#Goals of care: During this hospitalization, conversations were
had with the patient's son ___ and the patient himself. Based
on these goals of care conversations his code status was changed
from full code to DNR/DNI.
TRANSITIONAL ISSUES:
#Lasix dosing: The patient's furosemide was held during his
hospitalization due to the ARF. He was started back on his home
dose of 40mg QD on discharge. Monitor Cr upon discharge.
#Pain control: The patient came in to the hospital with altered
mental status. His morphine was held, and the patient never
complained of pain. He was kept on his home oxycodone dose. He
will be discharged with oxycodone but without morphine XR. His
pain control regimen should be revisited with his PCP. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Abdominal pain
Nausea
Vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ male with a hx of Hep C (genotype 1a),
Crohn's colitis refractory to medical therapy complicated by
SBOs, now s/p total abdominal colectomy w/ end ileostomy on
___ and recently s/p robotic proctocolectomy with J pouch
and diverting ileostomy in ___ presents with one week of
abdominal pain, nausea, and vomiting. The patient reports
progressively worsening pain for the past week with one episode
of nonblood, nonbilious emesis. He reports subjective abdominal
distension, but continues to pass flatus and stool through his
ostomy bag.
The patient reports that the pain is a dull and achy mostly
localized to his epigastrium and associated with nausea. The
patient reports pain is worsened with food and he continues to
endorse poor appetite and PO take. Of note, since ___, the
patient reports he has lost about ___ lbs. He denies recently
consuming high residue foods (corn, strawberries) and has not
had any recent fevers, chills, or rashes. He denies any recent
travels, sick contacts, cough, dysuria, or hematuria.
In the ED, initial VS were T 97.8 HR 80 BP 110/63 RR 18 and SpO2
99% RA. Initial labs were notable for leukocytosis 13.9,
platelets 533, Cr 1.4 (baseline Cr 0.7), and lactate 1.4. Of
note, ESR, CPR, LFTs, and lipase were not sent in the ED. UA was
notable for bacteruria. Abdominal CT and Pelvic CT w/ contrast
was unremarkable for bowel obstruction. In the ED, the patient
received 3 L LR, Dilaudid 0.5 mg IV x4, and Zofran 4 mg IV.
On the floor, the patient's VS were T 96.6, HR 125, BP 105/79
RR15 and SpO2 97% RA. He continued to complain of nausea and
epigastric pain. He denies any chest pain or dyspnea. He
continued to have poor appetite.
Past Medical History:
Past Medical History:Crohn's disease (diagnosed in ___, now
suspect UC, bipolar affective disorder, Hep C cirrhosis, h/o
polysubstance abuse, anxiety
Past Surgical History:robotic proctectomy J pouch and diverting
loop ___ ___, lap total abdominal colectomy, end
ileostomy ___, ___
Social History:
___
Family History:
Mother: arthritis.
Father: HTN
Brother is an alcoholic
grandmother is an alcoholic with history of pancreatic cancer,
grandfather coronary artery disease, cousin mental illness.
Physical Exam:
On Admission:
VS T 96.6, HR 125, BP 105/79 RR15 and SpO2 97% RA
GENERAL: Well-appearing in NAD.
HEENT: Sclera anicetric. Moist mucous membranes with no
oropharyngeal lesions.
Neck: Supple, no cervical lymphadenopathy.
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Soft, nondistended. Normoactive bowel sounds. No
peritoneal signs (no rigidity or tap or shake tenderness).
Ostomy bag filled with gas and loose stool, otherwise appears
clean, dry, and intact. Pain on palpation along epigastrium. No
hepatosplenomegaly. Negative Rovsign's sign. Negative ___
sign.
EXTREMITIES: Moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
On Discharge:
VS Tm 99.1, Tc 97.5 HR 50-82, BP 98/56-103/54 RR 18, SpO2
98-100%RA
GENERAL: Well-appearing in NAD.
HEENT: Sclera anicetric. Moist mucous membranes with no
oropharyngeal lesions.
Neck: Supple, no cervical lymphadenopathy.
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Soft, nondistended. Normoactive bowel sounds. No
peritoneal signs (no rigidity or tap or shake tenderness).
Ostomy bag filled with gas and loose stool, otherwise appears
clean, dry, and intact. Mild pain on palpation along
epigastrium. No hepatosplenomegaly. Negative Rovsign's sign.
Negative ___ sign.
EXTREMITIES: Moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
Admission Labs:
___ 04:09AM BLOOD WBC-13.9*# RBC-6.23*# Hgb-16.1# Hct-48.0#
MCV-77* MCH-25.8* MCHC-33.4 RDW-14.5 Plt ___
___ 04:09AM BLOOD Neuts-78.6* Lymphs-15.2* Monos-4.4
Eos-1.5 Baso-0.3
___ 04:09AM BLOOD Plt ___
___ 04:48AM BLOOD ESR-6
___ 04:09AM BLOOD Glucose-150* UreaN-36* Creat-1.4* Na-126*
K-4.9 Cl-89* HCO3-19* AnGap-23*
___ 01:00PM BLOOD ALT-23 AST-24 LD(LDH)-171 AlkPhos-93
TotBili-0.8
___ 04:09AM BLOOD Lipase-29
___ 04:09AM BLOOD Albumin-5.3*
___ 01:00PM BLOOD CRP-5.2*
___ 06:56AM BLOOD Lactate-1.4
Discharge Labs:
___ 04:48AM BLOOD WBC-4.8 RBC-4.66 Hgb-12.4* Hct-36.5*
MCV-78* MCH-26.6* MCHC-34.1 RDW-14.8 Plt ___
___ 04:48AM BLOOD Plt ___
___ 04:48AM BLOOD Glucose-95 UreaN-12 Creat-0.8 Na-134
K-4.5 Cl-99 HCO3-26 AnGap-14
___ 04:48AM BLOOD Calcium-9.3 Phos-2.8 Mg-2.2
Imaging:
CT ABD & PELVIS WITH CO ___:
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, without stones or
gallbladder wall thickening.
PANCREAS: The pancreas has normal attenuation throughout,
without evidence of focal lesions or pancreatic ductal
dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation
throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: The kidneys are of normal and symmetric size with
normal nephrogram. There is no evidence of stones, focal renal
lesions or hydronephrosis. There
are no urothelial lesions in the kidneys or ureters. There is no
perinephric abnormality.
GASTROINTESTINAL: Patient is status post proctocolectomy with
J-pouch and a diverting ileostomy. Contrast passes freely
throughout the small bowel and into the ileostomy bag. No
evidence of bowel obstruction. The J-pouch is unremarkable. No
surrounding fluid collections.
RETROPERITONEUM: There is no evidence of retroperitoneal and
mesenteric
lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. There is no
calcium burden in the abdominal aorta and great abdominal
arteries.
PELVIS:
The urinary bladder and distal ureters are unremarkable. There
is no evidence of pelvic or inguinal lymphadenopathy. There is
no free fluid in the pelvis.
REPRODUCTIVE ORGANS: Reproductive organs are within normal
limits
BONES AND SOFT TISSUES:
There is no evidence of worrisome lesions. Abdominal and pelvic
wall is within normal limits.
IMPRESSION:
No evidence of obstruction. No fluid collections. No findings to
explain
patient's symptoms.
LIVER OR GALLBLADDER US ___:
FINDINGS:
Appearance of the liver, gallbladder, and biliary tree are
unchanged from the CT performed yesterday.
Microbiology:
Blood Culture, Routine (Final ___: NO GROWTH.
URINE CULTURE (Final ___: NO GROWTH.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. QUEtiapine Fumarate 50 mg PO BID
2. Lorazepam 0.5 mg PO Q8H:PRN Anxiety
Discharge Medications:
1. Lorazepam 0.5 mg PO Q8H:PRN Anxiety
2. QUEtiapine Fumarate 50 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Discharge Worksheet-Discharge ___,
MD on ___ @ 1721
Crohn's disease s/p total colectomy with end ileostomy, s/p
proctocolectomy with J pouch diverting ileostomy
Partial small bowel obstruction
Acute Kidney Injury
Hyponatremia
Lactose Intolerance
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: NO_PO contrast; History: ___ with hx of crohns multiple sbos,
here w abd painNO_PO contrast // sbo?
TECHNIQUE: MDCT axial images were acquired through abdomen and pelvis
following intravenous contrast administration with split bolus technique.
Coronal and sagittal reformations were performed and submitted to PACS for
review.
Oral contrast was administered.
DOSE: DLP: 337 mGy-cm (abdomen and pelvis.
IV Contrast: 130 mL Omnipaque injected at a rate of 25 cc/sec
COMPARISON: None.
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 is within normal limits,
without stones or gallbladder wall thickening.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of stones, focal renal lesions or hydronephrosis. There
are no urothelial lesions in the kidneys or ureters. There is no perinephric
abnormality.
GASTROINTESTINAL: Patient is status post proctocolectomy with J-pouch and a
diverting ileostomy. Contrast passes freely throughout the small bowel and
into the ileostomy bag. No evidence of bowel obstruction. The J-pouch is
unremarkable. No surrounding fluid collections.
RETROPERITONEUM: There is no evidence of retroperitoneal and mesenteric
lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. There is no calcium burden
in the abdominal aorta and great abdominal arteries.
PELVIS:
The urinary bladder and distal ureters are unremarkable. There is no evidence
of pelvic or inguinal lymphadenopathy. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: Reproductive organs are within normal limits
BONES AND SOFT TISSUES:
There is no evidence of worrisome lesions. Abdominal and pelvic wall is within
normal limits.
IMPRESSION:
No evidence of obstruction. No fluid collections. No findings to explain
patient's symptoms.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old man with Crohn's status post total colectomy with end
ileostomy presenting with abdominal pain, nausea, and vomiting. Please
evaluate for gallbladder pathology.
TECHNIQUE: Grayscale and color Doppler ultrasound examination of the abdomen
was performed.
COMPARISON: CT performed 1 day earlier, ___ at 06:22.
FINDINGS:
Appearance of the liver, gallbladder, and biliary tree are unchanged from the
CT performed yesterday.
IMPRESSION:
No change from CT performed yesterday.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with ABDOMINAL PAIN OTHER SPECIED
temperature: 96.6
heartrate: 125.0
resprate: 15.0
o2sat: 97.0
sbp: 105.0
dbp: 79.0
level of pain: 4
level of acuity: 2.0 | Mr. ___ is a ___ male with a hx of Hep C (genotype
1a), Crohn's colitis refractory to medical therapy complicated
by SBOs, now s/p total abdominal colectomy w/ end ileostomy on
___ and recently s/p robotic proctocolectomy with J pouch
and diverting ileostomy in ___ presents with one week of
abdominal pain, nausea, and vomiting.
#Abdominal Pain/Nausea/Vomiting: On admission, the patient
complained of epigastric abdominal pain, nausea, and vomiting of
one week duration. This was associated with a ___ weight
loss in the past two months. The patient also endorsed poor
appetite and postpandrial pain. The patient's exam was notable
for pain on deep palpation of epigastrium and around his ostomy
site. His ostomy bag was filled with air and soft sool and did
not appear to be obstructed. An abdominal CT did not demonstrate
any evidence of bowel obstruction or Crohn's flare. Inflammatory
markers were not found to be elevated. LFTs and lipase were
within normal limits. A right upper quadrant ultrasound did not
show any gallbladder abnormalities. The patient was managed for
a partial small bowel obstruction with bowel rest, IV fluids,
pain medications, and Zofran. The patient's diet was slowly
advanced as tolerated. During this hospitalization, the patient
was started on a low residue, lactose free diet. Of note, the
patient endorsed no postprandial pain with his lactose free
meal. Colorectal surgery evaluated the patient and felt no
surgical interventions were indicated during this
hospitalization. At the time of discharge, the patient's
abdominal pain and nausea had significantly improved and he
demonstrated increased appetite and ability to tolerate solid
food.
# Acute Kidney Injury/Hyponatremia: On admission, the patient
was found to have a Cr 1.4 (baseline Cr 0.8) and a Na 126. This
was attributed to hypovolemia in the setting of poor PO intake
and nausea and vomiting. The patient was bolused with IV fluids
and subsequently encouraged to increase his PO intake. At the
time of discharge, the patient's Cr normalized to his baseline
and Na was 134.
# Leukocytosis: On admission, the patient had a leukocytosis to
13.9. The patient was afebrile and nontoxic appearing. He did
not have any cough, diarrhea, dysuria, or any signs of a focal
infection. Of note, the patient was not started on empiric
antibiotics. His blood and urine cultures showed no growth. The
patient's leukocytosis was attributed to a stress response in
the setting of his abdominal pain. At the time of discharge, the
patient WBC normalized to 4.6 after resolution of his abdominal
pain. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Abdominal pain, nausea, and emesis x1 day
Major Surgical or Invasive Procedure:
No surgical intervention
History of Present Illness:
Ms. ___ is a pleasant ___ woman with a history
significant for congenital bowel malrotation,
intussusception,and recurrent small bowel obstructions who came
to the hospital because of one day of nausea, abdominal pain,
and emesis. Ms. ___ reports that her symptoms started
yesterday with bloating, distention, and nausea. She initially
tried to ignore the sensation but subsequently began having
repeated episodes of non-bloody emesis, as well as worsening
diffuse, crampy abdominal pain. She is unsure when she last past
flatus or had a bowel movement. She has had similar episodes in
the past which have typically resolved without intervention,
however, on this particular occasion the pain was more severe
and unrelenting than it has been in the past, so she went to
___ for evaluation. A CT abdomen and pelvis at
___ revealed findings consistent with midgut volvulus and
obstruction with a malrotation pattern. An NGT was placed and
she was transferred to ___ for further management and care.
Past Medical History:
Past Medical History:
Congenital malrotation
Recurrent small bowel obstructions
Lower extremity varicosities
Benign parotid gland tumor (right), status post resection
Past Surgical History:
___ old - reduction of intussusception (CHB)
___ - first SBO -> LOA and appendectomy (CHB)
___ - SBO -> LOA (pt is unsure whether any SBR)
___ - SBO -> LOA (pt is unsure whether any SBR)
Right parotid gland benign tumor removal (Mass Eye and Ear)
Left lower extremity microphlebectomy
Social History:
___
Family History:
Brother - ulcerative colitis
Sister - breast ca x2 in ___ (both breasts), BRCA I/II negative;
hypothyroidism
Father - ___ lymphoma, deceased age ___, prostate cancer
Paternal grandfather - heart disease
___ grandfather - heart disease
Physical Exam:
Admission Physical Exam:
Vitals: T 97.4, HR 72, BP 108/60, RR 14, O2 sat 99% ra
GEN: Alert and oriented, no acute distress, conversant and
interactive.
HEENT: Sclerae anicteric, mucous membranes moist, oropharynx is
clear.
NECK: Trachea is midline, thyroid unremarkable, no palpable
cervical lymphadenopathy, no visible JVD.
CV: Regular rate and rhythm, no audible murmurs.
PULM/CHEST: Clear to auscultation bilaterally, respirations are
unlabored on room air.
ABD: Soft, minimally distended, mildly tender to palpation in
the
left mid-abdominal region into the left lower quadrant, no
rebound or guarding, nontympanitic, no palpable masses, no
palpable hernias, prior surgical incisions are well-healed.
Ext: No lower extremity edema, distal extremities feel warm and
appear well-perfused.
Discharge Physical Exam:
Gen: A+Ox3, NAD
CV: RRR, no audible murmurs
PULM: CTA b/l
ABD: soft, non-distended, non-tender
EXT: no edema, warm, well-perfused b/l
Pertinent Results:
___ 11:29AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 11:29AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 11:29AM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 08:51AM ___ TEMP-36.3 COMMENTS-GREEN TOP
___ 08:51AM ___ TEMP-36.3 COMMENTS-GREEN TOP
___ 08:51AM LACTATE-0.8
___ 08:45AM GLUCOSE-98 UREA N-14 CREAT-0.7 SODIUM-140
POTASSIUM-3.6 CHLORIDE-104 TOTAL CO2-24 ANION GAP-16
___ 08:45AM ALT(SGPT)-15 AST(SGOT)-19 ALK PHOS-57 TOT
BILI-0.5
___ 08:45AM ALBUMIN-3.8
___ 08:45AM WBC-7.4 RBC-4.00 HGB-12.1 HCT-36.7 MCV-92
MCH-30.3 MCHC-33.0 RDW-12.0 RDWSD-40.3
___ 08:45AM NEUTS-77.8* LYMPHS-12.1* MONOS-9.3 EOS-0.1*
BASOS-0.3 IM ___ AbsNeut-5.77 AbsLymp-0.90* AbsMono-0.69
AbsEos-0.01* AbsBaso-0.02
___ 08:45AM PLT COUNT-240
___ 08:45AM ___ PTT-28.7 ___
Imaging:
CT A/P (OSH) - midgut volvulus and obstruction with a
malrotation
pattern.
___: Portable Abdomen x-ray:
NG tube terminates in the mid gastric body.
Possible, focal small bowel ileus in the right mid abdomen.
Medications on Admission:
She occasionally takes Advil for headaches, but otherwise takes
no medications on a daily basis.
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
please hold for loose stool
2. Senna 8.6 mg PO BID:PRN constipation
3. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ woman with high NG tube output. Evaluate NG tube
placement.
TECHNIQUE: Supine abdominal radiographs.
COMPARISON: Abdominal radiograph from ___. CT abdomen from ___.
FINDINGS:
There are no abnormally dilated loops of large bowel. Nonspecific small bowel
gas pattern in the right mid abdomen could reflect focal ileus.
There is no free intraperitoneal air.
Osseous structures are unremarkable.
NG tube terminates in the mid gastric body. Small radiodensity projecting
over the left pelvis likely reflects a calcified uterine fibroid.
IMPRESSION:
NG tube terminates in the mid gastric body.
Possible, focal small bowel ileus in the right mid abdomen.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, SBO, Transfer
Diagnosed with VOLVULUS OF INTESTINE
temperature: 97.4
heartrate: 72.0
resprate: 14.0
o2sat: 99.0
sbp: 108.0
dbp: 60.0
level of pain: 5
level of acuity: 3.0 | Ms ___ is a ___ year-old female with a history significant for
congenital bowel malrotation, intussusception, and recurrent
small bowel obstructions, who was admitted to ___ on ___
for management of midgut volvulus and obstruction. She was
admitted to the Acute Care Surgery team and was conservatively
managed. She was transferred to the step-down surgical floor.
The rest of the ___ hospital course is described by system
below:
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with IV pain
medicine and then transitioned to oral pain medicine once
tolerating a diet.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
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: The patient was initially kept NPO with a
___ tube in place for decompression. Once the patient
began to pass flatus, the NGT was removed, therefore, the diet
was advanced sequentially to a Regular diet, which was well
tolerated. Patient's intake and output were closely monitored.
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, of which there were none.
Prophylaxis: 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: NEUROLOGY
Allergies:
vancomycin / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Double vision
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is a ___ year-old R-handed woman who presents with 4 days
of visual changes.
On ___, 4 days ago, pt noticed that when she was looking
down at her phone, her vision was "wonky" in that she would have
transient blurriness that would resolve if she moved her phone
up
or if she concentrated and refocused. She felt like her R eye
felt slightly "puffy" as well but there was no eye redness or
irritation.
This was stable until ___ morning, yesterday, when she felt
that her whole R eye was "heavy". By the afternoon, she felt
that
she was having intermittent blurry vision in other directions of
gaze but this would still resolve if she concentrated on
re-focusing. She felt that her R eye was "lagging" behind her L
eye - though she cannot explain how she knew this was happening.
This morning, ___, she awoke feeling that her R eye was more
"tired" and felt swollen. She denies any pain with EOM. She
presented to an urgent care who referred to an ER. At an OHS,
she
received a CTA H and N that was negative for aneurysm and is
viewable via LifeImage.
On neurologic exams in the EDs, she has noticed that she has
frank diplopia on right gaze and upgaze that will worsen as she
continues to strain.
She has never had symptoms like this before but when asked about
hx of visual symptoms, she reports that she noticed a dark spot
in her L eye upper quadrant last ___ that has remained
persistent.
Otherwise, in the last ___ weeks, she has felt increased nausea
that she attributed to her Lamisil and she has felt that when
she
jerks her head to the R or L suddenly, has brief lightheadedness
lasting seconds. Denies vertigo.
She did go on a field trip with her son recently after which one
of his teachers became sick and was found to have multiple tick
borne illnesses. Has dogs in the house that go outside. No
recent
rash, joint pain, known tick bites.
On neuro ROS, the pt + headache with history of migraine. Denies
loss of vision,dysarthria, dysphagia, vertigo, tinnitus or
hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness, numbness,
parasthesiae. No bowel or bladder incontinence or retention.
Denies difficulty with gait.
On general review of systems, the 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.
Past Medical History:
Headache - Migraines increased in the last 6 months
Hx kidney stones
Social History:
___
Family History:
No neurologic diseases.
Physical Exam:
Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Able
to
read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt was able to
register 3 objects and recall ___ at 5 minutes. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: R mild ptosis and R pupil 3.5mm vs L pupil 3mm
both briskly reactive to light. No RAPD. No red desaturation.
Gross EOMI without nystagmus but she has binocular diplopia on
far right gaze - when the left eye is covered the outer image
disappears, when the right eye is covered the inner image
disappears. Binocular blurry vision on left far gaze - resolves
when eyes are isolated. Diplopia that develops on sustained
upgaze. Upgaze itself does not fatigue. Normal saccades. VFF to
confrontation. Fundoscopic exam revealed no papilledema,
exudates, or hemorrhages.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
*No fatiguability with R deltoid after 30 deltoid pumps.
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, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 3 3 3 3 3
R 3 3 3 3 3
Plantar response was flexor bilaterally. 1 beat ankle clonus
b/l.
+b/l pectoral jerks and +crossed adductors.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
Pertinent Results:
Admission labs
___ 05:06AM BLOOD WBC-11.4* RBC-4.57 Hgb-13.8 Hct-41.1
MCV-90 MCH-30.2 MCHC-33.6 RDW-12.4 RDWSD-40.7 Plt ___
___ 05:06AM BLOOD Glucose-86 UreaN-10 Creat-0.6 Na-140
K-4.4 Cl-104 HCO3-25 AnGap-15
___ 05:06AM BLOOD ALT-10 AST-10 LD(LDH)-154 AlkPhos-69
TotBili-0.6
___ 05:06AM BLOOD Albumin-4.1 Calcium-9.0 Phos-4.0 Mg-2.1
___:06AM BLOOD TSH-1.9
___ 05:06AM BLOOD CRP-2.1
___ 05:06AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-8*
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ CXR
IMPRESSION:
No acute cardiopulmonary abnormalities
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LamISIL (terbinafine HCl) 250 mg oral DAILY
2. Sumatriptan Succinate 50 mg PO DAILY:PRN migraine
Discharge Medications:
1. LamISIL (terbinafine HCl) 250 mg oral DAILY
2. Sumatriptan Succinate 50 mg PO DAILY:PRN migraine
Discharge Disposition:
Home
Discharge Diagnosis:
Diplopia of unclear etiology
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with exam findings possibly consistent with
myasthenia ___ // thymoma
TECHNIQUE: Chest PA and lateral
COMPARISON: None.
FINDINGS:
Cardiomediastinal contours are normal. The lungs are clear. There is no
pneumothorax or pleural effusion. The osseous structures are unremarkable
IMPRESSION:
No acute cardiopulmonary abnormalities
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Visual changes
Diagnosed with Diplopia
temperature: 97.6
heartrate: 89.0
resprate: 16.0
o2sat: 98.0
sbp: 139.0
dbp: 91.0
level of pain: 0
level of acuity: 3.0 | ___ is a ___ with history of migraines admitted for
diplopia. Her exam was notable for diplopia on far right and
upward gaze, as well as mild right ptosis without other
localizing features. Inflammatory markers were normal, as well
as normal CBC. A CTA at an outside hospital did not reveal
aneurysm. We considered demyelinating diseases, neuromuscular
junction disorders, complex migraines, and infectious
etiologies, and sent off tests accordingly, although suspicion
for these etiologies was low. Given the stability of the
patient's exam, however, we elected to discharge the patient and
obtain an MRI as an outpatient to further assess for etiology of
her symptoms with follow up to monitor for progression |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Lisinopril /
Hydrochlorothiazide
Attending: ___
Chief Complaint:
Vaginal bleeding
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ ___ with history of fibroid uterus and abnormal uterine
bleeding presents with vaginal bleeding x10 days.
Patient has been followed by primary OB/GYN at ___ and ___
recently Dr. ___ in MIGS. Briefly, she has had heavy menstrual
bleeding for years. She has a nexplanon in place since ___ with minimal improvement in her vaginal bleeding. She was
counseled on her options in ___ and given rx for aygestin. On
followup ___, she elected to proceed with UAE for treatment.
Since her prior visit, she states that her period began ___.
She has had bleeding daily using a minimum of 6 super sized
tampons. She has passed tennis ball sized clots that are dark
red. On day of admission, she noticed heavier bleeding and used
6 tampons over a 5 hour period. She also had some
lightheadedness and therefore presented to the emergency room
for further evaluation.
There, she was found to be tachycardic to 135 and received 1L
IVF. Her labs were notable for a hematocrit of 27, downtrend
from 33 in ___. On examination, she had clot removed and
active bleeding with difficulty visualizing the cervical os. She
was given 1000mg tranexamic acid at ___.
Patient denies continued dizziness or lightheadedness. No CP,
SOB. She has abdominal cramps that are ___, at her baseline.
She stated she has continued to have vaginal bleeding and has
used 5 pads over a 4 hour period in the emergency room. She
states she did not use the prescribed aygestin as it gave her
nausea and discomfort.
Patient also states she wishes to have a hysterectomy at this
time. In the past she had considered UAE but is worried about
continued symptoms after the procedure. She has an appointment
scheduled with Dr. ___ on ___ and Dr. ___ on ___ to review
her options.
Past Medical History:
PObHx: G8P4
- SAB x 2
- TAB x 2
- SVD x 4
PGynHx:
- Denies dysmenorrhea, menorrhagia until IUD recently removed
- Distant h/o abnormal Pap, most recent was normal (last at
___
___
- 4.8cm simple right adnexal cyst and fibroid uterus noted on
___ PUS
- Denies history of STIs, gynecological diagnoses such a
endometriosis
- Has used the following contraceptive methods: Mirena IUD, OCPs
PMHx: nephrolithiasis, HTN, anemia
PSHx: lithotripsy
Social History:
___
Family History:
Non-contributory
Physical Exam:
General: NAD, resting comfortably in bed
CV: RRR
Lungs: LCTAB, no respiratory distress
Abd: soft, nontender, nondistended, +BS
GU: pad saturated with moderate blood, about to be changed
Extremities: Nexplanon palpable in L arm; no calf
tenderness/erythema
Pertinent Results:
___ 12:45PM BLOOD WBC-6.2 RBC-3.12* Hgb-9.3* Hct-27.6*
MCV-89 MCH-29.8 MCHC-33.7 RDW-14.5 RDWSD-44.8 Plt ___
___ 11:55AM BLOOD Neuts-65.4 ___ Monos-5.5 Eos-1.9
Baso-0.5 Im ___ AbsNeut-4.17 AbsLymp-1.67 AbsMono-0.35
AbsEos-0.12 AbsBaso-0.03
___ 12:45PM BLOOD Plt ___
___ 11:55AM BLOOD Glucose-110* UreaN-17 Creat-0.8 Na-143
K-5.3* Cl-107 HCO3-21* AnGap-15
Medications on Admission:
amlodipine 5, atenolol 50, epinephrine, nexplanon
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID constipation
take if constipated on iron
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*1
3. tranexamic acid ___ mg oral Q8H
RX *tranexamic acid ___ mg 2 tablet(s) by mouth three times a
day Disp #*20 Tablet Refills:*0
4. amLODIPine 5 mg PO DAILY
5. Atenolol 50 mg PO DAILY
6. Ferrous Sulfate 325 mg PO BID anemia
Discharge Disposition:
Home
Discharge Diagnosis:
Heavy vaginal bleeding
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: PELVIS, NON-OBSTETRIC
INDICATION: ___ with fibroids, menorrhagia, tachy// eval fibroids vs. other
source of uterine bleeding
TECHNIQUE: Grayscale and Doppler ultrasound images of the pelvis were
obtained with transabdominal approach.
COMPARISON: MR dated ___. Ultrasound dated ___.
FINDINGS:
The uterus is anteverted. The uterus is enlarged measuring 16.0 x 10.4 x 11.7
cm. There are multiple masses consistent with fibroids. The largest fibroid is
located in the uterine body and measures 11.8 x 8.8 x 10.0 cm, previously 12.0
x 9.3 x 10.3 cm. The endometrium is distorted by fibroids but where seen
measures 13.5 mm.
The right ovary is not well visualized. The left ovary is normal with normal
arterial and venous waveforms. There is no free fluid.
IMPRESSION:
Fibroid uterus with normal left ovary and nonvisualized right ovary.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Dizziness, Vaginal bleeding
Diagnosed with Other specified abnormal uterine and vaginal bleeding
temperature: 98.1
heartrate: 135.0
resprate: 22.0
o2sat: 100.0
sbp: 149.0
dbp: 105.0
level of pain: 7
level of acuity: 2.0 | Ms. ___ was admitted on ___ for management of her
abnormal uterine bleeding. A pelvic U/S ___ showed a fibroid
uterus, largest fibroid in uterine body 11.8 x 8.8 x 10.0 cm,
EMS 13.5mm. She received one dose of Tranexamic acid in the ED.
Her hematocrit and coags were stable.
On ___, she was clinically stable and was discharged with
Interventional Radiology follow-up as well as follow-up with Dr.
___. She was also discharged with a prescription for PO
tranexemic acid and PO iron. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Assault/facial trauma--right mandibular fracture
Major Surgical or Invasive Procedure:
1. ORIF Right mandibular Angle Fracture with MMF
2. Extraction of tooth #1
History of Present Illness:
___ is a ___ year old healthy male, who was
transferred from OSH with concerning CT finding of right
mandibular fx. Patient was assaulted earlier by two people,
punching his right-side of face. Patient denied LOC. At OSH, CT
was taken and patient was subsequently transferred to ___ for
further evaluation of OMFS with his mandible fx.
Patient arrives at ED in stable condition, denies fever, chill,
excessive pain, bleeding, SOB. Patient endorses malocclusion and
numbness along right side of mandible. Of note, he reports daily
use of marijuana but denies any other smoking, drinking, IVDU
habit.
Past Medical History:
None
Family History:
None pertinent to encounter
Physical Exam:
On admission:
Review of Systems:
General: NAD, WF/WN, denies recent unexplained weight changes
Eyes: No gross vision changes
Ears/Nose/Throat: Negative
Cardiovascular: Denies cp, palpatations
Respiratory: Denies SOB, no accessory muscle usage
Gastrointestinal: Denies abdominal pain, n/v, appetite changes
Genitourinary: Denies
Neurologic: Denies loss of sensation, tremors, weakness, or
paralysis except paresthesia of right V3 distribution
Psychiatric: AAOx3
Endocrine: Denies
Heme/Lymphatic: Denies
Physical Exam:
General: NAD
HEENT:
Head: atraumatic and normocephalic except tenderness along
right
mandible. Right forehead laceration, which was repaired (glued)
by OSH ED, covered with steri-strip, hemostatic.
Eyes: EOM Intact, PERRL, vision grossly normal
Ears: right ear normal, left ear normal, no external
deformities
and gross hearing intact
Nose: straight septum, straight nose, non-tender, no epistaxis
EOE: ___ ~45mm with pain
TMJ: no clicking, no popping, no crepitus, full range of
motion,
normal TMJ bilaterally
Neurology: cranial nerves II-XII grossly intact except
paresthesia of right V3 distribution
Neck: normal range of motion, supple, no JVD, and no
lymphadenopathy
IOE: Premature contact with teeth ___ area. Dentition
grossly
intact. No intraoral wound/cut/ecchymosis, non-mobile segments
of
jaw/teeth. Non-tender, non-elevated FOM.
On discharge:
Physical Exam:
General: AAOx3
HEENT:
Head: atraumatic and normocephalic except mild facial swelling
at right mandible c/w procedure
Neurology: cranial nerves II-XII grossly intact except R V3
parenthesis, which presents pre-operatively
Eyes: EOM Intact, PERRLA, no ptosis, no visual change, no
diplopia and vision grossly normal
Ears: right ear normal, left ear normal, no external
deformities and gross hearing intact
Nose: non-tender, non-tender sinuses, no saddle deformity, no
septal hematoma, no epistaxis and straight nasal dorsum
EOE: mild facial swelling at right mandible c/w procedure
TMJ: Unable to examine due to MMF
Neck: normal range of motion, supple, no masses and no
lymphadenopathy
IOE: Limited exam due to MMF. 3 IMF screws at mandible and
maxilla and MMF with 3 wires. Occlusion appeared to be stable.
Surgical site intact with suture and hemostatic. Extraction site
appeared to be hemostatic as well.
Pertinent Results:
___ 12:59AM ___ PTT-28.5 ___
___ 12:59AM PLT COUNT-293
___ 12:59AM NEUTS-80.8* LYMPHS-13.5* MONOS-5.1 EOS-0.0*
BASOS-0.2 IM ___ AbsNeut-8.48* AbsLymp-1.42 AbsMono-0.54
AbsEos-0.00* AbsBaso-0.02
___ 12:59AM WBC-10.5* RBC-5.68 HGB-15.6 HCT-46.6 MCV-82
MCH-27.5 MCHC-33.5 RDW-13.6 RDWSD-39.8
___ 12:59AM CALCIUM-10.0 PHOSPHATE-4.2 MAGNESIUM-1.9
___ 12:59AM estGFR-Using this
___ 12:59AM GLUCOSE-126* UREA N-12 CREAT-1.0 SODIUM-142
POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-25 ANION GAP-11
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen (Liquid) 1000 mg PO Q6H pain
RX *acetaminophen 500 mg/15 mL 30 ml by mouth every six (6)
hours Disp #*1260 Milliliter Refills:*0
2. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
RX *chlorhexidine gluconate [Peridex] 0.12 % Swish with 15mL for
30 seconds twice daily, then spit out. Do not eat or drink
anything for 30 minutes afterwards. twice a day Refills:*0
3. OxyCODONE Liquid 5 mg PO Q6H:PRN Pain - Moderate
RX *oxycodone 5 mg/5 mL 5 ml by mouth every six (6) hours Disp
___ Milliliter Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Right mandible fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MANDIBLE (PANOREX ONLY)
INDICATION: ___ year old man assaulted with R. Mandible fracture, repaired
___// S/p ORIF/extraction. OMFS requesting prior to DC (before early
afternoon)
TECHNIQUE: Single-view radiograph of the mandible.
COMPARISON: Single view radiograph of the mandible dated ___ as well
as CT of the mandible dated ___.
FINDINGS:
Images show interval placement of a fixation hardware consisting of plate and
screws between the 2 sides of right mandibular angle fracture. There also 3
sets of screws with wires as part of the mandibular maxillary fusion.
Alignment is unchanged from prior radiographs dated ___. For more
details please see the operative note.
IMPRESSION:
Interval placement of fixation hardware about the mandibular fracture as well
as maxillary mandibular fusion hardware, please see operative note for more
details.
Gender: M
Race: BLACK/CARIBBEAN ISLAND
Arrive by AMBULANCE
Chief complaint: Mandibular fracture, Transfer
Diagnosed with Fracture of angle of right mandible, 7thB, Assault by other bodily force, initial encounter, Laceration w/o fb of left eyelid and periocular area, init
temperature: 97.0
heartrate: 75.0
resprate: 16.0
o2sat: 98.0
sbp: 129.0
dbp: 81.0
level of pain: 3
level of acuity: 3.0 | Mr. ___ is a ___ year old male who presented to the ED as a
transfer from an OSH after he was found to have a mandibular
fracture on CT. Reports that he was assaulted by two people and
hit on the right side of his face. He did not strike his head
or
have loss of consciousness. He presented as stable and denied
fever,
chills, chest pain, or SOB. The next day, he proceeded to the OR
for isolated R, minimally displaced, open mandibular angle fx.
The patient did not have acute issues post-operatively and
tolerated the procedure well. He was instructed on oral hygiene,
follow-up, and a liquid diet with OMFS, with follow-up
appointment made prior to discharge. The patient was able to
ambulate, tolerate a liquid diet, with no acute nausea or
vomiting during his inpatient stay. He remained hemodynamically
stable throughout and was discharged per OMFS on ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
sulfa drugs / Cephalosporins / codeine
Attending: ___
Chief Complaint:
small bowel obstruction
Major Surgical or Invasive Procedure:
Laparoscopic small bowel resection, appendectomy, resection of
Meckels
History of Present Illness:
___ with h/o mild ileal chron's disease diagnosed in ___
who was trialed on budesonide and then taken off of it in ___
by
GI now presenting with 18 hours of crampy epigastric abdominal
pain and bilious emesis (>10 episodes). The pain is severe and
started after dinner around 6 ___ last night. Patient states that
his pain is intermittent. It does not radiate anywhere. No
diarrhea. No melena, hematochezia, or BRBPR. Patient endorses
chills and ? fevers overnight that have since resolved. His last
bm was formed and non-bloody this am, but he cannot recall the
last time he passed flatus. He also c/o feeling bloated. He
denies any flank pain, dysuria/hematuria/frequency. No sick
contacts. He does not think any food he ate could have
contributed. He is followed by gastroenterology here (Dr. ___.
He was hospitalized in ___ due to rectal bleeding, and that is
when he was started on budesonide by GI. In ___ it was
recommended that he stop the budesonide because he was doing
well
and if he developed recurrent pain and/or bleeding, to
potentially start treatment with a biologic.
At his last visit with Dr. ___ in ___ he reported ___ formed
stool per day. He had no abdominal pain, but occasional
bloating.
No further rectal bleeding. Energy levels were good, and weight
was stable.
At his last visit with Dr. ___ in ___ he reported ___ formed
stool per day. He had no abdominal pain, but occasional
bloating.
No further rectal bleeding. Energy levels were good, and weight
was stable.
Past Medical History:
Crohns
Anemia
Lactose Intolerance
Social History:
___
Family History:
___:
No history of autoimmune or GI diseases in family.
Physical Exam:
Physical Exam on Admission:
Vitals: Today 03:53 pain ___ 87 124/72 19 100% RA
Gen: AAO, NAD, appears stated age, well-nourished
HEENT: PERRL, no scleral icterus, dry cracked lips
Neck: Trachea midline, supple, no appreciable LAD
___: RRR, No murmurs appreciated
Pulm: CTABL
Abd: Soft, minimally distended, no rebound, voluntary guarding
and tenderness over epigastrium
Rectal: deferred
Ext: No edema
Vascular: palpable DP and ___ pulses
Physical Exam on Discharge:
Vitals: 24 HR Data (last updated ___ @ 743)
Temp: 97.8 (Tm 98.6), BP: 122/81 (111-143/71-89), HR: 70
(67-91), RR: 18 (___), O2 sat: 97% (97-99), O2 delivery: RA
Fluid Balance (last updated ___ @ 917)
Last 8 hours Total cumulative 210ml
IN: Total 360ml, PO Amt 360ml
OUT: Total 150ml, Urine Amt 150ml
Last 24 hours Total cumulative -107ml
IN: Total 1943ml, PO Amt 1620ml, IV Amt Infused 323ml
OUT: Total 2050ml, Urine Amt 2050ml
Physical exam:
Gen: NAD, AxOx3
Card: hemodynamically stable
Pulm: no respiratory distress
Abd: Soft, non-tender, non-distended
Wounds: c/d/i
Ext: No edema, warm well-perfused
Pertinent Results:
___ 06:45AM BLOOD WBC-6.2 RBC-4.52* Hgb-13.7 Hct-40.6
MCV-90 MCH-30.3 MCHC-33.7 RDW-11.9 RDWSD-38.5 Plt ___
___ 07:13AM BLOOD WBC-9.0 RBC-4.60 Hgb-13.9 Hct-41.0 MCV-89
MCH-30.2 MCHC-33.9 RDW-11.9 RDWSD-38.6 Plt ___
___ 07:30AM BLOOD WBC-4.6 RBC-4.72 Hgb-14.4 Hct-41.0 MCV-87
MCH-30.5 MCHC-35.1 RDW-11.6 RDWSD-37.2 Plt ___
___ 07:00AM BLOOD WBC-4.6 RBC-4.22* Hgb-12.8* Hct-37.9*
MCV-90 MCH-30.3 MCHC-33.8 RDW-11.7 RDWSD-38.2 Plt ___
___ 08:08AM BLOOD WBC-5.4 RBC-4.42* Hgb-13.5* Hct-40.8
MCV-92 MCH-30.5 MCHC-33.1 RDW-12.0 RDWSD-41.4 Plt ___
___ 07:50AM BLOOD WBC-6.1 RBC-4.48* Hgb-13.6* Hct-41.3
MCV-92 MCH-30.4 MCHC-32.9 RDW-12.3 RDWSD-42.0 Plt ___
___ 04:55AM BLOOD WBC-16.6* RBC-5.56 Hgb-17.0 Hct-49.6
MCV-89 MCH-30.6 MCHC-34.3 RDW-11.9 RDWSD-39.1 Plt ___
___ 04:55AM BLOOD Neuts-91.4* Lymphs-2.8* Monos-5.1
Eos-0.0* Baso-0.2 Im ___ AbsNeut-15.19* AbsLymp-0.46*
AbsMono-0.85* AbsEos-0.00* AbsBaso-0.03
___ 07:23AM BLOOD Glucose-91 UreaN-6 Creat-0.8 Na-146 K-3.9
Cl-104 HCO3-30 AnGap-12
___ 06:45AM BLOOD Glucose-82 UreaN-3* Creat-0.7 Na-141
K-3.9 Cl-102 HCO3-26 AnGap-13
___ 07:13AM BLOOD Glucose-67* UreaN-3* Creat-0.7 Na-140
K-3.8 Cl-99 HCO3-24 AnGap-17
___ 07:30AM BLOOD Glucose-76 UreaN-4* Creat-0.8 Na-142
K-3.7 Cl-100 HCO3-27 AnGap-15
___ 07:00AM BLOOD Glucose-53* UreaN-7 Creat-0.7 Na-141
K-3.8 Cl-101 HCO3-22 AnGap-18
___ 08:08AM BLOOD Glucose-61* UreaN-12 Creat-0.8 Na-146
K-3.5 Cl-104 HCO3-22 AnGap-20*
___ 07:50AM BLOOD Glucose-77 UreaN-16 Creat-0.8 Na-143
K-4.1 Cl-106 HCO3-27 AnGap-10
___ 04:55AM BLOOD Glucose-150* UreaN-20 Creat-1.2 Na-139
K-4.1 Cl-96 HCO3-19* AnGap-24*
___ 04:55AM BLOOD ALT-22 AST-29 AlkPhos-63 TotBili-1.3
___ 04:55AM BLOOD Lipase-27
___ 07:23AM BLOOD Calcium-9.1 Phos-3.7 Mg-1.9
___ 06:45AM BLOOD Calcium-9.0 Phos-3.3 Mg-1.8
___ 07:13AM BLOOD Calcium-8.8 Phos-2.9 Mg-1.9
___ 07:30AM BLOOD Calcium-8.8 Phos-3.5 Mg-1.9
___ 07:00AM BLOOD Calcium-8.8 Phos-2.6* Mg-1.8
___ 08:08AM BLOOD Calcium-8.5 Phos-3.1 Mg-1.8
___ 07:50AM BLOOD Calcium-8.8 Phos-1.9* Mg-2.1
___ 04:55AM BLOOD Albumin-5.5* Calcium-11.0* Phos-1.7*
Mg-1.9
___ 07:50AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG
___ 04:55AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG
___ 07:13AM BLOOD CRP-49.1*
___ 07:30AM BLOOD CRP-48.7*
___ 10:19AM BLOOD CRP-69.7*
___ 08:08AM BLOOD CRP-102.6*
___ 07:50AM BLOOD CRP-127.0*
___ 04:55AM BLOOD CRP-8.7*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ALPRAZolam 0.5 mg oral DAILY:PRN flying
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
2. Enoxaparin Sodium 40 mg SC DAILY
3. TraMADol 50-100 mg PO Q6H:PRN Pain - Moderate
Do not drink or drive while taking
4. ALPRAZolam 0.5 mg oral DAILY:PRN flying
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction
Crohn's disease
Meckel's diverticula
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 PMH Crohn's presenting with nominal pain with
intermittent severityNO_PO contrast // Concern for Crohn's flare, SBO,
appendicitis or other acute abnormalities
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 9.5 s, 0.5 cm; CTDIvol = 28.8 mGy (Body) DLP =
14.4 mGy-cm.
2) Spiral Acquisition 6.6 s, 51.8 cm; CTDIvol = 14.4 mGy (Body) DLP = 747.1
mGy-cm.
Total DLP (Body) = 762 mGy-cm.
COMPARISON: None.
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 are subcentimeter hypodense lesions at the hepatic dome and also in
segment seven posteriorly which are too small to characterize. There is no
evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder
is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is an 8 mm hypodense lesion in the left kidney that is too small to
characterize, but likely represents a simple cyst. There is no perinephric
abnormality.
GASTROINTESTINAL: There is a small hiatal hernia. There are multiple mid to
distal fluid-filled and dilated loops of small measuring up to 4.8 cm in
diameter. There is a transition point identified in the mid lower abdomen
(2:133, 601: 66) which may represent a stricture in this patient with a
history of Crohn's disease. Fecalization of enteric contents noted immediately
proximal to the obstruction and there is decompression of the distal small
bowel loops. There is a blind ending 5 cm long outpouching of the small bowel
in the right lower quadrant (601:51 and 2:141). Mesenteric free fluid is
noted. There is subtle hyperemia within the terminal ileum which is
relatively decompressed and mild surrounding stranding. This raises the
possibility mild acute inflammation in this region. The colon and rectum are
within normal limits. Appendix contains a 1 cm appendicolith though the
appendix itself is unremarkable without surrounding inflammation.
The appendix is prominent with multiple appendiculith, however it is air
filled withour hyperemia.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is a
small amount of 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.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
T9 vertebral body hemangioma is noted.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Small-bowel obstruction, with a transition point identified in the mid
lower abdomen which may represent a stricture in this patient with history of
Crohn's disease. Fecalization of enteric contents noted proximal to the
obstruction and decompressed distal small bowel loops.
2. Free fluid adjacent to small bowel loops tracking into the pelvis.
3. Mild hyperemia of the terminal ileum with surrounding stranding raising the
possibility of mild acute inflammation in the setting of Crohn's.
4. A 5 cm long blind-ending outpouching of the mid to distal small bowel in
the right lower quadrant which is likely a diverticulum, potentially a
Meckel's diverticulum. No evidence of associated inflammation.
Radiology Report
INDICATION: ___ with small bowel obstruction, status post NG tube placement
// Confirm NG tube placement.
TECHNIQUE: Single portable view of the chest.
COMPARISON: CT abdomen pelvis from ___.
FINDINGS:
Enteric tube is seen with tip coiled in the gastric fundus. Lung volumes are
low. Cardiomediastinal silhouette is within normal limits. Excreted contrast
noted in the renal pelves. No acute osseous abnormalities.
IMPRESSION:
Enteric tube noted within the gastric fundus.
Radiology Report
EXAMINATION: MR ___
INDICATION: ___ year old man with hx of Crohn's disease p/w SBO // Eval for
SBO in pt w/ hx of Crohn's disease
TECHNIQUE: T1 and T2-weighted multiplanar images of the abdomen and pelvis
were acquired within a 1.5 T magnet, including 3D dynamic sequences performed
prior to, during, and following the administration of 0.1 mmol/kg of Gadavist
intravenous contrast (8 cc). Oral contrast consisted of 1000 mL of Breeza. 1.0
mg of Glucagon was administered IM to reduce bowel peristalsis.
COMPARISON: CT scan dated ___
FINDINGS:
MR ENTEROGRAPHY:
Small bowel distention has improved when comparison is made with the CT scan
dated ___.
There are at least 3 short areas of segmental narrowing and focal dilatation
with associated hyperenhancement, visualized in the terminal ileum (1201:32,
35 and 39) with pseudo sacculation of the anti mesenteric border of the bowel
(9:33, 27), consistent with active and chronic inflammatory changes.
The apparent hyperenhancement visualized in the loops of proximal jejunum, is
related to underdistention.
The previously visualized right lower quadrant blind-ending structure, lateral
to loops of distal small bowel, is less conspicuously visualized(9:19), and
given its location remains suspicious for Meckel's diverticulum.
The appendix is mildly distended and contains 2 appendicoliths. No
periappendiceal inflammatory changes to suggest acute appendicitis.
No evidence of fistulizing disease and no intra-abdominal collection.
Colon appears unremarkable without wall thickening or focal abnormalities.
MRI OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST:
A 10 mm T2 hyperintense lesion in segment 8 of the liver is consistent with a
cyst. No other focal liver lesions. There is mild splenomegaly with the
spleen measuring 14 mm. No focal splenic lesion. There are subcentimeter
nonenhancing left renal lesions measuring up to 9 mm consistent with cysts.
The right kidney appears normal
The imaged aspect of the liver, gallbladder, pancreas, and adrenal glands are
unremarkable. No retroperitoneal or mesenteric lymphadenopathy is identified.
Abdominal aorta is normal size.
MRI OF THE PELVIS WITH AND WITHOUT IV CONTRAST:
The bladder and distal ureters appear unremarkable. Rectum is unremarkable. No
pelvic or inguinal lymphadenopathy. No free fluid.
OSSEOUS / SOFT TISSUE STRUCTURES:
No worrisome lesion is identified.
IMPRESSION:
1.
Skipped hyperenhancing lesions with short segments of luminal narrowing are
demonstrated in the distal ileum and at the terminal ileum, with associated
pseudo sacculation of the anti mesenteric border, in keeping with changes of
active on chronic inflammatory bowel disease.
2. Interval improvement in small bowel distension with no definite evidence of
mechanical obstruction.
3. No fistulizing disease or intra-abdominal collection.
4. Blind-ending structure in right iliac fossa is less conspicuous and better
characterized on recent CT of ___, remains suspicious for ___
diverticulum.
Radiology Report
INDICATION: ___ year old man with Crohn's disease p/w/ SBO // Eval for SBO
TECHNIQUE: Frontal abdominal radiographs were obtained.
COMPARISON: CT from ___
FINDINGS:
As a nasogastric tube in the proximal stomach. Persistent dilatation of the
small bowel loops up to 3 cm. Air within the colon. Appendicolith in the
appendix. There is no evidence of intraperitoneal free air. The bony
structures are unremarkable.
IMPRESSION:
Persistent small bowel obstruction.
Appendicolith.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Vomiting
Diagnosed with Unspecified abdominal pain
temperature: 97.0
heartrate: 87.0
resprate: 19.0
o2sat: 100.0
sbp: 124.0
dbp: 72.0
level of pain: 9
level of acuity: 2.0 | Mr. ___ is a ___ with history of mild Crohn's Disease who
presented to the ED at ___ on ___ and was diagnosed with
small bowel obstruction likely secondary to Crohn's stricture.
He was admitted to the Colorectal Surgery service given need for
possible ileocecectomy. He was made NPO and an NGT was placed.
GI was consulted and recommended ciprofloxacin and metronidazole
for protentional Crohn's flare in addition to quantiferon gold
testing which was negative. He underwent MRE which demonstrated
skipped hyperenhancing lesions with short segments of luminal
narrowing in the distal ileum and at the terminal ileum, with
associated pseudo sacculation of the anti mesenteric border, in
keeping with changes of active on chronic inflammatory bowel
disease, interval improvement in small bowel distension with no
evidence of mechanical obstruction, no fistulizing disease or
intra-abdominal collection, and suspicious for ___
diverticulum. On ___ he underwent laparoscopic small bowel
resection, appendectomy, resection of Meckels which he tolerated
well. He was transferred to the PACU in stable condition. After
an uneventful stay in the PACU, he was transferred to the floor.
Neuro: Pain was well controlled initially on Dilaudid PCA and
once tolerating oral intake he was transitioned to oral Tylenol
and tramadol for breakthrough pain.
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 initially kept NPO after the procedure with
the nasogastric tube still in place. The tube was removed on
POD1 and once the patient began passing flatus, his diet was
advanced to regular which was well tolerated. Patient's intake
and output were closely monitored.
GU: The patient had a Foley catheter that was removed after the
procedure. At time of discharge, the patient was voiding without
difficulty. Urine output was monitored as indicated.
ID: The antibiotics were discontinued on POD1. The patient was
closely monitored for signs and symptoms of infection and fever,
of which there was none.
Heme: The patient received subcutaneous heparin and TEDS during
this stay. He was encouraged to get up and ambulate as early as
possible. The patient is being discharged on prophylactic
Lovenox.
On ___, the patient was discharged to home. At discharge,
he was tolerating a regular diet, passing flatus, voiding, and
ambulating independently. He will follow-up in the clinic in ___
weeks. This information was communicated to the patient directly
prior to discharge.
Post-Surgical Complications During Inpatient Admission:
[ ] Post-Operative Ileus resolving w/o NGT
[ ] Post-Operative Ileus requiring management with NGT
[ ] UTI
[ ] Wound Infection
[ ] Anastomotic Leak
[ ] Staple Line Bleed
[ ] Congestive Heart failure
[ ] ARF
[ ] Acute Urinary retention, failure to void after Foley D/C'd
[ ] Acute Urinary Retention requiring discharge with Foley
Catheter
[ ] DVT
[ ] Pneumonia
[ ] Abscess
[x] None
Social Issues Causing a Delay in Discharge:
[ ] Delay in organization of ___ services
[ ] Difficulty finding appropriate rehab hospital disposition.
[ ] Lack of insurance coverage for ___ services
[ ] Lack of insurance coverage for prescribed medications.
[ ] Family not agreeable to discharge plan.
[ ] Patient knowledge deficit related to ileostomy delaying
dispo
[x] No social factors contributing in delay of discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Abdominal pain, nausea and vomiting
Major Surgical or Invasive Procedure:
ERCP with spent placement
Laparoscopic Cholecystectomy
History of Present Illness:
Mr. ___ is a ___ man with history of HTN, HLD,
OUD on ___ and long history of symptomatic cholethiasis who
presented to an OSH with nausea and vomiting, found to have
cholangitis and transferred to ___ for ERCP which he received
on ___.
The patient reports that he was in his usual state of health
until ___ when he suddenly developed nausea and
vomiting after eating a large meal. He also had diffuse
abdominal
pain that at the time that was particularly worse in the RUQ. He
continued to have intermittent nausea and vomiting that got
worse
on ___ after another meal, and at the time he reports feeling
fever and chills and decided to go to the local ER where he was
originally treated with IVFs and nausea medication before
returning home. He was called back to the on ___ due to blood
cultures with GNRs, but was afevrile at the time. Labs at the
time were significant for a elevated WBC and liver enzymes
(TBili
5.4,Dbili 3.9, AP 89, AST 243, ALT 312). He received ceftriaxone
and zosyn and was transferred to ___ for concern of
cholangitis
where he underwent ERCP on ___ with ___ placement.
On talking to him today Mr. ___ reports some mild
nonradiating intermittent RUQ tenderness that he rates ___
and
is more of a discomfort. He says that it has been there since
last ___ but that it is better now. He denies any
exacerbating
or relieving factors. He denies feeling feverish or chills, he
denies any nausea or vomiting currently but says he felt
nauseated and was vomiting "clear stuff" yesterday.
Past Medical History:
HTN; HLD; Opioid use disorder; Glaucoma; Cataracts;
Seizure
Social History:
___
Family History:
No pertinent family history
Physical Exam:
T:97.5 PO BP:157/78 HR:55 RR:18 O2 Sat:94% Ra
Gen: AAO3, NAD
HEENT: PERRL, no scleral icterus, MMM
Neck: Trachea midline, supple, no appreciable LAD
___: RRR
Pulm: No increased work of breathing
Abd: Soft, mildly tender to palpation on RUQ, negative ___
sign, no rebound, no guarding, incisions clean, dry, intact
Ext: No edema, warm
Vascular: palpable DP and ___ pulses
Pertinent Results:
___ 08:23AM BLOOD WBC-13.0* RBC-4.40* Hgb-13.6* Hct-40.0
MCV-91 MCH-30.9 MCHC-34.0 RDW-13.4 RDWSD-44.6 Plt ___
___ 08:23AM BLOOD Plt ___
___ 02:35AM BLOOD ___ PTT-29.4 ___
___ 08:23AM BLOOD Glucose-134* UreaN-9 Creat-0.9 Na-144
K-4.2 Cl-107 HCO3-20* AnGap-17
___ 02:35AM BLOOD ALT-111* AST-60* AlkPhos-126 TotBili-2.2*
___ 11:00PM BLOOD ALT-240* AST-179* AlkPhos-82 TotBili-5.1*
DirBili-4.2* IndBili-0.9
___ 08:23AM BLOOD Calcium-8.8 Phos-3.7 Mg-1.7
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. Simvastatin 40 mg PO QPM
3. tadalafil 20 mg oral DAILY:PRN
4. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild
5. Buprenorphine-Naloxone Tablet (8mg-2mg) 2 TAB SL DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
Do not take with alcohol or meds containing
Tylenol/acetaminophen.
2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 14 Days
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth every
twelve (12) hours Disp #*24 Tablet Refills:*0
3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
Don't take more than the recommended dose or drink alcohol or
drive while taking.
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*15 Tablet Refills:*0
4. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*60 Tablet Refills:*0
5. Lisinopril 20 mg PO DAILY
6. Simvastatin 40 mg PO QPM
7. tadalafil 20 mg oral DAILY:PRN
8. HELD- Buprenorphine-Naloxone Tablet (8mg-2mg) 2 TAB SL DAILY
This medication was held. Do not restart Buprenorphine-Naloxone
Tablet (8mg-2mg) until your appointment with Dr. ___
9. HELD- Ibuprofen 600 mg PO Q8H:PRN Pain - Mild This
medication was held. Do not restart Ibuprofen until follow up
appointment with ___ Surgery
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute calculus cholecystitis, Cholangitis
E coli bacteremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with nausea and vomiting x5 days, transferred from
___ for cholangitis// cholangitis
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: 3 mm
GALLBLADDER: The gallbladder is distended, and contains stones and sludge with
wall edema.
PANCREAS: The pancreas is not well visualized, largely obscured by overlying
bowel gas.
SPLEEN: Normal echogenicity.
Spleen length: 9.5 cm
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
Right kidney: 10.2 cm
Left kidney: 10.8 cm
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
Distended gallbladder with stones, sludge and wall edema could reflect acute
cholecystitis in the appropriate clinical setting.
Radiology Report
EXAMINATION: MRCP
INDICATION: ___ year old man with RUQ pain, OSH Tbili 5.4, direct bilirubin
3.9, bilirubin indirect 1.5, nausea and vomiting x5 days// cholangitis?
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
Intravenous contrast: 9 mL Gadavist.
Oral contrast: 1 cc of Gadavist mixed with 50 cc of water was administered
for oral contrast.
COMPARISON: Liver ultrasound ___.
FINDINGS:
Note that the quality of the study is degraded by presence of significant
motion artifact.
Lower thorax: Mild bibasilar atelectasis. Lung bases, visualized pleural
spaces, and lower mediastinal structures are otherwise unremarkable.
Liver: Liver is normal in contour. No liver steatosis. No morphologic
features of cirrhosis.
Biliary: Gallbladder lumen is not significantly distended. There is however
mild gallbladder wall thickening with mild pericholecystic fat stranding.
Incidental note is made of fundal adenomyomatosis. CBD is mildly prominent
proximally (7 mm), but tapers normally towards the ampulla. Subtle layering
T2 hypointense signal within the distal CBD (series 4, image 32) has no
correlation on any other pulse sequences.
There is incidental medial insertion of the cystic duct.
Please note, all post-contrast sequences are highly motion degraded limiting
optimal evaluation for cholangitis.
Pancreas: Pancreas maintains normal bulk. There is mild prominence of the
main pancreatic duct throughout its length, measuring up to 6 mm in diameter.
No focal strictures, filling defects or obstructing masses identified. No
focal parenchymal lesion noted.
Spleen: The spleen is not enlarged (12 cm).
Adrenals: Adrenal glands are normal.
Kidneys: Kidneys are unremarkable. No focal renal lesions. No
hydronephrosis.
Bowel: Visualized loops of large and small bowel are unremarkable. No mural
thickening. No luminal distention.
Vasculature: Abdominal aorta is normal in caliber. Major branch vessels are
patent. Incidental retroaortic left renal vein.
Lymph nodes: Scattered small retroperitoneal and mesenteric lymph nodes. No
lymphadenopathy.
Osseous/Soft Tissue: No focal destructive/marrow replacing osseous lesions.
Peritoneum: No free-fluid.
IMPRESSION:
As also noted on the ultrasound performed ___, there is evidence of
mild acute calculous cholecystitis. No evidence of choledocholithiasis. The
post-contrast images are highly motion degraded limiting evaluation for
cholangitis. Within this limitation, no hepatic abscess noted.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: N/V
Diagnosed with Other cholangitis
temperature: 99.1
heartrate: 70.0
resprate: 18.0
o2sat: 98.0
sbp: 135.0
dbp: 70.0
level of pain: 0
level of acuity: 3.0 | MEDICINE COURSE:
Mr. ___ is a ___ man with history
of HTN, HLD, OUD on ___ who presented to an outside
hospital
with nausea and vomiting, found to have E coli bacteremia and
cholangitis and transferred here for ERCP, which he underwent
___, confirming cholangitis, also had MRCP concerning for acute
calculous cholecystitis, awaiting cholecystecomy with ___
surgery. |
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 ___ woman with a past medical
history of bipolar, gastritis (s/p EGD ___, and
gallstones who presented ___ with epigastric abdominal pain.
Ms. ___ reported she has had intermittent epigastric and
right
upper quadrant pain for the last several days, becoming
continuous as of 10pm ___. Patient initially described pain
as 10 out of 10 in severity, "crampy and stabbing" in quality,
radiating to her back, associated with po intolerance, nausea
and
bilious vomiting.
She reports a history of GERD and in the past had been on a PPI
but not recently. In ___ she developed burning
epigastric discomfort that she says is distinctly different that
the pain she is experiencing on this encounter. However, that
discomfort was bad enough to drive to go to an urgent care
center. There she was diagnosed with gastritis and started on
omeprazole 20mg BID, sucralfate 1g TID, and prn ondansetron for
nausea. She reports her symptoms resolved.
She has a history of an ___ ED visit for acute abdominal
pain but abdominal exam was benign. CBC, CMP, Lipase all wnl. US
at the time showed evidence of cholelithiasis without evidence
of
cholecystitis or ductal dilation. It also showed possible
evidence of a fat-containing hernia. However, outpatient
follow-up CT abdomen/pelvis with contrast showed no evidence of
hernia, only evidence of non-obstructive gallstones as seen
previously. She was recommended elective cholecystectomy but
deferred it.
She has no history of cholecystitis or pancreatitis. She does
not
drink alcohol, use tomacco products, or use recreational drugs.
Her only medications are buspirone, lamotrigine, occasional prn
lorazepam, and recently started omeprazole and sucralfate and
prn
ondansetron. She denies a history of previous abdominal surgery.
Normal bowel movement one day prior to presenting. No change in
urinary frequency or function. No black/bloody BMs. Denies
fever,
chills, chest pain, shortness of breath, change in vision or
hearing, bruising, adenopathy, new rash or lesion.
ED course:
Initial VS: T ?96, HR 98, BP 148/74, 99% on RA
Labs notable for:
WBC 12.5->8.1, Neuts 81%->67.5%, Hgb 11.8->10
Glu 147->87, BUN 6, Cr 0.6
ALT 81, AST 140, AlkPhos 219, Tbili 0.8
Lipase 3750
Latate 5.0->0.9->0.7
UA without anything abnormal other than slightly hazy
Ucx ___ growing mixed bacterial flora, likely contaminated
Studies:
___ CT abd/pelvis w/contrast:
Acute interstitial pancreatitis, with the highest concentration
of inflammation near the pancreaticoduodenal groove, possibly
reflecting groove pancreatitis. No fluid collection or necrosis.
___ CXR:
Generalized bronchial inflammation. No evidence of pneumonia or
heart failure.
___ Abd US:
1. Echogenic liver with no focal lesions identified.
2. Cholelithiasis, without evidence of acute cholecystitis.
Interventions:
Zofran, 1L NS, IV morphine, 6 liters IVF, acetaminophen,
After copious fluids and failure to be able to advance her diet,
the ED recommended admission to medicine for further monitoring,
work-up, and management.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
- bipolar
- gastritis
- gallstones
Social History:
___
Family History:
Reviewed and found to be not relevant to this illness/reason for
hospitalization. Reports that diabetes type 2 runs on both sides
of the family.
Physical Exam:
T 98.2-98.3, HR ___, BP 100s-140s/60s-70s, RR 18, O2 sat
96-97% on room air
GENERAL: Woman sitting in a hospital bed, no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Breathing comfortably on room air. Lungs clear to
auscultation with good air movement bilaterally.
GI: Abdomen soft, obese, non-distended, tender to palpation in
epigastric area. Bowel sounds present.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: Pleasant, anxious, appropriately responds to questions
and
commands, appropriate affect
Exam on discharge;
Vitals: ___ ___ Temp: 99.0 PO BP: 113/70 L Lying HR: 84
RR:
18 O2 sat: 97% O2 delivery: Ra
GENERAL: Woman sitting in a hospital bed, no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Breathing comfortably on room air. Lungs clear to
auscultation with good air movement bilaterally.
GI: Abdomen soft, obese, non-distended, tender to palpation in
epigastric area. Bowel sounds present.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: Pleasant, anxious, appropriately responds to questions
and
commands, appropriate affect
Pertinent Results:
___ 07:05AM BLOOD WBC: 7.5 RBC: 4.02 Hgb: 11.1* Hct: 34.8
MCV: 87 MCH: 27.6 MCHC: 31.9* RDW: 12.7 RDWSD: 40.___
___ 07:05AM BLOOD Glucose: 91 UreaN: 4* Creat: 0.5 Na: 144
K: 4.3 Cl: 106 HCO3: 22 AnGap: 16
___ 07:05AM BLOOD ALT: 34 AST: 17 AlkPhos: 139* TotBili:
0.3
___ 07:05AM BLOOD Lipase: 199*
Micro
___ UCx growing mixed bacterial flora, likely contaminated
Imaging & Studies
___ CT abd/pelvis w/contrast:
IMPRESSION:
Acute interstitial pancreatitis, with the highest concentration
of inflammation near the pancreaticoduodenal groove, possibly
reflecting groove pancreatitis. No fluid collection or necrosis.
___ CXR:
IMPRESSION:
Generalized bronchial inflammation.
No evidence of pneumonia or heart failure.
___ Abd US:
IMPRESSION:
1. Echogenic liver with no focal lesions identified.
2. Cholelithiasis, without evidence of acute cholecystitis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LamoTRIgine 100 mg PO BID
2. Omeprazole 20 mg PO BID
3. LORazepam 0.5 mg PO DAILY:PRN anxiety
4. BusPIRone 15 mg PO BID
5. Sucralfate 1 gm PO TID epigastric pain
Discharge Medications:
1. BusPIRone 15 mg PO BID
2. LamoTRIgine 100 mg PO BID
3. LORazepam 0.5 mg PO DAILY:PRN anxiety
4. Omeprazole 20 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Acute pancreatitis
Gallstones
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with epigastric abdominal pain// Cholecystitis?
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT abdomen pelvis ___. Liver ultrasound ___.
FINDINGS:
LIVER: The liver is diffusely echogenic. 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: 5 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: 11.6 cm
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
Right kidney: 11.6 cm
Left kidney: 13.0 cm
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Echogenic liver with no focal lesions identified.
2. Cholelithiasis, without evidence of acute cholecystitis.
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 either MR ___ or US ___, 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: CHEST (PA AND LAT)
INDICATION: History: ___ with pancreatitis// Intrathoracic abnormality is
present?
TECHNIQUE: AP and lateral
COMPARISON: CT abdomen pelvis ___
FINDINGS:
Lung volumes are low. There is bibasilar atelectasis. Bronchial wall
thickening is generalized and suggests bronchial inflammation. No focal
consolidation. No pleural effusion or pneumothorax.
IMPRESSION:
Generalized bronchial inflammation. No evidence of pneumonia or heart
failure.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: NO_PO contrast; History: ___ with epigastric abdominal pain,
nausea, vomitingNO_PO contrast// Abscess? Appendicitis?
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 3.5 s, 0.5 cm; CTDIvol = 16.9 mGy (Body) DLP =
8.4 mGy-cm.
2) Spiral Acquisition 6.7 s, 53.1 cm; CTDIvol = 24.9 mGy (Body) DLP =
1,319.4 mGy-cm.
Total DLP (Body) = 1,328 mGy-cm.
COMPARISON: CT abdomen and pelvis ___
FINDINGS:
LOWER CHEST: There is bibasilar dependent atelectasis. There is no evidence
of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: There is mild stranding predominantly about the pancreatic head and
uncinate process, as well as the second portion of the duodenum. There is
associated reactive lymphadenopathy. There are no focal pancreatic lesions,
and the pancreatic duct is not dilated. No fluid collection, or evidence of
pancreatic necrosis. No evidence of splenic artery pseudoaneurysm
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: There is scarring of the right renal cortex, as before. The left
kidney is normally enhancing. There is no evidence of focal renal lesions or
hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Mild stranding about the
second portion of the duodenum in the region of the pancreaticoduodenal groove
is present as described above. Small bowel loops are otherwise unremarkable.
The colon and rectum are within normal limits. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus and adnexae are unremarkable.
LYMPH NODES: With the exception of reactive peripancreatic lymph nodes, there
is no abdominopelvic lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
Acute interstitial pancreatitis, with the highest concentration of
inflammation near the pancreaticoduodenal groove, possibly reflecting groove
pancreatitis. No fluid collection or necrosis.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Vomiting
Diagnosed with Acute pancreatitis without necrosis or infection, unsp
temperature: 96.0
heartrate: 98.0
resprate: 16.0
o2sat: 99.0
sbp: 148.0
dbp: 74.0
level of pain: 10
level of acuity: 3.0 | Ms. ___ is a ___ woman with a past medical
history of bipolar, gastritis (s/p EGD ___, and
gallstones who presented ___ with abdominal pain,
nausea/vomiting and was found to have acute pancreatitis likely
due to pancreatitis.
# Pancreatitis
# Nausea, vomiting, po intolerance
Presents with severe epigastric pain, nausea/vomiting, and
elevated lipase along with CT imaging confirms acute
pancreatitis. Given LFTs were initially elevated (alk phos and
transaminases) and then improved patient likely passed
gallstone. Discussed recommendation for cholecystectomy with
patient at ___. She is not
interested in cholecystectomy at this time and understands she
is at risk for acute pancreatitis. She was treated with IV
fluids, antiemetics and pain medications with improvement in her
abdominal pain. Her diet was advanced to regular which she
tolerated without pain. She will follow up with GI as an
outpatient and can see Dr. ___ she decides to pursue
cholecystectomy. The was counseled on a low fat diet and to
avoid alcohol
# Bipolar/anxiety
- continued home lamotrigine, buspirone |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sudafed / Reglan / domperidone / Benadryl
Attending: ___.
Chief Complaint:
Allergic reactions
Major Surgical or Invasive Procedure:
___ Esophagogastroduodenoscopy
___ Dobhoff nasogastric tube placed
History of Present Illness:
This is a ___ with PMH of Ehlers-Danlos, ___ cell activation
disorder, gastroparesis, and POTS, who presents with allergic
reaction.
Patient reports that for the past ___ years, she has had
frequent swollen lymph nodes, episodic rashes/hives,
gastroparesis, and severe body pain that was attributed to some
combination of EDS/unclear autoimmune disorder. Over this
period, she became progressively disabled and housebound. Over
the past ___ months, she has developed worsening "allergies",
with episodic rashes, hives, and lymph node swelling throughout
the day, generally worse at night. With some foods, she would
develop altered mental status with agitation, tongue swelling,
and sometimes sensation of throat closing (unable to drink).
These would be reversible over ___ hours with
claritin/hydroxyzine. She developed difficulty with breathing
___ times, requiring epipen administration by her spouse and
admissions to ___ and ___. She notes that in this period,
foods that she normally considers "safe" have started been
correlated with episodes. Despite good appetite, due to fear of
allergic reaction, she has lost ___ lbs over the past month. On
___, the patient had an episode of altered mental status and
tongue swelling with oatmeal, typically a safe food for her. On
___, she presented to her allergist Dr. ___
which she elected to eat gluten-free peanut butter, bananas, and
strawberry jam sandwich to trigger symptoms. She was noted to be
tachycardic to 135 and lethargic but able to speak in complete
sentences and with no rashes, facial swelling, or swelling of
visible OP/tongue. She was subsequently sent to ___ ED.
In the ED, initial vitals HR 140, BP 123/89, 100% RA.
- No exam is documented on the ED dashboard, although RN note
mentions airway intact. Initiated discussion regarding ENT
evaluation in the ED given documentation from allergist.
Inpatient team informed that ENT is not needed.
- Labs notable for: WBC 16.6 (67.6% PMN). Chem 7 WNL. Lactate
2.5. LFTs notable for with AST of 61, alk phos 28. Serum tox
screen negative.
- Imaging: CXR without cardiopulmonary abnormality
- Patient was given: 1L of IVF.
- Vitals prior to transfer: 98.9, 112, 135/67, 16, 100% RA
On arrival to the floor, pt reports being comfortable and in
NAD.
Past Medical History:
?___ hypermobility
Gastroparesis
Fibromyalgia
Headaches
Traumatic brain injury with occipital fracture and occipital
neuralgia
Episodic tachycardia
Orthostatic hypotension
Autism-spectrum disorder
Anxiety and depression
GERD
Costochondritis
Peripheral neuralgias
Social History:
___
Family History:
Her mother has SLE (seizures, renal) and food allergies. Her
father has an unknown kidney disease. Her sister has joint
hypermobility. Maternal uncle and grandfather have food
allergies. Grandmother with MS. ___ with renal and
?COPD/heart disorder. Paternal gradfather with stroke. Two
paternal uncles with SCD.
Physical Exam:
ADMISSION EXAM
==============
Vitals: 98.6F, 105, 128/85, 16, 100% RA.
General: AAOx3, comfortable appearing, in NAD, speaking
fluently.
HEENT: NCAT (including occiput), EOMI, PERRL. Sclera anicteric,
conjunctiva pink. MMM. OP clear, able to visualize top of uvula.
No evidence of swelling.
Neck: Supple, mildly tender anterior neck w/prominent
sternocleidomastoid, submandibular and anterior chain fullness
w/o palpable discrete LAD
Lungs: CTAB, no wheezes/rales/rhonchi
CV: Tachycardic regular rhythm w/respirophasic variation, normal
S1 and S2, no murmurs
Abdomen: Normoactive bs, soft, nontender, nondistended, no
hepatomegaly, no splenomegaly.
GU: No CVA or suprapubic tenderness.
Ext: WWP. 2+ peripheral pulses. No edema.
Skin: Back with occ dark macules and papules, no urticaria or
other lesions. Not particularly hyperelastic. Skin of back
mildly erythematous and edematous, with notable blanching with
light pressure.
DISCHARGE EXAM
==============
Vitals: 98.9 98.9 120 (60s-120s) 124/86 100%RA 59kg.
General: AAOx3, comfortable appearing, in NAD, speaking
fluently.
HEENT: NCAT, EOMI. Sclera anicteric, conjunctiva pink. MMM. OP
clear.
Neck: Supple, no LAD, no swelling.
Lungs: CTAB, no wheezes/rales/rhonchi before or after wheezing
CV: RRR, normal S1 and S2, no murmurs
Abdomen: Mild ttp RUQ/RLQ. Normoactive bs, soft, nondistended,
no hepatomegaly, no splenomegaly.
Ext: WWP. 2+ peripheral pulses. No edema.
Pertinent Results:
ADMISSION LABS
___ WBC-16.6*# RBC-4.62# Hgb-13.7 Hct-42.3# MCV-92 MCH-29.7
MCHC-32.4 RDW-13.1 RDWSD-43.8 Plt ___
Neuts-67.6 ___ Monos-5.7 Eos-0.2* Baso-0.2 Im ___
AbsNeut-11.20* AbsLymp-4.29* AbsMono-0.95* AbsEos-0.03*
AbsBaso-0.03
HEMOLYZED*** Glucose-86 UreaN-14 Creat-0.8 Na-135 K-6.3* Cl-99
HCO3-24 AnGap-18
Lactate-2.5* K-4.2
ALT-20 AST-61* AlkPhos-28* TotBili-0.3
Albumin-4.5 Calcium-9.5 Phos-3.1 Mg-2.6
ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG
Tricycl-NEG
PERTINENT LABS
___ neg HCG
___ 12:45PM TSH-2.9
TRYPTASE 1 ___ ng/mL NORMAL)
C1 INHIBITOR, FUNCTIONAL 68 (>=68 % NORMAL)
MOST RECENT LABS ON DISCHARGE
WBC-10.3* RBC-4.45 Hgb-13.1 Hct-41.0 MCV-92 MCH-29.4 MCHC-32.0
RDW-12.8 RDWSD-42.5 Plt ___
PERTINENT STUDIES
___: 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.
___ EKG: Sinus tachycardia. Compared to the previous tracing
of ___ no change.
___ Fiberoptic Exam:
Normal nasal cavity, no pus or polyps
Normal nasopharynx, no masses
Normal oropharynx
Epiglottis crisp
Supraglottic area normal
Arytenoid complexes mobile bilaterally/symetrically
Arytenoids and interarytenoid region with significant erythema
and redundant tissue in the postcricoid region.
True vocal folds symmetric and mobile bilaterally, no masses, no
erythema
Pyriform sinuses clear
No significant pooling of secretions
___ EGD: Normal mucosa in the whole esophagus (dilation,
biopsy, biopsy)
Normal mucosa in the whole stomach (biopsy)
Otherwise normal EGD to third part of the duodenum
___ EGD biopsies: 1. Mid esophagus biopsy: Within normal
limits.
2. Lower esophagus biopsy: Within normal limits.
3. Stomach biopsy: Within normal limits.
#CHEST XR:
There has been placement of a Dobbhoff tube with tip in the body
of the
stomach, appropriately sited. Cardiomediastinal silhouette is
within normal
limits. There are no focal consolidations, pleural effusion, or
pulmonary
edema. There are no pneumothoraces.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ranitidine 600 mg PO QHS
2. Amitriptyline 75 mg PO QHS
3. Mirtazapine 45 mg PO QHS
4. cromolyn 200 milligrams oral QID
5. Montelukast 10 mg PO DAILY
6. PredniSONE 20 mg PO DAILY
Tapered dose - DOWN
7. Loratadine 20 mg PO BID
8. HydrOXYzine 10 mg PO Q6H:PRN allergies
9. TraMADOL (Ultram) 50 mg PO Q8H:PRN pain
10. drospirenone-ethinyl estradiol ___ mg oral DAILY
11. arginine (L-arginine) unknown oral unknown
12. magnesium stearate unknown miscellaneous DAILY
13. Vitamin D Dose is Unknown PO DAILY
14. Probiotic
(B.breve-L.acid-L.rham-S.thermo;<br>L.acidophilus-Bif.
animalis;<br>L.rhamn ___
acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus
combination no.4;<br>lactobacillus combo no.11) unknown oral
unknown
15. Naproxen 500 mg PO Q8H:PRN pain
Discharge Medications:
1. cromolyn 200 milligrams oral QID
2. HydrOXYzine 10 mg PO Q6H:PRN allergies
3. Loratadine 20 mg PO BID
4. Mirtazapine 45 mg PO QHS
5. Montelukast 10 mg PO DAILY
6. Ranitidine 600 mg PO QHS
7. TraMADOL (Ultram) 50 mg PO Q8H:PRN pain
8. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
9. Tube feeds
Jevity 1.2 at 75ml/hour x 18 hours
Free water flushes 50ml every 4 hours
10. Amitriptyline 75 mg PO QHS
11. Probiotic
(B.breve-L.acid-L.rham-S.thermo;<br>L.acidophilus-Bif.
animalis;<br>L.rhamn ___
acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus
combination no.4;<br>lactobacillus combo no.11) 1 tab ORAL DAILY
12. drospirenone-ethinyl estradiol ___ mg oral DAILY
13. arginine (L-arginine) 1 tab ORAL Frequency is Unknown
14. magnesium stearate 1 tab MISCELLANEOUS DAILY
15. Naproxen 500 mg PO Q8H:PRN pain
16. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
- Gastroesophageal reflux disease
- Swallowing disorder NOS
SECONDARY:
- PosturalTachycardia
- Costochondritis
- Migraines
- Peripheral neuralgias
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
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 tachycardia
TECHNIQUE: Chest PA and lateral
COMPARISON: None.
FINDINGS:
Heart size is normal. The mediastinal and hilar contours are normal. The
pulmonary vasculature is normal. Lungs are clear. No pleural effusion or
pneumothorax is seen. There are no acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
INDICATION: ___ year old woman with EDS, ? POTS, gastroparesis who presents
with inability to tolerate PO without oral/neck swelling. // please assess
placement of NG dobhoff tube
COMPARISON: Radiographs from ___
IMPRESSION:
There has been placement of a Dobbhoff tube with tip in the body of the
stomach, appropriately sited. Cardiomediastinal silhouette is within normal
limits. There are no focal consolidations, pleural effusion, or pulmonary
edema. There are no pneumothoraces.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Allergic reaction, Tachycardia
Diagnosed with ALLERGY, UNSPECIFIED, ACCIDENT NOS, TACHYCARDIA NOS, SEMICOMA/STUPOR
temperature: nan
heartrate: 140.0
resprate: nan
o2sat: 100.0
sbp: 123.0
dbp: 89.0
level of pain: nan
level of acuity: 1.0 | ___ with PMH of Ehlers-Danlos, GERD, and episodic tachycardia,
who presents for evaluation of episodes of throat
closing/swelling. The initial concern was for anaphylactic
reaction to food, she demonstrated no evidence of respiratory
compromise or hemodynamic instability to suggest anaphylaxis.
ENT evaluation revealed severe laryngeotracheal reflux which may
be causing spasm or crichopharyngeal muscle dysfunction. She
was ultimately started on enteral feedings via nasogastric tube
and was able to gradually reintroduce food. Patient will follow
up with a ___ cell disorder specialist to evaluate for a
possible ___ cell disorder overlap syndrome.
# Food allergy / largyngeotracheal reflux:
Patient has been having episodes of throat closing/swelling for
the past ___ years, worsening over the last month. These episodes
were associated with subjective throat/neck swelling, facial
swelling, lip swelling, tongue swelling, rashes, and hives.
These would be associated with dysphagia and are associated with
food/worse in evenings. Sometimes, she would develop decreased
awareness +/- agitation for ___ hours. In the past month, she
has had ___ episodes with dyspnea but not stridor, prompting
epipen administration by her husband. These resulted in food
aversion and approximately 10lb weight loss over 2 months
(reported). She presented to allergy clinic after
self-triggering an episode with PB&J. Her allergist did not feel
that the patient had significant facial/tongue/OP swelling or
appearance of angioedema or e/o ___ cell dysfunction, but given
her food aversion she was admitted for evaluation.
On admission, labs notable for WBC 16.6 (67.6% PMN, 0.2% eos).
One of these episodes was observed on ___ in which there was
some possible right-sided swelling after eating but no features
concerning for anaphylaxis (respiratory compromise, hives, GI
distress) as well as no altered mental status. Etiology remains
unclear at discharge despite extensive investigation. GI
performed EGD with biopsies that were negative for esophageal
stricture and eosinophilic esophagitis. ENT evaluated with
laryngoscopy and thought this could be due to severe GERD
causing laryngeal spasm; on omeprazole and ranitidine now. Not
likely to be angioedema given normal C1 esterase inhibitor.
The patient's constellation of symptoms do not fit into a clear
medical diagnosis, although there is suspicion for a ___ cell
disorder. Psychiatry evaluated her for possible somatiform
disorder given her multiple somatic symptoms, and recommended
ongoing but prudent and safe work-up for more rare causes,
minimizing risk of iatrogenic harm from unnecessary tests or
treatments while also ensuring a thorough medical work-up. One
of the final remaining possibilities that deserves further
work-up is ___ cell dysfunction related to ___. We
have obtained records from Dr. ___, a geneticist
previously at ___ and now at ___
___, that confirms the diagnosis of EDS. A small study of 9
females with dual diagnoses of POTS and EDS, 66% had validated
symptoms of a ___ cell disorder, suggestive of ___ cell
activation syndrome ___ and ___ J Allergy Clin Immunol
___. She has an appointment with Dr. ___ at ___, who is a
___ cell specialist, on ___.
Nutrition was consulted due to concern that the patient was not
maintaining adequate PO intake because she was worried about
provoking a reaction. They recommended encouraging PO intake and
provided tube feed recommendations. A dobhoff was placed on
___ and tube feeds were initiated. The patient tolerated the
tube feeds well and FSBG were < 150. She began to have
improvement in her swallowing function and tolerance of food on
the day of discharge; feeding tube will remain in place as a
bridge to outpatient appointments and further work-up.
Tube feeds were started to maintain PO intake. She tolerated
tube feeds well. Metoprolol tartrate 25mg q6h was also started
with the idea that if there was an autonomic component to these
episodes, it might minimize her symptoms. It helped with the
sweating and may have dulled some of the sensations associated
with these episodes. This was transitioned to metoprolol
succinate 50mg daily on discharge. Home loratadine, montelukast,
and hydroxyzine were continued. She was put on a prednisone
taper (starting at 20mg) at OSH, but we spoke with her allergist
Dr. ___ did not feel that she needed it, and it was
stopped during this admission
# Tachycardia: Presumed to be autonomically mediated given
unclear h/o POTS vs. other autonomic dysfunction on prior tilt
table test in ___. No e/o acute cardiopulmonary
process eg PE from timeframe, history, or exam. Noted on tele to
have sinus tachycardia to max 150s; patient has palpitations but
no presyncope, dyspnea, or chest pain. She was started on
metoprolol tartrate 25mg q6h and transitioned to metoprolol
succinate 50mg bid on discharge.
# GERD: Noted on endoscopy despite ranitidine. Started on
omeprazole.
# Nutrition: Poor PO intake in the setting of food aversion due
to episodes of throat closing/swelling. Reported 10 pound weight
loss over 2 months. Nutrition consulted during hospitalization,
who found that intake was not meeting needs and made
recommendations for tube feeds. A dobhoff was placed. She
continued to take in POs, noting that her "safe foods" now
included bagels, grilled cheese, and rice. She was discharged on
tube feeds with the plan to continue as her swallowing function
improves.
# Vaginal bleeding: Started over past 3 weeks. ___ be
breakthrough bleeding on pill. Not frank menorrhagia (3
pads/day). No symptoms concerning for pelvic process. Neg HCG,
platelet count nml. Home birth control (continuous) continued.
CHRONIC ISSUES
==============
# Chronic pain: Ultram prn and elavil continued.
# Depression: Elavil and mirtazapine continued. GI notes elavil
probably bad for her from GI perspective, may want to discuss
transition to nortrip or other less-anti-cholinergic agent as an
outpatient.
TRANSITIONAL ISSUES
===================
- Patient will follow-up with her primary care provider and
allergist for ongoing management of swallowing dysfunction and
question of allergic etiology of her subjective throat swelling.
In the interim, ___ nasogastric feeding tube will remain in
place as swallowing function improves.
- Has appointment with Dr. ___ specialist) at
___ on ___.
- Patient will follow-up with ear/nose/throat for dysphagia
evaluation as an outpatient; may also want to consider formal
speech and swallow study as an outpatient
- metoprolol succinate 50mg daily prescribed for tachycardia
presumed to be autonomically-mediated given her prior testing
indicating autonomic dysfunction and postural tachycardia
- will take omeprazole in addition to ranitidine for reflux
- Patient will follow-up with PCP regarding vaginal bleeding.
# CODE STATUS: FULL (confirmed)
# ___ ___ |
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 distension
Major Surgical or Invasive Procedure:
Rectal tube placement
History of Present Illness:
___ yr old ___ female w/h/o dementia, rectal
sphincter stenosis, chronic constipation presenting after being
called to return to ED for question of volvulus.
Pt was in ___ until ___, developed abdominal distension, fever
to 101, low po intake and lethargy. Transferred to ___ ED.
Thought likely impacted, fecal disimpaction was attempted but
aborted after abdominal Xray revealed no evidence of excess
fecal matter. Rectal tube was placed for decompression. Pt was
also hypokalemic with K+ of 2.7; repleted. Urine dipstick was
positive, pt sent home w/ rectal tube to complete three-day
course of bactrim. At ___, potassium repletion was
continued. On ___ pt was started on ceftriaxone and IV
metronidazole at ___, MD note does not comment on
reason. Rehab was then contactted by the ___ ED staff, advised
to return to the ER after initial imaging suggested a possible
volvulus. Nursing staff deny any vomiting, small loose stools,
(2 soft BM recorded) no hematochezia.
In ED, initial vitals were 98.1 80 136/74 16 94%. Labs notable
for hypernatremia to 156, hypokalemia to 2.7. CT abdomen w/ no
e/o volvulus, but did reveal pseudoobstruction of the colon with
13cm distension.
Of note, pt had a prior episode of pseuodo-obstruction in ___.
Managed conservatively w/ enemas, resolved.
Pt started on D5W for hypernatremia, 40mEq KCL, transferred to
floor for further management. On arrival, pt's VSS, pt appeared
comfortable and calm.
Past Medical History:
Alzheimer dementia
Chronic constipation
Psychosis with history of suicidal ideations
Depression
Hypertension
PSH:
Left hip arthroplasty
Appendectomy
C section
Rectal sphincter stenosis dilation ___ yrs ago
Social History:
___
Family History:
non-contributory
Physical Exam:
Admission:
Vitals: T 97.8, BP 139/78, HR 76, RR 18, O2 95% on RA
General: AXO X 0, mumbles incoherently, appears comfortable
HEENT: NC, AT, dry MM, poor dentition
Lungs: CTAB anteriorly, pt does not cooperate w/ exam for
posterior auscultation
CV: Regular rhythm, normal rate, no m/g/r
Abdomen: Soft, distended, nontender
Ext: Wwp, no c/c/e
Neuro: Diffult to assess given MS, no obvious focal deficits
Discharge:
Vitals- 97.8 139/78 76 18 95%
General- alert, non-oriented, interactive but per ___
interpreter, does not "make any sense," exam difficult ___
patient participation
HEENT- Sclera anicteric, EOMI, PERRLA, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, II/VI holosystolic murmur left
sternal border
Abdomen- soft, nontender, distended, rare bowel sounds, no
rebound tenderness or guarding, no organomegaly. Rectal tube in
place
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
Admission labs:
WBC-10.8 RBC-3.81* Hgb-11.6* Hct-34.7* MCV-91 MCH-30.4 MCHC-33.4
RDW-13.1 Plt ___
Glucose-109* UreaN-26* Creat-0.5 Na-156* K-2.7* Cl-118* HCO3-29
AnGap-12
Urinalysis- Blood-SM Nitrite-NEG Protein-TR Glucose-NEG
Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
URINE RBC-11* WBC-144* Bacteri-FEW Yeast-NONE Epi-6 TransE-1
Pertinent discharge labs:
WBC-9.8 RBC-4.05* Hgb-12.4 Hct-36.9 MCV-91 MCH-30.6 MCHC-33.6
RDW-12.7 Plt ___
Glucose-100 UreaN-12 Creat-0.5 Na-147* K-3.6 Cl-110* HCO3-28
AnGap-13
Calcium-8.3* Phos-3.7 Mg-2.2
Microbiology:
___ Urine culture- pending with no growth to date
Imaging:
EKG on admission- rate: 77, NSR, U waves seen in V2 and V3
KUB- Extensive gaseous dilatation of the entire colon is re-
demonstrated, previously noted on the prior CT to be consistent
with colonic pseudo-obstruction. No free intraperitoneal air is
demonstrated. No dilated loops of small bowel are visualized.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Polyethylene Glycol 17 g PO BID
2. Metoprolol Tartrate 25 mg PO BID
Hold for SBP < 100, HR < 60
3. Mirtazapine 15 mg PO HS
4. Acetaminophen 650 mg PO Q6H:PRN pain
5. mupirocin *NF* 2 % Topical daily
6. Potassium Chloride 40 mEq PO DAILY
7. Sulfameth/Trimethoprim DS 1 TAB PO BID
Discharge Medications:
1. mupirocin *NF* 2 % Topical daily
2. Acetaminophen 650 mg PO Q6H:PRN pain
3. Metoprolol Tartrate 25 mg PO BID
4. Mirtazapine 15 mg PO HS
5. Potassium Chloride 40 mEq PO DAILY
6. Polyethylene Glycol 17 g PO BID
7. Benzonatate 100 mg PO TID:PRN cough
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
1. Colonic pseudo-obstruction
2. Hypernatremia
3. Hypokalemia
4. Dehydration
Secondary:
Advanced dementia
Discharge Condition:
Confused- all of the time
Not coherent.
Unable to ambulate independently
Followup Instructions:
___
Radiology Report
HISTORY: Increasing abdominal distention.
TECHNIQUE: Supine AP and left lateral decubitus views of the abdomen.
COMPARISON: ___.
FINDINGS:
Extensive gaseous dilatation of the entire colon is re- demonstrated,
previously noted on the prior CT to be consistent with colonic
pseudo-obstruction. No free intraperitoneal air is demonstrated. No dilated
loops of small bowel are visualized. The patient is status post left hip
hemiarthroplasty. There is diffuse demineralization of the osseous
structures. Multiple calcified phleboliths are noted within the pelvis. L2
burst fracture is again demonstrated.
IMPRESSION:
Diffuse dilatation of the entire colon, unchanged compared to the previous
exam from 1 day earlier, and previously characterized on CT to reflect colonic
pseudo-obstruction.
Gender: F
Race: WHITE - RUSSIAN
Arrive by AMBULANCE
Chief complaint: ABDOMINAL DISTENTION
Diagnosed with DEHYDRATION, HYPOSMOLALITY/HYPONATREMIA
temperature: 98.1
heartrate: 80.0
resprate: 16.0
o2sat: 94.0
sbp: 136.0
dbp: 74.0
level of pain: unable
level of acuity: 3.0 | ___ ___ lady with severe dementia and past history
of colonic pseudo-obstruction with rectal spincter stenosis
presenting with hypernatremia and hypokalemia.
# Hypernatremia: Attributed to lack of adequate hydration as
with IV fluid repletion sodium downtrended to normal range.
Patient unable to take in adequate fluids on own and will need
to continue fluid resuscitation with IV fluids at nursing
facility. We recommend ___ @ 75cc/hr with daily electrolyte
monitoring and adjustment of fluids as needed to maintain sodium
within normal limits, until more stabilized.
# Hypokalemia: As above, also attributed to poor oral intake, as
corrected with IV hydration and minimal oral repletion.
Recommend continuing IV fluids with daily electrolyte monitoring
until more consistently stable with oral powder repletion.
# Colonic pseudo-obstruction: Attributed to electrolyte
imbalance and urinary tract infection triggering poor bowel
peristalsis. Rectal tube placed with adequate decompression and
stool output. Recommend continuing rectal tube and repeating KUB
in 3 days. Abdomen soft and non-tender on discharge, consistent
with decompression. Would repeat KUB 24 hours after removal of
tube to ensure appropriate persistalsis and no further dilation.
# UTI: Diagnosed ___, with no growth to date on bactrim. Course
completed on day of discharge ___.
# Cough: Grand-daughter and nursing staff at nursing home
concerned for PNA, states patient has been coughing for the past
week. CXR ___ showed atelectasis likely related to poor
inspiratory effort. No leukocytosis or fever to suggest active
infection. Started Benzonatate 100mg TID yesterday to help with
cough.
# Hypertension: stable. Continued home metoprolol 25mg BID
# Dementia: Stable and unchanged |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Shellfish Derived / Enalapril
Attending: ___.
Chief Complaint:
Shortness of breath, cough
Major Surgical or Invasive Procedure:
Right ___ Catheterization via right internal jugular vein:
___
History of Present Illness:
Patient is a ___ with history of congestive ___ failure with
borderline ejection fraction (48%), coronary artery disease
(CABG
___ LIMA to LAD, SVGs to OM and RCA; LAD PCI ___
residual diagonal and OM disease, LCX PCI ___, CKD stage IV,
T2DM, and HTN who presents with shortness of breath and cough.
Patient says that he first experienced some diarrhea about 5days
ago (several family members had similar symptoms, including his
young grandchildren). He then noticed a productive cough
(yellow
sputum, no hemoptysis), subjective fevers, and worsening lower
extremity swelling over the past ___ (lower extremity
swelling especially over the past 1day). Patient also describes
~5lbs weight gain and exertional SOB/wheezing during this time.
No CP or palpitations. Patient was seen by his PCP last week in
this setting and was diagnosed with likely influenza (Tamiflu
was
not administered). Patient's wife called into ___ failure
clinic ___, concern for his flu like symptoms and lower
extremity swelling. Since patient's weight was going up
(172lbs->179lbs over the course of the past 1wk), his torsemide
was restarted @ 60mg qd (see below for recent dose changes).
Owing to the fact that his symptoms did not improve over the
next
2days, patient decided to present to the ___ ED for further
evaluation/treatment.
Of note, patient was admitted to ___ ___ (CHF
service) iso volume overload and ___ on CKD. Patient was
treated
for a ___ failure exacerbation with IV Lasix 80mg, precipitant
unclear (transitioned to torsemide 60mg qd on discharge). His
HTN was adjusted (hydralazine downtitrated to 75mg TID,
carvedilol was started at 25mg qd, losartan was started at 50mg
qd). He underwent a stress MIBI TTE on ___, which
revealed
no anginal symptoms or significant ST segment changes to
achieved
work-load (LVEF 48%, mild/fixed inferolateral wall defect, mild
LV global hypokinesis). Cr was elevated to 2.9 from baseline
(~2.5), likely cardiorenal.
Patient was last seen in ___ failure clinic ___, at
which point he appeared volume overloaded on exam. Torsemide
was
increased to 60-80mg BID. Patient was also started on a trial
of
imdur 30mg qd (previously had had issue with orthostasis).
Given
weight loss over the next week, torsemide was briefly held
___.
In the ED, initial VS were: 98.2 80 182/62 17 92% RA
Exam notable for: Wheezing diffusely. Productive type cough.
Generally appears unwell. Nontoxic. Bilateral, 3+ pitting edema
in the lower extremities. No abdominal tenderness.
EKG: NSR (82bpm), possible PAC vs. PVC, PR prolongation, widened
QRS, QTc ~550, RBBB, inferior Qwaves, TWIs in V1-2
Labs showed:
CBC 11.9>11.3/33.3<214 (83%PMNs)
BMP 142/5.2/101/___/3.0/153
Ca 8.8
Phos 4.4
Mg 2.2
INR 1.0
proBNP 7697
Trop .04
Lactate 1.1
UA: SG 1.015, pH 6.5, urobilinogen NEG, bili NEG, leuk NEG, bld
NEG, nitrite NEG, 300 protein, glucose NEG, ketone NEG, 2 RBCs,
1
WBC, few bacteria, no yeast, 3 hyaline casts
Flu A/B NEGATIVE
Imaging showed:
CXR ___
FINDINGS:
PA and lateral views of the chest provided. Midline sternotomy
wires are again seen. Pulmonary vascular congestion is noted.
Subtle reticulonodular opacities in the right upper lobe and
left
mid and lower lungs may represent multifocal pneumonia. No large
effusion or pneumothorax. Cardiomediastinal silhouette is
stable.
Bony structures are intact.
IMPRESSION:
Pulmonary vascular congestion and probable mild multifocal
pneumonia.
Consults: NONE
Patient received:
___ 23:20 IV CefePIME 2 g
___ 23:29 PO Acetaminophen 1000 mg
___ 00:16 IV Labetalol 5 mg
___ 00:37 PO Ibuprofen 600 mg
Transfer VS were: 100.7 85 180/83 18 95% 5LNC
On arrival to the floor, patient and his wife recount the
history
as above. Patient endorses some labored breathing and shortness
of breath. No CP or palpitations. No
lightheadedness/dizziness.
Ongoing subjective fevers/chills. No ongoing diarrhea, no
nausea/vomiting. No issues with urination, no dysuria or
urinary
frequency, no real change in urine color/smell. Patient has not
yet taken any of his medications today.
10-point ROS is otherwise NEGATIVE.
Past Medical History:
Chronic Kidney Disease
Colonic Adenoma
Coronary Artery Disease
Depression
Diabetes Mellitus, insulin dependent
Diabetic Retinopathy
Hyperparathyroidism
Hypertension
Social History:
___
Family History:
Mother - DM, CVA
Father - MI at ___
Daughter - ___ CA
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 99.6 177/72 68 20 91 2L
GENERAL: Uncomfortable appearing gentleman with wife at bedside,
noticeable labored breathing.
___: EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM.
NECK: JVP elevated to mid neck with head of bed at 45 degrees,
+AJR.
___: Distant ___ sounds, regular rate, largely regular
rhythm
though with intermittent premature beats, no appreciable
murmurs.
LUNGS: Diffuse inspiratory crackles and scattered wheezes
bilaterally, also rhoncorous upper airway sounds.
ABDOMEN: Normoaactive BS throughout. No abdominal distention or
tenderness to palpation. No palpable HSM.
EXTREMITIES: WWP. ___ pitting edema of the bilateral lower
extremities to the mid-shins.
PULSES: 2+ radial pulses bilaterally.
NEURO: A&Ox3, moving all 4 extremities with purpose.
SKIN: No excoriations or lesions, no rashes.
DISCHARGE PHYSICAL EXAM:
VS: ___ 0729 Temp: 97.6 PO BP: 154/68 L Lying HR: 73 RR: 20
O2 sat: 95% O2 delivery: 2L FSBG: 121
GENERAL: Obese older man sitting comfortably in a chair
Accompanied by wife.
___: No scleral icterus or injection. MMM.
NECK: No appreciable JVP
___: RRR, no appreciable murmurs.
LUNGS: Normal work of breathing. No objective orthopnea. End
expiratory wheezes bilaterally.
ABDOMEN: Soft, NDNT.
EXTREMITIES: WWP. trace edema to ankles
NEURO: A&Ox3, moving all 4 extremities with purpose.
SKIN: No excoriations, lesions, or rashes.
Pertinent Results:
Admission Labs:
---------------
___ 08:40PM BLOOD WBC-11.9* RBC-3.52* Hgb-11.3* Hct-33.3*
MCV-95 MCH-32.1* MCHC-33.9 RDW-11.9 RDWSD-41.2 Plt ___
___ 08:40PM BLOOD WBC-11.9* RBC-3.52* Hgb-11.3* Hct-33.3*
MCV-95 MCH-32.1* MCHC-33.9 RDW-11.9 RDWSD-41.2 Plt ___
___ 08:40PM BLOOD Neuts-83.1* Lymphs-7.0* Monos-9.0
Eos-0.5* Baso-0.1 Im ___ AbsNeut-9.87*# AbsLymp-0.83*
AbsMono-1.07* AbsEos-0.06 AbsBaso-0.01
___ 08:40PM BLOOD ___ PTT-31.5 ___
___ 08:40PM BLOOD Glucose-153* UreaN-52* Creat-3.0* Na-142
K-5.2* Cl-101 HCO3-23 AnGap-18
___ 08:40PM BLOOD proBNP-7697*
___ 08:40PM BLOOD cTropnT-0.04*
___ 08:40PM BLOOD Calcium-8.8 Phos-4.4 Mg-2.0
___ 10:29PM BLOOD Lactate-1.1
Trop .04 -> .05 -> .05
EKG: NSR (82bpm), possible PAC vs. PVC, PR prolongation, widened
QRS, QTc ~550, RBBB, inferior Q waves, TWIs in V1-2, stable from
prior.
UA bland
Microbiology:
-------------
S. PNEUMONIAE ANTIGENS URINE, DETECTED A
Legionella Urinary Antigen (Final ___: NEGATIVE FOR
LEGIONELLA SEROGROUP 1 ANTIGEN.
Flu A/B negative
MRSA SCREEN (Final ___: No MRSA isolated.
URINE CULTURE (Final ___: NO GROWTH.
Imaging:
--------
CXR ___
FINDINGS:
PA and lateral views of the chest provided. Midline sternotomy
wires are again seen. Pulmonary vascular congestion is noted.
Subtle reticulonodular opacities in the right upper lobe and
left mid and lower lungs may represent multifocal pneumonia. No
large effusion or pneumothorax. Cardiomediastinal silhouette is
stable. Bony structures are intact.
IMPRESSION: Pulmonary vascular congestion and probable mild
multifocal pneumonia.
Right ___ Cath ___
Impressions:
Normal bi-ventricular filling pressures.
Borderline pulmonary pressure.
Discharge Labs:
----------------
___ 06:50AM BLOOD WBC-8.8 RBC-2.74* Hgb-8.8* Hct-26.7*
MCV-97 MCH-32.1* MCHC-33.0 RDW-11.9 RDWSD-41.9 Plt ___
___ 06:50AM BLOOD ___
___ 06:50AM BLOOD Glucose-119* UreaN-63* Creat-3.1* Na-144
K-3.8 Cl-105 HCO3-25 AnGap-14
___ 06:50AM BLOOD Calcium-8.4 Phos-3.8 Mg-1.9
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
2. albuterol sulfate 90 mcg inhalation Q6H:PRN wheezing or
shortness of breath
3. Allopurinol ___ mg PO DAILY
4. amLODIPine 10 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
7. Carvedilol 25 mg PO BID
8. Docusate Sodium 100 mg PO DAILY
9. Ferrous Sulfate 325 mg PO DAILY
10. HydrALAZINE 75 mg PO TID
11. Ipratropium Bromide MDI 1 PUFF IH Q6H:PRN dyspnea
12. Levothyroxine Sodium 25 mcg PO DAILY
13. Omeprazole 40 mg PO DAILY
14. Senna 17.2 mg PO BID:PRN constipation
15. Vitamin D ___ UNIT PO DAILY
16. Ascorbic Acid ___ mg PO DAILY
17. Calcitriol 0.25 mcg PO 3 X'S/WEEK
18. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
19. Losartan Potassium 50 mg PO DAILY
20. Clotrimazole Cream 1 Appl TP BID
21. Torsemide 60 mg PO DAILY
22. Glargine 42 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
23. Isosorbide Mononitrate 30 mg PO DAILY
Discharge Medications:
1. Benzonatate 100 mg PO TID cough Duration: 7 Days
RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day
Disp #*30 Capsule Refills:*0
2. GuaiFENesin ___ mL PO Q6H:PRN cough
RX *guaifenesin 100 mg/5 mL ___ mL by mouth every six (6) hours
Refills:*0
3. Levofloxacin 500 mg PO Q48H Duration: 1 Dose
RX *levofloxacin [Levaquin] 500 mg 1 tablet(s) by mouth every
other day Disp #*1 Tablet Refills:*0
4. Ranitidine 75 mg PO DAILY
RX *ranitidine HCl 150 mg 1 capsule(s) by mouth once a day Disp
#*30 Capsule Refills:*0
5. HydrALAZINE 100 mg PO TID
RX *hydralazine 100 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
6. Glargine 35 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
RX *insulin glargine [Lantus] 100 unit/mL AS DIR 35 Units before
BKFT; Disp #*1 Vial Refills:*0
7. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
RX *isosorbide mononitrate 120 mg 1 tablet(s) by mouth once a
day Disp #*30 Tablet Refills:*0
8. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
9. albuterol sulfate 90 mcg inhalation Q6H:PRN wheezing or
shortness of breath
10. Allopurinol ___ mg PO DAILY
11. amLODIPine 10 mg PO DAILY
12. Ascorbic Acid ___ mg PO DAILY
13. Aspirin 81 mg PO DAILY
14. Atorvastatin 80 mg PO QPM
15. Calcitriol 0.25 mcg PO 3 X'S/WEEK
16. Carvedilol 25 mg PO BID
17. Clotrimazole Cream 1 Appl TP BID
18. Docusate Sodium 100 mg PO DAILY
19. Ferrous Sulfate 325 mg PO DAILY
20. Ipratropium Bromide MDI 1 PUFF IH Q6H:PRN dyspnea
21. Levothyroxine Sodium 25 mcg PO DAILY
22. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
23. Senna 17.2 mg PO BID:PRN constipation
24. Torsemide 60 mg PO DAILY
25. Vitamin D ___ UNIT PO DAILY
26. HELD- Losartan Potassium 50 mg PO DAILY This medication was
held. Do not restart Losartan Potassium until you meet with your
PCP
___:
Home
Discharge Diagnosis:
Primary Diagnosis:
------------------
Streptococcal Pneumonia
Acute on Chronic ___ Failure with Borderline Ejection Fraction
Acute on Chronic Renal Failure
Secondary Diagnosis:
Coronary Artery Disease s/p CABG and PCI
Diabetes mellitus, type 2, insulin dependent
Gastroesophageal reflux disease
Gout
Constipation
Hypothyroidism
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 cough, fever, hypoxia// PNA?>
COMPARISON: Prior exam from ___
FINDINGS:
PA and lateral views of the chest provided. Midline sternotomy wires are
again seen. Pulmonary vascular congestion is noted. Subtle reticulonodular
opacities in the right upper lobe and left mid and lower lungs may represent
multifocal pneumonia. No large effusion or pneumothorax. Cardiomediastinal
silhouette is stable. Bony structures are intact.
IMPRESSION:
Pulmonary vascular congestion and probable mild multifocal pneumonia.
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by WALK IN
Chief complaint: Cough, Dyspnea, Dyspnea, Weakness
Diagnosed with Pneumonia, unspecified organism
temperature: 98.2
heartrate: 80.0
resprate: 17.0
o2sat: 92.0
sbp: 182.0
dbp: 62.0
level of pain: 0
level of acuity: 2.0 | Summary:
--------
Mr. ___ is a ___ year old man with HFbEF (48%), CAD s/p
CABG/PCI, CKD IV, IDDM, who was admitted shortness of breath and
cough, and was found to have streptococcal pneumonia and ___
failure exacerbation. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins / cefepime
Attending: ___.
Chief Complaint:
severe malnutrition, failure to thrive
Major Surgical or Invasive Procedure:
s/p Whipple on prior admission
NJ tube placed on this admission
History of Present Illness:
Mr. ___ is a ___ year old male with history of multiple myeloma
s/p SCT and DVT/PE on lovenox s/p Whipple on ___ for
suspected ampullary malignancy complicated by a low output
pancreatic duct leak and GDA pseudoaneurysm bleed s/p GDA coil
embolization who presents with complains of nausea and vomiting.
Mr. ___ was last seen in clinic on ___ after he underwent
a
CT scan which demonstrated improvement in the size of his
hematoma and no change in coil position. He reported continued
poor appetite at that time, though he was starting to take in
more calories. He had no nausea or vomiting at that time.
However, on ___, he had severe nausea and upper
abdominal
pain which improved after a large bilious emesis. He had another
episode of vomiting morning of ___ in the setting
of nausea. Since then, his nausea has improved and his abdominal
pain has
resolved. He has been passing flatus and had a bowel movement
yesterday.
Past Medical History:
PMH/PSH:
-Multiple myeloma complicated by multiple lumbar spine
compression fractures
-Monoclonal gammopathy of unknown significance
-Pulmonary emboli x2 in ___ and ___, both felt to be provoked
by long plane rides, with hypercoagulability work-up reportedly
negative; per medications list in OMR goal INR 1.5-2.5
-Right knee meniscal tear status post arthroscopic surgery
-Melanoma/squamous cell cancer of right thigh
-Right femur fracture status post ORIF
-Polio as a young child
-History of malaria
Social History:
___
Family History:
Significant for mother with lung cancer, several aunts with
breast cancer, sister with uterine cancer, another sister who is
healthy, and 2 brothers who are alive and well. No known family
history of clotting.
Physical Exam:
Vitals: Temp 98.9 HR 58 BP 98/66 RR 18 98%RA
Gen: NAD
HEENT: NCAT, EOMI, dobbhoff tube in place secured w/tape
Pulm: Easy work of breathing, no respiratory distress
CV: RRR
Abd: soft, nontender, nondistended, no masses
Ext: WWP
Pertinent Results:
___ 06:22AM LACTATE-1.3 K+-4.2
___ 06:10AM GLUCOSE-119* UREA N-22* CREAT-1.1 SODIUM-140
POTASSIUM-5.6* CHLORIDE-98 TOTAL CO2-25 ANION GAP-17*
___ 06:10AM WBC-6.8 RBC-3.19* HGB-10.4* HCT-31.8*
MCV-100* MCH-32.6* MCHC-32.7 RDW-14.7 RDWSD-53.1*
___ 06:10AM NEUTS-85.0* LYMPHS-5.4* MONOS-6.4 EOS-2.0
BASOS-0.3 IM ___ AbsNeut-5.80# AbsLymp-0.37* AbsMono-0.44
AbsEos-0.14 AbsBaso-0.02
___ 05:52AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
___ 05:52AM URINE RBC-1 WBC-2 BACTERIA-NONE YEAST-NONE
EPI-0
Medications on Admission:
Acetaminophen ___ mg PO Q8H:PRN Pain - Mild
Enoxaparin Sodium 80 mg SC Q12H
Ferrous Sulfate 325 mg PO DAILY
Acyclovir 400 mg PO Q8H
Multivitamins W/minerals 1 TAB PO DAILY
OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Mild
Pantoprazole 40 mg PO Q24H
Tamsulosin 0.4 mg PO QHS
Discharge Medications:
1. Jevity 1.5 Cal (lactose-reduced food with fibr) 0.06
gram-1.5 kcal/mL oral DAILY
RX *lactose-reduced food with fibr [Jevity 1.5 Cal] 0.06
gram-1.5 kcal/mL 1560 mls NJT daily Refills:*5
2. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild
3. Acyclovir 400 mg PO Q8H
4. Creon 12 6 CAP PO TID W/MEALS
5. Enoxaparin Sodium 80 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
6. Ferrous Sulfate 325 mg PO DAILY
7. Multivitamins W/minerals 1 TAB PO DAILY
8. Pantoprazole 40 mg PO Q12H
9. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. s/p resection for large ampullary adenoma, postoperative GDA
pseudoaneurysm (bleeding) managed by ___ coil embolization.
2. Severe malnutrition
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: ___ year old man s/p whipple surgery with recent history of RLL
pneumonia// known RLL pneumonia, compare to prior
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
The lungs are hyperinflated, suggesting chronic obstructive pulmonary disease.
The previously seen right lower lobe consolidation has essentially resolved in
the interval with mild residua/scarring remaining. No pleural effusion or
pneumothorax is seen. The aorta is tortuous. The cardiac silhouette size is
top-normal. No pneumothorax is seen.
IMPRESSION:
Significant interval decrease in previously seen right lower lobe
consolidation with mild residual/scarring remaining.
Radiology Report
INDICATION: ___ year old man s/p whipple surgery and JP drains in place
presenting with abdominal pain, nausea, vomiting// concern for SBO
TECHNIQUE: Frontal abdominal radiographs were obtained.
COMPARISON: Scout radiograph from CT from ___
FINDINGS:
There are mildly dilated air-filled loops of small bowel in the left abdomen
with a few air-fluid levels seen. Air is seen in the region of the rectum.
Findings may represent early/partial small bowel obstruction versus regional
ileus. There is no evidence of free air. 2 catheters extend into the mid
abdomen. Partially imaged hardware in the proximal right femur. Degenerative
changes along the spine at bilateral hips.
IMPRESSION:
Mildly dilated air-filled loops of small bowel in the left abdomen with a few
air-fluid levels seen. Some air is seen in the region of the rectum.
However, findings raise concern for early/partial small bowel obstruction
versus regional ileus.
Radiology Report
INDICATION: ___ hx of MM DVT/PE on lovenox s/p Whipple on ___ for
ampullary malignancy c/b undrainable post panc collection GDA stump bleeding
now w/ gastroparesis and/or anastamotic leak// Please evaluate whether Dobhoff
is in pancreatic or enetro limb. Thank you
TECHNIQUE: Upright and supine radiographs of the upper abdomen are submitted.
COMPARISON: Abdominal radiographs from earlier the same date at 08:53
FINDINGS:
2 catheters are again noted with tip overlying the mid abdomen. Again
vascular coils are noted overlying the right hemi abdomen adjacent to the
midline. There has been interval placement of an enteric tube. Its tip is
seen overlying the mid left abdomen. Several dilated small bowel loops are
noted in the mid upper abdomen measuring up to 4.1 cm in diameter. No
evidence of free air.
IMPRESSION:
Interval placement of an enteric tube with tip overlying the mid left abdomen.
Mildly dilated small bowel loops which may represent early/partial small-bowel
obstruction versus ileus.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Vomiting
Diagnosed with Unspecified intestinal obstruction
temperature: 97.9
heartrate: 88.0
resprate: 16.0
o2sat: 99.0
sbp: 118.0
dbp: 92.0
level of pain: 4
level of acuity: 3.0 | The patient was admitted to the General Surgical Service for
evaluation and treatment.
Neuro: The patient was not in pain throught his hospital course
and received Acetaminophen as needed for pain control.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation was encouraged throughout
hospitalization.
GI/GU/FEN: On ___ NJ tube was placed by ERCP fellow and
patient was made NPO overnight till confirmation of position was
obtained. The patient was put on clears and Diet was advanced
as tolerated on HD1 when appropriate ___, which was well
tolerated. Patient's intake and output were closely monitored,
and IV fluid was stopped on HD1. Electrolytes were routinely
followed, and repleted when necessary.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required. The patient received
Enoxaparin Sodium 80 mg SC Q12H during this stay for therapeutic
management of known DVT/PE.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet as well as tolerating Jevity 1.5 tube feeds at 65cc/hr. He
was ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Levofloxacin / Cephalosporins / betalactams /
Carbapenems / Quinolones / Penicillin V / cefepime
Attending: ___.
Chief Complaint:
CHF exacerbation
Major Surgical or Invasive Procedure:
PICC line placement.
History of Present Illness:
___ year old man with history of CHF presenting with poductive
cough and fevers, worsening over past few days. He has been
febrile to 100.4. States that he has been sob the past couple of
months, worsening over the past few days. SOB improved with
sitting up. No other associated symptoms.
In the ED, ___ received vanc, azitromycin, and gent. He also
received Lasix 40mg IV, which did not yield much uop. Also
started on a nitro drip. ___ mental status has
decompensated whil ein the ER. ___ has waxing and waining
delirium, of which he is aware. States he is clastrophobic on
Bipap and can only tolerate it for short periods of time. desats
to ___ on RA, 95% on 4Lnc
In the ED, initial vitals: 100.4 ___ 22 98% 4L NC
Exam/labs were notable for:
wbc 13.1 w 83.2 pmns, hgb 6.3
INR 5.9
bnp ___
133 96 15
------------
4.3 27 0.9
Imaging showed: Worsened and mild to moderate pulmonary
edema. Persistent retrocardiac and left lower lobe
opacity, which could reflect a combination of fluid and
atelectasis.
___ was given: gent, azithro, nitro, lasix, tylenol,
duoneb, oxy, vanc
On transfer, vitals were: 97.7 103 120/68 23 100% NC
On arrival to the MICU, afebrile 93% 1L NC
Past Medical History:
- CAD, followed by Dr. ___.
- AFib, on Coumadin.
- Peripheral vascular disease, status post a left BKA at ___.
- Status post fall in ___, with a resultant shoulder and tib
fracture.
- COPD, not on home O2.
- History of hip fracture, status post repair by Dr. ___.
- History of peptic ulcer disease in the remote past.
- History of pernicious anemia.
- History of alcoholism with an isolated episode of DTs.
- History of CVA in the ICU at ___ (believed secondary to
atrial fibrillation) with resultant dysconjugate gaze.
Social History:
___
Family History:
NC
Physical Exam:
ADMISSION:
GENERAL: diaphoretic, labored breathing
HEENT: Sclera anicteric, MMM, oropharynx clear . L eye more
closed than right
NECK: supple, JVP not elevated,
LUNGS: crackles at ___ lower bases
CV: irregularly irregular
ABD: soft, non-tender, non-distended, no rebound tenderness or
guarding
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. L BKA with pain, chronic. Phantom limb.
NEURO: Alert and Oriented x3
DISCHARGE
Physical Exam:
Vitals- 97.7 - 135/82 - 89 - 18 - 100 on 2L, 91-93% on RA
weight 76.2kg <-- 76.4 kg
General- Alert, dishevelled, oriented to date and ___, able to
speak in 10 word sentences
HEENT- Sclerae anicteric, MM dry
Neck- supple
Lungs- improved air movement, no wheeze, no crackles
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- no foley
Ext- no edema, BKA left leg
Neuro- slight droop of left eyelid, MAE
Pertinent Results:
ADMISSION LABS
___ 12:40AM BLOOD WBC-13.1*# RBC-1.89* Hgb-6.3* Hct-21.8*
MCV-115*# MCH-33.3* MCHC-29.0* RDW-17.7* Plt ___
___ 01:30AM BLOOD WBC-9.8 RBC-2.25* Hgb-7.7* Hct-25.0*
MCV-111* MCH-34.1* MCHC-30.7* RDW-18.9* Plt ___
___ 12:40AM BLOOD ___ PTT-48.5* ___
___ 03:55PM BLOOD ___
___ 12:40AM BLOOD Glucose-106* UreaN-15 Creat-0.9 Na-133
K-4.3 Cl-96 HCO3-27 AnGap-14
___ 03:55PM BLOOD Glucose-117* UreaN-32* Creat-1.0 Na-134
K-3.9 Cl-91* HCO3-33* AnGap-14
___ 10:17AM BLOOD CK-MB-4 cTropnT-<0.01
___ 06:15PM BLOOD CK-MB-4 cTropnT-<0.01
___ 10:17AM BLOOD ALT-17 AST-22 LD(LDH)-230 AlkPhos-238*
TotBili-1.2
___ 10:17AM BLOOD Albumin-3.9 Calcium-9.1 Phos-3.9 Mg-1.8
DISCHARGE LABS
___ 05:10AM BLOOD WBC-8.3 RBC-2.26* Hgb-7.6* Hct-25.8*
MCV-114* MCH-33.5* MCHC-29.4* RDW-18.3* Plt ___
___ 05:10AM BLOOD ___
___ 05:10AM BLOOD Glucose-96 UreaN-34* Creat-0.9 Na-136
K-4.2 Cl-96 HCO3-35* AnGap-9
___ 12:40AM BLOOD ___
___ 10:17AM BLOOD CK-MB-4 cTropnT-<0.01
___ 06:15PM BLOOD CK-MB-4 cTropnT-<0.01
___ 10:17AM BLOOD Hapto-268*
___ 10:53AM BLOOD Vanco-22.7*
IMAGING/STUDIES
=================
___ ECHOCARDIOGRAPHY REPORT ___
___. ___ MRN: ___ Portable TTE
(Complete) Done ___ at 4:40:17 ___ FINAL
Referring Physician ___
___, Critical Care & ___
___/KS-___ Status: Inpatient DOB: ___
Age (years): ___ M Hgt (in): 73
BP (mm Hg): 145/85 Wgt (lb): 1858
HR (bpm): 102 BSA (m2): 5.55 m2
Indication: Shortness of breath. Pulmonary edema w/ fevers
Congestive heart failure. Left ventricular function.
ICD-9 Codes: 424.90, 428.0, 785.0, 786.05, 424.0, 424.2
___ Information
Date/Time: ___ at 16:40 ___ MD: ___.
___, MD
___ Type: Portable TTE (Complete) Sonographer: ___
___, ___
Doppler: Full Doppler and color Doppler ___ Location: ___
Contrast: None Tech Quality: Suboptimal
Tape #: ___-0:00 Machine: Q-2 Vivid
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.6 cm <= 4.0 cm
Right Atrium - Four Chamber Length: *5.9 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.1 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: >= 55% >= 55%
Right Ventricle - Diastolic Diameter: 4.0 cm <= 4.2 cm
Aorta - Sinus Level: 2.9 cm <= 3.6 cm
Aortic Valve - Peak Velocity: 1.8 m/sec <= 2.0 m/sec
Aortic Valve - LVOT diam: 2.0 cm
Mitral Valve - E Wave: 0.9 m/sec
Mitral Valve - E Wave deceleration time: *121 ms 140-250 ms
TR Gradient (+ RA = PASP): *40 to 50 mm Hg <= 25 mm Hg
Findings
This study was compared to the prior study of ___.
LEFT ATRIUM: Mild ___.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
global systolic function (LVEF>55%). Suboptimal technical
quality, a focal LV wall motion abnormality cannot be fully
excluded.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level.
AORTIC VALVE: Normal aortic valve leaflets (?#). No masses or
vegetations on aortic valve, but cannot be fully excluded due to
suboptimal image quality. No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No
masses or vegetations on mitral valve, but cannot be fully
excluded due to suboptimal image quality. Moderate mitral
annular calcification. Moderate (2+) MR.
___ VALVE: Normal tricuspid valve leaflets. Mild to
moderate [___] TR. Moderate PA systolic hypertension.
PERICARDIUM: There is an anterior space which most likely
represents a fat pad, though a loculated anterior pericardial
effusion cannot be excluded.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Suboptimal image quality as the ___ was difficult to
position. Suboptimal image quality - ___ unable to
cooperate. Resting tachycardia (HR>100bpm).
Conclusions
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (?#) appear structurally
normal with good leaflet excursion. No masses or vegetations are
seen on the aortic valve, but cannot be fully excluded due to
suboptimal image quality. There is no aortic valve stenosis. 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. There is moderate pulmonary artery
systolic hypertension. There is an anterior space which most
likely represents a prominent fat pad.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved global biventricular
systolic function. Moderate mitral regurgitation with grossly
normal valve morphology. Moderate tricuspid regurgitation with
grossly normal valve morphology. Pulmonary artery hypertension.
Compared with the prior study (images reviewed) of ___,
the estimated PA systolic pressure is now much higher. The
valvular regurgitation is similar (given the suboptimal image
quality of both studies).
EKG IN ED ___
Atrial fibrillation with rapid ventricular response. Delayed
precordial R wave progression. No major change from the previous
tracing.
Rate PR QRS QT/QTc P QRS T
130 162 96 316/438 75 0 68
___ cxr FINDINGS:
The heart is enlarged. There is persistent retrocardiac opacity
and left lower lobe opacification, which could reflect a
combination of pleural fluid and atelectasis. There is also mild
pulmonary edema which is worsened since prior exam. There is a
vague nodularity lateral to the left hila for which repeat
examination is recommended once edema clears. No pneumothorax
or focal consolidation identified.
IMPRESSION:
1. Mild pulmonary edema. Persistent retrocardiac and recurrent
left lower lobe opacity, which could reflect a combination of
fluid and atelectasis.
2. Vague nodularity lateral to the left hila for which repeat
examination is recommended once edema clears.
CXR ___
IMPRESSION: In comparison with the study of ___, there is
again substantial enlargement of the cardiac silhouette with
pulmonary edema. Retrocardiac opacification is consistent with
volume loss in the left lower lobe and probable fusion.
___ CXR IMPRESSION:
1. New right-sided PICC line with distal tip projecting over
low SVC.
2. Interval resolution of pulmonary edema.
3. Improved aeration of left lower lobe with residual left
basilar
atelectasis. Recommend repeat PA and lateral chest x-ray in 4
weeks time to confirm resolution.
NOTIFICATION: The above findings regarding positioning of
right-sided PICC line were discussed over the phone by Dr.
___ with IV nurse ___ on ___ at 09:35, at the time
of review.
MICROBIOLOGY
___ SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL
___ URINE URINE CULTURE-FINAL
___ BLOOD CULTURE Blood Culture, Routine-PENDING
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB
2. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO Q4H:PRN
dyspepsia
3. Ascorbic Acid ___ mg PO BID
4. Atorvastatin 10 mg PO DAILY
5. Cyanocobalamin 100 mcg PO DAILY
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
7. FoLIC Acid 1 mg PO DAILY
8. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB
9. Lidocaine 5% Patch 1 PTCH TD QAM
10. Metoprolol Tartrate 37.5 mg PO TID
11. Multivitamins 1 TAB PO DAILY
12. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
13. Paroxetine 40 mg PO DAILY
14. Tamsulosin 0.4 mg PO HS
15. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB
16. Warfarin 6 mg PO DAILY16
17. Vancomycin Oral Liquid ___ mg PO Q6H
18. Bisacodyl 10 mg PR HS:PRN constipation
19. Cholestyramine 4 gm PO DAILY
20. Fleet Enema 1 Enema PR ONCE:PRN constipation
21. Florastor (saccharomyces boulardii) 250 mg oral BID
22. lactobacillus acidophilus 1 billion cell oral daily
23. Magnesium Citrate 300 mL PO DAILY:PRN constipation
24. nystatin 100,000 unit/gram topical BID
25. Omeprazole 40 mg PO BID
26. Sodium Chloride 1 gm PO DAILY
27. Vitamin D ___ UNIT PO DAILY
28. Lorazepam 0.5 mg IV Q8H:PRN anxiety
29. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN shortness of
breath
30. Acetaminophen 650 mg PO Q6H:PRN pain, fever
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB
2. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB
3. Atorvastatin 10 mg PO DAILY
4. Bisacodyl 10 mg PR HS:PRN constipation
5. Cholestyramine 4 gm PO DAILY
6. Cyanocobalamin 100 mcg PO DAILY
7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
8. FoLIC Acid 1 mg PO DAILY
9. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
10. Paroxetine 40 mg PO DAILY
11. Acetaminophen ___ mg PO Q6H:PRN Pain, fever
12. Aztreonam 1000 mg IV Q8H
Ends ___
13. Vancomycin 750 mg IV Q 12H
Ends ___
14. Tiotropium Bromide 1 CAP IH DAILY
15. Furosemide 40 mg PO DAILY
16. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO Q4H:PRN
dyspepsia
17. Ascorbic Acid ___ mg PO BID
18. Florastor (saccharomyces boulardii) 250 mg oral BID
19. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB
20. lactobacillus acidophilus 1 billion cell oral daily
21. Lidocaine 5% Patch 1 PTCH TD QAM
22. Multivitamins 1 TAB PO DAILY
23. Tamsulosin 0.4 mg PO HS
24. Omeprazole 40 mg PO BID
25. Sodium Chloride 1 gm PO DAILY
26. Vitamin D ___ UNIT PO DAILY
27. Metoprolol Succinate XL 100 mg PO DAILY
hold for SBP<90
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Healthcare associated pneumonia
Acute diastolic CHF exacerbation
COPD exacerbation, mild
Pulmonary edema
Coagulopathy
Atrial fibrillation with RVR
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 RADIOGRAPH
INDICATION: Dyspnea, CHF // Eval for volume status.
TECHNIQUE: Portable AP chest radiographs.
COMPARISON: Prior chest radiograph from ___ and chest CT from ___.
FINDINGS:
The heart is enlarged. There is persistent retrocardiac opacity and left
lower lobe opacification, which could reflect a combination of pleural fluid
and atelectasis. There is also mild pulmonary edema which is worsened since
prior exam. There is a vague nodularity lateral to the left hila for which
repeat examination is recommended once edema clears. No pneumothorax or focal
consolidation identified.
IMPRESSION:
1. Mild pulmonary edema. Persistent retrocardiac and recurrent left lower lobe
opacity, which could reflect a combination of fluid and atelectasis.
2. Vague nodularity lateral to the left hila for which repeat examination is
recommended once edema clears.
NOTIFICATION: Final report discussed with Dr. ___ by ___ via
telephone on ___ at 9:05 AM.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with CHF presenting with SOB in the setting of
cough and fevers // ?interval change, ?pna/pulm edema ?interval change,
?pna/pulm edema
IMPRESSION:
In comparison with the study of ___, there is again substantial
enlargement of the cardiac silhouette with pulmonary edema. Retrocardiac
opacification is consistent with volume loss in the left lower lobe and
probable fusion.
Radiology Report
EXAMINATION: Portable AP chest x-ray.
INDICATION: ___ year old man with 48cm right PICC. ___ // 48cm right
PICC. ___ Contact name: ___: ___
TECHNIQUE: AP projection.
COMPARISON: Portable AP chest x-ray obtained ___.
FINDINGS:
There is a new right-sided PICC line whose distal tip projects over the low
SVC.
Allowing for changes due to differences in positioning, there is stable
enlargement of the cardiac silhouette, and the mediastinal contours are
unchanged.
There has been interval resolution of pulmonary edema. There is improved
aeration of the left lower lobe as evidenced by improved visualization of left
hemidiaphragm, however, there does appear to be some residual opacification
which may reflect left lower lobe atelectasis. However, given persistence of
left lower lobe opacity on multiple prior chest x-rays, it is recommended to
obtain a repeat chest x-ray in 4 weeks' time.
There are no pneumothoraces or effusions seen.
IMPRESSION:
1. New right-sided PICC line with distal tip projecting over low SVC.
2. Interval resolution of pulmonary edema.
3. Improved aeration of left lower lobe with residual left basilar
atelectasis. Recommend repeat PA and lateral chest x-ray in 4 weeks time to
confirm resolution.
NOTIFICATION: The above findings regarding positioning of right-sided PICC
line were discussed over the phone by Dr. ___ with IV nurse ___ on ___ at 09:35, at the time of review.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC
temperature: 100.4
heartrate: 125.0
resprate: 22.0
o2sat: 98.0
sbp: 150.0
dbp: 100.0
level of pain: 0
level of acuity: 2.0 | BRIEF HOSPITAL COURSE
=====================
___ year old chronically ill gentleman with history of systolic
and diastolic CHF presenting with progressive SOB in the setting
of cough and fevers, admitted to MICU and treated with
vanc/azithro/aztreonam for HCAP and steroid taper for COPD
exacerbation, as well as diuresis for diastolic CHF exacerbation
(in setting of hypertension and a fib with RVR in ED). Plan for
8 total days of IV antibiotics (ending ___ with vancomycin
and aztreonam given multiple drug allergies. Also completed
short prednisone taper for mild COPD exacerbation given wheeze.
ACTIVE MEDICAL ISSUES
=====================
# Hypoxia, dyspnea ___ pneumonia and acute on chronic diastolic
CHF exacerbation: He is comfortable on 2L NC and was 90% on RA
yesterday morning. Likely primarily due to healthcare associated
pneumonia and diastolic CHF exacerbation/flash pulmonary edema
in the setting of hypertension in the ED. Was also treated with
short burst of prednisone for COPD exacerbation giving wheezing
in MICU. He finished a course of steroids for copd exacerbation.
Peak flow is at baseline of 300.
- We discharged on a new dose of 40mg PO furosemide with goal to
keep even, please titrate at rehab based on weights and
oxygenation. Consider stopping if euvolemic as outpatient (has
intermittently been on furosemide in the past).
- continue vanc/aztreonam for HCAP given allergies x 8 days
total, ending ___.
- REPEAT CHEST IMAGING: CXR read noted improved aeration of left
lower lobe with residual left basilar atelectasis. Recommend
repeat PA and lateral chest x-ray in 4 weeks time to confirm
resolution. Previous CXR also noted vague nodularity lateral to
the left hila, recommend repeat for resolution.
- PICC in place.
# Toxic encephalopathy: Initially waxing and waning in the ED.
A+Ox3 in the unit. Does not recall events in the ED. Pleasant
and back to baseline throughout admission, though intermittently
was cantankerous, ___ has a health sense of humor.
# Coagulopathy: Likely ___ azithromcyin/warfarin interaction.
Hold dose day of discharge, recheck INR ___. See below.
# Atrial fibrillation on warfarin: Previously on 2mg daily
warfarin, held initially and restarted, but supratherapeutic on
discharge. Likely secondary to azithromycin. - Plan to HOLD
warfarin on ___ and re-check INR on ___ with plan to
restart if INR <3.
CHRONIC ISSUES
==============
# CAD/PAD: Continued home atorvastatin and metoprolol.
# Chronic anemia: Stable, chronic. MCV elevated. Treated with
folate and vitamin B12. Tbili was normal.
# Recent history of c. diff. By verbal report from MICU pt
finished c diff treatment 2 weeks ago and was initially placed
on PO vanc for prophylaxis. We did not continue as no diarrhea
or loose stools now.
TRANSITIONAL ISSUES
====================
- Code status: Full code.
- Recheck INR and titrate warfarin dosing as indicated
- ___, neighbor, ___. ___, sister:
___.
- Studies pending on discharge: Blood culture x 1 ___.
- REPEAT CHEST IMAGING: CXR read noted improved aeration of left
lower lobe with residual left basilar atelectasis. Recommend
repeat PA and lateral chest x-ray in 4 weeks time to confirm
resolution. Previous CXR also noted vague nodularity lateral to
the left hila, recommend repeat for resolution.
- At rehab: ___ has severe heart disease and pulmonary
disease. Please check oxygenation if appears to be in
respiratory distress. Oxygenation on discharge was adequate at
91-93% on room air.
- Consider stopping furosemide if euvolemic as outpatient (has
intermittently been on furosemide in the past). |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
vancomycin / Cephalosporins / Rocephin
Attending: ___.
Chief Complaint:
Chest pain, Dyspnea, Fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ M currently incarcerated w/ ESRD on HD due
to polycystic kidney disease on HD, CHF w/ EF 55%, and hx DVT
s/p IVC filter on warfarin who presents with fever, dyspnea,
chest pain and diarrhea.
Patient has intermittent chest pain that is nonexertional.
Sometimes worse with deep breathing and sometimes worse with
sitting up after lying flat. Patient also endorses 1 day of
diarrhea without abodminal pain, no recent abx.
Per ___ of Prisons documentation, on ___ patient went to
ED at ___ w/ CP and ruled out for MI. CPK
and D-dimer were not elevated. At HD, had low grade temp. No
cough, but reported rhinorrhea and abdominal pain. Blood cx sent
and given 100mg gentamicin followed by referral to ___ ED.
___ ED course
- pain ___
- initial vitals: 102.2 HR 70 91/54 14 100% RA
- WBC 5, no bands
- Bedside US: no pericardial effusion
- CTA Chest: no PE, mild pulmonary edema on preliminary report
- Linezolid
- Meropenem
- Renal c/s
- transfer vitals: 98.6 HR 85 103/65 18 97% NC
ROS: Full 10 pt review of systems negative except for above. Of
note, no vomiting or cough.
Past Medical History:
- CKD stage V ___ PCKD on hemodialysis since age ___.
- Complex vascular access with numerous failed BUE/Left femoral
AVF/AVG, now with tunneled right femoral groin HD line.
- Recurrent VTE s/p IVC filter
- IVC thrombosis with Budd-Chiari w/ abnormal right lobe and
left lobe hypertrophy, splenomegaly and small volume ascites.
- Hypertension
- Asthma
- Cholelithiasis
- Peptic ulcer disease
- Peripheral neuropathy
- Pneumothorax and tracheostomty after motorcycle accident ___
- Cadaveric renal transplant in ___ - removed 3 weeks later for
concern for malignancy.
- Left thigh exploration attempted revision c/b popliteal
thromboembolism s/p thrombolysis, angiojet and stenting (___)
- Evacuation left groin hematoma w/removal of segment of AV
graft
(___)
- Excision of infected left thigh AVG (___).
- Aortic valve thrombosis s/p sternotomy and thrombectomy
- Right arm fracture s/p ORIF with hardware
Social History:
___
Family History:
Significant for polycystic kidney disease in the family.
Apparently, his grandfather died while on dialysis. His mother
is an end-stage renal disease patient and is on dialysis
currently. The patient has a son with polycystic kidney
disease.
Physical Exam:
ON ADMISSION:
VS: 98.0 95/56 HR 76 sat 99% on 2L (89% on RA)
Gen: NAD
HEENT: bilateral medial ptyregoid
CV: normal rate, regular, no murmur; midline chest scar
Pulm: bibasilar crackles, nonlabored
Abd: soft, NT
GU: no Foley
Ext: no edema, R fem tunneled catheter looks clean
Skin: no lesions noted
Neuro: A&O, logical
Psych: appropriate affect
On Discharge:
Vitals: Tc 97.9, BP: 162/112, P: 60, R: 20, O2: 97% RA.
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, abnormal shape of ___ bilaterally,
EOMI, MMM, oropharynx clear.
Neck: supple
Lungs: clear to auscultation bilaterally, no wheezes, rales or
rhonchi
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops.
Abdomen: normoactive bowel sounds, soft, nontender,
non-distended, no rebound tenderness or guarding
Ext: Warm, well perfused, right tunnel catheter without erythema
Neuro: AOx3, no gross motor or sensory deficits.
Pertinent Results:
ADMISSION LABS:
___ 02:48PM BLOOD WBC-5.7# RBC-4.52* Hgb-13.1* Hct-41.6
MCV-92 MCH-28.9 MCHC-31.4 RDW-14.9 Plt ___
___ 02:48PM BLOOD Neuts-60.9 ___ Monos-15.7*
Eos-3.4 Baso-0.5
___ 10:27PM BLOOD ___
___ 02:48PM BLOOD Glucose-109* UreaN-19 Creat-8.1*# Na-138
K-3.8 Cl-93* HCO3-37* AnGap-12
___ 02:48PM BLOOD ALT-21 AST-24 CK(CPK)-43* AlkPhos-63
TotBili-2.5*
___ 06:20AM BLOOD ALT-17 AST-17 AlkPhos-60 TotBili-1.2
___ 02:48PM BLOOD cTropnT-0.12*
___ 04:40AM BLOOD CK-MB-2 cTropnT-0.09*
___ 02:48PM BLOOD Albumin-4.7
___ 04:40AM BLOOD Calcium-8.9 Phos-3.7# Mg-2.1
___ 03:01PM BLOOD Lactate-1.3
.
MICRO:
___ 4:00 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
GRAM POSITIVE COCCUS(COCCI). IN PAIRS AND CHAINS.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Reported to and read back by ___ ___ 9:40AM.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
___ 6:17 am BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Preliminary):
GRAM POSITIVE COCCUS(COCCI). IN PAIRS AND CHAINS.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
___
Blood Culture, Routine (Preliminary):
ENTEROCOCCUS FAECALIS.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___
FROM ___.
GRAM POSITIVE COCCUS(COCCI). IN CLUSTERS.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI.
IN CHAINS.
___: Daily cultures still pending, but remain negative
DISCHARGE LABS:
___ 06:50AM BLOOD WBC-4.5 RBC-3.67* Hgb-10.5* Hct-34.7*
MCV-95 MCH-28.7 MCHC-30.3* RDW-14.9 Plt ___
___ 06:50AM BLOOD Neuts-59.3 ___ Monos-5.2 Eos-8.9*
Baso-0.5
___ 06:50AM BLOOD ___ PTT-46.2* ___
___ 06:50AM BLOOD Glucose-79 UreaN-45* Creat-12.1*# Na-137
K-5.2* Cl-95* HCO3-26 AnGap-21*
___ 06:50AM BLOOD Calcium-10.6* Phos-5.2* Mg-2.4
IMAGING:
.
- CTA CHEST ___: IMPRESSION:
1. No central pulmonary embolism or acute aortic syndrome.
2. Mild diffuse hazy ground-glass opacities raise concern for
mild pulmonary
edema.
.
- ECHO (TTE) ___: The left atrium is mildly dilated. Left
ventricular wall thickness, cavity size, and global systolic
function are normal (LVEF = 70%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. The left ventricular inflow pattern suggests
impaired relaxation. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: no vegetations seen.
.
- RUQ U/S ___: IMPRESSION:
1. Unchanged mild hepatosplenomegaly.
2. Cholelithiasis. No definite evidence of cholecystitis.
3. Cortical nephrocalcinosis, limiting evaluation of the
kidneys. No
evidence of polycystic kidney disease.
TEE ___:
The left atrium is mildly dilated. No spontaneous echo contrast
or thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. Overall left ventricular systolic function is normal
(LVEF>55%). There are simple atheroma in the aortic arch and the
descending thoracic aorta. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. No masses or
vegetations are seen on the aortic valve. Trace aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. No mass or vegetation
is seen on the mitral valve. The tricuspid valve appears
structurally normal with mild-moderate tricuspid regurgitation.
No mass or vegetation is seen on the tricuspid valve.
IMPRESSION: Mild to moderate tricuspid regurgitation with normal
valve morphology. No discrete vegetation or abscess seen. Normal
global left ventricular systolic function.
Medications on Admission:
1. Carvedilol 12.5 mg PO BID
2. Clopidogrel 75 mg PO DAILY
3. Lisinopril 40 mg PO DAILY
4. Warfarin 3.75 mg PO DAILY16
5. Ursodiol 300 mg PO BID
6. Calcium Carbonate 1500 mg PO TID
7. Minoxidil 2.5 mg PO 4X/WEEK (___)
8. DiphenhydrAMINE 50 mg PO Q8H:PRN itching
9. Doxercalciferol 0.5 mcg IV 3X/WEEK (___)
Discharge Medications:
1. Calcium Carbonate 1500 mg PO TID
2. Clopidogrel 75 mg PO DAILY
3. DiphenhydrAMINE 50 mg PO Q8H:PRN itching
4. Ursodiol 300 mg PO BID
5. Warfarin 5 mg PO DAILY16
6. Acetaminophen 650 mg PO Q6H:PRN pain/headache/fever
7. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
8. Docusate Sodium (Liquid) 100 mg PO BID
9. Daptomycin 400 mg IV Q48H
Continue until ___
10. Daptomycin-Heparin Lock 10 mg LOCK TO HD CATHETER AT THE END
OF EACH DIALYSIS SESSION Duration: 4 Weeks
Daptomycin 2mg/mL
+ Heparin 100 Units/mL
11. Doxercalciferol 0.5 mcg IV 3X/WEEK (___)
12. Heparin Flush (1000 units/mL) ___ UNIT DWELL PRN line
flush
13. Sarna Lotion 1 Appl TP QID:PRN itching
14. Senna 8.6 mg PO BID:PRN Constipation
15. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
16. Carvedilol 12.5 mg PO BID
17. Outpatient Lab Work
Patient will need weekly labs ___,
___ including CBC, Chem 10 and CK drawn and faxed to
___ at the Infectious Disease clinic at ___
ICD-9: 790.7
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary:
- Enterococcus facaelis HD catheter associated BSI and sepsis
Secondary:
- CKD stage V ___ PCKD on hemodialysis since age ___.
- Complex vascular access with numerous failed BUE/Left femoral
AVF/AVG, now with tunneled right femoral groin HD line.
- Recurrent VTE s/p IVC filter
- IVC thrombosis with Budd-Chiari w/ abnormal right lobe and
left lobe hypertrophy, splenomegaly and small volume ascites.
- Hypertension
- Asthma
- Cholelithiasis
- Peptic ulcer disease
- Peripheral neuropathy
- Pneumothorax and tracheostomty after motorcycle accident ___
- Cadaveric renal transplant in ___ - removed 3 weeks later for
concern for malignancy.
- Left thigh exploration attempted revision c/b popliteal
thromboembolism s/p thrombolysis, angiojet and stenting (___)
- Evacuation left groin hematoma w/removal of segment of AV
graft
(___)
- Excision of infected left thigh AVG (___).
- Aortic valve thrombosis s/p sternotomy and thrombectomy
- Right arm fracture s/p ORIF with hardware
- Vascular Assessment ___:
--> US demonstrating nearly completely thrombosed R IJ
--> Upper extremity venogram via L IJ demosntrating complete
occlusion of SVC w/ UE extremity venous dainage through large
collaterals.
--> RLE venogram via RCFV demonstrating occluded R CFV around
in
situ HD and large tortous internal iliac vein draining RLE.
--> IVC angiogram demonstrating complete occlusion of suprarenal
IVC cranial to IVC filter. Return of blood flow to R atrium wsa
via tortouous collaterals.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with chest pain and fevers // Eval for pneumonia
TECHNIQUE: Chest PA and lateral
COMPARISON: Multiple prior chest radiographs dated ___ and ___..
FINDINGS:
Frontal and lateral radiographs of the chest demonstrate well expanded, clear
lungs. The cardiomediastinal and hilar contours are unremarkable. There is no
pneumothorax, pleural effusion, or consolidation.Multiple old left-sided rib
fractures are present.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
INDICATION: History: ___ with hypotension and chest pain // Eval for PE
TECHNIQUE: Multi detector CT images were obtained through the chest in
arterial phase after administration of 100 cc of IV Omnipaque contrast. Axial
images were interpreted in conjunction with coronal, sagittal, right oblique
MIP and left oblique MIP reformats.
COMPARISON: CTA of the abdomen and pelvis dated ___.
COMPARISON:
CTA of the abdomen and pelvis dated ___.
FINDINGS:
CHEST CTA: The thoracic aorta is normal caliber without evidence of aneurysm
or dissection. The main, lobar, and segmental subsegmental pulmonary arteries
are well opacified without filling defect. Assessment of subsegmental
pulmonary arteries is limited by contrast bolus. The azygous vein is large. A
hemodialysis catheter is present within the IVC.
CHEST: Axillary, mediastinal, and hilar lymph nodes are not pathologically
enlarged. The heart and mediastinum are normal. The pericardium is intact
without effusion.
Airways are patent to the subsegmental levels. Mild diffuse hazy ground-glass
opacities raises concern for mild pulmonary edema. Bibasilar atelectasis is
present. No discrete nodules are identified. No pleural effusion or
pneumothorax. The patient is status post prior right lung surgery.
The esophagus is unremarkable. The study is not tailored for assessment of
subdiaphragmatic structures. Allowing for this limitation, the kidneys
demonstrate dense cortical calcifications, and are mildly enlarged. The liver
does not show focal lesions.
OSSEOUS STRUCTURES: No focal lytic or sclerotic lesion concerning for
malignancy. Multiple old left-sided rib deformities are present.
IMPRESSION:
1. No central pulmonary embolism or acute aortic syndrome.
2. Mild diffuse hazy ground-glass opacities raise concern for mild pulmonary
edema.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: End-stage renal disease on hemodialysis secondary to polycystic
kidney disease. Now with fever, dyspnea, chest pain, and diarrhea. Has
elevated bilirubin. Evaluate for infection.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Right upper quadrant ultrasound from ___. Right upper
quadrant ultrasound from ___. CT of the abdomen and pelvis from ___.
FINDINGS:
LIVER: The liver is mildly enlarged, similar to the prior CT. The
echogenicity of the liver is normal and homogeneous. The contour of the liver
is smooth. There is no focal liver mass. The main portal vein is patent with
hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 2 mm.
GALLBLADDER: There is are small layering stones within the gallbladder. There
is no sludge. Mild apparent gallbladder wall thickening is likely due to
third spacing, as the gallbladder is not distended. There are no findings to
suggest acute cholecystitis.
PANCREAS: The pancreas is not well evaluated due to overlying bowel gas.
SPLEEN: The spleen is borderline enlarged, measuring 13.2 cm.
KIDNEYS: There are dense cortical calcifications, in keeping with cortical
nephrocalcinosis, as seen on the prior CT. Due to the calcifications, there
is acoustic shadowing, which limits evaluation of the kidneys, though there is
no evidence of polycystic kidney disease.
RETROPERITONEUM: The visualized portions of the aorta and IVC are within
normal limits.
IMPRESSION:
1. Unchanged mild hepatosplenomegaly.
2. Cholelithiasis. No definite evidence of cholecystitis.
3. Cortical nephrocalcinosis, limiting evaluation of the kidneys. No
evidence of polycystic kidney disease.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Fever
Diagnosed with FEVER, UNSPECIFIED
temperature: 102.2
heartrate: 70.0
resprate: 14.0
o2sat: 100.0
sbp: 91.0
dbp: 54.0
level of pain: 6
level of acuity: 2.0 | Mr. ___ is a ___ M currently incarcerated w/ ESRD on HD due
to polycystic kidney disease on HD, CHF w/ EF 55%, and hx DVT
s/p IVC filter on warfarin who presents with fever, dyspnea,
chest pain and diarrhea. Patient found to have GPC bacteremia
which grew out Enterococcus felt to be from his tunneled
dialysis catheter. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lisinopril / Univasc
Attending: ___
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with ETOH cirrhosis (listed for transplant, Childs C,
MELD-Na 21), complicated by variceal hemorrhage s/p TIPS and
refractory encephalopathy treated with TIPs revisions (last
___, who presents with confusion x 1 week in the setting of
worsening confusion over the past month.
Pt reports worsened confusion x 1 week, associated with malaise
in the setting of overall decline in functional status and
confusion over the past month. He was seen in ___ clinic
yesterday. Labs showed worsened LFTs/bilirubin, so he was
referred in to the Emergency Department for further evaluation.
Of note, patient was recently admitted from ___ for
hepatic encephalopathy. He was ruled out for infection and
treated with lactulose and rifaxamin. His doses of gabapentin,
Topamax, and trazodone were reduced.
After discharge, he was hospitalized again for encephalopathy,
this time in ___, where he was vacationing. He was
treated with a five day course of antibiotics for pneumonia. His
partner reports that he has been increasingly fatigued and
inattentive over the last month.
In the Emergency Department,
Initial vitals: 99.4 106 141/74 20 100% RA
Labs: WBC 7, stable thrombocytopenia (33), INR 2.1, Cr 0.8, Na
130, Tb 8.3 (from baseline 5.2), ALT 64 (baseline ~30s), AST 79
(baseline ~40s)
Imaging: CXR showed mild vascular congestion
Patient was given: 500cc IVF, 60 mEq KCl, lactulose, Topamax
100mg, tramadol 50mg.
In the room, the patient is AOx3 but appears tired. He denies
any fevers, chills, no recent sick contacts although he has
recently traveled to ___ and ___, being on a plane
and in a hospital in ___. He notes that his confusion is
slightly worse and that he has not been able to do the normal
activities that he use to. His partner notes significant decline
in his functional status. He will run one errand during the day
and then need to sleep the remainder of the day. he gets SOB
with walking short distances. He is overall very fatigued and
more confused. After his recent admission in ___, his
confusion improved slightly but he has not returned to his
baseline for over a month. He use to smoke cigarettes but none
recently. No recent ETOH use.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision
changes, rhinorrhea, congestion, sore throat, cough, nausea,
vomiting, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
Alcoholic Cirrhosis complicated by HE, esophageal varices and
UGI
bleed s/p TIPS and TIPS revisions, embolization of varices
(___)
Pulmonary hypertension
Hypertension
Hyperlipidemia
DM
Hypothyroidism
Insomnia
Hypogonadism
Osteopenia
H. Pylori
?Bipolar Disorder
Macroadenoma
Social History:
___
Family History:
No family history of liver disease.
MGM - died of breast CA
Father and grandfather with history of MI.
Physical Exam:
ADMISSION EXAM
==============
VS: 98.0, 149/75, 87, 20, 100 RA
General: AOx3, appears fatigued, nodding off during questions,
appears chronically ill
HEENT: PERRL, EOMI, oropharynx clear
Neck: supple, full ROM
CV: RRR, no m/r/g
Lungs: Diffuse coarse rhonchi b/l, no wheezes
Abdomen: distended, +BS, soft, non tender, no ascites, no
appreciable hepatosplenomegaly
GU: erythematous patch medial thighs not involving scrotum
Ext: WWP, no lower extremity edema
Neuro: +asterixis, AOx3 but slow to respond to questions, days
of week backwards said ___ otherwise
oriented to year, name, location. Moving all extremities, no
focal deficits, gait slow but steady
Skin: groin rash as described above, significant erythema
anterior chest, non jaundiced
DISCHARGE EXAM
==============
VS: 97.8, 117/45, 72, 18, 100RA
General: AOx3, able to name days of week backwards, smiling
HEENT: PERRL, EOMI, oropharynx clear
Neck: supple, full ROM
CV: RRR, no m/r/g
Lungs: CTAB, no wheezes
Abdomen: distended, +BS, soft, non tender, no ascites, no
appreciable hepatosplenomegaly
Ext: WWP, no lower extremity edema
Neuro: -asterixis, AOx3. Moving all extremities, no focal
deficits
Pertinent Results:
ADMISSION LABS
==============
___ 01:55PM WBC-7.9# RBC-3.36* HGB-12.8* HCT-34.6*
MCV-103*# MCH-38.1* MCHC-37.0 RDW-13.4 RDWSD-50.6*
___ 01:55PM NEUTS-71.4* LYMPHS-12.3* MONOS-13.5* EOS-1.8
BASOS-0.5 IM ___ AbsNeut-5.67# AbsLymp-0.98* AbsMono-1.07*
AbsEos-0.14 AbsBaso-0.04
___ 01:55PM PLT COUNT-44*
___ 01:55PM ___ PTT-44.5* ___
___ 01:55PM ALT(SGPT)-71* AST(SGOT)-81* ALK PHOS-105 TOT
BILI-9.9*
___ 01:55PM UREA N-23* CREAT-1.0 SODIUM-129*
POTASSIUM-3.1* CHLORIDE-103 TOTAL CO2-11* ANION GAP-18
DISCHARGE LABS
==============
___ 04:15AM BLOOD WBC-2.1* RBC-2.33* Hgb-8.7* Hct-24.3*
MCV-104* MCH-37.3* MCHC-35.8 RDW-13.3 RDWSD-50.0* Plt Ct-19*
___ 04:15AM BLOOD Plt Ct-19*
___ 04:15AM BLOOD ___ PTT-45.4* ___
___ 04:15AM BLOOD Glucose-113* UreaN-9 Creat-0.6 Na-137
K-3.7 Cl-108 HCO3-18* AnGap-15
___ 04:15AM BLOOD ALT-40 AST-42* AlkPhos-85 TotBili-3.8*
___ 04:15AM BLOOD Calcium-8.0* Phos-3.2 Mg-1.9
PERTINENT LABS
==============
___ 01:55PM BLOOD ALT-71* AST-81* AlkPhos-105 TotBili-9.9*
___ 09:30AM BLOOD ALT-64* AST-79* AlkPhos-102 TotBili-8.3*
DirBili-2.2* IndBili-6.1
___ 05:15AM BLOOD ALT-46* AST-50* AlkPhos-76 TotBili-5.2*
___ 05:20AM BLOOD ALT-47* AST-56* AlkPhos-78 TotBili-5.2*
___ 05:15AM BLOOD ALT-44* AST-51* AlkPhos-77 TotBili-4.5*
___ 04:30AM BLOOD ALT-47* AST-49* AlkPhos-108 TotBili-4.1*
___ 05:15AM BLOOD Hapto-12*
MICRO
=====
C. difficile DNA amplification assay (Final ___: Negative
for toxigenic C. difficile by the Illumigene DNA amplification
assay.
_________________________________________________________
URINE CULTURE (Final ___: <10,000 organisms/ml.
__________________________________________________________
Blood Culture, Routine (Pending):
STUDIES
=======
RUQ Ultrasound
No measurable flow is seen in the distal TIPS, which while may
in part be
technical due to difficulty with patient cooperation, is
concerning for
stenosis given redemonstrated echogenic material within the TIPS
and overall trend of increasing velocities in the measured
portions of the TIPS.
CXR
Mild central pulmonary vascular engorgement without overt
pulmonary edema. No focal consolidation to suggest pneumonia.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 2.5 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Furosemide 40 mg PO DAILY
4. Gabapentin 600 mg PO TID
5. Levothyroxine Sodium 100 mcg PO DAILY
6. Loratadine 10 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Omeprazole 40 mg PO BID
9. Potassium Chloride 40 mEq PO DAILY
10. Rifaximin 550 mg PO BID
11. Spironolactone 150 mg PO DAILY
12. Valsartan 40 mg PO DAILY
13. AndroGel (testosterone) 1.62 % (20.25 mg/1.25 gram)
transdermal DAILY
14. cabergoline 0.25 mg oral twice weekly
15. Cialis (tadalafil) 5 mg oral DAILY
16. econazole 1 % topical BID
17. GlipiZIDE 10 mg PO DAILY
18. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN wheeze
19. Tradjenta (linagliptin) 5 mg oral DAILY
20. Vitamin D 1000 UNIT PO DAILY
21. Lactulose 30 mL PO QID
22. Topiramate (Topamax) 100 mg PO BID
23. TraZODone 75 mg PO QHS:PRN insomnia
24. Glargine 70 Units Breakfast
Discharge Medications:
1. Amlodipine 2.5 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. cabergoline 0.25 mg oral 2X/WEEK (MO,FR)
4. Lactulose 30 mL PO BID
5. Lactulose 30 mL PO BID:PRN less than 4 BMs daily
6. Levothyroxine Sodium 100 mcg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Omeprazole 40 mg PO BID
9. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN wheeze
10. Rifaximin 550 mg PO BID
11. TraZODone 50 mg PO QHS:PRN insomnia
12. Valsartan 40 mg PO DAILY
13. Vitamin D 1000 UNIT PO DAILY
14. AndroGel (testosterone) 1.62 % (20.25 mg/1.25 gram)
transdermal DAILY
15. Cialis (tadalafil) 5 mg oral DAILY
16. econazole 1 % topical BID
17. Furosemide 20 mg PO DAILY
18. Glargine 70 Units Breakfast
19. Spironolactone 50 mg PO DAILY
20. Gabapentin 100 mg PO QHS
RX *gabapentin 100 mg 1 capsule(s) by mouth at bedtime Disp #*30
Capsule Refills:*0
21. Topiramate (Topamax) 50 mg PO DAILY
RX *topiramate 50 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
22. Loratadine 10 mg PO DAILY
23. Potassium Chloride 40 mEq PO DAILY
Hold for K >
24. Tradjenta (linagliptin) 5 mg oral DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Hepatic encephalopathy
Alcoholic Cirrhosis
Hyponatremia
Non-anion gap metabolic acidosis
Intertrigo
HTN
Hyperlipidemia
Diabetes Mellitus
Hypothyroidism
GERD
Macroadenoma
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 cirrhosis presenting with worsening LFT's and
abd pain // c/f PNA
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
The lungs are clear without focal consolidation. No pleural effusion or
pneumothorax is seen. The cardiac silhouette is mildly enlarged. Mediastinal
contours are unremarkable. There is persistent mild prominence of the central
pulmonary vasculature suggesting central pulmonary vascular engorgement
without overt pulmonary edema.
IMPRESSION:
Mild central pulmonary vascular engorgement without overt pulmonary edema. No
focal consolidation to suggest pneumonia.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with AMS, cirrhosis // please eval flow
TECHNIQUE: Grey scale, color, and spectral Doppler ultrasound images of the
abdomen were obtained.
COMPARISON: Prior TIPS ultrasound from ___
FINDINGS:
The scan was technically difficult as patient was not able to cooperate well
with breath holding commands. The liver appears diffusely coarsened and
nodular consistent with known cirrhosis. No focal liver lesions are
identified. There is no ascites. There is stable splenomegaly, with the spleen
measuring 14.2 cm.
The main portal vein is patent with hepatopetal flow.
The TIPS is patent and demonstrates wall-to-wall flow.
Portal vein and intra-TIPS velocities are as follows:
Main portal vein: 59.3 cm/sec, previously 56 cm/sec
Proximal TIPS: 97.9 cm/sec, previously 52cm/sec
Mid TIPS: 119 cm/sec, previously 84 cm/sec
Distal TIPS: Flow is not seen in the distal TIPS. Echogenic material is
again seen within the mid to distal TIPS.
Flow within the left portal vein is towards the TIPS shunt. Flow within the
right anterior and right posterior portal vein is towards the TIPS.
Appropriate flow is seen in the hepatic veins and IVC.
A calcified stone measuring 7 mm is noted in the gallbladder. The common bile
duct is not dilated, measuring 4 mm.
IMPRESSION:
No measurable flow is seen in the distal TIPS, which while may in part be
technical due to difficulty with patient cooperation, is concerning for
stenosis given redemonstrated echogenic material within the TIPS and overall
trend of increasing velocities in the measured portions of the TIPS.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abnormal labs, Abd pain
Diagnosed with Hepatic failure, unspecified without coma
temperature: 99.4
heartrate: 106.0
resprate: 20.0
o2sat: 100.0
sbp: 141.0
dbp: 74.0
level of pain: 9
level of acuity: 2.0 | ___ with ETOH cirrhosis (listed for transplant, Childs C,
MELD-Na 21), complicated by variceal hemorrhage s/p TIPS and
refractory encephalopathy treated with TIPs revisions (last
___, who presents with confusion x 1 week in the setting of
worsening confusion over the past month.
ACTIVE ISSUES
=============
# ETOH Cirrhosis: ___ C, MELD-Na 27 on admission, Listed
for transplant. He has a history of ascites (on diuretics),
variceal bleed s/p TIPS (last EGD ___ showing, hepatic
encephalopathy s/p TIPS revision (most recently ___. RUQ
ultrasound on admission was concerning for stenosis given no
measurable flow in the distal TIPS, however this was not
determined to be of critical significance. LFTs, TB, and ___
peaked and downtrended with improvement in HE. Infectious w/u
was negative. No e/o GIB. He will have a repeat CT scan done as
an outpatient prior to his next Liver Transplant appointment to
evaluate his TIPS and to help determine if he would be a
candidate for a live liver donor transplant.
# Hepatic encephalopathy: H/o HE on lactulose and rifaximin. He
has had multiple admissions recently for worsening confusion.
Infectious work up was negative this admission. Diagnostic
paracentesis was not able to be performed given no ascites.
Highest concern for encephalopathy was medication side effect
(gabapentin/topomax/trazodone) or electrolyte disturbances
hypokalemia. Gabapentin and Topomax were held on admission and
he was started on lactulose q2hr with electrolyte repletion.
Confusion improved dramatically over the fist 24 hours and
continued to improve over the course of his hospitalization. He
was discharged on Lactulose BID with BID prn for goal ___
BM/day. Gabapentin was restarted at 100mg qHS, Topamax at 50mg
daily and Trazodone at 50mg qHS prn.
# GIB/VARICES: Last EGD ___: 2 cords of grade I varices were
seen in the gastroesophageal junction. Now s/p TIPS and
refractory encephalopathy treated with TIPs revisions (last
___. This admission no e/o GIB. H/H stable without s/s
melena. He will need a repeat EGD as an outpatient.
# Hyponatremia. Na 130 on admission, below baseline 135. Sodium
improved with holding home lasix/spironolactone and IV albumin.
Diuretics were restarted at decreased dose on discharge (Lasix
20, Spironolactone 50), with titration as an outpatient.
CHRONIC ISSUES
===============
# HTN: Continued home amlodipine and valsartan.
# HLD: Continued home atorvastatin.
# Chronic neurological pain syndrome. Held home gabapentin and
topomax on admission, restarted at decreased dose Gabapentin
100mg qHS and Topomax 50mg daily.
# Diabetes: Held glipizide and linagliptan on admission.
Continued home insulin glargine with ISS. Recommended stopping
glipizide on discharge. He follows with ___.
# Insomnia: Continued trazodone at decreased dose 50mg qHS prn
# Hypothyroidism: Continue home levothyroxine 100mcg daily
# GERD: Continued home omeprazole 40mg po BID
# Macroadenoma: Continued on home cabergoline 0.25mg po twice
per week
# Hypogonadism: Held home testosterone patch
TRANSITIONAL ISSUES
===================
- Lactulose dosed BID with BID prn for goal ___ BM/day
- Recommend repeat labs done before Liver Transplant appointment
on ___. Monitor K+ as outpatient
- Will have CT A/P w/contrast scheduled prior to outpatient
appointment on ___ to evaluate TIPS location for surgical
planning purposes. Continue ongoing discussions regarding live
liver donor eligibility as an outpatient.
- Will need repeat EGD done as outpatient, to be scheduled with
Dr. ___ EGD was before TIPS revision)
- Stop glipizide given risk of hypoglycemia when given
concurrently with insulin
Medication Changes
- Lasix 20mg
- Spirnolactone 50mg
- Gabapentin 100mg qHS
- Topamax 50mg daily
- Trazodone 50mg qHS prn
- STOPPED glipizide
#Code: Full
#Contact: ___ (partner) ___, ___
(sister) ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
lisinopril / macadamia nut oil / shellfish derived
Attending: ___.
Chief Complaint:
code stroke
Major Surgical or Invasive Procedure:
EGD/colonoscopy ___
History of Present Illness:
Mr. ___ is a ___ year old right-handed man with PMH of HFpEF
(LVEF 45-50%, ___, CKD (Creatinine baseline 1.3-1.6), DMII
(A1C 5.6%, ___, HTN, HLD and left deep venous thrombosis
(nonocclusive peroneal) on apixiban for 3 months (___) who
code stroke was called for acute onset dysarthria and left hand
weakness.
Mr. ___ woke up normal this morning and was in the process of
getting out of bed at about 1030 when he acutely noticed that
his
voice did not sound normal and that his left hand was weak. His
girlfriend told him that his voice did not sound normal and that
it was difficult to understand him because he was mumbling. He
denies facial heaviness/weakness and slurring of his voice. Mr.
___ left hand was limp and was with little movement. He
denied that other parts of the left arm or leg felt weak. He
also endorsed that the left wrist and hand feel numb. He also
endorsed that when he first noticed the above symptoms that his
vision was blurred. He denies loss of vision or double vision.
His girlfriend drove him all the way here from ___. He
came
here because he likes this hospital and because he gets all of
his care here.
Mr. ___, on presentation, reports that he has not been taking
his medication for the last 3 days. He tells me that he is
currently being evicted from his home and has been distracted.
Pertinently, he brought all of his medications, but several are
missing including apixiban. He cannot tell me the last time he
took apixiban.
Code stroke was called on arrival here. Blood pressure was
normal. He was noted to have dysarhtric speech and weakness of
the left hand. NIHSS 1 for dysarthria. NCHCT without bleed.
CTA head and neck without occlusion. He endorsed that he is
heavily dependent on his left hand and would like TPA. He had
no
known absolute contraindication or relative contraindications to
TPA (MD ___. He was notified of the benefits and risks and
elected to proceed. TPA bolus was given at 1342. Door to needle
time 21 minutes. Mr. ___ hemoglobin returned at 5.6 and
his
baseline is 8 to 9. His hemoccult returned positive for blood.
He disclosed that he has been having black stool for weeks, but
thought it was because he was taking magnesium. Last
colonoscopy
___ with small polyp and diverticulosis. GI was consulted
and
recommendation was for 2 units of blood to be given.
Recommended
also PPI BID. We decided to abort TPA. He received the bolus
and about 10 ml of the drip (38 ml of 48.6 ml). He was also
noted to have light pink urine in Foley banister.
Mr. ___ reports that he feels fine right now and denies
feeling dizzy or shortness of breath. He feels that his voice
sounds much clearer than before he came into the hospital, but
feels that his left hand strength is either the same or only
slightly improved.
ROS:
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
HFpEF (LVEF 45-50%, ___
CKD (Creatinine baseline 1.3-1.6)
DMII (A1C 5.6%, ___
HTN
HLD
Left deep venous thrombosis (nonocclusive peroneal) on apixiban
for 3 months (___)
Gout
Restless leg syndrome
Social History:
___
Family History:
Mr. ___ reports his mother died of stroke at age ___ and
father
died at ___ of complications of prostate cancer.
Physical Exam:
ADMISSION EXAM:
===============
Vitals:
Blood pressure: 111/61
Heart rate: 103
Respiratory rate: 15
Oxygen saturation: 98%
General examination:
General: Comfortable and in no distress
Head: No irritation/exudate from eyes, nose, throat
Neck: Supple with no pain to flexion or extension
Cardio: Regular rate and rhythm, warm, no peripheral edema
Lungs: Unlabored breathing
Abdomen: Soft, non tender, non distended
Skin: No rashes or lesions
Performed around 30 minutes after TPA:
Neurologic:
Mental status:
He is awake, alert, and cooperative with the exam. He is
attentive, able to say months of the year backwards. Fund of
knowledge is intact. He is oriented to place and date.
Language
is fluent. Memory for recent and remote history is intact.
Cranial nerves:
No visual field cut. Pupils are equal and reactive.
Extraocular
movements are full. No nystagmus on primary or end gaze. No
double vision on primary or end gaze. Facial sensation and
movement are intact and symmetric. Hearing is intact to finger
rub bilaterally. Palate elevates symmetrically. SCM and
trapezius are full strength bilaterally. Tongue is midline.
Motor:
He is a thin man with little muscle mass. Tone is normal. He
has no pronator drift. His strength is full except for the left
hand (He deferred on left foot testing because of pain). He has
no antigravity extension of the wrist and the fingers and he can
only provide weak resistance with wrist and finger flexion.
Sensation:
Pinprick is intact in the hands and feet. Position sense is
intact in the toes bilaterally. .
Coordination:
Finger-nose-finger and finger-to-nose are intact in the right
without dysmetria. HTS without dysmetria on both sides. No
truncal ataxia with sitting upright.
Reflexes:
He is diffusely symmetrically hyperreflexic, including pectoral,
pre patellar, and cross abductor reflexes. No ankle clonus.
Plantar reflex is flexor on right and mute/extensor on the left
DISCHARGE EXAM:
===============
Vitals:
24 HR Data (last updated ___ @ 613)
Temp: 98.0 (Tm 100.0), BP: 148/84 (125-161/72-84), HR: 98
(89-123), RR: 18 (___), O2 sat: 100% (98-100), O2 delivery: RA
General examination:
General: Comfortable and in no distress, lying in bed,
engaged in conversation
Lungs: Unlabored breathing
Ext: L leg with bandage in place
Skin: No rashes or lesions
Neurologic:
Mental status:
He is awake, alert, and cooperative with the exam. He is
attentive.
Cranial nerves:
Pupils 5->3 bilaterally, EOMI. No dysarthria. face symmetric.
Motor:
No drift.
LUE: wrist extension 4, finger extension 5-, interosseous 4+,
finger flexion 5-, otherwise full
RUE: full strength
LLE: full strength
RLE: full strength
Sensation:
Intact to light touch throughout.
Coordination: not tested
Reflexes: not tested
Pertinent Results:
ADMISSION LABS:
___ 01:50PM BLOOD WBC-5.7 RBC-2.03* Hgb-5.6* Hct-17.7*
MCV-87 MCH-27.6 MCHC-31.6* RDW-15.9* RDWSD-50.0* Plt ___
___ 01:50PM BLOOD Neuts-73.1* Lymphs-12.4* Monos-11.3
Eos-1.9 Baso-0.2 Im ___ AbsNeut-4.14 AbsLymp-0.70*
AbsMono-0.64 AbsEos-0.11 AbsBaso-0.01
___ 01:50PM BLOOD ___ PTT-31.1 ___
___ 01:50PM BLOOD Plt ___
___ 01:50PM BLOOD UreaN-65*
___ 01:50PM BLOOD ALT-15 AST-30 AlkPhos-56 TotBili-0.2
___ 01:50PM BLOOD cTropnT-0.02*
___ 01:38AM BLOOD CK-MB-2 cTropnT-0.02*
___ 01:50PM BLOOD Albumin-3.0*
___ 01:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 02:01PM BLOOD Glucose-148* Creat-2.2* Na-130* K-5.3
Cl-98 calHCO3-23
___ 01:38AM BLOOD %HbA1c-6.6* eAG-143*
___ 01:38AM BLOOD Triglyc-68 HDL-42 CHOL/HD-2.5 LDLcalc-47
___ CT:
1. No acute intracranial abnormality.
2. Small chronic infarcts.
3. Mild narrowing arteries neck, head.
4. Suggestion of ulcerated plaque proximal right ICA.
5. No perfusion abnormality.
6. Ossific density left maxillary sinus, benign.
___ MR BRAIN:
1. Probable small subacute infarction in the right periatrial
white matter
posterolateral to the right thalamus, as discussed above.
Evaluation of this
area on FLAIR and T2 weighted images is limited due to slice
thickness and
volume averaging.
2. Small chronic infarctions in the right frontal lobe, right
parietal lobe,
and probably also in the left corona radiata.
3. Extensive supratentorial white matter T2/FLAIR
hyperintensities are
nonspecific but likely sequela of chronic small vessel ischemic
disease in
this age group.
___ CAROTID SERIES:
Right ICA <40% stenosis.
Left ICA <40% stenosis.
___ MR C-SPINE:
1. No significant spinal canal stenosis.
2. Severe left and moderate right neural foraminal narrowing is
seen at C6-C7
secondary to facet joint and uncovertebral arthropathy.
3. Moderate right and mild left neural foraminal narrowing at
C4-C5.
4. No cord signal abnormalities identified.
___ TTE:
Mild symmetric left ventricular hypertrophy with normal cavity
size and mildregional systolic dysfunction most consistent with
single vessel coronary artery disease (PDAdistribution). No
definite structural cardiac source of embolism identified, but
bubble study unableto be performed due to non-functioning IV.
DISCHARGE LABS:
___ 05:00AM BLOOD WBC-7.0 RBC-3.16* Hgb-8.9* Hct-27.9*
MCV-88 MCH-28.2 MCHC-31.9* RDW-15.9* RDWSD-51.5* Plt ___
___ 05:00AM BLOOD Plt ___
___ 05:00AM BLOOD Glucose-177* UreaN-23* Creat-1.0 Na-138
K-4.9 Cl-97 HCO3-28 AnGap-13
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Allopurinol ___ mg PO DAILY
2. amLODIPine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 10 mg PO QPM
5. CARVedilol 25 mg PO BID
6. Eplerenone 25 mg PO DAILY
7. Furosemide 40 mg PO DAILY
8. rOPINIRole 1 mg PO QHS:PRN restless legs
9. Tamsulosin 0.4 mg PO QHS
10. Apixaban 5 mg PO BID
11. Aliskiren 150 mg PO DAILY
12. Calcium Carbonate 500 mg PO BID
13. Centrum (multivit-min-ferrous
gluconate;<br>multivitamin-iron-folic acid) 400 mg-mcg oral
DAILY
14. Clobetasol Propionate 0.05% Cream 1 Appl TP BID:PRN eczema
15. Colchicine 0.6 mg PO DAILY:PRN gout
16. Cyanocobalamin 100 mcg PO DAILY
17. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN allergies
18. GlipiZIDE 5 mg PO DAILY
19. Indomethacin 50 mg PO TID:PRN gout
20. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
21. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. GlipiZIDE 5 mg PO DAILY
starting ___. Insulin SC
Sliding Scale
Fingerstick QACHS, HS
Insulin SC Sliding Scale using HUM Insulin
3. Omeprazole 40 mg PO DAILY
4. CARVedilol 37.5 mg PO BID
5. GlipiZIDE 5 mg PO BID Duration: 2 Days
take BID through ___, then resume taking daily on ___. Aliskiren 150 mg PO DAILY
7. Allopurinol ___ mg PO DAILY
8. amLODIPine 10 mg PO DAILY
9. Aspirin 81 mg PO DAILY
10. Atorvastatin 10 mg PO QPM
11. Calcium Carbonate 500 mg PO BID
12. Centrum (multivit-min-ferrous
gluconate;<br>multivitamin-iron-folic acid) 400 mg-mcg oral
DAILY
13. Clobetasol Propionate 0.05% Cream 1 Appl TP BID:PRN eczema
14. Colchicine 0.6 mg PO DAILY:PRN gout
15. Cyanocobalamin 100 mcg PO DAILY
16. Eplerenone 25 mg PO DAILY
17. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN allergies
18. Furosemide 40 mg PO DAILY
19. Indomethacin 50 mg PO TID:PRN gout
20. rOPINIRole 1 mg PO QHS:PRN restless legs
21. Tamsulosin 0.4 mg PO QHS
22. Vitamin D 1000 UNIT PO DAILY
23. HELD- MetFORMIN XR (Glucophage XR) 500 mg PO DAILY This
medication was held. Do not restart MetFORMIN XR (Glucophage XR)
until ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Brachial plexus injury
Resolved GI bleed
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CODE STROKE Q14 CT HEADNECK
INDICATION: Suspected stroke with acute neurological deficit.// Please
exclude ICH, signs of early ischemic stroke, large vessel occlusion, or other
vascular abnormality.
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 3.0 s, 0.5 cm; CTDIvol = 32.7 mGy (Head) DLP =
16.3 mGy-cm.
4) Spiral Acquisition 5.2 s, 40.5 cm; CTDIvol = 32.0 mGy (Head) DLP =
1,295.2 mGy-cm.
Total DLP (Head) = 4,628 mGy-cm.
COMPARISON: None.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is no evidence of acute large territorial
infarction,hemorrhage,edema,ormass. Small chronic infarcts right parietal
lobe, right middle frontal gyrus. The ventricles and sulci are prominent,
suggestive of volume loss. Chronic small vessel ischemic change.
There is an ossific density within the left maxillary sinus suggestive of
benign fibro-osseous lesion, may be osteoma or fibrous dysplasia or
postsurgical change. The visualized portion of the remaining paranasal
sinuses,mastoid air cells,and middle ear cavities are essentially clear. The
visualized portion of the orbits are unremarkable. Small mixed internal,
external right laryngocele. No mass at the larynx.
CTA HEAD:
Atherosclerotic calcifications bilateral cavernous, paraclinoid ICA, with mild
narrowing. The vessels of the circle of ___ and their principal
intracranial branches appear normal without stenosis, occlusion, or aneurysm
formation. There are bilateral fetal type origins of the PCAs. There are
moderate calcifications of the carotid siphons, with no flow limiting
stenosis. The dural venous sinuses are patent.
CTA NECK:
There are calcifications of the bilateral carotid bifurcations, with
suggestion of ulcerated plaque right ICA proximally. No evidence of internal
carotid stenosis by NASCET criteria. Mild narrowing distal V1 segment right
vertebral artery.
Otherwise, the carotidandvertebral arteries and their major branches appear
normal with no evidence of flow-limiting stenosis or occlusion.
PERFUSION:
No perfusion abnormality. T-max greater than 6 seconds 0 mL. CBF less than
30% volume 0 mm.
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. No acute intracranial abnormality.
2. Small chronic infarcts.
3. Mild narrowing arteries neck, head.
4. Suggestion of ulcerated plaque proximal right ICA.
5. No perfusion abnormality.
6. Ossific density left maxillary sinus, benign.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST
INDICATION: ___ year old man who presented with dysarhtria and left hand
weakness. Evaluate for stroke. Concern for right pontine versus right
cortical hand knob.
TECHNIQUE: Sagittal T1 weighted, and axial T2 weighted, FLAIR, gradient echo,
and diffusion-weighted images of the brain were obtained.
COMPARISON: CTA head and neck from 1 day prior on ___.
FINDINGS:
There is a small linear focus of high signal on the diffusion tracer sequence
in the right periatrial white matter posterolateral to the right thalamus,
image 402:16, without clear corresponding signal abnormality on the ADC map.
Evaluation of this area on axial FLAIR and T2 weighted images is limited due
to slice thickness and volume averaging. There appears to be a small
corresponding T1 hypointensity on sagittal T1 weighted image 3:7. This may
represent a small subacute infarct.
No other evidence for recent infarction. Small chronic infarctions are again
seen in the right middle frontal gyrus and right superior parietal lobe, and
probably also in the left corona radiata. Extensive confluent T2/FLAIR
hyperintensities in the periventricular and deep white matter of the cerebral
hemispheres, and scattered small T2/FLAIR hyperintensities in the subcortical
white matter, nonspecific but likely sequela of chronic small vessel ischemic
disease in this age group. There is mild global parenchymal volume loss with
mildly prominent ventricles and sulci. Major vascular flow voids appear
grossly preserved. No evidence for intracranial blood products allowing for
motion artifact on gradient echo images.
Calcified material is again seen in the left maxillary sinus. There is
minimal mucosal thickening in the bilateral ethmoid air cells.
IMPRESSION:
1. Probable small subacute infarction in the right periatrial white matter
posterolateral to the right thalamus, as discussed above. Evaluation of this
area on FLAIR and T2 weighted images is limited due to slice thickness and
volume averaging.
2. Small chronic infarctions in the right frontal lobe, right parietal lobe,
and probably also in the left corona radiata.
3. Extensive supratentorial white matter T2/FLAIR hyperintensities are
nonspecific but likely sequela of chronic small vessel ischemic disease in
this age group.
RECOMMENDATION(S): Consider follow-up MRI for reassessment of the probable
small subacute infarct in the right periatrial white matter.
NOTIFICATION: The findings and recommendations were discussed with ___
___, M.D. by ___, M.D. on the telephone on ___ at 2:53 pm, 10
minutes after discovery of the findings.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS LEFT
INDICATION: ___ year old man with h/o HFpEF, T2DM, HTN, HLD, LLE DVT,
presented with dysarthria and L hand weakness with concern for stroke.// eval
for persistence ___ DVT or new DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower extremity veins.
COMPARISON: Left lower extremity Doppler ultrasound from ___.
FINDINGS:
There is normal compressibility, color flow, and spectral doppler 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 left lower extremity veins.
Radiology Report
EXAMINATION: Carotid Artery ultrasound
INDICATION: ___ year old man s/p code stroke with L hand weakness// s/p code
stroke
TECHNIQUE: Real-time grayscale, color, and spectral Doppler ultrasound
imaging of the carotid arteries was obtained.
FINDINGS:
RIGHT:
There is mild heterogenous atherosclerotic plaque in the right carotid artery.
Segment: PSV (cm/s) / EDV (cm/s)
----------------------------------------------
CCA ___: 61.6 cm/s / 11.1 cm/s
CCA Distal: 90.3 cm/s / 13.5 cm/s
ICA ___: 66.8 cm/s / 14.1 cm/s
ICA Mid: 61.6 cm/s / 15.2 cm/s
ICA Distal: 59.4 cm/s / 15.2 cm/s
ECA: 98.5 cm/s
Vertebral: 72.7 cm/s
ICA/CCA Ratio: 0.74
The right vertebral artery flow is antegrade with a normal spectral waveform.
LEFT:
There is mild heterogenous atherosclerotic plaque in the left carotid artery.
Segment: PSV (cm/s) / EDV (cm/s)
----------------------------------------------
CCA ___: 98.2 cm/s / 12.6 cm/s
CCA Distal: 112 cm/s / 16.5 cm/s
ICA ___: 61.3 cm/s / 15.7 cm/s
ICA Mid: 66.4 cm/s / 17.9 cm/s
ICA Distal: 87.7 cm/s / 15 cm/s
ECA: 59.8 cm/s
Vertebral: 59.7 cm/s
ICA/CCA Ratio: 0.78
The left vertebral artery flow is antegrade with a normal spectral waveform.
IMPRESSION:
Right ICA <40% stenosis.
Left ICA <40% stenosis.
Radiology Report
EXAMINATION: MR CERVICAL SPINE W/O CONTRAST T___ MR ___ SPINE
INDICATION: Mr. ___ is a ___ yo M with PMHx of HFpEF (LVEF 45-50%, ___,
CKD (Creatinine baseline 1.3-1.6), DMII (A1C 5.6%, ___, HTN, HLD and left
deep venous thrombosis (nonocclusive peroneal) on apixiban for 3 months
(___) who code stroke was called for acute onset dysarthria and left hand
weakness.// Assess for cervical nerve compression Assess for cervical nerve
compression
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial T2 and gradient echo imaging were next performed.
COMPARISON: None.
FINDINGS:
The alignment is normal. No concerning bone marrow signal abnormalities are
identified. No cord signal abnormalities are seen. Diffuse loss of the
normal T2 signal is seen throughout the discs of the cervical spine.
C2-C3: There is no spinal canal or neural foraminal narrowing.
C3-C4: Mild disc bulge is seen resulting in mild spinal canal narrowing.
Facet joint and uncovertebral arthropathy results in mild left neural
foraminal narrowing.
C4-C5: Mild disc bulge is seen however there is no significant spinal canal
narrowing. Facet joint and uncovertebral arthropathy results in moderate
right and mild left neural foraminal narrowing.
C5-C6: There is no spinal canal or neural foraminal narrowing.
C6-C7: Mild disc bulge is seen resulting in mild spinal canal narrowing.
Facet joint and uncovertebral arthropathy results in severe left and moderate
right neural foraminal narrowing.
C7-T1: There is no spinal canal or neural foraminal narrowing.
No para vertebral or paraspinal soft tissue abnormalities are identified.
IMPRESSION:
1. No significant spinal canal stenosis.
2. Severe left and moderate right neural foraminal narrowing is seen at C6-C7
secondary to facet joint and uncovertebral arthropathy.
3. Moderate right and mild left neural foraminal narrowing at C4-C5.
4. No cord signal abnormalities identified.
Radiology Report
EXAMINATION: CTA CHEST
INDICATION: ___ year old man with DVT, GI, and new tachycardia.// Evaluate for
PE
TECHNIQUE: Multi detector CT of the chest was performed after the
administration of intravenous contrast. Axial coronal and sagittal
reconstructions were acquired. Maximum intensity projections were also
acquired
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.5 s, 33.7 cm; CTDIvol = 6.9 mGy (Body) DLP = 230.7
mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7
mGy-cm.
3) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 16.6 mGy (Body) DLP =
8.3 mGy-cm.
Total DLP (Body) = 241 mGy-cm.
COMPARISON: No prior CT chest is available for comparisons
FINDINGS:
CT ANGIOGRAM: The pulmonary embolism study is of good diagnostic quality.
There are no filling defects in the pulmonary artery and segmental
subsegmental branches to suggest pulmonary embolism. The aorta is
unremarkable.
THORACIC INLET: There are no enlarged supraclavicular lymph nodes
BREAST AND AXILLA : There are no enlarged axillary lymph nodes.
MEDIASTINUM: There are no enlarged mediastinal hilar lymph nodes. Heart size
is normal. There is no pericardial effusion. Trace pericardial effusion most
likely physiological.
PLEURA: There is no pleural effusion.
LUNG: Lungs are low volume with minimal bibasilar atelectasis. There is no
evidence of pneumonia pulmonary edema or interstitial abnormality.
BONES AND CHEST WALL : Review of bones is unremarkable.
UPPER ABDOMEN: Limited sections through the upper abdomen are unremarkable
IMPRESSION:
No evidence of pulmonary embolism.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: L Weakness
Diagnosed with Cerebral infarction, unspecified
temperature: 98.3
heartrate: 87.0
resprate: 18.0
o2sat: 98.0
sbp: 115.0
dbp: 50.0
level of pain: nan
level of acuity: 2.0 | TRANSITIONAL ISSUES:
[] He should have an EMG performed within ___ weeks after
discharge to evaluate for left brachial plexus injury.
[] He will need a follow-up appointment with vascular surgery
which should be referred from his PCP to evaluate his left lower
extremity pressure ulcer.
[] Plastic surgery would also like him referred to their clinic
after he sees vascular surgery.
[] If he has further anemia in the future, a capsule study
should be considered to further evaluate his GI tract.
[] He was discharged with omeprazole, which should be
discontinued after 2 months.
[] He required magnesium supplementation while inpatient, his
magnesium should be checked approximately 1 week after discharge
to determine need for oral supplementation.
[] Check CBC within one week of discharge for history of GI
bleeding.
[] Continue weight loss work-up as an outpatient with PCP.
[] He received IV contrast ___ and therefore his metformin was
held and glipizide was made BID. On ___, his metformin should
be restarted and glipizide decreased to daily. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo man w/ idiopathic pulmonary hypertension on tadalafil (2L
home O2), left frontal encephalomalacia suspected from infarct,
s/p craniectomy, alcohol abuse, seizure d/o (on keppra),
dyslipidemia, CKD (bc Cr 1.4), CHF, prostate CA presenting with
complaint of episode of sweating, chest pain and fatigue
overnight.
Pt reported in the ED that he was awakened from sleep by chest
pain, prescribed as pressure over the entire chest,
non-radiating
and associated w/ diaphoresis and fatigue, no associated
vomiting
or nausea. Patient reports that chest pain and diaphoresis
subsided after 30 minutes but fatigue persisted.
Pt reports increased swelling in his legs for past 2 days. No
fever, chills, abdominal pain, dysuria.
In the ED, initial vitals were: 98.2 102 108/50 20 95% RA
- Exam notable for: Ill-appearing and lethargic. 3+ pitting
edema
bilaterally.
- ECG: sinus, rate 91, right axis, normal intervals, TWI in III,
V1-V3 present on ___
- Labs notable for: trop 0.8, MB 5, bnp 239, lactate 1.0, BUN/Cr
74/1.9, bicarb 33, H/H at baseline, no leukocytosis, PLT wnl, UA
unremarkable.
- Imaging was notable for: CXR with no pleural effusions,
concern
for consolidation in hilum vs atelectasis.
Consults: none
Patient received: nothing
Transfer VS were: 97.4 66 111/64 14 96% 3L NC
- Of note, during last hospitalization, torsemide was held with
resultant improvement in renal function. Torsemide 20mg filled
___.
Upon arrival to the floor, patient was drowsy but arousable. He
denied any chest pain or shortness of breath. Per conversation
nurse at ___, patient may not be adherent to
medications.
ROS: Positive per HPI. Remaining 10 point ROS reviewed and
negative
Past Medical History:
Prostate Cancer
Diabetes mellitus type II
Hyperlipidemia
Seizure disorder
Idiopathic Pulmonary Hypertension on home O2
Right sided heart failure
Chronic Kidney Disease
Social History:
___
Family History:
NC
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
VITAL SIGNS:
___ ___ Temp: 97.7 PO BP: 136/73 HR: 60 RR: 14 O2 sat: 95%
O2 delivery: 2L
GENERAL: NAD, drowsy but arousable, A&Ox2. Seems to be blood on
the gown; unclear source.
HEENT: AT/NC, anicteric sclera, MMM
CARDIAC: rrr, no g/m/r
LUNGS: CTAB, no ronchi, no rales, no accessory muscles
ABDOMEN: NTND, bowel sounds present
EXTREMITIES: 2+ radial pulses; 1+ DP and ___ warm and dry. ___
pitting edema b/l ___.
NEUROLOGIC: A&Ox2, CNII-XII grossly intact
SKIN: warm and dry; venous stasis changes in lower extremities.
DISCHARGE PHYSICAL EXAM
========================
___ 1415 Temp: 98.2 PO BP: 143/60 HR: 74 RR: 18 O2 sat: 96%
O2 delivery: 2L
GENERAL: NAD, lying comfortably in bed
HEENT: AT/NC, anicteric sclera, MMM
CARDIAC: rrr, no g/m/r
LUNGS: CTAB, no wheezes
ABDOMEN: NTND, bowel sounds present
EXTREMITIES: trace pitting edema b/l ___.
Pertinent Results:
ADMISSION LABS:
===============
___ 01:50AM BLOOD WBC-6.8 RBC-3.56* Hgb-8.9* Hct-28.9*
MCV-81* MCH-25.0* MCHC-30.8* RDW-18.6* RDWSD-54.3* Plt ___
___ 01:50AM BLOOD Neuts-79.7* Lymphs-8.9* Monos-8.6 Eos-2.0
Baso-0.4 Im ___ AbsNeut-5.44 AbsLymp-0.61* AbsMono-0.59
AbsEos-0.14 AbsBaso-0.03
___ 09:36AM BLOOD ___ PTT-26.1 ___
___ 01:50AM BLOOD Plt ___
___ 01:50AM BLOOD Glucose-115* UreaN-74* Creat-1.9* Na-143
K-4.6 Cl-96 HCO3-33* AnGap-14
___ 09:36AM BLOOD ALT-18 AST-55* LD(LDH)-253* CK(CPK)-1490*
AlkPhos-58 TotBili-0.6
___ 01:50AM BLOOD CK-MB-5 proBNP-239
___ 01:50AM BLOOD cTropnT-0.08*
___ 09:36AM BLOOD CK-MB-13* MB Indx-0.9 cTropnT-0.10*
___ 05:21PM BLOOD CK-MB-11* MB Indx-0.7 cTropnT-0.09*
___ 09:36AM BLOOD Albumin-4.2 Calcium-9.3 Phos-4.2 Mg-2.7*
___ 02:00AM BLOOD Lactate-1.0
DISCHARGE LABS:
===============
___ 06:25AM BLOOD Glucose-91 UreaN-27* Creat-0.9 Na-147
K-4.9 Cl-105 HCO3-30 AnGap-12
Pertinent Imaging:
==================
CXR ___:
1. Persistent mild pulmonary edema with pulmonary vascular
congestion and
bibasilar atelectasis.
2. Persistent bibasilar atelectasis without new focal
consolidation.
Lower Extremity Doppler Ultrasound ___:
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
Transthoracic Echo ___:
Left atrial volume index severely increased. Mild symmetric left
ventricular hypertrophy with a normal cavity size. Visually
estimated left ventricular ejection fraction is 70%. Right
ventricular free wall is hypertrophied. Severely dilated right
ventricular cavity with moderate global free wall hypokinesis.
Abnormal interventricular septal motion c/w right ventricular
pressure and volume overload. Compared with prior TTE
(___) the right ventricle is now markedly dilated and
moderately hypokinetic. Inferior hypokinesis is now seen.
Cardiac Perfusion Pharm ___:
IMPRESSION: 1. Moderate fixed perfusion defect of the distal
LV anterior wall
and apex. 2. Mildly enlarged left ventricular cavity size with
normal LV wall
motion. LVEF is low normal at 57%.
Pharmacologic Stress Test ___:
IMPRESSION : No anginal symptoms with non-specific/borderline ST
segment
changes.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. LevETIRAcetam 750 mg PO BID
5. Mirtazapine 30 mg PO QHS
6. Multivitamins W/minerals 1 TAB PO DAILY
7. Senna 17.2 mg PO DAILY:PRN CONSTIPATION
8. Vitamin B-1 (thiamine HCl (vitamin B1)) 100 mg oral DAILY
9. Adcirca (tadalafil (antihypertensive)) 40 mg oral DAILY
10. Clotrimazole Cream 1 Appl TP DAILY
11. Magnesium Citrate 300 mL PO DAILY:PRN CONSTIPATION
12. Vitamin D ___ UNIT PO MONTHLY
13. Lisinopril 2.5 mg PO DAILY
14. Ferric ___ (polysaccharide iron complex) 150 mg iron oral
DAILY
15. Torsemide 20 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Adcirca (tadalafil (antihypertensive)) 40 mg oral DAILY
3. Aspirin 81 mg PO DAILY
4. Clotrimazole Cream 1 Appl TP DAILY
5. LevETIRAcetam 750 mg PO BID
6. Lisinopril 2.5 mg PO DAILY
7. Magnesium Citrate 300 mL PO DAILY:PRN CONSTIPATION
8. Mirtazapine 30 mg PO QHS
9. Multivitamins W/minerals 1 TAB PO DAILY
10. Senna 17.2 mg PO DAILY:PRN CONSTIPATION
11. Vitamin B-1 (thiamine HCl (vitamin B1)) 100 mg oral DAILY
12. Vitamin D ___ UNIT PO MONTHLY
13. HELD- Atorvastatin 80 mg PO QPM This medication was held.
Do not restart Atorvastatin until a physician tells you to
restart
14. HELD- Torsemide 20 mg PO DAILY This medication was held. Do
not restart Torsemide until you are told to by a physician
___:
Home
Discharge Diagnosis:
#Atypical Chest Pain
#Idiopathic pulmonary hypertension
#Congestive Heart Failure
#Acute Kidney Injury on Chronic Kidney Disease
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with fever// Evaluate for pneumonia
TECHNIQUE: Chest AP and lateral
COMPARISON: Multiple prior chest radiographs with the most recent dated ___.
FINDINGS:
The lung volume is small, exaggerating bronchovascular markings. Again
demonstrated mild pulmonary edema and pulmonary vascular congestion, similar
to ___. There is bibasilar atelectasis. No new focal consolidation.
There is small left pleural effusion. No right pleural effusion. No
pneumothorax. Cardiomegaly is unchanged. No acute osseous abnormalities.
IMPRESSION:
1. Persistent mild pulmonary edema with pulmonary vascular congestion and
bibasilar atelectasis.
2. Persistent bibasilar atelectasis without new focal consolidation.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ yo man w/ idiopathic pulmonary hypertension on tadalafil (2L
home O2), left frontal encephalomalacia suspected from infarct, s/p
craniectomy, alcohol abuse, seizure d/o (on keppra), CKD (bc Cr 1.4), CHF now
w/ new b/l LLE edema.// DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the bilateral
common femoral, femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Weakness
Diagnosed with Weakness
temperature: 98.2
heartrate: 102.0
resprate: 20.0
o2sat: 95.0
sbp: 108.0
dbp: 50.0
level of pain: 0
level of acuity: 3.0 | ___ yo M w/ idiopathic pulmonary hypertension on tadalafil (2L
home O2), left frontal encephalomalacia suspected from infarct,
s/p craniectomy, prior alcohol abuse, seizure d/o (on keppra),
dyslipidemia, CKD III, CHF, CAD, prostate CA presenting with
complaint of episode of sweating, chest pain and fatigue
overnight that did not recur, with TTE showing inferior
hypokinesis and worsened RV function but stress test negative
for reversible ischemia.
ACUTE ISSUES:
=============
#Idiopathic pulmonary hypertension / diastolic heart failure
- Was given sildenafil while in house instead of usual
tadalafil
- ECHO findings may represent worsening pulm hypertension given
right ventricle markedly dilated and moderately hypokinetic,
inferior hypokinesis is now seen compared to prior study.
- torsemide stopped given evidence of volume depletion
- At baseline O2 requirements, 2L
- Outpatient followup scheduled at ___ with Dr. ___ on
___ at 4:40 ___
#CAD/Inferior hypokinesis
Pt carries dx of CAD in past. Chest pain atypical and enzymes
not consistent with type I NSTEMI. TTE showed worsened RV
function and new inferior hypokinesis, concerning for prior
infarct. Nuclear stress obtained which showed anterior fixed
defect but no reversible ischemia. Cath deferred as patient
given lack of evidence for high risk lesion based on stress and
preference for medical management given his patient's risk of
nonadherence and desire to leave the hospital. Ultimately low
suspicion his initial chest pain was due to cardiac ischemia.
Statin held due to mild rhabdo, and beta blocker not yet
started due to borderline bradycardia, but these should both be
addressed in follow-up.
___ on CKD
Unclear whether pt was taking torsemide as outpatient.
Torsemide was stopped during last hospital admission ___
concerns pt was overdiuresing. Patient may have continued to
take old supply when he returned home. During admission
patient's Cr peaked at 1.9. When torsemide held in hospital Cr
returned to baseline, and he did not develop evidence of
worsening heart failure off torsemide. Will need to monitor
volume status and weight in follow-up for further data.
#Mild rhabdomyolysis
Patient's CK was elevated on admission up to ___ range.
Etiology was unclear but ddx included medication (statin) vs.
seizure in the setting of keppra non-compliance vs. trauma in
setting of reduced consciousness. CK levels peaked at 1651 and
then downtrended during admission. Of note his levels have been
moderately elevated in the past as well. Very unlikely to be
cardiac source given troponin levels. Held statin through
admission and at discharge. Will need CK followed up and
further decision about statin use.
#Chest Pain w/ elevated troponin
- patient presented with chest pain, fatigue and elevated
troponin. These complaints resolved on their prior to
admission. Patient's admission EKG was unchanged from prior on
___ with TWI in III, V1-V3 present. His mild troponinemia
was similar to prior and overall flat, not suggestive of type I
NSTEMI.
CHRONIC ISSUES:
===============
#HTN:
Continued home lisinopril
#Alcohol use history
#Seizure hx
Continued home keppra
#Anemia
He has been followed in heme with Dr. ___ believes the
anemia is related to multifactorial, chronic disease and iron
deficiency with steadily decreasing ferritin concerning for
GIB. B12 was normal. His iron supplement was stopped to
decrease medication burden in setting of dementia and his
refusal of many pills (and suspect larger component of
inflammation at this point given low TIBC, normocytic, normal
range ferritin)
# Dyslipidemia
Held home atorvastatin during admission as per above
TRANSITIONAL ISSUES
====================
- pulmonary hypertension clinic follow-up given worsening RV
dysfunction
- close monitoring of volume status and weight to ensure
discontinuation of diuretic is sustainable
- monitor renal function
- check CK, consider restarting statin if back to normal range,
consider further work-up otherwise
- consider very low dose beta blocker if HR will tolerate and
dont feel this is too much polypharmacy |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Diflucan / amlodipine
Attending: ___.
Chief Complaint:
Worsening of RLE ulcer
Major Surgical or Invasive Procedure:
Right below the knee amputation ___
History of Present Illness:
___ with h/o T2DM and severe PAD Hx right profund-BKpop bypass
with NRGSV c/b chronic non-healing wound on RLE, presented to
the
ED with chronic right foot ischemia with infection.
She was recently admitted ___ for IV antibiotics. She was
on vanc/zosyn prior to transitioning to levofloxacin PO and
ultimately, on discharge, she was transitioned to Moxifloxacin
as chronic suppressive therapy This admission was complicated by
an UGI bleed from stomach ulcer. s/p EGD on ___ with
epinephrine injection to ulcerated stomach lesion. Antiplatelet
therapy was discussed with vascular surgery and they recommended
holding plavix and continuing aspirin. She denied fevers or
chills, but reports her foot at times becomes "red like it's on
fire" with increased bleeding and discharge. The most recent
episode of this was yesterday.
In the ED, initial VS were: 100.8 113 130/72 18 99% RA
Exam notable for: Grossly infected RLE
Labs showed: WBC 20.7, plt 1166, lactate 1.6
Consults: Vascular surgery: No acute surgical intervention, but
ultimately needs amputation. Patient in past not amendable to
amputation.
Patient received: morphine 2 mg IV, oxycodone 10 mg, 1 g IV
vancomycin
Transfer VS were: Stable
On arrival to the floor, patient reports worsening appearance
and
pain in RLE, but no fevers, chills, rigors. Also denied any
blood
in stool. Patient reports that she is not amendable to
amputation, and would have it done this admission.
Past Medical History:
PAST MEDICAL AND SURGICAL HISTORY:
-Severe peripheral vascular disease
-Coronary artery disease s/p BMS to OM1 in ___ (for UA and
+ETT)
-Carotid artery stenosis
-Diabetes
-Hypertension
-Current tobacco use
PAST SURGICAL HISTORY:
-___ to ___ Numerous skin grafts and debridement surgeries for
infections of the right leg
-___: Right common profunda femoris to below the knee
popliteal bypass with non-reversed greater saphenous vein graft
tunneled subcutaneously. Angioscopy and lysis of valve using a
valvulotome.
-___: Right common femoral endarterectomy.
-___: Left common femoral-to-anterior tibial artery bypass
using a Distaflo polytetrafluoroethylene (PTFE) graft.
-___: Balloon angioplasty and stenting of left common
iliac
artery.
-___: Exploratory laparoscopy and open cholecystectomy.
Social History:
___
Family History:
Mother died at age ___ DM2.
Father died in ___ unknown cancer.
Asthma.
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
GENERAL: uncomfortable appearing in no acute distress
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: JVP not elevated
HEART: RRR, S1/S2, ___ SEM best heart at ___, holosystolic ___
murmur best heard at apex. No gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi. Mild bibasilar
crackles.
ABDOMEN: nondistended, mild epigatric tenderness. no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: RLE with extensive ulceration over dorsal aspect
from foot to mid shin with areas of necrosis and some purulent
exudate. ___ + edema at the knee.
PULSES: dopplerable per ED
NEURO: A&Ox3, moving all 4 extremities with purpose. Sleepy
DISCHARGE PHYSICAL EXAM
=========================
24 HR Data (last updated ___ @ 810)
Temp: 98.2 (Tm 98.2), BP: 105/65 (93-106/59-65), HR: 74
(70-86), RR: 18 (___), O2 sat: 100% (98-100), O2 delivery: RA
GENERAL: sitting up in bed, appears comfortable, calm and
pleasant
NECK: JVD not elevated at 90 degrees
HEART: RRR, S1/S2, III/VI systolic murmur at LSB heard
throughout
precordium
LUNGS: Good air movement without crackles, no accessary muscle
use
ABDOMEN: nondistended, nontender, no rebound/guarding
EXTREMITIES: RLE s/p BKA dressed, LLE with trace dependent edema
to mid thigh, warm
NEURO: A&Ox3, moving all 4 extremities with purpose
Pertinent Results:
ADMISSION LABS
==============
___ 03:20PM BLOOD WBC-20.6* RBC-2.98* Hgb-8.6* Hct-28.6*
MCV-96 MCH-28.9 MCHC-30.1* RDW-18.4* RDWSD-61.9* Plt ___
___ 03:20PM BLOOD Neuts-77.0* Lymphs-13.2* Monos-8.3
Eos-0.5* Baso-0.3 NRBC-0.1* Im ___ AbsNeut-15.82*
AbsLymp-2.72 AbsMono-1.70* AbsEos-0.11 AbsBaso-0.06
___ 06:51AM BLOOD Ret Man-2.9* Abs Ret-0.09
___ 03:20PM BLOOD UreaN-6 Creat-0.5 Na-137 K-5.7* Cl-94*
HCO3-26 AnGap-17
___ 12:28PM BLOOD ALT-54* AST-26 AlkPhos-99 TotBili-0.2
___ 12:28PM BLOOD Albumin-2.5*
___ 06:51AM BLOOD calTIBC-163* Ferritn-128 TRF-125*
___ 06:51AM BLOOD CRP-201.1*
IMAGING AND DIAGNOSTICS
========================
RIGHT FOOT XRAY ___:
1. Diffuse severe osteopenia limits evaluation for
osteomyelitis. No definite radiographic findings of
osteomyelitis.If high clinical concern persists, consider MRI
which is more sensitive.
2. Compared to ___, increased extensive soft tissue
edema of the
imaged right foot.
DISCHARGE LABS
==============
___ 06:18AM BLOOD WBC-13.9* RBC-2.87* Hgb-8.0* Hct-25.9*
MCV-90 MCH-27.9 MCHC-30.9* RDW-19.3* RDWSD-62.9* Plt ___
___ 06:18AM BLOOD Glucose-152* UreaN-8 Creat-0.4 Na-135
K-4.7 Cl-96 HCO3-26 AnGap-13
___ 06:18AM BLOOD Calcium-7.9* Phos-3.2 Mg-1.8
Radiology Report
EXAMINATION: FOOT AP,LAT AND OBL RIGHT
INDICATION: History: ___ with chronic RLE ulcer// please eval for evidence of
osteomyelitis
TECHNIQUE: Three views right foot.
COMPARISON: Right ankle and foot radiographs from ___.
FINDINGS:
Extensive soft tissue edema involving the imaged right foot is increased from
___. No acute fractures or dislocation are seen. There is diffuse
osseous demineralization, which limits sensitivity for the radiographic
detection of osteomyelitis. Given this, no definite radiographic evidence of
osteomyelitis is identified.
IMPRESSION:
1. Diffuse severe osteopenia limits evaluation for osteomyelitis. No definite
radiographic findings of osteomyelitis.If high clinical concern persists,
consider MRI which is more sensitive.
2. Compared to ___, increased extensive soft tissue edema of the
imaged right foot.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Abnormal labs
Diagnosed with Fever, unspecified
temperature: 100.8
heartrate: 113.0
resprate: 18.0
o2sat: 99.0
sbp: 130.0
dbp: 72.0
level of pain: 10
level of acuity: 2.0 | Ms. ___ is a ___ year old woman with type 2 diabetes, recent
peptic ulcer bleed ___ on Plavix, peripheral vascular
disease s/p RCFA endarterectomy ___ and R profund-BKpop
bypass with NRGSV ___ and chronic non-healing RLE wound who
presented with elevated WBC and exam concerning for RLE wet
gangrene, now s/p R BKA on ___.
# Leukocytosis
# RLE Wet Gangrene
# Severe peripheral vascular disease
# S/p R-BKA ___
Patient with long-standing history of severe peripheral vascular
disease and chronic RLE non-healing wound. She presented with
signs of acute wound infection: leukocytosis, thrombocytosis,
CRP >200, and exam consistent with RLE wound infection. She was
transitioned from moxifloxacin to vancomycin/cefepime/flagyl,
day of antibiotic ___. On ___ she went for R BKA with
vascular surgery. Aspirin was continued for vascular disease;
plavix was held in the setting of prior gastric ulcer bleed. She
continued IV antibiotics while admitted until ___ for a ___nd was transitioned to moxifloxacin at discharge to
complete antibiotics course on ___.
# Acute on Chronic Pain
Continued home regimen of: oxycontin 20mg BID. After discussion
with chronic pain team, she her home regimen was temporarily
increased in the post-operative period to lyrica 150mg BID,
dilaudid ___ Q4H for planned three days with titration back to
home regimen as outlined below. She received Morphine 4mg IV for
immediate post-operative pain.
# Hypoxia
Patient with 2.5L oxygen requirement, crackles and edema
post-op. ___ have been triggered by volume given during
procedure. TTE showed no significant heart failure. She was
diuresed with 20 mg IV lasix and then transitioned back to Lasix
20mg PO BID to help reduced peripheral edema and assist in wound
healing. She was discharged on 20mg daily Lasix.
# HFpEF
Patient with RLE edema, but LLE without much pitting edema.
Prior TTE in ___ with preserved EF, mild AS. As above, TTE
showed mild AS with no evidence of LV wall thickening or
depressed EF.
# Thrombocytosis
Elevated to 1000s, which seems to be how she presents in the
setting of infection. Hematology was consulted and recommended
sending JAK2 with reflex CALR and MPL; this will be done as an
outpatient. As above, she was continued on aspirin. Improved
slightly after amputation.
# Normocytic mixed anemia
Anemia workup consistent with combination of iron deficiency and
inflammation (likely chronic and acute inflammation). Patient
will need EGD post-discharge to biopsy peptic ulcer and rule out
malignancy post discharge. Home oral iron was continued.
# CAD s/p PCI (s/p BMS to OM1 in ___:
Continued aspirin as above.
# Type II Diabetes
A1c ___ 8.5%. Metformin was held and she was on ISS while
inpatient.
# HTN:
Held home losartan pre-op. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left subtrochanteric femur fracture
Major Surgical or Invasive Procedure:
___: Left long trochanteric femoral nail
History of Present Illness:
___ female past medical history hypertension,
hyperlipidemia who presents following a fall. Patient was
walking up stairs and slipped, falling down backwards 2 stairs
earlier this morning. She experienced immediate pain in her
left
hip and was unable to bear weight on it since then. There is no
head strike or loss of consciousness. She presented to outside
hospital where x-rays were performed demonstrating a hip
fracture. She was transferred to ___ per her preference.
Past Medical History:
Hypertension, hyperlipidemia
Social History:
___
Family History:
NC
Physical Exam:
Left lower Extremity
- Incisional dressing c/d/i
- Fires ___
- SILT s/s/sp/dp/tn
- Foot WWP
Pertinent Results:
See OMR
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 50 mg PO QPM
2. Hydrochlorothiazide 25 mg PO DAILY
3. Montelukast 10 mg PO QPM
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
3. Docusate Sodium 100 mg PO BID:PRN Constipation - Second Line
4. Enoxaparin (Prophylaxis) 40 mg SC QHS
RX *enoxaparin 40 mg/0.4 mL 1 syringe subcutaneously once a day
Disp #*28 Syringe Refills:*0
5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain
Partial fill OK. No driving/machinery. wean per discharge
instructions
RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours as needed
Disp #*30 Tablet Refills:*0
6. Senna 8.6 mg PO BID:PRN Constipation - First Line
7. Hydrochlorothiazide 25 mg PO DAILY
8. Losartan Potassium 50 mg PO QPM
9. Montelukast 10 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left subtrochanteric femur (hip) 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: FEMUR (AP AND LAT) LEFT
INDICATION: Left femur fracture ORIF.
TECHNIQUE: Intra op fluoroscopy was performed without a radiologist present.
Total fluoroscopy time 142.8 seconds.
COMPARISON: Left femur films from ___.
FINDINGS:
Eleven intraoperative images were acquired without a radiologist present.
Images show intraoperative placement an intramedullary rod and transfixing
screws for the femoral fracture..
IMPRESSION:
Intraoperative images were obtained during ORIF of left femoral fracture..
Please refer to the operative note for details of the procedure.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: L Hip fracture, Transfer
Diagnosed with Displaced intertrochanteric fracture of left femur, init, Fall on same level, unspecified, initial encounter
temperature: 97.8
heartrate: 83.0
resprate: 16.0
o2sat: 97.0
sbp: 110.0
dbp: 63.0
level of pain: 2
level of acuity: 3.0 | The patient presented to the emergency department and was
evaluated by the orthopaedic surgery team. The patient was found
to have left subtrochanteric femur fracture and was admitted to
the orthopaedic surgery service. The patient was taken to the
operating room on ___ for long trochanteric femoral nail,
which the patient tolerated well. For full details of the
procedure please see the separately dictated operative report.
The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to home was appropriate. The ___ hospital course
was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weightbearing as tolerated in the left lower extremity, and will
be discharged on Lovenox for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion was
had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
linezolid
Attending: ___.
Chief Complaint:
Rectal adenocarcinoma
Major Surgical or Invasive Procedure:
___ Transanal minimally invasive surgery
(TAMIS) excision of rectal cancer
___ TAMIS Coagulation postoperative bleeding
History of Present Illness:
___ with autoimmune pancreatitis c/b cholangitis and
pseudocysts. Also had multiple episodes of pyelonephritis c/b
empysematous pyelo requiring left nephrectomy c/b colonic
abscess
and fistula ultimately requiring diverting ileostomy. Most
recently on CT scan, pt noted to have colitis, underwent
lower endoscopy identifing a polyp in the rectum (path:
adenocarcinoma less than 1 mm from the margin). Consequently he
is scheduled to have surgery with Dr. ___ on
___.
Pt USH and asymptomatic when ___ today took vitals and noted
that
his HR was in the 130s and his BP was in the 140's. Given ETOH
abuse history, pt denies recent ETOH consumption. States
yesterday he drank 2 cups of milk and the day prior he drank
approximately 500 cc of water. Poor appetite, states he has had
10# weight loss/month. Denies f/c or abdominal pain. Ostomy
output normal (no diarrhea).
Past Medical History:
Past Medical History:
-Chronic autoimmune pancreatitis with EtOH abuse
-Distal biliary stricture with multiple ERCPs
-internal/external PTBD ___
-metal stent ___
-exchange metal for plastic stent w cholangitis ___
-removal of stent ___
-Recurrent renal bed abscess (___)
-colonic fistula (___)
-Klebsiella bacteremia (___)
-Strep viridans bacteremia (___)
-Chronic HCV (treated, viral load undetectable ___
-DM2
-Pyelonephritis s/p L nephrectomy ___
-Hypoaldosteronism (type 4 RTA)
-C. diff colitis
-Depression
Past Surgical History:
L nephrectomy ___ for pyelonephritis
Social History:
___
Family History:
Mother had stomach cancer.
Physical Exam:
PE: on admission
Supine 104 130/89
Sitting 120 119/84
Standing 139 ___ 99 135/86 20 99% RA
NAD, A+OX3
No jaundice, cachextic appearing
Tachycardic
CTAB
Soft, NT/ND, ostomy pink with toothpaste consistency stool
no c/c/e
on discharge
VS. 99.4, 98, 20, 103/70, 18, 100RA
Gen AAOX3 NAD, no juandice
RRR
CTAB
Soft, NT/ND ostomy pink with good output green in color
no edema in b/l ___
Rectum no lesion noted or blood seen
Pertinent Results:
___ 09:55PM URINE HOURS-RANDOM
___ 09:55PM URINE UHOLD-HOLD
___ 09:55PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 09:55PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 09:55PM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 09:55PM URINE HYALINE-1*
___ 09:55PM URINE MUCOUS-RARE
___ 09:15PM GLUCOSE-119* UREA N-14 CREAT-0.9 SODIUM-138
POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-17* ANION GAP-25*
___ 09:15PM ALT(SGPT)-52* AST(SGOT)-76* ALK PHOS-119 TOT
BILI-0.4
___ 09:15PM LIPASE-100*
___ 09:15PM ALBUMIN-4.0
___ 04:35PM ___ PTT-29.3 ___
___ 04:15PM LACTATE-7.8*
___ 03:25PM GLUCOSE-133* UREA N-16 CREAT-1.0 SODIUM-137
POTASSIUM-4.8 CHLORIDE-100 TOTAL CO2-18* ANION GAP-24*
___ 03:25PM estGFR-Using this
___ 03:25PM ALT(SGPT)-65* AST(SGOT)-97* ALK PHOS-139* TOT
BILI-0.4
___ 03:25PM LIPASE-91*
___ 03:25PM ALBUMIN-4.5 CALCIUM-9.1 PHOSPHATE-3.2
MAGNESIUM-1.7
___ 03:25PM ASA-NEG ___ ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 03:25PM WBC-7.6 RBC-3.61*# HGB-12.9*# HCT-38.5*#
MCV-107* MCH-35.6* MCHC-33.4 RDW-13.8
___ 03:25PM NEUTS-71.7* ___ MONOS-6.0 EOS-0.8
BASOS-0.6
___ 03:25PM PLT COUNT-237
Medications on Admission:
vit b 100', iron 325', folic acid', metformin 500'', omeprazole
___ 20', ensure
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 5 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth Q12hrs Disp #*4 Tablet Refills:*0
2. MetFORMIN (Glucophage) 500 mg PO BID
3. Omeprazole 20 mg PO DAILY
4. Acetaminophen 650 mg PO Q6H:PRN Pain
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by
mouth q8hrs Disp #*20 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Rectal Cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPHS
HISTORY: Fatigue and failure to thrive.
COMPARISONS: Radiographs from ___ and CT from ___.
TECHNIQUE: Chest, PA and lateral.
FINDINGS: The heart is normal in size. The mediastinal and hilar contours
appear within normal limits. There is no pleural effusion or pneumothorax.
The lungs appear clear. A pigtail catheter projects over the epigastric
region.
IMPRESSION: No evidence of acute disease.
Radiology Report
INDICATION: History of rising lactate and colostomy. Please evaluate for
abscess.
COMPARISONS: CT abdomen and pelvis from ___.
TECHNIQUE: ___ MDCT images were obtained through the abdomen and pelvis after
the administration of IV contrast. Multiplanar reformatted images in coronal
and sagittal axes were generated and reviewed.
FINDINGS: The bases of the lungs are clear.
Again noted is pneumobilia along with mild intrahepatic biliary ductal
dilatation; however, the biliary stent is overall unchanged in position. The
pancreas is diffusely calcified, consistent with chronic pancreatitis and the
splenic vein is attenuated with significant collateralization. The hepatic
and portal veins appear to be patent. The patient has had a prior left
nephrectomy. No drainable fluid collection is seen in this region; however,
there has been interval improvement of the previously noted fluid in this
region.
Compared to the prior exam from ___, there has been overall interval
improvement of the pancreatic tail pseudocyst, now measuring 2 cm x 1 cm,
series 2, image 26. It also appears to be less well defined. Again seen is
fluid and stranding in the left upper quadrant. Prominent peripancreatic and
left para-aortic lymph nodes are stable compared to the prior exam. The right
kidney enhances normally. The visualized portions of the stomach and small
bowel appear to be unremarkable. A colostomy is again seen. There appears to
be stable stranding surrounding the diverting ileostomy. The colon is
collapsed and chronically thickened with slight interval increase in
surrounding fat stranding on the right. There is no evidence of obstruction.
The abdominal aorta is normal in caliber.
CT PELVIS: The urinary bladder is mildly thickened. The prostate is
enlarged. The seminal vesicles are unremarkable. There is no pelvic wall or
inguinal lymphadenopathy.
OSSEOUS STRUCTURES: No lytic or blastic lesions concerning for malignancy are
identified.
IMPRESSION:
1. There is chronic thickening throughout the colon; however, there appears
to be slight interval increase in the surrounding fat stranding suggestive of
slight worsening of the patient's inflammatory bowel disease.
2. Interval improvement of the patient's pancreatic tail pseudocyst, now
measuring up to 2 cm compared to the prior exam at which time this measured up
to 4 cm. A superinfection cannot be excluded.
3. Status post left nephrectomy. There is evidence of stranding around the
body and tail of the pancreas. This appears slightly increased compared to
the prior exam.
Gender: M
Race: ASIAN - CHINESE
Arrive by AMBULANCE
Chief complaint: Dizziness, Weakness
Diagnosed with DEHYDRATION, ACIDOSIS
temperature: 99.2
heartrate: 112.0
resprate: 18.0
o2sat: 98.0
sbp: 117.0
dbp: 85.0
level of pain: 13
level of acuity: 2.0 | Patient was seen in the ED on the ___ for dehydration and
intoxication with alcohol. Blood alcohol level was 198. Patient
was held in ED observation for rehydration and put on CIWA
scale/protocol. On ___ he was admitted under the colorectal
service for his Transanal minimally invasive surgery (TAMIS) for
excision of rectal adenocarcinoma. On ___ the patient
fainted was hypotensive and tachycardica recieved a liter bolus
followed by a blood transfusion for HCT ___. On ___ he
underwent a TAMIS Coagulation for postoperative bleeding.
___ 1u pRBC, 30-->25.9-->25.7 felt dizzy, tachycardiac
recieved a unit of blood HCT was 30.2 and repeat oon ___
31.6. Patient is tolerating regular diet ambulating
independently vital signs stable ready for discharge home on
___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Azithromycin / Haldol / Cipro / clindamycin / Bactrim / Reglan /
Saphris / Keflex / adhesive tape / Zofran (as hydrochloride) /
Augmentin / erythromycin base / ciprofloxacin / doxycycline /
Penicillins / Latuda
Attending: ___.
Chief Complaint:
wt loss
Major Surgical or Invasive Procedure:
Port placement
GJ tube replacement
History of Present Illness:
Ms. ___ is a ___ woman with history of severe
anorexia nervosa ___ hospitalization at ___ s/p GJ tube for
malnutrition,anxiety/depression, recent admission for
malnutrition due to anorexia presenting with dizziness
Patient was admitted ___ to ___. She was referred from clinic
for electrolyte abnormalities and weight loss. She was treated
for anorexia and placed on an individualized eating disorder
protocol. She was followed closely by a multidisciplinary team
of
medicine, psychiatry, social work, nutrition, and case
management. She ultimately left AMA, which her court-appointed
guardian allowed. She was subsequently provided a letter of
termination from her primary care practice.
The patient was again admitted from ___ for syncope due
to
severe othostatic hypotension and malnutrition. After a
multidisciplinary team meeting, the patient was initiated on a
standard eating disorder protocol. However, the patient left
against medical advice with the assent of her court-appointed
guardian.
She then went to ___ in ___ in early ___ but
unfortunately was asked to leave after 4 days. She says unsure
why.
She was quite disappointed as she had pushed so hard to go to
___. At that point she felt there was no point in treating
anorexia. Since then wanted to focus on more palliative approach
which her guardian supported. Her PCP would visit weekly in her
in her home, but no lab tests or treatment were pursued with
just
waiting for her to die.
She has little to no oral intake and has lost signif wt. Wts
this
year:
___
Today 124 (BMI 19)
Patient reports worsening vision, weakness, joint pain, foot
swelling, dizziness. numbness in feet. frequent cramps. Coolness
of feet.
On ___ was playing a game where she felt orthostatic, fell to
her knees and then got back up. She was overall feeling much
weaker than normal and was dizzy. She reports feeling scared by
these symptoms and the thought of dying.
She has reversed course, but definitively states she wants to
live - therefore decided to come in for treatment.
In the ED, initial vitals: 7 98.6 78 109/62 16 100% RA
Exam notable for: Alert, cachectic appearing in NAD; Abd soft,
GJ
in place, ntnd; pain with abduction and adduction of both eyes,
vision intact
On arrival to the floor, the patient reports the above history.
Feels quite tired. worried about her symptoms. Very anxious
about
being here.
GJ tube balloon has come out and needs to be replaced. Periph IV
has blown and per pt she cannot have any more picc. No iv can be
placed.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
- Anorexia nervosa
- Anxiety/Depression/Borderline personality disorder
- Asthma
- Iron deficiency anemia
- Chronic abdominal pain/constipation
- PICC-associated DVT
Social History:
___
Family History:
years; multiple sclerosis.
Maternal grandmother: OCD and anxiety
Father: history of eating disorder
Maternal great uncle: committed suicide
Brother: ___ disease
Physical Exam:
VITALS: 98.8 PO 103 / 63 R Sitting 65 18 98% Room air
GENERAL: Alert and in no apparent distress, tired appearing,
markedly cachectic
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate, MM dry
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds decreased. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength ___
bilaterally, reflexes brisk
SKIN: No rashes or ulcerations noted, feet very cold to touch
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, cannot stand
PSYCH: pleasant, appropriate affect
Discharge exam
VITALS: afebrile and stable (Reviewed in Eflowsheets)
GEN: lying in bed in NAD
HEENT/Neck: NC/AT, external ear intact, anicteric sclera, MM
dry,
OP clear
MSK: R port site stable
CV: RRR no m/r/g, no carotid bruits appreciated
PULM: CTAB no wheezes, rales, or crackles. Symmetric expansion
GI: soft NT/ND +BS no rebound or guarding, GJ site clean
EXT: warm well perfused, no pitting edema
PSYCH: conversant, appropriate, makes good eye contact
SKIN: no rashes or jaundice
Pertinent Results:
___ 04:00AM BLOOD WBC-10.8* RBC-3.85* Hgb-11.6 Hct-34.6
MCV-90 MCH-30.1 MCHC-33.5 RDW-13.0 RDWSD-42.4 Plt ___
___ 02:29PM BLOOD Glucose-103* UreaN-4* Creat-0.6 Na-142
K-3.7 Cl-106 HCO3-25 AnGap-11
___ 02:29PM BLOOD Calcium-8.3* Phos-4.5 Mg-1.7
___ 04:00AM BLOOD ALT-7 AST-16 AlkPhos-63 TotBili-0.3
Discharge labs
___ 06:12AM BLOOD WBC-6.4 RBC-2.94* Hgb-8.8* Hct-27.0*
MCV-92 MCH-29.9 MCHC-32.6 RDW-12.6 RDWSD-41.4 Plt ___
___ 06:12AM BLOOD Glucose-93 UreaN-10 Creat-0.5 Na-144
K-4.1 Cl-110* HCO3-25 AnGap-9*
___ 06:12AM BLOOD Calcium-8.0* Phos-4.0 Mg-1.6 Iron-89
___ 06:12AM BLOOD calTIBC-205* Ferritn-13 TRF-158*
Xray
FINDINGS:
Patent right internal jugular vein. Final fluoroscopic image
showing port withcatheter tip terminating in the right atrium.
IMPRESSION:
Successful placement of a single lumen chest power Port-a-cath
via the right internal jugular venous approach. The tip of the
catheter terminates in the right atrium. The catheter is ready
for use.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Bisacodyl 10 mg PO QHS
2. ChlorproMAZINE 50 mg PO QID anxiety
3. ClonazePAM 1 mg PO BID:PRN anxiety, agitation
4. Lactulose 30 mL PO DAILY
5. LORazepam 2 mg PO QHS
6. Polyethylene Glycol 17 g PO TID:PRN Constipation - First Line
Reason for PRN duplicate override: Alternating agents for
similar severity
7. Promethazine 25 mg PO Q6H:PRN nausea / vomiting
8. Simethicone 40-80 mg PO QID:PRN stomach upset
9. TraZODone 100 mg PO QHS:PRN sleep
10. Prazosin 2 mg PO QHS
11. HydrOXYzine 25 mg PO BID:PRN itching
12. Meclizine 25 mg PO QHS:PRN nausea
13. Linzess (linaCLOtide) 290 mcg oral DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
2. Cetirizine 10 mg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Heparin Flush (10 units/ml) 5 mL IV DAILY and PRN, line
flush
5. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
6. Multivitamins W/minerals 15 mL PO DAILY
7. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
8. ChlorproMAZINE 75 mg PO QID anxiety
9. Polyethylene Glycol 17 g PO TID
10. Bisacodyl 10 mg PO QHS
11. ClonazePAM 1 mg PO BID:PRN anxiety, agitation
12. HydrOXYzine 25 mg PO BID:PRN itching
13. Lactulose 30 mL PO DAILY
14. Linzess (linaCLOtide) 290 mcg oral DAILY
15. LORazepam 2 mg PO QHS
16. Meclizine 25 mg PO QHS:PRN nausea
17. Prazosin 2 mg PO QHS
18. Promethazine 25 mg PO Q6H:PRN nausea / vomiting
19. Simethicone 40-80 mg PO QID:PRN stomach upset
20. TraZODone 100 mg PO QHS:PRN sleep
Discharge Disposition:
Home
Discharge Diagnosis:
Anorexia nervosa
Severe malnutrition
Anxiety/Depression
Discharge Condition:
Mental Status: Coherent
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old woman with long standing GJ tube. Balloon appears to
be leaking and tube now coming out. Unfortunately it has been done under MAC//
Can we replace GJ tube.
COMPARISON: None.
TECHNIQUE: OPERATORS: Dr. ___ Interventional ___ and
Dr. ___, Interventional Radiology fellow performed the procedure.
ANESTHESIA: General sedation was provided by anesthesia.
MEDICATIONS: Please see anesthesia note for medication details.
CONTRAST: 30 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 45 second, 2 mGy
PROCEDURE: MIC-KEY low profile gastrojejunostomy exchange.
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. The tube site was prepped and draped in the usual sterile fashion.
The existing tube was injected with contrast and showed opacification of the
gastric rugae and duodenum. A stiff Glidewire was introduced into the
duodenum through the jejunal port. The existing feeding tube was then
removed. A 18 ___ 2 cm stoma length MIC-KEY low profile gastrojejunostomy
catheter was advanced over the wire into position.
The catheter balloon was inflated with 7 mL of dilute contrast and retracted
to approximate the stomach wall. Contrast was injected through both ports did
confirm position. The catheter was then flushed and capped. Sterile
dressings were applied.
The patient tolerated the procedure well and there were no immediate
complications.
FINDINGS:
1. Successful exchange of a 18 ___ 2 cm stoma length MIC-KEY
gastrojejunostomy tube with its tip in the proximal jejunum.
IMPRESSION:
Successful exchange of a 18 ___ 2 cm stoma length MIC-KEY gastrojejunostomy
tube with its tip in the proximal jejunum.
Radiology Report
INDICATION: ___ year old woman with anorexia, malnutrition, multiple
admissions for dehydration and very poor access.// Single Lumen Port Placement
COMPARISON: None.
TECHNIQUE: OPERATORS: Dr. ___ Interventional ___ and
Dr. ___, Interventional Radiology fellow performed the procedure.
ANESTHESIA: General sedation was provided by anesthesia.
MEDICATIONS: Please see anesthesia note for medication details.
CONTRAST: None.
FLUOROSCOPY TIME AND DOSE: 43 seconds, 1 mGy
PROCEDURE
1. Right internal jugular approach chest single lumen Port-a-cath placement
PROCEDURE DETAILS: Following the explanation of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The upper chest was prepped and draped in the usual sterile fashion.
Under continuous ultrasound guidance, the patent right internal jugular vein
was compressible and accessed using a micropuncture needle. Permanent
ultrasound images were obtained before and after intravenous access, which
confirmed vein patency. Subsequently a Nitinol wire was passed into the right
atrium using fluoroscopic guidance. The needle was exchanged for a
micropuncture sheath. The Nitinol wire was removed and a short ___ wire was
advanced to make appropriate measurements for catheter length. The ___ wire
was then passed distally into the IVC.
Next, attention was turned towards creation of a subcutaneous pocket over the
upper anterior chest wall. After instilling superficial and deeper local
anesthesia using lidocaine mixed with epinephrine, a 2.5 cm transverse
incision was made and a subcutaneous pocket was created by using blunt
dissection. The single lumen port was then connected to the catheter. The
catheter was tunneled from the subcutaneous pocket towards the venotomy site
from where it was brought out using a tunneling device. The port was then
connected to the catheter and checks were made for any leakage by accessing
the diaphragm using a non-coring ___ needle. No leaks were found.
The venotomy tract was dilated using the introducer of the peel-away sheath
supplied. Following this, the peel-away sheath was placed over the ___ wire
through which the port was threaded into the right side of the heart with the
tip in the right atrium. The sheath was then peeled away.
The subcutaneous pocket was closed in layers with ___ interrupted and ___
subcuticular continuous Vicryl sutures. ___ subcuticular Vicryl sutures and
Steri-strips were used to close the venotomy incision site. Steri-Strips were
applied over the sutures. Final spot fluoroscopic image demonstrating good
alignment of the catheter and no kinking. The tip is in the right atrium.
The port was accessed using a non coring ___ needle and could be aspirated
and flushed easily. Sterile dressings were applied. The patient tolerated the
procedure well without immediate complication. The port was left accessed as
requested.
FINDINGS:
Patent right internal jugular vein. Final fluoroscopic image showing port with
catheter tip terminating in the right atrium.
IMPRESSION:
Successful placement of a single lumen chest power Port-a-cath via the right
internal jugular venous approach. The tip of the catheter terminates in the
right atrium. The catheter is ready for use.
Gender: F
Race: WHITE - EASTERN EUROPEAN
Arrive by WALK IN
Chief complaint: Body pain, Chest pain, Dizziness
Diagnosed with Anorexia nervosa, unspecified
temperature: 98.6
heartrate: 78.0
resprate: 16.0
o2sat: 100.0
sbp: 109.0
dbp: 62.0
level of pain: 7
level of acuity: 3.0 | ___ yo woman with severe anorexia nervosa,
anxiety/depression/borderline d/o, with several hospitalization
for severe malnutrition, presents now from home with weight loss
and poor PO intake.
# Severe Protein Calorie Malnutrition:
# Anorexia Nervosa:
The patient presented with significant weight loss with symptoms
of volume depletion and malnourishment. ___ is extremely
complex and gave conflicting signals. She does not want to die,
but also has many concerns about eating disorder protocol. She
also has concerns about which nurses ___ care for her, which
providers ___ see her, whether she can get a private room. She
was at high risk for refeeding syndrome.
Team meeting ___ occurred with psych, RN, and PCP with nutrition
to define next steps. Tube feeds were started and she was
monitored closely for refeeding syndrome. She remained
orthostatic and dependent of IVF as well. Her tube feeds were
advanced to goal and she tolerated them without diarrhea, n/v,
or abdominal pain.
Additional team meeting held on ___ and ___ to define further
goals for hospitalization and disposition. Goal was to have
patient's orthostasis improve so fluids could be stopped.
Patient agreed to partial hospitalization program at ___ in
___. However patient wanted to leave AMA on ___ and her
guardian was accepting of these riks and agreed to let her leave
AMA again. Please see note from ___ for further details of this
discussion.
# Depression
# Anxiety
# Borderline personality disorder:
Followed by psychiatry during last admission and they were
consulted for this admission as well.
- Continued clonazepam, lorazepam, chlorpromazine (at increased
dose 75mg QID for now), trazodone, prazosin
# Constipation
# Abdominal pain
# Suspected IBS:
- Continued aggressive bowel regimen utilized during recent
hospitalization
# Access:
Port placed for poor PIV access and apparently unable to have
PICC placement. She initially had pain and an adhesive reaction
which improved with benadry and temporary opioid analgesics
# Iron deficiency anemia: Received IV iron infusions previously
- Trended CBC
Greater than 30 minutes were spent providing and coordinating
care for this patient on day of discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain and umbilical bulge
Major Surgical or Invasive Procedure:
___: Umbilical hernia repair
History of Present Illness:
___ with no prior surgical history presents with acute onset
abdominal pain and bulge which he noticed around 2 pm today. He
works in ___ and his job does entail heavy lifting, but he
denies heavy lifting prior to this event. he recalls an episodes
of feeling mild pain and abdominal bulge a month ago, but it
spontaneously improved. He states that the pain was localized to
one spot- umbilical area and did not include the entire abdomen
or had crampy character. he had associated nausea but not
vomiting. He was able to move his bowel and was passing flatus.
In ED he continued to have pain and reportedly had incarcerated
umbilical hernia which was reduced by ED. He does reports that
even before the reduction he had some overlying skin erythema
but no sings of skin necrosis. After the reduction patient was
found to have lactate of 2.2 and WBC of 15. At that point
surgery consult was requested to manage this further. He reports
having no pain at this point, denies nausea or vomiting and
continues to be afebrile with stable vitals signs.
Past Medical History:
PMH: Asperger's syndrome
PSH: none
Social History:
___
Family History:
Non-contributory
Physical Exam:
Physical Exam:
Vitals: T 99.2, HR 104, BP 137/80, sat 95%/RA
GEN: A&Ox3, appears comfortable, non toxic looking
HEENT: No scleral icterus, mucus membranes dry appearing
CV: regular
PULM: Clear to auscultation b/l, No labored breathing
ABD: obese, Soft, nondistended, nontender, no rebound or
guarding, small area of erythema around the umbilicus, no
palpable bulge or mass, no tenderness or necrotic skin changes
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam:
VS: T: 98.1, BP: 121/61, HR: 103, RR: 18, O2: 96% RA
GENERAL: A+Ox3, NAD
CV: tachycardic, regular rhythm
PULM: CTA b/l
ABD: mid-abdominal incision with steristrips, 4x4 gauze and
tegaderm c/d/i. No s/s erythema. Mildly tender at incision site
with palpation.
EXTREMITIES: ___ warm, well-perfused b/l, no edema
Pertinent Results:
___ 08:13AM ___ COMMENTS-GREEN TOP
___ 08:13AM LACTATE-3.0*
___ 05:00AM GLUCOSE-75 UREA N-15 CREAT-0.8 SODIUM-142
POTASSIUM-3.7 CHLORIDE-102 TOTAL CO2-26 ANION GAP-18
___ 05:00AM CALCIUM-9.1 PHOSPHATE-4.1 MAGNESIUM-2.0
___ 05:00AM WBC-11.0* RBC-5.21 HGB-15.0 HCT-45.7 MCV-88
MCH-28.8 MCHC-32.8 RDW-11.9 RDWSD-38.3
___ 05:00AM PLT COUNT-270
___ 05:00AM ___ PTT-32.1 ___
___ 10:38PM LACTATE-2.2*
___ 10:35PM GLUCOSE-112* UREA N-15 CREAT-0.8 SODIUM-141
POTASSIUM-4.9 CHLORIDE-103 TOTAL CO2-25 ANION GAP-18
___ 10:35PM WBC-15.7* RBC-5.51 HGB-15.7 HCT-47.7 MCV-87
MCH-28.5 MCHC-32.9 RDW-11.9 RDWSD-37.3
___ 10:35PM NEUTS-91.6* LYMPHS-4.8* MONOS-3.0* EOS-0.1*
BASOS-0.2 IM ___ AbsNeut-14.38* AbsLymp-0.76* AbsMono-0.47
AbsEos-0.01* AbsBaso-0.03
___ 10:35PM PLT COUNT-247
IMAGING:
___: CT ABD/PEL:
1. Umbilical hernia containing strangulated omentum which is
likely ischemic.
2. Mild scattered sigmoid diverticulosis in this ___
patient.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Docusate Sodium 100 mg PO BID
please hold for loose stool
3. Senna 8.6 mg PO BID:PRN constipation
4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN pain
do NOT drink alcohol or drive while taking this medication
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*10 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Incarcerated umbilical hernia containing preperitoneal fat.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old man with umbilical hernia sp reduction in ED now with
rising lactate // Intra ab processes
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence: 1) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol
= 24.1 mGy (Body) DLP = 12.0 mGy-cm. 2) Spiral Acquisition 5.0 s, 55.4 cm;
CTDIvol = 16.3 mGy (Body) DLP = 904.4 mGy-cm. Total DLP (Body) = 916 mGy-cm.
COMPARISON: None available.
FINDINGS:
LOWER CHEST: There is scattered subsegmental atelectasis in the bases. There
is no evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There
is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. A few scattered
diverticuli of the sigmoid colon are seen, without evidence of wall thickening
and fat stranding. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: There is an umbilical hernia containing a portion of
hyperenhancing omentum and a small amount of free-fluid.
IMPRESSION:
1. Umbilical hernia containing strangulated omentum which is likely ischemic.
2. Mild scattered sigmoid diverticulosis in this ___ patient.
NOTIFICATION: Impression #1 above was discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 3:28 ___, 9 minutes after discovery
of the findings.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with Umbilical hernia without obstruction or gangrene
temperature: 97.9
heartrate: 98.0
resprate: 20.0
o2sat: 98.0
sbp: 134.0
dbp: 75.0
level of pain: 7
level of acuity: 3.0 | Mr. ___ is a ___ year-old male with no prior surgical history
who presented to the hospital with acute onset abdominal pain
and bulge and was noted to have an incarcerated umbilical hernia
which was reduced by the ED. After the reduction, the patient
was found to have lactate of 2.2 and WBC of 15 and the Acute
Care Surgery service was consulted. The patient was admitted to
the Acute Care Surgery service for further medical care.
On HD2, the patient was taken to the operating room and
underwent umbilical hernia repair. The patient tolerated the
procedure well. After remaining hemodynamically stable in the
PACU, the patient was transferred to the surgical floor for pain
control and to await return of bowel function. The patient was
written for diet as tolerated and tolerated a regular diet. His
pain was controlled with oral acetaminophen and oxycodone.
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, of which there were none.
The patient's blood counts were closely watched for signs of
bleeding, of which there were none. The patient received
subcutaneous heparin and ___ dyne boots were used during this
stay and was encouraged to get up and ambulate as early as
possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
dyspnea and lower extremity edema
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old man with history of DM, HTN, BPH, no known coronary
history, presented to ___ with ___ day history of
progressive DOE, leg edema and chest pressure. Found to be in
new Afib with old LBBB. Had troponin elevation to 0.15, BNP 586.
Given ASA 325, clopidogrel, statin, lasix 40mg IV and started on
heparin gtt prior to transfer for consideration of cardiac cath.
Upon arrival to ___ ED, initial VS 96.8 72 148/96 16 99% 4L.
He was asymptomatic on arrival. Labs here notable for trop 0.04,
mild anemia and mild BUN elevation, Cr 1.2.
On the floor, VS 98.2, 123/56, 85, 20, 94% 2L. Patient and
daughter give very conflicting histories. Appears that dyspnea
has been ongoing for several months vs years, per daughter worse
in the past week. He has been on lasix 40 for many years (for ___
edema) and increased to 80 recently but unchanged symptoms, now
back at 40. Was recently started on Flovent by PCP, without
change in symptoms. He had a 1 min episode of chest pain 5 days
ago without radiation, dyspnea, diaphoresis and self resolved.
___ had another episode last night, per daughter, but patient
denies. Sleeps in a recliner, but patient denies any orthopnea
or PND. ___ edema worse in past week. Has had decreased appetite
and early satiety recently. Patient denies any current chest
pain or pressure, palpitations, abdominal pain, nausea/vomiting.
No fevers/chills.
Past Medical History:
T2 DM: on metformin
Essential hypertension
HLD
Edema
Obesity
Spinal stenosis
Colonic polyps
Gout
Asbestos exposure
Venous insufficiency (chronic) (peripheral)
Mild persistent asthma
Stasis dermatitis of both legs
BPH with obstruction/lower urinary tract symptoms
Social History:
___
Family History:
noncontributory
Physical Exam:
==================
ADMISSION EXAM
==================
Vitals - 98.2, 123/56, 85, 20, 94% 2L
GENERAL: Alert, interactive, NAD
HEENT:sclera anicteric, OP clear. Dry mucous membranes.
NECK: No LAD. JVP at jawline with HOB 30 degrees
CARDIAC: Irregular rhythm, no murmurs appreciated
LUNG: Bibasilar crackles, otherwise clear without wheezes
ABDOMEN: obese, non-distended, non-tender, BS present
EXTREMITIES: moving all extremities well. Pitting edema ___ LEs
to thighs. Unable to palpate pulses due to edema
NEURO: CN II-XII intact. Oriented x3
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
==================
DISCHARGE EXAM
==================
VS: Weight=177.2 T=98.1 BP=142/74 HR=60 RR=18 O2 sat=97 on RA
___ while ambulating)
I/O: ___/3120 Net -1L
GENERAL: Obese elderly man in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. PERRL, EOMI. Conjunctiva were pink, no pallor or
cyanosis of the oral mucosa.
NECK: JVD was not elevated
CARDIAC: regular rate and rhythm, normal S1, S2. No m/r/g.
LUNGS: Resp were unlabored, no accessory muscle use. minimal
Bibasilar crackles
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: trace pitting edema up to knee, warm and well
perfused
Pertinent Results:
=============================
ADMISSION LABS
=============================
___ 01:40AM BLOOD WBC-6.9 RBC-3.72* Hgb-11.9* Hct-37.3*
MCV-100* MCH-32.0 MCHC-31.9 RDW-14.1 Plt ___
___ 01:40AM BLOOD Neuts-71.4* ___ Monos-5.1 Eos-2.0
Baso-0.4
___ 01:40AM BLOOD ___ PTT-56.5* ___
___ 01:40AM BLOOD Glucose-163* UreaN-28* Creat-1.2 Na-142
K-3.6 Cl-97 HCO3-32 AnGap-17
___ 01:40AM BLOOD cTropnT-0.04*
___ 06:31AM BLOOD CK-MB-4 cTropnT-0.04*
___ 12:50PM BLOOD CK-MB-4 cTropnT-0.04*
___ 01:40AM BLOOD Calcium-9.4 Phos-4.4 Mg-1.6
___ 06:31AM BLOOD TSH-3.2
___ 01:40 UA negative
=============================
DISCHARGE LABS
=============================
___ 07:10AM BLOOD WBC-8.5 RBC-4.05* Hgb-13.0* Hct-39.9*
MCV-99* MCH-32.1* MCHC-32.5 RDW-13.7 Plt ___
___ 07:10AM BLOOD ___ PTT-36.8* ___
___ 07:10AM BLOOD Glucose-192* UreaN-33* Creat-1.3* Na-140
K-3.9 Cl-94* HCO3-36* AnGap-14
___ 07:10AM BLOOD Calcium-9.8 Phos-3.6 Mg-1.9
___ 06:05AM BLOOD Triglyc-80 HDL-60 CHOL/HD-2.0 LDLcalc-42
=============================
STUDIES
=============================
___ TTE:
LEFT ATRIUM: Mild ___.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.
LEFT VENTRICLE: Suboptimal technical quality, a focal LV wall
motion abnormality cannot be fully excluded. False LV tendon
(normal variant). No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTIC VALVE: Mildly thickened aortic valve leaflets. Minimal
AS. Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Trivial MR. [Due to acoustic
shadowing, the severity of MR may be significantly
UNDERestimated.]
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild
[1+] TR. Indeterminate PA systolic pressure.
PERICARDIUM: No pericardial effusion. There is an anterior space
which most likely represents a fat pad, though a loculated
anterior pericardial effusion cannot be excluded.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Suboptimal image quality - body habitus.
Conclusions
The left atrium is mildly dilated. The right atrium is
moderately dilated. Due to suboptimal technical quality, a focal
wall motion abnormality cannot be fully excluded. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets are mildly thickened (?#). There is a
minimally increased gradient consistent with minimal aortic
valve stenosis. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
The tricuspid valve leaflets are mildly thickened. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion. There is an anterior space which most
likely represents a prominent fat pad.
IMPRESSION: Suboptimal image quality due to body habitus. Left
and right ventricular systolic function are probably normal, a
focal wall motion abnormality cannot be excluded. Minimal aortic
stenosis and trace aortic regurigtation.
___ Imaging CHEST (PA & LAT)
As compared to the previous radiograph, the lungs are
substantially better inflated. Pre-existing areas of atelectasis
at the left and right lung base have completely cleared. Still
visible are pleural calcifications, more extensive on the left
than on the right. Minimal not characteristic scarring at the
left lung base. No acute changes such as pneumonia or pulmonary
edema.
___ Imaging CARDIAC PERFUSION PHARM
1) Mild reversible perfusion defect in the inferior wall 2) EF
55%,
normal wall motion.
___ Cardiovascular STRESS ___
No angina or ischemic EKG changes to vasodilator stress.
Appropriate hemodynamic response to dypridamole. Nuclear report
sent
separately.
___ Cardiovascular ECG ___
Coarse atrial fibrillation with very bradycardic ventricular
rate with a single ventricular premature contraction or
aberrantly conducted beat. Low QRS amplitude throughout.
Computed QTc interval is prolonged. Compared to the previous
tracing ventricular response to atrial fibrillation is now
profoundly bradycardic with loss of QRS amplitude throughout and
the resolution of left axis deviation. QTc interval has
prolonged. An ongoing metabolic process is suggested. Clinical
correlation is suggested. TRACING #2
___ Imaging CHEST (PORTABLE AP)
FINDINGS: Comparison is made to prior study from ___.
Heart size is enlarged. There is mild pulmonary edema and some
atelectasis at the lung bases. Diaphragmatic calcification at
the right base is again seen. There are no pneumothoraces.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tamsulosin 0.4 mg PO HS
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Allopurinol ___ mg PO DAILY
4. Furosemide 40 mg PO DAILY
5. MetFORMIN (Glucophage) 500 mg PO BID
6. Simvastatin 20 mg PO DAILY
Discharge Medications:
1. Spironolactone 25 mg PO DAILY
2. Allopurinol ___ mg PO DAILY
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Simvastatin 20 mg PO DAILY
5. Tamsulosin 0.4 mg PO HS
6. Aspirin 81 mg PO DAILY
7. Docusate Sodium 100 mg PO BID:PRN constipation
8. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
9. MetFORMIN (Glucophage) 500 mg PO BID
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Senna 8.6 mg PO DAILY:PRN constipation
12. Torsemide 40 mg PO BID
13. Warfarin 5 mg PO DAILY16
14. TraZODone 25 mg PO HS:PRN insomnia
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
acute diastolic heart failure exacerbation
atrial flutter with variable conduction
SECONDARY DIAGNOSES:
HTN
DM
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
STUDY: AP chest, ___.
CLINICAL HISTORY: ___ male with heart failure. New O2 requirement.
Evaluate for pneumonia.
FINDINGS: Comparison is made to prior study from ___.
Heart size is enlarged. There is mild pulmonary edema and some atelectasis at
the lung bases. Diaphragmatic calcification at the right base is again seen.
There are no pneumothoraces.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with sCHF who presented with SOB. // Patient has
diuresed over 20lbs but still cannot come off oxygen. Question other pulmonary
etiology vs continuing pulmonary effusions?
COMPARISON: ___.
IMPRESSION:
As compared to the previous radiograph, the lungs are substantially better
inflated. Pre-existing areas of atelectasis at the left and right lung base
have completely cleared. Still visible are pleural calcifications, more
extensive on the left than on the right. Minimal not characteristic scarring
at the left lung base. No acute changes such as pneumonia or pulmonary edema.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ELEVATED TROPONIN
Diagnosed with CHEST PAIN NOS, DIABETES UNCOMPL ADULT, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA
temperature: 96.8
heartrate: 72.0
resprate: 16.0
o2sat: 99.0
sbp: 148.0
dbp: 96.0
level of pain: 0
level of acuity: 2.0 | ___ year old man with history of HTN, DM, presented to ___
___ with ___ day history of progressive DOE, leg edema and
one short episode of chest pressure. He was transferred to ___
and was found to be in new atrial fibrillation and volume
overloaded in the setting of acute dCHF.
=======================
ACUTE ISSUES
=======================
#Acute exacerbation of diastolic heart failure: Presents with
significant ___ edema, elevated JVP and hypoxemia that have
developed subacutely. No prior diagnosis of heart failure; he
does have a history ___ edema thought to be due to venous
stasis. TTE showed preserved EF, c/w diastolic HF exacerbation.
He was diuresed with lasix gtt with improvement in symptoms. He
was started on spirinolactone 25mg po daily; he was not started
on ___ due to h/o angioedema to lisinopril. He underwent
pharmacological myocardial perfusion stress test on ___ which
showed a small reversible wall abnormality. We chose not to
perform cath procedure due to co-morbidities and potential for a
combination of anti-platelets and warfarin. He was placed on
torsemide 40mg PO BID for maintenance diuresis. He will need to
recheck his CHEM 10 at rehab on ___ and follow-up with
his PCP and ___ as an outpatient.
# Atrial fibrillation w/ variable conduction, with bradycardia:
New finding, without RVR. CHADS-Vasc of 5. He was continued on
home beta blocker, but experienced episodes of bradycardia to
the ___ even at a reduced dose, so this was held briefly. After
diuresis, metoprolol succinate was restarted at 25mg qday and
patient did not have any symptoms. He was started on warfarin
5mg po daily for anticoagulation. Patient scheduled to recheck
INR on ___ in his rehab facility. EKG on day of
discharge showed possible spontaneous conversion into sinus
rhythm with QTc 439. Patient will have to schedule follow-up
with ___ clinic at ___.
# NSTEMI: TropI elevated to 0.15 at OSH, so was started on
heparin out of concern for NSTEMI, but troponin T here 0.04 x2 .
No history of CAD, and endorses only one 30 second episode of
chest pressure on ___, now chest pain free. EKG without
ischemic changes. Likely due to demand ischemia from heart
failure. Patient had no further episodes of chest pain while
inpatient.
=======================
CHRONIC ISSUES
=======================
# DM: A1c 5.8 (___), on metformin at home. Placed on sliding
scale insulin while inpatient. Will resume metformin at
discharge
# BPH: continued tamsulosin 0.4mg daily, no issues w/ urinary
retention.
# Gout: Continued allopurinol ___ PO daily.
=======================
TRANSITIONAL ISSUES
=======================
-Replaced home furosemide with Torsemide 40mg PO BID; will need
chem 10 checked at rehab on ___
-Spironolactone was started this admission, will need chem 10
checked as above
-Started warfarin: will need INR checked on ___ he
will need follow-up with NP at ___
-Will need to establish care with a cardiologist as an
outpatient within 3 weeks
-Metformin was held while inpatient and patient required sliding
scale. Will resume metformin at discharge to rehab, may
discontinue sliding scale if blood sugars <250 in rehab. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
sildenafil
Attending: ___.
Chief Complaint:
symptomatic hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of CAD s/p multiple DES, CHF LVEF 45%, DM1,
chronic anemia, hx colon ca s/p resection, latent TB on
treatment, ESRD on peritoneal dialysis undergoing transplant
evaluation presenting with generalized weakness and hypotension.
Reports generalized weakness and malaise today. He has not been
taking his midodrine at all. Checked his blood pressure and
which was 70 systolic so he called ___. Denies chest pain,
shortness of breath, abdominal pain, nausea, vomiting, blood in
the stool, melena, or return of his diarrhea.
In the ED, initial vitals were: 97 64 ___ 100% RA.
Initial labs were largely at his baseline: WBC 5.2, Hgb/Hct
10.4/30.0, Plt 153, ALT/AST WNL, Ap 169, ALB 3.0, Na 131, K 4.8,
___, BUN/Cr 50/11.7, Glucose 65, Trop 0.10--->0.10,
lactate 1.0. Patient received 1L NS as well as home meds - INH,
pyridoxine, protonix, PO vanc, PO midodrine, nephrocaps. Also
received 1amp d50 for low blood sugars.
Patient was seen by nephrology in the ED who recommended
restarting PD upon arrival and increasing calcium acetate for
hypocalcemia.
On the floor, pt reports he feels better than earlier. HE has no
complaints. He denies any current chest pain, dyspnea, abd pain,
nuasea, vomiting, diarrhea, dysuria.
Of note patient was recently admitted from ___ for chest
discomfort. Cardiac etiology was ruled out. He was found to
have upper GI bleed and required 3U PRBCs and was started on
PPI. His prasugrel was stopped per cardiology recommendations.
Additionally he was noted to have persistent hypotension on
ambulation, thought partially related to autonomic dysfunction
from long-standing diabetes for which he was started on
midodrine and compression stockings. Additinally his
hospitalization was complicated by c.diff colitis (on PO vanc
last day ___ and Left vitreous hemorrhage for which he was to
follow up with ophthalmology on ___.
Past Medical History:
# CAD -- BMES ___, ACSD with ___ ___, cath ___
LM-LAD stent patent,with stent of the distal RCA, BMS to
proximal RCA ___ for pretransplantation evaluation
# CHF -- TTE ___ with LVEF 45%. Normal LV cavity size with
regional hypokinesis. Mild mitral regurgitation with normal
valve morphology.
# Diabetes Mellitus Type 1 complicated by neuropathy and
nephropathy
# Peripheral Vascular Disease s/p balloon angioplasty to right
anterior tibial and dorsalis pedis arteries
# Chronic Kidney Disease Stage 5 on PD (previously on HD with
tunnelled cath in earlier ___
# Anemia of Chronic Disease
# Obstructive Sleep Apnea - CPAP at night
# Erectile Dysfunction
# Right great toe amputation (___)
# Right Carotid Artery Stent
# Colon cancer (Stage 3A, T1 N1 M0) s/p low anterior resection
in ___ and chemotherapy
# Right ulnar nerve decompression and anterior transposition
about the medal epicondyle
# Cubital tunnel release and anterior transposition of left
ulnar nerve
Social History:
___
Family History:
Father: ___, CAD. Died of prostate cancer at age ___.
Mother: Heart disease (died from MI at age ___
Physical Exam:
ADMISSION:
Vital Signs: 98.2 132/83 66 18 95% 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,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
DISCHARGE:
Tmc 98.3 126/65-146/70 61-65 16 98% RA
GEN: NAD, AOx3
HEENT: conjunctiva pink, sclera anicteric, MMM
NECK: supple, FROM, no LAD, JVP<10cm
CV: RRR, no m/r/g
LUNG: ctap b/l
ABD: benign
EXT: wwp, no c/c/e
NEURO: grossly intact b/l
Pertinent Results:
ADMISSION:
___ 12:02AM BLOOD WBC-5.2 RBC-3.38* Hgb-10.4* Hct-30.0*
MCV-89 MCH-30.7 MCHC-34.5 RDW-16.5* Plt ___
___ 12:02AM BLOOD WBC-5.2 RBC-3.38* Hgb-10.4* Hct-30.0*
MCV-89 MCH-30.7 MCHC-34.5 RDW-16.5* Plt ___
___ 12:02AM BLOOD Neuts-61.9 ___ Monos-8.4 Eos-1.8
Baso-0.6
___ 12:02AM BLOOD ___ PTT-35.1 ___
___ 12:02AM BLOOD Glucose-65* UreaN-50* Creat-11.7*#
Na-131* K-4.8 Cl-97 HCO3-18* AnGap-21*
___ 12:02AM BLOOD ALT-14 AST-30 AlkPhos-169* TotBili-0.2
___ 12:02AM BLOOD cTropnT-0.10*
___ 06:04AM BLOOD cTropnT-0.10*
___ 12:02AM BLOOD Albumin-3.0* Calcium-6.5* Phos-8.6*#
Mg-2.2
DISCHARGE:
___ 06:15AM BLOOD WBC-5.3 RBC-3.49* Hgb-10.6* Hct-30.3*
MCV-87 MCH-30.3 MCHC-35.0 RDW-16.9* Plt ___
___ 06:15AM BLOOD Neuts-57.6 ___ Monos-8.9 Eos-2.1
Baso-0.3
___ 06:15AM BLOOD Plt ___
___ 06:15AM BLOOD Glucose-157* UreaN-50* Creat-11.8* Na-133
K-3.5 Cl-99 HCO3-17* AnGap-21*
___ 06:15AM BLOOD Calcium-7.7* Phos-7.1* Mg-2.0
CXR: no acute cardiopulmonary process
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Calcitriol 0.5 mcg PO DAILY
4. Docusate Sodium 100 mg PO HS
5. Isoniazid ___ mg PO DAILY
6. Calcium Acetate 1334 mg PO TID W/MEALS
7. Gentamicin 0.1% Cream 1 Appl TP DAILY
8. B complex with C#20-folic acid 1 mg oral daily
9. darbepoetin alfa in ___ ___ units INJECTION 1X/WEEK
10. Nephrocaps 1 CAP PO DAILY
11. Pyridoxine 50 mg PO DAILY
12. Tamsulosin 0.4 mg PO HS
13. Pantoprazole 40 mg PO Q12H
14. Vancomycin Oral Liquid ___ mg PO Q6H
15. Midodrine 2.5 mg PO TID
16. Glargine 8 Units Breakfast
Glargine 8 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Calcium Acetate ___ mg PO TID W/MEALS
RX *calcium acetate 667 mg 3 tablet(s) by mouth TID w/ meals
Disp #*270 Tablet Refills:*0
4. Docusate Sodium 100 mg PO HS
5. Gentamicin 0.1% Cream 1 Appl TP DAILY
6. Isoniazid ___ mg PO DAILY
7. Nephrocaps 1 CAP PO DAILY
8. Pantoprazole 40 mg PO Q12H
9. Pyridoxine 50 mg PO DAILY
10. B complex with C#20-folic acid 1 mg oral daily
11. Calcitriol 0.5 mcg PO DAILY
12. darbepoetin alfa in ___ ___ units INJECTION 1X/WEEK
13. Glargine 8 Units Breakfast
Glargine 8 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
14. Midodrine 5 mg PO DAILY
Take 5 mg daily at 2pm
RX *midodrine 5 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
15. Midodrine 5 mg PO QAM
Take 5 mg daily at 8am
16. sevelamer CARBONATE 800 mg PO TID W/MEALS
RX *sevelamer carbonate [Renvela] 800 mg 1 tablet(s) by mouth
TID W/ MEALS Disp #*90 Tablet Refills:*0
17. Sodium Bicarbonate 650 mg PO TID
Please take 3 times per day with meals
RX *sodium bicarbonate 650 mg 1 tablet(s) by mouth three times a
day Disp #*90 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
Hypotension 2'/2 autonomic dysfunction
CAD
___
DM1
SECONDARY:
Latent TB
C. Diff
Colon Ca sp resection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with ESRD on PD, CAD p/w generalized weakness and
hypotension // R/O Pneumonia/CHF
COMPARISON: ___.
TECHNIQUE: Frontal and lateral views of the chest.
FINDINGS:
Heart size and cardiomediastinal contours are normal. A nodular opacity
overlying the right upper lung projects over the scapula, similar to prior.
Lungs are otherwise clear without focal consolidation, pleural effusion, or
pneumothorax.
IMPRESSION:
No acute cardiopulmonary process.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Weakness
Diagnosed with OTHER MALAISE AND FATIGUE
temperature: 97.0
heartrate: 64.0
resprate: 16.0
o2sat: 100.0
sbp: 112.0
dbp: 90.0
level of pain: 0
level of acuity: 2.0 | ___ w/ h/o CAD s/p multiple DES, HFrEF 45%, DMI, ESRD on PD p/w
generalized weakness and symptomatic hypotension in the setting
of midodrine non-compliance. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
isoniazid
Attending: ___.
Chief Complaint:
Fever, cough, URI
Major Surgical or Invasive Procedure:
n/a
History of Present Illness:
Mr. ___ is a ___ year old ___ speaking gentleman with PMH
notable ESRD from IgA nephropathy s/p failed allograft now on HD
(___), who presents with three days of progressive
dyspnea, non-productive cough, and fever.
His symptoms began on ___ as a dry hacking cough and
rhinorrhea. This morning, the patient developed fevers and his
cough became productive of a thick green sputum. He also
developed some LLQ abdominal pain whenever he coughs. He has a
mild headache but denies photophobia, neck stiffness, sore
throat, rash, diarrhea, or dysuria.
He denies any sick contacts or recent travel. He states that he
has remained compliant with his immunosuppressive regimen.
Patient had flu vaccine on ___.
In the ED, initial vital signs were:
T100.4 ___ BP160/100 R22 98% on RA.
Labs were notable for WBC of 8.3, hg, 13, bicarb 19, Na 133, and
K 4.7.
Flu swab was negative.
The patient underwent a CT abdomen with contrast with no acute
findings to explain his abdominal pain. CXR was without obvious
consolidation. The patient was given 2g IV cefepime and 1g IV
vancomycin.
Vitals on transfer: T98.4 HR 90, BP 140/79 RR 20 96% RA.
CT abd pelvis:
1. No acute CT findings in the abdomen or pelvis to account for
the patient's reported symptoms of abdominal pain.
2. ground-glass centrilobular nodular opacities within the lung
bases compatible with small airways disease, possibly of
infectious or inflammatory origin.
3. Atrophic native kidneys with unremarkable right lower
quadrant transplant kidney.
4. Colonic diverticulosis without evidence of diverticulitis.
5. 1.1 cm hyperdense structure in the spleen is unchanged since
prior ultrasound in ___, likely a hemangioma
REVIEW OF SYSTEMS:
(+) Per HPI
(-) 10 point ROS reviewed and negative unless stated above in
HPI
Past Medical History:
non infectious organizing pneumonia possibly due to INH
IGA nephrophathy
ESRD on HD s/p failed kidney transplant
Deceased donor kidney transplant ___
HTN
Gout
Dyslipidemia
Osteoporosis
History of shingles
Social History:
___
Family History:
Unremarkable for chronic kidney disease. Uncertain of mother and
father's health conditions. Son treated for ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITAL SIGNS: 98.5 PO 167/84 97 20 94 RA
GENERAL: Patient looking older than stated age in mild distress
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, II/VI systolic murmur at apex,
LUNG: Lungs, crackles at bilateral bases, up to mid right lung.
good air entry.
ABDOMEN: nondistended, no tenderness over DDRT over the RLQ.
left mid gastric area with tenderness to palpation. +BS, no
guarding or rebound
EXTREMITIES: no cyanosis, 2+ edema bilaterally to knees, right
brachiocephalic AV fistula, bruit over fistula. The radial
pulses intact.
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, ulcerated macular lesions over
upper portion of his back and two lesions on head biopsied from
derm. diffuse hyper and hypopigmented skin
LABS: reviewed. See below.
DISCHARGE PHYSICAL EXAM:
VS - Tmax 97.9 Tc 97.3 HR ___ BP 127/76 RR 18 02sat 95%RA
General: in HD, well appearing, NAD
HEENT: MMM, EOMI
CV: rrr, no m/r/g
Lungs: CTAB anteriorly, breathing comfortably
Abdomen: +BS, soft, non-tender, non-distended
Ext: warm and well perfused, pulses, trace edema b/l
Neuro: CN II-XII grossly intact
Pertinent Results:
ADMISSION LABS:
___ 03:59PM BLOOD WBC-8.3 RBC-4.05* Hgb-13.1* Hct-39.3*
MCV-97 MCH-32.3* MCHC-33.3 RDW-16.0* RDWSD-57.4* Plt ___
___ 03:59PM BLOOD Neuts-61.3 ___ Monos-12.5 Eos-4.5
Baso-0.2 Im ___ AbsNeut-5.10 AbsLymp-1.75 AbsMono-1.04*
AbsEos-0.37 AbsBaso-0.02
___ 03:05PM BLOOD Glucose-88 UreaN-68* Creat-7.7*# Na-133
K-4.7 Cl-93* HCO3-19* AnGap-26*
___ 03:05PM BLOOD ALT-10 AST-27 AlkPhos-84 TotBili-0.9
___ 03:05PM BLOOD Lipase-112*
___ 03:05PM BLOOD Albumin-3.8 Calcium-8.6 Phos-6.5* Mg-2.1
___ 12:19AM BLOOD ___ pO2-48* pCO2-40 pH-7.32*
calTCO2-22 Base XS--5
___ 03:16PM BLOOD Lactate-1.4
DISCHARGE LABS:
___ 06:40AM BLOOD WBC-5.9 RBC-3.34* Hgb-10.7* Hct-31.8*
MCV-95 MCH-32.0 MCHC-33.6 RDW-15.3 RDWSD-53.3* Plt ___
___ 06:40AM BLOOD Glucose-103* UreaN-38* Creat-5.0*# Na-139
K-3.6 Cl-95* HCO3-25 AnGap-23*
___ 06:40AM BLOOD ALT-7 AST-22 LD(LDH)-232 AlkPhos-70
TotBili-0.5
___ 06:40AM BLOOD Lipase-87*
___ 06:40AM BLOOD Calcium-7.9* Phos-6.8* Mg-2.1
___ 06:40AM BLOOD Cyclspr-92*
IMAGING:
CXR ___:
Cardiomegaly without superimposed acute cardiopulmonary process.
CT A/P ___:
1. No acute CT findings in the abdomen or pelvis to account for
the patient's reported symptoms of abdominal pain.
2. ground-glass centrilobular nodular opacities within the lung
bases
compatible with small airways disease, possibly of infectious or
inflammatory origin.
3. Atrophic native kidneys with unremarkable right lower
quadrant transplant kidney.
4. Colonic diverticulosis without evidence of diverticulitis.
5. 1.1 cm hyperdense structure in the spleen is unchanged since
prior
ultrasound in ___, likely a hemangioma.
CT CHEST ___:
New right lower lobe pneumonia
More chronic findings suggest chronic interstitial edema or less
likely
pneumonitis
Enlargement of the main pulmonary artery could correlate with
pulmonary
hypertension
Coronary calcifications
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Calcitriol 0.25 mcg PO DAILY
3. Carvedilol 12.5 mg PO BID
4. CycloSPORINE (Sandimmune) 50 mg PO Q12H
5. PredniSONE 5 mg PO DAILY
6. Torsemide 40 mg PO EVERY OTHER DAY
7. Torsemide 60 mg PO EVERY OTHER DAY
8. Tretinoin 0.025% Cream 1 Appl TP QHS
9. Nephrocaps 1 CAP PO DAILY
Discharge Medications:
1. Azithromycin 250 mg PO Q24H Duration: 4 Doses
RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*5
Tablet Refills:*0
2. Cefpodoxime Proxetil 400 mg PO Q24H
RX *cefpodoxime 200 mg 2 tablet(s) by mouth daily Disp #*10
Tablet Refills:*0
3. Allopurinol ___ mg PO EVERY OTHER DAY
4. Calcitriol 0.25 mcg PO DAILY
5. Carvedilol 12.5 mg PO BID
6. CycloSPORINE (Sandimmune) 50 mg PO Q12H
7. Nephrocaps 1 CAP PO DAILY
8. PredniSONE 5 mg PO DAILY
9. Torsemide 60 mg PO EVERY OTHER DAY
10. Torsemide 40 mg PO EVERY OTHER DAY
11. Tretinoin 0.025% Cream 1 Appl TP QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Community Acquired Pneumonia
Secondary: Interstitial Lung Disease, End stage renal disease on
hemodialysis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with cough, fever// PNA
TECHNIQUE: AP and lateral views the chest.
COMPARISON: ___.
FINDINGS:
The lungs are now clear without consolidation. Faint residual interstitial
markings project over the right upper lung. There is no edema or effusion.
Cardiac enlargement is similar compared to prior. Atherosclerotic
calcifications seen at the aortic arch and there is tortuosity of the
descending thoracic aorta. Old healed left-lateral rib fractures are noted.
IMPRESSION:
Cardiomegaly without superimposed acute cardiopulmonary process.
Radiology Report
EXAMINATION: CT abdomen and pelvis with contrast
INDICATION: History: ___ with abdominal pain, fever, immunosuppressed.
Evaluate for diverticulitis or 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.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 6.5 s, 0.5 cm; CTDIvol = 46.9 mGy (Body) DLP =
23.5 mGy-cm.
2) Spiral Acquisition 4.4 s, 48.0 cm; CTDIvol = 12.0 mGy (Body) DLP = 573.6
mGy-cm.
Total DLP (Body) = 597 mGy-cm.
COMPARISON: Liver gallbladder ultrasound ___, CT chest ___
FINDINGS:
LOWER CHEST: Bibasilar ___ ground-glass opacities are seen in the
lungs, likely reflective of small airways disease, possibly of infectious or
inflammatory origin. There is no evidence of pleural or pericardial effusion.
Atherosclerotic calcifications are seen in the coronary arteries. Heart size
is normal.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
Multiple hypodensities are seen in the liver, largest measuring up to 1.7 cm,
likely hepatic cysts or biliary hamartomas. 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 1.1 cm round hyperdensity is seen in the spleen, not fully
characterized on this exam, but possibly representing a hemangioma. Spleen is
otherwise normal in size.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The native kidneys appear atrophic with bilateral nonobstructing
calcified renal stones. There is a right lower quadrant renal transplant
without hydronephrosis. A subcentimeter hypodensity is seen in the transplant
kidney, likely a renal cyst, although too small too fully characterize. There
is no evidence of concerning focal renal lesions. There is no perinephric
abnormality surrounding the renal transplant.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. Colonic
diverticulosis is noted without evidence of diverticulitis. Otherwise, the
colon and rectum are within normal limits. The appendix is normal.
PELVIS: There is a small urinary bladder diverticulum (series 2: Image 66)
with an associated punctate calcification. The distal ureters appear
unremarkable. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate is not enlarged. A 1.3 cm hypodensity is
seen in the central prostate with a punctate calcification, likely a utricle
cyst.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
An old rib fracture is seen in the left ___ lateral rib.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits. A small
focus soft tissue thickening/edema is seen in the right gluteal region,
possibly a subcutaneous injection site.
IMPRESSION:
1. No acute CT findings in the abdomen or pelvis to account for the patient's
reported symptoms of abdominal pain.
2. ground-glass centrilobular nodular opacities within the lung bases
compatible with small airways disease, possibly of infectious or inflammatory
origin.
3. Atrophic native kidneys with unremarkable right lower quadrant transplant
kidney.
4. Colonic diverticulosis without evidence of diverticulitis.
5. 1.1 cm hyperdense structure in the spleen is unchanged since prior
ultrasound in ___, likely a hemangioma.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ yoM with PMHx of organizing PNA and ESRD s/p failed kidney
transplant admitted for SOB/Cough, nothing on CXR. any worsening disease since
___// ___ yoM with PMHx of organizing PNA and ESRD s/p failed kidney
transplant admitted for SOB/Cough, nothing on CXR. any worsening disease since
___?
TECHNIQUE: Multidetector helical scanning of the chest was performed without
IV contrast reconstructed as axial, coronal , parasagittal, and ,MIPs axial
images.
DOSE: DLP: 436 mGy
COMPARISON: ___
FINDINGS:
The thyroid is normal. Supraclavicular, axillary, mediastinal and hilar lymph
nodes are not enlarged. There is increased number mediastinal nodes, don't
meeting CT criteria for pathologic enlargement. Aorta is normal size. The
main pulmonary artery is enlarged measures 3.2 cm. Cardiac configuration is
normal and there are mild calcifications in all coronary arteries.
New peribronchial and ___ nodules in the right lower lobe most
consistent with a new infectious process. Underlying more chronic diffuse
ground-glass opacities associated with interlobular septal thickening and
bronchiectasis are grossly unchanged from prior study. Loss of
volume/fibrosis in the right upper lobe is unchanged
There is no pleural or pericardial effusion.
This examination is not tailored for subdiaphragmatic evaluation multiple
liver cysts unchanged. The kidneys are atrophic.
There are no bone findings of malignancy. Several left healed rib fractures
again noted
IMPRESSION:
New right lower lobe pneumonia
More chronic findings suggest chronic interstitial edema or less likely
pneumonitis
Enlargement of the main pulmonary artery could correlate with pulmonary
hypertension
Coronary calcifications
Gender: M
Race: ASIAN - CHINESE
Arrive by AMBULANCE
Chief complaint: Cough, Dyspnea
Diagnosed with Sepsis, unspecified organism
temperature: 100.4
heartrate: 110.0
resprate: 22.0
o2sat: 98.0
sbp: 160.0
dbp: 100.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ is a ___ w/ organizing pneumonia (cryptogenic vs.
INH-induced) on 5mg daily Prednisone and ESRD ___ IgA
nephropathy s/p failed allograft now on HD and Cyclosporine, now
p/w low-grade fever, cough, dyspnea, diarrhea x3 days.
# Fever, cough, dyspnea:
Symptoms thought to be secondary to viral illness vs. CAP given
low-grade fever, cough, chills, diarrhea. Patient was evaluated
by pulmonology given underlying interstitial lung disease. His
symptoms were less likely to be ILD exacerbation given no e/o
progression on CT chest. Unable to send urine strep pneumonia
and legionella antigen as patient does not produce urine. A CMV
viral load was sent given his diarrhea and immunosuppression in
the setting of a previous CMV IgG positive result. He received
Prednisone 40mg x1. He was treated with Vancomycin/Cefepime x1
(___) and was then transitioned to Azithromycin/Ceftriaxone
(___). He was discharged on Azithromycin and Cefpodoxime
(250 mg PO Q24H and 400 mg PO Q24H, respectively) for a 5-day
course, finishing on ___. He should follow-up with his PCP and
pulmonologist outpatient.
# Left lower quadrant abdominal pain:
The patient had LLQ abdominal pain on presentation thought to be
musculoskeletal secondary to cough. No correlate on CT
abd/pelvis, no tenderness to palpation, and no hematochezia or
melena (but had diarrhea, see below). Pain resolved during
hospitalization.
# Diarrhea:
Likely ___ systemic (possibly viral) illness. As mentioned
above, patient had no hematochezia or melena, and a CMV viral
load was pending at discharge.
# Elevated lipase:
Patient with elevated lipase of 112 in ED which downtrended to
87. No clear clinical or imaging correlate. Likely ___ known
renal failure as pancreatic enzymes are partially renally
cleared.
CHRONIC ISSUES:
# End-stage renal disease on hemodialysis secondary to IGA
nephropathy s/p failed deceased donor renal transplant:
The patient typically has ___ hemodialysis and missed his
___ session. Therefore, he received dialysis twice
while inpatient ___ and ___. He is on cyclosporine at home
for his deceased donor renal transplant, and he was started on
Azithromycin while in patient for his CAP. At discharge, his
cyclosporine level was 92. While inpatient, he was continued on
his home calcitriol, nephrocaps, cyclosporine, and torsemide.
# Organizing Pneumonia:
Patient was given 40mg Prednisone in the ED and then restarted
on his home 5mg. As described above, no current concern for
exacerbation/progression based on CT chest.
# Hypertension:
Pressures were stable on this admission. He was continued on his
home Carvedilol 12.5 mg PO BID.
# Gout:
He was continued on his home Allopurinol ___ mg PO DAILY.
======================
# CODE: Full Presumed
# CONTACT: ___ Wife ___ ___ ___
___ ___
======================
====================== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aspirin / Penicillins / Nsaids / Codeine / Percocet / Proventil
/ paper tape / midazolam
Attending: ___
Chief Complaint:
shakiness and fatigue
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ old woman who presents with fatigue and
generalized malaise in the setting of significant recent
diuresis
for diastolic heart failure and NASH-related cirrhosis. She has
been followed closely by ___, NP and Dr. ___
volume overload characterized by dyspnea and lower extremity
edema over the past few months. She has also been admitted
during
this time for altered mental status related to hepatic
encephalopathy and cellulitis. With regard to her recent
diuretic
regimen, she was discharged in ___ off all diuretics. Torsemide
200 mg qAM and 100 mg qPM was restarted by Dr. ___ in early
___ for volume overload, in addition to spironolactone 200 mg
daily. Her dyspnea and lower extremity edema improved
significantly on this regimen. However, yesterday she noted new
shakiness and fatigue and was instructed to decreased her total
torsemide dose to 200 mg daily. She continued to feel unwell and
presented to the ___ for further management. She has not
experienced any chest pain, dyspnea at rest, PND, palpitations,
lightheadedness, or syncope.
Past Medical History:
- Aortic stenosis s/p TAVR ___
- NASH cirrhosis c/b splenomegaly/thrombocytopenia. No hx of
variceal bleeding or ascites requiring paracentesis
- HFpEF, also with PH, moderate to severe MR by echo. RHC ___
with RAP 10, mPAP 27, PCWP 17 (plus large V waves), high output
(CI 3.8), PVR 1.5 ___.
- Asthma: Diagnosed as an adult. Denies recent prednisone
- Diabetes
- Hypertension
- Morbid obesity
- Episode of syncope, s/p LINQ implantation ___
- Thrombocytopenia, in setting of cirrhosis/splenomegaly
- Psoriasis
- s/p CCY
- s/p C-section x2
- Carpal tunnel
- Anxiety
- s/p IUD placement ___, for postmenopausal bleeding
Social History:
___
Family History:
Father with MI and died at the age of ___. Mother with unclear
heart disease and diabetes.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
============================
VITALS: BP 148/69. Heart rate 87. Weight 155 lb.
GEN: Appears comfortable. Mood and affect appropriate.
NECK: JVP 7 cm. No carotid bruits.
CARDIAC: Regular rhythm, normal S1 and normally-split S2. No
S3/4 or pathological murmurs.
LUNGS: Clear lungs.
ABD: Soft, nontender abdomen without hepatomegaly.
EXT: Trace pedal edema. Symmetric pedal pulses. No open foot
ulcers or venous stasis changes.
DISCHARGE PHYSICAL EXAMINATION:
============================
VS:98.5 122 / 59 81 18 100 Ra
WT: 73.94 kg
GENERAL: frail older woman, sitting up in bed in NAD. alert and
interactive
HEENT: anicteric sclera, MMM, poor dentition.
CARDIAC: RRR. Nl s1/s2. iii/vi holosystolic murmur best heard at
RUSB. No rubs or gallops.
PULMONARY: CTAB. No w/r/r
ABDOMEN: obese, soft, NTND
EXTREMITIES: No ___ edema.
SKIN: mild chronic venous stasis changes bilaterally but
otherwise no major rashes, sores, or other lesions.
NEUROLOGIC: Resting tremor and tremor in R>L, no asterixis.
AAOx3
Pertinent Results:
===============
Admission labs
===============
___ 08:22AM BLOOD WBC-2.4* RBC-2.62* Hgb-7.4* Hct-23.2*
MCV-89# MCH-28.2# MCHC-31.9* RDW-14.6 RDWSD-47.1* Plt Ct-20*
___ 05:00AM BLOOD UreaN-72* Creat-2.0* Na-139 K-4.5 Cl-101
HCO3-24 AnGap-14
___ 03:01PM BLOOD Ammonia-<10
___ 01:18PM BLOOD ___ Temp-37.1 pO2-57* pCO2-40
pH-7.41 calTCO2-26 Base XS-0
===============
Pertinent labs
===============
___ 08:22AM BLOOD Ammonia-111*
___ 05:57AM BLOOD AFP-54.1*
___ 05:57AM BLOOD Glucose-256* UreaN-60* Creat-1.7* Na-142
K-3.9 Cl-103 HCO3-23 AnGap-16
___ 05:57AM BLOOD ___ PTT-26.1 ___
===============
Discharge labs
===============
___ 06:14AM BLOOD WBC-3.9* RBC-2.53* Hgb-7.2* Hct-22.0*
MCV-87 MCH-28.5 MCHC-32.7 RDW-14.6 RDWSD-45.9 Plt Ct-23*
___ 06:14AM BLOOD ___ PTT-27.6 ___
___ 06:14AM BLOOD Glucose-137* UreaN-60* Creat-1.7* Na-137
K-4.6 Cl-99 HCO3-25 AnGap-13
___ 06:14AM BLOOD ALT-13 AST-24 AlkPhos-102 TotBili-1.0
___ 06:14AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.1
===============
Studies
===============
RUQUS (___): IMPRESSION:
1. Patent hepatic vasculature.
2. Cirrhotic liver without focal lesions identified.
3. Splenomegaly. Perisplenic varices are present.
4. Cholelithiasis.
CXR (___): FINDINGS: The study is compromised secondary to
technique. There are low lung volumes. There is no gross
consolidation. The patient is status post TAVR. The heart is
enlarged. There is cephalization of the pulmonary vasculature
suggestive of pulmonary venous congestion. There are no pleural
effusions. Degenerative changes are evident in the spine.
IMPRESSION: Postoperative changes. Pulmonary venous congestion.
Cardiomegaly.
===============
Microbiology
===============
Blood cultures
---------------
___: pendingx2
Urine cultures
--------------
___: contaminated
Radiology Report
EXAMINATION: Chest x-ray
INDICATION: ___ year old woman with NASH cirrhosis w/ history of hepatic
encephalopathy in setting of occult infection who presents again with AMS.//
please evaluate for focal consolidation/infectious process.
TECHNIQUE: Chest PA and lateral
COMPARISON: Previous chest x-ray from ___.
FINDINGS:
The study is compromised secondary to technique. There are low lung volumes.
There is no gross consolidation. The patient is status post TAVR. The heart
is enlarged. There is cephalization of the pulmonary vasculature suggestive
of pulmonary venous congestion. There are no pleural effusions. Degenerative
changes are evident in the spine.
IMPRESSION:
Postoperative changes. Pulmonary venous congestion. Cardiomegaly.
Radiology Report
EXAMINATION: DUPLEX DOPP ABD/PEL
INDICATION: evaluate HCC lesions, for ascites, for PVT
TECHNIQUE: Gray scale, color, and spectral Doppler evaluation of the abdomen
was performed.
COMPARISON: Ultrasound from ___.
FINDINGS:
Liver: The hepatic parenchyma is coarsened and nodular.. No focal liver
lesions are identified. There is no ascites.
Bile ducts: There is no intrahepatic biliary ductal dilation. The common
hepatic duct is not well visualized on this study.
Gallbladder: There is cholelithiasis without evidence of cholecystitis.
Pancreas: The imaged portion of the pancreas appears within normal limits,
with portions of the pancreatic tail obscured by overlying bowel gas.
Spleen: The spleen demonstrates normal echotexture, and measures 19.5 cm.
Kidneys: Limited evaluation demonstrates no hydronephrosis identified in
either kidney.
Doppler evaluation:
The main portal vein is patent, with flow in the appropriate direction.
Main portal vein velocity is 18.2 cm/sec.
Right and left portal veins are patent, with antegrade flow.
Splenic vein and superior mesenteric vein are patent, with retrograde flow.
Perisplenic varices are present.
IMPRESSION:
1. Patent hepatic vasculature.
2. Cirrhotic liver without focal lesions identified.
3. Splenomegaly. Perisplenic varices are present.
4. Cholelithiasis.
Gender: F
Race: PORTUGUESE
Arrive by UNKNOWN
Chief complaint: Hypertension
Diagnosed with Essential (primary) hypertension
temperature: 98.5
heartrate: 92.0
resprate: 18.0
o2sat: 100.0
sbp: 132.0
dbp: 52.0
level of pain: 0
level of acuity: 3.0 | Ms. ___ is a ___ old woman who presents with fatigue and
generalized malaise in the setting of significant recent
diuresis for diastolic heart failure and NASH-related cirrhosis.
She appears dehydrated on exam, and her labs demonstrate acute
renal failure and hyponatremia that are likely related to her
recent brisk diuresis. She is somnolent on admission, which
could be related to some combination of dehydration and hepatic
encephalopathy. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lipitor
Attending: ___.
Chief Complaint:
dizziness, falls
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with arthritis, knee replacement, hip replacement, COPD, HTN
presents with dizziness since this AM. Pt ___ tried to get pt
out of bed today and patient became dizzy. Felt as if the room
was spinning. Once patient stopped moving the dizziness
resolved.
Episodes are intermittent and brought on by head movement,
sitting up or standing up. She has had hx of dizziness for many
years, but today was worse as it occurred more frequently and
lasted longer than usual. No HA, fever, neck pain, rash, n/v/d.
She states that her appetite and food intake has not changed
during the past few days. Only change in medication is stopping
one of her HTN medication on ___ per PCP ___.
Patient states that she has a chronic cough for several years
due to her COPD that has improved with spiriva. Today, she felt
short of breath requiring oxygen when she arrived to the ED. Per
notes, she is supposed to be on home O2 but has not arranged for
it yet. At baseline, she walks with a walker but becomes short
of breath after walking about <10 feet to the bathroom. She has
two aids at home who help her with showering, cleaning,
dressing. She denies congestion, sputum, rhinorrhea,
fevers/chills, cp, abdominal pain.
Of note, she was recently at ___ ED (___) for a fall but left
AMA before a work up could be started. She has had three falls
in the last 9 days, and prior to this she had not had a fall for
a year. Her first fall occurred after her legs gave out while
she was pouring soup to a bowl. Second fall was after stumbling
and falling onto the sofa. third fall was when she slid while
holding her walker. No head strike or LOC during these episodes.
Denies any palpitations, chest pain, dizziness/lightheadedness
or prodrome before/after or during these episodes. Per ED notes,
daughter stated that patient falls occasionally and does not
seem to have any injuries. Denies loss of sensation,
tingling/numbness of bilateral feet. Patient is farsighted, but
states that she has good vision. VDD pacemaker last checked on
___ and functioning properly.
In the ED, initial vitals 97.8 99 134/74 12 95% RA. Exam notable
for coarse lung sounds and non-focal neuro exam. Labs notable
for WBC 11.5 with N: 80.6, L: 10.8. CT C-spine and CT head
without acute changes. EKG non-diagnostic. Patient desating with
ambulation. CXR with old right perihilar opacity 3.2x2.3 cm,
similar to prior, but also LLL retrocardiac opacity concerning
for pneumonia. She was given ceftriaxone 1mg, azithromycin
500mg, albuterol and ipratropium nebs. Blood cultures sent.
Vitals prior to transfer: 94 132/62 25 95% RA.
On arrival to the floor, patient states that she is feeling well
and has no complaints. Denies any fever, cough, CP, SOB, HA,
N/V, weakness.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
- multiple pulmonary nodules- slow growing. Thought to be
non-malignant per pulmonary note of ___.
- endometrial cancer, s/p TAH ___
- spinal stenosis
- hypertension
- COPD
- hyperlipidemia
- deviated septum
-RBBB and 2nd degree heart block s/p VVD pacer in ___
- grade I external hemorrhoids on most recent colonoscopy
___
- s/p left shoulder replacement
- s/p right hip replacement
- right rotator cuff tear
Social History:
___
Family History:
heart and thyroid problems in her mother. Her father had
prostate cancer
Physical Exam:
ADMISSION PHYSICAL EXAM
VS - 98.8, 120/70, 102, 24, 96% on 3L NC
GENERAL - well-appearing woman in NAD, comfortable, appropriate,
occasionally coughing
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, dried MM, OP
clear
NECK - supple, no thyromegaly, no JVD appreciated
LUNGS - rhonchi throughout without wheezes or crackles, resp
unlabored, no accessory muscle use
HEART - RRR although difficult to auscultate given significant
rhonchi, no MRG appreciated.
ABDOMEN - NABS, soft/NT/ND, no rebound/guarding, + BS
EXTREMITIES - WWP, no c/c, trace peripheral edmema up to ankles,
1+ peripheral pulses, significant bunions on b/l feet, varicose
veins b/l. B/l hands with ulnar deviation, chronic swelling of
MCP and PIP.
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs III-XII grossly intact, no facial
droop, muscle strength on LLE 4+/5 otherwise ___ throughout,
sensation grossly intact throughout, good short-term memory
(able to recall three objects), and attention (able to tell
months backwards only missing ___.
DISCHARGE PHYSICAL EXAM
VS - 98.4, 116/64, 93, 26, 93% on 1___
GENERAL - well-appearing woman in NAD, comfortable, appropriate,
occasionally coughing
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, dried MM, OP
clear
NECK - supple, no thyromegaly, no JVD appreciated
LUNGS - bibasilar crackles with occasional rhonchi and
transmitted upper respiratory sounds, resp unlabored, no
accessory muscle use
HEART - RRR although difficult to auscultate given significant
rhonchi, no MRG appreciated.
ABDOMEN - NABS, soft/NT/ND, no rebound/guarding, + BS
EXTREMITIES - WWP, no c/c, trace peripheral edmema up to ankles,
1+ peripheral pulses, significant bunions on b/l feet, varicose
veins b/l. B/l hands with ulnar deviation, chronic swelling of
MCP and PIP.
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs III-XII grossly intact, no facial
droop, muscle strength on LLE 4+/5 otherwise ___ throughout,
sensation grossly intact throughout, good short-term memory
(able to recall three objects), and attention (able to tell
months backwards only missing ___.
Pertinent Results:
ADMISSION LABS
___ 10:00AM BLOOD WBC-11.5* RBC-4.79 Hgb-15.9 Hct-47.9
MCV-100*# MCH-33.1* MCHC-33.2 RDW-12.8 Plt ___
___ 10:00AM BLOOD Neuts-80.6* Lymphs-10.8* Monos-6.3
Eos-2.0 Baso-0.4
___ 10:00AM BLOOD Glucose-100 UreaN-20 Creat-0.6 Na-142
K-5.9* Cl-103 HCO3-30 AnGap-15
___ 10:00AM BLOOD Albumin-3.4* Calcium-8.9 Phos-3.9 Mg-2.0
___ 10:00AM BLOOD VitB12-831
___ 10:00AM BLOOD TSH-0.90
___ 10:14AM BLOOD Lactate-1.4 K-4.8
DISCHARGE LABS
MICRO
___
DIRECT INFLUENZA A ANTIGEN TEST (Final ___:
Negative for Influenza A.
DIRECT INFLUENZA B ANTIGEN TEST (Final ___:
Negative for Influenza B.
___ BLOOD CULTURES X2: pending
IMAGING
___ CXR
FINDINGS: Frontal and lateral views of the chest were obtained.
Again seen in the right perihilar region is a rounded opacity
measuring 3.2 x 3.3 cm, grossly stable compared to prior. The
previously seen left mid lung rounded mass is not as well
appreciated on the prior study but still appears to be present,
measuring approximately 1.6 x 2.6 cm, although again not well
seen. There is patchy left base retrocardiac opacity. Cardiac
and mediastinal silhouettes are stable with the cardiac
silhouette mildly enlarged. The aorta is calcified.
Single-lead left-sided pacer device is seen with lead extending
to the expected location of the right ventricle. The lateral
view is slightly suboptimal due to some patient motion and
overlying external artifact. Partially imaged is the left
humeral prosthesis. Additional smaller pulmonary nodules may be
present in the upper lobes bilaterally, as better appreciated on
CT. Lingular atelectasis/scarring is seen.
IMPRESSION:
1. Findings worrisome for left lower lobe pneumonia.
2. Multiple pulmonary nodules again seen.
___ CT C-SPINE W/O CONTRAST
IMPRESSION:
1. Streak artifact limits evaluation, however, there is no
evidence of acute fracture
2. Multilevel degenerative changes including anterolisthesis
slightly more prominent since ___.
3. Biapical pulmonary nodules are overall minimally increased in
size.
___ CT HEAD W/O CONTRAST
No evidence of acute intracranial process.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Alendronate Sodium 70 mg PO QWEEK
2. benazepril *NF* 20 mg Oral daily
3. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Omeprazole 40 mg PO DAILY
6. Sertraline 25 mg PO DAILY
7. Simvastatin 20 mg PO DAILY
8. Tiotropium Bromide 1 CAP IH DAILY
9. Aspirin 81 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Naproxen 220 mg PO DAILY
12. Senna 1 TAB PO DAILY
13. Acetaminophen 500 mg PO Q6H:PRN pain
14. Bisacodyl ___AILY:PRN constipation
15. HydrALAzine 50 mg PO DAILY
16. Calcium Carbonate 500 mg PO BID
17. Benzonatate 100 mg PO DAILY
Discharge Medications:
1. Home Oxygen
O2 sats <88% on room air
Diagnosis: COPD, chronic bronchitis
ICD-9 491
2L nasal canula continuously
2. Acetaminophen 500 mg PO Q6H:PRN pain
3. Aspirin 81 mg PO DAILY
4. Benzonatate 100 mg PO DAILY
5. Bisacodyl ___AILY:PRN constipation
6. Calcium Carbonate 500 mg PO BID
7. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
8. Multivitamins 1 TAB PO DAILY
9. Omeprazole 40 mg PO DAILY
10. Senna 1 TAB PO DAILY
11. Sertraline 25 mg PO DAILY
12. Simvastatin 20 mg PO DAILY
13. Tiotropium Bromide 1 CAP IH DAILY
14. Amoxicillin 500 mg PO Q8H
RX *amoxicillin 500 mg 1 tablet(s) by mouth every 8 hours Disp
#*9 Tablet Refills:*0
15. Azithromycin 250 mg PO Q24H
RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
16. Alendronate Sodium 70 mg PO QWEEK
17. benazepril *NF* 20 mg ORAL DAILY
18. Naproxen 220 mg PO DAILY:PRN joint pain
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY: community acquired pneumonia, dizziness, falls
SECONDARY: COPD, hypertension, depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAM: Chest, frontal and lateral views.
CLINICAL INFORMATION: Recent fall with dizziness.
COMPARISON: Multiple priors including ___, and ___.
FINDINGS: Frontal and lateral views of the chest were obtained. Again seen
in the right perihilar region is a rounded opacity measuring 3.2 x 3.3 cm,
grossly stable compared to prior. The previously seen left mid lung rounded
mass is not as well appreciated on the prior study but still appears to be
present, measuring approximately 1.6 x 2.6 cm, although again not well seen.
There is patchy left base retrocardiac opacity. Cardiac and mediastinal
silhouettes are stable with the cardiac silhouette mildly enlarged. The aorta
is calcified. Single-lead left-sided pacer device is seen with lead extending
to the expected location of the right ventricle. The lateral view is slightly
suboptimal due to some patient motion and overlying external artifact.
Partially imaged is the left humeral prosthesis. Additional smaller pulmonary
nodules may be present in the upper lobes bilaterally, as better appreciated
on CT. Lingular atelectasis/scarring is seen.
IMPRESSION:
1. Findings worrisome for left lower lobe pneumonia.
2. Multiple pulmonary nodules again seen.
Radiology Report
HISTORY: Three falls in the last week. Now with dizziness. Evaluate for
subdural.
TECHNIQUE: Axial MDCT images were obtained through the brain without IV
contrast. Multiplanar axial, coronal, sagittal, and thin-section bone
algorithm reconstructed images were acquired. There was significant patient
motion and several images were repeated with partial improvement.
COMPARISON: Multiple prior CTs of the head, most recent ___.
FINDINGS:
Motion artifact most prominently at the skullbase limits evaluation. There is
no evidence of intracranial hemorrhage, edema, mass effect, or large
territorial infarction. The ventricles and sulci are again prominent
suggesting age-related atrophy. Periventricular and subcortical white matter
hyperintensities are nonspecific but likely represent chronic microvascular
ischemic disease. The basal cisterns are patent and there is preservation of
gray-white differentiation.
No fractures are seen. The mastoid air cells, middle ear cavities, and
partially visualized paranasal sinuses are clear. The cavernous internal
carotid arteries are calcified.
IMPRESSION:
No evidence of acute intracranial process.
Radiology Report
HISTORY: Three falls in the last week. Now with dizziness.
TECHNIQUE: Axial helical MDCT images were obtained from the skullbase to the
T3 left without IV contrast. Multiplanar axial, coronal, sagittal, and
thin-section bone algorithm reconstructed images were acquired.
COMPARISON: CT C-spine ___.
FINDINGS:
Left shoulder prosthesis causes significant streak artifact somewhat limiting
evaluation. However, there is no evidence of acute fracture or dislocation.
The occipital condyles are normally positioned on the lateral masses of C1.
Atlantodental distance is preserved. Multilevel degenerative changes are
similar to the comparison study. The transverse ligament of the atlas is
calcified and thickened. Grade 1 anterolisthesis of C5 on C6, C6 on C7, and
C7 on T1 is slightly more prominent. There is osseous fusion of the vertebral
bodies of T1 and T2. Posterior disc osteophyte complexes from C3-C7 results
in mild central canal narrowing. Uncovertebral hypertrophy and facet joint
hypertrophy results in bilateral foraminal narrowing, most prominent at C4-5
and C5-6. The prevertebral and paravertebral soft tissues are unremarkable.
The thyroid is unremarkable. The included lung apices reveal multiple
bilateral pulmonary nodules minimally increased in size since ___. For
example, a 1 cm right upper lobe nodule previously measured 9 mm. The 1.2 x
1.1 cm left upper lobe nodule previously measured 1 x 1 cm periods.
IMPRESSION:
1. Streak artifact limits evaluation, however, there is no evidence of acute
fracture
2. Multilevel degenerative changes including anterolisthesis slightly more
prominent since ___.
3. Biapical pulmonary nodules are overall minimally increased in size.
Gender: F
Race: OTHER
Arrive by AMBULANCE
Chief complaint: DIZZINESS
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED
temperature: 97.8
heartrate: 99.0
resprate: 12.0
o2sat: 95.0
sbp: 134.0
dbp: 74.0
level of pain: 0
level of acuity: 2.0 | ___ with arthritis, knee replacement, hip replacement, COPD,
HTN, heart block s/p VVD pacer presents for episode of dizziness
and recent falls found to have CAP.
# CAP: per CXR new LLL retrocardiac opacity that is concerning
for pneumonia. Leukocytosis with left shift along with new sob
requiring O2, and significant rhonchi on lung exam c/w
respiratory infection. CURB-___ 2 given BUN of ___ and age>___.
Treated in ED with CTX and azithromycin. She was switched to
amoxicillin and azithromycin. Blood cultures pending at
discharge.
# dizziness: appears to be occuring when sitting up or standing
from a sitted position which is consistent with orthostatics.
Has hx of chronic dizziness and likely exacerbated by feeling
sick lately with poor po intake due to her pna. She is also on
multiple BP medications including hydralazine, ACEI, amlodipine,
metoprolol. Recently discontinued amlodipine due to low BP on
___. To prevent further orthostatics, all BP meds were held and
patient BP stayed in the 120s range. On evening of ___, BP in
the 170s and patient was started in ACEI with good control of
BP. She was also found to be hypernatremia with free water
deficit, which was repleted.
# Fall: three falls in last 9 days. Likely multifactorial
including imaging showing deep white matter changes from
vascular disease, cervical spondylosis, peripheral neuropathy
leading to poor gait. All episodes appear to be mechanical.
Unlikely to be cardiac cause as patient without chest pain,
palpitations throughout these events. Last time pacemaker was
interrogated was in ___ with no events. Pacemaker
interrogated on ___ and functioning appropriately. ___ was
consulted who recommended home O2 and 24-hour help.
CHRONIC ISSUES
# HTN: continued on ACEI, but discontinued hydralizine and
metoprolol (patient already paced). BP was controlled. ___ need
to further adjust BP dosage.
# COPD: stable. No wheezing on exam. Continued on home spiriva
and advair.
# Pulmonary nodules: Patient reports that these nodules have
been present "for years" with negative evaluation for lung
cancer. She was evaluated on an inpatient basis by Pulmonary in
___, with the feeling that these were more likely slow-growing
nodule such as a hamartoma. Benign on lymph node biopsy and
washings/brushings in ___. On CXR appears stable from prior
imaging.
# dyslipidemia: continued on home simvastatin
# GERD: continue omeprazole 20mg daily
# depression: continue with sertraline 25 mg PO DAILY
# TRANSITIONAL ISSUES
-CAP treated with amoxicillin and azithromycin for 5 days
-started on home O2 given desaturation to mid-high ___ when
sitting/standing
-continued on ACEI and stopped all other BP medications to
prevent risk for falls. Please check BP and readjust dosage as
needed.
-please follow up with pending blood cultures |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
NSAIDS (Non-Steroidal Anti-Inflammatory Drug)
Attending: ___.
Chief Complaint:
Severe epigastric pain and vomit
Major Surgical or Invasive Procedure:
Exploratory laparotomy with lysis of adhesions.
History of Present Illness:
___ with history of duodenal switch in ___ presenting with 24
hours of severe epigastric pain, anorexia and a single episode
of
vomiting. Epigastric pain is dull, constant, ___ in
intensity,
non-radiating. He passed flatus this morning and his last BM was
last night, usual consistency, with some blood which he
attributes to hemorrhoids. Last meal was at 11 pm yesterday.
Past Medical History:
1. H/o Obesity, status post duodenal switch ___.
2. Secondary hyperparathyroidism.
3. Iron-deficiency anemia.
4. Hypovitaminosis D.
5. ACL surgery.
6. History of kidney failure.
PSH
-appendectomy, cholecystectomy, and duodenal switch in ___,
c/b
leak, pna, renal failure, all complications resolved.
-ventral hernia, "complete body lift" ___
-L ACL reconstruction ___
-hemorrhoids ___
-rhinoplasty septoplasty ___
-open LIH repair ___
Social History:
___
Family History:
-Mo: CVA in late ___
-Fa: MI at ___
Physical Exam:
P/E:
VS: T 97.9, BP 105/69, HR 75, RR 18, O2Sat 94%
GEN: WD, WN in NAD
HEENT: NCAT, EOMI, anicteric
CV: RRR, +S1S2 w no M/R/G
PULM: CTA B/L w no W/R/R, normal excursion, no respiratory
distress
BACK: no vertebral tenderness, no CVAT
ABD: soft, NT, ND, no mass, no hernia, mild abdominal diastasis,
incision CDI
PELVIS: testes descended, no abnormalities
EXT: WWP, no CCE, no tenderness, 2+ B/L ___
NEURO: A&Ox3, no focal neurologic deficits
PSYCH: normal judgment/insight, normal memory, normal
mood/affect
Pertinent Results:
___ 05:20AM BLOOD WBC-3.3* RBC-3.51* Hgb-10.1* Hct-31.3*
MCV-89 MCH-28.8 MCHC-32.3 RDW-16.0* RDWSD-52.6* Plt ___
___ 05:10AM BLOOD WBC-3.8* RBC-3.52* Hgb-10.2* Hct-31.6*
MCV-90 MCH-29.0 MCHC-32.3 RDW-16.1* RDWSD-53.2* Plt ___
___ 05:25AM BLOOD WBC-5.9 RBC-4.01* Hgb-11.3* Hct-35.7*
MCV-89 MCH-28.2 MCHC-31.7* RDW-16.2* RDWSD-53.3* Plt ___
___ 07:57AM BLOOD WBC-5.8 RBC-4.25* Hgb-12.1* Hct-37.3*
MCV-88 MCH-28.5 MCHC-32.4 RDW-16.1* RDWSD-51.8* Plt ___
___ 04:45AM BLOOD WBC-8.4 RBC-4.88 Hgb-13.9 Hct-43.1 MCV-88
MCH-28.5 MCHC-32.3 RDW-15.9* RDWSD-51.5* Plt ___
___ 02:45AM BLOOD WBC-7.8 RBC-4.81 Hgb-13.7 Hct-42.4 MCV-88
MCH-28.5 MCHC-32.3 RDW-15.9* RDWSD-51.0* Plt ___
___ 05:20AM BLOOD Glucose-77 UreaN-12 Creat-0.6 Na-142
K-4.0 Cl-111* HCO3-23 AnGap-8*
___ 05:10AM BLOOD Glucose-92 UreaN-9 Creat-0.5 Na-142 K-3.9
Cl-107 HCO3-24 AnGap-11
___ 05:25AM BLOOD Glucose-107* UreaN-13 Creat-0.6 Na-139
K-3.7 Cl-103 HCO3-21* AnGap-15
___ 07:57AM BLOOD Glucose-110* UreaN-12 Creat-0.6 Na-141
K-3.9 Cl-101 HCO3-26 AnGap-14
___ 04:45AM BLOOD Glucose-99 UreaN-9 Creat-0.7 Na-142 K-3.9
Cl-103 HCO3-22 AnGap-17
___ 05:20AM BLOOD Calcium-7.8* Phos-3.4 Mg-1.8
___ 05:10AM BLOOD Calcium-7.7* Phos-2.8 Mg-1.8
___ 05:25AM BLOOD Calcium-7.9* Phos-2.7 Mg-1.8
___ 04:45AM BLOOD Calcium-8.0* Phos-4.3 Mg-1.3*
Medications on Admission:
B12, Lipase/protease/amylase, Testosterone IM q 2 weeks
OTC: Zinc, Benefiber, Fish Oil, MV, Ferrous Gluconate, Docusate,
B Complex w/ Vit C, Calcium Citrate, Vit D 3
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO BID
3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
4. Pantoprazole 40 mg PO Q12H
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
6. FoLIC Acid 1 mg PO DAILY
7. Multivitamins W/minerals 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Closed-loop bowel obstruction.
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 with contrast
INDICATION: w/ PO contrast ; History: ___ with history of bariatric surgery,
abdominal painNO_PO contrast// eval SBO,
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were
acquired through the abdomen and pelvis following intravenous contrast
administration with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 739 mGy-cm.
COMPARISON: CT abdomen pelvis from ___
FINDINGS:
LOWER CHEST: Minimal dependent atelectasis noted..
ABDOMEN: Again seen is mild left hepatic lobe atrophy, as on prior. The
gallbladder was removed. The spleen, adrenal glands and kidneys are
unremarkable aside for a few stable hypodense renal lesions too small to
characterize. No hydronephrosis.
GASTROINTESTINAL: Patient is status post gastric bypass with duodenal switch
with similar dilatation of the jejunal anastomosis. There is a bowel
obstruction with a transition point in the right lower quadrant on series 2,
image 61 likely secondary to adhesions. Please note that there are two points
of transition at the level of this adhesion and an ileal loop in the deep
pelvis is considered a closed loop obstruction on series 2, images 63-67. The
terminal ileum is collapsed. No free air demonstrated.
PELVIS: There is trace 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. No atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions.
SOFT TISSUES: Bilateral injection gluteal granulomas are visualized. The
abdominal and pelvic wall is within normal limits.
IMPRESSION:
Small-bowel obstruction with a transition point in the right lower quadrant.
Please note that there are two transition points in the right lower quadrant
and an ileal loop in the pelvis is therefore considered a closed loop
obstruction as described above. The terminal ileum is collapsed. No free
air.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 1 EXAM
INDICATION: ___ year old man with SOB// NGT placement
COMPARISON: None
FINDINGS:
PA and lateral views of the chest provided.
A nasogastric tube is been placed which courses below the diaphragm and
terminates within the stomach. There is no focal consolidation, effusion, or
pneumothorax. The cardiac silhouette is normal. The hilar and mediastinal
contours are normal. Lucency is visualized underneath the left hemidiaphragm
may suggest pneumoperitoneum or secondary to an interposed bowel loop.
IMPRESSION:
1. NG tube terminates in the stomach.
2. Lucency visualized underneath left hemidiaphragm may suggest
pneumoperitoneum vs an interposed bowel loop. CT abdomen is recommended.
3. No focal consolidations identified.
Radiology Report
EXAMINATION: Postoperative abdominal radiograph
INDICATION: Assess retained surgical instrument
TECHNIQUE: 2 supine views of the abdomen provided.
COMPARISON: CT abdomen pelvis from ___
FINDINGS:
2 intraoperative images were acquired without a radiologist present.
Images show an NG tube terminating in the left upper abdomen. Surgical clips
in the right upper quadrant noted. Residual enteric contrast noted within
loops of small bowel. Gaseous distention of bowel noted. No retained
surgical instruments.
IMPRESSION:
No retained surgical instrument.
NOTIFICATION: The findings were discussed with Dr. ___. by ___,
M.D. on the telephone on ___ at 5:23 pm
Radiology Report
INDICATION: ___ w/ history of duodenal switch, ccy, appendectomy now here w/
SBO, s/p ex-lap w/ extensive LOA, now c/o nausea emesis x 2// ?ileus ?sob
?free air
TECHNIQUE: Supine and upright abdominal radiographs were obtained.
COMPARISON: Abdominal radiograph dated ___ and CT abdomen pelvis
dated ___.
FINDINGS:
Similar to prior, there are multiple dilated loops of small bowel in the upper
and mid abdomen measuring up to 11.0 cm in the upper abdomen with air-fluid
levels. Oral contrast is seen throughout the right hemiabdomen in the enteric
limb, extending into the ascending colon.
There is no free intraperitoneal air.
Osseous structures are unremarkable. Multiple surgical clips are seen
overlying the right upper quadrant. Surgical sutures are seen in the left
upper quadrant.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
No significant change in small bowel dilation suggesting persistent small
bowel obstruction.
Gender: M
Race: OTHER
Arrive by WALK IN
Chief complaint: Abd pain, Constipation
Diagnosed with Other intestnl obst unsp as to partial versus complete obst, Epigastric pain
temperature: 98.6
heartrate: 64.0
resprate: 16.0
o2sat: 100.0
sbp: 129.0
dbp: 84.0
level of pain: 5
level of acuity: 3.0 | The patient presented to Emergency Department on ___. Pt
was evaluated by ACS upon arrival to ED. Given findings, the
patient was taken to the operating room for exploratory
laparotomy with lysis of adhesions.
There were no adverse events in the operating room; please see
the operative note for details. Pt was extubated, taken to the
PACU until stable, then transferred to the ward for observation.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with an epidural
managed by the Acute Pain Service. Which was removed as he
improved and he was then transitioned to oral tylenol and
oxycodone once tolerating a diet.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
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: The patient was initially kept NPO with a
___ tube in place for decompression. On ___, the
NGT was removed, therefore, the diet was advanced sequentially
to a Regular diet, unfortunately he had an episode of vomit,
however, diet was eventually well tolerated. Patient's intake
and output were closely monitored.
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, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bactrim
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a ___ year old male with well controlled HIV (last
CD4 428 and VL <20 in ___, systemic sclerosis, interstitial
lung disease, ITP episodes, hypothyroidism, and recent admission
___ to ___ for a perianal fistula without abscess.
During that admission, he was noted to be neutropenic with WBC
2.6 and ANC 650 with unclear etiology.
.
He initially presented on his prior admission with fevers,
chills, and buttock pain. He says that his symptoms did not
really change much after discharge, with continued discomfort
and low grade fevers. He saw his PCP for followup on ___,
and was prescribed antibiotics for his perianal fistula, but was
unable to tolerate them due to nausea. He does not remember
which antibiotics were prescribed. Over the last few days, he
has noted increased chills and fevers up to 101 at home. He also
notes that his perianal is more tender and inflammed in a larger
area, with drainage of yellow fluid. He denies any other
complants except for his baseline cough productive of yellow
sputum, which has not changed recently.
.
Initial vitals in ED triage were T 98.3, HR 108, BP 122/76, RR
18, and SpO2 97% on RA. Blood cultures were sent. CBC showed WBC
3.4 with 38% neutrophils (absolute count 1292) and Plt 95 (same
as at discharge). His lactate was normal at 1.0 and his
chemistry panel was unremarkable. He was seen by Surgery
consult, who did not find an abscess on rectal exam, felt the
fistula was unlikely to be the source of his fevers, and
recommended admission to Medicine for further workup.
.
No urine sample was sent and no additional imaging was performed
in the ED. He was given Metronidazole 500 mg IV. Clindamycin 600
mg IV was ordered by not given before transfer. He was admitted
to medicine for further management of his perianal fistula,
fevers, and neutropenia. Vitals prior to floor transfer were T
98.5, HR 84, BP 118/74, RR 18, and SpO2 98% on RA. On reaching
the floor, he reported symptoms as above with no other current
complaints. His perianal pain is manageable when lying down
___, but can increase up to ___ if he sits for a long period
of time.
.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies night sweats, recent weight loss, or weight gain.
Denies headache, sinus tenderness, rhinorrhea, or congestion.
Denies chest pain, pressure, tightness, or palpitations.
Baseline cough. Denies nausea, vomiting, diarrhea, constipation,
or abdominal pain. No recent change in bowel or bladder habits.
No dysuria or hematuria. No rashes or concerning skin lesions.
No arthralgias or myalgias. Review of systems was otherwise
negative.
Past Medical History:
gout
HIV (last CD4 428 in ___, viral load <20 copies), diagnosed
in ___
Systemic sclerosis with bibasilar pulmonary infiltrates
consistent with nonspecific interstitial pneumonitis, as well as
esophageal dysfunction
___ phenomenon
ITP in ___ (treated with IVIg) and ___ (treated with
prednisone)
Hypothyroidism
MGUS
Anal condylomata s/p surgical resection in ___ and ___.
Social History:
___
Family History:
Brother with scleroderma and ___. Mother with platelet
problem and had her spleen removed. Two sisters, one brother,
and one paternal uncle with hypothyroidism.
Physical Exam:
VS: T 98.3, BP 102/70, HR 101, RR 20, SpO2 96% on RA
Gen: Middle aged male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM, OP benign.
Neck: Supple, full ROM. JVP not elevated. Shotty anterior
cervical nodes. Submental note about 0.5 cm. No axillary,
supraclavicular, or inguinal lymphadenopathy.
CV: Regular, rate mildly increased. No M/R/G appreciated.
Chest: Breathing comfortable without accessory muscle use. Good
air movement. Somewhat prolonged expiratory phase. Bibasilar
velcro crackles about half way up lungs fields.
Abd: Normal bowel sounds. Soft, NT, ND. No organomegaly or
masses.
Rectal: External exam with perianal induration, w/o tenderness,
no erythema noted, no drainage noted of perianal fistula, no
abscess palpated.
Ext: WWP. Pale nail beds. No lower extremity edema. Distal
pulses intact radial 2+, DP 2+, ___ 2+. Slight clubbing of
several fingers.
Skin: Patchy hypopigmentation posterior neck.
Neuro: CN II-XII grossly intact. Strength ___ in all
extremities.
Pertinent Results:
Pertinent Labs:
___ 08:00PM BLOOD WBC-3.4* RBC-5.05 Hgb-13.6* Hct-40.9
MCV-81* MCH-27.0 MCHC-33.3 RDW-14.4 Plt Ct-95*
___ 08:00PM BLOOD Neuts-38* Bands-0 Lymphs-46* Monos-14*
Eos-2 Baso-0 ___ Myelos-0
___ 06:00AM BLOOD WBC-3.1* RBC-4.89 Hgb-12.8* Hct-40.0
MCV-82 MCH-26.3* MCHC-32.1 RDW-14.4 Plt Ct-99*
___ 06:00AM BLOOD Neuts-22* Bands-1 Lymphs-56* Monos-18*
Eos-3 Baso-0 ___ Myelos-0 NRBC-1*
___ 08:00PM BLOOD ___ ___
___ 06:00AM BLOOD ___ ___
___ 06:00AM BLOOD WBC-3.1* Lymph-56* Abs ___ CD3%-85
Abs CD3-1470 CD4%-32 Abs CD4-553 CD8%-52 Abs CD8-902*
CD4/CD8-0.6*
___ 08:00PM BLOOD Glucose-101* UreaN-10 Creat-1.1 Na-137
K-3.6 Cl-101 HCO3-25 AnGap-15
___ 08:00PM BLOOD ALT-45* AST-41* LD(LDH)-245 AlkPhos-122
TotBili-2.5*
___ 06:00AM BLOOD Calcium-9.2 Phos-4.3 Mg-1.9
___ 08:00PM BLOOD TSH-0.080*
___ 08:00PM BLOOD Free T4-1.9*
___ 08:19PM BLOOD Lactate-1.0
___ 08:44AM URINE Color-Yellow Appear-Clear Sp ___
___ 08:44AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-6.0 Leuks-TR
___ 08:44AM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1 TransE-<1
Blood cultures and HIV viral load pending at time of discharge
CHEST (PA & LAT) Study Date of ___ 9:33 AM
There are again seen decreased lung volumes and increased
interstitial
opacities at the lung bases. These are unchanged and consistent
with the
patient's known interstitial lung disease, previously
characterized as
fibrotic NSIP related to scleroderma. There is some blunting of
the right CP
angle suggestive of small pleural effusion which is stable.
There is no
pneumothoraces or new suspicious areas for consolidation. Heart
size is
within normal limits.
Medications on Admission:
Reyataz (Atazanavir) 300 mg PO DAILY
Epzicom (Abacavir-Lamivudine) 600-300 mg PO DAILY
Norvir (Ritonavir) 100 mg PO DAILY
Nebupent (Penatmidine) 300 mg IH MONTHLY
Sildenafil 25 mg PO BID PRN Raynauds
DuoNeb (0.5 mg-3 mg) IH Q6H PRN wheeze -- not needed recently
ProAir HFA 90 mcg IH Q6H PRN wheeze -- not needed recently
Levothyroxine 250 mcg PO DAILY
Allopurinol ___ mg PO DAILY
Percocet ___ mg PO Q6H PRN pain
Discharge Medications:
1. atazanavir 150 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
2. Epzicom 600-300 mg Tablet Sig: One (1) Tablet PO once a day.
3. ritonavir 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. pentamidine 300 mg Recon Soln Sig: Three Hundred (300) mg
Inhalation once a month.
5. sildenafil 25 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for Raynauds.
6. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for
Nebulization Sig: One (1) treament Inhalation every six (6)
hours as needed for shortness of breath or wheezing.
7. ProAir HFA 90 mcg/actuation HFA Aerosol Inhaler Sig: One (1)
inhalation Inhalation every six (6) hours as needed for
shortness of breath or wheezing.
8. levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. allopurinol ___ mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. oxycodone-acetaminophen ___ mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Fever
Perianal fistula
Secondary:
Human immunodeficiency virus
Systemic Sclerosis
Interstitial Lung Disease
Raynauds Phenomenon
ITP
Hypothyroidism
Gout
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
STUDY: PA and lateral chest, ___.
CLINICAL HISTORY: ___ man with systemic sclerosis, interstitial lung
disease with recent neutropenia, presenting with fever.
FINDINGS:
Comparison is made to the prior study from ___.
There are again seen decreased lung volumes and increased interstitial
opacities at the lung bases. These are unchanged and consistent with the
patient's known interstitial lung disease, previously characterized as
fibrotic NSIP related to scleroderma. There is some blunting of the right CP
angle suggestive of small pleural effusion which is stable. There is no
pneumothoraces or new suspicious areas for consolidation. Heart size is
within normal limits.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: FEVER
Diagnosed with ANAL FISTULA, FEVER, UNSPECIFIED, ASYMPTOMATIC HIV INFECTION
temperature: 98.3
heartrate: 108.0
resprate: 18.0
o2sat: 97.0
sbp: 122.0
dbp: 76.0
level of pain: 8
level of acuity: 3.0 | The patient is a ___ year old male with well controlled HIV (last
CD4 428 and VL <20 in ___, systemic sclerosis, interstitial
lung disease, unexplained neutropenia, and recent admission for
perianal fistula without abscess. He now presents with several
days of fever at home and increased perianal tenderness without
new focal symptoms.
.
# Fever: He reports recent chills and fevers to 101 at home.
Initially there was concern in the ED of an infection at the
pt's perianal fistula site. Colorectal surgery evaluated the pt
and found no evidence of infection at perianal fistula site. No
fevers were documented in the hospital. His infectious workup
including CXR, U/A and blood cultures were negative for
infection. His current granulocyte count is approx 700 and his
CD 4 count is over 500. The pt was clinically well on exam and
was requesting to be discharged from the hospital. At the time
of discharge two blood cultures were pending and an HIV viral
load was pending as well.
.
# Perianal Fistula: No evidence of infection currently at
fistula site. Surgery evaluated in ED and also did not find
evidence of infection. He was given Metronidazole in the ED and
ordered for Clindamycin, which he did not receive before
admission. Antibx were not administered on arrival to the floor
as clinical suspicion for infection was low. He was discharged
without antibiotics
.
# HIV Infection: He has been well controlled on his current
regimen with last CD4 >500 and VL <20 in ___.
-- Checked HIV viral load and pending at time of d/c
-- Continued home Reyataz (Atazanavir) 300 mg PO DAILY
-- Continued home Epzicom (Abacavir-Lamivudine) 600-300 mg PO
DAILY
-- Continued home Norvir (Ritonavir) 100 mg PO DAILY
.
# Systemic Sclerosis:
-- Continued home Sildenafil 25 mg PO BID PRN for Raynauds
.
# Interstitial Lung Disease: He reports chronic cough productive
of yellow sputum which has not changed recently. A CXR on
admission was reassuring.
-- Albuterol and Ipratropium nebs were provided PRN
.
# Hypothyroidism: He is on a very high dose of Levothyroxine
based on his OMR records and recent discharge summary. His last
TFTs on ___ showed TSH 0.48 and free-T4 1.8 suggesting that
he may be over treated.
-- continued Levothyroxine 200 mcg PO DAILY as this was recently
decreased at ___ prior to admission
.
# Gout: No current symptoms.
-- Continued home Allopurinol ___ mg PO DAILY
.
# Pain Management: He has chronic pain from his Raynauds. He
denies any pain from his bilateral hip AVN.
-- Continued home Percocet ___ mg PO Q6H PRN pain
#Transitional:
1. Two blood cultures and an HIV viral load were pending at time
of discharge and should be followed up by the pt's primary care
physician.
2. We recommended the pt make a follow up appointment with his
primary care physician within two weeks of discharge for
re-evaluation |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
worsening jaundice, fever, cough, dyspnea
Major Surgical or Invasive Procedure:
Thoracentesis
History of Present Illness:
___ year old male with h/o ETOH cirrhosis (complicated by
varices, ascites, and hepatic encephalopathy), CAD s/p stents
referred from liver clinic with jaundice and ascites s/p recent
alcohol intake.
Mr. ___ reports that he was in his usual state of health
until 6 weeks ago, when his mother died, which triggered him to
start drinking again. Since then he has been drinking regularly
and has noted a worsening in his abdominal swelling and
increased jaundice. He reports that he had his last paracentesis
1 week ago and has already regained his ascites.
He saw his hepatologist today who referred him to the ED for
admission given his acute decompensation. No history of SBP. Has
a history of variceal bleeds but no recent hemoptysis and
melena. He endorses new cough, worsening SOB and DOE over the
past week.
In the ED his vitals were: 98.0 | 95 | 104/66 | 18 | 99% RA
-Endorsed subjective fevers and chills additionally to cough,
SOB, DOE
-CBC: WBC 13.4, 83%NPh, Hb 10.2
-Chemistry: low K 3.3, Cr 1.3, Mg 1.5, AST 172 / ALT 53, Tbili
13.2, Alb 2.3, lac 3.7
-Coags INR 1.7
-EKG: NSR. Q wave in III
-Ascitic fluid: WBC 188, NPh 10%, protein 0.5
-UA: 2 granular casts, 24 hyaline casts
-CXR: large R-sided pleural effusion w/overlying consolidation
-He received CTX 1g iv x1, ondansetron 4mg iv x1, CFP 2g iv x1,
Vancomycin 1g iv x1
Vitals prior to transfer were 98 | 90 | 108/71 | 24 | 97% RA
On arrival to the floor vitals were 98.3 | 118/70 | 88 | 23 |
100%/4L
-Patient denies dyspnea currently
ROS: per HPI, deniesnight sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, chest pain, abdominal pain,
nausea, vomiting, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
-Alcoholic cirrhosis
-Grade II esophageal varices
-CAD s/p stents
-Essential Hypertension
-Hyperlipidemia
-Chronic arthritis ___ lyme dz)
-NSAID-induced gastritis
Social History:
___
Family History:
Males on mother's side with heart issues
Mother died from
Father alive with dementia, strokes
Brother alive with HLD, no MI
2 daughters, one graduated from ___ and now a ___, the
other graduated from college also a ___
Physical Exam:
PHYSICAL EXAM ON ADMISSION
VS: 98.3 | 118/70 | 88 | 23 | 100%/4L
General: Chronically-ill appearing male, alert, oriented and in
NAD
HEENT: EOMI, icteric sclerae, pale conjunctiva, MMM
Neck: supple, no JVD, no LAD
CV: RRR, m/r/g
Lungs: Absent breath sounds halfway up R side of chest, crackles
overlying. L side of chest with some ronchi, no crackles.
Abdomen: Distended, collateral circulation, large ventral
hernia, soft, non-tender, patient non-compliant with deep
palpation
GU: No CVAT, no Foley
Ext: +1 lower extremity edema, WWP, good pulses
Neuro: mild asterixis, moves 4 extremities purposefully
Skin: jaundices, spider angiomata
PHYSICAL EXAM ON DISCHARGE
98.2 124/80 86 18 96%RA
General: AAOx3, and NAD on RA, +jaundice, + spider angiomata
HEENT: icteric sclerae
CV: RRR, m/r/g
Lungs: right side with improved breath sounds, L side clear
Abdomen: Distended, collateral circulation, large ventral
hernia, soft, non-tender,
GU: no Foley
Ext: +1 lower extremity edema, WWP, good pulses
Neuro: moves 4 extremities purposefully
Skin: jaundices, spider angiomata
Pertinent Results:
LABS ON ADMISSION
-------------------
___ 06:30PM BLOOD WBC-13.4*# RBC-3.14* Hgb-10.2* Hct-32.1*
MCV-102*# MCH-32.6*# MCHC-31.9 RDW-18.3* Plt ___
___ 06:30PM BLOOD Neuts-83.4* Lymphs-9.8* Monos-5.9 Eos-0.7
Baso-0.2
___ 06:30PM BLOOD ___ PTT-36.5 ___
___ 06:30PM BLOOD Glucose-108* UreaN-19 Creat-1.3* Na-133
K-3.3 Cl-94* HCO3-28 AnGap-14
___ 06:30PM BLOOD ALT-53* AST-172* AlkPhos-417*
TotBili-13.2*
___ 06:30PM BLOOD Lipase-16 GGT-228*
___ 06:30PM BLOOD Albumin-2.3* Calcium-8.1* Phos-3.5
Mg-1.5*
___ 06:30PM BLOOD Lactate-4.3*
PERTINENT RESULTS
--------------------
___ 06:30PM BLOOD Lipase-16 GGT-228*
___ 07:10AM BLOOD TSH-5.3*
___ 07:10AM BLOOD T4-5.0 T3-75*
LABS ON DISCHARGE
--------------------
___ 08:09AM BLOOD WBC-6.1 RBC-2.37* Hgb-7.9* Hct-24.8*
MCV-105* MCH-33.2* MCHC-31.6 RDW-19.9* Plt ___
___ 08:09AM BLOOD Plt ___
___ 08:09AM BLOOD ___ PTT-47.9* ___
___ 08:09AM BLOOD Glucose-78 UreaN-30* Creat-1.3* Na-139
K-3.1* Cl-103 HCO3-25 AnGap-14
___ 08:09AM BLOOD ALT-21 AST-60* AlkPhos-139* TotBili-8.3*
___ 08:09AM BLOOD Calcium-9.4 Phos-3.0 Mg-1.5*
OTHER FLUID ANALYSIS
___ 12:00PM PLEURAL WBC-159* RBC-161* Polys-12* Lymphs-17*
___ Meso-6* Macro-65*
___ 12:00PM PLEURAL TotProt-0.6 Glucose-133 LD(LDH)-64
Cholest-7
___ 09:30PM ASCITES WBC-188* RBC-165* Polys-10* Lymphs-15*
___ Mesothe-9* Macroph-66* Other-0
___ 09:30PM ASCITES TotPro-0.5 Glucose-132
MICROBIOLOGY
---------------
___ VANCOMYCIN RESISTANT
ENTEROCOCCUS-PENDINGINPATIENT
___ FLUIDGRAM STAIN-FINAL; FLUID
CULTURE-FINAL; ANAEROBIC CULTURE-PRELIMINARYINPATIENT
___ CULTURE-FINALINPATIENT
___ CULTUREBlood Culture,
Routine-PENDINGEMERGENCY WARD
___ CULTUREBlood Culture,
Routine-PENDINGEMERGENCY WARD
___ FLUIDGRAM STAIN-FINAL; FLUID
CULTURE-FINAL; ANAEROBIC CULTURE-PRELIMINARYEMERGENCY WARD
___ CULTUREBlood Culture,
Routine-PENDINGEMERGENCY WARD
IMAGING
----------
___ (PORTABLE AP)
IMPRESSION:
Large right pleural effusion is present with increasing
atelectasis in the
right perihilar region. It is difficult to compare to prior
study given the
difference in positioning of the patient. There is no
pneumothorax. There are
low lung volumes. No other interval change from prior study.
___ OR GALLBLADDER US/DUPLEX DOP ABD/PEL
LIMI
FINDINGS:
Severely limited examination due to patient's clinical condition
and body
habitus.
LIVER: Large pleural effusion noted. Unable to assess hepatic
parenchyma.Main
portal vein is patent with reversal of flow. The right portal
vein
demonstrates to and fro flow. The left portal vein demonstrates
appropriate
flow. The umbilical vein is patent. Moderate ascites is present.
BILE DUCTS: Unable to assess.
GALLBLADDER: Unable to assess.
PANCREAS: Unable to assess.
SPLEEN: Normal echogenicity, measuring 17.3 cm.
KIDNEYS: Unable to evaluate.
IMPRESSION:
1. Severely limited examination due to patient's clinical
condition and body
habitus. Consider repeating examination once more clinically
stable.
2. Large right pleural effusion.
3. Patent portal vein with reversed main and to and fro flow
within the right
portal vein. Appropriate flow within left portal vein. No
evidence of portal
venous thrombosis.
4. Moderate ascites.
5. Evidence of portal hypertension including splenomegaly.
6. Unable to evaluate bile ducts, gallbladder, pancreas,
hepatic parenchyma,
and kidneys.
___ (PA & LAT)
FINDINGS:
PA and lateral views of the chest provided. New from prior
exam, is
opacification of the right mid to lower lung which likely
represents a
combination of consolidation/atelectasis and effusion. The heart
is slightly
shifted to the left. There is no pneumothorax. Left lung is
clear. Right heart
border is obscured. Mediastinal contours unremarkable. Bony
structures are
intact.
IMPRESSION:
Opacification of the right mid to lower lung concerning for
effusion and
consolidation/atelectasis. Followup to resolution is advised.
___
Baseline artifact marring interpretation of rhythm but probable
sinus rhythm
versus ectopic atrial rhythm. Non-specific ST segment
flattening. Low voltage
in the limb leads. Compared to the previous tracing of ___
the Q-T interval
is shorter and ventricular ectopy is no longer appreciated.
Read ___.
IntervalsAxes
___
___
EGD/SPECIAL REPORTS ___
Impression:No evidence of esophageal varices and no banding
required.
Esophageal candidiasis Raised antral mucosa consistent with
nodular GAVE with nonbleeding ulcerations.
Mosaic appearance in the fundus and stomach body compatible with
portal hypertensive gastropathyOtherwise normal EGD to third
part of the duodenum
Recommendations:Return to the care of the inpatient Liver
Service
Start treatment for esophageal candidiasis with fluconazole per
Liver Service.
Repeat EGD in one year
PATHOLOGY/CYTOLOGY
___ FLUID ___
NEGATIVE FOR MALIGNANT CELLS
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin 81 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Escitalopram Oxalate 20 mg PO DAILY
4. Ondansetron 4 mg PO Q8H:PRN n/v
5. Furosemide 40 mg PO DAILY
6. Thiamine 100 mg PO DAILY
7. TraMADOL (Ultram) 50 mg PO BID
8. Propranolol 40 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Escitalopram Oxalate 20 mg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Propranolol 40 mg PO DAILY
5. Thiamine 100 mg PO DAILY
6. TraMADOL (Ultram) 50 mg PO BID
7. Levofloxacin 750 mg PO DAILY Duration: 4 Days
___ay ___ to End Date ___. Rifaximin 550 mg PO BID
9. Furosemide 40 mg PO DAILY
10. Ondansetron 4 mg PO Q8H:PRN n/v
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
-------------------
SEVERE ALCOHOLIC HEPATITIS
PNEUMONIA
SECONDARY DIAGNOSIS
HEPATIC HYDROTHORAX
ETOH CIRRHOSIS
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with h/o etoh cirrhosis s/p r ___ // ? ptx
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
IMPRESSION:
Large right pleural effusion is present with increasing atelectasis in the
right perihilar region. It is difficult to compare to prior study given the
difference in positioning of the patient. There is no pneumothorax. There are
low lung volumes. No other interval change from prior study.
Radiology Report
EXAMINATION: Ultrasound-guided paracenteses.
COMPARISON: ___.
TECHNIQUE: Grayscale ultrasound images were acquired over the abdomen in
anticipation of an ultrasound-guided paracentesis.
INDICATION: ___ year old man with cirrhosis.
FINDINGS:
Limited grayscale ultrasound imaging of the abdomen demonstrated no
appreciable, drainable fluid collection within the abdomen. The patient was
informed of the findings, and transported back to the in-patient floor.
EXAMINATION: No appreciable ascites was found, and no paracentesis was
performed.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Jaundice, Cough, Dyspnea
Diagnosed with JAUNDICE NOS, FLATUL/ERUCTAT/GAS PAIN, PNEUMONIA,ORGANISM UNSPECIFIED, COUGH, ALCOHOL CIRRHOSIS LIVER
temperature: 98.0
heartrate: 95.0
resprate: 18.0
o2sat: 99.0
sbp: 104.0
dbp: 66.0
level of pain: 0
level of acuity: 3.0 | BRIEF HOSPITAL COURSE
___ year old male with h/o ETOH cirrhosis (complicated by
varices, ascites, and hepatic encephalopathy), CAD s/p stents
referred from liver clinic with jaundice and ascites s/p recent
alcohol intake.
Mr. ___ reports that he was in his usual state of health
until 6 weeks ago, when his mother died, which triggered him to
start drinking again. Since then he has been drinking regularly
and has noted a worsening in his abdominal swelling and
increased jaundice. He reports that he had his last paracentesis
1 week ago and has already regained his ascites. There was
concern for infection. Diagnostic para showed no signs of
infection. Pt was noted to have a pleural effusion, which was
determined to be consistent with hepatic hydrothorax after
thoracentesis.
Pt was on abx empirically for 5 days, which were discontinued
after infection was ruled out. Pt was started on Prednisone 40mg
PO daily with plans for a 28 day course for severe alcoholic
hepatitis given DF in the ______. His bili, INR, and Cr all
trended down on prednisone. Bili was trending down at time of
discharge. Pt had screening EGD and no varices noted, however pt
had candidal esophagitis. Started on Fluconazole 100mg PO Q24
and will take for 7 days. Pt will follow up with his PCP and
___ as an outpt.
ACTIVE ISSUES
#SEVERE ALCOHOLIC HEPATITIS: Patient with recent alcohol
ingestion, rising bilirrubin, AST/ALT ratio >2, and prolonging
INR. Admission ___ df of 42, steroids deferred d/t active
infection (see below). ___ T. bili increasing - plateauing.
Steroid administration prednisone 40 x 28 days 48 (start d1:
___. LFTs improved and therefore would not be a candidate for
the ___ study. Pt will follow up with Liver Clinic and continue
prednisone for 28 day course.
# PNEUMONIA: Presumed HCAP given chills, cough and subjective
fevers and recent hospitalization in ___. Given alcohol
also at risk for aspiration. Started vanc cef for HCAP coverage
(___) narrowed to levo (___). No recurrent symptoms during
hospital stay.
# AFIB: Pt had two episodes afib ___ rate 90-100s on
___, converted back to sinus. Propranolol is pt's home med,
likely flipped into afib given lack of propranolol (was held for
c/f HRS), and infxn. Patient with new onset Afib per his report
that he has not discussed with his cardiologist. Patient had TTE
while in the hospital that showed no structural abnormalities.
# ___ : Worsening after propranolol administration for afib (see
above). Patient given doses of concentrated albumin during his
inpatient stay. His creatinine stabilized and slowly improved.
Cr was at baseline on discharge.
# HEPATIC HYDROTHORAX: New onset right sided effusion in setting
of worsening ascites. s/p thoracentesis and analysis c/w
transudative process, mostly likely hepatic hydrothorax v.
parapneumonic effusion which would be exudative in nature.
Appears to have reaccumulated. We continued to monitor and
reaccumulation did not occur during inpatient stay. Pt may need
thoracentesis as OP.
CHRONIC ISSUES
# HEPATIC ENCEPHALOPATHY: Patient was alert and oriented but
with subtle asterixis. We continued Lactulose 30mL TID and
titrate to 3BM daily and Rifaximin 550 BID.
# ASCITES: Significant in spite of diuretics, likely due to
alcohol consumption. No h/o SBP. Patient will follow up with
his Liver doctor and determine the continuing dosing of his
diuretics.
# ALCOHOLIC CIRRHOSIS: Currently still drinking. Given
super-imposed alc hep and infection MELD may be more reflective
of acuity than stage per se. Patient had a history of varices,
s/p banding about 1mo ago; was due for Dr. ___ EGD on ___
___. EGD on ___ showed ___ and pt started on
fluconazole.
# COAGULOPATHY: No evidence of bleeding on this admit. We cont
Heparin SC and gave vitamin k 5 mg x 3 days. |